hospital_name last_updated_on version hospital_location hospital_address license_number|SD "To the best of its knowledge and belief, the hospital has included all applicable standard charge information in accordance with the requirements of 45 CFR 180.50, and the information encoded is true, accurate, and complete as of the date indicated." general_contract_provisions Weston County Health Services 12/12/2024 2.0.0 Weston County Hospital """1124 Washington Blvd, Newcastle WY, 82701""" 531303 TRUE description code|1 code|1|type code|2 code|2|type code|3 code|3|type code|4 code|4|type modifiers setting drug_unit_of_measurement drug_type_of_measurement standard_charge|gross standard_charge|discounted_cash payer_name plan_name standard_charge|negotiated_dollar standard_charge|negotiated_percentage standard_charge|negotiated_algorithm estimated_amount standard_charge|methodology standard_charge|min standard_charge|max additional_generic_notes additional_generic_notes_with_LPP HC/HH Wch Supp IV Cath 22ga__4252519-02 PX-4505000002 CDM 4505000002 LOCAL 450 RC inpatient 14 14 BLUE CROSS BLUE SHIELD WELLMARK SB889 [3081026] BCBS WYOMING [308102603] 13.3 percent of total billed charges 8.68 13.3 Technical (Hospital) Services HC/HH Wch Supp IV Cath 22ga__4252519-02 PX-4505000002 CDM 4505000002 LOCAL 450 RC inpatient 14 14 MULTIPLAN INC 34080 [3081285] MULTIPLAN INC [308128501] 13.3 percent of total billed charges 8.68 13.3 Technical (Hospital) Services HC/HH Wch Supp IV Cath 22ga__4252519-02 PX-4505000002 CDM 4505000002 LOCAL 450 RC inpatient 14 14 HEALTHPARTNERS SX009 HEALTHPARTNERS 11.09 percent of total billed charges 8.68 13.3 Technical (Hospital) Services HC/HH Wch Supp IV Cath 22ga__4252519-02 PX-4505000002 CDM 4505000002 LOCAL 450 RC inpatient 14 14 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES EPO [308136803] 11.09 percent of total billed charges 8.68 13.3 Technical (Hospital) Services HC/HH Wch Supp IV Cath 22ga__4252519-02 PX-4505000002 CDM 4505000002 LOCAL 450 RC inpatient 14 14 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES HDHP [308136802] 11.09 percent of total billed charges 8.68 13.3 Technical (Hospital) Services HC/HH Wch Supp IV Cath 22ga__4252519-02 PX-4505000002 CDM 4505000002 LOCAL 450 RC inpatient 14 14 UNITED HEALTHCARE (COMMERCIAL) [3081199] UNITED HEALTHCARE 87726 [308119901] 8.68 percent of total billed charges 8.68 13.3 Technical (Hospital) Services HC/HH Wch Supp IV Cath 22ga__4252519-02 PX-4505000002 CDM 4505000002 LOCAL 450 RC inpatient 14 14 CIGNA 62308 [3081051] CIGNA 62308 [308105105] 11.09 percent of total billed charges 8.68 13.3 Technical (Hospital) Services HC/HH Wch Supp IV Cath 22ga__4252519-02 PX-4505000002 CDM 4505000002 LOCAL 450 RC inpatient 14 14 CIGNA 62308 [3081051] CIGNA STATE OF WYOMING [308105107] 11.09 percent of total billed charges 8.68 13.3 Technical (Hospital) Services HC/HH Wch Supp IV Cath 22ga__4252519-02 PX-4505000002 CDM 4505000002 LOCAL 450 RC inpatient 14 14 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES PPO [308136801] 11.09 percent of total billed charges 8.68 13.3 Technical (Hospital) Services HC/HH Wch Supp IV Cath 22ga__4252519-02 PX-4505000002 CDM 4505000002 LOCAL 450 RC inpatient 14 14 MEDICA (COMMERCIAL) 94265 [3081118] MEDICA CLAIMS [308111801] 12.6 percent of total billed charges 8.68 13.3 Technical (Hospital) Services HC/HH Wch Supp IV Cath 22ga__4252519-02 PX-4505000002 CDM 4505000002 LOCAL 450 RC outpatient 14 14 UNITED HEALTHCARE (COMMERCIAL) [3081199] UNITED HEALTHCARE 87726 [308119901] 8.68 percent of total billed charges 8.68 13.3 Technical (Hospital) Services HC/HH Wch Supp IV Cath 22ga__4252519-02 PX-4505000002 CDM 4505000002 LOCAL 450 RC outpatient 14 14 HEALTHPARTNERS SX009 HEALTHPARTNERS 11.2 percent of total billed charges 8.68 13.3 Technical (Hospital) Services HC/HH Wch Supp IV Cath 22ga__4252519-02 PX-4505000002 CDM 4505000002 LOCAL 450 RC outpatient 14 14 CIGNA 62308 [3081051] CIGNA 62308 [308105105] 11.2 percent of total billed charges 8.68 13.3 Technical (Hospital) Services HC/HH Wch Supp IV Cath 22ga__4252519-02 PX-4505000002 CDM 4505000002 LOCAL 450 RC outpatient 14 14 CIGNA 62308 [3081051] CIGNA STATE OF WYOMING [308105107] 11.2 percent of total billed charges 8.68 13.3 Technical (Hospital) Services HC/HH Wch Supp IV Cath 22ga__4252519-02 PX-4505000002 CDM 4505000002 LOCAL 450 RC outpatient 14 14 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES HDHP [308136802] 11.2 percent of total billed charges 8.68 13.3 Technical (Hospital) Services HC/HH Wch Supp IV Cath 22ga__4252519-02 PX-4505000002 CDM 4505000002 LOCAL 450 RC outpatient 14 14 BLUE CROSS BLUE SHIELD WELLMARK SB889 [3081026] BCBS WYOMING [308102603] 13.3 percent of total billed charges 8.68 13.3 Technical (Hospital) Services HC/HH Wch Supp IV Cath 22ga__4252519-02 PX-4505000002 CDM 4505000002 LOCAL 450 RC outpatient 14 14 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES EPO [308136803] 11.2 percent of total billed charges 8.68 13.3 Technical (Hospital) Services HC/HH Wch Supp IV Cath 22ga__4252519-02 PX-4505000002 CDM 4505000002 LOCAL 450 RC outpatient 14 14 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES PPO [308136801] 11.2 percent of total billed charges 8.68 13.3 Technical (Hospital) Services HC/HH Wch Supp IV Cath 22ga__4252519-02 PX-4505000002 CDM 4505000002 LOCAL 450 RC outpatient 14 14 MULTIPLAN INC 34080 [3081285] MULTIPLAN INC [308128501] 13.3 percent of total billed charges 8.68 13.3 Technical (Hospital) Services HC/HH Wch Supp IV Cath 22ga__4252519-02 PX-4505000002 CDM 4505000002 LOCAL 450 RC outpatient 14 14 MEDICA (COMMERCIAL) 94265 [3081118] MEDICA CLAIMS [308111801] 12.6 percent of total billed charges 8.68 13.3 Technical (Hospital) Services HC/HH Wch Supp Needle Aspiration 16ga__8881245164 PX-4505000001 CDM 4505000001 LOCAL 450 RC inpatient 22 22 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES EPO [308136803] 17.42 percent of total billed charges 13.64 20.9 Technical (Hospital) Services HC/HH Wch Supp Needle Aspiration 16ga__8881245164 PX-4505000001 CDM 4505000001 LOCAL 450 RC inpatient 22 22 MULTIPLAN INC 34080 [3081285] MULTIPLAN INC [308128501] 20.9 percent of total billed charges 13.64 20.9 Technical (Hospital) Services HC/HH Wch Supp Needle Aspiration 16ga__8881245164 PX-4505000001 CDM 4505000001 LOCAL 450 RC inpatient 22 22 BLUE CROSS BLUE SHIELD WELLMARK SB889 [3081026] BCBS WYOMING [308102603] 20.9 percent of total billed charges 13.64 20.9 Technical (Hospital) Services HC/HH Wch Supp Needle Aspiration 16ga__8881245164 PX-4505000001 CDM 4505000001 LOCAL 450 RC inpatient 22 22 HEALTHPARTNERS SX009 HEALTHPARTNERS 17.42 percent of total billed charges 13.64 20.9 Technical (Hospital) Services HC/HH Wch Supp Needle Aspiration 16ga__8881245164 PX-4505000001 CDM 4505000001 LOCAL 450 RC inpatient 22 22 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES PPO [308136801] 17.42 percent of total billed charges 13.64 20.9 Technical (Hospital) Services HC/HH Wch Supp Needle Aspiration 16ga__8881245164 PX-4505000001 CDM 4505000001 LOCAL 450 RC inpatient 22 22 MEDICA (COMMERCIAL) 94265 [3081118] MEDICA CLAIMS [308111801] 19.8 percent of total billed charges 13.64 20.9 Technical (Hospital) Services HC/HH Wch Supp Needle Aspiration 16ga__8881245164 PX-4505000001 CDM 4505000001 LOCAL 450 RC inpatient 22 22 UNITED HEALTHCARE (COMMERCIAL) [3081199] UNITED HEALTHCARE 87726 [308119901] 13.64 percent of total billed charges 13.64 20.9 Technical (Hospital) Services HC/HH Wch Supp Needle Aspiration 16ga__8881245164 PX-4505000001 CDM 4505000001 LOCAL 450 RC inpatient 22 22 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES HDHP [308136802] 17.42 percent of total billed charges 13.64 20.9 Technical (Hospital) Services HC/HH Wch Supp Needle Aspiration 16ga__8881245164 PX-4505000001 CDM 4505000001 LOCAL 450 RC inpatient 22 22 CIGNA 62308 [3081051] CIGNA 62308 [308105105] 17.42 percent of total billed charges 13.64 20.9 Technical (Hospital) Services HC/HH Wch Supp Needle Aspiration 16ga__8881245164 PX-4505000001 CDM 4505000001 LOCAL 450 RC inpatient 22 22 CIGNA 62308 [3081051] CIGNA STATE OF WYOMING [308105107] 17.42 percent of total billed charges 13.64 20.9 Technical (Hospital) Services HC/HH Wch Supp Needle Aspiration 16ga__8881245164 PX-4505000001 CDM 4505000001 LOCAL 450 RC outpatient 22 22 UNITED HEALTHCARE (COMMERCIAL) [3081199] UNITED HEALTHCARE 87726 [308119901] 13.64 percent of total billed charges 13.64 20.9 Technical (Hospital) Services HC/HH Wch Supp Needle Aspiration 16ga__8881245164 PX-4505000001 CDM 4505000001 LOCAL 450 RC outpatient 22 22 HEALTHPARTNERS SX009 HEALTHPARTNERS 17.6 percent of total billed charges 13.64 20.9 Technical (Hospital) Services HC/HH Wch Supp Needle Aspiration 16ga__8881245164 PX-4505000001 CDM 4505000001 LOCAL 450 RC outpatient 22 22 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES PPO [308136801] 17.6 percent of total billed charges 13.64 20.9 Technical (Hospital) Services HC/HH Wch Supp Needle Aspiration 16ga__8881245164 PX-4505000001 CDM 4505000001 LOCAL 450 RC outpatient 22 22 MULTIPLAN INC 34080 [3081285] MULTIPLAN INC [308128501] 20.9 percent of total billed charges 13.64 20.9 Technical (Hospital) Services HC/HH Wch Supp Needle Aspiration 16ga__8881245164 PX-4505000001 CDM 4505000001 LOCAL 450 RC outpatient 22 22 MEDICA (COMMERCIAL) 94265 [3081118] MEDICA CLAIMS [308111801] 19.8 percent of total billed charges 13.64 20.9 Technical (Hospital) Services HC/HH Wch Supp Needle Aspiration 16ga__8881245164 PX-4505000001 CDM 4505000001 LOCAL 450 RC outpatient 22 22 CIGNA 62308 [3081051] CIGNA 62308 [308105105] 17.6 percent of total billed charges 13.64 20.9 Technical (Hospital) Services HC/HH Wch Supp Needle Aspiration 16ga__8881245164 PX-4505000001 CDM 4505000001 LOCAL 450 RC outpatient 22 22 CIGNA 62308 [3081051] CIGNA STATE OF WYOMING [308105107] 17.6 percent of total billed charges 13.64 20.9 Technical (Hospital) Services HC/HH Wch Supp Needle Aspiration 16ga__8881245164 PX-4505000001 CDM 4505000001 LOCAL 450 RC outpatient 22 22 BLUE CROSS BLUE SHIELD WELLMARK SB889 [3081026] BCBS WYOMING [308102603] 20.9 percent of total billed charges 13.64 20.9 Technical (Hospital) Services HC/HH Wch Supp Needle Aspiration 16ga__8881245164 PX-4505000001 CDM 4505000001 LOCAL 450 RC outpatient 22 22 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES EPO [308136803] 17.6 percent of total billed charges 13.64 20.9 Technical (Hospital) Services HC/HH Wch Supp Needle Aspiration 16ga__8881245164 PX-4505000001 CDM 4505000001 LOCAL 450 RC outpatient 22 22 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES HDHP [308136802] 17.6 percent of total billed charges 13.64 20.9 Technical (Hospital) Services HC/HH Wch Supp Padding Cast St 6in__23626-560 PX-2745000002 CDM 2745000002 LOCAL 274 RC inpatient 22 22 MEDICA (COMMERCIAL) 94265 [3081118] MEDICA CLAIMS [308111801] 19.8 percent of total billed charges 13.64 20.9 Technical (Hospital) Services HC/HH Wch Supp Padding Cast St 6in__23626-560 PX-2745000002 CDM 2745000002 LOCAL 274 RC inpatient 22 22 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES PPO [308136801] 17.42 percent of total billed charges 13.64 20.9 Technical (Hospital) Services HC/HH Wch Supp Padding Cast St 6in__23626-560 PX-2745000002 CDM 2745000002 LOCAL 274 RC inpatient 22 22 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES HDHP [308136802] 17.42 percent of total billed charges 13.64 20.9 Technical (Hospital) Services HC/HH Wch Supp Padding Cast St 6in__23626-560 PX-2745000002 CDM 2745000002 LOCAL 274 RC inpatient 22 22 UNITED HEALTHCARE (COMMERCIAL) [3081199] UNITED HEALTHCARE 87726 [308119901] 13.64 percent of total billed charges 13.64 20.9 Technical (Hospital) Services HC/HH Wch Supp Padding Cast St 6in__23626-560 PX-2745000002 CDM 2745000002 LOCAL 274 RC inpatient 22 22 CIGNA 62308 [3081051] CIGNA 62308 [308105105] 17.42 percent of total billed charges 13.64 20.9 Technical (Hospital) Services HC/HH Wch Supp Padding Cast St 6in__23626-560 PX-2745000002 CDM 2745000002 LOCAL 274 RC inpatient 22 22 CIGNA 62308 [3081051] CIGNA STATE OF WYOMING [308105107] 17.42 percent of total billed charges 13.64 20.9 Technical (Hospital) Services HC/HH Wch Supp Padding Cast St 6in__23626-560 PX-2745000002 CDM 2745000002 LOCAL 274 RC inpatient 22 22 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES EPO [308136803] 17.42 percent of total billed charges 13.64 20.9 Technical (Hospital) Services HC/HH Wch Supp Padding Cast St 6in__23626-560 PX-2745000002 CDM 2745000002 LOCAL 274 RC inpatient 22 22 MULTIPLAN INC 34080 [3081285] MULTIPLAN INC [308128501] 20.9 percent of total billed charges 13.64 20.9 Technical (Hospital) Services HC/HH Wch Supp Padding Cast St 6in__23626-560 PX-2745000002 CDM 2745000002 LOCAL 274 RC inpatient 22 22 BLUE CROSS BLUE SHIELD WELLMARK SB889 [3081026] BCBS WYOMING [308102603] 20.9 percent of total billed charges 13.64 20.9 Technical (Hospital) Services HC/HH Wch Supp Padding Cast St 6in__23626-560 PX-2745000002 CDM 2745000002 LOCAL 274 RC inpatient 22 22 HEALTHPARTNERS SX009 HEALTHPARTNERS 17.42 percent of total billed charges 13.64 20.9 Technical (Hospital) Services HC/HH Wch Supp Padding Cast St 6in__23626-560 PX-2745000002 CDM 2745000002 LOCAL 274 RC outpatient 22 22 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES HDHP [308136802] 17.6 percent of total billed charges 13.64 20.9 Technical (Hospital) Services HC/HH Wch Supp Padding Cast St 6in__23626-560 PX-2745000002 CDM 2745000002 LOCAL 274 RC outpatient 22 22 BLUE CROSS BLUE SHIELD WELLMARK SB889 [3081026] BCBS WYOMING [308102603] 20.9 percent of total billed charges 13.64 20.9 Technical (Hospital) Services HC/HH Wch Supp Padding Cast St 6in__23626-560 PX-2745000002 CDM 2745000002 LOCAL 274 RC outpatient 22 22 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES EPO [308136803] 17.6 percent of total billed charges 13.64 20.9 Technical (Hospital) Services HC/HH Wch Supp Padding Cast St 6in__23626-560 PX-2745000002 CDM 2745000002 LOCAL 274 RC outpatient 22 22 CIGNA 62308 [3081051] CIGNA STATE OF WYOMING [308105107] 17.6 percent of total billed charges 13.64 20.9 Technical (Hospital) Services HC/HH Wch Supp Padding Cast St 6in__23626-560 PX-2745000002 CDM 2745000002 LOCAL 274 RC outpatient 22 22 CIGNA 62308 [3081051] CIGNA 62308 [308105105] 17.6 percent of total billed charges 13.64 20.9 Technical (Hospital) Services HC/HH Wch Supp Padding Cast St 6in__23626-560 PX-2745000002 CDM 2745000002 LOCAL 274 RC outpatient 22 22 HEALTHPARTNERS SX009 HEALTHPARTNERS 17.6 percent of total billed charges 13.64 20.9 Technical (Hospital) Services HC/HH Wch Supp Padding Cast St 6in__23626-560 PX-2745000002 CDM 2745000002 LOCAL 274 RC outpatient 22 22 UNITED HEALTHCARE (COMMERCIAL) [3081199] UNITED HEALTHCARE 87726 [308119901] 13.64 percent of total billed charges 13.64 20.9 Technical (Hospital) Services HC/HH Wch Supp Padding Cast St 6in__23626-560 PX-2745000002 CDM 2745000002 LOCAL 274 RC outpatient 22 22 MEDICA (COMMERCIAL) 94265 [3081118] MEDICA CLAIMS [308111801] 19.8 percent of total billed charges 13.64 20.9 Technical (Hospital) Services HC/HH Wch Supp Padding Cast St 6in__23626-560 PX-2745000002 CDM 2745000002 LOCAL 274 RC outpatient 22 22 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES PPO [308136801] 17.6 percent of total billed charges 13.64 20.9 Technical (Hospital) Services HC/HH Wch Supp Padding Cast St 6in__23626-560 PX-2745000002 CDM 2745000002 LOCAL 274 RC outpatient 22 22 MULTIPLAN INC 34080 [3081285] MULTIPLAN INC [308128501] 20.9 percent of total billed charges 13.64 20.9 Technical (Hospital) Services "HC/HH Wch Supp Knee Immobilizer 14__E200010""" PX-2745000001 CDM 2745000001 LOCAL 274 RC inpatient 126 126 BLUE CROSS BLUE SHIELD WELLMARK SB889 [3081026] BCBS WYOMING [308102603] 119.7 percent of total billed charges 78.12 119.7 Technical (Hospital) Services "HC/HH Wch Supp Knee Immobilizer 14__E200010""" PX-2745000001 CDM 2745000001 LOCAL 274 RC inpatient 126 126 MULTIPLAN INC 34080 [3081285] MULTIPLAN INC [308128501] 119.7 percent of total billed charges 78.12 119.7 Technical (Hospital) Services "HC/HH Wch Supp Knee Immobilizer 14__E200010""" PX-2745000001 CDM 2745000001 LOCAL 274 RC inpatient 126 126 HEALTHPARTNERS SX009 HEALTHPARTNERS 99.77 percent of total billed charges 78.12 119.7 Technical (Hospital) Services "HC/HH Wch Supp Knee Immobilizer 14__E200010""" PX-2745000001 CDM 2745000001 LOCAL 274 RC inpatient 126 126 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES EPO [308136803] 99.77 percent of total billed charges 78.12 119.7 Technical (Hospital) Services "HC/HH Wch Supp Knee Immobilizer 14__E200010""" PX-2745000001 CDM 2745000001 LOCAL 274 RC inpatient 126 126 UNITED HEALTHCARE (COMMERCIAL) [3081199] UNITED HEALTHCARE 87726 [308119901] 78.12 percent of total billed charges 78.12 119.7 Technical (Hospital) Services "HC/HH Wch Supp Knee Immobilizer 14__E200010""" PX-2745000001 CDM 2745000001 LOCAL 274 RC inpatient 126 126 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES HDHP [308136802] 99.77 percent of total billed charges 78.12 119.7 Technical (Hospital) Services "HC/HH Wch Supp Knee Immobilizer 14__E200010""" PX-2745000001 CDM 2745000001 LOCAL 274 RC inpatient 126 126 CIGNA 62308 [3081051] CIGNA 62308 [308105105] 99.77 percent of total billed charges 78.12 119.7 Technical (Hospital) Services "HC/HH Wch Supp Knee Immobilizer 14__E200010""" PX-2745000001 CDM 2745000001 LOCAL 274 RC inpatient 126 126 CIGNA 62308 [3081051] CIGNA STATE OF WYOMING [308105107] 99.77 percent of total billed charges 78.12 119.7 Technical (Hospital) Services "HC/HH Wch Supp Knee Immobilizer 14__E200010""" PX-2745000001 CDM 2745000001 LOCAL 274 RC inpatient 126 126 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES PPO [308136801] 99.77 percent of total billed charges 78.12 119.7 Technical (Hospital) Services "HC/HH Wch Supp Knee Immobilizer 14__E200010""" PX-2745000001 CDM 2745000001 LOCAL 274 RC inpatient 126 126 MEDICA (COMMERCIAL) 94265 [3081118] MEDICA CLAIMS [308111801] 113.4 percent of total billed charges 78.12 119.7 Technical (Hospital) Services "HC/HH Wch Supp Knee Immobilizer 14__E200010""" PX-2745000001 CDM 2745000001 LOCAL 274 RC outpatient 126 126 UNITED HEALTHCARE (COMMERCIAL) [3081199] UNITED HEALTHCARE 87726 [308119901] 78.12 percent of total billed charges 78.12 119.7 Technical (Hospital) Services "HC/HH Wch Supp Knee Immobilizer 14__E200010""" PX-2745000001 CDM 2745000001 LOCAL 274 RC outpatient 126 126 HEALTHPARTNERS SX009 HEALTHPARTNERS 100.8 percent of total billed charges 78.12 119.7 Technical (Hospital) Services "HC/HH Wch Supp Knee Immobilizer 14__E200010""" PX-2745000001 CDM 2745000001 LOCAL 274 RC outpatient 126 126 CIGNA 62308 [3081051] CIGNA 62308 [308105105] 100.8 percent of total billed charges 78.12 119.7 Technical (Hospital) Services "HC/HH Wch Supp Knee Immobilizer 14__E200010""" PX-2745000001 CDM 2745000001 LOCAL 274 RC outpatient 126 126 CIGNA 62308 [3081051] CIGNA STATE OF WYOMING [308105107] 100.8 percent of total billed charges 78.12 119.7 Technical (Hospital) Services "HC/HH Wch Supp Knee Immobilizer 14__E200010""" PX-2745000001 CDM 2745000001 LOCAL 274 RC outpatient 126 126 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES HDHP [308136802] 100.8 percent of total billed charges 78.12 119.7 Technical (Hospital) Services "HC/HH Wch Supp Knee Immobilizer 14__E200010""" PX-2745000001 CDM 2745000001 LOCAL 274 RC outpatient 126 126 BLUE CROSS BLUE SHIELD WELLMARK SB889 [3081026] BCBS WYOMING [308102603] 119.7 percent of total billed charges 78.12 119.7 Technical (Hospital) Services "HC/HH Wch Supp Knee Immobilizer 14__E200010""" PX-2745000001 CDM 2745000001 LOCAL 274 RC outpatient 126 126 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES EPO [308136803] 100.8 percent of total billed charges 78.12 119.7 Technical (Hospital) Services "HC/HH Wch Supp Knee Immobilizer 14__E200010""" PX-2745000001 CDM 2745000001 LOCAL 274 RC outpatient 126 126 MEDICA (COMMERCIAL) 94265 [3081118] MEDICA CLAIMS [308111801] 113.4 percent of total billed charges 78.12 119.7 Technical (Hospital) Services "HC/HH Wch Supp Knee Immobilizer 14__E200010""" PX-2745000001 CDM 2745000001 LOCAL 274 RC outpatient 126 126 MULTIPLAN INC 34080 [3081285] MULTIPLAN INC [308128501] 119.7 percent of total billed charges 78.12 119.7 Technical (Hospital) Services "HC/HH Wch Supp Knee Immobilizer 14__E200010""" PX-2745000001 CDM 2745000001 LOCAL 274 RC outpatient 126 126 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES PPO [308136801] 100.8 percent of total billed charges 78.12 119.7 Technical (Hospital) Services HC/HH Wch Supp Wound Closure Tray__756 PX-2725000133 CDM 2725000133 LOCAL 272 RC inpatient 38 38 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES PPO [308136801] 30.09 percent of total billed charges 23.56 36.1 Technical (Hospital) Services HC/HH Wch Supp Wound Closure Tray__756 PX-2725000133 CDM 2725000133 LOCAL 272 RC inpatient 38 38 MEDICA (COMMERCIAL) 94265 [3081118] MEDICA CLAIMS [308111801] 34.2 percent of total billed charges 23.56 36.1 Technical (Hospital) Services HC/HH Wch Supp Wound Closure Tray__756 PX-2725000133 CDM 2725000133 LOCAL 272 RC inpatient 38 38 UNITED HEALTHCARE (COMMERCIAL) [3081199] UNITED HEALTHCARE 87726 [308119901] 23.56 percent of total billed charges 23.56 36.1 Technical (Hospital) Services HC/HH Wch Supp Wound Closure Tray__756 PX-2725000133 CDM 2725000133 LOCAL 272 RC inpatient 38 38 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES HDHP [308136802] 30.09 percent of total billed charges 23.56 36.1 Technical (Hospital) Services HC/HH Wch Supp Wound Closure Tray__756 PX-2725000133 CDM 2725000133 LOCAL 272 RC inpatient 38 38 CIGNA 62308 [3081051] CIGNA 62308 [308105105] 30.09 percent of total billed charges 23.56 36.1 Technical (Hospital) Services HC/HH Wch Supp Wound Closure Tray__756 PX-2725000133 CDM 2725000133 LOCAL 272 RC inpatient 38 38 CIGNA 62308 [3081051] CIGNA STATE OF WYOMING [308105107] 30.09 percent of total billed charges 23.56 36.1 Technical (Hospital) Services HC/HH Wch Supp Wound Closure Tray__756 PX-2725000133 CDM 2725000133 LOCAL 272 RC inpatient 38 38 MULTIPLAN INC 34080 [3081285] MULTIPLAN INC [308128501] 36.1 percent of total billed charges 23.56 36.1 Technical (Hospital) Services HC/HH Wch Supp Wound Closure Tray__756 PX-2725000133 CDM 2725000133 LOCAL 272 RC inpatient 38 38 BLUE CROSS BLUE SHIELD WELLMARK SB889 [3081026] BCBS WYOMING [308102603] 36.1 percent of total billed charges 23.56 36.1 Technical (Hospital) Services HC/HH Wch Supp Wound Closure Tray__756 PX-2725000133 CDM 2725000133 LOCAL 272 RC inpatient 38 38 HEALTHPARTNERS SX009 HEALTHPARTNERS 30.09 percent of total billed charges 23.56 36.1 Technical (Hospital) Services HC/HH Wch Supp Wound Closure Tray__756 PX-2725000133 CDM 2725000133 LOCAL 272 RC inpatient 38 38 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES EPO [308136803] 30.09 percent of total billed charges 23.56 36.1 Technical (Hospital) Services HC/HH Wch Supp Wound Closure Tray__756 PX-2725000133 CDM 2725000133 LOCAL 272 RC outpatient 38 38 UNITED HEALTHCARE (COMMERCIAL) [3081199] UNITED HEALTHCARE 87726 [308119901] 23.56 percent of total billed charges 23.56 36.1 Technical (Hospital) Services HC/HH Wch Supp Wound Closure Tray__756 PX-2725000133 CDM 2725000133 LOCAL 272 RC outpatient 38 38 HEALTHPARTNERS SX009 HEALTHPARTNERS 30.4 percent of total billed charges 23.56 36.1 Technical (Hospital) Services HC/HH Wch Supp Wound Closure Tray__756 PX-2725000133 CDM 2725000133 LOCAL 272 RC outpatient 38 38 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES PPO [308136801] 30.4 percent of total billed charges 23.56 36.1 Technical (Hospital) Services HC/HH Wch Supp Wound Closure Tray__756 PX-2725000133 CDM 2725000133 LOCAL 272 RC outpatient 38 38 MULTIPLAN INC 34080 [3081285] MULTIPLAN INC [308128501] 36.1 percent of total billed charges 23.56 36.1 Technical (Hospital) Services HC/HH Wch Supp Wound Closure Tray__756 PX-2725000133 CDM 2725000133 LOCAL 272 RC outpatient 38 38 MEDICA (COMMERCIAL) 94265 [3081118] MEDICA CLAIMS [308111801] 34.2 percent of total billed charges 23.56 36.1 Technical (Hospital) Services HC/HH Wch Supp Wound Closure Tray__756 PX-2725000133 CDM 2725000133 LOCAL 272 RC outpatient 38 38 CIGNA 62308 [3081051] CIGNA 62308 [308105105] 30.4 percent of total billed charges 23.56 36.1 Technical (Hospital) Services HC/HH Wch Supp Wound Closure Tray__756 PX-2725000133 CDM 2725000133 LOCAL 272 RC outpatient 38 38 CIGNA 62308 [3081051] CIGNA STATE OF WYOMING [308105107] 30.4 percent of total billed charges 23.56 36.1 Technical (Hospital) Services HC/HH Wch Supp Wound Closure Tray__756 PX-2725000133 CDM 2725000133 LOCAL 272 RC outpatient 38 38 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES HDHP [308136802] 30.4 percent of total billed charges 23.56 36.1 Technical (Hospital) Services HC/HH Wch Supp Wound Closure Tray__756 PX-2725000133 CDM 2725000133 LOCAL 272 RC outpatient 38 38 BLUE CROSS BLUE SHIELD WELLMARK SB889 [3081026] BCBS WYOMING [308102603] 36.1 percent of total billed charges 23.56 36.1 Technical (Hospital) Services HC/HH Wch Supp Wound Closure Tray__756 PX-2725000133 CDM 2725000133 LOCAL 272 RC outpatient 38 38 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES EPO [308136803] 30.4 percent of total billed charges 23.56 36.1 Technical (Hospital) Services HC/HH Wch Supp Vicryl 4-0__Etj496g PX-2725000132 CDM 2725000132 LOCAL 272 RC inpatient 15 15 HEALTHPARTNERS SX009 HEALTHPARTNERS 11.88 percent of total billed charges 9.3 14.25 Technical (Hospital) Services HC/HH Wch Supp Vicryl 4-0__Etj496g PX-2725000132 CDM 2725000132 LOCAL 272 RC inpatient 15 15 MULTIPLAN INC 34080 [3081285] MULTIPLAN INC [308128501] 14.25 percent of total billed charges 9.3 14.25 Technical (Hospital) Services HC/HH Wch Supp Vicryl 4-0__Etj496g PX-2725000132 CDM 2725000132 LOCAL 272 RC inpatient 15 15 BLUE CROSS BLUE SHIELD WELLMARK SB889 [3081026] BCBS WYOMING [308102603] 14.25 percent of total billed charges 9.3 14.25 Technical (Hospital) Services HC/HH Wch Supp Vicryl 4-0__Etj496g PX-2725000132 CDM 2725000132 LOCAL 272 RC inpatient 15 15 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES EPO [308136803] 11.88 percent of total billed charges 9.3 14.25 Technical (Hospital) Services HC/HH Wch Supp Vicryl 4-0__Etj496g PX-2725000132 CDM 2725000132 LOCAL 272 RC inpatient 15 15 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES HDHP [308136802] 11.88 percent of total billed charges 9.3 14.25 Technical (Hospital) Services HC/HH Wch Supp Vicryl 4-0__Etj496g PX-2725000132 CDM 2725000132 LOCAL 272 RC inpatient 15 15 UNITED HEALTHCARE (COMMERCIAL) [3081199] UNITED HEALTHCARE 87726 [308119901] 9.3 percent of total billed charges 9.3 14.25 Technical (Hospital) Services HC/HH Wch Supp Vicryl 4-0__Etj496g PX-2725000132 CDM 2725000132 LOCAL 272 RC inpatient 15 15 CIGNA 62308 [3081051] CIGNA 62308 [308105105] 11.88 percent of total billed charges 9.3 14.25 Technical (Hospital) Services HC/HH Wch Supp Vicryl 4-0__Etj496g PX-2725000132 CDM 2725000132 LOCAL 272 RC inpatient 15 15 CIGNA 62308 [3081051] CIGNA STATE OF WYOMING [308105107] 11.88 percent of total billed charges 9.3 14.25 Technical (Hospital) Services HC/HH Wch Supp Vicryl 4-0__Etj496g PX-2725000132 CDM 2725000132 LOCAL 272 RC inpatient 15 15 MEDICA (COMMERCIAL) 94265 [3081118] MEDICA CLAIMS [308111801] 13.5 percent of total billed charges 9.3 14.25 Technical (Hospital) Services HC/HH Wch Supp Vicryl 4-0__Etj496g PX-2725000132 CDM 2725000132 LOCAL 272 RC inpatient 15 15 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES PPO [308136801] 11.88 percent of total billed charges 9.3 14.25 Technical (Hospital) Services HC/HH Wch Supp Vicryl 4-0__Etj496g PX-2725000132 CDM 2725000132 LOCAL 272 RC outpatient 15 15 HEALTHPARTNERS SX009 HEALTHPARTNERS 12 percent of total billed charges 9.3 14.25 Technical (Hospital) Services HC/HH Wch Supp Vicryl 4-0__Etj496g PX-2725000132 CDM 2725000132 LOCAL 272 RC outpatient 15 15 UNITED HEALTHCARE (COMMERCIAL) [3081199] UNITED HEALTHCARE 87726 [308119901] 9.3 percent of total billed charges 9.3 14.25 Technical (Hospital) Services HC/HH Wch Supp Vicryl 4-0__Etj496g PX-2725000132 CDM 2725000132 LOCAL 272 RC outpatient 15 15 CIGNA 62308 [3081051] CIGNA 62308 [308105105] 12 percent of total billed charges 9.3 14.25 Technical (Hospital) Services HC/HH Wch Supp Vicryl 4-0__Etj496g PX-2725000132 CDM 2725000132 LOCAL 272 RC outpatient 15 15 CIGNA 62308 [3081051] CIGNA STATE OF WYOMING [308105107] 12 percent of total billed charges 9.3 14.25 Technical (Hospital) Services HC/HH Wch Supp Vicryl 4-0__Etj496g PX-2725000132 CDM 2725000132 LOCAL 272 RC outpatient 15 15 BLUE CROSS BLUE SHIELD WELLMARK SB889 [3081026] BCBS WYOMING [308102603] 14.25 percent of total billed charges 9.3 14.25 Technical (Hospital) Services HC/HH Wch Supp Vicryl 4-0__Etj496g PX-2725000132 CDM 2725000132 LOCAL 272 RC outpatient 15 15 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES EPO [308136803] 12 percent of total billed charges 9.3 14.25 Technical (Hospital) Services HC/HH Wch Supp Vicryl 4-0__Etj496g PX-2725000132 CDM 2725000132 LOCAL 272 RC outpatient 15 15 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES HDHP [308136802] 12 percent of total billed charges 9.3 14.25 Technical (Hospital) Services HC/HH Wch Supp Vicryl 4-0__Etj496g PX-2725000132 CDM 2725000132 LOCAL 272 RC outpatient 15 15 MEDICA (COMMERCIAL) 94265 [3081118] MEDICA CLAIMS [308111801] 13.5 percent of total billed charges 9.3 14.25 Technical (Hospital) Services HC/HH Wch Supp Vicryl 4-0__Etj496g PX-2725000132 CDM 2725000132 LOCAL 272 RC outpatient 15 15 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES PPO [308136801] 12 percent of total billed charges 9.3 14.25 Technical (Hospital) Services HC/HH Wch Supp Vicryl 4-0__Etj496g PX-2725000132 CDM 2725000132 LOCAL 272 RC outpatient 15 15 MULTIPLAN INC 34080 [3081285] MULTIPLAN INC [308128501] 14.25 percent of total billed charges 9.3 14.25 Technical (Hospital) Services HC/HH Wch Supp Tube Trach Uncuffed 5.0__86466 PX-2725000130 CDM 2725000130 LOCAL 272 RC outpatient 13 13 BLUE CROSS BLUE SHIELD WELLMARK SB889 [3081026] BCBS WYOMING [308102603] 12.35 percent of total billed charges 8.06 12.35 Technical (Hospital) Services HC/HH Wch Supp Tube Trach Uncuffed 5.0__86466 PX-2725000130 CDM 2725000130 LOCAL 272 RC outpatient 13 13 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES EPO [308136803] 10.4 percent of total billed charges 8.06 12.35 Technical (Hospital) Services HC/HH Wch Supp Tube Trach Uncuffed 5.0__86466 PX-2725000130 CDM 2725000130 LOCAL 272 RC outpatient 13 13 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES HDHP [308136802] 10.4 percent of total billed charges 8.06 12.35 Technical (Hospital) Services HC/HH Wch Supp Tube Trach Uncuffed 5.0__86466 PX-2725000130 CDM 2725000130 LOCAL 272 RC outpatient 13 13 CIGNA 62308 [3081051] CIGNA 62308 [308105105] 10.4 percent of total billed charges 8.06 12.35 Technical (Hospital) Services HC/HH Wch Supp Tube Trach Uncuffed 5.0__86466 PX-2725000130 CDM 2725000130 LOCAL 272 RC outpatient 13 13 CIGNA 62308 [3081051] CIGNA STATE OF WYOMING [308105107] 10.4 percent of total billed charges 8.06 12.35 Technical (Hospital) Services HC/HH Wch Supp Tube Trach Uncuffed 5.0__86466 PX-2725000130 CDM 2725000130 LOCAL 272 RC outpatient 13 13 UNITED HEALTHCARE (COMMERCIAL) [3081199] UNITED HEALTHCARE 87726 [308119901] 8.06 percent of total billed charges 8.06 12.35 Technical (Hospital) Services HC/HH Wch Supp Tube Trach Uncuffed 5.0__86466 PX-2725000130 CDM 2725000130 LOCAL 272 RC outpatient 13 13 HEALTHPARTNERS SX009 HEALTHPARTNERS 10.4 percent of total billed charges 8.06 12.35 Technical (Hospital) Services HC/HH Wch Supp Tube Trach Uncuffed 5.0__86466 PX-2725000130 CDM 2725000130 LOCAL 272 RC outpatient 13 13 MULTIPLAN INC 34080 [3081285] MULTIPLAN INC [308128501] 12.35 percent of total billed charges 8.06 12.35 Technical (Hospital) Services HC/HH Wch Supp Tube Trach Uncuffed 5.0__86466 PX-2725000130 CDM 2725000130 LOCAL 272 RC outpatient 13 13 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES PPO [308136801] 10.4 percent of total billed charges 8.06 12.35 Technical (Hospital) Services HC/HH Wch Supp Tube Trach Uncuffed 5.0__86466 PX-2725000130 CDM 2725000130 LOCAL 272 RC outpatient 13 13 MEDICA (COMMERCIAL) 94265 [3081118] MEDICA CLAIMS [308111801] 11.7 percent of total billed charges 8.06 12.35 Technical (Hospital) Services HC/HH Wch Supp Tube Trach Uncuffed 5.0__86466 PX-2725000130 CDM 2725000130 LOCAL 272 RC inpatient 13 13 HEALTHPARTNERS SX009 HEALTHPARTNERS 10.29 percent of total billed charges 8.06 12.35 Technical (Hospital) Services HC/HH Wch Supp Tube Trach Uncuffed 5.0__86466 PX-2725000130 CDM 2725000130 LOCAL 272 RC inpatient 13 13 MULTIPLAN INC 34080 [3081285] MULTIPLAN INC [308128501] 12.35 percent of total billed charges 8.06 12.35 Technical (Hospital) Services HC/HH Wch Supp Tube Trach Uncuffed 5.0__86466 PX-2725000130 CDM 2725000130 LOCAL 272 RC inpatient 13 13 BLUE CROSS BLUE SHIELD WELLMARK SB889 [3081026] BCBS WYOMING [308102603] 12.35 percent of total billed charges 8.06 12.35 Technical (Hospital) Services HC/HH Wch Supp Tube Trach Uncuffed 5.0__86466 PX-2725000130 CDM 2725000130 LOCAL 272 RC inpatient 13 13 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES EPO [308136803] 10.29 percent of total billed charges 8.06 12.35 Technical (Hospital) Services HC/HH Wch Supp Tube Trach Uncuffed 5.0__86466 PX-2725000130 CDM 2725000130 LOCAL 272 RC inpatient 13 13 CIGNA 62308 [3081051] CIGNA 62308 [308105105] 10.29 percent of total billed charges 8.06 12.35 Technical (Hospital) Services HC/HH Wch Supp Tube Trach Uncuffed 5.0__86466 PX-2725000130 CDM 2725000130 LOCAL 272 RC inpatient 13 13 CIGNA 62308 [3081051] CIGNA STATE OF WYOMING [308105107] 10.29 percent of total billed charges 8.06 12.35 Technical (Hospital) Services HC/HH Wch Supp Tube Trach Uncuffed 5.0__86466 PX-2725000130 CDM 2725000130 LOCAL 272 RC inpatient 13 13 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES HDHP [308136802] 10.29 percent of total billed charges 8.06 12.35 Technical (Hospital) Services HC/HH Wch Supp Tube Trach Uncuffed 5.0__86466 PX-2725000130 CDM 2725000130 LOCAL 272 RC inpatient 13 13 UNITED HEALTHCARE (COMMERCIAL) [3081199] UNITED HEALTHCARE 87726 [308119901] 8.06 percent of total billed charges 8.06 12.35 Technical (Hospital) Services HC/HH Wch Supp Tube Trach Uncuffed 5.0__86466 PX-2725000130 CDM 2725000130 LOCAL 272 RC inpatient 13 13 MEDICA (COMMERCIAL) 94265 [3081118] MEDICA CLAIMS [308111801] 11.7 percent of total billed charges 8.06 12.35 Technical (Hospital) Services HC/HH Wch Supp Tube Trach Uncuffed 5.0__86466 PX-2725000130 CDM 2725000130 LOCAL 272 RC inpatient 13 13 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES PPO [308136801] 10.29 percent of total billed charges 8.06 12.35 Technical (Hospital) Services HC/HH Wch Supp Tube Trach Uncuffed 4.0__86464 PX-2725000129 CDM 2725000129 LOCAL 272 RC inpatient 15 15 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES PPO [308136801] 11.88 percent of total billed charges 9.3 14.25 Technical (Hospital) Services HC/HH Wch Supp Tube Trach Uncuffed 4.0__86464 PX-2725000129 CDM 2725000129 LOCAL 272 RC inpatient 15 15 MEDICA (COMMERCIAL) 94265 [3081118] MEDICA CLAIMS [308111801] 13.5 percent of total billed charges 9.3 14.25 Technical (Hospital) Services HC/HH Wch Supp Tube Trach Uncuffed 4.0__86464 PX-2725000129 CDM 2725000129 LOCAL 272 RC inpatient 15 15 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES HDHP [308136802] 11.88 percent of total billed charges 9.3 14.25 Technical (Hospital) Services HC/HH Wch Supp Tube Trach Uncuffed 4.0__86464 PX-2725000129 CDM 2725000129 LOCAL 272 RC inpatient 15 15 UNITED HEALTHCARE (COMMERCIAL) [3081199] UNITED HEALTHCARE 87726 [308119901] 9.3 percent of total billed charges 9.3 14.25 Technical (Hospital) Services HC/HH Wch Supp Tube Trach Uncuffed 4.0__86464 PX-2725000129 CDM 2725000129 LOCAL 272 RC inpatient 15 15 CIGNA 62308 [3081051] CIGNA 62308 [308105105] 11.88 percent of total billed charges 9.3 14.25 Technical (Hospital) Services HC/HH Wch Supp Tube Trach Uncuffed 4.0__86464 PX-2725000129 CDM 2725000129 LOCAL 272 RC inpatient 15 15 CIGNA 62308 [3081051] CIGNA STATE OF WYOMING [308105107] 11.88 percent of total billed charges 9.3 14.25 Technical (Hospital) Services HC/HH Wch Supp Tube Trach Uncuffed 4.0__86464 PX-2725000129 CDM 2725000129 LOCAL 272 RC inpatient 15 15 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES EPO [308136803] 11.88 percent of total billed charges 9.3 14.25 Technical (Hospital) Services HC/HH Wch Supp Tube Trach Uncuffed 4.0__86464 PX-2725000129 CDM 2725000129 LOCAL 272 RC inpatient 15 15 MULTIPLAN INC 34080 [3081285] MULTIPLAN INC [308128501] 14.25 percent of total billed charges 9.3 14.25 Technical (Hospital) Services HC/HH Wch Supp Tube Trach Uncuffed 4.0__86464 PX-2725000129 CDM 2725000129 LOCAL 272 RC inpatient 15 15 BLUE CROSS BLUE SHIELD WELLMARK SB889 [3081026] BCBS WYOMING [308102603] 14.25 percent of total billed charges 9.3 14.25 Technical (Hospital) Services HC/HH Wch Supp Tube Trach Uncuffed 4.0__86464 PX-2725000129 CDM 2725000129 LOCAL 272 RC inpatient 15 15 HEALTHPARTNERS SX009 HEALTHPARTNERS 11.88 percent of total billed charges 9.3 14.25 Technical (Hospital) Services HC/HH Wch Supp Tube Trach Uncuffed 4.0__86464 PX-2725000129 CDM 2725000129 LOCAL 272 RC outpatient 15 15 BLUE CROSS BLUE SHIELD WELLMARK SB889 [3081026] BCBS WYOMING [308102603] 14.25 percent of total billed charges 9.3 14.25 Technical (Hospital) Services HC/HH Wch Supp Tube Trach Uncuffed 4.0__86464 PX-2725000129 CDM 2725000129 LOCAL 272 RC outpatient 15 15 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES EPO [308136803] 12 percent of total billed charges 9.3 14.25 Technical (Hospital) Services HC/HH Wch Supp Tube Trach Uncuffed 4.0__86464 PX-2725000129 CDM 2725000129 LOCAL 272 RC outpatient 15 15 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES HDHP [308136802] 12 percent of total billed charges 9.3 14.25 Technical (Hospital) Services HC/HH Wch Supp Tube Trach Uncuffed 4.0__86464 PX-2725000129 CDM 2725000129 LOCAL 272 RC outpatient 15 15 CIGNA 62308 [3081051] CIGNA 62308 [308105105] 12 percent of total billed charges 9.3 14.25 Technical (Hospital) Services HC/HH Wch Supp Tube Trach Uncuffed 4.0__86464 PX-2725000129 CDM 2725000129 LOCAL 272 RC outpatient 15 15 CIGNA 62308 [3081051] CIGNA STATE OF WYOMING [308105107] 12 percent of total billed charges 9.3 14.25 Technical (Hospital) Services HC/HH Wch Supp Tube Trach Uncuffed 4.0__86464 PX-2725000129 CDM 2725000129 LOCAL 272 RC outpatient 15 15 MEDICA (COMMERCIAL) 94265 [3081118] MEDICA CLAIMS [308111801] 13.5 percent of total billed charges 9.3 14.25 Technical (Hospital) Services HC/HH Wch Supp Tube Trach Uncuffed 4.0__86464 PX-2725000129 CDM 2725000129 LOCAL 272 RC outpatient 15 15 MULTIPLAN INC 34080 [3081285] MULTIPLAN INC [308128501] 14.25 percent of total billed charges 9.3 14.25 Technical (Hospital) Services HC/HH Wch Supp Tube Trach Uncuffed 4.0__86464 PX-2725000129 CDM 2725000129 LOCAL 272 RC outpatient 15 15 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES PPO [308136801] 12 percent of total billed charges 9.3 14.25 Technical (Hospital) Services HC/HH Wch Supp Tube Trach Uncuffed 4.0__86464 PX-2725000129 CDM 2725000129 LOCAL 272 RC outpatient 15 15 UNITED HEALTHCARE (COMMERCIAL) [3081199] UNITED HEALTHCARE 87726 [308119901] 9.3 percent of total billed charges 9.3 14.25 Technical (Hospital) Services HC/HH Wch Supp Tube Trach Uncuffed 4.0__86464 PX-2725000129 CDM 2725000129 LOCAL 272 RC outpatient 15 15 HEALTHPARTNERS SX009 HEALTHPARTNERS 12 percent of total billed charges 9.3 14.25 Technical (Hospital) Services HC/HH Wch Supp Tube Trach Uncuffed 3.5__86224 PX-2725000128 CDM 2725000128 LOCAL 272 RC inpatient 15 15 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES EPO [308136803] 11.88 percent of total billed charges 9.3 14.25 Technical (Hospital) Services HC/HH Wch Supp Tube Trach Uncuffed 3.5__86224 PX-2725000128 CDM 2725000128 LOCAL 272 RC inpatient 15 15 HEALTHPARTNERS SX009 HEALTHPARTNERS 11.88 percent of total billed charges 9.3 14.25 Technical (Hospital) Services HC/HH Wch Supp Tube Trach Uncuffed 3.5__86224 PX-2725000128 CDM 2725000128 LOCAL 272 RC inpatient 15 15 MULTIPLAN INC 34080 [3081285] MULTIPLAN INC [308128501] 14.25 percent of total billed charges 9.3 14.25 Technical (Hospital) Services HC/HH Wch Supp Tube Trach Uncuffed 3.5__86224 PX-2725000128 CDM 2725000128 LOCAL 272 RC inpatient 15 15 BLUE CROSS BLUE SHIELD WELLMARK SB889 [3081026] BCBS WYOMING [308102603] 14.25 percent of total billed charges 9.3 14.25 Technical (Hospital) Services HC/HH Wch Supp Tube Trach Uncuffed 3.5__86224 PX-2725000128 CDM 2725000128 LOCAL 272 RC inpatient 15 15 MEDICA (COMMERCIAL) 94265 [3081118] MEDICA CLAIMS [308111801] 13.5 percent of total billed charges 9.3 14.25 Technical (Hospital) Services HC/HH Wch Supp Tube Trach Uncuffed 3.5__86224 PX-2725000128 CDM 2725000128 LOCAL 272 RC inpatient 15 15 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES PPO [308136801] 11.88 percent of total billed charges 9.3 14.25 Technical (Hospital) Services HC/HH Wch Supp Tube Trach Uncuffed 3.5__86224 PX-2725000128 CDM 2725000128 LOCAL 272 RC inpatient 15 15 CIGNA 62308 [3081051] CIGNA 62308 [308105105] 11.88 percent of total billed charges 9.3 14.25 Technical (Hospital) Services HC/HH Wch Supp Tube Trach Uncuffed 3.5__86224 PX-2725000128 CDM 2725000128 LOCAL 272 RC inpatient 15 15 CIGNA 62308 [3081051] CIGNA STATE OF WYOMING [308105107] 11.88 percent of total billed charges 9.3 14.25 Technical (Hospital) Services HC/HH Wch Supp Tube Trach Uncuffed 3.5__86224 PX-2725000128 CDM 2725000128 LOCAL 272 RC inpatient 15 15 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES HDHP [308136802] 11.88 percent of total billed charges 9.3 14.25 Technical (Hospital) Services HC/HH Wch Supp Tube Trach Uncuffed 3.5__86224 PX-2725000128 CDM 2725000128 LOCAL 272 RC inpatient 15 15 UNITED HEALTHCARE (COMMERCIAL) [3081199] UNITED HEALTHCARE 87726 [308119901] 9.3 percent of total billed charges 9.3 14.25 Technical (Hospital) Services HC/HH Wch Supp Tube Trach Uncuffed 3.5__86224 PX-2725000128 CDM 2725000128 LOCAL 272 RC outpatient 15 15 CIGNA 62308 [3081051] CIGNA 62308 [308105105] 12 percent of total billed charges 9.3 14.25 Technical (Hospital) Services HC/HH Wch Supp Tube Trach Uncuffed 3.5__86224 PX-2725000128 CDM 2725000128 LOCAL 272 RC outpatient 15 15 CIGNA 62308 [3081051] CIGNA STATE OF WYOMING [308105107] 12 percent of total billed charges 9.3 14.25 Technical (Hospital) Services HC/HH Wch Supp Tube Trach Uncuffed 3.5__86224 PX-2725000128 CDM 2725000128 LOCAL 272 RC outpatient 15 15 UNITED HEALTHCARE (COMMERCIAL) [3081199] UNITED HEALTHCARE 87726 [308119901] 9.3 percent of total billed charges 9.3 14.25 Technical (Hospital) Services HC/HH Wch Supp Tube Trach Uncuffed 3.5__86224 PX-2725000128 CDM 2725000128 LOCAL 272 RC outpatient 15 15 HEALTHPARTNERS SX009 HEALTHPARTNERS 12 percent of total billed charges 9.3 14.25 Technical (Hospital) Services HC/HH Wch Supp Tube Trach Uncuffed 3.5__86224 PX-2725000128 CDM 2725000128 LOCAL 272 RC outpatient 15 15 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES HDHP [308136802] 12 percent of total billed charges 9.3 14.25 Technical (Hospital) Services HC/HH Wch Supp Tube Trach Uncuffed 3.5__86224 PX-2725000128 CDM 2725000128 LOCAL 272 RC outpatient 15 15 BLUE CROSS BLUE SHIELD WELLMARK SB889 [3081026] BCBS WYOMING [308102603] 14.25 percent of total billed charges 9.3 14.25 Technical (Hospital) Services HC/HH Wch Supp Tube Trach Uncuffed 3.5__86224 PX-2725000128 CDM 2725000128 LOCAL 272 RC outpatient 15 15 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES EPO [308136803] 12 percent of total billed charges 9.3 14.25 Technical (Hospital) Services HC/HH Wch Supp Tube Trach Uncuffed 3.5__86224 PX-2725000128 CDM 2725000128 LOCAL 272 RC outpatient 15 15 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES PPO [308136801] 12 percent of total billed charges 9.3 14.25 Technical (Hospital) Services HC/HH Wch Supp Tube Trach Uncuffed 3.5__86224 PX-2725000128 CDM 2725000128 LOCAL 272 RC outpatient 15 15 MULTIPLAN INC 34080 [3081285] MULTIPLAN INC [308128501] 14.25 percent of total billed charges 9.3 14.25 Technical (Hospital) Services HC/HH Wch Supp Tube Trach Uncuffed 3.5__86224 PX-2725000128 CDM 2725000128 LOCAL 272 RC outpatient 15 15 MEDICA (COMMERCIAL) 94265 [3081118] MEDICA CLAIMS [308111801] 13.5 percent of total billed charges 9.3 14.25 Technical (Hospital) Services HC/HH Wch Supp Tube Trach Uncuffed 3.0__86223 PX-2725000127 CDM 2725000127 LOCAL 272 RC inpatient 13 13 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES PPO [308136801] 10.29 percent of total billed charges 8.06 12.35 Technical (Hospital) Services HC/HH Wch Supp Tube Trach Uncuffed 3.0__86223 PX-2725000127 CDM 2725000127 LOCAL 272 RC inpatient 13 13 MEDICA (COMMERCIAL) 94265 [3081118] MEDICA CLAIMS [308111801] 11.7 percent of total billed charges 8.06 12.35 Technical (Hospital) Services HC/HH Wch Supp Tube Trach Uncuffed 3.0__86223 PX-2725000127 CDM 2725000127 LOCAL 272 RC inpatient 13 13 UNITED HEALTHCARE (COMMERCIAL) [3081199] UNITED HEALTHCARE 87726 [308119901] 8.06 percent of total billed charges 8.06 12.35 Technical (Hospital) Services HC/HH Wch Supp Tube Trach Uncuffed 3.0__86223 PX-2725000127 CDM 2725000127 LOCAL 272 RC inpatient 13 13 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES HDHP [308136802] 10.29 percent of total billed charges 8.06 12.35 Technical (Hospital) Services HC/HH Wch Supp Tube Trach Uncuffed 3.0__86223 PX-2725000127 CDM 2725000127 LOCAL 272 RC inpatient 13 13 CIGNA 62308 [3081051] CIGNA 62308 [308105105] 10.29 percent of total billed charges 8.06 12.35 Technical (Hospital) Services HC/HH Wch Supp Tube Trach Uncuffed 3.0__86223 PX-2725000127 CDM 2725000127 LOCAL 272 RC inpatient 13 13 CIGNA 62308 [3081051] CIGNA STATE OF WYOMING [308105107] 10.29 percent of total billed charges 8.06 12.35 Technical (Hospital) Services HC/HH Wch Supp Tube Trach Uncuffed 3.0__86223 PX-2725000127 CDM 2725000127 LOCAL 272 RC inpatient 13 13 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES EPO [308136803] 10.29 percent of total billed charges 8.06 12.35 Technical (Hospital) Services HC/HH Wch Supp Tube Trach Uncuffed 3.0__86223 PX-2725000127 CDM 2725000127 LOCAL 272 RC inpatient 13 13 BLUE CROSS BLUE SHIELD WELLMARK SB889 [3081026] BCBS WYOMING [308102603] 12.35 percent of total billed charges 8.06 12.35 Technical (Hospital) Services HC/HH Wch Supp Tube Trach Uncuffed 3.0__86223 PX-2725000127 CDM 2725000127 LOCAL 272 RC inpatient 13 13 MULTIPLAN INC 34080 [3081285] MULTIPLAN INC [308128501] 12.35 percent of total billed charges 8.06 12.35 Technical (Hospital) Services HC/HH Wch Supp Tube Trach Uncuffed 3.0__86223 PX-2725000127 CDM 2725000127 LOCAL 272 RC inpatient 13 13 HEALTHPARTNERS SX009 HEALTHPARTNERS 10.29 percent of total billed charges 8.06 12.35 Technical (Hospital) Services HC/HH Wch Supp Tube Trach Uncuffed 3.0__86223 PX-2725000127 CDM 2725000127 LOCAL 272 RC outpatient 13 13 BLUE CROSS BLUE SHIELD WELLMARK SB889 [3081026] BCBS WYOMING [308102603] 12.35 percent of total billed charges 8.06 12.35 Technical (Hospital) Services HC/HH Wch Supp Tube Trach Uncuffed 3.0__86223 PX-2725000127 CDM 2725000127 LOCAL 272 RC outpatient 13 13 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES EPO [308136803] 10.4 percent of total billed charges 8.06 12.35 Technical (Hospital) Services HC/HH Wch Supp Tube Trach Uncuffed 3.0__86223 PX-2725000127 CDM 2725000127 LOCAL 272 RC outpatient 13 13 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES HDHP [308136802] 10.4 percent of total billed charges 8.06 12.35 Technical (Hospital) Services HC/HH Wch Supp Tube Trach Uncuffed 3.0__86223 PX-2725000127 CDM 2725000127 LOCAL 272 RC outpatient 13 13 UNITED HEALTHCARE (COMMERCIAL) [3081199] UNITED HEALTHCARE 87726 [308119901] 8.06 percent of total billed charges 8.06 12.35 Technical (Hospital) Services HC/HH Wch Supp Tube Trach Uncuffed 3.0__86223 PX-2725000127 CDM 2725000127 LOCAL 272 RC outpatient 13 13 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES PPO [308136801] 10.4 percent of total billed charges 8.06 12.35 Technical (Hospital) Services HC/HH Wch Supp Tube Trach Uncuffed 3.0__86223 PX-2725000127 CDM 2725000127 LOCAL 272 RC outpatient 13 13 HEALTHPARTNERS SX009 HEALTHPARTNERS 10.4 percent of total billed charges 8.06 12.35 Technical (Hospital) Services HC/HH Wch Supp Tube Trach Uncuffed 3.0__86223 PX-2725000127 CDM 2725000127 LOCAL 272 RC outpatient 13 13 CIGNA 62308 [3081051] CIGNA 62308 [308105105] 10.4 percent of total billed charges 8.06 12.35 Technical (Hospital) Services HC/HH Wch Supp Tube Trach Uncuffed 3.0__86223 PX-2725000127 CDM 2725000127 LOCAL 272 RC outpatient 13 13 CIGNA 62308 [3081051] CIGNA STATE OF WYOMING [308105107] 10.4 percent of total billed charges 8.06 12.35 Technical (Hospital) Services HC/HH Wch Supp Tube Trach Uncuffed 3.0__86223 PX-2725000127 CDM 2725000127 LOCAL 272 RC outpatient 13 13 MEDICA (COMMERCIAL) 94265 [3081118] MEDICA CLAIMS [308111801] 11.7 percent of total billed charges 8.06 12.35 Technical (Hospital) Services HC/HH Wch Supp Tube Trach Uncuffed 3.0__86223 PX-2725000127 CDM 2725000127 LOCAL 272 RC outpatient 13 13 MULTIPLAN INC 34080 [3081285] MULTIPLAN INC [308128501] 12.35 percent of total billed charges 8.06 12.35 Technical (Hospital) Services HC/HH Wch Supp Tube Trach Uncuffed 2.5__86222 PX-2725000126 CDM 2725000126 LOCAL 272 RC inpatient 9 9 UNITED HEALTHCARE (COMMERCIAL) [3081199] UNITED HEALTHCARE 87726 [308119901] 5.58 percent of total billed charges 5.58 8.55 Technical (Hospital) Services HC/HH Wch Supp Tube Trach Uncuffed 2.5__86222 PX-2725000126 CDM 2725000126 LOCAL 272 RC inpatient 9 9 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES HDHP [308136802] 7.13 percent of total billed charges 5.58 8.55 Technical (Hospital) Services HC/HH Wch Supp Tube Trach Uncuffed 2.5__86222 PX-2725000126 CDM 2725000126 LOCAL 272 RC inpatient 9 9 CIGNA 62308 [3081051] CIGNA 62308 [308105105] 7.13 percent of total billed charges 5.58 8.55 Technical (Hospital) Services HC/HH Wch Supp Tube Trach Uncuffed 2.5__86222 PX-2725000126 CDM 2725000126 LOCAL 272 RC inpatient 9 9 CIGNA 62308 [3081051] CIGNA STATE OF WYOMING [308105107] 7.13 percent of total billed charges 5.58 8.55 Technical (Hospital) Services HC/HH Wch Supp Tube Trach Uncuffed 2.5__86222 PX-2725000126 CDM 2725000126 LOCAL 272 RC inpatient 9 9 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES PPO [308136801] 7.13 percent of total billed charges 5.58 8.55 Technical (Hospital) Services HC/HH Wch Supp Tube Trach Uncuffed 2.5__86222 PX-2725000126 CDM 2725000126 LOCAL 272 RC inpatient 9 9 MEDICA (COMMERCIAL) 94265 [3081118] MEDICA CLAIMS [308111801] 8.1 percent of total billed charges 5.58 8.55 Technical (Hospital) Services HC/HH Wch Supp Tube Trach Uncuffed 2.5__86222 PX-2725000126 CDM 2725000126 LOCAL 272 RC inpatient 9 9 MULTIPLAN INC 34080 [3081285] MULTIPLAN INC [308128501] 8.55 percent of total billed charges 5.58 8.55 Technical (Hospital) Services HC/HH Wch Supp Tube Trach Uncuffed 2.5__86222 PX-2725000126 CDM 2725000126 LOCAL 272 RC inpatient 9 9 BLUE CROSS BLUE SHIELD WELLMARK SB889 [3081026] BCBS WYOMING [308102603] 8.55 percent of total billed charges 5.58 8.55 Technical (Hospital) Services HC/HH Wch Supp Tube Trach Uncuffed 2.5__86222 PX-2725000126 CDM 2725000126 LOCAL 272 RC inpatient 9 9 HEALTHPARTNERS SX009 HEALTHPARTNERS 7.13 percent of total billed charges 5.58 8.55 Technical (Hospital) Services HC/HH Wch Supp Tube Trach Uncuffed 2.5__86222 PX-2725000126 CDM 2725000126 LOCAL 272 RC inpatient 9 9 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES EPO [308136803] 7.13 percent of total billed charges 5.58 8.55 Technical (Hospital) Services HC/HH Wch Supp Tube Trach Uncuffed 2.5__86222 PX-2725000126 CDM 2725000126 LOCAL 272 RC outpatient 9 9 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES EPO [308136803] 7.2 percent of total billed charges 5.58 8.55 Technical (Hospital) Services HC/HH Wch Supp Tube Trach Uncuffed 2.5__86222 PX-2725000126 CDM 2725000126 LOCAL 272 RC outpatient 9 9 BLUE CROSS BLUE SHIELD WELLMARK SB889 [3081026] BCBS WYOMING [308102603] 8.55 percent of total billed charges 5.58 8.55 Technical (Hospital) Services HC/HH Wch Supp Tube Trach Uncuffed 2.5__86222 PX-2725000126 CDM 2725000126 LOCAL 272 RC outpatient 9 9 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES HDHP [308136802] 7.2 percent of total billed charges 5.58 8.55 Technical (Hospital) Services HC/HH Wch Supp Tube Trach Uncuffed 2.5__86222 PX-2725000126 CDM 2725000126 LOCAL 272 RC outpatient 9 9 UNITED HEALTHCARE (COMMERCIAL) [3081199] UNITED HEALTHCARE 87726 [308119901] 5.58 percent of total billed charges 5.58 8.55 Technical (Hospital) Services HC/HH Wch Supp Tube Trach Uncuffed 2.5__86222 PX-2725000126 CDM 2725000126 LOCAL 272 RC outpatient 9 9 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES PPO [308136801] 7.2 percent of total billed charges 5.58 8.55 Technical (Hospital) Services HC/HH Wch Supp Tube Trach Uncuffed 2.5__86222 PX-2725000126 CDM 2725000126 LOCAL 272 RC outpatient 9 9 HEALTHPARTNERS SX009 HEALTHPARTNERS 7.2 percent of total billed charges 5.58 8.55 Technical (Hospital) Services HC/HH Wch Supp Tube Trach Uncuffed 2.5__86222 PX-2725000126 CDM 2725000126 LOCAL 272 RC outpatient 9 9 CIGNA 62308 [3081051] CIGNA 62308 [308105105] 7.2 percent of total billed charges 5.58 8.55 Technical (Hospital) Services HC/HH Wch Supp Tube Trach Uncuffed 2.5__86222 PX-2725000126 CDM 2725000126 LOCAL 272 RC outpatient 9 9 CIGNA 62308 [3081051] CIGNA STATE OF WYOMING [308105107] 7.2 percent of total billed charges 5.58 8.55 Technical (Hospital) Services HC/HH Wch Supp Tube Trach Uncuffed 2.5__86222 PX-2725000126 CDM 2725000126 LOCAL 272 RC outpatient 9 9 MULTIPLAN INC 34080 [3081285] MULTIPLAN INC [308128501] 8.55 percent of total billed charges 5.58 8.55 Technical (Hospital) Services HC/HH Wch Supp Tube Trach Uncuffed 2.5__86222 PX-2725000126 CDM 2725000126 LOCAL 272 RC outpatient 9 9 MEDICA (COMMERCIAL) 94265 [3081118] MEDICA CLAIMS [308111801] 8.1 percent of total billed charges 5.58 8.55 Technical (Hospital) Services HC/HH Wch Supp Tube Trach Lo-Pro 9mm__86055 PX-2725000125 CDM 2725000125 LOCAL 272 RC inpatient 33 33 HEALTHPARTNERS SX009 HEALTHPARTNERS 26.13 percent of total billed charges 20.46 31.35 Technical (Hospital) Services HC/HH Wch Supp Tube Trach Lo-Pro 9mm__86055 PX-2725000125 CDM 2725000125 LOCAL 272 RC inpatient 33 33 BLUE CROSS BLUE SHIELD WELLMARK SB889 [3081026] BCBS WYOMING [308102603] 31.35 percent of total billed charges 20.46 31.35 Technical (Hospital) Services HC/HH Wch Supp Tube Trach Lo-Pro 9mm__86055 PX-2725000125 CDM 2725000125 LOCAL 272 RC inpatient 33 33 MULTIPLAN INC 34080 [3081285] MULTIPLAN INC [308128501] 31.35 percent of total billed charges 20.46 31.35 Technical (Hospital) Services HC/HH Wch Supp Tube Trach Lo-Pro 9mm__86055 PX-2725000125 CDM 2725000125 LOCAL 272 RC inpatient 33 33 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES EPO [308136803] 26.13 percent of total billed charges 20.46 31.35 Technical (Hospital) Services HC/HH Wch Supp Tube Trach Lo-Pro 9mm__86055 PX-2725000125 CDM 2725000125 LOCAL 272 RC inpatient 33 33 UNITED HEALTHCARE (COMMERCIAL) [3081199] UNITED HEALTHCARE 87726 [308119901] 20.46 percent of total billed charges 20.46 31.35 Technical (Hospital) Services HC/HH Wch Supp Tube Trach Lo-Pro 9mm__86055 PX-2725000125 CDM 2725000125 LOCAL 272 RC inpatient 33 33 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES HDHP [308136802] 26.13 percent of total billed charges 20.46 31.35 Technical (Hospital) Services HC/HH Wch Supp Tube Trach Lo-Pro 9mm__86055 PX-2725000125 CDM 2725000125 LOCAL 272 RC inpatient 33 33 CIGNA 62308 [3081051] CIGNA 62308 [308105105] 26.13 percent of total billed charges 20.46 31.35 Technical (Hospital) Services HC/HH Wch Supp Tube Trach Lo-Pro 9mm__86055 PX-2725000125 CDM 2725000125 LOCAL 272 RC inpatient 33 33 CIGNA 62308 [3081051] CIGNA STATE OF WYOMING [308105107] 26.13 percent of total billed charges 20.46 31.35 Technical (Hospital) Services HC/HH Wch Supp Tube Trach Lo-Pro 9mm__86055 PX-2725000125 CDM 2725000125 LOCAL 272 RC inpatient 33 33 MEDICA (COMMERCIAL) 94265 [3081118] MEDICA CLAIMS [308111801] 29.7 percent of total billed charges 20.46 31.35 Technical (Hospital) Services HC/HH Wch Supp Tube Trach Lo-Pro 9mm__86055 PX-2725000125 CDM 2725000125 LOCAL 272 RC inpatient 33 33 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES PPO [308136801] 26.13 percent of total billed charges 20.46 31.35 Technical (Hospital) Services HC/HH Wch Supp Tube Trach Lo-Pro 9mm__86055 PX-2725000125 CDM 2725000125 LOCAL 272 RC outpatient 33 33 HEALTHPARTNERS SX009 HEALTHPARTNERS 26.4 percent of total billed charges 20.46 31.35 Technical (Hospital) Services HC/HH Wch Supp Tube Trach Lo-Pro 9mm__86055 PX-2725000125 CDM 2725000125 LOCAL 272 RC outpatient 33 33 UNITED HEALTHCARE (COMMERCIAL) [3081199] UNITED HEALTHCARE 87726 [308119901] 20.46 percent of total billed charges 20.46 31.35 Technical (Hospital) Services HC/HH Wch Supp Tube Trach Lo-Pro 9mm__86055 PX-2725000125 CDM 2725000125 LOCAL 272 RC outpatient 33 33 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES PPO [308136801] 26.4 percent of total billed charges 20.46 31.35 Technical (Hospital) Services HC/HH Wch Supp Tube Trach Lo-Pro 9mm__86055 PX-2725000125 CDM 2725000125 LOCAL 272 RC outpatient 33 33 MULTIPLAN INC 34080 [3081285] MULTIPLAN INC [308128501] 31.35 percent of total billed charges 20.46 31.35 Technical (Hospital) Services HC/HH Wch Supp Tube Trach Lo-Pro 9mm__86055 PX-2725000125 CDM 2725000125 LOCAL 272 RC outpatient 33 33 MEDICA (COMMERCIAL) 94265 [3081118] MEDICA CLAIMS [308111801] 29.7 percent of total billed charges 20.46 31.35 Technical (Hospital) Services HC/HH Wch Supp Tube Trach Lo-Pro 9mm__86055 PX-2725000125 CDM 2725000125 LOCAL 272 RC outpatient 33 33 CIGNA 62308 [3081051] CIGNA 62308 [308105105] 26.4 percent of total billed charges 20.46 31.35 Technical (Hospital) Services HC/HH Wch Supp Tube Trach Lo-Pro 9mm__86055 PX-2725000125 CDM 2725000125 LOCAL 272 RC outpatient 33 33 CIGNA 62308 [3081051] CIGNA STATE OF WYOMING [308105107] 26.4 percent of total billed charges 20.46 31.35 Technical (Hospital) Services HC/HH Wch Supp Tube Trach Lo-Pro 9mm__86055 PX-2725000125 CDM 2725000125 LOCAL 272 RC outpatient 33 33 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES HDHP [308136802] 26.4 percent of total billed charges 20.46 31.35 Technical (Hospital) Services HC/HH Wch Supp Tube Trach Lo-Pro 9mm__86055 PX-2725000125 CDM 2725000125 LOCAL 272 RC outpatient 33 33 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES EPO [308136803] 26.4 percent of total billed charges 20.46 31.35 Technical (Hospital) Services HC/HH Wch Supp Tube Trach Lo-Pro 9mm__86055 PX-2725000125 CDM 2725000125 LOCAL 272 RC outpatient 33 33 BLUE CROSS BLUE SHIELD WELLMARK SB889 [3081026] BCBS WYOMING [308102603] 31.35 percent of total billed charges 20.46 31.35 Technical (Hospital) Services HC/HH Wch Supp Tube Trach Lo-Pro 8.5mm__86054 PX-2725000124 CDM 2725000124 LOCAL 272 RC outpatient 33 33 BLUE CROSS BLUE SHIELD WELLMARK SB889 [3081026] BCBS WYOMING [308102603] 31.35 percent of total billed charges 20.46 31.35 Technical (Hospital) Services HC/HH Wch Supp Tube Trach Lo-Pro 8.5mm__86054 PX-2725000124 CDM 2725000124 LOCAL 272 RC outpatient 33 33 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES EPO [308136803] 26.4 percent of total billed charges 20.46 31.35 Technical (Hospital) Services HC/HH Wch Supp Tube Trach Lo-Pro 8.5mm__86054 PX-2725000124 CDM 2725000124 LOCAL 272 RC outpatient 33 33 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES HDHP [308136802] 26.4 percent of total billed charges 20.46 31.35 Technical (Hospital) Services HC/HH Wch Supp Tube Trach Lo-Pro 8.5mm__86054 PX-2725000124 CDM 2725000124 LOCAL 272 RC outpatient 33 33 UNITED HEALTHCARE (COMMERCIAL) [3081199] UNITED HEALTHCARE 87726 [308119901] 20.46 percent of total billed charges 20.46 31.35 Technical (Hospital) Services HC/HH Wch Supp Tube Trach Lo-Pro 8.5mm__86054 PX-2725000124 CDM 2725000124 LOCAL 272 RC outpatient 33 33 HEALTHPARTNERS SX009 HEALTHPARTNERS 26.4 percent of total billed charges 20.46 31.35 Technical (Hospital) Services HC/HH Wch Supp Tube Trach Lo-Pro 8.5mm__86054 PX-2725000124 CDM 2725000124 LOCAL 272 RC outpatient 33 33 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES PPO [308136801] 26.4 percent of total billed charges 20.46 31.35 Technical (Hospital) Services HC/HH Wch Supp Tube Trach Lo-Pro 8.5mm__86054 PX-2725000124 CDM 2725000124 LOCAL 272 RC outpatient 33 33 CIGNA 62308 [3081051] CIGNA 62308 [308105105] 26.4 percent of total billed charges 20.46 31.35 Technical (Hospital) Services HC/HH Wch Supp Tube Trach Lo-Pro 8.5mm__86054 PX-2725000124 CDM 2725000124 LOCAL 272 RC outpatient 33 33 CIGNA 62308 [3081051] CIGNA STATE OF WYOMING [308105107] 26.4 percent of total billed charges 20.46 31.35 Technical (Hospital) Services HC/HH Wch Supp Tube Trach Lo-Pro 8.5mm__86054 PX-2725000124 CDM 2725000124 LOCAL 272 RC outpatient 33 33 MEDICA (COMMERCIAL) 94265 [3081118] MEDICA CLAIMS [308111801] 29.7 percent of total billed charges 20.46 31.35 Technical (Hospital) Services HC/HH Wch Supp Tube Trach Lo-Pro 8.5mm__86054 PX-2725000124 CDM 2725000124 LOCAL 272 RC outpatient 33 33 MULTIPLAN INC 34080 [3081285] MULTIPLAN INC [308128501] 31.35 percent of total billed charges 20.46 31.35 Technical (Hospital) Services HC/HH Wch Supp Tube Trach Lo-Pro 8.5mm__86054 PX-2725000124 CDM 2725000124 LOCAL 272 RC inpatient 33 33 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES PPO [308136801] 26.13 percent of total billed charges 20.46 31.35 Technical (Hospital) Services HC/HH Wch Supp Tube Trach Lo-Pro 8.5mm__86054 PX-2725000124 CDM 2725000124 LOCAL 272 RC inpatient 33 33 MEDICA (COMMERCIAL) 94265 [3081118] MEDICA CLAIMS [308111801] 29.7 percent of total billed charges 20.46 31.35 Technical (Hospital) Services HC/HH Wch Supp Tube Trach Lo-Pro 8.5mm__86054 PX-2725000124 CDM 2725000124 LOCAL 272 RC inpatient 33 33 CIGNA 62308 [3081051] CIGNA 62308 [308105105] 26.13 percent of total billed charges 20.46 31.35 Technical (Hospital) Services HC/HH Wch Supp Tube Trach Lo-Pro 8.5mm__86054 PX-2725000124 CDM 2725000124 LOCAL 272 RC inpatient 33 33 CIGNA 62308 [3081051] CIGNA STATE OF WYOMING [308105107] 26.13 percent of total billed charges 20.46 31.35 Technical (Hospital) Services HC/HH Wch Supp Tube Trach Lo-Pro 8.5mm__86054 PX-2725000124 CDM 2725000124 LOCAL 272 RC inpatient 33 33 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES HDHP [308136802] 26.13 percent of total billed charges 20.46 31.35 Technical (Hospital) Services HC/HH Wch Supp Tube Trach Lo-Pro 8.5mm__86054 PX-2725000124 CDM 2725000124 LOCAL 272 RC inpatient 33 33 UNITED HEALTHCARE (COMMERCIAL) [3081199] UNITED HEALTHCARE 87726 [308119901] 20.46 percent of total billed charges 20.46 31.35 Technical (Hospital) Services HC/HH Wch Supp Tube Trach Lo-Pro 8.5mm__86054 PX-2725000124 CDM 2725000124 LOCAL 272 RC inpatient 33 33 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES EPO [308136803] 26.13 percent of total billed charges 20.46 31.35 Technical (Hospital) Services HC/HH Wch Supp Tube Trach Lo-Pro 8.5mm__86054 PX-2725000124 CDM 2725000124 LOCAL 272 RC inpatient 33 33 MULTIPLAN INC 34080 [3081285] MULTIPLAN INC [308128501] 31.35 percent of total billed charges 20.46 31.35 Technical (Hospital) Services HC/HH Wch Supp Tube Trach Lo-Pro 8.5mm__86054 PX-2725000124 CDM 2725000124 LOCAL 272 RC inpatient 33 33 BLUE CROSS BLUE SHIELD WELLMARK SB889 [3081026] BCBS WYOMING [308102603] 31.35 percent of total billed charges 20.46 31.35 Technical (Hospital) Services HC/HH Wch Supp Tube Trach Lo-Pro 8.5mm__86054 PX-2725000124 CDM 2725000124 LOCAL 272 RC inpatient 33 33 HEALTHPARTNERS SX009 HEALTHPARTNERS 26.13 percent of total billed charges 20.46 31.35 Technical (Hospital) Services HC/HH Wch Supp Tube Trach Lo-Pro 6mm__86049 PX-2725000123 CDM 2725000123 LOCAL 272 RC outpatient 33 33 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES HDHP [308136802] 26.4 percent of total billed charges 20.46 31.35 Technical (Hospital) Services HC/HH Wch Supp Tube Trach Lo-Pro 6mm__86049 PX-2725000123 CDM 2725000123 LOCAL 272 RC outpatient 33 33 BLUE CROSS BLUE SHIELD WELLMARK SB889 [3081026] BCBS WYOMING [308102603] 31.35 percent of total billed charges 20.46 31.35 Technical (Hospital) Services HC/HH Wch Supp Tube Trach Lo-Pro 6mm__86049 PX-2725000123 CDM 2725000123 LOCAL 272 RC outpatient 33 33 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES EPO [308136803] 26.4 percent of total billed charges 20.46 31.35 Technical (Hospital) Services HC/HH Wch Supp Tube Trach Lo-Pro 6mm__86049 PX-2725000123 CDM 2725000123 LOCAL 272 RC outpatient 33 33 CIGNA 62308 [3081051] CIGNA 62308 [308105105] 26.4 percent of total billed charges 20.46 31.35 Technical (Hospital) Services HC/HH Wch Supp Tube Trach Lo-Pro 6mm__86049 PX-2725000123 CDM 2725000123 LOCAL 272 RC outpatient 33 33 CIGNA 62308 [3081051] CIGNA STATE OF WYOMING [308105107] 26.4 percent of total billed charges 20.46 31.35 Technical (Hospital) Services HC/HH Wch Supp Tube Trach Lo-Pro 6mm__86049 PX-2725000123 CDM 2725000123 LOCAL 272 RC outpatient 33 33 UNITED HEALTHCARE (COMMERCIAL) [3081199] UNITED HEALTHCARE 87726 [308119901] 20.46 percent of total billed charges 20.46 31.35 Technical (Hospital) Services HC/HH Wch Supp Tube Trach Lo-Pro 6mm__86049 PX-2725000123 CDM 2725000123 LOCAL 272 RC outpatient 33 33 HEALTHPARTNERS SX009 HEALTHPARTNERS 26.4 percent of total billed charges 20.46 31.35 Technical (Hospital) Services HC/HH Wch Supp Tube Trach Lo-Pro 6mm__86049 PX-2725000123 CDM 2725000123 LOCAL 272 RC outpatient 33 33 MULTIPLAN INC 34080 [3081285] MULTIPLAN INC [308128501] 31.35 percent of total billed charges 20.46 31.35 Technical (Hospital) Services HC/HH Wch Supp Tube Trach Lo-Pro 6mm__86049 PX-2725000123 CDM 2725000123 LOCAL 272 RC outpatient 33 33 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES PPO [308136801] 26.4 percent of total billed charges 20.46 31.35 Technical (Hospital) Services HC/HH Wch Supp Tube Trach Lo-Pro 6mm__86049 PX-2725000123 CDM 2725000123 LOCAL 272 RC outpatient 33 33 MEDICA (COMMERCIAL) 94265 [3081118] MEDICA CLAIMS [308111801] 29.7 percent of total billed charges 20.46 31.35 Technical (Hospital) Services HC/HH Wch Supp Tube Trach Lo-Pro 6mm__86049 PX-2725000123 CDM 2725000123 LOCAL 272 RC inpatient 33 33 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES PPO [308136801] 26.13 percent of total billed charges 20.46 31.35 Technical (Hospital) Services HC/HH Wch Supp Tube Trach Lo-Pro 6mm__86049 PX-2725000123 CDM 2725000123 LOCAL 272 RC inpatient 33 33 MEDICA (COMMERCIAL) 94265 [3081118] MEDICA CLAIMS [308111801] 29.7 percent of total billed charges 20.46 31.35 Technical (Hospital) Services HC/HH Wch Supp Tube Trach Lo-Pro 6mm__86049 PX-2725000123 CDM 2725000123 LOCAL 272 RC inpatient 33 33 UNITED HEALTHCARE (COMMERCIAL) [3081199] UNITED HEALTHCARE 87726 [308119901] 20.46 percent of total billed charges 20.46 31.35 Technical (Hospital) Services HC/HH Wch Supp Tube Trach Lo-Pro 6mm__86049 PX-2725000123 CDM 2725000123 LOCAL 272 RC inpatient 33 33 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES HDHP [308136802] 26.13 percent of total billed charges 20.46 31.35 Technical (Hospital) Services HC/HH Wch Supp Tube Trach Lo-Pro 6mm__86049 PX-2725000123 CDM 2725000123 LOCAL 272 RC inpatient 33 33 CIGNA 62308 [3081051] CIGNA 62308 [308105105] 26.13 percent of total billed charges 20.46 31.35 Technical (Hospital) Services HC/HH Wch Supp Tube Trach Lo-Pro 6mm__86049 PX-2725000123 CDM 2725000123 LOCAL 272 RC inpatient 33 33 CIGNA 62308 [3081051] CIGNA STATE OF WYOMING [308105107] 26.13 percent of total billed charges 20.46 31.35 Technical (Hospital) Services HC/HH Wch Supp Tube Trach Lo-Pro 6mm__86049 PX-2725000123 CDM 2725000123 LOCAL 272 RC inpatient 33 33 BLUE CROSS BLUE SHIELD WELLMARK SB889 [3081026] BCBS WYOMING [308102603] 31.35 percent of total billed charges 20.46 31.35 Technical (Hospital) Services HC/HH Wch Supp Tube Trach Lo-Pro 6mm__86049 PX-2725000123 CDM 2725000123 LOCAL 272 RC inpatient 33 33 MULTIPLAN INC 34080 [3081285] MULTIPLAN INC [308128501] 31.35 percent of total billed charges 20.46 31.35 Technical (Hospital) Services HC/HH Wch Supp Tube Trach Lo-Pro 6mm__86049 PX-2725000123 CDM 2725000123 LOCAL 272 RC inpatient 33 33 HEALTHPARTNERS SX009 HEALTHPARTNERS 26.13 percent of total billed charges 20.46 31.35 Technical (Hospital) Services HC/HH Wch Supp Tube Trach Lo-Pro 6mm__86049 PX-2725000123 CDM 2725000123 LOCAL 272 RC inpatient 33 33 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES EPO [308136803] 26.13 percent of total billed charges 20.46 31.35 Technical (Hospital) Services HC/HH Wch Supp Tube Trach Lo-Pro 5mm__86047 PX-2725000122 CDM 2725000122 LOCAL 272 RC inpatient 33 33 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES HDHP [308136802] 26.13 percent of total billed charges 20.46 31.35 Technical (Hospital) Services HC/HH Wch Supp Tube Trach Lo-Pro 5mm__86047 PX-2725000122 CDM 2725000122 LOCAL 272 RC inpatient 33 33 UNITED HEALTHCARE (COMMERCIAL) [3081199] UNITED HEALTHCARE 87726 [308119901] 20.46 percent of total billed charges 20.46 31.35 Technical (Hospital) Services HC/HH Wch Supp Tube Trach Lo-Pro 5mm__86047 PX-2725000122 CDM 2725000122 LOCAL 272 RC inpatient 33 33 CIGNA 62308 [3081051] CIGNA 62308 [308105105] 26.13 percent of total billed charges 20.46 31.35 Technical (Hospital) Services HC/HH Wch Supp Tube Trach Lo-Pro 5mm__86047 PX-2725000122 CDM 2725000122 LOCAL 272 RC inpatient 33 33 CIGNA 62308 [3081051] CIGNA STATE OF WYOMING [308105107] 26.13 percent of total billed charges 20.46 31.35 Technical (Hospital) Services HC/HH Wch Supp Tube Trach Lo-Pro 5mm__86047 PX-2725000122 CDM 2725000122 LOCAL 272 RC inpatient 33 33 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES PPO [308136801] 26.13 percent of total billed charges 20.46 31.35 Technical (Hospital) Services HC/HH Wch Supp Tube Trach Lo-Pro 5mm__86047 PX-2725000122 CDM 2725000122 LOCAL 272 RC inpatient 33 33 MEDICA (COMMERCIAL) 94265 [3081118] MEDICA CLAIMS [308111801] 29.7 percent of total billed charges 20.46 31.35 Technical (Hospital) Services HC/HH Wch Supp Tube Trach Lo-Pro 5mm__86047 PX-2725000122 CDM 2725000122 LOCAL 272 RC inpatient 33 33 BLUE CROSS BLUE SHIELD WELLMARK SB889 [3081026] BCBS WYOMING [308102603] 31.35 percent of total billed charges 20.46 31.35 Technical (Hospital) Services HC/HH Wch Supp Tube Trach Lo-Pro 5mm__86047 PX-2725000122 CDM 2725000122 LOCAL 272 RC inpatient 33 33 MULTIPLAN INC 34080 [3081285] MULTIPLAN INC [308128501] 31.35 percent of total billed charges 20.46 31.35 Technical (Hospital) Services HC/HH Wch Supp Tube Trach Lo-Pro 5mm__86047 PX-2725000122 CDM 2725000122 LOCAL 272 RC inpatient 33 33 HEALTHPARTNERS SX009 HEALTHPARTNERS 26.13 percent of total billed charges 20.46 31.35 Technical (Hospital) Services HC/HH Wch Supp Tube Trach Lo-Pro 5mm__86047 PX-2725000122 CDM 2725000122 LOCAL 272 RC inpatient 33 33 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES EPO [308136803] 26.13 percent of total billed charges 20.46 31.35 Technical (Hospital) Services HC/HH Wch Supp Tube Trach Lo-Pro 5mm__86047 PX-2725000122 CDM 2725000122 LOCAL 272 RC outpatient 33 33 CIGNA 62308 [3081051] CIGNA 62308 [308105105] 26.4 percent of total billed charges 20.46 31.35 Technical (Hospital) Services HC/HH Wch Supp Tube Trach Lo-Pro 5mm__86047 PX-2725000122 CDM 2725000122 LOCAL 272 RC outpatient 33 33 CIGNA 62308 [3081051] CIGNA STATE OF WYOMING [308105107] 26.4 percent of total billed charges 20.46 31.35 Technical (Hospital) Services HC/HH Wch Supp Tube Trach Lo-Pro 5mm__86047 PX-2725000122 CDM 2725000122 LOCAL 272 RC outpatient 33 33 UNITED HEALTHCARE (COMMERCIAL) [3081199] UNITED HEALTHCARE 87726 [308119901] 20.46 percent of total billed charges 20.46 31.35 Technical (Hospital) Services HC/HH Wch Supp Tube Trach Lo-Pro 5mm__86047 PX-2725000122 CDM 2725000122 LOCAL 272 RC outpatient 33 33 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES HDHP [308136802] 26.4 percent of total billed charges 20.46 31.35 Technical (Hospital) Services HC/HH Wch Supp Tube Trach Lo-Pro 5mm__86047 PX-2725000122 CDM 2725000122 LOCAL 272 RC outpatient 33 33 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES EPO [308136803] 26.4 percent of total billed charges 20.46 31.35 Technical (Hospital) Services HC/HH Wch Supp Tube Trach Lo-Pro 5mm__86047 PX-2725000122 CDM 2725000122 LOCAL 272 RC outpatient 33 33 BLUE CROSS BLUE SHIELD WELLMARK SB889 [3081026] BCBS WYOMING [308102603] 31.35 percent of total billed charges 20.46 31.35 Technical (Hospital) Services HC/HH Wch Supp Tube Trach Lo-Pro 5mm__86047 PX-2725000122 CDM 2725000122 LOCAL 272 RC outpatient 33 33 MULTIPLAN INC 34080 [3081285] MULTIPLAN INC [308128501] 31.35 percent of total billed charges 20.46 31.35 Technical (Hospital) Services HC/HH Wch Supp Tube Trach Lo-Pro 5mm__86047 PX-2725000122 CDM 2725000122 LOCAL 272 RC outpatient 33 33 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES PPO [308136801] 26.4 percent of total billed charges 20.46 31.35 Technical (Hospital) Services HC/HH Wch Supp Tube Trach Lo-Pro 5mm__86047 PX-2725000122 CDM 2725000122 LOCAL 272 RC outpatient 33 33 HEALTHPARTNERS SX009 HEALTHPARTNERS 26.4 percent of total billed charges 20.46 31.35 Technical (Hospital) Services HC/HH Wch Supp Tube Trach Lo-Pro 5mm__86047 PX-2725000122 CDM 2725000122 LOCAL 272 RC outpatient 33 33 MEDICA (COMMERCIAL) 94265 [3081118] MEDICA CLAIMS [308111801] 29.7 percent of total billed charges 20.46 31.35 Technical (Hospital) Services HC/HH Wch Supp Tube Trach Lo-Pro 5.5mm__86048 PX-2725000121 CDM 2725000121 LOCAL 272 RC outpatient 33 33 MULTIPLAN INC 34080 [3081285] MULTIPLAN INC [308128501] 31.35 percent of total billed charges 20.46 31.35 Technical (Hospital) Services HC/HH Wch Supp Tube Trach Lo-Pro 5.5mm__86048 PX-2725000121 CDM 2725000121 LOCAL 272 RC outpatient 33 33 MEDICA (COMMERCIAL) 94265 [3081118] MEDICA CLAIMS [308111801] 29.7 percent of total billed charges 20.46 31.35 Technical (Hospital) Services HC/HH Wch Supp Tube Trach Lo-Pro 5.5mm__86048 PX-2725000121 CDM 2725000121 LOCAL 272 RC outpatient 33 33 CIGNA 62308 [3081051] CIGNA 62308 [308105105] 26.4 percent of total billed charges 20.46 31.35 Technical (Hospital) Services HC/HH Wch Supp Tube Trach Lo-Pro 5.5mm__86048 PX-2725000121 CDM 2725000121 LOCAL 272 RC outpatient 33 33 CIGNA 62308 [3081051] CIGNA STATE OF WYOMING [308105107] 26.4 percent of total billed charges 20.46 31.35 Technical (Hospital) Services HC/HH Wch Supp Tube Trach Lo-Pro 5.5mm__86048 PX-2725000121 CDM 2725000121 LOCAL 272 RC outpatient 33 33 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES PPO [308136801] 26.4 percent of total billed charges 20.46 31.35 Technical (Hospital) Services HC/HH Wch Supp Tube Trach Lo-Pro 5.5mm__86048 PX-2725000121 CDM 2725000121 LOCAL 272 RC outpatient 33 33 HEALTHPARTNERS SX009 HEALTHPARTNERS 26.4 percent of total billed charges 20.46 31.35 Technical (Hospital) Services HC/HH Wch Supp Tube Trach Lo-Pro 5.5mm__86048 PX-2725000121 CDM 2725000121 LOCAL 272 RC outpatient 33 33 UNITED HEALTHCARE (COMMERCIAL) [3081199] UNITED HEALTHCARE 87726 [308119901] 20.46 percent of total billed charges 20.46 31.35 Technical (Hospital) Services HC/HH Wch Supp Tube Trach Lo-Pro 5.5mm__86048 PX-2725000121 CDM 2725000121 LOCAL 272 RC outpatient 33 33 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES HDHP [308136802] 26.4 percent of total billed charges 20.46 31.35 Technical (Hospital) Services HC/HH Wch Supp Tube Trach Lo-Pro 5.5mm__86048 PX-2725000121 CDM 2725000121 LOCAL 272 RC outpatient 33 33 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES EPO [308136803] 26.4 percent of total billed charges 20.46 31.35 Technical (Hospital) Services HC/HH Wch Supp Tube Trach Lo-Pro 5.5mm__86048 PX-2725000121 CDM 2725000121 LOCAL 272 RC outpatient 33 33 BLUE CROSS BLUE SHIELD WELLMARK SB889 [3081026] BCBS WYOMING [308102603] 31.35 percent of total billed charges 20.46 31.35 Technical (Hospital) Services HC/HH Wch Supp Tube Trach Lo-Pro 5.5mm__86048 PX-2725000121 CDM 2725000121 LOCAL 272 RC inpatient 33 33 BLUE CROSS BLUE SHIELD WELLMARK SB889 [3081026] BCBS WYOMING [308102603] 31.35 percent of total billed charges 20.46 31.35 Technical (Hospital) Services HC/HH Wch Supp Tube Trach Lo-Pro 5.5mm__86048 PX-2725000121 CDM 2725000121 LOCAL 272 RC inpatient 33 33 MULTIPLAN INC 34080 [3081285] MULTIPLAN INC [308128501] 31.35 percent of total billed charges 20.46 31.35 Technical (Hospital) Services HC/HH Wch Supp Tube Trach Lo-Pro 5.5mm__86048 PX-2725000121 CDM 2725000121 LOCAL 272 RC inpatient 33 33 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES EPO [308136803] 26.13 percent of total billed charges 20.46 31.35 Technical (Hospital) Services HC/HH Wch Supp Tube Trach Lo-Pro 5.5mm__86048 PX-2725000121 CDM 2725000121 LOCAL 272 RC inpatient 33 33 HEALTHPARTNERS SX009 HEALTHPARTNERS 26.13 percent of total billed charges 20.46 31.35 Technical (Hospital) Services HC/HH Wch Supp Tube Trach Lo-Pro 5.5mm__86048 PX-2725000121 CDM 2725000121 LOCAL 272 RC inpatient 33 33 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES PPO [308136801] 26.13 percent of total billed charges 20.46 31.35 Technical (Hospital) Services HC/HH Wch Supp Tube Trach Lo-Pro 5.5mm__86048 PX-2725000121 CDM 2725000121 LOCAL 272 RC inpatient 33 33 MEDICA (COMMERCIAL) 94265 [3081118] MEDICA CLAIMS [308111801] 29.7 percent of total billed charges 20.46 31.35 Technical (Hospital) Services HC/HH Wch Supp Tube Trach Lo-Pro 5.5mm__86048 PX-2725000121 CDM 2725000121 LOCAL 272 RC inpatient 33 33 CIGNA 62308 [3081051] CIGNA 62308 [308105105] 26.13 percent of total billed charges 20.46 31.35 Technical (Hospital) Services HC/HH Wch Supp Tube Trach Lo-Pro 5.5mm__86048 PX-2725000121 CDM 2725000121 LOCAL 272 RC inpatient 33 33 CIGNA 62308 [3081051] CIGNA STATE OF WYOMING [308105107] 26.13 percent of total billed charges 20.46 31.35 Technical (Hospital) Services HC/HH Wch Supp Tube Trach Lo-Pro 5.5mm__86048 PX-2725000121 CDM 2725000121 LOCAL 272 RC inpatient 33 33 UNITED HEALTHCARE (COMMERCIAL) [3081199] UNITED HEALTHCARE 87726 [308119901] 20.46 percent of total billed charges 20.46 31.35 Technical (Hospital) Services HC/HH Wch Supp Tube Trach Lo-Pro 5.5mm__86048 PX-2725000121 CDM 2725000121 LOCAL 272 RC inpatient 33 33 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES HDHP [308136802] 26.13 percent of total billed charges 20.46 31.35 Technical (Hospital) Services HC/HH Wch Supp Tube Trach Lo-Pro 4mm__86045 PX-2725000120 CDM 2725000120 LOCAL 272 RC inpatient 33 33 UNITED HEALTHCARE (COMMERCIAL) [3081199] UNITED HEALTHCARE 87726 [308119901] 20.46 percent of total billed charges 20.46 31.35 Technical (Hospital) Services HC/HH Wch Supp Tube Trach Lo-Pro 4mm__86045 PX-2725000120 CDM 2725000120 LOCAL 272 RC inpatient 33 33 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES HDHP [308136802] 26.13 percent of total billed charges 20.46 31.35 Technical (Hospital) Services HC/HH Wch Supp Tube Trach Lo-Pro 4mm__86045 PX-2725000120 CDM 2725000120 LOCAL 272 RC inpatient 33 33 CIGNA 62308 [3081051] CIGNA 62308 [308105105] 26.13 percent of total billed charges 20.46 31.35 Technical (Hospital) Services HC/HH Wch Supp Tube Trach Lo-Pro 4mm__86045 PX-2725000120 CDM 2725000120 LOCAL 272 RC inpatient 33 33 CIGNA 62308 [3081051] CIGNA STATE OF WYOMING [308105107] 26.13 percent of total billed charges 20.46 31.35 Technical (Hospital) Services HC/HH Wch Supp Tube Trach Lo-Pro 4mm__86045 PX-2725000120 CDM 2725000120 LOCAL 272 RC inpatient 33 33 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES PPO [308136801] 26.13 percent of total billed charges 20.46 31.35 Technical (Hospital) Services HC/HH Wch Supp Tube Trach Lo-Pro 4mm__86045 PX-2725000120 CDM 2725000120 LOCAL 272 RC inpatient 33 33 MEDICA (COMMERCIAL) 94265 [3081118] MEDICA CLAIMS [308111801] 29.7 percent of total billed charges 20.46 31.35 Technical (Hospital) Services HC/HH Wch Supp Tube Trach Lo-Pro 4mm__86045 PX-2725000120 CDM 2725000120 LOCAL 272 RC inpatient 33 33 BLUE CROSS BLUE SHIELD WELLMARK SB889 [3081026] BCBS WYOMING [308102603] 31.35 percent of total billed charges 20.46 31.35 Technical (Hospital) Services HC/HH Wch Supp Tube Trach Lo-Pro 4mm__86045 PX-2725000120 CDM 2725000120 LOCAL 272 RC inpatient 33 33 MULTIPLAN INC 34080 [3081285] MULTIPLAN INC [308128501] 31.35 percent of total billed charges 20.46 31.35 Technical (Hospital) Services HC/HH Wch Supp Tube Trach Lo-Pro 4mm__86045 PX-2725000120 CDM 2725000120 LOCAL 272 RC inpatient 33 33 HEALTHPARTNERS SX009 HEALTHPARTNERS 26.13 percent of total billed charges 20.46 31.35 Technical (Hospital) Services HC/HH Wch Supp Tube Trach Lo-Pro 4mm__86045 PX-2725000120 CDM 2725000120 LOCAL 272 RC inpatient 33 33 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES EPO [308136803] 26.13 percent of total billed charges 20.46 31.35 Technical (Hospital) Services HC/HH Wch Supp Tube Trach Lo-Pro 4mm__86045 PX-2725000120 CDM 2725000120 LOCAL 272 RC outpatient 33 33 CIGNA 62308 [3081051] CIGNA 62308 [308105105] 26.4 percent of total billed charges 20.46 31.35 Technical (Hospital) Services HC/HH Wch Supp Tube Trach Lo-Pro 4mm__86045 PX-2725000120 CDM 2725000120 LOCAL 272 RC outpatient 33 33 CIGNA 62308 [3081051] CIGNA STATE OF WYOMING [308105107] 26.4 percent of total billed charges 20.46 31.35 Technical (Hospital) Services HC/HH Wch Supp Tube Trach Lo-Pro 4mm__86045 PX-2725000120 CDM 2725000120 LOCAL 272 RC outpatient 33 33 UNITED HEALTHCARE (COMMERCIAL) [3081199] UNITED HEALTHCARE 87726 [308119901] 20.46 percent of total billed charges 20.46 31.35 Technical (Hospital) Services HC/HH Wch Supp Tube Trach Lo-Pro 4mm__86045 PX-2725000120 CDM 2725000120 LOCAL 272 RC outpatient 33 33 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES HDHP [308136802] 26.4 percent of total billed charges 20.46 31.35 Technical (Hospital) Services HC/HH Wch Supp Tube Trach Lo-Pro 4mm__86045 PX-2725000120 CDM 2725000120 LOCAL 272 RC outpatient 33 33 BLUE CROSS BLUE SHIELD WELLMARK SB889 [3081026] BCBS WYOMING [308102603] 31.35 percent of total billed charges 20.46 31.35 Technical (Hospital) Services HC/HH Wch Supp Tube Trach Lo-Pro 4mm__86045 PX-2725000120 CDM 2725000120 LOCAL 272 RC outpatient 33 33 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES EPO [308136803] 26.4 percent of total billed charges 20.46 31.35 Technical (Hospital) Services HC/HH Wch Supp Tube Trach Lo-Pro 4mm__86045 PX-2725000120 CDM 2725000120 LOCAL 272 RC outpatient 33 33 MEDICA (COMMERCIAL) 94265 [3081118] MEDICA CLAIMS [308111801] 29.7 percent of total billed charges 20.46 31.35 Technical (Hospital) Services HC/HH Wch Supp Tube Trach Lo-Pro 4mm__86045 PX-2725000120 CDM 2725000120 LOCAL 272 RC outpatient 33 33 HEALTHPARTNERS SX009 HEALTHPARTNERS 26.4 percent of total billed charges 20.46 31.35 Technical (Hospital) Services HC/HH Wch Supp Tube Trach Lo-Pro 4mm__86045 PX-2725000120 CDM 2725000120 LOCAL 272 RC outpatient 33 33 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES PPO [308136801] 26.4 percent of total billed charges 20.46 31.35 Technical (Hospital) Services HC/HH Wch Supp Tube Trach Lo-Pro 4mm__86045 PX-2725000120 CDM 2725000120 LOCAL 272 RC outpatient 33 33 MULTIPLAN INC 34080 [3081285] MULTIPLAN INC [308128501] 31.35 percent of total billed charges 20.46 31.35 Technical (Hospital) Services HC/HH Wch Supp Tube Trach Lo-Pro 3mm__86043 PX-2725000119 CDM 2725000119 LOCAL 272 RC outpatient 38 38 BLUE CROSS BLUE SHIELD WELLMARK SB889 [3081026] BCBS WYOMING [308102603] 36.1 percent of total billed charges 23.56 36.1 Technical (Hospital) Services HC/HH Wch Supp Tube Trach Lo-Pro 3mm__86043 PX-2725000119 CDM 2725000119 LOCAL 272 RC outpatient 38 38 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES EPO [308136803] 30.4 percent of total billed charges 23.56 36.1 Technical (Hospital) Services HC/HH Wch Supp Tube Trach Lo-Pro 3mm__86043 PX-2725000119 CDM 2725000119 LOCAL 272 RC outpatient 38 38 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES HDHP [308136802] 30.4 percent of total billed charges 23.56 36.1 Technical (Hospital) Services HC/HH Wch Supp Tube Trach Lo-Pro 3mm__86043 PX-2725000119 CDM 2725000119 LOCAL 272 RC outpatient 38 38 UNITED HEALTHCARE (COMMERCIAL) [3081199] UNITED HEALTHCARE 87726 [308119901] 23.56 percent of total billed charges 23.56 36.1 Technical (Hospital) Services HC/HH Wch Supp Tube Trach Lo-Pro 3mm__86043 PX-2725000119 CDM 2725000119 LOCAL 272 RC outpatient 38 38 HEALTHPARTNERS SX009 HEALTHPARTNERS 30.4 percent of total billed charges 23.56 36.1 Technical (Hospital) Services HC/HH Wch Supp Tube Trach Lo-Pro 3mm__86043 PX-2725000119 CDM 2725000119 LOCAL 272 RC outpatient 38 38 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES PPO [308136801] 30.4 percent of total billed charges 23.56 36.1 Technical (Hospital) Services HC/HH Wch Supp Tube Trach Lo-Pro 3mm__86043 PX-2725000119 CDM 2725000119 LOCAL 272 RC outpatient 38 38 CIGNA 62308 [3081051] CIGNA 62308 [308105105] 30.4 percent of total billed charges 23.56 36.1 Technical (Hospital) Services HC/HH Wch Supp Tube Trach Lo-Pro 3mm__86043 PX-2725000119 CDM 2725000119 LOCAL 272 RC outpatient 38 38 CIGNA 62308 [3081051] CIGNA STATE OF WYOMING [308105107] 30.4 percent of total billed charges 23.56 36.1 Technical (Hospital) Services HC/HH Wch Supp Tube Trach Lo-Pro 3mm__86043 PX-2725000119 CDM 2725000119 LOCAL 272 RC outpatient 38 38 MEDICA (COMMERCIAL) 94265 [3081118] MEDICA CLAIMS [308111801] 34.2 percent of total billed charges 23.56 36.1 Technical (Hospital) Services HC/HH Wch Supp Tube Trach Lo-Pro 3mm__86043 PX-2725000119 CDM 2725000119 LOCAL 272 RC outpatient 38 38 MULTIPLAN INC 34080 [3081285] MULTIPLAN INC [308128501] 36.1 percent of total billed charges 23.56 36.1 Technical (Hospital) Services HC/HH Wch Supp Tube Trach Lo-Pro 3mm__86043 PX-2725000119 CDM 2725000119 LOCAL 272 RC inpatient 38 38 MEDICA (COMMERCIAL) 94265 [3081118] MEDICA CLAIMS [308111801] 34.2 percent of total billed charges 23.56 36.1 Technical (Hospital) Services HC/HH Wch Supp Tube Trach Lo-Pro 3mm__86043 PX-2725000119 CDM 2725000119 LOCAL 272 RC inpatient 38 38 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES PPO [308136801] 30.09 percent of total billed charges 23.56 36.1 Technical (Hospital) Services HC/HH Wch Supp Tube Trach Lo-Pro 3mm__86043 PX-2725000119 CDM 2725000119 LOCAL 272 RC inpatient 38 38 UNITED HEALTHCARE (COMMERCIAL) [3081199] UNITED HEALTHCARE 87726 [308119901] 23.56 percent of total billed charges 23.56 36.1 Technical (Hospital) Services HC/HH Wch Supp Tube Trach Lo-Pro 3mm__86043 PX-2725000119 CDM 2725000119 LOCAL 272 RC inpatient 38 38 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES HDHP [308136802] 30.09 percent of total billed charges 23.56 36.1 Technical (Hospital) Services HC/HH Wch Supp Tube Trach Lo-Pro 3mm__86043 PX-2725000119 CDM 2725000119 LOCAL 272 RC inpatient 38 38 CIGNA 62308 [3081051] CIGNA 62308 [308105105] 30.09 percent of total billed charges 23.56 36.1 Technical (Hospital) Services HC/HH Wch Supp Tube Trach Lo-Pro 3mm__86043 PX-2725000119 CDM 2725000119 LOCAL 272 RC inpatient 38 38 CIGNA 62308 [3081051] CIGNA STATE OF WYOMING [308105107] 30.09 percent of total billed charges 23.56 36.1 Technical (Hospital) Services HC/HH Wch Supp Tube Trach Lo-Pro 3mm__86043 PX-2725000119 CDM 2725000119 LOCAL 272 RC inpatient 38 38 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES EPO [308136803] 30.09 percent of total billed charges 23.56 36.1 Technical (Hospital) Services HC/HH Wch Supp Tube Trach Lo-Pro 3mm__86043 PX-2725000119 CDM 2725000119 LOCAL 272 RC inpatient 38 38 MULTIPLAN INC 34080 [3081285] MULTIPLAN INC [308128501] 36.1 percent of total billed charges 23.56 36.1 Technical (Hospital) Services HC/HH Wch Supp Tube Trach Lo-Pro 3mm__86043 PX-2725000119 CDM 2725000119 LOCAL 272 RC inpatient 38 38 BLUE CROSS BLUE SHIELD WELLMARK SB889 [3081026] BCBS WYOMING [308102603] 36.1 percent of total billed charges 23.56 36.1 Technical (Hospital) Services HC/HH Wch Supp Tube Trach Lo-Pro 3mm__86043 PX-2725000119 CDM 2725000119 LOCAL 272 RC inpatient 38 38 HEALTHPARTNERS SX009 HEALTHPARTNERS 30.09 percent of total billed charges 23.56 36.1 Technical (Hospital) Services HC/HH Wch Supp Tube Trach Hi Lo 6.5 Mrphy Tip__86110 PX-2725000118 CDM 2725000118 LOCAL 272 RC inpatient 33 33 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES PPO [308136801] 26.13 percent of total billed charges 20.46 31.35 Technical (Hospital) Services HC/HH Wch Supp Tube Trach Hi Lo 6.5 Mrphy Tip__86110 PX-2725000118 CDM 2725000118 LOCAL 272 RC inpatient 33 33 MEDICA (COMMERCIAL) 94265 [3081118] MEDICA CLAIMS [308111801] 29.7 percent of total billed charges 20.46 31.35 Technical (Hospital) Services HC/HH Wch Supp Tube Trach Hi Lo 6.5 Mrphy Tip__86110 PX-2725000118 CDM 2725000118 LOCAL 272 RC inpatient 33 33 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES HDHP [308136802] 26.13 percent of total billed charges 20.46 31.35 Technical (Hospital) Services HC/HH Wch Supp Tube Trach Hi Lo 6.5 Mrphy Tip__86110 PX-2725000118 CDM 2725000118 LOCAL 272 RC inpatient 33 33 UNITED HEALTHCARE (COMMERCIAL) [3081199] UNITED HEALTHCARE 87726 [308119901] 20.46 percent of total billed charges 20.46 31.35 Technical (Hospital) Services HC/HH Wch Supp Tube Trach Hi Lo 6.5 Mrphy Tip__86110 PX-2725000118 CDM 2725000118 LOCAL 272 RC inpatient 33 33 CIGNA 62308 [3081051] CIGNA 62308 [308105105] 26.13 percent of total billed charges 20.46 31.35 Technical (Hospital) Services HC/HH Wch Supp Tube Trach Hi Lo 6.5 Mrphy Tip__86110 PX-2725000118 CDM 2725000118 LOCAL 272 RC inpatient 33 33 CIGNA 62308 [3081051] CIGNA STATE OF WYOMING [308105107] 26.13 percent of total billed charges 20.46 31.35 Technical (Hospital) Services HC/HH Wch Supp Tube Trach Hi Lo 6.5 Mrphy Tip__86110 PX-2725000118 CDM 2725000118 LOCAL 272 RC inpatient 33 33 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES EPO [308136803] 26.13 percent of total billed charges 20.46 31.35 Technical (Hospital) Services HC/HH Wch Supp Tube Trach Hi Lo 6.5 Mrphy Tip__86110 PX-2725000118 CDM 2725000118 LOCAL 272 RC inpatient 33 33 MULTIPLAN INC 34080 [3081285] MULTIPLAN INC [308128501] 31.35 percent of total billed charges 20.46 31.35 Technical (Hospital) Services HC/HH Wch Supp Tube Trach Hi Lo 6.5 Mrphy Tip__86110 PX-2725000118 CDM 2725000118 LOCAL 272 RC inpatient 33 33 BLUE CROSS BLUE SHIELD WELLMARK SB889 [3081026] BCBS WYOMING [308102603] 31.35 percent of total billed charges 20.46 31.35 Technical (Hospital) Services HC/HH Wch Supp Tube Trach Hi Lo 6.5 Mrphy Tip__86110 PX-2725000118 CDM 2725000118 LOCAL 272 RC inpatient 33 33 HEALTHPARTNERS SX009 HEALTHPARTNERS 26.13 percent of total billed charges 20.46 31.35 Technical (Hospital) Services HC/HH Wch Supp Tube Trach Hi Lo 6.5 Mrphy Tip__86110 PX-2725000118 CDM 2725000118 LOCAL 272 RC outpatient 33 33 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES HDHP [308136802] 26.4 percent of total billed charges 20.46 31.35 Technical (Hospital) Services HC/HH Wch Supp Tube Trach Hi Lo 6.5 Mrphy Tip__86110 PX-2725000118 CDM 2725000118 LOCAL 272 RC outpatient 33 33 BLUE CROSS BLUE SHIELD WELLMARK SB889 [3081026] BCBS WYOMING [308102603] 31.35 percent of total billed charges 20.46 31.35 Technical (Hospital) Services HC/HH Wch Supp Tube Trach Hi Lo 6.5 Mrphy Tip__86110 PX-2725000118 CDM 2725000118 LOCAL 272 RC outpatient 33 33 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES EPO [308136803] 26.4 percent of total billed charges 20.46 31.35 Technical (Hospital) Services HC/HH Wch Supp Tube Trach Hi Lo 6.5 Mrphy Tip__86110 PX-2725000118 CDM 2725000118 LOCAL 272 RC outpatient 33 33 CIGNA 62308 [3081051] CIGNA 62308 [308105105] 26.4 percent of total billed charges 20.46 31.35 Technical (Hospital) Services HC/HH Wch Supp Tube Trach Hi Lo 6.5 Mrphy Tip__86110 PX-2725000118 CDM 2725000118 LOCAL 272 RC outpatient 33 33 CIGNA 62308 [3081051] CIGNA STATE OF WYOMING [308105107] 26.4 percent of total billed charges 20.46 31.35 Technical (Hospital) Services HC/HH Wch Supp Tube Trach Hi Lo 6.5 Mrphy Tip__86110 PX-2725000118 CDM 2725000118 LOCAL 272 RC outpatient 33 33 UNITED HEALTHCARE (COMMERCIAL) [3081199] UNITED HEALTHCARE 87726 [308119901] 20.46 percent of total billed charges 20.46 31.35 Technical (Hospital) Services HC/HH Wch Supp Tube Trach Hi Lo 6.5 Mrphy Tip__86110 PX-2725000118 CDM 2725000118 LOCAL 272 RC outpatient 33 33 HEALTHPARTNERS SX009 HEALTHPARTNERS 26.4 percent of total billed charges 20.46 31.35 Technical (Hospital) Services HC/HH Wch Supp Tube Trach Hi Lo 6.5 Mrphy Tip__86110 PX-2725000118 CDM 2725000118 LOCAL 272 RC outpatient 33 33 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES PPO [308136801] 26.4 percent of total billed charges 20.46 31.35 Technical (Hospital) Services HC/HH Wch Supp Tube Trach Hi Lo 6.5 Mrphy Tip__86110 PX-2725000118 CDM 2725000118 LOCAL 272 RC outpatient 33 33 MEDICA (COMMERCIAL) 94265 [3081118] MEDICA CLAIMS [308111801] 29.7 percent of total billed charges 20.46 31.35 Technical (Hospital) Services HC/HH Wch Supp Tube Trach Hi Lo 6.5 Mrphy Tip__86110 PX-2725000118 CDM 2725000118 LOCAL 272 RC outpatient 33 33 MULTIPLAN INC 34080 [3081285] MULTIPLAN INC [308128501] 31.35 percent of total billed charges 20.46 31.35 Technical (Hospital) Services HC/HH Wch Supp Tube Salem Sump Sent 16fr 48__8888264960 PX-2725000117 CDM 2725000117 LOCAL 272 RC inpatient 16 16 HEALTHPARTNERS SX009 HEALTHPARTNERS 12.67 percent of total billed charges 9.92 15.2 Technical (Hospital) Services HC/HH Wch Supp Tube Salem Sump Sent 16fr 48__8888264960 PX-2725000117 CDM 2725000117 LOCAL 272 RC inpatient 16 16 BLUE CROSS BLUE SHIELD WELLMARK SB889 [3081026] BCBS WYOMING [308102603] 15.2 percent of total billed charges 9.92 15.2 Technical (Hospital) Services HC/HH Wch Supp Tube Salem Sump Sent 16fr 48__8888264960 PX-2725000117 CDM 2725000117 LOCAL 272 RC inpatient 16 16 MULTIPLAN INC 34080 [3081285] MULTIPLAN INC [308128501] 15.2 percent of total billed charges 9.92 15.2 Technical (Hospital) Services HC/HH Wch Supp Tube Salem Sump Sent 16fr 48__8888264960 PX-2725000117 CDM 2725000117 LOCAL 272 RC inpatient 16 16 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES EPO [308136803] 12.67 percent of total billed charges 9.92 15.2 Technical (Hospital) Services HC/HH Wch Supp Tube Salem Sump Sent 16fr 48__8888264960 PX-2725000117 CDM 2725000117 LOCAL 272 RC inpatient 16 16 CIGNA 62308 [3081051] CIGNA 62308 [308105105] 12.67 percent of total billed charges 9.92 15.2 Technical (Hospital) Services HC/HH Wch Supp Tube Salem Sump Sent 16fr 48__8888264960 PX-2725000117 CDM 2725000117 LOCAL 272 RC inpatient 16 16 CIGNA 62308 [3081051] CIGNA STATE OF WYOMING [308105107] 12.67 percent of total billed charges 9.92 15.2 Technical (Hospital) Services HC/HH Wch Supp Tube Salem Sump Sent 16fr 48__8888264960 PX-2725000117 CDM 2725000117 LOCAL 272 RC inpatient 16 16 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES HDHP [308136802] 12.67 percent of total billed charges 9.92 15.2 Technical (Hospital) Services HC/HH Wch Supp Tube Salem Sump Sent 16fr 48__8888264960 PX-2725000117 CDM 2725000117 LOCAL 272 RC inpatient 16 16 UNITED HEALTHCARE (COMMERCIAL) [3081199] UNITED HEALTHCARE 87726 [308119901] 9.92 percent of total billed charges 9.92 15.2 Technical (Hospital) Services HC/HH Wch Supp Tube Salem Sump Sent 16fr 48__8888264960 PX-2725000117 CDM 2725000117 LOCAL 272 RC inpatient 16 16 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES PPO [308136801] 12.67 percent of total billed charges 9.92 15.2 Technical (Hospital) Services HC/HH Wch Supp Tube Salem Sump Sent 16fr 48__8888264960 PX-2725000117 CDM 2725000117 LOCAL 272 RC inpatient 16 16 MEDICA (COMMERCIAL) 94265 [3081118] MEDICA CLAIMS [308111801] 14.4 percent of total billed charges 9.92 15.2 Technical (Hospital) Services HC/HH Wch Supp Tube Salem Sump Sent 16fr 48__8888264960 PX-2725000117 CDM 2725000117 LOCAL 272 RC outpatient 16 16 MEDICA (COMMERCIAL) 94265 [3081118] MEDICA CLAIMS [308111801] 14.4 percent of total billed charges 9.92 15.2 Technical (Hospital) Services HC/HH Wch Supp Tube Salem Sump Sent 16fr 48__8888264960 PX-2725000117 CDM 2725000117 LOCAL 272 RC outpatient 16 16 MULTIPLAN INC 34080 [3081285] MULTIPLAN INC [308128501] 15.2 percent of total billed charges 9.92 15.2 Technical (Hospital) Services HC/HH Wch Supp Tube Salem Sump Sent 16fr 48__8888264960 PX-2725000117 CDM 2725000117 LOCAL 272 RC outpatient 16 16 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES PPO [308136801] 12.8 percent of total billed charges 9.92 15.2 Technical (Hospital) Services HC/HH Wch Supp Tube Salem Sump Sent 16fr 48__8888264960 PX-2725000117 CDM 2725000117 LOCAL 272 RC outpatient 16 16 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES EPO [308136803] 12.8 percent of total billed charges 9.92 15.2 Technical (Hospital) Services HC/HH Wch Supp Tube Salem Sump Sent 16fr 48__8888264960 PX-2725000117 CDM 2725000117 LOCAL 272 RC outpatient 16 16 BLUE CROSS BLUE SHIELD WELLMARK SB889 [3081026] BCBS WYOMING [308102603] 15.2 percent of total billed charges 9.92 15.2 Technical (Hospital) Services HC/HH Wch Supp Tube Salem Sump Sent 16fr 48__8888264960 PX-2725000117 CDM 2725000117 LOCAL 272 RC outpatient 16 16 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES HDHP [308136802] 12.8 percent of total billed charges 9.92 15.2 Technical (Hospital) Services HC/HH Wch Supp Tube Salem Sump Sent 16fr 48__8888264960 PX-2725000117 CDM 2725000117 LOCAL 272 RC outpatient 16 16 HEALTHPARTNERS SX009 HEALTHPARTNERS 12.8 percent of total billed charges 9.92 15.2 Technical (Hospital) Services HC/HH Wch Supp Tube Salem Sump Sent 16fr 48__8888264960 PX-2725000117 CDM 2725000117 LOCAL 272 RC outpatient 16 16 UNITED HEALTHCARE (COMMERCIAL) [3081199] UNITED HEALTHCARE 87726 [308119901] 9.92 percent of total billed charges 9.92 15.2 Technical (Hospital) Services HC/HH Wch Supp Tube Salem Sump Sent 16fr 48__8888264960 PX-2725000117 CDM 2725000117 LOCAL 272 RC outpatient 16 16 CIGNA 62308 [3081051] CIGNA 62308 [308105105] 12.8 percent of total billed charges 9.92 15.2 Technical (Hospital) Services HC/HH Wch Supp Tube Salem Sump Sent 16fr 48__8888264960 PX-2725000117 CDM 2725000117 LOCAL 272 RC outpatient 16 16 CIGNA 62308 [3081051] CIGNA STATE OF WYOMING [308105107] 12.8 percent of total billed charges 9.92 15.2 Technical (Hospital) Services HC/HH Wch Supp Tray Lumbar Safe-T-Lp Peds__4302cs PX-2725000116 CDM 2725000116 LOCAL 272 RC inpatient 54 54 MEDICA (COMMERCIAL) 94265 [3081118] MEDICA CLAIMS [308111801] 48.6 percent of total billed charges 33.48 51.3 Technical (Hospital) Services HC/HH Wch Supp Tray Lumbar Safe-T-Lp Peds__4302cs PX-2725000116 CDM 2725000116 LOCAL 272 RC inpatient 54 54 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES PPO [308136801] 42.76 percent of total billed charges 33.48 51.3 Technical (Hospital) Services HC/HH Wch Supp Tray Lumbar Safe-T-Lp Peds__4302cs PX-2725000116 CDM 2725000116 LOCAL 272 RC inpatient 54 54 UNITED HEALTHCARE (COMMERCIAL) [3081199] UNITED HEALTHCARE 87726 [308119901] 33.48 percent of total billed charges 33.48 51.3 Technical (Hospital) Services HC/HH Wch Supp Tray Lumbar Safe-T-Lp Peds__4302cs PX-2725000116 CDM 2725000116 LOCAL 272 RC inpatient 54 54 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES HDHP [308136802] 42.76 percent of total billed charges 33.48 51.3 Technical (Hospital) Services HC/HH Wch Supp Tray Lumbar Safe-T-Lp Peds__4302cs PX-2725000116 CDM 2725000116 LOCAL 272 RC inpatient 54 54 CIGNA 62308 [3081051] CIGNA 62308 [308105105] 42.76 percent of total billed charges 33.48 51.3 Technical (Hospital) Services HC/HH Wch Supp Tray Lumbar Safe-T-Lp Peds__4302cs PX-2725000116 CDM 2725000116 LOCAL 272 RC inpatient 54 54 CIGNA 62308 [3081051] CIGNA STATE OF WYOMING [308105107] 42.76 percent of total billed charges 33.48 51.3 Technical (Hospital) Services HC/HH Wch Supp Tray Lumbar Safe-T-Lp Peds__4302cs PX-2725000116 CDM 2725000116 LOCAL 272 RC inpatient 54 54 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES EPO [308136803] 42.76 percent of total billed charges 33.48 51.3 Technical (Hospital) Services HC/HH Wch Supp Tray Lumbar Safe-T-Lp Peds__4302cs PX-2725000116 CDM 2725000116 LOCAL 272 RC inpatient 54 54 MULTIPLAN INC 34080 [3081285] MULTIPLAN INC [308128501] 51.3 percent of total billed charges 33.48 51.3 Technical (Hospital) Services HC/HH Wch Supp Tray Lumbar Safe-T-Lp Peds__4302cs PX-2725000116 CDM 2725000116 LOCAL 272 RC inpatient 54 54 BLUE CROSS BLUE SHIELD WELLMARK SB889 [3081026] BCBS WYOMING [308102603] 51.3 percent of total billed charges 33.48 51.3 Technical (Hospital) Services HC/HH Wch Supp Tray Lumbar Safe-T-Lp Peds__4302cs PX-2725000116 CDM 2725000116 LOCAL 272 RC inpatient 54 54 HEALTHPARTNERS SX009 HEALTHPARTNERS 42.76 percent of total billed charges 33.48 51.3 Technical (Hospital) Services HC/HH Wch Supp Tray Lumbar Safe-T-Lp Peds__4302cs PX-2725000116 CDM 2725000116 LOCAL 272 RC outpatient 54 54 MULTIPLAN INC 34080 [3081285] MULTIPLAN INC [308128501] 51.3 percent of total billed charges 33.48 51.3 Technical (Hospital) Services HC/HH Wch Supp Tray Lumbar Safe-T-Lp Peds__4302cs PX-2725000116 CDM 2725000116 LOCAL 272 RC outpatient 54 54 MEDICA (COMMERCIAL) 94265 [3081118] MEDICA CLAIMS [308111801] 48.6 percent of total billed charges 33.48 51.3 Technical (Hospital) Services HC/HH Wch Supp Tray Lumbar Safe-T-Lp Peds__4302cs PX-2725000116 CDM 2725000116 LOCAL 272 RC outpatient 54 54 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES EPO [308136803] 43.2 percent of total billed charges 33.48 51.3 Technical (Hospital) Services HC/HH Wch Supp Tray Lumbar Safe-T-Lp Peds__4302cs PX-2725000116 CDM 2725000116 LOCAL 272 RC outpatient 54 54 BLUE CROSS BLUE SHIELD WELLMARK SB889 [3081026] BCBS WYOMING [308102603] 51.3 percent of total billed charges 33.48 51.3 Technical (Hospital) Services HC/HH Wch Supp Tray Lumbar Safe-T-Lp Peds__4302cs PX-2725000116 CDM 2725000116 LOCAL 272 RC outpatient 54 54 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES HDHP [308136802] 43.2 percent of total billed charges 33.48 51.3 Technical (Hospital) Services HC/HH Wch Supp Tray Lumbar Safe-T-Lp Peds__4302cs PX-2725000116 CDM 2725000116 LOCAL 272 RC outpatient 54 54 HEALTHPARTNERS SX009 HEALTHPARTNERS 43.2 percent of total billed charges 33.48 51.3 Technical (Hospital) Services HC/HH Wch Supp Tray Lumbar Safe-T-Lp Peds__4302cs PX-2725000116 CDM 2725000116 LOCAL 272 RC outpatient 54 54 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES PPO [308136801] 43.2 percent of total billed charges 33.48 51.3 Technical (Hospital) Services HC/HH Wch Supp Tray Lumbar Safe-T-Lp Peds__4302cs PX-2725000116 CDM 2725000116 LOCAL 272 RC outpatient 54 54 UNITED HEALTHCARE (COMMERCIAL) [3081199] UNITED HEALTHCARE 87726 [308119901] 33.48 percent of total billed charges 33.48 51.3 Technical (Hospital) Services HC/HH Wch Supp Tray Lumbar Safe-T-Lp Peds__4302cs PX-2725000116 CDM 2725000116 LOCAL 272 RC outpatient 54 54 CIGNA 62308 [3081051] CIGNA 62308 [308105105] 43.2 percent of total billed charges 33.48 51.3 Technical (Hospital) Services HC/HH Wch Supp Tray Lumbar Safe-T-Lp Peds__4302cs PX-2725000116 CDM 2725000116 LOCAL 272 RC outpatient 54 54 CIGNA 62308 [3081051] CIGNA STATE OF WYOMING [308105107] 43.2 percent of total billed charges 33.48 51.3 Technical (Hospital) Services HC/HH Wch Supp Tray Lumbar Saf-T-Lp Adult__4301csp PX-2725000115 CDM 2725000115 LOCAL 272 RC inpatient 68 68 CIGNA 62308 [3081051] CIGNA 62308 [308105105] 53.84 percent of total billed charges 42.16 64.6 Technical (Hospital) Services HC/HH Wch Supp Tray Lumbar Saf-T-Lp Adult__4301csp PX-2725000115 CDM 2725000115 LOCAL 272 RC inpatient 68 68 CIGNA 62308 [3081051] CIGNA STATE OF WYOMING [308105107] 53.84 percent of total billed charges 42.16 64.6 Technical (Hospital) Services HC/HH Wch Supp Tray Lumbar Saf-T-Lp Adult__4301csp PX-2725000115 CDM 2725000115 LOCAL 272 RC inpatient 68 68 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES HDHP [308136802] 53.84 percent of total billed charges 42.16 64.6 Technical (Hospital) Services HC/HH Wch Supp Tray Lumbar Saf-T-Lp Adult__4301csp PX-2725000115 CDM 2725000115 LOCAL 272 RC inpatient 68 68 UNITED HEALTHCARE (COMMERCIAL) [3081199] UNITED HEALTHCARE 87726 [308119901] 42.16 percent of total billed charges 42.16 64.6 Technical (Hospital) Services HC/HH Wch Supp Tray Lumbar Saf-T-Lp Adult__4301csp PX-2725000115 CDM 2725000115 LOCAL 272 RC inpatient 68 68 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES PPO [308136801] 53.84 percent of total billed charges 42.16 64.6 Technical (Hospital) Services HC/HH Wch Supp Tray Lumbar Saf-T-Lp Adult__4301csp PX-2725000115 CDM 2725000115 LOCAL 272 RC inpatient 68 68 MEDICA (COMMERCIAL) 94265 [3081118] MEDICA CLAIMS [308111801] 61.2 percent of total billed charges 42.16 64.6 Technical (Hospital) Services HC/HH Wch Supp Tray Lumbar Saf-T-Lp Adult__4301csp PX-2725000115 CDM 2725000115 LOCAL 272 RC inpatient 68 68 MULTIPLAN INC 34080 [3081285] MULTIPLAN INC [308128501] 64.6 percent of total billed charges 42.16 64.6 Technical (Hospital) Services HC/HH Wch Supp Tray Lumbar Saf-T-Lp Adult__4301csp PX-2725000115 CDM 2725000115 LOCAL 272 RC inpatient 68 68 BLUE CROSS BLUE SHIELD WELLMARK SB889 [3081026] BCBS WYOMING [308102603] 64.6 percent of total billed charges 42.16 64.6 Technical (Hospital) Services HC/HH Wch Supp Tray Lumbar Saf-T-Lp Adult__4301csp PX-2725000115 CDM 2725000115 LOCAL 272 RC inpatient 68 68 HEALTHPARTNERS SX009 HEALTHPARTNERS 53.84 percent of total billed charges 42.16 64.6 Technical (Hospital) Services HC/HH Wch Supp Tray Lumbar Saf-T-Lp Adult__4301csp PX-2725000115 CDM 2725000115 LOCAL 272 RC inpatient 68 68 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES EPO [308136803] 53.84 percent of total billed charges 42.16 64.6 Technical (Hospital) Services HC/HH Wch Supp Tray Lumbar Saf-T-Lp Adult__4301csp PX-2725000115 CDM 2725000115 LOCAL 272 RC outpatient 68 68 MULTIPLAN INC 34080 [3081285] MULTIPLAN INC [308128501] 64.6 percent of total billed charges 42.16 64.6 Technical (Hospital) Services HC/HH Wch Supp Tray Lumbar Saf-T-Lp Adult__4301csp PX-2725000115 CDM 2725000115 LOCAL 272 RC outpatient 68 68 HEALTHPARTNERS SX009 HEALTHPARTNERS 54.4 percent of total billed charges 42.16 64.6 Technical (Hospital) Services HC/HH Wch Supp Tray Lumbar Saf-T-Lp Adult__4301csp PX-2725000115 CDM 2725000115 LOCAL 272 RC outpatient 68 68 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES PPO [308136801] 54.4 percent of total billed charges 42.16 64.6 Technical (Hospital) Services HC/HH Wch Supp Tray Lumbar Saf-T-Lp Adult__4301csp PX-2725000115 CDM 2725000115 LOCAL 272 RC outpatient 68 68 MEDICA (COMMERCIAL) 94265 [3081118] MEDICA CLAIMS [308111801] 61.2 percent of total billed charges 42.16 64.6 Technical (Hospital) Services HC/HH Wch Supp Tray Lumbar Saf-T-Lp Adult__4301csp PX-2725000115 CDM 2725000115 LOCAL 272 RC outpatient 68 68 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES EPO [308136803] 54.4 percent of total billed charges 42.16 64.6 Technical (Hospital) Services HC/HH Wch Supp Tray Lumbar Saf-T-Lp Adult__4301csp PX-2725000115 CDM 2725000115 LOCAL 272 RC outpatient 68 68 BLUE CROSS BLUE SHIELD WELLMARK SB889 [3081026] BCBS WYOMING [308102603] 64.6 percent of total billed charges 42.16 64.6 Technical (Hospital) Services HC/HH Wch Supp Tray Lumbar Saf-T-Lp Adult__4301csp PX-2725000115 CDM 2725000115 LOCAL 272 RC outpatient 68 68 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES HDHP [308136802] 54.4 percent of total billed charges 42.16 64.6 Technical (Hospital) Services HC/HH Wch Supp Tray Lumbar Saf-T-Lp Adult__4301csp PX-2725000115 CDM 2725000115 LOCAL 272 RC outpatient 68 68 UNITED HEALTHCARE (COMMERCIAL) [3081199] UNITED HEALTHCARE 87726 [308119901] 42.16 percent of total billed charges 42.16 64.6 Technical (Hospital) Services HC/HH Wch Supp Tray Lumbar Saf-T-Lp Adult__4301csp PX-2725000115 CDM 2725000115 LOCAL 272 RC outpatient 68 68 CIGNA 62308 [3081051] CIGNA 62308 [308105105] 54.4 percent of total billed charges 42.16 64.6 Technical (Hospital) Services HC/HH Wch Supp Tray Lumbar Saf-T-Lp Adult__4301csp PX-2725000115 CDM 2725000115 LOCAL 272 RC outpatient 68 68 CIGNA 62308 [3081051] CIGNA STATE OF WYOMING [308105107] 54.4 percent of total billed charges 42.16 64.6 Technical (Hospital) Services HC/HH Wch Supp Tray Cath Irrigation 70cc__750301 PX-2725000114 CDM 2725000114 LOCAL 272 RC inpatient 8 8 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES EPO [308136803] 6.33 percent of total billed charges 4.96 7.6 Technical (Hospital) Services HC/HH Wch Supp Tray Cath Irrigation 70cc__750301 PX-2725000114 CDM 2725000114 LOCAL 272 RC inpatient 8 8 HEALTHPARTNERS SX009 HEALTHPARTNERS 6.33 percent of total billed charges 4.96 7.6 Technical (Hospital) Services HC/HH Wch Supp Tray Cath Irrigation 70cc__750301 PX-2725000114 CDM 2725000114 LOCAL 272 RC inpatient 8 8 BLUE CROSS BLUE SHIELD WELLMARK SB889 [3081026] BCBS WYOMING [308102603] 7.6 percent of total billed charges 4.96 7.6 Technical (Hospital) Services HC/HH Wch Supp Tray Cath Irrigation 70cc__750301 PX-2725000114 CDM 2725000114 LOCAL 272 RC inpatient 8 8 MULTIPLAN INC 34080 [3081285] MULTIPLAN INC [308128501] 7.6 percent of total billed charges 4.96 7.6 Technical (Hospital) Services HC/HH Wch Supp Tray Cath Irrigation 70cc__750301 PX-2725000114 CDM 2725000114 LOCAL 272 RC inpatient 8 8 MEDICA (COMMERCIAL) 94265 [3081118] MEDICA CLAIMS [308111801] 7.2 percent of total billed charges 4.96 7.6 Technical (Hospital) Services HC/HH Wch Supp Tray Cath Irrigation 70cc__750301 PX-2725000114 CDM 2725000114 LOCAL 272 RC inpatient 8 8 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES PPO [308136801] 6.33 percent of total billed charges 4.96 7.6 Technical (Hospital) Services HC/HH Wch Supp Tray Cath Irrigation 70cc__750301 PX-2725000114 CDM 2725000114 LOCAL 272 RC inpatient 8 8 UNITED HEALTHCARE (COMMERCIAL) [3081199] UNITED HEALTHCARE 87726 [308119901] 4.96 percent of total billed charges 4.96 7.6 Technical (Hospital) Services HC/HH Wch Supp Tray Cath Irrigation 70cc__750301 PX-2725000114 CDM 2725000114 LOCAL 272 RC inpatient 8 8 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES HDHP [308136802] 6.33 percent of total billed charges 4.96 7.6 Technical (Hospital) Services HC/HH Wch Supp Tray Cath Irrigation 70cc__750301 PX-2725000114 CDM 2725000114 LOCAL 272 RC inpatient 8 8 CIGNA 62308 [3081051] CIGNA 62308 [308105105] 6.33 percent of total billed charges 4.96 7.6 Technical (Hospital) Services HC/HH Wch Supp Tray Cath Irrigation 70cc__750301 PX-2725000114 CDM 2725000114 LOCAL 272 RC inpatient 8 8 CIGNA 62308 [3081051] CIGNA STATE OF WYOMING [308105107] 6.33 percent of total billed charges 4.96 7.6 Technical (Hospital) Services HC/HH Wch Supp Tray Cath Irrigation 70cc__750301 PX-2725000114 CDM 2725000114 LOCAL 272 RC outpatient 8 8 CIGNA 62308 [3081051] CIGNA 62308 [308105105] 6.4 percent of total billed charges 4.96 7.6 Technical (Hospital) Services HC/HH Wch Supp Tray Cath Irrigation 70cc__750301 PX-2725000114 CDM 2725000114 LOCAL 272 RC outpatient 8 8 CIGNA 62308 [3081051] CIGNA STATE OF WYOMING [308105107] 6.4 percent of total billed charges 4.96 7.6 Technical (Hospital) Services HC/HH Wch Supp Tray Cath Irrigation 70cc__750301 PX-2725000114 CDM 2725000114 LOCAL 272 RC outpatient 8 8 UNITED HEALTHCARE (COMMERCIAL) [3081199] UNITED HEALTHCARE 87726 [308119901] 4.96 percent of total billed charges 4.96 7.6 Technical (Hospital) Services HC/HH Wch Supp Tray Cath Irrigation 70cc__750301 PX-2725000114 CDM 2725000114 LOCAL 272 RC outpatient 8 8 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES HDHP [308136802] 6.4 percent of total billed charges 4.96 7.6 Technical (Hospital) Services HC/HH Wch Supp Tray Cath Irrigation 70cc__750301 PX-2725000114 CDM 2725000114 LOCAL 272 RC outpatient 8 8 BLUE CROSS BLUE SHIELD WELLMARK SB889 [3081026] BCBS WYOMING [308102603] 7.6 percent of total billed charges 4.96 7.6 Technical (Hospital) Services HC/HH Wch Supp Tray Cath Irrigation 70cc__750301 PX-2725000114 CDM 2725000114 LOCAL 272 RC outpatient 8 8 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES EPO [308136803] 6.4 percent of total billed charges 4.96 7.6 Technical (Hospital) Services HC/HH Wch Supp Tray Cath Irrigation 70cc__750301 PX-2725000114 CDM 2725000114 LOCAL 272 RC outpatient 8 8 MEDICA (COMMERCIAL) 94265 [3081118] MEDICA CLAIMS [308111801] 7.2 percent of total billed charges 4.96 7.6 Technical (Hospital) Services HC/HH Wch Supp Tray Cath Irrigation 70cc__750301 PX-2725000114 CDM 2725000114 LOCAL 272 RC outpatient 8 8 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES PPO [308136801] 6.4 percent of total billed charges 4.96 7.6 Technical (Hospital) Services HC/HH Wch Supp Tray Cath Irrigation 70cc__750301 PX-2725000114 CDM 2725000114 LOCAL 272 RC outpatient 8 8 HEALTHPARTNERS SX009 HEALTHPARTNERS 6.4 percent of total billed charges 4.96 7.6 Technical (Hospital) Services HC/HH Wch Supp Tray Cath Irrigation 70cc__750301 PX-2725000114 CDM 2725000114 LOCAL 272 RC outpatient 8 8 MULTIPLAN INC 34080 [3081285] MULTIPLAN INC [308128501] 7.6 percent of total billed charges 4.96 7.6 Technical (Hospital) Services HC/HH Wch Supp Trach Tube Cuffed 8.0__5-10316 PX-2725000113 CDM 2725000113 LOCAL 272 RC outpatient 33 33 BLUE CROSS BLUE SHIELD WELLMARK SB889 [3081026] BCBS WYOMING [308102603] 31.35 percent of total billed charges 20.46 31.35 Technical (Hospital) Services HC/HH Wch Supp Trach Tube Cuffed 8.0__5-10316 PX-2725000113 CDM 2725000113 LOCAL 272 RC outpatient 33 33 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES EPO [308136803] 26.4 percent of total billed charges 20.46 31.35 Technical (Hospital) Services HC/HH Wch Supp Trach Tube Cuffed 8.0__5-10316 PX-2725000113 CDM 2725000113 LOCAL 272 RC outpatient 33 33 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES HDHP [308136802] 26.4 percent of total billed charges 20.46 31.35 Technical (Hospital) Services HC/HH Wch Supp Trach Tube Cuffed 8.0__5-10316 PX-2725000113 CDM 2725000113 LOCAL 272 RC outpatient 33 33 CIGNA 62308 [3081051] CIGNA 62308 [308105105] 26.4 percent of total billed charges 20.46 31.35 Technical (Hospital) Services HC/HH Wch Supp Trach Tube Cuffed 8.0__5-10316 PX-2725000113 CDM 2725000113 LOCAL 272 RC outpatient 33 33 CIGNA 62308 [3081051] CIGNA STATE OF WYOMING [308105107] 26.4 percent of total billed charges 20.46 31.35 Technical (Hospital) Services HC/HH Wch Supp Trach Tube Cuffed 8.0__5-10316 PX-2725000113 CDM 2725000113 LOCAL 272 RC outpatient 33 33 UNITED HEALTHCARE (COMMERCIAL) [3081199] UNITED HEALTHCARE 87726 [308119901] 20.46 percent of total billed charges 20.46 31.35 Technical (Hospital) Services HC/HH Wch Supp Trach Tube Cuffed 8.0__5-10316 PX-2725000113 CDM 2725000113 LOCAL 272 RC outpatient 33 33 HEALTHPARTNERS SX009 HEALTHPARTNERS 26.4 percent of total billed charges 20.46 31.35 Technical (Hospital) Services HC/HH Wch Supp Trach Tube Cuffed 8.0__5-10316 PX-2725000113 CDM 2725000113 LOCAL 272 RC outpatient 33 33 MEDICA (COMMERCIAL) 94265 [3081118] MEDICA CLAIMS [308111801] 29.7 percent of total billed charges 20.46 31.35 Technical (Hospital) Services HC/HH Wch Supp Trach Tube Cuffed 8.0__5-10316 PX-2725000113 CDM 2725000113 LOCAL 272 RC outpatient 33 33 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES PPO [308136801] 26.4 percent of total billed charges 20.46 31.35 Technical (Hospital) Services HC/HH Wch Supp Trach Tube Cuffed 8.0__5-10316 PX-2725000113 CDM 2725000113 LOCAL 272 RC outpatient 33 33 MULTIPLAN INC 34080 [3081285] MULTIPLAN INC [308128501] 31.35 percent of total billed charges 20.46 31.35 Technical (Hospital) Services HC/HH Wch Supp Trach Tube Cuffed 8.0__5-10316 PX-2725000113 CDM 2725000113 LOCAL 272 RC inpatient 33 33 HEALTHPARTNERS SX009 HEALTHPARTNERS 26.13 percent of total billed charges 20.46 31.35 Technical (Hospital) Services HC/HH Wch Supp Trach Tube Cuffed 8.0__5-10316 PX-2725000113 CDM 2725000113 LOCAL 272 RC inpatient 33 33 BLUE CROSS BLUE SHIELD WELLMARK SB889 [3081026] BCBS WYOMING [308102603] 31.35 percent of total billed charges 20.46 31.35 Technical (Hospital) Services HC/HH Wch Supp Trach Tube Cuffed 8.0__5-10316 PX-2725000113 CDM 2725000113 LOCAL 272 RC inpatient 33 33 MULTIPLAN INC 34080 [3081285] MULTIPLAN INC [308128501] 31.35 percent of total billed charges 20.46 31.35 Technical (Hospital) Services HC/HH Wch Supp Trach Tube Cuffed 8.0__5-10316 PX-2725000113 CDM 2725000113 LOCAL 272 RC inpatient 33 33 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES EPO [308136803] 26.13 percent of total billed charges 20.46 31.35 Technical (Hospital) Services HC/HH Wch Supp Trach Tube Cuffed 8.0__5-10316 PX-2725000113 CDM 2725000113 LOCAL 272 RC inpatient 33 33 CIGNA 62308 [3081051] CIGNA 62308 [308105105] 26.13 percent of total billed charges 20.46 31.35 Technical (Hospital) Services HC/HH Wch Supp Trach Tube Cuffed 8.0__5-10316 PX-2725000113 CDM 2725000113 LOCAL 272 RC inpatient 33 33 CIGNA 62308 [3081051] CIGNA STATE OF WYOMING [308105107] 26.13 percent of total billed charges 20.46 31.35 Technical (Hospital) Services HC/HH Wch Supp Trach Tube Cuffed 8.0__5-10316 PX-2725000113 CDM 2725000113 LOCAL 272 RC inpatient 33 33 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES HDHP [308136802] 26.13 percent of total billed charges 20.46 31.35 Technical (Hospital) Services HC/HH Wch Supp Trach Tube Cuffed 8.0__5-10316 PX-2725000113 CDM 2725000113 LOCAL 272 RC inpatient 33 33 UNITED HEALTHCARE (COMMERCIAL) [3081199] UNITED HEALTHCARE 87726 [308119901] 20.46 percent of total billed charges 20.46 31.35 Technical (Hospital) Services HC/HH Wch Supp Trach Tube Cuffed 8.0__5-10316 PX-2725000113 CDM 2725000113 LOCAL 272 RC inpatient 33 33 MEDICA (COMMERCIAL) 94265 [3081118] MEDICA CLAIMS [308111801] 29.7 percent of total billed charges 20.46 31.35 Technical (Hospital) Services HC/HH Wch Supp Trach Tube Cuffed 8.0__5-10316 PX-2725000113 CDM 2725000113 LOCAL 272 RC inpatient 33 33 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES PPO [308136801] 26.13 percent of total billed charges 20.46 31.35 Technical (Hospital) Services HC/HH Wch Supp Trach Tube Cuffed 7.5__5-10315 PX-2725000112 CDM 2725000112 LOCAL 272 RC inpatient 37 37 MULTIPLAN INC 34080 [3081285] MULTIPLAN INC [308128501] 35.15 percent of total billed charges 22.94 35.15 Technical (Hospital) Services HC/HH Wch Supp Trach Tube Cuffed 7.5__5-10315 PX-2725000112 CDM 2725000112 LOCAL 272 RC inpatient 37 37 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES EPO [308136803] 29.3 percent of total billed charges 22.94 35.15 Technical (Hospital) Services HC/HH Wch Supp Trach Tube Cuffed 7.5__5-10315 PX-2725000112 CDM 2725000112 LOCAL 272 RC inpatient 37 37 BLUE CROSS BLUE SHIELD WELLMARK SB889 [3081026] BCBS WYOMING [308102603] 35.15 percent of total billed charges 22.94 35.15 Technical (Hospital) Services HC/HH Wch Supp Trach Tube Cuffed 7.5__5-10315 PX-2725000112 CDM 2725000112 LOCAL 272 RC inpatient 37 37 HEALTHPARTNERS SX009 HEALTHPARTNERS 29.3 percent of total billed charges 22.94 35.15 Technical (Hospital) Services HC/HH Wch Supp Trach Tube Cuffed 7.5__5-10315 PX-2725000112 CDM 2725000112 LOCAL 272 RC inpatient 37 37 UNITED HEALTHCARE (COMMERCIAL) [3081199] UNITED HEALTHCARE 87726 [308119901] 22.94 percent of total billed charges 22.94 35.15 Technical (Hospital) Services HC/HH Wch Supp Trach Tube Cuffed 7.5__5-10315 PX-2725000112 CDM 2725000112 LOCAL 272 RC outpatient 37 37 CIGNA 62308 [3081051] CIGNA 62308 [308105105] 29.6 percent of total billed charges 22.94 35.15 Technical (Hospital) Services HC/HH Wch Supp Trach Tube Cuffed 7.5__5-10315 PX-2725000112 CDM 2725000112 LOCAL 272 RC outpatient 37 37 CIGNA 62308 [3081051] CIGNA STATE OF WYOMING [308105107] 29.6 percent of total billed charges 22.94 35.15 Technical (Hospital) Services HC/HH Wch Supp Trach Tube Cuffed 7.5__5-10315 PX-2725000112 CDM 2725000112 LOCAL 272 RC outpatient 37 37 UNITED HEALTHCARE (COMMERCIAL) [3081199] UNITED HEALTHCARE 87726 [308119901] 22.94 percent of total billed charges 22.94 35.15 Technical (Hospital) Services HC/HH Wch Supp Trach Tube Cuffed 7.5__5-10315 PX-2725000112 CDM 2725000112 LOCAL 272 RC outpatient 37 37 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES PPO [308136801] 29.6 percent of total billed charges 22.94 35.15 Technical (Hospital) Services HC/HH Wch Supp Trach Tube Cuffed 7.5__5-10315 PX-2725000112 CDM 2725000112 LOCAL 272 RC outpatient 37 37 HEALTHPARTNERS SX009 HEALTHPARTNERS 29.6 percent of total billed charges 22.94 35.15 Technical (Hospital) Services HC/HH Wch Supp Trach Tube Cuffed 7.5__5-10315 PX-2725000112 CDM 2725000112 LOCAL 272 RC outpatient 37 37 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES HDHP [308136802] 29.6 percent of total billed charges 22.94 35.15 Technical (Hospital) Services HC/HH Wch Supp Trach Tube Cuffed 7.5__5-10315 PX-2725000112 CDM 2725000112 LOCAL 272 RC outpatient 37 37 BLUE CROSS BLUE SHIELD WELLMARK SB889 [3081026] BCBS WYOMING [308102603] 35.15 percent of total billed charges 22.94 35.15 Technical (Hospital) Services HC/HH Wch Supp Trach Tube Cuffed 7.5__5-10315 PX-2725000112 CDM 2725000112 LOCAL 272 RC outpatient 37 37 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES EPO [308136803] 29.6 percent of total billed charges 22.94 35.15 Technical (Hospital) Services HC/HH Wch Supp Trach Tube Cuffed 7.5__5-10315 PX-2725000112 CDM 2725000112 LOCAL 272 RC outpatient 37 37 MEDICA (COMMERCIAL) 94265 [3081118] MEDICA CLAIMS [308111801] 33.3 percent of total billed charges 22.94 35.15 Technical (Hospital) Services HC/HH Wch Supp Trach Tube Cuffed 7.5__5-10315 PX-2725000112 CDM 2725000112 LOCAL 272 RC outpatient 37 37 MULTIPLAN INC 34080 [3081285] MULTIPLAN INC [308128501] 35.15 percent of total billed charges 22.94 35.15 Technical (Hospital) Services HC/HH Wch Supp Trach Tube Cuffed 7.5__5-10315 PX-2725000112 CDM 2725000112 LOCAL 272 RC inpatient 37 37 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES HDHP [308136802] 29.3 percent of total billed charges 22.94 35.15 Technical (Hospital) Services HC/HH Wch Supp Trach Tube Cuffed 7.5__5-10315 PX-2725000112 CDM 2725000112 LOCAL 272 RC inpatient 37 37 MEDICA (COMMERCIAL) 94265 [3081118] MEDICA CLAIMS [308111801] 33.3 percent of total billed charges 22.94 35.15 Technical (Hospital) Services HC/HH Wch Supp Trach Tube Cuffed 7.5__5-10315 PX-2725000112 CDM 2725000112 LOCAL 272 RC inpatient 37 37 CIGNA 62308 [3081051] CIGNA 62308 [308105105] 29.3 percent of total billed charges 22.94 35.15 Technical (Hospital) Services HC/HH Wch Supp Trach Tube Cuffed 7.5__5-10315 PX-2725000112 CDM 2725000112 LOCAL 272 RC inpatient 37 37 CIGNA 62308 [3081051] CIGNA STATE OF WYOMING [308105107] 29.3 percent of total billed charges 22.94 35.15 Technical (Hospital) Services HC/HH Wch Supp Trach Tube Cuffed 7.5__5-10315 PX-2725000112 CDM 2725000112 LOCAL 272 RC inpatient 37 37 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES PPO [308136801] 29.3 percent of total billed charges 22.94 35.15 Technical (Hospital) Services HC/HH Wch Supp Trach Tube Cuffed 7 Mrphy__5-10314 PX-2725000111 CDM 2725000111 LOCAL 272 RC inpatient 33 33 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES PPO [308136801] 26.13 percent of total billed charges 20.46 31.35 Technical (Hospital) Services HC/HH Wch Supp Trach Tube Cuffed 7 Mrphy__5-10314 PX-2725000111 CDM 2725000111 LOCAL 272 RC inpatient 33 33 MEDICA (COMMERCIAL) 94265 [3081118] MEDICA CLAIMS [308111801] 29.7 percent of total billed charges 20.46 31.35 Technical (Hospital) Services HC/HH Wch Supp Trach Tube Cuffed 7 Mrphy__5-10314 PX-2725000111 CDM 2725000111 LOCAL 272 RC inpatient 33 33 UNITED HEALTHCARE (COMMERCIAL) [3081199] UNITED HEALTHCARE 87726 [308119901] 20.46 percent of total billed charges 20.46 31.35 Technical (Hospital) Services HC/HH Wch Supp Trach Tube Cuffed 7 Mrphy__5-10314 PX-2725000111 CDM 2725000111 LOCAL 272 RC inpatient 33 33 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES HDHP [308136802] 26.13 percent of total billed charges 20.46 31.35 Technical (Hospital) Services HC/HH Wch Supp Trach Tube Cuffed 7 Mrphy__5-10314 PX-2725000111 CDM 2725000111 LOCAL 272 RC inpatient 33 33 CIGNA 62308 [3081051] CIGNA 62308 [308105105] 26.13 percent of total billed charges 20.46 31.35 Technical (Hospital) Services HC/HH Wch Supp Trach Tube Cuffed 7 Mrphy__5-10314 PX-2725000111 CDM 2725000111 LOCAL 272 RC inpatient 33 33 CIGNA 62308 [3081051] CIGNA STATE OF WYOMING [308105107] 26.13 percent of total billed charges 20.46 31.35 Technical (Hospital) Services HC/HH Wch Supp Trach Tube Cuffed 7 Mrphy__5-10314 PX-2725000111 CDM 2725000111 LOCAL 272 RC inpatient 33 33 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES EPO [308136803] 26.13 percent of total billed charges 20.46 31.35 Technical (Hospital) Services HC/HH Wch Supp Trach Tube Cuffed 7 Mrphy__5-10314 PX-2725000111 CDM 2725000111 LOCAL 272 RC inpatient 33 33 MULTIPLAN INC 34080 [3081285] MULTIPLAN INC [308128501] 31.35 percent of total billed charges 20.46 31.35 Technical (Hospital) Services HC/HH Wch Supp Trach Tube Cuffed 7 Mrphy__5-10314 PX-2725000111 CDM 2725000111 LOCAL 272 RC inpatient 33 33 BLUE CROSS BLUE SHIELD WELLMARK SB889 [3081026] BCBS WYOMING [308102603] 31.35 percent of total billed charges 20.46 31.35 Technical (Hospital) Services HC/HH Wch Supp Trach Tube Cuffed 7 Mrphy__5-10314 PX-2725000111 CDM 2725000111 LOCAL 272 RC inpatient 33 33 HEALTHPARTNERS SX009 HEALTHPARTNERS 26.13 percent of total billed charges 20.46 31.35 Technical (Hospital) Services HC/HH Wch Supp Trach Tube Cuffed 7 Mrphy__5-10314 PX-2725000111 CDM 2725000111 LOCAL 272 RC outpatient 33 33 MEDICA (COMMERCIAL) 94265 [3081118] MEDICA CLAIMS [308111801] 29.7 percent of total billed charges 20.46 31.35 Technical (Hospital) Services HC/HH Wch Supp Trach Tube Cuffed 7 Mrphy__5-10314 PX-2725000111 CDM 2725000111 LOCAL 272 RC outpatient 33 33 MULTIPLAN INC 34080 [3081285] MULTIPLAN INC [308128501] 31.35 percent of total billed charges 20.46 31.35 Technical (Hospital) Services HC/HH Wch Supp Trach Tube Cuffed 7 Mrphy__5-10314 PX-2725000111 CDM 2725000111 LOCAL 272 RC outpatient 33 33 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES PPO [308136801] 26.4 percent of total billed charges 20.46 31.35 Technical (Hospital) Services HC/HH Wch Supp Trach Tube Cuffed 7 Mrphy__5-10314 PX-2725000111 CDM 2725000111 LOCAL 272 RC outpatient 33 33 HEALTHPARTNERS SX009 HEALTHPARTNERS 26.4 percent of total billed charges 20.46 31.35 Technical (Hospital) Services HC/HH Wch Supp Trach Tube Cuffed 7 Mrphy__5-10314 PX-2725000111 CDM 2725000111 LOCAL 272 RC outpatient 33 33 UNITED HEALTHCARE (COMMERCIAL) [3081199] UNITED HEALTHCARE 87726 [308119901] 20.46 percent of total billed charges 20.46 31.35 Technical (Hospital) Services HC/HH Wch Supp Trach Tube Cuffed 7 Mrphy__5-10314 PX-2725000111 CDM 2725000111 LOCAL 272 RC outpatient 33 33 CIGNA 62308 [3081051] CIGNA 62308 [308105105] 26.4 percent of total billed charges 20.46 31.35 Technical (Hospital) Services HC/HH Wch Supp Trach Tube Cuffed 7 Mrphy__5-10314 PX-2725000111 CDM 2725000111 LOCAL 272 RC outpatient 33 33 CIGNA 62308 [3081051] CIGNA STATE OF WYOMING [308105107] 26.4 percent of total billed charges 20.46 31.35 Technical (Hospital) Services HC/HH Wch Supp Trach Tube Cuffed 7 Mrphy__5-10314 PX-2725000111 CDM 2725000111 LOCAL 272 RC outpatient 33 33 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES HDHP [308136802] 26.4 percent of total billed charges 20.46 31.35 Technical (Hospital) Services HC/HH Wch Supp Trach Tube Cuffed 7 Mrphy__5-10314 PX-2725000111 CDM 2725000111 LOCAL 272 RC outpatient 33 33 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES EPO [308136803] 26.4 percent of total billed charges 20.46 31.35 Technical (Hospital) Services HC/HH Wch Supp Trach Tube Cuffed 7 Mrphy__5-10314 PX-2725000111 CDM 2725000111 LOCAL 272 RC outpatient 33 33 BLUE CROSS BLUE SHIELD WELLMARK SB889 [3081026] BCBS WYOMING [308102603] 31.35 percent of total billed charges 20.46 31.35 Technical (Hospital) Services HC/HH Wch Supp Trach Tube Cuffed 4.5 Mrphy__5-10109 PX-2725000110 CDM 2725000110 LOCAL 272 RC inpatient 33 33 MEDICA (COMMERCIAL) 94265 [3081118] MEDICA CLAIMS [308111801] 29.7 percent of total billed charges 20.46 31.35 Technical (Hospital) Services HC/HH Wch Supp Trach Tube Cuffed 4.5 Mrphy__5-10109 PX-2725000110 CDM 2725000110 LOCAL 272 RC inpatient 33 33 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES PPO [308136801] 26.13 percent of total billed charges 20.46 31.35 Technical (Hospital) Services HC/HH Wch Supp Trach Tube Cuffed 4.5 Mrphy__5-10109 PX-2725000110 CDM 2725000110 LOCAL 272 RC inpatient 33 33 CIGNA 62308 [3081051] CIGNA 62308 [308105105] 26.13 percent of total billed charges 20.46 31.35 Technical (Hospital) Services HC/HH Wch Supp Trach Tube Cuffed 4.5 Mrphy__5-10109 PX-2725000110 CDM 2725000110 LOCAL 272 RC inpatient 33 33 CIGNA 62308 [3081051] CIGNA STATE OF WYOMING [308105107] 26.13 percent of total billed charges 20.46 31.35 Technical (Hospital) Services HC/HH Wch Supp Trach Tube Cuffed 4.5 Mrphy__5-10109 PX-2725000110 CDM 2725000110 LOCAL 272 RC inpatient 33 33 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES HDHP [308136802] 26.13 percent of total billed charges 20.46 31.35 Technical (Hospital) Services HC/HH Wch Supp Trach Tube Cuffed 4.5 Mrphy__5-10109 PX-2725000110 CDM 2725000110 LOCAL 272 RC inpatient 33 33 UNITED HEALTHCARE (COMMERCIAL) [3081199] UNITED HEALTHCARE 87726 [308119901] 20.46 percent of total billed charges 20.46 31.35 Technical (Hospital) Services HC/HH Wch Supp Trach Tube Cuffed 4.5 Mrphy__5-10109 PX-2725000110 CDM 2725000110 LOCAL 272 RC inpatient 33 33 MULTIPLAN INC 34080 [3081285] MULTIPLAN INC [308128501] 31.35 percent of total billed charges 20.46 31.35 Technical (Hospital) Services HC/HH Wch Supp Trach Tube Cuffed 4.5 Mrphy__5-10109 PX-2725000110 CDM 2725000110 LOCAL 272 RC inpatient 33 33 BLUE CROSS BLUE SHIELD WELLMARK SB889 [3081026] BCBS WYOMING [308102603] 31.35 percent of total billed charges 20.46 31.35 Technical (Hospital) Services HC/HH Wch Supp Trach Tube Cuffed 4.5 Mrphy__5-10109 PX-2725000110 CDM 2725000110 LOCAL 272 RC inpatient 33 33 HEALTHPARTNERS SX009 HEALTHPARTNERS 26.13 percent of total billed charges 20.46 31.35 Technical (Hospital) Services HC/HH Wch Supp Trach Tube Cuffed 4.5 Mrphy__5-10109 PX-2725000110 CDM 2725000110 LOCAL 272 RC inpatient 33 33 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES EPO [308136803] 26.13 percent of total billed charges 20.46 31.35 Technical (Hospital) Services HC/HH Wch Supp Trach Tube Cuffed 4.5 Mrphy__5-10109 PX-2725000110 CDM 2725000110 LOCAL 272 RC outpatient 33 33 CIGNA 62308 [3081051] CIGNA 62308 [308105105] 26.4 percent of total billed charges 20.46 31.35 Technical (Hospital) Services HC/HH Wch Supp Trach Tube Cuffed 4.5 Mrphy__5-10109 PX-2725000110 CDM 2725000110 LOCAL 272 RC outpatient 33 33 CIGNA 62308 [3081051] CIGNA STATE OF WYOMING [308105107] 26.4 percent of total billed charges 20.46 31.35 Technical (Hospital) Services HC/HH Wch Supp Trach Tube Cuffed 4.5 Mrphy__5-10109 PX-2725000110 CDM 2725000110 LOCAL 272 RC outpatient 33 33 UNITED HEALTHCARE (COMMERCIAL) [3081199] UNITED HEALTHCARE 87726 [308119901] 20.46 percent of total billed charges 20.46 31.35 Technical (Hospital) Services HC/HH Wch Supp Trach Tube Cuffed 4.5 Mrphy__5-10109 PX-2725000110 CDM 2725000110 LOCAL 272 RC outpatient 33 33 HEALTHPARTNERS SX009 HEALTHPARTNERS 26.4 percent of total billed charges 20.46 31.35 Technical (Hospital) Services HC/HH Wch Supp Trach Tube Cuffed 4.5 Mrphy__5-10109 PX-2725000110 CDM 2725000110 LOCAL 272 RC outpatient 33 33 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES HDHP [308136802] 26.4 percent of total billed charges 20.46 31.35 Technical (Hospital) Services HC/HH Wch Supp Trach Tube Cuffed 4.5 Mrphy__5-10109 PX-2725000110 CDM 2725000110 LOCAL 272 RC outpatient 33 33 BLUE CROSS BLUE SHIELD WELLMARK SB889 [3081026] BCBS WYOMING [308102603] 31.35 percent of total billed charges 20.46 31.35 Technical (Hospital) Services HC/HH Wch Supp Trach Tube Cuffed 4.5 Mrphy__5-10109 PX-2725000110 CDM 2725000110 LOCAL 272 RC outpatient 33 33 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES EPO [308136803] 26.4 percent of total billed charges 20.46 31.35 Technical (Hospital) Services HC/HH Wch Supp Trach Tube Cuffed 4.5 Mrphy__5-10109 PX-2725000110 CDM 2725000110 LOCAL 272 RC outpatient 33 33 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES PPO [308136801] 26.4 percent of total billed charges 20.46 31.35 Technical (Hospital) Services HC/HH Wch Supp Trach Tube Cuffed 4.5 Mrphy__5-10109 PX-2725000110 CDM 2725000110 LOCAL 272 RC outpatient 33 33 MULTIPLAN INC 34080 [3081285] MULTIPLAN INC [308128501] 31.35 percent of total billed charges 20.46 31.35 Technical (Hospital) Services HC/HH Wch Supp Trach Tube Cuffed 4.5 Mrphy__5-10109 PX-2725000110 CDM 2725000110 LOCAL 272 RC outpatient 33 33 MEDICA (COMMERCIAL) 94265 [3081118] MEDICA CLAIMS [308111801] 29.7 percent of total billed charges 20.46 31.35 Technical (Hospital) Services HC/HH Wch Supp Trach Tube Cuffed 3.5 Mrphy__5-10107 PX-2725000109 CDM 2725000109 LOCAL 272 RC inpatient 33 33 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES EPO [308136803] 26.13 percent of total billed charges 20.46 31.35 Technical (Hospital) Services HC/HH Wch Supp Trach Tube Cuffed 3.5 Mrphy__5-10107 PX-2725000109 CDM 2725000109 LOCAL 272 RC inpatient 33 33 HEALTHPARTNERS SX009 HEALTHPARTNERS 26.13 percent of total billed charges 20.46 31.35 Technical (Hospital) Services HC/HH Wch Supp Trach Tube Cuffed 3.5 Mrphy__5-10107 PX-2725000109 CDM 2725000109 LOCAL 272 RC inpatient 33 33 BLUE CROSS BLUE SHIELD WELLMARK SB889 [3081026] BCBS WYOMING [308102603] 31.35 percent of total billed charges 20.46 31.35 Technical (Hospital) Services HC/HH Wch Supp Trach Tube Cuffed 3.5 Mrphy__5-10107 PX-2725000109 CDM 2725000109 LOCAL 272 RC inpatient 33 33 MULTIPLAN INC 34080 [3081285] MULTIPLAN INC [308128501] 31.35 percent of total billed charges 20.46 31.35 Technical (Hospital) Services HC/HH Wch Supp Trach Tube Cuffed 3.5 Mrphy__5-10107 PX-2725000109 CDM 2725000109 LOCAL 272 RC inpatient 33 33 UNITED HEALTHCARE (COMMERCIAL) [3081199] UNITED HEALTHCARE 87726 [308119901] 20.46 percent of total billed charges 20.46 31.35 Technical (Hospital) Services HC/HH Wch Supp Trach Tube Cuffed 3.5 Mrphy__5-10107 PX-2725000109 CDM 2725000109 LOCAL 272 RC inpatient 33 33 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES HDHP [308136802] 26.13 percent of total billed charges 20.46 31.35 Technical (Hospital) Services HC/HH Wch Supp Trach Tube Cuffed 3.5 Mrphy__5-10107 PX-2725000109 CDM 2725000109 LOCAL 272 RC inpatient 33 33 CIGNA 62308 [3081051] CIGNA 62308 [308105105] 26.13 percent of total billed charges 20.46 31.35 Technical (Hospital) Services HC/HH Wch Supp Trach Tube Cuffed 3.5 Mrphy__5-10107 PX-2725000109 CDM 2725000109 LOCAL 272 RC inpatient 33 33 CIGNA 62308 [3081051] CIGNA STATE OF WYOMING [308105107] 26.13 percent of total billed charges 20.46 31.35 Technical (Hospital) Services HC/HH Wch Supp Trach Tube Cuffed 3.5 Mrphy__5-10107 PX-2725000109 CDM 2725000109 LOCAL 272 RC inpatient 33 33 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES PPO [308136801] 26.13 percent of total billed charges 20.46 31.35 Technical (Hospital) Services HC/HH Wch Supp Trach Tube Cuffed 3.5 Mrphy__5-10107 PX-2725000109 CDM 2725000109 LOCAL 272 RC inpatient 33 33 MEDICA (COMMERCIAL) 94265 [3081118] MEDICA CLAIMS [308111801] 29.7 percent of total billed charges 20.46 31.35 Technical (Hospital) Services HC/HH Wch Supp Trach Tube Cuffed 3.5 Mrphy__5-10107 PX-2725000109 CDM 2725000109 LOCAL 272 RC outpatient 33 33 MULTIPLAN INC 34080 [3081285] MULTIPLAN INC [308128501] 31.35 percent of total billed charges 20.46 31.35 Technical (Hospital) Services HC/HH Wch Supp Trach Tube Cuffed 3.5 Mrphy__5-10107 PX-2725000109 CDM 2725000109 LOCAL 272 RC outpatient 33 33 MEDICA (COMMERCIAL) 94265 [3081118] MEDICA CLAIMS [308111801] 29.7 percent of total billed charges 20.46 31.35 Technical (Hospital) Services HC/HH Wch Supp Trach Tube Cuffed 3.5 Mrphy__5-10107 PX-2725000109 CDM 2725000109 LOCAL 272 RC outpatient 33 33 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES EPO [308136803] 26.4 percent of total billed charges 20.46 31.35 Technical (Hospital) Services HC/HH Wch Supp Trach Tube Cuffed 3.5 Mrphy__5-10107 PX-2725000109 CDM 2725000109 LOCAL 272 RC outpatient 33 33 BLUE CROSS BLUE SHIELD WELLMARK SB889 [3081026] BCBS WYOMING [308102603] 31.35 percent of total billed charges 20.46 31.35 Technical (Hospital) Services HC/HH Wch Supp Trach Tube Cuffed 3.5 Mrphy__5-10107 PX-2725000109 CDM 2725000109 LOCAL 272 RC outpatient 33 33 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES HDHP [308136802] 26.4 percent of total billed charges 20.46 31.35 Technical (Hospital) Services HC/HH Wch Supp Trach Tube Cuffed 3.5 Mrphy__5-10107 PX-2725000109 CDM 2725000109 LOCAL 272 RC outpatient 33 33 HEALTHPARTNERS SX009 HEALTHPARTNERS 26.4 percent of total billed charges 20.46 31.35 Technical (Hospital) Services HC/HH Wch Supp Trach Tube Cuffed 3.5 Mrphy__5-10107 PX-2725000109 CDM 2725000109 LOCAL 272 RC outpatient 33 33 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES PPO [308136801] 26.4 percent of total billed charges 20.46 31.35 Technical (Hospital) Services HC/HH Wch Supp Trach Tube Cuffed 3.5 Mrphy__5-10107 PX-2725000109 CDM 2725000109 LOCAL 272 RC outpatient 33 33 UNITED HEALTHCARE (COMMERCIAL) [3081199] UNITED HEALTHCARE 87726 [308119901] 20.46 percent of total billed charges 20.46 31.35 Technical (Hospital) Services HC/HH Wch Supp Trach Tube Cuffed 3.5 Mrphy__5-10107 PX-2725000109 CDM 2725000109 LOCAL 272 RC outpatient 33 33 CIGNA 62308 [3081051] CIGNA 62308 [308105105] 26.4 percent of total billed charges 20.46 31.35 Technical (Hospital) Services HC/HH Wch Supp Trach Tube Cuffed 3.5 Mrphy__5-10107 PX-2725000109 CDM 2725000109 LOCAL 272 RC outpatient 33 33 CIGNA 62308 [3081051] CIGNA STATE OF WYOMING [308105107] 26.4 percent of total billed charges 20.46 31.35 Technical (Hospital) Services "HC/HH Wch Supp Thorac.Cath.24fr.16__8888561050""" PX-2725000108 CDM 2725000108 LOCAL 272 RC inpatient 70 70 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES EPO [308136803] 55.43 percent of total billed charges 43.4 66.5 Technical (Hospital) Services "HC/HH Wch Supp Thorac.Cath.24fr.16__8888561050""" PX-2725000108 CDM 2725000108 LOCAL 272 RC inpatient 70 70 MULTIPLAN INC 34080 [3081285] MULTIPLAN INC [308128501] 66.5 percent of total billed charges 43.4 66.5 Technical (Hospital) Services "HC/HH Wch Supp Thorac.Cath.24fr.16__8888561050""" PX-2725000108 CDM 2725000108 LOCAL 272 RC inpatient 70 70 BLUE CROSS BLUE SHIELD WELLMARK SB889 [3081026] BCBS WYOMING [308102603] 66.5 percent of total billed charges 43.4 66.5 Technical (Hospital) Services "HC/HH Wch Supp Thorac.Cath.24fr.16__8888561050""" PX-2725000108 CDM 2725000108 LOCAL 272 RC inpatient 70 70 HEALTHPARTNERS SX009 HEALTHPARTNERS 55.43 percent of total billed charges 43.4 66.5 Technical (Hospital) Services "HC/HH Wch Supp Thorac.Cath.24fr.16__8888561050""" PX-2725000108 CDM 2725000108 LOCAL 272 RC inpatient 70 70 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES PPO [308136801] 55.43 percent of total billed charges 43.4 66.5 Technical (Hospital) Services "HC/HH Wch Supp Thorac.Cath.24fr.16__8888561050""" PX-2725000108 CDM 2725000108 LOCAL 272 RC inpatient 70 70 MEDICA (COMMERCIAL) 94265 [3081118] MEDICA CLAIMS [308111801] 63 percent of total billed charges 43.4 66.5 Technical (Hospital) Services "HC/HH Wch Supp Thorac.Cath.24fr.16__8888561050""" PX-2725000108 CDM 2725000108 LOCAL 272 RC inpatient 70 70 UNITED HEALTHCARE (COMMERCIAL) [3081199] UNITED HEALTHCARE 87726 [308119901] 43.4 percent of total billed charges 43.4 66.5 Technical (Hospital) Services "HC/HH Wch Supp Thorac.Cath.24fr.16__8888561050""" PX-2725000108 CDM 2725000108 LOCAL 272 RC inpatient 70 70 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES HDHP [308136802] 55.43 percent of total billed charges 43.4 66.5 Technical (Hospital) Services "HC/HH Wch Supp Thorac.Cath.24fr.16__8888561050""" PX-2725000108 CDM 2725000108 LOCAL 272 RC inpatient 70 70 CIGNA 62308 [3081051] CIGNA 62308 [308105105] 55.43 percent of total billed charges 43.4 66.5 Technical (Hospital) Services "HC/HH Wch Supp Thorac.Cath.24fr.16__8888561050""" PX-2725000108 CDM 2725000108 LOCAL 272 RC inpatient 70 70 CIGNA 62308 [3081051] CIGNA STATE OF WYOMING [308105107] 55.43 percent of total billed charges 43.4 66.5 Technical (Hospital) Services "HC/HH Wch Supp Thorac.Cath.24fr.16__8888561050""" PX-2725000108 CDM 2725000108 LOCAL 272 RC outpatient 70 70 CIGNA 62308 [3081051] CIGNA 62308 [308105105] 56 percent of total billed charges 43.4 66.5 Technical (Hospital) Services "HC/HH Wch Supp Thorac.Cath.24fr.16__8888561050""" PX-2725000108 CDM 2725000108 LOCAL 272 RC outpatient 70 70 CIGNA 62308 [3081051] CIGNA STATE OF WYOMING [308105107] 56 percent of total billed charges 43.4 66.5 Technical (Hospital) Services "HC/HH Wch Supp Thorac.Cath.24fr.16__8888561050""" PX-2725000108 CDM 2725000108 LOCAL 272 RC outpatient 70 70 UNITED HEALTHCARE (COMMERCIAL) [3081199] UNITED HEALTHCARE 87726 [308119901] 43.4 percent of total billed charges 43.4 66.5 Technical (Hospital) Services "HC/HH Wch Supp Thorac.Cath.24fr.16__8888561050""" PX-2725000108 CDM 2725000108 LOCAL 272 RC outpatient 70 70 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES PPO [308136801] 56 percent of total billed charges 43.4 66.5 Technical (Hospital) Services "HC/HH Wch Supp Thorac.Cath.24fr.16__8888561050""" PX-2725000108 CDM 2725000108 LOCAL 272 RC outpatient 70 70 HEALTHPARTNERS SX009 HEALTHPARTNERS 56 percent of total billed charges 43.4 66.5 Technical (Hospital) Services "HC/HH Wch Supp Thorac.Cath.24fr.16__8888561050""" PX-2725000108 CDM 2725000108 LOCAL 272 RC outpatient 70 70 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES HDHP [308136802] 56 percent of total billed charges 43.4 66.5 Technical (Hospital) Services "HC/HH Wch Supp Thorac.Cath.24fr.16__8888561050""" PX-2725000108 CDM 2725000108 LOCAL 272 RC outpatient 70 70 BLUE CROSS BLUE SHIELD WELLMARK SB889 [3081026] BCBS WYOMING [308102603] 66.5 percent of total billed charges 43.4 66.5 Technical (Hospital) Services "HC/HH Wch Supp Thorac.Cath.24fr.16__8888561050""" PX-2725000108 CDM 2725000108 LOCAL 272 RC outpatient 70 70 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES EPO [308136803] 56 percent of total billed charges 43.4 66.5 Technical (Hospital) Services "HC/HH Wch Supp Thorac.Cath.24fr.16__8888561050""" PX-2725000108 CDM 2725000108 LOCAL 272 RC outpatient 70 70 MEDICA (COMMERCIAL) 94265 [3081118] MEDICA CLAIMS [308111801] 63 percent of total billed charges 43.4 66.5 Technical (Hospital) Services "HC/HH Wch Supp Thorac.Cath.24fr.16__8888561050""" PX-2725000108 CDM 2725000108 LOCAL 272 RC outpatient 70 70 MULTIPLAN INC 34080 [3081285] MULTIPLAN INC [308128501] 66.5 percent of total billed charges 43.4 66.5 Technical (Hospital) Services HC/HH Wch Supp Tape Steristrip .5x4__R1547 PX-2725000107 CDM 2725000107 LOCAL 272 RC inpatient 8 8 HEALTHPARTNERS SX009 HEALTHPARTNERS 6.33 percent of total billed charges 4.96 7.6 Technical (Hospital) Services HC/HH Wch Supp Tape Steristrip .5x4__R1547 PX-2725000107 CDM 2725000107 LOCAL 272 RC inpatient 8 8 BLUE CROSS BLUE SHIELD WELLMARK SB889 [3081026] BCBS WYOMING [308102603] 7.6 percent of total billed charges 4.96 7.6 Technical (Hospital) Services HC/HH Wch Supp Tape Steristrip .5x4__R1547 PX-2725000107 CDM 2725000107 LOCAL 272 RC inpatient 8 8 MULTIPLAN INC 34080 [3081285] MULTIPLAN INC [308128501] 7.6 percent of total billed charges 4.96 7.6 Technical (Hospital) Services HC/HH Wch Supp Tape Steristrip .5x4__R1547 PX-2725000107 CDM 2725000107 LOCAL 272 RC inpatient 8 8 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES EPO [308136803] 6.33 percent of total billed charges 4.96 7.6 Technical (Hospital) Services HC/HH Wch Supp Tape Steristrip .5x4__R1547 PX-2725000107 CDM 2725000107 LOCAL 272 RC inpatient 8 8 MEDICA (COMMERCIAL) 94265 [3081118] MEDICA CLAIMS [308111801] 7.2 percent of total billed charges 4.96 7.6 Technical (Hospital) Services HC/HH Wch Supp Tape Steristrip .5x4__R1547 PX-2725000107 CDM 2725000107 LOCAL 272 RC inpatient 8 8 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES PPO [308136801] 6.33 percent of total billed charges 4.96 7.6 Technical (Hospital) Services HC/HH Wch Supp Tape Steristrip .5x4__R1547 PX-2725000107 CDM 2725000107 LOCAL 272 RC inpatient 8 8 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES HDHP [308136802] 6.33 percent of total billed charges 4.96 7.6 Technical (Hospital) Services HC/HH Wch Supp Tape Steristrip .5x4__R1547 PX-2725000107 CDM 2725000107 LOCAL 272 RC inpatient 8 8 UNITED HEALTHCARE (COMMERCIAL) [3081199] UNITED HEALTHCARE 87726 [308119901] 4.96 percent of total billed charges 4.96 7.6 Technical (Hospital) Services HC/HH Wch Supp Tape Steristrip .5x4__R1547 PX-2725000107 CDM 2725000107 LOCAL 272 RC inpatient 8 8 CIGNA 62308 [3081051] CIGNA 62308 [308105105] 6.33 percent of total billed charges 4.96 7.6 Technical (Hospital) Services HC/HH Wch Supp Tape Steristrip .5x4__R1547 PX-2725000107 CDM 2725000107 LOCAL 272 RC inpatient 8 8 CIGNA 62308 [3081051] CIGNA STATE OF WYOMING [308105107] 6.33 percent of total billed charges 4.96 7.6 Technical (Hospital) Services HC/HH Wch Supp Tape Steristrip .5x4__R1547 PX-2725000107 CDM 2725000107 LOCAL 272 RC outpatient 8 8 CIGNA 62308 [3081051] CIGNA 62308 [308105105] 6.4 percent of total billed charges 4.96 7.6 Technical (Hospital) Services HC/HH Wch Supp Tape Steristrip .5x4__R1547 PX-2725000107 CDM 2725000107 LOCAL 272 RC outpatient 8 8 CIGNA 62308 [3081051] CIGNA STATE OF WYOMING [308105107] 6.4 percent of total billed charges 4.96 7.6 Technical (Hospital) Services HC/HH Wch Supp Tape Steristrip .5x4__R1547 PX-2725000107 CDM 2725000107 LOCAL 272 RC outpatient 8 8 UNITED HEALTHCARE (COMMERCIAL) [3081199] UNITED HEALTHCARE 87726 [308119901] 4.96 percent of total billed charges 4.96 7.6 Technical (Hospital) Services HC/HH Wch Supp Tape Steristrip .5x4__R1547 PX-2725000107 CDM 2725000107 LOCAL 272 RC outpatient 8 8 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES PPO [308136801] 6.4 percent of total billed charges 4.96 7.6 Technical (Hospital) Services HC/HH Wch Supp Tape Steristrip .5x4__R1547 PX-2725000107 CDM 2725000107 LOCAL 272 RC outpatient 8 8 HEALTHPARTNERS SX009 HEALTHPARTNERS 6.4 percent of total billed charges 4.96 7.6 Technical (Hospital) Services HC/HH Wch Supp Tape Steristrip .5x4__R1547 PX-2725000107 CDM 2725000107 LOCAL 272 RC outpatient 8 8 BLUE CROSS BLUE SHIELD WELLMARK SB889 [3081026] BCBS WYOMING [308102603] 7.6 percent of total billed charges 4.96 7.6 Technical (Hospital) Services HC/HH Wch Supp Tape Steristrip .5x4__R1547 PX-2725000107 CDM 2725000107 LOCAL 272 RC outpatient 8 8 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES EPO [308136803] 6.4 percent of total billed charges 4.96 7.6 Technical (Hospital) Services HC/HH Wch Supp Tape Steristrip .5x4__R1547 PX-2725000107 CDM 2725000107 LOCAL 272 RC outpatient 8 8 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES HDHP [308136802] 6.4 percent of total billed charges 4.96 7.6 Technical (Hospital) Services HC/HH Wch Supp Tape Steristrip .5x4__R1547 PX-2725000107 CDM 2725000107 LOCAL 272 RC outpatient 8 8 MEDICA (COMMERCIAL) 94265 [3081118] MEDICA CLAIMS [308111801] 7.2 percent of total billed charges 4.96 7.6 Technical (Hospital) Services HC/HH Wch Supp Tape Steristrip .5x4__R1547 PX-2725000107 CDM 2725000107 LOCAL 272 RC outpatient 8 8 MULTIPLAN INC 34080 [3081285] MULTIPLAN INC [308128501] 7.6 percent of total billed charges 4.96 7.6 Technical (Hospital) Services HC/HH Wch Supp Tape Steristrip .25x3__R1541 PX-2725000106 CDM 2725000106 LOCAL 272 RC inpatient 5 5 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES EPO [308136803] 3.96 percent of total billed charges 3.1 4.75 Technical (Hospital) Services HC/HH Wch Supp Tape Steristrip .25x3__R1541 PX-2725000106 CDM 2725000106 LOCAL 272 RC inpatient 5 5 MULTIPLAN INC 34080 [3081285] MULTIPLAN INC [308128501] 4.75 percent of total billed charges 3.1 4.75 Technical (Hospital) Services HC/HH Wch Supp Tape Steristrip .25x3__R1541 PX-2725000106 CDM 2725000106 LOCAL 272 RC inpatient 5 5 BLUE CROSS BLUE SHIELD WELLMARK SB889 [3081026] BCBS WYOMING [308102603] 4.75 percent of total billed charges 3.1 4.75 Technical (Hospital) Services HC/HH Wch Supp Tape Steristrip .25x3__R1541 PX-2725000106 CDM 2725000106 LOCAL 272 RC inpatient 5 5 HEALTHPARTNERS SX009 HEALTHPARTNERS 3.96 percent of total billed charges 3.1 4.75 Technical (Hospital) Services HC/HH Wch Supp Tape Steristrip .25x3__R1541 PX-2725000106 CDM 2725000106 LOCAL 272 RC inpatient 5 5 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES PPO [308136801] 3.96 percent of total billed charges 3.1 4.75 Technical (Hospital) Services HC/HH Wch Supp Tape Steristrip .25x3__R1541 PX-2725000106 CDM 2725000106 LOCAL 272 RC inpatient 5 5 MEDICA (COMMERCIAL) 94265 [3081118] MEDICA CLAIMS [308111801] 4.5 percent of total billed charges 3.1 4.75 Technical (Hospital) Services HC/HH Wch Supp Tape Steristrip .25x3__R1541 PX-2725000106 CDM 2725000106 LOCAL 272 RC inpatient 5 5 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES HDHP [308136802] 3.96 percent of total billed charges 3.1 4.75 Technical (Hospital) Services HC/HH Wch Supp Tape Steristrip .25x3__R1541 PX-2725000106 CDM 2725000106 LOCAL 272 RC inpatient 5 5 UNITED HEALTHCARE (COMMERCIAL) [3081199] UNITED HEALTHCARE 87726 [308119901] 3.1 percent of total billed charges 3.1 4.75 Technical (Hospital) Services HC/HH Wch Supp Tape Steristrip .25x3__R1541 PX-2725000106 CDM 2725000106 LOCAL 272 RC inpatient 5 5 CIGNA 62308 [3081051] CIGNA 62308 [308105105] 3.96 percent of total billed charges 3.1 4.75 Technical (Hospital) Services HC/HH Wch Supp Tape Steristrip .25x3__R1541 PX-2725000106 CDM 2725000106 LOCAL 272 RC inpatient 5 5 CIGNA 62308 [3081051] CIGNA STATE OF WYOMING [308105107] 3.96 percent of total billed charges 3.1 4.75 Technical (Hospital) Services HC/HH Wch Supp Tape Steristrip .25x3__R1541 PX-2725000106 CDM 2725000106 LOCAL 272 RC outpatient 5 5 CIGNA 62308 [3081051] CIGNA 62308 [308105105] 4 percent of total billed charges 3.1 4.75 Technical (Hospital) Services HC/HH Wch Supp Tape Steristrip .25x3__R1541 PX-2725000106 CDM 2725000106 LOCAL 272 RC outpatient 5 5 CIGNA 62308 [3081051] CIGNA STATE OF WYOMING [308105107] 4 percent of total billed charges 3.1 4.75 Technical (Hospital) Services HC/HH Wch Supp Tape Steristrip .25x3__R1541 PX-2725000106 CDM 2725000106 LOCAL 272 RC outpatient 5 5 UNITED HEALTHCARE (COMMERCIAL) [3081199] UNITED HEALTHCARE 87726 [308119901] 3.1 percent of total billed charges 3.1 4.75 Technical (Hospital) Services HC/HH Wch Supp Tape Steristrip .25x3__R1541 PX-2725000106 CDM 2725000106 LOCAL 272 RC outpatient 5 5 HEALTHPARTNERS SX009 HEALTHPARTNERS 4 percent of total billed charges 3.1 4.75 Technical (Hospital) Services HC/HH Wch Supp Tape Steristrip .25x3__R1541 PX-2725000106 CDM 2725000106 LOCAL 272 RC outpatient 5 5 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES PPO [308136801] 4 percent of total billed charges 3.1 4.75 Technical (Hospital) Services HC/HH Wch Supp Tape Steristrip .25x3__R1541 PX-2725000106 CDM 2725000106 LOCAL 272 RC outpatient 5 5 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES HDHP [308136802] 4 percent of total billed charges 3.1 4.75 Technical (Hospital) Services HC/HH Wch Supp Tape Steristrip .25x3__R1541 PX-2725000106 CDM 2725000106 LOCAL 272 RC outpatient 5 5 BLUE CROSS BLUE SHIELD WELLMARK SB889 [3081026] BCBS WYOMING [308102603] 4.75 percent of total billed charges 3.1 4.75 Technical (Hospital) Services HC/HH Wch Supp Tape Steristrip .25x3__R1541 PX-2725000106 CDM 2725000106 LOCAL 272 RC outpatient 5 5 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES EPO [308136803] 4 percent of total billed charges 3.1 4.75 Technical (Hospital) Services HC/HH Wch Supp Tape Steristrip .25x3__R1541 PX-2725000106 CDM 2725000106 LOCAL 272 RC outpatient 5 5 MULTIPLAN INC 34080 [3081285] MULTIPLAN INC [308128501] 4.75 percent of total billed charges 3.1 4.75 Technical (Hospital) Services HC/HH Wch Supp Tape Steristrip .25x3__R1541 PX-2725000106 CDM 2725000106 LOCAL 272 RC outpatient 5 5 MEDICA (COMMERCIAL) 94265 [3081118] MEDICA CLAIMS [308111801] 4.5 percent of total billed charges 3.1 4.75 Technical (Hospital) Services HC/HH Wch Supp Syringe Luer Lok 20ml__309661 PX-2725000105 CDM 2725000105 LOCAL 272 RC outpatient 6 6 MEDICA (COMMERCIAL) 94265 [3081118] MEDICA CLAIMS [308111801] 5.4 percent of total billed charges 3.72 5.7 Technical (Hospital) Services HC/HH Wch Supp Syringe Luer Lok 20ml__309661 PX-2725000105 CDM 2725000105 LOCAL 272 RC outpatient 6 6 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES PPO [308136801] 4.8 percent of total billed charges 3.72 5.7 Technical (Hospital) Services HC/HH Wch Supp Syringe Luer Lok 20ml__309661 PX-2725000105 CDM 2725000105 LOCAL 272 RC outpatient 6 6 MULTIPLAN INC 34080 [3081285] MULTIPLAN INC [308128501] 5.7 percent of total billed charges 3.72 5.7 Technical (Hospital) Services HC/HH Wch Supp Syringe Luer Lok 20ml__309661 PX-2725000105 CDM 2725000105 LOCAL 272 RC outpatient 6 6 HEALTHPARTNERS SX009 HEALTHPARTNERS 4.8 percent of total billed charges 3.72 5.7 Technical (Hospital) Services HC/HH Wch Supp Syringe Luer Lok 20ml__309661 PX-2725000105 CDM 2725000105 LOCAL 272 RC outpatient 6 6 UNITED HEALTHCARE (COMMERCIAL) [3081199] UNITED HEALTHCARE 87726 [308119901] 3.72 percent of total billed charges 3.72 5.7 Technical (Hospital) Services HC/HH Wch Supp Syringe Luer Lok 20ml__309661 PX-2725000105 CDM 2725000105 LOCAL 272 RC outpatient 6 6 CIGNA 62308 [3081051] CIGNA 62308 [308105105] 4.8 percent of total billed charges 3.72 5.7 Technical (Hospital) Services HC/HH Wch Supp Syringe Luer Lok 20ml__309661 PX-2725000105 CDM 2725000105 LOCAL 272 RC outpatient 6 6 CIGNA 62308 [3081051] CIGNA STATE OF WYOMING [308105107] 4.8 percent of total billed charges 3.72 5.7 Technical (Hospital) Services HC/HH Wch Supp Syringe Luer Lok 20ml__309661 PX-2725000105 CDM 2725000105 LOCAL 272 RC outpatient 6 6 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES HDHP [308136802] 4.8 percent of total billed charges 3.72 5.7 Technical (Hospital) Services HC/HH Wch Supp Syringe Luer Lok 20ml__309661 PX-2725000105 CDM 2725000105 LOCAL 272 RC outpatient 6 6 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES EPO [308136803] 4.8 percent of total billed charges 3.72 5.7 Technical (Hospital) Services HC/HH Wch Supp Syringe Luer Lok 20ml__309661 PX-2725000105 CDM 2725000105 LOCAL 272 RC outpatient 6 6 BLUE CROSS BLUE SHIELD WELLMARK SB889 [3081026] BCBS WYOMING [308102603] 5.7 percent of total billed charges 3.72 5.7 Technical (Hospital) Services HC/HH Wch Supp Syringe Luer Lok 20ml__309661 PX-2725000105 CDM 2725000105 LOCAL 272 RC inpatient 6 6 MEDICA (COMMERCIAL) 94265 [3081118] MEDICA CLAIMS [308111801] 5.4 percent of total billed charges 3.72 5.7 Technical (Hospital) Services HC/HH Wch Supp Syringe Luer Lok 20ml__309661 PX-2725000105 CDM 2725000105 LOCAL 272 RC inpatient 6 6 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES PPO [308136801] 4.75 percent of total billed charges 3.72 5.7 Technical (Hospital) Services HC/HH Wch Supp Syringe Luer Lok 20ml__309661 PX-2725000105 CDM 2725000105 LOCAL 272 RC inpatient 6 6 CIGNA 62308 [3081051] CIGNA 62308 [308105105] 4.75 percent of total billed charges 3.72 5.7 Technical (Hospital) Services HC/HH Wch Supp Syringe Luer Lok 20ml__309661 PX-2725000105 CDM 2725000105 LOCAL 272 RC inpatient 6 6 CIGNA 62308 [3081051] CIGNA STATE OF WYOMING [308105107] 4.75 percent of total billed charges 3.72 5.7 Technical (Hospital) Services HC/HH Wch Supp Syringe Luer Lok 20ml__309661 PX-2725000105 CDM 2725000105 LOCAL 272 RC inpatient 6 6 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES HDHP [308136802] 4.75 percent of total billed charges 3.72 5.7 Technical (Hospital) Services HC/HH Wch Supp Syringe Luer Lok 20ml__309661 PX-2725000105 CDM 2725000105 LOCAL 272 RC inpatient 6 6 UNITED HEALTHCARE (COMMERCIAL) [3081199] UNITED HEALTHCARE 87726 [308119901] 3.72 percent of total billed charges 3.72 5.7 Technical (Hospital) Services HC/HH Wch Supp Syringe Luer Lok 20ml__309661 PX-2725000105 CDM 2725000105 LOCAL 272 RC inpatient 6 6 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES EPO [308136803] 4.75 percent of total billed charges 3.72 5.7 Technical (Hospital) Services HC/HH Wch Supp Syringe Luer Lok 20ml__309661 PX-2725000105 CDM 2725000105 LOCAL 272 RC inpatient 6 6 HEALTHPARTNERS SX009 HEALTHPARTNERS 4.75 percent of total billed charges 3.72 5.7 Technical (Hospital) Services HC/HH Wch Supp Syringe Luer Lok 20ml__309661 PX-2725000105 CDM 2725000105 LOCAL 272 RC inpatient 6 6 MULTIPLAN INC 34080 [3081285] MULTIPLAN INC [308128501] 5.7 percent of total billed charges 3.72 5.7 Technical (Hospital) Services HC/HH Wch Supp Syringe Luer Lok 20ml__309661 PX-2725000105 CDM 2725000105 LOCAL 272 RC inpatient 6 6 BLUE CROSS BLUE SHIELD WELLMARK SB889 [3081026] BCBS WYOMING [308102603] 5.7 percent of total billed charges 3.72 5.7 Technical (Hospital) Services HC/HH Wch Supp Syringe Luer Lok 10ml__309604 PX-2725000104 CDM 2725000104 LOCAL 272 RC inpatient 6 6 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES EPO [308136803] 4.75 percent of total billed charges 3.72 5.7 Technical (Hospital) Services HC/HH Wch Supp Syringe Luer Lok 10ml__309604 PX-2725000104 CDM 2725000104 LOCAL 272 RC inpatient 6 6 BLUE CROSS BLUE SHIELD WELLMARK SB889 [3081026] BCBS WYOMING [308102603] 5.7 percent of total billed charges 3.72 5.7 Technical (Hospital) Services HC/HH Wch Supp Syringe Luer Lok 10ml__309604 PX-2725000104 CDM 2725000104 LOCAL 272 RC inpatient 6 6 MULTIPLAN INC 34080 [3081285] MULTIPLAN INC [308128501] 5.7 percent of total billed charges 3.72 5.7 Technical (Hospital) Services HC/HH Wch Supp Syringe Luer Lok 10ml__309604 PX-2725000104 CDM 2725000104 LOCAL 272 RC inpatient 6 6 HEALTHPARTNERS SX009 HEALTHPARTNERS 4.75 percent of total billed charges 3.72 5.7 Technical (Hospital) Services HC/HH Wch Supp Syringe Luer Lok 10ml__309604 PX-2725000104 CDM 2725000104 LOCAL 272 RC inpatient 6 6 MEDICA (COMMERCIAL) 94265 [3081118] MEDICA CLAIMS [308111801] 5.4 percent of total billed charges 3.72 5.7 Technical (Hospital) Services HC/HH Wch Supp Syringe Luer Lok 10ml__309604 PX-2725000104 CDM 2725000104 LOCAL 272 RC inpatient 6 6 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES PPO [308136801] 4.75 percent of total billed charges 3.72 5.7 Technical (Hospital) Services HC/HH Wch Supp Syringe Luer Lok 10ml__309604 PX-2725000104 CDM 2725000104 LOCAL 272 RC inpatient 6 6 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES HDHP [308136802] 4.75 percent of total billed charges 3.72 5.7 Technical (Hospital) Services HC/HH Wch Supp Syringe Luer Lok 10ml__309604 PX-2725000104 CDM 2725000104 LOCAL 272 RC inpatient 6 6 UNITED HEALTHCARE (COMMERCIAL) [3081199] UNITED HEALTHCARE 87726 [308119901] 3.72 percent of total billed charges 3.72 5.7 Technical (Hospital) Services HC/HH Wch Supp Syringe Luer Lok 10ml__309604 PX-2725000104 CDM 2725000104 LOCAL 272 RC inpatient 6 6 CIGNA 62308 [3081051] CIGNA 62308 [308105105] 4.75 percent of total billed charges 3.72 5.7 Technical (Hospital) Services HC/HH Wch Supp Syringe Luer Lok 10ml__309604 PX-2725000104 CDM 2725000104 LOCAL 272 RC inpatient 6 6 CIGNA 62308 [3081051] CIGNA STATE OF WYOMING [308105107] 4.75 percent of total billed charges 3.72 5.7 Technical (Hospital) Services HC/HH Wch Supp Syringe Luer Lok 10ml__309604 PX-2725000104 CDM 2725000104 LOCAL 272 RC outpatient 6 6 CIGNA 62308 [3081051] CIGNA 62308 [308105105] 4.8 percent of total billed charges 3.72 5.7 Technical (Hospital) Services HC/HH Wch Supp Syringe Luer Lok 10ml__309604 PX-2725000104 CDM 2725000104 LOCAL 272 RC outpatient 6 6 CIGNA 62308 [3081051] CIGNA STATE OF WYOMING [308105107] 4.8 percent of total billed charges 3.72 5.7 Technical (Hospital) Services HC/HH Wch Supp Syringe Luer Lok 10ml__309604 PX-2725000104 CDM 2725000104 LOCAL 272 RC outpatient 6 6 UNITED HEALTHCARE (COMMERCIAL) [3081199] UNITED HEALTHCARE 87726 [308119901] 3.72 percent of total billed charges 3.72 5.7 Technical (Hospital) Services HC/HH Wch Supp Syringe Luer Lok 10ml__309604 PX-2725000104 CDM 2725000104 LOCAL 272 RC outpatient 6 6 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES HDHP [308136802] 4.8 percent of total billed charges 3.72 5.7 Technical (Hospital) Services HC/HH Wch Supp Syringe Luer Lok 10ml__309604 PX-2725000104 CDM 2725000104 LOCAL 272 RC outpatient 6 6 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES EPO [308136803] 4.8 percent of total billed charges 3.72 5.7 Technical (Hospital) Services HC/HH Wch Supp Syringe Luer Lok 10ml__309604 PX-2725000104 CDM 2725000104 LOCAL 272 RC outpatient 6 6 BLUE CROSS BLUE SHIELD WELLMARK SB889 [3081026] BCBS WYOMING [308102603] 5.7 percent of total billed charges 3.72 5.7 Technical (Hospital) Services HC/HH Wch Supp Syringe Luer Lok 10ml__309604 PX-2725000104 CDM 2725000104 LOCAL 272 RC outpatient 6 6 MEDICA (COMMERCIAL) 94265 [3081118] MEDICA CLAIMS [308111801] 5.4 percent of total billed charges 3.72 5.7 Technical (Hospital) Services HC/HH Wch Supp Syringe Luer Lok 10ml__309604 PX-2725000104 CDM 2725000104 LOCAL 272 RC outpatient 6 6 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES PPO [308136801] 4.8 percent of total billed charges 3.72 5.7 Technical (Hospital) Services HC/HH Wch Supp Syringe Luer Lok 10ml__309604 PX-2725000104 CDM 2725000104 LOCAL 272 RC outpatient 6 6 HEALTHPARTNERS SX009 HEALTHPARTNERS 4.8 percent of total billed charges 3.72 5.7 Technical (Hospital) Services HC/HH Wch Supp Syringe Luer Lok 10ml__309604 PX-2725000104 CDM 2725000104 LOCAL 272 RC outpatient 6 6 MULTIPLAN INC 34080 [3081285] MULTIPLAN INC [308128501] 5.7 percent of total billed charges 3.72 5.7 Technical (Hospital) Services HC/HH Wch Supp Syringe Ear/Ulcer__4173 PX-2725000103 CDM 2725000103 LOCAL 272 RC inpatient 8 8 MULTIPLAN INC 34080 [3081285] MULTIPLAN INC [308128501] 7.6 percent of total billed charges 4.96 7.6 Technical (Hospital) Services HC/HH Wch Supp Syringe Ear/Ulcer__4173 PX-2725000103 CDM 2725000103 LOCAL 272 RC inpatient 8 8 BLUE CROSS BLUE SHIELD WELLMARK SB889 [3081026] BCBS WYOMING [308102603] 7.6 percent of total billed charges 4.96 7.6 Technical (Hospital) Services HC/HH Wch Supp Syringe Ear/Ulcer__4173 PX-2725000103 CDM 2725000103 LOCAL 272 RC inpatient 8 8 HEALTHPARTNERS SX009 HEALTHPARTNERS 6.33 percent of total billed charges 4.96 7.6 Technical (Hospital) Services HC/HH Wch Supp Syringe Ear/Ulcer__4173 PX-2725000103 CDM 2725000103 LOCAL 272 RC inpatient 8 8 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES EPO [308136803] 6.33 percent of total billed charges 4.96 7.6 Technical (Hospital) Services HC/HH Wch Supp Syringe Ear/Ulcer__4173 PX-2725000103 CDM 2725000103 LOCAL 272 RC inpatient 8 8 UNITED HEALTHCARE (COMMERCIAL) [3081199] UNITED HEALTHCARE 87726 [308119901] 4.96 percent of total billed charges 4.96 7.6 Technical (Hospital) Services HC/HH Wch Supp Syringe Ear/Ulcer__4173 PX-2725000103 CDM 2725000103 LOCAL 272 RC inpatient 8 8 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES HDHP [308136802] 6.33 percent of total billed charges 4.96 7.6 Technical (Hospital) Services HC/HH Wch Supp Syringe Ear/Ulcer__4173 PX-2725000103 CDM 2725000103 LOCAL 272 RC inpatient 8 8 CIGNA 62308 [3081051] CIGNA 62308 [308105105] 6.33 percent of total billed charges 4.96 7.6 Technical (Hospital) Services HC/HH Wch Supp Syringe Ear/Ulcer__4173 PX-2725000103 CDM 2725000103 LOCAL 272 RC inpatient 8 8 CIGNA 62308 [3081051] CIGNA STATE OF WYOMING [308105107] 6.33 percent of total billed charges 4.96 7.6 Technical (Hospital) Services HC/HH Wch Supp Syringe Ear/Ulcer__4173 PX-2725000103 CDM 2725000103 LOCAL 272 RC inpatient 8 8 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES PPO [308136801] 6.33 percent of total billed charges 4.96 7.6 Technical (Hospital) Services HC/HH Wch Supp Syringe Ear/Ulcer__4173 PX-2725000103 CDM 2725000103 LOCAL 272 RC inpatient 8 8 MEDICA (COMMERCIAL) 94265 [3081118] MEDICA CLAIMS [308111801] 7.2 percent of total billed charges 4.96 7.6 Technical (Hospital) Services HC/HH Wch Supp Syringe Ear/Ulcer__4173 PX-2725000103 CDM 2725000103 LOCAL 272 RC outpatient 8 8 MULTIPLAN INC 34080 [3081285] MULTIPLAN INC [308128501] 7.6 percent of total billed charges 4.96 7.6 Technical (Hospital) Services HC/HH Wch Supp Syringe Ear/Ulcer__4173 PX-2725000103 CDM 2725000103 LOCAL 272 RC outpatient 8 8 MEDICA (COMMERCIAL) 94265 [3081118] MEDICA CLAIMS [308111801] 7.2 percent of total billed charges 4.96 7.6 Technical (Hospital) Services HC/HH Wch Supp Syringe Ear/Ulcer__4173 PX-2725000103 CDM 2725000103 LOCAL 272 RC outpatient 8 8 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES EPO [308136803] 6.4 percent of total billed charges 4.96 7.6 Technical (Hospital) Services HC/HH Wch Supp Syringe Ear/Ulcer__4173 PX-2725000103 CDM 2725000103 LOCAL 272 RC outpatient 8 8 BLUE CROSS BLUE SHIELD WELLMARK SB889 [3081026] BCBS WYOMING [308102603] 7.6 percent of total billed charges 4.96 7.6 Technical (Hospital) Services HC/HH Wch Supp Syringe Ear/Ulcer__4173 PX-2725000103 CDM 2725000103 LOCAL 272 RC outpatient 8 8 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES HDHP [308136802] 6.4 percent of total billed charges 4.96 7.6 Technical (Hospital) Services HC/HH Wch Supp Syringe Ear/Ulcer__4173 PX-2725000103 CDM 2725000103 LOCAL 272 RC outpatient 8 8 CIGNA 62308 [3081051] CIGNA 62308 [308105105] 6.4 percent of total billed charges 4.96 7.6 Technical (Hospital) Services HC/HH Wch Supp Syringe Ear/Ulcer__4173 PX-2725000103 CDM 2725000103 LOCAL 272 RC outpatient 8 8 CIGNA 62308 [3081051] CIGNA STATE OF WYOMING [308105107] 6.4 percent of total billed charges 4.96 7.6 Technical (Hospital) Services HC/HH Wch Supp Syringe Ear/Ulcer__4173 PX-2725000103 CDM 2725000103 LOCAL 272 RC outpatient 8 8 HEALTHPARTNERS SX009 HEALTHPARTNERS 6.4 percent of total billed charges 4.96 7.6 Technical (Hospital) Services HC/HH Wch Supp Syringe Ear/Ulcer__4173 PX-2725000103 CDM 2725000103 LOCAL 272 RC outpatient 8 8 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES PPO [308136801] 6.4 percent of total billed charges 4.96 7.6 Technical (Hospital) Services HC/HH Wch Supp Syringe Ear/Ulcer__4173 PX-2725000103 CDM 2725000103 LOCAL 272 RC outpatient 8 8 UNITED HEALTHCARE (COMMERCIAL) [3081199] UNITED HEALTHCARE 87726 [308119901] 4.96 percent of total billed charges 4.96 7.6 Technical (Hospital) Services HC/HH Wch Supp Suture Prolene 6-0__Et8680g PX-2725000102 CDM 2725000102 LOCAL 272 RC inpatient 44 44 BLUE CROSS BLUE SHIELD WELLMARK SB889 [3081026] BCBS WYOMING [308102603] 41.8 percent of total billed charges 27.28 41.8 Technical (Hospital) Services HC/HH Wch Supp Suture Prolene 6-0__Et8680g PX-2725000102 CDM 2725000102 LOCAL 272 RC inpatient 44 44 MULTIPLAN INC 34080 [3081285] MULTIPLAN INC [308128501] 41.8 percent of total billed charges 27.28 41.8 Technical (Hospital) Services HC/HH Wch Supp Suture Prolene 6-0__Et8680g PX-2725000102 CDM 2725000102 LOCAL 272 RC inpatient 44 44 HEALTHPARTNERS SX009 HEALTHPARTNERS 34.84 percent of total billed charges 27.28 41.8 Technical (Hospital) Services HC/HH Wch Supp Suture Prolene 6-0__Et8680g PX-2725000102 CDM 2725000102 LOCAL 272 RC inpatient 44 44 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES EPO [308136803] 34.84 percent of total billed charges 27.28 41.8 Technical (Hospital) Services HC/HH Wch Supp Suture Prolene 6-0__Et8680g PX-2725000102 CDM 2725000102 LOCAL 272 RC inpatient 44 44 UNITED HEALTHCARE (COMMERCIAL) [3081199] UNITED HEALTHCARE 87726 [308119901] 27.28 percent of total billed charges 27.28 41.8 Technical (Hospital) Services HC/HH Wch Supp Suture Prolene 6-0__Et8680g PX-2725000102 CDM 2725000102 LOCAL 272 RC inpatient 44 44 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES HDHP [308136802] 34.84 percent of total billed charges 27.28 41.8 Technical (Hospital) Services HC/HH Wch Supp Suture Prolene 6-0__Et8680g PX-2725000102 CDM 2725000102 LOCAL 272 RC inpatient 44 44 CIGNA 62308 [3081051] CIGNA 62308 [308105105] 34.84 percent of total billed charges 27.28 41.8 Technical (Hospital) Services HC/HH Wch Supp Suture Prolene 6-0__Et8680g PX-2725000102 CDM 2725000102 LOCAL 272 RC inpatient 44 44 CIGNA 62308 [3081051] CIGNA STATE OF WYOMING [308105107] 34.84 percent of total billed charges 27.28 41.8 Technical (Hospital) Services HC/HH Wch Supp Suture Prolene 6-0__Et8680g PX-2725000102 CDM 2725000102 LOCAL 272 RC inpatient 44 44 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES PPO [308136801] 34.84 percent of total billed charges 27.28 41.8 Technical (Hospital) Services HC/HH Wch Supp Suture Prolene 6-0__Et8680g PX-2725000102 CDM 2725000102 LOCAL 272 RC inpatient 44 44 MEDICA (COMMERCIAL) 94265 [3081118] MEDICA CLAIMS [308111801] 39.6 percent of total billed charges 27.28 41.8 Technical (Hospital) Services HC/HH Wch Supp Suture Prolene 6-0__Et8680g PX-2725000102 CDM 2725000102 LOCAL 272 RC outpatient 44 44 MULTIPLAN INC 34080 [3081285] MULTIPLAN INC [308128501] 41.8 percent of total billed charges 27.28 41.8 Technical (Hospital) Services HC/HH Wch Supp Suture Prolene 6-0__Et8680g PX-2725000102 CDM 2725000102 LOCAL 272 RC outpatient 44 44 HEALTHPARTNERS SX009 HEALTHPARTNERS 35.2 percent of total billed charges 27.28 41.8 Technical (Hospital) Services HC/HH Wch Supp Suture Prolene 6-0__Et8680g PX-2725000102 CDM 2725000102 LOCAL 272 RC outpatient 44 44 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES PPO [308136801] 35.2 percent of total billed charges 27.28 41.8 Technical (Hospital) Services HC/HH Wch Supp Suture Prolene 6-0__Et8680g PX-2725000102 CDM 2725000102 LOCAL 272 RC outpatient 44 44 MEDICA (COMMERCIAL) 94265 [3081118] MEDICA CLAIMS [308111801] 39.6 percent of total billed charges 27.28 41.8 Technical (Hospital) Services HC/HH Wch Supp Suture Prolene 6-0__Et8680g PX-2725000102 CDM 2725000102 LOCAL 272 RC outpatient 44 44 UNITED HEALTHCARE (COMMERCIAL) [3081199] UNITED HEALTHCARE 87726 [308119901] 27.28 percent of total billed charges 27.28 41.8 Technical (Hospital) Services HC/HH Wch Supp Suture Prolene 6-0__Et8680g PX-2725000102 CDM 2725000102 LOCAL 272 RC outpatient 44 44 CIGNA 62308 [3081051] CIGNA 62308 [308105105] 35.2 percent of total billed charges 27.28 41.8 Technical (Hospital) Services HC/HH Wch Supp Suture Prolene 6-0__Et8680g PX-2725000102 CDM 2725000102 LOCAL 272 RC outpatient 44 44 CIGNA 62308 [3081051] CIGNA STATE OF WYOMING [308105107] 35.2 percent of total billed charges 27.28 41.8 Technical (Hospital) Services HC/HH Wch Supp Suture Prolene 6-0__Et8680g PX-2725000102 CDM 2725000102 LOCAL 272 RC outpatient 44 44 BLUE CROSS BLUE SHIELD WELLMARK SB889 [3081026] BCBS WYOMING [308102603] 41.8 percent of total billed charges 27.28 41.8 Technical (Hospital) Services HC/HH Wch Supp Suture Prolene 6-0__Et8680g PX-2725000102 CDM 2725000102 LOCAL 272 RC outpatient 44 44 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES EPO [308136803] 35.2 percent of total billed charges 27.28 41.8 Technical (Hospital) Services HC/HH Wch Supp Suture Prolene 6-0__Et8680g PX-2725000102 CDM 2725000102 LOCAL 272 RC outpatient 44 44 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES HDHP [308136802] 35.2 percent of total billed charges 27.28 41.8 Technical (Hospital) Services HC/HH Wch Supp Suture Prolene 5-0__Et8661g PX-2725000101 CDM 2725000101 LOCAL 272 RC inpatient 20 20 MEDICA (COMMERCIAL) 94265 [3081118] MEDICA CLAIMS [308111801] 18 percent of total billed charges 12.4 19 Technical (Hospital) Services HC/HH Wch Supp Suture Prolene 5-0__Et8661g PX-2725000101 CDM 2725000101 LOCAL 272 RC inpatient 20 20 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES PPO [308136801] 15.84 percent of total billed charges 12.4 19 Technical (Hospital) Services HC/HH Wch Supp Suture Prolene 5-0__Et8661g PX-2725000101 CDM 2725000101 LOCAL 272 RC inpatient 20 20 UNITED HEALTHCARE (COMMERCIAL) [3081199] UNITED HEALTHCARE 87726 [308119901] 12.4 percent of total billed charges 12.4 19 Technical (Hospital) Services HC/HH Wch Supp Suture Prolene 5-0__Et8661g PX-2725000101 CDM 2725000101 LOCAL 272 RC inpatient 20 20 CIGNA 62308 [3081051] CIGNA 62308 [308105105] 15.84 percent of total billed charges 12.4 19 Technical (Hospital) Services HC/HH Wch Supp Suture Prolene 5-0__Et8661g PX-2725000101 CDM 2725000101 LOCAL 272 RC inpatient 20 20 CIGNA 62308 [3081051] CIGNA STATE OF WYOMING [308105107] 15.84 percent of total billed charges 12.4 19 Technical (Hospital) Services HC/HH Wch Supp Suture Prolene 5-0__Et8661g PX-2725000101 CDM 2725000101 LOCAL 272 RC inpatient 20 20 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES HDHP [308136802] 15.84 percent of total billed charges 12.4 19 Technical (Hospital) Services HC/HH Wch Supp Suture Prolene 5-0__Et8661g PX-2725000101 CDM 2725000101 LOCAL 272 RC inpatient 20 20 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES EPO [308136803] 15.84 percent of total billed charges 12.4 19 Technical (Hospital) Services HC/HH Wch Supp Suture Prolene 5-0__Et8661g PX-2725000101 CDM 2725000101 LOCAL 272 RC inpatient 20 20 MULTIPLAN INC 34080 [3081285] MULTIPLAN INC [308128501] 19 percent of total billed charges 12.4 19 Technical (Hospital) Services HC/HH Wch Supp Suture Prolene 5-0__Et8661g PX-2725000101 CDM 2725000101 LOCAL 272 RC inpatient 20 20 BLUE CROSS BLUE SHIELD WELLMARK SB889 [3081026] BCBS WYOMING [308102603] 19 percent of total billed charges 12.4 19 Technical (Hospital) Services HC/HH Wch Supp Suture Prolene 5-0__Et8661g PX-2725000101 CDM 2725000101 LOCAL 272 RC inpatient 20 20 HEALTHPARTNERS SX009 HEALTHPARTNERS 15.84 percent of total billed charges 12.4 19 Technical (Hospital) Services HC/HH Wch Supp Suture Prolene 5-0__Et8661g PX-2725000101 CDM 2725000101 LOCAL 272 RC outpatient 20 20 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES HDHP [308136802] 16 percent of total billed charges 12.4 19 Technical (Hospital) Services HC/HH Wch Supp Suture Prolene 5-0__Et8661g PX-2725000101 CDM 2725000101 LOCAL 272 RC outpatient 20 20 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES EPO [308136803] 16 percent of total billed charges 12.4 19 Technical (Hospital) Services HC/HH Wch Supp Suture Prolene 5-0__Et8661g PX-2725000101 CDM 2725000101 LOCAL 272 RC outpatient 20 20 BLUE CROSS BLUE SHIELD WELLMARK SB889 [3081026] BCBS WYOMING [308102603] 19 percent of total billed charges 12.4 19 Technical (Hospital) Services HC/HH Wch Supp Suture Prolene 5-0__Et8661g PX-2725000101 CDM 2725000101 LOCAL 272 RC outpatient 20 20 CIGNA 62308 [3081051] CIGNA 62308 [308105105] 16 percent of total billed charges 12.4 19 Technical (Hospital) Services HC/HH Wch Supp Suture Prolene 5-0__Et8661g PX-2725000101 CDM 2725000101 LOCAL 272 RC outpatient 20 20 CIGNA 62308 [3081051] CIGNA STATE OF WYOMING [308105107] 16 percent of total billed charges 12.4 19 Technical (Hospital) Services HC/HH Wch Supp Suture Prolene 5-0__Et8661g PX-2725000101 CDM 2725000101 LOCAL 272 RC outpatient 20 20 UNITED HEALTHCARE (COMMERCIAL) [3081199] UNITED HEALTHCARE 87726 [308119901] 12.4 percent of total billed charges 12.4 19 Technical (Hospital) Services HC/HH Wch Supp Suture Prolene 5-0__Et8661g PX-2725000101 CDM 2725000101 LOCAL 272 RC outpatient 20 20 MEDICA (COMMERCIAL) 94265 [3081118] MEDICA CLAIMS [308111801] 18 percent of total billed charges 12.4 19 Technical (Hospital) Services HC/HH Wch Supp Suture Prolene 5-0__Et8661g PX-2725000101 CDM 2725000101 LOCAL 272 RC outpatient 20 20 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES PPO [308136801] 16 percent of total billed charges 12.4 19 Technical (Hospital) Services HC/HH Wch Supp Suture Prolene 5-0__Et8661g PX-2725000101 CDM 2725000101 LOCAL 272 RC outpatient 20 20 HEALTHPARTNERS SX009 HEALTHPARTNERS 16 percent of total billed charges 12.4 19 Technical (Hospital) Services HC/HH Wch Supp Suture Prolene 5-0__Et8661g PX-2725000101 CDM 2725000101 LOCAL 272 RC outpatient 20 20 MULTIPLAN INC 34080 [3081285] MULTIPLAN INC [308128501] 19 percent of total billed charges 12.4 19 Technical (Hospital) Services HC/HH Wch Supp Suture Prolene 4-0__Et8683g PX-2725000100 CDM 2725000100 LOCAL 272 RC outpatient 20 20 BLUE CROSS BLUE SHIELD WELLMARK SB889 [3081026] BCBS WYOMING [308102603] 19 percent of total billed charges 12.4 19 Technical (Hospital) Services HC/HH Wch Supp Suture Prolene 4-0__Et8683g PX-2725000100 CDM 2725000100 LOCAL 272 RC outpatient 20 20 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES EPO [308136803] 16 percent of total billed charges 12.4 19 Technical (Hospital) Services HC/HH Wch Supp Suture Prolene 4-0__Et8683g PX-2725000100 CDM 2725000100 LOCAL 272 RC outpatient 20 20 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES HDHP [308136802] 16 percent of total billed charges 12.4 19 Technical (Hospital) Services HC/HH Wch Supp Suture Prolene 4-0__Et8683g PX-2725000100 CDM 2725000100 LOCAL 272 RC outpatient 20 20 CIGNA 62308 [3081051] CIGNA 62308 [308105105] 16 percent of total billed charges 12.4 19 Technical (Hospital) Services HC/HH Wch Supp Suture Prolene 4-0__Et8683g PX-2725000100 CDM 2725000100 LOCAL 272 RC outpatient 20 20 CIGNA 62308 [3081051] CIGNA STATE OF WYOMING [308105107] 16 percent of total billed charges 12.4 19 Technical (Hospital) Services HC/HH Wch Supp Suture Prolene 4-0__Et8683g PX-2725000100 CDM 2725000100 LOCAL 272 RC outpatient 20 20 UNITED HEALTHCARE (COMMERCIAL) [3081199] UNITED HEALTHCARE 87726 [308119901] 12.4 percent of total billed charges 12.4 19 Technical (Hospital) Services HC/HH Wch Supp Suture Prolene 4-0__Et8683g PX-2725000100 CDM 2725000100 LOCAL 272 RC outpatient 20 20 HEALTHPARTNERS SX009 HEALTHPARTNERS 16 percent of total billed charges 12.4 19 Technical (Hospital) Services HC/HH Wch Supp Suture Prolene 4-0__Et8683g PX-2725000100 CDM 2725000100 LOCAL 272 RC outpatient 20 20 MULTIPLAN INC 34080 [3081285] MULTIPLAN INC [308128501] 19 percent of total billed charges 12.4 19 Technical (Hospital) Services HC/HH Wch Supp Suture Prolene 4-0__Et8683g PX-2725000100 CDM 2725000100 LOCAL 272 RC outpatient 20 20 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES PPO [308136801] 16 percent of total billed charges 12.4 19 Technical (Hospital) Services HC/HH Wch Supp Suture Prolene 4-0__Et8683g PX-2725000100 CDM 2725000100 LOCAL 272 RC outpatient 20 20 MEDICA (COMMERCIAL) 94265 [3081118] MEDICA CLAIMS [308111801] 18 percent of total billed charges 12.4 19 Technical (Hospital) Services HC/HH Wch Supp Suture Prolene 4-0__Et8683g PX-2725000100 CDM 2725000100 LOCAL 272 RC inpatient 20 20 MEDICA (COMMERCIAL) 94265 [3081118] MEDICA CLAIMS [308111801] 18 percent of total billed charges 12.4 19 Technical (Hospital) Services HC/HH Wch Supp Suture Prolene 4-0__Et8683g PX-2725000100 CDM 2725000100 LOCAL 272 RC inpatient 20 20 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES PPO [308136801] 15.84 percent of total billed charges 12.4 19 Technical (Hospital) Services HC/HH Wch Supp Suture Prolene 4-0__Et8683g PX-2725000100 CDM 2725000100 LOCAL 272 RC inpatient 20 20 CIGNA 62308 [3081051] CIGNA 62308 [308105105] 15.84 percent of total billed charges 12.4 19 Technical (Hospital) Services HC/HH Wch Supp Suture Prolene 4-0__Et8683g PX-2725000100 CDM 2725000100 LOCAL 272 RC inpatient 20 20 CIGNA 62308 [3081051] CIGNA STATE OF WYOMING [308105107] 15.84 percent of total billed charges 12.4 19 Technical (Hospital) Services HC/HH Wch Supp Suture Prolene 4-0__Et8683g PX-2725000100 CDM 2725000100 LOCAL 272 RC inpatient 20 20 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES HDHP [308136802] 15.84 percent of total billed charges 12.4 19 Technical (Hospital) Services HC/HH Wch Supp Suture Prolene 4-0__Et8683g PX-2725000100 CDM 2725000100 LOCAL 272 RC inpatient 20 20 UNITED HEALTHCARE (COMMERCIAL) [3081199] UNITED HEALTHCARE 87726 [308119901] 12.4 percent of total billed charges 12.4 19 Technical (Hospital) Services HC/HH Wch Supp Suture Prolene 4-0__Et8683g PX-2725000100 CDM 2725000100 LOCAL 272 RC inpatient 20 20 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES EPO [308136803] 15.84 percent of total billed charges 12.4 19 Technical (Hospital) Services HC/HH Wch Supp Suture Prolene 4-0__Et8683g PX-2725000100 CDM 2725000100 LOCAL 272 RC inpatient 20 20 HEALTHPARTNERS SX009 HEALTHPARTNERS 15.84 percent of total billed charges 12.4 19 Technical (Hospital) Services HC/HH Wch Supp Suture Prolene 4-0__Et8683g PX-2725000100 CDM 2725000100 LOCAL 272 RC inpatient 20 20 MULTIPLAN INC 34080 [3081285] MULTIPLAN INC [308128501] 19 percent of total billed charges 12.4 19 Technical (Hospital) Services HC/HH Wch Supp Suture Prolene 4-0__Et8683g PX-2725000100 CDM 2725000100 LOCAL 272 RC inpatient 20 20 BLUE CROSS BLUE SHIELD WELLMARK SB889 [3081026] BCBS WYOMING [308102603] 19 percent of total billed charges 12.4 19 Technical (Hospital) Services HC/HH Wch Supp Suture Prolene 3-0__Et8684g PX-2725000099 CDM 2725000099 LOCAL 272 RC inpatient 20 20 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES EPO [308136803] 15.84 percent of total billed charges 12.4 19 Technical (Hospital) Services HC/HH Wch Supp Suture Prolene 3-0__Et8684g PX-2725000099 CDM 2725000099 LOCAL 272 RC inpatient 20 20 BLUE CROSS BLUE SHIELD WELLMARK SB889 [3081026] BCBS WYOMING [308102603] 19 percent of total billed charges 12.4 19 Technical (Hospital) Services HC/HH Wch Supp Suture Prolene 3-0__Et8684g PX-2725000099 CDM 2725000099 LOCAL 272 RC inpatient 20 20 MULTIPLAN INC 34080 [3081285] MULTIPLAN INC [308128501] 19 percent of total billed charges 12.4 19 Technical (Hospital) Services HC/HH Wch Supp Suture Prolene 3-0__Et8684g PX-2725000099 CDM 2725000099 LOCAL 272 RC inpatient 20 20 HEALTHPARTNERS SX009 HEALTHPARTNERS 15.84 percent of total billed charges 12.4 19 Technical (Hospital) Services HC/HH Wch Supp Suture Prolene 3-0__Et8684g PX-2725000099 CDM 2725000099 LOCAL 272 RC inpatient 20 20 UNITED HEALTHCARE (COMMERCIAL) [3081199] UNITED HEALTHCARE 87726 [308119901] 12.4 percent of total billed charges 12.4 19 Technical (Hospital) Services HC/HH Wch Supp Suture Prolene 3-0__Et8684g PX-2725000099 CDM 2725000099 LOCAL 272 RC inpatient 20 20 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES HDHP [308136802] 15.84 percent of total billed charges 12.4 19 Technical (Hospital) Services HC/HH Wch Supp Suture Prolene 3-0__Et8684g PX-2725000099 CDM 2725000099 LOCAL 272 RC inpatient 20 20 CIGNA 62308 [3081051] CIGNA 62308 [308105105] 15.84 percent of total billed charges 12.4 19 Technical (Hospital) Services HC/HH Wch Supp Suture Prolene 3-0__Et8684g PX-2725000099 CDM 2725000099 LOCAL 272 RC inpatient 20 20 CIGNA 62308 [3081051] CIGNA STATE OF WYOMING [308105107] 15.84 percent of total billed charges 12.4 19 Technical (Hospital) Services HC/HH Wch Supp Suture Prolene 3-0__Et8684g PX-2725000099 CDM 2725000099 LOCAL 272 RC inpatient 20 20 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES PPO [308136801] 15.84 percent of total billed charges 12.4 19 Technical (Hospital) Services HC/HH Wch Supp Suture Prolene 3-0__Et8684g PX-2725000099 CDM 2725000099 LOCAL 272 RC inpatient 20 20 MEDICA (COMMERCIAL) 94265 [3081118] MEDICA CLAIMS [308111801] 18 percent of total billed charges 12.4 19 Technical (Hospital) Services HC/HH Wch Supp Suture Prolene 3-0__Et8684g PX-2725000099 CDM 2725000099 LOCAL 272 RC outpatient 20 20 UNITED HEALTHCARE (COMMERCIAL) [3081199] UNITED HEALTHCARE 87726 [308119901] 12.4 percent of total billed charges 12.4 19 Technical (Hospital) Services HC/HH Wch Supp Suture Prolene 3-0__Et8684g PX-2725000099 CDM 2725000099 LOCAL 272 RC outpatient 20 20 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES PPO [308136801] 16 percent of total billed charges 12.4 19 Technical (Hospital) Services HC/HH Wch Supp Suture Prolene 3-0__Et8684g PX-2725000099 CDM 2725000099 LOCAL 272 RC outpatient 20 20 HEALTHPARTNERS SX009 HEALTHPARTNERS 16 percent of total billed charges 12.4 19 Technical (Hospital) Services HC/HH Wch Supp Suture Prolene 3-0__Et8684g PX-2725000099 CDM 2725000099 LOCAL 272 RC outpatient 20 20 CIGNA 62308 [3081051] CIGNA 62308 [308105105] 16 percent of total billed charges 12.4 19 Technical (Hospital) Services HC/HH Wch Supp Suture Prolene 3-0__Et8684g PX-2725000099 CDM 2725000099 LOCAL 272 RC outpatient 20 20 CIGNA 62308 [3081051] CIGNA STATE OF WYOMING [308105107] 16 percent of total billed charges 12.4 19 Technical (Hospital) Services HC/HH Wch Supp Suture Prolene 3-0__Et8684g PX-2725000099 CDM 2725000099 LOCAL 272 RC outpatient 20 20 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES HDHP [308136802] 16 percent of total billed charges 12.4 19 Technical (Hospital) Services HC/HH Wch Supp Suture Prolene 3-0__Et8684g PX-2725000099 CDM 2725000099 LOCAL 272 RC outpatient 20 20 BLUE CROSS BLUE SHIELD WELLMARK SB889 [3081026] BCBS WYOMING [308102603] 19 percent of total billed charges 12.4 19 Technical (Hospital) Services HC/HH Wch Supp Suture Prolene 3-0__Et8684g PX-2725000099 CDM 2725000099 LOCAL 272 RC outpatient 20 20 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES EPO [308136803] 16 percent of total billed charges 12.4 19 Technical (Hospital) Services HC/HH Wch Supp Suture Prolene 3-0__Et8684g PX-2725000099 CDM 2725000099 LOCAL 272 RC outpatient 20 20 MEDICA (COMMERCIAL) 94265 [3081118] MEDICA CLAIMS [308111801] 18 percent of total billed charges 12.4 19 Technical (Hospital) Services HC/HH Wch Supp Suture Prolene 3-0__Et8684g PX-2725000099 CDM 2725000099 LOCAL 272 RC outpatient 20 20 MULTIPLAN INC 34080 [3081285] MULTIPLAN INC [308128501] 19 percent of total billed charges 12.4 19 Technical (Hospital) Services HC/HH Wch Supp Suture Prolene 2-0__Et8423h PX-2725000098 CDM 2725000098 LOCAL 272 RC inpatient 6 6 CIGNA 62308 [3081051] CIGNA 62308 [308105105] 4.75 percent of total billed charges 3.72 5.7 Technical (Hospital) Services HC/HH Wch Supp Suture Prolene 2-0__Et8423h PX-2725000098 CDM 2725000098 LOCAL 272 RC inpatient 6 6 CIGNA 62308 [3081051] CIGNA STATE OF WYOMING [308105107] 4.75 percent of total billed charges 3.72 5.7 Technical (Hospital) Services HC/HH Wch Supp Suture Prolene 2-0__Et8423h PX-2725000098 CDM 2725000098 LOCAL 272 RC inpatient 6 6 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES HDHP [308136802] 4.75 percent of total billed charges 3.72 5.7 Technical (Hospital) Services HC/HH Wch Supp Suture Prolene 2-0__Et8423h PX-2725000098 CDM 2725000098 LOCAL 272 RC inpatient 6 6 UNITED HEALTHCARE (COMMERCIAL) [3081199] UNITED HEALTHCARE 87726 [308119901] 3.72 percent of total billed charges 3.72 5.7 Technical (Hospital) Services HC/HH Wch Supp Suture Prolene 2-0__Et8423h PX-2725000098 CDM 2725000098 LOCAL 272 RC inpatient 6 6 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES PPO [308136801] 4.75 percent of total billed charges 3.72 5.7 Technical (Hospital) Services HC/HH Wch Supp Suture Prolene 2-0__Et8423h PX-2725000098 CDM 2725000098 LOCAL 272 RC inpatient 6 6 MEDICA (COMMERCIAL) 94265 [3081118] MEDICA CLAIMS [308111801] 5.4 percent of total billed charges 3.72 5.7 Technical (Hospital) Services HC/HH Wch Supp Suture Prolene 2-0__Et8423h PX-2725000098 CDM 2725000098 LOCAL 272 RC inpatient 6 6 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES EPO [308136803] 4.75 percent of total billed charges 3.72 5.7 Technical (Hospital) Services HC/HH Wch Supp Suture Prolene 2-0__Et8423h PX-2725000098 CDM 2725000098 LOCAL 272 RC inpatient 6 6 MULTIPLAN INC 34080 [3081285] MULTIPLAN INC [308128501] 5.7 percent of total billed charges 3.72 5.7 Technical (Hospital) Services HC/HH Wch Supp Suture Prolene 2-0__Et8423h PX-2725000098 CDM 2725000098 LOCAL 272 RC inpatient 6 6 BLUE CROSS BLUE SHIELD WELLMARK SB889 [3081026] BCBS WYOMING [308102603] 5.7 percent of total billed charges 3.72 5.7 Technical (Hospital) Services HC/HH Wch Supp Suture Prolene 2-0__Et8423h PX-2725000098 CDM 2725000098 LOCAL 272 RC inpatient 6 6 HEALTHPARTNERS SX009 HEALTHPARTNERS 4.75 percent of total billed charges 3.72 5.7 Technical (Hospital) Services HC/HH Wch Supp Suture Prolene 2-0__Et8423h PX-2725000098 CDM 2725000098 LOCAL 272 RC outpatient 6 6 MEDICA (COMMERCIAL) 94265 [3081118] MEDICA CLAIMS [308111801] 5.4 percent of total billed charges 3.72 5.7 Technical (Hospital) Services HC/HH Wch Supp Suture Prolene 2-0__Et8423h PX-2725000098 CDM 2725000098 LOCAL 272 RC outpatient 6 6 MULTIPLAN INC 34080 [3081285] MULTIPLAN INC [308128501] 5.7 percent of total billed charges 3.72 5.7 Technical (Hospital) Services HC/HH Wch Supp Suture Prolene 2-0__Et8423h PX-2725000098 CDM 2725000098 LOCAL 272 RC outpatient 6 6 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES PPO [308136801] 4.8 percent of total billed charges 3.72 5.7 Technical (Hospital) Services HC/HH Wch Supp Suture Prolene 2-0__Et8423h PX-2725000098 CDM 2725000098 LOCAL 272 RC outpatient 6 6 HEALTHPARTNERS SX009 HEALTHPARTNERS 4.8 percent of total billed charges 3.72 5.7 Technical (Hospital) Services HC/HH Wch Supp Suture Prolene 2-0__Et8423h PX-2725000098 CDM 2725000098 LOCAL 272 RC outpatient 6 6 UNITED HEALTHCARE (COMMERCIAL) [3081199] UNITED HEALTHCARE 87726 [308119901] 3.72 percent of total billed charges 3.72 5.7 Technical (Hospital) Services HC/HH Wch Supp Suture Prolene 2-0__Et8423h PX-2725000098 CDM 2725000098 LOCAL 272 RC outpatient 6 6 CIGNA 62308 [3081051] CIGNA 62308 [308105105] 4.8 percent of total billed charges 3.72 5.7 Technical (Hospital) Services HC/HH Wch Supp Suture Prolene 2-0__Et8423h PX-2725000098 CDM 2725000098 LOCAL 272 RC outpatient 6 6 CIGNA 62308 [3081051] CIGNA STATE OF WYOMING [308105107] 4.8 percent of total billed charges 3.72 5.7 Technical (Hospital) Services HC/HH Wch Supp Suture Prolene 2-0__Et8423h PX-2725000098 CDM 2725000098 LOCAL 272 RC outpatient 6 6 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES HDHP [308136802] 4.8 percent of total billed charges 3.72 5.7 Technical (Hospital) Services HC/HH Wch Supp Suture Prolene 2-0__Et8423h PX-2725000098 CDM 2725000098 LOCAL 272 RC outpatient 6 6 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES EPO [308136803] 4.8 percent of total billed charges 3.72 5.7 Technical (Hospital) Services HC/HH Wch Supp Suture Prolene 2-0__Et8423h PX-2725000098 CDM 2725000098 LOCAL 272 RC outpatient 6 6 BLUE CROSS BLUE SHIELD WELLMARK SB889 [3081026] BCBS WYOMING [308102603] 5.7 percent of total billed charges 3.72 5.7 Technical (Hospital) Services HC/HH Wch Supp Suture Chromic 4-0__G121h PX-2725000097 CDM 2725000097 LOCAL 272 RC outpatient 15 15 MEDICA (COMMERCIAL) 94265 [3081118] MEDICA CLAIMS [308111801] 13.5 percent of total billed charges 9.3 14.25 Technical (Hospital) Services HC/HH Wch Supp Suture Chromic 4-0__G121h PX-2725000097 CDM 2725000097 LOCAL 272 RC outpatient 15 15 MULTIPLAN INC 34080 [3081285] MULTIPLAN INC [308128501] 14.25 percent of total billed charges 9.3 14.25 Technical (Hospital) Services HC/HH Wch Supp Suture Chromic 4-0__G121h PX-2725000097 CDM 2725000097 LOCAL 272 RC outpatient 15 15 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES PPO [308136801] 12 percent of total billed charges 9.3 14.25 Technical (Hospital) Services HC/HH Wch Supp Suture Chromic 4-0__G121h PX-2725000097 CDM 2725000097 LOCAL 272 RC outpatient 15 15 HEALTHPARTNERS SX009 HEALTHPARTNERS 12 percent of total billed charges 9.3 14.25 Technical (Hospital) Services HC/HH Wch Supp Suture Chromic 4-0__G121h PX-2725000097 CDM 2725000097 LOCAL 272 RC outpatient 15 15 UNITED HEALTHCARE (COMMERCIAL) [3081199] UNITED HEALTHCARE 87726 [308119901] 9.3 percent of total billed charges 9.3 14.25 Technical (Hospital) Services HC/HH Wch Supp Suture Chromic 4-0__G121h PX-2725000097 CDM 2725000097 LOCAL 272 RC outpatient 15 15 CIGNA 62308 [3081051] CIGNA 62308 [308105105] 12 percent of total billed charges 9.3 14.25 Technical (Hospital) Services HC/HH Wch Supp Suture Chromic 4-0__G121h PX-2725000097 CDM 2725000097 LOCAL 272 RC outpatient 15 15 CIGNA 62308 [3081051] CIGNA STATE OF WYOMING [308105107] 12 percent of total billed charges 9.3 14.25 Technical (Hospital) Services HC/HH Wch Supp Suture Chromic 4-0__G121h PX-2725000097 CDM 2725000097 LOCAL 272 RC outpatient 15 15 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES EPO [308136803] 12 percent of total billed charges 9.3 14.25 Technical (Hospital) Services HC/HH Wch Supp Suture Chromic 4-0__G121h PX-2725000097 CDM 2725000097 LOCAL 272 RC outpatient 15 15 BLUE CROSS BLUE SHIELD WELLMARK SB889 [3081026] BCBS WYOMING [308102603] 14.25 percent of total billed charges 9.3 14.25 Technical (Hospital) Services HC/HH Wch Supp Suture Chromic 4-0__G121h PX-2725000097 CDM 2725000097 LOCAL 272 RC outpatient 15 15 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES HDHP [308136802] 12 percent of total billed charges 9.3 14.25 Technical (Hospital) Services HC/HH Wch Supp Suture Chromic 4-0__G121h PX-2725000097 CDM 2725000097 LOCAL 272 RC inpatient 15 15 BLUE CROSS BLUE SHIELD WELLMARK SB889 [3081026] BCBS WYOMING [308102603] 14.25 percent of total billed charges 9.3 14.25 Technical (Hospital) Services HC/HH Wch Supp Suture Chromic 4-0__G121h PX-2725000097 CDM 2725000097 LOCAL 272 RC inpatient 15 15 MULTIPLAN INC 34080 [3081285] MULTIPLAN INC [308128501] 14.25 percent of total billed charges 9.3 14.25 Technical (Hospital) Services HC/HH Wch Supp Suture Chromic 4-0__G121h PX-2725000097 CDM 2725000097 LOCAL 272 RC inpatient 15 15 HEALTHPARTNERS SX009 HEALTHPARTNERS 11.88 percent of total billed charges 9.3 14.25 Technical (Hospital) Services HC/HH Wch Supp Suture Chromic 4-0__G121h PX-2725000097 CDM 2725000097 LOCAL 272 RC inpatient 15 15 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES EPO [308136803] 11.88 percent of total billed charges 9.3 14.25 Technical (Hospital) Services HC/HH Wch Supp Suture Chromic 4-0__G121h PX-2725000097 CDM 2725000097 LOCAL 272 RC inpatient 15 15 UNITED HEALTHCARE (COMMERCIAL) [3081199] UNITED HEALTHCARE 87726 [308119901] 9.3 percent of total billed charges 9.3 14.25 Technical (Hospital) Services HC/HH Wch Supp Suture Chromic 4-0__G121h PX-2725000097 CDM 2725000097 LOCAL 272 RC inpatient 15 15 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES HDHP [308136802] 11.88 percent of total billed charges 9.3 14.25 Technical (Hospital) Services HC/HH Wch Supp Suture Chromic 4-0__G121h PX-2725000097 CDM 2725000097 LOCAL 272 RC inpatient 15 15 CIGNA 62308 [3081051] CIGNA 62308 [308105105] 11.88 percent of total billed charges 9.3 14.25 Technical (Hospital) Services HC/HH Wch Supp Suture Chromic 4-0__G121h PX-2725000097 CDM 2725000097 LOCAL 272 RC inpatient 15 15 CIGNA 62308 [3081051] CIGNA STATE OF WYOMING [308105107] 11.88 percent of total billed charges 9.3 14.25 Technical (Hospital) Services HC/HH Wch Supp Suture Chromic 4-0__G121h PX-2725000097 CDM 2725000097 LOCAL 272 RC inpatient 15 15 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES PPO [308136801] 11.88 percent of total billed charges 9.3 14.25 Technical (Hospital) Services HC/HH Wch Supp Suture Chromic 4-0__G121h PX-2725000097 CDM 2725000097 LOCAL 272 RC inpatient 15 15 MEDICA (COMMERCIAL) 94265 [3081118] MEDICA CLAIMS [308111801] 13.5 percent of total billed charges 9.3 14.25 Technical (Hospital) Services HC/HH Wch Supp Surgifoam__Et1972 PX-2725000096 CDM 2725000096 LOCAL 272 RC inpatient 37 37 HEALTHPARTNERS SX009 HEALTHPARTNERS 29.3 percent of total billed charges 22.94 35.15 Technical (Hospital) Services HC/HH Wch Supp Surgifoam__Et1972 PX-2725000096 CDM 2725000096 LOCAL 272 RC inpatient 37 37 BLUE CROSS BLUE SHIELD WELLMARK SB889 [3081026] BCBS WYOMING [308102603] 35.15 percent of total billed charges 22.94 35.15 Technical (Hospital) Services HC/HH Wch Supp Surgifoam__Et1972 PX-2725000096 CDM 2725000096 LOCAL 272 RC inpatient 37 37 MULTIPLAN INC 34080 [3081285] MULTIPLAN INC [308128501] 35.15 percent of total billed charges 22.94 35.15 Technical (Hospital) Services HC/HH Wch Supp Surgifoam__Et1972 PX-2725000096 CDM 2725000096 LOCAL 272 RC inpatient 37 37 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES EPO [308136803] 29.3 percent of total billed charges 22.94 35.15 Technical (Hospital) Services HC/HH Wch Supp Surgifoam__Et1972 PX-2725000096 CDM 2725000096 LOCAL 272 RC inpatient 37 37 MEDICA (COMMERCIAL) 94265 [3081118] MEDICA CLAIMS [308111801] 33.3 percent of total billed charges 22.94 35.15 Technical (Hospital) Services HC/HH Wch Supp Surgifoam__Et1972 PX-2725000096 CDM 2725000096 LOCAL 272 RC inpatient 37 37 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES PPO [308136801] 29.3 percent of total billed charges 22.94 35.15 Technical (Hospital) Services HC/HH Wch Supp Surgifoam__Et1972 PX-2725000096 CDM 2725000096 LOCAL 272 RC inpatient 37 37 UNITED HEALTHCARE (COMMERCIAL) [3081199] UNITED HEALTHCARE 87726 [308119901] 22.94 percent of total billed charges 22.94 35.15 Technical (Hospital) Services HC/HH Wch Supp Surgifoam__Et1972 PX-2725000096 CDM 2725000096 LOCAL 272 RC inpatient 37 37 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES HDHP [308136802] 29.3 percent of total billed charges 22.94 35.15 Technical (Hospital) Services HC/HH Wch Supp Surgifoam__Et1972 PX-2725000096 CDM 2725000096 LOCAL 272 RC inpatient 37 37 CIGNA 62308 [3081051] CIGNA 62308 [308105105] 29.3 percent of total billed charges 22.94 35.15 Technical (Hospital) Services HC/HH Wch Supp Surgifoam__Et1972 PX-2725000096 CDM 2725000096 LOCAL 272 RC inpatient 37 37 CIGNA 62308 [3081051] CIGNA STATE OF WYOMING [308105107] 29.3 percent of total billed charges 22.94 35.15 Technical (Hospital) Services HC/HH Wch Supp Surgifoam__Et1972 PX-2725000096 CDM 2725000096 LOCAL 272 RC outpatient 37 37 BLUE CROSS BLUE SHIELD WELLMARK SB889 [3081026] BCBS WYOMING [308102603] 35.15 percent of total billed charges 22.94 35.15 Technical (Hospital) Services HC/HH Wch Supp Surgifoam__Et1972 PX-2725000096 CDM 2725000096 LOCAL 272 RC outpatient 37 37 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES EPO [308136803] 29.6 percent of total billed charges 22.94 35.15 Technical (Hospital) Services HC/HH Wch Supp Surgifoam__Et1972 PX-2725000096 CDM 2725000096 LOCAL 272 RC outpatient 37 37 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES HDHP [308136802] 29.6 percent of total billed charges 22.94 35.15 Technical (Hospital) Services HC/HH Wch Supp Surgifoam__Et1972 PX-2725000096 CDM 2725000096 LOCAL 272 RC outpatient 37 37 CIGNA 62308 [3081051] CIGNA 62308 [308105105] 29.6 percent of total billed charges 22.94 35.15 Technical (Hospital) Services HC/HH Wch Supp Surgifoam__Et1972 PX-2725000096 CDM 2725000096 LOCAL 272 RC outpatient 37 37 CIGNA 62308 [3081051] CIGNA STATE OF WYOMING [308105107] 29.6 percent of total billed charges 22.94 35.15 Technical (Hospital) Services HC/HH Wch Supp Surgifoam__Et1972 PX-2725000096 CDM 2725000096 LOCAL 272 RC outpatient 37 37 UNITED HEALTHCARE (COMMERCIAL) [3081199] UNITED HEALTHCARE 87726 [308119901] 22.94 percent of total billed charges 22.94 35.15 Technical (Hospital) Services HC/HH Wch Supp Surgifoam__Et1972 PX-2725000096 CDM 2725000096 LOCAL 272 RC outpatient 37 37 HEALTHPARTNERS SX009 HEALTHPARTNERS 29.6 percent of total billed charges 22.94 35.15 Technical (Hospital) Services HC/HH Wch Supp Surgifoam__Et1972 PX-2725000096 CDM 2725000096 LOCAL 272 RC outpatient 37 37 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES PPO [308136801] 29.6 percent of total billed charges 22.94 35.15 Technical (Hospital) Services HC/HH Wch Supp Surgifoam__Et1972 PX-2725000096 CDM 2725000096 LOCAL 272 RC outpatient 37 37 MULTIPLAN INC 34080 [3081285] MULTIPLAN INC [308128501] 35.15 percent of total billed charges 22.94 35.15 Technical (Hospital) Services HC/HH Wch Supp Surgifoam__Et1972 PX-2725000096 CDM 2725000096 LOCAL 272 RC outpatient 37 37 MEDICA (COMMERCIAL) 94265 [3081118] MEDICA CLAIMS [308111801] 33.3 percent of total billed charges 22.94 35.15 Technical (Hospital) Services HC/HH Wch Supp Suction Tubing__Cfn510 PX-2725000095 CDM 2725000095 LOCAL 272 RC outpatient 14 14 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES HDHP [308136802] 11.2 percent of total billed charges 8.68 13.3 Technical (Hospital) Services HC/HH Wch Supp Suction Tubing__Cfn510 PX-2725000095 CDM 2725000095 LOCAL 272 RC outpatient 14 14 BLUE CROSS BLUE SHIELD WELLMARK SB889 [3081026] BCBS WYOMING [308102603] 13.3 percent of total billed charges 8.68 13.3 Technical (Hospital) Services HC/HH Wch Supp Suction Tubing__Cfn510 PX-2725000095 CDM 2725000095 LOCAL 272 RC outpatient 14 14 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES EPO [308136803] 11.2 percent of total billed charges 8.68 13.3 Technical (Hospital) Services HC/HH Wch Supp Suction Tubing__Cfn510 PX-2725000095 CDM 2725000095 LOCAL 272 RC outpatient 14 14 CIGNA 62308 [3081051] CIGNA 62308 [308105105] 11.2 percent of total billed charges 8.68 13.3 Technical (Hospital) Services HC/HH Wch Supp Suction Tubing__Cfn510 PX-2725000095 CDM 2725000095 LOCAL 272 RC outpatient 14 14 CIGNA 62308 [3081051] CIGNA STATE OF WYOMING [308105107] 11.2 percent of total billed charges 8.68 13.3 Technical (Hospital) Services HC/HH Wch Supp Suction Tubing__Cfn510 PX-2725000095 CDM 2725000095 LOCAL 272 RC outpatient 14 14 UNITED HEALTHCARE (COMMERCIAL) [3081199] UNITED HEALTHCARE 87726 [308119901] 8.68 percent of total billed charges 8.68 13.3 Technical (Hospital) Services HC/HH Wch Supp Suction Tubing__Cfn510 PX-2725000095 CDM 2725000095 LOCAL 272 RC outpatient 14 14 HEALTHPARTNERS SX009 HEALTHPARTNERS 11.2 percent of total billed charges 8.68 13.3 Technical (Hospital) Services HC/HH Wch Supp Suction Tubing__Cfn510 PX-2725000095 CDM 2725000095 LOCAL 272 RC outpatient 14 14 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES PPO [308136801] 11.2 percent of total billed charges 8.68 13.3 Technical (Hospital) Services HC/HH Wch Supp Suction Tubing__Cfn510 PX-2725000095 CDM 2725000095 LOCAL 272 RC outpatient 14 14 MULTIPLAN INC 34080 [3081285] MULTIPLAN INC [308128501] 13.3 percent of total billed charges 8.68 13.3 Technical (Hospital) Services HC/HH Wch Supp Suction Tubing__Cfn510 PX-2725000095 CDM 2725000095 LOCAL 272 RC outpatient 14 14 MEDICA (COMMERCIAL) 94265 [3081118] MEDICA CLAIMS [308111801] 12.6 percent of total billed charges 8.68 13.3 Technical (Hospital) Services HC/HH Wch Supp Suction Tubing__Cfn510 PX-2725000095 CDM 2725000095 LOCAL 272 RC inpatient 14 14 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES HDHP [308136802] 11.09 percent of total billed charges 8.68 13.3 Technical (Hospital) Services HC/HH Wch Supp Suction Tubing__Cfn510 PX-2725000095 CDM 2725000095 LOCAL 272 RC inpatient 14 14 CIGNA 62308 [3081051] CIGNA 62308 [308105105] 11.09 percent of total billed charges 8.68 13.3 Technical (Hospital) Services HC/HH Wch Supp Suction Tubing__Cfn510 PX-2725000095 CDM 2725000095 LOCAL 272 RC inpatient 14 14 CIGNA 62308 [3081051] CIGNA STATE OF WYOMING [308105107] 11.09 percent of total billed charges 8.68 13.3 Technical (Hospital) Services HC/HH Wch Supp Suction Tubing__Cfn510 PX-2725000095 CDM 2725000095 LOCAL 272 RC inpatient 14 14 UNITED HEALTHCARE (COMMERCIAL) [3081199] UNITED HEALTHCARE 87726 [308119901] 8.68 percent of total billed charges 8.68 13.3 Technical (Hospital) Services HC/HH Wch Supp Suction Tubing__Cfn510 PX-2725000095 CDM 2725000095 LOCAL 272 RC inpatient 14 14 MEDICA (COMMERCIAL) 94265 [3081118] MEDICA CLAIMS [308111801] 12.6 percent of total billed charges 8.68 13.3 Technical (Hospital) Services HC/HH Wch Supp Suction Tubing__Cfn510 PX-2725000095 CDM 2725000095 LOCAL 272 RC inpatient 14 14 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES PPO [308136801] 11.09 percent of total billed charges 8.68 13.3 Technical (Hospital) Services HC/HH Wch Supp Suction Tubing__Cfn510 PX-2725000095 CDM 2725000095 LOCAL 272 RC inpatient 14 14 HEALTHPARTNERS SX009 HEALTHPARTNERS 11.09 percent of total billed charges 8.68 13.3 Technical (Hospital) Services HC/HH Wch Supp Suction Tubing__Cfn510 PX-2725000095 CDM 2725000095 LOCAL 272 RC inpatient 14 14 BLUE CROSS BLUE SHIELD WELLMARK SB889 [3081026] BCBS WYOMING [308102603] 13.3 percent of total billed charges 8.68 13.3 Technical (Hospital) Services HC/HH Wch Supp Suction Tubing__Cfn510 PX-2725000095 CDM 2725000095 LOCAL 272 RC inpatient 14 14 MULTIPLAN INC 34080 [3081285] MULTIPLAN INC [308128501] 13.3 percent of total billed charges 8.68 13.3 Technical (Hospital) Services HC/HH Wch Supp Suction Tubing__Cfn510 PX-2725000095 CDM 2725000095 LOCAL 272 RC inpatient 14 14 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES EPO [308136803] 11.09 percent of total billed charges 8.68 13.3 Technical (Hospital) Services HC/HH Wch Supp Suction Cath Peds 8__30888 PX-2725000094 CDM 2725000094 LOCAL 272 RC outpatient 6 6 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES HDHP [308136802] 4.8 percent of total billed charges 3.72 5.7 Technical (Hospital) Services HC/HH Wch Supp Suction Cath Peds 8__30888 PX-2725000094 CDM 2725000094 LOCAL 272 RC outpatient 6 6 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES EPO [308136803] 4.8 percent of total billed charges 3.72 5.7 Technical (Hospital) Services HC/HH Wch Supp Suction Cath Peds 8__30888 PX-2725000094 CDM 2725000094 LOCAL 272 RC outpatient 6 6 BLUE CROSS BLUE SHIELD WELLMARK SB889 [3081026] BCBS WYOMING [308102603] 5.7 percent of total billed charges 3.72 5.7 Technical (Hospital) Services HC/HH Wch Supp Suction Cath Peds 8__30888 PX-2725000094 CDM 2725000094 LOCAL 272 RC outpatient 6 6 UNITED HEALTHCARE (COMMERCIAL) [3081199] UNITED HEALTHCARE 87726 [308119901] 3.72 percent of total billed charges 3.72 5.7 Technical (Hospital) Services HC/HH Wch Supp Suction Cath Peds 8__30888 PX-2725000094 CDM 2725000094 LOCAL 272 RC outpatient 6 6 HEALTHPARTNERS SX009 HEALTHPARTNERS 4.8 percent of total billed charges 3.72 5.7 Technical (Hospital) Services HC/HH Wch Supp Suction Cath Peds 8__30888 PX-2725000094 CDM 2725000094 LOCAL 272 RC outpatient 6 6 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES PPO [308136801] 4.8 percent of total billed charges 3.72 5.7 Technical (Hospital) Services HC/HH Wch Supp Suction Cath Peds 8__30888 PX-2725000094 CDM 2725000094 LOCAL 272 RC outpatient 6 6 CIGNA 62308 [3081051] CIGNA 62308 [308105105] 4.8 percent of total billed charges 3.72 5.7 Technical (Hospital) Services HC/HH Wch Supp Suction Cath Peds 8__30888 PX-2725000094 CDM 2725000094 LOCAL 272 RC outpatient 6 6 CIGNA 62308 [3081051] CIGNA STATE OF WYOMING [308105107] 4.8 percent of total billed charges 3.72 5.7 Technical (Hospital) Services HC/HH Wch Supp Suction Cath Peds 8__30888 PX-2725000094 CDM 2725000094 LOCAL 272 RC outpatient 6 6 MULTIPLAN INC 34080 [3081285] MULTIPLAN INC [308128501] 5.7 percent of total billed charges 3.72 5.7 Technical (Hospital) Services HC/HH Wch Supp Suction Cath Peds 8__30888 PX-2725000094 CDM 2725000094 LOCAL 272 RC outpatient 6 6 MEDICA (COMMERCIAL) 94265 [3081118] MEDICA CLAIMS [308111801] 5.4 percent of total billed charges 3.72 5.7 Technical (Hospital) Services HC/HH Wch Supp Suction Cath Peds 8__30888 PX-2725000094 CDM 2725000094 LOCAL 272 RC inpatient 6 6 MEDICA (COMMERCIAL) 94265 [3081118] MEDICA CLAIMS [308111801] 5.4 percent of total billed charges 3.72 5.7 Technical (Hospital) Services HC/HH Wch Supp Suction Cath Peds 8__30888 PX-2725000094 CDM 2725000094 LOCAL 272 RC inpatient 6 6 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES PPO [308136801] 4.75 percent of total billed charges 3.72 5.7 Technical (Hospital) Services HC/HH Wch Supp Suction Cath Peds 8__30888 PX-2725000094 CDM 2725000094 LOCAL 272 RC inpatient 6 6 UNITED HEALTHCARE (COMMERCIAL) [3081199] UNITED HEALTHCARE 87726 [308119901] 3.72 percent of total billed charges 3.72 5.7 Technical (Hospital) Services HC/HH Wch Supp Suction Cath Peds 8__30888 PX-2725000094 CDM 2725000094 LOCAL 272 RC inpatient 6 6 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES HDHP [308136802] 4.75 percent of total billed charges 3.72 5.7 Technical (Hospital) Services HC/HH Wch Supp Suction Cath Peds 8__30888 PX-2725000094 CDM 2725000094 LOCAL 272 RC inpatient 6 6 CIGNA 62308 [3081051] CIGNA 62308 [308105105] 4.75 percent of total billed charges 3.72 5.7 Technical (Hospital) Services HC/HH Wch Supp Suction Cath Peds 8__30888 PX-2725000094 CDM 2725000094 LOCAL 272 RC inpatient 6 6 CIGNA 62308 [3081051] CIGNA STATE OF WYOMING [308105107] 4.75 percent of total billed charges 3.72 5.7 Technical (Hospital) Services HC/HH Wch Supp Suction Cath Peds 8__30888 PX-2725000094 CDM 2725000094 LOCAL 272 RC inpatient 6 6 MULTIPLAN INC 34080 [3081285] MULTIPLAN INC [308128501] 5.7 percent of total billed charges 3.72 5.7 Technical (Hospital) Services HC/HH Wch Supp Suction Cath Peds 8__30888 PX-2725000094 CDM 2725000094 LOCAL 272 RC inpatient 6 6 BLUE CROSS BLUE SHIELD WELLMARK SB889 [3081026] BCBS WYOMING [308102603] 5.7 percent of total billed charges 3.72 5.7 Technical (Hospital) Services HC/HH Wch Supp Suction Cath Peds 8__30888 PX-2725000094 CDM 2725000094 LOCAL 272 RC inpatient 6 6 HEALTHPARTNERS SX009 HEALTHPARTNERS 4.75 percent of total billed charges 3.72 5.7 Technical (Hospital) Services HC/HH Wch Supp Suction Cath Peds 8__30888 PX-2725000094 CDM 2725000094 LOCAL 272 RC inpatient 6 6 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES EPO [308136803] 4.75 percent of total billed charges 3.72 5.7 Technical (Hospital) Services HC/HH Wch Supp Stylet Intubating 6fr__85863 PX-2725000093 CDM 2725000093 LOCAL 272 RC outpatient 24 24 MEDICA (COMMERCIAL) 94265 [3081118] MEDICA CLAIMS [308111801] 21.6 percent of total billed charges 14.88 22.8 Technical (Hospital) Services HC/HH Wch Supp Stylet Intubating 6fr__85863 PX-2725000093 CDM 2725000093 LOCAL 272 RC outpatient 24 24 MULTIPLAN INC 34080 [3081285] MULTIPLAN INC [308128501] 22.8 percent of total billed charges 14.88 22.8 Technical (Hospital) Services HC/HH Wch Supp Stylet Intubating 6fr__85863 PX-2725000093 CDM 2725000093 LOCAL 272 RC outpatient 24 24 HEALTHPARTNERS SX009 HEALTHPARTNERS 19.2 percent of total billed charges 14.88 22.8 Technical (Hospital) Services HC/HH Wch Supp Stylet Intubating 6fr__85863 PX-2725000093 CDM 2725000093 LOCAL 272 RC outpatient 24 24 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES PPO [308136801] 19.2 percent of total billed charges 14.88 22.8 Technical (Hospital) Services HC/HH Wch Supp Stylet Intubating 6fr__85863 PX-2725000093 CDM 2725000093 LOCAL 272 RC outpatient 24 24 UNITED HEALTHCARE (COMMERCIAL) [3081199] UNITED HEALTHCARE 87726 [308119901] 14.88 percent of total billed charges 14.88 22.8 Technical (Hospital) Services HC/HH Wch Supp Stylet Intubating 6fr__85863 PX-2725000093 CDM 2725000093 LOCAL 272 RC outpatient 24 24 CIGNA 62308 [3081051] CIGNA 62308 [308105105] 19.2 percent of total billed charges 14.88 22.8 Technical (Hospital) Services HC/HH Wch Supp Stylet Intubating 6fr__85863 PX-2725000093 CDM 2725000093 LOCAL 272 RC outpatient 24 24 CIGNA 62308 [3081051] CIGNA STATE OF WYOMING [308105107] 19.2 percent of total billed charges 14.88 22.8 Technical (Hospital) Services HC/HH Wch Supp Stylet Intubating 6fr__85863 PX-2725000093 CDM 2725000093 LOCAL 272 RC outpatient 24 24 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES EPO [308136803] 19.2 percent of total billed charges 14.88 22.8 Technical (Hospital) Services HC/HH Wch Supp Stylet Intubating 6fr__85863 PX-2725000093 CDM 2725000093 LOCAL 272 RC outpatient 24 24 BLUE CROSS BLUE SHIELD WELLMARK SB889 [3081026] BCBS WYOMING [308102603] 22.8 percent of total billed charges 14.88 22.8 Technical (Hospital) Services HC/HH Wch Supp Stylet Intubating 6fr__85863 PX-2725000093 CDM 2725000093 LOCAL 272 RC outpatient 24 24 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES HDHP [308136802] 19.2 percent of total billed charges 14.88 22.8 Technical (Hospital) Services HC/HH Wch Supp Stylet Intubating 6fr__85863 PX-2725000093 CDM 2725000093 LOCAL 272 RC inpatient 24 24 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES EPO [308136803] 19 percent of total billed charges 14.88 22.8 Technical (Hospital) Services HC/HH Wch Supp Stylet Intubating 6fr__85863 PX-2725000093 CDM 2725000093 LOCAL 272 RC inpatient 24 24 MULTIPLAN INC 34080 [3081285] MULTIPLAN INC [308128501] 22.8 percent of total billed charges 14.88 22.8 Technical (Hospital) Services HC/HH Wch Supp Stylet Intubating 6fr__85863 PX-2725000093 CDM 2725000093 LOCAL 272 RC inpatient 24 24 BLUE CROSS BLUE SHIELD WELLMARK SB889 [3081026] BCBS WYOMING [308102603] 22.8 percent of total billed charges 14.88 22.8 Technical (Hospital) Services HC/HH Wch Supp Stylet Intubating 6fr__85863 PX-2725000093 CDM 2725000093 LOCAL 272 RC inpatient 24 24 HEALTHPARTNERS SX009 HEALTHPARTNERS 19 percent of total billed charges 14.88 22.8 Technical (Hospital) Services HC/HH Wch Supp Stylet Intubating 6fr__85863 PX-2725000093 CDM 2725000093 LOCAL 272 RC inpatient 24 24 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES PPO [308136801] 19 percent of total billed charges 14.88 22.8 Technical (Hospital) Services HC/HH Wch Supp Stylet Intubating 6fr__85863 PX-2725000093 CDM 2725000093 LOCAL 272 RC inpatient 24 24 MEDICA (COMMERCIAL) 94265 [3081118] MEDICA CLAIMS [308111801] 21.6 percent of total billed charges 14.88 22.8 Technical (Hospital) Services HC/HH Wch Supp Stylet Intubating 6fr__85863 PX-2725000093 CDM 2725000093 LOCAL 272 RC inpatient 24 24 UNITED HEALTHCARE (COMMERCIAL) [3081199] UNITED HEALTHCARE 87726 [308119901] 14.88 percent of total billed charges 14.88 22.8 Technical (Hospital) Services HC/HH Wch Supp Stylet Intubating 6fr__85863 PX-2725000093 CDM 2725000093 LOCAL 272 RC inpatient 24 24 CIGNA 62308 [3081051] CIGNA 62308 [308105105] 19 percent of total billed charges 14.88 22.8 Technical (Hospital) Services HC/HH Wch Supp Stylet Intubating 6fr__85863 PX-2725000093 CDM 2725000093 LOCAL 272 RC inpatient 24 24 CIGNA 62308 [3081051] CIGNA STATE OF WYOMING [308105107] 19 percent of total billed charges 14.88 22.8 Technical (Hospital) Services HC/HH Wch Supp Stylet Intubating 6fr__85863 PX-2725000093 CDM 2725000093 LOCAL 272 RC inpatient 24 24 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES HDHP [308136802] 19 percent of total billed charges 14.88 22.8 Technical (Hospital) Services HC/HH Wch Supp Stylet Intubating 14fr__85865 PX-2725000092 CDM 2725000092 LOCAL 272 RC outpatient 24 24 MEDICA (COMMERCIAL) 94265 [3081118] MEDICA CLAIMS [308111801] 21.6 percent of total billed charges 14.88 22.8 Technical (Hospital) Services HC/HH Wch Supp Stylet Intubating 14fr__85865 PX-2725000092 CDM 2725000092 LOCAL 272 RC outpatient 24 24 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES PPO [308136801] 19.2 percent of total billed charges 14.88 22.8 Technical (Hospital) Services HC/HH Wch Supp Stylet Intubating 14fr__85865 PX-2725000092 CDM 2725000092 LOCAL 272 RC outpatient 24 24 MULTIPLAN INC 34080 [3081285] MULTIPLAN INC [308128501] 22.8 percent of total billed charges 14.88 22.8 Technical (Hospital) Services HC/HH Wch Supp Stylet Intubating 14fr__85865 PX-2725000092 CDM 2725000092 LOCAL 272 RC outpatient 24 24 HEALTHPARTNERS SX009 HEALTHPARTNERS 19.2 percent of total billed charges 14.88 22.8 Technical (Hospital) Services HC/HH Wch Supp Stylet Intubating 14fr__85865 PX-2725000092 CDM 2725000092 LOCAL 272 RC outpatient 24 24 UNITED HEALTHCARE (COMMERCIAL) [3081199] UNITED HEALTHCARE 87726 [308119901] 14.88 percent of total billed charges 14.88 22.8 Technical (Hospital) Services HC/HH Wch Supp Stylet Intubating 14fr__85865 PX-2725000092 CDM 2725000092 LOCAL 272 RC outpatient 24 24 CIGNA 62308 [3081051] CIGNA 62308 [308105105] 19.2 percent of total billed charges 14.88 22.8 Technical (Hospital) Services HC/HH Wch Supp Stylet Intubating 14fr__85865 PX-2725000092 CDM 2725000092 LOCAL 272 RC outpatient 24 24 CIGNA 62308 [3081051] CIGNA STATE OF WYOMING [308105107] 19.2 percent of total billed charges 14.88 22.8 Technical (Hospital) Services HC/HH Wch Supp Stylet Intubating 14fr__85865 PX-2725000092 CDM 2725000092 LOCAL 272 RC outpatient 24 24 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES HDHP [308136802] 19.2 percent of total billed charges 14.88 22.8 Technical (Hospital) Services HC/HH Wch Supp Stylet Intubating 14fr__85865 PX-2725000092 CDM 2725000092 LOCAL 272 RC outpatient 24 24 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES EPO [308136803] 19.2 percent of total billed charges 14.88 22.8 Technical (Hospital) Services HC/HH Wch Supp Stylet Intubating 14fr__85865 PX-2725000092 CDM 2725000092 LOCAL 272 RC outpatient 24 24 BLUE CROSS BLUE SHIELD WELLMARK SB889 [3081026] BCBS WYOMING [308102603] 22.8 percent of total billed charges 14.88 22.8 Technical (Hospital) Services HC/HH Wch Supp Stylet Intubating 14fr__85865 PX-2725000092 CDM 2725000092 LOCAL 272 RC inpatient 24 24 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES EPO [308136803] 19 percent of total billed charges 14.88 22.8 Technical (Hospital) Services HC/HH Wch Supp Stylet Intubating 14fr__85865 PX-2725000092 CDM 2725000092 LOCAL 272 RC inpatient 24 24 HEALTHPARTNERS SX009 HEALTHPARTNERS 19 percent of total billed charges 14.88 22.8 Technical (Hospital) Services HC/HH Wch Supp Stylet Intubating 14fr__85865 PX-2725000092 CDM 2725000092 LOCAL 272 RC inpatient 24 24 MULTIPLAN INC 34080 [3081285] MULTIPLAN INC [308128501] 22.8 percent of total billed charges 14.88 22.8 Technical (Hospital) Services HC/HH Wch Supp Stylet Intubating 14fr__85865 PX-2725000092 CDM 2725000092 LOCAL 272 RC inpatient 24 24 BLUE CROSS BLUE SHIELD WELLMARK SB889 [3081026] BCBS WYOMING [308102603] 22.8 percent of total billed charges 14.88 22.8 Technical (Hospital) Services HC/HH Wch Supp Stylet Intubating 14fr__85865 PX-2725000092 CDM 2725000092 LOCAL 272 RC inpatient 24 24 UNITED HEALTHCARE (COMMERCIAL) [3081199] UNITED HEALTHCARE 87726 [308119901] 14.88 percent of total billed charges 14.88 22.8 Technical (Hospital) Services HC/HH Wch Supp Stylet Intubating 14fr__85865 PX-2725000092 CDM 2725000092 LOCAL 272 RC inpatient 24 24 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES HDHP [308136802] 19 percent of total billed charges 14.88 22.8 Technical (Hospital) Services HC/HH Wch Supp Stylet Intubating 14fr__85865 PX-2725000092 CDM 2725000092 LOCAL 272 RC inpatient 24 24 CIGNA 62308 [3081051] CIGNA 62308 [308105105] 19 percent of total billed charges 14.88 22.8 Technical (Hospital) Services HC/HH Wch Supp Stylet Intubating 14fr__85865 PX-2725000092 CDM 2725000092 LOCAL 272 RC inpatient 24 24 CIGNA 62308 [3081051] CIGNA STATE OF WYOMING [308105107] 19 percent of total billed charges 14.88 22.8 Technical (Hospital) Services HC/HH Wch Supp Stylet Intubating 14fr__85865 PX-2725000092 CDM 2725000092 LOCAL 272 RC inpatient 24 24 MEDICA (COMMERCIAL) 94265 [3081118] MEDICA CLAIMS [308111801] 21.6 percent of total billed charges 14.88 22.8 Technical (Hospital) Services HC/HH Wch Supp Stylet Intubating 14fr__85865 PX-2725000092 CDM 2725000092 LOCAL 272 RC inpatient 24 24 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES PPO [308136801] 19 percent of total billed charges 14.88 22.8 Technical (Hospital) Services HC/HH Wch Supp Stop Cock 3 Way__2c6246 PX-2725000091 CDM 2725000091 LOCAL 272 RC outpatient 6 6 CIGNA 62308 [3081051] CIGNA 62308 [308105105] 4.8 percent of total billed charges 3.72 5.7 Technical (Hospital) Services HC/HH Wch Supp Stop Cock 3 Way__2c6246 PX-2725000091 CDM 2725000091 LOCAL 272 RC outpatient 6 6 CIGNA 62308 [3081051] CIGNA STATE OF WYOMING [308105107] 4.8 percent of total billed charges 3.72 5.7 Technical (Hospital) Services HC/HH Wch Supp Stop Cock 3 Way__2c6246 PX-2725000091 CDM 2725000091 LOCAL 272 RC outpatient 6 6 UNITED HEALTHCARE (COMMERCIAL) [3081199] UNITED HEALTHCARE 87726 [308119901] 3.72 percent of total billed charges 3.72 5.7 Technical (Hospital) Services HC/HH Wch Supp Stop Cock 3 Way__2c6246 PX-2725000091 CDM 2725000091 LOCAL 272 RC outpatient 6 6 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES PPO [308136801] 4.8 percent of total billed charges 3.72 5.7 Technical (Hospital) Services HC/HH Wch Supp Stop Cock 3 Way__2c6246 PX-2725000091 CDM 2725000091 LOCAL 272 RC outpatient 6 6 HEALTHPARTNERS SX009 HEALTHPARTNERS 4.8 percent of total billed charges 3.72 5.7 Technical (Hospital) Services HC/HH Wch Supp Stop Cock 3 Way__2c6246 PX-2725000091 CDM 2725000091 LOCAL 272 RC outpatient 6 6 BLUE CROSS BLUE SHIELD WELLMARK SB889 [3081026] BCBS WYOMING [308102603] 5.7 percent of total billed charges 3.72 5.7 Technical (Hospital) Services HC/HH Wch Supp Stop Cock 3 Way__2c6246 PX-2725000091 CDM 2725000091 LOCAL 272 RC outpatient 6 6 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES EPO [308136803] 4.8 percent of total billed charges 3.72 5.7 Technical (Hospital) Services HC/HH Wch Supp Stop Cock 3 Way__2c6246 PX-2725000091 CDM 2725000091 LOCAL 272 RC outpatient 6 6 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES HDHP [308136802] 4.8 percent of total billed charges 3.72 5.7 Technical (Hospital) Services HC/HH Wch Supp Stop Cock 3 Way__2c6246 PX-2725000091 CDM 2725000091 LOCAL 272 RC outpatient 6 6 MEDICA (COMMERCIAL) 94265 [3081118] MEDICA CLAIMS [308111801] 5.4 percent of total billed charges 3.72 5.7 Technical (Hospital) Services HC/HH Wch Supp Stop Cock 3 Way__2c6246 PX-2725000091 CDM 2725000091 LOCAL 272 RC outpatient 6 6 MULTIPLAN INC 34080 [3081285] MULTIPLAN INC [308128501] 5.7 percent of total billed charges 3.72 5.7 Technical (Hospital) Services HC/HH Wch Supp Stop Cock 3 Way__2c6246 PX-2725000091 CDM 2725000091 LOCAL 272 RC inpatient 6 6 UNITED HEALTHCARE (COMMERCIAL) [3081199] UNITED HEALTHCARE 87726 [308119901] 3.72 percent of total billed charges 3.72 5.7 Technical (Hospital) Services HC/HH Wch Supp Stop Cock 3 Way__2c6246 PX-2725000091 CDM 2725000091 LOCAL 272 RC inpatient 6 6 CIGNA 62308 [3081051] CIGNA 62308 [308105105] 4.75 percent of total billed charges 3.72 5.7 Technical (Hospital) Services HC/HH Wch Supp Stop Cock 3 Way__2c6246 PX-2725000091 CDM 2725000091 LOCAL 272 RC inpatient 6 6 CIGNA 62308 [3081051] CIGNA STATE OF WYOMING [308105107] 4.75 percent of total billed charges 3.72 5.7 Technical (Hospital) Services HC/HH Wch Supp Stop Cock 3 Way__2c6246 PX-2725000091 CDM 2725000091 LOCAL 272 RC inpatient 6 6 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES HDHP [308136802] 4.75 percent of total billed charges 3.72 5.7 Technical (Hospital) Services HC/HH Wch Supp Stop Cock 3 Way__2c6246 PX-2725000091 CDM 2725000091 LOCAL 272 RC inpatient 6 6 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES PPO [308136801] 4.75 percent of total billed charges 3.72 5.7 Technical (Hospital) Services HC/HH Wch Supp Stop Cock 3 Way__2c6246 PX-2725000091 CDM 2725000091 LOCAL 272 RC inpatient 6 6 MEDICA (COMMERCIAL) 94265 [3081118] MEDICA CLAIMS [308111801] 5.4 percent of total billed charges 3.72 5.7 Technical (Hospital) Services HC/HH Wch Supp Stop Cock 3 Way__2c6246 PX-2725000091 CDM 2725000091 LOCAL 272 RC inpatient 6 6 HEALTHPARTNERS SX009 HEALTHPARTNERS 4.75 percent of total billed charges 3.72 5.7 Technical (Hospital) Services HC/HH Wch Supp Stop Cock 3 Way__2c6246 PX-2725000091 CDM 2725000091 LOCAL 272 RC inpatient 6 6 BLUE CROSS BLUE SHIELD WELLMARK SB889 [3081026] BCBS WYOMING [308102603] 5.7 percent of total billed charges 3.72 5.7 Technical (Hospital) Services HC/HH Wch Supp Stop Cock 3 Way__2c6246 PX-2725000091 CDM 2725000091 LOCAL 272 RC inpatient 6 6 MULTIPLAN INC 34080 [3081285] MULTIPLAN INC [308128501] 5.7 percent of total billed charges 3.72 5.7 Technical (Hospital) Services HC/HH Wch Supp Stop Cock 3 Way__2c6246 PX-2725000091 CDM 2725000091 LOCAL 272 RC inpatient 6 6 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES EPO [308136803] 4.75 percent of total billed charges 3.72 5.7 Technical (Hospital) Services HC/HH Wch Supp Stat Padz__8900-4004 PX-2725000090 CDM 2725000090 LOCAL 272 RC inpatient 122 122 MULTIPLAN INC 34080 [3081285] MULTIPLAN INC [308128501] 115.9 percent of total billed charges 75.64 115.9 Technical (Hospital) Services HC/HH Wch Supp Stat Padz__8900-4004 PX-2725000090 CDM 2725000090 LOCAL 272 RC inpatient 122 122 BLUE CROSS BLUE SHIELD WELLMARK SB889 [3081026] BCBS WYOMING [308102603] 115.9 percent of total billed charges 75.64 115.9 Technical (Hospital) Services HC/HH Wch Supp Stat Padz__8900-4004 PX-2725000090 CDM 2725000090 LOCAL 272 RC inpatient 122 122 HEALTHPARTNERS SX009 HEALTHPARTNERS 96.6 percent of total billed charges 75.64 115.9 Technical (Hospital) Services HC/HH Wch Supp Stat Padz__8900-4004 PX-2725000090 CDM 2725000090 LOCAL 272 RC inpatient 122 122 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES EPO [308136803] 96.6 percent of total billed charges 75.64 115.9 Technical (Hospital) Services HC/HH Wch Supp Stat Padz__8900-4004 PX-2725000090 CDM 2725000090 LOCAL 272 RC inpatient 122 122 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES PPO [308136801] 96.6 percent of total billed charges 75.64 115.9 Technical (Hospital) Services HC/HH Wch Supp Stat Padz__8900-4004 PX-2725000090 CDM 2725000090 LOCAL 272 RC inpatient 122 122 MEDICA (COMMERCIAL) 94265 [3081118] MEDICA CLAIMS [308111801] 109.8 percent of total billed charges 75.64 115.9 Technical (Hospital) Services HC/HH Wch Supp Stat Padz__8900-4004 PX-2725000090 CDM 2725000090 LOCAL 272 RC inpatient 122 122 UNITED HEALTHCARE (COMMERCIAL) [3081199] UNITED HEALTHCARE 87726 [308119901] 75.64 percent of total billed charges 75.64 115.9 Technical (Hospital) Services HC/HH Wch Supp Stat Padz__8900-4004 PX-2725000090 CDM 2725000090 LOCAL 272 RC inpatient 122 122 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES HDHP [308136802] 96.6 percent of total billed charges 75.64 115.9 Technical (Hospital) Services HC/HH Wch Supp Stat Padz__8900-4004 PX-2725000090 CDM 2725000090 LOCAL 272 RC inpatient 122 122 CIGNA 62308 [3081051] CIGNA 62308 [308105105] 96.6 percent of total billed charges 75.64 115.9 Technical (Hospital) Services HC/HH Wch Supp Stat Padz__8900-4004 PX-2725000090 CDM 2725000090 LOCAL 272 RC inpatient 122 122 CIGNA 62308 [3081051] CIGNA STATE OF WYOMING [308105107] 96.6 percent of total billed charges 75.64 115.9 Technical (Hospital) Services HC/HH Wch Supp Stat Padz__8900-4004 PX-2725000090 CDM 2725000090 LOCAL 272 RC outpatient 122 122 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES EPO [308136803] 97.6 percent of total billed charges 75.64 115.9 Technical (Hospital) Services HC/HH Wch Supp Stat Padz__8900-4004 PX-2725000090 CDM 2725000090 LOCAL 272 RC outpatient 122 122 BLUE CROSS BLUE SHIELD WELLMARK SB889 [3081026] BCBS WYOMING [308102603] 115.9 percent of total billed charges 75.64 115.9 Technical (Hospital) Services HC/HH Wch Supp Stat Padz__8900-4004 PX-2725000090 CDM 2725000090 LOCAL 272 RC outpatient 122 122 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES HDHP [308136802] 97.6 percent of total billed charges 75.64 115.9 Technical (Hospital) Services HC/HH Wch Supp Stat Padz__8900-4004 PX-2725000090 CDM 2725000090 LOCAL 272 RC outpatient 122 122 CIGNA 62308 [3081051] CIGNA 62308 [308105105] 97.6 percent of total billed charges 75.64 115.9 Technical (Hospital) Services HC/HH Wch Supp Stat Padz__8900-4004 PX-2725000090 CDM 2725000090 LOCAL 272 RC outpatient 122 122 CIGNA 62308 [3081051] CIGNA STATE OF WYOMING [308105107] 97.6 percent of total billed charges 75.64 115.9 Technical (Hospital) Services HC/HH Wch Supp Stat Padz__8900-4004 PX-2725000090 CDM 2725000090 LOCAL 272 RC outpatient 122 122 UNITED HEALTHCARE (COMMERCIAL) [3081199] UNITED HEALTHCARE 87726 [308119901] 75.64 percent of total billed charges 75.64 115.9 Technical (Hospital) Services HC/HH Wch Supp Stat Padz__8900-4004 PX-2725000090 CDM 2725000090 LOCAL 272 RC outpatient 122 122 HEALTHPARTNERS SX009 HEALTHPARTNERS 97.6 percent of total billed charges 75.64 115.9 Technical (Hospital) Services HC/HH Wch Supp Stat Padz__8900-4004 PX-2725000090 CDM 2725000090 LOCAL 272 RC outpatient 122 122 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES PPO [308136801] 97.6 percent of total billed charges 75.64 115.9 Technical (Hospital) Services HC/HH Wch Supp Stat Padz__8900-4004 PX-2725000090 CDM 2725000090 LOCAL 272 RC outpatient 122 122 MULTIPLAN INC 34080 [3081285] MULTIPLAN INC [308128501] 115.9 percent of total billed charges 75.64 115.9 Technical (Hospital) Services HC/HH Wch Supp Stat Padz__8900-4004 PX-2725000090 CDM 2725000090 LOCAL 272 RC outpatient 122 122 MEDICA (COMMERCIAL) 94265 [3081118] MEDICA CLAIMS [308111801] 109.8 percent of total billed charges 75.64 115.9 Technical (Hospital) Services HC/HH Wch Supp Sol Surg Scrub Prevail__4vail PX-2725000089 CDM 2725000089 LOCAL 272 RC outpatient 17 17 BLUE CROSS BLUE SHIELD WELLMARK SB889 [3081026] BCBS WYOMING [308102603] 16.15 percent of total billed charges 10.54 16.15 Technical (Hospital) Services HC/HH Wch Supp Sol Surg Scrub Prevail__4vail PX-2725000089 CDM 2725000089 LOCAL 272 RC outpatient 17 17 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES EPO [308136803] 13.6 percent of total billed charges 10.54 16.15 Technical (Hospital) Services HC/HH Wch Supp Sol Surg Scrub Prevail__4vail PX-2725000089 CDM 2725000089 LOCAL 272 RC outpatient 17 17 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES HDHP [308136802] 13.6 percent of total billed charges 10.54 16.15 Technical (Hospital) Services HC/HH Wch Supp Sol Surg Scrub Prevail__4vail PX-2725000089 CDM 2725000089 LOCAL 272 RC outpatient 17 17 UNITED HEALTHCARE (COMMERCIAL) [3081199] UNITED HEALTHCARE 87726 [308119901] 10.54 percent of total billed charges 10.54 16.15 Technical (Hospital) Services HC/HH Wch Supp Sol Surg Scrub Prevail__4vail PX-2725000089 CDM 2725000089 LOCAL 272 RC outpatient 17 17 HEALTHPARTNERS SX009 HEALTHPARTNERS 13.6 percent of total billed charges 10.54 16.15 Technical (Hospital) Services HC/HH Wch Supp Sol Surg Scrub Prevail__4vail PX-2725000089 CDM 2725000089 LOCAL 272 RC outpatient 17 17 CIGNA 62308 [3081051] CIGNA 62308 [308105105] 13.6 percent of total billed charges 10.54 16.15 Technical (Hospital) Services HC/HH Wch Supp Sol Surg Scrub Prevail__4vail PX-2725000089 CDM 2725000089 LOCAL 272 RC outpatient 17 17 CIGNA 62308 [3081051] CIGNA STATE OF WYOMING [308105107] 13.6 percent of total billed charges 10.54 16.15 Technical (Hospital) Services HC/HH Wch Supp Sol Surg Scrub Prevail__4vail PX-2725000089 CDM 2725000089 LOCAL 272 RC outpatient 17 17 MEDICA (COMMERCIAL) 94265 [3081118] MEDICA CLAIMS [308111801] 15.3 percent of total billed charges 10.54 16.15 Technical (Hospital) Services HC/HH Wch Supp Sol Surg Scrub Prevail__4vail PX-2725000089 CDM 2725000089 LOCAL 272 RC outpatient 17 17 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES PPO [308136801] 13.6 percent of total billed charges 10.54 16.15 Technical (Hospital) Services HC/HH Wch Supp Sol Surg Scrub Prevail__4vail PX-2725000089 CDM 2725000089 LOCAL 272 RC outpatient 17 17 MULTIPLAN INC 34080 [3081285] MULTIPLAN INC [308128501] 16.15 percent of total billed charges 10.54 16.15 Technical (Hospital) Services HC/HH Wch Supp Sol Surg Scrub Prevail__4vail PX-2725000089 CDM 2725000089 LOCAL 272 RC inpatient 17 17 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES EPO [308136803] 13.46 percent of total billed charges 10.54 16.15 Technical (Hospital) Services HC/HH Wch Supp Sol Surg Scrub Prevail__4vail PX-2725000089 CDM 2725000089 LOCAL 272 RC inpatient 17 17 HEALTHPARTNERS SX009 HEALTHPARTNERS 13.46 percent of total billed charges 10.54 16.15 Technical (Hospital) Services HC/HH Wch Supp Sol Surg Scrub Prevail__4vail PX-2725000089 CDM 2725000089 LOCAL 272 RC inpatient 17 17 BLUE CROSS BLUE SHIELD WELLMARK SB889 [3081026] BCBS WYOMING [308102603] 16.15 percent of total billed charges 10.54 16.15 Technical (Hospital) Services HC/HH Wch Supp Sol Surg Scrub Prevail__4vail PX-2725000089 CDM 2725000089 LOCAL 272 RC inpatient 17 17 MULTIPLAN INC 34080 [3081285] MULTIPLAN INC [308128501] 16.15 percent of total billed charges 10.54 16.15 Technical (Hospital) Services HC/HH Wch Supp Sol Surg Scrub Prevail__4vail PX-2725000089 CDM 2725000089 LOCAL 272 RC inpatient 17 17 CIGNA 62308 [3081051] CIGNA 62308 [308105105] 13.46 percent of total billed charges 10.54 16.15 Technical (Hospital) Services HC/HH Wch Supp Sol Surg Scrub Prevail__4vail PX-2725000089 CDM 2725000089 LOCAL 272 RC inpatient 17 17 CIGNA 62308 [3081051] CIGNA STATE OF WYOMING [308105107] 13.46 percent of total billed charges 10.54 16.15 Technical (Hospital) Services HC/HH Wch Supp Sol Surg Scrub Prevail__4vail PX-2725000089 CDM 2725000089 LOCAL 272 RC inpatient 17 17 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES HDHP [308136802] 13.46 percent of total billed charges 10.54 16.15 Technical (Hospital) Services HC/HH Wch Supp Sol Surg Scrub Prevail__4vail PX-2725000089 CDM 2725000089 LOCAL 272 RC inpatient 17 17 UNITED HEALTHCARE (COMMERCIAL) [3081199] UNITED HEALTHCARE 87726 [308119901] 10.54 percent of total billed charges 10.54 16.15 Technical (Hospital) Services HC/HH Wch Supp Sol Surg Scrub Prevail__4vail PX-2725000089 CDM 2725000089 LOCAL 272 RC inpatient 17 17 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES PPO [308136801] 13.46 percent of total billed charges 10.54 16.15 Technical (Hospital) Services HC/HH Wch Supp Sol Surg Scrub Prevail__4vail PX-2725000089 CDM 2725000089 LOCAL 272 RC inpatient 17 17 MEDICA (COMMERCIAL) 94265 [3081118] MEDICA CLAIMS [308111801] 15.3 percent of total billed charges 10.54 16.15 Technical (Hospital) Services HC/HH Wch Supp Sol Irrigation Water St 250ml__2f7112 PX-2725000088 CDM 2725000088 LOCAL 272 RC inpatient 9 9 MEDICA (COMMERCIAL) 94265 [3081118] MEDICA CLAIMS [308111801] 8.1 percent of total billed charges 5.58 8.55 Technical (Hospital) Services HC/HH Wch Supp Sol Irrigation Water St 250ml__2f7112 PX-2725000088 CDM 2725000088 LOCAL 272 RC inpatient 9 9 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES PPO [308136801] 7.13 percent of total billed charges 5.58 8.55 Technical (Hospital) Services HC/HH Wch Supp Sol Irrigation Water St 250ml__2f7112 PX-2725000088 CDM 2725000088 LOCAL 272 RC inpatient 9 9 UNITED HEALTHCARE (COMMERCIAL) [3081199] UNITED HEALTHCARE 87726 [308119901] 5.58 percent of total billed charges 5.58 8.55 Technical (Hospital) Services HC/HH Wch Supp Sol Irrigation Water St 250ml__2f7112 PX-2725000088 CDM 2725000088 LOCAL 272 RC inpatient 9 9 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES HDHP [308136802] 7.13 percent of total billed charges 5.58 8.55 Technical (Hospital) Services HC/HH Wch Supp Sol Irrigation Water St 250ml__2f7112 PX-2725000088 CDM 2725000088 LOCAL 272 RC inpatient 9 9 CIGNA 62308 [3081051] CIGNA 62308 [308105105] 7.13 percent of total billed charges 5.58 8.55 Technical (Hospital) Services HC/HH Wch Supp Sol Irrigation Water St 250ml__2f7112 PX-2725000088 CDM 2725000088 LOCAL 272 RC inpatient 9 9 CIGNA 62308 [3081051] CIGNA STATE OF WYOMING [308105107] 7.13 percent of total billed charges 5.58 8.55 Technical (Hospital) Services HC/HH Wch Supp Sol Irrigation Water St 250ml__2f7112 PX-2725000088 CDM 2725000088 LOCAL 272 RC inpatient 9 9 MULTIPLAN INC 34080 [3081285] MULTIPLAN INC [308128501] 8.55 percent of total billed charges 5.58 8.55 Technical (Hospital) Services HC/HH Wch Supp Sol Irrigation Water St 250ml__2f7112 PX-2725000088 CDM 2725000088 LOCAL 272 RC inpatient 9 9 BLUE CROSS BLUE SHIELD WELLMARK SB889 [3081026] BCBS WYOMING [308102603] 8.55 percent of total billed charges 5.58 8.55 Technical (Hospital) Services HC/HH Wch Supp Sol Irrigation Water St 250ml__2f7112 PX-2725000088 CDM 2725000088 LOCAL 272 RC inpatient 9 9 HEALTHPARTNERS SX009 HEALTHPARTNERS 7.13 percent of total billed charges 5.58 8.55 Technical (Hospital) Services HC/HH Wch Supp Sol Irrigation Water St 250ml__2f7112 PX-2725000088 CDM 2725000088 LOCAL 272 RC inpatient 9 9 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES EPO [308136803] 7.13 percent of total billed charges 5.58 8.55 Technical (Hospital) Services HC/HH Wch Supp Sol Irrigation Water St 250ml__2f7112 PX-2725000088 CDM 2725000088 LOCAL 272 RC outpatient 9 9 BLUE CROSS BLUE SHIELD WELLMARK SB889 [3081026] BCBS WYOMING [308102603] 8.55 percent of total billed charges 5.58 8.55 Technical (Hospital) Services HC/HH Wch Supp Sol Irrigation Water St 250ml__2f7112 PX-2725000088 CDM 2725000088 LOCAL 272 RC outpatient 9 9 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES EPO [308136803] 7.2 percent of total billed charges 5.58 8.55 Technical (Hospital) Services HC/HH Wch Supp Sol Irrigation Water St 250ml__2f7112 PX-2725000088 CDM 2725000088 LOCAL 272 RC outpatient 9 9 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES HDHP [308136802] 7.2 percent of total billed charges 5.58 8.55 Technical (Hospital) Services HC/HH Wch Supp Sol Irrigation Water St 250ml__2f7112 PX-2725000088 CDM 2725000088 LOCAL 272 RC outpatient 9 9 CIGNA 62308 [3081051] CIGNA 62308 [308105105] 7.2 percent of total billed charges 5.58 8.55 Technical (Hospital) Services HC/HH Wch Supp Sol Irrigation Water St 250ml__2f7112 PX-2725000088 CDM 2725000088 LOCAL 272 RC outpatient 9 9 CIGNA 62308 [3081051] CIGNA STATE OF WYOMING [308105107] 7.2 percent of total billed charges 5.58 8.55 Technical (Hospital) Services HC/HH Wch Supp Sol Irrigation Water St 250ml__2f7112 PX-2725000088 CDM 2725000088 LOCAL 272 RC outpatient 9 9 UNITED HEALTHCARE (COMMERCIAL) [3081199] UNITED HEALTHCARE 87726 [308119901] 5.58 percent of total billed charges 5.58 8.55 Technical (Hospital) Services HC/HH Wch Supp Sol Irrigation Water St 250ml__2f7112 PX-2725000088 CDM 2725000088 LOCAL 272 RC outpatient 9 9 HEALTHPARTNERS SX009 HEALTHPARTNERS 7.2 percent of total billed charges 5.58 8.55 Technical (Hospital) Services HC/HH Wch Supp Sol Irrigation Water St 250ml__2f7112 PX-2725000088 CDM 2725000088 LOCAL 272 RC outpatient 9 9 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES PPO [308136801] 7.2 percent of total billed charges 5.58 8.55 Technical (Hospital) Services HC/HH Wch Supp Sol Irrigation Water St 250ml__2f7112 PX-2725000088 CDM 2725000088 LOCAL 272 RC outpatient 9 9 MULTIPLAN INC 34080 [3081285] MULTIPLAN INC [308128501] 8.55 percent of total billed charges 5.58 8.55 Technical (Hospital) Services HC/HH Wch Supp Sol Irrigation Water St 250ml__2f7112 PX-2725000088 CDM 2725000088 LOCAL 272 RC outpatient 9 9 MEDICA (COMMERCIAL) 94265 [3081118] MEDICA CLAIMS [308111801] 8.1 percent of total billed charges 5.58 8.55 Technical (Hospital) Services HC/HH Wch Supp Sol Irrigation Ns 0.9 250ml__2f7122 PX-2725000087 CDM 2725000087 LOCAL 272 RC inpatient 5 5 UNITED HEALTHCARE (COMMERCIAL) [3081199] UNITED HEALTHCARE 87726 [308119901] 3.1 percent of total billed charges 3.1 4.75 Technical (Hospital) Services HC/HH Wch Supp Sol Irrigation Ns 0.9 250ml__2f7122 PX-2725000087 CDM 2725000087 LOCAL 272 RC inpatient 5 5 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES HDHP [308136802] 3.96 percent of total billed charges 3.1 4.75 Technical (Hospital) Services HC/HH Wch Supp Sol Irrigation Ns 0.9 250ml__2f7122 PX-2725000087 CDM 2725000087 LOCAL 272 RC inpatient 5 5 CIGNA 62308 [3081051] CIGNA 62308 [308105105] 3.96 percent of total billed charges 3.1 4.75 Technical (Hospital) Services HC/HH Wch Supp Sol Irrigation Ns 0.9 250ml__2f7122 PX-2725000087 CDM 2725000087 LOCAL 272 RC inpatient 5 5 CIGNA 62308 [3081051] CIGNA STATE OF WYOMING [308105107] 3.96 percent of total billed charges 3.1 4.75 Technical (Hospital) Services HC/HH Wch Supp Sol Irrigation Ns 0.9 250ml__2f7122 PX-2725000087 CDM 2725000087 LOCAL 272 RC inpatient 5 5 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES PPO [308136801] 3.96 percent of total billed charges 3.1 4.75 Technical (Hospital) Services HC/HH Wch Supp Sol Irrigation Ns 0.9 250ml__2f7122 PX-2725000087 CDM 2725000087 LOCAL 272 RC inpatient 5 5 MEDICA (COMMERCIAL) 94265 [3081118] MEDICA CLAIMS [308111801] 4.5 percent of total billed charges 3.1 4.75 Technical (Hospital) Services HC/HH Wch Supp Sol Irrigation Ns 0.9 250ml__2f7122 PX-2725000087 CDM 2725000087 LOCAL 272 RC inpatient 5 5 HEALTHPARTNERS SX009 HEALTHPARTNERS 3.96 percent of total billed charges 3.1 4.75 Technical (Hospital) Services HC/HH Wch Supp Sol Irrigation Ns 0.9 250ml__2f7122 PX-2725000087 CDM 2725000087 LOCAL 272 RC inpatient 5 5 BLUE CROSS BLUE SHIELD WELLMARK SB889 [3081026] BCBS WYOMING [308102603] 4.75 percent of total billed charges 3.1 4.75 Technical (Hospital) Services HC/HH Wch Supp Sol Irrigation Ns 0.9 250ml__2f7122 PX-2725000087 CDM 2725000087 LOCAL 272 RC inpatient 5 5 MULTIPLAN INC 34080 [3081285] MULTIPLAN INC [308128501] 4.75 percent of total billed charges 3.1 4.75 Technical (Hospital) Services HC/HH Wch Supp Sol Irrigation Ns 0.9 250ml__2f7122 PX-2725000087 CDM 2725000087 LOCAL 272 RC inpatient 5 5 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES EPO [308136803] 3.96 percent of total billed charges 3.1 4.75 Technical (Hospital) Services HC/HH Wch Supp Sol Irrigation Ns 0.9 250ml__2f7122 PX-2725000087 CDM 2725000087 LOCAL 272 RC outpatient 5 5 MEDICA (COMMERCIAL) 94265 [3081118] MEDICA CLAIMS [308111801] 4.5 percent of total billed charges 3.1 4.75 Technical (Hospital) Services HC/HH Wch Supp Sol Irrigation Ns 0.9 250ml__2f7122 PX-2725000087 CDM 2725000087 LOCAL 272 RC outpatient 5 5 MULTIPLAN INC 34080 [3081285] MULTIPLAN INC [308128501] 4.75 percent of total billed charges 3.1 4.75 Technical (Hospital) Services HC/HH Wch Supp Sol Irrigation Ns 0.9 250ml__2f7122 PX-2725000087 CDM 2725000087 LOCAL 272 RC outpatient 5 5 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES HDHP [308136802] 4 percent of total billed charges 3.1 4.75 Technical (Hospital) Services HC/HH Wch Supp Sol Irrigation Ns 0.9 250ml__2f7122 PX-2725000087 CDM 2725000087 LOCAL 272 RC outpatient 5 5 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES EPO [308136803] 4 percent of total billed charges 3.1 4.75 Technical (Hospital) Services HC/HH Wch Supp Sol Irrigation Ns 0.9 250ml__2f7122 PX-2725000087 CDM 2725000087 LOCAL 272 RC outpatient 5 5 BLUE CROSS BLUE SHIELD WELLMARK SB889 [3081026] BCBS WYOMING [308102603] 4.75 percent of total billed charges 3.1 4.75 Technical (Hospital) Services HC/HH Wch Supp Sol Irrigation Ns 0.9 250ml__2f7122 PX-2725000087 CDM 2725000087 LOCAL 272 RC outpatient 5 5 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES PPO [308136801] 4 percent of total billed charges 3.1 4.75 Technical (Hospital) Services HC/HH Wch Supp Sol Irrigation Ns 0.9 250ml__2f7122 PX-2725000087 CDM 2725000087 LOCAL 272 RC outpatient 5 5 HEALTHPARTNERS SX009 HEALTHPARTNERS 4 percent of total billed charges 3.1 4.75 Technical (Hospital) Services HC/HH Wch Supp Sol Irrigation Ns 0.9 250ml__2f7122 PX-2725000087 CDM 2725000087 LOCAL 272 RC outpatient 5 5 UNITED HEALTHCARE (COMMERCIAL) [3081199] UNITED HEALTHCARE 87726 [308119901] 3.1 percent of total billed charges 3.1 4.75 Technical (Hospital) Services HC/HH Wch Supp Sol Irrigation Ns 0.9 250ml__2f7122 PX-2725000087 CDM 2725000087 LOCAL 272 RC outpatient 5 5 CIGNA 62308 [3081051] CIGNA 62308 [308105105] 4 percent of total billed charges 3.1 4.75 Technical (Hospital) Services HC/HH Wch Supp Sol Irrigation Ns 0.9 250ml__2f7122 PX-2725000087 CDM 2725000087 LOCAL 272 RC outpatient 5 5 CIGNA 62308 [3081051] CIGNA STATE OF WYOMING [308105107] 4 percent of total billed charges 3.1 4.75 Technical (Hospital) Services HC/HH Wch Supp Sol Irrigation Ns 0.9 1000ml__2f7124 PX-2725000086 CDM 2725000086 LOCAL 272 RC outpatient 6 6 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES HDHP [308136802] 4.8 percent of total billed charges 3.72 5.7 Technical (Hospital) Services HC/HH Wch Supp Sol Irrigation Ns 0.9 1000ml__2f7124 PX-2725000086 CDM 2725000086 LOCAL 272 RC outpatient 6 6 BLUE CROSS BLUE SHIELD WELLMARK SB889 [3081026] BCBS WYOMING [308102603] 5.7 percent of total billed charges 3.72 5.7 Technical (Hospital) Services HC/HH Wch Supp Sol Irrigation Ns 0.9 1000ml__2f7124 PX-2725000086 CDM 2725000086 LOCAL 272 RC outpatient 6 6 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES EPO [308136803] 4.8 percent of total billed charges 3.72 5.7 Technical (Hospital) Services HC/HH Wch Supp Sol Irrigation Ns 0.9 1000ml__2f7124 PX-2725000086 CDM 2725000086 LOCAL 272 RC outpatient 6 6 CIGNA 62308 [3081051] CIGNA 62308 [308105105] 4.8 percent of total billed charges 3.72 5.7 Technical (Hospital) Services HC/HH Wch Supp Sol Irrigation Ns 0.9 1000ml__2f7124 PX-2725000086 CDM 2725000086 LOCAL 272 RC outpatient 6 6 CIGNA 62308 [3081051] CIGNA STATE OF WYOMING [308105107] 4.8 percent of total billed charges 3.72 5.7 Technical (Hospital) Services HC/HH Wch Supp Sol Irrigation Ns 0.9 1000ml__2f7124 PX-2725000086 CDM 2725000086 LOCAL 272 RC outpatient 6 6 UNITED HEALTHCARE (COMMERCIAL) [3081199] UNITED HEALTHCARE 87726 [308119901] 3.72 percent of total billed charges 3.72 5.7 Technical (Hospital) Services HC/HH Wch Supp Sol Irrigation Ns 0.9 1000ml__2f7124 PX-2725000086 CDM 2725000086 LOCAL 272 RC outpatient 6 6 HEALTHPARTNERS SX009 HEALTHPARTNERS 4.8 percent of total billed charges 3.72 5.7 Technical (Hospital) Services HC/HH Wch Supp Sol Irrigation Ns 0.9 1000ml__2f7124 PX-2725000086 CDM 2725000086 LOCAL 272 RC outpatient 6 6 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES PPO [308136801] 4.8 percent of total billed charges 3.72 5.7 Technical (Hospital) Services HC/HH Wch Supp Sol Irrigation Ns 0.9 1000ml__2f7124 PX-2725000086 CDM 2725000086 LOCAL 272 RC outpatient 6 6 MULTIPLAN INC 34080 [3081285] MULTIPLAN INC [308128501] 5.7 percent of total billed charges 3.72 5.7 Technical (Hospital) Services HC/HH Wch Supp Sol Irrigation Ns 0.9 1000ml__2f7124 PX-2725000086 CDM 2725000086 LOCAL 272 RC outpatient 6 6 MEDICA (COMMERCIAL) 94265 [3081118] MEDICA CLAIMS [308111801] 5.4 percent of total billed charges 3.72 5.7 Technical (Hospital) Services HC/HH Wch Supp Sol Irrigation Ns 0.9 1000ml__2f7124 PX-2725000086 CDM 2725000086 LOCAL 272 RC inpatient 6 6 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES PPO [308136801] 4.75 percent of total billed charges 3.72 5.7 Technical (Hospital) Services HC/HH Wch Supp Sol Irrigation Ns 0.9 1000ml__2f7124 PX-2725000086 CDM 2725000086 LOCAL 272 RC inpatient 6 6 MEDICA (COMMERCIAL) 94265 [3081118] MEDICA CLAIMS [308111801] 5.4 percent of total billed charges 3.72 5.7 Technical (Hospital) Services HC/HH Wch Supp Sol Irrigation Ns 0.9 1000ml__2f7124 PX-2725000086 CDM 2725000086 LOCAL 272 RC inpatient 6 6 UNITED HEALTHCARE (COMMERCIAL) [3081199] UNITED HEALTHCARE 87726 [308119901] 3.72 percent of total billed charges 3.72 5.7 Technical (Hospital) Services HC/HH Wch Supp Sol Irrigation Ns 0.9 1000ml__2f7124 PX-2725000086 CDM 2725000086 LOCAL 272 RC inpatient 6 6 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES HDHP [308136802] 4.75 percent of total billed charges 3.72 5.7 Technical (Hospital) Services HC/HH Wch Supp Sol Irrigation Ns 0.9 1000ml__2f7124 PX-2725000086 CDM 2725000086 LOCAL 272 RC inpatient 6 6 CIGNA 62308 [3081051] CIGNA 62308 [308105105] 4.75 percent of total billed charges 3.72 5.7 Technical (Hospital) Services HC/HH Wch Supp Sol Irrigation Ns 0.9 1000ml__2f7124 PX-2725000086 CDM 2725000086 LOCAL 272 RC inpatient 6 6 CIGNA 62308 [3081051] CIGNA STATE OF WYOMING [308105107] 4.75 percent of total billed charges 3.72 5.7 Technical (Hospital) Services HC/HH Wch Supp Sol Irrigation Ns 0.9 1000ml__2f7124 PX-2725000086 CDM 2725000086 LOCAL 272 RC inpatient 6 6 MULTIPLAN INC 34080 [3081285] MULTIPLAN INC [308128501] 5.7 percent of total billed charges 3.72 5.7 Technical (Hospital) Services HC/HH Wch Supp Sol Irrigation Ns 0.9 1000ml__2f7124 PX-2725000086 CDM 2725000086 LOCAL 272 RC inpatient 6 6 BLUE CROSS BLUE SHIELD WELLMARK SB889 [3081026] BCBS WYOMING [308102603] 5.7 percent of total billed charges 3.72 5.7 Technical (Hospital) Services HC/HH Wch Supp Sol Irrigation Ns 0.9 1000ml__2f7124 PX-2725000086 CDM 2725000086 LOCAL 272 RC inpatient 6 6 HEALTHPARTNERS SX009 HEALTHPARTNERS 4.75 percent of total billed charges 3.72 5.7 Technical (Hospital) Services HC/HH Wch Supp Sol Irrigation Ns 0.9 1000ml__2f7124 PX-2725000086 CDM 2725000086 LOCAL 272 RC inpatient 6 6 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES EPO [308136803] 4.75 percent of total billed charges 3.72 5.7 Technical (Hospital) Services HC/HH Wch Supp Skin Stapler__Espmw35 PX-2725000085 CDM 2725000085 LOCAL 272 RC outpatient 25 25 HEALTHPARTNERS SX009 HEALTHPARTNERS 20 percent of total billed charges 15.5 23.75 Technical (Hospital) Services HC/HH Wch Supp Skin Stapler__Espmw35 PX-2725000085 CDM 2725000085 LOCAL 272 RC outpatient 25 25 UNITED HEALTHCARE (COMMERCIAL) [3081199] UNITED HEALTHCARE 87726 [308119901] 15.5 percent of total billed charges 15.5 23.75 Technical (Hospital) Services HC/HH Wch Supp Skin Stapler__Espmw35 PX-2725000085 CDM 2725000085 LOCAL 272 RC outpatient 25 25 CIGNA 62308 [3081051] CIGNA 62308 [308105105] 20 percent of total billed charges 15.5 23.75 Technical (Hospital) Services HC/HH Wch Supp Skin Stapler__Espmw35 PX-2725000085 CDM 2725000085 LOCAL 272 RC outpatient 25 25 CIGNA 62308 [3081051] CIGNA STATE OF WYOMING [308105107] 20 percent of total billed charges 15.5 23.75 Technical (Hospital) Services HC/HH Wch Supp Skin Stapler__Espmw35 PX-2725000085 CDM 2725000085 LOCAL 272 RC outpatient 25 25 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES HDHP [308136802] 20 percent of total billed charges 15.5 23.75 Technical (Hospital) Services HC/HH Wch Supp Skin Stapler__Espmw35 PX-2725000085 CDM 2725000085 LOCAL 272 RC outpatient 25 25 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES EPO [308136803] 20 percent of total billed charges 15.5 23.75 Technical (Hospital) Services HC/HH Wch Supp Skin Stapler__Espmw35 PX-2725000085 CDM 2725000085 LOCAL 272 RC outpatient 25 25 BLUE CROSS BLUE SHIELD WELLMARK SB889 [3081026] BCBS WYOMING [308102603] 23.75 percent of total billed charges 15.5 23.75 Technical (Hospital) Services HC/HH Wch Supp Skin Stapler__Espmw35 PX-2725000085 CDM 2725000085 LOCAL 272 RC outpatient 25 25 MEDICA (COMMERCIAL) 94265 [3081118] MEDICA CLAIMS [308111801] 22.5 percent of total billed charges 15.5 23.75 Technical (Hospital) Services HC/HH Wch Supp Skin Stapler__Espmw35 PX-2725000085 CDM 2725000085 LOCAL 272 RC outpatient 25 25 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES PPO [308136801] 20 percent of total billed charges 15.5 23.75 Technical (Hospital) Services HC/HH Wch Supp Skin Stapler__Espmw35 PX-2725000085 CDM 2725000085 LOCAL 272 RC outpatient 25 25 MULTIPLAN INC 34080 [3081285] MULTIPLAN INC [308128501] 23.75 percent of total billed charges 15.5 23.75 Technical (Hospital) Services HC/HH Wch Supp Skin Stapler__Espmw35 PX-2725000085 CDM 2725000085 LOCAL 272 RC inpatient 25 25 MEDICA (COMMERCIAL) 94265 [3081118] MEDICA CLAIMS [308111801] 22.5 percent of total billed charges 15.5 23.75 Technical (Hospital) Services HC/HH Wch Supp Skin Stapler__Espmw35 PX-2725000085 CDM 2725000085 LOCAL 272 RC inpatient 25 25 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES PPO [308136801] 19.8 percent of total billed charges 15.5 23.75 Technical (Hospital) Services HC/HH Wch Supp Skin Stapler__Espmw35 PX-2725000085 CDM 2725000085 LOCAL 272 RC inpatient 25 25 UNITED HEALTHCARE (COMMERCIAL) [3081199] UNITED HEALTHCARE 87726 [308119901] 15.5 percent of total billed charges 15.5 23.75 Technical (Hospital) Services HC/HH Wch Supp Skin Stapler__Espmw35 PX-2725000085 CDM 2725000085 LOCAL 272 RC inpatient 25 25 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES HDHP [308136802] 19.8 percent of total billed charges 15.5 23.75 Technical (Hospital) Services HC/HH Wch Supp Skin Stapler__Espmw35 PX-2725000085 CDM 2725000085 LOCAL 272 RC inpatient 25 25 CIGNA 62308 [3081051] CIGNA 62308 [308105105] 19.8 percent of total billed charges 15.5 23.75 Technical (Hospital) Services HC/HH Wch Supp Skin Stapler__Espmw35 PX-2725000085 CDM 2725000085 LOCAL 272 RC inpatient 25 25 CIGNA 62308 [3081051] CIGNA STATE OF WYOMING [308105107] 19.8 percent of total billed charges 15.5 23.75 Technical (Hospital) Services HC/HH Wch Supp Skin Stapler__Espmw35 PX-2725000085 CDM 2725000085 LOCAL 272 RC inpatient 25 25 MULTIPLAN INC 34080 [3081285] MULTIPLAN INC [308128501] 23.75 percent of total billed charges 15.5 23.75 Technical (Hospital) Services HC/HH Wch Supp Skin Stapler__Espmw35 PX-2725000085 CDM 2725000085 LOCAL 272 RC inpatient 25 25 BLUE CROSS BLUE SHIELD WELLMARK SB889 [3081026] BCBS WYOMING [308102603] 23.75 percent of total billed charges 15.5 23.75 Technical (Hospital) Services HC/HH Wch Supp Skin Stapler__Espmw35 PX-2725000085 CDM 2725000085 LOCAL 272 RC inpatient 25 25 HEALTHPARTNERS SX009 HEALTHPARTNERS 19.8 percent of total billed charges 15.5 23.75 Technical (Hospital) Services HC/HH Wch Supp Skin Stapler__Espmw35 PX-2725000085 CDM 2725000085 LOCAL 272 RC inpatient 25 25 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES EPO [308136803] 19.8 percent of total billed charges 15.5 23.75 Technical (Hospital) Services HC/HH Wch Supp Scalpel Protected Disp #11__372611 PX-2725000084 CDM 2725000084 LOCAL 272 RC inpatient 5 5 MULTIPLAN INC 34080 [3081285] MULTIPLAN INC [308128501] 4.75 percent of total billed charges 3.1 4.75 Technical (Hospital) Services HC/HH Wch Supp Scalpel Protected Disp #11__372611 PX-2725000084 CDM 2725000084 LOCAL 272 RC inpatient 5 5 BLUE CROSS BLUE SHIELD WELLMARK SB889 [3081026] BCBS WYOMING [308102603] 4.75 percent of total billed charges 3.1 4.75 Technical (Hospital) Services HC/HH Wch Supp Scalpel Protected Disp #11__372611 PX-2725000084 CDM 2725000084 LOCAL 272 RC inpatient 5 5 HEALTHPARTNERS SX009 HEALTHPARTNERS 3.96 percent of total billed charges 3.1 4.75 Technical (Hospital) Services HC/HH Wch Supp Scalpel Protected Disp #11__372611 PX-2725000084 CDM 2725000084 LOCAL 272 RC inpatient 5 5 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES EPO [308136803] 3.96 percent of total billed charges 3.1 4.75 Technical (Hospital) Services HC/HH Wch Supp Scalpel Protected Disp #11__372611 PX-2725000084 CDM 2725000084 LOCAL 272 RC inpatient 5 5 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES PPO [308136801] 3.96 percent of total billed charges 3.1 4.75 Technical (Hospital) Services HC/HH Wch Supp Scalpel Protected Disp #11__372611 PX-2725000084 CDM 2725000084 LOCAL 272 RC inpatient 5 5 MEDICA (COMMERCIAL) 94265 [3081118] MEDICA CLAIMS [308111801] 4.5 percent of total billed charges 3.1 4.75 Technical (Hospital) Services HC/HH Wch Supp Scalpel Protected Disp #11__372611 PX-2725000084 CDM 2725000084 LOCAL 272 RC inpatient 5 5 UNITED HEALTHCARE (COMMERCIAL) [3081199] UNITED HEALTHCARE 87726 [308119901] 3.1 percent of total billed charges 3.1 4.75 Technical (Hospital) Services HC/HH Wch Supp Scalpel Protected Disp #11__372611 PX-2725000084 CDM 2725000084 LOCAL 272 RC inpatient 5 5 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES HDHP [308136802] 3.96 percent of total billed charges 3.1 4.75 Technical (Hospital) Services HC/HH Wch Supp Scalpel Protected Disp #11__372611 PX-2725000084 CDM 2725000084 LOCAL 272 RC inpatient 5 5 CIGNA 62308 [3081051] CIGNA 62308 [308105105] 3.96 percent of total billed charges 3.1 4.75 Technical (Hospital) Services HC/HH Wch Supp Scalpel Protected Disp #11__372611 PX-2725000084 CDM 2725000084 LOCAL 272 RC inpatient 5 5 CIGNA 62308 [3081051] CIGNA STATE OF WYOMING [308105107] 3.96 percent of total billed charges 3.1 4.75 Technical (Hospital) Services HC/HH Wch Supp Scalpel Protected Disp #11__372611 PX-2725000084 CDM 2725000084 LOCAL 272 RC outpatient 5 5 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES HDHP [308136802] 4 percent of total billed charges 3.1 4.75 Technical (Hospital) Services HC/HH Wch Supp Scalpel Protected Disp #11__372611 PX-2725000084 CDM 2725000084 LOCAL 272 RC outpatient 5 5 BLUE CROSS BLUE SHIELD WELLMARK SB889 [3081026] BCBS WYOMING [308102603] 4.75 percent of total billed charges 3.1 4.75 Technical (Hospital) Services HC/HH Wch Supp Scalpel Protected Disp #11__372611 PX-2725000084 CDM 2725000084 LOCAL 272 RC outpatient 5 5 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES EPO [308136803] 4 percent of total billed charges 3.1 4.75 Technical (Hospital) Services HC/HH Wch Supp Scalpel Protected Disp #11__372611 PX-2725000084 CDM 2725000084 LOCAL 272 RC outpatient 5 5 CIGNA 62308 [3081051] CIGNA 62308 [308105105] 4 percent of total billed charges 3.1 4.75 Technical (Hospital) Services HC/HH Wch Supp Scalpel Protected Disp #11__372611 PX-2725000084 CDM 2725000084 LOCAL 272 RC outpatient 5 5 CIGNA 62308 [3081051] CIGNA STATE OF WYOMING [308105107] 4 percent of total billed charges 3.1 4.75 Technical (Hospital) Services HC/HH Wch Supp Scalpel Protected Disp #11__372611 PX-2725000084 CDM 2725000084 LOCAL 272 RC outpatient 5 5 UNITED HEALTHCARE (COMMERCIAL) [3081199] UNITED HEALTHCARE 87726 [308119901] 3.1 percent of total billed charges 3.1 4.75 Technical (Hospital) Services HC/HH Wch Supp Scalpel Protected Disp #11__372611 PX-2725000084 CDM 2725000084 LOCAL 272 RC outpatient 5 5 HEALTHPARTNERS SX009 HEALTHPARTNERS 4 percent of total billed charges 3.1 4.75 Technical (Hospital) Services HC/HH Wch Supp Scalpel Protected Disp #11__372611 PX-2725000084 CDM 2725000084 LOCAL 272 RC outpatient 5 5 MEDICA (COMMERCIAL) 94265 [3081118] MEDICA CLAIMS [308111801] 4.5 percent of total billed charges 3.1 4.75 Technical (Hospital) Services HC/HH Wch Supp Scalpel Protected Disp #11__372611 PX-2725000084 CDM 2725000084 LOCAL 272 RC outpatient 5 5 MULTIPLAN INC 34080 [3081285] MULTIPLAN INC [308128501] 4.75 percent of total billed charges 3.1 4.75 Technical (Hospital) Services HC/HH Wch Supp Scalpel Protected Disp #11__372611 PX-2725000084 CDM 2725000084 LOCAL 272 RC outpatient 5 5 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES PPO [308136801] 4 percent of total billed charges 3.1 4.75 Technical (Hospital) Services HC/HH Wch Supp Scalpel Protected Disp #10__372610 PX-2725000083 CDM 2725000083 LOCAL 272 RC outpatient 5 5 CIGNA 62308 [3081051] CIGNA 62308 [308105105] 4 percent of total billed charges 3.1 4.75 Technical (Hospital) Services HC/HH Wch Supp Scalpel Protected Disp #10__372610 PX-2725000083 CDM 2725000083 LOCAL 272 RC outpatient 5 5 CIGNA 62308 [3081051] CIGNA STATE OF WYOMING [308105107] 4 percent of total billed charges 3.1 4.75 Technical (Hospital) Services HC/HH Wch Supp Scalpel Protected Disp #10__372610 PX-2725000083 CDM 2725000083 LOCAL 272 RC outpatient 5 5 UNITED HEALTHCARE (COMMERCIAL) [3081199] UNITED HEALTHCARE 87726 [308119901] 3.1 percent of total billed charges 3.1 4.75 Technical (Hospital) Services HC/HH Wch Supp Scalpel Protected Disp #10__372610 PX-2725000083 CDM 2725000083 LOCAL 272 RC outpatient 5 5 HEALTHPARTNERS SX009 HEALTHPARTNERS 4 percent of total billed charges 3.1 4.75 Technical (Hospital) Services HC/HH Wch Supp Scalpel Protected Disp #10__372610 PX-2725000083 CDM 2725000083 LOCAL 272 RC outpatient 5 5 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES HDHP [308136802] 4 percent of total billed charges 3.1 4.75 Technical (Hospital) Services HC/HH Wch Supp Scalpel Protected Disp #10__372610 PX-2725000083 CDM 2725000083 LOCAL 272 RC outpatient 5 5 BLUE CROSS BLUE SHIELD WELLMARK SB889 [3081026] BCBS WYOMING [308102603] 4.75 percent of total billed charges 3.1 4.75 Technical (Hospital) Services HC/HH Wch Supp Scalpel Protected Disp #10__372610 PX-2725000083 CDM 2725000083 LOCAL 272 RC outpatient 5 5 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES EPO [308136803] 4 percent of total billed charges 3.1 4.75 Technical (Hospital) Services HC/HH Wch Supp Scalpel Protected Disp #10__372610 PX-2725000083 CDM 2725000083 LOCAL 272 RC outpatient 5 5 MULTIPLAN INC 34080 [3081285] MULTIPLAN INC [308128501] 4.75 percent of total billed charges 3.1 4.75 Technical (Hospital) Services HC/HH Wch Supp Scalpel Protected Disp #10__372610 PX-2725000083 CDM 2725000083 LOCAL 272 RC outpatient 5 5 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES PPO [308136801] 4 percent of total billed charges 3.1 4.75 Technical (Hospital) Services HC/HH Wch Supp Scalpel Protected Disp #10__372610 PX-2725000083 CDM 2725000083 LOCAL 272 RC outpatient 5 5 MEDICA (COMMERCIAL) 94265 [3081118] MEDICA CLAIMS [308111801] 4.5 percent of total billed charges 3.1 4.75 Technical (Hospital) Services HC/HH Wch Supp Scalpel Protected Disp #10__372610 PX-2725000083 CDM 2725000083 LOCAL 272 RC inpatient 5 5 MEDICA (COMMERCIAL) 94265 [3081118] MEDICA CLAIMS [308111801] 4.5 percent of total billed charges 3.1 4.75 Technical (Hospital) Services HC/HH Wch Supp Scalpel Protected Disp #10__372610 PX-2725000083 CDM 2725000083 LOCAL 272 RC inpatient 5 5 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES PPO [308136801] 3.96 percent of total billed charges 3.1 4.75 Technical (Hospital) Services HC/HH Wch Supp Scalpel Protected Disp #10__372610 PX-2725000083 CDM 2725000083 LOCAL 272 RC inpatient 5 5 CIGNA 62308 [3081051] CIGNA 62308 [308105105] 3.96 percent of total billed charges 3.1 4.75 Technical (Hospital) Services HC/HH Wch Supp Scalpel Protected Disp #10__372610 PX-2725000083 CDM 2725000083 LOCAL 272 RC inpatient 5 5 CIGNA 62308 [3081051] CIGNA STATE OF WYOMING [308105107] 3.96 percent of total billed charges 3.1 4.75 Technical (Hospital) Services HC/HH Wch Supp Scalpel Protected Disp #10__372610 PX-2725000083 CDM 2725000083 LOCAL 272 RC inpatient 5 5 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES HDHP [308136802] 3.96 percent of total billed charges 3.1 4.75 Technical (Hospital) Services HC/HH Wch Supp Scalpel Protected Disp #10__372610 PX-2725000083 CDM 2725000083 LOCAL 272 RC inpatient 5 5 UNITED HEALTHCARE (COMMERCIAL) [3081199] UNITED HEALTHCARE 87726 [308119901] 3.1 percent of total billed charges 3.1 4.75 Technical (Hospital) Services HC/HH Wch Supp Scalpel Protected Disp #10__372610 PX-2725000083 CDM 2725000083 LOCAL 272 RC inpatient 5 5 BLUE CROSS BLUE SHIELD WELLMARK SB889 [3081026] BCBS WYOMING [308102603] 4.75 percent of total billed charges 3.1 4.75 Technical (Hospital) Services HC/HH Wch Supp Scalpel Protected Disp #10__372610 PX-2725000083 CDM 2725000083 LOCAL 272 RC inpatient 5 5 MULTIPLAN INC 34080 [3081285] MULTIPLAN INC [308128501] 4.75 percent of total billed charges 3.1 4.75 Technical (Hospital) Services HC/HH Wch Supp Scalpel Protected Disp #10__372610 PX-2725000083 CDM 2725000083 LOCAL 272 RC inpatient 5 5 HEALTHPARTNERS SX009 HEALTHPARTNERS 3.96 percent of total billed charges 3.1 4.75 Technical (Hospital) Services HC/HH Wch Supp Scalpel Protected Disp #10__372610 PX-2725000083 CDM 2725000083 LOCAL 272 RC inpatient 5 5 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES EPO [308136803] 3.96 percent of total billed charges 3.1 4.75 Technical (Hospital) Services HC/HH Wch Supp Scalpel Protected Blade #15__372615 PX-2725000082 CDM 2725000082 LOCAL 272 RC outpatient 5 5 CIGNA 62308 [3081051] CIGNA 62308 [308105105] 4 percent of total billed charges 3.1 4.75 Technical (Hospital) Services HC/HH Wch Supp Scalpel Protected Blade #15__372615 PX-2725000082 CDM 2725000082 LOCAL 272 RC outpatient 5 5 CIGNA 62308 [3081051] CIGNA STATE OF WYOMING [308105107] 4 percent of total billed charges 3.1 4.75 Technical (Hospital) Services HC/HH Wch Supp Scalpel Protected Blade #15__372615 PX-2725000082 CDM 2725000082 LOCAL 272 RC outpatient 5 5 UNITED HEALTHCARE (COMMERCIAL) [3081199] UNITED HEALTHCARE 87726 [308119901] 3.1 percent of total billed charges 3.1 4.75 Technical (Hospital) Services HC/HH Wch Supp Scalpel Protected Blade #15__372615 PX-2725000082 CDM 2725000082 LOCAL 272 RC outpatient 5 5 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES PPO [308136801] 4 percent of total billed charges 3.1 4.75 Technical (Hospital) Services HC/HH Wch Supp Scalpel Protected Blade #15__372615 PX-2725000082 CDM 2725000082 LOCAL 272 RC outpatient 5 5 HEALTHPARTNERS SX009 HEALTHPARTNERS 4 percent of total billed charges 3.1 4.75 Technical (Hospital) Services HC/HH Wch Supp Scalpel Protected Blade #15__372615 PX-2725000082 CDM 2725000082 LOCAL 272 RC outpatient 5 5 BLUE CROSS BLUE SHIELD WELLMARK SB889 [3081026] BCBS WYOMING [308102603] 4.75 percent of total billed charges 3.1 4.75 Technical (Hospital) Services HC/HH Wch Supp Scalpel Protected Blade #15__372615 PX-2725000082 CDM 2725000082 LOCAL 272 RC outpatient 5 5 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES EPO [308136803] 4 percent of total billed charges 3.1 4.75 Technical (Hospital) Services HC/HH Wch Supp Scalpel Protected Blade #15__372615 PX-2725000082 CDM 2725000082 LOCAL 272 RC outpatient 5 5 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES HDHP [308136802] 4 percent of total billed charges 3.1 4.75 Technical (Hospital) Services HC/HH Wch Supp Scalpel Protected Blade #15__372615 PX-2725000082 CDM 2725000082 LOCAL 272 RC outpatient 5 5 MEDICA (COMMERCIAL) 94265 [3081118] MEDICA CLAIMS [308111801] 4.5 percent of total billed charges 3.1 4.75 Technical (Hospital) Services HC/HH Wch Supp Scalpel Protected Blade #15__372615 PX-2725000082 CDM 2725000082 LOCAL 272 RC outpatient 5 5 MULTIPLAN INC 34080 [3081285] MULTIPLAN INC [308128501] 4.75 percent of total billed charges 3.1 4.75 Technical (Hospital) Services HC/HH Wch Supp Scalpel Protected Blade #15__372615 PX-2725000082 CDM 2725000082 LOCAL 272 RC inpatient 5 5 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES EPO [308136803] 3.96 percent of total billed charges 3.1 4.75 Technical (Hospital) Services HC/HH Wch Supp Scalpel Protected Blade #15__372615 PX-2725000082 CDM 2725000082 LOCAL 272 RC inpatient 5 5 HEALTHPARTNERS SX009 HEALTHPARTNERS 3.96 percent of total billed charges 3.1 4.75 Technical (Hospital) Services HC/HH Wch Supp Scalpel Protected Blade #15__372615 PX-2725000082 CDM 2725000082 LOCAL 272 RC inpatient 5 5 MULTIPLAN INC 34080 [3081285] MULTIPLAN INC [308128501] 4.75 percent of total billed charges 3.1 4.75 Technical (Hospital) Services HC/HH Wch Supp Scalpel Protected Blade #15__372615 PX-2725000082 CDM 2725000082 LOCAL 272 RC inpatient 5 5 BLUE CROSS BLUE SHIELD WELLMARK SB889 [3081026] BCBS WYOMING [308102603] 4.75 percent of total billed charges 3.1 4.75 Technical (Hospital) Services HC/HH Wch Supp Scalpel Protected Blade #15__372615 PX-2725000082 CDM 2725000082 LOCAL 272 RC inpatient 5 5 MEDICA (COMMERCIAL) 94265 [3081118] MEDICA CLAIMS [308111801] 4.5 percent of total billed charges 3.1 4.75 Technical (Hospital) Services HC/HH Wch Supp Scalpel Protected Blade #15__372615 PX-2725000082 CDM 2725000082 LOCAL 272 RC inpatient 5 5 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES PPO [308136801] 3.96 percent of total billed charges 3.1 4.75 Technical (Hospital) Services HC/HH Wch Supp Scalpel Protected Blade #15__372615 PX-2725000082 CDM 2725000082 LOCAL 272 RC inpatient 5 5 CIGNA 62308 [3081051] CIGNA 62308 [308105105] 3.96 percent of total billed charges 3.1 4.75 Technical (Hospital) Services HC/HH Wch Supp Scalpel Protected Blade #15__372615 PX-2725000082 CDM 2725000082 LOCAL 272 RC inpatient 5 5 CIGNA 62308 [3081051] CIGNA STATE OF WYOMING [308105107] 3.96 percent of total billed charges 3.1 4.75 Technical (Hospital) Services HC/HH Wch Supp Scalpel Protected Blade #15__372615 PX-2725000082 CDM 2725000082 LOCAL 272 RC inpatient 5 5 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES HDHP [308136802] 3.96 percent of total billed charges 3.1 4.75 Technical (Hospital) Services HC/HH Wch Supp Scalpel Protected Blade #15__372615 PX-2725000082 CDM 2725000082 LOCAL 272 RC inpatient 5 5 UNITED HEALTHCARE (COMMERCIAL) [3081199] UNITED HEALTHCARE 87726 [308119901] 3.1 percent of total billed charges 3.1 4.75 Technical (Hospital) Services HC/HH Wch Supp Scalpel Protected Blade #12__372612 PX-2725000081 CDM 2725000081 LOCAL 272 RC inpatient 5 5 UNITED HEALTHCARE (COMMERCIAL) [3081199] UNITED HEALTHCARE 87726 [308119901] 3.1 percent of total billed charges 3.1 4.75 Technical (Hospital) Services HC/HH Wch Supp Scalpel Protected Blade #12__372612 PX-2725000081 CDM 2725000081 LOCAL 272 RC inpatient 5 5 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES HDHP [308136802] 3.96 percent of total billed charges 3.1 4.75 Technical (Hospital) Services HC/HH Wch Supp Scalpel Protected Blade #12__372612 PX-2725000081 CDM 2725000081 LOCAL 272 RC inpatient 5 5 CIGNA 62308 [3081051] CIGNA 62308 [308105105] 3.96 percent of total billed charges 3.1 4.75 Technical (Hospital) Services HC/HH Wch Supp Scalpel Protected Blade #12__372612 PX-2725000081 CDM 2725000081 LOCAL 272 RC inpatient 5 5 CIGNA 62308 [3081051] CIGNA STATE OF WYOMING [308105107] 3.96 percent of total billed charges 3.1 4.75 Technical (Hospital) Services HC/HH Wch Supp Scalpel Protected Blade #12__372612 PX-2725000081 CDM 2725000081 LOCAL 272 RC inpatient 5 5 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES PPO [308136801] 3.96 percent of total billed charges 3.1 4.75 Technical (Hospital) Services HC/HH Wch Supp Scalpel Protected Blade #12__372612 PX-2725000081 CDM 2725000081 LOCAL 272 RC inpatient 5 5 MEDICA (COMMERCIAL) 94265 [3081118] MEDICA CLAIMS [308111801] 4.5 percent of total billed charges 3.1 4.75 Technical (Hospital) Services HC/HH Wch Supp Scalpel Protected Blade #12__372612 PX-2725000081 CDM 2725000081 LOCAL 272 RC inpatient 5 5 BLUE CROSS BLUE SHIELD WELLMARK SB889 [3081026] BCBS WYOMING [308102603] 4.75 percent of total billed charges 3.1 4.75 Technical (Hospital) Services HC/HH Wch Supp Scalpel Protected Blade #12__372612 PX-2725000081 CDM 2725000081 LOCAL 272 RC inpatient 5 5 MULTIPLAN INC 34080 [3081285] MULTIPLAN INC [308128501] 4.75 percent of total billed charges 3.1 4.75 Technical (Hospital) Services HC/HH Wch Supp Scalpel Protected Blade #12__372612 PX-2725000081 CDM 2725000081 LOCAL 272 RC inpatient 5 5 HEALTHPARTNERS SX009 HEALTHPARTNERS 3.96 percent of total billed charges 3.1 4.75 Technical (Hospital) Services HC/HH Wch Supp Scalpel Protected Blade #12__372612 PX-2725000081 CDM 2725000081 LOCAL 272 RC inpatient 5 5 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES EPO [308136803] 3.96 percent of total billed charges 3.1 4.75 Technical (Hospital) Services HC/HH Wch Supp Scalpel Protected Blade #12__372612 PX-2725000081 CDM 2725000081 LOCAL 272 RC outpatient 5 5 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES EPO [308136803] 4 percent of total billed charges 3.1 4.75 Technical (Hospital) Services HC/HH Wch Supp Scalpel Protected Blade #12__372612 PX-2725000081 CDM 2725000081 LOCAL 272 RC outpatient 5 5 BLUE CROSS BLUE SHIELD WELLMARK SB889 [3081026] BCBS WYOMING [308102603] 4.75 percent of total billed charges 3.1 4.75 Technical (Hospital) Services HC/HH Wch Supp Scalpel Protected Blade #12__372612 PX-2725000081 CDM 2725000081 LOCAL 272 RC outpatient 5 5 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES HDHP [308136802] 4 percent of total billed charges 3.1 4.75 Technical (Hospital) Services HC/HH Wch Supp Scalpel Protected Blade #12__372612 PX-2725000081 CDM 2725000081 LOCAL 272 RC outpatient 5 5 CIGNA 62308 [3081051] CIGNA 62308 [308105105] 4 percent of total billed charges 3.1 4.75 Technical (Hospital) Services HC/HH Wch Supp Scalpel Protected Blade #12__372612 PX-2725000081 CDM 2725000081 LOCAL 272 RC outpatient 5 5 CIGNA 62308 [3081051] CIGNA STATE OF WYOMING [308105107] 4 percent of total billed charges 3.1 4.75 Technical (Hospital) Services HC/HH Wch Supp Scalpel Protected Blade #12__372612 PX-2725000081 CDM 2725000081 LOCAL 272 RC outpatient 5 5 UNITED HEALTHCARE (COMMERCIAL) [3081199] UNITED HEALTHCARE 87726 [308119901] 3.1 percent of total billed charges 3.1 4.75 Technical (Hospital) Services HC/HH Wch Supp Scalpel Protected Blade #12__372612 PX-2725000081 CDM 2725000081 LOCAL 272 RC outpatient 5 5 HEALTHPARTNERS SX009 HEALTHPARTNERS 4 percent of total billed charges 3.1 4.75 Technical (Hospital) Services HC/HH Wch Supp Scalpel Protected Blade #12__372612 PX-2725000081 CDM 2725000081 LOCAL 272 RC outpatient 5 5 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES PPO [308136801] 4 percent of total billed charges 3.1 4.75 Technical (Hospital) Services HC/HH Wch Supp Scalpel Protected Blade #12__372612 PX-2725000081 CDM 2725000081 LOCAL 272 RC outpatient 5 5 MULTIPLAN INC 34080 [3081285] MULTIPLAN INC [308128501] 4.75 percent of total billed charges 3.1 4.75 Technical (Hospital) Services HC/HH Wch Supp Scalpel Protected Blade #12__372612 PX-2725000081 CDM 2725000081 LOCAL 272 RC outpatient 5 5 MEDICA (COMMERCIAL) 94265 [3081118] MEDICA CLAIMS [308111801] 4.5 percent of total billed charges 3.1 4.75 Technical (Hospital) Services HC/HH Wch Supp Salem Sump Tube/18fr__8888264986 PX-2725000080 CDM 2725000080 LOCAL 272 RC outpatient 89 89 MULTIPLAN INC 34080 [3081285] MULTIPLAN INC [308128501] 84.55 percent of total billed charges 55.18 84.55 Technical (Hospital) Services HC/HH Wch Supp Salem Sump Tube/18fr__8888264986 PX-2725000080 CDM 2725000080 LOCAL 272 RC outpatient 89 89 MEDICA (COMMERCIAL) 94265 [3081118] MEDICA CLAIMS [308111801] 80.1 percent of total billed charges 55.18 84.55 Technical (Hospital) Services HC/HH Wch Supp Salem Sump Tube/18fr__8888264986 PX-2725000080 CDM 2725000080 LOCAL 272 RC outpatient 89 89 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES HDHP [308136802] 71.2 percent of total billed charges 55.18 84.55 Technical (Hospital) Services HC/HH Wch Supp Salem Sump Tube/18fr__8888264986 PX-2725000080 CDM 2725000080 LOCAL 272 RC outpatient 89 89 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES EPO [308136803] 71.2 percent of total billed charges 55.18 84.55 Technical (Hospital) Services HC/HH Wch Supp Salem Sump Tube/18fr__8888264986 PX-2725000080 CDM 2725000080 LOCAL 272 RC outpatient 89 89 BLUE CROSS BLUE SHIELD WELLMARK SB889 [3081026] BCBS WYOMING [308102603] 84.55 percent of total billed charges 55.18 84.55 Technical (Hospital) Services HC/HH Wch Supp Salem Sump Tube/18fr__8888264986 PX-2725000080 CDM 2725000080 LOCAL 272 RC outpatient 89 89 HEALTHPARTNERS SX009 HEALTHPARTNERS 71.2 percent of total billed charges 55.18 84.55 Technical (Hospital) Services HC/HH Wch Supp Salem Sump Tube/18fr__8888264986 PX-2725000080 CDM 2725000080 LOCAL 272 RC outpatient 89 89 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES PPO [308136801] 71.2 percent of total billed charges 55.18 84.55 Technical (Hospital) Services HC/HH Wch Supp Salem Sump Tube/18fr__8888264986 PX-2725000080 CDM 2725000080 LOCAL 272 RC outpatient 89 89 UNITED HEALTHCARE (COMMERCIAL) [3081199] UNITED HEALTHCARE 87726 [308119901] 55.18 percent of total billed charges 55.18 84.55 Technical (Hospital) Services HC/HH Wch Supp Salem Sump Tube/18fr__8888264986 PX-2725000080 CDM 2725000080 LOCAL 272 RC outpatient 89 89 CIGNA 62308 [3081051] CIGNA 62308 [308105105] 71.2 percent of total billed charges 55.18 84.55 Technical (Hospital) Services HC/HH Wch Supp Salem Sump Tube/18fr__8888264986 PX-2725000080 CDM 2725000080 LOCAL 272 RC outpatient 89 89 CIGNA 62308 [3081051] CIGNA STATE OF WYOMING [308105107] 71.2 percent of total billed charges 55.18 84.55 Technical (Hospital) Services HC/HH Wch Supp Salem Sump Tube/18fr__8888264986 PX-2725000080 CDM 2725000080 LOCAL 272 RC inpatient 89 89 MEDICA (COMMERCIAL) 94265 [3081118] MEDICA CLAIMS [308111801] 80.1 percent of total billed charges 55.18 84.55 Technical (Hospital) Services HC/HH Wch Supp Salem Sump Tube/18fr__8888264986 PX-2725000080 CDM 2725000080 LOCAL 272 RC inpatient 89 89 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES PPO [308136801] 70.47 percent of total billed charges 55.18 84.55 Technical (Hospital) Services HC/HH Wch Supp Salem Sump Tube/18fr__8888264986 PX-2725000080 CDM 2725000080 LOCAL 272 RC inpatient 89 89 UNITED HEALTHCARE (COMMERCIAL) [3081199] UNITED HEALTHCARE 87726 [308119901] 55.18 percent of total billed charges 55.18 84.55 Technical (Hospital) Services HC/HH Wch Supp Salem Sump Tube/18fr__8888264986 PX-2725000080 CDM 2725000080 LOCAL 272 RC inpatient 89 89 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES HDHP [308136802] 70.47 percent of total billed charges 55.18 84.55 Technical (Hospital) Services HC/HH Wch Supp Salem Sump Tube/18fr__8888264986 PX-2725000080 CDM 2725000080 LOCAL 272 RC inpatient 89 89 CIGNA 62308 [3081051] CIGNA 62308 [308105105] 70.47 percent of total billed charges 55.18 84.55 Technical (Hospital) Services HC/HH Wch Supp Salem Sump Tube/18fr__8888264986 PX-2725000080 CDM 2725000080 LOCAL 272 RC inpatient 89 89 CIGNA 62308 [3081051] CIGNA STATE OF WYOMING [308105107] 70.47 percent of total billed charges 55.18 84.55 Technical (Hospital) Services HC/HH Wch Supp Salem Sump Tube/18fr__8888264986 PX-2725000080 CDM 2725000080 LOCAL 272 RC inpatient 89 89 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES EPO [308136803] 70.47 percent of total billed charges 55.18 84.55 Technical (Hospital) Services HC/HH Wch Supp Salem Sump Tube/18fr__8888264986 PX-2725000080 CDM 2725000080 LOCAL 272 RC inpatient 89 89 BLUE CROSS BLUE SHIELD WELLMARK SB889 [3081026] BCBS WYOMING [308102603] 84.55 percent of total billed charges 55.18 84.55 Technical (Hospital) Services HC/HH Wch Supp Salem Sump Tube/18fr__8888264986 PX-2725000080 CDM 2725000080 LOCAL 272 RC inpatient 89 89 MULTIPLAN INC 34080 [3081285] MULTIPLAN INC [308128501] 84.55 percent of total billed charges 55.18 84.55 Technical (Hospital) Services HC/HH Wch Supp Salem Sump Tube/18fr__8888264986 PX-2725000080 CDM 2725000080 LOCAL 272 RC inpatient 89 89 HEALTHPARTNERS SX009 HEALTHPARTNERS 70.47 percent of total billed charges 55.18 84.55 Technical (Hospital) Services HC/HH Wch Supp Remover Staple Skin__Espsx PX-2725000079 CDM 2725000079 LOCAL 272 RC outpatient 16 16 CIGNA 62308 [3081051] CIGNA 62308 [308105105] 12.8 percent of total billed charges 9.92 15.2 Technical (Hospital) Services HC/HH Wch Supp Remover Staple Skin__Espsx PX-2725000079 CDM 2725000079 LOCAL 272 RC outpatient 16 16 CIGNA 62308 [3081051] CIGNA STATE OF WYOMING [308105107] 12.8 percent of total billed charges 9.92 15.2 Technical (Hospital) Services HC/HH Wch Supp Remover Staple Skin__Espsx PX-2725000079 CDM 2725000079 LOCAL 272 RC outpatient 16 16 UNITED HEALTHCARE (COMMERCIAL) [3081199] UNITED HEALTHCARE 87726 [308119901] 9.92 percent of total billed charges 9.92 15.2 Technical (Hospital) Services HC/HH Wch Supp Remover Staple Skin__Espsx PX-2725000079 CDM 2725000079 LOCAL 272 RC outpatient 16 16 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES PPO [308136801] 12.8 percent of total billed charges 9.92 15.2 Technical (Hospital) Services HC/HH Wch Supp Remover Staple Skin__Espsx PX-2725000079 CDM 2725000079 LOCAL 272 RC outpatient 16 16 HEALTHPARTNERS SX009 HEALTHPARTNERS 12.8 percent of total billed charges 9.92 15.2 Technical (Hospital) Services HC/HH Wch Supp Remover Staple Skin__Espsx PX-2725000079 CDM 2725000079 LOCAL 272 RC outpatient 16 16 BLUE CROSS BLUE SHIELD WELLMARK SB889 [3081026] BCBS WYOMING [308102603] 15.2 percent of total billed charges 9.92 15.2 Technical (Hospital) Services HC/HH Wch Supp Remover Staple Skin__Espsx PX-2725000079 CDM 2725000079 LOCAL 272 RC outpatient 16 16 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES EPO [308136803] 12.8 percent of total billed charges 9.92 15.2 Technical (Hospital) Services HC/HH Wch Supp Remover Staple Skin__Espsx PX-2725000079 CDM 2725000079 LOCAL 272 RC outpatient 16 16 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES HDHP [308136802] 12.8 percent of total billed charges 9.92 15.2 Technical (Hospital) Services HC/HH Wch Supp Remover Staple Skin__Espsx PX-2725000079 CDM 2725000079 LOCAL 272 RC outpatient 16 16 MEDICA (COMMERCIAL) 94265 [3081118] MEDICA CLAIMS [308111801] 14.4 percent of total billed charges 9.92 15.2 Technical (Hospital) Services HC/HH Wch Supp Remover Staple Skin__Espsx PX-2725000079 CDM 2725000079 LOCAL 272 RC outpatient 16 16 MULTIPLAN INC 34080 [3081285] MULTIPLAN INC [308128501] 15.2 percent of total billed charges 9.92 15.2 Technical (Hospital) Services HC/HH Wch Supp Remover Staple Skin__Espsx PX-2725000079 CDM 2725000079 LOCAL 272 RC inpatient 16 16 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES EPO [308136803] 12.67 percent of total billed charges 9.92 15.2 Technical (Hospital) Services HC/HH Wch Supp Remover Staple Skin__Espsx PX-2725000079 CDM 2725000079 LOCAL 272 RC inpatient 16 16 HEALTHPARTNERS SX009 HEALTHPARTNERS 12.67 percent of total billed charges 9.92 15.2 Technical (Hospital) Services HC/HH Wch Supp Remover Staple Skin__Espsx PX-2725000079 CDM 2725000079 LOCAL 272 RC inpatient 16 16 MULTIPLAN INC 34080 [3081285] MULTIPLAN INC [308128501] 15.2 percent of total billed charges 9.92 15.2 Technical (Hospital) Services HC/HH Wch Supp Remover Staple Skin__Espsx PX-2725000079 CDM 2725000079 LOCAL 272 RC inpatient 16 16 BLUE CROSS BLUE SHIELD WELLMARK SB889 [3081026] BCBS WYOMING [308102603] 15.2 percent of total billed charges 9.92 15.2 Technical (Hospital) Services HC/HH Wch Supp Remover Staple Skin__Espsx PX-2725000079 CDM 2725000079 LOCAL 272 RC inpatient 16 16 UNITED HEALTHCARE (COMMERCIAL) [3081199] UNITED HEALTHCARE 87726 [308119901] 9.92 percent of total billed charges 9.92 15.2 Technical (Hospital) Services HC/HH Wch Supp Remover Staple Skin__Espsx PX-2725000079 CDM 2725000079 LOCAL 272 RC inpatient 16 16 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES HDHP [308136802] 12.67 percent of total billed charges 9.92 15.2 Technical (Hospital) Services HC/HH Wch Supp Remover Staple Skin__Espsx PX-2725000079 CDM 2725000079 LOCAL 272 RC inpatient 16 16 CIGNA 62308 [3081051] CIGNA 62308 [308105105] 12.67 percent of total billed charges 9.92 15.2 Technical (Hospital) Services HC/HH Wch Supp Remover Staple Skin__Espsx PX-2725000079 CDM 2725000079 LOCAL 272 RC inpatient 16 16 CIGNA 62308 [3081051] CIGNA STATE OF WYOMING [308105107] 12.67 percent of total billed charges 9.92 15.2 Technical (Hospital) Services HC/HH Wch Supp Remover Staple Skin__Espsx PX-2725000079 CDM 2725000079 LOCAL 272 RC inpatient 16 16 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES PPO [308136801] 12.67 percent of total billed charges 9.92 15.2 Technical (Hospital) Services HC/HH Wch Supp Remover Staple Skin__Espsx PX-2725000079 CDM 2725000079 LOCAL 272 RC inpatient 16 16 MEDICA (COMMERCIAL) 94265 [3081118] MEDICA CLAIMS [308111801] 14.4 percent of total billed charges 9.92 15.2 Technical (Hospital) Services HC/HH Wch Supp Razor Nst__139004 PX-2725000078 CDM 2725000078 LOCAL 272 RC inpatient 5 5 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES EPO [308136803] 3.96 percent of total billed charges 3.1 4.75 Technical (Hospital) Services HC/HH Wch Supp Razor Nst__139004 PX-2725000078 CDM 2725000078 LOCAL 272 RC inpatient 5 5 MULTIPLAN INC 34080 [3081285] MULTIPLAN INC [308128501] 4.75 percent of total billed charges 3.1 4.75 Technical (Hospital) Services HC/HH Wch Supp Razor Nst__139004 PX-2725000078 CDM 2725000078 LOCAL 272 RC inpatient 5 5 BLUE CROSS BLUE SHIELD WELLMARK SB889 [3081026] BCBS WYOMING [308102603] 4.75 percent of total billed charges 3.1 4.75 Technical (Hospital) Services HC/HH Wch Supp Razor Nst__139004 PX-2725000078 CDM 2725000078 LOCAL 272 RC inpatient 5 5 HEALTHPARTNERS SX009 HEALTHPARTNERS 3.96 percent of total billed charges 3.1 4.75 Technical (Hospital) Services HC/HH Wch Supp Razor Nst__139004 PX-2725000078 CDM 2725000078 LOCAL 272 RC inpatient 5 5 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES PPO [308136801] 3.96 percent of total billed charges 3.1 4.75 Technical (Hospital) Services HC/HH Wch Supp Razor Nst__139004 PX-2725000078 CDM 2725000078 LOCAL 272 RC inpatient 5 5 MEDICA (COMMERCIAL) 94265 [3081118] MEDICA CLAIMS [308111801] 4.5 percent of total billed charges 3.1 4.75 Technical (Hospital) Services HC/HH Wch Supp Razor Nst__139004 PX-2725000078 CDM 2725000078 LOCAL 272 RC inpatient 5 5 UNITED HEALTHCARE (COMMERCIAL) [3081199] UNITED HEALTHCARE 87726 [308119901] 3.1 percent of total billed charges 3.1 4.75 Technical (Hospital) Services HC/HH Wch Supp Razor Nst__139004 PX-2725000078 CDM 2725000078 LOCAL 272 RC inpatient 5 5 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES HDHP [308136802] 3.96 percent of total billed charges 3.1 4.75 Technical (Hospital) Services HC/HH Wch Supp Razor Nst__139004 PX-2725000078 CDM 2725000078 LOCAL 272 RC inpatient 5 5 CIGNA 62308 [3081051] CIGNA 62308 [308105105] 3.96 percent of total billed charges 3.1 4.75 Technical (Hospital) Services HC/HH Wch Supp Razor Nst__139004 PX-2725000078 CDM 2725000078 LOCAL 272 RC inpatient 5 5 CIGNA 62308 [3081051] CIGNA STATE OF WYOMING [308105107] 3.96 percent of total billed charges 3.1 4.75 Technical (Hospital) Services HC/HH Wch Supp Razor Nst__139004 PX-2725000078 CDM 2725000078 LOCAL 272 RC outpatient 5 5 BLUE CROSS BLUE SHIELD WELLMARK SB889 [3081026] BCBS WYOMING [308102603] 4.75 percent of total billed charges 3.1 4.75 Technical (Hospital) Services HC/HH Wch Supp Razor Nst__139004 PX-2725000078 CDM 2725000078 LOCAL 272 RC outpatient 5 5 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES EPO [308136803] 4 percent of total billed charges 3.1 4.75 Technical (Hospital) Services HC/HH Wch Supp Razor Nst__139004 PX-2725000078 CDM 2725000078 LOCAL 272 RC outpatient 5 5 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES HDHP [308136802] 4 percent of total billed charges 3.1 4.75 Technical (Hospital) Services HC/HH Wch Supp Razor Nst__139004 PX-2725000078 CDM 2725000078 LOCAL 272 RC outpatient 5 5 CIGNA 62308 [3081051] CIGNA 62308 [308105105] 4 percent of total billed charges 3.1 4.75 Technical (Hospital) Services HC/HH Wch Supp Razor Nst__139004 PX-2725000078 CDM 2725000078 LOCAL 272 RC outpatient 5 5 CIGNA 62308 [3081051] CIGNA STATE OF WYOMING [308105107] 4 percent of total billed charges 3.1 4.75 Technical (Hospital) Services HC/HH Wch Supp Razor Nst__139004 PX-2725000078 CDM 2725000078 LOCAL 272 RC outpatient 5 5 HEALTHPARTNERS SX009 HEALTHPARTNERS 4 percent of total billed charges 3.1 4.75 Technical (Hospital) Services HC/HH Wch Supp Razor Nst__139004 PX-2725000078 CDM 2725000078 LOCAL 272 RC outpatient 5 5 UNITED HEALTHCARE (COMMERCIAL) [3081199] UNITED HEALTHCARE 87726 [308119901] 3.1 percent of total billed charges 3.1 4.75 Technical (Hospital) Services HC/HH Wch Supp Razor Nst__139004 PX-2725000078 CDM 2725000078 LOCAL 272 RC outpatient 5 5 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES PPO [308136801] 4 percent of total billed charges 3.1 4.75 Technical (Hospital) Services HC/HH Wch Supp Razor Nst__139004 PX-2725000078 CDM 2725000078 LOCAL 272 RC outpatient 5 5 MULTIPLAN INC 34080 [3081285] MULTIPLAN INC [308128501] 4.75 percent of total billed charges 3.1 4.75 Technical (Hospital) Services HC/HH Wch Supp Razor Nst__139004 PX-2725000078 CDM 2725000078 LOCAL 272 RC outpatient 5 5 MEDICA (COMMERCIAL) 94265 [3081118] MEDICA CLAIMS [308111801] 4.5 percent of total billed charges 3.1 4.75 Technical (Hospital) Services HC/HH Wch Supp Quicktrach 4.0__120900040 PX-2725000077 CDM 2725000077 LOCAL 272 RC inpatient 378 378 MEDICA (COMMERCIAL) 94265 [3081118] MEDICA CLAIMS [308111801] 340.2 percent of total billed charges 234.36 359.1 Technical (Hospital) Services HC/HH Wch Supp Quicktrach 4.0__120900040 PX-2725000077 CDM 2725000077 LOCAL 272 RC inpatient 378 378 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES PPO [308136801] 299.3 percent of total billed charges 234.36 359.1 Technical (Hospital) Services HC/HH Wch Supp Quicktrach 4.0__120900040 PX-2725000077 CDM 2725000077 LOCAL 272 RC inpatient 378 378 CIGNA 62308 [3081051] CIGNA 62308 [308105105] 299.3 percent of total billed charges 234.36 359.1 Technical (Hospital) Services HC/HH Wch Supp Quicktrach 4.0__120900040 PX-2725000077 CDM 2725000077 LOCAL 272 RC inpatient 378 378 CIGNA 62308 [3081051] CIGNA STATE OF WYOMING [308105107] 299.3 percent of total billed charges 234.36 359.1 Technical (Hospital) Services HC/HH Wch Supp Quicktrach 4.0__120900040 PX-2725000077 CDM 2725000077 LOCAL 272 RC inpatient 378 378 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES HDHP [308136802] 299.3 percent of total billed charges 234.36 359.1 Technical (Hospital) Services HC/HH Wch Supp Quicktrach 4.0__120900040 PX-2725000077 CDM 2725000077 LOCAL 272 RC inpatient 378 378 UNITED HEALTHCARE (COMMERCIAL) [3081199] UNITED HEALTHCARE 87726 [308119901] 234.36 percent of total billed charges 234.36 359.1 Technical (Hospital) Services HC/HH Wch Supp Quicktrach 4.0__120900040 PX-2725000077 CDM 2725000077 LOCAL 272 RC inpatient 378 378 BLUE CROSS BLUE SHIELD WELLMARK SB889 [3081026] BCBS WYOMING [308102603] 359.1 percent of total billed charges 234.36 359.1 Technical (Hospital) Services HC/HH Wch Supp Quicktrach 4.0__120900040 PX-2725000077 CDM 2725000077 LOCAL 272 RC inpatient 378 378 MULTIPLAN INC 34080 [3081285] MULTIPLAN INC [308128501] 359.1 percent of total billed charges 234.36 359.1 Technical (Hospital) Services HC/HH Wch Supp Quicktrach 4.0__120900040 PX-2725000077 CDM 2725000077 LOCAL 272 RC inpatient 378 378 HEALTHPARTNERS SX009 HEALTHPARTNERS 299.3 percent of total billed charges 234.36 359.1 Technical (Hospital) Services HC/HH Wch Supp Quicktrach 4.0__120900040 PX-2725000077 CDM 2725000077 LOCAL 272 RC inpatient 378 378 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES EPO [308136803] 299.3 percent of total billed charges 234.36 359.1 Technical (Hospital) Services HC/HH Wch Supp Quicktrach 4.0__120900040 PX-2725000077 CDM 2725000077 LOCAL 272 RC outpatient 378 378 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES EPO [308136803] 302.4 percent of total billed charges 234.36 359.1 Technical (Hospital) Services HC/HH Wch Supp Quicktrach 4.0__120900040 PX-2725000077 CDM 2725000077 LOCAL 272 RC outpatient 378 378 BLUE CROSS BLUE SHIELD WELLMARK SB889 [3081026] BCBS WYOMING [308102603] 359.1 percent of total billed charges 234.36 359.1 Technical (Hospital) Services HC/HH Wch Supp Quicktrach 4.0__120900040 PX-2725000077 CDM 2725000077 LOCAL 272 RC outpatient 378 378 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES HDHP [308136802] 302.4 percent of total billed charges 234.36 359.1 Technical (Hospital) Services HC/HH Wch Supp Quicktrach 4.0__120900040 PX-2725000077 CDM 2725000077 LOCAL 272 RC outpatient 378 378 UNITED HEALTHCARE (COMMERCIAL) [3081199] UNITED HEALTHCARE 87726 [308119901] 234.36 percent of total billed charges 234.36 359.1 Technical (Hospital) Services HC/HH Wch Supp Quicktrach 4.0__120900040 PX-2725000077 CDM 2725000077 LOCAL 272 RC outpatient 378 378 CIGNA 62308 [3081051] CIGNA 62308 [308105105] 302.4 percent of total billed charges 234.36 359.1 Technical (Hospital) Services HC/HH Wch Supp Quicktrach 4.0__120900040 PX-2725000077 CDM 2725000077 LOCAL 272 RC outpatient 378 378 CIGNA 62308 [3081051] CIGNA STATE OF WYOMING [308105107] 302.4 percent of total billed charges 234.36 359.1 Technical (Hospital) Services HC/HH Wch Supp Quicktrach 4.0__120900040 PX-2725000077 CDM 2725000077 LOCAL 272 RC outpatient 378 378 MEDICA (COMMERCIAL) 94265 [3081118] MEDICA CLAIMS [308111801] 340.2 percent of total billed charges 234.36 359.1 Technical (Hospital) Services HC/HH Wch Supp Quicktrach 4.0__120900040 PX-2725000077 CDM 2725000077 LOCAL 272 RC outpatient 378 378 HEALTHPARTNERS SX009 HEALTHPARTNERS 302.4 percent of total billed charges 234.36 359.1 Technical (Hospital) Services HC/HH Wch Supp Quicktrach 4.0__120900040 PX-2725000077 CDM 2725000077 LOCAL 272 RC outpatient 378 378 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES PPO [308136801] 302.4 percent of total billed charges 234.36 359.1 Technical (Hospital) Services HC/HH Wch Supp Quicktrach 4.0__120900040 PX-2725000077 CDM 2725000077 LOCAL 272 RC outpatient 378 378 MULTIPLAN INC 34080 [3081285] MULTIPLAN INC [308128501] 359.1 percent of total billed charges 234.36 359.1 Technical (Hospital) Services HC/HH Wch Supp Povidone-Iodine Swabstick__S41125 PX-2725000076 CDM 2725000076 LOCAL 272 RC inpatient 6 6 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES EPO [308136803] 4.75 percent of total billed charges 3.72 5.7 Technical (Hospital) Services HC/HH Wch Supp Povidone-Iodine Swabstick__S41125 PX-2725000076 CDM 2725000076 LOCAL 272 RC inpatient 6 6 HEALTHPARTNERS SX009 HEALTHPARTNERS 4.75 percent of total billed charges 3.72 5.7 Technical (Hospital) Services HC/HH Wch Supp Povidone-Iodine Swabstick__S41125 PX-2725000076 CDM 2725000076 LOCAL 272 RC inpatient 6 6 MULTIPLAN INC 34080 [3081285] MULTIPLAN INC [308128501] 5.7 percent of total billed charges 3.72 5.7 Technical (Hospital) Services HC/HH Wch Supp Povidone-Iodine Swabstick__S41125 PX-2725000076 CDM 2725000076 LOCAL 272 RC inpatient 6 6 BLUE CROSS BLUE SHIELD WELLMARK SB889 [3081026] BCBS WYOMING [308102603] 5.7 percent of total billed charges 3.72 5.7 Technical (Hospital) Services HC/HH Wch Supp Povidone-Iodine Swabstick__S41125 PX-2725000076 CDM 2725000076 LOCAL 272 RC inpatient 6 6 UNITED HEALTHCARE (COMMERCIAL) [3081199] UNITED HEALTHCARE 87726 [308119901] 3.72 percent of total billed charges 3.72 5.7 Technical (Hospital) Services HC/HH Wch Supp Povidone-Iodine Swabstick__S41125 PX-2725000076 CDM 2725000076 LOCAL 272 RC inpatient 6 6 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES HDHP [308136802] 4.75 percent of total billed charges 3.72 5.7 Technical (Hospital) Services HC/HH Wch Supp Povidone-Iodine Swabstick__S41125 PX-2725000076 CDM 2725000076 LOCAL 272 RC inpatient 6 6 CIGNA 62308 [3081051] CIGNA 62308 [308105105] 4.75 percent of total billed charges 3.72 5.7 Technical (Hospital) Services HC/HH Wch Supp Povidone-Iodine Swabstick__S41125 PX-2725000076 CDM 2725000076 LOCAL 272 RC inpatient 6 6 CIGNA 62308 [3081051] CIGNA STATE OF WYOMING [308105107] 4.75 percent of total billed charges 3.72 5.7 Technical (Hospital) Services HC/HH Wch Supp Povidone-Iodine Swabstick__S41125 PX-2725000076 CDM 2725000076 LOCAL 272 RC inpatient 6 6 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES PPO [308136801] 4.75 percent of total billed charges 3.72 5.7 Technical (Hospital) Services HC/HH Wch Supp Povidone-Iodine Swabstick__S41125 PX-2725000076 CDM 2725000076 LOCAL 272 RC inpatient 6 6 MEDICA (COMMERCIAL) 94265 [3081118] MEDICA CLAIMS [308111801] 5.4 percent of total billed charges 3.72 5.7 Technical (Hospital) Services HC/HH Wch Supp Povidone-Iodine Swabstick__S41125 PX-2725000076 CDM 2725000076 LOCAL 272 RC outpatient 6 6 MEDICA (COMMERCIAL) 94265 [3081118] MEDICA CLAIMS [308111801] 5.4 percent of total billed charges 3.72 5.7 Technical (Hospital) Services HC/HH Wch Supp Povidone-Iodine Swabstick__S41125 PX-2725000076 CDM 2725000076 LOCAL 272 RC outpatient 6 6 MULTIPLAN INC 34080 [3081285] MULTIPLAN INC [308128501] 5.7 percent of total billed charges 3.72 5.7 Technical (Hospital) Services HC/HH Wch Supp Povidone-Iodine Swabstick__S41125 PX-2725000076 CDM 2725000076 LOCAL 272 RC outpatient 6 6 HEALTHPARTNERS SX009 HEALTHPARTNERS 4.8 percent of total billed charges 3.72 5.7 Technical (Hospital) Services HC/HH Wch Supp Povidone-Iodine Swabstick__S41125 PX-2725000076 CDM 2725000076 LOCAL 272 RC outpatient 6 6 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES PPO [308136801] 4.8 percent of total billed charges 3.72 5.7 Technical (Hospital) Services HC/HH Wch Supp Povidone-Iodine Swabstick__S41125 PX-2725000076 CDM 2725000076 LOCAL 272 RC outpatient 6 6 UNITED HEALTHCARE (COMMERCIAL) [3081199] UNITED HEALTHCARE 87726 [308119901] 3.72 percent of total billed charges 3.72 5.7 Technical (Hospital) Services HC/HH Wch Supp Povidone-Iodine Swabstick__S41125 PX-2725000076 CDM 2725000076 LOCAL 272 RC outpatient 6 6 CIGNA 62308 [3081051] CIGNA 62308 [308105105] 4.8 percent of total billed charges 3.72 5.7 Technical (Hospital) Services HC/HH Wch Supp Povidone-Iodine Swabstick__S41125 PX-2725000076 CDM 2725000076 LOCAL 272 RC outpatient 6 6 CIGNA 62308 [3081051] CIGNA STATE OF WYOMING [308105107] 4.8 percent of total billed charges 3.72 5.7 Technical (Hospital) Services HC/HH Wch Supp Povidone-Iodine Swabstick__S41125 PX-2725000076 CDM 2725000076 LOCAL 272 RC outpatient 6 6 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES EPO [308136803] 4.8 percent of total billed charges 3.72 5.7 Technical (Hospital) Services HC/HH Wch Supp Povidone-Iodine Swabstick__S41125 PX-2725000076 CDM 2725000076 LOCAL 272 RC outpatient 6 6 BLUE CROSS BLUE SHIELD WELLMARK SB889 [3081026] BCBS WYOMING [308102603] 5.7 percent of total billed charges 3.72 5.7 Technical (Hospital) Services HC/HH Wch Supp Povidone-Iodine Swabstick__S41125 PX-2725000076 CDM 2725000076 LOCAL 272 RC outpatient 6 6 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES HDHP [308136802] 4.8 percent of total billed charges 3.72 5.7 Technical (Hospital) Services HC/HH Wch Supp Poole Suction Instru__0035040 PX-2725000075 CDM 2725000075 LOCAL 272 RC inpatient 16 16 MEDICA (COMMERCIAL) 94265 [3081118] MEDICA CLAIMS [308111801] 14.4 percent of total billed charges 9.92 15.2 Technical (Hospital) Services HC/HH Wch Supp Poole Suction Instru__0035040 PX-2725000075 CDM 2725000075 LOCAL 272 RC inpatient 16 16 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES PPO [308136801] 12.67 percent of total billed charges 9.92 15.2 Technical (Hospital) Services HC/HH Wch Supp Poole Suction Instru__0035040 PX-2725000075 CDM 2725000075 LOCAL 272 RC inpatient 16 16 CIGNA 62308 [3081051] CIGNA 62308 [308105105] 12.67 percent of total billed charges 9.92 15.2 Technical (Hospital) Services HC/HH Wch Supp Poole Suction Instru__0035040 PX-2725000075 CDM 2725000075 LOCAL 272 RC inpatient 16 16 CIGNA 62308 [3081051] CIGNA STATE OF WYOMING [308105107] 12.67 percent of total billed charges 9.92 15.2 Technical (Hospital) Services HC/HH Wch Supp Poole Suction Instru__0035040 PX-2725000075 CDM 2725000075 LOCAL 272 RC inpatient 16 16 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES HDHP [308136802] 12.67 percent of total billed charges 9.92 15.2 Technical (Hospital) Services HC/HH Wch Supp Poole Suction Instru__0035040 PX-2725000075 CDM 2725000075 LOCAL 272 RC inpatient 16 16 UNITED HEALTHCARE (COMMERCIAL) [3081199] UNITED HEALTHCARE 87726 [308119901] 9.92 percent of total billed charges 9.92 15.2 Technical (Hospital) Services HC/HH Wch Supp Poole Suction Instru__0035040 PX-2725000075 CDM 2725000075 LOCAL 272 RC inpatient 16 16 BLUE CROSS BLUE SHIELD WELLMARK SB889 [3081026] BCBS WYOMING [308102603] 15.2 percent of total billed charges 9.92 15.2 Technical (Hospital) Services HC/HH Wch Supp Poole Suction Instru__0035040 PX-2725000075 CDM 2725000075 LOCAL 272 RC inpatient 16 16 MULTIPLAN INC 34080 [3081285] MULTIPLAN INC [308128501] 15.2 percent of total billed charges 9.92 15.2 Technical (Hospital) Services HC/HH Wch Supp Poole Suction Instru__0035040 PX-2725000075 CDM 2725000075 LOCAL 272 RC inpatient 16 16 HEALTHPARTNERS SX009 HEALTHPARTNERS 12.67 percent of total billed charges 9.92 15.2 Technical (Hospital) Services HC/HH Wch Supp Poole Suction Instru__0035040 PX-2725000075 CDM 2725000075 LOCAL 272 RC inpatient 16 16 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES EPO [308136803] 12.67 percent of total billed charges 9.92 15.2 Technical (Hospital) Services HC/HH Wch Supp Poole Suction Instru__0035040 PX-2725000075 CDM 2725000075 LOCAL 272 RC outpatient 16 16 MULTIPLAN INC 34080 [3081285] MULTIPLAN INC [308128501] 15.2 percent of total billed charges 9.92 15.2 Technical (Hospital) Services HC/HH Wch Supp Poole Suction Instru__0035040 PX-2725000075 CDM 2725000075 LOCAL 272 RC outpatient 16 16 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES PPO [308136801] 12.8 percent of total billed charges 9.92 15.2 Technical (Hospital) Services HC/HH Wch Supp Poole Suction Instru__0035040 PX-2725000075 CDM 2725000075 LOCAL 272 RC outpatient 16 16 HEALTHPARTNERS SX009 HEALTHPARTNERS 12.8 percent of total billed charges 9.92 15.2 Technical (Hospital) Services HC/HH Wch Supp Poole Suction Instru__0035040 PX-2725000075 CDM 2725000075 LOCAL 272 RC outpatient 16 16 MEDICA (COMMERCIAL) 94265 [3081118] MEDICA CLAIMS [308111801] 14.4 percent of total billed charges 9.92 15.2 Technical (Hospital) Services HC/HH Wch Supp Poole Suction Instru__0035040 PX-2725000075 CDM 2725000075 LOCAL 272 RC outpatient 16 16 CIGNA 62308 [3081051] CIGNA 62308 [308105105] 12.8 percent of total billed charges 9.92 15.2 Technical (Hospital) Services HC/HH Wch Supp Poole Suction Instru__0035040 PX-2725000075 CDM 2725000075 LOCAL 272 RC outpatient 16 16 CIGNA 62308 [3081051] CIGNA STATE OF WYOMING [308105107] 12.8 percent of total billed charges 9.92 15.2 Technical (Hospital) Services HC/HH Wch Supp Poole Suction Instru__0035040 PX-2725000075 CDM 2725000075 LOCAL 272 RC outpatient 16 16 UNITED HEALTHCARE (COMMERCIAL) [3081199] UNITED HEALTHCARE 87726 [308119901] 9.92 percent of total billed charges 9.92 15.2 Technical (Hospital) Services HC/HH Wch Supp Poole Suction Instru__0035040 PX-2725000075 CDM 2725000075 LOCAL 272 RC outpatient 16 16 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES HDHP [308136802] 12.8 percent of total billed charges 9.92 15.2 Technical (Hospital) Services HC/HH Wch Supp Poole Suction Instru__0035040 PX-2725000075 CDM 2725000075 LOCAL 272 RC outpatient 16 16 BLUE CROSS BLUE SHIELD WELLMARK SB889 [3081026] BCBS WYOMING [308102603] 15.2 percent of total billed charges 9.92 15.2 Technical (Hospital) Services HC/HH Wch Supp Poole Suction Instru__0035040 PX-2725000075 CDM 2725000075 LOCAL 272 RC outpatient 16 16 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES EPO [308136803] 12.8 percent of total billed charges 9.92 15.2 Technical (Hospital) Services HC/HH Wch Supp Pad Abdominal 8x10__7198d PX-2725000074 CDM 2725000074 LOCAL 272 RC inpatient 6 6 MEDICA (COMMERCIAL) 94265 [3081118] MEDICA CLAIMS [308111801] 5.4 percent of total billed charges 3.72 5.7 Technical (Hospital) Services HC/HH Wch Supp Pad Abdominal 8x10__7198d PX-2725000074 CDM 2725000074 LOCAL 272 RC inpatient 6 6 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES PPO [308136801] 4.75 percent of total billed charges 3.72 5.7 Technical (Hospital) Services HC/HH Wch Supp Pad Abdominal 8x10__7198d PX-2725000074 CDM 2725000074 LOCAL 272 RC inpatient 6 6 UNITED HEALTHCARE (COMMERCIAL) [3081199] UNITED HEALTHCARE 87726 [308119901] 3.72 percent of total billed charges 3.72 5.7 Technical (Hospital) Services HC/HH Wch Supp Pad Abdominal 8x10__7198d PX-2725000074 CDM 2725000074 LOCAL 272 RC inpatient 6 6 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES HDHP [308136802] 4.75 percent of total billed charges 3.72 5.7 Technical (Hospital) Services HC/HH Wch Supp Pad Abdominal 8x10__7198d PX-2725000074 CDM 2725000074 LOCAL 272 RC inpatient 6 6 CIGNA 62308 [3081051] CIGNA STATE OF WYOMING [308105107] 4.75 percent of total billed charges 3.72 5.7 Technical (Hospital) Services HC/HH Wch Supp Pad Abdominal 8x10__7198d PX-2725000074 CDM 2725000074 LOCAL 272 RC inpatient 6 6 MULTIPLAN INC 34080 [3081285] MULTIPLAN INC [308128501] 5.7 percent of total billed charges 3.72 5.7 Technical (Hospital) Services HC/HH Wch Supp Pad Abdominal 8x10__7198d PX-2725000074 CDM 2725000074 LOCAL 272 RC inpatient 6 6 BLUE CROSS BLUE SHIELD WELLMARK SB889 [3081026] BCBS WYOMING [308102603] 5.7 percent of total billed charges 3.72 5.7 Technical (Hospital) Services HC/HH Wch Supp Pad Abdominal 8x10__7198d PX-2725000074 CDM 2725000074 LOCAL 272 RC inpatient 6 6 CIGNA 62308 [3081051] CIGNA 62308 [308105105] 4.75 percent of total billed charges 3.72 5.7 Technical (Hospital) Services HC/HH Wch Supp Pad Abdominal 8x10__7198d PX-2725000074 CDM 2725000074 LOCAL 272 RC inpatient 6 6 HEALTHPARTNERS SX009 HEALTHPARTNERS 4.75 percent of total billed charges 3.72 5.7 Technical (Hospital) Services HC/HH Wch Supp Pad Abdominal 8x10__7198d PX-2725000074 CDM 2725000074 LOCAL 272 RC inpatient 6 6 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES EPO [308136803] 4.75 percent of total billed charges 3.72 5.7 Technical (Hospital) Services HC/HH Wch Supp Pad Abdominal 8x10__7198d PX-2725000074 CDM 2725000074 LOCAL 272 RC outpatient 6 6 UNITED HEALTHCARE (COMMERCIAL) [3081199] UNITED HEALTHCARE 87726 [308119901] 3.72 percent of total billed charges 3.72 5.7 Technical (Hospital) Services HC/HH Wch Supp Pad Abdominal 8x10__7198d PX-2725000074 CDM 2725000074 LOCAL 272 RC outpatient 6 6 HEALTHPARTNERS SX009 HEALTHPARTNERS 4.8 percent of total billed charges 3.72 5.7 Technical (Hospital) Services HC/HH Wch Supp Pad Abdominal 8x10__7198d PX-2725000074 CDM 2725000074 LOCAL 272 RC outpatient 6 6 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES PPO [308136801] 4.8 percent of total billed charges 3.72 5.7 Technical (Hospital) Services HC/HH Wch Supp Pad Abdominal 8x10__7198d PX-2725000074 CDM 2725000074 LOCAL 272 RC outpatient 6 6 MULTIPLAN INC 34080 [3081285] MULTIPLAN INC [308128501] 5.7 percent of total billed charges 3.72 5.7 Technical (Hospital) Services HC/HH Wch Supp Pad Abdominal 8x10__7198d PX-2725000074 CDM 2725000074 LOCAL 272 RC outpatient 6 6 MEDICA (COMMERCIAL) 94265 [3081118] MEDICA CLAIMS [308111801] 5.4 percent of total billed charges 3.72 5.7 Technical (Hospital) Services HC/HH Wch Supp Pad Abdominal 8x10__7198d PX-2725000074 CDM 2725000074 LOCAL 272 RC outpatient 6 6 CIGNA 62308 [3081051] CIGNA 62308 [308105105] 4.8 percent of total billed charges 3.72 5.7 Technical (Hospital) Services HC/HH Wch Supp Pad Abdominal 8x10__7198d PX-2725000074 CDM 2725000074 LOCAL 272 RC outpatient 6 6 CIGNA 62308 [3081051] CIGNA STATE OF WYOMING [308105107] 4.8 percent of total billed charges 3.72 5.7 Technical (Hospital) Services HC/HH Wch Supp Pad Abdominal 8x10__7198d PX-2725000074 CDM 2725000074 LOCAL 272 RC outpatient 6 6 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES HDHP [308136802] 4.8 percent of total billed charges 3.72 5.7 Technical (Hospital) Services HC/HH Wch Supp Pad Abdominal 8x10__7198d PX-2725000074 CDM 2725000074 LOCAL 272 RC outpatient 6 6 BLUE CROSS BLUE SHIELD WELLMARK SB889 [3081026] BCBS WYOMING [308102603] 5.7 percent of total billed charges 3.72 5.7 Technical (Hospital) Services HC/HH Wch Supp Pad Abdominal 8x10__7198d PX-2725000074 CDM 2725000074 LOCAL 272 RC outpatient 6 6 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES EPO [308136803] 4.8 percent of total billed charges 3.72 5.7 Technical (Hospital) Services HC/HH Wch Supp Needle Spinal Quincke 26gx3.5__405164 PX-2725000073 CDM 2725000073 LOCAL 272 RC inpatient 9 9 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES PPO [308136801] 7.13 percent of total billed charges 5.58 8.55 Technical (Hospital) Services HC/HH Wch Supp Needle Spinal Quincke 26gx3.5__405164 PX-2725000073 CDM 2725000073 LOCAL 272 RC inpatient 9 9 MEDICA (COMMERCIAL) 94265 [3081118] MEDICA CLAIMS [308111801] 8.1 percent of total billed charges 5.58 8.55 Technical (Hospital) Services HC/HH Wch Supp Needle Spinal Quincke 26gx3.5__405164 PX-2725000073 CDM 2725000073 LOCAL 272 RC inpatient 9 9 UNITED HEALTHCARE (COMMERCIAL) [3081199] UNITED HEALTHCARE 87726 [308119901] 5.58 percent of total billed charges 5.58 8.55 Technical (Hospital) Services HC/HH Wch Supp Needle Spinal Quincke 26gx3.5__405164 PX-2725000073 CDM 2725000073 LOCAL 272 RC inpatient 9 9 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES HDHP [308136802] 7.13 percent of total billed charges 5.58 8.55 Technical (Hospital) Services HC/HH Wch Supp Needle Spinal Quincke 26gx3.5__405164 PX-2725000073 CDM 2725000073 LOCAL 272 RC inpatient 9 9 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES EPO [308136803] 7.13 percent of total billed charges 5.58 8.55 Technical (Hospital) Services HC/HH Wch Supp Needle Spinal Quincke 26gx3.5__405164 PX-2725000073 CDM 2725000073 LOCAL 272 RC inpatient 9 9 MULTIPLAN INC 34080 [3081285] MULTIPLAN INC [308128501] 8.55 percent of total billed charges 5.58 8.55 Technical (Hospital) Services HC/HH Wch Supp Needle Spinal Quincke 26gx3.5__405164 PX-2725000073 CDM 2725000073 LOCAL 272 RC inpatient 9 9 BLUE CROSS BLUE SHIELD WELLMARK SB889 [3081026] BCBS WYOMING [308102603] 8.55 percent of total billed charges 5.58 8.55 Technical (Hospital) Services HC/HH Wch Supp Needle Spinal Quincke 26gx3.5__405164 PX-2725000073 CDM 2725000073 LOCAL 272 RC inpatient 9 9 CIGNA 62308 [3081051] CIGNA 62308 [308105105] 7.13 percent of total billed charges 5.58 8.55 Technical (Hospital) Services HC/HH Wch Supp Needle Spinal Quincke 26gx3.5__405164 PX-2725000073 CDM 2725000073 LOCAL 272 RC inpatient 9 9 CIGNA 62308 [3081051] CIGNA STATE OF WYOMING [308105107] 7.13 percent of total billed charges 5.58 8.55 Technical (Hospital) Services HC/HH Wch Supp Needle Spinal Quincke 26gx3.5__405164 PX-2725000073 CDM 2725000073 LOCAL 272 RC inpatient 9 9 HEALTHPARTNERS SX009 HEALTHPARTNERS 7.13 percent of total billed charges 5.58 8.55 Technical (Hospital) Services HC/HH Wch Supp Needle Spinal Quincke 26gx3.5__405164 PX-2725000073 CDM 2725000073 LOCAL 272 RC outpatient 9 9 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES HDHP [308136802] 7.2 percent of total billed charges 5.58 8.55 Technical (Hospital) Services HC/HH Wch Supp Needle Spinal Quincke 26gx3.5__405164 PX-2725000073 CDM 2725000073 LOCAL 272 RC outpatient 9 9 BLUE CROSS BLUE SHIELD WELLMARK SB889 [3081026] BCBS WYOMING [308102603] 8.55 percent of total billed charges 5.58 8.55 Technical (Hospital) Services HC/HH Wch Supp Needle Spinal Quincke 26gx3.5__405164 PX-2725000073 CDM 2725000073 LOCAL 272 RC outpatient 9 9 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES EPO [308136803] 7.2 percent of total billed charges 5.58 8.55 Technical (Hospital) Services HC/HH Wch Supp Needle Spinal Quincke 26gx3.5__405164 PX-2725000073 CDM 2725000073 LOCAL 272 RC outpatient 9 9 CIGNA 62308 [3081051] CIGNA 62308 [308105105] 7.2 percent of total billed charges 5.58 8.55 Technical (Hospital) Services HC/HH Wch Supp Needle Spinal Quincke 26gx3.5__405164 PX-2725000073 CDM 2725000073 LOCAL 272 RC outpatient 9 9 CIGNA 62308 [3081051] CIGNA STATE OF WYOMING [308105107] 7.2 percent of total billed charges 5.58 8.55 Technical (Hospital) Services HC/HH Wch Supp Needle Spinal Quincke 26gx3.5__405164 PX-2725000073 CDM 2725000073 LOCAL 272 RC outpatient 9 9 UNITED HEALTHCARE (COMMERCIAL) [3081199] UNITED HEALTHCARE 87726 [308119901] 5.58 percent of total billed charges 5.58 8.55 Technical (Hospital) Services HC/HH Wch Supp Needle Spinal Quincke 26gx3.5__405164 PX-2725000073 CDM 2725000073 LOCAL 272 RC outpatient 9 9 HEALTHPARTNERS SX009 HEALTHPARTNERS 7.2 percent of total billed charges 5.58 8.55 Technical (Hospital) Services HC/HH Wch Supp Needle Spinal Quincke 26gx3.5__405164 PX-2725000073 CDM 2725000073 LOCAL 272 RC outpatient 9 9 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES PPO [308136801] 7.2 percent of total billed charges 5.58 8.55 Technical (Hospital) Services HC/HH Wch Supp Needle Spinal Quincke 26gx3.5__405164 PX-2725000073 CDM 2725000073 LOCAL 272 RC outpatient 9 9 MEDICA (COMMERCIAL) 94265 [3081118] MEDICA CLAIMS [308111801] 8.1 percent of total billed charges 5.58 8.55 Technical (Hospital) Services HC/HH Wch Supp Needle Spinal Quincke 26gx3.5__405164 PX-2725000073 CDM 2725000073 LOCAL 272 RC outpatient 9 9 MULTIPLAN INC 34080 [3081285] MULTIPLAN INC [308128501] 8.55 percent of total billed charges 5.58 8.55 Technical (Hospital) Services HC/HH Wch Supp Needle Spinal Quincke 22gx3.5__405181 PX-2725000072 CDM 2725000072 LOCAL 272 RC outpatient 8 8 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES HDHP [308136802] 6.4 percent of total billed charges 4.96 7.6 Technical (Hospital) Services HC/HH Wch Supp Needle Spinal Quincke 22gx3.5__405181 PX-2725000072 CDM 2725000072 LOCAL 272 RC outpatient 8 8 BLUE CROSS BLUE SHIELD WELLMARK SB889 [3081026] BCBS WYOMING [308102603] 7.6 percent of total billed charges 4.96 7.6 Technical (Hospital) Services HC/HH Wch Supp Needle Spinal Quincke 22gx3.5__405181 PX-2725000072 CDM 2725000072 LOCAL 272 RC outpatient 8 8 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES EPO [308136803] 6.4 percent of total billed charges 4.96 7.6 Technical (Hospital) Services HC/HH Wch Supp Needle Spinal Quincke 22gx3.5__405181 PX-2725000072 CDM 2725000072 LOCAL 272 RC outpatient 8 8 CIGNA 62308 [3081051] CIGNA 62308 [308105105] 6.4 percent of total billed charges 4.96 7.6 Technical (Hospital) Services HC/HH Wch Supp Needle Spinal Quincke 22gx3.5__405181 PX-2725000072 CDM 2725000072 LOCAL 272 RC outpatient 8 8 CIGNA 62308 [3081051] CIGNA STATE OF WYOMING [308105107] 6.4 percent of total billed charges 4.96 7.6 Technical (Hospital) Services HC/HH Wch Supp Needle Spinal Quincke 22gx3.5__405181 PX-2725000072 CDM 2725000072 LOCAL 272 RC outpatient 8 8 UNITED HEALTHCARE (COMMERCIAL) [3081199] UNITED HEALTHCARE 87726 [308119901] 4.96 percent of total billed charges 4.96 7.6 Technical (Hospital) Services HC/HH Wch Supp Needle Spinal Quincke 22gx3.5__405181 PX-2725000072 CDM 2725000072 LOCAL 272 RC outpatient 8 8 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES PPO [308136801] 6.4 percent of total billed charges 4.96 7.6 Technical (Hospital) Services HC/HH Wch Supp Needle Spinal Quincke 22gx3.5__405181 PX-2725000072 CDM 2725000072 LOCAL 272 RC outpatient 8 8 HEALTHPARTNERS SX009 HEALTHPARTNERS 6.4 percent of total billed charges 4.96 7.6 Technical (Hospital) Services HC/HH Wch Supp Needle Spinal Quincke 22gx3.5__405181 PX-2725000072 CDM 2725000072 LOCAL 272 RC outpatient 8 8 MEDICA (COMMERCIAL) 94265 [3081118] MEDICA CLAIMS [308111801] 7.2 percent of total billed charges 4.96 7.6 Technical (Hospital) Services HC/HH Wch Supp Needle Spinal Quincke 22gx3.5__405181 PX-2725000072 CDM 2725000072 LOCAL 272 RC outpatient 8 8 MULTIPLAN INC 34080 [3081285] MULTIPLAN INC [308128501] 7.6 percent of total billed charges 4.96 7.6 Technical (Hospital) Services HC/HH Wch Supp Needle Spinal Quincke 22gx3.5__405181 PX-2725000072 CDM 2725000072 LOCAL 272 RC inpatient 8 8 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES EPO [308136803] 6.33 percent of total billed charges 4.96 7.6 Technical (Hospital) Services HC/HH Wch Supp Needle Spinal Quincke 22gx3.5__405181 PX-2725000072 CDM 2725000072 LOCAL 272 RC inpatient 8 8 MULTIPLAN INC 34080 [3081285] MULTIPLAN INC [308128501] 7.6 percent of total billed charges 4.96 7.6 Technical (Hospital) Services HC/HH Wch Supp Needle Spinal Quincke 22gx3.5__405181 PX-2725000072 CDM 2725000072 LOCAL 272 RC inpatient 8 8 BLUE CROSS BLUE SHIELD WELLMARK SB889 [3081026] BCBS WYOMING [308102603] 7.6 percent of total billed charges 4.96 7.6 Technical (Hospital) Services HC/HH Wch Supp Needle Spinal Quincke 22gx3.5__405181 PX-2725000072 CDM 2725000072 LOCAL 272 RC inpatient 8 8 CIGNA 62308 [3081051] CIGNA 62308 [308105105] 6.33 percent of total billed charges 4.96 7.6 Technical (Hospital) Services HC/HH Wch Supp Needle Spinal Quincke 22gx3.5__405181 PX-2725000072 CDM 2725000072 LOCAL 272 RC inpatient 8 8 CIGNA 62308 [3081051] CIGNA STATE OF WYOMING [308105107] 6.33 percent of total billed charges 4.96 7.6 Technical (Hospital) Services HC/HH Wch Supp Needle Spinal Quincke 22gx3.5__405181 PX-2725000072 CDM 2725000072 LOCAL 272 RC inpatient 8 8 HEALTHPARTNERS SX009 HEALTHPARTNERS 6.33 percent of total billed charges 4.96 7.6 Technical (Hospital) Services HC/HH Wch Supp Needle Spinal Quincke 22gx3.5__405181 PX-2725000072 CDM 2725000072 LOCAL 272 RC inpatient 8 8 MEDICA (COMMERCIAL) 94265 [3081118] MEDICA CLAIMS [308111801] 7.2 percent of total billed charges 4.96 7.6 Technical (Hospital) Services HC/HH Wch Supp Needle Spinal Quincke 22gx3.5__405181 PX-2725000072 CDM 2725000072 LOCAL 272 RC inpatient 8 8 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES PPO [308136801] 6.33 percent of total billed charges 4.96 7.6 Technical (Hospital) Services HC/HH Wch Supp Needle Spinal Quincke 22gx3.5__405181 PX-2725000072 CDM 2725000072 LOCAL 272 RC inpatient 8 8 UNITED HEALTHCARE (COMMERCIAL) [3081199] UNITED HEALTHCARE 87726 [308119901] 4.96 percent of total billed charges 4.96 7.6 Technical (Hospital) Services HC/HH Wch Supp Needle Spinal Quincke 22gx3.5__405181 PX-2725000072 CDM 2725000072 LOCAL 272 RC inpatient 8 8 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES HDHP [308136802] 6.33 percent of total billed charges 4.96 7.6 Technical (Hospital) Services HC/HH Wch Supp Needle Bone Marrow 15gx3__Din1515x PX-2725000071 CDM 2725000071 LOCAL 272 RC outpatient 51 51 MULTIPLAN INC 34080 [3081285] MULTIPLAN INC [308128501] 48.45 percent of total billed charges 31.62 48.45 Technical (Hospital) Services HC/HH Wch Supp Needle Bone Marrow 15gx3__Din1515x PX-2725000071 CDM 2725000071 LOCAL 272 RC outpatient 51 51 MEDICA (COMMERCIAL) 94265 [3081118] MEDICA CLAIMS [308111801] 45.9 percent of total billed charges 31.62 48.45 Technical (Hospital) Services HC/HH Wch Supp Needle Bone Marrow 15gx3__Din1515x PX-2725000071 CDM 2725000071 LOCAL 272 RC outpatient 51 51 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES PPO [308136801] 40.8 percent of total billed charges 31.62 48.45 Technical (Hospital) Services HC/HH Wch Supp Needle Bone Marrow 15gx3__Din1515x PX-2725000071 CDM 2725000071 LOCAL 272 RC outpatient 51 51 HEALTHPARTNERS SX009 HEALTHPARTNERS 40.8 percent of total billed charges 31.62 48.45 Technical (Hospital) Services HC/HH Wch Supp Needle Bone Marrow 15gx3__Din1515x PX-2725000071 CDM 2725000071 LOCAL 272 RC outpatient 51 51 UNITED HEALTHCARE (COMMERCIAL) [3081199] UNITED HEALTHCARE 87726 [308119901] 31.62 percent of total billed charges 31.62 48.45 Technical (Hospital) Services HC/HH Wch Supp Needle Bone Marrow 15gx3__Din1515x PX-2725000071 CDM 2725000071 LOCAL 272 RC outpatient 51 51 CIGNA 62308 [3081051] CIGNA 62308 [308105105] 40.8 percent of total billed charges 31.62 48.45 Technical (Hospital) Services HC/HH Wch Supp Needle Bone Marrow 15gx3__Din1515x PX-2725000071 CDM 2725000071 LOCAL 272 RC outpatient 51 51 CIGNA 62308 [3081051] CIGNA STATE OF WYOMING [308105107] 40.8 percent of total billed charges 31.62 48.45 Technical (Hospital) Services HC/HH Wch Supp Needle Bone Marrow 15gx3__Din1515x PX-2725000071 CDM 2725000071 LOCAL 272 RC outpatient 51 51 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES EPO [308136803] 40.8 percent of total billed charges 31.62 48.45 Technical (Hospital) Services HC/HH Wch Supp Needle Bone Marrow 15gx3__Din1515x PX-2725000071 CDM 2725000071 LOCAL 272 RC outpatient 51 51 BLUE CROSS BLUE SHIELD WELLMARK SB889 [3081026] BCBS WYOMING [308102603] 48.45 percent of total billed charges 31.62 48.45 Technical (Hospital) Services HC/HH Wch Supp Needle Bone Marrow 15gx3__Din1515x PX-2725000071 CDM 2725000071 LOCAL 272 RC outpatient 51 51 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES HDHP [308136802] 40.8 percent of total billed charges 31.62 48.45 Technical (Hospital) Services HC/HH Wch Supp Needle Bone Marrow 15gx3__Din1515x PX-2725000071 CDM 2725000071 LOCAL 272 RC inpatient 51 51 MULTIPLAN INC 34080 [3081285] MULTIPLAN INC [308128501] 48.45 percent of total billed charges 31.62 48.45 Technical (Hospital) Services HC/HH Wch Supp Needle Bone Marrow 15gx3__Din1515x PX-2725000071 CDM 2725000071 LOCAL 272 RC inpatient 51 51 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES EPO [308136803] 40.38 percent of total billed charges 31.62 48.45 Technical (Hospital) Services HC/HH Wch Supp Needle Bone Marrow 15gx3__Din1515x PX-2725000071 CDM 2725000071 LOCAL 272 RC inpatient 51 51 BLUE CROSS BLUE SHIELD WELLMARK SB889 [3081026] BCBS WYOMING [308102603] 48.45 percent of total billed charges 31.62 48.45 Technical (Hospital) Services HC/HH Wch Supp Needle Bone Marrow 15gx3__Din1515x PX-2725000071 CDM 2725000071 LOCAL 272 RC inpatient 51 51 CIGNA 62308 [3081051] CIGNA 62308 [308105105] 40.38 percent of total billed charges 31.62 48.45 Technical (Hospital) Services HC/HH Wch Supp Needle Bone Marrow 15gx3__Din1515x PX-2725000071 CDM 2725000071 LOCAL 272 RC inpatient 51 51 CIGNA 62308 [3081051] CIGNA STATE OF WYOMING [308105107] 40.38 percent of total billed charges 31.62 48.45 Technical (Hospital) Services HC/HH Wch Supp Needle Bone Marrow 15gx3__Din1515x PX-2725000071 CDM 2725000071 LOCAL 272 RC inpatient 51 51 HEALTHPARTNERS SX009 HEALTHPARTNERS 40.38 percent of total billed charges 31.62 48.45 Technical (Hospital) Services HC/HH Wch Supp Needle Bone Marrow 15gx3__Din1515x PX-2725000071 CDM 2725000071 LOCAL 272 RC inpatient 51 51 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES HDHP [308136802] 40.38 percent of total billed charges 31.62 48.45 Technical (Hospital) Services HC/HH Wch Supp Needle Bone Marrow 15gx3__Din1515x PX-2725000071 CDM 2725000071 LOCAL 272 RC inpatient 51 51 UNITED HEALTHCARE (COMMERCIAL) [3081199] UNITED HEALTHCARE 87726 [308119901] 31.62 percent of total billed charges 31.62 48.45 Technical (Hospital) Services HC/HH Wch Supp Needle Bone Marrow 15gx3__Din1515x PX-2725000071 CDM 2725000071 LOCAL 272 RC inpatient 51 51 MEDICA (COMMERCIAL) 94265 [3081118] MEDICA CLAIMS [308111801] 45.9 percent of total billed charges 31.62 48.45 Technical (Hospital) Services HC/HH Wch Supp Needle Bone Marrow 15gx3__Din1515x PX-2725000071 CDM 2725000071 LOCAL 272 RC inpatient 51 51 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES PPO [308136801] 40.38 percent of total billed charges 31.62 48.45 Technical (Hospital) Services HC/HH Wch Supp Needle Biopsy 14gx6__2n2704x PX-2725000070 CDM 2725000070 LOCAL 272 RC inpatient 63 63 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES HDHP [308136802] 49.88 percent of total billed charges 39.06 59.85 Technical (Hospital) Services HC/HH Wch Supp Needle Biopsy 14gx6__2n2704x PX-2725000070 CDM 2725000070 LOCAL 272 RC inpatient 63 63 UNITED HEALTHCARE (COMMERCIAL) [3081199] UNITED HEALTHCARE 87726 [308119901] 39.06 percent of total billed charges 39.06 59.85 Technical (Hospital) Services HC/HH Wch Supp Needle Biopsy 14gx6__2n2704x PX-2725000070 CDM 2725000070 LOCAL 272 RC inpatient 63 63 MEDICA (COMMERCIAL) 94265 [3081118] MEDICA CLAIMS [308111801] 56.7 percent of total billed charges 39.06 59.85 Technical (Hospital) Services HC/HH Wch Supp Needle Biopsy 14gx6__2n2704x PX-2725000070 CDM 2725000070 LOCAL 272 RC inpatient 63 63 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES PPO [308136801] 49.88 percent of total billed charges 39.06 59.85 Technical (Hospital) Services HC/HH Wch Supp Needle Biopsy 14gx6__2n2704x PX-2725000070 CDM 2725000070 LOCAL 272 RC inpatient 63 63 HEALTHPARTNERS SX009 HEALTHPARTNERS 49.88 percent of total billed charges 39.06 59.85 Technical (Hospital) Services HC/HH Wch Supp Needle Biopsy 14gx6__2n2704x PX-2725000070 CDM 2725000070 LOCAL 272 RC inpatient 63 63 CIGNA 62308 [3081051] CIGNA 62308 [308105105] 49.88 percent of total billed charges 39.06 59.85 Technical (Hospital) Services HC/HH Wch Supp Needle Biopsy 14gx6__2n2704x PX-2725000070 CDM 2725000070 LOCAL 272 RC inpatient 63 63 CIGNA 62308 [3081051] CIGNA STATE OF WYOMING [308105107] 49.88 percent of total billed charges 39.06 59.85 Technical (Hospital) Services HC/HH Wch Supp Needle Biopsy 14gx6__2n2704x PX-2725000070 CDM 2725000070 LOCAL 272 RC inpatient 63 63 BLUE CROSS BLUE SHIELD WELLMARK SB889 [3081026] BCBS WYOMING [308102603] 59.85 percent of total billed charges 39.06 59.85 Technical (Hospital) Services HC/HH Wch Supp Needle Biopsy 14gx6__2n2704x PX-2725000070 CDM 2725000070 LOCAL 272 RC inpatient 63 63 MULTIPLAN INC 34080 [3081285] MULTIPLAN INC [308128501] 59.85 percent of total billed charges 39.06 59.85 Technical (Hospital) Services HC/HH Wch Supp Needle Biopsy 14gx6__2n2704x PX-2725000070 CDM 2725000070 LOCAL 272 RC inpatient 63 63 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES EPO [308136803] 49.88 percent of total billed charges 39.06 59.85 Technical (Hospital) Services HC/HH Wch Supp Needle Biopsy 14gx6__2n2704x PX-2725000070 CDM 2725000070 LOCAL 272 RC outpatient 63 63 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES HDHP [308136802] 50.4 percent of total billed charges 39.06 59.85 Technical (Hospital) Services HC/HH Wch Supp Needle Biopsy 14gx6__2n2704x PX-2725000070 CDM 2725000070 LOCAL 272 RC outpatient 63 63 BLUE CROSS BLUE SHIELD WELLMARK SB889 [3081026] BCBS WYOMING [308102603] 59.85 percent of total billed charges 39.06 59.85 Technical (Hospital) Services HC/HH Wch Supp Needle Biopsy 14gx6__2n2704x PX-2725000070 CDM 2725000070 LOCAL 272 RC outpatient 63 63 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES EPO [308136803] 50.4 percent of total billed charges 39.06 59.85 Technical (Hospital) Services HC/HH Wch Supp Needle Biopsy 14gx6__2n2704x PX-2725000070 CDM 2725000070 LOCAL 272 RC outpatient 63 63 CIGNA 62308 [3081051] CIGNA 62308 [308105105] 50.4 percent of total billed charges 39.06 59.85 Technical (Hospital) Services HC/HH Wch Supp Needle Biopsy 14gx6__2n2704x PX-2725000070 CDM 2725000070 LOCAL 272 RC outpatient 63 63 CIGNA 62308 [3081051] CIGNA STATE OF WYOMING [308105107] 50.4 percent of total billed charges 39.06 59.85 Technical (Hospital) Services HC/HH Wch Supp Needle Biopsy 14gx6__2n2704x PX-2725000070 CDM 2725000070 LOCAL 272 RC outpatient 63 63 UNITED HEALTHCARE (COMMERCIAL) [3081199] UNITED HEALTHCARE 87726 [308119901] 39.06 percent of total billed charges 39.06 59.85 Technical (Hospital) Services HC/HH Wch Supp Needle Biopsy 14gx6__2n2704x PX-2725000070 CDM 2725000070 LOCAL 272 RC outpatient 63 63 HEALTHPARTNERS SX009 HEALTHPARTNERS 50.4 percent of total billed charges 39.06 59.85 Technical (Hospital) Services HC/HH Wch Supp Needle Biopsy 14gx6__2n2704x PX-2725000070 CDM 2725000070 LOCAL 272 RC outpatient 63 63 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES PPO [308136801] 50.4 percent of total billed charges 39.06 59.85 Technical (Hospital) Services HC/HH Wch Supp Needle Biopsy 14gx6__2n2704x PX-2725000070 CDM 2725000070 LOCAL 272 RC outpatient 63 63 MEDICA (COMMERCIAL) 94265 [3081118] MEDICA CLAIMS [308111801] 56.7 percent of total billed charges 39.06 59.85 Technical (Hospital) Services HC/HH Wch Supp Needle Biopsy 14gx6__2n2704x PX-2725000070 CDM 2725000070 LOCAL 272 RC outpatient 63 63 MULTIPLAN INC 34080 [3081285] MULTIPLAN INC [308128501] 59.85 percent of total billed charges 39.06 59.85 Technical (Hospital) Services HC/HH Wch Supp King Airway Lt-D Size 3.0__Kltd203 PX-2725000069 CDM 2725000069 LOCAL 272 RC outpatient 126 126 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES HDHP [308136802] 100.8 percent of total billed charges 78.12 119.7 Technical (Hospital) Services HC/HH Wch Supp King Airway Lt-D Size 3.0__Kltd203 PX-2725000069 CDM 2725000069 LOCAL 272 RC outpatient 126 126 BLUE CROSS BLUE SHIELD WELLMARK SB889 [3081026] BCBS WYOMING [308102603] 119.7 percent of total billed charges 78.12 119.7 Technical (Hospital) Services HC/HH Wch Supp King Airway Lt-D Size 3.0__Kltd203 PX-2725000069 CDM 2725000069 LOCAL 272 RC outpatient 126 126 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES EPO [308136803] 100.8 percent of total billed charges 78.12 119.7 Technical (Hospital) Services HC/HH Wch Supp King Airway Lt-D Size 3.0__Kltd203 PX-2725000069 CDM 2725000069 LOCAL 272 RC outpatient 126 126 CIGNA 62308 [3081051] CIGNA 62308 [308105105] 100.8 percent of total billed charges 78.12 119.7 Technical (Hospital) Services HC/HH Wch Supp King Airway Lt-D Size 3.0__Kltd203 PX-2725000069 CDM 2725000069 LOCAL 272 RC outpatient 126 126 CIGNA 62308 [3081051] CIGNA STATE OF WYOMING [308105107] 100.8 percent of total billed charges 78.12 119.7 Technical (Hospital) Services HC/HH Wch Supp King Airway Lt-D Size 3.0__Kltd203 PX-2725000069 CDM 2725000069 LOCAL 272 RC outpatient 126 126 UNITED HEALTHCARE (COMMERCIAL) [3081199] UNITED HEALTHCARE 87726 [308119901] 78.12 percent of total billed charges 78.12 119.7 Technical (Hospital) Services HC/HH Wch Supp King Airway Lt-D Size 3.0__Kltd203 PX-2725000069 CDM 2725000069 LOCAL 272 RC outpatient 126 126 HEALTHPARTNERS SX009 HEALTHPARTNERS 100.8 percent of total billed charges 78.12 119.7 Technical (Hospital) Services HC/HH Wch Supp King Airway Lt-D Size 3.0__Kltd203 PX-2725000069 CDM 2725000069 LOCAL 272 RC outpatient 126 126 MULTIPLAN INC 34080 [3081285] MULTIPLAN INC [308128501] 119.7 percent of total billed charges 78.12 119.7 Technical (Hospital) Services HC/HH Wch Supp King Airway Lt-D Size 3.0__Kltd203 PX-2725000069 CDM 2725000069 LOCAL 272 RC outpatient 126 126 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES PPO [308136801] 100.8 percent of total billed charges 78.12 119.7 Technical (Hospital) Services HC/HH Wch Supp King Airway Lt-D Size 3.0__Kltd203 PX-2725000069 CDM 2725000069 LOCAL 272 RC outpatient 126 126 MEDICA (COMMERCIAL) 94265 [3081118] MEDICA CLAIMS [308111801] 113.4 percent of total billed charges 78.12 119.7 Technical (Hospital) Services HC/HH Wch Supp King Airway Lt-D Size 3.0__Kltd203 PX-2725000069 CDM 2725000069 LOCAL 272 RC inpatient 126 126 UNITED HEALTHCARE (COMMERCIAL) [3081199] UNITED HEALTHCARE 87726 [308119901] 78.12 percent of total billed charges 78.12 119.7 Technical (Hospital) Services HC/HH Wch Supp King Airway Lt-D Size 3.0__Kltd203 PX-2725000069 CDM 2725000069 LOCAL 272 RC inpatient 126 126 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES HDHP [308136802] 99.77 percent of total billed charges 78.12 119.7 Technical (Hospital) Services HC/HH Wch Supp King Airway Lt-D Size 3.0__Kltd203 PX-2725000069 CDM 2725000069 LOCAL 272 RC inpatient 126 126 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES PPO [308136801] 99.77 percent of total billed charges 78.12 119.7 Technical (Hospital) Services HC/HH Wch Supp King Airway Lt-D Size 3.0__Kltd203 PX-2725000069 CDM 2725000069 LOCAL 272 RC inpatient 126 126 MEDICA (COMMERCIAL) 94265 [3081118] MEDICA CLAIMS [308111801] 113.4 percent of total billed charges 78.12 119.7 Technical (Hospital) Services HC/HH Wch Supp King Airway Lt-D Size 3.0__Kltd203 PX-2725000069 CDM 2725000069 LOCAL 272 RC inpatient 126 126 MULTIPLAN INC 34080 [3081285] MULTIPLAN INC [308128501] 119.7 percent of total billed charges 78.12 119.7 Technical (Hospital) Services HC/HH Wch Supp King Airway Lt-D Size 3.0__Kltd203 PX-2725000069 CDM 2725000069 LOCAL 272 RC inpatient 126 126 BLUE CROSS BLUE SHIELD WELLMARK SB889 [3081026] BCBS WYOMING [308102603] 119.7 percent of total billed charges 78.12 119.7 Technical (Hospital) Services HC/HH Wch Supp King Airway Lt-D Size 3.0__Kltd203 PX-2725000069 CDM 2725000069 LOCAL 272 RC inpatient 126 126 CIGNA 62308 [3081051] CIGNA 62308 [308105105] 99.77 percent of total billed charges 78.12 119.7 Technical (Hospital) Services HC/HH Wch Supp King Airway Lt-D Size 3.0__Kltd203 PX-2725000069 CDM 2725000069 LOCAL 272 RC inpatient 126 126 CIGNA 62308 [3081051] CIGNA STATE OF WYOMING [308105107] 99.77 percent of total billed charges 78.12 119.7 Technical (Hospital) Services HC/HH Wch Supp King Airway Lt-D Size 3.0__Kltd203 PX-2725000069 CDM 2725000069 LOCAL 272 RC inpatient 126 126 HEALTHPARTNERS SX009 HEALTHPARTNERS 99.77 percent of total billed charges 78.12 119.7 Technical (Hospital) Services HC/HH Wch Supp King Airway Lt-D Size 3.0__Kltd203 PX-2725000069 CDM 2725000069 LOCAL 272 RC inpatient 126 126 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES EPO [308136803] 99.77 percent of total billed charges 78.12 119.7 Technical (Hospital) Services HC/HH Wch Supp IV Catheter Extension__2n8378 PX-2725000068 CDM 2725000068 LOCAL 272 RC inpatient 15 15 MEDICA (COMMERCIAL) 94265 [3081118] MEDICA CLAIMS [308111801] 13.5 percent of total billed charges 9.3 14.25 Technical (Hospital) Services HC/HH Wch Supp IV Catheter Extension__2n8378 PX-2725000068 CDM 2725000068 LOCAL 272 RC inpatient 15 15 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES PPO [308136801] 11.88 percent of total billed charges 9.3 14.25 Technical (Hospital) Services HC/HH Wch Supp IV Catheter Extension__2n8378 PX-2725000068 CDM 2725000068 LOCAL 272 RC inpatient 15 15 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES HDHP [308136802] 11.88 percent of total billed charges 9.3 14.25 Technical (Hospital) Services HC/HH Wch Supp IV Catheter Extension__2n8378 PX-2725000068 CDM 2725000068 LOCAL 272 RC inpatient 15 15 UNITED HEALTHCARE (COMMERCIAL) [3081199] UNITED HEALTHCARE 87726 [308119901] 9.3 percent of total billed charges 9.3 14.25 Technical (Hospital) Services HC/HH Wch Supp IV Catheter Extension__2n8378 PX-2725000068 CDM 2725000068 LOCAL 272 RC inpatient 15 15 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES EPO [308136803] 11.88 percent of total billed charges 9.3 14.25 Technical (Hospital) Services HC/HH Wch Supp IV Catheter Extension__2n8378 PX-2725000068 CDM 2725000068 LOCAL 272 RC inpatient 15 15 CIGNA 62308 [3081051] CIGNA 62308 [308105105] 11.88 percent of total billed charges 9.3 14.25 Technical (Hospital) Services HC/HH Wch Supp IV Catheter Extension__2n8378 PX-2725000068 CDM 2725000068 LOCAL 272 RC inpatient 15 15 CIGNA 62308 [3081051] CIGNA STATE OF WYOMING [308105107] 11.88 percent of total billed charges 9.3 14.25 Technical (Hospital) Services HC/HH Wch Supp IV Catheter Extension__2n8378 PX-2725000068 CDM 2725000068 LOCAL 272 RC inpatient 15 15 HEALTHPARTNERS SX009 HEALTHPARTNERS 11.88 percent of total billed charges 9.3 14.25 Technical (Hospital) Services HC/HH Wch Supp IV Catheter Extension__2n8378 PX-2725000068 CDM 2725000068 LOCAL 272 RC inpatient 15 15 BLUE CROSS BLUE SHIELD WELLMARK SB889 [3081026] BCBS WYOMING [308102603] 14.25 percent of total billed charges 9.3 14.25 Technical (Hospital) Services HC/HH Wch Supp IV Catheter Extension__2n8378 PX-2725000068 CDM 2725000068 LOCAL 272 RC inpatient 15 15 MULTIPLAN INC 34080 [3081285] MULTIPLAN INC [308128501] 14.25 percent of total billed charges 9.3 14.25 Technical (Hospital) Services HC/HH Wch Supp IV Catheter Extension__2n8378 PX-2725000068 CDM 2725000068 LOCAL 272 RC outpatient 15 15 UNITED HEALTHCARE (COMMERCIAL) [3081199] UNITED HEALTHCARE 87726 [308119901] 9.3 percent of total billed charges 9.3 14.25 Technical (Hospital) Services HC/HH Wch Supp IV Catheter Extension__2n8378 PX-2725000068 CDM 2725000068 LOCAL 272 RC outpatient 15 15 HEALTHPARTNERS SX009 HEALTHPARTNERS 12 percent of total billed charges 9.3 14.25 Technical (Hospital) Services HC/HH Wch Supp IV Catheter Extension__2n8378 PX-2725000068 CDM 2725000068 LOCAL 272 RC outpatient 15 15 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES PPO [308136801] 12 percent of total billed charges 9.3 14.25 Technical (Hospital) Services HC/HH Wch Supp IV Catheter Extension__2n8378 PX-2725000068 CDM 2725000068 LOCAL 272 RC outpatient 15 15 CIGNA 62308 [3081051] CIGNA 62308 [308105105] 12 percent of total billed charges 9.3 14.25 Technical (Hospital) Services HC/HH Wch Supp IV Catheter Extension__2n8378 PX-2725000068 CDM 2725000068 LOCAL 272 RC outpatient 15 15 CIGNA 62308 [3081051] CIGNA STATE OF WYOMING [308105107] 12 percent of total billed charges 9.3 14.25 Technical (Hospital) Services HC/HH Wch Supp IV Catheter Extension__2n8378 PX-2725000068 CDM 2725000068 LOCAL 272 RC outpatient 15 15 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES HDHP [308136802] 12 percent of total billed charges 9.3 14.25 Technical (Hospital) Services HC/HH Wch Supp IV Catheter Extension__2n8378 PX-2725000068 CDM 2725000068 LOCAL 272 RC outpatient 15 15 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES EPO [308136803] 12 percent of total billed charges 9.3 14.25 Technical (Hospital) Services HC/HH Wch Supp IV Catheter Extension__2n8378 PX-2725000068 CDM 2725000068 LOCAL 272 RC outpatient 15 15 BLUE CROSS BLUE SHIELD WELLMARK SB889 [3081026] BCBS WYOMING [308102603] 14.25 percent of total billed charges 9.3 14.25 Technical (Hospital) Services HC/HH Wch Supp IV Catheter Extension__2n8378 PX-2725000068 CDM 2725000068 LOCAL 272 RC outpatient 15 15 MEDICA (COMMERCIAL) 94265 [3081118] MEDICA CLAIMS [308111801] 13.5 percent of total billed charges 9.3 14.25 Technical (Hospital) Services HC/HH Wch Supp IV Catheter Extension__2n8378 PX-2725000068 CDM 2725000068 LOCAL 272 RC outpatient 15 15 MULTIPLAN INC 34080 [3081285] MULTIPLAN INC [308128501] 14.25 percent of total billed charges 9.3 14.25 Technical (Hospital) Services HC/HH Wch Supp Iodoform Packing 1/4__7831amd PX-2725000067 CDM 2725000067 LOCAL 272 RC inpatient 24 24 HEALTHPARTNERS SX009 HEALTHPARTNERS 19 percent of total billed charges 14.88 22.8 Technical (Hospital) Services HC/HH Wch Supp Iodoform Packing 1/4__7831amd PX-2725000067 CDM 2725000067 LOCAL 272 RC inpatient 24 24 CIGNA 62308 [3081051] CIGNA 62308 [308105105] 19 percent of total billed charges 14.88 22.8 Technical (Hospital) Services HC/HH Wch Supp Iodoform Packing 1/4__7831amd PX-2725000067 CDM 2725000067 LOCAL 272 RC inpatient 24 24 CIGNA 62308 [3081051] CIGNA STATE OF WYOMING [308105107] 19 percent of total billed charges 14.88 22.8 Technical (Hospital) Services HC/HH Wch Supp Iodoform Packing 1/4__7831amd PX-2725000067 CDM 2725000067 LOCAL 272 RC inpatient 24 24 BLUE CROSS BLUE SHIELD WELLMARK SB889 [3081026] BCBS WYOMING [308102603] 22.8 percent of total billed charges 14.88 22.8 Technical (Hospital) Services HC/HH Wch Supp Iodoform Packing 1/4__7831amd PX-2725000067 CDM 2725000067 LOCAL 272 RC inpatient 24 24 MULTIPLAN INC 34080 [3081285] MULTIPLAN INC [308128501] 22.8 percent of total billed charges 14.88 22.8 Technical (Hospital) Services HC/HH Wch Supp Iodoform Packing 1/4__7831amd PX-2725000067 CDM 2725000067 LOCAL 272 RC inpatient 24 24 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES EPO [308136803] 19 percent of total billed charges 14.88 22.8 Technical (Hospital) Services HC/HH Wch Supp Iodoform Packing 1/4__7831amd PX-2725000067 CDM 2725000067 LOCAL 272 RC inpatient 24 24 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES HDHP [308136802] 19 percent of total billed charges 14.88 22.8 Technical (Hospital) Services HC/HH Wch Supp Iodoform Packing 1/4__7831amd PX-2725000067 CDM 2725000067 LOCAL 272 RC inpatient 24 24 UNITED HEALTHCARE (COMMERCIAL) [3081199] UNITED HEALTHCARE 87726 [308119901] 14.88 percent of total billed charges 14.88 22.8 Technical (Hospital) Services HC/HH Wch Supp Iodoform Packing 1/4__7831amd PX-2725000067 CDM 2725000067 LOCAL 272 RC inpatient 24 24 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES PPO [308136801] 19 percent of total billed charges 14.88 22.8 Technical (Hospital) Services HC/HH Wch Supp Iodoform Packing 1/4__7831amd PX-2725000067 CDM 2725000067 LOCAL 272 RC inpatient 24 24 MEDICA (COMMERCIAL) 94265 [3081118] MEDICA CLAIMS [308111801] 21.6 percent of total billed charges 14.88 22.8 Technical (Hospital) Services HC/HH Wch Supp Iodoform Packing 1/4__7831amd PX-2725000067 CDM 2725000067 LOCAL 272 RC outpatient 24 24 MEDICA (COMMERCIAL) 94265 [3081118] MEDICA CLAIMS [308111801] 21.6 percent of total billed charges 14.88 22.8 Technical (Hospital) Services HC/HH Wch Supp Iodoform Packing 1/4__7831amd PX-2725000067 CDM 2725000067 LOCAL 272 RC outpatient 24 24 MULTIPLAN INC 34080 [3081285] MULTIPLAN INC [308128501] 22.8 percent of total billed charges 14.88 22.8 Technical (Hospital) Services HC/HH Wch Supp Iodoform Packing 1/4__7831amd PX-2725000067 CDM 2725000067 LOCAL 272 RC outpatient 24 24 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES PPO [308136801] 19.2 percent of total billed charges 14.88 22.8 Technical (Hospital) Services HC/HH Wch Supp Iodoform Packing 1/4__7831amd PX-2725000067 CDM 2725000067 LOCAL 272 RC outpatient 24 24 HEALTHPARTNERS SX009 HEALTHPARTNERS 19.2 percent of total billed charges 14.88 22.8 Technical (Hospital) Services HC/HH Wch Supp Iodoform Packing 1/4__7831amd PX-2725000067 CDM 2725000067 LOCAL 272 RC outpatient 24 24 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES EPO [308136803] 19.2 percent of total billed charges 14.88 22.8 Technical (Hospital) Services HC/HH Wch Supp Iodoform Packing 1/4__7831amd PX-2725000067 CDM 2725000067 LOCAL 272 RC outpatient 24 24 BLUE CROSS BLUE SHIELD WELLMARK SB889 [3081026] BCBS WYOMING [308102603] 22.8 percent of total billed charges 14.88 22.8 Technical (Hospital) Services HC/HH Wch Supp Iodoform Packing 1/4__7831amd PX-2725000067 CDM 2725000067 LOCAL 272 RC outpatient 24 24 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES HDHP [308136802] 19.2 percent of total billed charges 14.88 22.8 Technical (Hospital) Services HC/HH Wch Supp Iodoform Packing 1/4__7831amd PX-2725000067 CDM 2725000067 LOCAL 272 RC outpatient 24 24 UNITED HEALTHCARE (COMMERCIAL) [3081199] UNITED HEALTHCARE 87726 [308119901] 14.88 percent of total billed charges 14.88 22.8 Technical (Hospital) Services HC/HH Wch Supp Iodoform Packing 1/4__7831amd PX-2725000067 CDM 2725000067 LOCAL 272 RC outpatient 24 24 CIGNA 62308 [3081051] CIGNA 62308 [308105105] 19.2 percent of total billed charges 14.88 22.8 Technical (Hospital) Services HC/HH Wch Supp Iodoform Packing 1/4__7831amd PX-2725000067 CDM 2725000067 LOCAL 272 RC outpatient 24 24 CIGNA 62308 [3081051] CIGNA STATE OF WYOMING [308105107] 19.2 percent of total billed charges 14.88 22.8 Technical (Hospital) Services HC/HH Wch Supp Inf Set Huber 19x3/4__Pmi193s PX-2725000066 CDM 2725000066 LOCAL 272 RC inpatient 22 22 MEDICA (COMMERCIAL) 94265 [3081118] MEDICA CLAIMS [308111801] 19.8 percent of total billed charges 13.64 20.9 Technical (Hospital) Services HC/HH Wch Supp Inf Set Huber 19x3/4__Pmi193s PX-2725000066 CDM 2725000066 LOCAL 272 RC inpatient 22 22 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES PPO [308136801] 17.42 percent of total billed charges 13.64 20.9 Technical (Hospital) Services HC/HH Wch Supp Inf Set Huber 19x3/4__Pmi193s PX-2725000066 CDM 2725000066 LOCAL 272 RC inpatient 22 22 UNITED HEALTHCARE (COMMERCIAL) [3081199] UNITED HEALTHCARE 87726 [308119901] 13.64 percent of total billed charges 13.64 20.9 Technical (Hospital) Services HC/HH Wch Supp Inf Set Huber 19x3/4__Pmi193s PX-2725000066 CDM 2725000066 LOCAL 272 RC inpatient 22 22 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES HDHP [308136802] 17.42 percent of total billed charges 13.64 20.9 Technical (Hospital) Services HC/HH Wch Supp Inf Set Huber 19x3/4__Pmi193s PX-2725000066 CDM 2725000066 LOCAL 272 RC inpatient 22 22 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES EPO [308136803] 17.42 percent of total billed charges 13.64 20.9 Technical (Hospital) Services HC/HH Wch Supp Inf Set Huber 19x3/4__Pmi193s PX-2725000066 CDM 2725000066 LOCAL 272 RC inpatient 22 22 MULTIPLAN INC 34080 [3081285] MULTIPLAN INC [308128501] 20.9 percent of total billed charges 13.64 20.9 Technical (Hospital) Services HC/HH Wch Supp Inf Set Huber 19x3/4__Pmi193s PX-2725000066 CDM 2725000066 LOCAL 272 RC inpatient 22 22 BLUE CROSS BLUE SHIELD WELLMARK SB889 [3081026] BCBS WYOMING [308102603] 20.9 percent of total billed charges 13.64 20.9 Technical (Hospital) Services HC/HH Wch Supp Inf Set Huber 19x3/4__Pmi193s PX-2725000066 CDM 2725000066 LOCAL 272 RC inpatient 22 22 CIGNA 62308 [3081051] CIGNA 62308 [308105105] 17.42 percent of total billed charges 13.64 20.9 Technical (Hospital) Services HC/HH Wch Supp Inf Set Huber 19x3/4__Pmi193s PX-2725000066 CDM 2725000066 LOCAL 272 RC inpatient 22 22 CIGNA 62308 [3081051] CIGNA STATE OF WYOMING [308105107] 17.42 percent of total billed charges 13.64 20.9 Technical (Hospital) Services HC/HH Wch Supp Inf Set Huber 19x3/4__Pmi193s PX-2725000066 CDM 2725000066 LOCAL 272 RC inpatient 22 22 HEALTHPARTNERS SX009 HEALTHPARTNERS 17.42 percent of total billed charges 13.64 20.9 Technical (Hospital) Services HC/HH Wch Supp Inf Set Huber 19x3/4__Pmi193s PX-2725000066 CDM 2725000066 LOCAL 272 RC outpatient 22 22 MEDICA (COMMERCIAL) 94265 [3081118] MEDICA CLAIMS [308111801] 19.8 percent of total billed charges 13.64 20.9 Technical (Hospital) Services HC/HH Wch Supp Inf Set Huber 19x3/4__Pmi193s PX-2725000066 CDM 2725000066 LOCAL 272 RC outpatient 22 22 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES PPO [308136801] 17.6 percent of total billed charges 13.64 20.9 Technical (Hospital) Services HC/HH Wch Supp Inf Set Huber 19x3/4__Pmi193s PX-2725000066 CDM 2725000066 LOCAL 272 RC outpatient 22 22 MULTIPLAN INC 34080 [3081285] MULTIPLAN INC [308128501] 20.9 percent of total billed charges 13.64 20.9 Technical (Hospital) Services HC/HH Wch Supp Inf Set Huber 19x3/4__Pmi193s PX-2725000066 CDM 2725000066 LOCAL 272 RC outpatient 22 22 HEALTHPARTNERS SX009 HEALTHPARTNERS 17.6 percent of total billed charges 13.64 20.9 Technical (Hospital) Services HC/HH Wch Supp Inf Set Huber 19x3/4__Pmi193s PX-2725000066 CDM 2725000066 LOCAL 272 RC outpatient 22 22 UNITED HEALTHCARE (COMMERCIAL) [3081199] UNITED HEALTHCARE 87726 [308119901] 13.64 percent of total billed charges 13.64 20.9 Technical (Hospital) Services HC/HH Wch Supp Inf Set Huber 19x3/4__Pmi193s PX-2725000066 CDM 2725000066 LOCAL 272 RC outpatient 22 22 CIGNA 62308 [3081051] CIGNA 62308 [308105105] 17.6 percent of total billed charges 13.64 20.9 Technical (Hospital) Services HC/HH Wch Supp Inf Set Huber 19x3/4__Pmi193s PX-2725000066 CDM 2725000066 LOCAL 272 RC outpatient 22 22 CIGNA 62308 [3081051] CIGNA STATE OF WYOMING [308105107] 17.6 percent of total billed charges 13.64 20.9 Technical (Hospital) Services HC/HH Wch Supp Inf Set Huber 19x3/4__Pmi193s PX-2725000066 CDM 2725000066 LOCAL 272 RC outpatient 22 22 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES EPO [308136803] 17.6 percent of total billed charges 13.64 20.9 Technical (Hospital) Services HC/HH Wch Supp Inf Set Huber 19x3/4__Pmi193s PX-2725000066 CDM 2725000066 LOCAL 272 RC outpatient 22 22 BLUE CROSS BLUE SHIELD WELLMARK SB889 [3081026] BCBS WYOMING [308102603] 20.9 percent of total billed charges 13.64 20.9 Technical (Hospital) Services HC/HH Wch Supp Inf Set Huber 19x3/4__Pmi193s PX-2725000066 CDM 2725000066 LOCAL 272 RC outpatient 22 22 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES HDHP [308136802] 17.6 percent of total billed charges 13.64 20.9 Technical (Hospital) Services HC/HH Wch Supp Huber Inf Set Y 19x1 12/Bx__Pmi191ys PX-2725000065 CDM 2725000065 LOCAL 272 RC inpatient 16 16 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES EPO [308136803] 12.67 percent of total billed charges 9.92 15.2 Technical (Hospital) Services HC/HH Wch Supp Huber Inf Set Y 19x1 12/Bx__Pmi191ys PX-2725000065 CDM 2725000065 LOCAL 272 RC inpatient 16 16 MULTIPLAN INC 34080 [3081285] MULTIPLAN INC [308128501] 15.2 percent of total billed charges 9.92 15.2 Technical (Hospital) Services HC/HH Wch Supp Huber Inf Set Y 19x1 12/Bx__Pmi191ys PX-2725000065 CDM 2725000065 LOCAL 272 RC inpatient 16 16 BLUE CROSS BLUE SHIELD WELLMARK SB889 [3081026] BCBS WYOMING [308102603] 15.2 percent of total billed charges 9.92 15.2 Technical (Hospital) Services HC/HH Wch Supp Huber Inf Set Y 19x1 12/Bx__Pmi191ys PX-2725000065 CDM 2725000065 LOCAL 272 RC inpatient 16 16 CIGNA 62308 [3081051] CIGNA 62308 [308105105] 12.67 percent of total billed charges 9.92 15.2 Technical (Hospital) Services HC/HH Wch Supp Huber Inf Set Y 19x1 12/Bx__Pmi191ys PX-2725000065 CDM 2725000065 LOCAL 272 RC inpatient 16 16 CIGNA 62308 [3081051] CIGNA STATE OF WYOMING [308105107] 12.67 percent of total billed charges 9.92 15.2 Technical (Hospital) Services HC/HH Wch Supp Huber Inf Set Y 19x1 12/Bx__Pmi191ys PX-2725000065 CDM 2725000065 LOCAL 272 RC inpatient 16 16 HEALTHPARTNERS SX009 HEALTHPARTNERS 12.67 percent of total billed charges 9.92 15.2 Technical (Hospital) Services HC/HH Wch Supp Huber Inf Set Y 19x1 12/Bx__Pmi191ys PX-2725000065 CDM 2725000065 LOCAL 272 RC inpatient 16 16 UNITED HEALTHCARE (COMMERCIAL) [3081199] UNITED HEALTHCARE 87726 [308119901] 9.92 percent of total billed charges 9.92 15.2 Technical (Hospital) Services HC/HH Wch Supp Huber Inf Set Y 19x1 12/Bx__Pmi191ys PX-2725000065 CDM 2725000065 LOCAL 272 RC inpatient 16 16 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES HDHP [308136802] 12.67 percent of total billed charges 9.92 15.2 Technical (Hospital) Services HC/HH Wch Supp Huber Inf Set Y 19x1 12/Bx__Pmi191ys PX-2725000065 CDM 2725000065 LOCAL 272 RC inpatient 16 16 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES PPO [308136801] 12.67 percent of total billed charges 9.92 15.2 Technical (Hospital) Services HC/HH Wch Supp Huber Inf Set Y 19x1 12/Bx__Pmi191ys PX-2725000065 CDM 2725000065 LOCAL 272 RC inpatient 16 16 MEDICA (COMMERCIAL) 94265 [3081118] MEDICA CLAIMS [308111801] 14.4 percent of total billed charges 9.92 15.2 Technical (Hospital) Services HC/HH Wch Supp Huber Inf Set Y 19x1 12/Bx__Pmi191ys PX-2725000065 CDM 2725000065 LOCAL 272 RC outpatient 16 16 UNITED HEALTHCARE (COMMERCIAL) [3081199] UNITED HEALTHCARE 87726 [308119901] 9.92 percent of total billed charges 9.92 15.2 Technical (Hospital) Services HC/HH Wch Supp Huber Inf Set Y 19x1 12/Bx__Pmi191ys PX-2725000065 CDM 2725000065 LOCAL 272 RC outpatient 16 16 HEALTHPARTNERS SX009 HEALTHPARTNERS 12.8 percent of total billed charges 9.92 15.2 Technical (Hospital) Services HC/HH Wch Supp Huber Inf Set Y 19x1 12/Bx__Pmi191ys PX-2725000065 CDM 2725000065 LOCAL 272 RC outpatient 16 16 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES PPO [308136801] 12.8 percent of total billed charges 9.92 15.2 Technical (Hospital) Services HC/HH Wch Supp Huber Inf Set Y 19x1 12/Bx__Pmi191ys PX-2725000065 CDM 2725000065 LOCAL 272 RC outpatient 16 16 MULTIPLAN INC 34080 [3081285] MULTIPLAN INC [308128501] 15.2 percent of total billed charges 9.92 15.2 Technical (Hospital) Services HC/HH Wch Supp Huber Inf Set Y 19x1 12/Bx__Pmi191ys PX-2725000065 CDM 2725000065 LOCAL 272 RC outpatient 16 16 MEDICA (COMMERCIAL) 94265 [3081118] MEDICA CLAIMS [308111801] 14.4 percent of total billed charges 9.92 15.2 Technical (Hospital) Services HC/HH Wch Supp Huber Inf Set Y 19x1 12/Bx__Pmi191ys PX-2725000065 CDM 2725000065 LOCAL 272 RC outpatient 16 16 CIGNA 62308 [3081051] CIGNA 62308 [308105105] 12.8 percent of total billed charges 9.92 15.2 Technical (Hospital) Services HC/HH Wch Supp Huber Inf Set Y 19x1 12/Bx__Pmi191ys PX-2725000065 CDM 2725000065 LOCAL 272 RC outpatient 16 16 CIGNA 62308 [3081051] CIGNA STATE OF WYOMING [308105107] 12.8 percent of total billed charges 9.92 15.2 Technical (Hospital) Services HC/HH Wch Supp Huber Inf Set Y 19x1 12/Bx__Pmi191ys PX-2725000065 CDM 2725000065 LOCAL 272 RC outpatient 16 16 BLUE CROSS BLUE SHIELD WELLMARK SB889 [3081026] BCBS WYOMING [308102603] 15.2 percent of total billed charges 9.92 15.2 Technical (Hospital) Services HC/HH Wch Supp Huber Inf Set Y 19x1 12/Bx__Pmi191ys PX-2725000065 CDM 2725000065 LOCAL 272 RC outpatient 16 16 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES EPO [308136803] 12.8 percent of total billed charges 9.92 15.2 Technical (Hospital) Services HC/HH Wch Supp Huber Inf Set Y 19x1 12/Bx__Pmi191ys PX-2725000065 CDM 2725000065 LOCAL 272 RC outpatient 16 16 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES HDHP [308136802] 12.8 percent of total billed charges 9.92 15.2 Technical (Hospital) Services HC/HH Wch Supp Gauze Vaseline 1x8 PX-2725000064 CDM 2725000064 LOCAL 272 RC inpatient 8 8 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES EPO [308136803] 6.33 percent of total billed charges 4.96 7.6 Technical (Hospital) Services HC/HH Wch Supp Gauze Vaseline 1x8 PX-2725000064 CDM 2725000064 LOCAL 272 RC inpatient 8 8 BLUE CROSS BLUE SHIELD WELLMARK SB889 [3081026] BCBS WYOMING [308102603] 7.6 percent of total billed charges 4.96 7.6 Technical (Hospital) Services HC/HH Wch Supp Gauze Vaseline 1x8 PX-2725000064 CDM 2725000064 LOCAL 272 RC inpatient 8 8 MULTIPLAN INC 34080 [3081285] MULTIPLAN INC [308128501] 7.6 percent of total billed charges 4.96 7.6 Technical (Hospital) Services HC/HH Wch Supp Gauze Vaseline 1x8 PX-2725000064 CDM 2725000064 LOCAL 272 RC inpatient 8 8 CIGNA 62308 [3081051] CIGNA 62308 [308105105] 6.33 percent of total billed charges 4.96 7.6 Technical (Hospital) Services HC/HH Wch Supp Gauze Vaseline 1x8 PX-2725000064 CDM 2725000064 LOCAL 272 RC inpatient 8 8 CIGNA 62308 [3081051] CIGNA STATE OF WYOMING [308105107] 6.33 percent of total billed charges 4.96 7.6 Technical (Hospital) Services HC/HH Wch Supp Gauze Vaseline 1x8 PX-2725000064 CDM 2725000064 LOCAL 272 RC inpatient 8 8 HEALTHPARTNERS SX009 HEALTHPARTNERS 6.33 percent of total billed charges 4.96 7.6 Technical (Hospital) Services HC/HH Wch Supp Gauze Vaseline 1x8 PX-2725000064 CDM 2725000064 LOCAL 272 RC inpatient 8 8 UNITED HEALTHCARE (COMMERCIAL) [3081199] UNITED HEALTHCARE 87726 [308119901] 4.96 percent of total billed charges 4.96 7.6 Technical (Hospital) Services HC/HH Wch Supp Gauze Vaseline 1x8 PX-2725000064 CDM 2725000064 LOCAL 272 RC inpatient 8 8 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES HDHP [308136802] 6.33 percent of total billed charges 4.96 7.6 Technical (Hospital) Services HC/HH Wch Supp Gauze Vaseline 1x8 PX-2725000064 CDM 2725000064 LOCAL 272 RC inpatient 8 8 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES PPO [308136801] 6.33 percent of total billed charges 4.96 7.6 Technical (Hospital) Services HC/HH Wch Supp Gauze Vaseline 1x8 PX-2725000064 CDM 2725000064 LOCAL 272 RC inpatient 8 8 MEDICA (COMMERCIAL) 94265 [3081118] MEDICA CLAIMS [308111801] 7.2 percent of total billed charges 4.96 7.6 Technical (Hospital) Services HC/HH Wch Supp Gauze Vaseline 1x8 PX-2725000064 CDM 2725000064 LOCAL 272 RC outpatient 8 8 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES EPO [308136803] 6.4 percent of total billed charges 4.96 7.6 Technical (Hospital) Services HC/HH Wch Supp Gauze Vaseline 1x8 PX-2725000064 CDM 2725000064 LOCAL 272 RC outpatient 8 8 BLUE CROSS BLUE SHIELD WELLMARK SB889 [3081026] BCBS WYOMING [308102603] 7.6 percent of total billed charges 4.96 7.6 Technical (Hospital) Services HC/HH Wch Supp Gauze Vaseline 1x8 PX-2725000064 CDM 2725000064 LOCAL 272 RC outpatient 8 8 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES HDHP [308136802] 6.4 percent of total billed charges 4.96 7.6 Technical (Hospital) Services HC/HH Wch Supp Gauze Vaseline 1x8 PX-2725000064 CDM 2725000064 LOCAL 272 RC outpatient 8 8 CIGNA 62308 [3081051] CIGNA 62308 [308105105] 6.4 percent of total billed charges 4.96 7.6 Technical (Hospital) Services HC/HH Wch Supp Gauze Vaseline 1x8 PX-2725000064 CDM 2725000064 LOCAL 272 RC outpatient 8 8 CIGNA 62308 [3081051] CIGNA STATE OF WYOMING [308105107] 6.4 percent of total billed charges 4.96 7.6 Technical (Hospital) Services HC/HH Wch Supp Gauze Vaseline 1x8 PX-2725000064 CDM 2725000064 LOCAL 272 RC outpatient 8 8 UNITED HEALTHCARE (COMMERCIAL) [3081199] UNITED HEALTHCARE 87726 [308119901] 4.96 percent of total billed charges 4.96 7.6 Technical (Hospital) Services HC/HH Wch Supp Gauze Vaseline 1x8 PX-2725000064 CDM 2725000064 LOCAL 272 RC outpatient 8 8 HEALTHPARTNERS SX009 HEALTHPARTNERS 6.4 percent of total billed charges 4.96 7.6 Technical (Hospital) Services HC/HH Wch Supp Gauze Vaseline 1x8 PX-2725000064 CDM 2725000064 LOCAL 272 RC outpatient 8 8 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES PPO [308136801] 6.4 percent of total billed charges 4.96 7.6 Technical (Hospital) Services HC/HH Wch Supp Gauze Vaseline 1x8 PX-2725000064 CDM 2725000064 LOCAL 272 RC outpatient 8 8 MEDICA (COMMERCIAL) 94265 [3081118] MEDICA CLAIMS [308111801] 7.2 percent of total billed charges 4.96 7.6 Technical (Hospital) Services HC/HH Wch Supp Gauze Vaseline 1x8 PX-2725000064 CDM 2725000064 LOCAL 272 RC outpatient 8 8 MULTIPLAN INC 34080 [3081285] MULTIPLAN INC [308128501] 7.6 percent of total billed charges 4.96 7.6 Technical (Hospital) Services HC/HH Wch Supp Gown Surg St Xl__9545 PX-2725000063 CDM 2725000063 LOCAL 272 RC inpatient 17 17 MEDICA (COMMERCIAL) 94265 [3081118] MEDICA CLAIMS [308111801] 15.3 percent of total billed charges 10.54 16.15 Technical (Hospital) Services HC/HH Wch Supp Gown Surg St Xl__9545 PX-2725000063 CDM 2725000063 LOCAL 272 RC inpatient 17 17 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES PPO [308136801] 13.46 percent of total billed charges 10.54 16.15 Technical (Hospital) Services HC/HH Wch Supp Gown Surg St Xl__9545 PX-2725000063 CDM 2725000063 LOCAL 272 RC inpatient 17 17 UNITED HEALTHCARE (COMMERCIAL) [3081199] UNITED HEALTHCARE 87726 [308119901] 10.54 percent of total billed charges 10.54 16.15 Technical (Hospital) Services HC/HH Wch Supp Gown Surg St Xl__9545 PX-2725000063 CDM 2725000063 LOCAL 272 RC inpatient 17 17 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES HDHP [308136802] 13.46 percent of total billed charges 10.54 16.15 Technical (Hospital) Services HC/HH Wch Supp Gown Surg St Xl__9545 PX-2725000063 CDM 2725000063 LOCAL 272 RC inpatient 17 17 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES EPO [308136803] 13.46 percent of total billed charges 10.54 16.15 Technical (Hospital) Services HC/HH Wch Supp Gown Surg St Xl__9545 PX-2725000063 CDM 2725000063 LOCAL 272 RC inpatient 17 17 HEALTHPARTNERS SX009 HEALTHPARTNERS 13.46 percent of total billed charges 10.54 16.15 Technical (Hospital) Services HC/HH Wch Supp Gown Surg St Xl__9545 PX-2725000063 CDM 2725000063 LOCAL 272 RC inpatient 17 17 CIGNA 62308 [3081051] CIGNA 62308 [308105105] 13.46 percent of total billed charges 10.54 16.15 Technical (Hospital) Services HC/HH Wch Supp Gown Surg St Xl__9545 PX-2725000063 CDM 2725000063 LOCAL 272 RC inpatient 17 17 CIGNA 62308 [3081051] CIGNA STATE OF WYOMING [308105107] 13.46 percent of total billed charges 10.54 16.15 Technical (Hospital) Services HC/HH Wch Supp Gown Surg St Xl__9545 PX-2725000063 CDM 2725000063 LOCAL 272 RC inpatient 17 17 BLUE CROSS BLUE SHIELD WELLMARK SB889 [3081026] BCBS WYOMING [308102603] 16.15 percent of total billed charges 10.54 16.15 Technical (Hospital) Services HC/HH Wch Supp Gown Surg St Xl__9545 PX-2725000063 CDM 2725000063 LOCAL 272 RC inpatient 17 17 MULTIPLAN INC 34080 [3081285] MULTIPLAN INC [308128501] 16.15 percent of total billed charges 10.54 16.15 Technical (Hospital) Services HC/HH Wch Supp Gown Surg St Xl__9545 PX-2725000063 CDM 2725000063 LOCAL 272 RC outpatient 17 17 MULTIPLAN INC 34080 [3081285] MULTIPLAN INC [308128501] 16.15 percent of total billed charges 10.54 16.15 Technical (Hospital) Services HC/HH Wch Supp Gown Surg St Xl__9545 PX-2725000063 CDM 2725000063 LOCAL 272 RC outpatient 17 17 MEDICA (COMMERCIAL) 94265 [3081118] MEDICA CLAIMS [308111801] 15.3 percent of total billed charges 10.54 16.15 Technical (Hospital) Services HC/HH Wch Supp Gown Surg St Xl__9545 PX-2725000063 CDM 2725000063 LOCAL 272 RC outpatient 17 17 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES PPO [308136801] 13.6 percent of total billed charges 10.54 16.15 Technical (Hospital) Services HC/HH Wch Supp Gown Surg St Xl__9545 PX-2725000063 CDM 2725000063 LOCAL 272 RC outpatient 17 17 HEALTHPARTNERS SX009 HEALTHPARTNERS 13.6 percent of total billed charges 10.54 16.15 Technical (Hospital) Services HC/HH Wch Supp Gown Surg St Xl__9545 PX-2725000063 CDM 2725000063 LOCAL 272 RC outpatient 17 17 UNITED HEALTHCARE (COMMERCIAL) [3081199] UNITED HEALTHCARE 87726 [308119901] 10.54 percent of total billed charges 10.54 16.15 Technical (Hospital) Services HC/HH Wch Supp Gown Surg St Xl__9545 PX-2725000063 CDM 2725000063 LOCAL 272 RC outpatient 17 17 CIGNA 62308 [3081051] CIGNA 62308 [308105105] 13.6 percent of total billed charges 10.54 16.15 Technical (Hospital) Services HC/HH Wch Supp Gown Surg St Xl__9545 PX-2725000063 CDM 2725000063 LOCAL 272 RC outpatient 17 17 CIGNA 62308 [3081051] CIGNA STATE OF WYOMING [308105107] 13.6 percent of total billed charges 10.54 16.15 Technical (Hospital) Services HC/HH Wch Supp Gown Surg St Xl__9545 PX-2725000063 CDM 2725000063 LOCAL 272 RC outpatient 17 17 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES HDHP [308136802] 13.6 percent of total billed charges 10.54 16.15 Technical (Hospital) Services HC/HH Wch Supp Gown Surg St Xl__9545 PX-2725000063 CDM 2725000063 LOCAL 272 RC outpatient 17 17 BLUE CROSS BLUE SHIELD WELLMARK SB889 [3081026] BCBS WYOMING [308102603] 16.15 percent of total billed charges 10.54 16.15 Technical (Hospital) Services HC/HH Wch Supp Gown Surg St Xl__9545 PX-2725000063 CDM 2725000063 LOCAL 272 RC outpatient 17 17 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES EPO [308136803] 13.6 percent of total billed charges 10.54 16.15 Technical (Hospital) Services HC/HH Wch Supp Gauze Sponge Sterile 2x2__1806 PX-2725000062 CDM 2725000062 LOCAL 272 RC outpatient 8 8 MULTIPLAN INC 34080 [3081285] MULTIPLAN INC [308128501] 7.6 percent of total billed charges 4.96 7.6 Technical (Hospital) Services HC/HH Wch Supp Gauze Sponge Sterile 2x2__1806 PX-2725000062 CDM 2725000062 LOCAL 272 RC outpatient 8 8 MEDICA (COMMERCIAL) 94265 [3081118] MEDICA CLAIMS [308111801] 7.2 percent of total billed charges 4.96 7.6 Technical (Hospital) Services HC/HH Wch Supp Gauze Sponge Sterile 2x2__1806 PX-2725000062 CDM 2725000062 LOCAL 272 RC outpatient 8 8 CIGNA 62308 [3081051] CIGNA 62308 [308105105] 6.4 percent of total billed charges 4.96 7.6 Technical (Hospital) Services HC/HH Wch Supp Gauze Sponge Sterile 2x2__1806 PX-2725000062 CDM 2725000062 LOCAL 272 RC outpatient 8 8 CIGNA 62308 [3081051] CIGNA STATE OF WYOMING [308105107] 6.4 percent of total billed charges 4.96 7.6 Technical (Hospital) Services HC/HH Wch Supp Gauze Sponge Sterile 2x2__1806 PX-2725000062 CDM 2725000062 LOCAL 272 RC outpatient 8 8 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES PPO [308136801] 6.4 percent of total billed charges 4.96 7.6 Technical (Hospital) Services HC/HH Wch Supp Gauze Sponge Sterile 2x2__1806 PX-2725000062 CDM 2725000062 LOCAL 272 RC outpatient 8 8 HEALTHPARTNERS SX009 HEALTHPARTNERS 6.4 percent of total billed charges 4.96 7.6 Technical (Hospital) Services HC/HH Wch Supp Gauze Sponge Sterile 2x2__1806 PX-2725000062 CDM 2725000062 LOCAL 272 RC outpatient 8 8 UNITED HEALTHCARE (COMMERCIAL) [3081199] UNITED HEALTHCARE 87726 [308119901] 4.96 percent of total billed charges 4.96 7.6 Technical (Hospital) Services HC/HH Wch Supp Gauze Sponge Sterile 2x2__1806 PX-2725000062 CDM 2725000062 LOCAL 272 RC outpatient 8 8 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES HDHP [308136802] 6.4 percent of total billed charges 4.96 7.6 Technical (Hospital) Services HC/HH Wch Supp Gauze Sponge Sterile 2x2__1806 PX-2725000062 CDM 2725000062 LOCAL 272 RC outpatient 8 8 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES EPO [308136803] 6.4 percent of total billed charges 4.96 7.6 Technical (Hospital) Services HC/HH Wch Supp Gauze Sponge Sterile 2x2__1806 PX-2725000062 CDM 2725000062 LOCAL 272 RC outpatient 8 8 BLUE CROSS BLUE SHIELD WELLMARK SB889 [3081026] BCBS WYOMING [308102603] 7.6 percent of total billed charges 4.96 7.6 Technical (Hospital) Services HC/HH Wch Supp Gauze Sponge Sterile 2x2__1806 PX-2725000062 CDM 2725000062 LOCAL 272 RC inpatient 8 8 MULTIPLAN INC 34080 [3081285] MULTIPLAN INC [308128501] 7.6 percent of total billed charges 4.96 7.6 Technical (Hospital) Services HC/HH Wch Supp Gauze Sponge Sterile 2x2__1806 PX-2725000062 CDM 2725000062 LOCAL 272 RC inpatient 8 8 BLUE CROSS BLUE SHIELD WELLMARK SB889 [3081026] BCBS WYOMING [308102603] 7.6 percent of total billed charges 4.96 7.6 Technical (Hospital) Services HC/HH Wch Supp Gauze Sponge Sterile 2x2__1806 PX-2725000062 CDM 2725000062 LOCAL 272 RC inpatient 8 8 CIGNA 62308 [3081051] CIGNA 62308 [308105105] 6.33 percent of total billed charges 4.96 7.6 Technical (Hospital) Services HC/HH Wch Supp Gauze Sponge Sterile 2x2__1806 PX-2725000062 CDM 2725000062 LOCAL 272 RC inpatient 8 8 CIGNA 62308 [3081051] CIGNA STATE OF WYOMING [308105107] 6.33 percent of total billed charges 4.96 7.6 Technical (Hospital) Services HC/HH Wch Supp Gauze Sponge Sterile 2x2__1806 PX-2725000062 CDM 2725000062 LOCAL 272 RC inpatient 8 8 HEALTHPARTNERS SX009 HEALTHPARTNERS 6.33 percent of total billed charges 4.96 7.6 Technical (Hospital) Services HC/HH Wch Supp Gauze Sponge Sterile 2x2__1806 PX-2725000062 CDM 2725000062 LOCAL 272 RC inpatient 8 8 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES EPO [308136803] 6.33 percent of total billed charges 4.96 7.6 Technical (Hospital) Services HC/HH Wch Supp Gauze Sponge Sterile 2x2__1806 PX-2725000062 CDM 2725000062 LOCAL 272 RC inpatient 8 8 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES HDHP [308136802] 6.33 percent of total billed charges 4.96 7.6 Technical (Hospital) Services HC/HH Wch Supp Gauze Sponge Sterile 2x2__1806 PX-2725000062 CDM 2725000062 LOCAL 272 RC inpatient 8 8 UNITED HEALTHCARE (COMMERCIAL) [3081199] UNITED HEALTHCARE 87726 [308119901] 4.96 percent of total billed charges 4.96 7.6 Technical (Hospital) Services HC/HH Wch Supp Gauze Sponge Sterile 2x2__1806 PX-2725000062 CDM 2725000062 LOCAL 272 RC inpatient 8 8 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES PPO [308136801] 6.33 percent of total billed charges 4.96 7.6 Technical (Hospital) Services HC/HH Wch Supp Gauze Sponge Sterile 2x2__1806 PX-2725000062 CDM 2725000062 LOCAL 272 RC inpatient 8 8 MEDICA (COMMERCIAL) 94265 [3081118] MEDICA CLAIMS [308111801] 7.2 percent of total billed charges 4.96 7.6 Technical (Hospital) Services HC/HH Wch Supp Gauze Packing Plain 2in__7634 PX-2725000061 CDM 2725000061 LOCAL 272 RC outpatient 43 43 UNITED HEALTHCARE (COMMERCIAL) [3081199] UNITED HEALTHCARE 87726 [308119901] 26.66 percent of total billed charges 26.66 40.85 Technical (Hospital) Services HC/HH Wch Supp Gauze Packing Plain 2in__7634 PX-2725000061 CDM 2725000061 LOCAL 272 RC outpatient 43 43 HEALTHPARTNERS SX009 HEALTHPARTNERS 34.4 percent of total billed charges 26.66 40.85 Technical (Hospital) Services HC/HH Wch Supp Gauze Packing Plain 2in__7634 PX-2725000061 CDM 2725000061 LOCAL 272 RC outpatient 43 43 CIGNA 62308 [3081051] CIGNA 62308 [308105105] 34.4 percent of total billed charges 26.66 40.85 Technical (Hospital) Services HC/HH Wch Supp Gauze Packing Plain 2in__7634 PX-2725000061 CDM 2725000061 LOCAL 272 RC outpatient 43 43 CIGNA 62308 [3081051] CIGNA STATE OF WYOMING [308105107] 34.4 percent of total billed charges 26.66 40.85 Technical (Hospital) Services HC/HH Wch Supp Gauze Packing Plain 2in__7634 PX-2725000061 CDM 2725000061 LOCAL 272 RC outpatient 43 43 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES HDHP [308136802] 34.4 percent of total billed charges 26.66 40.85 Technical (Hospital) Services HC/HH Wch Supp Gauze Packing Plain 2in__7634 PX-2725000061 CDM 2725000061 LOCAL 272 RC outpatient 43 43 BLUE CROSS BLUE SHIELD WELLMARK SB889 [3081026] BCBS WYOMING [308102603] 40.85 percent of total billed charges 26.66 40.85 Technical (Hospital) Services HC/HH Wch Supp Gauze Packing Plain 2in__7634 PX-2725000061 CDM 2725000061 LOCAL 272 RC outpatient 43 43 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES EPO [308136803] 34.4 percent of total billed charges 26.66 40.85 Technical (Hospital) Services HC/HH Wch Supp Gauze Packing Plain 2in__7634 PX-2725000061 CDM 2725000061 LOCAL 272 RC outpatient 43 43 MEDICA (COMMERCIAL) 94265 [3081118] MEDICA CLAIMS [308111801] 38.7 percent of total billed charges 26.66 40.85 Technical (Hospital) Services HC/HH Wch Supp Gauze Packing Plain 2in__7634 PX-2725000061 CDM 2725000061 LOCAL 272 RC outpatient 43 43 MULTIPLAN INC 34080 [3081285] MULTIPLAN INC [308128501] 40.85 percent of total billed charges 26.66 40.85 Technical (Hospital) Services HC/HH Wch Supp Gauze Packing Plain 2in__7634 PX-2725000061 CDM 2725000061 LOCAL 272 RC outpatient 43 43 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES PPO [308136801] 34.4 percent of total billed charges 26.66 40.85 Technical (Hospital) Services HC/HH Wch Supp Gauze Packing Plain 2in__7634 PX-2725000061 CDM 2725000061 LOCAL 272 RC inpatient 43 43 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES PPO [308136801] 34.05 percent of total billed charges 26.66 40.85 Technical (Hospital) Services HC/HH Wch Supp Gauze Packing Plain 2in__7634 PX-2725000061 CDM 2725000061 LOCAL 272 RC inpatient 43 43 UNITED HEALTHCARE (COMMERCIAL) [3081199] UNITED HEALTHCARE 87726 [308119901] 26.66 percent of total billed charges 26.66 40.85 Technical (Hospital) Services HC/HH Wch Supp Gauze Packing Plain 2in__7634 PX-2725000061 CDM 2725000061 LOCAL 272 RC inpatient 43 43 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES HDHP [308136802] 34.05 percent of total billed charges 26.66 40.85 Technical (Hospital) Services HC/HH Wch Supp Gauze Packing Plain 2in__7634 PX-2725000061 CDM 2725000061 LOCAL 272 RC inpatient 43 43 MEDICA (COMMERCIAL) 94265 [3081118] MEDICA CLAIMS [308111801] 38.7 percent of total billed charges 26.66 40.85 Technical (Hospital) Services HC/HH Wch Supp Gauze Packing Plain 2in__7634 PX-2725000061 CDM 2725000061 LOCAL 272 RC inpatient 43 43 MULTIPLAN INC 34080 [3081285] MULTIPLAN INC [308128501] 40.85 percent of total billed charges 26.66 40.85 Technical (Hospital) Services HC/HH Wch Supp Gauze Packing Plain 2in__7634 PX-2725000061 CDM 2725000061 LOCAL 272 RC inpatient 43 43 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES EPO [308136803] 34.05 percent of total billed charges 26.66 40.85 Technical (Hospital) Services HC/HH Wch Supp Gauze Packing Plain 2in__7634 PX-2725000061 CDM 2725000061 LOCAL 272 RC inpatient 43 43 HEALTHPARTNERS SX009 HEALTHPARTNERS 34.05 percent of total billed charges 26.66 40.85 Technical (Hospital) Services HC/HH Wch Supp Gauze Packing Plain 2in__7634 PX-2725000061 CDM 2725000061 LOCAL 272 RC inpatient 43 43 BLUE CROSS BLUE SHIELD WELLMARK SB889 [3081026] BCBS WYOMING [308102603] 40.85 percent of total billed charges 26.66 40.85 Technical (Hospital) Services HC/HH Wch Supp Gauze Packing Plain 2in__7634 PX-2725000061 CDM 2725000061 LOCAL 272 RC inpatient 43 43 CIGNA 62308 [3081051] CIGNA 62308 [308105105] 34.05 percent of total billed charges 26.66 40.85 Technical (Hospital) Services HC/HH Wch Supp Gauze Packing Plain 2in__7634 PX-2725000061 CDM 2725000061 LOCAL 272 RC inpatient 43 43 CIGNA 62308 [3081051] CIGNA STATE OF WYOMING [308105107] 34.05 percent of total billed charges 26.66 40.85 Technical (Hospital) Services HC/HH Wch Supp Gauze Packing Plain 1in__7633 PX-2725000060 CDM 2725000060 LOCAL 272 RC inpatient 25 25 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES EPO [308136803] 19.8 percent of total billed charges 15.5 23.75 Technical (Hospital) Services HC/HH Wch Supp Gauze Packing Plain 1in__7633 PX-2725000060 CDM 2725000060 LOCAL 272 RC inpatient 25 25 CIGNA 62308 [3081051] CIGNA 62308 [308105105] 19.8 percent of total billed charges 15.5 23.75 Technical (Hospital) Services HC/HH Wch Supp Gauze Packing Plain 1in__7633 PX-2725000060 CDM 2725000060 LOCAL 272 RC inpatient 25 25 CIGNA 62308 [3081051] CIGNA STATE OF WYOMING [308105107] 19.8 percent of total billed charges 15.5 23.75 Technical (Hospital) Services HC/HH Wch Supp Gauze Packing Plain 1in__7633 PX-2725000060 CDM 2725000060 LOCAL 272 RC inpatient 25 25 MULTIPLAN INC 34080 [3081285] MULTIPLAN INC [308128501] 23.75 percent of total billed charges 15.5 23.75 Technical (Hospital) Services HC/HH Wch Supp Gauze Packing Plain 1in__7633 PX-2725000060 CDM 2725000060 LOCAL 272 RC inpatient 25 25 BLUE CROSS BLUE SHIELD WELLMARK SB889 [3081026] BCBS WYOMING [308102603] 23.75 percent of total billed charges 15.5 23.75 Technical (Hospital) Services HC/HH Wch Supp Gauze Packing Plain 1in__7633 PX-2725000060 CDM 2725000060 LOCAL 272 RC inpatient 25 25 HEALTHPARTNERS SX009 HEALTHPARTNERS 19.8 percent of total billed charges 15.5 23.75 Technical (Hospital) Services HC/HH Wch Supp Gauze Packing Plain 1in__7633 PX-2725000060 CDM 2725000060 LOCAL 272 RC inpatient 25 25 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES HDHP [308136802] 19.8 percent of total billed charges 15.5 23.75 Technical (Hospital) Services HC/HH Wch Supp Gauze Packing Plain 1in__7633 PX-2725000060 CDM 2725000060 LOCAL 272 RC inpatient 25 25 UNITED HEALTHCARE (COMMERCIAL) [3081199] UNITED HEALTHCARE 87726 [308119901] 15.5 percent of total billed charges 15.5 23.75 Technical (Hospital) Services HC/HH Wch Supp Gauze Packing Plain 1in__7633 PX-2725000060 CDM 2725000060 LOCAL 272 RC inpatient 25 25 MEDICA (COMMERCIAL) 94265 [3081118] MEDICA CLAIMS [308111801] 22.5 percent of total billed charges 15.5 23.75 Technical (Hospital) Services HC/HH Wch Supp Gauze Packing Plain 1in__7633 PX-2725000060 CDM 2725000060 LOCAL 272 RC inpatient 25 25 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES PPO [308136801] 19.8 percent of total billed charges 15.5 23.75 Technical (Hospital) Services HC/HH Wch Supp Gauze Packing Plain 1in__7633 PX-2725000060 CDM 2725000060 LOCAL 272 RC outpatient 25 25 CIGNA 62308 [3081051] CIGNA 62308 [308105105] 20 percent of total billed charges 15.5 23.75 Technical (Hospital) Services HC/HH Wch Supp Gauze Packing Plain 1in__7633 PX-2725000060 CDM 2725000060 LOCAL 272 RC outpatient 25 25 CIGNA 62308 [3081051] CIGNA STATE OF WYOMING [308105107] 20 percent of total billed charges 15.5 23.75 Technical (Hospital) Services HC/HH Wch Supp Gauze Packing Plain 1in__7633 PX-2725000060 CDM 2725000060 LOCAL 272 RC outpatient 25 25 UNITED HEALTHCARE (COMMERCIAL) [3081199] UNITED HEALTHCARE 87726 [308119901] 15.5 percent of total billed charges 15.5 23.75 Technical (Hospital) Services HC/HH Wch Supp Gauze Packing Plain 1in__7633 PX-2725000060 CDM 2725000060 LOCAL 272 RC outpatient 25 25 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES HDHP [308136802] 20 percent of total billed charges 15.5 23.75 Technical (Hospital) Services HC/HH Wch Supp Gauze Packing Plain 1in__7633 PX-2725000060 CDM 2725000060 LOCAL 272 RC outpatient 25 25 BLUE CROSS BLUE SHIELD WELLMARK SB889 [3081026] BCBS WYOMING [308102603] 23.75 percent of total billed charges 15.5 23.75 Technical (Hospital) Services HC/HH Wch Supp Gauze Packing Plain 1in__7633 PX-2725000060 CDM 2725000060 LOCAL 272 RC outpatient 25 25 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES EPO [308136803] 20 percent of total billed charges 15.5 23.75 Technical (Hospital) Services HC/HH Wch Supp Gauze Packing Plain 1in__7633 PX-2725000060 CDM 2725000060 LOCAL 272 RC outpatient 25 25 HEALTHPARTNERS SX009 HEALTHPARTNERS 20 percent of total billed charges 15.5 23.75 Technical (Hospital) Services HC/HH Wch Supp Gauze Packing Plain 1in__7633 PX-2725000060 CDM 2725000060 LOCAL 272 RC outpatient 25 25 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES PPO [308136801] 20 percent of total billed charges 15.5 23.75 Technical (Hospital) Services HC/HH Wch Supp Gauze Packing Plain 1in__7633 PX-2725000060 CDM 2725000060 LOCAL 272 RC outpatient 25 25 MULTIPLAN INC 34080 [3081285] MULTIPLAN INC [308128501] 23.75 percent of total billed charges 15.5 23.75 Technical (Hospital) Services HC/HH Wch Supp Gauze Packing Plain 1in__7633 PX-2725000060 CDM 2725000060 LOCAL 272 RC outpatient 25 25 MEDICA (COMMERCIAL) 94265 [3081118] MEDICA CLAIMS [308111801] 22.5 percent of total billed charges 15.5 23.75 Technical (Hospital) Services "HC/HH Wch Supp Gauze Packing Plain 1/4__7631""" PX-2725000059 CDM 2725000059 LOCAL 272 RC outpatient 25 25 UNITED HEALTHCARE (COMMERCIAL) [3081199] UNITED HEALTHCARE 87726 [308119901] 15.5 percent of total billed charges 15.5 23.75 Technical (Hospital) Services "HC/HH Wch Supp Gauze Packing Plain 1/4__7631""" PX-2725000059 CDM 2725000059 LOCAL 272 RC outpatient 25 25 HEALTHPARTNERS SX009 HEALTHPARTNERS 20 percent of total billed charges 15.5 23.75 Technical (Hospital) Services "HC/HH Wch Supp Gauze Packing Plain 1/4__7631""" PX-2725000059 CDM 2725000059 LOCAL 272 RC outpatient 25 25 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES PPO [308136801] 20 percent of total billed charges 15.5 23.75 Technical (Hospital) Services "HC/HH Wch Supp Gauze Packing Plain 1/4__7631""" PX-2725000059 CDM 2725000059 LOCAL 272 RC outpatient 25 25 CIGNA 62308 [3081051] CIGNA 62308 [308105105] 20 percent of total billed charges 15.5 23.75 Technical (Hospital) Services "HC/HH Wch Supp Gauze Packing Plain 1/4__7631""" PX-2725000059 CDM 2725000059 LOCAL 272 RC outpatient 25 25 CIGNA 62308 [3081051] CIGNA STATE OF WYOMING [308105107] 20 percent of total billed charges 15.5 23.75 Technical (Hospital) Services "HC/HH Wch Supp Gauze Packing Plain 1/4__7631""" PX-2725000059 CDM 2725000059 LOCAL 272 RC outpatient 25 25 BLUE CROSS BLUE SHIELD WELLMARK SB889 [3081026] BCBS WYOMING [308102603] 23.75 percent of total billed charges 15.5 23.75 Technical (Hospital) Services "HC/HH Wch Supp Gauze Packing Plain 1/4__7631""" PX-2725000059 CDM 2725000059 LOCAL 272 RC outpatient 25 25 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES EPO [308136803] 20 percent of total billed charges 15.5 23.75 Technical (Hospital) Services "HC/HH Wch Supp Gauze Packing Plain 1/4__7631""" PX-2725000059 CDM 2725000059 LOCAL 272 RC outpatient 25 25 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES HDHP [308136802] 20 percent of total billed charges 15.5 23.75 Technical (Hospital) Services "HC/HH Wch Supp Gauze Packing Plain 1/4__7631""" PX-2725000059 CDM 2725000059 LOCAL 272 RC outpatient 25 25 MEDICA (COMMERCIAL) 94265 [3081118] MEDICA CLAIMS [308111801] 22.5 percent of total billed charges 15.5 23.75 Technical (Hospital) Services "HC/HH Wch Supp Gauze Packing Plain 1/4__7631""" PX-2725000059 CDM 2725000059 LOCAL 272 RC outpatient 25 25 MULTIPLAN INC 34080 [3081285] MULTIPLAN INC [308128501] 23.75 percent of total billed charges 15.5 23.75 Technical (Hospital) Services "HC/HH Wch Supp Gauze Packing Plain 1/4__7631""" PX-2725000059 CDM 2725000059 LOCAL 272 RC inpatient 25 25 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES EPO [308136803] 19.8 percent of total billed charges 15.5 23.75 Technical (Hospital) Services "HC/HH Wch Supp Gauze Packing Plain 1/4__7631""" PX-2725000059 CDM 2725000059 LOCAL 272 RC inpatient 25 25 BLUE CROSS BLUE SHIELD WELLMARK SB889 [3081026] BCBS WYOMING [308102603] 23.75 percent of total billed charges 15.5 23.75 Technical (Hospital) Services "HC/HH Wch Supp Gauze Packing Plain 1/4__7631""" PX-2725000059 CDM 2725000059 LOCAL 272 RC inpatient 25 25 MULTIPLAN INC 34080 [3081285] MULTIPLAN INC [308128501] 23.75 percent of total billed charges 15.5 23.75 Technical (Hospital) Services "HC/HH Wch Supp Gauze Packing Plain 1/4__7631""" PX-2725000059 CDM 2725000059 LOCAL 272 RC inpatient 25 25 HEALTHPARTNERS SX009 HEALTHPARTNERS 19.8 percent of total billed charges 15.5 23.75 Technical (Hospital) Services "HC/HH Wch Supp Gauze Packing Plain 1/4__7631""" PX-2725000059 CDM 2725000059 LOCAL 272 RC inpatient 25 25 CIGNA 62308 [3081051] CIGNA 62308 [308105105] 19.8 percent of total billed charges 15.5 23.75 Technical (Hospital) Services "HC/HH Wch Supp Gauze Packing Plain 1/4__7631""" PX-2725000059 CDM 2725000059 LOCAL 272 RC inpatient 25 25 CIGNA 62308 [3081051] CIGNA STATE OF WYOMING [308105107] 19.8 percent of total billed charges 15.5 23.75 Technical (Hospital) Services "HC/HH Wch Supp Gauze Packing Plain 1/4__7631""" PX-2725000059 CDM 2725000059 LOCAL 272 RC inpatient 25 25 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES PPO [308136801] 19.8 percent of total billed charges 15.5 23.75 Technical (Hospital) Services "HC/HH Wch Supp Gauze Packing Plain 1/4__7631""" PX-2725000059 CDM 2725000059 LOCAL 272 RC inpatient 25 25 MEDICA (COMMERCIAL) 94265 [3081118] MEDICA CLAIMS [308111801] 22.5 percent of total billed charges 15.5 23.75 Technical (Hospital) Services "HC/HH Wch Supp Gauze Packing Plain 1/4__7631""" PX-2725000059 CDM 2725000059 LOCAL 272 RC inpatient 25 25 UNITED HEALTHCARE (COMMERCIAL) [3081199] UNITED HEALTHCARE 87726 [308119901] 15.5 percent of total billed charges 15.5 23.75 Technical (Hospital) Services "HC/HH Wch Supp Gauze Packing Plain 1/4__7631""" PX-2725000059 CDM 2725000059 LOCAL 272 RC inpatient 25 25 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES HDHP [308136802] 19.8 percent of total billed charges 15.5 23.75 Technical (Hospital) Services HC/HH Wch Supp Gauze Packing Plain 0.5in__7632 PX-2725000058 CDM 2725000058 LOCAL 272 RC inpatient 23 23 BLUE CROSS BLUE SHIELD WELLMARK SB889 [3081026] BCBS WYOMING [308102603] 21.85 percent of total billed charges 14.26 21.85 Technical (Hospital) Services HC/HH Wch Supp Gauze Packing Plain 0.5in__7632 PX-2725000058 CDM 2725000058 LOCAL 272 RC inpatient 23 23 MULTIPLAN INC 34080 [3081285] MULTIPLAN INC [308128501] 21.85 percent of total billed charges 14.26 21.85 Technical (Hospital) Services HC/HH Wch Supp Gauze Packing Plain 0.5in__7632 PX-2725000058 CDM 2725000058 LOCAL 272 RC inpatient 23 23 CIGNA 62308 [3081051] CIGNA 62308 [308105105] 18.21 percent of total billed charges 14.26 21.85 Technical (Hospital) Services HC/HH Wch Supp Gauze Packing Plain 0.5in__7632 PX-2725000058 CDM 2725000058 LOCAL 272 RC inpatient 23 23 CIGNA 62308 [3081051] CIGNA STATE OF WYOMING [308105107] 18.21 percent of total billed charges 14.26 21.85 Technical (Hospital) Services HC/HH Wch Supp Gauze Packing Plain 0.5in__7632 PX-2725000058 CDM 2725000058 LOCAL 272 RC inpatient 23 23 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES EPO [308136803] 18.21 percent of total billed charges 14.26 21.85 Technical (Hospital) Services HC/HH Wch Supp Gauze Packing Plain 0.5in__7632 PX-2725000058 CDM 2725000058 LOCAL 272 RC inpatient 23 23 HEALTHPARTNERS SX009 HEALTHPARTNERS 18.21 percent of total billed charges 14.26 21.85 Technical (Hospital) Services HC/HH Wch Supp Gauze Packing Plain 0.5in__7632 PX-2725000058 CDM 2725000058 LOCAL 272 RC inpatient 23 23 UNITED HEALTHCARE (COMMERCIAL) [3081199] UNITED HEALTHCARE 87726 [308119901] 14.26 percent of total billed charges 14.26 21.85 Technical (Hospital) Services HC/HH Wch Supp Gauze Packing Plain 0.5in__7632 PX-2725000058 CDM 2725000058 LOCAL 272 RC inpatient 23 23 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES HDHP [308136802] 18.21 percent of total billed charges 14.26 21.85 Technical (Hospital) Services HC/HH Wch Supp Gauze Packing Plain 0.5in__7632 PX-2725000058 CDM 2725000058 LOCAL 272 RC inpatient 23 23 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES PPO [308136801] 18.21 percent of total billed charges 14.26 21.85 Technical (Hospital) Services HC/HH Wch Supp Gauze Packing Plain 0.5in__7632 PX-2725000058 CDM 2725000058 LOCAL 272 RC inpatient 23 23 MEDICA (COMMERCIAL) 94265 [3081118] MEDICA CLAIMS [308111801] 20.7 percent of total billed charges 14.26 21.85 Technical (Hospital) Services HC/HH Wch Supp Gauze Packing Plain 0.5in__7632 PX-2725000058 CDM 2725000058 LOCAL 272 RC outpatient 23 23 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES HDHP [308136802] 18.4 percent of total billed charges 14.26 21.85 Technical (Hospital) Services HC/HH Wch Supp Gauze Packing Plain 0.5in__7632 PX-2725000058 CDM 2725000058 LOCAL 272 RC outpatient 23 23 BLUE CROSS BLUE SHIELD WELLMARK SB889 [3081026] BCBS WYOMING [308102603] 21.85 percent of total billed charges 14.26 21.85 Technical (Hospital) Services HC/HH Wch Supp Gauze Packing Plain 0.5in__7632 PX-2725000058 CDM 2725000058 LOCAL 272 RC outpatient 23 23 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES EPO [308136803] 18.4 percent of total billed charges 14.26 21.85 Technical (Hospital) Services HC/HH Wch Supp Gauze Packing Plain 0.5in__7632 PX-2725000058 CDM 2725000058 LOCAL 272 RC outpatient 23 23 UNITED HEALTHCARE (COMMERCIAL) [3081199] UNITED HEALTHCARE 87726 [308119901] 14.26 percent of total billed charges 14.26 21.85 Technical (Hospital) Services HC/HH Wch Supp Gauze Packing Plain 0.5in__7632 PX-2725000058 CDM 2725000058 LOCAL 272 RC outpatient 23 23 CIGNA 62308 [3081051] CIGNA STATE OF WYOMING [308105107] 18.4 percent of total billed charges 14.26 21.85 Technical (Hospital) Services HC/HH Wch Supp Gauze Packing Plain 0.5in__7632 PX-2725000058 CDM 2725000058 LOCAL 272 RC outpatient 23 23 CIGNA 62308 [3081051] CIGNA 62308 [308105105] 18.4 percent of total billed charges 14.26 21.85 Technical (Hospital) Services HC/HH Wch Supp Gauze Packing Plain 0.5in__7632 PX-2725000058 CDM 2725000058 LOCAL 272 RC outpatient 23 23 MEDICA (COMMERCIAL) 94265 [3081118] MEDICA CLAIMS [308111801] 20.7 percent of total billed charges 14.26 21.85 Technical (Hospital) Services HC/HH Wch Supp Gauze Packing Plain 0.5in__7632 PX-2725000058 CDM 2725000058 LOCAL 272 RC outpatient 23 23 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES PPO [308136801] 18.4 percent of total billed charges 14.26 21.85 Technical (Hospital) Services HC/HH Wch Supp Gauze Packing Plain 0.5in__7632 PX-2725000058 CDM 2725000058 LOCAL 272 RC outpatient 23 23 HEALTHPARTNERS SX009 HEALTHPARTNERS 18.4 percent of total billed charges 14.26 21.85 Technical (Hospital) Services HC/HH Wch Supp Gauze Packing Plain 0.5in__7632 PX-2725000058 CDM 2725000058 LOCAL 272 RC outpatient 23 23 MULTIPLAN INC 34080 [3081285] MULTIPLAN INC [308128501] 21.85 percent of total billed charges 14.26 21.85 Technical (Hospital) Services HC/HH Wch Supp Gauze Packing Iodoform 1in__7833 PX-2725000057 CDM 2725000057 LOCAL 272 RC outpatient 28 28 BLUE CROSS BLUE SHIELD WELLMARK SB889 [3081026] BCBS WYOMING [308102603] 26.6 percent of total billed charges 17.36 26.6 Technical (Hospital) Services HC/HH Wch Supp Gauze Packing Iodoform 1in__7833 PX-2725000057 CDM 2725000057 LOCAL 272 RC outpatient 28 28 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES EPO [308136803] 22.4 percent of total billed charges 17.36 26.6 Technical (Hospital) Services HC/HH Wch Supp Gauze Packing Iodoform 1in__7833 PX-2725000057 CDM 2725000057 LOCAL 272 RC outpatient 28 28 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES HDHP [308136802] 22.4 percent of total billed charges 17.36 26.6 Technical (Hospital) Services HC/HH Wch Supp Gauze Packing Iodoform 1in__7833 PX-2725000057 CDM 2725000057 LOCAL 272 RC outpatient 28 28 UNITED HEALTHCARE (COMMERCIAL) [3081199] UNITED HEALTHCARE 87726 [308119901] 17.36 percent of total billed charges 17.36 26.6 Technical (Hospital) Services HC/HH Wch Supp Gauze Packing Iodoform 1in__7833 PX-2725000057 CDM 2725000057 LOCAL 272 RC outpatient 28 28 HEALTHPARTNERS SX009 HEALTHPARTNERS 22.4 percent of total billed charges 17.36 26.6 Technical (Hospital) Services HC/HH Wch Supp Gauze Packing Iodoform 1in__7833 PX-2725000057 CDM 2725000057 LOCAL 272 RC outpatient 28 28 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES PPO [308136801] 22.4 percent of total billed charges 17.36 26.6 Technical (Hospital) Services HC/HH Wch Supp Gauze Packing Iodoform 1in__7833 PX-2725000057 CDM 2725000057 LOCAL 272 RC outpatient 28 28 CIGNA 62308 [3081051] CIGNA 62308 [308105105] 22.4 percent of total billed charges 17.36 26.6 Technical (Hospital) Services HC/HH Wch Supp Gauze Packing Iodoform 1in__7833 PX-2725000057 CDM 2725000057 LOCAL 272 RC outpatient 28 28 CIGNA 62308 [3081051] CIGNA STATE OF WYOMING [308105107] 22.4 percent of total billed charges 17.36 26.6 Technical (Hospital) Services HC/HH Wch Supp Gauze Packing Iodoform 1in__7833 PX-2725000057 CDM 2725000057 LOCAL 272 RC outpatient 28 28 MEDICA (COMMERCIAL) 94265 [3081118] MEDICA CLAIMS [308111801] 25.2 percent of total billed charges 17.36 26.6 Technical (Hospital) Services HC/HH Wch Supp Gauze Packing Iodoform 1in__7833 PX-2725000057 CDM 2725000057 LOCAL 272 RC outpatient 28 28 MULTIPLAN INC 34080 [3081285] MULTIPLAN INC [308128501] 26.6 percent of total billed charges 17.36 26.6 Technical (Hospital) Services HC/HH Wch Supp Gauze Packing Iodoform 1in__7833 PX-2725000057 CDM 2725000057 LOCAL 272 RC inpatient 28 28 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES HDHP [308136802] 22.17 percent of total billed charges 17.36 26.6 Technical (Hospital) Services HC/HH Wch Supp Gauze Packing Iodoform 1in__7833 PX-2725000057 CDM 2725000057 LOCAL 272 RC inpatient 28 28 UNITED HEALTHCARE (COMMERCIAL) [3081199] UNITED HEALTHCARE 87726 [308119901] 17.36 percent of total billed charges 17.36 26.6 Technical (Hospital) Services HC/HH Wch Supp Gauze Packing Iodoform 1in__7833 PX-2725000057 CDM 2725000057 LOCAL 272 RC inpatient 28 28 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES PPO [308136801] 22.17 percent of total billed charges 17.36 26.6 Technical (Hospital) Services HC/HH Wch Supp Gauze Packing Iodoform 1in__7833 PX-2725000057 CDM 2725000057 LOCAL 272 RC inpatient 28 28 MEDICA (COMMERCIAL) 94265 [3081118] MEDICA CLAIMS [308111801] 25.2 percent of total billed charges 17.36 26.6 Technical (Hospital) Services HC/HH Wch Supp Gauze Packing Iodoform 1in__7833 PX-2725000057 CDM 2725000057 LOCAL 272 RC inpatient 28 28 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES EPO [308136803] 22.17 percent of total billed charges 17.36 26.6 Technical (Hospital) Services HC/HH Wch Supp Gauze Packing Iodoform 1in__7833 PX-2725000057 CDM 2725000057 LOCAL 272 RC inpatient 28 28 HEALTHPARTNERS SX009 HEALTHPARTNERS 22.17 percent of total billed charges 17.36 26.6 Technical (Hospital) Services HC/HH Wch Supp Gauze Packing Iodoform 1in__7833 PX-2725000057 CDM 2725000057 LOCAL 272 RC inpatient 28 28 CIGNA 62308 [3081051] CIGNA 62308 [308105105] 22.17 percent of total billed charges 17.36 26.6 Technical (Hospital) Services HC/HH Wch Supp Gauze Packing Iodoform 1in__7833 PX-2725000057 CDM 2725000057 LOCAL 272 RC inpatient 28 28 CIGNA 62308 [3081051] CIGNA STATE OF WYOMING [308105107] 22.17 percent of total billed charges 17.36 26.6 Technical (Hospital) Services HC/HH Wch Supp Gauze Packing Iodoform 1in__7833 PX-2725000057 CDM 2725000057 LOCAL 272 RC inpatient 28 28 MULTIPLAN INC 34080 [3081285] MULTIPLAN INC [308128501] 26.6 percent of total billed charges 17.36 26.6 Technical (Hospital) Services HC/HH Wch Supp Gauze Packing Iodoform 1in__7833 PX-2725000057 CDM 2725000057 LOCAL 272 RC inpatient 28 28 BLUE CROSS BLUE SHIELD WELLMARK SB889 [3081026] BCBS WYOMING [308102603] 26.6 percent of total billed charges 17.36 26.6 Technical (Hospital) Services HC/HH Wch Supp Gauze Packing Iodoform 0.5in__7832 PX-2725000056 CDM 2725000056 LOCAL 272 RC inpatient 25 25 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES PPO [308136801] 19.8 percent of total billed charges 15.5 23.75 Technical (Hospital) Services HC/HH Wch Supp Gauze Packing Iodoform 0.5in__7832 PX-2725000056 CDM 2725000056 LOCAL 272 RC inpatient 25 25 MEDICA (COMMERCIAL) 94265 [3081118] MEDICA CLAIMS [308111801] 22.5 percent of total billed charges 15.5 23.75 Technical (Hospital) Services HC/HH Wch Supp Gauze Packing Iodoform 0.5in__7832 PX-2725000056 CDM 2725000056 LOCAL 272 RC inpatient 25 25 UNITED HEALTHCARE (COMMERCIAL) [3081199] UNITED HEALTHCARE 87726 [308119901] 15.5 percent of total billed charges 15.5 23.75 Technical (Hospital) Services HC/HH Wch Supp Gauze Packing Iodoform 0.5in__7832 PX-2725000056 CDM 2725000056 LOCAL 272 RC inpatient 25 25 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES HDHP [308136802] 19.8 percent of total billed charges 15.5 23.75 Technical (Hospital) Services HC/HH Wch Supp Gauze Packing Iodoform 0.5in__7832 PX-2725000056 CDM 2725000056 LOCAL 272 RC inpatient 25 25 HEALTHPARTNERS SX009 HEALTHPARTNERS 19.8 percent of total billed charges 15.5 23.75 Technical (Hospital) Services HC/HH Wch Supp Gauze Packing Iodoform 0.5in__7832 PX-2725000056 CDM 2725000056 LOCAL 272 RC inpatient 25 25 BLUE CROSS BLUE SHIELD WELLMARK SB889 [3081026] BCBS WYOMING [308102603] 23.75 percent of total billed charges 15.5 23.75 Technical (Hospital) Services HC/HH Wch Supp Gauze Packing Iodoform 0.5in__7832 PX-2725000056 CDM 2725000056 LOCAL 272 RC inpatient 25 25 MULTIPLAN INC 34080 [3081285] MULTIPLAN INC [308128501] 23.75 percent of total billed charges 15.5 23.75 Technical (Hospital) Services HC/HH Wch Supp Gauze Packing Iodoform 0.5in__7832 PX-2725000056 CDM 2725000056 LOCAL 272 RC inpatient 25 25 CIGNA 62308 [3081051] CIGNA 62308 [308105105] 19.8 percent of total billed charges 15.5 23.75 Technical (Hospital) Services HC/HH Wch Supp Gauze Packing Iodoform 0.5in__7832 PX-2725000056 CDM 2725000056 LOCAL 272 RC inpatient 25 25 CIGNA 62308 [3081051] CIGNA STATE OF WYOMING [308105107] 19.8 percent of total billed charges 15.5 23.75 Technical (Hospital) Services HC/HH Wch Supp Gauze Packing Iodoform 0.5in__7832 PX-2725000056 CDM 2725000056 LOCAL 272 RC inpatient 25 25 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES EPO [308136803] 19.8 percent of total billed charges 15.5 23.75 Technical (Hospital) Services HC/HH Wch Supp Gauze Packing Iodoform 0.5in__7832 PX-2725000056 CDM 2725000056 LOCAL 272 RC outpatient 25 25 BLUE CROSS BLUE SHIELD WELLMARK SB889 [3081026] BCBS WYOMING [308102603] 23.75 percent of total billed charges 15.5 23.75 Technical (Hospital) Services HC/HH Wch Supp Gauze Packing Iodoform 0.5in__7832 PX-2725000056 CDM 2725000056 LOCAL 272 RC outpatient 25 25 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES EPO [308136803] 20 percent of total billed charges 15.5 23.75 Technical (Hospital) Services HC/HH Wch Supp Gauze Packing Iodoform 0.5in__7832 PX-2725000056 CDM 2725000056 LOCAL 272 RC outpatient 25 25 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES HDHP [308136802] 20 percent of total billed charges 15.5 23.75 Technical (Hospital) Services HC/HH Wch Supp Gauze Packing Iodoform 0.5in__7832 PX-2725000056 CDM 2725000056 LOCAL 272 RC outpatient 25 25 CIGNA 62308 [3081051] CIGNA 62308 [308105105] 20 percent of total billed charges 15.5 23.75 Technical (Hospital) Services HC/HH Wch Supp Gauze Packing Iodoform 0.5in__7832 PX-2725000056 CDM 2725000056 LOCAL 272 RC outpatient 25 25 CIGNA 62308 [3081051] CIGNA STATE OF WYOMING [308105107] 20 percent of total billed charges 15.5 23.75 Technical (Hospital) Services HC/HH Wch Supp Gauze Packing Iodoform 0.5in__7832 PX-2725000056 CDM 2725000056 LOCAL 272 RC outpatient 25 25 UNITED HEALTHCARE (COMMERCIAL) [3081199] UNITED HEALTHCARE 87726 [308119901] 15.5 percent of total billed charges 15.5 23.75 Technical (Hospital) Services HC/HH Wch Supp Gauze Packing Iodoform 0.5in__7832 PX-2725000056 CDM 2725000056 LOCAL 272 RC outpatient 25 25 HEALTHPARTNERS SX009 HEALTHPARTNERS 20 percent of total billed charges 15.5 23.75 Technical (Hospital) Services HC/HH Wch Supp Gauze Packing Iodoform 0.5in__7832 PX-2725000056 CDM 2725000056 LOCAL 272 RC outpatient 25 25 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES PPO [308136801] 20 percent of total billed charges 15.5 23.75 Technical (Hospital) Services HC/HH Wch Supp Gauze Packing Iodoform 0.5in__7832 PX-2725000056 CDM 2725000056 LOCAL 272 RC outpatient 25 25 MEDICA (COMMERCIAL) 94265 [3081118] MEDICA CLAIMS [308111801] 22.5 percent of total billed charges 15.5 23.75 Technical (Hospital) Services HC/HH Wch Supp Gauze Packing Iodoform 0.5in__7832 PX-2725000056 CDM 2725000056 LOCAL 272 RC outpatient 25 25 MULTIPLAN INC 34080 [3081285] MULTIPLAN INC [308128501] 23.75 percent of total billed charges 15.5 23.75 Technical (Hospital) Services HC/HH Wch Supp Foley Cath Tray 16 F__899616 PX-2725000055 CDM 2725000055 LOCAL 272 RC inpatient 65 65 BLUE CROSS BLUE SHIELD WELLMARK SB889 [3081026] BCBS WYOMING [308102603] 61.75 percent of total billed charges 40.3 61.75 Technical (Hospital) Services HC/HH Wch Supp Foley Cath Tray 16 F__899616 PX-2725000055 CDM 2725000055 LOCAL 272 RC inpatient 65 65 MULTIPLAN INC 34080 [3081285] MULTIPLAN INC [308128501] 61.75 percent of total billed charges 40.3 61.75 Technical (Hospital) Services HC/HH Wch Supp Foley Cath Tray 16 F__899616 PX-2725000055 CDM 2725000055 LOCAL 272 RC inpatient 65 65 CIGNA 62308 [3081051] CIGNA 62308 [308105105] 51.47 percent of total billed charges 40.3 61.75 Technical (Hospital) Services HC/HH Wch Supp Foley Cath Tray 16 F__899616 PX-2725000055 CDM 2725000055 LOCAL 272 RC inpatient 65 65 CIGNA 62308 [3081051] CIGNA STATE OF WYOMING [308105107] 51.47 percent of total billed charges 40.3 61.75 Technical (Hospital) Services HC/HH Wch Supp Foley Cath Tray 16 F__899616 PX-2725000055 CDM 2725000055 LOCAL 272 RC inpatient 65 65 HEALTHPARTNERS SX009 HEALTHPARTNERS 51.47 percent of total billed charges 40.3 61.75 Technical (Hospital) Services HC/HH Wch Supp Foley Cath Tray 16 F__899616 PX-2725000055 CDM 2725000055 LOCAL 272 RC inpatient 65 65 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES EPO [308136803] 51.47 percent of total billed charges 40.3 61.75 Technical (Hospital) Services HC/HH Wch Supp Foley Cath Tray 16 F__899616 PX-2725000055 CDM 2725000055 LOCAL 272 RC inpatient 65 65 MEDICA (COMMERCIAL) 94265 [3081118] MEDICA CLAIMS [308111801] 58.5 percent of total billed charges 40.3 61.75 Technical (Hospital) Services HC/HH Wch Supp Foley Cath Tray 16 F__899616 PX-2725000055 CDM 2725000055 LOCAL 272 RC inpatient 65 65 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES PPO [308136801] 51.47 percent of total billed charges 40.3 61.75 Technical (Hospital) Services HC/HH Wch Supp Foley Cath Tray 16 F__899616 PX-2725000055 CDM 2725000055 LOCAL 272 RC inpatient 65 65 UNITED HEALTHCARE (COMMERCIAL) [3081199] UNITED HEALTHCARE 87726 [308119901] 40.3 percent of total billed charges 40.3 61.75 Technical (Hospital) Services HC/HH Wch Supp Foley Cath Tray 16 F__899616 PX-2725000055 CDM 2725000055 LOCAL 272 RC inpatient 65 65 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES HDHP [308136802] 51.47 percent of total billed charges 40.3 61.75 Technical (Hospital) Services HC/HH Wch Supp Foley Cath Tray 16 F__899616 PX-2725000055 CDM 2725000055 LOCAL 272 RC outpatient 65 65 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES HDHP [308136802] 52 percent of total billed charges 40.3 61.75 Technical (Hospital) Services HC/HH Wch Supp Foley Cath Tray 16 F__899616 PX-2725000055 CDM 2725000055 LOCAL 272 RC outpatient 65 65 BLUE CROSS BLUE SHIELD WELLMARK SB889 [3081026] BCBS WYOMING [308102603] 61.75 percent of total billed charges 40.3 61.75 Technical (Hospital) Services HC/HH Wch Supp Foley Cath Tray 16 F__899616 PX-2725000055 CDM 2725000055 LOCAL 272 RC outpatient 65 65 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES EPO [308136803] 52 percent of total billed charges 40.3 61.75 Technical (Hospital) Services HC/HH Wch Supp Foley Cath Tray 16 F__899616 PX-2725000055 CDM 2725000055 LOCAL 272 RC outpatient 65 65 CIGNA 62308 [3081051] CIGNA 62308 [308105105] 52 percent of total billed charges 40.3 61.75 Technical (Hospital) Services HC/HH Wch Supp Foley Cath Tray 16 F__899616 PX-2725000055 CDM 2725000055 LOCAL 272 RC outpatient 65 65 CIGNA 62308 [3081051] CIGNA STATE OF WYOMING [308105107] 52 percent of total billed charges 40.3 61.75 Technical (Hospital) Services HC/HH Wch Supp Foley Cath Tray 16 F__899616 PX-2725000055 CDM 2725000055 LOCAL 272 RC outpatient 65 65 HEALTHPARTNERS SX009 HEALTHPARTNERS 52 percent of total billed charges 40.3 61.75 Technical (Hospital) Services HC/HH Wch Supp Foley Cath Tray 16 F__899616 PX-2725000055 CDM 2725000055 LOCAL 272 RC outpatient 65 65 UNITED HEALTHCARE (COMMERCIAL) [3081199] UNITED HEALTHCARE 87726 [308119901] 40.3 percent of total billed charges 40.3 61.75 Technical (Hospital) Services HC/HH Wch Supp Foley Cath Tray 16 F__899616 PX-2725000055 CDM 2725000055 LOCAL 272 RC outpatient 65 65 MULTIPLAN INC 34080 [3081285] MULTIPLAN INC [308128501] 61.75 percent of total billed charges 40.3 61.75 Technical (Hospital) Services HC/HH Wch Supp Foley Cath Tray 16 F__899616 PX-2725000055 CDM 2725000055 LOCAL 272 RC outpatient 65 65 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES PPO [308136801] 52 percent of total billed charges 40.3 61.75 Technical (Hospital) Services HC/HH Wch Supp Foley Cath Tray 16 F__899616 PX-2725000055 CDM 2725000055 LOCAL 272 RC outpatient 65 65 MEDICA (COMMERCIAL) 94265 [3081118] MEDICA CLAIMS [308111801] 58.5 percent of total billed charges 40.3 61.75 Technical (Hospital) Services HC/HH Wch Supp Ez-Io Stabilizer__9066 PX-2725000054 CDM 2725000054 LOCAL 272 RC inpatient 23 23 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES PPO [308136801] 18.21 percent of total billed charges 14.26 21.85 Technical (Hospital) Services HC/HH Wch Supp Ez-Io Stabilizer__9066 PX-2725000054 CDM 2725000054 LOCAL 272 RC inpatient 23 23 MEDICA (COMMERCIAL) 94265 [3081118] MEDICA CLAIMS [308111801] 20.7 percent of total billed charges 14.26 21.85 Technical (Hospital) Services HC/HH Wch Supp Ez-Io Stabilizer__9066 PX-2725000054 CDM 2725000054 LOCAL 272 RC inpatient 23 23 UNITED HEALTHCARE (COMMERCIAL) [3081199] UNITED HEALTHCARE 87726 [308119901] 14.26 percent of total billed charges 14.26 21.85 Technical (Hospital) Services HC/HH Wch Supp Ez-Io Stabilizer__9066 PX-2725000054 CDM 2725000054 LOCAL 272 RC inpatient 23 23 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES HDHP [308136802] 18.21 percent of total billed charges 14.26 21.85 Technical (Hospital) Services HC/HH Wch Supp Ez-Io Stabilizer__9066 PX-2725000054 CDM 2725000054 LOCAL 272 RC inpatient 23 23 HEALTHPARTNERS SX009 HEALTHPARTNERS 18.21 percent of total billed charges 14.26 21.85 Technical (Hospital) Services HC/HH Wch Supp Ez-Io Stabilizer__9066 PX-2725000054 CDM 2725000054 LOCAL 272 RC inpatient 23 23 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES EPO [308136803] 18.21 percent of total billed charges 14.26 21.85 Technical (Hospital) Services HC/HH Wch Supp Ez-Io Stabilizer__9066 PX-2725000054 CDM 2725000054 LOCAL 272 RC inpatient 23 23 MULTIPLAN INC 34080 [3081285] MULTIPLAN INC [308128501] 21.85 percent of total billed charges 14.26 21.85 Technical (Hospital) Services HC/HH Wch Supp Ez-Io Stabilizer__9066 PX-2725000054 CDM 2725000054 LOCAL 272 RC inpatient 23 23 BLUE CROSS BLUE SHIELD WELLMARK SB889 [3081026] BCBS WYOMING [308102603] 21.85 percent of total billed charges 14.26 21.85 Technical (Hospital) Services HC/HH Wch Supp Ez-Io Stabilizer__9066 PX-2725000054 CDM 2725000054 LOCAL 272 RC inpatient 23 23 CIGNA 62308 [3081051] CIGNA 62308 [308105105] 18.21 percent of total billed charges 14.26 21.85 Technical (Hospital) Services HC/HH Wch Supp Ez-Io Stabilizer__9066 PX-2725000054 CDM 2725000054 LOCAL 272 RC inpatient 23 23 CIGNA 62308 [3081051] CIGNA STATE OF WYOMING [308105107] 18.21 percent of total billed charges 14.26 21.85 Technical (Hospital) Services HC/HH Wch Supp Ez-Io Stabilizer__9066 PX-2725000054 CDM 2725000054 LOCAL 272 RC outpatient 23 23 BLUE CROSS BLUE SHIELD WELLMARK SB889 [3081026] BCBS WYOMING [308102603] 21.85 percent of total billed charges 14.26 21.85 Technical (Hospital) Services HC/HH Wch Supp Ez-Io Stabilizer__9066 PX-2725000054 CDM 2725000054 LOCAL 272 RC outpatient 23 23 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES EPO [308136803] 18.4 percent of total billed charges 14.26 21.85 Technical (Hospital) Services HC/HH Wch Supp Ez-Io Stabilizer__9066 PX-2725000054 CDM 2725000054 LOCAL 272 RC outpatient 23 23 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES HDHP [308136802] 18.4 percent of total billed charges 14.26 21.85 Technical (Hospital) Services HC/HH Wch Supp Ez-Io Stabilizer__9066 PX-2725000054 CDM 2725000054 LOCAL 272 RC outpatient 23 23 UNITED HEALTHCARE (COMMERCIAL) [3081199] UNITED HEALTHCARE 87726 [308119901] 14.26 percent of total billed charges 14.26 21.85 Technical (Hospital) Services HC/HH Wch Supp Ez-Io Stabilizer__9066 PX-2725000054 CDM 2725000054 LOCAL 272 RC outpatient 23 23 HEALTHPARTNERS SX009 HEALTHPARTNERS 18.4 percent of total billed charges 14.26 21.85 Technical (Hospital) Services HC/HH Wch Supp Ez-Io Stabilizer__9066 PX-2725000054 CDM 2725000054 LOCAL 272 RC outpatient 23 23 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES PPO [308136801] 18.4 percent of total billed charges 14.26 21.85 Technical (Hospital) Services HC/HH Wch Supp Ez-Io Stabilizer__9066 PX-2725000054 CDM 2725000054 LOCAL 272 RC outpatient 23 23 CIGNA 62308 [3081051] CIGNA 62308 [308105105] 18.4 percent of total billed charges 14.26 21.85 Technical (Hospital) Services HC/HH Wch Supp Ez-Io Stabilizer__9066 PX-2725000054 CDM 2725000054 LOCAL 272 RC outpatient 23 23 CIGNA 62308 [3081051] CIGNA STATE OF WYOMING [308105107] 18.4 percent of total billed charges 14.26 21.85 Technical (Hospital) Services HC/HH Wch Supp Ez-Io Stabilizer__9066 PX-2725000054 CDM 2725000054 LOCAL 272 RC outpatient 23 23 MULTIPLAN INC 34080 [3081285] MULTIPLAN INC [308128501] 21.85 percent of total billed charges 14.26 21.85 Technical (Hospital) Services HC/HH Wch Supp Ez-Io Stabilizer__9066 PX-2725000054 CDM 2725000054 LOCAL 272 RC outpatient 23 23 MEDICA (COMMERCIAL) 94265 [3081118] MEDICA CLAIMS [308111801] 20.7 percent of total billed charges 14.26 21.85 Technical (Hospital) Services HC/HH Wch Supp Ez-Io 45mm Needle__9079 PX-2725000053 CDM 2725000053 LOCAL 272 RC inpatient 278 278 MEDICA (COMMERCIAL) 94265 [3081118] MEDICA CLAIMS [308111801] 250.2 percent of total billed charges 172.36 264.1 Technical (Hospital) Services HC/HH Wch Supp Ez-Io 45mm Needle__9079 PX-2725000053 CDM 2725000053 LOCAL 272 RC inpatient 278 278 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES PPO [308136801] 220.12 percent of total billed charges 172.36 264.1 Technical (Hospital) Services HC/HH Wch Supp Ez-Io 45mm Needle__9079 PX-2725000053 CDM 2725000053 LOCAL 272 RC inpatient 278 278 UNITED HEALTHCARE (COMMERCIAL) [3081199] UNITED HEALTHCARE 87726 [308119901] 172.36 percent of total billed charges 172.36 264.1 Technical (Hospital) Services HC/HH Wch Supp Ez-Io 45mm Needle__9079 PX-2725000053 CDM 2725000053 LOCAL 272 RC inpatient 278 278 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES HDHP [308136802] 220.12 percent of total billed charges 172.36 264.1 Technical (Hospital) Services HC/HH Wch Supp Ez-Io 45mm Needle__9079 PX-2725000053 CDM 2725000053 LOCAL 272 RC inpatient 278 278 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES EPO [308136803] 220.12 percent of total billed charges 172.36 264.1 Technical (Hospital) Services HC/HH Wch Supp Ez-Io 45mm Needle__9079 PX-2725000053 CDM 2725000053 LOCAL 272 RC inpatient 278 278 HEALTHPARTNERS SX009 HEALTHPARTNERS 220.12 percent of total billed charges 172.36 264.1 Technical (Hospital) Services HC/HH Wch Supp Ez-Io 45mm Needle__9079 PX-2725000053 CDM 2725000053 LOCAL 272 RC inpatient 278 278 MULTIPLAN INC 34080 [3081285] MULTIPLAN INC [308128501] 264.1 percent of total billed charges 172.36 264.1 Technical (Hospital) Services HC/HH Wch Supp Ez-Io 45mm Needle__9079 PX-2725000053 CDM 2725000053 LOCAL 272 RC inpatient 278 278 BLUE CROSS BLUE SHIELD WELLMARK SB889 [3081026] BCBS WYOMING [308102603] 264.1 percent of total billed charges 172.36 264.1 Technical (Hospital) Services HC/HH Wch Supp Ez-Io 45mm Needle__9079 PX-2725000053 CDM 2725000053 LOCAL 272 RC inpatient 278 278 CIGNA 62308 [3081051] CIGNA 62308 [308105105] 220.12 percent of total billed charges 172.36 264.1 Technical (Hospital) Services HC/HH Wch Supp Ez-Io 45mm Needle__9079 PX-2725000053 CDM 2725000053 LOCAL 272 RC inpatient 278 278 CIGNA 62308 [3081051] CIGNA STATE OF WYOMING [308105107] 220.12 percent of total billed charges 172.36 264.1 Technical (Hospital) Services HC/HH Wch Supp Ez-Io 45mm Needle__9079 PX-2725000053 CDM 2725000053 LOCAL 272 RC outpatient 278 278 MEDICA (COMMERCIAL) 94265 [3081118] MEDICA CLAIMS [308111801] 250.2 percent of total billed charges 172.36 264.1 Technical (Hospital) Services HC/HH Wch Supp Ez-Io 45mm Needle__9079 PX-2725000053 CDM 2725000053 LOCAL 272 RC outpatient 278 278 MULTIPLAN INC 34080 [3081285] MULTIPLAN INC [308128501] 264.1 percent of total billed charges 172.36 264.1 Technical (Hospital) Services HC/HH Wch Supp Ez-Io 45mm Needle__9079 PX-2725000053 CDM 2725000053 LOCAL 272 RC outpatient 278 278 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES PPO [308136801] 222.4 percent of total billed charges 172.36 264.1 Technical (Hospital) Services HC/HH Wch Supp Ez-Io 45mm Needle__9079 PX-2725000053 CDM 2725000053 LOCAL 272 RC outpatient 278 278 HEALTHPARTNERS SX009 HEALTHPARTNERS 222.4 percent of total billed charges 172.36 264.1 Technical (Hospital) Services HC/HH Wch Supp Ez-Io 45mm Needle__9079 PX-2725000053 CDM 2725000053 LOCAL 272 RC outpatient 278 278 CIGNA 62308 [3081051] CIGNA 62308 [308105105] 222.4 percent of total billed charges 172.36 264.1 Technical (Hospital) Services HC/HH Wch Supp Ez-Io 45mm Needle__9079 PX-2725000053 CDM 2725000053 LOCAL 272 RC outpatient 278 278 CIGNA 62308 [3081051] CIGNA STATE OF WYOMING [308105107] 222.4 percent of total billed charges 172.36 264.1 Technical (Hospital) Services HC/HH Wch Supp Ez-Io 45mm Needle__9079 PX-2725000053 CDM 2725000053 LOCAL 272 RC outpatient 278 278 UNITED HEALTHCARE (COMMERCIAL) [3081199] UNITED HEALTHCARE 87726 [308119901] 172.36 percent of total billed charges 172.36 264.1 Technical (Hospital) Services HC/HH Wch Supp Ez-Io 45mm Needle__9079 PX-2725000053 CDM 2725000053 LOCAL 272 RC outpatient 278 278 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES EPO [308136803] 222.4 percent of total billed charges 172.36 264.1 Technical (Hospital) Services HC/HH Wch Supp Ez-Io 45mm Needle__9079 PX-2725000053 CDM 2725000053 LOCAL 272 RC outpatient 278 278 BLUE CROSS BLUE SHIELD WELLMARK SB889 [3081026] BCBS WYOMING [308102603] 264.1 percent of total billed charges 172.36 264.1 Technical (Hospital) Services HC/HH Wch Supp Ez-Io 45mm Needle__9079 PX-2725000053 CDM 2725000053 LOCAL 272 RC outpatient 278 278 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES HDHP [308136802] 222.4 percent of total billed charges 172.36 264.1 Technical (Hospital) Services HC/HH Wch Supp Ez-Io 25mm Needle__9001 PX-2725000052 CDM 2725000052 LOCAL 272 RC inpatient 274 274 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES PPO [308136801] 216.95 percent of total billed charges 169.88 260.3 Technical (Hospital) Services HC/HH Wch Supp Ez-Io 25mm Needle__9001 PX-2725000052 CDM 2725000052 LOCAL 272 RC inpatient 274 274 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES HDHP [308136802] 216.95 percent of total billed charges 169.88 260.3 Technical (Hospital) Services HC/HH Wch Supp Ez-Io 25mm Needle__9001 PX-2725000052 CDM 2725000052 LOCAL 272 RC inpatient 274 274 UNITED HEALTHCARE (COMMERCIAL) [3081199] UNITED HEALTHCARE 87726 [308119901] 169.88 percent of total billed charges 169.88 260.3 Technical (Hospital) Services HC/HH Wch Supp Ez-Io 25mm Needle__9001 PX-2725000052 CDM 2725000052 LOCAL 272 RC inpatient 274 274 MEDICA (COMMERCIAL) 94265 [3081118] MEDICA CLAIMS [308111801] 246.6 percent of total billed charges 169.88 260.3 Technical (Hospital) Services HC/HH Wch Supp Ez-Io 25mm Needle__9001 PX-2725000052 CDM 2725000052 LOCAL 272 RC inpatient 274 274 MULTIPLAN INC 34080 [3081285] MULTIPLAN INC [308128501] 260.3 percent of total billed charges 169.88 260.3 Technical (Hospital) Services HC/HH Wch Supp Ez-Io 25mm Needle__9001 PX-2725000052 CDM 2725000052 LOCAL 272 RC inpatient 274 274 HEALTHPARTNERS SX009 HEALTHPARTNERS 216.95 percent of total billed charges 169.88 260.3 Technical (Hospital) Services HC/HH Wch Supp Ez-Io 25mm Needle__9001 PX-2725000052 CDM 2725000052 LOCAL 272 RC inpatient 274 274 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES EPO [308136803] 216.95 percent of total billed charges 169.88 260.3 Technical (Hospital) Services HC/HH Wch Supp Ez-Io 25mm Needle__9001 PX-2725000052 CDM 2725000052 LOCAL 272 RC inpatient 274 274 BLUE CROSS BLUE SHIELD WELLMARK SB889 [3081026] BCBS WYOMING [308102603] 260.3 percent of total billed charges 169.88 260.3 Technical (Hospital) Services HC/HH Wch Supp Ez-Io 25mm Needle__9001 PX-2725000052 CDM 2725000052 LOCAL 272 RC inpatient 274 274 CIGNA 62308 [3081051] CIGNA 62308 [308105105] 216.95 percent of total billed charges 169.88 260.3 Technical (Hospital) Services HC/HH Wch Supp Ez-Io 25mm Needle__9001 PX-2725000052 CDM 2725000052 LOCAL 272 RC inpatient 274 274 CIGNA 62308 [3081051] CIGNA STATE OF WYOMING [308105107] 216.95 percent of total billed charges 169.88 260.3 Technical (Hospital) Services HC/HH Wch Supp Ez-Io 25mm Needle__9001 PX-2725000052 CDM 2725000052 LOCAL 272 RC outpatient 274 274 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES HDHP [308136802] 219.2 percent of total billed charges 169.88 260.3 Technical (Hospital) Services HC/HH Wch Supp Ez-Io 25mm Needle__9001 PX-2725000052 CDM 2725000052 LOCAL 272 RC outpatient 274 274 BLUE CROSS BLUE SHIELD WELLMARK SB889 [3081026] BCBS WYOMING [308102603] 260.3 percent of total billed charges 169.88 260.3 Technical (Hospital) Services HC/HH Wch Supp Ez-Io 25mm Needle__9001 PX-2725000052 CDM 2725000052 LOCAL 272 RC outpatient 274 274 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES EPO [308136803] 219.2 percent of total billed charges 169.88 260.3 Technical (Hospital) Services HC/HH Wch Supp Ez-Io 25mm Needle__9001 PX-2725000052 CDM 2725000052 LOCAL 272 RC outpatient 274 274 UNITED HEALTHCARE (COMMERCIAL) [3081199] UNITED HEALTHCARE 87726 [308119901] 169.88 percent of total billed charges 169.88 260.3 Technical (Hospital) Services HC/HH Wch Supp Ez-Io 25mm Needle__9001 PX-2725000052 CDM 2725000052 LOCAL 272 RC outpatient 274 274 CIGNA 62308 [3081051] CIGNA 62308 [308105105] 219.2 percent of total billed charges 169.88 260.3 Technical (Hospital) Services HC/HH Wch Supp Ez-Io 25mm Needle__9001 PX-2725000052 CDM 2725000052 LOCAL 272 RC outpatient 274 274 CIGNA 62308 [3081051] CIGNA STATE OF WYOMING [308105107] 219.2 percent of total billed charges 169.88 260.3 Technical (Hospital) Services HC/HH Wch Supp Ez-Io 25mm Needle__9001 PX-2725000052 CDM 2725000052 LOCAL 272 RC outpatient 274 274 HEALTHPARTNERS SX009 HEALTHPARTNERS 219.2 percent of total billed charges 169.88 260.3 Technical (Hospital) Services HC/HH Wch Supp Ez-Io 25mm Needle__9001 PX-2725000052 CDM 2725000052 LOCAL 272 RC outpatient 274 274 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES PPO [308136801] 219.2 percent of total billed charges 169.88 260.3 Technical (Hospital) Services HC/HH Wch Supp Ez-Io 25mm Needle__9001 PX-2725000052 CDM 2725000052 LOCAL 272 RC outpatient 274 274 MULTIPLAN INC 34080 [3081285] MULTIPLAN INC [308128501] 260.3 percent of total billed charges 169.88 260.3 Technical (Hospital) Services HC/HH Wch Supp Ez-Io 25mm Needle__9001 PX-2725000052 CDM 2725000052 LOCAL 272 RC outpatient 274 274 MEDICA (COMMERCIAL) 94265 [3081118] MEDICA CLAIMS [308111801] 246.6 percent of total billed charges 169.88 260.3 Technical (Hospital) Services HC/HH Wch Supp Drssng Telfa St 3x4__2132 PX-2725000051 CDM 2725000051 LOCAL 272 RC outpatient 5 5 BLUE CROSS BLUE SHIELD WELLMARK SB889 [3081026] BCBS WYOMING [308102603] 4.75 percent of total billed charges 3.1 4.75 Technical (Hospital) Services HC/HH Wch Supp Drssng Telfa St 3x4__2132 PX-2725000051 CDM 2725000051 LOCAL 272 RC outpatient 5 5 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES EPO [308136803] 4 percent of total billed charges 3.1 4.75 Technical (Hospital) Services HC/HH Wch Supp Drssng Telfa St 3x4__2132 PX-2725000051 CDM 2725000051 LOCAL 272 RC outpatient 5 5 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES HDHP [308136802] 4 percent of total billed charges 3.1 4.75 Technical (Hospital) Services HC/HH Wch Supp Drssng Telfa St 3x4__2132 PX-2725000051 CDM 2725000051 LOCAL 272 RC outpatient 5 5 UNITED HEALTHCARE (COMMERCIAL) [3081199] UNITED HEALTHCARE 87726 [308119901] 3.1 percent of total billed charges 3.1 4.75 Technical (Hospital) Services HC/HH Wch Supp Drssng Telfa St 3x4__2132 PX-2725000051 CDM 2725000051 LOCAL 272 RC outpatient 5 5 HEALTHPARTNERS SX009 HEALTHPARTNERS 4 percent of total billed charges 3.1 4.75 Technical (Hospital) Services HC/HH Wch Supp Drssng Telfa St 3x4__2132 PX-2725000051 CDM 2725000051 LOCAL 272 RC outpatient 5 5 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES PPO [308136801] 4 percent of total billed charges 3.1 4.75 Technical (Hospital) Services HC/HH Wch Supp Drssng Telfa St 3x4__2132 PX-2725000051 CDM 2725000051 LOCAL 272 RC outpatient 5 5 CIGNA 62308 [3081051] CIGNA 62308 [308105105] 4 percent of total billed charges 3.1 4.75 Technical (Hospital) Services HC/HH Wch Supp Drssng Telfa St 3x4__2132 PX-2725000051 CDM 2725000051 LOCAL 272 RC outpatient 5 5 CIGNA 62308 [3081051] CIGNA STATE OF WYOMING [308105107] 4 percent of total billed charges 3.1 4.75 Technical (Hospital) Services HC/HH Wch Supp Drssng Telfa St 3x4__2132 PX-2725000051 CDM 2725000051 LOCAL 272 RC outpatient 5 5 MEDICA (COMMERCIAL) 94265 [3081118] MEDICA CLAIMS [308111801] 4.5 percent of total billed charges 3.1 4.75 Technical (Hospital) Services HC/HH Wch Supp Drssng Telfa St 3x4__2132 PX-2725000051 CDM 2725000051 LOCAL 272 RC outpatient 5 5 MULTIPLAN INC 34080 [3081285] MULTIPLAN INC [308128501] 4.75 percent of total billed charges 3.1 4.75 Technical (Hospital) Services HC/HH Wch Supp Drssng Telfa St 3x4__2132 PX-2725000051 CDM 2725000051 LOCAL 272 RC inpatient 5 5 UNITED HEALTHCARE (COMMERCIAL) [3081199] UNITED HEALTHCARE 87726 [308119901] 3.1 percent of total billed charges 3.1 4.75 Technical (Hospital) Services HC/HH Wch Supp Drssng Telfa St 3x4__2132 PX-2725000051 CDM 2725000051 LOCAL 272 RC inpatient 5 5 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES HDHP [308136802] 3.96 percent of total billed charges 3.1 4.75 Technical (Hospital) Services HC/HH Wch Supp Drssng Telfa St 3x4__2132 PX-2725000051 CDM 2725000051 LOCAL 272 RC inpatient 5 5 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES PPO [308136801] 3.96 percent of total billed charges 3.1 4.75 Technical (Hospital) Services HC/HH Wch Supp Drssng Telfa St 3x4__2132 PX-2725000051 CDM 2725000051 LOCAL 272 RC inpatient 5 5 MEDICA (COMMERCIAL) 94265 [3081118] MEDICA CLAIMS [308111801] 4.5 percent of total billed charges 3.1 4.75 Technical (Hospital) Services HC/HH Wch Supp Drssng Telfa St 3x4__2132 PX-2725000051 CDM 2725000051 LOCAL 272 RC inpatient 5 5 BLUE CROSS BLUE SHIELD WELLMARK SB889 [3081026] BCBS WYOMING [308102603] 4.75 percent of total billed charges 3.1 4.75 Technical (Hospital) Services HC/HH Wch Supp Drssng Telfa St 3x4__2132 PX-2725000051 CDM 2725000051 LOCAL 272 RC inpatient 5 5 MULTIPLAN INC 34080 [3081285] MULTIPLAN INC [308128501] 4.75 percent of total billed charges 3.1 4.75 Technical (Hospital) Services HC/HH Wch Supp Drssng Telfa St 3x4__2132 PX-2725000051 CDM 2725000051 LOCAL 272 RC inpatient 5 5 CIGNA 62308 [3081051] CIGNA 62308 [308105105] 3.96 percent of total billed charges 3.1 4.75 Technical (Hospital) Services HC/HH Wch Supp Drssng Telfa St 3x4__2132 PX-2725000051 CDM 2725000051 LOCAL 272 RC inpatient 5 5 CIGNA 62308 [3081051] CIGNA STATE OF WYOMING [308105107] 3.96 percent of total billed charges 3.1 4.75 Technical (Hospital) Services HC/HH Wch Supp Drssng Telfa St 3x4__2132 PX-2725000051 CDM 2725000051 LOCAL 272 RC inpatient 5 5 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES EPO [308136803] 3.96 percent of total billed charges 3.1 4.75 Technical (Hospital) Services HC/HH Wch Supp Drssng Telfa St 3x4__2132 PX-2725000051 CDM 2725000051 LOCAL 272 RC inpatient 5 5 HEALTHPARTNERS SX009 HEALTHPARTNERS 3.96 percent of total billed charges 3.1 4.75 Technical (Hospital) Services HC/HH Wch Supp Drssng Tegaderm Film 4x4__90021 PX-2725000050 CDM 2725000050 LOCAL 272 RC outpatient 15 15 BLUE CROSS BLUE SHIELD WELLMARK SB889 [3081026] BCBS WYOMING [308102603] 14.25 percent of total billed charges 9.3 14.25 Technical (Hospital) Services HC/HH Wch Supp Drssng Tegaderm Film 4x4__90021 PX-2725000050 CDM 2725000050 LOCAL 272 RC outpatient 15 15 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES EPO [308136803] 12 percent of total billed charges 9.3 14.25 Technical (Hospital) Services HC/HH Wch Supp Drssng Tegaderm Film 4x4__90021 PX-2725000050 CDM 2725000050 LOCAL 272 RC outpatient 15 15 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES HDHP [308136802] 12 percent of total billed charges 9.3 14.25 Technical (Hospital) Services HC/HH Wch Supp Drssng Tegaderm Film 4x4__90021 PX-2725000050 CDM 2725000050 LOCAL 272 RC outpatient 15 15 CIGNA 62308 [3081051] CIGNA 62308 [308105105] 12 percent of total billed charges 9.3 14.25 Technical (Hospital) Services HC/HH Wch Supp Drssng Tegaderm Film 4x4__90021 PX-2725000050 CDM 2725000050 LOCAL 272 RC outpatient 15 15 CIGNA 62308 [3081051] CIGNA STATE OF WYOMING [308105107] 12 percent of total billed charges 9.3 14.25 Technical (Hospital) Services HC/HH Wch Supp Drssng Tegaderm Film 4x4__90021 PX-2725000050 CDM 2725000050 LOCAL 272 RC outpatient 15 15 UNITED HEALTHCARE (COMMERCIAL) [3081199] UNITED HEALTHCARE 87726 [308119901] 9.3 percent of total billed charges 9.3 14.25 Technical (Hospital) Services HC/HH Wch Supp Drssng Tegaderm Film 4x4__90021 PX-2725000050 CDM 2725000050 LOCAL 272 RC outpatient 15 15 HEALTHPARTNERS SX009 HEALTHPARTNERS 12 percent of total billed charges 9.3 14.25 Technical (Hospital) Services HC/HH Wch Supp Drssng Tegaderm Film 4x4__90021 PX-2725000050 CDM 2725000050 LOCAL 272 RC outpatient 15 15 MEDICA (COMMERCIAL) 94265 [3081118] MEDICA CLAIMS [308111801] 13.5 percent of total billed charges 9.3 14.25 Technical (Hospital) Services HC/HH Wch Supp Drssng Tegaderm Film 4x4__90021 PX-2725000050 CDM 2725000050 LOCAL 272 RC outpatient 15 15 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES PPO [308136801] 12 percent of total billed charges 9.3 14.25 Technical (Hospital) Services HC/HH Wch Supp Drssng Tegaderm Film 4x4__90021 PX-2725000050 CDM 2725000050 LOCAL 272 RC outpatient 15 15 MULTIPLAN INC 34080 [3081285] MULTIPLAN INC [308128501] 14.25 percent of total billed charges 9.3 14.25 Technical (Hospital) Services HC/HH Wch Supp Drssng Tegaderm Film 4x4__90021 PX-2725000050 CDM 2725000050 LOCAL 272 RC inpatient 15 15 HEALTHPARTNERS SX009 HEALTHPARTNERS 11.88 percent of total billed charges 9.3 14.25 Technical (Hospital) Services HC/HH Wch Supp Drssng Tegaderm Film 4x4__90021 PX-2725000050 CDM 2725000050 LOCAL 272 RC inpatient 15 15 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES EPO [308136803] 11.88 percent of total billed charges 9.3 14.25 Technical (Hospital) Services HC/HH Wch Supp Drssng Tegaderm Film 4x4__90021 PX-2725000050 CDM 2725000050 LOCAL 272 RC inpatient 15 15 MULTIPLAN INC 34080 [3081285] MULTIPLAN INC [308128501] 14.25 percent of total billed charges 9.3 14.25 Technical (Hospital) Services HC/HH Wch Supp Drssng Tegaderm Film 4x4__90021 PX-2725000050 CDM 2725000050 LOCAL 272 RC inpatient 15 15 BLUE CROSS BLUE SHIELD WELLMARK SB889 [3081026] BCBS WYOMING [308102603] 14.25 percent of total billed charges 9.3 14.25 Technical (Hospital) Services HC/HH Wch Supp Drssng Tegaderm Film 4x4__90021 PX-2725000050 CDM 2725000050 LOCAL 272 RC inpatient 15 15 CIGNA 62308 [3081051] CIGNA 62308 [308105105] 11.88 percent of total billed charges 9.3 14.25 Technical (Hospital) Services HC/HH Wch Supp Drssng Tegaderm Film 4x4__90021 PX-2725000050 CDM 2725000050 LOCAL 272 RC inpatient 15 15 CIGNA 62308 [3081051] CIGNA STATE OF WYOMING [308105107] 11.88 percent of total billed charges 9.3 14.25 Technical (Hospital) Services HC/HH Wch Supp Drssng Tegaderm Film 4x4__90021 PX-2725000050 CDM 2725000050 LOCAL 272 RC inpatient 15 15 MEDICA (COMMERCIAL) 94265 [3081118] MEDICA CLAIMS [308111801] 13.5 percent of total billed charges 9.3 14.25 Technical (Hospital) Services HC/HH Wch Supp Drssng Tegaderm Film 4x4__90021 PX-2725000050 CDM 2725000050 LOCAL 272 RC inpatient 15 15 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES PPO [308136801] 11.88 percent of total billed charges 9.3 14.25 Technical (Hospital) Services HC/HH Wch Supp Drssng Tegaderm Film 4x4__90021 PX-2725000050 CDM 2725000050 LOCAL 272 RC inpatient 15 15 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES HDHP [308136802] 11.88 percent of total billed charges 9.3 14.25 Technical (Hospital) Services HC/HH Wch Supp Drssng Tegaderm Film 4x4__90021 PX-2725000050 CDM 2725000050 LOCAL 272 RC inpatient 15 15 UNITED HEALTHCARE (COMMERCIAL) [3081199] UNITED HEALTHCARE 87726 [308119901] 9.3 percent of total billed charges 9.3 14.25 Technical (Hospital) Services HC/HH Wch Supp Drssng Duoderm 5.5 Sq__403327 PX-2725000049 CDM 2725000049 LOCAL 272 RC inpatient 29 29 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES PPO [308136801] 22.96 percent of total billed charges 17.98 27.55 Technical (Hospital) Services HC/HH Wch Supp Drssng Duoderm 5.5 Sq__403327 PX-2725000049 CDM 2725000049 LOCAL 272 RC inpatient 29 29 MEDICA (COMMERCIAL) 94265 [3081118] MEDICA CLAIMS [308111801] 26.1 percent of total billed charges 17.98 27.55 Technical (Hospital) Services HC/HH Wch Supp Drssng Duoderm 5.5 Sq__403327 PX-2725000049 CDM 2725000049 LOCAL 272 RC inpatient 29 29 UNITED HEALTHCARE (COMMERCIAL) [3081199] UNITED HEALTHCARE 87726 [308119901] 17.98 percent of total billed charges 17.98 27.55 Technical (Hospital) Services HC/HH Wch Supp Drssng Duoderm 5.5 Sq__403327 PX-2725000049 CDM 2725000049 LOCAL 272 RC inpatient 29 29 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES HDHP [308136802] 22.96 percent of total billed charges 17.98 27.55 Technical (Hospital) Services HC/HH Wch Supp Drssng Duoderm 5.5 Sq__403327 PX-2725000049 CDM 2725000049 LOCAL 272 RC inpatient 29 29 BLUE CROSS BLUE SHIELD WELLMARK SB889 [3081026] BCBS WYOMING [308102603] 27.55 percent of total billed charges 17.98 27.55 Technical (Hospital) Services HC/HH Wch Supp Drssng Duoderm 5.5 Sq__403327 PX-2725000049 CDM 2725000049 LOCAL 272 RC inpatient 29 29 MULTIPLAN INC 34080 [3081285] MULTIPLAN INC [308128501] 27.55 percent of total billed charges 17.98 27.55 Technical (Hospital) Services HC/HH Wch Supp Drssng Duoderm 5.5 Sq__403327 PX-2725000049 CDM 2725000049 LOCAL 272 RC inpatient 29 29 HEALTHPARTNERS SX009 HEALTHPARTNERS 22.96 percent of total billed charges 17.98 27.55 Technical (Hospital) Services HC/HH Wch Supp Drssng Duoderm 5.5 Sq__403327 PX-2725000049 CDM 2725000049 LOCAL 272 RC inpatient 29 29 CIGNA 62308 [3081051] CIGNA 62308 [308105105] 22.96 percent of total billed charges 17.98 27.55 Technical (Hospital) Services HC/HH Wch Supp Drssng Duoderm 5.5 Sq__403327 PX-2725000049 CDM 2725000049 LOCAL 272 RC inpatient 29 29 CIGNA 62308 [3081051] CIGNA STATE OF WYOMING [308105107] 22.96 percent of total billed charges 17.98 27.55 Technical (Hospital) Services HC/HH Wch Supp Drssng Duoderm 5.5 Sq__403327 PX-2725000049 CDM 2725000049 LOCAL 272 RC inpatient 29 29 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES EPO [308136803] 22.96 percent of total billed charges 17.98 27.55 Technical (Hospital) Services HC/HH Wch Supp Drssng Duoderm 5.5 Sq__403327 PX-2725000049 CDM 2725000049 LOCAL 272 RC outpatient 29 29 CIGNA 62308 [3081051] CIGNA 62308 [308105105] 23.2 percent of total billed charges 17.98 27.55 Technical (Hospital) Services HC/HH Wch Supp Drssng Duoderm 5.5 Sq__403327 PX-2725000049 CDM 2725000049 LOCAL 272 RC outpatient 29 29 CIGNA 62308 [3081051] CIGNA STATE OF WYOMING [308105107] 23.2 percent of total billed charges 17.98 27.55 Technical (Hospital) Services HC/HH Wch Supp Drssng Duoderm 5.5 Sq__403327 PX-2725000049 CDM 2725000049 LOCAL 272 RC outpatient 29 29 UNITED HEALTHCARE (COMMERCIAL) [3081199] UNITED HEALTHCARE 87726 [308119901] 17.98 percent of total billed charges 17.98 27.55 Technical (Hospital) Services HC/HH Wch Supp Drssng Duoderm 5.5 Sq__403327 PX-2725000049 CDM 2725000049 LOCAL 272 RC outpatient 29 29 HEALTHPARTNERS SX009 HEALTHPARTNERS 23.2 percent of total billed charges 17.98 27.55 Technical (Hospital) Services HC/HH Wch Supp Drssng Duoderm 5.5 Sq__403327 PX-2725000049 CDM 2725000049 LOCAL 272 RC outpatient 29 29 BLUE CROSS BLUE SHIELD WELLMARK SB889 [3081026] BCBS WYOMING [308102603] 27.55 percent of total billed charges 17.98 27.55 Technical (Hospital) Services HC/HH Wch Supp Drssng Duoderm 5.5 Sq__403327 PX-2725000049 CDM 2725000049 LOCAL 272 RC outpatient 29 29 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES EPO [308136803] 23.2 percent of total billed charges 17.98 27.55 Technical (Hospital) Services HC/HH Wch Supp Drssng Duoderm 5.5 Sq__403327 PX-2725000049 CDM 2725000049 LOCAL 272 RC outpatient 29 29 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES HDHP [308136802] 23.2 percent of total billed charges 17.98 27.55 Technical (Hospital) Services HC/HH Wch Supp Drssng Duoderm 5.5 Sq__403327 PX-2725000049 CDM 2725000049 LOCAL 272 RC outpatient 29 29 MEDICA (COMMERCIAL) 94265 [3081118] MEDICA CLAIMS [308111801] 26.1 percent of total billed charges 17.98 27.55 Technical (Hospital) Services HC/HH Wch Supp Drssng Duoderm 5.5 Sq__403327 PX-2725000049 CDM 2725000049 LOCAL 272 RC outpatient 29 29 MULTIPLAN INC 34080 [3081285] MULTIPLAN INC [308128501] 27.55 percent of total billed charges 17.98 27.55 Technical (Hospital) Services HC/HH Wch Supp Drssng Duoderm 5.5 Sq__403327 PX-2725000049 CDM 2725000049 LOCAL 272 RC outpatient 29 29 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES PPO [308136801] 23.2 percent of total billed charges 17.98 27.55 Technical (Hospital) Services HC/HH Wch Supp Drssng Combiderm Acd 4x 4__651031 PX-2725000048 CDM 2725000048 LOCAL 272 RC outpatient 16 16 MULTIPLAN INC 34080 [3081285] MULTIPLAN INC [308128501] 15.2 percent of total billed charges 9.92 15.2 Technical (Hospital) Services HC/HH Wch Supp Drssng Combiderm Acd 4x 4__651031 PX-2725000048 CDM 2725000048 LOCAL 272 RC outpatient 16 16 MEDICA (COMMERCIAL) 94265 [3081118] MEDICA CLAIMS [308111801] 14.4 percent of total billed charges 9.92 15.2 Technical (Hospital) Services HC/HH Wch Supp Drssng Combiderm Acd 4x 4__651031 PX-2725000048 CDM 2725000048 LOCAL 272 RC outpatient 16 16 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES HDHP [308136802] 12.8 percent of total billed charges 9.92 15.2 Technical (Hospital) Services HC/HH Wch Supp Drssng Combiderm Acd 4x 4__651031 PX-2725000048 CDM 2725000048 LOCAL 272 RC outpatient 16 16 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES EPO [308136803] 12.8 percent of total billed charges 9.92 15.2 Technical (Hospital) Services HC/HH Wch Supp Drssng Combiderm Acd 4x 4__651031 PX-2725000048 CDM 2725000048 LOCAL 272 RC outpatient 16 16 BLUE CROSS BLUE SHIELD WELLMARK SB889 [3081026] BCBS WYOMING [308102603] 15.2 percent of total billed charges 9.92 15.2 Technical (Hospital) Services HC/HH Wch Supp Drssng Combiderm Acd 4x 4__651031 PX-2725000048 CDM 2725000048 LOCAL 272 RC outpatient 16 16 CIGNA 62308 [3081051] CIGNA 62308 [308105105] 12.8 percent of total billed charges 9.92 15.2 Technical (Hospital) Services HC/HH Wch Supp Drssng Combiderm Acd 4x 4__651031 PX-2725000048 CDM 2725000048 LOCAL 272 RC outpatient 16 16 CIGNA 62308 [3081051] CIGNA STATE OF WYOMING [308105107] 12.8 percent of total billed charges 9.92 15.2 Technical (Hospital) Services HC/HH Wch Supp Drssng Combiderm Acd 4x 4__651031 PX-2725000048 CDM 2725000048 LOCAL 272 RC outpatient 16 16 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES PPO [308136801] 12.8 percent of total billed charges 9.92 15.2 Technical (Hospital) Services HC/HH Wch Supp Drssng Combiderm Acd 4x 4__651031 PX-2725000048 CDM 2725000048 LOCAL 272 RC outpatient 16 16 HEALTHPARTNERS SX009 HEALTHPARTNERS 12.8 percent of total billed charges 9.92 15.2 Technical (Hospital) Services HC/HH Wch Supp Drssng Combiderm Acd 4x 4__651031 PX-2725000048 CDM 2725000048 LOCAL 272 RC outpatient 16 16 UNITED HEALTHCARE (COMMERCIAL) [3081199] UNITED HEALTHCARE 87726 [308119901] 9.92 percent of total billed charges 9.92 15.2 Technical (Hospital) Services HC/HH Wch Supp Drssng Combiderm Acd 4x 4__651031 PX-2725000048 CDM 2725000048 LOCAL 272 RC inpatient 16 16 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES EPO [308136803] 12.67 percent of total billed charges 9.92 15.2 Technical (Hospital) Services HC/HH Wch Supp Drssng Combiderm Acd 4x 4__651031 PX-2725000048 CDM 2725000048 LOCAL 272 RC inpatient 16 16 HEALTHPARTNERS SX009 HEALTHPARTNERS 12.67 percent of total billed charges 9.92 15.2 Technical (Hospital) Services HC/HH Wch Supp Drssng Combiderm Acd 4x 4__651031 PX-2725000048 CDM 2725000048 LOCAL 272 RC inpatient 16 16 MULTIPLAN INC 34080 [3081285] MULTIPLAN INC [308128501] 15.2 percent of total billed charges 9.92 15.2 Technical (Hospital) Services HC/HH Wch Supp Drssng Combiderm Acd 4x 4__651031 PX-2725000048 CDM 2725000048 LOCAL 272 RC inpatient 16 16 BLUE CROSS BLUE SHIELD WELLMARK SB889 [3081026] BCBS WYOMING [308102603] 15.2 percent of total billed charges 9.92 15.2 Technical (Hospital) Services HC/HH Wch Supp Drssng Combiderm Acd 4x 4__651031 PX-2725000048 CDM 2725000048 LOCAL 272 RC inpatient 16 16 CIGNA 62308 [3081051] CIGNA 62308 [308105105] 12.67 percent of total billed charges 9.92 15.2 Technical (Hospital) Services HC/HH Wch Supp Drssng Combiderm Acd 4x 4__651031 PX-2725000048 CDM 2725000048 LOCAL 272 RC inpatient 16 16 CIGNA 62308 [3081051] CIGNA STATE OF WYOMING [308105107] 12.67 percent of total billed charges 9.92 15.2 Technical (Hospital) Services HC/HH Wch Supp Drssng Combiderm Acd 4x 4__651031 PX-2725000048 CDM 2725000048 LOCAL 272 RC inpatient 16 16 MEDICA (COMMERCIAL) 94265 [3081118] MEDICA CLAIMS [308111801] 14.4 percent of total billed charges 9.92 15.2 Technical (Hospital) Services HC/HH Wch Supp Drssng Combiderm Acd 4x 4__651031 PX-2725000048 CDM 2725000048 LOCAL 272 RC inpatient 16 16 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES PPO [308136801] 12.67 percent of total billed charges 9.92 15.2 Technical (Hospital) Services HC/HH Wch Supp Drssng Combiderm Acd 4x 4__651031 PX-2725000048 CDM 2725000048 LOCAL 272 RC inpatient 16 16 UNITED HEALTHCARE (COMMERCIAL) [3081199] UNITED HEALTHCARE 87726 [308119901] 9.92 percent of total billed charges 9.92 15.2 Technical (Hospital) Services HC/HH Wch Supp Drssng Combiderm Acd 4x 4__651031 PX-2725000048 CDM 2725000048 LOCAL 272 RC inpatient 16 16 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES HDHP [308136802] 12.67 percent of total billed charges 9.92 15.2 Technical (Hospital) Services HC/HH Wch Supp Drssng Combiderm Acd 6x7__651027 PX-2725000047 CDM 2725000047 LOCAL 272 RC inpatient 22 22 UNITED HEALTHCARE (COMMERCIAL) [3081199] UNITED HEALTHCARE 87726 [308119901] 13.64 percent of total billed charges 13.64 20.9 Technical (Hospital) Services HC/HH Wch Supp Drssng Combiderm Acd 6x7__651027 PX-2725000047 CDM 2725000047 LOCAL 272 RC inpatient 22 22 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES HDHP [308136802] 17.42 percent of total billed charges 13.64 20.9 Technical (Hospital) Services HC/HH Wch Supp Drssng Combiderm Acd 6x7__651027 PX-2725000047 CDM 2725000047 LOCAL 272 RC inpatient 22 22 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES PPO [308136801] 17.42 percent of total billed charges 13.64 20.9 Technical (Hospital) Services HC/HH Wch Supp Drssng Combiderm Acd 6x7__651027 PX-2725000047 CDM 2725000047 LOCAL 272 RC inpatient 22 22 MEDICA (COMMERCIAL) 94265 [3081118] MEDICA CLAIMS [308111801] 19.8 percent of total billed charges 13.64 20.9 Technical (Hospital) Services HC/HH Wch Supp Drssng Combiderm Acd 6x7__651027 PX-2725000047 CDM 2725000047 LOCAL 272 RC inpatient 22 22 MULTIPLAN INC 34080 [3081285] MULTIPLAN INC [308128501] 20.9 percent of total billed charges 13.64 20.9 Technical (Hospital) Services HC/HH Wch Supp Drssng Combiderm Acd 6x7__651027 PX-2725000047 CDM 2725000047 LOCAL 272 RC inpatient 22 22 BLUE CROSS BLUE SHIELD WELLMARK SB889 [3081026] BCBS WYOMING [308102603] 20.9 percent of total billed charges 13.64 20.9 Technical (Hospital) Services HC/HH Wch Supp Drssng Combiderm Acd 6x7__651027 PX-2725000047 CDM 2725000047 LOCAL 272 RC inpatient 22 22 CIGNA 62308 [3081051] CIGNA 62308 [308105105] 17.42 percent of total billed charges 13.64 20.9 Technical (Hospital) Services HC/HH Wch Supp Drssng Combiderm Acd 6x7__651027 PX-2725000047 CDM 2725000047 LOCAL 272 RC inpatient 22 22 CIGNA 62308 [3081051] CIGNA STATE OF WYOMING [308105107] 17.42 percent of total billed charges 13.64 20.9 Technical (Hospital) Services HC/HH Wch Supp Drssng Combiderm Acd 6x7__651027 PX-2725000047 CDM 2725000047 LOCAL 272 RC inpatient 22 22 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES EPO [308136803] 17.42 percent of total billed charges 13.64 20.9 Technical (Hospital) Services HC/HH Wch Supp Drssng Combiderm Acd 6x7__651027 PX-2725000047 CDM 2725000047 LOCAL 272 RC inpatient 22 22 HEALTHPARTNERS SX009 HEALTHPARTNERS 17.42 percent of total billed charges 13.64 20.9 Technical (Hospital) Services HC/HH Wch Supp Drssng Combiderm Acd 6x7__651027 PX-2725000047 CDM 2725000047 LOCAL 272 RC outpatient 22 22 BLUE CROSS BLUE SHIELD WELLMARK SB889 [3081026] BCBS WYOMING [308102603] 20.9 percent of total billed charges 13.64 20.9 Technical (Hospital) Services HC/HH Wch Supp Drssng Combiderm Acd 6x7__651027 PX-2725000047 CDM 2725000047 LOCAL 272 RC outpatient 22 22 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES EPO [308136803] 17.6 percent of total billed charges 13.64 20.9 Technical (Hospital) Services HC/HH Wch Supp Drssng Combiderm Acd 6x7__651027 PX-2725000047 CDM 2725000047 LOCAL 272 RC outpatient 22 22 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES HDHP [308136802] 17.6 percent of total billed charges 13.64 20.9 Technical (Hospital) Services HC/HH Wch Supp Drssng Combiderm Acd 6x7__651027 PX-2725000047 CDM 2725000047 LOCAL 272 RC outpatient 22 22 UNITED HEALTHCARE (COMMERCIAL) [3081199] UNITED HEALTHCARE 87726 [308119901] 13.64 percent of total billed charges 13.64 20.9 Technical (Hospital) Services HC/HH Wch Supp Drssng Combiderm Acd 6x7__651027 PX-2725000047 CDM 2725000047 LOCAL 272 RC outpatient 22 22 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES PPO [308136801] 17.6 percent of total billed charges 13.64 20.9 Technical (Hospital) Services HC/HH Wch Supp Drssng Combiderm Acd 6x7__651027 PX-2725000047 CDM 2725000047 LOCAL 272 RC outpatient 22 22 HEALTHPARTNERS SX009 HEALTHPARTNERS 17.6 percent of total billed charges 13.64 20.9 Technical (Hospital) Services HC/HH Wch Supp Drssng Combiderm Acd 6x7__651027 PX-2725000047 CDM 2725000047 LOCAL 272 RC outpatient 22 22 CIGNA 62308 [3081051] CIGNA 62308 [308105105] 17.6 percent of total billed charges 13.64 20.9 Technical (Hospital) Services HC/HH Wch Supp Drssng Combiderm Acd 6x7__651027 PX-2725000047 CDM 2725000047 LOCAL 272 RC outpatient 22 22 CIGNA 62308 [3081051] CIGNA STATE OF WYOMING [308105107] 17.6 percent of total billed charges 13.64 20.9 Technical (Hospital) Services HC/HH Wch Supp Drssng Combiderm Acd 6x7__651027 PX-2725000047 CDM 2725000047 LOCAL 272 RC outpatient 22 22 MEDICA (COMMERCIAL) 94265 [3081118] MEDICA CLAIMS [308111801] 19.8 percent of total billed charges 13.64 20.9 Technical (Hospital) Services HC/HH Wch Supp Drssng Combiderm Acd 6x7__651027 PX-2725000047 CDM 2725000047 LOCAL 272 RC outpatient 22 22 MULTIPLAN INC 34080 [3081285] MULTIPLAN INC [308128501] 20.9 percent of total billed charges 13.64 20.9 Technical (Hospital) Services HC/HH Wch Supp Drssng Combiderm Acd 5x5__187725 PX-2725000046 CDM 2725000046 LOCAL 272 RC outpatient 22 22 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES PPO [308136801] 17.6 percent of total billed charges 13.64 20.9 Technical (Hospital) Services HC/HH Wch Supp Drssng Combiderm Acd 5x5__187725 PX-2725000046 CDM 2725000046 LOCAL 272 RC outpatient 22 22 MULTIPLAN INC 34080 [3081285] MULTIPLAN INC [308128501] 20.9 percent of total billed charges 13.64 20.9 Technical (Hospital) Services HC/HH Wch Supp Drssng Combiderm Acd 5x5__187725 PX-2725000046 CDM 2725000046 LOCAL 272 RC outpatient 22 22 MEDICA (COMMERCIAL) 94265 [3081118] MEDICA CLAIMS [308111801] 19.8 percent of total billed charges 13.64 20.9 Technical (Hospital) Services HC/HH Wch Supp Drssng Combiderm Acd 5x5__187725 PX-2725000046 CDM 2725000046 LOCAL 272 RC outpatient 22 22 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES HDHP [308136802] 17.6 percent of total billed charges 13.64 20.9 Technical (Hospital) Services HC/HH Wch Supp Drssng Combiderm Acd 5x5__187725 PX-2725000046 CDM 2725000046 LOCAL 272 RC outpatient 22 22 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES EPO [308136803] 17.6 percent of total billed charges 13.64 20.9 Technical (Hospital) Services HC/HH Wch Supp Drssng Combiderm Acd 5x5__187725 PX-2725000046 CDM 2725000046 LOCAL 272 RC outpatient 22 22 BLUE CROSS BLUE SHIELD WELLMARK SB889 [3081026] BCBS WYOMING [308102603] 20.9 percent of total billed charges 13.64 20.9 Technical (Hospital) Services HC/HH Wch Supp Drssng Combiderm Acd 5x5__187725 PX-2725000046 CDM 2725000046 LOCAL 272 RC outpatient 22 22 HEALTHPARTNERS SX009 HEALTHPARTNERS 17.6 percent of total billed charges 13.64 20.9 Technical (Hospital) Services HC/HH Wch Supp Drssng Combiderm Acd 5x5__187725 PX-2725000046 CDM 2725000046 LOCAL 272 RC outpatient 22 22 UNITED HEALTHCARE (COMMERCIAL) [3081199] UNITED HEALTHCARE 87726 [308119901] 13.64 percent of total billed charges 13.64 20.9 Technical (Hospital) Services HC/HH Wch Supp Drssng Combiderm Acd 5x5__187725 PX-2725000046 CDM 2725000046 LOCAL 272 RC outpatient 22 22 CIGNA 62308 [3081051] CIGNA 62308 [308105105] 17.6 percent of total billed charges 13.64 20.9 Technical (Hospital) Services HC/HH Wch Supp Drssng Combiderm Acd 5x5__187725 PX-2725000046 CDM 2725000046 LOCAL 272 RC outpatient 22 22 CIGNA 62308 [3081051] CIGNA STATE OF WYOMING [308105107] 17.6 percent of total billed charges 13.64 20.9 Technical (Hospital) Services HC/HH Wch Supp Drssng Combiderm Acd 5x5__187725 PX-2725000046 CDM 2725000046 LOCAL 272 RC inpatient 22 22 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES HDHP [308136802] 17.42 percent of total billed charges 13.64 20.9 Technical (Hospital) Services HC/HH Wch Supp Drssng Combiderm Acd 5x5__187725 PX-2725000046 CDM 2725000046 LOCAL 272 RC inpatient 22 22 UNITED HEALTHCARE (COMMERCIAL) [3081199] UNITED HEALTHCARE 87726 [308119901] 13.64 percent of total billed charges 13.64 20.9 Technical (Hospital) Services HC/HH Wch Supp Drssng Combiderm Acd 5x5__187725 PX-2725000046 CDM 2725000046 LOCAL 272 RC inpatient 22 22 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES PPO [308136801] 17.42 percent of total billed charges 13.64 20.9 Technical (Hospital) Services HC/HH Wch Supp Drssng Combiderm Acd 5x5__187725 PX-2725000046 CDM 2725000046 LOCAL 272 RC inpatient 22 22 MEDICA (COMMERCIAL) 94265 [3081118] MEDICA CLAIMS [308111801] 19.8 percent of total billed charges 13.64 20.9 Technical (Hospital) Services HC/HH Wch Supp Drssng Combiderm Acd 5x5__187725 PX-2725000046 CDM 2725000046 LOCAL 272 RC inpatient 22 22 CIGNA 62308 [3081051] CIGNA 62308 [308105105] 17.42 percent of total billed charges 13.64 20.9 Technical (Hospital) Services HC/HH Wch Supp Drssng Combiderm Acd 5x5__187725 PX-2725000046 CDM 2725000046 LOCAL 272 RC inpatient 22 22 CIGNA 62308 [3081051] CIGNA STATE OF WYOMING [308105107] 17.42 percent of total billed charges 13.64 20.9 Technical (Hospital) Services HC/HH Wch Supp Drssng Combiderm Acd 5x5__187725 PX-2725000046 CDM 2725000046 LOCAL 272 RC inpatient 22 22 MULTIPLAN INC 34080 [3081285] MULTIPLAN INC [308128501] 20.9 percent of total billed charges 13.64 20.9 Technical (Hospital) Services HC/HH Wch Supp Drssng Combiderm Acd 5x5__187725 PX-2725000046 CDM 2725000046 LOCAL 272 RC inpatient 22 22 BLUE CROSS BLUE SHIELD WELLMARK SB889 [3081026] BCBS WYOMING [308102603] 20.9 percent of total billed charges 13.64 20.9 Technical (Hospital) Services HC/HH Wch Supp Drssng Combiderm Acd 5x5__187725 PX-2725000046 CDM 2725000046 LOCAL 272 RC inpatient 22 22 HEALTHPARTNERS SX009 HEALTHPARTNERS 17.42 percent of total billed charges 13.64 20.9 Technical (Hospital) Services HC/HH Wch Supp Drssng Combiderm Acd 5x5__187725 PX-2725000046 CDM 2725000046 LOCAL 272 RC inpatient 22 22 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES EPO [308136803] 17.42 percent of total billed charges 13.64 20.9 Technical (Hospital) Services HC/HH Wch Supp Drssing Tegaderm 4x4.75__1626w PX-2725000045 CDM 2725000045 LOCAL 272 RC inpatient 6 6 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES EPO [308136803] 4.75 percent of total billed charges 3.72 5.7 Technical (Hospital) Services HC/HH Wch Supp Drssing Tegaderm 4x4.75__1626w PX-2725000045 CDM 2725000045 LOCAL 272 RC inpatient 6 6 CIGNA 62308 [3081051] CIGNA 62308 [308105105] 4.75 percent of total billed charges 3.72 5.7 Technical (Hospital) Services HC/HH Wch Supp Drssing Tegaderm 4x4.75__1626w PX-2725000045 CDM 2725000045 LOCAL 272 RC inpatient 6 6 CIGNA 62308 [3081051] CIGNA STATE OF WYOMING [308105107] 4.75 percent of total billed charges 3.72 5.7 Technical (Hospital) Services HC/HH Wch Supp Drssing Tegaderm 4x4.75__1626w PX-2725000045 CDM 2725000045 LOCAL 272 RC inpatient 6 6 HEALTHPARTNERS SX009 HEALTHPARTNERS 4.75 percent of total billed charges 3.72 5.7 Technical (Hospital) Services HC/HH Wch Supp Drssing Tegaderm 4x4.75__1626w PX-2725000045 CDM 2725000045 LOCAL 272 RC inpatient 6 6 MULTIPLAN INC 34080 [3081285] MULTIPLAN INC [308128501] 5.7 percent of total billed charges 3.72 5.7 Technical (Hospital) Services HC/HH Wch Supp Drssing Tegaderm 4x4.75__1626w PX-2725000045 CDM 2725000045 LOCAL 272 RC inpatient 6 6 BLUE CROSS BLUE SHIELD WELLMARK SB889 [3081026] BCBS WYOMING [308102603] 5.7 percent of total billed charges 3.72 5.7 Technical (Hospital) Services HC/HH Wch Supp Drssing Tegaderm 4x4.75__1626w PX-2725000045 CDM 2725000045 LOCAL 272 RC inpatient 6 6 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES HDHP [308136802] 4.75 percent of total billed charges 3.72 5.7 Technical (Hospital) Services HC/HH Wch Supp Drssing Tegaderm 4x4.75__1626w PX-2725000045 CDM 2725000045 LOCAL 272 RC inpatient 6 6 UNITED HEALTHCARE (COMMERCIAL) [3081199] UNITED HEALTHCARE 87726 [308119901] 3.72 percent of total billed charges 3.72 5.7 Technical (Hospital) Services HC/HH Wch Supp Drssing Tegaderm 4x4.75__1626w PX-2725000045 CDM 2725000045 LOCAL 272 RC inpatient 6 6 MEDICA (COMMERCIAL) 94265 [3081118] MEDICA CLAIMS [308111801] 5.4 percent of total billed charges 3.72 5.7 Technical (Hospital) Services HC/HH Wch Supp Drssing Tegaderm 4x4.75__1626w PX-2725000045 CDM 2725000045 LOCAL 272 RC inpatient 6 6 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES PPO [308136801] 4.75 percent of total billed charges 3.72 5.7 Technical (Hospital) Services HC/HH Wch Supp Drssing Tegaderm 4x4.75__1626w PX-2725000045 CDM 2725000045 LOCAL 272 RC outpatient 6 6 BLUE CROSS BLUE SHIELD WELLMARK SB889 [3081026] BCBS WYOMING [308102603] 5.7 percent of total billed charges 3.72 5.7 Technical (Hospital) Services HC/HH Wch Supp Drssing Tegaderm 4x4.75__1626w PX-2725000045 CDM 2725000045 LOCAL 272 RC outpatient 6 6 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES EPO [308136803] 4.8 percent of total billed charges 3.72 5.7 Technical (Hospital) Services HC/HH Wch Supp Drssing Tegaderm 4x4.75__1626w PX-2725000045 CDM 2725000045 LOCAL 272 RC outpatient 6 6 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES HDHP [308136802] 4.8 percent of total billed charges 3.72 5.7 Technical (Hospital) Services HC/HH Wch Supp Drssing Tegaderm 4x4.75__1626w PX-2725000045 CDM 2725000045 LOCAL 272 RC outpatient 6 6 CIGNA 62308 [3081051] CIGNA 62308 [308105105] 4.8 percent of total billed charges 3.72 5.7 Technical (Hospital) Services HC/HH Wch Supp Drssing Tegaderm 4x4.75__1626w PX-2725000045 CDM 2725000045 LOCAL 272 RC outpatient 6 6 CIGNA 62308 [3081051] CIGNA STATE OF WYOMING [308105107] 4.8 percent of total billed charges 3.72 5.7 Technical (Hospital) Services HC/HH Wch Supp Drssing Tegaderm 4x4.75__1626w PX-2725000045 CDM 2725000045 LOCAL 272 RC outpatient 6 6 UNITED HEALTHCARE (COMMERCIAL) [3081199] UNITED HEALTHCARE 87726 [308119901] 3.72 percent of total billed charges 3.72 5.7 Technical (Hospital) Services HC/HH Wch Supp Drssing Tegaderm 4x4.75__1626w PX-2725000045 CDM 2725000045 LOCAL 272 RC outpatient 6 6 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES PPO [308136801] 4.8 percent of total billed charges 3.72 5.7 Technical (Hospital) Services HC/HH Wch Supp Drssing Tegaderm 4x4.75__1626w PX-2725000045 CDM 2725000045 LOCAL 272 RC outpatient 6 6 HEALTHPARTNERS SX009 HEALTHPARTNERS 4.8 percent of total billed charges 3.72 5.7 Technical (Hospital) Services HC/HH Wch Supp Drssing Tegaderm 4x4.75__1626w PX-2725000045 CDM 2725000045 LOCAL 272 RC outpatient 6 6 MULTIPLAN INC 34080 [3081285] MULTIPLAN INC [308128501] 5.7 percent of total billed charges 3.72 5.7 Technical (Hospital) Services HC/HH Wch Supp Drssing Tegaderm 4x4.75__1626w PX-2725000045 CDM 2725000045 LOCAL 272 RC outpatient 6 6 MEDICA (COMMERCIAL) 94265 [3081118] MEDICA CLAIMS [308111801] 5.4 percent of total billed charges 3.72 5.7 Technical (Hospital) Services HC/HH Wch Supp Drssing Tegaderm 2.38x2.75__1624w PX-2725000044 CDM 2725000044 LOCAL 272 RC outpatient 6 6 UNITED HEALTHCARE (COMMERCIAL) [3081199] UNITED HEALTHCARE 87726 [308119901] 3.72 percent of total billed charges 3.72 5.7 Technical (Hospital) Services HC/HH Wch Supp Drssing Tegaderm 2.38x2.75__1624w PX-2725000044 CDM 2725000044 LOCAL 272 RC outpatient 6 6 HEALTHPARTNERS SX009 HEALTHPARTNERS 4.8 percent of total billed charges 3.72 5.7 Technical (Hospital) Services HC/HH Wch Supp Drssing Tegaderm 2.38x2.75__1624w PX-2725000044 CDM 2725000044 LOCAL 272 RC outpatient 6 6 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES PPO [308136801] 4.8 percent of total billed charges 3.72 5.7 Technical (Hospital) Services HC/HH Wch Supp Drssing Tegaderm 2.38x2.75__1624w PX-2725000044 CDM 2725000044 LOCAL 272 RC outpatient 6 6 CIGNA 62308 [3081051] CIGNA STATE OF WYOMING [308105107] 4.8 percent of total billed charges 3.72 5.7 Technical (Hospital) Services HC/HH Wch Supp Drssing Tegaderm 2.38x2.75__1624w PX-2725000044 CDM 2725000044 LOCAL 272 RC outpatient 6 6 CIGNA 62308 [3081051] CIGNA 62308 [308105105] 4.8 percent of total billed charges 3.72 5.7 Technical (Hospital) Services HC/HH Wch Supp Drssing Tegaderm 2.38x2.75__1624w PX-2725000044 CDM 2725000044 LOCAL 272 RC outpatient 6 6 BLUE CROSS BLUE SHIELD WELLMARK SB889 [3081026] BCBS WYOMING [308102603] 5.7 percent of total billed charges 3.72 5.7 Technical (Hospital) Services HC/HH Wch Supp Drssing Tegaderm 2.38x2.75__1624w PX-2725000044 CDM 2725000044 LOCAL 272 RC outpatient 6 6 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES EPO [308136803] 4.8 percent of total billed charges 3.72 5.7 Technical (Hospital) Services HC/HH Wch Supp Drssing Tegaderm 2.38x2.75__1624w PX-2725000044 CDM 2725000044 LOCAL 272 RC outpatient 6 6 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES HDHP [308136802] 4.8 percent of total billed charges 3.72 5.7 Technical (Hospital) Services HC/HH Wch Supp Drssing Tegaderm 2.38x2.75__1624w PX-2725000044 CDM 2725000044 LOCAL 272 RC outpatient 6 6 MEDICA (COMMERCIAL) 94265 [3081118] MEDICA CLAIMS [308111801] 5.4 percent of total billed charges 3.72 5.7 Technical (Hospital) Services HC/HH Wch Supp Drssing Tegaderm 2.38x2.75__1624w PX-2725000044 CDM 2725000044 LOCAL 272 RC outpatient 6 6 MULTIPLAN INC 34080 [3081285] MULTIPLAN INC [308128501] 5.7 percent of total billed charges 3.72 5.7 Technical (Hospital) Services HC/HH Wch Supp Drssing Tegaderm 2.38x2.75__1624w PX-2725000044 CDM 2725000044 LOCAL 272 RC inpatient 6 6 MEDICA (COMMERCIAL) 94265 [3081118] MEDICA CLAIMS [308111801] 5.4 percent of total billed charges 3.72 5.7 Technical (Hospital) Services HC/HH Wch Supp Drssing Tegaderm 2.38x2.75__1624w PX-2725000044 CDM 2725000044 LOCAL 272 RC inpatient 6 6 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES PPO [308136801] 4.75 percent of total billed charges 3.72 5.7 Technical (Hospital) Services HC/HH Wch Supp Drssing Tegaderm 2.38x2.75__1624w PX-2725000044 CDM 2725000044 LOCAL 272 RC inpatient 6 6 UNITED HEALTHCARE (COMMERCIAL) [3081199] UNITED HEALTHCARE 87726 [308119901] 3.72 percent of total billed charges 3.72 5.7 Technical (Hospital) Services HC/HH Wch Supp Drssing Tegaderm 2.38x2.75__1624w PX-2725000044 CDM 2725000044 LOCAL 272 RC inpatient 6 6 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES HDHP [308136802] 4.75 percent of total billed charges 3.72 5.7 Technical (Hospital) Services HC/HH Wch Supp Drssing Tegaderm 2.38x2.75__1624w PX-2725000044 CDM 2725000044 LOCAL 272 RC inpatient 6 6 HEALTHPARTNERS SX009 HEALTHPARTNERS 4.75 percent of total billed charges 3.72 5.7 Technical (Hospital) Services HC/HH Wch Supp Drssing Tegaderm 2.38x2.75__1624w PX-2725000044 CDM 2725000044 LOCAL 272 RC inpatient 6 6 BLUE CROSS BLUE SHIELD WELLMARK SB889 [3081026] BCBS WYOMING [308102603] 5.7 percent of total billed charges 3.72 5.7 Technical (Hospital) Services HC/HH Wch Supp Drssing Tegaderm 2.38x2.75__1624w PX-2725000044 CDM 2725000044 LOCAL 272 RC inpatient 6 6 MULTIPLAN INC 34080 [3081285] MULTIPLAN INC [308128501] 5.7 percent of total billed charges 3.72 5.7 Technical (Hospital) Services HC/HH Wch Supp Drssing Tegaderm 2.38x2.75__1624w PX-2725000044 CDM 2725000044 LOCAL 272 RC inpatient 6 6 CIGNA 62308 [3081051] CIGNA 62308 [308105105] 4.75 percent of total billed charges 3.72 5.7 Technical (Hospital) Services HC/HH Wch Supp Drssing Tegaderm 2.38x2.75__1624w PX-2725000044 CDM 2725000044 LOCAL 272 RC inpatient 6 6 CIGNA 62308 [3081051] CIGNA STATE OF WYOMING [308105107] 4.75 percent of total billed charges 3.72 5.7 Technical (Hospital) Services HC/HH Wch Supp Drssing Tegaderm 2.38x2.75__1624w PX-2725000044 CDM 2725000044 LOCAL 272 RC inpatient 6 6 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES EPO [308136803] 4.75 percent of total billed charges 3.72 5.7 Technical (Hospital) Services HC/HH Wch Supp Drssing Adptc St Non-Adh 3x3__2012 PX-2725000043 CDM 2725000043 LOCAL 272 RC inpatient 6 6 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES PPO [308136801] 4.75 percent of total billed charges 3.72 5.7 Technical (Hospital) Services HC/HH Wch Supp Drssing Adptc St Non-Adh 3x3__2012 PX-2725000043 CDM 2725000043 LOCAL 272 RC inpatient 6 6 MEDICA (COMMERCIAL) 94265 [3081118] MEDICA CLAIMS [308111801] 5.4 percent of total billed charges 3.72 5.7 Technical (Hospital) Services HC/HH Wch Supp Drssing Adptc St Non-Adh 3x3__2012 PX-2725000043 CDM 2725000043 LOCAL 272 RC inpatient 6 6 UNITED HEALTHCARE (COMMERCIAL) [3081199] UNITED HEALTHCARE 87726 [308119901] 3.72 percent of total billed charges 3.72 5.7 Technical (Hospital) Services HC/HH Wch Supp Drssing Adptc St Non-Adh 3x3__2012 PX-2725000043 CDM 2725000043 LOCAL 272 RC inpatient 6 6 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES HDHP [308136802] 4.75 percent of total billed charges 3.72 5.7 Technical (Hospital) Services HC/HH Wch Supp Drssing Adptc St Non-Adh 3x3__2012 PX-2725000043 CDM 2725000043 LOCAL 272 RC inpatient 6 6 MULTIPLAN INC 34080 [3081285] MULTIPLAN INC [308128501] 5.7 percent of total billed charges 3.72 5.7 Technical (Hospital) Services HC/HH Wch Supp Drssing Adptc St Non-Adh 3x3__2012 PX-2725000043 CDM 2725000043 LOCAL 272 RC inpatient 6 6 BLUE CROSS BLUE SHIELD WELLMARK SB889 [3081026] BCBS WYOMING [308102603] 5.7 percent of total billed charges 3.72 5.7 Technical (Hospital) Services HC/HH Wch Supp Drssing Adptc St Non-Adh 3x3__2012 PX-2725000043 CDM 2725000043 LOCAL 272 RC inpatient 6 6 CIGNA 62308 [3081051] CIGNA 62308 [308105105] 4.75 percent of total billed charges 3.72 5.7 Technical (Hospital) Services HC/HH Wch Supp Drssing Adptc St Non-Adh 3x3__2012 PX-2725000043 CDM 2725000043 LOCAL 272 RC inpatient 6 6 CIGNA 62308 [3081051] CIGNA STATE OF WYOMING [308105107] 4.75 percent of total billed charges 3.72 5.7 Technical (Hospital) Services HC/HH Wch Supp Drssing Adptc St Non-Adh 3x3__2012 PX-2725000043 CDM 2725000043 LOCAL 272 RC inpatient 6 6 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES EPO [308136803] 4.75 percent of total billed charges 3.72 5.7 Technical (Hospital) Services HC/HH Wch Supp Drssing Adptc St Non-Adh 3x3__2012 PX-2725000043 CDM 2725000043 LOCAL 272 RC inpatient 6 6 HEALTHPARTNERS SX009 HEALTHPARTNERS 4.75 percent of total billed charges 3.72 5.7 Technical (Hospital) Services HC/HH Wch Supp Drssing Adptc St Non-Adh 3x3__2012 PX-2725000043 CDM 2725000043 LOCAL 272 RC outpatient 6 6 MEDICA (COMMERCIAL) 94265 [3081118] MEDICA CLAIMS [308111801] 5.4 percent of total billed charges 3.72 5.7 Technical (Hospital) Services HC/HH Wch Supp Drssing Adptc St Non-Adh 3x3__2012 PX-2725000043 CDM 2725000043 LOCAL 272 RC outpatient 6 6 MULTIPLAN INC 34080 [3081285] MULTIPLAN INC [308128501] 5.7 percent of total billed charges 3.72 5.7 Technical (Hospital) Services HC/HH Wch Supp Drssing Adptc St Non-Adh 3x3__2012 PX-2725000043 CDM 2725000043 LOCAL 272 RC outpatient 6 6 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES PPO [308136801] 4.8 percent of total billed charges 3.72 5.7 Technical (Hospital) Services HC/HH Wch Supp Drssing Adptc St Non-Adh 3x3__2012 PX-2725000043 CDM 2725000043 LOCAL 272 RC outpatient 6 6 HEALTHPARTNERS SX009 HEALTHPARTNERS 4.8 percent of total billed charges 3.72 5.7 Technical (Hospital) Services HC/HH Wch Supp Drssing Adptc St Non-Adh 3x3__2012 PX-2725000043 CDM 2725000043 LOCAL 272 RC outpatient 6 6 CIGNA 62308 [3081051] CIGNA 62308 [308105105] 4.8 percent of total billed charges 3.72 5.7 Technical (Hospital) Services HC/HH Wch Supp Drssing Adptc St Non-Adh 3x3__2012 PX-2725000043 CDM 2725000043 LOCAL 272 RC outpatient 6 6 CIGNA 62308 [3081051] CIGNA STATE OF WYOMING [308105107] 4.8 percent of total billed charges 3.72 5.7 Technical (Hospital) Services HC/HH Wch Supp Drssing Adptc St Non-Adh 3x3__2012 PX-2725000043 CDM 2725000043 LOCAL 272 RC outpatient 6 6 UNITED HEALTHCARE (COMMERCIAL) [3081199] UNITED HEALTHCARE 87726 [308119901] 3.72 percent of total billed charges 3.72 5.7 Technical (Hospital) Services HC/HH Wch Supp Drssing Adptc St Non-Adh 3x3__2012 PX-2725000043 CDM 2725000043 LOCAL 272 RC outpatient 6 6 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES EPO [308136803] 4.8 percent of total billed charges 3.72 5.7 Technical (Hospital) Services HC/HH Wch Supp Drssing Adptc St Non-Adh 3x3__2012 PX-2725000043 CDM 2725000043 LOCAL 272 RC outpatient 6 6 BLUE CROSS BLUE SHIELD WELLMARK SB889 [3081026] BCBS WYOMING [308102603] 5.7 percent of total billed charges 3.72 5.7 Technical (Hospital) Services HC/HH Wch Supp Drssing Adptc St Non-Adh 3x3__2012 PX-2725000043 CDM 2725000043 LOCAL 272 RC outpatient 6 6 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES HDHP [308136802] 4.8 percent of total billed charges 3.72 5.7 Technical (Hospital) Services HC/HH Wch Supp Dressing Non Adhesive 3x16__6114 PX-2725000042 CDM 2725000042 LOCAL 272 RC inpatient 9 9 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES PPO [308136801] 7.13 percent of total billed charges 5.58 8.55 Technical (Hospital) Services HC/HH Wch Supp Dressing Non Adhesive 3x16__6114 PX-2725000042 CDM 2725000042 LOCAL 272 RC inpatient 9 9 MEDICA (COMMERCIAL) 94265 [3081118] MEDICA CLAIMS [308111801] 8.1 percent of total billed charges 5.58 8.55 Technical (Hospital) Services HC/HH Wch Supp Dressing Non Adhesive 3x16__6114 PX-2725000042 CDM 2725000042 LOCAL 272 RC inpatient 9 9 UNITED HEALTHCARE (COMMERCIAL) [3081199] UNITED HEALTHCARE 87726 [308119901] 5.58 percent of total billed charges 5.58 8.55 Technical (Hospital) Services HC/HH Wch Supp Dressing Non Adhesive 3x16__6114 PX-2725000042 CDM 2725000042 LOCAL 272 RC inpatient 9 9 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES HDHP [308136802] 7.13 percent of total billed charges 5.58 8.55 Technical (Hospital) Services HC/HH Wch Supp Dressing Non Adhesive 3x16__6114 PX-2725000042 CDM 2725000042 LOCAL 272 RC inpatient 9 9 BLUE CROSS BLUE SHIELD WELLMARK SB889 [3081026] BCBS WYOMING [308102603] 8.55 percent of total billed charges 5.58 8.55 Technical (Hospital) Services HC/HH Wch Supp Dressing Non Adhesive 3x16__6114 PX-2725000042 CDM 2725000042 LOCAL 272 RC inpatient 9 9 MULTIPLAN INC 34080 [3081285] MULTIPLAN INC [308128501] 8.55 percent of total billed charges 5.58 8.55 Technical (Hospital) Services HC/HH Wch Supp Dressing Non Adhesive 3x16__6114 PX-2725000042 CDM 2725000042 LOCAL 272 RC inpatient 9 9 HEALTHPARTNERS SX009 HEALTHPARTNERS 7.13 percent of total billed charges 5.58 8.55 Technical (Hospital) Services HC/HH Wch Supp Dressing Non Adhesive 3x16__6114 PX-2725000042 CDM 2725000042 LOCAL 272 RC inpatient 9 9 CIGNA 62308 [3081051] CIGNA 62308 [308105105] 7.13 percent of total billed charges 5.58 8.55 Technical (Hospital) Services HC/HH Wch Supp Dressing Non Adhesive 3x16__6114 PX-2725000042 CDM 2725000042 LOCAL 272 RC inpatient 9 9 CIGNA 62308 [3081051] CIGNA STATE OF WYOMING [308105107] 7.13 percent of total billed charges 5.58 8.55 Technical (Hospital) Services HC/HH Wch Supp Dressing Non Adhesive 3x16__6114 PX-2725000042 CDM 2725000042 LOCAL 272 RC inpatient 9 9 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES EPO [308136803] 7.13 percent of total billed charges 5.58 8.55 Technical (Hospital) Services HC/HH Wch Supp Dressing Non Adhesive 3x16__6114 PX-2725000042 CDM 2725000042 LOCAL 272 RC outpatient 9 9 CIGNA 62308 [3081051] CIGNA 62308 [308105105] 7.2 percent of total billed charges 5.58 8.55 Technical (Hospital) Services HC/HH Wch Supp Dressing Non Adhesive 3x16__6114 PX-2725000042 CDM 2725000042 LOCAL 272 RC outpatient 9 9 CIGNA 62308 [3081051] CIGNA STATE OF WYOMING [308105107] 7.2 percent of total billed charges 5.58 8.55 Technical (Hospital) Services HC/HH Wch Supp Dressing Non Adhesive 3x16__6114 PX-2725000042 CDM 2725000042 LOCAL 272 RC outpatient 9 9 UNITED HEALTHCARE (COMMERCIAL) [3081199] UNITED HEALTHCARE 87726 [308119901] 5.58 percent of total billed charges 5.58 8.55 Technical (Hospital) Services HC/HH Wch Supp Dressing Non Adhesive 3x16__6114 PX-2725000042 CDM 2725000042 LOCAL 272 RC outpatient 9 9 HEALTHPARTNERS SX009 HEALTHPARTNERS 7.2 percent of total billed charges 5.58 8.55 Technical (Hospital) Services HC/HH Wch Supp Dressing Non Adhesive 3x16__6114 PX-2725000042 CDM 2725000042 LOCAL 272 RC outpatient 9 9 BLUE CROSS BLUE SHIELD WELLMARK SB889 [3081026] BCBS WYOMING [308102603] 8.55 percent of total billed charges 5.58 8.55 Technical (Hospital) Services HC/HH Wch Supp Dressing Non Adhesive 3x16__6114 PX-2725000042 CDM 2725000042 LOCAL 272 RC outpatient 9 9 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES EPO [308136803] 7.2 percent of total billed charges 5.58 8.55 Technical (Hospital) Services HC/HH Wch Supp Dressing Non Adhesive 3x16__6114 PX-2725000042 CDM 2725000042 LOCAL 272 RC outpatient 9 9 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES HDHP [308136802] 7.2 percent of total billed charges 5.58 8.55 Technical (Hospital) Services HC/HH Wch Supp Dressing Non Adhesive 3x16__6114 PX-2725000042 CDM 2725000042 LOCAL 272 RC outpatient 9 9 MEDICA (COMMERCIAL) 94265 [3081118] MEDICA CLAIMS [308111801] 8.1 percent of total billed charges 5.58 8.55 Technical (Hospital) Services HC/HH Wch Supp Dressing Non Adhesive 3x16__6114 PX-2725000042 CDM 2725000042 LOCAL 272 RC outpatient 9 9 MULTIPLAN INC 34080 [3081285] MULTIPLAN INC [308128501] 8.55 percent of total billed charges 5.58 8.55 Technical (Hospital) Services HC/HH Wch Supp Dressing Non Adhesive 3x16__6114 PX-2725000042 CDM 2725000042 LOCAL 272 RC outpatient 9 9 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES PPO [308136801] 7.2 percent of total billed charges 5.58 8.55 Technical (Hospital) Services HC/HH Wch Supp Drape Sheet 44x57 Half__9358 PX-2725000041 CDM 2725000041 LOCAL 272 RC inpatient 8 8 HEALTHPARTNERS SX009 HEALTHPARTNERS 6.33 percent of total billed charges 4.96 7.6 Technical (Hospital) Services HC/HH Wch Supp Drape Sheet 44x57 Half__9358 PX-2725000041 CDM 2725000041 LOCAL 272 RC inpatient 8 8 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES EPO [308136803] 6.33 percent of total billed charges 4.96 7.6 Technical (Hospital) Services HC/HH Wch Supp Drape Sheet 44x57 Half__9358 PX-2725000041 CDM 2725000041 LOCAL 272 RC inpatient 8 8 CIGNA 62308 [3081051] CIGNA 62308 [308105105] 6.33 percent of total billed charges 4.96 7.6 Technical (Hospital) Services HC/HH Wch Supp Drape Sheet 44x57 Half__9358 PX-2725000041 CDM 2725000041 LOCAL 272 RC inpatient 8 8 CIGNA 62308 [3081051] CIGNA STATE OF WYOMING [308105107] 6.33 percent of total billed charges 4.96 7.6 Technical (Hospital) Services HC/HH Wch Supp Drape Sheet 44x57 Half__9358 PX-2725000041 CDM 2725000041 LOCAL 272 RC inpatient 8 8 BLUE CROSS BLUE SHIELD WELLMARK SB889 [3081026] BCBS WYOMING [308102603] 7.6 percent of total billed charges 4.96 7.6 Technical (Hospital) Services HC/HH Wch Supp Drape Sheet 44x57 Half__9358 PX-2725000041 CDM 2725000041 LOCAL 272 RC inpatient 8 8 MULTIPLAN INC 34080 [3081285] MULTIPLAN INC [308128501] 7.6 percent of total billed charges 4.96 7.6 Technical (Hospital) Services HC/HH Wch Supp Drape Sheet 44x57 Half__9358 PX-2725000041 CDM 2725000041 LOCAL 272 RC inpatient 8 8 MEDICA (COMMERCIAL) 94265 [3081118] MEDICA CLAIMS [308111801] 7.2 percent of total billed charges 4.96 7.6 Technical (Hospital) Services HC/HH Wch Supp Drape Sheet 44x57 Half__9358 PX-2725000041 CDM 2725000041 LOCAL 272 RC inpatient 8 8 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES PPO [308136801] 6.33 percent of total billed charges 4.96 7.6 Technical (Hospital) Services HC/HH Wch Supp Drape Sheet 44x57 Half__9358 PX-2725000041 CDM 2725000041 LOCAL 272 RC inpatient 8 8 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES HDHP [308136802] 6.33 percent of total billed charges 4.96 7.6 Technical (Hospital) Services HC/HH Wch Supp Drape Sheet 44x57 Half__9358 PX-2725000041 CDM 2725000041 LOCAL 272 RC inpatient 8 8 UNITED HEALTHCARE (COMMERCIAL) [3081199] UNITED HEALTHCARE 87726 [308119901] 4.96 percent of total billed charges 4.96 7.6 Technical (Hospital) Services HC/HH Wch Supp Drape Sheet 44x57 Half__9358 PX-2725000041 CDM 2725000041 LOCAL 272 RC outpatient 8 8 BLUE CROSS BLUE SHIELD WELLMARK SB889 [3081026] BCBS WYOMING [308102603] 7.6 percent of total billed charges 4.96 7.6 Technical (Hospital) Services HC/HH Wch Supp Drape Sheet 44x57 Half__9358 PX-2725000041 CDM 2725000041 LOCAL 272 RC outpatient 8 8 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES EPO [308136803] 6.4 percent of total billed charges 4.96 7.6 Technical (Hospital) Services HC/HH Wch Supp Drape Sheet 44x57 Half__9358 PX-2725000041 CDM 2725000041 LOCAL 272 RC outpatient 8 8 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES HDHP [308136802] 6.4 percent of total billed charges 4.96 7.6 Technical (Hospital) Services HC/HH Wch Supp Drape Sheet 44x57 Half__9358 PX-2725000041 CDM 2725000041 LOCAL 272 RC outpatient 8 8 CIGNA 62308 [3081051] CIGNA 62308 [308105105] 6.4 percent of total billed charges 4.96 7.6 Technical (Hospital) Services HC/HH Wch Supp Drape Sheet 44x57 Half__9358 PX-2725000041 CDM 2725000041 LOCAL 272 RC outpatient 8 8 CIGNA 62308 [3081051] CIGNA STATE OF WYOMING [308105107] 6.4 percent of total billed charges 4.96 7.6 Technical (Hospital) Services HC/HH Wch Supp Drape Sheet 44x57 Half__9358 PX-2725000041 CDM 2725000041 LOCAL 272 RC outpatient 8 8 UNITED HEALTHCARE (COMMERCIAL) [3081199] UNITED HEALTHCARE 87726 [308119901] 4.96 percent of total billed charges 4.96 7.6 Technical (Hospital) Services HC/HH Wch Supp Drape Sheet 44x57 Half__9358 PX-2725000041 CDM 2725000041 LOCAL 272 RC outpatient 8 8 HEALTHPARTNERS SX009 HEALTHPARTNERS 6.4 percent of total billed charges 4.96 7.6 Technical (Hospital) Services HC/HH Wch Supp Drape Sheet 44x57 Half__9358 PX-2725000041 CDM 2725000041 LOCAL 272 RC outpatient 8 8 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES PPO [308136801] 6.4 percent of total billed charges 4.96 7.6 Technical (Hospital) Services HC/HH Wch Supp Drape Sheet 44x57 Half__9358 PX-2725000041 CDM 2725000041 LOCAL 272 RC outpatient 8 8 MEDICA (COMMERCIAL) 94265 [3081118] MEDICA CLAIMS [308111801] 7.2 percent of total billed charges 4.96 7.6 Technical (Hospital) Services HC/HH Wch Supp Drape Sheet 44x57 Half__9358 PX-2725000041 CDM 2725000041 LOCAL 272 RC outpatient 8 8 MULTIPLAN INC 34080 [3081285] MULTIPLAN INC [308128501] 7.6 percent of total billed charges 4.96 7.6 Technical (Hospital) Services HC/HH Wch Supp Drain Penrose .75x12__20414-075 PX-2725000040 CDM 2725000040 LOCAL 272 RC inpatient 5 5 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES PPO [308136801] 3.96 percent of total billed charges 3.1 4.75 Technical (Hospital) Services HC/HH Wch Supp Drain Penrose .75x12__20414-075 PX-2725000040 CDM 2725000040 LOCAL 272 RC inpatient 5 5 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES HDHP [308136802] 3.96 percent of total billed charges 3.1 4.75 Technical (Hospital) Services HC/HH Wch Supp Drain Penrose .75x12__20414-075 PX-2725000040 CDM 2725000040 LOCAL 272 RC inpatient 5 5 UNITED HEALTHCARE (COMMERCIAL) [3081199] UNITED HEALTHCARE 87726 [308119901] 3.1 percent of total billed charges 3.1 4.75 Technical (Hospital) Services HC/HH Wch Supp Drain Penrose .75x12__20414-075 PX-2725000040 CDM 2725000040 LOCAL 272 RC inpatient 5 5 MEDICA (COMMERCIAL) 94265 [3081118] MEDICA CLAIMS [308111801] 4.5 percent of total billed charges 3.1 4.75 Technical (Hospital) Services HC/HH Wch Supp Drain Penrose .75x12__20414-075 PX-2725000040 CDM 2725000040 LOCAL 272 RC inpatient 5 5 CIGNA 62308 [3081051] CIGNA 62308 [308105105] 3.96 percent of total billed charges 3.1 4.75 Technical (Hospital) Services HC/HH Wch Supp Drain Penrose .75x12__20414-075 PX-2725000040 CDM 2725000040 LOCAL 272 RC inpatient 5 5 CIGNA 62308 [3081051] CIGNA STATE OF WYOMING [308105107] 3.96 percent of total billed charges 3.1 4.75 Technical (Hospital) Services HC/HH Wch Supp Drain Penrose .75x12__20414-075 PX-2725000040 CDM 2725000040 LOCAL 272 RC inpatient 5 5 BLUE CROSS BLUE SHIELD WELLMARK SB889 [3081026] BCBS WYOMING [308102603] 4.75 percent of total billed charges 3.1 4.75 Technical (Hospital) Services HC/HH Wch Supp Drain Penrose .75x12__20414-075 PX-2725000040 CDM 2725000040 LOCAL 272 RC inpatient 5 5 MULTIPLAN INC 34080 [3081285] MULTIPLAN INC [308128501] 4.75 percent of total billed charges 3.1 4.75 Technical (Hospital) Services HC/HH Wch Supp Drain Penrose .75x12__20414-075 PX-2725000040 CDM 2725000040 LOCAL 272 RC inpatient 5 5 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES EPO [308136803] 3.96 percent of total billed charges 3.1 4.75 Technical (Hospital) Services HC/HH Wch Supp Drain Penrose .75x12__20414-075 PX-2725000040 CDM 2725000040 LOCAL 272 RC inpatient 5 5 HEALTHPARTNERS SX009 HEALTHPARTNERS 3.96 percent of total billed charges 3.1 4.75 Technical (Hospital) Services HC/HH Wch Supp Drain Penrose .75x12__20414-075 PX-2725000040 CDM 2725000040 LOCAL 272 RC outpatient 5 5 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES HDHP [308136802] 4 percent of total billed charges 3.1 4.75 Technical (Hospital) Services HC/HH Wch Supp Drain Penrose .75x12__20414-075 PX-2725000040 CDM 2725000040 LOCAL 272 RC outpatient 5 5 BLUE CROSS BLUE SHIELD WELLMARK SB889 [3081026] BCBS WYOMING [308102603] 4.75 percent of total billed charges 3.1 4.75 Technical (Hospital) Services HC/HH Wch Supp Drain Penrose .75x12__20414-075 PX-2725000040 CDM 2725000040 LOCAL 272 RC outpatient 5 5 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES EPO [308136803] 4 percent of total billed charges 3.1 4.75 Technical (Hospital) Services HC/HH Wch Supp Drain Penrose .75x12__20414-075 PX-2725000040 CDM 2725000040 LOCAL 272 RC outpatient 5 5 UNITED HEALTHCARE (COMMERCIAL) [3081199] UNITED HEALTHCARE 87726 [308119901] 3.1 percent of total billed charges 3.1 4.75 Technical (Hospital) Services HC/HH Wch Supp Drain Penrose .75x12__20414-075 PX-2725000040 CDM 2725000040 LOCAL 272 RC outpatient 5 5 CIGNA 62308 [3081051] CIGNA 62308 [308105105] 4 percent of total billed charges 3.1 4.75 Technical (Hospital) Services HC/HH Wch Supp Drain Penrose .75x12__20414-075 PX-2725000040 CDM 2725000040 LOCAL 272 RC outpatient 5 5 CIGNA 62308 [3081051] CIGNA STATE OF WYOMING [308105107] 4 percent of total billed charges 3.1 4.75 Technical (Hospital) Services HC/HH Wch Supp Drain Penrose .75x12__20414-075 PX-2725000040 CDM 2725000040 LOCAL 272 RC outpatient 5 5 HEALTHPARTNERS SX009 HEALTHPARTNERS 4 percent of total billed charges 3.1 4.75 Technical (Hospital) Services HC/HH Wch Supp Drain Penrose .75x12__20414-075 PX-2725000040 CDM 2725000040 LOCAL 272 RC outpatient 5 5 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES PPO [308136801] 4 percent of total billed charges 3.1 4.75 Technical (Hospital) Services HC/HH Wch Supp Drain Penrose .75x12__20414-075 PX-2725000040 CDM 2725000040 LOCAL 272 RC outpatient 5 5 MULTIPLAN INC 34080 [3081285] MULTIPLAN INC [308128501] 4.75 percent of total billed charges 3.1 4.75 Technical (Hospital) Services HC/HH Wch Supp Drain Penrose .75x12__20414-075 PX-2725000040 CDM 2725000040 LOCAL 272 RC outpatient 5 5 MEDICA (COMMERCIAL) 94265 [3081118] MEDICA CLAIMS [308111801] 4.5 percent of total billed charges 3.1 4.75 Technical (Hospital) Services HC/HH Wch Supp Drain Penrose .5x12__20414-050 PX-2725000039 CDM 2725000039 LOCAL 272 RC outpatient 5 5 BLUE CROSS BLUE SHIELD WELLMARK SB889 [3081026] BCBS WYOMING [308102603] 4.75 percent of total billed charges 3.1 4.75 Technical (Hospital) Services HC/HH Wch Supp Drain Penrose .5x12__20414-050 PX-2725000039 CDM 2725000039 LOCAL 272 RC outpatient 5 5 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES EPO [308136803] 4 percent of total billed charges 3.1 4.75 Technical (Hospital) Services HC/HH Wch Supp Drain Penrose .5x12__20414-050 PX-2725000039 CDM 2725000039 LOCAL 272 RC outpatient 5 5 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES HDHP [308136802] 4 percent of total billed charges 3.1 4.75 Technical (Hospital) Services HC/HH Wch Supp Drain Penrose .5x12__20414-050 PX-2725000039 CDM 2725000039 LOCAL 272 RC outpatient 5 5 CIGNA 62308 [3081051] CIGNA 62308 [308105105] 4 percent of total billed charges 3.1 4.75 Technical (Hospital) Services HC/HH Wch Supp Drain Penrose .5x12__20414-050 PX-2725000039 CDM 2725000039 LOCAL 272 RC outpatient 5 5 CIGNA 62308 [3081051] CIGNA STATE OF WYOMING [308105107] 4 percent of total billed charges 3.1 4.75 Technical (Hospital) Services HC/HH Wch Supp Drain Penrose .5x12__20414-050 PX-2725000039 CDM 2725000039 LOCAL 272 RC outpatient 5 5 UNITED HEALTHCARE (COMMERCIAL) [3081199] UNITED HEALTHCARE 87726 [308119901] 3.1 percent of total billed charges 3.1 4.75 Technical (Hospital) Services HC/HH Wch Supp Drain Penrose .5x12__20414-050 PX-2725000039 CDM 2725000039 LOCAL 272 RC outpatient 5 5 HEALTHPARTNERS SX009 HEALTHPARTNERS 4 percent of total billed charges 3.1 4.75 Technical (Hospital) Services HC/HH Wch Supp Drain Penrose .5x12__20414-050 PX-2725000039 CDM 2725000039 LOCAL 272 RC outpatient 5 5 MULTIPLAN INC 34080 [3081285] MULTIPLAN INC [308128501] 4.75 percent of total billed charges 3.1 4.75 Technical (Hospital) Services HC/HH Wch Supp Drain Penrose .5x12__20414-050 PX-2725000039 CDM 2725000039 LOCAL 272 RC outpatient 5 5 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES PPO [308136801] 4 percent of total billed charges 3.1 4.75 Technical (Hospital) Services HC/HH Wch Supp Drain Penrose .5x12__20414-050 PX-2725000039 CDM 2725000039 LOCAL 272 RC outpatient 5 5 MEDICA (COMMERCIAL) 94265 [3081118] MEDICA CLAIMS [308111801] 4.5 percent of total billed charges 3.1 4.75 Technical (Hospital) Services HC/HH Wch Supp Drain Penrose .5x12__20414-050 PX-2725000039 CDM 2725000039 LOCAL 272 RC inpatient 5 5 MULTIPLAN INC 34080 [3081285] MULTIPLAN INC [308128501] 4.75 percent of total billed charges 3.1 4.75 Technical (Hospital) Services HC/HH Wch Supp Drain Penrose .5x12__20414-050 PX-2725000039 CDM 2725000039 LOCAL 272 RC inpatient 5 5 BLUE CROSS BLUE SHIELD WELLMARK SB889 [3081026] BCBS WYOMING [308102603] 4.75 percent of total billed charges 3.1 4.75 Technical (Hospital) Services HC/HH Wch Supp Drain Penrose .5x12__20414-050 PX-2725000039 CDM 2725000039 LOCAL 272 RC inpatient 5 5 CIGNA 62308 [3081051] CIGNA 62308 [308105105] 3.96 percent of total billed charges 3.1 4.75 Technical (Hospital) Services HC/HH Wch Supp Drain Penrose .5x12__20414-050 PX-2725000039 CDM 2725000039 LOCAL 272 RC inpatient 5 5 CIGNA 62308 [3081051] CIGNA STATE OF WYOMING [308105107] 3.96 percent of total billed charges 3.1 4.75 Technical (Hospital) Services HC/HH Wch Supp Drain Penrose .5x12__20414-050 PX-2725000039 CDM 2725000039 LOCAL 272 RC inpatient 5 5 HEALTHPARTNERS SX009 HEALTHPARTNERS 3.96 percent of total billed charges 3.1 4.75 Technical (Hospital) Services HC/HH Wch Supp Drain Penrose .5x12__20414-050 PX-2725000039 CDM 2725000039 LOCAL 272 RC inpatient 5 5 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES EPO [308136803] 3.96 percent of total billed charges 3.1 4.75 Technical (Hospital) Services HC/HH Wch Supp Drain Penrose .5x12__20414-050 PX-2725000039 CDM 2725000039 LOCAL 272 RC inpatient 5 5 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES PPO [308136801] 3.96 percent of total billed charges 3.1 4.75 Technical (Hospital) Services HC/HH Wch Supp Drain Penrose .5x12__20414-050 PX-2725000039 CDM 2725000039 LOCAL 272 RC inpatient 5 5 MEDICA (COMMERCIAL) 94265 [3081118] MEDICA CLAIMS [308111801] 4.5 percent of total billed charges 3.1 4.75 Technical (Hospital) Services HC/HH Wch Supp Drain Penrose .5x12__20414-050 PX-2725000039 CDM 2725000039 LOCAL 272 RC inpatient 5 5 UNITED HEALTHCARE (COMMERCIAL) [3081199] UNITED HEALTHCARE 87726 [308119901] 3.1 percent of total billed charges 3.1 4.75 Technical (Hospital) Services HC/HH Wch Supp Drain Penrose .5x12__20414-050 PX-2725000039 CDM 2725000039 LOCAL 272 RC inpatient 5 5 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES HDHP [308136802] 3.96 percent of total billed charges 3.1 4.75 Technical (Hospital) Services HC/HH Wch Supp Drain Penrose .25x12__20414-025 PX-2725000038 CDM 2725000038 LOCAL 272 RC outpatient 5 5 MEDICA (COMMERCIAL) 94265 [3081118] MEDICA CLAIMS [308111801] 4.5 percent of total billed charges 3.1 4.75 Technical (Hospital) Services HC/HH Wch Supp Drain Penrose .25x12__20414-025 PX-2725000038 CDM 2725000038 LOCAL 272 RC outpatient 5 5 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES PPO [308136801] 4 percent of total billed charges 3.1 4.75 Technical (Hospital) Services HC/HH Wch Supp Drain Penrose .25x12__20414-025 PX-2725000038 CDM 2725000038 LOCAL 272 RC outpatient 5 5 MULTIPLAN INC 34080 [3081285] MULTIPLAN INC [308128501] 4.75 percent of total billed charges 3.1 4.75 Technical (Hospital) Services HC/HH Wch Supp Drain Penrose .25x12__20414-025 PX-2725000038 CDM 2725000038 LOCAL 272 RC outpatient 5 5 HEALTHPARTNERS SX009 HEALTHPARTNERS 4 percent of total billed charges 3.1 4.75 Technical (Hospital) Services HC/HH Wch Supp Drain Penrose .25x12__20414-025 PX-2725000038 CDM 2725000038 LOCAL 272 RC outpatient 5 5 UNITED HEALTHCARE (COMMERCIAL) [3081199] UNITED HEALTHCARE 87726 [308119901] 3.1 percent of total billed charges 3.1 4.75 Technical (Hospital) Services HC/HH Wch Supp Drain Penrose .25x12__20414-025 PX-2725000038 CDM 2725000038 LOCAL 272 RC outpatient 5 5 CIGNA 62308 [3081051] CIGNA 62308 [308105105] 4 percent of total billed charges 3.1 4.75 Technical (Hospital) Services HC/HH Wch Supp Drain Penrose .25x12__20414-025 PX-2725000038 CDM 2725000038 LOCAL 272 RC outpatient 5 5 CIGNA 62308 [3081051] CIGNA STATE OF WYOMING [308105107] 4 percent of total billed charges 3.1 4.75 Technical (Hospital) Services HC/HH Wch Supp Drain Penrose .25x12__20414-025 PX-2725000038 CDM 2725000038 LOCAL 272 RC outpatient 5 5 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES HDHP [308136802] 4 percent of total billed charges 3.1 4.75 Technical (Hospital) Services HC/HH Wch Supp Drain Penrose .25x12__20414-025 PX-2725000038 CDM 2725000038 LOCAL 272 RC outpatient 5 5 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES EPO [308136803] 4 percent of total billed charges 3.1 4.75 Technical (Hospital) Services HC/HH Wch Supp Drain Penrose .25x12__20414-025 PX-2725000038 CDM 2725000038 LOCAL 272 RC outpatient 5 5 BLUE CROSS BLUE SHIELD WELLMARK SB889 [3081026] BCBS WYOMING [308102603] 4.75 percent of total billed charges 3.1 4.75 Technical (Hospital) Services HC/HH Wch Supp Drain Penrose .25x12__20414-025 PX-2725000038 CDM 2725000038 LOCAL 272 RC inpatient 5 5 UNITED HEALTHCARE (COMMERCIAL) [3081199] UNITED HEALTHCARE 87726 [308119901] 3.1 percent of total billed charges 3.1 4.75 Technical (Hospital) Services HC/HH Wch Supp Drain Penrose .25x12__20414-025 PX-2725000038 CDM 2725000038 LOCAL 272 RC inpatient 5 5 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES HDHP [308136802] 3.96 percent of total billed charges 3.1 4.75 Technical (Hospital) Services HC/HH Wch Supp Drain Penrose .25x12__20414-025 PX-2725000038 CDM 2725000038 LOCAL 272 RC inpatient 5 5 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES PPO [308136801] 3.96 percent of total billed charges 3.1 4.75 Technical (Hospital) Services HC/HH Wch Supp Drain Penrose .25x12__20414-025 PX-2725000038 CDM 2725000038 LOCAL 272 RC inpatient 5 5 MEDICA (COMMERCIAL) 94265 [3081118] MEDICA CLAIMS [308111801] 4.5 percent of total billed charges 3.1 4.75 Technical (Hospital) Services HC/HH Wch Supp Drain Penrose .25x12__20414-025 PX-2725000038 CDM 2725000038 LOCAL 272 RC inpatient 5 5 MULTIPLAN INC 34080 [3081285] MULTIPLAN INC [308128501] 4.75 percent of total billed charges 3.1 4.75 Technical (Hospital) Services HC/HH Wch Supp Drain Penrose .25x12__20414-025 PX-2725000038 CDM 2725000038 LOCAL 272 RC inpatient 5 5 BLUE CROSS BLUE SHIELD WELLMARK SB889 [3081026] BCBS WYOMING [308102603] 4.75 percent of total billed charges 3.1 4.75 Technical (Hospital) Services HC/HH Wch Supp Drain Penrose .25x12__20414-025 PX-2725000038 CDM 2725000038 LOCAL 272 RC inpatient 5 5 CIGNA 62308 [3081051] CIGNA 62308 [308105105] 3.96 percent of total billed charges 3.1 4.75 Technical (Hospital) Services HC/HH Wch Supp Drain Penrose .25x12__20414-025 PX-2725000038 CDM 2725000038 LOCAL 272 RC inpatient 5 5 CIGNA 62308 [3081051] CIGNA STATE OF WYOMING [308105107] 3.96 percent of total billed charges 3.1 4.75 Technical (Hospital) Services HC/HH Wch Supp Drain Penrose .25x12__20414-025 PX-2725000038 CDM 2725000038 LOCAL 272 RC inpatient 5 5 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES EPO [308136803] 3.96 percent of total billed charges 3.1 4.75 Technical (Hospital) Services HC/HH Wch Supp Drain Penrose .25x12__20414-025 PX-2725000038 CDM 2725000038 LOCAL 272 RC inpatient 5 5 HEALTHPARTNERS SX009 HEALTHPARTNERS 3.96 percent of total billed charges 3.1 4.75 Technical (Hospital) Services HC/HH Wch Supp Cotton Balls Unsteri__P159025 PX-2725000037 CDM 2725000037 LOCAL 272 RC outpatient 6 6 CIGNA 62308 [3081051] CIGNA 62308 [308105105] 4.8 percent of total billed charges 3.72 5.7 Technical (Hospital) Services HC/HH Wch Supp Cotton Balls Unsteri__P159025 PX-2725000037 CDM 2725000037 LOCAL 272 RC outpatient 6 6 CIGNA 62308 [3081051] CIGNA STATE OF WYOMING [308105107] 4.8 percent of total billed charges 3.72 5.7 Technical (Hospital) Services HC/HH Wch Supp Cotton Balls Unsteri__P159025 PX-2725000037 CDM 2725000037 LOCAL 272 RC outpatient 6 6 UNITED HEALTHCARE (COMMERCIAL) [3081199] UNITED HEALTHCARE 87726 [308119901] 3.72 percent of total billed charges 3.72 5.7 Technical (Hospital) Services HC/HH Wch Supp Cotton Balls Unsteri__P159025 PX-2725000037 CDM 2725000037 LOCAL 272 RC outpatient 6 6 HEALTHPARTNERS SX009 HEALTHPARTNERS 4.8 percent of total billed charges 3.72 5.7 Technical (Hospital) Services HC/HH Wch Supp Cotton Balls Unsteri__P159025 PX-2725000037 CDM 2725000037 LOCAL 272 RC outpatient 6 6 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES PPO [308136801] 4.8 percent of total billed charges 3.72 5.7 Technical (Hospital) Services HC/HH Wch Supp Cotton Balls Unsteri__P159025 PX-2725000037 CDM 2725000037 LOCAL 272 RC outpatient 6 6 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES HDHP [308136802] 4.8 percent of total billed charges 3.72 5.7 Technical (Hospital) Services HC/HH Wch Supp Cotton Balls Unsteri__P159025 PX-2725000037 CDM 2725000037 LOCAL 272 RC outpatient 6 6 BLUE CROSS BLUE SHIELD WELLMARK SB889 [3081026] BCBS WYOMING [308102603] 5.7 percent of total billed charges 3.72 5.7 Technical (Hospital) Services HC/HH Wch Supp Cotton Balls Unsteri__P159025 PX-2725000037 CDM 2725000037 LOCAL 272 RC outpatient 6 6 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES EPO [308136803] 4.8 percent of total billed charges 3.72 5.7 Technical (Hospital) Services HC/HH Wch Supp Cotton Balls Unsteri__P159025 PX-2725000037 CDM 2725000037 LOCAL 272 RC outpatient 6 6 MEDICA (COMMERCIAL) 94265 [3081118] MEDICA CLAIMS [308111801] 5.4 percent of total billed charges 3.72 5.7 Technical (Hospital) Services HC/HH Wch Supp Cotton Balls Unsteri__P159025 PX-2725000037 CDM 2725000037 LOCAL 272 RC outpatient 6 6 MULTIPLAN INC 34080 [3081285] MULTIPLAN INC [308128501] 5.7 percent of total billed charges 3.72 5.7 Technical (Hospital) Services HC/HH Wch Supp Cotton Balls Unsteri__P159025 PX-2725000037 CDM 2725000037 LOCAL 272 RC inpatient 6 6 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES EPO [308136803] 4.75 percent of total billed charges 3.72 5.7 Technical (Hospital) Services HC/HH Wch Supp Cotton Balls Unsteri__P159025 PX-2725000037 CDM 2725000037 LOCAL 272 RC inpatient 6 6 HEALTHPARTNERS SX009 HEALTHPARTNERS 4.75 percent of total billed charges 3.72 5.7 Technical (Hospital) Services HC/HH Wch Supp Cotton Balls Unsteri__P159025 PX-2725000037 CDM 2725000037 LOCAL 272 RC inpatient 6 6 BLUE CROSS BLUE SHIELD WELLMARK SB889 [3081026] BCBS WYOMING [308102603] 5.7 percent of total billed charges 3.72 5.7 Technical (Hospital) Services HC/HH Wch Supp Cotton Balls Unsteri__P159025 PX-2725000037 CDM 2725000037 LOCAL 272 RC inpatient 6 6 MULTIPLAN INC 34080 [3081285] MULTIPLAN INC [308128501] 5.7 percent of total billed charges 3.72 5.7 Technical (Hospital) Services HC/HH Wch Supp Cotton Balls Unsteri__P159025 PX-2725000037 CDM 2725000037 LOCAL 272 RC inpatient 6 6 CIGNA 62308 [3081051] CIGNA 62308 [308105105] 4.75 percent of total billed charges 3.72 5.7 Technical (Hospital) Services HC/HH Wch Supp Cotton Balls Unsteri__P159025 PX-2725000037 CDM 2725000037 LOCAL 272 RC inpatient 6 6 CIGNA 62308 [3081051] CIGNA STATE OF WYOMING [308105107] 4.75 percent of total billed charges 3.72 5.7 Technical (Hospital) Services HC/HH Wch Supp Cotton Balls Unsteri__P159025 PX-2725000037 CDM 2725000037 LOCAL 272 RC inpatient 6 6 MEDICA (COMMERCIAL) 94265 [3081118] MEDICA CLAIMS [308111801] 5.4 percent of total billed charges 3.72 5.7 Technical (Hospital) Services HC/HH Wch Supp Cotton Balls Unsteri__P159025 PX-2725000037 CDM 2725000037 LOCAL 272 RC inpatient 6 6 UNITED HEALTHCARE (COMMERCIAL) [3081199] UNITED HEALTHCARE 87726 [308119901] 3.72 percent of total billed charges 3.72 5.7 Technical (Hospital) Services HC/HH Wch Supp Cotton Balls Unsteri__P159025 PX-2725000037 CDM 2725000037 LOCAL 272 RC inpatient 6 6 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES HDHP [308136802] 4.75 percent of total billed charges 3.72 5.7 Technical (Hospital) Services HC/HH Wch Supp Cotton Balls Unsteri__P159025 PX-2725000037 CDM 2725000037 LOCAL 272 RC inpatient 6 6 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES PPO [308136801] 4.75 percent of total billed charges 3.72 5.7 Technical (Hospital) Services HC/HH Wch Supp Cathfoley-Suprapubic__Dynd11782 PX-2725000036 CDM 2725000036 LOCAL 272 RC inpatient 41 41 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES PPO [308136801] 32.46 percent of total billed charges 25.42 38.95 Technical (Hospital) Services HC/HH Wch Supp Cathfoley-Suprapubic__Dynd11782 PX-2725000036 CDM 2725000036 LOCAL 272 RC inpatient 41 41 MEDICA (COMMERCIAL) 94265 [3081118] MEDICA CLAIMS [308111801] 36.9 percent of total billed charges 25.42 38.95 Technical (Hospital) Services HC/HH Wch Supp Cathfoley-Suprapubic__Dynd11782 PX-2725000036 CDM 2725000036 LOCAL 272 RC inpatient 41 41 UNITED HEALTHCARE (COMMERCIAL) [3081199] UNITED HEALTHCARE 87726 [308119901] 25.42 percent of total billed charges 25.42 38.95 Technical (Hospital) Services HC/HH Wch Supp Cathfoley-Suprapubic__Dynd11782 PX-2725000036 CDM 2725000036 LOCAL 272 RC inpatient 41 41 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES HDHP [308136802] 32.46 percent of total billed charges 25.42 38.95 Technical (Hospital) Services HC/HH Wch Supp Cathfoley-Suprapubic__Dynd11782 PX-2725000036 CDM 2725000036 LOCAL 272 RC inpatient 41 41 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES EPO [308136803] 32.46 percent of total billed charges 25.42 38.95 Technical (Hospital) Services HC/HH Wch Supp Cathfoley-Suprapubic__Dynd11782 PX-2725000036 CDM 2725000036 LOCAL 272 RC inpatient 41 41 HEALTHPARTNERS SX009 HEALTHPARTNERS 32.46 percent of total billed charges 25.42 38.95 Technical (Hospital) Services HC/HH Wch Supp Cathfoley-Suprapubic__Dynd11782 PX-2725000036 CDM 2725000036 LOCAL 272 RC inpatient 41 41 MULTIPLAN INC 34080 [3081285] MULTIPLAN INC [308128501] 38.95 percent of total billed charges 25.42 38.95 Technical (Hospital) Services HC/HH Wch Supp Cathfoley-Suprapubic__Dynd11782 PX-2725000036 CDM 2725000036 LOCAL 272 RC inpatient 41 41 BLUE CROSS BLUE SHIELD WELLMARK SB889 [3081026] BCBS WYOMING [308102603] 38.95 percent of total billed charges 25.42 38.95 Technical (Hospital) Services HC/HH Wch Supp Cathfoley-Suprapubic__Dynd11782 PX-2725000036 CDM 2725000036 LOCAL 272 RC inpatient 41 41 CIGNA 62308 [3081051] CIGNA 62308 [308105105] 32.46 percent of total billed charges 25.42 38.95 Technical (Hospital) Services HC/HH Wch Supp Cathfoley-Suprapubic__Dynd11782 PX-2725000036 CDM 2725000036 LOCAL 272 RC inpatient 41 41 CIGNA 62308 [3081051] CIGNA STATE OF WYOMING [308105107] 32.46 percent of total billed charges 25.42 38.95 Technical (Hospital) Services HC/HH Wch Supp Cathfoley-Suprapubic__Dynd11782 PX-2725000036 CDM 2725000036 LOCAL 272 RC outpatient 41 41 CIGNA 62308 [3081051] CIGNA 62308 [308105105] 32.8 percent of total billed charges 25.42 38.95 Technical (Hospital) Services HC/HH Wch Supp Cathfoley-Suprapubic__Dynd11782 PX-2725000036 CDM 2725000036 LOCAL 272 RC outpatient 41 41 CIGNA 62308 [3081051] CIGNA STATE OF WYOMING [308105107] 32.8 percent of total billed charges 25.42 38.95 Technical (Hospital) Services HC/HH Wch Supp Cathfoley-Suprapubic__Dynd11782 PX-2725000036 CDM 2725000036 LOCAL 272 RC outpatient 41 41 HEALTHPARTNERS SX009 HEALTHPARTNERS 32.8 percent of total billed charges 25.42 38.95 Technical (Hospital) Services HC/HH Wch Supp Cathfoley-Suprapubic__Dynd11782 PX-2725000036 CDM 2725000036 LOCAL 272 RC outpatient 41 41 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES PPO [308136801] 32.8 percent of total billed charges 25.42 38.95 Technical (Hospital) Services HC/HH Wch Supp Cathfoley-Suprapubic__Dynd11782 PX-2725000036 CDM 2725000036 LOCAL 272 RC outpatient 41 41 UNITED HEALTHCARE (COMMERCIAL) [3081199] UNITED HEALTHCARE 87726 [308119901] 25.42 percent of total billed charges 25.42 38.95 Technical (Hospital) Services HC/HH Wch Supp Cathfoley-Suprapubic__Dynd11782 PX-2725000036 CDM 2725000036 LOCAL 272 RC outpatient 41 41 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES HDHP [308136802] 32.8 percent of total billed charges 25.42 38.95 Technical (Hospital) Services HC/HH Wch Supp Cathfoley-Suprapubic__Dynd11782 PX-2725000036 CDM 2725000036 LOCAL 272 RC outpatient 41 41 BLUE CROSS BLUE SHIELD WELLMARK SB889 [3081026] BCBS WYOMING [308102603] 38.95 percent of total billed charges 25.42 38.95 Technical (Hospital) Services HC/HH Wch Supp Cathfoley-Suprapubic__Dynd11782 PX-2725000036 CDM 2725000036 LOCAL 272 RC outpatient 41 41 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES EPO [308136803] 32.8 percent of total billed charges 25.42 38.95 Technical (Hospital) Services HC/HH Wch Supp Cathfoley-Suprapubic__Dynd11782 PX-2725000036 CDM 2725000036 LOCAL 272 RC outpatient 41 41 MULTIPLAN INC 34080 [3081285] MULTIPLAN INC [308128501] 38.95 percent of total billed charges 25.42 38.95 Technical (Hospital) Services HC/HH Wch Supp Cathfoley-Suprapubic__Dynd11782 PX-2725000036 CDM 2725000036 LOCAL 272 RC outpatient 41 41 MEDICA (COMMERCIAL) 94265 [3081118] MEDICA CLAIMS [308111801] 36.9 percent of total billed charges 25.42 38.95 Technical (Hospital) Services HC/HH Wch Supp Catheter Thoracic 36fr__8888570564 PX-2725000035 CDM 2725000035 LOCAL 272 RC inpatient 42 42 MEDICA (COMMERCIAL) 94265 [3081118] MEDICA CLAIMS [308111801] 37.8 percent of total billed charges 26.04 39.9 Technical (Hospital) Services HC/HH Wch Supp Catheter Thoracic 36fr__8888570564 PX-2725000035 CDM 2725000035 LOCAL 272 RC inpatient 42 42 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES PPO [308136801] 33.26 percent of total billed charges 26.04 39.9 Technical (Hospital) Services HC/HH Wch Supp Catheter Thoracic 36fr__8888570564 PX-2725000035 CDM 2725000035 LOCAL 272 RC inpatient 42 42 UNITED HEALTHCARE (COMMERCIAL) [3081199] UNITED HEALTHCARE 87726 [308119901] 26.04 percent of total billed charges 26.04 39.9 Technical (Hospital) Services HC/HH Wch Supp Catheter Thoracic 36fr__8888570564 PX-2725000035 CDM 2725000035 LOCAL 272 RC inpatient 42 42 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES HDHP [308136802] 33.26 percent of total billed charges 26.04 39.9 Technical (Hospital) Services HC/HH Wch Supp Catheter Thoracic 36fr__8888570564 PX-2725000035 CDM 2725000035 LOCAL 272 RC inpatient 42 42 CIGNA 62308 [3081051] CIGNA 62308 [308105105] 33.26 percent of total billed charges 26.04 39.9 Technical (Hospital) Services HC/HH Wch Supp Catheter Thoracic 36fr__8888570564 PX-2725000035 CDM 2725000035 LOCAL 272 RC inpatient 42 42 CIGNA 62308 [3081051] CIGNA STATE OF WYOMING [308105107] 33.26 percent of total billed charges 26.04 39.9 Technical (Hospital) Services HC/HH Wch Supp Catheter Thoracic 36fr__8888570564 PX-2725000035 CDM 2725000035 LOCAL 272 RC inpatient 42 42 HEALTHPARTNERS SX009 HEALTHPARTNERS 33.26 percent of total billed charges 26.04 39.9 Technical (Hospital) Services HC/HH Wch Supp Catheter Thoracic 36fr__8888570564 PX-2725000035 CDM 2725000035 LOCAL 272 RC inpatient 42 42 BLUE CROSS BLUE SHIELD WELLMARK SB889 [3081026] BCBS WYOMING [308102603] 39.9 percent of total billed charges 26.04 39.9 Technical (Hospital) Services HC/HH Wch Supp Catheter Thoracic 36fr__8888570564 PX-2725000035 CDM 2725000035 LOCAL 272 RC inpatient 42 42 MULTIPLAN INC 34080 [3081285] MULTIPLAN INC [308128501] 39.9 percent of total billed charges 26.04 39.9 Technical (Hospital) Services HC/HH Wch Supp Catheter Thoracic 36fr__8888570564 PX-2725000035 CDM 2725000035 LOCAL 272 RC inpatient 42 42 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES EPO [308136803] 33.26 percent of total billed charges 26.04 39.9 Technical (Hospital) Services HC/HH Wch Supp Catheter Thoracic 36fr__8888570564 PX-2725000035 CDM 2725000035 LOCAL 272 RC outpatient 42 42 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES HDHP [308136802] 33.6 percent of total billed charges 26.04 39.9 Technical (Hospital) Services HC/HH Wch Supp Catheter Thoracic 36fr__8888570564 PX-2725000035 CDM 2725000035 LOCAL 272 RC outpatient 42 42 BLUE CROSS BLUE SHIELD WELLMARK SB889 [3081026] BCBS WYOMING [308102603] 39.9 percent of total billed charges 26.04 39.9 Technical (Hospital) Services HC/HH Wch Supp Catheter Thoracic 36fr__8888570564 PX-2725000035 CDM 2725000035 LOCAL 272 RC outpatient 42 42 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES EPO [308136803] 33.6 percent of total billed charges 26.04 39.9 Technical (Hospital) Services HC/HH Wch Supp Catheter Thoracic 36fr__8888570564 PX-2725000035 CDM 2725000035 LOCAL 272 RC outpatient 42 42 CIGNA 62308 [3081051] CIGNA 62308 [308105105] 33.6 percent of total billed charges 26.04 39.9 Technical (Hospital) Services HC/HH Wch Supp Catheter Thoracic 36fr__8888570564 PX-2725000035 CDM 2725000035 LOCAL 272 RC outpatient 42 42 CIGNA 62308 [3081051] CIGNA STATE OF WYOMING [308105107] 33.6 percent of total billed charges 26.04 39.9 Technical (Hospital) Services HC/HH Wch Supp Catheter Thoracic 36fr__8888570564 PX-2725000035 CDM 2725000035 LOCAL 272 RC outpatient 42 42 UNITED HEALTHCARE (COMMERCIAL) [3081199] UNITED HEALTHCARE 87726 [308119901] 26.04 percent of total billed charges 26.04 39.9 Technical (Hospital) Services HC/HH Wch Supp Catheter Thoracic 36fr__8888570564 PX-2725000035 CDM 2725000035 LOCAL 272 RC outpatient 42 42 HEALTHPARTNERS SX009 HEALTHPARTNERS 33.6 percent of total billed charges 26.04 39.9 Technical (Hospital) Services HC/HH Wch Supp Catheter Thoracic 36fr__8888570564 PX-2725000035 CDM 2725000035 LOCAL 272 RC outpatient 42 42 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES PPO [308136801] 33.6 percent of total billed charges 26.04 39.9 Technical (Hospital) Services HC/HH Wch Supp Catheter Thoracic 36fr__8888570564 PX-2725000035 CDM 2725000035 LOCAL 272 RC outpatient 42 42 MULTIPLAN INC 34080 [3081285] MULTIPLAN INC [308128501] 39.9 percent of total billed charges 26.04 39.9 Technical (Hospital) Services HC/HH Wch Supp Catheter Thoracic 36fr__8888570564 PX-2725000035 CDM 2725000035 LOCAL 272 RC outpatient 42 42 MEDICA (COMMERCIAL) 94265 [3081118] MEDICA CLAIMS [308111801] 37.8 percent of total billed charges 26.04 39.9 Technical (Hospital) Services HC/HH Wch Supp Catheter Thoracic 32fr__8888570556 PX-2725000034 CDM 2725000034 LOCAL 272 RC outpatient 42 42 MULTIPLAN INC 34080 [3081285] MULTIPLAN INC [308128501] 39.9 percent of total billed charges 26.04 39.9 Technical (Hospital) Services HC/HH Wch Supp Catheter Thoracic 32fr__8888570556 PX-2725000034 CDM 2725000034 LOCAL 272 RC outpatient 42 42 MEDICA (COMMERCIAL) 94265 [3081118] MEDICA CLAIMS [308111801] 37.8 percent of total billed charges 26.04 39.9 Technical (Hospital) Services HC/HH Wch Supp Catheter Thoracic 32fr__8888570556 PX-2725000034 CDM 2725000034 LOCAL 272 RC outpatient 42 42 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES PPO [308136801] 33.6 percent of total billed charges 26.04 39.9 Technical (Hospital) Services HC/HH Wch Supp Catheter Thoracic 32fr__8888570556 PX-2725000034 CDM 2725000034 LOCAL 272 RC outpatient 42 42 HEALTHPARTNERS SX009 HEALTHPARTNERS 33.6 percent of total billed charges 26.04 39.9 Technical (Hospital) Services HC/HH Wch Supp Catheter Thoracic 32fr__8888570556 PX-2725000034 CDM 2725000034 LOCAL 272 RC outpatient 42 42 UNITED HEALTHCARE (COMMERCIAL) [3081199] UNITED HEALTHCARE 87726 [308119901] 26.04 percent of total billed charges 26.04 39.9 Technical (Hospital) Services HC/HH Wch Supp Catheter Thoracic 32fr__8888570556 PX-2725000034 CDM 2725000034 LOCAL 272 RC outpatient 42 42 CIGNA 62308 [3081051] CIGNA 62308 [308105105] 33.6 percent of total billed charges 26.04 39.9 Technical (Hospital) Services HC/HH Wch Supp Catheter Thoracic 32fr__8888570556 PX-2725000034 CDM 2725000034 LOCAL 272 RC outpatient 42 42 CIGNA 62308 [3081051] CIGNA STATE OF WYOMING [308105107] 33.6 percent of total billed charges 26.04 39.9 Technical (Hospital) Services HC/HH Wch Supp Catheter Thoracic 32fr__8888570556 PX-2725000034 CDM 2725000034 LOCAL 272 RC outpatient 42 42 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES EPO [308136803] 33.6 percent of total billed charges 26.04 39.9 Technical (Hospital) Services HC/HH Wch Supp Catheter Thoracic 32fr__8888570556 PX-2725000034 CDM 2725000034 LOCAL 272 RC outpatient 42 42 BLUE CROSS BLUE SHIELD WELLMARK SB889 [3081026] BCBS WYOMING [308102603] 39.9 percent of total billed charges 26.04 39.9 Technical (Hospital) Services HC/HH Wch Supp Catheter Thoracic 32fr__8888570556 PX-2725000034 CDM 2725000034 LOCAL 272 RC outpatient 42 42 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES HDHP [308136802] 33.6 percent of total billed charges 26.04 39.9 Technical (Hospital) Services HC/HH Wch Supp Catheter Thoracic 32fr__8888570556 PX-2725000034 CDM 2725000034 LOCAL 272 RC inpatient 42 42 MEDICA (COMMERCIAL) 94265 [3081118] MEDICA CLAIMS [308111801] 37.8 percent of total billed charges 26.04 39.9 Technical (Hospital) Services HC/HH Wch Supp Catheter Thoracic 32fr__8888570556 PX-2725000034 CDM 2725000034 LOCAL 272 RC inpatient 42 42 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES PPO [308136801] 33.26 percent of total billed charges 26.04 39.9 Technical (Hospital) Services HC/HH Wch Supp Catheter Thoracic 32fr__8888570556 PX-2725000034 CDM 2725000034 LOCAL 272 RC inpatient 42 42 UNITED HEALTHCARE (COMMERCIAL) [3081199] UNITED HEALTHCARE 87726 [308119901] 26.04 percent of total billed charges 26.04 39.9 Technical (Hospital) Services HC/HH Wch Supp Catheter Thoracic 32fr__8888570556 PX-2725000034 CDM 2725000034 LOCAL 272 RC inpatient 42 42 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES HDHP [308136802] 33.26 percent of total billed charges 26.04 39.9 Technical (Hospital) Services HC/HH Wch Supp Catheter Thoracic 32fr__8888570556 PX-2725000034 CDM 2725000034 LOCAL 272 RC inpatient 42 42 HEALTHPARTNERS SX009 HEALTHPARTNERS 33.26 percent of total billed charges 26.04 39.9 Technical (Hospital) Services HC/HH Wch Supp Catheter Thoracic 32fr__8888570556 PX-2725000034 CDM 2725000034 LOCAL 272 RC inpatient 42 42 BLUE CROSS BLUE SHIELD WELLMARK SB889 [3081026] BCBS WYOMING [308102603] 39.9 percent of total billed charges 26.04 39.9 Technical (Hospital) Services HC/HH Wch Supp Catheter Thoracic 32fr__8888570556 PX-2725000034 CDM 2725000034 LOCAL 272 RC inpatient 42 42 MULTIPLAN INC 34080 [3081285] MULTIPLAN INC [308128501] 39.9 percent of total billed charges 26.04 39.9 Technical (Hospital) Services HC/HH Wch Supp Catheter Thoracic 32fr__8888570556 PX-2725000034 CDM 2725000034 LOCAL 272 RC inpatient 42 42 CIGNA 62308 [3081051] CIGNA 62308 [308105105] 33.26 percent of total billed charges 26.04 39.9 Technical (Hospital) Services HC/HH Wch Supp Catheter Thoracic 32fr__8888570556 PX-2725000034 CDM 2725000034 LOCAL 272 RC inpatient 42 42 CIGNA 62308 [3081051] CIGNA STATE OF WYOMING [308105107] 33.26 percent of total billed charges 26.04 39.9 Technical (Hospital) Services HC/HH Wch Supp Catheter Thoracic 32fr__8888570556 PX-2725000034 CDM 2725000034 LOCAL 272 RC inpatient 42 42 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES EPO [308136803] 33.26 percent of total billed charges 26.04 39.9 Technical (Hospital) Services HC/HH Wch Supp Catheter Thoracic 12fr__8888570507 PX-2725000033 CDM 2725000033 LOCAL 272 RC outpatient 41 41 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES HDHP [308136802] 32.8 percent of total billed charges 25.42 38.95 Technical (Hospital) Services HC/HH Wch Supp Catheter Thoracic 12fr__8888570507 PX-2725000033 CDM 2725000033 LOCAL 272 RC outpatient 41 41 BLUE CROSS BLUE SHIELD WELLMARK SB889 [3081026] BCBS WYOMING [308102603] 38.95 percent of total billed charges 25.42 38.95 Technical (Hospital) Services HC/HH Wch Supp Catheter Thoracic 12fr__8888570507 PX-2725000033 CDM 2725000033 LOCAL 272 RC outpatient 41 41 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES EPO [308136803] 32.8 percent of total billed charges 25.42 38.95 Technical (Hospital) Services HC/HH Wch Supp Catheter Thoracic 12fr__8888570507 PX-2725000033 CDM 2725000033 LOCAL 272 RC outpatient 41 41 HEALTHPARTNERS SX009 HEALTHPARTNERS 32.8 percent of total billed charges 25.42 38.95 Technical (Hospital) Services HC/HH Wch Supp Catheter Thoracic 12fr__8888570507 PX-2725000033 CDM 2725000033 LOCAL 272 RC outpatient 41 41 UNITED HEALTHCARE (COMMERCIAL) [3081199] UNITED HEALTHCARE 87726 [308119901] 25.42 percent of total billed charges 25.42 38.95 Technical (Hospital) Services HC/HH Wch Supp Catheter Thoracic 12fr__8888570507 PX-2725000033 CDM 2725000033 LOCAL 272 RC outpatient 41 41 CIGNA 62308 [3081051] CIGNA 62308 [308105105] 32.8 percent of total billed charges 25.42 38.95 Technical (Hospital) Services HC/HH Wch Supp Catheter Thoracic 12fr__8888570507 PX-2725000033 CDM 2725000033 LOCAL 272 RC outpatient 41 41 CIGNA 62308 [3081051] CIGNA STATE OF WYOMING [308105107] 32.8 percent of total billed charges 25.42 38.95 Technical (Hospital) Services HC/HH Wch Supp Catheter Thoracic 12fr__8888570507 PX-2725000033 CDM 2725000033 LOCAL 272 RC outpatient 41 41 MEDICA (COMMERCIAL) 94265 [3081118] MEDICA CLAIMS [308111801] 36.9 percent of total billed charges 25.42 38.95 Technical (Hospital) Services HC/HH Wch Supp Catheter Thoracic 12fr__8888570507 PX-2725000033 CDM 2725000033 LOCAL 272 RC outpatient 41 41 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES PPO [308136801] 32.8 percent of total billed charges 25.42 38.95 Technical (Hospital) Services HC/HH Wch Supp Catheter Thoracic 12fr__8888570507 PX-2725000033 CDM 2725000033 LOCAL 272 RC outpatient 41 41 MULTIPLAN INC 34080 [3081285] MULTIPLAN INC [308128501] 38.95 percent of total billed charges 25.42 38.95 Technical (Hospital) Services HC/HH Wch Supp Catheter Thoracic 12fr__8888570507 PX-2725000033 CDM 2725000033 LOCAL 272 RC inpatient 41 41 CIGNA 62308 [3081051] CIGNA 62308 [308105105] 32.46 percent of total billed charges 25.42 38.95 Technical (Hospital) Services HC/HH Wch Supp Catheter Thoracic 12fr__8888570507 PX-2725000033 CDM 2725000033 LOCAL 272 RC inpatient 41 41 CIGNA 62308 [3081051] CIGNA STATE OF WYOMING [308105107] 32.46 percent of total billed charges 25.42 38.95 Technical (Hospital) Services HC/HH Wch Supp Catheter Thoracic 12fr__8888570507 PX-2725000033 CDM 2725000033 LOCAL 272 RC inpatient 41 41 BLUE CROSS BLUE SHIELD WELLMARK SB889 [3081026] BCBS WYOMING [308102603] 38.95 percent of total billed charges 25.42 38.95 Technical (Hospital) Services HC/HH Wch Supp Catheter Thoracic 12fr__8888570507 PX-2725000033 CDM 2725000033 LOCAL 272 RC inpatient 41 41 MULTIPLAN INC 34080 [3081285] MULTIPLAN INC [308128501] 38.95 percent of total billed charges 25.42 38.95 Technical (Hospital) Services HC/HH Wch Supp Catheter Thoracic 12fr__8888570507 PX-2725000033 CDM 2725000033 LOCAL 272 RC inpatient 41 41 HEALTHPARTNERS SX009 HEALTHPARTNERS 32.46 percent of total billed charges 25.42 38.95 Technical (Hospital) Services HC/HH Wch Supp Catheter Thoracic 12fr__8888570507 PX-2725000033 CDM 2725000033 LOCAL 272 RC inpatient 41 41 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES EPO [308136803] 32.46 percent of total billed charges 25.42 38.95 Technical (Hospital) Services HC/HH Wch Supp Catheter Thoracic 12fr__8888570507 PX-2725000033 CDM 2725000033 LOCAL 272 RC inpatient 41 41 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES HDHP [308136802] 32.46 percent of total billed charges 25.42 38.95 Technical (Hospital) Services HC/HH Wch Supp Catheter Thoracic 12fr__8888570507 PX-2725000033 CDM 2725000033 LOCAL 272 RC inpatient 41 41 UNITED HEALTHCARE (COMMERCIAL) [3081199] UNITED HEALTHCARE 87726 [308119901] 25.42 percent of total billed charges 25.42 38.95 Technical (Hospital) Services HC/HH Wch Supp Catheter Thoracic 12fr__8888570507 PX-2725000033 CDM 2725000033 LOCAL 272 RC inpatient 41 41 MEDICA (COMMERCIAL) 94265 [3081118] MEDICA CLAIMS [308111801] 36.9 percent of total billed charges 25.42 38.95 Technical (Hospital) Services HC/HH Wch Supp Catheter Thoracic 12fr__8888570507 PX-2725000033 CDM 2725000033 LOCAL 272 RC inpatient 41 41 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES PPO [308136801] 32.46 percent of total billed charges 25.42 38.95 Technical (Hospital) Services HC/HH Wch Supp Catheter Delee 8fr Mucus Trap__8888257378 PX-2725000032 CDM 2725000032 LOCAL 272 RC inpatient 15 15 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES PPO [308136801] 11.88 percent of total billed charges 9.3 14.25 Technical (Hospital) Services HC/HH Wch Supp Catheter Delee 8fr Mucus Trap__8888257378 PX-2725000032 CDM 2725000032 LOCAL 272 RC inpatient 15 15 MEDICA (COMMERCIAL) 94265 [3081118] MEDICA CLAIMS [308111801] 13.5 percent of total billed charges 9.3 14.25 Technical (Hospital) Services HC/HH Wch Supp Catheter Delee 8fr Mucus Trap__8888257378 PX-2725000032 CDM 2725000032 LOCAL 272 RC inpatient 15 15 UNITED HEALTHCARE (COMMERCIAL) [3081199] UNITED HEALTHCARE 87726 [308119901] 9.3 percent of total billed charges 9.3 14.25 Technical (Hospital) Services HC/HH Wch Supp Catheter Delee 8fr Mucus Trap__8888257378 PX-2725000032 CDM 2725000032 LOCAL 272 RC inpatient 15 15 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES HDHP [308136802] 11.88 percent of total billed charges 9.3 14.25 Technical (Hospital) Services HC/HH Wch Supp Catheter Delee 8fr Mucus Trap__8888257378 PX-2725000032 CDM 2725000032 LOCAL 272 RC inpatient 15 15 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES EPO [308136803] 11.88 percent of total billed charges 9.3 14.25 Technical (Hospital) Services HC/HH Wch Supp Catheter Delee 8fr Mucus Trap__8888257378 PX-2725000032 CDM 2725000032 LOCAL 272 RC inpatient 15 15 HEALTHPARTNERS SX009 HEALTHPARTNERS 11.88 percent of total billed charges 9.3 14.25 Technical (Hospital) Services HC/HH Wch Supp Catheter Delee 8fr Mucus Trap__8888257378 PX-2725000032 CDM 2725000032 LOCAL 272 RC inpatient 15 15 MULTIPLAN INC 34080 [3081285] MULTIPLAN INC [308128501] 14.25 percent of total billed charges 9.3 14.25 Technical (Hospital) Services HC/HH Wch Supp Catheter Delee 8fr Mucus Trap__8888257378 PX-2725000032 CDM 2725000032 LOCAL 272 RC inpatient 15 15 BLUE CROSS BLUE SHIELD WELLMARK SB889 [3081026] BCBS WYOMING [308102603] 14.25 percent of total billed charges 9.3 14.25 Technical (Hospital) Services HC/HH Wch Supp Catheter Delee 8fr Mucus Trap__8888257378 PX-2725000032 CDM 2725000032 LOCAL 272 RC inpatient 15 15 CIGNA 62308 [3081051] CIGNA 62308 [308105105] 11.88 percent of total billed charges 9.3 14.25 Technical (Hospital) Services HC/HH Wch Supp Catheter Delee 8fr Mucus Trap__8888257378 PX-2725000032 CDM 2725000032 LOCAL 272 RC inpatient 15 15 CIGNA 62308 [3081051] CIGNA STATE OF WYOMING [308105107] 11.88 percent of total billed charges 9.3 14.25 Technical (Hospital) Services HC/HH Wch Supp Catheter Delee 8fr Mucus Trap__8888257378 PX-2725000032 CDM 2725000032 LOCAL 272 RC outpatient 15 15 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES HDHP [308136802] 12 percent of total billed charges 9.3 14.25 Technical (Hospital) Services HC/HH Wch Supp Catheter Delee 8fr Mucus Trap__8888257378 PX-2725000032 CDM 2725000032 LOCAL 272 RC outpatient 15 15 BLUE CROSS BLUE SHIELD WELLMARK SB889 [3081026] BCBS WYOMING [308102603] 14.25 percent of total billed charges 9.3 14.25 Technical (Hospital) Services HC/HH Wch Supp Catheter Delee 8fr Mucus Trap__8888257378 PX-2725000032 CDM 2725000032 LOCAL 272 RC outpatient 15 15 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES EPO [308136803] 12 percent of total billed charges 9.3 14.25 Technical (Hospital) Services HC/HH Wch Supp Catheter Delee 8fr Mucus Trap__8888257378 PX-2725000032 CDM 2725000032 LOCAL 272 RC outpatient 15 15 CIGNA 62308 [3081051] CIGNA 62308 [308105105] 12 percent of total billed charges 9.3 14.25 Technical (Hospital) Services HC/HH Wch Supp Catheter Delee 8fr Mucus Trap__8888257378 PX-2725000032 CDM 2725000032 LOCAL 272 RC outpatient 15 15 CIGNA 62308 [3081051] CIGNA STATE OF WYOMING [308105107] 12 percent of total billed charges 9.3 14.25 Technical (Hospital) Services HC/HH Wch Supp Catheter Delee 8fr Mucus Trap__8888257378 PX-2725000032 CDM 2725000032 LOCAL 272 RC outpatient 15 15 UNITED HEALTHCARE (COMMERCIAL) [3081199] UNITED HEALTHCARE 87726 [308119901] 9.3 percent of total billed charges 9.3 14.25 Technical (Hospital) Services HC/HH Wch Supp Catheter Delee 8fr Mucus Trap__8888257378 PX-2725000032 CDM 2725000032 LOCAL 272 RC outpatient 15 15 HEALTHPARTNERS SX009 HEALTHPARTNERS 12 percent of total billed charges 9.3 14.25 Technical (Hospital) Services HC/HH Wch Supp Catheter Delee 8fr Mucus Trap__8888257378 PX-2725000032 CDM 2725000032 LOCAL 272 RC outpatient 15 15 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES PPO [308136801] 12 percent of total billed charges 9.3 14.25 Technical (Hospital) Services HC/HH Wch Supp Catheter Delee 8fr Mucus Trap__8888257378 PX-2725000032 CDM 2725000032 LOCAL 272 RC outpatient 15 15 MEDICA (COMMERCIAL) 94265 [3081118] MEDICA CLAIMS [308111801] 13.5 percent of total billed charges 9.3 14.25 Technical (Hospital) Services HC/HH Wch Supp Catheter Delee 8fr Mucus Trap__8888257378 PX-2725000032 CDM 2725000032 LOCAL 272 RC outpatient 15 15 MULTIPLAN INC 34080 [3081285] MULTIPLAN INC [308128501] 14.25 percent of total billed charges 9.3 14.25 Technical (Hospital) Services HC/HH Wch Supp Cath-Foley 24fr 30cc__0166l 24 PX-2725000031 CDM 2725000031 LOCAL 272 RC outpatient 65 65 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES HDHP [308136802] 52 percent of total billed charges 40.3 61.75 Technical (Hospital) Services HC/HH Wch Supp Cath-Foley 24fr 30cc__0166l 24 PX-2725000031 CDM 2725000031 LOCAL 272 RC outpatient 65 65 BLUE CROSS BLUE SHIELD WELLMARK SB889 [3081026] BCBS WYOMING [308102603] 61.75 percent of total billed charges 40.3 61.75 Technical (Hospital) Services HC/HH Wch Supp Cath-Foley 24fr 30cc__0166l 24 PX-2725000031 CDM 2725000031 LOCAL 272 RC outpatient 65 65 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES EPO [308136803] 52 percent of total billed charges 40.3 61.75 Technical (Hospital) Services HC/HH Wch Supp Cath-Foley 24fr 30cc__0166l 24 PX-2725000031 CDM 2725000031 LOCAL 272 RC outpatient 65 65 CIGNA 62308 [3081051] CIGNA 62308 [308105105] 52 percent of total billed charges 40.3 61.75 Technical (Hospital) Services HC/HH Wch Supp Cath-Foley 24fr 30cc__0166l 24 PX-2725000031 CDM 2725000031 LOCAL 272 RC outpatient 65 65 CIGNA 62308 [3081051] CIGNA STATE OF WYOMING [308105107] 52 percent of total billed charges 40.3 61.75 Technical (Hospital) Services HC/HH Wch Supp Cath-Foley 24fr 30cc__0166l 24 PX-2725000031 CDM 2725000031 LOCAL 272 RC outpatient 65 65 UNITED HEALTHCARE (COMMERCIAL) [3081199] UNITED HEALTHCARE 87726 [308119901] 40.3 percent of total billed charges 40.3 61.75 Technical (Hospital) Services HC/HH Wch Supp Cath-Foley 24fr 30cc__0166l 24 PX-2725000031 CDM 2725000031 LOCAL 272 RC outpatient 65 65 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES PPO [308136801] 52 percent of total billed charges 40.3 61.75 Technical (Hospital) Services HC/HH Wch Supp Cath-Foley 24fr 30cc__0166l 24 PX-2725000031 CDM 2725000031 LOCAL 272 RC outpatient 65 65 HEALTHPARTNERS SX009 HEALTHPARTNERS 52 percent of total billed charges 40.3 61.75 Technical (Hospital) Services HC/HH Wch Supp Cath-Foley 24fr 30cc__0166l 24 PX-2725000031 CDM 2725000031 LOCAL 272 RC outpatient 65 65 MULTIPLAN INC 34080 [3081285] MULTIPLAN INC [308128501] 61.75 percent of total billed charges 40.3 61.75 Technical (Hospital) Services HC/HH Wch Supp Cath-Foley 24fr 30cc__0166l 24 PX-2725000031 CDM 2725000031 LOCAL 272 RC outpatient 65 65 MEDICA (COMMERCIAL) 94265 [3081118] MEDICA CLAIMS [308111801] 58.5 percent of total billed charges 40.3 61.75 Technical (Hospital) Services HC/HH Wch Supp Cath-Foley 24fr 30cc__0166l 24 PX-2725000031 CDM 2725000031 LOCAL 272 RC inpatient 65 65 HEALTHPARTNERS SX009 HEALTHPARTNERS 51.47 percent of total billed charges 40.3 61.75 Technical (Hospital) Services HC/HH Wch Supp Cath-Foley 24fr 30cc__0166l 24 PX-2725000031 CDM 2725000031 LOCAL 272 RC inpatient 65 65 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES EPO [308136803] 51.47 percent of total billed charges 40.3 61.75 Technical (Hospital) Services HC/HH Wch Supp Cath-Foley 24fr 30cc__0166l 24 PX-2725000031 CDM 2725000031 LOCAL 272 RC inpatient 65 65 MULTIPLAN INC 34080 [3081285] MULTIPLAN INC [308128501] 61.75 percent of total billed charges 40.3 61.75 Technical (Hospital) Services HC/HH Wch Supp Cath-Foley 24fr 30cc__0166l 24 PX-2725000031 CDM 2725000031 LOCAL 272 RC inpatient 65 65 BLUE CROSS BLUE SHIELD WELLMARK SB889 [3081026] BCBS WYOMING [308102603] 61.75 percent of total billed charges 40.3 61.75 Technical (Hospital) Services HC/HH Wch Supp Cath-Foley 24fr 30cc__0166l 24 PX-2725000031 CDM 2725000031 LOCAL 272 RC inpatient 65 65 CIGNA 62308 [3081051] CIGNA 62308 [308105105] 51.47 percent of total billed charges 40.3 61.75 Technical (Hospital) Services HC/HH Wch Supp Cath-Foley 24fr 30cc__0166l 24 PX-2725000031 CDM 2725000031 LOCAL 272 RC inpatient 65 65 CIGNA 62308 [3081051] CIGNA STATE OF WYOMING [308105107] 51.47 percent of total billed charges 40.3 61.75 Technical (Hospital) Services HC/HH Wch Supp Cath-Foley 24fr 30cc__0166l 24 PX-2725000031 CDM 2725000031 LOCAL 272 RC inpatient 65 65 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES PPO [308136801] 51.47 percent of total billed charges 40.3 61.75 Technical (Hospital) Services HC/HH Wch Supp Cath-Foley 24fr 30cc__0166l 24 PX-2725000031 CDM 2725000031 LOCAL 272 RC inpatient 65 65 MEDICA (COMMERCIAL) 94265 [3081118] MEDICA CLAIMS [308111801] 58.5 percent of total billed charges 40.3 61.75 Technical (Hospital) Services HC/HH Wch Supp Cath-Foley 24fr 30cc__0166l 24 PX-2725000031 CDM 2725000031 LOCAL 272 RC inpatient 65 65 UNITED HEALTHCARE (COMMERCIAL) [3081199] UNITED HEALTHCARE 87726 [308119901] 40.3 percent of total billed charges 40.3 61.75 Technical (Hospital) Services HC/HH Wch Supp Cath-Foley 24fr 30cc__0166l 24 PX-2725000031 CDM 2725000031 LOCAL 272 RC inpatient 65 65 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES HDHP [308136802] 51.47 percent of total billed charges 40.3 61.75 Technical (Hospital) Services HC/HH Wch Supp Cath Suction 14f Straight__31400 PX-2725000030 CDM 2725000030 LOCAL 272 RC inpatient 8 8 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES EPO [308136803] 6.33 percent of total billed charges 4.96 7.6 Technical (Hospital) Services HC/HH Wch Supp Cath Suction 14f Straight__31400 PX-2725000030 CDM 2725000030 LOCAL 272 RC inpatient 8 8 MULTIPLAN INC 34080 [3081285] MULTIPLAN INC [308128501] 7.6 percent of total billed charges 4.96 7.6 Technical (Hospital) Services HC/HH Wch Supp Cath Suction 14f Straight__31400 PX-2725000030 CDM 2725000030 LOCAL 272 RC inpatient 8 8 BLUE CROSS BLUE SHIELD WELLMARK SB889 [3081026] BCBS WYOMING [308102603] 7.6 percent of total billed charges 4.96 7.6 Technical (Hospital) Services HC/HH Wch Supp Cath Suction 14f Straight__31400 PX-2725000030 CDM 2725000030 LOCAL 272 RC inpatient 8 8 HEALTHPARTNERS SX009 HEALTHPARTNERS 6.33 percent of total billed charges 4.96 7.6 Technical (Hospital) Services HC/HH Wch Supp Cath Suction 14f Straight__31400 PX-2725000030 CDM 2725000030 LOCAL 272 RC inpatient 8 8 CIGNA 62308 [3081051] CIGNA 62308 [308105105] 6.33 percent of total billed charges 4.96 7.6 Technical (Hospital) Services HC/HH Wch Supp Cath Suction 14f Straight__31400 PX-2725000030 CDM 2725000030 LOCAL 272 RC inpatient 8 8 CIGNA 62308 [3081051] CIGNA STATE OF WYOMING [308105107] 6.33 percent of total billed charges 4.96 7.6 Technical (Hospital) Services HC/HH Wch Supp Cath Suction 14f Straight__31400 PX-2725000030 CDM 2725000030 LOCAL 272 RC inpatient 8 8 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES HDHP [308136802] 6.33 percent of total billed charges 4.96 7.6 Technical (Hospital) Services HC/HH Wch Supp Cath Suction 14f Straight__31400 PX-2725000030 CDM 2725000030 LOCAL 272 RC inpatient 8 8 UNITED HEALTHCARE (COMMERCIAL) [3081199] UNITED HEALTHCARE 87726 [308119901] 4.96 percent of total billed charges 4.96 7.6 Technical (Hospital) Services HC/HH Wch Supp Cath Suction 14f Straight__31400 PX-2725000030 CDM 2725000030 LOCAL 272 RC inpatient 8 8 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES PPO [308136801] 6.33 percent of total billed charges 4.96 7.6 Technical (Hospital) Services HC/HH Wch Supp Cath Suction 14f Straight__31400 PX-2725000030 CDM 2725000030 LOCAL 272 RC inpatient 8 8 MEDICA (COMMERCIAL) 94265 [3081118] MEDICA CLAIMS [308111801] 7.2 percent of total billed charges 4.96 7.6 Technical (Hospital) Services HC/HH Wch Supp Cath Suction 14f Straight__31400 PX-2725000030 CDM 2725000030 LOCAL 272 RC outpatient 8 8 CIGNA 62308 [3081051] CIGNA 62308 [308105105] 6.4 percent of total billed charges 4.96 7.6 Technical (Hospital) Services HC/HH Wch Supp Cath Suction 14f Straight__31400 PX-2725000030 CDM 2725000030 LOCAL 272 RC outpatient 8 8 CIGNA 62308 [3081051] CIGNA STATE OF WYOMING [308105107] 6.4 percent of total billed charges 4.96 7.6 Technical (Hospital) Services HC/HH Wch Supp Cath Suction 14f Straight__31400 PX-2725000030 CDM 2725000030 LOCAL 272 RC outpatient 8 8 UNITED HEALTHCARE (COMMERCIAL) [3081199] UNITED HEALTHCARE 87726 [308119901] 4.96 percent of total billed charges 4.96 7.6 Technical (Hospital) Services HC/HH Wch Supp Cath Suction 14f Straight__31400 PX-2725000030 CDM 2725000030 LOCAL 272 RC outpatient 8 8 HEALTHPARTNERS SX009 HEALTHPARTNERS 6.4 percent of total billed charges 4.96 7.6 Technical (Hospital) Services HC/HH Wch Supp Cath Suction 14f Straight__31400 PX-2725000030 CDM 2725000030 LOCAL 272 RC outpatient 8 8 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES PPO [308136801] 6.4 percent of total billed charges 4.96 7.6 Technical (Hospital) Services HC/HH Wch Supp Cath Suction 14f Straight__31400 PX-2725000030 CDM 2725000030 LOCAL 272 RC outpatient 8 8 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES HDHP [308136802] 6.4 percent of total billed charges 4.96 7.6 Technical (Hospital) Services HC/HH Wch Supp Cath Suction 14f Straight__31400 PX-2725000030 CDM 2725000030 LOCAL 272 RC outpatient 8 8 BLUE CROSS BLUE SHIELD WELLMARK SB889 [3081026] BCBS WYOMING [308102603] 7.6 percent of total billed charges 4.96 7.6 Technical (Hospital) Services HC/HH Wch Supp Cath Suction 14f Straight__31400 PX-2725000030 CDM 2725000030 LOCAL 272 RC outpatient 8 8 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES EPO [308136803] 6.4 percent of total billed charges 4.96 7.6 Technical (Hospital) Services HC/HH Wch Supp Cath Suction 14f Straight__31400 PX-2725000030 CDM 2725000030 LOCAL 272 RC outpatient 8 8 MEDICA (COMMERCIAL) 94265 [3081118] MEDICA CLAIMS [308111801] 7.2 percent of total billed charges 4.96 7.6 Technical (Hospital) Services HC/HH Wch Supp Cath Suction 14f Straight__31400 PX-2725000030 CDM 2725000030 LOCAL 272 RC outpatient 8 8 MULTIPLAN INC 34080 [3081285] MULTIPLAN INC [308128501] 7.6 percent of total billed charges 4.96 7.6 Technical (Hospital) Services HC/HH Wch Supp Cath Suction 10fr__31000 PX-2725000029 CDM 2725000029 LOCAL 272 RC outpatient 6 6 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES HDHP [308136802] 4.8 percent of total billed charges 3.72 5.7 Technical (Hospital) Services HC/HH Wch Supp Cath Suction 10fr__31000 PX-2725000029 CDM 2725000029 LOCAL 272 RC outpatient 6 6 BLUE CROSS BLUE SHIELD WELLMARK SB889 [3081026] BCBS WYOMING [308102603] 5.7 percent of total billed charges 3.72 5.7 Technical (Hospital) Services HC/HH Wch Supp Cath Suction 10fr__31000 PX-2725000029 CDM 2725000029 LOCAL 272 RC outpatient 6 6 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES EPO [308136803] 4.8 percent of total billed charges 3.72 5.7 Technical (Hospital) Services HC/HH Wch Supp Cath Suction 10fr__31000 PX-2725000029 CDM 2725000029 LOCAL 272 RC outpatient 6 6 CIGNA 62308 [3081051] CIGNA 62308 [308105105] 4.8 percent of total billed charges 3.72 5.7 Technical (Hospital) Services HC/HH Wch Supp Cath Suction 10fr__31000 PX-2725000029 CDM 2725000029 LOCAL 272 RC outpatient 6 6 CIGNA 62308 [3081051] CIGNA STATE OF WYOMING [308105107] 4.8 percent of total billed charges 3.72 5.7 Technical (Hospital) Services HC/HH Wch Supp Cath Suction 10fr__31000 PX-2725000029 CDM 2725000029 LOCAL 272 RC outpatient 6 6 UNITED HEALTHCARE (COMMERCIAL) [3081199] UNITED HEALTHCARE 87726 [308119901] 3.72 percent of total billed charges 3.72 5.7 Technical (Hospital) Services HC/HH Wch Supp Cath Suction 10fr__31000 PX-2725000029 CDM 2725000029 LOCAL 272 RC outpatient 6 6 HEALTHPARTNERS SX009 HEALTHPARTNERS 4.8 percent of total billed charges 3.72 5.7 Technical (Hospital) Services HC/HH Wch Supp Cath Suction 10fr__31000 PX-2725000029 CDM 2725000029 LOCAL 272 RC outpatient 6 6 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES PPO [308136801] 4.8 percent of total billed charges 3.72 5.7 Technical (Hospital) Services HC/HH Wch Supp Cath Suction 10fr__31000 PX-2725000029 CDM 2725000029 LOCAL 272 RC outpatient 6 6 MEDICA (COMMERCIAL) 94265 [3081118] MEDICA CLAIMS [308111801] 5.4 percent of total billed charges 3.72 5.7 Technical (Hospital) Services HC/HH Wch Supp Cath Suction 10fr__31000 PX-2725000029 CDM 2725000029 LOCAL 272 RC outpatient 6 6 MULTIPLAN INC 34080 [3081285] MULTIPLAN INC [308128501] 5.7 percent of total billed charges 3.72 5.7 Technical (Hospital) Services HC/HH Wch Supp Cath Suction 10fr__31000 PX-2725000029 CDM 2725000029 LOCAL 272 RC inpatient 6 6 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES PPO [308136801] 4.75 percent of total billed charges 3.72 5.7 Technical (Hospital) Services HC/HH Wch Supp Cath Suction 10fr__31000 PX-2725000029 CDM 2725000029 LOCAL 272 RC inpatient 6 6 MEDICA (COMMERCIAL) 94265 [3081118] MEDICA CLAIMS [308111801] 5.4 percent of total billed charges 3.72 5.7 Technical (Hospital) Services HC/HH Wch Supp Cath Suction 10fr__31000 PX-2725000029 CDM 2725000029 LOCAL 272 RC inpatient 6 6 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES HDHP [308136802] 4.75 percent of total billed charges 3.72 5.7 Technical (Hospital) Services HC/HH Wch Supp Cath Suction 10fr__31000 PX-2725000029 CDM 2725000029 LOCAL 272 RC inpatient 6 6 UNITED HEALTHCARE (COMMERCIAL) [3081199] UNITED HEALTHCARE 87726 [308119901] 3.72 percent of total billed charges 3.72 5.7 Technical (Hospital) Services HC/HH Wch Supp Cath Suction 10fr__31000 PX-2725000029 CDM 2725000029 LOCAL 272 RC inpatient 6 6 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES EPO [308136803] 4.75 percent of total billed charges 3.72 5.7 Technical (Hospital) Services HC/HH Wch Supp Cath Suction 10fr__31000 PX-2725000029 CDM 2725000029 LOCAL 272 RC inpatient 6 6 HEALTHPARTNERS SX009 HEALTHPARTNERS 4.75 percent of total billed charges 3.72 5.7 Technical (Hospital) Services HC/HH Wch Supp Cath Suction 10fr__31000 PX-2725000029 CDM 2725000029 LOCAL 272 RC inpatient 6 6 BLUE CROSS BLUE SHIELD WELLMARK SB889 [3081026] BCBS WYOMING [308102603] 5.7 percent of total billed charges 3.72 5.7 Technical (Hospital) Services HC/HH Wch Supp Cath Suction 10fr__31000 PX-2725000029 CDM 2725000029 LOCAL 272 RC inpatient 6 6 MULTIPLAN INC 34080 [3081285] MULTIPLAN INC [308128501] 5.7 percent of total billed charges 3.72 5.7 Technical (Hospital) Services HC/HH Wch Supp Cath Suction 10fr__31000 PX-2725000029 CDM 2725000029 LOCAL 272 RC inpatient 6 6 CIGNA 62308 [3081051] CIGNA 62308 [308105105] 4.75 percent of total billed charges 3.72 5.7 Technical (Hospital) Services HC/HH Wch Supp Cath Suction 10fr__31000 PX-2725000029 CDM 2725000029 LOCAL 272 RC inpatient 6 6 CIGNA 62308 [3081051] CIGNA STATE OF WYOMING [308105107] 4.75 percent of total billed charges 3.72 5.7 Technical (Hospital) Services HC/HH Wch Supp Cath Foley8 Fr.3cc__165808 PX-2725000028 CDM 2725000028 LOCAL 272 RC inpatient 25 25 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES EPO [308136803] 19.8 percent of total billed charges 15.5 23.75 Technical (Hospital) Services HC/HH Wch Supp Cath Foley8 Fr.3cc__165808 PX-2725000028 CDM 2725000028 LOCAL 272 RC inpatient 25 25 HEALTHPARTNERS SX009 HEALTHPARTNERS 19.8 percent of total billed charges 15.5 23.75 Technical (Hospital) Services HC/HH Wch Supp Cath Foley8 Fr.3cc__165808 PX-2725000028 CDM 2725000028 LOCAL 272 RC inpatient 25 25 BLUE CROSS BLUE SHIELD WELLMARK SB889 [3081026] BCBS WYOMING [308102603] 23.75 percent of total billed charges 15.5 23.75 Technical (Hospital) Services HC/HH Wch Supp Cath Foley8 Fr.3cc__165808 PX-2725000028 CDM 2725000028 LOCAL 272 RC inpatient 25 25 MULTIPLAN INC 34080 [3081285] MULTIPLAN INC [308128501] 23.75 percent of total billed charges 15.5 23.75 Technical (Hospital) Services HC/HH Wch Supp Cath Foley8 Fr.3cc__165808 PX-2725000028 CDM 2725000028 LOCAL 272 RC inpatient 25 25 CIGNA 62308 [3081051] CIGNA 62308 [308105105] 19.8 percent of total billed charges 15.5 23.75 Technical (Hospital) Services HC/HH Wch Supp Cath Foley8 Fr.3cc__165808 PX-2725000028 CDM 2725000028 LOCAL 272 RC inpatient 25 25 CIGNA 62308 [3081051] CIGNA STATE OF WYOMING [308105107] 19.8 percent of total billed charges 15.5 23.75 Technical (Hospital) Services HC/HH Wch Supp Cath Foley8 Fr.3cc__165808 PX-2725000028 CDM 2725000028 LOCAL 272 RC inpatient 25 25 UNITED HEALTHCARE (COMMERCIAL) [3081199] UNITED HEALTHCARE 87726 [308119901] 15.5 percent of total billed charges 15.5 23.75 Technical (Hospital) Services HC/HH Wch Supp Cath Foley8 Fr.3cc__165808 PX-2725000028 CDM 2725000028 LOCAL 272 RC inpatient 25 25 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES HDHP [308136802] 19.8 percent of total billed charges 15.5 23.75 Technical (Hospital) Services HC/HH Wch Supp Cath Foley8 Fr.3cc__165808 PX-2725000028 CDM 2725000028 LOCAL 272 RC inpatient 25 25 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES PPO [308136801] 19.8 percent of total billed charges 15.5 23.75 Technical (Hospital) Services HC/HH Wch Supp Cath Foley8 Fr.3cc__165808 PX-2725000028 CDM 2725000028 LOCAL 272 RC inpatient 25 25 MEDICA (COMMERCIAL) 94265 [3081118] MEDICA CLAIMS [308111801] 22.5 percent of total billed charges 15.5 23.75 Technical (Hospital) Services HC/HH Wch Supp Cath Foley8 Fr.3cc__165808 PX-2725000028 CDM 2725000028 LOCAL 272 RC outpatient 25 25 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES HDHP [308136802] 20 percent of total billed charges 15.5 23.75 Technical (Hospital) Services HC/HH Wch Supp Cath Foley8 Fr.3cc__165808 PX-2725000028 CDM 2725000028 LOCAL 272 RC outpatient 25 25 BLUE CROSS BLUE SHIELD WELLMARK SB889 [3081026] BCBS WYOMING [308102603] 23.75 percent of total billed charges 15.5 23.75 Technical (Hospital) Services HC/HH Wch Supp Cath Foley8 Fr.3cc__165808 PX-2725000028 CDM 2725000028 LOCAL 272 RC outpatient 25 25 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES EPO [308136803] 20 percent of total billed charges 15.5 23.75 Technical (Hospital) Services HC/HH Wch Supp Cath Foley8 Fr.3cc__165808 PX-2725000028 CDM 2725000028 LOCAL 272 RC outpatient 25 25 HEALTHPARTNERS SX009 HEALTHPARTNERS 20 percent of total billed charges 15.5 23.75 Technical (Hospital) Services HC/HH Wch Supp Cath Foley8 Fr.3cc__165808 PX-2725000028 CDM 2725000028 LOCAL 272 RC outpatient 25 25 UNITED HEALTHCARE (COMMERCIAL) [3081199] UNITED HEALTHCARE 87726 [308119901] 15.5 percent of total billed charges 15.5 23.75 Technical (Hospital) Services HC/HH Wch Supp Cath Foley8 Fr.3cc__165808 PX-2725000028 CDM 2725000028 LOCAL 272 RC outpatient 25 25 CIGNA 62308 [3081051] CIGNA 62308 [308105105] 20 percent of total billed charges 15.5 23.75 Technical (Hospital) Services HC/HH Wch Supp Cath Foley8 Fr.3cc__165808 PX-2725000028 CDM 2725000028 LOCAL 272 RC outpatient 25 25 CIGNA 62308 [3081051] CIGNA STATE OF WYOMING [308105107] 20 percent of total billed charges 15.5 23.75 Technical (Hospital) Services HC/HH Wch Supp Cath Foley8 Fr.3cc__165808 PX-2725000028 CDM 2725000028 LOCAL 272 RC outpatient 25 25 MEDICA (COMMERCIAL) 94265 [3081118] MEDICA CLAIMS [308111801] 22.5 percent of total billed charges 15.5 23.75 Technical (Hospital) Services HC/HH Wch Supp Cath Foley8 Fr.3cc__165808 PX-2725000028 CDM 2725000028 LOCAL 272 RC outpatient 25 25 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES PPO [308136801] 20 percent of total billed charges 15.5 23.75 Technical (Hospital) Services HC/HH Wch Supp Cath Foley8 Fr.3cc__165808 PX-2725000028 CDM 2725000028 LOCAL 272 RC outpatient 25 25 MULTIPLAN INC 34080 [3081285] MULTIPLAN INC [308128501] 23.75 percent of total billed charges 15.5 23.75 Technical (Hospital) Services HC/HH Wch Supp Cath Foley16 Fr 5cc__265716 PX-2725000027 CDM 2725000027 LOCAL 272 RC inpatient 15 15 HEALTHPARTNERS SX009 HEALTHPARTNERS 11.88 percent of total billed charges 9.3 14.25 Technical (Hospital) Services HC/HH Wch Supp Cath Foley16 Fr 5cc__265716 PX-2725000027 CDM 2725000027 LOCAL 272 RC inpatient 15 15 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES EPO [308136803] 11.88 percent of total billed charges 9.3 14.25 Technical (Hospital) Services HC/HH Wch Supp Cath Foley16 Fr 5cc__265716 PX-2725000027 CDM 2725000027 LOCAL 272 RC inpatient 15 15 MULTIPLAN INC 34080 [3081285] MULTIPLAN INC [308128501] 14.25 percent of total billed charges 9.3 14.25 Technical (Hospital) Services HC/HH Wch Supp Cath Foley16 Fr 5cc__265716 PX-2725000027 CDM 2725000027 LOCAL 272 RC inpatient 15 15 BLUE CROSS BLUE SHIELD WELLMARK SB889 [3081026] BCBS WYOMING [308102603] 14.25 percent of total billed charges 9.3 14.25 Technical (Hospital) Services HC/HH Wch Supp Cath Foley16 Fr 5cc__265716 PX-2725000027 CDM 2725000027 LOCAL 272 RC inpatient 15 15 CIGNA 62308 [3081051] CIGNA 62308 [308105105] 11.88 percent of total billed charges 9.3 14.25 Technical (Hospital) Services HC/HH Wch Supp Cath Foley16 Fr 5cc__265716 PX-2725000027 CDM 2725000027 LOCAL 272 RC inpatient 15 15 CIGNA 62308 [3081051] CIGNA STATE OF WYOMING [308105107] 11.88 percent of total billed charges 9.3 14.25 Technical (Hospital) Services HC/HH Wch Supp Cath Foley16 Fr 5cc__265716 PX-2725000027 CDM 2725000027 LOCAL 272 RC inpatient 15 15 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES HDHP [308136802] 11.88 percent of total billed charges 9.3 14.25 Technical (Hospital) Services HC/HH Wch Supp Cath Foley16 Fr 5cc__265716 PX-2725000027 CDM 2725000027 LOCAL 272 RC inpatient 15 15 UNITED HEALTHCARE (COMMERCIAL) [3081199] UNITED HEALTHCARE 87726 [308119901] 9.3 percent of total billed charges 9.3 14.25 Technical (Hospital) Services HC/HH Wch Supp Cath Foley16 Fr 5cc__265716 PX-2725000027 CDM 2725000027 LOCAL 272 RC inpatient 15 15 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES PPO [308136801] 11.88 percent of total billed charges 9.3 14.25 Technical (Hospital) Services HC/HH Wch Supp Cath Foley16 Fr 5cc__265716 PX-2725000027 CDM 2725000027 LOCAL 272 RC inpatient 15 15 MEDICA (COMMERCIAL) 94265 [3081118] MEDICA CLAIMS [308111801] 13.5 percent of total billed charges 9.3 14.25 Technical (Hospital) Services HC/HH Wch Supp Cath Foley16 Fr 5cc__265716 PX-2725000027 CDM 2725000027 LOCAL 272 RC outpatient 15 15 UNITED HEALTHCARE (COMMERCIAL) [3081199] UNITED HEALTHCARE 87726 [308119901] 9.3 percent of total billed charges 9.3 14.25 Technical (Hospital) Services HC/HH Wch Supp Cath Foley16 Fr 5cc__265716 PX-2725000027 CDM 2725000027 LOCAL 272 RC outpatient 15 15 HEALTHPARTNERS SX009 HEALTHPARTNERS 12 percent of total billed charges 9.3 14.25 Technical (Hospital) Services HC/HH Wch Supp Cath Foley16 Fr 5cc__265716 PX-2725000027 CDM 2725000027 LOCAL 272 RC outpatient 15 15 CIGNA 62308 [3081051] CIGNA 62308 [308105105] 12 percent of total billed charges 9.3 14.25 Technical (Hospital) Services HC/HH Wch Supp Cath Foley16 Fr 5cc__265716 PX-2725000027 CDM 2725000027 LOCAL 272 RC outpatient 15 15 CIGNA 62308 [3081051] CIGNA STATE OF WYOMING [308105107] 12 percent of total billed charges 9.3 14.25 Technical (Hospital) Services HC/HH Wch Supp Cath Foley16 Fr 5cc__265716 PX-2725000027 CDM 2725000027 LOCAL 272 RC outpatient 15 15 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES HDHP [308136802] 12 percent of total billed charges 9.3 14.25 Technical (Hospital) Services HC/HH Wch Supp Cath Foley16 Fr 5cc__265716 PX-2725000027 CDM 2725000027 LOCAL 272 RC outpatient 15 15 BLUE CROSS BLUE SHIELD WELLMARK SB889 [3081026] BCBS WYOMING [308102603] 14.25 percent of total billed charges 9.3 14.25 Technical (Hospital) Services HC/HH Wch Supp Cath Foley16 Fr 5cc__265716 PX-2725000027 CDM 2725000027 LOCAL 272 RC outpatient 15 15 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES EPO [308136803] 12 percent of total billed charges 9.3 14.25 Technical (Hospital) Services HC/HH Wch Supp Cath Foley16 Fr 5cc__265716 PX-2725000027 CDM 2725000027 LOCAL 272 RC outpatient 15 15 MULTIPLAN INC 34080 [3081285] MULTIPLAN INC [308128501] 14.25 percent of total billed charges 9.3 14.25 Technical (Hospital) Services HC/HH Wch Supp Cath Foley16 Fr 5cc__265716 PX-2725000027 CDM 2725000027 LOCAL 272 RC outpatient 15 15 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES PPO [308136801] 12 percent of total billed charges 9.3 14.25 Technical (Hospital) Services HC/HH Wch Supp Cath Foley16 Fr 5cc__265716 PX-2725000027 CDM 2725000027 LOCAL 272 RC outpatient 15 15 MEDICA (COMMERCIAL) 94265 [3081118] MEDICA CLAIMS [308111801] 13.5 percent of total billed charges 9.3 14.25 Technical (Hospital) Services HC/HH Wch Supp Cath Foley14 Fr 30cc__266714 PX-2725000026 CDM 2725000026 LOCAL 272 RC inpatient 18 18 MEDICA (COMMERCIAL) 94265 [3081118] MEDICA CLAIMS [308111801] 16.2 percent of total billed charges 11.16 17.1 Technical (Hospital) Services HC/HH Wch Supp Cath Foley14 Fr 30cc__266714 PX-2725000026 CDM 2725000026 LOCAL 272 RC inpatient 18 18 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES PPO [308136801] 14.25 percent of total billed charges 11.16 17.1 Technical (Hospital) Services HC/HH Wch Supp Cath Foley14 Fr 30cc__266714 PX-2725000026 CDM 2725000026 LOCAL 272 RC inpatient 18 18 UNITED HEALTHCARE (COMMERCIAL) [3081199] UNITED HEALTHCARE 87726 [308119901] 11.16 percent of total billed charges 11.16 17.1 Technical (Hospital) Services HC/HH Wch Supp Cath Foley14 Fr 30cc__266714 PX-2725000026 CDM 2725000026 LOCAL 272 RC inpatient 18 18 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES HDHP [308136802] 14.25 percent of total billed charges 11.16 17.1 Technical (Hospital) Services HC/HH Wch Supp Cath Foley14 Fr 30cc__266714 PX-2725000026 CDM 2725000026 LOCAL 272 RC inpatient 18 18 HEALTHPARTNERS SX009 HEALTHPARTNERS 14.25 percent of total billed charges 11.16 17.1 Technical (Hospital) Services HC/HH Wch Supp Cath Foley14 Fr 30cc__266714 PX-2725000026 CDM 2725000026 LOCAL 272 RC inpatient 18 18 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES EPO [308136803] 14.25 percent of total billed charges 11.16 17.1 Technical (Hospital) Services HC/HH Wch Supp Cath Foley14 Fr 30cc__266714 PX-2725000026 CDM 2725000026 LOCAL 272 RC inpatient 18 18 MULTIPLAN INC 34080 [3081285] MULTIPLAN INC [308128501] 17.1 percent of total billed charges 11.16 17.1 Technical (Hospital) Services HC/HH Wch Supp Cath Foley14 Fr 30cc__266714 PX-2725000026 CDM 2725000026 LOCAL 272 RC inpatient 18 18 BLUE CROSS BLUE SHIELD WELLMARK SB889 [3081026] BCBS WYOMING [308102603] 17.1 percent of total billed charges 11.16 17.1 Technical (Hospital) Services HC/HH Wch Supp Cath Foley14 Fr 30cc__266714 PX-2725000026 CDM 2725000026 LOCAL 272 RC inpatient 18 18 CIGNA 62308 [3081051] CIGNA 62308 [308105105] 14.25 percent of total billed charges 11.16 17.1 Technical (Hospital) Services HC/HH Wch Supp Cath Foley14 Fr 30cc__266714 PX-2725000026 CDM 2725000026 LOCAL 272 RC inpatient 18 18 CIGNA 62308 [3081051] CIGNA STATE OF WYOMING [308105107] 14.25 percent of total billed charges 11.16 17.1 Technical (Hospital) Services HC/HH Wch Supp Cath Foley14 Fr 30cc__266714 PX-2725000026 CDM 2725000026 LOCAL 272 RC outpatient 18 18 MEDICA (COMMERCIAL) 94265 [3081118] MEDICA CLAIMS [308111801] 16.2 percent of total billed charges 11.16 17.1 Technical (Hospital) Services HC/HH Wch Supp Cath Foley14 Fr 30cc__266714 PX-2725000026 CDM 2725000026 LOCAL 272 RC outpatient 18 18 MULTIPLAN INC 34080 [3081285] MULTIPLAN INC [308128501] 17.1 percent of total billed charges 11.16 17.1 Technical (Hospital) Services HC/HH Wch Supp Cath Foley14 Fr 30cc__266714 PX-2725000026 CDM 2725000026 LOCAL 272 RC outpatient 18 18 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES EPO [308136803] 14.4 percent of total billed charges 11.16 17.1 Technical (Hospital) Services HC/HH Wch Supp Cath Foley14 Fr 30cc__266714 PX-2725000026 CDM 2725000026 LOCAL 272 RC outpatient 18 18 BLUE CROSS BLUE SHIELD WELLMARK SB889 [3081026] BCBS WYOMING [308102603] 17.1 percent of total billed charges 11.16 17.1 Technical (Hospital) Services HC/HH Wch Supp Cath Foley14 Fr 30cc__266714 PX-2725000026 CDM 2725000026 LOCAL 272 RC outpatient 18 18 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES HDHP [308136802] 14.4 percent of total billed charges 11.16 17.1 Technical (Hospital) Services HC/HH Wch Supp Cath Foley14 Fr 30cc__266714 PX-2725000026 CDM 2725000026 LOCAL 272 RC outpatient 18 18 UNITED HEALTHCARE (COMMERCIAL) [3081199] UNITED HEALTHCARE 87726 [308119901] 11.16 percent of total billed charges 11.16 17.1 Technical (Hospital) Services HC/HH Wch Supp Cath Foley14 Fr 30cc__266714 PX-2725000026 CDM 2725000026 LOCAL 272 RC outpatient 18 18 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES PPO [308136801] 14.4 percent of total billed charges 11.16 17.1 Technical (Hospital) Services HC/HH Wch Supp Cath Foley14 Fr 30cc__266714 PX-2725000026 CDM 2725000026 LOCAL 272 RC outpatient 18 18 HEALTHPARTNERS SX009 HEALTHPARTNERS 14.4 percent of total billed charges 11.16 17.1 Technical (Hospital) Services HC/HH Wch Supp Cath Foley14 Fr 30cc__266714 PX-2725000026 CDM 2725000026 LOCAL 272 RC outpatient 18 18 CIGNA 62308 [3081051] CIGNA 62308 [308105105] 14.4 percent of total billed charges 11.16 17.1 Technical (Hospital) Services HC/HH Wch Supp Cath Foley14 Fr 30cc__266714 PX-2725000026 CDM 2725000026 LOCAL 272 RC outpatient 18 18 CIGNA 62308 [3081051] CIGNA STATE OF WYOMING [308105107] 14.4 percent of total billed charges 11.16 17.1 Technical (Hospital) Services HC/HH Wch Supp Cath Foley Sil Ped 10fr__165810 PX-2725000025 CDM 2725000025 LOCAL 272 RC outpatient 25 25 UNITED HEALTHCARE (COMMERCIAL) [3081199] UNITED HEALTHCARE 87726 [308119901] 15.5 percent of total billed charges 15.5 23.75 Technical (Hospital) Services HC/HH Wch Supp Cath Foley Sil Ped 10fr__165810 PX-2725000025 CDM 2725000025 LOCAL 272 RC outpatient 25 25 HEALTHPARTNERS SX009 HEALTHPARTNERS 20 percent of total billed charges 15.5 23.75 Technical (Hospital) Services HC/HH Wch Supp Cath Foley Sil Ped 10fr__165810 PX-2725000025 CDM 2725000025 LOCAL 272 RC outpatient 25 25 CIGNA 62308 [3081051] CIGNA 62308 [308105105] 20 percent of total billed charges 15.5 23.75 Technical (Hospital) Services HC/HH Wch Supp Cath Foley Sil Ped 10fr__165810 PX-2725000025 CDM 2725000025 LOCAL 272 RC outpatient 25 25 CIGNA 62308 [3081051] CIGNA STATE OF WYOMING [308105107] 20 percent of total billed charges 15.5 23.75 Technical (Hospital) Services HC/HH Wch Supp Cath Foley Sil Ped 10fr__165810 PX-2725000025 CDM 2725000025 LOCAL 272 RC outpatient 25 25 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES HDHP [308136802] 20 percent of total billed charges 15.5 23.75 Technical (Hospital) Services HC/HH Wch Supp Cath Foley Sil Ped 10fr__165810 PX-2725000025 CDM 2725000025 LOCAL 272 RC outpatient 25 25 BLUE CROSS BLUE SHIELD WELLMARK SB889 [3081026] BCBS WYOMING [308102603] 23.75 percent of total billed charges 15.5 23.75 Technical (Hospital) Services HC/HH Wch Supp Cath Foley Sil Ped 10fr__165810 PX-2725000025 CDM 2725000025 LOCAL 272 RC outpatient 25 25 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES EPO [308136803] 20 percent of total billed charges 15.5 23.75 Technical (Hospital) Services HC/HH Wch Supp Cath Foley Sil Ped 10fr__165810 PX-2725000025 CDM 2725000025 LOCAL 272 RC outpatient 25 25 MEDICA (COMMERCIAL) 94265 [3081118] MEDICA CLAIMS [308111801] 22.5 percent of total billed charges 15.5 23.75 Technical (Hospital) Services HC/HH Wch Supp Cath Foley Sil Ped 10fr__165810 PX-2725000025 CDM 2725000025 LOCAL 272 RC outpatient 25 25 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES PPO [308136801] 20 percent of total billed charges 15.5 23.75 Technical (Hospital) Services HC/HH Wch Supp Cath Foley Sil Ped 10fr__165810 PX-2725000025 CDM 2725000025 LOCAL 272 RC outpatient 25 25 MULTIPLAN INC 34080 [3081285] MULTIPLAN INC [308128501] 23.75 percent of total billed charges 15.5 23.75 Technical (Hospital) Services HC/HH Wch Supp Cath Foley Sil Ped 10fr__165810 PX-2725000025 CDM 2725000025 LOCAL 272 RC inpatient 25 25 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES PPO [308136801] 19.8 percent of total billed charges 15.5 23.75 Technical (Hospital) Services HC/HH Wch Supp Cath Foley Sil Ped 10fr__165810 PX-2725000025 CDM 2725000025 LOCAL 272 RC inpatient 25 25 MEDICA (COMMERCIAL) 94265 [3081118] MEDICA CLAIMS [308111801] 22.5 percent of total billed charges 15.5 23.75 Technical (Hospital) Services HC/HH Wch Supp Cath Foley Sil Ped 10fr__165810 PX-2725000025 CDM 2725000025 LOCAL 272 RC inpatient 25 25 UNITED HEALTHCARE (COMMERCIAL) [3081199] UNITED HEALTHCARE 87726 [308119901] 15.5 percent of total billed charges 15.5 23.75 Technical (Hospital) Services HC/HH Wch Supp Cath Foley Sil Ped 10fr__165810 PX-2725000025 CDM 2725000025 LOCAL 272 RC inpatient 25 25 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES HDHP [308136802] 19.8 percent of total billed charges 15.5 23.75 Technical (Hospital) Services HC/HH Wch Supp Cath Foley Sil Ped 10fr__165810 PX-2725000025 CDM 2725000025 LOCAL 272 RC inpatient 25 25 HEALTHPARTNERS SX009 HEALTHPARTNERS 19.8 percent of total billed charges 15.5 23.75 Technical (Hospital) Services HC/HH Wch Supp Cath Foley Sil Ped 10fr__165810 PX-2725000025 CDM 2725000025 LOCAL 272 RC inpatient 25 25 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES EPO [308136803] 19.8 percent of total billed charges 15.5 23.75 Technical (Hospital) Services HC/HH Wch Supp Cath Foley Sil Ped 10fr__165810 PX-2725000025 CDM 2725000025 LOCAL 272 RC inpatient 25 25 BLUE CROSS BLUE SHIELD WELLMARK SB889 [3081026] BCBS WYOMING [308102603] 23.75 percent of total billed charges 15.5 23.75 Technical (Hospital) Services HC/HH Wch Supp Cath Foley Sil Ped 10fr__165810 PX-2725000025 CDM 2725000025 LOCAL 272 RC inpatient 25 25 MULTIPLAN INC 34080 [3081285] MULTIPLAN INC [308128501] 23.75 percent of total billed charges 15.5 23.75 Technical (Hospital) Services HC/HH Wch Supp Cath Foley Sil Ped 10fr__165810 PX-2725000025 CDM 2725000025 LOCAL 272 RC inpatient 25 25 CIGNA 62308 [3081051] CIGNA 62308 [308105105] 19.8 percent of total billed charges 15.5 23.75 Technical (Hospital) Services HC/HH Wch Supp Cath Foley Sil Ped 10fr__165810 PX-2725000025 CDM 2725000025 LOCAL 272 RC inpatient 25 25 CIGNA 62308 [3081051] CIGNA STATE OF WYOMING [308105107] 19.8 percent of total billed charges 15.5 23.75 Technical (Hospital) Services HC/HH Wch Supp Cath Foley Sil Lx 5cc 12 Fr__265712 PX-2725000024 CDM 2725000024 LOCAL 272 RC outpatient 24 24 CIGNA 62308 [3081051] CIGNA 62308 [308105105] 19.2 percent of total billed charges 14.88 22.8 Technical (Hospital) Services HC/HH Wch Supp Cath Foley Sil Lx 5cc 12 Fr__265712 PX-2725000024 CDM 2725000024 LOCAL 272 RC outpatient 24 24 CIGNA 62308 [3081051] CIGNA STATE OF WYOMING [308105107] 19.2 percent of total billed charges 14.88 22.8 Technical (Hospital) Services HC/HH Wch Supp Cath Foley Sil Lx 5cc 12 Fr__265712 PX-2725000024 CDM 2725000024 LOCAL 272 RC outpatient 24 24 HEALTHPARTNERS SX009 HEALTHPARTNERS 19.2 percent of total billed charges 14.88 22.8 Technical (Hospital) Services HC/HH Wch Supp Cath Foley Sil Lx 5cc 12 Fr__265712 PX-2725000024 CDM 2725000024 LOCAL 272 RC outpatient 24 24 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES PPO [308136801] 19.2 percent of total billed charges 14.88 22.8 Technical (Hospital) Services HC/HH Wch Supp Cath Foley Sil Lx 5cc 12 Fr__265712 PX-2725000024 CDM 2725000024 LOCAL 272 RC outpatient 24 24 UNITED HEALTHCARE (COMMERCIAL) [3081199] UNITED HEALTHCARE 87726 [308119901] 14.88 percent of total billed charges 14.88 22.8 Technical (Hospital) Services HC/HH Wch Supp Cath Foley Sil Lx 5cc 12 Fr__265712 PX-2725000024 CDM 2725000024 LOCAL 272 RC outpatient 24 24 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES HDHP [308136802] 19.2 percent of total billed charges 14.88 22.8 Technical (Hospital) Services HC/HH Wch Supp Cath Foley Sil Lx 5cc 12 Fr__265712 PX-2725000024 CDM 2725000024 LOCAL 272 RC outpatient 24 24 BLUE CROSS BLUE SHIELD WELLMARK SB889 [3081026] BCBS WYOMING [308102603] 22.8 percent of total billed charges 14.88 22.8 Technical (Hospital) Services HC/HH Wch Supp Cath Foley Sil Lx 5cc 12 Fr__265712 PX-2725000024 CDM 2725000024 LOCAL 272 RC outpatient 24 24 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES EPO [308136803] 19.2 percent of total billed charges 14.88 22.8 Technical (Hospital) Services HC/HH Wch Supp Cath Foley Sil Lx 5cc 12 Fr__265712 PX-2725000024 CDM 2725000024 LOCAL 272 RC outpatient 24 24 MULTIPLAN INC 34080 [3081285] MULTIPLAN INC [308128501] 22.8 percent of total billed charges 14.88 22.8 Technical (Hospital) Services HC/HH Wch Supp Cath Foley Sil Lx 5cc 12 Fr__265712 PX-2725000024 CDM 2725000024 LOCAL 272 RC outpatient 24 24 MEDICA (COMMERCIAL) 94265 [3081118] MEDICA CLAIMS [308111801] 21.6 percent of total billed charges 14.88 22.8 Technical (Hospital) Services HC/HH Wch Supp Cath Foley Sil Lx 5cc 12 Fr__265712 PX-2725000024 CDM 2725000024 LOCAL 272 RC inpatient 24 24 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES EPO [308136803] 19 percent of total billed charges 14.88 22.8 Technical (Hospital) Services HC/HH Wch Supp Cath Foley Sil Lx 5cc 12 Fr__265712 PX-2725000024 CDM 2725000024 LOCAL 272 RC inpatient 24 24 MULTIPLAN INC 34080 [3081285] MULTIPLAN INC [308128501] 22.8 percent of total billed charges 14.88 22.8 Technical (Hospital) Services HC/HH Wch Supp Cath Foley Sil Lx 5cc 12 Fr__265712 PX-2725000024 CDM 2725000024 LOCAL 272 RC inpatient 24 24 BLUE CROSS BLUE SHIELD WELLMARK SB889 [3081026] BCBS WYOMING [308102603] 22.8 percent of total billed charges 14.88 22.8 Technical (Hospital) Services HC/HH Wch Supp Cath Foley Sil Lx 5cc 12 Fr__265712 PX-2725000024 CDM 2725000024 LOCAL 272 RC inpatient 24 24 HEALTHPARTNERS SX009 HEALTHPARTNERS 19 percent of total billed charges 14.88 22.8 Technical (Hospital) Services HC/HH Wch Supp Cath Foley Sil Lx 5cc 12 Fr__265712 PX-2725000024 CDM 2725000024 LOCAL 272 RC inpatient 24 24 CIGNA 62308 [3081051] CIGNA 62308 [308105105] 19 percent of total billed charges 14.88 22.8 Technical (Hospital) Services HC/HH Wch Supp Cath Foley Sil Lx 5cc 12 Fr__265712 PX-2725000024 CDM 2725000024 LOCAL 272 RC inpatient 24 24 CIGNA 62308 [3081051] CIGNA STATE OF WYOMING [308105107] 19 percent of total billed charges 14.88 22.8 Technical (Hospital) Services HC/HH Wch Supp Cath Foley Sil Lx 5cc 12 Fr__265712 PX-2725000024 CDM 2725000024 LOCAL 272 RC inpatient 24 24 UNITED HEALTHCARE (COMMERCIAL) [3081199] UNITED HEALTHCARE 87726 [308119901] 14.88 percent of total billed charges 14.88 22.8 Technical (Hospital) Services HC/HH Wch Supp Cath Foley Sil Lx 5cc 12 Fr__265712 PX-2725000024 CDM 2725000024 LOCAL 272 RC inpatient 24 24 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES HDHP [308136802] 19 percent of total billed charges 14.88 22.8 Technical (Hospital) Services HC/HH Wch Supp Cath Foley Sil Lx 5cc 12 Fr__265712 PX-2725000024 CDM 2725000024 LOCAL 272 RC inpatient 24 24 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES PPO [308136801] 19 percent of total billed charges 14.88 22.8 Technical (Hospital) Services HC/HH Wch Supp Cath Foley Sil Lx 5cc 12 Fr__265712 PX-2725000024 CDM 2725000024 LOCAL 272 RC inpatient 24 24 MEDICA (COMMERCIAL) 94265 [3081118] MEDICA CLAIMS [308111801] 21.6 percent of total billed charges 14.88 22.8 Technical (Hospital) Services HC/HH Wch Supp Cath Foley 3way 30cc 22fr__0167v22s PX-2725000023 CDM 2725000023 LOCAL 272 RC inpatient 17 17 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES EPO [308136803] 13.46 percent of total billed charges 10.54 16.15 Technical (Hospital) Services HC/HH Wch Supp Cath Foley 3way 30cc 22fr__0167v22s PX-2725000023 CDM 2725000023 LOCAL 272 RC inpatient 17 17 CIGNA 62308 [3081051] CIGNA 62308 [308105105] 13.46 percent of total billed charges 10.54 16.15 Technical (Hospital) Services HC/HH Wch Supp Cath Foley 3way 30cc 22fr__0167v22s PX-2725000023 CDM 2725000023 LOCAL 272 RC inpatient 17 17 CIGNA 62308 [3081051] CIGNA STATE OF WYOMING [308105107] 13.46 percent of total billed charges 10.54 16.15 Technical (Hospital) Services HC/HH Wch Supp Cath Foley 3way 30cc 22fr__0167v22s PX-2725000023 CDM 2725000023 LOCAL 272 RC inpatient 17 17 BLUE CROSS BLUE SHIELD WELLMARK SB889 [3081026] BCBS WYOMING [308102603] 16.15 percent of total billed charges 10.54 16.15 Technical (Hospital) Services HC/HH Wch Supp Cath Foley 3way 30cc 22fr__0167v22s PX-2725000023 CDM 2725000023 LOCAL 272 RC inpatient 17 17 MULTIPLAN INC 34080 [3081285] MULTIPLAN INC [308128501] 16.15 percent of total billed charges 10.54 16.15 Technical (Hospital) Services HC/HH Wch Supp Cath Foley 3way 30cc 22fr__0167v22s PX-2725000023 CDM 2725000023 LOCAL 272 RC inpatient 17 17 HEALTHPARTNERS SX009 HEALTHPARTNERS 13.46 percent of total billed charges 10.54 16.15 Technical (Hospital) Services HC/HH Wch Supp Cath Foley 3way 30cc 22fr__0167v22s PX-2725000023 CDM 2725000023 LOCAL 272 RC inpatient 17 17 UNITED HEALTHCARE (COMMERCIAL) [3081199] UNITED HEALTHCARE 87726 [308119901] 10.54 percent of total billed charges 10.54 16.15 Technical (Hospital) Services HC/HH Wch Supp Cath Foley 3way 30cc 22fr__0167v22s PX-2725000023 CDM 2725000023 LOCAL 272 RC inpatient 17 17 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES HDHP [308136802] 13.46 percent of total billed charges 10.54 16.15 Technical (Hospital) Services HC/HH Wch Supp Cath Foley 3way 30cc 22fr__0167v22s PX-2725000023 CDM 2725000023 LOCAL 272 RC inpatient 17 17 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES PPO [308136801] 13.46 percent of total billed charges 10.54 16.15 Technical (Hospital) Services HC/HH Wch Supp Cath Foley 3way 30cc 22fr__0167v22s PX-2725000023 CDM 2725000023 LOCAL 272 RC inpatient 17 17 MEDICA (COMMERCIAL) 94265 [3081118] MEDICA CLAIMS [308111801] 15.3 percent of total billed charges 10.54 16.15 Technical (Hospital) Services HC/HH Wch Supp Cath Foley 3way 30cc 22fr__0167v22s PX-2725000023 CDM 2725000023 LOCAL 272 RC outpatient 17 17 UNITED HEALTHCARE (COMMERCIAL) [3081199] UNITED HEALTHCARE 87726 [308119901] 10.54 percent of total billed charges 10.54 16.15 Technical (Hospital) Services HC/HH Wch Supp Cath Foley 3way 30cc 22fr__0167v22s PX-2725000023 CDM 2725000023 LOCAL 272 RC outpatient 17 17 CIGNA 62308 [3081051] CIGNA 62308 [308105105] 13.6 percent of total billed charges 10.54 16.15 Technical (Hospital) Services HC/HH Wch Supp Cath Foley 3way 30cc 22fr__0167v22s PX-2725000023 CDM 2725000023 LOCAL 272 RC outpatient 17 17 CIGNA 62308 [3081051] CIGNA STATE OF WYOMING [308105107] 13.6 percent of total billed charges 10.54 16.15 Technical (Hospital) Services HC/HH Wch Supp Cath Foley 3way 30cc 22fr__0167v22s PX-2725000023 CDM 2725000023 LOCAL 272 RC outpatient 17 17 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES HDHP [308136802] 13.6 percent of total billed charges 10.54 16.15 Technical (Hospital) Services HC/HH Wch Supp Cath Foley 3way 30cc 22fr__0167v22s PX-2725000023 CDM 2725000023 LOCAL 272 RC outpatient 17 17 BLUE CROSS BLUE SHIELD WELLMARK SB889 [3081026] BCBS WYOMING [308102603] 16.15 percent of total billed charges 10.54 16.15 Technical (Hospital) Services HC/HH Wch Supp Cath Foley 3way 30cc 22fr__0167v22s PX-2725000023 CDM 2725000023 LOCAL 272 RC outpatient 17 17 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES EPO [308136803] 13.6 percent of total billed charges 10.54 16.15 Technical (Hospital) Services HC/HH Wch Supp Cath Foley 3way 30cc 22fr__0167v22s PX-2725000023 CDM 2725000023 LOCAL 272 RC outpatient 17 17 MEDICA (COMMERCIAL) 94265 [3081118] MEDICA CLAIMS [308111801] 15.3 percent of total billed charges 10.54 16.15 Technical (Hospital) Services HC/HH Wch Supp Cath Foley 3way 30cc 22fr__0167v22s PX-2725000023 CDM 2725000023 LOCAL 272 RC outpatient 17 17 HEALTHPARTNERS SX009 HEALTHPARTNERS 13.6 percent of total billed charges 10.54 16.15 Technical (Hospital) Services HC/HH Wch Supp Cath Foley 3way 30cc 22fr__0167v22s PX-2725000023 CDM 2725000023 LOCAL 272 RC outpatient 17 17 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES PPO [308136801] 13.6 percent of total billed charges 10.54 16.15 Technical (Hospital) Services HC/HH Wch Supp Cath Foley 3way 30cc 22fr__0167v22s PX-2725000023 CDM 2725000023 LOCAL 272 RC outpatient 17 17 MULTIPLAN INC 34080 [3081285] MULTIPLAN INC [308128501] 16.15 percent of total billed charges 10.54 16.15 Technical (Hospital) Services HC/HH Wch Supp Cath Foley 16fr 30cc__266716 PX-2725000022 CDM 2725000022 LOCAL 272 RC inpatient 23 23 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES EPO [308136803] 18.21 percent of total billed charges 14.26 21.85 Technical (Hospital) Services HC/HH Wch Supp Cath Foley 16fr 30cc__266716 PX-2725000022 CDM 2725000022 LOCAL 272 RC inpatient 23 23 HEALTHPARTNERS SX009 HEALTHPARTNERS 18.21 percent of total billed charges 14.26 21.85 Technical (Hospital) Services HC/HH Wch Supp Cath Foley 16fr 30cc__266716 PX-2725000022 CDM 2725000022 LOCAL 272 RC inpatient 23 23 CIGNA 62308 [3081051] CIGNA 62308 [308105105] 18.21 percent of total billed charges 14.26 21.85 Technical (Hospital) Services HC/HH Wch Supp Cath Foley 16fr 30cc__266716 PX-2725000022 CDM 2725000022 LOCAL 272 RC inpatient 23 23 CIGNA 62308 [3081051] CIGNA STATE OF WYOMING [308105107] 18.21 percent of total billed charges 14.26 21.85 Technical (Hospital) Services HC/HH Wch Supp Cath Foley 16fr 30cc__266716 PX-2725000022 CDM 2725000022 LOCAL 272 RC inpatient 23 23 BLUE CROSS BLUE SHIELD WELLMARK SB889 [3081026] BCBS WYOMING [308102603] 21.85 percent of total billed charges 14.26 21.85 Technical (Hospital) Services HC/HH Wch Supp Cath Foley 16fr 30cc__266716 PX-2725000022 CDM 2725000022 LOCAL 272 RC inpatient 23 23 MULTIPLAN INC 34080 [3081285] MULTIPLAN INC [308128501] 21.85 percent of total billed charges 14.26 21.85 Technical (Hospital) Services HC/HH Wch Supp Cath Foley 16fr 30cc__266716 PX-2725000022 CDM 2725000022 LOCAL 272 RC inpatient 23 23 UNITED HEALTHCARE (COMMERCIAL) [3081199] UNITED HEALTHCARE 87726 [308119901] 14.26 percent of total billed charges 14.26 21.85 Technical (Hospital) Services HC/HH Wch Supp Cath Foley 16fr 30cc__266716 PX-2725000022 CDM 2725000022 LOCAL 272 RC inpatient 23 23 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES HDHP [308136802] 18.21 percent of total billed charges 14.26 21.85 Technical (Hospital) Services HC/HH Wch Supp Cath Foley 16fr 30cc__266716 PX-2725000022 CDM 2725000022 LOCAL 272 RC inpatient 23 23 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES PPO [308136801] 18.21 percent of total billed charges 14.26 21.85 Technical (Hospital) Services HC/HH Wch Supp Cath Foley 16fr 30cc__266716 PX-2725000022 CDM 2725000022 LOCAL 272 RC inpatient 23 23 MEDICA (COMMERCIAL) 94265 [3081118] MEDICA CLAIMS [308111801] 20.7 percent of total billed charges 14.26 21.85 Technical (Hospital) Services HC/HH Wch Supp Cath Foley 16fr 30cc__266716 PX-2725000022 CDM 2725000022 LOCAL 272 RC outpatient 23 23 MULTIPLAN INC 34080 [3081285] MULTIPLAN INC [308128501] 21.85 percent of total billed charges 14.26 21.85 Technical (Hospital) Services HC/HH Wch Supp Cath Foley 16fr 30cc__266716 PX-2725000022 CDM 2725000022 LOCAL 272 RC outpatient 23 23 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES PPO [308136801] 18.4 percent of total billed charges 14.26 21.85 Technical (Hospital) Services HC/HH Wch Supp Cath Foley 16fr 30cc__266716 PX-2725000022 CDM 2725000022 LOCAL 272 RC outpatient 23 23 MEDICA (COMMERCIAL) 94265 [3081118] MEDICA CLAIMS [308111801] 20.7 percent of total billed charges 14.26 21.85 Technical (Hospital) Services HC/HH Wch Supp Cath Foley 16fr 30cc__266716 PX-2725000022 CDM 2725000022 LOCAL 272 RC outpatient 23 23 CIGNA 62308 [3081051] CIGNA 62308 [308105105] 18.4 percent of total billed charges 14.26 21.85 Technical (Hospital) Services HC/HH Wch Supp Cath Foley 16fr 30cc__266716 PX-2725000022 CDM 2725000022 LOCAL 272 RC outpatient 23 23 CIGNA 62308 [3081051] CIGNA STATE OF WYOMING [308105107] 18.4 percent of total billed charges 14.26 21.85 Technical (Hospital) Services HC/HH Wch Supp Cath Foley 16fr 30cc__266716 PX-2725000022 CDM 2725000022 LOCAL 272 RC outpatient 23 23 UNITED HEALTHCARE (COMMERCIAL) [3081199] UNITED HEALTHCARE 87726 [308119901] 14.26 percent of total billed charges 14.26 21.85 Technical (Hospital) Services HC/HH Wch Supp Cath Foley 16fr 30cc__266716 PX-2725000022 CDM 2725000022 LOCAL 272 RC outpatient 23 23 HEALTHPARTNERS SX009 HEALTHPARTNERS 18.4 percent of total billed charges 14.26 21.85 Technical (Hospital) Services HC/HH Wch Supp Cath Foley 16fr 30cc__266716 PX-2725000022 CDM 2725000022 LOCAL 272 RC outpatient 23 23 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES EPO [308136803] 18.4 percent of total billed charges 14.26 21.85 Technical (Hospital) Services HC/HH Wch Supp Cath Foley 16fr 30cc__266716 PX-2725000022 CDM 2725000022 LOCAL 272 RC outpatient 23 23 BLUE CROSS BLUE SHIELD WELLMARK SB889 [3081026] BCBS WYOMING [308102603] 21.85 percent of total billed charges 14.26 21.85 Technical (Hospital) Services HC/HH Wch Supp Cath Foley 16fr 30cc__266716 PX-2725000022 CDM 2725000022 LOCAL 272 RC outpatient 23 23 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES HDHP [308136802] 18.4 percent of total billed charges 14.26 21.85 Technical (Hospital) Services HC/HH Wch Supp Cath Foley 14 Fr 5cc__265714 PX-2725000021 CDM 2725000021 LOCAL 272 RC outpatient 46 46 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES HDHP [308136802] 36.8 percent of total billed charges 28.52 43.7 Technical (Hospital) Services HC/HH Wch Supp Cath Foley 14 Fr 5cc__265714 PX-2725000021 CDM 2725000021 LOCAL 272 RC outpatient 46 46 BLUE CROSS BLUE SHIELD WELLMARK SB889 [3081026] BCBS WYOMING [308102603] 43.7 percent of total billed charges 28.52 43.7 Technical (Hospital) Services HC/HH Wch Supp Cath Foley 14 Fr 5cc__265714 PX-2725000021 CDM 2725000021 LOCAL 272 RC outpatient 46 46 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES EPO [308136803] 36.8 percent of total billed charges 28.52 43.7 Technical (Hospital) Services HC/HH Wch Supp Cath Foley 14 Fr 5cc__265714 PX-2725000021 CDM 2725000021 LOCAL 272 RC outpatient 46 46 HEALTHPARTNERS SX009 HEALTHPARTNERS 36.8 percent of total billed charges 28.52 43.7 Technical (Hospital) Services HC/HH Wch Supp Cath Foley 14 Fr 5cc__265714 PX-2725000021 CDM 2725000021 LOCAL 272 RC outpatient 46 46 UNITED HEALTHCARE (COMMERCIAL) [3081199] UNITED HEALTHCARE 87726 [308119901] 28.52 percent of total billed charges 28.52 43.7 Technical (Hospital) Services HC/HH Wch Supp Cath Foley 14 Fr 5cc__265714 PX-2725000021 CDM 2725000021 LOCAL 272 RC outpatient 46 46 CIGNA 62308 [3081051] CIGNA 62308 [308105105] 36.8 percent of total billed charges 28.52 43.7 Technical (Hospital) Services HC/HH Wch Supp Cath Foley 14 Fr 5cc__265714 PX-2725000021 CDM 2725000021 LOCAL 272 RC outpatient 46 46 CIGNA 62308 [3081051] CIGNA STATE OF WYOMING [308105107] 36.8 percent of total billed charges 28.52 43.7 Technical (Hospital) Services HC/HH Wch Supp Cath Foley 14 Fr 5cc__265714 PX-2725000021 CDM 2725000021 LOCAL 272 RC outpatient 46 46 MEDICA (COMMERCIAL) 94265 [3081118] MEDICA CLAIMS [308111801] 41.4 percent of total billed charges 28.52 43.7 Technical (Hospital) Services HC/HH Wch Supp Cath Foley 14 Fr 5cc__265714 PX-2725000021 CDM 2725000021 LOCAL 272 RC outpatient 46 46 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES PPO [308136801] 36.8 percent of total billed charges 28.52 43.7 Technical (Hospital) Services HC/HH Wch Supp Cath Foley 14 Fr 5cc__265714 PX-2725000021 CDM 2725000021 LOCAL 272 RC outpatient 46 46 MULTIPLAN INC 34080 [3081285] MULTIPLAN INC [308128501] 43.7 percent of total billed charges 28.52 43.7 Technical (Hospital) Services HC/HH Wch Supp Cath Foley 14 Fr 5cc__265714 PX-2725000021 CDM 2725000021 LOCAL 272 RC inpatient 46 46 HEALTHPARTNERS SX009 HEALTHPARTNERS 36.42 percent of total billed charges 28.52 43.7 Technical (Hospital) Services HC/HH Wch Supp Cath Foley 14 Fr 5cc__265714 PX-2725000021 CDM 2725000021 LOCAL 272 RC inpatient 46 46 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES EPO [308136803] 36.42 percent of total billed charges 28.52 43.7 Technical (Hospital) Services HC/HH Wch Supp Cath Foley 14 Fr 5cc__265714 PX-2725000021 CDM 2725000021 LOCAL 272 RC inpatient 46 46 CIGNA 62308 [3081051] CIGNA 62308 [308105105] 36.42 percent of total billed charges 28.52 43.7 Technical (Hospital) Services HC/HH Wch Supp Cath Foley 14 Fr 5cc__265714 PX-2725000021 CDM 2725000021 LOCAL 272 RC inpatient 46 46 CIGNA 62308 [3081051] CIGNA STATE OF WYOMING [308105107] 36.42 percent of total billed charges 28.52 43.7 Technical (Hospital) Services HC/HH Wch Supp Cath Foley 14 Fr 5cc__265714 PX-2725000021 CDM 2725000021 LOCAL 272 RC inpatient 46 46 BLUE CROSS BLUE SHIELD WELLMARK SB889 [3081026] BCBS WYOMING [308102603] 43.7 percent of total billed charges 28.52 43.7 Technical (Hospital) Services HC/HH Wch Supp Cath Foley 14 Fr 5cc__265714 PX-2725000021 CDM 2725000021 LOCAL 272 RC inpatient 46 46 MULTIPLAN INC 34080 [3081285] MULTIPLAN INC [308128501] 43.7 percent of total billed charges 28.52 43.7 Technical (Hospital) Services HC/HH Wch Supp Cath Foley 14 Fr 5cc__265714 PX-2725000021 CDM 2725000021 LOCAL 272 RC inpatient 46 46 MEDICA (COMMERCIAL) 94265 [3081118] MEDICA CLAIMS [308111801] 41.4 percent of total billed charges 28.52 43.7 Technical (Hospital) Services HC/HH Wch Supp Cath Foley 14 Fr 5cc__265714 PX-2725000021 CDM 2725000021 LOCAL 272 RC inpatient 46 46 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES PPO [308136801] 36.42 percent of total billed charges 28.52 43.7 Technical (Hospital) Services HC/HH Wch Supp Cath Foley 14 Fr 5cc__265714 PX-2725000021 CDM 2725000021 LOCAL 272 RC inpatient 46 46 UNITED HEALTHCARE (COMMERCIAL) [3081199] UNITED HEALTHCARE 87726 [308119901] 28.52 percent of total billed charges 28.52 43.7 Technical (Hospital) Services HC/HH Wch Supp Cath Foley 14 Fr 5cc__265714 PX-2725000021 CDM 2725000021 LOCAL 272 RC inpatient 46 46 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES HDHP [308136802] 36.42 percent of total billed charges 28.52 43.7 Technical (Hospital) Services HC/HH Wch Supp Bndg Plaster 3x3__7373 PX-2725000020 CDM 2725000020 LOCAL 272 RC outpatient 8 8 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES HDHP [308136802] 6.4 percent of total billed charges 4.96 7.6 Technical (Hospital) Services HC/HH Wch Supp Bndg Plaster 3x3__7373 PX-2725000020 CDM 2725000020 LOCAL 272 RC outpatient 8 8 BLUE CROSS BLUE SHIELD WELLMARK SB889 [3081026] BCBS WYOMING [308102603] 7.6 percent of total billed charges 4.96 7.6 Technical (Hospital) Services HC/HH Wch Supp Bndg Plaster 3x3__7373 PX-2725000020 CDM 2725000020 LOCAL 272 RC outpatient 8 8 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES EPO [308136803] 6.4 percent of total billed charges 4.96 7.6 Technical (Hospital) Services HC/HH Wch Supp Bndg Plaster 3x3__7373 PX-2725000020 CDM 2725000020 LOCAL 272 RC outpatient 8 8 CIGNA 62308 [3081051] CIGNA 62308 [308105105] 6.4 percent of total billed charges 4.96 7.6 Technical (Hospital) Services HC/HH Wch Supp Bndg Plaster 3x3__7373 PX-2725000020 CDM 2725000020 LOCAL 272 RC outpatient 8 8 CIGNA 62308 [3081051] CIGNA STATE OF WYOMING [308105107] 6.4 percent of total billed charges 4.96 7.6 Technical (Hospital) Services HC/HH Wch Supp Bndg Plaster 3x3__7373 PX-2725000020 CDM 2725000020 LOCAL 272 RC outpatient 8 8 HEALTHPARTNERS SX009 HEALTHPARTNERS 6.4 percent of total billed charges 4.96 7.6 Technical (Hospital) Services HC/HH Wch Supp Bndg Plaster 3x3__7373 PX-2725000020 CDM 2725000020 LOCAL 272 RC outpatient 8 8 UNITED HEALTHCARE (COMMERCIAL) [3081199] UNITED HEALTHCARE 87726 [308119901] 4.96 percent of total billed charges 4.96 7.6 Technical (Hospital) Services HC/HH Wch Supp Bndg Plaster 3x3__7373 PX-2725000020 CDM 2725000020 LOCAL 272 RC outpatient 8 8 MEDICA (COMMERCIAL) 94265 [3081118] MEDICA CLAIMS [308111801] 7.2 percent of total billed charges 4.96 7.6 Technical (Hospital) Services HC/HH Wch Supp Bndg Plaster 3x3__7373 PX-2725000020 CDM 2725000020 LOCAL 272 RC outpatient 8 8 MULTIPLAN INC 34080 [3081285] MULTIPLAN INC [308128501] 7.6 percent of total billed charges 4.96 7.6 Technical (Hospital) Services HC/HH Wch Supp Bndg Plaster 3x3__7373 PX-2725000020 CDM 2725000020 LOCAL 272 RC outpatient 8 8 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES PPO [308136801] 6.4 percent of total billed charges 4.96 7.6 Technical (Hospital) Services HC/HH Wch Supp Bndg Plaster 3x3__7373 PX-2725000020 CDM 2725000020 LOCAL 272 RC inpatient 8 8 HEALTHPARTNERS SX009 HEALTHPARTNERS 6.33 percent of total billed charges 4.96 7.6 Technical (Hospital) Services HC/HH Wch Supp Bndg Plaster 3x3__7373 PX-2725000020 CDM 2725000020 LOCAL 272 RC inpatient 8 8 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES EPO [308136803] 6.33 percent of total billed charges 4.96 7.6 Technical (Hospital) Services HC/HH Wch Supp Bndg Plaster 3x3__7373 PX-2725000020 CDM 2725000020 LOCAL 272 RC inpatient 8 8 MULTIPLAN INC 34080 [3081285] MULTIPLAN INC [308128501] 7.6 percent of total billed charges 4.96 7.6 Technical (Hospital) Services HC/HH Wch Supp Bndg Plaster 3x3__7373 PX-2725000020 CDM 2725000020 LOCAL 272 RC inpatient 8 8 BLUE CROSS BLUE SHIELD WELLMARK SB889 [3081026] BCBS WYOMING [308102603] 7.6 percent of total billed charges 4.96 7.6 Technical (Hospital) Services HC/HH Wch Supp Bndg Plaster 3x3__7373 PX-2725000020 CDM 2725000020 LOCAL 272 RC inpatient 8 8 CIGNA 62308 [3081051] CIGNA 62308 [308105105] 6.33 percent of total billed charges 4.96 7.6 Technical (Hospital) Services HC/HH Wch Supp Bndg Plaster 3x3__7373 PX-2725000020 CDM 2725000020 LOCAL 272 RC inpatient 8 8 CIGNA 62308 [3081051] CIGNA STATE OF WYOMING [308105107] 6.33 percent of total billed charges 4.96 7.6 Technical (Hospital) Services HC/HH Wch Supp Bndg Plaster 3x3__7373 PX-2725000020 CDM 2725000020 LOCAL 272 RC inpatient 8 8 MEDICA (COMMERCIAL) 94265 [3081118] MEDICA CLAIMS [308111801] 7.2 percent of total billed charges 4.96 7.6 Technical (Hospital) Services HC/HH Wch Supp Bndg Plaster 3x3__7373 PX-2725000020 CDM 2725000020 LOCAL 272 RC inpatient 8 8 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES PPO [308136801] 6.33 percent of total billed charges 4.96 7.6 Technical (Hospital) Services HC/HH Wch Supp Bndg Plaster 3x3__7373 PX-2725000020 CDM 2725000020 LOCAL 272 RC inpatient 8 8 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES HDHP [308136802] 6.33 percent of total billed charges 4.96 7.6 Technical (Hospital) Services HC/HH Wch Supp Bndg Plaster 3x3__7373 PX-2725000020 CDM 2725000020 LOCAL 272 RC inpatient 8 8 UNITED HEALTHCARE (COMMERCIAL) [3081199] UNITED HEALTHCARE 87726 [308119901] 4.96 percent of total billed charges 4.96 7.6 Technical (Hospital) Services HC/HH Wch Supp Bndg Non Adh 3x8__6115 PX-2725000019 CDM 2725000019 LOCAL 272 RC outpatient 9 9 BLUE CROSS BLUE SHIELD WELLMARK SB889 [3081026] BCBS WYOMING [308102603] 8.55 percent of total billed charges 5.58 8.55 Technical (Hospital) Services HC/HH Wch Supp Bndg Non Adh 3x8__6115 PX-2725000019 CDM 2725000019 LOCAL 272 RC outpatient 9 9 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES EPO [308136803] 7.2 percent of total billed charges 5.58 8.55 Technical (Hospital) Services HC/HH Wch Supp Bndg Non Adh 3x8__6115 PX-2725000019 CDM 2725000019 LOCAL 272 RC outpatient 9 9 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES HDHP [308136802] 7.2 percent of total billed charges 5.58 8.55 Technical (Hospital) Services HC/HH Wch Supp Bndg Non Adh 3x8__6115 PX-2725000019 CDM 2725000019 LOCAL 272 RC outpatient 9 9 CIGNA 62308 [3081051] CIGNA 62308 [308105105] 7.2 percent of total billed charges 5.58 8.55 Technical (Hospital) Services HC/HH Wch Supp Bndg Non Adh 3x8__6115 PX-2725000019 CDM 2725000019 LOCAL 272 RC outpatient 9 9 CIGNA 62308 [3081051] CIGNA STATE OF WYOMING [308105107] 7.2 percent of total billed charges 5.58 8.55 Technical (Hospital) Services HC/HH Wch Supp Bndg Non Adh 3x8__6115 PX-2725000019 CDM 2725000019 LOCAL 272 RC outpatient 9 9 HEALTHPARTNERS SX009 HEALTHPARTNERS 7.2 percent of total billed charges 5.58 8.55 Technical (Hospital) Services HC/HH Wch Supp Bndg Non Adh 3x8__6115 PX-2725000019 CDM 2725000019 LOCAL 272 RC outpatient 9 9 UNITED HEALTHCARE (COMMERCIAL) [3081199] UNITED HEALTHCARE 87726 [308119901] 5.58 percent of total billed charges 5.58 8.55 Technical (Hospital) Services HC/HH Wch Supp Bndg Non Adh 3x8__6115 PX-2725000019 CDM 2725000019 LOCAL 272 RC outpatient 9 9 MEDICA (COMMERCIAL) 94265 [3081118] MEDICA CLAIMS [308111801] 8.1 percent of total billed charges 5.58 8.55 Technical (Hospital) Services HC/HH Wch Supp Bndg Non Adh 3x8__6115 PX-2725000019 CDM 2725000019 LOCAL 272 RC outpatient 9 9 MULTIPLAN INC 34080 [3081285] MULTIPLAN INC [308128501] 8.55 percent of total billed charges 5.58 8.55 Technical (Hospital) Services HC/HH Wch Supp Bndg Non Adh 3x8__6115 PX-2725000019 CDM 2725000019 LOCAL 272 RC outpatient 9 9 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES PPO [308136801] 7.2 percent of total billed charges 5.58 8.55 Technical (Hospital) Services HC/HH Wch Supp Bndg Non Adh 3x8__6115 PX-2725000019 CDM 2725000019 LOCAL 272 RC inpatient 9 9 UNITED HEALTHCARE (COMMERCIAL) [3081199] UNITED HEALTHCARE 87726 [308119901] 5.58 percent of total billed charges 5.58 8.55 Technical (Hospital) Services HC/HH Wch Supp Bndg Non Adh 3x8__6115 PX-2725000019 CDM 2725000019 LOCAL 272 RC inpatient 9 9 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES HDHP [308136802] 7.13 percent of total billed charges 5.58 8.55 Technical (Hospital) Services HC/HH Wch Supp Bndg Non Adh 3x8__6115 PX-2725000019 CDM 2725000019 LOCAL 272 RC inpatient 9 9 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES PPO [308136801] 7.13 percent of total billed charges 5.58 8.55 Technical (Hospital) Services HC/HH Wch Supp Bndg Non Adh 3x8__6115 PX-2725000019 CDM 2725000019 LOCAL 272 RC inpatient 9 9 MEDICA (COMMERCIAL) 94265 [3081118] MEDICA CLAIMS [308111801] 8.1 percent of total billed charges 5.58 8.55 Technical (Hospital) Services HC/HH Wch Supp Bndg Non Adh 3x8__6115 PX-2725000019 CDM 2725000019 LOCAL 272 RC inpatient 9 9 BLUE CROSS BLUE SHIELD WELLMARK SB889 [3081026] BCBS WYOMING [308102603] 8.55 percent of total billed charges 5.58 8.55 Technical (Hospital) Services HC/HH Wch Supp Bndg Non Adh 3x8__6115 PX-2725000019 CDM 2725000019 LOCAL 272 RC inpatient 9 9 MULTIPLAN INC 34080 [3081285] MULTIPLAN INC [308128501] 8.55 percent of total billed charges 5.58 8.55 Technical (Hospital) Services HC/HH Wch Supp Bndg Non Adh 3x8__6115 PX-2725000019 CDM 2725000019 LOCAL 272 RC inpatient 9 9 CIGNA 62308 [3081051] CIGNA 62308 [308105105] 7.13 percent of total billed charges 5.58 8.55 Technical (Hospital) Services HC/HH Wch Supp Bndg Non Adh 3x8__6115 PX-2725000019 CDM 2725000019 LOCAL 272 RC inpatient 9 9 CIGNA 62308 [3081051] CIGNA STATE OF WYOMING [308105107] 7.13 percent of total billed charges 5.58 8.55 Technical (Hospital) Services HC/HH Wch Supp Bndg Non Adh 3x8__6115 PX-2725000019 CDM 2725000019 LOCAL 272 RC inpatient 9 9 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES EPO [308136803] 7.13 percent of total billed charges 5.58 8.55 Technical (Hospital) Services HC/HH Wch Supp Bndg Non Adh 3x8__6115 PX-2725000019 CDM 2725000019 LOCAL 272 RC inpatient 9 9 HEALTHPARTNERS SX009 HEALTHPARTNERS 7.13 percent of total billed charges 5.58 8.55 Technical (Hospital) Services HC/HH Wch Supp Bndg Coban 2 Layer__2094 PX-2725000018 CDM 2725000018 LOCAL 272 RC outpatient 50 50 MULTIPLAN INC 34080 [3081285] MULTIPLAN INC [308128501] 47.5 percent of total billed charges 31 47.5 Technical (Hospital) Services HC/HH Wch Supp Bndg Coban 2 Layer__2094 PX-2725000018 CDM 2725000018 LOCAL 272 RC outpatient 50 50 MEDICA (COMMERCIAL) 94265 [3081118] MEDICA CLAIMS [308111801] 45 percent of total billed charges 31 47.5 Technical (Hospital) Services HC/HH Wch Supp Bndg Coban 2 Layer__2094 PX-2725000018 CDM 2725000018 LOCAL 272 RC outpatient 50 50 CIGNA 62308 [3081051] CIGNA 62308 [308105105] 40 percent of total billed charges 31 47.5 Technical (Hospital) Services HC/HH Wch Supp Bndg Coban 2 Layer__2094 PX-2725000018 CDM 2725000018 LOCAL 272 RC outpatient 50 50 CIGNA 62308 [3081051] CIGNA STATE OF WYOMING [308105107] 40 percent of total billed charges 31 47.5 Technical (Hospital) Services HC/HH Wch Supp Bndg Coban 2 Layer__2094 PX-2725000018 CDM 2725000018 LOCAL 272 RC outpatient 50 50 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES PPO [308136801] 40 percent of total billed charges 31 47.5 Technical (Hospital) Services HC/HH Wch Supp Bndg Coban 2 Layer__2094 PX-2725000018 CDM 2725000018 LOCAL 272 RC outpatient 50 50 HEALTHPARTNERS SX009 HEALTHPARTNERS 40 percent of total billed charges 31 47.5 Technical (Hospital) Services HC/HH Wch Supp Bndg Coban 2 Layer__2094 PX-2725000018 CDM 2725000018 LOCAL 272 RC outpatient 50 50 UNITED HEALTHCARE (COMMERCIAL) [3081199] UNITED HEALTHCARE 87726 [308119901] 31 percent of total billed charges 31 47.5 Technical (Hospital) Services HC/HH Wch Supp Bndg Coban 2 Layer__2094 PX-2725000018 CDM 2725000018 LOCAL 272 RC outpatient 50 50 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES EPO [308136803] 40 percent of total billed charges 31 47.5 Technical (Hospital) Services HC/HH Wch Supp Bndg Coban 2 Layer__2094 PX-2725000018 CDM 2725000018 LOCAL 272 RC outpatient 50 50 BLUE CROSS BLUE SHIELD WELLMARK SB889 [3081026] BCBS WYOMING [308102603] 47.5 percent of total billed charges 31 47.5 Technical (Hospital) Services HC/HH Wch Supp Bndg Coban 2 Layer__2094 PX-2725000018 CDM 2725000018 LOCAL 272 RC outpatient 50 50 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES HDHP [308136802] 40 percent of total billed charges 31 47.5 Technical (Hospital) Services HC/HH Wch Supp Bndg Coban 2 Layer__2094 PX-2725000018 CDM 2725000018 LOCAL 272 RC inpatient 50 50 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES HDHP [308136802] 39.59 percent of total billed charges 31 47.5 Technical (Hospital) Services HC/HH Wch Supp Bndg Coban 2 Layer__2094 PX-2725000018 CDM 2725000018 LOCAL 272 RC inpatient 50 50 UNITED HEALTHCARE (COMMERCIAL) [3081199] UNITED HEALTHCARE 87726 [308119901] 31 percent of total billed charges 31 47.5 Technical (Hospital) Services HC/HH Wch Supp Bndg Coban 2 Layer__2094 PX-2725000018 CDM 2725000018 LOCAL 272 RC inpatient 50 50 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES PPO [308136801] 39.59 percent of total billed charges 31 47.5 Technical (Hospital) Services HC/HH Wch Supp Bndg Coban 2 Layer__2094 PX-2725000018 CDM 2725000018 LOCAL 272 RC inpatient 50 50 MEDICA (COMMERCIAL) 94265 [3081118] MEDICA CLAIMS [308111801] 45 percent of total billed charges 31 47.5 Technical (Hospital) Services HC/HH Wch Supp Bndg Coban 2 Layer__2094 PX-2725000018 CDM 2725000018 LOCAL 272 RC inpatient 50 50 CIGNA 62308 [3081051] CIGNA 62308 [308105105] 39.59 percent of total billed charges 31 47.5 Technical (Hospital) Services HC/HH Wch Supp Bndg Coban 2 Layer__2094 PX-2725000018 CDM 2725000018 LOCAL 272 RC inpatient 50 50 CIGNA 62308 [3081051] CIGNA STATE OF WYOMING [308105107] 39.59 percent of total billed charges 31 47.5 Technical (Hospital) Services HC/HH Wch Supp Bndg Coban 2 Layer__2094 PX-2725000018 CDM 2725000018 LOCAL 272 RC inpatient 50 50 BLUE CROSS BLUE SHIELD WELLMARK SB889 [3081026] BCBS WYOMING [308102603] 47.5 percent of total billed charges 31 47.5 Technical (Hospital) Services HC/HH Wch Supp Bndg Coban 2 Layer__2094 PX-2725000018 CDM 2725000018 LOCAL 272 RC inpatient 50 50 MULTIPLAN INC 34080 [3081285] MULTIPLAN INC [308128501] 47.5 percent of total billed charges 31 47.5 Technical (Hospital) Services HC/HH Wch Supp Bndg Coban 2 Layer__2094 PX-2725000018 CDM 2725000018 LOCAL 272 RC inpatient 50 50 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES EPO [308136803] 39.59 percent of total billed charges 31 47.5 Technical (Hospital) Services HC/HH Wch Supp Bndg Coban 2 Layer__2094 PX-2725000018 CDM 2725000018 LOCAL 272 RC inpatient 50 50 HEALTHPARTNERS SX009 HEALTHPARTNERS 39.59 percent of total billed charges 31 47.5 Technical (Hospital) Services HC/HH Wch Supp Bndg Cnfrm Stretch St 6x82__2238 PX-2725000017 CDM 2725000017 LOCAL 272 RC outpatient 6 6 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES HDHP [308136802] 4.8 percent of total billed charges 3.72 5.7 Technical (Hospital) Services HC/HH Wch Supp Bndg Cnfrm Stretch St 6x82__2238 PX-2725000017 CDM 2725000017 LOCAL 272 RC outpatient 6 6 BLUE CROSS BLUE SHIELD WELLMARK SB889 [3081026] BCBS WYOMING [308102603] 5.7 percent of total billed charges 3.72 5.7 Technical (Hospital) Services HC/HH Wch Supp Bndg Cnfrm Stretch St 6x82__2238 PX-2725000017 CDM 2725000017 LOCAL 272 RC outpatient 6 6 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES EPO [308136803] 4.8 percent of total billed charges 3.72 5.7 Technical (Hospital) Services HC/HH Wch Supp Bndg Cnfrm Stretch St 6x82__2238 PX-2725000017 CDM 2725000017 LOCAL 272 RC outpatient 6 6 UNITED HEALTHCARE (COMMERCIAL) [3081199] UNITED HEALTHCARE 87726 [308119901] 3.72 percent of total billed charges 3.72 5.7 Technical (Hospital) Services HC/HH Wch Supp Bndg Cnfrm Stretch St 6x82__2238 PX-2725000017 CDM 2725000017 LOCAL 272 RC outpatient 6 6 CIGNA 62308 [3081051] CIGNA 62308 [308105105] 4.8 percent of total billed charges 3.72 5.7 Technical (Hospital) Services HC/HH Wch Supp Bndg Cnfrm Stretch St 6x82__2238 PX-2725000017 CDM 2725000017 LOCAL 272 RC outpatient 6 6 CIGNA 62308 [3081051] CIGNA STATE OF WYOMING [308105107] 4.8 percent of total billed charges 3.72 5.7 Technical (Hospital) Services HC/HH Wch Supp Bndg Cnfrm Stretch St 6x82__2238 PX-2725000017 CDM 2725000017 LOCAL 272 RC outpatient 6 6 HEALTHPARTNERS SX009 HEALTHPARTNERS 4.8 percent of total billed charges 3.72 5.7 Technical (Hospital) Services HC/HH Wch Supp Bndg Cnfrm Stretch St 6x82__2238 PX-2725000017 CDM 2725000017 LOCAL 272 RC outpatient 6 6 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES PPO [308136801] 4.8 percent of total billed charges 3.72 5.7 Technical (Hospital) Services HC/HH Wch Supp Bndg Cnfrm Stretch St 6x82__2238 PX-2725000017 CDM 2725000017 LOCAL 272 RC outpatient 6 6 MULTIPLAN INC 34080 [3081285] MULTIPLAN INC [308128501] 5.7 percent of total billed charges 3.72 5.7 Technical (Hospital) Services HC/HH Wch Supp Bndg Cnfrm Stretch St 6x82__2238 PX-2725000017 CDM 2725000017 LOCAL 272 RC outpatient 6 6 MEDICA (COMMERCIAL) 94265 [3081118] MEDICA CLAIMS [308111801] 5.4 percent of total billed charges 3.72 5.7 Technical (Hospital) Services HC/HH Wch Supp Bndg Cnfrm Stretch St 6x82__2238 PX-2725000017 CDM 2725000017 LOCAL 272 RC inpatient 6 6 HEALTHPARTNERS SX009 HEALTHPARTNERS 4.75 percent of total billed charges 3.72 5.7 Technical (Hospital) Services HC/HH Wch Supp Bndg Cnfrm Stretch St 6x82__2238 PX-2725000017 CDM 2725000017 LOCAL 272 RC inpatient 6 6 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES EPO [308136803] 4.75 percent of total billed charges 3.72 5.7 Technical (Hospital) Services HC/HH Wch Supp Bndg Cnfrm Stretch St 6x82__2238 PX-2725000017 CDM 2725000017 LOCAL 272 RC inpatient 6 6 MULTIPLAN INC 34080 [3081285] MULTIPLAN INC [308128501] 5.7 percent of total billed charges 3.72 5.7 Technical (Hospital) Services HC/HH Wch Supp Bndg Cnfrm Stretch St 6x82__2238 PX-2725000017 CDM 2725000017 LOCAL 272 RC inpatient 6 6 BLUE CROSS BLUE SHIELD WELLMARK SB889 [3081026] BCBS WYOMING [308102603] 5.7 percent of total billed charges 3.72 5.7 Technical (Hospital) Services HC/HH Wch Supp Bndg Cnfrm Stretch St 6x82__2238 PX-2725000017 CDM 2725000017 LOCAL 272 RC inpatient 6 6 CIGNA 62308 [3081051] CIGNA 62308 [308105105] 4.75 percent of total billed charges 3.72 5.7 Technical (Hospital) Services HC/HH Wch Supp Bndg Cnfrm Stretch St 6x82__2238 PX-2725000017 CDM 2725000017 LOCAL 272 RC inpatient 6 6 CIGNA 62308 [3081051] CIGNA STATE OF WYOMING [308105107] 4.75 percent of total billed charges 3.72 5.7 Technical (Hospital) Services HC/HH Wch Supp Bndg Cnfrm Stretch St 6x82__2238 PX-2725000017 CDM 2725000017 LOCAL 272 RC inpatient 6 6 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES HDHP [308136802] 4.75 percent of total billed charges 3.72 5.7 Technical (Hospital) Services HC/HH Wch Supp Bndg Cnfrm Stretch St 6x82__2238 PX-2725000017 CDM 2725000017 LOCAL 272 RC inpatient 6 6 UNITED HEALTHCARE (COMMERCIAL) [3081199] UNITED HEALTHCARE 87726 [308119901] 3.72 percent of total billed charges 3.72 5.7 Technical (Hospital) Services HC/HH Wch Supp Bndg Cnfrm Stretch St 6x82__2238 PX-2725000017 CDM 2725000017 LOCAL 272 RC inpatient 6 6 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES PPO [308136801] 4.75 percent of total billed charges 3.72 5.7 Technical (Hospital) Services HC/HH Wch Supp Bndg Cnfrm Stretch St 6x82__2238 PX-2725000017 CDM 2725000017 LOCAL 272 RC inpatient 6 6 MEDICA (COMMERCIAL) 94265 [3081118] MEDICA CLAIMS [308111801] 5.4 percent of total billed charges 3.72 5.7 Technical (Hospital) Services HC/HH Wch Supp Bag Urine Leg Drain M__9645 PX-2725000016 CDM 2725000016 LOCAL 272 RC outpatient 58 58 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES EPO [308136803] 46.4 percent of total billed charges 35.96 55.1 Technical (Hospital) Services HC/HH Wch Supp Bag Urine Leg Drain M__9645 PX-2725000016 CDM 2725000016 LOCAL 272 RC outpatient 58 58 BLUE CROSS BLUE SHIELD WELLMARK SB889 [3081026] BCBS WYOMING [308102603] 55.1 percent of total billed charges 35.96 55.1 Technical (Hospital) Services HC/HH Wch Supp Bag Urine Leg Drain M__9645 PX-2725000016 CDM 2725000016 LOCAL 272 RC outpatient 58 58 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES HDHP [308136802] 46.4 percent of total billed charges 35.96 55.1 Technical (Hospital) Services HC/HH Wch Supp Bag Urine Leg Drain M__9645 PX-2725000016 CDM 2725000016 LOCAL 272 RC outpatient 58 58 UNITED HEALTHCARE (COMMERCIAL) [3081199] UNITED HEALTHCARE 87726 [308119901] 35.96 percent of total billed charges 35.96 55.1 Technical (Hospital) Services HC/HH Wch Supp Bag Urine Leg Drain M__9645 PX-2725000016 CDM 2725000016 LOCAL 272 RC outpatient 58 58 HEALTHPARTNERS SX009 HEALTHPARTNERS 46.4 percent of total billed charges 35.96 55.1 Technical (Hospital) Services HC/HH Wch Supp Bag Urine Leg Drain M__9645 PX-2725000016 CDM 2725000016 LOCAL 272 RC outpatient 58 58 CIGNA 62308 [3081051] CIGNA STATE OF WYOMING [308105107] 46.4 percent of total billed charges 35.96 55.1 Technical (Hospital) Services HC/HH Wch Supp Bag Urine Leg Drain M__9645 PX-2725000016 CDM 2725000016 LOCAL 272 RC outpatient 58 58 CIGNA 62308 [3081051] CIGNA 62308 [308105105] 46.4 percent of total billed charges 35.96 55.1 Technical (Hospital) Services HC/HH Wch Supp Bag Urine Leg Drain M__9645 PX-2725000016 CDM 2725000016 LOCAL 272 RC outpatient 58 58 MEDICA (COMMERCIAL) 94265 [3081118] MEDICA CLAIMS [308111801] 52.2 percent of total billed charges 35.96 55.1 Technical (Hospital) Services HC/HH Wch Supp Bag Urine Leg Drain M__9645 PX-2725000016 CDM 2725000016 LOCAL 272 RC outpatient 58 58 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES PPO [308136801] 46.4 percent of total billed charges 35.96 55.1 Technical (Hospital) Services HC/HH Wch Supp Bag Urine Leg Drain M__9645 PX-2725000016 CDM 2725000016 LOCAL 272 RC outpatient 58 58 MULTIPLAN INC 34080 [3081285] MULTIPLAN INC [308128501] 55.1 percent of total billed charges 35.96 55.1 Technical (Hospital) Services HC/HH Wch Supp Bag Urine Leg Drain M__9645 PX-2725000016 CDM 2725000016 LOCAL 272 RC inpatient 58 58 HEALTHPARTNERS SX009 HEALTHPARTNERS 45.92 percent of total billed charges 35.96 55.1 Technical (Hospital) Services HC/HH Wch Supp Bag Urine Leg Drain M__9645 PX-2725000016 CDM 2725000016 LOCAL 272 RC inpatient 58 58 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES EPO [308136803] 45.92 percent of total billed charges 35.96 55.1 Technical (Hospital) Services HC/HH Wch Supp Bag Urine Leg Drain M__9645 PX-2725000016 CDM 2725000016 LOCAL 272 RC inpatient 58 58 MULTIPLAN INC 34080 [3081285] MULTIPLAN INC [308128501] 55.1 percent of total billed charges 35.96 55.1 Technical (Hospital) Services HC/HH Wch Supp Bag Urine Leg Drain M__9645 PX-2725000016 CDM 2725000016 LOCAL 272 RC inpatient 58 58 BLUE CROSS BLUE SHIELD WELLMARK SB889 [3081026] BCBS WYOMING [308102603] 55.1 percent of total billed charges 35.96 55.1 Technical (Hospital) Services HC/HH Wch Supp Bag Urine Leg Drain M__9645 PX-2725000016 CDM 2725000016 LOCAL 272 RC inpatient 58 58 CIGNA 62308 [3081051] CIGNA 62308 [308105105] 45.92 percent of total billed charges 35.96 55.1 Technical (Hospital) Services HC/HH Wch Supp Bag Urine Leg Drain M__9645 PX-2725000016 CDM 2725000016 LOCAL 272 RC inpatient 58 58 CIGNA 62308 [3081051] CIGNA STATE OF WYOMING [308105107] 45.92 percent of total billed charges 35.96 55.1 Technical (Hospital) Services HC/HH Wch Supp Bag Urine Leg Drain M__9645 PX-2725000016 CDM 2725000016 LOCAL 272 RC inpatient 58 58 MEDICA (COMMERCIAL) 94265 [3081118] MEDICA CLAIMS [308111801] 52.2 percent of total billed charges 35.96 55.1 Technical (Hospital) Services HC/HH Wch Supp Bag Urine Leg Drain M__9645 PX-2725000016 CDM 2725000016 LOCAL 272 RC inpatient 58 58 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES PPO [308136801] 45.92 percent of total billed charges 35.96 55.1 Technical (Hospital) Services HC/HH Wch Supp Bag Urine Leg Drain M__9645 PX-2725000016 CDM 2725000016 LOCAL 272 RC inpatient 58 58 UNITED HEALTHCARE (COMMERCIAL) [3081199] UNITED HEALTHCARE 87726 [308119901] 35.96 percent of total billed charges 35.96 55.1 Technical (Hospital) Services HC/HH Wch Supp Bag Urine Leg Drain M__9645 PX-2725000016 CDM 2725000016 LOCAL 272 RC inpatient 58 58 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES HDHP [308136802] 45.92 percent of total billed charges 35.96 55.1 Technical (Hospital) Services HC/HH Wch Supp Aspirator Meconium__N0101 PX-2725000015 CDM 2725000015 LOCAL 272 RC inpatient 22 22 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES HDHP [308136802] 17.42 percent of total billed charges 13.64 20.9 Technical (Hospital) Services HC/HH Wch Supp Aspirator Meconium__N0101 PX-2725000015 CDM 2725000015 LOCAL 272 RC inpatient 22 22 UNITED HEALTHCARE (COMMERCIAL) [3081199] UNITED HEALTHCARE 87726 [308119901] 13.64 percent of total billed charges 13.64 20.9 Technical (Hospital) Services HC/HH Wch Supp Aspirator Meconium__N0101 PX-2725000015 CDM 2725000015 LOCAL 272 RC inpatient 22 22 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES PPO [308136801] 17.42 percent of total billed charges 13.64 20.9 Technical (Hospital) Services HC/HH Wch Supp Aspirator Meconium__N0101 PX-2725000015 CDM 2725000015 LOCAL 272 RC inpatient 22 22 MEDICA (COMMERCIAL) 94265 [3081118] MEDICA CLAIMS [308111801] 19.8 percent of total billed charges 13.64 20.9 Technical (Hospital) Services HC/HH Wch Supp Aspirator Meconium__N0101 PX-2725000015 CDM 2725000015 LOCAL 272 RC inpatient 22 22 BLUE CROSS BLUE SHIELD WELLMARK SB889 [3081026] BCBS WYOMING [308102603] 20.9 percent of total billed charges 13.64 20.9 Technical (Hospital) Services HC/HH Wch Supp Aspirator Meconium__N0101 PX-2725000015 CDM 2725000015 LOCAL 272 RC inpatient 22 22 MULTIPLAN INC 34080 [3081285] MULTIPLAN INC [308128501] 20.9 percent of total billed charges 13.64 20.9 Technical (Hospital) Services HC/HH Wch Supp Aspirator Meconium__N0101 PX-2725000015 CDM 2725000015 LOCAL 272 RC inpatient 22 22 CIGNA 62308 [3081051] CIGNA 62308 [308105105] 17.42 percent of total billed charges 13.64 20.9 Technical (Hospital) Services HC/HH Wch Supp Aspirator Meconium__N0101 PX-2725000015 CDM 2725000015 LOCAL 272 RC inpatient 22 22 CIGNA 62308 [3081051] CIGNA STATE OF WYOMING [308105107] 17.42 percent of total billed charges 13.64 20.9 Technical (Hospital) Services HC/HH Wch Supp Aspirator Meconium__N0101 PX-2725000015 CDM 2725000015 LOCAL 272 RC inpatient 22 22 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES EPO [308136803] 17.42 percent of total billed charges 13.64 20.9 Technical (Hospital) Services HC/HH Wch Supp Aspirator Meconium__N0101 PX-2725000015 CDM 2725000015 LOCAL 272 RC inpatient 22 22 HEALTHPARTNERS SX009 HEALTHPARTNERS 17.42 percent of total billed charges 13.64 20.9 Technical (Hospital) Services HC/HH Wch Supp Aspirator Meconium__N0101 PX-2725000015 CDM 2725000015 LOCAL 272 RC outpatient 22 22 BLUE CROSS BLUE SHIELD WELLMARK SB889 [3081026] BCBS WYOMING [308102603] 20.9 percent of total billed charges 13.64 20.9 Technical (Hospital) Services HC/HH Wch Supp Aspirator Meconium__N0101 PX-2725000015 CDM 2725000015 LOCAL 272 RC outpatient 22 22 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES EPO [308136803] 17.6 percent of total billed charges 13.64 20.9 Technical (Hospital) Services HC/HH Wch Supp Aspirator Meconium__N0101 PX-2725000015 CDM 2725000015 LOCAL 272 RC outpatient 22 22 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES HDHP [308136802] 17.6 percent of total billed charges 13.64 20.9 Technical (Hospital) Services HC/HH Wch Supp Aspirator Meconium__N0101 PX-2725000015 CDM 2725000015 LOCAL 272 RC outpatient 22 22 UNITED HEALTHCARE (COMMERCIAL) [3081199] UNITED HEALTHCARE 87726 [308119901] 13.64 percent of total billed charges 13.64 20.9 Technical (Hospital) Services HC/HH Wch Supp Aspirator Meconium__N0101 PX-2725000015 CDM 2725000015 LOCAL 272 RC outpatient 22 22 HEALTHPARTNERS SX009 HEALTHPARTNERS 17.6 percent of total billed charges 13.64 20.9 Technical (Hospital) Services HC/HH Wch Supp Aspirator Meconium__N0101 PX-2725000015 CDM 2725000015 LOCAL 272 RC outpatient 22 22 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES PPO [308136801] 17.6 percent of total billed charges 13.64 20.9 Technical (Hospital) Services HC/HH Wch Supp Aspirator Meconium__N0101 PX-2725000015 CDM 2725000015 LOCAL 272 RC outpatient 22 22 CIGNA 62308 [3081051] CIGNA STATE OF WYOMING [308105107] 17.6 percent of total billed charges 13.64 20.9 Technical (Hospital) Services HC/HH Wch Supp Aspirator Meconium__N0101 PX-2725000015 CDM 2725000015 LOCAL 272 RC outpatient 22 22 CIGNA 62308 [3081051] CIGNA 62308 [308105105] 17.6 percent of total billed charges 13.64 20.9 Technical (Hospital) Services HC/HH Wch Supp Aspirator Meconium__N0101 PX-2725000015 CDM 2725000015 LOCAL 272 RC outpatient 22 22 MULTIPLAN INC 34080 [3081285] MULTIPLAN INC [308128501] 20.9 percent of total billed charges 13.64 20.9 Technical (Hospital) Services HC/HH Wch Supp Aspirator Meconium__N0101 PX-2725000015 CDM 2725000015 LOCAL 272 RC outpatient 22 22 MEDICA (COMMERCIAL) 94265 [3081118] MEDICA CLAIMS [308111801] 19.8 percent of total billed charges 13.64 20.9 Technical (Hospital) Services HC/HH Wch Supp Airway Nasoph 34fr__8888247064 PX-2725000014 CDM 2725000014 LOCAL 272 RC outpatient 32 32 CIGNA 62308 [3081051] CIGNA 62308 [308105105] 25.6 percent of total billed charges 19.84 30.4 Technical (Hospital) Services HC/HH Wch Supp Airway Nasoph 34fr__8888247064 PX-2725000014 CDM 2725000014 LOCAL 272 RC outpatient 32 32 CIGNA 62308 [3081051] CIGNA STATE OF WYOMING [308105107] 25.6 percent of total billed charges 19.84 30.4 Technical (Hospital) Services HC/HH Wch Supp Airway Nasoph 34fr__8888247064 PX-2725000014 CDM 2725000014 LOCAL 272 RC outpatient 32 32 UNITED HEALTHCARE (COMMERCIAL) [3081199] UNITED HEALTHCARE 87726 [308119901] 19.84 percent of total billed charges 19.84 30.4 Technical (Hospital) Services HC/HH Wch Supp Airway Nasoph 34fr__8888247064 PX-2725000014 CDM 2725000014 LOCAL 272 RC outpatient 32 32 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES PPO [308136801] 25.6 percent of total billed charges 19.84 30.4 Technical (Hospital) Services HC/HH Wch Supp Airway Nasoph 34fr__8888247064 PX-2725000014 CDM 2725000014 LOCAL 272 RC outpatient 32 32 HEALTHPARTNERS SX009 HEALTHPARTNERS 25.6 percent of total billed charges 19.84 30.4 Technical (Hospital) Services HC/HH Wch Supp Airway Nasoph 34fr__8888247064 PX-2725000014 CDM 2725000014 LOCAL 272 RC outpatient 32 32 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES EPO [308136803] 25.6 percent of total billed charges 19.84 30.4 Technical (Hospital) Services HC/HH Wch Supp Airway Nasoph 34fr__8888247064 PX-2725000014 CDM 2725000014 LOCAL 272 RC outpatient 32 32 BLUE CROSS BLUE SHIELD WELLMARK SB889 [3081026] BCBS WYOMING [308102603] 30.4 percent of total billed charges 19.84 30.4 Technical (Hospital) Services HC/HH Wch Supp Airway Nasoph 34fr__8888247064 PX-2725000014 CDM 2725000014 LOCAL 272 RC outpatient 32 32 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES HDHP [308136802] 25.6 percent of total billed charges 19.84 30.4 Technical (Hospital) Services HC/HH Wch Supp Airway Nasoph 34fr__8888247064 PX-2725000014 CDM 2725000014 LOCAL 272 RC outpatient 32 32 MULTIPLAN INC 34080 [3081285] MULTIPLAN INC [308128501] 30.4 percent of total billed charges 19.84 30.4 Technical (Hospital) Services HC/HH Wch Supp Airway Nasoph 34fr__8888247064 PX-2725000014 CDM 2725000014 LOCAL 272 RC outpatient 32 32 MEDICA (COMMERCIAL) 94265 [3081118] MEDICA CLAIMS [308111801] 28.8 percent of total billed charges 19.84 30.4 Technical (Hospital) Services HC/HH Wch Supp Airway Nasoph 34fr__8888247064 PX-2725000014 CDM 2725000014 LOCAL 272 RC inpatient 32 32 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES PPO [308136801] 25.34 percent of total billed charges 19.84 30.4 Technical (Hospital) Services HC/HH Wch Supp Airway Nasoph 34fr__8888247064 PX-2725000014 CDM 2725000014 LOCAL 272 RC inpatient 32 32 MEDICA (COMMERCIAL) 94265 [3081118] MEDICA CLAIMS [308111801] 28.8 percent of total billed charges 19.84 30.4 Technical (Hospital) Services HC/HH Wch Supp Airway Nasoph 34fr__8888247064 PX-2725000014 CDM 2725000014 LOCAL 272 RC inpatient 32 32 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES HDHP [308136802] 25.34 percent of total billed charges 19.84 30.4 Technical (Hospital) Services HC/HH Wch Supp Airway Nasoph 34fr__8888247064 PX-2725000014 CDM 2725000014 LOCAL 272 RC inpatient 32 32 UNITED HEALTHCARE (COMMERCIAL) [3081199] UNITED HEALTHCARE 87726 [308119901] 19.84 percent of total billed charges 19.84 30.4 Technical (Hospital) Services HC/HH Wch Supp Airway Nasoph 34fr__8888247064 PX-2725000014 CDM 2725000014 LOCAL 272 RC inpatient 32 32 MULTIPLAN INC 34080 [3081285] MULTIPLAN INC [308128501] 30.4 percent of total billed charges 19.84 30.4 Technical (Hospital) Services HC/HH Wch Supp Airway Nasoph 34fr__8888247064 PX-2725000014 CDM 2725000014 LOCAL 272 RC inpatient 32 32 BLUE CROSS BLUE SHIELD WELLMARK SB889 [3081026] BCBS WYOMING [308102603] 30.4 percent of total billed charges 19.84 30.4 Technical (Hospital) Services HC/HH Wch Supp Airway Nasoph 34fr__8888247064 PX-2725000014 CDM 2725000014 LOCAL 272 RC inpatient 32 32 HEALTHPARTNERS SX009 HEALTHPARTNERS 25.34 percent of total billed charges 19.84 30.4 Technical (Hospital) Services HC/HH Wch Supp Airway Nasoph 34fr__8888247064 PX-2725000014 CDM 2725000014 LOCAL 272 RC inpatient 32 32 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES EPO [308136803] 25.34 percent of total billed charges 19.84 30.4 Technical (Hospital) Services HC/HH Wch Supp Airway Nasoph 34fr__8888247064 PX-2725000014 CDM 2725000014 LOCAL 272 RC inpatient 32 32 CIGNA 62308 [3081051] CIGNA 62308 [308105105] 25.34 percent of total billed charges 19.84 30.4 Technical (Hospital) Services HC/HH Wch Supp Airway Nasoph 34fr__8888247064 PX-2725000014 CDM 2725000014 LOCAL 272 RC inpatient 32 32 CIGNA 62308 [3081051] CIGNA STATE OF WYOMING [308105107] 25.34 percent of total billed charges 19.84 30.4 Technical (Hospital) Services HC/HH Wch Supp Airway Nasoph 32fr__8888247056 PX-2725000013 CDM 2725000013 LOCAL 272 RC outpatient 37 37 CIGNA 62308 [3081051] CIGNA 62308 [308105105] 29.6 percent of total billed charges 22.94 35.15 Technical (Hospital) Services HC/HH Wch Supp Airway Nasoph 32fr__8888247056 PX-2725000013 CDM 2725000013 LOCAL 272 RC outpatient 37 37 CIGNA 62308 [3081051] CIGNA STATE OF WYOMING [308105107] 29.6 percent of total billed charges 22.94 35.15 Technical (Hospital) Services HC/HH Wch Supp Airway Nasoph 32fr__8888247056 PX-2725000013 CDM 2725000013 LOCAL 272 RC outpatient 37 37 UNITED HEALTHCARE (COMMERCIAL) [3081199] UNITED HEALTHCARE 87726 [308119901] 22.94 percent of total billed charges 22.94 35.15 Technical (Hospital) Services HC/HH Wch Supp Airway Nasoph 32fr__8888247056 PX-2725000013 CDM 2725000013 LOCAL 272 RC outpatient 37 37 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES HDHP [308136802] 29.6 percent of total billed charges 22.94 35.15 Technical (Hospital) Services HC/HH Wch Supp Airway Nasoph 32fr__8888247056 PX-2725000013 CDM 2725000013 LOCAL 272 RC outpatient 37 37 BLUE CROSS BLUE SHIELD WELLMARK SB889 [3081026] BCBS WYOMING [308102603] 35.15 percent of total billed charges 22.94 35.15 Technical (Hospital) Services HC/HH Wch Supp Airway Nasoph 32fr__8888247056 PX-2725000013 CDM 2725000013 LOCAL 272 RC outpatient 37 37 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES EPO [308136803] 29.6 percent of total billed charges 22.94 35.15 Technical (Hospital) Services HC/HH Wch Supp Airway Nasoph 32fr__8888247056 PX-2725000013 CDM 2725000013 LOCAL 272 RC outpatient 37 37 MEDICA (COMMERCIAL) 94265 [3081118] MEDICA CLAIMS [308111801] 33.3 percent of total billed charges 22.94 35.15 Technical (Hospital) Services HC/HH Wch Supp Airway Nasoph 32fr__8888247056 PX-2725000013 CDM 2725000013 LOCAL 272 RC outpatient 37 37 HEALTHPARTNERS SX009 HEALTHPARTNERS 29.6 percent of total billed charges 22.94 35.15 Technical (Hospital) Services HC/HH Wch Supp Airway Nasoph 32fr__8888247056 PX-2725000013 CDM 2725000013 LOCAL 272 RC outpatient 37 37 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES PPO [308136801] 29.6 percent of total billed charges 22.94 35.15 Technical (Hospital) Services HC/HH Wch Supp Airway Nasoph 32fr__8888247056 PX-2725000013 CDM 2725000013 LOCAL 272 RC inpatient 37 37 UNITED HEALTHCARE (COMMERCIAL) [3081199] UNITED HEALTHCARE 87726 [308119901] 22.94 percent of total billed charges 22.94 35.15 Technical (Hospital) Services HC/HH Wch Supp Airway Nasoph 32fr__8888247056 PX-2725000013 CDM 2725000013 LOCAL 272 RC inpatient 37 37 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES HDHP [308136802] 29.3 percent of total billed charges 22.94 35.15 Technical (Hospital) Services HC/HH Wch Supp Airway Nasoph 32fr__8888247056 PX-2725000013 CDM 2725000013 LOCAL 272 RC inpatient 37 37 MEDICA (COMMERCIAL) 94265 [3081118] MEDICA CLAIMS [308111801] 33.3 percent of total billed charges 22.94 35.15 Technical (Hospital) Services HC/HH Wch Supp Airway Nasoph 32fr__8888247056 PX-2725000013 CDM 2725000013 LOCAL 272 RC inpatient 37 37 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES PPO [308136801] 29.3 percent of total billed charges 22.94 35.15 Technical (Hospital) Services HC/HH Wch Supp Airway Nasoph 32fr__8888247056 PX-2725000013 CDM 2725000013 LOCAL 272 RC inpatient 37 37 CIGNA 62308 [3081051] CIGNA 62308 [308105105] 29.3 percent of total billed charges 22.94 35.15 Technical (Hospital) Services HC/HH Wch Supp Airway Nasoph 32fr__8888247056 PX-2725000013 CDM 2725000013 LOCAL 272 RC inpatient 37 37 CIGNA 62308 [3081051] CIGNA STATE OF WYOMING [308105107] 29.3 percent of total billed charges 22.94 35.15 Technical (Hospital) Services HC/HH Wch Supp Airway Nasoph 32fr__8888247056 PX-2725000013 CDM 2725000013 LOCAL 272 RC inpatient 37 37 BLUE CROSS BLUE SHIELD WELLMARK SB889 [3081026] BCBS WYOMING [308102603] 35.15 percent of total billed charges 22.94 35.15 Technical (Hospital) Services HC/HH Wch Supp Airway Nasoph 32fr__8888247056 PX-2725000013 CDM 2725000013 LOCAL 272 RC inpatient 37 37 MULTIPLAN INC 34080 [3081285] MULTIPLAN INC [308128501] 35.15 percent of total billed charges 22.94 35.15 Technical (Hospital) Services HC/HH Wch Supp Airway Nasoph 32fr__8888247056 PX-2725000013 CDM 2725000013 LOCAL 272 RC inpatient 37 37 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES EPO [308136803] 29.3 percent of total billed charges 22.94 35.15 Technical (Hospital) Services HC/HH Wch Supp Airway Nasoph 32fr__8888247056 PX-2725000013 CDM 2725000013 LOCAL 272 RC inpatient 37 37 HEALTHPARTNERS SX009 HEALTHPARTNERS 29.3 percent of total billed charges 22.94 35.15 Technical (Hospital) Services HC/HH Wch Supp Airway Nasoph 32fr__8888247056 PX-2725000013 CDM 2725000013 LOCAL 272 RC outpatient 37 37 MULTIPLAN INC 34080 [3081285] MULTIPLAN INC [308128501] 35.15 percent of total billed charges 22.94 35.15 Technical (Hospital) Services HC/HH Wch Supp Airway Nasoph 30fr__8888247049 PX-2725000012 CDM 2725000012 LOCAL 272 RC outpatient 34 34 BLUE CROSS BLUE SHIELD WELLMARK SB889 [3081026] BCBS WYOMING [308102603] 32.3 percent of total billed charges 21.08 32.3 Technical (Hospital) Services HC/HH Wch Supp Airway Nasoph 30fr__8888247049 PX-2725000012 CDM 2725000012 LOCAL 272 RC outpatient 34 34 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES EPO [308136803] 27.2 percent of total billed charges 21.08 32.3 Technical (Hospital) Services HC/HH Wch Supp Airway Nasoph 30fr__8888247049 PX-2725000012 CDM 2725000012 LOCAL 272 RC outpatient 34 34 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES HDHP [308136802] 27.2 percent of total billed charges 21.08 32.3 Technical (Hospital) Services HC/HH Wch Supp Airway Nasoph 30fr__8888247049 PX-2725000012 CDM 2725000012 LOCAL 272 RC outpatient 34 34 UNITED HEALTHCARE (COMMERCIAL) [3081199] UNITED HEALTHCARE 87726 [308119901] 21.08 percent of total billed charges 21.08 32.3 Technical (Hospital) Services HC/HH Wch Supp Airway Nasoph 30fr__8888247049 PX-2725000012 CDM 2725000012 LOCAL 272 RC outpatient 34 34 HEALTHPARTNERS SX009 HEALTHPARTNERS 27.2 percent of total billed charges 21.08 32.3 Technical (Hospital) Services HC/HH Wch Supp Airway Nasoph 30fr__8888247049 PX-2725000012 CDM 2725000012 LOCAL 272 RC outpatient 34 34 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES PPO [308136801] 27.2 percent of total billed charges 21.08 32.3 Technical (Hospital) Services HC/HH Wch Supp Airway Nasoph 30fr__8888247049 PX-2725000012 CDM 2725000012 LOCAL 272 RC outpatient 34 34 CIGNA 62308 [3081051] CIGNA 62308 [308105105] 27.2 percent of total billed charges 21.08 32.3 Technical (Hospital) Services HC/HH Wch Supp Airway Nasoph 30fr__8888247049 PX-2725000012 CDM 2725000012 LOCAL 272 RC outpatient 34 34 CIGNA 62308 [3081051] CIGNA STATE OF WYOMING [308105107] 27.2 percent of total billed charges 21.08 32.3 Technical (Hospital) Services HC/HH Wch Supp Airway Nasoph 30fr__8888247049 PX-2725000012 CDM 2725000012 LOCAL 272 RC outpatient 34 34 MULTIPLAN INC 34080 [3081285] MULTIPLAN INC [308128501] 32.3 percent of total billed charges 21.08 32.3 Technical (Hospital) Services HC/HH Wch Supp Airway Nasoph 30fr__8888247049 PX-2725000012 CDM 2725000012 LOCAL 272 RC outpatient 34 34 MEDICA (COMMERCIAL) 94265 [3081118] MEDICA CLAIMS [308111801] 30.6 percent of total billed charges 21.08 32.3 Technical (Hospital) Services HC/HH Wch Supp Airway Nasoph 30fr__8888247049 PX-2725000012 CDM 2725000012 LOCAL 272 RC inpatient 34 34 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES HDHP [308136802] 26.92 percent of total billed charges 21.08 32.3 Technical (Hospital) Services HC/HH Wch Supp Airway Nasoph 30fr__8888247049 PX-2725000012 CDM 2725000012 LOCAL 272 RC inpatient 34 34 UNITED HEALTHCARE (COMMERCIAL) [3081199] UNITED HEALTHCARE 87726 [308119901] 21.08 percent of total billed charges 21.08 32.3 Technical (Hospital) Services HC/HH Wch Supp Airway Nasoph 30fr__8888247049 PX-2725000012 CDM 2725000012 LOCAL 272 RC inpatient 34 34 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES PPO [308136801] 26.92 percent of total billed charges 21.08 32.3 Technical (Hospital) Services HC/HH Wch Supp Airway Nasoph 30fr__8888247049 PX-2725000012 CDM 2725000012 LOCAL 272 RC inpatient 34 34 MEDICA (COMMERCIAL) 94265 [3081118] MEDICA CLAIMS [308111801] 30.6 percent of total billed charges 21.08 32.3 Technical (Hospital) Services HC/HH Wch Supp Airway Nasoph 30fr__8888247049 PX-2725000012 CDM 2725000012 LOCAL 272 RC inpatient 34 34 HEALTHPARTNERS SX009 HEALTHPARTNERS 26.92 percent of total billed charges 21.08 32.3 Technical (Hospital) Services HC/HH Wch Supp Airway Nasoph 30fr__8888247049 PX-2725000012 CDM 2725000012 LOCAL 272 RC inpatient 34 34 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES EPO [308136803] 26.92 percent of total billed charges 21.08 32.3 Technical (Hospital) Services HC/HH Wch Supp Airway Nasoph 30fr__8888247049 PX-2725000012 CDM 2725000012 LOCAL 272 RC inpatient 34 34 MULTIPLAN INC 34080 [3081285] MULTIPLAN INC [308128501] 32.3 percent of total billed charges 21.08 32.3 Technical (Hospital) Services HC/HH Wch Supp Airway Nasoph 30fr__8888247049 PX-2725000012 CDM 2725000012 LOCAL 272 RC inpatient 34 34 BLUE CROSS BLUE SHIELD WELLMARK SB889 [3081026] BCBS WYOMING [308102603] 32.3 percent of total billed charges 21.08 32.3 Technical (Hospital) Services HC/HH Wch Supp Airway Nasoph 30fr__8888247049 PX-2725000012 CDM 2725000012 LOCAL 272 RC inpatient 34 34 CIGNA 62308 [3081051] CIGNA 62308 [308105105] 26.92 percent of total billed charges 21.08 32.3 Technical (Hospital) Services HC/HH Wch Supp Airway Nasoph 30fr__8888247049 PX-2725000012 CDM 2725000012 LOCAL 272 RC inpatient 34 34 CIGNA 62308 [3081051] CIGNA STATE OF WYOMING [308105107] 26.92 percent of total billed charges 21.08 32.3 Technical (Hospital) Services HC/HH Wch Supp Airway Nasoph 28fr__8888247031 PX-2725000011 CDM 2725000011 LOCAL 272 RC inpatient 32 32 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES HDHP [308136802] 25.34 percent of total billed charges 19.84 30.4 Technical (Hospital) Services HC/HH Wch Supp Airway Nasoph 28fr__8888247031 PX-2725000011 CDM 2725000011 LOCAL 272 RC inpatient 32 32 UNITED HEALTHCARE (COMMERCIAL) [3081199] UNITED HEALTHCARE 87726 [308119901] 19.84 percent of total billed charges 19.84 30.4 Technical (Hospital) Services HC/HH Wch Supp Airway Nasoph 28fr__8888247031 PX-2725000011 CDM 2725000011 LOCAL 272 RC inpatient 32 32 MEDICA (COMMERCIAL) 94265 [3081118] MEDICA CLAIMS [308111801] 28.8 percent of total billed charges 19.84 30.4 Technical (Hospital) Services HC/HH Wch Supp Airway Nasoph 28fr__8888247031 PX-2725000011 CDM 2725000011 LOCAL 272 RC inpatient 32 32 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES PPO [308136801] 25.34 percent of total billed charges 19.84 30.4 Technical (Hospital) Services HC/HH Wch Supp Airway Nasoph 28fr__8888247031 PX-2725000011 CDM 2725000011 LOCAL 272 RC inpatient 32 32 CIGNA 62308 [3081051] CIGNA 62308 [308105105] 25.34 percent of total billed charges 19.84 30.4 Technical (Hospital) Services HC/HH Wch Supp Airway Nasoph 28fr__8888247031 PX-2725000011 CDM 2725000011 LOCAL 272 RC inpatient 32 32 CIGNA 62308 [3081051] CIGNA STATE OF WYOMING [308105107] 25.34 percent of total billed charges 19.84 30.4 Technical (Hospital) Services HC/HH Wch Supp Airway Nasoph 28fr__8888247031 PX-2725000011 CDM 2725000011 LOCAL 272 RC inpatient 32 32 MULTIPLAN INC 34080 [3081285] MULTIPLAN INC [308128501] 30.4 percent of total billed charges 19.84 30.4 Technical (Hospital) Services HC/HH Wch Supp Airway Nasoph 28fr__8888247031 PX-2725000011 CDM 2725000011 LOCAL 272 RC inpatient 32 32 BLUE CROSS BLUE SHIELD WELLMARK SB889 [3081026] BCBS WYOMING [308102603] 30.4 percent of total billed charges 19.84 30.4 Technical (Hospital) Services HC/HH Wch Supp Airway Nasoph 28fr__8888247031 PX-2725000011 CDM 2725000011 LOCAL 272 RC inpatient 32 32 HEALTHPARTNERS SX009 HEALTHPARTNERS 25.34 percent of total billed charges 19.84 30.4 Technical (Hospital) Services HC/HH Wch Supp Airway Nasoph 28fr__8888247031 PX-2725000011 CDM 2725000011 LOCAL 272 RC inpatient 32 32 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES EPO [308136803] 25.34 percent of total billed charges 19.84 30.4 Technical (Hospital) Services HC/HH Wch Supp Airway Nasoph 28fr__8888247031 PX-2725000011 CDM 2725000011 LOCAL 272 RC outpatient 32 32 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES HDHP [308136802] 25.6 percent of total billed charges 19.84 30.4 Technical (Hospital) Services HC/HH Wch Supp Airway Nasoph 28fr__8888247031 PX-2725000011 CDM 2725000011 LOCAL 272 RC outpatient 32 32 BLUE CROSS BLUE SHIELD WELLMARK SB889 [3081026] BCBS WYOMING [308102603] 30.4 percent of total billed charges 19.84 30.4 Technical (Hospital) Services HC/HH Wch Supp Airway Nasoph 28fr__8888247031 PX-2725000011 CDM 2725000011 LOCAL 272 RC outpatient 32 32 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES EPO [308136803] 25.6 percent of total billed charges 19.84 30.4 Technical (Hospital) Services HC/HH Wch Supp Airway Nasoph 28fr__8888247031 PX-2725000011 CDM 2725000011 LOCAL 272 RC outpatient 32 32 UNITED HEALTHCARE (COMMERCIAL) [3081199] UNITED HEALTHCARE 87726 [308119901] 19.84 percent of total billed charges 19.84 30.4 Technical (Hospital) Services HC/HH Wch Supp Airway Nasoph 28fr__8888247031 PX-2725000011 CDM 2725000011 LOCAL 272 RC outpatient 32 32 HEALTHPARTNERS SX009 HEALTHPARTNERS 25.6 percent of total billed charges 19.84 30.4 Technical (Hospital) Services HC/HH Wch Supp Airway Nasoph 28fr__8888247031 PX-2725000011 CDM 2725000011 LOCAL 272 RC outpatient 32 32 CIGNA 62308 [3081051] CIGNA 62308 [308105105] 25.6 percent of total billed charges 19.84 30.4 Technical (Hospital) Services HC/HH Wch Supp Airway Nasoph 28fr__8888247031 PX-2725000011 CDM 2725000011 LOCAL 272 RC outpatient 32 32 CIGNA 62308 [3081051] CIGNA STATE OF WYOMING [308105107] 25.6 percent of total billed charges 19.84 30.4 Technical (Hospital) Services HC/HH Wch Supp Airway Nasoph 28fr__8888247031 PX-2725000011 CDM 2725000011 LOCAL 272 RC outpatient 32 32 MEDICA (COMMERCIAL) 94265 [3081118] MEDICA CLAIMS [308111801] 28.8 percent of total billed charges 19.84 30.4 Technical (Hospital) Services HC/HH Wch Supp Airway Nasoph 28fr__8888247031 PX-2725000011 CDM 2725000011 LOCAL 272 RC outpatient 32 32 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES PPO [308136801] 25.6 percent of total billed charges 19.84 30.4 Technical (Hospital) Services HC/HH Wch Supp Airway Nasoph 28fr__8888247031 PX-2725000011 CDM 2725000011 LOCAL 272 RC outpatient 32 32 MULTIPLAN INC 34080 [3081285] MULTIPLAN INC [308128501] 30.4 percent of total billed charges 19.84 30.4 Technical (Hospital) Services HC/HH Wch Supp Airway Nasoph 26fr__8888247023 PX-2725000010 CDM 2725000010 LOCAL 272 RC outpatient 32 32 MEDICA (COMMERCIAL) 94265 [3081118] MEDICA CLAIMS [308111801] 28.8 percent of total billed charges 19.84 30.4 Technical (Hospital) Services HC/HH Wch Supp Airway Nasoph 26fr__8888247023 PX-2725000010 CDM 2725000010 LOCAL 272 RC outpatient 32 32 MULTIPLAN INC 34080 [3081285] MULTIPLAN INC [308128501] 30.4 percent of total billed charges 19.84 30.4 Technical (Hospital) Services HC/HH Wch Supp Airway Nasoph 26fr__8888247023 PX-2725000010 CDM 2725000010 LOCAL 272 RC outpatient 32 32 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES HDHP [308136802] 25.6 percent of total billed charges 19.84 30.4 Technical (Hospital) Services HC/HH Wch Supp Airway Nasoph 26fr__8888247023 PX-2725000010 CDM 2725000010 LOCAL 272 RC outpatient 32 32 BLUE CROSS BLUE SHIELD WELLMARK SB889 [3081026] BCBS WYOMING [308102603] 30.4 percent of total billed charges 19.84 30.4 Technical (Hospital) Services HC/HH Wch Supp Airway Nasoph 26fr__8888247023 PX-2725000010 CDM 2725000010 LOCAL 272 RC outpatient 32 32 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES EPO [308136803] 25.6 percent of total billed charges 19.84 30.4 Technical (Hospital) Services HC/HH Wch Supp Airway Nasoph 26fr__8888247023 PX-2725000010 CDM 2725000010 LOCAL 272 RC outpatient 32 32 HEALTHPARTNERS SX009 HEALTHPARTNERS 25.6 percent of total billed charges 19.84 30.4 Technical (Hospital) Services HC/HH Wch Supp Airway Nasoph 26fr__8888247023 PX-2725000010 CDM 2725000010 LOCAL 272 RC outpatient 32 32 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES PPO [308136801] 25.6 percent of total billed charges 19.84 30.4 Technical (Hospital) Services HC/HH Wch Supp Airway Nasoph 26fr__8888247023 PX-2725000010 CDM 2725000010 LOCAL 272 RC outpatient 32 32 UNITED HEALTHCARE (COMMERCIAL) [3081199] UNITED HEALTHCARE 87726 [308119901] 19.84 percent of total billed charges 19.84 30.4 Technical (Hospital) Services HC/HH Wch Supp Airway Nasoph 26fr__8888247023 PX-2725000010 CDM 2725000010 LOCAL 272 RC outpatient 32 32 CIGNA 62308 [3081051] CIGNA 62308 [308105105] 25.6 percent of total billed charges 19.84 30.4 Technical (Hospital) Services HC/HH Wch Supp Airway Nasoph 26fr__8888247023 PX-2725000010 CDM 2725000010 LOCAL 272 RC outpatient 32 32 CIGNA 62308 [3081051] CIGNA STATE OF WYOMING [308105107] 25.6 percent of total billed charges 19.84 30.4 Technical (Hospital) Services HC/HH Wch Supp Airway Nasoph 26fr__8888247023 PX-2725000010 CDM 2725000010 LOCAL 272 RC inpatient 32 32 HEALTHPARTNERS SX009 HEALTHPARTNERS 25.34 percent of total billed charges 19.84 30.4 Technical (Hospital) Services HC/HH Wch Supp Airway Nasoph 26fr__8888247023 PX-2725000010 CDM 2725000010 LOCAL 272 RC inpatient 32 32 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES EPO [308136803] 25.34 percent of total billed charges 19.84 30.4 Technical (Hospital) Services HC/HH Wch Supp Airway Nasoph 26fr__8888247023 PX-2725000010 CDM 2725000010 LOCAL 272 RC inpatient 32 32 MULTIPLAN INC 34080 [3081285] MULTIPLAN INC [308128501] 30.4 percent of total billed charges 19.84 30.4 Technical (Hospital) Services HC/HH Wch Supp Airway Nasoph 26fr__8888247023 PX-2725000010 CDM 2725000010 LOCAL 272 RC inpatient 32 32 BLUE CROSS BLUE SHIELD WELLMARK SB889 [3081026] BCBS WYOMING [308102603] 30.4 percent of total billed charges 19.84 30.4 Technical (Hospital) Services HC/HH Wch Supp Airway Nasoph 26fr__8888247023 PX-2725000010 CDM 2725000010 LOCAL 272 RC inpatient 32 32 CIGNA 62308 [3081051] CIGNA 62308 [308105105] 25.34 percent of total billed charges 19.84 30.4 Technical (Hospital) Services HC/HH Wch Supp Airway Nasoph 26fr__8888247023 PX-2725000010 CDM 2725000010 LOCAL 272 RC inpatient 32 32 CIGNA 62308 [3081051] CIGNA STATE OF WYOMING [308105107] 25.34 percent of total billed charges 19.84 30.4 Technical (Hospital) Services HC/HH Wch Supp Airway Nasoph 26fr__8888247023 PX-2725000010 CDM 2725000010 LOCAL 272 RC inpatient 32 32 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES PPO [308136801] 25.34 percent of total billed charges 19.84 30.4 Technical (Hospital) Services HC/HH Wch Supp Airway Nasoph 26fr__8888247023 PX-2725000010 CDM 2725000010 LOCAL 272 RC inpatient 32 32 MEDICA (COMMERCIAL) 94265 [3081118] MEDICA CLAIMS [308111801] 28.8 percent of total billed charges 19.84 30.4 Technical (Hospital) Services HC/HH Wch Supp Airway Nasoph 26fr__8888247023 PX-2725000010 CDM 2725000010 LOCAL 272 RC inpatient 32 32 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES HDHP [308136802] 25.34 percent of total billed charges 19.84 30.4 Technical (Hospital) Services HC/HH Wch Supp Airway Nasoph 26fr__8888247023 PX-2725000010 CDM 2725000010 LOCAL 272 RC inpatient 32 32 UNITED HEALTHCARE (COMMERCIAL) [3081199] UNITED HEALTHCARE 87726 [308119901] 19.84 percent of total billed charges 19.84 30.4 Technical (Hospital) Services HC/HH Wch Supp Adhesive Mastisol Vial__0523-48 PX-2725000009 CDM 2725000009 LOCAL 272 RC outpatient 9 9 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES HDHP [308136802] 7.2 percent of total billed charges 5.58 8.55 Technical (Hospital) Services HC/HH Wch Supp Adhesive Mastisol Vial__0523-48 PX-2725000009 CDM 2725000009 LOCAL 272 RC outpatient 9 9 BLUE CROSS BLUE SHIELD WELLMARK SB889 [3081026] BCBS WYOMING [308102603] 8.55 percent of total billed charges 5.58 8.55 Technical (Hospital) Services HC/HH Wch Supp Adhesive Mastisol Vial__0523-48 PX-2725000009 CDM 2725000009 LOCAL 272 RC outpatient 9 9 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES EPO [308136803] 7.2 percent of total billed charges 5.58 8.55 Technical (Hospital) Services HC/HH Wch Supp Adhesive Mastisol Vial__0523-48 PX-2725000009 CDM 2725000009 LOCAL 272 RC outpatient 9 9 CIGNA 62308 [3081051] CIGNA 62308 [308105105] 7.2 percent of total billed charges 5.58 8.55 Technical (Hospital) Services HC/HH Wch Supp Adhesive Mastisol Vial__0523-48 PX-2725000009 CDM 2725000009 LOCAL 272 RC outpatient 9 9 CIGNA 62308 [3081051] CIGNA STATE OF WYOMING [308105107] 7.2 percent of total billed charges 5.58 8.55 Technical (Hospital) Services HC/HH Wch Supp Adhesive Mastisol Vial__0523-48 PX-2725000009 CDM 2725000009 LOCAL 272 RC outpatient 9 9 UNITED HEALTHCARE (COMMERCIAL) [3081199] UNITED HEALTHCARE 87726 [308119901] 5.58 percent of total billed charges 5.58 8.55 Technical (Hospital) Services HC/HH Wch Supp Adhesive Mastisol Vial__0523-48 PX-2725000009 CDM 2725000009 LOCAL 272 RC outpatient 9 9 HEALTHPARTNERS SX009 HEALTHPARTNERS 7.2 percent of total billed charges 5.58 8.55 Technical (Hospital) Services HC/HH Wch Supp Adhesive Mastisol Vial__0523-48 PX-2725000009 CDM 2725000009 LOCAL 272 RC outpatient 9 9 MULTIPLAN INC 34080 [3081285] MULTIPLAN INC [308128501] 8.55 percent of total billed charges 5.58 8.55 Technical (Hospital) Services HC/HH Wch Supp Adhesive Mastisol Vial__0523-48 PX-2725000009 CDM 2725000009 LOCAL 272 RC outpatient 9 9 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES PPO [308136801] 7.2 percent of total billed charges 5.58 8.55 Technical (Hospital) Services HC/HH Wch Supp Adhesive Mastisol Vial__0523-48 PX-2725000009 CDM 2725000009 LOCAL 272 RC outpatient 9 9 MEDICA (COMMERCIAL) 94265 [3081118] MEDICA CLAIMS [308111801] 8.1 percent of total billed charges 5.58 8.55 Technical (Hospital) Services HC/HH Wch Supp Adhesive Mastisol Vial__0523-48 PX-2725000009 CDM 2725000009 LOCAL 272 RC inpatient 9 9 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES EPO [308136803] 7.13 percent of total billed charges 5.58 8.55 Technical (Hospital) Services HC/HH Wch Supp Adhesive Mastisol Vial__0523-48 PX-2725000009 CDM 2725000009 LOCAL 272 RC inpatient 9 9 BLUE CROSS BLUE SHIELD WELLMARK SB889 [3081026] BCBS WYOMING [308102603] 8.55 percent of total billed charges 5.58 8.55 Technical (Hospital) Services HC/HH Wch Supp Adhesive Mastisol Vial__0523-48 PX-2725000009 CDM 2725000009 LOCAL 272 RC inpatient 9 9 MULTIPLAN INC 34080 [3081285] MULTIPLAN INC [308128501] 8.55 percent of total billed charges 5.58 8.55 Technical (Hospital) Services HC/HH Wch Supp Adhesive Mastisol Vial__0523-48 PX-2725000009 CDM 2725000009 LOCAL 272 RC inpatient 9 9 HEALTHPARTNERS SX009 HEALTHPARTNERS 7.13 percent of total billed charges 5.58 8.55 Technical (Hospital) Services HC/HH Wch Supp Adhesive Mastisol Vial__0523-48 PX-2725000009 CDM 2725000009 LOCAL 272 RC inpatient 9 9 CIGNA 62308 [3081051] CIGNA 62308 [308105105] 7.13 percent of total billed charges 5.58 8.55 Technical (Hospital) Services HC/HH Wch Supp Adhesive Mastisol Vial__0523-48 PX-2725000009 CDM 2725000009 LOCAL 272 RC inpatient 9 9 CIGNA 62308 [3081051] CIGNA STATE OF WYOMING [308105107] 7.13 percent of total billed charges 5.58 8.55 Technical (Hospital) Services HC/HH Wch Supp Adhesive Mastisol Vial__0523-48 PX-2725000009 CDM 2725000009 LOCAL 272 RC inpatient 9 9 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES PPO [308136801] 7.13 percent of total billed charges 5.58 8.55 Technical (Hospital) Services HC/HH Wch Supp Adhesive Mastisol Vial__0523-48 PX-2725000009 CDM 2725000009 LOCAL 272 RC inpatient 9 9 MEDICA (COMMERCIAL) 94265 [3081118] MEDICA CLAIMS [308111801] 8.1 percent of total billed charges 5.58 8.55 Technical (Hospital) Services HC/HH Wch Supp Adhesive Mastisol Vial__0523-48 PX-2725000009 CDM 2725000009 LOCAL 272 RC inpatient 9 9 UNITED HEALTHCARE (COMMERCIAL) [3081199] UNITED HEALTHCARE 87726 [308119901] 5.58 percent of total billed charges 5.58 8.55 Technical (Hospital) Services HC/HH Wch Supp Adhesive Mastisol Vial__0523-48 PX-2725000009 CDM 2725000009 LOCAL 272 RC inpatient 9 9 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES HDHP [308136802] 7.13 percent of total billed charges 5.58 8.55 Technical (Hospital) Services HC/HH Wch Supp Add a Foley Tray__896300 PX-2725000008 CDM 2725000008 LOCAL 272 RC inpatient 105 105 CIGNA 62308 [3081051] CIGNA 62308 [308105105] 83.14 percent of total billed charges 65.1 99.75 Technical (Hospital) Services HC/HH Wch Supp Add a Foley Tray__896300 PX-2725000008 CDM 2725000008 LOCAL 272 RC inpatient 105 105 CIGNA 62308 [3081051] CIGNA STATE OF WYOMING [308105107] 83.14 percent of total billed charges 65.1 99.75 Technical (Hospital) Services HC/HH Wch Supp Add a Foley Tray__896300 PX-2725000008 CDM 2725000008 LOCAL 272 RC inpatient 105 105 MULTIPLAN INC 34080 [3081285] MULTIPLAN INC [308128501] 99.75 percent of total billed charges 65.1 99.75 Technical (Hospital) Services HC/HH Wch Supp Add a Foley Tray__896300 PX-2725000008 CDM 2725000008 LOCAL 272 RC inpatient 105 105 BLUE CROSS BLUE SHIELD WELLMARK SB889 [3081026] BCBS WYOMING [308102603] 99.75 percent of total billed charges 65.1 99.75 Technical (Hospital) Services HC/HH Wch Supp Add a Foley Tray__896300 PX-2725000008 CDM 2725000008 LOCAL 272 RC inpatient 105 105 HEALTHPARTNERS SX009 HEALTHPARTNERS 83.14 percent of total billed charges 65.1 99.75 Technical (Hospital) Services HC/HH Wch Supp Add a Foley Tray__896300 PX-2725000008 CDM 2725000008 LOCAL 272 RC inpatient 105 105 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES EPO [308136803] 83.14 percent of total billed charges 65.1 99.75 Technical (Hospital) Services HC/HH Wch Supp Add a Foley Tray__896300 PX-2725000008 CDM 2725000008 LOCAL 272 RC inpatient 105 105 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES HDHP [308136802] 83.14 percent of total billed charges 65.1 99.75 Technical (Hospital) Services HC/HH Wch Supp Add a Foley Tray__896300 PX-2725000008 CDM 2725000008 LOCAL 272 RC inpatient 105 105 UNITED HEALTHCARE (COMMERCIAL) [3081199] UNITED HEALTHCARE 87726 [308119901] 65.1 percent of total billed charges 65.1 99.75 Technical (Hospital) Services HC/HH Wch Supp Add a Foley Tray__896300 PX-2725000008 CDM 2725000008 LOCAL 272 RC inpatient 105 105 MEDICA (COMMERCIAL) 94265 [3081118] MEDICA CLAIMS [308111801] 94.5 percent of total billed charges 65.1 99.75 Technical (Hospital) Services HC/HH Wch Supp Add a Foley Tray__896300 PX-2725000008 CDM 2725000008 LOCAL 272 RC inpatient 105 105 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES PPO [308136801] 83.14 percent of total billed charges 65.1 99.75 Technical (Hospital) Services HC/HH Wch Supp Add a Foley Tray__896300 PX-2725000008 CDM 2725000008 LOCAL 272 RC outpatient 105 105 CIGNA 62308 [3081051] CIGNA 62308 [308105105] 84 percent of total billed charges 65.1 99.75 Technical (Hospital) Services HC/HH Wch Supp Add a Foley Tray__896300 PX-2725000008 CDM 2725000008 LOCAL 272 RC outpatient 105 105 CIGNA 62308 [3081051] CIGNA STATE OF WYOMING [308105107] 84 percent of total billed charges 65.1 99.75 Technical (Hospital) Services HC/HH Wch Supp Add a Foley Tray__896300 PX-2725000008 CDM 2725000008 LOCAL 272 RC outpatient 105 105 UNITED HEALTHCARE (COMMERCIAL) [3081199] UNITED HEALTHCARE 87726 [308119901] 65.1 percent of total billed charges 65.1 99.75 Technical (Hospital) Services HC/HH Wch Supp Add a Foley Tray__896300 PX-2725000008 CDM 2725000008 LOCAL 272 RC outpatient 105 105 HEALTHPARTNERS SX009 HEALTHPARTNERS 84 percent of total billed charges 65.1 99.75 Technical (Hospital) Services HC/HH Wch Supp Add a Foley Tray__896300 PX-2725000008 CDM 2725000008 LOCAL 272 RC outpatient 105 105 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES PPO [308136801] 84 percent of total billed charges 65.1 99.75 Technical (Hospital) Services HC/HH Wch Supp Add a Foley Tray__896300 PX-2725000008 CDM 2725000008 LOCAL 272 RC outpatient 105 105 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES HDHP [308136802] 84 percent of total billed charges 65.1 99.75 Technical (Hospital) Services HC/HH Wch Supp Add a Foley Tray__896300 PX-2725000008 CDM 2725000008 LOCAL 272 RC outpatient 105 105 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES EPO [308136803] 84 percent of total billed charges 65.1 99.75 Technical (Hospital) Services HC/HH Wch Supp Add a Foley Tray__896300 PX-2725000008 CDM 2725000008 LOCAL 272 RC outpatient 105 105 BLUE CROSS BLUE SHIELD WELLMARK SB889 [3081026] BCBS WYOMING [308102603] 99.75 percent of total billed charges 65.1 99.75 Technical (Hospital) Services HC/HH Wch Supp Add a Foley Tray__896300 PX-2725000008 CDM 2725000008 LOCAL 272 RC outpatient 105 105 MULTIPLAN INC 34080 [3081285] MULTIPLAN INC [308128501] 99.75 percent of total billed charges 65.1 99.75 Technical (Hospital) Services HC/HH Wch Supp Add a Foley Tray__896300 PX-2725000008 CDM 2725000008 LOCAL 272 RC outpatient 105 105 MEDICA (COMMERCIAL) 94265 [3081118] MEDICA CLAIMS [308111801] 94.5 percent of total billed charges 65.1 99.75 Technical (Hospital) Services HC/HH Wch Supp 3m Surgical Clipper Blade__9660 PX-2725000007 CDM 2725000007 LOCAL 272 RC inpatient 16 16 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES PPO [308136801] 12.67 percent of total billed charges 9.92 15.2 Technical (Hospital) Services HC/HH Wch Supp 3m Surgical Clipper Blade__9660 PX-2725000007 CDM 2725000007 LOCAL 272 RC inpatient 16 16 MEDICA (COMMERCIAL) 94265 [3081118] MEDICA CLAIMS [308111801] 14.4 percent of total billed charges 9.92 15.2 Technical (Hospital) Services HC/HH Wch Supp 3m Surgical Clipper Blade__9660 PX-2725000007 CDM 2725000007 LOCAL 272 RC inpatient 16 16 UNITED HEALTHCARE (COMMERCIAL) [3081199] UNITED HEALTHCARE 87726 [308119901] 9.92 percent of total billed charges 9.92 15.2 Technical (Hospital) Services HC/HH Wch Supp 3m Surgical Clipper Blade__9660 PX-2725000007 CDM 2725000007 LOCAL 272 RC inpatient 16 16 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES HDHP [308136802] 12.67 percent of total billed charges 9.92 15.2 Technical (Hospital) Services HC/HH Wch Supp 3m Surgical Clipper Blade__9660 PX-2725000007 CDM 2725000007 LOCAL 272 RC inpatient 16 16 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES EPO [308136803] 12.67 percent of total billed charges 9.92 15.2 Technical (Hospital) Services HC/HH Wch Supp 3m Surgical Clipper Blade__9660 PX-2725000007 CDM 2725000007 LOCAL 272 RC inpatient 16 16 HEALTHPARTNERS SX009 HEALTHPARTNERS 12.67 percent of total billed charges 9.92 15.2 Technical (Hospital) Services HC/HH Wch Supp 3m Surgical Clipper Blade__9660 PX-2725000007 CDM 2725000007 LOCAL 272 RC inpatient 16 16 BLUE CROSS BLUE SHIELD WELLMARK SB889 [3081026] BCBS WYOMING [308102603] 15.2 percent of total billed charges 9.92 15.2 Technical (Hospital) Services HC/HH Wch Supp 3m Surgical Clipper Blade__9660 PX-2725000007 CDM 2725000007 LOCAL 272 RC inpatient 16 16 MULTIPLAN INC 34080 [3081285] MULTIPLAN INC [308128501] 15.2 percent of total billed charges 9.92 15.2 Technical (Hospital) Services HC/HH Wch Supp 3m Surgical Clipper Blade__9660 PX-2725000007 CDM 2725000007 LOCAL 272 RC inpatient 16 16 CIGNA 62308 [3081051] CIGNA 62308 [308105105] 12.67 percent of total billed charges 9.92 15.2 Technical (Hospital) Services HC/HH Wch Supp 3m Surgical Clipper Blade__9660 PX-2725000007 CDM 2725000007 LOCAL 272 RC inpatient 16 16 CIGNA 62308 [3081051] CIGNA STATE OF WYOMING [308105107] 12.67 percent of total billed charges 9.92 15.2 Technical (Hospital) Services HC/HH Wch Supp 3m Surgical Clipper Blade__9660 PX-2725000007 CDM 2725000007 LOCAL 272 RC outpatient 16 16 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES EPO [308136803] 12.8 percent of total billed charges 9.92 15.2 Technical (Hospital) Services HC/HH Wch Supp 3m Surgical Clipper Blade__9660 PX-2725000007 CDM 2725000007 LOCAL 272 RC outpatient 16 16 BLUE CROSS BLUE SHIELD WELLMARK SB889 [3081026] BCBS WYOMING [308102603] 15.2 percent of total billed charges 9.92 15.2 Technical (Hospital) Services HC/HH Wch Supp 3m Surgical Clipper Blade__9660 PX-2725000007 CDM 2725000007 LOCAL 272 RC outpatient 16 16 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES HDHP [308136802] 12.8 percent of total billed charges 9.92 15.2 Technical (Hospital) Services HC/HH Wch Supp 3m Surgical Clipper Blade__9660 PX-2725000007 CDM 2725000007 LOCAL 272 RC outpatient 16 16 CIGNA 62308 [3081051] CIGNA 62308 [308105105] 12.8 percent of total billed charges 9.92 15.2 Technical (Hospital) Services HC/HH Wch Supp 3m Surgical Clipper Blade__9660 PX-2725000007 CDM 2725000007 LOCAL 272 RC outpatient 16 16 CIGNA 62308 [3081051] CIGNA STATE OF WYOMING [308105107] 12.8 percent of total billed charges 9.92 15.2 Technical (Hospital) Services HC/HH Wch Supp 3m Surgical Clipper Blade__9660 PX-2725000007 CDM 2725000007 LOCAL 272 RC outpatient 16 16 UNITED HEALTHCARE (COMMERCIAL) [3081199] UNITED HEALTHCARE 87726 [308119901] 9.92 percent of total billed charges 9.92 15.2 Technical (Hospital) Services HC/HH Wch Supp 3m Surgical Clipper Blade__9660 PX-2725000007 CDM 2725000007 LOCAL 272 RC outpatient 16 16 MEDICA (COMMERCIAL) 94265 [3081118] MEDICA CLAIMS [308111801] 14.4 percent of total billed charges 9.92 15.2 Technical (Hospital) Services HC/HH Wch Supp 3m Surgical Clipper Blade__9660 PX-2725000007 CDM 2725000007 LOCAL 272 RC outpatient 16 16 HEALTHPARTNERS SX009 HEALTHPARTNERS 12.8 percent of total billed charges 9.92 15.2 Technical (Hospital) Services HC/HH Wch Supp 3m Surgical Clipper Blade__9660 PX-2725000007 CDM 2725000007 LOCAL 272 RC outpatient 16 16 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES PPO [308136801] 12.8 percent of total billed charges 9.92 15.2 Technical (Hospital) Services HC/HH Wch Supp 3m Surgical Clipper Blade__9660 PX-2725000007 CDM 2725000007 LOCAL 272 RC outpatient 16 16 MULTIPLAN INC 34080 [3081285] MULTIPLAN INC [308128501] 15.2 percent of total billed charges 9.92 15.2 Technical (Hospital) Services HC/HH Wch Supp Pathodx Strep B Grp 60 Test__R62031 PX-2715000003 CDM 2715000003 LOCAL 271 RC inpatient 87 87 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES EPO [308136803] 68.89 percent of total billed charges 53.94 82.65 Technical (Hospital) Services HC/HH Wch Supp Pathodx Strep B Grp 60 Test__R62031 PX-2715000003 CDM 2715000003 LOCAL 271 RC inpatient 87 87 HEALTHPARTNERS SX009 HEALTHPARTNERS 68.89 percent of total billed charges 53.94 82.65 Technical (Hospital) Services HC/HH Wch Supp Pathodx Strep B Grp 60 Test__R62031 PX-2715000003 CDM 2715000003 LOCAL 271 RC inpatient 87 87 BLUE CROSS BLUE SHIELD WELLMARK SB889 [3081026] BCBS WYOMING [308102603] 82.65 percent of total billed charges 53.94 82.65 Technical (Hospital) Services HC/HH Wch Supp Pathodx Strep B Grp 60 Test__R62031 PX-2715000003 CDM 2715000003 LOCAL 271 RC inpatient 87 87 MULTIPLAN INC 34080 [3081285] MULTIPLAN INC [308128501] 82.65 percent of total billed charges 53.94 82.65 Technical (Hospital) Services HC/HH Wch Supp Pathodx Strep B Grp 60 Test__R62031 PX-2715000003 CDM 2715000003 LOCAL 271 RC inpatient 87 87 CIGNA 62308 [3081051] CIGNA 62308 [308105105] 68.89 percent of total billed charges 53.94 82.65 Technical (Hospital) Services HC/HH Wch Supp Pathodx Strep B Grp 60 Test__R62031 PX-2715000003 CDM 2715000003 LOCAL 271 RC inpatient 87 87 CIGNA 62308 [3081051] CIGNA STATE OF WYOMING [308105107] 68.89 percent of total billed charges 53.94 82.65 Technical (Hospital) Services HC/HH Wch Supp Pathodx Strep B Grp 60 Test__R62031 PX-2715000003 CDM 2715000003 LOCAL 271 RC inpatient 87 87 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES HDHP [308136802] 68.89 percent of total billed charges 53.94 82.65 Technical (Hospital) Services HC/HH Wch Supp Pathodx Strep B Grp 60 Test__R62031 PX-2715000003 CDM 2715000003 LOCAL 271 RC inpatient 87 87 UNITED HEALTHCARE (COMMERCIAL) [3081199] UNITED HEALTHCARE 87726 [308119901] 53.94 percent of total billed charges 53.94 82.65 Technical (Hospital) Services HC/HH Wch Supp Pathodx Strep B Grp 60 Test__R62031 PX-2715000003 CDM 2715000003 LOCAL 271 RC inpatient 87 87 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES PPO [308136801] 68.89 percent of total billed charges 53.94 82.65 Technical (Hospital) Services HC/HH Wch Supp Pathodx Strep B Grp 60 Test__R62031 PX-2715000003 CDM 2715000003 LOCAL 271 RC inpatient 87 87 MEDICA (COMMERCIAL) 94265 [3081118] MEDICA CLAIMS [308111801] 78.3 percent of total billed charges 53.94 82.65 Technical (Hospital) Services HC/HH Wch Supp Pathodx Strep B Grp 60 Test__R62031 PX-2715000003 CDM 2715000003 LOCAL 271 RC outpatient 87 87 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES EPO [308136803] 69.6 percent of total billed charges 53.94 82.65 Technical (Hospital) Services HC/HH Wch Supp Pathodx Strep B Grp 60 Test__R62031 PX-2715000003 CDM 2715000003 LOCAL 271 RC outpatient 87 87 BLUE CROSS BLUE SHIELD WELLMARK SB889 [3081026] BCBS WYOMING [308102603] 82.65 percent of total billed charges 53.94 82.65 Technical (Hospital) Services HC/HH Wch Supp Pathodx Strep B Grp 60 Test__R62031 PX-2715000003 CDM 2715000003 LOCAL 271 RC outpatient 87 87 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES HDHP [308136802] 69.6 percent of total billed charges 53.94 82.65 Technical (Hospital) Services HC/HH Wch Supp Pathodx Strep B Grp 60 Test__R62031 PX-2715000003 CDM 2715000003 LOCAL 271 RC outpatient 87 87 HEALTHPARTNERS SX009 HEALTHPARTNERS 69.6 percent of total billed charges 53.94 82.65 Technical (Hospital) Services HC/HH Wch Supp Pathodx Strep B Grp 60 Test__R62031 PX-2715000003 CDM 2715000003 LOCAL 271 RC outpatient 87 87 UNITED HEALTHCARE (COMMERCIAL) [3081199] UNITED HEALTHCARE 87726 [308119901] 53.94 percent of total billed charges 53.94 82.65 Technical (Hospital) Services HC/HH Wch Supp Pathodx Strep B Grp 60 Test__R62031 PX-2715000003 CDM 2715000003 LOCAL 271 RC outpatient 87 87 CIGNA 62308 [3081051] CIGNA STATE OF WYOMING [308105107] 69.6 percent of total billed charges 53.94 82.65 Technical (Hospital) Services HC/HH Wch Supp Pathodx Strep B Grp 60 Test__R62031 PX-2715000003 CDM 2715000003 LOCAL 271 RC outpatient 87 87 CIGNA 62308 [3081051] CIGNA 62308 [308105105] 69.6 percent of total billed charges 53.94 82.65 Technical (Hospital) Services HC/HH Wch Supp Pathodx Strep B Grp 60 Test__R62031 PX-2715000003 CDM 2715000003 LOCAL 271 RC outpatient 87 87 MEDICA (COMMERCIAL) 94265 [3081118] MEDICA CLAIMS [308111801] 78.3 percent of total billed charges 53.94 82.65 Technical (Hospital) Services HC/HH Wch Supp Pathodx Strep B Grp 60 Test__R62031 PX-2715000003 CDM 2715000003 LOCAL 271 RC outpatient 87 87 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES PPO [308136801] 69.6 percent of total billed charges 53.94 82.65 Technical (Hospital) Services HC/HH Wch Supp Pathodx Strep B Grp 60 Test__R62031 PX-2715000003 CDM 2715000003 LOCAL 271 RC outpatient 87 87 MULTIPLAN INC 34080 [3081285] MULTIPLAN INC [308128501] 82.65 percent of total billed charges 53.94 82.65 Technical (Hospital) Services HC/HH Wch Supp Knee Immobilizer 12__8142662 PX-2715000002 CDM 2715000002 LOCAL 271 RC inpatient 66 66 HEALTHPARTNERS SX009 HEALTHPARTNERS 52.26 percent of total billed charges 40.92 62.7 Technical (Hospital) Services HC/HH Wch Supp Knee Immobilizer 12__8142662 PX-2715000002 CDM 2715000002 LOCAL 271 RC inpatient 66 66 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES EPO [308136803] 52.26 percent of total billed charges 40.92 62.7 Technical (Hospital) Services HC/HH Wch Supp Knee Immobilizer 12__8142662 PX-2715000002 CDM 2715000002 LOCAL 271 RC inpatient 66 66 MULTIPLAN INC 34080 [3081285] MULTIPLAN INC [308128501] 62.7 percent of total billed charges 40.92 62.7 Technical (Hospital) Services HC/HH Wch Supp Knee Immobilizer 12__8142662 PX-2715000002 CDM 2715000002 LOCAL 271 RC inpatient 66 66 BLUE CROSS BLUE SHIELD WELLMARK SB889 [3081026] BCBS WYOMING [308102603] 62.7 percent of total billed charges 40.92 62.7 Technical (Hospital) Services HC/HH Wch Supp Knee Immobilizer 12__8142662 PX-2715000002 CDM 2715000002 LOCAL 271 RC inpatient 66 66 CIGNA 62308 [3081051] CIGNA 62308 [308105105] 52.26 percent of total billed charges 40.92 62.7 Technical (Hospital) Services HC/HH Wch Supp Knee Immobilizer 12__8142662 PX-2715000002 CDM 2715000002 LOCAL 271 RC inpatient 66 66 CIGNA 62308 [3081051] CIGNA STATE OF WYOMING [308105107] 52.26 percent of total billed charges 40.92 62.7 Technical (Hospital) Services HC/HH Wch Supp Knee Immobilizer 12__8142662 PX-2715000002 CDM 2715000002 LOCAL 271 RC inpatient 66 66 UNITED HEALTHCARE (COMMERCIAL) [3081199] UNITED HEALTHCARE 87726 [308119901] 40.92 percent of total billed charges 40.92 62.7 Technical (Hospital) Services HC/HH Wch Supp Knee Immobilizer 12__8142662 PX-2715000002 CDM 2715000002 LOCAL 271 RC inpatient 66 66 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES HDHP [308136802] 52.26 percent of total billed charges 40.92 62.7 Technical (Hospital) Services HC/HH Wch Supp Knee Immobilizer 12__8142662 PX-2715000002 CDM 2715000002 LOCAL 271 RC inpatient 66 66 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES PPO [308136801] 52.26 percent of total billed charges 40.92 62.7 Technical (Hospital) Services HC/HH Wch Supp Knee Immobilizer 12__8142662 PX-2715000002 CDM 2715000002 LOCAL 271 RC inpatient 66 66 MEDICA (COMMERCIAL) 94265 [3081118] MEDICA CLAIMS [308111801] 59.4 percent of total billed charges 40.92 62.7 Technical (Hospital) Services HC/HH Wch Supp Knee Immobilizer 12__8142662 PX-2715000002 CDM 2715000002 LOCAL 271 RC outpatient 66 66 UNITED HEALTHCARE (COMMERCIAL) [3081199] UNITED HEALTHCARE 87726 [308119901] 40.92 percent of total billed charges 40.92 62.7 Technical (Hospital) Services HC/HH Wch Supp Knee Immobilizer 12__8142662 PX-2715000002 CDM 2715000002 LOCAL 271 RC outpatient 66 66 HEALTHPARTNERS SX009 HEALTHPARTNERS 52.8 percent of total billed charges 40.92 62.7 Technical (Hospital) Services HC/HH Wch Supp Knee Immobilizer 12__8142662 PX-2715000002 CDM 2715000002 LOCAL 271 RC outpatient 66 66 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES PPO [308136801] 52.8 percent of total billed charges 40.92 62.7 Technical (Hospital) Services HC/HH Wch Supp Knee Immobilizer 12__8142662 PX-2715000002 CDM 2715000002 LOCAL 271 RC outpatient 66 66 MULTIPLAN INC 34080 [3081285] MULTIPLAN INC [308128501] 62.7 percent of total billed charges 40.92 62.7 Technical (Hospital) Services HC/HH Wch Supp Knee Immobilizer 12__8142662 PX-2715000002 CDM 2715000002 LOCAL 271 RC outpatient 66 66 MEDICA (COMMERCIAL) 94265 [3081118] MEDICA CLAIMS [308111801] 59.4 percent of total billed charges 40.92 62.7 Technical (Hospital) Services HC/HH Wch Supp Knee Immobilizer 12__8142662 PX-2715000002 CDM 2715000002 LOCAL 271 RC outpatient 66 66 CIGNA 62308 [3081051] CIGNA 62308 [308105105] 52.8 percent of total billed charges 40.92 62.7 Technical (Hospital) Services HC/HH Wch Supp Knee Immobilizer 12__8142662 PX-2715000002 CDM 2715000002 LOCAL 271 RC outpatient 66 66 CIGNA 62308 [3081051] CIGNA STATE OF WYOMING [308105107] 52.8 percent of total billed charges 40.92 62.7 Technical (Hospital) Services HC/HH Wch Supp Knee Immobilizer 12__8142662 PX-2715000002 CDM 2715000002 LOCAL 271 RC outpatient 66 66 BLUE CROSS BLUE SHIELD WELLMARK SB889 [3081026] BCBS WYOMING [308102603] 62.7 percent of total billed charges 40.92 62.7 Technical (Hospital) Services HC/HH Wch Supp Knee Immobilizer 12__8142662 PX-2715000002 CDM 2715000002 LOCAL 271 RC outpatient 66 66 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES EPO [308136803] 52.8 percent of total billed charges 40.92 62.7 Technical (Hospital) Services HC/HH Wch Supp Knee Immobilizer 12__8142662 PX-2715000002 CDM 2715000002 LOCAL 271 RC outpatient 66 66 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES HDHP [308136802] 52.8 percent of total billed charges 40.92 62.7 Technical (Hospital) Services HC/HH Wch Supp Green Chux__Msc282030lb PX-2715000001 CDM 2715000001 LOCAL 271 RC inpatient 9 9 BLUE CROSS BLUE SHIELD WELLMARK SB889 [3081026] BCBS WYOMING [308102603] 8.55 percent of total billed charges 5.58 8.55 Technical (Hospital) Services HC/HH Wch Supp Green Chux__Msc282030lb PX-2715000001 CDM 2715000001 LOCAL 271 RC inpatient 9 9 MULTIPLAN INC 34080 [3081285] MULTIPLAN INC [308128501] 8.55 percent of total billed charges 5.58 8.55 Technical (Hospital) Services HC/HH Wch Supp Green Chux__Msc282030lb PX-2715000001 CDM 2715000001 LOCAL 271 RC inpatient 9 9 CIGNA 62308 [3081051] CIGNA 62308 [308105105] 7.13 percent of total billed charges 5.58 8.55 Technical (Hospital) Services HC/HH Wch Supp Green Chux__Msc282030lb PX-2715000001 CDM 2715000001 LOCAL 271 RC inpatient 9 9 CIGNA 62308 [3081051] CIGNA STATE OF WYOMING [308105107] 7.13 percent of total billed charges 5.58 8.55 Technical (Hospital) Services HC/HH Wch Supp Green Chux__Msc282030lb PX-2715000001 CDM 2715000001 LOCAL 271 RC inpatient 9 9 HEALTHPARTNERS SX009 HEALTHPARTNERS 7.13 percent of total billed charges 5.58 8.55 Technical (Hospital) Services HC/HH Wch Supp Green Chux__Msc282030lb PX-2715000001 CDM 2715000001 LOCAL 271 RC inpatient 9 9 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES EPO [308136803] 7.13 percent of total billed charges 5.58 8.55 Technical (Hospital) Services HC/HH Wch Supp Green Chux__Msc282030lb PX-2715000001 CDM 2715000001 LOCAL 271 RC inpatient 9 9 MEDICA (COMMERCIAL) 94265 [3081118] MEDICA CLAIMS [308111801] 8.1 percent of total billed charges 5.58 8.55 Technical (Hospital) Services HC/HH Wch Supp Green Chux__Msc282030lb PX-2715000001 CDM 2715000001 LOCAL 271 RC inpatient 9 9 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES PPO [308136801] 7.13 percent of total billed charges 5.58 8.55 Technical (Hospital) Services HC/HH Wch Supp Green Chux__Msc282030lb PX-2715000001 CDM 2715000001 LOCAL 271 RC inpatient 9 9 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES HDHP [308136802] 7.13 percent of total billed charges 5.58 8.55 Technical (Hospital) Services HC/HH Wch Supp Green Chux__Msc282030lb PX-2715000001 CDM 2715000001 LOCAL 271 RC inpatient 9 9 UNITED HEALTHCARE (COMMERCIAL) [3081199] UNITED HEALTHCARE 87726 [308119901] 5.58 percent of total billed charges 5.58 8.55 Technical (Hospital) Services HC/HH Wch Supp Green Chux__Msc282030lb PX-2715000001 CDM 2715000001 LOCAL 271 RC outpatient 9 9 CIGNA 62308 [3081051] CIGNA 62308 [308105105] 7.2 percent of total billed charges 5.58 8.55 Technical (Hospital) Services HC/HH Wch Supp Green Chux__Msc282030lb PX-2715000001 CDM 2715000001 LOCAL 271 RC outpatient 9 9 CIGNA 62308 [3081051] CIGNA STATE OF WYOMING [308105107] 7.2 percent of total billed charges 5.58 8.55 Technical (Hospital) Services HC/HH Wch Supp Green Chux__Msc282030lb PX-2715000001 CDM 2715000001 LOCAL 271 RC outpatient 9 9 HEALTHPARTNERS SX009 HEALTHPARTNERS 7.2 percent of total billed charges 5.58 8.55 Technical (Hospital) Services HC/HH Wch Supp Green Chux__Msc282030lb PX-2715000001 CDM 2715000001 LOCAL 271 RC outpatient 9 9 UNITED HEALTHCARE (COMMERCIAL) [3081199] UNITED HEALTHCARE 87726 [308119901] 5.58 percent of total billed charges 5.58 8.55 Technical (Hospital) Services HC/HH Wch Supp Green Chux__Msc282030lb PX-2715000001 CDM 2715000001 LOCAL 271 RC outpatient 9 9 BLUE CROSS BLUE SHIELD WELLMARK SB889 [3081026] BCBS WYOMING [308102603] 8.55 percent of total billed charges 5.58 8.55 Technical (Hospital) Services HC/HH Wch Supp Green Chux__Msc282030lb PX-2715000001 CDM 2715000001 LOCAL 271 RC outpatient 9 9 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES EPO [308136803] 7.2 percent of total billed charges 5.58 8.55 Technical (Hospital) Services HC/HH Wch Supp Green Chux__Msc282030lb PX-2715000001 CDM 2715000001 LOCAL 271 RC outpatient 9 9 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES HDHP [308136802] 7.2 percent of total billed charges 5.58 8.55 Technical (Hospital) Services HC/HH Wch Supp Green Chux__Msc282030lb PX-2715000001 CDM 2715000001 LOCAL 271 RC outpatient 9 9 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES PPO [308136801] 7.2 percent of total billed charges 5.58 8.55 Technical (Hospital) Services HC/HH Wch Supp Green Chux__Msc282030lb PX-2715000001 CDM 2715000001 LOCAL 271 RC outpatient 9 9 MULTIPLAN INC 34080 [3081285] MULTIPLAN INC [308128501] 8.55 percent of total billed charges 5.58 8.55 Technical (Hospital) Services HC/HH Wch Supp Green Chux__Msc282030lb PX-2715000001 CDM 2715000001 LOCAL 271 RC outpatient 9 9 MEDICA (COMMERCIAL) 94265 [3081118] MEDICA CLAIMS [308111801] 8.1 percent of total billed charges 5.58 8.55 Technical (Hospital) Services HC/HH Wch Supp Yankauer Suction Tip__Cfk82 PX-2705000241 CDM 2705000241 LOCAL 270 RC outpatient 15 15 UNITED HEALTHCARE (COMMERCIAL) [3081199] UNITED HEALTHCARE 87726 [308119901] 9.3 percent of total billed charges 9.3 14.25 Technical (Hospital) Services HC/HH Wch Supp Yankauer Suction Tip__Cfk82 PX-2705000241 CDM 2705000241 LOCAL 270 RC outpatient 15 15 HEALTHPARTNERS SX009 HEALTHPARTNERS 12 percent of total billed charges 9.3 14.25 Technical (Hospital) Services HC/HH Wch Supp Yankauer Suction Tip__Cfk82 PX-2705000241 CDM 2705000241 LOCAL 270 RC outpatient 15 15 CIGNA 62308 [3081051] CIGNA 62308 [308105105] 12 percent of total billed charges 9.3 14.25 Technical (Hospital) Services HC/HH Wch Supp Yankauer Suction Tip__Cfk82 PX-2705000241 CDM 2705000241 LOCAL 270 RC outpatient 15 15 CIGNA 62308 [3081051] CIGNA STATE OF WYOMING [308105107] 12 percent of total billed charges 9.3 14.25 Technical (Hospital) Services HC/HH Wch Supp Yankauer Suction Tip__Cfk82 PX-2705000241 CDM 2705000241 LOCAL 270 RC outpatient 15 15 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES HDHP [308136802] 12 percent of total billed charges 9.3 14.25 Technical (Hospital) Services HC/HH Wch Supp Yankauer Suction Tip__Cfk82 PX-2705000241 CDM 2705000241 LOCAL 270 RC outpatient 15 15 BLUE CROSS BLUE SHIELD WELLMARK SB889 [3081026] BCBS WYOMING [308102603] 14.25 percent of total billed charges 9.3 14.25 Technical (Hospital) Services HC/HH Wch Supp Yankauer Suction Tip__Cfk82 PX-2705000241 CDM 2705000241 LOCAL 270 RC outpatient 15 15 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES EPO [308136803] 12 percent of total billed charges 9.3 14.25 Technical (Hospital) Services HC/HH Wch Supp Yankauer Suction Tip__Cfk82 PX-2705000241 CDM 2705000241 LOCAL 270 RC outpatient 15 15 MULTIPLAN INC 34080 [3081285] MULTIPLAN INC [308128501] 14.25 percent of total billed charges 9.3 14.25 Technical (Hospital) Services HC/HH Wch Supp Yankauer Suction Tip__Cfk82 PX-2705000241 CDM 2705000241 LOCAL 270 RC outpatient 15 15 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES PPO [308136801] 12 percent of total billed charges 9.3 14.25 Technical (Hospital) Services HC/HH Wch Supp Yankauer Suction Tip__Cfk82 PX-2705000241 CDM 2705000241 LOCAL 270 RC outpatient 15 15 MEDICA (COMMERCIAL) 94265 [3081118] MEDICA CLAIMS [308111801] 13.5 percent of total billed charges 9.3 14.25 Technical (Hospital) Services HC/HH Wch Supp Yankauer Suction Tip__Cfk82 PX-2705000241 CDM 2705000241 LOCAL 270 RC inpatient 15 15 HEALTHPARTNERS SX009 HEALTHPARTNERS 11.88 percent of total billed charges 9.3 14.25 Technical (Hospital) Services HC/HH Wch Supp Yankauer Suction Tip__Cfk82 PX-2705000241 CDM 2705000241 LOCAL 270 RC inpatient 15 15 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES EPO [308136803] 11.88 percent of total billed charges 9.3 14.25 Technical (Hospital) Services HC/HH Wch Supp Yankauer Suction Tip__Cfk82 PX-2705000241 CDM 2705000241 LOCAL 270 RC inpatient 15 15 MULTIPLAN INC 34080 [3081285] MULTIPLAN INC [308128501] 14.25 percent of total billed charges 9.3 14.25 Technical (Hospital) Services HC/HH Wch Supp Yankauer Suction Tip__Cfk82 PX-2705000241 CDM 2705000241 LOCAL 270 RC inpatient 15 15 BLUE CROSS BLUE SHIELD WELLMARK SB889 [3081026] BCBS WYOMING [308102603] 14.25 percent of total billed charges 9.3 14.25 Technical (Hospital) Services HC/HH Wch Supp Yankauer Suction Tip__Cfk82 PX-2705000241 CDM 2705000241 LOCAL 270 RC inpatient 15 15 CIGNA 62308 [3081051] CIGNA 62308 [308105105] 11.88 percent of total billed charges 9.3 14.25 Technical (Hospital) Services HC/HH Wch Supp Yankauer Suction Tip__Cfk82 PX-2705000241 CDM 2705000241 LOCAL 270 RC inpatient 15 15 CIGNA 62308 [3081051] CIGNA STATE OF WYOMING [308105107] 11.88 percent of total billed charges 9.3 14.25 Technical (Hospital) Services HC/HH Wch Supp Yankauer Suction Tip__Cfk82 PX-2705000241 CDM 2705000241 LOCAL 270 RC inpatient 15 15 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES PPO [308136801] 11.88 percent of total billed charges 9.3 14.25 Technical (Hospital) Services HC/HH Wch Supp Yankauer Suction Tip__Cfk82 PX-2705000241 CDM 2705000241 LOCAL 270 RC inpatient 15 15 MEDICA (COMMERCIAL) 94265 [3081118] MEDICA CLAIMS [308111801] 13.5 percent of total billed charges 9.3 14.25 Technical (Hospital) Services HC/HH Wch Supp Yankauer Suction Tip__Cfk82 PX-2705000241 CDM 2705000241 LOCAL 270 RC inpatient 15 15 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES HDHP [308136802] 11.88 percent of total billed charges 9.3 14.25 Technical (Hospital) Services HC/HH Wch Supp Yankauer Suction Tip__Cfk82 PX-2705000241 CDM 2705000241 LOCAL 270 RC inpatient 15 15 UNITED HEALTHCARE (COMMERCIAL) [3081199] UNITED HEALTHCARE 87726 [308119901] 9.3 percent of total billed charges 9.3 14.25 Technical (Hospital) Services HC/HH Wch Supp Xsm Air Walker__Aw0200 PX-2705000240 CDM 2705000240 LOCAL 270 RC inpatient 175 175 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES PPO [308136801] 138.57 percent of total billed charges 108.5 166.25 Technical (Hospital) Services HC/HH Wch Supp Xsm Air Walker__Aw0200 PX-2705000240 CDM 2705000240 LOCAL 270 RC inpatient 175 175 MEDICA (COMMERCIAL) 94265 [3081118] MEDICA CLAIMS [308111801] 157.5 percent of total billed charges 108.5 166.25 Technical (Hospital) Services HC/HH Wch Supp Xsm Air Walker__Aw0200 PX-2705000240 CDM 2705000240 LOCAL 270 RC inpatient 175 175 UNITED HEALTHCARE (COMMERCIAL) [3081199] UNITED HEALTHCARE 87726 [308119901] 108.5 percent of total billed charges 108.5 166.25 Technical (Hospital) Services HC/HH Wch Supp Xsm Air Walker__Aw0200 PX-2705000240 CDM 2705000240 LOCAL 270 RC inpatient 175 175 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES HDHP [308136802] 138.57 percent of total billed charges 108.5 166.25 Technical (Hospital) Services HC/HH Wch Supp Xsm Air Walker__Aw0200 PX-2705000240 CDM 2705000240 LOCAL 270 RC inpatient 175 175 BLUE CROSS BLUE SHIELD WELLMARK SB889 [3081026] BCBS WYOMING [308102603] 166.25 percent of total billed charges 108.5 166.25 Technical (Hospital) Services HC/HH Wch Supp Xsm Air Walker__Aw0200 PX-2705000240 CDM 2705000240 LOCAL 270 RC inpatient 175 175 MULTIPLAN INC 34080 [3081285] MULTIPLAN INC [308128501] 166.25 percent of total billed charges 108.5 166.25 Technical (Hospital) Services HC/HH Wch Supp Xsm Air Walker__Aw0200 PX-2705000240 CDM 2705000240 LOCAL 270 RC inpatient 175 175 CIGNA 62308 [3081051] CIGNA 62308 [308105105] 138.57 percent of total billed charges 108.5 166.25 Technical (Hospital) Services HC/HH Wch Supp Xsm Air Walker__Aw0200 PX-2705000240 CDM 2705000240 LOCAL 270 RC inpatient 175 175 CIGNA 62308 [3081051] CIGNA STATE OF WYOMING [308105107] 138.57 percent of total billed charges 108.5 166.25 Technical (Hospital) Services HC/HH Wch Supp Xsm Air Walker__Aw0200 PX-2705000240 CDM 2705000240 LOCAL 270 RC inpatient 175 175 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES EPO [308136803] 138.57 percent of total billed charges 108.5 166.25 Technical (Hospital) Services HC/HH Wch Supp Xsm Air Walker__Aw0200 PX-2705000240 CDM 2705000240 LOCAL 270 RC inpatient 175 175 HEALTHPARTNERS SX009 HEALTHPARTNERS 138.57 percent of total billed charges 108.5 166.25 Technical (Hospital) Services HC/HH Wch Supp Xsm Air Walker__Aw0200 PX-2705000240 CDM 2705000240 LOCAL 270 RC outpatient 175 175 CIGNA 62308 [3081051] CIGNA 62308 [308105105] 140 percent of total billed charges 108.5 166.25 Technical (Hospital) Services HC/HH Wch Supp Xsm Air Walker__Aw0200 PX-2705000240 CDM 2705000240 LOCAL 270 RC outpatient 175 175 CIGNA 62308 [3081051] CIGNA STATE OF WYOMING [308105107] 140 percent of total billed charges 108.5 166.25 Technical (Hospital) Services HC/HH Wch Supp Xsm Air Walker__Aw0200 PX-2705000240 CDM 2705000240 LOCAL 270 RC outpatient 175 175 BLUE CROSS BLUE SHIELD WELLMARK SB889 [3081026] BCBS WYOMING [308102603] 166.25 percent of total billed charges 108.5 166.25 Technical (Hospital) Services HC/HH Wch Supp Xsm Air Walker__Aw0200 PX-2705000240 CDM 2705000240 LOCAL 270 RC outpatient 175 175 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES EPO [308136803] 140 percent of total billed charges 108.5 166.25 Technical (Hospital) Services HC/HH Wch Supp Xsm Air Walker__Aw0200 PX-2705000240 CDM 2705000240 LOCAL 270 RC outpatient 175 175 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES HDHP [308136802] 140 percent of total billed charges 108.5 166.25 Technical (Hospital) Services HC/HH Wch Supp Xsm Air Walker__Aw0200 PX-2705000240 CDM 2705000240 LOCAL 270 RC outpatient 175 175 UNITED HEALTHCARE (COMMERCIAL) [3081199] UNITED HEALTHCARE 87726 [308119901] 108.5 percent of total billed charges 108.5 166.25 Technical (Hospital) Services HC/HH Wch Supp Xsm Air Walker__Aw0200 PX-2705000240 CDM 2705000240 LOCAL 270 RC outpatient 175 175 HEALTHPARTNERS SX009 HEALTHPARTNERS 140 percent of total billed charges 108.5 166.25 Technical (Hospital) Services HC/HH Wch Supp Xsm Air Walker__Aw0200 PX-2705000240 CDM 2705000240 LOCAL 270 RC outpatient 175 175 MULTIPLAN INC 34080 [3081285] MULTIPLAN INC [308128501] 166.25 percent of total billed charges 108.5 166.25 Technical (Hospital) Services HC/HH Wch Supp Xsm Air Walker__Aw0200 PX-2705000240 CDM 2705000240 LOCAL 270 RC outpatient 175 175 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES PPO [308136801] 140 percent of total billed charges 108.5 166.25 Technical (Hospital) Services HC/HH Wch Supp Xsm Air Walker__Aw0200 PX-2705000240 CDM 2705000240 LOCAL 270 RC outpatient 175 175 MEDICA (COMMERCIAL) 94265 [3081118] MEDICA CLAIMS [308111801] 157.5 percent of total billed charges 108.5 166.25 Technical (Hospital) Services HC/HH Wch Supp Xlg Air Walker__Aw1000blk PX-2705000239 CDM 2705000239 LOCAL 270 RC inpatient 175 175 UNITED HEALTHCARE (COMMERCIAL) [3081199] UNITED HEALTHCARE 87726 [308119901] 108.5 percent of total billed charges 108.5 166.25 Technical (Hospital) Services HC/HH Wch Supp Xlg Air Walker__Aw1000blk PX-2705000239 CDM 2705000239 LOCAL 270 RC inpatient 175 175 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES HDHP [308136802] 138.57 percent of total billed charges 108.5 166.25 Technical (Hospital) Services HC/HH Wch Supp Xlg Air Walker__Aw1000blk PX-2705000239 CDM 2705000239 LOCAL 270 RC inpatient 175 175 MEDICA (COMMERCIAL) 94265 [3081118] MEDICA CLAIMS [308111801] 157.5 percent of total billed charges 108.5 166.25 Technical (Hospital) Services HC/HH Wch Supp Xlg Air Walker__Aw1000blk PX-2705000239 CDM 2705000239 LOCAL 270 RC inpatient 175 175 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES PPO [308136801] 138.57 percent of total billed charges 108.5 166.25 Technical (Hospital) Services HC/HH Wch Supp Xlg Air Walker__Aw1000blk PX-2705000239 CDM 2705000239 LOCAL 270 RC inpatient 175 175 CIGNA 62308 [3081051] CIGNA 62308 [308105105] 138.57 percent of total billed charges 108.5 166.25 Technical (Hospital) Services HC/HH Wch Supp Xlg Air Walker__Aw1000blk PX-2705000239 CDM 2705000239 LOCAL 270 RC inpatient 175 175 CIGNA 62308 [3081051] CIGNA STATE OF WYOMING [308105107] 138.57 percent of total billed charges 108.5 166.25 Technical (Hospital) Services HC/HH Wch Supp Xlg Air Walker__Aw1000blk PX-2705000239 CDM 2705000239 LOCAL 270 RC inpatient 175 175 BLUE CROSS BLUE SHIELD WELLMARK SB889 [3081026] BCBS WYOMING [308102603] 166.25 percent of total billed charges 108.5 166.25 Technical (Hospital) Services HC/HH Wch Supp Xlg Air Walker__Aw1000blk PX-2705000239 CDM 2705000239 LOCAL 270 RC inpatient 175 175 MULTIPLAN INC 34080 [3081285] MULTIPLAN INC [308128501] 166.25 percent of total billed charges 108.5 166.25 Technical (Hospital) Services HC/HH Wch Supp Xlg Air Walker__Aw1000blk PX-2705000239 CDM 2705000239 LOCAL 270 RC inpatient 175 175 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES EPO [308136803] 138.57 percent of total billed charges 108.5 166.25 Technical (Hospital) Services HC/HH Wch Supp Xlg Air Walker__Aw1000blk PX-2705000239 CDM 2705000239 LOCAL 270 RC inpatient 175 175 HEALTHPARTNERS SX009 HEALTHPARTNERS 138.57 percent of total billed charges 108.5 166.25 Technical (Hospital) Services HC/HH Wch Supp Xlg Air Walker__Aw1000blk PX-2705000239 CDM 2705000239 LOCAL 270 RC outpatient 175 175 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES EPO [308136803] 140 percent of total billed charges 108.5 166.25 Technical (Hospital) Services HC/HH Wch Supp Xlg Air Walker__Aw1000blk PX-2705000239 CDM 2705000239 LOCAL 270 RC outpatient 175 175 CIGNA 62308 [3081051] CIGNA 62308 [308105105] 140 percent of total billed charges 108.5 166.25 Technical (Hospital) Services HC/HH Wch Supp Xlg Air Walker__Aw1000blk PX-2705000239 CDM 2705000239 LOCAL 270 RC outpatient 175 175 CIGNA 62308 [3081051] CIGNA STATE OF WYOMING [308105107] 140 percent of total billed charges 108.5 166.25 Technical (Hospital) Services HC/HH Wch Supp Xlg Air Walker__Aw1000blk PX-2705000239 CDM 2705000239 LOCAL 270 RC outpatient 175 175 BLUE CROSS BLUE SHIELD WELLMARK SB889 [3081026] BCBS WYOMING [308102603] 166.25 percent of total billed charges 108.5 166.25 Technical (Hospital) Services HC/HH Wch Supp Xlg Air Walker__Aw1000blk PX-2705000239 CDM 2705000239 LOCAL 270 RC outpatient 175 175 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES HDHP [308136802] 140 percent of total billed charges 108.5 166.25 Technical (Hospital) Services HC/HH Wch Supp Xlg Air Walker__Aw1000blk PX-2705000239 CDM 2705000239 LOCAL 270 RC outpatient 175 175 UNITED HEALTHCARE (COMMERCIAL) [3081199] UNITED HEALTHCARE 87726 [308119901] 108.5 percent of total billed charges 108.5 166.25 Technical (Hospital) Services HC/HH Wch Supp Xlg Air Walker__Aw1000blk PX-2705000239 CDM 2705000239 LOCAL 270 RC outpatient 175 175 MEDICA (COMMERCIAL) 94265 [3081118] MEDICA CLAIMS [308111801] 157.5 percent of total billed charges 108.5 166.25 Technical (Hospital) Services HC/HH Wch Supp Xlg Air Walker__Aw1000blk PX-2705000239 CDM 2705000239 LOCAL 270 RC outpatient 175 175 MULTIPLAN INC 34080 [3081285] MULTIPLAN INC [308128501] 166.25 percent of total billed charges 108.5 166.25 Technical (Hospital) Services HC/HH Wch Supp Xlg Air Walker__Aw1000blk PX-2705000239 CDM 2705000239 LOCAL 270 RC outpatient 175 175 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES PPO [308136801] 140 percent of total billed charges 108.5 166.25 Technical (Hospital) Services HC/HH Wch Supp Xlg Air Walker__Aw1000blk PX-2705000239 CDM 2705000239 LOCAL 270 RC outpatient 175 175 HEALTHPARTNERS SX009 HEALTHPARTNERS 140 percent of total billed charges 108.5 166.25 Technical (Hospital) Services HC/HH Wch Supp Wrist Splint Xsm__E317072 PX-2705000237 CDM 2705000237 LOCAL 270 RC inpatient 42 42 UNITED HEALTHCARE (COMMERCIAL) [3081199] UNITED HEALTHCARE 87726 [308119901] 26.04 percent of total billed charges 26.04 39.9 Technical (Hospital) Services HC/HH Wch Supp Wrist Splint Xsm__E317072 PX-2705000237 CDM 2705000237 LOCAL 270 RC inpatient 42 42 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES HDHP [308136802] 33.26 percent of total billed charges 26.04 39.9 Technical (Hospital) Services HC/HH Wch Supp Wrist Splint Xsm__E317072 PX-2705000237 CDM 2705000237 LOCAL 270 RC inpatient 42 42 MEDICA (COMMERCIAL) 94265 [3081118] MEDICA CLAIMS [308111801] 37.8 percent of total billed charges 26.04 39.9 Technical (Hospital) Services HC/HH Wch Supp Wrist Splint Xsm__E317072 PX-2705000237 CDM 2705000237 LOCAL 270 RC inpatient 42 42 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES PPO [308136801] 33.26 percent of total billed charges 26.04 39.9 Technical (Hospital) Services HC/HH Wch Supp Wrist Splint Xsm__E317072 PX-2705000237 CDM 2705000237 LOCAL 270 RC inpatient 42 42 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES EPO [308136803] 33.26 percent of total billed charges 26.04 39.9 Technical (Hospital) Services HC/HH Wch Supp Wrist Splint Xsm__E317072 PX-2705000237 CDM 2705000237 LOCAL 270 RC inpatient 42 42 HEALTHPARTNERS SX009 HEALTHPARTNERS 33.26 percent of total billed charges 26.04 39.9 Technical (Hospital) Services HC/HH Wch Supp Wrist Splint Xsm__E317072 PX-2705000237 CDM 2705000237 LOCAL 270 RC inpatient 42 42 CIGNA 62308 [3081051] CIGNA 62308 [308105105] 33.26 percent of total billed charges 26.04 39.9 Technical (Hospital) Services HC/HH Wch Supp Wrist Splint Xsm__E317072 PX-2705000237 CDM 2705000237 LOCAL 270 RC inpatient 42 42 CIGNA 62308 [3081051] CIGNA STATE OF WYOMING [308105107] 33.26 percent of total billed charges 26.04 39.9 Technical (Hospital) Services HC/HH Wch Supp Wrist Splint Xsm__E317072 PX-2705000237 CDM 2705000237 LOCAL 270 RC inpatient 42 42 MULTIPLAN INC 34080 [3081285] MULTIPLAN INC [308128501] 39.9 percent of total billed charges 26.04 39.9 Technical (Hospital) Services HC/HH Wch Supp Wrist Splint Xsm__E317072 PX-2705000237 CDM 2705000237 LOCAL 270 RC inpatient 42 42 BLUE CROSS BLUE SHIELD WELLMARK SB889 [3081026] BCBS WYOMING [308102603] 39.9 percent of total billed charges 26.04 39.9 Technical (Hospital) Services HC/HH Wch Supp Wrist Splint Xsm__E317072 PX-2705000237 CDM 2705000237 LOCAL 270 RC outpatient 42 42 MULTIPLAN INC 34080 [3081285] MULTIPLAN INC [308128501] 39.9 percent of total billed charges 26.04 39.9 Technical (Hospital) Services HC/HH Wch Supp Wrist Splint Xsm__E317072 PX-2705000237 CDM 2705000237 LOCAL 270 RC outpatient 42 42 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES PPO [308136801] 33.6 percent of total billed charges 26.04 39.9 Technical (Hospital) Services HC/HH Wch Supp Wrist Splint Xsm__E317072 PX-2705000237 CDM 2705000237 LOCAL 270 RC outpatient 42 42 MEDICA (COMMERCIAL) 94265 [3081118] MEDICA CLAIMS [308111801] 37.8 percent of total billed charges 26.04 39.9 Technical (Hospital) Services HC/HH Wch Supp Wrist Splint Xsm__E317072 PX-2705000237 CDM 2705000237 LOCAL 270 RC outpatient 42 42 BLUE CROSS BLUE SHIELD WELLMARK SB889 [3081026] BCBS WYOMING [308102603] 39.9 percent of total billed charges 26.04 39.9 Technical (Hospital) Services HC/HH Wch Supp Wrist Splint Xsm__E317072 PX-2705000237 CDM 2705000237 LOCAL 270 RC outpatient 42 42 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES EPO [308136803] 33.6 percent of total billed charges 26.04 39.9 Technical (Hospital) Services HC/HH Wch Supp Wrist Splint Xsm__E317072 PX-2705000237 CDM 2705000237 LOCAL 270 RC outpatient 42 42 CIGNA 62308 [3081051] CIGNA 62308 [308105105] 33.6 percent of total billed charges 26.04 39.9 Technical (Hospital) Services HC/HH Wch Supp Wrist Splint Xsm__E317072 PX-2705000237 CDM 2705000237 LOCAL 270 RC outpatient 42 42 CIGNA 62308 [3081051] CIGNA STATE OF WYOMING [308105107] 33.6 percent of total billed charges 26.04 39.9 Technical (Hospital) Services HC/HH Wch Supp Wrist Splint Xsm__E317072 PX-2705000237 CDM 2705000237 LOCAL 270 RC outpatient 42 42 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES HDHP [308136802] 33.6 percent of total billed charges 26.04 39.9 Technical (Hospital) Services HC/HH Wch Supp Wrist Splint Xsm__E317072 PX-2705000237 CDM 2705000237 LOCAL 270 RC outpatient 42 42 UNITED HEALTHCARE (COMMERCIAL) [3081199] UNITED HEALTHCARE 87726 [308119901] 26.04 percent of total billed charges 26.04 39.9 Technical (Hospital) Services HC/HH Wch Supp Wrist Splint Xsm__E317072 PX-2705000237 CDM 2705000237 LOCAL 270 RC outpatient 42 42 HEALTHPARTNERS SX009 HEALTHPARTNERS 33.6 percent of total billed charges 26.04 39.9 Technical (Hospital) Services HC/HH Wch Supp Wrist Splint Xsm__E317072 PX-2705000236 CDM 2705000236 LOCAL 270 RC inpatient 48 48 MULTIPLAN INC 34080 [3081285] MULTIPLAN INC [308128501] 45.6 percent of total billed charges 29.76 45.6 Technical (Hospital) Services HC/HH Wch Supp Wrist Splint Xsm__E317072 PX-2705000236 CDM 2705000236 LOCAL 270 RC inpatient 48 48 BLUE CROSS BLUE SHIELD WELLMARK SB889 [3081026] BCBS WYOMING [308102603] 45.6 percent of total billed charges 29.76 45.6 Technical (Hospital) Services HC/HH Wch Supp Wrist Splint Xsm__E317072 PX-2705000236 CDM 2705000236 LOCAL 270 RC inpatient 48 48 CIGNA 62308 [3081051] CIGNA 62308 [308105105] 38.01 percent of total billed charges 29.76 45.6 Technical (Hospital) Services HC/HH Wch Supp Wrist Splint Xsm__E317072 PX-2705000236 CDM 2705000236 LOCAL 270 RC inpatient 48 48 CIGNA 62308 [3081051] CIGNA STATE OF WYOMING [308105107] 38.01 percent of total billed charges 29.76 45.6 Technical (Hospital) Services HC/HH Wch Supp Wrist Splint Xsm__E317072 PX-2705000236 CDM 2705000236 LOCAL 270 RC inpatient 48 48 HEALTHPARTNERS SX009 HEALTHPARTNERS 38.01 percent of total billed charges 29.76 45.6 Technical (Hospital) Services HC/HH Wch Supp Wrist Splint Xsm__E317072 PX-2705000236 CDM 2705000236 LOCAL 270 RC inpatient 48 48 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES EPO [308136803] 38.01 percent of total billed charges 29.76 45.6 Technical (Hospital) Services HC/HH Wch Supp Wrist Splint Xsm__E317072 PX-2705000236 CDM 2705000236 LOCAL 270 RC inpatient 48 48 UNITED HEALTHCARE (COMMERCIAL) [3081199] UNITED HEALTHCARE 87726 [308119901] 29.76 percent of total billed charges 29.76 45.6 Technical (Hospital) Services HC/HH Wch Supp Wrist Splint Xsm__E317072 PX-2705000236 CDM 2705000236 LOCAL 270 RC inpatient 48 48 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES HDHP [308136802] 38.01 percent of total billed charges 29.76 45.6 Technical (Hospital) Services HC/HH Wch Supp Wrist Splint Xsm__E317072 PX-2705000236 CDM 2705000236 LOCAL 270 RC inpatient 48 48 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES PPO [308136801] 38.01 percent of total billed charges 29.76 45.6 Technical (Hospital) Services HC/HH Wch Supp Wrist Splint Xsm__E317072 PX-2705000236 CDM 2705000236 LOCAL 270 RC inpatient 48 48 MEDICA (COMMERCIAL) 94265 [3081118] MEDICA CLAIMS [308111801] 43.2 percent of total billed charges 29.76 45.6 Technical (Hospital) Services HC/HH Wch Supp Wrist Splint Xsm__E317072 PX-2705000236 CDM 2705000236 LOCAL 270 RC outpatient 48 48 UNITED HEALTHCARE (COMMERCIAL) [3081199] UNITED HEALTHCARE 87726 [308119901] 29.76 percent of total billed charges 29.76 45.6 Technical (Hospital) Services HC/HH Wch Supp Wrist Splint Xsm__E317072 PX-2705000236 CDM 2705000236 LOCAL 270 RC outpatient 48 48 HEALTHPARTNERS SX009 HEALTHPARTNERS 38.4 percent of total billed charges 29.76 45.6 Technical (Hospital) Services HC/HH Wch Supp Wrist Splint Xsm__E317072 PX-2705000236 CDM 2705000236 LOCAL 270 RC outpatient 48 48 CIGNA 62308 [3081051] CIGNA 62308 [308105105] 38.4 percent of total billed charges 29.76 45.6 Technical (Hospital) Services HC/HH Wch Supp Wrist Splint Xsm__E317072 PX-2705000236 CDM 2705000236 LOCAL 270 RC outpatient 48 48 CIGNA 62308 [3081051] CIGNA STATE OF WYOMING [308105107] 38.4 percent of total billed charges 29.76 45.6 Technical (Hospital) Services HC/HH Wch Supp Wrist Splint Xsm__E317072 PX-2705000236 CDM 2705000236 LOCAL 270 RC outpatient 48 48 BLUE CROSS BLUE SHIELD WELLMARK SB889 [3081026] BCBS WYOMING [308102603] 45.6 percent of total billed charges 29.76 45.6 Technical (Hospital) Services HC/HH Wch Supp Wrist Splint Xsm__E317072 PX-2705000236 CDM 2705000236 LOCAL 270 RC outpatient 48 48 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES EPO [308136803] 38.4 percent of total billed charges 29.76 45.6 Technical (Hospital) Services HC/HH Wch Supp Wrist Splint Xsm__E317072 PX-2705000236 CDM 2705000236 LOCAL 270 RC outpatient 48 48 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES HDHP [308136802] 38.4 percent of total billed charges 29.76 45.6 Technical (Hospital) Services HC/HH Wch Supp Wrist Splint Xsm__E317072 PX-2705000236 CDM 2705000236 LOCAL 270 RC outpatient 48 48 MULTIPLAN INC 34080 [3081285] MULTIPLAN INC [308128501] 45.6 percent of total billed charges 29.76 45.6 Technical (Hospital) Services HC/HH Wch Supp Wrist Splint Xsm__E317072 PX-2705000236 CDM 2705000236 LOCAL 270 RC outpatient 48 48 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES PPO [308136801] 38.4 percent of total billed charges 29.76 45.6 Technical (Hospital) Services HC/HH Wch Supp Wrist Splint Xsm__E317072 PX-2705000236 CDM 2705000236 LOCAL 270 RC outpatient 48 48 MEDICA (COMMERCIAL) 94265 [3081118] MEDICA CLAIMS [308111801] 43.2 percent of total billed charges 29.76 45.6 Technical (Hospital) Services HC/HH Wch Supp Wrist Splint Xlg Rt__E317078 PX-2705000235 CDM 2705000235 LOCAL 270 RC inpatient 33 33 BLUE CROSS BLUE SHIELD WELLMARK SB889 [3081026] BCBS WYOMING [308102603] 31.35 percent of total billed charges 20.46 31.35 Technical (Hospital) Services HC/HH Wch Supp Wrist Splint Xlg Rt__E317078 PX-2705000235 CDM 2705000235 LOCAL 270 RC inpatient 33 33 MULTIPLAN INC 34080 [3081285] MULTIPLAN INC [308128501] 31.35 percent of total billed charges 20.46 31.35 Technical (Hospital) Services HC/HH Wch Supp Wrist Splint Xlg Rt__E317078 PX-2705000235 CDM 2705000235 LOCAL 270 RC inpatient 33 33 CIGNA 62308 [3081051] CIGNA 62308 [308105105] 26.13 percent of total billed charges 20.46 31.35 Technical (Hospital) Services HC/HH Wch Supp Wrist Splint Xlg Rt__E317078 PX-2705000235 CDM 2705000235 LOCAL 270 RC inpatient 33 33 CIGNA 62308 [3081051] CIGNA STATE OF WYOMING [308105107] 26.13 percent of total billed charges 20.46 31.35 Technical (Hospital) Services HC/HH Wch Supp Wrist Splint Xlg Rt__E317078 PX-2705000235 CDM 2705000235 LOCAL 270 RC inpatient 33 33 HEALTHPARTNERS SX009 HEALTHPARTNERS 26.13 percent of total billed charges 20.46 31.35 Technical (Hospital) Services HC/HH Wch Supp Wrist Splint Xlg Rt__E317078 PX-2705000235 CDM 2705000235 LOCAL 270 RC inpatient 33 33 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES EPO [308136803] 26.13 percent of total billed charges 20.46 31.35 Technical (Hospital) Services HC/HH Wch Supp Wrist Splint Xlg Rt__E317078 PX-2705000235 CDM 2705000235 LOCAL 270 RC inpatient 33 33 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES PPO [308136801] 26.13 percent of total billed charges 20.46 31.35 Technical (Hospital) Services HC/HH Wch Supp Wrist Splint Xlg Rt__E317078 PX-2705000235 CDM 2705000235 LOCAL 270 RC inpatient 33 33 MEDICA (COMMERCIAL) 94265 [3081118] MEDICA CLAIMS [308111801] 29.7 percent of total billed charges 20.46 31.35 Technical (Hospital) Services HC/HH Wch Supp Wrist Splint Xlg Rt__E317078 PX-2705000235 CDM 2705000235 LOCAL 270 RC inpatient 33 33 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES HDHP [308136802] 26.13 percent of total billed charges 20.46 31.35 Technical (Hospital) Services HC/HH Wch Supp Wrist Splint Xlg Rt__E317078 PX-2705000235 CDM 2705000235 LOCAL 270 RC inpatient 33 33 UNITED HEALTHCARE (COMMERCIAL) [3081199] UNITED HEALTHCARE 87726 [308119901] 20.46 percent of total billed charges 20.46 31.35 Technical (Hospital) Services HC/HH Wch Supp Wrist Splint Xlg Rt__E317078 PX-2705000235 CDM 2705000235 LOCAL 270 RC outpatient 33 33 HEALTHPARTNERS SX009 HEALTHPARTNERS 26.4 percent of total billed charges 20.46 31.35 Technical (Hospital) Services HC/HH Wch Supp Wrist Splint Xlg Rt__E317078 PX-2705000235 CDM 2705000235 LOCAL 270 RC outpatient 33 33 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES PPO [308136801] 26.4 percent of total billed charges 20.46 31.35 Technical (Hospital) Services HC/HH Wch Supp Wrist Splint Xlg Rt__E317078 PX-2705000235 CDM 2705000235 LOCAL 270 RC outpatient 33 33 MULTIPLAN INC 34080 [3081285] MULTIPLAN INC [308128501] 31.35 percent of total billed charges 20.46 31.35 Technical (Hospital) Services HC/HH Wch Supp Wrist Splint Xlg Rt__E317078 PX-2705000235 CDM 2705000235 LOCAL 270 RC outpatient 33 33 MEDICA (COMMERCIAL) 94265 [3081118] MEDICA CLAIMS [308111801] 29.7 percent of total billed charges 20.46 31.35 Technical (Hospital) Services HC/HH Wch Supp Wrist Splint Xlg Rt__E317078 PX-2705000235 CDM 2705000235 LOCAL 270 RC outpatient 33 33 UNITED HEALTHCARE (COMMERCIAL) [3081199] UNITED HEALTHCARE 87726 [308119901] 20.46 percent of total billed charges 20.46 31.35 Technical (Hospital) Services HC/HH Wch Supp Wrist Splint Xlg Rt__E317078 PX-2705000235 CDM 2705000235 LOCAL 270 RC outpatient 33 33 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES HDHP [308136802] 26.4 percent of total billed charges 20.46 31.35 Technical (Hospital) Services HC/HH Wch Supp Wrist Splint Xlg Rt__E317078 PX-2705000235 CDM 2705000235 LOCAL 270 RC outpatient 33 33 BLUE CROSS BLUE SHIELD WELLMARK SB889 [3081026] BCBS WYOMING [308102603] 31.35 percent of total billed charges 20.46 31.35 Technical (Hospital) Services HC/HH Wch Supp Wrist Splint Xlg Rt__E317078 PX-2705000235 CDM 2705000235 LOCAL 270 RC outpatient 33 33 CIGNA 62308 [3081051] CIGNA 62308 [308105105] 26.4 percent of total billed charges 20.46 31.35 Technical (Hospital) Services HC/HH Wch Supp Wrist Splint Xlg Rt__E317078 PX-2705000235 CDM 2705000235 LOCAL 270 RC outpatient 33 33 CIGNA 62308 [3081051] CIGNA STATE OF WYOMING [308105107] 26.4 percent of total billed charges 20.46 31.35 Technical (Hospital) Services HC/HH Wch Supp Wrist Splint Xlg Rt__E317078 PX-2705000235 CDM 2705000235 LOCAL 270 RC outpatient 33 33 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES EPO [308136803] 26.4 percent of total billed charges 20.46 31.35 Technical (Hospital) Services HC/HH Wch Supp Wrist Splint Sml__E317083 PX-2705000233 CDM 2705000233 LOCAL 270 RC inpatient 32 32 MEDICA (COMMERCIAL) 94265 [3081118] MEDICA CLAIMS [308111801] 28.8 percent of total billed charges 19.84 30.4 Technical (Hospital) Services HC/HH Wch Supp Wrist Splint Sml__E317083 PX-2705000233 CDM 2705000233 LOCAL 270 RC inpatient 32 32 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES PPO [308136801] 25.34 percent of total billed charges 19.84 30.4 Technical (Hospital) Services HC/HH Wch Supp Wrist Splint Sml__E317083 PX-2705000233 CDM 2705000233 LOCAL 270 RC inpatient 32 32 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES HDHP [308136802] 25.34 percent of total billed charges 19.84 30.4 Technical (Hospital) Services HC/HH Wch Supp Wrist Splint Sml__E317083 PX-2705000233 CDM 2705000233 LOCAL 270 RC inpatient 32 32 UNITED HEALTHCARE (COMMERCIAL) [3081199] UNITED HEALTHCARE 87726 [308119901] 19.84 percent of total billed charges 19.84 30.4 Technical (Hospital) Services HC/HH Wch Supp Wrist Splint Sml__E317083 PX-2705000233 CDM 2705000233 LOCAL 270 RC inpatient 32 32 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES EPO [308136803] 25.34 percent of total billed charges 19.84 30.4 Technical (Hospital) Services HC/HH Wch Supp Wrist Splint Sml__E317083 PX-2705000233 CDM 2705000233 LOCAL 270 RC inpatient 32 32 HEALTHPARTNERS SX009 HEALTHPARTNERS 25.34 percent of total billed charges 19.84 30.4 Technical (Hospital) Services HC/HH Wch Supp Wrist Splint Sml__E317083 PX-2705000233 CDM 2705000233 LOCAL 270 RC inpatient 32 32 CIGNA 62308 [3081051] CIGNA 62308 [308105105] 25.34 percent of total billed charges 19.84 30.4 Technical (Hospital) Services HC/HH Wch Supp Wrist Splint Sml__E317083 PX-2705000233 CDM 2705000233 LOCAL 270 RC inpatient 32 32 CIGNA 62308 [3081051] CIGNA STATE OF WYOMING [308105107] 25.34 percent of total billed charges 19.84 30.4 Technical (Hospital) Services HC/HH Wch Supp Wrist Splint Sml__E317083 PX-2705000233 CDM 2705000233 LOCAL 270 RC inpatient 32 32 BLUE CROSS BLUE SHIELD WELLMARK SB889 [3081026] BCBS WYOMING [308102603] 30.4 percent of total billed charges 19.84 30.4 Technical (Hospital) Services HC/HH Wch Supp Wrist Splint Sml__E317083 PX-2705000233 CDM 2705000233 LOCAL 270 RC inpatient 32 32 MULTIPLAN INC 34080 [3081285] MULTIPLAN INC [308128501] 30.4 percent of total billed charges 19.84 30.4 Technical (Hospital) Services HC/HH Wch Supp Wrist Splint Sml__E317083 PX-2705000233 CDM 2705000233 LOCAL 270 RC outpatient 32 32 HEALTHPARTNERS SX009 HEALTHPARTNERS 25.6 percent of total billed charges 19.84 30.4 Technical (Hospital) Services HC/HH Wch Supp Wrist Splint Sml__E317083 PX-2705000233 CDM 2705000233 LOCAL 270 RC outpatient 32 32 UNITED HEALTHCARE (COMMERCIAL) [3081199] UNITED HEALTHCARE 87726 [308119901] 19.84 percent of total billed charges 19.84 30.4 Technical (Hospital) Services HC/HH Wch Supp Wrist Splint Sml__E317083 PX-2705000233 CDM 2705000233 LOCAL 270 RC outpatient 32 32 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES HDHP [308136802] 25.6 percent of total billed charges 19.84 30.4 Technical (Hospital) Services HC/HH Wch Supp Wrist Splint Sml__E317083 PX-2705000233 CDM 2705000233 LOCAL 270 RC outpatient 32 32 CIGNA 62308 [3081051] CIGNA 62308 [308105105] 25.6 percent of total billed charges 19.84 30.4 Technical (Hospital) Services HC/HH Wch Supp Wrist Splint Sml__E317083 PX-2705000233 CDM 2705000233 LOCAL 270 RC outpatient 32 32 CIGNA 62308 [3081051] CIGNA STATE OF WYOMING [308105107] 25.6 percent of total billed charges 19.84 30.4 Technical (Hospital) Services HC/HH Wch Supp Wrist Splint Sml__E317083 PX-2705000233 CDM 2705000233 LOCAL 270 RC outpatient 32 32 BLUE CROSS BLUE SHIELD WELLMARK SB889 [3081026] BCBS WYOMING [308102603] 30.4 percent of total billed charges 19.84 30.4 Technical (Hospital) Services HC/HH Wch Supp Wrist Splint Sml__E317083 PX-2705000233 CDM 2705000233 LOCAL 270 RC outpatient 32 32 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES EPO [308136803] 25.6 percent of total billed charges 19.84 30.4 Technical (Hospital) Services HC/HH Wch Supp Wrist Splint Sml__E317083 PX-2705000233 CDM 2705000233 LOCAL 270 RC outpatient 32 32 MEDICA (COMMERCIAL) 94265 [3081118] MEDICA CLAIMS [308111801] 28.8 percent of total billed charges 19.84 30.4 Technical (Hospital) Services HC/HH Wch Supp Wrist Splint Sml__E317083 PX-2705000233 CDM 2705000233 LOCAL 270 RC outpatient 32 32 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES PPO [308136801] 25.6 percent of total billed charges 19.84 30.4 Technical (Hospital) Services HC/HH Wch Supp Wrist Splint Sml__E317083 PX-2705000233 CDM 2705000233 LOCAL 270 RC outpatient 32 32 MULTIPLAN INC 34080 [3081285] MULTIPLAN INC [308128501] 30.4 percent of total billed charges 19.84 30.4 Technical (Hospital) Services HC/HH Wch Supp Wrist Splint Med__E317085 PX-2705000231 CDM 2705000231 LOCAL 270 RC outpatient 75 75 BLUE CROSS BLUE SHIELD WELLMARK SB889 [3081026] BCBS WYOMING [308102603] 71.25 percent of total billed charges 46.5 71.25 Technical (Hospital) Services HC/HH Wch Supp Wrist Splint Med__E317085 PX-2705000231 CDM 2705000231 LOCAL 270 RC outpatient 75 75 CIGNA 62308 [3081051] CIGNA 62308 [308105105] 60 percent of total billed charges 46.5 71.25 Technical (Hospital) Services HC/HH Wch Supp Wrist Splint Med__E317085 PX-2705000231 CDM 2705000231 LOCAL 270 RC outpatient 75 75 CIGNA 62308 [3081051] CIGNA STATE OF WYOMING [308105107] 60 percent of total billed charges 46.5 71.25 Technical (Hospital) Services HC/HH Wch Supp Wrist Splint Med__E317085 PX-2705000231 CDM 2705000231 LOCAL 270 RC outpatient 75 75 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES EPO [308136803] 60 percent of total billed charges 46.5 71.25 Technical (Hospital) Services HC/HH Wch Supp Wrist Splint Med__E317085 PX-2705000231 CDM 2705000231 LOCAL 270 RC outpatient 75 75 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES HDHP [308136802] 60 percent of total billed charges 46.5 71.25 Technical (Hospital) Services HC/HH Wch Supp Wrist Splint Med__E317085 PX-2705000231 CDM 2705000231 LOCAL 270 RC outpatient 75 75 UNITED HEALTHCARE (COMMERCIAL) [3081199] UNITED HEALTHCARE 87726 [308119901] 46.5 percent of total billed charges 46.5 71.25 Technical (Hospital) Services HC/HH Wch Supp Wrist Splint Med__E317085 PX-2705000231 CDM 2705000231 LOCAL 270 RC outpatient 75 75 HEALTHPARTNERS SX009 HEALTHPARTNERS 60 percent of total billed charges 46.5 71.25 Technical (Hospital) Services HC/HH Wch Supp Wrist Splint Med__E317085 PX-2705000231 CDM 2705000231 LOCAL 270 RC outpatient 75 75 MEDICA (COMMERCIAL) 94265 [3081118] MEDICA CLAIMS [308111801] 67.5 percent of total billed charges 46.5 71.25 Technical (Hospital) Services HC/HH Wch Supp Wrist Splint Med__E317085 PX-2705000231 CDM 2705000231 LOCAL 270 RC outpatient 75 75 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES PPO [308136801] 60 percent of total billed charges 46.5 71.25 Technical (Hospital) Services HC/HH Wch Supp Wrist Splint Med__E317085 PX-2705000231 CDM 2705000231 LOCAL 270 RC outpatient 75 75 MULTIPLAN INC 34080 [3081285] MULTIPLAN INC [308128501] 71.25 percent of total billed charges 46.5 71.25 Technical (Hospital) Services HC/HH Wch Supp Wrist Splint Med__E317085 PX-2705000231 CDM 2705000231 LOCAL 270 RC inpatient 75 75 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES EPO [308136803] 59.39 percent of total billed charges 46.5 71.25 Technical (Hospital) Services HC/HH Wch Supp Wrist Splint Med__E317085 PX-2705000231 CDM 2705000231 LOCAL 270 RC inpatient 75 75 HEALTHPARTNERS SX009 HEALTHPARTNERS 59.39 percent of total billed charges 46.5 71.25 Technical (Hospital) Services HC/HH Wch Supp Wrist Splint Med__E317085 PX-2705000231 CDM 2705000231 LOCAL 270 RC inpatient 75 75 MULTIPLAN INC 34080 [3081285] MULTIPLAN INC [308128501] 71.25 percent of total billed charges 46.5 71.25 Technical (Hospital) Services HC/HH Wch Supp Wrist Splint Med__E317085 PX-2705000231 CDM 2705000231 LOCAL 270 RC inpatient 75 75 BLUE CROSS BLUE SHIELD WELLMARK SB889 [3081026] BCBS WYOMING [308102603] 71.25 percent of total billed charges 46.5 71.25 Technical (Hospital) Services HC/HH Wch Supp Wrist Splint Med__E317085 PX-2705000231 CDM 2705000231 LOCAL 270 RC inpatient 75 75 CIGNA 62308 [3081051] CIGNA 62308 [308105105] 59.39 percent of total billed charges 46.5 71.25 Technical (Hospital) Services HC/HH Wch Supp Wrist Splint Med__E317085 PX-2705000231 CDM 2705000231 LOCAL 270 RC inpatient 75 75 CIGNA 62308 [3081051] CIGNA STATE OF WYOMING [308105107] 59.39 percent of total billed charges 46.5 71.25 Technical (Hospital) Services HC/HH Wch Supp Wrist Splint Med__E317085 PX-2705000231 CDM 2705000231 LOCAL 270 RC inpatient 75 75 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES PPO [308136801] 59.39 percent of total billed charges 46.5 71.25 Technical (Hospital) Services HC/HH Wch Supp Wrist Splint Med__E317085 PX-2705000231 CDM 2705000231 LOCAL 270 RC inpatient 75 75 MEDICA (COMMERCIAL) 94265 [3081118] MEDICA CLAIMS [308111801] 67.5 percent of total billed charges 46.5 71.25 Technical (Hospital) Services HC/HH Wch Supp Wrist Splint Med__E317085 PX-2705000231 CDM 2705000231 LOCAL 270 RC inpatient 75 75 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES HDHP [308136802] 59.39 percent of total billed charges 46.5 71.25 Technical (Hospital) Services HC/HH Wch Supp Wrist Splint Med__E317085 PX-2705000231 CDM 2705000231 LOCAL 270 RC inpatient 75 75 UNITED HEALTHCARE (COMMERCIAL) [3081199] UNITED HEALTHCARE 87726 [308119901] 46.5 percent of total billed charges 46.5 71.25 Technical (Hospital) Services HC/HH Wch Supp Wrist Splint Lg__E317087 PX-2705000229 CDM 2705000229 LOCAL 270 RC inpatient 32 32 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES PPO [308136801] 25.34 percent of total billed charges 19.84 30.4 Technical (Hospital) Services HC/HH Wch Supp Wrist Splint Lg__E317087 PX-2705000229 CDM 2705000229 LOCAL 270 RC inpatient 32 32 MEDICA (COMMERCIAL) 94265 [3081118] MEDICA CLAIMS [308111801] 28.8 percent of total billed charges 19.84 30.4 Technical (Hospital) Services HC/HH Wch Supp Wrist Splint Lg__E317087 PX-2705000229 CDM 2705000229 LOCAL 270 RC inpatient 32 32 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES HDHP [308136802] 25.34 percent of total billed charges 19.84 30.4 Technical (Hospital) Services HC/HH Wch Supp Wrist Splint Lg__E317087 PX-2705000229 CDM 2705000229 LOCAL 270 RC inpatient 32 32 UNITED HEALTHCARE (COMMERCIAL) [3081199] UNITED HEALTHCARE 87726 [308119901] 19.84 percent of total billed charges 19.84 30.4 Technical (Hospital) Services HC/HH Wch Supp Wrist Splint Lg__E317087 PX-2705000229 CDM 2705000229 LOCAL 270 RC inpatient 32 32 MULTIPLAN INC 34080 [3081285] MULTIPLAN INC [308128501] 30.4 percent of total billed charges 19.84 30.4 Technical (Hospital) Services HC/HH Wch Supp Wrist Splint Lg__E317087 PX-2705000229 CDM 2705000229 LOCAL 270 RC inpatient 32 32 BLUE CROSS BLUE SHIELD WELLMARK SB889 [3081026] BCBS WYOMING [308102603] 30.4 percent of total billed charges 19.84 30.4 Technical (Hospital) Services HC/HH Wch Supp Wrist Splint Lg__E317087 PX-2705000229 CDM 2705000229 LOCAL 270 RC inpatient 32 32 CIGNA 62308 [3081051] CIGNA 62308 [308105105] 25.34 percent of total billed charges 19.84 30.4 Technical (Hospital) Services HC/HH Wch Supp Wrist Splint Lg__E317087 PX-2705000229 CDM 2705000229 LOCAL 270 RC inpatient 32 32 CIGNA 62308 [3081051] CIGNA STATE OF WYOMING [308105107] 25.34 percent of total billed charges 19.84 30.4 Technical (Hospital) Services HC/HH Wch Supp Wrist Splint Lg__E317087 PX-2705000229 CDM 2705000229 LOCAL 270 RC inpatient 32 32 HEALTHPARTNERS SX009 HEALTHPARTNERS 25.34 percent of total billed charges 19.84 30.4 Technical (Hospital) Services HC/HH Wch Supp Wrist Splint Lg__E317087 PX-2705000229 CDM 2705000229 LOCAL 270 RC inpatient 32 32 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES EPO [308136803] 25.34 percent of total billed charges 19.84 30.4 Technical (Hospital) Services HC/HH Wch Supp Wrist Splint Lg__E317087 PX-2705000229 CDM 2705000229 LOCAL 270 RC outpatient 32 32 UNITED HEALTHCARE (COMMERCIAL) [3081199] UNITED HEALTHCARE 87726 [308119901] 19.84 percent of total billed charges 19.84 30.4 Technical (Hospital) Services HC/HH Wch Supp Wrist Splint Lg__E317087 PX-2705000229 CDM 2705000229 LOCAL 270 RC outpatient 32 32 HEALTHPARTNERS SX009 HEALTHPARTNERS 25.6 percent of total billed charges 19.84 30.4 Technical (Hospital) Services HC/HH Wch Supp Wrist Splint Lg__E317087 PX-2705000229 CDM 2705000229 LOCAL 270 RC outpatient 32 32 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES PPO [308136801] 25.6 percent of total billed charges 19.84 30.4 Technical (Hospital) Services HC/HH Wch Supp Wrist Splint Lg__E317087 PX-2705000229 CDM 2705000229 LOCAL 270 RC outpatient 32 32 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES EPO [308136803] 25.6 percent of total billed charges 19.84 30.4 Technical (Hospital) Services HC/HH Wch Supp Wrist Splint Lg__E317087 PX-2705000229 CDM 2705000229 LOCAL 270 RC outpatient 32 32 CIGNA 62308 [3081051] CIGNA 62308 [308105105] 25.6 percent of total billed charges 19.84 30.4 Technical (Hospital) Services HC/HH Wch Supp Wrist Splint Lg__E317087 PX-2705000229 CDM 2705000229 LOCAL 270 RC outpatient 32 32 CIGNA 62308 [3081051] CIGNA STATE OF WYOMING [308105107] 25.6 percent of total billed charges 19.84 30.4 Technical (Hospital) Services HC/HH Wch Supp Wrist Splint Lg__E317087 PX-2705000229 CDM 2705000229 LOCAL 270 RC outpatient 32 32 BLUE CROSS BLUE SHIELD WELLMARK SB889 [3081026] BCBS WYOMING [308102603] 30.4 percent of total billed charges 19.84 30.4 Technical (Hospital) Services HC/HH Wch Supp Wrist Splint Lg__E317087 PX-2705000229 CDM 2705000229 LOCAL 270 RC outpatient 32 32 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES HDHP [308136802] 25.6 percent of total billed charges 19.84 30.4 Technical (Hospital) Services HC/HH Wch Supp Wrist Splint Lg__E317087 PX-2705000229 CDM 2705000229 LOCAL 270 RC outpatient 32 32 MULTIPLAN INC 34080 [3081285] MULTIPLAN INC [308128501] 30.4 percent of total billed charges 19.84 30.4 Technical (Hospital) Services HC/HH Wch Supp Wrist Splint Lg__E317087 PX-2705000229 CDM 2705000229 LOCAL 270 RC outpatient 32 32 MEDICA (COMMERCIAL) 94265 [3081118] MEDICA CLAIMS [308111801] 28.8 percent of total billed charges 19.84 30.4 Technical (Hospital) Services HC/HH Wch Supp Wrist Cockup Xlg__207048 PX-2705000227 CDM 2705000227 LOCAL 270 RC outpatient 45 45 MEDICA (COMMERCIAL) 94265 [3081118] MEDICA CLAIMS [308111801] 40.5 percent of total billed charges 27.9 42.75 Technical (Hospital) Services HC/HH Wch Supp Wrist Cockup Xlg__207048 PX-2705000227 CDM 2705000227 LOCAL 270 RC outpatient 45 45 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES PPO [308136801] 36 percent of total billed charges 27.9 42.75 Technical (Hospital) Services HC/HH Wch Supp Wrist Cockup Xlg__207048 PX-2705000227 CDM 2705000227 LOCAL 270 RC outpatient 45 45 MULTIPLAN INC 34080 [3081285] MULTIPLAN INC [308128501] 42.75 percent of total billed charges 27.9 42.75 Technical (Hospital) Services HC/HH Wch Supp Wrist Cockup Xlg__207048 PX-2705000227 CDM 2705000227 LOCAL 270 RC outpatient 45 45 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES EPO [308136803] 36 percent of total billed charges 27.9 42.75 Technical (Hospital) Services HC/HH Wch Supp Wrist Cockup Xlg__207048 PX-2705000227 CDM 2705000227 LOCAL 270 RC outpatient 45 45 BLUE CROSS BLUE SHIELD WELLMARK SB889 [3081026] BCBS WYOMING [308102603] 42.75 percent of total billed charges 27.9 42.75 Technical (Hospital) Services HC/HH Wch Supp Wrist Cockup Xlg__207048 PX-2705000227 CDM 2705000227 LOCAL 270 RC outpatient 45 45 CIGNA 62308 [3081051] CIGNA 62308 [308105105] 36 percent of total billed charges 27.9 42.75 Technical (Hospital) Services HC/HH Wch Supp Wrist Cockup Xlg__207048 PX-2705000227 CDM 2705000227 LOCAL 270 RC outpatient 45 45 CIGNA 62308 [3081051] CIGNA STATE OF WYOMING [308105107] 36 percent of total billed charges 27.9 42.75 Technical (Hospital) Services HC/HH Wch Supp Wrist Cockup Xlg__207048 PX-2705000227 CDM 2705000227 LOCAL 270 RC outpatient 45 45 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES HDHP [308136802] 36 percent of total billed charges 27.9 42.75 Technical (Hospital) Services HC/HH Wch Supp Wrist Cockup Xlg__207048 PX-2705000227 CDM 2705000227 LOCAL 270 RC outpatient 45 45 HEALTHPARTNERS SX009 HEALTHPARTNERS 36 percent of total billed charges 27.9 42.75 Technical (Hospital) Services HC/HH Wch Supp Wrist Cockup Xlg__207048 PX-2705000227 CDM 2705000227 LOCAL 270 RC outpatient 45 45 UNITED HEALTHCARE (COMMERCIAL) [3081199] UNITED HEALTHCARE 87726 [308119901] 27.9 percent of total billed charges 27.9 42.75 Technical (Hospital) Services HC/HH Wch Supp Wrist Cockup Xlg__207048 PX-2705000227 CDM 2705000227 LOCAL 270 RC inpatient 45 45 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES EPO [308136803] 35.63 percent of total billed charges 27.9 42.75 Technical (Hospital) Services HC/HH Wch Supp Wrist Cockup Xlg__207048 PX-2705000227 CDM 2705000227 LOCAL 270 RC inpatient 45 45 BLUE CROSS BLUE SHIELD WELLMARK SB889 [3081026] BCBS WYOMING [308102603] 42.75 percent of total billed charges 27.9 42.75 Technical (Hospital) Services HC/HH Wch Supp Wrist Cockup Xlg__207048 PX-2705000227 CDM 2705000227 LOCAL 270 RC inpatient 45 45 MULTIPLAN INC 34080 [3081285] MULTIPLAN INC [308128501] 42.75 percent of total billed charges 27.9 42.75 Technical (Hospital) Services HC/HH Wch Supp Wrist Cockup Xlg__207048 PX-2705000227 CDM 2705000227 LOCAL 270 RC inpatient 45 45 HEALTHPARTNERS SX009 HEALTHPARTNERS 35.63 percent of total billed charges 27.9 42.75 Technical (Hospital) Services HC/HH Wch Supp Wrist Cockup Xlg__207048 PX-2705000227 CDM 2705000227 LOCAL 270 RC inpatient 45 45 CIGNA 62308 [3081051] CIGNA 62308 [308105105] 35.63 percent of total billed charges 27.9 42.75 Technical (Hospital) Services HC/HH Wch Supp Wrist Cockup Xlg__207048 PX-2705000227 CDM 2705000227 LOCAL 270 RC inpatient 45 45 CIGNA 62308 [3081051] CIGNA STATE OF WYOMING [308105107] 35.63 percent of total billed charges 27.9 42.75 Technical (Hospital) Services HC/HH Wch Supp Wrist Cockup Xlg__207048 PX-2705000227 CDM 2705000227 LOCAL 270 RC inpatient 45 45 UNITED HEALTHCARE (COMMERCIAL) [3081199] UNITED HEALTHCARE 87726 [308119901] 27.9 percent of total billed charges 27.9 42.75 Technical (Hospital) Services HC/HH Wch Supp Wrist Cockup Xlg__207048 PX-2705000227 CDM 2705000227 LOCAL 270 RC inpatient 45 45 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES HDHP [308136802] 35.63 percent of total billed charges 27.9 42.75 Technical (Hospital) Services HC/HH Wch Supp Wrist Cockup Xlg__207048 PX-2705000227 CDM 2705000227 LOCAL 270 RC inpatient 45 45 MEDICA (COMMERCIAL) 94265 [3081118] MEDICA CLAIMS [308111801] 40.5 percent of total billed charges 27.9 42.75 Technical (Hospital) Services HC/HH Wch Supp Wrist Cockup Xlg__207048 PX-2705000227 CDM 2705000227 LOCAL 270 RC inpatient 45 45 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES PPO [308136801] 35.63 percent of total billed charges 27.9 42.75 Technical (Hospital) Services HC/HH Wch Supp Wrist Cockup Sm__207043 PX-2705000225 CDM 2705000225 LOCAL 270 RC inpatient 57 57 HEALTHPARTNERS SX009 HEALTHPARTNERS 45.13 percent of total billed charges 35.34 54.15 Technical (Hospital) Services HC/HH Wch Supp Wrist Cockup Sm__207043 PX-2705000225 CDM 2705000225 LOCAL 270 RC inpatient 57 57 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES EPO [308136803] 45.13 percent of total billed charges 35.34 54.15 Technical (Hospital) Services HC/HH Wch Supp Wrist Cockup Sm__207043 PX-2705000225 CDM 2705000225 LOCAL 270 RC inpatient 57 57 CIGNA 62308 [3081051] CIGNA 62308 [308105105] 45.13 percent of total billed charges 35.34 54.15 Technical (Hospital) Services HC/HH Wch Supp Wrist Cockup Sm__207043 PX-2705000225 CDM 2705000225 LOCAL 270 RC inpatient 57 57 CIGNA 62308 [3081051] CIGNA STATE OF WYOMING [308105107] 45.13 percent of total billed charges 35.34 54.15 Technical (Hospital) Services HC/HH Wch Supp Wrist Cockup Sm__207043 PX-2705000225 CDM 2705000225 LOCAL 270 RC inpatient 57 57 BLUE CROSS BLUE SHIELD WELLMARK SB889 [3081026] BCBS WYOMING [308102603] 54.15 percent of total billed charges 35.34 54.15 Technical (Hospital) Services HC/HH Wch Supp Wrist Cockup Sm__207043 PX-2705000225 CDM 2705000225 LOCAL 270 RC inpatient 57 57 MULTIPLAN INC 34080 [3081285] MULTIPLAN INC [308128501] 54.15 percent of total billed charges 35.34 54.15 Technical (Hospital) Services HC/HH Wch Supp Wrist Cockup Sm__207043 PX-2705000225 CDM 2705000225 LOCAL 270 RC inpatient 57 57 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES HDHP [308136802] 45.13 percent of total billed charges 35.34 54.15 Technical (Hospital) Services HC/HH Wch Supp Wrist Cockup Sm__207043 PX-2705000225 CDM 2705000225 LOCAL 270 RC inpatient 57 57 UNITED HEALTHCARE (COMMERCIAL) [3081199] UNITED HEALTHCARE 87726 [308119901] 35.34 percent of total billed charges 35.34 54.15 Technical (Hospital) Services HC/HH Wch Supp Wrist Cockup Sm__207043 PX-2705000225 CDM 2705000225 LOCAL 270 RC inpatient 57 57 MEDICA (COMMERCIAL) 94265 [3081118] MEDICA CLAIMS [308111801] 51.3 percent of total billed charges 35.34 54.15 Technical (Hospital) Services HC/HH Wch Supp Wrist Cockup Sm__207043 PX-2705000225 CDM 2705000225 LOCAL 270 RC inpatient 57 57 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES PPO [308136801] 45.13 percent of total billed charges 35.34 54.15 Technical (Hospital) Services HC/HH Wch Supp Wrist Cockup Sm__207043 PX-2705000225 CDM 2705000225 LOCAL 270 RC outpatient 57 57 MULTIPLAN INC 34080 [3081285] MULTIPLAN INC [308128501] 54.15 percent of total billed charges 35.34 54.15 Technical (Hospital) Services HC/HH Wch Supp Wrist Cockup Sm__207043 PX-2705000225 CDM 2705000225 LOCAL 270 RC outpatient 57 57 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES PPO [308136801] 45.6 percent of total billed charges 35.34 54.15 Technical (Hospital) Services HC/HH Wch Supp Wrist Cockup Sm__207043 PX-2705000225 CDM 2705000225 LOCAL 270 RC outpatient 57 57 MEDICA (COMMERCIAL) 94265 [3081118] MEDICA CLAIMS [308111801] 51.3 percent of total billed charges 35.34 54.15 Technical (Hospital) Services HC/HH Wch Supp Wrist Cockup Sm__207043 PX-2705000225 CDM 2705000225 LOCAL 270 RC outpatient 57 57 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES EPO [308136803] 45.6 percent of total billed charges 35.34 54.15 Technical (Hospital) Services HC/HH Wch Supp Wrist Cockup Sm__207043 PX-2705000225 CDM 2705000225 LOCAL 270 RC outpatient 57 57 BLUE CROSS BLUE SHIELD WELLMARK SB889 [3081026] BCBS WYOMING [308102603] 54.15 percent of total billed charges 35.34 54.15 Technical (Hospital) Services HC/HH Wch Supp Wrist Cockup Sm__207043 PX-2705000225 CDM 2705000225 LOCAL 270 RC outpatient 57 57 CIGNA 62308 [3081051] CIGNA 62308 [308105105] 45.6 percent of total billed charges 35.34 54.15 Technical (Hospital) Services HC/HH Wch Supp Wrist Cockup Sm__207043 PX-2705000225 CDM 2705000225 LOCAL 270 RC outpatient 57 57 CIGNA 62308 [3081051] CIGNA STATE OF WYOMING [308105107] 45.6 percent of total billed charges 35.34 54.15 Technical (Hospital) Services HC/HH Wch Supp Wrist Cockup Sm__207043 PX-2705000225 CDM 2705000225 LOCAL 270 RC outpatient 57 57 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES HDHP [308136802] 45.6 percent of total billed charges 35.34 54.15 Technical (Hospital) Services HC/HH Wch Supp Wrist Cockup Sm__207043 PX-2705000225 CDM 2705000225 LOCAL 270 RC outpatient 57 57 UNITED HEALTHCARE (COMMERCIAL) [3081199] UNITED HEALTHCARE 87726 [308119901] 35.34 percent of total billed charges 35.34 54.15 Technical (Hospital) Services HC/HH Wch Supp Wrist Cockup Sm__207043 PX-2705000225 CDM 2705000225 LOCAL 270 RC outpatient 57 57 HEALTHPARTNERS SX009 HEALTHPARTNERS 45.6 percent of total billed charges 35.34 54.15 Technical (Hospital) Services HC/HH Wch Supp Wrist Cockup Med__207045 PX-2705000223 CDM 2705000223 LOCAL 270 RC inpatient 57 57 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES EPO [308136803] 45.13 percent of total billed charges 35.34 54.15 Technical (Hospital) Services HC/HH Wch Supp Wrist Cockup Med__207045 PX-2705000223 CDM 2705000223 LOCAL 270 RC inpatient 57 57 HEALTHPARTNERS SX009 HEALTHPARTNERS 45.13 percent of total billed charges 35.34 54.15 Technical (Hospital) Services HC/HH Wch Supp Wrist Cockup Med__207045 PX-2705000223 CDM 2705000223 LOCAL 270 RC inpatient 57 57 CIGNA 62308 [3081051] CIGNA 62308 [308105105] 45.13 percent of total billed charges 35.34 54.15 Technical (Hospital) Services HC/HH Wch Supp Wrist Cockup Med__207045 PX-2705000223 CDM 2705000223 LOCAL 270 RC inpatient 57 57 CIGNA 62308 [3081051] CIGNA STATE OF WYOMING [308105107] 45.13 percent of total billed charges 35.34 54.15 Technical (Hospital) Services HC/HH Wch Supp Wrist Cockup Med__207045 PX-2705000223 CDM 2705000223 LOCAL 270 RC inpatient 57 57 BLUE CROSS BLUE SHIELD WELLMARK SB889 [3081026] BCBS WYOMING [308102603] 54.15 percent of total billed charges 35.34 54.15 Technical (Hospital) Services HC/HH Wch Supp Wrist Cockup Med__207045 PX-2705000223 CDM 2705000223 LOCAL 270 RC inpatient 57 57 MULTIPLAN INC 34080 [3081285] MULTIPLAN INC [308128501] 54.15 percent of total billed charges 35.34 54.15 Technical (Hospital) Services HC/HH Wch Supp Wrist Cockup Med__207045 PX-2705000223 CDM 2705000223 LOCAL 270 RC inpatient 57 57 UNITED HEALTHCARE (COMMERCIAL) [3081199] UNITED HEALTHCARE 87726 [308119901] 35.34 percent of total billed charges 35.34 54.15 Technical (Hospital) Services HC/HH Wch Supp Wrist Cockup Med__207045 PX-2705000223 CDM 2705000223 LOCAL 270 RC inpatient 57 57 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES HDHP [308136802] 45.13 percent of total billed charges 35.34 54.15 Technical (Hospital) Services HC/HH Wch Supp Wrist Cockup Med__207045 PX-2705000223 CDM 2705000223 LOCAL 270 RC inpatient 57 57 MEDICA (COMMERCIAL) 94265 [3081118] MEDICA CLAIMS [308111801] 51.3 percent of total billed charges 35.34 54.15 Technical (Hospital) Services HC/HH Wch Supp Wrist Cockup Med__207045 PX-2705000223 CDM 2705000223 LOCAL 270 RC inpatient 57 57 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES PPO [308136801] 45.13 percent of total billed charges 35.34 54.15 Technical (Hospital) Services HC/HH Wch Supp Wrist Cockup Med__207045 PX-2705000223 CDM 2705000223 LOCAL 270 RC outpatient 57 57 UNITED HEALTHCARE (COMMERCIAL) [3081199] UNITED HEALTHCARE 87726 [308119901] 35.34 percent of total billed charges 35.34 54.15 Technical (Hospital) Services HC/HH Wch Supp Wrist Cockup Med__207045 PX-2705000223 CDM 2705000223 LOCAL 270 RC outpatient 57 57 HEALTHPARTNERS SX009 HEALTHPARTNERS 45.6 percent of total billed charges 35.34 54.15 Technical (Hospital) Services HC/HH Wch Supp Wrist Cockup Med__207045 PX-2705000223 CDM 2705000223 LOCAL 270 RC outpatient 57 57 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES HDHP [308136802] 45.6 percent of total billed charges 35.34 54.15 Technical (Hospital) Services HC/HH Wch Supp Wrist Cockup Med__207045 PX-2705000223 CDM 2705000223 LOCAL 270 RC outpatient 57 57 CIGNA 62308 [3081051] CIGNA 62308 [308105105] 45.6 percent of total billed charges 35.34 54.15 Technical (Hospital) Services HC/HH Wch Supp Wrist Cockup Med__207045 PX-2705000223 CDM 2705000223 LOCAL 270 RC outpatient 57 57 CIGNA 62308 [3081051] CIGNA STATE OF WYOMING [308105107] 45.6 percent of total billed charges 35.34 54.15 Technical (Hospital) Services HC/HH Wch Supp Wrist Cockup Med__207045 PX-2705000223 CDM 2705000223 LOCAL 270 RC outpatient 57 57 BLUE CROSS BLUE SHIELD WELLMARK SB889 [3081026] BCBS WYOMING [308102603] 54.15 percent of total billed charges 35.34 54.15 Technical (Hospital) Services HC/HH Wch Supp Wrist Cockup Med__207045 PX-2705000223 CDM 2705000223 LOCAL 270 RC outpatient 57 57 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES EPO [308136803] 45.6 percent of total billed charges 35.34 54.15 Technical (Hospital) Services HC/HH Wch Supp Wrist Cockup Med__207045 PX-2705000223 CDM 2705000223 LOCAL 270 RC outpatient 57 57 MULTIPLAN INC 34080 [3081285] MULTIPLAN INC [308128501] 54.15 percent of total billed charges 35.34 54.15 Technical (Hospital) Services HC/HH Wch Supp Wrist Cockup Med__207045 PX-2705000223 CDM 2705000223 LOCAL 270 RC outpatient 57 57 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES PPO [308136801] 45.6 percent of total billed charges 35.34 54.15 Technical (Hospital) Services HC/HH Wch Supp Wrist Cockup Med__207045 PX-2705000223 CDM 2705000223 LOCAL 270 RC outpatient 57 57 MEDICA (COMMERCIAL) 94265 [3081118] MEDICA CLAIMS [308111801] 51.3 percent of total billed charges 35.34 54.15 Technical (Hospital) Services HC/HH Wch Supp Wrist Cockup Lg__207047 PX-2705000221 CDM 2705000221 LOCAL 270 RC inpatient 51 51 MULTIPLAN INC 34080 [3081285] MULTIPLAN INC [308128501] 48.45 percent of total billed charges 31.62 48.45 Technical (Hospital) Services HC/HH Wch Supp Wrist Cockup Lg__207047 PX-2705000221 CDM 2705000221 LOCAL 270 RC inpatient 51 51 BLUE CROSS BLUE SHIELD WELLMARK SB889 [3081026] BCBS WYOMING [308102603] 48.45 percent of total billed charges 31.62 48.45 Technical (Hospital) Services HC/HH Wch Supp Wrist Cockup Lg__207047 PX-2705000221 CDM 2705000221 LOCAL 270 RC inpatient 51 51 CIGNA 62308 [3081051] CIGNA 62308 [308105105] 40.38 percent of total billed charges 31.62 48.45 Technical (Hospital) Services HC/HH Wch Supp Wrist Cockup Lg__207047 PX-2705000221 CDM 2705000221 LOCAL 270 RC inpatient 51 51 CIGNA 62308 [3081051] CIGNA STATE OF WYOMING [308105107] 40.38 percent of total billed charges 31.62 48.45 Technical (Hospital) Services HC/HH Wch Supp Wrist Cockup Lg__207047 PX-2705000221 CDM 2705000221 LOCAL 270 RC inpatient 51 51 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES EPO [308136803] 40.38 percent of total billed charges 31.62 48.45 Technical (Hospital) Services HC/HH Wch Supp Wrist Cockup Lg__207047 PX-2705000221 CDM 2705000221 LOCAL 270 RC inpatient 51 51 HEALTHPARTNERS SX009 HEALTHPARTNERS 40.38 percent of total billed charges 31.62 48.45 Technical (Hospital) Services HC/HH Wch Supp Wrist Cockup Lg__207047 PX-2705000221 CDM 2705000221 LOCAL 270 RC inpatient 51 51 UNITED HEALTHCARE (COMMERCIAL) [3081199] UNITED HEALTHCARE 87726 [308119901] 31.62 percent of total billed charges 31.62 48.45 Technical (Hospital) Services HC/HH Wch Supp Wrist Cockup Lg__207047 PX-2705000221 CDM 2705000221 LOCAL 270 RC inpatient 51 51 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES HDHP [308136802] 40.38 percent of total billed charges 31.62 48.45 Technical (Hospital) Services HC/HH Wch Supp Wrist Cockup Lg__207047 PX-2705000221 CDM 2705000221 LOCAL 270 RC inpatient 51 51 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES PPO [308136801] 40.38 percent of total billed charges 31.62 48.45 Technical (Hospital) Services HC/HH Wch Supp Wrist Cockup Lg__207047 PX-2705000221 CDM 2705000221 LOCAL 270 RC inpatient 51 51 MEDICA (COMMERCIAL) 94265 [3081118] MEDICA CLAIMS [308111801] 45.9 percent of total billed charges 31.62 48.45 Technical (Hospital) Services HC/HH Wch Supp Wrist Cockup Lg__207047 PX-2705000221 CDM 2705000221 LOCAL 270 RC outpatient 51 51 HEALTHPARTNERS SX009 HEALTHPARTNERS 40.8 percent of total billed charges 31.62 48.45 Technical (Hospital) Services HC/HH Wch Supp Wrist Cockup Lg__207047 PX-2705000221 CDM 2705000221 LOCAL 270 RC outpatient 51 51 UNITED HEALTHCARE (COMMERCIAL) [3081199] UNITED HEALTHCARE 87726 [308119901] 31.62 percent of total billed charges 31.62 48.45 Technical (Hospital) Services HC/HH Wch Supp Wrist Cockup Lg__207047 PX-2705000221 CDM 2705000221 LOCAL 270 RC outpatient 51 51 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES HDHP [308136802] 40.8 percent of total billed charges 31.62 48.45 Technical (Hospital) Services HC/HH Wch Supp Wrist Cockup Lg__207047 PX-2705000221 CDM 2705000221 LOCAL 270 RC outpatient 51 51 CIGNA 62308 [3081051] CIGNA 62308 [308105105] 40.8 percent of total billed charges 31.62 48.45 Technical (Hospital) Services HC/HH Wch Supp Wrist Cockup Lg__207047 PX-2705000221 CDM 2705000221 LOCAL 270 RC outpatient 51 51 CIGNA 62308 [3081051] CIGNA STATE OF WYOMING [308105107] 40.8 percent of total billed charges 31.62 48.45 Technical (Hospital) Services HC/HH Wch Supp Wrist Cockup Lg__207047 PX-2705000221 CDM 2705000221 LOCAL 270 RC outpatient 51 51 BLUE CROSS BLUE SHIELD WELLMARK SB889 [3081026] BCBS WYOMING [308102603] 48.45 percent of total billed charges 31.62 48.45 Technical (Hospital) Services HC/HH Wch Supp Wrist Cockup Lg__207047 PX-2705000221 CDM 2705000221 LOCAL 270 RC outpatient 51 51 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES EPO [308136803] 40.8 percent of total billed charges 31.62 48.45 Technical (Hospital) Services HC/HH Wch Supp Wrist Cockup Lg__207047 PX-2705000221 CDM 2705000221 LOCAL 270 RC outpatient 51 51 MEDICA (COMMERCIAL) 94265 [3081118] MEDICA CLAIMS [308111801] 45.9 percent of total billed charges 31.62 48.45 Technical (Hospital) Services HC/HH Wch Supp Wrist Cockup Lg__207047 PX-2705000221 CDM 2705000221 LOCAL 270 RC outpatient 51 51 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES PPO [308136801] 40.8 percent of total billed charges 31.62 48.45 Technical (Hospital) Services HC/HH Wch Supp Wrist Cockup Lg__207047 PX-2705000221 CDM 2705000221 LOCAL 270 RC outpatient 51 51 MULTIPLAN INC 34080 [3081285] MULTIPLAN INC [308128501] 48.45 percent of total billed charges 31.62 48.45 Technical (Hospital) Services HC/HH Wch Supp Wchs Med/Supply Pickup PX-2705000220 CDM 2705000220 LOCAL 270 RC outpatient 30 30 UNITED HEALTHCARE (COMMERCIAL) [3081199] UNITED HEALTHCARE 87726 [308119901] 18.6 percent of total billed charges 18.6 28.5 Technical (Hospital) Services HC/HH Wch Supp Wchs Med/Supply Pickup PX-2705000220 CDM 2705000220 LOCAL 270 RC outpatient 30 30 HEALTHPARTNERS SX009 HEALTHPARTNERS 24 percent of total billed charges 18.6 28.5 Technical (Hospital) Services HC/HH Wch Supp Wchs Med/Supply Pickup PX-2705000220 CDM 2705000220 LOCAL 270 RC outpatient 30 30 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES PPO [308136801] 24 percent of total billed charges 18.6 28.5 Technical (Hospital) Services HC/HH Wch Supp Wchs Med/Supply Pickup PX-2705000220 CDM 2705000220 LOCAL 270 RC outpatient 30 30 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES HDHP [308136802] 24 percent of total billed charges 18.6 28.5 Technical (Hospital) Services HC/HH Wch Supp Wchs Med/Supply Pickup PX-2705000220 CDM 2705000220 LOCAL 270 RC outpatient 30 30 CIGNA 62308 [3081051] CIGNA 62308 [308105105] 24 percent of total billed charges 18.6 28.5 Technical (Hospital) Services HC/HH Wch Supp Wchs Med/Supply Pickup PX-2705000220 CDM 2705000220 LOCAL 270 RC outpatient 30 30 CIGNA 62308 [3081051] CIGNA STATE OF WYOMING [308105107] 24 percent of total billed charges 18.6 28.5 Technical (Hospital) Services HC/HH Wch Supp Wchs Med/Supply Pickup PX-2705000220 CDM 2705000220 LOCAL 270 RC outpatient 30 30 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES EPO [308136803] 24 percent of total billed charges 18.6 28.5 Technical (Hospital) Services HC/HH Wch Supp Wchs Med/Supply Pickup PX-2705000220 CDM 2705000220 LOCAL 270 RC outpatient 30 30 BLUE CROSS BLUE SHIELD WELLMARK SB889 [3081026] BCBS WYOMING [308102603] 28.5 percent of total billed charges 18.6 28.5 Technical (Hospital) Services HC/HH Wch Supp Wchs Med/Supply Pickup PX-2705000220 CDM 2705000220 LOCAL 270 RC outpatient 30 30 MEDICA (COMMERCIAL) 94265 [3081118] MEDICA CLAIMS [308111801] 27 percent of total billed charges 18.6 28.5 Technical (Hospital) Services HC/HH Wch Supp Wchs Med/Supply Pickup PX-2705000220 CDM 2705000220 LOCAL 270 RC outpatient 30 30 MULTIPLAN INC 34080 [3081285] MULTIPLAN INC [308128501] 28.5 percent of total billed charges 18.6 28.5 Technical (Hospital) Services HC/HH Wch Supp Wchs Med/Supply Pickup PX-2705000220 CDM 2705000220 LOCAL 270 RC inpatient 30 30 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES EPO [308136803] 23.75 percent of total billed charges 18.6 28.5 Technical (Hospital) Services HC/HH Wch Supp Wchs Med/Supply Pickup PX-2705000220 CDM 2705000220 LOCAL 270 RC inpatient 30 30 HEALTHPARTNERS SX009 HEALTHPARTNERS 23.75 percent of total billed charges 18.6 28.5 Technical (Hospital) Services HC/HH Wch Supp Wchs Med/Supply Pickup PX-2705000220 CDM 2705000220 LOCAL 270 RC inpatient 30 30 BLUE CROSS BLUE SHIELD WELLMARK SB889 [3081026] BCBS WYOMING [308102603] 28.5 percent of total billed charges 18.6 28.5 Technical (Hospital) Services HC/HH Wch Supp Wchs Med/Supply Pickup PX-2705000220 CDM 2705000220 LOCAL 270 RC inpatient 30 30 MULTIPLAN INC 34080 [3081285] MULTIPLAN INC [308128501] 28.5 percent of total billed charges 18.6 28.5 Technical (Hospital) Services HC/HH Wch Supp Wchs Med/Supply Pickup PX-2705000220 CDM 2705000220 LOCAL 270 RC inpatient 30 30 CIGNA 62308 [3081051] CIGNA 62308 [308105105] 23.75 percent of total billed charges 18.6 28.5 Technical (Hospital) Services HC/HH Wch Supp Wchs Med/Supply Pickup PX-2705000220 CDM 2705000220 LOCAL 270 RC inpatient 30 30 CIGNA 62308 [3081051] CIGNA STATE OF WYOMING [308105107] 23.75 percent of total billed charges 18.6 28.5 Technical (Hospital) Services HC/HH Wch Supp Wchs Med/Supply Pickup PX-2705000220 CDM 2705000220 LOCAL 270 RC inpatient 30 30 MEDICA (COMMERCIAL) 94265 [3081118] MEDICA CLAIMS [308111801] 27 percent of total billed charges 18.6 28.5 Technical (Hospital) Services HC/HH Wch Supp Wchs Med/Supply Pickup PX-2705000220 CDM 2705000220 LOCAL 270 RC inpatient 30 30 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES HDHP [308136802] 23.75 percent of total billed charges 18.6 28.5 Technical (Hospital) Services HC/HH Wch Supp Wchs Med/Supply Pickup PX-2705000220 CDM 2705000220 LOCAL 270 RC inpatient 30 30 UNITED HEALTHCARE (COMMERCIAL) [3081199] UNITED HEALTHCARE 87726 [308119901] 18.6 percent of total billed charges 18.6 28.5 Technical (Hospital) Services HC/HH Wch Supp Wchs Med/Supply Pickup PX-2705000220 CDM 2705000220 LOCAL 270 RC inpatient 30 30 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES PPO [308136801] 23.75 percent of total billed charges 18.6 28.5 Technical (Hospital) Services HC/HH Wch Supp Washcloth Pre-Moistened__6599n PX-2705000219 CDM 2705000219 LOCAL 270 RC inpatient 22 22 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES PPO [308136801] 17.42 percent of total billed charges 13.64 20.9 Technical (Hospital) Services HC/HH Wch Supp Washcloth Pre-Moistened__6599n PX-2705000219 CDM 2705000219 LOCAL 270 RC inpatient 22 22 MEDICA (COMMERCIAL) 94265 [3081118] MEDICA CLAIMS [308111801] 19.8 percent of total billed charges 13.64 20.9 Technical (Hospital) Services HC/HH Wch Supp Washcloth Pre-Moistened__6599n PX-2705000219 CDM 2705000219 LOCAL 270 RC inpatient 22 22 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES HDHP [308136802] 17.42 percent of total billed charges 13.64 20.9 Technical (Hospital) Services HC/HH Wch Supp Washcloth Pre-Moistened__6599n PX-2705000219 CDM 2705000219 LOCAL 270 RC inpatient 22 22 UNITED HEALTHCARE (COMMERCIAL) [3081199] UNITED HEALTHCARE 87726 [308119901] 13.64 percent of total billed charges 13.64 20.9 Technical (Hospital) Services HC/HH Wch Supp Washcloth Pre-Moistened__6599n PX-2705000219 CDM 2705000219 LOCAL 270 RC inpatient 22 22 MULTIPLAN INC 34080 [3081285] MULTIPLAN INC [308128501] 20.9 percent of total billed charges 13.64 20.9 Technical (Hospital) Services HC/HH Wch Supp Washcloth Pre-Moistened__6599n PX-2705000219 CDM 2705000219 LOCAL 270 RC inpatient 22 22 BLUE CROSS BLUE SHIELD WELLMARK SB889 [3081026] BCBS WYOMING [308102603] 20.9 percent of total billed charges 13.64 20.9 Technical (Hospital) Services HC/HH Wch Supp Washcloth Pre-Moistened__6599n PX-2705000219 CDM 2705000219 LOCAL 270 RC inpatient 22 22 CIGNA 62308 [3081051] CIGNA 62308 [308105105] 17.42 percent of total billed charges 13.64 20.9 Technical (Hospital) Services HC/HH Wch Supp Washcloth Pre-Moistened__6599n PX-2705000219 CDM 2705000219 LOCAL 270 RC inpatient 22 22 CIGNA 62308 [3081051] CIGNA STATE OF WYOMING [308105107] 17.42 percent of total billed charges 13.64 20.9 Technical (Hospital) Services HC/HH Wch Supp Washcloth Pre-Moistened__6599n PX-2705000219 CDM 2705000219 LOCAL 270 RC inpatient 22 22 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES EPO [308136803] 17.42 percent of total billed charges 13.64 20.9 Technical (Hospital) Services HC/HH Wch Supp Washcloth Pre-Moistened__6599n PX-2705000219 CDM 2705000219 LOCAL 270 RC inpatient 22 22 HEALTHPARTNERS SX009 HEALTHPARTNERS 17.42 percent of total billed charges 13.64 20.9 Technical (Hospital) Services HC/HH Wch Supp Washcloth Pre-Moistened__6599n PX-2705000219 CDM 2705000219 LOCAL 270 RC outpatient 22 22 MULTIPLAN INC 34080 [3081285] MULTIPLAN INC [308128501] 20.9 percent of total billed charges 13.64 20.9 Technical (Hospital) Services HC/HH Wch Supp Washcloth Pre-Moistened__6599n PX-2705000219 CDM 2705000219 LOCAL 270 RC outpatient 22 22 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES PPO [308136801] 17.6 percent of total billed charges 13.64 20.9 Technical (Hospital) Services HC/HH Wch Supp Washcloth Pre-Moistened__6599n PX-2705000219 CDM 2705000219 LOCAL 270 RC outpatient 22 22 MEDICA (COMMERCIAL) 94265 [3081118] MEDICA CLAIMS [308111801] 19.8 percent of total billed charges 13.64 20.9 Technical (Hospital) Services HC/HH Wch Supp Washcloth Pre-Moistened__6599n PX-2705000219 CDM 2705000219 LOCAL 270 RC outpatient 22 22 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES EPO [308136803] 17.6 percent of total billed charges 13.64 20.9 Technical (Hospital) Services HC/HH Wch Supp Washcloth Pre-Moistened__6599n PX-2705000219 CDM 2705000219 LOCAL 270 RC outpatient 22 22 BLUE CROSS BLUE SHIELD WELLMARK SB889 [3081026] BCBS WYOMING [308102603] 20.9 percent of total billed charges 13.64 20.9 Technical (Hospital) Services HC/HH Wch Supp Washcloth Pre-Moistened__6599n PX-2705000219 CDM 2705000219 LOCAL 270 RC outpatient 22 22 CIGNA 62308 [3081051] CIGNA 62308 [308105105] 17.6 percent of total billed charges 13.64 20.9 Technical (Hospital) Services HC/HH Wch Supp Washcloth Pre-Moistened__6599n PX-2705000219 CDM 2705000219 LOCAL 270 RC outpatient 22 22 CIGNA 62308 [3081051] CIGNA STATE OF WYOMING [308105107] 17.6 percent of total billed charges 13.64 20.9 Technical (Hospital) Services HC/HH Wch Supp Washcloth Pre-Moistened__6599n PX-2705000219 CDM 2705000219 LOCAL 270 RC outpatient 22 22 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES HDHP [308136802] 17.6 percent of total billed charges 13.64 20.9 Technical (Hospital) Services HC/HH Wch Supp Washcloth Pre-Moistened__6599n PX-2705000219 CDM 2705000219 LOCAL 270 RC outpatient 22 22 UNITED HEALTHCARE (COMMERCIAL) [3081199] UNITED HEALTHCARE 87726 [308119901] 13.64 percent of total billed charges 13.64 20.9 Technical (Hospital) Services HC/HH Wch Supp Washcloth Pre-Moistened__6599n PX-2705000219 CDM 2705000219 LOCAL 270 RC outpatient 22 22 HEALTHPARTNERS SX009 HEALTHPARTNERS 17.6 percent of total billed charges 13.64 20.9 Technical (Hospital) Services HC/HH Wch Supp Warmer Heel Infant 4x4__11460-010t PX-2705000218 CDM 2705000218 LOCAL 270 RC inpatient 6 6 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES EPO [308136803] 4.75 percent of total billed charges 3.72 5.7 Technical (Hospital) Services HC/HH Wch Supp Warmer Heel Infant 4x4__11460-010t PX-2705000218 CDM 2705000218 LOCAL 270 RC inpatient 6 6 CIGNA 62308 [3081051] CIGNA 62308 [308105105] 4.75 percent of total billed charges 3.72 5.7 Technical (Hospital) Services HC/HH Wch Supp Warmer Heel Infant 4x4__11460-010t PX-2705000218 CDM 2705000218 LOCAL 270 RC inpatient 6 6 CIGNA 62308 [3081051] CIGNA STATE OF WYOMING [308105107] 4.75 percent of total billed charges 3.72 5.7 Technical (Hospital) Services HC/HH Wch Supp Warmer Heel Infant 4x4__11460-010t PX-2705000218 CDM 2705000218 LOCAL 270 RC inpatient 6 6 MULTIPLAN INC 34080 [3081285] MULTIPLAN INC [308128501] 5.7 percent of total billed charges 3.72 5.7 Technical (Hospital) Services HC/HH Wch Supp Warmer Heel Infant 4x4__11460-010t PX-2705000218 CDM 2705000218 LOCAL 270 RC inpatient 6 6 BLUE CROSS BLUE SHIELD WELLMARK SB889 [3081026] BCBS WYOMING [308102603] 5.7 percent of total billed charges 3.72 5.7 Technical (Hospital) Services HC/HH Wch Supp Warmer Heel Infant 4x4__11460-010t PX-2705000218 CDM 2705000218 LOCAL 270 RC inpatient 6 6 HEALTHPARTNERS SX009 HEALTHPARTNERS 4.75 percent of total billed charges 3.72 5.7 Technical (Hospital) Services HC/HH Wch Supp Warmer Heel Infant 4x4__11460-010t PX-2705000218 CDM 2705000218 LOCAL 270 RC inpatient 6 6 UNITED HEALTHCARE (COMMERCIAL) [3081199] UNITED HEALTHCARE 87726 [308119901] 3.72 percent of total billed charges 3.72 5.7 Technical (Hospital) Services HC/HH Wch Supp Warmer Heel Infant 4x4__11460-010t PX-2705000218 CDM 2705000218 LOCAL 270 RC inpatient 6 6 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES HDHP [308136802] 4.75 percent of total billed charges 3.72 5.7 Technical (Hospital) Services HC/HH Wch Supp Warmer Heel Infant 4x4__11460-010t PX-2705000218 CDM 2705000218 LOCAL 270 RC inpatient 6 6 MEDICA (COMMERCIAL) 94265 [3081118] MEDICA CLAIMS [308111801] 5.4 percent of total billed charges 3.72 5.7 Technical (Hospital) Services HC/HH Wch Supp Warmer Heel Infant 4x4__11460-010t PX-2705000218 CDM 2705000218 LOCAL 270 RC inpatient 6 6 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES PPO [308136801] 4.75 percent of total billed charges 3.72 5.7 Technical (Hospital) Services HC/HH Wch Supp Warmer Heel Infant 4x4__11460-010t PX-2705000218 CDM 2705000218 LOCAL 270 RC outpatient 6 6 HEALTHPARTNERS SX009 HEALTHPARTNERS 4.8 percent of total billed charges 3.72 5.7 Technical (Hospital) Services HC/HH Wch Supp Warmer Heel Infant 4x4__11460-010t PX-2705000218 CDM 2705000218 LOCAL 270 RC outpatient 6 6 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES PPO [308136801] 4.8 percent of total billed charges 3.72 5.7 Technical (Hospital) Services HC/HH Wch Supp Warmer Heel Infant 4x4__11460-010t PX-2705000218 CDM 2705000218 LOCAL 270 RC outpatient 6 6 MULTIPLAN INC 34080 [3081285] MULTIPLAN INC [308128501] 5.7 percent of total billed charges 3.72 5.7 Technical (Hospital) Services HC/HH Wch Supp Warmer Heel Infant 4x4__11460-010t PX-2705000218 CDM 2705000218 LOCAL 270 RC outpatient 6 6 MEDICA (COMMERCIAL) 94265 [3081118] MEDICA CLAIMS [308111801] 5.4 percent of total billed charges 3.72 5.7 Technical (Hospital) Services HC/HH Wch Supp Warmer Heel Infant 4x4__11460-010t PX-2705000218 CDM 2705000218 LOCAL 270 RC outpatient 6 6 UNITED HEALTHCARE (COMMERCIAL) [3081199] UNITED HEALTHCARE 87726 [308119901] 3.72 percent of total billed charges 3.72 5.7 Technical (Hospital) Services HC/HH Wch Supp Warmer Heel Infant 4x4__11460-010t PX-2705000218 CDM 2705000218 LOCAL 270 RC outpatient 6 6 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES HDHP [308136802] 4.8 percent of total billed charges 3.72 5.7 Technical (Hospital) Services HC/HH Wch Supp Warmer Heel Infant 4x4__11460-010t PX-2705000218 CDM 2705000218 LOCAL 270 RC outpatient 6 6 CIGNA 62308 [3081051] CIGNA 62308 [308105105] 4.8 percent of total billed charges 3.72 5.7 Technical (Hospital) Services HC/HH Wch Supp Warmer Heel Infant 4x4__11460-010t PX-2705000218 CDM 2705000218 LOCAL 270 RC outpatient 6 6 CIGNA 62308 [3081051] CIGNA STATE OF WYOMING [308105107] 4.8 percent of total billed charges 3.72 5.7 Technical (Hospital) Services HC/HH Wch Supp Warmer Heel Infant 4x4__11460-010t PX-2705000218 CDM 2705000218 LOCAL 270 RC outpatient 6 6 BLUE CROSS BLUE SHIELD WELLMARK SB889 [3081026] BCBS WYOMING [308102603] 5.7 percent of total billed charges 3.72 5.7 Technical (Hospital) Services HC/HH Wch Supp Warmer Heel Infant 4x4__11460-010t PX-2705000218 CDM 2705000218 LOCAL 270 RC outpatient 6 6 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES EPO [308136803] 4.8 percent of total billed charges 3.72 5.7 Technical (Hospital) Services HC/HH Wch Supp Ventilation Circuit__L599-010 PX-2705000217 CDM 2705000217 LOCAL 270 RC outpatient 48 48 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES EPO [308136803] 38.4 percent of total billed charges 29.76 45.6 Technical (Hospital) Services HC/HH Wch Supp Ventilation Circuit__L599-010 PX-2705000217 CDM 2705000217 LOCAL 270 RC outpatient 48 48 CIGNA 62308 [3081051] CIGNA 62308 [308105105] 38.4 percent of total billed charges 29.76 45.6 Technical (Hospital) Services HC/HH Wch Supp Ventilation Circuit__L599-010 PX-2705000217 CDM 2705000217 LOCAL 270 RC outpatient 48 48 CIGNA 62308 [3081051] CIGNA STATE OF WYOMING [308105107] 38.4 percent of total billed charges 29.76 45.6 Technical (Hospital) Services HC/HH Wch Supp Ventilation Circuit__L599-010 PX-2705000217 CDM 2705000217 LOCAL 270 RC outpatient 48 48 BLUE CROSS BLUE SHIELD WELLMARK SB889 [3081026] BCBS WYOMING [308102603] 45.6 percent of total billed charges 29.76 45.6 Technical (Hospital) Services HC/HH Wch Supp Ventilation Circuit__L599-010 PX-2705000217 CDM 2705000217 LOCAL 270 RC outpatient 48 48 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES HDHP [308136802] 38.4 percent of total billed charges 29.76 45.6 Technical (Hospital) Services HC/HH Wch Supp Ventilation Circuit__L599-010 PX-2705000217 CDM 2705000217 LOCAL 270 RC outpatient 48 48 UNITED HEALTHCARE (COMMERCIAL) [3081199] UNITED HEALTHCARE 87726 [308119901] 29.76 percent of total billed charges 29.76 45.6 Technical (Hospital) Services HC/HH Wch Supp Ventilation Circuit__L599-010 PX-2705000217 CDM 2705000217 LOCAL 270 RC outpatient 48 48 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES PPO [308136801] 38.4 percent of total billed charges 29.76 45.6 Technical (Hospital) Services HC/HH Wch Supp Ventilation Circuit__L599-010 PX-2705000217 CDM 2705000217 LOCAL 270 RC outpatient 48 48 HEALTHPARTNERS SX009 HEALTHPARTNERS 38.4 percent of total billed charges 29.76 45.6 Technical (Hospital) Services HC/HH Wch Supp Ventilation Circuit__L599-010 PX-2705000217 CDM 2705000217 LOCAL 270 RC outpatient 48 48 MULTIPLAN INC 34080 [3081285] MULTIPLAN INC [308128501] 45.6 percent of total billed charges 29.76 45.6 Technical (Hospital) Services HC/HH Wch Supp Ventilation Circuit__L599-010 PX-2705000217 CDM 2705000217 LOCAL 270 RC outpatient 48 48 MEDICA (COMMERCIAL) 94265 [3081118] MEDICA CLAIMS [308111801] 43.2 percent of total billed charges 29.76 45.6 Technical (Hospital) Services HC/HH Wch Supp Ventilation Circuit__L599-010 PX-2705000217 CDM 2705000217 LOCAL 270 RC inpatient 48 48 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES EPO [308136803] 38.01 percent of total billed charges 29.76 45.6 Technical (Hospital) Services HC/HH Wch Supp Ventilation Circuit__L599-010 PX-2705000217 CDM 2705000217 LOCAL 270 RC inpatient 48 48 HEALTHPARTNERS SX009 HEALTHPARTNERS 38.01 percent of total billed charges 29.76 45.6 Technical (Hospital) Services HC/HH Wch Supp Ventilation Circuit__L599-010 PX-2705000217 CDM 2705000217 LOCAL 270 RC inpatient 48 48 MULTIPLAN INC 34080 [3081285] MULTIPLAN INC [308128501] 45.6 percent of total billed charges 29.76 45.6 Technical (Hospital) Services HC/HH Wch Supp Ventilation Circuit__L599-010 PX-2705000217 CDM 2705000217 LOCAL 270 RC inpatient 48 48 BLUE CROSS BLUE SHIELD WELLMARK SB889 [3081026] BCBS WYOMING [308102603] 45.6 percent of total billed charges 29.76 45.6 Technical (Hospital) Services HC/HH Wch Supp Ventilation Circuit__L599-010 PX-2705000217 CDM 2705000217 LOCAL 270 RC inpatient 48 48 CIGNA 62308 [3081051] CIGNA 62308 [308105105] 38.01 percent of total billed charges 29.76 45.6 Technical (Hospital) Services HC/HH Wch Supp Ventilation Circuit__L599-010 PX-2705000217 CDM 2705000217 LOCAL 270 RC inpatient 48 48 CIGNA 62308 [3081051] CIGNA STATE OF WYOMING [308105107] 38.01 percent of total billed charges 29.76 45.6 Technical (Hospital) Services HC/HH Wch Supp Ventilation Circuit__L599-010 PX-2705000217 CDM 2705000217 LOCAL 270 RC inpatient 48 48 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES PPO [308136801] 38.01 percent of total billed charges 29.76 45.6 Technical (Hospital) Services HC/HH Wch Supp Ventilation Circuit__L599-010 PX-2705000217 CDM 2705000217 LOCAL 270 RC inpatient 48 48 MEDICA (COMMERCIAL) 94265 [3081118] MEDICA CLAIMS [308111801] 43.2 percent of total billed charges 29.76 45.6 Technical (Hospital) Services HC/HH Wch Supp Ventilation Circuit__L599-010 PX-2705000217 CDM 2705000217 LOCAL 270 RC inpatient 48 48 UNITED HEALTHCARE (COMMERCIAL) [3081199] UNITED HEALTHCARE 87726 [308119901] 29.76 percent of total billed charges 29.76 45.6 Technical (Hospital) Services HC/HH Wch Supp Ventilation Circuit__L599-010 PX-2705000217 CDM 2705000217 LOCAL 270 RC inpatient 48 48 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES HDHP [308136802] 38.01 percent of total billed charges 29.76 45.6 Technical (Hospital) Services HC/HH Wch Supp Valve Clearlink Luer Activated__2n8399 PX-2705000216 CDM 2705000216 LOCAL 270 RC outpatient 8 8 HEALTHPARTNERS SX009 HEALTHPARTNERS 6.4 percent of total billed charges 4.96 7.6 Technical (Hospital) Services HC/HH Wch Supp Valve Clearlink Luer Activated__2n8399 PX-2705000216 CDM 2705000216 LOCAL 270 RC outpatient 8 8 UNITED HEALTHCARE (COMMERCIAL) [3081199] UNITED HEALTHCARE 87726 [308119901] 4.96 percent of total billed charges 4.96 7.6 Technical (Hospital) Services HC/HH Wch Supp Valve Clearlink Luer Activated__2n8399 PX-2705000216 CDM 2705000216 LOCAL 270 RC outpatient 8 8 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES HDHP [308136802] 6.4 percent of total billed charges 4.96 7.6 Technical (Hospital) Services HC/HH Wch Supp Valve Clearlink Luer Activated__2n8399 PX-2705000216 CDM 2705000216 LOCAL 270 RC outpatient 8 8 CIGNA 62308 [3081051] CIGNA 62308 [308105105] 6.4 percent of total billed charges 4.96 7.6 Technical (Hospital) Services HC/HH Wch Supp Valve Clearlink Luer Activated__2n8399 PX-2705000216 CDM 2705000216 LOCAL 270 RC outpatient 8 8 CIGNA 62308 [3081051] CIGNA STATE OF WYOMING [308105107] 6.4 percent of total billed charges 4.96 7.6 Technical (Hospital) Services HC/HH Wch Supp Valve Clearlink Luer Activated__2n8399 PX-2705000216 CDM 2705000216 LOCAL 270 RC outpatient 8 8 BLUE CROSS BLUE SHIELD WELLMARK SB889 [3081026] BCBS WYOMING [308102603] 7.6 percent of total billed charges 4.96 7.6 Technical (Hospital) Services HC/HH Wch Supp Valve Clearlink Luer Activated__2n8399 PX-2705000216 CDM 2705000216 LOCAL 270 RC outpatient 8 8 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES EPO [308136803] 6.4 percent of total billed charges 4.96 7.6 Technical (Hospital) Services HC/HH Wch Supp Valve Clearlink Luer Activated__2n8399 PX-2705000216 CDM 2705000216 LOCAL 270 RC outpatient 8 8 MEDICA (COMMERCIAL) 94265 [3081118] MEDICA CLAIMS [308111801] 7.2 percent of total billed charges 4.96 7.6 Technical (Hospital) Services HC/HH Wch Supp Valve Clearlink Luer Activated__2n8399 PX-2705000216 CDM 2705000216 LOCAL 270 RC outpatient 8 8 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES PPO [308136801] 6.4 percent of total billed charges 4.96 7.6 Technical (Hospital) Services HC/HH Wch Supp Valve Clearlink Luer Activated__2n8399 PX-2705000216 CDM 2705000216 LOCAL 270 RC outpatient 8 8 MULTIPLAN INC 34080 [3081285] MULTIPLAN INC [308128501] 7.6 percent of total billed charges 4.96 7.6 Technical (Hospital) Services HC/HH Wch Supp Valve Clearlink Luer Activated__2n8399 PX-2705000216 CDM 2705000216 LOCAL 270 RC inpatient 8 8 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES PPO [308136801] 6.33 percent of total billed charges 4.96 7.6 Technical (Hospital) Services HC/HH Wch Supp Valve Clearlink Luer Activated__2n8399 PX-2705000216 CDM 2705000216 LOCAL 270 RC inpatient 8 8 MEDICA (COMMERCIAL) 94265 [3081118] MEDICA CLAIMS [308111801] 7.2 percent of total billed charges 4.96 7.6 Technical (Hospital) Services HC/HH Wch Supp Valve Clearlink Luer Activated__2n8399 PX-2705000216 CDM 2705000216 LOCAL 270 RC inpatient 8 8 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES HDHP [308136802] 6.33 percent of total billed charges 4.96 7.6 Technical (Hospital) Services HC/HH Wch Supp Valve Clearlink Luer Activated__2n8399 PX-2705000216 CDM 2705000216 LOCAL 270 RC inpatient 8 8 UNITED HEALTHCARE (COMMERCIAL) [3081199] UNITED HEALTHCARE 87726 [308119901] 4.96 percent of total billed charges 4.96 7.6 Technical (Hospital) Services HC/HH Wch Supp Valve Clearlink Luer Activated__2n8399 PX-2705000216 CDM 2705000216 LOCAL 270 RC inpatient 8 8 HEALTHPARTNERS SX009 HEALTHPARTNERS 6.33 percent of total billed charges 4.96 7.6 Technical (Hospital) Services HC/HH Wch Supp Valve Clearlink Luer Activated__2n8399 PX-2705000216 CDM 2705000216 LOCAL 270 RC inpatient 8 8 BLUE CROSS BLUE SHIELD WELLMARK SB889 [3081026] BCBS WYOMING [308102603] 7.6 percent of total billed charges 4.96 7.6 Technical (Hospital) Services HC/HH Wch Supp Valve Clearlink Luer Activated__2n8399 PX-2705000216 CDM 2705000216 LOCAL 270 RC inpatient 8 8 MULTIPLAN INC 34080 [3081285] MULTIPLAN INC [308128501] 7.6 percent of total billed charges 4.96 7.6 Technical (Hospital) Services HC/HH Wch Supp Valve Clearlink Luer Activated__2n8399 PX-2705000216 CDM 2705000216 LOCAL 270 RC inpatient 8 8 CIGNA 62308 [3081051] CIGNA 62308 [308105105] 6.33 percent of total billed charges 4.96 7.6 Technical (Hospital) Services HC/HH Wch Supp Valve Clearlink Luer Activated__2n8399 PX-2705000216 CDM 2705000216 LOCAL 270 RC inpatient 8 8 CIGNA 62308 [3081051] CIGNA STATE OF WYOMING [308105107] 6.33 percent of total billed charges 4.96 7.6 Technical (Hospital) Services HC/HH Wch Supp Valve Clearlink Luer Activated__2n8399 PX-2705000216 CDM 2705000216 LOCAL 270 RC inpatient 8 8 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES EPO [308136803] 6.33 percent of total billed charges 4.96 7.6 Technical (Hospital) Services HC/HH Wch Supp Univ-Extri Collar Peds__0814-9427 PX-2705000215 CDM 2705000215 LOCAL 270 RC inpatient 11 11 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES PPO [308136801] 8.71 percent of total billed charges 6.82 10.45 Technical (Hospital) Services HC/HH Wch Supp Univ-Extri Collar Peds__0814-9427 PX-2705000215 CDM 2705000215 LOCAL 270 RC inpatient 11 11 MEDICA (COMMERCIAL) 94265 [3081118] MEDICA CLAIMS [308111801] 9.9 percent of total billed charges 6.82 10.45 Technical (Hospital) Services HC/HH Wch Supp Univ-Extri Collar Peds__0814-9427 PX-2705000215 CDM 2705000215 LOCAL 270 RC inpatient 11 11 UNITED HEALTHCARE (COMMERCIAL) [3081199] UNITED HEALTHCARE 87726 [308119901] 6.82 percent of total billed charges 6.82 10.45 Technical (Hospital) Services HC/HH Wch Supp Univ-Extri Collar Peds__0814-9427 PX-2705000215 CDM 2705000215 LOCAL 270 RC inpatient 11 11 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES HDHP [308136802] 8.71 percent of total billed charges 6.82 10.45 Technical (Hospital) Services HC/HH Wch Supp Univ-Extri Collar Peds__0814-9427 PX-2705000215 CDM 2705000215 LOCAL 270 RC inpatient 11 11 HEALTHPARTNERS SX009 HEALTHPARTNERS 8.71 percent of total billed charges 6.82 10.45 Technical (Hospital) Services HC/HH Wch Supp Univ-Extri Collar Peds__0814-9427 PX-2705000215 CDM 2705000215 LOCAL 270 RC inpatient 11 11 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES EPO [308136803] 8.71 percent of total billed charges 6.82 10.45 Technical (Hospital) Services HC/HH Wch Supp Univ-Extri Collar Peds__0814-9427 PX-2705000215 CDM 2705000215 LOCAL 270 RC inpatient 11 11 MULTIPLAN INC 34080 [3081285] MULTIPLAN INC [308128501] 10.45 percent of total billed charges 6.82 10.45 Technical (Hospital) Services HC/HH Wch Supp Univ-Extri Collar Peds__0814-9427 PX-2705000215 CDM 2705000215 LOCAL 270 RC inpatient 11 11 BLUE CROSS BLUE SHIELD WELLMARK SB889 [3081026] BCBS WYOMING [308102603] 10.45 percent of total billed charges 6.82 10.45 Technical (Hospital) Services HC/HH Wch Supp Univ-Extri Collar Peds__0814-9427 PX-2705000215 CDM 2705000215 LOCAL 270 RC inpatient 11 11 CIGNA 62308 [3081051] CIGNA 62308 [308105105] 8.71 percent of total billed charges 6.82 10.45 Technical (Hospital) Services HC/HH Wch Supp Univ-Extri Collar Peds__0814-9427 PX-2705000215 CDM 2705000215 LOCAL 270 RC inpatient 11 11 CIGNA 62308 [3081051] CIGNA STATE OF WYOMING [308105107] 8.71 percent of total billed charges 6.82 10.45 Technical (Hospital) Services HC/HH Wch Supp Univ-Extri Collar Peds__0814-9427 PX-2705000215 CDM 2705000215 LOCAL 270 RC outpatient 11 11 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES PPO [308136801] 8.8 percent of total billed charges 6.82 10.45 Technical (Hospital) Services HC/HH Wch Supp Univ-Extri Collar Peds__0814-9427 PX-2705000215 CDM 2705000215 LOCAL 270 RC outpatient 11 11 MEDICA (COMMERCIAL) 94265 [3081118] MEDICA CLAIMS [308111801] 9.9 percent of total billed charges 6.82 10.45 Technical (Hospital) Services HC/HH Wch Supp Univ-Extri Collar Peds__0814-9427 PX-2705000215 CDM 2705000215 LOCAL 270 RC outpatient 11 11 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES EPO [308136803] 8.8 percent of total billed charges 6.82 10.45 Technical (Hospital) Services HC/HH Wch Supp Univ-Extri Collar Peds__0814-9427 PX-2705000215 CDM 2705000215 LOCAL 270 RC outpatient 11 11 BLUE CROSS BLUE SHIELD WELLMARK SB889 [3081026] BCBS WYOMING [308102603] 10.45 percent of total billed charges 6.82 10.45 Technical (Hospital) Services HC/HH Wch Supp Univ-Extri Collar Peds__0814-9427 PX-2705000215 CDM 2705000215 LOCAL 270 RC outpatient 11 11 CIGNA 62308 [3081051] CIGNA 62308 [308105105] 8.8 percent of total billed charges 6.82 10.45 Technical (Hospital) Services HC/HH Wch Supp Univ-Extri Collar Peds__0814-9427 PX-2705000215 CDM 2705000215 LOCAL 270 RC outpatient 11 11 CIGNA 62308 [3081051] CIGNA STATE OF WYOMING [308105107] 8.8 percent of total billed charges 6.82 10.45 Technical (Hospital) Services HC/HH Wch Supp Univ-Extri Collar Peds__0814-9427 PX-2705000215 CDM 2705000215 LOCAL 270 RC outpatient 11 11 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES HDHP [308136802] 8.8 percent of total billed charges 6.82 10.45 Technical (Hospital) Services HC/HH Wch Supp Univ-Extri Collar Peds__0814-9427 PX-2705000215 CDM 2705000215 LOCAL 270 RC outpatient 11 11 UNITED HEALTHCARE (COMMERCIAL) [3081199] UNITED HEALTHCARE 87726 [308119901] 6.82 percent of total billed charges 6.82 10.45 Technical (Hospital) Services HC/HH Wch Supp Univ-Extri Collar Peds__0814-9427 PX-2705000215 CDM 2705000215 LOCAL 270 RC outpatient 11 11 HEALTHPARTNERS SX009 HEALTHPARTNERS 8.8 percent of total billed charges 6.82 10.45 Technical (Hospital) Services HC/HH Wch Supp Univ Extri Collar Ad__0814-9428 PX-2705000214 CDM 2705000214 LOCAL 270 RC outpatient 11 11 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES HDHP [308136802] 8.8 percent of total billed charges 6.82 10.45 Technical (Hospital) Services HC/HH Wch Supp Univ Extri Collar Ad__0814-9428 PX-2705000214 CDM 2705000214 LOCAL 270 RC outpatient 11 11 BLUE CROSS BLUE SHIELD WELLMARK SB889 [3081026] BCBS WYOMING [308102603] 10.45 percent of total billed charges 6.82 10.45 Technical (Hospital) Services HC/HH Wch Supp Univ Extri Collar Ad__0814-9428 PX-2705000214 CDM 2705000214 LOCAL 270 RC outpatient 11 11 CIGNA 62308 [3081051] CIGNA 62308 [308105105] 8.8 percent of total billed charges 6.82 10.45 Technical (Hospital) Services HC/HH Wch Supp Univ Extri Collar Ad__0814-9428 PX-2705000214 CDM 2705000214 LOCAL 270 RC outpatient 11 11 CIGNA 62308 [3081051] CIGNA STATE OF WYOMING [308105107] 8.8 percent of total billed charges 6.82 10.45 Technical (Hospital) Services HC/HH Wch Supp Univ Extri Collar Ad__0814-9428 PX-2705000214 CDM 2705000214 LOCAL 270 RC outpatient 11 11 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES EPO [308136803] 8.8 percent of total billed charges 6.82 10.45 Technical (Hospital) Services HC/HH Wch Supp Univ Extri Collar Ad__0814-9428 PX-2705000214 CDM 2705000214 LOCAL 270 RC outpatient 11 11 UNITED HEALTHCARE (COMMERCIAL) [3081199] UNITED HEALTHCARE 87726 [308119901] 6.82 percent of total billed charges 6.82 10.45 Technical (Hospital) Services HC/HH Wch Supp Univ Extri Collar Ad__0814-9428 PX-2705000214 CDM 2705000214 LOCAL 270 RC outpatient 11 11 HEALTHPARTNERS SX009 HEALTHPARTNERS 8.8 percent of total billed charges 6.82 10.45 Technical (Hospital) Services HC/HH Wch Supp Univ Extri Collar Ad__0814-9428 PX-2705000214 CDM 2705000214 LOCAL 270 RC outpatient 11 11 MULTIPLAN INC 34080 [3081285] MULTIPLAN INC [308128501] 10.45 percent of total billed charges 6.82 10.45 Technical (Hospital) Services HC/HH Wch Supp Univ Extri Collar Ad__0814-9428 PX-2705000214 CDM 2705000214 LOCAL 270 RC outpatient 11 11 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES PPO [308136801] 8.8 percent of total billed charges 6.82 10.45 Technical (Hospital) Services HC/HH Wch Supp Univ Extri Collar Ad__0814-9428 PX-2705000214 CDM 2705000214 LOCAL 270 RC outpatient 11 11 MEDICA (COMMERCIAL) 94265 [3081118] MEDICA CLAIMS [308111801] 9.9 percent of total billed charges 6.82 10.45 Technical (Hospital) Services HC/HH Wch Supp Univ Extri Collar Ad__0814-9428 PX-2705000214 CDM 2705000214 LOCAL 270 RC inpatient 11 11 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES EPO [308136803] 8.71 percent of total billed charges 6.82 10.45 Technical (Hospital) Services HC/HH Wch Supp Univ Extri Collar Ad__0814-9428 PX-2705000214 CDM 2705000214 LOCAL 270 RC inpatient 11 11 HEALTHPARTNERS SX009 HEALTHPARTNERS 8.71 percent of total billed charges 6.82 10.45 Technical (Hospital) Services HC/HH Wch Supp Univ Extri Collar Ad__0814-9428 PX-2705000214 CDM 2705000214 LOCAL 270 RC inpatient 11 11 BLUE CROSS BLUE SHIELD WELLMARK SB889 [3081026] BCBS WYOMING [308102603] 10.45 percent of total billed charges 6.82 10.45 Technical (Hospital) Services HC/HH Wch Supp Univ Extri Collar Ad__0814-9428 PX-2705000214 CDM 2705000214 LOCAL 270 RC inpatient 11 11 MULTIPLAN INC 34080 [3081285] MULTIPLAN INC [308128501] 10.45 percent of total billed charges 6.82 10.45 Technical (Hospital) Services HC/HH Wch Supp Univ Extri Collar Ad__0814-9428 PX-2705000214 CDM 2705000214 LOCAL 270 RC inpatient 11 11 CIGNA 62308 [3081051] CIGNA 62308 [308105105] 8.71 percent of total billed charges 6.82 10.45 Technical (Hospital) Services HC/HH Wch Supp Univ Extri Collar Ad__0814-9428 PX-2705000214 CDM 2705000214 LOCAL 270 RC inpatient 11 11 CIGNA 62308 [3081051] CIGNA STATE OF WYOMING [308105107] 8.71 percent of total billed charges 6.82 10.45 Technical (Hospital) Services HC/HH Wch Supp Univ Extri Collar Ad__0814-9428 PX-2705000214 CDM 2705000214 LOCAL 270 RC inpatient 11 11 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES PPO [308136801] 8.71 percent of total billed charges 6.82 10.45 Technical (Hospital) Services HC/HH Wch Supp Univ Extri Collar Ad__0814-9428 PX-2705000214 CDM 2705000214 LOCAL 270 RC inpatient 11 11 MEDICA (COMMERCIAL) 94265 [3081118] MEDICA CLAIMS [308111801] 9.9 percent of total billed charges 6.82 10.45 Technical (Hospital) Services HC/HH Wch Supp Univ Extri Collar Ad__0814-9428 PX-2705000214 CDM 2705000214 LOCAL 270 RC inpatient 11 11 UNITED HEALTHCARE (COMMERCIAL) [3081199] UNITED HEALTHCARE 87726 [308119901] 6.82 percent of total billed charges 6.82 10.45 Technical (Hospital) Services HC/HH Wch Supp Univ Extri Collar Ad__0814-9428 PX-2705000214 CDM 2705000214 LOCAL 270 RC inpatient 11 11 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES HDHP [308136802] 8.71 percent of total billed charges 6.82 10.45 Technical (Hospital) Services HC/HH Wch Supp Tubular Dressing Sz 4__Gl704 PX-2705000213 CDM 2705000213 LOCAL 270 RC inpatient 6 6 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES PPO [308136801] 4.75 percent of total billed charges 3.72 5.7 Technical (Hospital) Services HC/HH Wch Supp Tubular Dressing Sz 4__Gl704 PX-2705000213 CDM 2705000213 LOCAL 270 RC inpatient 6 6 MEDICA (COMMERCIAL) 94265 [3081118] MEDICA CLAIMS [308111801] 5.4 percent of total billed charges 3.72 5.7 Technical (Hospital) Services HC/HH Wch Supp Tubular Dressing Sz 4__Gl704 PX-2705000213 CDM 2705000213 LOCAL 270 RC inpatient 6 6 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES HDHP [308136802] 4.75 percent of total billed charges 3.72 5.7 Technical (Hospital) Services HC/HH Wch Supp Tubular Dressing Sz 4__Gl704 PX-2705000213 CDM 2705000213 LOCAL 270 RC inpatient 6 6 UNITED HEALTHCARE (COMMERCIAL) [3081199] UNITED HEALTHCARE 87726 [308119901] 3.72 percent of total billed charges 3.72 5.7 Technical (Hospital) Services HC/HH Wch Supp Tubular Dressing Sz 4__Gl704 PX-2705000213 CDM 2705000213 LOCAL 270 RC inpatient 6 6 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES EPO [308136803] 4.75 percent of total billed charges 3.72 5.7 Technical (Hospital) Services HC/HH Wch Supp Tubular Dressing Sz 4__Gl704 PX-2705000213 CDM 2705000213 LOCAL 270 RC inpatient 6 6 HEALTHPARTNERS SX009 HEALTHPARTNERS 4.75 percent of total billed charges 3.72 5.7 Technical (Hospital) Services HC/HH Wch Supp Tubular Dressing Sz 4__Gl704 PX-2705000213 CDM 2705000213 LOCAL 270 RC inpatient 6 6 BLUE CROSS BLUE SHIELD WELLMARK SB889 [3081026] BCBS WYOMING [308102603] 5.7 percent of total billed charges 3.72 5.7 Technical (Hospital) Services HC/HH Wch Supp Tubular Dressing Sz 4__Gl704 PX-2705000213 CDM 2705000213 LOCAL 270 RC inpatient 6 6 MULTIPLAN INC 34080 [3081285] MULTIPLAN INC [308128501] 5.7 percent of total billed charges 3.72 5.7 Technical (Hospital) Services HC/HH Wch Supp Tubular Dressing Sz 4__Gl704 PX-2705000213 CDM 2705000213 LOCAL 270 RC inpatient 6 6 CIGNA 62308 [3081051] CIGNA 62308 [308105105] 4.75 percent of total billed charges 3.72 5.7 Technical (Hospital) Services HC/HH Wch Supp Tubular Dressing Sz 4__Gl704 PX-2705000213 CDM 2705000213 LOCAL 270 RC inpatient 6 6 CIGNA 62308 [3081051] CIGNA STATE OF WYOMING [308105107] 4.75 percent of total billed charges 3.72 5.7 Technical (Hospital) Services HC/HH Wch Supp Tubular Dressing Sz 4__Gl704 PX-2705000213 CDM 2705000213 LOCAL 270 RC outpatient 6 6 HEALTHPARTNERS SX009 HEALTHPARTNERS 4.8 percent of total billed charges 3.72 5.7 Technical (Hospital) Services HC/HH Wch Supp Tubular Dressing Sz 4__Gl704 PX-2705000213 CDM 2705000213 LOCAL 270 RC outpatient 6 6 UNITED HEALTHCARE (COMMERCIAL) [3081199] UNITED HEALTHCARE 87726 [308119901] 3.72 percent of total billed charges 3.72 5.7 Technical (Hospital) Services HC/HH Wch Supp Tubular Dressing Sz 4__Gl704 PX-2705000213 CDM 2705000213 LOCAL 270 RC outpatient 6 6 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES HDHP [308136802] 4.8 percent of total billed charges 3.72 5.7 Technical (Hospital) Services HC/HH Wch Supp Tubular Dressing Sz 4__Gl704 PX-2705000213 CDM 2705000213 LOCAL 270 RC outpatient 6 6 CIGNA 62308 [3081051] CIGNA 62308 [308105105] 4.8 percent of total billed charges 3.72 5.7 Technical (Hospital) Services HC/HH Wch Supp Tubular Dressing Sz 4__Gl704 PX-2705000213 CDM 2705000213 LOCAL 270 RC outpatient 6 6 CIGNA 62308 [3081051] CIGNA STATE OF WYOMING [308105107] 4.8 percent of total billed charges 3.72 5.7 Technical (Hospital) Services HC/HH Wch Supp Tubular Dressing Sz 4__Gl704 PX-2705000213 CDM 2705000213 LOCAL 270 RC outpatient 6 6 BLUE CROSS BLUE SHIELD WELLMARK SB889 [3081026] BCBS WYOMING [308102603] 5.7 percent of total billed charges 3.72 5.7 Technical (Hospital) Services HC/HH Wch Supp Tubular Dressing Sz 4__Gl704 PX-2705000213 CDM 2705000213 LOCAL 270 RC outpatient 6 6 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES EPO [308136803] 4.8 percent of total billed charges 3.72 5.7 Technical (Hospital) Services HC/HH Wch Supp Tubular Dressing Sz 4__Gl704 PX-2705000213 CDM 2705000213 LOCAL 270 RC outpatient 6 6 MEDICA (COMMERCIAL) 94265 [3081118] MEDICA CLAIMS [308111801] 5.4 percent of total billed charges 3.72 5.7 Technical (Hospital) Services HC/HH Wch Supp Tubular Dressing Sz 4__Gl704 PX-2705000213 CDM 2705000213 LOCAL 270 RC outpatient 6 6 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES PPO [308136801] 4.8 percent of total billed charges 3.72 5.7 Technical (Hospital) Services HC/HH Wch Supp Tubular Dressing Sz 4__Gl704 PX-2705000213 CDM 2705000213 LOCAL 270 RC outpatient 6 6 MULTIPLAN INC 34080 [3081285] MULTIPLAN INC [308128501] 5.7 percent of total billed charges 3.72 5.7 Technical (Hospital) Services HC/HH Wch Supp Tubular Dressing Sz 3__Gl703 PX-2705000212 CDM 2705000212 LOCAL 270 RC inpatient 6 6 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES HDHP [308136802] 4.75 percent of total billed charges 3.72 5.7 Technical (Hospital) Services HC/HH Wch Supp Tubular Dressing Sz 3__Gl703 PX-2705000212 CDM 2705000212 LOCAL 270 RC inpatient 6 6 UNITED HEALTHCARE (COMMERCIAL) [3081199] UNITED HEALTHCARE 87726 [308119901] 3.72 percent of total billed charges 3.72 5.7 Technical (Hospital) Services HC/HH Wch Supp Tubular Dressing Sz 3__Gl703 PX-2705000212 CDM 2705000212 LOCAL 270 RC inpatient 6 6 MEDICA (COMMERCIAL) 94265 [3081118] MEDICA CLAIMS [308111801] 5.4 percent of total billed charges 3.72 5.7 Technical (Hospital) Services HC/HH Wch Supp Tubular Dressing Sz 3__Gl703 PX-2705000212 CDM 2705000212 LOCAL 270 RC inpatient 6 6 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES PPO [308136801] 4.75 percent of total billed charges 3.72 5.7 Technical (Hospital) Services HC/HH Wch Supp Tubular Dressing Sz 3__Gl703 PX-2705000212 CDM 2705000212 LOCAL 270 RC inpatient 6 6 CIGNA 62308 [3081051] CIGNA 62308 [308105105] 4.75 percent of total billed charges 3.72 5.7 Technical (Hospital) Services HC/HH Wch Supp Tubular Dressing Sz 3__Gl703 PX-2705000212 CDM 2705000212 LOCAL 270 RC inpatient 6 6 CIGNA 62308 [3081051] CIGNA STATE OF WYOMING [308105107] 4.75 percent of total billed charges 3.72 5.7 Technical (Hospital) Services HC/HH Wch Supp Tubular Dressing Sz 3__Gl703 PX-2705000212 CDM 2705000212 LOCAL 270 RC inpatient 6 6 MULTIPLAN INC 34080 [3081285] MULTIPLAN INC [308128501] 5.7 percent of total billed charges 3.72 5.7 Technical (Hospital) Services HC/HH Wch Supp Tubular Dressing Sz 3__Gl703 PX-2705000212 CDM 2705000212 LOCAL 270 RC inpatient 6 6 BLUE CROSS BLUE SHIELD WELLMARK SB889 [3081026] BCBS WYOMING [308102603] 5.7 percent of total billed charges 3.72 5.7 Technical (Hospital) Services HC/HH Wch Supp Tubular Dressing Sz 3__Gl703 PX-2705000212 CDM 2705000212 LOCAL 270 RC inpatient 6 6 HEALTHPARTNERS SX009 HEALTHPARTNERS 4.75 percent of total billed charges 3.72 5.7 Technical (Hospital) Services HC/HH Wch Supp Tubular Dressing Sz 3__Gl703 PX-2705000212 CDM 2705000212 LOCAL 270 RC inpatient 6 6 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES EPO [308136803] 4.75 percent of total billed charges 3.72 5.7 Technical (Hospital) Services HC/HH Wch Supp Tubular Dressing Sz 3__Gl703 PX-2705000212 CDM 2705000212 LOCAL 270 RC outpatient 6 6 CIGNA 62308 [3081051] CIGNA 62308 [308105105] 4.8 percent of total billed charges 3.72 5.7 Technical (Hospital) Services HC/HH Wch Supp Tubular Dressing Sz 3__Gl703 PX-2705000212 CDM 2705000212 LOCAL 270 RC outpatient 6 6 CIGNA 62308 [3081051] CIGNA STATE OF WYOMING [308105107] 4.8 percent of total billed charges 3.72 5.7 Technical (Hospital) Services HC/HH Wch Supp Tubular Dressing Sz 3__Gl703 PX-2705000212 CDM 2705000212 LOCAL 270 RC outpatient 6 6 BLUE CROSS BLUE SHIELD WELLMARK SB889 [3081026] BCBS WYOMING [308102603] 5.7 percent of total billed charges 3.72 5.7 Technical (Hospital) Services HC/HH Wch Supp Tubular Dressing Sz 3__Gl703 PX-2705000212 CDM 2705000212 LOCAL 270 RC outpatient 6 6 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES EPO [308136803] 4.8 percent of total billed charges 3.72 5.7 Technical (Hospital) Services HC/HH Wch Supp Tubular Dressing Sz 3__Gl703 PX-2705000212 CDM 2705000212 LOCAL 270 RC outpatient 6 6 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES HDHP [308136802] 4.8 percent of total billed charges 3.72 5.7 Technical (Hospital) Services HC/HH Wch Supp Tubular Dressing Sz 3__Gl703 PX-2705000212 CDM 2705000212 LOCAL 270 RC outpatient 6 6 UNITED HEALTHCARE (COMMERCIAL) [3081199] UNITED HEALTHCARE 87726 [308119901] 3.72 percent of total billed charges 3.72 5.7 Technical (Hospital) Services HC/HH Wch Supp Tubular Dressing Sz 3__Gl703 PX-2705000212 CDM 2705000212 LOCAL 270 RC outpatient 6 6 HEALTHPARTNERS SX009 HEALTHPARTNERS 4.8 percent of total billed charges 3.72 5.7 Technical (Hospital) Services HC/HH Wch Supp Tubular Dressing Sz 3__Gl703 PX-2705000212 CDM 2705000212 LOCAL 270 RC outpatient 6 6 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES PPO [308136801] 4.8 percent of total billed charges 3.72 5.7 Technical (Hospital) Services HC/HH Wch Supp Tubular Dressing Sz 3__Gl703 PX-2705000212 CDM 2705000212 LOCAL 270 RC outpatient 6 6 MULTIPLAN INC 34080 [3081285] MULTIPLAN INC [308128501] 5.7 percent of total billed charges 3.72 5.7 Technical (Hospital) Services HC/HH Wch Supp Tubular Dressing Sz 3__Gl703 PX-2705000212 CDM 2705000212 LOCAL 270 RC outpatient 6 6 MEDICA (COMMERCIAL) 94265 [3081118] MEDICA CLAIMS [308111801] 5.4 percent of total billed charges 3.72 5.7 Technical (Hospital) Services HC/HH Wch Supp Tubular Dressing Sz 1__Gl701 PX-2705000211 CDM 2705000211 LOCAL 270 RC inpatient 6 6 HEALTHPARTNERS SX009 HEALTHPARTNERS 4.75 percent of total billed charges 3.72 5.7 Technical (Hospital) Services HC/HH Wch Supp Tubular Dressing Sz 1__Gl701 PX-2705000211 CDM 2705000211 LOCAL 270 RC inpatient 6 6 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES EPO [308136803] 4.75 percent of total billed charges 3.72 5.7 Technical (Hospital) Services HC/HH Wch Supp Tubular Dressing Sz 1__Gl701 PX-2705000211 CDM 2705000211 LOCAL 270 RC inpatient 6 6 CIGNA 62308 [3081051] CIGNA 62308 [308105105] 4.75 percent of total billed charges 3.72 5.7 Technical (Hospital) Services HC/HH Wch Supp Tubular Dressing Sz 1__Gl701 PX-2705000211 CDM 2705000211 LOCAL 270 RC inpatient 6 6 CIGNA 62308 [3081051] CIGNA STATE OF WYOMING [308105107] 4.75 percent of total billed charges 3.72 5.7 Technical (Hospital) Services HC/HH Wch Supp Tubular Dressing Sz 1__Gl701 PX-2705000211 CDM 2705000211 LOCAL 270 RC inpatient 6 6 MULTIPLAN INC 34080 [3081285] MULTIPLAN INC [308128501] 5.7 percent of total billed charges 3.72 5.7 Technical (Hospital) Services HC/HH Wch Supp Tubular Dressing Sz 1__Gl701 PX-2705000211 CDM 2705000211 LOCAL 270 RC inpatient 6 6 BLUE CROSS BLUE SHIELD WELLMARK SB889 [3081026] BCBS WYOMING [308102603] 5.7 percent of total billed charges 3.72 5.7 Technical (Hospital) Services HC/HH Wch Supp Tubular Dressing Sz 1__Gl701 PX-2705000211 CDM 2705000211 LOCAL 270 RC inpatient 6 6 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES HDHP [308136802] 4.75 percent of total billed charges 3.72 5.7 Technical (Hospital) Services HC/HH Wch Supp Tubular Dressing Sz 1__Gl701 PX-2705000211 CDM 2705000211 LOCAL 270 RC inpatient 6 6 UNITED HEALTHCARE (COMMERCIAL) [3081199] UNITED HEALTHCARE 87726 [308119901] 3.72 percent of total billed charges 3.72 5.7 Technical (Hospital) Services HC/HH Wch Supp Tubular Dressing Sz 1__Gl701 PX-2705000211 CDM 2705000211 LOCAL 270 RC inpatient 6 6 MEDICA (COMMERCIAL) 94265 [3081118] MEDICA CLAIMS [308111801] 5.4 percent of total billed charges 3.72 5.7 Technical (Hospital) Services HC/HH Wch Supp Tubular Dressing Sz 1__Gl701 PX-2705000211 CDM 2705000211 LOCAL 270 RC inpatient 6 6 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES PPO [308136801] 4.75 percent of total billed charges 3.72 5.7 Technical (Hospital) Services HC/HH Wch Supp Tubular Dressing Sz 1__Gl701 PX-2705000211 CDM 2705000211 LOCAL 270 RC outpatient 6 6 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES PPO [308136801] 4.8 percent of total billed charges 3.72 5.7 Technical (Hospital) Services HC/HH Wch Supp Tubular Dressing Sz 1__Gl701 PX-2705000211 CDM 2705000211 LOCAL 270 RC outpatient 6 6 HEALTHPARTNERS SX009 HEALTHPARTNERS 4.8 percent of total billed charges 3.72 5.7 Technical (Hospital) Services HC/HH Wch Supp Tubular Dressing Sz 1__Gl701 PX-2705000211 CDM 2705000211 LOCAL 270 RC outpatient 6 6 UNITED HEALTHCARE (COMMERCIAL) [3081199] UNITED HEALTHCARE 87726 [308119901] 3.72 percent of total billed charges 3.72 5.7 Technical (Hospital) Services HC/HH Wch Supp Tubular Dressing Sz 1__Gl701 PX-2705000211 CDM 2705000211 LOCAL 270 RC outpatient 6 6 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES HDHP [308136802] 4.8 percent of total billed charges 3.72 5.7 Technical (Hospital) Services HC/HH Wch Supp Tubular Dressing Sz 1__Gl701 PX-2705000211 CDM 2705000211 LOCAL 270 RC outpatient 6 6 BLUE CROSS BLUE SHIELD WELLMARK SB889 [3081026] BCBS WYOMING [308102603] 5.7 percent of total billed charges 3.72 5.7 Technical (Hospital) Services HC/HH Wch Supp Tubular Dressing Sz 1__Gl701 PX-2705000211 CDM 2705000211 LOCAL 270 RC outpatient 6 6 CIGNA 62308 [3081051] CIGNA 62308 [308105105] 4.8 percent of total billed charges 3.72 5.7 Technical (Hospital) Services HC/HH Wch Supp Tubular Dressing Sz 1__Gl701 PX-2705000211 CDM 2705000211 LOCAL 270 RC outpatient 6 6 CIGNA 62308 [3081051] CIGNA STATE OF WYOMING [308105107] 4.8 percent of total billed charges 3.72 5.7 Technical (Hospital) Services HC/HH Wch Supp Tubular Dressing Sz 1__Gl701 PX-2705000211 CDM 2705000211 LOCAL 270 RC outpatient 6 6 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES EPO [308136803] 4.8 percent of total billed charges 3.72 5.7 Technical (Hospital) Services HC/HH Wch Supp Tubular Dressing Sz 1__Gl701 PX-2705000211 CDM 2705000211 LOCAL 270 RC outpatient 6 6 MEDICA (COMMERCIAL) 94265 [3081118] MEDICA CLAIMS [308111801] 5.4 percent of total billed charges 3.72 5.7 Technical (Hospital) Services HC/HH Wch Supp Tubular Dressing Sz 1__Gl701 PX-2705000211 CDM 2705000211 LOCAL 270 RC outpatient 6 6 MULTIPLAN INC 34080 [3081285] MULTIPLAN INC [308128501] 5.7 percent of total billed charges 3.72 5.7 Technical (Hospital) Services HC/HH Wch Supp Tubular Dressing Sz 10__Gl711 PX-2705000210 CDM 2705000210 LOCAL 270 RC outpatient 112 112 MEDICA (COMMERCIAL) 94265 [3081118] MEDICA CLAIMS [308111801] 100.8 percent of total billed charges 69.44 106.4 Technical (Hospital) Services HC/HH Wch Supp Tubular Dressing Sz 10__Gl711 PX-2705000210 CDM 2705000210 LOCAL 270 RC outpatient 112 112 MULTIPLAN INC 34080 [3081285] MULTIPLAN INC [308128501] 106.4 percent of total billed charges 69.44 106.4 Technical (Hospital) Services HC/HH Wch Supp Tubular Dressing Sz 10__Gl711 PX-2705000210 CDM 2705000210 LOCAL 270 RC outpatient 112 112 HEALTHPARTNERS SX009 HEALTHPARTNERS 89.6 percent of total billed charges 69.44 106.4 Technical (Hospital) Services HC/HH Wch Supp Tubular Dressing Sz 10__Gl711 PX-2705000210 CDM 2705000210 LOCAL 270 RC outpatient 112 112 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES PPO [308136801] 89.6 percent of total billed charges 69.44 106.4 Technical (Hospital) Services HC/HH Wch Supp Tubular Dressing Sz 10__Gl711 PX-2705000210 CDM 2705000210 LOCAL 270 RC outpatient 112 112 UNITED HEALTHCARE (COMMERCIAL) [3081199] UNITED HEALTHCARE 87726 [308119901] 69.44 percent of total billed charges 69.44 106.4 Technical (Hospital) Services HC/HH Wch Supp Tubular Dressing Sz 10__Gl711 PX-2705000210 CDM 2705000210 LOCAL 270 RC outpatient 112 112 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES HDHP [308136802] 89.6 percent of total billed charges 69.44 106.4 Technical (Hospital) Services HC/HH Wch Supp Tubular Dressing Sz 10__Gl711 PX-2705000210 CDM 2705000210 LOCAL 270 RC outpatient 112 112 BLUE CROSS BLUE SHIELD WELLMARK SB889 [3081026] BCBS WYOMING [308102603] 106.4 percent of total billed charges 69.44 106.4 Technical (Hospital) Services HC/HH Wch Supp Tubular Dressing Sz 10__Gl711 PX-2705000210 CDM 2705000210 LOCAL 270 RC outpatient 112 112 CIGNA 62308 [3081051] CIGNA 62308 [308105105] 89.6 percent of total billed charges 69.44 106.4 Technical (Hospital) Services HC/HH Wch Supp Tubular Dressing Sz 10__Gl711 PX-2705000210 CDM 2705000210 LOCAL 270 RC outpatient 112 112 CIGNA 62308 [3081051] CIGNA STATE OF WYOMING [308105107] 89.6 percent of total billed charges 69.44 106.4 Technical (Hospital) Services HC/HH Wch Supp Tubular Dressing Sz 10__Gl711 PX-2705000210 CDM 2705000210 LOCAL 270 RC outpatient 112 112 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES EPO [308136803] 89.6 percent of total billed charges 69.44 106.4 Technical (Hospital) Services HC/HH Wch Supp Tubular Dressing Sz 10__Gl711 PX-2705000210 CDM 2705000210 LOCAL 270 RC inpatient 112 112 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES EPO [308136803] 88.68 percent of total billed charges 69.44 106.4 Technical (Hospital) Services HC/HH Wch Supp Tubular Dressing Sz 10__Gl711 PX-2705000210 CDM 2705000210 LOCAL 270 RC inpatient 112 112 HEALTHPARTNERS SX009 HEALTHPARTNERS 88.68 percent of total billed charges 69.44 106.4 Technical (Hospital) Services HC/HH Wch Supp Tubular Dressing Sz 10__Gl711 PX-2705000210 CDM 2705000210 LOCAL 270 RC inpatient 112 112 BLUE CROSS BLUE SHIELD WELLMARK SB889 [3081026] BCBS WYOMING [308102603] 106.4 percent of total billed charges 69.44 106.4 Technical (Hospital) Services HC/HH Wch Supp Tubular Dressing Sz 10__Gl711 PX-2705000210 CDM 2705000210 LOCAL 270 RC inpatient 112 112 MULTIPLAN INC 34080 [3081285] MULTIPLAN INC [308128501] 106.4 percent of total billed charges 69.44 106.4 Technical (Hospital) Services HC/HH Wch Supp Tubular Dressing Sz 10__Gl711 PX-2705000210 CDM 2705000210 LOCAL 270 RC inpatient 112 112 CIGNA 62308 [3081051] CIGNA 62308 [308105105] 88.68 percent of total billed charges 69.44 106.4 Technical (Hospital) Services HC/HH Wch Supp Tubular Dressing Sz 10__Gl711 PX-2705000210 CDM 2705000210 LOCAL 270 RC inpatient 112 112 CIGNA 62308 [3081051] CIGNA STATE OF WYOMING [308105107] 88.68 percent of total billed charges 69.44 106.4 Technical (Hospital) Services HC/HH Wch Supp Tubular Dressing Sz 10__Gl711 PX-2705000210 CDM 2705000210 LOCAL 270 RC inpatient 112 112 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES PPO [308136801] 88.68 percent of total billed charges 69.44 106.4 Technical (Hospital) Services HC/HH Wch Supp Tubular Dressing Sz 10__Gl711 PX-2705000210 CDM 2705000210 LOCAL 270 RC inpatient 112 112 MEDICA (COMMERCIAL) 94265 [3081118] MEDICA CLAIMS [308111801] 100.8 percent of total billed charges 69.44 106.4 Technical (Hospital) Services HC/HH Wch Supp Tubular Dressing Sz 10__Gl711 PX-2705000210 CDM 2705000210 LOCAL 270 RC inpatient 112 112 UNITED HEALTHCARE (COMMERCIAL) [3081199] UNITED HEALTHCARE 87726 [308119901] 69.44 percent of total billed charges 69.44 106.4 Technical (Hospital) Services HC/HH Wch Supp Tubular Dressing Sz 10__Gl711 PX-2705000210 CDM 2705000210 LOCAL 270 RC inpatient 112 112 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES HDHP [308136802] 88.68 percent of total billed charges 69.44 106.4 Technical (Hospital) Services HC/HH Wch Supp Tubular Bandage Sz 2__C15510220 PX-2705000209 CDM 2705000209 LOCAL 270 RC outpatient 6 6 MEDICA (COMMERCIAL) 94265 [3081118] MEDICA CLAIMS [308111801] 5.4 percent of total billed charges 3.72 5.7 Technical (Hospital) Services HC/HH Wch Supp Tubular Bandage Sz 2__C15510220 PX-2705000209 CDM 2705000209 LOCAL 270 RC outpatient 6 6 MULTIPLAN INC 34080 [3081285] MULTIPLAN INC [308128501] 5.7 percent of total billed charges 3.72 5.7 Technical (Hospital) Services HC/HH Wch Supp Tubular Bandage Sz 2__C15510220 PX-2705000209 CDM 2705000209 LOCAL 270 RC outpatient 6 6 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES HDHP [308136802] 4.8 percent of total billed charges 3.72 5.7 Technical (Hospital) Services HC/HH Wch Supp Tubular Bandage Sz 2__C15510220 PX-2705000209 CDM 2705000209 LOCAL 270 RC outpatient 6 6 BLUE CROSS BLUE SHIELD WELLMARK SB889 [3081026] BCBS WYOMING [308102603] 5.7 percent of total billed charges 3.72 5.7 Technical (Hospital) Services HC/HH Wch Supp Tubular Bandage Sz 2__C15510220 PX-2705000209 CDM 2705000209 LOCAL 270 RC outpatient 6 6 CIGNA 62308 [3081051] CIGNA 62308 [308105105] 4.8 percent of total billed charges 3.72 5.7 Technical (Hospital) Services HC/HH Wch Supp Tubular Bandage Sz 2__C15510220 PX-2705000209 CDM 2705000209 LOCAL 270 RC outpatient 6 6 CIGNA 62308 [3081051] CIGNA STATE OF WYOMING [308105107] 4.8 percent of total billed charges 3.72 5.7 Technical (Hospital) Services HC/HH Wch Supp Tubular Bandage Sz 2__C15510220 PX-2705000209 CDM 2705000209 LOCAL 270 RC outpatient 6 6 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES EPO [308136803] 4.8 percent of total billed charges 3.72 5.7 Technical (Hospital) Services HC/HH Wch Supp Tubular Bandage Sz 2__C15510220 PX-2705000209 CDM 2705000209 LOCAL 270 RC outpatient 6 6 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES PPO [308136801] 4.8 percent of total billed charges 3.72 5.7 Technical (Hospital) Services HC/HH Wch Supp Tubular Bandage Sz 2__C15510220 PX-2705000209 CDM 2705000209 LOCAL 270 RC outpatient 6 6 HEALTHPARTNERS SX009 HEALTHPARTNERS 4.8 percent of total billed charges 3.72 5.7 Technical (Hospital) Services HC/HH Wch Supp Tubular Bandage Sz 2__C15510220 PX-2705000209 CDM 2705000209 LOCAL 270 RC outpatient 6 6 UNITED HEALTHCARE (COMMERCIAL) [3081199] UNITED HEALTHCARE 87726 [308119901] 3.72 percent of total billed charges 3.72 5.7 Technical (Hospital) Services HC/HH Wch Supp Tubular Bandage Sz 2__C15510220 PX-2705000209 CDM 2705000209 LOCAL 270 RC inpatient 6 6 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES EPO [308136803] 4.75 percent of total billed charges 3.72 5.7 Technical (Hospital) Services HC/HH Wch Supp Tubular Bandage Sz 2__C15510220 PX-2705000209 CDM 2705000209 LOCAL 270 RC inpatient 6 6 HEALTHPARTNERS SX009 HEALTHPARTNERS 4.75 percent of total billed charges 3.72 5.7 Technical (Hospital) Services HC/HH Wch Supp Tubular Bandage Sz 2__C15510220 PX-2705000209 CDM 2705000209 LOCAL 270 RC inpatient 6 6 BLUE CROSS BLUE SHIELD WELLMARK SB889 [3081026] BCBS WYOMING [308102603] 5.7 percent of total billed charges 3.72 5.7 Technical (Hospital) Services HC/HH Wch Supp Tubular Bandage Sz 2__C15510220 PX-2705000209 CDM 2705000209 LOCAL 270 RC inpatient 6 6 MULTIPLAN INC 34080 [3081285] MULTIPLAN INC [308128501] 5.7 percent of total billed charges 3.72 5.7 Technical (Hospital) Services HC/HH Wch Supp Tubular Bandage Sz 2__C15510220 PX-2705000209 CDM 2705000209 LOCAL 270 RC inpatient 6 6 CIGNA 62308 [3081051] CIGNA 62308 [308105105] 4.75 percent of total billed charges 3.72 5.7 Technical (Hospital) Services HC/HH Wch Supp Tubular Bandage Sz 2__C15510220 PX-2705000209 CDM 2705000209 LOCAL 270 RC inpatient 6 6 CIGNA 62308 [3081051] CIGNA STATE OF WYOMING [308105107] 4.75 percent of total billed charges 3.72 5.7 Technical (Hospital) Services HC/HH Wch Supp Tubular Bandage Sz 2__C15510220 PX-2705000209 CDM 2705000209 LOCAL 270 RC inpatient 6 6 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES PPO [308136801] 4.75 percent of total billed charges 3.72 5.7 Technical (Hospital) Services HC/HH Wch Supp Tubular Bandage Sz 2__C15510220 PX-2705000209 CDM 2705000209 LOCAL 270 RC inpatient 6 6 MEDICA (COMMERCIAL) 94265 [3081118] MEDICA CLAIMS [308111801] 5.4 percent of total billed charges 3.72 5.7 Technical (Hospital) Services HC/HH Wch Supp Tubular Bandage Sz 2__C15510220 PX-2705000209 CDM 2705000209 LOCAL 270 RC inpatient 6 6 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES HDHP [308136802] 4.75 percent of total billed charges 3.72 5.7 Technical (Hospital) Services HC/HH Wch Supp Tubular Bandage Sz 2__C15510220 PX-2705000209 CDM 2705000209 LOCAL 270 RC inpatient 6 6 UNITED HEALTHCARE (COMMERCIAL) [3081199] UNITED HEALTHCARE 87726 [308119901] 3.72 percent of total billed charges 3.72 5.7 Technical (Hospital) Services HC/HH Wch Supp Tubular Bandage Size__Mttg319 PX-2705000208 CDM 2705000208 LOCAL 270 RC outpatient 6 6 UNITED HEALTHCARE (COMMERCIAL) [3081199] UNITED HEALTHCARE 87726 [308119901] 3.72 percent of total billed charges 3.72 5.7 Technical (Hospital) Services HC/HH Wch Supp Tubular Bandage Size__Mttg319 PX-2705000208 CDM 2705000208 LOCAL 270 RC outpatient 6 6 HEALTHPARTNERS SX009 HEALTHPARTNERS 4.8 percent of total billed charges 3.72 5.7 Technical (Hospital) Services HC/HH Wch Supp Tubular Bandage Size__Mttg319 PX-2705000208 CDM 2705000208 LOCAL 270 RC outpatient 6 6 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES PPO [308136801] 4.8 percent of total billed charges 3.72 5.7 Technical (Hospital) Services HC/HH Wch Supp Tubular Bandage Size__Mttg319 PX-2705000208 CDM 2705000208 LOCAL 270 RC outpatient 6 6 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES EPO [308136803] 4.8 percent of total billed charges 3.72 5.7 Technical (Hospital) Services HC/HH Wch Supp Tubular Bandage Size__Mttg319 PX-2705000208 CDM 2705000208 LOCAL 270 RC outpatient 6 6 CIGNA 62308 [3081051] CIGNA 62308 [308105105] 4.8 percent of total billed charges 3.72 5.7 Technical (Hospital) Services HC/HH Wch Supp Tubular Bandage Size__Mttg319 PX-2705000208 CDM 2705000208 LOCAL 270 RC outpatient 6 6 CIGNA 62308 [3081051] CIGNA STATE OF WYOMING [308105107] 4.8 percent of total billed charges 3.72 5.7 Technical (Hospital) Services HC/HH Wch Supp Tubular Bandage Size__Mttg319 PX-2705000208 CDM 2705000208 LOCAL 270 RC outpatient 6 6 BLUE CROSS BLUE SHIELD WELLMARK SB889 [3081026] BCBS WYOMING [308102603] 5.7 percent of total billed charges 3.72 5.7 Technical (Hospital) Services HC/HH Wch Supp Tubular Bandage Size__Mttg319 PX-2705000208 CDM 2705000208 LOCAL 270 RC outpatient 6 6 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES HDHP [308136802] 4.8 percent of total billed charges 3.72 5.7 Technical (Hospital) Services HC/HH Wch Supp Tubular Bandage Size__Mttg319 PX-2705000208 CDM 2705000208 LOCAL 270 RC outpatient 6 6 MULTIPLAN INC 34080 [3081285] MULTIPLAN INC [308128501] 5.7 percent of total billed charges 3.72 5.7 Technical (Hospital) Services HC/HH Wch Supp Tubular Bandage Size__Mttg319 PX-2705000208 CDM 2705000208 LOCAL 270 RC outpatient 6 6 MEDICA (COMMERCIAL) 94265 [3081118] MEDICA CLAIMS [308111801] 5.4 percent of total billed charges 3.72 5.7 Technical (Hospital) Services HC/HH Wch Supp Tubular Bandage Size__Mttg319 PX-2705000208 CDM 2705000208 LOCAL 270 RC inpatient 6 6 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES PPO [308136801] 4.75 percent of total billed charges 3.72 5.7 Technical (Hospital) Services HC/HH Wch Supp Tubular Bandage Size__Mttg319 PX-2705000208 CDM 2705000208 LOCAL 270 RC inpatient 6 6 UNITED HEALTHCARE (COMMERCIAL) [3081199] UNITED HEALTHCARE 87726 [308119901] 3.72 percent of total billed charges 3.72 5.7 Technical (Hospital) Services HC/HH Wch Supp Tubular Bandage Size__Mttg319 PX-2705000208 CDM 2705000208 LOCAL 270 RC inpatient 6 6 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES HDHP [308136802] 4.75 percent of total billed charges 3.72 5.7 Technical (Hospital) Services HC/HH Wch Supp Tubular Bandage Size__Mttg319 PX-2705000208 CDM 2705000208 LOCAL 270 RC inpatient 6 6 MEDICA (COMMERCIAL) 94265 [3081118] MEDICA CLAIMS [308111801] 5.4 percent of total billed charges 3.72 5.7 Technical (Hospital) Services HC/HH Wch Supp Tubular Bandage Size__Mttg319 PX-2705000208 CDM 2705000208 LOCAL 270 RC inpatient 6 6 MULTIPLAN INC 34080 [3081285] MULTIPLAN INC [308128501] 5.7 percent of total billed charges 3.72 5.7 Technical (Hospital) Services HC/HH Wch Supp Tubular Bandage Size__Mttg319 PX-2705000208 CDM 2705000208 LOCAL 270 RC inpatient 6 6 BLUE CROSS BLUE SHIELD WELLMARK SB889 [3081026] BCBS WYOMING [308102603] 5.7 percent of total billed charges 3.72 5.7 Technical (Hospital) Services HC/HH Wch Supp Tubular Bandage Size__Mttg319 PX-2705000208 CDM 2705000208 LOCAL 270 RC inpatient 6 6 HEALTHPARTNERS SX009 HEALTHPARTNERS 4.75 percent of total billed charges 3.72 5.7 Technical (Hospital) Services HC/HH Wch Supp Tubular Bandage Size__Mttg319 PX-2705000208 CDM 2705000208 LOCAL 270 RC inpatient 6 6 CIGNA 62308 [3081051] CIGNA 62308 [308105105] 4.75 percent of total billed charges 3.72 5.7 Technical (Hospital) Services HC/HH Wch Supp Tubular Bandage Size__Mttg319 PX-2705000208 CDM 2705000208 LOCAL 270 RC inpatient 6 6 CIGNA 62308 [3081051] CIGNA STATE OF WYOMING [308105107] 4.75 percent of total billed charges 3.72 5.7 Technical (Hospital) Services HC/HH Wch Supp Tubular Bandage Size__Mttg319 PX-2705000208 CDM 2705000208 LOCAL 270 RC inpatient 6 6 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES EPO [308136803] 4.75 percent of total billed charges 3.72 5.7 Technical (Hospital) Services HC/HH Wch Supp Tubing Bair Hugger Fluid__24110 PX-2705000207 CDM 2705000207 LOCAL 270 RC inpatient 33 33 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES PPO [308136801] 26.13 percent of total billed charges 20.46 31.35 Technical (Hospital) Services HC/HH Wch Supp Tubing Bair Hugger Fluid__24110 PX-2705000207 CDM 2705000207 LOCAL 270 RC inpatient 33 33 MEDICA (COMMERCIAL) 94265 [3081118] MEDICA CLAIMS [308111801] 29.7 percent of total billed charges 20.46 31.35 Technical (Hospital) Services HC/HH Wch Supp Tubing Bair Hugger Fluid__24110 PX-2705000207 CDM 2705000207 LOCAL 270 RC inpatient 33 33 UNITED HEALTHCARE (COMMERCIAL) [3081199] UNITED HEALTHCARE 87726 [308119901] 20.46 percent of total billed charges 20.46 31.35 Technical (Hospital) Services HC/HH Wch Supp Tubing Bair Hugger Fluid__24110 PX-2705000207 CDM 2705000207 LOCAL 270 RC inpatient 33 33 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES HDHP [308136802] 26.13 percent of total billed charges 20.46 31.35 Technical (Hospital) Services HC/HH Wch Supp Tubing Bair Hugger Fluid__24110 PX-2705000207 CDM 2705000207 LOCAL 270 RC inpatient 33 33 BLUE CROSS BLUE SHIELD WELLMARK SB889 [3081026] BCBS WYOMING [308102603] 31.35 percent of total billed charges 20.46 31.35 Technical (Hospital) Services HC/HH Wch Supp Tubing Bair Hugger Fluid__24110 PX-2705000207 CDM 2705000207 LOCAL 270 RC inpatient 33 33 MULTIPLAN INC 34080 [3081285] MULTIPLAN INC [308128501] 31.35 percent of total billed charges 20.46 31.35 Technical (Hospital) Services HC/HH Wch Supp Tubing Bair Hugger Fluid__24110 PX-2705000207 CDM 2705000207 LOCAL 270 RC inpatient 33 33 CIGNA 62308 [3081051] CIGNA 62308 [308105105] 26.13 percent of total billed charges 20.46 31.35 Technical (Hospital) Services HC/HH Wch Supp Tubing Bair Hugger Fluid__24110 PX-2705000207 CDM 2705000207 LOCAL 270 RC inpatient 33 33 CIGNA 62308 [3081051] CIGNA STATE OF WYOMING [308105107] 26.13 percent of total billed charges 20.46 31.35 Technical (Hospital) Services HC/HH Wch Supp Tubing Bair Hugger Fluid__24110 PX-2705000207 CDM 2705000207 LOCAL 270 RC inpatient 33 33 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES EPO [308136803] 26.13 percent of total billed charges 20.46 31.35 Technical (Hospital) Services HC/HH Wch Supp Tubing Bair Hugger Fluid__24110 PX-2705000207 CDM 2705000207 LOCAL 270 RC inpatient 33 33 HEALTHPARTNERS SX009 HEALTHPARTNERS 26.13 percent of total billed charges 20.46 31.35 Technical (Hospital) Services HC/HH Wch Supp Tubing Bair Hugger Fluid__24110 PX-2705000207 CDM 2705000207 LOCAL 270 RC outpatient 33 33 MULTIPLAN INC 34080 [3081285] MULTIPLAN INC [308128501] 31.35 percent of total billed charges 20.46 31.35 Technical (Hospital) Services HC/HH Wch Supp Tubing Bair Hugger Fluid__24110 PX-2705000207 CDM 2705000207 LOCAL 270 RC outpatient 33 33 MEDICA (COMMERCIAL) 94265 [3081118] MEDICA CLAIMS [308111801] 29.7 percent of total billed charges 20.46 31.35 Technical (Hospital) Services HC/HH Wch Supp Tubing Bair Hugger Fluid__24110 PX-2705000207 CDM 2705000207 LOCAL 270 RC outpatient 33 33 HEALTHPARTNERS SX009 HEALTHPARTNERS 26.4 percent of total billed charges 20.46 31.35 Technical (Hospital) Services HC/HH Wch Supp Tubing Bair Hugger Fluid__24110 PX-2705000207 CDM 2705000207 LOCAL 270 RC outpatient 33 33 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES PPO [308136801] 26.4 percent of total billed charges 20.46 31.35 Technical (Hospital) Services HC/HH Wch Supp Tubing Bair Hugger Fluid__24110 PX-2705000207 CDM 2705000207 LOCAL 270 RC outpatient 33 33 UNITED HEALTHCARE (COMMERCIAL) [3081199] UNITED HEALTHCARE 87726 [308119901] 20.46 percent of total billed charges 20.46 31.35 Technical (Hospital) Services HC/HH Wch Supp Tubing Bair Hugger Fluid__24110 PX-2705000207 CDM 2705000207 LOCAL 270 RC outpatient 33 33 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES HDHP [308136802] 26.4 percent of total billed charges 20.46 31.35 Technical (Hospital) Services HC/HH Wch Supp Tubing Bair Hugger Fluid__24110 PX-2705000207 CDM 2705000207 LOCAL 270 RC outpatient 33 33 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES EPO [308136803] 26.4 percent of total billed charges 20.46 31.35 Technical (Hospital) Services HC/HH Wch Supp Tubing Bair Hugger Fluid__24110 PX-2705000207 CDM 2705000207 LOCAL 270 RC outpatient 33 33 BLUE CROSS BLUE SHIELD WELLMARK SB889 [3081026] BCBS WYOMING [308102603] 31.35 percent of total billed charges 20.46 31.35 Technical (Hospital) Services HC/HH Wch Supp Tubing Bair Hugger Fluid__24110 PX-2705000207 CDM 2705000207 LOCAL 270 RC outpatient 33 33 CIGNA 62308 [3081051] CIGNA 62308 [308105105] 26.4 percent of total billed charges 20.46 31.35 Technical (Hospital) Services HC/HH Wch Supp Tubing Bair Hugger Fluid__24110 PX-2705000207 CDM 2705000207 LOCAL 270 RC outpatient 33 33 CIGNA 62308 [3081051] CIGNA STATE OF WYOMING [308105107] 26.4 percent of total billed charges 20.46 31.35 Technical (Hospital) Services HC/HH Wch Supp Tubigrip Bandage Sz E__1434 PX-2705000206 CDM 2705000206 LOCAL 270 RC outpatient 108 108 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES HDHP [308136802] 86.4 percent of total billed charges 66.96 102.6 Technical (Hospital) Services HC/HH Wch Supp Tubigrip Bandage Sz E__1434 PX-2705000206 CDM 2705000206 LOCAL 270 RC outpatient 108 108 CIGNA 62308 [3081051] CIGNA 62308 [308105105] 86.4 percent of total billed charges 66.96 102.6 Technical (Hospital) Services HC/HH Wch Supp Tubigrip Bandage Sz E__1434 PX-2705000206 CDM 2705000206 LOCAL 270 RC outpatient 108 108 CIGNA 62308 [3081051] CIGNA STATE OF WYOMING [308105107] 86.4 percent of total billed charges 66.96 102.6 Technical (Hospital) Services HC/HH Wch Supp Tubigrip Bandage Sz E__1434 PX-2705000206 CDM 2705000206 LOCAL 270 RC outpatient 108 108 BLUE CROSS BLUE SHIELD WELLMARK SB889 [3081026] BCBS WYOMING [308102603] 102.6 percent of total billed charges 66.96 102.6 Technical (Hospital) Services HC/HH Wch Supp Tubigrip Bandage Sz E__1434 PX-2705000206 CDM 2705000206 LOCAL 270 RC outpatient 108 108 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES EPO [308136803] 86.4 percent of total billed charges 66.96 102.6 Technical (Hospital) Services HC/HH Wch Supp Tubigrip Bandage Sz E__1434 PX-2705000206 CDM 2705000206 LOCAL 270 RC outpatient 108 108 UNITED HEALTHCARE (COMMERCIAL) [3081199] UNITED HEALTHCARE 87726 [308119901] 66.96 percent of total billed charges 66.96 102.6 Technical (Hospital) Services HC/HH Wch Supp Tubigrip Bandage Sz E__1434 PX-2705000206 CDM 2705000206 LOCAL 270 RC outpatient 108 108 HEALTHPARTNERS SX009 HEALTHPARTNERS 86.4 percent of total billed charges 66.96 102.6 Technical (Hospital) Services HC/HH Wch Supp Tubigrip Bandage Sz E__1434 PX-2705000206 CDM 2705000206 LOCAL 270 RC outpatient 108 108 MEDICA (COMMERCIAL) 94265 [3081118] MEDICA CLAIMS [308111801] 97.2 percent of total billed charges 66.96 102.6 Technical (Hospital) Services HC/HH Wch Supp Tubigrip Bandage Sz E__1434 PX-2705000206 CDM 2705000206 LOCAL 270 RC outpatient 108 108 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES PPO [308136801] 86.4 percent of total billed charges 66.96 102.6 Technical (Hospital) Services HC/HH Wch Supp Tubigrip Bandage Sz E__1434 PX-2705000206 CDM 2705000206 LOCAL 270 RC outpatient 108 108 MULTIPLAN INC 34080 [3081285] MULTIPLAN INC [308128501] 102.6 percent of total billed charges 66.96 102.6 Technical (Hospital) Services HC/HH Wch Supp Tubigrip Bandage Sz E__1434 PX-2705000206 CDM 2705000206 LOCAL 270 RC inpatient 108 108 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES EPO [308136803] 85.51 percent of total billed charges 66.96 102.6 Technical (Hospital) Services HC/HH Wch Supp Tubigrip Bandage Sz E__1434 PX-2705000206 CDM 2705000206 LOCAL 270 RC inpatient 108 108 HEALTHPARTNERS SX009 HEALTHPARTNERS 85.51 percent of total billed charges 66.96 102.6 Technical (Hospital) Services HC/HH Wch Supp Tubigrip Bandage Sz E__1434 PX-2705000206 CDM 2705000206 LOCAL 270 RC inpatient 108 108 MULTIPLAN INC 34080 [3081285] MULTIPLAN INC [308128501] 102.6 percent of total billed charges 66.96 102.6 Technical (Hospital) Services HC/HH Wch Supp Tubigrip Bandage Sz E__1434 PX-2705000206 CDM 2705000206 LOCAL 270 RC inpatient 108 108 BLUE CROSS BLUE SHIELD WELLMARK SB889 [3081026] BCBS WYOMING [308102603] 102.6 percent of total billed charges 66.96 102.6 Technical (Hospital) Services HC/HH Wch Supp Tubigrip Bandage Sz E__1434 PX-2705000206 CDM 2705000206 LOCAL 270 RC inpatient 108 108 CIGNA 62308 [3081051] CIGNA 62308 [308105105] 85.51 percent of total billed charges 66.96 102.6 Technical (Hospital) Services HC/HH Wch Supp Tubigrip Bandage Sz E__1434 PX-2705000206 CDM 2705000206 LOCAL 270 RC inpatient 108 108 CIGNA 62308 [3081051] CIGNA STATE OF WYOMING [308105107] 85.51 percent of total billed charges 66.96 102.6 Technical (Hospital) Services HC/HH Wch Supp Tubigrip Bandage Sz E__1434 PX-2705000206 CDM 2705000206 LOCAL 270 RC inpatient 108 108 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES PPO [308136801] 85.51 percent of total billed charges 66.96 102.6 Technical (Hospital) Services HC/HH Wch Supp Tubigrip Bandage Sz E__1434 PX-2705000206 CDM 2705000206 LOCAL 270 RC inpatient 108 108 MEDICA (COMMERCIAL) 94265 [3081118] MEDICA CLAIMS [308111801] 97.2 percent of total billed charges 66.96 102.6 Technical (Hospital) Services HC/HH Wch Supp Tubigrip Bandage Sz E__1434 PX-2705000206 CDM 2705000206 LOCAL 270 RC inpatient 108 108 UNITED HEALTHCARE (COMMERCIAL) [3081199] UNITED HEALTHCARE 87726 [308119901] 66.96 percent of total billed charges 66.96 102.6 Technical (Hospital) Services HC/HH Wch Supp Tubigrip Bandage Sz E__1434 PX-2705000206 CDM 2705000206 LOCAL 270 RC inpatient 108 108 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES HDHP [308136802] 85.51 percent of total billed charges 66.96 102.6 Technical (Hospital) Services HC/HH Wch Supp Tubigrip Bandage Sz D__1437 PX-2705000205 CDM 2705000205 LOCAL 270 RC inpatient 95 95 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES PPO [308136801] 75.22 percent of total billed charges 58.9 90.25 Technical (Hospital) Services HC/HH Wch Supp Tubigrip Bandage Sz D__1437 PX-2705000205 CDM 2705000205 LOCAL 270 RC inpatient 95 95 MEDICA (COMMERCIAL) 94265 [3081118] MEDICA CLAIMS [308111801] 85.5 percent of total billed charges 58.9 90.25 Technical (Hospital) Services HC/HH Wch Supp Tubigrip Bandage Sz D__1437 PX-2705000205 CDM 2705000205 LOCAL 270 RC inpatient 95 95 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES HDHP [308136802] 75.22 percent of total billed charges 58.9 90.25 Technical (Hospital) Services HC/HH Wch Supp Tubigrip Bandage Sz D__1437 PX-2705000205 CDM 2705000205 LOCAL 270 RC inpatient 95 95 UNITED HEALTHCARE (COMMERCIAL) [3081199] UNITED HEALTHCARE 87726 [308119901] 58.9 percent of total billed charges 58.9 90.25 Technical (Hospital) Services HC/HH Wch Supp Tubigrip Bandage Sz D__1437 PX-2705000205 CDM 2705000205 LOCAL 270 RC inpatient 95 95 MULTIPLAN INC 34080 [3081285] MULTIPLAN INC [308128501] 90.25 percent of total billed charges 58.9 90.25 Technical (Hospital) Services HC/HH Wch Supp Tubigrip Bandage Sz D__1437 PX-2705000205 CDM 2705000205 LOCAL 270 RC inpatient 95 95 BLUE CROSS BLUE SHIELD WELLMARK SB889 [3081026] BCBS WYOMING [308102603] 90.25 percent of total billed charges 58.9 90.25 Technical (Hospital) Services HC/HH Wch Supp Tubigrip Bandage Sz D__1437 PX-2705000205 CDM 2705000205 LOCAL 270 RC inpatient 95 95 CIGNA 62308 [3081051] CIGNA 62308 [308105105] 75.22 percent of total billed charges 58.9 90.25 Technical (Hospital) Services HC/HH Wch Supp Tubigrip Bandage Sz D__1437 PX-2705000205 CDM 2705000205 LOCAL 270 RC inpatient 95 95 CIGNA 62308 [3081051] CIGNA STATE OF WYOMING [308105107] 75.22 percent of total billed charges 58.9 90.25 Technical (Hospital) Services HC/HH Wch Supp Tubigrip Bandage Sz D__1437 PX-2705000205 CDM 2705000205 LOCAL 270 RC inpatient 95 95 HEALTHPARTNERS SX009 HEALTHPARTNERS 75.22 percent of total billed charges 58.9 90.25 Technical (Hospital) Services HC/HH Wch Supp Tubigrip Bandage Sz D__1437 PX-2705000205 CDM 2705000205 LOCAL 270 RC inpatient 95 95 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES EPO [308136803] 75.22 percent of total billed charges 58.9 90.25 Technical (Hospital) Services HC/HH Wch Supp Tubigrip Bandage Sz D__1437 PX-2705000205 CDM 2705000205 LOCAL 270 RC outpatient 95 95 MULTIPLAN INC 34080 [3081285] MULTIPLAN INC [308128501] 90.25 percent of total billed charges 58.9 90.25 Technical (Hospital) Services HC/HH Wch Supp Tubigrip Bandage Sz D__1437 PX-2705000205 CDM 2705000205 LOCAL 270 RC outpatient 95 95 MEDICA (COMMERCIAL) 94265 [3081118] MEDICA CLAIMS [308111801] 85.5 percent of total billed charges 58.9 90.25 Technical (Hospital) Services HC/HH Wch Supp Tubigrip Bandage Sz D__1437 PX-2705000205 CDM 2705000205 LOCAL 270 RC outpatient 95 95 CIGNA 62308 [3081051] CIGNA 62308 [308105105] 76 percent of total billed charges 58.9 90.25 Technical (Hospital) Services HC/HH Wch Supp Tubigrip Bandage Sz D__1437 PX-2705000205 CDM 2705000205 LOCAL 270 RC outpatient 95 95 CIGNA 62308 [3081051] CIGNA STATE OF WYOMING [308105107] 76 percent of total billed charges 58.9 90.25 Technical (Hospital) Services HC/HH Wch Supp Tubigrip Bandage Sz D__1437 PX-2705000205 CDM 2705000205 LOCAL 270 RC outpatient 95 95 BLUE CROSS BLUE SHIELD WELLMARK SB889 [3081026] BCBS WYOMING [308102603] 90.25 percent of total billed charges 58.9 90.25 Technical (Hospital) Services HC/HH Wch Supp Tubigrip Bandage Sz D__1437 PX-2705000205 CDM 2705000205 LOCAL 270 RC outpatient 95 95 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES EPO [308136803] 76 percent of total billed charges 58.9 90.25 Technical (Hospital) Services HC/HH Wch Supp Tubigrip Bandage Sz D__1437 PX-2705000205 CDM 2705000205 LOCAL 270 RC outpatient 95 95 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES HDHP [308136802] 76 percent of total billed charges 58.9 90.25 Technical (Hospital) Services HC/HH Wch Supp Tubigrip Bandage Sz D__1437 PX-2705000205 CDM 2705000205 LOCAL 270 RC outpatient 95 95 HEALTHPARTNERS SX009 HEALTHPARTNERS 76 percent of total billed charges 58.9 90.25 Technical (Hospital) Services HC/HH Wch Supp Tubigrip Bandage Sz D__1437 PX-2705000205 CDM 2705000205 LOCAL 270 RC outpatient 95 95 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES PPO [308136801] 76 percent of total billed charges 58.9 90.25 Technical (Hospital) Services HC/HH Wch Supp Tubigrip Bandage Sz D__1437 PX-2705000205 CDM 2705000205 LOCAL 270 RC outpatient 95 95 UNITED HEALTHCARE (COMMERCIAL) [3081199] UNITED HEALTHCARE 87726 [308119901] 58.9 percent of total billed charges 58.9 90.25 Technical (Hospital) Services HC/HH Wch Supp Tube Connector O2__1420 PX-2705000204 CDM 2705000204 LOCAL 270 RC inpatient 4 4 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES PPO [308136801] 3.17 percent of total billed charges 2.48 3.8 Technical (Hospital) Services HC/HH Wch Supp Tube Connector O2__1420 PX-2705000204 CDM 2705000204 LOCAL 270 RC inpatient 4 4 MEDICA (COMMERCIAL) 94265 [3081118] MEDICA CLAIMS [308111801] 3.6 percent of total billed charges 2.48 3.8 Technical (Hospital) Services HC/HH Wch Supp Tube Connector O2__1420 PX-2705000204 CDM 2705000204 LOCAL 270 RC inpatient 4 4 UNITED HEALTHCARE (COMMERCIAL) [3081199] UNITED HEALTHCARE 87726 [308119901] 2.48 percent of total billed charges 2.48 3.8 Technical (Hospital) Services HC/HH Wch Supp Tube Connector O2__1420 PX-2705000204 CDM 2705000204 LOCAL 270 RC inpatient 4 4 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES HDHP [308136802] 3.17 percent of total billed charges 2.48 3.8 Technical (Hospital) Services HC/HH Wch Supp Tube Connector O2__1420 PX-2705000204 CDM 2705000204 LOCAL 270 RC inpatient 4 4 CIGNA 62308 [3081051] CIGNA 62308 [308105105] 3.17 percent of total billed charges 2.48 3.8 Technical (Hospital) Services HC/HH Wch Supp Tube Connector O2__1420 PX-2705000204 CDM 2705000204 LOCAL 270 RC inpatient 4 4 CIGNA 62308 [3081051] CIGNA STATE OF WYOMING [308105107] 3.17 percent of total billed charges 2.48 3.8 Technical (Hospital) Services HC/HH Wch Supp Tube Connector O2__1420 PX-2705000204 CDM 2705000204 LOCAL 270 RC inpatient 4 4 BLUE CROSS BLUE SHIELD WELLMARK SB889 [3081026] BCBS WYOMING [308102603] 3.8 percent of total billed charges 2.48 3.8 Technical (Hospital) Services HC/HH Wch Supp Tube Connector O2__1420 PX-2705000204 CDM 2705000204 LOCAL 270 RC inpatient 4 4 MULTIPLAN INC 34080 [3081285] MULTIPLAN INC [308128501] 3.8 percent of total billed charges 2.48 3.8 Technical (Hospital) Services HC/HH Wch Supp Tube Connector O2__1420 PX-2705000204 CDM 2705000204 LOCAL 270 RC inpatient 4 4 HEALTHPARTNERS SX009 HEALTHPARTNERS 3.17 percent of total billed charges 2.48 3.8 Technical (Hospital) Services HC/HH Wch Supp Tube Connector O2__1420 PX-2705000204 CDM 2705000204 LOCAL 270 RC inpatient 4 4 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES EPO [308136803] 3.17 percent of total billed charges 2.48 3.8 Technical (Hospital) Services HC/HH Wch Supp Tube Connector O2__1420 PX-2705000204 CDM 2705000204 LOCAL 270 RC outpatient 4 4 CIGNA 62308 [3081051] CIGNA STATE OF WYOMING [308105107] 3.2 percent of total billed charges 2.48 3.8 Technical (Hospital) Services HC/HH Wch Supp Tube Connector O2__1420 PX-2705000204 CDM 2705000204 LOCAL 270 RC outpatient 4 4 BLUE CROSS BLUE SHIELD WELLMARK SB889 [3081026] BCBS WYOMING [308102603] 3.8 percent of total billed charges 2.48 3.8 Technical (Hospital) Services HC/HH Wch Supp Tube Connector O2__1420 PX-2705000204 CDM 2705000204 LOCAL 270 RC outpatient 4 4 CIGNA 62308 [3081051] CIGNA 62308 [308105105] 3.2 percent of total billed charges 2.48 3.8 Technical (Hospital) Services HC/HH Wch Supp Tube Connector O2__1420 PX-2705000204 CDM 2705000204 LOCAL 270 RC outpatient 4 4 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES EPO [308136803] 3.2 percent of total billed charges 2.48 3.8 Technical (Hospital) Services HC/HH Wch Supp Tube Connector O2__1420 PX-2705000204 CDM 2705000204 LOCAL 270 RC outpatient 4 4 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES HDHP [308136802] 3.2 percent of total billed charges 2.48 3.8 Technical (Hospital) Services HC/HH Wch Supp Tube Connector O2__1420 PX-2705000204 CDM 2705000204 LOCAL 270 RC outpatient 4 4 UNITED HEALTHCARE (COMMERCIAL) [3081199] UNITED HEALTHCARE 87726 [308119901] 2.48 percent of total billed charges 2.48 3.8 Technical (Hospital) Services HC/HH Wch Supp Tube Connector O2__1420 PX-2705000204 CDM 2705000204 LOCAL 270 RC outpatient 4 4 HEALTHPARTNERS SX009 HEALTHPARTNERS 3.2 percent of total billed charges 2.48 3.8 Technical (Hospital) Services HC/HH Wch Supp Tube Connector O2__1420 PX-2705000204 CDM 2705000204 LOCAL 270 RC outpatient 4 4 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES PPO [308136801] 3.2 percent of total billed charges 2.48 3.8 Technical (Hospital) Services HC/HH Wch Supp Tube Connector O2__1420 PX-2705000204 CDM 2705000204 LOCAL 270 RC outpatient 4 4 MULTIPLAN INC 34080 [3081285] MULTIPLAN INC [308128501] 3.8 percent of total billed charges 2.48 3.8 Technical (Hospital) Services HC/HH Wch Supp Tube Connector O2__1420 PX-2705000204 CDM 2705000204 LOCAL 270 RC outpatient 4 4 MEDICA (COMMERCIAL) 94265 [3081118] MEDICA CLAIMS [308111801] 3.6 percent of total billed charges 2.48 3.8 Technical (Hospital) Services HC/HH Wch Supp Thumb Spica Xsm__3020 PX-2705000202 CDM 2705000202 LOCAL 270 RC inpatient 118 118 MEDICA (COMMERCIAL) 94265 [3081118] MEDICA CLAIMS [308111801] 106.2 percent of total billed charges 73.16 112.1 Technical (Hospital) Services HC/HH Wch Supp Thumb Spica Xsm__3020 PX-2705000202 CDM 2705000202 LOCAL 270 RC inpatient 118 118 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES PPO [308136801] 93.43 percent of total billed charges 73.16 112.1 Technical (Hospital) Services HC/HH Wch Supp Thumb Spica Xsm__3020 PX-2705000202 CDM 2705000202 LOCAL 270 RC inpatient 118 118 UNITED HEALTHCARE (COMMERCIAL) [3081199] UNITED HEALTHCARE 87726 [308119901] 73.16 percent of total billed charges 73.16 112.1 Technical (Hospital) Services HC/HH Wch Supp Thumb Spica Xsm__3020 PX-2705000202 CDM 2705000202 LOCAL 270 RC inpatient 118 118 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES HDHP [308136802] 93.43 percent of total billed charges 73.16 112.1 Technical (Hospital) Services HC/HH Wch Supp Thumb Spica Xsm__3020 PX-2705000202 CDM 2705000202 LOCAL 270 RC inpatient 118 118 BLUE CROSS BLUE SHIELD WELLMARK SB889 [3081026] BCBS WYOMING [308102603] 112.1 percent of total billed charges 73.16 112.1 Technical (Hospital) Services HC/HH Wch Supp Thumb Spica Xsm__3020 PX-2705000202 CDM 2705000202 LOCAL 270 RC inpatient 118 118 MULTIPLAN INC 34080 [3081285] MULTIPLAN INC [308128501] 112.1 percent of total billed charges 73.16 112.1 Technical (Hospital) Services HC/HH Wch Supp Thumb Spica Xsm__3020 PX-2705000202 CDM 2705000202 LOCAL 270 RC inpatient 118 118 CIGNA 62308 [3081051] CIGNA 62308 [308105105] 93.43 percent of total billed charges 73.16 112.1 Technical (Hospital) Services HC/HH Wch Supp Thumb Spica Xsm__3020 PX-2705000202 CDM 2705000202 LOCAL 270 RC inpatient 118 118 CIGNA 62308 [3081051] CIGNA STATE OF WYOMING [308105107] 93.43 percent of total billed charges 73.16 112.1 Technical (Hospital) Services HC/HH Wch Supp Thumb Spica Xsm__3020 PX-2705000202 CDM 2705000202 LOCAL 270 RC inpatient 118 118 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES EPO [308136803] 93.43 percent of total billed charges 73.16 112.1 Technical (Hospital) Services HC/HH Wch Supp Thumb Spica Xsm__3020 PX-2705000202 CDM 2705000202 LOCAL 270 RC inpatient 118 118 HEALTHPARTNERS SX009 HEALTHPARTNERS 93.43 percent of total billed charges 73.16 112.1 Technical (Hospital) Services HC/HH Wch Supp Thumb Spica Xsm__3020 PX-2705000202 CDM 2705000202 LOCAL 270 RC outpatient 118 118 CIGNA 62308 [3081051] CIGNA 62308 [308105105] 94.4 percent of total billed charges 73.16 112.1 Technical (Hospital) Services HC/HH Wch Supp Thumb Spica Xsm__3020 PX-2705000202 CDM 2705000202 LOCAL 270 RC outpatient 118 118 CIGNA 62308 [3081051] CIGNA STATE OF WYOMING [308105107] 94.4 percent of total billed charges 73.16 112.1 Technical (Hospital) Services HC/HH Wch Supp Thumb Spica Xsm__3020 PX-2705000202 CDM 2705000202 LOCAL 270 RC outpatient 118 118 BLUE CROSS BLUE SHIELD WELLMARK SB889 [3081026] BCBS WYOMING [308102603] 112.1 percent of total billed charges 73.16 112.1 Technical (Hospital) Services HC/HH Wch Supp Thumb Spica Xsm__3020 PX-2705000202 CDM 2705000202 LOCAL 270 RC outpatient 118 118 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES EPO [308136803] 94.4 percent of total billed charges 73.16 112.1 Technical (Hospital) Services HC/HH Wch Supp Thumb Spica Xsm__3020 PX-2705000202 CDM 2705000202 LOCAL 270 RC outpatient 118 118 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES HDHP [308136802] 94.4 percent of total billed charges 73.16 112.1 Technical (Hospital) Services HC/HH Wch Supp Thumb Spica Xsm__3020 PX-2705000202 CDM 2705000202 LOCAL 270 RC outpatient 118 118 UNITED HEALTHCARE (COMMERCIAL) [3081199] UNITED HEALTHCARE 87726 [308119901] 73.16 percent of total billed charges 73.16 112.1 Technical (Hospital) Services HC/HH Wch Supp Thumb Spica Xsm__3020 PX-2705000202 CDM 2705000202 LOCAL 270 RC outpatient 118 118 HEALTHPARTNERS SX009 HEALTHPARTNERS 94.4 percent of total billed charges 73.16 112.1 Technical (Hospital) Services HC/HH Wch Supp Thumb Spica Xsm__3020 PX-2705000202 CDM 2705000202 LOCAL 270 RC outpatient 118 118 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES PPO [308136801] 94.4 percent of total billed charges 73.16 112.1 Technical (Hospital) Services HC/HH Wch Supp Thumb Spica Xsm__3020 PX-2705000202 CDM 2705000202 LOCAL 270 RC outpatient 118 118 MULTIPLAN INC 34080 [3081285] MULTIPLAN INC [308128501] 112.1 percent of total billed charges 73.16 112.1 Technical (Hospital) Services HC/HH Wch Supp Thumb Spica Xsm__3020 PX-2705000202 CDM 2705000202 LOCAL 270 RC outpatient 118 118 MEDICA (COMMERCIAL) 94265 [3081118] MEDICA CLAIMS [308111801] 106.2 percent of total billed charges 73.16 112.1 Technical (Hospital) Services HC/HH Wch Supp Thumb Spica Xlg__3180 PX-2705000200 CDM 2705000200 LOCAL 270 RC inpatient 118 118 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES EPO [308136803] 93.43 percent of total billed charges 73.16 112.1 Technical (Hospital) Services HC/HH Wch Supp Thumb Spica Xlg__3180 PX-2705000200 CDM 2705000200 LOCAL 270 RC inpatient 118 118 HEALTHPARTNERS SX009 HEALTHPARTNERS 93.43 percent of total billed charges 73.16 112.1 Technical (Hospital) Services HC/HH Wch Supp Thumb Spica Xlg__3180 PX-2705000200 CDM 2705000200 LOCAL 270 RC inpatient 118 118 BLUE CROSS BLUE SHIELD WELLMARK SB889 [3081026] BCBS WYOMING [308102603] 112.1 percent of total billed charges 73.16 112.1 Technical (Hospital) Services HC/HH Wch Supp Thumb Spica Xlg__3180 PX-2705000200 CDM 2705000200 LOCAL 270 RC inpatient 118 118 MULTIPLAN INC 34080 [3081285] MULTIPLAN INC [308128501] 112.1 percent of total billed charges 73.16 112.1 Technical (Hospital) Services HC/HH Wch Supp Thumb Spica Xlg__3180 PX-2705000200 CDM 2705000200 LOCAL 270 RC inpatient 118 118 CIGNA 62308 [3081051] CIGNA 62308 [308105105] 93.43 percent of total billed charges 73.16 112.1 Technical (Hospital) Services HC/HH Wch Supp Thumb Spica Xlg__3180 PX-2705000200 CDM 2705000200 LOCAL 270 RC inpatient 118 118 CIGNA 62308 [3081051] CIGNA STATE OF WYOMING [308105107] 93.43 percent of total billed charges 73.16 112.1 Technical (Hospital) Services HC/HH Wch Supp Thumb Spica Xlg__3180 PX-2705000200 CDM 2705000200 LOCAL 270 RC inpatient 118 118 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES PPO [308136801] 93.43 percent of total billed charges 73.16 112.1 Technical (Hospital) Services HC/HH Wch Supp Thumb Spica Xlg__3180 PX-2705000200 CDM 2705000200 LOCAL 270 RC inpatient 118 118 MEDICA (COMMERCIAL) 94265 [3081118] MEDICA CLAIMS [308111801] 106.2 percent of total billed charges 73.16 112.1 Technical (Hospital) Services HC/HH Wch Supp Thumb Spica Xlg__3180 PX-2705000200 CDM 2705000200 LOCAL 270 RC inpatient 118 118 UNITED HEALTHCARE (COMMERCIAL) [3081199] UNITED HEALTHCARE 87726 [308119901] 73.16 percent of total billed charges 73.16 112.1 Technical (Hospital) Services HC/HH Wch Supp Thumb Spica Xlg__3180 PX-2705000200 CDM 2705000200 LOCAL 270 RC inpatient 118 118 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES HDHP [308136802] 93.43 percent of total billed charges 73.16 112.1 Technical (Hospital) Services HC/HH Wch Supp Thumb Spica Xlg__3180 PX-2705000200 CDM 2705000200 LOCAL 270 RC outpatient 118 118 MEDICA (COMMERCIAL) 94265 [3081118] MEDICA CLAIMS [308111801] 106.2 percent of total billed charges 73.16 112.1 Technical (Hospital) Services HC/HH Wch Supp Thumb Spica Xlg__3180 PX-2705000200 CDM 2705000200 LOCAL 270 RC outpatient 118 118 MULTIPLAN INC 34080 [3081285] MULTIPLAN INC [308128501] 112.1 percent of total billed charges 73.16 112.1 Technical (Hospital) Services HC/HH Wch Supp Thumb Spica Xlg__3180 PX-2705000200 CDM 2705000200 LOCAL 270 RC outpatient 118 118 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES PPO [308136801] 94.4 percent of total billed charges 73.16 112.1 Technical (Hospital) Services HC/HH Wch Supp Thumb Spica Xlg__3180 PX-2705000200 CDM 2705000200 LOCAL 270 RC outpatient 118 118 HEALTHPARTNERS SX009 HEALTHPARTNERS 94.4 percent of total billed charges 73.16 112.1 Technical (Hospital) Services HC/HH Wch Supp Thumb Spica Xlg__3180 PX-2705000200 CDM 2705000200 LOCAL 270 RC outpatient 118 118 UNITED HEALTHCARE (COMMERCIAL) [3081199] UNITED HEALTHCARE 87726 [308119901] 73.16 percent of total billed charges 73.16 112.1 Technical (Hospital) Services HC/HH Wch Supp Thumb Spica Xlg__3180 PX-2705000200 CDM 2705000200 LOCAL 270 RC outpatient 118 118 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES HDHP [308136802] 94.4 percent of total billed charges 73.16 112.1 Technical (Hospital) Services HC/HH Wch Supp Thumb Spica Xlg__3180 PX-2705000200 CDM 2705000200 LOCAL 270 RC outpatient 118 118 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES EPO [308136803] 94.4 percent of total billed charges 73.16 112.1 Technical (Hospital) Services HC/HH Wch Supp Thumb Spica Xlg__3180 PX-2705000200 CDM 2705000200 LOCAL 270 RC outpatient 118 118 BLUE CROSS BLUE SHIELD WELLMARK SB889 [3081026] BCBS WYOMING [308102603] 112.1 percent of total billed charges 73.16 112.1 Technical (Hospital) Services HC/HH Wch Supp Thumb Spica Xlg__3180 PX-2705000200 CDM 2705000200 LOCAL 270 RC outpatient 118 118 CIGNA 62308 [3081051] CIGNA 62308 [308105105] 94.4 percent of total billed charges 73.16 112.1 Technical (Hospital) Services HC/HH Wch Supp Thumb Spica Xlg__3180 PX-2705000200 CDM 2705000200 LOCAL 270 RC outpatient 118 118 CIGNA 62308 [3081051] CIGNA STATE OF WYOMING [308105107] 94.4 percent of total billed charges 73.16 112.1 Technical (Hospital) Services HC/HH Wch Supp Thumb Spica Sm__3030 PX-2705000198 CDM 2705000198 LOCAL 270 RC inpatient 118 118 MEDICA (COMMERCIAL) 94265 [3081118] MEDICA CLAIMS [308111801] 106.2 percent of total billed charges 73.16 112.1 Technical (Hospital) Services HC/HH Wch Supp Thumb Spica Sm__3030 PX-2705000198 CDM 2705000198 LOCAL 270 RC inpatient 118 118 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES PPO [308136801] 93.43 percent of total billed charges 73.16 112.1 Technical (Hospital) Services HC/HH Wch Supp Thumb Spica Sm__3030 PX-2705000198 CDM 2705000198 LOCAL 270 RC inpatient 118 118 UNITED HEALTHCARE (COMMERCIAL) [3081199] UNITED HEALTHCARE 87726 [308119901] 73.16 percent of total billed charges 73.16 112.1 Technical (Hospital) Services HC/HH Wch Supp Thumb Spica Sm__3030 PX-2705000198 CDM 2705000198 LOCAL 270 RC inpatient 118 118 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES HDHP [308136802] 93.43 percent of total billed charges 73.16 112.1 Technical (Hospital) Services HC/HH Wch Supp Thumb Spica Sm__3030 PX-2705000198 CDM 2705000198 LOCAL 270 RC inpatient 118 118 HEALTHPARTNERS SX009 HEALTHPARTNERS 93.43 percent of total billed charges 73.16 112.1 Technical (Hospital) Services HC/HH Wch Supp Thumb Spica Sm__3030 PX-2705000198 CDM 2705000198 LOCAL 270 RC inpatient 118 118 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES EPO [308136803] 93.43 percent of total billed charges 73.16 112.1 Technical (Hospital) Services HC/HH Wch Supp Thumb Spica Sm__3030 PX-2705000198 CDM 2705000198 LOCAL 270 RC inpatient 118 118 MULTIPLAN INC 34080 [3081285] MULTIPLAN INC [308128501] 112.1 percent of total billed charges 73.16 112.1 Technical (Hospital) Services HC/HH Wch Supp Thumb Spica Sm__3030 PX-2705000198 CDM 2705000198 LOCAL 270 RC inpatient 118 118 BLUE CROSS BLUE SHIELD WELLMARK SB889 [3081026] BCBS WYOMING [308102603] 112.1 percent of total billed charges 73.16 112.1 Technical (Hospital) Services HC/HH Wch Supp Thumb Spica Sm__3030 PX-2705000198 CDM 2705000198 LOCAL 270 RC inpatient 118 118 CIGNA 62308 [3081051] CIGNA 62308 [308105105] 93.43 percent of total billed charges 73.16 112.1 Technical (Hospital) Services HC/HH Wch Supp Thumb Spica Sm__3030 PX-2705000198 CDM 2705000198 LOCAL 270 RC inpatient 118 118 CIGNA 62308 [3081051] CIGNA STATE OF WYOMING [308105107] 93.43 percent of total billed charges 73.16 112.1 Technical (Hospital) Services HC/HH Wch Supp Thumb Spica Sm__3030 PX-2705000198 CDM 2705000198 LOCAL 270 RC outpatient 118 118 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES HDHP [308136802] 94.4 percent of total billed charges 73.16 112.1 Technical (Hospital) Services HC/HH Wch Supp Thumb Spica Sm__3030 PX-2705000198 CDM 2705000198 LOCAL 270 RC outpatient 118 118 CIGNA 62308 [3081051] CIGNA 62308 [308105105] 94.4 percent of total billed charges 73.16 112.1 Technical (Hospital) Services HC/HH Wch Supp Thumb Spica Sm__3030 PX-2705000198 CDM 2705000198 LOCAL 270 RC outpatient 118 118 CIGNA 62308 [3081051] CIGNA STATE OF WYOMING [308105107] 94.4 percent of total billed charges 73.16 112.1 Technical (Hospital) Services HC/HH Wch Supp Thumb Spica Sm__3030 PX-2705000198 CDM 2705000198 LOCAL 270 RC outpatient 118 118 BLUE CROSS BLUE SHIELD WELLMARK SB889 [3081026] BCBS WYOMING [308102603] 112.1 percent of total billed charges 73.16 112.1 Technical (Hospital) Services HC/HH Wch Supp Thumb Spica Sm__3030 PX-2705000198 CDM 2705000198 LOCAL 270 RC outpatient 118 118 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES EPO [308136803] 94.4 percent of total billed charges 73.16 112.1 Technical (Hospital) Services HC/HH Wch Supp Thumb Spica Sm__3030 PX-2705000198 CDM 2705000198 LOCAL 270 RC outpatient 118 118 HEALTHPARTNERS SX009 HEALTHPARTNERS 94.4 percent of total billed charges 73.16 112.1 Technical (Hospital) Services HC/HH Wch Supp Thumb Spica Sm__3030 PX-2705000198 CDM 2705000198 LOCAL 270 RC outpatient 118 118 UNITED HEALTHCARE (COMMERCIAL) [3081199] UNITED HEALTHCARE 87726 [308119901] 73.16 percent of total billed charges 73.16 112.1 Technical (Hospital) Services HC/HH Wch Supp Thumb Spica Sm__3030 PX-2705000198 CDM 2705000198 LOCAL 270 RC outpatient 118 118 MEDICA (COMMERCIAL) 94265 [3081118] MEDICA CLAIMS [308111801] 106.2 percent of total billed charges 73.16 112.1 Technical (Hospital) Services HC/HH Wch Supp Thumb Spica Sm__3030 PX-2705000198 CDM 2705000198 LOCAL 270 RC outpatient 118 118 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES PPO [308136801] 94.4 percent of total billed charges 73.16 112.1 Technical (Hospital) Services HC/HH Wch Supp Thumb Spica Sm__3030 PX-2705000198 CDM 2705000198 LOCAL 270 RC outpatient 118 118 MULTIPLAN INC 34080 [3081285] MULTIPLAN INC [308128501] 112.1 percent of total billed charges 73.16 112.1 Technical (Hospital) Services HC/HH Wch Supp Thumb Spica Med Lt__3050 PX-2705000197 CDM 2705000197 LOCAL 270 RC inpatient 118 118 HEALTHPARTNERS SX009 HEALTHPARTNERS 93.43 percent of total billed charges 73.16 112.1 Technical (Hospital) Services HC/HH Wch Supp Thumb Spica Med Lt__3050 PX-2705000197 CDM 2705000197 LOCAL 270 RC inpatient 118 118 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES EPO [308136803] 93.43 percent of total billed charges 73.16 112.1 Technical (Hospital) Services HC/HH Wch Supp Thumb Spica Med Lt__3050 PX-2705000197 CDM 2705000197 LOCAL 270 RC inpatient 118 118 BLUE CROSS BLUE SHIELD WELLMARK SB889 [3081026] BCBS WYOMING [308102603] 112.1 percent of total billed charges 73.16 112.1 Technical (Hospital) Services HC/HH Wch Supp Thumb Spica Med Lt__3050 PX-2705000197 CDM 2705000197 LOCAL 270 RC inpatient 118 118 MULTIPLAN INC 34080 [3081285] MULTIPLAN INC [308128501] 112.1 percent of total billed charges 73.16 112.1 Technical (Hospital) Services HC/HH Wch Supp Thumb Spica Med Lt__3050 PX-2705000197 CDM 2705000197 LOCAL 270 RC inpatient 118 118 CIGNA 62308 [3081051] CIGNA 62308 [308105105] 93.43 percent of total billed charges 73.16 112.1 Technical (Hospital) Services HC/HH Wch Supp Thumb Spica Med Lt__3050 PX-2705000197 CDM 2705000197 LOCAL 270 RC inpatient 118 118 CIGNA 62308 [3081051] CIGNA STATE OF WYOMING [308105107] 93.43 percent of total billed charges 73.16 112.1 Technical (Hospital) Services HC/HH Wch Supp Thumb Spica Med Lt__3050 PX-2705000197 CDM 2705000197 LOCAL 270 RC inpatient 118 118 MEDICA (COMMERCIAL) 94265 [3081118] MEDICA CLAIMS [308111801] 106.2 percent of total billed charges 73.16 112.1 Technical (Hospital) Services HC/HH Wch Supp Thumb Spica Med Lt__3050 PX-2705000197 CDM 2705000197 LOCAL 270 RC inpatient 118 118 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES PPO [308136801] 93.43 percent of total billed charges 73.16 112.1 Technical (Hospital) Services HC/HH Wch Supp Thumb Spica Med Lt__3050 PX-2705000197 CDM 2705000197 LOCAL 270 RC inpatient 118 118 UNITED HEALTHCARE (COMMERCIAL) [3081199] UNITED HEALTHCARE 87726 [308119901] 73.16 percent of total billed charges 73.16 112.1 Technical (Hospital) Services HC/HH Wch Supp Thumb Spica Med Lt__3050 PX-2705000197 CDM 2705000197 LOCAL 270 RC inpatient 118 118 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES HDHP [308136802] 93.43 percent of total billed charges 73.16 112.1 Technical (Hospital) Services HC/HH Wch Supp Thumb Spica Med Lt__3050 PX-2705000197 CDM 2705000197 LOCAL 270 RC outpatient 118 118 MULTIPLAN INC 34080 [3081285] MULTIPLAN INC [308128501] 112.1 percent of total billed charges 73.16 112.1 Technical (Hospital) Services HC/HH Wch Supp Thumb Spica Med Lt__3050 PX-2705000197 CDM 2705000197 LOCAL 270 RC outpatient 118 118 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES PPO [308136801] 94.4 percent of total billed charges 73.16 112.1 Technical (Hospital) Services HC/HH Wch Supp Thumb Spica Med Lt__3050 PX-2705000197 CDM 2705000197 LOCAL 270 RC outpatient 118 118 MEDICA (COMMERCIAL) 94265 [3081118] MEDICA CLAIMS [308111801] 106.2 percent of total billed charges 73.16 112.1 Technical (Hospital) Services HC/HH Wch Supp Thumb Spica Med Lt__3050 PX-2705000197 CDM 2705000197 LOCAL 270 RC outpatient 118 118 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES HDHP [308136802] 94.4 percent of total billed charges 73.16 112.1 Technical (Hospital) Services HC/HH Wch Supp Thumb Spica Med Lt__3050 PX-2705000197 CDM 2705000197 LOCAL 270 RC outpatient 118 118 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES EPO [308136803] 94.4 percent of total billed charges 73.16 112.1 Technical (Hospital) Services HC/HH Wch Supp Thumb Spica Med Lt__3050 PX-2705000197 CDM 2705000197 LOCAL 270 RC outpatient 118 118 BLUE CROSS BLUE SHIELD WELLMARK SB889 [3081026] BCBS WYOMING [308102603] 112.1 percent of total billed charges 73.16 112.1 Technical (Hospital) Services HC/HH Wch Supp Thumb Spica Med Lt__3050 PX-2705000197 CDM 2705000197 LOCAL 270 RC outpatient 118 118 CIGNA 62308 [3081051] CIGNA 62308 [308105105] 94.4 percent of total billed charges 73.16 112.1 Technical (Hospital) Services HC/HH Wch Supp Thumb Spica Med Lt__3050 PX-2705000197 CDM 2705000197 LOCAL 270 RC outpatient 118 118 CIGNA 62308 [3081051] CIGNA STATE OF WYOMING [308105107] 94.4 percent of total billed charges 73.16 112.1 Technical (Hospital) Services HC/HH Wch Supp Thumb Spica Med Lt__3050 PX-2705000197 CDM 2705000197 LOCAL 270 RC outpatient 118 118 HEALTHPARTNERS SX009 HEALTHPARTNERS 94.4 percent of total billed charges 73.16 112.1 Technical (Hospital) Services HC/HH Wch Supp Thumb Spica Med Lt__3050 PX-2705000197 CDM 2705000197 LOCAL 270 RC outpatient 118 118 UNITED HEALTHCARE (COMMERCIAL) [3081199] UNITED HEALTHCARE 87726 [308119901] 73.16 percent of total billed charges 73.16 112.1 Technical (Hospital) Services HC/HH Wch Supp Tena Underpad 23x24 Blue Chux__354 PX-2705000196 CDM 2705000196 LOCAL 270 RC inpatient 9 9 CIGNA 62308 [3081051] CIGNA 62308 [308105105] 7.13 percent of total billed charges 5.58 8.55 Technical (Hospital) Services HC/HH Wch Supp Tena Underpad 23x24 Blue Chux__354 PX-2705000196 CDM 2705000196 LOCAL 270 RC inpatient 9 9 CIGNA 62308 [3081051] CIGNA STATE OF WYOMING [308105107] 7.13 percent of total billed charges 5.58 8.55 Technical (Hospital) Services HC/HH Wch Supp Tena Underpad 23x24 Blue Chux__354 PX-2705000196 CDM 2705000196 LOCAL 270 RC inpatient 9 9 MULTIPLAN INC 34080 [3081285] MULTIPLAN INC [308128501] 8.55 percent of total billed charges 5.58 8.55 Technical (Hospital) Services HC/HH Wch Supp Tena Underpad 23x24 Blue Chux__354 PX-2705000196 CDM 2705000196 LOCAL 270 RC inpatient 9 9 BLUE CROSS BLUE SHIELD WELLMARK SB889 [3081026] BCBS WYOMING [308102603] 8.55 percent of total billed charges 5.58 8.55 Technical (Hospital) Services HC/HH Wch Supp Tena Underpad 23x24 Blue Chux__354 PX-2705000196 CDM 2705000196 LOCAL 270 RC inpatient 9 9 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES EPO [308136803] 7.13 percent of total billed charges 5.58 8.55 Technical (Hospital) Services HC/HH Wch Supp Tena Underpad 23x24 Blue Chux__354 PX-2705000196 CDM 2705000196 LOCAL 270 RC inpatient 9 9 HEALTHPARTNERS SX009 HEALTHPARTNERS 7.13 percent of total billed charges 5.58 8.55 Technical (Hospital) Services HC/HH Wch Supp Tena Underpad 23x24 Blue Chux__354 PX-2705000196 CDM 2705000196 LOCAL 270 RC inpatient 9 9 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES HDHP [308136802] 7.13 percent of total billed charges 5.58 8.55 Technical (Hospital) Services HC/HH Wch Supp Tena Underpad 23x24 Blue Chux__354 PX-2705000196 CDM 2705000196 LOCAL 270 RC inpatient 9 9 UNITED HEALTHCARE (COMMERCIAL) [3081199] UNITED HEALTHCARE 87726 [308119901] 5.58 percent of total billed charges 5.58 8.55 Technical (Hospital) Services HC/HH Wch Supp Tena Underpad 23x24 Blue Chux__354 PX-2705000196 CDM 2705000196 LOCAL 270 RC inpatient 9 9 MEDICA (COMMERCIAL) 94265 [3081118] MEDICA CLAIMS [308111801] 8.1 percent of total billed charges 5.58 8.55 Technical (Hospital) Services HC/HH Wch Supp Tena Underpad 23x24 Blue Chux__354 PX-2705000196 CDM 2705000196 LOCAL 270 RC inpatient 9 9 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES PPO [308136801] 7.13 percent of total billed charges 5.58 8.55 Technical (Hospital) Services HC/HH Wch Supp Tena Underpad 23x24 Blue Chux__354 PX-2705000196 CDM 2705000196 LOCAL 270 RC outpatient 9 9 UNITED HEALTHCARE (COMMERCIAL) [3081199] UNITED HEALTHCARE 87726 [308119901] 5.58 percent of total billed charges 5.58 8.55 Technical (Hospital) Services HC/HH Wch Supp Tena Underpad 23x24 Blue Chux__354 PX-2705000196 CDM 2705000196 LOCAL 270 RC outpatient 9 9 HEALTHPARTNERS SX009 HEALTHPARTNERS 7.2 percent of total billed charges 5.58 8.55 Technical (Hospital) Services HC/HH Wch Supp Tena Underpad 23x24 Blue Chux__354 PX-2705000196 CDM 2705000196 LOCAL 270 RC outpatient 9 9 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES PPO [308136801] 7.2 percent of total billed charges 5.58 8.55 Technical (Hospital) Services HC/HH Wch Supp Tena Underpad 23x24 Blue Chux__354 PX-2705000196 CDM 2705000196 LOCAL 270 RC outpatient 9 9 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES HDHP [308136802] 7.2 percent of total billed charges 5.58 8.55 Technical (Hospital) Services HC/HH Wch Supp Tena Underpad 23x24 Blue Chux__354 PX-2705000196 CDM 2705000196 LOCAL 270 RC outpatient 9 9 CIGNA 62308 [3081051] CIGNA 62308 [308105105] 7.2 percent of total billed charges 5.58 8.55 Technical (Hospital) Services HC/HH Wch Supp Tena Underpad 23x24 Blue Chux__354 PX-2705000196 CDM 2705000196 LOCAL 270 RC outpatient 9 9 CIGNA 62308 [3081051] CIGNA STATE OF WYOMING [308105107] 7.2 percent of total billed charges 5.58 8.55 Technical (Hospital) Services HC/HH Wch Supp Tena Underpad 23x24 Blue Chux__354 PX-2705000196 CDM 2705000196 LOCAL 270 RC outpatient 9 9 BLUE CROSS BLUE SHIELD WELLMARK SB889 [3081026] BCBS WYOMING [308102603] 8.55 percent of total billed charges 5.58 8.55 Technical (Hospital) Services HC/HH Wch Supp Tena Underpad 23x24 Blue Chux__354 PX-2705000196 CDM 2705000196 LOCAL 270 RC outpatient 9 9 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES EPO [308136803] 7.2 percent of total billed charges 5.58 8.55 Technical (Hospital) Services HC/HH Wch Supp Tena Underpad 23x24 Blue Chux__354 PX-2705000196 CDM 2705000196 LOCAL 270 RC outpatient 9 9 MULTIPLAN INC 34080 [3081285] MULTIPLAN INC [308128501] 8.55 percent of total billed charges 5.58 8.55 Technical (Hospital) Services HC/HH Wch Supp Tena Underpad 23x24 Blue Chux__354 PX-2705000196 CDM 2705000196 LOCAL 270 RC outpatient 9 9 MEDICA (COMMERCIAL) 94265 [3081118] MEDICA CLAIMS [308111801] 8.1 percent of total billed charges 5.58 8.55 Technical (Hospital) Services HC/HH Wch Supp Tena Pull-Ups Xlarge__72412 PX-2705000195 CDM 2705000195 LOCAL 270 RC inpatient 20 20 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES PPO [308136801] 15.84 percent of total billed charges 12.4 19 Technical (Hospital) Services HC/HH Wch Supp Tena Pull-Ups Xlarge__72412 PX-2705000195 CDM 2705000195 LOCAL 270 RC inpatient 20 20 MEDICA (COMMERCIAL) 94265 [3081118] MEDICA CLAIMS [308111801] 18 percent of total billed charges 12.4 19 Technical (Hospital) Services HC/HH Wch Supp Tena Pull-Ups Xlarge__72412 PX-2705000195 CDM 2705000195 LOCAL 270 RC inpatient 20 20 UNITED HEALTHCARE (COMMERCIAL) [3081199] UNITED HEALTHCARE 87726 [308119901] 12.4 percent of total billed charges 12.4 19 Technical (Hospital) Services HC/HH Wch Supp Tena Pull-Ups Xlarge__72412 PX-2705000195 CDM 2705000195 LOCAL 270 RC inpatient 20 20 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES HDHP [308136802] 15.84 percent of total billed charges 12.4 19 Technical (Hospital) Services HC/HH Wch Supp Tena Pull-Ups Xlarge__72412 PX-2705000195 CDM 2705000195 LOCAL 270 RC inpatient 20 20 HEALTHPARTNERS SX009 HEALTHPARTNERS 15.84 percent of total billed charges 12.4 19 Technical (Hospital) Services HC/HH Wch Supp Tena Pull-Ups Xlarge__72412 PX-2705000195 CDM 2705000195 LOCAL 270 RC inpatient 20 20 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES EPO [308136803] 15.84 percent of total billed charges 12.4 19 Technical (Hospital) Services HC/HH Wch Supp Tena Pull-Ups Xlarge__72412 PX-2705000195 CDM 2705000195 LOCAL 270 RC inpatient 20 20 BLUE CROSS BLUE SHIELD WELLMARK SB889 [3081026] BCBS WYOMING [308102603] 19 percent of total billed charges 12.4 19 Technical (Hospital) Services HC/HH Wch Supp Tena Pull-Ups Xlarge__72412 PX-2705000195 CDM 2705000195 LOCAL 270 RC inpatient 20 20 MULTIPLAN INC 34080 [3081285] MULTIPLAN INC [308128501] 19 percent of total billed charges 12.4 19 Technical (Hospital) Services HC/HH Wch Supp Tena Pull-Ups Xlarge__72412 PX-2705000195 CDM 2705000195 LOCAL 270 RC inpatient 20 20 CIGNA 62308 [3081051] CIGNA 62308 [308105105] 15.84 percent of total billed charges 12.4 19 Technical (Hospital) Services HC/HH Wch Supp Tena Pull-Ups Xlarge__72412 PX-2705000195 CDM 2705000195 LOCAL 270 RC inpatient 20 20 CIGNA 62308 [3081051] CIGNA STATE OF WYOMING [308105107] 15.84 percent of total billed charges 12.4 19 Technical (Hospital) Services HC/HH Wch Supp Tena Pull-Ups Xlarge__72412 PX-2705000195 CDM 2705000195 LOCAL 270 RC outpatient 20 20 CIGNA 62308 [3081051] CIGNA 62308 [308105105] 16 percent of total billed charges 12.4 19 Technical (Hospital) Services HC/HH Wch Supp Tena Pull-Ups Xlarge__72412 PX-2705000195 CDM 2705000195 LOCAL 270 RC outpatient 20 20 CIGNA 62308 [3081051] CIGNA STATE OF WYOMING [308105107] 16 percent of total billed charges 12.4 19 Technical (Hospital) Services HC/HH Wch Supp Tena Pull-Ups Xlarge__72412 PX-2705000195 CDM 2705000195 LOCAL 270 RC outpatient 20 20 BLUE CROSS BLUE SHIELD WELLMARK SB889 [3081026] BCBS WYOMING [308102603] 19 percent of total billed charges 12.4 19 Technical (Hospital) Services HC/HH Wch Supp Tena Pull-Ups Xlarge__72412 PX-2705000195 CDM 2705000195 LOCAL 270 RC outpatient 20 20 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES EPO [308136803] 16 percent of total billed charges 12.4 19 Technical (Hospital) Services HC/HH Wch Supp Tena Pull-Ups Xlarge__72412 PX-2705000195 CDM 2705000195 LOCAL 270 RC outpatient 20 20 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES HDHP [308136802] 16 percent of total billed charges 12.4 19 Technical (Hospital) Services HC/HH Wch Supp Tena Pull-Ups Xlarge__72412 PX-2705000195 CDM 2705000195 LOCAL 270 RC outpatient 20 20 UNITED HEALTHCARE (COMMERCIAL) [3081199] UNITED HEALTHCARE 87726 [308119901] 12.4 percent of total billed charges 12.4 19 Technical (Hospital) Services HC/HH Wch Supp Tena Pull-Ups Xlarge__72412 PX-2705000195 CDM 2705000195 LOCAL 270 RC outpatient 20 20 HEALTHPARTNERS SX009 HEALTHPARTNERS 16 percent of total billed charges 12.4 19 Technical (Hospital) Services HC/HH Wch Supp Tena Pull-Ups Xlarge__72412 PX-2705000195 CDM 2705000195 LOCAL 270 RC outpatient 20 20 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES PPO [308136801] 16 percent of total billed charges 12.4 19 Technical (Hospital) Services HC/HH Wch Supp Tena Pull-Ups Xlarge__72412 PX-2705000195 CDM 2705000195 LOCAL 270 RC outpatient 20 20 MULTIPLAN INC 34080 [3081285] MULTIPLAN INC [308128501] 19 percent of total billed charges 12.4 19 Technical (Hospital) Services HC/HH Wch Supp Tena Pull-Ups Xlarge__72412 PX-2705000195 CDM 2705000195 LOCAL 270 RC outpatient 20 20 MEDICA (COMMERCIAL) 94265 [3081118] MEDICA CLAIMS [308111801] 18 percent of total billed charges 12.4 19 Technical (Hospital) Services HC/HH Wch Supp Teds Thigh High Sm/Short__3071lf PX-2705000194 CDM 2705000194 LOCAL 270 RC outpatient 41 41 MULTIPLAN INC 34080 [3081285] MULTIPLAN INC [308128501] 38.95 percent of total billed charges 25.42 38.95 Technical (Hospital) Services HC/HH Wch Supp Teds Thigh High Sm/Short__3071lf PX-2705000194 CDM 2705000194 LOCAL 270 RC outpatient 41 41 MEDICA (COMMERCIAL) 94265 [3081118] MEDICA CLAIMS [308111801] 36.9 percent of total billed charges 25.42 38.95 Technical (Hospital) Services HC/HH Wch Supp Teds Thigh High Sm/Short__3071lf PX-2705000194 CDM 2705000194 LOCAL 270 RC outpatient 41 41 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES HDHP [308136802] 32.8 percent of total billed charges 25.42 38.95 Technical (Hospital) Services HC/HH Wch Supp Teds Thigh High Sm/Short__3071lf PX-2705000194 CDM 2705000194 LOCAL 270 RC outpatient 41 41 BLUE CROSS BLUE SHIELD WELLMARK SB889 [3081026] BCBS WYOMING [308102603] 38.95 percent of total billed charges 25.42 38.95 Technical (Hospital) Services HC/HH Wch Supp Teds Thigh High Sm/Short__3071lf PX-2705000194 CDM 2705000194 LOCAL 270 RC outpatient 41 41 CIGNA 62308 [3081051] CIGNA 62308 [308105105] 32.8 percent of total billed charges 25.42 38.95 Technical (Hospital) Services HC/HH Wch Supp Teds Thigh High Sm/Short__3071lf PX-2705000194 CDM 2705000194 LOCAL 270 RC outpatient 41 41 CIGNA 62308 [3081051] CIGNA STATE OF WYOMING [308105107] 32.8 percent of total billed charges 25.42 38.95 Technical (Hospital) Services HC/HH Wch Supp Teds Thigh High Sm/Short__3071lf PX-2705000194 CDM 2705000194 LOCAL 270 RC outpatient 41 41 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES EPO [308136803] 32.8 percent of total billed charges 25.42 38.95 Technical (Hospital) Services HC/HH Wch Supp Teds Thigh High Sm/Short__3071lf PX-2705000194 CDM 2705000194 LOCAL 270 RC outpatient 41 41 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES PPO [308136801] 32.8 percent of total billed charges 25.42 38.95 Technical (Hospital) Services HC/HH Wch Supp Teds Thigh High Sm/Short__3071lf PX-2705000194 CDM 2705000194 LOCAL 270 RC outpatient 41 41 UNITED HEALTHCARE (COMMERCIAL) [3081199] UNITED HEALTHCARE 87726 [308119901] 25.42 percent of total billed charges 25.42 38.95 Technical (Hospital) Services HC/HH Wch Supp Teds Thigh High Sm/Short__3071lf PX-2705000194 CDM 2705000194 LOCAL 270 RC outpatient 41 41 HEALTHPARTNERS SX009 HEALTHPARTNERS 32.8 percent of total billed charges 25.42 38.95 Technical (Hospital) Services HC/HH Wch Supp Teds Thigh High Sm/Short__3071lf PX-2705000194 CDM 2705000194 LOCAL 270 RC inpatient 41 41 HEALTHPARTNERS SX009 HEALTHPARTNERS 32.46 percent of total billed charges 25.42 38.95 Technical (Hospital) Services HC/HH Wch Supp Teds Thigh High Sm/Short__3071lf PX-2705000194 CDM 2705000194 LOCAL 270 RC inpatient 41 41 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES EPO [308136803] 32.46 percent of total billed charges 25.42 38.95 Technical (Hospital) Services HC/HH Wch Supp Teds Thigh High Sm/Short__3071lf PX-2705000194 CDM 2705000194 LOCAL 270 RC inpatient 41 41 CIGNA 62308 [3081051] CIGNA 62308 [308105105] 32.46 percent of total billed charges 25.42 38.95 Technical (Hospital) Services HC/HH Wch Supp Teds Thigh High Sm/Short__3071lf PX-2705000194 CDM 2705000194 LOCAL 270 RC inpatient 41 41 CIGNA 62308 [3081051] CIGNA STATE OF WYOMING [308105107] 32.46 percent of total billed charges 25.42 38.95 Technical (Hospital) Services HC/HH Wch Supp Teds Thigh High Sm/Short__3071lf PX-2705000194 CDM 2705000194 LOCAL 270 RC inpatient 41 41 MULTIPLAN INC 34080 [3081285] MULTIPLAN INC [308128501] 38.95 percent of total billed charges 25.42 38.95 Technical (Hospital) Services HC/HH Wch Supp Teds Thigh High Sm/Short__3071lf PX-2705000194 CDM 2705000194 LOCAL 270 RC inpatient 41 41 BLUE CROSS BLUE SHIELD WELLMARK SB889 [3081026] BCBS WYOMING [308102603] 38.95 percent of total billed charges 25.42 38.95 Technical (Hospital) Services HC/HH Wch Supp Teds Thigh High Sm/Short__3071lf PX-2705000194 CDM 2705000194 LOCAL 270 RC inpatient 41 41 UNITED HEALTHCARE (COMMERCIAL) [3081199] UNITED HEALTHCARE 87726 [308119901] 25.42 percent of total billed charges 25.42 38.95 Technical (Hospital) Services HC/HH Wch Supp Teds Thigh High Sm/Short__3071lf PX-2705000194 CDM 2705000194 LOCAL 270 RC inpatient 41 41 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES HDHP [308136802] 32.46 percent of total billed charges 25.42 38.95 Technical (Hospital) Services HC/HH Wch Supp Teds Thigh High Sm/Short__3071lf PX-2705000194 CDM 2705000194 LOCAL 270 RC inpatient 41 41 MEDICA (COMMERCIAL) 94265 [3081118] MEDICA CLAIMS [308111801] 36.9 percent of total billed charges 25.42 38.95 Technical (Hospital) Services HC/HH Wch Supp Teds Thigh High Sm/Short__3071lf PX-2705000194 CDM 2705000194 LOCAL 270 RC inpatient 41 41 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES PPO [308136801] 32.46 percent of total billed charges 25.42 38.95 Technical (Hospital) Services HC/HH Wch Supp Teds Thigh High Sm/Reg__3130lf PX-2705000193 CDM 2705000193 LOCAL 270 RC inpatient 44 44 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES PPO [308136801] 34.84 percent of total billed charges 27.28 41.8 Technical (Hospital) Services HC/HH Wch Supp Teds Thigh High Sm/Reg__3130lf PX-2705000193 CDM 2705000193 LOCAL 270 RC outpatient 44 44 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES HDHP [308136802] 35.2 percent of total billed charges 27.28 41.8 Technical (Hospital) Services HC/HH Wch Supp Teds Thigh High Sm/Reg__3130lf PX-2705000193 CDM 2705000193 LOCAL 270 RC outpatient 44 44 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES EPO [308136803] 35.2 percent of total billed charges 27.28 41.8 Technical (Hospital) Services HC/HH Wch Supp Teds Thigh High Sm/Reg__3130lf PX-2705000193 CDM 2705000193 LOCAL 270 RC outpatient 44 44 CIGNA 62308 [3081051] CIGNA 62308 [308105105] 35.2 percent of total billed charges 27.28 41.8 Technical (Hospital) Services HC/HH Wch Supp Teds Thigh High Sm/Reg__3130lf PX-2705000193 CDM 2705000193 LOCAL 270 RC outpatient 44 44 BLUE CROSS BLUE SHIELD WELLMARK SB889 [3081026] BCBS WYOMING [308102603] 41.8 percent of total billed charges 27.28 41.8 Technical (Hospital) Services HC/HH Wch Supp Teds Thigh High Sm/Reg__3130lf PX-2705000193 CDM 2705000193 LOCAL 270 RC outpatient 44 44 CIGNA 62308 [3081051] CIGNA STATE OF WYOMING [308105107] 35.2 percent of total billed charges 27.28 41.8 Technical (Hospital) Services HC/HH Wch Supp Teds Thigh High Sm/Reg__3130lf PX-2705000193 CDM 2705000193 LOCAL 270 RC outpatient 44 44 UNITED HEALTHCARE (COMMERCIAL) [3081199] UNITED HEALTHCARE 87726 [308119901] 27.28 percent of total billed charges 27.28 41.8 Technical (Hospital) Services HC/HH Wch Supp Teds Thigh High Sm/Reg__3130lf PX-2705000193 CDM 2705000193 LOCAL 270 RC outpatient 44 44 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES PPO [308136801] 35.2 percent of total billed charges 27.28 41.8 Technical (Hospital) Services HC/HH Wch Supp Teds Thigh High Sm/Reg__3130lf PX-2705000193 CDM 2705000193 LOCAL 270 RC outpatient 44 44 HEALTHPARTNERS SX009 HEALTHPARTNERS 35.2 percent of total billed charges 27.28 41.8 Technical (Hospital) Services HC/HH Wch Supp Teds Thigh High Sm/Reg__3130lf PX-2705000193 CDM 2705000193 LOCAL 270 RC outpatient 44 44 MULTIPLAN INC 34080 [3081285] MULTIPLAN INC [308128501] 41.8 percent of total billed charges 27.28 41.8 Technical (Hospital) Services HC/HH Wch Supp Teds Thigh High Sm/Reg__3130lf PX-2705000193 CDM 2705000193 LOCAL 270 RC outpatient 44 44 MEDICA (COMMERCIAL) 94265 [3081118] MEDICA CLAIMS [308111801] 39.6 percent of total billed charges 27.28 41.8 Technical (Hospital) Services HC/HH Wch Supp Teds Thigh High Sm/Reg__3130lf PX-2705000193 CDM 2705000193 LOCAL 270 RC inpatient 44 44 MEDICA (COMMERCIAL) 94265 [3081118] MEDICA CLAIMS [308111801] 39.6 percent of total billed charges 27.28 41.8 Technical (Hospital) Services HC/HH Wch Supp Teds Thigh High Sm/Reg__3130lf PX-2705000193 CDM 2705000193 LOCAL 270 RC inpatient 44 44 UNITED HEALTHCARE (COMMERCIAL) [3081199] UNITED HEALTHCARE 87726 [308119901] 27.28 percent of total billed charges 27.28 41.8 Technical (Hospital) Services HC/HH Wch Supp Teds Thigh High Sm/Reg__3130lf PX-2705000193 CDM 2705000193 LOCAL 270 RC inpatient 44 44 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES HDHP [308136802] 34.84 percent of total billed charges 27.28 41.8 Technical (Hospital) Services HC/HH Wch Supp Teds Thigh High Sm/Reg__3130lf PX-2705000193 CDM 2705000193 LOCAL 270 RC inpatient 44 44 MULTIPLAN INC 34080 [3081285] MULTIPLAN INC [308128501] 41.8 percent of total billed charges 27.28 41.8 Technical (Hospital) Services HC/HH Wch Supp Teds Thigh High Sm/Reg__3130lf PX-2705000193 CDM 2705000193 LOCAL 270 RC inpatient 44 44 BLUE CROSS BLUE SHIELD WELLMARK SB889 [3081026] BCBS WYOMING [308102603] 41.8 percent of total billed charges 27.28 41.8 Technical (Hospital) Services HC/HH Wch Supp Teds Thigh High Sm/Reg__3130lf PX-2705000193 CDM 2705000193 LOCAL 270 RC inpatient 44 44 CIGNA 62308 [3081051] CIGNA 62308 [308105105] 34.84 percent of total billed charges 27.28 41.8 Technical (Hospital) Services HC/HH Wch Supp Teds Thigh High Sm/Reg__3130lf PX-2705000193 CDM 2705000193 LOCAL 270 RC inpatient 44 44 CIGNA 62308 [3081051] CIGNA STATE OF WYOMING [308105107] 34.84 percent of total billed charges 27.28 41.8 Technical (Hospital) Services HC/HH Wch Supp Teds Thigh High Sm/Reg__3130lf PX-2705000193 CDM 2705000193 LOCAL 270 RC inpatient 44 44 HEALTHPARTNERS SX009 HEALTHPARTNERS 34.84 percent of total billed charges 27.28 41.8 Technical (Hospital) Services HC/HH Wch Supp Teds Thigh High Sm/Reg__3130lf PX-2705000193 CDM 2705000193 LOCAL 270 RC inpatient 44 44 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES EPO [308136803] 34.84 percent of total billed charges 27.28 41.8 Technical (Hospital) Services HC/HH Wch Supp Teds Thigh High Sm/Long__3222lf PX-2705000192 CDM 2705000192 LOCAL 270 RC outpatient 44 44 CIGNA 62308 [3081051] CIGNA 62308 [308105105] 35.2 percent of total billed charges 27.28 41.8 Technical (Hospital) Services HC/HH Wch Supp Teds Thigh High Sm/Long__3222lf PX-2705000192 CDM 2705000192 LOCAL 270 RC outpatient 44 44 CIGNA 62308 [3081051] CIGNA STATE OF WYOMING [308105107] 35.2 percent of total billed charges 27.28 41.8 Technical (Hospital) Services HC/HH Wch Supp Teds Thigh High Sm/Long__3222lf PX-2705000192 CDM 2705000192 LOCAL 270 RC outpatient 44 44 BLUE CROSS BLUE SHIELD WELLMARK SB889 [3081026] BCBS WYOMING [308102603] 41.8 percent of total billed charges 27.28 41.8 Technical (Hospital) Services HC/HH Wch Supp Teds Thigh High Sm/Long__3222lf PX-2705000192 CDM 2705000192 LOCAL 270 RC outpatient 44 44 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES EPO [308136803] 35.2 percent of total billed charges 27.28 41.8 Technical (Hospital) Services HC/HH Wch Supp Teds Thigh High Sm/Long__3222lf PX-2705000192 CDM 2705000192 LOCAL 270 RC outpatient 44 44 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES HDHP [308136802] 35.2 percent of total billed charges 27.28 41.8 Technical (Hospital) Services HC/HH Wch Supp Teds Thigh High Sm/Long__3222lf PX-2705000192 CDM 2705000192 LOCAL 270 RC outpatient 44 44 HEALTHPARTNERS SX009 HEALTHPARTNERS 35.2 percent of total billed charges 27.28 41.8 Technical (Hospital) Services HC/HH Wch Supp Teds Thigh High Sm/Long__3222lf PX-2705000192 CDM 2705000192 LOCAL 270 RC outpatient 44 44 UNITED HEALTHCARE (COMMERCIAL) [3081199] UNITED HEALTHCARE 87726 [308119901] 27.28 percent of total billed charges 27.28 41.8 Technical (Hospital) Services HC/HH Wch Supp Teds Thigh High Sm/Long__3222lf PX-2705000192 CDM 2705000192 LOCAL 270 RC outpatient 44 44 MULTIPLAN INC 34080 [3081285] MULTIPLAN INC [308128501] 41.8 percent of total billed charges 27.28 41.8 Technical (Hospital) Services HC/HH Wch Supp Teds Thigh High Sm/Long__3222lf PX-2705000192 CDM 2705000192 LOCAL 270 RC outpatient 44 44 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES PPO [308136801] 35.2 percent of total billed charges 27.28 41.8 Technical (Hospital) Services HC/HH Wch Supp Teds Thigh High Sm/Long__3222lf PX-2705000192 CDM 2705000192 LOCAL 270 RC outpatient 44 44 MEDICA (COMMERCIAL) 94265 [3081118] MEDICA CLAIMS [308111801] 39.6 percent of total billed charges 27.28 41.8 Technical (Hospital) Services HC/HH Wch Supp Teds Thigh High Sm/Long__3222lf PX-2705000192 CDM 2705000192 LOCAL 270 RC inpatient 44 44 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES PPO [308136801] 34.84 percent of total billed charges 27.28 41.8 Technical (Hospital) Services HC/HH Wch Supp Teds Thigh High Sm/Long__3222lf PX-2705000192 CDM 2705000192 LOCAL 270 RC inpatient 44 44 MEDICA (COMMERCIAL) 94265 [3081118] MEDICA CLAIMS [308111801] 39.6 percent of total billed charges 27.28 41.8 Technical (Hospital) Services HC/HH Wch Supp Teds Thigh High Sm/Long__3222lf PX-2705000192 CDM 2705000192 LOCAL 270 RC inpatient 44 44 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES HDHP [308136802] 34.84 percent of total billed charges 27.28 41.8 Technical (Hospital) Services HC/HH Wch Supp Teds Thigh High Sm/Long__3222lf PX-2705000192 CDM 2705000192 LOCAL 270 RC inpatient 44 44 UNITED HEALTHCARE (COMMERCIAL) [3081199] UNITED HEALTHCARE 87726 [308119901] 27.28 percent of total billed charges 27.28 41.8 Technical (Hospital) Services HC/HH Wch Supp Teds Thigh High Sm/Long__3222lf PX-2705000192 CDM 2705000192 LOCAL 270 RC inpatient 44 44 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES EPO [308136803] 34.84 percent of total billed charges 27.28 41.8 Technical (Hospital) Services HC/HH Wch Supp Teds Thigh High Sm/Long__3222lf PX-2705000192 CDM 2705000192 LOCAL 270 RC inpatient 44 44 HEALTHPARTNERS SX009 HEALTHPARTNERS 34.84 percent of total billed charges 27.28 41.8 Technical (Hospital) Services HC/HH Wch Supp Teds Thigh High Sm/Long__3222lf PX-2705000192 CDM 2705000192 LOCAL 270 RC inpatient 44 44 BLUE CROSS BLUE SHIELD WELLMARK SB889 [3081026] BCBS WYOMING [308102603] 41.8 percent of total billed charges 27.28 41.8 Technical (Hospital) Services HC/HH Wch Supp Teds Thigh High Sm/Long__3222lf PX-2705000192 CDM 2705000192 LOCAL 270 RC inpatient 44 44 MULTIPLAN INC 34080 [3081285] MULTIPLAN INC [308128501] 41.8 percent of total billed charges 27.28 41.8 Technical (Hospital) Services HC/HH Wch Supp Teds Thigh High Sm/Long__3222lf PX-2705000192 CDM 2705000192 LOCAL 270 RC inpatient 44 44 CIGNA 62308 [3081051] CIGNA 62308 [308105105] 34.84 percent of total billed charges 27.28 41.8 Technical (Hospital) Services HC/HH Wch Supp Teds Thigh High Sm/Long__3222lf PX-2705000192 CDM 2705000192 LOCAL 270 RC inpatient 44 44 CIGNA 62308 [3081051] CIGNA STATE OF WYOMING [308105107] 34.84 percent of total billed charges 27.28 41.8 Technical (Hospital) Services HC/HH Wch Supp Teds Thigh High Med/Short__3310lf PX-2705000191 CDM 2705000191 LOCAL 270 RC inpatient 44 44 MEDICA (COMMERCIAL) 94265 [3081118] MEDICA CLAIMS [308111801] 39.6 percent of total billed charges 27.28 41.8 Technical (Hospital) Services HC/HH Wch Supp Teds Thigh High Med/Short__3310lf PX-2705000191 CDM 2705000191 LOCAL 270 RC inpatient 44 44 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES PPO [308136801] 34.84 percent of total billed charges 27.28 41.8 Technical (Hospital) Services HC/HH Wch Supp Teds Thigh High Med/Short__3310lf PX-2705000191 CDM 2705000191 LOCAL 270 RC inpatient 44 44 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES HDHP [308136802] 34.84 percent of total billed charges 27.28 41.8 Technical (Hospital) Services HC/HH Wch Supp Teds Thigh High Med/Short__3310lf PX-2705000191 CDM 2705000191 LOCAL 270 RC inpatient 44 44 UNITED HEALTHCARE (COMMERCIAL) [3081199] UNITED HEALTHCARE 87726 [308119901] 27.28 percent of total billed charges 27.28 41.8 Technical (Hospital) Services HC/HH Wch Supp Teds Thigh High Med/Short__3310lf PX-2705000191 CDM 2705000191 LOCAL 270 RC inpatient 44 44 BLUE CROSS BLUE SHIELD WELLMARK SB889 [3081026] BCBS WYOMING [308102603] 41.8 percent of total billed charges 27.28 41.8 Technical (Hospital) Services HC/HH Wch Supp Teds Thigh High Med/Short__3310lf PX-2705000191 CDM 2705000191 LOCAL 270 RC inpatient 44 44 MULTIPLAN INC 34080 [3081285] MULTIPLAN INC [308128501] 41.8 percent of total billed charges 27.28 41.8 Technical (Hospital) Services HC/HH Wch Supp Teds Thigh High Med/Short__3310lf PX-2705000191 CDM 2705000191 LOCAL 270 RC inpatient 44 44 CIGNA 62308 [3081051] CIGNA 62308 [308105105] 34.84 percent of total billed charges 27.28 41.8 Technical (Hospital) Services HC/HH Wch Supp Teds Thigh High Med/Short__3310lf PX-2705000191 CDM 2705000191 LOCAL 270 RC inpatient 44 44 CIGNA 62308 [3081051] CIGNA STATE OF WYOMING [308105107] 34.84 percent of total billed charges 27.28 41.8 Technical (Hospital) Services HC/HH Wch Supp Teds Thigh High Med/Short__3310lf PX-2705000191 CDM 2705000191 LOCAL 270 RC inpatient 44 44 HEALTHPARTNERS SX009 HEALTHPARTNERS 34.84 percent of total billed charges 27.28 41.8 Technical (Hospital) Services HC/HH Wch Supp Teds Thigh High Med/Short__3310lf PX-2705000191 CDM 2705000191 LOCAL 270 RC inpatient 44 44 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES EPO [308136803] 34.84 percent of total billed charges 27.28 41.8 Technical (Hospital) Services HC/HH Wch Supp Teds Thigh High Med/Short__3310lf PX-2705000191 CDM 2705000191 LOCAL 270 RC outpatient 44 44 MEDICA (COMMERCIAL) 94265 [3081118] MEDICA CLAIMS [308111801] 39.6 percent of total billed charges 27.28 41.8 Technical (Hospital) Services HC/HH Wch Supp Teds Thigh High Med/Short__3310lf PX-2705000191 CDM 2705000191 LOCAL 270 RC outpatient 44 44 MULTIPLAN INC 34080 [3081285] MULTIPLAN INC [308128501] 41.8 percent of total billed charges 27.28 41.8 Technical (Hospital) Services HC/HH Wch Supp Teds Thigh High Med/Short__3310lf PX-2705000191 CDM 2705000191 LOCAL 270 RC outpatient 44 44 UNITED HEALTHCARE (COMMERCIAL) [3081199] UNITED HEALTHCARE 87726 [308119901] 27.28 percent of total billed charges 27.28 41.8 Technical (Hospital) Services HC/HH Wch Supp Teds Thigh High Med/Short__3310lf PX-2705000191 CDM 2705000191 LOCAL 270 RC outpatient 44 44 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES PPO [308136801] 35.2 percent of total billed charges 27.28 41.8 Technical (Hospital) Services HC/HH Wch Supp Teds Thigh High Med/Short__3310lf PX-2705000191 CDM 2705000191 LOCAL 270 RC outpatient 44 44 HEALTHPARTNERS SX009 HEALTHPARTNERS 35.2 percent of total billed charges 27.28 41.8 Technical (Hospital) Services HC/HH Wch Supp Teds Thigh High Med/Short__3310lf PX-2705000191 CDM 2705000191 LOCAL 270 RC outpatient 44 44 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES HDHP [308136802] 35.2 percent of total billed charges 27.28 41.8 Technical (Hospital) Services HC/HH Wch Supp Teds Thigh High Med/Short__3310lf PX-2705000191 CDM 2705000191 LOCAL 270 RC outpatient 44 44 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES EPO [308136803] 35.2 percent of total billed charges 27.28 41.8 Technical (Hospital) Services HC/HH Wch Supp Teds Thigh High Med/Short__3310lf PX-2705000191 CDM 2705000191 LOCAL 270 RC outpatient 44 44 BLUE CROSS BLUE SHIELD WELLMARK SB889 [3081026] BCBS WYOMING [308102603] 41.8 percent of total billed charges 27.28 41.8 Technical (Hospital) Services HC/HH Wch Supp Teds Thigh High Med/Short__3310lf PX-2705000191 CDM 2705000191 LOCAL 270 RC outpatient 44 44 CIGNA 62308 [3081051] CIGNA 62308 [308105105] 35.2 percent of total billed charges 27.28 41.8 Technical (Hospital) Services HC/HH Wch Supp Teds Thigh High Med/Short__3310lf PX-2705000191 CDM 2705000191 LOCAL 270 RC outpatient 44 44 CIGNA 62308 [3081051] CIGNA STATE OF WYOMING [308105107] 35.2 percent of total billed charges 27.28 41.8 Technical (Hospital) Services HC/HH Wch Supp Teds Thigh High Med/Reg__3416lf PX-2705000190 CDM 2705000190 LOCAL 270 RC outpatient 44 44 CIGNA 62308 [3081051] CIGNA 62308 [308105105] 35.2 percent of total billed charges 27.28 41.8 Technical (Hospital) Services HC/HH Wch Supp Teds Thigh High Med/Reg__3416lf PX-2705000190 CDM 2705000190 LOCAL 270 RC outpatient 44 44 CIGNA 62308 [3081051] CIGNA STATE OF WYOMING [308105107] 35.2 percent of total billed charges 27.28 41.8 Technical (Hospital) Services HC/HH Wch Supp Teds Thigh High Med/Reg__3416lf PX-2705000190 CDM 2705000190 LOCAL 270 RC outpatient 44 44 BLUE CROSS BLUE SHIELD WELLMARK SB889 [3081026] BCBS WYOMING [308102603] 41.8 percent of total billed charges 27.28 41.8 Technical (Hospital) Services HC/HH Wch Supp Teds Thigh High Med/Reg__3416lf PX-2705000190 CDM 2705000190 LOCAL 270 RC outpatient 44 44 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES EPO [308136803] 35.2 percent of total billed charges 27.28 41.8 Technical (Hospital) Services HC/HH Wch Supp Teds Thigh High Med/Reg__3416lf PX-2705000190 CDM 2705000190 LOCAL 270 RC outpatient 44 44 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES HDHP [308136802] 35.2 percent of total billed charges 27.28 41.8 Technical (Hospital) Services HC/HH Wch Supp Teds Thigh High Med/Reg__3416lf PX-2705000190 CDM 2705000190 LOCAL 270 RC outpatient 44 44 HEALTHPARTNERS SX009 HEALTHPARTNERS 35.2 percent of total billed charges 27.28 41.8 Technical (Hospital) Services HC/HH Wch Supp Teds Thigh High Med/Reg__3416lf PX-2705000190 CDM 2705000190 LOCAL 270 RC outpatient 44 44 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES PPO [308136801] 35.2 percent of total billed charges 27.28 41.8 Technical (Hospital) Services HC/HH Wch Supp Teds Thigh High Med/Reg__3416lf PX-2705000190 CDM 2705000190 LOCAL 270 RC outpatient 44 44 UNITED HEALTHCARE (COMMERCIAL) [3081199] UNITED HEALTHCARE 87726 [308119901] 27.28 percent of total billed charges 27.28 41.8 Technical (Hospital) Services HC/HH Wch Supp Teds Thigh High Med/Reg__3416lf PX-2705000190 CDM 2705000190 LOCAL 270 RC outpatient 44 44 MULTIPLAN INC 34080 [3081285] MULTIPLAN INC [308128501] 41.8 percent of total billed charges 27.28 41.8 Technical (Hospital) Services HC/HH Wch Supp Teds Thigh High Med/Reg__3416lf PX-2705000190 CDM 2705000190 LOCAL 270 RC outpatient 44 44 MEDICA (COMMERCIAL) 94265 [3081118] MEDICA CLAIMS [308111801] 39.6 percent of total billed charges 27.28 41.8 Technical (Hospital) Services HC/HH Wch Supp Teds Thigh High Med/Reg__3416lf PX-2705000190 CDM 2705000190 LOCAL 270 RC inpatient 44 44 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES EPO [308136803] 34.84 percent of total billed charges 27.28 41.8 Technical (Hospital) Services HC/HH Wch Supp Teds Thigh High Med/Reg__3416lf PX-2705000190 CDM 2705000190 LOCAL 270 RC inpatient 44 44 HEALTHPARTNERS SX009 HEALTHPARTNERS 34.84 percent of total billed charges 27.28 41.8 Technical (Hospital) Services HC/HH Wch Supp Teds Thigh High Med/Reg__3416lf PX-2705000190 CDM 2705000190 LOCAL 270 RC inpatient 44 44 CIGNA 62308 [3081051] CIGNA 62308 [308105105] 34.84 percent of total billed charges 27.28 41.8 Technical (Hospital) Services HC/HH Wch Supp Teds Thigh High Med/Reg__3416lf PX-2705000190 CDM 2705000190 LOCAL 270 RC inpatient 44 44 CIGNA 62308 [3081051] CIGNA STATE OF WYOMING [308105107] 34.84 percent of total billed charges 27.28 41.8 Technical (Hospital) Services HC/HH Wch Supp Teds Thigh High Med/Reg__3416lf PX-2705000190 CDM 2705000190 LOCAL 270 RC inpatient 44 44 BLUE CROSS BLUE SHIELD WELLMARK SB889 [3081026] BCBS WYOMING [308102603] 41.8 percent of total billed charges 27.28 41.8 Technical (Hospital) Services HC/HH Wch Supp Teds Thigh High Med/Reg__3416lf PX-2705000190 CDM 2705000190 LOCAL 270 RC inpatient 44 44 MULTIPLAN INC 34080 [3081285] MULTIPLAN INC [308128501] 41.8 percent of total billed charges 27.28 41.8 Technical (Hospital) Services HC/HH Wch Supp Teds Thigh High Med/Reg__3416lf PX-2705000190 CDM 2705000190 LOCAL 270 RC inpatient 44 44 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES HDHP [308136802] 34.84 percent of total billed charges 27.28 41.8 Technical (Hospital) Services HC/HH Wch Supp Teds Thigh High Med/Reg__3416lf PX-2705000190 CDM 2705000190 LOCAL 270 RC inpatient 44 44 UNITED HEALTHCARE (COMMERCIAL) [3081199] UNITED HEALTHCARE 87726 [308119901] 27.28 percent of total billed charges 27.28 41.8 Technical (Hospital) Services HC/HH Wch Supp Teds Thigh High Med/Reg__3416lf PX-2705000190 CDM 2705000190 LOCAL 270 RC inpatient 44 44 MEDICA (COMMERCIAL) 94265 [3081118] MEDICA CLAIMS [308111801] 39.6 percent of total billed charges 27.28 41.8 Technical (Hospital) Services HC/HH Wch Supp Teds Thigh High Med/Reg__3416lf PX-2705000190 CDM 2705000190 LOCAL 270 RC inpatient 44 44 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES PPO [308136801] 34.84 percent of total billed charges 27.28 41.8 Technical (Hospital) Services HC/HH Wch Supp Teds Thigh High Med/Long__3549lf PX-2705000189 CDM 2705000189 LOCAL 270 RC outpatient 44 44 HEALTHPARTNERS SX009 HEALTHPARTNERS 35.2 percent of total billed charges 27.28 41.8 Technical (Hospital) Services HC/HH Wch Supp Teds Thigh High Med/Long__3549lf PX-2705000189 CDM 2705000189 LOCAL 270 RC outpatient 44 44 UNITED HEALTHCARE (COMMERCIAL) [3081199] UNITED HEALTHCARE 87726 [308119901] 27.28 percent of total billed charges 27.28 41.8 Technical (Hospital) Services HC/HH Wch Supp Teds Thigh High Med/Long__3549lf PX-2705000189 CDM 2705000189 LOCAL 270 RC outpatient 44 44 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES HDHP [308136802] 35.2 percent of total billed charges 27.28 41.8 Technical (Hospital) Services HC/HH Wch Supp Teds Thigh High Med/Long__3549lf PX-2705000189 CDM 2705000189 LOCAL 270 RC outpatient 44 44 CIGNA 62308 [3081051] CIGNA 62308 [308105105] 35.2 percent of total billed charges 27.28 41.8 Technical (Hospital) Services HC/HH Wch Supp Teds Thigh High Med/Long__3549lf PX-2705000189 CDM 2705000189 LOCAL 270 RC outpatient 44 44 CIGNA 62308 [3081051] CIGNA STATE OF WYOMING [308105107] 35.2 percent of total billed charges 27.28 41.8 Technical (Hospital) Services HC/HH Wch Supp Teds Thigh High Med/Long__3549lf PX-2705000189 CDM 2705000189 LOCAL 270 RC outpatient 44 44 BLUE CROSS BLUE SHIELD WELLMARK SB889 [3081026] BCBS WYOMING [308102603] 41.8 percent of total billed charges 27.28 41.8 Technical (Hospital) Services HC/HH Wch Supp Teds Thigh High Med/Long__3549lf PX-2705000189 CDM 2705000189 LOCAL 270 RC outpatient 44 44 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES EPO [308136803] 35.2 percent of total billed charges 27.28 41.8 Technical (Hospital) Services HC/HH Wch Supp Teds Thigh High Med/Long__3549lf PX-2705000189 CDM 2705000189 LOCAL 270 RC outpatient 44 44 MULTIPLAN INC 34080 [3081285] MULTIPLAN INC [308128501] 41.8 percent of total billed charges 27.28 41.8 Technical (Hospital) Services HC/HH Wch Supp Teds Thigh High Med/Long__3549lf PX-2705000189 CDM 2705000189 LOCAL 270 RC outpatient 44 44 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES PPO [308136801] 35.2 percent of total billed charges 27.28 41.8 Technical (Hospital) Services HC/HH Wch Supp Teds Thigh High Med/Long__3549lf PX-2705000189 CDM 2705000189 LOCAL 270 RC outpatient 44 44 MEDICA (COMMERCIAL) 94265 [3081118] MEDICA CLAIMS [308111801] 39.6 percent of total billed charges 27.28 41.8 Technical (Hospital) Services HC/HH Wch Supp Teds Thigh High Med/Long__3549lf PX-2705000189 CDM 2705000189 LOCAL 270 RC inpatient 44 44 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES PPO [308136801] 34.84 percent of total billed charges 27.28 41.8 Technical (Hospital) Services HC/HH Wch Supp Teds Thigh High Med/Long__3549lf PX-2705000189 CDM 2705000189 LOCAL 270 RC inpatient 44 44 MEDICA (COMMERCIAL) 94265 [3081118] MEDICA CLAIMS [308111801] 39.6 percent of total billed charges 27.28 41.8 Technical (Hospital) Services HC/HH Wch Supp Teds Thigh High Med/Long__3549lf PX-2705000189 CDM 2705000189 LOCAL 270 RC inpatient 44 44 UNITED HEALTHCARE (COMMERCIAL) [3081199] UNITED HEALTHCARE 87726 [308119901] 27.28 percent of total billed charges 27.28 41.8 Technical (Hospital) Services HC/HH Wch Supp Teds Thigh High Med/Long__3549lf PX-2705000189 CDM 2705000189 LOCAL 270 RC inpatient 44 44 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES HDHP [308136802] 34.84 percent of total billed charges 27.28 41.8 Technical (Hospital) Services HC/HH Wch Supp Teds Thigh High Med/Long__3549lf PX-2705000189 CDM 2705000189 LOCAL 270 RC inpatient 44 44 BLUE CROSS BLUE SHIELD WELLMARK SB889 [3081026] BCBS WYOMING [308102603] 41.8 percent of total billed charges 27.28 41.8 Technical (Hospital) Services HC/HH Wch Supp Teds Thigh High Med/Long__3549lf PX-2705000189 CDM 2705000189 LOCAL 270 RC inpatient 44 44 MULTIPLAN INC 34080 [3081285] MULTIPLAN INC [308128501] 41.8 percent of total billed charges 27.28 41.8 Technical (Hospital) Services HC/HH Wch Supp Teds Thigh High Med/Long__3549lf PX-2705000189 CDM 2705000189 LOCAL 270 RC inpatient 44 44 CIGNA 62308 [3081051] CIGNA 62308 [308105105] 34.84 percent of total billed charges 27.28 41.8 Technical (Hospital) Services HC/HH Wch Supp Teds Thigh High Med/Long__3549lf PX-2705000189 CDM 2705000189 LOCAL 270 RC inpatient 44 44 CIGNA 62308 [3081051] CIGNA STATE OF WYOMING [308105107] 34.84 percent of total billed charges 27.28 41.8 Technical (Hospital) Services HC/HH Wch Supp Teds Thigh High Med/Long__3549lf PX-2705000189 CDM 2705000189 LOCAL 270 RC inpatient 44 44 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES EPO [308136803] 34.84 percent of total billed charges 27.28 41.8 Technical (Hospital) Services HC/HH Wch Supp Teds Thigh High Med/Long__3549lf PX-2705000189 CDM 2705000189 LOCAL 270 RC inpatient 44 44 HEALTHPARTNERS SX009 HEALTHPARTNERS 34.84 percent of total billed charges 27.28 41.8 Technical (Hospital) Services HC/HH Wch Supp Teds Thigh High Lrg/Long__3856lf PX-2705000188 CDM 2705000188 LOCAL 270 RC outpatient 44 44 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES PPO [308136801] 35.2 percent of total billed charges 27.28 41.8 Technical (Hospital) Services HC/HH Wch Supp Teds Thigh High Lrg/Long__3856lf PX-2705000188 CDM 2705000188 LOCAL 270 RC outpatient 44 44 MULTIPLAN INC 34080 [3081285] MULTIPLAN INC [308128501] 41.8 percent of total billed charges 27.28 41.8 Technical (Hospital) Services HC/HH Wch Supp Teds Thigh High Lrg/Long__3856lf PX-2705000188 CDM 2705000188 LOCAL 270 RC outpatient 44 44 MEDICA (COMMERCIAL) 94265 [3081118] MEDICA CLAIMS [308111801] 39.6 percent of total billed charges 27.28 41.8 Technical (Hospital) Services HC/HH Wch Supp Teds Thigh High Lrg/Long__3856lf PX-2705000188 CDM 2705000188 LOCAL 270 RC outpatient 44 44 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES HDHP [308136802] 35.2 percent of total billed charges 27.28 41.8 Technical (Hospital) Services HC/HH Wch Supp Teds Thigh High Lrg/Long__3856lf PX-2705000188 CDM 2705000188 LOCAL 270 RC outpatient 44 44 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES EPO [308136803] 35.2 percent of total billed charges 27.28 41.8 Technical (Hospital) Services HC/HH Wch Supp Teds Thigh High Lrg/Long__3856lf PX-2705000188 CDM 2705000188 LOCAL 270 RC outpatient 44 44 CIGNA 62308 [3081051] CIGNA 62308 [308105105] 35.2 percent of total billed charges 27.28 41.8 Technical (Hospital) Services HC/HH Wch Supp Teds Thigh High Lrg/Long__3856lf PX-2705000188 CDM 2705000188 LOCAL 270 RC outpatient 44 44 CIGNA 62308 [3081051] CIGNA STATE OF WYOMING [308105107] 35.2 percent of total billed charges 27.28 41.8 Technical (Hospital) Services HC/HH Wch Supp Teds Thigh High Lrg/Long__3856lf PX-2705000188 CDM 2705000188 LOCAL 270 RC outpatient 44 44 BLUE CROSS BLUE SHIELD WELLMARK SB889 [3081026] BCBS WYOMING [308102603] 41.8 percent of total billed charges 27.28 41.8 Technical (Hospital) Services HC/HH Wch Supp Teds Thigh High Lrg/Long__3856lf PX-2705000188 CDM 2705000188 LOCAL 270 RC outpatient 44 44 HEALTHPARTNERS SX009 HEALTHPARTNERS 35.2 percent of total billed charges 27.28 41.8 Technical (Hospital) Services HC/HH Wch Supp Teds Thigh High Lrg/Long__3856lf PX-2705000188 CDM 2705000188 LOCAL 270 RC outpatient 44 44 UNITED HEALTHCARE (COMMERCIAL) [3081199] UNITED HEALTHCARE 87726 [308119901] 27.28 percent of total billed charges 27.28 41.8 Technical (Hospital) Services HC/HH Wch Supp Teds Thigh High Lrg/Long__3856lf PX-2705000188 CDM 2705000188 LOCAL 270 RC inpatient 44 44 CIGNA 62308 [3081051] CIGNA 62308 [308105105] 34.84 percent of total billed charges 27.28 41.8 Technical (Hospital) Services HC/HH Wch Supp Teds Thigh High Lrg/Long__3856lf PX-2705000188 CDM 2705000188 LOCAL 270 RC inpatient 44 44 CIGNA 62308 [3081051] CIGNA STATE OF WYOMING [308105107] 34.84 percent of total billed charges 27.28 41.8 Technical (Hospital) Services HC/HH Wch Supp Teds Thigh High Lrg/Long__3856lf PX-2705000188 CDM 2705000188 LOCAL 270 RC inpatient 44 44 MULTIPLAN INC 34080 [3081285] MULTIPLAN INC [308128501] 41.8 percent of total billed charges 27.28 41.8 Technical (Hospital) Services HC/HH Wch Supp Teds Thigh High Lrg/Long__3856lf PX-2705000188 CDM 2705000188 LOCAL 270 RC inpatient 44 44 BLUE CROSS BLUE SHIELD WELLMARK SB889 [3081026] BCBS WYOMING [308102603] 41.8 percent of total billed charges 27.28 41.8 Technical (Hospital) Services HC/HH Wch Supp Teds Thigh High Lrg/Long__3856lf PX-2705000188 CDM 2705000188 LOCAL 270 RC inpatient 44 44 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES EPO [308136803] 34.84 percent of total billed charges 27.28 41.8 Technical (Hospital) Services HC/HH Wch Supp Teds Thigh High Lrg/Long__3856lf PX-2705000188 CDM 2705000188 LOCAL 270 RC inpatient 44 44 HEALTHPARTNERS SX009 HEALTHPARTNERS 34.84 percent of total billed charges 27.28 41.8 Technical (Hospital) Services HC/HH Wch Supp Teds Thigh High Lrg/Long__3856lf PX-2705000188 CDM 2705000188 LOCAL 270 RC inpatient 44 44 UNITED HEALTHCARE (COMMERCIAL) [3081199] UNITED HEALTHCARE 87726 [308119901] 27.28 percent of total billed charges 27.28 41.8 Technical (Hospital) Services HC/HH Wch Supp Teds Thigh High Lrg/Long__3856lf PX-2705000188 CDM 2705000188 LOCAL 270 RC inpatient 44 44 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES HDHP [308136802] 34.84 percent of total billed charges 27.28 41.8 Technical (Hospital) Services HC/HH Wch Supp Teds Thigh High Lrg/Long__3856lf PX-2705000188 CDM 2705000188 LOCAL 270 RC inpatient 44 44 MEDICA (COMMERCIAL) 94265 [3081118] MEDICA CLAIMS [308111801] 39.6 percent of total billed charges 27.28 41.8 Technical (Hospital) Services HC/HH Wch Supp Teds Thigh High Lrg/Long__3856lf PX-2705000188 CDM 2705000188 LOCAL 270 RC inpatient 44 44 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES PPO [308136801] 34.84 percent of total billed charges 27.28 41.8 Technical (Hospital) Services HC/HH Wch Supp Teds Thigh High Lg/Short__3634lf PX-2705000187 CDM 2705000187 LOCAL 270 RC outpatient 44 44 UNITED HEALTHCARE (COMMERCIAL) [3081199] UNITED HEALTHCARE 87726 [308119901] 27.28 percent of total billed charges 27.28 41.8 Technical (Hospital) Services HC/HH Wch Supp Teds Thigh High Lg/Short__3634lf PX-2705000187 CDM 2705000187 LOCAL 270 RC outpatient 44 44 HEALTHPARTNERS SX009 HEALTHPARTNERS 35.2 percent of total billed charges 27.28 41.8 Technical (Hospital) Services HC/HH Wch Supp Teds Thigh High Lg/Short__3634lf PX-2705000187 CDM 2705000187 LOCAL 270 RC outpatient 44 44 BLUE CROSS BLUE SHIELD WELLMARK SB889 [3081026] BCBS WYOMING [308102603] 41.8 percent of total billed charges 27.28 41.8 Technical (Hospital) Services HC/HH Wch Supp Teds Thigh High Lg/Short__3634lf PX-2705000187 CDM 2705000187 LOCAL 270 RC outpatient 44 44 CIGNA 62308 [3081051] CIGNA 62308 [308105105] 35.2 percent of total billed charges 27.28 41.8 Technical (Hospital) Services HC/HH Wch Supp Teds Thigh High Lg/Short__3634lf PX-2705000187 CDM 2705000187 LOCAL 270 RC outpatient 44 44 CIGNA 62308 [3081051] CIGNA STATE OF WYOMING [308105107] 35.2 percent of total billed charges 27.28 41.8 Technical (Hospital) Services HC/HH Wch Supp Teds Thigh High Lg/Short__3634lf PX-2705000187 CDM 2705000187 LOCAL 270 RC outpatient 44 44 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES EPO [308136803] 35.2 percent of total billed charges 27.28 41.8 Technical (Hospital) Services HC/HH Wch Supp Teds Thigh High Lg/Short__3634lf PX-2705000187 CDM 2705000187 LOCAL 270 RC outpatient 44 44 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES HDHP [308136802] 35.2 percent of total billed charges 27.28 41.8 Technical (Hospital) Services HC/HH Wch Supp Teds Thigh High Lg/Short__3634lf PX-2705000187 CDM 2705000187 LOCAL 270 RC outpatient 44 44 MEDICA (COMMERCIAL) 94265 [3081118] MEDICA CLAIMS [308111801] 39.6 percent of total billed charges 27.28 41.8 Technical (Hospital) Services HC/HH Wch Supp Teds Thigh High Lg/Short__3634lf PX-2705000187 CDM 2705000187 LOCAL 270 RC outpatient 44 44 MULTIPLAN INC 34080 [3081285] MULTIPLAN INC [308128501] 41.8 percent of total billed charges 27.28 41.8 Technical (Hospital) Services HC/HH Wch Supp Teds Thigh High Lg/Short__3634lf PX-2705000187 CDM 2705000187 LOCAL 270 RC outpatient 44 44 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES PPO [308136801] 35.2 percent of total billed charges 27.28 41.8 Technical (Hospital) Services HC/HH Wch Supp Teds Thigh High Lg/Short__3634lf PX-2705000187 CDM 2705000187 LOCAL 270 RC inpatient 44 44 HEALTHPARTNERS SX009 HEALTHPARTNERS 34.84 percent of total billed charges 27.28 41.8 Technical (Hospital) Services HC/HH Wch Supp Teds Thigh High Lg/Short__3634lf PX-2705000187 CDM 2705000187 LOCAL 270 RC inpatient 44 44 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES EPO [308136803] 34.84 percent of total billed charges 27.28 41.8 Technical (Hospital) Services HC/HH Wch Supp Teds Thigh High Lg/Short__3634lf PX-2705000187 CDM 2705000187 LOCAL 270 RC inpatient 44 44 CIGNA 62308 [3081051] CIGNA 62308 [308105105] 34.84 percent of total billed charges 27.28 41.8 Technical (Hospital) Services HC/HH Wch Supp Teds Thigh High Lg/Short__3634lf PX-2705000187 CDM 2705000187 LOCAL 270 RC inpatient 44 44 CIGNA 62308 [3081051] CIGNA STATE OF WYOMING [308105107] 34.84 percent of total billed charges 27.28 41.8 Technical (Hospital) Services HC/HH Wch Supp Teds Thigh High Lg/Short__3634lf PX-2705000187 CDM 2705000187 LOCAL 270 RC inpatient 44 44 MULTIPLAN INC 34080 [3081285] MULTIPLAN INC [308128501] 41.8 percent of total billed charges 27.28 41.8 Technical (Hospital) Services HC/HH Wch Supp Teds Thigh High Lg/Short__3634lf PX-2705000187 CDM 2705000187 LOCAL 270 RC inpatient 44 44 BLUE CROSS BLUE SHIELD WELLMARK SB889 [3081026] BCBS WYOMING [308102603] 41.8 percent of total billed charges 27.28 41.8 Technical (Hospital) Services HC/HH Wch Supp Teds Thigh High Lg/Short__3634lf PX-2705000187 CDM 2705000187 LOCAL 270 RC inpatient 44 44 UNITED HEALTHCARE (COMMERCIAL) [3081199] UNITED HEALTHCARE 87726 [308119901] 27.28 percent of total billed charges 27.28 41.8 Technical (Hospital) Services HC/HH Wch Supp Teds Thigh High Lg/Short__3634lf PX-2705000187 CDM 2705000187 LOCAL 270 RC inpatient 44 44 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES HDHP [308136802] 34.84 percent of total billed charges 27.28 41.8 Technical (Hospital) Services HC/HH Wch Supp Teds Thigh High Lg/Short__3634lf PX-2705000187 CDM 2705000187 LOCAL 270 RC inpatient 44 44 MEDICA (COMMERCIAL) 94265 [3081118] MEDICA CLAIMS [308111801] 39.6 percent of total billed charges 27.28 41.8 Technical (Hospital) Services HC/HH Wch Supp Teds Thigh High Lg/Short__3634lf PX-2705000187 CDM 2705000187 LOCAL 270 RC inpatient 44 44 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES PPO [308136801] 34.84 percent of total billed charges 27.28 41.8 Technical (Hospital) Services HC/HH Wch Supp Teds Thigh High Lg/Reg__3728lf PX-2705000186 CDM 2705000186 LOCAL 270 RC outpatient 44 44 MEDICA (COMMERCIAL) 94265 [3081118] MEDICA CLAIMS [308111801] 39.6 percent of total billed charges 27.28 41.8 Technical (Hospital) Services HC/HH Wch Supp Teds Thigh High Lg/Reg__3728lf PX-2705000186 CDM 2705000186 LOCAL 270 RC outpatient 44 44 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES PPO [308136801] 35.2 percent of total billed charges 27.28 41.8 Technical (Hospital) Services HC/HH Wch Supp Teds Thigh High Lg/Reg__3728lf PX-2705000186 CDM 2705000186 LOCAL 270 RC outpatient 44 44 MULTIPLAN INC 34080 [3081285] MULTIPLAN INC [308128501] 41.8 percent of total billed charges 27.28 41.8 Technical (Hospital) Services HC/HH Wch Supp Teds Thigh High Lg/Reg__3728lf PX-2705000186 CDM 2705000186 LOCAL 270 RC outpatient 44 44 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES EPO [308136803] 35.2 percent of total billed charges 27.28 41.8 Technical (Hospital) Services HC/HH Wch Supp Teds Thigh High Lg/Reg__3728lf PX-2705000186 CDM 2705000186 LOCAL 270 RC outpatient 44 44 BLUE CROSS BLUE SHIELD WELLMARK SB889 [3081026] BCBS WYOMING [308102603] 41.8 percent of total billed charges 27.28 41.8 Technical (Hospital) Services HC/HH Wch Supp Teds Thigh High Lg/Reg__3728lf PX-2705000186 CDM 2705000186 LOCAL 270 RC outpatient 44 44 CIGNA 62308 [3081051] CIGNA 62308 [308105105] 35.2 percent of total billed charges 27.28 41.8 Technical (Hospital) Services HC/HH Wch Supp Teds Thigh High Lg/Reg__3728lf PX-2705000186 CDM 2705000186 LOCAL 270 RC outpatient 44 44 CIGNA 62308 [3081051] CIGNA STATE OF WYOMING [308105107] 35.2 percent of total billed charges 27.28 41.8 Technical (Hospital) Services HC/HH Wch Supp Teds Thigh High Lg/Reg__3728lf PX-2705000186 CDM 2705000186 LOCAL 270 RC outpatient 44 44 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES HDHP [308136802] 35.2 percent of total billed charges 27.28 41.8 Technical (Hospital) Services HC/HH Wch Supp Teds Thigh High Lg/Reg__3728lf PX-2705000186 CDM 2705000186 LOCAL 270 RC outpatient 44 44 HEALTHPARTNERS SX009 HEALTHPARTNERS 35.2 percent of total billed charges 27.28 41.8 Technical (Hospital) Services HC/HH Wch Supp Teds Thigh High Lg/Reg__3728lf PX-2705000186 CDM 2705000186 LOCAL 270 RC outpatient 44 44 UNITED HEALTHCARE (COMMERCIAL) [3081199] UNITED HEALTHCARE 87726 [308119901] 27.28 percent of total billed charges 27.28 41.8 Technical (Hospital) Services HC/HH Wch Supp Teds Thigh High Lg/Reg__3728lf PX-2705000186 CDM 2705000186 LOCAL 270 RC inpatient 44 44 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES PPO [308136801] 34.84 percent of total billed charges 27.28 41.8 Technical (Hospital) Services HC/HH Wch Supp Teds Thigh High Lg/Reg__3728lf PX-2705000186 CDM 2705000186 LOCAL 270 RC inpatient 44 44 MEDICA (COMMERCIAL) 94265 [3081118] MEDICA CLAIMS [308111801] 39.6 percent of total billed charges 27.28 41.8 Technical (Hospital) Services HC/HH Wch Supp Teds Thigh High Lg/Reg__3728lf PX-2705000186 CDM 2705000186 LOCAL 270 RC inpatient 44 44 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES HDHP [308136802] 34.84 percent of total billed charges 27.28 41.8 Technical (Hospital) Services HC/HH Wch Supp Teds Thigh High Lg/Reg__3728lf PX-2705000186 CDM 2705000186 LOCAL 270 RC inpatient 44 44 UNITED HEALTHCARE (COMMERCIAL) [3081199] UNITED HEALTHCARE 87726 [308119901] 27.28 percent of total billed charges 27.28 41.8 Technical (Hospital) Services HC/HH Wch Supp Teds Thigh High Lg/Reg__3728lf PX-2705000186 CDM 2705000186 LOCAL 270 RC inpatient 44 44 BLUE CROSS BLUE SHIELD WELLMARK SB889 [3081026] BCBS WYOMING [308102603] 41.8 percent of total billed charges 27.28 41.8 Technical (Hospital) Services HC/HH Wch Supp Teds Thigh High Lg/Reg__3728lf PX-2705000186 CDM 2705000186 LOCAL 270 RC inpatient 44 44 MULTIPLAN INC 34080 [3081285] MULTIPLAN INC [308128501] 41.8 percent of total billed charges 27.28 41.8 Technical (Hospital) Services HC/HH Wch Supp Teds Thigh High Lg/Reg__3728lf PX-2705000186 CDM 2705000186 LOCAL 270 RC inpatient 44 44 CIGNA 62308 [3081051] CIGNA 62308 [308105105] 34.84 percent of total billed charges 27.28 41.8 Technical (Hospital) Services HC/HH Wch Supp Teds Thigh High Lg/Reg__3728lf PX-2705000186 CDM 2705000186 LOCAL 270 RC inpatient 44 44 CIGNA 62308 [3081051] CIGNA STATE OF WYOMING [308105107] 34.84 percent of total billed charges 27.28 41.8 Technical (Hospital) Services HC/HH Wch Supp Teds Thigh High Lg/Reg__3728lf PX-2705000186 CDM 2705000186 LOCAL 270 RC inpatient 44 44 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES EPO [308136803] 34.84 percent of total billed charges 27.28 41.8 Technical (Hospital) Services HC/HH Wch Supp Teds Thigh High Lg/Reg__3728lf PX-2705000186 CDM 2705000186 LOCAL 270 RC inpatient 44 44 HEALTHPARTNERS SX009 HEALTHPARTNERS 34.84 percent of total billed charges 27.28 41.8 Technical (Hospital) Services HC/HH Wch Supp Teds Knee Hi Sm/Reg__7071 PX-2705000185 CDM 2705000185 LOCAL 270 RC inpatient 22 22 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES PPO [308136801] 17.42 percent of total billed charges 13.64 20.9 Technical (Hospital) Services HC/HH Wch Supp Teds Knee Hi Sm/Reg__7071 PX-2705000185 CDM 2705000185 LOCAL 270 RC inpatient 22 22 MEDICA (COMMERCIAL) 94265 [3081118] MEDICA CLAIMS [308111801] 19.8 percent of total billed charges 13.64 20.9 Technical (Hospital) Services HC/HH Wch Supp Teds Knee Hi Sm/Reg__7071 PX-2705000185 CDM 2705000185 LOCAL 270 RC inpatient 22 22 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES HDHP [308136802] 17.42 percent of total billed charges 13.64 20.9 Technical (Hospital) Services HC/HH Wch Supp Teds Knee Hi Sm/Reg__7071 PX-2705000185 CDM 2705000185 LOCAL 270 RC inpatient 22 22 UNITED HEALTHCARE (COMMERCIAL) [3081199] UNITED HEALTHCARE 87726 [308119901] 13.64 percent of total billed charges 13.64 20.9 Technical (Hospital) Services HC/HH Wch Supp Teds Knee Hi Sm/Reg__7071 PX-2705000185 CDM 2705000185 LOCAL 270 RC inpatient 22 22 BLUE CROSS BLUE SHIELD WELLMARK SB889 [3081026] BCBS WYOMING [308102603] 20.9 percent of total billed charges 13.64 20.9 Technical (Hospital) Services HC/HH Wch Supp Teds Knee Hi Sm/Reg__7071 PX-2705000185 CDM 2705000185 LOCAL 270 RC inpatient 22 22 MULTIPLAN INC 34080 [3081285] MULTIPLAN INC [308128501] 20.9 percent of total billed charges 13.64 20.9 Technical (Hospital) Services HC/HH Wch Supp Teds Knee Hi Sm/Reg__7071 PX-2705000185 CDM 2705000185 LOCAL 270 RC inpatient 22 22 CIGNA 62308 [3081051] CIGNA 62308 [308105105] 17.42 percent of total billed charges 13.64 20.9 Technical (Hospital) Services HC/HH Wch Supp Teds Knee Hi Sm/Reg__7071 PX-2705000185 CDM 2705000185 LOCAL 270 RC inpatient 22 22 CIGNA 62308 [3081051] CIGNA STATE OF WYOMING [308105107] 17.42 percent of total billed charges 13.64 20.9 Technical (Hospital) Services HC/HH Wch Supp Teds Knee Hi Sm/Reg__7071 PX-2705000185 CDM 2705000185 LOCAL 270 RC inpatient 22 22 HEALTHPARTNERS SX009 HEALTHPARTNERS 17.42 percent of total billed charges 13.64 20.9 Technical (Hospital) Services HC/HH Wch Supp Teds Knee Hi Sm/Reg__7071 PX-2705000185 CDM 2705000185 LOCAL 270 RC inpatient 22 22 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES EPO [308136803] 17.42 percent of total billed charges 13.64 20.9 Technical (Hospital) Services HC/HH Wch Supp Teds Knee Hi Sm/Reg__7071 PX-2705000185 CDM 2705000185 LOCAL 270 RC outpatient 22 22 MEDICA (COMMERCIAL) 94265 [3081118] MEDICA CLAIMS [308111801] 19.8 percent of total billed charges 13.64 20.9 Technical (Hospital) Services HC/HH Wch Supp Teds Knee Hi Sm/Reg__7071 PX-2705000185 CDM 2705000185 LOCAL 270 RC outpatient 22 22 MULTIPLAN INC 34080 [3081285] MULTIPLAN INC [308128501] 20.9 percent of total billed charges 13.64 20.9 Technical (Hospital) Services HC/HH Wch Supp Teds Knee Hi Sm/Reg__7071 PX-2705000185 CDM 2705000185 LOCAL 270 RC outpatient 22 22 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES EPO [308136803] 17.6 percent of total billed charges 13.64 20.9 Technical (Hospital) Services HC/HH Wch Supp Teds Knee Hi Sm/Reg__7071 PX-2705000185 CDM 2705000185 LOCAL 270 RC outpatient 22 22 BLUE CROSS BLUE SHIELD WELLMARK SB889 [3081026] BCBS WYOMING [308102603] 20.9 percent of total billed charges 13.64 20.9 Technical (Hospital) Services HC/HH Wch Supp Teds Knee Hi Sm/Reg__7071 PX-2705000185 CDM 2705000185 LOCAL 270 RC outpatient 22 22 CIGNA 62308 [3081051] CIGNA 62308 [308105105] 17.6 percent of total billed charges 13.64 20.9 Technical (Hospital) Services HC/HH Wch Supp Teds Knee Hi Sm/Reg__7071 PX-2705000185 CDM 2705000185 LOCAL 270 RC outpatient 22 22 CIGNA 62308 [3081051] CIGNA STATE OF WYOMING [308105107] 17.6 percent of total billed charges 13.64 20.9 Technical (Hospital) Services HC/HH Wch Supp Teds Knee Hi Sm/Reg__7071 PX-2705000185 CDM 2705000185 LOCAL 270 RC outpatient 22 22 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES HDHP [308136802] 17.6 percent of total billed charges 13.64 20.9 Technical (Hospital) Services HC/HH Wch Supp Teds Knee Hi Sm/Reg__7071 PX-2705000185 CDM 2705000185 LOCAL 270 RC outpatient 22 22 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES PPO [308136801] 17.6 percent of total billed charges 13.64 20.9 Technical (Hospital) Services HC/HH Wch Supp Teds Knee Hi Sm/Reg__7071 PX-2705000185 CDM 2705000185 LOCAL 270 RC outpatient 22 22 HEALTHPARTNERS SX009 HEALTHPARTNERS 17.6 percent of total billed charges 13.64 20.9 Technical (Hospital) Services HC/HH Wch Supp Teds Knee Hi Sm/Reg__7071 PX-2705000185 CDM 2705000185 LOCAL 270 RC outpatient 22 22 UNITED HEALTHCARE (COMMERCIAL) [3081199] UNITED HEALTHCARE 87726 [308119901] 13.64 percent of total billed charges 13.64 20.9 Technical (Hospital) Services HC/HH Wch Supp Teds Knee Hi Med/Reg__7115 PX-2705000184 CDM 2705000184 LOCAL 270 RC outpatient 22 22 UNITED HEALTHCARE (COMMERCIAL) [3081199] UNITED HEALTHCARE 87726 [308119901] 13.64 percent of total billed charges 13.64 20.9 Technical (Hospital) Services HC/HH Wch Supp Teds Knee Hi Med/Reg__7115 PX-2705000184 CDM 2705000184 LOCAL 270 RC outpatient 22 22 HEALTHPARTNERS SX009 HEALTHPARTNERS 17.6 percent of total billed charges 13.64 20.9 Technical (Hospital) Services HC/HH Wch Supp Teds Knee Hi Med/Reg__7115 PX-2705000184 CDM 2705000184 LOCAL 270 RC outpatient 22 22 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES HDHP [308136802] 17.6 percent of total billed charges 13.64 20.9 Technical (Hospital) Services HC/HH Wch Supp Teds Knee Hi Med/Reg__7115 PX-2705000184 CDM 2705000184 LOCAL 270 RC outpatient 22 22 CIGNA 62308 [3081051] CIGNA 62308 [308105105] 17.6 percent of total billed charges 13.64 20.9 Technical (Hospital) Services HC/HH Wch Supp Teds Knee Hi Med/Reg__7115 PX-2705000184 CDM 2705000184 LOCAL 270 RC outpatient 22 22 CIGNA 62308 [3081051] CIGNA STATE OF WYOMING [308105107] 17.6 percent of total billed charges 13.64 20.9 Technical (Hospital) Services HC/HH Wch Supp Teds Knee Hi Med/Reg__7115 PX-2705000184 CDM 2705000184 LOCAL 270 RC outpatient 22 22 BLUE CROSS BLUE SHIELD WELLMARK SB889 [3081026] BCBS WYOMING [308102603] 20.9 percent of total billed charges 13.64 20.9 Technical (Hospital) Services HC/HH Wch Supp Teds Knee Hi Med/Reg__7115 PX-2705000184 CDM 2705000184 LOCAL 270 RC outpatient 22 22 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES EPO [308136803] 17.6 percent of total billed charges 13.64 20.9 Technical (Hospital) Services HC/HH Wch Supp Teds Knee Hi Med/Reg__7115 PX-2705000184 CDM 2705000184 LOCAL 270 RC outpatient 22 22 MULTIPLAN INC 34080 [3081285] MULTIPLAN INC [308128501] 20.9 percent of total billed charges 13.64 20.9 Technical (Hospital) Services HC/HH Wch Supp Teds Knee Hi Med/Reg__7115 PX-2705000184 CDM 2705000184 LOCAL 270 RC outpatient 22 22 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES PPO [308136801] 17.6 percent of total billed charges 13.64 20.9 Technical (Hospital) Services HC/HH Wch Supp Teds Knee Hi Med/Reg__7115 PX-2705000184 CDM 2705000184 LOCAL 270 RC outpatient 22 22 MEDICA (COMMERCIAL) 94265 [3081118] MEDICA CLAIMS [308111801] 19.8 percent of total billed charges 13.64 20.9 Technical (Hospital) Services HC/HH Wch Supp Teds Knee Hi Med/Reg__7115 PX-2705000184 CDM 2705000184 LOCAL 270 RC inpatient 22 22 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES PPO [308136801] 17.42 percent of total billed charges 13.64 20.9 Technical (Hospital) Services HC/HH Wch Supp Teds Knee Hi Med/Reg__7115 PX-2705000184 CDM 2705000184 LOCAL 270 RC inpatient 22 22 MEDICA (COMMERCIAL) 94265 [3081118] MEDICA CLAIMS [308111801] 19.8 percent of total billed charges 13.64 20.9 Technical (Hospital) Services HC/HH Wch Supp Teds Knee Hi Med/Reg__7115 PX-2705000184 CDM 2705000184 LOCAL 270 RC inpatient 22 22 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES HDHP [308136802] 17.42 percent of total billed charges 13.64 20.9 Technical (Hospital) Services HC/HH Wch Supp Teds Knee Hi Med/Reg__7115 PX-2705000184 CDM 2705000184 LOCAL 270 RC inpatient 22 22 UNITED HEALTHCARE (COMMERCIAL) [3081199] UNITED HEALTHCARE 87726 [308119901] 13.64 percent of total billed charges 13.64 20.9 Technical (Hospital) Services HC/HH Wch Supp Teds Knee Hi Med/Reg__7115 PX-2705000184 CDM 2705000184 LOCAL 270 RC inpatient 22 22 HEALTHPARTNERS SX009 HEALTHPARTNERS 17.42 percent of total billed charges 13.64 20.9 Technical (Hospital) Services HC/HH Wch Supp Teds Knee Hi Med/Reg__7115 PX-2705000184 CDM 2705000184 LOCAL 270 RC inpatient 22 22 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES EPO [308136803] 17.42 percent of total billed charges 13.64 20.9 Technical (Hospital) Services HC/HH Wch Supp Teds Knee Hi Med/Reg__7115 PX-2705000184 CDM 2705000184 LOCAL 270 RC inpatient 22 22 BLUE CROSS BLUE SHIELD WELLMARK SB889 [3081026] BCBS WYOMING [308102603] 20.9 percent of total billed charges 13.64 20.9 Technical (Hospital) Services HC/HH Wch Supp Teds Knee Hi Med/Reg__7115 PX-2705000184 CDM 2705000184 LOCAL 270 RC inpatient 22 22 MULTIPLAN INC 34080 [3081285] MULTIPLAN INC [308128501] 20.9 percent of total billed charges 13.64 20.9 Technical (Hospital) Services HC/HH Wch Supp Teds Knee Hi Med/Reg__7115 PX-2705000184 CDM 2705000184 LOCAL 270 RC inpatient 22 22 CIGNA 62308 [3081051] CIGNA 62308 [308105105] 17.42 percent of total billed charges 13.64 20.9 Technical (Hospital) Services HC/HH Wch Supp Teds Knee Hi Med/Reg__7115 PX-2705000184 CDM 2705000184 LOCAL 270 RC inpatient 22 22 CIGNA 62308 [3081051] CIGNA STATE OF WYOMING [308105107] 17.42 percent of total billed charges 13.64 20.9 Technical (Hospital) Services HC/HH Wch Supp Teds Knee Hi Lg/Reg__7203 PX-2705000183 CDM 2705000183 LOCAL 270 RC inpatient 22 22 BLUE CROSS BLUE SHIELD WELLMARK SB889 [3081026] BCBS WYOMING [308102603] 20.9 percent of total billed charges 13.64 20.9 Technical (Hospital) Services HC/HH Wch Supp Teds Knee Hi Lg/Reg__7203 PX-2705000183 CDM 2705000183 LOCAL 270 RC inpatient 22 22 MULTIPLAN INC 34080 [3081285] MULTIPLAN INC [308128501] 20.9 percent of total billed charges 13.64 20.9 Technical (Hospital) Services HC/HH Wch Supp Teds Knee Hi Lg/Reg__7203 PX-2705000183 CDM 2705000183 LOCAL 270 RC inpatient 22 22 CIGNA 62308 [3081051] CIGNA 62308 [308105105] 17.42 percent of total billed charges 13.64 20.9 Technical (Hospital) Services HC/HH Wch Supp Teds Knee Hi Lg/Reg__7203 PX-2705000183 CDM 2705000183 LOCAL 270 RC inpatient 22 22 CIGNA 62308 [3081051] CIGNA STATE OF WYOMING [308105107] 17.42 percent of total billed charges 13.64 20.9 Technical (Hospital) Services HC/HH Wch Supp Teds Knee Hi Lg/Reg__7203 PX-2705000183 CDM 2705000183 LOCAL 270 RC inpatient 22 22 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES EPO [308136803] 17.42 percent of total billed charges 13.64 20.9 Technical (Hospital) Services HC/HH Wch Supp Teds Knee Hi Lg/Reg__7203 PX-2705000183 CDM 2705000183 LOCAL 270 RC inpatient 22 22 HEALTHPARTNERS SX009 HEALTHPARTNERS 17.42 percent of total billed charges 13.64 20.9 Technical (Hospital) Services HC/HH Wch Supp Teds Knee Hi Lg/Reg__7203 PX-2705000183 CDM 2705000183 LOCAL 270 RC inpatient 22 22 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES PPO [308136801] 17.42 percent of total billed charges 13.64 20.9 Technical (Hospital) Services HC/HH Wch Supp Teds Knee Hi Lg/Reg__7203 PX-2705000183 CDM 2705000183 LOCAL 270 RC inpatient 22 22 MEDICA (COMMERCIAL) 94265 [3081118] MEDICA CLAIMS [308111801] 19.8 percent of total billed charges 13.64 20.9 Technical (Hospital) Services HC/HH Wch Supp Teds Knee Hi Lg/Reg__7203 PX-2705000183 CDM 2705000183 LOCAL 270 RC inpatient 22 22 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES HDHP [308136802] 17.42 percent of total billed charges 13.64 20.9 Technical (Hospital) Services HC/HH Wch Supp Teds Knee Hi Lg/Reg__7203 PX-2705000183 CDM 2705000183 LOCAL 270 RC inpatient 22 22 UNITED HEALTHCARE (COMMERCIAL) [3081199] UNITED HEALTHCARE 87726 [308119901] 13.64 percent of total billed charges 13.64 20.9 Technical (Hospital) Services HC/HH Wch Supp Teds Knee Hi Lg/Reg__7203 PX-2705000183 CDM 2705000183 LOCAL 270 RC outpatient 22 22 CIGNA 62308 [3081051] CIGNA 62308 [308105105] 17.6 percent of total billed charges 13.64 20.9 Technical (Hospital) Services HC/HH Wch Supp Teds Knee Hi Lg/Reg__7203 PX-2705000183 CDM 2705000183 LOCAL 270 RC outpatient 22 22 CIGNA 62308 [3081051] CIGNA STATE OF WYOMING [308105107] 17.6 percent of total billed charges 13.64 20.9 Technical (Hospital) Services HC/HH Wch Supp Teds Knee Hi Lg/Reg__7203 PX-2705000183 CDM 2705000183 LOCAL 270 RC outpatient 22 22 BLUE CROSS BLUE SHIELD WELLMARK SB889 [3081026] BCBS WYOMING [308102603] 20.9 percent of total billed charges 13.64 20.9 Technical (Hospital) Services HC/HH Wch Supp Teds Knee Hi Lg/Reg__7203 PX-2705000183 CDM 2705000183 LOCAL 270 RC outpatient 22 22 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES EPO [308136803] 17.6 percent of total billed charges 13.64 20.9 Technical (Hospital) Services HC/HH Wch Supp Teds Knee Hi Lg/Reg__7203 PX-2705000183 CDM 2705000183 LOCAL 270 RC outpatient 22 22 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES HDHP [308136802] 17.6 percent of total billed charges 13.64 20.9 Technical (Hospital) Services HC/HH Wch Supp Teds Knee Hi Lg/Reg__7203 PX-2705000183 CDM 2705000183 LOCAL 270 RC outpatient 22 22 HEALTHPARTNERS SX009 HEALTHPARTNERS 17.6 percent of total billed charges 13.64 20.9 Technical (Hospital) Services HC/HH Wch Supp Teds Knee Hi Lg/Reg__7203 PX-2705000183 CDM 2705000183 LOCAL 270 RC outpatient 22 22 UNITED HEALTHCARE (COMMERCIAL) [3081199] UNITED HEALTHCARE 87726 [308119901] 13.64 percent of total billed charges 13.64 20.9 Technical (Hospital) Services HC/HH Wch Supp Teds Knee Hi Lg/Reg__7203 PX-2705000183 CDM 2705000183 LOCAL 270 RC outpatient 22 22 MEDICA (COMMERCIAL) 94265 [3081118] MEDICA CLAIMS [308111801] 19.8 percent of total billed charges 13.64 20.9 Technical (Hospital) Services HC/HH Wch Supp Teds Knee Hi Lg/Reg__7203 PX-2705000183 CDM 2705000183 LOCAL 270 RC outpatient 22 22 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES PPO [308136801] 17.6 percent of total billed charges 13.64 20.9 Technical (Hospital) Services HC/HH Wch Supp Teds Knee Hi Lg/Reg__7203 PX-2705000183 CDM 2705000183 LOCAL 270 RC outpatient 22 22 MULTIPLAN INC 34080 [3081285] MULTIPLAN INC [308128501] 20.9 percent of total billed charges 13.64 20.9 Technical (Hospital) Services HC/HH Wch Supp Tape Plastic Transpore 2x10__1527-2 PX-2705000182 CDM 2705000182 LOCAL 270 RC inpatient 14 14 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES PPO [308136801] 11.09 percent of total billed charges 8.68 13.3 Technical (Hospital) Services HC/HH Wch Supp Tape Plastic Transpore 2x10__1527-2 PX-2705000182 CDM 2705000182 LOCAL 270 RC inpatient 14 14 MEDICA (COMMERCIAL) 94265 [3081118] MEDICA CLAIMS [308111801] 12.6 percent of total billed charges 8.68 13.3 Technical (Hospital) Services HC/HH Wch Supp Tape Plastic Transpore 2x10__1527-2 PX-2705000182 CDM 2705000182 LOCAL 270 RC inpatient 14 14 UNITED HEALTHCARE (COMMERCIAL) [3081199] UNITED HEALTHCARE 87726 [308119901] 8.68 percent of total billed charges 8.68 13.3 Technical (Hospital) Services HC/HH Wch Supp Tape Plastic Transpore 2x10__1527-2 PX-2705000182 CDM 2705000182 LOCAL 270 RC inpatient 14 14 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES HDHP [308136802] 11.09 percent of total billed charges 8.68 13.3 Technical (Hospital) Services HC/HH Wch Supp Tape Plastic Transpore 2x10__1527-2 PX-2705000182 CDM 2705000182 LOCAL 270 RC inpatient 14 14 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES EPO [308136803] 11.09 percent of total billed charges 8.68 13.3 Technical (Hospital) Services HC/HH Wch Supp Tape Plastic Transpore 2x10__1527-2 PX-2705000182 CDM 2705000182 LOCAL 270 RC inpatient 14 14 HEALTHPARTNERS SX009 HEALTHPARTNERS 11.09 percent of total billed charges 8.68 13.3 Technical (Hospital) Services HC/HH Wch Supp Tape Plastic Transpore 2x10__1527-2 PX-2705000182 CDM 2705000182 LOCAL 270 RC inpatient 14 14 BLUE CROSS BLUE SHIELD WELLMARK SB889 [3081026] BCBS WYOMING [308102603] 13.3 percent of total billed charges 8.68 13.3 Technical (Hospital) Services HC/HH Wch Supp Tape Plastic Transpore 2x10__1527-2 PX-2705000182 CDM 2705000182 LOCAL 270 RC inpatient 14 14 MULTIPLAN INC 34080 [3081285] MULTIPLAN INC [308128501] 13.3 percent of total billed charges 8.68 13.3 Technical (Hospital) Services HC/HH Wch Supp Tape Plastic Transpore 2x10__1527-2 PX-2705000182 CDM 2705000182 LOCAL 270 RC inpatient 14 14 CIGNA 62308 [3081051] CIGNA 62308 [308105105] 11.09 percent of total billed charges 8.68 13.3 Technical (Hospital) Services HC/HH Wch Supp Tape Plastic Transpore 2x10__1527-2 PX-2705000182 CDM 2705000182 LOCAL 270 RC inpatient 14 14 CIGNA 62308 [3081051] CIGNA STATE OF WYOMING [308105107] 11.09 percent of total billed charges 8.68 13.3 Technical (Hospital) Services HC/HH Wch Supp Tape Plastic Transpore 2x10__1527-2 PX-2705000182 CDM 2705000182 LOCAL 270 RC outpatient 14 14 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES HDHP [308136802] 11.2 percent of total billed charges 8.68 13.3 Technical (Hospital) Services HC/HH Wch Supp Tape Plastic Transpore 2x10__1527-2 PX-2705000182 CDM 2705000182 LOCAL 270 RC outpatient 14 14 BLUE CROSS BLUE SHIELD WELLMARK SB889 [3081026] BCBS WYOMING [308102603] 13.3 percent of total billed charges 8.68 13.3 Technical (Hospital) Services HC/HH Wch Supp Tape Plastic Transpore 2x10__1527-2 PX-2705000182 CDM 2705000182 LOCAL 270 RC outpatient 14 14 CIGNA 62308 [3081051] CIGNA 62308 [308105105] 11.2 percent of total billed charges 8.68 13.3 Technical (Hospital) Services HC/HH Wch Supp Tape Plastic Transpore 2x10__1527-2 PX-2705000182 CDM 2705000182 LOCAL 270 RC outpatient 14 14 CIGNA 62308 [3081051] CIGNA STATE OF WYOMING [308105107] 11.2 percent of total billed charges 8.68 13.3 Technical (Hospital) Services HC/HH Wch Supp Tape Plastic Transpore 2x10__1527-2 PX-2705000182 CDM 2705000182 LOCAL 270 RC outpatient 14 14 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES EPO [308136803] 11.2 percent of total billed charges 8.68 13.3 Technical (Hospital) Services HC/HH Wch Supp Tape Plastic Transpore 2x10__1527-2 PX-2705000182 CDM 2705000182 LOCAL 270 RC outpatient 14 14 UNITED HEALTHCARE (COMMERCIAL) [3081199] UNITED HEALTHCARE 87726 [308119901] 8.68 percent of total billed charges 8.68 13.3 Technical (Hospital) Services HC/HH Wch Supp Tape Plastic Transpore 2x10__1527-2 PX-2705000182 CDM 2705000182 LOCAL 270 RC outpatient 14 14 HEALTHPARTNERS SX009 HEALTHPARTNERS 11.2 percent of total billed charges 8.68 13.3 Technical (Hospital) Services HC/HH Wch Supp Tape Plastic Transpore 2x10__1527-2 PX-2705000182 CDM 2705000182 LOCAL 270 RC outpatient 14 14 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES PPO [308136801] 11.2 percent of total billed charges 8.68 13.3 Technical (Hospital) Services HC/HH Wch Supp Tape Plastic Transpore 2x10__1527-2 PX-2705000182 CDM 2705000182 LOCAL 270 RC outpatient 14 14 MEDICA (COMMERCIAL) 94265 [3081118] MEDICA CLAIMS [308111801] 12.6 percent of total billed charges 8.68 13.3 Technical (Hospital) Services HC/HH Wch Supp Tape Plastic Transpore 2x10__1527-2 PX-2705000182 CDM 2705000182 LOCAL 270 RC outpatient 14 14 MULTIPLAN INC 34080 [3081285] MULTIPLAN INC [308128501] 13.3 percent of total billed charges 8.68 13.3 Technical (Hospital) Services HC/HH Wch Supp Tape Plastic Transpore 1x10__1527-1 PX-2705000181 CDM 2705000181 LOCAL 270 RC outpatient 5 5 MEDICA (COMMERCIAL) 94265 [3081118] MEDICA CLAIMS [308111801] 4.5 percent of total billed charges 3.1 4.75 Technical (Hospital) Services HC/HH Wch Supp Tape Plastic Transpore 1x10__1527-1 PX-2705000181 CDM 2705000181 LOCAL 270 RC outpatient 5 5 MULTIPLAN INC 34080 [3081285] MULTIPLAN INC [308128501] 4.75 percent of total billed charges 3.1 4.75 Technical (Hospital) Services HC/HH Wch Supp Tape Plastic Transpore 1x10__1527-1 PX-2705000181 CDM 2705000181 LOCAL 270 RC outpatient 5 5 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES EPO [308136803] 4 percent of total billed charges 3.1 4.75 Technical (Hospital) Services HC/HH Wch Supp Tape Plastic Transpore 1x10__1527-1 PX-2705000181 CDM 2705000181 LOCAL 270 RC outpatient 5 5 BLUE CROSS BLUE SHIELD WELLMARK SB889 [3081026] BCBS WYOMING [308102603] 4.75 percent of total billed charges 3.1 4.75 Technical (Hospital) Services HC/HH Wch Supp Tape Plastic Transpore 1x10__1527-1 PX-2705000181 CDM 2705000181 LOCAL 270 RC outpatient 5 5 CIGNA 62308 [3081051] CIGNA 62308 [308105105] 4 percent of total billed charges 3.1 4.75 Technical (Hospital) Services HC/HH Wch Supp Tape Plastic Transpore 1x10__1527-1 PX-2705000181 CDM 2705000181 LOCAL 270 RC outpatient 5 5 CIGNA 62308 [3081051] CIGNA STATE OF WYOMING [308105107] 4 percent of total billed charges 3.1 4.75 Technical (Hospital) Services HC/HH Wch Supp Tape Plastic Transpore 1x10__1527-1 PX-2705000181 CDM 2705000181 LOCAL 270 RC outpatient 5 5 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES HDHP [308136802] 4 percent of total billed charges 3.1 4.75 Technical (Hospital) Services HC/HH Wch Supp Tape Plastic Transpore 1x10__1527-1 PX-2705000181 CDM 2705000181 LOCAL 270 RC outpatient 5 5 UNITED HEALTHCARE (COMMERCIAL) [3081199] UNITED HEALTHCARE 87726 [308119901] 3.1 percent of total billed charges 3.1 4.75 Technical (Hospital) Services HC/HH Wch Supp Tape Plastic Transpore 1x10__1527-1 PX-2705000181 CDM 2705000181 LOCAL 270 RC outpatient 5 5 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES PPO [308136801] 4 percent of total billed charges 3.1 4.75 Technical (Hospital) Services HC/HH Wch Supp Tape Plastic Transpore 1x10__1527-1 PX-2705000181 CDM 2705000181 LOCAL 270 RC outpatient 5 5 HEALTHPARTNERS SX009 HEALTHPARTNERS 4 percent of total billed charges 3.1 4.75 Technical (Hospital) Services HC/HH Wch Supp Tape Plastic Transpore 1x10__1527-1 PX-2705000181 CDM 2705000181 LOCAL 270 RC inpatient 5 5 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES PPO [308136801] 3.96 percent of total billed charges 3.1 4.75 Technical (Hospital) Services HC/HH Wch Supp Tape Plastic Transpore 1x10__1527-1 PX-2705000181 CDM 2705000181 LOCAL 270 RC inpatient 5 5 MEDICA (COMMERCIAL) 94265 [3081118] MEDICA CLAIMS [308111801] 4.5 percent of total billed charges 3.1 4.75 Technical (Hospital) Services HC/HH Wch Supp Tape Plastic Transpore 1x10__1527-1 PX-2705000181 CDM 2705000181 LOCAL 270 RC inpatient 5 5 UNITED HEALTHCARE (COMMERCIAL) [3081199] UNITED HEALTHCARE 87726 [308119901] 3.1 percent of total billed charges 3.1 4.75 Technical (Hospital) Services HC/HH Wch Supp Tape Plastic Transpore 1x10__1527-1 PX-2705000181 CDM 2705000181 LOCAL 270 RC inpatient 5 5 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES HDHP [308136802] 3.96 percent of total billed charges 3.1 4.75 Technical (Hospital) Services HC/HH Wch Supp Tape Plastic Transpore 1x10__1527-1 PX-2705000181 CDM 2705000181 LOCAL 270 RC inpatient 5 5 MULTIPLAN INC 34080 [3081285] MULTIPLAN INC [308128501] 4.75 percent of total billed charges 3.1 4.75 Technical (Hospital) Services HC/HH Wch Supp Tape Plastic Transpore 1x10__1527-1 PX-2705000181 CDM 2705000181 LOCAL 270 RC inpatient 5 5 BLUE CROSS BLUE SHIELD WELLMARK SB889 [3081026] BCBS WYOMING [308102603] 4.75 percent of total billed charges 3.1 4.75 Technical (Hospital) Services HC/HH Wch Supp Tape Plastic Transpore 1x10__1527-1 PX-2705000181 CDM 2705000181 LOCAL 270 RC inpatient 5 5 CIGNA 62308 [3081051] CIGNA 62308 [308105105] 3.96 percent of total billed charges 3.1 4.75 Technical (Hospital) Services HC/HH Wch Supp Tape Plastic Transpore 1x10__1527-1 PX-2705000181 CDM 2705000181 LOCAL 270 RC inpatient 5 5 CIGNA 62308 [3081051] CIGNA STATE OF WYOMING [308105107] 3.96 percent of total billed charges 3.1 4.75 Technical (Hospital) Services HC/HH Wch Supp Tape Plastic Transpore 1x10__1527-1 PX-2705000181 CDM 2705000181 LOCAL 270 RC inpatient 5 5 HEALTHPARTNERS SX009 HEALTHPARTNERS 3.96 percent of total billed charges 3.1 4.75 Technical (Hospital) Services HC/HH Wch Supp Tape Plastic Transpore 1x10__1527-1 PX-2705000181 CDM 2705000181 LOCAL 270 RC inpatient 5 5 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES EPO [308136803] 3.96 percent of total billed charges 3.1 4.75 Technical (Hospital) Services HC/HH Wch Supp Tape Paper Micropore 2inx10__1530-2 PX-2705000180 CDM 2705000180 LOCAL 270 RC inpatient 17 17 MEDICA (COMMERCIAL) 94265 [3081118] MEDICA CLAIMS [308111801] 15.3 percent of total billed charges 10.54 16.15 Technical (Hospital) Services HC/HH Wch Supp Tape Paper Micropore 2inx10__1530-2 PX-2705000180 CDM 2705000180 LOCAL 270 RC inpatient 17 17 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES PPO [308136801] 13.46 percent of total billed charges 10.54 16.15 Technical (Hospital) Services HC/HH Wch Supp Tape Paper Micropore 2inx10__1530-2 PX-2705000180 CDM 2705000180 LOCAL 270 RC inpatient 17 17 UNITED HEALTHCARE (COMMERCIAL) [3081199] UNITED HEALTHCARE 87726 [308119901] 10.54 percent of total billed charges 10.54 16.15 Technical (Hospital) Services HC/HH Wch Supp Tape Paper Micropore 2inx10__1530-2 PX-2705000180 CDM 2705000180 LOCAL 270 RC inpatient 17 17 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES HDHP [308136802] 13.46 percent of total billed charges 10.54 16.15 Technical (Hospital) Services HC/HH Wch Supp Tape Paper Micropore 2inx10__1530-2 PX-2705000180 CDM 2705000180 LOCAL 270 RC inpatient 17 17 MULTIPLAN INC 34080 [3081285] MULTIPLAN INC [308128501] 16.15 percent of total billed charges 10.54 16.15 Technical (Hospital) Services HC/HH Wch Supp Tape Paper Micropore 2inx10__1530-2 PX-2705000180 CDM 2705000180 LOCAL 270 RC inpatient 17 17 BLUE CROSS BLUE SHIELD WELLMARK SB889 [3081026] BCBS WYOMING [308102603] 16.15 percent of total billed charges 10.54 16.15 Technical (Hospital) Services HC/HH Wch Supp Tape Paper Micropore 2inx10__1530-2 PX-2705000180 CDM 2705000180 LOCAL 270 RC inpatient 17 17 CIGNA 62308 [3081051] CIGNA 62308 [308105105] 13.46 percent of total billed charges 10.54 16.15 Technical (Hospital) Services HC/HH Wch Supp Tape Paper Micropore 2inx10__1530-2 PX-2705000180 CDM 2705000180 LOCAL 270 RC inpatient 17 17 CIGNA 62308 [3081051] CIGNA STATE OF WYOMING [308105107] 13.46 percent of total billed charges 10.54 16.15 Technical (Hospital) Services HC/HH Wch Supp Tape Paper Micropore 2inx10__1530-2 PX-2705000180 CDM 2705000180 LOCAL 270 RC inpatient 17 17 HEALTHPARTNERS SX009 HEALTHPARTNERS 13.46 percent of total billed charges 10.54 16.15 Technical (Hospital) Services HC/HH Wch Supp Tape Paper Micropore 2inx10__1530-2 PX-2705000180 CDM 2705000180 LOCAL 270 RC inpatient 17 17 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES EPO [308136803] 13.46 percent of total billed charges 10.54 16.15 Technical (Hospital) Services HC/HH Wch Supp Tape Paper Micropore 2inx10__1530-2 PX-2705000180 CDM 2705000180 LOCAL 270 RC outpatient 17 17 UNITED HEALTHCARE (COMMERCIAL) [3081199] UNITED HEALTHCARE 87726 [308119901] 10.54 percent of total billed charges 10.54 16.15 Technical (Hospital) Services HC/HH Wch Supp Tape Paper Micropore 2inx10__1530-2 PX-2705000180 CDM 2705000180 LOCAL 270 RC outpatient 17 17 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES PPO [308136801] 13.6 percent of total billed charges 10.54 16.15 Technical (Hospital) Services HC/HH Wch Supp Tape Paper Micropore 2inx10__1530-2 PX-2705000180 CDM 2705000180 LOCAL 270 RC outpatient 17 17 HEALTHPARTNERS SX009 HEALTHPARTNERS 13.6 percent of total billed charges 10.54 16.15 Technical (Hospital) Services HC/HH Wch Supp Tape Paper Micropore 2inx10__1530-2 PX-2705000180 CDM 2705000180 LOCAL 270 RC outpatient 17 17 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES HDHP [308136802] 13.6 percent of total billed charges 10.54 16.15 Technical (Hospital) Services HC/HH Wch Supp Tape Paper Micropore 2inx10__1530-2 PX-2705000180 CDM 2705000180 LOCAL 270 RC outpatient 17 17 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES EPO [308136803] 13.6 percent of total billed charges 10.54 16.15 Technical (Hospital) Services HC/HH Wch Supp Tape Paper Micropore 2inx10__1530-2 PX-2705000180 CDM 2705000180 LOCAL 270 RC outpatient 17 17 CIGNA 62308 [3081051] CIGNA 62308 [308105105] 13.6 percent of total billed charges 10.54 16.15 Technical (Hospital) Services HC/HH Wch Supp Tape Paper Micropore 2inx10__1530-2 PX-2705000180 CDM 2705000180 LOCAL 270 RC outpatient 17 17 CIGNA 62308 [3081051] CIGNA STATE OF WYOMING [308105107] 13.6 percent of total billed charges 10.54 16.15 Technical (Hospital) Services HC/HH Wch Supp Tape Paper Micropore 2inx10__1530-2 PX-2705000180 CDM 2705000180 LOCAL 270 RC outpatient 17 17 BLUE CROSS BLUE SHIELD WELLMARK SB889 [3081026] BCBS WYOMING [308102603] 16.15 percent of total billed charges 10.54 16.15 Technical (Hospital) Services HC/HH Wch Supp Tape Paper Micropore 2inx10__1530-2 PX-2705000180 CDM 2705000180 LOCAL 270 RC outpatient 17 17 MEDICA (COMMERCIAL) 94265 [3081118] MEDICA CLAIMS [308111801] 15.3 percent of total billed charges 10.54 16.15 Technical (Hospital) Services HC/HH Wch Supp Tape Paper Micropore 2inx10__1530-2 PX-2705000180 CDM 2705000180 LOCAL 270 RC outpatient 17 17 MULTIPLAN INC 34080 [3081285] MULTIPLAN INC [308128501] 16.15 percent of total billed charges 10.54 16.15 Technical (Hospital) Services HC/HH Wch Supp Tape Paper Micropore .5inx10__1530-0 PX-2705000179 CDM 2705000179 LOCAL 270 RC outpatient 17 17 HEALTHPARTNERS SX009 HEALTHPARTNERS 13.6 percent of total billed charges 10.54 16.15 Technical (Hospital) Services HC/HH Wch Supp Tape Paper Micropore .5inx10__1530-0 PX-2705000179 CDM 2705000179 LOCAL 270 RC outpatient 17 17 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES PPO [308136801] 13.6 percent of total billed charges 10.54 16.15 Technical (Hospital) Services HC/HH Wch Supp Tape Paper Micropore .5inx10__1530-0 PX-2705000179 CDM 2705000179 LOCAL 270 RC outpatient 17 17 UNITED HEALTHCARE (COMMERCIAL) [3081199] UNITED HEALTHCARE 87726 [308119901] 10.54 percent of total billed charges 10.54 16.15 Technical (Hospital) Services HC/HH Wch Supp Tape Paper Micropore .5inx10__1530-0 PX-2705000179 CDM 2705000179 LOCAL 270 RC outpatient 17 17 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES HDHP [308136802] 13.6 percent of total billed charges 10.54 16.15 Technical (Hospital) Services HC/HH Wch Supp Tape Paper Micropore .5inx10__1530-0 PX-2705000179 CDM 2705000179 LOCAL 270 RC outpatient 17 17 CIGNA 62308 [3081051] CIGNA 62308 [308105105] 13.6 percent of total billed charges 10.54 16.15 Technical (Hospital) Services HC/HH Wch Supp Tape Paper Micropore .5inx10__1530-0 PX-2705000179 CDM 2705000179 LOCAL 270 RC outpatient 17 17 CIGNA 62308 [3081051] CIGNA STATE OF WYOMING [308105107] 13.6 percent of total billed charges 10.54 16.15 Technical (Hospital) Services HC/HH Wch Supp Tape Paper Micropore .5inx10__1530-0 PX-2705000179 CDM 2705000179 LOCAL 270 RC outpatient 17 17 BLUE CROSS BLUE SHIELD WELLMARK SB889 [3081026] BCBS WYOMING [308102603] 16.15 percent of total billed charges 10.54 16.15 Technical (Hospital) Services HC/HH Wch Supp Tape Paper Micropore .5inx10__1530-0 PX-2705000179 CDM 2705000179 LOCAL 270 RC outpatient 17 17 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES EPO [308136803] 13.6 percent of total billed charges 10.54 16.15 Technical (Hospital) Services HC/HH Wch Supp Tape Paper Micropore .5inx10__1530-0 PX-2705000179 CDM 2705000179 LOCAL 270 RC outpatient 17 17 MULTIPLAN INC 34080 [3081285] MULTIPLAN INC [308128501] 16.15 percent of total billed charges 10.54 16.15 Technical (Hospital) Services HC/HH Wch Supp Tape Paper Micropore .5inx10__1530-0 PX-2705000179 CDM 2705000179 LOCAL 270 RC outpatient 17 17 MEDICA (COMMERCIAL) 94265 [3081118] MEDICA CLAIMS [308111801] 15.3 percent of total billed charges 10.54 16.15 Technical (Hospital) Services HC/HH Wch Supp Tape Paper Micropore .5inx10__1530-0 PX-2705000179 CDM 2705000179 LOCAL 270 RC inpatient 17 17 CIGNA 62308 [3081051] CIGNA 62308 [308105105] 13.46 percent of total billed charges 10.54 16.15 Technical (Hospital) Services HC/HH Wch Supp Tape Paper Micropore .5inx10__1530-0 PX-2705000179 CDM 2705000179 LOCAL 270 RC inpatient 17 17 CIGNA 62308 [3081051] CIGNA STATE OF WYOMING [308105107] 13.46 percent of total billed charges 10.54 16.15 Technical (Hospital) Services HC/HH Wch Supp Tape Paper Micropore .5inx10__1530-0 PX-2705000179 CDM 2705000179 LOCAL 270 RC inpatient 17 17 MULTIPLAN INC 34080 [3081285] MULTIPLAN INC [308128501] 16.15 percent of total billed charges 10.54 16.15 Technical (Hospital) Services HC/HH Wch Supp Tape Paper Micropore .5inx10__1530-0 PX-2705000179 CDM 2705000179 LOCAL 270 RC inpatient 17 17 BLUE CROSS BLUE SHIELD WELLMARK SB889 [3081026] BCBS WYOMING [308102603] 16.15 percent of total billed charges 10.54 16.15 Technical (Hospital) Services HC/HH Wch Supp Tape Paper Micropore .5inx10__1530-0 PX-2705000179 CDM 2705000179 LOCAL 270 RC inpatient 17 17 HEALTHPARTNERS SX009 HEALTHPARTNERS 13.46 percent of total billed charges 10.54 16.15 Technical (Hospital) Services HC/HH Wch Supp Tape Paper Micropore .5inx10__1530-0 PX-2705000179 CDM 2705000179 LOCAL 270 RC inpatient 17 17 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES EPO [308136803] 13.46 percent of total billed charges 10.54 16.15 Technical (Hospital) Services HC/HH Wch Supp Tape Paper Micropore .5inx10__1530-0 PX-2705000179 CDM 2705000179 LOCAL 270 RC inpatient 17 17 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES HDHP [308136802] 13.46 percent of total billed charges 10.54 16.15 Technical (Hospital) Services HC/HH Wch Supp Tape Paper Micropore .5inx10__1530-0 PX-2705000179 CDM 2705000179 LOCAL 270 RC inpatient 17 17 UNITED HEALTHCARE (COMMERCIAL) [3081199] UNITED HEALTHCARE 87726 [308119901] 10.54 percent of total billed charges 10.54 16.15 Technical (Hospital) Services HC/HH Wch Supp Tape Paper Micropore .5inx10__1530-0 PX-2705000179 CDM 2705000179 LOCAL 270 RC inpatient 17 17 MEDICA (COMMERCIAL) 94265 [3081118] MEDICA CLAIMS [308111801] 15.3 percent of total billed charges 10.54 16.15 Technical (Hospital) Services HC/HH Wch Supp Tape Paper Micropore .5inx10__1530-0 PX-2705000179 CDM 2705000179 LOCAL 270 RC inpatient 17 17 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES PPO [308136801] 13.46 percent of total billed charges 10.54 16.15 Technical (Hospital) Services HC/HH Wch Supp Tape Cloth Medipore 2x10__2962 PX-2705000178 CDM 2705000178 LOCAL 270 RC inpatient 23 23 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES PPO [308136801] 18.21 percent of total billed charges 14.26 21.85 Technical (Hospital) Services HC/HH Wch Supp Tape Cloth Medipore 2x10__2962 PX-2705000178 CDM 2705000178 LOCAL 270 RC inpatient 23 23 MEDICA (COMMERCIAL) 94265 [3081118] MEDICA CLAIMS [308111801] 20.7 percent of total billed charges 14.26 21.85 Technical (Hospital) Services HC/HH Wch Supp Tape Cloth Medipore 2x10__2962 PX-2705000178 CDM 2705000178 LOCAL 270 RC inpatient 23 23 UNITED HEALTHCARE (COMMERCIAL) [3081199] UNITED HEALTHCARE 87726 [308119901] 14.26 percent of total billed charges 14.26 21.85 Technical (Hospital) Services HC/HH Wch Supp Tape Cloth Medipore 2x10__2962 PX-2705000178 CDM 2705000178 LOCAL 270 RC inpatient 23 23 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES HDHP [308136802] 18.21 percent of total billed charges 14.26 21.85 Technical (Hospital) Services HC/HH Wch Supp Tape Cloth Medipore 2x10__2962 PX-2705000178 CDM 2705000178 LOCAL 270 RC inpatient 23 23 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES EPO [308136803] 18.21 percent of total billed charges 14.26 21.85 Technical (Hospital) Services HC/HH Wch Supp Tape Cloth Medipore 2x10__2962 PX-2705000178 CDM 2705000178 LOCAL 270 RC inpatient 23 23 HEALTHPARTNERS SX009 HEALTHPARTNERS 18.21 percent of total billed charges 14.26 21.85 Technical (Hospital) Services HC/HH Wch Supp Tape Cloth Medipore 2x10__2962 PX-2705000178 CDM 2705000178 LOCAL 270 RC inpatient 23 23 BLUE CROSS BLUE SHIELD WELLMARK SB889 [3081026] BCBS WYOMING [308102603] 21.85 percent of total billed charges 14.26 21.85 Technical (Hospital) Services HC/HH Wch Supp Tape Cloth Medipore 2x10__2962 PX-2705000178 CDM 2705000178 LOCAL 270 RC inpatient 23 23 MULTIPLAN INC 34080 [3081285] MULTIPLAN INC [308128501] 21.85 percent of total billed charges 14.26 21.85 Technical (Hospital) Services HC/HH Wch Supp Tape Cloth Medipore 2x10__2962 PX-2705000178 CDM 2705000178 LOCAL 270 RC inpatient 23 23 CIGNA 62308 [3081051] CIGNA 62308 [308105105] 18.21 percent of total billed charges 14.26 21.85 Technical (Hospital) Services HC/HH Wch Supp Tape Cloth Medipore 2x10__2962 PX-2705000178 CDM 2705000178 LOCAL 270 RC inpatient 23 23 CIGNA 62308 [3081051] CIGNA STATE OF WYOMING [308105107] 18.21 percent of total billed charges 14.26 21.85 Technical (Hospital) Services HC/HH Wch Supp Tape Cloth Medipore 2x10__2962 PX-2705000178 CDM 2705000178 LOCAL 270 RC outpatient 23 23 BLUE CROSS BLUE SHIELD WELLMARK SB889 [3081026] BCBS WYOMING [308102603] 21.85 percent of total billed charges 14.26 21.85 Technical (Hospital) Services HC/HH Wch Supp Tape Cloth Medipore 2x10__2962 PX-2705000178 CDM 2705000178 LOCAL 270 RC outpatient 23 23 CIGNA 62308 [3081051] CIGNA 62308 [308105105] 18.4 percent of total billed charges 14.26 21.85 Technical (Hospital) Services HC/HH Wch Supp Tape Cloth Medipore 2x10__2962 PX-2705000178 CDM 2705000178 LOCAL 270 RC outpatient 23 23 CIGNA 62308 [3081051] CIGNA STATE OF WYOMING [308105107] 18.4 percent of total billed charges 14.26 21.85 Technical (Hospital) Services HC/HH Wch Supp Tape Cloth Medipore 2x10__2962 PX-2705000178 CDM 2705000178 LOCAL 270 RC outpatient 23 23 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES EPO [308136803] 18.4 percent of total billed charges 14.26 21.85 Technical (Hospital) Services HC/HH Wch Supp Tape Cloth Medipore 2x10__2962 PX-2705000178 CDM 2705000178 LOCAL 270 RC outpatient 23 23 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES HDHP [308136802] 18.4 percent of total billed charges 14.26 21.85 Technical (Hospital) Services HC/HH Wch Supp Tape Cloth Medipore 2x10__2962 PX-2705000178 CDM 2705000178 LOCAL 270 RC outpatient 23 23 UNITED HEALTHCARE (COMMERCIAL) [3081199] UNITED HEALTHCARE 87726 [308119901] 14.26 percent of total billed charges 14.26 21.85 Technical (Hospital) Services HC/HH Wch Supp Tape Cloth Medipore 2x10__2962 PX-2705000178 CDM 2705000178 LOCAL 270 RC outpatient 23 23 HEALTHPARTNERS SX009 HEALTHPARTNERS 18.4 percent of total billed charges 14.26 21.85 Technical (Hospital) Services HC/HH Wch Supp Tape Cloth Medipore 2x10__2962 PX-2705000178 CDM 2705000178 LOCAL 270 RC outpatient 23 23 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES PPO [308136801] 18.4 percent of total billed charges 14.26 21.85 Technical (Hospital) Services HC/HH Wch Supp Tape Cloth Medipore 2x10__2962 PX-2705000178 CDM 2705000178 LOCAL 270 RC outpatient 23 23 MULTIPLAN INC 34080 [3081285] MULTIPLAN INC [308128501] 21.85 percent of total billed charges 14.26 21.85 Technical (Hospital) Services HC/HH Wch Supp Tape Cloth Medipore 2x10__2962 PX-2705000178 CDM 2705000178 LOCAL 270 RC outpatient 23 23 MEDICA (COMMERCIAL) 94265 [3081118] MEDICA CLAIMS [308111801] 20.7 percent of total billed charges 14.26 21.85 Technical (Hospital) Services "HC/HH Wch Supp Tape Casting 5 Wht__82005""" PX-2705000177 CDM 2705000177 LOCAL 270 RC outpatient 20 20 UNITED HEALTHCARE (COMMERCIAL) [3081199] UNITED HEALTHCARE 87726 [308119901] 12.4 percent of total billed charges 12.4 19 Technical (Hospital) Services "HC/HH Wch Supp Tape Casting 5 Wht__82005""" PX-2705000177 CDM 2705000177 LOCAL 270 RC outpatient 20 20 HEALTHPARTNERS SX009 HEALTHPARTNERS 16 percent of total billed charges 12.4 19 Technical (Hospital) Services "HC/HH Wch Supp Tape Casting 5 Wht__82005""" PX-2705000177 CDM 2705000177 LOCAL 270 RC outpatient 20 20 CIGNA 62308 [3081051] CIGNA 62308 [308105105] 16 percent of total billed charges 12.4 19 Technical (Hospital) Services "HC/HH Wch Supp Tape Casting 5 Wht__82005""" PX-2705000177 CDM 2705000177 LOCAL 270 RC outpatient 20 20 CIGNA 62308 [3081051] CIGNA STATE OF WYOMING [308105107] 16 percent of total billed charges 12.4 19 Technical (Hospital) Services "HC/HH Wch Supp Tape Casting 5 Wht__82005""" PX-2705000177 CDM 2705000177 LOCAL 270 RC outpatient 20 20 BLUE CROSS BLUE SHIELD WELLMARK SB889 [3081026] BCBS WYOMING [308102603] 19 percent of total billed charges 12.4 19 Technical (Hospital) Services "HC/HH Wch Supp Tape Casting 5 Wht__82005""" PX-2705000177 CDM 2705000177 LOCAL 270 RC outpatient 20 20 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES EPO [308136803] 16 percent of total billed charges 12.4 19 Technical (Hospital) Services "HC/HH Wch Supp Tape Casting 5 Wht__82005""" PX-2705000177 CDM 2705000177 LOCAL 270 RC outpatient 20 20 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES HDHP [308136802] 16 percent of total billed charges 12.4 19 Technical (Hospital) Services "HC/HH Wch Supp Tape Casting 5 Wht__82005""" PX-2705000177 CDM 2705000177 LOCAL 270 RC outpatient 20 20 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES PPO [308136801] 16 percent of total billed charges 12.4 19 Technical (Hospital) Services "HC/HH Wch Supp Tape Casting 5 Wht__82005""" PX-2705000177 CDM 2705000177 LOCAL 270 RC outpatient 20 20 MULTIPLAN INC 34080 [3081285] MULTIPLAN INC [308128501] 19 percent of total billed charges 12.4 19 Technical (Hospital) Services "HC/HH Wch Supp Tape Casting 5 Wht__82005""" PX-2705000177 CDM 2705000177 LOCAL 270 RC outpatient 20 20 MEDICA (COMMERCIAL) 94265 [3081118] MEDICA CLAIMS [308111801] 18 percent of total billed charges 12.4 19 Technical (Hospital) Services "HC/HH Wch Supp Tape Casting 5 Wht__82005""" PX-2705000177 CDM 2705000177 LOCAL 270 RC inpatient 20 20 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES EPO [308136803] 15.84 percent of total billed charges 12.4 19 Technical (Hospital) Services "HC/HH Wch Supp Tape Casting 5 Wht__82005""" PX-2705000177 CDM 2705000177 LOCAL 270 RC inpatient 20 20 HEALTHPARTNERS SX009 HEALTHPARTNERS 15.84 percent of total billed charges 12.4 19 Technical (Hospital) Services "HC/HH Wch Supp Tape Casting 5 Wht__82005""" PX-2705000177 CDM 2705000177 LOCAL 270 RC inpatient 20 20 CIGNA 62308 [3081051] CIGNA 62308 [308105105] 15.84 percent of total billed charges 12.4 19 Technical (Hospital) Services "HC/HH Wch Supp Tape Casting 5 Wht__82005""" PX-2705000177 CDM 2705000177 LOCAL 270 RC inpatient 20 20 CIGNA 62308 [3081051] CIGNA STATE OF WYOMING [308105107] 15.84 percent of total billed charges 12.4 19 Technical (Hospital) Services "HC/HH Wch Supp Tape Casting 5 Wht__82005""" PX-2705000177 CDM 2705000177 LOCAL 270 RC inpatient 20 20 MULTIPLAN INC 34080 [3081285] MULTIPLAN INC [308128501] 19 percent of total billed charges 12.4 19 Technical (Hospital) Services "HC/HH Wch Supp Tape Casting 5 Wht__82005""" PX-2705000177 CDM 2705000177 LOCAL 270 RC inpatient 20 20 BLUE CROSS BLUE SHIELD WELLMARK SB889 [3081026] BCBS WYOMING [308102603] 19 percent of total billed charges 12.4 19 Technical (Hospital) Services "HC/HH Wch Supp Tape Casting 5 Wht__82005""" PX-2705000177 CDM 2705000177 LOCAL 270 RC inpatient 20 20 UNITED HEALTHCARE (COMMERCIAL) [3081199] UNITED HEALTHCARE 87726 [308119901] 12.4 percent of total billed charges 12.4 19 Technical (Hospital) Services "HC/HH Wch Supp Tape Casting 5 Wht__82005""" PX-2705000177 CDM 2705000177 LOCAL 270 RC inpatient 20 20 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES HDHP [308136802] 15.84 percent of total billed charges 12.4 19 Technical (Hospital) Services "HC/HH Wch Supp Tape Casting 5 Wht__82005""" PX-2705000177 CDM 2705000177 LOCAL 270 RC inpatient 20 20 MEDICA (COMMERCIAL) 94265 [3081118] MEDICA CLAIMS [308111801] 18 percent of total billed charges 12.4 19 Technical (Hospital) Services "HC/HH Wch Supp Tape Casting 5 Wht__82005""" PX-2705000177 CDM 2705000177 LOCAL 270 RC inpatient 20 20 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES PPO [308136801] 15.84 percent of total billed charges 12.4 19 Technical (Hospital) Services "HC/HH Wch Supp Tape Casting 4 Wht__82004""" PX-2705000176 CDM 2705000176 LOCAL 270 RC outpatient 34 34 MULTIPLAN INC 34080 [3081285] MULTIPLAN INC [308128501] 32.3 percent of total billed charges 21.08 32.3 Technical (Hospital) Services "HC/HH Wch Supp Tape Casting 4 Wht__82004""" PX-2705000176 CDM 2705000176 LOCAL 270 RC outpatient 34 34 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES PPO [308136801] 27.2 percent of total billed charges 21.08 32.3 Technical (Hospital) Services "HC/HH Wch Supp Tape Casting 4 Wht__82004""" PX-2705000176 CDM 2705000176 LOCAL 270 RC outpatient 34 34 MEDICA (COMMERCIAL) 94265 [3081118] MEDICA CLAIMS [308111801] 30.6 percent of total billed charges 21.08 32.3 Technical (Hospital) Services "HC/HH Wch Supp Tape Casting 4 Wht__82004""" PX-2705000176 CDM 2705000176 LOCAL 270 RC outpatient 34 34 CIGNA 62308 [3081051] CIGNA 62308 [308105105] 27.2 percent of total billed charges 21.08 32.3 Technical (Hospital) Services "HC/HH Wch Supp Tape Casting 4 Wht__82004""" PX-2705000176 CDM 2705000176 LOCAL 270 RC outpatient 34 34 CIGNA 62308 [3081051] CIGNA STATE OF WYOMING [308105107] 27.2 percent of total billed charges 21.08 32.3 Technical (Hospital) Services "HC/HH Wch Supp Tape Casting 4 Wht__82004""" PX-2705000176 CDM 2705000176 LOCAL 270 RC outpatient 34 34 BLUE CROSS BLUE SHIELD WELLMARK SB889 [3081026] BCBS WYOMING [308102603] 32.3 percent of total billed charges 21.08 32.3 Technical (Hospital) Services "HC/HH Wch Supp Tape Casting 4 Wht__82004""" PX-2705000176 CDM 2705000176 LOCAL 270 RC outpatient 34 34 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES EPO [308136803] 27.2 percent of total billed charges 21.08 32.3 Technical (Hospital) Services "HC/HH Wch Supp Tape Casting 4 Wht__82004""" PX-2705000176 CDM 2705000176 LOCAL 270 RC outpatient 34 34 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES HDHP [308136802] 27.2 percent of total billed charges 21.08 32.3 Technical (Hospital) Services "HC/HH Wch Supp Tape Casting 4 Wht__82004""" PX-2705000176 CDM 2705000176 LOCAL 270 RC outpatient 34 34 HEALTHPARTNERS SX009 HEALTHPARTNERS 27.2 percent of total billed charges 21.08 32.3 Technical (Hospital) Services "HC/HH Wch Supp Tape Casting 4 Wht__82004""" PX-2705000176 CDM 2705000176 LOCAL 270 RC outpatient 34 34 UNITED HEALTHCARE (COMMERCIAL) [3081199] UNITED HEALTHCARE 87726 [308119901] 21.08 percent of total billed charges 21.08 32.3 Technical (Hospital) Services "HC/HH Wch Supp Tape Casting 4 Wht__82004""" PX-2705000176 CDM 2705000176 LOCAL 270 RC inpatient 34 34 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES PPO [308136801] 26.92 percent of total billed charges 21.08 32.3 Technical (Hospital) Services "HC/HH Wch Supp Tape Casting 4 Wht__82004""" PX-2705000176 CDM 2705000176 LOCAL 270 RC inpatient 34 34 MEDICA (COMMERCIAL) 94265 [3081118] MEDICA CLAIMS [308111801] 30.6 percent of total billed charges 21.08 32.3 Technical (Hospital) Services "HC/HH Wch Supp Tape Casting 4 Wht__82004""" PX-2705000176 CDM 2705000176 LOCAL 270 RC inpatient 34 34 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES HDHP [308136802] 26.92 percent of total billed charges 21.08 32.3 Technical (Hospital) Services "HC/HH Wch Supp Tape Casting 4 Wht__82004""" PX-2705000176 CDM 2705000176 LOCAL 270 RC inpatient 34 34 UNITED HEALTHCARE (COMMERCIAL) [3081199] UNITED HEALTHCARE 87726 [308119901] 21.08 percent of total billed charges 21.08 32.3 Technical (Hospital) Services "HC/HH Wch Supp Tape Casting 4 Wht__82004""" PX-2705000176 CDM 2705000176 LOCAL 270 RC inpatient 34 34 BLUE CROSS BLUE SHIELD WELLMARK SB889 [3081026] BCBS WYOMING [308102603] 32.3 percent of total billed charges 21.08 32.3 Technical (Hospital) Services "HC/HH Wch Supp Tape Casting 4 Wht__82004""" PX-2705000176 CDM 2705000176 LOCAL 270 RC inpatient 34 34 MULTIPLAN INC 34080 [3081285] MULTIPLAN INC [308128501] 32.3 percent of total billed charges 21.08 32.3 Technical (Hospital) Services "HC/HH Wch Supp Tape Casting 4 Wht__82004""" PX-2705000176 CDM 2705000176 LOCAL 270 RC inpatient 34 34 CIGNA 62308 [3081051] CIGNA 62308 [308105105] 26.92 percent of total billed charges 21.08 32.3 Technical (Hospital) Services "HC/HH Wch Supp Tape Casting 4 Wht__82004""" PX-2705000176 CDM 2705000176 LOCAL 270 RC inpatient 34 34 CIGNA 62308 [3081051] CIGNA STATE OF WYOMING [308105107] 26.92 percent of total billed charges 21.08 32.3 Technical (Hospital) Services "HC/HH Wch Supp Tape Casting 4 Wht__82004""" PX-2705000176 CDM 2705000176 LOCAL 270 RC inpatient 34 34 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES EPO [308136803] 26.92 percent of total billed charges 21.08 32.3 Technical (Hospital) Services "HC/HH Wch Supp Tape Casting 4 Wht__82004""" PX-2705000176 CDM 2705000176 LOCAL 270 RC inpatient 34 34 HEALTHPARTNERS SX009 HEALTHPARTNERS 26.92 percent of total billed charges 21.08 32.3 Technical (Hospital) Services "HC/HH Wch Supp Tape Casting 3 Wht__82003""" PX-2705000175 CDM 2705000175 LOCAL 270 RC inpatient 27 27 UNITED HEALTHCARE (COMMERCIAL) [3081199] UNITED HEALTHCARE 87726 [308119901] 16.74 percent of total billed charges 16.74 25.65 Technical (Hospital) Services "HC/HH Wch Supp Tape Casting 3 Wht__82003""" PX-2705000175 CDM 2705000175 LOCAL 270 RC inpatient 27 27 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES HDHP [308136802] 21.38 percent of total billed charges 16.74 25.65 Technical (Hospital) Services "HC/HH Wch Supp Tape Casting 3 Wht__82003""" PX-2705000175 CDM 2705000175 LOCAL 270 RC inpatient 27 27 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES PPO [308136801] 21.38 percent of total billed charges 16.74 25.65 Technical (Hospital) Services "HC/HH Wch Supp Tape Casting 3 Wht__82003""" PX-2705000175 CDM 2705000175 LOCAL 270 RC inpatient 27 27 MEDICA (COMMERCIAL) 94265 [3081118] MEDICA CLAIMS [308111801] 24.3 percent of total billed charges 16.74 25.65 Technical (Hospital) Services "HC/HH Wch Supp Tape Casting 3 Wht__82003""" PX-2705000175 CDM 2705000175 LOCAL 270 RC inpatient 27 27 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES EPO [308136803] 21.38 percent of total billed charges 16.74 25.65 Technical (Hospital) Services "HC/HH Wch Supp Tape Casting 3 Wht__82003""" PX-2705000175 CDM 2705000175 LOCAL 270 RC inpatient 27 27 HEALTHPARTNERS SX009 HEALTHPARTNERS 21.38 percent of total billed charges 16.74 25.65 Technical (Hospital) Services "HC/HH Wch Supp Tape Casting 3 Wht__82003""" PX-2705000175 CDM 2705000175 LOCAL 270 RC inpatient 27 27 MULTIPLAN INC 34080 [3081285] MULTIPLAN INC [308128501] 25.65 percent of total billed charges 16.74 25.65 Technical (Hospital) Services "HC/HH Wch Supp Tape Casting 3 Wht__82003""" PX-2705000175 CDM 2705000175 LOCAL 270 RC inpatient 27 27 BLUE CROSS BLUE SHIELD WELLMARK SB889 [3081026] BCBS WYOMING [308102603] 25.65 percent of total billed charges 16.74 25.65 Technical (Hospital) Services "HC/HH Wch Supp Tape Casting 3 Wht__82003""" PX-2705000175 CDM 2705000175 LOCAL 270 RC inpatient 27 27 CIGNA 62308 [3081051] CIGNA 62308 [308105105] 21.38 percent of total billed charges 16.74 25.65 Technical (Hospital) Services "HC/HH Wch Supp Tape Casting 3 Wht__82003""" PX-2705000175 CDM 2705000175 LOCAL 270 RC inpatient 27 27 CIGNA 62308 [3081051] CIGNA STATE OF WYOMING [308105107] 21.38 percent of total billed charges 16.74 25.65 Technical (Hospital) Services "HC/HH Wch Supp Tape Casting 3 Wht__82003""" PX-2705000175 CDM 2705000175 LOCAL 270 RC outpatient 27 27 CIGNA 62308 [3081051] CIGNA 62308 [308105105] 21.6 percent of total billed charges 16.74 25.65 Technical (Hospital) Services "HC/HH Wch Supp Tape Casting 3 Wht__82003""" PX-2705000175 CDM 2705000175 LOCAL 270 RC outpatient 27 27 CIGNA 62308 [3081051] CIGNA STATE OF WYOMING [308105107] 21.6 percent of total billed charges 16.74 25.65 Technical (Hospital) Services "HC/HH Wch Supp Tape Casting 3 Wht__82003""" PX-2705000175 CDM 2705000175 LOCAL 270 RC outpatient 27 27 BLUE CROSS BLUE SHIELD WELLMARK SB889 [3081026] BCBS WYOMING [308102603] 25.65 percent of total billed charges 16.74 25.65 Technical (Hospital) Services "HC/HH Wch Supp Tape Casting 3 Wht__82003""" PX-2705000175 CDM 2705000175 LOCAL 270 RC outpatient 27 27 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES EPO [308136803] 21.6 percent of total billed charges 16.74 25.65 Technical (Hospital) Services "HC/HH Wch Supp Tape Casting 3 Wht__82003""" PX-2705000175 CDM 2705000175 LOCAL 270 RC outpatient 27 27 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES HDHP [308136802] 21.6 percent of total billed charges 16.74 25.65 Technical (Hospital) Services "HC/HH Wch Supp Tape Casting 3 Wht__82003""" PX-2705000175 CDM 2705000175 LOCAL 270 RC outpatient 27 27 UNITED HEALTHCARE (COMMERCIAL) [3081199] UNITED HEALTHCARE 87726 [308119901] 16.74 percent of total billed charges 16.74 25.65 Technical (Hospital) Services "HC/HH Wch Supp Tape Casting 3 Wht__82003""" PX-2705000175 CDM 2705000175 LOCAL 270 RC outpatient 27 27 HEALTHPARTNERS SX009 HEALTHPARTNERS 21.6 percent of total billed charges 16.74 25.65 Technical (Hospital) Services "HC/HH Wch Supp Tape Casting 3 Wht__82003""" PX-2705000175 CDM 2705000175 LOCAL 270 RC outpatient 27 27 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES PPO [308136801] 21.6 percent of total billed charges 16.74 25.65 Technical (Hospital) Services "HC/HH Wch Supp Tape Casting 3 Wht__82003""" PX-2705000175 CDM 2705000175 LOCAL 270 RC outpatient 27 27 MEDICA (COMMERCIAL) 94265 [3081118] MEDICA CLAIMS [308111801] 24.3 percent of total billed charges 16.74 25.65 Technical (Hospital) Services "HC/HH Wch Supp Tape Casting 3 Wht__82003""" PX-2705000175 CDM 2705000175 LOCAL 270 RC outpatient 27 27 MULTIPLAN INC 34080 [3081285] MULTIPLAN INC [308128501] 25.65 percent of total billed charges 16.74 25.65 Technical (Hospital) Services "HC/HH Wch Supp Tape Casting 2 Wht__82002""" PX-2705000174 CDM 2705000174 LOCAL 270 RC inpatient 14 14 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES EPO [308136803] 11.09 percent of total billed charges 8.68 13.3 Technical (Hospital) Services "HC/HH Wch Supp Tape Casting 2 Wht__82002""" PX-2705000174 CDM 2705000174 LOCAL 270 RC inpatient 14 14 HEALTHPARTNERS SX009 HEALTHPARTNERS 11.09 percent of total billed charges 8.68 13.3 Technical (Hospital) Services "HC/HH Wch Supp Tape Casting 2 Wht__82002""" PX-2705000174 CDM 2705000174 LOCAL 270 RC inpatient 14 14 MULTIPLAN INC 34080 [3081285] MULTIPLAN INC [308128501] 13.3 percent of total billed charges 8.68 13.3 Technical (Hospital) Services "HC/HH Wch Supp Tape Casting 2 Wht__82002""" PX-2705000174 CDM 2705000174 LOCAL 270 RC inpatient 14 14 BLUE CROSS BLUE SHIELD WELLMARK SB889 [3081026] BCBS WYOMING [308102603] 13.3 percent of total billed charges 8.68 13.3 Technical (Hospital) Services "HC/HH Wch Supp Tape Casting 2 Wht__82002""" PX-2705000174 CDM 2705000174 LOCAL 270 RC inpatient 14 14 CIGNA 62308 [3081051] CIGNA 62308 [308105105] 11.09 percent of total billed charges 8.68 13.3 Technical (Hospital) Services "HC/HH Wch Supp Tape Casting 2 Wht__82002""" PX-2705000174 CDM 2705000174 LOCAL 270 RC inpatient 14 14 CIGNA 62308 [3081051] CIGNA STATE OF WYOMING [308105107] 11.09 percent of total billed charges 8.68 13.3 Technical (Hospital) Services "HC/HH Wch Supp Tape Casting 2 Wht__82002""" PX-2705000174 CDM 2705000174 LOCAL 270 RC inpatient 14 14 UNITED HEALTHCARE (COMMERCIAL) [3081199] UNITED HEALTHCARE 87726 [308119901] 8.68 percent of total billed charges 8.68 13.3 Technical (Hospital) Services "HC/HH Wch Supp Tape Casting 2 Wht__82002""" PX-2705000174 CDM 2705000174 LOCAL 270 RC inpatient 14 14 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES HDHP [308136802] 11.09 percent of total billed charges 8.68 13.3 Technical (Hospital) Services "HC/HH Wch Supp Tape Casting 2 Wht__82002""" PX-2705000174 CDM 2705000174 LOCAL 270 RC inpatient 14 14 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES PPO [308136801] 11.09 percent of total billed charges 8.68 13.3 Technical (Hospital) Services "HC/HH Wch Supp Tape Casting 2 Wht__82002""" PX-2705000174 CDM 2705000174 LOCAL 270 RC inpatient 14 14 MEDICA (COMMERCIAL) 94265 [3081118] MEDICA CLAIMS [308111801] 12.6 percent of total billed charges 8.68 13.3 Technical (Hospital) Services "HC/HH Wch Supp Tape Casting 2 Wht__82002""" PX-2705000174 CDM 2705000174 LOCAL 270 RC outpatient 14 14 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES HDHP [308136802] 11.2 percent of total billed charges 8.68 13.3 Technical (Hospital) Services "HC/HH Wch Supp Tape Casting 2 Wht__82002""" PX-2705000174 CDM 2705000174 LOCAL 270 RC outpatient 14 14 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES EPO [308136803] 11.2 percent of total billed charges 8.68 13.3 Technical (Hospital) Services "HC/HH Wch Supp Tape Casting 2 Wht__82002""" PX-2705000174 CDM 2705000174 LOCAL 270 RC outpatient 14 14 CIGNA 62308 [3081051] CIGNA 62308 [308105105] 11.2 percent of total billed charges 8.68 13.3 Technical (Hospital) Services "HC/HH Wch Supp Tape Casting 2 Wht__82002""" PX-2705000174 CDM 2705000174 LOCAL 270 RC outpatient 14 14 CIGNA 62308 [3081051] CIGNA STATE OF WYOMING [308105107] 11.2 percent of total billed charges 8.68 13.3 Technical (Hospital) Services "HC/HH Wch Supp Tape Casting 2 Wht__82002""" PX-2705000174 CDM 2705000174 LOCAL 270 RC outpatient 14 14 BLUE CROSS BLUE SHIELD WELLMARK SB889 [3081026] BCBS WYOMING [308102603] 13.3 percent of total billed charges 8.68 13.3 Technical (Hospital) Services "HC/HH Wch Supp Tape Casting 2 Wht__82002""" PX-2705000174 CDM 2705000174 LOCAL 270 RC outpatient 14 14 UNITED HEALTHCARE (COMMERCIAL) [3081199] UNITED HEALTHCARE 87726 [308119901] 8.68 percent of total billed charges 8.68 13.3 Technical (Hospital) Services "HC/HH Wch Supp Tape Casting 2 Wht__82002""" PX-2705000174 CDM 2705000174 LOCAL 270 RC outpatient 14 14 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES PPO [308136801] 11.2 percent of total billed charges 8.68 13.3 Technical (Hospital) Services "HC/HH Wch Supp Tape Casting 2 Wht__82002""" PX-2705000174 CDM 2705000174 LOCAL 270 RC outpatient 14 14 HEALTHPARTNERS SX009 HEALTHPARTNERS 11.2 percent of total billed charges 8.68 13.3 Technical (Hospital) Services "HC/HH Wch Supp Tape Casting 2 Wht__82002""" PX-2705000174 CDM 2705000174 LOCAL 270 RC outpatient 14 14 MEDICA (COMMERCIAL) 94265 [3081118] MEDICA CLAIMS [308111801] 12.6 percent of total billed charges 8.68 13.3 Technical (Hospital) Services "HC/HH Wch Supp Tape Casting 2 Wht__82002""" PX-2705000174 CDM 2705000174 LOCAL 270 RC outpatient 14 14 MULTIPLAN INC 34080 [3081285] MULTIPLAN INC [308128501] 13.3 percent of total billed charges 8.68 13.3 Technical (Hospital) Services HC/HH Wch Supp Support Lumbosacral S__A818030 PX-2705000172 CDM 2705000172 LOCAL 270 RC inpatient 14 14 UNITED HEALTHCARE (COMMERCIAL) [3081199] UNITED HEALTHCARE 87726 [308119901] 8.68 percent of total billed charges 8.68 13.3 Technical (Hospital) Services HC/HH Wch Supp Support Lumbosacral S__A818030 PX-2705000172 CDM 2705000172 LOCAL 270 RC inpatient 14 14 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES HDHP [308136802] 11.09 percent of total billed charges 8.68 13.3 Technical (Hospital) Services HC/HH Wch Supp Support Lumbosacral S__A818030 PX-2705000172 CDM 2705000172 LOCAL 270 RC inpatient 14 14 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES PPO [308136801] 11.09 percent of total billed charges 8.68 13.3 Technical (Hospital) Services HC/HH Wch Supp Support Lumbosacral S__A818030 PX-2705000172 CDM 2705000172 LOCAL 270 RC inpatient 14 14 MEDICA (COMMERCIAL) 94265 [3081118] MEDICA CLAIMS [308111801] 12.6 percent of total billed charges 8.68 13.3 Technical (Hospital) Services HC/HH Wch Supp Support Lumbosacral S__A818030 PX-2705000172 CDM 2705000172 LOCAL 270 RC inpatient 14 14 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES EPO [308136803] 11.09 percent of total billed charges 8.68 13.3 Technical (Hospital) Services HC/HH Wch Supp Support Lumbosacral S__A818030 PX-2705000172 CDM 2705000172 LOCAL 270 RC inpatient 14 14 HEALTHPARTNERS SX009 HEALTHPARTNERS 11.09 percent of total billed charges 8.68 13.3 Technical (Hospital) Services HC/HH Wch Supp Support Lumbosacral S__A818030 PX-2705000172 CDM 2705000172 LOCAL 270 RC inpatient 14 14 BLUE CROSS BLUE SHIELD WELLMARK SB889 [3081026] BCBS WYOMING [308102603] 13.3 percent of total billed charges 8.68 13.3 Technical (Hospital) Services HC/HH Wch Supp Support Lumbosacral S__A818030 PX-2705000172 CDM 2705000172 LOCAL 270 RC inpatient 14 14 MULTIPLAN INC 34080 [3081285] MULTIPLAN INC [308128501] 13.3 percent of total billed charges 8.68 13.3 Technical (Hospital) Services HC/HH Wch Supp Support Lumbosacral S__A818030 PX-2705000172 CDM 2705000172 LOCAL 270 RC inpatient 14 14 CIGNA 62308 [3081051] CIGNA 62308 [308105105] 11.09 percent of total billed charges 8.68 13.3 Technical (Hospital) Services HC/HH Wch Supp Support Lumbosacral S__A818030 PX-2705000172 CDM 2705000172 LOCAL 270 RC inpatient 14 14 CIGNA 62308 [3081051] CIGNA STATE OF WYOMING [308105107] 11.09 percent of total billed charges 8.68 13.3 Technical (Hospital) Services HC/HH Wch Supp Support Lumbosacral S__A818030 PX-2705000172 CDM 2705000172 LOCAL 270 RC outpatient 14 14 CIGNA 62308 [3081051] CIGNA 62308 [308105105] 11.2 percent of total billed charges 8.68 13.3 Technical (Hospital) Services HC/HH Wch Supp Support Lumbosacral S__A818030 PX-2705000172 CDM 2705000172 LOCAL 270 RC outpatient 14 14 CIGNA 62308 [3081051] CIGNA STATE OF WYOMING [308105107] 11.2 percent of total billed charges 8.68 13.3 Technical (Hospital) Services HC/HH Wch Supp Support Lumbosacral S__A818030 PX-2705000172 CDM 2705000172 LOCAL 270 RC outpatient 14 14 BLUE CROSS BLUE SHIELD WELLMARK SB889 [3081026] BCBS WYOMING [308102603] 13.3 percent of total billed charges 8.68 13.3 Technical (Hospital) Services HC/HH Wch Supp Support Lumbosacral S__A818030 PX-2705000172 CDM 2705000172 LOCAL 270 RC outpatient 14 14 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES EPO [308136803] 11.2 percent of total billed charges 8.68 13.3 Technical (Hospital) Services HC/HH Wch Supp Support Lumbosacral S__A818030 PX-2705000172 CDM 2705000172 LOCAL 270 RC outpatient 14 14 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES HDHP [308136802] 11.2 percent of total billed charges 8.68 13.3 Technical (Hospital) Services HC/HH Wch Supp Support Lumbosacral S__A818030 PX-2705000172 CDM 2705000172 LOCAL 270 RC outpatient 14 14 HEALTHPARTNERS SX009 HEALTHPARTNERS 11.2 percent of total billed charges 8.68 13.3 Technical (Hospital) Services HC/HH Wch Supp Support Lumbosacral S__A818030 PX-2705000172 CDM 2705000172 LOCAL 270 RC outpatient 14 14 UNITED HEALTHCARE (COMMERCIAL) [3081199] UNITED HEALTHCARE 87726 [308119901] 8.68 percent of total billed charges 8.68 13.3 Technical (Hospital) Services HC/HH Wch Supp Support Lumbosacral S__A818030 PX-2705000172 CDM 2705000172 LOCAL 270 RC outpatient 14 14 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES PPO [308136801] 11.2 percent of total billed charges 8.68 13.3 Technical (Hospital) Services HC/HH Wch Supp Support Lumbosacral S__A818030 PX-2705000172 CDM 2705000172 LOCAL 270 RC outpatient 14 14 MULTIPLAN INC 34080 [3081285] MULTIPLAN INC [308128501] 13.3 percent of total billed charges 8.68 13.3 Technical (Hospital) Services HC/HH Wch Supp Support Lumbosacral S__A818030 PX-2705000172 CDM 2705000172 LOCAL 270 RC outpatient 14 14 MEDICA (COMMERCIAL) 94265 [3081118] MEDICA CLAIMS [308111801] 12.6 percent of total billed charges 8.68 13.3 Technical (Hospital) Services HC/HH Wch Supp Strap Montgomery__1583702 PX-2705000171 CDM 2705000171 LOCAL 270 RC outpatient 8 8 UNITED HEALTHCARE (COMMERCIAL) [3081199] UNITED HEALTHCARE 87726 [308119901] 4.96 percent of total billed charges 4.96 7.6 Technical (Hospital) Services HC/HH Wch Supp Strap Montgomery__1583702 PX-2705000171 CDM 2705000171 LOCAL 270 RC outpatient 8 8 HEALTHPARTNERS SX009 HEALTHPARTNERS 6.4 percent of total billed charges 4.96 7.6 Technical (Hospital) Services HC/HH Wch Supp Strap Montgomery__1583702 PX-2705000171 CDM 2705000171 LOCAL 270 RC outpatient 8 8 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES HDHP [308136802] 6.4 percent of total billed charges 4.96 7.6 Technical (Hospital) Services HC/HH Wch Supp Strap Montgomery__1583702 PX-2705000171 CDM 2705000171 LOCAL 270 RC outpatient 8 8 CIGNA 62308 [3081051] CIGNA 62308 [308105105] 6.4 percent of total billed charges 4.96 7.6 Technical (Hospital) Services HC/HH Wch Supp Strap Montgomery__1583702 PX-2705000171 CDM 2705000171 LOCAL 270 RC outpatient 8 8 CIGNA 62308 [3081051] CIGNA STATE OF WYOMING [308105107] 6.4 percent of total billed charges 4.96 7.6 Technical (Hospital) Services HC/HH Wch Supp Strap Montgomery__1583702 PX-2705000171 CDM 2705000171 LOCAL 270 RC outpatient 8 8 BLUE CROSS BLUE SHIELD WELLMARK SB889 [3081026] BCBS WYOMING [308102603] 7.6 percent of total billed charges 4.96 7.6 Technical (Hospital) Services HC/HH Wch Supp Strap Montgomery__1583702 PX-2705000171 CDM 2705000171 LOCAL 270 RC outpatient 8 8 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES EPO [308136803] 6.4 percent of total billed charges 4.96 7.6 Technical (Hospital) Services HC/HH Wch Supp Strap Montgomery__1583702 PX-2705000171 CDM 2705000171 LOCAL 270 RC outpatient 8 8 MEDICA (COMMERCIAL) 94265 [3081118] MEDICA CLAIMS [308111801] 7.2 percent of total billed charges 4.96 7.6 Technical (Hospital) Services HC/HH Wch Supp Strap Montgomery__1583702 PX-2705000171 CDM 2705000171 LOCAL 270 RC outpatient 8 8 MULTIPLAN INC 34080 [3081285] MULTIPLAN INC [308128501] 7.6 percent of total billed charges 4.96 7.6 Technical (Hospital) Services HC/HH Wch Supp Strap Montgomery__1583702 PX-2705000171 CDM 2705000171 LOCAL 270 RC outpatient 8 8 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES PPO [308136801] 6.4 percent of total billed charges 4.96 7.6 Technical (Hospital) Services HC/HH Wch Supp Strap Montgomery__1583702 PX-2705000171 CDM 2705000171 LOCAL 270 RC inpatient 8 8 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES PPO [308136801] 6.33 percent of total billed charges 4.96 7.6 Technical (Hospital) Services HC/HH Wch Supp Strap Montgomery__1583702 PX-2705000171 CDM 2705000171 LOCAL 270 RC inpatient 8 8 MEDICA (COMMERCIAL) 94265 [3081118] MEDICA CLAIMS [308111801] 7.2 percent of total billed charges 4.96 7.6 Technical (Hospital) Services HC/HH Wch Supp Strap Montgomery__1583702 PX-2705000171 CDM 2705000171 LOCAL 270 RC inpatient 8 8 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES HDHP [308136802] 6.33 percent of total billed charges 4.96 7.6 Technical (Hospital) Services HC/HH Wch Supp Strap Montgomery__1583702 PX-2705000171 CDM 2705000171 LOCAL 270 RC inpatient 8 8 UNITED HEALTHCARE (COMMERCIAL) [3081199] UNITED HEALTHCARE 87726 [308119901] 4.96 percent of total billed charges 4.96 7.6 Technical (Hospital) Services HC/HH Wch Supp Strap Montgomery__1583702 PX-2705000171 CDM 2705000171 LOCAL 270 RC inpatient 8 8 BLUE CROSS BLUE SHIELD WELLMARK SB889 [3081026] BCBS WYOMING [308102603] 7.6 percent of total billed charges 4.96 7.6 Technical (Hospital) Services HC/HH Wch Supp Strap Montgomery__1583702 PX-2705000171 CDM 2705000171 LOCAL 270 RC inpatient 8 8 MULTIPLAN INC 34080 [3081285] MULTIPLAN INC [308128501] 7.6 percent of total billed charges 4.96 7.6 Technical (Hospital) Services HC/HH Wch Supp Strap Montgomery__1583702 PX-2705000171 CDM 2705000171 LOCAL 270 RC inpatient 8 8 CIGNA 62308 [3081051] CIGNA 62308 [308105105] 6.33 percent of total billed charges 4.96 7.6 Technical (Hospital) Services HC/HH Wch Supp Strap Montgomery__1583702 PX-2705000171 CDM 2705000171 LOCAL 270 RC inpatient 8 8 CIGNA 62308 [3081051] CIGNA STATE OF WYOMING [308105107] 6.33 percent of total billed charges 4.96 7.6 Technical (Hospital) Services HC/HH Wch Supp Strap Montgomery__1583702 PX-2705000171 CDM 2705000171 LOCAL 270 RC inpatient 8 8 HEALTHPARTNERS SX009 HEALTHPARTNERS 6.33 percent of total billed charges 4.96 7.6 Technical (Hospital) Services HC/HH Wch Supp Strap Montgomery__1583702 PX-2705000171 CDM 2705000171 LOCAL 270 RC inpatient 8 8 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES EPO [308136803] 6.33 percent of total billed charges 4.96 7.6 Technical (Hospital) Services HC/HH Wch Supp Strap Arm Padded Xl__0814-1315 PX-2705000170 CDM 2705000170 LOCAL 270 RC outpatient 22 22 BLUE CROSS BLUE SHIELD WELLMARK SB889 [3081026] BCBS WYOMING [308102603] 20.9 percent of total billed charges 13.64 20.9 Technical (Hospital) Services HC/HH Wch Supp Strap Arm Padded Xl__0814-1315 PX-2705000170 CDM 2705000170 LOCAL 270 RC outpatient 22 22 CIGNA 62308 [3081051] CIGNA 62308 [308105105] 17.6 percent of total billed charges 13.64 20.9 Technical (Hospital) Services HC/HH Wch Supp Strap Arm Padded Xl__0814-1315 PX-2705000170 CDM 2705000170 LOCAL 270 RC outpatient 22 22 CIGNA 62308 [3081051] CIGNA STATE OF WYOMING [308105107] 17.6 percent of total billed charges 13.64 20.9 Technical (Hospital) Services HC/HH Wch Supp Strap Arm Padded Xl__0814-1315 PX-2705000170 CDM 2705000170 LOCAL 270 RC outpatient 22 22 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES EPO [308136803] 17.6 percent of total billed charges 13.64 20.9 Technical (Hospital) Services HC/HH Wch Supp Strap Arm Padded Xl__0814-1315 PX-2705000170 CDM 2705000170 LOCAL 270 RC outpatient 22 22 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES HDHP [308136802] 17.6 percent of total billed charges 13.64 20.9 Technical (Hospital) Services HC/HH Wch Supp Strap Arm Padded Xl__0814-1315 PX-2705000170 CDM 2705000170 LOCAL 270 RC outpatient 22 22 UNITED HEALTHCARE (COMMERCIAL) [3081199] UNITED HEALTHCARE 87726 [308119901] 13.64 percent of total billed charges 13.64 20.9 Technical (Hospital) Services HC/HH Wch Supp Strap Arm Padded Xl__0814-1315 PX-2705000170 CDM 2705000170 LOCAL 270 RC outpatient 22 22 HEALTHPARTNERS SX009 HEALTHPARTNERS 17.6 percent of total billed charges 13.64 20.9 Technical (Hospital) Services HC/HH Wch Supp Strap Arm Padded Xl__0814-1315 PX-2705000170 CDM 2705000170 LOCAL 270 RC outpatient 22 22 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES PPO [308136801] 17.6 percent of total billed charges 13.64 20.9 Technical (Hospital) Services HC/HH Wch Supp Strap Arm Padded Xl__0814-1315 PX-2705000170 CDM 2705000170 LOCAL 270 RC outpatient 22 22 MEDICA (COMMERCIAL) 94265 [3081118] MEDICA CLAIMS [308111801] 19.8 percent of total billed charges 13.64 20.9 Technical (Hospital) Services HC/HH Wch Supp Strap Arm Padded Xl__0814-1315 PX-2705000170 CDM 2705000170 LOCAL 270 RC outpatient 22 22 MULTIPLAN INC 34080 [3081285] MULTIPLAN INC [308128501] 20.9 percent of total billed charges 13.64 20.9 Technical (Hospital) Services HC/HH Wch Supp Strap Arm Padded Xl__0814-1315 PX-2705000170 CDM 2705000170 LOCAL 270 RC inpatient 22 22 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES PPO [308136801] 17.42 percent of total billed charges 13.64 20.9 Technical (Hospital) Services HC/HH Wch Supp Strap Arm Padded Xl__0814-1315 PX-2705000170 CDM 2705000170 LOCAL 270 RC inpatient 22 22 UNITED HEALTHCARE (COMMERCIAL) [3081199] UNITED HEALTHCARE 87726 [308119901] 13.64 percent of total billed charges 13.64 20.9 Technical (Hospital) Services HC/HH Wch Supp Strap Arm Padded Xl__0814-1315 PX-2705000170 CDM 2705000170 LOCAL 270 RC inpatient 22 22 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES HDHP [308136802] 17.42 percent of total billed charges 13.64 20.9 Technical (Hospital) Services HC/HH Wch Supp Strap Arm Padded Xl__0814-1315 PX-2705000170 CDM 2705000170 LOCAL 270 RC inpatient 22 22 MEDICA (COMMERCIAL) 94265 [3081118] MEDICA CLAIMS [308111801] 19.8 percent of total billed charges 13.64 20.9 Technical (Hospital) Services HC/HH Wch Supp Strap Arm Padded Xl__0814-1315 PX-2705000170 CDM 2705000170 LOCAL 270 RC inpatient 22 22 MULTIPLAN INC 34080 [3081285] MULTIPLAN INC [308128501] 20.9 percent of total billed charges 13.64 20.9 Technical (Hospital) Services HC/HH Wch Supp Strap Arm Padded Xl__0814-1315 PX-2705000170 CDM 2705000170 LOCAL 270 RC inpatient 22 22 BLUE CROSS BLUE SHIELD WELLMARK SB889 [3081026] BCBS WYOMING [308102603] 20.9 percent of total billed charges 13.64 20.9 Technical (Hospital) Services HC/HH Wch Supp Strap Arm Padded Xl__0814-1315 PX-2705000170 CDM 2705000170 LOCAL 270 RC inpatient 22 22 CIGNA 62308 [3081051] CIGNA 62308 [308105105] 17.42 percent of total billed charges 13.64 20.9 Technical (Hospital) Services HC/HH Wch Supp Strap Arm Padded Xl__0814-1315 PX-2705000170 CDM 2705000170 LOCAL 270 RC inpatient 22 22 CIGNA 62308 [3081051] CIGNA STATE OF WYOMING [308105107] 17.42 percent of total billed charges 13.64 20.9 Technical (Hospital) Services HC/HH Wch Supp Strap Arm Padded Xl__0814-1315 PX-2705000170 CDM 2705000170 LOCAL 270 RC inpatient 22 22 HEALTHPARTNERS SX009 HEALTHPARTNERS 17.42 percent of total billed charges 13.64 20.9 Technical (Hospital) Services HC/HH Wch Supp Strap Arm Padded Xl__0814-1315 PX-2705000170 CDM 2705000170 LOCAL 270 RC inpatient 22 22 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES EPO [308136803] 17.42 percent of total billed charges 13.64 20.9 Technical (Hospital) Services HC/HH Wch Supp Strap Arm Padded S__8141312 PX-2705000169 CDM 2705000169 LOCAL 270 RC inpatient 18 18 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES PPO [308136801] 14.25 percent of total billed charges 11.16 17.1 Technical (Hospital) Services HC/HH Wch Supp Strap Arm Padded S__8141312 PX-2705000169 CDM 2705000169 LOCAL 270 RC inpatient 18 18 MEDICA (COMMERCIAL) 94265 [3081118] MEDICA CLAIMS [308111801] 16.2 percent of total billed charges 11.16 17.1 Technical (Hospital) Services HC/HH Wch Supp Strap Arm Padded S__8141312 PX-2705000169 CDM 2705000169 LOCAL 270 RC inpatient 18 18 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES HDHP [308136802] 14.25 percent of total billed charges 11.16 17.1 Technical (Hospital) Services HC/HH Wch Supp Strap Arm Padded S__8141312 PX-2705000169 CDM 2705000169 LOCAL 270 RC inpatient 18 18 UNITED HEALTHCARE (COMMERCIAL) [3081199] UNITED HEALTHCARE 87726 [308119901] 11.16 percent of total billed charges 11.16 17.1 Technical (Hospital) Services HC/HH Wch Supp Strap Arm Padded S__8141312 PX-2705000169 CDM 2705000169 LOCAL 270 RC inpatient 18 18 HEALTHPARTNERS SX009 HEALTHPARTNERS 14.25 percent of total billed charges 11.16 17.1 Technical (Hospital) Services HC/HH Wch Supp Strap Arm Padded S__8141312 PX-2705000169 CDM 2705000169 LOCAL 270 RC inpatient 18 18 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES EPO [308136803] 14.25 percent of total billed charges 11.16 17.1 Technical (Hospital) Services HC/HH Wch Supp Strap Arm Padded S__8141312 PX-2705000169 CDM 2705000169 LOCAL 270 RC inpatient 18 18 MULTIPLAN INC 34080 [3081285] MULTIPLAN INC [308128501] 17.1 percent of total billed charges 11.16 17.1 Technical (Hospital) Services HC/HH Wch Supp Strap Arm Padded S__8141312 PX-2705000169 CDM 2705000169 LOCAL 270 RC inpatient 18 18 BLUE CROSS BLUE SHIELD WELLMARK SB889 [3081026] BCBS WYOMING [308102603] 17.1 percent of total billed charges 11.16 17.1 Technical (Hospital) Services HC/HH Wch Supp Strap Arm Padded S__8141312 PX-2705000169 CDM 2705000169 LOCAL 270 RC inpatient 18 18 CIGNA 62308 [3081051] CIGNA 62308 [308105105] 14.25 percent of total billed charges 11.16 17.1 Technical (Hospital) Services HC/HH Wch Supp Strap Arm Padded S__8141312 PX-2705000169 CDM 2705000169 LOCAL 270 RC inpatient 18 18 CIGNA 62308 [3081051] CIGNA STATE OF WYOMING [308105107] 14.25 percent of total billed charges 11.16 17.1 Technical (Hospital) Services HC/HH Wch Supp Strap Arm Padded S__8141312 PX-2705000169 CDM 2705000169 LOCAL 270 RC outpatient 18 18 BLUE CROSS BLUE SHIELD WELLMARK SB889 [3081026] BCBS WYOMING [308102603] 17.1 percent of total billed charges 11.16 17.1 Technical (Hospital) Services HC/HH Wch Supp Strap Arm Padded S__8141312 PX-2705000169 CDM 2705000169 LOCAL 270 RC outpatient 18 18 CIGNA 62308 [3081051] CIGNA 62308 [308105105] 14.4 percent of total billed charges 11.16 17.1 Technical (Hospital) Services HC/HH Wch Supp Strap Arm Padded S__8141312 PX-2705000169 CDM 2705000169 LOCAL 270 RC outpatient 18 18 CIGNA 62308 [3081051] CIGNA STATE OF WYOMING [308105107] 14.4 percent of total billed charges 11.16 17.1 Technical (Hospital) Services HC/HH Wch Supp Strap Arm Padded S__8141312 PX-2705000169 CDM 2705000169 LOCAL 270 RC outpatient 18 18 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES EPO [308136803] 14.4 percent of total billed charges 11.16 17.1 Technical (Hospital) Services HC/HH Wch Supp Strap Arm Padded S__8141312 PX-2705000169 CDM 2705000169 LOCAL 270 RC outpatient 18 18 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES HDHP [308136802] 14.4 percent of total billed charges 11.16 17.1 Technical (Hospital) Services HC/HH Wch Supp Strap Arm Padded S__8141312 PX-2705000169 CDM 2705000169 LOCAL 270 RC outpatient 18 18 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES PPO [308136801] 14.4 percent of total billed charges 11.16 17.1 Technical (Hospital) Services HC/HH Wch Supp Strap Arm Padded S__8141312 PX-2705000169 CDM 2705000169 LOCAL 270 RC outpatient 18 18 HEALTHPARTNERS SX009 HEALTHPARTNERS 14.4 percent of total billed charges 11.16 17.1 Technical (Hospital) Services HC/HH Wch Supp Strap Arm Padded S__8141312 PX-2705000169 CDM 2705000169 LOCAL 270 RC outpatient 18 18 UNITED HEALTHCARE (COMMERCIAL) [3081199] UNITED HEALTHCARE 87726 [308119901] 11.16 percent of total billed charges 11.16 17.1 Technical (Hospital) Services HC/HH Wch Supp Strap Arm Padded S__8141312 PX-2705000169 CDM 2705000169 LOCAL 270 RC outpatient 18 18 MEDICA (COMMERCIAL) 94265 [3081118] MEDICA CLAIMS [308111801] 16.2 percent of total billed charges 11.16 17.1 Technical (Hospital) Services HC/HH Wch Supp Strap Arm Padded S__8141312 PX-2705000169 CDM 2705000169 LOCAL 270 RC outpatient 18 18 MULTIPLAN INC 34080 [3081285] MULTIPLAN INC [308128501] 17.1 percent of total billed charges 11.16 17.1 Technical (Hospital) Services HC/HH Wch Supp Strap Arm Padded M__0814-1313 PX-2705000168 CDM 2705000168 LOCAL 270 RC inpatient 55 55 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES HDHP [308136802] 43.55 percent of total billed charges 34.1 52.25 Technical (Hospital) Services HC/HH Wch Supp Strap Arm Padded M__0814-1313 PX-2705000168 CDM 2705000168 LOCAL 270 RC inpatient 55 55 UNITED HEALTHCARE (COMMERCIAL) [3081199] UNITED HEALTHCARE 87726 [308119901] 34.1 percent of total billed charges 34.1 52.25 Technical (Hospital) Services HC/HH Wch Supp Strap Arm Padded M__0814-1313 PX-2705000168 CDM 2705000168 LOCAL 270 RC inpatient 55 55 MEDICA (COMMERCIAL) 94265 [3081118] MEDICA CLAIMS [308111801] 49.5 percent of total billed charges 34.1 52.25 Technical (Hospital) Services HC/HH Wch Supp Strap Arm Padded M__0814-1313 PX-2705000168 CDM 2705000168 LOCAL 270 RC inpatient 55 55 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES PPO [308136801] 43.55 percent of total billed charges 34.1 52.25 Technical (Hospital) Services HC/HH Wch Supp Strap Arm Padded M__0814-1313 PX-2705000168 CDM 2705000168 LOCAL 270 RC inpatient 55 55 HEALTHPARTNERS SX009 HEALTHPARTNERS 43.55 percent of total billed charges 34.1 52.25 Technical (Hospital) Services HC/HH Wch Supp Strap Arm Padded M__0814-1313 PX-2705000168 CDM 2705000168 LOCAL 270 RC inpatient 55 55 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES EPO [308136803] 43.55 percent of total billed charges 34.1 52.25 Technical (Hospital) Services HC/HH Wch Supp Strap Arm Padded M__0814-1313 PX-2705000168 CDM 2705000168 LOCAL 270 RC inpatient 55 55 CIGNA 62308 [3081051] CIGNA 62308 [308105105] 43.55 percent of total billed charges 34.1 52.25 Technical (Hospital) Services HC/HH Wch Supp Strap Arm Padded M__0814-1313 PX-2705000168 CDM 2705000168 LOCAL 270 RC inpatient 55 55 CIGNA 62308 [3081051] CIGNA STATE OF WYOMING [308105107] 43.55 percent of total billed charges 34.1 52.25 Technical (Hospital) Services HC/HH Wch Supp Strap Arm Padded M__0814-1313 PX-2705000168 CDM 2705000168 LOCAL 270 RC inpatient 55 55 MULTIPLAN INC 34080 [3081285] MULTIPLAN INC [308128501] 52.25 percent of total billed charges 34.1 52.25 Technical (Hospital) Services HC/HH Wch Supp Strap Arm Padded M__0814-1313 PX-2705000168 CDM 2705000168 LOCAL 270 RC inpatient 55 55 BLUE CROSS BLUE SHIELD WELLMARK SB889 [3081026] BCBS WYOMING [308102603] 52.25 percent of total billed charges 34.1 52.25 Technical (Hospital) Services HC/HH Wch Supp Strap Arm Padded M__0814-1313 PX-2705000168 CDM 2705000168 LOCAL 270 RC outpatient 55 55 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES PPO [308136801] 44 percent of total billed charges 34.1 52.25 Technical (Hospital) Services HC/HH Wch Supp Strap Arm Padded M__0814-1313 PX-2705000168 CDM 2705000168 LOCAL 270 RC outpatient 55 55 MULTIPLAN INC 34080 [3081285] MULTIPLAN INC [308128501] 52.25 percent of total billed charges 34.1 52.25 Technical (Hospital) Services HC/HH Wch Supp Strap Arm Padded M__0814-1313 PX-2705000168 CDM 2705000168 LOCAL 270 RC outpatient 55 55 MEDICA (COMMERCIAL) 94265 [3081118] MEDICA CLAIMS [308111801] 49.5 percent of total billed charges 34.1 52.25 Technical (Hospital) Services HC/HH Wch Supp Strap Arm Padded M__0814-1313 PX-2705000168 CDM 2705000168 LOCAL 270 RC outpatient 55 55 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES EPO [308136803] 44 percent of total billed charges 34.1 52.25 Technical (Hospital) Services HC/HH Wch Supp Strap Arm Padded M__0814-1313 PX-2705000168 CDM 2705000168 LOCAL 270 RC outpatient 55 55 BLUE CROSS BLUE SHIELD WELLMARK SB889 [3081026] BCBS WYOMING [308102603] 52.25 percent of total billed charges 34.1 52.25 Technical (Hospital) Services HC/HH Wch Supp Strap Arm Padded M__0814-1313 PX-2705000168 CDM 2705000168 LOCAL 270 RC outpatient 55 55 CIGNA 62308 [3081051] CIGNA 62308 [308105105] 44 percent of total billed charges 34.1 52.25 Technical (Hospital) Services HC/HH Wch Supp Strap Arm Padded M__0814-1313 PX-2705000168 CDM 2705000168 LOCAL 270 RC outpatient 55 55 CIGNA 62308 [3081051] CIGNA STATE OF WYOMING [308105107] 44 percent of total billed charges 34.1 52.25 Technical (Hospital) Services HC/HH Wch Supp Strap Arm Padded M__0814-1313 PX-2705000168 CDM 2705000168 LOCAL 270 RC outpatient 55 55 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES HDHP [308136802] 44 percent of total billed charges 34.1 52.25 Technical (Hospital) Services HC/HH Wch Supp Strap Arm Padded M__0814-1313 PX-2705000168 CDM 2705000168 LOCAL 270 RC outpatient 55 55 HEALTHPARTNERS SX009 HEALTHPARTNERS 44 percent of total billed charges 34.1 52.25 Technical (Hospital) Services HC/HH Wch Supp Strap Arm Padded M__0814-1313 PX-2705000168 CDM 2705000168 LOCAL 270 RC outpatient 55 55 UNITED HEALTHCARE (COMMERCIAL) [3081199] UNITED HEALTHCARE 87726 [308119901] 34.1 percent of total billed charges 34.1 52.25 Technical (Hospital) Services HC/HH Wch Supp Strap Arm Padded L__0814-1314 PX-2705000167 CDM 2705000167 LOCAL 270 RC inpatient 60 60 BLUE CROSS BLUE SHIELD WELLMARK SB889 [3081026] BCBS WYOMING [308102603] 57 percent of total billed charges 37.2 57 Technical (Hospital) Services HC/HH Wch Supp Strap Arm Padded L__0814-1314 PX-2705000167 CDM 2705000167 LOCAL 270 RC inpatient 60 60 MULTIPLAN INC 34080 [3081285] MULTIPLAN INC [308128501] 57 percent of total billed charges 37.2 57 Technical (Hospital) Services HC/HH Wch Supp Strap Arm Padded L__0814-1314 PX-2705000167 CDM 2705000167 LOCAL 270 RC inpatient 60 60 CIGNA 62308 [3081051] CIGNA 62308 [308105105] 47.51 percent of total billed charges 37.2 57 Technical (Hospital) Services HC/HH Wch Supp Strap Arm Padded L__0814-1314 PX-2705000167 CDM 2705000167 LOCAL 270 RC inpatient 60 60 CIGNA 62308 [3081051] CIGNA STATE OF WYOMING [308105107] 47.51 percent of total billed charges 37.2 57 Technical (Hospital) Services HC/HH Wch Supp Strap Arm Padded L__0814-1314 PX-2705000167 CDM 2705000167 LOCAL 270 RC inpatient 60 60 HEALTHPARTNERS SX009 HEALTHPARTNERS 47.51 percent of total billed charges 37.2 57 Technical (Hospital) Services HC/HH Wch Supp Strap Arm Padded L__0814-1314 PX-2705000167 CDM 2705000167 LOCAL 270 RC inpatient 60 60 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES EPO [308136803] 47.51 percent of total billed charges 37.2 57 Technical (Hospital) Services HC/HH Wch Supp Strap Arm Padded L__0814-1314 PX-2705000167 CDM 2705000167 LOCAL 270 RC inpatient 60 60 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES PPO [308136801] 47.51 percent of total billed charges 37.2 57 Technical (Hospital) Services HC/HH Wch Supp Strap Arm Padded L__0814-1314 PX-2705000167 CDM 2705000167 LOCAL 270 RC inpatient 60 60 MEDICA (COMMERCIAL) 94265 [3081118] MEDICA CLAIMS [308111801] 54 percent of total billed charges 37.2 57 Technical (Hospital) Services HC/HH Wch Supp Strap Arm Padded L__0814-1314 PX-2705000167 CDM 2705000167 LOCAL 270 RC inpatient 60 60 UNITED HEALTHCARE (COMMERCIAL) [3081199] UNITED HEALTHCARE 87726 [308119901] 37.2 percent of total billed charges 37.2 57 Technical (Hospital) Services HC/HH Wch Supp Strap Arm Padded L__0814-1314 PX-2705000167 CDM 2705000167 LOCAL 270 RC inpatient 60 60 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES HDHP [308136802] 47.51 percent of total billed charges 37.2 57 Technical (Hospital) Services HC/HH Wch Supp Strap Arm Padded L__0814-1314 PX-2705000167 CDM 2705000167 LOCAL 270 RC outpatient 60 60 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES HDHP [308136802] 48 percent of total billed charges 37.2 57 Technical (Hospital) Services HC/HH Wch Supp Strap Arm Padded L__0814-1314 PX-2705000167 CDM 2705000167 LOCAL 270 RC outpatient 60 60 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES EPO [308136803] 48 percent of total billed charges 37.2 57 Technical (Hospital) Services HC/HH Wch Supp Strap Arm Padded L__0814-1314 PX-2705000167 CDM 2705000167 LOCAL 270 RC outpatient 60 60 BLUE CROSS BLUE SHIELD WELLMARK SB889 [3081026] BCBS WYOMING [308102603] 57 percent of total billed charges 37.2 57 Technical (Hospital) Services HC/HH Wch Supp Strap Arm Padded L__0814-1314 PX-2705000167 CDM 2705000167 LOCAL 270 RC outpatient 60 60 CIGNA 62308 [3081051] CIGNA 62308 [308105105] 48 percent of total billed charges 37.2 57 Technical (Hospital) Services HC/HH Wch Supp Strap Arm Padded L__0814-1314 PX-2705000167 CDM 2705000167 LOCAL 270 RC outpatient 60 60 CIGNA 62308 [3081051] CIGNA STATE OF WYOMING [308105107] 48 percent of total billed charges 37.2 57 Technical (Hospital) Services HC/HH Wch Supp Strap Arm Padded L__0814-1314 PX-2705000167 CDM 2705000167 LOCAL 270 RC outpatient 60 60 UNITED HEALTHCARE (COMMERCIAL) [3081199] UNITED HEALTHCARE 87726 [308119901] 37.2 percent of total billed charges 37.2 57 Technical (Hospital) Services HC/HH Wch Supp Strap Arm Padded L__0814-1314 PX-2705000167 CDM 2705000167 LOCAL 270 RC outpatient 60 60 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES PPO [308136801] 48 percent of total billed charges 37.2 57 Technical (Hospital) Services HC/HH Wch Supp Strap Arm Padded L__0814-1314 PX-2705000167 CDM 2705000167 LOCAL 270 RC outpatient 60 60 HEALTHPARTNERS SX009 HEALTHPARTNERS 48 percent of total billed charges 37.2 57 Technical (Hospital) Services HC/HH Wch Supp Strap Arm Padded L__0814-1314 PX-2705000167 CDM 2705000167 LOCAL 270 RC outpatient 60 60 MEDICA (COMMERCIAL) 94265 [3081118] MEDICA CLAIMS [308111801] 54 percent of total billed charges 37.2 57 Technical (Hospital) Services HC/HH Wch Supp Strap Arm Padded L__0814-1314 PX-2705000167 CDM 2705000167 LOCAL 270 RC outpatient 60 60 MULTIPLAN INC 34080 [3081285] MULTIPLAN INC [308128501] 57 percent of total billed charges 37.2 57 Technical (Hospital) Services HC/HH Wch Supp Stockinette Synth 4__Ms04 PX-2705000166 CDM 2705000166 LOCAL 270 RC inpatient 6 6 UNITED HEALTHCARE (COMMERCIAL) [3081199] UNITED HEALTHCARE 87726 [308119901] 3.72 percent of total billed charges 3.72 5.7 Technical (Hospital) Services HC/HH Wch Supp Stockinette Synth 4__Ms04 PX-2705000166 CDM 2705000166 LOCAL 270 RC inpatient 6 6 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES HDHP [308136802] 4.75 percent of total billed charges 3.72 5.7 Technical (Hospital) Services HC/HH Wch Supp Stockinette Synth 4__Ms04 PX-2705000166 CDM 2705000166 LOCAL 270 RC inpatient 6 6 MEDICA (COMMERCIAL) 94265 [3081118] MEDICA CLAIMS [308111801] 5.4 percent of total billed charges 3.72 5.7 Technical (Hospital) Services HC/HH Wch Supp Stockinette Synth 4__Ms04 PX-2705000166 CDM 2705000166 LOCAL 270 RC inpatient 6 6 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES PPO [308136801] 4.75 percent of total billed charges 3.72 5.7 Technical (Hospital) Services HC/HH Wch Supp Stockinette Synth 4__Ms04 PX-2705000166 CDM 2705000166 LOCAL 270 RC inpatient 6 6 HEALTHPARTNERS SX009 HEALTHPARTNERS 4.75 percent of total billed charges 3.72 5.7 Technical (Hospital) Services HC/HH Wch Supp Stockinette Synth 4__Ms04 PX-2705000166 CDM 2705000166 LOCAL 270 RC inpatient 6 6 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES EPO [308136803] 4.75 percent of total billed charges 3.72 5.7 Technical (Hospital) Services HC/HH Wch Supp Stockinette Synth 4__Ms04 PX-2705000166 CDM 2705000166 LOCAL 270 RC inpatient 6 6 MULTIPLAN INC 34080 [3081285] MULTIPLAN INC [308128501] 5.7 percent of total billed charges 3.72 5.7 Technical (Hospital) Services HC/HH Wch Supp Stockinette Synth 4__Ms04 PX-2705000166 CDM 2705000166 LOCAL 270 RC inpatient 6 6 CIGNA 62308 [3081051] CIGNA 62308 [308105105] 4.75 percent of total billed charges 3.72 5.7 Technical (Hospital) Services HC/HH Wch Supp Stockinette Synth 4__Ms04 PX-2705000166 CDM 2705000166 LOCAL 270 RC inpatient 6 6 CIGNA 62308 [3081051] CIGNA STATE OF WYOMING [308105107] 4.75 percent of total billed charges 3.72 5.7 Technical (Hospital) Services HC/HH Wch Supp Stockinette Synth 4__Ms04 PX-2705000166 CDM 2705000166 LOCAL 270 RC inpatient 6 6 BLUE CROSS BLUE SHIELD WELLMARK SB889 [3081026] BCBS WYOMING [308102603] 5.7 percent of total billed charges 3.72 5.7 Technical (Hospital) Services HC/HH Wch Supp Stockinette Synth 4__Ms04 PX-2705000166 CDM 2705000166 LOCAL 270 RC outpatient 6 6 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES EPO [308136803] 4.8 percent of total billed charges 3.72 5.7 Technical (Hospital) Services HC/HH Wch Supp Stockinette Synth 4__Ms04 PX-2705000166 CDM 2705000166 LOCAL 270 RC outpatient 6 6 BLUE CROSS BLUE SHIELD WELLMARK SB889 [3081026] BCBS WYOMING [308102603] 5.7 percent of total billed charges 3.72 5.7 Technical (Hospital) Services HC/HH Wch Supp Stockinette Synth 4__Ms04 PX-2705000166 CDM 2705000166 LOCAL 270 RC outpatient 6 6 CIGNA 62308 [3081051] CIGNA 62308 [308105105] 4.8 percent of total billed charges 3.72 5.7 Technical (Hospital) Services HC/HH Wch Supp Stockinette Synth 4__Ms04 PX-2705000166 CDM 2705000166 LOCAL 270 RC outpatient 6 6 CIGNA 62308 [3081051] CIGNA STATE OF WYOMING [308105107] 4.8 percent of total billed charges 3.72 5.7 Technical (Hospital) Services HC/HH Wch Supp Stockinette Synth 4__Ms04 PX-2705000166 CDM 2705000166 LOCAL 270 RC outpatient 6 6 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES HDHP [308136802] 4.8 percent of total billed charges 3.72 5.7 Technical (Hospital) Services HC/HH Wch Supp Stockinette Synth 4__Ms04 PX-2705000166 CDM 2705000166 LOCAL 270 RC outpatient 6 6 UNITED HEALTHCARE (COMMERCIAL) [3081199] UNITED HEALTHCARE 87726 [308119901] 3.72 percent of total billed charges 3.72 5.7 Technical (Hospital) Services HC/HH Wch Supp Stockinette Synth 4__Ms04 PX-2705000166 CDM 2705000166 LOCAL 270 RC outpatient 6 6 HEALTHPARTNERS SX009 HEALTHPARTNERS 4.8 percent of total billed charges 3.72 5.7 Technical (Hospital) Services HC/HH Wch Supp Stockinette Synth 4__Ms04 PX-2705000166 CDM 2705000166 LOCAL 270 RC outpatient 6 6 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES PPO [308136801] 4.8 percent of total billed charges 3.72 5.7 Technical (Hospital) Services HC/HH Wch Supp Stockinette Synth 4__Ms04 PX-2705000166 CDM 2705000166 LOCAL 270 RC outpatient 6 6 MULTIPLAN INC 34080 [3081285] MULTIPLAN INC [308128501] 5.7 percent of total billed charges 3.72 5.7 Technical (Hospital) Services HC/HH Wch Supp Stockinette Synth 4__Ms04 PX-2705000166 CDM 2705000166 LOCAL 270 RC outpatient 6 6 MEDICA (COMMERCIAL) 94265 [3081118] MEDICA CLAIMS [308111801] 5.4 percent of total billed charges 3.72 5.7 Technical (Hospital) Services HC/HH Wch Supp Stockinette Synth 3__Ms03 PX-2705000165 CDM 2705000165 LOCAL 270 RC inpatient 6 6 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES EPO [308136803] 4.75 percent of total billed charges 3.72 5.7 Technical (Hospital) Services HC/HH Wch Supp Stockinette Synth 3__Ms03 PX-2705000165 CDM 2705000165 LOCAL 270 RC inpatient 6 6 HEALTHPARTNERS SX009 HEALTHPARTNERS 4.75 percent of total billed charges 3.72 5.7 Technical (Hospital) Services HC/HH Wch Supp Stockinette Synth 3__Ms03 PX-2705000165 CDM 2705000165 LOCAL 270 RC inpatient 6 6 MULTIPLAN INC 34080 [3081285] MULTIPLAN INC [308128501] 5.7 percent of total billed charges 3.72 5.7 Technical (Hospital) Services HC/HH Wch Supp Stockinette Synth 3__Ms03 PX-2705000165 CDM 2705000165 LOCAL 270 RC inpatient 6 6 BLUE CROSS BLUE SHIELD WELLMARK SB889 [3081026] BCBS WYOMING [308102603] 5.7 percent of total billed charges 3.72 5.7 Technical (Hospital) Services HC/HH Wch Supp Stockinette Synth 3__Ms03 PX-2705000165 CDM 2705000165 LOCAL 270 RC inpatient 6 6 CIGNA 62308 [3081051] CIGNA 62308 [308105105] 4.75 percent of total billed charges 3.72 5.7 Technical (Hospital) Services HC/HH Wch Supp Stockinette Synth 3__Ms03 PX-2705000165 CDM 2705000165 LOCAL 270 RC inpatient 6 6 CIGNA 62308 [3081051] CIGNA STATE OF WYOMING [308105107] 4.75 percent of total billed charges 3.72 5.7 Technical (Hospital) Services HC/HH Wch Supp Stockinette Synth 3__Ms03 PX-2705000165 CDM 2705000165 LOCAL 270 RC inpatient 6 6 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES PPO [308136801] 4.75 percent of total billed charges 3.72 5.7 Technical (Hospital) Services HC/HH Wch Supp Stockinette Synth 3__Ms03 PX-2705000165 CDM 2705000165 LOCAL 270 RC inpatient 6 6 MEDICA (COMMERCIAL) 94265 [3081118] MEDICA CLAIMS [308111801] 5.4 percent of total billed charges 3.72 5.7 Technical (Hospital) Services HC/HH Wch Supp Stockinette Synth 3__Ms03 PX-2705000165 CDM 2705000165 LOCAL 270 RC inpatient 6 6 UNITED HEALTHCARE (COMMERCIAL) [3081199] UNITED HEALTHCARE 87726 [308119901] 3.72 percent of total billed charges 3.72 5.7 Technical (Hospital) Services HC/HH Wch Supp Stockinette Synth 3__Ms03 PX-2705000165 CDM 2705000165 LOCAL 270 RC inpatient 6 6 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES HDHP [308136802] 4.75 percent of total billed charges 3.72 5.7 Technical (Hospital) Services HC/HH Wch Supp Stockinette Synth 3__Ms03 PX-2705000165 CDM 2705000165 LOCAL 270 RC outpatient 6 6 UNITED HEALTHCARE (COMMERCIAL) [3081199] UNITED HEALTHCARE 87726 [308119901] 3.72 percent of total billed charges 3.72 5.7 Technical (Hospital) Services HC/HH Wch Supp Stockinette Synth 3__Ms03 PX-2705000165 CDM 2705000165 LOCAL 270 RC outpatient 6 6 HEALTHPARTNERS SX009 HEALTHPARTNERS 4.8 percent of total billed charges 3.72 5.7 Technical (Hospital) Services HC/HH Wch Supp Stockinette Synth 3__Ms03 PX-2705000165 CDM 2705000165 LOCAL 270 RC outpatient 6 6 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES HDHP [308136802] 4.8 percent of total billed charges 3.72 5.7 Technical (Hospital) Services HC/HH Wch Supp Stockinette Synth 3__Ms03 PX-2705000165 CDM 2705000165 LOCAL 270 RC outpatient 6 6 CIGNA 62308 [3081051] CIGNA 62308 [308105105] 4.8 percent of total billed charges 3.72 5.7 Technical (Hospital) Services HC/HH Wch Supp Stockinette Synth 3__Ms03 PX-2705000165 CDM 2705000165 LOCAL 270 RC outpatient 6 6 CIGNA 62308 [3081051] CIGNA STATE OF WYOMING [308105107] 4.8 percent of total billed charges 3.72 5.7 Technical (Hospital) Services HC/HH Wch Supp Stockinette Synth 3__Ms03 PX-2705000165 CDM 2705000165 LOCAL 270 RC outpatient 6 6 BLUE CROSS BLUE SHIELD WELLMARK SB889 [3081026] BCBS WYOMING [308102603] 5.7 percent of total billed charges 3.72 5.7 Technical (Hospital) Services HC/HH Wch Supp Stockinette Synth 3__Ms03 PX-2705000165 CDM 2705000165 LOCAL 270 RC outpatient 6 6 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES EPO [308136803] 4.8 percent of total billed charges 3.72 5.7 Technical (Hospital) Services HC/HH Wch Supp Stockinette Synth 3__Ms03 PX-2705000165 CDM 2705000165 LOCAL 270 RC outpatient 6 6 MEDICA (COMMERCIAL) 94265 [3081118] MEDICA CLAIMS [308111801] 5.4 percent of total billed charges 3.72 5.7 Technical (Hospital) Services HC/HH Wch Supp Stockinette Synth 3__Ms03 PX-2705000165 CDM 2705000165 LOCAL 270 RC outpatient 6 6 MULTIPLAN INC 34080 [3081285] MULTIPLAN INC [308128501] 5.7 percent of total billed charges 3.72 5.7 Technical (Hospital) Services HC/HH Wch Supp Stockinette Synth 3__Ms03 PX-2705000165 CDM 2705000165 LOCAL 270 RC outpatient 6 6 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES PPO [308136801] 4.8 percent of total billed charges 3.72 5.7 Technical (Hospital) Services HC/HH Wch Supp Stockinette Synth 2__Ms02 PX-2705000164 CDM 2705000164 LOCAL 270 RC inpatient 6 6 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES PPO [308136801] 4.75 percent of total billed charges 3.72 5.7 Technical (Hospital) Services HC/HH Wch Supp Stockinette Synth 2__Ms02 PX-2705000164 CDM 2705000164 LOCAL 270 RC inpatient 6 6 MEDICA (COMMERCIAL) 94265 [3081118] MEDICA CLAIMS [308111801] 5.4 percent of total billed charges 3.72 5.7 Technical (Hospital) Services HC/HH Wch Supp Stockinette Synth 2__Ms02 PX-2705000164 CDM 2705000164 LOCAL 270 RC inpatient 6 6 UNITED HEALTHCARE (COMMERCIAL) [3081199] UNITED HEALTHCARE 87726 [308119901] 3.72 percent of total billed charges 3.72 5.7 Technical (Hospital) Services HC/HH Wch Supp Stockinette Synth 2__Ms02 PX-2705000164 CDM 2705000164 LOCAL 270 RC inpatient 6 6 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES HDHP [308136802] 4.75 percent of total billed charges 3.72 5.7 Technical (Hospital) Services HC/HH Wch Supp Stockinette Synth 2__Ms02 PX-2705000164 CDM 2705000164 LOCAL 270 RC inpatient 6 6 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES EPO [308136803] 4.75 percent of total billed charges 3.72 5.7 Technical (Hospital) Services HC/HH Wch Supp Stockinette Synth 2__Ms02 PX-2705000164 CDM 2705000164 LOCAL 270 RC inpatient 6 6 HEALTHPARTNERS SX009 HEALTHPARTNERS 4.75 percent of total billed charges 3.72 5.7 Technical (Hospital) Services HC/HH Wch Supp Stockinette Synth 2__Ms02 PX-2705000164 CDM 2705000164 LOCAL 270 RC inpatient 6 6 BLUE CROSS BLUE SHIELD WELLMARK SB889 [3081026] BCBS WYOMING [308102603] 5.7 percent of total billed charges 3.72 5.7 Technical (Hospital) Services HC/HH Wch Supp Stockinette Synth 2__Ms02 PX-2705000164 CDM 2705000164 LOCAL 270 RC inpatient 6 6 MULTIPLAN INC 34080 [3081285] MULTIPLAN INC [308128501] 5.7 percent of total billed charges 3.72 5.7 Technical (Hospital) Services HC/HH Wch Supp Stockinette Synth 2__Ms02 PX-2705000164 CDM 2705000164 LOCAL 270 RC inpatient 6 6 CIGNA 62308 [3081051] CIGNA 62308 [308105105] 4.75 percent of total billed charges 3.72 5.7 Technical (Hospital) Services HC/HH Wch Supp Stockinette Synth 2__Ms02 PX-2705000164 CDM 2705000164 LOCAL 270 RC inpatient 6 6 CIGNA 62308 [3081051] CIGNA STATE OF WYOMING [308105107] 4.75 percent of total billed charges 3.72 5.7 Technical (Hospital) Services HC/HH Wch Supp Stockinette Synth 2__Ms02 PX-2705000164 CDM 2705000164 LOCAL 270 RC outpatient 6 6 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES HDHP [308136802] 4.8 percent of total billed charges 3.72 5.7 Technical (Hospital) Services HC/HH Wch Supp Stockinette Synth 2__Ms02 PX-2705000164 CDM 2705000164 LOCAL 270 RC outpatient 6 6 CIGNA 62308 [3081051] CIGNA 62308 [308105105] 4.8 percent of total billed charges 3.72 5.7 Technical (Hospital) Services HC/HH Wch Supp Stockinette Synth 2__Ms02 PX-2705000164 CDM 2705000164 LOCAL 270 RC outpatient 6 6 CIGNA 62308 [3081051] CIGNA STATE OF WYOMING [308105107] 4.8 percent of total billed charges 3.72 5.7 Technical (Hospital) Services HC/HH Wch Supp Stockinette Synth 2__Ms02 PX-2705000164 CDM 2705000164 LOCAL 270 RC outpatient 6 6 BLUE CROSS BLUE SHIELD WELLMARK SB889 [3081026] BCBS WYOMING [308102603] 5.7 percent of total billed charges 3.72 5.7 Technical (Hospital) Services HC/HH Wch Supp Stockinette Synth 2__Ms02 PX-2705000164 CDM 2705000164 LOCAL 270 RC outpatient 6 6 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES EPO [308136803] 4.8 percent of total billed charges 3.72 5.7 Technical (Hospital) Services HC/HH Wch Supp Stockinette Synth 2__Ms02 PX-2705000164 CDM 2705000164 LOCAL 270 RC outpatient 6 6 UNITED HEALTHCARE (COMMERCIAL) [3081199] UNITED HEALTHCARE 87726 [308119901] 3.72 percent of total billed charges 3.72 5.7 Technical (Hospital) Services HC/HH Wch Supp Stockinette Synth 2__Ms02 PX-2705000164 CDM 2705000164 LOCAL 270 RC outpatient 6 6 HEALTHPARTNERS SX009 HEALTHPARTNERS 4.8 percent of total billed charges 3.72 5.7 Technical (Hospital) Services HC/HH Wch Supp Stockinette Synth 2__Ms02 PX-2705000164 CDM 2705000164 LOCAL 270 RC outpatient 6 6 MEDICA (COMMERCIAL) 94265 [3081118] MEDICA CLAIMS [308111801] 5.4 percent of total billed charges 3.72 5.7 Technical (Hospital) Services HC/HH Wch Supp Stockinette Synth 2__Ms02 PX-2705000164 CDM 2705000164 LOCAL 270 RC outpatient 6 6 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES PPO [308136801] 4.8 percent of total billed charges 3.72 5.7 Technical (Hospital) Services HC/HH Wch Supp Stockinette Synth 2__Ms02 PX-2705000164 CDM 2705000164 LOCAL 270 RC outpatient 6 6 MULTIPLAN INC 34080 [3081285] MULTIPLAN INC [308128501] 5.7 percent of total billed charges 3.72 5.7 Technical (Hospital) Services HC/HH Wch Supp Stockinette Bias 6in__760 PX-2705000163 CDM 2705000163 LOCAL 270 RC outpatient 6 6 UNITED HEALTHCARE (COMMERCIAL) [3081199] UNITED HEALTHCARE 87726 [308119901] 3.72 percent of total billed charges 3.72 5.7 Technical (Hospital) Services HC/HH Wch Supp Stockinette Bias 6in__760 PX-2705000163 CDM 2705000163 LOCAL 270 RC outpatient 6 6 HEALTHPARTNERS SX009 HEALTHPARTNERS 4.8 percent of total billed charges 3.72 5.7 Technical (Hospital) Services HC/HH Wch Supp Stockinette Bias 6in__760 PX-2705000163 CDM 2705000163 LOCAL 270 RC outpatient 6 6 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES HDHP [308136802] 4.8 percent of total billed charges 3.72 5.7 Technical (Hospital) Services HC/HH Wch Supp Stockinette Bias 6in__760 PX-2705000163 CDM 2705000163 LOCAL 270 RC outpatient 6 6 CIGNA 62308 [3081051] CIGNA 62308 [308105105] 4.8 percent of total billed charges 3.72 5.7 Technical (Hospital) Services HC/HH Wch Supp Stockinette Bias 6in__760 PX-2705000163 CDM 2705000163 LOCAL 270 RC inpatient 6 6 BLUE CROSS BLUE SHIELD WELLMARK SB889 [3081026] BCBS WYOMING [308102603] 5.7 percent of total billed charges 3.72 5.7 Technical (Hospital) Services HC/HH Wch Supp Stockinette Bias 6in__760 PX-2705000163 CDM 2705000163 LOCAL 270 RC inpatient 6 6 CIGNA 62308 [3081051] CIGNA 62308 [308105105] 4.75 percent of total billed charges 3.72 5.7 Technical (Hospital) Services HC/HH Wch Supp Stockinette Bias 6in__760 PX-2705000163 CDM 2705000163 LOCAL 270 RC inpatient 6 6 CIGNA 62308 [3081051] CIGNA STATE OF WYOMING [308105107] 4.75 percent of total billed charges 3.72 5.7 Technical (Hospital) Services HC/HH Wch Supp Stockinette Bias 6in__760 PX-2705000163 CDM 2705000163 LOCAL 270 RC inpatient 6 6 MULTIPLAN INC 34080 [3081285] MULTIPLAN INC [308128501] 5.7 percent of total billed charges 3.72 5.7 Technical (Hospital) Services HC/HH Wch Supp Stockinette Bias 6in__760 PX-2705000163 CDM 2705000163 LOCAL 270 RC inpatient 6 6 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES EPO [308136803] 4.75 percent of total billed charges 3.72 5.7 Technical (Hospital) Services HC/HH Wch Supp Stockinette Bias 6in__760 PX-2705000163 CDM 2705000163 LOCAL 270 RC inpatient 6 6 HEALTHPARTNERS SX009 HEALTHPARTNERS 4.75 percent of total billed charges 3.72 5.7 Technical (Hospital) Services HC/HH Wch Supp Stockinette Bias 6in__760 PX-2705000163 CDM 2705000163 LOCAL 270 RC inpatient 6 6 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES PPO [308136801] 4.75 percent of total billed charges 3.72 5.7 Technical (Hospital) Services HC/HH Wch Supp Stockinette Bias 6in__760 PX-2705000163 CDM 2705000163 LOCAL 270 RC outpatient 6 6 CIGNA 62308 [3081051] CIGNA STATE OF WYOMING [308105107] 4.8 percent of total billed charges 3.72 5.7 Technical (Hospital) Services HC/HH Wch Supp Stockinette Bias 6in__760 PX-2705000163 CDM 2705000163 LOCAL 270 RC outpatient 6 6 BLUE CROSS BLUE SHIELD WELLMARK SB889 [3081026] BCBS WYOMING [308102603] 5.7 percent of total billed charges 3.72 5.7 Technical (Hospital) Services HC/HH Wch Supp Stockinette Bias 6in__760 PX-2705000163 CDM 2705000163 LOCAL 270 RC outpatient 6 6 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES EPO [308136803] 4.8 percent of total billed charges 3.72 5.7 Technical (Hospital) Services HC/HH Wch Supp Stockinette Bias 6in__760 PX-2705000163 CDM 2705000163 LOCAL 270 RC outpatient 6 6 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES PPO [308136801] 4.8 percent of total billed charges 3.72 5.7 Technical (Hospital) Services HC/HH Wch Supp Stockinette Bias 6in__760 PX-2705000163 CDM 2705000163 LOCAL 270 RC outpatient 6 6 MULTIPLAN INC 34080 [3081285] MULTIPLAN INC [308128501] 5.7 percent of total billed charges 3.72 5.7 Technical (Hospital) Services HC/HH Wch Supp Stockinette Bias 6in__760 PX-2705000163 CDM 2705000163 LOCAL 270 RC outpatient 6 6 MEDICA (COMMERCIAL) 94265 [3081118] MEDICA CLAIMS [308111801] 5.4 percent of total billed charges 3.72 5.7 Technical (Hospital) Services HC/HH Wch Supp Stockinette Bias 6in__760 PX-2705000163 CDM 2705000163 LOCAL 270 RC inpatient 6 6 MEDICA (COMMERCIAL) 94265 [3081118] MEDICA CLAIMS [308111801] 5.4 percent of total billed charges 3.72 5.7 Technical (Hospital) Services HC/HH Wch Supp Stockinette Bias 6in__760 PX-2705000163 CDM 2705000163 LOCAL 270 RC inpatient 6 6 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES HDHP [308136802] 4.75 percent of total billed charges 3.72 5.7 Technical (Hospital) Services HC/HH Wch Supp Stockinette Bias 6in__760 PX-2705000163 CDM 2705000163 LOCAL 270 RC inpatient 6 6 UNITED HEALTHCARE (COMMERCIAL) [3081199] UNITED HEALTHCARE 87726 [308119901] 3.72 percent of total billed charges 3.72 5.7 Technical (Hospital) Services HC/HH Wch Supp Stockinette Bias 4in__740 PX-2705000162 CDM 2705000162 LOCAL 270 RC inpatient 6 6 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES PPO [308136801] 4.75 percent of total billed charges 3.72 5.7 Technical (Hospital) Services HC/HH Wch Supp Stockinette Bias 4in__740 PX-2705000162 CDM 2705000162 LOCAL 270 RC inpatient 6 6 MEDICA (COMMERCIAL) 94265 [3081118] MEDICA CLAIMS [308111801] 5.4 percent of total billed charges 3.72 5.7 Technical (Hospital) Services HC/HH Wch Supp Stockinette Bias 4in__740 PX-2705000162 CDM 2705000162 LOCAL 270 RC inpatient 6 6 UNITED HEALTHCARE (COMMERCIAL) [3081199] UNITED HEALTHCARE 87726 [308119901] 3.72 percent of total billed charges 3.72 5.7 Technical (Hospital) Services HC/HH Wch Supp Stockinette Bias 4in__740 PX-2705000162 CDM 2705000162 LOCAL 270 RC inpatient 6 6 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES HDHP [308136802] 4.75 percent of total billed charges 3.72 5.7 Technical (Hospital) Services HC/HH Wch Supp Stockinette Bias 4in__740 PX-2705000162 CDM 2705000162 LOCAL 270 RC inpatient 6 6 BLUE CROSS BLUE SHIELD WELLMARK SB889 [3081026] BCBS WYOMING [308102603] 5.7 percent of total billed charges 3.72 5.7 Technical (Hospital) Services HC/HH Wch Supp Stockinette Bias 4in__740 PX-2705000162 CDM 2705000162 LOCAL 270 RC inpatient 6 6 CIGNA 62308 [3081051] CIGNA 62308 [308105105] 4.75 percent of total billed charges 3.72 5.7 Technical (Hospital) Services HC/HH Wch Supp Stockinette Bias 4in__740 PX-2705000162 CDM 2705000162 LOCAL 270 RC inpatient 6 6 CIGNA 62308 [3081051] CIGNA STATE OF WYOMING [308105107] 4.75 percent of total billed charges 3.72 5.7 Technical (Hospital) Services HC/HH Wch Supp Stockinette Bias 4in__740 PX-2705000162 CDM 2705000162 LOCAL 270 RC inpatient 6 6 MULTIPLAN INC 34080 [3081285] MULTIPLAN INC [308128501] 5.7 percent of total billed charges 3.72 5.7 Technical (Hospital) Services HC/HH Wch Supp Stockinette Bias 4in__740 PX-2705000162 CDM 2705000162 LOCAL 270 RC inpatient 6 6 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES EPO [308136803] 4.75 percent of total billed charges 3.72 5.7 Technical (Hospital) Services HC/HH Wch Supp Stockinette Bias 4in__740 PX-2705000162 CDM 2705000162 LOCAL 270 RC inpatient 6 6 HEALTHPARTNERS SX009 HEALTHPARTNERS 4.75 percent of total billed charges 3.72 5.7 Technical (Hospital) Services HC/HH Wch Supp Stockinette Bias 4in__740 PX-2705000162 CDM 2705000162 LOCAL 270 RC outpatient 6 6 MEDICA (COMMERCIAL) 94265 [3081118] MEDICA CLAIMS [308111801] 5.4 percent of total billed charges 3.72 5.7 Technical (Hospital) Services HC/HH Wch Supp Stockinette Bias 4in__740 PX-2705000162 CDM 2705000162 LOCAL 270 RC outpatient 6 6 MULTIPLAN INC 34080 [3081285] MULTIPLAN INC [308128501] 5.7 percent of total billed charges 3.72 5.7 Technical (Hospital) Services HC/HH Wch Supp Stockinette Bias 4in__740 PX-2705000162 CDM 2705000162 LOCAL 270 RC outpatient 6 6 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES PPO [308136801] 4.8 percent of total billed charges 3.72 5.7 Technical (Hospital) Services HC/HH Wch Supp Stockinette Bias 4in__740 PX-2705000162 CDM 2705000162 LOCAL 270 RC outpatient 6 6 HEALTHPARTNERS SX009 HEALTHPARTNERS 4.8 percent of total billed charges 3.72 5.7 Technical (Hospital) Services HC/HH Wch Supp Stockinette Bias 4in__740 PX-2705000162 CDM 2705000162 LOCAL 270 RC outpatient 6 6 UNITED HEALTHCARE (COMMERCIAL) [3081199] UNITED HEALTHCARE 87726 [308119901] 3.72 percent of total billed charges 3.72 5.7 Technical (Hospital) Services HC/HH Wch Supp Stockinette Bias 4in__740 PX-2705000162 CDM 2705000162 LOCAL 270 RC outpatient 6 6 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES HDHP [308136802] 4.8 percent of total billed charges 3.72 5.7 Technical (Hospital) Services HC/HH Wch Supp Stockinette Bias 4in__740 PX-2705000162 CDM 2705000162 LOCAL 270 RC outpatient 6 6 CIGNA 62308 [3081051] CIGNA 62308 [308105105] 4.8 percent of total billed charges 3.72 5.7 Technical (Hospital) Services HC/HH Wch Supp Stockinette Bias 4in__740 PX-2705000162 CDM 2705000162 LOCAL 270 RC outpatient 6 6 CIGNA 62308 [3081051] CIGNA STATE OF WYOMING [308105107] 4.8 percent of total billed charges 3.72 5.7 Technical (Hospital) Services HC/HH Wch Supp Stockinette Bias 4in__740 PX-2705000162 CDM 2705000162 LOCAL 270 RC outpatient 6 6 BLUE CROSS BLUE SHIELD WELLMARK SB889 [3081026] BCBS WYOMING [308102603] 5.7 percent of total billed charges 3.72 5.7 Technical (Hospital) Services HC/HH Wch Supp Stockinette Bias 4in__740 PX-2705000162 CDM 2705000162 LOCAL 270 RC outpatient 6 6 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES EPO [308136803] 4.8 percent of total billed charges 3.72 5.7 Technical (Hospital) Services HC/HH Wch Supp Stockinette Bias 3in__730 PX-2705000161 CDM 2705000161 LOCAL 270 RC inpatient 51 51 BLUE CROSS BLUE SHIELD WELLMARK SB889 [3081026] BCBS WYOMING [308102603] 48.45 percent of total billed charges 31.62 48.45 Technical (Hospital) Services HC/HH Wch Supp Stockinette Bias 3in__730 PX-2705000161 CDM 2705000161 LOCAL 270 RC inpatient 51 51 MULTIPLAN INC 34080 [3081285] MULTIPLAN INC [308128501] 48.45 percent of total billed charges 31.62 48.45 Technical (Hospital) Services HC/HH Wch Supp Stockinette Bias 3in__730 PX-2705000161 CDM 2705000161 LOCAL 270 RC inpatient 51 51 CIGNA 62308 [3081051] CIGNA 62308 [308105105] 40.38 percent of total billed charges 31.62 48.45 Technical (Hospital) Services HC/HH Wch Supp Stockinette Bias 3in__730 PX-2705000161 CDM 2705000161 LOCAL 270 RC inpatient 51 51 CIGNA 62308 [3081051] CIGNA STATE OF WYOMING [308105107] 40.38 percent of total billed charges 31.62 48.45 Technical (Hospital) Services HC/HH Wch Supp Stockinette Bias 3in__730 PX-2705000161 CDM 2705000161 LOCAL 270 RC inpatient 51 51 HEALTHPARTNERS SX009 HEALTHPARTNERS 40.38 percent of total billed charges 31.62 48.45 Technical (Hospital) Services HC/HH Wch Supp Stockinette Bias 3in__730 PX-2705000161 CDM 2705000161 LOCAL 270 RC inpatient 51 51 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES EPO [308136803] 40.38 percent of total billed charges 31.62 48.45 Technical (Hospital) Services HC/HH Wch Supp Stockinette Bias 3in__730 PX-2705000161 CDM 2705000161 LOCAL 270 RC inpatient 51 51 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES PPO [308136801] 40.38 percent of total billed charges 31.62 48.45 Technical (Hospital) Services HC/HH Wch Supp Stockinette Bias 3in__730 PX-2705000161 CDM 2705000161 LOCAL 270 RC inpatient 51 51 MEDICA (COMMERCIAL) 94265 [3081118] MEDICA CLAIMS [308111801] 45.9 percent of total billed charges 31.62 48.45 Technical (Hospital) Services HC/HH Wch Supp Stockinette Bias 3in__730 PX-2705000161 CDM 2705000161 LOCAL 270 RC inpatient 51 51 UNITED HEALTHCARE (COMMERCIAL) [3081199] UNITED HEALTHCARE 87726 [308119901] 31.62 percent of total billed charges 31.62 48.45 Technical (Hospital) Services HC/HH Wch Supp Stockinette Bias 3in__730 PX-2705000161 CDM 2705000161 LOCAL 270 RC inpatient 51 51 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES HDHP [308136802] 40.38 percent of total billed charges 31.62 48.45 Technical (Hospital) Services HC/HH Wch Supp Stockinette Bias 3in__730 PX-2705000161 CDM 2705000161 LOCAL 270 RC outpatient 51 51 HEALTHPARTNERS SX009 HEALTHPARTNERS 40.8 percent of total billed charges 31.62 48.45 Technical (Hospital) Services HC/HH Wch Supp Stockinette Bias 3in__730 PX-2705000161 CDM 2705000161 LOCAL 270 RC outpatient 51 51 UNITED HEALTHCARE (COMMERCIAL) [3081199] UNITED HEALTHCARE 87726 [308119901] 31.62 percent of total billed charges 31.62 48.45 Technical (Hospital) Services HC/HH Wch Supp Stockinette Bias 3in__730 PX-2705000161 CDM 2705000161 LOCAL 270 RC outpatient 51 51 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES PPO [308136801] 40.8 percent of total billed charges 31.62 48.45 Technical (Hospital) Services HC/HH Wch Supp Stockinette Bias 3in__730 PX-2705000161 CDM 2705000161 LOCAL 270 RC outpatient 51 51 CIGNA 62308 [3081051] CIGNA 62308 [308105105] 40.8 percent of total billed charges 31.62 48.45 Technical (Hospital) Services HC/HH Wch Supp Stockinette Bias 3in__730 PX-2705000161 CDM 2705000161 LOCAL 270 RC outpatient 51 51 CIGNA 62308 [3081051] CIGNA STATE OF WYOMING [308105107] 40.8 percent of total billed charges 31.62 48.45 Technical (Hospital) Services HC/HH Wch Supp Stockinette Bias 3in__730 PX-2705000161 CDM 2705000161 LOCAL 270 RC outpatient 51 51 BLUE CROSS BLUE SHIELD WELLMARK SB889 [3081026] BCBS WYOMING [308102603] 48.45 percent of total billed charges 31.62 48.45 Technical (Hospital) Services HC/HH Wch Supp Stockinette Bias 3in__730 PX-2705000161 CDM 2705000161 LOCAL 270 RC outpatient 51 51 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES EPO [308136803] 40.8 percent of total billed charges 31.62 48.45 Technical (Hospital) Services HC/HH Wch Supp Stockinette Bias 3in__730 PX-2705000161 CDM 2705000161 LOCAL 270 RC outpatient 51 51 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES HDHP [308136802] 40.8 percent of total billed charges 31.62 48.45 Technical (Hospital) Services HC/HH Wch Supp Stockinette Bias 3in__730 PX-2705000161 CDM 2705000161 LOCAL 270 RC outpatient 51 51 MULTIPLAN INC 34080 [3081285] MULTIPLAN INC [308128501] 48.45 percent of total billed charges 31.62 48.45 Technical (Hospital) Services HC/HH Wch Supp Stockinette Bias 3in__730 PX-2705000161 CDM 2705000161 LOCAL 270 RC outpatient 51 51 MEDICA (COMMERCIAL) 94265 [3081118] MEDICA CLAIMS [308111801] 45.9 percent of total billed charges 31.62 48.45 Technical (Hospital) Services HC/HH Wch Supp Stax Finger Splint #5.5__72246 PX-2705000160 CDM 2705000160 LOCAL 270 RC outpatient 18 18 HEALTHPARTNERS SX009 HEALTHPARTNERS 14.4 percent of total billed charges 11.16 17.1 Technical (Hospital) Services HC/HH Wch Supp Stax Finger Splint #5.5__72246 PX-2705000160 CDM 2705000160 LOCAL 270 RC outpatient 18 18 UNITED HEALTHCARE (COMMERCIAL) [3081199] UNITED HEALTHCARE 87726 [308119901] 11.16 percent of total billed charges 11.16 17.1 Technical (Hospital) Services HC/HH Wch Supp Stax Finger Splint #5.5__72246 PX-2705000160 CDM 2705000160 LOCAL 270 RC outpatient 18 18 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES PPO [308136801] 14.4 percent of total billed charges 11.16 17.1 Technical (Hospital) Services HC/HH Wch Supp Stax Finger Splint #5.5__72246 PX-2705000160 CDM 2705000160 LOCAL 270 RC outpatient 18 18 BLUE CROSS BLUE SHIELD WELLMARK SB889 [3081026] BCBS WYOMING [308102603] 17.1 percent of total billed charges 11.16 17.1 Technical (Hospital) Services HC/HH Wch Supp Stax Finger Splint #5.5__72246 PX-2705000160 CDM 2705000160 LOCAL 270 RC outpatient 18 18 CIGNA 62308 [3081051] CIGNA 62308 [308105105] 14.4 percent of total billed charges 11.16 17.1 Technical (Hospital) Services HC/HH Wch Supp Stax Finger Splint #5.5__72246 PX-2705000160 CDM 2705000160 LOCAL 270 RC outpatient 18 18 CIGNA 62308 [3081051] CIGNA STATE OF WYOMING [308105107] 14.4 percent of total billed charges 11.16 17.1 Technical (Hospital) Services HC/HH Wch Supp Stax Finger Splint #5.5__72246 PX-2705000160 CDM 2705000160 LOCAL 270 RC outpatient 18 18 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES EPO [308136803] 14.4 percent of total billed charges 11.16 17.1 Technical (Hospital) Services HC/HH Wch Supp Stax Finger Splint #5.5__72246 PX-2705000160 CDM 2705000160 LOCAL 270 RC outpatient 18 18 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES HDHP [308136802] 14.4 percent of total billed charges 11.16 17.1 Technical (Hospital) Services HC/HH Wch Supp Stax Finger Splint #5.5__72246 PX-2705000160 CDM 2705000160 LOCAL 270 RC outpatient 18 18 MEDICA (COMMERCIAL) 94265 [3081118] MEDICA CLAIMS [308111801] 16.2 percent of total billed charges 11.16 17.1 Technical (Hospital) Services HC/HH Wch Supp Stax Finger Splint #5.5__72246 PX-2705000160 CDM 2705000160 LOCAL 270 RC outpatient 18 18 MULTIPLAN INC 34080 [3081285] MULTIPLAN INC [308128501] 17.1 percent of total billed charges 11.16 17.1 Technical (Hospital) Services HC/HH Wch Supp Stax Finger Splint #5.5__72246 PX-2705000160 CDM 2705000160 LOCAL 270 RC inpatient 18 18 HEALTHPARTNERS SX009 HEALTHPARTNERS 14.25 percent of total billed charges 11.16 17.1 Technical (Hospital) Services HC/HH Wch Supp Stax Finger Splint #5.5__72246 PX-2705000160 CDM 2705000160 LOCAL 270 RC inpatient 18 18 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES EPO [308136803] 14.25 percent of total billed charges 11.16 17.1 Technical (Hospital) Services HC/HH Wch Supp Stax Finger Splint #5.5__72246 PX-2705000160 CDM 2705000160 LOCAL 270 RC inpatient 18 18 BLUE CROSS BLUE SHIELD WELLMARK SB889 [3081026] BCBS WYOMING [308102603] 17.1 percent of total billed charges 11.16 17.1 Technical (Hospital) Services HC/HH Wch Supp Stax Finger Splint #5.5__72246 PX-2705000160 CDM 2705000160 LOCAL 270 RC inpatient 18 18 MULTIPLAN INC 34080 [3081285] MULTIPLAN INC [308128501] 17.1 percent of total billed charges 11.16 17.1 Technical (Hospital) Services HC/HH Wch Supp Stax Finger Splint #5.5__72246 PX-2705000160 CDM 2705000160 LOCAL 270 RC inpatient 18 18 CIGNA 62308 [3081051] CIGNA 62308 [308105105] 14.25 percent of total billed charges 11.16 17.1 Technical (Hospital) Services HC/HH Wch Supp Stax Finger Splint #5.5__72246 PX-2705000160 CDM 2705000160 LOCAL 270 RC inpatient 18 18 CIGNA 62308 [3081051] CIGNA STATE OF WYOMING [308105107] 14.25 percent of total billed charges 11.16 17.1 Technical (Hospital) Services HC/HH Wch Supp Stax Finger Splint #5.5__72246 PX-2705000160 CDM 2705000160 LOCAL 270 RC inpatient 18 18 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES HDHP [308136802] 14.25 percent of total billed charges 11.16 17.1 Technical (Hospital) Services HC/HH Wch Supp Stax Finger Splint #5.5__72246 PX-2705000160 CDM 2705000160 LOCAL 270 RC inpatient 18 18 UNITED HEALTHCARE (COMMERCIAL) [3081199] UNITED HEALTHCARE 87726 [308119901] 11.16 percent of total billed charges 11.16 17.1 Technical (Hospital) Services HC/HH Wch Supp Stax Finger Splint #5.5__72246 PX-2705000160 CDM 2705000160 LOCAL 270 RC inpatient 18 18 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES PPO [308136801] 14.25 percent of total billed charges 11.16 17.1 Technical (Hospital) Services HC/HH Wch Supp Stax Finger Splint #5.5__72246 PX-2705000160 CDM 2705000160 LOCAL 270 RC inpatient 18 18 MEDICA (COMMERCIAL) 94265 [3081118] MEDICA CLAIMS [308111801] 16.2 percent of total billed charges 11.16 17.1 Technical (Hospital) Services HC/HH Wch Supp Splint Ortho-Glass 6x30__Og-6pc PX-2705000158 CDM 2705000158 LOCAL 270 RC outpatient 102 102 CIGNA 62308 [3081051] CIGNA 62308 [308105105] 81.6 percent of total billed charges 63.24 96.9 Technical (Hospital) Services HC/HH Wch Supp Splint Ortho-Glass 6x30__Og-6pc PX-2705000158 CDM 2705000158 LOCAL 270 RC outpatient 102 102 CIGNA 62308 [3081051] CIGNA STATE OF WYOMING [308105107] 81.6 percent of total billed charges 63.24 96.9 Technical (Hospital) Services HC/HH Wch Supp Splint Ortho-Glass 6x30__Og-6pc PX-2705000158 CDM 2705000158 LOCAL 270 RC outpatient 102 102 BLUE CROSS BLUE SHIELD WELLMARK SB889 [3081026] BCBS WYOMING [308102603] 96.9 percent of total billed charges 63.24 96.9 Technical (Hospital) Services HC/HH Wch Supp Splint Ortho-Glass 6x30__Og-6pc PX-2705000158 CDM 2705000158 LOCAL 270 RC outpatient 102 102 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES EPO [308136803] 81.6 percent of total billed charges 63.24 96.9 Technical (Hospital) Services HC/HH Wch Supp Splint Ortho-Glass 6x30__Og-6pc PX-2705000158 CDM 2705000158 LOCAL 270 RC outpatient 102 102 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES HDHP [308136802] 81.6 percent of total billed charges 63.24 96.9 Technical (Hospital) Services HC/HH Wch Supp Splint Ortho-Glass 6x30__Og-6pc PX-2705000158 CDM 2705000158 LOCAL 270 RC outpatient 102 102 HEALTHPARTNERS SX009 HEALTHPARTNERS 81.6 percent of total billed charges 63.24 96.9 Technical (Hospital) Services HC/HH Wch Supp Splint Ortho-Glass 6x30__Og-6pc PX-2705000158 CDM 2705000158 LOCAL 270 RC outpatient 102 102 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES PPO [308136801] 81.6 percent of total billed charges 63.24 96.9 Technical (Hospital) Services HC/HH Wch Supp Splint Ortho-Glass 6x30__Og-6pc PX-2705000158 CDM 2705000158 LOCAL 270 RC outpatient 102 102 UNITED HEALTHCARE (COMMERCIAL) [3081199] UNITED HEALTHCARE 87726 [308119901] 63.24 percent of total billed charges 63.24 96.9 Technical (Hospital) Services HC/HH Wch Supp Splint Ortho-Glass 6x30__Og-6pc PX-2705000158 CDM 2705000158 LOCAL 270 RC outpatient 102 102 MULTIPLAN INC 34080 [3081285] MULTIPLAN INC [308128501] 96.9 percent of total billed charges 63.24 96.9 Technical (Hospital) Services HC/HH Wch Supp Splint Ortho-Glass 6x30__Og-6pc PX-2705000158 CDM 2705000158 LOCAL 270 RC outpatient 102 102 MEDICA (COMMERCIAL) 94265 [3081118] MEDICA CLAIMS [308111801] 91.8 percent of total billed charges 63.24 96.9 Technical (Hospital) Services HC/HH Wch Supp Splint Ortho-Glass 6x30__Og-6pc PX-2705000158 CDM 2705000158 LOCAL 270 RC inpatient 102 102 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES PPO [308136801] 80.76 percent of total billed charges 63.24 96.9 Technical (Hospital) Services HC/HH Wch Supp Splint Ortho-Glass 6x30__Og-6pc PX-2705000158 CDM 2705000158 LOCAL 270 RC inpatient 102 102 MEDICA (COMMERCIAL) 94265 [3081118] MEDICA CLAIMS [308111801] 91.8 percent of total billed charges 63.24 96.9 Technical (Hospital) Services HC/HH Wch Supp Splint Ortho-Glass 6x30__Og-6pc PX-2705000158 CDM 2705000158 LOCAL 270 RC inpatient 102 102 UNITED HEALTHCARE (COMMERCIAL) [3081199] UNITED HEALTHCARE 87726 [308119901] 63.24 percent of total billed charges 63.24 96.9 Technical (Hospital) Services HC/HH Wch Supp Splint Ortho-Glass 6x30__Og-6pc PX-2705000158 CDM 2705000158 LOCAL 270 RC inpatient 102 102 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES HDHP [308136802] 80.76 percent of total billed charges 63.24 96.9 Technical (Hospital) Services HC/HH Wch Supp Splint Ortho-Glass 6x30__Og-6pc PX-2705000158 CDM 2705000158 LOCAL 270 RC inpatient 102 102 BLUE CROSS BLUE SHIELD WELLMARK SB889 [3081026] BCBS WYOMING [308102603] 96.9 percent of total billed charges 63.24 96.9 Technical (Hospital) Services HC/HH Wch Supp Splint Ortho-Glass 6x30__Og-6pc PX-2705000158 CDM 2705000158 LOCAL 270 RC inpatient 102 102 MULTIPLAN INC 34080 [3081285] MULTIPLAN INC [308128501] 96.9 percent of total billed charges 63.24 96.9 Technical (Hospital) Services HC/HH Wch Supp Splint Ortho-Glass 6x30__Og-6pc PX-2705000158 CDM 2705000158 LOCAL 270 RC inpatient 102 102 CIGNA 62308 [3081051] CIGNA 62308 [308105105] 80.76 percent of total billed charges 63.24 96.9 Technical (Hospital) Services HC/HH Wch Supp Splint Ortho-Glass 6x30__Og-6pc PX-2705000158 CDM 2705000158 LOCAL 270 RC inpatient 102 102 CIGNA 62308 [3081051] CIGNA STATE OF WYOMING [308105107] 80.76 percent of total billed charges 63.24 96.9 Technical (Hospital) Services HC/HH Wch Supp Splint Ortho-Glass 6x30__Og-6pc PX-2705000158 CDM 2705000158 LOCAL 270 RC inpatient 102 102 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES EPO [308136803] 80.76 percent of total billed charges 63.24 96.9 Technical (Hospital) Services HC/HH Wch Supp Splint Ortho-Glass 6x30__Og-6pc PX-2705000158 CDM 2705000158 LOCAL 270 RC inpatient 102 102 HEALTHPARTNERS SX009 HEALTHPARTNERS 80.76 percent of total billed charges 63.24 96.9 Technical (Hospital) Services HC/HH Wch Supp Splint Ortho-Glass 4x30__Og-430pc PX-2705000157 CDM 2705000157 LOCAL 270 RC outpatient 50 50 MEDICA (COMMERCIAL) 94265 [3081118] MEDICA CLAIMS [308111801] 45 percent of total billed charges 31 47.5 Technical (Hospital) Services HC/HH Wch Supp Splint Ortho-Glass 4x30__Og-430pc PX-2705000157 CDM 2705000157 LOCAL 270 RC outpatient 50 50 MULTIPLAN INC 34080 [3081285] MULTIPLAN INC [308128501] 47.5 percent of total billed charges 31 47.5 Technical (Hospital) Services HC/HH Wch Supp Splint Ortho-Glass 4x30__Og-430pc PX-2705000157 CDM 2705000157 LOCAL 270 RC outpatient 50 50 UNITED HEALTHCARE (COMMERCIAL) [3081199] UNITED HEALTHCARE 87726 [308119901] 31 percent of total billed charges 31 47.5 Technical (Hospital) Services HC/HH Wch Supp Splint Ortho-Glass 4x30__Og-430pc PX-2705000157 CDM 2705000157 LOCAL 270 RC outpatient 50 50 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES PPO [308136801] 40 percent of total billed charges 31 47.5 Technical (Hospital) Services HC/HH Wch Supp Splint Ortho-Glass 4x30__Og-430pc PX-2705000157 CDM 2705000157 LOCAL 270 RC outpatient 50 50 HEALTHPARTNERS SX009 HEALTHPARTNERS 40 percent of total billed charges 31 47.5 Technical (Hospital) Services HC/HH Wch Supp Splint Ortho-Glass 4x30__Og-430pc PX-2705000157 CDM 2705000157 LOCAL 270 RC outpatient 50 50 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES HDHP [308136802] 40 percent of total billed charges 31 47.5 Technical (Hospital) Services HC/HH Wch Supp Splint Ortho-Glass 4x30__Og-430pc PX-2705000157 CDM 2705000157 LOCAL 270 RC outpatient 50 50 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES EPO [308136803] 40 percent of total billed charges 31 47.5 Technical (Hospital) Services HC/HH Wch Supp Splint Ortho-Glass 4x30__Og-430pc PX-2705000157 CDM 2705000157 LOCAL 270 RC outpatient 50 50 BLUE CROSS BLUE SHIELD WELLMARK SB889 [3081026] BCBS WYOMING [308102603] 47.5 percent of total billed charges 31 47.5 Technical (Hospital) Services HC/HH Wch Supp Splint Ortho-Glass 4x30__Og-430pc PX-2705000157 CDM 2705000157 LOCAL 270 RC outpatient 50 50 CIGNA 62308 [3081051] CIGNA 62308 [308105105] 40 percent of total billed charges 31 47.5 Technical (Hospital) Services HC/HH Wch Supp Splint Ortho-Glass 4x30__Og-430pc PX-2705000157 CDM 2705000157 LOCAL 270 RC outpatient 50 50 CIGNA 62308 [3081051] CIGNA STATE OF WYOMING [308105107] 40 percent of total billed charges 31 47.5 Technical (Hospital) Services HC/HH Wch Supp Splint Ortho-Glass 4x30__Og-430pc PX-2705000157 CDM 2705000157 LOCAL 270 RC inpatient 50 50 HEALTHPARTNERS SX009 HEALTHPARTNERS 39.59 percent of total billed charges 31 47.5 Technical (Hospital) Services HC/HH Wch Supp Splint Ortho-Glass 4x30__Og-430pc PX-2705000157 CDM 2705000157 LOCAL 270 RC inpatient 50 50 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES EPO [308136803] 39.59 percent of total billed charges 31 47.5 Technical (Hospital) Services HC/HH Wch Supp Splint Ortho-Glass 4x30__Og-430pc PX-2705000157 CDM 2705000157 LOCAL 270 RC inpatient 50 50 CIGNA 62308 [3081051] CIGNA 62308 [308105105] 39.59 percent of total billed charges 31 47.5 Technical (Hospital) Services HC/HH Wch Supp Splint Ortho-Glass 4x30__Og-430pc PX-2705000157 CDM 2705000157 LOCAL 270 RC inpatient 50 50 CIGNA 62308 [3081051] CIGNA STATE OF WYOMING [308105107] 39.59 percent of total billed charges 31 47.5 Technical (Hospital) Services HC/HH Wch Supp Splint Ortho-Glass 4x30__Og-430pc PX-2705000157 CDM 2705000157 LOCAL 270 RC inpatient 50 50 MULTIPLAN INC 34080 [3081285] MULTIPLAN INC [308128501] 47.5 percent of total billed charges 31 47.5 Technical (Hospital) Services HC/HH Wch Supp Splint Ortho-Glass 4x30__Og-430pc PX-2705000157 CDM 2705000157 LOCAL 270 RC inpatient 50 50 BLUE CROSS BLUE SHIELD WELLMARK SB889 [3081026] BCBS WYOMING [308102603] 47.5 percent of total billed charges 31 47.5 Technical (Hospital) Services HC/HH Wch Supp Splint Ortho-Glass 4x30__Og-430pc PX-2705000157 CDM 2705000157 LOCAL 270 RC inpatient 50 50 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES HDHP [308136802] 39.59 percent of total billed charges 31 47.5 Technical (Hospital) Services HC/HH Wch Supp Splint Ortho-Glass 4x30__Og-430pc PX-2705000157 CDM 2705000157 LOCAL 270 RC inpatient 50 50 UNITED HEALTHCARE (COMMERCIAL) [3081199] UNITED HEALTHCARE 87726 [308119901] 31 percent of total billed charges 31 47.5 Technical (Hospital) Services HC/HH Wch Supp Splint Ortho-Glass 4x30__Og-430pc PX-2705000157 CDM 2705000157 LOCAL 270 RC inpatient 50 50 MEDICA (COMMERCIAL) 94265 [3081118] MEDICA CLAIMS [308111801] 45 percent of total billed charges 31 47.5 Technical (Hospital) Services HC/HH Wch Supp Splint Ortho-Glass 4x30__Og-430pc PX-2705000157 CDM 2705000157 LOCAL 270 RC inpatient 50 50 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES PPO [308136801] 39.59 percent of total billed charges 31 47.5 Technical (Hospital) Services HC/HH Wch Supp Splint Ortho-Glass 2x12__Og-2pc PX-2705000156 CDM 2705000156 LOCAL 270 RC outpatient 22 22 CIGNA 62308 [3081051] CIGNA 62308 [308105105] 17.6 percent of total billed charges 13.64 20.9 Technical (Hospital) Services HC/HH Wch Supp Splint Ortho-Glass 2x12__Og-2pc PX-2705000156 CDM 2705000156 LOCAL 270 RC outpatient 22 22 CIGNA 62308 [3081051] CIGNA STATE OF WYOMING [308105107] 17.6 percent of total billed charges 13.64 20.9 Technical (Hospital) Services HC/HH Wch Supp Splint Ortho-Glass 2x12__Og-2pc PX-2705000156 CDM 2705000156 LOCAL 270 RC outpatient 22 22 BLUE CROSS BLUE SHIELD WELLMARK SB889 [3081026] BCBS WYOMING [308102603] 20.9 percent of total billed charges 13.64 20.9 Technical (Hospital) Services HC/HH Wch Supp Splint Ortho-Glass 2x12__Og-2pc PX-2705000156 CDM 2705000156 LOCAL 270 RC outpatient 22 22 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES EPO [308136803] 17.6 percent of total billed charges 13.64 20.9 Technical (Hospital) Services HC/HH Wch Supp Splint Ortho-Glass 2x12__Og-2pc PX-2705000156 CDM 2705000156 LOCAL 270 RC outpatient 22 22 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES HDHP [308136802] 17.6 percent of total billed charges 13.64 20.9 Technical (Hospital) Services HC/HH Wch Supp Splint Ortho-Glass 2x12__Og-2pc PX-2705000156 CDM 2705000156 LOCAL 270 RC outpatient 22 22 HEALTHPARTNERS SX009 HEALTHPARTNERS 17.6 percent of total billed charges 13.64 20.9 Technical (Hospital) Services HC/HH Wch Supp Splint Ortho-Glass 2x12__Og-2pc PX-2705000156 CDM 2705000156 LOCAL 270 RC outpatient 22 22 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES PPO [308136801] 17.6 percent of total billed charges 13.64 20.9 Technical (Hospital) Services HC/HH Wch Supp Splint Ortho-Glass 2x12__Og-2pc PX-2705000156 CDM 2705000156 LOCAL 270 RC outpatient 22 22 UNITED HEALTHCARE (COMMERCIAL) [3081199] UNITED HEALTHCARE 87726 [308119901] 13.64 percent of total billed charges 13.64 20.9 Technical (Hospital) Services HC/HH Wch Supp Splint Ortho-Glass 2x12__Og-2pc PX-2705000156 CDM 2705000156 LOCAL 270 RC outpatient 22 22 MULTIPLAN INC 34080 [3081285] MULTIPLAN INC [308128501] 20.9 percent of total billed charges 13.64 20.9 Technical (Hospital) Services HC/HH Wch Supp Splint Ortho-Glass 2x12__Og-2pc PX-2705000156 CDM 2705000156 LOCAL 270 RC outpatient 22 22 MEDICA (COMMERCIAL) 94265 [3081118] MEDICA CLAIMS [308111801] 19.8 percent of total billed charges 13.64 20.9 Technical (Hospital) Services HC/HH Wch Supp Splint Ortho-Glass 2x12__Og-2pc PX-2705000156 CDM 2705000156 LOCAL 270 RC inpatient 22 22 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES PPO [308136801] 17.42 percent of total billed charges 13.64 20.9 Technical (Hospital) Services HC/HH Wch Supp Splint Ortho-Glass 2x12__Og-2pc PX-2705000156 CDM 2705000156 LOCAL 270 RC inpatient 22 22 MEDICA (COMMERCIAL) 94265 [3081118] MEDICA CLAIMS [308111801] 19.8 percent of total billed charges 13.64 20.9 Technical (Hospital) Services HC/HH Wch Supp Splint Ortho-Glass 2x12__Og-2pc PX-2705000156 CDM 2705000156 LOCAL 270 RC inpatient 22 22 UNITED HEALTHCARE (COMMERCIAL) [3081199] UNITED HEALTHCARE 87726 [308119901] 13.64 percent of total billed charges 13.64 20.9 Technical (Hospital) Services HC/HH Wch Supp Splint Ortho-Glass 2x12__Og-2pc PX-2705000156 CDM 2705000156 LOCAL 270 RC inpatient 22 22 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES HDHP [308136802] 17.42 percent of total billed charges 13.64 20.9 Technical (Hospital) Services HC/HH Wch Supp Splint Ortho-Glass 2x12__Og-2pc PX-2705000156 CDM 2705000156 LOCAL 270 RC inpatient 22 22 BLUE CROSS BLUE SHIELD WELLMARK SB889 [3081026] BCBS WYOMING [308102603] 20.9 percent of total billed charges 13.64 20.9 Technical (Hospital) Services HC/HH Wch Supp Splint Ortho-Glass 2x12__Og-2pc PX-2705000156 CDM 2705000156 LOCAL 270 RC inpatient 22 22 MULTIPLAN INC 34080 [3081285] MULTIPLAN INC [308128501] 20.9 percent of total billed charges 13.64 20.9 Technical (Hospital) Services HC/HH Wch Supp Splint Ortho-Glass 2x12__Og-2pc PX-2705000156 CDM 2705000156 LOCAL 270 RC inpatient 22 22 CIGNA 62308 [3081051] CIGNA 62308 [308105105] 17.42 percent of total billed charges 13.64 20.9 Technical (Hospital) Services HC/HH Wch Supp Splint Ortho-Glass 2x12__Og-2pc PX-2705000156 CDM 2705000156 LOCAL 270 RC inpatient 22 22 CIGNA 62308 [3081051] CIGNA STATE OF WYOMING [308105107] 17.42 percent of total billed charges 13.64 20.9 Technical (Hospital) Services HC/HH Wch Supp Splint Ortho-Glass 2x12__Og-2pc PX-2705000156 CDM 2705000156 LOCAL 270 RC inpatient 22 22 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES EPO [308136803] 17.42 percent of total billed charges 13.64 20.9 Technical (Hospital) Services HC/HH Wch Supp Splint Ortho-Glass 2x12__Og-2pc PX-2705000156 CDM 2705000156 LOCAL 270 RC inpatient 22 22 HEALTHPARTNERS SX009 HEALTHPARTNERS 17.42 percent of total billed charges 13.64 20.9 Technical (Hospital) Services HC/HH Wch Supp Splint Ortho Glass 3x35__Og-335pc PX-2705000155 CDM 2705000155 LOCAL 270 RC outpatient 55 55 MEDICA (COMMERCIAL) 94265 [3081118] MEDICA CLAIMS [308111801] 49.5 percent of total billed charges 34.1 52.25 Technical (Hospital) Services HC/HH Wch Supp Splint Ortho Glass 3x35__Og-335pc PX-2705000155 CDM 2705000155 LOCAL 270 RC outpatient 55 55 MULTIPLAN INC 34080 [3081285] MULTIPLAN INC [308128501] 52.25 percent of total billed charges 34.1 52.25 Technical (Hospital) Services HC/HH Wch Supp Splint Ortho Glass 3x35__Og-335pc PX-2705000155 CDM 2705000155 LOCAL 270 RC outpatient 55 55 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES PPO [308136801] 44 percent of total billed charges 34.1 52.25 Technical (Hospital) Services HC/HH Wch Supp Splint Ortho Glass 3x35__Og-335pc PX-2705000155 CDM 2705000155 LOCAL 270 RC outpatient 55 55 UNITED HEALTHCARE (COMMERCIAL) [3081199] UNITED HEALTHCARE 87726 [308119901] 34.1 percent of total billed charges 34.1 52.25 Technical (Hospital) Services HC/HH Wch Supp Splint Ortho Glass 3x35__Og-335pc PX-2705000155 CDM 2705000155 LOCAL 270 RC outpatient 55 55 HEALTHPARTNERS SX009 HEALTHPARTNERS 44 percent of total billed charges 34.1 52.25 Technical (Hospital) Services HC/HH Wch Supp Splint Ortho Glass 3x35__Og-335pc PX-2705000155 CDM 2705000155 LOCAL 270 RC outpatient 55 55 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES EPO [308136803] 44 percent of total billed charges 34.1 52.25 Technical (Hospital) Services HC/HH Wch Supp Splint Ortho Glass 3x35__Og-335pc PX-2705000155 CDM 2705000155 LOCAL 270 RC outpatient 55 55 BLUE CROSS BLUE SHIELD WELLMARK SB889 [3081026] BCBS WYOMING [308102603] 52.25 percent of total billed charges 34.1 52.25 Technical (Hospital) Services HC/HH Wch Supp Splint Ortho Glass 3x35__Og-335pc PX-2705000155 CDM 2705000155 LOCAL 270 RC outpatient 55 55 CIGNA 62308 [3081051] CIGNA 62308 [308105105] 44 percent of total billed charges 34.1 52.25 Technical (Hospital) Services HC/HH Wch Supp Splint Ortho Glass 3x35__Og-335pc PX-2705000155 CDM 2705000155 LOCAL 270 RC outpatient 55 55 CIGNA 62308 [3081051] CIGNA STATE OF WYOMING [308105107] 44 percent of total billed charges 34.1 52.25 Technical (Hospital) Services HC/HH Wch Supp Splint Ortho Glass 3x35__Og-335pc PX-2705000155 CDM 2705000155 LOCAL 270 RC outpatient 55 55 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES HDHP [308136802] 44 percent of total billed charges 34.1 52.25 Technical (Hospital) Services HC/HH Wch Supp Splint Ortho Glass 3x35__Og-335pc PX-2705000155 CDM 2705000155 LOCAL 270 RC inpatient 55 55 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES PPO [308136801] 43.55 percent of total billed charges 34.1 52.25 Technical (Hospital) Services HC/HH Wch Supp Splint Ortho Glass 3x35__Og-335pc PX-2705000155 CDM 2705000155 LOCAL 270 RC inpatient 55 55 UNITED HEALTHCARE (COMMERCIAL) [3081199] UNITED HEALTHCARE 87726 [308119901] 34.1 percent of total billed charges 34.1 52.25 Technical (Hospital) Services HC/HH Wch Supp Splint Ortho Glass 3x35__Og-335pc PX-2705000155 CDM 2705000155 LOCAL 270 RC inpatient 55 55 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES HDHP [308136802] 43.55 percent of total billed charges 34.1 52.25 Technical (Hospital) Services HC/HH Wch Supp Splint Ortho Glass 3x35__Og-335pc PX-2705000155 CDM 2705000155 LOCAL 270 RC inpatient 55 55 MEDICA (COMMERCIAL) 94265 [3081118] MEDICA CLAIMS [308111801] 49.5 percent of total billed charges 34.1 52.25 Technical (Hospital) Services HC/HH Wch Supp Splint Ortho Glass 3x35__Og-335pc PX-2705000155 CDM 2705000155 LOCAL 270 RC inpatient 55 55 MULTIPLAN INC 34080 [3081285] MULTIPLAN INC [308128501] 52.25 percent of total billed charges 34.1 52.25 Technical (Hospital) Services HC/HH Wch Supp Splint Ortho Glass 3x35__Og-335pc PX-2705000155 CDM 2705000155 LOCAL 270 RC inpatient 55 55 BLUE CROSS BLUE SHIELD WELLMARK SB889 [3081026] BCBS WYOMING [308102603] 52.25 percent of total billed charges 34.1 52.25 Technical (Hospital) Services HC/HH Wch Supp Splint Ortho Glass 3x35__Og-335pc PX-2705000155 CDM 2705000155 LOCAL 270 RC inpatient 55 55 CIGNA 62308 [3081051] CIGNA 62308 [308105105] 43.55 percent of total billed charges 34.1 52.25 Technical (Hospital) Services HC/HH Wch Supp Splint Ortho Glass 3x35__Og-335pc PX-2705000155 CDM 2705000155 LOCAL 270 RC inpatient 55 55 CIGNA 62308 [3081051] CIGNA STATE OF WYOMING [308105107] 43.55 percent of total billed charges 34.1 52.25 Technical (Hospital) Services HC/HH Wch Supp Splint Ortho Glass 3x35__Og-335pc PX-2705000155 CDM 2705000155 LOCAL 270 RC inpatient 55 55 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES EPO [308136803] 43.55 percent of total billed charges 34.1 52.25 Technical (Hospital) Services HC/HH Wch Supp Splint Ortho Glass 3x35__Og-335pc PX-2705000155 CDM 2705000155 LOCAL 270 RC inpatient 55 55 HEALTHPARTNERS SX009 HEALTHPARTNERS 43.55 percent of total billed charges 34.1 52.25 Technical (Hospital) Services HC/HH Wch Supp Splint Cockup Univ Rt__1769-02 PX-2705000154 CDM 2705000154 LOCAL 270 RC outpatient 45 45 MULTIPLAN INC 34080 [3081285] MULTIPLAN INC [308128501] 42.75 percent of total billed charges 27.9 42.75 Technical (Hospital) Services HC/HH Wch Supp Splint Cockup Univ Rt__1769-02 PX-2705000154 CDM 2705000154 LOCAL 270 RC outpatient 45 45 MEDICA (COMMERCIAL) 94265 [3081118] MEDICA CLAIMS [308111801] 40.5 percent of total billed charges 27.9 42.75 Technical (Hospital) Services HC/HH Wch Supp Splint Cockup Univ Rt__1769-02 PX-2705000154 CDM 2705000154 LOCAL 270 RC outpatient 45 45 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES HDHP [308136802] 36 percent of total billed charges 27.9 42.75 Technical (Hospital) Services HC/HH Wch Supp Splint Cockup Univ Rt__1769-02 PX-2705000154 CDM 2705000154 LOCAL 270 RC outpatient 45 45 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES EPO [308136803] 36 percent of total billed charges 27.9 42.75 Technical (Hospital) Services HC/HH Wch Supp Splint Cockup Univ Rt__1769-02 PX-2705000154 CDM 2705000154 LOCAL 270 RC outpatient 45 45 CIGNA 62308 [3081051] CIGNA 62308 [308105105] 36 percent of total billed charges 27.9 42.75 Technical (Hospital) Services HC/HH Wch Supp Splint Cockup Univ Rt__1769-02 PX-2705000154 CDM 2705000154 LOCAL 270 RC outpatient 45 45 CIGNA 62308 [3081051] CIGNA STATE OF WYOMING [308105107] 36 percent of total billed charges 27.9 42.75 Technical (Hospital) Services HC/HH Wch Supp Splint Cockup Univ Rt__1769-02 PX-2705000154 CDM 2705000154 LOCAL 270 RC outpatient 45 45 BLUE CROSS BLUE SHIELD WELLMARK SB889 [3081026] BCBS WYOMING [308102603] 42.75 percent of total billed charges 27.9 42.75 Technical (Hospital) Services HC/HH Wch Supp Splint Cockup Univ Rt__1769-02 PX-2705000154 CDM 2705000154 LOCAL 270 RC outpatient 45 45 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES PPO [308136801] 36 percent of total billed charges 27.9 42.75 Technical (Hospital) Services HC/HH Wch Supp Splint Cockup Univ Rt__1769-02 PX-2705000154 CDM 2705000154 LOCAL 270 RC outpatient 45 45 UNITED HEALTHCARE (COMMERCIAL) [3081199] UNITED HEALTHCARE 87726 [308119901] 27.9 percent of total billed charges 27.9 42.75 Technical (Hospital) Services HC/HH Wch Supp Splint Cockup Univ Rt__1769-02 PX-2705000154 CDM 2705000154 LOCAL 270 RC outpatient 45 45 HEALTHPARTNERS SX009 HEALTHPARTNERS 36 percent of total billed charges 27.9 42.75 Technical (Hospital) Services HC/HH Wch Supp Splint Cockup Univ Rt__1769-02 PX-2705000154 CDM 2705000154 LOCAL 270 RC inpatient 45 45 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES PPO [308136801] 35.63 percent of total billed charges 27.9 42.75 Technical (Hospital) Services HC/HH Wch Supp Splint Cockup Univ Rt__1769-02 PX-2705000154 CDM 2705000154 LOCAL 270 RC inpatient 45 45 MEDICA (COMMERCIAL) 94265 [3081118] MEDICA CLAIMS [308111801] 40.5 percent of total billed charges 27.9 42.75 Technical (Hospital) Services HC/HH Wch Supp Splint Cockup Univ Rt__1769-02 PX-2705000154 CDM 2705000154 LOCAL 270 RC inpatient 45 45 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES HDHP [308136802] 35.63 percent of total billed charges 27.9 42.75 Technical (Hospital) Services HC/HH Wch Supp Splint Cockup Univ Rt__1769-02 PX-2705000154 CDM 2705000154 LOCAL 270 RC inpatient 45 45 UNITED HEALTHCARE (COMMERCIAL) [3081199] UNITED HEALTHCARE 87726 [308119901] 27.9 percent of total billed charges 27.9 42.75 Technical (Hospital) Services HC/HH Wch Supp Splint Cockup Univ Rt__1769-02 PX-2705000154 CDM 2705000154 LOCAL 270 RC inpatient 45 45 BLUE CROSS BLUE SHIELD WELLMARK SB889 [3081026] BCBS WYOMING [308102603] 42.75 percent of total billed charges 27.9 42.75 Technical (Hospital) Services HC/HH Wch Supp Splint Cockup Univ Rt__1769-02 PX-2705000154 CDM 2705000154 LOCAL 270 RC inpatient 45 45 MULTIPLAN INC 34080 [3081285] MULTIPLAN INC [308128501] 42.75 percent of total billed charges 27.9 42.75 Technical (Hospital) Services HC/HH Wch Supp Splint Cockup Univ Rt__1769-02 PX-2705000154 CDM 2705000154 LOCAL 270 RC inpatient 45 45 CIGNA 62308 [3081051] CIGNA 62308 [308105105] 35.63 percent of total billed charges 27.9 42.75 Technical (Hospital) Services HC/HH Wch Supp Splint Cockup Univ Rt__1769-02 PX-2705000154 CDM 2705000154 LOCAL 270 RC inpatient 45 45 CIGNA 62308 [3081051] CIGNA STATE OF WYOMING [308105107] 35.63 percent of total billed charges 27.9 42.75 Technical (Hospital) Services HC/HH Wch Supp Splint Cockup Univ Rt__1769-02 PX-2705000154 CDM 2705000154 LOCAL 270 RC inpatient 45 45 HEALTHPARTNERS SX009 HEALTHPARTNERS 35.63 percent of total billed charges 27.9 42.75 Technical (Hospital) Services HC/HH Wch Supp Splint Cockup Univ Rt__1769-02 PX-2705000154 CDM 2705000154 LOCAL 270 RC inpatient 45 45 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES EPO [308136803] 35.63 percent of total billed charges 27.9 42.75 Technical (Hospital) Services HC/HH Wch Supp Splint Cockup Univ Lt__1769-03 PX-2705000153 CDM 2705000153 LOCAL 270 RC inpatient 41 41 HEALTHPARTNERS SX009 HEALTHPARTNERS 32.46 percent of total billed charges 25.42 38.95 Technical (Hospital) Services HC/HH Wch Supp Splint Cockup Univ Lt__1769-03 PX-2705000153 CDM 2705000153 LOCAL 270 RC inpatient 41 41 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES EPO [308136803] 32.46 percent of total billed charges 25.42 38.95 Technical (Hospital) Services HC/HH Wch Supp Splint Cockup Univ Lt__1769-03 PX-2705000153 CDM 2705000153 LOCAL 270 RC inpatient 41 41 BLUE CROSS BLUE SHIELD WELLMARK SB889 [3081026] BCBS WYOMING [308102603] 38.95 percent of total billed charges 25.42 38.95 Technical (Hospital) Services HC/HH Wch Supp Splint Cockup Univ Lt__1769-03 PX-2705000153 CDM 2705000153 LOCAL 270 RC inpatient 41 41 MULTIPLAN INC 34080 [3081285] MULTIPLAN INC [308128501] 38.95 percent of total billed charges 25.42 38.95 Technical (Hospital) Services HC/HH Wch Supp Splint Cockup Univ Lt__1769-03 PX-2705000153 CDM 2705000153 LOCAL 270 RC inpatient 41 41 CIGNA 62308 [3081051] CIGNA 62308 [308105105] 32.46 percent of total billed charges 25.42 38.95 Technical (Hospital) Services HC/HH Wch Supp Splint Cockup Univ Lt__1769-03 PX-2705000153 CDM 2705000153 LOCAL 270 RC inpatient 41 41 CIGNA 62308 [3081051] CIGNA STATE OF WYOMING [308105107] 32.46 percent of total billed charges 25.42 38.95 Technical (Hospital) Services HC/HH Wch Supp Splint Cockup Univ Lt__1769-03 PX-2705000153 CDM 2705000153 LOCAL 270 RC inpatient 41 41 MEDICA (COMMERCIAL) 94265 [3081118] MEDICA CLAIMS [308111801] 36.9 percent of total billed charges 25.42 38.95 Technical (Hospital) Services HC/HH Wch Supp Splint Cockup Univ Lt__1769-03 PX-2705000153 CDM 2705000153 LOCAL 270 RC inpatient 41 41 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES PPO [308136801] 32.46 percent of total billed charges 25.42 38.95 Technical (Hospital) Services HC/HH Wch Supp Splint Cockup Univ Lt__1769-03 PX-2705000153 CDM 2705000153 LOCAL 270 RC inpatient 41 41 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES HDHP [308136802] 32.46 percent of total billed charges 25.42 38.95 Technical (Hospital) Services HC/HH Wch Supp Splint Cockup Univ Lt__1769-03 PX-2705000153 CDM 2705000153 LOCAL 270 RC inpatient 41 41 UNITED HEALTHCARE (COMMERCIAL) [3081199] UNITED HEALTHCARE 87726 [308119901] 25.42 percent of total billed charges 25.42 38.95 Technical (Hospital) Services HC/HH Wch Supp Splint Cockup Univ Lt__1769-03 PX-2705000153 CDM 2705000153 LOCAL 270 RC outpatient 41 41 HEALTHPARTNERS SX009 HEALTHPARTNERS 32.8 percent of total billed charges 25.42 38.95 Technical (Hospital) Services HC/HH Wch Supp Splint Cockup Univ Lt__1769-03 PX-2705000153 CDM 2705000153 LOCAL 270 RC outpatient 41 41 UNITED HEALTHCARE (COMMERCIAL) [3081199] UNITED HEALTHCARE 87726 [308119901] 25.42 percent of total billed charges 25.42 38.95 Technical (Hospital) Services HC/HH Wch Supp Splint Cockup Univ Lt__1769-03 PX-2705000153 CDM 2705000153 LOCAL 270 RC outpatient 41 41 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES PPO [308136801] 32.8 percent of total billed charges 25.42 38.95 Technical (Hospital) Services HC/HH Wch Supp Splint Cockup Univ Lt__1769-03 PX-2705000153 CDM 2705000153 LOCAL 270 RC outpatient 41 41 BLUE CROSS BLUE SHIELD WELLMARK SB889 [3081026] BCBS WYOMING [308102603] 38.95 percent of total billed charges 25.42 38.95 Technical (Hospital) Services HC/HH Wch Supp Splint Cockup Univ Lt__1769-03 PX-2705000153 CDM 2705000153 LOCAL 270 RC outpatient 41 41 CIGNA 62308 [3081051] CIGNA 62308 [308105105] 32.8 percent of total billed charges 25.42 38.95 Technical (Hospital) Services HC/HH Wch Supp Splint Cockup Univ Lt__1769-03 PX-2705000153 CDM 2705000153 LOCAL 270 RC outpatient 41 41 CIGNA 62308 [3081051] CIGNA STATE OF WYOMING [308105107] 32.8 percent of total billed charges 25.42 38.95 Technical (Hospital) Services HC/HH Wch Supp Splint Cockup Univ Lt__1769-03 PX-2705000153 CDM 2705000153 LOCAL 270 RC outpatient 41 41 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES EPO [308136803] 32.8 percent of total billed charges 25.42 38.95 Technical (Hospital) Services HC/HH Wch Supp Splint Cockup Univ Lt__1769-03 PX-2705000153 CDM 2705000153 LOCAL 270 RC outpatient 41 41 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES HDHP [308136802] 32.8 percent of total billed charges 25.42 38.95 Technical (Hospital) Services HC/HH Wch Supp Splint Cockup Univ Lt__1769-03 PX-2705000153 CDM 2705000153 LOCAL 270 RC outpatient 41 41 MEDICA (COMMERCIAL) 94265 [3081118] MEDICA CLAIMS [308111801] 36.9 percent of total billed charges 25.42 38.95 Technical (Hospital) Services HC/HH Wch Supp Splint Cockup Univ Lt__1769-03 PX-2705000153 CDM 2705000153 LOCAL 270 RC outpatient 41 41 MULTIPLAN INC 34080 [3081285] MULTIPLAN INC [308128501] 38.95 percent of total billed charges 25.42 38.95 Technical (Hospital) Services HC/HH Wch Supp Splint Clavicle/Sml__0814-1232 PX-2705000152 CDM 2705000152 LOCAL 270 RC outpatient 33 33 MULTIPLAN INC 34080 [3081285] MULTIPLAN INC [308128501] 31.35 percent of total billed charges 20.46 31.35 Technical (Hospital) Services HC/HH Wch Supp Splint Clavicle/Sml__0814-1232 PX-2705000152 CDM 2705000152 LOCAL 270 RC outpatient 33 33 MEDICA (COMMERCIAL) 94265 [3081118] MEDICA CLAIMS [308111801] 29.7 percent of total billed charges 20.46 31.35 Technical (Hospital) Services HC/HH Wch Supp Splint Clavicle/Sml__0814-1232 PX-2705000152 CDM 2705000152 LOCAL 270 RC outpatient 33 33 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES PPO [308136801] 26.4 percent of total billed charges 20.46 31.35 Technical (Hospital) Services HC/HH Wch Supp Splint Clavicle/Sml__0814-1232 PX-2705000152 CDM 2705000152 LOCAL 270 RC outpatient 33 33 HEALTHPARTNERS SX009 HEALTHPARTNERS 26.4 percent of total billed charges 20.46 31.35 Technical (Hospital) Services HC/HH Wch Supp Splint Clavicle/Sml__0814-1232 PX-2705000152 CDM 2705000152 LOCAL 270 RC outpatient 33 33 UNITED HEALTHCARE (COMMERCIAL) [3081199] UNITED HEALTHCARE 87726 [308119901] 20.46 percent of total billed charges 20.46 31.35 Technical (Hospital) Services HC/HH Wch Supp Splint Clavicle/Sml__0814-1232 PX-2705000152 CDM 2705000152 LOCAL 270 RC outpatient 33 33 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES HDHP [308136802] 26.4 percent of total billed charges 20.46 31.35 Technical (Hospital) Services HC/HH Wch Supp Splint Clavicle/Sml__0814-1232 PX-2705000152 CDM 2705000152 LOCAL 270 RC outpatient 33 33 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES EPO [308136803] 26.4 percent of total billed charges 20.46 31.35 Technical (Hospital) Services HC/HH Wch Supp Splint Clavicle/Sml__0814-1232 PX-2705000152 CDM 2705000152 LOCAL 270 RC outpatient 33 33 CIGNA 62308 [3081051] CIGNA 62308 [308105105] 26.4 percent of total billed charges 20.46 31.35 Technical (Hospital) Services HC/HH Wch Supp Splint Clavicle/Sml__0814-1232 PX-2705000152 CDM 2705000152 LOCAL 270 RC outpatient 33 33 CIGNA 62308 [3081051] CIGNA STATE OF WYOMING [308105107] 26.4 percent of total billed charges 20.46 31.35 Technical (Hospital) Services HC/HH Wch Supp Splint Clavicle/Sml__0814-1232 PX-2705000152 CDM 2705000152 LOCAL 270 RC outpatient 33 33 BLUE CROSS BLUE SHIELD WELLMARK SB889 [3081026] BCBS WYOMING [308102603] 31.35 percent of total billed charges 20.46 31.35 Technical (Hospital) Services HC/HH Wch Supp Splint Clavicle/Sml__0814-1232 PX-2705000152 CDM 2705000152 LOCAL 270 RC inpatient 33 33 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES EPO [308136803] 26.13 percent of total billed charges 20.46 31.35 Technical (Hospital) Services HC/HH Wch Supp Splint Clavicle/Sml__0814-1232 PX-2705000152 CDM 2705000152 LOCAL 270 RC inpatient 33 33 HEALTHPARTNERS SX009 HEALTHPARTNERS 26.13 percent of total billed charges 20.46 31.35 Technical (Hospital) Services HC/HH Wch Supp Splint Clavicle/Sml__0814-1232 PX-2705000152 CDM 2705000152 LOCAL 270 RC inpatient 33 33 CIGNA 62308 [3081051] CIGNA 62308 [308105105] 26.13 percent of total billed charges 20.46 31.35 Technical (Hospital) Services HC/HH Wch Supp Splint Clavicle/Sml__0814-1232 PX-2705000152 CDM 2705000152 LOCAL 270 RC inpatient 33 33 CIGNA 62308 [3081051] CIGNA STATE OF WYOMING [308105107] 26.13 percent of total billed charges 20.46 31.35 Technical (Hospital) Services HC/HH Wch Supp Splint Clavicle/Sml__0814-1232 PX-2705000152 CDM 2705000152 LOCAL 270 RC inpatient 33 33 MULTIPLAN INC 34080 [3081285] MULTIPLAN INC [308128501] 31.35 percent of total billed charges 20.46 31.35 Technical (Hospital) Services HC/HH Wch Supp Splint Clavicle/Sml__0814-1232 PX-2705000152 CDM 2705000152 LOCAL 270 RC inpatient 33 33 BLUE CROSS BLUE SHIELD WELLMARK SB889 [3081026] BCBS WYOMING [308102603] 31.35 percent of total billed charges 20.46 31.35 Technical (Hospital) Services HC/HH Wch Supp Splint Clavicle/Sml__0814-1232 PX-2705000152 CDM 2705000152 LOCAL 270 RC inpatient 33 33 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES HDHP [308136802] 26.13 percent of total billed charges 20.46 31.35 Technical (Hospital) Services HC/HH Wch Supp Splint Clavicle/Sml__0814-1232 PX-2705000152 CDM 2705000152 LOCAL 270 RC inpatient 33 33 UNITED HEALTHCARE (COMMERCIAL) [3081199] UNITED HEALTHCARE 87726 [308119901] 20.46 percent of total billed charges 20.46 31.35 Technical (Hospital) Services HC/HH Wch Supp Splint Clavicle/Sml__0814-1232 PX-2705000152 CDM 2705000152 LOCAL 270 RC inpatient 33 33 MEDICA (COMMERCIAL) 94265 [3081118] MEDICA CLAIMS [308111801] 29.7 percent of total billed charges 20.46 31.35 Technical (Hospital) Services HC/HH Wch Supp Splint Clavicle/Sml__0814-1232 PX-2705000152 CDM 2705000152 LOCAL 270 RC inpatient 33 33 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES PPO [308136801] 26.13 percent of total billed charges 20.46 31.35 Technical (Hospital) Services HC/HH Wch Supp Spirometer Incentive__001902a PX-2705000151 CDM 2705000151 LOCAL 270 RC inpatient 28 28 UNITED HEALTHCARE (COMMERCIAL) [3081199] UNITED HEALTHCARE 87726 [308119901] 17.36 percent of total billed charges 17.36 26.6 Technical (Hospital) Services HC/HH Wch Supp Spirometer Incentive__001902a PX-2705000151 CDM 2705000151 LOCAL 270 RC inpatient 28 28 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES HDHP [308136802] 22.17 percent of total billed charges 17.36 26.6 Technical (Hospital) Services HC/HH Wch Supp Spirometer Incentive__001902a PX-2705000151 CDM 2705000151 LOCAL 270 RC inpatient 28 28 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES PPO [308136801] 22.17 percent of total billed charges 17.36 26.6 Technical (Hospital) Services HC/HH Wch Supp Spirometer Incentive__001902a PX-2705000151 CDM 2705000151 LOCAL 270 RC inpatient 28 28 MEDICA (COMMERCIAL) 94265 [3081118] MEDICA CLAIMS [308111801] 25.2 percent of total billed charges 17.36 26.6 Technical (Hospital) Services HC/HH Wch Supp Spirometer Incentive__001902a PX-2705000151 CDM 2705000151 LOCAL 270 RC inpatient 28 28 MULTIPLAN INC 34080 [3081285] MULTIPLAN INC [308128501] 26.6 percent of total billed charges 17.36 26.6 Technical (Hospital) Services HC/HH Wch Supp Spirometer Incentive__001902a PX-2705000151 CDM 2705000151 LOCAL 270 RC inpatient 28 28 BLUE CROSS BLUE SHIELD WELLMARK SB889 [3081026] BCBS WYOMING [308102603] 26.6 percent of total billed charges 17.36 26.6 Technical (Hospital) Services HC/HH Wch Supp Spirometer Incentive__001902a PX-2705000151 CDM 2705000151 LOCAL 270 RC inpatient 28 28 CIGNA 62308 [3081051] CIGNA 62308 [308105105] 22.17 percent of total billed charges 17.36 26.6 Technical (Hospital) Services HC/HH Wch Supp Spirometer Incentive__001902a PX-2705000151 CDM 2705000151 LOCAL 270 RC inpatient 28 28 CIGNA 62308 [3081051] CIGNA STATE OF WYOMING [308105107] 22.17 percent of total billed charges 17.36 26.6 Technical (Hospital) Services HC/HH Wch Supp Spirometer Incentive__001902a PX-2705000151 CDM 2705000151 LOCAL 270 RC inpatient 28 28 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES EPO [308136803] 22.17 percent of total billed charges 17.36 26.6 Technical (Hospital) Services HC/HH Wch Supp Spirometer Incentive__001902a PX-2705000151 CDM 2705000151 LOCAL 270 RC inpatient 28 28 HEALTHPARTNERS SX009 HEALTHPARTNERS 22.17 percent of total billed charges 17.36 26.6 Technical (Hospital) Services HC/HH Wch Supp Spirometer Incentive__001902a PX-2705000151 CDM 2705000151 LOCAL 270 RC outpatient 28 28 CIGNA 62308 [3081051] CIGNA 62308 [308105105] 22.4 percent of total billed charges 17.36 26.6 Technical (Hospital) Services HC/HH Wch Supp Spirometer Incentive__001902a PX-2705000151 CDM 2705000151 LOCAL 270 RC outpatient 28 28 CIGNA 62308 [3081051] CIGNA STATE OF WYOMING [308105107] 22.4 percent of total billed charges 17.36 26.6 Technical (Hospital) Services HC/HH Wch Supp Spirometer Incentive__001902a PX-2705000151 CDM 2705000151 LOCAL 270 RC outpatient 28 28 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES EPO [308136803] 22.4 percent of total billed charges 17.36 26.6 Technical (Hospital) Services HC/HH Wch Supp Spirometer Incentive__001902a PX-2705000151 CDM 2705000151 LOCAL 270 RC outpatient 28 28 BLUE CROSS BLUE SHIELD WELLMARK SB889 [3081026] BCBS WYOMING [308102603] 26.6 percent of total billed charges 17.36 26.6 Technical (Hospital) Services HC/HH Wch Supp Spirometer Incentive__001902a PX-2705000151 CDM 2705000151 LOCAL 270 RC outpatient 28 28 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES HDHP [308136802] 22.4 percent of total billed charges 17.36 26.6 Technical (Hospital) Services HC/HH Wch Supp Spirometer Incentive__001902a PX-2705000151 CDM 2705000151 LOCAL 270 RC outpatient 28 28 UNITED HEALTHCARE (COMMERCIAL) [3081199] UNITED HEALTHCARE 87726 [308119901] 17.36 percent of total billed charges 17.36 26.6 Technical (Hospital) Services HC/HH Wch Supp Spirometer Incentive__001902a PX-2705000151 CDM 2705000151 LOCAL 270 RC outpatient 28 28 HEALTHPARTNERS SX009 HEALTHPARTNERS 22.4 percent of total billed charges 17.36 26.6 Technical (Hospital) Services HC/HH Wch Supp Spirometer Incentive__001902a PX-2705000151 CDM 2705000151 LOCAL 270 RC outpatient 28 28 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES PPO [308136801] 22.4 percent of total billed charges 17.36 26.6 Technical (Hospital) Services HC/HH Wch Supp Spirometer Incentive__001902a PX-2705000151 CDM 2705000151 LOCAL 270 RC outpatient 28 28 MEDICA (COMMERCIAL) 94265 [3081118] MEDICA CLAIMS [308111801] 25.2 percent of total billed charges 17.36 26.6 Technical (Hospital) Services HC/HH Wch Supp Spirometer Incentive__001902a PX-2705000151 CDM 2705000151 LOCAL 270 RC outpatient 28 28 MULTIPLAN INC 34080 [3081285] MULTIPLAN INC [308128501] 26.6 percent of total billed charges 17.36 26.6 Technical (Hospital) Services HC/HH Wch Supp Specimen Trap__8884724500 PX-2705000150 CDM 2705000150 LOCAL 270 RC outpatient 8 8 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES HDHP [308136802] 6.4 percent of total billed charges 4.96 7.6 Technical (Hospital) Services HC/HH Wch Supp Specimen Trap__8884724500 PX-2705000150 CDM 2705000150 LOCAL 270 RC outpatient 8 8 CIGNA 62308 [3081051] CIGNA 62308 [308105105] 6.4 percent of total billed charges 4.96 7.6 Technical (Hospital) Services HC/HH Wch Supp Specimen Trap__8884724500 PX-2705000150 CDM 2705000150 LOCAL 270 RC outpatient 8 8 CIGNA 62308 [3081051] CIGNA STATE OF WYOMING [308105107] 6.4 percent of total billed charges 4.96 7.6 Technical (Hospital) Services HC/HH Wch Supp Specimen Trap__8884724500 PX-2705000150 CDM 2705000150 LOCAL 270 RC outpatient 8 8 BLUE CROSS BLUE SHIELD WELLMARK SB889 [3081026] BCBS WYOMING [308102603] 7.6 percent of total billed charges 4.96 7.6 Technical (Hospital) Services HC/HH Wch Supp Specimen Trap__8884724500 PX-2705000150 CDM 2705000150 LOCAL 270 RC outpatient 8 8 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES EPO [308136803] 6.4 percent of total billed charges 4.96 7.6 Technical (Hospital) Services HC/HH Wch Supp Specimen Trap__8884724500 PX-2705000150 CDM 2705000150 LOCAL 270 RC outpatient 8 8 HEALTHPARTNERS SX009 HEALTHPARTNERS 6.4 percent of total billed charges 4.96 7.6 Technical (Hospital) Services HC/HH Wch Supp Specimen Trap__8884724500 PX-2705000150 CDM 2705000150 LOCAL 270 RC outpatient 8 8 UNITED HEALTHCARE (COMMERCIAL) [3081199] UNITED HEALTHCARE 87726 [308119901] 4.96 percent of total billed charges 4.96 7.6 Technical (Hospital) Services HC/HH Wch Supp Specimen Trap__8884724500 PX-2705000150 CDM 2705000150 LOCAL 270 RC outpatient 8 8 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES PPO [308136801] 6.4 percent of total billed charges 4.96 7.6 Technical (Hospital) Services HC/HH Wch Supp Specimen Trap__8884724500 PX-2705000150 CDM 2705000150 LOCAL 270 RC outpatient 8 8 MULTIPLAN INC 34080 [3081285] MULTIPLAN INC [308128501] 7.6 percent of total billed charges 4.96 7.6 Technical (Hospital) Services HC/HH Wch Supp Specimen Trap__8884724500 PX-2705000150 CDM 2705000150 LOCAL 270 RC outpatient 8 8 MEDICA (COMMERCIAL) 94265 [3081118] MEDICA CLAIMS [308111801] 7.2 percent of total billed charges 4.96 7.6 Technical (Hospital) Services HC/HH Wch Supp Specimen Trap__8884724500 PX-2705000150 CDM 2705000150 LOCAL 270 RC inpatient 8 8 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES EPO [308136803] 6.33 percent of total billed charges 4.96 7.6 Technical (Hospital) Services HC/HH Wch Supp Specimen Trap__8884724500 PX-2705000150 CDM 2705000150 LOCAL 270 RC inpatient 8 8 HEALTHPARTNERS SX009 HEALTHPARTNERS 6.33 percent of total billed charges 4.96 7.6 Technical (Hospital) Services HC/HH Wch Supp Specimen Trap__8884724500 PX-2705000150 CDM 2705000150 LOCAL 270 RC inpatient 8 8 CIGNA 62308 [3081051] CIGNA 62308 [308105105] 6.33 percent of total billed charges 4.96 7.6 Technical (Hospital) Services HC/HH Wch Supp Specimen Trap__8884724500 PX-2705000150 CDM 2705000150 LOCAL 270 RC inpatient 8 8 CIGNA 62308 [3081051] CIGNA STATE OF WYOMING [308105107] 6.33 percent of total billed charges 4.96 7.6 Technical (Hospital) Services HC/HH Wch Supp Specimen Trap__8884724500 PX-2705000150 CDM 2705000150 LOCAL 270 RC inpatient 8 8 MULTIPLAN INC 34080 [3081285] MULTIPLAN INC [308128501] 7.6 percent of total billed charges 4.96 7.6 Technical (Hospital) Services HC/HH Wch Supp Specimen Trap__8884724500 PX-2705000150 CDM 2705000150 LOCAL 270 RC inpatient 8 8 BLUE CROSS BLUE SHIELD WELLMARK SB889 [3081026] BCBS WYOMING [308102603] 7.6 percent of total billed charges 4.96 7.6 Technical (Hospital) Services HC/HH Wch Supp Specimen Trap__8884724500 PX-2705000150 CDM 2705000150 LOCAL 270 RC inpatient 8 8 UNITED HEALTHCARE (COMMERCIAL) [3081199] UNITED HEALTHCARE 87726 [308119901] 4.96 percent of total billed charges 4.96 7.6 Technical (Hospital) Services HC/HH Wch Supp Specimen Trap__8884724500 PX-2705000150 CDM 2705000150 LOCAL 270 RC inpatient 8 8 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES HDHP [308136802] 6.33 percent of total billed charges 4.96 7.6 Technical (Hospital) Services HC/HH Wch Supp Specimen Trap__8884724500 PX-2705000150 CDM 2705000150 LOCAL 270 RC inpatient 8 8 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES PPO [308136801] 6.33 percent of total billed charges 4.96 7.6 Technical (Hospital) Services HC/HH Wch Supp Specimen Trap__8884724500 PX-2705000150 CDM 2705000150 LOCAL 270 RC inpatient 8 8 MEDICA (COMMERCIAL) 94265 [3081118] MEDICA CLAIMS [308111801] 7.2 percent of total billed charges 4.96 7.6 Technical (Hospital) Services HC/HH Wch Supp Sol Cleanser Wound Shur Clens__121253 PX-2705000149 CDM 2705000149 LOCAL 270 RC inpatient 16 16 HEALTHPARTNERS SX009 HEALTHPARTNERS 12.67 percent of total billed charges 9.92 15.2 Technical (Hospital) Services HC/HH Wch Supp Sol Cleanser Wound Shur Clens__121253 PX-2705000149 CDM 2705000149 LOCAL 270 RC inpatient 16 16 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES EPO [308136803] 12.67 percent of total billed charges 9.92 15.2 Technical (Hospital) Services HC/HH Wch Supp Sol Cleanser Wound Shur Clens__121253 PX-2705000149 CDM 2705000149 LOCAL 270 RC inpatient 16 16 BLUE CROSS BLUE SHIELD WELLMARK SB889 [3081026] BCBS WYOMING [308102603] 15.2 percent of total billed charges 9.92 15.2 Technical (Hospital) Services HC/HH Wch Supp Sol Cleanser Wound Shur Clens__121253 PX-2705000149 CDM 2705000149 LOCAL 270 RC inpatient 16 16 MULTIPLAN INC 34080 [3081285] MULTIPLAN INC [308128501] 15.2 percent of total billed charges 9.92 15.2 Technical (Hospital) Services HC/HH Wch Supp Sol Cleanser Wound Shur Clens__121253 PX-2705000149 CDM 2705000149 LOCAL 270 RC inpatient 16 16 CIGNA 62308 [3081051] CIGNA 62308 [308105105] 12.67 percent of total billed charges 9.92 15.2 Technical (Hospital) Services HC/HH Wch Supp Sol Cleanser Wound Shur Clens__121253 PX-2705000149 CDM 2705000149 LOCAL 270 RC inpatient 16 16 CIGNA 62308 [3081051] CIGNA STATE OF WYOMING [308105107] 12.67 percent of total billed charges 9.92 15.2 Technical (Hospital) Services HC/HH Wch Supp Sol Cleanser Wound Shur Clens__121253 PX-2705000149 CDM 2705000149 LOCAL 270 RC inpatient 16 16 MEDICA (COMMERCIAL) 94265 [3081118] MEDICA CLAIMS [308111801] 14.4 percent of total billed charges 9.92 15.2 Technical (Hospital) Services HC/HH Wch Supp Sol Cleanser Wound Shur Clens__121253 PX-2705000149 CDM 2705000149 LOCAL 270 RC inpatient 16 16 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES PPO [308136801] 12.67 percent of total billed charges 9.92 15.2 Technical (Hospital) Services HC/HH Wch Supp Sol Cleanser Wound Shur Clens__121253 PX-2705000149 CDM 2705000149 LOCAL 270 RC inpatient 16 16 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES HDHP [308136802] 12.67 percent of total billed charges 9.92 15.2 Technical (Hospital) Services HC/HH Wch Supp Sol Cleanser Wound Shur Clens__121253 PX-2705000149 CDM 2705000149 LOCAL 270 RC inpatient 16 16 UNITED HEALTHCARE (COMMERCIAL) [3081199] UNITED HEALTHCARE 87726 [308119901] 9.92 percent of total billed charges 9.92 15.2 Technical (Hospital) Services HC/HH Wch Supp Sol Cleanser Wound Shur Clens__121253 PX-2705000149 CDM 2705000149 LOCAL 270 RC outpatient 16 16 BLUE CROSS BLUE SHIELD WELLMARK SB889 [3081026] BCBS WYOMING [308102603] 15.2 percent of total billed charges 9.92 15.2 Technical (Hospital) Services HC/HH Wch Supp Sol Cleanser Wound Shur Clens__121253 PX-2705000149 CDM 2705000149 LOCAL 270 RC outpatient 16 16 CIGNA 62308 [3081051] CIGNA 62308 [308105105] 12.8 percent of total billed charges 9.92 15.2 Technical (Hospital) Services HC/HH Wch Supp Sol Cleanser Wound Shur Clens__121253 PX-2705000149 CDM 2705000149 LOCAL 270 RC outpatient 16 16 CIGNA 62308 [3081051] CIGNA STATE OF WYOMING [308105107] 12.8 percent of total billed charges 9.92 15.2 Technical (Hospital) Services HC/HH Wch Supp Sol Cleanser Wound Shur Clens__121253 PX-2705000149 CDM 2705000149 LOCAL 270 RC outpatient 16 16 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES EPO [308136803] 12.8 percent of total billed charges 9.92 15.2 Technical (Hospital) Services HC/HH Wch Supp Sol Cleanser Wound Shur Clens__121253 PX-2705000149 CDM 2705000149 LOCAL 270 RC outpatient 16 16 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES HDHP [308136802] 12.8 percent of total billed charges 9.92 15.2 Technical (Hospital) Services HC/HH Wch Supp Sol Cleanser Wound Shur Clens__121253 PX-2705000149 CDM 2705000149 LOCAL 270 RC outpatient 16 16 UNITED HEALTHCARE (COMMERCIAL) [3081199] UNITED HEALTHCARE 87726 [308119901] 9.92 percent of total billed charges 9.92 15.2 Technical (Hospital) Services HC/HH Wch Supp Sol Cleanser Wound Shur Clens__121253 PX-2705000149 CDM 2705000149 LOCAL 270 RC outpatient 16 16 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES PPO [308136801] 12.8 percent of total billed charges 9.92 15.2 Technical (Hospital) Services HC/HH Wch Supp Sol Cleanser Wound Shur Clens__121253 PX-2705000149 CDM 2705000149 LOCAL 270 RC outpatient 16 16 HEALTHPARTNERS SX009 HEALTHPARTNERS 12.8 percent of total billed charges 9.92 15.2 Technical (Hospital) Services HC/HH Wch Supp Sol Cleanser Wound Shur Clens__121253 PX-2705000149 CDM 2705000149 LOCAL 270 RC outpatient 16 16 MULTIPLAN INC 34080 [3081285] MULTIPLAN INC [308128501] 15.2 percent of total billed charges 9.92 15.2 Technical (Hospital) Services HC/HH Wch Supp Sol Cleanser Wound Shur Clens__121253 PX-2705000149 CDM 2705000149 LOCAL 270 RC outpatient 16 16 MEDICA (COMMERCIAL) 94265 [3081118] MEDICA CLAIMS [308111801] 14.4 percent of total billed charges 9.92 15.2 Technical (Hospital) Services HC/HH Wch Supp Sol Cleanser Perineal 8oz__324509 PX-2705000148 CDM 2705000148 LOCAL 270 RC outpatient 8 8 HEALTHPARTNERS SX009 HEALTHPARTNERS 6.4 percent of total billed charges 4.96 7.6 Technical (Hospital) Services HC/HH Wch Supp Sol Cleanser Perineal 8oz__324509 PX-2705000148 CDM 2705000148 LOCAL 270 RC outpatient 8 8 UNITED HEALTHCARE (COMMERCIAL) [3081199] UNITED HEALTHCARE 87726 [308119901] 4.96 percent of total billed charges 4.96 7.6 Technical (Hospital) Services HC/HH Wch Supp Sol Cleanser Perineal 8oz__324509 PX-2705000148 CDM 2705000148 LOCAL 270 RC outpatient 8 8 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES HDHP [308136802] 6.4 percent of total billed charges 4.96 7.6 Technical (Hospital) Services HC/HH Wch Supp Sol Cleanser Perineal 8oz__324509 PX-2705000148 CDM 2705000148 LOCAL 270 RC outpatient 8 8 BLUE CROSS BLUE SHIELD WELLMARK SB889 [3081026] BCBS WYOMING [308102603] 7.6 percent of total billed charges 4.96 7.6 Technical (Hospital) Services HC/HH Wch Supp Sol Cleanser Perineal 8oz__324509 PX-2705000148 CDM 2705000148 LOCAL 270 RC outpatient 8 8 CIGNA 62308 [3081051] CIGNA 62308 [308105105] 6.4 percent of total billed charges 4.96 7.6 Technical (Hospital) Services HC/HH Wch Supp Sol Cleanser Perineal 8oz__324509 PX-2705000148 CDM 2705000148 LOCAL 270 RC outpatient 8 8 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES EPO [308136803] 6.4 percent of total billed charges 4.96 7.6 Technical (Hospital) Services HC/HH Wch Supp Sol Cleanser Perineal 8oz__324509 PX-2705000148 CDM 2705000148 LOCAL 270 RC outpatient 8 8 CIGNA 62308 [3081051] CIGNA STATE OF WYOMING [308105107] 6.4 percent of total billed charges 4.96 7.6 Technical (Hospital) Services HC/HH Wch Supp Sol Cleanser Perineal 8oz__324509 PX-2705000148 CDM 2705000148 LOCAL 270 RC outpatient 8 8 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES PPO [308136801] 6.4 percent of total billed charges 4.96 7.6 Technical (Hospital) Services HC/HH Wch Supp Sol Cleanser Perineal 8oz__324509 PX-2705000148 CDM 2705000148 LOCAL 270 RC outpatient 8 8 MEDICA (COMMERCIAL) 94265 [3081118] MEDICA CLAIMS [308111801] 7.2 percent of total billed charges 4.96 7.6 Technical (Hospital) Services HC/HH Wch Supp Sol Cleanser Perineal 8oz__324509 PX-2705000148 CDM 2705000148 LOCAL 270 RC outpatient 8 8 MULTIPLAN INC 34080 [3081285] MULTIPLAN INC [308128501] 7.6 percent of total billed charges 4.96 7.6 Technical (Hospital) Services HC/HH Wch Supp Sol Cleanser Perineal 8oz__324509 PX-2705000148 CDM 2705000148 LOCAL 270 RC inpatient 8 8 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES PPO [308136801] 6.33 percent of total billed charges 4.96 7.6 Technical (Hospital) Services HC/HH Wch Supp Sol Cleanser Perineal 8oz__324509 PX-2705000148 CDM 2705000148 LOCAL 270 RC inpatient 8 8 MEDICA (COMMERCIAL) 94265 [3081118] MEDICA CLAIMS [308111801] 7.2 percent of total billed charges 4.96 7.6 Technical (Hospital) Services HC/HH Wch Supp Sol Cleanser Perineal 8oz__324509 PX-2705000148 CDM 2705000148 LOCAL 270 RC inpatient 8 8 UNITED HEALTHCARE (COMMERCIAL) [3081199] UNITED HEALTHCARE 87726 [308119901] 4.96 percent of total billed charges 4.96 7.6 Technical (Hospital) Services HC/HH Wch Supp Sol Cleanser Perineal 8oz__324509 PX-2705000148 CDM 2705000148 LOCAL 270 RC inpatient 8 8 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES HDHP [308136802] 6.33 percent of total billed charges 4.96 7.6 Technical (Hospital) Services HC/HH Wch Supp Sol Cleanser Perineal 8oz__324509 PX-2705000148 CDM 2705000148 LOCAL 270 RC inpatient 8 8 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES EPO [308136803] 6.33 percent of total billed charges 4.96 7.6 Technical (Hospital) Services HC/HH Wch Supp Sol Cleanser Perineal 8oz__324509 PX-2705000148 CDM 2705000148 LOCAL 270 RC inpatient 8 8 HEALTHPARTNERS SX009 HEALTHPARTNERS 6.33 percent of total billed charges 4.96 7.6 Technical (Hospital) Services HC/HH Wch Supp Sol Cleanser Perineal 8oz__324509 PX-2705000148 CDM 2705000148 LOCAL 270 RC inpatient 8 8 MULTIPLAN INC 34080 [3081285] MULTIPLAN INC [308128501] 7.6 percent of total billed charges 4.96 7.6 Technical (Hospital) Services HC/HH Wch Supp Sol Cleanser Perineal 8oz__324509 PX-2705000148 CDM 2705000148 LOCAL 270 RC inpatient 8 8 BLUE CROSS BLUE SHIELD WELLMARK SB889 [3081026] BCBS WYOMING [308102603] 7.6 percent of total billed charges 4.96 7.6 Technical (Hospital) Services HC/HH Wch Supp Sol Cleanser Perineal 8oz__324509 PX-2705000148 CDM 2705000148 LOCAL 270 RC inpatient 8 8 CIGNA 62308 [3081051] CIGNA 62308 [308105105] 6.33 percent of total billed charges 4.96 7.6 Technical (Hospital) Services HC/HH Wch Supp Sol Cleanser Perineal 8oz__324509 PX-2705000148 CDM 2705000148 LOCAL 270 RC inpatient 8 8 CIGNA 62308 [3081051] CIGNA STATE OF WYOMING [308105107] 6.33 percent of total billed charges 4.96 7.6 Technical (Hospital) Services HC/HH Wch Supp Sm Air Walker__Aw0400 PX-2705000147 CDM 2705000147 LOCAL 270 RC outpatient 175 175 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES HDHP [308136802] 140 percent of total billed charges 108.5 166.25 Technical (Hospital) Services HC/HH Wch Supp Sm Air Walker__Aw0400 PX-2705000147 CDM 2705000147 LOCAL 270 RC outpatient 175 175 BLUE CROSS BLUE SHIELD WELLMARK SB889 [3081026] BCBS WYOMING [308102603] 166.25 percent of total billed charges 108.5 166.25 Technical (Hospital) Services HC/HH Wch Supp Sm Air Walker__Aw0400 PX-2705000147 CDM 2705000147 LOCAL 270 RC outpatient 175 175 CIGNA 62308 [3081051] CIGNA 62308 [308105105] 140 percent of total billed charges 108.5 166.25 Technical (Hospital) Services HC/HH Wch Supp Sm Air Walker__Aw0400 PX-2705000147 CDM 2705000147 LOCAL 270 RC outpatient 175 175 CIGNA 62308 [3081051] CIGNA STATE OF WYOMING [308105107] 140 percent of total billed charges 108.5 166.25 Technical (Hospital) Services HC/HH Wch Supp Sm Air Walker__Aw0400 PX-2705000147 CDM 2705000147 LOCAL 270 RC outpatient 175 175 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES EPO [308136803] 140 percent of total billed charges 108.5 166.25 Technical (Hospital) Services HC/HH Wch Supp Sm Air Walker__Aw0400 PX-2705000147 CDM 2705000147 LOCAL 270 RC outpatient 175 175 HEALTHPARTNERS SX009 HEALTHPARTNERS 140 percent of total billed charges 108.5 166.25 Technical (Hospital) Services HC/HH Wch Supp Sm Air Walker__Aw0400 PX-2705000147 CDM 2705000147 LOCAL 270 RC outpatient 175 175 UNITED HEALTHCARE (COMMERCIAL) [3081199] UNITED HEALTHCARE 87726 [308119901] 108.5 percent of total billed charges 108.5 166.25 Technical (Hospital) Services HC/HH Wch Supp Sm Air Walker__Aw0400 PX-2705000147 CDM 2705000147 LOCAL 270 RC outpatient 175 175 MEDICA (COMMERCIAL) 94265 [3081118] MEDICA CLAIMS [308111801] 157.5 percent of total billed charges 108.5 166.25 Technical (Hospital) Services HC/HH Wch Supp Sm Air Walker__Aw0400 PX-2705000147 CDM 2705000147 LOCAL 270 RC outpatient 175 175 MULTIPLAN INC 34080 [3081285] MULTIPLAN INC [308128501] 166.25 percent of total billed charges 108.5 166.25 Technical (Hospital) Services HC/HH Wch Supp Sm Air Walker__Aw0400 PX-2705000147 CDM 2705000147 LOCAL 270 RC outpatient 175 175 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES PPO [308136801] 140 percent of total billed charges 108.5 166.25 Technical (Hospital) Services HC/HH Wch Supp Sm Air Walker__Aw0400 PX-2705000147 CDM 2705000147 LOCAL 270 RC inpatient 175 175 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES PPO [308136801] 138.57 percent of total billed charges 108.5 166.25 Technical (Hospital) Services HC/HH Wch Supp Sm Air Walker__Aw0400 PX-2705000147 CDM 2705000147 LOCAL 270 RC inpatient 175 175 MEDICA (COMMERCIAL) 94265 [3081118] MEDICA CLAIMS [308111801] 157.5 percent of total billed charges 108.5 166.25 Technical (Hospital) Services HC/HH Wch Supp Sm Air Walker__Aw0400 PX-2705000147 CDM 2705000147 LOCAL 270 RC inpatient 175 175 UNITED HEALTHCARE (COMMERCIAL) [3081199] UNITED HEALTHCARE 87726 [308119901] 108.5 percent of total billed charges 108.5 166.25 Technical (Hospital) Services HC/HH Wch Supp Sm Air Walker__Aw0400 PX-2705000147 CDM 2705000147 LOCAL 270 RC inpatient 175 175 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES HDHP [308136802] 138.57 percent of total billed charges 108.5 166.25 Technical (Hospital) Services HC/HH Wch Supp Sm Air Walker__Aw0400 PX-2705000147 CDM 2705000147 LOCAL 270 RC inpatient 175 175 BLUE CROSS BLUE SHIELD WELLMARK SB889 [3081026] BCBS WYOMING [308102603] 166.25 percent of total billed charges 108.5 166.25 Technical (Hospital) Services HC/HH Wch Supp Sm Air Walker__Aw0400 PX-2705000147 CDM 2705000147 LOCAL 270 RC inpatient 175 175 MULTIPLAN INC 34080 [3081285] MULTIPLAN INC [308128501] 166.25 percent of total billed charges 108.5 166.25 Technical (Hospital) Services HC/HH Wch Supp Sm Air Walker__Aw0400 PX-2705000147 CDM 2705000147 LOCAL 270 RC inpatient 175 175 CIGNA 62308 [3081051] CIGNA 62308 [308105105] 138.57 percent of total billed charges 108.5 166.25 Technical (Hospital) Services HC/HH Wch Supp Sm Air Walker__Aw0400 PX-2705000147 CDM 2705000147 LOCAL 270 RC inpatient 175 175 CIGNA 62308 [3081051] CIGNA STATE OF WYOMING [308105107] 138.57 percent of total billed charges 108.5 166.25 Technical (Hospital) Services HC/HH Wch Supp Sm Air Walker__Aw0400 PX-2705000147 CDM 2705000147 LOCAL 270 RC inpatient 175 175 HEALTHPARTNERS SX009 HEALTHPARTNERS 138.57 percent of total billed charges 108.5 166.25 Technical (Hospital) Services HC/HH Wch Supp Sm Air Walker__Aw0400 PX-2705000147 CDM 2705000147 LOCAL 270 RC inpatient 175 175 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES EPO [308136803] 138.57 percent of total billed charges 108.5 166.25 Technical (Hospital) Services HC/HH Wch Supp Slippers Medium__80103 PX-2705000146 CDM 2705000146 LOCAL 270 RC outpatient 6 6 HEALTHPARTNERS SX009 HEALTHPARTNERS 4.8 percent of total billed charges 3.72 5.7 Technical (Hospital) Services HC/HH Wch Supp Slippers Medium__80103 PX-2705000146 CDM 2705000146 LOCAL 270 RC outpatient 6 6 UNITED HEALTHCARE (COMMERCIAL) [3081199] UNITED HEALTHCARE 87726 [308119901] 3.72 percent of total billed charges 3.72 5.7 Technical (Hospital) Services HC/HH Wch Supp Slippers Medium__80103 PX-2705000146 CDM 2705000146 LOCAL 270 RC outpatient 6 6 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES PPO [308136801] 4.8 percent of total billed charges 3.72 5.7 Technical (Hospital) Services HC/HH Wch Supp Slippers Medium__80103 PX-2705000146 CDM 2705000146 LOCAL 270 RC outpatient 6 6 CIGNA 62308 [3081051] CIGNA 62308 [308105105] 4.8 percent of total billed charges 3.72 5.7 Technical (Hospital) Services HC/HH Wch Supp Slippers Medium__80103 PX-2705000146 CDM 2705000146 LOCAL 270 RC outpatient 6 6 CIGNA 62308 [3081051] CIGNA STATE OF WYOMING [308105107] 4.8 percent of total billed charges 3.72 5.7 Technical (Hospital) Services HC/HH Wch Supp Slippers Medium__80103 PX-2705000146 CDM 2705000146 LOCAL 270 RC outpatient 6 6 BLUE CROSS BLUE SHIELD WELLMARK SB889 [3081026] BCBS WYOMING [308102603] 5.7 percent of total billed charges 3.72 5.7 Technical (Hospital) Services HC/HH Wch Supp Slippers Medium__80103 PX-2705000146 CDM 2705000146 LOCAL 270 RC outpatient 6 6 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES EPO [308136803] 4.8 percent of total billed charges 3.72 5.7 Technical (Hospital) Services HC/HH Wch Supp Slippers Medium__80103 PX-2705000146 CDM 2705000146 LOCAL 270 RC outpatient 6 6 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES HDHP [308136802] 4.8 percent of total billed charges 3.72 5.7 Technical (Hospital) Services HC/HH Wch Supp Slippers Medium__80103 PX-2705000146 CDM 2705000146 LOCAL 270 RC outpatient 6 6 MEDICA (COMMERCIAL) 94265 [3081118] MEDICA CLAIMS [308111801] 5.4 percent of total billed charges 3.72 5.7 Technical (Hospital) Services HC/HH Wch Supp Slippers Medium__80103 PX-2705000146 CDM 2705000146 LOCAL 270 RC outpatient 6 6 MULTIPLAN INC 34080 [3081285] MULTIPLAN INC [308128501] 5.7 percent of total billed charges 3.72 5.7 Technical (Hospital) Services HC/HH Wch Supp Slippers Medium__80103 PX-2705000146 CDM 2705000146 LOCAL 270 RC inpatient 6 6 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES PPO [308136801] 4.75 percent of total billed charges 3.72 5.7 Technical (Hospital) Services HC/HH Wch Supp Slippers Medium__80103 PX-2705000146 CDM 2705000146 LOCAL 270 RC inpatient 6 6 MEDICA (COMMERCIAL) 94265 [3081118] MEDICA CLAIMS [308111801] 5.4 percent of total billed charges 3.72 5.7 Technical (Hospital) Services HC/HH Wch Supp Slippers Medium__80103 PX-2705000146 CDM 2705000146 LOCAL 270 RC inpatient 6 6 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES HDHP [308136802] 4.75 percent of total billed charges 3.72 5.7 Technical (Hospital) Services HC/HH Wch Supp Slippers Medium__80103 PX-2705000146 CDM 2705000146 LOCAL 270 RC inpatient 6 6 UNITED HEALTHCARE (COMMERCIAL) [3081199] UNITED HEALTHCARE 87726 [308119901] 3.72 percent of total billed charges 3.72 5.7 Technical (Hospital) Services HC/HH Wch Supp Slippers Medium__80103 PX-2705000146 CDM 2705000146 LOCAL 270 RC inpatient 6 6 MULTIPLAN INC 34080 [3081285] MULTIPLAN INC [308128501] 5.7 percent of total billed charges 3.72 5.7 Technical (Hospital) Services HC/HH Wch Supp Slippers Medium__80103 PX-2705000146 CDM 2705000146 LOCAL 270 RC inpatient 6 6 BLUE CROSS BLUE SHIELD WELLMARK SB889 [3081026] BCBS WYOMING [308102603] 5.7 percent of total billed charges 3.72 5.7 Technical (Hospital) Services HC/HH Wch Supp Slippers Medium__80103 PX-2705000146 CDM 2705000146 LOCAL 270 RC inpatient 6 6 CIGNA 62308 [3081051] CIGNA 62308 [308105105] 4.75 percent of total billed charges 3.72 5.7 Technical (Hospital) Services HC/HH Wch Supp Slippers Medium__80103 PX-2705000146 CDM 2705000146 LOCAL 270 RC inpatient 6 6 CIGNA 62308 [3081051] CIGNA STATE OF WYOMING [308105107] 4.75 percent of total billed charges 3.72 5.7 Technical (Hospital) Services HC/HH Wch Supp Slippers Medium__80103 PX-2705000146 CDM 2705000146 LOCAL 270 RC inpatient 6 6 HEALTHPARTNERS SX009 HEALTHPARTNERS 4.75 percent of total billed charges 3.72 5.7 Technical (Hospital) Services HC/HH Wch Supp Slippers Medium__80103 PX-2705000146 CDM 2705000146 LOCAL 270 RC inpatient 6 6 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES EPO [308136803] 4.75 percent of total billed charges 3.72 5.7 Technical (Hospital) Services HC/HH Wch Supp Sling Arm W/Foam Med Adult__08141063 PX-2705000145 CDM 2705000145 LOCAL 270 RC outpatient 33 33 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES PPO [308136801] 26.4 percent of total billed charges 20.46 31.35 Technical (Hospital) Services HC/HH Wch Supp Sling Arm W/Foam Med Adult__08141063 PX-2705000145 CDM 2705000145 LOCAL 270 RC outpatient 33 33 MULTIPLAN INC 34080 [3081285] MULTIPLAN INC [308128501] 31.35 percent of total billed charges 20.46 31.35 Technical (Hospital) Services HC/HH Wch Supp Sling Arm W/Foam Med Adult__08141063 PX-2705000145 CDM 2705000145 LOCAL 270 RC outpatient 33 33 MEDICA (COMMERCIAL) 94265 [3081118] MEDICA CLAIMS [308111801] 29.7 percent of total billed charges 20.46 31.35 Technical (Hospital) Services HC/HH Wch Supp Sling Arm W/Foam Med Adult__08141063 PX-2705000145 CDM 2705000145 LOCAL 270 RC outpatient 33 33 UNITED HEALTHCARE (COMMERCIAL) [3081199] UNITED HEALTHCARE 87726 [308119901] 20.46 percent of total billed charges 20.46 31.35 Technical (Hospital) Services HC/HH Wch Supp Sling Arm W/Foam Med Adult__08141063 PX-2705000145 CDM 2705000145 LOCAL 270 RC outpatient 33 33 HEALTHPARTNERS SX009 HEALTHPARTNERS 26.4 percent of total billed charges 20.46 31.35 Technical (Hospital) Services HC/HH Wch Supp Sling Arm W/Foam Med Adult__08141063 PX-2705000145 CDM 2705000145 LOCAL 270 RC outpatient 33 33 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES EPO [308136803] 26.4 percent of total billed charges 20.46 31.35 Technical (Hospital) Services HC/HH Wch Supp Sling Arm W/Foam Med Adult__08141063 PX-2705000145 CDM 2705000145 LOCAL 270 RC outpatient 33 33 CIGNA 62308 [3081051] CIGNA 62308 [308105105] 26.4 percent of total billed charges 20.46 31.35 Technical (Hospital) Services HC/HH Wch Supp Sling Arm W/Foam Med Adult__08141063 PX-2705000145 CDM 2705000145 LOCAL 270 RC outpatient 33 33 CIGNA 62308 [3081051] CIGNA STATE OF WYOMING [308105107] 26.4 percent of total billed charges 20.46 31.35 Technical (Hospital) Services HC/HH Wch Supp Sling Arm W/Foam Med Adult__08141063 PX-2705000145 CDM 2705000145 LOCAL 270 RC outpatient 33 33 BLUE CROSS BLUE SHIELD WELLMARK SB889 [3081026] BCBS WYOMING [308102603] 31.35 percent of total billed charges 20.46 31.35 Technical (Hospital) Services HC/HH Wch Supp Sling Arm W/Foam Med Adult__08141063 PX-2705000145 CDM 2705000145 LOCAL 270 RC outpatient 33 33 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES HDHP [308136802] 26.4 percent of total billed charges 20.46 31.35 Technical (Hospital) Services HC/HH Wch Supp Sling Arm W/Foam Med Adult__08141063 PX-2705000145 CDM 2705000145 LOCAL 270 RC inpatient 33 33 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES EPO [308136803] 26.13 percent of total billed charges 20.46 31.35 Technical (Hospital) Services HC/HH Wch Supp Sling Arm W/Foam Med Adult__08141063 PX-2705000145 CDM 2705000145 LOCAL 270 RC inpatient 33 33 HEALTHPARTNERS SX009 HEALTHPARTNERS 26.13 percent of total billed charges 20.46 31.35 Technical (Hospital) Services HC/HH Wch Supp Sling Arm W/Foam Med Adult__08141063 PX-2705000145 CDM 2705000145 LOCAL 270 RC inpatient 33 33 CIGNA 62308 [3081051] CIGNA 62308 [308105105] 26.13 percent of total billed charges 20.46 31.35 Technical (Hospital) Services HC/HH Wch Supp Sling Arm W/Foam Med Adult__08141063 PX-2705000145 CDM 2705000145 LOCAL 270 RC inpatient 33 33 CIGNA 62308 [3081051] CIGNA STATE OF WYOMING [308105107] 26.13 percent of total billed charges 20.46 31.35 Technical (Hospital) Services HC/HH Wch Supp Sling Arm W/Foam Med Adult__08141063 PX-2705000145 CDM 2705000145 LOCAL 270 RC inpatient 33 33 BLUE CROSS BLUE SHIELD WELLMARK SB889 [3081026] BCBS WYOMING [308102603] 31.35 percent of total billed charges 20.46 31.35 Technical (Hospital) Services HC/HH Wch Supp Sling Arm W/Foam Med Adult__08141063 PX-2705000145 CDM 2705000145 LOCAL 270 RC inpatient 33 33 MULTIPLAN INC 34080 [3081285] MULTIPLAN INC [308128501] 31.35 percent of total billed charges 20.46 31.35 Technical (Hospital) Services HC/HH Wch Supp Sling Arm W/Foam Med Adult__08141063 PX-2705000145 CDM 2705000145 LOCAL 270 RC inpatient 33 33 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES HDHP [308136802] 26.13 percent of total billed charges 20.46 31.35 Technical (Hospital) Services HC/HH Wch Supp Sling Arm W/Foam Med Adult__08141063 PX-2705000145 CDM 2705000145 LOCAL 270 RC inpatient 33 33 MEDICA (COMMERCIAL) 94265 [3081118] MEDICA CLAIMS [308111801] 29.7 percent of total billed charges 20.46 31.35 Technical (Hospital) Services HC/HH Wch Supp Sling Arm W/Foam Med Adult__08141063 PX-2705000145 CDM 2705000145 LOCAL 270 RC inpatient 33 33 UNITED HEALTHCARE (COMMERCIAL) [3081199] UNITED HEALTHCARE 87726 [308119901] 20.46 percent of total billed charges 20.46 31.35 Technical (Hospital) Services HC/HH Wch Supp Sling Arm W/Foam Med Adult__08141063 PX-2705000145 CDM 2705000145 LOCAL 270 RC inpatient 33 33 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES PPO [308136801] 26.13 percent of total billed charges 20.46 31.35 Technical (Hospital) Services HC/HH Wch Supp Sling Arm W/Foam Large__8141064 PX-2705000144 CDM 2705000144 LOCAL 270 RC inpatient 30 30 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES PPO [308136801] 23.75 percent of total billed charges 18.6 28.5 Technical (Hospital) Services HC/HH Wch Supp Sling Arm W/Foam Large__8141064 PX-2705000144 CDM 2705000144 LOCAL 270 RC inpatient 30 30 MEDICA (COMMERCIAL) 94265 [3081118] MEDICA CLAIMS [308111801] 27 percent of total billed charges 18.6 28.5 Technical (Hospital) Services HC/HH Wch Supp Sling Arm W/Foam Large__8141064 PX-2705000144 CDM 2705000144 LOCAL 270 RC inpatient 30 30 UNITED HEALTHCARE (COMMERCIAL) [3081199] UNITED HEALTHCARE 87726 [308119901] 18.6 percent of total billed charges 18.6 28.5 Technical (Hospital) Services HC/HH Wch Supp Sling Arm W/Foam Large__8141064 PX-2705000144 CDM 2705000144 LOCAL 270 RC inpatient 30 30 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES HDHP [308136802] 23.75 percent of total billed charges 18.6 28.5 Technical (Hospital) Services HC/HH Wch Supp Sling Arm W/Foam Large__8141064 PX-2705000144 CDM 2705000144 LOCAL 270 RC inpatient 30 30 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES EPO [308136803] 23.75 percent of total billed charges 18.6 28.5 Technical (Hospital) Services HC/HH Wch Supp Sling Arm W/Foam Large__8141064 PX-2705000144 CDM 2705000144 LOCAL 270 RC inpatient 30 30 HEALTHPARTNERS SX009 HEALTHPARTNERS 23.75 percent of total billed charges 18.6 28.5 Technical (Hospital) Services HC/HH Wch Supp Sling Arm W/Foam Large__8141064 PX-2705000144 CDM 2705000144 LOCAL 270 RC inpatient 30 30 BLUE CROSS BLUE SHIELD WELLMARK SB889 [3081026] BCBS WYOMING [308102603] 28.5 percent of total billed charges 18.6 28.5 Technical (Hospital) Services HC/HH Wch Supp Sling Arm W/Foam Large__8141064 PX-2705000144 CDM 2705000144 LOCAL 270 RC inpatient 30 30 CIGNA 62308 [3081051] CIGNA 62308 [308105105] 23.75 percent of total billed charges 18.6 28.5 Technical (Hospital) Services HC/HH Wch Supp Sling Arm W/Foam Large__8141064 PX-2705000144 CDM 2705000144 LOCAL 270 RC inpatient 30 30 CIGNA 62308 [3081051] CIGNA STATE OF WYOMING [308105107] 23.75 percent of total billed charges 18.6 28.5 Technical (Hospital) Services HC/HH Wch Supp Sling Arm W/Foam Large__8141064 PX-2705000144 CDM 2705000144 LOCAL 270 RC inpatient 30 30 MULTIPLAN INC 34080 [3081285] MULTIPLAN INC [308128501] 28.5 percent of total billed charges 18.6 28.5 Technical (Hospital) Services HC/HH Wch Supp Sling Arm W/Foam Large__8141064 PX-2705000144 CDM 2705000144 LOCAL 270 RC outpatient 30 30 CIGNA 62308 [3081051] CIGNA 62308 [308105105] 24 percent of total billed charges 18.6 28.5 Technical (Hospital) Services HC/HH Wch Supp Sling Arm W/Foam Large__8141064 PX-2705000144 CDM 2705000144 LOCAL 270 RC outpatient 30 30 CIGNA 62308 [3081051] CIGNA STATE OF WYOMING [308105107] 24 percent of total billed charges 18.6 28.5 Technical (Hospital) Services HC/HH Wch Supp Sling Arm W/Foam Large__8141064 PX-2705000144 CDM 2705000144 LOCAL 270 RC outpatient 30 30 BLUE CROSS BLUE SHIELD WELLMARK SB889 [3081026] BCBS WYOMING [308102603] 28.5 percent of total billed charges 18.6 28.5 Technical (Hospital) Services HC/HH Wch Supp Sling Arm W/Foam Large__8141064 PX-2705000144 CDM 2705000144 LOCAL 270 RC outpatient 30 30 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES EPO [308136803] 24 percent of total billed charges 18.6 28.5 Technical (Hospital) Services HC/HH Wch Supp Sling Arm W/Foam Large__8141064 PX-2705000144 CDM 2705000144 LOCAL 270 RC outpatient 30 30 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES HDHP [308136802] 24 percent of total billed charges 18.6 28.5 Technical (Hospital) Services HC/HH Wch Supp Sling Arm W/Foam Large__8141064 PX-2705000144 CDM 2705000144 LOCAL 270 RC outpatient 30 30 HEALTHPARTNERS SX009 HEALTHPARTNERS 24 percent of total billed charges 18.6 28.5 Technical (Hospital) Services HC/HH Wch Supp Sling Arm W/Foam Large__8141064 PX-2705000144 CDM 2705000144 LOCAL 270 RC outpatient 30 30 UNITED HEALTHCARE (COMMERCIAL) [3081199] UNITED HEALTHCARE 87726 [308119901] 18.6 percent of total billed charges 18.6 28.5 Technical (Hospital) Services HC/HH Wch Supp Sling Arm W/Foam Large__8141064 PX-2705000144 CDM 2705000144 LOCAL 270 RC outpatient 30 30 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES PPO [308136801] 24 percent of total billed charges 18.6 28.5 Technical (Hospital) Services HC/HH Wch Supp Sling Arm W/Foam Large__8141064 PX-2705000144 CDM 2705000144 LOCAL 270 RC outpatient 30 30 MULTIPLAN INC 34080 [3081285] MULTIPLAN INC [308128501] 28.5 percent of total billed charges 18.6 28.5 Technical (Hospital) Services HC/HH Wch Supp Sling Arm W/Foam Large__8141064 PX-2705000144 CDM 2705000144 LOCAL 270 RC outpatient 30 30 MEDICA (COMMERCIAL) 94265 [3081118] MEDICA CLAIMS [308111801] 27 percent of total billed charges 18.6 28.5 Technical (Hospital) Services HC/HH Wch Supp Sling Arm Universal Envelope__0814-0015 PX-2705000143 CDM 2705000143 LOCAL 270 RC outpatient 32 32 MULTIPLAN INC 34080 [3081285] MULTIPLAN INC [308128501] 30.4 percent of total billed charges 19.84 30.4 Technical (Hospital) Services HC/HH Wch Supp Sling Arm Universal Envelope__0814-0015 PX-2705000143 CDM 2705000143 LOCAL 270 RC outpatient 32 32 MEDICA (COMMERCIAL) 94265 [3081118] MEDICA CLAIMS [308111801] 28.8 percent of total billed charges 19.84 30.4 Technical (Hospital) Services HC/HH Wch Supp Sling Arm Universal Envelope__0814-0015 PX-2705000143 CDM 2705000143 LOCAL 270 RC outpatient 32 32 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES PPO [308136801] 25.6 percent of total billed charges 19.84 30.4 Technical (Hospital) Services HC/HH Wch Supp Sling Arm Universal Envelope__0814-0015 PX-2705000143 CDM 2705000143 LOCAL 270 RC outpatient 32 32 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES EPO [308136803] 25.6 percent of total billed charges 19.84 30.4 Technical (Hospital) Services HC/HH Wch Supp Sling Arm Universal Envelope__0814-0015 PX-2705000143 CDM 2705000143 LOCAL 270 RC outpatient 32 32 CIGNA 62308 [3081051] CIGNA 62308 [308105105] 25.6 percent of total billed charges 19.84 30.4 Technical (Hospital) Services HC/HH Wch Supp Sling Arm Universal Envelope__0814-0015 PX-2705000143 CDM 2705000143 LOCAL 270 RC outpatient 32 32 CIGNA 62308 [3081051] CIGNA STATE OF WYOMING [308105107] 25.6 percent of total billed charges 19.84 30.4 Technical (Hospital) Services HC/HH Wch Supp Sling Arm Universal Envelope__0814-0015 PX-2705000143 CDM 2705000143 LOCAL 270 RC outpatient 32 32 BLUE CROSS BLUE SHIELD WELLMARK SB889 [3081026] BCBS WYOMING [308102603] 30.4 percent of total billed charges 19.84 30.4 Technical (Hospital) Services HC/HH Wch Supp Sling Arm Universal Envelope__0814-0015 PX-2705000143 CDM 2705000143 LOCAL 270 RC outpatient 32 32 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES HDHP [308136802] 25.6 percent of total billed charges 19.84 30.4 Technical (Hospital) Services HC/HH Wch Supp Sling Arm Universal Envelope__0814-0015 PX-2705000143 CDM 2705000143 LOCAL 270 RC outpatient 32 32 UNITED HEALTHCARE (COMMERCIAL) [3081199] UNITED HEALTHCARE 87726 [308119901] 19.84 percent of total billed charges 19.84 30.4 Technical (Hospital) Services HC/HH Wch Supp Sling Arm Universal Envelope__0814-0015 PX-2705000143 CDM 2705000143 LOCAL 270 RC outpatient 32 32 HEALTHPARTNERS SX009 HEALTHPARTNERS 25.6 percent of total billed charges 19.84 30.4 Technical (Hospital) Services HC/HH Wch Supp Sling Arm Universal Envelope__0814-0015 PX-2705000143 CDM 2705000143 LOCAL 270 RC inpatient 32 32 BLUE CROSS BLUE SHIELD WELLMARK SB889 [3081026] BCBS WYOMING [308102603] 30.4 percent of total billed charges 19.84 30.4 Technical (Hospital) Services HC/HH Wch Supp Sling Arm Universal Envelope__0814-0015 PX-2705000143 CDM 2705000143 LOCAL 270 RC inpatient 32 32 MULTIPLAN INC 34080 [3081285] MULTIPLAN INC [308128501] 30.4 percent of total billed charges 19.84 30.4 Technical (Hospital) Services HC/HH Wch Supp Sling Arm Universal Envelope__0814-0015 PX-2705000143 CDM 2705000143 LOCAL 270 RC inpatient 32 32 CIGNA 62308 [3081051] CIGNA 62308 [308105105] 25.34 percent of total billed charges 19.84 30.4 Technical (Hospital) Services HC/HH Wch Supp Sling Arm Universal Envelope__0814-0015 PX-2705000143 CDM 2705000143 LOCAL 270 RC inpatient 32 32 CIGNA 62308 [3081051] CIGNA STATE OF WYOMING [308105107] 25.34 percent of total billed charges 19.84 30.4 Technical (Hospital) Services HC/HH Wch Supp Sling Arm Universal Envelope__0814-0015 PX-2705000143 CDM 2705000143 LOCAL 270 RC inpatient 32 32 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES EPO [308136803] 25.34 percent of total billed charges 19.84 30.4 Technical (Hospital) Services HC/HH Wch Supp Sling Arm Universal Envelope__0814-0015 PX-2705000143 CDM 2705000143 LOCAL 270 RC inpatient 32 32 HEALTHPARTNERS SX009 HEALTHPARTNERS 25.34 percent of total billed charges 19.84 30.4 Technical (Hospital) Services HC/HH Wch Supp Sling Arm Universal Envelope__0814-0015 PX-2705000143 CDM 2705000143 LOCAL 270 RC inpatient 32 32 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES PPO [308136801] 25.34 percent of total billed charges 19.84 30.4 Technical (Hospital) Services HC/HH Wch Supp Sling Arm Universal Envelope__0814-0015 PX-2705000143 CDM 2705000143 LOCAL 270 RC inpatient 32 32 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES HDHP [308136802] 25.34 percent of total billed charges 19.84 30.4 Technical (Hospital) Services HC/HH Wch Supp Sling Arm Universal Envelope__0814-0015 PX-2705000143 CDM 2705000143 LOCAL 270 RC inpatient 32 32 MEDICA (COMMERCIAL) 94265 [3081118] MEDICA CLAIMS [308111801] 28.8 percent of total billed charges 19.84 30.4 Technical (Hospital) Services HC/HH Wch Supp Sling Arm Universal Envelope__0814-0015 PX-2705000143 CDM 2705000143 LOCAL 270 RC inpatient 32 32 UNITED HEALTHCARE (COMMERCIAL) [3081199] UNITED HEALTHCARE 87726 [308119901] 19.84 percent of total billed charges 19.84 30.4 Technical (Hospital) Services HC/HH Wch Supp Sling Arm Peds Xs__0814-0061 PX-2705000142 CDM 2705000142 LOCAL 270 RC inpatient 30 30 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES EPO [308136803] 23.75 percent of total billed charges 18.6 28.5 Technical (Hospital) Services HC/HH Wch Supp Sling Arm Peds Xs__0814-0061 PX-2705000142 CDM 2705000142 LOCAL 270 RC inpatient 30 30 HEALTHPARTNERS SX009 HEALTHPARTNERS 23.75 percent of total billed charges 18.6 28.5 Technical (Hospital) Services HC/HH Wch Supp Sling Arm Peds Xs__0814-0061 PX-2705000142 CDM 2705000142 LOCAL 270 RC inpatient 30 30 MULTIPLAN INC 34080 [3081285] MULTIPLAN INC [308128501] 28.5 percent of total billed charges 18.6 28.5 Technical (Hospital) Services HC/HH Wch Supp Sling Arm Peds Xs__0814-0061 PX-2705000142 CDM 2705000142 LOCAL 270 RC inpatient 30 30 BLUE CROSS BLUE SHIELD WELLMARK SB889 [3081026] BCBS WYOMING [308102603] 28.5 percent of total billed charges 18.6 28.5 Technical (Hospital) Services HC/HH Wch Supp Sling Arm Peds Xs__0814-0061 PX-2705000142 CDM 2705000142 LOCAL 270 RC inpatient 30 30 CIGNA 62308 [3081051] CIGNA 62308 [308105105] 23.75 percent of total billed charges 18.6 28.5 Technical (Hospital) Services HC/HH Wch Supp Sling Arm Peds Xs__0814-0061 PX-2705000142 CDM 2705000142 LOCAL 270 RC inpatient 30 30 CIGNA 62308 [3081051] CIGNA STATE OF WYOMING [308105107] 23.75 percent of total billed charges 18.6 28.5 Technical (Hospital) Services HC/HH Wch Supp Sling Arm Peds Xs__0814-0061 PX-2705000142 CDM 2705000142 LOCAL 270 RC inpatient 30 30 UNITED HEALTHCARE (COMMERCIAL) [3081199] UNITED HEALTHCARE 87726 [308119901] 18.6 percent of total billed charges 18.6 28.5 Technical (Hospital) Services HC/HH Wch Supp Sling Arm Peds Xs__0814-0061 PX-2705000142 CDM 2705000142 LOCAL 270 RC inpatient 30 30 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES HDHP [308136802] 23.75 percent of total billed charges 18.6 28.5 Technical (Hospital) Services HC/HH Wch Supp Sling Arm Peds Xs__0814-0061 PX-2705000142 CDM 2705000142 LOCAL 270 RC inpatient 30 30 MEDICA (COMMERCIAL) 94265 [3081118] MEDICA CLAIMS [308111801] 27 percent of total billed charges 18.6 28.5 Technical (Hospital) Services HC/HH Wch Supp Sling Arm Peds Xs__0814-0061 PX-2705000142 CDM 2705000142 LOCAL 270 RC inpatient 30 30 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES PPO [308136801] 23.75 percent of total billed charges 18.6 28.5 Technical (Hospital) Services HC/HH Wch Supp Sling Arm Peds Xs__0814-0061 PX-2705000142 CDM 2705000142 LOCAL 270 RC outpatient 30 30 HEALTHPARTNERS SX009 HEALTHPARTNERS 24 percent of total billed charges 18.6 28.5 Technical (Hospital) Services HC/HH Wch Supp Sling Arm Peds Xs__0814-0061 PX-2705000142 CDM 2705000142 LOCAL 270 RC outpatient 30 30 UNITED HEALTHCARE (COMMERCIAL) [3081199] UNITED HEALTHCARE 87726 [308119901] 18.6 percent of total billed charges 18.6 28.5 Technical (Hospital) Services HC/HH Wch Supp Sling Arm Peds Xs__0814-0061 PX-2705000142 CDM 2705000142 LOCAL 270 RC outpatient 30 30 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES HDHP [308136802] 24 percent of total billed charges 18.6 28.5 Technical (Hospital) Services HC/HH Wch Supp Sling Arm Peds Xs__0814-0061 PX-2705000142 CDM 2705000142 LOCAL 270 RC outpatient 30 30 BLUE CROSS BLUE SHIELD WELLMARK SB889 [3081026] BCBS WYOMING [308102603] 28.5 percent of total billed charges 18.6 28.5 Technical (Hospital) Services HC/HH Wch Supp Sling Arm Peds Xs__0814-0061 PX-2705000142 CDM 2705000142 LOCAL 270 RC outpatient 30 30 CIGNA 62308 [3081051] CIGNA 62308 [308105105] 24 percent of total billed charges 18.6 28.5 Technical (Hospital) Services HC/HH Wch Supp Sling Arm Peds Xs__0814-0061 PX-2705000142 CDM 2705000142 LOCAL 270 RC outpatient 30 30 CIGNA 62308 [3081051] CIGNA STATE OF WYOMING [308105107] 24 percent of total billed charges 18.6 28.5 Technical (Hospital) Services HC/HH Wch Supp Sling Arm Peds Xs__0814-0061 PX-2705000142 CDM 2705000142 LOCAL 270 RC outpatient 30 30 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES EPO [308136803] 24 percent of total billed charges 18.6 28.5 Technical (Hospital) Services HC/HH Wch Supp Sling Arm Peds Xs__0814-0061 PX-2705000142 CDM 2705000142 LOCAL 270 RC outpatient 30 30 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES PPO [308136801] 24 percent of total billed charges 18.6 28.5 Technical (Hospital) Services HC/HH Wch Supp Sling Arm Peds Xs__0814-0061 PX-2705000142 CDM 2705000142 LOCAL 270 RC outpatient 30 30 MEDICA (COMMERCIAL) 94265 [3081118] MEDICA CLAIMS [308111801] 27 percent of total billed charges 18.6 28.5 Technical (Hospital) Services HC/HH Wch Supp Sling Arm Peds Xs__0814-0061 PX-2705000142 CDM 2705000142 LOCAL 270 RC outpatient 30 30 MULTIPLAN INC 34080 [3081285] MULTIPLAN INC [308128501] 28.5 percent of total billed charges 18.6 28.5 Technical (Hospital) Services HC/HH Wch Supp Sling Arm Adult Xl__8140065 PX-2705000141 CDM 2705000141 LOCAL 270 RC inpatient 30 30 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES PPO [308136801] 23.75 percent of total billed charges 18.6 28.5 Technical (Hospital) Services HC/HH Wch Supp Sling Arm Adult Xl__8140065 PX-2705000141 CDM 2705000141 LOCAL 270 RC inpatient 30 30 MEDICA (COMMERCIAL) 94265 [3081118] MEDICA CLAIMS [308111801] 27 percent of total billed charges 18.6 28.5 Technical (Hospital) Services HC/HH Wch Supp Sling Arm Adult Xl__8140065 PX-2705000141 CDM 2705000141 LOCAL 270 RC inpatient 30 30 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES HDHP [308136802] 23.75 percent of total billed charges 18.6 28.5 Technical (Hospital) Services HC/HH Wch Supp Sling Arm Adult Xl__8140065 PX-2705000141 CDM 2705000141 LOCAL 270 RC inpatient 30 30 UNITED HEALTHCARE (COMMERCIAL) [3081199] UNITED HEALTHCARE 87726 [308119901] 18.6 percent of total billed charges 18.6 28.5 Technical (Hospital) Services HC/HH Wch Supp Sling Arm Adult Xl__8140065 PX-2705000141 CDM 2705000141 LOCAL 270 RC inpatient 30 30 HEALTHPARTNERS SX009 HEALTHPARTNERS 23.75 percent of total billed charges 18.6 28.5 Technical (Hospital) Services HC/HH Wch Supp Sling Arm Adult Xl__8140065 PX-2705000141 CDM 2705000141 LOCAL 270 RC inpatient 30 30 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES EPO [308136803] 23.75 percent of total billed charges 18.6 28.5 Technical (Hospital) Services HC/HH Wch Supp Sling Arm Adult Xl__8140065 PX-2705000141 CDM 2705000141 LOCAL 270 RC inpatient 30 30 BLUE CROSS BLUE SHIELD WELLMARK SB889 [3081026] BCBS WYOMING [308102603] 28.5 percent of total billed charges 18.6 28.5 Technical (Hospital) Services HC/HH Wch Supp Sling Arm Adult Xl__8140065 PX-2705000141 CDM 2705000141 LOCAL 270 RC inpatient 30 30 MULTIPLAN INC 34080 [3081285] MULTIPLAN INC [308128501] 28.5 percent of total billed charges 18.6 28.5 Technical (Hospital) Services HC/HH Wch Supp Sling Arm Adult Xl__8140065 PX-2705000141 CDM 2705000141 LOCAL 270 RC inpatient 30 30 CIGNA 62308 [3081051] CIGNA 62308 [308105105] 23.75 percent of total billed charges 18.6 28.5 Technical (Hospital) Services HC/HH Wch Supp Sling Arm Adult Xl__8140065 PX-2705000141 CDM 2705000141 LOCAL 270 RC inpatient 30 30 CIGNA 62308 [3081051] CIGNA STATE OF WYOMING [308105107] 23.75 percent of total billed charges 18.6 28.5 Technical (Hospital) Services HC/HH Wch Supp Sling Arm Adult Xl__8140065 PX-2705000141 CDM 2705000141 LOCAL 270 RC outpatient 30 30 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES HDHP [308136802] 24 percent of total billed charges 18.6 28.5 Technical (Hospital) Services HC/HH Wch Supp Sling Arm Adult Xl__8140065 PX-2705000141 CDM 2705000141 LOCAL 270 RC outpatient 30 30 BLUE CROSS BLUE SHIELD WELLMARK SB889 [3081026] BCBS WYOMING [308102603] 28.5 percent of total billed charges 18.6 28.5 Technical (Hospital) Services HC/HH Wch Supp Sling Arm Adult Xl__8140065 PX-2705000141 CDM 2705000141 LOCAL 270 RC outpatient 30 30 CIGNA 62308 [3081051] CIGNA 62308 [308105105] 24 percent of total billed charges 18.6 28.5 Technical (Hospital) Services HC/HH Wch Supp Sling Arm Adult Xl__8140065 PX-2705000141 CDM 2705000141 LOCAL 270 RC outpatient 30 30 CIGNA 62308 [3081051] CIGNA STATE OF WYOMING [308105107] 24 percent of total billed charges 18.6 28.5 Technical (Hospital) Services HC/HH Wch Supp Sling Arm Adult Xl__8140065 PX-2705000141 CDM 2705000141 LOCAL 270 RC outpatient 30 30 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES EPO [308136803] 24 percent of total billed charges 18.6 28.5 Technical (Hospital) Services HC/HH Wch Supp Sling Arm Adult Xl__8140065 PX-2705000141 CDM 2705000141 LOCAL 270 RC outpatient 30 30 HEALTHPARTNERS SX009 HEALTHPARTNERS 24 percent of total billed charges 18.6 28.5 Technical (Hospital) Services HC/HH Wch Supp Sling Arm Adult Xl__8140065 PX-2705000141 CDM 2705000141 LOCAL 270 RC outpatient 30 30 UNITED HEALTHCARE (COMMERCIAL) [3081199] UNITED HEALTHCARE 87726 [308119901] 18.6 percent of total billed charges 18.6 28.5 Technical (Hospital) Services HC/HH Wch Supp Sling Arm Adult Xl__8140065 PX-2705000141 CDM 2705000141 LOCAL 270 RC outpatient 30 30 MEDICA (COMMERCIAL) 94265 [3081118] MEDICA CLAIMS [308111801] 27 percent of total billed charges 18.6 28.5 Technical (Hospital) Services HC/HH Wch Supp Sling Arm Adult Xl__8140065 PX-2705000141 CDM 2705000141 LOCAL 270 RC outpatient 30 30 MULTIPLAN INC 34080 [3081285] MULTIPLAN INC [308128501] 28.5 percent of total billed charges 18.6 28.5 Technical (Hospital) Services HC/HH Wch Supp Sling Arm Adult Xl__8140065 PX-2705000141 CDM 2705000141 LOCAL 270 RC outpatient 30 30 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES PPO [308136801] 24 percent of total billed charges 18.6 28.5 Technical (Hospital) Services HC/HH Wch Supp Sling Arm Adult Small__8140062 PX-2705000140 CDM 2705000140 LOCAL 270 RC outpatient 30 30 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES HDHP [308136802] 24 percent of total billed charges 18.6 28.5 Technical (Hospital) Services HC/HH Wch Supp Sling Arm Adult Small__8140062 PX-2705000140 CDM 2705000140 LOCAL 270 RC outpatient 30 30 BLUE CROSS BLUE SHIELD WELLMARK SB889 [3081026] BCBS WYOMING [308102603] 28.5 percent of total billed charges 18.6 28.5 Technical (Hospital) Services HC/HH Wch Supp Sling Arm Adult Small__8140062 PX-2705000140 CDM 2705000140 LOCAL 270 RC outpatient 30 30 CIGNA 62308 [3081051] CIGNA 62308 [308105105] 24 percent of total billed charges 18.6 28.5 Technical (Hospital) Services HC/HH Wch Supp Sling Arm Adult Small__8140062 PX-2705000140 CDM 2705000140 LOCAL 270 RC outpatient 30 30 CIGNA 62308 [3081051] CIGNA STATE OF WYOMING [308105107] 24 percent of total billed charges 18.6 28.5 Technical (Hospital) Services HC/HH Wch Supp Sling Arm Adult Small__8140062 PX-2705000140 CDM 2705000140 LOCAL 270 RC outpatient 30 30 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES EPO [308136803] 24 percent of total billed charges 18.6 28.5 Technical (Hospital) Services HC/HH Wch Supp Sling Arm Adult Small__8140062 PX-2705000140 CDM 2705000140 LOCAL 270 RC outpatient 30 30 HEALTHPARTNERS SX009 HEALTHPARTNERS 24 percent of total billed charges 18.6 28.5 Technical (Hospital) Services HC/HH Wch Supp Sling Arm Adult Small__8140062 PX-2705000140 CDM 2705000140 LOCAL 270 RC outpatient 30 30 UNITED HEALTHCARE (COMMERCIAL) [3081199] UNITED HEALTHCARE 87726 [308119901] 18.6 percent of total billed charges 18.6 28.5 Technical (Hospital) Services HC/HH Wch Supp Sling Arm Adult Small__8140062 PX-2705000140 CDM 2705000140 LOCAL 270 RC outpatient 30 30 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES PPO [308136801] 24 percent of total billed charges 18.6 28.5 Technical (Hospital) Services HC/HH Wch Supp Sling Arm Adult Small__8140062 PX-2705000140 CDM 2705000140 LOCAL 270 RC outpatient 30 30 MEDICA (COMMERCIAL) 94265 [3081118] MEDICA CLAIMS [308111801] 27 percent of total billed charges 18.6 28.5 Technical (Hospital) Services HC/HH Wch Supp Sling Arm Adult Small__8140062 PX-2705000140 CDM 2705000140 LOCAL 270 RC outpatient 30 30 MULTIPLAN INC 34080 [3081285] MULTIPLAN INC [308128501] 28.5 percent of total billed charges 18.6 28.5 Technical (Hospital) Services HC/HH Wch Supp Sling Arm Adult Small__8140062 PX-2705000140 CDM 2705000140 LOCAL 270 RC inpatient 30 30 UNITED HEALTHCARE (COMMERCIAL) [3081199] UNITED HEALTHCARE 87726 [308119901] 18.6 percent of total billed charges 18.6 28.5 Technical (Hospital) Services HC/HH Wch Supp Sling Arm Adult Small__8140062 PX-2705000140 CDM 2705000140 LOCAL 270 RC inpatient 30 30 MEDICA (COMMERCIAL) 94265 [3081118] MEDICA CLAIMS [308111801] 27 percent of total billed charges 18.6 28.5 Technical (Hospital) Services HC/HH Wch Supp Sling Arm Adult Small__8140062 PX-2705000140 CDM 2705000140 LOCAL 270 RC inpatient 30 30 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES HDHP [308136802] 23.75 percent of total billed charges 18.6 28.5 Technical (Hospital) Services HC/HH Wch Supp Sling Arm Adult Small__8140062 PX-2705000140 CDM 2705000140 LOCAL 270 RC inpatient 30 30 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES PPO [308136801] 23.75 percent of total billed charges 18.6 28.5 Technical (Hospital) Services HC/HH Wch Supp Sling Arm Adult Small__8140062 PX-2705000140 CDM 2705000140 LOCAL 270 RC inpatient 30 30 HEALTHPARTNERS SX009 HEALTHPARTNERS 23.75 percent of total billed charges 18.6 28.5 Technical (Hospital) Services HC/HH Wch Supp Sling Arm Adult Small__8140062 PX-2705000140 CDM 2705000140 LOCAL 270 RC inpatient 30 30 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES EPO [308136803] 23.75 percent of total billed charges 18.6 28.5 Technical (Hospital) Services HC/HH Wch Supp Sling Arm Adult Small__8140062 PX-2705000140 CDM 2705000140 LOCAL 270 RC inpatient 30 30 CIGNA 62308 [3081051] CIGNA 62308 [308105105] 23.75 percent of total billed charges 18.6 28.5 Technical (Hospital) Services HC/HH Wch Supp Sling Arm Adult Small__8140062 PX-2705000140 CDM 2705000140 LOCAL 270 RC inpatient 30 30 CIGNA 62308 [3081051] CIGNA STATE OF WYOMING [308105107] 23.75 percent of total billed charges 18.6 28.5 Technical (Hospital) Services HC/HH Wch Supp Sling Arm Adult Small__8140062 PX-2705000140 CDM 2705000140 LOCAL 270 RC inpatient 30 30 MULTIPLAN INC 34080 [3081285] MULTIPLAN INC [308128501] 28.5 percent of total billed charges 18.6 28.5 Technical (Hospital) Services HC/HH Wch Supp Sling Arm Adult Small__8140062 PX-2705000140 CDM 2705000140 LOCAL 270 RC inpatient 30 30 BLUE CROSS BLUE SHIELD WELLMARK SB889 [3081026] BCBS WYOMING [308102603] 28.5 percent of total billed charges 18.6 28.5 Technical (Hospital) Services HC/HH Wch Supp Shoulder Immob Sm__8144502 PX-2705000139 CDM 2705000139 LOCAL 270 RC inpatient 29 29 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES PPO [308136801] 22.96 percent of total billed charges 17.98 27.55 Technical (Hospital) Services HC/HH Wch Supp Shoulder Immob Sm__8144502 PX-2705000139 CDM 2705000139 LOCAL 270 RC inpatient 29 29 UNITED HEALTHCARE (COMMERCIAL) [3081199] UNITED HEALTHCARE 87726 [308119901] 17.98 percent of total billed charges 17.98 27.55 Technical (Hospital) Services HC/HH Wch Supp Shoulder Immob Sm__8144502 PX-2705000139 CDM 2705000139 LOCAL 270 RC inpatient 29 29 MEDICA (COMMERCIAL) 94265 [3081118] MEDICA CLAIMS [308111801] 26.1 percent of total billed charges 17.98 27.55 Technical (Hospital) Services HC/HH Wch Supp Shoulder Immob Sm__8144502 PX-2705000139 CDM 2705000139 LOCAL 270 RC inpatient 29 29 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES HDHP [308136802] 22.96 percent of total billed charges 17.98 27.55 Technical (Hospital) Services HC/HH Wch Supp Shoulder Immob Sm__8144502 PX-2705000139 CDM 2705000139 LOCAL 270 RC inpatient 29 29 MULTIPLAN INC 34080 [3081285] MULTIPLAN INC [308128501] 27.55 percent of total billed charges 17.98 27.55 Technical (Hospital) Services HC/HH Wch Supp Shoulder Immob Sm__8144502 PX-2705000139 CDM 2705000139 LOCAL 270 RC inpatient 29 29 BLUE CROSS BLUE SHIELD WELLMARK SB889 [3081026] BCBS WYOMING [308102603] 27.55 percent of total billed charges 17.98 27.55 Technical (Hospital) Services HC/HH Wch Supp Shoulder Immob Sm__8144502 PX-2705000139 CDM 2705000139 LOCAL 270 RC inpatient 29 29 CIGNA 62308 [3081051] CIGNA 62308 [308105105] 22.96 percent of total billed charges 17.98 27.55 Technical (Hospital) Services HC/HH Wch Supp Shoulder Immob Sm__8144502 PX-2705000139 CDM 2705000139 LOCAL 270 RC inpatient 29 29 CIGNA 62308 [3081051] CIGNA STATE OF WYOMING [308105107] 22.96 percent of total billed charges 17.98 27.55 Technical (Hospital) Services HC/HH Wch Supp Shoulder Immob Sm__8144502 PX-2705000139 CDM 2705000139 LOCAL 270 RC inpatient 29 29 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES EPO [308136803] 22.96 percent of total billed charges 17.98 27.55 Technical (Hospital) Services HC/HH Wch Supp Shoulder Immob Sm__8144502 PX-2705000139 CDM 2705000139 LOCAL 270 RC inpatient 29 29 HEALTHPARTNERS SX009 HEALTHPARTNERS 22.96 percent of total billed charges 17.98 27.55 Technical (Hospital) Services HC/HH Wch Supp Shoulder Immob Sm__8144502 PX-2705000139 CDM 2705000139 LOCAL 270 RC outpatient 29 29 MEDICA (COMMERCIAL) 94265 [3081118] MEDICA CLAIMS [308111801] 26.1 percent of total billed charges 17.98 27.55 Technical (Hospital) Services HC/HH Wch Supp Shoulder Immob Sm__8144502 PX-2705000139 CDM 2705000139 LOCAL 270 RC outpatient 29 29 MULTIPLAN INC 34080 [3081285] MULTIPLAN INC [308128501] 27.55 percent of total billed charges 17.98 27.55 Technical (Hospital) Services HC/HH Wch Supp Shoulder Immob Sm__8144502 PX-2705000139 CDM 2705000139 LOCAL 270 RC outpatient 29 29 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES EPO [308136803] 23.2 percent of total billed charges 17.98 27.55 Technical (Hospital) Services HC/HH Wch Supp Shoulder Immob Sm__8144502 PX-2705000139 CDM 2705000139 LOCAL 270 RC outpatient 29 29 CIGNA 62308 [3081051] CIGNA 62308 [308105105] 23.2 percent of total billed charges 17.98 27.55 Technical (Hospital) Services HC/HH Wch Supp Shoulder Immob Sm__8144502 PX-2705000139 CDM 2705000139 LOCAL 270 RC outpatient 29 29 CIGNA 62308 [3081051] CIGNA STATE OF WYOMING [308105107] 23.2 percent of total billed charges 17.98 27.55 Technical (Hospital) Services HC/HH Wch Supp Shoulder Immob Sm__8144502 PX-2705000139 CDM 2705000139 LOCAL 270 RC outpatient 29 29 BLUE CROSS BLUE SHIELD WELLMARK SB889 [3081026] BCBS WYOMING [308102603] 27.55 percent of total billed charges 17.98 27.55 Technical (Hospital) Services HC/HH Wch Supp Shoulder Immob Sm__8144502 PX-2705000139 CDM 2705000139 LOCAL 270 RC outpatient 29 29 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES HDHP [308136802] 23.2 percent of total billed charges 17.98 27.55 Technical (Hospital) Services HC/HH Wch Supp Shoulder Immob Sm__8144502 PX-2705000139 CDM 2705000139 LOCAL 270 RC outpatient 29 29 HEALTHPARTNERS SX009 HEALTHPARTNERS 23.2 percent of total billed charges 17.98 27.55 Technical (Hospital) Services HC/HH Wch Supp Shoulder Immob Sm__8144502 PX-2705000139 CDM 2705000139 LOCAL 270 RC outpatient 29 29 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES PPO [308136801] 23.2 percent of total billed charges 17.98 27.55 Technical (Hospital) Services HC/HH Wch Supp Shoulder Immob Sm__8144502 PX-2705000139 CDM 2705000139 LOCAL 270 RC outpatient 29 29 UNITED HEALTHCARE (COMMERCIAL) [3081199] UNITED HEALTHCARE 87726 [308119901] 17.98 percent of total billed charges 17.98 27.55 Technical (Hospital) Services HC/HH Wch Supp Shoulder Immob Med__8144503 PX-2705000138 CDM 2705000138 LOCAL 270 RC outpatient 32 32 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES HDHP [308136802] 25.6 percent of total billed charges 19.84 30.4 Technical (Hospital) Services HC/HH Wch Supp Shoulder Immob Med__8144503 PX-2705000138 CDM 2705000138 LOCAL 270 RC outpatient 32 32 BLUE CROSS BLUE SHIELD WELLMARK SB889 [3081026] BCBS WYOMING [308102603] 30.4 percent of total billed charges 19.84 30.4 Technical (Hospital) Services HC/HH Wch Supp Shoulder Immob Med__8144503 PX-2705000138 CDM 2705000138 LOCAL 270 RC outpatient 32 32 CIGNA 62308 [3081051] CIGNA 62308 [308105105] 25.6 percent of total billed charges 19.84 30.4 Technical (Hospital) Services HC/HH Wch Supp Shoulder Immob Med__8144503 PX-2705000138 CDM 2705000138 LOCAL 270 RC outpatient 32 32 CIGNA 62308 [3081051] CIGNA STATE OF WYOMING [308105107] 25.6 percent of total billed charges 19.84 30.4 Technical (Hospital) Services HC/HH Wch Supp Shoulder Immob Med__8144503 PX-2705000138 CDM 2705000138 LOCAL 270 RC outpatient 32 32 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES EPO [308136803] 25.6 percent of total billed charges 19.84 30.4 Technical (Hospital) Services HC/HH Wch Supp Shoulder Immob Med__8144503 PX-2705000138 CDM 2705000138 LOCAL 270 RC outpatient 32 32 HEALTHPARTNERS SX009 HEALTHPARTNERS 25.6 percent of total billed charges 19.84 30.4 Technical (Hospital) Services HC/HH Wch Supp Shoulder Immob Med__8144503 PX-2705000138 CDM 2705000138 LOCAL 270 RC outpatient 32 32 UNITED HEALTHCARE (COMMERCIAL) [3081199] UNITED HEALTHCARE 87726 [308119901] 19.84 percent of total billed charges 19.84 30.4 Technical (Hospital) Services HC/HH Wch Supp Shoulder Immob Med__8144503 PX-2705000138 CDM 2705000138 LOCAL 270 RC outpatient 32 32 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES PPO [308136801] 25.6 percent of total billed charges 19.84 30.4 Technical (Hospital) Services HC/HH Wch Supp Shoulder Immob Med__8144503 PX-2705000138 CDM 2705000138 LOCAL 270 RC outpatient 32 32 MULTIPLAN INC 34080 [3081285] MULTIPLAN INC [308128501] 30.4 percent of total billed charges 19.84 30.4 Technical (Hospital) Services HC/HH Wch Supp Shoulder Immob Med__8144503 PX-2705000138 CDM 2705000138 LOCAL 270 RC outpatient 32 32 MEDICA (COMMERCIAL) 94265 [3081118] MEDICA CLAIMS [308111801] 28.8 percent of total billed charges 19.84 30.4 Technical (Hospital) Services HC/HH Wch Supp Shoulder Immob Med__8144503 PX-2705000138 CDM 2705000138 LOCAL 270 RC inpatient 32 32 BLUE CROSS BLUE SHIELD WELLMARK SB889 [3081026] BCBS WYOMING [308102603] 30.4 percent of total billed charges 19.84 30.4 Technical (Hospital) Services HC/HH Wch Supp Shoulder Immob Med__8144503 PX-2705000138 CDM 2705000138 LOCAL 270 RC inpatient 32 32 MULTIPLAN INC 34080 [3081285] MULTIPLAN INC [308128501] 30.4 percent of total billed charges 19.84 30.4 Technical (Hospital) Services HC/HH Wch Supp Shoulder Immob Med__8144503 PX-2705000138 CDM 2705000138 LOCAL 270 RC inpatient 32 32 CIGNA 62308 [3081051] CIGNA 62308 [308105105] 25.34 percent of total billed charges 19.84 30.4 Technical (Hospital) Services HC/HH Wch Supp Shoulder Immob Med__8144503 PX-2705000138 CDM 2705000138 LOCAL 270 RC inpatient 32 32 CIGNA 62308 [3081051] CIGNA STATE OF WYOMING [308105107] 25.34 percent of total billed charges 19.84 30.4 Technical (Hospital) Services HC/HH Wch Supp Shoulder Immob Med__8144503 PX-2705000138 CDM 2705000138 LOCAL 270 RC inpatient 32 32 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES EPO [308136803] 25.34 percent of total billed charges 19.84 30.4 Technical (Hospital) Services HC/HH Wch Supp Shoulder Immob Med__8144503 PX-2705000138 CDM 2705000138 LOCAL 270 RC inpatient 32 32 HEALTHPARTNERS SX009 HEALTHPARTNERS 25.34 percent of total billed charges 19.84 30.4 Technical (Hospital) Services HC/HH Wch Supp Shoulder Immob Med__8144503 PX-2705000138 CDM 2705000138 LOCAL 270 RC inpatient 32 32 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES PPO [308136801] 25.34 percent of total billed charges 19.84 30.4 Technical (Hospital) Services HC/HH Wch Supp Shoulder Immob Med__8144503 PX-2705000138 CDM 2705000138 LOCAL 270 RC inpatient 32 32 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES HDHP [308136802] 25.34 percent of total billed charges 19.84 30.4 Technical (Hospital) Services HC/HH Wch Supp Shoulder Immob Med__8144503 PX-2705000138 CDM 2705000138 LOCAL 270 RC inpatient 32 32 MEDICA (COMMERCIAL) 94265 [3081118] MEDICA CLAIMS [308111801] 28.8 percent of total billed charges 19.84 30.4 Technical (Hospital) Services HC/HH Wch Supp Shoulder Immob Med__8144503 PX-2705000138 CDM 2705000138 LOCAL 270 RC inpatient 32 32 UNITED HEALTHCARE (COMMERCIAL) [3081199] UNITED HEALTHCARE 87726 [308119901] 19.84 percent of total billed charges 19.84 30.4 Technical (Hospital) Services HC/HH Wch Supp Shoe/Post-OP/X.Large__18018 PX-2705000137 CDM 2705000137 LOCAL 270 RC inpatient 43 43 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES PPO [308136801] 34.05 percent of total billed charges 26.66 40.85 Technical (Hospital) Services HC/HH Wch Supp Shoe/Post-OP/X.Large__18018 PX-2705000137 CDM 2705000137 LOCAL 270 RC inpatient 43 43 UNITED HEALTHCARE (COMMERCIAL) [3081199] UNITED HEALTHCARE 87726 [308119901] 26.66 percent of total billed charges 26.66 40.85 Technical (Hospital) Services HC/HH Wch Supp Shoe/Post-OP/X.Large__18018 PX-2705000137 CDM 2705000137 LOCAL 270 RC inpatient 43 43 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES HDHP [308136802] 34.05 percent of total billed charges 26.66 40.85 Technical (Hospital) Services HC/HH Wch Supp Shoe/Post-OP/X.Large__18018 PX-2705000137 CDM 2705000137 LOCAL 270 RC inpatient 43 43 MEDICA (COMMERCIAL) 94265 [3081118] MEDICA CLAIMS [308111801] 38.7 percent of total billed charges 26.66 40.85 Technical (Hospital) Services HC/HH Wch Supp Shoe/Post-OP/X.Large__18018 PX-2705000137 CDM 2705000137 LOCAL 270 RC inpatient 43 43 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES EPO [308136803] 34.05 percent of total billed charges 26.66 40.85 Technical (Hospital) Services HC/HH Wch Supp Shoe/Post-OP/X.Large__18018 PX-2705000137 CDM 2705000137 LOCAL 270 RC inpatient 43 43 HEALTHPARTNERS SX009 HEALTHPARTNERS 34.05 percent of total billed charges 26.66 40.85 Technical (Hospital) Services HC/HH Wch Supp Shoe/Post-OP/X.Large__18018 PX-2705000137 CDM 2705000137 LOCAL 270 RC inpatient 43 43 BLUE CROSS BLUE SHIELD WELLMARK SB889 [3081026] BCBS WYOMING [308102603] 40.85 percent of total billed charges 26.66 40.85 Technical (Hospital) Services HC/HH Wch Supp Shoe/Post-OP/X.Large__18018 PX-2705000137 CDM 2705000137 LOCAL 270 RC inpatient 43 43 MULTIPLAN INC 34080 [3081285] MULTIPLAN INC [308128501] 40.85 percent of total billed charges 26.66 40.85 Technical (Hospital) Services HC/HH Wch Supp Shoe/Post-OP/X.Large__18018 PX-2705000137 CDM 2705000137 LOCAL 270 RC inpatient 43 43 CIGNA 62308 [3081051] CIGNA 62308 [308105105] 34.05 percent of total billed charges 26.66 40.85 Technical (Hospital) Services HC/HH Wch Supp Shoe/Post-OP/X.Large__18018 PX-2705000137 CDM 2705000137 LOCAL 270 RC inpatient 43 43 CIGNA 62308 [3081051] CIGNA STATE OF WYOMING [308105107] 34.05 percent of total billed charges 26.66 40.85 Technical (Hospital) Services HC/HH Wch Supp Shoe/Post-OP/X.Large__18018 PX-2705000137 CDM 2705000137 LOCAL 270 RC outpatient 43 43 HEALTHPARTNERS SX009 HEALTHPARTNERS 34.4 percent of total billed charges 26.66 40.85 Technical (Hospital) Services HC/HH Wch Supp Shoe/Post-OP/X.Large__18018 PX-2705000137 CDM 2705000137 LOCAL 270 RC outpatient 43 43 UNITED HEALTHCARE (COMMERCIAL) [3081199] UNITED HEALTHCARE 87726 [308119901] 26.66 percent of total billed charges 26.66 40.85 Technical (Hospital) Services HC/HH Wch Supp Shoe/Post-OP/X.Large__18018 PX-2705000137 CDM 2705000137 LOCAL 270 RC outpatient 43 43 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES PPO [308136801] 34.4 percent of total billed charges 26.66 40.85 Technical (Hospital) Services HC/HH Wch Supp Shoe/Post-OP/X.Large__18018 PX-2705000137 CDM 2705000137 LOCAL 270 RC outpatient 43 43 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES HDHP [308136802] 34.4 percent of total billed charges 26.66 40.85 Technical (Hospital) Services HC/HH Wch Supp Shoe/Post-OP/X.Large__18018 PX-2705000137 CDM 2705000137 LOCAL 270 RC outpatient 43 43 BLUE CROSS BLUE SHIELD WELLMARK SB889 [3081026] BCBS WYOMING [308102603] 40.85 percent of total billed charges 26.66 40.85 Technical (Hospital) Services HC/HH Wch Supp Shoe/Post-OP/X.Large__18018 PX-2705000137 CDM 2705000137 LOCAL 270 RC outpatient 43 43 CIGNA 62308 [3081051] CIGNA 62308 [308105105] 34.4 percent of total billed charges 26.66 40.85 Technical (Hospital) Services HC/HH Wch Supp Shoe/Post-OP/X.Large__18018 PX-2705000137 CDM 2705000137 LOCAL 270 RC outpatient 43 43 CIGNA 62308 [3081051] CIGNA STATE OF WYOMING [308105107] 34.4 percent of total billed charges 26.66 40.85 Technical (Hospital) Services HC/HH Wch Supp Shoe/Post-OP/X.Large__18018 PX-2705000137 CDM 2705000137 LOCAL 270 RC outpatient 43 43 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES EPO [308136803] 34.4 percent of total billed charges 26.66 40.85 Technical (Hospital) Services HC/HH Wch Supp Shoe/Post-OP/X.Large__18018 PX-2705000137 CDM 2705000137 LOCAL 270 RC outpatient 43 43 MULTIPLAN INC 34080 [3081285] MULTIPLAN INC [308128501] 40.85 percent of total billed charges 26.66 40.85 Technical (Hospital) Services HC/HH Wch Supp Shoe/Post-OP/X.Large__18018 PX-2705000137 CDM 2705000137 LOCAL 270 RC outpatient 43 43 MEDICA (COMMERCIAL) 94265 [3081118] MEDICA CLAIMS [308111801] 38.7 percent of total billed charges 26.66 40.85 Technical (Hospital) Services HC/HH Wch Supp Shoe/Post-OP/Small__18013 PX-2705000136 CDM 2705000136 LOCAL 270 RC inpatient 33 33 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES HDHP [308136802] 26.13 percent of total billed charges 20.46 31.35 Technical (Hospital) Services HC/HH Wch Supp Shoe/Post-OP/Small__18013 PX-2705000136 CDM 2705000136 LOCAL 270 RC inpatient 33 33 UNITED HEALTHCARE (COMMERCIAL) [3081199] UNITED HEALTHCARE 87726 [308119901] 20.46 percent of total billed charges 20.46 31.35 Technical (Hospital) Services HC/HH Wch Supp Shoe/Post-OP/Small__18013 PX-2705000136 CDM 2705000136 LOCAL 270 RC inpatient 33 33 MEDICA (COMMERCIAL) 94265 [3081118] MEDICA CLAIMS [308111801] 29.7 percent of total billed charges 20.46 31.35 Technical (Hospital) Services HC/HH Wch Supp Shoe/Post-OP/Small__18013 PX-2705000136 CDM 2705000136 LOCAL 270 RC inpatient 33 33 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES PPO [308136801] 26.13 percent of total billed charges 20.46 31.35 Technical (Hospital) Services HC/HH Wch Supp Shoe/Post-OP/Small__18013 PX-2705000136 CDM 2705000136 LOCAL 270 RC inpatient 33 33 HEALTHPARTNERS SX009 HEALTHPARTNERS 26.13 percent of total billed charges 20.46 31.35 Technical (Hospital) Services HC/HH Wch Supp Shoe/Post-OP/Small__18013 PX-2705000136 CDM 2705000136 LOCAL 270 RC inpatient 33 33 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES EPO [308136803] 26.13 percent of total billed charges 20.46 31.35 Technical (Hospital) Services HC/HH Wch Supp Shoe/Post-OP/Small__18013 PX-2705000136 CDM 2705000136 LOCAL 270 RC inpatient 33 33 MULTIPLAN INC 34080 [3081285] MULTIPLAN INC [308128501] 31.35 percent of total billed charges 20.46 31.35 Technical (Hospital) Services HC/HH Wch Supp Shoe/Post-OP/Small__18013 PX-2705000136 CDM 2705000136 LOCAL 270 RC inpatient 33 33 CIGNA 62308 [3081051] CIGNA 62308 [308105105] 26.13 percent of total billed charges 20.46 31.35 Technical (Hospital) Services HC/HH Wch Supp Shoe/Post-OP/Small__18013 PX-2705000136 CDM 2705000136 LOCAL 270 RC inpatient 33 33 CIGNA 62308 [3081051] CIGNA STATE OF WYOMING [308105107] 26.13 percent of total billed charges 20.46 31.35 Technical (Hospital) Services HC/HH Wch Supp Shoe/Post-OP/Small__18013 PX-2705000136 CDM 2705000136 LOCAL 270 RC inpatient 33 33 BLUE CROSS BLUE SHIELD WELLMARK SB889 [3081026] BCBS WYOMING [308102603] 31.35 percent of total billed charges 20.46 31.35 Technical (Hospital) Services HC/HH Wch Supp Shoe/Post-OP/Small__18013 PX-2705000136 CDM 2705000136 LOCAL 270 RC outpatient 33 33 MEDICA (COMMERCIAL) 94265 [3081118] MEDICA CLAIMS [308111801] 29.7 percent of total billed charges 20.46 31.35 Technical (Hospital) Services HC/HH Wch Supp Shoe/Post-OP/Small__18013 PX-2705000136 CDM 2705000136 LOCAL 270 RC outpatient 33 33 MULTIPLAN INC 34080 [3081285] MULTIPLAN INC [308128501] 31.35 percent of total billed charges 20.46 31.35 Technical (Hospital) Services HC/HH Wch Supp Shoe/Post-OP/Small__18013 PX-2705000136 CDM 2705000136 LOCAL 270 RC outpatient 33 33 BLUE CROSS BLUE SHIELD WELLMARK SB889 [3081026] BCBS WYOMING [308102603] 31.35 percent of total billed charges 20.46 31.35 Technical (Hospital) Services HC/HH Wch Supp Shoe/Post-OP/Small__18013 PX-2705000136 CDM 2705000136 LOCAL 270 RC outpatient 33 33 CIGNA 62308 [3081051] CIGNA 62308 [308105105] 26.4 percent of total billed charges 20.46 31.35 Technical (Hospital) Services HC/HH Wch Supp Shoe/Post-OP/Small__18013 PX-2705000136 CDM 2705000136 LOCAL 270 RC outpatient 33 33 CIGNA 62308 [3081051] CIGNA STATE OF WYOMING [308105107] 26.4 percent of total billed charges 20.46 31.35 Technical (Hospital) Services HC/HH Wch Supp Shoe/Post-OP/Small__18013 PX-2705000136 CDM 2705000136 LOCAL 270 RC outpatient 33 33 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES EPO [308136803] 26.4 percent of total billed charges 20.46 31.35 Technical (Hospital) Services HC/HH Wch Supp Shoe/Post-OP/Small__18013 PX-2705000136 CDM 2705000136 LOCAL 270 RC outpatient 33 33 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES HDHP [308136802] 26.4 percent of total billed charges 20.46 31.35 Technical (Hospital) Services HC/HH Wch Supp Shoe/Post-OP/Small__18013 PX-2705000136 CDM 2705000136 LOCAL 270 RC outpatient 33 33 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES PPO [308136801] 26.4 percent of total billed charges 20.46 31.35 Technical (Hospital) Services HC/HH Wch Supp Shoe/Post-OP/Small__18013 PX-2705000136 CDM 2705000136 LOCAL 270 RC outpatient 33 33 HEALTHPARTNERS SX009 HEALTHPARTNERS 26.4 percent of total billed charges 20.46 31.35 Technical (Hospital) Services HC/HH Wch Supp Shoe/Post-OP/Small__18013 PX-2705000136 CDM 2705000136 LOCAL 270 RC outpatient 33 33 UNITED HEALTHCARE (COMMERCIAL) [3081199] UNITED HEALTHCARE 87726 [308119901] 20.46 percent of total billed charges 20.46 31.35 Technical (Hospital) Services HC/HH Wch Supp Shoe/Post-OP/Pediatr__117pedb PX-2705000135 CDM 2705000135 LOCAL 270 RC outpatient 37 37 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES HDHP [308136802] 29.6 percent of total billed charges 22.94 35.15 Technical (Hospital) Services HC/HH Wch Supp Shoe/Post-OP/Pediatr__117pedb PX-2705000135 CDM 2705000135 LOCAL 270 RC outpatient 37 37 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES EPO [308136803] 29.6 percent of total billed charges 22.94 35.15 Technical (Hospital) Services HC/HH Wch Supp Shoe/Post-OP/Pediatr__117pedb PX-2705000135 CDM 2705000135 LOCAL 270 RC outpatient 37 37 CIGNA 62308 [3081051] CIGNA 62308 [308105105] 29.6 percent of total billed charges 22.94 35.15 Technical (Hospital) Services HC/HH Wch Supp Shoe/Post-OP/Pediatr__117pedb PX-2705000135 CDM 2705000135 LOCAL 270 RC outpatient 37 37 CIGNA 62308 [3081051] CIGNA STATE OF WYOMING [308105107] 29.6 percent of total billed charges 22.94 35.15 Technical (Hospital) Services HC/HH Wch Supp Shoe/Post-OP/Pediatr__117pedb PX-2705000135 CDM 2705000135 LOCAL 270 RC outpatient 37 37 BLUE CROSS BLUE SHIELD WELLMARK SB889 [3081026] BCBS WYOMING [308102603] 35.15 percent of total billed charges 22.94 35.15 Technical (Hospital) Services HC/HH Wch Supp Shoe/Post-OP/Pediatr__117pedb PX-2705000135 CDM 2705000135 LOCAL 270 RC outpatient 37 37 UNITED HEALTHCARE (COMMERCIAL) [3081199] UNITED HEALTHCARE 87726 [308119901] 22.94 percent of total billed charges 22.94 35.15 Technical (Hospital) Services HC/HH Wch Supp Shoe/Post-OP/Pediatr__117pedb PX-2705000135 CDM 2705000135 LOCAL 270 RC outpatient 37 37 HEALTHPARTNERS SX009 HEALTHPARTNERS 29.6 percent of total billed charges 22.94 35.15 Technical (Hospital) Services HC/HH Wch Supp Shoe/Post-OP/Pediatr__117pedb PX-2705000135 CDM 2705000135 LOCAL 270 RC outpatient 37 37 MEDICA (COMMERCIAL) 94265 [3081118] MEDICA CLAIMS [308111801] 33.3 percent of total billed charges 22.94 35.15 Technical (Hospital) Services HC/HH Wch Supp Shoe/Post-OP/Pediatr__117pedb PX-2705000135 CDM 2705000135 LOCAL 270 RC outpatient 37 37 MULTIPLAN INC 34080 [3081285] MULTIPLAN INC [308128501] 35.15 percent of total billed charges 22.94 35.15 Technical (Hospital) Services HC/HH Wch Supp Shoe/Post-OP/Pediatr__117pedb PX-2705000135 CDM 2705000135 LOCAL 270 RC outpatient 37 37 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES PPO [308136801] 29.6 percent of total billed charges 22.94 35.15 Technical (Hospital) Services HC/HH Wch Supp Shoe/Post-OP/Pediatr__117pedb PX-2705000135 CDM 2705000135 LOCAL 270 RC inpatient 37 37 UNITED HEALTHCARE (COMMERCIAL) [3081199] UNITED HEALTHCARE 87726 [308119901] 22.94 percent of total billed charges 22.94 35.15 Technical (Hospital) Services HC/HH Wch Supp Shoe/Post-OP/Pediatr__117pedb PX-2705000135 CDM 2705000135 LOCAL 270 RC inpatient 37 37 MEDICA (COMMERCIAL) 94265 [3081118] MEDICA CLAIMS [308111801] 33.3 percent of total billed charges 22.94 35.15 Technical (Hospital) Services HC/HH Wch Supp Shoe/Post-OP/Pediatr__117pedb PX-2705000135 CDM 2705000135 LOCAL 270 RC inpatient 37 37 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES HDHP [308136802] 29.3 percent of total billed charges 22.94 35.15 Technical (Hospital) Services HC/HH Wch Supp Shoe/Post-OP/Pediatr__117pedb PX-2705000135 CDM 2705000135 LOCAL 270 RC inpatient 37 37 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES PPO [308136801] 29.3 percent of total billed charges 22.94 35.15 Technical (Hospital) Services HC/HH Wch Supp Shoe/Post-OP/Pediatr__117pedb PX-2705000135 CDM 2705000135 LOCAL 270 RC inpatient 37 37 HEALTHPARTNERS SX009 HEALTHPARTNERS 29.3 percent of total billed charges 22.94 35.15 Technical (Hospital) Services HC/HH Wch Supp Shoe/Post-OP/Pediatr__117pedb PX-2705000135 CDM 2705000135 LOCAL 270 RC inpatient 37 37 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES EPO [308136803] 29.3 percent of total billed charges 22.94 35.15 Technical (Hospital) Services HC/HH Wch Supp Shoe/Post-OP/Pediatr__117pedb PX-2705000135 CDM 2705000135 LOCAL 270 RC inpatient 37 37 CIGNA 62308 [3081051] CIGNA 62308 [308105105] 29.3 percent of total billed charges 22.94 35.15 Technical (Hospital) Services HC/HH Wch Supp Shoe/Post-OP/Pediatr__117pedb PX-2705000135 CDM 2705000135 LOCAL 270 RC inpatient 37 37 CIGNA 62308 [3081051] CIGNA STATE OF WYOMING [308105107] 29.3 percent of total billed charges 22.94 35.15 Technical (Hospital) Services HC/HH Wch Supp Shoe/Post-OP/Pediatr__117pedb PX-2705000135 CDM 2705000135 LOCAL 270 RC inpatient 37 37 MULTIPLAN INC 34080 [3081285] MULTIPLAN INC [308128501] 35.15 percent of total billed charges 22.94 35.15 Technical (Hospital) Services HC/HH Wch Supp Shoe/Post-OP/Pediatr__117pedb PX-2705000135 CDM 2705000135 LOCAL 270 RC inpatient 37 37 BLUE CROSS BLUE SHIELD WELLMARK SB889 [3081026] BCBS WYOMING [308102603] 35.15 percent of total billed charges 22.94 35.15 Technical (Hospital) Services HC/HH Wch Supp Shoe/Post-OP/Medium__18015 PX-2705000134 CDM 2705000134 LOCAL 270 RC outpatient 37 37 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES PPO [308136801] 29.6 percent of total billed charges 22.94 35.15 Technical (Hospital) Services HC/HH Wch Supp Shoe/Post-OP/Medium__18015 PX-2705000134 CDM 2705000134 LOCAL 270 RC outpatient 37 37 MULTIPLAN INC 34080 [3081285] MULTIPLAN INC [308128501] 35.15 percent of total billed charges 22.94 35.15 Technical (Hospital) Services HC/HH Wch Supp Shoe/Post-OP/Medium__18015 PX-2705000134 CDM 2705000134 LOCAL 270 RC outpatient 37 37 MEDICA (COMMERCIAL) 94265 [3081118] MEDICA CLAIMS [308111801] 33.3 percent of total billed charges 22.94 35.15 Technical (Hospital) Services HC/HH Wch Supp Shoe/Post-OP/Medium__18015 PX-2705000134 CDM 2705000134 LOCAL 270 RC outpatient 37 37 HEALTHPARTNERS SX009 HEALTHPARTNERS 29.6 percent of total billed charges 22.94 35.15 Technical (Hospital) Services HC/HH Wch Supp Shoe/Post-OP/Medium__18015 PX-2705000134 CDM 2705000134 LOCAL 270 RC outpatient 37 37 UNITED HEALTHCARE (COMMERCIAL) [3081199] UNITED HEALTHCARE 87726 [308119901] 22.94 percent of total billed charges 22.94 35.15 Technical (Hospital) Services HC/HH Wch Supp Shoe/Post-OP/Medium__18015 PX-2705000134 CDM 2705000134 LOCAL 270 RC outpatient 37 37 BLUE CROSS BLUE SHIELD WELLMARK SB889 [3081026] BCBS WYOMING [308102603] 35.15 percent of total billed charges 22.94 35.15 Technical (Hospital) Services HC/HH Wch Supp Shoe/Post-OP/Medium__18015 PX-2705000134 CDM 2705000134 LOCAL 270 RC outpatient 37 37 CIGNA 62308 [3081051] CIGNA 62308 [308105105] 29.6 percent of total billed charges 22.94 35.15 Technical (Hospital) Services HC/HH Wch Supp Shoe/Post-OP/Medium__18015 PX-2705000134 CDM 2705000134 LOCAL 270 RC outpatient 37 37 CIGNA 62308 [3081051] CIGNA STATE OF WYOMING [308105107] 29.6 percent of total billed charges 22.94 35.15 Technical (Hospital) Services HC/HH Wch Supp Shoe/Post-OP/Medium__18015 PX-2705000134 CDM 2705000134 LOCAL 270 RC outpatient 37 37 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES EPO [308136803] 29.6 percent of total billed charges 22.94 35.15 Technical (Hospital) Services HC/HH Wch Supp Shoe/Post-OP/Medium__18015 PX-2705000134 CDM 2705000134 LOCAL 270 RC outpatient 37 37 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES HDHP [308136802] 29.6 percent of total billed charges 22.94 35.15 Technical (Hospital) Services HC/HH Wch Supp Shoe/Post-OP/Medium__18015 PX-2705000134 CDM 2705000134 LOCAL 270 RC inpatient 37 37 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES EPO [308136803] 29.3 percent of total billed charges 22.94 35.15 Technical (Hospital) Services HC/HH Wch Supp Shoe/Post-OP/Medium__18015 PX-2705000134 CDM 2705000134 LOCAL 270 RC inpatient 37 37 HEALTHPARTNERS SX009 HEALTHPARTNERS 29.3 percent of total billed charges 22.94 35.15 Technical (Hospital) Services HC/HH Wch Supp Shoe/Post-OP/Medium__18015 PX-2705000134 CDM 2705000134 LOCAL 270 RC inpatient 37 37 CIGNA 62308 [3081051] CIGNA 62308 [308105105] 29.3 percent of total billed charges 22.94 35.15 Technical (Hospital) Services HC/HH Wch Supp Shoe/Post-OP/Medium__18015 PX-2705000134 CDM 2705000134 LOCAL 270 RC inpatient 37 37 CIGNA 62308 [3081051] CIGNA STATE OF WYOMING [308105107] 29.3 percent of total billed charges 22.94 35.15 Technical (Hospital) Services HC/HH Wch Supp Shoe/Post-OP/Medium__18015 PX-2705000134 CDM 2705000134 LOCAL 270 RC inpatient 37 37 MULTIPLAN INC 34080 [3081285] MULTIPLAN INC [308128501] 35.15 percent of total billed charges 22.94 35.15 Technical (Hospital) Services HC/HH Wch Supp Shoe/Post-OP/Medium__18015 PX-2705000134 CDM 2705000134 LOCAL 270 RC inpatient 37 37 BLUE CROSS BLUE SHIELD WELLMARK SB889 [3081026] BCBS WYOMING [308102603] 35.15 percent of total billed charges 22.94 35.15 Technical (Hospital) Services HC/HH Wch Supp Shoe/Post-OP/Medium__18015 PX-2705000134 CDM 2705000134 LOCAL 270 RC inpatient 37 37 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES HDHP [308136802] 29.3 percent of total billed charges 22.94 35.15 Technical (Hospital) Services HC/HH Wch Supp Shoe/Post-OP/Medium__18015 PX-2705000134 CDM 2705000134 LOCAL 270 RC inpatient 37 37 UNITED HEALTHCARE (COMMERCIAL) [3081199] UNITED HEALTHCARE 87726 [308119901] 22.94 percent of total billed charges 22.94 35.15 Technical (Hospital) Services HC/HH Wch Supp Shoe/Post-OP/Medium__18015 PX-2705000134 CDM 2705000134 LOCAL 270 RC inpatient 37 37 MEDICA (COMMERCIAL) 94265 [3081118] MEDICA CLAIMS [308111801] 33.3 percent of total billed charges 22.94 35.15 Technical (Hospital) Services HC/HH Wch Supp Shoe/Post-OP/Medium__18015 PX-2705000134 CDM 2705000134 LOCAL 270 RC inpatient 37 37 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES PPO [308136801] 29.3 percent of total billed charges 22.94 35.15 Technical (Hospital) Services HC/HH Wch Supp Shoe/Post-OP/Large__18017 PX-2705000133 CDM 2705000133 LOCAL 270 RC outpatient 40 40 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES PPO [308136801] 32 percent of total billed charges 24.8 38 Technical (Hospital) Services HC/HH Wch Supp Shoe/Post-OP/Large__18017 PX-2705000133 CDM 2705000133 LOCAL 270 RC outpatient 40 40 MULTIPLAN INC 34080 [3081285] MULTIPLAN INC [308128501] 38 percent of total billed charges 24.8 38 Technical (Hospital) Services HC/HH Wch Supp Shoe/Post-OP/Large__18017 PX-2705000133 CDM 2705000133 LOCAL 270 RC outpatient 40 40 MEDICA (COMMERCIAL) 94265 [3081118] MEDICA CLAIMS [308111801] 36 percent of total billed charges 24.8 38 Technical (Hospital) Services HC/HH Wch Supp Shoe/Post-OP/Large__18017 PX-2705000133 CDM 2705000133 LOCAL 270 RC outpatient 40 40 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES EPO [308136803] 32 percent of total billed charges 24.8 38 Technical (Hospital) Services HC/HH Wch Supp Shoe/Post-OP/Large__18017 PX-2705000133 CDM 2705000133 LOCAL 270 RC outpatient 40 40 CIGNA 62308 [3081051] CIGNA 62308 [308105105] 32 percent of total billed charges 24.8 38 Technical (Hospital) Services HC/HH Wch Supp Shoe/Post-OP/Large__18017 PX-2705000133 CDM 2705000133 LOCAL 270 RC outpatient 40 40 CIGNA 62308 [3081051] CIGNA STATE OF WYOMING [308105107] 32 percent of total billed charges 24.8 38 Technical (Hospital) Services HC/HH Wch Supp Shoe/Post-OP/Large__18017 PX-2705000133 CDM 2705000133 LOCAL 270 RC outpatient 40 40 BLUE CROSS BLUE SHIELD WELLMARK SB889 [3081026] BCBS WYOMING [308102603] 38 percent of total billed charges 24.8 38 Technical (Hospital) Services HC/HH Wch Supp Shoe/Post-OP/Large__18017 PX-2705000133 CDM 2705000133 LOCAL 270 RC outpatient 40 40 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES HDHP [308136802] 32 percent of total billed charges 24.8 38 Technical (Hospital) Services HC/HH Wch Supp Shoe/Post-OP/Large__18017 PX-2705000133 CDM 2705000133 LOCAL 270 RC outpatient 40 40 UNITED HEALTHCARE (COMMERCIAL) [3081199] UNITED HEALTHCARE 87726 [308119901] 24.8 percent of total billed charges 24.8 38 Technical (Hospital) Services HC/HH Wch Supp Shoe/Post-OP/Large__18017 PX-2705000133 CDM 2705000133 LOCAL 270 RC outpatient 40 40 HEALTHPARTNERS SX009 HEALTHPARTNERS 32 percent of total billed charges 24.8 38 Technical (Hospital) Services HC/HH Wch Supp Shoe/Post-OP/Large__18017 PX-2705000133 CDM 2705000133 LOCAL 270 RC inpatient 40 40 BLUE CROSS BLUE SHIELD WELLMARK SB889 [3081026] BCBS WYOMING [308102603] 38 percent of total billed charges 24.8 38 Technical (Hospital) Services HC/HH Wch Supp Shoe/Post-OP/Large__18017 PX-2705000133 CDM 2705000133 LOCAL 270 RC inpatient 40 40 MULTIPLAN INC 34080 [3081285] MULTIPLAN INC [308128501] 38 percent of total billed charges 24.8 38 Technical (Hospital) Services HC/HH Wch Supp Shoe/Post-OP/Large__18017 PX-2705000133 CDM 2705000133 LOCAL 270 RC inpatient 40 40 CIGNA 62308 [3081051] CIGNA 62308 [308105105] 31.67 percent of total billed charges 24.8 38 Technical (Hospital) Services HC/HH Wch Supp Shoe/Post-OP/Large__18017 PX-2705000133 CDM 2705000133 LOCAL 270 RC inpatient 40 40 CIGNA 62308 [3081051] CIGNA STATE OF WYOMING [308105107] 31.67 percent of total billed charges 24.8 38 Technical (Hospital) Services HC/HH Wch Supp Shoe/Post-OP/Large__18017 PX-2705000133 CDM 2705000133 LOCAL 270 RC inpatient 40 40 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES EPO [308136803] 31.67 percent of total billed charges 24.8 38 Technical (Hospital) Services HC/HH Wch Supp Shoe/Post-OP/Large__18017 PX-2705000133 CDM 2705000133 LOCAL 270 RC inpatient 40 40 HEALTHPARTNERS SX009 HEALTHPARTNERS 31.67 percent of total billed charges 24.8 38 Technical (Hospital) Services HC/HH Wch Supp Shoe/Post-OP/Large__18017 PX-2705000133 CDM 2705000133 LOCAL 270 RC inpatient 40 40 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES PPO [308136801] 31.67 percent of total billed charges 24.8 38 Technical (Hospital) Services HC/HH Wch Supp Shoe/Post-OP/Large__18017 PX-2705000133 CDM 2705000133 LOCAL 270 RC inpatient 40 40 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES HDHP [308136802] 31.67 percent of total billed charges 24.8 38 Technical (Hospital) Services HC/HH Wch Supp Shoe/Post-OP/Large__18017 PX-2705000133 CDM 2705000133 LOCAL 270 RC inpatient 40 40 MEDICA (COMMERCIAL) 94265 [3081118] MEDICA CLAIMS [308111801] 36 percent of total billed charges 24.8 38 Technical (Hospital) Services HC/HH Wch Supp Shoe/Post-OP/Large__18017 PX-2705000133 CDM 2705000133 LOCAL 270 RC inpatient 40 40 UNITED HEALTHCARE (COMMERCIAL) [3081199] UNITED HEALTHCARE 87726 [308119901] 24.8 percent of total billed charges 24.8 38 Technical (Hospital) Services HC/HH Wch Supp Sam Sling M__Sl556652 PX-2705000132 CDM 2705000132 LOCAL 270 RC outpatient 119 119 MULTIPLAN INC 34080 [3081285] MULTIPLAN INC [308128501] 113.05 percent of total billed charges 73.78 113.05 Technical (Hospital) Services HC/HH Wch Supp Sam Sling M__Sl556652 PX-2705000132 CDM 2705000132 LOCAL 270 RC outpatient 119 119 MEDICA (COMMERCIAL) 94265 [3081118] MEDICA CLAIMS [308111801] 107.1 percent of total billed charges 73.78 113.05 Technical (Hospital) Services HC/HH Wch Supp Sam Sling M__Sl556652 PX-2705000132 CDM 2705000132 LOCAL 270 RC outpatient 119 119 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES PPO [308136801] 95.2 percent of total billed charges 73.78 113.05 Technical (Hospital) Services HC/HH Wch Supp Sam Sling M__Sl556652 PX-2705000132 CDM 2705000132 LOCAL 270 RC outpatient 119 119 UNITED HEALTHCARE (COMMERCIAL) [3081199] UNITED HEALTHCARE 87726 [308119901] 73.78 percent of total billed charges 73.78 113.05 Technical (Hospital) Services HC/HH Wch Supp Sam Sling M__Sl556652 PX-2705000132 CDM 2705000132 LOCAL 270 RC outpatient 119 119 HEALTHPARTNERS SX009 HEALTHPARTNERS 95.2 percent of total billed charges 73.78 113.05 Technical (Hospital) Services HC/HH Wch Supp Sam Sling M__Sl556652 PX-2705000132 CDM 2705000132 LOCAL 270 RC outpatient 119 119 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES EPO [308136803] 95.2 percent of total billed charges 73.78 113.05 Technical (Hospital) Services HC/HH Wch Supp Sam Sling M__Sl556652 PX-2705000132 CDM 2705000132 LOCAL 270 RC outpatient 119 119 CIGNA 62308 [3081051] CIGNA 62308 [308105105] 95.2 percent of total billed charges 73.78 113.05 Technical (Hospital) Services HC/HH Wch Supp Sam Sling M__Sl556652 PX-2705000132 CDM 2705000132 LOCAL 270 RC outpatient 119 119 BLUE CROSS BLUE SHIELD WELLMARK SB889 [3081026] BCBS WYOMING [308102603] 113.05 percent of total billed charges 73.78 113.05 Technical (Hospital) Services HC/HH Wch Supp Sam Sling M__Sl556652 PX-2705000132 CDM 2705000132 LOCAL 270 RC outpatient 119 119 CIGNA 62308 [3081051] CIGNA STATE OF WYOMING [308105107] 95.2 percent of total billed charges 73.78 113.05 Technical (Hospital) Services HC/HH Wch Supp Sam Sling M__Sl556652 PX-2705000132 CDM 2705000132 LOCAL 270 RC outpatient 119 119 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES HDHP [308136802] 95.2 percent of total billed charges 73.78 113.05 Technical (Hospital) Services HC/HH Wch Supp Sam Sling M__Sl556652 PX-2705000132 CDM 2705000132 LOCAL 270 RC inpatient 119 119 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES PPO [308136801] 94.22 percent of total billed charges 73.78 113.05 Technical (Hospital) Services HC/HH Wch Supp Sam Sling M__Sl556652 PX-2705000132 CDM 2705000132 LOCAL 270 RC inpatient 119 119 UNITED HEALTHCARE (COMMERCIAL) [3081199] UNITED HEALTHCARE 87726 [308119901] 73.78 percent of total billed charges 73.78 113.05 Technical (Hospital) Services HC/HH Wch Supp Sam Sling M__Sl556652 PX-2705000132 CDM 2705000132 LOCAL 270 RC inpatient 119 119 MEDICA (COMMERCIAL) 94265 [3081118] MEDICA CLAIMS [308111801] 107.1 percent of total billed charges 73.78 113.05 Technical (Hospital) Services HC/HH Wch Supp Sam Sling M__Sl556652 PX-2705000132 CDM 2705000132 LOCAL 270 RC inpatient 119 119 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES HDHP [308136802] 94.22 percent of total billed charges 73.78 113.05 Technical (Hospital) Services HC/HH Wch Supp Sam Sling M__Sl556652 PX-2705000132 CDM 2705000132 LOCAL 270 RC inpatient 119 119 MULTIPLAN INC 34080 [3081285] MULTIPLAN INC [308128501] 113.05 percent of total billed charges 73.78 113.05 Technical (Hospital) Services HC/HH Wch Supp Sam Sling M__Sl556652 PX-2705000132 CDM 2705000132 LOCAL 270 RC inpatient 119 119 BLUE CROSS BLUE SHIELD WELLMARK SB889 [3081026] BCBS WYOMING [308102603] 113.05 percent of total billed charges 73.78 113.05 Technical (Hospital) Services HC/HH Wch Supp Sam Sling M__Sl556652 PX-2705000132 CDM 2705000132 LOCAL 270 RC inpatient 119 119 CIGNA 62308 [3081051] CIGNA 62308 [308105105] 94.22 percent of total billed charges 73.78 113.05 Technical (Hospital) Services HC/HH Wch Supp Sam Sling M__Sl556652 PX-2705000132 CDM 2705000132 LOCAL 270 RC inpatient 119 119 CIGNA 62308 [3081051] CIGNA STATE OF WYOMING [308105107] 94.22 percent of total billed charges 73.78 113.05 Technical (Hospital) Services HC/HH Wch Supp Sam Sling M__Sl556652 PX-2705000132 CDM 2705000132 LOCAL 270 RC inpatient 119 119 HEALTHPARTNERS SX009 HEALTHPARTNERS 94.22 percent of total billed charges 73.78 113.05 Technical (Hospital) Services HC/HH Wch Supp Sam Sling M__Sl556652 PX-2705000132 CDM 2705000132 LOCAL 270 RC inpatient 119 119 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES EPO [308136803] 94.22 percent of total billed charges 73.78 113.05 Technical (Hospital) Services HC/HH Wch Supp Sam Sling L__Sl55662 PX-2705000131 CDM 2705000131 LOCAL 270 RC inpatient 86 86 HEALTHPARTNERS SX009 HEALTHPARTNERS 68.09 percent of total billed charges 53.32 81.7 Technical (Hospital) Services HC/HH Wch Supp Sam Sling L__Sl55662 PX-2705000131 CDM 2705000131 LOCAL 270 RC inpatient 86 86 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES EPO [308136803] 68.09 percent of total billed charges 53.32 81.7 Technical (Hospital) Services HC/HH Wch Supp Sam Sling L__Sl55662 PX-2705000131 CDM 2705000131 LOCAL 270 RC inpatient 86 86 CIGNA 62308 [3081051] CIGNA 62308 [308105105] 68.09 percent of total billed charges 53.32 81.7 Technical (Hospital) Services HC/HH Wch Supp Sam Sling L__Sl55662 PX-2705000131 CDM 2705000131 LOCAL 270 RC inpatient 86 86 CIGNA 62308 [3081051] CIGNA STATE OF WYOMING [308105107] 68.09 percent of total billed charges 53.32 81.7 Technical (Hospital) Services HC/HH Wch Supp Sam Sling L__Sl55662 PX-2705000131 CDM 2705000131 LOCAL 270 RC inpatient 86 86 BLUE CROSS BLUE SHIELD WELLMARK SB889 [3081026] BCBS WYOMING [308102603] 81.7 percent of total billed charges 53.32 81.7 Technical (Hospital) Services HC/HH Wch Supp Sam Sling L__Sl55662 PX-2705000131 CDM 2705000131 LOCAL 270 RC inpatient 86 86 MULTIPLAN INC 34080 [3081285] MULTIPLAN INC [308128501] 81.7 percent of total billed charges 53.32 81.7 Technical (Hospital) Services HC/HH Wch Supp Sam Sling L__Sl55662 PX-2705000131 CDM 2705000131 LOCAL 270 RC inpatient 86 86 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES HDHP [308136802] 68.09 percent of total billed charges 53.32 81.7 Technical (Hospital) Services HC/HH Wch Supp Sam Sling L__Sl55662 PX-2705000131 CDM 2705000131 LOCAL 270 RC inpatient 86 86 UNITED HEALTHCARE (COMMERCIAL) [3081199] UNITED HEALTHCARE 87726 [308119901] 53.32 percent of total billed charges 53.32 81.7 Technical (Hospital) Services HC/HH Wch Supp Sam Sling L__Sl55662 PX-2705000131 CDM 2705000131 LOCAL 270 RC inpatient 86 86 MEDICA (COMMERCIAL) 94265 [3081118] MEDICA CLAIMS [308111801] 77.4 percent of total billed charges 53.32 81.7 Technical (Hospital) Services HC/HH Wch Supp Sam Sling L__Sl55662 PX-2705000131 CDM 2705000131 LOCAL 270 RC inpatient 86 86 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES PPO [308136801] 68.09 percent of total billed charges 53.32 81.7 Technical (Hospital) Services HC/HH Wch Supp Sam Sling L__Sl55662 PX-2705000131 CDM 2705000131 LOCAL 270 RC outpatient 86 86 HEALTHPARTNERS SX009 HEALTHPARTNERS 68.8 percent of total billed charges 53.32 81.7 Technical (Hospital) Services HC/HH Wch Supp Sam Sling L__Sl55662 PX-2705000131 CDM 2705000131 LOCAL 270 RC outpatient 86 86 UNITED HEALTHCARE (COMMERCIAL) [3081199] UNITED HEALTHCARE 87726 [308119901] 53.32 percent of total billed charges 53.32 81.7 Technical (Hospital) Services HC/HH Wch Supp Sam Sling L__Sl55662 PX-2705000131 CDM 2705000131 LOCAL 270 RC outpatient 86 86 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES HDHP [308136802] 68.8 percent of total billed charges 53.32 81.7 Technical (Hospital) Services HC/HH Wch Supp Sam Sling L__Sl55662 PX-2705000131 CDM 2705000131 LOCAL 270 RC outpatient 86 86 BLUE CROSS BLUE SHIELD WELLMARK SB889 [3081026] BCBS WYOMING [308102603] 81.7 percent of total billed charges 53.32 81.7 Technical (Hospital) Services HC/HH Wch Supp Sam Sling L__Sl55662 PX-2705000131 CDM 2705000131 LOCAL 270 RC outpatient 86 86 CIGNA 62308 [3081051] CIGNA 62308 [308105105] 68.8 percent of total billed charges 53.32 81.7 Technical (Hospital) Services HC/HH Wch Supp Sam Sling L__Sl55662 PX-2705000131 CDM 2705000131 LOCAL 270 RC outpatient 86 86 CIGNA 62308 [3081051] CIGNA STATE OF WYOMING [308105107] 68.8 percent of total billed charges 53.32 81.7 Technical (Hospital) Services HC/HH Wch Supp Sam Sling L__Sl55662 PX-2705000131 CDM 2705000131 LOCAL 270 RC outpatient 86 86 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES EPO [308136803] 68.8 percent of total billed charges 53.32 81.7 Technical (Hospital) Services HC/HH Wch Supp Sam Sling L__Sl55662 PX-2705000131 CDM 2705000131 LOCAL 270 RC outpatient 86 86 MEDICA (COMMERCIAL) 94265 [3081118] MEDICA CLAIMS [308111801] 77.4 percent of total billed charges 53.32 81.7 Technical (Hospital) Services HC/HH Wch Supp Sam Sling L__Sl55662 PX-2705000131 CDM 2705000131 LOCAL 270 RC outpatient 86 86 MULTIPLAN INC 34080 [3081285] MULTIPLAN INC [308128501] 81.7 percent of total billed charges 53.32 81.7 Technical (Hospital) Services HC/HH Wch Supp Sam Sling L__Sl55662 PX-2705000131 CDM 2705000131 LOCAL 270 RC outpatient 86 86 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES PPO [308136801] 68.8 percent of total billed charges 53.32 81.7 Technical (Hospital) Services HC/HH Wch Supp Rib Belt X Lrg__89068 PX-2705000130 CDM 2705000130 LOCAL 270 RC outpatient 38 38 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES HDHP [308136802] 30.4 percent of total billed charges 23.56 36.1 Technical (Hospital) Services HC/HH Wch Supp Rib Belt X Lrg__89068 PX-2705000130 CDM 2705000130 LOCAL 270 RC outpatient 38 38 BLUE CROSS BLUE SHIELD WELLMARK SB889 [3081026] BCBS WYOMING [308102603] 36.1 percent of total billed charges 23.56 36.1 Technical (Hospital) Services HC/HH Wch Supp Rib Belt X Lrg__89068 PX-2705000130 CDM 2705000130 LOCAL 270 RC outpatient 38 38 CIGNA 62308 [3081051] CIGNA 62308 [308105105] 30.4 percent of total billed charges 23.56 36.1 Technical (Hospital) Services HC/HH Wch Supp Rib Belt X Lrg__89068 PX-2705000130 CDM 2705000130 LOCAL 270 RC inpatient 38 38 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES EPO [308136803] 30.09 percent of total billed charges 23.56 36.1 Technical (Hospital) Services HC/HH Wch Supp Rib Belt X Lrg__89068 PX-2705000130 CDM 2705000130 LOCAL 270 RC inpatient 38 38 HEALTHPARTNERS SX009 HEALTHPARTNERS 30.09 percent of total billed charges 23.56 36.1 Technical (Hospital) Services HC/HH Wch Supp Rib Belt X Lrg__89068 PX-2705000130 CDM 2705000130 LOCAL 270 RC inpatient 38 38 BLUE CROSS BLUE SHIELD WELLMARK SB889 [3081026] BCBS WYOMING [308102603] 36.1 percent of total billed charges 23.56 36.1 Technical (Hospital) Services HC/HH Wch Supp Rib Belt X Lrg__89068 PX-2705000130 CDM 2705000130 LOCAL 270 RC inpatient 38 38 MULTIPLAN INC 34080 [3081285] MULTIPLAN INC [308128501] 36.1 percent of total billed charges 23.56 36.1 Technical (Hospital) Services HC/HH Wch Supp Rib Belt X Lrg__89068 PX-2705000130 CDM 2705000130 LOCAL 270 RC inpatient 38 38 CIGNA 62308 [3081051] CIGNA 62308 [308105105] 30.09 percent of total billed charges 23.56 36.1 Technical (Hospital) Services HC/HH Wch Supp Rib Belt X Lrg__89068 PX-2705000130 CDM 2705000130 LOCAL 270 RC inpatient 38 38 CIGNA 62308 [3081051] CIGNA STATE OF WYOMING [308105107] 30.09 percent of total billed charges 23.56 36.1 Technical (Hospital) Services HC/HH Wch Supp Rib Belt X Lrg__89068 PX-2705000130 CDM 2705000130 LOCAL 270 RC inpatient 38 38 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES PPO [308136801] 30.09 percent of total billed charges 23.56 36.1 Technical (Hospital) Services HC/HH Wch Supp Rib Belt X Lrg__89068 PX-2705000130 CDM 2705000130 LOCAL 270 RC inpatient 38 38 UNITED HEALTHCARE (COMMERCIAL) [3081199] UNITED HEALTHCARE 87726 [308119901] 23.56 percent of total billed charges 23.56 36.1 Technical (Hospital) Services HC/HH Wch Supp Rib Belt X Lrg__89068 PX-2705000130 CDM 2705000130 LOCAL 270 RC inpatient 38 38 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES HDHP [308136802] 30.09 percent of total billed charges 23.56 36.1 Technical (Hospital) Services HC/HH Wch Supp Rib Belt X Lrg__89068 PX-2705000130 CDM 2705000130 LOCAL 270 RC inpatient 38 38 MEDICA (COMMERCIAL) 94265 [3081118] MEDICA CLAIMS [308111801] 34.2 percent of total billed charges 23.56 36.1 Technical (Hospital) Services HC/HH Wch Supp Rib Belt X Lrg__89068 PX-2705000130 CDM 2705000130 LOCAL 270 RC outpatient 38 38 CIGNA 62308 [3081051] CIGNA STATE OF WYOMING [308105107] 30.4 percent of total billed charges 23.56 36.1 Technical (Hospital) Services HC/HH Wch Supp Rib Belt X Lrg__89068 PX-2705000130 CDM 2705000130 LOCAL 270 RC outpatient 38 38 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES EPO [308136803] 30.4 percent of total billed charges 23.56 36.1 Technical (Hospital) Services HC/HH Wch Supp Rib Belt X Lrg__89068 PX-2705000130 CDM 2705000130 LOCAL 270 RC outpatient 38 38 HEALTHPARTNERS SX009 HEALTHPARTNERS 30.4 percent of total billed charges 23.56 36.1 Technical (Hospital) Services HC/HH Wch Supp Rib Belt X Lrg__89068 PX-2705000130 CDM 2705000130 LOCAL 270 RC outpatient 38 38 UNITED HEALTHCARE (COMMERCIAL) [3081199] UNITED HEALTHCARE 87726 [308119901] 23.56 percent of total billed charges 23.56 36.1 Technical (Hospital) Services HC/HH Wch Supp Rib Belt X Lrg__89068 PX-2705000130 CDM 2705000130 LOCAL 270 RC outpatient 38 38 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES PPO [308136801] 30.4 percent of total billed charges 23.56 36.1 Technical (Hospital) Services HC/HH Wch Supp Rib Belt X Lrg__89068 PX-2705000130 CDM 2705000130 LOCAL 270 RC outpatient 38 38 MEDICA (COMMERCIAL) 94265 [3081118] MEDICA CLAIMS [308111801] 34.2 percent of total billed charges 23.56 36.1 Technical (Hospital) Services HC/HH Wch Supp Rib Belt X Lrg__89068 PX-2705000130 CDM 2705000130 LOCAL 270 RC outpatient 38 38 MULTIPLAN INC 34080 [3081285] MULTIPLAN INC [308128501] 36.1 percent of total billed charges 23.56 36.1 Technical (Hospital) Services HC/HH Wch Supp Rib Belt Male Sm__0814-1388 PX-2705000129 CDM 2705000129 LOCAL 270 RC inpatient 25 25 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES PPO [308136801] 19.8 percent of total billed charges 15.5 23.75 Technical (Hospital) Services HC/HH Wch Supp Rib Belt Male Sm__0814-1388 PX-2705000129 CDM 2705000129 LOCAL 270 RC inpatient 25 25 UNITED HEALTHCARE (COMMERCIAL) [3081199] UNITED HEALTHCARE 87726 [308119901] 15.5 percent of total billed charges 15.5 23.75 Technical (Hospital) Services HC/HH Wch Supp Rib Belt Male Sm__0814-1388 PX-2705000129 CDM 2705000129 LOCAL 270 RC inpatient 25 25 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES HDHP [308136802] 19.8 percent of total billed charges 15.5 23.75 Technical (Hospital) Services HC/HH Wch Supp Rib Belt Male Sm__0814-1388 PX-2705000129 CDM 2705000129 LOCAL 270 RC inpatient 25 25 MEDICA (COMMERCIAL) 94265 [3081118] MEDICA CLAIMS [308111801] 22.5 percent of total billed charges 15.5 23.75 Technical (Hospital) Services HC/HH Wch Supp Rib Belt Male Sm__0814-1388 PX-2705000129 CDM 2705000129 LOCAL 270 RC inpatient 25 25 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES EPO [308136803] 19.8 percent of total billed charges 15.5 23.75 Technical (Hospital) Services HC/HH Wch Supp Rib Belt Male Sm__0814-1388 PX-2705000129 CDM 2705000129 LOCAL 270 RC inpatient 25 25 HEALTHPARTNERS SX009 HEALTHPARTNERS 19.8 percent of total billed charges 15.5 23.75 Technical (Hospital) Services HC/HH Wch Supp Rib Belt Male Sm__0814-1388 PX-2705000129 CDM 2705000129 LOCAL 270 RC inpatient 25 25 BLUE CROSS BLUE SHIELD WELLMARK SB889 [3081026] BCBS WYOMING [308102603] 23.75 percent of total billed charges 15.5 23.75 Technical (Hospital) Services HC/HH Wch Supp Rib Belt Male Sm__0814-1388 PX-2705000129 CDM 2705000129 LOCAL 270 RC inpatient 25 25 MULTIPLAN INC 34080 [3081285] MULTIPLAN INC [308128501] 23.75 percent of total billed charges 15.5 23.75 Technical (Hospital) Services HC/HH Wch Supp Rib Belt Male Sm__0814-1388 PX-2705000129 CDM 2705000129 LOCAL 270 RC inpatient 25 25 CIGNA 62308 [3081051] CIGNA 62308 [308105105] 19.8 percent of total billed charges 15.5 23.75 Technical (Hospital) Services HC/HH Wch Supp Rib Belt Male Sm__0814-1388 PX-2705000129 CDM 2705000129 LOCAL 270 RC inpatient 25 25 CIGNA 62308 [3081051] CIGNA STATE OF WYOMING [308105107] 19.8 percent of total billed charges 15.5 23.75 Technical (Hospital) Services HC/HH Wch Supp Rib Belt Male Sm__0814-1388 PX-2705000129 CDM 2705000129 LOCAL 270 RC outpatient 25 25 MULTIPLAN INC 34080 [3081285] MULTIPLAN INC [308128501] 23.75 percent of total billed charges 15.5 23.75 Technical (Hospital) Services HC/HH Wch Supp Rib Belt Male Sm__0814-1388 PX-2705000129 CDM 2705000129 LOCAL 270 RC outpatient 25 25 MEDICA (COMMERCIAL) 94265 [3081118] MEDICA CLAIMS [308111801] 22.5 percent of total billed charges 15.5 23.75 Technical (Hospital) Services HC/HH Wch Supp Rib Belt Male Sm__0814-1388 PX-2705000129 CDM 2705000129 LOCAL 270 RC outpatient 25 25 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES PPO [308136801] 20 percent of total billed charges 15.5 23.75 Technical (Hospital) Services HC/HH Wch Supp Rib Belt Male Sm__0814-1388 PX-2705000129 CDM 2705000129 LOCAL 270 RC outpatient 25 25 UNITED HEALTHCARE (COMMERCIAL) [3081199] UNITED HEALTHCARE 87726 [308119901] 15.5 percent of total billed charges 15.5 23.75 Technical (Hospital) Services HC/HH Wch Supp Rib Belt Male Sm__0814-1388 PX-2705000129 CDM 2705000129 LOCAL 270 RC outpatient 25 25 HEALTHPARTNERS SX009 HEALTHPARTNERS 20 percent of total billed charges 15.5 23.75 Technical (Hospital) Services HC/HH Wch Supp Rib Belt Male Sm__0814-1388 PX-2705000129 CDM 2705000129 LOCAL 270 RC outpatient 25 25 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES EPO [308136803] 20 percent of total billed charges 15.5 23.75 Technical (Hospital) Services HC/HH Wch Supp Rib Belt Male Sm__0814-1388 PX-2705000129 CDM 2705000129 LOCAL 270 RC outpatient 25 25 CIGNA 62308 [3081051] CIGNA 62308 [308105105] 20 percent of total billed charges 15.5 23.75 Technical (Hospital) Services HC/HH Wch Supp Rib Belt Male Sm__0814-1388 PX-2705000129 CDM 2705000129 LOCAL 270 RC outpatient 25 25 CIGNA 62308 [3081051] CIGNA STATE OF WYOMING [308105107] 20 percent of total billed charges 15.5 23.75 Technical (Hospital) Services HC/HH Wch Supp Rib Belt Male Sm__0814-1388 PX-2705000129 CDM 2705000129 LOCAL 270 RC outpatient 25 25 BLUE CROSS BLUE SHIELD WELLMARK SB889 [3081026] BCBS WYOMING [308102603] 23.75 percent of total billed charges 15.5 23.75 Technical (Hospital) Services HC/HH Wch Supp Rib Belt Male Sm__0814-1388 PX-2705000129 CDM 2705000129 LOCAL 270 RC outpatient 25 25 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES HDHP [308136802] 20 percent of total billed charges 15.5 23.75 Technical (Hospital) Services "HC/HH Wch Supp Rib Belt 6 Female M__13780400""" PX-2705000128 CDM 2705000128 LOCAL 270 RC outpatient 53 53 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES HDHP [308136802] 42.4 percent of total billed charges 32.86 50.35 Technical (Hospital) Services "HC/HH Wch Supp Rib Belt 6 Female M__13780400""" PX-2705000128 CDM 2705000128 LOCAL 270 RC outpatient 53 53 BLUE CROSS BLUE SHIELD WELLMARK SB889 [3081026] BCBS WYOMING [308102603] 50.35 percent of total billed charges 32.86 50.35 Technical (Hospital) Services "HC/HH Wch Supp Rib Belt 6 Female M__13780400""" PX-2705000128 CDM 2705000128 LOCAL 270 RC outpatient 53 53 CIGNA 62308 [3081051] CIGNA 62308 [308105105] 42.4 percent of total billed charges 32.86 50.35 Technical (Hospital) Services "HC/HH Wch Supp Rib Belt 6 Female M__13780400""" PX-2705000128 CDM 2705000128 LOCAL 270 RC outpatient 53 53 CIGNA 62308 [3081051] CIGNA STATE OF WYOMING [308105107] 42.4 percent of total billed charges 32.86 50.35 Technical (Hospital) Services "HC/HH Wch Supp Rib Belt 6 Female M__13780400""" PX-2705000128 CDM 2705000128 LOCAL 270 RC outpatient 53 53 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES EPO [308136803] 42.4 percent of total billed charges 32.86 50.35 Technical (Hospital) Services "HC/HH Wch Supp Rib Belt 6 Female M__13780400""" PX-2705000128 CDM 2705000128 LOCAL 270 RC outpatient 53 53 HEALTHPARTNERS SX009 HEALTHPARTNERS 42.4 percent of total billed charges 32.86 50.35 Technical (Hospital) Services "HC/HH Wch Supp Rib Belt 6 Female M__13780400""" PX-2705000128 CDM 2705000128 LOCAL 270 RC outpatient 53 53 UNITED HEALTHCARE (COMMERCIAL) [3081199] UNITED HEALTHCARE 87726 [308119901] 32.86 percent of total billed charges 32.86 50.35 Technical (Hospital) Services "HC/HH Wch Supp Rib Belt 6 Female M__13780400""" PX-2705000128 CDM 2705000128 LOCAL 270 RC outpatient 53 53 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES PPO [308136801] 42.4 percent of total billed charges 32.86 50.35 Technical (Hospital) Services "HC/HH Wch Supp Rib Belt 6 Female M__13780400""" PX-2705000128 CDM 2705000128 LOCAL 270 RC outpatient 53 53 MEDICA (COMMERCIAL) 94265 [3081118] MEDICA CLAIMS [308111801] 47.7 percent of total billed charges 32.86 50.35 Technical (Hospital) Services "HC/HH Wch Supp Rib Belt 6 Female M__13780400""" PX-2705000128 CDM 2705000128 LOCAL 270 RC outpatient 53 53 MULTIPLAN INC 34080 [3081285] MULTIPLAN INC [308128501] 50.35 percent of total billed charges 32.86 50.35 Technical (Hospital) Services "HC/HH Wch Supp Rib Belt 6 Female M__13780400""" PX-2705000128 CDM 2705000128 LOCAL 270 RC inpatient 53 53 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES EPO [308136803] 41.97 percent of total billed charges 32.86 50.35 Technical (Hospital) Services "HC/HH Wch Supp Rib Belt 6 Female M__13780400""" PX-2705000128 CDM 2705000128 LOCAL 270 RC inpatient 53 53 HEALTHPARTNERS SX009 HEALTHPARTNERS 41.97 percent of total billed charges 32.86 50.35 Technical (Hospital) Services "HC/HH Wch Supp Rib Belt 6 Female M__13780400""" PX-2705000128 CDM 2705000128 LOCAL 270 RC inpatient 53 53 CIGNA 62308 [3081051] CIGNA 62308 [308105105] 41.97 percent of total billed charges 32.86 50.35 Technical (Hospital) Services "HC/HH Wch Supp Rib Belt 6 Female M__13780400""" PX-2705000128 CDM 2705000128 LOCAL 270 RC inpatient 53 53 CIGNA 62308 [3081051] CIGNA STATE OF WYOMING [308105107] 41.97 percent of total billed charges 32.86 50.35 Technical (Hospital) Services "HC/HH Wch Supp Rib Belt 6 Female M__13780400""" PX-2705000128 CDM 2705000128 LOCAL 270 RC inpatient 53 53 BLUE CROSS BLUE SHIELD WELLMARK SB889 [3081026] BCBS WYOMING [308102603] 50.35 percent of total billed charges 32.86 50.35 Technical (Hospital) Services "HC/HH Wch Supp Rib Belt 6 Female M__13780400""" PX-2705000128 CDM 2705000128 LOCAL 270 RC inpatient 53 53 MULTIPLAN INC 34080 [3081285] MULTIPLAN INC [308128501] 50.35 percent of total billed charges 32.86 50.35 Technical (Hospital) Services "HC/HH Wch Supp Rib Belt 6 Female M__13780400""" PX-2705000128 CDM 2705000128 LOCAL 270 RC inpatient 53 53 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES HDHP [308136802] 41.97 percent of total billed charges 32.86 50.35 Technical (Hospital) Services "HC/HH Wch Supp Rib Belt 6 Female M__13780400""" PX-2705000128 CDM 2705000128 LOCAL 270 RC inpatient 53 53 MEDICA (COMMERCIAL) 94265 [3081118] MEDICA CLAIMS [308111801] 47.7 percent of total billed charges 32.86 50.35 Technical (Hospital) Services "HC/HH Wch Supp Rib Belt 6 Female M__13780400""" PX-2705000128 CDM 2705000128 LOCAL 270 RC inpatient 53 53 UNITED HEALTHCARE (COMMERCIAL) [3081199] UNITED HEALTHCARE 87726 [308119901] 32.86 percent of total billed charges 32.86 50.35 Technical (Hospital) Services "HC/HH Wch Supp Rib Belt 6 Female M__13780400""" PX-2705000128 CDM 2705000128 LOCAL 270 RC inpatient 53 53 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES PPO [308136801] 41.97 percent of total billed charges 32.86 50.35 Technical (Hospital) Services "HC/HH Wch Supp Rib Belt 6 Female L__0814-1389""" PX-2705000127 CDM 2705000127 LOCAL 270 RC inpatient 26 26 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES PPO [308136801] 20.59 percent of total billed charges 16.12 24.7 Technical (Hospital) Services "HC/HH Wch Supp Rib Belt 6 Female L__0814-1389""" PX-2705000127 CDM 2705000127 LOCAL 270 RC inpatient 26 26 MEDICA (COMMERCIAL) 94265 [3081118] MEDICA CLAIMS [308111801] 23.4 percent of total billed charges 16.12 24.7 Technical (Hospital) Services "HC/HH Wch Supp Rib Belt 6 Female L__0814-1389""" PX-2705000127 CDM 2705000127 LOCAL 270 RC inpatient 26 26 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES HDHP [308136802] 20.59 percent of total billed charges 16.12 24.7 Technical (Hospital) Services "HC/HH Wch Supp Rib Belt 6 Female L__0814-1389""" PX-2705000127 CDM 2705000127 LOCAL 270 RC inpatient 26 26 UNITED HEALTHCARE (COMMERCIAL) [3081199] UNITED HEALTHCARE 87726 [308119901] 16.12 percent of total billed charges 16.12 24.7 Technical (Hospital) Services "HC/HH Wch Supp Rib Belt 6 Female L__0814-1389""" PX-2705000127 CDM 2705000127 LOCAL 270 RC inpatient 26 26 HEALTHPARTNERS SX009 HEALTHPARTNERS 20.59 percent of total billed charges 16.12 24.7 Technical (Hospital) Services "HC/HH Wch Supp Rib Belt 6 Female L__0814-1389""" PX-2705000127 CDM 2705000127 LOCAL 270 RC inpatient 26 26 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES EPO [308136803] 20.59 percent of total billed charges 16.12 24.7 Technical (Hospital) Services "HC/HH Wch Supp Rib Belt 6 Female L__0814-1389""" PX-2705000127 CDM 2705000127 LOCAL 270 RC inpatient 26 26 MULTIPLAN INC 34080 [3081285] MULTIPLAN INC [308128501] 24.7 percent of total billed charges 16.12 24.7 Technical (Hospital) Services "HC/HH Wch Supp Rib Belt 6 Female L__0814-1389""" PX-2705000127 CDM 2705000127 LOCAL 270 RC inpatient 26 26 BLUE CROSS BLUE SHIELD WELLMARK SB889 [3081026] BCBS WYOMING [308102603] 24.7 percent of total billed charges 16.12 24.7 Technical (Hospital) Services "HC/HH Wch Supp Rib Belt 6 Female L__0814-1389""" PX-2705000127 CDM 2705000127 LOCAL 270 RC inpatient 26 26 CIGNA 62308 [3081051] CIGNA 62308 [308105105] 20.59 percent of total billed charges 16.12 24.7 Technical (Hospital) Services "HC/HH Wch Supp Rib Belt 6 Female L__0814-1389""" PX-2705000127 CDM 2705000127 LOCAL 270 RC inpatient 26 26 CIGNA 62308 [3081051] CIGNA STATE OF WYOMING [308105107] 20.59 percent of total billed charges 16.12 24.7 Technical (Hospital) Services "HC/HH Wch Supp Rib Belt 6 Female L__0814-1389""" PX-2705000127 CDM 2705000127 LOCAL 270 RC outpatient 26 26 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES HDHP [308136802] 20.8 percent of total billed charges 16.12 24.7 Technical (Hospital) Services "HC/HH Wch Supp Rib Belt 6 Female L__0814-1389""" PX-2705000127 CDM 2705000127 LOCAL 270 RC outpatient 26 26 CIGNA 62308 [3081051] CIGNA 62308 [308105105] 20.8 percent of total billed charges 16.12 24.7 Technical (Hospital) Services "HC/HH Wch Supp Rib Belt 6 Female L__0814-1389""" PX-2705000127 CDM 2705000127 LOCAL 270 RC outpatient 26 26 CIGNA 62308 [3081051] CIGNA STATE OF WYOMING [308105107] 20.8 percent of total billed charges 16.12 24.7 Technical (Hospital) Services "HC/HH Wch Supp Rib Belt 6 Female L__0814-1389""" PX-2705000127 CDM 2705000127 LOCAL 270 RC outpatient 26 26 BLUE CROSS BLUE SHIELD WELLMARK SB889 [3081026] BCBS WYOMING [308102603] 24.7 percent of total billed charges 16.12 24.7 Technical (Hospital) Services "HC/HH Wch Supp Rib Belt 6 Female L__0814-1389""" PX-2705000127 CDM 2705000127 LOCAL 270 RC outpatient 26 26 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES EPO [308136803] 20.8 percent of total billed charges 16.12 24.7 Technical (Hospital) Services "HC/HH Wch Supp Rib Belt 6 Female L__0814-1389""" PX-2705000127 CDM 2705000127 LOCAL 270 RC outpatient 26 26 HEALTHPARTNERS SX009 HEALTHPARTNERS 20.8 percent of total billed charges 16.12 24.7 Technical (Hospital) Services "HC/HH Wch Supp Rib Belt 6 Female L__0814-1389""" PX-2705000127 CDM 2705000127 LOCAL 270 RC outpatient 26 26 UNITED HEALTHCARE (COMMERCIAL) [3081199] UNITED HEALTHCARE 87726 [308119901] 16.12 percent of total billed charges 16.12 24.7 Technical (Hospital) Services "HC/HH Wch Supp Rib Belt 6 Female L__0814-1389""" PX-2705000127 CDM 2705000127 LOCAL 270 RC outpatient 26 26 MEDICA (COMMERCIAL) 94265 [3081118] MEDICA CLAIMS [308111801] 23.4 percent of total billed charges 16.12 24.7 Technical (Hospital) Services "HC/HH Wch Supp Rib Belt 6 Female L__0814-1389""" PX-2705000127 CDM 2705000127 LOCAL 270 RC outpatient 26 26 MULTIPLAN INC 34080 [3081285] MULTIPLAN INC [308128501] 24.7 percent of total billed charges 16.12 24.7 Technical (Hospital) Services "HC/HH Wch Supp Rib Belt 6 Female L__0814-1389""" PX-2705000127 CDM 2705000127 LOCAL 270 RC outpatient 26 26 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES PPO [308136801] 20.8 percent of total billed charges 16.12 24.7 Technical (Hospital) Services HC/HH Wch Supp Rhino Rocket Small__11s-S0300-08as PX-2705000126 CDM 2705000126 LOCAL 270 RC outpatient 47 47 MULTIPLAN INC 34080 [3081285] MULTIPLAN INC [308128501] 44.65 percent of total billed charges 29.14 44.65 Technical (Hospital) Services HC/HH Wch Supp Rhino Rocket Small__11s-S0300-08as PX-2705000126 CDM 2705000126 LOCAL 270 RC outpatient 47 47 MEDICA (COMMERCIAL) 94265 [3081118] MEDICA CLAIMS [308111801] 42.3 percent of total billed charges 29.14 44.65 Technical (Hospital) Services HC/HH Wch Supp Rhino Rocket Small__11s-S0300-08as PX-2705000126 CDM 2705000126 LOCAL 270 RC outpatient 47 47 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES PPO [308136801] 37.6 percent of total billed charges 29.14 44.65 Technical (Hospital) Services HC/HH Wch Supp Rhino Rocket Small__11s-S0300-08as PX-2705000126 CDM 2705000126 LOCAL 270 RC outpatient 47 47 UNITED HEALTHCARE (COMMERCIAL) [3081199] UNITED HEALTHCARE 87726 [308119901] 29.14 percent of total billed charges 29.14 44.65 Technical (Hospital) Services HC/HH Wch Supp Rhino Rocket Small__11s-S0300-08as PX-2705000126 CDM 2705000126 LOCAL 270 RC outpatient 47 47 HEALTHPARTNERS SX009 HEALTHPARTNERS 37.6 percent of total billed charges 29.14 44.65 Technical (Hospital) Services HC/HH Wch Supp Rhino Rocket Small__11s-S0300-08as PX-2705000126 CDM 2705000126 LOCAL 270 RC outpatient 47 47 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES EPO [308136803] 37.6 percent of total billed charges 29.14 44.65 Technical (Hospital) Services HC/HH Wch Supp Rhino Rocket Small__11s-S0300-08as PX-2705000126 CDM 2705000126 LOCAL 270 RC outpatient 47 47 CIGNA 62308 [3081051] CIGNA 62308 [308105105] 37.6 percent of total billed charges 29.14 44.65 Technical (Hospital) Services HC/HH Wch Supp Rhino Rocket Small__11s-S0300-08as PX-2705000126 CDM 2705000126 LOCAL 270 RC outpatient 47 47 CIGNA 62308 [3081051] CIGNA STATE OF WYOMING [308105107] 37.6 percent of total billed charges 29.14 44.65 Technical (Hospital) Services HC/HH Wch Supp Rhino Rocket Small__11s-S0300-08as PX-2705000126 CDM 2705000126 LOCAL 270 RC outpatient 47 47 BLUE CROSS BLUE SHIELD WELLMARK SB889 [3081026] BCBS WYOMING [308102603] 44.65 percent of total billed charges 29.14 44.65 Technical (Hospital) Services HC/HH Wch Supp Rhino Rocket Small__11s-S0300-08as PX-2705000126 CDM 2705000126 LOCAL 270 RC outpatient 47 47 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES HDHP [308136802] 37.6 percent of total billed charges 29.14 44.65 Technical (Hospital) Services HC/HH Wch Supp Rhino Rocket Small__11s-S0300-08as PX-2705000126 CDM 2705000126 LOCAL 270 RC inpatient 47 47 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES PPO [308136801] 37.21 percent of total billed charges 29.14 44.65 Technical (Hospital) Services HC/HH Wch Supp Rhino Rocket Small__11s-S0300-08as PX-2705000126 CDM 2705000126 LOCAL 270 RC inpatient 47 47 UNITED HEALTHCARE (COMMERCIAL) [3081199] UNITED HEALTHCARE 87726 [308119901] 29.14 percent of total billed charges 29.14 44.65 Technical (Hospital) Services HC/HH Wch Supp Rhino Rocket Small__11s-S0300-08as PX-2705000126 CDM 2705000126 LOCAL 270 RC inpatient 47 47 MEDICA (COMMERCIAL) 94265 [3081118] MEDICA CLAIMS [308111801] 42.3 percent of total billed charges 29.14 44.65 Technical (Hospital) Services HC/HH Wch Supp Rhino Rocket Small__11s-S0300-08as PX-2705000126 CDM 2705000126 LOCAL 270 RC inpatient 47 47 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES HDHP [308136802] 37.21 percent of total billed charges 29.14 44.65 Technical (Hospital) Services HC/HH Wch Supp Rhino Rocket Small__11s-S0300-08as PX-2705000126 CDM 2705000126 LOCAL 270 RC inpatient 47 47 MULTIPLAN INC 34080 [3081285] MULTIPLAN INC [308128501] 44.65 percent of total billed charges 29.14 44.65 Technical (Hospital) Services HC/HH Wch Supp Rhino Rocket Small__11s-S0300-08as PX-2705000126 CDM 2705000126 LOCAL 270 RC inpatient 47 47 BLUE CROSS BLUE SHIELD WELLMARK SB889 [3081026] BCBS WYOMING [308102603] 44.65 percent of total billed charges 29.14 44.65 Technical (Hospital) Services HC/HH Wch Supp Rhino Rocket Small__11s-S0300-08as PX-2705000126 CDM 2705000126 LOCAL 270 RC inpatient 47 47 CIGNA 62308 [3081051] CIGNA 62308 [308105105] 37.21 percent of total billed charges 29.14 44.65 Technical (Hospital) Services HC/HH Wch Supp Rhino Rocket Small__11s-S0300-08as PX-2705000126 CDM 2705000126 LOCAL 270 RC inpatient 47 47 CIGNA 62308 [3081051] CIGNA STATE OF WYOMING [308105107] 37.21 percent of total billed charges 29.14 44.65 Technical (Hospital) Services HC/HH Wch Supp Rhino Rocket Small__11s-S0300-08as PX-2705000126 CDM 2705000126 LOCAL 270 RC inpatient 47 47 HEALTHPARTNERS SX009 HEALTHPARTNERS 37.21 percent of total billed charges 29.14 44.65 Technical (Hospital) Services HC/HH Wch Supp Rhino Rocket Small__11s-S0300-08as PX-2705000126 CDM 2705000126 LOCAL 270 RC inpatient 47 47 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES EPO [308136803] 37.21 percent of total billed charges 29.14 44.65 Technical (Hospital) Services HC/HH Wch Supp Rhino Rocket Med__11s-S0500-08as PX-2705000125 CDM 2705000125 LOCAL 270 RC outpatient 47 47 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES HDHP [308136802] 37.6 percent of total billed charges 29.14 44.65 Technical (Hospital) Services HC/HH Wch Supp Rhino Rocket Med__11s-S0500-08as PX-2705000125 CDM 2705000125 LOCAL 270 RC outpatient 47 47 BLUE CROSS BLUE SHIELD WELLMARK SB889 [3081026] BCBS WYOMING [308102603] 44.65 percent of total billed charges 29.14 44.65 Technical (Hospital) Services HC/HH Wch Supp Rhino Rocket Med__11s-S0500-08as PX-2705000125 CDM 2705000125 LOCAL 270 RC outpatient 47 47 CIGNA 62308 [3081051] CIGNA 62308 [308105105] 37.6 percent of total billed charges 29.14 44.65 Technical (Hospital) Services HC/HH Wch Supp Rhino Rocket Med__11s-S0500-08as PX-2705000125 CDM 2705000125 LOCAL 270 RC outpatient 47 47 CIGNA 62308 [3081051] CIGNA STATE OF WYOMING [308105107] 37.6 percent of total billed charges 29.14 44.65 Technical (Hospital) Services HC/HH Wch Supp Rhino Rocket Med__11s-S0500-08as PX-2705000125 CDM 2705000125 LOCAL 270 RC outpatient 47 47 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES EPO [308136803] 37.6 percent of total billed charges 29.14 44.65 Technical (Hospital) Services HC/HH Wch Supp Rhino Rocket Med__11s-S0500-08as PX-2705000125 CDM 2705000125 LOCAL 270 RC outpatient 47 47 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES PPO [308136801] 37.6 percent of total billed charges 29.14 44.65 Technical (Hospital) Services HC/HH Wch Supp Rhino Rocket Med__11s-S0500-08as PX-2705000125 CDM 2705000125 LOCAL 270 RC outpatient 47 47 HEALTHPARTNERS SX009 HEALTHPARTNERS 37.6 percent of total billed charges 29.14 44.65 Technical (Hospital) Services HC/HH Wch Supp Rhino Rocket Med__11s-S0500-08as PX-2705000125 CDM 2705000125 LOCAL 270 RC outpatient 47 47 UNITED HEALTHCARE (COMMERCIAL) [3081199] UNITED HEALTHCARE 87726 [308119901] 29.14 percent of total billed charges 29.14 44.65 Technical (Hospital) Services HC/HH Wch Supp Rhino Rocket Med__11s-S0500-08as PX-2705000125 CDM 2705000125 LOCAL 270 RC outpatient 47 47 MULTIPLAN INC 34080 [3081285] MULTIPLAN INC [308128501] 44.65 percent of total billed charges 29.14 44.65 Technical (Hospital) Services HC/HH Wch Supp Rhino Rocket Med__11s-S0500-08as PX-2705000125 CDM 2705000125 LOCAL 270 RC outpatient 47 47 MEDICA (COMMERCIAL) 94265 [3081118] MEDICA CLAIMS [308111801] 42.3 percent of total billed charges 29.14 44.65 Technical (Hospital) Services HC/HH Wch Supp Rhino Rocket Med__11s-S0500-08as PX-2705000125 CDM 2705000125 LOCAL 270 RC inpatient 47 47 UNITED HEALTHCARE (COMMERCIAL) [3081199] UNITED HEALTHCARE 87726 [308119901] 29.14 percent of total billed charges 29.14 44.65 Technical (Hospital) Services HC/HH Wch Supp Rhino Rocket Med__11s-S0500-08as PX-2705000125 CDM 2705000125 LOCAL 270 RC inpatient 47 47 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES HDHP [308136802] 37.21 percent of total billed charges 29.14 44.65 Technical (Hospital) Services HC/HH Wch Supp Rhino Rocket Med__11s-S0500-08as PX-2705000125 CDM 2705000125 LOCAL 270 RC inpatient 47 47 MEDICA (COMMERCIAL) 94265 [3081118] MEDICA CLAIMS [308111801] 42.3 percent of total billed charges 29.14 44.65 Technical (Hospital) Services HC/HH Wch Supp Rhino Rocket Med__11s-S0500-08as PX-2705000125 CDM 2705000125 LOCAL 270 RC inpatient 47 47 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES PPO [308136801] 37.21 percent of total billed charges 29.14 44.65 Technical (Hospital) Services HC/HH Wch Supp Rhino Rocket Med__11s-S0500-08as PX-2705000125 CDM 2705000125 LOCAL 270 RC inpatient 47 47 MULTIPLAN INC 34080 [3081285] MULTIPLAN INC [308128501] 44.65 percent of total billed charges 29.14 44.65 Technical (Hospital) Services HC/HH Wch Supp Rhino Rocket Med__11s-S0500-08as PX-2705000125 CDM 2705000125 LOCAL 270 RC inpatient 47 47 BLUE CROSS BLUE SHIELD WELLMARK SB889 [3081026] BCBS WYOMING [308102603] 44.65 percent of total billed charges 29.14 44.65 Technical (Hospital) Services HC/HH Wch Supp Rhino Rocket Med__11s-S0500-08as PX-2705000125 CDM 2705000125 LOCAL 270 RC inpatient 47 47 CIGNA 62308 [3081051] CIGNA 62308 [308105105] 37.21 percent of total billed charges 29.14 44.65 Technical (Hospital) Services HC/HH Wch Supp Rhino Rocket Med__11s-S0500-08as PX-2705000125 CDM 2705000125 LOCAL 270 RC inpatient 47 47 CIGNA 62308 [3081051] CIGNA STATE OF WYOMING [308105107] 37.21 percent of total billed charges 29.14 44.65 Technical (Hospital) Services HC/HH Wch Supp Rhino Rocket Med__11s-S0500-08as PX-2705000125 CDM 2705000125 LOCAL 270 RC inpatient 47 47 HEALTHPARTNERS SX009 HEALTHPARTNERS 37.21 percent of total billed charges 29.14 44.65 Technical (Hospital) Services HC/HH Wch Supp Rhino Rocket Med__11s-S0500-08as PX-2705000125 CDM 2705000125 LOCAL 270 RC inpatient 47 47 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES EPO [308136803] 37.21 percent of total billed charges 29.14 44.65 Technical (Hospital) Services HC/HH Wch Supp Rhino Rocket Large__11s-S0800-08as PX-2705000124 CDM 2705000124 LOCAL 270 RC outpatient 55 55 UNITED HEALTHCARE (COMMERCIAL) [3081199] UNITED HEALTHCARE 87726 [308119901] 34.1 percent of total billed charges 34.1 52.25 Technical (Hospital) Services HC/HH Wch Supp Rhino Rocket Large__11s-S0800-08as PX-2705000124 CDM 2705000124 LOCAL 270 RC outpatient 55 55 HEALTHPARTNERS SX009 HEALTHPARTNERS 44 percent of total billed charges 34.1 52.25 Technical (Hospital) Services HC/HH Wch Supp Rhino Rocket Large__11s-S0800-08as PX-2705000124 CDM 2705000124 LOCAL 270 RC outpatient 55 55 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES PPO [308136801] 44 percent of total billed charges 34.1 52.25 Technical (Hospital) Services HC/HH Wch Supp Rhino Rocket Large__11s-S0800-08as PX-2705000124 CDM 2705000124 LOCAL 270 RC outpatient 55 55 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES HDHP [308136802] 44 percent of total billed charges 34.1 52.25 Technical (Hospital) Services HC/HH Wch Supp Rhino Rocket Large__11s-S0800-08as PX-2705000124 CDM 2705000124 LOCAL 270 RC outpatient 55 55 BLUE CROSS BLUE SHIELD WELLMARK SB889 [3081026] BCBS WYOMING [308102603] 52.25 percent of total billed charges 34.1 52.25 Technical (Hospital) Services HC/HH Wch Supp Rhino Rocket Large__11s-S0800-08as PX-2705000124 CDM 2705000124 LOCAL 270 RC outpatient 55 55 CIGNA 62308 [3081051] CIGNA 62308 [308105105] 44 percent of total billed charges 34.1 52.25 Technical (Hospital) Services HC/HH Wch Supp Rhino Rocket Large__11s-S0800-08as PX-2705000124 CDM 2705000124 LOCAL 270 RC outpatient 55 55 CIGNA 62308 [3081051] CIGNA STATE OF WYOMING [308105107] 44 percent of total billed charges 34.1 52.25 Technical (Hospital) Services HC/HH Wch Supp Rhino Rocket Large__11s-S0800-08as PX-2705000124 CDM 2705000124 LOCAL 270 RC outpatient 55 55 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES EPO [308136803] 44 percent of total billed charges 34.1 52.25 Technical (Hospital) Services HC/HH Wch Supp Rhino Rocket Large__11s-S0800-08as PX-2705000124 CDM 2705000124 LOCAL 270 RC outpatient 55 55 MULTIPLAN INC 34080 [3081285] MULTIPLAN INC [308128501] 52.25 percent of total billed charges 34.1 52.25 Technical (Hospital) Services HC/HH Wch Supp Rhino Rocket Large__11s-S0800-08as PX-2705000124 CDM 2705000124 LOCAL 270 RC outpatient 55 55 MEDICA (COMMERCIAL) 94265 [3081118] MEDICA CLAIMS [308111801] 49.5 percent of total billed charges 34.1 52.25 Technical (Hospital) Services HC/HH Wch Supp Rhino Rocket Large__11s-S0800-08as PX-2705000124 CDM 2705000124 LOCAL 270 RC inpatient 55 55 HEALTHPARTNERS SX009 HEALTHPARTNERS 43.55 percent of total billed charges 34.1 52.25 Technical (Hospital) Services HC/HH Wch Supp Rhino Rocket Large__11s-S0800-08as PX-2705000124 CDM 2705000124 LOCAL 270 RC inpatient 55 55 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES EPO [308136803] 43.55 percent of total billed charges 34.1 52.25 Technical (Hospital) Services HC/HH Wch Supp Rhino Rocket Large__11s-S0800-08as PX-2705000124 CDM 2705000124 LOCAL 270 RC inpatient 55 55 CIGNA 62308 [3081051] CIGNA 62308 [308105105] 43.55 percent of total billed charges 34.1 52.25 Technical (Hospital) Services HC/HH Wch Supp Rhino Rocket Large__11s-S0800-08as PX-2705000124 CDM 2705000124 LOCAL 270 RC inpatient 55 55 CIGNA 62308 [3081051] CIGNA STATE OF WYOMING [308105107] 43.55 percent of total billed charges 34.1 52.25 Technical (Hospital) Services HC/HH Wch Supp Rhino Rocket Large__11s-S0800-08as PX-2705000124 CDM 2705000124 LOCAL 270 RC inpatient 55 55 BLUE CROSS BLUE SHIELD WELLMARK SB889 [3081026] BCBS WYOMING [308102603] 52.25 percent of total billed charges 34.1 52.25 Technical (Hospital) Services HC/HH Wch Supp Rhino Rocket Large__11s-S0800-08as PX-2705000124 CDM 2705000124 LOCAL 270 RC inpatient 55 55 MULTIPLAN INC 34080 [3081285] MULTIPLAN INC [308128501] 52.25 percent of total billed charges 34.1 52.25 Technical (Hospital) Services HC/HH Wch Supp Rhino Rocket Large__11s-S0800-08as PX-2705000124 CDM 2705000124 LOCAL 270 RC inpatient 55 55 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES PPO [308136801] 43.55 percent of total billed charges 34.1 52.25 Technical (Hospital) Services HC/HH Wch Supp Rhino Rocket Large__11s-S0800-08as PX-2705000124 CDM 2705000124 LOCAL 270 RC inpatient 55 55 MEDICA (COMMERCIAL) 94265 [3081118] MEDICA CLAIMS [308111801] 49.5 percent of total billed charges 34.1 52.25 Technical (Hospital) Services HC/HH Wch Supp Rhino Rocket Large__11s-S0800-08as PX-2705000124 CDM 2705000124 LOCAL 270 RC inpatient 55 55 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES HDHP [308136802] 43.55 percent of total billed charges 34.1 52.25 Technical (Hospital) Services HC/HH Wch Supp Rhino Rocket Large__11s-S0800-08as PX-2705000124 CDM 2705000124 LOCAL 270 RC inpatient 55 55 UNITED HEALTHCARE (COMMERCIAL) [3081199] UNITED HEALTHCARE 87726 [308119901] 34.1 percent of total billed charges 34.1 52.25 Technical (Hospital) Services HC/HH Wch Supp Razor Nonsterile__Kend139083 PX-2705000123 CDM 2705000123 LOCAL 270 RC inpatient 6 6 UNITED HEALTHCARE (COMMERCIAL) [3081199] UNITED HEALTHCARE 87726 [308119901] 3.72 percent of total billed charges 3.72 5.7 Technical (Hospital) Services HC/HH Wch Supp Razor Nonsterile__Kend139083 PX-2705000123 CDM 2705000123 LOCAL 270 RC inpatient 6 6 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES HDHP [308136802] 4.75 percent of total billed charges 3.72 5.7 Technical (Hospital) Services HC/HH Wch Supp Razor Nonsterile__Kend139083 PX-2705000123 CDM 2705000123 LOCAL 270 RC inpatient 6 6 MEDICA (COMMERCIAL) 94265 [3081118] MEDICA CLAIMS [308111801] 5.4 percent of total billed charges 3.72 5.7 Technical (Hospital) Services HC/HH Wch Supp Razor Nonsterile__Kend139083 PX-2705000123 CDM 2705000123 LOCAL 270 RC inpatient 6 6 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES PPO [308136801] 4.75 percent of total billed charges 3.72 5.7 Technical (Hospital) Services HC/HH Wch Supp Razor Nonsterile__Kend139083 PX-2705000123 CDM 2705000123 LOCAL 270 RC inpatient 6 6 MULTIPLAN INC 34080 [3081285] MULTIPLAN INC [308128501] 5.7 percent of total billed charges 3.72 5.7 Technical (Hospital) Services HC/HH Wch Supp Razor Nonsterile__Kend139083 PX-2705000123 CDM 2705000123 LOCAL 270 RC inpatient 6 6 BLUE CROSS BLUE SHIELD WELLMARK SB889 [3081026] BCBS WYOMING [308102603] 5.7 percent of total billed charges 3.72 5.7 Technical (Hospital) Services HC/HH Wch Supp Razor Nonsterile__Kend139083 PX-2705000123 CDM 2705000123 LOCAL 270 RC inpatient 6 6 CIGNA 62308 [3081051] CIGNA 62308 [308105105] 4.75 percent of total billed charges 3.72 5.7 Technical (Hospital) Services HC/HH Wch Supp Razor Nonsterile__Kend139083 PX-2705000123 CDM 2705000123 LOCAL 270 RC inpatient 6 6 CIGNA 62308 [3081051] CIGNA STATE OF WYOMING [308105107] 4.75 percent of total billed charges 3.72 5.7 Technical (Hospital) Services HC/HH Wch Supp Razor Nonsterile__Kend139083 PX-2705000123 CDM 2705000123 LOCAL 270 RC inpatient 6 6 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES EPO [308136803] 4.75 percent of total billed charges 3.72 5.7 Technical (Hospital) Services HC/HH Wch Supp Razor Nonsterile__Kend139083 PX-2705000123 CDM 2705000123 LOCAL 270 RC inpatient 6 6 HEALTHPARTNERS SX009 HEALTHPARTNERS 4.75 percent of total billed charges 3.72 5.7 Technical (Hospital) Services HC/HH Wch Supp Razor Nonsterile__Kend139083 PX-2705000123 CDM 2705000123 LOCAL 270 RC outpatient 6 6 MEDICA (COMMERCIAL) 94265 [3081118] MEDICA CLAIMS [308111801] 5.4 percent of total billed charges 3.72 5.7 Technical (Hospital) Services HC/HH Wch Supp Razor Nonsterile__Kend139083 PX-2705000123 CDM 2705000123 LOCAL 270 RC outpatient 6 6 MULTIPLAN INC 34080 [3081285] MULTIPLAN INC [308128501] 5.7 percent of total billed charges 3.72 5.7 Technical (Hospital) Services HC/HH Wch Supp Razor Nonsterile__Kend139083 PX-2705000123 CDM 2705000123 LOCAL 270 RC outpatient 6 6 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES PPO [308136801] 4.8 percent of total billed charges 3.72 5.7 Technical (Hospital) Services HC/HH Wch Supp Razor Nonsterile__Kend139083 PX-2705000123 CDM 2705000123 LOCAL 270 RC outpatient 6 6 HEALTHPARTNERS SX009 HEALTHPARTNERS 4.8 percent of total billed charges 3.72 5.7 Technical (Hospital) Services HC/HH Wch Supp Razor Nonsterile__Kend139083 PX-2705000123 CDM 2705000123 LOCAL 270 RC outpatient 6 6 UNITED HEALTHCARE (COMMERCIAL) [3081199] UNITED HEALTHCARE 87726 [308119901] 3.72 percent of total billed charges 3.72 5.7 Technical (Hospital) Services HC/HH Wch Supp Razor Nonsterile__Kend139083 PX-2705000123 CDM 2705000123 LOCAL 270 RC outpatient 6 6 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES HDHP [308136802] 4.8 percent of total billed charges 3.72 5.7 Technical (Hospital) Services HC/HH Wch Supp Razor Nonsterile__Kend139083 PX-2705000123 CDM 2705000123 LOCAL 270 RC outpatient 6 6 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES EPO [308136803] 4.8 percent of total billed charges 3.72 5.7 Technical (Hospital) Services HC/HH Wch Supp Razor Nonsterile__Kend139083 PX-2705000123 CDM 2705000123 LOCAL 270 RC outpatient 6 6 BLUE CROSS BLUE SHIELD WELLMARK SB889 [3081026] BCBS WYOMING [308102603] 5.7 percent of total billed charges 3.72 5.7 Technical (Hospital) Services HC/HH Wch Supp Razor Nonsterile__Kend139083 PX-2705000123 CDM 2705000123 LOCAL 270 RC outpatient 6 6 CIGNA 62308 [3081051] CIGNA 62308 [308105105] 4.8 percent of total billed charges 3.72 5.7 Technical (Hospital) Services HC/HH Wch Supp Razor Nonsterile__Kend139083 PX-2705000123 CDM 2705000123 LOCAL 270 RC outpatient 6 6 CIGNA 62308 [3081051] CIGNA STATE OF WYOMING [308105107] 4.8 percent of total billed charges 3.72 5.7 Technical (Hospital) Services HC/HH Wch Supp Quickvue One-Step Hcg Combo__00178 PX-2705000122 CDM 2705000122 LOCAL 270 RC inpatient 4 4 BLUE CROSS BLUE SHIELD WELLMARK SB889 [3081026] BCBS WYOMING [308102603] 3.8 percent of total billed charges 2.48 3.8 Technical (Hospital) Services HC/HH Wch Supp Quickvue One-Step Hcg Combo__00178 PX-2705000122 CDM 2705000122 LOCAL 270 RC inpatient 4 4 CIGNA 62308 [3081051] CIGNA 62308 [308105105] 3.17 percent of total billed charges 2.48 3.8 Technical (Hospital) Services HC/HH Wch Supp Quickvue One-Step Hcg Combo__00178 PX-2705000122 CDM 2705000122 LOCAL 270 RC inpatient 4 4 CIGNA 62308 [3081051] CIGNA STATE OF WYOMING [308105107] 3.17 percent of total billed charges 2.48 3.8 Technical (Hospital) Services HC/HH Wch Supp Quickvue One-Step Hcg Combo__00178 PX-2705000122 CDM 2705000122 LOCAL 270 RC inpatient 4 4 MULTIPLAN INC 34080 [3081285] MULTIPLAN INC [308128501] 3.8 percent of total billed charges 2.48 3.8 Technical (Hospital) Services HC/HH Wch Supp Quickvue One-Step Hcg Combo__00178 PX-2705000122 CDM 2705000122 LOCAL 270 RC inpatient 4 4 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES EPO [308136803] 3.17 percent of total billed charges 2.48 3.8 Technical (Hospital) Services HC/HH Wch Supp Quickvue One-Step Hcg Combo__00178 PX-2705000122 CDM 2705000122 LOCAL 270 RC inpatient 4 4 HEALTHPARTNERS SX009 HEALTHPARTNERS 3.17 percent of total billed charges 2.48 3.8 Technical (Hospital) Services HC/HH Wch Supp Quickvue One-Step Hcg Combo__00178 PX-2705000122 CDM 2705000122 LOCAL 270 RC inpatient 4 4 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES PPO [308136801] 3.17 percent of total billed charges 2.48 3.8 Technical (Hospital) Services HC/HH Wch Supp Quickvue One-Step Hcg Combo__00178 PX-2705000122 CDM 2705000122 LOCAL 270 RC inpatient 4 4 MEDICA (COMMERCIAL) 94265 [3081118] MEDICA CLAIMS [308111801] 3.6 percent of total billed charges 2.48 3.8 Technical (Hospital) Services HC/HH Wch Supp Quickvue One-Step Hcg Combo__00178 PX-2705000122 CDM 2705000122 LOCAL 270 RC inpatient 4 4 UNITED HEALTHCARE (COMMERCIAL) [3081199] UNITED HEALTHCARE 87726 [308119901] 2.48 percent of total billed charges 2.48 3.8 Technical (Hospital) Services HC/HH Wch Supp Quickvue One-Step Hcg Combo__00178 PX-2705000122 CDM 2705000122 LOCAL 270 RC inpatient 4 4 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES HDHP [308136802] 3.17 percent of total billed charges 2.48 3.8 Technical (Hospital) Services HC/HH Wch Supp Quickvue One-Step Hcg Combo__00178 PX-2705000122 CDM 2705000122 LOCAL 270 RC outpatient 4 4 CIGNA 62308 [3081051] CIGNA 62308 [308105105] 3.2 percent of total billed charges 2.48 3.8 Technical (Hospital) Services HC/HH Wch Supp Quickvue One-Step Hcg Combo__00178 PX-2705000122 CDM 2705000122 LOCAL 270 RC outpatient 4 4 CIGNA 62308 [3081051] CIGNA STATE OF WYOMING [308105107] 3.2 percent of total billed charges 2.48 3.8 Technical (Hospital) Services HC/HH Wch Supp Quickvue One-Step Hcg Combo__00178 PX-2705000122 CDM 2705000122 LOCAL 270 RC outpatient 4 4 BLUE CROSS BLUE SHIELD WELLMARK SB889 [3081026] BCBS WYOMING [308102603] 3.8 percent of total billed charges 2.48 3.8 Technical (Hospital) Services HC/HH Wch Supp Quickvue One-Step Hcg Combo__00178 PX-2705000122 CDM 2705000122 LOCAL 270 RC outpatient 4 4 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES EPO [308136803] 3.2 percent of total billed charges 2.48 3.8 Technical (Hospital) Services HC/HH Wch Supp Quickvue One-Step Hcg Combo__00178 PX-2705000122 CDM 2705000122 LOCAL 270 RC outpatient 4 4 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES HDHP [308136802] 3.2 percent of total billed charges 2.48 3.8 Technical (Hospital) Services HC/HH Wch Supp Quickvue One-Step Hcg Combo__00178 PX-2705000122 CDM 2705000122 LOCAL 270 RC outpatient 4 4 HEALTHPARTNERS SX009 HEALTHPARTNERS 3.2 percent of total billed charges 2.48 3.8 Technical (Hospital) Services HC/HH Wch Supp Quickvue One-Step Hcg Combo__00178 PX-2705000122 CDM 2705000122 LOCAL 270 RC outpatient 4 4 UNITED HEALTHCARE (COMMERCIAL) [3081199] UNITED HEALTHCARE 87726 [308119901] 2.48 percent of total billed charges 2.48 3.8 Technical (Hospital) Services HC/HH Wch Supp Quickvue One-Step Hcg Combo__00178 PX-2705000122 CDM 2705000122 LOCAL 270 RC outpatient 4 4 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES PPO [308136801] 3.2 percent of total billed charges 2.48 3.8 Technical (Hospital) Services HC/HH Wch Supp Quickvue One-Step Hcg Combo__00178 PX-2705000122 CDM 2705000122 LOCAL 270 RC outpatient 4 4 MULTIPLAN INC 34080 [3081285] MULTIPLAN INC [308128501] 3.8 percent of total billed charges 2.48 3.8 Technical (Hospital) Services HC/HH Wch Supp Quickvue One-Step Hcg Combo__00178 PX-2705000122 CDM 2705000122 LOCAL 270 RC outpatient 4 4 MEDICA (COMMERCIAL) 94265 [3081118] MEDICA CLAIMS [308111801] 3.6 percent of total billed charges 2.48 3.8 Technical (Hospital) Services HC/HH Wch Supp Pump Set Kangaroo Flh__8884773600 PX-2705000121 CDM 2705000121 LOCAL 270 RC inpatient 19 19 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES PPO [308136801] 15.04 percent of total billed charges 11.78 18.05 Technical (Hospital) Services HC/HH Wch Supp Pump Set Kangaroo Flh__8884773600 PX-2705000121 CDM 2705000121 LOCAL 270 RC inpatient 19 19 UNITED HEALTHCARE (COMMERCIAL) [3081199] UNITED HEALTHCARE 87726 [308119901] 11.78 percent of total billed charges 11.78 18.05 Technical (Hospital) Services HC/HH Wch Supp Pump Set Kangaroo Flh__8884773600 PX-2705000121 CDM 2705000121 LOCAL 270 RC inpatient 19 19 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES HDHP [308136802] 15.04 percent of total billed charges 11.78 18.05 Technical (Hospital) Services HC/HH Wch Supp Pump Set Kangaroo Flh__8884773600 PX-2705000121 CDM 2705000121 LOCAL 270 RC inpatient 19 19 MEDICA (COMMERCIAL) 94265 [3081118] MEDICA CLAIMS [308111801] 17.1 percent of total billed charges 11.78 18.05 Technical (Hospital) Services HC/HH Wch Supp Pump Set Kangaroo Flh__8884773600 PX-2705000121 CDM 2705000121 LOCAL 270 RC inpatient 19 19 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES EPO [308136803] 15.04 percent of total billed charges 11.78 18.05 Technical (Hospital) Services HC/HH Wch Supp Pump Set Kangaroo Flh__8884773600 PX-2705000121 CDM 2705000121 LOCAL 270 RC inpatient 19 19 HEALTHPARTNERS SX009 HEALTHPARTNERS 15.04 percent of total billed charges 11.78 18.05 Technical (Hospital) Services HC/HH Wch Supp Pump Set Kangaroo Flh__8884773600 PX-2705000121 CDM 2705000121 LOCAL 270 RC inpatient 19 19 BLUE CROSS BLUE SHIELD WELLMARK SB889 [3081026] BCBS WYOMING [308102603] 18.05 percent of total billed charges 11.78 18.05 Technical (Hospital) Services HC/HH Wch Supp Pump Set Kangaroo Flh__8884773600 PX-2705000121 CDM 2705000121 LOCAL 270 RC inpatient 19 19 MULTIPLAN INC 34080 [3081285] MULTIPLAN INC [308128501] 18.05 percent of total billed charges 11.78 18.05 Technical (Hospital) Services HC/HH Wch Supp Pump Set Kangaroo Flh__8884773600 PX-2705000121 CDM 2705000121 LOCAL 270 RC inpatient 19 19 CIGNA 62308 [3081051] CIGNA 62308 [308105105] 15.04 percent of total billed charges 11.78 18.05 Technical (Hospital) Services HC/HH Wch Supp Pump Set Kangaroo Flh__8884773600 PX-2705000121 CDM 2705000121 LOCAL 270 RC inpatient 19 19 CIGNA 62308 [3081051] CIGNA STATE OF WYOMING [308105107] 15.04 percent of total billed charges 11.78 18.05 Technical (Hospital) Services HC/HH Wch Supp Pump Set Kangaroo Flh__8884773600 PX-2705000121 CDM 2705000121 LOCAL 270 RC outpatient 19 19 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES HDHP [308136802] 15.2 percent of total billed charges 11.78 18.05 Technical (Hospital) Services HC/HH Wch Supp Pump Set Kangaroo Flh__8884773600 PX-2705000121 CDM 2705000121 LOCAL 270 RC outpatient 19 19 BLUE CROSS BLUE SHIELD WELLMARK SB889 [3081026] BCBS WYOMING [308102603] 18.05 percent of total billed charges 11.78 18.05 Technical (Hospital) Services HC/HH Wch Supp Pump Set Kangaroo Flh__8884773600 PX-2705000121 CDM 2705000121 LOCAL 270 RC outpatient 19 19 CIGNA 62308 [3081051] CIGNA 62308 [308105105] 15.2 percent of total billed charges 11.78 18.05 Technical (Hospital) Services HC/HH Wch Supp Pump Set Kangaroo Flh__8884773600 PX-2705000121 CDM 2705000121 LOCAL 270 RC outpatient 19 19 CIGNA 62308 [3081051] CIGNA STATE OF WYOMING [308105107] 15.2 percent of total billed charges 11.78 18.05 Technical (Hospital) Services HC/HH Wch Supp Pump Set Kangaroo Flh__8884773600 PX-2705000121 CDM 2705000121 LOCAL 270 RC outpatient 19 19 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES EPO [308136803] 15.2 percent of total billed charges 11.78 18.05 Technical (Hospital) Services HC/HH Wch Supp Pump Set Kangaroo Flh__8884773600 PX-2705000121 CDM 2705000121 LOCAL 270 RC outpatient 19 19 HEALTHPARTNERS SX009 HEALTHPARTNERS 15.2 percent of total billed charges 11.78 18.05 Technical (Hospital) Services HC/HH Wch Supp Pump Set Kangaroo Flh__8884773600 PX-2705000121 CDM 2705000121 LOCAL 270 RC outpatient 19 19 UNITED HEALTHCARE (COMMERCIAL) [3081199] UNITED HEALTHCARE 87726 [308119901] 11.78 percent of total billed charges 11.78 18.05 Technical (Hospital) Services HC/HH Wch Supp Pump Set Kangaroo Flh__8884773600 PX-2705000121 CDM 2705000121 LOCAL 270 RC outpatient 19 19 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES PPO [308136801] 15.2 percent of total billed charges 11.78 18.05 Technical (Hospital) Services HC/HH Wch Supp Pump Set Kangaroo Flh__8884773600 PX-2705000121 CDM 2705000121 LOCAL 270 RC outpatient 19 19 MEDICA (COMMERCIAL) 94265 [3081118] MEDICA CLAIMS [308111801] 17.1 percent of total billed charges 11.78 18.05 Technical (Hospital) Services HC/HH Wch Supp Pump Set Kangaroo Flh__8884773600 PX-2705000121 CDM 2705000121 LOCAL 270 RC outpatient 19 19 MULTIPLAN INC 34080 [3081285] MULTIPLAN INC [308128501] 18.05 percent of total billed charges 11.78 18.05 Technical (Hospital) Services HC/HH Wch Supp Porous Tape 3 Inch__5108 PX-2705000120 CDM 2705000120 LOCAL 270 RC inpatient 15 15 CIGNA 62308 [3081051] CIGNA 62308 [308105105] 11.88 percent of total billed charges 9.3 14.25 Technical (Hospital) Services HC/HH Wch Supp Porous Tape 3 Inch__5108 PX-2705000120 CDM 2705000120 LOCAL 270 RC inpatient 15 15 CIGNA 62308 [3081051] CIGNA STATE OF WYOMING [308105107] 11.88 percent of total billed charges 9.3 14.25 Technical (Hospital) Services HC/HH Wch Supp Porous Tape 3 Inch__5108 PX-2705000120 CDM 2705000120 LOCAL 270 RC inpatient 15 15 MULTIPLAN INC 34080 [3081285] MULTIPLAN INC [308128501] 14.25 percent of total billed charges 9.3 14.25 Technical (Hospital) Services HC/HH Wch Supp Porous Tape 3 Inch__5108 PX-2705000120 CDM 2705000120 LOCAL 270 RC inpatient 15 15 BLUE CROSS BLUE SHIELD WELLMARK SB889 [3081026] BCBS WYOMING [308102603] 14.25 percent of total billed charges 9.3 14.25 Technical (Hospital) Services HC/HH Wch Supp Porous Tape 3 Inch__5108 PX-2705000120 CDM 2705000120 LOCAL 270 RC inpatient 15 15 HEALTHPARTNERS SX009 HEALTHPARTNERS 11.88 percent of total billed charges 9.3 14.25 Technical (Hospital) Services HC/HH Wch Supp Porous Tape 3 Inch__5108 PX-2705000120 CDM 2705000120 LOCAL 270 RC inpatient 15 15 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES EPO [308136803] 11.88 percent of total billed charges 9.3 14.25 Technical (Hospital) Services HC/HH Wch Supp Porous Tape 3 Inch__5108 PX-2705000120 CDM 2705000120 LOCAL 270 RC inpatient 15 15 MEDICA (COMMERCIAL) 94265 [3081118] MEDICA CLAIMS [308111801] 13.5 percent of total billed charges 9.3 14.25 Technical (Hospital) Services HC/HH Wch Supp Porous Tape 3 Inch__5108 PX-2705000120 CDM 2705000120 LOCAL 270 RC inpatient 15 15 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES HDHP [308136802] 11.88 percent of total billed charges 9.3 14.25 Technical (Hospital) Services HC/HH Wch Supp Porous Tape 3 Inch__5108 PX-2705000120 CDM 2705000120 LOCAL 270 RC inpatient 15 15 UNITED HEALTHCARE (COMMERCIAL) [3081199] UNITED HEALTHCARE 87726 [308119901] 9.3 percent of total billed charges 9.3 14.25 Technical (Hospital) Services HC/HH Wch Supp Porous Tape 3 Inch__5108 PX-2705000120 CDM 2705000120 LOCAL 270 RC inpatient 15 15 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES PPO [308136801] 11.88 percent of total billed charges 9.3 14.25 Technical (Hospital) Services HC/HH Wch Supp Porous Tape 3 Inch__5108 PX-2705000120 CDM 2705000120 LOCAL 270 RC outpatient 15 15 CIGNA 62308 [3081051] CIGNA 62308 [308105105] 12 percent of total billed charges 9.3 14.25 Technical (Hospital) Services HC/HH Wch Supp Porous Tape 3 Inch__5108 PX-2705000120 CDM 2705000120 LOCAL 270 RC outpatient 15 15 CIGNA 62308 [3081051] CIGNA STATE OF WYOMING [308105107] 12 percent of total billed charges 9.3 14.25 Technical (Hospital) Services HC/HH Wch Supp Porous Tape 3 Inch__5108 PX-2705000120 CDM 2705000120 LOCAL 270 RC outpatient 15 15 BLUE CROSS BLUE SHIELD WELLMARK SB889 [3081026] BCBS WYOMING [308102603] 14.25 percent of total billed charges 9.3 14.25 Technical (Hospital) Services HC/HH Wch Supp Porous Tape 3 Inch__5108 PX-2705000120 CDM 2705000120 LOCAL 270 RC outpatient 15 15 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES EPO [308136803] 12 percent of total billed charges 9.3 14.25 Technical (Hospital) Services HC/HH Wch Supp Porous Tape 3 Inch__5108 PX-2705000120 CDM 2705000120 LOCAL 270 RC outpatient 15 15 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES HDHP [308136802] 12 percent of total billed charges 9.3 14.25 Technical (Hospital) Services HC/HH Wch Supp Porous Tape 3 Inch__5108 PX-2705000120 CDM 2705000120 LOCAL 270 RC outpatient 15 15 UNITED HEALTHCARE (COMMERCIAL) [3081199] UNITED HEALTHCARE 87726 [308119901] 9.3 percent of total billed charges 9.3 14.25 Technical (Hospital) Services HC/HH Wch Supp Porous Tape 3 Inch__5108 PX-2705000120 CDM 2705000120 LOCAL 270 RC outpatient 15 15 HEALTHPARTNERS SX009 HEALTHPARTNERS 12 percent of total billed charges 9.3 14.25 Technical (Hospital) Services HC/HH Wch Supp Porous Tape 3 Inch__5108 PX-2705000120 CDM 2705000120 LOCAL 270 RC outpatient 15 15 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES PPO [308136801] 12 percent of total billed charges 9.3 14.25 Technical (Hospital) Services HC/HH Wch Supp Porous Tape 3 Inch__5108 PX-2705000120 CDM 2705000120 LOCAL 270 RC outpatient 15 15 MULTIPLAN INC 34080 [3081285] MULTIPLAN INC [308128501] 14.25 percent of total billed charges 9.3 14.25 Technical (Hospital) Services HC/HH Wch Supp Porous Tape 3 Inch__5108 PX-2705000120 CDM 2705000120 LOCAL 270 RC outpatient 15 15 MEDICA (COMMERCIAL) 94265 [3081118] MEDICA CLAIMS [308111801] 13.5 percent of total billed charges 9.3 14.25 Technical (Hospital) Services HC/HH Wch Supp Porous Tape 2 Inch__5106 PX-2705000119 CDM 2705000119 LOCAL 270 RC inpatient 13 13 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES PPO [308136801] 10.29 percent of total billed charges 8.06 12.35 Technical (Hospital) Services HC/HH Wch Supp Porous Tape 2 Inch__5106 PX-2705000119 CDM 2705000119 LOCAL 270 RC inpatient 13 13 UNITED HEALTHCARE (COMMERCIAL) [3081199] UNITED HEALTHCARE 87726 [308119901] 8.06 percent of total billed charges 8.06 12.35 Technical (Hospital) Services HC/HH Wch Supp Porous Tape 2 Inch__5106 PX-2705000119 CDM 2705000119 LOCAL 270 RC inpatient 13 13 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES HDHP [308136802] 10.29 percent of total billed charges 8.06 12.35 Technical (Hospital) Services HC/HH Wch Supp Porous Tape 2 Inch__5106 PX-2705000119 CDM 2705000119 LOCAL 270 RC inpatient 13 13 MEDICA (COMMERCIAL) 94265 [3081118] MEDICA CLAIMS [308111801] 11.7 percent of total billed charges 8.06 12.35 Technical (Hospital) Services HC/HH Wch Supp Porous Tape 2 Inch__5106 PX-2705000119 CDM 2705000119 LOCAL 270 RC inpatient 13 13 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES EPO [308136803] 10.29 percent of total billed charges 8.06 12.35 Technical (Hospital) Services HC/HH Wch Supp Porous Tape 2 Inch__5106 PX-2705000119 CDM 2705000119 LOCAL 270 RC inpatient 13 13 HEALTHPARTNERS SX009 HEALTHPARTNERS 10.29 percent of total billed charges 8.06 12.35 Technical (Hospital) Services HC/HH Wch Supp Porous Tape 2 Inch__5106 PX-2705000119 CDM 2705000119 LOCAL 270 RC inpatient 13 13 BLUE CROSS BLUE SHIELD WELLMARK SB889 [3081026] BCBS WYOMING [308102603] 12.35 percent of total billed charges 8.06 12.35 Technical (Hospital) Services HC/HH Wch Supp Porous Tape 2 Inch__5106 PX-2705000119 CDM 2705000119 LOCAL 270 RC inpatient 13 13 MULTIPLAN INC 34080 [3081285] MULTIPLAN INC [308128501] 12.35 percent of total billed charges 8.06 12.35 Technical (Hospital) Services HC/HH Wch Supp Porous Tape 2 Inch__5106 PX-2705000119 CDM 2705000119 LOCAL 270 RC inpatient 13 13 CIGNA 62308 [3081051] CIGNA 62308 [308105105] 10.29 percent of total billed charges 8.06 12.35 Technical (Hospital) Services HC/HH Wch Supp Porous Tape 2 Inch__5106 PX-2705000119 CDM 2705000119 LOCAL 270 RC inpatient 13 13 CIGNA 62308 [3081051] CIGNA STATE OF WYOMING [308105107] 10.29 percent of total billed charges 8.06 12.35 Technical (Hospital) Services HC/HH Wch Supp Porous Tape 2 Inch__5106 PX-2705000119 CDM 2705000119 LOCAL 270 RC outpatient 13 13 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES HDHP [308136802] 10.4 percent of total billed charges 8.06 12.35 Technical (Hospital) Services HC/HH Wch Supp Porous Tape 2 Inch__5106 PX-2705000119 CDM 2705000119 LOCAL 270 RC outpatient 13 13 CIGNA 62308 [3081051] CIGNA 62308 [308105105] 10.4 percent of total billed charges 8.06 12.35 Technical (Hospital) Services HC/HH Wch Supp Porous Tape 2 Inch__5106 PX-2705000119 CDM 2705000119 LOCAL 270 RC outpatient 13 13 CIGNA 62308 [3081051] CIGNA STATE OF WYOMING [308105107] 10.4 percent of total billed charges 8.06 12.35 Technical (Hospital) Services HC/HH Wch Supp Porous Tape 2 Inch__5106 PX-2705000119 CDM 2705000119 LOCAL 270 RC outpatient 13 13 BLUE CROSS BLUE SHIELD WELLMARK SB889 [3081026] BCBS WYOMING [308102603] 12.35 percent of total billed charges 8.06 12.35 Technical (Hospital) Services HC/HH Wch Supp Porous Tape 2 Inch__5106 PX-2705000119 CDM 2705000119 LOCAL 270 RC outpatient 13 13 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES EPO [308136803] 10.4 percent of total billed charges 8.06 12.35 Technical (Hospital) Services HC/HH Wch Supp Porous Tape 2 Inch__5106 PX-2705000119 CDM 2705000119 LOCAL 270 RC outpatient 13 13 HEALTHPARTNERS SX009 HEALTHPARTNERS 10.4 percent of total billed charges 8.06 12.35 Technical (Hospital) Services HC/HH Wch Supp Porous Tape 2 Inch__5106 PX-2705000119 CDM 2705000119 LOCAL 270 RC outpatient 13 13 UNITED HEALTHCARE (COMMERCIAL) [3081199] UNITED HEALTHCARE 87726 [308119901] 8.06 percent of total billed charges 8.06 12.35 Technical (Hospital) Services HC/HH Wch Supp Porous Tape 2 Inch__5106 PX-2705000119 CDM 2705000119 LOCAL 270 RC outpatient 13 13 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES PPO [308136801] 10.4 percent of total billed charges 8.06 12.35 Technical (Hospital) Services HC/HH Wch Supp Porous Tape 2 Inch__5106 PX-2705000119 CDM 2705000119 LOCAL 270 RC outpatient 13 13 MEDICA (COMMERCIAL) 94265 [3081118] MEDICA CLAIMS [308111801] 11.7 percent of total billed charges 8.06 12.35 Technical (Hospital) Services HC/HH Wch Supp Porous Tape 2 Inch__5106 PX-2705000119 CDM 2705000119 LOCAL 270 RC outpatient 13 13 MULTIPLAN INC 34080 [3081285] MULTIPLAN INC [308128501] 12.35 percent of total billed charges 8.06 12.35 Technical (Hospital) Services HC/HH Wch Supp Porous Tape 1 Inch__5104 PX-2705000118 CDM 2705000118 LOCAL 270 RC outpatient 6 6 UNITED HEALTHCARE (COMMERCIAL) [3081199] UNITED HEALTHCARE 87726 [308119901] 3.72 percent of total billed charges 3.72 5.7 Technical (Hospital) Services HC/HH Wch Supp Porous Tape 1 Inch__5104 PX-2705000118 CDM 2705000118 LOCAL 270 RC outpatient 6 6 HEALTHPARTNERS SX009 HEALTHPARTNERS 4.8 percent of total billed charges 3.72 5.7 Technical (Hospital) Services HC/HH Wch Supp Porous Tape 1 Inch__5104 PX-2705000118 CDM 2705000118 LOCAL 270 RC outpatient 6 6 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES PPO [308136801] 4.8 percent of total billed charges 3.72 5.7 Technical (Hospital) Services HC/HH Wch Supp Porous Tape 1 Inch__5104 PX-2705000118 CDM 2705000118 LOCAL 270 RC outpatient 6 6 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES HDHP [308136802] 4.8 percent of total billed charges 3.72 5.7 Technical (Hospital) Services HC/HH Wch Supp Porous Tape 1 Inch__5104 PX-2705000118 CDM 2705000118 LOCAL 270 RC outpatient 6 6 CIGNA 62308 [3081051] CIGNA 62308 [308105105] 4.8 percent of total billed charges 3.72 5.7 Technical (Hospital) Services HC/HH Wch Supp Porous Tape 1 Inch__5104 PX-2705000118 CDM 2705000118 LOCAL 270 RC outpatient 6 6 CIGNA 62308 [3081051] CIGNA STATE OF WYOMING [308105107] 4.8 percent of total billed charges 3.72 5.7 Technical (Hospital) Services HC/HH Wch Supp Porous Tape 1 Inch__5104 PX-2705000118 CDM 2705000118 LOCAL 270 RC outpatient 6 6 BLUE CROSS BLUE SHIELD WELLMARK SB889 [3081026] BCBS WYOMING [308102603] 5.7 percent of total billed charges 3.72 5.7 Technical (Hospital) Services HC/HH Wch Supp Porous Tape 1 Inch__5104 PX-2705000118 CDM 2705000118 LOCAL 270 RC outpatient 6 6 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES EPO [308136803] 4.8 percent of total billed charges 3.72 5.7 Technical (Hospital) Services HC/HH Wch Supp Porous Tape 1 Inch__5104 PX-2705000118 CDM 2705000118 LOCAL 270 RC outpatient 6 6 MEDICA (COMMERCIAL) 94265 [3081118] MEDICA CLAIMS [308111801] 5.4 percent of total billed charges 3.72 5.7 Technical (Hospital) Services HC/HH Wch Supp Porous Tape 1 Inch__5104 PX-2705000118 CDM 2705000118 LOCAL 270 RC outpatient 6 6 MULTIPLAN INC 34080 [3081285] MULTIPLAN INC [308128501] 5.7 percent of total billed charges 3.72 5.7 Technical (Hospital) Services HC/HH Wch Supp Porous Tape 1 Inch__5104 PX-2705000118 CDM 2705000118 LOCAL 270 RC inpatient 6 6 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES PPO [308136801] 4.75 percent of total billed charges 3.72 5.7 Technical (Hospital) Services HC/HH Wch Supp Porous Tape 1 Inch__5104 PX-2705000118 CDM 2705000118 LOCAL 270 RC inpatient 6 6 UNITED HEALTHCARE (COMMERCIAL) [3081199] UNITED HEALTHCARE 87726 [308119901] 3.72 percent of total billed charges 3.72 5.7 Technical (Hospital) Services HC/HH Wch Supp Porous Tape 1 Inch__5104 PX-2705000118 CDM 2705000118 LOCAL 270 RC inpatient 6 6 MEDICA (COMMERCIAL) 94265 [3081118] MEDICA CLAIMS [308111801] 5.4 percent of total billed charges 3.72 5.7 Technical (Hospital) Services HC/HH Wch Supp Porous Tape 1 Inch__5104 PX-2705000118 CDM 2705000118 LOCAL 270 RC inpatient 6 6 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES HDHP [308136802] 4.75 percent of total billed charges 3.72 5.7 Technical (Hospital) Services HC/HH Wch Supp Porous Tape 1 Inch__5104 PX-2705000118 CDM 2705000118 LOCAL 270 RC inpatient 6 6 MULTIPLAN INC 34080 [3081285] MULTIPLAN INC [308128501] 5.7 percent of total billed charges 3.72 5.7 Technical (Hospital) Services HC/HH Wch Supp Porous Tape 1 Inch__5104 PX-2705000118 CDM 2705000118 LOCAL 270 RC inpatient 6 6 BLUE CROSS BLUE SHIELD WELLMARK SB889 [3081026] BCBS WYOMING [308102603] 5.7 percent of total billed charges 3.72 5.7 Technical (Hospital) Services HC/HH Wch Supp Porous Tape 1 Inch__5104 PX-2705000118 CDM 2705000118 LOCAL 270 RC inpatient 6 6 CIGNA 62308 [3081051] CIGNA 62308 [308105105] 4.75 percent of total billed charges 3.72 5.7 Technical (Hospital) Services HC/HH Wch Supp Porous Tape 1 Inch__5104 PX-2705000118 CDM 2705000118 LOCAL 270 RC inpatient 6 6 CIGNA 62308 [3081051] CIGNA STATE OF WYOMING [308105107] 4.75 percent of total billed charges 3.72 5.7 Technical (Hospital) Services HC/HH Wch Supp Porous Tape 1 Inch__5104 PX-2705000118 CDM 2705000118 LOCAL 270 RC inpatient 6 6 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES EPO [308136803] 4.75 percent of total billed charges 3.72 5.7 Technical (Hospital) Services HC/HH Wch Supp Porous Tape 1 Inch__5104 PX-2705000118 CDM 2705000118 LOCAL 270 RC inpatient 6 6 HEALTHPARTNERS SX009 HEALTHPARTNERS 4.75 percent of total billed charges 3.72 5.7 Technical (Hospital) Services HC/HH Wch Supp Plaster Bandage 2__7372 PX-2705000117 CDM 2705000117 LOCAL 270 RC outpatient 6 6 UNITED HEALTHCARE (COMMERCIAL) [3081199] UNITED HEALTHCARE 87726 [308119901] 3.72 percent of total billed charges 3.72 5.7 Technical (Hospital) Services HC/HH Wch Supp Plaster Bandage 2__7372 PX-2705000117 CDM 2705000117 LOCAL 270 RC outpatient 6 6 HEALTHPARTNERS SX009 HEALTHPARTNERS 4.8 percent of total billed charges 3.72 5.7 Technical (Hospital) Services HC/HH Wch Supp Plaster Bandage 2__7372 PX-2705000117 CDM 2705000117 LOCAL 270 RC outpatient 6 6 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES PPO [308136801] 4.8 percent of total billed charges 3.72 5.7 Technical (Hospital) Services HC/HH Wch Supp Plaster Bandage 2__7372 PX-2705000117 CDM 2705000117 LOCAL 270 RC outpatient 6 6 CIGNA 62308 [3081051] CIGNA 62308 [308105105] 4.8 percent of total billed charges 3.72 5.7 Technical (Hospital) Services HC/HH Wch Supp Plaster Bandage 2__7372 PX-2705000117 CDM 2705000117 LOCAL 270 RC outpatient 6 6 CIGNA 62308 [3081051] CIGNA STATE OF WYOMING [308105107] 4.8 percent of total billed charges 3.72 5.7 Technical (Hospital) Services HC/HH Wch Supp Plaster Bandage 2__7372 PX-2705000117 CDM 2705000117 LOCAL 270 RC outpatient 6 6 BLUE CROSS BLUE SHIELD WELLMARK SB889 [3081026] BCBS WYOMING [308102603] 5.7 percent of total billed charges 3.72 5.7 Technical (Hospital) Services HC/HH Wch Supp Plaster Bandage 2__7372 PX-2705000117 CDM 2705000117 LOCAL 270 RC outpatient 6 6 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES EPO [308136803] 4.8 percent of total billed charges 3.72 5.7 Technical (Hospital) Services HC/HH Wch Supp Plaster Bandage 2__7372 PX-2705000117 CDM 2705000117 LOCAL 270 RC outpatient 6 6 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES HDHP [308136802] 4.8 percent of total billed charges 3.72 5.7 Technical (Hospital) Services HC/HH Wch Supp Plaster Bandage 2__7372 PX-2705000117 CDM 2705000117 LOCAL 270 RC outpatient 6 6 MEDICA (COMMERCIAL) 94265 [3081118] MEDICA CLAIMS [308111801] 5.4 percent of total billed charges 3.72 5.7 Technical (Hospital) Services HC/HH Wch Supp Plaster Bandage 2__7372 PX-2705000117 CDM 2705000117 LOCAL 270 RC outpatient 6 6 MULTIPLAN INC 34080 [3081285] MULTIPLAN INC [308128501] 5.7 percent of total billed charges 3.72 5.7 Technical (Hospital) Services HC/HH Wch Supp Plaster Bandage 2__7372 PX-2705000117 CDM 2705000117 LOCAL 270 RC inpatient 6 6 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES PPO [308136801] 4.75 percent of total billed charges 3.72 5.7 Technical (Hospital) Services HC/HH Wch Supp Plaster Bandage 2__7372 PX-2705000117 CDM 2705000117 LOCAL 270 RC inpatient 6 6 MEDICA (COMMERCIAL) 94265 [3081118] MEDICA CLAIMS [308111801] 5.4 percent of total billed charges 3.72 5.7 Technical (Hospital) Services HC/HH Wch Supp Plaster Bandage 2__7372 PX-2705000117 CDM 2705000117 LOCAL 270 RC inpatient 6 6 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES HDHP [308136802] 4.75 percent of total billed charges 3.72 5.7 Technical (Hospital) Services HC/HH Wch Supp Plaster Bandage 2__7372 PX-2705000117 CDM 2705000117 LOCAL 270 RC inpatient 6 6 UNITED HEALTHCARE (COMMERCIAL) [3081199] UNITED HEALTHCARE 87726 [308119901] 3.72 percent of total billed charges 3.72 5.7 Technical (Hospital) Services HC/HH Wch Supp Plaster Bandage 2__7372 PX-2705000117 CDM 2705000117 LOCAL 270 RC inpatient 6 6 BLUE CROSS BLUE SHIELD WELLMARK SB889 [3081026] BCBS WYOMING [308102603] 5.7 percent of total billed charges 3.72 5.7 Technical (Hospital) Services HC/HH Wch Supp Plaster Bandage 2__7372 PX-2705000117 CDM 2705000117 LOCAL 270 RC inpatient 6 6 MULTIPLAN INC 34080 [3081285] MULTIPLAN INC [308128501] 5.7 percent of total billed charges 3.72 5.7 Technical (Hospital) Services HC/HH Wch Supp Plaster Bandage 2__7372 PX-2705000117 CDM 2705000117 LOCAL 270 RC inpatient 6 6 CIGNA 62308 [3081051] CIGNA 62308 [308105105] 4.75 percent of total billed charges 3.72 5.7 Technical (Hospital) Services HC/HH Wch Supp Plaster Bandage 2__7372 PX-2705000117 CDM 2705000117 LOCAL 270 RC inpatient 6 6 CIGNA 62308 [3081051] CIGNA STATE OF WYOMING [308105107] 4.75 percent of total billed charges 3.72 5.7 Technical (Hospital) Services HC/HH Wch Supp Plaster Bandage 2__7372 PX-2705000117 CDM 2705000117 LOCAL 270 RC inpatient 6 6 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES EPO [308136803] 4.75 percent of total billed charges 3.72 5.7 Technical (Hospital) Services HC/HH Wch Supp Plaster Bandage 2__7372 PX-2705000117 CDM 2705000117 LOCAL 270 RC inpatient 6 6 HEALTHPARTNERS SX009 HEALTHPARTNERS 4.75 percent of total billed charges 3.72 5.7 Technical (Hospital) Services HC/HH Wch Supp Pathodx Disposable S__R62070 PX-2705000116 CDM 2705000116 LOCAL 270 RC outpatient 165 165 BLUE CROSS BLUE SHIELD WELLMARK SB889 [3081026] BCBS WYOMING [308102603] 156.75 percent of total billed charges 102.3 156.75 Technical (Hospital) Services HC/HH Wch Supp Pathodx Disposable S__R62070 PX-2705000116 CDM 2705000116 LOCAL 270 RC outpatient 165 165 CIGNA 62308 [3081051] CIGNA 62308 [308105105] 132 percent of total billed charges 102.3 156.75 Technical (Hospital) Services HC/HH Wch Supp Pathodx Disposable S__R62070 PX-2705000116 CDM 2705000116 LOCAL 270 RC outpatient 165 165 CIGNA 62308 [3081051] CIGNA STATE OF WYOMING [308105107] 132 percent of total billed charges 102.3 156.75 Technical (Hospital) Services HC/HH Wch Supp Pathodx Disposable S__R62070 PX-2705000116 CDM 2705000116 LOCAL 270 RC outpatient 165 165 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES EPO [308136803] 132 percent of total billed charges 102.3 156.75 Technical (Hospital) Services HC/HH Wch Supp Pathodx Disposable S__R62070 PX-2705000116 CDM 2705000116 LOCAL 270 RC outpatient 165 165 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES HDHP [308136802] 132 percent of total billed charges 102.3 156.75 Technical (Hospital) Services HC/HH Wch Supp Pathodx Disposable S__R62070 PX-2705000116 CDM 2705000116 LOCAL 270 RC outpatient 165 165 HEALTHPARTNERS SX009 HEALTHPARTNERS 132 percent of total billed charges 102.3 156.75 Technical (Hospital) Services HC/HH Wch Supp Pathodx Disposable S__R62070 PX-2705000116 CDM 2705000116 LOCAL 270 RC outpatient 165 165 UNITED HEALTHCARE (COMMERCIAL) [3081199] UNITED HEALTHCARE 87726 [308119901] 102.3 percent of total billed charges 102.3 156.75 Technical (Hospital) Services HC/HH Wch Supp Pathodx Disposable S__R62070 PX-2705000116 CDM 2705000116 LOCAL 270 RC outpatient 165 165 MEDICA (COMMERCIAL) 94265 [3081118] MEDICA CLAIMS [308111801] 148.5 percent of total billed charges 102.3 156.75 Technical (Hospital) Services HC/HH Wch Supp Pathodx Disposable S__R62070 PX-2705000116 CDM 2705000116 LOCAL 270 RC outpatient 165 165 MULTIPLAN INC 34080 [3081285] MULTIPLAN INC [308128501] 156.75 percent of total billed charges 102.3 156.75 Technical (Hospital) Services HC/HH Wch Supp Pathodx Disposable S__R62070 PX-2705000116 CDM 2705000116 LOCAL 270 RC outpatient 165 165 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES PPO [308136801] 132 percent of total billed charges 102.3 156.75 Technical (Hospital) Services HC/HH Wch Supp Pathodx Disposable S__R62070 PX-2705000116 CDM 2705000116 LOCAL 270 RC inpatient 165 165 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES PPO [308136801] 130.65 percent of total billed charges 102.3 156.75 Technical (Hospital) Services HC/HH Wch Supp Pathodx Disposable S__R62070 PX-2705000116 CDM 2705000116 LOCAL 270 RC inpatient 165 165 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES HDHP [308136802] 130.65 percent of total billed charges 102.3 156.75 Technical (Hospital) Services HC/HH Wch Supp Pathodx Disposable S__R62070 PX-2705000116 CDM 2705000116 LOCAL 270 RC inpatient 165 165 UNITED HEALTHCARE (COMMERCIAL) [3081199] UNITED HEALTHCARE 87726 [308119901] 102.3 percent of total billed charges 102.3 156.75 Technical (Hospital) Services HC/HH Wch Supp Pathodx Disposable S__R62070 PX-2705000116 CDM 2705000116 LOCAL 270 RC inpatient 165 165 MEDICA (COMMERCIAL) 94265 [3081118] MEDICA CLAIMS [308111801] 148.5 percent of total billed charges 102.3 156.75 Technical (Hospital) Services HC/HH Wch Supp Pathodx Disposable S__R62070 PX-2705000116 CDM 2705000116 LOCAL 270 RC inpatient 165 165 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES EPO [308136803] 130.65 percent of total billed charges 102.3 156.75 Technical (Hospital) Services HC/HH Wch Supp Pathodx Disposable S__R62070 PX-2705000116 CDM 2705000116 LOCAL 270 RC inpatient 165 165 HEALTHPARTNERS SX009 HEALTHPARTNERS 130.65 percent of total billed charges 102.3 156.75 Technical (Hospital) Services HC/HH Wch Supp Pathodx Disposable S__R62070 PX-2705000116 CDM 2705000116 LOCAL 270 RC inpatient 165 165 BLUE CROSS BLUE SHIELD WELLMARK SB889 [3081026] BCBS WYOMING [308102603] 156.75 percent of total billed charges 102.3 156.75 Technical (Hospital) Services HC/HH Wch Supp Pathodx Disposable S__R62070 PX-2705000116 CDM 2705000116 LOCAL 270 RC inpatient 165 165 MULTIPLAN INC 34080 [3081285] MULTIPLAN INC [308128501] 156.75 percent of total billed charges 102.3 156.75 Technical (Hospital) Services HC/HH Wch Supp Pathodx Disposable S__R62070 PX-2705000116 CDM 2705000116 LOCAL 270 RC inpatient 165 165 CIGNA 62308 [3081051] CIGNA 62308 [308105105] 130.65 percent of total billed charges 102.3 156.75 Technical (Hospital) Services HC/HH Wch Supp Pathodx Disposable S__R62070 PX-2705000116 CDM 2705000116 LOCAL 270 RC inpatient 165 165 CIGNA 62308 [3081051] CIGNA STATE OF WYOMING [308105107] 130.65 percent of total billed charges 102.3 156.75 Technical (Hospital) Services HC/HH Wch Supp Paddng Undrcst Webril 6x4__3489 PX-2705000115 CDM 2705000115 LOCAL 270 RC outpatient 23 23 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES PPO [308136801] 18.4 percent of total billed charges 14.26 21.85 Technical (Hospital) Services HC/HH Wch Supp Paddng Undrcst Webril 6x4__3489 PX-2705000115 CDM 2705000115 LOCAL 270 RC outpatient 23 23 MULTIPLAN INC 34080 [3081285] MULTIPLAN INC [308128501] 21.85 percent of total billed charges 14.26 21.85 Technical (Hospital) Services HC/HH Wch Supp Paddng Undrcst Webril 6x4__3489 PX-2705000115 CDM 2705000115 LOCAL 270 RC outpatient 23 23 MEDICA (COMMERCIAL) 94265 [3081118] MEDICA CLAIMS [308111801] 20.7 percent of total billed charges 14.26 21.85 Technical (Hospital) Services HC/HH Wch Supp Paddng Undrcst Webril 6x4__3489 PX-2705000115 CDM 2705000115 LOCAL 270 RC outpatient 23 23 UNITED HEALTHCARE (COMMERCIAL) [3081199] UNITED HEALTHCARE 87726 [308119901] 14.26 percent of total billed charges 14.26 21.85 Technical (Hospital) Services HC/HH Wch Supp Paddng Undrcst Webril 6x4__3489 PX-2705000115 CDM 2705000115 LOCAL 270 RC outpatient 23 23 HEALTHPARTNERS SX009 HEALTHPARTNERS 18.4 percent of total billed charges 14.26 21.85 Technical (Hospital) Services HC/HH Wch Supp Paddng Undrcst Webril 6x4__3489 PX-2705000115 CDM 2705000115 LOCAL 270 RC outpatient 23 23 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES HDHP [308136802] 18.4 percent of total billed charges 14.26 21.85 Technical (Hospital) Services HC/HH Wch Supp Paddng Undrcst Webril 6x4__3489 PX-2705000115 CDM 2705000115 LOCAL 270 RC outpatient 23 23 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES EPO [308136803] 18.4 percent of total billed charges 14.26 21.85 Technical (Hospital) Services HC/HH Wch Supp Paddng Undrcst Webril 6x4__3489 PX-2705000115 CDM 2705000115 LOCAL 270 RC outpatient 23 23 BLUE CROSS BLUE SHIELD WELLMARK SB889 [3081026] BCBS WYOMING [308102603] 21.85 percent of total billed charges 14.26 21.85 Technical (Hospital) Services HC/HH Wch Supp Paddng Undrcst Webril 6x4__3489 PX-2705000115 CDM 2705000115 LOCAL 270 RC outpatient 23 23 CIGNA 62308 [3081051] CIGNA 62308 [308105105] 18.4 percent of total billed charges 14.26 21.85 Technical (Hospital) Services HC/HH Wch Supp Paddng Undrcst Webril 6x4__3489 PX-2705000115 CDM 2705000115 LOCAL 270 RC outpatient 23 23 CIGNA 62308 [3081051] CIGNA STATE OF WYOMING [308105107] 18.4 percent of total billed charges 14.26 21.85 Technical (Hospital) Services HC/HH Wch Supp Paddng Undrcst Webril 6x4__3489 PX-2705000115 CDM 2705000115 LOCAL 270 RC inpatient 23 23 HEALTHPARTNERS SX009 HEALTHPARTNERS 18.21 percent of total billed charges 14.26 21.85 Technical (Hospital) Services HC/HH Wch Supp Paddng Undrcst Webril 6x4__3489 PX-2705000115 CDM 2705000115 LOCAL 270 RC inpatient 23 23 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES EPO [308136803] 18.21 percent of total billed charges 14.26 21.85 Technical (Hospital) Services HC/HH Wch Supp Paddng Undrcst Webril 6x4__3489 PX-2705000115 CDM 2705000115 LOCAL 270 RC inpatient 23 23 CIGNA 62308 [3081051] CIGNA 62308 [308105105] 18.21 percent of total billed charges 14.26 21.85 Technical (Hospital) Services HC/HH Wch Supp Paddng Undrcst Webril 6x4__3489 PX-2705000115 CDM 2705000115 LOCAL 270 RC inpatient 23 23 CIGNA 62308 [3081051] CIGNA STATE OF WYOMING [308105107] 18.21 percent of total billed charges 14.26 21.85 Technical (Hospital) Services HC/HH Wch Supp Paddng Undrcst Webril 6x4__3489 PX-2705000115 CDM 2705000115 LOCAL 270 RC inpatient 23 23 MULTIPLAN INC 34080 [3081285] MULTIPLAN INC [308128501] 21.85 percent of total billed charges 14.26 21.85 Technical (Hospital) Services HC/HH Wch Supp Paddng Undrcst Webril 6x4__3489 PX-2705000115 CDM 2705000115 LOCAL 270 RC inpatient 23 23 BLUE CROSS BLUE SHIELD WELLMARK SB889 [3081026] BCBS WYOMING [308102603] 21.85 percent of total billed charges 14.26 21.85 Technical (Hospital) Services HC/HH Wch Supp Paddng Undrcst Webril 6x4__3489 PX-2705000115 CDM 2705000115 LOCAL 270 RC inpatient 23 23 UNITED HEALTHCARE (COMMERCIAL) [3081199] UNITED HEALTHCARE 87726 [308119901] 14.26 percent of total billed charges 14.26 21.85 Technical (Hospital) Services HC/HH Wch Supp Paddng Undrcst Webril 6x4__3489 PX-2705000115 CDM 2705000115 LOCAL 270 RC inpatient 23 23 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES HDHP [308136802] 18.21 percent of total billed charges 14.26 21.85 Technical (Hospital) Services HC/HH Wch Supp Paddng Undrcst Webril 6x4__3489 PX-2705000115 CDM 2705000115 LOCAL 270 RC inpatient 23 23 MEDICA (COMMERCIAL) 94265 [3081118] MEDICA CLAIMS [308111801] 20.7 percent of total billed charges 14.26 21.85 Technical (Hospital) Services HC/HH Wch Supp Paddng Undrcst Webril 6x4__3489 PX-2705000115 CDM 2705000115 LOCAL 270 RC inpatient 23 23 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES PPO [308136801] 18.21 percent of total billed charges 14.26 21.85 Technical (Hospital) Services HC/HH Wch Supp Paddng Undrcst Webril 4x4__3175 PX-2705000114 CDM 2705000114 LOCAL 270 RC inpatient 8 8 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES PPO [308136801] 6.33 percent of total billed charges 4.96 7.6 Technical (Hospital) Services HC/HH Wch Supp Paddng Undrcst Webril 4x4__3175 PX-2705000114 CDM 2705000114 LOCAL 270 RC inpatient 8 8 MEDICA (COMMERCIAL) 94265 [3081118] MEDICA CLAIMS [308111801] 7.2 percent of total billed charges 4.96 7.6 Technical (Hospital) Services HC/HH Wch Supp Paddng Undrcst Webril 4x4__3175 PX-2705000114 CDM 2705000114 LOCAL 270 RC inpatient 8 8 UNITED HEALTHCARE (COMMERCIAL) [3081199] UNITED HEALTHCARE 87726 [308119901] 4.96 percent of total billed charges 4.96 7.6 Technical (Hospital) Services HC/HH Wch Supp Paddng Undrcst Webril 4x4__3175 PX-2705000114 CDM 2705000114 LOCAL 270 RC inpatient 8 8 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES HDHP [308136802] 6.33 percent of total billed charges 4.96 7.6 Technical (Hospital) Services HC/HH Wch Supp Paddng Undrcst Webril 4x4__3175 PX-2705000114 CDM 2705000114 LOCAL 270 RC inpatient 8 8 BLUE CROSS BLUE SHIELD WELLMARK SB889 [3081026] BCBS WYOMING [308102603] 7.6 percent of total billed charges 4.96 7.6 Technical (Hospital) Services HC/HH Wch Supp Paddng Undrcst Webril 4x4__3175 PX-2705000114 CDM 2705000114 LOCAL 270 RC inpatient 8 8 CIGNA 62308 [3081051] CIGNA 62308 [308105105] 6.33 percent of total billed charges 4.96 7.6 Technical (Hospital) Services HC/HH Wch Supp Paddng Undrcst Webril 4x4__3175 PX-2705000114 CDM 2705000114 LOCAL 270 RC inpatient 8 8 CIGNA 62308 [3081051] CIGNA STATE OF WYOMING [308105107] 6.33 percent of total billed charges 4.96 7.6 Technical (Hospital) Services HC/HH Wch Supp Paddng Undrcst Webril 4x4__3175 PX-2705000114 CDM 2705000114 LOCAL 270 RC inpatient 8 8 MULTIPLAN INC 34080 [3081285] MULTIPLAN INC [308128501] 7.6 percent of total billed charges 4.96 7.6 Technical (Hospital) Services HC/HH Wch Supp Paddng Undrcst Webril 4x4__3175 PX-2705000114 CDM 2705000114 LOCAL 270 RC inpatient 8 8 HEALTHPARTNERS SX009 HEALTHPARTNERS 6.33 percent of total billed charges 4.96 7.6 Technical (Hospital) Services HC/HH Wch Supp Paddng Undrcst Webril 4x4__3175 PX-2705000114 CDM 2705000114 LOCAL 270 RC inpatient 8 8 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES EPO [308136803] 6.33 percent of total billed charges 4.96 7.6 Technical (Hospital) Services HC/HH Wch Supp Paddng Undrcst Webril 4x4__3175 PX-2705000114 CDM 2705000114 LOCAL 270 RC outpatient 8 8 BLUE CROSS BLUE SHIELD WELLMARK SB889 [3081026] BCBS WYOMING [308102603] 7.6 percent of total billed charges 4.96 7.6 Technical (Hospital) Services HC/HH Wch Supp Paddng Undrcst Webril 4x4__3175 PX-2705000114 CDM 2705000114 LOCAL 270 RC outpatient 8 8 CIGNA 62308 [3081051] CIGNA 62308 [308105105] 6.4 percent of total billed charges 4.96 7.6 Technical (Hospital) Services HC/HH Wch Supp Paddng Undrcst Webril 4x4__3175 PX-2705000114 CDM 2705000114 LOCAL 270 RC outpatient 8 8 CIGNA 62308 [3081051] CIGNA STATE OF WYOMING [308105107] 6.4 percent of total billed charges 4.96 7.6 Technical (Hospital) Services HC/HH Wch Supp Paddng Undrcst Webril 4x4__3175 PX-2705000114 CDM 2705000114 LOCAL 270 RC outpatient 8 8 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES EPO [308136803] 6.4 percent of total billed charges 4.96 7.6 Technical (Hospital) Services HC/HH Wch Supp Paddng Undrcst Webril 4x4__3175 PX-2705000114 CDM 2705000114 LOCAL 270 RC outpatient 8 8 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES HDHP [308136802] 6.4 percent of total billed charges 4.96 7.6 Technical (Hospital) Services HC/HH Wch Supp Paddng Undrcst Webril 4x4__3175 PX-2705000114 CDM 2705000114 LOCAL 270 RC outpatient 8 8 UNITED HEALTHCARE (COMMERCIAL) [3081199] UNITED HEALTHCARE 87726 [308119901] 4.96 percent of total billed charges 4.96 7.6 Technical (Hospital) Services HC/HH Wch Supp Paddng Undrcst Webril 4x4__3175 PX-2705000114 CDM 2705000114 LOCAL 270 RC outpatient 8 8 MEDICA (COMMERCIAL) 94265 [3081118] MEDICA CLAIMS [308111801] 7.2 percent of total billed charges 4.96 7.6 Technical (Hospital) Services HC/HH Wch Supp Paddng Undrcst Webril 4x4__3175 PX-2705000114 CDM 2705000114 LOCAL 270 RC outpatient 8 8 MULTIPLAN INC 34080 [3081285] MULTIPLAN INC [308128501] 7.6 percent of total billed charges 4.96 7.6 Technical (Hospital) Services HC/HH Wch Supp Paddng Undrcst Webril 4x4__3175 PX-2705000114 CDM 2705000114 LOCAL 270 RC outpatient 8 8 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES PPO [308136801] 6.4 percent of total billed charges 4.96 7.6 Technical (Hospital) Services HC/HH Wch Supp Paddng Undrcst Webril 4x4__3175 PX-2705000114 CDM 2705000114 LOCAL 270 RC outpatient 8 8 HEALTHPARTNERS SX009 HEALTHPARTNERS 6.4 percent of total billed charges 4.96 7.6 Technical (Hospital) Services HC/HH Wch Supp Paddng Undrcst Webril 3inx4yds__2059 PX-2705000113 CDM 2705000113 LOCAL 270 RC inpatient 6 6 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES HDHP [308136802] 4.75 percent of total billed charges 3.72 5.7 Technical (Hospital) Services HC/HH Wch Supp Paddng Undrcst Webril 3inx4yds__2059 PX-2705000113 CDM 2705000113 LOCAL 270 RC inpatient 6 6 UNITED HEALTHCARE (COMMERCIAL) [3081199] UNITED HEALTHCARE 87726 [308119901] 3.72 percent of total billed charges 3.72 5.7 Technical (Hospital) Services HC/HH Wch Supp Paddng Undrcst Webril 3inx4yds__2059 PX-2705000113 CDM 2705000113 LOCAL 270 RC inpatient 6 6 MEDICA (COMMERCIAL) 94265 [3081118] MEDICA CLAIMS [308111801] 5.4 percent of total billed charges 3.72 5.7 Technical (Hospital) Services HC/HH Wch Supp Paddng Undrcst Webril 3inx4yds__2059 PX-2705000113 CDM 2705000113 LOCAL 270 RC inpatient 6 6 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES PPO [308136801] 4.75 percent of total billed charges 3.72 5.7 Technical (Hospital) Services HC/HH Wch Supp Paddng Undrcst Webril 3inx4yds__2059 PX-2705000113 CDM 2705000113 LOCAL 270 RC inpatient 6 6 MULTIPLAN INC 34080 [3081285] MULTIPLAN INC [308128501] 5.7 percent of total billed charges 3.72 5.7 Technical (Hospital) Services HC/HH Wch Supp Paddng Undrcst Webril 3inx4yds__2059 PX-2705000113 CDM 2705000113 LOCAL 270 RC inpatient 6 6 CIGNA 62308 [3081051] CIGNA 62308 [308105105] 4.75 percent of total billed charges 3.72 5.7 Technical (Hospital) Services HC/HH Wch Supp Paddng Undrcst Webril 3inx4yds__2059 PX-2705000113 CDM 2705000113 LOCAL 270 RC inpatient 6 6 CIGNA 62308 [3081051] CIGNA STATE OF WYOMING [308105107] 4.75 percent of total billed charges 3.72 5.7 Technical (Hospital) Services HC/HH Wch Supp Paddng Undrcst Webril 3inx4yds__2059 PX-2705000113 CDM 2705000113 LOCAL 270 RC inpatient 6 6 BLUE CROSS BLUE SHIELD WELLMARK SB889 [3081026] BCBS WYOMING [308102603] 5.7 percent of total billed charges 3.72 5.7 Technical (Hospital) Services HC/HH Wch Supp Paddng Undrcst Webril 3inx4yds__2059 PX-2705000113 CDM 2705000113 LOCAL 270 RC inpatient 6 6 HEALTHPARTNERS SX009 HEALTHPARTNERS 4.75 percent of total billed charges 3.72 5.7 Technical (Hospital) Services HC/HH Wch Supp Paddng Undrcst Webril 3inx4yds__2059 PX-2705000113 CDM 2705000113 LOCAL 270 RC inpatient 6 6 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES EPO [308136803] 4.75 percent of total billed charges 3.72 5.7 Technical (Hospital) Services HC/HH Wch Supp Paddng Undrcst Webril 3inx4yds__2059 PX-2705000113 CDM 2705000113 LOCAL 270 RC outpatient 6 6 BLUE CROSS BLUE SHIELD WELLMARK SB889 [3081026] BCBS WYOMING [308102603] 5.7 percent of total billed charges 3.72 5.7 Technical (Hospital) Services HC/HH Wch Supp Paddng Undrcst Webril 3inx4yds__2059 PX-2705000113 CDM 2705000113 LOCAL 270 RC outpatient 6 6 CIGNA 62308 [3081051] CIGNA 62308 [308105105] 4.8 percent of total billed charges 3.72 5.7 Technical (Hospital) Services HC/HH Wch Supp Paddng Undrcst Webril 3inx4yds__2059 PX-2705000113 CDM 2705000113 LOCAL 270 RC outpatient 6 6 CIGNA 62308 [3081051] CIGNA STATE OF WYOMING [308105107] 4.8 percent of total billed charges 3.72 5.7 Technical (Hospital) Services HC/HH Wch Supp Paddng Undrcst Webril 3inx4yds__2059 PX-2705000113 CDM 2705000113 LOCAL 270 RC outpatient 6 6 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES EPO [308136803] 4.8 percent of total billed charges 3.72 5.7 Technical (Hospital) Services HC/HH Wch Supp Paddng Undrcst Webril 3inx4yds__2059 PX-2705000113 CDM 2705000113 LOCAL 270 RC outpatient 6 6 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES HDHP [308136802] 4.8 percent of total billed charges 3.72 5.7 Technical (Hospital) Services HC/HH Wch Supp Paddng Undrcst Webril 3inx4yds__2059 PX-2705000113 CDM 2705000113 LOCAL 270 RC outpatient 6 6 HEALTHPARTNERS SX009 HEALTHPARTNERS 4.8 percent of total billed charges 3.72 5.7 Technical (Hospital) Services HC/HH Wch Supp Paddng Undrcst Webril 3inx4yds__2059 PX-2705000113 CDM 2705000113 LOCAL 270 RC outpatient 6 6 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES PPO [308136801] 4.8 percent of total billed charges 3.72 5.7 Technical (Hospital) Services HC/HH Wch Supp Paddng Undrcst Webril 3inx4yds__2059 PX-2705000113 CDM 2705000113 LOCAL 270 RC outpatient 6 6 UNITED HEALTHCARE (COMMERCIAL) [3081199] UNITED HEALTHCARE 87726 [308119901] 3.72 percent of total billed charges 3.72 5.7 Technical (Hospital) Services HC/HH Wch Supp Paddng Undrcst Webril 3inx4yds__2059 PX-2705000113 CDM 2705000113 LOCAL 270 RC outpatient 6 6 MULTIPLAN INC 34080 [3081285] MULTIPLAN INC [308128501] 5.7 percent of total billed charges 3.72 5.7 Technical (Hospital) Services HC/HH Wch Supp Paddng Undrcst Webril 3inx4yds__2059 PX-2705000113 CDM 2705000113 LOCAL 270 RC outpatient 6 6 MEDICA (COMMERCIAL) 94265 [3081118] MEDICA CLAIMS [308111801] 5.4 percent of total billed charges 3.72 5.7 Technical (Hospital) Services HC/HH Wch Supp Padding Cast Synthetic 3x4__Cmw03 PX-2705000111 CDM 2705000111 LOCAL 270 RC inpatient 6 6 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES PPO [308136801] 4.75 percent of total billed charges 3.72 5.7 Technical (Hospital) Services HC/HH Wch Supp Padding Cast Synthetic 3x4__Cmw03 PX-2705000111 CDM 2705000111 LOCAL 270 RC inpatient 6 6 UNITED HEALTHCARE (COMMERCIAL) [3081199] UNITED HEALTHCARE 87726 [308119901] 3.72 percent of total billed charges 3.72 5.7 Technical (Hospital) Services HC/HH Wch Supp Padding Cast Synthetic 3x4__Cmw03 PX-2705000111 CDM 2705000111 LOCAL 270 RC inpatient 6 6 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES HDHP [308136802] 4.75 percent of total billed charges 3.72 5.7 Technical (Hospital) Services HC/HH Wch Supp Padding Cast Synthetic 3x4__Cmw03 PX-2705000111 CDM 2705000111 LOCAL 270 RC inpatient 6 6 MEDICA (COMMERCIAL) 94265 [3081118] MEDICA CLAIMS [308111801] 5.4 percent of total billed charges 3.72 5.7 Technical (Hospital) Services HC/HH Wch Supp Padding Cast Synthetic 3x4__Cmw03 PX-2705000111 CDM 2705000111 LOCAL 270 RC inpatient 6 6 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES EPO [308136803] 4.75 percent of total billed charges 3.72 5.7 Technical (Hospital) Services HC/HH Wch Supp Padding Cast Synthetic 3x4__Cmw03 PX-2705000111 CDM 2705000111 LOCAL 270 RC inpatient 6 6 HEALTHPARTNERS SX009 HEALTHPARTNERS 4.75 percent of total billed charges 3.72 5.7 Technical (Hospital) Services HC/HH Wch Supp Padding Cast Synthetic 3x4__Cmw03 PX-2705000111 CDM 2705000111 LOCAL 270 RC inpatient 6 6 MULTIPLAN INC 34080 [3081285] MULTIPLAN INC [308128501] 5.7 percent of total billed charges 3.72 5.7 Technical (Hospital) Services HC/HH Wch Supp Padding Cast Synthetic 3x4__Cmw03 PX-2705000111 CDM 2705000111 LOCAL 270 RC inpatient 6 6 BLUE CROSS BLUE SHIELD WELLMARK SB889 [3081026] BCBS WYOMING [308102603] 5.7 percent of total billed charges 3.72 5.7 Technical (Hospital) Services HC/HH Wch Supp Padding Cast Synthetic 3x4__Cmw03 PX-2705000111 CDM 2705000111 LOCAL 270 RC inpatient 6 6 CIGNA 62308 [3081051] CIGNA 62308 [308105105] 4.75 percent of total billed charges 3.72 5.7 Technical (Hospital) Services HC/HH Wch Supp Padding Cast Synthetic 3x4__Cmw03 PX-2705000111 CDM 2705000111 LOCAL 270 RC inpatient 6 6 CIGNA 62308 [3081051] CIGNA STATE OF WYOMING [308105107] 4.75 percent of total billed charges 3.72 5.7 Technical (Hospital) Services HC/HH Wch Supp Padding Cast Synthetic 3x4__Cmw03 PX-2705000111 CDM 2705000111 LOCAL 270 RC outpatient 6 6 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES PPO [308136801] 4.8 percent of total billed charges 3.72 5.7 Technical (Hospital) Services HC/HH Wch Supp Padding Cast Synthetic 3x4__Cmw03 PX-2705000111 CDM 2705000111 LOCAL 270 RC outpatient 6 6 MULTIPLAN INC 34080 [3081285] MULTIPLAN INC [308128501] 5.7 percent of total billed charges 3.72 5.7 Technical (Hospital) Services HC/HH Wch Supp Padding Cast Synthetic 3x4__Cmw03 PX-2705000111 CDM 2705000111 LOCAL 270 RC outpatient 6 6 MEDICA (COMMERCIAL) 94265 [3081118] MEDICA CLAIMS [308111801] 5.4 percent of total billed charges 3.72 5.7 Technical (Hospital) Services HC/HH Wch Supp Padding Cast Synthetic 3x4__Cmw03 PX-2705000111 CDM 2705000111 LOCAL 270 RC outpatient 6 6 UNITED HEALTHCARE (COMMERCIAL) [3081199] UNITED HEALTHCARE 87726 [308119901] 3.72 percent of total billed charges 3.72 5.7 Technical (Hospital) Services HC/HH Wch Supp Padding Cast Synthetic 3x4__Cmw03 PX-2705000111 CDM 2705000111 LOCAL 270 RC outpatient 6 6 HEALTHPARTNERS SX009 HEALTHPARTNERS 4.8 percent of total billed charges 3.72 5.7 Technical (Hospital) Services HC/HH Wch Supp Padding Cast Synthetic 3x4__Cmw03 PX-2705000111 CDM 2705000111 LOCAL 270 RC outpatient 6 6 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES HDHP [308136802] 4.8 percent of total billed charges 3.72 5.7 Technical (Hospital) Services HC/HH Wch Supp Padding Cast Synthetic 3x4__Cmw03 PX-2705000111 CDM 2705000111 LOCAL 270 RC outpatient 6 6 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES EPO [308136803] 4.8 percent of total billed charges 3.72 5.7 Technical (Hospital) Services HC/HH Wch Supp Padding Cast Synthetic 3x4__Cmw03 PX-2705000111 CDM 2705000111 LOCAL 270 RC outpatient 6 6 BLUE CROSS BLUE SHIELD WELLMARK SB889 [3081026] BCBS WYOMING [308102603] 5.7 percent of total billed charges 3.72 5.7 Technical (Hospital) Services HC/HH Wch Supp Padding Cast Synthetic 3x4__Cmw03 PX-2705000111 CDM 2705000111 LOCAL 270 RC outpatient 6 6 CIGNA 62308 [3081051] CIGNA 62308 [308105105] 4.8 percent of total billed charges 3.72 5.7 Technical (Hospital) Services HC/HH Wch Supp Padding Cast Synthetic 3x4__Cmw03 PX-2705000111 CDM 2705000111 LOCAL 270 RC outpatient 6 6 CIGNA 62308 [3081051] CIGNA STATE OF WYOMING [308105107] 4.8 percent of total billed charges 3.72 5.7 Technical (Hospital) Services HC/HH Wch Supp Padding Cast Synthetic 2x4__Cmw02 PX-2705000110 CDM 2705000110 LOCAL 270 RC inpatient 6 6 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES EPO [308136803] 4.75 percent of total billed charges 3.72 5.7 Technical (Hospital) Services HC/HH Wch Supp Padding Cast Synthetic 2x4__Cmw02 PX-2705000110 CDM 2705000110 LOCAL 270 RC inpatient 6 6 HEALTHPARTNERS SX009 HEALTHPARTNERS 4.75 percent of total billed charges 3.72 5.7 Technical (Hospital) Services HC/HH Wch Supp Padding Cast Synthetic 2x4__Cmw02 PX-2705000110 CDM 2705000110 LOCAL 270 RC inpatient 6 6 BLUE CROSS BLUE SHIELD WELLMARK SB889 [3081026] BCBS WYOMING [308102603] 5.7 percent of total billed charges 3.72 5.7 Technical (Hospital) Services HC/HH Wch Supp Padding Cast Synthetic 2x4__Cmw02 PX-2705000110 CDM 2705000110 LOCAL 270 RC inpatient 6 6 CIGNA 62308 [3081051] CIGNA 62308 [308105105] 4.75 percent of total billed charges 3.72 5.7 Technical (Hospital) Services HC/HH Wch Supp Padding Cast Synthetic 2x4__Cmw02 PX-2705000110 CDM 2705000110 LOCAL 270 RC inpatient 6 6 CIGNA 62308 [3081051] CIGNA STATE OF WYOMING [308105107] 4.75 percent of total billed charges 3.72 5.7 Technical (Hospital) Services HC/HH Wch Supp Padding Cast Synthetic 2x4__Cmw02 PX-2705000110 CDM 2705000110 LOCAL 270 RC inpatient 6 6 MULTIPLAN INC 34080 [3081285] MULTIPLAN INC [308128501] 5.7 percent of total billed charges 3.72 5.7 Technical (Hospital) Services HC/HH Wch Supp Padding Cast Synthetic 2x4__Cmw02 PX-2705000110 CDM 2705000110 LOCAL 270 RC inpatient 6 6 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES PPO [308136801] 4.75 percent of total billed charges 3.72 5.7 Technical (Hospital) Services HC/HH Wch Supp Padding Cast Synthetic 2x4__Cmw02 PX-2705000110 CDM 2705000110 LOCAL 270 RC inpatient 6 6 UNITED HEALTHCARE (COMMERCIAL) [3081199] UNITED HEALTHCARE 87726 [308119901] 3.72 percent of total billed charges 3.72 5.7 Technical (Hospital) Services HC/HH Wch Supp Padding Cast Synthetic 2x4__Cmw02 PX-2705000110 CDM 2705000110 LOCAL 270 RC inpatient 6 6 MEDICA (COMMERCIAL) 94265 [3081118] MEDICA CLAIMS [308111801] 5.4 percent of total billed charges 3.72 5.7 Technical (Hospital) Services HC/HH Wch Supp Padding Cast Synthetic 2x4__Cmw02 PX-2705000110 CDM 2705000110 LOCAL 270 RC inpatient 6 6 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES HDHP [308136802] 4.75 percent of total billed charges 3.72 5.7 Technical (Hospital) Services HC/HH Wch Supp Padding Cast Synthetic 2x4__Cmw02 PX-2705000110 CDM 2705000110 LOCAL 270 RC outpatient 6 6 CIGNA 62308 [3081051] CIGNA 62308 [308105105] 4.8 percent of total billed charges 3.72 5.7 Technical (Hospital) Services HC/HH Wch Supp Padding Cast Synthetic 2x4__Cmw02 PX-2705000110 CDM 2705000110 LOCAL 270 RC outpatient 6 6 CIGNA 62308 [3081051] CIGNA STATE OF WYOMING [308105107] 4.8 percent of total billed charges 3.72 5.7 Technical (Hospital) Services HC/HH Wch Supp Padding Cast Synthetic 2x4__Cmw02 PX-2705000110 CDM 2705000110 LOCAL 270 RC outpatient 6 6 BLUE CROSS BLUE SHIELD WELLMARK SB889 [3081026] BCBS WYOMING [308102603] 5.7 percent of total billed charges 3.72 5.7 Technical (Hospital) Services HC/HH Wch Supp Padding Cast Synthetic 2x4__Cmw02 PX-2705000110 CDM 2705000110 LOCAL 270 RC outpatient 6 6 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES EPO [308136803] 4.8 percent of total billed charges 3.72 5.7 Technical (Hospital) Services HC/HH Wch Supp Padding Cast Synthetic 2x4__Cmw02 PX-2705000110 CDM 2705000110 LOCAL 270 RC outpatient 6 6 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES HDHP [308136802] 4.8 percent of total billed charges 3.72 5.7 Technical (Hospital) Services HC/HH Wch Supp Padding Cast Synthetic 2x4__Cmw02 PX-2705000110 CDM 2705000110 LOCAL 270 RC outpatient 6 6 HEALTHPARTNERS SX009 HEALTHPARTNERS 4.8 percent of total billed charges 3.72 5.7 Technical (Hospital) Services HC/HH Wch Supp Padding Cast Synthetic 2x4__Cmw02 PX-2705000110 CDM 2705000110 LOCAL 270 RC outpatient 6 6 UNITED HEALTHCARE (COMMERCIAL) [3081199] UNITED HEALTHCARE 87726 [308119901] 3.72 percent of total billed charges 3.72 5.7 Technical (Hospital) Services HC/HH Wch Supp Padding Cast Synthetic 2x4__Cmw02 PX-2705000110 CDM 2705000110 LOCAL 270 RC outpatient 6 6 MEDICA (COMMERCIAL) 94265 [3081118] MEDICA CLAIMS [308111801] 5.4 percent of total billed charges 3.72 5.7 Technical (Hospital) Services HC/HH Wch Supp Padding Cast Synthetic 2x4__Cmw02 PX-2705000110 CDM 2705000110 LOCAL 270 RC outpatient 6 6 MULTIPLAN INC 34080 [3081285] MULTIPLAN INC [308128501] 5.7 percent of total billed charges 3.72 5.7 Technical (Hospital) Services HC/HH Wch Supp Padding Cast Synthetic 2x4__Cmw02 PX-2705000110 CDM 2705000110 LOCAL 270 RC outpatient 6 6 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES PPO [308136801] 4.8 percent of total billed charges 3.72 5.7 Technical (Hospital) Services HC/HH Wch Supp Packing for Setopress__650948 PX-2705000109 CDM 2705000109 LOCAL 270 RC outpatient 33 33 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES PPO [308136801] 26.4 percent of total billed charges 20.46 31.35 Technical (Hospital) Services HC/HH Wch Supp Packing for Setopress__650948 PX-2705000109 CDM 2705000109 LOCAL 270 RC outpatient 33 33 MULTIPLAN INC 34080 [3081285] MULTIPLAN INC [308128501] 31.35 percent of total billed charges 20.46 31.35 Technical (Hospital) Services HC/HH Wch Supp Packing for Setopress__650948 PX-2705000109 CDM 2705000109 LOCAL 270 RC outpatient 33 33 MEDICA (COMMERCIAL) 94265 [3081118] MEDICA CLAIMS [308111801] 29.7 percent of total billed charges 20.46 31.35 Technical (Hospital) Services HC/HH Wch Supp Packing for Setopress__650948 PX-2705000109 CDM 2705000109 LOCAL 270 RC outpatient 33 33 UNITED HEALTHCARE (COMMERCIAL) [3081199] UNITED HEALTHCARE 87726 [308119901] 20.46 percent of total billed charges 20.46 31.35 Technical (Hospital) Services HC/HH Wch Supp Packing for Setopress__650948 PX-2705000109 CDM 2705000109 LOCAL 270 RC outpatient 33 33 HEALTHPARTNERS SX009 HEALTHPARTNERS 26.4 percent of total billed charges 20.46 31.35 Technical (Hospital) Services HC/HH Wch Supp Packing for Setopress__650948 PX-2705000109 CDM 2705000109 LOCAL 270 RC outpatient 33 33 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES HDHP [308136802] 26.4 percent of total billed charges 20.46 31.35 Technical (Hospital) Services HC/HH Wch Supp Packing for Setopress__650948 PX-2705000109 CDM 2705000109 LOCAL 270 RC outpatient 33 33 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES EPO [308136803] 26.4 percent of total billed charges 20.46 31.35 Technical (Hospital) Services HC/HH Wch Supp Packing for Setopress__650948 PX-2705000109 CDM 2705000109 LOCAL 270 RC outpatient 33 33 BLUE CROSS BLUE SHIELD WELLMARK SB889 [3081026] BCBS WYOMING [308102603] 31.35 percent of total billed charges 20.46 31.35 Technical (Hospital) Services HC/HH Wch Supp Packing for Setopress__650948 PX-2705000109 CDM 2705000109 LOCAL 270 RC outpatient 33 33 CIGNA 62308 [3081051] CIGNA 62308 [308105105] 26.4 percent of total billed charges 20.46 31.35 Technical (Hospital) Services HC/HH Wch Supp Packing for Setopress__650948 PX-2705000109 CDM 2705000109 LOCAL 270 RC outpatient 33 33 CIGNA 62308 [3081051] CIGNA STATE OF WYOMING [308105107] 26.4 percent of total billed charges 20.46 31.35 Technical (Hospital) Services HC/HH Wch Supp Packing for Setopress__650948 PX-2705000109 CDM 2705000109 LOCAL 270 RC inpatient 33 33 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES PPO [308136801] 26.13 percent of total billed charges 20.46 31.35 Technical (Hospital) Services HC/HH Wch Supp Packing for Setopress__650948 PX-2705000109 CDM 2705000109 LOCAL 270 RC inpatient 33 33 MEDICA (COMMERCIAL) 94265 [3081118] MEDICA CLAIMS [308111801] 29.7 percent of total billed charges 20.46 31.35 Technical (Hospital) Services HC/HH Wch Supp Packing for Setopress__650948 PX-2705000109 CDM 2705000109 LOCAL 270 RC inpatient 33 33 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES HDHP [308136802] 26.13 percent of total billed charges 20.46 31.35 Technical (Hospital) Services HC/HH Wch Supp Packing for Setopress__650948 PX-2705000109 CDM 2705000109 LOCAL 270 RC inpatient 33 33 UNITED HEALTHCARE (COMMERCIAL) [3081199] UNITED HEALTHCARE 87726 [308119901] 20.46 percent of total billed charges 20.46 31.35 Technical (Hospital) Services HC/HH Wch Supp Packing for Setopress__650948 PX-2705000109 CDM 2705000109 LOCAL 270 RC inpatient 33 33 BLUE CROSS BLUE SHIELD WELLMARK SB889 [3081026] BCBS WYOMING [308102603] 31.35 percent of total billed charges 20.46 31.35 Technical (Hospital) Services HC/HH Wch Supp Packing for Setopress__650948 PX-2705000109 CDM 2705000109 LOCAL 270 RC inpatient 33 33 CIGNA 62308 [3081051] CIGNA 62308 [308105105] 26.13 percent of total billed charges 20.46 31.35 Technical (Hospital) Services HC/HH Wch Supp Packing for Setopress__650948 PX-2705000109 CDM 2705000109 LOCAL 270 RC inpatient 33 33 MULTIPLAN INC 34080 [3081285] MULTIPLAN INC [308128501] 31.35 percent of total billed charges 20.46 31.35 Technical (Hospital) Services HC/HH Wch Supp Packing for Setopress__650948 PX-2705000109 CDM 2705000109 LOCAL 270 RC inpatient 33 33 CIGNA 62308 [3081051] CIGNA STATE OF WYOMING [308105107] 26.13 percent of total billed charges 20.46 31.35 Technical (Hospital) Services HC/HH Wch Supp Packing for Setopress__650948 PX-2705000109 CDM 2705000109 LOCAL 270 RC inpatient 33 33 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES EPO [308136803] 26.13 percent of total billed charges 20.46 31.35 Technical (Hospital) Services HC/HH Wch Supp Packing for Setopress__650948 PX-2705000109 CDM 2705000109 LOCAL 270 RC inpatient 33 33 HEALTHPARTNERS SX009 HEALTHPARTNERS 26.13 percent of total billed charges 20.46 31.35 Technical (Hospital) Services HC/HH Wch Supp Ointment/Antifungal__325102 PX-2705000108 CDM 2705000108 LOCAL 270 RC outpatient 23 23 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES HDHP [308136802] 18.4 percent of total billed charges 14.26 21.85 Technical (Hospital) Services HC/HH Wch Supp Ointment/Antifungal__325102 PX-2705000108 CDM 2705000108 LOCAL 270 RC outpatient 23 23 CIGNA 62308 [3081051] CIGNA 62308 [308105105] 18.4 percent of total billed charges 14.26 21.85 Technical (Hospital) Services HC/HH Wch Supp Ointment/Antifungal__325102 PX-2705000108 CDM 2705000108 LOCAL 270 RC outpatient 23 23 CIGNA 62308 [3081051] CIGNA STATE OF WYOMING [308105107] 18.4 percent of total billed charges 14.26 21.85 Technical (Hospital) Services HC/HH Wch Supp Ointment/Antifungal__325102 PX-2705000108 CDM 2705000108 LOCAL 270 RC inpatient 23 23 MULTIPLAN INC 34080 [3081285] MULTIPLAN INC [308128501] 21.85 percent of total billed charges 14.26 21.85 Technical (Hospital) Services HC/HH Wch Supp Ointment/Antifungal__325102 PX-2705000108 CDM 2705000108 LOCAL 270 RC inpatient 23 23 CIGNA 62308 [3081051] CIGNA 62308 [308105105] 18.21 percent of total billed charges 14.26 21.85 Technical (Hospital) Services HC/HH Wch Supp Ointment/Antifungal__325102 PX-2705000108 CDM 2705000108 LOCAL 270 RC inpatient 23 23 CIGNA 62308 [3081051] CIGNA STATE OF WYOMING [308105107] 18.21 percent of total billed charges 14.26 21.85 Technical (Hospital) Services HC/HH Wch Supp Ointment/Antifungal__325102 PX-2705000108 CDM 2705000108 LOCAL 270 RC inpatient 23 23 BLUE CROSS BLUE SHIELD WELLMARK SB889 [3081026] BCBS WYOMING [308102603] 21.85 percent of total billed charges 14.26 21.85 Technical (Hospital) Services HC/HH Wch Supp Ointment/Antifungal__325102 PX-2705000108 CDM 2705000108 LOCAL 270 RC inpatient 23 23 HEALTHPARTNERS SX009 HEALTHPARTNERS 18.21 percent of total billed charges 14.26 21.85 Technical (Hospital) Services HC/HH Wch Supp Ointment/Antifungal__325102 PX-2705000108 CDM 2705000108 LOCAL 270 RC inpatient 23 23 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES EPO [308136803] 18.21 percent of total billed charges 14.26 21.85 Technical (Hospital) Services HC/HH Wch Supp Ointment/Antifungal__325102 PX-2705000108 CDM 2705000108 LOCAL 270 RC inpatient 23 23 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES HDHP [308136802] 18.21 percent of total billed charges 14.26 21.85 Technical (Hospital) Services HC/HH Wch Supp Ointment/Antifungal__325102 PX-2705000108 CDM 2705000108 LOCAL 270 RC outpatient 23 23 BLUE CROSS BLUE SHIELD WELLMARK SB889 [3081026] BCBS WYOMING [308102603] 21.85 percent of total billed charges 14.26 21.85 Technical (Hospital) Services HC/HH Wch Supp Ointment/Antifungal__325102 PX-2705000108 CDM 2705000108 LOCAL 270 RC outpatient 23 23 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES EPO [308136803] 18.4 percent of total billed charges 14.26 21.85 Technical (Hospital) Services HC/HH Wch Supp Ointment/Antifungal__325102 PX-2705000108 CDM 2705000108 LOCAL 270 RC outpatient 23 23 HEALTHPARTNERS SX009 HEALTHPARTNERS 18.4 percent of total billed charges 14.26 21.85 Technical (Hospital) Services HC/HH Wch Supp Ointment/Antifungal__325102 PX-2705000108 CDM 2705000108 LOCAL 270 RC outpatient 23 23 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES PPO [308136801] 18.4 percent of total billed charges 14.26 21.85 Technical (Hospital) Services HC/HH Wch Supp Ointment/Antifungal__325102 PX-2705000108 CDM 2705000108 LOCAL 270 RC outpatient 23 23 UNITED HEALTHCARE (COMMERCIAL) [3081199] UNITED HEALTHCARE 87726 [308119901] 14.26 percent of total billed charges 14.26 21.85 Technical (Hospital) Services HC/HH Wch Supp Ointment/Antifungal__325102 PX-2705000108 CDM 2705000108 LOCAL 270 RC outpatient 23 23 MULTIPLAN INC 34080 [3081285] MULTIPLAN INC [308128501] 21.85 percent of total billed charges 14.26 21.85 Technical (Hospital) Services HC/HH Wch Supp Ointment/Antifungal__325102 PX-2705000108 CDM 2705000108 LOCAL 270 RC outpatient 23 23 MEDICA (COMMERCIAL) 94265 [3081118] MEDICA CLAIMS [308111801] 20.7 percent of total billed charges 14.26 21.85 Technical (Hospital) Services HC/HH Wch Supp Ointment/Antifungal__325102 PX-2705000108 CDM 2705000108 LOCAL 270 RC inpatient 23 23 UNITED HEALTHCARE (COMMERCIAL) [3081199] UNITED HEALTHCARE 87726 [308119901] 14.26 percent of total billed charges 14.26 21.85 Technical (Hospital) Services HC/HH Wch Supp Ointment/Antifungal__325102 PX-2705000108 CDM 2705000108 LOCAL 270 RC inpatient 23 23 MEDICA (COMMERCIAL) 94265 [3081118] MEDICA CLAIMS [308111801] 20.7 percent of total billed charges 14.26 21.85 Technical (Hospital) Services HC/HH Wch Supp Ointment/Antifungal__325102 PX-2705000108 CDM 2705000108 LOCAL 270 RC inpatient 23 23 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES PPO [308136801] 18.21 percent of total billed charges 14.26 21.85 Technical (Hospital) Services HC/HH Wch Supp Ointment Barrier Sensicare 4oz__325614 PX-2705000107 CDM 2705000107 LOCAL 270 RC outpatient 28 28 CIGNA 62308 [3081051] CIGNA 62308 [308105105] 22.4 percent of total billed charges 17.36 26.6 Technical (Hospital) Services HC/HH Wch Supp Ointment Barrier Sensicare 4oz__325614 PX-2705000107 CDM 2705000107 LOCAL 270 RC outpatient 28 28 CIGNA 62308 [3081051] CIGNA STATE OF WYOMING [308105107] 22.4 percent of total billed charges 17.36 26.6 Technical (Hospital) Services HC/HH Wch Supp Ointment Barrier Sensicare 4oz__325614 PX-2705000107 CDM 2705000107 LOCAL 270 RC outpatient 28 28 BLUE CROSS BLUE SHIELD WELLMARK SB889 [3081026] BCBS WYOMING [308102603] 26.6 percent of total billed charges 17.36 26.6 Technical (Hospital) Services HC/HH Wch Supp Ointment Barrier Sensicare 4oz__325614 PX-2705000107 CDM 2705000107 LOCAL 270 RC outpatient 28 28 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES EPO [308136803] 22.4 percent of total billed charges 17.36 26.6 Technical (Hospital) Services HC/HH Wch Supp Ointment Barrier Sensicare 4oz__325614 PX-2705000107 CDM 2705000107 LOCAL 270 RC outpatient 28 28 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES HDHP [308136802] 22.4 percent of total billed charges 17.36 26.6 Technical (Hospital) Services HC/HH Wch Supp Ointment Barrier Sensicare 4oz__325614 PX-2705000107 CDM 2705000107 LOCAL 270 RC outpatient 28 28 HEALTHPARTNERS SX009 HEALTHPARTNERS 22.4 percent of total billed charges 17.36 26.6 Technical (Hospital) Services HC/HH Wch Supp Ointment Barrier Sensicare 4oz__325614 PX-2705000107 CDM 2705000107 LOCAL 270 RC outpatient 28 28 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES PPO [308136801] 22.4 percent of total billed charges 17.36 26.6 Technical (Hospital) Services HC/HH Wch Supp Ointment Barrier Sensicare 4oz__325614 PX-2705000107 CDM 2705000107 LOCAL 270 RC outpatient 28 28 UNITED HEALTHCARE (COMMERCIAL) [3081199] UNITED HEALTHCARE 87726 [308119901] 17.36 percent of total billed charges 17.36 26.6 Technical (Hospital) Services HC/HH Wch Supp Ointment Barrier Sensicare 4oz__325614 PX-2705000107 CDM 2705000107 LOCAL 270 RC outpatient 28 28 MULTIPLAN INC 34080 [3081285] MULTIPLAN INC [308128501] 26.6 percent of total billed charges 17.36 26.6 Technical (Hospital) Services HC/HH Wch Supp Ointment Barrier Sensicare 4oz__325614 PX-2705000107 CDM 2705000107 LOCAL 270 RC outpatient 28 28 MEDICA (COMMERCIAL) 94265 [3081118] MEDICA CLAIMS [308111801] 25.2 percent of total billed charges 17.36 26.6 Technical (Hospital) Services HC/HH Wch Supp Ointment Barrier Sensicare 4oz__325614 PX-2705000107 CDM 2705000107 LOCAL 270 RC inpatient 28 28 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES HDHP [308136802] 22.17 percent of total billed charges 17.36 26.6 Technical (Hospital) Services HC/HH Wch Supp Ointment Barrier Sensicare 4oz__325614 PX-2705000107 CDM 2705000107 LOCAL 270 RC inpatient 28 28 MEDICA (COMMERCIAL) 94265 [3081118] MEDICA CLAIMS [308111801] 25.2 percent of total billed charges 17.36 26.6 Technical (Hospital) Services HC/HH Wch Supp Ointment Barrier Sensicare 4oz__325614 PX-2705000107 CDM 2705000107 LOCAL 270 RC inpatient 28 28 UNITED HEALTHCARE (COMMERCIAL) [3081199] UNITED HEALTHCARE 87726 [308119901] 17.36 percent of total billed charges 17.36 26.6 Technical (Hospital) Services HC/HH Wch Supp Ointment Barrier Sensicare 4oz__325614 PX-2705000107 CDM 2705000107 LOCAL 270 RC inpatient 28 28 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES PPO [308136801] 22.17 percent of total billed charges 17.36 26.6 Technical (Hospital) Services HC/HH Wch Supp Ointment Barrier Sensicare 4oz__325614 PX-2705000107 CDM 2705000107 LOCAL 270 RC inpatient 28 28 MULTIPLAN INC 34080 [3081285] MULTIPLAN INC [308128501] 26.6 percent of total billed charges 17.36 26.6 Technical (Hospital) Services HC/HH Wch Supp Ointment Barrier Sensicare 4oz__325614 PX-2705000107 CDM 2705000107 LOCAL 270 RC inpatient 28 28 CIGNA 62308 [3081051] CIGNA 62308 [308105105] 22.17 percent of total billed charges 17.36 26.6 Technical (Hospital) Services HC/HH Wch Supp Ointment Barrier Sensicare 4oz__325614 PX-2705000107 CDM 2705000107 LOCAL 270 RC inpatient 28 28 CIGNA 62308 [3081051] CIGNA STATE OF WYOMING [308105107] 22.17 percent of total billed charges 17.36 26.6 Technical (Hospital) Services HC/HH Wch Supp Ointment Barrier Sensicare 4oz__325614 PX-2705000107 CDM 2705000107 LOCAL 270 RC inpatient 28 28 BLUE CROSS BLUE SHIELD WELLMARK SB889 [3081026] BCBS WYOMING [308102603] 26.6 percent of total billed charges 17.36 26.6 Technical (Hospital) Services HC/HH Wch Supp Ointment Barrier Sensicare 4oz__325614 PX-2705000107 CDM 2705000107 LOCAL 270 RC inpatient 28 28 HEALTHPARTNERS SX009 HEALTHPARTNERS 22.17 percent of total billed charges 17.36 26.6 Technical (Hospital) Services HC/HH Wch Supp Ointment Barrier Sensicare 4oz__325614 PX-2705000107 CDM 2705000107 LOCAL 270 RC inpatient 28 28 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES EPO [308136803] 22.17 percent of total billed charges 17.36 26.6 Technical (Hospital) Services HC/HH Wch Supp Nebulizer Sidestream__002174 PX-2705000106 CDM 2705000106 LOCAL 270 RC outpatient 9 9 HEALTHPARTNERS SX009 HEALTHPARTNERS 7.2 percent of total billed charges 5.58 8.55 Technical (Hospital) Services HC/HH Wch Supp Nebulizer Sidestream__002174 PX-2705000106 CDM 2705000106 LOCAL 270 RC outpatient 9 9 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES PPO [308136801] 7.2 percent of total billed charges 5.58 8.55 Technical (Hospital) Services HC/HH Wch Supp Nebulizer Sidestream__002174 PX-2705000106 CDM 2705000106 LOCAL 270 RC outpatient 9 9 UNITED HEALTHCARE (COMMERCIAL) [3081199] UNITED HEALTHCARE 87726 [308119901] 5.58 percent of total billed charges 5.58 8.55 Technical (Hospital) Services HC/HH Wch Supp Nebulizer Sidestream__002174 PX-2705000106 CDM 2705000106 LOCAL 270 RC outpatient 9 9 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES HDHP [308136802] 7.2 percent of total billed charges 5.58 8.55 Technical (Hospital) Services HC/HH Wch Supp Nebulizer Sidestream__002174 PX-2705000106 CDM 2705000106 LOCAL 270 RC outpatient 9 9 CIGNA 62308 [3081051] CIGNA 62308 [308105105] 7.2 percent of total billed charges 5.58 8.55 Technical (Hospital) Services HC/HH Wch Supp Nebulizer Sidestream__002174 PX-2705000106 CDM 2705000106 LOCAL 270 RC outpatient 9 9 CIGNA 62308 [3081051] CIGNA STATE OF WYOMING [308105107] 7.2 percent of total billed charges 5.58 8.55 Technical (Hospital) Services HC/HH Wch Supp Nebulizer Sidestream__002174 PX-2705000106 CDM 2705000106 LOCAL 270 RC outpatient 9 9 BLUE CROSS BLUE SHIELD WELLMARK SB889 [3081026] BCBS WYOMING [308102603] 8.55 percent of total billed charges 5.58 8.55 Technical (Hospital) Services HC/HH Wch Supp Nebulizer Sidestream__002174 PX-2705000106 CDM 2705000106 LOCAL 270 RC outpatient 9 9 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES EPO [308136803] 7.2 percent of total billed charges 5.58 8.55 Technical (Hospital) Services HC/HH Wch Supp Nebulizer Sidestream__002174 PX-2705000106 CDM 2705000106 LOCAL 270 RC outpatient 9 9 MEDICA (COMMERCIAL) 94265 [3081118] MEDICA CLAIMS [308111801] 8.1 percent of total billed charges 5.58 8.55 Technical (Hospital) Services HC/HH Wch Supp Nebulizer Sidestream__002174 PX-2705000106 CDM 2705000106 LOCAL 270 RC outpatient 9 9 MULTIPLAN INC 34080 [3081285] MULTIPLAN INC [308128501] 8.55 percent of total billed charges 5.58 8.55 Technical (Hospital) Services HC/HH Wch Supp Nebulizer Sidestream__002174 PX-2705000106 CDM 2705000106 LOCAL 270 RC inpatient 9 9 HEALTHPARTNERS SX009 HEALTHPARTNERS 7.13 percent of total billed charges 5.58 8.55 Technical (Hospital) Services HC/HH Wch Supp Nebulizer Sidestream__002174 PX-2705000106 CDM 2705000106 LOCAL 270 RC inpatient 9 9 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES EPO [308136803] 7.13 percent of total billed charges 5.58 8.55 Technical (Hospital) Services HC/HH Wch Supp Nebulizer Sidestream__002174 PX-2705000106 CDM 2705000106 LOCAL 270 RC inpatient 9 9 MULTIPLAN INC 34080 [3081285] MULTIPLAN INC [308128501] 8.55 percent of total billed charges 5.58 8.55 Technical (Hospital) Services HC/HH Wch Supp Nebulizer Sidestream__002174 PX-2705000106 CDM 2705000106 LOCAL 270 RC inpatient 9 9 CIGNA 62308 [3081051] CIGNA 62308 [308105105] 7.13 percent of total billed charges 5.58 8.55 Technical (Hospital) Services HC/HH Wch Supp Nebulizer Sidestream__002174 PX-2705000106 CDM 2705000106 LOCAL 270 RC inpatient 9 9 CIGNA 62308 [3081051] CIGNA STATE OF WYOMING [308105107] 7.13 percent of total billed charges 5.58 8.55 Technical (Hospital) Services HC/HH Wch Supp Nebulizer Sidestream__002174 PX-2705000106 CDM 2705000106 LOCAL 270 RC inpatient 9 9 BLUE CROSS BLUE SHIELD WELLMARK SB889 [3081026] BCBS WYOMING [308102603] 8.55 percent of total billed charges 5.58 8.55 Technical (Hospital) Services HC/HH Wch Supp Nebulizer Sidestream__002174 PX-2705000106 CDM 2705000106 LOCAL 270 RC inpatient 9 9 UNITED HEALTHCARE (COMMERCIAL) [3081199] UNITED HEALTHCARE 87726 [308119901] 5.58 percent of total billed charges 5.58 8.55 Technical (Hospital) Services HC/HH Wch Supp Nebulizer Sidestream__002174 PX-2705000106 CDM 2705000106 LOCAL 270 RC inpatient 9 9 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES HDHP [308136802] 7.13 percent of total billed charges 5.58 8.55 Technical (Hospital) Services HC/HH Wch Supp Nebulizer Sidestream__002174 PX-2705000106 CDM 2705000106 LOCAL 270 RC inpatient 9 9 MEDICA (COMMERCIAL) 94265 [3081118] MEDICA CLAIMS [308111801] 8.1 percent of total billed charges 5.58 8.55 Technical (Hospital) Services HC/HH Wch Supp Nebulizer Sidestream__002174 PX-2705000106 CDM 2705000106 LOCAL 270 RC inpatient 9 9 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES PPO [308136801] 7.13 percent of total billed charges 5.58 8.55 Technical (Hospital) Services HC/HH Wch Supp Nasal Cannula__1600 PX-2705000105 CDM 2705000105 LOCAL 270 RC outpatient 6 6 MEDICA (COMMERCIAL) 94265 [3081118] MEDICA CLAIMS [308111801] 5.4 percent of total billed charges 3.72 5.7 Technical (Hospital) Services HC/HH Wch Supp Nasal Cannula__1600 PX-2705000105 CDM 2705000105 LOCAL 270 RC outpatient 6 6 MULTIPLAN INC 34080 [3081285] MULTIPLAN INC [308128501] 5.7 percent of total billed charges 3.72 5.7 Technical (Hospital) Services HC/HH Wch Supp Nasal Cannula__1600 PX-2705000105 CDM 2705000105 LOCAL 270 RC outpatient 6 6 UNITED HEALTHCARE (COMMERCIAL) [3081199] UNITED HEALTHCARE 87726 [308119901] 3.72 percent of total billed charges 3.72 5.7 Technical (Hospital) Services HC/HH Wch Supp Nasal Cannula__1600 PX-2705000105 CDM 2705000105 LOCAL 270 RC outpatient 6 6 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES PPO [308136801] 4.8 percent of total billed charges 3.72 5.7 Technical (Hospital) Services HC/HH Wch Supp Nasal Cannula__1600 PX-2705000105 CDM 2705000105 LOCAL 270 RC outpatient 6 6 HEALTHPARTNERS SX009 HEALTHPARTNERS 4.8 percent of total billed charges 3.72 5.7 Technical (Hospital) Services HC/HH Wch Supp Nasal Cannula__1600 PX-2705000105 CDM 2705000105 LOCAL 270 RC outpatient 6 6 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES HDHP [308136802] 4.8 percent of total billed charges 3.72 5.7 Technical (Hospital) Services HC/HH Wch Supp Nasal Cannula__1600 PX-2705000105 CDM 2705000105 LOCAL 270 RC outpatient 6 6 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES EPO [308136803] 4.8 percent of total billed charges 3.72 5.7 Technical (Hospital) Services HC/HH Wch Supp Nasal Cannula__1600 PX-2705000105 CDM 2705000105 LOCAL 270 RC outpatient 6 6 CIGNA 62308 [3081051] CIGNA 62308 [308105105] 4.8 percent of total billed charges 3.72 5.7 Technical (Hospital) Services HC/HH Wch Supp Nasal Cannula__1600 PX-2705000105 CDM 2705000105 LOCAL 270 RC outpatient 6 6 CIGNA 62308 [3081051] CIGNA STATE OF WYOMING [308105107] 4.8 percent of total billed charges 3.72 5.7 Technical (Hospital) Services HC/HH Wch Supp Nasal Cannula__1600 PX-2705000105 CDM 2705000105 LOCAL 270 RC outpatient 6 6 BLUE CROSS BLUE SHIELD WELLMARK SB889 [3081026] BCBS WYOMING [308102603] 5.7 percent of total billed charges 3.72 5.7 Technical (Hospital) Services HC/HH Wch Supp Nasal Cannula__1600 PX-2705000105 CDM 2705000105 LOCAL 270 RC inpatient 6 6 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES PPO [308136801] 4.75 percent of total billed charges 3.72 5.7 Technical (Hospital) Services HC/HH Wch Supp Nasal Cannula__1600 PX-2705000105 CDM 2705000105 LOCAL 270 RC inpatient 6 6 MEDICA (COMMERCIAL) 94265 [3081118] MEDICA CLAIMS [308111801] 5.4 percent of total billed charges 3.72 5.7 Technical (Hospital) Services HC/HH Wch Supp Nasal Cannula__1600 PX-2705000105 CDM 2705000105 LOCAL 270 RC inpatient 6 6 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES HDHP [308136802] 4.75 percent of total billed charges 3.72 5.7 Technical (Hospital) Services HC/HH Wch Supp Nasal Cannula__1600 PX-2705000105 CDM 2705000105 LOCAL 270 RC inpatient 6 6 UNITED HEALTHCARE (COMMERCIAL) [3081199] UNITED HEALTHCARE 87726 [308119901] 3.72 percent of total billed charges 3.72 5.7 Technical (Hospital) Services HC/HH Wch Supp Nasal Cannula__1600 PX-2705000105 CDM 2705000105 LOCAL 270 RC inpatient 6 6 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES EPO [308136803] 4.75 percent of total billed charges 3.72 5.7 Technical (Hospital) Services HC/HH Wch Supp Nasal Cannula__1600 PX-2705000105 CDM 2705000105 LOCAL 270 RC inpatient 6 6 HEALTHPARTNERS SX009 HEALTHPARTNERS 4.75 percent of total billed charges 3.72 5.7 Technical (Hospital) Services HC/HH Wch Supp Nasal Cannula__1600 PX-2705000105 CDM 2705000105 LOCAL 270 RC inpatient 6 6 MULTIPLAN INC 34080 [3081285] MULTIPLAN INC [308128501] 5.7 percent of total billed charges 3.72 5.7 Technical (Hospital) Services HC/HH Wch Supp Nasal Cannula__1600 PX-2705000105 CDM 2705000105 LOCAL 270 RC inpatient 6 6 BLUE CROSS BLUE SHIELD WELLMARK SB889 [3081026] BCBS WYOMING [308102603] 5.7 percent of total billed charges 3.72 5.7 Technical (Hospital) Services HC/HH Wch Supp Nasal Cannula__1600 PX-2705000105 CDM 2705000105 LOCAL 270 RC inpatient 6 6 CIGNA 62308 [3081051] CIGNA 62308 [308105105] 4.75 percent of total billed charges 3.72 5.7 Technical (Hospital) Services HC/HH Wch Supp Nasal Cannula__1600 PX-2705000105 CDM 2705000105 LOCAL 270 RC inpatient 6 6 CIGNA 62308 [3081051] CIGNA STATE OF WYOMING [308105107] 4.75 percent of total billed charges 3.72 5.7 Technical (Hospital) Services HC/HH Wch Supp Moisturizer Mouth__6083 PX-2705000104 CDM 2705000104 LOCAL 270 RC inpatient 8 8 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES PPO [308136801] 6.33 percent of total billed charges 4.96 7.6 Technical (Hospital) Services HC/HH Wch Supp Moisturizer Mouth__6083 PX-2705000104 CDM 2705000104 LOCAL 270 RC outpatient 8 8 BLUE CROSS BLUE SHIELD WELLMARK SB889 [3081026] BCBS WYOMING [308102603] 7.6 percent of total billed charges 4.96 7.6 Technical (Hospital) Services HC/HH Wch Supp Moisturizer Mouth__6083 PX-2705000104 CDM 2705000104 LOCAL 270 RC outpatient 8 8 CIGNA 62308 [3081051] CIGNA STATE OF WYOMING [308105107] 6.4 percent of total billed charges 4.96 7.6 Technical (Hospital) Services HC/HH Wch Supp Moisturizer Mouth__6083 PX-2705000104 CDM 2705000104 LOCAL 270 RC outpatient 8 8 CIGNA 62308 [3081051] CIGNA 62308 [308105105] 6.4 percent of total billed charges 4.96 7.6 Technical (Hospital) Services HC/HH Wch Supp Moisturizer Mouth__6083 PX-2705000104 CDM 2705000104 LOCAL 270 RC outpatient 8 8 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES EPO [308136803] 6.4 percent of total billed charges 4.96 7.6 Technical (Hospital) Services HC/HH Wch Supp Moisturizer Mouth__6083 PX-2705000104 CDM 2705000104 LOCAL 270 RC outpatient 8 8 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES HDHP [308136802] 6.4 percent of total billed charges 4.96 7.6 Technical (Hospital) Services HC/HH Wch Supp Moisturizer Mouth__6083 PX-2705000104 CDM 2705000104 LOCAL 270 RC outpatient 8 8 HEALTHPARTNERS SX009 HEALTHPARTNERS 6.4 percent of total billed charges 4.96 7.6 Technical (Hospital) Services HC/HH Wch Supp Moisturizer Mouth__6083 PX-2705000104 CDM 2705000104 LOCAL 270 RC outpatient 8 8 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES PPO [308136801] 6.4 percent of total billed charges 4.96 7.6 Technical (Hospital) Services HC/HH Wch Supp Moisturizer Mouth__6083 PX-2705000104 CDM 2705000104 LOCAL 270 RC outpatient 8 8 UNITED HEALTHCARE (COMMERCIAL) [3081199] UNITED HEALTHCARE 87726 [308119901] 4.96 percent of total billed charges 4.96 7.6 Technical (Hospital) Services HC/HH Wch Supp Moisturizer Mouth__6083 PX-2705000104 CDM 2705000104 LOCAL 270 RC outpatient 8 8 MULTIPLAN INC 34080 [3081285] MULTIPLAN INC [308128501] 7.6 percent of total billed charges 4.96 7.6 Technical (Hospital) Services HC/HH Wch Supp Moisturizer Mouth__6083 PX-2705000104 CDM 2705000104 LOCAL 270 RC outpatient 8 8 MEDICA (COMMERCIAL) 94265 [3081118] MEDICA CLAIMS [308111801] 7.2 percent of total billed charges 4.96 7.6 Technical (Hospital) Services HC/HH Wch Supp Moisturizer Mouth__6083 PX-2705000104 CDM 2705000104 LOCAL 270 RC inpatient 8 8 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES HDHP [308136802] 6.33 percent of total billed charges 4.96 7.6 Technical (Hospital) Services HC/HH Wch Supp Moisturizer Mouth__6083 PX-2705000104 CDM 2705000104 LOCAL 270 RC inpatient 8 8 UNITED HEALTHCARE (COMMERCIAL) [3081199] UNITED HEALTHCARE 87726 [308119901] 4.96 percent of total billed charges 4.96 7.6 Technical (Hospital) Services HC/HH Wch Supp Moisturizer Mouth__6083 PX-2705000104 CDM 2705000104 LOCAL 270 RC inpatient 8 8 MEDICA (COMMERCIAL) 94265 [3081118] MEDICA CLAIMS [308111801] 7.2 percent of total billed charges 4.96 7.6 Technical (Hospital) Services HC/HH Wch Supp Moisturizer Mouth__6083 PX-2705000104 CDM 2705000104 LOCAL 270 RC inpatient 8 8 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES EPO [308136803] 6.33 percent of total billed charges 4.96 7.6 Technical (Hospital) Services HC/HH Wch Supp Moisturizer Mouth__6083 PX-2705000104 CDM 2705000104 LOCAL 270 RC inpatient 8 8 HEALTHPARTNERS SX009 HEALTHPARTNERS 6.33 percent of total billed charges 4.96 7.6 Technical (Hospital) Services HC/HH Wch Supp Moisturizer Mouth__6083 PX-2705000104 CDM 2705000104 LOCAL 270 RC inpatient 8 8 BLUE CROSS BLUE SHIELD WELLMARK SB889 [3081026] BCBS WYOMING [308102603] 7.6 percent of total billed charges 4.96 7.6 Technical (Hospital) Services HC/HH Wch Supp Moisturizer Mouth__6083 PX-2705000104 CDM 2705000104 LOCAL 270 RC inpatient 8 8 MULTIPLAN INC 34080 [3081285] MULTIPLAN INC [308128501] 7.6 percent of total billed charges 4.96 7.6 Technical (Hospital) Services HC/HH Wch Supp Moisturizer Mouth__6083 PX-2705000104 CDM 2705000104 LOCAL 270 RC inpatient 8 8 CIGNA 62308 [3081051] CIGNA 62308 [308105105] 6.33 percent of total billed charges 4.96 7.6 Technical (Hospital) Services HC/HH Wch Supp Moisturizer Mouth__6083 PX-2705000104 CDM 2705000104 LOCAL 270 RC inpatient 8 8 CIGNA 62308 [3081051] CIGNA STATE OF WYOMING [308105107] 6.33 percent of total billed charges 4.96 7.6 Technical (Hospital) Services HC/HH Wch Supp Meter Peak Flow Access Fl Rng__Hs710-012 PX-2705000103 CDM 2705000103 LOCAL 270 RC outpatient 55 55 MEDICA (COMMERCIAL) 94265 [3081118] MEDICA CLAIMS [308111801] 49.5 percent of total billed charges 34.1 52.25 Technical (Hospital) Services HC/HH Wch Supp Meter Peak Flow Access Fl Rng__Hs710-012 PX-2705000103 CDM 2705000103 LOCAL 270 RC outpatient 55 55 MULTIPLAN INC 34080 [3081285] MULTIPLAN INC [308128501] 52.25 percent of total billed charges 34.1 52.25 Technical (Hospital) Services HC/HH Wch Supp Meter Peak Flow Access Fl Rng__Hs710-012 PX-2705000103 CDM 2705000103 LOCAL 270 RC outpatient 55 55 UNITED HEALTHCARE (COMMERCIAL) [3081199] UNITED HEALTHCARE 87726 [308119901] 34.1 percent of total billed charges 34.1 52.25 Technical (Hospital) Services HC/HH Wch Supp Meter Peak Flow Access Fl Rng__Hs710-012 PX-2705000103 CDM 2705000103 LOCAL 270 RC outpatient 55 55 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES PPO [308136801] 44 percent of total billed charges 34.1 52.25 Technical (Hospital) Services HC/HH Wch Supp Meter Peak Flow Access Fl Rng__Hs710-012 PX-2705000103 CDM 2705000103 LOCAL 270 RC outpatient 55 55 HEALTHPARTNERS SX009 HEALTHPARTNERS 44 percent of total billed charges 34.1 52.25 Technical (Hospital) Services HC/HH Wch Supp Meter Peak Flow Access Fl Rng__Hs710-012 PX-2705000103 CDM 2705000103 LOCAL 270 RC outpatient 55 55 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES HDHP [308136802] 44 percent of total billed charges 34.1 52.25 Technical (Hospital) Services HC/HH Wch Supp Meter Peak Flow Access Fl Rng__Hs710-012 PX-2705000103 CDM 2705000103 LOCAL 270 RC outpatient 55 55 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES EPO [308136803] 44 percent of total billed charges 34.1 52.25 Technical (Hospital) Services HC/HH Wch Supp Meter Peak Flow Access Fl Rng__Hs710-012 PX-2705000103 CDM 2705000103 LOCAL 270 RC outpatient 55 55 CIGNA 62308 [3081051] CIGNA 62308 [308105105] 44 percent of total billed charges 34.1 52.25 Technical (Hospital) Services HC/HH Wch Supp Meter Peak Flow Access Fl Rng__Hs710-012 PX-2705000103 CDM 2705000103 LOCAL 270 RC outpatient 55 55 CIGNA 62308 [3081051] CIGNA STATE OF WYOMING [308105107] 44 percent of total billed charges 34.1 52.25 Technical (Hospital) Services HC/HH Wch Supp Meter Peak Flow Access Fl Rng__Hs710-012 PX-2705000103 CDM 2705000103 LOCAL 270 RC outpatient 55 55 BLUE CROSS BLUE SHIELD WELLMARK SB889 [3081026] BCBS WYOMING [308102603] 52.25 percent of total billed charges 34.1 52.25 Technical (Hospital) Services HC/HH Wch Supp Meter Peak Flow Access Fl Rng__Hs710-012 PX-2705000103 CDM 2705000103 LOCAL 270 RC inpatient 55 55 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES PPO [308136801] 43.55 percent of total billed charges 34.1 52.25 Technical (Hospital) Services HC/HH Wch Supp Meter Peak Flow Access Fl Rng__Hs710-012 PX-2705000103 CDM 2705000103 LOCAL 270 RC inpatient 55 55 MEDICA (COMMERCIAL) 94265 [3081118] MEDICA CLAIMS [308111801] 49.5 percent of total billed charges 34.1 52.25 Technical (Hospital) Services HC/HH Wch Supp Meter Peak Flow Access Fl Rng__Hs710-012 PX-2705000103 CDM 2705000103 LOCAL 270 RC inpatient 55 55 UNITED HEALTHCARE (COMMERCIAL) [3081199] UNITED HEALTHCARE 87726 [308119901] 34.1 percent of total billed charges 34.1 52.25 Technical (Hospital) Services HC/HH Wch Supp Meter Peak Flow Access Fl Rng__Hs710-012 PX-2705000103 CDM 2705000103 LOCAL 270 RC inpatient 55 55 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES HDHP [308136802] 43.55 percent of total billed charges 34.1 52.25 Technical (Hospital) Services HC/HH Wch Supp Meter Peak Flow Access Fl Rng__Hs710-012 PX-2705000103 CDM 2705000103 LOCAL 270 RC inpatient 55 55 HEALTHPARTNERS SX009 HEALTHPARTNERS 43.55 percent of total billed charges 34.1 52.25 Technical (Hospital) Services HC/HH Wch Supp Meter Peak Flow Access Fl Rng__Hs710-012 PX-2705000103 CDM 2705000103 LOCAL 270 RC inpatient 55 55 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES EPO [308136803] 43.55 percent of total billed charges 34.1 52.25 Technical (Hospital) Services HC/HH Wch Supp Meter Peak Flow Access Fl Rng__Hs710-012 PX-2705000103 CDM 2705000103 LOCAL 270 RC inpatient 55 55 BLUE CROSS BLUE SHIELD WELLMARK SB889 [3081026] BCBS WYOMING [308102603] 52.25 percent of total billed charges 34.1 52.25 Technical (Hospital) Services HC/HH Wch Supp Meter Peak Flow Access Fl Rng__Hs710-012 PX-2705000103 CDM 2705000103 LOCAL 270 RC inpatient 55 55 CIGNA 62308 [3081051] CIGNA 62308 [308105105] 43.55 percent of total billed charges 34.1 52.25 Technical (Hospital) Services HC/HH Wch Supp Meter Peak Flow Access Fl Rng__Hs710-012 PX-2705000103 CDM 2705000103 LOCAL 270 RC inpatient 55 55 CIGNA 62308 [3081051] CIGNA STATE OF WYOMING [308105107] 43.55 percent of total billed charges 34.1 52.25 Technical (Hospital) Services HC/HH Wch Supp Meter Peak Flow Access Fl Rng__Hs710-012 PX-2705000103 CDM 2705000103 LOCAL 270 RC inpatient 55 55 MULTIPLAN INC 34080 [3081285] MULTIPLAN INC [308128501] 52.25 percent of total billed charges 34.1 52.25 Technical (Hospital) Services HC/HH Wch Supp Mesh Underwear Xxl__Msc86500 PX-2705000102 CDM 2705000102 LOCAL 270 RC inpatient 32 32 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES PPO [308136801] 25.34 percent of total billed charges 19.84 30.4 Technical (Hospital) Services HC/HH Wch Supp Mesh Underwear Xxl__Msc86500 PX-2705000102 CDM 2705000102 LOCAL 270 RC inpatient 32 32 MEDICA (COMMERCIAL) 94265 [3081118] MEDICA CLAIMS [308111801] 28.8 percent of total billed charges 19.84 30.4 Technical (Hospital) Services HC/HH Wch Supp Mesh Underwear Xxl__Msc86500 PX-2705000102 CDM 2705000102 LOCAL 270 RC inpatient 32 32 UNITED HEALTHCARE (COMMERCIAL) [3081199] UNITED HEALTHCARE 87726 [308119901] 19.84 percent of total billed charges 19.84 30.4 Technical (Hospital) Services HC/HH Wch Supp Mesh Underwear Xxl__Msc86500 PX-2705000102 CDM 2705000102 LOCAL 270 RC inpatient 32 32 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES HDHP [308136802] 25.34 percent of total billed charges 19.84 30.4 Technical (Hospital) Services HC/HH Wch Supp Mesh Underwear Xxl__Msc86500 PX-2705000102 CDM 2705000102 LOCAL 270 RC inpatient 32 32 HEALTHPARTNERS SX009 HEALTHPARTNERS 25.34 percent of total billed charges 19.84 30.4 Technical (Hospital) Services HC/HH Wch Supp Mesh Underwear Xxl__Msc86500 PX-2705000102 CDM 2705000102 LOCAL 270 RC inpatient 32 32 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES EPO [308136803] 25.34 percent of total billed charges 19.84 30.4 Technical (Hospital) Services HC/HH Wch Supp Mesh Underwear Xxl__Msc86500 PX-2705000102 CDM 2705000102 LOCAL 270 RC inpatient 32 32 CIGNA 62308 [3081051] CIGNA 62308 [308105105] 25.34 percent of total billed charges 19.84 30.4 Technical (Hospital) Services HC/HH Wch Supp Mesh Underwear Xxl__Msc86500 PX-2705000102 CDM 2705000102 LOCAL 270 RC inpatient 32 32 CIGNA 62308 [3081051] CIGNA STATE OF WYOMING [308105107] 25.34 percent of total billed charges 19.84 30.4 Technical (Hospital) Services HC/HH Wch Supp Mesh Underwear Xxl__Msc86500 PX-2705000102 CDM 2705000102 LOCAL 270 RC inpatient 32 32 MULTIPLAN INC 34080 [3081285] MULTIPLAN INC [308128501] 30.4 percent of total billed charges 19.84 30.4 Technical (Hospital) Services HC/HH Wch Supp Mesh Underwear Xxl__Msc86500 PX-2705000102 CDM 2705000102 LOCAL 270 RC inpatient 32 32 BLUE CROSS BLUE SHIELD WELLMARK SB889 [3081026] BCBS WYOMING [308102603] 30.4 percent of total billed charges 19.84 30.4 Technical (Hospital) Services HC/HH Wch Supp Mesh Underwear Xxl__Msc86500 PX-2705000102 CDM 2705000102 LOCAL 270 RC outpatient 32 32 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES HDHP [308136802] 25.6 percent of total billed charges 19.84 30.4 Technical (Hospital) Services HC/HH Wch Supp Mesh Underwear Xxl__Msc86500 PX-2705000102 CDM 2705000102 LOCAL 270 RC outpatient 32 32 BLUE CROSS BLUE SHIELD WELLMARK SB889 [3081026] BCBS WYOMING [308102603] 30.4 percent of total billed charges 19.84 30.4 Technical (Hospital) Services HC/HH Wch Supp Mesh Underwear Xxl__Msc86500 PX-2705000102 CDM 2705000102 LOCAL 270 RC outpatient 32 32 CIGNA 62308 [3081051] CIGNA 62308 [308105105] 25.6 percent of total billed charges 19.84 30.4 Technical (Hospital) Services HC/HH Wch Supp Mesh Underwear Xxl__Msc86500 PX-2705000102 CDM 2705000102 LOCAL 270 RC outpatient 32 32 CIGNA 62308 [3081051] CIGNA STATE OF WYOMING [308105107] 25.6 percent of total billed charges 19.84 30.4 Technical (Hospital) Services HC/HH Wch Supp Mesh Underwear Xxl__Msc86500 PX-2705000102 CDM 2705000102 LOCAL 270 RC outpatient 32 32 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES EPO [308136803] 25.6 percent of total billed charges 19.84 30.4 Technical (Hospital) Services HC/HH Wch Supp Mesh Underwear Xxl__Msc86500 PX-2705000102 CDM 2705000102 LOCAL 270 RC outpatient 32 32 HEALTHPARTNERS SX009 HEALTHPARTNERS 25.6 percent of total billed charges 19.84 30.4 Technical (Hospital) Services HC/HH Wch Supp Mesh Underwear Xxl__Msc86500 PX-2705000102 CDM 2705000102 LOCAL 270 RC outpatient 32 32 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES PPO [308136801] 25.6 percent of total billed charges 19.84 30.4 Technical (Hospital) Services HC/HH Wch Supp Mesh Underwear Xxl__Msc86500 PX-2705000102 CDM 2705000102 LOCAL 270 RC outpatient 32 32 UNITED HEALTHCARE (COMMERCIAL) [3081199] UNITED HEALTHCARE 87726 [308119901] 19.84 percent of total billed charges 19.84 30.4 Technical (Hospital) Services HC/HH Wch Supp Mesh Underwear Xxl__Msc86500 PX-2705000102 CDM 2705000102 LOCAL 270 RC outpatient 32 32 MULTIPLAN INC 34080 [3081285] MULTIPLAN INC [308128501] 30.4 percent of total billed charges 19.84 30.4 Technical (Hospital) Services HC/HH Wch Supp Mesh Underwear Xxl__Msc86500 PX-2705000102 CDM 2705000102 LOCAL 270 RC outpatient 32 32 MEDICA (COMMERCIAL) 94265 [3081118] MEDICA CLAIMS [308111801] 28.8 percent of total billed charges 19.84 30.4 Technical (Hospital) Services HC/HH Wch Supp Mesh Underwear Xl__Msc86400 PX-2705000101 CDM 2705000101 LOCAL 270 RC outpatient 29 29 MEDICA (COMMERCIAL) 94265 [3081118] MEDICA CLAIMS [308111801] 26.1 percent of total billed charges 17.98 27.55 Technical (Hospital) Services HC/HH Wch Supp Mesh Underwear Xl__Msc86400 PX-2705000101 CDM 2705000101 LOCAL 270 RC outpatient 29 29 MULTIPLAN INC 34080 [3081285] MULTIPLAN INC [308128501] 27.55 percent of total billed charges 17.98 27.55 Technical (Hospital) Services HC/HH Wch Supp Mesh Underwear Xl__Msc86400 PX-2705000101 CDM 2705000101 LOCAL 270 RC outpatient 29 29 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES HDHP [308136802] 23.2 percent of total billed charges 17.98 27.55 Technical (Hospital) Services HC/HH Wch Supp Mesh Underwear Xl__Msc86400 PX-2705000101 CDM 2705000101 LOCAL 270 RC outpatient 29 29 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES EPO [308136803] 23.2 percent of total billed charges 17.98 27.55 Technical (Hospital) Services HC/HH Wch Supp Mesh Underwear Xl__Msc86400 PX-2705000101 CDM 2705000101 LOCAL 270 RC outpatient 29 29 BLUE CROSS BLUE SHIELD WELLMARK SB889 [3081026] BCBS WYOMING [308102603] 27.55 percent of total billed charges 17.98 27.55 Technical (Hospital) Services HC/HH Wch Supp Mesh Underwear Xl__Msc86400 PX-2705000101 CDM 2705000101 LOCAL 270 RC outpatient 29 29 CIGNA 62308 [3081051] CIGNA 62308 [308105105] 23.2 percent of total billed charges 17.98 27.55 Technical (Hospital) Services HC/HH Wch Supp Mesh Underwear Xl__Msc86400 PX-2705000101 CDM 2705000101 LOCAL 270 RC outpatient 29 29 CIGNA 62308 [3081051] CIGNA STATE OF WYOMING [308105107] 23.2 percent of total billed charges 17.98 27.55 Technical (Hospital) Services HC/HH Wch Supp Mesh Underwear Xl__Msc86400 PX-2705000101 CDM 2705000101 LOCAL 270 RC outpatient 29 29 UNITED HEALTHCARE (COMMERCIAL) [3081199] UNITED HEALTHCARE 87726 [308119901] 17.98 percent of total billed charges 17.98 27.55 Technical (Hospital) Services HC/HH Wch Supp Mesh Underwear Xl__Msc86400 PX-2705000101 CDM 2705000101 LOCAL 270 RC outpatient 29 29 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES PPO [308136801] 23.2 percent of total billed charges 17.98 27.55 Technical (Hospital) Services HC/HH Wch Supp Mesh Underwear Xl__Msc86400 PX-2705000101 CDM 2705000101 LOCAL 270 RC outpatient 29 29 HEALTHPARTNERS SX009 HEALTHPARTNERS 23.2 percent of total billed charges 17.98 27.55 Technical (Hospital) Services HC/HH Wch Supp Mesh Underwear Xl__Msc86400 PX-2705000101 CDM 2705000101 LOCAL 270 RC inpatient 29 29 MULTIPLAN INC 34080 [3081285] MULTIPLAN INC [308128501] 27.55 percent of total billed charges 17.98 27.55 Technical (Hospital) Services HC/HH Wch Supp Mesh Underwear Xl__Msc86400 PX-2705000101 CDM 2705000101 LOCAL 270 RC inpatient 29 29 BLUE CROSS BLUE SHIELD WELLMARK SB889 [3081026] BCBS WYOMING [308102603] 27.55 percent of total billed charges 17.98 27.55 Technical (Hospital) Services HC/HH Wch Supp Mesh Underwear Xl__Msc86400 PX-2705000101 CDM 2705000101 LOCAL 270 RC inpatient 29 29 CIGNA 62308 [3081051] CIGNA 62308 [308105105] 22.96 percent of total billed charges 17.98 27.55 Technical (Hospital) Services HC/HH Wch Supp Mesh Underwear Xl__Msc86400 PX-2705000101 CDM 2705000101 LOCAL 270 RC inpatient 29 29 CIGNA 62308 [3081051] CIGNA STATE OF WYOMING [308105107] 22.96 percent of total billed charges 17.98 27.55 Technical (Hospital) Services HC/HH Wch Supp Mesh Underwear Xl__Msc86400 PX-2705000101 CDM 2705000101 LOCAL 270 RC inpatient 29 29 HEALTHPARTNERS SX009 HEALTHPARTNERS 22.96 percent of total billed charges 17.98 27.55 Technical (Hospital) Services HC/HH Wch Supp Mesh Underwear Xl__Msc86400 PX-2705000101 CDM 2705000101 LOCAL 270 RC inpatient 29 29 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES EPO [308136803] 22.96 percent of total billed charges 17.98 27.55 Technical (Hospital) Services HC/HH Wch Supp Mesh Underwear Xl__Msc86400 PX-2705000101 CDM 2705000101 LOCAL 270 RC inpatient 29 29 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES HDHP [308136802] 22.96 percent of total billed charges 17.98 27.55 Technical (Hospital) Services HC/HH Wch Supp Mesh Underwear Xl__Msc86400 PX-2705000101 CDM 2705000101 LOCAL 270 RC inpatient 29 29 MEDICA (COMMERCIAL) 94265 [3081118] MEDICA CLAIMS [308111801] 26.1 percent of total billed charges 17.98 27.55 Technical (Hospital) Services HC/HH Wch Supp Mesh Underwear Xl__Msc86400 PX-2705000101 CDM 2705000101 LOCAL 270 RC inpatient 29 29 UNITED HEALTHCARE (COMMERCIAL) [3081199] UNITED HEALTHCARE 87726 [308119901] 17.98 percent of total billed charges 17.98 27.55 Technical (Hospital) Services HC/HH Wch Supp Mesh Underwear Xl__Msc86400 PX-2705000101 CDM 2705000101 LOCAL 270 RC inpatient 29 29 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES PPO [308136801] 22.96 percent of total billed charges 17.98 27.55 Technical (Hospital) Services HC/HH Wch Supp Mepitel Safetac 10x18cm Silicn__291099 PX-2705000100 CDM 2705000100 LOCAL 270 RC outpatient 50 50 BLUE CROSS BLUE SHIELD WELLMARK SB889 [3081026] BCBS WYOMING [308102603] 47.5 percent of total billed charges 31 47.5 Technical (Hospital) Services HC/HH Wch Supp Mepitel Safetac 10x18cm Silicn__291099 PX-2705000100 CDM 2705000100 LOCAL 270 RC outpatient 50 50 CIGNA 62308 [3081051] CIGNA 62308 [308105105] 40 percent of total billed charges 31 47.5 Technical (Hospital) Services HC/HH Wch Supp Mepitel Safetac 10x18cm Silicn__291099 PX-2705000100 CDM 2705000100 LOCAL 270 RC outpatient 50 50 CIGNA 62308 [3081051] CIGNA STATE OF WYOMING [308105107] 40 percent of total billed charges 31 47.5 Technical (Hospital) Services HC/HH Wch Supp Mepitel Safetac 10x18cm Silicn__291099 PX-2705000100 CDM 2705000100 LOCAL 270 RC outpatient 50 50 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES EPO [308136803] 40 percent of total billed charges 31 47.5 Technical (Hospital) Services HC/HH Wch Supp Mepitel Safetac 10x18cm Silicn__291099 PX-2705000100 CDM 2705000100 LOCAL 270 RC outpatient 50 50 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES HDHP [308136802] 40 percent of total billed charges 31 47.5 Technical (Hospital) Services HC/HH Wch Supp Mepitel Safetac 10x18cm Silicn__291099 PX-2705000100 CDM 2705000100 LOCAL 270 RC outpatient 50 50 HEALTHPARTNERS SX009 HEALTHPARTNERS 40 percent of total billed charges 31 47.5 Technical (Hospital) Services HC/HH Wch Supp Mepitel Safetac 10x18cm Silicn__291099 PX-2705000100 CDM 2705000100 LOCAL 270 RC outpatient 50 50 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES PPO [308136801] 40 percent of total billed charges 31 47.5 Technical (Hospital) Services HC/HH Wch Supp Mepitel Safetac 10x18cm Silicn__291099 PX-2705000100 CDM 2705000100 LOCAL 270 RC outpatient 50 50 UNITED HEALTHCARE (COMMERCIAL) [3081199] UNITED HEALTHCARE 87726 [308119901] 31 percent of total billed charges 31 47.5 Technical (Hospital) Services HC/HH Wch Supp Mepitel Safetac 10x18cm Silicn__291099 PX-2705000100 CDM 2705000100 LOCAL 270 RC outpatient 50 50 MULTIPLAN INC 34080 [3081285] MULTIPLAN INC [308128501] 47.5 percent of total billed charges 31 47.5 Technical (Hospital) Services HC/HH Wch Supp Mepitel Safetac 10x18cm Silicn__291099 PX-2705000100 CDM 2705000100 LOCAL 270 RC outpatient 50 50 MEDICA (COMMERCIAL) 94265 [3081118] MEDICA CLAIMS [308111801] 45 percent of total billed charges 31 47.5 Technical (Hospital) Services HC/HH Wch Supp Mepitel Safetac 10x18cm Silicn__291099 PX-2705000100 CDM 2705000100 LOCAL 270 RC inpatient 50 50 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES PPO [308136801] 39.59 percent of total billed charges 31 47.5 Technical (Hospital) Services HC/HH Wch Supp Mepitel Safetac 10x18cm Silicn__291099 PX-2705000100 CDM 2705000100 LOCAL 270 RC inpatient 50 50 MEDICA (COMMERCIAL) 94265 [3081118] MEDICA CLAIMS [308111801] 45 percent of total billed charges 31 47.5 Technical (Hospital) Services HC/HH Wch Supp Mepitel Safetac 10x18cm Silicn__291099 PX-2705000100 CDM 2705000100 LOCAL 270 RC inpatient 50 50 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES HDHP [308136802] 39.59 percent of total billed charges 31 47.5 Technical (Hospital) Services HC/HH Wch Supp Mepitel Safetac 10x18cm Silicn__291099 PX-2705000100 CDM 2705000100 LOCAL 270 RC inpatient 50 50 UNITED HEALTHCARE (COMMERCIAL) [3081199] UNITED HEALTHCARE 87726 [308119901] 31 percent of total billed charges 31 47.5 Technical (Hospital) Services HC/HH Wch Supp Mepitel Safetac 10x18cm Silicn__291099 PX-2705000100 CDM 2705000100 LOCAL 270 RC inpatient 50 50 BLUE CROSS BLUE SHIELD WELLMARK SB889 [3081026] BCBS WYOMING [308102603] 47.5 percent of total billed charges 31 47.5 Technical (Hospital) Services HC/HH Wch Supp Mepitel Safetac 10x18cm Silicn__291099 PX-2705000100 CDM 2705000100 LOCAL 270 RC inpatient 50 50 CIGNA 62308 [3081051] CIGNA 62308 [308105105] 39.59 percent of total billed charges 31 47.5 Technical (Hospital) Services HC/HH Wch Supp Mepitel Safetac 10x18cm Silicn__291099 PX-2705000100 CDM 2705000100 LOCAL 270 RC inpatient 50 50 CIGNA 62308 [3081051] CIGNA STATE OF WYOMING [308105107] 39.59 percent of total billed charges 31 47.5 Technical (Hospital) Services HC/HH Wch Supp Mepitel Safetac 10x18cm Silicn__291099 PX-2705000100 CDM 2705000100 LOCAL 270 RC inpatient 50 50 MULTIPLAN INC 34080 [3081285] MULTIPLAN INC [308128501] 47.5 percent of total billed charges 31 47.5 Technical (Hospital) Services HC/HH Wch Supp Mepitel Safetac 10x18cm Silicn__291099 PX-2705000100 CDM 2705000100 LOCAL 270 RC inpatient 50 50 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES EPO [308136803] 39.59 percent of total billed charges 31 47.5 Technical (Hospital) Services HC/HH Wch Supp Mepitel Safetac 10x18cm Silicn__291099 PX-2705000100 CDM 2705000100 LOCAL 270 RC inpatient 50 50 HEALTHPARTNERS SX009 HEALTHPARTNERS 39.59 percent of total billed charges 31 47.5 Technical (Hospital) Services HC/HH Wch Supp Mepilex With Safetac__294199 PX-2705000099 CDM 2705000099 LOCAL 270 RC outpatient 14 14 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES HDHP [308136802] 11.2 percent of total billed charges 8.68 13.3 Technical (Hospital) Services HC/HH Wch Supp Mepilex With Safetac__294199 PX-2705000099 CDM 2705000099 LOCAL 270 RC outpatient 14 14 BLUE CROSS BLUE SHIELD WELLMARK SB889 [3081026] BCBS WYOMING [308102603] 13.3 percent of total billed charges 8.68 13.3 Technical (Hospital) Services HC/HH Wch Supp Mepilex With Safetac__294199 PX-2705000099 CDM 2705000099 LOCAL 270 RC outpatient 14 14 CIGNA 62308 [3081051] CIGNA 62308 [308105105] 11.2 percent of total billed charges 8.68 13.3 Technical (Hospital) Services HC/HH Wch Supp Mepilex With Safetac__294199 PX-2705000099 CDM 2705000099 LOCAL 270 RC outpatient 14 14 CIGNA 62308 [3081051] CIGNA STATE OF WYOMING [308105107] 11.2 percent of total billed charges 8.68 13.3 Technical (Hospital) Services HC/HH Wch Supp Mepilex With Safetac__294199 PX-2705000099 CDM 2705000099 LOCAL 270 RC outpatient 14 14 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES EPO [308136803] 11.2 percent of total billed charges 8.68 13.3 Technical (Hospital) Services HC/HH Wch Supp Mepilex With Safetac__294199 PX-2705000099 CDM 2705000099 LOCAL 270 RC outpatient 14 14 HEALTHPARTNERS SX009 HEALTHPARTNERS 11.2 percent of total billed charges 8.68 13.3 Technical (Hospital) Services HC/HH Wch Supp Mepilex With Safetac__294199 PX-2705000099 CDM 2705000099 LOCAL 270 RC outpatient 14 14 UNITED HEALTHCARE (COMMERCIAL) [3081199] UNITED HEALTHCARE 87726 [308119901] 8.68 percent of total billed charges 8.68 13.3 Technical (Hospital) Services HC/HH Wch Supp Mepilex With Safetac__294199 PX-2705000099 CDM 2705000099 LOCAL 270 RC outpatient 14 14 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES PPO [308136801] 11.2 percent of total billed charges 8.68 13.3 Technical (Hospital) Services HC/HH Wch Supp Mepilex With Safetac__294199 PX-2705000099 CDM 2705000099 LOCAL 270 RC outpatient 14 14 MEDICA (COMMERCIAL) 94265 [3081118] MEDICA CLAIMS [308111801] 12.6 percent of total billed charges 8.68 13.3 Technical (Hospital) Services HC/HH Wch Supp Mepilex With Safetac__294199 PX-2705000099 CDM 2705000099 LOCAL 270 RC outpatient 14 14 MULTIPLAN INC 34080 [3081285] MULTIPLAN INC [308128501] 13.3 percent of total billed charges 8.68 13.3 Technical (Hospital) Services HC/HH Wch Supp Mepilex With Safetac__294199 PX-2705000099 CDM 2705000099 LOCAL 270 RC inpatient 14 14 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES EPO [308136803] 11.09 percent of total billed charges 8.68 13.3 Technical (Hospital) Services HC/HH Wch Supp Mepilex With Safetac__294199 PX-2705000099 CDM 2705000099 LOCAL 270 RC inpatient 14 14 HEALTHPARTNERS SX009 HEALTHPARTNERS 11.09 percent of total billed charges 8.68 13.3 Technical (Hospital) Services HC/HH Wch Supp Mepilex With Safetac__294199 PX-2705000099 CDM 2705000099 LOCAL 270 RC inpatient 14 14 MULTIPLAN INC 34080 [3081285] MULTIPLAN INC [308128501] 13.3 percent of total billed charges 8.68 13.3 Technical (Hospital) Services HC/HH Wch Supp Mepilex With Safetac__294199 PX-2705000099 CDM 2705000099 LOCAL 270 RC inpatient 14 14 CIGNA 62308 [3081051] CIGNA 62308 [308105105] 11.09 percent of total billed charges 8.68 13.3 Technical (Hospital) Services HC/HH Wch Supp Mepilex With Safetac__294199 PX-2705000099 CDM 2705000099 LOCAL 270 RC inpatient 14 14 CIGNA 62308 [3081051] CIGNA STATE OF WYOMING [308105107] 11.09 percent of total billed charges 8.68 13.3 Technical (Hospital) Services HC/HH Wch Supp Mepilex With Safetac__294199 PX-2705000099 CDM 2705000099 LOCAL 270 RC inpatient 14 14 BLUE CROSS BLUE SHIELD WELLMARK SB889 [3081026] BCBS WYOMING [308102603] 13.3 percent of total billed charges 8.68 13.3 Technical (Hospital) Services HC/HH Wch Supp Mepilex With Safetac__294199 PX-2705000099 CDM 2705000099 LOCAL 270 RC inpatient 14 14 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES PPO [308136801] 11.09 percent of total billed charges 8.68 13.3 Technical (Hospital) Services HC/HH Wch Supp Mepilex With Safetac__294199 PX-2705000099 CDM 2705000099 LOCAL 270 RC inpatient 14 14 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES HDHP [308136802] 11.09 percent of total billed charges 8.68 13.3 Technical (Hospital) Services HC/HH Wch Supp Mepilex With Safetac__294199 PX-2705000099 CDM 2705000099 LOCAL 270 RC inpatient 14 14 UNITED HEALTHCARE (COMMERCIAL) [3081199] UNITED HEALTHCARE 87726 [308119901] 8.68 percent of total billed charges 8.68 13.3 Technical (Hospital) Services HC/HH Wch Supp Mepilex With Safetac__294199 PX-2705000099 CDM 2705000099 LOCAL 270 RC inpatient 14 14 MEDICA (COMMERCIAL) 94265 [3081118] MEDICA CLAIMS [308111801] 12.6 percent of total billed charges 8.68 13.3 Technical (Hospital) Services HC/HH Wch Supp Mepilex With Border 4x4__295300 PX-2705000098 CDM 2705000098 LOCAL 270 RC inpatient 18 18 BLUE CROSS BLUE SHIELD WELLMARK SB889 [3081026] BCBS WYOMING [308102603] 17.1 percent of total billed charges 11.16 17.1 Technical (Hospital) Services HC/HH Wch Supp Mepilex With Border 4x4__295300 PX-2705000098 CDM 2705000098 LOCAL 270 RC inpatient 18 18 MULTIPLAN INC 34080 [3081285] MULTIPLAN INC [308128501] 17.1 percent of total billed charges 11.16 17.1 Technical (Hospital) Services HC/HH Wch Supp Mepilex With Border 4x4__295300 PX-2705000098 CDM 2705000098 LOCAL 270 RC inpatient 18 18 CIGNA 62308 [3081051] CIGNA 62308 [308105105] 14.25 percent of total billed charges 11.16 17.1 Technical (Hospital) Services HC/HH Wch Supp Mepilex With Border 4x4__295300 PX-2705000098 CDM 2705000098 LOCAL 270 RC inpatient 18 18 CIGNA 62308 [3081051] CIGNA STATE OF WYOMING [308105107] 14.25 percent of total billed charges 11.16 17.1 Technical (Hospital) Services HC/HH Wch Supp Mepilex With Border 4x4__295300 PX-2705000098 CDM 2705000098 LOCAL 270 RC inpatient 18 18 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES EPO [308136803] 14.25 percent of total billed charges 11.16 17.1 Technical (Hospital) Services HC/HH Wch Supp Mepilex With Border 4x4__295300 PX-2705000098 CDM 2705000098 LOCAL 270 RC inpatient 18 18 HEALTHPARTNERS SX009 HEALTHPARTNERS 14.25 percent of total billed charges 11.16 17.1 Technical (Hospital) Services HC/HH Wch Supp Mepilex With Border 4x4__295300 PX-2705000098 CDM 2705000098 LOCAL 270 RC inpatient 18 18 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES HDHP [308136802] 14.25 percent of total billed charges 11.16 17.1 Technical (Hospital) Services HC/HH Wch Supp Mepilex With Border 4x4__295300 PX-2705000098 CDM 2705000098 LOCAL 270 RC inpatient 18 18 UNITED HEALTHCARE (COMMERCIAL) [3081199] UNITED HEALTHCARE 87726 [308119901] 11.16 percent of total billed charges 11.16 17.1 Technical (Hospital) Services HC/HH Wch Supp Mepilex With Border 4x4__295300 PX-2705000098 CDM 2705000098 LOCAL 270 RC inpatient 18 18 MEDICA (COMMERCIAL) 94265 [3081118] MEDICA CLAIMS [308111801] 16.2 percent of total billed charges 11.16 17.1 Technical (Hospital) Services HC/HH Wch Supp Mepilex With Border 4x4__295300 PX-2705000098 CDM 2705000098 LOCAL 270 RC inpatient 18 18 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES PPO [308136801] 14.25 percent of total billed charges 11.16 17.1 Technical (Hospital) Services HC/HH Wch Supp Mepilex With Border 4x4__295300 PX-2705000098 CDM 2705000098 LOCAL 270 RC outpatient 18 18 HEALTHPARTNERS SX009 HEALTHPARTNERS 14.4 percent of total billed charges 11.16 17.1 Technical (Hospital) Services HC/HH Wch Supp Mepilex With Border 4x4__295300 PX-2705000098 CDM 2705000098 LOCAL 270 RC outpatient 18 18 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES PPO [308136801] 14.4 percent of total billed charges 11.16 17.1 Technical (Hospital) Services HC/HH Wch Supp Mepilex With Border 4x4__295300 PX-2705000098 CDM 2705000098 LOCAL 270 RC outpatient 18 18 MEDICA (COMMERCIAL) 94265 [3081118] MEDICA CLAIMS [308111801] 16.2 percent of total billed charges 11.16 17.1 Technical (Hospital) Services HC/HH Wch Supp Mepilex With Border 4x4__295300 PX-2705000098 CDM 2705000098 LOCAL 270 RC outpatient 18 18 MULTIPLAN INC 34080 [3081285] MULTIPLAN INC [308128501] 17.1 percent of total billed charges 11.16 17.1 Technical (Hospital) Services HC/HH Wch Supp Mepilex With Border 4x4__295300 PX-2705000098 CDM 2705000098 LOCAL 270 RC outpatient 18 18 UNITED HEALTHCARE (COMMERCIAL) [3081199] UNITED HEALTHCARE 87726 [308119901] 11.16 percent of total billed charges 11.16 17.1 Technical (Hospital) Services HC/HH Wch Supp Mepilex With Border 4x4__295300 PX-2705000098 CDM 2705000098 LOCAL 270 RC outpatient 18 18 CIGNA 62308 [3081051] CIGNA STATE OF WYOMING [308105107] 14.4 percent of total billed charges 11.16 17.1 Technical (Hospital) Services HC/HH Wch Supp Mepilex With Border 4x4__295300 PX-2705000098 CDM 2705000098 LOCAL 270 RC outpatient 18 18 BLUE CROSS BLUE SHIELD WELLMARK SB889 [3081026] BCBS WYOMING [308102603] 17.1 percent of total billed charges 11.16 17.1 Technical (Hospital) Services HC/HH Wch Supp Mepilex With Border 4x4__295300 PX-2705000098 CDM 2705000098 LOCAL 270 RC outpatient 18 18 CIGNA 62308 [3081051] CIGNA 62308 [308105105] 14.4 percent of total billed charges 11.16 17.1 Technical (Hospital) Services HC/HH Wch Supp Mepilex With Border 4x4__295300 PX-2705000098 CDM 2705000098 LOCAL 270 RC outpatient 18 18 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES EPO [308136803] 14.4 percent of total billed charges 11.16 17.1 Technical (Hospital) Services HC/HH Wch Supp Mepilex With Border 4x4__295300 PX-2705000098 CDM 2705000098 LOCAL 270 RC outpatient 18 18 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES HDHP [308136802] 14.4 percent of total billed charges 11.16 17.1 Technical (Hospital) Services HC/HH Wch Supp Mepilex Ag 4x4__287100 PX-2705000097 CDM 2705000097 LOCAL 270 RC inpatient 44 44 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES PPO [308136801] 34.84 percent of total billed charges 27.28 41.8 Technical (Hospital) Services HC/HH Wch Supp Mepilex Ag 4x4__287100 PX-2705000097 CDM 2705000097 LOCAL 270 RC inpatient 44 44 MEDICA (COMMERCIAL) 94265 [3081118] MEDICA CLAIMS [308111801] 39.6 percent of total billed charges 27.28 41.8 Technical (Hospital) Services HC/HH Wch Supp Mepilex Ag 4x4__287100 PX-2705000097 CDM 2705000097 LOCAL 270 RC inpatient 44 44 UNITED HEALTHCARE (COMMERCIAL) [3081199] UNITED HEALTHCARE 87726 [308119901] 27.28 percent of total billed charges 27.28 41.8 Technical (Hospital) Services HC/HH Wch Supp Mepilex Ag 4x4__287100 PX-2705000097 CDM 2705000097 LOCAL 270 RC inpatient 44 44 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES HDHP [308136802] 34.84 percent of total billed charges 27.28 41.8 Technical (Hospital) Services HC/HH Wch Supp Mepilex Ag 4x4__287100 PX-2705000097 CDM 2705000097 LOCAL 270 RC inpatient 44 44 HEALTHPARTNERS SX009 HEALTHPARTNERS 34.84 percent of total billed charges 27.28 41.8 Technical (Hospital) Services HC/HH Wch Supp Mepilex Ag 4x4__287100 PX-2705000097 CDM 2705000097 LOCAL 270 RC inpatient 44 44 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES EPO [308136803] 34.84 percent of total billed charges 27.28 41.8 Technical (Hospital) Services HC/HH Wch Supp Mepilex Ag 4x4__287100 PX-2705000097 CDM 2705000097 LOCAL 270 RC inpatient 44 44 CIGNA 62308 [3081051] CIGNA 62308 [308105105] 34.84 percent of total billed charges 27.28 41.8 Technical (Hospital) Services HC/HH Wch Supp Mepilex Ag 4x4__287100 PX-2705000097 CDM 2705000097 LOCAL 270 RC inpatient 44 44 CIGNA 62308 [3081051] CIGNA STATE OF WYOMING [308105107] 34.84 percent of total billed charges 27.28 41.8 Technical (Hospital) Services HC/HH Wch Supp Mepilex Ag 4x4__287100 PX-2705000097 CDM 2705000097 LOCAL 270 RC inpatient 44 44 MULTIPLAN INC 34080 [3081285] MULTIPLAN INC [308128501] 41.8 percent of total billed charges 27.28 41.8 Technical (Hospital) Services HC/HH Wch Supp Mepilex Ag 4x4__287100 PX-2705000097 CDM 2705000097 LOCAL 270 RC inpatient 44 44 BLUE CROSS BLUE SHIELD WELLMARK SB889 [3081026] BCBS WYOMING [308102603] 41.8 percent of total billed charges 27.28 41.8 Technical (Hospital) Services HC/HH Wch Supp Mepilex Ag 4x4__287100 PX-2705000097 CDM 2705000097 LOCAL 270 RC outpatient 44 44 HEALTHPARTNERS SX009 HEALTHPARTNERS 35.2 percent of total billed charges 27.28 41.8 Technical (Hospital) Services HC/HH Wch Supp Mepilex Ag 4x4__287100 PX-2705000097 CDM 2705000097 LOCAL 270 RC outpatient 44 44 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES PPO [308136801] 35.2 percent of total billed charges 27.28 41.8 Technical (Hospital) Services HC/HH Wch Supp Mepilex Ag 4x4__287100 PX-2705000097 CDM 2705000097 LOCAL 270 RC outpatient 44 44 UNITED HEALTHCARE (COMMERCIAL) [3081199] UNITED HEALTHCARE 87726 [308119901] 27.28 percent of total billed charges 27.28 41.8 Technical (Hospital) Services HC/HH Wch Supp Mepilex Ag 4x4__287100 PX-2705000097 CDM 2705000097 LOCAL 270 RC outpatient 44 44 CIGNA 62308 [3081051] CIGNA 62308 [308105105] 35.2 percent of total billed charges 27.28 41.8 Technical (Hospital) Services HC/HH Wch Supp Mepilex Ag 4x4__287100 PX-2705000097 CDM 2705000097 LOCAL 270 RC outpatient 44 44 CIGNA 62308 [3081051] CIGNA STATE OF WYOMING [308105107] 35.2 percent of total billed charges 27.28 41.8 Technical (Hospital) Services HC/HH Wch Supp Mepilex Ag 4x4__287100 PX-2705000097 CDM 2705000097 LOCAL 270 RC outpatient 44 44 BLUE CROSS BLUE SHIELD WELLMARK SB889 [3081026] BCBS WYOMING [308102603] 41.8 percent of total billed charges 27.28 41.8 Technical (Hospital) Services HC/HH Wch Supp Mepilex Ag 4x4__287100 PX-2705000097 CDM 2705000097 LOCAL 270 RC outpatient 44 44 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES EPO [308136803] 35.2 percent of total billed charges 27.28 41.8 Technical (Hospital) Services HC/HH Wch Supp Mepilex Ag 4x4__287100 PX-2705000097 CDM 2705000097 LOCAL 270 RC outpatient 44 44 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES HDHP [308136802] 35.2 percent of total billed charges 27.28 41.8 Technical (Hospital) Services HC/HH Wch Supp Mepilex Ag 4x4__287100 PX-2705000097 CDM 2705000097 LOCAL 270 RC outpatient 44 44 MULTIPLAN INC 34080 [3081285] MULTIPLAN INC [308128501] 41.8 percent of total billed charges 27.28 41.8 Technical (Hospital) Services HC/HH Wch Supp Mepilex Ag 4x4__287100 PX-2705000097 CDM 2705000097 LOCAL 270 RC outpatient 44 44 MEDICA (COMMERCIAL) 94265 [3081118] MEDICA CLAIMS [308111801] 39.6 percent of total billed charges 27.28 41.8 Technical (Hospital) Services HC/HH Wch Supp Mepilex Border 3x3__295200 PX-2705000096 CDM 2705000096 LOCAL 270 RC inpatient 20 20 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES PPO [308136801] 15.84 percent of total billed charges 12.4 19 Technical (Hospital) Services HC/HH Wch Supp Mepilex Border 3x3__295200 PX-2705000096 CDM 2705000096 LOCAL 270 RC inpatient 20 20 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES HDHP [308136802] 15.84 percent of total billed charges 12.4 19 Technical (Hospital) Services HC/HH Wch Supp Mepilex Border 3x3__295200 PX-2705000096 CDM 2705000096 LOCAL 270 RC inpatient 20 20 UNITED HEALTHCARE (COMMERCIAL) [3081199] UNITED HEALTHCARE 87726 [308119901] 12.4 percent of total billed charges 12.4 19 Technical (Hospital) Services HC/HH Wch Supp Mepilex Border 3x3__295200 PX-2705000096 CDM 2705000096 LOCAL 270 RC inpatient 20 20 MEDICA (COMMERCIAL) 94265 [3081118] MEDICA CLAIMS [308111801] 18 percent of total billed charges 12.4 19 Technical (Hospital) Services HC/HH Wch Supp Mepilex Border 3x3__295200 PX-2705000096 CDM 2705000096 LOCAL 270 RC inpatient 20 20 MULTIPLAN INC 34080 [3081285] MULTIPLAN INC [308128501] 19 percent of total billed charges 12.4 19 Technical (Hospital) Services HC/HH Wch Supp Mepilex Border 3x3__295200 PX-2705000096 CDM 2705000096 LOCAL 270 RC inpatient 20 20 BLUE CROSS BLUE SHIELD WELLMARK SB889 [3081026] BCBS WYOMING [308102603] 19 percent of total billed charges 12.4 19 Technical (Hospital) Services HC/HH Wch Supp Mepilex Border 3x3__295200 PX-2705000096 CDM 2705000096 LOCAL 270 RC inpatient 20 20 CIGNA 62308 [3081051] CIGNA 62308 [308105105] 15.84 percent of total billed charges 12.4 19 Technical (Hospital) Services HC/HH Wch Supp Mepilex Border 3x3__295200 PX-2705000096 CDM 2705000096 LOCAL 270 RC inpatient 20 20 CIGNA 62308 [3081051] CIGNA STATE OF WYOMING [308105107] 15.84 percent of total billed charges 12.4 19 Technical (Hospital) Services HC/HH Wch Supp Mepilex Border 3x3__295200 PX-2705000096 CDM 2705000096 LOCAL 270 RC inpatient 20 20 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES EPO [308136803] 15.84 percent of total billed charges 12.4 19 Technical (Hospital) Services HC/HH Wch Supp Mepilex Border 3x3__295200 PX-2705000096 CDM 2705000096 LOCAL 270 RC inpatient 20 20 HEALTHPARTNERS SX009 HEALTHPARTNERS 15.84 percent of total billed charges 12.4 19 Technical (Hospital) Services HC/HH Wch Supp Mepilex Border 3x3__295200 PX-2705000096 CDM 2705000096 LOCAL 270 RC outpatient 20 20 CIGNA 62308 [3081051] CIGNA 62308 [308105105] 16 percent of total billed charges 12.4 19 Technical (Hospital) Services HC/HH Wch Supp Mepilex Border 3x3__295200 PX-2705000096 CDM 2705000096 LOCAL 270 RC outpatient 20 20 CIGNA 62308 [3081051] CIGNA STATE OF WYOMING [308105107] 16 percent of total billed charges 12.4 19 Technical (Hospital) Services HC/HH Wch Supp Mepilex Border 3x3__295200 PX-2705000096 CDM 2705000096 LOCAL 270 RC outpatient 20 20 BLUE CROSS BLUE SHIELD WELLMARK SB889 [3081026] BCBS WYOMING [308102603] 19 percent of total billed charges 12.4 19 Technical (Hospital) Services HC/HH Wch Supp Mepilex Border 3x3__295200 PX-2705000096 CDM 2705000096 LOCAL 270 RC outpatient 20 20 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES EPO [308136803] 16 percent of total billed charges 12.4 19 Technical (Hospital) Services HC/HH Wch Supp Mepilex Border 3x3__295200 PX-2705000096 CDM 2705000096 LOCAL 270 RC outpatient 20 20 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES HDHP [308136802] 16 percent of total billed charges 12.4 19 Technical (Hospital) Services HC/HH Wch Supp Mepilex Border 3x3__295200 PX-2705000096 CDM 2705000096 LOCAL 270 RC outpatient 20 20 HEALTHPARTNERS SX009 HEALTHPARTNERS 16 percent of total billed charges 12.4 19 Technical (Hospital) Services HC/HH Wch Supp Mepilex Border 3x3__295200 PX-2705000096 CDM 2705000096 LOCAL 270 RC outpatient 20 20 UNITED HEALTHCARE (COMMERCIAL) [3081199] UNITED HEALTHCARE 87726 [308119901] 12.4 percent of total billed charges 12.4 19 Technical (Hospital) Services HC/HH Wch Supp Mepilex Border 3x3__295200 PX-2705000096 CDM 2705000096 LOCAL 270 RC outpatient 20 20 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES PPO [308136801] 16 percent of total billed charges 12.4 19 Technical (Hospital) Services HC/HH Wch Supp Mepilex Border 3x3__295200 PX-2705000096 CDM 2705000096 LOCAL 270 RC outpatient 20 20 MEDICA (COMMERCIAL) 94265 [3081118] MEDICA CLAIMS [308111801] 18 percent of total billed charges 12.4 19 Technical (Hospital) Services HC/HH Wch Supp Mepilex Border 3x3__295200 PX-2705000096 CDM 2705000096 LOCAL 270 RC outpatient 20 20 MULTIPLAN INC 34080 [3081285] MULTIPLAN INC [308128501] 19 percent of total billed charges 12.4 19 Technical (Hospital) Services HC/HH Wch Supp Mask Oxygen Val Peds__001268 PX-2705000095 CDM 2705000095 LOCAL 270 RC outpatient 6 6 CIGNA 62308 [3081051] CIGNA 62308 [308105105] 4.8 percent of total billed charges 3.72 5.7 Technical (Hospital) Services HC/HH Wch Supp Mask Oxygen Val Peds__001268 PX-2705000095 CDM 2705000095 LOCAL 270 RC outpatient 6 6 CIGNA 62308 [3081051] CIGNA STATE OF WYOMING [308105107] 4.8 percent of total billed charges 3.72 5.7 Technical (Hospital) Services HC/HH Wch Supp Mask Oxygen Val Peds__001268 PX-2705000095 CDM 2705000095 LOCAL 270 RC outpatient 6 6 BLUE CROSS BLUE SHIELD WELLMARK SB889 [3081026] BCBS WYOMING [308102603] 5.7 percent of total billed charges 3.72 5.7 Technical (Hospital) Services HC/HH Wch Supp Mask Oxygen Val Peds__001268 PX-2705000095 CDM 2705000095 LOCAL 270 RC outpatient 6 6 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES HDHP [308136802] 4.8 percent of total billed charges 3.72 5.7 Technical (Hospital) Services HC/HH Wch Supp Mask Oxygen Val Peds__001268 PX-2705000095 CDM 2705000095 LOCAL 270 RC outpatient 6 6 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES EPO [308136803] 4.8 percent of total billed charges 3.72 5.7 Technical (Hospital) Services HC/HH Wch Supp Mask Oxygen Val Peds__001268 PX-2705000095 CDM 2705000095 LOCAL 270 RC outpatient 6 6 HEALTHPARTNERS SX009 HEALTHPARTNERS 4.8 percent of total billed charges 3.72 5.7 Technical (Hospital) Services HC/HH Wch Supp Mask Oxygen Val Peds__001268 PX-2705000095 CDM 2705000095 LOCAL 270 RC outpatient 6 6 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES PPO [308136801] 4.8 percent of total billed charges 3.72 5.7 Technical (Hospital) Services HC/HH Wch Supp Mask Oxygen Val Peds__001268 PX-2705000095 CDM 2705000095 LOCAL 270 RC outpatient 6 6 UNITED HEALTHCARE (COMMERCIAL) [3081199] UNITED HEALTHCARE 87726 [308119901] 3.72 percent of total billed charges 3.72 5.7 Technical (Hospital) Services HC/HH Wch Supp Mask Oxygen Val Peds__001268 PX-2705000095 CDM 2705000095 LOCAL 270 RC outpatient 6 6 MULTIPLAN INC 34080 [3081285] MULTIPLAN INC [308128501] 5.7 percent of total billed charges 3.72 5.7 Technical (Hospital) Services HC/HH Wch Supp Mask Oxygen Val Peds__001268 PX-2705000095 CDM 2705000095 LOCAL 270 RC outpatient 6 6 MEDICA (COMMERCIAL) 94265 [3081118] MEDICA CLAIMS [308111801] 5.4 percent of total billed charges 3.72 5.7 Technical (Hospital) Services HC/HH Wch Supp Mask Oxygen Val Peds__001268 PX-2705000095 CDM 2705000095 LOCAL 270 RC inpatient 6 6 CIGNA 62308 [3081051] CIGNA 62308 [308105105] 4.75 percent of total billed charges 3.72 5.7 Technical (Hospital) Services HC/HH Wch Supp Mask Oxygen Val Peds__001268 PX-2705000095 CDM 2705000095 LOCAL 270 RC inpatient 6 6 CIGNA 62308 [3081051] CIGNA STATE OF WYOMING [308105107] 4.75 percent of total billed charges 3.72 5.7 Technical (Hospital) Services HC/HH Wch Supp Mask Oxygen Val Peds__001268 PX-2705000095 CDM 2705000095 LOCAL 270 RC inpatient 6 6 BLUE CROSS BLUE SHIELD WELLMARK SB889 [3081026] BCBS WYOMING [308102603] 5.7 percent of total billed charges 3.72 5.7 Technical (Hospital) Services HC/HH Wch Supp Mask Oxygen Val Peds__001268 PX-2705000095 CDM 2705000095 LOCAL 270 RC inpatient 6 6 MULTIPLAN INC 34080 [3081285] MULTIPLAN INC [308128501] 5.7 percent of total billed charges 3.72 5.7 Technical (Hospital) Services HC/HH Wch Supp Mask Oxygen Val Peds__001268 PX-2705000095 CDM 2705000095 LOCAL 270 RC inpatient 6 6 HEALTHPARTNERS SX009 HEALTHPARTNERS 4.75 percent of total billed charges 3.72 5.7 Technical (Hospital) Services HC/HH Wch Supp Mask Oxygen Val Peds__001268 PX-2705000095 CDM 2705000095 LOCAL 270 RC inpatient 6 6 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES EPO [308136803] 4.75 percent of total billed charges 3.72 5.7 Technical (Hospital) Services HC/HH Wch Supp Mask Oxygen Val Peds__001268 PX-2705000095 CDM 2705000095 LOCAL 270 RC inpatient 6 6 UNITED HEALTHCARE (COMMERCIAL) [3081199] UNITED HEALTHCARE 87726 [308119901] 3.72 percent of total billed charges 3.72 5.7 Technical (Hospital) Services HC/HH Wch Supp Mask Oxygen Val Peds__001268 PX-2705000095 CDM 2705000095 LOCAL 270 RC inpatient 6 6 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES HDHP [308136802] 4.75 percent of total billed charges 3.72 5.7 Technical (Hospital) Services HC/HH Wch Supp Mask Oxygen Val Peds__001268 PX-2705000095 CDM 2705000095 LOCAL 270 RC inpatient 6 6 MEDICA (COMMERCIAL) 94265 [3081118] MEDICA CLAIMS [308111801] 5.4 percent of total billed charges 3.72 5.7 Technical (Hospital) Services HC/HH Wch Supp Mask Oxygen Val Peds__001268 PX-2705000095 CDM 2705000095 LOCAL 270 RC inpatient 6 6 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES PPO [308136801] 4.75 percent of total billed charges 3.72 5.7 Technical (Hospital) Services HC/HH Wch Supp Mask Oxygen Peds No Valve__001267 PX-2705000094 CDM 2705000094 LOCAL 270 RC inpatient 6 6 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES PPO [308136801] 4.75 percent of total billed charges 3.72 5.7 Technical (Hospital) Services HC/HH Wch Supp Mask Oxygen Peds No Valve__001267 PX-2705000094 CDM 2705000094 LOCAL 270 RC inpatient 6 6 MEDICA (COMMERCIAL) 94265 [3081118] MEDICA CLAIMS [308111801] 5.4 percent of total billed charges 3.72 5.7 Technical (Hospital) Services HC/HH Wch Supp Mask Oxygen Peds No Valve__001267 PX-2705000094 CDM 2705000094 LOCAL 270 RC inpatient 6 6 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES HDHP [308136802] 4.75 percent of total billed charges 3.72 5.7 Technical (Hospital) Services HC/HH Wch Supp Mask Oxygen Peds No Valve__001267 PX-2705000094 CDM 2705000094 LOCAL 270 RC inpatient 6 6 UNITED HEALTHCARE (COMMERCIAL) [3081199] UNITED HEALTHCARE 87726 [308119901] 3.72 percent of total billed charges 3.72 5.7 Technical (Hospital) Services HC/HH Wch Supp Mask Oxygen Peds No Valve__001267 PX-2705000094 CDM 2705000094 LOCAL 270 RC inpatient 6 6 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES EPO [308136803] 4.75 percent of total billed charges 3.72 5.7 Technical (Hospital) Services HC/HH Wch Supp Mask Oxygen Peds No Valve__001267 PX-2705000094 CDM 2705000094 LOCAL 270 RC inpatient 6 6 HEALTHPARTNERS SX009 HEALTHPARTNERS 4.75 percent of total billed charges 3.72 5.7 Technical (Hospital) Services HC/HH Wch Supp Mask Oxygen Peds No Valve__001267 PX-2705000094 CDM 2705000094 LOCAL 270 RC inpatient 6 6 MULTIPLAN INC 34080 [3081285] MULTIPLAN INC [308128501] 5.7 percent of total billed charges 3.72 5.7 Technical (Hospital) Services HC/HH Wch Supp Mask Oxygen Peds No Valve__001267 PX-2705000094 CDM 2705000094 LOCAL 270 RC inpatient 6 6 BLUE CROSS BLUE SHIELD WELLMARK SB889 [3081026] BCBS WYOMING [308102603] 5.7 percent of total billed charges 3.72 5.7 Technical (Hospital) Services HC/HH Wch Supp Mask Oxygen Peds No Valve__001267 PX-2705000094 CDM 2705000094 LOCAL 270 RC inpatient 6 6 CIGNA 62308 [3081051] CIGNA 62308 [308105105] 4.75 percent of total billed charges 3.72 5.7 Technical (Hospital) Services HC/HH Wch Supp Mask Oxygen Peds No Valve__001267 PX-2705000094 CDM 2705000094 LOCAL 270 RC inpatient 6 6 CIGNA 62308 [3081051] CIGNA STATE OF WYOMING [308105107] 4.75 percent of total billed charges 3.72 5.7 Technical (Hospital) Services HC/HH Wch Supp Mask Oxygen Peds No Valve__001267 PX-2705000094 CDM 2705000094 LOCAL 270 RC outpatient 6 6 HEALTHPARTNERS SX009 HEALTHPARTNERS 4.8 percent of total billed charges 3.72 5.7 Technical (Hospital) Services HC/HH Wch Supp Mask Oxygen Peds No Valve__001267 PX-2705000094 CDM 2705000094 LOCAL 270 RC outpatient 6 6 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES PPO [308136801] 4.8 percent of total billed charges 3.72 5.7 Technical (Hospital) Services HC/HH Wch Supp Mask Oxygen Peds No Valve__001267 PX-2705000094 CDM 2705000094 LOCAL 270 RC outpatient 6 6 UNITED HEALTHCARE (COMMERCIAL) [3081199] UNITED HEALTHCARE 87726 [308119901] 3.72 percent of total billed charges 3.72 5.7 Technical (Hospital) Services HC/HH Wch Supp Mask Oxygen Peds No Valve__001267 PX-2705000094 CDM 2705000094 LOCAL 270 RC outpatient 6 6 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES HDHP [308136802] 4.8 percent of total billed charges 3.72 5.7 Technical (Hospital) Services HC/HH Wch Supp Mask Oxygen Peds No Valve__001267 PX-2705000094 CDM 2705000094 LOCAL 270 RC outpatient 6 6 BLUE CROSS BLUE SHIELD WELLMARK SB889 [3081026] BCBS WYOMING [308102603] 5.7 percent of total billed charges 3.72 5.7 Technical (Hospital) Services HC/HH Wch Supp Mask Oxygen Peds No Valve__001267 PX-2705000094 CDM 2705000094 LOCAL 270 RC outpatient 6 6 CIGNA 62308 [3081051] CIGNA 62308 [308105105] 4.8 percent of total billed charges 3.72 5.7 Technical (Hospital) Services HC/HH Wch Supp Mask Oxygen Peds No Valve__001267 PX-2705000094 CDM 2705000094 LOCAL 270 RC outpatient 6 6 CIGNA 62308 [3081051] CIGNA STATE OF WYOMING [308105107] 4.8 percent of total billed charges 3.72 5.7 Technical (Hospital) Services HC/HH Wch Supp Mask Oxygen Peds No Valve__001267 PX-2705000094 CDM 2705000094 LOCAL 270 RC outpatient 6 6 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES EPO [308136803] 4.8 percent of total billed charges 3.72 5.7 Technical (Hospital) Services HC/HH Wch Supp Mask Oxygen Peds No Valve__001267 PX-2705000094 CDM 2705000094 LOCAL 270 RC outpatient 6 6 MULTIPLAN INC 34080 [3081285] MULTIPLAN INC [308128501] 5.7 percent of total billed charges 3.72 5.7 Technical (Hospital) Services HC/HH Wch Supp Mask Oxygen Peds No Valve__001267 PX-2705000094 CDM 2705000094 LOCAL 270 RC outpatient 6 6 MEDICA (COMMERCIAL) 94265 [3081118] MEDICA CLAIMS [308111801] 5.4 percent of total billed charges 3.72 5.7 Technical (Hospital) Services HC/HH Wch Supp Mask Multi-Vent Adult__1088 PX-2705000093 CDM 2705000093 LOCAL 270 RC outpatient 14 14 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES HDHP [308136802] 11.2 percent of total billed charges 8.68 13.3 Technical (Hospital) Services HC/HH Wch Supp Mask Multi-Vent Adult__1088 PX-2705000093 CDM 2705000093 LOCAL 270 RC outpatient 14 14 BLUE CROSS BLUE SHIELD WELLMARK SB889 [3081026] BCBS WYOMING [308102603] 13.3 percent of total billed charges 8.68 13.3 Technical (Hospital) Services HC/HH Wch Supp Mask Multi-Vent Adult__1088 PX-2705000093 CDM 2705000093 LOCAL 270 RC outpatient 14 14 CIGNA 62308 [3081051] CIGNA 62308 [308105105] 11.2 percent of total billed charges 8.68 13.3 Technical (Hospital) Services HC/HH Wch Supp Mask Multi-Vent Adult__1088 PX-2705000093 CDM 2705000093 LOCAL 270 RC outpatient 14 14 CIGNA 62308 [3081051] CIGNA STATE OF WYOMING [308105107] 11.2 percent of total billed charges 8.68 13.3 Technical (Hospital) Services HC/HH Wch Supp Mask Multi-Vent Adult__1088 PX-2705000093 CDM 2705000093 LOCAL 270 RC outpatient 14 14 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES EPO [308136803] 11.2 percent of total billed charges 8.68 13.3 Technical (Hospital) Services HC/HH Wch Supp Mask Multi-Vent Adult__1088 PX-2705000093 CDM 2705000093 LOCAL 270 RC outpatient 14 14 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES PPO [308136801] 11.2 percent of total billed charges 8.68 13.3 Technical (Hospital) Services HC/HH Wch Supp Mask Multi-Vent Adult__1088 PX-2705000093 CDM 2705000093 LOCAL 270 RC outpatient 14 14 HEALTHPARTNERS SX009 HEALTHPARTNERS 11.2 percent of total billed charges 8.68 13.3 Technical (Hospital) Services HC/HH Wch Supp Mask Multi-Vent Adult__1088 PX-2705000093 CDM 2705000093 LOCAL 270 RC outpatient 14 14 UNITED HEALTHCARE (COMMERCIAL) [3081199] UNITED HEALTHCARE 87726 [308119901] 8.68 percent of total billed charges 8.68 13.3 Technical (Hospital) Services HC/HH Wch Supp Mask Multi-Vent Adult__1088 PX-2705000093 CDM 2705000093 LOCAL 270 RC outpatient 14 14 MEDICA (COMMERCIAL) 94265 [3081118] MEDICA CLAIMS [308111801] 12.6 percent of total billed charges 8.68 13.3 Technical (Hospital) Services HC/HH Wch Supp Mask Multi-Vent Adult__1088 PX-2705000093 CDM 2705000093 LOCAL 270 RC outpatient 14 14 MULTIPLAN INC 34080 [3081285] MULTIPLAN INC [308128501] 13.3 percent of total billed charges 8.68 13.3 Technical (Hospital) Services HC/HH Wch Supp Mask Multi-Vent Adult__1088 PX-2705000093 CDM 2705000093 LOCAL 270 RC inpatient 14 14 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES PPO [308136801] 11.09 percent of total billed charges 8.68 13.3 Technical (Hospital) Services HC/HH Wch Supp Mask Multi-Vent Adult__1088 PX-2705000093 CDM 2705000093 LOCAL 270 RC inpatient 14 14 UNITED HEALTHCARE (COMMERCIAL) [3081199] UNITED HEALTHCARE 87726 [308119901] 8.68 percent of total billed charges 8.68 13.3 Technical (Hospital) Services HC/HH Wch Supp Mask Multi-Vent Adult__1088 PX-2705000093 CDM 2705000093 LOCAL 270 RC inpatient 14 14 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES HDHP [308136802] 11.09 percent of total billed charges 8.68 13.3 Technical (Hospital) Services HC/HH Wch Supp Mask Multi-Vent Adult__1088 PX-2705000093 CDM 2705000093 LOCAL 270 RC inpatient 14 14 MEDICA (COMMERCIAL) 94265 [3081118] MEDICA CLAIMS [308111801] 12.6 percent of total billed charges 8.68 13.3 Technical (Hospital) Services HC/HH Wch Supp Mask Multi-Vent Adult__1088 PX-2705000093 CDM 2705000093 LOCAL 270 RC inpatient 14 14 BLUE CROSS BLUE SHIELD WELLMARK SB889 [3081026] BCBS WYOMING [308102603] 13.3 percent of total billed charges 8.68 13.3 Technical (Hospital) Services HC/HH Wch Supp Mask Multi-Vent Adult__1088 PX-2705000093 CDM 2705000093 LOCAL 270 RC inpatient 14 14 MULTIPLAN INC 34080 [3081285] MULTIPLAN INC [308128501] 13.3 percent of total billed charges 8.68 13.3 Technical (Hospital) Services HC/HH Wch Supp Mask Multi-Vent Adult__1088 PX-2705000093 CDM 2705000093 LOCAL 270 RC inpatient 14 14 CIGNA 62308 [3081051] CIGNA 62308 [308105105] 11.09 percent of total billed charges 8.68 13.3 Technical (Hospital) Services HC/HH Wch Supp Mask Multi-Vent Adult__1088 PX-2705000093 CDM 2705000093 LOCAL 270 RC inpatient 14 14 CIGNA 62308 [3081051] CIGNA STATE OF WYOMING [308105107] 11.09 percent of total billed charges 8.68 13.3 Technical (Hospital) Services HC/HH Wch Supp Mask Multi-Vent Adult__1088 PX-2705000093 CDM 2705000093 LOCAL 270 RC inpatient 14 14 HEALTHPARTNERS SX009 HEALTHPARTNERS 11.09 percent of total billed charges 8.68 13.3 Technical (Hospital) Services HC/HH Wch Supp Mask Multi-Vent Adult__1088 PX-2705000093 CDM 2705000093 LOCAL 270 RC inpatient 14 14 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES EPO [308136803] 11.09 percent of total billed charges 8.68 13.3 Technical (Hospital) Services HC/HH Wch Supp Mask Cpap Comfortfull II Small__1004880 PX-2705000092 CDM 2705000092 LOCAL 270 RC outpatient 301 301 MULTIPLAN INC 34080 [3081285] MULTIPLAN INC [308128501] 285.95 percent of total billed charges 186.62 285.95 Technical (Hospital) Services HC/HH Wch Supp Mask Cpap Comfortfull II Small__1004880 PX-2705000092 CDM 2705000092 LOCAL 270 RC outpatient 301 301 MEDICA (COMMERCIAL) 94265 [3081118] MEDICA CLAIMS [308111801] 270.9 percent of total billed charges 186.62 285.95 Technical (Hospital) Services HC/HH Wch Supp Mask Cpap Comfortfull II Small__1004880 PX-2705000092 CDM 2705000092 LOCAL 270 RC outpatient 301 301 UNITED HEALTHCARE (COMMERCIAL) [3081199] UNITED HEALTHCARE 87726 [308119901] 186.62 percent of total billed charges 186.62 285.95 Technical (Hospital) Services HC/HH Wch Supp Mask Cpap Comfortfull II Small__1004880 PX-2705000092 CDM 2705000092 LOCAL 270 RC outpatient 301 301 HEALTHPARTNERS SX009 HEALTHPARTNERS 240.8 percent of total billed charges 186.62 285.95 Technical (Hospital) Services HC/HH Wch Supp Mask Cpap Comfortfull II Small__1004880 PX-2705000092 CDM 2705000092 LOCAL 270 RC outpatient 301 301 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES PPO [308136801] 240.8 percent of total billed charges 186.62 285.95 Technical (Hospital) Services HC/HH Wch Supp Mask Cpap Comfortfull II Small__1004880 PX-2705000092 CDM 2705000092 LOCAL 270 RC outpatient 301 301 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES EPO [308136803] 240.8 percent of total billed charges 186.62 285.95 Technical (Hospital) Services HC/HH Wch Supp Mask Cpap Comfortfull II Small__1004880 PX-2705000092 CDM 2705000092 LOCAL 270 RC outpatient 301 301 BLUE CROSS BLUE SHIELD WELLMARK SB889 [3081026] BCBS WYOMING [308102603] 285.95 percent of total billed charges 186.62 285.95 Technical (Hospital) Services HC/HH Wch Supp Mask Cpap Comfortfull II Small__1004880 PX-2705000092 CDM 2705000092 LOCAL 270 RC outpatient 301 301 CIGNA 62308 [3081051] CIGNA 62308 [308105105] 240.8 percent of total billed charges 186.62 285.95 Technical (Hospital) Services HC/HH Wch Supp Mask Cpap Comfortfull II Small__1004880 PX-2705000092 CDM 2705000092 LOCAL 270 RC outpatient 301 301 CIGNA 62308 [3081051] CIGNA STATE OF WYOMING [308105107] 240.8 percent of total billed charges 186.62 285.95 Technical (Hospital) Services HC/HH Wch Supp Mask Cpap Comfortfull II Small__1004880 PX-2705000092 CDM 2705000092 LOCAL 270 RC outpatient 301 301 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES HDHP [308136802] 240.8 percent of total billed charges 186.62 285.95 Technical (Hospital) Services HC/HH Wch Supp Mask Cpap Comfortfull II Small__1004880 PX-2705000092 CDM 2705000092 LOCAL 270 RC inpatient 301 301 HEALTHPARTNERS SX009 HEALTHPARTNERS 238.33 percent of total billed charges 186.62 285.95 Technical (Hospital) Services HC/HH Wch Supp Mask Cpap Comfortfull II Small__1004880 PX-2705000092 CDM 2705000092 LOCAL 270 RC inpatient 301 301 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES EPO [308136803] 238.33 percent of total billed charges 186.62 285.95 Technical (Hospital) Services HC/HH Wch Supp Mask Cpap Comfortfull II Small__1004880 PX-2705000092 CDM 2705000092 LOCAL 270 RC inpatient 301 301 CIGNA 62308 [3081051] CIGNA 62308 [308105105] 238.33 percent of total billed charges 186.62 285.95 Technical (Hospital) Services HC/HH Wch Supp Mask Cpap Comfortfull II Small__1004880 PX-2705000092 CDM 2705000092 LOCAL 270 RC inpatient 301 301 CIGNA 62308 [3081051] CIGNA STATE OF WYOMING [308105107] 238.33 percent of total billed charges 186.62 285.95 Technical (Hospital) Services HC/HH Wch Supp Mask Cpap Comfortfull II Small__1004880 PX-2705000092 CDM 2705000092 LOCAL 270 RC inpatient 301 301 MULTIPLAN INC 34080 [3081285] MULTIPLAN INC [308128501] 285.95 percent of total billed charges 186.62 285.95 Technical (Hospital) Services HC/HH Wch Supp Mask Cpap Comfortfull II Small__1004880 PX-2705000092 CDM 2705000092 LOCAL 270 RC inpatient 301 301 BLUE CROSS BLUE SHIELD WELLMARK SB889 [3081026] BCBS WYOMING [308102603] 285.95 percent of total billed charges 186.62 285.95 Technical (Hospital) Services HC/HH Wch Supp Mask Cpap Comfortfull II Small__1004880 PX-2705000092 CDM 2705000092 LOCAL 270 RC inpatient 301 301 MEDICA (COMMERCIAL) 94265 [3081118] MEDICA CLAIMS [308111801] 270.9 percent of total billed charges 186.62 285.95 Technical (Hospital) Services HC/HH Wch Supp Mask Cpap Comfortfull II Small__1004880 PX-2705000092 CDM 2705000092 LOCAL 270 RC inpatient 301 301 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES HDHP [308136802] 238.33 percent of total billed charges 186.62 285.95 Technical (Hospital) Services HC/HH Wch Supp Mask Cpap Comfortfull II Small__1004880 PX-2705000092 CDM 2705000092 LOCAL 270 RC inpatient 301 301 UNITED HEALTHCARE (COMMERCIAL) [3081199] UNITED HEALTHCARE 87726 [308119901] 186.62 percent of total billed charges 186.62 285.95 Technical (Hospital) Services HC/HH Wch Supp Mask Cpap Comfortfull II Small__1004880 PX-2705000092 CDM 2705000092 LOCAL 270 RC inpatient 301 301 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES PPO [308136801] 238.33 percent of total billed charges 186.62 285.95 Technical (Hospital) Services HC/HH Wch Supp Mask Cpap Comfortfull II Med__1004872 PX-2705000091 CDM 2705000091 LOCAL 270 RC outpatient 280 280 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES HDHP [308136802] 224 percent of total billed charges 173.6 266 Technical (Hospital) Services HC/HH Wch Supp Mask Cpap Comfortfull II Med__1004872 PX-2705000091 CDM 2705000091 LOCAL 270 RC outpatient 280 280 CIGNA 62308 [3081051] CIGNA 62308 [308105105] 224 percent of total billed charges 173.6 266 Technical (Hospital) Services HC/HH Wch Supp Mask Cpap Comfortfull II Med__1004872 PX-2705000091 CDM 2705000091 LOCAL 270 RC outpatient 280 280 CIGNA 62308 [3081051] CIGNA STATE OF WYOMING [308105107] 224 percent of total billed charges 173.6 266 Technical (Hospital) Services HC/HH Wch Supp Mask Cpap Comfortfull II Med__1004872 PX-2705000091 CDM 2705000091 LOCAL 270 RC outpatient 280 280 BLUE CROSS BLUE SHIELD WELLMARK SB889 [3081026] BCBS WYOMING [308102603] 266 percent of total billed charges 173.6 266 Technical (Hospital) Services HC/HH Wch Supp Mask Cpap Comfortfull II Med__1004872 PX-2705000091 CDM 2705000091 LOCAL 270 RC outpatient 280 280 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES EPO [308136803] 224 percent of total billed charges 173.6 266 Technical (Hospital) Services HC/HH Wch Supp Mask Cpap Comfortfull II Med__1004872 PX-2705000091 CDM 2705000091 LOCAL 270 RC outpatient 280 280 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES PPO [308136801] 224 percent of total billed charges 173.6 266 Technical (Hospital) Services HC/HH Wch Supp Mask Cpap Comfortfull II Med__1004872 PX-2705000091 CDM 2705000091 LOCAL 270 RC outpatient 280 280 HEALTHPARTNERS SX009 HEALTHPARTNERS 224 percent of total billed charges 173.6 266 Technical (Hospital) Services HC/HH Wch Supp Mask Cpap Comfortfull II Med__1004872 PX-2705000091 CDM 2705000091 LOCAL 270 RC outpatient 280 280 UNITED HEALTHCARE (COMMERCIAL) [3081199] UNITED HEALTHCARE 87726 [308119901] 173.6 percent of total billed charges 173.6 266 Technical (Hospital) Services HC/HH Wch Supp Mask Cpap Comfortfull II Med__1004872 PX-2705000091 CDM 2705000091 LOCAL 270 RC outpatient 280 280 MEDICA (COMMERCIAL) 94265 [3081118] MEDICA CLAIMS [308111801] 252 percent of total billed charges 173.6 266 Technical (Hospital) Services HC/HH Wch Supp Mask Cpap Comfortfull II Med__1004872 PX-2705000091 CDM 2705000091 LOCAL 270 RC outpatient 280 280 MULTIPLAN INC 34080 [3081285] MULTIPLAN INC [308128501] 266 percent of total billed charges 173.6 266 Technical (Hospital) Services HC/HH Wch Supp Mask Cpap Comfortfull II Med__1004872 PX-2705000091 CDM 2705000091 LOCAL 270 RC inpatient 280 280 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES PPO [308136801] 221.7 percent of total billed charges 173.6 266 Technical (Hospital) Services HC/HH Wch Supp Mask Cpap Comfortfull II Med__1004872 PX-2705000091 CDM 2705000091 LOCAL 270 RC inpatient 280 280 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES HDHP [308136802] 221.7 percent of total billed charges 173.6 266 Technical (Hospital) Services HC/HH Wch Supp Mask Cpap Comfortfull II Med__1004872 PX-2705000091 CDM 2705000091 LOCAL 270 RC inpatient 280 280 UNITED HEALTHCARE (COMMERCIAL) [3081199] UNITED HEALTHCARE 87726 [308119901] 173.6 percent of total billed charges 173.6 266 Technical (Hospital) Services HC/HH Wch Supp Mask Cpap Comfortfull II Med__1004872 PX-2705000091 CDM 2705000091 LOCAL 270 RC inpatient 280 280 MEDICA (COMMERCIAL) 94265 [3081118] MEDICA CLAIMS [308111801] 252 percent of total billed charges 173.6 266 Technical (Hospital) Services HC/HH Wch Supp Mask Cpap Comfortfull II Med__1004872 PX-2705000091 CDM 2705000091 LOCAL 270 RC inpatient 280 280 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES EPO [308136803] 221.7 percent of total billed charges 173.6 266 Technical (Hospital) Services HC/HH Wch Supp Mask Cpap Comfortfull II Med__1004872 PX-2705000091 CDM 2705000091 LOCAL 270 RC inpatient 280 280 HEALTHPARTNERS SX009 HEALTHPARTNERS 221.7 percent of total billed charges 173.6 266 Technical (Hospital) Services HC/HH Wch Supp Mask Cpap Comfortfull II Med__1004872 PX-2705000091 CDM 2705000091 LOCAL 270 RC inpatient 280 280 BLUE CROSS BLUE SHIELD WELLMARK SB889 [3081026] BCBS WYOMING [308102603] 266 percent of total billed charges 173.6 266 Technical (Hospital) Services HC/HH Wch Supp Mask Cpap Comfortfull II Med__1004872 PX-2705000091 CDM 2705000091 LOCAL 270 RC inpatient 280 280 MULTIPLAN INC 34080 [3081285] MULTIPLAN INC [308128501] 266 percent of total billed charges 173.6 266 Technical (Hospital) Services HC/HH Wch Supp Mask Cpap Comfortfull II Med__1004872 PX-2705000091 CDM 2705000091 LOCAL 270 RC inpatient 280 280 CIGNA 62308 [3081051] CIGNA 62308 [308105105] 221.7 percent of total billed charges 173.6 266 Technical (Hospital) Services HC/HH Wch Supp Mask Cpap Comfortfull II Med__1004872 PX-2705000091 CDM 2705000091 LOCAL 270 RC inpatient 280 280 CIGNA 62308 [3081051] CIGNA STATE OF WYOMING [308105107] 221.7 percent of total billed charges 173.6 266 Technical (Hospital) Services HC/HH Wch Supp Mask Cpap Comfortfull II Large__1004950 PX-2705000090 CDM 2705000090 LOCAL 270 RC inpatient 280 280 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES PPO [308136801] 221.7 percent of total billed charges 173.6 266 Technical (Hospital) Services HC/HH Wch Supp Mask Cpap Comfortfull II Large__1004950 PX-2705000090 CDM 2705000090 LOCAL 270 RC inpatient 280 280 UNITED HEALTHCARE (COMMERCIAL) [3081199] UNITED HEALTHCARE 87726 [308119901] 173.6 percent of total billed charges 173.6 266 Technical (Hospital) Services HC/HH Wch Supp Mask Cpap Comfortfull II Large__1004950 PX-2705000090 CDM 2705000090 LOCAL 270 RC inpatient 280 280 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES HDHP [308136802] 221.7 percent of total billed charges 173.6 266 Technical (Hospital) Services HC/HH Wch Supp Mask Cpap Comfortfull II Large__1004950 PX-2705000090 CDM 2705000090 LOCAL 270 RC inpatient 280 280 MEDICA (COMMERCIAL) 94265 [3081118] MEDICA CLAIMS [308111801] 252 percent of total billed charges 173.6 266 Technical (Hospital) Services HC/HH Wch Supp Mask Cpap Comfortfull II Large__1004950 PX-2705000090 CDM 2705000090 LOCAL 270 RC inpatient 280 280 HEALTHPARTNERS SX009 HEALTHPARTNERS 221.7 percent of total billed charges 173.6 266 Technical (Hospital) Services HC/HH Wch Supp Mask Cpap Comfortfull II Large__1004950 PX-2705000090 CDM 2705000090 LOCAL 270 RC inpatient 280 280 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES EPO [308136803] 221.7 percent of total billed charges 173.6 266 Technical (Hospital) Services HC/HH Wch Supp Mask Cpap Comfortfull II Large__1004950 PX-2705000090 CDM 2705000090 LOCAL 270 RC inpatient 280 280 BLUE CROSS BLUE SHIELD WELLMARK SB889 [3081026] BCBS WYOMING [308102603] 266 percent of total billed charges 173.6 266 Technical (Hospital) Services HC/HH Wch Supp Mask Cpap Comfortfull II Large__1004950 PX-2705000090 CDM 2705000090 LOCAL 270 RC inpatient 280 280 CIGNA 62308 [3081051] CIGNA 62308 [308105105] 221.7 percent of total billed charges 173.6 266 Technical (Hospital) Services HC/HH Wch Supp Mask Cpap Comfortfull II Large__1004950 PX-2705000090 CDM 2705000090 LOCAL 270 RC inpatient 280 280 MULTIPLAN INC 34080 [3081285] MULTIPLAN INC [308128501] 266 percent of total billed charges 173.6 266 Technical (Hospital) Services HC/HH Wch Supp Mask Cpap Comfortfull II Large__1004950 PX-2705000090 CDM 2705000090 LOCAL 270 RC inpatient 280 280 CIGNA 62308 [3081051] CIGNA STATE OF WYOMING [308105107] 221.7 percent of total billed charges 173.6 266 Technical (Hospital) Services HC/HH Wch Supp Mask Cpap Comfortfull II Large__1004950 PX-2705000090 CDM 2705000090 LOCAL 270 RC outpatient 280 280 CIGNA 62308 [3081051] CIGNA 62308 [308105105] 224 percent of total billed charges 173.6 266 Technical (Hospital) Services HC/HH Wch Supp Mask Cpap Comfortfull II Large__1004950 PX-2705000090 CDM 2705000090 LOCAL 270 RC outpatient 280 280 CIGNA 62308 [3081051] CIGNA STATE OF WYOMING [308105107] 224 percent of total billed charges 173.6 266 Technical (Hospital) Services HC/HH Wch Supp Mask Cpap Comfortfull II Large__1004950 PX-2705000090 CDM 2705000090 LOCAL 270 RC outpatient 280 280 BLUE CROSS BLUE SHIELD WELLMARK SB889 [3081026] BCBS WYOMING [308102603] 266 percent of total billed charges 173.6 266 Technical (Hospital) Services HC/HH Wch Supp Mask Cpap Comfortfull II Large__1004950 PX-2705000090 CDM 2705000090 LOCAL 270 RC outpatient 280 280 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES EPO [308136803] 224 percent of total billed charges 173.6 266 Technical (Hospital) Services HC/HH Wch Supp Mask Cpap Comfortfull II Large__1004950 PX-2705000090 CDM 2705000090 LOCAL 270 RC outpatient 280 280 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES HDHP [308136802] 224 percent of total billed charges 173.6 266 Technical (Hospital) Services HC/HH Wch Supp Mask Cpap Comfortfull II Large__1004950 PX-2705000090 CDM 2705000090 LOCAL 270 RC outpatient 280 280 HEALTHPARTNERS SX009 HEALTHPARTNERS 224 percent of total billed charges 173.6 266 Technical (Hospital) Services HC/HH Wch Supp Mask Cpap Comfortfull II Large__1004950 PX-2705000090 CDM 2705000090 LOCAL 270 RC outpatient 280 280 UNITED HEALTHCARE (COMMERCIAL) [3081199] UNITED HEALTHCARE 87726 [308119901] 173.6 percent of total billed charges 173.6 266 Technical (Hospital) Services HC/HH Wch Supp Mask Cpap Comfortfull II Large__1004950 PX-2705000090 CDM 2705000090 LOCAL 270 RC outpatient 280 280 MEDICA (COMMERCIAL) 94265 [3081118] MEDICA CLAIMS [308111801] 252 percent of total billed charges 173.6 266 Technical (Hospital) Services HC/HH Wch Supp Mask Cpap Comfortfull II Large__1004950 PX-2705000090 CDM 2705000090 LOCAL 270 RC outpatient 280 280 MULTIPLAN INC 34080 [3081285] MULTIPLAN INC [308128501] 266 percent of total billed charges 173.6 266 Technical (Hospital) Services HC/HH Wch Supp Mask Cpap Comfortfull II Large__1004950 PX-2705000090 CDM 2705000090 LOCAL 270 RC outpatient 280 280 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES PPO [308136801] 224 percent of total billed charges 173.6 266 Technical (Hospital) Services "HC/HH Wch Supp Mac 3 Blade Adult, Disposable__48033" PX-2705000089 CDM 2705000089 LOCAL 270 RC outpatient 28 28 CIGNA 62308 [3081051] CIGNA 62308 [308105105] 22.4 percent of total billed charges 17.36 26.6 Technical (Hospital) Services "HC/HH Wch Supp Mac 3 Blade Adult, Disposable__48033" PX-2705000089 CDM 2705000089 LOCAL 270 RC outpatient 28 28 CIGNA 62308 [3081051] CIGNA STATE OF WYOMING [308105107] 22.4 percent of total billed charges 17.36 26.6 Technical (Hospital) Services "HC/HH Wch Supp Mac 3 Blade Adult, Disposable__48033" PX-2705000089 CDM 2705000089 LOCAL 270 RC outpatient 28 28 BLUE CROSS BLUE SHIELD WELLMARK SB889 [3081026] BCBS WYOMING [308102603] 26.6 percent of total billed charges 17.36 26.6 Technical (Hospital) Services "HC/HH Wch Supp Mac 3 Blade Adult, Disposable__48033" PX-2705000089 CDM 2705000089 LOCAL 270 RC outpatient 28 28 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES EPO [308136803] 22.4 percent of total billed charges 17.36 26.6 Technical (Hospital) Services "HC/HH Wch Supp Mac 3 Blade Adult, Disposable__48033" PX-2705000089 CDM 2705000089 LOCAL 270 RC outpatient 28 28 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES HDHP [308136802] 22.4 percent of total billed charges 17.36 26.6 Technical (Hospital) Services "HC/HH Wch Supp Mac 3 Blade Adult, Disposable__48033" PX-2705000089 CDM 2705000089 LOCAL 270 RC outpatient 28 28 HEALTHPARTNERS SX009 HEALTHPARTNERS 22.4 percent of total billed charges 17.36 26.6 Technical (Hospital) Services "HC/HH Wch Supp Mac 3 Blade Adult, Disposable__48033" PX-2705000089 CDM 2705000089 LOCAL 270 RC outpatient 28 28 UNITED HEALTHCARE (COMMERCIAL) [3081199] UNITED HEALTHCARE 87726 [308119901] 17.36 percent of total billed charges 17.36 26.6 Technical (Hospital) Services "HC/HH Wch Supp Mac 3 Blade Adult, Disposable__48033" PX-2705000089 CDM 2705000089 LOCAL 270 RC outpatient 28 28 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES PPO [308136801] 22.4 percent of total billed charges 17.36 26.6 Technical (Hospital) Services "HC/HH Wch Supp Mac 3 Blade Adult, Disposable__48033" PX-2705000089 CDM 2705000089 LOCAL 270 RC outpatient 28 28 MULTIPLAN INC 34080 [3081285] MULTIPLAN INC [308128501] 26.6 percent of total billed charges 17.36 26.6 Technical (Hospital) Services "HC/HH Wch Supp Mac 3 Blade Adult, Disposable__48033" PX-2705000089 CDM 2705000089 LOCAL 270 RC outpatient 28 28 MEDICA (COMMERCIAL) 94265 [3081118] MEDICA CLAIMS [308111801] 25.2 percent of total billed charges 17.36 26.6 Technical (Hospital) Services "HC/HH Wch Supp Mac 3 Blade Adult, Disposable__48033" PX-2705000089 CDM 2705000089 LOCAL 270 RC inpatient 28 28 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES PPO [308136801] 22.17 percent of total billed charges 17.36 26.6 Technical (Hospital) Services "HC/HH Wch Supp Mac 3 Blade Adult, Disposable__48033" PX-2705000089 CDM 2705000089 LOCAL 270 RC inpatient 28 28 UNITED HEALTHCARE (COMMERCIAL) [3081199] UNITED HEALTHCARE 87726 [308119901] 17.36 percent of total billed charges 17.36 26.6 Technical (Hospital) Services "HC/HH Wch Supp Mac 3 Blade Adult, Disposable__48033" PX-2705000089 CDM 2705000089 LOCAL 270 RC inpatient 28 28 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES HDHP [308136802] 22.17 percent of total billed charges 17.36 26.6 Technical (Hospital) Services "HC/HH Wch Supp Mac 3 Blade Adult, Disposable__48033" PX-2705000089 CDM 2705000089 LOCAL 270 RC inpatient 28 28 MEDICA (COMMERCIAL) 94265 [3081118] MEDICA CLAIMS [308111801] 25.2 percent of total billed charges 17.36 26.6 Technical (Hospital) Services "HC/HH Wch Supp Mac 3 Blade Adult, Disposable__48033" PX-2705000089 CDM 2705000089 LOCAL 270 RC inpatient 28 28 BLUE CROSS BLUE SHIELD WELLMARK SB889 [3081026] BCBS WYOMING [308102603] 26.6 percent of total billed charges 17.36 26.6 Technical (Hospital) Services "HC/HH Wch Supp Mac 3 Blade Adult, Disposable__48033" PX-2705000089 CDM 2705000089 LOCAL 270 RC inpatient 28 28 MULTIPLAN INC 34080 [3081285] MULTIPLAN INC [308128501] 26.6 percent of total billed charges 17.36 26.6 Technical (Hospital) Services "HC/HH Wch Supp Mac 3 Blade Adult, Disposable__48033" PX-2705000089 CDM 2705000089 LOCAL 270 RC inpatient 28 28 CIGNA 62308 [3081051] CIGNA 62308 [308105105] 22.17 percent of total billed charges 17.36 26.6 Technical (Hospital) Services "HC/HH Wch Supp Mac 3 Blade Adult, Disposable__48033" PX-2705000089 CDM 2705000089 LOCAL 270 RC inpatient 28 28 CIGNA 62308 [3081051] CIGNA STATE OF WYOMING [308105107] 22.17 percent of total billed charges 17.36 26.6 Technical (Hospital) Services "HC/HH Wch Supp Mac 3 Blade Adult, Disposable__48033" PX-2705000089 CDM 2705000089 LOCAL 270 RC inpatient 28 28 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES EPO [308136803] 22.17 percent of total billed charges 17.36 26.6 Technical (Hospital) Services "HC/HH Wch Supp Mac 3 Blade Adult, Disposable__48033" PX-2705000089 CDM 2705000089 LOCAL 270 RC inpatient 28 28 HEALTHPARTNERS SX009 HEALTHPARTNERS 22.17 percent of total billed charges 17.36 26.6 Technical (Hospital) Services HC/HH Wch Supp Lube Gel Foil Pack 3__0281-0205-43 PX-2705000088 CDM 2705000088 LOCAL 270 RC outpatient 5 5 MEDICA (COMMERCIAL) 94265 [3081118] MEDICA CLAIMS [308111801] 4.5 percent of total billed charges 3.1 4.75 Technical (Hospital) Services HC/HH Wch Supp Lube Gel Foil Pack 3__0281-0205-43 PX-2705000088 CDM 2705000088 LOCAL 270 RC outpatient 5 5 MULTIPLAN INC 34080 [3081285] MULTIPLAN INC [308128501] 4.75 percent of total billed charges 3.1 4.75 Technical (Hospital) Services HC/HH Wch Supp Lube Gel Foil Pack 3__0281-0205-43 PX-2705000088 CDM 2705000088 LOCAL 270 RC outpatient 5 5 CIGNA 62308 [3081051] CIGNA 62308 [308105105] 4 percent of total billed charges 3.1 4.75 Technical (Hospital) Services HC/HH Wch Supp Lube Gel Foil Pack 3__0281-0205-43 PX-2705000088 CDM 2705000088 LOCAL 270 RC outpatient 5 5 CIGNA 62308 [3081051] CIGNA STATE OF WYOMING [308105107] 4 percent of total billed charges 3.1 4.75 Technical (Hospital) Services HC/HH Wch Supp Lube Gel Foil Pack 3__0281-0205-43 PX-2705000088 CDM 2705000088 LOCAL 270 RC outpatient 5 5 BLUE CROSS BLUE SHIELD WELLMARK SB889 [3081026] BCBS WYOMING [308102603] 4.75 percent of total billed charges 3.1 4.75 Technical (Hospital) Services HC/HH Wch Supp Lube Gel Foil Pack 3__0281-0205-43 PX-2705000088 CDM 2705000088 LOCAL 270 RC outpatient 5 5 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES EPO [308136803] 4 percent of total billed charges 3.1 4.75 Technical (Hospital) Services HC/HH Wch Supp Lube Gel Foil Pack 3__0281-0205-43 PX-2705000088 CDM 2705000088 LOCAL 270 RC outpatient 5 5 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES HDHP [308136802] 4 percent of total billed charges 3.1 4.75 Technical (Hospital) Services HC/HH Wch Supp Lube Gel Foil Pack 3__0281-0205-43 PX-2705000088 CDM 2705000088 LOCAL 270 RC outpatient 5 5 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES PPO [308136801] 4 percent of total billed charges 3.1 4.75 Technical (Hospital) Services HC/HH Wch Supp Lube Gel Foil Pack 3__0281-0205-43 PX-2705000088 CDM 2705000088 LOCAL 270 RC outpatient 5 5 HEALTHPARTNERS SX009 HEALTHPARTNERS 4 percent of total billed charges 3.1 4.75 Technical (Hospital) Services HC/HH Wch Supp Lube Gel Foil Pack 3__0281-0205-43 PX-2705000088 CDM 2705000088 LOCAL 270 RC outpatient 5 5 UNITED HEALTHCARE (COMMERCIAL) [3081199] UNITED HEALTHCARE 87726 [308119901] 3.1 percent of total billed charges 3.1 4.75 Technical (Hospital) Services HC/HH Wch Supp Lube Gel Foil Pack 3__0281-0205-43 PX-2705000088 CDM 2705000088 LOCAL 270 RC inpatient 5 5 BLUE CROSS BLUE SHIELD WELLMARK SB889 [3081026] BCBS WYOMING [308102603] 4.75 percent of total billed charges 3.1 4.75 Technical (Hospital) Services HC/HH Wch Supp Lube Gel Foil Pack 3__0281-0205-43 PX-2705000088 CDM 2705000088 LOCAL 270 RC inpatient 5 5 MULTIPLAN INC 34080 [3081285] MULTIPLAN INC [308128501] 4.75 percent of total billed charges 3.1 4.75 Technical (Hospital) Services HC/HH Wch Supp Lube Gel Foil Pack 3__0281-0205-43 PX-2705000088 CDM 2705000088 LOCAL 270 RC inpatient 5 5 CIGNA 62308 [3081051] CIGNA 62308 [308105105] 3.96 percent of total billed charges 3.1 4.75 Technical (Hospital) Services HC/HH Wch Supp Lube Gel Foil Pack 3__0281-0205-43 PX-2705000088 CDM 2705000088 LOCAL 270 RC inpatient 5 5 CIGNA 62308 [3081051] CIGNA STATE OF WYOMING [308105107] 3.96 percent of total billed charges 3.1 4.75 Technical (Hospital) Services HC/HH Wch Supp Lube Gel Foil Pack 3__0281-0205-43 PX-2705000088 CDM 2705000088 LOCAL 270 RC inpatient 5 5 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES EPO [308136803] 3.96 percent of total billed charges 3.1 4.75 Technical (Hospital) Services HC/HH Wch Supp Lube Gel Foil Pack 3__0281-0205-43 PX-2705000088 CDM 2705000088 LOCAL 270 RC inpatient 5 5 HEALTHPARTNERS SX009 HEALTHPARTNERS 3.96 percent of total billed charges 3.1 4.75 Technical (Hospital) Services HC/HH Wch Supp Lube Gel Foil Pack 3__0281-0205-43 PX-2705000088 CDM 2705000088 LOCAL 270 RC inpatient 5 5 UNITED HEALTHCARE (COMMERCIAL) [3081199] UNITED HEALTHCARE 87726 [308119901] 3.1 percent of total billed charges 3.1 4.75 Technical (Hospital) Services HC/HH Wch Supp Lube Gel Foil Pack 3__0281-0205-43 PX-2705000088 CDM 2705000088 LOCAL 270 RC inpatient 5 5 MEDICA (COMMERCIAL) 94265 [3081118] MEDICA CLAIMS [308111801] 4.5 percent of total billed charges 3.1 4.75 Technical (Hospital) Services HC/HH Wch Supp Lube Gel Foil Pack 3__0281-0205-43 PX-2705000088 CDM 2705000088 LOCAL 270 RC inpatient 5 5 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES HDHP [308136802] 3.96 percent of total billed charges 3.1 4.75 Technical (Hospital) Services HC/HH Wch Supp Lube Gel Foil Pack 3__0281-0205-43 PX-2705000088 CDM 2705000088 LOCAL 270 RC inpatient 5 5 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES PPO [308136801] 3.96 percent of total billed charges 3.1 4.75 Technical (Hospital) Services HC/HH Wch Supp Lotion Aloe 4oz__324804 PX-2705000087 CDM 2705000087 LOCAL 270 RC inpatient 6 6 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES PPO [308136801] 4.75 percent of total billed charges 3.72 5.7 Technical (Hospital) Services HC/HH Wch Supp Lotion Aloe 4oz__324804 PX-2705000087 CDM 2705000087 LOCAL 270 RC inpatient 6 6 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES HDHP [308136802] 4.75 percent of total billed charges 3.72 5.7 Technical (Hospital) Services HC/HH Wch Supp Lotion Aloe 4oz__324804 PX-2705000087 CDM 2705000087 LOCAL 270 RC inpatient 6 6 UNITED HEALTHCARE (COMMERCIAL) [3081199] UNITED HEALTHCARE 87726 [308119901] 3.72 percent of total billed charges 3.72 5.7 Technical (Hospital) Services HC/HH Wch Supp Lotion Aloe 4oz__324804 PX-2705000087 CDM 2705000087 LOCAL 270 RC inpatient 6 6 MEDICA (COMMERCIAL) 94265 [3081118] MEDICA CLAIMS [308111801] 5.4 percent of total billed charges 3.72 5.7 Technical (Hospital) Services HC/HH Wch Supp Lotion Aloe 4oz__324804 PX-2705000087 CDM 2705000087 LOCAL 270 RC inpatient 6 6 HEALTHPARTNERS SX009 HEALTHPARTNERS 4.75 percent of total billed charges 3.72 5.7 Technical (Hospital) Services HC/HH Wch Supp Lotion Aloe 4oz__324804 PX-2705000087 CDM 2705000087 LOCAL 270 RC inpatient 6 6 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES EPO [308136803] 4.75 percent of total billed charges 3.72 5.7 Technical (Hospital) Services HC/HH Wch Supp Lotion Aloe 4oz__324804 PX-2705000087 CDM 2705000087 LOCAL 270 RC inpatient 6 6 BLUE CROSS BLUE SHIELD WELLMARK SB889 [3081026] BCBS WYOMING [308102603] 5.7 percent of total billed charges 3.72 5.7 Technical (Hospital) Services HC/HH Wch Supp Lotion Aloe 4oz__324804 PX-2705000087 CDM 2705000087 LOCAL 270 RC inpatient 6 6 MULTIPLAN INC 34080 [3081285] MULTIPLAN INC [308128501] 5.7 percent of total billed charges 3.72 5.7 Technical (Hospital) Services HC/HH Wch Supp Lotion Aloe 4oz__324804 PX-2705000087 CDM 2705000087 LOCAL 270 RC inpatient 6 6 CIGNA 62308 [3081051] CIGNA 62308 [308105105] 4.75 percent of total billed charges 3.72 5.7 Technical (Hospital) Services HC/HH Wch Supp Lotion Aloe 4oz__324804 PX-2705000087 CDM 2705000087 LOCAL 270 RC inpatient 6 6 CIGNA 62308 [3081051] CIGNA STATE OF WYOMING [308105107] 4.75 percent of total billed charges 3.72 5.7 Technical (Hospital) Services HC/HH Wch Supp Lotion Aloe 4oz__324804 PX-2705000087 CDM 2705000087 LOCAL 270 RC outpatient 6 6 UNITED HEALTHCARE (COMMERCIAL) [3081199] UNITED HEALTHCARE 87726 [308119901] 3.72 percent of total billed charges 3.72 5.7 Technical (Hospital) Services HC/HH Wch Supp Lotion Aloe 4oz__324804 PX-2705000087 CDM 2705000087 LOCAL 270 RC outpatient 6 6 HEALTHPARTNERS SX009 HEALTHPARTNERS 4.8 percent of total billed charges 3.72 5.7 Technical (Hospital) Services HC/HH Wch Supp Lotion Aloe 4oz__324804 PX-2705000087 CDM 2705000087 LOCAL 270 RC outpatient 6 6 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES PPO [308136801] 4.8 percent of total billed charges 3.72 5.7 Technical (Hospital) Services HC/HH Wch Supp Lotion Aloe 4oz__324804 PX-2705000087 CDM 2705000087 LOCAL 270 RC outpatient 6 6 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES HDHP [308136802] 4.8 percent of total billed charges 3.72 5.7 Technical (Hospital) Services HC/HH Wch Supp Lotion Aloe 4oz__324804 PX-2705000087 CDM 2705000087 LOCAL 270 RC outpatient 6 6 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES EPO [308136803] 4.8 percent of total billed charges 3.72 5.7 Technical (Hospital) Services HC/HH Wch Supp Lotion Aloe 4oz__324804 PX-2705000087 CDM 2705000087 LOCAL 270 RC outpatient 6 6 BLUE CROSS BLUE SHIELD WELLMARK SB889 [3081026] BCBS WYOMING [308102603] 5.7 percent of total billed charges 3.72 5.7 Technical (Hospital) Services HC/HH Wch Supp Lotion Aloe 4oz__324804 PX-2705000087 CDM 2705000087 LOCAL 270 RC outpatient 6 6 CIGNA 62308 [3081051] CIGNA 62308 [308105105] 4.8 percent of total billed charges 3.72 5.7 Technical (Hospital) Services HC/HH Wch Supp Lotion Aloe 4oz__324804 PX-2705000087 CDM 2705000087 LOCAL 270 RC outpatient 6 6 CIGNA 62308 [3081051] CIGNA STATE OF WYOMING [308105107] 4.8 percent of total billed charges 3.72 5.7 Technical (Hospital) Services HC/HH Wch Supp Lotion Aloe 4oz__324804 PX-2705000087 CDM 2705000087 LOCAL 270 RC outpatient 6 6 MULTIPLAN INC 34080 [3081285] MULTIPLAN INC [308128501] 5.7 percent of total billed charges 3.72 5.7 Technical (Hospital) Services HC/HH Wch Supp Lotion Aloe 4oz__324804 PX-2705000087 CDM 2705000087 LOCAL 270 RC outpatient 6 6 MEDICA (COMMERCIAL) 94265 [3081118] MEDICA CLAIMS [308111801] 5.4 percent of total billed charges 3.72 5.7 Technical (Hospital) Services HC/HH Wch Supp Lifeband__8700-0706-01 PX-2705000086 CDM 2705000086 LOCAL 270 RC outpatient 293 293 MEDICA (COMMERCIAL) 94265 [3081118] MEDICA CLAIMS [308111801] 263.7 percent of total billed charges 181.66 278.35 Technical (Hospital) Services HC/HH Wch Supp Lifeband__8700-0706-01 PX-2705000086 CDM 2705000086 LOCAL 270 RC outpatient 293 293 MULTIPLAN INC 34080 [3081285] MULTIPLAN INC [308128501] 278.35 percent of total billed charges 181.66 278.35 Technical (Hospital) Services HC/HH Wch Supp Lifeband__8700-0706-01 PX-2705000086 CDM 2705000086 LOCAL 270 RC outpatient 293 293 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES EPO [308136803] 234.4 percent of total billed charges 181.66 278.35 Technical (Hospital) Services HC/HH Wch Supp Lifeband__8700-0706-01 PX-2705000086 CDM 2705000086 LOCAL 270 RC outpatient 293 293 CIGNA 62308 [3081051] CIGNA 62308 [308105105] 234.4 percent of total billed charges 181.66 278.35 Technical (Hospital) Services HC/HH Wch Supp Lifeband__8700-0706-01 PX-2705000086 CDM 2705000086 LOCAL 270 RC outpatient 293 293 CIGNA 62308 [3081051] CIGNA STATE OF WYOMING [308105107] 234.4 percent of total billed charges 181.66 278.35 Technical (Hospital) Services HC/HH Wch Supp Lifeband__8700-0706-01 PX-2705000086 CDM 2705000086 LOCAL 270 RC outpatient 293 293 BLUE CROSS BLUE SHIELD WELLMARK SB889 [3081026] BCBS WYOMING [308102603] 278.35 percent of total billed charges 181.66 278.35 Technical (Hospital) Services HC/HH Wch Supp Lifeband__8700-0706-01 PX-2705000086 CDM 2705000086 LOCAL 270 RC outpatient 293 293 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES HDHP [308136802] 234.4 percent of total billed charges 181.66 278.35 Technical (Hospital) Services HC/HH Wch Supp Lifeband__8700-0706-01 PX-2705000086 CDM 2705000086 LOCAL 270 RC outpatient 293 293 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES PPO [308136801] 234.4 percent of total billed charges 181.66 278.35 Technical (Hospital) Services HC/HH Wch Supp Lifeband__8700-0706-01 PX-2705000086 CDM 2705000086 LOCAL 270 RC outpatient 293 293 HEALTHPARTNERS SX009 HEALTHPARTNERS 234.4 percent of total billed charges 181.66 278.35 Technical (Hospital) Services HC/HH Wch Supp Lifeband__8700-0706-01 PX-2705000086 CDM 2705000086 LOCAL 270 RC outpatient 293 293 UNITED HEALTHCARE (COMMERCIAL) [3081199] UNITED HEALTHCARE 87726 [308119901] 181.66 percent of total billed charges 181.66 278.35 Technical (Hospital) Services HC/HH Wch Supp Lifeband__8700-0706-01 PX-2705000086 CDM 2705000086 LOCAL 270 RC inpatient 293 293 HEALTHPARTNERS SX009 HEALTHPARTNERS 232 percent of total billed charges 181.66 278.35 Technical (Hospital) Services HC/HH Wch Supp Lifeband__8700-0706-01 PX-2705000086 CDM 2705000086 LOCAL 270 RC inpatient 293 293 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES EPO [308136803] 232 percent of total billed charges 181.66 278.35 Technical (Hospital) Services HC/HH Wch Supp Lifeband__8700-0706-01 PX-2705000086 CDM 2705000086 LOCAL 270 RC inpatient 293 293 BLUE CROSS BLUE SHIELD WELLMARK SB889 [3081026] BCBS WYOMING [308102603] 278.35 percent of total billed charges 181.66 278.35 Technical (Hospital) Services HC/HH Wch Supp Lifeband__8700-0706-01 PX-2705000086 CDM 2705000086 LOCAL 270 RC inpatient 293 293 CIGNA 62308 [3081051] CIGNA 62308 [308105105] 232 percent of total billed charges 181.66 278.35 Technical (Hospital) Services HC/HH Wch Supp Lifeband__8700-0706-01 PX-2705000086 CDM 2705000086 LOCAL 270 RC inpatient 293 293 CIGNA 62308 [3081051] CIGNA STATE OF WYOMING [308105107] 232 percent of total billed charges 181.66 278.35 Technical (Hospital) Services HC/HH Wch Supp Lifeband__8700-0706-01 PX-2705000086 CDM 2705000086 LOCAL 270 RC inpatient 293 293 MULTIPLAN INC 34080 [3081285] MULTIPLAN INC [308128501] 278.35 percent of total billed charges 181.66 278.35 Technical (Hospital) Services HC/HH Wch Supp Lifeband__8700-0706-01 PX-2705000086 CDM 2705000086 LOCAL 270 RC inpatient 293 293 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES PPO [308136801] 232 percent of total billed charges 181.66 278.35 Technical (Hospital) Services HC/HH Wch Supp Lifeband__8700-0706-01 PX-2705000086 CDM 2705000086 LOCAL 270 RC inpatient 293 293 UNITED HEALTHCARE (COMMERCIAL) [3081199] UNITED HEALTHCARE 87726 [308119901] 181.66 percent of total billed charges 181.66 278.35 Technical (Hospital) Services HC/HH Wch Supp Lifeband__8700-0706-01 PX-2705000086 CDM 2705000086 LOCAL 270 RC inpatient 293 293 MEDICA (COMMERCIAL) 94265 [3081118] MEDICA CLAIMS [308111801] 263.7 percent of total billed charges 181.66 278.35 Technical (Hospital) Services HC/HH Wch Supp Lifeband__8700-0706-01 PX-2705000086 CDM 2705000086 LOCAL 270 RC inpatient 293 293 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES HDHP [308136802] 232 percent of total billed charges 181.66 278.35 Technical (Hospital) Services "HC/HH Wch Supp Knee Immobilizer 24__200030""" PX-2705000085 CDM 2705000085 LOCAL 270 RC outpatient 135 135 MEDICA (COMMERCIAL) 94265 [3081118] MEDICA CLAIMS [308111801] 121.5 percent of total billed charges 83.7 128.25 Technical (Hospital) Services "HC/HH Wch Supp Knee Immobilizer 24__200030""" PX-2705000085 CDM 2705000085 LOCAL 270 RC outpatient 135 135 MULTIPLAN INC 34080 [3081285] MULTIPLAN INC [308128501] 128.25 percent of total billed charges 83.7 128.25 Technical (Hospital) Services "HC/HH Wch Supp Knee Immobilizer 24__200030""" PX-2705000085 CDM 2705000085 LOCAL 270 RC outpatient 135 135 CIGNA 62308 [3081051] CIGNA 62308 [308105105] 108 percent of total billed charges 83.7 128.25 Technical (Hospital) Services "HC/HH Wch Supp Knee Immobilizer 24__200030""" PX-2705000085 CDM 2705000085 LOCAL 270 RC outpatient 135 135 CIGNA 62308 [3081051] CIGNA STATE OF WYOMING [308105107] 108 percent of total billed charges 83.7 128.25 Technical (Hospital) Services "HC/HH Wch Supp Knee Immobilizer 24__200030""" PX-2705000085 CDM 2705000085 LOCAL 270 RC outpatient 135 135 BLUE CROSS BLUE SHIELD WELLMARK SB889 [3081026] BCBS WYOMING [308102603] 128.25 percent of total billed charges 83.7 128.25 Technical (Hospital) Services "HC/HH Wch Supp Knee Immobilizer 24__200030""" PX-2705000085 CDM 2705000085 LOCAL 270 RC outpatient 135 135 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES EPO [308136803] 108 percent of total billed charges 83.7 128.25 Technical (Hospital) Services "HC/HH Wch Supp Knee Immobilizer 24__200030""" PX-2705000085 CDM 2705000085 LOCAL 270 RC outpatient 135 135 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES HDHP [308136802] 108 percent of total billed charges 83.7 128.25 Technical (Hospital) Services "HC/HH Wch Supp Knee Immobilizer 24__200030""" PX-2705000085 CDM 2705000085 LOCAL 270 RC outpatient 135 135 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES PPO [308136801] 108 percent of total billed charges 83.7 128.25 Technical (Hospital) Services "HC/HH Wch Supp Knee Immobilizer 24__200030""" PX-2705000085 CDM 2705000085 LOCAL 270 RC outpatient 135 135 HEALTHPARTNERS SX009 HEALTHPARTNERS 108 percent of total billed charges 83.7 128.25 Technical (Hospital) Services "HC/HH Wch Supp Knee Immobilizer 24__200030""" PX-2705000085 CDM 2705000085 LOCAL 270 RC outpatient 135 135 UNITED HEALTHCARE (COMMERCIAL) [3081199] UNITED HEALTHCARE 87726 [308119901] 83.7 percent of total billed charges 83.7 128.25 Technical (Hospital) Services "HC/HH Wch Supp Knee Immobilizer 24__200030""" PX-2705000085 CDM 2705000085 LOCAL 270 RC inpatient 135 135 MEDICA (COMMERCIAL) 94265 [3081118] MEDICA CLAIMS [308111801] 121.5 percent of total billed charges 83.7 128.25 Technical (Hospital) Services "HC/HH Wch Supp Knee Immobilizer 24__200030""" PX-2705000085 CDM 2705000085 LOCAL 270 RC inpatient 135 135 UNITED HEALTHCARE (COMMERCIAL) [3081199] UNITED HEALTHCARE 87726 [308119901] 83.7 percent of total billed charges 83.7 128.25 Technical (Hospital) Services "HC/HH Wch Supp Knee Immobilizer 24__200030""" PX-2705000085 CDM 2705000085 LOCAL 270 RC inpatient 135 135 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES HDHP [308136802] 106.89 percent of total billed charges 83.7 128.25 Technical (Hospital) Services "HC/HH Wch Supp Knee Immobilizer 24__200030""" PX-2705000085 CDM 2705000085 LOCAL 270 RC inpatient 135 135 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES PPO [308136801] 106.89 percent of total billed charges 83.7 128.25 Technical (Hospital) Services "HC/HH Wch Supp Knee Immobilizer 24__200030""" PX-2705000085 CDM 2705000085 LOCAL 270 RC inpatient 135 135 BLUE CROSS BLUE SHIELD WELLMARK SB889 [3081026] BCBS WYOMING [308102603] 128.25 percent of total billed charges 83.7 128.25 Technical (Hospital) Services "HC/HH Wch Supp Knee Immobilizer 24__200030""" PX-2705000085 CDM 2705000085 LOCAL 270 RC inpatient 135 135 MULTIPLAN INC 34080 [3081285] MULTIPLAN INC [308128501] 128.25 percent of total billed charges 83.7 128.25 Technical (Hospital) Services "HC/HH Wch Supp Knee Immobilizer 24__200030""" PX-2705000085 CDM 2705000085 LOCAL 270 RC inpatient 135 135 CIGNA 62308 [3081051] CIGNA 62308 [308105105] 106.89 percent of total billed charges 83.7 128.25 Technical (Hospital) Services "HC/HH Wch Supp Knee Immobilizer 24__200030""" PX-2705000085 CDM 2705000085 LOCAL 270 RC inpatient 135 135 CIGNA 62308 [3081051] CIGNA STATE OF WYOMING [308105107] 106.89 percent of total billed charges 83.7 128.25 Technical (Hospital) Services "HC/HH Wch Supp Knee Immobilizer 24__200030""" PX-2705000085 CDM 2705000085 LOCAL 270 RC inpatient 135 135 HEALTHPARTNERS SX009 HEALTHPARTNERS 106.89 percent of total billed charges 83.7 128.25 Technical (Hospital) Services "HC/HH Wch Supp Knee Immobilizer 24__200030""" PX-2705000085 CDM 2705000085 LOCAL 270 RC inpatient 135 135 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES EPO [308136803] 106.89 percent of total billed charges 83.7 128.25 Technical (Hospital) Services HC/HH Wch Supp Knee Immobilizer 20in__8142744 PX-2705000084 CDM 2705000084 LOCAL 270 RC inpatient 137 137 MULTIPLAN INC 34080 [3081285] MULTIPLAN INC [308128501] 130.15 percent of total billed charges 84.94 130.15 Technical (Hospital) Services HC/HH Wch Supp Knee Immobilizer 20in__8142744 PX-2705000084 CDM 2705000084 LOCAL 270 RC inpatient 137 137 CIGNA 62308 [3081051] CIGNA 62308 [308105105] 108.48 percent of total billed charges 84.94 130.15 Technical (Hospital) Services HC/HH Wch Supp Knee Immobilizer 20in__8142744 PX-2705000084 CDM 2705000084 LOCAL 270 RC inpatient 137 137 CIGNA 62308 [3081051] CIGNA STATE OF WYOMING [308105107] 108.48 percent of total billed charges 84.94 130.15 Technical (Hospital) Services HC/HH Wch Supp Knee Immobilizer 20in__8142744 PX-2705000084 CDM 2705000084 LOCAL 270 RC inpatient 137 137 BLUE CROSS BLUE SHIELD WELLMARK SB889 [3081026] BCBS WYOMING [308102603] 130.15 percent of total billed charges 84.94 130.15 Technical (Hospital) Services HC/HH Wch Supp Knee Immobilizer 20in__8142744 PX-2705000084 CDM 2705000084 LOCAL 270 RC inpatient 137 137 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES EPO [308136803] 108.48 percent of total billed charges 84.94 130.15 Technical (Hospital) Services HC/HH Wch Supp Knee Immobilizer 20in__8142744 PX-2705000084 CDM 2705000084 LOCAL 270 RC inpatient 137 137 HEALTHPARTNERS SX009 HEALTHPARTNERS 108.48 percent of total billed charges 84.94 130.15 Technical (Hospital) Services HC/HH Wch Supp Knee Immobilizer 20in__8142744 PX-2705000084 CDM 2705000084 LOCAL 270 RC inpatient 137 137 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES HDHP [308136802] 108.48 percent of total billed charges 84.94 130.15 Technical (Hospital) Services HC/HH Wch Supp Knee Immobilizer 20in__8142744 PX-2705000084 CDM 2705000084 LOCAL 270 RC inpatient 137 137 MEDICA (COMMERCIAL) 94265 [3081118] MEDICA CLAIMS [308111801] 123.3 percent of total billed charges 84.94 130.15 Technical (Hospital) Services HC/HH Wch Supp Knee Immobilizer 20in__8142744 PX-2705000084 CDM 2705000084 LOCAL 270 RC inpatient 137 137 UNITED HEALTHCARE (COMMERCIAL) [3081199] UNITED HEALTHCARE 87726 [308119901] 84.94 percent of total billed charges 84.94 130.15 Technical (Hospital) Services HC/HH Wch Supp Knee Immobilizer 20in__8142744 PX-2705000084 CDM 2705000084 LOCAL 270 RC inpatient 137 137 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES PPO [308136801] 108.48 percent of total billed charges 84.94 130.15 Technical (Hospital) Services HC/HH Wch Supp Knee Immobilizer 20in__8142744 PX-2705000084 CDM 2705000084 LOCAL 270 RC outpatient 137 137 HEALTHPARTNERS SX009 HEALTHPARTNERS 109.6 percent of total billed charges 84.94 130.15 Technical (Hospital) Services HC/HH Wch Supp Knee Immobilizer 20in__8142744 PX-2705000084 CDM 2705000084 LOCAL 270 RC outpatient 137 137 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES PPO [308136801] 109.6 percent of total billed charges 84.94 130.15 Technical (Hospital) Services HC/HH Wch Supp Knee Immobilizer 20in__8142744 PX-2705000084 CDM 2705000084 LOCAL 270 RC outpatient 137 137 UNITED HEALTHCARE (COMMERCIAL) [3081199] UNITED HEALTHCARE 87726 [308119901] 84.94 percent of total billed charges 84.94 130.15 Technical (Hospital) Services HC/HH Wch Supp Knee Immobilizer 20in__8142744 PX-2705000084 CDM 2705000084 LOCAL 270 RC outpatient 137 137 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES HDHP [308136802] 109.6 percent of total billed charges 84.94 130.15 Technical (Hospital) Services HC/HH Wch Supp Knee Immobilizer 20in__8142744 PX-2705000084 CDM 2705000084 LOCAL 270 RC outpatient 137 137 CIGNA 62308 [3081051] CIGNA 62308 [308105105] 109.6 percent of total billed charges 84.94 130.15 Technical (Hospital) Services HC/HH Wch Supp Knee Immobilizer 20in__8142744 PX-2705000084 CDM 2705000084 LOCAL 270 RC outpatient 137 137 CIGNA 62308 [3081051] CIGNA STATE OF WYOMING [308105107] 109.6 percent of total billed charges 84.94 130.15 Technical (Hospital) Services HC/HH Wch Supp Knee Immobilizer 20in__8142744 PX-2705000084 CDM 2705000084 LOCAL 270 RC outpatient 137 137 BLUE CROSS BLUE SHIELD WELLMARK SB889 [3081026] BCBS WYOMING [308102603] 130.15 percent of total billed charges 84.94 130.15 Technical (Hospital) Services HC/HH Wch Supp Knee Immobilizer 20in__8142744 PX-2705000084 CDM 2705000084 LOCAL 270 RC outpatient 137 137 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES EPO [308136803] 109.6 percent of total billed charges 84.94 130.15 Technical (Hospital) Services HC/HH Wch Supp Knee Immobilizer 20in__8142744 PX-2705000084 CDM 2705000084 LOCAL 270 RC outpatient 137 137 MEDICA (COMMERCIAL) 94265 [3081118] MEDICA CLAIMS [308111801] 123.3 percent of total billed charges 84.94 130.15 Technical (Hospital) Services HC/HH Wch Supp Knee Immobilizer 20in__8142744 PX-2705000084 CDM 2705000084 LOCAL 270 RC outpatient 137 137 MULTIPLAN INC 34080 [3081285] MULTIPLAN INC [308128501] 130.15 percent of total billed charges 84.94 130.15 Technical (Hospital) Services "HC/HH Wch Supp Knee Immobilizer 16__200016""" PX-2705000083 CDM 2705000083 LOCAL 270 RC outpatient 135 135 HEALTHPARTNERS SX009 HEALTHPARTNERS 108 percent of total billed charges 83.7 128.25 Technical (Hospital) Services "HC/HH Wch Supp Knee Immobilizer 16__200016""" PX-2705000083 CDM 2705000083 LOCAL 270 RC outpatient 135 135 UNITED HEALTHCARE (COMMERCIAL) [3081199] UNITED HEALTHCARE 87726 [308119901] 83.7 percent of total billed charges 83.7 128.25 Technical (Hospital) Services "HC/HH Wch Supp Knee Immobilizer 16__200016""" PX-2705000083 CDM 2705000083 LOCAL 270 RC outpatient 135 135 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES PPO [308136801] 108 percent of total billed charges 83.7 128.25 Technical (Hospital) Services "HC/HH Wch Supp Knee Immobilizer 16__200016""" PX-2705000083 CDM 2705000083 LOCAL 270 RC outpatient 135 135 CIGNA 62308 [3081051] CIGNA 62308 [308105105] 108 percent of total billed charges 83.7 128.25 Technical (Hospital) Services "HC/HH Wch Supp Knee Immobilizer 16__200016""" PX-2705000083 CDM 2705000083 LOCAL 270 RC outpatient 135 135 CIGNA 62308 [3081051] CIGNA STATE OF WYOMING [308105107] 108 percent of total billed charges 83.7 128.25 Technical (Hospital) Services "HC/HH Wch Supp Knee Immobilizer 16__200016""" PX-2705000083 CDM 2705000083 LOCAL 270 RC outpatient 135 135 BLUE CROSS BLUE SHIELD WELLMARK SB889 [3081026] BCBS WYOMING [308102603] 128.25 percent of total billed charges 83.7 128.25 Technical (Hospital) Services "HC/HH Wch Supp Knee Immobilizer 16__200016""" PX-2705000083 CDM 2705000083 LOCAL 270 RC outpatient 135 135 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES EPO [308136803] 108 percent of total billed charges 83.7 128.25 Technical (Hospital) Services "HC/HH Wch Supp Knee Immobilizer 16__200016""" PX-2705000083 CDM 2705000083 LOCAL 270 RC outpatient 135 135 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES HDHP [308136802] 108 percent of total billed charges 83.7 128.25 Technical (Hospital) Services "HC/HH Wch Supp Knee Immobilizer 16__200016""" PX-2705000083 CDM 2705000083 LOCAL 270 RC outpatient 135 135 MEDICA (COMMERCIAL) 94265 [3081118] MEDICA CLAIMS [308111801] 121.5 percent of total billed charges 83.7 128.25 Technical (Hospital) Services "HC/HH Wch Supp Knee Immobilizer 16__200016""" PX-2705000083 CDM 2705000083 LOCAL 270 RC outpatient 135 135 MULTIPLAN INC 34080 [3081285] MULTIPLAN INC [308128501] 128.25 percent of total billed charges 83.7 128.25 Technical (Hospital) Services "HC/HH Wch Supp Knee Immobilizer 16__200016""" PX-2705000083 CDM 2705000083 LOCAL 270 RC inpatient 135 135 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES EPO [308136803] 106.89 percent of total billed charges 83.7 128.25 Technical (Hospital) Services "HC/HH Wch Supp Knee Immobilizer 16__200016""" PX-2705000083 CDM 2705000083 LOCAL 270 RC inpatient 135 135 HEALTHPARTNERS SX009 HEALTHPARTNERS 106.89 percent of total billed charges 83.7 128.25 Technical (Hospital) Services "HC/HH Wch Supp Knee Immobilizer 16__200016""" PX-2705000083 CDM 2705000083 LOCAL 270 RC inpatient 135 135 CIGNA 62308 [3081051] CIGNA 62308 [308105105] 106.89 percent of total billed charges 83.7 128.25 Technical (Hospital) Services "HC/HH Wch Supp Knee Immobilizer 16__200016""" PX-2705000083 CDM 2705000083 LOCAL 270 RC inpatient 135 135 CIGNA 62308 [3081051] CIGNA STATE OF WYOMING [308105107] 106.89 percent of total billed charges 83.7 128.25 Technical (Hospital) Services "HC/HH Wch Supp Knee Immobilizer 16__200016""" PX-2705000083 CDM 2705000083 LOCAL 270 RC inpatient 135 135 MULTIPLAN INC 34080 [3081285] MULTIPLAN INC [308128501] 128.25 percent of total billed charges 83.7 128.25 Technical (Hospital) Services "HC/HH Wch Supp Knee Immobilizer 16__200016""" PX-2705000083 CDM 2705000083 LOCAL 270 RC inpatient 135 135 BLUE CROSS BLUE SHIELD WELLMARK SB889 [3081026] BCBS WYOMING [308102603] 128.25 percent of total billed charges 83.7 128.25 Technical (Hospital) Services "HC/HH Wch Supp Knee Immobilizer 16__200016""" PX-2705000083 CDM 2705000083 LOCAL 270 RC inpatient 135 135 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES PPO [308136801] 106.89 percent of total billed charges 83.7 128.25 Technical (Hospital) Services "HC/HH Wch Supp Knee Immobilizer 16__200016""" PX-2705000083 CDM 2705000083 LOCAL 270 RC inpatient 135 135 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES HDHP [308136802] 106.89 percent of total billed charges 83.7 128.25 Technical (Hospital) Services "HC/HH Wch Supp Knee Immobilizer 16__200016""" PX-2705000083 CDM 2705000083 LOCAL 270 RC inpatient 135 135 UNITED HEALTHCARE (COMMERCIAL) [3081199] UNITED HEALTHCARE 87726 [308119901] 83.7 percent of total billed charges 83.7 128.25 Technical (Hospital) Services "HC/HH Wch Supp Knee Immobilizer 16__200016""" PX-2705000083 CDM 2705000083 LOCAL 270 RC inpatient 135 135 MEDICA (COMMERCIAL) 94265 [3081118] MEDICA CLAIMS [308111801] 121.5 percent of total billed charges 83.7 128.25 Technical (Hospital) Services HC/HH Wch Supp Kit Combitube 37fr__5-18537 PX-2705000082 CDM 2705000082 LOCAL 270 RC outpatient 207 207 UNITED HEALTHCARE (COMMERCIAL) [3081199] UNITED HEALTHCARE 87726 [308119901] 128.34 percent of total billed charges 128.34 196.65 Technical (Hospital) Services HC/HH Wch Supp Kit Combitube 37fr__5-18537 PX-2705000082 CDM 2705000082 LOCAL 270 RC outpatient 207 207 HEALTHPARTNERS SX009 HEALTHPARTNERS 165.6 percent of total billed charges 128.34 196.65 Technical (Hospital) Services HC/HH Wch Supp Kit Combitube 37fr__5-18537 PX-2705000082 CDM 2705000082 LOCAL 270 RC outpatient 207 207 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES PPO [308136801] 165.6 percent of total billed charges 128.34 196.65 Technical (Hospital) Services HC/HH Wch Supp Kit Combitube 37fr__5-18537 PX-2705000082 CDM 2705000082 LOCAL 270 RC outpatient 207 207 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES HDHP [308136802] 165.6 percent of total billed charges 128.34 196.65 Technical (Hospital) Services HC/HH Wch Supp Kit Combitube 37fr__5-18537 PX-2705000082 CDM 2705000082 LOCAL 270 RC outpatient 207 207 BLUE CROSS BLUE SHIELD WELLMARK SB889 [3081026] BCBS WYOMING [308102603] 196.65 percent of total billed charges 128.34 196.65 Technical (Hospital) Services HC/HH Wch Supp Kit Combitube 37fr__5-18537 PX-2705000082 CDM 2705000082 LOCAL 270 RC outpatient 207 207 CIGNA 62308 [3081051] CIGNA 62308 [308105105] 165.6 percent of total billed charges 128.34 196.65 Technical (Hospital) Services HC/HH Wch Supp Kit Combitube 37fr__5-18537 PX-2705000082 CDM 2705000082 LOCAL 270 RC outpatient 207 207 CIGNA 62308 [3081051] CIGNA STATE OF WYOMING [308105107] 165.6 percent of total billed charges 128.34 196.65 Technical (Hospital) Services HC/HH Wch Supp Kit Combitube 37fr__5-18537 PX-2705000082 CDM 2705000082 LOCAL 270 RC outpatient 207 207 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES EPO [308136803] 165.6 percent of total billed charges 128.34 196.65 Technical (Hospital) Services HC/HH Wch Supp Kit Combitube 37fr__5-18537 PX-2705000082 CDM 2705000082 LOCAL 270 RC outpatient 207 207 MULTIPLAN INC 34080 [3081285] MULTIPLAN INC [308128501] 196.65 percent of total billed charges 128.34 196.65 Technical (Hospital) Services HC/HH Wch Supp Kit Combitube 37fr__5-18537 PX-2705000082 CDM 2705000082 LOCAL 270 RC outpatient 207 207 MEDICA (COMMERCIAL) 94265 [3081118] MEDICA CLAIMS [308111801] 186.3 percent of total billed charges 128.34 196.65 Technical (Hospital) Services HC/HH Wch Supp Kit Combitube 37fr__5-18537 PX-2705000082 CDM 2705000082 LOCAL 270 RC inpatient 207 207 MULTIPLAN INC 34080 [3081285] MULTIPLAN INC [308128501] 196.65 percent of total billed charges 128.34 196.65 Technical (Hospital) Services HC/HH Wch Supp Kit Combitube 37fr__5-18537 PX-2705000082 CDM 2705000082 LOCAL 270 RC inpatient 207 207 BLUE CROSS BLUE SHIELD WELLMARK SB889 [3081026] BCBS WYOMING [308102603] 196.65 percent of total billed charges 128.34 196.65 Technical (Hospital) Services HC/HH Wch Supp Kit Combitube 37fr__5-18537 PX-2705000082 CDM 2705000082 LOCAL 270 RC inpatient 207 207 CIGNA 62308 [3081051] CIGNA 62308 [308105105] 163.9 percent of total billed charges 128.34 196.65 Technical (Hospital) Services HC/HH Wch Supp Kit Combitube 37fr__5-18537 PX-2705000082 CDM 2705000082 LOCAL 270 RC inpatient 207 207 CIGNA 62308 [3081051] CIGNA STATE OF WYOMING [308105107] 163.9 percent of total billed charges 128.34 196.65 Technical (Hospital) Services HC/HH Wch Supp Kit Combitube 37fr__5-18537 PX-2705000082 CDM 2705000082 LOCAL 270 RC inpatient 207 207 HEALTHPARTNERS SX009 HEALTHPARTNERS 163.9 percent of total billed charges 128.34 196.65 Technical (Hospital) Services HC/HH Wch Supp Kit Combitube 37fr__5-18537 PX-2705000082 CDM 2705000082 LOCAL 270 RC inpatient 207 207 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES EPO [308136803] 163.9 percent of total billed charges 128.34 196.65 Technical (Hospital) Services HC/HH Wch Supp Kit Combitube 37fr__5-18537 PX-2705000082 CDM 2705000082 LOCAL 270 RC inpatient 207 207 UNITED HEALTHCARE (COMMERCIAL) [3081199] UNITED HEALTHCARE 87726 [308119901] 128.34 percent of total billed charges 128.34 196.65 Technical (Hospital) Services HC/HH Wch Supp Kit Combitube 37fr__5-18537 PX-2705000082 CDM 2705000082 LOCAL 270 RC inpatient 207 207 MEDICA (COMMERCIAL) 94265 [3081118] MEDICA CLAIMS [308111801] 186.3 percent of total billed charges 128.34 196.65 Technical (Hospital) Services HC/HH Wch Supp Kit Combitube 37fr__5-18537 PX-2705000082 CDM 2705000082 LOCAL 270 RC inpatient 207 207 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES HDHP [308136802] 163.9 percent of total billed charges 128.34 196.65 Technical (Hospital) Services HC/HH Wch Supp Kit Combitube 37fr__5-18537 PX-2705000082 CDM 2705000082 LOCAL 270 RC inpatient 207 207 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES PPO [308136801] 163.9 percent of total billed charges 128.34 196.65 Technical (Hospital) Services HC/HH Wch Supp IV Ns 0.9 Viaflex 1000ml__2b1324x PX-2705000081 CDM 2705000081 LOCAL 270 RC inpatient 144 144 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES PPO [308136801] 114.02 percent of total billed charges 89.28 136.8 Technical (Hospital) Services HC/HH Wch Supp IV Ns 0.9 Viaflex 1000ml__2b1324x PX-2705000081 CDM 2705000081 LOCAL 270 RC inpatient 144 144 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES HDHP [308136802] 114.02 percent of total billed charges 89.28 136.8 Technical (Hospital) Services HC/HH Wch Supp IV Ns 0.9 Viaflex 1000ml__2b1324x PX-2705000081 CDM 2705000081 LOCAL 270 RC inpatient 144 144 MEDICA (COMMERCIAL) 94265 [3081118] MEDICA CLAIMS [308111801] 129.6 percent of total billed charges 89.28 136.8 Technical (Hospital) Services HC/HH Wch Supp IV Ns 0.9 Viaflex 1000ml__2b1324x PX-2705000081 CDM 2705000081 LOCAL 270 RC inpatient 144 144 UNITED HEALTHCARE (COMMERCIAL) [3081199] UNITED HEALTHCARE 87726 [308119901] 89.28 percent of total billed charges 89.28 136.8 Technical (Hospital) Services HC/HH Wch Supp IV Ns 0.9 Viaflex 1000ml__2b1324x PX-2705000081 CDM 2705000081 LOCAL 270 RC inpatient 144 144 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES EPO [308136803] 114.02 percent of total billed charges 89.28 136.8 Technical (Hospital) Services HC/HH Wch Supp IV Ns 0.9 Viaflex 1000ml__2b1324x PX-2705000081 CDM 2705000081 LOCAL 270 RC inpatient 144 144 HEALTHPARTNERS SX009 HEALTHPARTNERS 114.02 percent of total billed charges 89.28 136.8 Technical (Hospital) Services HC/HH Wch Supp IV Ns 0.9 Viaflex 1000ml__2b1324x PX-2705000081 CDM 2705000081 LOCAL 270 RC inpatient 144 144 CIGNA 62308 [3081051] CIGNA 62308 [308105105] 114.02 percent of total billed charges 89.28 136.8 Technical (Hospital) Services HC/HH Wch Supp IV Ns 0.9 Viaflex 1000ml__2b1324x PX-2705000081 CDM 2705000081 LOCAL 270 RC inpatient 144 144 CIGNA 62308 [3081051] CIGNA STATE OF WYOMING [308105107] 114.02 percent of total billed charges 89.28 136.8 Technical (Hospital) Services HC/HH Wch Supp IV Ns 0.9 Viaflex 1000ml__2b1324x PX-2705000081 CDM 2705000081 LOCAL 270 RC inpatient 144 144 BLUE CROSS BLUE SHIELD WELLMARK SB889 [3081026] BCBS WYOMING [308102603] 136.8 percent of total billed charges 89.28 136.8 Technical (Hospital) Services HC/HH Wch Supp IV Ns 0.9 Viaflex 1000ml__2b1324x PX-2705000081 CDM 2705000081 LOCAL 270 RC inpatient 144 144 MULTIPLAN INC 34080 [3081285] MULTIPLAN INC [308128501] 136.8 percent of total billed charges 89.28 136.8 Technical (Hospital) Services HC/HH Wch Supp IV Ns 0.9 Viaflex 1000ml__2b1324x PX-2705000081 CDM 2705000081 LOCAL 270 RC outpatient 144 144 MULTIPLAN INC 34080 [3081285] MULTIPLAN INC [308128501] 136.8 percent of total billed charges 89.28 136.8 Technical (Hospital) Services HC/HH Wch Supp IV Ns 0.9 Viaflex 1000ml__2b1324x PX-2705000081 CDM 2705000081 LOCAL 270 RC outpatient 144 144 MEDICA (COMMERCIAL) 94265 [3081118] MEDICA CLAIMS [308111801] 129.6 percent of total billed charges 89.28 136.8 Technical (Hospital) Services HC/HH Wch Supp IV Ns 0.9 Viaflex 1000ml__2b1324x PX-2705000081 CDM 2705000081 LOCAL 270 RC outpatient 144 144 CIGNA 62308 [3081051] CIGNA 62308 [308105105] 115.2 percent of total billed charges 89.28 136.8 Technical (Hospital) Services HC/HH Wch Supp IV Ns 0.9 Viaflex 1000ml__2b1324x PX-2705000081 CDM 2705000081 LOCAL 270 RC outpatient 144 144 BLUE CROSS BLUE SHIELD WELLMARK SB889 [3081026] BCBS WYOMING [308102603] 136.8 percent of total billed charges 89.28 136.8 Technical (Hospital) Services HC/HH Wch Supp IV Ns 0.9 Viaflex 1000ml__2b1324x PX-2705000081 CDM 2705000081 LOCAL 270 RC outpatient 144 144 CIGNA 62308 [3081051] CIGNA STATE OF WYOMING [308105107] 115.2 percent of total billed charges 89.28 136.8 Technical (Hospital) Services HC/HH Wch Supp IV Ns 0.9 Viaflex 1000ml__2b1324x PX-2705000081 CDM 2705000081 LOCAL 270 RC outpatient 144 144 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES EPO [308136803] 115.2 percent of total billed charges 89.28 136.8 Technical (Hospital) Services HC/HH Wch Supp IV Ns 0.9 Viaflex 1000ml__2b1324x PX-2705000081 CDM 2705000081 LOCAL 270 RC outpatient 144 144 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES HDHP [308136802] 115.2 percent of total billed charges 89.28 136.8 Technical (Hospital) Services HC/HH Wch Supp IV Ns 0.9 Viaflex 1000ml__2b1324x PX-2705000081 CDM 2705000081 LOCAL 270 RC outpatient 144 144 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES PPO [308136801] 115.2 percent of total billed charges 89.28 136.8 Technical (Hospital) Services HC/HH Wch Supp IV Ns 0.9 Viaflex 1000ml__2b1324x PX-2705000081 CDM 2705000081 LOCAL 270 RC outpatient 144 144 UNITED HEALTHCARE (COMMERCIAL) [3081199] UNITED HEALTHCARE 87726 [308119901] 89.28 percent of total billed charges 89.28 136.8 Technical (Hospital) Services HC/HH Wch Supp IV Ns 0.9 Viaflex 1000ml__2b1324x PX-2705000081 CDM 2705000081 LOCAL 270 RC outpatient 144 144 HEALTHPARTNERS SX009 HEALTHPARTNERS 115.2 percent of total billed charges 89.28 136.8 Technical (Hospital) Services HC/HH Wch Supp Irrigation System__0210-100-000 PX-2705000080 CDM 2705000080 LOCAL 270 RC inpatient 249 249 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES PPO [308136801] 197.16 percent of total billed charges 154.38 236.55 Technical (Hospital) Services HC/HH Wch Supp Irrigation System__0210-100-000 PX-2705000080 CDM 2705000080 LOCAL 270 RC inpatient 249 249 MEDICA (COMMERCIAL) 94265 [3081118] MEDICA CLAIMS [308111801] 224.1 percent of total billed charges 154.38 236.55 Technical (Hospital) Services HC/HH Wch Supp Irrigation System__0210-100-000 PX-2705000080 CDM 2705000080 LOCAL 270 RC inpatient 249 249 UNITED HEALTHCARE (COMMERCIAL) [3081199] UNITED HEALTHCARE 87726 [308119901] 154.38 percent of total billed charges 154.38 236.55 Technical (Hospital) Services HC/HH Wch Supp Irrigation System__0210-100-000 PX-2705000080 CDM 2705000080 LOCAL 270 RC inpatient 249 249 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES HDHP [308136802] 197.16 percent of total billed charges 154.38 236.55 Technical (Hospital) Services HC/HH Wch Supp Irrigation System__0210-100-000 PX-2705000080 CDM 2705000080 LOCAL 270 RC inpatient 249 249 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES EPO [308136803] 197.16 percent of total billed charges 154.38 236.55 Technical (Hospital) Services HC/HH Wch Supp Irrigation System__0210-100-000 PX-2705000080 CDM 2705000080 LOCAL 270 RC inpatient 249 249 HEALTHPARTNERS SX009 HEALTHPARTNERS 197.16 percent of total billed charges 154.38 236.55 Technical (Hospital) Services HC/HH Wch Supp Irrigation System__0210-100-000 PX-2705000080 CDM 2705000080 LOCAL 270 RC inpatient 249 249 BLUE CROSS BLUE SHIELD WELLMARK SB889 [3081026] BCBS WYOMING [308102603] 236.55 percent of total billed charges 154.38 236.55 Technical (Hospital) Services HC/HH Wch Supp Irrigation System__0210-100-000 PX-2705000080 CDM 2705000080 LOCAL 270 RC inpatient 249 249 MULTIPLAN INC 34080 [3081285] MULTIPLAN INC [308128501] 236.55 percent of total billed charges 154.38 236.55 Technical (Hospital) Services HC/HH Wch Supp Irrigation System__0210-100-000 PX-2705000080 CDM 2705000080 LOCAL 270 RC inpatient 249 249 CIGNA 62308 [3081051] CIGNA 62308 [308105105] 197.16 percent of total billed charges 154.38 236.55 Technical (Hospital) Services HC/HH Wch Supp Irrigation System__0210-100-000 PX-2705000080 CDM 2705000080 LOCAL 270 RC inpatient 249 249 CIGNA 62308 [3081051] CIGNA STATE OF WYOMING [308105107] 197.16 percent of total billed charges 154.38 236.55 Technical (Hospital) Services HC/HH Wch Supp Irrigation System__0210-100-000 PX-2705000080 CDM 2705000080 LOCAL 270 RC outpatient 249 249 MEDICA (COMMERCIAL) 94265 [3081118] MEDICA CLAIMS [308111801] 224.1 percent of total billed charges 154.38 236.55 Technical (Hospital) Services HC/HH Wch Supp Irrigation System__0210-100-000 PX-2705000080 CDM 2705000080 LOCAL 270 RC outpatient 249 249 MULTIPLAN INC 34080 [3081285] MULTIPLAN INC [308128501] 236.55 percent of total billed charges 154.38 236.55 Technical (Hospital) Services HC/HH Wch Supp Irrigation System__0210-100-000 PX-2705000080 CDM 2705000080 LOCAL 270 RC outpatient 249 249 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES EPO [308136803] 199.2 percent of total billed charges 154.38 236.55 Technical (Hospital) Services HC/HH Wch Supp Irrigation System__0210-100-000 PX-2705000080 CDM 2705000080 LOCAL 270 RC outpatient 249 249 BLUE CROSS BLUE SHIELD WELLMARK SB889 [3081026] BCBS WYOMING [308102603] 236.55 percent of total billed charges 154.38 236.55 Technical (Hospital) Services HC/HH Wch Supp Irrigation System__0210-100-000 PX-2705000080 CDM 2705000080 LOCAL 270 RC outpatient 249 249 CIGNA 62308 [3081051] CIGNA 62308 [308105105] 199.2 percent of total billed charges 154.38 236.55 Technical (Hospital) Services HC/HH Wch Supp Irrigation System__0210-100-000 PX-2705000080 CDM 2705000080 LOCAL 270 RC outpatient 249 249 CIGNA 62308 [3081051] CIGNA STATE OF WYOMING [308105107] 199.2 percent of total billed charges 154.38 236.55 Technical (Hospital) Services HC/HH Wch Supp Irrigation System__0210-100-000 PX-2705000080 CDM 2705000080 LOCAL 270 RC outpatient 249 249 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES HDHP [308136802] 199.2 percent of total billed charges 154.38 236.55 Technical (Hospital) Services HC/HH Wch Supp Irrigation System__0210-100-000 PX-2705000080 CDM 2705000080 LOCAL 270 RC outpatient 249 249 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES PPO [308136801] 199.2 percent of total billed charges 154.38 236.55 Technical (Hospital) Services HC/HH Wch Supp Irrigation System__0210-100-000 PX-2705000080 CDM 2705000080 LOCAL 270 RC outpatient 249 249 UNITED HEALTHCARE (COMMERCIAL) [3081199] UNITED HEALTHCARE 87726 [308119901] 154.38 percent of total billed charges 154.38 236.55 Technical (Hospital) Services HC/HH Wch Supp Irrigation System__0210-100-000 PX-2705000080 CDM 2705000080 LOCAL 270 RC outpatient 249 249 HEALTHPARTNERS SX009 HEALTHPARTNERS 199.2 percent of total billed charges 154.38 236.55 Technical (Hospital) Services HC/HH Wch Supp Immobilizer Shdlr L__08144504 PX-2705000079 CDM 2705000079 LOCAL 270 RC outpatient 32 32 HEALTHPARTNERS SX009 HEALTHPARTNERS 25.6 percent of total billed charges 19.84 30.4 Technical (Hospital) Services HC/HH Wch Supp Immobilizer Shdlr L__08144504 PX-2705000079 CDM 2705000079 LOCAL 270 RC outpatient 32 32 UNITED HEALTHCARE (COMMERCIAL) [3081199] UNITED HEALTHCARE 87726 [308119901] 19.84 percent of total billed charges 19.84 30.4 Technical (Hospital) Services HC/HH Wch Supp Immobilizer Shdlr L__08144504 PX-2705000079 CDM 2705000079 LOCAL 270 RC outpatient 32 32 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES PPO [308136801] 25.6 percent of total billed charges 19.84 30.4 Technical (Hospital) Services HC/HH Wch Supp Immobilizer Shdlr L__08144504 PX-2705000079 CDM 2705000079 LOCAL 270 RC outpatient 32 32 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES HDHP [308136802] 25.6 percent of total billed charges 19.84 30.4 Technical (Hospital) Services HC/HH Wch Supp Immobilizer Shdlr L__08144504 PX-2705000079 CDM 2705000079 LOCAL 270 RC outpatient 32 32 CIGNA 62308 [3081051] CIGNA 62308 [308105105] 25.6 percent of total billed charges 19.84 30.4 Technical (Hospital) Services HC/HH Wch Supp Immobilizer Shdlr L__08144504 PX-2705000079 CDM 2705000079 LOCAL 270 RC outpatient 32 32 CIGNA 62308 [3081051] CIGNA STATE OF WYOMING [308105107] 25.6 percent of total billed charges 19.84 30.4 Technical (Hospital) Services HC/HH Wch Supp Immobilizer Shdlr L__08144504 PX-2705000079 CDM 2705000079 LOCAL 270 RC outpatient 32 32 BLUE CROSS BLUE SHIELD WELLMARK SB889 [3081026] BCBS WYOMING [308102603] 30.4 percent of total billed charges 19.84 30.4 Technical (Hospital) Services HC/HH Wch Supp Immobilizer Shdlr L__08144504 PX-2705000079 CDM 2705000079 LOCAL 270 RC outpatient 32 32 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES EPO [308136803] 25.6 percent of total billed charges 19.84 30.4 Technical (Hospital) Services HC/HH Wch Supp Immobilizer Shdlr L__08144504 PX-2705000079 CDM 2705000079 LOCAL 270 RC inpatient 32 32 MULTIPLAN INC 34080 [3081285] MULTIPLAN INC [308128501] 30.4 percent of total billed charges 19.84 30.4 Technical (Hospital) Services HC/HH Wch Supp Immobilizer Shdlr L__08144504 PX-2705000079 CDM 2705000079 LOCAL 270 RC inpatient 32 32 BLUE CROSS BLUE SHIELD WELLMARK SB889 [3081026] BCBS WYOMING [308102603] 30.4 percent of total billed charges 19.84 30.4 Technical (Hospital) Services HC/HH Wch Supp Immobilizer Shdlr L__08144504 PX-2705000079 CDM 2705000079 LOCAL 270 RC inpatient 32 32 CIGNA 62308 [3081051] CIGNA 62308 [308105105] 25.34 percent of total billed charges 19.84 30.4 Technical (Hospital) Services HC/HH Wch Supp Immobilizer Shdlr L__08144504 PX-2705000079 CDM 2705000079 LOCAL 270 RC inpatient 32 32 CIGNA 62308 [3081051] CIGNA STATE OF WYOMING [308105107] 25.34 percent of total billed charges 19.84 30.4 Technical (Hospital) Services HC/HH Wch Supp Immobilizer Shdlr L__08144504 PX-2705000079 CDM 2705000079 LOCAL 270 RC inpatient 32 32 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES EPO [308136803] 25.34 percent of total billed charges 19.84 30.4 Technical (Hospital) Services HC/HH Wch Supp Immobilizer Shdlr L__08144504 PX-2705000079 CDM 2705000079 LOCAL 270 RC inpatient 32 32 HEALTHPARTNERS SX009 HEALTHPARTNERS 25.34 percent of total billed charges 19.84 30.4 Technical (Hospital) Services HC/HH Wch Supp Immobilizer Shdlr L__08144504 PX-2705000079 CDM 2705000079 LOCAL 270 RC inpatient 32 32 UNITED HEALTHCARE (COMMERCIAL) [3081199] UNITED HEALTHCARE 87726 [308119901] 19.84 percent of total billed charges 19.84 30.4 Technical (Hospital) Services HC/HH Wch Supp Immobilizer Shdlr L__08144504 PX-2705000079 CDM 2705000079 LOCAL 270 RC inpatient 32 32 MEDICA (COMMERCIAL) 94265 [3081118] MEDICA CLAIMS [308111801] 28.8 percent of total billed charges 19.84 30.4 Technical (Hospital) Services HC/HH Wch Supp Immobilizer Shdlr L__08144504 PX-2705000079 CDM 2705000079 LOCAL 270 RC inpatient 32 32 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES HDHP [308136802] 25.34 percent of total billed charges 19.84 30.4 Technical (Hospital) Services HC/HH Wch Supp Immobilizer Shdlr L__08144504 PX-2705000079 CDM 2705000079 LOCAL 270 RC inpatient 32 32 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES PPO [308136801] 25.34 percent of total billed charges 19.84 30.4 Technical (Hospital) Services HC/HH Wch Supp Immobilizer Shdlr L__08144504 PX-2705000079 CDM 2705000079 LOCAL 270 RC outpatient 32 32 MULTIPLAN INC 34080 [3081285] MULTIPLAN INC [308128501] 30.4 percent of total billed charges 19.84 30.4 Technical (Hospital) Services HC/HH Wch Supp Immobilizer Shdlr L__08144504 PX-2705000079 CDM 2705000079 LOCAL 270 RC outpatient 32 32 MEDICA (COMMERCIAL) 94265 [3081118] MEDICA CLAIMS [308111801] 28.8 percent of total billed charges 19.84 30.4 Technical (Hospital) Services HC/HH Wch Supp Holder Endotrach Tube__Pm 1110 PX-2705000078 CDM 2705000078 LOCAL 270 RC outpatient 18 18 MEDICA (COMMERCIAL) 94265 [3081118] MEDICA CLAIMS [308111801] 16.2 percent of total billed charges 11.16 17.1 Technical (Hospital) Services HC/HH Wch Supp Holder Endotrach Tube__Pm 1110 PX-2705000078 CDM 2705000078 LOCAL 270 RC outpatient 18 18 MULTIPLAN INC 34080 [3081285] MULTIPLAN INC [308128501] 17.1 percent of total billed charges 11.16 17.1 Technical (Hospital) Services HC/HH Wch Supp Holder Endotrach Tube__Pm 1110 PX-2705000078 CDM 2705000078 LOCAL 270 RC outpatient 18 18 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES HDHP [308136802] 14.4 percent of total billed charges 11.16 17.1 Technical (Hospital) Services HC/HH Wch Supp Holder Endotrach Tube__Pm 1110 PX-2705000078 CDM 2705000078 LOCAL 270 RC outpatient 18 18 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES EPO [308136803] 14.4 percent of total billed charges 11.16 17.1 Technical (Hospital) Services HC/HH Wch Supp Holder Endotrach Tube__Pm 1110 PX-2705000078 CDM 2705000078 LOCAL 270 RC outpatient 18 18 BLUE CROSS BLUE SHIELD WELLMARK SB889 [3081026] BCBS WYOMING [308102603] 17.1 percent of total billed charges 11.16 17.1 Technical (Hospital) Services HC/HH Wch Supp Holder Endotrach Tube__Pm 1110 PX-2705000078 CDM 2705000078 LOCAL 270 RC outpatient 18 18 CIGNA 62308 [3081051] CIGNA 62308 [308105105] 14.4 percent of total billed charges 11.16 17.1 Technical (Hospital) Services HC/HH Wch Supp Holder Endotrach Tube__Pm 1110 PX-2705000078 CDM 2705000078 LOCAL 270 RC outpatient 18 18 CIGNA 62308 [3081051] CIGNA STATE OF WYOMING [308105107] 14.4 percent of total billed charges 11.16 17.1 Technical (Hospital) Services HC/HH Wch Supp Holder Endotrach Tube__Pm 1110 PX-2705000078 CDM 2705000078 LOCAL 270 RC outpatient 18 18 UNITED HEALTHCARE (COMMERCIAL) [3081199] UNITED HEALTHCARE 87726 [308119901] 11.16 percent of total billed charges 11.16 17.1 Technical (Hospital) Services HC/HH Wch Supp Holder Endotrach Tube__Pm 1110 PX-2705000078 CDM 2705000078 LOCAL 270 RC outpatient 18 18 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES PPO [308136801] 14.4 percent of total billed charges 11.16 17.1 Technical (Hospital) Services HC/HH Wch Supp Holder Endotrach Tube__Pm 1110 PX-2705000078 CDM 2705000078 LOCAL 270 RC outpatient 18 18 HEALTHPARTNERS SX009 HEALTHPARTNERS 14.4 percent of total billed charges 11.16 17.1 Technical (Hospital) Services HC/HH Wch Supp Holder Endotrach Tube__Pm 1110 PX-2705000078 CDM 2705000078 LOCAL 270 RC inpatient 18 18 CIGNA 62308 [3081051] CIGNA 62308 [308105105] 14.25 percent of total billed charges 11.16 17.1 Technical (Hospital) Services HC/HH Wch Supp Holder Endotrach Tube__Pm 1110 PX-2705000078 CDM 2705000078 LOCAL 270 RC inpatient 18 18 CIGNA 62308 [3081051] CIGNA STATE OF WYOMING [308105107] 14.25 percent of total billed charges 11.16 17.1 Technical (Hospital) Services HC/HH Wch Supp Holder Endotrach Tube__Pm 1110 PX-2705000078 CDM 2705000078 LOCAL 270 RC inpatient 18 18 BLUE CROSS BLUE SHIELD WELLMARK SB889 [3081026] BCBS WYOMING [308102603] 17.1 percent of total billed charges 11.16 17.1 Technical (Hospital) Services HC/HH Wch Supp Holder Endotrach Tube__Pm 1110 PX-2705000078 CDM 2705000078 LOCAL 270 RC inpatient 18 18 MULTIPLAN INC 34080 [3081285] MULTIPLAN INC [308128501] 17.1 percent of total billed charges 11.16 17.1 Technical (Hospital) Services HC/HH Wch Supp Holder Endotrach Tube__Pm 1110 PX-2705000078 CDM 2705000078 LOCAL 270 RC inpatient 18 18 HEALTHPARTNERS SX009 HEALTHPARTNERS 14.25 percent of total billed charges 11.16 17.1 Technical (Hospital) Services HC/HH Wch Supp Holder Endotrach Tube__Pm 1110 PX-2705000078 CDM 2705000078 LOCAL 270 RC inpatient 18 18 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES EPO [308136803] 14.25 percent of total billed charges 11.16 17.1 Technical (Hospital) Services HC/HH Wch Supp Holder Endotrach Tube__Pm 1110 PX-2705000078 CDM 2705000078 LOCAL 270 RC inpatient 18 18 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES HDHP [308136802] 14.25 percent of total billed charges 11.16 17.1 Technical (Hospital) Services HC/HH Wch Supp Holder Endotrach Tube__Pm 1110 PX-2705000078 CDM 2705000078 LOCAL 270 RC inpatient 18 18 UNITED HEALTHCARE (COMMERCIAL) [3081199] UNITED HEALTHCARE 87726 [308119901] 11.16 percent of total billed charges 11.16 17.1 Technical (Hospital) Services HC/HH Wch Supp Holder Endotrach Tube__Pm 1110 PX-2705000078 CDM 2705000078 LOCAL 270 RC inpatient 18 18 MEDICA (COMMERCIAL) 94265 [3081118] MEDICA CLAIMS [308111801] 16.2 percent of total billed charges 11.16 17.1 Technical (Hospital) Services HC/HH Wch Supp Holder Endotrach Tube__Pm 1110 PX-2705000078 CDM 2705000078 LOCAL 270 RC inpatient 18 18 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES PPO [308136801] 14.25 percent of total billed charges 11.16 17.1 Technical (Hospital) Services HC/HH Wch Supp Gown Isolation__Nonth150 PX-2705000077 CDM 2705000077 LOCAL 270 RC outpatient 7 7 CIGNA 62308 [3081051] CIGNA 62308 [308105105] 5.6 percent of total billed charges 4.34 6.65 Technical (Hospital) Services HC/HH Wch Supp Gown Isolation__Nonth150 PX-2705000077 CDM 2705000077 LOCAL 270 RC outpatient 7 7 CIGNA 62308 [3081051] CIGNA STATE OF WYOMING [308105107] 5.6 percent of total billed charges 4.34 6.65 Technical (Hospital) Services HC/HH Wch Supp Gown Isolation__Nonth150 PX-2705000077 CDM 2705000077 LOCAL 270 RC outpatient 7 7 BLUE CROSS BLUE SHIELD WELLMARK SB889 [3081026] BCBS WYOMING [308102603] 6.65 percent of total billed charges 4.34 6.65 Technical (Hospital) Services HC/HH Wch Supp Gown Isolation__Nonth150 PX-2705000077 CDM 2705000077 LOCAL 270 RC outpatient 7 7 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES HDHP [308136802] 5.6 percent of total billed charges 4.34 6.65 Technical (Hospital) Services HC/HH Wch Supp Gown Isolation__Nonth150 PX-2705000077 CDM 2705000077 LOCAL 270 RC outpatient 7 7 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES EPO [308136803] 5.6 percent of total billed charges 4.34 6.65 Technical (Hospital) Services HC/HH Wch Supp Gown Isolation__Nonth150 PX-2705000077 CDM 2705000077 LOCAL 270 RC outpatient 7 7 HEALTHPARTNERS SX009 HEALTHPARTNERS 5.6 percent of total billed charges 4.34 6.65 Technical (Hospital) Services HC/HH Wch Supp Gown Isolation__Nonth150 PX-2705000077 CDM 2705000077 LOCAL 270 RC outpatient 7 7 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES PPO [308136801] 5.6 percent of total billed charges 4.34 6.65 Technical (Hospital) Services HC/HH Wch Supp Gown Isolation__Nonth150 PX-2705000077 CDM 2705000077 LOCAL 270 RC outpatient 7 7 UNITED HEALTHCARE (COMMERCIAL) [3081199] UNITED HEALTHCARE 87726 [308119901] 4.34 percent of total billed charges 4.34 6.65 Technical (Hospital) Services HC/HH Wch Supp Gown Isolation__Nonth150 PX-2705000077 CDM 2705000077 LOCAL 270 RC outpatient 7 7 MEDICA (COMMERCIAL) 94265 [3081118] MEDICA CLAIMS [308111801] 6.3 percent of total billed charges 4.34 6.65 Technical (Hospital) Services HC/HH Wch Supp Gown Isolation__Nonth150 PX-2705000077 CDM 2705000077 LOCAL 270 RC outpatient 7 7 MULTIPLAN INC 34080 [3081285] MULTIPLAN INC [308128501] 6.65 percent of total billed charges 4.34 6.65 Technical (Hospital) Services HC/HH Wch Supp Gown Isolation__Nonth150 PX-2705000077 CDM 2705000077 LOCAL 270 RC inpatient 7 7 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES PPO [308136801] 5.54 percent of total billed charges 4.34 6.65 Technical (Hospital) Services HC/HH Wch Supp Gown Isolation__Nonth150 PX-2705000077 CDM 2705000077 LOCAL 270 RC inpatient 7 7 MEDICA (COMMERCIAL) 94265 [3081118] MEDICA CLAIMS [308111801] 6.3 percent of total billed charges 4.34 6.65 Technical (Hospital) Services HC/HH Wch Supp Gown Isolation__Nonth150 PX-2705000077 CDM 2705000077 LOCAL 270 RC inpatient 7 7 UNITED HEALTHCARE (COMMERCIAL) [3081199] UNITED HEALTHCARE 87726 [308119901] 4.34 percent of total billed charges 4.34 6.65 Technical (Hospital) Services HC/HH Wch Supp Gown Isolation__Nonth150 PX-2705000077 CDM 2705000077 LOCAL 270 RC inpatient 7 7 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES HDHP [308136802] 5.54 percent of total billed charges 4.34 6.65 Technical (Hospital) Services HC/HH Wch Supp Gown Isolation__Nonth150 PX-2705000077 CDM 2705000077 LOCAL 270 RC inpatient 7 7 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES EPO [308136803] 5.54 percent of total billed charges 4.34 6.65 Technical (Hospital) Services HC/HH Wch Supp Gown Isolation__Nonth150 PX-2705000077 CDM 2705000077 LOCAL 270 RC inpatient 7 7 HEALTHPARTNERS SX009 HEALTHPARTNERS 5.54 percent of total billed charges 4.34 6.65 Technical (Hospital) Services HC/HH Wch Supp Gown Isolation__Nonth150 PX-2705000077 CDM 2705000077 LOCAL 270 RC inpatient 7 7 MULTIPLAN INC 34080 [3081285] MULTIPLAN INC [308128501] 6.65 percent of total billed charges 4.34 6.65 Technical (Hospital) Services HC/HH Wch Supp Gown Isolation__Nonth150 PX-2705000077 CDM 2705000077 LOCAL 270 RC inpatient 7 7 BLUE CROSS BLUE SHIELD WELLMARK SB889 [3081026] BCBS WYOMING [308102603] 6.65 percent of total billed charges 4.34 6.65 Technical (Hospital) Services HC/HH Wch Supp Gown Isolation__Nonth150 PX-2705000077 CDM 2705000077 LOCAL 270 RC inpatient 7 7 CIGNA 62308 [3081051] CIGNA 62308 [308105105] 5.54 percent of total billed charges 4.34 6.65 Technical (Hospital) Services HC/HH Wch Supp Gown Isolation__Nonth150 PX-2705000077 CDM 2705000077 LOCAL 270 RC inpatient 7 7 CIGNA 62308 [3081051] CIGNA STATE OF WYOMING [308105107] 5.54 percent of total billed charges 4.34 6.65 Technical (Hospital) Services HC/HH Wch Supp Gel Ankle Brace-Righ__E8020r PX-2705000076 CDM 2705000076 LOCAL 270 RC inpatient 102 102 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES PPO [308136801] 80.76 percent of total billed charges 63.24 96.9 Technical (Hospital) Services HC/HH Wch Supp Gel Ankle Brace-Righ__E8020r PX-2705000076 CDM 2705000076 LOCAL 270 RC inpatient 102 102 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES HDHP [308136802] 80.76 percent of total billed charges 63.24 96.9 Technical (Hospital) Services HC/HH Wch Supp Gel Ankle Brace-Righ__E8020r PX-2705000076 CDM 2705000076 LOCAL 270 RC inpatient 102 102 UNITED HEALTHCARE (COMMERCIAL) [3081199] UNITED HEALTHCARE 87726 [308119901] 63.24 percent of total billed charges 63.24 96.9 Technical (Hospital) Services HC/HH Wch Supp Gel Ankle Brace-Righ__E8020r PX-2705000076 CDM 2705000076 LOCAL 270 RC inpatient 102 102 MEDICA (COMMERCIAL) 94265 [3081118] MEDICA CLAIMS [308111801] 91.8 percent of total billed charges 63.24 96.9 Technical (Hospital) Services HC/HH Wch Supp Gel Ankle Brace-Righ__E8020r PX-2705000076 CDM 2705000076 LOCAL 270 RC inpatient 102 102 HEALTHPARTNERS SX009 HEALTHPARTNERS 80.76 percent of total billed charges 63.24 96.9 Technical (Hospital) Services HC/HH Wch Supp Gel Ankle Brace-Righ__E8020r PX-2705000076 CDM 2705000076 LOCAL 270 RC inpatient 102 102 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES EPO [308136803] 80.76 percent of total billed charges 63.24 96.9 Technical (Hospital) Services HC/HH Wch Supp Gel Ankle Brace-Righ__E8020r PX-2705000076 CDM 2705000076 LOCAL 270 RC inpatient 102 102 BLUE CROSS BLUE SHIELD WELLMARK SB889 [3081026] BCBS WYOMING [308102603] 96.9 percent of total billed charges 63.24 96.9 Technical (Hospital) Services HC/HH Wch Supp Gel Ankle Brace-Righ__E8020r PX-2705000076 CDM 2705000076 LOCAL 270 RC inpatient 102 102 MULTIPLAN INC 34080 [3081285] MULTIPLAN INC [308128501] 96.9 percent of total billed charges 63.24 96.9 Technical (Hospital) Services HC/HH Wch Supp Gel Ankle Brace-Righ__E8020r PX-2705000076 CDM 2705000076 LOCAL 270 RC inpatient 102 102 CIGNA 62308 [3081051] CIGNA 62308 [308105105] 80.76 percent of total billed charges 63.24 96.9 Technical (Hospital) Services HC/HH Wch Supp Gel Ankle Brace-Righ__E8020r PX-2705000076 CDM 2705000076 LOCAL 270 RC inpatient 102 102 CIGNA 62308 [3081051] CIGNA STATE OF WYOMING [308105107] 80.76 percent of total billed charges 63.24 96.9 Technical (Hospital) Services HC/HH Wch Supp Gel Ankle Brace-Righ__E8020r PX-2705000076 CDM 2705000076 LOCAL 270 RC outpatient 102 102 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES HDHP [308136802] 81.6 percent of total billed charges 63.24 96.9 Technical (Hospital) Services HC/HH Wch Supp Gel Ankle Brace-Righ__E8020r PX-2705000076 CDM 2705000076 LOCAL 270 RC outpatient 102 102 BLUE CROSS BLUE SHIELD WELLMARK SB889 [3081026] BCBS WYOMING [308102603] 96.9 percent of total billed charges 63.24 96.9 Technical (Hospital) Services HC/HH Wch Supp Gel Ankle Brace-Righ__E8020r PX-2705000076 CDM 2705000076 LOCAL 270 RC outpatient 102 102 CIGNA 62308 [3081051] CIGNA 62308 [308105105] 81.6 percent of total billed charges 63.24 96.9 Technical (Hospital) Services HC/HH Wch Supp Gel Ankle Brace-Righ__E8020r PX-2705000076 CDM 2705000076 LOCAL 270 RC outpatient 102 102 CIGNA 62308 [3081051] CIGNA STATE OF WYOMING [308105107] 81.6 percent of total billed charges 63.24 96.9 Technical (Hospital) Services HC/HH Wch Supp Gel Ankle Brace-Righ__E8020r PX-2705000076 CDM 2705000076 LOCAL 270 RC outpatient 102 102 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES EPO [308136803] 81.6 percent of total billed charges 63.24 96.9 Technical (Hospital) Services HC/HH Wch Supp Gel Ankle Brace-Righ__E8020r PX-2705000076 CDM 2705000076 LOCAL 270 RC outpatient 102 102 UNITED HEALTHCARE (COMMERCIAL) [3081199] UNITED HEALTHCARE 87726 [308119901] 63.24 percent of total billed charges 63.24 96.9 Technical (Hospital) Services HC/HH Wch Supp Gel Ankle Brace-Righ__E8020r PX-2705000076 CDM 2705000076 LOCAL 270 RC outpatient 102 102 HEALTHPARTNERS SX009 HEALTHPARTNERS 81.6 percent of total billed charges 63.24 96.9 Technical (Hospital) Services HC/HH Wch Supp Gel Ankle Brace-Righ__E8020r PX-2705000076 CDM 2705000076 LOCAL 270 RC outpatient 102 102 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES PPO [308136801] 81.6 percent of total billed charges 63.24 96.9 Technical (Hospital) Services HC/HH Wch Supp Gel Ankle Brace-Righ__E8020r PX-2705000076 CDM 2705000076 LOCAL 270 RC outpatient 102 102 MEDICA (COMMERCIAL) 94265 [3081118] MEDICA CLAIMS [308111801] 91.8 percent of total billed charges 63.24 96.9 Technical (Hospital) Services HC/HH Wch Supp Gel Ankle Brace-Righ__E8020r PX-2705000076 CDM 2705000076 LOCAL 270 RC outpatient 102 102 MULTIPLAN INC 34080 [3081285] MULTIPLAN INC [308128501] 96.9 percent of total billed charges 63.24 96.9 Technical (Hospital) Services HC/HH Wch Supp Gel Ankle Brace-Pony__E200pr PX-2705000075 CDM 2705000075 LOCAL 270 RC inpatient 56 56 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES HDHP [308136802] 44.34 percent of total billed charges 34.72 53.2 Technical (Hospital) Services HC/HH Wch Supp Gel Ankle Brace-Pony__E200pr PX-2705000075 CDM 2705000075 LOCAL 270 RC inpatient 56 56 MEDICA (COMMERCIAL) 94265 [3081118] MEDICA CLAIMS [308111801] 50.4 percent of total billed charges 34.72 53.2 Technical (Hospital) Services HC/HH Wch Supp Gel Ankle Brace-Pony__E200pr PX-2705000075 CDM 2705000075 LOCAL 270 RC inpatient 56 56 UNITED HEALTHCARE (COMMERCIAL) [3081199] UNITED HEALTHCARE 87726 [308119901] 34.72 percent of total billed charges 34.72 53.2 Technical (Hospital) Services HC/HH Wch Supp Gel Ankle Brace-Pony__E200pr PX-2705000075 CDM 2705000075 LOCAL 270 RC inpatient 56 56 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES PPO [308136801] 44.34 percent of total billed charges 34.72 53.2 Technical (Hospital) Services HC/HH Wch Supp Gel Ankle Brace-Pony__E200pr PX-2705000075 CDM 2705000075 LOCAL 270 RC inpatient 56 56 CIGNA 62308 [3081051] CIGNA 62308 [308105105] 44.34 percent of total billed charges 34.72 53.2 Technical (Hospital) Services HC/HH Wch Supp Gel Ankle Brace-Pony__E200pr PX-2705000075 CDM 2705000075 LOCAL 270 RC inpatient 56 56 CIGNA 62308 [3081051] CIGNA STATE OF WYOMING [308105107] 44.34 percent of total billed charges 34.72 53.2 Technical (Hospital) Services HC/HH Wch Supp Gel Ankle Brace-Pony__E200pr PX-2705000075 CDM 2705000075 LOCAL 270 RC inpatient 56 56 MULTIPLAN INC 34080 [3081285] MULTIPLAN INC [308128501] 53.2 percent of total billed charges 34.72 53.2 Technical (Hospital) Services HC/HH Wch Supp Gel Ankle Brace-Pony__E200pr PX-2705000075 CDM 2705000075 LOCAL 270 RC inpatient 56 56 BLUE CROSS BLUE SHIELD WELLMARK SB889 [3081026] BCBS WYOMING [308102603] 53.2 percent of total billed charges 34.72 53.2 Technical (Hospital) Services HC/HH Wch Supp Gel Ankle Brace-Pony__E200pr PX-2705000075 CDM 2705000075 LOCAL 270 RC inpatient 56 56 HEALTHPARTNERS SX009 HEALTHPARTNERS 44.34 percent of total billed charges 34.72 53.2 Technical (Hospital) Services HC/HH Wch Supp Gel Ankle Brace-Pony__E200pr PX-2705000075 CDM 2705000075 LOCAL 270 RC inpatient 56 56 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES EPO [308136803] 44.34 percent of total billed charges 34.72 53.2 Technical (Hospital) Services HC/HH Wch Supp Gel Ankle Brace-Pony__E200pr PX-2705000075 CDM 2705000075 LOCAL 270 RC outpatient 56 56 MEDICA (COMMERCIAL) 94265 [3081118] MEDICA CLAIMS [308111801] 50.4 percent of total billed charges 34.72 53.2 Technical (Hospital) Services HC/HH Wch Supp Gel Ankle Brace-Pony__E200pr PX-2705000075 CDM 2705000075 LOCAL 270 RC outpatient 56 56 MULTIPLAN INC 34080 [3081285] MULTIPLAN INC [308128501] 53.2 percent of total billed charges 34.72 53.2 Technical (Hospital) Services HC/HH Wch Supp Gel Ankle Brace-Pony__E200pr PX-2705000075 CDM 2705000075 LOCAL 270 RC outpatient 56 56 HEALTHPARTNERS SX009 HEALTHPARTNERS 44.8 percent of total billed charges 34.72 53.2 Technical (Hospital) Services HC/HH Wch Supp Gel Ankle Brace-Pony__E200pr PX-2705000075 CDM 2705000075 LOCAL 270 RC outpatient 56 56 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES PPO [308136801] 44.8 percent of total billed charges 34.72 53.2 Technical (Hospital) Services HC/HH Wch Supp Gel Ankle Brace-Pony__E200pr PX-2705000075 CDM 2705000075 LOCAL 270 RC outpatient 56 56 UNITED HEALTHCARE (COMMERCIAL) [3081199] UNITED HEALTHCARE 87726 [308119901] 34.72 percent of total billed charges 34.72 53.2 Technical (Hospital) Services HC/HH Wch Supp Gel Ankle Brace-Pony__E200pr PX-2705000075 CDM 2705000075 LOCAL 270 RC outpatient 56 56 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES EPO [308136803] 44.8 percent of total billed charges 34.72 53.2 Technical (Hospital) Services HC/HH Wch Supp Gel Ankle Brace-Pony__E200pr PX-2705000075 CDM 2705000075 LOCAL 270 RC outpatient 56 56 CIGNA 62308 [3081051] CIGNA 62308 [308105105] 44.8 percent of total billed charges 34.72 53.2 Technical (Hospital) Services HC/HH Wch Supp Gel Ankle Brace-Pony__E200pr PX-2705000075 CDM 2705000075 LOCAL 270 RC outpatient 56 56 CIGNA 62308 [3081051] CIGNA STATE OF WYOMING [308105107] 44.8 percent of total billed charges 34.72 53.2 Technical (Hospital) Services HC/HH Wch Supp Gel Ankle Brace-Pony__E200pr PX-2705000075 CDM 2705000075 LOCAL 270 RC outpatient 56 56 BLUE CROSS BLUE SHIELD WELLMARK SB889 [3081026] BCBS WYOMING [308102603] 53.2 percent of total billed charges 34.72 53.2 Technical (Hospital) Services HC/HH Wch Supp Gel Ankle Brace-Pony__E200pr PX-2705000075 CDM 2705000075 LOCAL 270 RC outpatient 56 56 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES HDHP [308136802] 44.8 percent of total billed charges 34.72 53.2 Technical (Hospital) Services HC/HH Wch Supp Gel Ankle Brace-Left__E8020l PX-2705000074 CDM 2705000074 LOCAL 270 RC inpatient 102 102 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES EPO [308136803] 80.76 percent of total billed charges 63.24 96.9 Technical (Hospital) Services HC/HH Wch Supp Gel Ankle Brace-Left__E8020l PX-2705000074 CDM 2705000074 LOCAL 270 RC inpatient 102 102 HEALTHPARTNERS SX009 HEALTHPARTNERS 80.76 percent of total billed charges 63.24 96.9 Technical (Hospital) Services HC/HH Wch Supp Gel Ankle Brace-Left__E8020l PX-2705000074 CDM 2705000074 LOCAL 270 RC inpatient 102 102 BLUE CROSS BLUE SHIELD WELLMARK SB889 [3081026] BCBS WYOMING [308102603] 96.9 percent of total billed charges 63.24 96.9 Technical (Hospital) Services HC/HH Wch Supp Gel Ankle Brace-Left__E8020l PX-2705000074 CDM 2705000074 LOCAL 270 RC inpatient 102 102 MULTIPLAN INC 34080 [3081285] MULTIPLAN INC [308128501] 96.9 percent of total billed charges 63.24 96.9 Technical (Hospital) Services HC/HH Wch Supp Gel Ankle Brace-Left__E8020l PX-2705000074 CDM 2705000074 LOCAL 270 RC inpatient 102 102 CIGNA 62308 [3081051] CIGNA 62308 [308105105] 80.76 percent of total billed charges 63.24 96.9 Technical (Hospital) Services HC/HH Wch Supp Gel Ankle Brace-Left__E8020l PX-2705000074 CDM 2705000074 LOCAL 270 RC inpatient 102 102 CIGNA 62308 [3081051] CIGNA STATE OF WYOMING [308105107] 80.76 percent of total billed charges 63.24 96.9 Technical (Hospital) Services HC/HH Wch Supp Gel Ankle Brace-Left__E8020l PX-2705000074 CDM 2705000074 LOCAL 270 RC inpatient 102 102 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES PPO [308136801] 80.76 percent of total billed charges 63.24 96.9 Technical (Hospital) Services HC/HH Wch Supp Gel Ankle Brace-Left__E8020l PX-2705000074 CDM 2705000074 LOCAL 270 RC inpatient 102 102 UNITED HEALTHCARE (COMMERCIAL) [3081199] UNITED HEALTHCARE 87726 [308119901] 63.24 percent of total billed charges 63.24 96.9 Technical (Hospital) Services HC/HH Wch Supp Gel Ankle Brace-Left__E8020l PX-2705000074 CDM 2705000074 LOCAL 270 RC inpatient 102 102 MEDICA (COMMERCIAL) 94265 [3081118] MEDICA CLAIMS [308111801] 91.8 percent of total billed charges 63.24 96.9 Technical (Hospital) Services HC/HH Wch Supp Gel Ankle Brace-Left__E8020l PX-2705000074 CDM 2705000074 LOCAL 270 RC inpatient 102 102 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES HDHP [308136802] 80.76 percent of total billed charges 63.24 96.9 Technical (Hospital) Services HC/HH Wch Supp Gel Ankle Brace-Left__E8020l PX-2705000074 CDM 2705000074 LOCAL 270 RC outpatient 102 102 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES HDHP [308136802] 81.6 percent of total billed charges 63.24 96.9 Technical (Hospital) Services HC/HH Wch Supp Gel Ankle Brace-Left__E8020l PX-2705000074 CDM 2705000074 LOCAL 270 RC outpatient 102 102 CIGNA 62308 [3081051] CIGNA 62308 [308105105] 81.6 percent of total billed charges 63.24 96.9 Technical (Hospital) Services HC/HH Wch Supp Gel Ankle Brace-Left__E8020l PX-2705000074 CDM 2705000074 LOCAL 270 RC outpatient 102 102 BLUE CROSS BLUE SHIELD WELLMARK SB889 [3081026] BCBS WYOMING [308102603] 96.9 percent of total billed charges 63.24 96.9 Technical (Hospital) Services HC/HH Wch Supp Gel Ankle Brace-Left__E8020l PX-2705000074 CDM 2705000074 LOCAL 270 RC outpatient 102 102 CIGNA 62308 [3081051] CIGNA STATE OF WYOMING [308105107] 81.6 percent of total billed charges 63.24 96.9 Technical (Hospital) Services HC/HH Wch Supp Gel Ankle Brace-Left__E8020l PX-2705000074 CDM 2705000074 LOCAL 270 RC outpatient 102 102 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES EPO [308136803] 81.6 percent of total billed charges 63.24 96.9 Technical (Hospital) Services HC/HH Wch Supp Gel Ankle Brace-Left__E8020l PX-2705000074 CDM 2705000074 LOCAL 270 RC outpatient 102 102 UNITED HEALTHCARE (COMMERCIAL) [3081199] UNITED HEALTHCARE 87726 [308119901] 63.24 percent of total billed charges 63.24 96.9 Technical (Hospital) Services HC/HH Wch Supp Gel Ankle Brace-Left__E8020l PX-2705000074 CDM 2705000074 LOCAL 270 RC outpatient 102 102 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES PPO [308136801] 81.6 percent of total billed charges 63.24 96.9 Technical (Hospital) Services HC/HH Wch Supp Gel Ankle Brace-Left__E8020l PX-2705000074 CDM 2705000074 LOCAL 270 RC outpatient 102 102 HEALTHPARTNERS SX009 HEALTHPARTNERS 81.6 percent of total billed charges 63.24 96.9 Technical (Hospital) Services HC/HH Wch Supp Gel Ankle Brace-Left__E8020l PX-2705000074 CDM 2705000074 LOCAL 270 RC outpatient 102 102 MULTIPLAN INC 34080 [3081285] MULTIPLAN INC [308128501] 96.9 percent of total billed charges 63.24 96.9 Technical (Hospital) Services HC/HH Wch Supp Gel Ankle Brace-Left__E8020l PX-2705000074 CDM 2705000074 LOCAL 270 RC outpatient 102 102 MEDICA (COMMERCIAL) 94265 [3081118] MEDICA CLAIMS [308111801] 91.8 percent of total billed charges 63.24 96.9 Technical (Hospital) Services HC/HH Wch Supp Fingher/Thumb Splint__510717 PX-2705000073 CDM 2705000073 LOCAL 270 RC outpatient 47 47 HEALTHPARTNERS SX009 HEALTHPARTNERS 37.6 percent of total billed charges 29.14 44.65 Technical (Hospital) Services HC/HH Wch Supp Fingher/Thumb Splint__510717 PX-2705000073 CDM 2705000073 LOCAL 270 RC outpatient 47 47 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES PPO [308136801] 37.6 percent of total billed charges 29.14 44.65 Technical (Hospital) Services HC/HH Wch Supp Fingher/Thumb Splint__510717 PX-2705000073 CDM 2705000073 LOCAL 270 RC outpatient 47 47 UNITED HEALTHCARE (COMMERCIAL) [3081199] UNITED HEALTHCARE 87726 [308119901] 29.14 percent of total billed charges 29.14 44.65 Technical (Hospital) Services HC/HH Wch Supp Fingher/Thumb Splint__510717 PX-2705000073 CDM 2705000073 LOCAL 270 RC outpatient 47 47 CIGNA 62308 [3081051] CIGNA 62308 [308105105] 37.6 percent of total billed charges 29.14 44.65 Technical (Hospital) Services HC/HH Wch Supp Fingher/Thumb Splint__510717 PX-2705000073 CDM 2705000073 LOCAL 270 RC outpatient 47 47 CIGNA 62308 [3081051] CIGNA STATE OF WYOMING [308105107] 37.6 percent of total billed charges 29.14 44.65 Technical (Hospital) Services HC/HH Wch Supp Fingher/Thumb Splint__510717 PX-2705000073 CDM 2705000073 LOCAL 270 RC outpatient 47 47 BLUE CROSS BLUE SHIELD WELLMARK SB889 [3081026] BCBS WYOMING [308102603] 44.65 percent of total billed charges 29.14 44.65 Technical (Hospital) Services HC/HH Wch Supp Fingher/Thumb Splint__510717 PX-2705000073 CDM 2705000073 LOCAL 270 RC outpatient 47 47 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES EPO [308136803] 37.6 percent of total billed charges 29.14 44.65 Technical (Hospital) Services HC/HH Wch Supp Fingher/Thumb Splint__510717 PX-2705000073 CDM 2705000073 LOCAL 270 RC outpatient 47 47 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES HDHP [308136802] 37.6 percent of total billed charges 29.14 44.65 Technical (Hospital) Services HC/HH Wch Supp Fingher/Thumb Splint__510717 PX-2705000073 CDM 2705000073 LOCAL 270 RC outpatient 47 47 MEDICA (COMMERCIAL) 94265 [3081118] MEDICA CLAIMS [308111801] 42.3 percent of total billed charges 29.14 44.65 Technical (Hospital) Services HC/HH Wch Supp Fingher/Thumb Splint__510717 PX-2705000073 CDM 2705000073 LOCAL 270 RC outpatient 47 47 MULTIPLAN INC 34080 [3081285] MULTIPLAN INC [308128501] 44.65 percent of total billed charges 29.14 44.65 Technical (Hospital) Services HC/HH Wch Supp Fingher/Thumb Splint__510717 PX-2705000073 CDM 2705000073 LOCAL 270 RC inpatient 47 47 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES PPO [308136801] 37.21 percent of total billed charges 29.14 44.65 Technical (Hospital) Services HC/HH Wch Supp Fingher/Thumb Splint__510717 PX-2705000073 CDM 2705000073 LOCAL 270 RC inpatient 47 47 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES HDHP [308136802] 37.21 percent of total billed charges 29.14 44.65 Technical (Hospital) Services HC/HH Wch Supp Fingher/Thumb Splint__510717 PX-2705000073 CDM 2705000073 LOCAL 270 RC inpatient 47 47 UNITED HEALTHCARE (COMMERCIAL) [3081199] UNITED HEALTHCARE 87726 [308119901] 29.14 percent of total billed charges 29.14 44.65 Technical (Hospital) Services HC/HH Wch Supp Fingher/Thumb Splint__510717 PX-2705000073 CDM 2705000073 LOCAL 270 RC inpatient 47 47 MEDICA (COMMERCIAL) 94265 [3081118] MEDICA CLAIMS [308111801] 42.3 percent of total billed charges 29.14 44.65 Technical (Hospital) Services HC/HH Wch Supp Fingher/Thumb Splint__510717 PX-2705000073 CDM 2705000073 LOCAL 270 RC inpatient 47 47 BLUE CROSS BLUE SHIELD WELLMARK SB889 [3081026] BCBS WYOMING [308102603] 44.65 percent of total billed charges 29.14 44.65 Technical (Hospital) Services HC/HH Wch Supp Fingher/Thumb Splint__510717 PX-2705000073 CDM 2705000073 LOCAL 270 RC inpatient 47 47 MULTIPLAN INC 34080 [3081285] MULTIPLAN INC [308128501] 44.65 percent of total billed charges 29.14 44.65 Technical (Hospital) Services HC/HH Wch Supp Fingher/Thumb Splint__510717 PX-2705000073 CDM 2705000073 LOCAL 270 RC inpatient 47 47 CIGNA 62308 [3081051] CIGNA 62308 [308105105] 37.21 percent of total billed charges 29.14 44.65 Technical (Hospital) Services HC/HH Wch Supp Fingher/Thumb Splint__510717 PX-2705000073 CDM 2705000073 LOCAL 270 RC inpatient 47 47 CIGNA 62308 [3081051] CIGNA STATE OF WYOMING [308105107] 37.21 percent of total billed charges 29.14 44.65 Technical (Hospital) Services HC/HH Wch Supp Fingher/Thumb Splint__510717 PX-2705000073 CDM 2705000073 LOCAL 270 RC inpatient 47 47 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES EPO [308136803] 37.21 percent of total billed charges 29.14 44.65 Technical (Hospital) Services HC/HH Wch Supp Fingher/Thumb Splint__510717 PX-2705000073 CDM 2705000073 LOCAL 270 RC inpatient 47 47 HEALTHPARTNERS SX009 HEALTHPARTNERS 37.21 percent of total billed charges 29.14 44.65 Technical (Hospital) Services HC/HH Wch Supp Fingersplint/Abducti__510718 PX-2705000072 CDM 2705000072 LOCAL 270 RC inpatient 47 47 BLUE CROSS BLUE SHIELD WELLMARK SB889 [3081026] BCBS WYOMING [308102603] 44.65 percent of total billed charges 29.14 44.65 Technical (Hospital) Services HC/HH Wch Supp Fingersplint/Abducti__510718 PX-2705000072 CDM 2705000072 LOCAL 270 RC inpatient 47 47 MULTIPLAN INC 34080 [3081285] MULTIPLAN INC [308128501] 44.65 percent of total billed charges 29.14 44.65 Technical (Hospital) Services HC/HH Wch Supp Fingersplint/Abducti__510718 PX-2705000072 CDM 2705000072 LOCAL 270 RC inpatient 47 47 CIGNA 62308 [3081051] CIGNA 62308 [308105105] 37.21 percent of total billed charges 29.14 44.65 Technical (Hospital) Services HC/HH Wch Supp Fingersplint/Abducti__510718 PX-2705000072 CDM 2705000072 LOCAL 270 RC inpatient 47 47 CIGNA 62308 [3081051] CIGNA STATE OF WYOMING [308105107] 37.21 percent of total billed charges 29.14 44.65 Technical (Hospital) Services HC/HH Wch Supp Fingersplint/Abducti__510718 PX-2705000072 CDM 2705000072 LOCAL 270 RC inpatient 47 47 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES EPO [308136803] 37.21 percent of total billed charges 29.14 44.65 Technical (Hospital) Services HC/HH Wch Supp Fingersplint/Abducti__510718 PX-2705000072 CDM 2705000072 LOCAL 270 RC inpatient 47 47 HEALTHPARTNERS SX009 HEALTHPARTNERS 37.21 percent of total billed charges 29.14 44.65 Technical (Hospital) Services HC/HH Wch Supp Fingersplint/Abducti__510718 PX-2705000072 CDM 2705000072 LOCAL 270 RC inpatient 47 47 UNITED HEALTHCARE (COMMERCIAL) [3081199] UNITED HEALTHCARE 87726 [308119901] 29.14 percent of total billed charges 29.14 44.65 Technical (Hospital) Services HC/HH Wch Supp Fingersplint/Abducti__510718 PX-2705000072 CDM 2705000072 LOCAL 270 RC inpatient 47 47 MEDICA (COMMERCIAL) 94265 [3081118] MEDICA CLAIMS [308111801] 42.3 percent of total billed charges 29.14 44.65 Technical (Hospital) Services HC/HH Wch Supp Fingersplint/Abducti__510718 PX-2705000072 CDM 2705000072 LOCAL 270 RC inpatient 47 47 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES HDHP [308136802] 37.21 percent of total billed charges 29.14 44.65 Technical (Hospital) Services HC/HH Wch Supp Fingersplint/Abducti__510718 PX-2705000072 CDM 2705000072 LOCAL 270 RC inpatient 47 47 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES PPO [308136801] 37.21 percent of total billed charges 29.14 44.65 Technical (Hospital) Services HC/HH Wch Supp Fingersplint/Abducti__510718 PX-2705000072 CDM 2705000072 LOCAL 270 RC outpatient 47 47 HEALTHPARTNERS SX009 HEALTHPARTNERS 37.6 percent of total billed charges 29.14 44.65 Technical (Hospital) Services HC/HH Wch Supp Fingersplint/Abducti__510718 PX-2705000072 CDM 2705000072 LOCAL 270 RC outpatient 47 47 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES PPO [308136801] 37.6 percent of total billed charges 29.14 44.65 Technical (Hospital) Services HC/HH Wch Supp Fingersplint/Abducti__510718 PX-2705000072 CDM 2705000072 LOCAL 270 RC outpatient 47 47 MEDICA (COMMERCIAL) 94265 [3081118] MEDICA CLAIMS [308111801] 42.3 percent of total billed charges 29.14 44.65 Technical (Hospital) Services HC/HH Wch Supp Fingersplint/Abducti__510718 PX-2705000072 CDM 2705000072 LOCAL 270 RC outpatient 47 47 MULTIPLAN INC 34080 [3081285] MULTIPLAN INC [308128501] 44.65 percent of total billed charges 29.14 44.65 Technical (Hospital) Services HC/HH Wch Supp Fingersplint/Abducti__510718 PX-2705000072 CDM 2705000072 LOCAL 270 RC outpatient 47 47 UNITED HEALTHCARE (COMMERCIAL) [3081199] UNITED HEALTHCARE 87726 [308119901] 29.14 percent of total billed charges 29.14 44.65 Technical (Hospital) Services HC/HH Wch Supp Fingersplint/Abducti__510718 PX-2705000072 CDM 2705000072 LOCAL 270 RC outpatient 47 47 BLUE CROSS BLUE SHIELD WELLMARK SB889 [3081026] BCBS WYOMING [308102603] 44.65 percent of total billed charges 29.14 44.65 Technical (Hospital) Services HC/HH Wch Supp Fingersplint/Abducti__510718 PX-2705000072 CDM 2705000072 LOCAL 270 RC outpatient 47 47 CIGNA 62308 [3081051] CIGNA 62308 [308105105] 37.6 percent of total billed charges 29.14 44.65 Technical (Hospital) Services HC/HH Wch Supp Fingersplint/Abducti__510718 PX-2705000072 CDM 2705000072 LOCAL 270 RC outpatient 47 47 CIGNA 62308 [3081051] CIGNA STATE OF WYOMING [308105107] 37.6 percent of total billed charges 29.14 44.65 Technical (Hospital) Services HC/HH Wch Supp Fingersplint/Abducti__510718 PX-2705000072 CDM 2705000072 LOCAL 270 RC outpatient 47 47 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES EPO [308136803] 37.6 percent of total billed charges 29.14 44.65 Technical (Hospital) Services HC/HH Wch Supp Fingersplint/Abducti__510718 PX-2705000072 CDM 2705000072 LOCAL 270 RC outpatient 47 47 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES HDHP [308136802] 37.6 percent of total billed charges 29.14 44.65 Technical (Hospital) Services HC/HH Wch Supp Finger/Thumb Splint__510719 PX-2705000071 CDM 2705000071 LOCAL 270 RC outpatient 47 47 MULTIPLAN INC 34080 [3081285] MULTIPLAN INC [308128501] 44.65 percent of total billed charges 29.14 44.65 Technical (Hospital) Services HC/HH Wch Supp Finger/Thumb Splint__510719 PX-2705000071 CDM 2705000071 LOCAL 270 RC outpatient 47 47 MEDICA (COMMERCIAL) 94265 [3081118] MEDICA CLAIMS [308111801] 42.3 percent of total billed charges 29.14 44.65 Technical (Hospital) Services HC/HH Wch Supp Finger/Thumb Splint__510719 PX-2705000071 CDM 2705000071 LOCAL 270 RC outpatient 47 47 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES PPO [308136801] 37.6 percent of total billed charges 29.14 44.65 Technical (Hospital) Services HC/HH Wch Supp Finger/Thumb Splint__510719 PX-2705000071 CDM 2705000071 LOCAL 270 RC outpatient 47 47 HEALTHPARTNERS SX009 HEALTHPARTNERS 37.6 percent of total billed charges 29.14 44.65 Technical (Hospital) Services HC/HH Wch Supp Finger/Thumb Splint__510719 PX-2705000071 CDM 2705000071 LOCAL 270 RC outpatient 47 47 UNITED HEALTHCARE (COMMERCIAL) [3081199] UNITED HEALTHCARE 87726 [308119901] 29.14 percent of total billed charges 29.14 44.65 Technical (Hospital) Services HC/HH Wch Supp Finger/Thumb Splint__510719 PX-2705000071 CDM 2705000071 LOCAL 270 RC outpatient 47 47 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES EPO [308136803] 37.6 percent of total billed charges 29.14 44.65 Technical (Hospital) Services HC/HH Wch Supp Finger/Thumb Splint__510719 PX-2705000071 CDM 2705000071 LOCAL 270 RC outpatient 47 47 CIGNA 62308 [3081051] CIGNA 62308 [308105105] 37.6 percent of total billed charges 29.14 44.65 Technical (Hospital) Services HC/HH Wch Supp Finger/Thumb Splint__510719 PX-2705000071 CDM 2705000071 LOCAL 270 RC outpatient 47 47 CIGNA 62308 [3081051] CIGNA STATE OF WYOMING [308105107] 37.6 percent of total billed charges 29.14 44.65 Technical (Hospital) Services HC/HH Wch Supp Finger/Thumb Splint__510719 PX-2705000071 CDM 2705000071 LOCAL 270 RC outpatient 47 47 BLUE CROSS BLUE SHIELD WELLMARK SB889 [3081026] BCBS WYOMING [308102603] 44.65 percent of total billed charges 29.14 44.65 Technical (Hospital) Services HC/HH Wch Supp Finger/Thumb Splint__510719 PX-2705000071 CDM 2705000071 LOCAL 270 RC outpatient 47 47 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES HDHP [308136802] 37.6 percent of total billed charges 29.14 44.65 Technical (Hospital) Services HC/HH Wch Supp Finger/Thumb Splint__510719 PX-2705000071 CDM 2705000071 LOCAL 270 RC inpatient 47 47 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES HDHP [308136802] 37.21 percent of total billed charges 29.14 44.65 Technical (Hospital) Services HC/HH Wch Supp Finger/Thumb Splint__510719 PX-2705000071 CDM 2705000071 LOCAL 270 RC inpatient 47 47 UNITED HEALTHCARE (COMMERCIAL) [3081199] UNITED HEALTHCARE 87726 [308119901] 29.14 percent of total billed charges 29.14 44.65 Technical (Hospital) Services HC/HH Wch Supp Finger/Thumb Splint__510719 PX-2705000071 CDM 2705000071 LOCAL 270 RC inpatient 47 47 MEDICA (COMMERCIAL) 94265 [3081118] MEDICA CLAIMS [308111801] 42.3 percent of total billed charges 29.14 44.65 Technical (Hospital) Services HC/HH Wch Supp Finger/Thumb Splint__510719 PX-2705000071 CDM 2705000071 LOCAL 270 RC inpatient 47 47 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES PPO [308136801] 37.21 percent of total billed charges 29.14 44.65 Technical (Hospital) Services HC/HH Wch Supp Finger/Thumb Splint__510719 PX-2705000071 CDM 2705000071 LOCAL 270 RC inpatient 47 47 CIGNA 62308 [3081051] CIGNA 62308 [308105105] 37.21 percent of total billed charges 29.14 44.65 Technical (Hospital) Services HC/HH Wch Supp Finger/Thumb Splint__510719 PX-2705000071 CDM 2705000071 LOCAL 270 RC inpatient 47 47 CIGNA 62308 [3081051] CIGNA STATE OF WYOMING [308105107] 37.21 percent of total billed charges 29.14 44.65 Technical (Hospital) Services HC/HH Wch Supp Finger/Thumb Splint__510719 PX-2705000071 CDM 2705000071 LOCAL 270 RC inpatient 47 47 MULTIPLAN INC 34080 [3081285] MULTIPLAN INC [308128501] 44.65 percent of total billed charges 29.14 44.65 Technical (Hospital) Services HC/HH Wch Supp Finger/Thumb Splint__510719 PX-2705000071 CDM 2705000071 LOCAL 270 RC inpatient 47 47 BLUE CROSS BLUE SHIELD WELLMARK SB889 [3081026] BCBS WYOMING [308102603] 44.65 percent of total billed charges 29.14 44.65 Technical (Hospital) Services HC/HH Wch Supp Finger/Thumb Splint__510719 PX-2705000071 CDM 2705000071 LOCAL 270 RC inpatient 47 47 HEALTHPARTNERS SX009 HEALTHPARTNERS 37.21 percent of total billed charges 29.14 44.65 Technical (Hospital) Services HC/HH Wch Supp Finger/Thumb Splint__510719 PX-2705000071 CDM 2705000071 LOCAL 270 RC inpatient 47 47 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES EPO [308136803] 37.21 percent of total billed charges 29.14 44.65 Technical (Hospital) Services "HC/HH Wch Supp Finger Cot-Xsm 1__71902""" PX-2705000070 CDM 2705000070 LOCAL 270 RC outpatient 8 8 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES EPO [308136803] 6.4 percent of total billed charges 4.96 7.6 Technical (Hospital) Services "HC/HH Wch Supp Finger Cot-Xsm 1__71902""" PX-2705000070 CDM 2705000070 LOCAL 270 RC outpatient 8 8 BLUE CROSS BLUE SHIELD WELLMARK SB889 [3081026] BCBS WYOMING [308102603] 7.6 percent of total billed charges 4.96 7.6 Technical (Hospital) Services "HC/HH Wch Supp Finger Cot-Xsm 1__71902""" PX-2705000070 CDM 2705000070 LOCAL 270 RC outpatient 8 8 CIGNA 62308 [3081051] CIGNA 62308 [308105105] 6.4 percent of total billed charges 4.96 7.6 Technical (Hospital) Services "HC/HH Wch Supp Finger Cot-Xsm 1__71902""" PX-2705000070 CDM 2705000070 LOCAL 270 RC outpatient 8 8 CIGNA 62308 [3081051] CIGNA STATE OF WYOMING [308105107] 6.4 percent of total billed charges 4.96 7.6 Technical (Hospital) Services "HC/HH Wch Supp Finger Cot-Xsm 1__71902""" PX-2705000070 CDM 2705000070 LOCAL 270 RC outpatient 8 8 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES HDHP [308136802] 6.4 percent of total billed charges 4.96 7.6 Technical (Hospital) Services "HC/HH Wch Supp Finger Cot-Xsm 1__71902""" PX-2705000070 CDM 2705000070 LOCAL 270 RC outpatient 8 8 UNITED HEALTHCARE (COMMERCIAL) [3081199] UNITED HEALTHCARE 87726 [308119901] 4.96 percent of total billed charges 4.96 7.6 Technical (Hospital) Services "HC/HH Wch Supp Finger Cot-Xsm 1__71902""" PX-2705000070 CDM 2705000070 LOCAL 270 RC outpatient 8 8 HEALTHPARTNERS SX009 HEALTHPARTNERS 6.4 percent of total billed charges 4.96 7.6 Technical (Hospital) Services "HC/HH Wch Supp Finger Cot-Xsm 1__71902""" PX-2705000070 CDM 2705000070 LOCAL 270 RC outpatient 8 8 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES PPO [308136801] 6.4 percent of total billed charges 4.96 7.6 Technical (Hospital) Services "HC/HH Wch Supp Finger Cot-Xsm 1__71902""" PX-2705000070 CDM 2705000070 LOCAL 270 RC outpatient 8 8 MULTIPLAN INC 34080 [3081285] MULTIPLAN INC [308128501] 7.6 percent of total billed charges 4.96 7.6 Technical (Hospital) Services "HC/HH Wch Supp Finger Cot-Xsm 1__71902""" PX-2705000070 CDM 2705000070 LOCAL 270 RC outpatient 8 8 MEDICA (COMMERCIAL) 94265 [3081118] MEDICA CLAIMS [308111801] 7.2 percent of total billed charges 4.96 7.6 Technical (Hospital) Services "HC/HH Wch Supp Finger Cot-Xsm 1__71902""" PX-2705000070 CDM 2705000070 LOCAL 270 RC inpatient 8 8 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES EPO [308136803] 6.33 percent of total billed charges 4.96 7.6 Technical (Hospital) Services "HC/HH Wch Supp Finger Cot-Xsm 1__71902""" PX-2705000070 CDM 2705000070 LOCAL 270 RC inpatient 8 8 HEALTHPARTNERS SX009 HEALTHPARTNERS 6.33 percent of total billed charges 4.96 7.6 Technical (Hospital) Services "HC/HH Wch Supp Finger Cot-Xsm 1__71902""" PX-2705000070 CDM 2705000070 LOCAL 270 RC inpatient 8 8 BLUE CROSS BLUE SHIELD WELLMARK SB889 [3081026] BCBS WYOMING [308102603] 7.6 percent of total billed charges 4.96 7.6 Technical (Hospital) Services "HC/HH Wch Supp Finger Cot-Xsm 1__71902""" PX-2705000070 CDM 2705000070 LOCAL 270 RC inpatient 8 8 MULTIPLAN INC 34080 [3081285] MULTIPLAN INC [308128501] 7.6 percent of total billed charges 4.96 7.6 Technical (Hospital) Services "HC/HH Wch Supp Finger Cot-Xsm 1__71902""" PX-2705000070 CDM 2705000070 LOCAL 270 RC inpatient 8 8 CIGNA 62308 [3081051] CIGNA 62308 [308105105] 6.33 percent of total billed charges 4.96 7.6 Technical (Hospital) Services "HC/HH Wch Supp Finger Cot-Xsm 1__71902""" PX-2705000070 CDM 2705000070 LOCAL 270 RC inpatient 8 8 CIGNA 62308 [3081051] CIGNA STATE OF WYOMING [308105107] 6.33 percent of total billed charges 4.96 7.6 Technical (Hospital) Services "HC/HH Wch Supp Finger Cot-Xsm 1__71902""" PX-2705000070 CDM 2705000070 LOCAL 270 RC inpatient 8 8 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES PPO [308136801] 6.33 percent of total billed charges 4.96 7.6 Technical (Hospital) Services "HC/HH Wch Supp Finger Cot-Xsm 1__71902""" PX-2705000070 CDM 2705000070 LOCAL 270 RC inpatient 8 8 MEDICA (COMMERCIAL) 94265 [3081118] MEDICA CLAIMS [308111801] 7.2 percent of total billed charges 4.96 7.6 Technical (Hospital) Services "HC/HH Wch Supp Finger Cot-Xsm 1__71902""" PX-2705000070 CDM 2705000070 LOCAL 270 RC inpatient 8 8 UNITED HEALTHCARE (COMMERCIAL) [3081199] UNITED HEALTHCARE 87726 [308119901] 4.96 percent of total billed charges 4.96 7.6 Technical (Hospital) Services "HC/HH Wch Supp Finger Cot-Xsm 1__71902""" PX-2705000070 CDM 2705000070 LOCAL 270 RC inpatient 8 8 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES HDHP [308136802] 6.33 percent of total billed charges 4.96 7.6 Technical (Hospital) Services "HC/HH Wch Supp Finger Cot-Sml 1.5*__71903""" PX-2705000069 CDM 2705000069 LOCAL 270 RC inpatient 8 8 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES PPO [308136801] 6.33 percent of total billed charges 4.96 7.6 Technical (Hospital) Services "HC/HH Wch Supp Finger Cot-Sml 1.5*__71903""" PX-2705000069 CDM 2705000069 LOCAL 270 RC inpatient 8 8 MEDICA (COMMERCIAL) 94265 [3081118] MEDICA CLAIMS [308111801] 7.2 percent of total billed charges 4.96 7.6 Technical (Hospital) Services "HC/HH Wch Supp Finger Cot-Sml 1.5*__71903""" PX-2705000069 CDM 2705000069 LOCAL 270 RC inpatient 8 8 UNITED HEALTHCARE (COMMERCIAL) [3081199] UNITED HEALTHCARE 87726 [308119901] 4.96 percent of total billed charges 4.96 7.6 Technical (Hospital) Services "HC/HH Wch Supp Finger Cot-Sml 1.5*__71903""" PX-2705000069 CDM 2705000069 LOCAL 270 RC inpatient 8 8 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES HDHP [308136802] 6.33 percent of total billed charges 4.96 7.6 Technical (Hospital) Services "HC/HH Wch Supp Finger Cot-Sml 1.5*__71903""" PX-2705000069 CDM 2705000069 LOCAL 270 RC inpatient 8 8 HEALTHPARTNERS SX009 HEALTHPARTNERS 6.33 percent of total billed charges 4.96 7.6 Technical (Hospital) Services "HC/HH Wch Supp Finger Cot-Sml 1.5*__71903""" PX-2705000069 CDM 2705000069 LOCAL 270 RC inpatient 8 8 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES EPO [308136803] 6.33 percent of total billed charges 4.96 7.6 Technical (Hospital) Services "HC/HH Wch Supp Finger Cot-Sml 1.5*__71903""" PX-2705000069 CDM 2705000069 LOCAL 270 RC inpatient 8 8 BLUE CROSS BLUE SHIELD WELLMARK SB889 [3081026] BCBS WYOMING [308102603] 7.6 percent of total billed charges 4.96 7.6 Technical (Hospital) Services "HC/HH Wch Supp Finger Cot-Sml 1.5*__71903""" PX-2705000069 CDM 2705000069 LOCAL 270 RC inpatient 8 8 MULTIPLAN INC 34080 [3081285] MULTIPLAN INC [308128501] 7.6 percent of total billed charges 4.96 7.6 Technical (Hospital) Services "HC/HH Wch Supp Finger Cot-Sml 1.5*__71903""" PX-2705000069 CDM 2705000069 LOCAL 270 RC inpatient 8 8 CIGNA 62308 [3081051] CIGNA 62308 [308105105] 6.33 percent of total billed charges 4.96 7.6 Technical (Hospital) Services "HC/HH Wch Supp Finger Cot-Sml 1.5*__71903""" PX-2705000069 CDM 2705000069 LOCAL 270 RC inpatient 8 8 CIGNA 62308 [3081051] CIGNA STATE OF WYOMING [308105107] 6.33 percent of total billed charges 4.96 7.6 Technical (Hospital) Services "HC/HH Wch Supp Finger Cot-Sml 1.5*__71903""" PX-2705000069 CDM 2705000069 LOCAL 270 RC outpatient 8 8 MEDICA (COMMERCIAL) 94265 [3081118] MEDICA CLAIMS [308111801] 7.2 percent of total billed charges 4.96 7.6 Technical (Hospital) Services "HC/HH Wch Supp Finger Cot-Sml 1.5*__71903""" PX-2705000069 CDM 2705000069 LOCAL 270 RC outpatient 8 8 MULTIPLAN INC 34080 [3081285] MULTIPLAN INC [308128501] 7.6 percent of total billed charges 4.96 7.6 Technical (Hospital) Services "HC/HH Wch Supp Finger Cot-Sml 1.5*__71903""" PX-2705000069 CDM 2705000069 LOCAL 270 RC outpatient 8 8 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES EPO [308136803] 6.4 percent of total billed charges 4.96 7.6 Technical (Hospital) Services "HC/HH Wch Supp Finger Cot-Sml 1.5*__71903""" PX-2705000069 CDM 2705000069 LOCAL 270 RC outpatient 8 8 CIGNA 62308 [3081051] CIGNA 62308 [308105105] 6.4 percent of total billed charges 4.96 7.6 Technical (Hospital) Services "HC/HH Wch Supp Finger Cot-Sml 1.5*__71903""" PX-2705000069 CDM 2705000069 LOCAL 270 RC outpatient 8 8 CIGNA 62308 [3081051] CIGNA STATE OF WYOMING [308105107] 6.4 percent of total billed charges 4.96 7.6 Technical (Hospital) Services "HC/HH Wch Supp Finger Cot-Sml 1.5*__71903""" PX-2705000069 CDM 2705000069 LOCAL 270 RC outpatient 8 8 BLUE CROSS BLUE SHIELD WELLMARK SB889 [3081026] BCBS WYOMING [308102603] 7.6 percent of total billed charges 4.96 7.6 Technical (Hospital) Services "HC/HH Wch Supp Finger Cot-Sml 1.5*__71903""" PX-2705000069 CDM 2705000069 LOCAL 270 RC outpatient 8 8 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES HDHP [308136802] 6.4 percent of total billed charges 4.96 7.6 Technical (Hospital) Services "HC/HH Wch Supp Finger Cot-Sml 1.5*__71903""" PX-2705000069 CDM 2705000069 LOCAL 270 RC outpatient 8 8 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES PPO [308136801] 6.4 percent of total billed charges 4.96 7.6 Technical (Hospital) Services "HC/HH Wch Supp Finger Cot-Sml 1.5*__71903""" PX-2705000069 CDM 2705000069 LOCAL 270 RC outpatient 8 8 UNITED HEALTHCARE (COMMERCIAL) [3081199] UNITED HEALTHCARE 87726 [308119901] 4.96 percent of total billed charges 4.96 7.6 Technical (Hospital) Services "HC/HH Wch Supp Finger Cot-Sml 1.5*__71903""" PX-2705000069 CDM 2705000069 LOCAL 270 RC outpatient 8 8 HEALTHPARTNERS SX009 HEALTHPARTNERS 6.4 percent of total billed charges 4.96 7.6 Technical (Hospital) Services "HC/HH Wch Supp Finger Cot-Med 2.25__71905""" PX-2705000068 CDM 2705000068 LOCAL 270 RC outpatient 7 7 MEDICA (COMMERCIAL) 94265 [3081118] MEDICA CLAIMS [308111801] 6.3 percent of total billed charges 4.34 6.65 Technical (Hospital) Services "HC/HH Wch Supp Finger Cot-Med 2.25__71905""" PX-2705000068 CDM 2705000068 LOCAL 270 RC outpatient 7 7 MULTIPLAN INC 34080 [3081285] MULTIPLAN INC [308128501] 6.65 percent of total billed charges 4.34 6.65 Technical (Hospital) Services "HC/HH Wch Supp Finger Cot-Med 2.25__71905""" PX-2705000068 CDM 2705000068 LOCAL 270 RC outpatient 7 7 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES PPO [308136801] 5.6 percent of total billed charges 4.34 6.65 Technical (Hospital) Services "HC/HH Wch Supp Finger Cot-Med 2.25__71905""" PX-2705000068 CDM 2705000068 LOCAL 270 RC outpatient 7 7 HEALTHPARTNERS SX009 HEALTHPARTNERS 5.6 percent of total billed charges 4.34 6.65 Technical (Hospital) Services "HC/HH Wch Supp Finger Cot-Med 2.25__71905""" PX-2705000068 CDM 2705000068 LOCAL 270 RC outpatient 7 7 UNITED HEALTHCARE (COMMERCIAL) [3081199] UNITED HEALTHCARE 87726 [308119901] 4.34 percent of total billed charges 4.34 6.65 Technical (Hospital) Services "HC/HH Wch Supp Finger Cot-Med 2.25__71905""" PX-2705000068 CDM 2705000068 LOCAL 270 RC outpatient 7 7 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES HDHP [308136802] 5.6 percent of total billed charges 4.34 6.65 Technical (Hospital) Services "HC/HH Wch Supp Finger Cot-Med 2.25__71905""" PX-2705000068 CDM 2705000068 LOCAL 270 RC outpatient 7 7 CIGNA 62308 [3081051] CIGNA 62308 [308105105] 5.6 percent of total billed charges 4.34 6.65 Technical (Hospital) Services "HC/HH Wch Supp Finger Cot-Med 2.25__71905""" PX-2705000068 CDM 2705000068 LOCAL 270 RC outpatient 7 7 CIGNA 62308 [3081051] CIGNA STATE OF WYOMING [308105107] 5.6 percent of total billed charges 4.34 6.65 Technical (Hospital) Services "HC/HH Wch Supp Finger Cot-Med 2.25__71905""" PX-2705000068 CDM 2705000068 LOCAL 270 RC outpatient 7 7 BLUE CROSS BLUE SHIELD WELLMARK SB889 [3081026] BCBS WYOMING [308102603] 6.65 percent of total billed charges 4.34 6.65 Technical (Hospital) Services "HC/HH Wch Supp Finger Cot-Med 2.25__71905""" PX-2705000068 CDM 2705000068 LOCAL 270 RC outpatient 7 7 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES EPO [308136803] 5.6 percent of total billed charges 4.34 6.65 Technical (Hospital) Services "HC/HH Wch Supp Finger Cot-Med 2.25__71905""" PX-2705000068 CDM 2705000068 LOCAL 270 RC inpatient 7 7 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES PPO [308136801] 5.54 percent of total billed charges 4.34 6.65 Technical (Hospital) Services "HC/HH Wch Supp Finger Cot-Med 2.25__71905""" PX-2705000068 CDM 2705000068 LOCAL 270 RC inpatient 7 7 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES HDHP [308136802] 5.54 percent of total billed charges 4.34 6.65 Technical (Hospital) Services "HC/HH Wch Supp Finger Cot-Med 2.25__71905""" PX-2705000068 CDM 2705000068 LOCAL 270 RC inpatient 7 7 UNITED HEALTHCARE (COMMERCIAL) [3081199] UNITED HEALTHCARE 87726 [308119901] 4.34 percent of total billed charges 4.34 6.65 Technical (Hospital) Services "HC/HH Wch Supp Finger Cot-Med 2.25__71905""" PX-2705000068 CDM 2705000068 LOCAL 270 RC inpatient 7 7 MEDICA (COMMERCIAL) 94265 [3081118] MEDICA CLAIMS [308111801] 6.3 percent of total billed charges 4.34 6.65 Technical (Hospital) Services "HC/HH Wch Supp Finger Cot-Med 2.25__71905""" PX-2705000068 CDM 2705000068 LOCAL 270 RC inpatient 7 7 HEALTHPARTNERS SX009 HEALTHPARTNERS 5.54 percent of total billed charges 4.34 6.65 Technical (Hospital) Services "HC/HH Wch Supp Finger Cot-Med 2.25__71905""" PX-2705000068 CDM 2705000068 LOCAL 270 RC inpatient 7 7 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES EPO [308136803] 5.54 percent of total billed charges 4.34 6.65 Technical (Hospital) Services "HC/HH Wch Supp Finger Cot-Med 2.25__71905""" PX-2705000068 CDM 2705000068 LOCAL 270 RC inpatient 7 7 MULTIPLAN INC 34080 [3081285] MULTIPLAN INC [308128501] 6.65 percent of total billed charges 4.34 6.65 Technical (Hospital) Services "HC/HH Wch Supp Finger Cot-Med 2.25__71905""" PX-2705000068 CDM 2705000068 LOCAL 270 RC inpatient 7 7 CIGNA 62308 [3081051] CIGNA 62308 [308105105] 5.54 percent of total billed charges 4.34 6.65 Technical (Hospital) Services "HC/HH Wch Supp Finger Cot-Med 2.25__71905""" PX-2705000068 CDM 2705000068 LOCAL 270 RC inpatient 7 7 CIGNA 62308 [3081051] CIGNA STATE OF WYOMING [308105107] 5.54 percent of total billed charges 4.34 6.65 Technical (Hospital) Services "HC/HH Wch Supp Finger Cot-Med 2.25__71905""" PX-2705000068 CDM 2705000068 LOCAL 270 RC inpatient 7 7 BLUE CROSS BLUE SHIELD WELLMARK SB889 [3081026] BCBS WYOMING [308102603] 6.65 percent of total billed charges 4.34 6.65 Technical (Hospital) Services "HC/HH Wch Supp Finger Cot-Lrg 3__71907""" PX-2705000067 CDM 2705000067 LOCAL 270 RC inpatient 7 7 MULTIPLAN INC 34080 [3081285] MULTIPLAN INC [308128501] 6.65 percent of total billed charges 4.34 6.65 Technical (Hospital) Services "HC/HH Wch Supp Finger Cot-Lrg 3__71907""" PX-2705000067 CDM 2705000067 LOCAL 270 RC inpatient 7 7 CIGNA 62308 [3081051] CIGNA 62308 [308105105] 5.54 percent of total billed charges 4.34 6.65 Technical (Hospital) Services "HC/HH Wch Supp Finger Cot-Lrg 3__71907""" PX-2705000067 CDM 2705000067 LOCAL 270 RC inpatient 7 7 CIGNA 62308 [3081051] CIGNA STATE OF WYOMING [308105107] 5.54 percent of total billed charges 4.34 6.65 Technical (Hospital) Services "HC/HH Wch Supp Finger Cot-Lrg 3__71907""" PX-2705000067 CDM 2705000067 LOCAL 270 RC inpatient 7 7 BLUE CROSS BLUE SHIELD WELLMARK SB889 [3081026] BCBS WYOMING [308102603] 6.65 percent of total billed charges 4.34 6.65 Technical (Hospital) Services "HC/HH Wch Supp Finger Cot-Lrg 3__71907""" PX-2705000067 CDM 2705000067 LOCAL 270 RC inpatient 7 7 HEALTHPARTNERS SX009 HEALTHPARTNERS 5.54 percent of total billed charges 4.34 6.65 Technical (Hospital) Services "HC/HH Wch Supp Finger Cot-Lrg 3__71907""" PX-2705000067 CDM 2705000067 LOCAL 270 RC inpatient 7 7 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES EPO [308136803] 5.54 percent of total billed charges 4.34 6.65 Technical (Hospital) Services "HC/HH Wch Supp Finger Cot-Lrg 3__71907""" PX-2705000067 CDM 2705000067 LOCAL 270 RC inpatient 7 7 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES HDHP [308136802] 5.54 percent of total billed charges 4.34 6.65 Technical (Hospital) Services "HC/HH Wch Supp Finger Cot-Lrg 3__71907""" PX-2705000067 CDM 2705000067 LOCAL 270 RC inpatient 7 7 UNITED HEALTHCARE (COMMERCIAL) [3081199] UNITED HEALTHCARE 87726 [308119901] 4.34 percent of total billed charges 4.34 6.65 Technical (Hospital) Services "HC/HH Wch Supp Finger Cot-Lrg 3__71907""" PX-2705000067 CDM 2705000067 LOCAL 270 RC inpatient 7 7 MEDICA (COMMERCIAL) 94265 [3081118] MEDICA CLAIMS [308111801] 6.3 percent of total billed charges 4.34 6.65 Technical (Hospital) Services "HC/HH Wch Supp Finger Cot-Lrg 3__71907""" PX-2705000067 CDM 2705000067 LOCAL 270 RC inpatient 7 7 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES PPO [308136801] 5.54 percent of total billed charges 4.34 6.65 Technical (Hospital) Services "HC/HH Wch Supp Finger Cot-Lrg 3__71907""" PX-2705000067 CDM 2705000067 LOCAL 270 RC outpatient 7 7 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES EPO [308136803] 5.6 percent of total billed charges 4.34 6.65 Technical (Hospital) Services "HC/HH Wch Supp Finger Cot-Lrg 3__71907""" PX-2705000067 CDM 2705000067 LOCAL 270 RC outpatient 7 7 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES HDHP [308136802] 5.6 percent of total billed charges 4.34 6.65 Technical (Hospital) Services "HC/HH Wch Supp Finger Cot-Lrg 3__71907""" PX-2705000067 CDM 2705000067 LOCAL 270 RC outpatient 7 7 BLUE CROSS BLUE SHIELD WELLMARK SB889 [3081026] BCBS WYOMING [308102603] 6.65 percent of total billed charges 4.34 6.65 Technical (Hospital) Services "HC/HH Wch Supp Finger Cot-Lrg 3__71907""" PX-2705000067 CDM 2705000067 LOCAL 270 RC outpatient 7 7 CIGNA 62308 [3081051] CIGNA 62308 [308105105] 5.6 percent of total billed charges 4.34 6.65 Technical (Hospital) Services "HC/HH Wch Supp Finger Cot-Lrg 3__71907""" PX-2705000067 CDM 2705000067 LOCAL 270 RC outpatient 7 7 CIGNA 62308 [3081051] CIGNA STATE OF WYOMING [308105107] 5.6 percent of total billed charges 4.34 6.65 Technical (Hospital) Services "HC/HH Wch Supp Finger Cot-Lrg 3__71907""" PX-2705000067 CDM 2705000067 LOCAL 270 RC outpatient 7 7 UNITED HEALTHCARE (COMMERCIAL) [3081199] UNITED HEALTHCARE 87726 [308119901] 4.34 percent of total billed charges 4.34 6.65 Technical (Hospital) Services "HC/HH Wch Supp Finger Cot-Lrg 3__71907""" PX-2705000067 CDM 2705000067 LOCAL 270 RC outpatient 7 7 HEALTHPARTNERS SX009 HEALTHPARTNERS 5.6 percent of total billed charges 4.34 6.65 Technical (Hospital) Services "HC/HH Wch Supp Finger Cot-Lrg 3__71907""" PX-2705000067 CDM 2705000067 LOCAL 270 RC outpatient 7 7 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES PPO [308136801] 5.6 percent of total billed charges 4.34 6.65 Technical (Hospital) Services "HC/HH Wch Supp Finger Cot-Lrg 3__71907""" PX-2705000067 CDM 2705000067 LOCAL 270 RC outpatient 7 7 MULTIPLAN INC 34080 [3081285] MULTIPLAN INC [308128501] 6.65 percent of total billed charges 4.34 6.65 Technical (Hospital) Services "HC/HH Wch Supp Finger Cot-Lrg 3__71907""" PX-2705000067 CDM 2705000067 LOCAL 270 RC outpatient 7 7 MEDICA (COMMERCIAL) 94265 [3081118] MEDICA CLAIMS [308111801] 6.3 percent of total billed charges 4.34 6.65 Technical (Hospital) Services HC/HH Wch Supp Fetal Monitor Belt__40000008 PX-2705000066 CDM 2705000066 LOCAL 270 RC inpatient 29 29 CIGNA 62308 [3081051] CIGNA 62308 [308105105] 22.96 percent of total billed charges 17.98 27.55 Technical (Hospital) Services HC/HH Wch Supp Fetal Monitor Belt__40000008 PX-2705000066 CDM 2705000066 LOCAL 270 RC inpatient 29 29 CIGNA 62308 [3081051] CIGNA STATE OF WYOMING [308105107] 22.96 percent of total billed charges 17.98 27.55 Technical (Hospital) Services HC/HH Wch Supp Fetal Monitor Belt__40000008 PX-2705000066 CDM 2705000066 LOCAL 270 RC inpatient 29 29 MULTIPLAN INC 34080 [3081285] MULTIPLAN INC [308128501] 27.55 percent of total billed charges 17.98 27.55 Technical (Hospital) Services HC/HH Wch Supp Fetal Monitor Belt__40000008 PX-2705000066 CDM 2705000066 LOCAL 270 RC inpatient 29 29 BLUE CROSS BLUE SHIELD WELLMARK SB889 [3081026] BCBS WYOMING [308102603] 27.55 percent of total billed charges 17.98 27.55 Technical (Hospital) Services HC/HH Wch Supp Fetal Monitor Belt__40000008 PX-2705000066 CDM 2705000066 LOCAL 270 RC inpatient 29 29 HEALTHPARTNERS SX009 HEALTHPARTNERS 22.96 percent of total billed charges 17.98 27.55 Technical (Hospital) Services HC/HH Wch Supp Fetal Monitor Belt__40000008 PX-2705000066 CDM 2705000066 LOCAL 270 RC inpatient 29 29 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES EPO [308136803] 22.96 percent of total billed charges 17.98 27.55 Technical (Hospital) Services HC/HH Wch Supp Fetal Monitor Belt__40000008 PX-2705000066 CDM 2705000066 LOCAL 270 RC inpatient 29 29 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES HDHP [308136802] 22.96 percent of total billed charges 17.98 27.55 Technical (Hospital) Services HC/HH Wch Supp Fetal Monitor Belt__40000008 PX-2705000066 CDM 2705000066 LOCAL 270 RC inpatient 29 29 UNITED HEALTHCARE (COMMERCIAL) [3081199] UNITED HEALTHCARE 87726 [308119901] 17.98 percent of total billed charges 17.98 27.55 Technical (Hospital) Services HC/HH Wch Supp Fetal Monitor Belt__40000008 PX-2705000066 CDM 2705000066 LOCAL 270 RC inpatient 29 29 MEDICA (COMMERCIAL) 94265 [3081118] MEDICA CLAIMS [308111801] 26.1 percent of total billed charges 17.98 27.55 Technical (Hospital) Services HC/HH Wch Supp Fetal Monitor Belt__40000008 PX-2705000066 CDM 2705000066 LOCAL 270 RC inpatient 29 29 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES PPO [308136801] 22.96 percent of total billed charges 17.98 27.55 Technical (Hospital) Services HC/HH Wch Supp Fetal Monitor Belt__40000008 PX-2705000066 CDM 2705000066 LOCAL 270 RC outpatient 29 29 MEDICA (COMMERCIAL) 94265 [3081118] MEDICA CLAIMS [308111801] 26.1 percent of total billed charges 17.98 27.55 Technical (Hospital) Services HC/HH Wch Supp Fetal Monitor Belt__40000008 PX-2705000066 CDM 2705000066 LOCAL 270 RC outpatient 29 29 MULTIPLAN INC 34080 [3081285] MULTIPLAN INC [308128501] 27.55 percent of total billed charges 17.98 27.55 Technical (Hospital) Services HC/HH Wch Supp Fetal Monitor Belt__40000008 PX-2705000066 CDM 2705000066 LOCAL 270 RC outpatient 29 29 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES PPO [308136801] 23.2 percent of total billed charges 17.98 27.55 Technical (Hospital) Services HC/HH Wch Supp Fetal Monitor Belt__40000008 PX-2705000066 CDM 2705000066 LOCAL 270 RC outpatient 29 29 HEALTHPARTNERS SX009 HEALTHPARTNERS 23.2 percent of total billed charges 17.98 27.55 Technical (Hospital) Services HC/HH Wch Supp Fetal Monitor Belt__40000008 PX-2705000066 CDM 2705000066 LOCAL 270 RC outpatient 29 29 UNITED HEALTHCARE (COMMERCIAL) [3081199] UNITED HEALTHCARE 87726 [308119901] 17.98 percent of total billed charges 17.98 27.55 Technical (Hospital) Services HC/HH Wch Supp Fetal Monitor Belt__40000008 PX-2705000066 CDM 2705000066 LOCAL 270 RC outpatient 29 29 CIGNA 62308 [3081051] CIGNA 62308 [308105105] 23.2 percent of total billed charges 17.98 27.55 Technical (Hospital) Services HC/HH Wch Supp Fetal Monitor Belt__40000008 PX-2705000066 CDM 2705000066 LOCAL 270 RC outpatient 29 29 CIGNA 62308 [3081051] CIGNA STATE OF WYOMING [308105107] 23.2 percent of total billed charges 17.98 27.55 Technical (Hospital) Services HC/HH Wch Supp Fetal Monitor Belt__40000008 PX-2705000066 CDM 2705000066 LOCAL 270 RC outpatient 29 29 BLUE CROSS BLUE SHIELD WELLMARK SB889 [3081026] BCBS WYOMING [308102603] 27.55 percent of total billed charges 17.98 27.55 Technical (Hospital) Services HC/HH Wch Supp Fetal Monitor Belt__40000008 PX-2705000066 CDM 2705000066 LOCAL 270 RC outpatient 29 29 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES HDHP [308136802] 23.2 percent of total billed charges 17.98 27.55 Technical (Hospital) Services HC/HH Wch Supp Fetal Monitor Belt__40000008 PX-2705000066 CDM 2705000066 LOCAL 270 RC outpatient 29 29 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES EPO [308136803] 23.2 percent of total billed charges 17.98 27.55 Technical (Hospital) Services HC/HH Wch Supp Eye Protector Pad Med__G 7013-1276 PX-2705000065 CDM 2705000065 LOCAL 270 RC inpatient 6 6 CIGNA 62308 [3081051] CIGNA 62308 [308105105] 4.75 percent of total billed charges 3.72 5.7 Technical (Hospital) Services HC/HH Wch Supp Eye Protector Pad Med__G 7013-1276 PX-2705000065 CDM 2705000065 LOCAL 270 RC inpatient 6 6 CIGNA 62308 [3081051] CIGNA STATE OF WYOMING [308105107] 4.75 percent of total billed charges 3.72 5.7 Technical (Hospital) Services HC/HH Wch Supp Eye Protector Pad Med__G 7013-1276 PX-2705000065 CDM 2705000065 LOCAL 270 RC inpatient 6 6 MULTIPLAN INC 34080 [3081285] MULTIPLAN INC [308128501] 5.7 percent of total billed charges 3.72 5.7 Technical (Hospital) Services HC/HH Wch Supp Eye Protector Pad Med__G 7013-1276 PX-2705000065 CDM 2705000065 LOCAL 270 RC inpatient 6 6 BLUE CROSS BLUE SHIELD WELLMARK SB889 [3081026] BCBS WYOMING [308102603] 5.7 percent of total billed charges 3.72 5.7 Technical (Hospital) Services HC/HH Wch Supp Eye Protector Pad Med__G 7013-1276 PX-2705000065 CDM 2705000065 LOCAL 270 RC inpatient 6 6 HEALTHPARTNERS SX009 HEALTHPARTNERS 4.75 percent of total billed charges 3.72 5.7 Technical (Hospital) Services HC/HH Wch Supp Eye Protector Pad Med__G 7013-1276 PX-2705000065 CDM 2705000065 LOCAL 270 RC inpatient 6 6 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES EPO [308136803] 4.75 percent of total billed charges 3.72 5.7 Technical (Hospital) Services HC/HH Wch Supp Eye Protector Pad Med__G 7013-1276 PX-2705000065 CDM 2705000065 LOCAL 270 RC inpatient 6 6 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES HDHP [308136802] 4.75 percent of total billed charges 3.72 5.7 Technical (Hospital) Services HC/HH Wch Supp Eye Protector Pad Med__G 7013-1276 PX-2705000065 CDM 2705000065 LOCAL 270 RC inpatient 6 6 MEDICA (COMMERCIAL) 94265 [3081118] MEDICA CLAIMS [308111801] 5.4 percent of total billed charges 3.72 5.7 Technical (Hospital) Services HC/HH Wch Supp Eye Protector Pad Med__G 7013-1276 PX-2705000065 CDM 2705000065 LOCAL 270 RC inpatient 6 6 UNITED HEALTHCARE (COMMERCIAL) [3081199] UNITED HEALTHCARE 87726 [308119901] 3.72 percent of total billed charges 3.72 5.7 Technical (Hospital) Services HC/HH Wch Supp Eye Protector Pad Med__G 7013-1276 PX-2705000065 CDM 2705000065 LOCAL 270 RC inpatient 6 6 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES PPO [308136801] 4.75 percent of total billed charges 3.72 5.7 Technical (Hospital) Services HC/HH Wch Supp Eye Protector Pad Med__G 7013-1276 PX-2705000065 CDM 2705000065 LOCAL 270 RC outpatient 6 6 HEALTHPARTNERS SX009 HEALTHPARTNERS 4.8 percent of total billed charges 3.72 5.7 Technical (Hospital) Services HC/HH Wch Supp Eye Protector Pad Med__G 7013-1276 PX-2705000065 CDM 2705000065 LOCAL 270 RC outpatient 6 6 UNITED HEALTHCARE (COMMERCIAL) [3081199] UNITED HEALTHCARE 87726 [308119901] 3.72 percent of total billed charges 3.72 5.7 Technical (Hospital) Services HC/HH Wch Supp Eye Protector Pad Med__G 7013-1276 PX-2705000065 CDM 2705000065 LOCAL 270 RC outpatient 6 6 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES PPO [308136801] 4.8 percent of total billed charges 3.72 5.7 Technical (Hospital) Services HC/HH Wch Supp Eye Protector Pad Med__G 7013-1276 PX-2705000065 CDM 2705000065 LOCAL 270 RC outpatient 6 6 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES HDHP [308136802] 4.8 percent of total billed charges 3.72 5.7 Technical (Hospital) Services HC/HH Wch Supp Eye Protector Pad Med__G 7013-1276 PX-2705000065 CDM 2705000065 LOCAL 270 RC outpatient 6 6 BLUE CROSS BLUE SHIELD WELLMARK SB889 [3081026] BCBS WYOMING [308102603] 5.7 percent of total billed charges 3.72 5.7 Technical (Hospital) Services HC/HH Wch Supp Eye Protector Pad Med__G 7013-1276 PX-2705000065 CDM 2705000065 LOCAL 270 RC outpatient 6 6 CIGNA 62308 [3081051] CIGNA 62308 [308105105] 4.8 percent of total billed charges 3.72 5.7 Technical (Hospital) Services HC/HH Wch Supp Eye Protector Pad Med__G 7013-1276 PX-2705000065 CDM 2705000065 LOCAL 270 RC outpatient 6 6 CIGNA 62308 [3081051] CIGNA STATE OF WYOMING [308105107] 4.8 percent of total billed charges 3.72 5.7 Technical (Hospital) Services HC/HH Wch Supp Eye Protector Pad Med__G 7013-1276 PX-2705000065 CDM 2705000065 LOCAL 270 RC outpatient 6 6 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES EPO [308136803] 4.8 percent of total billed charges 3.72 5.7 Technical (Hospital) Services HC/HH Wch Supp Eye Protector Pad Med__G 7013-1276 PX-2705000065 CDM 2705000065 LOCAL 270 RC outpatient 6 6 MULTIPLAN INC 34080 [3081285] MULTIPLAN INC [308128501] 5.7 percent of total billed charges 3.72 5.7 Technical (Hospital) Services HC/HH Wch Supp Eye Protector Pad Med__G 7013-1276 PX-2705000065 CDM 2705000065 LOCAL 270 RC outpatient 6 6 MEDICA (COMMERCIAL) 94265 [3081118] MEDICA CLAIMS [308111801] 5.4 percent of total billed charges 3.72 5.7 Technical (Hospital) Services HC/HH Wch Supp Drssng Tegaderm 6x8__1628 PX-2705000064 CDM 2705000064 LOCAL 270 RC inpatient 8 8 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES PPO [308136801] 6.33 percent of total billed charges 4.96 7.6 Technical (Hospital) Services HC/HH Wch Supp Drssng Tegaderm 6x8__1628 PX-2705000064 CDM 2705000064 LOCAL 270 RC inpatient 8 8 UNITED HEALTHCARE (COMMERCIAL) [3081199] UNITED HEALTHCARE 87726 [308119901] 4.96 percent of total billed charges 4.96 7.6 Technical (Hospital) Services HC/HH Wch Supp Drssng Tegaderm 6x8__1628 PX-2705000064 CDM 2705000064 LOCAL 270 RC inpatient 8 8 MEDICA (COMMERCIAL) 94265 [3081118] MEDICA CLAIMS [308111801] 7.2 percent of total billed charges 4.96 7.6 Technical (Hospital) Services HC/HH Wch Supp Drssng Tegaderm 6x8__1628 PX-2705000064 CDM 2705000064 LOCAL 270 RC inpatient 8 8 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES HDHP [308136802] 6.33 percent of total billed charges 4.96 7.6 Technical (Hospital) Services HC/HH Wch Supp Drssng Tegaderm 6x8__1628 PX-2705000064 CDM 2705000064 LOCAL 270 RC inpatient 8 8 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES EPO [308136803] 6.33 percent of total billed charges 4.96 7.6 Technical (Hospital) Services HC/HH Wch Supp Drssng Tegaderm 6x8__1628 PX-2705000064 CDM 2705000064 LOCAL 270 RC inpatient 8 8 HEALTHPARTNERS SX009 HEALTHPARTNERS 6.33 percent of total billed charges 4.96 7.6 Technical (Hospital) Services HC/HH Wch Supp Drssng Tegaderm 6x8__1628 PX-2705000064 CDM 2705000064 LOCAL 270 RC inpatient 8 8 BLUE CROSS BLUE SHIELD WELLMARK SB889 [3081026] BCBS WYOMING [308102603] 7.6 percent of total billed charges 4.96 7.6 Technical (Hospital) Services HC/HH Wch Supp Drssng Tegaderm 6x8__1628 PX-2705000064 CDM 2705000064 LOCAL 270 RC inpatient 8 8 MULTIPLAN INC 34080 [3081285] MULTIPLAN INC [308128501] 7.6 percent of total billed charges 4.96 7.6 Technical (Hospital) Services HC/HH Wch Supp Drssng Tegaderm 6x8__1628 PX-2705000064 CDM 2705000064 LOCAL 270 RC inpatient 8 8 CIGNA 62308 [3081051] CIGNA 62308 [308105105] 6.33 percent of total billed charges 4.96 7.6 Technical (Hospital) Services HC/HH Wch Supp Drssng Tegaderm 6x8__1628 PX-2705000064 CDM 2705000064 LOCAL 270 RC inpatient 8 8 CIGNA 62308 [3081051] CIGNA STATE OF WYOMING [308105107] 6.33 percent of total billed charges 4.96 7.6 Technical (Hospital) Services HC/HH Wch Supp Drssng Tegaderm 6x8__1628 PX-2705000064 CDM 2705000064 LOCAL 270 RC outpatient 8 8 HEALTHPARTNERS SX009 HEALTHPARTNERS 6.4 percent of total billed charges 4.96 7.6 Technical (Hospital) Services HC/HH Wch Supp Drssng Tegaderm 6x8__1628 PX-2705000064 CDM 2705000064 LOCAL 270 RC outpatient 8 8 UNITED HEALTHCARE (COMMERCIAL) [3081199] UNITED HEALTHCARE 87726 [308119901] 4.96 percent of total billed charges 4.96 7.6 Technical (Hospital) Services HC/HH Wch Supp Drssng Tegaderm 6x8__1628 PX-2705000064 CDM 2705000064 LOCAL 270 RC outpatient 8 8 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES HDHP [308136802] 6.4 percent of total billed charges 4.96 7.6 Technical (Hospital) Services HC/HH Wch Supp Drssng Tegaderm 6x8__1628 PX-2705000064 CDM 2705000064 LOCAL 270 RC outpatient 8 8 CIGNA 62308 [3081051] CIGNA 62308 [308105105] 6.4 percent of total billed charges 4.96 7.6 Technical (Hospital) Services HC/HH Wch Supp Drssng Tegaderm 6x8__1628 PX-2705000064 CDM 2705000064 LOCAL 270 RC outpatient 8 8 CIGNA 62308 [3081051] CIGNA STATE OF WYOMING [308105107] 6.4 percent of total billed charges 4.96 7.6 Technical (Hospital) Services HC/HH Wch Supp Drssng Tegaderm 6x8__1628 PX-2705000064 CDM 2705000064 LOCAL 270 RC outpatient 8 8 BLUE CROSS BLUE SHIELD WELLMARK SB889 [3081026] BCBS WYOMING [308102603] 7.6 percent of total billed charges 4.96 7.6 Technical (Hospital) Services HC/HH Wch Supp Drssng Tegaderm 6x8__1628 PX-2705000064 CDM 2705000064 LOCAL 270 RC outpatient 8 8 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES EPO [308136803] 6.4 percent of total billed charges 4.96 7.6 Technical (Hospital) Services HC/HH Wch Supp Drssng Tegaderm 6x8__1628 PX-2705000064 CDM 2705000064 LOCAL 270 RC outpatient 8 8 MEDICA (COMMERCIAL) 94265 [3081118] MEDICA CLAIMS [308111801] 7.2 percent of total billed charges 4.96 7.6 Technical (Hospital) Services HC/HH Wch Supp Drssng Tegaderm 6x8__1628 PX-2705000064 CDM 2705000064 LOCAL 270 RC outpatient 8 8 MULTIPLAN INC 34080 [3081285] MULTIPLAN INC [308128501] 7.6 percent of total billed charges 4.96 7.6 Technical (Hospital) Services HC/HH Wch Supp Drssng Tegaderm 6x8__1628 PX-2705000064 CDM 2705000064 LOCAL 270 RC outpatient 8 8 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES PPO [308136801] 6.4 percent of total billed charges 4.96 7.6 Technical (Hospital) Services HC/HH Wch Supp Drssng Net Surgilast #8__Gl709 PX-2705000063 CDM 2705000063 LOCAL 270 RC inpatient 6 6 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES PPO [308136801] 4.75 percent of total billed charges 3.72 5.7 Technical (Hospital) Services HC/HH Wch Supp Drssng Net Surgilast #8__Gl709 PX-2705000063 CDM 2705000063 LOCAL 270 RC inpatient 6 6 MEDICA (COMMERCIAL) 94265 [3081118] MEDICA CLAIMS [308111801] 5.4 percent of total billed charges 3.72 5.7 Technical (Hospital) Services HC/HH Wch Supp Drssng Net Surgilast #8__Gl709 PX-2705000063 CDM 2705000063 LOCAL 270 RC inpatient 6 6 UNITED HEALTHCARE (COMMERCIAL) [3081199] UNITED HEALTHCARE 87726 [308119901] 3.72 percent of total billed charges 3.72 5.7 Technical (Hospital) Services HC/HH Wch Supp Drssng Net Surgilast #8__Gl709 PX-2705000063 CDM 2705000063 LOCAL 270 RC inpatient 6 6 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES HDHP [308136802] 4.75 percent of total billed charges 3.72 5.7 Technical (Hospital) Services HC/HH Wch Supp Drssng Net Surgilast #8__Gl709 PX-2705000063 CDM 2705000063 LOCAL 270 RC inpatient 6 6 BLUE CROSS BLUE SHIELD WELLMARK SB889 [3081026] BCBS WYOMING [308102603] 5.7 percent of total billed charges 3.72 5.7 Technical (Hospital) Services HC/HH Wch Supp Drssng Net Surgilast #8__Gl709 PX-2705000063 CDM 2705000063 LOCAL 270 RC inpatient 6 6 MULTIPLAN INC 34080 [3081285] MULTIPLAN INC [308128501] 5.7 percent of total billed charges 3.72 5.7 Technical (Hospital) Services HC/HH Wch Supp Drssng Net Surgilast #8__Gl709 PX-2705000063 CDM 2705000063 LOCAL 270 RC inpatient 6 6 CIGNA 62308 [3081051] CIGNA 62308 [308105105] 4.75 percent of total billed charges 3.72 5.7 Technical (Hospital) Services HC/HH Wch Supp Drssng Net Surgilast #8__Gl709 PX-2705000063 CDM 2705000063 LOCAL 270 RC inpatient 6 6 CIGNA 62308 [3081051] CIGNA STATE OF WYOMING [308105107] 4.75 percent of total billed charges 3.72 5.7 Technical (Hospital) Services HC/HH Wch Supp Drssng Net Surgilast #8__Gl709 PX-2705000063 CDM 2705000063 LOCAL 270 RC inpatient 6 6 HEALTHPARTNERS SX009 HEALTHPARTNERS 4.75 percent of total billed charges 3.72 5.7 Technical (Hospital) Services HC/HH Wch Supp Drssng Net Surgilast #8__Gl709 PX-2705000063 CDM 2705000063 LOCAL 270 RC inpatient 6 6 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES EPO [308136803] 4.75 percent of total billed charges 3.72 5.7 Technical (Hospital) Services HC/HH Wch Supp Drssng Net Surgilast #8__Gl709 PX-2705000063 CDM 2705000063 LOCAL 270 RC outpatient 6 6 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES HDHP [308136802] 4.8 percent of total billed charges 3.72 5.7 Technical (Hospital) Services HC/HH Wch Supp Drssng Net Surgilast #8__Gl709 PX-2705000063 CDM 2705000063 LOCAL 270 RC outpatient 6 6 BLUE CROSS BLUE SHIELD WELLMARK SB889 [3081026] BCBS WYOMING [308102603] 5.7 percent of total billed charges 3.72 5.7 Technical (Hospital) Services HC/HH Wch Supp Drssng Net Surgilast #8__Gl709 PX-2705000063 CDM 2705000063 LOCAL 270 RC outpatient 6 6 CIGNA 62308 [3081051] CIGNA 62308 [308105105] 4.8 percent of total billed charges 3.72 5.7 Technical (Hospital) Services HC/HH Wch Supp Drssng Net Surgilast #8__Gl709 PX-2705000063 CDM 2705000063 LOCAL 270 RC outpatient 6 6 CIGNA 62308 [3081051] CIGNA STATE OF WYOMING [308105107] 4.8 percent of total billed charges 3.72 5.7 Technical (Hospital) Services HC/HH Wch Supp Drssng Net Surgilast #8__Gl709 PX-2705000063 CDM 2705000063 LOCAL 270 RC outpatient 6 6 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES EPO [308136803] 4.8 percent of total billed charges 3.72 5.7 Technical (Hospital) Services HC/HH Wch Supp Drssng Net Surgilast #8__Gl709 PX-2705000063 CDM 2705000063 LOCAL 270 RC outpatient 6 6 UNITED HEALTHCARE (COMMERCIAL) [3081199] UNITED HEALTHCARE 87726 [308119901] 3.72 percent of total billed charges 3.72 5.7 Technical (Hospital) Services HC/HH Wch Supp Drssng Net Surgilast #8__Gl709 PX-2705000063 CDM 2705000063 LOCAL 270 RC outpatient 6 6 HEALTHPARTNERS SX009 HEALTHPARTNERS 4.8 percent of total billed charges 3.72 5.7 Technical (Hospital) Services HC/HH Wch Supp Drssng Net Surgilast #8__Gl709 PX-2705000063 CDM 2705000063 LOCAL 270 RC outpatient 6 6 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES PPO [308136801] 4.8 percent of total billed charges 3.72 5.7 Technical (Hospital) Services HC/HH Wch Supp Drssng Net Surgilast #8__Gl709 PX-2705000063 CDM 2705000063 LOCAL 270 RC outpatient 6 6 MULTIPLAN INC 34080 [3081285] MULTIPLAN INC [308128501] 5.7 percent of total billed charges 3.72 5.7 Technical (Hospital) Services HC/HH Wch Supp Drssng Net Surgilast #8__Gl709 PX-2705000063 CDM 2705000063 LOCAL 270 RC outpatient 6 6 MEDICA (COMMERCIAL) 94265 [3081118] MEDICA CLAIMS [308111801] 5.4 percent of total billed charges 3.72 5.7 Technical (Hospital) Services HC/HH Wch Supp Drssng Net Surgilast #6__Gl707 PX-2705000062 CDM 2705000062 LOCAL 270 RC inpatient 32 32 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES EPO [308136803] 25.34 percent of total billed charges 19.84 30.4 Technical (Hospital) Services HC/HH Wch Supp Drssng Net Surgilast #6__Gl707 PX-2705000062 CDM 2705000062 LOCAL 270 RC inpatient 32 32 HEALTHPARTNERS SX009 HEALTHPARTNERS 25.34 percent of total billed charges 19.84 30.4 Technical (Hospital) Services HC/HH Wch Supp Drssng Net Surgilast #6__Gl707 PX-2705000062 CDM 2705000062 LOCAL 270 RC inpatient 32 32 CIGNA 62308 [3081051] CIGNA 62308 [308105105] 25.34 percent of total billed charges 19.84 30.4 Technical (Hospital) Services HC/HH Wch Supp Drssng Net Surgilast #6__Gl707 PX-2705000062 CDM 2705000062 LOCAL 270 RC inpatient 32 32 CIGNA 62308 [3081051] CIGNA STATE OF WYOMING [308105107] 25.34 percent of total billed charges 19.84 30.4 Technical (Hospital) Services HC/HH Wch Supp Drssng Net Surgilast #6__Gl707 PX-2705000062 CDM 2705000062 LOCAL 270 RC inpatient 32 32 MULTIPLAN INC 34080 [3081285] MULTIPLAN INC [308128501] 30.4 percent of total billed charges 19.84 30.4 Technical (Hospital) Services HC/HH Wch Supp Drssng Net Surgilast #6__Gl707 PX-2705000062 CDM 2705000062 LOCAL 270 RC inpatient 32 32 BLUE CROSS BLUE SHIELD WELLMARK SB889 [3081026] BCBS WYOMING [308102603] 30.4 percent of total billed charges 19.84 30.4 Technical (Hospital) Services HC/HH Wch Supp Drssng Net Surgilast #6__Gl707 PX-2705000062 CDM 2705000062 LOCAL 270 RC inpatient 32 32 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES HDHP [308136802] 25.34 percent of total billed charges 19.84 30.4 Technical (Hospital) Services HC/HH Wch Supp Drssng Net Surgilast #6__Gl707 PX-2705000062 CDM 2705000062 LOCAL 270 RC inpatient 32 32 UNITED HEALTHCARE (COMMERCIAL) [3081199] UNITED HEALTHCARE 87726 [308119901] 19.84 percent of total billed charges 19.84 30.4 Technical (Hospital) Services HC/HH Wch Supp Drssng Net Surgilast #6__Gl707 PX-2705000062 CDM 2705000062 LOCAL 270 RC inpatient 32 32 MEDICA (COMMERCIAL) 94265 [3081118] MEDICA CLAIMS [308111801] 28.8 percent of total billed charges 19.84 30.4 Technical (Hospital) Services HC/HH Wch Supp Drssng Net Surgilast #6__Gl707 PX-2705000062 CDM 2705000062 LOCAL 270 RC inpatient 32 32 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES PPO [308136801] 25.34 percent of total billed charges 19.84 30.4 Technical (Hospital) Services HC/HH Wch Supp Drssng Net Surgilast #6__Gl707 PX-2705000062 CDM 2705000062 LOCAL 270 RC outpatient 32 32 MULTIPLAN INC 34080 [3081285] MULTIPLAN INC [308128501] 30.4 percent of total billed charges 19.84 30.4 Technical (Hospital) Services HC/HH Wch Supp Drssng Net Surgilast #6__Gl707 PX-2705000062 CDM 2705000062 LOCAL 270 RC outpatient 32 32 MEDICA (COMMERCIAL) 94265 [3081118] MEDICA CLAIMS [308111801] 28.8 percent of total billed charges 19.84 30.4 Technical (Hospital) Services HC/HH Wch Supp Drssng Net Surgilast #6__Gl707 PX-2705000062 CDM 2705000062 LOCAL 270 RC outpatient 32 32 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES HDHP [308136802] 25.6 percent of total billed charges 19.84 30.4 Technical (Hospital) Services HC/HH Wch Supp Drssng Net Surgilast #6__Gl707 PX-2705000062 CDM 2705000062 LOCAL 270 RC outpatient 32 32 BLUE CROSS BLUE SHIELD WELLMARK SB889 [3081026] BCBS WYOMING [308102603] 30.4 percent of total billed charges 19.84 30.4 Technical (Hospital) Services HC/HH Wch Supp Drssng Net Surgilast #6__Gl707 PX-2705000062 CDM 2705000062 LOCAL 270 RC outpatient 32 32 CIGNA 62308 [3081051] CIGNA 62308 [308105105] 25.6 percent of total billed charges 19.84 30.4 Technical (Hospital) Services HC/HH Wch Supp Drssng Net Surgilast #6__Gl707 PX-2705000062 CDM 2705000062 LOCAL 270 RC outpatient 32 32 CIGNA 62308 [3081051] CIGNA STATE OF WYOMING [308105107] 25.6 percent of total billed charges 19.84 30.4 Technical (Hospital) Services HC/HH Wch Supp Drssng Net Surgilast #6__Gl707 PX-2705000062 CDM 2705000062 LOCAL 270 RC outpatient 32 32 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES EPO [308136803] 25.6 percent of total billed charges 19.84 30.4 Technical (Hospital) Services HC/HH Wch Supp Drssng Net Surgilast #6__Gl707 PX-2705000062 CDM 2705000062 LOCAL 270 RC outpatient 32 32 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES PPO [308136801] 25.6 percent of total billed charges 19.84 30.4 Technical (Hospital) Services HC/HH Wch Supp Drssng Net Surgilast #6__Gl707 PX-2705000062 CDM 2705000062 LOCAL 270 RC outpatient 32 32 HEALTHPARTNERS SX009 HEALTHPARTNERS 25.6 percent of total billed charges 19.84 30.4 Technical (Hospital) Services HC/HH Wch Supp Drssng Net Surgilast #6__Gl707 PX-2705000062 CDM 2705000062 LOCAL 270 RC outpatient 32 32 UNITED HEALTHCARE (COMMERCIAL) [3081199] UNITED HEALTHCARE 87726 [308119901] 19.84 percent of total billed charges 19.84 30.4 Technical (Hospital) Services HC/HH Wch Supp Drssng Duoderm Extra Thin Spot__187932 PX-2705000061 CDM 2705000061 LOCAL 270 RC outpatient 5 5 MEDICA (COMMERCIAL) 94265 [3081118] MEDICA CLAIMS [308111801] 4.5 percent of total billed charges 3.1 4.75 Technical (Hospital) Services HC/HH Wch Supp Drssng Duoderm Extra Thin Spot__187932 PX-2705000061 CDM 2705000061 LOCAL 270 RC outpatient 5 5 MULTIPLAN INC 34080 [3081285] MULTIPLAN INC [308128501] 4.75 percent of total billed charges 3.1 4.75 Technical (Hospital) Services HC/HH Wch Supp Drssng Duoderm Extra Thin Spot__187932 PX-2705000061 CDM 2705000061 LOCAL 270 RC outpatient 5 5 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES PPO [308136801] 4 percent of total billed charges 3.1 4.75 Technical (Hospital) Services HC/HH Wch Supp Drssng Duoderm Extra Thin Spot__187932 PX-2705000061 CDM 2705000061 LOCAL 270 RC outpatient 5 5 HEALTHPARTNERS SX009 HEALTHPARTNERS 4 percent of total billed charges 3.1 4.75 Technical (Hospital) Services HC/HH Wch Supp Drssng Duoderm Extra Thin Spot__187932 PX-2705000061 CDM 2705000061 LOCAL 270 RC outpatient 5 5 UNITED HEALTHCARE (COMMERCIAL) [3081199] UNITED HEALTHCARE 87726 [308119901] 3.1 percent of total billed charges 3.1 4.75 Technical (Hospital) Services HC/HH Wch Supp Drssng Duoderm Extra Thin Spot__187932 PX-2705000061 CDM 2705000061 LOCAL 270 RC outpatient 5 5 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES HDHP [308136802] 4 percent of total billed charges 3.1 4.75 Technical (Hospital) Services HC/HH Wch Supp Drssng Duoderm Extra Thin Spot__187932 PX-2705000061 CDM 2705000061 LOCAL 270 RC outpatient 5 5 CIGNA 62308 [3081051] CIGNA 62308 [308105105] 4 percent of total billed charges 3.1 4.75 Technical (Hospital) Services HC/HH Wch Supp Drssng Duoderm Extra Thin Spot__187932 PX-2705000061 CDM 2705000061 LOCAL 270 RC outpatient 5 5 CIGNA 62308 [3081051] CIGNA STATE OF WYOMING [308105107] 4 percent of total billed charges 3.1 4.75 Technical (Hospital) Services HC/HH Wch Supp Drssng Duoderm Extra Thin Spot__187932 PX-2705000061 CDM 2705000061 LOCAL 270 RC outpatient 5 5 BLUE CROSS BLUE SHIELD WELLMARK SB889 [3081026] BCBS WYOMING [308102603] 4.75 percent of total billed charges 3.1 4.75 Technical (Hospital) Services HC/HH Wch Supp Drssng Duoderm Extra Thin Spot__187932 PX-2705000061 CDM 2705000061 LOCAL 270 RC outpatient 5 5 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES EPO [308136803] 4 percent of total billed charges 3.1 4.75 Technical (Hospital) Services HC/HH Wch Supp Drssng Duoderm Extra Thin Spot__187932 PX-2705000061 CDM 2705000061 LOCAL 270 RC inpatient 5 5 HEALTHPARTNERS SX009 HEALTHPARTNERS 3.96 percent of total billed charges 3.1 4.75 Technical (Hospital) Services HC/HH Wch Supp Drssng Duoderm Extra Thin Spot__187932 PX-2705000061 CDM 2705000061 LOCAL 270 RC inpatient 5 5 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES EPO [308136803] 3.96 percent of total billed charges 3.1 4.75 Technical (Hospital) Services HC/HH Wch Supp Drssng Duoderm Extra Thin Spot__187932 PX-2705000061 CDM 2705000061 LOCAL 270 RC inpatient 5 5 CIGNA 62308 [3081051] CIGNA 62308 [308105105] 3.96 percent of total billed charges 3.1 4.75 Technical (Hospital) Services HC/HH Wch Supp Drssng Duoderm Extra Thin Spot__187932 PX-2705000061 CDM 2705000061 LOCAL 270 RC inpatient 5 5 CIGNA 62308 [3081051] CIGNA STATE OF WYOMING [308105107] 3.96 percent of total billed charges 3.1 4.75 Technical (Hospital) Services HC/HH Wch Supp Drssng Duoderm Extra Thin Spot__187932 PX-2705000061 CDM 2705000061 LOCAL 270 RC inpatient 5 5 MULTIPLAN INC 34080 [3081285] MULTIPLAN INC [308128501] 4.75 percent of total billed charges 3.1 4.75 Technical (Hospital) Services HC/HH Wch Supp Drssng Duoderm Extra Thin Spot__187932 PX-2705000061 CDM 2705000061 LOCAL 270 RC inpatient 5 5 BLUE CROSS BLUE SHIELD WELLMARK SB889 [3081026] BCBS WYOMING [308102603] 4.75 percent of total billed charges 3.1 4.75 Technical (Hospital) Services HC/HH Wch Supp Drssng Duoderm Extra Thin Spot__187932 PX-2705000061 CDM 2705000061 LOCAL 270 RC inpatient 5 5 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES HDHP [308136802] 3.96 percent of total billed charges 3.1 4.75 Technical (Hospital) Services HC/HH Wch Supp Drssng Duoderm Extra Thin Spot__187932 PX-2705000061 CDM 2705000061 LOCAL 270 RC inpatient 5 5 UNITED HEALTHCARE (COMMERCIAL) [3081199] UNITED HEALTHCARE 87726 [308119901] 3.1 percent of total billed charges 3.1 4.75 Technical (Hospital) Services HC/HH Wch Supp Drssng Duoderm Extra Thin Spot__187932 PX-2705000061 CDM 2705000061 LOCAL 270 RC inpatient 5 5 MEDICA (COMMERCIAL) 94265 [3081118] MEDICA CLAIMS [308111801] 4.5 percent of total billed charges 3.1 4.75 Technical (Hospital) Services HC/HH Wch Supp Drssng Duoderm Extra Thin Spot__187932 PX-2705000061 CDM 2705000061 LOCAL 270 RC inpatient 5 5 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES PPO [308136801] 3.96 percent of total billed charges 3.1 4.75 Technical (Hospital) Services HC/HH Wch Supp Detector Co2 Easy Cap II__Easycap II 6 PX-2705000060 CDM 2705000060 LOCAL 270 RC inpatient 47 47 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES EPO [308136803] 37.21 percent of total billed charges 29.14 44.65 Technical (Hospital) Services HC/HH Wch Supp Detector Co2 Easy Cap II__Easycap II 6 PX-2705000060 CDM 2705000060 LOCAL 270 RC inpatient 47 47 HEALTHPARTNERS SX009 HEALTHPARTNERS 37.21 percent of total billed charges 29.14 44.65 Technical (Hospital) Services HC/HH Wch Supp Detector Co2 Easy Cap II__Easycap II 6 PX-2705000060 CDM 2705000060 LOCAL 270 RC inpatient 47 47 CIGNA 62308 [3081051] CIGNA 62308 [308105105] 37.21 percent of total billed charges 29.14 44.65 Technical (Hospital) Services HC/HH Wch Supp Detector Co2 Easy Cap II__Easycap II 6 PX-2705000060 CDM 2705000060 LOCAL 270 RC inpatient 47 47 CIGNA 62308 [3081051] CIGNA STATE OF WYOMING [308105107] 37.21 percent of total billed charges 29.14 44.65 Technical (Hospital) Services HC/HH Wch Supp Detector Co2 Easy Cap II__Easycap II 6 PX-2705000060 CDM 2705000060 LOCAL 270 RC inpatient 47 47 MULTIPLAN INC 34080 [3081285] MULTIPLAN INC [308128501] 44.65 percent of total billed charges 29.14 44.65 Technical (Hospital) Services HC/HH Wch Supp Detector Co2 Easy Cap II__Easycap II 6 PX-2705000060 CDM 2705000060 LOCAL 270 RC inpatient 47 47 BLUE CROSS BLUE SHIELD WELLMARK SB889 [3081026] BCBS WYOMING [308102603] 44.65 percent of total billed charges 29.14 44.65 Technical (Hospital) Services HC/HH Wch Supp Detector Co2 Easy Cap II__Easycap II 6 PX-2705000060 CDM 2705000060 LOCAL 270 RC inpatient 47 47 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES PPO [308136801] 37.21 percent of total billed charges 29.14 44.65 Technical (Hospital) Services HC/HH Wch Supp Detector Co2 Easy Cap II__Easycap II 6 PX-2705000060 CDM 2705000060 LOCAL 270 RC inpatient 47 47 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES HDHP [308136802] 37.21 percent of total billed charges 29.14 44.65 Technical (Hospital) Services HC/HH Wch Supp Detector Co2 Easy Cap II__Easycap II 6 PX-2705000060 CDM 2705000060 LOCAL 270 RC inpatient 47 47 MEDICA (COMMERCIAL) 94265 [3081118] MEDICA CLAIMS [308111801] 42.3 percent of total billed charges 29.14 44.65 Technical (Hospital) Services HC/HH Wch Supp Detector Co2 Easy Cap II__Easycap II 6 PX-2705000060 CDM 2705000060 LOCAL 270 RC inpatient 47 47 UNITED HEALTHCARE (COMMERCIAL) [3081199] UNITED HEALTHCARE 87726 [308119901] 29.14 percent of total billed charges 29.14 44.65 Technical (Hospital) Services HC/HH Wch Supp Detector Co2 Easy Cap II__Easycap II 6 PX-2705000060 CDM 2705000060 LOCAL 270 RC outpatient 47 47 MEDICA (COMMERCIAL) 94265 [3081118] MEDICA CLAIMS [308111801] 42.3 percent of total billed charges 29.14 44.65 Technical (Hospital) Services HC/HH Wch Supp Detector Co2 Easy Cap II__Easycap II 6 PX-2705000060 CDM 2705000060 LOCAL 270 RC outpatient 47 47 MULTIPLAN INC 34080 [3081285] MULTIPLAN INC [308128501] 44.65 percent of total billed charges 29.14 44.65 Technical (Hospital) Services HC/HH Wch Supp Detector Co2 Easy Cap II__Easycap II 6 PX-2705000060 CDM 2705000060 LOCAL 270 RC outpatient 47 47 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES HDHP [308136802] 37.6 percent of total billed charges 29.14 44.65 Technical (Hospital) Services HC/HH Wch Supp Detector Co2 Easy Cap II__Easycap II 6 PX-2705000060 CDM 2705000060 LOCAL 270 RC outpatient 47 47 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES EPO [308136803] 37.6 percent of total billed charges 29.14 44.65 Technical (Hospital) Services HC/HH Wch Supp Detector Co2 Easy Cap II__Easycap II 6 PX-2705000060 CDM 2705000060 LOCAL 270 RC outpatient 47 47 BLUE CROSS BLUE SHIELD WELLMARK SB889 [3081026] BCBS WYOMING [308102603] 44.65 percent of total billed charges 29.14 44.65 Technical (Hospital) Services HC/HH Wch Supp Detector Co2 Easy Cap II__Easycap II 6 PX-2705000060 CDM 2705000060 LOCAL 270 RC outpatient 47 47 CIGNA 62308 [3081051] CIGNA STATE OF WYOMING [308105107] 37.6 percent of total billed charges 29.14 44.65 Technical (Hospital) Services HC/HH Wch Supp Detector Co2 Easy Cap II__Easycap II 6 PX-2705000060 CDM 2705000060 LOCAL 270 RC outpatient 47 47 CIGNA 62308 [3081051] CIGNA 62308 [308105105] 37.6 percent of total billed charges 29.14 44.65 Technical (Hospital) Services HC/HH Wch Supp Detector Co2 Easy Cap II__Easycap II 6 PX-2705000060 CDM 2705000060 LOCAL 270 RC outpatient 47 47 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES PPO [308136801] 37.6 percent of total billed charges 29.14 44.65 Technical (Hospital) Services HC/HH Wch Supp Detector Co2 Easy Cap II__Easycap II 6 PX-2705000060 CDM 2705000060 LOCAL 270 RC outpatient 47 47 UNITED HEALTHCARE (COMMERCIAL) [3081199] UNITED HEALTHCARE 87726 [308119901] 29.14 percent of total billed charges 29.14 44.65 Technical (Hospital) Services HC/HH Wch Supp Detector Co2 Easy Cap II__Easycap II 6 PX-2705000060 CDM 2705000060 LOCAL 270 RC outpatient 47 47 HEALTHPARTNERS SX009 HEALTHPARTNERS 37.6 percent of total billed charges 29.14 44.65 Technical (Hospital) Services HC/HH Wch Supp Cover Probe Ultrasound__38-01 PX-2705000059 CDM 2705000059 LOCAL 270 RC inpatient 6 6 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES EPO [308136803] 4.75 percent of total billed charges 3.72 5.7 Technical (Hospital) Services HC/HH Wch Supp Cover Probe Ultrasound__38-01 PX-2705000059 CDM 2705000059 LOCAL 270 RC inpatient 6 6 HEALTHPARTNERS SX009 HEALTHPARTNERS 4.75 percent of total billed charges 3.72 5.7 Technical (Hospital) Services HC/HH Wch Supp Cover Probe Ultrasound__38-01 PX-2705000059 CDM 2705000059 LOCAL 270 RC inpatient 6 6 BLUE CROSS BLUE SHIELD WELLMARK SB889 [3081026] BCBS WYOMING [308102603] 5.7 percent of total billed charges 3.72 5.7 Technical (Hospital) Services HC/HH Wch Supp Cover Probe Ultrasound__38-01 PX-2705000059 CDM 2705000059 LOCAL 270 RC inpatient 6 6 MULTIPLAN INC 34080 [3081285] MULTIPLAN INC [308128501] 5.7 percent of total billed charges 3.72 5.7 Technical (Hospital) Services HC/HH Wch Supp Cover Probe Ultrasound__38-01 PX-2705000059 CDM 2705000059 LOCAL 270 RC inpatient 6 6 CIGNA 62308 [3081051] CIGNA 62308 [308105105] 4.75 percent of total billed charges 3.72 5.7 Technical (Hospital) Services HC/HH Wch Supp Cover Probe Ultrasound__38-01 PX-2705000059 CDM 2705000059 LOCAL 270 RC inpatient 6 6 CIGNA 62308 [3081051] CIGNA STATE OF WYOMING [308105107] 4.75 percent of total billed charges 3.72 5.7 Technical (Hospital) Services HC/HH Wch Supp Cover Probe Ultrasound__38-01 PX-2705000059 CDM 2705000059 LOCAL 270 RC inpatient 6 6 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES PPO [308136801] 4.75 percent of total billed charges 3.72 5.7 Technical (Hospital) Services HC/HH Wch Supp Cover Probe Ultrasound__38-01 PX-2705000059 CDM 2705000059 LOCAL 270 RC inpatient 6 6 UNITED HEALTHCARE (COMMERCIAL) [3081199] UNITED HEALTHCARE 87726 [308119901] 3.72 percent of total billed charges 3.72 5.7 Technical (Hospital) Services HC/HH Wch Supp Cover Probe Ultrasound__38-01 PX-2705000059 CDM 2705000059 LOCAL 270 RC inpatient 6 6 MEDICA (COMMERCIAL) 94265 [3081118] MEDICA CLAIMS [308111801] 5.4 percent of total billed charges 3.72 5.7 Technical (Hospital) Services HC/HH Wch Supp Cover Probe Ultrasound__38-01 PX-2705000059 CDM 2705000059 LOCAL 270 RC inpatient 6 6 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES HDHP [308136802] 4.75 percent of total billed charges 3.72 5.7 Technical (Hospital) Services HC/HH Wch Supp Cover Probe Ultrasound__38-01 PX-2705000059 CDM 2705000059 LOCAL 270 RC outpatient 6 6 HEALTHPARTNERS SX009 HEALTHPARTNERS 4.8 percent of total billed charges 3.72 5.7 Technical (Hospital) Services HC/HH Wch Supp Cover Probe Ultrasound__38-01 PX-2705000059 CDM 2705000059 LOCAL 270 RC outpatient 6 6 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES PPO [308136801] 4.8 percent of total billed charges 3.72 5.7 Technical (Hospital) Services HC/HH Wch Supp Cover Probe Ultrasound__38-01 PX-2705000059 CDM 2705000059 LOCAL 270 RC outpatient 6 6 UNITED HEALTHCARE (COMMERCIAL) [3081199] UNITED HEALTHCARE 87726 [308119901] 3.72 percent of total billed charges 3.72 5.7 Technical (Hospital) Services HC/HH Wch Supp Cover Probe Ultrasound__38-01 PX-2705000059 CDM 2705000059 LOCAL 270 RC outpatient 6 6 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES HDHP [308136802] 4.8 percent of total billed charges 3.72 5.7 Technical (Hospital) Services HC/HH Wch Supp Cover Probe Ultrasound__38-01 PX-2705000059 CDM 2705000059 LOCAL 270 RC outpatient 6 6 CIGNA 62308 [3081051] CIGNA 62308 [308105105] 4.8 percent of total billed charges 3.72 5.7 Technical (Hospital) Services HC/HH Wch Supp Cover Probe Ultrasound__38-01 PX-2705000059 CDM 2705000059 LOCAL 270 RC outpatient 6 6 CIGNA 62308 [3081051] CIGNA STATE OF WYOMING [308105107] 4.8 percent of total billed charges 3.72 5.7 Technical (Hospital) Services HC/HH Wch Supp Cover Probe Ultrasound__38-01 PX-2705000059 CDM 2705000059 LOCAL 270 RC outpatient 6 6 BLUE CROSS BLUE SHIELD WELLMARK SB889 [3081026] BCBS WYOMING [308102603] 5.7 percent of total billed charges 3.72 5.7 Technical (Hospital) Services HC/HH Wch Supp Cover Probe Ultrasound__38-01 PX-2705000059 CDM 2705000059 LOCAL 270 RC outpatient 6 6 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES EPO [308136803] 4.8 percent of total billed charges 3.72 5.7 Technical (Hospital) Services HC/HH Wch Supp Cover Probe Ultrasound__38-01 PX-2705000059 CDM 2705000059 LOCAL 270 RC outpatient 6 6 MEDICA (COMMERCIAL) 94265 [3081118] MEDICA CLAIMS [308111801] 5.4 percent of total billed charges 3.72 5.7 Technical (Hospital) Services HC/HH Wch Supp Cover Probe Ultrasound__38-01 PX-2705000059 CDM 2705000059 LOCAL 270 RC outpatient 6 6 MULTIPLAN INC 34080 [3081285] MULTIPLAN INC [308128501] 5.7 percent of total billed charges 3.72 5.7 Technical (Hospital) Services HC/HH Wch Supp Cotton Roll #1__2287 PX-2705000058 CDM 2705000058 LOCAL 270 RC inpatient 33 33 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES PPO [308136801] 26.13 percent of total billed charges 20.46 31.35 Technical (Hospital) Services HC/HH Wch Supp Cotton Roll #1__2287 PX-2705000058 CDM 2705000058 LOCAL 270 RC inpatient 33 33 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES HDHP [308136802] 26.13 percent of total billed charges 20.46 31.35 Technical (Hospital) Services HC/HH Wch Supp Cotton Roll #1__2287 PX-2705000058 CDM 2705000058 LOCAL 270 RC inpatient 33 33 UNITED HEALTHCARE (COMMERCIAL) [3081199] UNITED HEALTHCARE 87726 [308119901] 20.46 percent of total billed charges 20.46 31.35 Technical (Hospital) Services HC/HH Wch Supp Cotton Roll #1__2287 PX-2705000058 CDM 2705000058 LOCAL 270 RC inpatient 33 33 MEDICA (COMMERCIAL) 94265 [3081118] MEDICA CLAIMS [308111801] 29.7 percent of total billed charges 20.46 31.35 Technical (Hospital) Services HC/HH Wch Supp Cotton Roll #1__2287 PX-2705000058 CDM 2705000058 LOCAL 270 RC inpatient 33 33 BLUE CROSS BLUE SHIELD WELLMARK SB889 [3081026] BCBS WYOMING [308102603] 31.35 percent of total billed charges 20.46 31.35 Technical (Hospital) Services HC/HH Wch Supp Cotton Roll #1__2287 PX-2705000058 CDM 2705000058 LOCAL 270 RC inpatient 33 33 CIGNA 62308 [3081051] CIGNA 62308 [308105105] 26.13 percent of total billed charges 20.46 31.35 Technical (Hospital) Services HC/HH Wch Supp Cotton Roll #1__2287 PX-2705000058 CDM 2705000058 LOCAL 270 RC inpatient 33 33 CIGNA 62308 [3081051] CIGNA STATE OF WYOMING [308105107] 26.13 percent of total billed charges 20.46 31.35 Technical (Hospital) Services HC/HH Wch Supp Cotton Roll #1__2287 PX-2705000058 CDM 2705000058 LOCAL 270 RC inpatient 33 33 MULTIPLAN INC 34080 [3081285] MULTIPLAN INC [308128501] 31.35 percent of total billed charges 20.46 31.35 Technical (Hospital) Services HC/HH Wch Supp Cotton Roll #1__2287 PX-2705000058 CDM 2705000058 LOCAL 270 RC inpatient 33 33 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES EPO [308136803] 26.13 percent of total billed charges 20.46 31.35 Technical (Hospital) Services HC/HH Wch Supp Cotton Roll #1__2287 PX-2705000058 CDM 2705000058 LOCAL 270 RC inpatient 33 33 HEALTHPARTNERS SX009 HEALTHPARTNERS 26.13 percent of total billed charges 20.46 31.35 Technical (Hospital) Services HC/HH Wch Supp Cotton Roll #1__2287 PX-2705000058 CDM 2705000058 LOCAL 270 RC outpatient 33 33 BLUE CROSS BLUE SHIELD WELLMARK SB889 [3081026] BCBS WYOMING [308102603] 31.35 percent of total billed charges 20.46 31.35 Technical (Hospital) Services HC/HH Wch Supp Cotton Roll #1__2287 PX-2705000058 CDM 2705000058 LOCAL 270 RC outpatient 33 33 CIGNA 62308 [3081051] CIGNA 62308 [308105105] 26.4 percent of total billed charges 20.46 31.35 Technical (Hospital) Services HC/HH Wch Supp Cotton Roll #1__2287 PX-2705000058 CDM 2705000058 LOCAL 270 RC outpatient 33 33 CIGNA 62308 [3081051] CIGNA STATE OF WYOMING [308105107] 26.4 percent of total billed charges 20.46 31.35 Technical (Hospital) Services HC/HH Wch Supp Cotton Roll #1__2287 PX-2705000058 CDM 2705000058 LOCAL 270 RC outpatient 33 33 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES EPO [308136803] 26.4 percent of total billed charges 20.46 31.35 Technical (Hospital) Services HC/HH Wch Supp Cotton Roll #1__2287 PX-2705000058 CDM 2705000058 LOCAL 270 RC outpatient 33 33 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES HDHP [308136802] 26.4 percent of total billed charges 20.46 31.35 Technical (Hospital) Services HC/HH Wch Supp Cotton Roll #1__2287 PX-2705000058 CDM 2705000058 LOCAL 270 RC outpatient 33 33 HEALTHPARTNERS SX009 HEALTHPARTNERS 26.4 percent of total billed charges 20.46 31.35 Technical (Hospital) Services HC/HH Wch Supp Cotton Roll #1__2287 PX-2705000058 CDM 2705000058 LOCAL 270 RC outpatient 33 33 UNITED HEALTHCARE (COMMERCIAL) [3081199] UNITED HEALTHCARE 87726 [308119901] 20.46 percent of total billed charges 20.46 31.35 Technical (Hospital) Services HC/HH Wch Supp Cotton Roll #1__2287 PX-2705000058 CDM 2705000058 LOCAL 270 RC outpatient 33 33 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES PPO [308136801] 26.4 percent of total billed charges 20.46 31.35 Technical (Hospital) Services HC/HH Wch Supp Cotton Roll #1__2287 PX-2705000058 CDM 2705000058 LOCAL 270 RC outpatient 33 33 MULTIPLAN INC 34080 [3081285] MULTIPLAN INC [308128501] 31.35 percent of total billed charges 20.46 31.35 Technical (Hospital) Services HC/HH Wch Supp Cotton Roll #1__2287 PX-2705000058 CDM 2705000058 LOCAL 270 RC outpatient 33 33 MEDICA (COMMERCIAL) 94265 [3081118] MEDICA CLAIMS [308111801] 29.7 percent of total billed charges 20.46 31.35 Technical (Hospital) Services HC/HH Wch Supp Compression Sleeve Thigh Hi__Kdl5345h PX-2705000057 CDM 2705000057 LOCAL 270 RC inpatient 261 261 HEALTHPARTNERS SX009 HEALTHPARTNERS 206.66 percent of total billed charges 161.82 247.95 Technical (Hospital) Services HC/HH Wch Supp Compression Sleeve Thigh Hi__Kdl5345h PX-2705000057 CDM 2705000057 LOCAL 270 RC inpatient 261 261 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES EPO [308136803] 206.66 percent of total billed charges 161.82 247.95 Technical (Hospital) Services HC/HH Wch Supp Compression Sleeve Thigh Hi__Kdl5345h PX-2705000057 CDM 2705000057 LOCAL 270 RC inpatient 261 261 BLUE CROSS BLUE SHIELD WELLMARK SB889 [3081026] BCBS WYOMING [308102603] 247.95 percent of total billed charges 161.82 247.95 Technical (Hospital) Services HC/HH Wch Supp Compression Sleeve Thigh Hi__Kdl5345h PX-2705000057 CDM 2705000057 LOCAL 270 RC inpatient 261 261 CIGNA 62308 [3081051] CIGNA 62308 [308105105] 206.66 percent of total billed charges 161.82 247.95 Technical (Hospital) Services HC/HH Wch Supp Compression Sleeve Thigh Hi__Kdl5345h PX-2705000057 CDM 2705000057 LOCAL 270 RC inpatient 261 261 CIGNA 62308 [3081051] CIGNA STATE OF WYOMING [308105107] 206.66 percent of total billed charges 161.82 247.95 Technical (Hospital) Services HC/HH Wch Supp Compression Sleeve Thigh Hi__Kdl5345h PX-2705000057 CDM 2705000057 LOCAL 270 RC inpatient 261 261 MULTIPLAN INC 34080 [3081285] MULTIPLAN INC [308128501] 247.95 percent of total billed charges 161.82 247.95 Technical (Hospital) Services HC/HH Wch Supp Compression Sleeve Thigh Hi__Kdl5345h PX-2705000057 CDM 2705000057 LOCAL 270 RC inpatient 261 261 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES PPO [308136801] 206.66 percent of total billed charges 161.82 247.95 Technical (Hospital) Services HC/HH Wch Supp Compression Sleeve Thigh Hi__Kdl5345h PX-2705000057 CDM 2705000057 LOCAL 270 RC inpatient 261 261 MEDICA (COMMERCIAL) 94265 [3081118] MEDICA CLAIMS [308111801] 234.9 percent of total billed charges 161.82 247.95 Technical (Hospital) Services HC/HH Wch Supp Compression Sleeve Thigh Hi__Kdl5345h PX-2705000057 CDM 2705000057 LOCAL 270 RC inpatient 261 261 UNITED HEALTHCARE (COMMERCIAL) [3081199] UNITED HEALTHCARE 87726 [308119901] 161.82 percent of total billed charges 161.82 247.95 Technical (Hospital) Services HC/HH Wch Supp Compression Sleeve Thigh Hi__Kdl5345h PX-2705000057 CDM 2705000057 LOCAL 270 RC inpatient 261 261 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES HDHP [308136802] 206.66 percent of total billed charges 161.82 247.95 Technical (Hospital) Services HC/HH Wch Supp Compression Sleeve Thigh Hi__Kdl5345h PX-2705000057 CDM 2705000057 LOCAL 270 RC outpatient 261 261 MEDICA (COMMERCIAL) 94265 [3081118] MEDICA CLAIMS [308111801] 234.9 percent of total billed charges 161.82 247.95 Technical (Hospital) Services HC/HH Wch Supp Compression Sleeve Thigh Hi__Kdl5345h PX-2705000057 CDM 2705000057 LOCAL 270 RC outpatient 261 261 MULTIPLAN INC 34080 [3081285] MULTIPLAN INC [308128501] 247.95 percent of total billed charges 161.82 247.95 Technical (Hospital) Services HC/HH Wch Supp Compression Sleeve Thigh Hi__Kdl5345h PX-2705000057 CDM 2705000057 LOCAL 270 RC outpatient 261 261 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES PPO [308136801] 208.8 percent of total billed charges 161.82 247.95 Technical (Hospital) Services HC/HH Wch Supp Compression Sleeve Thigh Hi__Kdl5345h PX-2705000057 CDM 2705000057 LOCAL 270 RC outpatient 261 261 HEALTHPARTNERS SX009 HEALTHPARTNERS 208.8 percent of total billed charges 161.82 247.95 Technical (Hospital) Services HC/HH Wch Supp Compression Sleeve Thigh Hi__Kdl5345h PX-2705000057 CDM 2705000057 LOCAL 270 RC outpatient 261 261 UNITED HEALTHCARE (COMMERCIAL) [3081199] UNITED HEALTHCARE 87726 [308119901] 161.82 percent of total billed charges 161.82 247.95 Technical (Hospital) Services HC/HH Wch Supp Compression Sleeve Thigh Hi__Kdl5345h PX-2705000057 CDM 2705000057 LOCAL 270 RC outpatient 261 261 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES EPO [308136803] 208.8 percent of total billed charges 161.82 247.95 Technical (Hospital) Services HC/HH Wch Supp Compression Sleeve Thigh Hi__Kdl5345h PX-2705000057 CDM 2705000057 LOCAL 270 RC outpatient 261 261 BLUE CROSS BLUE SHIELD WELLMARK SB889 [3081026] BCBS WYOMING [308102603] 247.95 percent of total billed charges 161.82 247.95 Technical (Hospital) Services HC/HH Wch Supp Compression Sleeve Thigh Hi__Kdl5345h PX-2705000057 CDM 2705000057 LOCAL 270 RC outpatient 261 261 CIGNA 62308 [3081051] CIGNA 62308 [308105105] 208.8 percent of total billed charges 161.82 247.95 Technical (Hospital) Services HC/HH Wch Supp Compression Sleeve Thigh Hi__Kdl5345h PX-2705000057 CDM 2705000057 LOCAL 270 RC outpatient 261 261 CIGNA 62308 [3081051] CIGNA STATE OF WYOMING [308105107] 208.8 percent of total billed charges 161.82 247.95 Technical (Hospital) Services HC/HH Wch Supp Compression Sleeve Thigh Hi__Kdl5345h PX-2705000057 CDM 2705000057 LOCAL 270 RC outpatient 261 261 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES HDHP [308136802] 208.8 percent of total billed charges 161.82 247.95 Technical (Hospital) Services HC/HH Wch Supp Collection Unit Specipan__4014 PX-2705000056 CDM 2705000056 LOCAL 270 RC outpatient 5 5 HEALTHPARTNERS SX009 HEALTHPARTNERS 4 percent of total billed charges 3.1 4.75 Technical (Hospital) Services HC/HH Wch Supp Collection Unit Specipan__4014 PX-2705000056 CDM 2705000056 LOCAL 270 RC outpatient 5 5 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES PPO [308136801] 4 percent of total billed charges 3.1 4.75 Technical (Hospital) Services HC/HH Wch Supp Collection Unit Specipan__4014 PX-2705000056 CDM 2705000056 LOCAL 270 RC outpatient 5 5 UNITED HEALTHCARE (COMMERCIAL) [3081199] UNITED HEALTHCARE 87726 [308119901] 3.1 percent of total billed charges 3.1 4.75 Technical (Hospital) Services HC/HH Wch Supp Collection Unit Specipan__4014 PX-2705000056 CDM 2705000056 LOCAL 270 RC outpatient 5 5 BLUE CROSS BLUE SHIELD WELLMARK SB889 [3081026] BCBS WYOMING [308102603] 4.75 percent of total billed charges 3.1 4.75 Technical (Hospital) Services HC/HH Wch Supp Collection Unit Specipan__4014 PX-2705000056 CDM 2705000056 LOCAL 270 RC outpatient 5 5 CIGNA 62308 [3081051] CIGNA 62308 [308105105] 4 percent of total billed charges 3.1 4.75 Technical (Hospital) Services HC/HH Wch Supp Collection Unit Specipan__4014 PX-2705000056 CDM 2705000056 LOCAL 270 RC outpatient 5 5 CIGNA 62308 [3081051] CIGNA STATE OF WYOMING [308105107] 4 percent of total billed charges 3.1 4.75 Technical (Hospital) Services HC/HH Wch Supp Collection Unit Specipan__4014 PX-2705000056 CDM 2705000056 LOCAL 270 RC outpatient 5 5 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES HDHP [308136802] 4 percent of total billed charges 3.1 4.75 Technical (Hospital) Services HC/HH Wch Supp Collection Unit Specipan__4014 PX-2705000056 CDM 2705000056 LOCAL 270 RC outpatient 5 5 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES EPO [308136803] 4 percent of total billed charges 3.1 4.75 Technical (Hospital) Services HC/HH Wch Supp Collection Unit Specipan__4014 PX-2705000056 CDM 2705000056 LOCAL 270 RC outpatient 5 5 MULTIPLAN INC 34080 [3081285] MULTIPLAN INC [308128501] 4.75 percent of total billed charges 3.1 4.75 Technical (Hospital) Services HC/HH Wch Supp Collection Unit Specipan__4014 PX-2705000056 CDM 2705000056 LOCAL 270 RC outpatient 5 5 MEDICA (COMMERCIAL) 94265 [3081118] MEDICA CLAIMS [308111801] 4.5 percent of total billed charges 3.1 4.75 Technical (Hospital) Services HC/HH Wch Supp Collection Unit Specipan__4014 PX-2705000056 CDM 2705000056 LOCAL 270 RC inpatient 5 5 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES PPO [308136801] 3.96 percent of total billed charges 3.1 4.75 Technical (Hospital) Services HC/HH Wch Supp Collection Unit Specipan__4014 PX-2705000056 CDM 2705000056 LOCAL 270 RC inpatient 5 5 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES HDHP [308136802] 3.96 percent of total billed charges 3.1 4.75 Technical (Hospital) Services HC/HH Wch Supp Collection Unit Specipan__4014 PX-2705000056 CDM 2705000056 LOCAL 270 RC inpatient 5 5 UNITED HEALTHCARE (COMMERCIAL) [3081199] UNITED HEALTHCARE 87726 [308119901] 3.1 percent of total billed charges 3.1 4.75 Technical (Hospital) Services HC/HH Wch Supp Collection Unit Specipan__4014 PX-2705000056 CDM 2705000056 LOCAL 270 RC inpatient 5 5 MEDICA (COMMERCIAL) 94265 [3081118] MEDICA CLAIMS [308111801] 4.5 percent of total billed charges 3.1 4.75 Technical (Hospital) Services HC/HH Wch Supp Collection Unit Specipan__4014 PX-2705000056 CDM 2705000056 LOCAL 270 RC inpatient 5 5 MULTIPLAN INC 34080 [3081285] MULTIPLAN INC [308128501] 4.75 percent of total billed charges 3.1 4.75 Technical (Hospital) Services HC/HH Wch Supp Collection Unit Specipan__4014 PX-2705000056 CDM 2705000056 LOCAL 270 RC inpatient 5 5 BLUE CROSS BLUE SHIELD WELLMARK SB889 [3081026] BCBS WYOMING [308102603] 4.75 percent of total billed charges 3.1 4.75 Technical (Hospital) Services HC/HH Wch Supp Collection Unit Specipan__4014 PX-2705000056 CDM 2705000056 LOCAL 270 RC inpatient 5 5 CIGNA 62308 [3081051] CIGNA 62308 [308105105] 3.96 percent of total billed charges 3.1 4.75 Technical (Hospital) Services HC/HH Wch Supp Collection Unit Specipan__4014 PX-2705000056 CDM 2705000056 LOCAL 270 RC inpatient 5 5 CIGNA 62308 [3081051] CIGNA STATE OF WYOMING [308105107] 3.96 percent of total billed charges 3.1 4.75 Technical (Hospital) Services HC/HH Wch Supp Collection Unit Specipan__4014 PX-2705000056 CDM 2705000056 LOCAL 270 RC inpatient 5 5 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES EPO [308136803] 3.96 percent of total billed charges 3.1 4.75 Technical (Hospital) Services HC/HH Wch Supp Collection Unit Specipan__4014 PX-2705000056 CDM 2705000056 LOCAL 270 RC inpatient 5 5 HEALTHPARTNERS SX009 HEALTHPARTNERS 3.96 percent of total billed charges 3.1 4.75 Technical (Hospital) Services HC/HH Wch Supp Collar Cervical Rd Lg 4.5x22__0814-9704 PX-2705000055 CDM 2705000055 LOCAL 270 RC inpatient 32 32 MULTIPLAN INC 34080 [3081285] MULTIPLAN INC [308128501] 30.4 percent of total billed charges 19.84 30.4 Technical (Hospital) Services HC/HH Wch Supp Collar Cervical Rd Lg 4.5x22__0814-9704 PX-2705000055 CDM 2705000055 LOCAL 270 RC inpatient 32 32 CIGNA 62308 [3081051] CIGNA 62308 [308105105] 25.34 percent of total billed charges 19.84 30.4 Technical (Hospital) Services HC/HH Wch Supp Collar Cervical Rd Lg 4.5x22__0814-9704 PX-2705000055 CDM 2705000055 LOCAL 270 RC inpatient 32 32 CIGNA 62308 [3081051] CIGNA STATE OF WYOMING [308105107] 25.34 percent of total billed charges 19.84 30.4 Technical (Hospital) Services HC/HH Wch Supp Collar Cervical Rd Lg 4.5x22__0814-9704 PX-2705000055 CDM 2705000055 LOCAL 270 RC inpatient 32 32 BLUE CROSS BLUE SHIELD WELLMARK SB889 [3081026] BCBS WYOMING [308102603] 30.4 percent of total billed charges 19.84 30.4 Technical (Hospital) Services HC/HH Wch Supp Collar Cervical Rd Lg 4.5x22__0814-9704 PX-2705000055 CDM 2705000055 LOCAL 270 RC inpatient 32 32 HEALTHPARTNERS SX009 HEALTHPARTNERS 25.34 percent of total billed charges 19.84 30.4 Technical (Hospital) Services HC/HH Wch Supp Collar Cervical Rd Lg 4.5x22__0814-9704 PX-2705000055 CDM 2705000055 LOCAL 270 RC inpatient 32 32 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES EPO [308136803] 25.34 percent of total billed charges 19.84 30.4 Technical (Hospital) Services HC/HH Wch Supp Collar Cervical Rd Lg 4.5x22__0814-9704 PX-2705000055 CDM 2705000055 LOCAL 270 RC inpatient 32 32 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES HDHP [308136802] 25.34 percent of total billed charges 19.84 30.4 Technical (Hospital) Services HC/HH Wch Supp Collar Cervical Rd Lg 4.5x22__0814-9704 PX-2705000055 CDM 2705000055 LOCAL 270 RC inpatient 32 32 UNITED HEALTHCARE (COMMERCIAL) [3081199] UNITED HEALTHCARE 87726 [308119901] 19.84 percent of total billed charges 19.84 30.4 Technical (Hospital) Services HC/HH Wch Supp Collar Cervical Rd Lg 4.5x22__0814-9704 PX-2705000055 CDM 2705000055 LOCAL 270 RC inpatient 32 32 MEDICA (COMMERCIAL) 94265 [3081118] MEDICA CLAIMS [308111801] 28.8 percent of total billed charges 19.84 30.4 Technical (Hospital) Services HC/HH Wch Supp Collar Cervical Rd Lg 4.5x22__0814-9704 PX-2705000055 CDM 2705000055 LOCAL 270 RC inpatient 32 32 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES PPO [308136801] 25.34 percent of total billed charges 19.84 30.4 Technical (Hospital) Services HC/HH Wch Supp Collar Cervical Rd Lg 4.5x22__0814-9704 PX-2705000055 CDM 2705000055 LOCAL 270 RC outpatient 32 32 BLUE CROSS BLUE SHIELD WELLMARK SB889 [3081026] BCBS WYOMING [308102603] 30.4 percent of total billed charges 19.84 30.4 Technical (Hospital) Services HC/HH Wch Supp Collar Cervical Rd Lg 4.5x22__0814-9704 PX-2705000055 CDM 2705000055 LOCAL 270 RC outpatient 32 32 CIGNA 62308 [3081051] CIGNA 62308 [308105105] 25.6 percent of total billed charges 19.84 30.4 Technical (Hospital) Services HC/HH Wch Supp Collar Cervical Rd Lg 4.5x22__0814-9704 PX-2705000055 CDM 2705000055 LOCAL 270 RC outpatient 32 32 CIGNA 62308 [3081051] CIGNA STATE OF WYOMING [308105107] 25.6 percent of total billed charges 19.84 30.4 Technical (Hospital) Services HC/HH Wch Supp Collar Cervical Rd Lg 4.5x22__0814-9704 PX-2705000055 CDM 2705000055 LOCAL 270 RC outpatient 32 32 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES EPO [308136803] 25.6 percent of total billed charges 19.84 30.4 Technical (Hospital) Services HC/HH Wch Supp Collar Cervical Rd Lg 4.5x22__0814-9704 PX-2705000055 CDM 2705000055 LOCAL 270 RC outpatient 32 32 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES HDHP [308136802] 25.6 percent of total billed charges 19.84 30.4 Technical (Hospital) Services HC/HH Wch Supp Collar Cervical Rd Lg 4.5x22__0814-9704 PX-2705000055 CDM 2705000055 LOCAL 270 RC outpatient 32 32 HEALTHPARTNERS SX009 HEALTHPARTNERS 25.6 percent of total billed charges 19.84 30.4 Technical (Hospital) Services HC/HH Wch Supp Collar Cervical Rd Lg 4.5x22__0814-9704 PX-2705000055 CDM 2705000055 LOCAL 270 RC outpatient 32 32 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES PPO [308136801] 25.6 percent of total billed charges 19.84 30.4 Technical (Hospital) Services HC/HH Wch Supp Collar Cervical Rd Lg 4.5x22__0814-9704 PX-2705000055 CDM 2705000055 LOCAL 270 RC outpatient 32 32 UNITED HEALTHCARE (COMMERCIAL) [3081199] UNITED HEALTHCARE 87726 [308119901] 19.84 percent of total billed charges 19.84 30.4 Technical (Hospital) Services HC/HH Wch Supp Collar Cervical Rd Lg 4.5x22__0814-9704 PX-2705000055 CDM 2705000055 LOCAL 270 RC outpatient 32 32 MULTIPLAN INC 34080 [3081285] MULTIPLAN INC [308128501] 30.4 percent of total billed charges 19.84 30.4 Technical (Hospital) Services HC/HH Wch Supp Collar Cervical Rd Lg 4.5x22__0814-9704 PX-2705000055 CDM 2705000055 LOCAL 270 RC outpatient 32 32 MEDICA (COMMERCIAL) 94265 [3081118] MEDICA CLAIMS [308111801] 28.8 percent of total billed charges 19.84 30.4 Technical (Hospital) Services HC/HH Wch Supp Collar Cervical 3.5 Reg S__0814-9702 PX-2705000054 CDM 2705000054 LOCAL 270 RC inpatient 32 32 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES PPO [308136801] 25.34 percent of total billed charges 19.84 30.4 Technical (Hospital) Services HC/HH Wch Supp Collar Cervical 3.5 Reg S__0814-9702 PX-2705000054 CDM 2705000054 LOCAL 270 RC inpatient 32 32 MEDICA (COMMERCIAL) 94265 [3081118] MEDICA CLAIMS [308111801] 28.8 percent of total billed charges 19.84 30.4 Technical (Hospital) Services HC/HH Wch Supp Collar Cervical 3.5 Reg S__0814-9702 PX-2705000054 CDM 2705000054 LOCAL 270 RC inpatient 32 32 UNITED HEALTHCARE (COMMERCIAL) [3081199] UNITED HEALTHCARE 87726 [308119901] 19.84 percent of total billed charges 19.84 30.4 Technical (Hospital) Services HC/HH Wch Supp Collar Cervical 3.5 Reg S__0814-9702 PX-2705000054 CDM 2705000054 LOCAL 270 RC inpatient 32 32 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES HDHP [308136802] 25.34 percent of total billed charges 19.84 30.4 Technical (Hospital) Services HC/HH Wch Supp Collar Cervical 3.5 Reg S__0814-9702 PX-2705000054 CDM 2705000054 LOCAL 270 RC inpatient 32 32 CIGNA 62308 [3081051] CIGNA 62308 [308105105] 25.34 percent of total billed charges 19.84 30.4 Technical (Hospital) Services HC/HH Wch Supp Collar Cervical 3.5 Reg S__0814-9702 PX-2705000054 CDM 2705000054 LOCAL 270 RC inpatient 32 32 CIGNA 62308 [3081051] CIGNA STATE OF WYOMING [308105107] 25.34 percent of total billed charges 19.84 30.4 Technical (Hospital) Services HC/HH Wch Supp Collar Cervical 3.5 Reg S__0814-9702 PX-2705000054 CDM 2705000054 LOCAL 270 RC inpatient 32 32 BLUE CROSS BLUE SHIELD WELLMARK SB889 [3081026] BCBS WYOMING [308102603] 30.4 percent of total billed charges 19.84 30.4 Technical (Hospital) Services HC/HH Wch Supp Collar Cervical 3.5 Reg S__0814-9702 PX-2705000054 CDM 2705000054 LOCAL 270 RC inpatient 32 32 MULTIPLAN INC 34080 [3081285] MULTIPLAN INC [308128501] 30.4 percent of total billed charges 19.84 30.4 Technical (Hospital) Services HC/HH Wch Supp Collar Cervical 3.5 Reg S__0814-9702 PX-2705000054 CDM 2705000054 LOCAL 270 RC inpatient 32 32 HEALTHPARTNERS SX009 HEALTHPARTNERS 25.34 percent of total billed charges 19.84 30.4 Technical (Hospital) Services HC/HH Wch Supp Collar Cervical 3.5 Reg S__0814-9702 PX-2705000054 CDM 2705000054 LOCAL 270 RC inpatient 32 32 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES EPO [308136803] 25.34 percent of total billed charges 19.84 30.4 Technical (Hospital) Services HC/HH Wch Supp Collar Cervical 3.5 Reg S__0814-9702 PX-2705000054 CDM 2705000054 LOCAL 270 RC outpatient 32 32 CIGNA 62308 [3081051] CIGNA 62308 [308105105] 25.6 percent of total billed charges 19.84 30.4 Technical (Hospital) Services HC/HH Wch Supp Collar Cervical 3.5 Reg S__0814-9702 PX-2705000054 CDM 2705000054 LOCAL 270 RC outpatient 32 32 CIGNA 62308 [3081051] CIGNA STATE OF WYOMING [308105107] 25.6 percent of total billed charges 19.84 30.4 Technical (Hospital) Services HC/HH Wch Supp Collar Cervical 3.5 Reg S__0814-9702 PX-2705000054 CDM 2705000054 LOCAL 270 RC outpatient 32 32 BLUE CROSS BLUE SHIELD WELLMARK SB889 [3081026] BCBS WYOMING [308102603] 30.4 percent of total billed charges 19.84 30.4 Technical (Hospital) Services HC/HH Wch Supp Collar Cervical 3.5 Reg S__0814-9702 PX-2705000054 CDM 2705000054 LOCAL 270 RC outpatient 32 32 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES EPO [308136803] 25.6 percent of total billed charges 19.84 30.4 Technical (Hospital) Services HC/HH Wch Supp Collar Cervical 3.5 Reg S__0814-9702 PX-2705000054 CDM 2705000054 LOCAL 270 RC outpatient 32 32 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES HDHP [308136802] 25.6 percent of total billed charges 19.84 30.4 Technical (Hospital) Services HC/HH Wch Supp Collar Cervical 3.5 Reg S__0814-9702 PX-2705000054 CDM 2705000054 LOCAL 270 RC outpatient 32 32 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES PPO [308136801] 25.6 percent of total billed charges 19.84 30.4 Technical (Hospital) Services HC/HH Wch Supp Collar Cervical 3.5 Reg S__0814-9702 PX-2705000054 CDM 2705000054 LOCAL 270 RC outpatient 32 32 HEALTHPARTNERS SX009 HEALTHPARTNERS 25.6 percent of total billed charges 19.84 30.4 Technical (Hospital) Services HC/HH Wch Supp Collar Cervical 3.5 Reg S__0814-9702 PX-2705000054 CDM 2705000054 LOCAL 270 RC outpatient 32 32 UNITED HEALTHCARE (COMMERCIAL) [3081199] UNITED HEALTHCARE 87726 [308119901] 19.84 percent of total billed charges 19.84 30.4 Technical (Hospital) Services HC/HH Wch Supp Collar Cervical 3.5 Reg S__0814-9702 PX-2705000054 CDM 2705000054 LOCAL 270 RC outpatient 32 32 MEDICA (COMMERCIAL) 94265 [3081118] MEDICA CLAIMS [308111801] 28.8 percent of total billed charges 19.84 30.4 Technical (Hospital) Services HC/HH Wch Supp Collar Cervical 3.5 Reg S__0814-9702 PX-2705000054 CDM 2705000054 LOCAL 270 RC outpatient 32 32 MULTIPLAN INC 34080 [3081285] MULTIPLAN INC [308128501] 30.4 percent of total billed charges 19.84 30.4 Technical (Hospital) Services HC/HH Wch Supp Collar Cervical 3.5 L Uni__0814-0381 PX-2705000053 CDM 2705000053 LOCAL 270 RC inpatient 32 32 MEDICA (COMMERCIAL) 94265 [3081118] MEDICA CLAIMS [308111801] 28.8 percent of total billed charges 19.84 30.4 Technical (Hospital) Services HC/HH Wch Supp Collar Cervical 3.5 L Uni__0814-0381 PX-2705000053 CDM 2705000053 LOCAL 270 RC inpatient 32 32 UNITED HEALTHCARE (COMMERCIAL) [3081199] UNITED HEALTHCARE 87726 [308119901] 19.84 percent of total billed charges 19.84 30.4 Technical (Hospital) Services HC/HH Wch Supp Collar Cervical 3.5 L Uni__0814-0381 PX-2705000053 CDM 2705000053 LOCAL 270 RC inpatient 32 32 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES HDHP [308136802] 25.34 percent of total billed charges 19.84 30.4 Technical (Hospital) Services HC/HH Wch Supp Collar Cervical 3.5 L Uni__0814-0381 PX-2705000053 CDM 2705000053 LOCAL 270 RC inpatient 32 32 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES PPO [308136801] 25.34 percent of total billed charges 19.84 30.4 Technical (Hospital) Services HC/HH Wch Supp Collar Cervical 3.5 L Uni__0814-0381 PX-2705000053 CDM 2705000053 LOCAL 270 RC inpatient 32 32 BLUE CROSS BLUE SHIELD WELLMARK SB889 [3081026] BCBS WYOMING [308102603] 30.4 percent of total billed charges 19.84 30.4 Technical (Hospital) Services HC/HH Wch Supp Collar Cervical 3.5 L Uni__0814-0381 PX-2705000053 CDM 2705000053 LOCAL 270 RC inpatient 32 32 MULTIPLAN INC 34080 [3081285] MULTIPLAN INC [308128501] 30.4 percent of total billed charges 19.84 30.4 Technical (Hospital) Services HC/HH Wch Supp Collar Cervical 3.5 L Uni__0814-0381 PX-2705000053 CDM 2705000053 LOCAL 270 RC inpatient 32 32 CIGNA 62308 [3081051] CIGNA 62308 [308105105] 25.34 percent of total billed charges 19.84 30.4 Technical (Hospital) Services HC/HH Wch Supp Collar Cervical 3.5 L Uni__0814-0381 PX-2705000053 CDM 2705000053 LOCAL 270 RC inpatient 32 32 CIGNA 62308 [3081051] CIGNA STATE OF WYOMING [308105107] 25.34 percent of total billed charges 19.84 30.4 Technical (Hospital) Services HC/HH Wch Supp Collar Cervical 3.5 L Uni__0814-0381 PX-2705000053 CDM 2705000053 LOCAL 270 RC inpatient 32 32 HEALTHPARTNERS SX009 HEALTHPARTNERS 25.34 percent of total billed charges 19.84 30.4 Technical (Hospital) Services HC/HH Wch Supp Collar Cervical 3.5 L Uni__0814-0381 PX-2705000053 CDM 2705000053 LOCAL 270 RC inpatient 32 32 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES EPO [308136803] 25.34 percent of total billed charges 19.84 30.4 Technical (Hospital) Services HC/HH Wch Supp Collar Cervical 3.5 L Uni__0814-0381 PX-2705000053 CDM 2705000053 LOCAL 270 RC outpatient 32 32 HEALTHPARTNERS SX009 HEALTHPARTNERS 25.6 percent of total billed charges 19.84 30.4 Technical (Hospital) Services HC/HH Wch Supp Collar Cervical 3.5 L Uni__0814-0381 PX-2705000053 CDM 2705000053 LOCAL 270 RC outpatient 32 32 UNITED HEALTHCARE (COMMERCIAL) [3081199] UNITED HEALTHCARE 87726 [308119901] 19.84 percent of total billed charges 19.84 30.4 Technical (Hospital) Services HC/HH Wch Supp Collar Cervical 3.5 L Uni__0814-0381 PX-2705000053 CDM 2705000053 LOCAL 270 RC outpatient 32 32 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES PPO [308136801] 25.6 percent of total billed charges 19.84 30.4 Technical (Hospital) Services HC/HH Wch Supp Collar Cervical 3.5 L Uni__0814-0381 PX-2705000053 CDM 2705000053 LOCAL 270 RC outpatient 32 32 CIGNA 62308 [3081051] CIGNA 62308 [308105105] 25.6 percent of total billed charges 19.84 30.4 Technical (Hospital) Services HC/HH Wch Supp Collar Cervical 3.5 L Uni__0814-0381 PX-2705000053 CDM 2705000053 LOCAL 270 RC outpatient 32 32 CIGNA 62308 [3081051] CIGNA STATE OF WYOMING [308105107] 25.6 percent of total billed charges 19.84 30.4 Technical (Hospital) Services HC/HH Wch Supp Collar Cervical 3.5 L Uni__0814-0381 PX-2705000053 CDM 2705000053 LOCAL 270 RC outpatient 32 32 BLUE CROSS BLUE SHIELD WELLMARK SB889 [3081026] BCBS WYOMING [308102603] 30.4 percent of total billed charges 19.84 30.4 Technical (Hospital) Services HC/HH Wch Supp Collar Cervical 3.5 L Uni__0814-0381 PX-2705000053 CDM 2705000053 LOCAL 270 RC outpatient 32 32 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES EPO [308136803] 25.6 percent of total billed charges 19.84 30.4 Technical (Hospital) Services HC/HH Wch Supp Collar Cervical 3.5 L Uni__0814-0381 PX-2705000053 CDM 2705000053 LOCAL 270 RC outpatient 32 32 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES HDHP [308136802] 25.6 percent of total billed charges 19.84 30.4 Technical (Hospital) Services HC/HH Wch Supp Collar Cervical 3.5 L Uni__0814-0381 PX-2705000053 CDM 2705000053 LOCAL 270 RC outpatient 32 32 MEDICA (COMMERCIAL) 94265 [3081118] MEDICA CLAIMS [308111801] 28.8 percent of total billed charges 19.84 30.4 Technical (Hospital) Services HC/HH Wch Supp Collar Cervical 3.5 L Uni__0814-0381 PX-2705000053 CDM 2705000053 LOCAL 270 RC outpatient 32 32 MULTIPLAN INC 34080 [3081285] MULTIPLAN INC [308128501] 30.4 percent of total billed charges 19.84 30.4 Technical (Hospital) Services "HC/HH Wch Supp Collar Cerv Lo Univ 3__08140380""" PX-2705000052 CDM 2705000052 LOCAL 270 RC inpatient 37 37 BLUE CROSS BLUE SHIELD WELLMARK SB889 [3081026] BCBS WYOMING [308102603] 35.15 percent of total billed charges 22.94 35.15 Technical (Hospital) Services "HC/HH Wch Supp Collar Cerv Lo Univ 3__08140380""" PX-2705000052 CDM 2705000052 LOCAL 270 RC inpatient 37 37 MULTIPLAN INC 34080 [3081285] MULTIPLAN INC [308128501] 35.15 percent of total billed charges 22.94 35.15 Technical (Hospital) Services "HC/HH Wch Supp Collar Cerv Lo Univ 3__08140380""" PX-2705000052 CDM 2705000052 LOCAL 270 RC inpatient 37 37 CIGNA 62308 [3081051] CIGNA 62308 [308105105] 29.3 percent of total billed charges 22.94 35.15 Technical (Hospital) Services "HC/HH Wch Supp Collar Cerv Lo Univ 3__08140380""" PX-2705000052 CDM 2705000052 LOCAL 270 RC inpatient 37 37 CIGNA 62308 [3081051] CIGNA STATE OF WYOMING [308105107] 29.3 percent of total billed charges 22.94 35.15 Technical (Hospital) Services "HC/HH Wch Supp Collar Cerv Lo Univ 3__08140380""" PX-2705000052 CDM 2705000052 LOCAL 270 RC inpatient 37 37 HEALTHPARTNERS SX009 HEALTHPARTNERS 29.3 percent of total billed charges 22.94 35.15 Technical (Hospital) Services "HC/HH Wch Supp Collar Cerv Lo Univ 3__08140380""" PX-2705000052 CDM 2705000052 LOCAL 270 RC inpatient 37 37 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES EPO [308136803] 29.3 percent of total billed charges 22.94 35.15 Technical (Hospital) Services "HC/HH Wch Supp Collar Cerv Lo Univ 3__08140380""" PX-2705000052 CDM 2705000052 LOCAL 270 RC inpatient 37 37 MEDICA (COMMERCIAL) 94265 [3081118] MEDICA CLAIMS [308111801] 33.3 percent of total billed charges 22.94 35.15 Technical (Hospital) Services "HC/HH Wch Supp Collar Cerv Lo Univ 3__08140380""" PX-2705000052 CDM 2705000052 LOCAL 270 RC inpatient 37 37 UNITED HEALTHCARE (COMMERCIAL) [3081199] UNITED HEALTHCARE 87726 [308119901] 22.94 percent of total billed charges 22.94 35.15 Technical (Hospital) Services "HC/HH Wch Supp Collar Cerv Lo Univ 3__08140380""" PX-2705000052 CDM 2705000052 LOCAL 270 RC inpatient 37 37 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES HDHP [308136802] 29.3 percent of total billed charges 22.94 35.15 Technical (Hospital) Services "HC/HH Wch Supp Collar Cerv Lo Univ 3__08140380""" PX-2705000052 CDM 2705000052 LOCAL 270 RC inpatient 37 37 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES PPO [308136801] 29.3 percent of total billed charges 22.94 35.15 Technical (Hospital) Services "HC/HH Wch Supp Collar Cerv Lo Univ 3__08140380""" PX-2705000052 CDM 2705000052 LOCAL 270 RC outpatient 37 37 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES HDHP [308136802] 29.6 percent of total billed charges 22.94 35.15 Technical (Hospital) Services "HC/HH Wch Supp Collar Cerv Lo Univ 3__08140380""" PX-2705000052 CDM 2705000052 LOCAL 270 RC outpatient 37 37 CIGNA 62308 [3081051] CIGNA 62308 [308105105] 29.6 percent of total billed charges 22.94 35.15 Technical (Hospital) Services "HC/HH Wch Supp Collar Cerv Lo Univ 3__08140380""" PX-2705000052 CDM 2705000052 LOCAL 270 RC outpatient 37 37 CIGNA 62308 [3081051] CIGNA STATE OF WYOMING [308105107] 29.6 percent of total billed charges 22.94 35.15 Technical (Hospital) Services "HC/HH Wch Supp Collar Cerv Lo Univ 3__08140380""" PX-2705000052 CDM 2705000052 LOCAL 270 RC outpatient 37 37 BLUE CROSS BLUE SHIELD WELLMARK SB889 [3081026] BCBS WYOMING [308102603] 35.15 percent of total billed charges 22.94 35.15 Technical (Hospital) Services "HC/HH Wch Supp Collar Cerv Lo Univ 3__08140380""" PX-2705000052 CDM 2705000052 LOCAL 270 RC outpatient 37 37 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES EPO [308136803] 29.6 percent of total billed charges 22.94 35.15 Technical (Hospital) Services "HC/HH Wch Supp Collar Cerv Lo Univ 3__08140380""" PX-2705000052 CDM 2705000052 LOCAL 270 RC outpatient 37 37 UNITED HEALTHCARE (COMMERCIAL) [3081199] UNITED HEALTHCARE 87726 [308119901] 22.94 percent of total billed charges 22.94 35.15 Technical (Hospital) Services "HC/HH Wch Supp Collar Cerv Lo Univ 3__08140380""" PX-2705000052 CDM 2705000052 LOCAL 270 RC outpatient 37 37 HEALTHPARTNERS SX009 HEALTHPARTNERS 29.6 percent of total billed charges 22.94 35.15 Technical (Hospital) Services "HC/HH Wch Supp Collar Cerv Lo Univ 3__08140380""" PX-2705000052 CDM 2705000052 LOCAL 270 RC outpatient 37 37 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES PPO [308136801] 29.6 percent of total billed charges 22.94 35.15 Technical (Hospital) Services "HC/HH Wch Supp Collar Cerv Lo Univ 3__08140380""" PX-2705000052 CDM 2705000052 LOCAL 270 RC outpatient 37 37 MULTIPLAN INC 34080 [3081285] MULTIPLAN INC [308128501] 35.15 percent of total billed charges 22.94 35.15 Technical (Hospital) Services "HC/HH Wch Supp Collar Cerv Lo Univ 3__08140380""" PX-2705000052 CDM 2705000052 LOCAL 270 RC outpatient 37 37 MEDICA (COMMERCIAL) 94265 [3081118] MEDICA CLAIMS [308111801] 33.3 percent of total billed charges 22.94 35.15 Technical (Hospital) Services HC/HH Wch Supp Cloth Tape 2 Inch__7139c PX-2705000051 CDM 2705000051 LOCAL 270 RC inpatient 9 9 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES EPO [308136803] 7.13 percent of total billed charges 5.58 8.55 Technical (Hospital) Services HC/HH Wch Supp Cloth Tape 2 Inch__7139c PX-2705000051 CDM 2705000051 LOCAL 270 RC inpatient 9 9 HEALTHPARTNERS SX009 HEALTHPARTNERS 7.13 percent of total billed charges 5.58 8.55 Technical (Hospital) Services HC/HH Wch Supp Cloth Tape 2 Inch__7139c PX-2705000051 CDM 2705000051 LOCAL 270 RC inpatient 9 9 MULTIPLAN INC 34080 [3081285] MULTIPLAN INC [308128501] 8.55 percent of total billed charges 5.58 8.55 Technical (Hospital) Services HC/HH Wch Supp Cloth Tape 2 Inch__7139c PX-2705000051 CDM 2705000051 LOCAL 270 RC inpatient 9 9 BLUE CROSS BLUE SHIELD WELLMARK SB889 [3081026] BCBS WYOMING [308102603] 8.55 percent of total billed charges 5.58 8.55 Technical (Hospital) Services HC/HH Wch Supp Cloth Tape 2 Inch__7139c PX-2705000051 CDM 2705000051 LOCAL 270 RC inpatient 9 9 CIGNA 62308 [3081051] CIGNA 62308 [308105105] 7.13 percent of total billed charges 5.58 8.55 Technical (Hospital) Services HC/HH Wch Supp Cloth Tape 2 Inch__7139c PX-2705000051 CDM 2705000051 LOCAL 270 RC inpatient 9 9 CIGNA 62308 [3081051] CIGNA STATE OF WYOMING [308105107] 7.13 percent of total billed charges 5.58 8.55 Technical (Hospital) Services HC/HH Wch Supp Cloth Tape 2 Inch__7139c PX-2705000051 CDM 2705000051 LOCAL 270 RC inpatient 9 9 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES HDHP [308136802] 7.13 percent of total billed charges 5.58 8.55 Technical (Hospital) Services HC/HH Wch Supp Cloth Tape 2 Inch__7139c PX-2705000051 CDM 2705000051 LOCAL 270 RC inpatient 9 9 UNITED HEALTHCARE (COMMERCIAL) [3081199] UNITED HEALTHCARE 87726 [308119901] 5.58 percent of total billed charges 5.58 8.55 Technical (Hospital) Services HC/HH Wch Supp Cloth Tape 2 Inch__7139c PX-2705000051 CDM 2705000051 LOCAL 270 RC inpatient 9 9 MEDICA (COMMERCIAL) 94265 [3081118] MEDICA CLAIMS [308111801] 8.1 percent of total billed charges 5.58 8.55 Technical (Hospital) Services HC/HH Wch Supp Cloth Tape 2 Inch__7139c PX-2705000051 CDM 2705000051 LOCAL 270 RC inpatient 9 9 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES PPO [308136801] 7.13 percent of total billed charges 5.58 8.55 Technical (Hospital) Services HC/HH Wch Supp Cloth Tape 2 Inch__7139c PX-2705000051 CDM 2705000051 LOCAL 270 RC outpatient 9 9 BLUE CROSS BLUE SHIELD WELLMARK SB889 [3081026] BCBS WYOMING [308102603] 8.55 percent of total billed charges 5.58 8.55 Technical (Hospital) Services HC/HH Wch Supp Cloth Tape 2 Inch__7139c PX-2705000051 CDM 2705000051 LOCAL 270 RC outpatient 9 9 CIGNA 62308 [3081051] CIGNA 62308 [308105105] 7.2 percent of total billed charges 5.58 8.55 Technical (Hospital) Services HC/HH Wch Supp Cloth Tape 2 Inch__7139c PX-2705000051 CDM 2705000051 LOCAL 270 RC outpatient 9 9 CIGNA 62308 [3081051] CIGNA STATE OF WYOMING [308105107] 7.2 percent of total billed charges 5.58 8.55 Technical (Hospital) Services HC/HH Wch Supp Cloth Tape 2 Inch__7139c PX-2705000051 CDM 2705000051 LOCAL 270 RC outpatient 9 9 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES EPO [308136803] 7.2 percent of total billed charges 5.58 8.55 Technical (Hospital) Services HC/HH Wch Supp Cloth Tape 2 Inch__7139c PX-2705000051 CDM 2705000051 LOCAL 270 RC outpatient 9 9 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES HDHP [308136802] 7.2 percent of total billed charges 5.58 8.55 Technical (Hospital) Services HC/HH Wch Supp Cloth Tape 2 Inch__7139c PX-2705000051 CDM 2705000051 LOCAL 270 RC outpatient 9 9 HEALTHPARTNERS SX009 HEALTHPARTNERS 7.2 percent of total billed charges 5.58 8.55 Technical (Hospital) Services HC/HH Wch Supp Cloth Tape 2 Inch__7139c PX-2705000051 CDM 2705000051 LOCAL 270 RC outpatient 9 9 UNITED HEALTHCARE (COMMERCIAL) [3081199] UNITED HEALTHCARE 87726 [308119901] 5.58 percent of total billed charges 5.58 8.55 Technical (Hospital) Services HC/HH Wch Supp Cloth Tape 2 Inch__7139c PX-2705000051 CDM 2705000051 LOCAL 270 RC outpatient 9 9 MEDICA (COMMERCIAL) 94265 [3081118] MEDICA CLAIMS [308111801] 8.1 percent of total billed charges 5.58 8.55 Technical (Hospital) Services HC/HH Wch Supp Cloth Tape 2 Inch__7139c PX-2705000051 CDM 2705000051 LOCAL 270 RC outpatient 9 9 MULTIPLAN INC 34080 [3081285] MULTIPLAN INC [308128501] 8.55 percent of total billed charges 5.58 8.55 Technical (Hospital) Services HC/HH Wch Supp Cloth Tape 2 Inch__7139c PX-2705000051 CDM 2705000051 LOCAL 270 RC outpatient 9 9 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES PPO [308136801] 7.2 percent of total billed charges 5.58 8.55 Technical (Hospital) Services HC/HH Wch Supp Cloth Tape 1 Inch__7138c PX-2705000050 CDM 2705000050 LOCAL 270 RC outpatient 6 6 MULTIPLAN INC 34080 [3081285] MULTIPLAN INC [308128501] 5.7 percent of total billed charges 3.72 5.7 Technical (Hospital) Services HC/HH Wch Supp Cloth Tape 1 Inch__7138c PX-2705000050 CDM 2705000050 LOCAL 270 RC outpatient 6 6 MEDICA (COMMERCIAL) 94265 [3081118] MEDICA CLAIMS [308111801] 5.4 percent of total billed charges 3.72 5.7 Technical (Hospital) Services HC/HH Wch Supp Cloth Tape 1 Inch__7138c PX-2705000050 CDM 2705000050 LOCAL 270 RC outpatient 6 6 UNITED HEALTHCARE (COMMERCIAL) [3081199] UNITED HEALTHCARE 87726 [308119901] 3.72 percent of total billed charges 3.72 5.7 Technical (Hospital) Services HC/HH Wch Supp Cloth Tape 1 Inch__7138c PX-2705000050 CDM 2705000050 LOCAL 270 RC outpatient 6 6 HEALTHPARTNERS SX009 HEALTHPARTNERS 4.8 percent of total billed charges 3.72 5.7 Technical (Hospital) Services HC/HH Wch Supp Cloth Tape 1 Inch__7138c PX-2705000050 CDM 2705000050 LOCAL 270 RC outpatient 6 6 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES PPO [308136801] 4.8 percent of total billed charges 3.72 5.7 Technical (Hospital) Services HC/HH Wch Supp Cloth Tape 1 Inch__7138c PX-2705000050 CDM 2705000050 LOCAL 270 RC outpatient 6 6 CIGNA 62308 [3081051] CIGNA 62308 [308105105] 4.8 percent of total billed charges 3.72 5.7 Technical (Hospital) Services HC/HH Wch Supp Cloth Tape 1 Inch__7138c PX-2705000050 CDM 2705000050 LOCAL 270 RC outpatient 6 6 CIGNA 62308 [3081051] CIGNA STATE OF WYOMING [308105107] 4.8 percent of total billed charges 3.72 5.7 Technical (Hospital) Services HC/HH Wch Supp Cloth Tape 1 Inch__7138c PX-2705000050 CDM 2705000050 LOCAL 270 RC outpatient 6 6 BLUE CROSS BLUE SHIELD WELLMARK SB889 [3081026] BCBS WYOMING [308102603] 5.7 percent of total billed charges 3.72 5.7 Technical (Hospital) Services HC/HH Wch Supp Cloth Tape 1 Inch__7138c PX-2705000050 CDM 2705000050 LOCAL 270 RC outpatient 6 6 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES EPO [308136803] 4.8 percent of total billed charges 3.72 5.7 Technical (Hospital) Services HC/HH Wch Supp Cloth Tape 1 Inch__7138c PX-2705000050 CDM 2705000050 LOCAL 270 RC outpatient 6 6 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES HDHP [308136802] 4.8 percent of total billed charges 3.72 5.7 Technical (Hospital) Services HC/HH Wch Supp Cloth Tape 1 Inch__7138c PX-2705000050 CDM 2705000050 LOCAL 270 RC inpatient 6 6 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES HDHP [308136802] 4.75 percent of total billed charges 3.72 5.7 Technical (Hospital) Services HC/HH Wch Supp Cloth Tape 1 Inch__7138c PX-2705000050 CDM 2705000050 LOCAL 270 RC inpatient 6 6 UNITED HEALTHCARE (COMMERCIAL) [3081199] UNITED HEALTHCARE 87726 [308119901] 3.72 percent of total billed charges 3.72 5.7 Technical (Hospital) Services HC/HH Wch Supp Cloth Tape 1 Inch__7138c PX-2705000050 CDM 2705000050 LOCAL 270 RC inpatient 6 6 MEDICA (COMMERCIAL) 94265 [3081118] MEDICA CLAIMS [308111801] 5.4 percent of total billed charges 3.72 5.7 Technical (Hospital) Services HC/HH Wch Supp Cloth Tape 1 Inch__7138c PX-2705000050 CDM 2705000050 LOCAL 270 RC inpatient 6 6 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES PPO [308136801] 4.75 percent of total billed charges 3.72 5.7 Technical (Hospital) Services HC/HH Wch Supp Cloth Tape 1 Inch__7138c PX-2705000050 CDM 2705000050 LOCAL 270 RC inpatient 6 6 CIGNA 62308 [3081051] CIGNA 62308 [308105105] 4.75 percent of total billed charges 3.72 5.7 Technical (Hospital) Services HC/HH Wch Supp Cloth Tape 1 Inch__7138c PX-2705000050 CDM 2705000050 LOCAL 270 RC inpatient 6 6 CIGNA 62308 [3081051] CIGNA STATE OF WYOMING [308105107] 4.75 percent of total billed charges 3.72 5.7 Technical (Hospital) Services HC/HH Wch Supp Cloth Tape 1 Inch__7138c PX-2705000050 CDM 2705000050 LOCAL 270 RC inpatient 6 6 MULTIPLAN INC 34080 [3081285] MULTIPLAN INC [308128501] 5.7 percent of total billed charges 3.72 5.7 Technical (Hospital) Services HC/HH Wch Supp Cloth Tape 1 Inch__7138c PX-2705000050 CDM 2705000050 LOCAL 270 RC inpatient 6 6 BLUE CROSS BLUE SHIELD WELLMARK SB889 [3081026] BCBS WYOMING [308102603] 5.7 percent of total billed charges 3.72 5.7 Technical (Hospital) Services HC/HH Wch Supp Cloth Tape 1 Inch__7138c PX-2705000050 CDM 2705000050 LOCAL 270 RC inpatient 6 6 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES EPO [308136803] 4.75 percent of total billed charges 3.72 5.7 Technical (Hospital) Services HC/HH Wch Supp Cloth Tape 1 Inch__7138c PX-2705000050 CDM 2705000050 LOCAL 270 RC inpatient 6 6 HEALTHPARTNERS SX009 HEALTHPARTNERS 4.75 percent of total billed charges 3.72 5.7 Technical (Hospital) Services HC/HH Wch Supp Cath Tray Urethral__772416 PX-2705000049 CDM 2705000049 LOCAL 270 RC inpatient 17 17 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES PPO [308136801] 13.46 percent of total billed charges 10.54 16.15 Technical (Hospital) Services HC/HH Wch Supp Cath Tray Urethral__772416 PX-2705000049 CDM 2705000049 LOCAL 270 RC inpatient 17 17 MEDICA (COMMERCIAL) 94265 [3081118] MEDICA CLAIMS [308111801] 15.3 percent of total billed charges 10.54 16.15 Technical (Hospital) Services HC/HH Wch Supp Cath Tray Urethral__772416 PX-2705000049 CDM 2705000049 LOCAL 270 RC inpatient 17 17 UNITED HEALTHCARE (COMMERCIAL) [3081199] UNITED HEALTHCARE 87726 [308119901] 10.54 percent of total billed charges 10.54 16.15 Technical (Hospital) Services HC/HH Wch Supp Cath Tray Urethral__772416 PX-2705000049 CDM 2705000049 LOCAL 270 RC inpatient 17 17 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES HDHP [308136802] 13.46 percent of total billed charges 10.54 16.15 Technical (Hospital) Services HC/HH Wch Supp Cath Tray Urethral__772416 PX-2705000049 CDM 2705000049 LOCAL 270 RC inpatient 17 17 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES EPO [308136803] 13.46 percent of total billed charges 10.54 16.15 Technical (Hospital) Services HC/HH Wch Supp Cath Tray Urethral__772416 PX-2705000049 CDM 2705000049 LOCAL 270 RC inpatient 17 17 HEALTHPARTNERS SX009 HEALTHPARTNERS 13.46 percent of total billed charges 10.54 16.15 Technical (Hospital) Services HC/HH Wch Supp Cath Tray Urethral__772416 PX-2705000049 CDM 2705000049 LOCAL 270 RC inpatient 17 17 BLUE CROSS BLUE SHIELD WELLMARK SB889 [3081026] BCBS WYOMING [308102603] 16.15 percent of total billed charges 10.54 16.15 Technical (Hospital) Services HC/HH Wch Supp Cath Tray Urethral__772416 PX-2705000049 CDM 2705000049 LOCAL 270 RC inpatient 17 17 MULTIPLAN INC 34080 [3081285] MULTIPLAN INC [308128501] 16.15 percent of total billed charges 10.54 16.15 Technical (Hospital) Services HC/HH Wch Supp Cath Tray Urethral__772416 PX-2705000049 CDM 2705000049 LOCAL 270 RC inpatient 17 17 CIGNA 62308 [3081051] CIGNA 62308 [308105105] 13.46 percent of total billed charges 10.54 16.15 Technical (Hospital) Services HC/HH Wch Supp Cath Tray Urethral__772416 PX-2705000049 CDM 2705000049 LOCAL 270 RC inpatient 17 17 CIGNA 62308 [3081051] CIGNA STATE OF WYOMING [308105107] 13.46 percent of total billed charges 10.54 16.15 Technical (Hospital) Services HC/HH Wch Supp Cath Tray Urethral__772416 PX-2705000049 CDM 2705000049 LOCAL 270 RC outpatient 17 17 CIGNA 62308 [3081051] CIGNA 62308 [308105105] 13.6 percent of total billed charges 10.54 16.15 Technical (Hospital) Services HC/HH Wch Supp Cath Tray Urethral__772416 PX-2705000049 CDM 2705000049 LOCAL 270 RC outpatient 17 17 CIGNA 62308 [3081051] CIGNA STATE OF WYOMING [308105107] 13.6 percent of total billed charges 10.54 16.15 Technical (Hospital) Services HC/HH Wch Supp Cath Tray Urethral__772416 PX-2705000049 CDM 2705000049 LOCAL 270 RC outpatient 17 17 BLUE CROSS BLUE SHIELD WELLMARK SB889 [3081026] BCBS WYOMING [308102603] 16.15 percent of total billed charges 10.54 16.15 Technical (Hospital) Services HC/HH Wch Supp Cath Tray Urethral__772416 PX-2705000049 CDM 2705000049 LOCAL 270 RC outpatient 17 17 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES EPO [308136803] 13.6 percent of total billed charges 10.54 16.15 Technical (Hospital) Services HC/HH Wch Supp Cath Tray Urethral__772416 PX-2705000049 CDM 2705000049 LOCAL 270 RC outpatient 17 17 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES HDHP [308136802] 13.6 percent of total billed charges 10.54 16.15 Technical (Hospital) Services HC/HH Wch Supp Cath Tray Urethral__772416 PX-2705000049 CDM 2705000049 LOCAL 270 RC outpatient 17 17 HEALTHPARTNERS SX009 HEALTHPARTNERS 13.6 percent of total billed charges 10.54 16.15 Technical (Hospital) Services HC/HH Wch Supp Cath Tray Urethral__772416 PX-2705000049 CDM 2705000049 LOCAL 270 RC outpatient 17 17 UNITED HEALTHCARE (COMMERCIAL) [3081199] UNITED HEALTHCARE 87726 [308119901] 10.54 percent of total billed charges 10.54 16.15 Technical (Hospital) Services HC/HH Wch Supp Cath Tray Urethral__772416 PX-2705000049 CDM 2705000049 LOCAL 270 RC outpatient 17 17 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES PPO [308136801] 13.6 percent of total billed charges 10.54 16.15 Technical (Hospital) Services HC/HH Wch Supp Cath Tray Urethral__772416 PX-2705000049 CDM 2705000049 LOCAL 270 RC outpatient 17 17 MULTIPLAN INC 34080 [3081285] MULTIPLAN INC [308128501] 16.15 percent of total billed charges 10.54 16.15 Technical (Hospital) Services HC/HH Wch Supp Cath Tray Urethral__772416 PX-2705000049 CDM 2705000049 LOCAL 270 RC outpatient 17 17 MEDICA (COMMERCIAL) 94265 [3081118] MEDICA CLAIMS [308111801] 15.3 percent of total billed charges 10.54 16.15 Technical (Hospital) Services HC/HH Wch Supp Cath Foley16fr 10cc__Dynd11502 PX-2705000048 CDM 2705000048 LOCAL 270 RC outpatient 28 28 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES HDHP [308136802] 22.4 percent of total billed charges 17.36 26.6 Technical (Hospital) Services HC/HH Wch Supp Cath Foley16fr 10cc__Dynd11502 PX-2705000048 CDM 2705000048 LOCAL 270 RC outpatient 28 28 BLUE CROSS BLUE SHIELD WELLMARK SB889 [3081026] BCBS WYOMING [308102603] 26.6 percent of total billed charges 17.36 26.6 Technical (Hospital) Services HC/HH Wch Supp Cath Foley16fr 10cc__Dynd11502 PX-2705000048 CDM 2705000048 LOCAL 270 RC outpatient 28 28 CIGNA 62308 [3081051] CIGNA 62308 [308105105] 22.4 percent of total billed charges 17.36 26.6 Technical (Hospital) Services HC/HH Wch Supp Cath Foley16fr 10cc__Dynd11502 PX-2705000048 CDM 2705000048 LOCAL 270 RC outpatient 28 28 CIGNA 62308 [3081051] CIGNA STATE OF WYOMING [308105107] 22.4 percent of total billed charges 17.36 26.6 Technical (Hospital) Services HC/HH Wch Supp Cath Foley16fr 10cc__Dynd11502 PX-2705000048 CDM 2705000048 LOCAL 270 RC outpatient 28 28 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES EPO [308136803] 22.4 percent of total billed charges 17.36 26.6 Technical (Hospital) Services HC/HH Wch Supp Cath Foley16fr 10cc__Dynd11502 PX-2705000048 CDM 2705000048 LOCAL 270 RC outpatient 28 28 HEALTHPARTNERS SX009 HEALTHPARTNERS 22.4 percent of total billed charges 17.36 26.6 Technical (Hospital) Services HC/HH Wch Supp Cath Foley16fr 10cc__Dynd11502 PX-2705000048 CDM 2705000048 LOCAL 270 RC outpatient 28 28 UNITED HEALTHCARE (COMMERCIAL) [3081199] UNITED HEALTHCARE 87726 [308119901] 17.36 percent of total billed charges 17.36 26.6 Technical (Hospital) Services HC/HH Wch Supp Cath Foley16fr 10cc__Dynd11502 PX-2705000048 CDM 2705000048 LOCAL 270 RC outpatient 28 28 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES PPO [308136801] 22.4 percent of total billed charges 17.36 26.6 Technical (Hospital) Services HC/HH Wch Supp Cath Foley16fr 10cc__Dynd11502 PX-2705000048 CDM 2705000048 LOCAL 270 RC outpatient 28 28 MULTIPLAN INC 34080 [3081285] MULTIPLAN INC [308128501] 26.6 percent of total billed charges 17.36 26.6 Technical (Hospital) Services HC/HH Wch Supp Cath Foley16fr 10cc__Dynd11502 PX-2705000048 CDM 2705000048 LOCAL 270 RC outpatient 28 28 MEDICA (COMMERCIAL) 94265 [3081118] MEDICA CLAIMS [308111801] 25.2 percent of total billed charges 17.36 26.6 Technical (Hospital) Services HC/HH Wch Supp Cath Foley16fr 10cc__Dynd11502 PX-2705000048 CDM 2705000048 LOCAL 270 RC inpatient 28 28 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES PPO [308136801] 22.17 percent of total billed charges 17.36 26.6 Technical (Hospital) Services HC/HH Wch Supp Cath Foley16fr 10cc__Dynd11502 PX-2705000048 CDM 2705000048 LOCAL 270 RC inpatient 28 28 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES HDHP [308136802] 22.17 percent of total billed charges 17.36 26.6 Technical (Hospital) Services HC/HH Wch Supp Cath Foley16fr 10cc__Dynd11502 PX-2705000048 CDM 2705000048 LOCAL 270 RC inpatient 28 28 UNITED HEALTHCARE (COMMERCIAL) [3081199] UNITED HEALTHCARE 87726 [308119901] 17.36 percent of total billed charges 17.36 26.6 Technical (Hospital) Services HC/HH Wch Supp Cath Foley16fr 10cc__Dynd11502 PX-2705000048 CDM 2705000048 LOCAL 270 RC inpatient 28 28 MEDICA (COMMERCIAL) 94265 [3081118] MEDICA CLAIMS [308111801] 25.2 percent of total billed charges 17.36 26.6 Technical (Hospital) Services HC/HH Wch Supp Cath Foley16fr 10cc__Dynd11502 PX-2705000048 CDM 2705000048 LOCAL 270 RC inpatient 28 28 CIGNA 62308 [3081051] CIGNA 62308 [308105105] 22.17 percent of total billed charges 17.36 26.6 Technical (Hospital) Services HC/HH Wch Supp Cath Foley16fr 10cc__Dynd11502 PX-2705000048 CDM 2705000048 LOCAL 270 RC inpatient 28 28 CIGNA 62308 [3081051] CIGNA STATE OF WYOMING [308105107] 22.17 percent of total billed charges 17.36 26.6 Technical (Hospital) Services HC/HH Wch Supp Cath Foley16fr 10cc__Dynd11502 PX-2705000048 CDM 2705000048 LOCAL 270 RC inpatient 28 28 MULTIPLAN INC 34080 [3081285] MULTIPLAN INC [308128501] 26.6 percent of total billed charges 17.36 26.6 Technical (Hospital) Services HC/HH Wch Supp Cath Foley16fr 10cc__Dynd11502 PX-2705000048 CDM 2705000048 LOCAL 270 RC inpatient 28 28 BLUE CROSS BLUE SHIELD WELLMARK SB889 [3081026] BCBS WYOMING [308102603] 26.6 percent of total billed charges 17.36 26.6 Technical (Hospital) Services HC/HH Wch Supp Cath Foley16fr 10cc__Dynd11502 PX-2705000048 CDM 2705000048 LOCAL 270 RC inpatient 28 28 HEALTHPARTNERS SX009 HEALTHPARTNERS 22.17 percent of total billed charges 17.36 26.6 Technical (Hospital) Services HC/HH Wch Supp Cath Foley16fr 10cc__Dynd11502 PX-2705000048 CDM 2705000048 LOCAL 270 RC inpatient 28 28 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES EPO [308136803] 22.17 percent of total billed charges 17.36 26.6 Technical (Hospital) Services "HC/HH Wch Supp Cast Padding 2 Cott__1418""" PX-2705000047 CDM 2705000047 LOCAL 270 RC inpatient 5 5 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES PPO [308136801] 3.96 percent of total billed charges 3.1 4.75 Technical (Hospital) Services "HC/HH Wch Supp Cast Padding 2 Cott__1418""" PX-2705000047 CDM 2705000047 LOCAL 270 RC inpatient 5 5 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES HDHP [308136802] 3.96 percent of total billed charges 3.1 4.75 Technical (Hospital) Services "HC/HH Wch Supp Cast Padding 2 Cott__1418""" PX-2705000047 CDM 2705000047 LOCAL 270 RC inpatient 5 5 UNITED HEALTHCARE (COMMERCIAL) [3081199] UNITED HEALTHCARE 87726 [308119901] 3.1 percent of total billed charges 3.1 4.75 Technical (Hospital) Services "HC/HH Wch Supp Cast Padding 2 Cott__1418""" PX-2705000047 CDM 2705000047 LOCAL 270 RC inpatient 5 5 MEDICA (COMMERCIAL) 94265 [3081118] MEDICA CLAIMS [308111801] 4.5 percent of total billed charges 3.1 4.75 Technical (Hospital) Services "HC/HH Wch Supp Cast Padding 2 Cott__1418""" PX-2705000047 CDM 2705000047 LOCAL 270 RC inpatient 5 5 MULTIPLAN INC 34080 [3081285] MULTIPLAN INC [308128501] 4.75 percent of total billed charges 3.1 4.75 Technical (Hospital) Services "HC/HH Wch Supp Cast Padding 2 Cott__1418""" PX-2705000047 CDM 2705000047 LOCAL 270 RC inpatient 5 5 BLUE CROSS BLUE SHIELD WELLMARK SB889 [3081026] BCBS WYOMING [308102603] 4.75 percent of total billed charges 3.1 4.75 Technical (Hospital) Services "HC/HH Wch Supp Cast Padding 2 Cott__1418""" PX-2705000047 CDM 2705000047 LOCAL 270 RC inpatient 5 5 CIGNA 62308 [3081051] CIGNA 62308 [308105105] 3.96 percent of total billed charges 3.1 4.75 Technical (Hospital) Services "HC/HH Wch Supp Cast Padding 2 Cott__1418""" PX-2705000047 CDM 2705000047 LOCAL 270 RC inpatient 5 5 CIGNA 62308 [3081051] CIGNA STATE OF WYOMING [308105107] 3.96 percent of total billed charges 3.1 4.75 Technical (Hospital) Services "HC/HH Wch Supp Cast Padding 2 Cott__1418""" PX-2705000047 CDM 2705000047 LOCAL 270 RC inpatient 5 5 HEALTHPARTNERS SX009 HEALTHPARTNERS 3.96 percent of total billed charges 3.1 4.75 Technical (Hospital) Services "HC/HH Wch Supp Cast Padding 2 Cott__1418""" PX-2705000047 CDM 2705000047 LOCAL 270 RC inpatient 5 5 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES EPO [308136803] 3.96 percent of total billed charges 3.1 4.75 Technical (Hospital) Services "HC/HH Wch Supp Cast Padding 2 Cott__1418""" PX-2705000047 CDM 2705000047 LOCAL 270 RC outpatient 5 5 MEDICA (COMMERCIAL) 94265 [3081118] MEDICA CLAIMS [308111801] 4.5 percent of total billed charges 3.1 4.75 Technical (Hospital) Services "HC/HH Wch Supp Cast Padding 2 Cott__1418""" PX-2705000047 CDM 2705000047 LOCAL 270 RC outpatient 5 5 MULTIPLAN INC 34080 [3081285] MULTIPLAN INC [308128501] 4.75 percent of total billed charges 3.1 4.75 Technical (Hospital) Services "HC/HH Wch Supp Cast Padding 2 Cott__1418""" PX-2705000047 CDM 2705000047 LOCAL 270 RC outpatient 5 5 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES EPO [308136803] 4 percent of total billed charges 3.1 4.75 Technical (Hospital) Services "HC/HH Wch Supp Cast Padding 2 Cott__1418""" PX-2705000047 CDM 2705000047 LOCAL 270 RC outpatient 5 5 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES HDHP [308136802] 4 percent of total billed charges 3.1 4.75 Technical (Hospital) Services "HC/HH Wch Supp Cast Padding 2 Cott__1418""" PX-2705000047 CDM 2705000047 LOCAL 270 RC outpatient 5 5 CIGNA 62308 [3081051] CIGNA 62308 [308105105] 4 percent of total billed charges 3.1 4.75 Technical (Hospital) Services "HC/HH Wch Supp Cast Padding 2 Cott__1418""" PX-2705000047 CDM 2705000047 LOCAL 270 RC outpatient 5 5 CIGNA 62308 [3081051] CIGNA STATE OF WYOMING [308105107] 4 percent of total billed charges 3.1 4.75 Technical (Hospital) Services "HC/HH Wch Supp Cast Padding 2 Cott__1418""" PX-2705000047 CDM 2705000047 LOCAL 270 RC outpatient 5 5 BLUE CROSS BLUE SHIELD WELLMARK SB889 [3081026] BCBS WYOMING [308102603] 4.75 percent of total billed charges 3.1 4.75 Technical (Hospital) Services "HC/HH Wch Supp Cast Padding 2 Cott__1418""" PX-2705000047 CDM 2705000047 LOCAL 270 RC outpatient 5 5 UNITED HEALTHCARE (COMMERCIAL) [3081199] UNITED HEALTHCARE 87726 [308119901] 3.1 percent of total billed charges 3.1 4.75 Technical (Hospital) Services "HC/HH Wch Supp Cast Padding 2 Cott__1418""" PX-2705000047 CDM 2705000047 LOCAL 270 RC outpatient 5 5 HEALTHPARTNERS SX009 HEALTHPARTNERS 4 percent of total billed charges 3.1 4.75 Technical (Hospital) Services "HC/HH Wch Supp Cast Padding 2 Cott__1418""" PX-2705000047 CDM 2705000047 LOCAL 270 RC outpatient 5 5 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES PPO [308136801] 4 percent of total billed charges 3.1 4.75 Technical (Hospital) Services HC/HH Wch Supp Cast Air Walker M__Aw0600 PX-2705000046 CDM 2705000046 LOCAL 270 RC outpatient 175 175 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES HDHP [308136802] 140 percent of total billed charges 108.5 166.25 Technical (Hospital) Services HC/HH Wch Supp Cast Air Walker M__Aw0600 PX-2705000046 CDM 2705000046 LOCAL 270 RC outpatient 175 175 CIGNA 62308 [3081051] CIGNA 62308 [308105105] 140 percent of total billed charges 108.5 166.25 Technical (Hospital) Services HC/HH Wch Supp Cast Air Walker M__Aw0600 PX-2705000046 CDM 2705000046 LOCAL 270 RC outpatient 175 175 CIGNA 62308 [3081051] CIGNA STATE OF WYOMING [308105107] 140 percent of total billed charges 108.5 166.25 Technical (Hospital) Services HC/HH Wch Supp Cast Air Walker M__Aw0600 PX-2705000046 CDM 2705000046 LOCAL 270 RC outpatient 175 175 BLUE CROSS BLUE SHIELD WELLMARK SB889 [3081026] BCBS WYOMING [308102603] 166.25 percent of total billed charges 108.5 166.25 Technical (Hospital) Services HC/HH Wch Supp Cast Air Walker M__Aw0600 PX-2705000046 CDM 2705000046 LOCAL 270 RC outpatient 175 175 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES EPO [308136803] 140 percent of total billed charges 108.5 166.25 Technical (Hospital) Services HC/HH Wch Supp Cast Air Walker M__Aw0600 PX-2705000046 CDM 2705000046 LOCAL 270 RC outpatient 175 175 HEALTHPARTNERS SX009 HEALTHPARTNERS 140 percent of total billed charges 108.5 166.25 Technical (Hospital) Services HC/HH Wch Supp Cast Air Walker M__Aw0600 PX-2705000046 CDM 2705000046 LOCAL 270 RC outpatient 175 175 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES PPO [308136801] 140 percent of total billed charges 108.5 166.25 Technical (Hospital) Services HC/HH Wch Supp Cast Air Walker M__Aw0600 PX-2705000046 CDM 2705000046 LOCAL 270 RC outpatient 175 175 UNITED HEALTHCARE (COMMERCIAL) [3081199] UNITED HEALTHCARE 87726 [308119901] 108.5 percent of total billed charges 108.5 166.25 Technical (Hospital) Services HC/HH Wch Supp Cast Air Walker M__Aw0600 PX-2705000046 CDM 2705000046 LOCAL 270 RC outpatient 175 175 MEDICA (COMMERCIAL) 94265 [3081118] MEDICA CLAIMS [308111801] 157.5 percent of total billed charges 108.5 166.25 Technical (Hospital) Services HC/HH Wch Supp Cast Air Walker M__Aw0600 PX-2705000046 CDM 2705000046 LOCAL 270 RC outpatient 175 175 MULTIPLAN INC 34080 [3081285] MULTIPLAN INC [308128501] 166.25 percent of total billed charges 108.5 166.25 Technical (Hospital) Services HC/HH Wch Supp Cast Air Walker M__Aw0600 PX-2705000046 CDM 2705000046 LOCAL 270 RC inpatient 175 175 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES PPO [308136801] 138.57 percent of total billed charges 108.5 166.25 Technical (Hospital) Services HC/HH Wch Supp Cast Air Walker M__Aw0600 PX-2705000046 CDM 2705000046 LOCAL 270 RC inpatient 175 175 UNITED HEALTHCARE (COMMERCIAL) [3081199] UNITED HEALTHCARE 87726 [308119901] 108.5 percent of total billed charges 108.5 166.25 Technical (Hospital) Services HC/HH Wch Supp Cast Air Walker M__Aw0600 PX-2705000046 CDM 2705000046 LOCAL 270 RC inpatient 175 175 MEDICA (COMMERCIAL) 94265 [3081118] MEDICA CLAIMS [308111801] 157.5 percent of total billed charges 108.5 166.25 Technical (Hospital) Services HC/HH Wch Supp Cast Air Walker M__Aw0600 PX-2705000046 CDM 2705000046 LOCAL 270 RC inpatient 175 175 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES HDHP [308136802] 138.57 percent of total billed charges 108.5 166.25 Technical (Hospital) Services HC/HH Wch Supp Cast Air Walker M__Aw0600 PX-2705000046 CDM 2705000046 LOCAL 270 RC inpatient 175 175 HEALTHPARTNERS SX009 HEALTHPARTNERS 138.57 percent of total billed charges 108.5 166.25 Technical (Hospital) Services HC/HH Wch Supp Cast Air Walker M__Aw0600 PX-2705000046 CDM 2705000046 LOCAL 270 RC inpatient 175 175 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES EPO [308136803] 138.57 percent of total billed charges 108.5 166.25 Technical (Hospital) Services HC/HH Wch Supp Cast Air Walker M__Aw0600 PX-2705000046 CDM 2705000046 LOCAL 270 RC inpatient 175 175 BLUE CROSS BLUE SHIELD WELLMARK SB889 [3081026] BCBS WYOMING [308102603] 166.25 percent of total billed charges 108.5 166.25 Technical (Hospital) Services HC/HH Wch Supp Cast Air Walker M__Aw0600 PX-2705000046 CDM 2705000046 LOCAL 270 RC inpatient 175 175 CIGNA 62308 [3081051] CIGNA 62308 [308105105] 138.57 percent of total billed charges 108.5 166.25 Technical (Hospital) Services HC/HH Wch Supp Cast Air Walker M__Aw0600 PX-2705000046 CDM 2705000046 LOCAL 270 RC inpatient 175 175 CIGNA 62308 [3081051] CIGNA STATE OF WYOMING [308105107] 138.57 percent of total billed charges 108.5 166.25 Technical (Hospital) Services HC/HH Wch Supp Cast Air Walker M__Aw0600 PX-2705000046 CDM 2705000046 LOCAL 270 RC inpatient 175 175 MULTIPLAN INC 34080 [3081285] MULTIPLAN INC [308128501] 166.25 percent of total billed charges 108.5 166.25 Technical (Hospital) Services HC/HH Wch Supp Cast Air Walker L__Aw0800 PX-2705000045 CDM 2705000045 LOCAL 270 RC inpatient 175 175 HEALTHPARTNERS SX009 HEALTHPARTNERS 138.57 percent of total billed charges 108.5 166.25 Technical (Hospital) Services HC/HH Wch Supp Cast Air Walker L__Aw0800 PX-2705000045 CDM 2705000045 LOCAL 270 RC inpatient 175 175 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES EPO [308136803] 138.57 percent of total billed charges 108.5 166.25 Technical (Hospital) Services HC/HH Wch Supp Cast Air Walker L__Aw0800 PX-2705000045 CDM 2705000045 LOCAL 270 RC inpatient 175 175 MULTIPLAN INC 34080 [3081285] MULTIPLAN INC [308128501] 166.25 percent of total billed charges 108.5 166.25 Technical (Hospital) Services HC/HH Wch Supp Cast Air Walker L__Aw0800 PX-2705000045 CDM 2705000045 LOCAL 270 RC inpatient 175 175 CIGNA 62308 [3081051] CIGNA 62308 [308105105] 138.57 percent of total billed charges 108.5 166.25 Technical (Hospital) Services HC/HH Wch Supp Cast Air Walker L__Aw0800 PX-2705000045 CDM 2705000045 LOCAL 270 RC inpatient 175 175 CIGNA 62308 [3081051] CIGNA STATE OF WYOMING [308105107] 138.57 percent of total billed charges 108.5 166.25 Technical (Hospital) Services HC/HH Wch Supp Cast Air Walker L__Aw0800 PX-2705000045 CDM 2705000045 LOCAL 270 RC inpatient 175 175 BLUE CROSS BLUE SHIELD WELLMARK SB889 [3081026] BCBS WYOMING [308102603] 166.25 percent of total billed charges 108.5 166.25 Technical (Hospital) Services HC/HH Wch Supp Cast Air Walker L__Aw0800 PX-2705000045 CDM 2705000045 LOCAL 270 RC inpatient 175 175 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES PPO [308136801] 138.57 percent of total billed charges 108.5 166.25 Technical (Hospital) Services HC/HH Wch Supp Cast Air Walker L__Aw0800 PX-2705000045 CDM 2705000045 LOCAL 270 RC inpatient 175 175 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES HDHP [308136802] 138.57 percent of total billed charges 108.5 166.25 Technical (Hospital) Services HC/HH Wch Supp Cast Air Walker L__Aw0800 PX-2705000045 CDM 2705000045 LOCAL 270 RC inpatient 175 175 MEDICA (COMMERCIAL) 94265 [3081118] MEDICA CLAIMS [308111801] 157.5 percent of total billed charges 108.5 166.25 Technical (Hospital) Services HC/HH Wch Supp Cast Air Walker L__Aw0800 PX-2705000045 CDM 2705000045 LOCAL 270 RC inpatient 175 175 UNITED HEALTHCARE (COMMERCIAL) [3081199] UNITED HEALTHCARE 87726 [308119901] 108.5 percent of total billed charges 108.5 166.25 Technical (Hospital) Services HC/HH Wch Supp Cast Air Walker L__Aw0800 PX-2705000045 CDM 2705000045 LOCAL 270 RC outpatient 175 175 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES HDHP [308136802] 140 percent of total billed charges 108.5 166.25 Technical (Hospital) Services HC/HH Wch Supp Cast Air Walker L__Aw0800 PX-2705000045 CDM 2705000045 LOCAL 270 RC outpatient 175 175 CIGNA 62308 [3081051] CIGNA 62308 [308105105] 140 percent of total billed charges 108.5 166.25 Technical (Hospital) Services HC/HH Wch Supp Cast Air Walker L__Aw0800 PX-2705000045 CDM 2705000045 LOCAL 270 RC outpatient 175 175 CIGNA 62308 [3081051] CIGNA STATE OF WYOMING [308105107] 140 percent of total billed charges 108.5 166.25 Technical (Hospital) Services HC/HH Wch Supp Cast Air Walker L__Aw0800 PX-2705000045 CDM 2705000045 LOCAL 270 RC outpatient 175 175 BLUE CROSS BLUE SHIELD WELLMARK SB889 [3081026] BCBS WYOMING [308102603] 166.25 percent of total billed charges 108.5 166.25 Technical (Hospital) Services HC/HH Wch Supp Cast Air Walker L__Aw0800 PX-2705000045 CDM 2705000045 LOCAL 270 RC outpatient 175 175 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES EPO [308136803] 140 percent of total billed charges 108.5 166.25 Technical (Hospital) Services HC/HH Wch Supp Cast Air Walker L__Aw0800 PX-2705000045 CDM 2705000045 LOCAL 270 RC outpatient 175 175 UNITED HEALTHCARE (COMMERCIAL) [3081199] UNITED HEALTHCARE 87726 [308119901] 108.5 percent of total billed charges 108.5 166.25 Technical (Hospital) Services HC/HH Wch Supp Cast Air Walker L__Aw0800 PX-2705000045 CDM 2705000045 LOCAL 270 RC outpatient 175 175 HEALTHPARTNERS SX009 HEALTHPARTNERS 140 percent of total billed charges 108.5 166.25 Technical (Hospital) Services HC/HH Wch Supp Cast Air Walker L__Aw0800 PX-2705000045 CDM 2705000045 LOCAL 270 RC outpatient 175 175 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES PPO [308136801] 140 percent of total billed charges 108.5 166.25 Technical (Hospital) Services HC/HH Wch Supp Cast Air Walker L__Aw0800 PX-2705000045 CDM 2705000045 LOCAL 270 RC outpatient 175 175 MEDICA (COMMERCIAL) 94265 [3081118] MEDICA CLAIMS [308111801] 157.5 percent of total billed charges 108.5 166.25 Technical (Hospital) Services HC/HH Wch Supp Cast Air Walker L__Aw0800 PX-2705000045 CDM 2705000045 LOCAL 270 RC outpatient 175 175 MULTIPLAN INC 34080 [3081285] MULTIPLAN INC [308128501] 166.25 percent of total billed charges 108.5 166.25 Technical (Hospital) Services HC/HH Wch Supp Cap Shampoo__7909 PX-2705000044 CDM 2705000044 LOCAL 270 RC outpatient 14 14 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES PPO [308136801] 11.2 percent of total billed charges 8.68 13.3 Technical (Hospital) Services HC/HH Wch Supp Cap Shampoo__7909 PX-2705000044 CDM 2705000044 LOCAL 270 RC outpatient 14 14 HEALTHPARTNERS SX009 HEALTHPARTNERS 11.2 percent of total billed charges 8.68 13.3 Technical (Hospital) Services HC/HH Wch Supp Cap Shampoo__7909 PX-2705000044 CDM 2705000044 LOCAL 270 RC outpatient 14 14 UNITED HEALTHCARE (COMMERCIAL) [3081199] UNITED HEALTHCARE 87726 [308119901] 8.68 percent of total billed charges 8.68 13.3 Technical (Hospital) Services HC/HH Wch Supp Cap Shampoo__7909 PX-2705000044 CDM 2705000044 LOCAL 270 RC outpatient 14 14 BLUE CROSS BLUE SHIELD WELLMARK SB889 [3081026] BCBS WYOMING [308102603] 13.3 percent of total billed charges 8.68 13.3 Technical (Hospital) Services HC/HH Wch Supp Cap Shampoo__7909 PX-2705000044 CDM 2705000044 LOCAL 270 RC outpatient 14 14 CIGNA 62308 [3081051] CIGNA 62308 [308105105] 11.2 percent of total billed charges 8.68 13.3 Technical (Hospital) Services HC/HH Wch Supp Cap Shampoo__7909 PX-2705000044 CDM 2705000044 LOCAL 270 RC outpatient 14 14 CIGNA 62308 [3081051] CIGNA STATE OF WYOMING [308105107] 11.2 percent of total billed charges 8.68 13.3 Technical (Hospital) Services HC/HH Wch Supp Cap Shampoo__7909 PX-2705000044 CDM 2705000044 LOCAL 270 RC outpatient 14 14 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES HDHP [308136802] 11.2 percent of total billed charges 8.68 13.3 Technical (Hospital) Services HC/HH Wch Supp Cap Shampoo__7909 PX-2705000044 CDM 2705000044 LOCAL 270 RC outpatient 14 14 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES EPO [308136803] 11.2 percent of total billed charges 8.68 13.3 Technical (Hospital) Services HC/HH Wch Supp Cap Shampoo__7909 PX-2705000044 CDM 2705000044 LOCAL 270 RC outpatient 14 14 MEDICA (COMMERCIAL) 94265 [3081118] MEDICA CLAIMS [308111801] 12.6 percent of total billed charges 8.68 13.3 Technical (Hospital) Services HC/HH Wch Supp Cap Shampoo__7909 PX-2705000044 CDM 2705000044 LOCAL 270 RC outpatient 14 14 MULTIPLAN INC 34080 [3081285] MULTIPLAN INC [308128501] 13.3 percent of total billed charges 8.68 13.3 Technical (Hospital) Services HC/HH Wch Supp Cap Shampoo__7909 PX-2705000044 CDM 2705000044 LOCAL 270 RC inpatient 14 14 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES PPO [308136801] 11.09 percent of total billed charges 8.68 13.3 Technical (Hospital) Services HC/HH Wch Supp Cap Shampoo__7909 PX-2705000044 CDM 2705000044 LOCAL 270 RC inpatient 14 14 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES HDHP [308136802] 11.09 percent of total billed charges 8.68 13.3 Technical (Hospital) Services HC/HH Wch Supp Cap Shampoo__7909 PX-2705000044 CDM 2705000044 LOCAL 270 RC inpatient 14 14 MEDICA (COMMERCIAL) 94265 [3081118] MEDICA CLAIMS [308111801] 12.6 percent of total billed charges 8.68 13.3 Technical (Hospital) Services HC/HH Wch Supp Cap Shampoo__7909 PX-2705000044 CDM 2705000044 LOCAL 270 RC inpatient 14 14 UNITED HEALTHCARE (COMMERCIAL) [3081199] UNITED HEALTHCARE 87726 [308119901] 8.68 percent of total billed charges 8.68 13.3 Technical (Hospital) Services HC/HH Wch Supp Cap Shampoo__7909 PX-2705000044 CDM 2705000044 LOCAL 270 RC inpatient 14 14 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES EPO [308136803] 11.09 percent of total billed charges 8.68 13.3 Technical (Hospital) Services HC/HH Wch Supp Cap Shampoo__7909 PX-2705000044 CDM 2705000044 LOCAL 270 RC inpatient 14 14 HEALTHPARTNERS SX009 HEALTHPARTNERS 11.09 percent of total billed charges 8.68 13.3 Technical (Hospital) Services HC/HH Wch Supp Cap Shampoo__7909 PX-2705000044 CDM 2705000044 LOCAL 270 RC inpatient 14 14 BLUE CROSS BLUE SHIELD WELLMARK SB889 [3081026] BCBS WYOMING [308102603] 13.3 percent of total billed charges 8.68 13.3 Technical (Hospital) Services HC/HH Wch Supp Cap Shampoo__7909 PX-2705000044 CDM 2705000044 LOCAL 270 RC inpatient 14 14 CIGNA 62308 [3081051] CIGNA 62308 [308105105] 11.09 percent of total billed charges 8.68 13.3 Technical (Hospital) Services HC/HH Wch Supp Cap Shampoo__7909 PX-2705000044 CDM 2705000044 LOCAL 270 RC inpatient 14 14 CIGNA 62308 [3081051] CIGNA STATE OF WYOMING [308105107] 11.09 percent of total billed charges 8.68 13.3 Technical (Hospital) Services HC/HH Wch Supp Cap Shampoo__7909 PX-2705000044 CDM 2705000044 LOCAL 270 RC inpatient 14 14 MULTIPLAN INC 34080 [3081285] MULTIPLAN INC [308128501] 13.3 percent of total billed charges 8.68 13.3 Technical (Hospital) Services HC/HH Wch Supp Cannula O2 Nasal Ped__1101 PX-2705000043 CDM 2705000043 LOCAL 270 RC inpatient 8 8 UNITED HEALTHCARE (COMMERCIAL) [3081199] UNITED HEALTHCARE 87726 [308119901] 4.96 percent of total billed charges 4.96 7.6 Technical (Hospital) Services HC/HH Wch Supp Cannula O2 Nasal Ped__1101 PX-2705000043 CDM 2705000043 LOCAL 270 RC inpatient 8 8 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES HDHP [308136802] 6.33 percent of total billed charges 4.96 7.6 Technical (Hospital) Services HC/HH Wch Supp Cannula O2 Nasal Ped__1101 PX-2705000043 CDM 2705000043 LOCAL 270 RC inpatient 8 8 MEDICA (COMMERCIAL) 94265 [3081118] MEDICA CLAIMS [308111801] 7.2 percent of total billed charges 4.96 7.6 Technical (Hospital) Services HC/HH Wch Supp Cannula O2 Nasal Ped__1101 PX-2705000043 CDM 2705000043 LOCAL 270 RC inpatient 8 8 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES PPO [308136801] 6.33 percent of total billed charges 4.96 7.6 Technical (Hospital) Services HC/HH Wch Supp Cannula O2 Nasal Ped__1101 PX-2705000043 CDM 2705000043 LOCAL 270 RC inpatient 8 8 HEALTHPARTNERS SX009 HEALTHPARTNERS 6.33 percent of total billed charges 4.96 7.6 Technical (Hospital) Services HC/HH Wch Supp Cannula O2 Nasal Ped__1101 PX-2705000043 CDM 2705000043 LOCAL 270 RC inpatient 8 8 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES EPO [308136803] 6.33 percent of total billed charges 4.96 7.6 Technical (Hospital) Services HC/HH Wch Supp Cannula O2 Nasal Ped__1101 PX-2705000043 CDM 2705000043 LOCAL 270 RC inpatient 8 8 MULTIPLAN INC 34080 [3081285] MULTIPLAN INC [308128501] 7.6 percent of total billed charges 4.96 7.6 Technical (Hospital) Services HC/HH Wch Supp Cannula O2 Nasal Ped__1101 PX-2705000043 CDM 2705000043 LOCAL 270 RC inpatient 8 8 CIGNA 62308 [3081051] CIGNA 62308 [308105105] 6.33 percent of total billed charges 4.96 7.6 Technical (Hospital) Services HC/HH Wch Supp Cannula O2 Nasal Ped__1101 PX-2705000043 CDM 2705000043 LOCAL 270 RC inpatient 8 8 CIGNA 62308 [3081051] CIGNA STATE OF WYOMING [308105107] 6.33 percent of total billed charges 4.96 7.6 Technical (Hospital) Services HC/HH Wch Supp Cannula O2 Nasal Ped__1101 PX-2705000043 CDM 2705000043 LOCAL 270 RC inpatient 8 8 BLUE CROSS BLUE SHIELD WELLMARK SB889 [3081026] BCBS WYOMING [308102603] 7.6 percent of total billed charges 4.96 7.6 Technical (Hospital) Services HC/HH Wch Supp Cannula O2 Nasal Ped__1101 PX-2705000043 CDM 2705000043 LOCAL 270 RC outpatient 8 8 MEDICA (COMMERCIAL) 94265 [3081118] MEDICA CLAIMS [308111801] 7.2 percent of total billed charges 4.96 7.6 Technical (Hospital) Services HC/HH Wch Supp Cannula O2 Nasal Ped__1101 PX-2705000043 CDM 2705000043 LOCAL 270 RC outpatient 8 8 MULTIPLAN INC 34080 [3081285] MULTIPLAN INC [308128501] 7.6 percent of total billed charges 4.96 7.6 Technical (Hospital) Services HC/HH Wch Supp Cannula O2 Nasal Ped__1101 PX-2705000043 CDM 2705000043 LOCAL 270 RC outpatient 8 8 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES EPO [308136803] 6.4 percent of total billed charges 4.96 7.6 Technical (Hospital) Services HC/HH Wch Supp Cannula O2 Nasal Ped__1101 PX-2705000043 CDM 2705000043 LOCAL 270 RC outpatient 8 8 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES HDHP [308136802] 6.4 percent of total billed charges 4.96 7.6 Technical (Hospital) Services HC/HH Wch Supp Cannula O2 Nasal Ped__1101 PX-2705000043 CDM 2705000043 LOCAL 270 RC outpatient 8 8 CIGNA 62308 [3081051] CIGNA 62308 [308105105] 6.4 percent of total billed charges 4.96 7.6 Technical (Hospital) Services HC/HH Wch Supp Cannula O2 Nasal Ped__1101 PX-2705000043 CDM 2705000043 LOCAL 270 RC outpatient 8 8 CIGNA 62308 [3081051] CIGNA STATE OF WYOMING [308105107] 6.4 percent of total billed charges 4.96 7.6 Technical (Hospital) Services HC/HH Wch Supp Cannula O2 Nasal Ped__1101 PX-2705000043 CDM 2705000043 LOCAL 270 RC outpatient 8 8 BLUE CROSS BLUE SHIELD WELLMARK SB889 [3081026] BCBS WYOMING [308102603] 7.6 percent of total billed charges 4.96 7.6 Technical (Hospital) Services HC/HH Wch Supp Cannula O2 Nasal Ped__1101 PX-2705000043 CDM 2705000043 LOCAL 270 RC outpatient 8 8 UNITED HEALTHCARE (COMMERCIAL) [3081199] UNITED HEALTHCARE 87726 [308119901] 4.96 percent of total billed charges 4.96 7.6 Technical (Hospital) Services HC/HH Wch Supp Cannula O2 Nasal Ped__1101 PX-2705000043 CDM 2705000043 LOCAL 270 RC outpatient 8 8 HEALTHPARTNERS SX009 HEALTHPARTNERS 6.4 percent of total billed charges 4.96 7.6 Technical (Hospital) Services HC/HH Wch Supp Cannula O2 Nasal Ped__1101 PX-2705000043 CDM 2705000043 LOCAL 270 RC outpatient 8 8 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES PPO [308136801] 6.4 percent of total billed charges 4.96 7.6 Technical (Hospital) Services HC/HH Wch Supp Cannister Suction Ortho 1500cc__65651-515 PX-2705000042 CDM 2705000042 LOCAL 270 RC outpatient 16 16 HEALTHPARTNERS SX009 HEALTHPARTNERS 12.8 percent of total billed charges 9.92 15.2 Technical (Hospital) Services HC/HH Wch Supp Cannister Suction Ortho 1500cc__65651-515 PX-2705000042 CDM 2705000042 LOCAL 270 RC outpatient 16 16 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES PPO [308136801] 12.8 percent of total billed charges 9.92 15.2 Technical (Hospital) Services HC/HH Wch Supp Cannister Suction Ortho 1500cc__65651-515 PX-2705000042 CDM 2705000042 LOCAL 270 RC outpatient 16 16 UNITED HEALTHCARE (COMMERCIAL) [3081199] UNITED HEALTHCARE 87726 [308119901] 9.92 percent of total billed charges 9.92 15.2 Technical (Hospital) Services HC/HH Wch Supp Cannister Suction Ortho 1500cc__65651-515 PX-2705000042 CDM 2705000042 LOCAL 270 RC outpatient 16 16 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES HDHP [308136802] 12.8 percent of total billed charges 9.92 15.2 Technical (Hospital) Services HC/HH Wch Supp Cannister Suction Ortho 1500cc__65651-515 PX-2705000042 CDM 2705000042 LOCAL 270 RC outpatient 16 16 BLUE CROSS BLUE SHIELD WELLMARK SB889 [3081026] BCBS WYOMING [308102603] 15.2 percent of total billed charges 9.92 15.2 Technical (Hospital) Services HC/HH Wch Supp Cannister Suction Ortho 1500cc__65651-515 PX-2705000042 CDM 2705000042 LOCAL 270 RC outpatient 16 16 CIGNA 62308 [3081051] CIGNA 62308 [308105105] 12.8 percent of total billed charges 9.92 15.2 Technical (Hospital) Services HC/HH Wch Supp Cannister Suction Ortho 1500cc__65651-515 PX-2705000042 CDM 2705000042 LOCAL 270 RC outpatient 16 16 CIGNA 62308 [3081051] CIGNA STATE OF WYOMING [308105107] 12.8 percent of total billed charges 9.92 15.2 Technical (Hospital) Services HC/HH Wch Supp Cannister Suction Ortho 1500cc__65651-515 PX-2705000042 CDM 2705000042 LOCAL 270 RC outpatient 16 16 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES EPO [308136803] 12.8 percent of total billed charges 9.92 15.2 Technical (Hospital) Services HC/HH Wch Supp Cannister Suction Ortho 1500cc__65651-515 PX-2705000042 CDM 2705000042 LOCAL 270 RC outpatient 16 16 MULTIPLAN INC 34080 [3081285] MULTIPLAN INC [308128501] 15.2 percent of total billed charges 9.92 15.2 Technical (Hospital) Services HC/HH Wch Supp Cannister Suction Ortho 1500cc__65651-515 PX-2705000042 CDM 2705000042 LOCAL 270 RC outpatient 16 16 MEDICA (COMMERCIAL) 94265 [3081118] MEDICA CLAIMS [308111801] 14.4 percent of total billed charges 9.92 15.2 Technical (Hospital) Services HC/HH Wch Supp Cannister Suction Ortho 1500cc__65651-515 PX-2705000042 CDM 2705000042 LOCAL 270 RC inpatient 16 16 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES PPO [308136801] 12.67 percent of total billed charges 9.92 15.2 Technical (Hospital) Services HC/HH Wch Supp Cannister Suction Ortho 1500cc__65651-515 PX-2705000042 CDM 2705000042 LOCAL 270 RC inpatient 16 16 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES HDHP [308136802] 12.67 percent of total billed charges 9.92 15.2 Technical (Hospital) Services HC/HH Wch Supp Cannister Suction Ortho 1500cc__65651-515 PX-2705000042 CDM 2705000042 LOCAL 270 RC inpatient 16 16 MEDICA (COMMERCIAL) 94265 [3081118] MEDICA CLAIMS [308111801] 14.4 percent of total billed charges 9.92 15.2 Technical (Hospital) Services HC/HH Wch Supp Cannister Suction Ortho 1500cc__65651-515 PX-2705000042 CDM 2705000042 LOCAL 270 RC inpatient 16 16 UNITED HEALTHCARE (COMMERCIAL) [3081199] UNITED HEALTHCARE 87726 [308119901] 9.92 percent of total billed charges 9.92 15.2 Technical (Hospital) Services HC/HH Wch Supp Cannister Suction Ortho 1500cc__65651-515 PX-2705000042 CDM 2705000042 LOCAL 270 RC inpatient 16 16 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES EPO [308136803] 12.67 percent of total billed charges 9.92 15.2 Technical (Hospital) Services HC/HH Wch Supp Cannister Suction Ortho 1500cc__65651-515 PX-2705000042 CDM 2705000042 LOCAL 270 RC inpatient 16 16 HEALTHPARTNERS SX009 HEALTHPARTNERS 12.67 percent of total billed charges 9.92 15.2 Technical (Hospital) Services HC/HH Wch Supp Cannister Suction Ortho 1500cc__65651-515 PX-2705000042 CDM 2705000042 LOCAL 270 RC inpatient 16 16 BLUE CROSS BLUE SHIELD WELLMARK SB889 [3081026] BCBS WYOMING [308102603] 15.2 percent of total billed charges 9.92 15.2 Technical (Hospital) Services HC/HH Wch Supp Cannister Suction Ortho 1500cc__65651-515 PX-2705000042 CDM 2705000042 LOCAL 270 RC inpatient 16 16 MULTIPLAN INC 34080 [3081285] MULTIPLAN INC [308128501] 15.2 percent of total billed charges 9.92 15.2 Technical (Hospital) Services HC/HH Wch Supp Cannister Suction Ortho 1500cc__65651-515 PX-2705000042 CDM 2705000042 LOCAL 270 RC inpatient 16 16 CIGNA 62308 [3081051] CIGNA 62308 [308105105] 12.67 percent of total billed charges 9.92 15.2 Technical (Hospital) Services HC/HH Wch Supp Cannister Suction Ortho 1500cc__65651-515 PX-2705000042 CDM 2705000042 LOCAL 270 RC inpatient 16 16 CIGNA 62308 [3081051] CIGNA STATE OF WYOMING [308105107] 12.67 percent of total billed charges 9.92 15.2 Technical (Hospital) Services HC/HH Wch Supp Brace Clavicle Xl__1179556 PX-2705000041 CDM 2705000041 LOCAL 270 RC outpatient 37 37 BLUE CROSS BLUE SHIELD WELLMARK SB889 [3081026] BCBS WYOMING [308102603] 35.15 percent of total billed charges 22.94 35.15 Technical (Hospital) Services HC/HH Wch Supp Brace Clavicle Xl__1179556 PX-2705000041 CDM 2705000041 LOCAL 270 RC outpatient 37 37 CIGNA 62308 [3081051] CIGNA STATE OF WYOMING [308105107] 29.6 percent of total billed charges 22.94 35.15 Technical (Hospital) Services HC/HH Wch Supp Brace Clavicle Xl__1179556 PX-2705000041 CDM 2705000041 LOCAL 270 RC outpatient 37 37 CIGNA 62308 [3081051] CIGNA 62308 [308105105] 29.6 percent of total billed charges 22.94 35.15 Technical (Hospital) Services HC/HH Wch Supp Brace Clavicle Xl__1179556 PX-2705000041 CDM 2705000041 LOCAL 270 RC outpatient 37 37 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES EPO [308136803] 29.6 percent of total billed charges 22.94 35.15 Technical (Hospital) Services HC/HH Wch Supp Brace Clavicle Xl__1179556 PX-2705000041 CDM 2705000041 LOCAL 270 RC outpatient 37 37 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES HDHP [308136802] 29.6 percent of total billed charges 22.94 35.15 Technical (Hospital) Services HC/HH Wch Supp Brace Clavicle Xl__1179556 PX-2705000041 CDM 2705000041 LOCAL 270 RC outpatient 37 37 HEALTHPARTNERS SX009 HEALTHPARTNERS 29.6 percent of total billed charges 22.94 35.15 Technical (Hospital) Services HC/HH Wch Supp Brace Clavicle Xl__1179556 PX-2705000041 CDM 2705000041 LOCAL 270 RC outpatient 37 37 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES PPO [308136801] 29.6 percent of total billed charges 22.94 35.15 Technical (Hospital) Services HC/HH Wch Supp Brace Clavicle Xl__1179556 PX-2705000041 CDM 2705000041 LOCAL 270 RC outpatient 37 37 UNITED HEALTHCARE (COMMERCIAL) [3081199] UNITED HEALTHCARE 87726 [308119901] 22.94 percent of total billed charges 22.94 35.15 Technical (Hospital) Services HC/HH Wch Supp Brace Clavicle Xl__1179556 PX-2705000041 CDM 2705000041 LOCAL 270 RC outpatient 37 37 MEDICA (COMMERCIAL) 94265 [3081118] MEDICA CLAIMS [308111801] 33.3 percent of total billed charges 22.94 35.15 Technical (Hospital) Services HC/HH Wch Supp Brace Clavicle Xl__1179556 PX-2705000041 CDM 2705000041 LOCAL 270 RC outpatient 37 37 MULTIPLAN INC 34080 [3081285] MULTIPLAN INC [308128501] 35.15 percent of total billed charges 22.94 35.15 Technical (Hospital) Services HC/HH Wch Supp Brace Clavicle Xl__1179556 PX-2705000041 CDM 2705000041 LOCAL 270 RC inpatient 37 37 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES PPO [308136801] 29.3 percent of total billed charges 22.94 35.15 Technical (Hospital) Services HC/HH Wch Supp Brace Clavicle Xl__1179556 PX-2705000041 CDM 2705000041 LOCAL 270 RC inpatient 37 37 UNITED HEALTHCARE (COMMERCIAL) [3081199] UNITED HEALTHCARE 87726 [308119901] 22.94 percent of total billed charges 22.94 35.15 Technical (Hospital) Services HC/HH Wch Supp Brace Clavicle Xl__1179556 PX-2705000041 CDM 2705000041 LOCAL 270 RC inpatient 37 37 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES HDHP [308136802] 29.3 percent of total billed charges 22.94 35.15 Technical (Hospital) Services HC/HH Wch Supp Brace Clavicle Xl__1179556 PX-2705000041 CDM 2705000041 LOCAL 270 RC inpatient 37 37 MEDICA (COMMERCIAL) 94265 [3081118] MEDICA CLAIMS [308111801] 33.3 percent of total billed charges 22.94 35.15 Technical (Hospital) Services HC/HH Wch Supp Brace Clavicle Xl__1179556 PX-2705000041 CDM 2705000041 LOCAL 270 RC inpatient 37 37 MULTIPLAN INC 34080 [3081285] MULTIPLAN INC [308128501] 35.15 percent of total billed charges 22.94 35.15 Technical (Hospital) Services HC/HH Wch Supp Brace Clavicle Xl__1179556 PX-2705000041 CDM 2705000041 LOCAL 270 RC inpatient 37 37 BLUE CROSS BLUE SHIELD WELLMARK SB889 [3081026] BCBS WYOMING [308102603] 35.15 percent of total billed charges 22.94 35.15 Technical (Hospital) Services HC/HH Wch Supp Brace Clavicle Xl__1179556 PX-2705000041 CDM 2705000041 LOCAL 270 RC inpatient 37 37 CIGNA 62308 [3081051] CIGNA 62308 [308105105] 29.3 percent of total billed charges 22.94 35.15 Technical (Hospital) Services HC/HH Wch Supp Brace Clavicle Xl__1179556 PX-2705000041 CDM 2705000041 LOCAL 270 RC inpatient 37 37 CIGNA 62308 [3081051] CIGNA STATE OF WYOMING [308105107] 29.3 percent of total billed charges 22.94 35.15 Technical (Hospital) Services HC/HH Wch Supp Brace Clavicle Xl__1179556 PX-2705000041 CDM 2705000041 LOCAL 270 RC inpatient 37 37 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES EPO [308136803] 29.3 percent of total billed charges 22.94 35.15 Technical (Hospital) Services HC/HH Wch Supp Brace Clavicle Xl__1179556 PX-2705000041 CDM 2705000041 LOCAL 270 RC inpatient 37 37 HEALTHPARTNERS SX009 HEALTHPARTNERS 29.3 percent of total billed charges 22.94 35.15 Technical (Hospital) Services HC/HH Wch Supp Brace Clavicle Velcro Strap Xs__0814-1231 PX-2705000040 CDM 2705000040 LOCAL 270 RC outpatient 32 32 MULTIPLAN INC 34080 [3081285] MULTIPLAN INC [308128501] 30.4 percent of total billed charges 19.84 30.4 Technical (Hospital) Services HC/HH Wch Supp Brace Clavicle Velcro Strap Xs__0814-1231 PX-2705000040 CDM 2705000040 LOCAL 270 RC outpatient 32 32 MEDICA (COMMERCIAL) 94265 [3081118] MEDICA CLAIMS [308111801] 28.8 percent of total billed charges 19.84 30.4 Technical (Hospital) Services HC/HH Wch Supp Brace Clavicle Velcro Strap Xs__0814-1231 PX-2705000040 CDM 2705000040 LOCAL 270 RC outpatient 32 32 UNITED HEALTHCARE (COMMERCIAL) [3081199] UNITED HEALTHCARE 87726 [308119901] 19.84 percent of total billed charges 19.84 30.4 Technical (Hospital) Services HC/HH Wch Supp Brace Clavicle Velcro Strap Xs__0814-1231 PX-2705000040 CDM 2705000040 LOCAL 270 RC outpatient 32 32 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES PPO [308136801] 25.6 percent of total billed charges 19.84 30.4 Technical (Hospital) Services HC/HH Wch Supp Brace Clavicle Velcro Strap Xs__0814-1231 PX-2705000040 CDM 2705000040 LOCAL 270 RC outpatient 32 32 HEALTHPARTNERS SX009 HEALTHPARTNERS 25.6 percent of total billed charges 19.84 30.4 Technical (Hospital) Services HC/HH Wch Supp Brace Clavicle Velcro Strap Xs__0814-1231 PX-2705000040 CDM 2705000040 LOCAL 270 RC outpatient 32 32 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES HDHP [308136802] 25.6 percent of total billed charges 19.84 30.4 Technical (Hospital) Services HC/HH Wch Supp Brace Clavicle Velcro Strap Xs__0814-1231 PX-2705000040 CDM 2705000040 LOCAL 270 RC outpatient 32 32 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES EPO [308136803] 25.6 percent of total billed charges 19.84 30.4 Technical (Hospital) Services HC/HH Wch Supp Brace Clavicle Velcro Strap Xs__0814-1231 PX-2705000040 CDM 2705000040 LOCAL 270 RC outpatient 32 32 CIGNA 62308 [3081051] CIGNA 62308 [308105105] 25.6 percent of total billed charges 19.84 30.4 Technical (Hospital) Services HC/HH Wch Supp Brace Clavicle Velcro Strap Xs__0814-1231 PX-2705000040 CDM 2705000040 LOCAL 270 RC outpatient 32 32 CIGNA 62308 [3081051] CIGNA STATE OF WYOMING [308105107] 25.6 percent of total billed charges 19.84 30.4 Technical (Hospital) Services HC/HH Wch Supp Brace Clavicle Velcro Strap Xs__0814-1231 PX-2705000040 CDM 2705000040 LOCAL 270 RC outpatient 32 32 BLUE CROSS BLUE SHIELD WELLMARK SB889 [3081026] BCBS WYOMING [308102603] 30.4 percent of total billed charges 19.84 30.4 Technical (Hospital) Services HC/HH Wch Supp Brace Clavicle Velcro Strap Xs__0814-1231 PX-2705000040 CDM 2705000040 LOCAL 270 RC inpatient 32 32 BLUE CROSS BLUE SHIELD WELLMARK SB889 [3081026] BCBS WYOMING [308102603] 30.4 percent of total billed charges 19.84 30.4 Technical (Hospital) Services HC/HH Wch Supp Brace Clavicle Velcro Strap Xs__0814-1231 PX-2705000040 CDM 2705000040 LOCAL 270 RC inpatient 32 32 CIGNA 62308 [3081051] CIGNA 62308 [308105105] 25.34 percent of total billed charges 19.84 30.4 Technical (Hospital) Services HC/HH Wch Supp Brace Clavicle Velcro Strap Xs__0814-1231 PX-2705000040 CDM 2705000040 LOCAL 270 RC inpatient 32 32 CIGNA 62308 [3081051] CIGNA STATE OF WYOMING [308105107] 25.34 percent of total billed charges 19.84 30.4 Technical (Hospital) Services HC/HH Wch Supp Brace Clavicle Velcro Strap Xs__0814-1231 PX-2705000040 CDM 2705000040 LOCAL 270 RC inpatient 32 32 MULTIPLAN INC 34080 [3081285] MULTIPLAN INC [308128501] 30.4 percent of total billed charges 19.84 30.4 Technical (Hospital) Services HC/HH Wch Supp Brace Clavicle Velcro Strap Xs__0814-1231 PX-2705000040 CDM 2705000040 LOCAL 270 RC inpatient 32 32 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES EPO [308136803] 25.34 percent of total billed charges 19.84 30.4 Technical (Hospital) Services HC/HH Wch Supp Brace Clavicle Velcro Strap Xs__0814-1231 PX-2705000040 CDM 2705000040 LOCAL 270 RC inpatient 32 32 HEALTHPARTNERS SX009 HEALTHPARTNERS 25.34 percent of total billed charges 19.84 30.4 Technical (Hospital) Services HC/HH Wch Supp Brace Clavicle Velcro Strap Xs__0814-1231 PX-2705000040 CDM 2705000040 LOCAL 270 RC inpatient 32 32 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES PPO [308136801] 25.34 percent of total billed charges 19.84 30.4 Technical (Hospital) Services HC/HH Wch Supp Brace Clavicle Velcro Strap Xs__0814-1231 PX-2705000040 CDM 2705000040 LOCAL 270 RC inpatient 32 32 MEDICA (COMMERCIAL) 94265 [3081118] MEDICA CLAIMS [308111801] 28.8 percent of total billed charges 19.84 30.4 Technical (Hospital) Services HC/HH Wch Supp Brace Clavicle Velcro Strap Xs__0814-1231 PX-2705000040 CDM 2705000040 LOCAL 270 RC inpatient 32 32 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES HDHP [308136802] 25.34 percent of total billed charges 19.84 30.4 Technical (Hospital) Services HC/HH Wch Supp Brace Clavicle Velcro Strap Xs__0814-1231 PX-2705000040 CDM 2705000040 LOCAL 270 RC inpatient 32 32 UNITED HEALTHCARE (COMMERCIAL) [3081199] UNITED HEALTHCARE 87726 [308119901] 19.84 percent of total billed charges 19.84 30.4 Technical (Hospital) Services HC/HH Wch Supp Bndge Setopress 4in__3505 PX-2705000039 CDM 2705000039 LOCAL 270 RC outpatient 48 48 HEALTHPARTNERS SX009 HEALTHPARTNERS 38.4 percent of total billed charges 29.76 45.6 Technical (Hospital) Services HC/HH Wch Supp Bndge Setopress 4in__3505 PX-2705000039 CDM 2705000039 LOCAL 270 RC outpatient 48 48 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES PPO [308136801] 38.4 percent of total billed charges 29.76 45.6 Technical (Hospital) Services HC/HH Wch Supp Bndge Setopress 4in__3505 PX-2705000039 CDM 2705000039 LOCAL 270 RC outpatient 48 48 UNITED HEALTHCARE (COMMERCIAL) [3081199] UNITED HEALTHCARE 87726 [308119901] 29.76 percent of total billed charges 29.76 45.6 Technical (Hospital) Services HC/HH Wch Supp Bndge Setopress 4in__3505 PX-2705000039 CDM 2705000039 LOCAL 270 RC outpatient 48 48 BLUE CROSS BLUE SHIELD WELLMARK SB889 [3081026] BCBS WYOMING [308102603] 45.6 percent of total billed charges 29.76 45.6 Technical (Hospital) Services HC/HH Wch Supp Bndge Setopress 4in__3505 PX-2705000039 CDM 2705000039 LOCAL 270 RC outpatient 48 48 CIGNA 62308 [3081051] CIGNA 62308 [308105105] 38.4 percent of total billed charges 29.76 45.6 Technical (Hospital) Services HC/HH Wch Supp Bndge Setopress 4in__3505 PX-2705000039 CDM 2705000039 LOCAL 270 RC outpatient 48 48 CIGNA 62308 [3081051] CIGNA STATE OF WYOMING [308105107] 38.4 percent of total billed charges 29.76 45.6 Technical (Hospital) Services HC/HH Wch Supp Bndge Setopress 4in__3505 PX-2705000039 CDM 2705000039 LOCAL 270 RC outpatient 48 48 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES HDHP [308136802] 38.4 percent of total billed charges 29.76 45.6 Technical (Hospital) Services HC/HH Wch Supp Bndge Setopress 4in__3505 PX-2705000039 CDM 2705000039 LOCAL 270 RC outpatient 48 48 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES EPO [308136803] 38.4 percent of total billed charges 29.76 45.6 Technical (Hospital) Services HC/HH Wch Supp Bndge Setopress 4in__3505 PX-2705000039 CDM 2705000039 LOCAL 270 RC outpatient 48 48 MULTIPLAN INC 34080 [3081285] MULTIPLAN INC [308128501] 45.6 percent of total billed charges 29.76 45.6 Technical (Hospital) Services HC/HH Wch Supp Bndge Setopress 4in__3505 PX-2705000039 CDM 2705000039 LOCAL 270 RC outpatient 48 48 MEDICA (COMMERCIAL) 94265 [3081118] MEDICA CLAIMS [308111801] 43.2 percent of total billed charges 29.76 45.6 Technical (Hospital) Services HC/HH Wch Supp Bndge Setopress 4in__3505 PX-2705000039 CDM 2705000039 LOCAL 270 RC inpatient 48 48 CIGNA 62308 [3081051] CIGNA 62308 [308105105] 38.01 percent of total billed charges 29.76 45.6 Technical (Hospital) Services HC/HH Wch Supp Bndge Setopress 4in__3505 PX-2705000039 CDM 2705000039 LOCAL 270 RC inpatient 48 48 CIGNA 62308 [3081051] CIGNA STATE OF WYOMING [308105107] 38.01 percent of total billed charges 29.76 45.6 Technical (Hospital) Services HC/HH Wch Supp Bndge Setopress 4in__3505 PX-2705000039 CDM 2705000039 LOCAL 270 RC inpatient 48 48 MULTIPLAN INC 34080 [3081285] MULTIPLAN INC [308128501] 45.6 percent of total billed charges 29.76 45.6 Technical (Hospital) Services HC/HH Wch Supp Bndge Setopress 4in__3505 PX-2705000039 CDM 2705000039 LOCAL 270 RC inpatient 48 48 BLUE CROSS BLUE SHIELD WELLMARK SB889 [3081026] BCBS WYOMING [308102603] 45.6 percent of total billed charges 29.76 45.6 Technical (Hospital) Services HC/HH Wch Supp Bndge Setopress 4in__3505 PX-2705000039 CDM 2705000039 LOCAL 270 RC inpatient 48 48 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES EPO [308136803] 38.01 percent of total billed charges 29.76 45.6 Technical (Hospital) Services HC/HH Wch Supp Bndge Setopress 4in__3505 PX-2705000039 CDM 2705000039 LOCAL 270 RC inpatient 48 48 HEALTHPARTNERS SX009 HEALTHPARTNERS 38.01 percent of total billed charges 29.76 45.6 Technical (Hospital) Services HC/HH Wch Supp Bndge Setopress 4in__3505 PX-2705000039 CDM 2705000039 LOCAL 270 RC inpatient 48 48 UNITED HEALTHCARE (COMMERCIAL) [3081199] UNITED HEALTHCARE 87726 [308119901] 29.76 percent of total billed charges 29.76 45.6 Technical (Hospital) Services HC/HH Wch Supp Bndge Setopress 4in__3505 PX-2705000039 CDM 2705000039 LOCAL 270 RC inpatient 48 48 MEDICA (COMMERCIAL) 94265 [3081118] MEDICA CLAIMS [308111801] 43.2 percent of total billed charges 29.76 45.6 Technical (Hospital) Services HC/HH Wch Supp Bndge Setopress 4in__3505 PX-2705000039 CDM 2705000039 LOCAL 270 RC inpatient 48 48 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES HDHP [308136802] 38.01 percent of total billed charges 29.76 45.6 Technical (Hospital) Services HC/HH Wch Supp Bndge Setopress 4in__3505 PX-2705000039 CDM 2705000039 LOCAL 270 RC inpatient 48 48 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES PPO [308136801] 38.01 percent of total billed charges 29.76 45.6 Technical (Hospital) Services HC/HH Wch Supp Bndg Roll Nst 4in__6021 PX-2705000038 CDM 2705000038 LOCAL 270 RC outpatient 6 6 BLUE CROSS BLUE SHIELD WELLMARK SB889 [3081026] BCBS WYOMING [308102603] 5.7 percent of total billed charges 3.72 5.7 Technical (Hospital) Services HC/HH Wch Supp Bndg Roll Nst 4in__6021 PX-2705000038 CDM 2705000038 LOCAL 270 RC outpatient 6 6 CIGNA 62308 [3081051] CIGNA 62308 [308105105] 4.8 percent of total billed charges 3.72 5.7 Technical (Hospital) Services HC/HH Wch Supp Bndg Roll Nst 4in__6021 PX-2705000038 CDM 2705000038 LOCAL 270 RC outpatient 6 6 CIGNA 62308 [3081051] CIGNA STATE OF WYOMING [308105107] 4.8 percent of total billed charges 3.72 5.7 Technical (Hospital) Services HC/HH Wch Supp Bndg Roll Nst 4in__6021 PX-2705000038 CDM 2705000038 LOCAL 270 RC outpatient 6 6 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES EPO [308136803] 4.8 percent of total billed charges 3.72 5.7 Technical (Hospital) Services HC/HH Wch Supp Bndg Roll Nst 4in__6021 PX-2705000038 CDM 2705000038 LOCAL 270 RC outpatient 6 6 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES HDHP [308136802] 4.8 percent of total billed charges 3.72 5.7 Technical (Hospital) Services HC/HH Wch Supp Bndg Roll Nst 4in__6021 PX-2705000038 CDM 2705000038 LOCAL 270 RC outpatient 6 6 HEALTHPARTNERS SX009 HEALTHPARTNERS 4.8 percent of total billed charges 3.72 5.7 Technical (Hospital) Services HC/HH Wch Supp Bndg Roll Nst 4in__6021 PX-2705000038 CDM 2705000038 LOCAL 270 RC outpatient 6 6 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES PPO [308136801] 4.8 percent of total billed charges 3.72 5.7 Technical (Hospital) Services HC/HH Wch Supp Bndg Roll Nst 4in__6021 PX-2705000038 CDM 2705000038 LOCAL 270 RC outpatient 6 6 UNITED HEALTHCARE (COMMERCIAL) [3081199] UNITED HEALTHCARE 87726 [308119901] 3.72 percent of total billed charges 3.72 5.7 Technical (Hospital) Services HC/HH Wch Supp Bndg Roll Nst 4in__6021 PX-2705000038 CDM 2705000038 LOCAL 270 RC outpatient 6 6 MEDICA (COMMERCIAL) 94265 [3081118] MEDICA CLAIMS [308111801] 5.4 percent of total billed charges 3.72 5.7 Technical (Hospital) Services HC/HH Wch Supp Bndg Roll Nst 4in__6021 PX-2705000038 CDM 2705000038 LOCAL 270 RC outpatient 6 6 MULTIPLAN INC 34080 [3081285] MULTIPLAN INC [308128501] 5.7 percent of total billed charges 3.72 5.7 Technical (Hospital) Services HC/HH Wch Supp Bndg Roll Nst 4in__6021 PX-2705000038 CDM 2705000038 LOCAL 270 RC inpatient 6 6 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES PPO [308136801] 4.75 percent of total billed charges 3.72 5.7 Technical (Hospital) Services HC/HH Wch Supp Bndg Roll Nst 4in__6021 PX-2705000038 CDM 2705000038 LOCAL 270 RC inpatient 6 6 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES HDHP [308136802] 4.75 percent of total billed charges 3.72 5.7 Technical (Hospital) Services HC/HH Wch Supp Bndg Roll Nst 4in__6021 PX-2705000038 CDM 2705000038 LOCAL 270 RC inpatient 6 6 MEDICA (COMMERCIAL) 94265 [3081118] MEDICA CLAIMS [308111801] 5.4 percent of total billed charges 3.72 5.7 Technical (Hospital) Services HC/HH Wch Supp Bndg Roll Nst 4in__6021 PX-2705000038 CDM 2705000038 LOCAL 270 RC inpatient 6 6 UNITED HEALTHCARE (COMMERCIAL) [3081199] UNITED HEALTHCARE 87726 [308119901] 3.72 percent of total billed charges 3.72 5.7 Technical (Hospital) Services HC/HH Wch Supp Bndg Roll Nst 4in__6021 PX-2705000038 CDM 2705000038 LOCAL 270 RC inpatient 6 6 HEALTHPARTNERS SX009 HEALTHPARTNERS 4.75 percent of total billed charges 3.72 5.7 Technical (Hospital) Services HC/HH Wch Supp Bndg Roll Nst 4in__6021 PX-2705000038 CDM 2705000038 LOCAL 270 RC inpatient 6 6 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES EPO [308136803] 4.75 percent of total billed charges 3.72 5.7 Technical (Hospital) Services HC/HH Wch Supp Bndg Roll Nst 4in__6021 PX-2705000038 CDM 2705000038 LOCAL 270 RC inpatient 6 6 BLUE CROSS BLUE SHIELD WELLMARK SB889 [3081026] BCBS WYOMING [308102603] 5.7 percent of total billed charges 3.72 5.7 Technical (Hospital) Services HC/HH Wch Supp Bndg Roll Nst 4in__6021 PX-2705000038 CDM 2705000038 LOCAL 270 RC inpatient 6 6 MULTIPLAN INC 34080 [3081285] MULTIPLAN INC [308128501] 5.7 percent of total billed charges 3.72 5.7 Technical (Hospital) Services HC/HH Wch Supp Bndg Roll Nst 4in__6021 PX-2705000038 CDM 2705000038 LOCAL 270 RC inpatient 6 6 CIGNA 62308 [3081051] CIGNA 62308 [308105105] 4.75 percent of total billed charges 3.72 5.7 Technical (Hospital) Services HC/HH Wch Supp Bndg Roll Nst 4in__6021 PX-2705000038 CDM 2705000038 LOCAL 270 RC inpatient 6 6 CIGNA 62308 [3081051] CIGNA STATE OF WYOMING [308105107] 4.75 percent of total billed charges 3.72 5.7 Technical (Hospital) Services HC/HH Wch Supp Bndg Plaster 6x5__7376 PX-2705000037 CDM 2705000037 LOCAL 270 RC outpatient 15 15 MULTIPLAN INC 34080 [3081285] MULTIPLAN INC [308128501] 14.25 percent of total billed charges 9.3 14.25 Technical (Hospital) Services HC/HH Wch Supp Bndg Plaster 6x5__7376 PX-2705000037 CDM 2705000037 LOCAL 270 RC outpatient 15 15 MEDICA (COMMERCIAL) 94265 [3081118] MEDICA CLAIMS [308111801] 13.5 percent of total billed charges 9.3 14.25 Technical (Hospital) Services HC/HH Wch Supp Bndg Plaster 6x5__7376 PX-2705000037 CDM 2705000037 LOCAL 270 RC outpatient 15 15 UNITED HEALTHCARE (COMMERCIAL) [3081199] UNITED HEALTHCARE 87726 [308119901] 9.3 percent of total billed charges 9.3 14.25 Technical (Hospital) Services HC/HH Wch Supp Bndg Plaster 6x5__7376 PX-2705000037 CDM 2705000037 LOCAL 270 RC outpatient 15 15 HEALTHPARTNERS SX009 HEALTHPARTNERS 12 percent of total billed charges 9.3 14.25 Technical (Hospital) Services HC/HH Wch Supp Bndg Plaster 6x5__7376 PX-2705000037 CDM 2705000037 LOCAL 270 RC outpatient 15 15 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES PPO [308136801] 12 percent of total billed charges 9.3 14.25 Technical (Hospital) Services HC/HH Wch Supp Bndg Plaster 6x5__7376 PX-2705000037 CDM 2705000037 LOCAL 270 RC outpatient 15 15 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES EPO [308136803] 12 percent of total billed charges 9.3 14.25 Technical (Hospital) Services HC/HH Wch Supp Bndg Plaster 6x5__7376 PX-2705000037 CDM 2705000037 LOCAL 270 RC outpatient 15 15 BLUE CROSS BLUE SHIELD WELLMARK SB889 [3081026] BCBS WYOMING [308102603] 14.25 percent of total billed charges 9.3 14.25 Technical (Hospital) Services HC/HH Wch Supp Bndg Plaster 6x5__7376 PX-2705000037 CDM 2705000037 LOCAL 270 RC outpatient 15 15 CIGNA 62308 [3081051] CIGNA 62308 [308105105] 12 percent of total billed charges 9.3 14.25 Technical (Hospital) Services HC/HH Wch Supp Bndg Plaster 6x5__7376 PX-2705000037 CDM 2705000037 LOCAL 270 RC outpatient 15 15 CIGNA 62308 [3081051] CIGNA STATE OF WYOMING [308105107] 12 percent of total billed charges 9.3 14.25 Technical (Hospital) Services HC/HH Wch Supp Bndg Plaster 6x5__7376 PX-2705000037 CDM 2705000037 LOCAL 270 RC outpatient 15 15 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES HDHP [308136802] 12 percent of total billed charges 9.3 14.25 Technical (Hospital) Services HC/HH Wch Supp Bndg Plaster 6x5__7376 PX-2705000037 CDM 2705000037 LOCAL 270 RC inpatient 15 15 HEALTHPARTNERS SX009 HEALTHPARTNERS 11.88 percent of total billed charges 9.3 14.25 Technical (Hospital) Services HC/HH Wch Supp Bndg Plaster 6x5__7376 PX-2705000037 CDM 2705000037 LOCAL 270 RC inpatient 15 15 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES EPO [308136803] 11.88 percent of total billed charges 9.3 14.25 Technical (Hospital) Services HC/HH Wch Supp Bndg Plaster 6x5__7376 PX-2705000037 CDM 2705000037 LOCAL 270 RC inpatient 15 15 CIGNA 62308 [3081051] CIGNA 62308 [308105105] 11.88 percent of total billed charges 9.3 14.25 Technical (Hospital) Services HC/HH Wch Supp Bndg Plaster 6x5__7376 PX-2705000037 CDM 2705000037 LOCAL 270 RC inpatient 15 15 CIGNA 62308 [3081051] CIGNA STATE OF WYOMING [308105107] 11.88 percent of total billed charges 9.3 14.25 Technical (Hospital) Services HC/HH Wch Supp Bndg Plaster 6x5__7376 PX-2705000037 CDM 2705000037 LOCAL 270 RC inpatient 15 15 MULTIPLAN INC 34080 [3081285] MULTIPLAN INC [308128501] 14.25 percent of total billed charges 9.3 14.25 Technical (Hospital) Services HC/HH Wch Supp Bndg Plaster 6x5__7376 PX-2705000037 CDM 2705000037 LOCAL 270 RC inpatient 15 15 BLUE CROSS BLUE SHIELD WELLMARK SB889 [3081026] BCBS WYOMING [308102603] 14.25 percent of total billed charges 9.3 14.25 Technical (Hospital) Services HC/HH Wch Supp Bndg Plaster 6x5__7376 PX-2705000037 CDM 2705000037 LOCAL 270 RC inpatient 15 15 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES PPO [308136801] 11.88 percent of total billed charges 9.3 14.25 Technical (Hospital) Services HC/HH Wch Supp Bndg Plaster 6x5__7376 PX-2705000037 CDM 2705000037 LOCAL 270 RC inpatient 15 15 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES HDHP [308136802] 11.88 percent of total billed charges 9.3 14.25 Technical (Hospital) Services HC/HH Wch Supp Bndg Plaster 6x5__7376 PX-2705000037 CDM 2705000037 LOCAL 270 RC inpatient 15 15 UNITED HEALTHCARE (COMMERCIAL) [3081199] UNITED HEALTHCARE 87726 [308119901] 9.3 percent of total billed charges 9.3 14.25 Technical (Hospital) Services HC/HH Wch Supp Bndg Plaster 6x5__7376 PX-2705000037 CDM 2705000037 LOCAL 270 RC inpatient 15 15 MEDICA (COMMERCIAL) 94265 [3081118] MEDICA CLAIMS [308111801] 13.5 percent of total billed charges 9.3 14.25 Technical (Hospital) Services HC/HH Wch Supp Bndg Plaster 4x5__7374 PX-2705000036 CDM 2705000036 LOCAL 270 RC inpatient 11 11 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES PPO [308136801] 8.71 percent of total billed charges 6.82 10.45 Technical (Hospital) Services HC/HH Wch Supp Bndg Plaster 4x5__7374 PX-2705000036 CDM 2705000036 LOCAL 270 RC inpatient 11 11 UNITED HEALTHCARE (COMMERCIAL) [3081199] UNITED HEALTHCARE 87726 [308119901] 6.82 percent of total billed charges 6.82 10.45 Technical (Hospital) Services HC/HH Wch Supp Bndg Plaster 4x5__7374 PX-2705000036 CDM 2705000036 LOCAL 270 RC inpatient 11 11 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES HDHP [308136802] 8.71 percent of total billed charges 6.82 10.45 Technical (Hospital) Services HC/HH Wch Supp Bndg Plaster 4x5__7374 PX-2705000036 CDM 2705000036 LOCAL 270 RC inpatient 11 11 MEDICA (COMMERCIAL) 94265 [3081118] MEDICA CLAIMS [308111801] 9.9 percent of total billed charges 6.82 10.45 Technical (Hospital) Services HC/HH Wch Supp Bndg Plaster 4x5__7374 PX-2705000036 CDM 2705000036 LOCAL 270 RC inpatient 11 11 BLUE CROSS BLUE SHIELD WELLMARK SB889 [3081026] BCBS WYOMING [308102603] 10.45 percent of total billed charges 6.82 10.45 Technical (Hospital) Services HC/HH Wch Supp Bndg Plaster 4x5__7374 PX-2705000036 CDM 2705000036 LOCAL 270 RC inpatient 11 11 MULTIPLAN INC 34080 [3081285] MULTIPLAN INC [308128501] 10.45 percent of total billed charges 6.82 10.45 Technical (Hospital) Services HC/HH Wch Supp Bndg Plaster 4x5__7374 PX-2705000036 CDM 2705000036 LOCAL 270 RC inpatient 11 11 CIGNA 62308 [3081051] CIGNA 62308 [308105105] 8.71 percent of total billed charges 6.82 10.45 Technical (Hospital) Services HC/HH Wch Supp Bndg Plaster 4x5__7374 PX-2705000036 CDM 2705000036 LOCAL 270 RC inpatient 11 11 CIGNA 62308 [3081051] CIGNA STATE OF WYOMING [308105107] 8.71 percent of total billed charges 6.82 10.45 Technical (Hospital) Services HC/HH Wch Supp Bndg Plaster 4x5__7374 PX-2705000036 CDM 2705000036 LOCAL 270 RC inpatient 11 11 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES EPO [308136803] 8.71 percent of total billed charges 6.82 10.45 Technical (Hospital) Services HC/HH Wch Supp Bndg Plaster 4x5__7374 PX-2705000036 CDM 2705000036 LOCAL 270 RC inpatient 11 11 HEALTHPARTNERS SX009 HEALTHPARTNERS 8.71 percent of total billed charges 6.82 10.45 Technical (Hospital) Services HC/HH Wch Supp Bndg Plaster 4x5__7374 PX-2705000036 CDM 2705000036 LOCAL 270 RC outpatient 11 11 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES PPO [308136801] 8.8 percent of total billed charges 6.82 10.45 Technical (Hospital) Services HC/HH Wch Supp Bndg Plaster 4x5__7374 PX-2705000036 CDM 2705000036 LOCAL 270 RC outpatient 11 11 MULTIPLAN INC 34080 [3081285] MULTIPLAN INC [308128501] 10.45 percent of total billed charges 6.82 10.45 Technical (Hospital) Services HC/HH Wch Supp Bndg Plaster 4x5__7374 PX-2705000036 CDM 2705000036 LOCAL 270 RC outpatient 11 11 MEDICA (COMMERCIAL) 94265 [3081118] MEDICA CLAIMS [308111801] 9.9 percent of total billed charges 6.82 10.45 Technical (Hospital) Services HC/HH Wch Supp Bndg Plaster 4x5__7374 PX-2705000036 CDM 2705000036 LOCAL 270 RC outpatient 11 11 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES EPO [308136803] 8.8 percent of total billed charges 6.82 10.45 Technical (Hospital) Services HC/HH Wch Supp Bndg Plaster 4x5__7374 PX-2705000036 CDM 2705000036 LOCAL 270 RC outpatient 11 11 CIGNA 62308 [3081051] CIGNA 62308 [308105105] 8.8 percent of total billed charges 6.82 10.45 Technical (Hospital) Services HC/HH Wch Supp Bndg Plaster 4x5__7374 PX-2705000036 CDM 2705000036 LOCAL 270 RC outpatient 11 11 CIGNA 62308 [3081051] CIGNA STATE OF WYOMING [308105107] 8.8 percent of total billed charges 6.82 10.45 Technical (Hospital) Services HC/HH Wch Supp Bndg Plaster 4x5__7374 PX-2705000036 CDM 2705000036 LOCAL 270 RC outpatient 11 11 BLUE CROSS BLUE SHIELD WELLMARK SB889 [3081026] BCBS WYOMING [308102603] 10.45 percent of total billed charges 6.82 10.45 Technical (Hospital) Services HC/HH Wch Supp Bndg Plaster 4x5__7374 PX-2705000036 CDM 2705000036 LOCAL 270 RC outpatient 11 11 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES HDHP [308136802] 8.8 percent of total billed charges 6.82 10.45 Technical (Hospital) Services HC/HH Wch Supp Bndg Plaster 4x5__7374 PX-2705000036 CDM 2705000036 LOCAL 270 RC outpatient 11 11 UNITED HEALTHCARE (COMMERCIAL) [3081199] UNITED HEALTHCARE 87726 [308119901] 6.82 percent of total billed charges 6.82 10.45 Technical (Hospital) Services HC/HH Wch Supp Bndg Plaster 4x5__7374 PX-2705000036 CDM 2705000036 LOCAL 270 RC outpatient 11 11 HEALTHPARTNERS SX009 HEALTHPARTNERS 8.8 percent of total billed charges 6.82 10.45 Technical (Hospital) Services HC/HH Wch Supp Bndg Kerlix 4in__8074 PX-2705000035 CDM 2705000035 LOCAL 270 RC inpatient 81 81 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES PPO [308136801] 64.14 percent of total billed charges 50.22 76.95 Technical (Hospital) Services HC/HH Wch Supp Bndg Kerlix 4in__8074 PX-2705000035 CDM 2705000035 LOCAL 270 RC inpatient 81 81 UNITED HEALTHCARE (COMMERCIAL) [3081199] UNITED HEALTHCARE 87726 [308119901] 50.22 percent of total billed charges 50.22 76.95 Technical (Hospital) Services HC/HH Wch Supp Bndg Kerlix 4in__8074 PX-2705000035 CDM 2705000035 LOCAL 270 RC inpatient 81 81 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES HDHP [308136802] 64.14 percent of total billed charges 50.22 76.95 Technical (Hospital) Services HC/HH Wch Supp Bndg Kerlix 4in__8074 PX-2705000035 CDM 2705000035 LOCAL 270 RC inpatient 81 81 MEDICA (COMMERCIAL) 94265 [3081118] MEDICA CLAIMS [308111801] 72.9 percent of total billed charges 50.22 76.95 Technical (Hospital) Services HC/HH Wch Supp Bndg Kerlix 4in__8074 PX-2705000035 CDM 2705000035 LOCAL 270 RC inpatient 81 81 BLUE CROSS BLUE SHIELD WELLMARK SB889 [3081026] BCBS WYOMING [308102603] 76.95 percent of total billed charges 50.22 76.95 Technical (Hospital) Services HC/HH Wch Supp Bndg Kerlix 4in__8074 PX-2705000035 CDM 2705000035 LOCAL 270 RC inpatient 81 81 MULTIPLAN INC 34080 [3081285] MULTIPLAN INC [308128501] 76.95 percent of total billed charges 50.22 76.95 Technical (Hospital) Services HC/HH Wch Supp Bndg Kerlix 4in__8074 PX-2705000035 CDM 2705000035 LOCAL 270 RC inpatient 81 81 CIGNA 62308 [3081051] CIGNA 62308 [308105105] 64.14 percent of total billed charges 50.22 76.95 Technical (Hospital) Services HC/HH Wch Supp Bndg Kerlix 4in__8074 PX-2705000035 CDM 2705000035 LOCAL 270 RC inpatient 81 81 CIGNA 62308 [3081051] CIGNA STATE OF WYOMING [308105107] 64.14 percent of total billed charges 50.22 76.95 Technical (Hospital) Services HC/HH Wch Supp Bndg Kerlix 4in__8074 PX-2705000035 CDM 2705000035 LOCAL 270 RC inpatient 81 81 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES EPO [308136803] 64.14 percent of total billed charges 50.22 76.95 Technical (Hospital) Services HC/HH Wch Supp Bndg Kerlix 4in__8074 PX-2705000035 CDM 2705000035 LOCAL 270 RC inpatient 81 81 HEALTHPARTNERS SX009 HEALTHPARTNERS 64.14 percent of total billed charges 50.22 76.95 Technical (Hospital) Services HC/HH Wch Supp Bndg Kerlix 4in__8074 PX-2705000035 CDM 2705000035 LOCAL 270 RC outpatient 81 81 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES PPO [308136801] 64.8 percent of total billed charges 50.22 76.95 Technical (Hospital) Services HC/HH Wch Supp Bndg Kerlix 4in__8074 PX-2705000035 CDM 2705000035 LOCAL 270 RC outpatient 81 81 HEALTHPARTNERS SX009 HEALTHPARTNERS 64.8 percent of total billed charges 50.22 76.95 Technical (Hospital) Services HC/HH Wch Supp Bndg Kerlix 4in__8074 PX-2705000035 CDM 2705000035 LOCAL 270 RC outpatient 81 81 UNITED HEALTHCARE (COMMERCIAL) [3081199] UNITED HEALTHCARE 87726 [308119901] 50.22 percent of total billed charges 50.22 76.95 Technical (Hospital) Services HC/HH Wch Supp Bndg Kerlix 4in__8074 PX-2705000035 CDM 2705000035 LOCAL 270 RC outpatient 81 81 BLUE CROSS BLUE SHIELD WELLMARK SB889 [3081026] BCBS WYOMING [308102603] 76.95 percent of total billed charges 50.22 76.95 Technical (Hospital) Services HC/HH Wch Supp Bndg Kerlix 4in__8074 PX-2705000035 CDM 2705000035 LOCAL 270 RC outpatient 81 81 CIGNA 62308 [3081051] CIGNA 62308 [308105105] 64.8 percent of total billed charges 50.22 76.95 Technical (Hospital) Services HC/HH Wch Supp Bndg Kerlix 4in__8074 PX-2705000035 CDM 2705000035 LOCAL 270 RC outpatient 81 81 CIGNA 62308 [3081051] CIGNA STATE OF WYOMING [308105107] 64.8 percent of total billed charges 50.22 76.95 Technical (Hospital) Services HC/HH Wch Supp Bndg Kerlix 4in__8074 PX-2705000035 CDM 2705000035 LOCAL 270 RC outpatient 81 81 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES HDHP [308136802] 64.8 percent of total billed charges 50.22 76.95 Technical (Hospital) Services HC/HH Wch Supp Bndg Kerlix 4in__8074 PX-2705000035 CDM 2705000035 LOCAL 270 RC outpatient 81 81 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES EPO [308136803] 64.8 percent of total billed charges 50.22 76.95 Technical (Hospital) Services HC/HH Wch Supp Bndg Kerlix 4in__8074 PX-2705000035 CDM 2705000035 LOCAL 270 RC outpatient 81 81 MEDICA (COMMERCIAL) 94265 [3081118] MEDICA CLAIMS [308111801] 72.9 percent of total billed charges 50.22 76.95 Technical (Hospital) Services HC/HH Wch Supp Bndg Kerlix 4in__8074 PX-2705000035 CDM 2705000035 LOCAL 270 RC outpatient 81 81 MULTIPLAN INC 34080 [3081285] MULTIPLAN INC [308128501] 76.95 percent of total billed charges 50.22 76.95 Technical (Hospital) Services HC/HH Wch Supp Bndg Elastic Nst 6in__23593-06lf PX-2705000034 CDM 2705000034 LOCAL 270 RC inpatient 14 14 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES EPO [308136803] 11.09 percent of total billed charges 8.68 13.3 Technical (Hospital) Services HC/HH Wch Supp Bndg Elastic Nst 6in__23593-06lf PX-2705000034 CDM 2705000034 LOCAL 270 RC inpatient 14 14 HEALTHPARTNERS SX009 HEALTHPARTNERS 11.09 percent of total billed charges 8.68 13.3 Technical (Hospital) Services HC/HH Wch Supp Bndg Elastic Nst 6in__23593-06lf PX-2705000034 CDM 2705000034 LOCAL 270 RC inpatient 14 14 BLUE CROSS BLUE SHIELD WELLMARK SB889 [3081026] BCBS WYOMING [308102603] 13.3 percent of total billed charges 8.68 13.3 Technical (Hospital) Services HC/HH Wch Supp Bndg Elastic Nst 6in__23593-06lf PX-2705000034 CDM 2705000034 LOCAL 270 RC inpatient 14 14 MULTIPLAN INC 34080 [3081285] MULTIPLAN INC [308128501] 13.3 percent of total billed charges 8.68 13.3 Technical (Hospital) Services HC/HH Wch Supp Bndg Elastic Nst 6in__23593-06lf PX-2705000034 CDM 2705000034 LOCAL 270 RC inpatient 14 14 CIGNA 62308 [3081051] CIGNA 62308 [308105105] 11.09 percent of total billed charges 8.68 13.3 Technical (Hospital) Services HC/HH Wch Supp Bndg Elastic Nst 6in__23593-06lf PX-2705000034 CDM 2705000034 LOCAL 270 RC inpatient 14 14 CIGNA 62308 [3081051] CIGNA STATE OF WYOMING [308105107] 11.09 percent of total billed charges 8.68 13.3 Technical (Hospital) Services HC/HH Wch Supp Bndg Elastic Nst 6in__23593-06lf PX-2705000034 CDM 2705000034 LOCAL 270 RC inpatient 14 14 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES PPO [308136801] 11.09 percent of total billed charges 8.68 13.3 Technical (Hospital) Services HC/HH Wch Supp Bndg Elastic Nst 6in__23593-06lf PX-2705000034 CDM 2705000034 LOCAL 270 RC inpatient 14 14 MEDICA (COMMERCIAL) 94265 [3081118] MEDICA CLAIMS [308111801] 12.6 percent of total billed charges 8.68 13.3 Technical (Hospital) Services HC/HH Wch Supp Bndg Elastic Nst 6in__23593-06lf PX-2705000034 CDM 2705000034 LOCAL 270 RC inpatient 14 14 UNITED HEALTHCARE (COMMERCIAL) [3081199] UNITED HEALTHCARE 87726 [308119901] 8.68 percent of total billed charges 8.68 13.3 Technical (Hospital) Services HC/HH Wch Supp Bndg Elastic Nst 6in__23593-06lf PX-2705000034 CDM 2705000034 LOCAL 270 RC inpatient 14 14 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES HDHP [308136802] 11.09 percent of total billed charges 8.68 13.3 Technical (Hospital) Services HC/HH Wch Supp Bndg Elastic Nst 6in__23593-06lf PX-2705000034 CDM 2705000034 LOCAL 270 RC outpatient 14 14 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES HDHP [308136802] 11.2 percent of total billed charges 8.68 13.3 Technical (Hospital) Services HC/HH Wch Supp Bndg Elastic Nst 6in__23593-06lf PX-2705000034 CDM 2705000034 LOCAL 270 RC outpatient 14 14 CIGNA 62308 [3081051] CIGNA 62308 [308105105] 11.2 percent of total billed charges 8.68 13.3 Technical (Hospital) Services HC/HH Wch Supp Bndg Elastic Nst 6in__23593-06lf PX-2705000034 CDM 2705000034 LOCAL 270 RC outpatient 14 14 CIGNA 62308 [3081051] CIGNA STATE OF WYOMING [308105107] 11.2 percent of total billed charges 8.68 13.3 Technical (Hospital) Services HC/HH Wch Supp Bndg Elastic Nst 6in__23593-06lf PX-2705000034 CDM 2705000034 LOCAL 270 RC outpatient 14 14 BLUE CROSS BLUE SHIELD WELLMARK SB889 [3081026] BCBS WYOMING [308102603] 13.3 percent of total billed charges 8.68 13.3 Technical (Hospital) Services HC/HH Wch Supp Bndg Elastic Nst 6in__23593-06lf PX-2705000034 CDM 2705000034 LOCAL 270 RC outpatient 14 14 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES EPO [308136803] 11.2 percent of total billed charges 8.68 13.3 Technical (Hospital) Services HC/HH Wch Supp Bndg Elastic Nst 6in__23593-06lf PX-2705000034 CDM 2705000034 LOCAL 270 RC outpatient 14 14 HEALTHPARTNERS SX009 HEALTHPARTNERS 11.2 percent of total billed charges 8.68 13.3 Technical (Hospital) Services HC/HH Wch Supp Bndg Elastic Nst 6in__23593-06lf PX-2705000034 CDM 2705000034 LOCAL 270 RC outpatient 14 14 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES PPO [308136801] 11.2 percent of total billed charges 8.68 13.3 Technical (Hospital) Services HC/HH Wch Supp Bndg Elastic Nst 6in__23593-06lf PX-2705000034 CDM 2705000034 LOCAL 270 RC outpatient 14 14 UNITED HEALTHCARE (COMMERCIAL) [3081199] UNITED HEALTHCARE 87726 [308119901] 8.68 percent of total billed charges 8.68 13.3 Technical (Hospital) Services HC/HH Wch Supp Bndg Elastic Nst 6in__23593-06lf PX-2705000034 CDM 2705000034 LOCAL 270 RC outpatient 14 14 MULTIPLAN INC 34080 [3081285] MULTIPLAN INC [308128501] 13.3 percent of total billed charges 8.68 13.3 Technical (Hospital) Services HC/HH Wch Supp Bndg Elastic Nst 6in__23593-06lf PX-2705000034 CDM 2705000034 LOCAL 270 RC outpatient 14 14 MEDICA (COMMERCIAL) 94265 [3081118] MEDICA CLAIMS [308111801] 12.6 percent of total billed charges 8.68 13.3 Technical (Hospital) Services HC/HH Wch Supp Bndg Elastic Nst 4in__23593-04lf PX-2705000033 CDM 2705000033 LOCAL 270 RC outpatient 13 13 HEALTHPARTNERS SX009 HEALTHPARTNERS 10.4 percent of total billed charges 8.06 12.35 Technical (Hospital) Services HC/HH Wch Supp Bndg Elastic Nst 4in__23593-04lf PX-2705000033 CDM 2705000033 LOCAL 270 RC outpatient 13 13 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES PPO [308136801] 10.4 percent of total billed charges 8.06 12.35 Technical (Hospital) Services HC/HH Wch Supp Bndg Elastic Nst 4in__23593-04lf PX-2705000033 CDM 2705000033 LOCAL 270 RC outpatient 13 13 UNITED HEALTHCARE (COMMERCIAL) [3081199] UNITED HEALTHCARE 87726 [308119901] 8.06 percent of total billed charges 8.06 12.35 Technical (Hospital) Services HC/HH Wch Supp Bndg Elastic Nst 4in__23593-04lf PX-2705000033 CDM 2705000033 LOCAL 270 RC outpatient 13 13 BLUE CROSS BLUE SHIELD WELLMARK SB889 [3081026] BCBS WYOMING [308102603] 12.35 percent of total billed charges 8.06 12.35 Technical (Hospital) Services HC/HH Wch Supp Bndg Elastic Nst 4in__23593-04lf PX-2705000033 CDM 2705000033 LOCAL 270 RC outpatient 13 13 CIGNA 62308 [3081051] CIGNA 62308 [308105105] 10.4 percent of total billed charges 8.06 12.35 Technical (Hospital) Services HC/HH Wch Supp Bndg Elastic Nst 4in__23593-04lf PX-2705000033 CDM 2705000033 LOCAL 270 RC outpatient 13 13 CIGNA 62308 [3081051] CIGNA STATE OF WYOMING [308105107] 10.4 percent of total billed charges 8.06 12.35 Technical (Hospital) Services HC/HH Wch Supp Bndg Elastic Nst 4in__23593-04lf PX-2705000033 CDM 2705000033 LOCAL 270 RC outpatient 13 13 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES HDHP [308136802] 10.4 percent of total billed charges 8.06 12.35 Technical (Hospital) Services HC/HH Wch Supp Bndg Elastic Nst 4in__23593-04lf PX-2705000033 CDM 2705000033 LOCAL 270 RC outpatient 13 13 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES EPO [308136803] 10.4 percent of total billed charges 8.06 12.35 Technical (Hospital) Services HC/HH Wch Supp Bndg Elastic Nst 4in__23593-04lf PX-2705000033 CDM 2705000033 LOCAL 270 RC outpatient 13 13 MULTIPLAN INC 34080 [3081285] MULTIPLAN INC [308128501] 12.35 percent of total billed charges 8.06 12.35 Technical (Hospital) Services HC/HH Wch Supp Bndg Elastic Nst 4in__23593-04lf PX-2705000033 CDM 2705000033 LOCAL 270 RC outpatient 13 13 MEDICA (COMMERCIAL) 94265 [3081118] MEDICA CLAIMS [308111801] 11.7 percent of total billed charges 8.06 12.35 Technical (Hospital) Services HC/HH Wch Supp Bndg Elastic Nst 4in__23593-04lf PX-2705000033 CDM 2705000033 LOCAL 270 RC inpatient 13 13 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES EPO [308136803] 10.29 percent of total billed charges 8.06 12.35 Technical (Hospital) Services HC/HH Wch Supp Bndg Elastic Nst 4in__23593-04lf PX-2705000033 CDM 2705000033 LOCAL 270 RC inpatient 13 13 HEALTHPARTNERS SX009 HEALTHPARTNERS 10.29 percent of total billed charges 8.06 12.35 Technical (Hospital) Services HC/HH Wch Supp Bndg Elastic Nst 4in__23593-04lf PX-2705000033 CDM 2705000033 LOCAL 270 RC inpatient 13 13 BLUE CROSS BLUE SHIELD WELLMARK SB889 [3081026] BCBS WYOMING [308102603] 12.35 percent of total billed charges 8.06 12.35 Technical (Hospital) Services HC/HH Wch Supp Bndg Elastic Nst 4in__23593-04lf PX-2705000033 CDM 2705000033 LOCAL 270 RC inpatient 13 13 CIGNA 62308 [3081051] CIGNA 62308 [308105105] 10.29 percent of total billed charges 8.06 12.35 Technical (Hospital) Services HC/HH Wch Supp Bndg Elastic Nst 4in__23593-04lf PX-2705000033 CDM 2705000033 LOCAL 270 RC inpatient 13 13 CIGNA 62308 [3081051] CIGNA STATE OF WYOMING [308105107] 10.29 percent of total billed charges 8.06 12.35 Technical (Hospital) Services HC/HH Wch Supp Bndg Elastic Nst 4in__23593-04lf PX-2705000033 CDM 2705000033 LOCAL 270 RC inpatient 13 13 MULTIPLAN INC 34080 [3081285] MULTIPLAN INC [308128501] 12.35 percent of total billed charges 8.06 12.35 Technical (Hospital) Services HC/HH Wch Supp Bndg Elastic Nst 4in__23593-04lf PX-2705000033 CDM 2705000033 LOCAL 270 RC inpatient 13 13 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES PPO [308136801] 10.29 percent of total billed charges 8.06 12.35 Technical (Hospital) Services HC/HH Wch Supp Bndg Elastic Nst 4in__23593-04lf PX-2705000033 CDM 2705000033 LOCAL 270 RC inpatient 13 13 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES HDHP [308136802] 10.29 percent of total billed charges 8.06 12.35 Technical (Hospital) Services HC/HH Wch Supp Bndg Elastic Nst 4in__23593-04lf PX-2705000033 CDM 2705000033 LOCAL 270 RC inpatient 13 13 UNITED HEALTHCARE (COMMERCIAL) [3081199] UNITED HEALTHCARE 87726 [308119901] 8.06 percent of total billed charges 8.06 12.35 Technical (Hospital) Services HC/HH Wch Supp Bndg Elastic Nst 4in__23593-04lf PX-2705000033 CDM 2705000033 LOCAL 270 RC inpatient 13 13 MEDICA (COMMERCIAL) 94265 [3081118] MEDICA CLAIMS [308111801] 11.7 percent of total billed charges 8.06 12.35 Technical (Hospital) Services HC/HH Wch Supp Bndg Elastic Nst 3in__23593-03lf PX-2705000032 CDM 2705000032 LOCAL 270 RC inpatient 8 8 UNITED HEALTHCARE (COMMERCIAL) [3081199] UNITED HEALTHCARE 87726 [308119901] 4.96 percent of total billed charges 4.96 7.6 Technical (Hospital) Services HC/HH Wch Supp Bndg Elastic Nst 3in__23593-03lf PX-2705000032 CDM 2705000032 LOCAL 270 RC inpatient 8 8 MEDICA (COMMERCIAL) 94265 [3081118] MEDICA CLAIMS [308111801] 7.2 percent of total billed charges 4.96 7.6 Technical (Hospital) Services HC/HH Wch Supp Bndg Elastic Nst 3in__23593-03lf PX-2705000032 CDM 2705000032 LOCAL 270 RC inpatient 8 8 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES HDHP [308136802] 6.33 percent of total billed charges 4.96 7.6 Technical (Hospital) Services HC/HH Wch Supp Bndg Elastic Nst 3in__23593-03lf PX-2705000032 CDM 2705000032 LOCAL 270 RC inpatient 8 8 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES PPO [308136801] 6.33 percent of total billed charges 4.96 7.6 Technical (Hospital) Services HC/HH Wch Supp Bndg Elastic Nst 3in__23593-03lf PX-2705000032 CDM 2705000032 LOCAL 270 RC inpatient 8 8 HEALTHPARTNERS SX009 HEALTHPARTNERS 6.33 percent of total billed charges 4.96 7.6 Technical (Hospital) Services HC/HH Wch Supp Bndg Elastic Nst 3in__23593-03lf PX-2705000032 CDM 2705000032 LOCAL 270 RC inpatient 8 8 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES EPO [308136803] 6.33 percent of total billed charges 4.96 7.6 Technical (Hospital) Services HC/HH Wch Supp Bndg Elastic Nst 3in__23593-03lf PX-2705000032 CDM 2705000032 LOCAL 270 RC inpatient 8 8 MULTIPLAN INC 34080 [3081285] MULTIPLAN INC [308128501] 7.6 percent of total billed charges 4.96 7.6 Technical (Hospital) Services HC/HH Wch Supp Bndg Elastic Nst 3in__23593-03lf PX-2705000032 CDM 2705000032 LOCAL 270 RC inpatient 8 8 CIGNA 62308 [3081051] CIGNA 62308 [308105105] 6.33 percent of total billed charges 4.96 7.6 Technical (Hospital) Services HC/HH Wch Supp Bndg Elastic Nst 3in__23593-03lf PX-2705000032 CDM 2705000032 LOCAL 270 RC inpatient 8 8 CIGNA 62308 [3081051] CIGNA STATE OF WYOMING [308105107] 6.33 percent of total billed charges 4.96 7.6 Technical (Hospital) Services HC/HH Wch Supp Bndg Elastic Nst 3in__23593-03lf PX-2705000032 CDM 2705000032 LOCAL 270 RC inpatient 8 8 BLUE CROSS BLUE SHIELD WELLMARK SB889 [3081026] BCBS WYOMING [308102603] 7.6 percent of total billed charges 4.96 7.6 Technical (Hospital) Services HC/HH Wch Supp Bndg Elastic Nst 3in__23593-03lf PX-2705000032 CDM 2705000032 LOCAL 270 RC outpatient 8 8 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES HDHP [308136802] 6.4 percent of total billed charges 4.96 7.6 Technical (Hospital) Services HC/HH Wch Supp Bndg Elastic Nst 3in__23593-03lf PX-2705000032 CDM 2705000032 LOCAL 270 RC outpatient 8 8 BLUE CROSS BLUE SHIELD WELLMARK SB889 [3081026] BCBS WYOMING [308102603] 7.6 percent of total billed charges 4.96 7.6 Technical (Hospital) Services HC/HH Wch Supp Bndg Elastic Nst 3in__23593-03lf PX-2705000032 CDM 2705000032 LOCAL 270 RC outpatient 8 8 CIGNA 62308 [3081051] CIGNA 62308 [308105105] 6.4 percent of total billed charges 4.96 7.6 Technical (Hospital) Services HC/HH Wch Supp Bndg Elastic Nst 3in__23593-03lf PX-2705000032 CDM 2705000032 LOCAL 270 RC outpatient 8 8 CIGNA 62308 [3081051] CIGNA STATE OF WYOMING [308105107] 6.4 percent of total billed charges 4.96 7.6 Technical (Hospital) Services HC/HH Wch Supp Bndg Elastic Nst 3in__23593-03lf PX-2705000032 CDM 2705000032 LOCAL 270 RC outpatient 8 8 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES EPO [308136803] 6.4 percent of total billed charges 4.96 7.6 Technical (Hospital) Services HC/HH Wch Supp Bndg Elastic Nst 3in__23593-03lf PX-2705000032 CDM 2705000032 LOCAL 270 RC outpatient 8 8 UNITED HEALTHCARE (COMMERCIAL) [3081199] UNITED HEALTHCARE 87726 [308119901] 4.96 percent of total billed charges 4.96 7.6 Technical (Hospital) Services HC/HH Wch Supp Bndg Elastic Nst 3in__23593-03lf PX-2705000032 CDM 2705000032 LOCAL 270 RC outpatient 8 8 HEALTHPARTNERS SX009 HEALTHPARTNERS 6.4 percent of total billed charges 4.96 7.6 Technical (Hospital) Services HC/HH Wch Supp Bndg Elastic Nst 3in__23593-03lf PX-2705000032 CDM 2705000032 LOCAL 270 RC outpatient 8 8 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES PPO [308136801] 6.4 percent of total billed charges 4.96 7.6 Technical (Hospital) Services HC/HH Wch Supp Bndg Elastic Nst 3in__23593-03lf PX-2705000032 CDM 2705000032 LOCAL 270 RC outpatient 8 8 MULTIPLAN INC 34080 [3081285] MULTIPLAN INC [308128501] 7.6 percent of total billed charges 4.96 7.6 Technical (Hospital) Services HC/HH Wch Supp Bndg Elastic Nst 3in__23593-03lf PX-2705000032 CDM 2705000032 LOCAL 270 RC outpatient 8 8 MEDICA (COMMERCIAL) 94265 [3081118] MEDICA CLAIMS [308111801] 7.2 percent of total billed charges 4.96 7.6 Technical (Hospital) Services HC/HH Wch Supp Bndg Elastic Nst 2in__23593-02lf PX-2705000031 CDM 2705000031 LOCAL 270 RC inpatient 5 5 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES EPO [308136803] 3.96 percent of total billed charges 3.1 4.75 Technical (Hospital) Services HC/HH Wch Supp Bndg Elastic Nst 2in__23593-02lf PX-2705000031 CDM 2705000031 LOCAL 270 RC inpatient 5 5 HEALTHPARTNERS SX009 HEALTHPARTNERS 3.96 percent of total billed charges 3.1 4.75 Technical (Hospital) Services HC/HH Wch Supp Bndg Elastic Nst 2in__23593-02lf PX-2705000031 CDM 2705000031 LOCAL 270 RC inpatient 5 5 CIGNA 62308 [3081051] CIGNA 62308 [308105105] 3.96 percent of total billed charges 3.1 4.75 Technical (Hospital) Services HC/HH Wch Supp Bndg Elastic Nst 2in__23593-02lf PX-2705000031 CDM 2705000031 LOCAL 270 RC inpatient 5 5 CIGNA 62308 [3081051] CIGNA STATE OF WYOMING [308105107] 3.96 percent of total billed charges 3.1 4.75 Technical (Hospital) Services HC/HH Wch Supp Bndg Elastic Nst 2in__23593-02lf PX-2705000031 CDM 2705000031 LOCAL 270 RC inpatient 5 5 MULTIPLAN INC 34080 [3081285] MULTIPLAN INC [308128501] 4.75 percent of total billed charges 3.1 4.75 Technical (Hospital) Services HC/HH Wch Supp Bndg Elastic Nst 2in__23593-02lf PX-2705000031 CDM 2705000031 LOCAL 270 RC inpatient 5 5 BLUE CROSS BLUE SHIELD WELLMARK SB889 [3081026] BCBS WYOMING [308102603] 4.75 percent of total billed charges 3.1 4.75 Technical (Hospital) Services HC/HH Wch Supp Bndg Elastic Nst 2in__23593-02lf PX-2705000031 CDM 2705000031 LOCAL 270 RC inpatient 5 5 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES PPO [308136801] 3.96 percent of total billed charges 3.1 4.75 Technical (Hospital) Services HC/HH Wch Supp Bndg Elastic Nst 2in__23593-02lf PX-2705000031 CDM 2705000031 LOCAL 270 RC inpatient 5 5 UNITED HEALTHCARE (COMMERCIAL) [3081199] UNITED HEALTHCARE 87726 [308119901] 3.1 percent of total billed charges 3.1 4.75 Technical (Hospital) Services HC/HH Wch Supp Bndg Elastic Nst 2in__23593-02lf PX-2705000031 CDM 2705000031 LOCAL 270 RC inpatient 5 5 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES HDHP [308136802] 3.96 percent of total billed charges 3.1 4.75 Technical (Hospital) Services HC/HH Wch Supp Bndg Elastic Nst 2in__23593-02lf PX-2705000031 CDM 2705000031 LOCAL 270 RC inpatient 5 5 MEDICA (COMMERCIAL) 94265 [3081118] MEDICA CLAIMS [308111801] 4.5 percent of total billed charges 3.1 4.75 Technical (Hospital) Services HC/HH Wch Supp Bndg Elastic Nst 2in__23593-02lf PX-2705000031 CDM 2705000031 LOCAL 270 RC outpatient 5 5 HEALTHPARTNERS SX009 HEALTHPARTNERS 4 percent of total billed charges 3.1 4.75 Technical (Hospital) Services HC/HH Wch Supp Bndg Elastic Nst 2in__23593-02lf PX-2705000031 CDM 2705000031 LOCAL 270 RC outpatient 5 5 UNITED HEALTHCARE (COMMERCIAL) [3081199] UNITED HEALTHCARE 87726 [308119901] 3.1 percent of total billed charges 3.1 4.75 Technical (Hospital) Services HC/HH Wch Supp Bndg Elastic Nst 2in__23593-02lf PX-2705000031 CDM 2705000031 LOCAL 270 RC outpatient 5 5 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES HDHP [308136802] 4 percent of total billed charges 3.1 4.75 Technical (Hospital) Services HC/HH Wch Supp Bndg Elastic Nst 2in__23593-02lf PX-2705000031 CDM 2705000031 LOCAL 270 RC outpatient 5 5 BLUE CROSS BLUE SHIELD WELLMARK SB889 [3081026] BCBS WYOMING [308102603] 4.75 percent of total billed charges 3.1 4.75 Technical (Hospital) Services HC/HH Wch Supp Bndg Elastic Nst 2in__23593-02lf PX-2705000031 CDM 2705000031 LOCAL 270 RC outpatient 5 5 CIGNA 62308 [3081051] CIGNA 62308 [308105105] 4 percent of total billed charges 3.1 4.75 Technical (Hospital) Services HC/HH Wch Supp Bndg Elastic Nst 2in__23593-02lf PX-2705000031 CDM 2705000031 LOCAL 270 RC outpatient 5 5 CIGNA 62308 [3081051] CIGNA STATE OF WYOMING [308105107] 4 percent of total billed charges 3.1 4.75 Technical (Hospital) Services HC/HH Wch Supp Bndg Elastic Nst 2in__23593-02lf PX-2705000031 CDM 2705000031 LOCAL 270 RC outpatient 5 5 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES EPO [308136803] 4 percent of total billed charges 3.1 4.75 Technical (Hospital) Services HC/HH Wch Supp Bndg Elastic Nst 2in__23593-02lf PX-2705000031 CDM 2705000031 LOCAL 270 RC outpatient 5 5 MEDICA (COMMERCIAL) 94265 [3081118] MEDICA CLAIMS [308111801] 4.5 percent of total billed charges 3.1 4.75 Technical (Hospital) Services HC/HH Wch Supp Bndg Elastic Nst 2in__23593-02lf PX-2705000031 CDM 2705000031 LOCAL 270 RC outpatient 5 5 MULTIPLAN INC 34080 [3081285] MULTIPLAN INC [308128501] 4.75 percent of total billed charges 3.1 4.75 Technical (Hospital) Services HC/HH Wch Supp Bndg Elastic Nst 2in__23593-02lf PX-2705000031 CDM 2705000031 LOCAL 270 RC outpatient 5 5 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES PPO [308136801] 4 percent of total billed charges 3.1 4.75 Technical (Hospital) Services HC/HH Wch Supp Bndg Compression Lf 6in__23594-060 PX-2705000030 CDM 2705000030 LOCAL 270 RC inpatient 37 37 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES EPO [308136803] 29.3 percent of total billed charges 22.94 35.15 Technical (Hospital) Services HC/HH Wch Supp Bndg Compression Lf 6in__23594-060 PX-2705000030 CDM 2705000030 LOCAL 270 RC inpatient 37 37 HEALTHPARTNERS SX009 HEALTHPARTNERS 29.3 percent of total billed charges 22.94 35.15 Technical (Hospital) Services HC/HH Wch Supp Bndg Compression Lf 6in__23594-060 PX-2705000030 CDM 2705000030 LOCAL 270 RC inpatient 37 37 BLUE CROSS BLUE SHIELD WELLMARK SB889 [3081026] BCBS WYOMING [308102603] 35.15 percent of total billed charges 22.94 35.15 Technical (Hospital) Services HC/HH Wch Supp Bndg Compression Lf 6in__23594-060 PX-2705000030 CDM 2705000030 LOCAL 270 RC inpatient 37 37 MULTIPLAN INC 34080 [3081285] MULTIPLAN INC [308128501] 35.15 percent of total billed charges 22.94 35.15 Technical (Hospital) Services HC/HH Wch Supp Bndg Compression Lf 6in__23594-060 PX-2705000030 CDM 2705000030 LOCAL 270 RC inpatient 37 37 CIGNA 62308 [3081051] CIGNA 62308 [308105105] 29.3 percent of total billed charges 22.94 35.15 Technical (Hospital) Services HC/HH Wch Supp Bndg Compression Lf 6in__23594-060 PX-2705000030 CDM 2705000030 LOCAL 270 RC inpatient 37 37 CIGNA 62308 [3081051] CIGNA STATE OF WYOMING [308105107] 29.3 percent of total billed charges 22.94 35.15 Technical (Hospital) Services HC/HH Wch Supp Bndg Compression Lf 6in__23594-060 PX-2705000030 CDM 2705000030 LOCAL 270 RC inpatient 37 37 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES PPO [308136801] 29.3 percent of total billed charges 22.94 35.15 Technical (Hospital) Services HC/HH Wch Supp Bndg Compression Lf 6in__23594-060 PX-2705000030 CDM 2705000030 LOCAL 270 RC inpatient 37 37 MEDICA (COMMERCIAL) 94265 [3081118] MEDICA CLAIMS [308111801] 33.3 percent of total billed charges 22.94 35.15 Technical (Hospital) Services HC/HH Wch Supp Bndg Compression Lf 6in__23594-060 PX-2705000030 CDM 2705000030 LOCAL 270 RC inpatient 37 37 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES HDHP [308136802] 29.3 percent of total billed charges 22.94 35.15 Technical (Hospital) Services HC/HH Wch Supp Bndg Compression Lf 6in__23594-060 PX-2705000030 CDM 2705000030 LOCAL 270 RC inpatient 37 37 UNITED HEALTHCARE (COMMERCIAL) [3081199] UNITED HEALTHCARE 87726 [308119901] 22.94 percent of total billed charges 22.94 35.15 Technical (Hospital) Services HC/HH Wch Supp Bndg Compression Lf 6in__23594-060 PX-2705000030 CDM 2705000030 LOCAL 270 RC outpatient 37 37 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES PPO [308136801] 29.6 percent of total billed charges 22.94 35.15 Technical (Hospital) Services HC/HH Wch Supp Bndg Compression Lf 6in__23594-060 PX-2705000030 CDM 2705000030 LOCAL 270 RC outpatient 37 37 HEALTHPARTNERS SX009 HEALTHPARTNERS 29.6 percent of total billed charges 22.94 35.15 Technical (Hospital) Services HC/HH Wch Supp Bndg Compression Lf 6in__23594-060 PX-2705000030 CDM 2705000030 LOCAL 270 RC outpatient 37 37 UNITED HEALTHCARE (COMMERCIAL) [3081199] UNITED HEALTHCARE 87726 [308119901] 22.94 percent of total billed charges 22.94 35.15 Technical (Hospital) Services HC/HH Wch Supp Bndg Compression Lf 6in__23594-060 PX-2705000030 CDM 2705000030 LOCAL 270 RC outpatient 37 37 BLUE CROSS BLUE SHIELD WELLMARK SB889 [3081026] BCBS WYOMING [308102603] 35.15 percent of total billed charges 22.94 35.15 Technical (Hospital) Services HC/HH Wch Supp Bndg Compression Lf 6in__23594-060 PX-2705000030 CDM 2705000030 LOCAL 270 RC outpatient 37 37 CIGNA 62308 [3081051] CIGNA 62308 [308105105] 29.6 percent of total billed charges 22.94 35.15 Technical (Hospital) Services HC/HH Wch Supp Bndg Compression Lf 6in__23594-060 PX-2705000030 CDM 2705000030 LOCAL 270 RC outpatient 37 37 CIGNA 62308 [3081051] CIGNA STATE OF WYOMING [308105107] 29.6 percent of total billed charges 22.94 35.15 Technical (Hospital) Services HC/HH Wch Supp Bndg Compression Lf 6in__23594-060 PX-2705000030 CDM 2705000030 LOCAL 270 RC outpatient 37 37 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES HDHP [308136802] 29.6 percent of total billed charges 22.94 35.15 Technical (Hospital) Services HC/HH Wch Supp Bndg Compression Lf 6in__23594-060 PX-2705000030 CDM 2705000030 LOCAL 270 RC outpatient 37 37 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES EPO [308136803] 29.6 percent of total billed charges 22.94 35.15 Technical (Hospital) Services HC/HH Wch Supp Bndg Compression Lf 6in__23594-060 PX-2705000030 CDM 2705000030 LOCAL 270 RC outpatient 37 37 MEDICA (COMMERCIAL) 94265 [3081118] MEDICA CLAIMS [308111801] 33.3 percent of total billed charges 22.94 35.15 Technical (Hospital) Services HC/HH Wch Supp Bndg Compression Lf 6in__23594-060 PX-2705000030 CDM 2705000030 LOCAL 270 RC outpatient 37 37 MULTIPLAN INC 34080 [3081285] MULTIPLAN INC [308128501] 35.15 percent of total billed charges 22.94 35.15 Technical (Hospital) Services HC/HH Wch Supp Bndg Compression Lf 4in__23594-040 PX-2705000029 CDM 2705000029 LOCAL 270 RC inpatient 15 15 BLUE CROSS BLUE SHIELD WELLMARK SB889 [3081026] BCBS WYOMING [308102603] 14.25 percent of total billed charges 9.3 14.25 Technical (Hospital) Services HC/HH Wch Supp Bndg Compression Lf 4in__23594-040 PX-2705000029 CDM 2705000029 LOCAL 270 RC inpatient 15 15 CIGNA 62308 [3081051] CIGNA 62308 [308105105] 11.88 percent of total billed charges 9.3 14.25 Technical (Hospital) Services HC/HH Wch Supp Bndg Compression Lf 4in__23594-040 PX-2705000029 CDM 2705000029 LOCAL 270 RC inpatient 15 15 CIGNA 62308 [3081051] CIGNA STATE OF WYOMING [308105107] 11.88 percent of total billed charges 9.3 14.25 Technical (Hospital) Services HC/HH Wch Supp Bndg Compression Lf 4in__23594-040 PX-2705000029 CDM 2705000029 LOCAL 270 RC inpatient 15 15 MULTIPLAN INC 34080 [3081285] MULTIPLAN INC [308128501] 14.25 percent of total billed charges 9.3 14.25 Technical (Hospital) Services HC/HH Wch Supp Bndg Compression Lf 4in__23594-040 PX-2705000029 CDM 2705000029 LOCAL 270 RC inpatient 15 15 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES EPO [308136803] 11.88 percent of total billed charges 9.3 14.25 Technical (Hospital) Services HC/HH Wch Supp Bndg Compression Lf 4in__23594-040 PX-2705000029 CDM 2705000029 LOCAL 270 RC inpatient 15 15 HEALTHPARTNERS SX009 HEALTHPARTNERS 11.88 percent of total billed charges 9.3 14.25 Technical (Hospital) Services HC/HH Wch Supp Bndg Compression Lf 4in__23594-040 PX-2705000029 CDM 2705000029 LOCAL 270 RC inpatient 15 15 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES PPO [308136801] 11.88 percent of total billed charges 9.3 14.25 Technical (Hospital) Services HC/HH Wch Supp Bndg Compression Lf 4in__23594-040 PX-2705000029 CDM 2705000029 LOCAL 270 RC inpatient 15 15 MEDICA (COMMERCIAL) 94265 [3081118] MEDICA CLAIMS [308111801] 13.5 percent of total billed charges 9.3 14.25 Technical (Hospital) Services HC/HH Wch Supp Bndg Compression Lf 4in__23594-040 PX-2705000029 CDM 2705000029 LOCAL 270 RC inpatient 15 15 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES HDHP [308136802] 11.88 percent of total billed charges 9.3 14.25 Technical (Hospital) Services HC/HH Wch Supp Bndg Compression Lf 4in__23594-040 PX-2705000029 CDM 2705000029 LOCAL 270 RC inpatient 15 15 UNITED HEALTHCARE (COMMERCIAL) [3081199] UNITED HEALTHCARE 87726 [308119901] 9.3 percent of total billed charges 9.3 14.25 Technical (Hospital) Services HC/HH Wch Supp Bndg Compression Lf 4in__23594-040 PX-2705000029 CDM 2705000029 LOCAL 270 RC outpatient 15 15 MULTIPLAN INC 34080 [3081285] MULTIPLAN INC [308128501] 14.25 percent of total billed charges 9.3 14.25 Technical (Hospital) Services HC/HH Wch Supp Bndg Compression Lf 4in__23594-040 PX-2705000029 CDM 2705000029 LOCAL 270 RC outpatient 15 15 MEDICA (COMMERCIAL) 94265 [3081118] MEDICA CLAIMS [308111801] 13.5 percent of total billed charges 9.3 14.25 Technical (Hospital) Services HC/HH Wch Supp Bndg Compression Lf 4in__23594-040 PX-2705000029 CDM 2705000029 LOCAL 270 RC outpatient 15 15 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES EPO [308136803] 12 percent of total billed charges 9.3 14.25 Technical (Hospital) Services HC/HH Wch Supp Bndg Compression Lf 4in__23594-040 PX-2705000029 CDM 2705000029 LOCAL 270 RC outpatient 15 15 CIGNA 62308 [3081051] CIGNA 62308 [308105105] 12 percent of total billed charges 9.3 14.25 Technical (Hospital) Services HC/HH Wch Supp Bndg Compression Lf 4in__23594-040 PX-2705000029 CDM 2705000029 LOCAL 270 RC outpatient 15 15 CIGNA 62308 [3081051] CIGNA STATE OF WYOMING [308105107] 12 percent of total billed charges 9.3 14.25 Technical (Hospital) Services HC/HH Wch Supp Bndg Compression Lf 4in__23594-040 PX-2705000029 CDM 2705000029 LOCAL 270 RC outpatient 15 15 BLUE CROSS BLUE SHIELD WELLMARK SB889 [3081026] BCBS WYOMING [308102603] 14.25 percent of total billed charges 9.3 14.25 Technical (Hospital) Services HC/HH Wch Supp Bndg Compression Lf 4in__23594-040 PX-2705000029 CDM 2705000029 LOCAL 270 RC outpatient 15 15 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES HDHP [308136802] 12 percent of total billed charges 9.3 14.25 Technical (Hospital) Services HC/HH Wch Supp Bndg Compression Lf 4in__23594-040 PX-2705000029 CDM 2705000029 LOCAL 270 RC outpatient 15 15 UNITED HEALTHCARE (COMMERCIAL) [3081199] UNITED HEALTHCARE 87726 [308119901] 9.3 percent of total billed charges 9.3 14.25 Technical (Hospital) Services HC/HH Wch Supp Bndg Compression Lf 4in__23594-040 PX-2705000029 CDM 2705000029 LOCAL 270 RC outpatient 15 15 HEALTHPARTNERS SX009 HEALTHPARTNERS 12 percent of total billed charges 9.3 14.25 Technical (Hospital) Services HC/HH Wch Supp Bndg Compression Lf 4in__23594-040 PX-2705000029 CDM 2705000029 LOCAL 270 RC outpatient 15 15 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES PPO [308136801] 12 percent of total billed charges 9.3 14.25 Technical (Hospital) Services HC/HH Wch Supp Bndg Coban Tan 2x5__1582 PX-2705000028 CDM 2705000028 LOCAL 270 RC outpatient 11 11 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES EPO [308136803] 8.8 percent of total billed charges 6.82 10.45 Technical (Hospital) Services HC/HH Wch Supp Bndg Coban Tan 2x5__1582 PX-2705000028 CDM 2705000028 LOCAL 270 RC outpatient 11 11 BLUE CROSS BLUE SHIELD WELLMARK SB889 [3081026] BCBS WYOMING [308102603] 10.45 percent of total billed charges 6.82 10.45 Technical (Hospital) Services HC/HH Wch Supp Bndg Coban Tan 2x5__1582 PX-2705000028 CDM 2705000028 LOCAL 270 RC outpatient 11 11 CIGNA 62308 [3081051] CIGNA 62308 [308105105] 8.8 percent of total billed charges 6.82 10.45 Technical (Hospital) Services HC/HH Wch Supp Bndg Coban Tan 2x5__1582 PX-2705000028 CDM 2705000028 LOCAL 270 RC outpatient 11 11 CIGNA 62308 [3081051] CIGNA STATE OF WYOMING [308105107] 8.8 percent of total billed charges 6.82 10.45 Technical (Hospital) Services HC/HH Wch Supp Bndg Coban Tan 2x5__1582 PX-2705000028 CDM 2705000028 LOCAL 270 RC outpatient 11 11 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES HDHP [308136802] 8.8 percent of total billed charges 6.82 10.45 Technical (Hospital) Services HC/HH Wch Supp Bndg Coban Tan 2x5__1582 PX-2705000028 CDM 2705000028 LOCAL 270 RC outpatient 11 11 UNITED HEALTHCARE (COMMERCIAL) [3081199] UNITED HEALTHCARE 87726 [308119901] 6.82 percent of total billed charges 6.82 10.45 Technical (Hospital) Services HC/HH Wch Supp Bndg Coban Tan 2x5__1582 PX-2705000028 CDM 2705000028 LOCAL 270 RC outpatient 11 11 HEALTHPARTNERS SX009 HEALTHPARTNERS 8.8 percent of total billed charges 6.82 10.45 Technical (Hospital) Services HC/HH Wch Supp Bndg Coban Tan 2x5__1582 PX-2705000028 CDM 2705000028 LOCAL 270 RC outpatient 11 11 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES PPO [308136801] 8.8 percent of total billed charges 6.82 10.45 Technical (Hospital) Services HC/HH Wch Supp Bndg Coban Tan 2x5__1582 PX-2705000028 CDM 2705000028 LOCAL 270 RC outpatient 11 11 MULTIPLAN INC 34080 [3081285] MULTIPLAN INC [308128501] 10.45 percent of total billed charges 6.82 10.45 Technical (Hospital) Services HC/HH Wch Supp Bndg Coban Tan 2x5__1582 PX-2705000028 CDM 2705000028 LOCAL 270 RC outpatient 11 11 MEDICA (COMMERCIAL) 94265 [3081118] MEDICA CLAIMS [308111801] 9.9 percent of total billed charges 6.82 10.45 Technical (Hospital) Services HC/HH Wch Supp Bndg Coban Tan 2x5__1582 PX-2705000028 CDM 2705000028 LOCAL 270 RC inpatient 11 11 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES PPO [308136801] 8.71 percent of total billed charges 6.82 10.45 Technical (Hospital) Services HC/HH Wch Supp Bndg Coban Tan 2x5__1582 PX-2705000028 CDM 2705000028 LOCAL 270 RC inpatient 11 11 UNITED HEALTHCARE (COMMERCIAL) [3081199] UNITED HEALTHCARE 87726 [308119901] 6.82 percent of total billed charges 6.82 10.45 Technical (Hospital) Services HC/HH Wch Supp Bndg Coban Tan 2x5__1582 PX-2705000028 CDM 2705000028 LOCAL 270 RC inpatient 11 11 MEDICA (COMMERCIAL) 94265 [3081118] MEDICA CLAIMS [308111801] 9.9 percent of total billed charges 6.82 10.45 Technical (Hospital) Services HC/HH Wch Supp Bndg Coban Tan 2x5__1582 PX-2705000028 CDM 2705000028 LOCAL 270 RC inpatient 11 11 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES HDHP [308136802] 8.71 percent of total billed charges 6.82 10.45 Technical (Hospital) Services HC/HH Wch Supp Bndg Coban Tan 2x5__1582 PX-2705000028 CDM 2705000028 LOCAL 270 RC inpatient 11 11 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES EPO [308136803] 8.71 percent of total billed charges 6.82 10.45 Technical (Hospital) Services HC/HH Wch Supp Bndg Coban Tan 2x5__1582 PX-2705000028 CDM 2705000028 LOCAL 270 RC inpatient 11 11 HEALTHPARTNERS SX009 HEALTHPARTNERS 8.71 percent of total billed charges 6.82 10.45 Technical (Hospital) Services HC/HH Wch Supp Bndg Coban Tan 2x5__1582 PX-2705000028 CDM 2705000028 LOCAL 270 RC inpatient 11 11 BLUE CROSS BLUE SHIELD WELLMARK SB889 [3081026] BCBS WYOMING [308102603] 10.45 percent of total billed charges 6.82 10.45 Technical (Hospital) Services HC/HH Wch Supp Bndg Coban Tan 2x5__1582 PX-2705000028 CDM 2705000028 LOCAL 270 RC inpatient 11 11 CIGNA 62308 [3081051] CIGNA 62308 [308105105] 8.71 percent of total billed charges 6.82 10.45 Technical (Hospital) Services HC/HH Wch Supp Bndg Coban Tan 2x5__1582 PX-2705000028 CDM 2705000028 LOCAL 270 RC inpatient 11 11 CIGNA 62308 [3081051] CIGNA STATE OF WYOMING [308105107] 8.71 percent of total billed charges 6.82 10.45 Technical (Hospital) Services HC/HH Wch Supp Bndg Coban Tan 2x5__1582 PX-2705000028 CDM 2705000028 LOCAL 270 RC inpatient 11 11 MULTIPLAN INC 34080 [3081285] MULTIPLAN INC [308128501] 10.45 percent of total billed charges 6.82 10.45 Technical (Hospital) Services HC/HH Wch Supp Bndg Coban Lf 2x5__2082 PX-2705000027 CDM 2705000027 LOCAL 270 RC inpatient 11 11 UNITED HEALTHCARE (COMMERCIAL) [3081199] UNITED HEALTHCARE 87726 [308119901] 6.82 percent of total billed charges 6.82 10.45 Technical (Hospital) Services HC/HH Wch Supp Bndg Coban Lf 2x5__2082 PX-2705000027 CDM 2705000027 LOCAL 270 RC inpatient 11 11 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES HDHP [308136802] 8.71 percent of total billed charges 6.82 10.45 Technical (Hospital) Services HC/HH Wch Supp Bndg Coban Lf 2x5__2082 PX-2705000027 CDM 2705000027 LOCAL 270 RC inpatient 11 11 MEDICA (COMMERCIAL) 94265 [3081118] MEDICA CLAIMS [308111801] 9.9 percent of total billed charges 6.82 10.45 Technical (Hospital) Services HC/HH Wch Supp Bndg Coban Lf 2x5__2082 PX-2705000027 CDM 2705000027 LOCAL 270 RC inpatient 11 11 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES PPO [308136801] 8.71 percent of total billed charges 6.82 10.45 Technical (Hospital) Services HC/HH Wch Supp Bndg Coban Lf 2x5__2082 PX-2705000027 CDM 2705000027 LOCAL 270 RC inpatient 11 11 CIGNA 62308 [3081051] CIGNA 62308 [308105105] 8.71 percent of total billed charges 6.82 10.45 Technical (Hospital) Services HC/HH Wch Supp Bndg Coban Lf 2x5__2082 PX-2705000027 CDM 2705000027 LOCAL 270 RC inpatient 11 11 CIGNA 62308 [3081051] CIGNA STATE OF WYOMING [308105107] 8.71 percent of total billed charges 6.82 10.45 Technical (Hospital) Services HC/HH Wch Supp Bndg Coban Lf 2x5__2082 PX-2705000027 CDM 2705000027 LOCAL 270 RC inpatient 11 11 MULTIPLAN INC 34080 [3081285] MULTIPLAN INC [308128501] 10.45 percent of total billed charges 6.82 10.45 Technical (Hospital) Services HC/HH Wch Supp Bndg Coban Lf 2x5__2082 PX-2705000027 CDM 2705000027 LOCAL 270 RC inpatient 11 11 BLUE CROSS BLUE SHIELD WELLMARK SB889 [3081026] BCBS WYOMING [308102603] 10.45 percent of total billed charges 6.82 10.45 Technical (Hospital) Services HC/HH Wch Supp Bndg Coban Lf 2x5__2082 PX-2705000027 CDM 2705000027 LOCAL 270 RC inpatient 11 11 HEALTHPARTNERS SX009 HEALTHPARTNERS 8.71 percent of total billed charges 6.82 10.45 Technical (Hospital) Services HC/HH Wch Supp Bndg Coban Lf 2x5__2082 PX-2705000027 CDM 2705000027 LOCAL 270 RC inpatient 11 11 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES EPO [308136803] 8.71 percent of total billed charges 6.82 10.45 Technical (Hospital) Services HC/HH Wch Supp Bndg Coban Lf 2x5__2082 PX-2705000027 CDM 2705000027 LOCAL 270 RC outpatient 11 11 UNITED HEALTHCARE (COMMERCIAL) [3081199] UNITED HEALTHCARE 87726 [308119901] 6.82 percent of total billed charges 6.82 10.45 Technical (Hospital) Services HC/HH Wch Supp Bndg Coban Lf 2x5__2082 PX-2705000027 CDM 2705000027 LOCAL 270 RC outpatient 11 11 HEALTHPARTNERS SX009 HEALTHPARTNERS 8.8 percent of total billed charges 6.82 10.45 Technical (Hospital) Services HC/HH Wch Supp Bndg Coban Lf 2x5__2082 PX-2705000027 CDM 2705000027 LOCAL 270 RC outpatient 11 11 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES PPO [308136801] 8.8 percent of total billed charges 6.82 10.45 Technical (Hospital) Services HC/HH Wch Supp Bndg Coban Lf 2x5__2082 PX-2705000027 CDM 2705000027 LOCAL 270 RC outpatient 11 11 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES HDHP [308136802] 8.8 percent of total billed charges 6.82 10.45 Technical (Hospital) Services HC/HH Wch Supp Bndg Coban Lf 2x5__2082 PX-2705000027 CDM 2705000027 LOCAL 270 RC outpatient 11 11 CIGNA 62308 [3081051] CIGNA 62308 [308105105] 8.8 percent of total billed charges 6.82 10.45 Technical (Hospital) Services HC/HH Wch Supp Bndg Coban Lf 2x5__2082 PX-2705000027 CDM 2705000027 LOCAL 270 RC outpatient 11 11 CIGNA 62308 [3081051] CIGNA STATE OF WYOMING [308105107] 8.8 percent of total billed charges 6.82 10.45 Technical (Hospital) Services HC/HH Wch Supp Bndg Coban Lf 2x5__2082 PX-2705000027 CDM 2705000027 LOCAL 270 RC outpatient 11 11 BLUE CROSS BLUE SHIELD WELLMARK SB889 [3081026] BCBS WYOMING [308102603] 10.45 percent of total billed charges 6.82 10.45 Technical (Hospital) Services HC/HH Wch Supp Bndg Coban Lf 2x5__2082 PX-2705000027 CDM 2705000027 LOCAL 270 RC outpatient 11 11 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES EPO [308136803] 8.8 percent of total billed charges 6.82 10.45 Technical (Hospital) Services HC/HH Wch Supp Bndg Coban Lf 2x5__2082 PX-2705000027 CDM 2705000027 LOCAL 270 RC outpatient 11 11 MEDICA (COMMERCIAL) 94265 [3081118] MEDICA CLAIMS [308111801] 9.9 percent of total billed charges 6.82 10.45 Technical (Hospital) Services HC/HH Wch Supp Bndg Coban Lf 2x5__2082 PX-2705000027 CDM 2705000027 LOCAL 270 RC outpatient 11 11 MULTIPLAN INC 34080 [3081285] MULTIPLAN INC [308128501] 10.45 percent of total billed charges 6.82 10.45 Technical (Hospital) Services HC/HH Wch Supp Blanket Bair Hugger__11101 PX-2705000026 CDM 2705000026 LOCAL 270 RC inpatient 172 172 BLUE CROSS BLUE SHIELD WELLMARK SB889 [3081026] BCBS WYOMING [308102603] 163.4 percent of total billed charges 106.64 163.4 Technical (Hospital) Services HC/HH Wch Supp Blanket Bair Hugger__11101 PX-2705000026 CDM 2705000026 LOCAL 270 RC inpatient 172 172 MULTIPLAN INC 34080 [3081285] MULTIPLAN INC [308128501] 163.4 percent of total billed charges 106.64 163.4 Technical (Hospital) Services HC/HH Wch Supp Blanket Bair Hugger__11101 PX-2705000026 CDM 2705000026 LOCAL 270 RC inpatient 172 172 CIGNA 62308 [3081051] CIGNA 62308 [308105105] 136.19 percent of total billed charges 106.64 163.4 Technical (Hospital) Services HC/HH Wch Supp Blanket Bair Hugger__11101 PX-2705000026 CDM 2705000026 LOCAL 270 RC inpatient 172 172 CIGNA 62308 [3081051] CIGNA STATE OF WYOMING [308105107] 136.19 percent of total billed charges 106.64 163.4 Technical (Hospital) Services HC/HH Wch Supp Blanket Bair Hugger__11101 PX-2705000026 CDM 2705000026 LOCAL 270 RC inpatient 172 172 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES EPO [308136803] 136.19 percent of total billed charges 106.64 163.4 Technical (Hospital) Services HC/HH Wch Supp Blanket Bair Hugger__11101 PX-2705000026 CDM 2705000026 LOCAL 270 RC inpatient 172 172 HEALTHPARTNERS SX009 HEALTHPARTNERS 136.19 percent of total billed charges 106.64 163.4 Technical (Hospital) Services HC/HH Wch Supp Blanket Bair Hugger__11101 PX-2705000026 CDM 2705000026 LOCAL 270 RC inpatient 172 172 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES PPO [308136801] 136.19 percent of total billed charges 106.64 163.4 Technical (Hospital) Services HC/HH Wch Supp Blanket Bair Hugger__11101 PX-2705000026 CDM 2705000026 LOCAL 270 RC inpatient 172 172 UNITED HEALTHCARE (COMMERCIAL) [3081199] UNITED HEALTHCARE 87726 [308119901] 106.64 percent of total billed charges 106.64 163.4 Technical (Hospital) Services HC/HH Wch Supp Blanket Bair Hugger__11101 PX-2705000026 CDM 2705000026 LOCAL 270 RC inpatient 172 172 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES HDHP [308136802] 136.19 percent of total billed charges 106.64 163.4 Technical (Hospital) Services HC/HH Wch Supp Blanket Bair Hugger__11101 PX-2705000026 CDM 2705000026 LOCAL 270 RC inpatient 172 172 MEDICA (COMMERCIAL) 94265 [3081118] MEDICA CLAIMS [308111801] 154.8 percent of total billed charges 106.64 163.4 Technical (Hospital) Services HC/HH Wch Supp Blanket Bair Hugger__11101 PX-2705000026 CDM 2705000026 LOCAL 270 RC outpatient 172 172 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES PPO [308136801] 137.6 percent of total billed charges 106.64 163.4 Technical (Hospital) Services HC/HH Wch Supp Blanket Bair Hugger__11101 PX-2705000026 CDM 2705000026 LOCAL 270 RC outpatient 172 172 HEALTHPARTNERS SX009 HEALTHPARTNERS 137.6 percent of total billed charges 106.64 163.4 Technical (Hospital) Services HC/HH Wch Supp Blanket Bair Hugger__11101 PX-2705000026 CDM 2705000026 LOCAL 270 RC outpatient 172 172 UNITED HEALTHCARE (COMMERCIAL) [3081199] UNITED HEALTHCARE 87726 [308119901] 106.64 percent of total billed charges 106.64 163.4 Technical (Hospital) Services HC/HH Wch Supp Blanket Bair Hugger__11101 PX-2705000026 CDM 2705000026 LOCAL 270 RC outpatient 172 172 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES HDHP [308136802] 137.6 percent of total billed charges 106.64 163.4 Technical (Hospital) Services HC/HH Wch Supp Blanket Bair Hugger__11101 PX-2705000026 CDM 2705000026 LOCAL 270 RC outpatient 172 172 BLUE CROSS BLUE SHIELD WELLMARK SB889 [3081026] BCBS WYOMING [308102603] 163.4 percent of total billed charges 106.64 163.4 Technical (Hospital) Services HC/HH Wch Supp Blanket Bair Hugger__11101 PX-2705000026 CDM 2705000026 LOCAL 270 RC outpatient 172 172 CIGNA 62308 [3081051] CIGNA 62308 [308105105] 137.6 percent of total billed charges 106.64 163.4 Technical (Hospital) Services HC/HH Wch Supp Blanket Bair Hugger__11101 PX-2705000026 CDM 2705000026 LOCAL 270 RC outpatient 172 172 CIGNA 62308 [3081051] CIGNA STATE OF WYOMING [308105107] 137.6 percent of total billed charges 106.64 163.4 Technical (Hospital) Services HC/HH Wch Supp Blanket Bair Hugger__11101 PX-2705000026 CDM 2705000026 LOCAL 270 RC outpatient 172 172 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES EPO [308136803] 137.6 percent of total billed charges 106.64 163.4 Technical (Hospital) Services HC/HH Wch Supp Blanket Bair Hugger__11101 PX-2705000026 CDM 2705000026 LOCAL 270 RC outpatient 172 172 MEDICA (COMMERCIAL) 94265 [3081118] MEDICA CLAIMS [308111801] 154.8 percent of total billed charges 106.64 163.4 Technical (Hospital) Services HC/HH Wch Supp Blanket Bair Hugger__11101 PX-2705000026 CDM 2705000026 LOCAL 270 RC outpatient 172 172 MULTIPLAN INC 34080 [3081285] MULTIPLAN INC [308128501] 163.4 percent of total billed charges 106.64 163.4 Technical (Hospital) Services HC/HH Wch Supp Blanket Bair Hugger Upper Body__52200 PX-2705000025 CDM 2705000025 LOCAL 270 RC inpatient 172 172 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES EPO [308136803] 136.19 percent of total billed charges 106.64 163.4 Technical (Hospital) Services HC/HH Wch Supp Blanket Bair Hugger Upper Body__52200 PX-2705000025 CDM 2705000025 LOCAL 270 RC inpatient 172 172 HEALTHPARTNERS SX009 HEALTHPARTNERS 136.19 percent of total billed charges 106.64 163.4 Technical (Hospital) Services HC/HH Wch Supp Blanket Bair Hugger Upper Body__52200 PX-2705000025 CDM 2705000025 LOCAL 270 RC inpatient 172 172 BLUE CROSS BLUE SHIELD WELLMARK SB889 [3081026] BCBS WYOMING [308102603] 163.4 percent of total billed charges 106.64 163.4 Technical (Hospital) Services HC/HH Wch Supp Blanket Bair Hugger Upper Body__52200 PX-2705000025 CDM 2705000025 LOCAL 270 RC inpatient 172 172 MULTIPLAN INC 34080 [3081285] MULTIPLAN INC [308128501] 163.4 percent of total billed charges 106.64 163.4 Technical (Hospital) Services HC/HH Wch Supp Blanket Bair Hugger Upper Body__52200 PX-2705000025 CDM 2705000025 LOCAL 270 RC inpatient 172 172 CIGNA 62308 [3081051] CIGNA 62308 [308105105] 136.19 percent of total billed charges 106.64 163.4 Technical (Hospital) Services HC/HH Wch Supp Blanket Bair Hugger Upper Body__52200 PX-2705000025 CDM 2705000025 LOCAL 270 RC inpatient 172 172 CIGNA 62308 [3081051] CIGNA STATE OF WYOMING [308105107] 136.19 percent of total billed charges 106.64 163.4 Technical (Hospital) Services HC/HH Wch Supp Blanket Bair Hugger Upper Body__52200 PX-2705000025 CDM 2705000025 LOCAL 270 RC inpatient 172 172 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES PPO [308136801] 136.19 percent of total billed charges 106.64 163.4 Technical (Hospital) Services HC/HH Wch Supp Blanket Bair Hugger Upper Body__52200 PX-2705000025 CDM 2705000025 LOCAL 270 RC inpatient 172 172 MEDICA (COMMERCIAL) 94265 [3081118] MEDICA CLAIMS [308111801] 154.8 percent of total billed charges 106.64 163.4 Technical (Hospital) Services HC/HH Wch Supp Blanket Bair Hugger Upper Body__52200 PX-2705000025 CDM 2705000025 LOCAL 270 RC inpatient 172 172 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES HDHP [308136802] 136.19 percent of total billed charges 106.64 163.4 Technical (Hospital) Services HC/HH Wch Supp Blanket Bair Hugger Upper Body__52200 PX-2705000025 CDM 2705000025 LOCAL 270 RC inpatient 172 172 UNITED HEALTHCARE (COMMERCIAL) [3081199] UNITED HEALTHCARE 87726 [308119901] 106.64 percent of total billed charges 106.64 163.4 Technical (Hospital) Services HC/HH Wch Supp Blanket Bair Hugger Upper Body__52200 PX-2705000025 CDM 2705000025 LOCAL 270 RC outpatient 172 172 MULTIPLAN INC 34080 [3081285] MULTIPLAN INC [308128501] 163.4 percent of total billed charges 106.64 163.4 Technical (Hospital) Services HC/HH Wch Supp Blanket Bair Hugger Upper Body__52200 PX-2705000025 CDM 2705000025 LOCAL 270 RC outpatient 172 172 MEDICA (COMMERCIAL) 94265 [3081118] MEDICA CLAIMS [308111801] 154.8 percent of total billed charges 106.64 163.4 Technical (Hospital) Services HC/HH Wch Supp Blanket Bair Hugger Upper Body__52200 PX-2705000025 CDM 2705000025 LOCAL 270 RC outpatient 172 172 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES PPO [308136801] 137.6 percent of total billed charges 106.64 163.4 Technical (Hospital) Services HC/HH Wch Supp Blanket Bair Hugger Upper Body__52200 PX-2705000025 CDM 2705000025 LOCAL 270 RC outpatient 172 172 HEALTHPARTNERS SX009 HEALTHPARTNERS 137.6 percent of total billed charges 106.64 163.4 Technical (Hospital) Services HC/HH Wch Supp Blanket Bair Hugger Upper Body__52200 PX-2705000025 CDM 2705000025 LOCAL 270 RC outpatient 172 172 UNITED HEALTHCARE (COMMERCIAL) [3081199] UNITED HEALTHCARE 87726 [308119901] 106.64 percent of total billed charges 106.64 163.4 Technical (Hospital) Services HC/HH Wch Supp Blanket Bair Hugger Upper Body__52200 PX-2705000025 CDM 2705000025 LOCAL 270 RC outpatient 172 172 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES EPO [308136803] 137.6 percent of total billed charges 106.64 163.4 Technical (Hospital) Services HC/HH Wch Supp Blanket Bair Hugger Upper Body__52200 PX-2705000025 CDM 2705000025 LOCAL 270 RC outpatient 172 172 CIGNA 62308 [3081051] CIGNA 62308 [308105105] 137.6 percent of total billed charges 106.64 163.4 Technical (Hospital) Services HC/HH Wch Supp Blanket Bair Hugger Upper Body__52200 PX-2705000025 CDM 2705000025 LOCAL 270 RC outpatient 172 172 CIGNA 62308 [3081051] CIGNA STATE OF WYOMING [308105107] 137.6 percent of total billed charges 106.64 163.4 Technical (Hospital) Services HC/HH Wch Supp Blanket Bair Hugger Upper Body__52200 PX-2705000025 CDM 2705000025 LOCAL 270 RC outpatient 172 172 BLUE CROSS BLUE SHIELD WELLMARK SB889 [3081026] BCBS WYOMING [308102603] 163.4 percent of total billed charges 106.64 163.4 Technical (Hospital) Services HC/HH Wch Supp Blanket Bair Hugger Upper Body__52200 PX-2705000025 CDM 2705000025 LOCAL 270 RC outpatient 172 172 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES HDHP [308136802] 137.6 percent of total billed charges 106.64 163.4 Technical (Hospital) Services HC/HH Wch Supp Bite Blocks Disp__1140 PX-2705000024 CDM 2705000024 LOCAL 270 RC outpatient 15 15 MEDICA (COMMERCIAL) 94265 [3081118] MEDICA CLAIMS [308111801] 13.5 percent of total billed charges 9.3 14.25 Technical (Hospital) Services HC/HH Wch Supp Bite Blocks Disp__1140 PX-2705000024 CDM 2705000024 LOCAL 270 RC outpatient 15 15 MULTIPLAN INC 34080 [3081285] MULTIPLAN INC [308128501] 14.25 percent of total billed charges 9.3 14.25 Technical (Hospital) Services HC/HH Wch Supp Bite Blocks Disp__1140 PX-2705000024 CDM 2705000024 LOCAL 270 RC outpatient 15 15 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES PPO [308136801] 12 percent of total billed charges 9.3 14.25 Technical (Hospital) Services HC/HH Wch Supp Bite Blocks Disp__1140 PX-2705000024 CDM 2705000024 LOCAL 270 RC outpatient 15 15 HEALTHPARTNERS SX009 HEALTHPARTNERS 12 percent of total billed charges 9.3 14.25 Technical (Hospital) Services HC/HH Wch Supp Bite Blocks Disp__1140 PX-2705000024 CDM 2705000024 LOCAL 270 RC outpatient 15 15 UNITED HEALTHCARE (COMMERCIAL) [3081199] UNITED HEALTHCARE 87726 [308119901] 9.3 percent of total billed charges 9.3 14.25 Technical (Hospital) Services HC/HH Wch Supp Bite Blocks Disp__1140 PX-2705000024 CDM 2705000024 LOCAL 270 RC outpatient 15 15 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES HDHP [308136802] 12 percent of total billed charges 9.3 14.25 Technical (Hospital) Services HC/HH Wch Supp Bite Blocks Disp__1140 PX-2705000024 CDM 2705000024 LOCAL 270 RC outpatient 15 15 CIGNA 62308 [3081051] CIGNA 62308 [308105105] 12 percent of total billed charges 9.3 14.25 Technical (Hospital) Services HC/HH Wch Supp Bite Blocks Disp__1140 PX-2705000024 CDM 2705000024 LOCAL 270 RC outpatient 15 15 CIGNA 62308 [3081051] CIGNA STATE OF WYOMING [308105107] 12 percent of total billed charges 9.3 14.25 Technical (Hospital) Services HC/HH Wch Supp Bite Blocks Disp__1140 PX-2705000024 CDM 2705000024 LOCAL 270 RC outpatient 15 15 BLUE CROSS BLUE SHIELD WELLMARK SB889 [3081026] BCBS WYOMING [308102603] 14.25 percent of total billed charges 9.3 14.25 Technical (Hospital) Services HC/HH Wch Supp Bite Blocks Disp__1140 PX-2705000024 CDM 2705000024 LOCAL 270 RC outpatient 15 15 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES EPO [308136803] 12 percent of total billed charges 9.3 14.25 Technical (Hospital) Services HC/HH Wch Supp Bite Blocks Disp__1140 PX-2705000024 CDM 2705000024 LOCAL 270 RC inpatient 15 15 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES EPO [308136803] 11.88 percent of total billed charges 9.3 14.25 Technical (Hospital) Services HC/HH Wch Supp Bite Blocks Disp__1140 PX-2705000024 CDM 2705000024 LOCAL 270 RC inpatient 15 15 HEALTHPARTNERS SX009 HEALTHPARTNERS 11.88 percent of total billed charges 9.3 14.25 Technical (Hospital) Services HC/HH Wch Supp Bite Blocks Disp__1140 PX-2705000024 CDM 2705000024 LOCAL 270 RC inpatient 15 15 BLUE CROSS BLUE SHIELD WELLMARK SB889 [3081026] BCBS WYOMING [308102603] 14.25 percent of total billed charges 9.3 14.25 Technical (Hospital) Services HC/HH Wch Supp Bite Blocks Disp__1140 PX-2705000024 CDM 2705000024 LOCAL 270 RC inpatient 15 15 MULTIPLAN INC 34080 [3081285] MULTIPLAN INC [308128501] 14.25 percent of total billed charges 9.3 14.25 Technical (Hospital) Services HC/HH Wch Supp Bite Blocks Disp__1140 PX-2705000024 CDM 2705000024 LOCAL 270 RC inpatient 15 15 CIGNA 62308 [3081051] CIGNA 62308 [308105105] 11.88 percent of total billed charges 9.3 14.25 Technical (Hospital) Services HC/HH Wch Supp Bite Blocks Disp__1140 PX-2705000024 CDM 2705000024 LOCAL 270 RC inpatient 15 15 CIGNA 62308 [3081051] CIGNA STATE OF WYOMING [308105107] 11.88 percent of total billed charges 9.3 14.25 Technical (Hospital) Services HC/HH Wch Supp Bite Blocks Disp__1140 PX-2705000024 CDM 2705000024 LOCAL 270 RC inpatient 15 15 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES PPO [308136801] 11.88 percent of total billed charges 9.3 14.25 Technical (Hospital) Services HC/HH Wch Supp Bite Blocks Disp__1140 PX-2705000024 CDM 2705000024 LOCAL 270 RC inpatient 15 15 MEDICA (COMMERCIAL) 94265 [3081118] MEDICA CLAIMS [308111801] 13.5 percent of total billed charges 9.3 14.25 Technical (Hospital) Services HC/HH Wch Supp Bite Blocks Disp__1140 PX-2705000024 CDM 2705000024 LOCAL 270 RC inpatient 15 15 UNITED HEALTHCARE (COMMERCIAL) [3081199] UNITED HEALTHCARE 87726 [308119901] 9.3 percent of total billed charges 9.3 14.25 Technical (Hospital) Services HC/HH Wch Supp Bite Blocks Disp__1140 PX-2705000024 CDM 2705000024 LOCAL 270 RC inpatient 15 15 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES HDHP [308136802] 11.88 percent of total billed charges 9.3 14.25 Technical (Hospital) Services HC/HH Wch Supp Bag Resuscitation Man Ped__2k8008 PX-2705000023 CDM 2705000023 LOCAL 270 RC inpatient 96 96 MEDICA (COMMERCIAL) 94265 [3081118] MEDICA CLAIMS [308111801] 86.4 percent of total billed charges 59.52 91.2 Technical (Hospital) Services HC/HH Wch Supp Bag Resuscitation Man Ped__2k8008 PX-2705000023 CDM 2705000023 LOCAL 270 RC inpatient 96 96 UNITED HEALTHCARE (COMMERCIAL) [3081199] UNITED HEALTHCARE 87726 [308119901] 59.52 percent of total billed charges 59.52 91.2 Technical (Hospital) Services HC/HH Wch Supp Bag Resuscitation Man Ped__2k8008 PX-2705000023 CDM 2705000023 LOCAL 270 RC inpatient 96 96 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES HDHP [308136802] 76.01 percent of total billed charges 59.52 91.2 Technical (Hospital) Services HC/HH Wch Supp Bag Resuscitation Man Ped__2k8008 PX-2705000023 CDM 2705000023 LOCAL 270 RC inpatient 96 96 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES PPO [308136801] 76.01 percent of total billed charges 59.52 91.2 Technical (Hospital) Services HC/HH Wch Supp Bag Resuscitation Man Ped__2k8008 PX-2705000023 CDM 2705000023 LOCAL 270 RC inpatient 96 96 CIGNA 62308 [3081051] CIGNA 62308 [308105105] 76.01 percent of total billed charges 59.52 91.2 Technical (Hospital) Services HC/HH Wch Supp Bag Resuscitation Man Ped__2k8008 PX-2705000023 CDM 2705000023 LOCAL 270 RC inpatient 96 96 CIGNA 62308 [3081051] CIGNA STATE OF WYOMING [308105107] 76.01 percent of total billed charges 59.52 91.2 Technical (Hospital) Services HC/HH Wch Supp Bag Resuscitation Man Ped__2k8008 PX-2705000023 CDM 2705000023 LOCAL 270 RC inpatient 96 96 BLUE CROSS BLUE SHIELD WELLMARK SB889 [3081026] BCBS WYOMING [308102603] 91.2 percent of total billed charges 59.52 91.2 Technical (Hospital) Services HC/HH Wch Supp Bag Resuscitation Man Ped__2k8008 PX-2705000023 CDM 2705000023 LOCAL 270 RC inpatient 96 96 MULTIPLAN INC 34080 [3081285] MULTIPLAN INC [308128501] 91.2 percent of total billed charges 59.52 91.2 Technical (Hospital) Services HC/HH Wch Supp Bag Resuscitation Man Ped__2k8008 PX-2705000023 CDM 2705000023 LOCAL 270 RC inpatient 96 96 HEALTHPARTNERS SX009 HEALTHPARTNERS 76.01 percent of total billed charges 59.52 91.2 Technical (Hospital) Services HC/HH Wch Supp Bag Resuscitation Man Ped__2k8008 PX-2705000023 CDM 2705000023 LOCAL 270 RC inpatient 96 96 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES EPO [308136803] 76.01 percent of total billed charges 59.52 91.2 Technical (Hospital) Services HC/HH Wch Supp Bag Resuscitation Man Ped__2k8008 PX-2705000023 CDM 2705000023 LOCAL 270 RC outpatient 96 96 HEALTHPARTNERS SX009 HEALTHPARTNERS 76.8 percent of total billed charges 59.52 91.2 Technical (Hospital) Services HC/HH Wch Supp Bag Resuscitation Man Ped__2k8008 PX-2705000023 CDM 2705000023 LOCAL 270 RC outpatient 96 96 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES PPO [308136801] 76.8 percent of total billed charges 59.52 91.2 Technical (Hospital) Services HC/HH Wch Supp Bag Resuscitation Man Ped__2k8008 PX-2705000023 CDM 2705000023 LOCAL 270 RC outpatient 96 96 UNITED HEALTHCARE (COMMERCIAL) [3081199] UNITED HEALTHCARE 87726 [308119901] 59.52 percent of total billed charges 59.52 91.2 Technical (Hospital) Services HC/HH Wch Supp Bag Resuscitation Man Ped__2k8008 PX-2705000023 CDM 2705000023 LOCAL 270 RC outpatient 96 96 BLUE CROSS BLUE SHIELD WELLMARK SB889 [3081026] BCBS WYOMING [308102603] 91.2 percent of total billed charges 59.52 91.2 Technical (Hospital) Services HC/HH Wch Supp Bag Resuscitation Man Ped__2k8008 PX-2705000023 CDM 2705000023 LOCAL 270 RC outpatient 96 96 CIGNA 62308 [3081051] CIGNA 62308 [308105105] 76.8 percent of total billed charges 59.52 91.2 Technical (Hospital) Services HC/HH Wch Supp Bag Resuscitation Man Ped__2k8008 PX-2705000023 CDM 2705000023 LOCAL 270 RC outpatient 96 96 CIGNA 62308 [3081051] CIGNA STATE OF WYOMING [308105107] 76.8 percent of total billed charges 59.52 91.2 Technical (Hospital) Services HC/HH Wch Supp Bag Resuscitation Man Ped__2k8008 PX-2705000023 CDM 2705000023 LOCAL 270 RC outpatient 96 96 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES HDHP [308136802] 76.8 percent of total billed charges 59.52 91.2 Technical (Hospital) Services HC/HH Wch Supp Bag Resuscitation Man Ped__2k8008 PX-2705000023 CDM 2705000023 LOCAL 270 RC outpatient 96 96 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES EPO [308136803] 76.8 percent of total billed charges 59.52 91.2 Technical (Hospital) Services HC/HH Wch Supp Bag Resuscitation Man Ped__2k8008 PX-2705000023 CDM 2705000023 LOCAL 270 RC outpatient 96 96 MULTIPLAN INC 34080 [3081285] MULTIPLAN INC [308128501] 91.2 percent of total billed charges 59.52 91.2 Technical (Hospital) Services HC/HH Wch Supp Bag Resuscitation Man Ped__2k8008 PX-2705000023 CDM 2705000023 LOCAL 270 RC outpatient 96 96 MEDICA (COMMERCIAL) 94265 [3081118] MEDICA CLAIMS [308111801] 86.4 percent of total billed charges 59.52 91.2 Technical (Hospital) Services HC/HH Wch Supp Bag Resuscitation Man Infant__2k8038 PX-2705000022 CDM 2705000022 LOCAL 270 RC inpatient 96 96 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES EPO [308136803] 76.01 percent of total billed charges 59.52 91.2 Technical (Hospital) Services HC/HH Wch Supp Bag Resuscitation Man Infant__2k8038 PX-2705000022 CDM 2705000022 LOCAL 270 RC inpatient 96 96 HEALTHPARTNERS SX009 HEALTHPARTNERS 76.01 percent of total billed charges 59.52 91.2 Technical (Hospital) Services HC/HH Wch Supp Bag Resuscitation Man Infant__2k8038 PX-2705000022 CDM 2705000022 LOCAL 270 RC inpatient 96 96 CIGNA 62308 [3081051] CIGNA 62308 [308105105] 76.01 percent of total billed charges 59.52 91.2 Technical (Hospital) Services HC/HH Wch Supp Bag Resuscitation Man Infant__2k8038 PX-2705000022 CDM 2705000022 LOCAL 270 RC inpatient 96 96 CIGNA 62308 [3081051] CIGNA STATE OF WYOMING [308105107] 76.01 percent of total billed charges 59.52 91.2 Technical (Hospital) Services HC/HH Wch Supp Bag Resuscitation Man Infant__2k8038 PX-2705000022 CDM 2705000022 LOCAL 270 RC inpatient 96 96 MULTIPLAN INC 34080 [3081285] MULTIPLAN INC [308128501] 91.2 percent of total billed charges 59.52 91.2 Technical (Hospital) Services HC/HH Wch Supp Bag Resuscitation Man Infant__2k8038 PX-2705000022 CDM 2705000022 LOCAL 270 RC inpatient 96 96 BLUE CROSS BLUE SHIELD WELLMARK SB889 [3081026] BCBS WYOMING [308102603] 91.2 percent of total billed charges 59.52 91.2 Technical (Hospital) Services HC/HH Wch Supp Bag Resuscitation Man Infant__2k8038 PX-2705000022 CDM 2705000022 LOCAL 270 RC inpatient 96 96 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES PPO [308136801] 76.01 percent of total billed charges 59.52 91.2 Technical (Hospital) Services HC/HH Wch Supp Bag Resuscitation Man Infant__2k8038 PX-2705000022 CDM 2705000022 LOCAL 270 RC inpatient 96 96 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES HDHP [308136802] 76.01 percent of total billed charges 59.52 91.2 Technical (Hospital) Services HC/HH Wch Supp Bag Resuscitation Man Infant__2k8038 PX-2705000022 CDM 2705000022 LOCAL 270 RC inpatient 96 96 UNITED HEALTHCARE (COMMERCIAL) [3081199] UNITED HEALTHCARE 87726 [308119901] 59.52 percent of total billed charges 59.52 91.2 Technical (Hospital) Services HC/HH Wch Supp Bag Resuscitation Man Infant__2k8038 PX-2705000022 CDM 2705000022 LOCAL 270 RC inpatient 96 96 MEDICA (COMMERCIAL) 94265 [3081118] MEDICA CLAIMS [308111801] 86.4 percent of total billed charges 59.52 91.2 Technical (Hospital) Services HC/HH Wch Supp Bag Resuscitation Man Infant__2k8038 PX-2705000022 CDM 2705000022 LOCAL 270 RC outpatient 96 96 HEALTHPARTNERS SX009 HEALTHPARTNERS 76.8 percent of total billed charges 59.52 91.2 Technical (Hospital) Services HC/HH Wch Supp Bag Resuscitation Man Infant__2k8038 PX-2705000022 CDM 2705000022 LOCAL 270 RC outpatient 96 96 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES PPO [308136801] 76.8 percent of total billed charges 59.52 91.2 Technical (Hospital) Services HC/HH Wch Supp Bag Resuscitation Man Infant__2k8038 PX-2705000022 CDM 2705000022 LOCAL 270 RC outpatient 96 96 UNITED HEALTHCARE (COMMERCIAL) [3081199] UNITED HEALTHCARE 87726 [308119901] 59.52 percent of total billed charges 59.52 91.2 Technical (Hospital) Services HC/HH Wch Supp Bag Resuscitation Man Infant__2k8038 PX-2705000022 CDM 2705000022 LOCAL 270 RC outpatient 96 96 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES HDHP [308136802] 76.8 percent of total billed charges 59.52 91.2 Technical (Hospital) Services HC/HH Wch Supp Bag Resuscitation Man Infant__2k8038 PX-2705000022 CDM 2705000022 LOCAL 270 RC outpatient 96 96 BLUE CROSS BLUE SHIELD WELLMARK SB889 [3081026] BCBS WYOMING [308102603] 91.2 percent of total billed charges 59.52 91.2 Technical (Hospital) Services HC/HH Wch Supp Bag Resuscitation Man Infant__2k8038 PX-2705000022 CDM 2705000022 LOCAL 270 RC outpatient 96 96 CIGNA 62308 [3081051] CIGNA 62308 [308105105] 76.8 percent of total billed charges 59.52 91.2 Technical (Hospital) Services HC/HH Wch Supp Bag Resuscitation Man Infant__2k8038 PX-2705000022 CDM 2705000022 LOCAL 270 RC outpatient 96 96 CIGNA 62308 [3081051] CIGNA STATE OF WYOMING [308105107] 76.8 percent of total billed charges 59.52 91.2 Technical (Hospital) Services HC/HH Wch Supp Bag Resuscitation Man Infant__2k8038 PX-2705000022 CDM 2705000022 LOCAL 270 RC outpatient 96 96 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES EPO [308136803] 76.8 percent of total billed charges 59.52 91.2 Technical (Hospital) Services HC/HH Wch Supp Bag Resuscitation Man Infant__2k8038 PX-2705000022 CDM 2705000022 LOCAL 270 RC outpatient 96 96 MEDICA (COMMERCIAL) 94265 [3081118] MEDICA CLAIMS [308111801] 86.4 percent of total billed charges 59.52 91.2 Technical (Hospital) Services HC/HH Wch Supp Bag Resuscitation Man Infant__2k8038 PX-2705000022 CDM 2705000022 LOCAL 270 RC outpatient 96 96 MULTIPLAN INC 34080 [3081285] MULTIPLAN INC [308128501] 91.2 percent of total billed charges 59.52 91.2 Technical (Hospital) Services HC/HH Wch Supp Bag Resuscitation Man Adult__2k8005 PX-2705000021 CDM 2705000021 LOCAL 270 RC inpatient 100 100 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES EPO [308136803] 79.18 percent of total billed charges 62 95 Technical (Hospital) Services HC/HH Wch Supp Bag Resuscitation Man Adult__2k8005 PX-2705000021 CDM 2705000021 LOCAL 270 RC inpatient 100 100 HEALTHPARTNERS SX009 HEALTHPARTNERS 79.18 percent of total billed charges 62 95 Technical (Hospital) Services HC/HH Wch Supp Bag Resuscitation Man Adult__2k8005 PX-2705000021 CDM 2705000021 LOCAL 270 RC inpatient 100 100 MULTIPLAN INC 34080 [3081285] MULTIPLAN INC [308128501] 95 percent of total billed charges 62 95 Technical (Hospital) Services HC/HH Wch Supp Bag Resuscitation Man Adult__2k8005 PX-2705000021 CDM 2705000021 LOCAL 270 RC inpatient 100 100 BLUE CROSS BLUE SHIELD WELLMARK SB889 [3081026] BCBS WYOMING [308102603] 95 percent of total billed charges 62 95 Technical (Hospital) Services HC/HH Wch Supp Bag Resuscitation Man Adult__2k8005 PX-2705000021 CDM 2705000021 LOCAL 270 RC inpatient 100 100 CIGNA 62308 [3081051] CIGNA 62308 [308105105] 79.18 percent of total billed charges 62 95 Technical (Hospital) Services HC/HH Wch Supp Bag Resuscitation Man Adult__2k8005 PX-2705000021 CDM 2705000021 LOCAL 270 RC inpatient 100 100 CIGNA 62308 [3081051] CIGNA STATE OF WYOMING [308105107] 79.18 percent of total billed charges 62 95 Technical (Hospital) Services HC/HH Wch Supp Bag Resuscitation Man Adult__2k8005 PX-2705000021 CDM 2705000021 LOCAL 270 RC inpatient 100 100 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES PPO [308136801] 79.18 percent of total billed charges 62 95 Technical (Hospital) Services HC/HH Wch Supp Bag Resuscitation Man Adult__2k8005 PX-2705000021 CDM 2705000021 LOCAL 270 RC inpatient 100 100 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES HDHP [308136802] 79.18 percent of total billed charges 62 95 Technical (Hospital) Services HC/HH Wch Supp Bag Resuscitation Man Adult__2k8005 PX-2705000021 CDM 2705000021 LOCAL 270 RC inpatient 100 100 UNITED HEALTHCARE (COMMERCIAL) [3081199] UNITED HEALTHCARE 87726 [308119901] 62 percent of total billed charges 62 95 Technical (Hospital) Services HC/HH Wch Supp Bag Resuscitation Man Adult__2k8005 PX-2705000021 CDM 2705000021 LOCAL 270 RC inpatient 100 100 MEDICA (COMMERCIAL) 94265 [3081118] MEDICA CLAIMS [308111801] 90 percent of total billed charges 62 95 Technical (Hospital) Services HC/HH Wch Supp Bag Resuscitation Man Adult__2k8005 PX-2705000021 CDM 2705000021 LOCAL 270 RC outpatient 100 100 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES HDHP [308136802] 80 percent of total billed charges 62 95 Technical (Hospital) Services HC/HH Wch Supp Bag Resuscitation Man Adult__2k8005 PX-2705000021 CDM 2705000021 LOCAL 270 RC outpatient 100 100 BLUE CROSS BLUE SHIELD WELLMARK SB889 [3081026] BCBS WYOMING [308102603] 95 percent of total billed charges 62 95 Technical (Hospital) Services HC/HH Wch Supp Bag Resuscitation Man Adult__2k8005 PX-2705000021 CDM 2705000021 LOCAL 270 RC outpatient 100 100 CIGNA 62308 [3081051] CIGNA 62308 [308105105] 80 percent of total billed charges 62 95 Technical (Hospital) Services HC/HH Wch Supp Bag Resuscitation Man Adult__2k8005 PX-2705000021 CDM 2705000021 LOCAL 270 RC outpatient 100 100 CIGNA 62308 [3081051] CIGNA STATE OF WYOMING [308105107] 80 percent of total billed charges 62 95 Technical (Hospital) Services HC/HH Wch Supp Bag Resuscitation Man Adult__2k8005 PX-2705000021 CDM 2705000021 LOCAL 270 RC outpatient 100 100 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES EPO [308136803] 80 percent of total billed charges 62 95 Technical (Hospital) Services HC/HH Wch Supp Bag Resuscitation Man Adult__2k8005 PX-2705000021 CDM 2705000021 LOCAL 270 RC outpatient 100 100 UNITED HEALTHCARE (COMMERCIAL) [3081199] UNITED HEALTHCARE 87726 [308119901] 62 percent of total billed charges 62 95 Technical (Hospital) Services HC/HH Wch Supp Bag Resuscitation Man Adult__2k8005 PX-2705000021 CDM 2705000021 LOCAL 270 RC outpatient 100 100 HEALTHPARTNERS SX009 HEALTHPARTNERS 80 percent of total billed charges 62 95 Technical (Hospital) Services HC/HH Wch Supp Bag Resuscitation Man Adult__2k8005 PX-2705000021 CDM 2705000021 LOCAL 270 RC outpatient 100 100 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES PPO [308136801] 80 percent of total billed charges 62 95 Technical (Hospital) Services HC/HH Wch Supp Bag Resuscitation Man Adult__2k8005 PX-2705000021 CDM 2705000021 LOCAL 270 RC outpatient 100 100 MEDICA (COMMERCIAL) 94265 [3081118] MEDICA CLAIMS [308111801] 90 percent of total billed charges 62 95 Technical (Hospital) Services HC/HH Wch Supp Bag Resuscitation Man Adult__2k8005 PX-2705000021 CDM 2705000021 LOCAL 270 RC outpatient 100 100 MULTIPLAN INC 34080 [3081285] MULTIPLAN INC [308128501] 95 percent of total billed charges 62 95 Technical (Hospital) Services HC/HH Wch Supp Athletic Support-Sma__202460 PX-2705000020 CDM 2705000020 LOCAL 270 RC outpatient 38 38 MEDICA (COMMERCIAL) 94265 [3081118] MEDICA CLAIMS [308111801] 34.2 percent of total billed charges 23.56 36.1 Technical (Hospital) Services HC/HH Wch Supp Athletic Support-Sma__202460 PX-2705000020 CDM 2705000020 LOCAL 270 RC outpatient 38 38 MULTIPLAN INC 34080 [3081285] MULTIPLAN INC [308128501] 36.1 percent of total billed charges 23.56 36.1 Technical (Hospital) Services HC/HH Wch Supp Athletic Support-Sma__202460 PX-2705000020 CDM 2705000020 LOCAL 270 RC outpatient 38 38 UNITED HEALTHCARE (COMMERCIAL) [3081199] UNITED HEALTHCARE 87726 [308119901] 23.56 percent of total billed charges 23.56 36.1 Technical (Hospital) Services HC/HH Wch Supp Athletic Support-Sma__202460 PX-2705000020 CDM 2705000020 LOCAL 270 RC outpatient 38 38 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES PPO [308136801] 30.4 percent of total billed charges 23.56 36.1 Technical (Hospital) Services HC/HH Wch Supp Athletic Support-Sma__202460 PX-2705000020 CDM 2705000020 LOCAL 270 RC outpatient 38 38 HEALTHPARTNERS SX009 HEALTHPARTNERS 30.4 percent of total billed charges 23.56 36.1 Technical (Hospital) Services HC/HH Wch Supp Athletic Support-Sma__202460 PX-2705000020 CDM 2705000020 LOCAL 270 RC outpatient 38 38 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES EPO [308136803] 30.4 percent of total billed charges 23.56 36.1 Technical (Hospital) Services HC/HH Wch Supp Athletic Support-Sma__202460 PX-2705000020 CDM 2705000020 LOCAL 270 RC outpatient 38 38 CIGNA 62308 [3081051] CIGNA 62308 [308105105] 30.4 percent of total billed charges 23.56 36.1 Technical (Hospital) Services HC/HH Wch Supp Athletic Support-Sma__202460 PX-2705000020 CDM 2705000020 LOCAL 270 RC outpatient 38 38 CIGNA 62308 [3081051] CIGNA STATE OF WYOMING [308105107] 30.4 percent of total billed charges 23.56 36.1 Technical (Hospital) Services HC/HH Wch Supp Athletic Support-Sma__202460 PX-2705000020 CDM 2705000020 LOCAL 270 RC outpatient 38 38 BLUE CROSS BLUE SHIELD WELLMARK SB889 [3081026] BCBS WYOMING [308102603] 36.1 percent of total billed charges 23.56 36.1 Technical (Hospital) Services HC/HH Wch Supp Athletic Support-Sma__202460 PX-2705000020 CDM 2705000020 LOCAL 270 RC outpatient 38 38 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES HDHP [308136802] 30.4 percent of total billed charges 23.56 36.1 Technical (Hospital) Services HC/HH Wch Supp Athletic Support-Sma__202460 PX-2705000020 CDM 2705000020 LOCAL 270 RC inpatient 38 38 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES PPO [308136801] 30.09 percent of total billed charges 23.56 36.1 Technical (Hospital) Services HC/HH Wch Supp Athletic Support-Sma__202460 PX-2705000020 CDM 2705000020 LOCAL 270 RC inpatient 38 38 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES HDHP [308136802] 30.09 percent of total billed charges 23.56 36.1 Technical (Hospital) Services HC/HH Wch Supp Athletic Support-Sma__202460 PX-2705000020 CDM 2705000020 LOCAL 270 RC inpatient 38 38 UNITED HEALTHCARE (COMMERCIAL) [3081199] UNITED HEALTHCARE 87726 [308119901] 23.56 percent of total billed charges 23.56 36.1 Technical (Hospital) Services HC/HH Wch Supp Athletic Support-Sma__202460 PX-2705000020 CDM 2705000020 LOCAL 270 RC inpatient 38 38 MEDICA (COMMERCIAL) 94265 [3081118] MEDICA CLAIMS [308111801] 34.2 percent of total billed charges 23.56 36.1 Technical (Hospital) Services HC/HH Wch Supp Athletic Support-Sma__202460 PX-2705000020 CDM 2705000020 LOCAL 270 RC inpatient 38 38 BLUE CROSS BLUE SHIELD WELLMARK SB889 [3081026] BCBS WYOMING [308102603] 36.1 percent of total billed charges 23.56 36.1 Technical (Hospital) Services HC/HH Wch Supp Athletic Support-Sma__202460 PX-2705000020 CDM 2705000020 LOCAL 270 RC inpatient 38 38 MULTIPLAN INC 34080 [3081285] MULTIPLAN INC [308128501] 36.1 percent of total billed charges 23.56 36.1 Technical (Hospital) Services HC/HH Wch Supp Athletic Support-Sma__202460 PX-2705000020 CDM 2705000020 LOCAL 270 RC inpatient 38 38 CIGNA 62308 [3081051] CIGNA 62308 [308105105] 30.09 percent of total billed charges 23.56 36.1 Technical (Hospital) Services HC/HH Wch Supp Athletic Support-Sma__202460 PX-2705000020 CDM 2705000020 LOCAL 270 RC inpatient 38 38 CIGNA 62308 [3081051] CIGNA STATE OF WYOMING [308105107] 30.09 percent of total billed charges 23.56 36.1 Technical (Hospital) Services HC/HH Wch Supp Athletic Support-Sma__202460 PX-2705000020 CDM 2705000020 LOCAL 270 RC inpatient 38 38 HEALTHPARTNERS SX009 HEALTHPARTNERS 30.09 percent of total billed charges 23.56 36.1 Technical (Hospital) Services HC/HH Wch Supp Athletic Support-Sma__202460 PX-2705000020 CDM 2705000020 LOCAL 270 RC inpatient 38 38 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES EPO [308136803] 30.09 percent of total billed charges 23.56 36.1 Technical (Hospital) Services HC/HH Wch Supp Athletic Support M__202549 PX-2705000019 CDM 2705000019 LOCAL 270 RC inpatient 26 26 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES PPO [308136801] 20.59 percent of total billed charges 16.12 24.7 Technical (Hospital) Services HC/HH Wch Supp Athletic Support M__202549 PX-2705000019 CDM 2705000019 LOCAL 270 RC inpatient 26 26 UNITED HEALTHCARE (COMMERCIAL) [3081199] UNITED HEALTHCARE 87726 [308119901] 16.12 percent of total billed charges 16.12 24.7 Technical (Hospital) Services HC/HH Wch Supp Athletic Support M__202549 PX-2705000019 CDM 2705000019 LOCAL 270 RC inpatient 26 26 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES HDHP [308136802] 20.59 percent of total billed charges 16.12 24.7 Technical (Hospital) Services HC/HH Wch Supp Athletic Support M__202549 PX-2705000019 CDM 2705000019 LOCAL 270 RC inpatient 26 26 MEDICA (COMMERCIAL) 94265 [3081118] MEDICA CLAIMS [308111801] 23.4 percent of total billed charges 16.12 24.7 Technical (Hospital) Services HC/HH Wch Supp Athletic Support M__202549 PX-2705000019 CDM 2705000019 LOCAL 270 RC inpatient 26 26 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES EPO [308136803] 20.59 percent of total billed charges 16.12 24.7 Technical (Hospital) Services HC/HH Wch Supp Athletic Support M__202549 PX-2705000019 CDM 2705000019 LOCAL 270 RC inpatient 26 26 HEALTHPARTNERS SX009 HEALTHPARTNERS 20.59 percent of total billed charges 16.12 24.7 Technical (Hospital) Services HC/HH Wch Supp Athletic Support M__202549 PX-2705000019 CDM 2705000019 LOCAL 270 RC inpatient 26 26 BLUE CROSS BLUE SHIELD WELLMARK SB889 [3081026] BCBS WYOMING [308102603] 24.7 percent of total billed charges 16.12 24.7 Technical (Hospital) Services HC/HH Wch Supp Athletic Support M__202549 PX-2705000019 CDM 2705000019 LOCAL 270 RC inpatient 26 26 MULTIPLAN INC 34080 [3081285] MULTIPLAN INC [308128501] 24.7 percent of total billed charges 16.12 24.7 Technical (Hospital) Services HC/HH Wch Supp Athletic Support M__202549 PX-2705000019 CDM 2705000019 LOCAL 270 RC inpatient 26 26 CIGNA 62308 [3081051] CIGNA 62308 [308105105] 20.59 percent of total billed charges 16.12 24.7 Technical (Hospital) Services HC/HH Wch Supp Athletic Support M__202549 PX-2705000019 CDM 2705000019 LOCAL 270 RC inpatient 26 26 CIGNA 62308 [3081051] CIGNA STATE OF WYOMING [308105107] 20.59 percent of total billed charges 16.12 24.7 Technical (Hospital) Services HC/HH Wch Supp Athletic Support M__202549 PX-2705000019 CDM 2705000019 LOCAL 270 RC outpatient 26 26 MEDICA (COMMERCIAL) 94265 [3081118] MEDICA CLAIMS [308111801] 23.4 percent of total billed charges 16.12 24.7 Technical (Hospital) Services HC/HH Wch Supp Athletic Support M__202549 PX-2705000019 CDM 2705000019 LOCAL 270 RC outpatient 26 26 MULTIPLAN INC 34080 [3081285] MULTIPLAN INC [308128501] 24.7 percent of total billed charges 16.12 24.7 Technical (Hospital) Services HC/HH Wch Supp Athletic Support M__202549 PX-2705000019 CDM 2705000019 LOCAL 270 RC outpatient 26 26 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES PPO [308136801] 20.8 percent of total billed charges 16.12 24.7 Technical (Hospital) Services HC/HH Wch Supp Athletic Support M__202549 PX-2705000019 CDM 2705000019 LOCAL 270 RC outpatient 26 26 HEALTHPARTNERS SX009 HEALTHPARTNERS 20.8 percent of total billed charges 16.12 24.7 Technical (Hospital) Services HC/HH Wch Supp Athletic Support M__202549 PX-2705000019 CDM 2705000019 LOCAL 270 RC outpatient 26 26 UNITED HEALTHCARE (COMMERCIAL) [3081199] UNITED HEALTHCARE 87726 [308119901] 16.12 percent of total billed charges 16.12 24.7 Technical (Hospital) Services HC/HH Wch Supp Athletic Support M__202549 PX-2705000019 CDM 2705000019 LOCAL 270 RC outpatient 26 26 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES EPO [308136803] 20.8 percent of total billed charges 16.12 24.7 Technical (Hospital) Services HC/HH Wch Supp Athletic Support M__202549 PX-2705000019 CDM 2705000019 LOCAL 270 RC outpatient 26 26 BLUE CROSS BLUE SHIELD WELLMARK SB889 [3081026] BCBS WYOMING [308102603] 24.7 percent of total billed charges 16.12 24.7 Technical (Hospital) Services HC/HH Wch Supp Athletic Support M__202549 PX-2705000019 CDM 2705000019 LOCAL 270 RC outpatient 26 26 CIGNA 62308 [3081051] CIGNA 62308 [308105105] 20.8 percent of total billed charges 16.12 24.7 Technical (Hospital) Services HC/HH Wch Supp Athletic Support M__202549 PX-2705000019 CDM 2705000019 LOCAL 270 RC outpatient 26 26 CIGNA 62308 [3081051] CIGNA STATE OF WYOMING [308105107] 20.8 percent of total billed charges 16.12 24.7 Technical (Hospital) Services HC/HH Wch Supp Athletic Support M__202549 PX-2705000019 CDM 2705000019 LOCAL 270 RC outpatient 26 26 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES HDHP [308136802] 20.8 percent of total billed charges 16.12 24.7 Technical (Hospital) Services HC/HH Wch Supp Athletic Support L__202636 PX-2705000018 CDM 2705000018 LOCAL 270 RC outpatient 26 26 UNITED HEALTHCARE (COMMERCIAL) [3081199] UNITED HEALTHCARE 87726 [308119901] 16.12 percent of total billed charges 16.12 24.7 Technical (Hospital) Services HC/HH Wch Supp Athletic Support L__202636 PX-2705000018 CDM 2705000018 LOCAL 270 RC outpatient 26 26 HEALTHPARTNERS SX009 HEALTHPARTNERS 20.8 percent of total billed charges 16.12 24.7 Technical (Hospital) Services HC/HH Wch Supp Athletic Support L__202636 PX-2705000018 CDM 2705000018 LOCAL 270 RC outpatient 26 26 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES PPO [308136801] 20.8 percent of total billed charges 16.12 24.7 Technical (Hospital) Services HC/HH Wch Supp Athletic Support L__202636 PX-2705000018 CDM 2705000018 LOCAL 270 RC outpatient 26 26 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES HDHP [308136802] 20.8 percent of total billed charges 16.12 24.7 Technical (Hospital) Services HC/HH Wch Supp Athletic Support L__202636 PX-2705000018 CDM 2705000018 LOCAL 270 RC outpatient 26 26 BLUE CROSS BLUE SHIELD WELLMARK SB889 [3081026] BCBS WYOMING [308102603] 24.7 percent of total billed charges 16.12 24.7 Technical (Hospital) Services HC/HH Wch Supp Athletic Support L__202636 PX-2705000018 CDM 2705000018 LOCAL 270 RC outpatient 26 26 CIGNA 62308 [3081051] CIGNA 62308 [308105105] 20.8 percent of total billed charges 16.12 24.7 Technical (Hospital) Services HC/HH Wch Supp Athletic Support L__202636 PX-2705000018 CDM 2705000018 LOCAL 270 RC outpatient 26 26 CIGNA 62308 [3081051] CIGNA STATE OF WYOMING [308105107] 20.8 percent of total billed charges 16.12 24.7 Technical (Hospital) Services HC/HH Wch Supp Athletic Support L__202636 PX-2705000018 CDM 2705000018 LOCAL 270 RC outpatient 26 26 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES EPO [308136803] 20.8 percent of total billed charges 16.12 24.7 Technical (Hospital) Services HC/HH Wch Supp Athletic Support L__202636 PX-2705000018 CDM 2705000018 LOCAL 270 RC outpatient 26 26 MULTIPLAN INC 34080 [3081285] MULTIPLAN INC [308128501] 24.7 percent of total billed charges 16.12 24.7 Technical (Hospital) Services HC/HH Wch Supp Athletic Support L__202636 PX-2705000018 CDM 2705000018 LOCAL 270 RC outpatient 26 26 MEDICA (COMMERCIAL) 94265 [3081118] MEDICA CLAIMS [308111801] 23.4 percent of total billed charges 16.12 24.7 Technical (Hospital) Services HC/HH Wch Supp Athletic Support L__202636 PX-2705000018 CDM 2705000018 LOCAL 270 RC inpatient 26 26 MEDICA (COMMERCIAL) 94265 [3081118] MEDICA CLAIMS [308111801] 23.4 percent of total billed charges 16.12 24.7 Technical (Hospital) Services HC/HH Wch Supp Athletic Support L__202636 PX-2705000018 CDM 2705000018 LOCAL 270 RC inpatient 26 26 UNITED HEALTHCARE (COMMERCIAL) [3081199] UNITED HEALTHCARE 87726 [308119901] 16.12 percent of total billed charges 16.12 24.7 Technical (Hospital) Services HC/HH Wch Supp Athletic Support L__202636 PX-2705000018 CDM 2705000018 LOCAL 270 RC inpatient 26 26 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES HDHP [308136802] 20.59 percent of total billed charges 16.12 24.7 Technical (Hospital) Services HC/HH Wch Supp Athletic Support L__202636 PX-2705000018 CDM 2705000018 LOCAL 270 RC inpatient 26 26 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES PPO [308136801] 20.59 percent of total billed charges 16.12 24.7 Technical (Hospital) Services HC/HH Wch Supp Athletic Support L__202636 PX-2705000018 CDM 2705000018 LOCAL 270 RC inpatient 26 26 BLUE CROSS BLUE SHIELD WELLMARK SB889 [3081026] BCBS WYOMING [308102603] 24.7 percent of total billed charges 16.12 24.7 Technical (Hospital) Services HC/HH Wch Supp Athletic Support L__202636 PX-2705000018 CDM 2705000018 LOCAL 270 RC inpatient 26 26 MULTIPLAN INC 34080 [3081285] MULTIPLAN INC [308128501] 24.7 percent of total billed charges 16.12 24.7 Technical (Hospital) Services HC/HH Wch Supp Athletic Support L__202636 PX-2705000018 CDM 2705000018 LOCAL 270 RC inpatient 26 26 CIGNA 62308 [3081051] CIGNA 62308 [308105105] 20.59 percent of total billed charges 16.12 24.7 Technical (Hospital) Services HC/HH Wch Supp Athletic Support L__202636 PX-2705000018 CDM 2705000018 LOCAL 270 RC inpatient 26 26 CIGNA 62308 [3081051] CIGNA STATE OF WYOMING [308105107] 20.59 percent of total billed charges 16.12 24.7 Technical (Hospital) Services HC/HH Wch Supp Athletic Support L__202636 PX-2705000018 CDM 2705000018 LOCAL 270 RC inpatient 26 26 HEALTHPARTNERS SX009 HEALTHPARTNERS 20.59 percent of total billed charges 16.12 24.7 Technical (Hospital) Services HC/HH Wch Supp Athletic Support L__202636 PX-2705000018 CDM 2705000018 LOCAL 270 RC inpatient 26 26 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES EPO [308136803] 20.59 percent of total billed charges 16.12 24.7 Technical (Hospital) Services HC/HH Wch Supp Arm Sling Envelope Style S__0814-0062 PX-2705000017 CDM 2705000017 LOCAL 270 RC inpatient 30 30 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES EPO [308136803] 23.75 percent of total billed charges 18.6 28.5 Technical (Hospital) Services HC/HH Wch Supp Arm Sling Envelope Style S__0814-0062 PX-2705000017 CDM 2705000017 LOCAL 270 RC inpatient 30 30 HEALTHPARTNERS SX009 HEALTHPARTNERS 23.75 percent of total billed charges 18.6 28.5 Technical (Hospital) Services HC/HH Wch Supp Arm Sling Envelope Style S__0814-0062 PX-2705000017 CDM 2705000017 LOCAL 270 RC inpatient 30 30 BLUE CROSS BLUE SHIELD WELLMARK SB889 [3081026] BCBS WYOMING [308102603] 28.5 percent of total billed charges 18.6 28.5 Technical (Hospital) Services HC/HH Wch Supp Arm Sling Envelope Style S__0814-0062 PX-2705000017 CDM 2705000017 LOCAL 270 RC inpatient 30 30 CIGNA 62308 [3081051] CIGNA 62308 [308105105] 23.75 percent of total billed charges 18.6 28.5 Technical (Hospital) Services HC/HH Wch Supp Arm Sling Envelope Style S__0814-0062 PX-2705000017 CDM 2705000017 LOCAL 270 RC inpatient 30 30 CIGNA 62308 [3081051] CIGNA STATE OF WYOMING [308105107] 23.75 percent of total billed charges 18.6 28.5 Technical (Hospital) Services HC/HH Wch Supp Arm Sling Envelope Style S__0814-0062 PX-2705000017 CDM 2705000017 LOCAL 270 RC inpatient 30 30 MULTIPLAN INC 34080 [3081285] MULTIPLAN INC [308128501] 28.5 percent of total billed charges 18.6 28.5 Technical (Hospital) Services HC/HH Wch Supp Arm Sling Envelope Style S__0814-0062 PX-2705000017 CDM 2705000017 LOCAL 270 RC inpatient 30 30 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES PPO [308136801] 23.75 percent of total billed charges 18.6 28.5 Technical (Hospital) Services HC/HH Wch Supp Arm Sling Envelope Style S__0814-0062 PX-2705000017 CDM 2705000017 LOCAL 270 RC inpatient 30 30 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES HDHP [308136802] 23.75 percent of total billed charges 18.6 28.5 Technical (Hospital) Services HC/HH Wch Supp Arm Sling Envelope Style S__0814-0062 PX-2705000017 CDM 2705000017 LOCAL 270 RC inpatient 30 30 UNITED HEALTHCARE (COMMERCIAL) [3081199] UNITED HEALTHCARE 87726 [308119901] 18.6 percent of total billed charges 18.6 28.5 Technical (Hospital) Services HC/HH Wch Supp Arm Sling Envelope Style S__0814-0062 PX-2705000017 CDM 2705000017 LOCAL 270 RC inpatient 30 30 MEDICA (COMMERCIAL) 94265 [3081118] MEDICA CLAIMS [308111801] 27 percent of total billed charges 18.6 28.5 Technical (Hospital) Services HC/HH Wch Supp Arm Sling Envelope Style S__0814-0062 PX-2705000017 CDM 2705000017 LOCAL 270 RC outpatient 30 30 BLUE CROSS BLUE SHIELD WELLMARK SB889 [3081026] BCBS WYOMING [308102603] 28.5 percent of total billed charges 18.6 28.5 Technical (Hospital) Services HC/HH Wch Supp Arm Sling Envelope Style S__0814-0062 PX-2705000017 CDM 2705000017 LOCAL 270 RC outpatient 30 30 CIGNA 62308 [3081051] CIGNA 62308 [308105105] 24 percent of total billed charges 18.6 28.5 Technical (Hospital) Services HC/HH Wch Supp Arm Sling Envelope Style S__0814-0062 PX-2705000017 CDM 2705000017 LOCAL 270 RC outpatient 30 30 CIGNA 62308 [3081051] CIGNA STATE OF WYOMING [308105107] 24 percent of total billed charges 18.6 28.5 Technical (Hospital) Services HC/HH Wch Supp Arm Sling Envelope Style S__0814-0062 PX-2705000017 CDM 2705000017 LOCAL 270 RC outpatient 30 30 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES EPO [308136803] 24 percent of total billed charges 18.6 28.5 Technical (Hospital) Services HC/HH Wch Supp Arm Sling Envelope Style S__0814-0062 PX-2705000017 CDM 2705000017 LOCAL 270 RC outpatient 30 30 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES HDHP [308136802] 24 percent of total billed charges 18.6 28.5 Technical (Hospital) Services HC/HH Wch Supp Arm Sling Envelope Style S__0814-0062 PX-2705000017 CDM 2705000017 LOCAL 270 RC outpatient 30 30 HEALTHPARTNERS SX009 HEALTHPARTNERS 24 percent of total billed charges 18.6 28.5 Technical (Hospital) Services HC/HH Wch Supp Arm Sling Envelope Style S__0814-0062 PX-2705000017 CDM 2705000017 LOCAL 270 RC outpatient 30 30 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES PPO [308136801] 24 percent of total billed charges 18.6 28.5 Technical (Hospital) Services HC/HH Wch Supp Arm Sling Envelope Style S__0814-0062 PX-2705000017 CDM 2705000017 LOCAL 270 RC outpatient 30 30 UNITED HEALTHCARE (COMMERCIAL) [3081199] UNITED HEALTHCARE 87726 [308119901] 18.6 percent of total billed charges 18.6 28.5 Technical (Hospital) Services HC/HH Wch Supp Arm Sling Envelope Style S__0814-0062 PX-2705000017 CDM 2705000017 LOCAL 270 RC outpatient 30 30 MULTIPLAN INC 34080 [3081285] MULTIPLAN INC [308128501] 28.5 percent of total billed charges 18.6 28.5 Technical (Hospital) Services HC/HH Wch Supp Arm Sling Envelope Style S__0814-0062 PX-2705000017 CDM 2705000017 LOCAL 270 RC outpatient 30 30 MEDICA (COMMERCIAL) 94265 [3081118] MEDICA CLAIMS [308111801] 27 percent of total billed charges 18.6 28.5 Technical (Hospital) Services HC/HH Wch Supp Arm Sling Adult Universal__8140015 PX-2705000016 CDM 2705000016 LOCAL 270 RC inpatient 32 32 MEDICA (COMMERCIAL) 94265 [3081118] MEDICA CLAIMS [308111801] 28.8 percent of total billed charges 19.84 30.4 Technical (Hospital) Services HC/HH Wch Supp Arm Sling Adult Universal__8140015 PX-2705000016 CDM 2705000016 LOCAL 270 RC inpatient 32 32 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES HDHP [308136802] 25.34 percent of total billed charges 19.84 30.4 Technical (Hospital) Services HC/HH Wch Supp Arm Sling Adult Universal__8140015 PX-2705000016 CDM 2705000016 LOCAL 270 RC inpatient 32 32 UNITED HEALTHCARE (COMMERCIAL) [3081199] UNITED HEALTHCARE 87726 [308119901] 19.84 percent of total billed charges 19.84 30.4 Technical (Hospital) Services HC/HH Wch Supp Arm Sling Adult Universal__8140015 PX-2705000016 CDM 2705000016 LOCAL 270 RC inpatient 32 32 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES PPO [308136801] 25.34 percent of total billed charges 19.84 30.4 Technical (Hospital) Services HC/HH Wch Supp Arm Sling Adult Universal__8140015 PX-2705000016 CDM 2705000016 LOCAL 270 RC inpatient 32 32 HEALTHPARTNERS SX009 HEALTHPARTNERS 25.34 percent of total billed charges 19.84 30.4 Technical (Hospital) Services HC/HH Wch Supp Arm Sling Adult Universal__8140015 PX-2705000016 CDM 2705000016 LOCAL 270 RC inpatient 32 32 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES EPO [308136803] 25.34 percent of total billed charges 19.84 30.4 Technical (Hospital) Services HC/HH Wch Supp Arm Sling Adult Universal__8140015 PX-2705000016 CDM 2705000016 LOCAL 270 RC inpatient 32 32 CIGNA 62308 [3081051] CIGNA 62308 [308105105] 25.34 percent of total billed charges 19.84 30.4 Technical (Hospital) Services HC/HH Wch Supp Arm Sling Adult Universal__8140015 PX-2705000016 CDM 2705000016 LOCAL 270 RC inpatient 32 32 CIGNA 62308 [3081051] CIGNA STATE OF WYOMING [308105107] 25.34 percent of total billed charges 19.84 30.4 Technical (Hospital) Services HC/HH Wch Supp Arm Sling Adult Universal__8140015 PX-2705000016 CDM 2705000016 LOCAL 270 RC inpatient 32 32 MULTIPLAN INC 34080 [3081285] MULTIPLAN INC [308128501] 30.4 percent of total billed charges 19.84 30.4 Technical (Hospital) Services HC/HH Wch Supp Arm Sling Adult Universal__8140015 PX-2705000016 CDM 2705000016 LOCAL 270 RC inpatient 32 32 BLUE CROSS BLUE SHIELD WELLMARK SB889 [3081026] BCBS WYOMING [308102603] 30.4 percent of total billed charges 19.84 30.4 Technical (Hospital) Services HC/HH Wch Supp Arm Sling Adult Universal__8140015 PX-2705000016 CDM 2705000016 LOCAL 270 RC outpatient 32 32 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES HDHP [308136802] 25.6 percent of total billed charges 19.84 30.4 Technical (Hospital) Services HC/HH Wch Supp Arm Sling Adult Universal__8140015 PX-2705000016 CDM 2705000016 LOCAL 270 RC outpatient 32 32 BLUE CROSS BLUE SHIELD WELLMARK SB889 [3081026] BCBS WYOMING [308102603] 30.4 percent of total billed charges 19.84 30.4 Technical (Hospital) Services HC/HH Wch Supp Arm Sling Adult Universal__8140015 PX-2705000016 CDM 2705000016 LOCAL 270 RC outpatient 32 32 CIGNA 62308 [3081051] CIGNA 62308 [308105105] 25.6 percent of total billed charges 19.84 30.4 Technical (Hospital) Services HC/HH Wch Supp Arm Sling Adult Universal__8140015 PX-2705000016 CDM 2705000016 LOCAL 270 RC outpatient 32 32 CIGNA 62308 [3081051] CIGNA STATE OF WYOMING [308105107] 25.6 percent of total billed charges 19.84 30.4 Technical (Hospital) Services HC/HH Wch Supp Arm Sling Adult Universal__8140015 PX-2705000016 CDM 2705000016 LOCAL 270 RC outpatient 32 32 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES EPO [308136803] 25.6 percent of total billed charges 19.84 30.4 Technical (Hospital) Services HC/HH Wch Supp Arm Sling Adult Universal__8140015 PX-2705000016 CDM 2705000016 LOCAL 270 RC outpatient 32 32 HEALTHPARTNERS SX009 HEALTHPARTNERS 25.6 percent of total billed charges 19.84 30.4 Technical (Hospital) Services HC/HH Wch Supp Arm Sling Adult Universal__8140015 PX-2705000016 CDM 2705000016 LOCAL 270 RC outpatient 32 32 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES PPO [308136801] 25.6 percent of total billed charges 19.84 30.4 Technical (Hospital) Services HC/HH Wch Supp Arm Sling Adult Universal__8140015 PX-2705000016 CDM 2705000016 LOCAL 270 RC outpatient 32 32 UNITED HEALTHCARE (COMMERCIAL) [3081199] UNITED HEALTHCARE 87726 [308119901] 19.84 percent of total billed charges 19.84 30.4 Technical (Hospital) Services HC/HH Wch Supp Arm Sling Adult Universal__8140015 PX-2705000016 CDM 2705000016 LOCAL 270 RC outpatient 32 32 MULTIPLAN INC 34080 [3081285] MULTIPLAN INC [308128501] 30.4 percent of total billed charges 19.84 30.4 Technical (Hospital) Services HC/HH Wch Supp Arm Sling Adult Universal__8140015 PX-2705000016 CDM 2705000016 LOCAL 270 RC outpatient 32 32 MEDICA (COMMERCIAL) 94265 [3081118] MEDICA CLAIMS [308111801] 28.8 percent of total billed charges 19.84 30.4 Technical (Hospital) Services HC/HH Wch Supp Aquacel Silver 4x4__403765 PX-2705000015 CDM 2705000015 LOCAL 270 RC inpatient 28 28 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES EPO [308136803] 22.17 percent of total billed charges 17.36 26.6 Technical (Hospital) Services HC/HH Wch Supp Aquacel Silver 4x4__403765 PX-2705000015 CDM 2705000015 LOCAL 270 RC inpatient 28 28 HEALTHPARTNERS SX009 HEALTHPARTNERS 22.17 percent of total billed charges 17.36 26.6 Technical (Hospital) Services HC/HH Wch Supp Aquacel Silver 4x4__403765 PX-2705000015 CDM 2705000015 LOCAL 270 RC inpatient 28 28 CIGNA 62308 [3081051] CIGNA 62308 [308105105] 22.17 percent of total billed charges 17.36 26.6 Technical (Hospital) Services HC/HH Wch Supp Aquacel Silver 4x4__403765 PX-2705000015 CDM 2705000015 LOCAL 270 RC inpatient 28 28 CIGNA 62308 [3081051] CIGNA STATE OF WYOMING [308105107] 22.17 percent of total billed charges 17.36 26.6 Technical (Hospital) Services HC/HH Wch Supp Aquacel Silver 4x4__403765 PX-2705000015 CDM 2705000015 LOCAL 270 RC inpatient 28 28 MULTIPLAN INC 34080 [3081285] MULTIPLAN INC [308128501] 26.6 percent of total billed charges 17.36 26.6 Technical (Hospital) Services HC/HH Wch Supp Aquacel Silver 4x4__403765 PX-2705000015 CDM 2705000015 LOCAL 270 RC inpatient 28 28 BLUE CROSS BLUE SHIELD WELLMARK SB889 [3081026] BCBS WYOMING [308102603] 26.6 percent of total billed charges 17.36 26.6 Technical (Hospital) Services HC/HH Wch Supp Aquacel Silver 4x4__403765 PX-2705000015 CDM 2705000015 LOCAL 270 RC inpatient 28 28 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES PPO [308136801] 22.17 percent of total billed charges 17.36 26.6 Technical (Hospital) Services HC/HH Wch Supp Aquacel Silver 4x4__403765 PX-2705000015 CDM 2705000015 LOCAL 270 RC inpatient 28 28 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES HDHP [308136802] 22.17 percent of total billed charges 17.36 26.6 Technical (Hospital) Services HC/HH Wch Supp Aquacel Silver 4x4__403765 PX-2705000015 CDM 2705000015 LOCAL 270 RC inpatient 28 28 UNITED HEALTHCARE (COMMERCIAL) [3081199] UNITED HEALTHCARE 87726 [308119901] 17.36 percent of total billed charges 17.36 26.6 Technical (Hospital) Services HC/HH Wch Supp Aquacel Silver 4x4__403765 PX-2705000015 CDM 2705000015 LOCAL 270 RC inpatient 28 28 MEDICA (COMMERCIAL) 94265 [3081118] MEDICA CLAIMS [308111801] 25.2 percent of total billed charges 17.36 26.6 Technical (Hospital) Services HC/HH Wch Supp Aquacel Silver 4x4__403765 PX-2705000015 CDM 2705000015 LOCAL 270 RC outpatient 28 28 MEDICA (COMMERCIAL) 94265 [3081118] MEDICA CLAIMS [308111801] 25.2 percent of total billed charges 17.36 26.6 Technical (Hospital) Services HC/HH Wch Supp Aquacel Silver 4x4__403765 PX-2705000015 CDM 2705000015 LOCAL 270 RC outpatient 28 28 MULTIPLAN INC 34080 [3081285] MULTIPLAN INC [308128501] 26.6 percent of total billed charges 17.36 26.6 Technical (Hospital) Services HC/HH Wch Supp Aquacel Silver 4x4__403765 PX-2705000015 CDM 2705000015 LOCAL 270 RC outpatient 28 28 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES EPO [308136803] 22.4 percent of total billed charges 17.36 26.6 Technical (Hospital) Services HC/HH Wch Supp Aquacel Silver 4x4__403765 PX-2705000015 CDM 2705000015 LOCAL 270 RC outpatient 28 28 CIGNA 62308 [3081051] CIGNA 62308 [308105105] 22.4 percent of total billed charges 17.36 26.6 Technical (Hospital) Services HC/HH Wch Supp Aquacel Silver 4x4__403765 PX-2705000015 CDM 2705000015 LOCAL 270 RC outpatient 28 28 CIGNA 62308 [3081051] CIGNA STATE OF WYOMING [308105107] 22.4 percent of total billed charges 17.36 26.6 Technical (Hospital) Services HC/HH Wch Supp Aquacel Silver 4x4__403765 PX-2705000015 CDM 2705000015 LOCAL 270 RC outpatient 28 28 BLUE CROSS BLUE SHIELD WELLMARK SB889 [3081026] BCBS WYOMING [308102603] 26.6 percent of total billed charges 17.36 26.6 Technical (Hospital) Services HC/HH Wch Supp Aquacel Silver 4x4__403765 PX-2705000015 CDM 2705000015 LOCAL 270 RC outpatient 28 28 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES HDHP [308136802] 22.4 percent of total billed charges 17.36 26.6 Technical (Hospital) Services HC/HH Wch Supp Aquacel Silver 4x4__403765 PX-2705000015 CDM 2705000015 LOCAL 270 RC outpatient 28 28 UNITED HEALTHCARE (COMMERCIAL) [3081199] UNITED HEALTHCARE 87726 [308119901] 17.36 percent of total billed charges 17.36 26.6 Technical (Hospital) Services HC/HH Wch Supp Aquacel Silver 4x4__403765 PX-2705000015 CDM 2705000015 LOCAL 270 RC outpatient 28 28 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES PPO [308136801] 22.4 percent of total billed charges 17.36 26.6 Technical (Hospital) Services HC/HH Wch Supp Aquacel Silver 4x4__403765 PX-2705000015 CDM 2705000015 LOCAL 270 RC outpatient 28 28 HEALTHPARTNERS SX009 HEALTHPARTNERS 22.4 percent of total billed charges 17.36 26.6 Technical (Hospital) Services HC/HH Wch Supp Aquacel 4x4__177902 PX-2705000014 CDM 2705000014 LOCAL 270 RC outpatient 28 28 HEALTHPARTNERS SX009 HEALTHPARTNERS 22.4 percent of total billed charges 17.36 26.6 Technical (Hospital) Services HC/HH Wch Supp Aquacel 4x4__177902 PX-2705000014 CDM 2705000014 LOCAL 270 RC outpatient 28 28 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES PPO [308136801] 22.4 percent of total billed charges 17.36 26.6 Technical (Hospital) Services HC/HH Wch Supp Aquacel 4x4__177902 PX-2705000014 CDM 2705000014 LOCAL 270 RC outpatient 28 28 UNITED HEALTHCARE (COMMERCIAL) [3081199] UNITED HEALTHCARE 87726 [308119901] 17.36 percent of total billed charges 17.36 26.6 Technical (Hospital) Services HC/HH Wch Supp Aquacel 4x4__177902 PX-2705000014 CDM 2705000014 LOCAL 270 RC outpatient 28 28 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES HDHP [308136802] 22.4 percent of total billed charges 17.36 26.6 Technical (Hospital) Services HC/HH Wch Supp Aquacel 4x4__177902 PX-2705000014 CDM 2705000014 LOCAL 270 RC outpatient 28 28 BLUE CROSS BLUE SHIELD WELLMARK SB889 [3081026] BCBS WYOMING [308102603] 26.6 percent of total billed charges 17.36 26.6 Technical (Hospital) Services HC/HH Wch Supp Aquacel 4x4__177902 PX-2705000014 CDM 2705000014 LOCAL 270 RC outpatient 28 28 CIGNA 62308 [3081051] CIGNA 62308 [308105105] 22.4 percent of total billed charges 17.36 26.6 Technical (Hospital) Services HC/HH Wch Supp Aquacel 4x4__177902 PX-2705000014 CDM 2705000014 LOCAL 270 RC outpatient 28 28 CIGNA 62308 [3081051] CIGNA STATE OF WYOMING [308105107] 22.4 percent of total billed charges 17.36 26.6 Technical (Hospital) Services HC/HH Wch Supp Aquacel 4x4__177902 PX-2705000014 CDM 2705000014 LOCAL 270 RC outpatient 28 28 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES EPO [308136803] 22.4 percent of total billed charges 17.36 26.6 Technical (Hospital) Services HC/HH Wch Supp Aquacel 4x4__177902 PX-2705000014 CDM 2705000014 LOCAL 270 RC outpatient 28 28 MULTIPLAN INC 34080 [3081285] MULTIPLAN INC [308128501] 26.6 percent of total billed charges 17.36 26.6 Technical (Hospital) Services HC/HH Wch Supp Aquacel 4x4__177902 PX-2705000014 CDM 2705000014 LOCAL 270 RC outpatient 28 28 MEDICA (COMMERCIAL) 94265 [3081118] MEDICA CLAIMS [308111801] 25.2 percent of total billed charges 17.36 26.6 Technical (Hospital) Services HC/HH Wch Supp Aquacel 4x4__177902 PX-2705000014 CDM 2705000014 LOCAL 270 RC inpatient 28 28 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES PPO [308136801] 22.17 percent of total billed charges 17.36 26.6 Technical (Hospital) Services HC/HH Wch Supp Aquacel 4x4__177902 PX-2705000014 CDM 2705000014 LOCAL 270 RC inpatient 28 28 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES HDHP [308136802] 22.17 percent of total billed charges 17.36 26.6 Technical (Hospital) Services HC/HH Wch Supp Aquacel 4x4__177902 PX-2705000014 CDM 2705000014 LOCAL 270 RC inpatient 28 28 UNITED HEALTHCARE (COMMERCIAL) [3081199] UNITED HEALTHCARE 87726 [308119901] 17.36 percent of total billed charges 17.36 26.6 Technical (Hospital) Services HC/HH Wch Supp Aquacel 4x4__177902 PX-2705000014 CDM 2705000014 LOCAL 270 RC inpatient 28 28 MEDICA (COMMERCIAL) 94265 [3081118] MEDICA CLAIMS [308111801] 25.2 percent of total billed charges 17.36 26.6 Technical (Hospital) Services HC/HH Wch Supp Aquacel 4x4__177902 PX-2705000014 CDM 2705000014 LOCAL 270 RC inpatient 28 28 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES EPO [308136803] 22.17 percent of total billed charges 17.36 26.6 Technical (Hospital) Services HC/HH Wch Supp Aquacel 4x4__177902 PX-2705000014 CDM 2705000014 LOCAL 270 RC inpatient 28 28 HEALTHPARTNERS SX009 HEALTHPARTNERS 22.17 percent of total billed charges 17.36 26.6 Technical (Hospital) Services HC/HH Wch Supp Aquacel 4x4__177902 PX-2705000014 CDM 2705000014 LOCAL 270 RC inpatient 28 28 BLUE CROSS BLUE SHIELD WELLMARK SB889 [3081026] BCBS WYOMING [308102603] 26.6 percent of total billed charges 17.36 26.6 Technical (Hospital) Services HC/HH Wch Supp Aquacel 4x4__177902 PX-2705000014 CDM 2705000014 LOCAL 270 RC inpatient 28 28 MULTIPLAN INC 34080 [3081285] MULTIPLAN INC [308128501] 26.6 percent of total billed charges 17.36 26.6 Technical (Hospital) Services HC/HH Wch Supp Aquacel 4x4__177902 PX-2705000014 CDM 2705000014 LOCAL 270 RC inpatient 28 28 CIGNA 62308 [3081051] CIGNA 62308 [308105105] 22.17 percent of total billed charges 17.36 26.6 Technical (Hospital) Services HC/HH Wch Supp Aquacel 4x4__177902 PX-2705000014 CDM 2705000014 LOCAL 270 RC inpatient 28 28 CIGNA 62308 [3081051] CIGNA STATE OF WYOMING [308105107] 22.17 percent of total billed charges 17.36 26.6 Technical (Hospital) Services HC/HH Wch Supp Ankle Stirrup-Right__80101 PX-2705000013 CDM 2705000013 LOCAL 270 RC inpatient 98 98 BLUE CROSS BLUE SHIELD WELLMARK SB889 [3081026] BCBS WYOMING [308102603] 93.1 percent of total billed charges 60.76 93.1 Technical (Hospital) Services HC/HH Wch Supp Ankle Stirrup-Right__80101 PX-2705000013 CDM 2705000013 LOCAL 270 RC inpatient 98 98 MULTIPLAN INC 34080 [3081285] MULTIPLAN INC [308128501] 93.1 percent of total billed charges 60.76 93.1 Technical (Hospital) Services HC/HH Wch Supp Ankle Stirrup-Right__80101 PX-2705000013 CDM 2705000013 LOCAL 270 RC inpatient 98 98 CIGNA 62308 [3081051] CIGNA 62308 [308105105] 77.6 percent of total billed charges 60.76 93.1 Technical (Hospital) Services HC/HH Wch Supp Ankle Stirrup-Right__80101 PX-2705000013 CDM 2705000013 LOCAL 270 RC inpatient 98 98 CIGNA 62308 [3081051] CIGNA STATE OF WYOMING [308105107] 77.6 percent of total billed charges 60.76 93.1 Technical (Hospital) Services HC/HH Wch Supp Ankle Stirrup-Right__80101 PX-2705000013 CDM 2705000013 LOCAL 270 RC inpatient 98 98 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES EPO [308136803] 77.6 percent of total billed charges 60.76 93.1 Technical (Hospital) Services HC/HH Wch Supp Ankle Stirrup-Right__80101 PX-2705000013 CDM 2705000013 LOCAL 270 RC inpatient 98 98 HEALTHPARTNERS SX009 HEALTHPARTNERS 77.6 percent of total billed charges 60.76 93.1 Technical (Hospital) Services HC/HH Wch Supp Ankle Stirrup-Right__80101 PX-2705000013 CDM 2705000013 LOCAL 270 RC inpatient 98 98 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES PPO [308136801] 77.6 percent of total billed charges 60.76 93.1 Technical (Hospital) Services HC/HH Wch Supp Ankle Stirrup-Right__80101 PX-2705000013 CDM 2705000013 LOCAL 270 RC inpatient 98 98 UNITED HEALTHCARE (COMMERCIAL) [3081199] UNITED HEALTHCARE 87726 [308119901] 60.76 percent of total billed charges 60.76 93.1 Technical (Hospital) Services HC/HH Wch Supp Ankle Stirrup-Right__80101 PX-2705000013 CDM 2705000013 LOCAL 270 RC inpatient 98 98 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES HDHP [308136802] 77.6 percent of total billed charges 60.76 93.1 Technical (Hospital) Services HC/HH Wch Supp Ankle Stirrup-Right__80101 PX-2705000013 CDM 2705000013 LOCAL 270 RC inpatient 98 98 MEDICA (COMMERCIAL) 94265 [3081118] MEDICA CLAIMS [308111801] 88.2 percent of total billed charges 60.76 93.1 Technical (Hospital) Services HC/HH Wch Supp Ankle Stirrup-Right__80101 PX-2705000013 CDM 2705000013 LOCAL 270 RC outpatient 98 98 HEALTHPARTNERS SX009 HEALTHPARTNERS 78.4 percent of total billed charges 60.76 93.1 Technical (Hospital) Services HC/HH Wch Supp Ankle Stirrup-Right__80101 PX-2705000013 CDM 2705000013 LOCAL 270 RC outpatient 98 98 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES PPO [308136801] 78.4 percent of total billed charges 60.76 93.1 Technical (Hospital) Services HC/HH Wch Supp Ankle Stirrup-Right__80101 PX-2705000013 CDM 2705000013 LOCAL 270 RC outpatient 98 98 UNITED HEALTHCARE (COMMERCIAL) [3081199] UNITED HEALTHCARE 87726 [308119901] 60.76 percent of total billed charges 60.76 93.1 Technical (Hospital) Services HC/HH Wch Supp Ankle Stirrup-Right__80101 PX-2705000013 CDM 2705000013 LOCAL 270 RC outpatient 98 98 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES HDHP [308136802] 78.4 percent of total billed charges 60.76 93.1 Technical (Hospital) Services HC/HH Wch Supp Ankle Stirrup-Right__80101 PX-2705000013 CDM 2705000013 LOCAL 270 RC outpatient 98 98 BLUE CROSS BLUE SHIELD WELLMARK SB889 [3081026] BCBS WYOMING [308102603] 93.1 percent of total billed charges 60.76 93.1 Technical (Hospital) Services HC/HH Wch Supp Ankle Stirrup-Right__80101 PX-2705000013 CDM 2705000013 LOCAL 270 RC outpatient 98 98 CIGNA 62308 [3081051] CIGNA 62308 [308105105] 78.4 percent of total billed charges 60.76 93.1 Technical (Hospital) Services HC/HH Wch Supp Ankle Stirrup-Right__80101 PX-2705000013 CDM 2705000013 LOCAL 270 RC outpatient 98 98 CIGNA 62308 [3081051] CIGNA STATE OF WYOMING [308105107] 78.4 percent of total billed charges 60.76 93.1 Technical (Hospital) Services HC/HH Wch Supp Ankle Stirrup-Right__80101 PX-2705000013 CDM 2705000013 LOCAL 270 RC outpatient 98 98 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES EPO [308136803] 78.4 percent of total billed charges 60.76 93.1 Technical (Hospital) Services HC/HH Wch Supp Ankle Stirrup-Right__80101 PX-2705000013 CDM 2705000013 LOCAL 270 RC outpatient 98 98 MULTIPLAN INC 34080 [3081285] MULTIPLAN INC [308128501] 93.1 percent of total billed charges 60.76 93.1 Technical (Hospital) Services HC/HH Wch Supp Ankle Stirrup-Right__80101 PX-2705000013 CDM 2705000013 LOCAL 270 RC outpatient 98 98 MEDICA (COMMERCIAL) 94265 [3081118] MEDICA CLAIMS [308111801] 88.2 percent of total billed charges 60.76 93.1 Technical (Hospital) Services HC/HH Wch Supp Ankle Stirrup-Left__80100 PX-2705000012 CDM 2705000012 LOCAL 270 RC outpatient 98 98 UNITED HEALTHCARE (COMMERCIAL) [3081199] UNITED HEALTHCARE 87726 [308119901] 60.76 percent of total billed charges 60.76 93.1 Technical (Hospital) Services HC/HH Wch Supp Ankle Stirrup-Left__80100 PX-2705000012 CDM 2705000012 LOCAL 270 RC outpatient 98 98 HEALTHPARTNERS SX009 HEALTHPARTNERS 78.4 percent of total billed charges 60.76 93.1 Technical (Hospital) Services HC/HH Wch Supp Ankle Stirrup-Left__80100 PX-2705000012 CDM 2705000012 LOCAL 270 RC outpatient 98 98 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES PPO [308136801] 78.4 percent of total billed charges 60.76 93.1 Technical (Hospital) Services HC/HH Wch Supp Ankle Stirrup-Left__80100 PX-2705000012 CDM 2705000012 LOCAL 270 RC outpatient 98 98 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES EPO [308136803] 78.4 percent of total billed charges 60.76 93.1 Technical (Hospital) Services HC/HH Wch Supp Ankle Stirrup-Left__80100 PX-2705000012 CDM 2705000012 LOCAL 270 RC outpatient 98 98 CIGNA 62308 [3081051] CIGNA 62308 [308105105] 78.4 percent of total billed charges 60.76 93.1 Technical (Hospital) Services HC/HH Wch Supp Ankle Stirrup-Left__80100 PX-2705000012 CDM 2705000012 LOCAL 270 RC outpatient 98 98 CIGNA 62308 [3081051] CIGNA STATE OF WYOMING [308105107] 78.4 percent of total billed charges 60.76 93.1 Technical (Hospital) Services HC/HH Wch Supp Ankle Stirrup-Left__80100 PX-2705000012 CDM 2705000012 LOCAL 270 RC outpatient 98 98 BLUE CROSS BLUE SHIELD WELLMARK SB889 [3081026] BCBS WYOMING [308102603] 93.1 percent of total billed charges 60.76 93.1 Technical (Hospital) Services HC/HH Wch Supp Ankle Stirrup-Left__80100 PX-2705000012 CDM 2705000012 LOCAL 270 RC outpatient 98 98 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES HDHP [308136802] 78.4 percent of total billed charges 60.76 93.1 Technical (Hospital) Services HC/HH Wch Supp Ankle Stirrup-Left__80100 PX-2705000012 CDM 2705000012 LOCAL 270 RC outpatient 98 98 MEDICA (COMMERCIAL) 94265 [3081118] MEDICA CLAIMS [308111801] 88.2 percent of total billed charges 60.76 93.1 Technical (Hospital) Services HC/HH Wch Supp Ankle Stirrup-Left__80100 PX-2705000012 CDM 2705000012 LOCAL 270 RC outpatient 98 98 MULTIPLAN INC 34080 [3081285] MULTIPLAN INC [308128501] 93.1 percent of total billed charges 60.76 93.1 Technical (Hospital) Services HC/HH Wch Supp Ankle Stirrup-Left__80100 PX-2705000012 CDM 2705000012 LOCAL 270 RC inpatient 98 98 HEALTHPARTNERS SX009 HEALTHPARTNERS 77.6 percent of total billed charges 60.76 93.1 Technical (Hospital) Services HC/HH Wch Supp Ankle Stirrup-Left__80100 PX-2705000012 CDM 2705000012 LOCAL 270 RC inpatient 98 98 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES EPO [308136803] 77.6 percent of total billed charges 60.76 93.1 Technical (Hospital) Services HC/HH Wch Supp Ankle Stirrup-Left__80100 PX-2705000012 CDM 2705000012 LOCAL 270 RC inpatient 98 98 MULTIPLAN INC 34080 [3081285] MULTIPLAN INC [308128501] 93.1 percent of total billed charges 60.76 93.1 Technical (Hospital) Services HC/HH Wch Supp Ankle Stirrup-Left__80100 PX-2705000012 CDM 2705000012 LOCAL 270 RC inpatient 98 98 CIGNA 62308 [3081051] CIGNA 62308 [308105105] 77.6 percent of total billed charges 60.76 93.1 Technical (Hospital) Services HC/HH Wch Supp Ankle Stirrup-Left__80100 PX-2705000012 CDM 2705000012 LOCAL 270 RC inpatient 98 98 CIGNA 62308 [3081051] CIGNA STATE OF WYOMING [308105107] 77.6 percent of total billed charges 60.76 93.1 Technical (Hospital) Services HC/HH Wch Supp Ankle Stirrup-Left__80100 PX-2705000012 CDM 2705000012 LOCAL 270 RC inpatient 98 98 BLUE CROSS BLUE SHIELD WELLMARK SB889 [3081026] BCBS WYOMING [308102603] 93.1 percent of total billed charges 60.76 93.1 Technical (Hospital) Services HC/HH Wch Supp Ankle Stirrup-Left__80100 PX-2705000012 CDM 2705000012 LOCAL 270 RC inpatient 98 98 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES PPO [308136801] 77.6 percent of total billed charges 60.76 93.1 Technical (Hospital) Services HC/HH Wch Supp Ankle Stirrup-Left__80100 PX-2705000012 CDM 2705000012 LOCAL 270 RC inpatient 98 98 MEDICA (COMMERCIAL) 94265 [3081118] MEDICA CLAIMS [308111801] 88.2 percent of total billed charges 60.76 93.1 Technical (Hospital) Services HC/HH Wch Supp Ankle Stirrup-Left__80100 PX-2705000012 CDM 2705000012 LOCAL 270 RC inpatient 98 98 UNITED HEALTHCARE (COMMERCIAL) [3081199] UNITED HEALTHCARE 87726 [308119901] 60.76 percent of total billed charges 60.76 93.1 Technical (Hospital) Services HC/HH Wch Supp Ankle Stirrup-Left__80100 PX-2705000012 CDM 2705000012 LOCAL 270 RC inpatient 98 98 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES HDHP [308136802] 77.6 percent of total billed charges 60.76 93.1 Technical (Hospital) Services HC/HH Wch Supp Ankle Brace W/Straps__B-212000004 PX-2705000011 CDM 2705000011 LOCAL 270 RC inpatient 90 90 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES EPO [308136803] 71.26 percent of total billed charges 55.8 85.5 Technical (Hospital) Services HC/HH Wch Supp Ankle Brace W/Straps__B-212000004 PX-2705000011 CDM 2705000011 LOCAL 270 RC inpatient 90 90 HEALTHPARTNERS SX009 HEALTHPARTNERS 71.26 percent of total billed charges 55.8 85.5 Technical (Hospital) Services HC/HH Wch Supp Ankle Brace W/Straps__B-212000004 PX-2705000011 CDM 2705000011 LOCAL 270 RC inpatient 90 90 BLUE CROSS BLUE SHIELD WELLMARK SB889 [3081026] BCBS WYOMING [308102603] 85.5 percent of total billed charges 55.8 85.5 Technical (Hospital) Services HC/HH Wch Supp Ankle Brace W/Straps__B-212000004 PX-2705000011 CDM 2705000011 LOCAL 270 RC inpatient 90 90 MULTIPLAN INC 34080 [3081285] MULTIPLAN INC [308128501] 85.5 percent of total billed charges 55.8 85.5 Technical (Hospital) Services HC/HH Wch Supp Ankle Brace W/Straps__B-212000004 PX-2705000011 CDM 2705000011 LOCAL 270 RC inpatient 90 90 CIGNA 62308 [3081051] CIGNA 62308 [308105105] 71.26 percent of total billed charges 55.8 85.5 Technical (Hospital) Services HC/HH Wch Supp Ankle Brace W/Straps__B-212000004 PX-2705000011 CDM 2705000011 LOCAL 270 RC inpatient 90 90 CIGNA 62308 [3081051] CIGNA STATE OF WYOMING [308105107] 71.26 percent of total billed charges 55.8 85.5 Technical (Hospital) Services HC/HH Wch Supp Ankle Brace W/Straps__B-212000004 PX-2705000011 CDM 2705000011 LOCAL 270 RC inpatient 90 90 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES PPO [308136801] 71.26 percent of total billed charges 55.8 85.5 Technical (Hospital) Services HC/HH Wch Supp Ankle Brace W/Straps__B-212000004 PX-2705000011 CDM 2705000011 LOCAL 270 RC inpatient 90 90 MEDICA (COMMERCIAL) 94265 [3081118] MEDICA CLAIMS [308111801] 81 percent of total billed charges 55.8 85.5 Technical (Hospital) Services HC/HH Wch Supp Ankle Brace W/Straps__B-212000004 PX-2705000011 CDM 2705000011 LOCAL 270 RC inpatient 90 90 UNITED HEALTHCARE (COMMERCIAL) [3081199] UNITED HEALTHCARE 87726 [308119901] 55.8 percent of total billed charges 55.8 85.5 Technical (Hospital) Services HC/HH Wch Supp Ankle Brace W/Straps__B-212000004 PX-2705000011 CDM 2705000011 LOCAL 270 RC inpatient 90 90 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES HDHP [308136802] 71.26 percent of total billed charges 55.8 85.5 Technical (Hospital) Services HC/HH Wch Supp Ankle Brace W/Straps__B-212000004 PX-2705000011 CDM 2705000011 LOCAL 270 RC outpatient 90 90 MULTIPLAN INC 34080 [3081285] MULTIPLAN INC [308128501] 85.5 percent of total billed charges 55.8 85.5 Technical (Hospital) Services HC/HH Wch Supp Ankle Brace W/Straps__B-212000004 PX-2705000011 CDM 2705000011 LOCAL 270 RC outpatient 90 90 MEDICA (COMMERCIAL) 94265 [3081118] MEDICA CLAIMS [308111801] 81 percent of total billed charges 55.8 85.5 Technical (Hospital) Services HC/HH Wch Supp Ankle Brace W/Straps__B-212000004 PX-2705000011 CDM 2705000011 LOCAL 270 RC outpatient 90 90 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES HDHP [308136802] 72 percent of total billed charges 55.8 85.5 Technical (Hospital) Services HC/HH Wch Supp Ankle Brace W/Straps__B-212000004 PX-2705000011 CDM 2705000011 LOCAL 270 RC outpatient 90 90 BLUE CROSS BLUE SHIELD WELLMARK SB889 [3081026] BCBS WYOMING [308102603] 85.5 percent of total billed charges 55.8 85.5 Technical (Hospital) Services HC/HH Wch Supp Ankle Brace W/Straps__B-212000004 PX-2705000011 CDM 2705000011 LOCAL 270 RC outpatient 90 90 CIGNA 62308 [3081051] CIGNA 62308 [308105105] 72 percent of total billed charges 55.8 85.5 Technical (Hospital) Services HC/HH Wch Supp Ankle Brace W/Straps__B-212000004 PX-2705000011 CDM 2705000011 LOCAL 270 RC outpatient 90 90 CIGNA 62308 [3081051] CIGNA STATE OF WYOMING [308105107] 72 percent of total billed charges 55.8 85.5 Technical (Hospital) Services HC/HH Wch Supp Ankle Brace W/Straps__B-212000004 PX-2705000011 CDM 2705000011 LOCAL 270 RC outpatient 90 90 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES EPO [308136803] 72 percent of total billed charges 55.8 85.5 Technical (Hospital) Services HC/HH Wch Supp Ankle Brace W/Straps__B-212000004 PX-2705000011 CDM 2705000011 LOCAL 270 RC outpatient 90 90 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES PPO [308136801] 72 percent of total billed charges 55.8 85.5 Technical (Hospital) Services HC/HH Wch Supp Ankle Brace W/Straps__B-212000004 PX-2705000011 CDM 2705000011 LOCAL 270 RC outpatient 90 90 HEALTHPARTNERS SX009 HEALTHPARTNERS 72 percent of total billed charges 55.8 85.5 Technical (Hospital) Services HC/HH Wch Supp Ankle Brace W/Straps__B-212000004 PX-2705000011 CDM 2705000011 LOCAL 270 RC outpatient 90 90 UNITED HEALTHCARE (COMMERCIAL) [3081199] UNITED HEALTHCARE 87726 [308119901] 55.8 percent of total billed charges 55.8 85.5 Technical (Hospital) Services HC/HH Wch Supp Ankle Brace W/Straps__B-212000003 PX-2705000010 CDM 2705000010 LOCAL 270 RC inpatient 90 90 BLUE CROSS BLUE SHIELD WELLMARK SB889 [3081026] BCBS WYOMING [308102603] 85.5 percent of total billed charges 55.8 85.5 Technical (Hospital) Services HC/HH Wch Supp Ankle Brace W/Straps__B-212000003 PX-2705000010 CDM 2705000010 LOCAL 270 RC inpatient 90 90 CIGNA 62308 [3081051] CIGNA 62308 [308105105] 71.26 percent of total billed charges 55.8 85.5 Technical (Hospital) Services HC/HH Wch Supp Ankle Brace W/Straps__B-212000003 PX-2705000010 CDM 2705000010 LOCAL 270 RC inpatient 90 90 CIGNA 62308 [3081051] CIGNA STATE OF WYOMING [308105107] 71.26 percent of total billed charges 55.8 85.5 Technical (Hospital) Services HC/HH Wch Supp Ankle Brace W/Straps__B-212000003 PX-2705000010 CDM 2705000010 LOCAL 270 RC inpatient 90 90 MULTIPLAN INC 34080 [3081285] MULTIPLAN INC [308128501] 85.5 percent of total billed charges 55.8 85.5 Technical (Hospital) Services HC/HH Wch Supp Ankle Brace W/Straps__B-212000003 PX-2705000010 CDM 2705000010 LOCAL 270 RC inpatient 90 90 HEALTHPARTNERS SX009 HEALTHPARTNERS 71.26 percent of total billed charges 55.8 85.5 Technical (Hospital) Services HC/HH Wch Supp Ankle Brace W/Straps__B-212000003 PX-2705000010 CDM 2705000010 LOCAL 270 RC inpatient 90 90 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES EPO [308136803] 71.26 percent of total billed charges 55.8 85.5 Technical (Hospital) Services HC/HH Wch Supp Ankle Brace W/Straps__B-212000003 PX-2705000010 CDM 2705000010 LOCAL 270 RC inpatient 90 90 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES PPO [308136801] 71.26 percent of total billed charges 55.8 85.5 Technical (Hospital) Services HC/HH Wch Supp Ankle Brace W/Straps__B-212000003 PX-2705000010 CDM 2705000010 LOCAL 270 RC inpatient 90 90 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES HDHP [308136802] 71.26 percent of total billed charges 55.8 85.5 Technical (Hospital) Services HC/HH Wch Supp Ankle Brace W/Straps__B-212000003 PX-2705000010 CDM 2705000010 LOCAL 270 RC inpatient 90 90 UNITED HEALTHCARE (COMMERCIAL) [3081199] UNITED HEALTHCARE 87726 [308119901] 55.8 percent of total billed charges 55.8 85.5 Technical (Hospital) Services HC/HH Wch Supp Ankle Brace W/Straps__B-212000003 PX-2705000010 CDM 2705000010 LOCAL 270 RC inpatient 90 90 MEDICA (COMMERCIAL) 94265 [3081118] MEDICA CLAIMS [308111801] 81 percent of total billed charges 55.8 85.5 Technical (Hospital) Services HC/HH Wch Supp Ankle Brace W/Straps__B-212000003 PX-2705000010 CDM 2705000010 LOCAL 270 RC outpatient 90 90 UNITED HEALTHCARE (COMMERCIAL) [3081199] UNITED HEALTHCARE 87726 [308119901] 55.8 percent of total billed charges 55.8 85.5 Technical (Hospital) Services HC/HH Wch Supp Ankle Brace W/Straps__B-212000003 PX-2705000010 CDM 2705000010 LOCAL 270 RC outpatient 90 90 HEALTHPARTNERS SX009 HEALTHPARTNERS 72 percent of total billed charges 55.8 85.5 Technical (Hospital) Services HC/HH Wch Supp Ankle Brace W/Straps__B-212000003 PX-2705000010 CDM 2705000010 LOCAL 270 RC outpatient 90 90 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES PPO [308136801] 72 percent of total billed charges 55.8 85.5 Technical (Hospital) Services HC/HH Wch Supp Ankle Brace W/Straps__B-212000003 PX-2705000010 CDM 2705000010 LOCAL 270 RC outpatient 90 90 CIGNA 62308 [3081051] CIGNA 62308 [308105105] 72 percent of total billed charges 55.8 85.5 Technical (Hospital) Services HC/HH Wch Supp Ankle Brace W/Straps__B-212000003 PX-2705000010 CDM 2705000010 LOCAL 270 RC outpatient 90 90 CIGNA 62308 [3081051] CIGNA STATE OF WYOMING [308105107] 72 percent of total billed charges 55.8 85.5 Technical (Hospital) Services HC/HH Wch Supp Ankle Brace W/Straps__B-212000003 PX-2705000010 CDM 2705000010 LOCAL 270 RC outpatient 90 90 BLUE CROSS BLUE SHIELD WELLMARK SB889 [3081026] BCBS WYOMING [308102603] 85.5 percent of total billed charges 55.8 85.5 Technical (Hospital) Services HC/HH Wch Supp Ankle Brace W/Straps__B-212000003 PX-2705000010 CDM 2705000010 LOCAL 270 RC outpatient 90 90 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES HDHP [308136802] 72 percent of total billed charges 55.8 85.5 Technical (Hospital) Services HC/HH Wch Supp Ankle Brace W/Straps__B-212000003 PX-2705000010 CDM 2705000010 LOCAL 270 RC outpatient 90 90 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES EPO [308136803] 72 percent of total billed charges 55.8 85.5 Technical (Hospital) Services HC/HH Wch Supp Ankle Brace W/Straps__B-212000003 PX-2705000010 CDM 2705000010 LOCAL 270 RC outpatient 90 90 MEDICA (COMMERCIAL) 94265 [3081118] MEDICA CLAIMS [308111801] 81 percent of total billed charges 55.8 85.5 Technical (Hospital) Services HC/HH Wch Supp Ankle Brace W/Straps__B-212000003 PX-2705000010 CDM 2705000010 LOCAL 270 RC outpatient 90 90 MULTIPLAN INC 34080 [3081285] MULTIPLAN INC [308128501] 85.5 percent of total billed charges 55.8 85.5 Technical (Hospital) Services HC/HH Wch Supp Ankle Brace W/Straps__B-212000002 PX-2705000009 CDM 2705000009 LOCAL 270 RC inpatient 90 90 MEDICA (COMMERCIAL) 94265 [3081118] MEDICA CLAIMS [308111801] 81 percent of total billed charges 55.8 85.5 Technical (Hospital) Services HC/HH Wch Supp Ankle Brace W/Straps__B-212000002 PX-2705000009 CDM 2705000009 LOCAL 270 RC inpatient 90 90 UNITED HEALTHCARE (COMMERCIAL) [3081199] UNITED HEALTHCARE 87726 [308119901] 55.8 percent of total billed charges 55.8 85.5 Technical (Hospital) Services HC/HH Wch Supp Ankle Brace W/Straps__B-212000002 PX-2705000009 CDM 2705000009 LOCAL 270 RC inpatient 90 90 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES HDHP [308136802] 71.26 percent of total billed charges 55.8 85.5 Technical (Hospital) Services HC/HH Wch Supp Ankle Brace W/Straps__B-212000002 PX-2705000009 CDM 2705000009 LOCAL 270 RC inpatient 90 90 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES PPO [308136801] 71.26 percent of total billed charges 55.8 85.5 Technical (Hospital) Services HC/HH Wch Supp Ankle Brace W/Straps__B-212000002 PX-2705000009 CDM 2705000009 LOCAL 270 RC inpatient 90 90 BLUE CROSS BLUE SHIELD WELLMARK SB889 [3081026] BCBS WYOMING [308102603] 85.5 percent of total billed charges 55.8 85.5 Technical (Hospital) Services HC/HH Wch Supp Ankle Brace W/Straps__B-212000002 PX-2705000009 CDM 2705000009 LOCAL 270 RC inpatient 90 90 MULTIPLAN INC 34080 [3081285] MULTIPLAN INC [308128501] 85.5 percent of total billed charges 55.8 85.5 Technical (Hospital) Services HC/HH Wch Supp Ankle Brace W/Straps__B-212000002 PX-2705000009 CDM 2705000009 LOCAL 270 RC inpatient 90 90 CIGNA 62308 [3081051] CIGNA 62308 [308105105] 71.26 percent of total billed charges 55.8 85.5 Technical (Hospital) Services HC/HH Wch Supp Ankle Brace W/Straps__B-212000002 PX-2705000009 CDM 2705000009 LOCAL 270 RC inpatient 90 90 CIGNA 62308 [3081051] CIGNA STATE OF WYOMING [308105107] 71.26 percent of total billed charges 55.8 85.5 Technical (Hospital) Services HC/HH Wch Supp Ankle Brace W/Straps__B-212000002 PX-2705000009 CDM 2705000009 LOCAL 270 RC inpatient 90 90 HEALTHPARTNERS SX009 HEALTHPARTNERS 71.26 percent of total billed charges 55.8 85.5 Technical (Hospital) Services HC/HH Wch Supp Ankle Brace W/Straps__B-212000002 PX-2705000009 CDM 2705000009 LOCAL 270 RC inpatient 90 90 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES EPO [308136803] 71.26 percent of total billed charges 55.8 85.5 Technical (Hospital) Services HC/HH Wch Supp Ankle Brace W/Straps__B-212000002 PX-2705000009 CDM 2705000009 LOCAL 270 RC outpatient 90 90 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES HDHP [308136802] 72 percent of total billed charges 55.8 85.5 Technical (Hospital) Services HC/HH Wch Supp Ankle Brace W/Straps__B-212000002 PX-2705000009 CDM 2705000009 LOCAL 270 RC outpatient 90 90 BLUE CROSS BLUE SHIELD WELLMARK SB889 [3081026] BCBS WYOMING [308102603] 85.5 percent of total billed charges 55.8 85.5 Technical (Hospital) Services HC/HH Wch Supp Ankle Brace W/Straps__B-212000002 PX-2705000009 CDM 2705000009 LOCAL 270 RC outpatient 90 90 CIGNA 62308 [3081051] CIGNA 62308 [308105105] 72 percent of total billed charges 55.8 85.5 Technical (Hospital) Services HC/HH Wch Supp Ankle Brace W/Straps__B-212000002 PX-2705000009 CDM 2705000009 LOCAL 270 RC outpatient 90 90 CIGNA 62308 [3081051] CIGNA STATE OF WYOMING [308105107] 72 percent of total billed charges 55.8 85.5 Technical (Hospital) Services HC/HH Wch Supp Ankle Brace W/Straps__B-212000002 PX-2705000009 CDM 2705000009 LOCAL 270 RC outpatient 90 90 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES EPO [308136803] 72 percent of total billed charges 55.8 85.5 Technical (Hospital) Services HC/HH Wch Supp Ankle Brace W/Straps__B-212000002 PX-2705000009 CDM 2705000009 LOCAL 270 RC outpatient 90 90 UNITED HEALTHCARE (COMMERCIAL) [3081199] UNITED HEALTHCARE 87726 [308119901] 55.8 percent of total billed charges 55.8 85.5 Technical (Hospital) Services HC/HH Wch Supp Ankle Brace W/Straps__B-212000002 PX-2705000009 CDM 2705000009 LOCAL 270 RC outpatient 90 90 HEALTHPARTNERS SX009 HEALTHPARTNERS 72 percent of total billed charges 55.8 85.5 Technical (Hospital) Services HC/HH Wch Supp Ankle Brace W/Straps__B-212000002 PX-2705000009 CDM 2705000009 LOCAL 270 RC outpatient 90 90 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES PPO [308136801] 72 percent of total billed charges 55.8 85.5 Technical (Hospital) Services HC/HH Wch Supp Ankle Brace W/Straps__B-212000002 PX-2705000009 CDM 2705000009 LOCAL 270 RC outpatient 90 90 MULTIPLAN INC 34080 [3081285] MULTIPLAN INC [308128501] 85.5 percent of total billed charges 55.8 85.5 Technical (Hospital) Services HC/HH Wch Supp Ankle Brace W/Straps__B-212000002 PX-2705000009 CDM 2705000009 LOCAL 270 RC outpatient 90 90 MEDICA (COMMERCIAL) 94265 [3081118] MEDICA CLAIMS [308111801] 81 percent of total billed charges 55.8 85.5 Technical (Hospital) Services HC/HH Wch Supp Aloe Vesta Cleansing Foam__325208 PX-2705000008 CDM 2705000008 LOCAL 270 RC outpatient 23 23 MEDICA (COMMERCIAL) 94265 [3081118] MEDICA CLAIMS [308111801] 20.7 percent of total billed charges 14.26 21.85 Technical (Hospital) Services HC/HH Wch Supp Aloe Vesta Cleansing Foam__325208 PX-2705000008 CDM 2705000008 LOCAL 270 RC outpatient 23 23 MULTIPLAN INC 34080 [3081285] MULTIPLAN INC [308128501] 21.85 percent of total billed charges 14.26 21.85 Technical (Hospital) Services HC/HH Wch Supp Aloe Vesta Cleansing Foam__325208 PX-2705000008 CDM 2705000008 LOCAL 270 RC outpatient 23 23 UNITED HEALTHCARE (COMMERCIAL) [3081199] UNITED HEALTHCARE 87726 [308119901] 14.26 percent of total billed charges 14.26 21.85 Technical (Hospital) Services HC/HH Wch Supp Aloe Vesta Cleansing Foam__325208 PX-2705000008 CDM 2705000008 LOCAL 270 RC outpatient 23 23 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES PPO [308136801] 18.4 percent of total billed charges 14.26 21.85 Technical (Hospital) Services HC/HH Wch Supp Aloe Vesta Cleansing Foam__325208 PX-2705000008 CDM 2705000008 LOCAL 270 RC outpatient 23 23 HEALTHPARTNERS SX009 HEALTHPARTNERS 18.4 percent of total billed charges 14.26 21.85 Technical (Hospital) Services HC/HH Wch Supp Aloe Vesta Cleansing Foam__325208 PX-2705000008 CDM 2705000008 LOCAL 270 RC outpatient 23 23 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES HDHP [308136802] 18.4 percent of total billed charges 14.26 21.85 Technical (Hospital) Services HC/HH Wch Supp Aloe Vesta Cleansing Foam__325208 PX-2705000008 CDM 2705000008 LOCAL 270 RC outpatient 23 23 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES EPO [308136803] 18.4 percent of total billed charges 14.26 21.85 Technical (Hospital) Services HC/HH Wch Supp Aloe Vesta Cleansing Foam__325208 PX-2705000008 CDM 2705000008 LOCAL 270 RC outpatient 23 23 CIGNA 62308 [3081051] CIGNA 62308 [308105105] 18.4 percent of total billed charges 14.26 21.85 Technical (Hospital) Services HC/HH Wch Supp Aloe Vesta Cleansing Foam__325208 PX-2705000008 CDM 2705000008 LOCAL 270 RC outpatient 23 23 CIGNA 62308 [3081051] CIGNA STATE OF WYOMING [308105107] 18.4 percent of total billed charges 14.26 21.85 Technical (Hospital) Services HC/HH Wch Supp Aloe Vesta Cleansing Foam__325208 PX-2705000008 CDM 2705000008 LOCAL 270 RC outpatient 23 23 BLUE CROSS BLUE SHIELD WELLMARK SB889 [3081026] BCBS WYOMING [308102603] 21.85 percent of total billed charges 14.26 21.85 Technical (Hospital) Services HC/HH Wch Supp Aloe Vesta Cleansing Foam__325208 PX-2705000008 CDM 2705000008 LOCAL 270 RC inpatient 23 23 MEDICA (COMMERCIAL) 94265 [3081118] MEDICA CLAIMS [308111801] 20.7 percent of total billed charges 14.26 21.85 Technical (Hospital) Services HC/HH Wch Supp Aloe Vesta Cleansing Foam__325208 PX-2705000008 CDM 2705000008 LOCAL 270 RC inpatient 23 23 UNITED HEALTHCARE (COMMERCIAL) [3081199] UNITED HEALTHCARE 87726 [308119901] 14.26 percent of total billed charges 14.26 21.85 Technical (Hospital) Services HC/HH Wch Supp Aloe Vesta Cleansing Foam__325208 PX-2705000008 CDM 2705000008 LOCAL 270 RC inpatient 23 23 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES HDHP [308136802] 18.21 percent of total billed charges 14.26 21.85 Technical (Hospital) Services HC/HH Wch Supp Aloe Vesta Cleansing Foam__325208 PX-2705000008 CDM 2705000008 LOCAL 270 RC inpatient 23 23 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES PPO [308136801] 18.21 percent of total billed charges 14.26 21.85 Technical (Hospital) Services HC/HH Wch Supp Aloe Vesta Cleansing Foam__325208 PX-2705000008 CDM 2705000008 LOCAL 270 RC inpatient 23 23 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES EPO [308136803] 18.21 percent of total billed charges 14.26 21.85 Technical (Hospital) Services HC/HH Wch Supp Aloe Vesta Cleansing Foam__325208 PX-2705000008 CDM 2705000008 LOCAL 270 RC inpatient 23 23 HEALTHPARTNERS SX009 HEALTHPARTNERS 18.21 percent of total billed charges 14.26 21.85 Technical (Hospital) Services HC/HH Wch Supp Aloe Vesta Cleansing Foam__325208 PX-2705000008 CDM 2705000008 LOCAL 270 RC inpatient 23 23 MULTIPLAN INC 34080 [3081285] MULTIPLAN INC [308128501] 21.85 percent of total billed charges 14.26 21.85 Technical (Hospital) Services HC/HH Wch Supp Aloe Vesta Cleansing Foam__325208 PX-2705000008 CDM 2705000008 LOCAL 270 RC inpatient 23 23 CIGNA 62308 [3081051] CIGNA 62308 [308105105] 18.21 percent of total billed charges 14.26 21.85 Technical (Hospital) Services HC/HH Wch Supp Aloe Vesta Cleansing Foam__325208 PX-2705000008 CDM 2705000008 LOCAL 270 RC inpatient 23 23 CIGNA 62308 [3081051] CIGNA STATE OF WYOMING [308105107] 18.21 percent of total billed charges 14.26 21.85 Technical (Hospital) Services HC/HH Wch Supp Aloe Vesta Cleansing Foam__325208 PX-2705000008 CDM 2705000008 LOCAL 270 RC inpatient 23 23 BLUE CROSS BLUE SHIELD WELLMARK SB889 [3081026] BCBS WYOMING [308102603] 21.85 percent of total billed charges 14.26 21.85 Technical (Hospital) Services HC/HH Wch Supp Airway/Infant 40mm__8400-12#0 PX-2705000007 CDM 2705000007 LOCAL 270 RC outpatient 6 6 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES HDHP [308136802] 4.8 percent of total billed charges 3.72 5.7 Technical (Hospital) Services HC/HH Wch Supp Airway/Infant 40mm__8400-12#0 PX-2705000007 CDM 2705000007 LOCAL 270 RC outpatient 6 6 BLUE CROSS BLUE SHIELD WELLMARK SB889 [3081026] BCBS WYOMING [308102603] 5.7 percent of total billed charges 3.72 5.7 Technical (Hospital) Services HC/HH Wch Supp Airway/Infant 40mm__8400-12#0 PX-2705000007 CDM 2705000007 LOCAL 270 RC outpatient 6 6 CIGNA 62308 [3081051] CIGNA 62308 [308105105] 4.8 percent of total billed charges 3.72 5.7 Technical (Hospital) Services HC/HH Wch Supp Airway/Infant 40mm__8400-12#0 PX-2705000007 CDM 2705000007 LOCAL 270 RC outpatient 6 6 CIGNA 62308 [3081051] CIGNA STATE OF WYOMING [308105107] 4.8 percent of total billed charges 3.72 5.7 Technical (Hospital) Services HC/HH Wch Supp Airway/Infant 40mm__8400-12#0 PX-2705000007 CDM 2705000007 LOCAL 270 RC outpatient 6 6 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES EPO [308136803] 4.8 percent of total billed charges 3.72 5.7 Technical (Hospital) Services HC/HH Wch Supp Airway/Infant 40mm__8400-12#0 PX-2705000007 CDM 2705000007 LOCAL 270 RC outpatient 6 6 UNITED HEALTHCARE (COMMERCIAL) [3081199] UNITED HEALTHCARE 87726 [308119901] 3.72 percent of total billed charges 3.72 5.7 Technical (Hospital) Services HC/HH Wch Supp Airway/Infant 40mm__8400-12#0 PX-2705000007 CDM 2705000007 LOCAL 270 RC outpatient 6 6 HEALTHPARTNERS SX009 HEALTHPARTNERS 4.8 percent of total billed charges 3.72 5.7 Technical (Hospital) Services HC/HH Wch Supp Airway/Infant 40mm__8400-12#0 PX-2705000007 CDM 2705000007 LOCAL 270 RC outpatient 6 6 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES PPO [308136801] 4.8 percent of total billed charges 3.72 5.7 Technical (Hospital) Services HC/HH Wch Supp Airway/Infant 40mm__8400-12#0 PX-2705000007 CDM 2705000007 LOCAL 270 RC outpatient 6 6 MULTIPLAN INC 34080 [3081285] MULTIPLAN INC [308128501] 5.7 percent of total billed charges 3.72 5.7 Technical (Hospital) Services HC/HH Wch Supp Airway/Infant 40mm__8400-12#0 PX-2705000007 CDM 2705000007 LOCAL 270 RC outpatient 6 6 MEDICA (COMMERCIAL) 94265 [3081118] MEDICA CLAIMS [308111801] 5.4 percent of total billed charges 3.72 5.7 Technical (Hospital) Services HC/HH Wch Supp Airway/Infant 40mm__8400-12#0 PX-2705000007 CDM 2705000007 LOCAL 270 RC inpatient 6 6 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES EPO [308136803] 4.75 percent of total billed charges 3.72 5.7 Technical (Hospital) Services HC/HH Wch Supp Airway/Infant 40mm__8400-12#0 PX-2705000007 CDM 2705000007 LOCAL 270 RC inpatient 6 6 HEALTHPARTNERS SX009 HEALTHPARTNERS 4.75 percent of total billed charges 3.72 5.7 Technical (Hospital) Services HC/HH Wch Supp Airway/Infant 40mm__8400-12#0 PX-2705000007 CDM 2705000007 LOCAL 270 RC inpatient 6 6 MULTIPLAN INC 34080 [3081285] MULTIPLAN INC [308128501] 5.7 percent of total billed charges 3.72 5.7 Technical (Hospital) Services HC/HH Wch Supp Airway/Infant 40mm__8400-12#0 PX-2705000007 CDM 2705000007 LOCAL 270 RC inpatient 6 6 BLUE CROSS BLUE SHIELD WELLMARK SB889 [3081026] BCBS WYOMING [308102603] 5.7 percent of total billed charges 3.72 5.7 Technical (Hospital) Services HC/HH Wch Supp Airway/Infant 40mm__8400-12#0 PX-2705000007 CDM 2705000007 LOCAL 270 RC inpatient 6 6 CIGNA 62308 [3081051] CIGNA 62308 [308105105] 4.75 percent of total billed charges 3.72 5.7 Technical (Hospital) Services HC/HH Wch Supp Airway/Infant 40mm__8400-12#0 PX-2705000007 CDM 2705000007 LOCAL 270 RC inpatient 6 6 CIGNA 62308 [3081051] CIGNA STATE OF WYOMING [308105107] 4.75 percent of total billed charges 3.72 5.7 Technical (Hospital) Services HC/HH Wch Supp Airway/Infant 40mm__8400-12#0 PX-2705000007 CDM 2705000007 LOCAL 270 RC inpatient 6 6 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES PPO [308136801] 4.75 percent of total billed charges 3.72 5.7 Technical (Hospital) Services HC/HH Wch Supp Airway/Infant 40mm__8400-12#0 PX-2705000007 CDM 2705000007 LOCAL 270 RC inpatient 6 6 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES HDHP [308136802] 4.75 percent of total billed charges 3.72 5.7 Technical (Hospital) Services HC/HH Wch Supp Airway/Infant 40mm__8400-12#0 PX-2705000007 CDM 2705000007 LOCAL 270 RC inpatient 6 6 UNITED HEALTHCARE (COMMERCIAL) [3081199] UNITED HEALTHCARE 87726 [308119901] 3.72 percent of total billed charges 3.72 5.7 Technical (Hospital) Services HC/HH Wch Supp Airway/Infant 40mm__8400-12#0 PX-2705000007 CDM 2705000007 LOCAL 270 RC inpatient 6 6 MEDICA (COMMERCIAL) 94265 [3081118] MEDICA CLAIMS [308111801] 5.4 percent of total billed charges 3.72 5.7 Technical (Hospital) Services HC/HH Wch Supp Airway 90mm Adult M__10-80090 PX-2705000006 CDM 2705000006 LOCAL 270 RC outpatient 6 6 MULTIPLAN INC 34080 [3081285] MULTIPLAN INC [308128501] 5.7 percent of total billed charges 3.72 5.7 Technical (Hospital) Services HC/HH Wch Supp Airway 90mm Adult M__10-80090 PX-2705000006 CDM 2705000006 LOCAL 270 RC outpatient 6 6 MEDICA (COMMERCIAL) 94265 [3081118] MEDICA CLAIMS [308111801] 5.4 percent of total billed charges 3.72 5.7 Technical (Hospital) Services HC/HH Wch Supp Airway 90mm Adult M__10-80090 PX-2705000006 CDM 2705000006 LOCAL 270 RC outpatient 6 6 HEALTHPARTNERS SX009 HEALTHPARTNERS 4.8 percent of total billed charges 3.72 5.7 Technical (Hospital) Services HC/HH Wch Supp Airway 90mm Adult M__10-80090 PX-2705000006 CDM 2705000006 LOCAL 270 RC outpatient 6 6 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES PPO [308136801] 4.8 percent of total billed charges 3.72 5.7 Technical (Hospital) Services HC/HH Wch Supp Airway 90mm Adult M__10-80090 PX-2705000006 CDM 2705000006 LOCAL 270 RC outpatient 6 6 UNITED HEALTHCARE (COMMERCIAL) [3081199] UNITED HEALTHCARE 87726 [308119901] 3.72 percent of total billed charges 3.72 5.7 Technical (Hospital) Services HC/HH Wch Supp Airway 90mm Adult M__10-80090 PX-2705000006 CDM 2705000006 LOCAL 270 RC outpatient 6 6 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES EPO [308136803] 4.8 percent of total billed charges 3.72 5.7 Technical (Hospital) Services HC/HH Wch Supp Airway 90mm Adult M__10-80090 PX-2705000006 CDM 2705000006 LOCAL 270 RC outpatient 6 6 BLUE CROSS BLUE SHIELD WELLMARK SB889 [3081026] BCBS WYOMING [308102603] 5.7 percent of total billed charges 3.72 5.7 Technical (Hospital) Services HC/HH Wch Supp Airway 90mm Adult M__10-80090 PX-2705000006 CDM 2705000006 LOCAL 270 RC outpatient 6 6 CIGNA 62308 [3081051] CIGNA 62308 [308105105] 4.8 percent of total billed charges 3.72 5.7 Technical (Hospital) Services HC/HH Wch Supp Airway 90mm Adult M__10-80090 PX-2705000006 CDM 2705000006 LOCAL 270 RC outpatient 6 6 CIGNA 62308 [3081051] CIGNA STATE OF WYOMING [308105107] 4.8 percent of total billed charges 3.72 5.7 Technical (Hospital) Services HC/HH Wch Supp Airway 90mm Adult M__10-80090 PX-2705000006 CDM 2705000006 LOCAL 270 RC outpatient 6 6 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES HDHP [308136802] 4.8 percent of total billed charges 3.72 5.7 Technical (Hospital) Services HC/HH Wch Supp Airway 90mm Adult M__10-80090 PX-2705000006 CDM 2705000006 LOCAL 270 RC inpatient 6 6 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES EPO [308136803] 4.75 percent of total billed charges 3.72 5.7 Technical (Hospital) Services HC/HH Wch Supp Airway 90mm Adult M__10-80090 PX-2705000006 CDM 2705000006 LOCAL 270 RC inpatient 6 6 HEALTHPARTNERS SX009 HEALTHPARTNERS 4.75 percent of total billed charges 3.72 5.7 Technical (Hospital) Services HC/HH Wch Supp Airway 90mm Adult M__10-80090 PX-2705000006 CDM 2705000006 LOCAL 270 RC inpatient 6 6 BLUE CROSS BLUE SHIELD WELLMARK SB889 [3081026] BCBS WYOMING [308102603] 5.7 percent of total billed charges 3.72 5.7 Technical (Hospital) Services HC/HH Wch Supp Airway 90mm Adult M__10-80090 PX-2705000006 CDM 2705000006 LOCAL 270 RC inpatient 6 6 MULTIPLAN INC 34080 [3081285] MULTIPLAN INC [308128501] 5.7 percent of total billed charges 3.72 5.7 Technical (Hospital) Services HC/HH Wch Supp Airway 90mm Adult M__10-80090 PX-2705000006 CDM 2705000006 LOCAL 270 RC inpatient 6 6 CIGNA 62308 [3081051] CIGNA 62308 [308105105] 4.75 percent of total billed charges 3.72 5.7 Technical (Hospital) Services HC/HH Wch Supp Airway 90mm Adult M__10-80090 PX-2705000006 CDM 2705000006 LOCAL 270 RC inpatient 6 6 CIGNA 62308 [3081051] CIGNA STATE OF WYOMING [308105107] 4.75 percent of total billed charges 3.72 5.7 Technical (Hospital) Services HC/HH Wch Supp Airway 90mm Adult M__10-80090 PX-2705000006 CDM 2705000006 LOCAL 270 RC inpatient 6 6 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES PPO [308136801] 4.75 percent of total billed charges 3.72 5.7 Technical (Hospital) Services HC/HH Wch Supp Airway 90mm Adult M__10-80090 PX-2705000006 CDM 2705000006 LOCAL 270 RC inpatient 6 6 MEDICA (COMMERCIAL) 94265 [3081118] MEDICA CLAIMS [308111801] 5.4 percent of total billed charges 3.72 5.7 Technical (Hospital) Services HC/HH Wch Supp Airway 90mm Adult M__10-80090 PX-2705000006 CDM 2705000006 LOCAL 270 RC inpatient 6 6 UNITED HEALTHCARE (COMMERCIAL) [3081199] UNITED HEALTHCARE 87726 [308119901] 3.72 percent of total billed charges 3.72 5.7 Technical (Hospital) Services HC/HH Wch Supp Airway 90mm Adult M__10-80090 PX-2705000006 CDM 2705000006 LOCAL 270 RC inpatient 6 6 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES HDHP [308136802] 4.75 percent of total billed charges 3.72 5.7 Technical (Hospital) Services HC/HH Wch Supp Adult One Step Pads__8900021401 PX-2705000005 CDM 2705000005 LOCAL 270 RC outpatient 200 200 HEALTHPARTNERS SX009 HEALTHPARTNERS 160 percent of total billed charges 124 190 Technical (Hospital) Services HC/HH Wch Supp Adult One Step Pads__8900021401 PX-2705000005 CDM 2705000005 LOCAL 270 RC outpatient 200 200 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES PPO [308136801] 160 percent of total billed charges 124 190 Technical (Hospital) Services HC/HH Wch Supp Adult One Step Pads__8900021401 PX-2705000005 CDM 2705000005 LOCAL 270 RC outpatient 200 200 UNITED HEALTHCARE (COMMERCIAL) [3081199] UNITED HEALTHCARE 87726 [308119901] 124 percent of total billed charges 124 190 Technical (Hospital) Services HC/HH Wch Supp Adult One Step Pads__8900021401 PX-2705000005 CDM 2705000005 LOCAL 270 RC outpatient 200 200 CIGNA 62308 [3081051] CIGNA 62308 [308105105] 160 percent of total billed charges 124 190 Technical (Hospital) Services HC/HH Wch Supp Adult One Step Pads__8900021401 PX-2705000005 CDM 2705000005 LOCAL 270 RC outpatient 200 200 CIGNA 62308 [3081051] CIGNA STATE OF WYOMING [308105107] 160 percent of total billed charges 124 190 Technical (Hospital) Services HC/HH Wch Supp Adult One Step Pads__8900021401 PX-2705000005 CDM 2705000005 LOCAL 270 RC outpatient 200 200 BLUE CROSS BLUE SHIELD WELLMARK SB889 [3081026] BCBS WYOMING [308102603] 190 percent of total billed charges 124 190 Technical (Hospital) Services HC/HH Wch Supp Adult One Step Pads__8900021401 PX-2705000005 CDM 2705000005 LOCAL 270 RC outpatient 200 200 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES EPO [308136803] 160 percent of total billed charges 124 190 Technical (Hospital) Services HC/HH Wch Supp Adult One Step Pads__8900021401 PX-2705000005 CDM 2705000005 LOCAL 270 RC outpatient 200 200 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES HDHP [308136802] 160 percent of total billed charges 124 190 Technical (Hospital) Services HC/HH Wch Supp Adult One Step Pads__8900021401 PX-2705000005 CDM 2705000005 LOCAL 270 RC outpatient 200 200 MEDICA (COMMERCIAL) 94265 [3081118] MEDICA CLAIMS [308111801] 180 percent of total billed charges 124 190 Technical (Hospital) Services HC/HH Wch Supp Adult One Step Pads__8900021401 PX-2705000005 CDM 2705000005 LOCAL 270 RC outpatient 200 200 MULTIPLAN INC 34080 [3081285] MULTIPLAN INC [308128501] 190 percent of total billed charges 124 190 Technical (Hospital) Services HC/HH Wch Supp Adult One Step Pads__8900021401 PX-2705000005 CDM 2705000005 LOCAL 270 RC inpatient 200 200 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES HDHP [308136802] 158.36 percent of total billed charges 124 190 Technical (Hospital) Services HC/HH Wch Supp Adult One Step Pads__8900021401 PX-2705000005 CDM 2705000005 LOCAL 270 RC inpatient 200 200 UNITED HEALTHCARE (COMMERCIAL) [3081199] UNITED HEALTHCARE 87726 [308119901] 124 percent of total billed charges 124 190 Technical (Hospital) Services HC/HH Wch Supp Adult One Step Pads__8900021401 PX-2705000005 CDM 2705000005 LOCAL 270 RC inpatient 200 200 MEDICA (COMMERCIAL) 94265 [3081118] MEDICA CLAIMS [308111801] 180 percent of total billed charges 124 190 Technical (Hospital) Services HC/HH Wch Supp Adult One Step Pads__8900021401 PX-2705000005 CDM 2705000005 LOCAL 270 RC inpatient 200 200 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES PPO [308136801] 158.36 percent of total billed charges 124 190 Technical (Hospital) Services HC/HH Wch Supp Adult One Step Pads__8900021401 PX-2705000005 CDM 2705000005 LOCAL 270 RC inpatient 200 200 CIGNA 62308 [3081051] CIGNA 62308 [308105105] 158.36 percent of total billed charges 124 190 Technical (Hospital) Services HC/HH Wch Supp Adult One Step Pads__8900021401 PX-2705000005 CDM 2705000005 LOCAL 270 RC inpatient 200 200 CIGNA 62308 [3081051] CIGNA STATE OF WYOMING [308105107] 158.36 percent of total billed charges 124 190 Technical (Hospital) Services HC/HH Wch Supp Adult One Step Pads__8900021401 PX-2705000005 CDM 2705000005 LOCAL 270 RC inpatient 200 200 MULTIPLAN INC 34080 [3081285] MULTIPLAN INC [308128501] 190 percent of total billed charges 124 190 Technical (Hospital) Services HC/HH Wch Supp Adult One Step Pads__8900021401 PX-2705000005 CDM 2705000005 LOCAL 270 RC inpatient 200 200 BLUE CROSS BLUE SHIELD WELLMARK SB889 [3081026] BCBS WYOMING [308102603] 190 percent of total billed charges 124 190 Technical (Hospital) Services HC/HH Wch Supp Adult One Step Pads__8900021401 PX-2705000005 CDM 2705000005 LOCAL 270 RC inpatient 200 200 HEALTHPARTNERS SX009 HEALTHPARTNERS 158.36 percent of total billed charges 124 190 Technical (Hospital) Services HC/HH Wch Supp Adult One Step Pads__8900021401 PX-2705000005 CDM 2705000005 LOCAL 270 RC inpatient 200 200 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES EPO [308136803] 158.36 percent of total billed charges 124 190 Technical (Hospital) Services Ref Novel Coronavirus Real Time Rt-Pcr Diagnostic Test Panel PX-3060000100 CDM U0001 HCPCS 306 RC inpatient 0.01 0.01 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES EPO [308136803] 0.01 percent of total billed charges 0.01 0.01 Technical (Hospital) Services Ref Novel Coronavirus Real Time Rt-Pcr Diagnostic Test Panel PX-3060000100 CDM U0001 HCPCS 306 RC inpatient 0.01 0.01 HEALTHPARTNERS SX009 HEALTHPARTNERS 0.01 percent of total billed charges 0.01 0.01 Technical (Hospital) Services Ref Novel Coronavirus Real Time Rt-Pcr Diagnostic Test Panel PX-3060000100 CDM U0001 HCPCS 306 RC inpatient 0.01 0.01 BLUE CROSS BLUE SHIELD WELLMARK SB889 [3081026] BCBS WYOMING [308102603] 0.01 percent of total billed charges 0.01 0.01 Technical (Hospital) Services Ref Novel Coronavirus Real Time Rt-Pcr Diagnostic Test Panel PX-3060000100 CDM U0001 HCPCS 306 RC inpatient 0.01 0.01 MULTIPLAN INC 34080 [3081285] MULTIPLAN INC [308128501] 0.01 percent of total billed charges 0.01 0.01 Technical (Hospital) Services Ref Novel Coronavirus Real Time Rt-Pcr Diagnostic Test Panel PX-3060000100 CDM U0001 HCPCS 306 RC inpatient 0.01 0.01 CIGNA 62308 [3081051] CIGNA 62308 [308105105] 0.01 percent of total billed charges 0.01 0.01 Technical (Hospital) Services Ref Novel Coronavirus Real Time Rt-Pcr Diagnostic Test Panel PX-3060000100 CDM U0001 HCPCS 306 RC inpatient 0.01 0.01 CIGNA 62308 [3081051] CIGNA STATE OF WYOMING [308105107] 0.01 percent of total billed charges 0.01 0.01 Technical (Hospital) Services Ref Novel Coronavirus Real Time Rt-Pcr Diagnostic Test Panel PX-3060000100 CDM U0001 HCPCS 306 RC inpatient 0.01 0.01 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES HDHP [308136802] 0.01 percent of total billed charges 0.01 0.01 Technical (Hospital) Services Ref Novel Coronavirus Real Time Rt-Pcr Diagnostic Test Panel PX-3060000100 CDM U0001 HCPCS 306 RC inpatient 0.01 0.01 UNITED HEALTHCARE (COMMERCIAL) [3081199] UNITED HEALTHCARE 87726 [308119901] 0.01 percent of total billed charges 0.01 0.01 Technical (Hospital) Services Ref Novel Coronavirus Real Time Rt-Pcr Diagnostic Test Panel PX-3060000100 CDM U0001 HCPCS 306 RC inpatient 0.01 0.01 MEDICA (COMMERCIAL) 94265 [3081118] MEDICA CLAIMS [308111801] 0.01 percent of total billed charges 0.01 0.01 Technical (Hospital) Services Ref Novel Coronavirus Real Time Rt-Pcr Diagnostic Test Panel PX-3060000100 CDM U0001 HCPCS 306 RC inpatient 0.01 0.01 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES PPO [308136801] 0.01 percent of total billed charges 0.01 0.01 Technical (Hospital) Services Ref Novel Coronavirus Real Time Rt-Pcr Diagnostic Test Panel PX-3060000100 CDM U0001 HCPCS 306 RC outpatient 0.01 0.01 CIGNA 62308 [3081051] CIGNA 62308 [308105105] 0.01 percent of total billed charges 0.01 0.01 Technical (Hospital) Services Ref Novel Coronavirus Real Time Rt-Pcr Diagnostic Test Panel PX-3060000100 CDM U0001 HCPCS 306 RC outpatient 0.01 0.01 CIGNA 62308 [3081051] CIGNA STATE OF WYOMING [308105107] 0.01 percent of total billed charges 0.01 0.01 Technical (Hospital) Services Ref Novel Coronavirus Real Time Rt-Pcr Diagnostic Test Panel PX-3060000100 CDM U0001 HCPCS 306 RC outpatient 0.01 0.01 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES EPO [308136803] 0.01 percent of total billed charges 0.01 0.01 Technical (Hospital) Services Ref Novel Coronavirus Real Time Rt-Pcr Diagnostic Test Panel PX-3060000100 CDM U0001 HCPCS 306 RC outpatient 0.01 0.01 BLUE CROSS BLUE SHIELD WELLMARK SB889 [3081026] BCBS WYOMING [308102603] 0.01 percent of total billed charges 0.01 0.01 Technical (Hospital) Services Ref Novel Coronavirus Real Time Rt-Pcr Diagnostic Test Panel PX-3060000100 CDM U0001 HCPCS 306 RC outpatient 0.01 0.01 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES HDHP [308136802] 0.01 percent of total billed charges 0.01 0.01 Technical (Hospital) Services Ref Novel Coronavirus Real Time Rt-Pcr Diagnostic Test Panel PX-3060000100 CDM U0001 HCPCS 306 RC outpatient 0.01 0.01 UNITED HEALTHCARE (COMMERCIAL) [3081199] UNITED HEALTHCARE 87726 [308119901] 0.01 percent of total billed charges 0.01 0.01 Technical (Hospital) Services Ref Novel Coronavirus Real Time Rt-Pcr Diagnostic Test Panel PX-3060000100 CDM U0001 HCPCS 306 RC outpatient 0.01 0.01 HEALTHPARTNERS SX009 HEALTHPARTNERS 0.01 percent of total billed charges 0.01 0.01 Technical (Hospital) Services Ref Novel Coronavirus Real Time Rt-Pcr Diagnostic Test Panel PX-3060000100 CDM U0001 HCPCS 306 RC outpatient 0.01 0.01 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES PPO [308136801] 0.01 percent of total billed charges 0.01 0.01 Technical (Hospital) Services Ref Novel Coronavirus Real Time Rt-Pcr Diagnostic Test Panel PX-3060000100 CDM U0001 HCPCS 306 RC outpatient 0.01 0.01 MULTIPLAN INC 34080 [3081285] MULTIPLAN INC [308128501] 0.01 percent of total billed charges 0.01 0.01 Technical (Hospital) Services Ref Novel Coronavirus Real Time Rt-Pcr Diagnostic Test Panel PX-3060000100 CDM U0001 HCPCS 306 RC outpatient 0.01 0.01 MEDICA (COMMERCIAL) 94265 [3081118] MEDICA CLAIMS [308111801] 0.01 percent of total billed charges 0.01 0.01 Technical (Hospital) Services CLINDAMYCIN 150 MG/ML INJECTION SOLUTION RX-82301 CDM S0077 HCPCS 250 RC 67457-0814-02 NDC outpatient 4 ML 68.73 68.73 CIGNA 62308 [3081051] CIGNA 62308 [308105105] 54.98 percent of total billed charges 42.61 65.29 Technical (Hospital) Services CLINDAMYCIN 150 MG/ML INJECTION SOLUTION RX-82301 CDM S0077 HCPCS 250 RC 67457-0814-02 NDC outpatient 4 ML 68.73 68.73 CIGNA 62308 [3081051] CIGNA STATE OF WYOMING [308105107] 54.98 percent of total billed charges 42.61 65.29 Technical (Hospital) Services CLINDAMYCIN 150 MG/ML INJECTION SOLUTION RX-82301 CDM S0077 HCPCS 250 RC 67457-0814-02 NDC outpatient 4 ML 68.73 68.73 MULTIPLAN INC 34080 [3081285] MULTIPLAN INC [308128501] 65.29 percent of total billed charges 42.61 65.29 Technical (Hospital) Services CLINDAMYCIN 150 MG/ML INJECTION SOLUTION RX-82301 CDM S0077 HCPCS 250 RC 67457-0814-02 NDC outpatient 4 ML 68.73 68.73 MEDICA (COMMERCIAL) 94265 [3081118] MEDICA CLAIMS [308111801] 61.86 percent of total billed charges 42.61 65.29 Technical (Hospital) Services CLINDAMYCIN 150 MG/ML INJECTION SOLUTION RX-82301 CDM S0077 HCPCS 250 RC 67457-0814-02 NDC outpatient 4 ML 68.73 68.73 UNITED HEALTHCARE (COMMERCIAL) [3081199] UNITED HEALTHCARE 87726 [308119901] 42.61 percent of total billed charges 42.61 65.29 Technical (Hospital) Services CLINDAMYCIN 150 MG/ML INJECTION SOLUTION RX-82301 CDM S0077 HCPCS 250 RC 67457-0814-02 NDC outpatient 4 ML 68.73 68.73 HEALTHPARTNERS SX009 HEALTHPARTNERS 54.98 percent of total billed charges 42.61 65.29 Technical (Hospital) Services CLINDAMYCIN 150 MG/ML INJECTION SOLUTION RX-82301 CDM S0077 HCPCS 250 RC 67457-0814-02 NDC outpatient 4 ML 68.73 68.73 BLUE CROSS BLUE SHIELD WELLMARK SB889 [3081026] BCBS WYOMING [308102603] 65.29 percent of total billed charges 42.61 65.29 Technical (Hospital) Services CLINDAMYCIN 150 MG/ML INJECTION SOLUTION RX-82301 CDM S0077 HCPCS 250 RC 67457-0814-02 NDC outpatient 4 ML 68.73 68.73 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES HDHP [308136802] 54.98 percent of total billed charges 42.61 65.29 Technical (Hospital) Services CLINDAMYCIN 150 MG/ML INJECTION SOLUTION RX-82301 CDM S0077 HCPCS 250 RC 67457-0814-02 NDC outpatient 4 ML 68.73 68.73 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES PPO [308136801] 54.98 percent of total billed charges 42.61 65.29 Technical (Hospital) Services CLINDAMYCIN 150 MG/ML INJECTION SOLUTION RX-82301 CDM S0077 HCPCS 250 RC 67457-0814-02 NDC outpatient 4 ML 68.73 68.73 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES EPO [308136803] 54.98 percent of total billed charges 42.61 65.29 Technical (Hospital) Services CLINDAMYCIN 150 MG/ML INJECTION SOLUTION RX-82301 CDM S0077 HCPCS 250 RC 67457-0814-02 NDC inpatient 4 ML 68.73 68.73 UNITED HEALTHCARE (COMMERCIAL) [3081199] UNITED HEALTHCARE 87726 [308119901] 42.61 percent of total billed charges 42.61 65.29 Technical (Hospital) Services CLINDAMYCIN 150 MG/ML INJECTION SOLUTION RX-82301 CDM S0077 HCPCS 250 RC 67457-0814-02 NDC inpatient 4 ML 68.73 68.73 CIGNA 62308 [3081051] CIGNA STATE OF WYOMING [308105107] 54.42 percent of total billed charges 42.61 65.29 Technical (Hospital) Services CLINDAMYCIN 150 MG/ML INJECTION SOLUTION RX-82301 CDM S0077 HCPCS 250 RC 67457-0814-02 NDC inpatient 4 ML 68.73 68.73 CIGNA 62308 [3081051] CIGNA 62308 [308105105] 54.42 percent of total billed charges 42.61 65.29 Technical (Hospital) Services CLINDAMYCIN 150 MG/ML INJECTION SOLUTION RX-82301 CDM S0077 HCPCS 250 RC 67457-0814-02 NDC inpatient 4 ML 68.73 68.73 BLUE CROSS BLUE SHIELD WELLMARK SB889 [3081026] BCBS WYOMING [308102603] 65.29 percent of total billed charges 42.61 65.29 Technical (Hospital) Services CLINDAMYCIN 150 MG/ML INJECTION SOLUTION RX-82301 CDM S0077 HCPCS 250 RC 67457-0814-02 NDC inpatient 4 ML 68.73 68.73 MULTIPLAN INC 34080 [3081285] MULTIPLAN INC [308128501] 65.29 percent of total billed charges 42.61 65.29 Technical (Hospital) Services CLINDAMYCIN 150 MG/ML INJECTION SOLUTION RX-82301 CDM S0077 HCPCS 250 RC 67457-0814-02 NDC inpatient 4 ML 68.73 68.73 MEDICA (COMMERCIAL) 94265 [3081118] MEDICA CLAIMS [308111801] 61.86 percent of total billed charges 42.61 65.29 Technical (Hospital) Services CLINDAMYCIN 150 MG/ML INJECTION SOLUTION RX-82301 CDM S0077 HCPCS 250 RC 67457-0814-02 NDC inpatient 4 ML 68.73 68.73 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES EPO [308136803] 54.42 percent of total billed charges 42.61 65.29 Technical (Hospital) Services CLINDAMYCIN 150 MG/ML INJECTION SOLUTION RX-82301 CDM S0077 HCPCS 250 RC 67457-0814-02 NDC inpatient 4 ML 68.73 68.73 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES HDHP [308136802] 54.42 percent of total billed charges 42.61 65.29 Technical (Hospital) Services CLINDAMYCIN 150 MG/ML INJECTION SOLUTION RX-82301 CDM S0077 HCPCS 250 RC 67457-0814-02 NDC inpatient 4 ML 68.73 68.73 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES PPO [308136801] 54.42 percent of total billed charges 42.61 65.29 Technical (Hospital) Services CLINDAMYCIN 150 MG/ML INJECTION SOLUTION RX-82301 CDM S0077 HCPCS 250 RC 67457-0814-02 NDC inpatient 4 ML 68.73 68.73 HEALTHPARTNERS SX009 HEALTHPARTNERS 54.42 percent of total billed charges 42.61 65.29 Technical (Hospital) Services CLINDAMYCIN 300 MG/50 ML IN 5 % DEXTROSE INTRAVENOUS PIGGYBACK RX-9625 CDM S0077 HCPCS 250 RC 00781-3288-91 NDC inpatient 50 ML 7.85 7.85 MULTIPLAN INC 34080 [3081285] MULTIPLAN INC [308128501] 7.46 percent of total billed charges 4.87 7.46 Technical (Hospital) Services CLINDAMYCIN 300 MG/50 ML IN 5 % DEXTROSE INTRAVENOUS PIGGYBACK RX-9625 CDM S0077 HCPCS 250 RC 00781-3288-91 NDC inpatient 50 ML 7.85 7.85 MEDICA (COMMERCIAL) 94265 [3081118] MEDICA CLAIMS [308111801] 7.07 percent of total billed charges 4.87 7.46 Technical (Hospital) Services CLINDAMYCIN 300 MG/50 ML IN 5 % DEXTROSE INTRAVENOUS PIGGYBACK RX-9625 CDM S0077 HCPCS 250 RC 00781-3288-91 NDC inpatient 50 ML 7.85 7.85 HEALTHPARTNERS SX009 HEALTHPARTNERS 6.22 percent of total billed charges 4.87 7.46 Technical (Hospital) Services CLINDAMYCIN 300 MG/50 ML IN 5 % DEXTROSE INTRAVENOUS PIGGYBACK RX-9625 CDM S0077 HCPCS 250 RC 00781-3288-91 NDC inpatient 50 ML 7.85 7.85 UNITED HEALTHCARE (COMMERCIAL) [3081199] UNITED HEALTHCARE 87726 [308119901] 4.87 percent of total billed charges 4.87 7.46 Technical (Hospital) Services CLINDAMYCIN 300 MG/50 ML IN 5 % DEXTROSE INTRAVENOUS PIGGYBACK RX-9625 CDM S0077 HCPCS 250 RC 00781-3288-91 NDC inpatient 50 ML 7.85 7.85 BLUE CROSS BLUE SHIELD WELLMARK SB889 [3081026] BCBS WYOMING [308102603] 7.46 percent of total billed charges 4.87 7.46 Technical (Hospital) Services CLINDAMYCIN 300 MG/50 ML IN 5 % DEXTROSE INTRAVENOUS PIGGYBACK RX-9625 CDM S0077 HCPCS 250 RC 00781-3288-91 NDC inpatient 50 ML 7.85 7.85 CIGNA 62308 [3081051] CIGNA 62308 [308105105] 6.22 percent of total billed charges 4.87 7.46 Technical (Hospital) Services CLINDAMYCIN 300 MG/50 ML IN 5 % DEXTROSE INTRAVENOUS PIGGYBACK RX-9625 CDM S0077 HCPCS 250 RC 00781-3288-91 NDC inpatient 50 ML 7.85 7.85 CIGNA 62308 [3081051] CIGNA STATE OF WYOMING [308105107] 6.22 percent of total billed charges 4.87 7.46 Technical (Hospital) Services CLINDAMYCIN 300 MG/50 ML IN 5 % DEXTROSE INTRAVENOUS PIGGYBACK RX-9625 CDM S0077 HCPCS 250 RC 00781-3288-91 NDC inpatient 50 ML 7.85 7.85 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES EPO [308136803] 6.22 percent of total billed charges 4.87 7.46 Technical (Hospital) Services CLINDAMYCIN 300 MG/50 ML IN 5 % DEXTROSE INTRAVENOUS PIGGYBACK RX-9625 CDM S0077 HCPCS 250 RC 00781-3288-91 NDC inpatient 50 ML 7.85 7.85 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES HDHP [308136802] 6.22 percent of total billed charges 4.87 7.46 Technical (Hospital) Services CLINDAMYCIN 300 MG/50 ML IN 5 % DEXTROSE INTRAVENOUS PIGGYBACK RX-9625 CDM S0077 HCPCS 250 RC 00781-3288-91 NDC inpatient 50 ML 7.85 7.85 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES PPO [308136801] 6.22 percent of total billed charges 4.87 7.46 Technical (Hospital) Services CLINDAMYCIN 300 MG/50 ML IN 5 % DEXTROSE INTRAVENOUS PIGGYBACK RX-9625 CDM S0077 HCPCS 250 RC 00781-3288-91 NDC outpatient 50 ML 7.85 7.85 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES HDHP [308136802] 6.28 percent of total billed charges 4.87 7.46 Technical (Hospital) Services CLINDAMYCIN 300 MG/50 ML IN 5 % DEXTROSE INTRAVENOUS PIGGYBACK RX-9625 CDM S0077 HCPCS 250 RC 00781-3288-91 NDC outpatient 50 ML 7.85 7.85 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES PPO [308136801] 6.28 percent of total billed charges 4.87 7.46 Technical (Hospital) Services CLINDAMYCIN 300 MG/50 ML IN 5 % DEXTROSE INTRAVENOUS PIGGYBACK RX-9625 CDM S0077 HCPCS 250 RC 00781-3288-91 NDC outpatient 50 ML 7.85 7.85 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES EPO [308136803] 6.28 percent of total billed charges 4.87 7.46 Technical (Hospital) Services CLINDAMYCIN 300 MG/50 ML IN 5 % DEXTROSE INTRAVENOUS PIGGYBACK RX-9625 CDM S0077 HCPCS 250 RC 00781-3288-91 NDC outpatient 50 ML 7.85 7.85 UNITED HEALTHCARE (COMMERCIAL) [3081199] UNITED HEALTHCARE 87726 [308119901] 4.87 percent of total billed charges 4.87 7.46 Technical (Hospital) Services CLINDAMYCIN 300 MG/50 ML IN 5 % DEXTROSE INTRAVENOUS PIGGYBACK RX-9625 CDM S0077 HCPCS 250 RC 00781-3288-91 NDC outpatient 50 ML 7.85 7.85 BLUE CROSS BLUE SHIELD WELLMARK SB889 [3081026] BCBS WYOMING [308102603] 7.46 percent of total billed charges 4.87 7.46 Technical (Hospital) Services CLINDAMYCIN 300 MG/50 ML IN 5 % DEXTROSE INTRAVENOUS PIGGYBACK RX-9625 CDM S0077 HCPCS 250 RC 00781-3288-91 NDC outpatient 50 ML 7.85 7.85 HEALTHPARTNERS SX009 HEALTHPARTNERS 6.28 percent of total billed charges 4.87 7.46 Technical (Hospital) Services CLINDAMYCIN 300 MG/50 ML IN 5 % DEXTROSE INTRAVENOUS PIGGYBACK RX-9625 CDM S0077 HCPCS 250 RC 00781-3288-91 NDC outpatient 50 ML 7.85 7.85 MULTIPLAN INC 34080 [3081285] MULTIPLAN INC [308128501] 7.46 percent of total billed charges 4.87 7.46 Technical (Hospital) Services CLINDAMYCIN 300 MG/50 ML IN 5 % DEXTROSE INTRAVENOUS PIGGYBACK RX-9625 CDM S0077 HCPCS 250 RC 00781-3288-91 NDC outpatient 50 ML 7.85 7.85 MEDICA (COMMERCIAL) 94265 [3081118] MEDICA CLAIMS [308111801] 7.07 percent of total billed charges 4.87 7.46 Technical (Hospital) Services CLINDAMYCIN 300 MG/50 ML IN 5 % DEXTROSE INTRAVENOUS PIGGYBACK RX-9625 CDM S0077 HCPCS 250 RC 00781-3288-91 NDC outpatient 50 ML 7.85 7.85 CIGNA 62308 [3081051] CIGNA 62308 [308105105] 6.28 percent of total billed charges 4.87 7.46 Technical (Hospital) Services CLINDAMYCIN 300 MG/50 ML IN 5 % DEXTROSE INTRAVENOUS PIGGYBACK RX-9625 CDM S0077 HCPCS 250 RC 00781-3288-91 NDC outpatient 50 ML 7.85 7.85 CIGNA 62308 [3081051] CIGNA STATE OF WYOMING [308105107] 6.28 percent of total billed charges 4.87 7.46 Technical (Hospital) Services NAFCILLIN 2 GRAM SOLUTION FOR INJECTION RX-5335 CDM S0032 HCPCS 250 RC 63323-0328-20 NDC inpatient 8 ML 171.67 171.67 MEDICA (COMMERCIAL) 94265 [3081118] MEDICA CLAIMS [308111801] 154.5 percent of total billed charges 106.44 163.09 Technical (Hospital) Services NAFCILLIN 2 GRAM SOLUTION FOR INJECTION RX-5335 CDM S0032 HCPCS 250 RC 63323-0328-20 NDC inpatient 8 ML 171.67 171.67 MULTIPLAN INC 34080 [3081285] MULTIPLAN INC [308128501] 163.09 percent of total billed charges 106.44 163.09 Technical (Hospital) Services NAFCILLIN 2 GRAM SOLUTION FOR INJECTION RX-5335 CDM S0032 HCPCS 250 RC 63323-0328-20 NDC inpatient 8 ML 171.67 171.67 CIGNA 62308 [3081051] CIGNA 62308 [308105105] 135.93 percent of total billed charges 106.44 163.09 Technical (Hospital) Services NAFCILLIN 2 GRAM SOLUTION FOR INJECTION RX-5335 CDM S0032 HCPCS 250 RC 63323-0328-20 NDC inpatient 8 ML 171.67 171.67 CIGNA 62308 [3081051] CIGNA STATE OF WYOMING [308105107] 135.93 percent of total billed charges 106.44 163.09 Technical (Hospital) Services NAFCILLIN 2 GRAM SOLUTION FOR INJECTION RX-5335 CDM S0032 HCPCS 250 RC 63323-0328-20 NDC inpatient 8 ML 171.67 171.67 UNITED HEALTHCARE (COMMERCIAL) [3081199] UNITED HEALTHCARE 87726 [308119901] 106.44 percent of total billed charges 106.44 163.09 Technical (Hospital) Services NAFCILLIN 2 GRAM SOLUTION FOR INJECTION RX-5335 CDM S0032 HCPCS 250 RC 63323-0328-20 NDC inpatient 8 ML 171.67 171.67 BLUE CROSS BLUE SHIELD WELLMARK SB889 [3081026] BCBS WYOMING [308102603] 163.09 percent of total billed charges 106.44 163.09 Technical (Hospital) Services NAFCILLIN 2 GRAM SOLUTION FOR INJECTION RX-5335 CDM S0032 HCPCS 250 RC 63323-0328-20 NDC inpatient 8 ML 171.67 171.67 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES HDHP [308136802] 135.93 percent of total billed charges 106.44 163.09 Technical (Hospital) Services NAFCILLIN 2 GRAM SOLUTION FOR INJECTION RX-5335 CDM S0032 HCPCS 250 RC 63323-0328-20 NDC inpatient 8 ML 171.67 171.67 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES PPO [308136801] 135.93 percent of total billed charges 106.44 163.09 Technical (Hospital) Services NAFCILLIN 2 GRAM SOLUTION FOR INJECTION RX-5335 CDM S0032 HCPCS 250 RC 63323-0328-20 NDC inpatient 8 ML 171.67 171.67 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES EPO [308136803] 135.93 percent of total billed charges 106.44 163.09 Technical (Hospital) Services NAFCILLIN 2 GRAM SOLUTION FOR INJECTION RX-5335 CDM S0032 HCPCS 250 RC 63323-0328-20 NDC inpatient 8 ML 171.67 171.67 HEALTHPARTNERS SX009 HEALTHPARTNERS 135.93 percent of total billed charges 106.44 163.09 Technical (Hospital) Services NAFCILLIN 2 GRAM SOLUTION FOR INJECTION RX-5335 CDM S0032 HCPCS 250 RC 63323-0328-20 NDC outpatient 8 ML 171.67 171.67 BLUE CROSS BLUE SHIELD WELLMARK SB889 [3081026] BCBS WYOMING [308102603] 163.09 percent of total billed charges 106.44 163.09 Technical (Hospital) Services NAFCILLIN 2 GRAM SOLUTION FOR INJECTION RX-5335 CDM S0032 HCPCS 250 RC 63323-0328-20 NDC outpatient 8 ML 171.67 171.67 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES EPO [308136803] 137.34 percent of total billed charges 106.44 163.09 Technical (Hospital) Services NAFCILLIN 2 GRAM SOLUTION FOR INJECTION RX-5335 CDM S0032 HCPCS 250 RC 63323-0328-20 NDC outpatient 8 ML 171.67 171.67 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES HDHP [308136802] 137.34 percent of total billed charges 106.44 163.09 Technical (Hospital) Services NAFCILLIN 2 GRAM SOLUTION FOR INJECTION RX-5335 CDM S0032 HCPCS 250 RC 63323-0328-20 NDC outpatient 8 ML 171.67 171.67 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES PPO [308136801] 137.34 percent of total billed charges 106.44 163.09 Technical (Hospital) Services NAFCILLIN 2 GRAM SOLUTION FOR INJECTION RX-5335 CDM S0032 HCPCS 250 RC 63323-0328-20 NDC outpatient 8 ML 171.67 171.67 HEALTHPARTNERS SX009 HEALTHPARTNERS 137.34 percent of total billed charges 106.44 163.09 Technical (Hospital) Services NAFCILLIN 2 GRAM SOLUTION FOR INJECTION RX-5335 CDM S0032 HCPCS 250 RC 63323-0328-20 NDC outpatient 8 ML 171.67 171.67 UNITED HEALTHCARE (COMMERCIAL) [3081199] UNITED HEALTHCARE 87726 [308119901] 106.44 percent of total billed charges 106.44 163.09 Technical (Hospital) Services NAFCILLIN 2 GRAM SOLUTION FOR INJECTION RX-5335 CDM S0032 HCPCS 250 RC 63323-0328-20 NDC outpatient 8 ML 171.67 171.67 MEDICA (COMMERCIAL) 94265 [3081118] MEDICA CLAIMS [308111801] 154.5 percent of total billed charges 106.44 163.09 Technical (Hospital) Services NAFCILLIN 2 GRAM SOLUTION FOR INJECTION RX-5335 CDM S0032 HCPCS 250 RC 63323-0328-20 NDC outpatient 8 ML 171.67 171.67 MULTIPLAN INC 34080 [3081285] MULTIPLAN INC [308128501] 163.09 percent of total billed charges 106.44 163.09 Technical (Hospital) Services NAFCILLIN 2 GRAM SOLUTION FOR INJECTION RX-5335 CDM S0032 HCPCS 250 RC 63323-0328-20 NDC outpatient 8 ML 171.67 171.67 CIGNA 62308 [3081051] CIGNA 62308 [308105105] 137.34 percent of total billed charges 106.44 163.09 Technical (Hospital) Services NAFCILLIN 2 GRAM SOLUTION FOR INJECTION RX-5335 CDM S0032 HCPCS 250 RC 63323-0328-20 NDC outpatient 8 ML 171.67 171.67 CIGNA 62308 [3081051] CIGNA STATE OF WYOMING [308105107] 137.34 percent of total billed charges 106.44 163.09 Technical (Hospital) Services PEGFILGRASTIM-BMEZ 6 MG/0.6 ML SUBCUTANEOUS SYRINGE RX-178593 CDM Q5120 HCPCS 636 RC 61314-0866-01 NDC outpatient 0.6 ML 6375.53 6375.53 BLUE CROSS BLUE SHIELD WELLMARK SB889 [3081026] BCBS WYOMING [308102603] 6056.75 percent of total billed charges 3952.83 6056.75 Technical (Hospital) Services PEGFILGRASTIM-BMEZ 6 MG/0.6 ML SUBCUTANEOUS SYRINGE RX-178593 CDM Q5120 HCPCS 636 RC 61314-0866-01 NDC outpatient 0.6 ML 6375.53 6375.53 HEALTHPARTNERS SX009 HEALTHPARTNERS 5100.42 percent of total billed charges 3952.83 6056.75 Technical (Hospital) Services PEGFILGRASTIM-BMEZ 6 MG/0.6 ML SUBCUTANEOUS SYRINGE RX-178593 CDM Q5120 HCPCS 636 RC 61314-0866-01 NDC outpatient 0.6 ML 6375.53 6375.53 MEDICA (COMMERCIAL) 94265 [3081118] MEDICA CLAIMS [308111801] 5737.98 percent of total billed charges 3952.83 6056.75 Technical (Hospital) Services PEGFILGRASTIM-BMEZ 6 MG/0.6 ML SUBCUTANEOUS SYRINGE RX-178593 CDM Q5120 HCPCS 636 RC 61314-0866-01 NDC outpatient 0.6 ML 6375.53 6375.53 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES HDHP [308136802] 5100.42 percent of total billed charges 3952.83 6056.75 Technical (Hospital) Services PEGFILGRASTIM-BMEZ 6 MG/0.6 ML SUBCUTANEOUS SYRINGE RX-178593 CDM Q5120 HCPCS 636 RC 61314-0866-01 NDC outpatient 0.6 ML 6375.53 6375.53 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES PPO [308136801] 5100.42 percent of total billed charges 3952.83 6056.75 Technical (Hospital) Services PEGFILGRASTIM-BMEZ 6 MG/0.6 ML SUBCUTANEOUS SYRINGE RX-178593 CDM Q5120 HCPCS 636 RC 61314-0866-01 NDC outpatient 0.6 ML 6375.53 6375.53 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES EPO [308136803] 5100.42 percent of total billed charges 3952.83 6056.75 Technical (Hospital) Services PEGFILGRASTIM-BMEZ 6 MG/0.6 ML SUBCUTANEOUS SYRINGE RX-178593 CDM Q5120 HCPCS 636 RC 61314-0866-01 NDC outpatient 0.6 ML 6375.53 6375.53 UNITED HEALTHCARE (COMMERCIAL) [3081199] UNITED HEALTHCARE 87726 [308119901] 3952.83 percent of total billed charges 3952.83 6056.75 Technical (Hospital) Services PEGFILGRASTIM-BMEZ 6 MG/0.6 ML SUBCUTANEOUS SYRINGE RX-178593 CDM Q5120 HCPCS 636 RC 61314-0866-01 NDC outpatient 0.6 ML 6375.53 6375.53 MULTIPLAN INC 34080 [3081285] MULTIPLAN INC [308128501] 6056.75 percent of total billed charges 3952.83 6056.75 Technical (Hospital) Services PEGFILGRASTIM-BMEZ 6 MG/0.6 ML SUBCUTANEOUS SYRINGE RX-178593 CDM Q5120 HCPCS 636 RC 61314-0866-01 NDC outpatient 0.6 ML 6375.53 6375.53 CIGNA 62308 [3081051] CIGNA 62308 [308105105] 5100.42 percent of total billed charges 3952.83 6056.75 Technical (Hospital) Services PEGFILGRASTIM-BMEZ 6 MG/0.6 ML SUBCUTANEOUS SYRINGE RX-178593 CDM Q5120 HCPCS 636 RC 61314-0866-01 NDC outpatient 0.6 ML 6375.53 6375.53 CIGNA 62308 [3081051] CIGNA STATE OF WYOMING [308105107] 5100.42 percent of total billed charges 3952.83 6056.75 Technical (Hospital) Services PEGFILGRASTIM-BMEZ 6 MG/0.6 ML SUBCUTANEOUS SYRINGE RX-178593 CDM Q5120 HCPCS 636 RC 61314-0866-01 NDC inpatient 0.6 ML 6375.53 6375.53 BLUE CROSS BLUE SHIELD WELLMARK SB889 [3081026] BCBS WYOMING [308102603] 6056.75 percent of total billed charges 3952.83 6056.75 Technical (Hospital) Services PEGFILGRASTIM-BMEZ 6 MG/0.6 ML SUBCUTANEOUS SYRINGE RX-178593 CDM Q5120 HCPCS 636 RC 61314-0866-01 NDC inpatient 0.6 ML 6375.53 6375.53 UNITED HEALTHCARE (COMMERCIAL) [3081199] UNITED HEALTHCARE 87726 [308119901] 3952.83 percent of total billed charges 3952.83 6056.75 Technical (Hospital) Services PEGFILGRASTIM-BMEZ 6 MG/0.6 ML SUBCUTANEOUS SYRINGE RX-178593 CDM Q5120 HCPCS 636 RC 61314-0866-01 NDC inpatient 0.6 ML 6375.53 6375.53 MEDICA (COMMERCIAL) 94265 [3081118] MEDICA CLAIMS [308111801] 5737.98 percent of total billed charges 3952.83 6056.75 Technical (Hospital) Services PEGFILGRASTIM-BMEZ 6 MG/0.6 ML SUBCUTANEOUS SYRINGE RX-178593 CDM Q5120 HCPCS 636 RC 61314-0866-01 NDC inpatient 0.6 ML 6375.53 6375.53 HEALTHPARTNERS SX009 HEALTHPARTNERS 5048.14 percent of total billed charges 3952.83 6056.75 Technical (Hospital) Services PEGFILGRASTIM-BMEZ 6 MG/0.6 ML SUBCUTANEOUS SYRINGE RX-178593 CDM Q5120 HCPCS 636 RC 61314-0866-01 NDC inpatient 0.6 ML 6375.53 6375.53 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES PPO [308136801] 5048.14 percent of total billed charges 3952.83 6056.75 Technical (Hospital) Services PEGFILGRASTIM-BMEZ 6 MG/0.6 ML SUBCUTANEOUS SYRINGE RX-178593 CDM Q5120 HCPCS 636 RC 61314-0866-01 NDC inpatient 0.6 ML 6375.53 6375.53 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES EPO [308136803] 5048.14 percent of total billed charges 3952.83 6056.75 Technical (Hospital) Services PEGFILGRASTIM-BMEZ 6 MG/0.6 ML SUBCUTANEOUS SYRINGE RX-178593 CDM Q5120 HCPCS 636 RC 61314-0866-01 NDC inpatient 0.6 ML 6375.53 6375.53 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES HDHP [308136802] 5048.14 percent of total billed charges 3952.83 6056.75 Technical (Hospital) Services PEGFILGRASTIM-BMEZ 6 MG/0.6 ML SUBCUTANEOUS SYRINGE RX-178593 CDM Q5120 HCPCS 636 RC 61314-0866-01 NDC inpatient 0.6 ML 6375.53 6375.53 CIGNA 62308 [3081051] CIGNA 62308 [308105105] 5048.14 percent of total billed charges 3952.83 6056.75 Technical (Hospital) Services PEGFILGRASTIM-BMEZ 6 MG/0.6 ML SUBCUTANEOUS SYRINGE RX-178593 CDM Q5120 HCPCS 636 RC 61314-0866-01 NDC inpatient 0.6 ML 6375.53 6375.53 CIGNA 62308 [3081051] CIGNA STATE OF WYOMING [308105107] 5048.14 percent of total billed charges 3952.83 6056.75 Technical (Hospital) Services PEGFILGRASTIM-BMEZ 6 MG/0.6 ML SUBCUTANEOUS SYRINGE RX-178593 CDM Q5120 HCPCS 636 RC 61314-0866-01 NDC inpatient 0.6 ML 6375.53 6375.53 MULTIPLAN INC 34080 [3081285] MULTIPLAN INC [308128501] 6056.75 percent of total billed charges 3952.83 6056.75 Technical (Hospital) Services PEGFILGRASTIM-CBQV 6 MG/0.6 ML SUBCUTANEOUS SYRINGE RX-175906 CDM Q5111 HCPCS 636 RC 70114-0101-01 NDC outpatient 0.6 ML 6625 6625 CIGNA 62308 [3081051] CIGNA 62308 [308105105] 5300 percent of total billed charges 4107.5 6293.75 Technical (Hospital) Services PEGFILGRASTIM-CBQV 6 MG/0.6 ML SUBCUTANEOUS SYRINGE RX-175906 CDM Q5111 HCPCS 636 RC 70114-0101-01 NDC outpatient 0.6 ML 6625 6625 CIGNA 62308 [3081051] CIGNA STATE OF WYOMING [308105107] 5300 percent of total billed charges 4107.5 6293.75 Technical (Hospital) Services PEGFILGRASTIM-CBQV 6 MG/0.6 ML SUBCUTANEOUS SYRINGE RX-175906 CDM Q5111 HCPCS 636 RC 70114-0101-01 NDC outpatient 0.6 ML 6625 6625 MULTIPLAN INC 34080 [3081285] MULTIPLAN INC [308128501] 6293.75 percent of total billed charges 4107.5 6293.75 Technical (Hospital) Services PEGFILGRASTIM-CBQV 6 MG/0.6 ML SUBCUTANEOUS SYRINGE RX-175906 CDM Q5111 HCPCS 636 RC 70114-0101-01 NDC outpatient 0.6 ML 6625 6625 UNITED HEALTHCARE (COMMERCIAL) [3081199] UNITED HEALTHCARE 87726 [308119901] 4107.5 percent of total billed charges 4107.5 6293.75 Technical (Hospital) Services PEGFILGRASTIM-CBQV 6 MG/0.6 ML SUBCUTANEOUS SYRINGE RX-175906 CDM Q5111 HCPCS 636 RC 70114-0101-01 NDC outpatient 0.6 ML 6625 6625 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES EPO [308136803] 5300 percent of total billed charges 4107.5 6293.75 Technical (Hospital) Services PEGFILGRASTIM-CBQV 6 MG/0.6 ML SUBCUTANEOUS SYRINGE RX-175906 CDM Q5111 HCPCS 636 RC 70114-0101-01 NDC outpatient 0.6 ML 6625 6625 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES HDHP [308136802] 5300 percent of total billed charges 4107.5 6293.75 Technical (Hospital) Services PEGFILGRASTIM-CBQV 6 MG/0.6 ML SUBCUTANEOUS SYRINGE RX-175906 CDM Q5111 HCPCS 636 RC 70114-0101-01 NDC outpatient 0.6 ML 6625 6625 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES PPO [308136801] 5300 percent of total billed charges 4107.5 6293.75 Technical (Hospital) Services PEGFILGRASTIM-CBQV 6 MG/0.6 ML SUBCUTANEOUS SYRINGE RX-175906 CDM Q5111 HCPCS 636 RC 70114-0101-01 NDC outpatient 0.6 ML 6625 6625 MEDICA (COMMERCIAL) 94265 [3081118] MEDICA CLAIMS [308111801] 5962.5 percent of total billed charges 4107.5 6293.75 Technical (Hospital) Services PEGFILGRASTIM-CBQV 6 MG/0.6 ML SUBCUTANEOUS SYRINGE RX-175906 CDM Q5111 HCPCS 636 RC 70114-0101-01 NDC outpatient 0.6 ML 6625 6625 HEALTHPARTNERS SX009 HEALTHPARTNERS 5300 percent of total billed charges 4107.5 6293.75 Technical (Hospital) Services PEGFILGRASTIM-CBQV 6 MG/0.6 ML SUBCUTANEOUS SYRINGE RX-175906 CDM Q5111 HCPCS 636 RC 70114-0101-01 NDC outpatient 0.6 ML 6625 6625 BLUE CROSS BLUE SHIELD WELLMARK SB889 [3081026] BCBS WYOMING [308102603] 6293.75 percent of total billed charges 4107.5 6293.75 Technical (Hospital) Services PEGFILGRASTIM-CBQV 6 MG/0.6 ML SUBCUTANEOUS SYRINGE RX-175906 CDM Q5111 HCPCS 636 RC 70114-0101-01 NDC inpatient 0.6 ML 6625 6625 HEALTHPARTNERS SX009 HEALTHPARTNERS 5245.68 percent of total billed charges 4107.5 6293.75 Technical (Hospital) Services PEGFILGRASTIM-CBQV 6 MG/0.6 ML SUBCUTANEOUS SYRINGE RX-175906 CDM Q5111 HCPCS 636 RC 70114-0101-01 NDC inpatient 0.6 ML 6625 6625 MEDICA (COMMERCIAL) 94265 [3081118] MEDICA CLAIMS [308111801] 5962.5 percent of total billed charges 4107.5 6293.75 Technical (Hospital) Services PEGFILGRASTIM-CBQV 6 MG/0.6 ML SUBCUTANEOUS SYRINGE RX-175906 CDM Q5111 HCPCS 636 RC 70114-0101-01 NDC inpatient 0.6 ML 6625 6625 MULTIPLAN INC 34080 [3081285] MULTIPLAN INC [308128501] 6293.75 percent of total billed charges 4107.5 6293.75 Technical (Hospital) Services PEGFILGRASTIM-CBQV 6 MG/0.6 ML SUBCUTANEOUS SYRINGE RX-175906 CDM Q5111 HCPCS 636 RC 70114-0101-01 NDC inpatient 0.6 ML 6625 6625 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES EPO [308136803] 5245.68 percent of total billed charges 4107.5 6293.75 Technical (Hospital) Services PEGFILGRASTIM-CBQV 6 MG/0.6 ML SUBCUTANEOUS SYRINGE RX-175906 CDM Q5111 HCPCS 636 RC 70114-0101-01 NDC inpatient 0.6 ML 6625 6625 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES HDHP [308136802] 5245.68 percent of total billed charges 4107.5 6293.75 Technical (Hospital) Services PEGFILGRASTIM-CBQV 6 MG/0.6 ML SUBCUTANEOUS SYRINGE RX-175906 CDM Q5111 HCPCS 636 RC 70114-0101-01 NDC inpatient 0.6 ML 6625 6625 CIGNA 62308 [3081051] CIGNA 62308 [308105105] 5245.68 percent of total billed charges 4107.5 6293.75 Technical (Hospital) Services PEGFILGRASTIM-CBQV 6 MG/0.6 ML SUBCUTANEOUS SYRINGE RX-175906 CDM Q5111 HCPCS 636 RC 70114-0101-01 NDC inpatient 0.6 ML 6625 6625 CIGNA 62308 [3081051] CIGNA STATE OF WYOMING [308105107] 5245.68 percent of total billed charges 4107.5 6293.75 Technical (Hospital) Services PEGFILGRASTIM-CBQV 6 MG/0.6 ML SUBCUTANEOUS SYRINGE RX-175906 CDM Q5111 HCPCS 636 RC 70114-0101-01 NDC inpatient 0.6 ML 6625 6625 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES PPO [308136801] 5245.68 percent of total billed charges 4107.5 6293.75 Technical (Hospital) Services PEGFILGRASTIM-CBQV 6 MG/0.6 ML SUBCUTANEOUS SYRINGE RX-175906 CDM Q5111 HCPCS 636 RC 70114-0101-01 NDC inpatient 0.6 ML 6625 6625 UNITED HEALTHCARE (COMMERCIAL) [3081199] UNITED HEALTHCARE 87726 [308119901] 4107.5 percent of total billed charges 4107.5 6293.75 Technical (Hospital) Services PEGFILGRASTIM-CBQV 6 MG/0.6 ML SUBCUTANEOUS SYRINGE RX-175906 CDM Q5111 HCPCS 636 RC 70114-0101-01 NDC inpatient 0.6 ML 6625 6625 BLUE CROSS BLUE SHIELD WELLMARK SB889 [3081026] BCBS WYOMING [308102603] 6293.75 percent of total billed charges 4107.5 6293.75 Technical (Hospital) Services FILGRASTIM-SNDZ 300 MCG/0.5 ML INJECTION SYRINGE RX-129453 CDM Q5101 HCPCS 636 RC 61314-0318-01 NDC outpatient 0.5 ML 674.36 674.36 BLUE CROSS BLUE SHIELD WELLMARK SB889 [3081026] BCBS WYOMING [308102603] 640.64 percent of total billed charges 418.1 640.64 Technical (Hospital) Services FILGRASTIM-SNDZ 300 MCG/0.5 ML INJECTION SYRINGE RX-129453 CDM Q5101 HCPCS 636 RC 61314-0318-01 NDC outpatient 0.5 ML 674.36 674.36 HEALTHPARTNERS SX009 HEALTHPARTNERS 539.49 percent of total billed charges 418.1 640.64 Technical (Hospital) Services FILGRASTIM-SNDZ 300 MCG/0.5 ML INJECTION SYRINGE RX-129453 CDM Q5101 HCPCS 636 RC 61314-0318-01 NDC outpatient 0.5 ML 674.36 674.36 UNITED HEALTHCARE (COMMERCIAL) [3081199] UNITED HEALTHCARE 87726 [308119901] 418.1 percent of total billed charges 418.1 640.64 Technical (Hospital) Services FILGRASTIM-SNDZ 300 MCG/0.5 ML INJECTION SYRINGE RX-129453 CDM Q5101 HCPCS 636 RC 61314-0318-01 NDC outpatient 0.5 ML 674.36 674.36 MULTIPLAN INC 34080 [3081285] MULTIPLAN INC [308128501] 640.64 percent of total billed charges 418.1 640.64 Technical (Hospital) Services FILGRASTIM-SNDZ 300 MCG/0.5 ML INJECTION SYRINGE RX-129453 CDM Q5101 HCPCS 636 RC 61314-0318-01 NDC outpatient 0.5 ML 674.36 674.36 CIGNA 62308 [3081051] CIGNA 62308 [308105105] 539.49 percent of total billed charges 418.1 640.64 Technical (Hospital) Services FILGRASTIM-SNDZ 300 MCG/0.5 ML INJECTION SYRINGE RX-129453 CDM Q5101 HCPCS 636 RC 61314-0318-01 NDC outpatient 0.5 ML 674.36 674.36 CIGNA 62308 [3081051] CIGNA STATE OF WYOMING [308105107] 539.49 percent of total billed charges 418.1 640.64 Technical (Hospital) Services FILGRASTIM-SNDZ 300 MCG/0.5 ML INJECTION SYRINGE RX-129453 CDM Q5101 HCPCS 636 RC 61314-0318-01 NDC outpatient 0.5 ML 674.36 674.36 MEDICA (COMMERCIAL) 94265 [3081118] MEDICA CLAIMS [308111801] 606.92 percent of total billed charges 418.1 640.64 Technical (Hospital) Services FILGRASTIM-SNDZ 300 MCG/0.5 ML INJECTION SYRINGE RX-129453 CDM Q5101 HCPCS 636 RC 61314-0318-01 NDC outpatient 0.5 ML 674.36 674.36 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES HDHP [308136802] 539.49 percent of total billed charges 418.1 640.64 Technical (Hospital) Services FILGRASTIM-SNDZ 300 MCG/0.5 ML INJECTION SYRINGE RX-129453 CDM Q5101 HCPCS 636 RC 61314-0318-01 NDC outpatient 0.5 ML 674.36 674.36 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES PPO [308136801] 539.49 percent of total billed charges 418.1 640.64 Technical (Hospital) Services FILGRASTIM-SNDZ 300 MCG/0.5 ML INJECTION SYRINGE RX-129453 CDM Q5101 HCPCS 636 RC 61314-0318-01 NDC outpatient 0.5 ML 674.36 674.36 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES EPO [308136803] 539.49 percent of total billed charges 418.1 640.64 Technical (Hospital) Services FILGRASTIM-SNDZ 300 MCG/0.5 ML INJECTION SYRINGE RX-129453 CDM Q5101 HCPCS 636 RC 61314-0318-01 NDC inpatient 0.5 ML 674.36 674.36 BLUE CROSS BLUE SHIELD WELLMARK SB889 [3081026] BCBS WYOMING [308102603] 640.64 percent of total billed charges 418.1 640.64 Technical (Hospital) Services FILGRASTIM-SNDZ 300 MCG/0.5 ML INJECTION SYRINGE RX-129453 CDM Q5101 HCPCS 636 RC 61314-0318-01 NDC inpatient 0.5 ML 674.36 674.36 UNITED HEALTHCARE (COMMERCIAL) [3081199] UNITED HEALTHCARE 87726 [308119901] 418.1 percent of total billed charges 418.1 640.64 Technical (Hospital) Services FILGRASTIM-SNDZ 300 MCG/0.5 ML INJECTION SYRINGE RX-129453 CDM Q5101 HCPCS 636 RC 61314-0318-01 NDC inpatient 0.5 ML 674.36 674.36 HEALTHPARTNERS SX009 HEALTHPARTNERS 533.96 percent of total billed charges 418.1 640.64 Technical (Hospital) Services FILGRASTIM-SNDZ 300 MCG/0.5 ML INJECTION SYRINGE RX-129453 CDM Q5101 HCPCS 636 RC 61314-0318-01 NDC inpatient 0.5 ML 674.36 674.36 MEDICA (COMMERCIAL) 94265 [3081118] MEDICA CLAIMS [308111801] 606.92 percent of total billed charges 418.1 640.64 Technical (Hospital) Services FILGRASTIM-SNDZ 300 MCG/0.5 ML INJECTION SYRINGE RX-129453 CDM Q5101 HCPCS 636 RC 61314-0318-01 NDC inpatient 0.5 ML 674.36 674.36 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES EPO [308136803] 533.96 percent of total billed charges 418.1 640.64 Technical (Hospital) Services FILGRASTIM-SNDZ 300 MCG/0.5 ML INJECTION SYRINGE RX-129453 CDM Q5101 HCPCS 636 RC 61314-0318-01 NDC inpatient 0.5 ML 674.36 674.36 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES HDHP [308136802] 533.96 percent of total billed charges 418.1 640.64 Technical (Hospital) Services FILGRASTIM-SNDZ 300 MCG/0.5 ML INJECTION SYRINGE RX-129453 CDM Q5101 HCPCS 636 RC 61314-0318-01 NDC inpatient 0.5 ML 674.36 674.36 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES PPO [308136801] 533.96 percent of total billed charges 418.1 640.64 Technical (Hospital) Services FILGRASTIM-SNDZ 300 MCG/0.5 ML INJECTION SYRINGE RX-129453 CDM Q5101 HCPCS 636 RC 61314-0318-01 NDC inpatient 0.5 ML 674.36 674.36 CIGNA 62308 [3081051] CIGNA 62308 [308105105] 533.96 percent of total billed charges 418.1 640.64 Technical (Hospital) Services FILGRASTIM-SNDZ 300 MCG/0.5 ML INJECTION SYRINGE RX-129453 CDM Q5101 HCPCS 636 RC 61314-0318-01 NDC inpatient 0.5 ML 674.36 674.36 CIGNA 62308 [3081051] CIGNA STATE OF WYOMING [308105107] 533.96 percent of total billed charges 418.1 640.64 Technical (Hospital) Services FILGRASTIM-SNDZ 300 MCG/0.5 ML INJECTION SYRINGE RX-129453 CDM Q5101 HCPCS 636 RC 61314-0318-01 NDC inpatient 0.5 ML 674.36 674.36 MULTIPLAN INC 34080 [3081285] MULTIPLAN INC [308128501] 640.64 percent of total billed charges 418.1 640.64 Technical (Hospital) Services FILGRASTIM-SNDZ 480 MCG/0.8 ML INJECTION SYRINGE RX-129454 CDM Q5101 HCPCS 636 RC 61314-0326-01 NDC outpatient 0.8 ML 1088.98 1088.98 HEALTHPARTNERS SX009 HEALTHPARTNERS 871.18 percent of total billed charges 675.17 1034.53 Technical (Hospital) Services FILGRASTIM-SNDZ 480 MCG/0.8 ML INJECTION SYRINGE RX-129454 CDM Q5101 HCPCS 636 RC 61314-0326-01 NDC outpatient 0.8 ML 1088.98 1088.98 BLUE CROSS BLUE SHIELD WELLMARK SB889 [3081026] BCBS WYOMING [308102603] 1034.53 percent of total billed charges 675.17 1034.53 Technical (Hospital) Services FILGRASTIM-SNDZ 480 MCG/0.8 ML INJECTION SYRINGE RX-129454 CDM Q5101 HCPCS 636 RC 61314-0326-01 NDC outpatient 0.8 ML 1088.98 1088.98 MEDICA (COMMERCIAL) 94265 [3081118] MEDICA CLAIMS [308111801] 980.08 percent of total billed charges 675.17 1034.53 Technical (Hospital) Services FILGRASTIM-SNDZ 480 MCG/0.8 ML INJECTION SYRINGE RX-129454 CDM Q5101 HCPCS 636 RC 61314-0326-01 NDC outpatient 0.8 ML 1088.98 1088.98 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES EPO [308136803] 871.18 percent of total billed charges 675.17 1034.53 Technical (Hospital) Services FILGRASTIM-SNDZ 480 MCG/0.8 ML INJECTION SYRINGE RX-129454 CDM Q5101 HCPCS 636 RC 61314-0326-01 NDC outpatient 0.8 ML 1088.98 1088.98 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES HDHP [308136802] 871.18 percent of total billed charges 675.17 1034.53 Technical (Hospital) Services FILGRASTIM-SNDZ 480 MCG/0.8 ML INJECTION SYRINGE RX-129454 CDM Q5101 HCPCS 636 RC 61314-0326-01 NDC outpatient 0.8 ML 1088.98 1088.98 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES PPO [308136801] 871.18 percent of total billed charges 675.17 1034.53 Technical (Hospital) Services FILGRASTIM-SNDZ 480 MCG/0.8 ML INJECTION SYRINGE RX-129454 CDM Q5101 HCPCS 636 RC 61314-0326-01 NDC outpatient 0.8 ML 1088.98 1088.98 CIGNA 62308 [3081051] CIGNA 62308 [308105105] 871.18 percent of total billed charges 675.17 1034.53 Technical (Hospital) Services FILGRASTIM-SNDZ 480 MCG/0.8 ML INJECTION SYRINGE RX-129454 CDM Q5101 HCPCS 636 RC 61314-0326-01 NDC outpatient 0.8 ML 1088.98 1088.98 CIGNA 62308 [3081051] CIGNA STATE OF WYOMING [308105107] 871.18 percent of total billed charges 675.17 1034.53 Technical (Hospital) Services FILGRASTIM-SNDZ 480 MCG/0.8 ML INJECTION SYRINGE RX-129454 CDM Q5101 HCPCS 636 RC 61314-0326-01 NDC outpatient 0.8 ML 1088.98 1088.98 MULTIPLAN INC 34080 [3081285] MULTIPLAN INC [308128501] 1034.53 percent of total billed charges 675.17 1034.53 Technical (Hospital) Services FILGRASTIM-SNDZ 480 MCG/0.8 ML INJECTION SYRINGE RX-129454 CDM Q5101 HCPCS 636 RC 61314-0326-01 NDC outpatient 0.8 ML 1088.98 1088.98 UNITED HEALTHCARE (COMMERCIAL) [3081199] UNITED HEALTHCARE 87726 [308119901] 675.17 percent of total billed charges 675.17 1034.53 Technical (Hospital) Services FILGRASTIM-SNDZ 480 MCG/0.8 ML INJECTION SYRINGE RX-129454 CDM Q5101 HCPCS 636 RC 61314-0326-01 NDC inpatient 0.8 ML 1088.98 1088.98 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES EPO [308136803] 862.25 percent of total billed charges 675.17 1034.53 Technical (Hospital) Services FILGRASTIM-SNDZ 480 MCG/0.8 ML INJECTION SYRINGE RX-129454 CDM Q5101 HCPCS 636 RC 61314-0326-01 NDC inpatient 0.8 ML 1088.98 1088.98 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES HDHP [308136802] 862.25 percent of total billed charges 675.17 1034.53 Technical (Hospital) Services FILGRASTIM-SNDZ 480 MCG/0.8 ML INJECTION SYRINGE RX-129454 CDM Q5101 HCPCS 636 RC 61314-0326-01 NDC inpatient 0.8 ML 1088.98 1088.98 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES PPO [308136801] 862.25 percent of total billed charges 675.17 1034.53 Technical (Hospital) Services FILGRASTIM-SNDZ 480 MCG/0.8 ML INJECTION SYRINGE RX-129454 CDM Q5101 HCPCS 636 RC 61314-0326-01 NDC inpatient 0.8 ML 1088.98 1088.98 CIGNA 62308 [3081051] CIGNA 62308 [308105105] 862.25 percent of total billed charges 675.17 1034.53 Technical (Hospital) Services FILGRASTIM-SNDZ 480 MCG/0.8 ML INJECTION SYRINGE RX-129454 CDM Q5101 HCPCS 636 RC 61314-0326-01 NDC inpatient 0.8 ML 1088.98 1088.98 CIGNA 62308 [3081051] CIGNA STATE OF WYOMING [308105107] 862.25 percent of total billed charges 675.17 1034.53 Technical (Hospital) Services FILGRASTIM-SNDZ 480 MCG/0.8 ML INJECTION SYRINGE RX-129454 CDM Q5101 HCPCS 636 RC 61314-0326-01 NDC inpatient 0.8 ML 1088.98 1088.98 BLUE CROSS BLUE SHIELD WELLMARK SB889 [3081026] BCBS WYOMING [308102603] 1034.53 percent of total billed charges 675.17 1034.53 Technical (Hospital) Services FILGRASTIM-SNDZ 480 MCG/0.8 ML INJECTION SYRINGE RX-129454 CDM Q5101 HCPCS 636 RC 61314-0326-01 NDC inpatient 0.8 ML 1088.98 1088.98 UNITED HEALTHCARE (COMMERCIAL) [3081199] UNITED HEALTHCARE 87726 [308119901] 675.17 percent of total billed charges 675.17 1034.53 Technical (Hospital) Services FILGRASTIM-SNDZ 480 MCG/0.8 ML INJECTION SYRINGE RX-129454 CDM Q5101 HCPCS 636 RC 61314-0326-01 NDC inpatient 0.8 ML 1088.98 1088.98 MULTIPLAN INC 34080 [3081285] MULTIPLAN INC [308128501] 1034.53 percent of total billed charges 675.17 1034.53 Technical (Hospital) Services FILGRASTIM-SNDZ 480 MCG/0.8 ML INJECTION SYRINGE RX-129454 CDM Q5101 HCPCS 636 RC 61314-0326-01 NDC inpatient 0.8 ML 1088.98 1088.98 HEALTHPARTNERS SX009 HEALTHPARTNERS 862.25 percent of total billed charges 675.17 1034.53 Technical (Hospital) Services FILGRASTIM-SNDZ 480 MCG/0.8 ML INJECTION SYRINGE RX-129454 CDM Q5101 HCPCS 636 RC 61314-0326-01 NDC inpatient 0.8 ML 1088.98 1088.98 MEDICA (COMMERCIAL) 94265 [3081118] MEDICA CLAIMS [308111801] 980.08 percent of total billed charges 675.17 1034.53 Technical (Hospital) Services FOSPHENYTOIN 100 MG PE/2 ML INJECTION SOLUTION RX-88011 CDM Q2009 HCPCS 636 RC 67457-0516-25 NDC inpatient 2 ML 85 85 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES HDHP [308136802] 67.3 percent of total billed charges 52.7 80.75 Technical (Hospital) Services FOSPHENYTOIN 100 MG PE/2 ML INJECTION SOLUTION RX-88011 CDM Q2009 HCPCS 636 RC 67457-0516-25 NDC inpatient 2 ML 85 85 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES PPO [308136801] 67.3 percent of total billed charges 52.7 80.75 Technical (Hospital) Services FOSPHENYTOIN 100 MG PE/2 ML INJECTION SOLUTION RX-88011 CDM Q2009 HCPCS 636 RC 67457-0516-25 NDC inpatient 2 ML 85 85 HEALTHPARTNERS SX009 HEALTHPARTNERS 67.3 percent of total billed charges 52.7 80.75 Technical (Hospital) Services FOSPHENYTOIN 100 MG PE/2 ML INJECTION SOLUTION RX-88011 CDM Q2009 HCPCS 636 RC 67457-0516-25 NDC inpatient 2 ML 85 85 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES EPO [308136803] 67.3 percent of total billed charges 52.7 80.75 Technical (Hospital) Services FOSPHENYTOIN 100 MG PE/2 ML INJECTION SOLUTION RX-88011 CDM Q2009 HCPCS 636 RC 67457-0516-25 NDC inpatient 2 ML 85 85 BLUE CROSS BLUE SHIELD WELLMARK SB889 [3081026] BCBS WYOMING [308102603] 80.75 percent of total billed charges 52.7 80.75 Technical (Hospital) Services FOSPHENYTOIN 100 MG PE/2 ML INJECTION SOLUTION RX-88011 CDM Q2009 HCPCS 636 RC 67457-0516-25 NDC inpatient 2 ML 85 85 UNITED HEALTHCARE (COMMERCIAL) [3081199] UNITED HEALTHCARE 87726 [308119901] 52.7 percent of total billed charges 52.7 80.75 Technical (Hospital) Services FOSPHENYTOIN 100 MG PE/2 ML INJECTION SOLUTION RX-88011 CDM Q2009 HCPCS 636 RC 67457-0516-25 NDC inpatient 2 ML 85 85 CIGNA 62308 [3081051] CIGNA 62308 [308105105] 67.3 percent of total billed charges 52.7 80.75 Technical (Hospital) Services FOSPHENYTOIN 100 MG PE/2 ML INJECTION SOLUTION RX-88011 CDM Q2009 HCPCS 636 RC 67457-0516-25 NDC inpatient 2 ML 85 85 CIGNA 62308 [3081051] CIGNA STATE OF WYOMING [308105107] 67.3 percent of total billed charges 52.7 80.75 Technical (Hospital) Services FOSPHENYTOIN 100 MG PE/2 ML INJECTION SOLUTION RX-88011 CDM Q2009 HCPCS 636 RC 67457-0516-25 NDC inpatient 2 ML 85 85 MULTIPLAN INC 34080 [3081285] MULTIPLAN INC [308128501] 80.75 percent of total billed charges 52.7 80.75 Technical (Hospital) Services FOSPHENYTOIN 100 MG PE/2 ML INJECTION SOLUTION RX-88011 CDM Q2009 HCPCS 636 RC 67457-0516-25 NDC inpatient 2 ML 85 85 MEDICA (COMMERCIAL) 94265 [3081118] MEDICA CLAIMS [308111801] 76.5 percent of total billed charges 52.7 80.75 Technical (Hospital) Services FOSPHENYTOIN 100 MG PE/2 ML INJECTION SOLUTION RX-88011 CDM Q2009 HCPCS 636 RC 67457-0516-25 NDC outpatient 2 ML 85 85 MULTIPLAN INC 34080 [3081285] MULTIPLAN INC [308128501] 80.75 percent of total billed charges 52.7 80.75 Technical (Hospital) Services FOSPHENYTOIN 100 MG PE/2 ML INJECTION SOLUTION RX-88011 CDM Q2009 HCPCS 636 RC 67457-0516-25 NDC outpatient 2 ML 85 85 MEDICA (COMMERCIAL) 94265 [3081118] MEDICA CLAIMS [308111801] 76.5 percent of total billed charges 52.7 80.75 Technical (Hospital) Services FOSPHENYTOIN 100 MG PE/2 ML INJECTION SOLUTION RX-88011 CDM Q2009 HCPCS 636 RC 67457-0516-25 NDC outpatient 2 ML 85 85 CIGNA 62308 [3081051] CIGNA 62308 [308105105] 68 percent of total billed charges 52.7 80.75 Technical (Hospital) Services FOSPHENYTOIN 100 MG PE/2 ML INJECTION SOLUTION RX-88011 CDM Q2009 HCPCS 636 RC 67457-0516-25 NDC outpatient 2 ML 85 85 CIGNA 62308 [3081051] CIGNA STATE OF WYOMING [308105107] 68 percent of total billed charges 52.7 80.75 Technical (Hospital) Services FOSPHENYTOIN 100 MG PE/2 ML INJECTION SOLUTION RX-88011 CDM Q2009 HCPCS 636 RC 67457-0516-25 NDC outpatient 2 ML 85 85 HEALTHPARTNERS SX009 HEALTHPARTNERS 68 percent of total billed charges 52.7 80.75 Technical (Hospital) Services FOSPHENYTOIN 100 MG PE/2 ML INJECTION SOLUTION RX-88011 CDM Q2009 HCPCS 636 RC 67457-0516-25 NDC outpatient 2 ML 85 85 UNITED HEALTHCARE (COMMERCIAL) [3081199] UNITED HEALTHCARE 87726 [308119901] 52.7 percent of total billed charges 52.7 80.75 Technical (Hospital) Services FOSPHENYTOIN 100 MG PE/2 ML INJECTION SOLUTION RX-88011 CDM Q2009 HCPCS 636 RC 67457-0516-25 NDC outpatient 2 ML 85 85 BLUE CROSS BLUE SHIELD WELLMARK SB889 [3081026] BCBS WYOMING [308102603] 80.75 percent of total billed charges 52.7 80.75 Technical (Hospital) Services FOSPHENYTOIN 100 MG PE/2 ML INJECTION SOLUTION RX-88011 CDM Q2009 HCPCS 636 RC 67457-0516-25 NDC outpatient 2 ML 85 85 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES EPO [308136803] 68 percent of total billed charges 52.7 80.75 Technical (Hospital) Services FOSPHENYTOIN 100 MG PE/2 ML INJECTION SOLUTION RX-88011 CDM Q2009 HCPCS 636 RC 67457-0516-25 NDC outpatient 2 ML 85 85 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES HDHP [308136802] 68 percent of total billed charges 52.7 80.75 Technical (Hospital) Services FOSPHENYTOIN 100 MG PE/2 ML INJECTION SOLUTION RX-88011 CDM Q2009 HCPCS 636 RC 67457-0516-25 NDC outpatient 2 ML 85 85 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES PPO [308136801] 68 percent of total billed charges 52.7 80.75 Technical (Hospital) Services Fresh Frozen Plasma 24 Hrs PX-3900905900 CDM P9059 HCPCS 390 RC inpatient 298 298 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES PPO [308136801] 235.96 percent of total billed charges 184.76 283.1 Technical (Hospital) Services Fresh Frozen Plasma 24 Hrs PX-3900905900 CDM P9059 HCPCS 390 RC inpatient 298 298 UNITED HEALTHCARE (COMMERCIAL) [3081199] UNITED HEALTHCARE 87726 [308119901] 184.76 percent of total billed charges 184.76 283.1 Technical (Hospital) Services Fresh Frozen Plasma 24 Hrs PX-3900905900 CDM P9059 HCPCS 390 RC inpatient 298 298 BLUE CROSS BLUE SHIELD WELLMARK SB889 [3081026] BCBS WYOMING [308102603] 283.1 percent of total billed charges 184.76 283.1 Technical (Hospital) Services Fresh Frozen Plasma 24 Hrs PX-3900905900 CDM P9059 HCPCS 390 RC inpatient 298 298 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES HDHP [308136802] 235.96 percent of total billed charges 184.76 283.1 Technical (Hospital) Services Fresh Frozen Plasma 24 Hrs PX-3900905900 CDM P9059 HCPCS 390 RC inpatient 298 298 MEDICA (COMMERCIAL) 94265 [3081118] MEDICA CLAIMS [308111801] 268.2 percent of total billed charges 184.76 283.1 Technical (Hospital) Services Fresh Frozen Plasma 24 Hrs PX-3900905900 CDM P9059 HCPCS 390 RC inpatient 298 298 MULTIPLAN INC 34080 [3081285] MULTIPLAN INC [308128501] 283.1 percent of total billed charges 184.76 283.1 Technical (Hospital) Services Fresh Frozen Plasma 24 Hrs PX-3900905900 CDM P9059 HCPCS 390 RC inpatient 298 298 HEALTHPARTNERS SX009 HEALTHPARTNERS 235.96 percent of total billed charges 184.76 283.1 Technical (Hospital) Services Fresh Frozen Plasma 24 Hrs PX-3900905900 CDM P9059 HCPCS 390 RC inpatient 298 298 CIGNA 62308 [3081051] CIGNA 62308 [308105105] 235.96 percent of total billed charges 184.76 283.1 Technical (Hospital) Services Fresh Frozen Plasma 24 Hrs PX-3900905900 CDM P9059 HCPCS 390 RC inpatient 298 298 CIGNA 62308 [3081051] CIGNA STATE OF WYOMING [308105107] 235.96 percent of total billed charges 184.76 283.1 Technical (Hospital) Services Fresh Frozen Plasma 24 Hrs PX-3900905900 CDM P9059 HCPCS 390 RC inpatient 298 298 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES EPO [308136803] 235.96 percent of total billed charges 184.76 283.1 Technical (Hospital) Services Fresh Frozen Plasma 24 Hrs PX-3900905900 CDM P9059 HCPCS 390 RC outpatient 298 298 CIGNA 62308 [3081051] CIGNA 62308 [308105105] 238.4 percent of total billed charges 184.76 283.1 Technical (Hospital) Services Fresh Frozen Plasma 24 Hrs PX-3900905900 CDM P9059 HCPCS 390 RC outpatient 298 298 CIGNA 62308 [3081051] CIGNA STATE OF WYOMING [308105107] 238.4 percent of total billed charges 184.76 283.1 Technical (Hospital) Services Fresh Frozen Plasma 24 Hrs PX-3900905900 CDM P9059 HCPCS 390 RC outpatient 298 298 BLUE CROSS BLUE SHIELD WELLMARK SB889 [3081026] BCBS WYOMING [308102603] 283.1 percent of total billed charges 184.76 283.1 Technical (Hospital) Services Fresh Frozen Plasma 24 Hrs PX-3900905900 CDM P9059 HCPCS 390 RC outpatient 298 298 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES HDHP [308136802] 238.4 percent of total billed charges 184.76 283.1 Technical (Hospital) Services Fresh Frozen Plasma 24 Hrs PX-3900905900 CDM P9059 HCPCS 390 RC outpatient 298 298 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES EPO [308136803] 238.4 percent of total billed charges 184.76 283.1 Technical (Hospital) Services Fresh Frozen Plasma 24 Hrs PX-3900905900 CDM P9059 HCPCS 390 RC outpatient 298 298 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES PPO [308136801] 238.4 percent of total billed charges 184.76 283.1 Technical (Hospital) Services Fresh Frozen Plasma 24 Hrs PX-3900905900 CDM P9059 HCPCS 390 RC outpatient 298 298 UNITED HEALTHCARE (COMMERCIAL) [3081199] UNITED HEALTHCARE 87726 [308119901] 184.76 percent of total billed charges 184.76 283.1 Technical (Hospital) Services Fresh Frozen Plasma 24 Hrs PX-3900905900 CDM P9059 HCPCS 390 RC outpatient 298 298 HEALTHPARTNERS SX009 HEALTHPARTNERS 238.4 percent of total billed charges 184.76 283.1 Technical (Hospital) Services Fresh Frozen Plasma 24 Hrs PX-3900905900 CDM P9059 HCPCS 390 RC outpatient 298 298 MEDICA (COMMERCIAL) 94265 [3081118] MEDICA CLAIMS [308111801] 268.2 percent of total billed charges 184.76 283.1 Technical (Hospital) Services Fresh Frozen Plasma 24 Hrs PX-3900905900 CDM P9059 HCPCS 390 RC outpatient 298 298 MULTIPLAN INC 34080 [3081285] MULTIPLAN INC [308128501] 283.1 percent of total billed charges 184.76 283.1 Technical (Hospital) Services "ALBUMIN, HUMAN 25 % INTRAVENOUS SOLUTION" RX-8981 CDM P9047 HCPCS 636 RC 68982-0643-01 NDC inpatient 50 ML 249.4 249.4 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES HDHP [308136802] 197.47 percent of total billed charges 154.63 236.93 Technical (Hospital) Services "ALBUMIN, HUMAN 25 % INTRAVENOUS SOLUTION" RX-8981 CDM P9047 HCPCS 636 RC 68982-0643-01 NDC inpatient 50 ML 249.4 249.4 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES PPO [308136801] 197.47 percent of total billed charges 154.63 236.93 Technical (Hospital) Services "ALBUMIN, HUMAN 25 % INTRAVENOUS SOLUTION" RX-8981 CDM P9047 HCPCS 636 RC 68982-0643-01 NDC inpatient 50 ML 249.4 249.4 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES EPO [308136803] 197.47 percent of total billed charges 154.63 236.93 Technical (Hospital) Services "ALBUMIN, HUMAN 25 % INTRAVENOUS SOLUTION" RX-8981 CDM P9047 HCPCS 636 RC 68982-0643-01 NDC inpatient 50 ML 249.4 249.4 CIGNA 62308 [3081051] CIGNA 62308 [308105105] 197.47 percent of total billed charges 154.63 236.93 Technical (Hospital) Services "ALBUMIN, HUMAN 25 % INTRAVENOUS SOLUTION" RX-8981 CDM P9047 HCPCS 636 RC 68982-0643-01 NDC inpatient 50 ML 249.4 249.4 CIGNA 62308 [3081051] CIGNA STATE OF WYOMING [308105107] 197.47 percent of total billed charges 154.63 236.93 Technical (Hospital) Services "ALBUMIN, HUMAN 25 % INTRAVENOUS SOLUTION" RX-8981 CDM P9047 HCPCS 636 RC 68982-0643-01 NDC inpatient 50 ML 249.4 249.4 BLUE CROSS BLUE SHIELD WELLMARK SB889 [3081026] BCBS WYOMING [308102603] 236.93 percent of total billed charges 154.63 236.93 Technical (Hospital) Services "ALBUMIN, HUMAN 25 % INTRAVENOUS SOLUTION" RX-8981 CDM P9047 HCPCS 636 RC 68982-0643-01 NDC inpatient 50 ML 249.4 249.4 UNITED HEALTHCARE (COMMERCIAL) [3081199] UNITED HEALTHCARE 87726 [308119901] 154.63 percent of total billed charges 154.63 236.93 Technical (Hospital) Services "ALBUMIN, HUMAN 25 % INTRAVENOUS SOLUTION" RX-8981 CDM P9047 HCPCS 636 RC 68982-0643-01 NDC inpatient 50 ML 249.4 249.4 MEDICA (COMMERCIAL) 94265 [3081118] MEDICA CLAIMS [308111801] 224.46 percent of total billed charges 154.63 236.93 Technical (Hospital) Services "ALBUMIN, HUMAN 25 % INTRAVENOUS SOLUTION" RX-8981 CDM P9047 HCPCS 636 RC 68982-0643-01 NDC inpatient 50 ML 249.4 249.4 MULTIPLAN INC 34080 [3081285] MULTIPLAN INC [308128501] 236.93 percent of total billed charges 154.63 236.93 Technical (Hospital) Services "ALBUMIN, HUMAN 25 % INTRAVENOUS SOLUTION" RX-8981 CDM P9047 HCPCS 636 RC 68982-0643-01 NDC outpatient 50 ML 249.4 249.4 CIGNA 62308 [3081051] CIGNA 62308 [308105105] 199.52 percent of total billed charges 154.63 236.93 Technical (Hospital) Services "ALBUMIN, HUMAN 25 % INTRAVENOUS SOLUTION" RX-8981 CDM P9047 HCPCS 636 RC 68982-0643-01 NDC outpatient 50 ML 249.4 249.4 CIGNA 62308 [3081051] CIGNA STATE OF WYOMING [308105107] 199.52 percent of total billed charges 154.63 236.93 Technical (Hospital) Services "ALBUMIN, HUMAN 25 % INTRAVENOUS SOLUTION" RX-8981 CDM P9047 HCPCS 636 RC 68982-0643-01 NDC outpatient 50 ML 249.4 249.4 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES PPO [308136801] 199.52 percent of total billed charges 154.63 236.93 Technical (Hospital) Services "ALBUMIN, HUMAN 25 % INTRAVENOUS SOLUTION" RX-8981 CDM P9047 HCPCS 636 RC 68982-0643-01 NDC outpatient 50 ML 249.4 249.4 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES EPO [308136803] 199.52 percent of total billed charges 154.63 236.93 Technical (Hospital) Services "ALBUMIN, HUMAN 25 % INTRAVENOUS SOLUTION" RX-8981 CDM P9047 HCPCS 636 RC 68982-0643-01 NDC outpatient 50 ML 249.4 249.4 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES HDHP [308136802] 199.52 percent of total billed charges 154.63 236.93 Technical (Hospital) Services "ALBUMIN, HUMAN 25 % INTRAVENOUS SOLUTION" RX-8981 CDM P9047 HCPCS 636 RC 68982-0643-01 NDC outpatient 50 ML 249.4 249.4 BLUE CROSS BLUE SHIELD WELLMARK SB889 [3081026] BCBS WYOMING [308102603] 236.93 percent of total billed charges 154.63 236.93 Technical (Hospital) Services "ALBUMIN, HUMAN 25 % INTRAVENOUS SOLUTION" RX-8981 CDM P9047 HCPCS 636 RC 68982-0643-01 NDC outpatient 50 ML 249.4 249.4 UNITED HEALTHCARE (COMMERCIAL) [3081199] UNITED HEALTHCARE 87726 [308119901] 154.63 percent of total billed charges 154.63 236.93 Technical (Hospital) Services "ALBUMIN, HUMAN 25 % INTRAVENOUS SOLUTION" RX-8981 CDM P9047 HCPCS 636 RC 68982-0643-01 NDC outpatient 50 ML 249.4 249.4 HEALTHPARTNERS SX009 HEALTHPARTNERS 199.52 percent of total billed charges 154.63 236.93 Technical (Hospital) Services "ALBUMIN, HUMAN 25 % INTRAVENOUS SOLUTION" RX-8981 CDM P9047 HCPCS 636 RC 68982-0643-01 NDC inpatient 50 ML 249.4 249.4 HEALTHPARTNERS SX009 HEALTHPARTNERS 197.47 percent of total billed charges 154.63 236.93 Technical (Hospital) Services "ALBUMIN, HUMAN 25 % INTRAVENOUS SOLUTION" RX-8981 CDM P9047 HCPCS 636 RC 68982-0643-01 NDC outpatient 50 ML 249.4 249.4 MEDICA (COMMERCIAL) 94265 [3081118] MEDICA CLAIMS [308111801] 224.46 percent of total billed charges 154.63 236.93 Technical (Hospital) Services "ALBUMIN, HUMAN 25 % INTRAVENOUS SOLUTION" RX-8981 CDM P9047 HCPCS 636 RC 68982-0643-01 NDC outpatient 50 ML 249.4 249.4 MULTIPLAN INC 34080 [3081285] MULTIPLAN INC [308128501] 236.93 percent of total billed charges 154.63 236.93 Technical (Hospital) Services Fresh Frozen Plasma One Donor PX-3900901700 CDM P9017 HCPCS 390 RC inpatient 298 298 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES EPO [308136803] 235.96 percent of total billed charges 184.76 283.1 Technical (Hospital) Services Fresh Frozen Plasma One Donor PX-3900901700 CDM P9017 HCPCS 390 RC inpatient 298 298 CIGNA 62308 [3081051] CIGNA 62308 [308105105] 235.96 percent of total billed charges 184.76 283.1 Technical (Hospital) Services Fresh Frozen Plasma One Donor PX-3900901700 CDM P9017 HCPCS 390 RC inpatient 298 298 CIGNA 62308 [3081051] CIGNA STATE OF WYOMING [308105107] 235.96 percent of total billed charges 184.76 283.1 Technical (Hospital) Services Fresh Frozen Plasma One Donor PX-3900901700 CDM P9017 HCPCS 390 RC inpatient 298 298 HEALTHPARTNERS SX009 HEALTHPARTNERS 235.96 percent of total billed charges 184.76 283.1 Technical (Hospital) Services Fresh Frozen Plasma One Donor PX-3900901700 CDM P9017 HCPCS 390 RC inpatient 298 298 MEDICA (COMMERCIAL) 94265 [3081118] MEDICA CLAIMS [308111801] 268.2 percent of total billed charges 184.76 283.1 Technical (Hospital) Services Fresh Frozen Plasma One Donor PX-3900901700 CDM P9017 HCPCS 390 RC inpatient 298 298 MULTIPLAN INC 34080 [3081285] MULTIPLAN INC [308128501] 283.1 percent of total billed charges 184.76 283.1 Technical (Hospital) Services Fresh Frozen Plasma One Donor PX-3900901700 CDM P9017 HCPCS 390 RC inpatient 298 298 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES HDHP [308136802] 235.96 percent of total billed charges 184.76 283.1 Technical (Hospital) Services Fresh Frozen Plasma One Donor PX-3900901700 CDM P9017 HCPCS 390 RC inpatient 298 298 UNITED HEALTHCARE (COMMERCIAL) [3081199] UNITED HEALTHCARE 87726 [308119901] 184.76 percent of total billed charges 184.76 283.1 Technical (Hospital) Services Fresh Frozen Plasma One Donor PX-3900901700 CDM P9017 HCPCS 390 RC inpatient 298 298 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES PPO [308136801] 235.96 percent of total billed charges 184.76 283.1 Technical (Hospital) Services Fresh Frozen Plasma One Donor PX-3900901700 CDM P9017 HCPCS 390 RC inpatient 298 298 BLUE CROSS BLUE SHIELD WELLMARK SB889 [3081026] BCBS WYOMING [308102603] 283.1 percent of total billed charges 184.76 283.1 Technical (Hospital) Services Fresh Frozen Plasma One Donor PX-3900901700 CDM P9017 HCPCS 390 RC outpatient 298 298 CIGNA 62308 [3081051] CIGNA 62308 [308105105] 238.4 percent of total billed charges 184.76 283.1 Technical (Hospital) Services Fresh Frozen Plasma One Donor PX-3900901700 CDM P9017 HCPCS 390 RC outpatient 298 298 CIGNA 62308 [3081051] CIGNA STATE OF WYOMING [308105107] 238.4 percent of total billed charges 184.76 283.1 Technical (Hospital) Services Fresh Frozen Plasma One Donor PX-3900901700 CDM P9017 HCPCS 390 RC outpatient 298 298 MEDICA (COMMERCIAL) 94265 [3081118] MEDICA CLAIMS [308111801] 268.2 percent of total billed charges 184.76 283.1 Technical (Hospital) Services Fresh Frozen Plasma One Donor PX-3900901700 CDM P9017 HCPCS 390 RC outpatient 298 298 MULTIPLAN INC 34080 [3081285] MULTIPLAN INC [308128501] 283.1 percent of total billed charges 184.76 283.1 Technical (Hospital) Services Fresh Frozen Plasma One Donor PX-3900901700 CDM P9017 HCPCS 390 RC outpatient 298 298 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES EPO [308136803] 238.4 percent of total billed charges 184.76 283.1 Technical (Hospital) Services Fresh Frozen Plasma One Donor PX-3900901700 CDM P9017 HCPCS 390 RC outpatient 298 298 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES PPO [308136801] 238.4 percent of total billed charges 184.76 283.1 Technical (Hospital) Services Fresh Frozen Plasma One Donor PX-3900901700 CDM P9017 HCPCS 390 RC outpatient 298 298 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES HDHP [308136802] 238.4 percent of total billed charges 184.76 283.1 Technical (Hospital) Services Fresh Frozen Plasma One Donor PX-3900901700 CDM P9017 HCPCS 390 RC outpatient 298 298 BLUE CROSS BLUE SHIELD WELLMARK SB889 [3081026] BCBS WYOMING [308102603] 283.1 percent of total billed charges 184.76 283.1 Technical (Hospital) Services Fresh Frozen Plasma One Donor PX-3900901700 CDM P9017 HCPCS 390 RC outpatient 298 298 UNITED HEALTHCARE (COMMERCIAL) [3081199] UNITED HEALTHCARE 87726 [308119901] 184.76 percent of total billed charges 184.76 283.1 Technical (Hospital) Services Fresh Frozen Plasma One Donor PX-3900901700 CDM P9017 HCPCS 390 RC outpatient 298 298 HEALTHPARTNERS SX009 HEALTHPARTNERS 238.4 percent of total billed charges 184.76 283.1 Technical (Hospital) Services RBC Leuko Reduced PX-3900901600 CDM P9016 HCPCS 390 RC inpatient 978 978 CIGNA 62308 [3081051] CIGNA 62308 [308105105] 774.38 percent of total billed charges 606.36 929.1 Technical (Hospital) Services RBC Leuko Reduced PX-3900901600 CDM P9016 HCPCS 390 RC inpatient 978 978 CIGNA 62308 [3081051] CIGNA STATE OF WYOMING [308105107] 774.38 percent of total billed charges 606.36 929.1 Technical (Hospital) Services RBC Leuko Reduced PX-3900901600 CDM P9016 HCPCS 390 RC inpatient 978 978 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES EPO [308136803] 774.38 percent of total billed charges 606.36 929.1 Technical (Hospital) Services RBC Leuko Reduced PX-3900901600 CDM P9016 HCPCS 390 RC inpatient 978 978 BLUE CROSS BLUE SHIELD WELLMARK SB889 [3081026] BCBS WYOMING [308102603] 929.1 percent of total billed charges 606.36 929.1 Technical (Hospital) Services RBC Leuko Reduced PX-3900901600 CDM P9016 HCPCS 390 RC inpatient 978 978 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES PPO [308136801] 774.38 percent of total billed charges 606.36 929.1 Technical (Hospital) Services RBC Leuko Reduced PX-3900901600 CDM P9016 HCPCS 390 RC inpatient 978 978 UNITED HEALTHCARE (COMMERCIAL) [3081199] UNITED HEALTHCARE 87726 [308119901] 606.36 percent of total billed charges 606.36 929.1 Technical (Hospital) Services RBC Leuko Reduced PX-3900901600 CDM P9016 HCPCS 390 RC inpatient 978 978 HEALTHPARTNERS SX009 HEALTHPARTNERS 774.38 percent of total billed charges 606.36 929.1 Technical (Hospital) Services RBC Leuko Reduced PX-3900901600 CDM P9016 HCPCS 390 RC inpatient 978 978 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES HDHP [308136802] 774.38 percent of total billed charges 606.36 929.1 Technical (Hospital) Services RBC Leuko Reduced PX-3900901600 CDM P9016 HCPCS 390 RC inpatient 978 978 MEDICA (COMMERCIAL) 94265 [3081118] MEDICA CLAIMS [308111801] 880.2 percent of total billed charges 606.36 929.1 Technical (Hospital) Services RBC Leuko Reduced PX-3900901600 CDM P9016 HCPCS 390 RC inpatient 978 978 MULTIPLAN INC 34080 [3081285] MULTIPLAN INC [308128501] 929.1 percent of total billed charges 606.36 929.1 Technical (Hospital) Services RBC Leuko Reduced PX-3900901600 CDM P9016 HCPCS 390 RC outpatient 978 978 UNITED HEALTHCARE (COMMERCIAL) [3081199] UNITED HEALTHCARE 87726 [308119901] 606.36 percent of total billed charges 606.36 929.1 Technical (Hospital) Services RBC Leuko Reduced PX-3900901600 CDM P9016 HCPCS 390 RC outpatient 978 978 HEALTHPARTNERS SX009 HEALTHPARTNERS 782.4 percent of total billed charges 606.36 929.1 Technical (Hospital) Services RBC Leuko Reduced PX-3900901600 CDM P9016 HCPCS 390 RC outpatient 978 978 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES PPO [308136801] 782.4 percent of total billed charges 606.36 929.1 Technical (Hospital) Services RBC Leuko Reduced PX-3900901600 CDM P9016 HCPCS 390 RC outpatient 978 978 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES EPO [308136803] 782.4 percent of total billed charges 606.36 929.1 Technical (Hospital) Services RBC Leuko Reduced PX-3900901600 CDM P9016 HCPCS 390 RC outpatient 978 978 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES HDHP [308136802] 782.4 percent of total billed charges 606.36 929.1 Technical (Hospital) Services RBC Leuko Reduced PX-3900901600 CDM P9016 HCPCS 390 RC outpatient 978 978 BLUE CROSS BLUE SHIELD WELLMARK SB889 [3081026] BCBS WYOMING [308102603] 929.1 percent of total billed charges 606.36 929.1 Technical (Hospital) Services RBC Leuko Reduced PX-3900901600 CDM P9016 HCPCS 390 RC outpatient 978 978 MEDICA (COMMERCIAL) 94265 [3081118] MEDICA CLAIMS [308111801] 880.2 percent of total billed charges 606.36 929.1 Technical (Hospital) Services RBC Leuko Reduced PX-3900901600 CDM P9016 HCPCS 390 RC outpatient 978 978 MULTIPLAN INC 34080 [3081285] MULTIPLAN INC [308128501] 929.1 percent of total billed charges 606.36 929.1 Technical (Hospital) Services RBC Leuko Reduced PX-3900901600 CDM P9016 HCPCS 390 RC outpatient 978 978 CIGNA 62308 [3081051] CIGNA 62308 [308105105] 782.4 percent of total billed charges 606.36 929.1 Technical (Hospital) Services RBC Leuko Reduced PX-3900901600 CDM P9016 HCPCS 390 RC outpatient 978 978 CIGNA 62308 [3081051] CIGNA STATE OF WYOMING [308105107] 782.4 percent of total billed charges 606.36 929.1 Technical (Hospital) Services "IV Infusion, Casirivimab and Imdevimab Includes Infusion and Post Administration Monitoring" PX-2600024300 CDM M0243 HCPCS 260 RC inpatient 1053 1053 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES PPO [308136801] 833.77 percent of total billed charges 652.86 1000.35 Technical (Hospital) Services "IV Infusion, Casirivimab and Imdevimab Includes Infusion and Post Administration Monitoring" PX-2600024300 CDM M0243 HCPCS 260 RC inpatient 1053 1053 BLUE CROSS BLUE SHIELD WELLMARK SB889 [3081026] BCBS WYOMING [308102603] 1000.35 percent of total billed charges 652.86 1000.35 Technical (Hospital) Services "IV Infusion, Casirivimab and Imdevimab Includes Infusion and Post Administration Monitoring" PX-2600024300 CDM M0243 HCPCS 260 RC inpatient 1053 1053 UNITED HEALTHCARE (COMMERCIAL) [3081199] UNITED HEALTHCARE 87726 [308119901] 652.86 percent of total billed charges 652.86 1000.35 Technical (Hospital) Services "IV Infusion, Casirivimab and Imdevimab Includes Infusion and Post Administration Monitoring" PX-2600024300 CDM M0243 HCPCS 260 RC inpatient 1053 1053 HEALTHPARTNERS SX009 HEALTHPARTNERS 833.77 percent of total billed charges 652.86 1000.35 Technical (Hospital) Services "IV Infusion, Casirivimab and Imdevimab Includes Infusion and Post Administration Monitoring" PX-2600024300 CDM M0243 HCPCS 260 RC inpatient 1053 1053 MULTIPLAN INC 34080 [3081285] MULTIPLAN INC [308128501] 1000.35 percent of total billed charges 652.86 1000.35 Technical (Hospital) Services "IV Infusion, Casirivimab and Imdevimab Includes Infusion and Post Administration Monitoring" PX-2600024300 CDM M0243 HCPCS 260 RC inpatient 1053 1053 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES HDHP [308136802] 833.77 percent of total billed charges 652.86 1000.35 Technical (Hospital) Services "IV Infusion, Casirivimab and Imdevimab Includes Infusion and Post Administration Monitoring" PX-2600024300 CDM M0243 HCPCS 260 RC inpatient 1053 1053 MEDICA (COMMERCIAL) 94265 [3081118] MEDICA CLAIMS [308111801] 947.7 percent of total billed charges 652.86 1000.35 Technical (Hospital) Services "IV Infusion, Casirivimab and Imdevimab Includes Infusion and Post Administration Monitoring" PX-2600024300 CDM M0243 HCPCS 260 RC inpatient 1053 1053 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES EPO [308136803] 833.77 percent of total billed charges 652.86 1000.35 Technical (Hospital) Services "IV Infusion, Casirivimab and Imdevimab Includes Infusion and Post Administration Monitoring" PX-2600024300 CDM M0243 HCPCS 260 RC inpatient 1053 1053 CIGNA 62308 [3081051] CIGNA 62308 [308105105] 833.77 percent of total billed charges 652.86 1000.35 Technical (Hospital) Services "IV Infusion, Casirivimab and Imdevimab Includes Infusion and Post Administration Monitoring" PX-2600024300 CDM M0243 HCPCS 260 RC inpatient 1053 1053 CIGNA 62308 [3081051] CIGNA STATE OF WYOMING [308105107] 833.77 percent of total billed charges 652.86 1000.35 Technical (Hospital) Services "IV Infusion, Casirivimab and Imdevimab Includes Infusion and Post Administration Monitoring" PX-2600024300 CDM M0243 HCPCS 260 RC outpatient 1053 1053 HEALTHPARTNERS SX009 HEALTHPARTNERS 842.4 percent of total billed charges 652.86 1000.35 Technical (Hospital) Services "IV Infusion, Casirivimab and Imdevimab Includes Infusion and Post Administration Monitoring" PX-2600024300 CDM M0243 HCPCS 260 RC outpatient 1053 1053 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES EPO [308136803] 842.4 percent of total billed charges 652.86 1000.35 Technical (Hospital) Services "IV Infusion, Casirivimab and Imdevimab Includes Infusion and Post Administration Monitoring" PX-2600024300 CDM M0243 HCPCS 260 RC outpatient 1053 1053 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES PPO [308136801] 842.4 percent of total billed charges 652.86 1000.35 Technical (Hospital) Services "IV Infusion, Casirivimab and Imdevimab Includes Infusion and Post Administration Monitoring" PX-2600024300 CDM M0243 HCPCS 260 RC outpatient 1053 1053 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES HDHP [308136802] 842.4 percent of total billed charges 652.86 1000.35 Technical (Hospital) Services "IV Infusion, Casirivimab and Imdevimab Includes Infusion and Post Administration Monitoring" PX-2600024300 CDM M0243 HCPCS 260 RC outpatient 1053 1053 BLUE CROSS BLUE SHIELD WELLMARK SB889 [3081026] BCBS WYOMING [308102603] 1000.35 percent of total billed charges 652.86 1000.35 Technical (Hospital) Services "IV Infusion, Casirivimab and Imdevimab Includes Infusion and Post Administration Monitoring" PX-2600024300 CDM M0243 HCPCS 260 RC outpatient 1053 1053 UNITED HEALTHCARE (COMMERCIAL) [3081199] UNITED HEALTHCARE 87726 [308119901] 652.86 percent of total billed charges 652.86 1000.35 Technical (Hospital) Services "IV Infusion, Casirivimab and Imdevimab Includes Infusion and Post Administration Monitoring" PX-2600024300 CDM M0243 HCPCS 260 RC outpatient 1053 1053 CIGNA 62308 [3081051] CIGNA 62308 [308105105] 842.4 percent of total billed charges 652.86 1000.35 Technical (Hospital) Services "IV Infusion, Casirivimab and Imdevimab Includes Infusion and Post Administration Monitoring" PX-2600024300 CDM M0243 HCPCS 260 RC outpatient 1053 1053 CIGNA 62308 [3081051] CIGNA STATE OF WYOMING [308105107] 842.4 percent of total billed charges 652.86 1000.35 Technical (Hospital) Services "IV Infusion, Casirivimab and Imdevimab Includes Infusion and Post Administration Monitoring" PX-2600024300 CDM M0243 HCPCS 260 RC outpatient 1053 1053 MEDICA (COMMERCIAL) 94265 [3081118] MEDICA CLAIMS [308111801] 947.7 percent of total billed charges 652.86 1000.35 Technical (Hospital) Services "IV Infusion, Casirivimab and Imdevimab Includes Infusion and Post Administration Monitoring" PX-2600024300 CDM M0243 HCPCS 260 RC outpatient 1053 1053 MULTIPLAN INC 34080 [3081285] MULTIPLAN INC [308128501] 1000.35 percent of total billed charges 652.86 1000.35 Technical (Hospital) Services HC/HH Wch Supp Thumb Spica Lg.Lt__3070 PX-2705000002 CDM L3807 HCPCS 270 RC outpatient 124 124 HEALTHPARTNERS SX009 HEALTHPARTNERS 99.2 percent of total billed charges 76.88 117.8 Technical (Hospital) Services HC/HH Wch Supp Thumb Spica Lg.Lt__3070 PX-2705000002 CDM L3807 HCPCS 270 RC outpatient 124 124 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES PPO [308136801] 99.2 percent of total billed charges 76.88 117.8 Technical (Hospital) Services HC/HH Wch Supp Thumb Spica Lg.Lt__3070 PX-2705000002 CDM L3807 HCPCS 270 RC outpatient 124 124 UNITED HEALTHCARE (COMMERCIAL) [3081199] UNITED HEALTHCARE 87726 [308119901] 76.88 percent of total billed charges 76.88 117.8 Technical (Hospital) Services HC/HH Wch Supp Thumb Spica Lg.Lt__3070 PX-2705000002 CDM L3807 HCPCS 270 RC outpatient 124 124 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES HDHP [308136802] 99.2 percent of total billed charges 76.88 117.8 Technical (Hospital) Services HC/HH Wch Supp Thumb Spica Lg.Lt__3070 PX-2705000002 CDM L3807 HCPCS 270 RC outpatient 124 124 BLUE CROSS BLUE SHIELD WELLMARK SB889 [3081026] BCBS WYOMING [308102603] 117.8 percent of total billed charges 76.88 117.8 Technical (Hospital) Services HC/HH Wch Supp Thumb Spica Lg.Lt__3070 PX-2705000002 CDM L3807 HCPCS 270 RC outpatient 124 124 CIGNA 62308 [3081051] CIGNA 62308 [308105105] 99.2 percent of total billed charges 76.88 117.8 Technical (Hospital) Services HC/HH Wch Supp Thumb Spica Lg.Lt__3070 PX-2705000002 CDM L3807 HCPCS 270 RC outpatient 124 124 CIGNA 62308 [3081051] CIGNA STATE OF WYOMING [308105107] 99.2 percent of total billed charges 76.88 117.8 Technical (Hospital) Services HC/HH Wch Supp Thumb Spica Lg.Lt__3070 PX-2705000002 CDM L3807 HCPCS 270 RC outpatient 124 124 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES EPO [308136803] 99.2 percent of total billed charges 76.88 117.8 Technical (Hospital) Services HC/HH Wch Supp Thumb Spica Lg.Lt__3070 PX-2705000002 CDM L3807 HCPCS 270 RC outpatient 124 124 MEDICA (COMMERCIAL) 94265 [3081118] MEDICA CLAIMS [308111801] 111.6 percent of total billed charges 76.88 117.8 Technical (Hospital) Services HC/HH Wch Supp Thumb Spica Lg.Lt__3070 PX-2705000002 CDM L3807 HCPCS 270 RC outpatient 124 124 MULTIPLAN INC 34080 [3081285] MULTIPLAN INC [308128501] 117.8 percent of total billed charges 76.88 117.8 Technical (Hospital) Services HC/HH Wch Supp Thumb Spica Lg.Lt__3070 PX-2705000002 CDM L3807 HCPCS 270 RC inpatient 124 124 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES EPO [308136803] 98.18 percent of total billed charges 76.88 117.8 Technical (Hospital) Services HC/HH Wch Supp Thumb Spica Lg.Lt__3070 PX-2705000002 CDM L3807 HCPCS 270 RC inpatient 124 124 HEALTHPARTNERS SX009 HEALTHPARTNERS 98.18 percent of total billed charges 76.88 117.8 Technical (Hospital) Services HC/HH Wch Supp Thumb Spica Lg.Lt__3070 PX-2705000002 CDM L3807 HCPCS 270 RC inpatient 124 124 MULTIPLAN INC 34080 [3081285] MULTIPLAN INC [308128501] 117.8 percent of total billed charges 76.88 117.8 Technical (Hospital) Services HC/HH Wch Supp Thumb Spica Lg.Lt__3070 PX-2705000002 CDM L3807 HCPCS 270 RC inpatient 124 124 BLUE CROSS BLUE SHIELD WELLMARK SB889 [3081026] BCBS WYOMING [308102603] 117.8 percent of total billed charges 76.88 117.8 Technical (Hospital) Services HC/HH Wch Supp Thumb Spica Lg.Lt__3070 PX-2705000002 CDM L3807 HCPCS 270 RC inpatient 124 124 CIGNA 62308 [3081051] CIGNA 62308 [308105105] 98.18 percent of total billed charges 76.88 117.8 Technical (Hospital) Services HC/HH Wch Supp Thumb Spica Lg.Lt__3070 PX-2705000002 CDM L3807 HCPCS 270 RC inpatient 124 124 CIGNA 62308 [3081051] CIGNA STATE OF WYOMING [308105107] 98.18 percent of total billed charges 76.88 117.8 Technical (Hospital) Services HC/HH Wch Supp Thumb Spica Lg.Lt__3070 PX-2705000002 CDM L3807 HCPCS 270 RC inpatient 124 124 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES PPO [308136801] 98.18 percent of total billed charges 76.88 117.8 Technical (Hospital) Services HC/HH Wch Supp Thumb Spica Lg.Lt__3070 PX-2705000002 CDM L3807 HCPCS 270 RC inpatient 124 124 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES HDHP [308136802] 98.18 percent of total billed charges 76.88 117.8 Technical (Hospital) Services HC/HH Wch Supp Thumb Spica Lg.Lt__3070 PX-2705000002 CDM L3807 HCPCS 270 RC inpatient 124 124 UNITED HEALTHCARE (COMMERCIAL) [3081199] UNITED HEALTHCARE 87726 [308119901] 76.88 percent of total billed charges 76.88 117.8 Technical (Hospital) Services HC/HH Wch Supp Thumb Spica Lg.Lt__3070 PX-2705000002 CDM L3807 HCPCS 270 RC inpatient 124 124 MEDICA (COMMERCIAL) 94265 [3081118] MEDICA CLAIMS [308111801] 111.6 percent of total billed charges 76.88 117.8 Technical (Hospital) Services HC/HH Wch Supp Thumb Spica Lg.Rt__3170 PX-2705000003 CDM L3807 HCPCS 270 RC outpatient 124 124 UNITED HEALTHCARE (COMMERCIAL) [3081199] UNITED HEALTHCARE 87726 [308119901] 76.88 percent of total billed charges 76.88 117.8 Technical (Hospital) Services HC/HH Wch Supp Thumb Spica Lg.Rt__3170 PX-2705000003 CDM L3807 HCPCS 270 RC outpatient 124 124 HEALTHPARTNERS SX009 HEALTHPARTNERS 99.2 percent of total billed charges 76.88 117.8 Technical (Hospital) Services HC/HH Wch Supp Thumb Spica Lg.Rt__3170 PX-2705000003 CDM L3807 HCPCS 270 RC outpatient 124 124 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES PPO [308136801] 99.2 percent of total billed charges 76.88 117.8 Technical (Hospital) Services HC/HH Wch Supp Thumb Spica Lg.Rt__3170 PX-2705000003 CDM L3807 HCPCS 270 RC outpatient 124 124 BLUE CROSS BLUE SHIELD WELLMARK SB889 [3081026] BCBS WYOMING [308102603] 117.8 percent of total billed charges 76.88 117.8 Technical (Hospital) Services HC/HH Wch Supp Thumb Spica Lg.Rt__3170 PX-2705000003 CDM L3807 HCPCS 270 RC outpatient 124 124 CIGNA 62308 [3081051] CIGNA 62308 [308105105] 99.2 percent of total billed charges 76.88 117.8 Technical (Hospital) Services HC/HH Wch Supp Thumb Spica Lg.Rt__3170 PX-2705000003 CDM L3807 HCPCS 270 RC outpatient 124 124 CIGNA 62308 [3081051] CIGNA STATE OF WYOMING [308105107] 99.2 percent of total billed charges 76.88 117.8 Technical (Hospital) Services HC/HH Wch Supp Thumb Spica Lg.Rt__3170 PX-2705000003 CDM L3807 HCPCS 270 RC outpatient 124 124 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES EPO [308136803] 99.2 percent of total billed charges 76.88 117.8 Technical (Hospital) Services HC/HH Wch Supp Thumb Spica Lg.Rt__3170 PX-2705000003 CDM L3807 HCPCS 270 RC outpatient 124 124 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES HDHP [308136802] 99.2 percent of total billed charges 76.88 117.8 Technical (Hospital) Services HC/HH Wch Supp Thumb Spica Lg.Rt__3170 PX-2705000003 CDM L3807 HCPCS 270 RC outpatient 124 124 MEDICA (COMMERCIAL) 94265 [3081118] MEDICA CLAIMS [308111801] 111.6 percent of total billed charges 76.88 117.8 Technical (Hospital) Services HC/HH Wch Supp Thumb Spica Lg.Rt__3170 PX-2705000003 CDM L3807 HCPCS 270 RC outpatient 124 124 MULTIPLAN INC 34080 [3081285] MULTIPLAN INC [308128501] 117.8 percent of total billed charges 76.88 117.8 Technical (Hospital) Services HC/HH Wch Supp Thumb Spica Lg.Rt__3170 PX-2705000003 CDM L3807 HCPCS 270 RC inpatient 124 124 MEDICA (COMMERCIAL) 94265 [3081118] MEDICA CLAIMS [308111801] 111.6 percent of total billed charges 76.88 117.8 Technical (Hospital) Services HC/HH Wch Supp Thumb Spica Lg.Rt__3170 PX-2705000003 CDM L3807 HCPCS 270 RC inpatient 124 124 UNITED HEALTHCARE (COMMERCIAL) [3081199] UNITED HEALTHCARE 87726 [308119901] 76.88 percent of total billed charges 76.88 117.8 Technical (Hospital) Services HC/HH Wch Supp Thumb Spica Lg.Rt__3170 PX-2705000003 CDM L3807 HCPCS 270 RC inpatient 124 124 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES HDHP [308136802] 98.18 percent of total billed charges 76.88 117.8 Technical (Hospital) Services HC/HH Wch Supp Thumb Spica Lg.Rt__3170 PX-2705000003 CDM L3807 HCPCS 270 RC inpatient 124 124 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES PPO [308136801] 98.18 percent of total billed charges 76.88 117.8 Technical (Hospital) Services HC/HH Wch Supp Thumb Spica Lg.Rt__3170 PX-2705000003 CDM L3807 HCPCS 270 RC inpatient 124 124 CIGNA 62308 [3081051] CIGNA 62308 [308105105] 98.18 percent of total billed charges 76.88 117.8 Technical (Hospital) Services HC/HH Wch Supp Thumb Spica Lg.Rt__3170 PX-2705000003 CDM L3807 HCPCS 270 RC inpatient 124 124 CIGNA 62308 [3081051] CIGNA STATE OF WYOMING [308105107] 98.18 percent of total billed charges 76.88 117.8 Technical (Hospital) Services HC/HH Wch Supp Thumb Spica Lg.Rt__3170 PX-2705000003 CDM L3807 HCPCS 270 RC inpatient 124 124 BLUE CROSS BLUE SHIELD WELLMARK SB889 [3081026] BCBS WYOMING [308102603] 117.8 percent of total billed charges 76.88 117.8 Technical (Hospital) Services HC/HH Wch Supp Thumb Spica Lg.Rt__3170 PX-2705000003 CDM L3807 HCPCS 270 RC inpatient 124 124 MULTIPLAN INC 34080 [3081285] MULTIPLAN INC [308128501] 117.8 percent of total billed charges 76.88 117.8 Technical (Hospital) Services HC/HH Wch Supp Thumb Spica Lg.Rt__3170 PX-2705000003 CDM L3807 HCPCS 270 RC inpatient 124 124 HEALTHPARTNERS SX009 HEALTHPARTNERS 98.18 percent of total billed charges 76.88 117.8 Technical (Hospital) Services HC/HH Wch Supp Thumb Spica Lg.Rt__3170 PX-2705000003 CDM L3807 HCPCS 270 RC inpatient 124 124 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES EPO [308136803] 98.18 percent of total billed charges 76.88 117.8 Technical (Hospital) Services HC/HH Wch Supp Thumb Spica Med Rt__3150 PX-2705000004 CDM L3807 HCPCS 270 RC outpatient 129 129 HEALTHPARTNERS SX009 HEALTHPARTNERS 103.2 percent of total billed charges 79.98 122.55 Technical (Hospital) Services HC/HH Wch Supp Thumb Spica Med Rt__3150 PX-2705000004 CDM L3807 HCPCS 270 RC outpatient 129 129 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES PPO [308136801] 103.2 percent of total billed charges 79.98 122.55 Technical (Hospital) Services HC/HH Wch Supp Thumb Spica Med Rt__3150 PX-2705000004 CDM L3807 HCPCS 270 RC outpatient 129 129 UNITED HEALTHCARE (COMMERCIAL) [3081199] UNITED HEALTHCARE 87726 [308119901] 79.98 percent of total billed charges 79.98 122.55 Technical (Hospital) Services HC/HH Wch Supp Thumb Spica Med Rt__3150 PX-2705000004 CDM L3807 HCPCS 270 RC outpatient 129 129 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES HDHP [308136802] 103.2 percent of total billed charges 79.98 122.55 Technical (Hospital) Services HC/HH Wch Supp Thumb Spica Med Rt__3150 PX-2705000004 CDM L3807 HCPCS 270 RC outpatient 129 129 CIGNA 62308 [3081051] CIGNA 62308 [308105105] 103.2 percent of total billed charges 79.98 122.55 Technical (Hospital) Services HC/HH Wch Supp Thumb Spica Med Rt__3150 PX-2705000004 CDM L3807 HCPCS 270 RC outpatient 129 129 CIGNA 62308 [3081051] CIGNA STATE OF WYOMING [308105107] 103.2 percent of total billed charges 79.98 122.55 Technical (Hospital) Services HC/HH Wch Supp Thumb Spica Med Rt__3150 PX-2705000004 CDM L3807 HCPCS 270 RC outpatient 129 129 BLUE CROSS BLUE SHIELD WELLMARK SB889 [3081026] BCBS WYOMING [308102603] 122.55 percent of total billed charges 79.98 122.55 Technical (Hospital) Services HC/HH Wch Supp Thumb Spica Med Rt__3150 PX-2705000004 CDM L3807 HCPCS 270 RC outpatient 129 129 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES EPO [308136803] 103.2 percent of total billed charges 79.98 122.55 Technical (Hospital) Services HC/HH Wch Supp Thumb Spica Med Rt__3150 PX-2705000004 CDM L3807 HCPCS 270 RC outpatient 129 129 MULTIPLAN INC 34080 [3081285] MULTIPLAN INC [308128501] 122.55 percent of total billed charges 79.98 122.55 Technical (Hospital) Services HC/HH Wch Supp Thumb Spica Med Rt__3150 PX-2705000004 CDM L3807 HCPCS 270 RC outpatient 129 129 MEDICA (COMMERCIAL) 94265 [3081118] MEDICA CLAIMS [308111801] 116.1 percent of total billed charges 79.98 122.55 Technical (Hospital) Services HC/HH Wch Supp Thumb Spica Med Rt__3150 PX-2705000004 CDM L3807 HCPCS 270 RC inpatient 129 129 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES EPO [308136803] 102.14 percent of total billed charges 79.98 122.55 Technical (Hospital) Services HC/HH Wch Supp Thumb Spica Med Rt__3150 PX-2705000004 CDM L3807 HCPCS 270 RC inpatient 129 129 HEALTHPARTNERS SX009 HEALTHPARTNERS 102.14 percent of total billed charges 79.98 122.55 Technical (Hospital) Services HC/HH Wch Supp Thumb Spica Med Rt__3150 PX-2705000004 CDM L3807 HCPCS 270 RC inpatient 129 129 MULTIPLAN INC 34080 [3081285] MULTIPLAN INC [308128501] 122.55 percent of total billed charges 79.98 122.55 Technical (Hospital) Services HC/HH Wch Supp Thumb Spica Med Rt__3150 PX-2705000004 CDM L3807 HCPCS 270 RC inpatient 129 129 BLUE CROSS BLUE SHIELD WELLMARK SB889 [3081026] BCBS WYOMING [308102603] 122.55 percent of total billed charges 79.98 122.55 Technical (Hospital) Services HC/HH Wch Supp Thumb Spica Med Rt__3150 PX-2705000004 CDM L3807 HCPCS 270 RC inpatient 129 129 CIGNA 62308 [3081051] CIGNA 62308 [308105105] 102.14 percent of total billed charges 79.98 122.55 Technical (Hospital) Services HC/HH Wch Supp Thumb Spica Med Rt__3150 PX-2705000004 CDM L3807 HCPCS 270 RC inpatient 129 129 CIGNA 62308 [3081051] CIGNA STATE OF WYOMING [308105107] 102.14 percent of total billed charges 79.98 122.55 Technical (Hospital) Services HC/HH Wch Supp Thumb Spica Med Rt__3150 PX-2705000004 CDM L3807 HCPCS 270 RC inpatient 129 129 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES PPO [308136801] 102.14 percent of total billed charges 79.98 122.55 Technical (Hospital) Services HC/HH Wch Supp Thumb Spica Med Rt__3150 PX-2705000004 CDM L3807 HCPCS 270 RC inpatient 129 129 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES HDHP [308136802] 102.14 percent of total billed charges 79.98 122.55 Technical (Hospital) Services HC/HH Wch Supp Thumb Spica Med Rt__3150 PX-2705000004 CDM L3807 HCPCS 270 RC inpatient 129 129 UNITED HEALTHCARE (COMMERCIAL) [3081199] UNITED HEALTHCARE 87726 [308119901] 79.98 percent of total billed charges 79.98 122.55 Technical (Hospital) Services HC/HH Wch Supp Thumb Spica Med Rt__3150 PX-2705000004 CDM L3807 HCPCS 270 RC inpatient 129 129 MEDICA (COMMERCIAL) 94265 [3081118] MEDICA CLAIMS [308111801] 116.1 percent of total billed charges 79.98 122.55 Technical (Hospital) Services LEUPROLIDE (LUPRON) 45 MG INTRAMUSCULAR SYRINGE KIT (6 MONTH) RX-110751 CDM J9217 HCPCS 636 RC 00074-3473-03 NDC inpatient 1 UN 18764.75 18764.75 BLUE CROSS BLUE SHIELD WELLMARK SB889 [3081026] BCBS WYOMING [308102603] 17826.51 percent of total billed charges 11634.15 17826.51 Technical (Hospital) Services LEUPROLIDE (LUPRON) 45 MG INTRAMUSCULAR SYRINGE KIT (6 MONTH) RX-110751 CDM J9217 HCPCS 636 RC 00074-3473-03 NDC inpatient 1 UN 18764.75 18764.75 UNITED HEALTHCARE (COMMERCIAL) [3081199] UNITED HEALTHCARE 87726 [308119901] 11634.15 percent of total billed charges 11634.15 17826.51 Technical (Hospital) Services LEUPROLIDE (LUPRON) 45 MG INTRAMUSCULAR SYRINGE KIT (6 MONTH) RX-110751 CDM J9217 HCPCS 636 RC 00074-3473-03 NDC inpatient 1 UN 18764.75 18764.75 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES HDHP [308136802] 14857.93 percent of total billed charges 11634.15 17826.51 Technical (Hospital) Services LEUPROLIDE (LUPRON) 45 MG INTRAMUSCULAR SYRINGE KIT (6 MONTH) RX-110751 CDM J9217 HCPCS 636 RC 00074-3473-03 NDC inpatient 1 UN 18764.75 18764.75 CIGNA 62308 [3081051] CIGNA 62308 [308105105] 14857.93 percent of total billed charges 11634.15 17826.51 Technical (Hospital) Services LEUPROLIDE (LUPRON) 45 MG INTRAMUSCULAR SYRINGE KIT (6 MONTH) RX-110751 CDM J9217 HCPCS 636 RC 00074-3473-03 NDC inpatient 1 UN 18764.75 18764.75 CIGNA 62308 [3081051] CIGNA STATE OF WYOMING [308105107] 14857.93 percent of total billed charges 11634.15 17826.51 Technical (Hospital) Services LEUPROLIDE (LUPRON) 45 MG INTRAMUSCULAR SYRINGE KIT (6 MONTH) RX-110751 CDM J9217 HCPCS 636 RC 00074-3473-03 NDC inpatient 1 UN 18764.75 18764.75 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES EPO [308136803] 14857.93 percent of total billed charges 11634.15 17826.51 Technical (Hospital) Services LEUPROLIDE (LUPRON) 45 MG INTRAMUSCULAR SYRINGE KIT (6 MONTH) RX-110751 CDM J9217 HCPCS 636 RC 00074-3473-03 NDC inpatient 1 UN 18764.75 18764.75 HEALTHPARTNERS SX009 HEALTHPARTNERS 14857.93 percent of total billed charges 11634.15 17826.51 Technical (Hospital) Services LEUPROLIDE (LUPRON) 45 MG INTRAMUSCULAR SYRINGE KIT (6 MONTH) RX-110751 CDM J9217 HCPCS 636 RC 00074-3473-03 NDC inpatient 1 UN 18764.75 18764.75 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES PPO [308136801] 14857.93 percent of total billed charges 11634.15 17826.51 Technical (Hospital) Services LEUPROLIDE (LUPRON) 45 MG INTRAMUSCULAR SYRINGE KIT (6 MONTH) RX-110751 CDM J9217 HCPCS 636 RC 00074-3473-03 NDC inpatient 1 UN 18764.75 18764.75 MEDICA (COMMERCIAL) 94265 [3081118] MEDICA CLAIMS [308111801] 16888.28 percent of total billed charges 11634.15 17826.51 Technical (Hospital) Services LEUPROLIDE (LUPRON) 45 MG INTRAMUSCULAR SYRINGE KIT (6 MONTH) RX-110751 CDM J9217 HCPCS 636 RC 00074-3473-03 NDC inpatient 1 UN 18764.75 18764.75 MULTIPLAN INC 34080 [3081285] MULTIPLAN INC [308128501] 17826.51 percent of total billed charges 11634.15 17826.51 Technical (Hospital) Services LEUPROLIDE (LUPRON) 45 MG INTRAMUSCULAR SYRINGE KIT (6 MONTH) RX-110751 CDM J9217 HCPCS 636 RC 00074-3473-03 NDC outpatient 1 UN 18764.75 18764.75 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES EPO [308136803] 15011.8 percent of total billed charges 11634.15 17826.51 Technical (Hospital) Services LEUPROLIDE (LUPRON) 45 MG INTRAMUSCULAR SYRINGE KIT (6 MONTH) RX-110751 CDM J9217 HCPCS 636 RC 00074-3473-03 NDC outpatient 1 UN 18764.75 18764.75 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES HDHP [308136802] 15011.8 percent of total billed charges 11634.15 17826.51 Technical (Hospital) Services LEUPROLIDE (LUPRON) 45 MG INTRAMUSCULAR SYRINGE KIT (6 MONTH) RX-110751 CDM J9217 HCPCS 636 RC 00074-3473-03 NDC outpatient 1 UN 18764.75 18764.75 UNITED HEALTHCARE (COMMERCIAL) [3081199] UNITED HEALTHCARE 87726 [308119901] 11634.15 percent of total billed charges 11634.15 17826.51 Technical (Hospital) Services LEUPROLIDE (LUPRON) 45 MG INTRAMUSCULAR SYRINGE KIT (6 MONTH) RX-110751 CDM J9217 HCPCS 636 RC 00074-3473-03 NDC outpatient 1 UN 18764.75 18764.75 MULTIPLAN INC 34080 [3081285] MULTIPLAN INC [308128501] 17826.51 percent of total billed charges 11634.15 17826.51 Technical (Hospital) Services LEUPROLIDE (LUPRON) 45 MG INTRAMUSCULAR SYRINGE KIT (6 MONTH) RX-110751 CDM J9217 HCPCS 636 RC 00074-3473-03 NDC outpatient 1 UN 18764.75 18764.75 HEALTHPARTNERS SX009 HEALTHPARTNERS 15011.8 percent of total billed charges 11634.15 17826.51 Technical (Hospital) Services LEUPROLIDE (LUPRON) 45 MG INTRAMUSCULAR SYRINGE KIT (6 MONTH) RX-110751 CDM J9217 HCPCS 636 RC 00074-3473-03 NDC outpatient 1 UN 18764.75 18764.75 CIGNA 62308 [3081051] CIGNA 62308 [308105105] 15011.8 percent of total billed charges 11634.15 17826.51 Technical (Hospital) Services LEUPROLIDE (LUPRON) 45 MG INTRAMUSCULAR SYRINGE KIT (6 MONTH) RX-110751 CDM J9217 HCPCS 636 RC 00074-3473-03 NDC outpatient 1 UN 18764.75 18764.75 CIGNA 62308 [3081051] CIGNA STATE OF WYOMING [308105107] 15011.8 percent of total billed charges 11634.15 17826.51 Technical (Hospital) Services LEUPROLIDE (LUPRON) 45 MG INTRAMUSCULAR SYRINGE KIT (6 MONTH) RX-110751 CDM J9217 HCPCS 636 RC 00074-3473-03 NDC outpatient 1 UN 18764.75 18764.75 MEDICA (COMMERCIAL) 94265 [3081118] MEDICA CLAIMS [308111801] 16888.28 percent of total billed charges 11634.15 17826.51 Technical (Hospital) Services LEUPROLIDE (LUPRON) 45 MG INTRAMUSCULAR SYRINGE KIT (6 MONTH) RX-110751 CDM J9217 HCPCS 636 RC 00074-3473-03 NDC outpatient 1 UN 18764.75 18764.75 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES PPO [308136801] 15011.8 percent of total billed charges 11634.15 17826.51 Technical (Hospital) Services LEUPROLIDE (LUPRON) 45 MG INTRAMUSCULAR SYRINGE KIT (6 MONTH) RX-110751 CDM J9217 HCPCS 636 RC 00074-3473-03 NDC outpatient 1 UN 18764.75 18764.75 BLUE CROSS BLUE SHIELD WELLMARK SB889 [3081026] BCBS WYOMING [308102603] 17826.51 percent of total billed charges 11634.15 17826.51 Technical (Hospital) Services LEUPROLIDE 7.5 MG (LUPRON) INTRAMUSCULAR SYRINGE KIT RX-130740 CDM J9217 HCPCS 636 RC 00074-3642-03 NDC outpatient 1 UN 4494.1 4494.1 CIGNA 62308 [3081051] CIGNA 62308 [308105105] 3595.28 percent of total billed charges 2786.34 4269.4 Technical (Hospital) Services LEUPROLIDE 7.5 MG (LUPRON) INTRAMUSCULAR SYRINGE KIT RX-130740 CDM J9217 HCPCS 636 RC 00074-3642-03 NDC outpatient 1 UN 4494.1 4494.1 CIGNA 62308 [3081051] CIGNA STATE OF WYOMING [308105107] 3595.28 percent of total billed charges 2786.34 4269.4 Technical (Hospital) Services LEUPROLIDE 7.5 MG (LUPRON) INTRAMUSCULAR SYRINGE KIT RX-130740 CDM J9217 HCPCS 636 RC 00074-3642-03 NDC outpatient 1 UN 4494.1 4494.1 MEDICA (COMMERCIAL) 94265 [3081118] MEDICA CLAIMS [308111801] 4044.69 percent of total billed charges 2786.34 4269.4 Technical (Hospital) Services LEUPROLIDE 7.5 MG (LUPRON) INTRAMUSCULAR SYRINGE KIT RX-130740 CDM J9217 HCPCS 636 RC 00074-3642-03 NDC outpatient 1 UN 4494.1 4494.1 HEALTHPARTNERS SX009 HEALTHPARTNERS 3595.28 percent of total billed charges 2786.34 4269.4 Technical (Hospital) Services LEUPROLIDE 7.5 MG (LUPRON) INTRAMUSCULAR SYRINGE KIT RX-130740 CDM J9217 HCPCS 636 RC 00074-3642-03 NDC outpatient 1 UN 4494.1 4494.1 MULTIPLAN INC 34080 [3081285] MULTIPLAN INC [308128501] 4269.4 percent of total billed charges 2786.34 4269.4 Technical (Hospital) Services LEUPROLIDE 7.5 MG (LUPRON) INTRAMUSCULAR SYRINGE KIT RX-130740 CDM J9217 HCPCS 636 RC 00074-3642-03 NDC outpatient 1 UN 4494.1 4494.1 UNITED HEALTHCARE (COMMERCIAL) [3081199] UNITED HEALTHCARE 87726 [308119901] 2786.34 percent of total billed charges 2786.34 4269.4 Technical (Hospital) Services LEUPROLIDE 7.5 MG (LUPRON) INTRAMUSCULAR SYRINGE KIT RX-130740 CDM J9217 HCPCS 636 RC 00074-3642-03 NDC outpatient 1 UN 4494.1 4494.1 BLUE CROSS BLUE SHIELD WELLMARK SB889 [3081026] BCBS WYOMING [308102603] 4269.4 percent of total billed charges 2786.34 4269.4 Technical (Hospital) Services LEUPROLIDE 7.5 MG (LUPRON) INTRAMUSCULAR SYRINGE KIT RX-130740 CDM J9217 HCPCS 636 RC 00074-3642-03 NDC outpatient 1 UN 4494.1 4494.1 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES PPO [308136801] 3595.28 percent of total billed charges 2786.34 4269.4 Technical (Hospital) Services LEUPROLIDE 7.5 MG (LUPRON) INTRAMUSCULAR SYRINGE KIT RX-130740 CDM J9217 HCPCS 636 RC 00074-3642-03 NDC outpatient 1 UN 4494.1 4494.1 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES EPO [308136803] 3595.28 percent of total billed charges 2786.34 4269.4 Technical (Hospital) Services LEUPROLIDE 7.5 MG (LUPRON) INTRAMUSCULAR SYRINGE KIT RX-130740 CDM J9217 HCPCS 636 RC 00074-3642-03 NDC outpatient 1 UN 4494.1 4494.1 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES HDHP [308136802] 3595.28 percent of total billed charges 2786.34 4269.4 Technical (Hospital) Services LEUPROLIDE 7.5 MG (LUPRON) INTRAMUSCULAR SYRINGE KIT RX-130740 CDM J9217 HCPCS 636 RC 00074-3642-03 NDC inpatient 1 UN 4494.1 4494.1 MEDICA (COMMERCIAL) 94265 [3081118] MEDICA CLAIMS [308111801] 4044.69 percent of total billed charges 2786.34 4269.4 Technical (Hospital) Services LEUPROLIDE 7.5 MG (LUPRON) INTRAMUSCULAR SYRINGE KIT RX-130740 CDM J9217 HCPCS 636 RC 00074-3642-03 NDC inpatient 1 UN 4494.1 4494.1 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES PPO [308136801] 3558.43 percent of total billed charges 2786.34 4269.4 Technical (Hospital) Services LEUPROLIDE 7.5 MG (LUPRON) INTRAMUSCULAR SYRINGE KIT RX-130740 CDM J9217 HCPCS 636 RC 00074-3642-03 NDC inpatient 1 UN 4494.1 4494.1 HEALTHPARTNERS SX009 HEALTHPARTNERS 3558.43 percent of total billed charges 2786.34 4269.4 Technical (Hospital) Services LEUPROLIDE 7.5 MG (LUPRON) INTRAMUSCULAR SYRINGE KIT RX-130740 CDM J9217 HCPCS 636 RC 00074-3642-03 NDC inpatient 1 UN 4494.1 4494.1 MULTIPLAN INC 34080 [3081285] MULTIPLAN INC [308128501] 4269.4 percent of total billed charges 2786.34 4269.4 Technical (Hospital) Services LEUPROLIDE 7.5 MG (LUPRON) INTRAMUSCULAR SYRINGE KIT RX-130740 CDM J9217 HCPCS 636 RC 00074-3642-03 NDC inpatient 1 UN 4494.1 4494.1 BLUE CROSS BLUE SHIELD WELLMARK SB889 [3081026] BCBS WYOMING [308102603] 4269.4 percent of total billed charges 2786.34 4269.4 Technical (Hospital) Services LEUPROLIDE 7.5 MG (LUPRON) INTRAMUSCULAR SYRINGE KIT RX-130740 CDM J9217 HCPCS 636 RC 00074-3642-03 NDC inpatient 1 UN 4494.1 4494.1 UNITED HEALTHCARE (COMMERCIAL) [3081199] UNITED HEALTHCARE 87726 [308119901] 2786.34 percent of total billed charges 2786.34 4269.4 Technical (Hospital) Services LEUPROLIDE 7.5 MG (LUPRON) INTRAMUSCULAR SYRINGE KIT RX-130740 CDM J9217 HCPCS 636 RC 00074-3642-03 NDC inpatient 1 UN 4494.1 4494.1 CIGNA 62308 [3081051] CIGNA 62308 [308105105] 3558.43 percent of total billed charges 2786.34 4269.4 Technical (Hospital) Services LEUPROLIDE 7.5 MG (LUPRON) INTRAMUSCULAR SYRINGE KIT RX-130740 CDM J9217 HCPCS 636 RC 00074-3642-03 NDC inpatient 1 UN 4494.1 4494.1 CIGNA 62308 [3081051] CIGNA STATE OF WYOMING [308105107] 3558.43 percent of total billed charges 2786.34 4269.4 Technical (Hospital) Services LEUPROLIDE 7.5 MG (LUPRON) INTRAMUSCULAR SYRINGE KIT RX-130740 CDM J9217 HCPCS 636 RC 00074-3642-03 NDC inpatient 1 UN 4494.1 4494.1 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES HDHP [308136802] 3558.43 percent of total billed charges 2786.34 4269.4 Technical (Hospital) Services LEUPROLIDE 7.5 MG (LUPRON) INTRAMUSCULAR SYRINGE KIT RX-130740 CDM J9217 HCPCS 636 RC 00074-3642-03 NDC inpatient 1 UN 4494.1 4494.1 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES EPO [308136803] 3558.43 percent of total billed charges 2786.34 4269.4 Technical (Hospital) Services LEUPROLIDE 22.5 MG (LUPRON) INTRAMUSCULAR SYRINGE KIT (3 MONTH) RX-21045 CDM J9217 HCPCS 636 RC 00074-3346-03 NDC inpatient 22.5 ME 9882.27 9882.27 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES EPO [308136803] 7824.78 percent of total billed charges 6127.01 9388.16 Technical (Hospital) Services LEUPROLIDE 22.5 MG (LUPRON) INTRAMUSCULAR SYRINGE KIT (3 MONTH) RX-21045 CDM J9217 HCPCS 636 RC 00074-3346-03 NDC inpatient 22.5 ME 9882.27 9882.27 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES HDHP [308136802] 7824.78 percent of total billed charges 6127.01 9388.16 Technical (Hospital) Services LEUPROLIDE 22.5 MG (LUPRON) INTRAMUSCULAR SYRINGE KIT (3 MONTH) RX-21045 CDM J9217 HCPCS 636 RC 00074-3346-03 NDC inpatient 22.5 ME 9882.27 9882.27 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES PPO [308136801] 7824.78 percent of total billed charges 6127.01 9388.16 Technical (Hospital) Services LEUPROLIDE 22.5 MG (LUPRON) INTRAMUSCULAR SYRINGE KIT (3 MONTH) RX-21045 CDM J9217 HCPCS 636 RC 00074-3346-03 NDC inpatient 22.5 ME 9882.27 9882.27 CIGNA 62308 [3081051] CIGNA 62308 [308105105] 7824.78 percent of total billed charges 6127.01 9388.16 Technical (Hospital) Services LEUPROLIDE 22.5 MG (LUPRON) INTRAMUSCULAR SYRINGE KIT (3 MONTH) RX-21045 CDM J9217 HCPCS 636 RC 00074-3346-03 NDC inpatient 22.5 ME 9882.27 9882.27 CIGNA 62308 [3081051] CIGNA STATE OF WYOMING [308105107] 7824.78 percent of total billed charges 6127.01 9388.16 Technical (Hospital) Services LEUPROLIDE 22.5 MG (LUPRON) INTRAMUSCULAR SYRINGE KIT (3 MONTH) RX-21045 CDM J9217 HCPCS 636 RC 00074-3346-03 NDC inpatient 22.5 ME 9882.27 9882.27 HEALTHPARTNERS SX009 HEALTHPARTNERS 7824.78 percent of total billed charges 6127.01 9388.16 Technical (Hospital) Services LEUPROLIDE 22.5 MG (LUPRON) INTRAMUSCULAR SYRINGE KIT (3 MONTH) RX-21045 CDM J9217 HCPCS 636 RC 00074-3346-03 NDC inpatient 22.5 ME 9882.27 9882.27 UNITED HEALTHCARE (COMMERCIAL) [3081199] UNITED HEALTHCARE 87726 [308119901] 6127.01 percent of total billed charges 6127.01 9388.16 Technical (Hospital) Services LEUPROLIDE 22.5 MG (LUPRON) INTRAMUSCULAR SYRINGE KIT (3 MONTH) RX-21045 CDM J9217 HCPCS 636 RC 00074-3346-03 NDC inpatient 22.5 ME 9882.27 9882.27 BLUE CROSS BLUE SHIELD WELLMARK SB889 [3081026] BCBS WYOMING [308102603] 9388.16 percent of total billed charges 6127.01 9388.16 Technical (Hospital) Services LEUPROLIDE 22.5 MG (LUPRON) INTRAMUSCULAR SYRINGE KIT (3 MONTH) RX-21045 CDM J9217 HCPCS 636 RC 00074-3346-03 NDC inpatient 22.5 ME 9882.27 9882.27 MEDICA (COMMERCIAL) 94265 [3081118] MEDICA CLAIMS [308111801] 8894.04 percent of total billed charges 6127.01 9388.16 Technical (Hospital) Services LEUPROLIDE 22.5 MG (LUPRON) INTRAMUSCULAR SYRINGE KIT (3 MONTH) RX-21045 CDM J9217 HCPCS 636 RC 00074-3346-03 NDC inpatient 22.5 ME 9882.27 9882.27 MULTIPLAN INC 34080 [3081285] MULTIPLAN INC [308128501] 9388.16 percent of total billed charges 6127.01 9388.16 Technical (Hospital) Services LEUPROLIDE 22.5 MG (LUPRON) INTRAMUSCULAR SYRINGE KIT (3 MONTH) RX-21045 CDM J9217 HCPCS 636 RC 00074-3346-03 NDC outpatient 22.5 ME 9882.27 9882.27 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES EPO [308136803] 7905.82 percent of total billed charges 6127.01 9388.16 Technical (Hospital) Services LEUPROLIDE 22.5 MG (LUPRON) INTRAMUSCULAR SYRINGE KIT (3 MONTH) RX-21045 CDM J9217 HCPCS 636 RC 00074-3346-03 NDC outpatient 22.5 ME 9882.27 9882.27 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES HDHP [308136802] 7905.82 percent of total billed charges 6127.01 9388.16 Technical (Hospital) Services LEUPROLIDE 22.5 MG (LUPRON) INTRAMUSCULAR SYRINGE KIT (3 MONTH) RX-21045 CDM J9217 HCPCS 636 RC 00074-3346-03 NDC outpatient 22.5 ME 9882.27 9882.27 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES PPO [308136801] 7905.82 percent of total billed charges 6127.01 9388.16 Technical (Hospital) Services LEUPROLIDE 22.5 MG (LUPRON) INTRAMUSCULAR SYRINGE KIT (3 MONTH) RX-21045 CDM J9217 HCPCS 636 RC 00074-3346-03 NDC outpatient 22.5 ME 9882.27 9882.27 BLUE CROSS BLUE SHIELD WELLMARK SB889 [3081026] BCBS WYOMING [308102603] 9388.16 percent of total billed charges 6127.01 9388.16 Technical (Hospital) Services LEUPROLIDE 22.5 MG (LUPRON) INTRAMUSCULAR SYRINGE KIT (3 MONTH) RX-21045 CDM J9217 HCPCS 636 RC 00074-3346-03 NDC outpatient 22.5 ME 9882.27 9882.27 HEALTHPARTNERS SX009 HEALTHPARTNERS 7905.82 percent of total billed charges 6127.01 9388.16 Technical (Hospital) Services LEUPROLIDE 22.5 MG (LUPRON) INTRAMUSCULAR SYRINGE KIT (3 MONTH) RX-21045 CDM J9217 HCPCS 636 RC 00074-3346-03 NDC outpatient 22.5 ME 9882.27 9882.27 UNITED HEALTHCARE (COMMERCIAL) [3081199] UNITED HEALTHCARE 87726 [308119901] 6127.01 percent of total billed charges 6127.01 9388.16 Technical (Hospital) Services LEUPROLIDE 22.5 MG (LUPRON) INTRAMUSCULAR SYRINGE KIT (3 MONTH) RX-21045 CDM J9217 HCPCS 636 RC 00074-3346-03 NDC outpatient 22.5 ME 9882.27 9882.27 MEDICA (COMMERCIAL) 94265 [3081118] MEDICA CLAIMS [308111801] 8894.04 percent of total billed charges 6127.01 9388.16 Technical (Hospital) Services LEUPROLIDE 22.5 MG (LUPRON) INTRAMUSCULAR SYRINGE KIT (3 MONTH) RX-21045 CDM J9217 HCPCS 636 RC 00074-3346-03 NDC outpatient 22.5 ME 9882.27 9882.27 MULTIPLAN INC 34080 [3081285] MULTIPLAN INC [308128501] 9388.16 percent of total billed charges 6127.01 9388.16 Technical (Hospital) Services LEUPROLIDE 22.5 MG (LUPRON) INTRAMUSCULAR SYRINGE KIT (3 MONTH) RX-21045 CDM J9217 HCPCS 636 RC 00074-3346-03 NDC outpatient 22.5 ME 9882.27 9882.27 CIGNA 62308 [3081051] CIGNA 62308 [308105105] 7905.82 percent of total billed charges 6127.01 9388.16 Technical (Hospital) Services LEUPROLIDE 22.5 MG (LUPRON) INTRAMUSCULAR SYRINGE KIT (3 MONTH) RX-21045 CDM J9217 HCPCS 636 RC 00074-3346-03 NDC outpatient 22.5 ME 9882.27 9882.27 CIGNA 62308 [3081051] CIGNA STATE OF WYOMING [308105107] 7905.82 percent of total billed charges 6127.01 9388.16 Technical (Hospital) Services LEUPROLIDE 30 MG (LUPRON) INTRAMUSCULAR SYRINGE KIT (4 MONTH) RX-21108 CDM J9217 HCPCS 636 RC 00074-3683-03 NDC outpatient 30 ME 13426.38 13426.38 MULTIPLAN INC 34080 [3081285] MULTIPLAN INC [308128501] 12755.06 percent of total billed charges 8324.36 12755.06 Technical (Hospital) Services LEUPROLIDE 30 MG (LUPRON) INTRAMUSCULAR SYRINGE KIT (4 MONTH) RX-21108 CDM J9217 HCPCS 636 RC 00074-3683-03 NDC outpatient 30 ME 13426.38 13426.38 MEDICA (COMMERCIAL) 94265 [3081118] MEDICA CLAIMS [308111801] 12083.74 percent of total billed charges 8324.36 12755.06 Technical (Hospital) Services LEUPROLIDE 30 MG (LUPRON) INTRAMUSCULAR SYRINGE KIT (4 MONTH) RX-21108 CDM J9217 HCPCS 636 RC 00074-3683-03 NDC outpatient 30 ME 13426.38 13426.38 HEALTHPARTNERS SX009 HEALTHPARTNERS 10741.1 percent of total billed charges 8324.36 12755.06 Technical (Hospital) Services LEUPROLIDE 30 MG (LUPRON) INTRAMUSCULAR SYRINGE KIT (4 MONTH) RX-21108 CDM J9217 HCPCS 636 RC 00074-3683-03 NDC outpatient 30 ME 13426.38 13426.38 UNITED HEALTHCARE (COMMERCIAL) [3081199] UNITED HEALTHCARE 87726 [308119901] 8324.36 percent of total billed charges 8324.36 12755.06 Technical (Hospital) Services LEUPROLIDE 30 MG (LUPRON) INTRAMUSCULAR SYRINGE KIT (4 MONTH) RX-21108 CDM J9217 HCPCS 636 RC 00074-3683-03 NDC outpatient 30 ME 13426.38 13426.38 BLUE CROSS BLUE SHIELD WELLMARK SB889 [3081026] BCBS WYOMING [308102603] 12755.06 percent of total billed charges 8324.36 12755.06 Technical (Hospital) Services LEUPROLIDE 30 MG (LUPRON) INTRAMUSCULAR SYRINGE KIT (4 MONTH) RX-21108 CDM J9217 HCPCS 636 RC 00074-3683-03 NDC outpatient 30 ME 13426.38 13426.38 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES EPO [308136803] 10741.1 percent of total billed charges 8324.36 12755.06 Technical (Hospital) Services LEUPROLIDE 30 MG (LUPRON) INTRAMUSCULAR SYRINGE KIT (4 MONTH) RX-21108 CDM J9217 HCPCS 636 RC 00074-3683-03 NDC outpatient 30 ME 13426.38 13426.38 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES HDHP [308136802] 10741.1 percent of total billed charges 8324.36 12755.06 Technical (Hospital) Services LEUPROLIDE 30 MG (LUPRON) INTRAMUSCULAR SYRINGE KIT (4 MONTH) RX-21108 CDM J9217 HCPCS 636 RC 00074-3683-03 NDC outpatient 30 ME 13426.38 13426.38 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES PPO [308136801] 10741.1 percent of total billed charges 8324.36 12755.06 Technical (Hospital) Services LEUPROLIDE 30 MG (LUPRON) INTRAMUSCULAR SYRINGE KIT (4 MONTH) RX-21108 CDM J9217 HCPCS 636 RC 00074-3683-03 NDC outpatient 30 ME 13426.38 13426.38 CIGNA 62308 [3081051] CIGNA 62308 [308105105] 10741.1 percent of total billed charges 8324.36 12755.06 Technical (Hospital) Services LEUPROLIDE 30 MG (LUPRON) INTRAMUSCULAR SYRINGE KIT (4 MONTH) RX-21108 CDM J9217 HCPCS 636 RC 00074-3683-03 NDC outpatient 30 ME 13426.38 13426.38 CIGNA 62308 [3081051] CIGNA STATE OF WYOMING [308105107] 10741.1 percent of total billed charges 8324.36 12755.06 Technical (Hospital) Services LEUPROLIDE 30 MG (LUPRON) INTRAMUSCULAR SYRINGE KIT (4 MONTH) RX-21108 CDM J9217 HCPCS 636 RC 00074-3683-03 NDC inpatient 30 ME 13426.38 13426.38 MULTIPLAN INC 34080 [3081285] MULTIPLAN INC [308128501] 12755.06 percent of total billed charges 8324.36 12755.06 Technical (Hospital) Services LEUPROLIDE 30 MG (LUPRON) INTRAMUSCULAR SYRINGE KIT (4 MONTH) RX-21108 CDM J9217 HCPCS 636 RC 00074-3683-03 NDC inpatient 30 ME 13426.38 13426.38 MEDICA (COMMERCIAL) 94265 [3081118] MEDICA CLAIMS [308111801] 12083.74 percent of total billed charges 8324.36 12755.06 Technical (Hospital) Services LEUPROLIDE 30 MG (LUPRON) INTRAMUSCULAR SYRINGE KIT (4 MONTH) RX-21108 CDM J9217 HCPCS 636 RC 00074-3683-03 NDC inpatient 30 ME 13426.38 13426.38 HEALTHPARTNERS SX009 HEALTHPARTNERS 10631.01 percent of total billed charges 8324.36 12755.06 Technical (Hospital) Services LEUPROLIDE 30 MG (LUPRON) INTRAMUSCULAR SYRINGE KIT (4 MONTH) RX-21108 CDM J9217 HCPCS 636 RC 00074-3683-03 NDC inpatient 30 ME 13426.38 13426.38 UNITED HEALTHCARE (COMMERCIAL) [3081199] UNITED HEALTHCARE 87726 [308119901] 8324.36 percent of total billed charges 8324.36 12755.06 Technical (Hospital) Services LEUPROLIDE 30 MG (LUPRON) INTRAMUSCULAR SYRINGE KIT (4 MONTH) RX-21108 CDM J9217 HCPCS 636 RC 00074-3683-03 NDC inpatient 30 ME 13426.38 13426.38 BLUE CROSS BLUE SHIELD WELLMARK SB889 [3081026] BCBS WYOMING [308102603] 12755.06 percent of total billed charges 8324.36 12755.06 Technical (Hospital) Services LEUPROLIDE 30 MG (LUPRON) INTRAMUSCULAR SYRINGE KIT (4 MONTH) RX-21108 CDM J9217 HCPCS 636 RC 00074-3683-03 NDC inpatient 30 ME 13426.38 13426.38 CIGNA 62308 [3081051] CIGNA 62308 [308105105] 10631.01 percent of total billed charges 8324.36 12755.06 Technical (Hospital) Services LEUPROLIDE 30 MG (LUPRON) INTRAMUSCULAR SYRINGE KIT (4 MONTH) RX-21108 CDM J9217 HCPCS 636 RC 00074-3683-03 NDC inpatient 30 ME 13426.38 13426.38 CIGNA 62308 [3081051] CIGNA STATE OF WYOMING [308105107] 10631.01 percent of total billed charges 8324.36 12755.06 Technical (Hospital) Services LEUPROLIDE 30 MG (LUPRON) INTRAMUSCULAR SYRINGE KIT (4 MONTH) RX-21108 CDM J9217 HCPCS 636 RC 00074-3683-03 NDC inpatient 30 ME 13426.38 13426.38 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES PPO [308136801] 10631.01 percent of total billed charges 8324.36 12755.06 Technical (Hospital) Services LEUPROLIDE 30 MG (LUPRON) INTRAMUSCULAR SYRINGE KIT (4 MONTH) RX-21108 CDM J9217 HCPCS 636 RC 00074-3683-03 NDC inpatient 30 ME 13426.38 13426.38 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES EPO [308136803] 10631.01 percent of total billed charges 8324.36 12755.06 Technical (Hospital) Services LEUPROLIDE 30 MG (LUPRON) INTRAMUSCULAR SYRINGE KIT (4 MONTH) RX-21108 CDM J9217 HCPCS 636 RC 00074-3683-03 NDC inpatient 30 ME 13426.38 13426.38 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES HDHP [308136802] 10631.01 percent of total billed charges 8324.36 12755.06 Technical (Hospital) Services LEUPROLIDE 7.5 MG (ELIGARD) SUBCUTANEOUS SYRINGE (1 MONTH) RX-32893 CDM J9217 HCPCS 636 RC 62935-0753-75 NDC inpatient 1 UN 1101.69 1101.69 MEDICA (COMMERCIAL) 94265 [3081118] MEDICA CLAIMS [308111801] 991.52 percent of total billed charges 683.05 1046.61 Technical (Hospital) Services LEUPROLIDE 7.5 MG (ELIGARD) SUBCUTANEOUS SYRINGE (1 MONTH) RX-32893 CDM J9217 HCPCS 636 RC 62935-0753-75 NDC inpatient 1 UN 1101.69 1101.69 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES PPO [308136801] 872.32 percent of total billed charges 683.05 1046.61 Technical (Hospital) Services LEUPROLIDE 7.5 MG (ELIGARD) SUBCUTANEOUS SYRINGE (1 MONTH) RX-32893 CDM J9217 HCPCS 636 RC 62935-0753-75 NDC inpatient 1 UN 1101.69 1101.69 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES HDHP [308136802] 872.32 percent of total billed charges 683.05 1046.61 Technical (Hospital) Services LEUPROLIDE 7.5 MG (ELIGARD) SUBCUTANEOUS SYRINGE (1 MONTH) RX-32893 CDM J9217 HCPCS 636 RC 62935-0753-75 NDC inpatient 1 UN 1101.69 1101.69 HEALTHPARTNERS SX009 HEALTHPARTNERS 872.32 percent of total billed charges 683.05 1046.61 Technical (Hospital) Services LEUPROLIDE 7.5 MG (ELIGARD) SUBCUTANEOUS SYRINGE (1 MONTH) RX-32893 CDM J9217 HCPCS 636 RC 62935-0753-75 NDC inpatient 1 UN 1101.69 1101.69 MULTIPLAN INC 34080 [3081285] MULTIPLAN INC [308128501] 1046.61 percent of total billed charges 683.05 1046.61 Technical (Hospital) Services LEUPROLIDE 7.5 MG (ELIGARD) SUBCUTANEOUS SYRINGE (1 MONTH) RX-32893 CDM J9217 HCPCS 636 RC 62935-0753-75 NDC inpatient 1 UN 1101.69 1101.69 BLUE CROSS BLUE SHIELD WELLMARK SB889 [3081026] BCBS WYOMING [308102603] 1046.61 percent of total billed charges 683.05 1046.61 Technical (Hospital) Services LEUPROLIDE 7.5 MG (ELIGARD) SUBCUTANEOUS SYRINGE (1 MONTH) RX-32893 CDM J9217 HCPCS 636 RC 62935-0753-75 NDC inpatient 1 UN 1101.69 1101.69 UNITED HEALTHCARE (COMMERCIAL) [3081199] UNITED HEALTHCARE 87726 [308119901] 683.05 percent of total billed charges 683.05 1046.61 Technical (Hospital) Services LEUPROLIDE 7.5 MG (ELIGARD) SUBCUTANEOUS SYRINGE (1 MONTH) RX-32893 CDM J9217 HCPCS 636 RC 62935-0753-75 NDC inpatient 1 UN 1101.69 1101.69 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES EPO [308136803] 872.32 percent of total billed charges 683.05 1046.61 Technical (Hospital) Services LEUPROLIDE 7.5 MG (ELIGARD) SUBCUTANEOUS SYRINGE (1 MONTH) RX-32893 CDM J9217 HCPCS 636 RC 62935-0753-75 NDC inpatient 1 UN 1101.69 1101.69 CIGNA 62308 [3081051] CIGNA STATE OF WYOMING [308105107] 872.32 percent of total billed charges 683.05 1046.61 Technical (Hospital) Services LEUPROLIDE 7.5 MG (ELIGARD) SUBCUTANEOUS SYRINGE (1 MONTH) RX-32893 CDM J9217 HCPCS 636 RC 62935-0753-75 NDC inpatient 1 UN 1101.69 1101.69 CIGNA 62308 [3081051] CIGNA 62308 [308105105] 872.32 percent of total billed charges 683.05 1046.61 Technical (Hospital) Services LEUPROLIDE 7.5 MG (ELIGARD) SUBCUTANEOUS SYRINGE (1 MONTH) RX-32893 CDM J9217 HCPCS 636 RC 62935-0753-75 NDC outpatient 1 UN 1101.69 1101.69 CIGNA 62308 [3081051] CIGNA 62308 [308105105] 881.35 percent of total billed charges 683.05 1046.61 Technical (Hospital) Services LEUPROLIDE 7.5 MG (ELIGARD) SUBCUTANEOUS SYRINGE (1 MONTH) RX-32893 CDM J9217 HCPCS 636 RC 62935-0753-75 NDC outpatient 1 UN 1101.69 1101.69 CIGNA 62308 [3081051] CIGNA STATE OF WYOMING [308105107] 881.35 percent of total billed charges 683.05 1046.61 Technical (Hospital) Services LEUPROLIDE 7.5 MG (ELIGARD) SUBCUTANEOUS SYRINGE (1 MONTH) RX-32893 CDM J9217 HCPCS 636 RC 62935-0753-75 NDC outpatient 1 UN 1101.69 1101.69 MEDICA (COMMERCIAL) 94265 [3081118] MEDICA CLAIMS [308111801] 991.52 percent of total billed charges 683.05 1046.61 Technical (Hospital) Services LEUPROLIDE 7.5 MG (ELIGARD) SUBCUTANEOUS SYRINGE (1 MONTH) RX-32893 CDM J9217 HCPCS 636 RC 62935-0753-75 NDC outpatient 1 UN 1101.69 1101.69 UNITED HEALTHCARE (COMMERCIAL) [3081199] UNITED HEALTHCARE 87726 [308119901] 683.05 percent of total billed charges 683.05 1046.61 Technical (Hospital) Services LEUPROLIDE 7.5 MG (ELIGARD) SUBCUTANEOUS SYRINGE (1 MONTH) RX-32893 CDM J9217 HCPCS 636 RC 62935-0753-75 NDC outpatient 1 UN 1101.69 1101.69 MULTIPLAN INC 34080 [3081285] MULTIPLAN INC [308128501] 1046.61 percent of total billed charges 683.05 1046.61 Technical (Hospital) Services LEUPROLIDE 7.5 MG (ELIGARD) SUBCUTANEOUS SYRINGE (1 MONTH) RX-32893 CDM J9217 HCPCS 636 RC 62935-0753-75 NDC outpatient 1 UN 1101.69 1101.69 HEALTHPARTNERS SX009 HEALTHPARTNERS 881.35 percent of total billed charges 683.05 1046.61 Technical (Hospital) Services LEUPROLIDE 7.5 MG (ELIGARD) SUBCUTANEOUS SYRINGE (1 MONTH) RX-32893 CDM J9217 HCPCS 636 RC 62935-0753-75 NDC outpatient 1 UN 1101.69 1101.69 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES PPO [308136801] 881.35 percent of total billed charges 683.05 1046.61 Technical (Hospital) Services LEUPROLIDE 7.5 MG (ELIGARD) SUBCUTANEOUS SYRINGE (1 MONTH) RX-32893 CDM J9217 HCPCS 636 RC 62935-0753-75 NDC outpatient 1 UN 1101.69 1101.69 BLUE CROSS BLUE SHIELD WELLMARK SB889 [3081026] BCBS WYOMING [308102603] 1046.61 percent of total billed charges 683.05 1046.61 Technical (Hospital) Services LEUPROLIDE 7.5 MG (ELIGARD) SUBCUTANEOUS SYRINGE (1 MONTH) RX-32893 CDM J9217 HCPCS 636 RC 62935-0753-75 NDC outpatient 1 UN 1101.69 1101.69 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES EPO [308136803] 881.35 percent of total billed charges 683.05 1046.61 Technical (Hospital) Services LEUPROLIDE 7.5 MG (ELIGARD) SUBCUTANEOUS SYRINGE (1 MONTH) RX-32893 CDM J9217 HCPCS 636 RC 62935-0753-75 NDC outpatient 1 UN 1101.69 1101.69 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES HDHP [308136802] 881.35 percent of total billed charges 683.05 1046.61 Technical (Hospital) Services LEUPROLIDE 22.5 MG (ELIGARD) SUBCUTANEOUS SYRINGE (3 MONTH) RX-33669 CDM J9217 HCPCS 636 RC 62935-0223-05 NDC inpatient 1 UN 2580.07 2580.07 MEDICA (COMMERCIAL) 94265 [3081118] MEDICA CLAIMS [308111801] 2322.06 percent of total billed charges 1599.64 2451.07 Technical (Hospital) Services LEUPROLIDE 22.5 MG (ELIGARD) SUBCUTANEOUS SYRINGE (3 MONTH) RX-33669 CDM J9217 HCPCS 636 RC 62935-0223-05 NDC inpatient 1 UN 2580.07 2580.07 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES PPO [308136801] 2042.9 percent of total billed charges 1599.64 2451.07 Technical (Hospital) Services LEUPROLIDE 22.5 MG (ELIGARD) SUBCUTANEOUS SYRINGE (3 MONTH) RX-33669 CDM J9217 HCPCS 636 RC 62935-0223-05 NDC inpatient 1 UN 2580.07 2580.07 HEALTHPARTNERS SX009 HEALTHPARTNERS 2042.9 percent of total billed charges 1599.64 2451.07 Technical (Hospital) Services LEUPROLIDE 22.5 MG (ELIGARD) SUBCUTANEOUS SYRINGE (3 MONTH) RX-33669 CDM J9217 HCPCS 636 RC 62935-0223-05 NDC inpatient 1 UN 2580.07 2580.07 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES HDHP [308136802] 2042.9 percent of total billed charges 1599.64 2451.07 Technical (Hospital) Services LEUPROLIDE 22.5 MG (ELIGARD) SUBCUTANEOUS SYRINGE (3 MONTH) RX-33669 CDM J9217 HCPCS 636 RC 62935-0223-05 NDC inpatient 1 UN 2580.07 2580.07 MULTIPLAN INC 34080 [3081285] MULTIPLAN INC [308128501] 2451.07 percent of total billed charges 1599.64 2451.07 Technical (Hospital) Services LEUPROLIDE 22.5 MG (ELIGARD) SUBCUTANEOUS SYRINGE (3 MONTH) RX-33669 CDM J9217 HCPCS 636 RC 62935-0223-05 NDC inpatient 1 UN 2580.07 2580.07 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES EPO [308136803] 2042.9 percent of total billed charges 1599.64 2451.07 Technical (Hospital) Services LEUPROLIDE 22.5 MG (ELIGARD) SUBCUTANEOUS SYRINGE (3 MONTH) RX-33669 CDM J9217 HCPCS 636 RC 62935-0223-05 NDC inpatient 1 UN 2580.07 2580.07 UNITED HEALTHCARE (COMMERCIAL) [3081199] UNITED HEALTHCARE 87726 [308119901] 1599.64 percent of total billed charges 1599.64 2451.07 Technical (Hospital) Services LEUPROLIDE 22.5 MG (ELIGARD) SUBCUTANEOUS SYRINGE (3 MONTH) RX-33669 CDM J9217 HCPCS 636 RC 62935-0223-05 NDC inpatient 1 UN 2580.07 2580.07 BLUE CROSS BLUE SHIELD WELLMARK SB889 [3081026] BCBS WYOMING [308102603] 2451.07 percent of total billed charges 1599.64 2451.07 Technical (Hospital) Services LEUPROLIDE 22.5 MG (ELIGARD) SUBCUTANEOUS SYRINGE (3 MONTH) RX-33669 CDM J9217 HCPCS 636 RC 62935-0223-05 NDC inpatient 1 UN 2580.07 2580.07 CIGNA 62308 [3081051] CIGNA 62308 [308105105] 2042.9 percent of total billed charges 1599.64 2451.07 Technical (Hospital) Services LEUPROLIDE 22.5 MG (ELIGARD) SUBCUTANEOUS SYRINGE (3 MONTH) RX-33669 CDM J9217 HCPCS 636 RC 62935-0223-05 NDC inpatient 1 UN 2580.07 2580.07 CIGNA 62308 [3081051] CIGNA STATE OF WYOMING [308105107] 2042.9 percent of total billed charges 1599.64 2451.07 Technical (Hospital) Services LEUPROLIDE 22.5 MG (ELIGARD) SUBCUTANEOUS SYRINGE (3 MONTH) RX-33669 CDM J9217 HCPCS 636 RC 62935-0223-05 NDC outpatient 1 UN 2580.07 2580.07 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES PPO [308136801] 2064.06 percent of total billed charges 1599.64 2451.07 Technical (Hospital) Services LEUPROLIDE 22.5 MG (ELIGARD) SUBCUTANEOUS SYRINGE (3 MONTH) RX-33669 CDM J9217 HCPCS 636 RC 62935-0223-05 NDC outpatient 1 UN 2580.07 2580.07 BLUE CROSS BLUE SHIELD WELLMARK SB889 [3081026] BCBS WYOMING [308102603] 2451.07 percent of total billed charges 1599.64 2451.07 Technical (Hospital) Services LEUPROLIDE 22.5 MG (ELIGARD) SUBCUTANEOUS SYRINGE (3 MONTH) RX-33669 CDM J9217 HCPCS 636 RC 62935-0223-05 NDC outpatient 1 UN 2580.07 2580.07 MEDICA (COMMERCIAL) 94265 [3081118] MEDICA CLAIMS [308111801] 2322.06 percent of total billed charges 1599.64 2451.07 Technical (Hospital) Services LEUPROLIDE 22.5 MG (ELIGARD) SUBCUTANEOUS SYRINGE (3 MONTH) RX-33669 CDM J9217 HCPCS 636 RC 62935-0223-05 NDC outpatient 1 UN 2580.07 2580.07 CIGNA 62308 [3081051] CIGNA 62308 [308105105] 2064.06 percent of total billed charges 1599.64 2451.07 Technical (Hospital) Services LEUPROLIDE 22.5 MG (ELIGARD) SUBCUTANEOUS SYRINGE (3 MONTH) RX-33669 CDM J9217 HCPCS 636 RC 62935-0223-05 NDC outpatient 1 UN 2580.07 2580.07 CIGNA 62308 [3081051] CIGNA STATE OF WYOMING [308105107] 2064.06 percent of total billed charges 1599.64 2451.07 Technical (Hospital) Services LEUPROLIDE 22.5 MG (ELIGARD) SUBCUTANEOUS SYRINGE (3 MONTH) RX-33669 CDM J9217 HCPCS 636 RC 62935-0223-05 NDC outpatient 1 UN 2580.07 2580.07 UNITED HEALTHCARE (COMMERCIAL) [3081199] UNITED HEALTHCARE 87726 [308119901] 1599.64 percent of total billed charges 1599.64 2451.07 Technical (Hospital) Services LEUPROLIDE 22.5 MG (ELIGARD) SUBCUTANEOUS SYRINGE (3 MONTH) RX-33669 CDM J9217 HCPCS 636 RC 62935-0223-05 NDC outpatient 1 UN 2580.07 2580.07 MULTIPLAN INC 34080 [3081285] MULTIPLAN INC [308128501] 2451.07 percent of total billed charges 1599.64 2451.07 Technical (Hospital) Services LEUPROLIDE 22.5 MG (ELIGARD) SUBCUTANEOUS SYRINGE (3 MONTH) RX-33669 CDM J9217 HCPCS 636 RC 62935-0223-05 NDC outpatient 1 UN 2580.07 2580.07 HEALTHPARTNERS SX009 HEALTHPARTNERS 2064.06 percent of total billed charges 1599.64 2451.07 Technical (Hospital) Services LEUPROLIDE 22.5 MG (ELIGARD) SUBCUTANEOUS SYRINGE (3 MONTH) RX-33669 CDM J9217 HCPCS 636 RC 62935-0223-05 NDC outpatient 1 UN 2580.07 2580.07 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES HDHP [308136802] 2064.06 percent of total billed charges 1599.64 2451.07 Technical (Hospital) Services LEUPROLIDE 22.5 MG (ELIGARD) SUBCUTANEOUS SYRINGE (3 MONTH) RX-33669 CDM J9217 HCPCS 636 RC 62935-0223-05 NDC outpatient 1 UN 2580.07 2580.07 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES EPO [308136803] 2064.06 percent of total billed charges 1599.64 2451.07 Technical (Hospital) Services LEUPROLIDE 30 MG (ELIGARD) SUBCUTANEOUS SYRINGE (4 MONTH) RX-35236 CDM J9217 HCPCS 636 RC 62935-0303-30 NDC inpatient 1 UN 4258.76 4258.76 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES EPO [308136803] 3372.09 percent of total billed charges 2640.43 4045.82 Technical (Hospital) Services LEUPROLIDE 30 MG (ELIGARD) SUBCUTANEOUS SYRINGE (4 MONTH) RX-35236 CDM J9217 HCPCS 636 RC 62935-0303-30 NDC inpatient 1 UN 4258.76 4258.76 CIGNA 62308 [3081051] CIGNA 62308 [308105105] 3372.09 percent of total billed charges 2640.43 4045.82 Technical (Hospital) Services LEUPROLIDE 30 MG (ELIGARD) SUBCUTANEOUS SYRINGE (4 MONTH) RX-35236 CDM J9217 HCPCS 636 RC 62935-0303-30 NDC inpatient 1 UN 4258.76 4258.76 CIGNA 62308 [3081051] CIGNA STATE OF WYOMING [308105107] 3372.09 percent of total billed charges 2640.43 4045.82 Technical (Hospital) Services LEUPROLIDE 30 MG (ELIGARD) SUBCUTANEOUS SYRINGE (4 MONTH) RX-35236 CDM J9217 HCPCS 636 RC 62935-0303-30 NDC inpatient 1 UN 4258.76 4258.76 BLUE CROSS BLUE SHIELD WELLMARK SB889 [3081026] BCBS WYOMING [308102603] 4045.82 percent of total billed charges 2640.43 4045.82 Technical (Hospital) Services LEUPROLIDE 30 MG (ELIGARD) SUBCUTANEOUS SYRINGE (4 MONTH) RX-35236 CDM J9217 HCPCS 636 RC 62935-0303-30 NDC inpatient 1 UN 4258.76 4258.76 UNITED HEALTHCARE (COMMERCIAL) [3081199] UNITED HEALTHCARE 87726 [308119901] 2640.43 percent of total billed charges 2640.43 4045.82 Technical (Hospital) Services LEUPROLIDE 30 MG (ELIGARD) SUBCUTANEOUS SYRINGE (4 MONTH) RX-35236 CDM J9217 HCPCS 636 RC 62935-0303-30 NDC inpatient 1 UN 4258.76 4258.76 MEDICA (COMMERCIAL) 94265 [3081118] MEDICA CLAIMS [308111801] 3832.88 percent of total billed charges 2640.43 4045.82 Technical (Hospital) Services LEUPROLIDE 30 MG (ELIGARD) SUBCUTANEOUS SYRINGE (4 MONTH) RX-35236 CDM J9217 HCPCS 636 RC 62935-0303-30 NDC inpatient 1 UN 4258.76 4258.76 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES PPO [308136801] 3372.09 percent of total billed charges 2640.43 4045.82 Technical (Hospital) Services LEUPROLIDE 30 MG (ELIGARD) SUBCUTANEOUS SYRINGE (4 MONTH) RX-35236 CDM J9217 HCPCS 636 RC 62935-0303-30 NDC inpatient 1 UN 4258.76 4258.76 HEALTHPARTNERS SX009 HEALTHPARTNERS 3372.09 percent of total billed charges 2640.43 4045.82 Technical (Hospital) Services LEUPROLIDE 30 MG (ELIGARD) SUBCUTANEOUS SYRINGE (4 MONTH) RX-35236 CDM J9217 HCPCS 636 RC 62935-0303-30 NDC inpatient 1 UN 4258.76 4258.76 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES HDHP [308136802] 3372.09 percent of total billed charges 2640.43 4045.82 Technical (Hospital) Services LEUPROLIDE 30 MG (ELIGARD) SUBCUTANEOUS SYRINGE (4 MONTH) RX-35236 CDM J9217 HCPCS 636 RC 62935-0303-30 NDC inpatient 1 UN 4258.76 4258.76 MULTIPLAN INC 34080 [3081285] MULTIPLAN INC [308128501] 4045.82 percent of total billed charges 2640.43 4045.82 Technical (Hospital) Services LEUPROLIDE 30 MG (ELIGARD) SUBCUTANEOUS SYRINGE (4 MONTH) RX-35236 CDM J9217 HCPCS 636 RC 62935-0303-30 NDC outpatient 1 UN 4258.76 4258.76 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES EPO [308136803] 3407.01 percent of total billed charges 2640.43 4045.82 Technical (Hospital) Services LEUPROLIDE 30 MG (ELIGARD) SUBCUTANEOUS SYRINGE (4 MONTH) RX-35236 CDM J9217 HCPCS 636 RC 62935-0303-30 NDC outpatient 1 UN 4258.76 4258.76 MEDICA (COMMERCIAL) 94265 [3081118] MEDICA CLAIMS [308111801] 3832.88 percent of total billed charges 2640.43 4045.82 Technical (Hospital) Services LEUPROLIDE 30 MG (ELIGARD) SUBCUTANEOUS SYRINGE (4 MONTH) RX-35236 CDM J9217 HCPCS 636 RC 62935-0303-30 NDC outpatient 1 UN 4258.76 4258.76 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES HDHP [308136802] 3407.01 percent of total billed charges 2640.43 4045.82 Technical (Hospital) Services LEUPROLIDE 30 MG (ELIGARD) SUBCUTANEOUS SYRINGE (4 MONTH) RX-35236 CDM J9217 HCPCS 636 RC 62935-0303-30 NDC outpatient 1 UN 4258.76 4258.76 CIGNA 62308 [3081051] CIGNA 62308 [308105105] 3407.01 percent of total billed charges 2640.43 4045.82 Technical (Hospital) Services LEUPROLIDE 30 MG (ELIGARD) SUBCUTANEOUS SYRINGE (4 MONTH) RX-35236 CDM J9217 HCPCS 636 RC 62935-0303-30 NDC outpatient 1 UN 4258.76 4258.76 CIGNA 62308 [3081051] CIGNA STATE OF WYOMING [308105107] 3407.01 percent of total billed charges 2640.43 4045.82 Technical (Hospital) Services LEUPROLIDE 30 MG (ELIGARD) SUBCUTANEOUS SYRINGE (4 MONTH) RX-35236 CDM J9217 HCPCS 636 RC 62935-0303-30 NDC outpatient 1 UN 4258.76 4258.76 HEALTHPARTNERS SX009 HEALTHPARTNERS 3407.01 percent of total billed charges 2640.43 4045.82 Technical (Hospital) Services LEUPROLIDE 30 MG (ELIGARD) SUBCUTANEOUS SYRINGE (4 MONTH) RX-35236 CDM J9217 HCPCS 636 RC 62935-0303-30 NDC outpatient 1 UN 4258.76 4258.76 UNITED HEALTHCARE (COMMERCIAL) [3081199] UNITED HEALTHCARE 87726 [308119901] 2640.43 percent of total billed charges 2640.43 4045.82 Technical (Hospital) Services LEUPROLIDE 30 MG (ELIGARD) SUBCUTANEOUS SYRINGE (4 MONTH) RX-35236 CDM J9217 HCPCS 636 RC 62935-0303-30 NDC outpatient 1 UN 4258.76 4258.76 MULTIPLAN INC 34080 [3081285] MULTIPLAN INC [308128501] 4045.82 percent of total billed charges 2640.43 4045.82 Technical (Hospital) Services LEUPROLIDE 30 MG (ELIGARD) SUBCUTANEOUS SYRINGE (4 MONTH) RX-35236 CDM J9217 HCPCS 636 RC 62935-0303-30 NDC outpatient 1 UN 4258.76 4258.76 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES PPO [308136801] 3407.01 percent of total billed charges 2640.43 4045.82 Technical (Hospital) Services LEUPROLIDE 30 MG (ELIGARD) SUBCUTANEOUS SYRINGE (4 MONTH) RX-35236 CDM J9217 HCPCS 636 RC 62935-0303-30 NDC outpatient 1 UN 4258.76 4258.76 BLUE CROSS BLUE SHIELD WELLMARK SB889 [3081026] BCBS WYOMING [308102603] 4045.82 percent of total billed charges 2640.43 4045.82 Technical (Hospital) Services LEUPROLIDE 45 MG (ELIGARD) SUBCUTANEOUS SYRINGE (6 MONTH) RX-40801 CDM J9217 HCPCS 636 RC 62935-0453-45 NDC inpatient 1 UN 5160.13 5160.13 MULTIPLAN INC 34080 [3081285] MULTIPLAN INC [308128501] 4902.12 percent of total billed charges 3199.28 4902.12 Technical (Hospital) Services LEUPROLIDE 45 MG (ELIGARD) SUBCUTANEOUS SYRINGE (6 MONTH) RX-40801 CDM J9217 HCPCS 636 RC 62935-0453-45 NDC inpatient 1 UN 5160.13 5160.13 MEDICA (COMMERCIAL) 94265 [3081118] MEDICA CLAIMS [308111801] 4644.12 percent of total billed charges 3199.28 4902.12 Technical (Hospital) Services LEUPROLIDE 45 MG (ELIGARD) SUBCUTANEOUS SYRINGE (6 MONTH) RX-40801 CDM J9217 HCPCS 636 RC 62935-0453-45 NDC inpatient 1 UN 5160.13 5160.13 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES HDHP [308136802] 4085.79 percent of total billed charges 3199.28 4902.12 Technical (Hospital) Services LEUPROLIDE 45 MG (ELIGARD) SUBCUTANEOUS SYRINGE (6 MONTH) RX-40801 CDM J9217 HCPCS 636 RC 62935-0453-45 NDC inpatient 1 UN 5160.13 5160.13 HEALTHPARTNERS SX009 HEALTHPARTNERS 4085.79 percent of total billed charges 3199.28 4902.12 Technical (Hospital) Services LEUPROLIDE 45 MG (ELIGARD) SUBCUTANEOUS SYRINGE (6 MONTH) RX-40801 CDM J9217 HCPCS 636 RC 62935-0453-45 NDC inpatient 1 UN 5160.13 5160.13 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES PPO [308136801] 4085.79 percent of total billed charges 3199.28 4902.12 Technical (Hospital) Services LEUPROLIDE 45 MG (ELIGARD) SUBCUTANEOUS SYRINGE (6 MONTH) RX-40801 CDM J9217 HCPCS 636 RC 62935-0453-45 NDC inpatient 1 UN 5160.13 5160.13 UNITED HEALTHCARE (COMMERCIAL) [3081199] UNITED HEALTHCARE 87726 [308119901] 3199.28 percent of total billed charges 3199.28 4902.12 Technical (Hospital) Services LEUPROLIDE 45 MG (ELIGARD) SUBCUTANEOUS SYRINGE (6 MONTH) RX-40801 CDM J9217 HCPCS 636 RC 62935-0453-45 NDC inpatient 1 UN 5160.13 5160.13 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES EPO [308136803] 4085.79 percent of total billed charges 3199.28 4902.12 Technical (Hospital) Services LEUPROLIDE 45 MG (ELIGARD) SUBCUTANEOUS SYRINGE (6 MONTH) RX-40801 CDM J9217 HCPCS 636 RC 62935-0453-45 NDC inpatient 1 UN 5160.13 5160.13 BLUE CROSS BLUE SHIELD WELLMARK SB889 [3081026] BCBS WYOMING [308102603] 4902.12 percent of total billed charges 3199.28 4902.12 Technical (Hospital) Services LEUPROLIDE 45 MG (ELIGARD) SUBCUTANEOUS SYRINGE (6 MONTH) RX-40801 CDM J9217 HCPCS 636 RC 62935-0453-45 NDC inpatient 1 UN 5160.13 5160.13 CIGNA 62308 [3081051] CIGNA 62308 [308105105] 4085.79 percent of total billed charges 3199.28 4902.12 Technical (Hospital) Services LEUPROLIDE 45 MG (ELIGARD) SUBCUTANEOUS SYRINGE (6 MONTH) RX-40801 CDM J9217 HCPCS 636 RC 62935-0453-45 NDC inpatient 1 UN 5160.13 5160.13 CIGNA 62308 [3081051] CIGNA STATE OF WYOMING [308105107] 4085.79 percent of total billed charges 3199.28 4902.12 Technical (Hospital) Services LEUPROLIDE 45 MG (ELIGARD) SUBCUTANEOUS SYRINGE (6 MONTH) RX-40801 CDM J9217 HCPCS 636 RC 62935-0453-45 NDC outpatient 1 UN 5160.13 5160.13 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES HDHP [308136802] 4128.1 percent of total billed charges 3199.28 4902.12 Technical (Hospital) Services LEUPROLIDE 45 MG (ELIGARD) SUBCUTANEOUS SYRINGE (6 MONTH) RX-40801 CDM J9217 HCPCS 636 RC 62935-0453-45 NDC outpatient 1 UN 5160.13 5160.13 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES EPO [308136803] 4128.1 percent of total billed charges 3199.28 4902.12 Technical (Hospital) Services LEUPROLIDE 45 MG (ELIGARD) SUBCUTANEOUS SYRINGE (6 MONTH) RX-40801 CDM J9217 HCPCS 636 RC 62935-0453-45 NDC outpatient 1 UN 5160.13 5160.13 MEDICA (COMMERCIAL) 94265 [3081118] MEDICA CLAIMS [308111801] 4644.12 percent of total billed charges 3199.28 4902.12 Technical (Hospital) Services LEUPROLIDE 45 MG (ELIGARD) SUBCUTANEOUS SYRINGE (6 MONTH) RX-40801 CDM J9217 HCPCS 636 RC 62935-0453-45 NDC outpatient 1 UN 5160.13 5160.13 CIGNA 62308 [3081051] CIGNA 62308 [308105105] 4128.1 percent of total billed charges 3199.28 4902.12 Technical (Hospital) Services LEUPROLIDE 45 MG (ELIGARD) SUBCUTANEOUS SYRINGE (6 MONTH) RX-40801 CDM J9217 HCPCS 636 RC 62935-0453-45 NDC outpatient 1 UN 5160.13 5160.13 CIGNA 62308 [3081051] CIGNA STATE OF WYOMING [308105107] 4128.1 percent of total billed charges 3199.28 4902.12 Technical (Hospital) Services LEUPROLIDE 45 MG (ELIGARD) SUBCUTANEOUS SYRINGE (6 MONTH) RX-40801 CDM J9217 HCPCS 636 RC 62935-0453-45 NDC outpatient 1 UN 5160.13 5160.13 MULTIPLAN INC 34080 [3081285] MULTIPLAN INC [308128501] 4902.12 percent of total billed charges 3199.28 4902.12 Technical (Hospital) Services LEUPROLIDE 45 MG (ELIGARD) SUBCUTANEOUS SYRINGE (6 MONTH) RX-40801 CDM J9217 HCPCS 636 RC 62935-0453-45 NDC outpatient 1 UN 5160.13 5160.13 UNITED HEALTHCARE (COMMERCIAL) [3081199] UNITED HEALTHCARE 87726 [308119901] 3199.28 percent of total billed charges 3199.28 4902.12 Technical (Hospital) Services LEUPROLIDE 45 MG (ELIGARD) SUBCUTANEOUS SYRINGE (6 MONTH) RX-40801 CDM J9217 HCPCS 636 RC 62935-0453-45 NDC outpatient 1 UN 5160.13 5160.13 HEALTHPARTNERS SX009 HEALTHPARTNERS 4128.1 percent of total billed charges 3199.28 4902.12 Technical (Hospital) Services LEUPROLIDE 45 MG (ELIGARD) SUBCUTANEOUS SYRINGE (6 MONTH) RX-40801 CDM J9217 HCPCS 636 RC 62935-0453-45 NDC outpatient 1 UN 5160.13 5160.13 BLUE CROSS BLUE SHIELD WELLMARK SB889 [3081026] BCBS WYOMING [308102603] 4902.12 percent of total billed charges 3199.28 4902.12 Technical (Hospital) Services LEUPROLIDE 45 MG (ELIGARD) SUBCUTANEOUS SYRINGE (6 MONTH) RX-40801 CDM J9217 HCPCS 636 RC 62935-0453-45 NDC outpatient 1 UN 5160.13 5160.13 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES PPO [308136801] 4128.1 percent of total billed charges 3199.28 4902.12 Technical (Hospital) Services METHOTREXATE SODIUM 2.5 MG TABLET RX-4973 CDM J8610 HCPCS 250 RC 00054-8550-25 NDC outpatient 1 UN 15.05 15.05 CIGNA 62308 [3081051] CIGNA 62308 [308105105] 12.04 percent of total billed charges 9.33 14.3 Technical (Hospital) Services METHOTREXATE SODIUM 2.5 MG TABLET RX-4973 CDM J8610 HCPCS 250 RC 00054-8550-25 NDC outpatient 1 UN 15.05 15.05 CIGNA 62308 [3081051] CIGNA STATE OF WYOMING [308105107] 12.04 percent of total billed charges 9.33 14.3 Technical (Hospital) Services METHOTREXATE SODIUM 2.5 MG TABLET RX-4973 CDM J8610 HCPCS 250 RC 00054-8550-25 NDC outpatient 1 UN 15.05 15.05 MEDICA (COMMERCIAL) 94265 [3081118] MEDICA CLAIMS [308111801] 13.55 percent of total billed charges 9.33 14.3 Technical (Hospital) Services METHOTREXATE SODIUM 2.5 MG TABLET RX-4973 CDM J8610 HCPCS 250 RC 00054-8550-25 NDC outpatient 1 UN 15.05 15.05 UNITED HEALTHCARE (COMMERCIAL) [3081199] UNITED HEALTHCARE 87726 [308119901] 9.33 percent of total billed charges 9.33 14.3 Technical (Hospital) Services METHOTREXATE SODIUM 2.5 MG TABLET RX-4973 CDM J8610 HCPCS 250 RC 00054-8550-25 NDC outpatient 1 UN 15.05 15.05 MULTIPLAN INC 34080 [3081285] MULTIPLAN INC [308128501] 14.3 percent of total billed charges 9.33 14.3 Technical (Hospital) Services METHOTREXATE SODIUM 2.5 MG TABLET RX-4973 CDM J8610 HCPCS 250 RC 00054-8550-25 NDC outpatient 1 UN 15.05 15.05 HEALTHPARTNERS SX009 HEALTHPARTNERS 12.04 percent of total billed charges 9.33 14.3 Technical (Hospital) Services METHOTREXATE SODIUM 2.5 MG TABLET RX-4973 CDM J8610 HCPCS 250 RC 00054-8550-25 NDC outpatient 1 UN 15.05 15.05 BLUE CROSS BLUE SHIELD WELLMARK SB889 [3081026] BCBS WYOMING [308102603] 14.3 percent of total billed charges 9.33 14.3 Technical (Hospital) Services METHOTREXATE SODIUM 2.5 MG TABLET RX-4973 CDM J8610 HCPCS 250 RC 00054-8550-25 NDC outpatient 1 UN 15.05 15.05 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES EPO [308136803] 12.04 percent of total billed charges 9.33 14.3 Technical (Hospital) Services METHOTREXATE SODIUM 2.5 MG TABLET RX-4973 CDM J8610 HCPCS 250 RC 00054-8550-25 NDC outpatient 1 UN 15.05 15.05 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES HDHP [308136802] 12.04 percent of total billed charges 9.33 14.3 Technical (Hospital) Services METHOTREXATE SODIUM 2.5 MG TABLET RX-4973 CDM J8610 HCPCS 250 RC 00054-8550-25 NDC outpatient 1 UN 15.05 15.05 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES PPO [308136801] 12.04 percent of total billed charges 9.33 14.3 Technical (Hospital) Services METHOTREXATE SODIUM 2.5 MG TABLET RX-4973 CDM J8610 HCPCS 250 RC 00054-8550-25 NDC inpatient 1 UN 15.05 15.05 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES PPO [308136801] 11.92 percent of total billed charges 9.33 14.3 Technical (Hospital) Services METHOTREXATE SODIUM 2.5 MG TABLET RX-4973 CDM J8610 HCPCS 250 RC 00054-8550-25 NDC inpatient 1 UN 15.05 15.05 MEDICA (COMMERCIAL) 94265 [3081118] MEDICA CLAIMS [308111801] 13.55 percent of total billed charges 9.33 14.3 Technical (Hospital) Services METHOTREXATE SODIUM 2.5 MG TABLET RX-4973 CDM J8610 HCPCS 250 RC 00054-8550-25 NDC inpatient 1 UN 15.05 15.05 HEALTHPARTNERS SX009 HEALTHPARTNERS 11.92 percent of total billed charges 9.33 14.3 Technical (Hospital) Services METHOTREXATE SODIUM 2.5 MG TABLET RX-4973 CDM J8610 HCPCS 250 RC 00054-8550-25 NDC inpatient 1 UN 15.05 15.05 MULTIPLAN INC 34080 [3081285] MULTIPLAN INC [308128501] 14.3 percent of total billed charges 9.33 14.3 Technical (Hospital) Services METHOTREXATE SODIUM 2.5 MG TABLET RX-4973 CDM J8610 HCPCS 250 RC 00054-8550-25 NDC inpatient 1 UN 15.05 15.05 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES EPO [308136803] 11.92 percent of total billed charges 9.33 14.3 Technical (Hospital) Services METHOTREXATE SODIUM 2.5 MG TABLET RX-4973 CDM J8610 HCPCS 250 RC 00054-8550-25 NDC inpatient 1 UN 15.05 15.05 CIGNA 62308 [3081051] CIGNA 62308 [308105105] 11.92 percent of total billed charges 9.33 14.3 Technical (Hospital) Services METHOTREXATE SODIUM 2.5 MG TABLET RX-4973 CDM J8610 HCPCS 250 RC 00054-8550-25 NDC inpatient 1 UN 15.05 15.05 CIGNA 62308 [3081051] CIGNA STATE OF WYOMING [308105107] 11.92 percent of total billed charges 9.33 14.3 Technical (Hospital) Services METHOTREXATE SODIUM 2.5 MG TABLET RX-4973 CDM J8610 HCPCS 250 RC 00054-8550-25 NDC inpatient 1 UN 15.05 15.05 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES HDHP [308136802] 11.92 percent of total billed charges 9.33 14.3 Technical (Hospital) Services METHOTREXATE SODIUM 2.5 MG TABLET RX-4973 CDM J8610 HCPCS 250 RC 00054-8550-25 NDC inpatient 1 UN 15.05 15.05 UNITED HEALTHCARE (COMMERCIAL) [3081199] UNITED HEALTHCARE 87726 [308119901] 9.33 percent of total billed charges 9.33 14.3 Technical (Hospital) Services METHOTREXATE SODIUM 2.5 MG TABLET RX-4973 CDM J8610 HCPCS 250 RC 00054-8550-25 NDC inpatient 1 UN 15.05 15.05 BLUE CROSS BLUE SHIELD WELLMARK SB889 [3081026] BCBS WYOMING [308102603] 14.3 percent of total billed charges 9.33 14.3 Technical (Hospital) Services DEXAMETHASONE 4 MG TABLET RX-2327 CDM J8540 HCPCS 636 RC 00054-4184-25 NDC inpatient 1 UN 6.61 6.61 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES PPO [308136801] 5.23 percent of total billed charges 4.1 6.28 Technical (Hospital) Services DEXAMETHASONE 4 MG TABLET RX-2327 CDM J8540 HCPCS 636 RC 00054-4184-25 NDC inpatient 1 UN 6.61 6.61 MEDICA (COMMERCIAL) 94265 [3081118] MEDICA CLAIMS [308111801] 5.95 percent of total billed charges 4.1 6.28 Technical (Hospital) Services DEXAMETHASONE 4 MG TABLET RX-2327 CDM J8540 HCPCS 636 RC 00054-4184-25 NDC inpatient 1 UN 6.61 6.61 MULTIPLAN INC 34080 [3081285] MULTIPLAN INC [308128501] 6.28 percent of total billed charges 4.1 6.28 Technical (Hospital) Services DEXAMETHASONE 4 MG TABLET RX-2327 CDM J8540 HCPCS 636 RC 00054-4184-25 NDC inpatient 1 UN 6.61 6.61 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES EPO [308136803] 5.23 percent of total billed charges 4.1 6.28 Technical (Hospital) Services DEXAMETHASONE 4 MG TABLET RX-2327 CDM J8540 HCPCS 636 RC 00054-4184-25 NDC inpatient 1 UN 6.61 6.61 UNITED HEALTHCARE (COMMERCIAL) [3081199] UNITED HEALTHCARE 87726 [308119901] 4.1 percent of total billed charges 4.1 6.28 Technical (Hospital) Services DEXAMETHASONE 4 MG TABLET RX-2327 CDM J8540 HCPCS 636 RC 00054-4184-25 NDC inpatient 1 UN 6.61 6.61 BLUE CROSS BLUE SHIELD WELLMARK SB889 [3081026] BCBS WYOMING [308102603] 6.28 percent of total billed charges 4.1 6.28 Technical (Hospital) Services DEXAMETHASONE 4 MG TABLET RX-2327 CDM J8540 HCPCS 636 RC 00054-4184-25 NDC inpatient 1 UN 6.61 6.61 CIGNA 62308 [3081051] CIGNA 62308 [308105105] 5.23 percent of total billed charges 4.1 6.28 Technical (Hospital) Services DEXAMETHASONE 4 MG TABLET RX-2327 CDM J8540 HCPCS 636 RC 00054-4184-25 NDC inpatient 1 UN 6.61 6.61 CIGNA 62308 [3081051] CIGNA STATE OF WYOMING [308105107] 5.23 percent of total billed charges 4.1 6.28 Technical (Hospital) Services DEXAMETHASONE 4 MG TABLET RX-2327 CDM J8540 HCPCS 636 RC 00054-4184-25 NDC inpatient 1 UN 6.61 6.61 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES HDHP [308136802] 5.23 percent of total billed charges 4.1 6.28 Technical (Hospital) Services DEXAMETHASONE 4 MG TABLET RX-2327 CDM J8540 HCPCS 636 RC 00054-4184-25 NDC inpatient 1 UN 6.61 6.61 HEALTHPARTNERS SX009 HEALTHPARTNERS 5.23 percent of total billed charges 4.1 6.28 Technical (Hospital) Services DEXAMETHASONE 4 MG TABLET RX-2327 CDM J8540 HCPCS 636 RC 00054-4184-25 NDC outpatient 1 UN 6.61 6.61 MEDICA (COMMERCIAL) 94265 [3081118] MEDICA CLAIMS [308111801] 5.95 percent of total billed charges 4.1 6.28 Technical (Hospital) Services DEXAMETHASONE 4 MG TABLET RX-2327 CDM J8540 HCPCS 636 RC 00054-4184-25 NDC outpatient 1 UN 6.61 6.61 CIGNA 62308 [3081051] CIGNA 62308 [308105105] 5.29 percent of total billed charges 4.1 6.28 Technical (Hospital) Services DEXAMETHASONE 4 MG TABLET RX-2327 CDM J8540 HCPCS 636 RC 00054-4184-25 NDC outpatient 1 UN 6.61 6.61 CIGNA 62308 [3081051] CIGNA STATE OF WYOMING [308105107] 5.29 percent of total billed charges 4.1 6.28 Technical (Hospital) Services DEXAMETHASONE 4 MG TABLET RX-2327 CDM J8540 HCPCS 636 RC 00054-4184-25 NDC outpatient 1 UN 6.61 6.61 HEALTHPARTNERS SX009 HEALTHPARTNERS 5.29 percent of total billed charges 4.1 6.28 Technical (Hospital) Services DEXAMETHASONE 4 MG TABLET RX-2327 CDM J8540 HCPCS 636 RC 00054-4184-25 NDC outpatient 1 UN 6.61 6.61 MULTIPLAN INC 34080 [3081285] MULTIPLAN INC [308128501] 6.28 percent of total billed charges 4.1 6.28 Technical (Hospital) Services DEXAMETHASONE 4 MG TABLET RX-2327 CDM J8540 HCPCS 636 RC 00054-4184-25 NDC outpatient 1 UN 6.61 6.61 UNITED HEALTHCARE (COMMERCIAL) [3081199] UNITED HEALTHCARE 87726 [308119901] 4.1 percent of total billed charges 4.1 6.28 Technical (Hospital) Services DEXAMETHASONE 4 MG TABLET RX-2327 CDM J8540 HCPCS 636 RC 00054-4184-25 NDC outpatient 1 UN 6.61 6.61 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES PPO [308136801] 5.29 percent of total billed charges 4.1 6.28 Technical (Hospital) Services DEXAMETHASONE 4 MG TABLET RX-2327 CDM J8540 HCPCS 636 RC 00054-4184-25 NDC outpatient 1 UN 6.61 6.61 BLUE CROSS BLUE SHIELD WELLMARK SB889 [3081026] BCBS WYOMING [308102603] 6.28 percent of total billed charges 4.1 6.28 Technical (Hospital) Services DEXAMETHASONE 4 MG TABLET RX-2327 CDM J8540 HCPCS 636 RC 00054-4184-25 NDC outpatient 1 UN 6.61 6.61 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES HDHP [308136802] 5.29 percent of total billed charges 4.1 6.28 Technical (Hospital) Services DEXAMETHASONE 4 MG TABLET RX-2327 CDM J8540 HCPCS 636 RC 00054-4184-25 NDC outpatient 1 UN 6.61 6.61 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES EPO [308136803] 5.29 percent of total billed charges 4.1 6.28 Technical (Hospital) Services RACEPINEPHRINE 2.25 % SOLUTION FOR NEBULIZATION RX-113082 CDM J7699 HCPCS 636 RC 00487-2784-01 NDC inpatient 0.5 ML 7.62 7.62 HEALTHPARTNERS SX009 HEALTHPARTNERS 6.03 percent of total billed charges 4.72 7.24 Technical (Hospital) Services RACEPINEPHRINE 2.25 % SOLUTION FOR NEBULIZATION RX-113082 CDM J7699 HCPCS 636 RC 00487-2784-01 NDC inpatient 0.5 ML 7.62 7.62 MEDICA (COMMERCIAL) 94265 [3081118] MEDICA CLAIMS [308111801] 6.86 percent of total billed charges 4.72 7.24 Technical (Hospital) Services RACEPINEPHRINE 2.25 % SOLUTION FOR NEBULIZATION RX-113082 CDM J7699 HCPCS 636 RC 00487-2784-01 NDC inpatient 0.5 ML 7.62 7.62 MULTIPLAN INC 34080 [3081285] MULTIPLAN INC [308128501] 7.24 percent of total billed charges 4.72 7.24 Technical (Hospital) Services RACEPINEPHRINE 2.25 % SOLUTION FOR NEBULIZATION RX-113082 CDM J7699 HCPCS 636 RC 00487-2784-01 NDC inpatient 0.5 ML 7.62 7.62 CIGNA 62308 [3081051] CIGNA 62308 [308105105] 6.03 percent of total billed charges 4.72 7.24 Technical (Hospital) Services RACEPINEPHRINE 2.25 % SOLUTION FOR NEBULIZATION RX-113082 CDM J7699 HCPCS 636 RC 00487-2784-01 NDC inpatient 0.5 ML 7.62 7.62 CIGNA 62308 [3081051] CIGNA STATE OF WYOMING [308105107] 6.03 percent of total billed charges 4.72 7.24 Technical (Hospital) Services RACEPINEPHRINE 2.25 % SOLUTION FOR NEBULIZATION RX-113082 CDM J7699 HCPCS 636 RC 00487-2784-01 NDC inpatient 0.5 ML 7.62 7.62 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES HDHP [308136802] 6.03 percent of total billed charges 4.72 7.24 Technical (Hospital) Services RACEPINEPHRINE 2.25 % SOLUTION FOR NEBULIZATION RX-113082 CDM J7699 HCPCS 636 RC 00487-2784-01 NDC inpatient 0.5 ML 7.62 7.62 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES EPO [308136803] 6.03 percent of total billed charges 4.72 7.24 Technical (Hospital) Services RACEPINEPHRINE 2.25 % SOLUTION FOR NEBULIZATION RX-113082 CDM J7699 HCPCS 636 RC 00487-2784-01 NDC inpatient 0.5 ML 7.62 7.62 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES PPO [308136801] 6.03 percent of total billed charges 4.72 7.24 Technical (Hospital) Services RACEPINEPHRINE 2.25 % SOLUTION FOR NEBULIZATION RX-113082 CDM J7699 HCPCS 636 RC 00487-2784-01 NDC inpatient 0.5 ML 7.62 7.62 UNITED HEALTHCARE (COMMERCIAL) [3081199] UNITED HEALTHCARE 87726 [308119901] 4.72 percent of total billed charges 4.72 7.24 Technical (Hospital) Services RACEPINEPHRINE 2.25 % SOLUTION FOR NEBULIZATION RX-113082 CDM J7699 HCPCS 636 RC 00487-2784-01 NDC inpatient 0.5 ML 7.62 7.62 BLUE CROSS BLUE SHIELD WELLMARK SB889 [3081026] BCBS WYOMING [308102603] 7.24 percent of total billed charges 4.72 7.24 Technical (Hospital) Services RACEPINEPHRINE 2.25 % SOLUTION FOR NEBULIZATION RX-113082 CDM J7699 HCPCS 636 RC 00487-2784-01 NDC outpatient 0.5 ML 7.62 7.62 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES PPO [308136801] 6.1 percent of total billed charges 4.72 7.24 Technical (Hospital) Services RACEPINEPHRINE 2.25 % SOLUTION FOR NEBULIZATION RX-113082 CDM J7699 HCPCS 636 RC 00487-2784-01 NDC outpatient 0.5 ML 7.62 7.62 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES HDHP [308136802] 6.1 percent of total billed charges 4.72 7.24 Technical (Hospital) Services RACEPINEPHRINE 2.25 % SOLUTION FOR NEBULIZATION RX-113082 CDM J7699 HCPCS 636 RC 00487-2784-01 NDC outpatient 0.5 ML 7.62 7.62 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES EPO [308136803] 6.1 percent of total billed charges 4.72 7.24 Technical (Hospital) Services RACEPINEPHRINE 2.25 % SOLUTION FOR NEBULIZATION RX-113082 CDM J7699 HCPCS 636 RC 00487-2784-01 NDC outpatient 0.5 ML 7.62 7.62 MEDICA (COMMERCIAL) 94265 [3081118] MEDICA CLAIMS [308111801] 6.86 percent of total billed charges 4.72 7.24 Technical (Hospital) Services RACEPINEPHRINE 2.25 % SOLUTION FOR NEBULIZATION RX-113082 CDM J7699 HCPCS 636 RC 00487-2784-01 NDC outpatient 0.5 ML 7.62 7.62 CIGNA 62308 [3081051] CIGNA 62308 [308105105] 6.1 percent of total billed charges 4.72 7.24 Technical (Hospital) Services RACEPINEPHRINE 2.25 % SOLUTION FOR NEBULIZATION RX-113082 CDM J7699 HCPCS 636 RC 00487-2784-01 NDC outpatient 0.5 ML 7.62 7.62 CIGNA 62308 [3081051] CIGNA STATE OF WYOMING [308105107] 6.1 percent of total billed charges 4.72 7.24 Technical (Hospital) Services RACEPINEPHRINE 2.25 % SOLUTION FOR NEBULIZATION RX-113082 CDM J7699 HCPCS 636 RC 00487-2784-01 NDC outpatient 0.5 ML 7.62 7.62 MULTIPLAN INC 34080 [3081285] MULTIPLAN INC [308128501] 7.24 percent of total billed charges 4.72 7.24 Technical (Hospital) Services RACEPINEPHRINE 2.25 % SOLUTION FOR NEBULIZATION RX-113082 CDM J7699 HCPCS 636 RC 00487-2784-01 NDC outpatient 0.5 ML 7.62 7.62 UNITED HEALTHCARE (COMMERCIAL) [3081199] UNITED HEALTHCARE 87726 [308119901] 4.72 percent of total billed charges 4.72 7.24 Technical (Hospital) Services RACEPINEPHRINE 2.25 % SOLUTION FOR NEBULIZATION RX-113082 CDM J7699 HCPCS 636 RC 00487-2784-01 NDC outpatient 0.5 ML 7.62 7.62 HEALTHPARTNERS SX009 HEALTHPARTNERS 6.1 percent of total billed charges 4.72 7.24 Technical (Hospital) Services RACEPINEPHRINE 2.25 % SOLUTION FOR NEBULIZATION RX-113082 CDM J7699 HCPCS 636 RC 00487-2784-01 NDC outpatient 0.5 ML 7.62 7.62 BLUE CROSS BLUE SHIELD WELLMARK SB889 [3081026] BCBS WYOMING [308102603] 7.24 percent of total billed charges 4.72 7.24 Technical (Hospital) Services SODIUM CHLORIDE 0.9 % FOR NEBULIZATION RX-7325 CDM J7699 HCPCS 636 RC 00487-9301-03 NDC inpatient 3 ML 5.72 5.72 HEALTHPARTNERS SX009 HEALTHPARTNERS 4.53 percent of total billed charges 3.55 5.43 Technical (Hospital) Services SODIUM CHLORIDE 0.9 % FOR NEBULIZATION RX-7325 CDM J7699 HCPCS 636 RC 00487-9301-03 NDC inpatient 3 ML 5.72 5.72 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES EPO [308136803] 4.53 percent of total billed charges 3.55 5.43 Technical (Hospital) Services SODIUM CHLORIDE 0.9 % FOR NEBULIZATION RX-7325 CDM J7699 HCPCS 636 RC 00487-9301-03 NDC inpatient 3 ML 5.72 5.72 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES PPO [308136801] 4.53 percent of total billed charges 3.55 5.43 Technical (Hospital) Services SODIUM CHLORIDE 0.9 % FOR NEBULIZATION RX-7325 CDM J7699 HCPCS 636 RC 00487-9301-03 NDC inpatient 3 ML 5.72 5.72 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES HDHP [308136802] 4.53 percent of total billed charges 3.55 5.43 Technical (Hospital) Services SODIUM CHLORIDE 0.9 % FOR NEBULIZATION RX-7325 CDM J7699 HCPCS 636 RC 00487-9301-03 NDC inpatient 3 ML 5.72 5.72 MULTIPLAN INC 34080 [3081285] MULTIPLAN INC [308128501] 5.43 percent of total billed charges 3.55 5.43 Technical (Hospital) Services SODIUM CHLORIDE 0.9 % FOR NEBULIZATION RX-7325 CDM J7699 HCPCS 636 RC 00487-9301-03 NDC inpatient 3 ML 5.72 5.72 MEDICA (COMMERCIAL) 94265 [3081118] MEDICA CLAIMS [308111801] 5.15 percent of total billed charges 3.55 5.43 Technical (Hospital) Services SODIUM CHLORIDE 0.9 % FOR NEBULIZATION RX-7325 CDM J7699 HCPCS 636 RC 00487-9301-03 NDC inpatient 3 ML 5.72 5.72 UNITED HEALTHCARE (COMMERCIAL) [3081199] UNITED HEALTHCARE 87726 [308119901] 3.55 percent of total billed charges 3.55 5.43 Technical (Hospital) Services SODIUM CHLORIDE 0.9 % FOR NEBULIZATION RX-7325 CDM J7699 HCPCS 636 RC 00487-9301-03 NDC inpatient 3 ML 5.72 5.72 CIGNA 62308 [3081051] CIGNA 62308 [308105105] 4.53 percent of total billed charges 3.55 5.43 Technical (Hospital) Services SODIUM CHLORIDE 0.9 % FOR NEBULIZATION RX-7325 CDM J7699 HCPCS 636 RC 00487-9301-03 NDC inpatient 3 ML 5.72 5.72 CIGNA 62308 [3081051] CIGNA STATE OF WYOMING [308105107] 4.53 percent of total billed charges 3.55 5.43 Technical (Hospital) Services SODIUM CHLORIDE 0.9 % FOR NEBULIZATION RX-7325 CDM J7699 HCPCS 636 RC 00487-9301-03 NDC inpatient 3 ML 5.72 5.72 BLUE CROSS BLUE SHIELD WELLMARK SB889 [3081026] BCBS WYOMING [308102603] 5.43 percent of total billed charges 3.55 5.43 Technical (Hospital) Services SODIUM CHLORIDE 0.9 % FOR NEBULIZATION RX-7325 CDM J7699 HCPCS 636 RC 00487-9301-03 NDC outpatient 3 ML 5.72 5.72 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES PPO [308136801] 4.58 percent of total billed charges 3.55 5.43 Technical (Hospital) Services SODIUM CHLORIDE 0.9 % FOR NEBULIZATION RX-7325 CDM J7699 HCPCS 636 RC 00487-9301-03 NDC outpatient 3 ML 5.72 5.72 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES HDHP [308136802] 4.58 percent of total billed charges 3.55 5.43 Technical (Hospital) Services SODIUM CHLORIDE 0.9 % FOR NEBULIZATION RX-7325 CDM J7699 HCPCS 636 RC 00487-9301-03 NDC outpatient 3 ML 5.72 5.72 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES EPO [308136803] 4.58 percent of total billed charges 3.55 5.43 Technical (Hospital) Services SODIUM CHLORIDE 0.9 % FOR NEBULIZATION RX-7325 CDM J7699 HCPCS 636 RC 00487-9301-03 NDC outpatient 3 ML 5.72 5.72 BLUE CROSS BLUE SHIELD WELLMARK SB889 [3081026] BCBS WYOMING [308102603] 5.43 percent of total billed charges 3.55 5.43 Technical (Hospital) Services SODIUM CHLORIDE 0.9 % FOR NEBULIZATION RX-7325 CDM J7699 HCPCS 636 RC 00487-9301-03 NDC outpatient 3 ML 5.72 5.72 CIGNA 62308 [3081051] CIGNA 62308 [308105105] 4.58 percent of total billed charges 3.55 5.43 Technical (Hospital) Services SODIUM CHLORIDE 0.9 % FOR NEBULIZATION RX-7325 CDM J7699 HCPCS 636 RC 00487-9301-03 NDC outpatient 3 ML 5.72 5.72 CIGNA 62308 [3081051] CIGNA STATE OF WYOMING [308105107] 4.58 percent of total billed charges 3.55 5.43 Technical (Hospital) Services SODIUM CHLORIDE 0.9 % FOR NEBULIZATION RX-7325 CDM J7699 HCPCS 636 RC 00487-9301-03 NDC outpatient 3 ML 5.72 5.72 UNITED HEALTHCARE (COMMERCIAL) [3081199] UNITED HEALTHCARE 87726 [308119901] 3.55 percent of total billed charges 3.55 5.43 Technical (Hospital) Services SODIUM CHLORIDE 0.9 % FOR NEBULIZATION RX-7325 CDM J7699 HCPCS 636 RC 00487-9301-03 NDC outpatient 3 ML 5.72 5.72 HEALTHPARTNERS SX009 HEALTHPARTNERS 4.58 percent of total billed charges 3.55 5.43 Technical (Hospital) Services SODIUM CHLORIDE 0.9 % FOR NEBULIZATION RX-7325 CDM J7699 HCPCS 636 RC 00487-9301-03 NDC outpatient 3 ML 5.72 5.72 MULTIPLAN INC 34080 [3081285] MULTIPLAN INC [308128501] 5.43 percent of total billed charges 3.55 5.43 Technical (Hospital) Services SODIUM CHLORIDE 0.9 % FOR NEBULIZATION RX-7325 CDM J7699 HCPCS 636 RC 00487-9301-03 NDC outpatient 3 ML 5.72 5.72 MEDICA (COMMERCIAL) 94265 [3081118] MEDICA CLAIMS [308111801] 5.15 percent of total billed charges 3.55 5.43 Technical (Hospital) Services REVEFENACIN 175 MCG/3 ML SOLUTION FOR NEBULIZATION RX-175690 CDM J7677 HCPCS 636 RC 49502-0806-32 NDC inpatient 3 ML 190.05 190.05 HEALTHPARTNERS SX009 HEALTHPARTNERS 150.48 percent of total billed charges 117.83 180.55 Technical (Hospital) Services REVEFENACIN 175 MCG/3 ML SOLUTION FOR NEBULIZATION RX-175690 CDM J7677 HCPCS 636 RC 49502-0806-32 NDC inpatient 3 ML 190.05 190.05 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES EPO [308136803] 150.48 percent of total billed charges 117.83 180.55 Technical (Hospital) Services REVEFENACIN 175 MCG/3 ML SOLUTION FOR NEBULIZATION RX-175690 CDM J7677 HCPCS 636 RC 49502-0806-32 NDC inpatient 3 ML 190.05 190.05 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES HDHP [308136802] 150.48 percent of total billed charges 117.83 180.55 Technical (Hospital) Services REVEFENACIN 175 MCG/3 ML SOLUTION FOR NEBULIZATION RX-175690 CDM J7677 HCPCS 636 RC 49502-0806-32 NDC inpatient 3 ML 190.05 190.05 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES PPO [308136801] 150.48 percent of total billed charges 117.83 180.55 Technical (Hospital) Services REVEFENACIN 175 MCG/3 ML SOLUTION FOR NEBULIZATION RX-175690 CDM J7677 HCPCS 636 RC 49502-0806-32 NDC inpatient 3 ML 190.05 190.05 CIGNA 62308 [3081051] CIGNA 62308 [308105105] 150.48 percent of total billed charges 117.83 180.55 Technical (Hospital) Services REVEFENACIN 175 MCG/3 ML SOLUTION FOR NEBULIZATION RX-175690 CDM J7677 HCPCS 636 RC 49502-0806-32 NDC inpatient 3 ML 190.05 190.05 CIGNA 62308 [3081051] CIGNA STATE OF WYOMING [308105107] 150.48 percent of total billed charges 117.83 180.55 Technical (Hospital) Services REVEFENACIN 175 MCG/3 ML SOLUTION FOR NEBULIZATION RX-175690 CDM J7677 HCPCS 636 RC 49502-0806-32 NDC inpatient 3 ML 190.05 190.05 BLUE CROSS BLUE SHIELD WELLMARK SB889 [3081026] BCBS WYOMING [308102603] 180.55 percent of total billed charges 117.83 180.55 Technical (Hospital) Services REVEFENACIN 175 MCG/3 ML SOLUTION FOR NEBULIZATION RX-175690 CDM J7677 HCPCS 636 RC 49502-0806-32 NDC inpatient 3 ML 190.05 190.05 UNITED HEALTHCARE (COMMERCIAL) [3081199] UNITED HEALTHCARE 87726 [308119901] 117.83 percent of total billed charges 117.83 180.55 Technical (Hospital) Services REVEFENACIN 175 MCG/3 ML SOLUTION FOR NEBULIZATION RX-175690 CDM J7677 HCPCS 636 RC 49502-0806-32 NDC inpatient 3 ML 190.05 190.05 MEDICA (COMMERCIAL) 94265 [3081118] MEDICA CLAIMS [308111801] 171.05 percent of total billed charges 117.83 180.55 Technical (Hospital) Services REVEFENACIN 175 MCG/3 ML SOLUTION FOR NEBULIZATION RX-175690 CDM J7677 HCPCS 636 RC 49502-0806-32 NDC inpatient 3 ML 190.05 190.05 MULTIPLAN INC 34080 [3081285] MULTIPLAN INC [308128501] 180.55 percent of total billed charges 117.83 180.55 Technical (Hospital) Services REVEFENACIN 175 MCG/3 ML SOLUTION FOR NEBULIZATION RX-175690 CDM J7677 HCPCS 636 RC 49502-0806-32 NDC outpatient 3 ML 190.05 190.05 HEALTHPARTNERS SX009 HEALTHPARTNERS 152.04 percent of total billed charges 117.83 180.55 Technical (Hospital) Services REVEFENACIN 175 MCG/3 ML SOLUTION FOR NEBULIZATION RX-175690 CDM J7677 HCPCS 636 RC 49502-0806-32 NDC outpatient 3 ML 190.05 190.05 UNITED HEALTHCARE (COMMERCIAL) [3081199] UNITED HEALTHCARE 87726 [308119901] 117.83 percent of total billed charges 117.83 180.55 Technical (Hospital) Services REVEFENACIN 175 MCG/3 ML SOLUTION FOR NEBULIZATION RX-175690 CDM J7677 HCPCS 636 RC 49502-0806-32 NDC outpatient 3 ML 190.05 190.05 CIGNA 62308 [3081051] CIGNA 62308 [308105105] 152.04 percent of total billed charges 117.83 180.55 Technical (Hospital) Services REVEFENACIN 175 MCG/3 ML SOLUTION FOR NEBULIZATION RX-175690 CDM J7677 HCPCS 636 RC 49502-0806-32 NDC outpatient 3 ML 190.05 190.05 CIGNA 62308 [3081051] CIGNA STATE OF WYOMING [308105107] 152.04 percent of total billed charges 117.83 180.55 Technical (Hospital) Services REVEFENACIN 175 MCG/3 ML SOLUTION FOR NEBULIZATION RX-175690 CDM J7677 HCPCS 636 RC 49502-0806-32 NDC outpatient 3 ML 190.05 190.05 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES PPO [308136801] 152.04 percent of total billed charges 117.83 180.55 Technical (Hospital) Services REVEFENACIN 175 MCG/3 ML SOLUTION FOR NEBULIZATION RX-175690 CDM J7677 HCPCS 636 RC 49502-0806-32 NDC outpatient 3 ML 190.05 190.05 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES HDHP [308136802] 152.04 percent of total billed charges 117.83 180.55 Technical (Hospital) Services REVEFENACIN 175 MCG/3 ML SOLUTION FOR NEBULIZATION RX-175690 CDM J7677 HCPCS 636 RC 49502-0806-32 NDC outpatient 3 ML 190.05 190.05 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES EPO [308136803] 152.04 percent of total billed charges 117.83 180.55 Technical (Hospital) Services REVEFENACIN 175 MCG/3 ML SOLUTION FOR NEBULIZATION RX-175690 CDM J7677 HCPCS 636 RC 49502-0806-32 NDC outpatient 3 ML 190.05 190.05 BLUE CROSS BLUE SHIELD WELLMARK SB889 [3081026] BCBS WYOMING [308102603] 180.55 percent of total billed charges 117.83 180.55 Technical (Hospital) Services REVEFENACIN 175 MCG/3 ML SOLUTION FOR NEBULIZATION RX-175690 CDM J7677 HCPCS 636 RC 49502-0806-32 NDC outpatient 3 ML 190.05 190.05 MULTIPLAN INC 34080 [3081285] MULTIPLAN INC [308128501] 180.55 percent of total billed charges 117.83 180.55 Technical (Hospital) Services REVEFENACIN 175 MCG/3 ML SOLUTION FOR NEBULIZATION RX-175690 CDM J7677 HCPCS 636 RC 49502-0806-32 NDC outpatient 3 ML 190.05 190.05 MEDICA (COMMERCIAL) 94265 [3081118] MEDICA CLAIMS [308111801] 171.05 percent of total billed charges 117.83 180.55 Technical (Hospital) Services IPRATROPIUM BROMIDE 0.02 % SOLUTION FOR INHALATION RX-12580 CDM J7644 HCPCS 636 RC 00487-9801-60 NDC outpatient 2.5 ML 5.87 5.87 HEALTHPARTNERS SX009 HEALTHPARTNERS 4.7 percent of total billed charges 3.64 5.58 Technical (Hospital) Services IPRATROPIUM BROMIDE 0.02 % SOLUTION FOR INHALATION RX-12580 CDM J7644 HCPCS 636 RC 00487-9801-60 NDC outpatient 2.5 ML 5.87 5.87 UNITED HEALTHCARE (COMMERCIAL) [3081199] UNITED HEALTHCARE 87726 [308119901] 3.64 percent of total billed charges 3.64 5.58 Technical (Hospital) Services IPRATROPIUM BROMIDE 0.02 % SOLUTION FOR INHALATION RX-12580 CDM J7644 HCPCS 636 RC 00487-9801-60 NDC outpatient 2.5 ML 5.87 5.87 CIGNA 62308 [3081051] CIGNA 62308 [308105105] 4.7 percent of total billed charges 3.64 5.58 Technical (Hospital) Services IPRATROPIUM BROMIDE 0.02 % SOLUTION FOR INHALATION RX-12580 CDM J7644 HCPCS 636 RC 00487-9801-60 NDC outpatient 2.5 ML 5.87 5.87 CIGNA 62308 [3081051] CIGNA STATE OF WYOMING [308105107] 4.7 percent of total billed charges 3.64 5.58 Technical (Hospital) Services IPRATROPIUM BROMIDE 0.02 % SOLUTION FOR INHALATION RX-12580 CDM J7644 HCPCS 636 RC 00487-9801-60 NDC outpatient 2.5 ML 5.87 5.87 MULTIPLAN INC 34080 [3081285] MULTIPLAN INC [308128501] 5.58 percent of total billed charges 3.64 5.58 Technical (Hospital) Services IPRATROPIUM BROMIDE 0.02 % SOLUTION FOR INHALATION RX-12580 CDM J7644 HCPCS 636 RC 00487-9801-60 NDC outpatient 2.5 ML 5.87 5.87 MEDICA (COMMERCIAL) 94265 [3081118] MEDICA CLAIMS [308111801] 5.28 percent of total billed charges 3.64 5.58 Technical (Hospital) Services IPRATROPIUM BROMIDE 0.02 % SOLUTION FOR INHALATION RX-12580 CDM J7644 HCPCS 636 RC 00487-9801-60 NDC outpatient 2.5 ML 5.87 5.87 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES EPO [308136803] 4.7 percent of total billed charges 3.64 5.58 Technical (Hospital) Services IPRATROPIUM BROMIDE 0.02 % SOLUTION FOR INHALATION RX-12580 CDM J7644 HCPCS 636 RC 00487-9801-60 NDC outpatient 2.5 ML 5.87 5.87 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES HDHP [308136802] 4.7 percent of total billed charges 3.64 5.58 Technical (Hospital) Services IPRATROPIUM BROMIDE 0.02 % SOLUTION FOR INHALATION RX-12580 CDM J7644 HCPCS 636 RC 00487-9801-60 NDC outpatient 2.5 ML 5.87 5.87 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES PPO [308136801] 4.7 percent of total billed charges 3.64 5.58 Technical (Hospital) Services IPRATROPIUM BROMIDE 0.02 % SOLUTION FOR INHALATION RX-12580 CDM J7644 HCPCS 636 RC 00487-9801-60 NDC outpatient 2.5 ML 5.87 5.87 BLUE CROSS BLUE SHIELD WELLMARK SB889 [3081026] BCBS WYOMING [308102603] 5.58 percent of total billed charges 3.64 5.58 Technical (Hospital) Services IPRATROPIUM BROMIDE 0.02 % SOLUTION FOR INHALATION RX-12580 CDM J7644 HCPCS 636 RC 00487-9801-60 NDC inpatient 2.5 ML 5.87 5.87 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES EPO [308136803] 4.65 percent of total billed charges 3.64 5.58 Technical (Hospital) Services IPRATROPIUM BROMIDE 0.02 % SOLUTION FOR INHALATION RX-12580 CDM J7644 HCPCS 636 RC 00487-9801-60 NDC inpatient 2.5 ML 5.87 5.87 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES HDHP [308136802] 4.65 percent of total billed charges 3.64 5.58 Technical (Hospital) Services IPRATROPIUM BROMIDE 0.02 % SOLUTION FOR INHALATION RX-12580 CDM J7644 HCPCS 636 RC 00487-9801-60 NDC inpatient 2.5 ML 5.87 5.87 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES PPO [308136801] 4.65 percent of total billed charges 3.64 5.58 Technical (Hospital) Services IPRATROPIUM BROMIDE 0.02 % SOLUTION FOR INHALATION RX-12580 CDM J7644 HCPCS 636 RC 00487-9801-60 NDC inpatient 2.5 ML 5.87 5.87 HEALTHPARTNERS SX009 HEALTHPARTNERS 4.65 percent of total billed charges 3.64 5.58 Technical (Hospital) Services IPRATROPIUM BROMIDE 0.02 % SOLUTION FOR INHALATION RX-12580 CDM J7644 HCPCS 636 RC 00487-9801-60 NDC inpatient 2.5 ML 5.87 5.87 MULTIPLAN INC 34080 [3081285] MULTIPLAN INC [308128501] 5.58 percent of total billed charges 3.64 5.58 Technical (Hospital) Services IPRATROPIUM BROMIDE 0.02 % SOLUTION FOR INHALATION RX-12580 CDM J7644 HCPCS 636 RC 00487-9801-60 NDC inpatient 2.5 ML 5.87 5.87 MEDICA (COMMERCIAL) 94265 [3081118] MEDICA CLAIMS [308111801] 5.28 percent of total billed charges 3.64 5.58 Technical (Hospital) Services IPRATROPIUM BROMIDE 0.02 % SOLUTION FOR INHALATION RX-12580 CDM J7644 HCPCS 636 RC 00487-9801-60 NDC inpatient 2.5 ML 5.87 5.87 UNITED HEALTHCARE (COMMERCIAL) [3081199] UNITED HEALTHCARE 87726 [308119901] 3.64 percent of total billed charges 3.64 5.58 Technical (Hospital) Services IPRATROPIUM BROMIDE 0.02 % SOLUTION FOR INHALATION RX-12580 CDM J7644 HCPCS 636 RC 00487-9801-60 NDC inpatient 2.5 ML 5.87 5.87 BLUE CROSS BLUE SHIELD WELLMARK SB889 [3081026] BCBS WYOMING [308102603] 5.58 percent of total billed charges 3.64 5.58 Technical (Hospital) Services IPRATROPIUM BROMIDE 0.02 % SOLUTION FOR INHALATION RX-12580 CDM J7644 HCPCS 636 RC 00487-9801-60 NDC inpatient 2.5 ML 5.87 5.87 CIGNA 62308 [3081051] CIGNA 62308 [308105105] 4.65 percent of total billed charges 3.64 5.58 Technical (Hospital) Services IPRATROPIUM BROMIDE 0.02 % SOLUTION FOR INHALATION RX-12580 CDM J7644 HCPCS 636 RC 00487-9801-60 NDC inpatient 2.5 ML 5.87 5.87 CIGNA 62308 [3081051] CIGNA STATE OF WYOMING [308105107] 4.65 percent of total billed charges 3.64 5.58 Technical (Hospital) Services BUDESONIDE 0.5 MG/2 ML SUSPENSION FOR NEBULIZATION RX-28775 CDM J7626 HCPCS 636 RC 00781-7516-14 NDC inpatient 2 ML 14.98 14.98 MEDICA (COMMERCIAL) 94265 [3081118] MEDICA CLAIMS [308111801] 13.48 percent of total billed charges 9.29 14.23 Technical (Hospital) Services BUDESONIDE 0.5 MG/2 ML SUSPENSION FOR NEBULIZATION RX-28775 CDM J7626 HCPCS 636 RC 00781-7516-14 NDC inpatient 2 ML 14.98 14.98 MULTIPLAN INC 34080 [3081285] MULTIPLAN INC [308128501] 14.23 percent of total billed charges 9.29 14.23 Technical (Hospital) Services BUDESONIDE 0.5 MG/2 ML SUSPENSION FOR NEBULIZATION RX-28775 CDM J7626 HCPCS 636 RC 00781-7516-14 NDC inpatient 2 ML 14.98 14.98 BLUE CROSS BLUE SHIELD WELLMARK SB889 [3081026] BCBS WYOMING [308102603] 14.23 percent of total billed charges 9.29 14.23 Technical (Hospital) Services BUDESONIDE 0.5 MG/2 ML SUSPENSION FOR NEBULIZATION RX-28775 CDM J7626 HCPCS 636 RC 00781-7516-14 NDC inpatient 2 ML 14.98 14.98 UNITED HEALTHCARE (COMMERCIAL) [3081199] UNITED HEALTHCARE 87726 [308119901] 9.29 percent of total billed charges 9.29 14.23 Technical (Hospital) Services BUDESONIDE 0.5 MG/2 ML SUSPENSION FOR NEBULIZATION RX-28775 CDM J7626 HCPCS 636 RC 00781-7516-14 NDC inpatient 2 ML 14.98 14.98 CIGNA 62308 [3081051] CIGNA 62308 [308105105] 11.86 percent of total billed charges 9.29 14.23 Technical (Hospital) Services BUDESONIDE 0.5 MG/2 ML SUSPENSION FOR NEBULIZATION RX-28775 CDM J7626 HCPCS 636 RC 00781-7516-14 NDC inpatient 2 ML 14.98 14.98 CIGNA 62308 [3081051] CIGNA STATE OF WYOMING [308105107] 11.86 percent of total billed charges 9.29 14.23 Technical (Hospital) Services BUDESONIDE 0.5 MG/2 ML SUSPENSION FOR NEBULIZATION RX-28775 CDM J7626 HCPCS 636 RC 00781-7516-14 NDC inpatient 2 ML 14.98 14.98 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES EPO [308136803] 11.86 percent of total billed charges 9.29 14.23 Technical (Hospital) Services BUDESONIDE 0.5 MG/2 ML SUSPENSION FOR NEBULIZATION RX-28775 CDM J7626 HCPCS 636 RC 00781-7516-14 NDC inpatient 2 ML 14.98 14.98 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES HDHP [308136802] 11.86 percent of total billed charges 9.29 14.23 Technical (Hospital) Services BUDESONIDE 0.5 MG/2 ML SUSPENSION FOR NEBULIZATION RX-28775 CDM J7626 HCPCS 636 RC 00781-7516-14 NDC inpatient 2 ML 14.98 14.98 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES PPO [308136801] 11.86 percent of total billed charges 9.29 14.23 Technical (Hospital) Services BUDESONIDE 0.5 MG/2 ML SUSPENSION FOR NEBULIZATION RX-28775 CDM J7626 HCPCS 636 RC 00781-7516-14 NDC inpatient 2 ML 14.98 14.98 HEALTHPARTNERS SX009 HEALTHPARTNERS 11.86 percent of total billed charges 9.29 14.23 Technical (Hospital) Services BUDESONIDE 0.5 MG/2 ML SUSPENSION FOR NEBULIZATION RX-28775 CDM J7626 HCPCS 636 RC 00781-7516-14 NDC outpatient 2 ML 14.98 14.98 MEDICA (COMMERCIAL) 94265 [3081118] MEDICA CLAIMS [308111801] 13.48 percent of total billed charges 9.29 14.23 Technical (Hospital) Services BUDESONIDE 0.5 MG/2 ML SUSPENSION FOR NEBULIZATION RX-28775 CDM J7626 HCPCS 636 RC 00781-7516-14 NDC outpatient 2 ML 14.98 14.98 CIGNA 62308 [3081051] CIGNA 62308 [308105105] 11.98 percent of total billed charges 9.29 14.23 Technical (Hospital) Services BUDESONIDE 0.5 MG/2 ML SUSPENSION FOR NEBULIZATION RX-28775 CDM J7626 HCPCS 636 RC 00781-7516-14 NDC outpatient 2 ML 14.98 14.98 CIGNA 62308 [3081051] CIGNA STATE OF WYOMING [308105107] 11.98 percent of total billed charges 9.29 14.23 Technical (Hospital) Services BUDESONIDE 0.5 MG/2 ML SUSPENSION FOR NEBULIZATION RX-28775 CDM J7626 HCPCS 636 RC 00781-7516-14 NDC outpatient 2 ML 14.98 14.98 MULTIPLAN INC 34080 [3081285] MULTIPLAN INC [308128501] 14.23 percent of total billed charges 9.29 14.23 Technical (Hospital) Services BUDESONIDE 0.5 MG/2 ML SUSPENSION FOR NEBULIZATION RX-28775 CDM J7626 HCPCS 636 RC 00781-7516-14 NDC outpatient 2 ML 14.98 14.98 UNITED HEALTHCARE (COMMERCIAL) [3081199] UNITED HEALTHCARE 87726 [308119901] 9.29 percent of total billed charges 9.29 14.23 Technical (Hospital) Services BUDESONIDE 0.5 MG/2 ML SUSPENSION FOR NEBULIZATION RX-28775 CDM J7626 HCPCS 636 RC 00781-7516-14 NDC outpatient 2 ML 14.98 14.98 HEALTHPARTNERS SX009 HEALTHPARTNERS 11.98 percent of total billed charges 9.29 14.23 Technical (Hospital) Services BUDESONIDE 0.5 MG/2 ML SUSPENSION FOR NEBULIZATION RX-28775 CDM J7626 HCPCS 636 RC 00781-7516-14 NDC outpatient 2 ML 14.98 14.98 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES EPO [308136803] 11.98 percent of total billed charges 9.29 14.23 Technical (Hospital) Services BUDESONIDE 0.5 MG/2 ML SUSPENSION FOR NEBULIZATION RX-28775 CDM J7626 HCPCS 636 RC 00781-7516-14 NDC outpatient 2 ML 14.98 14.98 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES HDHP [308136802] 11.98 percent of total billed charges 9.29 14.23 Technical (Hospital) Services BUDESONIDE 0.5 MG/2 ML SUSPENSION FOR NEBULIZATION RX-28775 CDM J7626 HCPCS 636 RC 00781-7516-14 NDC outpatient 2 ML 14.98 14.98 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES PPO [308136801] 11.98 percent of total billed charges 9.29 14.23 Technical (Hospital) Services BUDESONIDE 0.5 MG/2 ML SUSPENSION FOR NEBULIZATION RX-28775 CDM J7626 HCPCS 636 RC 00781-7516-14 NDC outpatient 2 ML 14.98 14.98 BLUE CROSS BLUE SHIELD WELLMARK SB889 [3081026] BCBS WYOMING [308102603] 14.23 percent of total billed charges 9.29 14.23 Technical (Hospital) Services IPRATROPIUM-ALBUTEROL 0.5-2.5 (3) MG/3ML IN SOLN RX-93931 CDM J7620 HCPCS 636 RC 69097-0173-48 NDC inpatient 3 ML 5.92 5.92 HEALTHPARTNERS SX009 HEALTHPARTNERS 4.69 percent of total billed charges 3.67 5.62 Technical (Hospital) Services IPRATROPIUM-ALBUTEROL 0.5-2.5 (3) MG/3ML IN SOLN RX-93931 CDM J7620 HCPCS 636 RC 69097-0173-48 NDC inpatient 3 ML 5.92 5.92 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES PPO [308136801] 4.69 percent of total billed charges 3.67 5.62 Technical (Hospital) Services IPRATROPIUM-ALBUTEROL 0.5-2.5 (3) MG/3ML IN SOLN RX-93931 CDM J7620 HCPCS 636 RC 69097-0173-48 NDC inpatient 3 ML 5.92 5.92 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES HDHP [308136802] 4.69 percent of total billed charges 3.67 5.62 Technical (Hospital) Services IPRATROPIUM-ALBUTEROL 0.5-2.5 (3) MG/3ML IN SOLN RX-93931 CDM J7620 HCPCS 636 RC 69097-0173-48 NDC inpatient 3 ML 5.92 5.92 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES EPO [308136803] 4.69 percent of total billed charges 3.67 5.62 Technical (Hospital) Services IPRATROPIUM-ALBUTEROL 0.5-2.5 (3) MG/3ML IN SOLN RX-93931 CDM J7620 HCPCS 636 RC 69097-0173-48 NDC inpatient 3 ML 5.92 5.92 MEDICA (COMMERCIAL) 94265 [3081118] MEDICA CLAIMS [308111801] 5.33 percent of total billed charges 3.67 5.62 Technical (Hospital) Services IPRATROPIUM-ALBUTEROL 0.5-2.5 (3) MG/3ML IN SOLN RX-93931 CDM J7620 HCPCS 636 RC 69097-0173-48 NDC inpatient 3 ML 5.92 5.92 MULTIPLAN INC 34080 [3081285] MULTIPLAN INC [308128501] 5.62 percent of total billed charges 3.67 5.62 Technical (Hospital) Services IPRATROPIUM-ALBUTEROL 0.5-2.5 (3) MG/3ML IN SOLN RX-93931 CDM J7620 HCPCS 636 RC 69097-0173-48 NDC inpatient 3 ML 5.92 5.92 BLUE CROSS BLUE SHIELD WELLMARK SB889 [3081026] BCBS WYOMING [308102603] 5.62 percent of total billed charges 3.67 5.62 Technical (Hospital) Services IPRATROPIUM-ALBUTEROL 0.5-2.5 (3) MG/3ML IN SOLN RX-93931 CDM J7620 HCPCS 636 RC 69097-0173-48 NDC inpatient 3 ML 5.92 5.92 UNITED HEALTHCARE (COMMERCIAL) [3081199] UNITED HEALTHCARE 87726 [308119901] 3.67 percent of total billed charges 3.67 5.62 Technical (Hospital) Services IPRATROPIUM-ALBUTEROL 0.5-2.5 (3) MG/3ML IN SOLN RX-93931 CDM J7620 HCPCS 636 RC 69097-0173-48 NDC inpatient 3 ML 5.92 5.92 CIGNA 62308 [3081051] CIGNA 62308 [308105105] 4.69 percent of total billed charges 3.67 5.62 Technical (Hospital) Services IPRATROPIUM-ALBUTEROL 0.5-2.5 (3) MG/3ML IN SOLN RX-93931 CDM J7620 HCPCS 636 RC 69097-0173-48 NDC inpatient 3 ML 5.92 5.92 CIGNA 62308 [3081051] CIGNA STATE OF WYOMING [308105107] 4.69 percent of total billed charges 3.67 5.62 Technical (Hospital) Services IPRATROPIUM-ALBUTEROL 0.5-2.5 (3) MG/3ML IN SOLN RX-93931 CDM J7620 HCPCS 636 RC 69097-0173-48 NDC outpatient 3 ML 5.92 5.92 BLUE CROSS BLUE SHIELD WELLMARK SB889 [3081026] BCBS WYOMING [308102603] 5.62 percent of total billed charges 3.67 5.62 Technical (Hospital) Services IPRATROPIUM-ALBUTEROL 0.5-2.5 (3) MG/3ML IN SOLN RX-93931 CDM J7620 HCPCS 636 RC 69097-0173-48 NDC outpatient 3 ML 5.92 5.92 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES PPO [308136801] 4.74 percent of total billed charges 3.67 5.62 Technical (Hospital) Services IPRATROPIUM-ALBUTEROL 0.5-2.5 (3) MG/3ML IN SOLN RX-93931 CDM J7620 HCPCS 636 RC 69097-0173-48 NDC outpatient 3 ML 5.92 5.92 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES EPO [308136803] 4.74 percent of total billed charges 3.67 5.62 Technical (Hospital) Services IPRATROPIUM-ALBUTEROL 0.5-2.5 (3) MG/3ML IN SOLN RX-93931 CDM J7620 HCPCS 636 RC 69097-0173-48 NDC outpatient 3 ML 5.92 5.92 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES HDHP [308136802] 4.74 percent of total billed charges 3.67 5.62 Technical (Hospital) Services IPRATROPIUM-ALBUTEROL 0.5-2.5 (3) MG/3ML IN SOLN RX-93931 CDM J7620 HCPCS 636 RC 69097-0173-48 NDC outpatient 3 ML 5.92 5.92 HEALTHPARTNERS SX009 HEALTHPARTNERS 4.74 percent of total billed charges 3.67 5.62 Technical (Hospital) Services IPRATROPIUM-ALBUTEROL 0.5-2.5 (3) MG/3ML IN SOLN RX-93931 CDM J7620 HCPCS 636 RC 69097-0173-48 NDC outpatient 3 ML 5.92 5.92 CIGNA 62308 [3081051] CIGNA 62308 [308105105] 4.74 percent of total billed charges 3.67 5.62 Technical (Hospital) Services IPRATROPIUM-ALBUTEROL 0.5-2.5 (3) MG/3ML IN SOLN RX-93931 CDM J7620 HCPCS 636 RC 69097-0173-48 NDC outpatient 3 ML 5.92 5.92 CIGNA 62308 [3081051] CIGNA STATE OF WYOMING [308105107] 4.74 percent of total billed charges 3.67 5.62 Technical (Hospital) Services IPRATROPIUM-ALBUTEROL 0.5-2.5 (3) MG/3ML IN SOLN RX-93931 CDM J7620 HCPCS 636 RC 69097-0173-48 NDC outpatient 3 ML 5.92 5.92 UNITED HEALTHCARE (COMMERCIAL) [3081199] UNITED HEALTHCARE 87726 [308119901] 3.67 percent of total billed charges 3.67 5.62 Technical (Hospital) Services IPRATROPIUM-ALBUTEROL 0.5-2.5 (3) MG/3ML IN SOLN RX-93931 CDM J7620 HCPCS 636 RC 69097-0173-48 NDC outpatient 3 ML 5.92 5.92 MULTIPLAN INC 34080 [3081285] MULTIPLAN INC [308128501] 5.62 percent of total billed charges 3.67 5.62 Technical (Hospital) Services IPRATROPIUM-ALBUTEROL 0.5-2.5 (3) MG/3ML IN SOLN RX-93931 CDM J7620 HCPCS 636 RC 69097-0173-48 NDC outpatient 3 ML 5.92 5.92 MEDICA (COMMERCIAL) 94265 [3081118] MEDICA CLAIMS [308111801] 5.33 percent of total billed charges 3.67 5.62 Technical (Hospital) Services LEVALBUTEROL 1.25 MG/3 ML SOLUTION FOR NEBULIZATION RX-24916 CDM J7614 HCPCS 636 RC 76204-0900-01 NDC inpatient 3 ML 7.22 7.22 MULTIPLAN INC 34080 [3081285] MULTIPLAN INC [308128501] 6.86 percent of total billed charges 4.48 6.86 Technical (Hospital) Services LEVALBUTEROL 1.25 MG/3 ML SOLUTION FOR NEBULIZATION RX-24916 CDM J7614 HCPCS 636 RC 76204-0900-01 NDC inpatient 3 ML 7.22 7.22 MEDICA (COMMERCIAL) 94265 [3081118] MEDICA CLAIMS [308111801] 6.5 percent of total billed charges 4.48 6.86 Technical (Hospital) Services LEVALBUTEROL 1.25 MG/3 ML SOLUTION FOR NEBULIZATION RX-24916 CDM J7614 HCPCS 636 RC 76204-0900-01 NDC inpatient 3 ML 7.22 7.22 BLUE CROSS BLUE SHIELD WELLMARK SB889 [3081026] BCBS WYOMING [308102603] 6.86 percent of total billed charges 4.48 6.86 Technical (Hospital) Services LEVALBUTEROL 1.25 MG/3 ML SOLUTION FOR NEBULIZATION RX-24916 CDM J7614 HCPCS 636 RC 76204-0900-01 NDC inpatient 3 ML 7.22 7.22 CIGNA 62308 [3081051] CIGNA 62308 [308105105] 5.72 percent of total billed charges 4.48 6.86 Technical (Hospital) Services LEVALBUTEROL 1.25 MG/3 ML SOLUTION FOR NEBULIZATION RX-24916 CDM J7614 HCPCS 636 RC 76204-0900-01 NDC inpatient 3 ML 7.22 7.22 CIGNA 62308 [3081051] CIGNA STATE OF WYOMING [308105107] 5.72 percent of total billed charges 4.48 6.86 Technical (Hospital) Services LEVALBUTEROL 1.25 MG/3 ML SOLUTION FOR NEBULIZATION RX-24916 CDM J7614 HCPCS 636 RC 76204-0900-01 NDC inpatient 3 ML 7.22 7.22 UNITED HEALTHCARE (COMMERCIAL) [3081199] UNITED HEALTHCARE 87726 [308119901] 4.48 percent of total billed charges 4.48 6.86 Technical (Hospital) Services LEVALBUTEROL 1.25 MG/3 ML SOLUTION FOR NEBULIZATION RX-24916 CDM J7614 HCPCS 636 RC 76204-0900-01 NDC inpatient 3 ML 7.22 7.22 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES PPO [308136801] 5.72 percent of total billed charges 4.48 6.86 Technical (Hospital) Services LEVALBUTEROL 1.25 MG/3 ML SOLUTION FOR NEBULIZATION RX-24916 CDM J7614 HCPCS 636 RC 76204-0900-01 NDC inpatient 3 ML 7.22 7.22 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES HDHP [308136802] 5.72 percent of total billed charges 4.48 6.86 Technical (Hospital) Services LEVALBUTEROL 1.25 MG/3 ML SOLUTION FOR NEBULIZATION RX-24916 CDM J7614 HCPCS 636 RC 76204-0900-01 NDC inpatient 3 ML 7.22 7.22 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES EPO [308136803] 5.72 percent of total billed charges 4.48 6.86 Technical (Hospital) Services LEVALBUTEROL 1.25 MG/3 ML SOLUTION FOR NEBULIZATION RX-24916 CDM J7614 HCPCS 636 RC 76204-0900-01 NDC inpatient 3 ML 7.22 7.22 HEALTHPARTNERS SX009 HEALTHPARTNERS 5.72 percent of total billed charges 4.48 6.86 Technical (Hospital) Services LEVALBUTEROL 1.25 MG/3 ML SOLUTION FOR NEBULIZATION RX-24916 CDM J7614 HCPCS 636 RC 76204-0900-01 NDC outpatient 3 ML 7.22 7.22 MULTIPLAN INC 34080 [3081285] MULTIPLAN INC [308128501] 6.86 percent of total billed charges 4.48 6.86 Technical (Hospital) Services LEVALBUTEROL 1.25 MG/3 ML SOLUTION FOR NEBULIZATION RX-24916 CDM J7614 HCPCS 636 RC 76204-0900-01 NDC outpatient 3 ML 7.22 7.22 MEDICA (COMMERCIAL) 94265 [3081118] MEDICA CLAIMS [308111801] 6.5 percent of total billed charges 4.48 6.86 Technical (Hospital) Services LEVALBUTEROL 1.25 MG/3 ML SOLUTION FOR NEBULIZATION RX-24916 CDM J7614 HCPCS 636 RC 76204-0900-01 NDC outpatient 3 ML 7.22 7.22 CIGNA 62308 [3081051] CIGNA 62308 [308105105] 5.78 percent of total billed charges 4.48 6.86 Technical (Hospital) Services LEVALBUTEROL 1.25 MG/3 ML SOLUTION FOR NEBULIZATION RX-24916 CDM J7614 HCPCS 636 RC 76204-0900-01 NDC outpatient 3 ML 7.22 7.22 CIGNA 62308 [3081051] CIGNA STATE OF WYOMING [308105107] 5.78 percent of total billed charges 4.48 6.86 Technical (Hospital) Services LEVALBUTEROL 1.25 MG/3 ML SOLUTION FOR NEBULIZATION RX-24916 CDM J7614 HCPCS 636 RC 76204-0900-01 NDC outpatient 3 ML 7.22 7.22 HEALTHPARTNERS SX009 HEALTHPARTNERS 5.78 percent of total billed charges 4.48 6.86 Technical (Hospital) Services LEVALBUTEROL 1.25 MG/3 ML SOLUTION FOR NEBULIZATION RX-24916 CDM J7614 HCPCS 636 RC 76204-0900-01 NDC outpatient 3 ML 7.22 7.22 UNITED HEALTHCARE (COMMERCIAL) [3081199] UNITED HEALTHCARE 87726 [308119901] 4.48 percent of total billed charges 4.48 6.86 Technical (Hospital) Services LEVALBUTEROL 1.25 MG/3 ML SOLUTION FOR NEBULIZATION RX-24916 CDM J7614 HCPCS 636 RC 76204-0900-01 NDC outpatient 3 ML 7.22 7.22 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES HDHP [308136802] 5.78 percent of total billed charges 4.48 6.86 Technical (Hospital) Services LEVALBUTEROL 1.25 MG/3 ML SOLUTION FOR NEBULIZATION RX-24916 CDM J7614 HCPCS 636 RC 76204-0900-01 NDC outpatient 3 ML 7.22 7.22 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES EPO [308136803] 5.78 percent of total billed charges 4.48 6.86 Technical (Hospital) Services LEVALBUTEROL 1.25 MG/3 ML SOLUTION FOR NEBULIZATION RX-24916 CDM J7614 HCPCS 636 RC 76204-0900-01 NDC outpatient 3 ML 7.22 7.22 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES PPO [308136801] 5.78 percent of total billed charges 4.48 6.86 Technical (Hospital) Services LEVALBUTEROL 1.25 MG/3 ML SOLUTION FOR NEBULIZATION RX-24916 CDM J7614 HCPCS 636 RC 76204-0900-01 NDC outpatient 3 ML 7.22 7.22 BLUE CROSS BLUE SHIELD WELLMARK SB889 [3081026] BCBS WYOMING [308102603] 6.86 percent of total billed charges 4.48 6.86 Technical (Hospital) Services ALBUTEROL SULFATE 2.5 MG/3 ML (0.083 %) SOLUTION FOR NEBULIZATION RX-250 CDM J7613 HCPCS 636 RC 00487-9501-60 NDC outpatient 3 ML 5.87 5.87 CIGNA 62308 [3081051] CIGNA 62308 [308105105] 4.7 percent of total billed charges 3.64 5.58 Technical (Hospital) Services ALBUTEROL SULFATE 2.5 MG/3 ML (0.083 %) SOLUTION FOR NEBULIZATION RX-250 CDM J7613 HCPCS 636 RC 00487-9501-60 NDC outpatient 3 ML 5.87 5.87 CIGNA 62308 [3081051] CIGNA STATE OF WYOMING [308105107] 4.7 percent of total billed charges 3.64 5.58 Technical (Hospital) Services ALBUTEROL SULFATE 2.5 MG/3 ML (0.083 %) SOLUTION FOR NEBULIZATION RX-250 CDM J7613 HCPCS 636 RC 00487-9501-60 NDC outpatient 3 ML 5.87 5.87 HEALTHPARTNERS SX009 HEALTHPARTNERS 4.7 percent of total billed charges 3.64 5.58 Technical (Hospital) Services ALBUTEROL SULFATE 2.5 MG/3 ML (0.083 %) SOLUTION FOR NEBULIZATION RX-250 CDM J7613 HCPCS 636 RC 00487-9501-60 NDC outpatient 3 ML 5.87 5.87 UNITED HEALTHCARE (COMMERCIAL) [3081199] UNITED HEALTHCARE 87726 [308119901] 3.64 percent of total billed charges 3.64 5.58 Technical (Hospital) Services ALBUTEROL SULFATE 2.5 MG/3 ML (0.083 %) SOLUTION FOR NEBULIZATION RX-250 CDM J7613 HCPCS 636 RC 00487-9501-60 NDC outpatient 3 ML 5.87 5.87 BLUE CROSS BLUE SHIELD WELLMARK SB889 [3081026] BCBS WYOMING [308102603] 5.58 percent of total billed charges 3.64 5.58 Technical (Hospital) Services ALBUTEROL SULFATE 2.5 MG/3 ML (0.083 %) SOLUTION FOR NEBULIZATION RX-250 CDM J7613 HCPCS 636 RC 00487-9501-60 NDC outpatient 3 ML 5.87 5.87 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES EPO [308136803] 4.7 percent of total billed charges 3.64 5.58 Technical (Hospital) Services ALBUTEROL SULFATE 2.5 MG/3 ML (0.083 %) SOLUTION FOR NEBULIZATION RX-250 CDM J7613 HCPCS 636 RC 00487-9501-60 NDC outpatient 3 ML 5.87 5.87 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES HDHP [308136802] 4.7 percent of total billed charges 3.64 5.58 Technical (Hospital) Services ALBUTEROL SULFATE 2.5 MG/3 ML (0.083 %) SOLUTION FOR NEBULIZATION RX-250 CDM J7613 HCPCS 636 RC 00487-9501-60 NDC outpatient 3 ML 5.87 5.87 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES PPO [308136801] 4.7 percent of total billed charges 3.64 5.58 Technical (Hospital) Services ALBUTEROL SULFATE 2.5 MG/3 ML (0.083 %) SOLUTION FOR NEBULIZATION RX-250 CDM J7613 HCPCS 636 RC 00487-9501-60 NDC outpatient 3 ML 5.87 5.87 MEDICA (COMMERCIAL) 94265 [3081118] MEDICA CLAIMS [308111801] 5.28 percent of total billed charges 3.64 5.58 Technical (Hospital) Services ALBUTEROL SULFATE 2.5 MG/3 ML (0.083 %) SOLUTION FOR NEBULIZATION RX-250 CDM J7613 HCPCS 636 RC 00487-9501-60 NDC outpatient 3 ML 5.87 5.87 MULTIPLAN INC 34080 [3081285] MULTIPLAN INC [308128501] 5.58 percent of total billed charges 3.64 5.58 Technical (Hospital) Services ALBUTEROL SULFATE 2.5 MG/3 ML (0.083 %) SOLUTION FOR NEBULIZATION RX-250 CDM J7613 HCPCS 636 RC 00487-9501-60 NDC inpatient 3 ML 5.87 5.87 MEDICA (COMMERCIAL) 94265 [3081118] MEDICA CLAIMS [308111801] 5.28 percent of total billed charges 3.64 5.58 Technical (Hospital) Services ALBUTEROL SULFATE 2.5 MG/3 ML (0.083 %) SOLUTION FOR NEBULIZATION RX-250 CDM J7613 HCPCS 636 RC 00487-9501-60 NDC inpatient 3 ML 5.87 5.87 MULTIPLAN INC 34080 [3081285] MULTIPLAN INC [308128501] 5.58 percent of total billed charges 3.64 5.58 Technical (Hospital) Services ALBUTEROL SULFATE 2.5 MG/3 ML (0.083 %) SOLUTION FOR NEBULIZATION RX-250 CDM J7613 HCPCS 636 RC 00487-9501-60 NDC inpatient 3 ML 5.87 5.87 UNITED HEALTHCARE (COMMERCIAL) [3081199] UNITED HEALTHCARE 87726 [308119901] 3.64 percent of total billed charges 3.64 5.58 Technical (Hospital) Services ALBUTEROL SULFATE 2.5 MG/3 ML (0.083 %) SOLUTION FOR NEBULIZATION RX-250 CDM J7613 HCPCS 636 RC 00487-9501-60 NDC inpatient 3 ML 5.87 5.87 BLUE CROSS BLUE SHIELD WELLMARK SB889 [3081026] BCBS WYOMING [308102603] 5.58 percent of total billed charges 3.64 5.58 Technical (Hospital) Services ALBUTEROL SULFATE 2.5 MG/3 ML (0.083 %) SOLUTION FOR NEBULIZATION RX-250 CDM J7613 HCPCS 636 RC 00487-9501-60 NDC inpatient 3 ML 5.87 5.87 CIGNA 62308 [3081051] CIGNA 62308 [308105105] 4.65 percent of total billed charges 3.64 5.58 Technical (Hospital) Services ALBUTEROL SULFATE 2.5 MG/3 ML (0.083 %) SOLUTION FOR NEBULIZATION RX-250 CDM J7613 HCPCS 636 RC 00487-9501-60 NDC inpatient 3 ML 5.87 5.87 CIGNA 62308 [3081051] CIGNA STATE OF WYOMING [308105107] 4.65 percent of total billed charges 3.64 5.58 Technical (Hospital) Services ALBUTEROL SULFATE 2.5 MG/3 ML (0.083 %) SOLUTION FOR NEBULIZATION RX-250 CDM J7613 HCPCS 636 RC 00487-9501-60 NDC inpatient 3 ML 5.87 5.87 HEALTHPARTNERS SX009 HEALTHPARTNERS 4.65 percent of total billed charges 3.64 5.58 Technical (Hospital) Services ALBUTEROL SULFATE 2.5 MG/3 ML (0.083 %) SOLUTION FOR NEBULIZATION RX-250 CDM J7613 HCPCS 636 RC 00487-9501-60 NDC inpatient 3 ML 5.87 5.87 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES PPO [308136801] 4.65 percent of total billed charges 3.64 5.58 Technical (Hospital) Services ALBUTEROL SULFATE 2.5 MG/3 ML (0.083 %) SOLUTION FOR NEBULIZATION RX-250 CDM J7613 HCPCS 636 RC 00487-9501-60 NDC inpatient 3 ML 5.87 5.87 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES HDHP [308136802] 4.65 percent of total billed charges 3.64 5.58 Technical (Hospital) Services ALBUTEROL SULFATE 2.5 MG/3 ML (0.083 %) SOLUTION FOR NEBULIZATION RX-250 CDM J7613 HCPCS 636 RC 00487-9501-60 NDC inpatient 3 ML 5.87 5.87 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES EPO [308136803] 4.65 percent of total billed charges 3.64 5.58 Technical (Hospital) Services ACETYLCYSTEINE 200 MG/ML (20 %) SOLUTION RX-123 CDM J7608 HCPCS 636 RC 63323-0690-41 NDC inpatient 3 ML 6.28 6.28 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES EPO [308136803] 4.97 percent of total billed charges 3.89 5.97 Technical (Hospital) Services ACETYLCYSTEINE 200 MG/ML (20 %) SOLUTION RX-123 CDM J7608 HCPCS 636 RC 63323-0690-41 NDC inpatient 3 ML 6.28 6.28 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES HDHP [308136802] 4.97 percent of total billed charges 3.89 5.97 Technical (Hospital) Services ACETYLCYSTEINE 200 MG/ML (20 %) SOLUTION RX-123 CDM J7608 HCPCS 636 RC 63323-0690-41 NDC inpatient 3 ML 6.28 6.28 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES PPO [308136801] 4.97 percent of total billed charges 3.89 5.97 Technical (Hospital) Services ACETYLCYSTEINE 200 MG/ML (20 %) SOLUTION RX-123 CDM J7608 HCPCS 636 RC 63323-0690-41 NDC inpatient 3 ML 6.28 6.28 HEALTHPARTNERS SX009 HEALTHPARTNERS 4.97 percent of total billed charges 3.89 5.97 Technical (Hospital) Services ACETYLCYSTEINE 200 MG/ML (20 %) SOLUTION RX-123 CDM J7608 HCPCS 636 RC 63323-0690-41 NDC inpatient 3 ML 6.28 6.28 CIGNA 62308 [3081051] CIGNA 62308 [308105105] 4.97 percent of total billed charges 3.89 5.97 Technical (Hospital) Services ACETYLCYSTEINE 200 MG/ML (20 %) SOLUTION RX-123 CDM J7608 HCPCS 636 RC 63323-0690-41 NDC inpatient 3 ML 6.28 6.28 CIGNA 62308 [3081051] CIGNA STATE OF WYOMING [308105107] 4.97 percent of total billed charges 3.89 5.97 Technical (Hospital) Services ACETYLCYSTEINE 200 MG/ML (20 %) SOLUTION RX-123 CDM J7608 HCPCS 636 RC 63323-0690-41 NDC inpatient 3 ML 6.28 6.28 BLUE CROSS BLUE SHIELD WELLMARK SB889 [3081026] BCBS WYOMING [308102603] 5.97 percent of total billed charges 3.89 5.97 Technical (Hospital) Services ACETYLCYSTEINE 200 MG/ML (20 %) SOLUTION RX-123 CDM J7608 HCPCS 636 RC 63323-0690-41 NDC inpatient 3 ML 6.28 6.28 UNITED HEALTHCARE (COMMERCIAL) [3081199] UNITED HEALTHCARE 87726 [308119901] 3.89 percent of total billed charges 3.89 5.97 Technical (Hospital) Services ACETYLCYSTEINE 200 MG/ML (20 %) SOLUTION RX-123 CDM J7608 HCPCS 636 RC 63323-0690-41 NDC inpatient 3 ML 6.28 6.28 MULTIPLAN INC 34080 [3081285] MULTIPLAN INC [308128501] 5.97 percent of total billed charges 3.89 5.97 Technical (Hospital) Services ACETYLCYSTEINE 200 MG/ML (20 %) SOLUTION RX-123 CDM J7608 HCPCS 636 RC 63323-0690-41 NDC inpatient 3 ML 6.28 6.28 MEDICA (COMMERCIAL) 94265 [3081118] MEDICA CLAIMS [308111801] 5.65 percent of total billed charges 3.89 5.97 Technical (Hospital) Services ACETYLCYSTEINE 200 MG/ML (20 %) SOLUTION RX-123 CDM J7608 HCPCS 636 RC 63323-0690-41 NDC outpatient 3 ML 6.28 6.28 BLUE CROSS BLUE SHIELD WELLMARK SB889 [3081026] BCBS WYOMING [308102603] 5.97 percent of total billed charges 3.89 5.97 Technical (Hospital) Services ACETYLCYSTEINE 200 MG/ML (20 %) SOLUTION RX-123 CDM J7608 HCPCS 636 RC 63323-0690-41 NDC outpatient 3 ML 6.28 6.28 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES PPO [308136801] 5.02 percent of total billed charges 3.89 5.97 Technical (Hospital) Services ACETYLCYSTEINE 200 MG/ML (20 %) SOLUTION RX-123 CDM J7608 HCPCS 636 RC 63323-0690-41 NDC outpatient 3 ML 6.28 6.28 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES HDHP [308136802] 5.02 percent of total billed charges 3.89 5.97 Technical (Hospital) Services ACETYLCYSTEINE 200 MG/ML (20 %) SOLUTION RX-123 CDM J7608 HCPCS 636 RC 63323-0690-41 NDC outpatient 3 ML 6.28 6.28 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES EPO [308136803] 5.02 percent of total billed charges 3.89 5.97 Technical (Hospital) Services ACETYLCYSTEINE 200 MG/ML (20 %) SOLUTION RX-123 CDM J7608 HCPCS 636 RC 63323-0690-41 NDC outpatient 3 ML 6.28 6.28 HEALTHPARTNERS SX009 HEALTHPARTNERS 5.02 percent of total billed charges 3.89 5.97 Technical (Hospital) Services ACETYLCYSTEINE 200 MG/ML (20 %) SOLUTION RX-123 CDM J7608 HCPCS 636 RC 63323-0690-41 NDC outpatient 3 ML 6.28 6.28 UNITED HEALTHCARE (COMMERCIAL) [3081199] UNITED HEALTHCARE 87726 [308119901] 3.89 percent of total billed charges 3.89 5.97 Technical (Hospital) Services ACETYLCYSTEINE 200 MG/ML (20 %) SOLUTION RX-123 CDM J7608 HCPCS 636 RC 63323-0690-41 NDC outpatient 3 ML 6.28 6.28 CIGNA 62308 [3081051] CIGNA 62308 [308105105] 5.02 percent of total billed charges 3.89 5.97 Technical (Hospital) Services ACETYLCYSTEINE 200 MG/ML (20 %) SOLUTION RX-123 CDM J7608 HCPCS 636 RC 63323-0690-41 NDC outpatient 3 ML 6.28 6.28 CIGNA 62308 [3081051] CIGNA STATE OF WYOMING [308105107] 5.02 percent of total billed charges 3.89 5.97 Technical (Hospital) Services ACETYLCYSTEINE 200 MG/ML (20 %) SOLUTION RX-123 CDM J7608 HCPCS 636 RC 63323-0690-41 NDC outpatient 3 ML 6.28 6.28 MULTIPLAN INC 34080 [3081285] MULTIPLAN INC [308128501] 5.97 percent of total billed charges 3.89 5.97 Technical (Hospital) Services ACETYLCYSTEINE 200 MG/ML (20 %) SOLUTION RX-123 CDM J7608 HCPCS 636 RC 63323-0690-41 NDC outpatient 3 ML 6.28 6.28 MEDICA (COMMERCIAL) 94265 [3081118] MEDICA CLAIMS [308111801] 5.65 percent of total billed charges 3.89 5.97 Technical (Hospital) Services ARFORMOTEROL 15 MCG/2 ML SOLUTION FOR NEBULIZATION RX-77581 CDM J7605 HCPCS 636 RC 63402-0911-04 NDC outpatient 2 ML 67.7 67.7 BLUE CROSS BLUE SHIELD WELLMARK SB889 [3081026] BCBS WYOMING [308102603] 64.32 percent of total billed charges 41.97 64.32 Technical (Hospital) Services ARFORMOTEROL 15 MCG/2 ML SOLUTION FOR NEBULIZATION RX-77581 CDM J7605 HCPCS 636 RC 63402-0911-04 NDC outpatient 2 ML 67.7 67.7 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES HDHP [308136802] 54.16 percent of total billed charges 41.97 64.32 Technical (Hospital) Services ARFORMOTEROL 15 MCG/2 ML SOLUTION FOR NEBULIZATION RX-77581 CDM J7605 HCPCS 636 RC 63402-0911-04 NDC outpatient 2 ML 67.7 67.7 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES PPO [308136801] 54.16 percent of total billed charges 41.97 64.32 Technical (Hospital) Services ARFORMOTEROL 15 MCG/2 ML SOLUTION FOR NEBULIZATION RX-77581 CDM J7605 HCPCS 636 RC 63402-0911-04 NDC outpatient 2 ML 67.7 67.7 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES EPO [308136803] 54.16 percent of total billed charges 41.97 64.32 Technical (Hospital) Services ARFORMOTEROL 15 MCG/2 ML SOLUTION FOR NEBULIZATION RX-77581 CDM J7605 HCPCS 636 RC 63402-0911-04 NDC outpatient 2 ML 67.7 67.7 HEALTHPARTNERS SX009 HEALTHPARTNERS 54.16 percent of total billed charges 41.97 64.32 Technical (Hospital) Services ARFORMOTEROL 15 MCG/2 ML SOLUTION FOR NEBULIZATION RX-77581 CDM J7605 HCPCS 636 RC 63402-0911-04 NDC outpatient 2 ML 67.7 67.7 UNITED HEALTHCARE (COMMERCIAL) [3081199] UNITED HEALTHCARE 87726 [308119901] 41.97 percent of total billed charges 41.97 64.32 Technical (Hospital) Services ARFORMOTEROL 15 MCG/2 ML SOLUTION FOR NEBULIZATION RX-77581 CDM J7605 HCPCS 636 RC 63402-0911-04 NDC outpatient 2 ML 67.7 67.7 MULTIPLAN INC 34080 [3081285] MULTIPLAN INC [308128501] 64.32 percent of total billed charges 41.97 64.32 Technical (Hospital) Services ARFORMOTEROL 15 MCG/2 ML SOLUTION FOR NEBULIZATION RX-77581 CDM J7605 HCPCS 636 RC 63402-0911-04 NDC outpatient 2 ML 67.7 67.7 CIGNA 62308 [3081051] CIGNA 62308 [308105105] 54.16 percent of total billed charges 41.97 64.32 Technical (Hospital) Services ARFORMOTEROL 15 MCG/2 ML SOLUTION FOR NEBULIZATION RX-77581 CDM J7605 HCPCS 636 RC 63402-0911-04 NDC outpatient 2 ML 67.7 67.7 CIGNA 62308 [3081051] CIGNA STATE OF WYOMING [308105107] 54.16 percent of total billed charges 41.97 64.32 Technical (Hospital) Services ARFORMOTEROL 15 MCG/2 ML SOLUTION FOR NEBULIZATION RX-77581 CDM J7605 HCPCS 636 RC 63402-0911-04 NDC outpatient 2 ML 67.7 67.7 MEDICA (COMMERCIAL) 94265 [3081118] MEDICA CLAIMS [308111801] 60.93 percent of total billed charges 41.97 64.32 Technical (Hospital) Services ARFORMOTEROL 15 MCG/2 ML SOLUTION FOR NEBULIZATION RX-77581 CDM J7605 HCPCS 636 RC 63402-0911-04 NDC inpatient 2 ML 67.7 67.7 HEALTHPARTNERS SX009 HEALTHPARTNERS 53.6 percent of total billed charges 41.97 64.32 Technical (Hospital) Services ARFORMOTEROL 15 MCG/2 ML SOLUTION FOR NEBULIZATION RX-77581 CDM J7605 HCPCS 636 RC 63402-0911-04 NDC inpatient 2 ML 67.7 67.7 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES HDHP [308136802] 53.6 percent of total billed charges 41.97 64.32 Technical (Hospital) Services ARFORMOTEROL 15 MCG/2 ML SOLUTION FOR NEBULIZATION RX-77581 CDM J7605 HCPCS 636 RC 63402-0911-04 NDC inpatient 2 ML 67.7 67.7 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES EPO [308136803] 53.6 percent of total billed charges 41.97 64.32 Technical (Hospital) Services ARFORMOTEROL 15 MCG/2 ML SOLUTION FOR NEBULIZATION RX-77581 CDM J7605 HCPCS 636 RC 63402-0911-04 NDC inpatient 2 ML 67.7 67.7 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES PPO [308136801] 53.6 percent of total billed charges 41.97 64.32 Technical (Hospital) Services ARFORMOTEROL 15 MCG/2 ML SOLUTION FOR NEBULIZATION RX-77581 CDM J7605 HCPCS 636 RC 63402-0911-04 NDC inpatient 2 ML 67.7 67.7 MULTIPLAN INC 34080 [3081285] MULTIPLAN INC [308128501] 64.32 percent of total billed charges 41.97 64.32 Technical (Hospital) Services ARFORMOTEROL 15 MCG/2 ML SOLUTION FOR NEBULIZATION RX-77581 CDM J7605 HCPCS 636 RC 63402-0911-04 NDC inpatient 2 ML 67.7 67.7 MEDICA (COMMERCIAL) 94265 [3081118] MEDICA CLAIMS [308111801] 60.93 percent of total billed charges 41.97 64.32 Technical (Hospital) Services ARFORMOTEROL 15 MCG/2 ML SOLUTION FOR NEBULIZATION RX-77581 CDM J7605 HCPCS 636 RC 63402-0911-04 NDC inpatient 2 ML 67.7 67.7 UNITED HEALTHCARE (COMMERCIAL) [3081199] UNITED HEALTHCARE 87726 [308119901] 41.97 percent of total billed charges 41.97 64.32 Technical (Hospital) Services ARFORMOTEROL 15 MCG/2 ML SOLUTION FOR NEBULIZATION RX-77581 CDM J7605 HCPCS 636 RC 63402-0911-04 NDC inpatient 2 ML 67.7 67.7 BLUE CROSS BLUE SHIELD WELLMARK SB889 [3081026] BCBS WYOMING [308102603] 64.32 percent of total billed charges 41.97 64.32 Technical (Hospital) Services ARFORMOTEROL 15 MCG/2 ML SOLUTION FOR NEBULIZATION RX-77581 CDM J7605 HCPCS 636 RC 63402-0911-04 NDC inpatient 2 ML 67.7 67.7 CIGNA 62308 [3081051] CIGNA 62308 [308105105] 53.6 percent of total billed charges 41.97 64.32 Technical (Hospital) Services ARFORMOTEROL 15 MCG/2 ML SOLUTION FOR NEBULIZATION RX-77581 CDM J7605 HCPCS 636 RC 63402-0911-04 NDC inpatient 2 ML 67.7 67.7 CIGNA 62308 [3081051] CIGNA STATE OF WYOMING [308105107] 53.6 percent of total billed charges 41.97 64.32 Technical (Hospital) Services MYCOPHENOLATE MOFETIL 500 MG TABLET RX-21374 CDM J7517 HCPCS 636 RC 64380-0725-06 NDC outpatient 1 UN 6.02 6.02 MEDICA (COMMERCIAL) 94265 [3081118] MEDICA CLAIMS [308111801] 5.42 percent of total billed charges 3.73 5.72 Technical (Hospital) Services MYCOPHENOLATE MOFETIL 500 MG TABLET RX-21374 CDM J7517 HCPCS 636 RC 64380-0725-06 NDC outpatient 1 UN 6.02 6.02 CIGNA 62308 [3081051] CIGNA 62308 [308105105] 4.82 percent of total billed charges 3.73 5.72 Technical (Hospital) Services MYCOPHENOLATE MOFETIL 500 MG TABLET RX-21374 CDM J7517 HCPCS 636 RC 64380-0725-06 NDC outpatient 1 UN 6.02 6.02 CIGNA 62308 [3081051] CIGNA STATE OF WYOMING [308105107] 4.82 percent of total billed charges 3.73 5.72 Technical (Hospital) Services MYCOPHENOLATE MOFETIL 500 MG TABLET RX-21374 CDM J7517 HCPCS 636 RC 64380-0725-06 NDC outpatient 1 UN 6.02 6.02 HEALTHPARTNERS SX009 HEALTHPARTNERS 4.82 percent of total billed charges 3.73 5.72 Technical (Hospital) Services MYCOPHENOLATE MOFETIL 500 MG TABLET RX-21374 CDM J7517 HCPCS 636 RC 64380-0725-06 NDC outpatient 1 UN 6.02 6.02 UNITED HEALTHCARE (COMMERCIAL) [3081199] UNITED HEALTHCARE 87726 [308119901] 3.73 percent of total billed charges 3.73 5.72 Technical (Hospital) Services MYCOPHENOLATE MOFETIL 500 MG TABLET RX-21374 CDM J7517 HCPCS 636 RC 64380-0725-06 NDC outpatient 1 UN 6.02 6.02 MULTIPLAN INC 34080 [3081285] MULTIPLAN INC [308128501] 5.72 percent of total billed charges 3.73 5.72 Technical (Hospital) Services MYCOPHENOLATE MOFETIL 500 MG TABLET RX-21374 CDM J7517 HCPCS 636 RC 64380-0725-06 NDC outpatient 1 UN 6.02 6.02 BLUE CROSS BLUE SHIELD WELLMARK SB889 [3081026] BCBS WYOMING [308102603] 5.72 percent of total billed charges 3.73 5.72 Technical (Hospital) Services MYCOPHENOLATE MOFETIL 500 MG TABLET RX-21374 CDM J7517 HCPCS 636 RC 64380-0725-06 NDC outpatient 1 UN 6.02 6.02 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES PPO [308136801] 4.82 percent of total billed charges 3.73 5.72 Technical (Hospital) Services MYCOPHENOLATE MOFETIL 500 MG TABLET RX-21374 CDM J7517 HCPCS 636 RC 64380-0725-06 NDC outpatient 1 UN 6.02 6.02 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES HDHP [308136802] 4.82 percent of total billed charges 3.73 5.72 Technical (Hospital) Services MYCOPHENOLATE MOFETIL 500 MG TABLET RX-21374 CDM J7517 HCPCS 636 RC 64380-0725-06 NDC outpatient 1 UN 6.02 6.02 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES EPO [308136803] 4.82 percent of total billed charges 3.73 5.72 Technical (Hospital) Services MYCOPHENOLATE MOFETIL 500 MG TABLET RX-21374 CDM J7517 HCPCS 636 RC 64380-0725-06 NDC inpatient 1 UN 6.02 6.02 MEDICA (COMMERCIAL) 94265 [3081118] MEDICA CLAIMS [308111801] 5.42 percent of total billed charges 3.73 5.72 Technical (Hospital) Services MYCOPHENOLATE MOFETIL 500 MG TABLET RX-21374 CDM J7517 HCPCS 636 RC 64380-0725-06 NDC inpatient 1 UN 6.02 6.02 HEALTHPARTNERS SX009 HEALTHPARTNERS 4.77 percent of total billed charges 3.73 5.72 Technical (Hospital) Services MYCOPHENOLATE MOFETIL 500 MG TABLET RX-21374 CDM J7517 HCPCS 636 RC 64380-0725-06 NDC inpatient 1 UN 6.02 6.02 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES PPO [308136801] 4.77 percent of total billed charges 3.73 5.72 Technical (Hospital) Services MYCOPHENOLATE MOFETIL 500 MG TABLET RX-21374 CDM J7517 HCPCS 636 RC 64380-0725-06 NDC inpatient 1 UN 6.02 6.02 MULTIPLAN INC 34080 [3081285] MULTIPLAN INC [308128501] 5.72 percent of total billed charges 3.73 5.72 Technical (Hospital) Services MYCOPHENOLATE MOFETIL 500 MG TABLET RX-21374 CDM J7517 HCPCS 636 RC 64380-0725-06 NDC inpatient 1 UN 6.02 6.02 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES HDHP [308136802] 4.77 percent of total billed charges 3.73 5.72 Technical (Hospital) Services MYCOPHENOLATE MOFETIL 500 MG TABLET RX-21374 CDM J7517 HCPCS 636 RC 64380-0725-06 NDC inpatient 1 UN 6.02 6.02 UNITED HEALTHCARE (COMMERCIAL) [3081199] UNITED HEALTHCARE 87726 [308119901] 3.73 percent of total billed charges 3.73 5.72 Technical (Hospital) Services MYCOPHENOLATE MOFETIL 500 MG TABLET RX-21374 CDM J7517 HCPCS 636 RC 64380-0725-06 NDC inpatient 1 UN 6.02 6.02 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES EPO [308136803] 4.77 percent of total billed charges 3.73 5.72 Technical (Hospital) Services MYCOPHENOLATE MOFETIL 500 MG TABLET RX-21374 CDM J7517 HCPCS 636 RC 64380-0725-06 NDC inpatient 1 UN 6.02 6.02 CIGNA 62308 [3081051] CIGNA 62308 [308105105] 4.77 percent of total billed charges 3.73 5.72 Technical (Hospital) Services MYCOPHENOLATE MOFETIL 500 MG TABLET RX-21374 CDM J7517 HCPCS 636 RC 64380-0725-06 NDC inpatient 1 UN 6.02 6.02 CIGNA 62308 [3081051] CIGNA STATE OF WYOMING [308105107] 4.77 percent of total billed charges 3.73 5.72 Technical (Hospital) Services MYCOPHENOLATE MOFETIL 500 MG TABLET RX-21374 CDM J7517 HCPCS 636 RC 64380-0725-06 NDC inpatient 1 UN 6.02 6.02 BLUE CROSS BLUE SHIELD WELLMARK SB889 [3081026] BCBS WYOMING [308102603] 5.72 percent of total billed charges 3.73 5.72 Technical (Hospital) Services WCH ED PREDNISONE 10 MG TAB #12 RX-408840028 CDM J7512 HCPCS 636 RC 09999-9990-26 NDC outpatient 120 ME 15.85 15.85 MULTIPLAN INC 34080 [3081285] MULTIPLAN INC [308128501] 15.06 percent of total billed charges 9.83 15.06 Technical (Hospital) Services WCH ED PREDNISONE 10 MG TAB #12 RX-408840028 CDM J7512 HCPCS 636 RC 09999-9990-26 NDC outpatient 120 ME 15.85 15.85 MEDICA (COMMERCIAL) 94265 [3081118] MEDICA CLAIMS [308111801] 14.27 percent of total billed charges 9.83 15.06 Technical (Hospital) Services WCH ED PREDNISONE 10 MG TAB #12 RX-408840028 CDM J7512 HCPCS 636 RC 09999-9990-26 NDC outpatient 120 ME 15.85 15.85 CIGNA 62308 [3081051] CIGNA 62308 [308105105] 12.68 percent of total billed charges 9.83 15.06 Technical (Hospital) Services WCH ED PREDNISONE 10 MG TAB #12 RX-408840028 CDM J7512 HCPCS 636 RC 09999-9990-26 NDC outpatient 120 ME 15.85 15.85 CIGNA 62308 [3081051] CIGNA STATE OF WYOMING [308105107] 12.68 percent of total billed charges 9.83 15.06 Technical (Hospital) Services WCH ED PREDNISONE 10 MG TAB #12 RX-408840028 CDM J7512 HCPCS 636 RC 09999-9990-26 NDC outpatient 120 ME 15.85 15.85 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES EPO [308136803] 12.68 percent of total billed charges 9.83 15.06 Technical (Hospital) Services WCH ED PREDNISONE 10 MG TAB #12 RX-408840028 CDM J7512 HCPCS 636 RC 09999-9990-26 NDC outpatient 120 ME 15.85 15.85 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES HDHP [308136802] 12.68 percent of total billed charges 9.83 15.06 Technical (Hospital) Services WCH ED PREDNISONE 10 MG TAB #12 RX-408840028 CDM J7512 HCPCS 636 RC 09999-9990-26 NDC outpatient 120 ME 15.85 15.85 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES PPO [308136801] 12.68 percent of total billed charges 9.83 15.06 Technical (Hospital) Services WCH ED PREDNISONE 10 MG TAB #12 RX-408840028 CDM J7512 HCPCS 636 RC 09999-9990-26 NDC outpatient 120 ME 15.85 15.85 BLUE CROSS BLUE SHIELD WELLMARK SB889 [3081026] BCBS WYOMING [308102603] 15.06 percent of total billed charges 9.83 15.06 Technical (Hospital) Services WCH ED PREDNISONE 10 MG TAB #12 RX-408840028 CDM J7512 HCPCS 636 RC 09999-9990-26 NDC outpatient 120 ME 15.85 15.85 HEALTHPARTNERS SX009 HEALTHPARTNERS 12.68 percent of total billed charges 9.83 15.06 Technical (Hospital) Services WCH ED PREDNISONE 10 MG TAB #12 RX-408840028 CDM J7512 HCPCS 636 RC 09999-9990-26 NDC outpatient 120 ME 15.85 15.85 UNITED HEALTHCARE (COMMERCIAL) [3081199] UNITED HEALTHCARE 87726 [308119901] 9.83 percent of total billed charges 9.83 15.06 Technical (Hospital) Services WCH ED PREDNISONE 10 MG TAB #12 RX-408840028 CDM J7512 HCPCS 636 RC 09999-9990-26 NDC inpatient 120 ME 15.85 15.85 MULTIPLAN INC 34080 [3081285] MULTIPLAN INC [308128501] 15.06 percent of total billed charges 9.83 15.06 Technical (Hospital) Services WCH ED PREDNISONE 10 MG TAB #12 RX-408840028 CDM J7512 HCPCS 636 RC 09999-9990-26 NDC inpatient 120 ME 15.85 15.85 MEDICA (COMMERCIAL) 94265 [3081118] MEDICA CLAIMS [308111801] 14.27 percent of total billed charges 9.83 15.06 Technical (Hospital) Services WCH ED PREDNISONE 10 MG TAB #12 RX-408840028 CDM J7512 HCPCS 636 RC 09999-9990-26 NDC inpatient 120 ME 15.85 15.85 HEALTHPARTNERS SX009 HEALTHPARTNERS 12.55 percent of total billed charges 9.83 15.06 Technical (Hospital) Services WCH ED PREDNISONE 10 MG TAB #12 RX-408840028 CDM J7512 HCPCS 636 RC 09999-9990-26 NDC inpatient 120 ME 15.85 15.85 UNITED HEALTHCARE (COMMERCIAL) [3081199] UNITED HEALTHCARE 87726 [308119901] 9.83 percent of total billed charges 9.83 15.06 Technical (Hospital) Services WCH ED PREDNISONE 10 MG TAB #12 RX-408840028 CDM J7512 HCPCS 636 RC 09999-9990-26 NDC inpatient 120 ME 15.85 15.85 BLUE CROSS BLUE SHIELD WELLMARK SB889 [3081026] BCBS WYOMING [308102603] 15.06 percent of total billed charges 9.83 15.06 Technical (Hospital) Services WCH ED PREDNISONE 10 MG TAB #12 RX-408840028 CDM J7512 HCPCS 636 RC 09999-9990-26 NDC inpatient 120 ME 15.85 15.85 CIGNA 62308 [3081051] CIGNA 62308 [308105105] 12.55 percent of total billed charges 9.83 15.06 Technical (Hospital) Services WCH ED PREDNISONE 10 MG TAB #12 RX-408840028 CDM J7512 HCPCS 636 RC 09999-9990-26 NDC inpatient 120 ME 15.85 15.85 CIGNA 62308 [3081051] CIGNA STATE OF WYOMING [308105107] 12.55 percent of total billed charges 9.83 15.06 Technical (Hospital) Services WCH ED PREDNISONE 10 MG TAB #12 RX-408840028 CDM J7512 HCPCS 636 RC 09999-9990-26 NDC inpatient 120 ME 15.85 15.85 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES EPO [308136803] 12.55 percent of total billed charges 9.83 15.06 Technical (Hospital) Services WCH ED PREDNISONE 10 MG TAB #12 RX-408840028 CDM J7512 HCPCS 636 RC 09999-9990-26 NDC inpatient 120 ME 15.85 15.85 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES HDHP [308136802] 12.55 percent of total billed charges 9.83 15.06 Technical (Hospital) Services WCH ED PREDNISONE 10 MG TAB #12 RX-408840028 CDM J7512 HCPCS 636 RC 09999-9990-26 NDC inpatient 120 ME 15.85 15.85 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES PPO [308136801] 12.55 percent of total billed charges 9.83 15.06 Technical (Hospital) Services PREDNISONE 1 MG TABLET RX-6493 CDM J7512 HCPCS 636 RC 00603-5335-21 NDC inpatient 1 UN 5.82 5.82 BLUE CROSS BLUE SHIELD WELLMARK SB889 [3081026] BCBS WYOMING [308102603] 5.53 percent of total billed charges 3.61 5.53 Technical (Hospital) Services PREDNISONE 1 MG TABLET RX-6493 CDM J7512 HCPCS 636 RC 00603-5335-21 NDC inpatient 1 UN 5.82 5.82 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES EPO [308136803] 4.61 percent of total billed charges 3.61 5.53 Technical (Hospital) Services PREDNISONE 1 MG TABLET RX-6493 CDM J7512 HCPCS 636 RC 00603-5335-21 NDC inpatient 1 UN 5.82 5.82 UNITED HEALTHCARE (COMMERCIAL) [3081199] UNITED HEALTHCARE 87726 [308119901] 3.61 percent of total billed charges 3.61 5.53 Technical (Hospital) Services PREDNISONE 1 MG TABLET RX-6493 CDM J7512 HCPCS 636 RC 00603-5335-21 NDC inpatient 1 UN 5.82 5.82 HEALTHPARTNERS SX009 HEALTHPARTNERS 4.61 percent of total billed charges 3.61 5.53 Technical (Hospital) Services PREDNISONE 1 MG TABLET RX-6493 CDM J7512 HCPCS 636 RC 00603-5335-21 NDC inpatient 1 UN 5.82 5.82 CIGNA 62308 [3081051] CIGNA 62308 [308105105] 4.61 percent of total billed charges 3.61 5.53 Technical (Hospital) Services PREDNISONE 1 MG TABLET RX-6493 CDM J7512 HCPCS 636 RC 00603-5335-21 NDC inpatient 1 UN 5.82 5.82 CIGNA 62308 [3081051] CIGNA STATE OF WYOMING [308105107] 4.61 percent of total billed charges 3.61 5.53 Technical (Hospital) Services PREDNISONE 1 MG TABLET RX-6493 CDM J7512 HCPCS 636 RC 00603-5335-21 NDC inpatient 1 UN 5.82 5.82 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES HDHP [308136802] 4.61 percent of total billed charges 3.61 5.53 Technical (Hospital) Services PREDNISONE 1 MG TABLET RX-6493 CDM J7512 HCPCS 636 RC 00603-5335-21 NDC inpatient 1 UN 5.82 5.82 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES PPO [308136801] 4.61 percent of total billed charges 3.61 5.53 Technical (Hospital) Services PREDNISONE 1 MG TABLET RX-6493 CDM J7512 HCPCS 636 RC 00603-5335-21 NDC inpatient 1 UN 5.82 5.82 MEDICA (COMMERCIAL) 94265 [3081118] MEDICA CLAIMS [308111801] 5.24 percent of total billed charges 3.61 5.53 Technical (Hospital) Services PREDNISONE 1 MG TABLET RX-6493 CDM J7512 HCPCS 636 RC 00603-5335-21 NDC inpatient 1 UN 5.82 5.82 MULTIPLAN INC 34080 [3081285] MULTIPLAN INC [308128501] 5.53 percent of total billed charges 3.61 5.53 Technical (Hospital) Services PREDNISONE 1 MG TABLET RX-6493 CDM J7512 HCPCS 636 RC 00603-5335-21 NDC outpatient 1 UN 5.82 5.82 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES HDHP [308136802] 4.66 percent of total billed charges 3.61 5.53 Technical (Hospital) Services PREDNISONE 1 MG TABLET RX-6493 CDM J7512 HCPCS 636 RC 00603-5335-21 NDC outpatient 1 UN 5.82 5.82 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES EPO [308136803] 4.66 percent of total billed charges 3.61 5.53 Technical (Hospital) Services PREDNISONE 1 MG TABLET RX-6493 CDM J7512 HCPCS 636 RC 00603-5335-21 NDC outpatient 1 UN 5.82 5.82 MEDICA (COMMERCIAL) 94265 [3081118] MEDICA CLAIMS [308111801] 5.24 percent of total billed charges 3.61 5.53 Technical (Hospital) Services PREDNISONE 1 MG TABLET RX-6493 CDM J7512 HCPCS 636 RC 00603-5335-21 NDC outpatient 1 UN 5.82 5.82 CIGNA 62308 [3081051] CIGNA 62308 [308105105] 4.66 percent of total billed charges 3.61 5.53 Technical (Hospital) Services PREDNISONE 1 MG TABLET RX-6493 CDM J7512 HCPCS 636 RC 00603-5335-21 NDC outpatient 1 UN 5.82 5.82 CIGNA 62308 [3081051] CIGNA STATE OF WYOMING [308105107] 4.66 percent of total billed charges 3.61 5.53 Technical (Hospital) Services PREDNISONE 1 MG TABLET RX-6493 CDM J7512 HCPCS 636 RC 00603-5335-21 NDC outpatient 1 UN 5.82 5.82 MULTIPLAN INC 34080 [3081285] MULTIPLAN INC [308128501] 5.53 percent of total billed charges 3.61 5.53 Technical (Hospital) Services PREDNISONE 1 MG TABLET RX-6493 CDM J7512 HCPCS 636 RC 00603-5335-21 NDC outpatient 1 UN 5.82 5.82 UNITED HEALTHCARE (COMMERCIAL) [3081199] UNITED HEALTHCARE 87726 [308119901] 3.61 percent of total billed charges 3.61 5.53 Technical (Hospital) Services PREDNISONE 1 MG TABLET RX-6493 CDM J7512 HCPCS 636 RC 00603-5335-21 NDC outpatient 1 UN 5.82 5.82 HEALTHPARTNERS SX009 HEALTHPARTNERS 4.66 percent of total billed charges 3.61 5.53 Technical (Hospital) Services PREDNISONE 1 MG TABLET RX-6493 CDM J7512 HCPCS 636 RC 00603-5335-21 NDC outpatient 1 UN 5.82 5.82 BLUE CROSS BLUE SHIELD WELLMARK SB889 [3081026] BCBS WYOMING [308102603] 5.53 percent of total billed charges 3.61 5.53 Technical (Hospital) Services PREDNISONE 1 MG TABLET RX-6493 CDM J7512 HCPCS 636 RC 00603-5335-21 NDC outpatient 1 UN 5.82 5.82 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES PPO [308136801] 4.66 percent of total billed charges 3.61 5.53 Technical (Hospital) Services PREDNISONE 10 MG TABLET RX-6494 CDM J7512 HCPCS 636 RC 00054-9817-25 NDC inpatient 1 UN 5.81 5.81 MULTIPLAN INC 34080 [3081285] MULTIPLAN INC [308128501] 5.52 percent of total billed charges 3.6 5.52 Technical (Hospital) Services PREDNISONE 10 MG TABLET RX-6494 CDM J7512 HCPCS 636 RC 00054-9817-25 NDC inpatient 1 UN 5.81 5.81 MEDICA (COMMERCIAL) 94265 [3081118] MEDICA CLAIMS [308111801] 5.23 percent of total billed charges 3.6 5.52 Technical (Hospital) Services PREDNISONE 10 MG TABLET RX-6494 CDM J7512 HCPCS 636 RC 00054-9817-25 NDC inpatient 1 UN 5.81 5.81 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES PPO [308136801] 4.6 percent of total billed charges 3.6 5.52 Technical (Hospital) Services PREDNISONE 10 MG TABLET RX-6494 CDM J7512 HCPCS 636 RC 00054-9817-25 NDC inpatient 1 UN 5.81 5.81 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES HDHP [308136802] 4.6 percent of total billed charges 3.6 5.52 Technical (Hospital) Services PREDNISONE 10 MG TABLET RX-6494 CDM J7512 HCPCS 636 RC 00054-9817-25 NDC inpatient 1 UN 5.81 5.81 CIGNA 62308 [3081051] CIGNA 62308 [308105105] 4.6 percent of total billed charges 3.6 5.52 Technical (Hospital) Services PREDNISONE 10 MG TABLET RX-6494 CDM J7512 HCPCS 636 RC 00054-9817-25 NDC inpatient 1 UN 5.81 5.81 CIGNA 62308 [3081051] CIGNA STATE OF WYOMING [308105107] 4.6 percent of total billed charges 3.6 5.52 Technical (Hospital) Services PREDNISONE 10 MG TABLET RX-6494 CDM J7512 HCPCS 636 RC 00054-9817-25 NDC inpatient 1 UN 5.81 5.81 HEALTHPARTNERS SX009 HEALTHPARTNERS 4.6 percent of total billed charges 3.6 5.52 Technical (Hospital) Services PREDNISONE 10 MG TABLET RX-6494 CDM J7512 HCPCS 636 RC 00054-9817-25 NDC inpatient 1 UN 5.81 5.81 UNITED HEALTHCARE (COMMERCIAL) [3081199] UNITED HEALTHCARE 87726 [308119901] 3.6 percent of total billed charges 3.6 5.52 Technical (Hospital) Services PREDNISONE 10 MG TABLET RX-6494 CDM J7512 HCPCS 636 RC 00054-9817-25 NDC inpatient 1 UN 5.81 5.81 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES EPO [308136803] 4.6 percent of total billed charges 3.6 5.52 Technical (Hospital) Services PREDNISONE 10 MG TABLET RX-6494 CDM J7512 HCPCS 636 RC 00054-9817-25 NDC inpatient 1 UN 5.81 5.81 BLUE CROSS BLUE SHIELD WELLMARK SB889 [3081026] BCBS WYOMING [308102603] 5.52 percent of total billed charges 3.6 5.52 Technical (Hospital) Services PREDNISONE 10 MG TABLET RX-6494 CDM J7512 HCPCS 636 RC 00054-9817-25 NDC outpatient 1 UN 5.81 5.81 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES PPO [308136801] 4.65 percent of total billed charges 3.6 5.52 Technical (Hospital) Services PREDNISONE 10 MG TABLET RX-6494 CDM J7512 HCPCS 636 RC 00054-9817-25 NDC outpatient 1 UN 5.81 5.81 BLUE CROSS BLUE SHIELD WELLMARK SB889 [3081026] BCBS WYOMING [308102603] 5.52 percent of total billed charges 3.6 5.52 Technical (Hospital) Services PREDNISONE 10 MG TABLET RX-6494 CDM J7512 HCPCS 636 RC 00054-9817-25 NDC outpatient 1 UN 5.81 5.81 HEALTHPARTNERS SX009 HEALTHPARTNERS 4.65 percent of total billed charges 3.6 5.52 Technical (Hospital) Services PREDNISONE 10 MG TABLET RX-6494 CDM J7512 HCPCS 636 RC 00054-9817-25 NDC outpatient 1 UN 5.81 5.81 UNITED HEALTHCARE (COMMERCIAL) [3081199] UNITED HEALTHCARE 87726 [308119901] 3.6 percent of total billed charges 3.6 5.52 Technical (Hospital) Services PREDNISONE 10 MG TABLET RX-6494 CDM J7512 HCPCS 636 RC 00054-9817-25 NDC outpatient 1 UN 5.81 5.81 MULTIPLAN INC 34080 [3081285] MULTIPLAN INC [308128501] 5.52 percent of total billed charges 3.6 5.52 Technical (Hospital) Services PREDNISONE 10 MG TABLET RX-6494 CDM J7512 HCPCS 636 RC 00054-9817-25 NDC outpatient 1 UN 5.81 5.81 CIGNA 62308 [3081051] CIGNA 62308 [308105105] 4.65 percent of total billed charges 3.6 5.52 Technical (Hospital) Services PREDNISONE 10 MG TABLET RX-6494 CDM J7512 HCPCS 636 RC 00054-9817-25 NDC outpatient 1 UN 5.81 5.81 CIGNA 62308 [3081051] CIGNA STATE OF WYOMING [308105107] 4.65 percent of total billed charges 3.6 5.52 Technical (Hospital) Services PREDNISONE 10 MG TABLET RX-6494 CDM J7512 HCPCS 636 RC 00054-9817-25 NDC outpatient 1 UN 5.81 5.81 MEDICA (COMMERCIAL) 94265 [3081118] MEDICA CLAIMS [308111801] 5.23 percent of total billed charges 3.6 5.52 Technical (Hospital) Services PREDNISONE 10 MG TABLET RX-6494 CDM J7512 HCPCS 636 RC 00054-9817-25 NDC outpatient 1 UN 5.81 5.81 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES EPO [308136803] 4.65 percent of total billed charges 3.6 5.52 Technical (Hospital) Services PREDNISONE 10 MG TABLET RX-6494 CDM J7512 HCPCS 636 RC 00054-9817-25 NDC outpatient 1 UN 5.81 5.81 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES HDHP [308136802] 4.65 percent of total billed charges 3.6 5.52 Technical (Hospital) Services PREDNISONE 20 MG TABLET RX-6496 CDM J7512 HCPCS 636 RC 00904-7127-61 NDC inpatient 1 UN 5.79 5.79 CIGNA 62308 [3081051] CIGNA 62308 [308105105] 4.58 percent of total billed charges 3.59 5.5 Technical (Hospital) Services PREDNISONE 20 MG TABLET RX-6496 CDM J7512 HCPCS 636 RC 00904-7127-61 NDC inpatient 1 UN 5.79 5.79 CIGNA 62308 [3081051] CIGNA STATE OF WYOMING [308105107] 4.58 percent of total billed charges 3.59 5.5 Technical (Hospital) Services PREDNISONE 20 MG TABLET RX-6496 CDM J7512 HCPCS 636 RC 00904-7127-61 NDC inpatient 1 UN 5.79 5.79 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES EPO [308136803] 4.58 percent of total billed charges 3.59 5.5 Technical (Hospital) Services PREDNISONE 20 MG TABLET RX-6496 CDM J7512 HCPCS 636 RC 00904-7127-61 NDC inpatient 1 UN 5.79 5.79 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES HDHP [308136802] 4.58 percent of total billed charges 3.59 5.5 Technical (Hospital) Services PREDNISONE 20 MG TABLET RX-6496 CDM J7512 HCPCS 636 RC 00904-7127-61 NDC inpatient 1 UN 5.79 5.79 BLUE CROSS BLUE SHIELD WELLMARK SB889 [3081026] BCBS WYOMING [308102603] 5.5 percent of total billed charges 3.59 5.5 Technical (Hospital) Services PREDNISONE 20 MG TABLET RX-6496 CDM J7512 HCPCS 636 RC 00904-7127-61 NDC inpatient 1 UN 5.79 5.79 UNITED HEALTHCARE (COMMERCIAL) [3081199] UNITED HEALTHCARE 87726 [308119901] 3.59 percent of total billed charges 3.59 5.5 Technical (Hospital) Services PREDNISONE 20 MG TABLET RX-6496 CDM J7512 HCPCS 636 RC 00904-7127-61 NDC inpatient 1 UN 5.79 5.79 MEDICA (COMMERCIAL) 94265 [3081118] MEDICA CLAIMS [308111801] 5.21 percent of total billed charges 3.59 5.5 Technical (Hospital) Services PREDNISONE 20 MG TABLET RX-6496 CDM J7512 HCPCS 636 RC 00904-7127-61 NDC inpatient 1 UN 5.79 5.79 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES PPO [308136801] 4.58 percent of total billed charges 3.59 5.5 Technical (Hospital) Services PREDNISONE 20 MG TABLET RX-6496 CDM J7512 HCPCS 636 RC 00904-7127-61 NDC inpatient 1 UN 5.79 5.79 HEALTHPARTNERS SX009 HEALTHPARTNERS 4.58 percent of total billed charges 3.59 5.5 Technical (Hospital) Services PREDNISONE 20 MG TABLET RX-6496 CDM J7512 HCPCS 636 RC 00904-7127-61 NDC inpatient 1 UN 5.79 5.79 MULTIPLAN INC 34080 [3081285] MULTIPLAN INC [308128501] 5.5 percent of total billed charges 3.59 5.5 Technical (Hospital) Services PREDNISONE 20 MG TABLET RX-6496 CDM J7512 HCPCS 636 RC 00904-7127-61 NDC outpatient 1 UN 5.79 5.79 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES PPO [308136801] 4.63 percent of total billed charges 3.59 5.5 Technical (Hospital) Services PREDNISONE 20 MG TABLET RX-6496 CDM J7512 HCPCS 636 RC 00904-7127-61 NDC outpatient 1 UN 5.79 5.79 BLUE CROSS BLUE SHIELD WELLMARK SB889 [3081026] BCBS WYOMING [308102603] 5.5 percent of total billed charges 3.59 5.5 Technical (Hospital) Services PREDNISONE 20 MG TABLET RX-6496 CDM J7512 HCPCS 636 RC 00904-7127-61 NDC outpatient 1 UN 5.79 5.79 HEALTHPARTNERS SX009 HEALTHPARTNERS 4.63 percent of total billed charges 3.59 5.5 Technical (Hospital) Services PREDNISONE 20 MG TABLET RX-6496 CDM J7512 HCPCS 636 RC 00904-7127-61 NDC outpatient 1 UN 5.79 5.79 MULTIPLAN INC 34080 [3081285] MULTIPLAN INC [308128501] 5.5 percent of total billed charges 3.59 5.5 Technical (Hospital) Services PREDNISONE 20 MG TABLET RX-6496 CDM J7512 HCPCS 636 RC 00904-7127-61 NDC outpatient 1 UN 5.79 5.79 UNITED HEALTHCARE (COMMERCIAL) [3081199] UNITED HEALTHCARE 87726 [308119901] 3.59 percent of total billed charges 3.59 5.5 Technical (Hospital) Services PREDNISONE 20 MG TABLET RX-6496 CDM J7512 HCPCS 636 RC 00904-7127-61 NDC outpatient 1 UN 5.79 5.79 MEDICA (COMMERCIAL) 94265 [3081118] MEDICA CLAIMS [308111801] 5.21 percent of total billed charges 3.59 5.5 Technical (Hospital) Services PREDNISONE 20 MG TABLET RX-6496 CDM J7512 HCPCS 636 RC 00904-7127-61 NDC outpatient 1 UN 5.79 5.79 CIGNA 62308 [3081051] CIGNA 62308 [308105105] 4.63 percent of total billed charges 3.59 5.5 Technical (Hospital) Services PREDNISONE 20 MG TABLET RX-6496 CDM J7512 HCPCS 636 RC 00904-7127-61 NDC outpatient 1 UN 5.79 5.79 CIGNA 62308 [3081051] CIGNA STATE OF WYOMING [308105107] 4.63 percent of total billed charges 3.59 5.5 Technical (Hospital) Services PREDNISONE 20 MG TABLET RX-6496 CDM J7512 HCPCS 636 RC 00904-7127-61 NDC outpatient 1 UN 5.79 5.79 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES HDHP [308136802] 4.63 percent of total billed charges 3.59 5.5 Technical (Hospital) Services PREDNISONE 20 MG TABLET RX-6496 CDM J7512 HCPCS 636 RC 00904-7127-61 NDC outpatient 1 UN 5.79 5.79 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES EPO [308136803] 4.63 percent of total billed charges 3.59 5.5 Technical (Hospital) Services PREDNISONE 5 MG TABLET RX-6497 CDM J7512 HCPCS 636 RC 00054-4728-25 NDC outpatient 1 UN 5.8 5.8 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES PPO [308136801] 4.64 percent of total billed charges 3.6 5.51 Technical (Hospital) Services PREDNISONE 5 MG TABLET RX-6497 CDM J7512 HCPCS 636 RC 00054-4728-25 NDC outpatient 1 UN 5.8 5.8 BLUE CROSS BLUE SHIELD WELLMARK SB889 [3081026] BCBS WYOMING [308102603] 5.51 percent of total billed charges 3.6 5.51 Technical (Hospital) Services PREDNISONE 5 MG TABLET RX-6497 CDM J7512 HCPCS 636 RC 00054-4728-25 NDC outpatient 1 UN 5.8 5.8 CIGNA 62308 [3081051] CIGNA 62308 [308105105] 4.64 percent of total billed charges 3.6 5.51 Technical (Hospital) Services PREDNISONE 5 MG TABLET RX-6497 CDM J7512 HCPCS 636 RC 00054-4728-25 NDC outpatient 1 UN 5.8 5.8 CIGNA 62308 [3081051] CIGNA STATE OF WYOMING [308105107] 4.64 percent of total billed charges 3.6 5.51 Technical (Hospital) Services PREDNISONE 5 MG TABLET RX-6497 CDM J7512 HCPCS 636 RC 00054-4728-25 NDC outpatient 1 UN 5.8 5.8 MEDICA (COMMERCIAL) 94265 [3081118] MEDICA CLAIMS [308111801] 5.22 percent of total billed charges 3.6 5.51 Technical (Hospital) Services PREDNISONE 5 MG TABLET RX-6497 CDM J7512 HCPCS 636 RC 00054-4728-25 NDC outpatient 1 UN 5.8 5.8 MULTIPLAN INC 34080 [3081285] MULTIPLAN INC [308128501] 5.51 percent of total billed charges 3.6 5.51 Technical (Hospital) Services PREDNISONE 5 MG TABLET RX-6497 CDM J7512 HCPCS 636 RC 00054-4728-25 NDC outpatient 1 UN 5.8 5.8 UNITED HEALTHCARE (COMMERCIAL) [3081199] UNITED HEALTHCARE 87726 [308119901] 3.6 percent of total billed charges 3.6 5.51 Technical (Hospital) Services PREDNISONE 5 MG TABLET RX-6497 CDM J7512 HCPCS 636 RC 00054-4728-25 NDC outpatient 1 UN 5.8 5.8 HEALTHPARTNERS SX009 HEALTHPARTNERS 4.64 percent of total billed charges 3.6 5.51 Technical (Hospital) Services PREDNISONE 5 MG TABLET RX-6497 CDM J7512 HCPCS 636 RC 00054-4728-25 NDC outpatient 1 UN 5.8 5.8 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES EPO [308136803] 4.64 percent of total billed charges 3.6 5.51 Technical (Hospital) Services PREDNISONE 5 MG TABLET RX-6497 CDM J7512 HCPCS 636 RC 00054-4728-25 NDC outpatient 1 UN 5.8 5.8 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES HDHP [308136802] 4.64 percent of total billed charges 3.6 5.51 Technical (Hospital) Services PREDNISONE 5 MG TABLET RX-6497 CDM J7512 HCPCS 636 RC 00054-4728-25 NDC inpatient 1 UN 5.8 5.8 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES EPO [308136803] 4.59 percent of total billed charges 3.6 5.51 Technical (Hospital) Services PREDNISONE 5 MG TABLET RX-6497 CDM J7512 HCPCS 636 RC 00054-4728-25 NDC inpatient 1 UN 5.8 5.8 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES HDHP [308136802] 4.59 percent of total billed charges 3.6 5.51 Technical (Hospital) Services PREDNISONE 5 MG TABLET RX-6497 CDM J7512 HCPCS 636 RC 00054-4728-25 NDC inpatient 1 UN 5.8 5.8 CIGNA 62308 [3081051] CIGNA 62308 [308105105] 4.59 percent of total billed charges 3.6 5.51 Technical (Hospital) Services PREDNISONE 5 MG TABLET RX-6497 CDM J7512 HCPCS 636 RC 00054-4728-25 NDC inpatient 1 UN 5.8 5.8 CIGNA 62308 [3081051] CIGNA STATE OF WYOMING [308105107] 4.59 percent of total billed charges 3.6 5.51 Technical (Hospital) Services PREDNISONE 5 MG TABLET RX-6497 CDM J7512 HCPCS 636 RC 00054-4728-25 NDC inpatient 1 UN 5.8 5.8 UNITED HEALTHCARE (COMMERCIAL) [3081199] UNITED HEALTHCARE 87726 [308119901] 3.6 percent of total billed charges 3.6 5.51 Technical (Hospital) Services PREDNISONE 5 MG TABLET RX-6497 CDM J7512 HCPCS 636 RC 00054-4728-25 NDC inpatient 1 UN 5.8 5.8 BLUE CROSS BLUE SHIELD WELLMARK SB889 [3081026] BCBS WYOMING [308102603] 5.51 percent of total billed charges 3.6 5.51 Technical (Hospital) Services PREDNISONE 5 MG TABLET RX-6497 CDM J7512 HCPCS 636 RC 00054-4728-25 NDC inpatient 1 UN 5.8 5.8 MULTIPLAN INC 34080 [3081285] MULTIPLAN INC [308128501] 5.51 percent of total billed charges 3.6 5.51 Technical (Hospital) Services PREDNISONE 5 MG TABLET RX-6497 CDM J7512 HCPCS 636 RC 00054-4728-25 NDC inpatient 1 UN 5.8 5.8 HEALTHPARTNERS SX009 HEALTHPARTNERS 4.59 percent of total billed charges 3.6 5.51 Technical (Hospital) Services PREDNISONE 5 MG TABLET RX-6497 CDM J7512 HCPCS 636 RC 00054-4728-25 NDC inpatient 1 UN 5.8 5.8 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES PPO [308136801] 4.59 percent of total billed charges 3.6 5.51 Technical (Hospital) Services PREDNISONE 5 MG TABLET RX-6497 CDM J7512 HCPCS 636 RC 00054-4728-25 NDC inpatient 1 UN 5.8 5.8 MEDICA (COMMERCIAL) 94265 [3081118] MEDICA CLAIMS [308111801] 5.22 percent of total billed charges 3.6 5.51 Technical (Hospital) Services PREDNISOLONE SODIUM PHOSPHATE 15 MG/5 ML (3 MG/ML) ORAL SOLUTION RX-29302 CDM J7510 HCPCS 636 RC 00121-0759-08 NDC inpatient 237 ML 191.9 191.9 MEDICA (COMMERCIAL) 94265 [3081118] MEDICA CLAIMS [308111801] 172.71 percent of total billed charges 118.98 182.31 Technical (Hospital) Services PREDNISOLONE SODIUM PHOSPHATE 15 MG/5 ML (3 MG/ML) ORAL SOLUTION RX-29302 CDM J7510 HCPCS 636 RC 00121-0759-08 NDC inpatient 237 ML 191.9 191.9 MULTIPLAN INC 34080 [3081285] MULTIPLAN INC [308128501] 182.31 percent of total billed charges 118.98 182.31 Technical (Hospital) Services PREDNISOLONE SODIUM PHOSPHATE 15 MG/5 ML (3 MG/ML) ORAL SOLUTION RX-29302 CDM J7510 HCPCS 636 RC 00121-0759-08 NDC inpatient 237 ML 191.9 191.9 HEALTHPARTNERS SX009 HEALTHPARTNERS 151.95 percent of total billed charges 118.98 182.31 Technical (Hospital) Services PREDNISOLONE SODIUM PHOSPHATE 15 MG/5 ML (3 MG/ML) ORAL SOLUTION RX-29302 CDM J7510 HCPCS 636 RC 00121-0759-08 NDC inpatient 237 ML 191.9 191.9 BLUE CROSS BLUE SHIELD WELLMARK SB889 [3081026] BCBS WYOMING [308102603] 182.31 percent of total billed charges 118.98 182.31 Technical (Hospital) Services PREDNISOLONE SODIUM PHOSPHATE 15 MG/5 ML (3 MG/ML) ORAL SOLUTION RX-29302 CDM J7510 HCPCS 636 RC 00121-0759-08 NDC inpatient 237 ML 191.9 191.9 UNITED HEALTHCARE (COMMERCIAL) [3081199] UNITED HEALTHCARE 87726 [308119901] 118.98 percent of total billed charges 118.98 182.31 Technical (Hospital) Services PREDNISOLONE SODIUM PHOSPHATE 15 MG/5 ML (3 MG/ML) ORAL SOLUTION RX-29302 CDM J7510 HCPCS 636 RC 00121-0759-08 NDC inpatient 237 ML 191.9 191.9 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES EPO [308136803] 151.95 percent of total billed charges 118.98 182.31 Technical (Hospital) Services PREDNISOLONE SODIUM PHOSPHATE 15 MG/5 ML (3 MG/ML) ORAL SOLUTION RX-29302 CDM J7510 HCPCS 636 RC 00121-0759-08 NDC inpatient 237 ML 191.9 191.9 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES HDHP [308136802] 151.95 percent of total billed charges 118.98 182.31 Technical (Hospital) Services PREDNISOLONE SODIUM PHOSPHATE 15 MG/5 ML (3 MG/ML) ORAL SOLUTION RX-29302 CDM J7510 HCPCS 636 RC 00121-0759-08 NDC inpatient 237 ML 191.9 191.9 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES PPO [308136801] 151.95 percent of total billed charges 118.98 182.31 Technical (Hospital) Services PREDNISOLONE SODIUM PHOSPHATE 15 MG/5 ML (3 MG/ML) ORAL SOLUTION RX-29302 CDM J7510 HCPCS 636 RC 00121-0759-08 NDC inpatient 237 ML 191.9 191.9 CIGNA 62308 [3081051] CIGNA 62308 [308105105] 151.95 percent of total billed charges 118.98 182.31 Technical (Hospital) Services PREDNISOLONE SODIUM PHOSPHATE 15 MG/5 ML (3 MG/ML) ORAL SOLUTION RX-29302 CDM J7510 HCPCS 636 RC 00121-0759-08 NDC inpatient 237 ML 191.9 191.9 CIGNA 62308 [3081051] CIGNA STATE OF WYOMING [308105107] 151.95 percent of total billed charges 118.98 182.31 Technical (Hospital) Services PREDNISOLONE SODIUM PHOSPHATE 15 MG/5 ML (3 MG/ML) ORAL SOLUTION RX-29302 CDM J7510 HCPCS 636 RC 00121-0759-08 NDC outpatient 237 ML 191.9 191.9 BLUE CROSS BLUE SHIELD WELLMARK SB889 [3081026] BCBS WYOMING [308102603] 182.31 percent of total billed charges 118.98 182.31 Technical (Hospital) Services PREDNISOLONE SODIUM PHOSPHATE 15 MG/5 ML (3 MG/ML) ORAL SOLUTION RX-29302 CDM J7510 HCPCS 636 RC 00121-0759-08 NDC outpatient 237 ML 191.9 191.9 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES EPO [308136803] 153.52 percent of total billed charges 118.98 182.31 Technical (Hospital) Services PREDNISOLONE SODIUM PHOSPHATE 15 MG/5 ML (3 MG/ML) ORAL SOLUTION RX-29302 CDM J7510 HCPCS 636 RC 00121-0759-08 NDC outpatient 237 ML 191.9 191.9 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES HDHP [308136802] 153.52 percent of total billed charges 118.98 182.31 Technical (Hospital) Services PREDNISOLONE SODIUM PHOSPHATE 15 MG/5 ML (3 MG/ML) ORAL SOLUTION RX-29302 CDM J7510 HCPCS 636 RC 00121-0759-08 NDC outpatient 237 ML 191.9 191.9 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES PPO [308136801] 153.52 percent of total billed charges 118.98 182.31 Technical (Hospital) Services PREDNISOLONE SODIUM PHOSPHATE 15 MG/5 ML (3 MG/ML) ORAL SOLUTION RX-29302 CDM J7510 HCPCS 636 RC 00121-0759-08 NDC outpatient 237 ML 191.9 191.9 HEALTHPARTNERS SX009 HEALTHPARTNERS 153.52 percent of total billed charges 118.98 182.31 Technical (Hospital) Services PREDNISOLONE SODIUM PHOSPHATE 15 MG/5 ML (3 MG/ML) ORAL SOLUTION RX-29302 CDM J7510 HCPCS 636 RC 00121-0759-08 NDC outpatient 237 ML 191.9 191.9 UNITED HEALTHCARE (COMMERCIAL) [3081199] UNITED HEALTHCARE 87726 [308119901] 118.98 percent of total billed charges 118.98 182.31 Technical (Hospital) Services PREDNISOLONE SODIUM PHOSPHATE 15 MG/5 ML (3 MG/ML) ORAL SOLUTION RX-29302 CDM J7510 HCPCS 636 RC 00121-0759-08 NDC outpatient 237 ML 191.9 191.9 MEDICA (COMMERCIAL) 94265 [3081118] MEDICA CLAIMS [308111801] 172.71 percent of total billed charges 118.98 182.31 Technical (Hospital) Services PREDNISOLONE SODIUM PHOSPHATE 15 MG/5 ML (3 MG/ML) ORAL SOLUTION RX-29302 CDM J7510 HCPCS 636 RC 00121-0759-08 NDC outpatient 237 ML 191.9 191.9 MULTIPLAN INC 34080 [3081285] MULTIPLAN INC [308128501] 182.31 percent of total billed charges 118.98 182.31 Technical (Hospital) Services PREDNISOLONE SODIUM PHOSPHATE 15 MG/5 ML (3 MG/ML) ORAL SOLUTION RX-29302 CDM J7510 HCPCS 636 RC 00121-0759-08 NDC outpatient 237 ML 191.9 191.9 CIGNA 62308 [3081051] CIGNA 62308 [308105105] 153.52 percent of total billed charges 118.98 182.31 Technical (Hospital) Services PREDNISOLONE SODIUM PHOSPHATE 15 MG/5 ML (3 MG/ML) ORAL SOLUTION RX-29302 CDM J7510 HCPCS 636 RC 00121-0759-08 NDC outpatient 237 ML 191.9 191.9 CIGNA 62308 [3081051] CIGNA STATE OF WYOMING [308105107] 153.52 percent of total billed charges 118.98 182.31 Technical (Hospital) Services WCH ED PREDNISOLONE 15MG/5ML ORAL LIQUID #30ML RX-408840037 CDM J7510 HCPCS 636 RC 09999-9990-25 NDC outpatient 90 ME 16.48 16.48 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES EPO [308136803] 13.18 percent of total billed charges 10.22 15.66 Technical (Hospital) Services WCH ED PREDNISOLONE 15MG/5ML ORAL LIQUID #30ML RX-408840037 CDM J7510 HCPCS 636 RC 09999-9990-25 NDC outpatient 90 ME 16.48 16.48 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES HDHP [308136802] 13.18 percent of total billed charges 10.22 15.66 Technical (Hospital) Services WCH ED PREDNISOLONE 15MG/5ML ORAL LIQUID #30ML RX-408840037 CDM J7510 HCPCS 636 RC 09999-9990-25 NDC outpatient 90 ME 16.48 16.48 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES PPO [308136801] 13.18 percent of total billed charges 10.22 15.66 Technical (Hospital) Services WCH ED PREDNISOLONE 15MG/5ML ORAL LIQUID #30ML RX-408840037 CDM J7510 HCPCS 636 RC 09999-9990-25 NDC outpatient 90 ME 16.48 16.48 BLUE CROSS BLUE SHIELD WELLMARK SB889 [3081026] BCBS WYOMING [308102603] 15.66 percent of total billed charges 10.22 15.66 Technical (Hospital) Services WCH ED PREDNISOLONE 15MG/5ML ORAL LIQUID #30ML RX-408840037 CDM J7510 HCPCS 636 RC 09999-9990-25 NDC outpatient 90 ME 16.48 16.48 UNITED HEALTHCARE (COMMERCIAL) [3081199] UNITED HEALTHCARE 87726 [308119901] 10.22 percent of total billed charges 10.22 15.66 Technical (Hospital) Services WCH ED PREDNISOLONE 15MG/5ML ORAL LIQUID #30ML RX-408840037 CDM J7510 HCPCS 636 RC 09999-9990-25 NDC outpatient 90 ME 16.48 16.48 HEALTHPARTNERS SX009 HEALTHPARTNERS 13.18 percent of total billed charges 10.22 15.66 Technical (Hospital) Services WCH ED PREDNISOLONE 15MG/5ML ORAL LIQUID #30ML RX-408840037 CDM J7510 HCPCS 636 RC 09999-9990-25 NDC outpatient 90 ME 16.48 16.48 MULTIPLAN INC 34080 [3081285] MULTIPLAN INC [308128501] 15.66 percent of total billed charges 10.22 15.66 Technical (Hospital) Services WCH ED PREDNISOLONE 15MG/5ML ORAL LIQUID #30ML RX-408840037 CDM J7510 HCPCS 636 RC 09999-9990-25 NDC outpatient 90 ME 16.48 16.48 MEDICA (COMMERCIAL) 94265 [3081118] MEDICA CLAIMS [308111801] 14.83 percent of total billed charges 10.22 15.66 Technical (Hospital) Services WCH ED PREDNISOLONE 15MG/5ML ORAL LIQUID #30ML RX-408840037 CDM J7510 HCPCS 636 RC 09999-9990-25 NDC outpatient 90 ME 16.48 16.48 CIGNA 62308 [3081051] CIGNA 62308 [308105105] 13.18 percent of total billed charges 10.22 15.66 Technical (Hospital) Services WCH ED PREDNISOLONE 15MG/5ML ORAL LIQUID #30ML RX-408840037 CDM J7510 HCPCS 636 RC 09999-9990-25 NDC outpatient 90 ME 16.48 16.48 CIGNA 62308 [3081051] CIGNA STATE OF WYOMING [308105107] 13.18 percent of total billed charges 10.22 15.66 Technical (Hospital) Services WCH ED PREDNISOLONE 15MG/5ML ORAL LIQUID #30ML RX-408840037 CDM J7510 HCPCS 636 RC 09999-9990-25 NDC inpatient 90 ME 16.48 16.48 BLUE CROSS BLUE SHIELD WELLMARK SB889 [3081026] BCBS WYOMING [308102603] 15.66 percent of total billed charges 10.22 15.66 Technical (Hospital) Services WCH ED PREDNISOLONE 15MG/5ML ORAL LIQUID #30ML RX-408840037 CDM J7510 HCPCS 636 RC 09999-9990-25 NDC inpatient 90 ME 16.48 16.48 UNITED HEALTHCARE (COMMERCIAL) [3081199] UNITED HEALTHCARE 87726 [308119901] 10.22 percent of total billed charges 10.22 15.66 Technical (Hospital) Services WCH ED PREDNISOLONE 15MG/5ML ORAL LIQUID #30ML RX-408840037 CDM J7510 HCPCS 636 RC 09999-9990-25 NDC inpatient 90 ME 16.48 16.48 HEALTHPARTNERS SX009 HEALTHPARTNERS 13.05 percent of total billed charges 10.22 15.66 Technical (Hospital) Services WCH ED PREDNISOLONE 15MG/5ML ORAL LIQUID #30ML RX-408840037 CDM J7510 HCPCS 636 RC 09999-9990-25 NDC inpatient 90 ME 16.48 16.48 MEDICA (COMMERCIAL) 94265 [3081118] MEDICA CLAIMS [308111801] 14.83 percent of total billed charges 10.22 15.66 Technical (Hospital) Services WCH ED PREDNISOLONE 15MG/5ML ORAL LIQUID #30ML RX-408840037 CDM J7510 HCPCS 636 RC 09999-9990-25 NDC inpatient 90 ME 16.48 16.48 MULTIPLAN INC 34080 [3081285] MULTIPLAN INC [308128501] 15.66 percent of total billed charges 10.22 15.66 Technical (Hospital) Services WCH ED PREDNISOLONE 15MG/5ML ORAL LIQUID #30ML RX-408840037 CDM J7510 HCPCS 636 RC 09999-9990-25 NDC inpatient 90 ME 16.48 16.48 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES EPO [308136803] 13.05 percent of total billed charges 10.22 15.66 Technical (Hospital) Services WCH ED PREDNISOLONE 15MG/5ML ORAL LIQUID #30ML RX-408840037 CDM J7510 HCPCS 636 RC 09999-9990-25 NDC inpatient 90 ME 16.48 16.48 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES HDHP [308136802] 13.05 percent of total billed charges 10.22 15.66 Technical (Hospital) Services WCH ED PREDNISOLONE 15MG/5ML ORAL LIQUID #30ML RX-408840037 CDM J7510 HCPCS 636 RC 09999-9990-25 NDC inpatient 90 ME 16.48 16.48 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES PPO [308136801] 13.05 percent of total billed charges 10.22 15.66 Technical (Hospital) Services WCH ED PREDNISOLONE 15MG/5ML ORAL LIQUID #30ML RX-408840037 CDM J7510 HCPCS 636 RC 09999-9990-25 NDC inpatient 90 ME 16.48 16.48 CIGNA 62308 [3081051] CIGNA 62308 [308105105] 13.05 percent of total billed charges 10.22 15.66 Technical (Hospital) Services WCH ED PREDNISOLONE 15MG/5ML ORAL LIQUID #30ML RX-408840037 CDM J7510 HCPCS 636 RC 09999-9990-25 NDC inpatient 90 ME 16.48 16.48 CIGNA 62308 [3081051] CIGNA STATE OF WYOMING [308105107] 13.05 percent of total billed charges 10.22 15.66 Technical (Hospital) Services METHYLPREDNISOLONE 4 MG TABLET RX-4993 CDM J7509 HCPCS 636 RC 59746-0001-06 NDC inpatient 1 UN 5.94 5.94 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES HDHP [308136802] 4.7 percent of total billed charges 3.68 5.64 Technical (Hospital) Services METHYLPREDNISOLONE 4 MG TABLET RX-4993 CDM J7509 HCPCS 636 RC 59746-0001-06 NDC inpatient 1 UN 5.94 5.94 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES EPO [308136803] 4.7 percent of total billed charges 3.68 5.64 Technical (Hospital) Services METHYLPREDNISOLONE 4 MG TABLET RX-4993 CDM J7509 HCPCS 636 RC 59746-0001-06 NDC inpatient 1 UN 5.94 5.94 CIGNA 62308 [3081051] CIGNA 62308 [308105105] 4.7 percent of total billed charges 3.68 5.64 Technical (Hospital) Services METHYLPREDNISOLONE 4 MG TABLET RX-4993 CDM J7509 HCPCS 636 RC 59746-0001-06 NDC inpatient 1 UN 5.94 5.94 CIGNA 62308 [3081051] CIGNA STATE OF WYOMING [308105107] 4.7 percent of total billed charges 3.68 5.64 Technical (Hospital) Services METHYLPREDNISOLONE 4 MG TABLET RX-4993 CDM J7509 HCPCS 636 RC 59746-0001-06 NDC inpatient 1 UN 5.94 5.94 BLUE CROSS BLUE SHIELD WELLMARK SB889 [3081026] BCBS WYOMING [308102603] 5.64 percent of total billed charges 3.68 5.64 Technical (Hospital) Services METHYLPREDNISOLONE 4 MG TABLET RX-4993 CDM J7509 HCPCS 636 RC 59746-0001-06 NDC inpatient 1 UN 5.94 5.94 UNITED HEALTHCARE (COMMERCIAL) [3081199] UNITED HEALTHCARE 87726 [308119901] 3.68 percent of total billed charges 3.68 5.64 Technical (Hospital) Services METHYLPREDNISOLONE 4 MG TABLET RX-4993 CDM J7509 HCPCS 636 RC 59746-0001-06 NDC outpatient 1 UN 5.94 5.94 BLUE CROSS BLUE SHIELD WELLMARK SB889 [3081026] BCBS WYOMING [308102603] 5.64 percent of total billed charges 3.68 5.64 Technical (Hospital) Services METHYLPREDNISOLONE 4 MG TABLET RX-4993 CDM J7509 HCPCS 636 RC 59746-0001-06 NDC outpatient 1 UN 5.94 5.94 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES PPO [308136801] 4.75 percent of total billed charges 3.68 5.64 Technical (Hospital) Services METHYLPREDNISOLONE 4 MG TABLET RX-4993 CDM J7509 HCPCS 636 RC 59746-0001-06 NDC outpatient 1 UN 5.94 5.94 UNITED HEALTHCARE (COMMERCIAL) [3081199] UNITED HEALTHCARE 87726 [308119901] 3.68 percent of total billed charges 3.68 5.64 Technical (Hospital) Services METHYLPREDNISOLONE 4 MG TABLET RX-4993 CDM J7509 HCPCS 636 RC 59746-0001-06 NDC inpatient 1 UN 5.94 5.94 MULTIPLAN INC 34080 [3081285] MULTIPLAN INC [308128501] 5.64 percent of total billed charges 3.68 5.64 Technical (Hospital) Services METHYLPREDNISOLONE 4 MG TABLET RX-4993 CDM J7509 HCPCS 636 RC 59746-0001-06 NDC inpatient 1 UN 5.94 5.94 HEALTHPARTNERS SX009 HEALTHPARTNERS 4.7 percent of total billed charges 3.68 5.64 Technical (Hospital) Services METHYLPREDNISOLONE 4 MG TABLET RX-4993 CDM J7509 HCPCS 636 RC 59746-0001-06 NDC inpatient 1 UN 5.94 5.94 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES PPO [308136801] 4.7 percent of total billed charges 3.68 5.64 Technical (Hospital) Services METHYLPREDNISOLONE 4 MG TABLET RX-4993 CDM J7509 HCPCS 636 RC 59746-0001-06 NDC inpatient 1 UN 5.94 5.94 MEDICA (COMMERCIAL) 94265 [3081118] MEDICA CLAIMS [308111801] 5.35 percent of total billed charges 3.68 5.64 Technical (Hospital) Services METHYLPREDNISOLONE 4 MG TABLET RX-4993 CDM J7509 HCPCS 636 RC 59746-0001-06 NDC outpatient 1 UN 5.94 5.94 MULTIPLAN INC 34080 [3081285] MULTIPLAN INC [308128501] 5.64 percent of total billed charges 3.68 5.64 Technical (Hospital) Services METHYLPREDNISOLONE 4 MG TABLET RX-4993 CDM J7509 HCPCS 636 RC 59746-0001-06 NDC outpatient 1 UN 5.94 5.94 HEALTHPARTNERS SX009 HEALTHPARTNERS 4.75 percent of total billed charges 3.68 5.64 Technical (Hospital) Services METHYLPREDNISOLONE 4 MG TABLET RX-4993 CDM J7509 HCPCS 636 RC 59746-0001-06 NDC outpatient 1 UN 5.94 5.94 MEDICA (COMMERCIAL) 94265 [3081118] MEDICA CLAIMS [308111801] 5.35 percent of total billed charges 3.68 5.64 Technical (Hospital) Services METHYLPREDNISOLONE 4 MG TABLET RX-4993 CDM J7509 HCPCS 636 RC 59746-0001-06 NDC outpatient 1 UN 5.94 5.94 CIGNA 62308 [3081051] CIGNA 62308 [308105105] 4.75 percent of total billed charges 3.68 5.64 Technical (Hospital) Services METHYLPREDNISOLONE 4 MG TABLET RX-4993 CDM J7509 HCPCS 636 RC 59746-0001-06 NDC outpatient 1 UN 5.94 5.94 CIGNA 62308 [3081051] CIGNA STATE OF WYOMING [308105107] 4.75 percent of total billed charges 3.68 5.64 Technical (Hospital) Services METHYLPREDNISOLONE 4 MG TABLET RX-4993 CDM J7509 HCPCS 636 RC 59746-0001-06 NDC outpatient 1 UN 5.94 5.94 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES HDHP [308136802] 4.75 percent of total billed charges 3.68 5.64 Technical (Hospital) Services METHYLPREDNISOLONE 4 MG TABLET RX-4993 CDM J7509 HCPCS 636 RC 59746-0001-06 NDC outpatient 1 UN 5.94 5.94 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES EPO [308136803] 4.75 percent of total billed charges 3.68 5.64 Technical (Hospital) Services "TACROLIMUS 1 MG CAPSULE, IMMEDIATE-RELEASE" RX-12933 CDM J7507 HCPCS 636 RC 16729-0042-01 NDC outpatient 1 UN 6.2 6.2 BLUE CROSS BLUE SHIELD WELLMARK SB889 [3081026] BCBS WYOMING [308102603] 5.89 percent of total billed charges 3.84 5.89 Technical (Hospital) Services "TACROLIMUS 1 MG CAPSULE, IMMEDIATE-RELEASE" RX-12933 CDM J7507 HCPCS 636 RC 16729-0042-01 NDC outpatient 1 UN 6.2 6.2 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES PPO [308136801] 4.96 percent of total billed charges 3.84 5.89 Technical (Hospital) Services "TACROLIMUS 1 MG CAPSULE, IMMEDIATE-RELEASE" RX-12933 CDM J7507 HCPCS 636 RC 16729-0042-01 NDC outpatient 1 UN 6.2 6.2 CIGNA 62308 [3081051] CIGNA 62308 [308105105] 4.96 percent of total billed charges 3.84 5.89 Technical (Hospital) Services "TACROLIMUS 1 MG CAPSULE, IMMEDIATE-RELEASE" RX-12933 CDM J7507 HCPCS 636 RC 16729-0042-01 NDC outpatient 1 UN 6.2 6.2 CIGNA 62308 [3081051] CIGNA STATE OF WYOMING [308105107] 4.96 percent of total billed charges 3.84 5.89 Technical (Hospital) Services "TACROLIMUS 1 MG CAPSULE, IMMEDIATE-RELEASE" RX-12933 CDM J7507 HCPCS 636 RC 16729-0042-01 NDC outpatient 1 UN 6.2 6.2 MEDICA (COMMERCIAL) 94265 [3081118] MEDICA CLAIMS [308111801] 5.58 percent of total billed charges 3.84 5.89 Technical (Hospital) Services "TACROLIMUS 1 MG CAPSULE, IMMEDIATE-RELEASE" RX-12933 CDM J7507 HCPCS 636 RC 16729-0042-01 NDC outpatient 1 UN 6.2 6.2 HEALTHPARTNERS SX009 HEALTHPARTNERS 4.96 percent of total billed charges 3.84 5.89 Technical (Hospital) Services "TACROLIMUS 1 MG CAPSULE, IMMEDIATE-RELEASE" RX-12933 CDM J7507 HCPCS 636 RC 16729-0042-01 NDC outpatient 1 UN 6.2 6.2 UNITED HEALTHCARE (COMMERCIAL) [3081199] UNITED HEALTHCARE 87726 [308119901] 3.84 percent of total billed charges 3.84 5.89 Technical (Hospital) Services "TACROLIMUS 1 MG CAPSULE, IMMEDIATE-RELEASE" RX-12933 CDM J7507 HCPCS 636 RC 16729-0042-01 NDC outpatient 1 UN 6.2 6.2 MULTIPLAN INC 34080 [3081285] MULTIPLAN INC [308128501] 5.89 percent of total billed charges 3.84 5.89 Technical (Hospital) Services "TACROLIMUS 1 MG CAPSULE, IMMEDIATE-RELEASE" RX-12933 CDM J7507 HCPCS 636 RC 16729-0042-01 NDC outpatient 1 UN 6.2 6.2 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES EPO [308136803] 4.96 percent of total billed charges 3.84 5.89 Technical (Hospital) Services "TACROLIMUS 1 MG CAPSULE, IMMEDIATE-RELEASE" RX-12933 CDM J7507 HCPCS 636 RC 16729-0042-01 NDC outpatient 1 UN 6.2 6.2 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES HDHP [308136802] 4.96 percent of total billed charges 3.84 5.89 Technical (Hospital) Services "TACROLIMUS 1 MG CAPSULE, IMMEDIATE-RELEASE" RX-12933 CDM J7507 HCPCS 636 RC 16729-0042-01 NDC inpatient 1 UN 6.2 6.2 BLUE CROSS BLUE SHIELD WELLMARK SB889 [3081026] BCBS WYOMING [308102603] 5.89 percent of total billed charges 3.84 5.89 Technical (Hospital) Services "TACROLIMUS 1 MG CAPSULE, IMMEDIATE-RELEASE" RX-12933 CDM J7507 HCPCS 636 RC 16729-0042-01 NDC inpatient 1 UN 6.2 6.2 UNITED HEALTHCARE (COMMERCIAL) [3081199] UNITED HEALTHCARE 87726 [308119901] 3.84 percent of total billed charges 3.84 5.89 Technical (Hospital) Services "TACROLIMUS 1 MG CAPSULE, IMMEDIATE-RELEASE" RX-12933 CDM J7507 HCPCS 636 RC 16729-0042-01 NDC inpatient 1 UN 6.2 6.2 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES EPO [308136803] 4.91 percent of total billed charges 3.84 5.89 Technical (Hospital) Services "TACROLIMUS 1 MG CAPSULE, IMMEDIATE-RELEASE" RX-12933 CDM J7507 HCPCS 636 RC 16729-0042-01 NDC inpatient 1 UN 6.2 6.2 CIGNA 62308 [3081051] CIGNA 62308 [308105105] 4.91 percent of total billed charges 3.84 5.89 Technical (Hospital) Services "TACROLIMUS 1 MG CAPSULE, IMMEDIATE-RELEASE" RX-12933 CDM J7507 HCPCS 636 RC 16729-0042-01 NDC inpatient 1 UN 6.2 6.2 CIGNA 62308 [3081051] CIGNA STATE OF WYOMING [308105107] 4.91 percent of total billed charges 3.84 5.89 Technical (Hospital) Services "TACROLIMUS 1 MG CAPSULE, IMMEDIATE-RELEASE" RX-12933 CDM J7507 HCPCS 636 RC 16729-0042-01 NDC inpatient 1 UN 6.2 6.2 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES HDHP [308136802] 4.91 percent of total billed charges 3.84 5.89 Technical (Hospital) Services "TACROLIMUS 1 MG CAPSULE, IMMEDIATE-RELEASE" RX-12933 CDM J7507 HCPCS 636 RC 16729-0042-01 NDC inpatient 1 UN 6.2 6.2 MEDICA (COMMERCIAL) 94265 [3081118] MEDICA CLAIMS [308111801] 5.58 percent of total billed charges 3.84 5.89 Technical (Hospital) Services "TACROLIMUS 1 MG CAPSULE, IMMEDIATE-RELEASE" RX-12933 CDM J7507 HCPCS 636 RC 16729-0042-01 NDC inpatient 1 UN 6.2 6.2 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES PPO [308136801] 4.91 percent of total billed charges 3.84 5.89 Technical (Hospital) Services "TACROLIMUS 1 MG CAPSULE, IMMEDIATE-RELEASE" RX-12933 CDM J7507 HCPCS 636 RC 16729-0042-01 NDC inpatient 1 UN 6.2 6.2 HEALTHPARTNERS SX009 HEALTHPARTNERS 4.91 percent of total billed charges 3.84 5.89 Technical (Hospital) Services "TACROLIMUS 1 MG CAPSULE, IMMEDIATE-RELEASE" RX-12933 CDM J7507 HCPCS 636 RC 16729-0042-01 NDC inpatient 1 UN 6.2 6.2 MULTIPLAN INC 34080 [3081285] MULTIPLAN INC [308128501] 5.89 percent of total billed charges 3.84 5.89 Technical (Hospital) Services "FACTOR XA,INACTIVATED-ZHZO (RECOMBINANT) 200 MG INTRAVENOUS SOLUTION" RX-176167 CDM J7169 HCPCS 636 RC 00310-3200-01 NDC inpatient 40 ML 8750 8750 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES EPO [308136803] 6928.25 percent of total billed charges 5425 8312.5 Technical (Hospital) Services "FACTOR XA,INACTIVATED-ZHZO (RECOMBINANT) 200 MG INTRAVENOUS SOLUTION" RX-176167 CDM J7169 HCPCS 636 RC 00310-3200-01 NDC inpatient 40 ML 8750 8750 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES HDHP [308136802] 6928.25 percent of total billed charges 5425 8312.5 Technical (Hospital) Services "FACTOR XA,INACTIVATED-ZHZO (RECOMBINANT) 200 MG INTRAVENOUS SOLUTION" RX-176167 CDM J7169 HCPCS 636 RC 00310-3200-01 NDC inpatient 40 ML 8750 8750 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES PPO [308136801] 6928.25 percent of total billed charges 5425 8312.5 Technical (Hospital) Services "FACTOR XA,INACTIVATED-ZHZO (RECOMBINANT) 200 MG INTRAVENOUS SOLUTION" RX-176167 CDM J7169 HCPCS 636 RC 00310-3200-01 NDC inpatient 40 ML 8750 8750 CIGNA 62308 [3081051] CIGNA 62308 [308105105] 6928.25 percent of total billed charges 5425 8312.5 Technical (Hospital) Services "FACTOR XA,INACTIVATED-ZHZO (RECOMBINANT) 200 MG INTRAVENOUS SOLUTION" RX-176167 CDM J7169 HCPCS 636 RC 00310-3200-01 NDC inpatient 40 ML 8750 8750 CIGNA 62308 [3081051] CIGNA STATE OF WYOMING [308105107] 6928.25 percent of total billed charges 5425 8312.5 Technical (Hospital) Services "FACTOR XA,INACTIVATED-ZHZO (RECOMBINANT) 200 MG INTRAVENOUS SOLUTION" RX-176167 CDM J7169 HCPCS 636 RC 00310-3200-01 NDC inpatient 40 ML 8750 8750 UNITED HEALTHCARE (COMMERCIAL) [3081199] UNITED HEALTHCARE 87726 [308119901] 5425 percent of total billed charges 5425 8312.5 Technical (Hospital) Services "FACTOR XA,INACTIVATED-ZHZO (RECOMBINANT) 200 MG INTRAVENOUS SOLUTION" RX-176167 CDM J7169 HCPCS 636 RC 00310-3200-01 NDC inpatient 40 ML 8750 8750 BLUE CROSS BLUE SHIELD WELLMARK SB889 [3081026] BCBS WYOMING [308102603] 8312.5 percent of total billed charges 5425 8312.5 Technical (Hospital) Services "FACTOR XA,INACTIVATED-ZHZO (RECOMBINANT) 200 MG INTRAVENOUS SOLUTION" RX-176167 CDM J7169 HCPCS 636 RC 00310-3200-01 NDC inpatient 40 ML 8750 8750 HEALTHPARTNERS SX009 HEALTHPARTNERS 6928.25 percent of total billed charges 5425 8312.5 Technical (Hospital) Services "FACTOR XA,INACTIVATED-ZHZO (RECOMBINANT) 200 MG INTRAVENOUS SOLUTION" RX-176167 CDM J7169 HCPCS 636 RC 00310-3200-01 NDC inpatient 40 ML 8750 8750 MEDICA (COMMERCIAL) 94265 [3081118] MEDICA CLAIMS [308111801] 7875 percent of total billed charges 5425 8312.5 Technical (Hospital) Services "FACTOR XA,INACTIVATED-ZHZO (RECOMBINANT) 200 MG INTRAVENOUS SOLUTION" RX-176167 CDM J7169 HCPCS 636 RC 00310-3200-01 NDC inpatient 40 ML 8750 8750 MULTIPLAN INC 34080 [3081285] MULTIPLAN INC [308128501] 8312.5 percent of total billed charges 5425 8312.5 Technical (Hospital) Services "FACTOR XA,INACTIVATED-ZHZO (RECOMBINANT) 200 MG INTRAVENOUS SOLUTION" RX-176167 CDM J7169 HCPCS 636 RC 00310-3200-01 NDC outpatient 40 ML 8750 8750 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES EPO [308136803] 7000 percent of total billed charges 5425 8312.5 Technical (Hospital) Services "FACTOR XA,INACTIVATED-ZHZO (RECOMBINANT) 200 MG INTRAVENOUS SOLUTION" RX-176167 CDM J7169 HCPCS 636 RC 00310-3200-01 NDC outpatient 40 ML 8750 8750 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES HDHP [308136802] 7000 percent of total billed charges 5425 8312.5 Technical (Hospital) Services "FACTOR XA,INACTIVATED-ZHZO (RECOMBINANT) 200 MG INTRAVENOUS SOLUTION" RX-176167 CDM J7169 HCPCS 636 RC 00310-3200-01 NDC outpatient 40 ML 8750 8750 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES PPO [308136801] 7000 percent of total billed charges 5425 8312.5 Technical (Hospital) Services "FACTOR XA,INACTIVATED-ZHZO (RECOMBINANT) 200 MG INTRAVENOUS SOLUTION" RX-176167 CDM J7169 HCPCS 636 RC 00310-3200-01 NDC outpatient 40 ML 8750 8750 UNITED HEALTHCARE (COMMERCIAL) [3081199] UNITED HEALTHCARE 87726 [308119901] 5425 percent of total billed charges 5425 8312.5 Technical (Hospital) Services "FACTOR XA,INACTIVATED-ZHZO (RECOMBINANT) 200 MG INTRAVENOUS SOLUTION" RX-176167 CDM J7169 HCPCS 636 RC 00310-3200-01 NDC outpatient 40 ML 8750 8750 BLUE CROSS BLUE SHIELD WELLMARK SB889 [3081026] BCBS WYOMING [308102603] 8312.5 percent of total billed charges 5425 8312.5 Technical (Hospital) Services "FACTOR XA,INACTIVATED-ZHZO (RECOMBINANT) 200 MG INTRAVENOUS SOLUTION" RX-176167 CDM J7169 HCPCS 636 RC 00310-3200-01 NDC outpatient 40 ML 8750 8750 HEALTHPARTNERS SX009 HEALTHPARTNERS 7000 percent of total billed charges 5425 8312.5 Technical (Hospital) Services "FACTOR XA,INACTIVATED-ZHZO (RECOMBINANT) 200 MG INTRAVENOUS SOLUTION" RX-176167 CDM J7169 HCPCS 636 RC 00310-3200-01 NDC outpatient 40 ML 8750 8750 MEDICA (COMMERCIAL) 94265 [3081118] MEDICA CLAIMS [308111801] 7875 percent of total billed charges 5425 8312.5 Technical (Hospital) Services "FACTOR XA,INACTIVATED-ZHZO (RECOMBINANT) 200 MG INTRAVENOUS SOLUTION" RX-176167 CDM J7169 HCPCS 636 RC 00310-3200-01 NDC outpatient 40 ML 8750 8750 MULTIPLAN INC 34080 [3081285] MULTIPLAN INC [308128501] 8312.5 percent of total billed charges 5425 8312.5 Technical (Hospital) Services "FACTOR XA,INACTIVATED-ZHZO (RECOMBINANT) 200 MG INTRAVENOUS SOLUTION" RX-176167 CDM J7169 HCPCS 636 RC 00310-3200-01 NDC outpatient 40 ML 8750 8750 CIGNA 62308 [3081051] CIGNA 62308 [308105105] 7000 percent of total billed charges 5425 8312.5 Technical (Hospital) Services "FACTOR XA,INACTIVATED-ZHZO (RECOMBINANT) 200 MG INTRAVENOUS SOLUTION" RX-176167 CDM J7169 HCPCS 636 RC 00310-3200-01 NDC outpatient 40 ML 8750 8750 CIGNA 62308 [3081051] CIGNA STATE OF WYOMING [308105107] 7000 percent of total billed charges 5425 8312.5 Technical (Hospital) Services PROTHROMBIN CPLX HUMAN (PCC) 4FACTOR 500 UNIT (400-620 UNIT) IV SOLUTION RX-132765 CDM J7168 HCPCS 636 RC 63833-0386-02 NDC outpatient 2 UN 4150 4150 BLUE CROSS BLUE SHIELD WELLMARK SB889 [3081026] BCBS WYOMING [308102603] 3942.5 percent of total billed charges 2573 3942.5 Technical (Hospital) Services PROTHROMBIN CPLX HUMAN (PCC) 4FACTOR 500 UNIT (400-620 UNIT) IV SOLUTION RX-132765 CDM J7168 HCPCS 636 RC 63833-0386-02 NDC outpatient 2 UN 4150 4150 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES PPO [308136801] 3320 percent of total billed charges 2573 3942.5 Technical (Hospital) Services PROTHROMBIN CPLX HUMAN (PCC) 4FACTOR 500 UNIT (400-620 UNIT) IV SOLUTION RX-132765 CDM J7168 HCPCS 636 RC 63833-0386-02 NDC outpatient 2 UN 4150 4150 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES HDHP [308136802] 3320 percent of total billed charges 2573 3942.5 Technical (Hospital) Services PROTHROMBIN CPLX HUMAN (PCC) 4FACTOR 500 UNIT (400-620 UNIT) IV SOLUTION RX-132765 CDM J7168 HCPCS 636 RC 63833-0386-02 NDC outpatient 2 UN 4150 4150 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES EPO [308136803] 3320 percent of total billed charges 2573 3942.5 Technical (Hospital) Services PROTHROMBIN CPLX HUMAN (PCC) 4FACTOR 500 UNIT (400-620 UNIT) IV SOLUTION RX-132765 CDM J7168 HCPCS 636 RC 63833-0386-02 NDC outpatient 2 UN 4150 4150 MULTIPLAN INC 34080 [3081285] MULTIPLAN INC [308128501] 3942.5 percent of total billed charges 2573 3942.5 Technical (Hospital) Services PROTHROMBIN CPLX HUMAN (PCC) 4FACTOR 500 UNIT (400-620 UNIT) IV SOLUTION RX-132765 CDM J7168 HCPCS 636 RC 63833-0386-02 NDC outpatient 2 UN 4150 4150 CIGNA 62308 [3081051] CIGNA 62308 [308105105] 3320 percent of total billed charges 2573 3942.5 Technical (Hospital) Services PROTHROMBIN CPLX HUMAN (PCC) 4FACTOR 500 UNIT (400-620 UNIT) IV SOLUTION RX-132765 CDM J7168 HCPCS 636 RC 63833-0386-02 NDC outpatient 2 UN 4150 4150 CIGNA 62308 [3081051] CIGNA STATE OF WYOMING [308105107] 3320 percent of total billed charges 2573 3942.5 Technical (Hospital) Services PROTHROMBIN CPLX HUMAN (PCC) 4FACTOR 500 UNIT (400-620 UNIT) IV SOLUTION RX-132765 CDM J7168 HCPCS 636 RC 63833-0386-02 NDC outpatient 2 UN 4150 4150 MEDICA (COMMERCIAL) 94265 [3081118] MEDICA CLAIMS [308111801] 3735 percent of total billed charges 2573 3942.5 Technical (Hospital) Services PROTHROMBIN CPLX HUMAN (PCC) 4FACTOR 500 UNIT (400-620 UNIT) IV SOLUTION RX-132765 CDM J7168 HCPCS 636 RC 63833-0386-02 NDC outpatient 2 UN 4150 4150 HEALTHPARTNERS SX009 HEALTHPARTNERS 3320 percent of total billed charges 2573 3942.5 Technical (Hospital) Services PROTHROMBIN CPLX HUMAN (PCC) 4FACTOR 500 UNIT (400-620 UNIT) IV SOLUTION RX-132765 CDM J7168 HCPCS 636 RC 63833-0386-02 NDC outpatient 2 UN 4150 4150 UNITED HEALTHCARE (COMMERCIAL) [3081199] UNITED HEALTHCARE 87726 [308119901] 2573 percent of total billed charges 2573 3942.5 Technical (Hospital) Services PROTHROMBIN CPLX HUMAN (PCC) 4FACTOR 500 UNIT (400-620 UNIT) IV SOLUTION RX-132765 CDM J7168 HCPCS 636 RC 63833-0386-02 NDC inpatient 2 UN 4150 4150 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES EPO [308136803] 3285.97 percent of total billed charges 2573 3942.5 Technical (Hospital) Services PROTHROMBIN CPLX HUMAN (PCC) 4FACTOR 500 UNIT (400-620 UNIT) IV SOLUTION RX-132765 CDM J7168 HCPCS 636 RC 63833-0386-02 NDC inpatient 2 UN 4150 4150 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES PPO [308136801] 3285.97 percent of total billed charges 2573 3942.5 Technical (Hospital) Services PROTHROMBIN CPLX HUMAN (PCC) 4FACTOR 500 UNIT (400-620 UNIT) IV SOLUTION RX-132765 CDM J7168 HCPCS 636 RC 63833-0386-02 NDC inpatient 2 UN 4150 4150 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES HDHP [308136802] 3285.97 percent of total billed charges 2573 3942.5 Technical (Hospital) Services PROTHROMBIN CPLX HUMAN (PCC) 4FACTOR 500 UNIT (400-620 UNIT) IV SOLUTION RX-132765 CDM J7168 HCPCS 636 RC 63833-0386-02 NDC inpatient 2 UN 4150 4150 HEALTHPARTNERS SX009 HEALTHPARTNERS 3285.97 percent of total billed charges 2573 3942.5 Technical (Hospital) Services PROTHROMBIN CPLX HUMAN (PCC) 4FACTOR 500 UNIT (400-620 UNIT) IV SOLUTION RX-132765 CDM J7168 HCPCS 636 RC 63833-0386-02 NDC inpatient 2 UN 4150 4150 CIGNA 62308 [3081051] CIGNA 62308 [308105105] 3285.97 percent of total billed charges 2573 3942.5 Technical (Hospital) Services PROTHROMBIN CPLX HUMAN (PCC) 4FACTOR 500 UNIT (400-620 UNIT) IV SOLUTION RX-132765 CDM J7168 HCPCS 636 RC 63833-0386-02 NDC inpatient 2 UN 4150 4150 CIGNA 62308 [3081051] CIGNA STATE OF WYOMING [308105107] 3285.97 percent of total billed charges 2573 3942.5 Technical (Hospital) Services PROTHROMBIN CPLX HUMAN (PCC) 4FACTOR 500 UNIT (400-620 UNIT) IV SOLUTION RX-132765 CDM J7168 HCPCS 636 RC 63833-0386-02 NDC inpatient 2 UN 4150 4150 BLUE CROSS BLUE SHIELD WELLMARK SB889 [3081026] BCBS WYOMING [308102603] 3942.5 percent of total billed charges 2573 3942.5 Technical (Hospital) Services PROTHROMBIN CPLX HUMAN (PCC) 4FACTOR 500 UNIT (400-620 UNIT) IV SOLUTION RX-132765 CDM J7168 HCPCS 636 RC 63833-0386-02 NDC inpatient 2 UN 4150 4150 UNITED HEALTHCARE (COMMERCIAL) [3081199] UNITED HEALTHCARE 87726 [308119901] 2573 percent of total billed charges 2573 3942.5 Technical (Hospital) Services PROTHROMBIN CPLX HUMAN (PCC) 4FACTOR 500 UNIT (400-620 UNIT) IV SOLUTION RX-132765 CDM J7168 HCPCS 636 RC 63833-0386-02 NDC inpatient 2 UN 4150 4150 MEDICA (COMMERCIAL) 94265 [3081118] MEDICA CLAIMS [308111801] 3735 percent of total billed charges 2573 3942.5 Technical (Hospital) Services PROTHROMBIN CPLX HUMAN (PCC) 4FACTOR 500 UNIT (400-620 UNIT) IV SOLUTION RX-132765 CDM J7168 HCPCS 636 RC 63833-0386-02 NDC inpatient 2 UN 4150 4150 MULTIPLAN INC 34080 [3081285] MULTIPLAN INC [308128501] 3942.5 percent of total billed charges 2573 3942.5 Technical (Hospital) Services "PROTHROMBIN CPLX HUMAN (PCC)4FACT 1,000 UNIT (800-1,240 UNIT) IV SOLUTION" RX-132835 CDM J7168 HCPCS 636 RC 63833-0387-02 NDC outpatient 1 UN 4184 4184 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES PPO [308136801] 3347.2 percent of total billed charges 2594.08 3974.8 Technical (Hospital) Services "PROTHROMBIN CPLX HUMAN (PCC)4FACT 1,000 UNIT (800-1,240 UNIT) IV SOLUTION" RX-132835 CDM J7168 HCPCS 636 RC 63833-0387-02 NDC outpatient 1 UN 4184 4184 BLUE CROSS BLUE SHIELD WELLMARK SB889 [3081026] BCBS WYOMING [308102603] 3974.8 percent of total billed charges 2594.08 3974.8 Technical (Hospital) Services "PROTHROMBIN CPLX HUMAN (PCC)4FACT 1,000 UNIT (800-1,240 UNIT) IV SOLUTION" RX-132835 CDM J7168 HCPCS 636 RC 63833-0387-02 NDC outpatient 1 UN 4184 4184 HEALTHPARTNERS SX009 HEALTHPARTNERS 3347.2 percent of total billed charges 2594.08 3974.8 Technical (Hospital) Services "PROTHROMBIN CPLX HUMAN (PCC)4FACT 1,000 UNIT (800-1,240 UNIT) IV SOLUTION" RX-132835 CDM J7168 HCPCS 636 RC 63833-0387-02 NDC outpatient 1 UN 4184 4184 UNITED HEALTHCARE (COMMERCIAL) [3081199] UNITED HEALTHCARE 87726 [308119901] 2594.08 percent of total billed charges 2594.08 3974.8 Technical (Hospital) Services "PROTHROMBIN CPLX HUMAN (PCC)4FACT 1,000 UNIT (800-1,240 UNIT) IV SOLUTION" RX-132835 CDM J7168 HCPCS 636 RC 63833-0387-02 NDC outpatient 1 UN 4184 4184 MULTIPLAN INC 34080 [3081285] MULTIPLAN INC [308128501] 3974.8 percent of total billed charges 2594.08 3974.8 Technical (Hospital) Services "PROTHROMBIN CPLX HUMAN (PCC)4FACT 1,000 UNIT (800-1,240 UNIT) IV SOLUTION" RX-132835 CDM J7168 HCPCS 636 RC 63833-0387-02 NDC outpatient 1 UN 4184 4184 CIGNA 62308 [3081051] CIGNA 62308 [308105105] 3347.2 percent of total billed charges 2594.08 3974.8 Technical (Hospital) Services "PROTHROMBIN CPLX HUMAN (PCC)4FACT 1,000 UNIT (800-1,240 UNIT) IV SOLUTION" RX-132835 CDM J7168 HCPCS 636 RC 63833-0387-02 NDC outpatient 1 UN 4184 4184 CIGNA 62308 [3081051] CIGNA STATE OF WYOMING [308105107] 3347.2 percent of total billed charges 2594.08 3974.8 Technical (Hospital) Services "PROTHROMBIN CPLX HUMAN (PCC)4FACT 1,000 UNIT (800-1,240 UNIT) IV SOLUTION" RX-132835 CDM J7168 HCPCS 636 RC 63833-0387-02 NDC outpatient 1 UN 4184 4184 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES EPO [308136803] 3347.2 percent of total billed charges 2594.08 3974.8 Technical (Hospital) Services "PROTHROMBIN CPLX HUMAN (PCC)4FACT 1,000 UNIT (800-1,240 UNIT) IV SOLUTION" RX-132835 CDM J7168 HCPCS 636 RC 63833-0387-02 NDC outpatient 1 UN 4184 4184 MEDICA (COMMERCIAL) 94265 [3081118] MEDICA CLAIMS [308111801] 3765.6 percent of total billed charges 2594.08 3974.8 Technical (Hospital) Services "PROTHROMBIN CPLX HUMAN (PCC)4FACT 1,000 UNIT (800-1,240 UNIT) IV SOLUTION" RX-132835 CDM J7168 HCPCS 636 RC 63833-0387-02 NDC outpatient 1 UN 4184 4184 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES HDHP [308136802] 3347.2 percent of total billed charges 2594.08 3974.8 Technical (Hospital) Services "PROTHROMBIN CPLX HUMAN (PCC)4FACT 1,000 UNIT (800-1,240 UNIT) IV SOLUTION" RX-132835 CDM J7168 HCPCS 636 RC 63833-0387-02 NDC inpatient 1 UN 4184 4184 MULTIPLAN INC 34080 [3081285] MULTIPLAN INC [308128501] 3974.8 percent of total billed charges 2594.08 3974.8 Technical (Hospital) Services "PROTHROMBIN CPLX HUMAN (PCC)4FACT 1,000 UNIT (800-1,240 UNIT) IV SOLUTION" RX-132835 CDM J7168 HCPCS 636 RC 63833-0387-02 NDC inpatient 1 UN 4184 4184 MEDICA (COMMERCIAL) 94265 [3081118] MEDICA CLAIMS [308111801] 3765.6 percent of total billed charges 2594.08 3974.8 Technical (Hospital) Services "PROTHROMBIN CPLX HUMAN (PCC)4FACT 1,000 UNIT (800-1,240 UNIT) IV SOLUTION" RX-132835 CDM J7168 HCPCS 636 RC 63833-0387-02 NDC inpatient 1 UN 4184 4184 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES PPO [308136801] 3312.89 percent of total billed charges 2594.08 3974.8 Technical (Hospital) Services "PROTHROMBIN CPLX HUMAN (PCC)4FACT 1,000 UNIT (800-1,240 UNIT) IV SOLUTION" RX-132835 CDM J7168 HCPCS 636 RC 63833-0387-02 NDC inpatient 1 UN 4184 4184 HEALTHPARTNERS SX009 HEALTHPARTNERS 3312.89 percent of total billed charges 2594.08 3974.8 Technical (Hospital) Services "PROTHROMBIN CPLX HUMAN (PCC)4FACT 1,000 UNIT (800-1,240 UNIT) IV SOLUTION" RX-132835 CDM J7168 HCPCS 636 RC 63833-0387-02 NDC inpatient 1 UN 4184 4184 BLUE CROSS BLUE SHIELD WELLMARK SB889 [3081026] BCBS WYOMING [308102603] 3974.8 percent of total billed charges 2594.08 3974.8 Technical (Hospital) Services "PROTHROMBIN CPLX HUMAN (PCC)4FACT 1,000 UNIT (800-1,240 UNIT) IV SOLUTION" RX-132835 CDM J7168 HCPCS 636 RC 63833-0387-02 NDC inpatient 1 UN 4184 4184 UNITED HEALTHCARE (COMMERCIAL) [3081199] UNITED HEALTHCARE 87726 [308119901] 2594.08 percent of total billed charges 2594.08 3974.8 Technical (Hospital) Services "PROTHROMBIN CPLX HUMAN (PCC)4FACT 1,000 UNIT (800-1,240 UNIT) IV SOLUTION" RX-132835 CDM J7168 HCPCS 636 RC 63833-0387-02 NDC inpatient 1 UN 4184 4184 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES EPO [308136803] 3312.89 percent of total billed charges 2594.08 3974.8 Technical (Hospital) Services "PROTHROMBIN CPLX HUMAN (PCC)4FACT 1,000 UNIT (800-1,240 UNIT) IV SOLUTION" RX-132835 CDM J7168 HCPCS 636 RC 63833-0387-02 NDC inpatient 1 UN 4184 4184 CIGNA 62308 [3081051] CIGNA 62308 [308105105] 3312.89 percent of total billed charges 2594.08 3974.8 Technical (Hospital) Services "PROTHROMBIN CPLX HUMAN (PCC)4FACT 1,000 UNIT (800-1,240 UNIT) IV SOLUTION" RX-132835 CDM J7168 HCPCS 636 RC 63833-0387-02 NDC inpatient 1 UN 4184 4184 CIGNA 62308 [3081051] CIGNA STATE OF WYOMING [308105107] 3312.89 percent of total billed charges 2594.08 3974.8 Technical (Hospital) Services "PROTHROMBIN CPLX HUMAN (PCC)4FACT 1,000 UNIT (800-1,240 UNIT) IV SOLUTION" RX-132835 CDM J7168 HCPCS 636 RC 63833-0387-02 NDC inpatient 1 UN 4184 4184 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES HDHP [308136802] 3312.89 percent of total billed charges 2594.08 3974.8 Technical (Hospital) Services RINGER'S INTRAVENOUS SOLUTION RX-11295 CDM J7120 HCPCS 250 RC 00990-7982-09 NDC inpatient 1000 ML 69.5 BLUE CROSS BLUE SHIELD WELLMARK SB889 [3081026] BCBS WYOMING [308102603] 66.03 percent of total billed charges 66.03 66.03 Technical (Hospital) Services RINGER'S INTRAVENOUS SOLUTION RX-11295 CDM J7120 HCPCS 250 RC 00990-7982-09 NDC outpatient 1000 ML 69.5 BLUE CROSS BLUE SHIELD WELLMARK SB889 [3081026] BCBS WYOMING [308102603] 66.03 percent of total billed charges 66.03 66.03 Technical (Hospital) Services LACTATED RINGERS INTRAVENOUS SOLUTION RX-4318 CDM J7120 HCPCS 250 RC 00338-0117-04 NDC inpatient 1000 ML 69.5 BLUE CROSS BLUE SHIELD WELLMARK SB889 [3081026] BCBS WYOMING [308102603] 66.03 percent of total billed charges 66.03 66.03 Technical (Hospital) Services LACTATED RINGERS INTRAVENOUS SOLUTION RX-4318 CDM J7120 HCPCS 250 RC 00338-0117-04 NDC outpatient 1000 ML 69.5 BLUE CROSS BLUE SHIELD WELLMARK SB889 [3081026] BCBS WYOMING [308102603] 66.03 percent of total billed charges 66.03 66.03 Technical (Hospital) Services RINGER'S INTRAVENOUS SOLUTION RX-11295 CDM J7120 HCPCS 258 RC 00990-7982-09 NDC inpatient 1000 ML 69.5 69.5 HEALTHPARTNERS SX009 HEALTHPARTNERS 55.03 percent of total billed charges 43.09 66.03 Technical (Hospital) Services RINGER'S INTRAVENOUS SOLUTION RX-11295 CDM J7120 HCPCS 258 RC 00990-7982-09 NDC inpatient 1000 ML 69.5 69.5 MULTIPLAN INC 34080 [3081285] MULTIPLAN INC [308128501] 66.03 percent of total billed charges 43.09 66.03 Technical (Hospital) Services RINGER'S INTRAVENOUS SOLUTION RX-11295 CDM J7120 HCPCS 258 RC 00990-7982-09 NDC inpatient 1000 ML 69.5 69.5 MEDICA (COMMERCIAL) 94265 [3081118] MEDICA CLAIMS [308111801] 62.55 percent of total billed charges 43.09 66.03 Technical (Hospital) Services RINGER'S INTRAVENOUS SOLUTION RX-11295 CDM J7120 HCPCS 258 RC 00990-7982-09 NDC inpatient 1000 ML 69.5 69.5 UNITED HEALTHCARE (COMMERCIAL) [3081199] UNITED HEALTHCARE 87726 [308119901] 43.09 percent of total billed charges 43.09 66.03 Technical (Hospital) Services RINGER'S INTRAVENOUS SOLUTION RX-11295 CDM J7120 HCPCS 258 RC 00990-7982-09 NDC inpatient 1000 ML 69.5 69.5 CIGNA 62308 [3081051] CIGNA 62308 [308105105] 55.03 percent of total billed charges 43.09 66.03 Technical (Hospital) Services RINGER'S INTRAVENOUS SOLUTION RX-11295 CDM J7120 HCPCS 258 RC 00990-7982-09 NDC inpatient 1000 ML 69.5 69.5 CIGNA 62308 [3081051] CIGNA STATE OF WYOMING [308105107] 55.03 percent of total billed charges 43.09 66.03 Technical (Hospital) Services RINGER'S INTRAVENOUS SOLUTION RX-11295 CDM J7120 HCPCS 258 RC 00990-7982-09 NDC inpatient 1000 ML 69.5 69.5 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES HDHP [308136802] 55.03 percent of total billed charges 43.09 66.03 Technical (Hospital) Services RINGER'S INTRAVENOUS SOLUTION RX-11295 CDM J7120 HCPCS 258 RC 00990-7982-09 NDC inpatient 1000 ML 69.5 69.5 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES PPO [308136801] 55.03 percent of total billed charges 43.09 66.03 Technical (Hospital) Services RINGER'S INTRAVENOUS SOLUTION RX-11295 CDM J7120 HCPCS 258 RC 00990-7982-09 NDC inpatient 1000 ML 69.5 69.5 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES EPO [308136803] 55.03 percent of total billed charges 43.09 66.03 Technical (Hospital) Services RINGER'S INTRAVENOUS SOLUTION RX-11295 CDM J7120 HCPCS 258 RC 00990-7982-09 NDC outpatient 1000 ML 69.5 69.5 CIGNA 62308 [3081051] CIGNA 62308 [308105105] 55.6 percent of total billed charges 43.09 66.03 Technical (Hospital) Services RINGER'S INTRAVENOUS SOLUTION RX-11295 CDM J7120 HCPCS 258 RC 00990-7982-09 NDC outpatient 1000 ML 69.5 69.5 CIGNA 62308 [3081051] CIGNA STATE OF WYOMING [308105107] 55.6 percent of total billed charges 43.09 66.03 Technical (Hospital) Services RINGER'S INTRAVENOUS SOLUTION RX-11295 CDM J7120 HCPCS 258 RC 00990-7982-09 NDC outpatient 1000 ML 69.5 69.5 MEDICA (COMMERCIAL) 94265 [3081118] MEDICA CLAIMS [308111801] 62.55 percent of total billed charges 43.09 66.03 Technical (Hospital) Services RINGER'S INTRAVENOUS SOLUTION RX-11295 CDM J7120 HCPCS 258 RC 00990-7982-09 NDC outpatient 1000 ML 69.5 69.5 MULTIPLAN INC 34080 [3081285] MULTIPLAN INC [308128501] 66.03 percent of total billed charges 43.09 66.03 Technical (Hospital) Services RINGER'S INTRAVENOUS SOLUTION RX-11295 CDM J7120 HCPCS 258 RC 00990-7982-09 NDC outpatient 1000 ML 69.5 69.5 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES HDHP [308136802] 55.6 percent of total billed charges 43.09 66.03 Technical (Hospital) Services RINGER'S INTRAVENOUS SOLUTION RX-11295 CDM J7120 HCPCS 258 RC 00990-7982-09 NDC outpatient 1000 ML 69.5 69.5 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES PPO [308136801] 55.6 percent of total billed charges 43.09 66.03 Technical (Hospital) Services RINGER'S INTRAVENOUS SOLUTION RX-11295 CDM J7120 HCPCS 258 RC 00990-7982-09 NDC outpatient 1000 ML 69.5 69.5 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES EPO [308136803] 55.6 percent of total billed charges 43.09 66.03 Technical (Hospital) Services RINGER'S INTRAVENOUS SOLUTION RX-11295 CDM J7120 HCPCS 258 RC 00990-7982-09 NDC outpatient 1000 ML 69.5 69.5 UNITED HEALTHCARE (COMMERCIAL) [3081199] UNITED HEALTHCARE 87726 [308119901] 43.09 percent of total billed charges 43.09 66.03 Technical (Hospital) Services RINGER'S INTRAVENOUS SOLUTION RX-11295 CDM J7120 HCPCS 258 RC 00990-7982-09 NDC outpatient 1000 ML 69.5 69.5 HEALTHPARTNERS SX009 HEALTHPARTNERS 55.6 percent of total billed charges 43.09 66.03 Technical (Hospital) Services LACTATED RINGERS INTRAVENOUS SOLUTION RX-4318 CDM J7120 HCPCS 258 RC 00338-0117-04 NDC outpatient 1000 ML 69.5 69.5 CIGNA 62308 [3081051] CIGNA 62308 [308105105] 55.6 percent of total billed charges 43.09 66.03 Technical (Hospital) Services LACTATED RINGERS INTRAVENOUS SOLUTION RX-4318 CDM J7120 HCPCS 258 RC 00338-0117-04 NDC outpatient 1000 ML 69.5 69.5 CIGNA 62308 [3081051] CIGNA STATE OF WYOMING [308105107] 55.6 percent of total billed charges 43.09 66.03 Technical (Hospital) Services LACTATED RINGERS INTRAVENOUS SOLUTION RX-4318 CDM J7120 HCPCS 258 RC 00338-0117-04 NDC outpatient 1000 ML 69.5 69.5 MULTIPLAN INC 34080 [3081285] MULTIPLAN INC [308128501] 66.03 percent of total billed charges 43.09 66.03 Technical (Hospital) Services LACTATED RINGERS INTRAVENOUS SOLUTION RX-4318 CDM J7120 HCPCS 258 RC 00338-0117-04 NDC outpatient 1000 ML 69.5 69.5 MEDICA (COMMERCIAL) 94265 [3081118] MEDICA CLAIMS [308111801] 62.55 percent of total billed charges 43.09 66.03 Technical (Hospital) Services LACTATED RINGERS INTRAVENOUS SOLUTION RX-4318 CDM J7120 HCPCS 258 RC 00338-0117-04 NDC outpatient 1000 ML 69.5 69.5 HEALTHPARTNERS SX009 HEALTHPARTNERS 55.6 percent of total billed charges 43.09 66.03 Technical (Hospital) Services LACTATED RINGERS INTRAVENOUS SOLUTION RX-4318 CDM J7120 HCPCS 258 RC 00338-0117-04 NDC outpatient 1000 ML 69.5 69.5 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES PPO [308136801] 55.6 percent of total billed charges 43.09 66.03 Technical (Hospital) Services LACTATED RINGERS INTRAVENOUS SOLUTION RX-4318 CDM J7120 HCPCS 258 RC 00338-0117-04 NDC outpatient 1000 ML 69.5 69.5 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES EPO [308136803] 55.6 percent of total billed charges 43.09 66.03 Technical (Hospital) Services LACTATED RINGERS INTRAVENOUS SOLUTION RX-4318 CDM J7120 HCPCS 258 RC 00338-0117-04 NDC outpatient 1000 ML 69.5 69.5 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES HDHP [308136802] 55.6 percent of total billed charges 43.09 66.03 Technical (Hospital) Services LACTATED RINGERS INTRAVENOUS SOLUTION RX-4318 CDM J7120 HCPCS 258 RC 00338-0117-04 NDC outpatient 1000 ML 69.5 69.5 UNITED HEALTHCARE (COMMERCIAL) [3081199] UNITED HEALTHCARE 87726 [308119901] 43.09 percent of total billed charges 43.09 66.03 Technical (Hospital) Services LACTATED RINGERS INTRAVENOUS SOLUTION RX-4318 CDM J7120 HCPCS 258 RC 00338-0117-04 NDC inpatient 1000 ML 69.5 69.5 UNITED HEALTHCARE (COMMERCIAL) [3081199] UNITED HEALTHCARE 87726 [308119901] 43.09 percent of total billed charges 43.09 66.03 Technical (Hospital) Services LACTATED RINGERS INTRAVENOUS SOLUTION RX-4318 CDM J7120 HCPCS 258 RC 00338-0117-04 NDC inpatient 1000 ML 69.5 69.5 MEDICA (COMMERCIAL) 94265 [3081118] MEDICA CLAIMS [308111801] 62.55 percent of total billed charges 43.09 66.03 Technical (Hospital) Services LACTATED RINGERS INTRAVENOUS SOLUTION RX-4318 CDM J7120 HCPCS 258 RC 00338-0117-04 NDC inpatient 1000 ML 69.5 69.5 MULTIPLAN INC 34080 [3081285] MULTIPLAN INC [308128501] 66.03 percent of total billed charges 43.09 66.03 Technical (Hospital) Services LACTATED RINGERS INTRAVENOUS SOLUTION RX-4318 CDM J7120 HCPCS 258 RC 00338-0117-04 NDC inpatient 1000 ML 69.5 69.5 HEALTHPARTNERS SX009 HEALTHPARTNERS 55.03 percent of total billed charges 43.09 66.03 Technical (Hospital) Services LACTATED RINGERS INTRAVENOUS SOLUTION RX-4318 CDM J7120 HCPCS 258 RC 00338-0117-04 NDC inpatient 1000 ML 69.5 69.5 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES HDHP [308136802] 55.03 percent of total billed charges 43.09 66.03 Technical (Hospital) Services LACTATED RINGERS INTRAVENOUS SOLUTION RX-4318 CDM J7120 HCPCS 258 RC 00338-0117-04 NDC inpatient 1000 ML 69.5 69.5 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES PPO [308136801] 55.03 percent of total billed charges 43.09 66.03 Technical (Hospital) Services LACTATED RINGERS INTRAVENOUS SOLUTION RX-4318 CDM J7120 HCPCS 258 RC 00338-0117-04 NDC inpatient 1000 ML 69.5 69.5 CIGNA 62308 [3081051] CIGNA 62308 [308105105] 55.03 percent of total billed charges 43.09 66.03 Technical (Hospital) Services LACTATED RINGERS INTRAVENOUS SOLUTION RX-4318 CDM J7120 HCPCS 258 RC 00338-0117-04 NDC inpatient 1000 ML 69.5 69.5 CIGNA 62308 [3081051] CIGNA STATE OF WYOMING [308105107] 55.03 percent of total billed charges 43.09 66.03 Technical (Hospital) Services LACTATED RINGERS INTRAVENOUS SOLUTION RX-4318 CDM J7120 HCPCS 258 RC 00338-0117-04 NDC inpatient 1000 ML 69.5 69.5 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES EPO [308136803] 55.03 percent of total billed charges 43.09 66.03 Technical (Hospital) Services DEXTROSE 5 % IN WATER (D5W) INTRAVENOUS SOLUTION RX-2364 CDM J7070 HCPCS 250 RC 00338-0017-18 NDC outpatient 100 ML 60.8 BLUE CROSS BLUE SHIELD WELLMARK SB889 [3081026] BCBS WYOMING [308102603] 57.76 percent of total billed charges 57.76 57.76 Technical (Hospital) Services DEXTROSE 5 % IN WATER (D5W) INTRAVENOUS SOLUTION RX-2364 CDM J7070 HCPCS 250 RC 00338-0017-18 NDC inpatient 100 ML 60.8 BLUE CROSS BLUE SHIELD WELLMARK SB889 [3081026] BCBS WYOMING [308102603] 57.76 percent of total billed charges 57.76 57.76 Technical (Hospital) Services DEXTROSE 5 % IN WATER (D5W) INTRAVENOUS SOLUTION RX-2364 CDM J7070 HCPCS 258 RC 00338-0017-18 NDC inpatient 100 ML 60.8 60.8 CIGNA 62308 [3081051] CIGNA 62308 [308105105] 48.14 percent of total billed charges 37.7 57.76 Technical (Hospital) Services DEXTROSE 5 % IN WATER (D5W) INTRAVENOUS SOLUTION RX-2364 CDM J7070 HCPCS 258 RC 00338-0017-18 NDC inpatient 100 ML 60.8 60.8 CIGNA 62308 [3081051] CIGNA STATE OF WYOMING [308105107] 48.14 percent of total billed charges 37.7 57.76 Technical (Hospital) Services DEXTROSE 5 % IN WATER (D5W) INTRAVENOUS SOLUTION RX-2364 CDM J7070 HCPCS 258 RC 00338-0017-18 NDC inpatient 100 ML 60.8 60.8 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES HDHP [308136802] 48.14 percent of total billed charges 37.7 57.76 Technical (Hospital) Services DEXTROSE 5 % IN WATER (D5W) INTRAVENOUS SOLUTION RX-2364 CDM J7070 HCPCS 258 RC 00338-0017-18 NDC inpatient 100 ML 60.8 60.8 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES EPO [308136803] 48.14 percent of total billed charges 37.7 57.76 Technical (Hospital) Services DEXTROSE 5 % IN WATER (D5W) INTRAVENOUS SOLUTION RX-2364 CDM J7070 HCPCS 258 RC 00338-0017-18 NDC inpatient 100 ML 60.8 60.8 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES PPO [308136801] 48.14 percent of total billed charges 37.7 57.76 Technical (Hospital) Services DEXTROSE 5 % IN WATER (D5W) INTRAVENOUS SOLUTION RX-2364 CDM J7070 HCPCS 258 RC 00338-0017-18 NDC inpatient 100 ML 60.8 60.8 HEALTHPARTNERS SX009 HEALTHPARTNERS 48.14 percent of total billed charges 37.7 57.76 Technical (Hospital) Services DEXTROSE 5 % IN WATER (D5W) INTRAVENOUS SOLUTION RX-2364 CDM J7070 HCPCS 258 RC 00338-0017-18 NDC inpatient 100 ML 60.8 60.8 MULTIPLAN INC 34080 [3081285] MULTIPLAN INC [308128501] 57.76 percent of total billed charges 37.7 57.76 Technical (Hospital) Services DEXTROSE 5 % IN WATER (D5W) INTRAVENOUS SOLUTION RX-2364 CDM J7070 HCPCS 258 RC 00338-0017-18 NDC inpatient 100 ML 60.8 60.8 MEDICA (COMMERCIAL) 94265 [3081118] MEDICA CLAIMS [308111801] 54.72 percent of total billed charges 37.7 57.76 Technical (Hospital) Services DEXTROSE 5 % IN WATER (D5W) INTRAVENOUS SOLUTION RX-2364 CDM J7070 HCPCS 258 RC 00338-0017-18 NDC inpatient 100 ML 60.8 60.8 UNITED HEALTHCARE (COMMERCIAL) [3081199] UNITED HEALTHCARE 87726 [308119901] 37.7 percent of total billed charges 37.7 57.76 Technical (Hospital) Services DEXTROSE 5 % IN WATER (D5W) INTRAVENOUS SOLUTION RX-2364 CDM J7070 HCPCS 258 RC 00338-0017-18 NDC outpatient 100 ML 60.8 60.8 UNITED HEALTHCARE (COMMERCIAL) [3081199] UNITED HEALTHCARE 87726 [308119901] 37.7 percent of total billed charges 37.7 57.76 Technical (Hospital) Services DEXTROSE 5 % IN WATER (D5W) INTRAVENOUS SOLUTION RX-2364 CDM J7070 HCPCS 258 RC 00338-0017-18 NDC outpatient 100 ML 60.8 60.8 HEALTHPARTNERS SX009 HEALTHPARTNERS 48.64 percent of total billed charges 37.7 57.76 Technical (Hospital) Services DEXTROSE 5 % IN WATER (D5W) INTRAVENOUS SOLUTION RX-2364 CDM J7070 HCPCS 258 RC 00338-0017-18 NDC outpatient 100 ML 60.8 60.8 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES PPO [308136801] 48.64 percent of total billed charges 37.7 57.76 Technical (Hospital) Services DEXTROSE 5 % IN WATER (D5W) INTRAVENOUS SOLUTION RX-2364 CDM J7070 HCPCS 258 RC 00338-0017-18 NDC outpatient 100 ML 60.8 60.8 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES EPO [308136803] 48.64 percent of total billed charges 37.7 57.76 Technical (Hospital) Services DEXTROSE 5 % IN WATER (D5W) INTRAVENOUS SOLUTION RX-2364 CDM J7070 HCPCS 258 RC 00338-0017-18 NDC outpatient 100 ML 60.8 60.8 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES HDHP [308136802] 48.64 percent of total billed charges 37.7 57.76 Technical (Hospital) Services DEXTROSE 5 % IN WATER (D5W) INTRAVENOUS SOLUTION RX-2364 CDM J7070 HCPCS 258 RC 00338-0017-18 NDC outpatient 100 ML 60.8 60.8 CIGNA 62308 [3081051] CIGNA STATE OF WYOMING [308105107] 48.64 percent of total billed charges 37.7 57.76 Technical (Hospital) Services DEXTROSE 5 % IN WATER (D5W) INTRAVENOUS SOLUTION RX-2364 CDM J7070 HCPCS 258 RC 00338-0017-18 NDC outpatient 100 ML 60.8 60.8 CIGNA 62308 [3081051] CIGNA 62308 [308105105] 48.64 percent of total billed charges 37.7 57.76 Technical (Hospital) Services DEXTROSE 5 % IN WATER (D5W) INTRAVENOUS SOLUTION RX-2364 CDM J7070 HCPCS 258 RC 00338-0017-18 NDC outpatient 100 ML 60.8 60.8 MEDICA (COMMERCIAL) 94265 [3081118] MEDICA CLAIMS [308111801] 54.72 percent of total billed charges 37.7 57.76 Technical (Hospital) Services DEXTROSE 5 % IN WATER (D5W) INTRAVENOUS SOLUTION RX-2364 CDM J7070 HCPCS 258 RC 00338-0017-18 NDC outpatient 100 ML 60.8 60.8 MULTIPLAN INC 34080 [3081285] MULTIPLAN INC [308128501] 57.76 percent of total billed charges 37.7 57.76 Technical (Hospital) Services SODIUM CHLORIDE 0.9 % INTRAVENOUS SOLUTION RX-27838 CDM J7050 HCPCS 250 RC 00338-0049-02 NDC inpatient 250 ML 68.75 BLUE CROSS BLUE SHIELD WELLMARK SB889 [3081026] BCBS WYOMING [308102603] 65.31 percent of total billed charges 65.31 65.31 Technical (Hospital) Services SODIUM CHLORIDE 0.9 % INTRAVENOUS SOLUTION RX-27838 CDM J7050 HCPCS 250 RC 00338-0049-02 NDC outpatient 250 ML 68.75 BLUE CROSS BLUE SHIELD WELLMARK SB889 [3081026] BCBS WYOMING [308102603] 65.31 percent of total billed charges 65.31 65.31 Technical (Hospital) Services SODIUM CHLORIDE 0.9 % INTRAVENOUS SOLUTION RX-27838 CDM J7050 HCPCS 258 RC 00338-0049-02 NDC inpatient 250 ML 68.75 68.75 UNITED HEALTHCARE (COMMERCIAL) [3081199] UNITED HEALTHCARE 87726 [308119901] 42.63 percent of total billed charges 42.63 65.31 Technical (Hospital) Services SODIUM CHLORIDE 0.9 % INTRAVENOUS SOLUTION RX-27838 CDM J7050 HCPCS 258 RC 00338-0049-02 NDC inpatient 250 ML 68.75 68.75 MEDICA (COMMERCIAL) 94265 [3081118] MEDICA CLAIMS [308111801] 61.88 percent of total billed charges 42.63 65.31 Technical (Hospital) Services SODIUM CHLORIDE 0.9 % INTRAVENOUS SOLUTION RX-27838 CDM J7050 HCPCS 258 RC 00338-0049-02 NDC inpatient 250 ML 68.75 68.75 MULTIPLAN INC 34080 [3081285] MULTIPLAN INC [308128501] 65.31 percent of total billed charges 42.63 65.31 Technical (Hospital) Services SODIUM CHLORIDE 0.9 % INTRAVENOUS SOLUTION RX-27838 CDM J7050 HCPCS 258 RC 00338-0049-02 NDC inpatient 250 ML 68.75 68.75 HEALTHPARTNERS SX009 HEALTHPARTNERS 54.44 percent of total billed charges 42.63 65.31 Technical (Hospital) Services SODIUM CHLORIDE 0.9 % INTRAVENOUS SOLUTION RX-27838 CDM J7050 HCPCS 258 RC 00338-0049-02 NDC inpatient 250 ML 68.75 68.75 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES EPO [308136803] 54.44 percent of total billed charges 42.63 65.31 Technical (Hospital) Services SODIUM CHLORIDE 0.9 % INTRAVENOUS SOLUTION RX-27838 CDM J7050 HCPCS 258 RC 00338-0049-02 NDC inpatient 250 ML 68.75 68.75 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES HDHP [308136802] 54.44 percent of total billed charges 42.63 65.31 Technical (Hospital) Services SODIUM CHLORIDE 0.9 % INTRAVENOUS SOLUTION RX-27838 CDM J7050 HCPCS 258 RC 00338-0049-02 NDC inpatient 250 ML 68.75 68.75 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES PPO [308136801] 54.44 percent of total billed charges 42.63 65.31 Technical (Hospital) Services SODIUM CHLORIDE 0.9 % INTRAVENOUS SOLUTION RX-27838 CDM J7050 HCPCS 258 RC 00338-0049-02 NDC inpatient 250 ML 68.75 68.75 CIGNA 62308 [3081051] CIGNA 62308 [308105105] 54.44 percent of total billed charges 42.63 65.31 Technical (Hospital) Services SODIUM CHLORIDE 0.9 % INTRAVENOUS SOLUTION RX-27838 CDM J7050 HCPCS 258 RC 00338-0049-02 NDC inpatient 250 ML 68.75 68.75 CIGNA 62308 [3081051] CIGNA STATE OF WYOMING [308105107] 54.44 percent of total billed charges 42.63 65.31 Technical (Hospital) Services SODIUM CHLORIDE 0.9 % INTRAVENOUS SOLUTION RX-27838 CDM J7050 HCPCS 258 RC 00338-0049-02 NDC outpatient 250 ML 68.75 68.75 MEDICA (COMMERCIAL) 94265 [3081118] MEDICA CLAIMS [308111801] 61.88 percent of total billed charges 42.63 65.31 Technical (Hospital) Services SODIUM CHLORIDE 0.9 % INTRAVENOUS SOLUTION RX-27838 CDM J7050 HCPCS 258 RC 00338-0049-02 NDC outpatient 250 ML 68.75 68.75 MULTIPLAN INC 34080 [3081285] MULTIPLAN INC [308128501] 65.31 percent of total billed charges 42.63 65.31 Technical (Hospital) Services SODIUM CHLORIDE 0.9 % INTRAVENOUS SOLUTION RX-27838 CDM J7050 HCPCS 258 RC 00338-0049-02 NDC outpatient 250 ML 68.75 68.75 CIGNA 62308 [3081051] CIGNA 62308 [308105105] 55 percent of total billed charges 42.63 65.31 Technical (Hospital) Services SODIUM CHLORIDE 0.9 % INTRAVENOUS SOLUTION RX-27838 CDM J7050 HCPCS 258 RC 00338-0049-02 NDC outpatient 250 ML 68.75 68.75 CIGNA 62308 [3081051] CIGNA STATE OF WYOMING [308105107] 55 percent of total billed charges 42.63 65.31 Technical (Hospital) Services SODIUM CHLORIDE 0.9 % INTRAVENOUS SOLUTION RX-27838 CDM J7050 HCPCS 258 RC 00338-0049-02 NDC outpatient 250 ML 68.75 68.75 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES EPO [308136803] 55 percent of total billed charges 42.63 65.31 Technical (Hospital) Services SODIUM CHLORIDE 0.9 % INTRAVENOUS SOLUTION RX-27838 CDM J7050 HCPCS 258 RC 00338-0049-02 NDC outpatient 250 ML 68.75 68.75 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES HDHP [308136802] 55 percent of total billed charges 42.63 65.31 Technical (Hospital) Services SODIUM CHLORIDE 0.9 % INTRAVENOUS SOLUTION RX-27838 CDM J7050 HCPCS 258 RC 00338-0049-02 NDC outpatient 250 ML 68.75 68.75 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES PPO [308136801] 55 percent of total billed charges 42.63 65.31 Technical (Hospital) Services SODIUM CHLORIDE 0.9 % INTRAVENOUS SOLUTION RX-27838 CDM J7050 HCPCS 258 RC 00338-0049-02 NDC outpatient 250 ML 68.75 68.75 UNITED HEALTHCARE (COMMERCIAL) [3081199] UNITED HEALTHCARE 87726 [308119901] 42.63 percent of total billed charges 42.63 65.31 Technical (Hospital) Services SODIUM CHLORIDE 0.9 % INTRAVENOUS SOLUTION RX-27838 CDM J7050 HCPCS 258 RC 00338-0049-02 NDC outpatient 250 ML 68.75 68.75 HEALTHPARTNERS SX009 HEALTHPARTNERS 55 percent of total billed charges 42.63 65.31 Technical (Hospital) Services DEXTROSE 5 % AND 0.2 % SODIUM CHLORIDE INTRAVENOUS SOLUTION RX-9812 CDM J7042 HCPCS 250 RC 00338-0077-04 NDC inpatient 1000 ML 70.5 BLUE CROSS BLUE SHIELD WELLMARK SB889 [3081026] BCBS WYOMING [308102603] 66.98 percent of total billed charges 66.98 66.98 Technical (Hospital) Services DEXTROSE 5 % AND 0.2 % SODIUM CHLORIDE INTRAVENOUS SOLUTION RX-9812 CDM J7042 HCPCS 250 RC 00338-0077-04 NDC outpatient 1000 ML 70.5 BLUE CROSS BLUE SHIELD WELLMARK SB889 [3081026] BCBS WYOMING [308102603] 66.98 percent of total billed charges 66.98 66.98 Technical (Hospital) Services DEXTROSE 5 % AND 0.45 % SODIUM CHLORIDE INTRAVENOUS SOLUTION RX-9814 CDM J7042 HCPCS 250 RC 00338-0085-04 NDC outpatient 1000 ML 70.5 BLUE CROSS BLUE SHIELD WELLMARK SB889 [3081026] BCBS WYOMING [308102603] 66.98 percent of total billed charges 66.98 66.98 Technical (Hospital) Services DEXTROSE 5 % AND 0.45 % SODIUM CHLORIDE INTRAVENOUS SOLUTION RX-9814 CDM J7042 HCPCS 250 RC 00338-0085-04 NDC inpatient 1000 ML 70.5 BLUE CROSS BLUE SHIELD WELLMARK SB889 [3081026] BCBS WYOMING [308102603] 66.98 percent of total billed charges 66.98 66.98 Technical (Hospital) Services DEXTROSE 5 % AND 0.2 % SODIUM CHLORIDE INTRAVENOUS SOLUTION RX-9812 CDM J7042 HCPCS 258 RC 00338-0077-04 NDC outpatient 1000 ML 70.5 70.5 HEALTHPARTNERS SX009 HEALTHPARTNERS 56.4 percent of total billed charges 43.71 66.98 Technical (Hospital) Services DEXTROSE 5 % AND 0.2 % SODIUM CHLORIDE INTRAVENOUS SOLUTION RX-9812 CDM J7042 HCPCS 258 RC 00338-0077-04 NDC outpatient 1000 ML 70.5 70.5 UNITED HEALTHCARE (COMMERCIAL) [3081199] UNITED HEALTHCARE 87726 [308119901] 43.71 percent of total billed charges 43.71 66.98 Technical (Hospital) Services DEXTROSE 5 % AND 0.2 % SODIUM CHLORIDE INTRAVENOUS SOLUTION RX-9812 CDM J7042 HCPCS 258 RC 00338-0077-04 NDC outpatient 1000 ML 70.5 70.5 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES EPO [308136803] 56.4 percent of total billed charges 43.71 66.98 Technical (Hospital) Services DEXTROSE 5 % AND 0.2 % SODIUM CHLORIDE INTRAVENOUS SOLUTION RX-9812 CDM J7042 HCPCS 258 RC 00338-0077-04 NDC outpatient 1000 ML 70.5 70.5 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES HDHP [308136802] 56.4 percent of total billed charges 43.71 66.98 Technical (Hospital) Services DEXTROSE 5 % AND 0.2 % SODIUM CHLORIDE INTRAVENOUS SOLUTION RX-9812 CDM J7042 HCPCS 258 RC 00338-0077-04 NDC outpatient 1000 ML 70.5 70.5 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES PPO [308136801] 56.4 percent of total billed charges 43.71 66.98 Technical (Hospital) Services DEXTROSE 5 % AND 0.2 % SODIUM CHLORIDE INTRAVENOUS SOLUTION RX-9812 CDM J7042 HCPCS 258 RC 00338-0077-04 NDC outpatient 1000 ML 70.5 70.5 CIGNA 62308 [3081051] CIGNA 62308 [308105105] 56.4 percent of total billed charges 43.71 66.98 Technical (Hospital) Services DEXTROSE 5 % AND 0.2 % SODIUM CHLORIDE INTRAVENOUS SOLUTION RX-9812 CDM J7042 HCPCS 258 RC 00338-0077-04 NDC outpatient 1000 ML 70.5 70.5 CIGNA 62308 [3081051] CIGNA STATE OF WYOMING [308105107] 56.4 percent of total billed charges 43.71 66.98 Technical (Hospital) Services DEXTROSE 5 % AND 0.2 % SODIUM CHLORIDE INTRAVENOUS SOLUTION RX-9812 CDM J7042 HCPCS 258 RC 00338-0077-04 NDC outpatient 1000 ML 70.5 70.5 MULTIPLAN INC 34080 [3081285] MULTIPLAN INC [308128501] 66.98 percent of total billed charges 43.71 66.98 Technical (Hospital) Services DEXTROSE 5 % AND 0.2 % SODIUM CHLORIDE INTRAVENOUS SOLUTION RX-9812 CDM J7042 HCPCS 258 RC 00338-0077-04 NDC outpatient 1000 ML 70.5 70.5 MEDICA (COMMERCIAL) 94265 [3081118] MEDICA CLAIMS [308111801] 63.45 percent of total billed charges 43.71 66.98 Technical (Hospital) Services DEXTROSE 5 % AND 0.2 % SODIUM CHLORIDE INTRAVENOUS SOLUTION RX-9812 CDM J7042 HCPCS 258 RC 00338-0077-04 NDC inpatient 1000 ML 70.5 70.5 UNITED HEALTHCARE (COMMERCIAL) [3081199] UNITED HEALTHCARE 87726 [308119901] 43.71 percent of total billed charges 43.71 66.98 Technical (Hospital) Services DEXTROSE 5 % AND 0.2 % SODIUM CHLORIDE INTRAVENOUS SOLUTION RX-9812 CDM J7042 HCPCS 258 RC 00338-0077-04 NDC inpatient 1000 ML 70.5 70.5 MULTIPLAN INC 34080 [3081285] MULTIPLAN INC [308128501] 66.98 percent of total billed charges 43.71 66.98 Technical (Hospital) Services DEXTROSE 5 % AND 0.2 % SODIUM CHLORIDE INTRAVENOUS SOLUTION RX-9812 CDM J7042 HCPCS 258 RC 00338-0077-04 NDC inpatient 1000 ML 70.5 70.5 MEDICA (COMMERCIAL) 94265 [3081118] MEDICA CLAIMS [308111801] 63.45 percent of total billed charges 43.71 66.98 Technical (Hospital) Services DEXTROSE 5 % AND 0.2 % SODIUM CHLORIDE INTRAVENOUS SOLUTION RX-9812 CDM J7042 HCPCS 258 RC 00338-0077-04 NDC inpatient 1000 ML 70.5 70.5 HEALTHPARTNERS SX009 HEALTHPARTNERS 55.82 percent of total billed charges 43.71 66.98 Technical (Hospital) Services DEXTROSE 5 % AND 0.2 % SODIUM CHLORIDE INTRAVENOUS SOLUTION RX-9812 CDM J7042 HCPCS 258 RC 00338-0077-04 NDC inpatient 1000 ML 70.5 70.5 CIGNA 62308 [3081051] CIGNA 62308 [308105105] 55.82 percent of total billed charges 43.71 66.98 Technical (Hospital) Services DEXTROSE 5 % AND 0.2 % SODIUM CHLORIDE INTRAVENOUS SOLUTION RX-9812 CDM J7042 HCPCS 258 RC 00338-0077-04 NDC inpatient 1000 ML 70.5 70.5 CIGNA 62308 [3081051] CIGNA STATE OF WYOMING [308105107] 55.82 percent of total billed charges 43.71 66.98 Technical (Hospital) Services DEXTROSE 5 % AND 0.2 % SODIUM CHLORIDE INTRAVENOUS SOLUTION RX-9812 CDM J7042 HCPCS 258 RC 00338-0077-04 NDC inpatient 1000 ML 70.5 70.5 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES PPO [308136801] 55.82 percent of total billed charges 43.71 66.98 Technical (Hospital) Services DEXTROSE 5 % AND 0.2 % SODIUM CHLORIDE INTRAVENOUS SOLUTION RX-9812 CDM J7042 HCPCS 258 RC 00338-0077-04 NDC inpatient 1000 ML 70.5 70.5 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES HDHP [308136802] 55.82 percent of total billed charges 43.71 66.98 Technical (Hospital) Services DEXTROSE 5 % AND 0.2 % SODIUM CHLORIDE INTRAVENOUS SOLUTION RX-9812 CDM J7042 HCPCS 258 RC 00338-0077-04 NDC inpatient 1000 ML 70.5 70.5 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES EPO [308136803] 55.82 percent of total billed charges 43.71 66.98 Technical (Hospital) Services DEXTROSE 5 % AND 0.45 % SODIUM CHLORIDE INTRAVENOUS SOLUTION RX-9814 CDM J7042 HCPCS 258 RC 00338-0085-04 NDC outpatient 1000 ML 70.5 70.5 HEALTHPARTNERS SX009 HEALTHPARTNERS 56.4 percent of total billed charges 43.71 66.98 Technical (Hospital) Services DEXTROSE 5 % AND 0.45 % SODIUM CHLORIDE INTRAVENOUS SOLUTION RX-9814 CDM J7042 HCPCS 258 RC 00338-0085-04 NDC outpatient 1000 ML 70.5 70.5 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES EPO [308136803] 56.4 percent of total billed charges 43.71 66.98 Technical (Hospital) Services DEXTROSE 5 % AND 0.45 % SODIUM CHLORIDE INTRAVENOUS SOLUTION RX-9814 CDM J7042 HCPCS 258 RC 00338-0085-04 NDC outpatient 1000 ML 70.5 70.5 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES HDHP [308136802] 56.4 percent of total billed charges 43.71 66.98 Technical (Hospital) Services DEXTROSE 5 % AND 0.45 % SODIUM CHLORIDE INTRAVENOUS SOLUTION RX-9814 CDM J7042 HCPCS 258 RC 00338-0085-04 NDC outpatient 1000 ML 70.5 70.5 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES PPO [308136801] 56.4 percent of total billed charges 43.71 66.98 Technical (Hospital) Services DEXTROSE 5 % AND 0.45 % SODIUM CHLORIDE INTRAVENOUS SOLUTION RX-9814 CDM J7042 HCPCS 258 RC 00338-0085-04 NDC outpatient 1000 ML 70.5 70.5 UNITED HEALTHCARE (COMMERCIAL) [3081199] UNITED HEALTHCARE 87726 [308119901] 43.71 percent of total billed charges 43.71 66.98 Technical (Hospital) Services DEXTROSE 5 % AND 0.45 % SODIUM CHLORIDE INTRAVENOUS SOLUTION RX-9814 CDM J7042 HCPCS 258 RC 00338-0085-04 NDC outpatient 1000 ML 70.5 70.5 CIGNA 62308 [3081051] CIGNA 62308 [308105105] 56.4 percent of total billed charges 43.71 66.98 Technical (Hospital) Services DEXTROSE 5 % AND 0.45 % SODIUM CHLORIDE INTRAVENOUS SOLUTION RX-9814 CDM J7042 HCPCS 258 RC 00338-0085-04 NDC outpatient 1000 ML 70.5 70.5 CIGNA 62308 [3081051] CIGNA STATE OF WYOMING [308105107] 56.4 percent of total billed charges 43.71 66.98 Technical (Hospital) Services DEXTROSE 5 % AND 0.45 % SODIUM CHLORIDE INTRAVENOUS SOLUTION RX-9814 CDM J7042 HCPCS 258 RC 00338-0085-04 NDC outpatient 1000 ML 70.5 70.5 MULTIPLAN INC 34080 [3081285] MULTIPLAN INC [308128501] 66.98 percent of total billed charges 43.71 66.98 Technical (Hospital) Services DEXTROSE 5 % AND 0.45 % SODIUM CHLORIDE INTRAVENOUS SOLUTION RX-9814 CDM J7042 HCPCS 258 RC 00338-0085-04 NDC outpatient 1000 ML 70.5 70.5 MEDICA (COMMERCIAL) 94265 [3081118] MEDICA CLAIMS [308111801] 63.45 percent of total billed charges 43.71 66.98 Technical (Hospital) Services DEXTROSE 5 % AND 0.45 % SODIUM CHLORIDE INTRAVENOUS SOLUTION RX-9814 CDM J7042 HCPCS 258 RC 00338-0085-04 NDC inpatient 1000 ML 70.5 70.5 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES HDHP [308136802] 55.82 percent of total billed charges 43.71 66.98 Technical (Hospital) Services DEXTROSE 5 % AND 0.45 % SODIUM CHLORIDE INTRAVENOUS SOLUTION RX-9814 CDM J7042 HCPCS 258 RC 00338-0085-04 NDC inpatient 1000 ML 70.5 70.5 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES PPO [308136801] 55.82 percent of total billed charges 43.71 66.98 Technical (Hospital) Services DEXTROSE 5 % AND 0.45 % SODIUM CHLORIDE INTRAVENOUS SOLUTION RX-9814 CDM J7042 HCPCS 258 RC 00338-0085-04 NDC inpatient 1000 ML 70.5 70.5 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES EPO [308136803] 55.82 percent of total billed charges 43.71 66.98 Technical (Hospital) Services DEXTROSE 5 % AND 0.45 % SODIUM CHLORIDE INTRAVENOUS SOLUTION RX-9814 CDM J7042 HCPCS 258 RC 00338-0085-04 NDC inpatient 1000 ML 70.5 70.5 CIGNA 62308 [3081051] CIGNA 62308 [308105105] 55.82 percent of total billed charges 43.71 66.98 Technical (Hospital) Services DEXTROSE 5 % AND 0.45 % SODIUM CHLORIDE INTRAVENOUS SOLUTION RX-9814 CDM J7042 HCPCS 258 RC 00338-0085-04 NDC inpatient 1000 ML 70.5 70.5 CIGNA 62308 [3081051] CIGNA STATE OF WYOMING [308105107] 55.82 percent of total billed charges 43.71 66.98 Technical (Hospital) Services DEXTROSE 5 % AND 0.45 % SODIUM CHLORIDE INTRAVENOUS SOLUTION RX-9814 CDM J7042 HCPCS 258 RC 00338-0085-04 NDC inpatient 1000 ML 70.5 70.5 UNITED HEALTHCARE (COMMERCIAL) [3081199] UNITED HEALTHCARE 87726 [308119901] 43.71 percent of total billed charges 43.71 66.98 Technical (Hospital) Services DEXTROSE 5 % AND 0.45 % SODIUM CHLORIDE INTRAVENOUS SOLUTION RX-9814 CDM J7042 HCPCS 258 RC 00338-0085-04 NDC inpatient 1000 ML 70.5 70.5 MULTIPLAN INC 34080 [3081285] MULTIPLAN INC [308128501] 66.98 percent of total billed charges 43.71 66.98 Technical (Hospital) Services DEXTROSE 5 % AND 0.45 % SODIUM CHLORIDE INTRAVENOUS SOLUTION RX-9814 CDM J7042 HCPCS 258 RC 00338-0085-04 NDC inpatient 1000 ML 70.5 70.5 MEDICA (COMMERCIAL) 94265 [3081118] MEDICA CLAIMS [308111801] 63.45 percent of total billed charges 43.71 66.98 Technical (Hospital) Services DEXTROSE 5 % AND 0.45 % SODIUM CHLORIDE INTRAVENOUS SOLUTION RX-9814 CDM J7042 HCPCS 258 RC 00338-0085-04 NDC inpatient 1000 ML 70.5 70.5 HEALTHPARTNERS SX009 HEALTHPARTNERS 55.82 percent of total billed charges 43.71 66.98 Technical (Hospital) Services SODIUM CHLORIDE 0.9 % INTRAVENOUS BOLUS RX-40800427838 CDM J7030 HCPCS 250 RC 00338-0049-04 NDC outpatient 1000 ML 70.5 BLUE CROSS BLUE SHIELD WELLMARK SB889 [3081026] BCBS WYOMING [308102603] 66.98 percent of total billed charges 66.98 66.98 Technical (Hospital) Services SODIUM CHLORIDE 0.9 % INTRAVENOUS BOLUS RX-40800427838 CDM J7030 HCPCS 250 RC 00338-0049-04 NDC inpatient 1000 ML 70.5 BLUE CROSS BLUE SHIELD WELLMARK SB889 [3081026] BCBS WYOMING [308102603] 66.98 percent of total billed charges 66.98 66.98 Technical (Hospital) Services SODIUM CHLORIDE 0.9 % INTRAVENOUS BOLUS RX-40800427838 CDM J7030 HCPCS 258 RC 00338-0049-04 NDC inpatient 1000 ML 70.5 70.5 MEDICA (COMMERCIAL) 94265 [3081118] MEDICA CLAIMS [308111801] 63.45 percent of total billed charges 43.71 66.98 Technical (Hospital) Services SODIUM CHLORIDE 0.9 % INTRAVENOUS BOLUS RX-40800427838 CDM J7030 HCPCS 258 RC 00338-0049-04 NDC inpatient 1000 ML 70.5 70.5 MULTIPLAN INC 34080 [3081285] MULTIPLAN INC [308128501] 66.98 percent of total billed charges 43.71 66.98 Technical (Hospital) Services SODIUM CHLORIDE 0.9 % INTRAVENOUS BOLUS RX-40800427838 CDM J7030 HCPCS 258 RC 00338-0049-04 NDC inpatient 1000 ML 70.5 70.5 HEALTHPARTNERS SX009 HEALTHPARTNERS 55.82 percent of total billed charges 43.71 66.98 Technical (Hospital) Services SODIUM CHLORIDE 0.9 % INTRAVENOUS BOLUS RX-40800427838 CDM J7030 HCPCS 258 RC 00338-0049-04 NDC inpatient 1000 ML 70.5 70.5 UNITED HEALTHCARE (COMMERCIAL) [3081199] UNITED HEALTHCARE 87726 [308119901] 43.71 percent of total billed charges 43.71 66.98 Technical (Hospital) Services SODIUM CHLORIDE 0.9 % INTRAVENOUS BOLUS RX-40800427838 CDM J7030 HCPCS 258 RC 00338-0049-04 NDC inpatient 1000 ML 70.5 70.5 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES HDHP [308136802] 55.82 percent of total billed charges 43.71 66.98 Technical (Hospital) Services SODIUM CHLORIDE 0.9 % INTRAVENOUS BOLUS RX-40800427838 CDM J7030 HCPCS 258 RC 00338-0049-04 NDC inpatient 1000 ML 70.5 70.5 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES PPO [308136801] 55.82 percent of total billed charges 43.71 66.98 Technical (Hospital) Services SODIUM CHLORIDE 0.9 % INTRAVENOUS BOLUS RX-40800427838 CDM J7030 HCPCS 258 RC 00338-0049-04 NDC inpatient 1000 ML 70.5 70.5 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES EPO [308136803] 55.82 percent of total billed charges 43.71 66.98 Technical (Hospital) Services SODIUM CHLORIDE 0.9 % INTRAVENOUS BOLUS RX-40800427838 CDM J7030 HCPCS 258 RC 00338-0049-04 NDC inpatient 1000 ML 70.5 70.5 CIGNA 62308 [3081051] CIGNA 62308 [308105105] 55.82 percent of total billed charges 43.71 66.98 Technical (Hospital) Services SODIUM CHLORIDE 0.9 % INTRAVENOUS BOLUS RX-40800427838 CDM J7030 HCPCS 258 RC 00338-0049-04 NDC inpatient 1000 ML 70.5 70.5 CIGNA 62308 [3081051] CIGNA STATE OF WYOMING [308105107] 55.82 percent of total billed charges 43.71 66.98 Technical (Hospital) Services SODIUM CHLORIDE 0.9 % INTRAVENOUS BOLUS RX-40800427838 CDM J7030 HCPCS 258 RC 00338-0049-04 NDC outpatient 1000 ML 70.5 70.5 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES EPO [308136803] 56.4 percent of total billed charges 43.71 66.98 Technical (Hospital) Services SODIUM CHLORIDE 0.9 % INTRAVENOUS BOLUS RX-40800427838 CDM J7030 HCPCS 258 RC 00338-0049-04 NDC outpatient 1000 ML 70.5 70.5 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES HDHP [308136802] 56.4 percent of total billed charges 43.71 66.98 Technical (Hospital) Services SODIUM CHLORIDE 0.9 % INTRAVENOUS BOLUS RX-40800427838 CDM J7030 HCPCS 258 RC 00338-0049-04 NDC outpatient 1000 ML 70.5 70.5 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES PPO [308136801] 56.4 percent of total billed charges 43.71 66.98 Technical (Hospital) Services SODIUM CHLORIDE 0.9 % INTRAVENOUS BOLUS RX-40800427838 CDM J7030 HCPCS 258 RC 00338-0049-04 NDC outpatient 1000 ML 70.5 70.5 UNITED HEALTHCARE (COMMERCIAL) [3081199] UNITED HEALTHCARE 87726 [308119901] 43.71 percent of total billed charges 43.71 66.98 Technical (Hospital) Services SODIUM CHLORIDE 0.9 % INTRAVENOUS BOLUS RX-40800427838 CDM J7030 HCPCS 258 RC 00338-0049-04 NDC outpatient 1000 ML 70.5 70.5 HEALTHPARTNERS SX009 HEALTHPARTNERS 56.4 percent of total billed charges 43.71 66.98 Technical (Hospital) Services SODIUM CHLORIDE 0.9 % INTRAVENOUS BOLUS RX-40800427838 CDM J7030 HCPCS 258 RC 00338-0049-04 NDC outpatient 1000 ML 70.5 70.5 CIGNA 62308 [3081051] CIGNA 62308 [308105105] 56.4 percent of total billed charges 43.71 66.98 Technical (Hospital) Services SODIUM CHLORIDE 0.9 % INTRAVENOUS BOLUS RX-40800427838 CDM J7030 HCPCS 258 RC 00338-0049-04 NDC outpatient 1000 ML 70.5 70.5 CIGNA 62308 [3081051] CIGNA STATE OF WYOMING [308105107] 56.4 percent of total billed charges 43.71 66.98 Technical (Hospital) Services SODIUM CHLORIDE 0.9 % INTRAVENOUS BOLUS RX-40800427838 CDM J7030 HCPCS 258 RC 00338-0049-04 NDC outpatient 1000 ML 70.5 70.5 MULTIPLAN INC 34080 [3081285] MULTIPLAN INC [308128501] 66.98 percent of total billed charges 43.71 66.98 Technical (Hospital) Services SODIUM CHLORIDE 0.9 % INTRAVENOUS BOLUS RX-40800427838 CDM J7030 HCPCS 258 RC 00338-0049-04 NDC outpatient 1000 ML 70.5 70.5 MEDICA (COMMERCIAL) 94265 [3081118] MEDICA CLAIMS [308111801] 63.45 percent of total billed charges 43.71 66.98 Technical (Hospital) Services DEXMEDETOMIDINE 100 MCG/ML INTRAVENOUS SOLUTION RX-123049 CDM J3490 HCPCS 250 RC 44567-0601-04 NDC inpatient 10 ML 395.23 395.23 BLUE CROSS BLUE SHIELD WELLMARK SB889 [3081026] BCBS WYOMING [308102603] 375.47 percent of total billed charges 245.04 375.47 Technical (Hospital) Services DEXMEDETOMIDINE 100 MCG/ML INTRAVENOUS SOLUTION RX-123049 CDM J3490 HCPCS 250 RC 44567-0601-04 NDC inpatient 10 ML 395.23 395.23 UNITED HEALTHCARE (COMMERCIAL) [3081199] UNITED HEALTHCARE 87726 [308119901] 245.04 percent of total billed charges 245.04 375.47 Technical (Hospital) Services DEXMEDETOMIDINE 100 MCG/ML INTRAVENOUS SOLUTION RX-123049 CDM J3490 HCPCS 250 RC 44567-0601-04 NDC inpatient 10 ML 395.23 395.23 CIGNA 62308 [3081051] CIGNA 62308 [308105105] 312.94 percent of total billed charges 245.04 375.47 Technical (Hospital) Services DEXMEDETOMIDINE 100 MCG/ML INTRAVENOUS SOLUTION RX-123049 CDM J3490 HCPCS 250 RC 44567-0601-04 NDC inpatient 10 ML 395.23 395.23 CIGNA 62308 [3081051] CIGNA STATE OF WYOMING [308105107] 312.94 percent of total billed charges 245.04 375.47 Technical (Hospital) Services DEXMEDETOMIDINE 100 MCG/ML INTRAVENOUS SOLUTION RX-123049 CDM J3490 HCPCS 250 RC 44567-0601-04 NDC inpatient 10 ML 395.23 395.23 MULTIPLAN INC 34080 [3081285] MULTIPLAN INC [308128501] 375.47 percent of total billed charges 245.04 375.47 Technical (Hospital) Services DEXMEDETOMIDINE 100 MCG/ML INTRAVENOUS SOLUTION RX-123049 CDM J3490 HCPCS 250 RC 44567-0601-04 NDC inpatient 10 ML 395.23 395.23 MEDICA (COMMERCIAL) 94265 [3081118] MEDICA CLAIMS [308111801] 355.71 percent of total billed charges 245.04 375.47 Technical (Hospital) Services DEXMEDETOMIDINE 100 MCG/ML INTRAVENOUS SOLUTION RX-123049 CDM J3490 HCPCS 250 RC 44567-0601-04 NDC inpatient 10 ML 395.23 395.23 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES PPO [308136801] 312.94 percent of total billed charges 245.04 375.47 Technical (Hospital) Services DEXMEDETOMIDINE 100 MCG/ML INTRAVENOUS SOLUTION RX-123049 CDM J3490 HCPCS 250 RC 44567-0601-04 NDC inpatient 10 ML 395.23 395.23 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES HDHP [308136802] 312.94 percent of total billed charges 245.04 375.47 Technical (Hospital) Services DEXMEDETOMIDINE 100 MCG/ML INTRAVENOUS SOLUTION RX-123049 CDM J3490 HCPCS 250 RC 44567-0601-04 NDC inpatient 10 ML 395.23 395.23 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES EPO [308136803] 312.94 percent of total billed charges 245.04 375.47 Technical (Hospital) Services DEXMEDETOMIDINE 100 MCG/ML INTRAVENOUS SOLUTION RX-123049 CDM J3490 HCPCS 250 RC 44567-0601-04 NDC inpatient 10 ML 395.23 395.23 HEALTHPARTNERS SX009 HEALTHPARTNERS 312.94 percent of total billed charges 245.04 375.47 Technical (Hospital) Services DEXMEDETOMIDINE 100 MCG/ML INTRAVENOUS SOLUTION RX-123049 CDM J3490 HCPCS 250 RC 44567-0601-04 NDC outpatient 10 ML 395.23 395.23 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES EPO [308136803] 316.18 percent of total billed charges 245.04 375.47 Technical (Hospital) Services DEXMEDETOMIDINE 100 MCG/ML INTRAVENOUS SOLUTION RX-123049 CDM J3490 HCPCS 250 RC 44567-0601-04 NDC outpatient 10 ML 395.23 395.23 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES HDHP [308136802] 316.18 percent of total billed charges 245.04 375.47 Technical (Hospital) Services DEXMEDETOMIDINE 100 MCG/ML INTRAVENOUS SOLUTION RX-123049 CDM J3490 HCPCS 250 RC 44567-0601-04 NDC outpatient 10 ML 395.23 395.23 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES PPO [308136801] 316.18 percent of total billed charges 245.04 375.47 Technical (Hospital) Services DEXMEDETOMIDINE 100 MCG/ML INTRAVENOUS SOLUTION RX-123049 CDM J3490 HCPCS 250 RC 44567-0601-04 NDC outpatient 10 ML 395.23 395.23 UNITED HEALTHCARE (COMMERCIAL) [3081199] UNITED HEALTHCARE 87726 [308119901] 245.04 percent of total billed charges 245.04 375.47 Technical (Hospital) Services DEXMEDETOMIDINE 100 MCG/ML INTRAVENOUS SOLUTION RX-123049 CDM J3490 HCPCS 250 RC 44567-0601-04 NDC outpatient 10 ML 395.23 395.23 HEALTHPARTNERS SX009 HEALTHPARTNERS 316.18 percent of total billed charges 245.04 375.47 Technical (Hospital) Services DEXMEDETOMIDINE 100 MCG/ML INTRAVENOUS SOLUTION RX-123049 CDM J3490 HCPCS 250 RC 44567-0601-04 NDC outpatient 10 ML 395.23 395.23 BLUE CROSS BLUE SHIELD WELLMARK SB889 [3081026] BCBS WYOMING [308102603] 375.47 percent of total billed charges 245.04 375.47 Technical (Hospital) Services DEXMEDETOMIDINE 100 MCG/ML INTRAVENOUS SOLUTION RX-123049 CDM J3490 HCPCS 250 RC 44567-0601-04 NDC outpatient 10 ML 395.23 395.23 MEDICA (COMMERCIAL) 94265 [3081118] MEDICA CLAIMS [308111801] 355.71 percent of total billed charges 245.04 375.47 Technical (Hospital) Services DEXMEDETOMIDINE 100 MCG/ML INTRAVENOUS SOLUTION RX-123049 CDM J3490 HCPCS 250 RC 44567-0601-04 NDC outpatient 10 ML 395.23 395.23 MULTIPLAN INC 34080 [3081285] MULTIPLAN INC [308128501] 375.47 percent of total billed charges 245.04 375.47 Technical (Hospital) Services DEXMEDETOMIDINE 100 MCG/ML INTRAVENOUS SOLUTION RX-123049 CDM J3490 HCPCS 250 RC 44567-0601-04 NDC outpatient 10 ML 395.23 395.23 CIGNA 62308 [3081051] CIGNA 62308 [308105105] 316.18 percent of total billed charges 245.04 375.47 Technical (Hospital) Services DEXMEDETOMIDINE 100 MCG/ML INTRAVENOUS SOLUTION RX-123049 CDM J3490 HCPCS 250 RC 44567-0601-04 NDC outpatient 10 ML 395.23 395.23 CIGNA 62308 [3081051] CIGNA STATE OF WYOMING [308105107] 316.18 percent of total billed charges 245.04 375.47 Technical (Hospital) Services EVOLOCUMAB 140 MG/ML SUBCUTANEOUS SYRINGE RX-130155 CDM J3490 HCPCS 250 RC 72511-0750-01 NDC outpatient 1 ML 680.74 680.74 BLUE CROSS BLUE SHIELD WELLMARK SB889 [3081026] BCBS WYOMING [308102603] 646.7 percent of total billed charges 422.06 646.7 Technical (Hospital) Services EVOLOCUMAB 140 MG/ML SUBCUTANEOUS SYRINGE RX-130155 CDM J3490 HCPCS 250 RC 72511-0750-01 NDC outpatient 1 ML 680.74 680.74 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES PPO [308136801] 544.59 percent of total billed charges 422.06 646.7 Technical (Hospital) Services EVOLOCUMAB 140 MG/ML SUBCUTANEOUS SYRINGE RX-130155 CDM J3490 HCPCS 250 RC 72511-0750-01 NDC outpatient 1 ML 680.74 680.74 HEALTHPARTNERS SX009 HEALTHPARTNERS 544.59 percent of total billed charges 422.06 646.7 Technical (Hospital) Services EVOLOCUMAB 140 MG/ML SUBCUTANEOUS SYRINGE RX-130155 CDM J3490 HCPCS 250 RC 72511-0750-01 NDC outpatient 1 ML 680.74 680.74 UNITED HEALTHCARE (COMMERCIAL) [3081199] UNITED HEALTHCARE 87726 [308119901] 422.06 percent of total billed charges 422.06 646.7 Technical (Hospital) Services EVOLOCUMAB 140 MG/ML SUBCUTANEOUS SYRINGE RX-130155 CDM J3490 HCPCS 250 RC 72511-0750-01 NDC outpatient 1 ML 680.74 680.74 MULTIPLAN INC 34080 [3081285] MULTIPLAN INC [308128501] 646.7 percent of total billed charges 422.06 646.7 Technical (Hospital) Services EVOLOCUMAB 140 MG/ML SUBCUTANEOUS SYRINGE RX-130155 CDM J3490 HCPCS 250 RC 72511-0750-01 NDC outpatient 1 ML 680.74 680.74 CIGNA 62308 [3081051] CIGNA 62308 [308105105] 544.59 percent of total billed charges 422.06 646.7 Technical (Hospital) Services EVOLOCUMAB 140 MG/ML SUBCUTANEOUS SYRINGE RX-130155 CDM J3490 HCPCS 250 RC 72511-0750-01 NDC outpatient 1 ML 680.74 680.74 CIGNA 62308 [3081051] CIGNA STATE OF WYOMING [308105107] 544.59 percent of total billed charges 422.06 646.7 Technical (Hospital) Services EVOLOCUMAB 140 MG/ML SUBCUTANEOUS SYRINGE RX-130155 CDM J3490 HCPCS 250 RC 72511-0750-01 NDC outpatient 1 ML 680.74 680.74 MEDICA (COMMERCIAL) 94265 [3081118] MEDICA CLAIMS [308111801] 612.67 percent of total billed charges 422.06 646.7 Technical (Hospital) Services EVOLOCUMAB 140 MG/ML SUBCUTANEOUS SYRINGE RX-130155 CDM J3490 HCPCS 250 RC 72511-0750-01 NDC outpatient 1 ML 680.74 680.74 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES EPO [308136803] 544.59 percent of total billed charges 422.06 646.7 Technical (Hospital) Services EVOLOCUMAB 140 MG/ML SUBCUTANEOUS SYRINGE RX-130155 CDM J3490 HCPCS 250 RC 72511-0750-01 NDC outpatient 1 ML 680.74 680.74 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES HDHP [308136802] 544.59 percent of total billed charges 422.06 646.7 Technical (Hospital) Services EVOLOCUMAB 140 MG/ML SUBCUTANEOUS SYRINGE RX-130155 CDM J3490 HCPCS 250 RC 72511-0750-01 NDC inpatient 1 ML 680.74 680.74 UNITED HEALTHCARE (COMMERCIAL) [3081199] UNITED HEALTHCARE 87726 [308119901] 422.06 percent of total billed charges 422.06 646.7 Technical (Hospital) Services EVOLOCUMAB 140 MG/ML SUBCUTANEOUS SYRINGE RX-130155 CDM J3490 HCPCS 250 RC 72511-0750-01 NDC inpatient 1 ML 680.74 680.74 BLUE CROSS BLUE SHIELD WELLMARK SB889 [3081026] BCBS WYOMING [308102603] 646.7 percent of total billed charges 422.06 646.7 Technical (Hospital) Services EVOLOCUMAB 140 MG/ML SUBCUTANEOUS SYRINGE RX-130155 CDM J3490 HCPCS 250 RC 72511-0750-01 NDC inpatient 1 ML 680.74 680.74 CIGNA 62308 [3081051] CIGNA 62308 [308105105] 539.01 percent of total billed charges 422.06 646.7 Technical (Hospital) Services EVOLOCUMAB 140 MG/ML SUBCUTANEOUS SYRINGE RX-130155 CDM J3490 HCPCS 250 RC 72511-0750-01 NDC inpatient 1 ML 680.74 680.74 CIGNA 62308 [3081051] CIGNA STATE OF WYOMING [308105107] 539.01 percent of total billed charges 422.06 646.7 Technical (Hospital) Services EVOLOCUMAB 140 MG/ML SUBCUTANEOUS SYRINGE RX-130155 CDM J3490 HCPCS 250 RC 72511-0750-01 NDC inpatient 1 ML 680.74 680.74 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES EPO [308136803] 539.01 percent of total billed charges 422.06 646.7 Technical (Hospital) Services EVOLOCUMAB 140 MG/ML SUBCUTANEOUS SYRINGE RX-130155 CDM J3490 HCPCS 250 RC 72511-0750-01 NDC inpatient 1 ML 680.74 680.74 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES HDHP [308136802] 539.01 percent of total billed charges 422.06 646.7 Technical (Hospital) Services EVOLOCUMAB 140 MG/ML SUBCUTANEOUS SYRINGE RX-130155 CDM J3490 HCPCS 250 RC 72511-0750-01 NDC inpatient 1 ML 680.74 680.74 MULTIPLAN INC 34080 [3081285] MULTIPLAN INC [308128501] 646.7 percent of total billed charges 422.06 646.7 Technical (Hospital) Services EVOLOCUMAB 140 MG/ML SUBCUTANEOUS SYRINGE RX-130155 CDM J3490 HCPCS 250 RC 72511-0750-01 NDC inpatient 1 ML 680.74 680.74 HEALTHPARTNERS SX009 HEALTHPARTNERS 539.01 percent of total billed charges 422.06 646.7 Technical (Hospital) Services EVOLOCUMAB 140 MG/ML SUBCUTANEOUS SYRINGE RX-130155 CDM J3490 HCPCS 250 RC 72511-0750-01 NDC inpatient 1 ML 680.74 680.74 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES PPO [308136801] 539.01 percent of total billed charges 422.06 646.7 Technical (Hospital) Services EVOLOCUMAB 140 MG/ML SUBCUTANEOUS SYRINGE RX-130155 CDM J3490 HCPCS 250 RC 72511-0750-01 NDC inpatient 1 ML 680.74 680.74 MEDICA (COMMERCIAL) 94265 [3081118] MEDICA CLAIMS [308111801] 612.67 percent of total billed charges 422.06 646.7 Technical (Hospital) Services FAMOTIDINE (PF) 20 MG/2 ML INTRAVENOUS SOLUTION RX-124962 CDM J3490 HCPCS 636 RC 63323-0739-16 NDC inpatient 2 ML 59.03 59.03 MEDICA (COMMERCIAL) 94265 [3081118] MEDICA CLAIMS [308111801] 53.13 percent of total billed charges 36.6 56.08 Technical (Hospital) Services FAMOTIDINE (PF) 20 MG/2 ML INTRAVENOUS SOLUTION RX-124962 CDM J3490 HCPCS 636 RC 63323-0739-16 NDC inpatient 2 ML 59.03 59.03 MULTIPLAN INC 34080 [3081285] MULTIPLAN INC [308128501] 56.08 percent of total billed charges 36.6 56.08 Technical (Hospital) Services FAMOTIDINE (PF) 20 MG/2 ML INTRAVENOUS SOLUTION RX-124962 CDM J3490 HCPCS 636 RC 63323-0739-16 NDC inpatient 2 ML 59.03 59.03 CIGNA 62308 [3081051] CIGNA 62308 [308105105] 46.74 percent of total billed charges 36.6 56.08 Technical (Hospital) Services FAMOTIDINE (PF) 20 MG/2 ML INTRAVENOUS SOLUTION RX-124962 CDM J3490 HCPCS 636 RC 63323-0739-16 NDC inpatient 2 ML 59.03 59.03 CIGNA 62308 [3081051] CIGNA STATE OF WYOMING [308105107] 46.74 percent of total billed charges 36.6 56.08 Technical (Hospital) Services FAMOTIDINE (PF) 20 MG/2 ML INTRAVENOUS SOLUTION RX-124962 CDM J3490 HCPCS 636 RC 63323-0739-16 NDC inpatient 2 ML 59.03 59.03 UNITED HEALTHCARE (COMMERCIAL) [3081199] UNITED HEALTHCARE 87726 [308119901] 36.6 percent of total billed charges 36.6 56.08 Technical (Hospital) Services FAMOTIDINE (PF) 20 MG/2 ML INTRAVENOUS SOLUTION RX-124962 CDM J3490 HCPCS 636 RC 63323-0739-16 NDC inpatient 2 ML 59.03 59.03 BLUE CROSS BLUE SHIELD WELLMARK SB889 [3081026] BCBS WYOMING [308102603] 56.08 percent of total billed charges 36.6 56.08 Technical (Hospital) Services FAMOTIDINE (PF) 20 MG/2 ML INTRAVENOUS SOLUTION RX-124962 CDM J3490 HCPCS 636 RC 63323-0739-16 NDC inpatient 2 ML 59.03 59.03 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES HDHP [308136802] 46.74 percent of total billed charges 36.6 56.08 Technical (Hospital) Services FAMOTIDINE (PF) 20 MG/2 ML INTRAVENOUS SOLUTION RX-124962 CDM J3490 HCPCS 636 RC 63323-0739-16 NDC inpatient 2 ML 59.03 59.03 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES EPO [308136803] 46.74 percent of total billed charges 36.6 56.08 Technical (Hospital) Services FAMOTIDINE (PF) 20 MG/2 ML INTRAVENOUS SOLUTION RX-124962 CDM J3490 HCPCS 636 RC 63323-0739-16 NDC inpatient 2 ML 59.03 59.03 HEALTHPARTNERS SX009 HEALTHPARTNERS 46.74 percent of total billed charges 36.6 56.08 Technical (Hospital) Services FAMOTIDINE (PF) 20 MG/2 ML INTRAVENOUS SOLUTION RX-124962 CDM J3490 HCPCS 636 RC 63323-0739-16 NDC inpatient 2 ML 59.03 59.03 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES PPO [308136801] 46.74 percent of total billed charges 36.6 56.08 Technical (Hospital) Services FAMOTIDINE (PF) 20 MG/2 ML INTRAVENOUS SOLUTION RX-124962 CDM J3490 HCPCS 636 RC 63323-0739-16 NDC outpatient 2 ML 59.03 59.03 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES EPO [308136803] 47.22 percent of total billed charges 36.6 56.08 Technical (Hospital) Services FAMOTIDINE (PF) 20 MG/2 ML INTRAVENOUS SOLUTION RX-124962 CDM J3490 HCPCS 636 RC 63323-0739-16 NDC outpatient 2 ML 59.03 59.03 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES PPO [308136801] 47.22 percent of total billed charges 36.6 56.08 Technical (Hospital) Services FAMOTIDINE (PF) 20 MG/2 ML INTRAVENOUS SOLUTION RX-124962 CDM J3490 HCPCS 636 RC 63323-0739-16 NDC outpatient 2 ML 59.03 59.03 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES HDHP [308136802] 47.22 percent of total billed charges 36.6 56.08 Technical (Hospital) Services FAMOTIDINE (PF) 20 MG/2 ML INTRAVENOUS SOLUTION RX-124962 CDM J3490 HCPCS 636 RC 63323-0739-16 NDC outpatient 2 ML 59.03 59.03 BLUE CROSS BLUE SHIELD WELLMARK SB889 [3081026] BCBS WYOMING [308102603] 56.08 percent of total billed charges 36.6 56.08 Technical (Hospital) Services FAMOTIDINE (PF) 20 MG/2 ML INTRAVENOUS SOLUTION RX-124962 CDM J3490 HCPCS 636 RC 63323-0739-16 NDC outpatient 2 ML 59.03 59.03 MULTIPLAN INC 34080 [3081285] MULTIPLAN INC [308128501] 56.08 percent of total billed charges 36.6 56.08 Technical (Hospital) Services FAMOTIDINE (PF) 20 MG/2 ML INTRAVENOUS SOLUTION RX-124962 CDM J3490 HCPCS 636 RC 63323-0739-16 NDC outpatient 2 ML 59.03 59.03 CIGNA 62308 [3081051] CIGNA 62308 [308105105] 47.22 percent of total billed charges 36.6 56.08 Technical (Hospital) Services FAMOTIDINE (PF) 20 MG/2 ML INTRAVENOUS SOLUTION RX-124962 CDM J3490 HCPCS 636 RC 63323-0739-16 NDC outpatient 2 ML 59.03 59.03 CIGNA 62308 [3081051] CIGNA STATE OF WYOMING [308105107] 47.22 percent of total billed charges 36.6 56.08 Technical (Hospital) Services FAMOTIDINE (PF) 20 MG/2 ML INTRAVENOUS SOLUTION RX-124962 CDM J3490 HCPCS 636 RC 63323-0739-16 NDC outpatient 2 ML 59.03 59.03 MEDICA (COMMERCIAL) 94265 [3081118] MEDICA CLAIMS [308111801] 53.13 percent of total billed charges 36.6 56.08 Technical (Hospital) Services FAMOTIDINE (PF) 20 MG/2 ML INTRAVENOUS SOLUTION RX-124962 CDM J3490 HCPCS 636 RC 63323-0739-16 NDC outpatient 2 ML 59.03 59.03 HEALTHPARTNERS SX009 HEALTHPARTNERS 47.22 percent of total billed charges 36.6 56.08 Technical (Hospital) Services FAMOTIDINE (PF) 20 MG/2 ML INTRAVENOUS SOLUTION RX-124962 CDM J3490 HCPCS 636 RC 63323-0739-16 NDC outpatient 2 ML 59.03 59.03 UNITED HEALTHCARE (COMMERCIAL) [3081199] UNITED HEALTHCARE 87726 [308119901] 36.6 percent of total billed charges 36.6 56.08 Technical (Hospital) Services ZOLEDRONIC ACID 4 MG/100 ML IN MANNITOL 5 %-WATER INTRAVENOUS PIGGYBCK RX-130943 CDM J3489 HCPCS 636 RC 70860-0210-51 NDC inpatient 100 ML 229.5 229.5 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES PPO [308136801] 181.72 percent of total billed charges 142.29 218.03 Technical (Hospital) Services ZOLEDRONIC ACID 4 MG/100 ML IN MANNITOL 5 %-WATER INTRAVENOUS PIGGYBCK RX-130943 CDM J3489 HCPCS 636 RC 70860-0210-51 NDC inpatient 100 ML 229.5 229.5 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES HDHP [308136802] 181.72 percent of total billed charges 142.29 218.03 Technical (Hospital) Services ZOLEDRONIC ACID 4 MG/100 ML IN MANNITOL 5 %-WATER INTRAVENOUS PIGGYBCK RX-130943 CDM J3489 HCPCS 636 RC 70860-0210-51 NDC inpatient 100 ML 229.5 229.5 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES EPO [308136803] 181.72 percent of total billed charges 142.29 218.03 Technical (Hospital) Services ZOLEDRONIC ACID 4 MG/100 ML IN MANNITOL 5 %-WATER INTRAVENOUS PIGGYBCK RX-130943 CDM J3489 HCPCS 636 RC 70860-0210-51 NDC inpatient 100 ML 229.5 229.5 CIGNA 62308 [3081051] CIGNA 62308 [308105105] 181.72 percent of total billed charges 142.29 218.03 Technical (Hospital) Services ZOLEDRONIC ACID 4 MG/100 ML IN MANNITOL 5 %-WATER INTRAVENOUS PIGGYBCK RX-130943 CDM J3489 HCPCS 636 RC 70860-0210-51 NDC inpatient 100 ML 229.5 229.5 CIGNA 62308 [3081051] CIGNA STATE OF WYOMING [308105107] 181.72 percent of total billed charges 142.29 218.03 Technical (Hospital) Services ZOLEDRONIC ACID 4 MG/100 ML IN MANNITOL 5 %-WATER INTRAVENOUS PIGGYBCK RX-130943 CDM J3489 HCPCS 636 RC 70860-0210-51 NDC inpatient 100 ML 229.5 229.5 BLUE CROSS BLUE SHIELD WELLMARK SB889 [3081026] BCBS WYOMING [308102603] 218.03 percent of total billed charges 142.29 218.03 Technical (Hospital) Services ZOLEDRONIC ACID 4 MG/100 ML IN MANNITOL 5 %-WATER INTRAVENOUS PIGGYBCK RX-130943 CDM J3489 HCPCS 636 RC 70860-0210-51 NDC inpatient 100 ML 229.5 229.5 UNITED HEALTHCARE (COMMERCIAL) [3081199] UNITED HEALTHCARE 87726 [308119901] 142.29 percent of total billed charges 142.29 218.03 Technical (Hospital) Services ZOLEDRONIC ACID 4 MG/100 ML IN MANNITOL 5 %-WATER INTRAVENOUS PIGGYBCK RX-130943 CDM J3489 HCPCS 636 RC 70860-0210-51 NDC inpatient 100 ML 229.5 229.5 MULTIPLAN INC 34080 [3081285] MULTIPLAN INC [308128501] 218.03 percent of total billed charges 142.29 218.03 Technical (Hospital) Services ZOLEDRONIC ACID 4 MG/100 ML IN MANNITOL 5 %-WATER INTRAVENOUS PIGGYBCK RX-130943 CDM J3489 HCPCS 636 RC 70860-0210-51 NDC inpatient 100 ML 229.5 229.5 MEDICA (COMMERCIAL) 94265 [3081118] MEDICA CLAIMS [308111801] 206.55 percent of total billed charges 142.29 218.03 Technical (Hospital) Services ZOLEDRONIC ACID 4 MG/100 ML IN MANNITOL 5 %-WATER INTRAVENOUS PIGGYBCK RX-130943 CDM J3489 HCPCS 636 RC 70860-0210-51 NDC inpatient 100 ML 229.5 229.5 HEALTHPARTNERS SX009 HEALTHPARTNERS 181.72 percent of total billed charges 142.29 218.03 Technical (Hospital) Services ZOLEDRONIC ACID 4 MG/100 ML IN MANNITOL 5 %-WATER INTRAVENOUS PIGGYBCK RX-130943 CDM J3489 HCPCS 636 RC 70860-0210-51 NDC outpatient 100 ML 229.5 229.5 MEDICA (COMMERCIAL) 94265 [3081118] MEDICA CLAIMS [308111801] 206.55 percent of total billed charges 142.29 218.03 Technical (Hospital) Services ZOLEDRONIC ACID 4 MG/100 ML IN MANNITOL 5 %-WATER INTRAVENOUS PIGGYBCK RX-130943 CDM J3489 HCPCS 636 RC 70860-0210-51 NDC outpatient 100 ML 229.5 229.5 MULTIPLAN INC 34080 [3081285] MULTIPLAN INC [308128501] 218.03 percent of total billed charges 142.29 218.03 Technical (Hospital) Services ZOLEDRONIC ACID 4 MG/100 ML IN MANNITOL 5 %-WATER INTRAVENOUS PIGGYBCK RX-130943 CDM J3489 HCPCS 636 RC 70860-0210-51 NDC outpatient 100 ML 229.5 229.5 CIGNA 62308 [3081051] CIGNA 62308 [308105105] 183.6 percent of total billed charges 142.29 218.03 Technical (Hospital) Services ZOLEDRONIC ACID 4 MG/100 ML IN MANNITOL 5 %-WATER INTRAVENOUS PIGGYBCK RX-130943 CDM J3489 HCPCS 636 RC 70860-0210-51 NDC outpatient 100 ML 229.5 229.5 CIGNA 62308 [3081051] CIGNA STATE OF WYOMING [308105107] 183.6 percent of total billed charges 142.29 218.03 Technical (Hospital) Services ZOLEDRONIC ACID 4 MG/100 ML IN MANNITOL 5 %-WATER INTRAVENOUS PIGGYBCK RX-130943 CDM J3489 HCPCS 636 RC 70860-0210-51 NDC outpatient 100 ML 229.5 229.5 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES EPO [308136803] 183.6 percent of total billed charges 142.29 218.03 Technical (Hospital) Services ZOLEDRONIC ACID 4 MG/100 ML IN MANNITOL 5 %-WATER INTRAVENOUS PIGGYBCK RX-130943 CDM J3489 HCPCS 636 RC 70860-0210-51 NDC outpatient 100 ML 229.5 229.5 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES HDHP [308136802] 183.6 percent of total billed charges 142.29 218.03 Technical (Hospital) Services ZOLEDRONIC ACID 4 MG/100 ML IN MANNITOL 5 %-WATER INTRAVENOUS PIGGYBCK RX-130943 CDM J3489 HCPCS 636 RC 70860-0210-51 NDC outpatient 100 ML 229.5 229.5 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES PPO [308136801] 183.6 percent of total billed charges 142.29 218.03 Technical (Hospital) Services ZOLEDRONIC ACID 4 MG/100 ML IN MANNITOL 5 %-WATER INTRAVENOUS PIGGYBCK RX-130943 CDM J3489 HCPCS 636 RC 70860-0210-51 NDC outpatient 100 ML 229.5 229.5 UNITED HEALTHCARE (COMMERCIAL) [3081199] UNITED HEALTHCARE 87726 [308119901] 142.29 percent of total billed charges 142.29 218.03 Technical (Hospital) Services ZOLEDRONIC ACID 4 MG/100 ML IN MANNITOL 5 %-WATER INTRAVENOUS PIGGYBCK RX-130943 CDM J3489 HCPCS 636 RC 70860-0210-51 NDC outpatient 100 ML 229.5 229.5 HEALTHPARTNERS SX009 HEALTHPARTNERS 183.6 percent of total billed charges 142.29 218.03 Technical (Hospital) Services ZOLEDRONIC ACID 4 MG/100 ML IN MANNITOL 5 %-WATER INTRAVENOUS PIGGYBCK RX-130943 CDM J3489 HCPCS 636 RC 70860-0210-51 NDC outpatient 100 ML 229.5 229.5 BLUE CROSS BLUE SHIELD WELLMARK SB889 [3081026] BCBS WYOMING [308102603] 218.03 percent of total billed charges 142.29 218.03 Technical (Hospital) Services ZOLEDRONIC ACID 4 MG/5 ML INTRAVENOUS SOLUTION RX-35640 CDM J3489 HCPCS 636 RC 25021-0801-66 NDC outpatient 5 ML 530 530 MULTIPLAN INC 34080 [3081285] MULTIPLAN INC [308128501] 503.5 percent of total billed charges 328.6 503.5 Technical (Hospital) Services ZOLEDRONIC ACID 4 MG/5 ML INTRAVENOUS SOLUTION RX-35640 CDM J3489 HCPCS 636 RC 25021-0801-66 NDC outpatient 5 ML 530 530 MEDICA (COMMERCIAL) 94265 [3081118] MEDICA CLAIMS [308111801] 477 percent of total billed charges 328.6 503.5 Technical (Hospital) Services ZOLEDRONIC ACID 4 MG/5 ML INTRAVENOUS SOLUTION RX-35640 CDM J3489 HCPCS 636 RC 25021-0801-66 NDC outpatient 5 ML 530 530 HEALTHPARTNERS SX009 HEALTHPARTNERS 424 percent of total billed charges 328.6 503.5 Technical (Hospital) Services ZOLEDRONIC ACID 4 MG/5 ML INTRAVENOUS SOLUTION RX-35640 CDM J3489 HCPCS 636 RC 25021-0801-66 NDC outpatient 5 ML 530 530 UNITED HEALTHCARE (COMMERCIAL) [3081199] UNITED HEALTHCARE 87726 [308119901] 328.6 percent of total billed charges 328.6 503.5 Technical (Hospital) Services ZOLEDRONIC ACID 4 MG/5 ML INTRAVENOUS SOLUTION RX-35640 CDM J3489 HCPCS 636 RC 25021-0801-66 NDC outpatient 5 ML 530 530 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES EPO [308136803] 424 percent of total billed charges 328.6 503.5 Technical (Hospital) Services ZOLEDRONIC ACID 4 MG/5 ML INTRAVENOUS SOLUTION RX-35640 CDM J3489 HCPCS 636 RC 25021-0801-66 NDC outpatient 5 ML 530 530 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES PPO [308136801] 424 percent of total billed charges 328.6 503.5 Technical (Hospital) Services ZOLEDRONIC ACID 4 MG/5 ML INTRAVENOUS SOLUTION RX-35640 CDM J3489 HCPCS 636 RC 25021-0801-66 NDC outpatient 5 ML 530 530 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES HDHP [308136802] 424 percent of total billed charges 328.6 503.5 Technical (Hospital) Services ZOLEDRONIC ACID 4 MG/5 ML INTRAVENOUS SOLUTION RX-35640 CDM J3489 HCPCS 636 RC 25021-0801-66 NDC outpatient 5 ML 530 530 BLUE CROSS BLUE SHIELD WELLMARK SB889 [3081026] BCBS WYOMING [308102603] 503.5 percent of total billed charges 328.6 503.5 Technical (Hospital) Services ZOLEDRONIC ACID 4 MG/5 ML INTRAVENOUS SOLUTION RX-35640 CDM J3489 HCPCS 636 RC 25021-0801-66 NDC outpatient 5 ML 530 530 CIGNA 62308 [3081051] CIGNA 62308 [308105105] 424 percent of total billed charges 328.6 503.5 Technical (Hospital) Services ZOLEDRONIC ACID 4 MG/5 ML INTRAVENOUS SOLUTION RX-35640 CDM J3489 HCPCS 636 RC 25021-0801-66 NDC outpatient 5 ML 530 530 CIGNA 62308 [3081051] CIGNA STATE OF WYOMING [308105107] 424 percent of total billed charges 328.6 503.5 Technical (Hospital) Services ZOLEDRONIC ACID 4 MG/5 ML INTRAVENOUS SOLUTION RX-35640 CDM J3489 HCPCS 636 RC 25021-0801-66 NDC inpatient 5 ML 530 530 MEDICA (COMMERCIAL) 94265 [3081118] MEDICA CLAIMS [308111801] 477 percent of total billed charges 328.6 503.5 Technical (Hospital) Services ZOLEDRONIC ACID 4 MG/5 ML INTRAVENOUS SOLUTION RX-35640 CDM J3489 HCPCS 636 RC 25021-0801-66 NDC inpatient 5 ML 530 530 MULTIPLAN INC 34080 [3081285] MULTIPLAN INC [308128501] 503.5 percent of total billed charges 328.6 503.5 Technical (Hospital) Services ZOLEDRONIC ACID 4 MG/5 ML INTRAVENOUS SOLUTION RX-35640 CDM J3489 HCPCS 636 RC 25021-0801-66 NDC inpatient 5 ML 530 530 CIGNA 62308 [3081051] CIGNA 62308 [308105105] 419.65 percent of total billed charges 328.6 503.5 Technical (Hospital) Services ZOLEDRONIC ACID 4 MG/5 ML INTRAVENOUS SOLUTION RX-35640 CDM J3489 HCPCS 636 RC 25021-0801-66 NDC inpatient 5 ML 530 530 CIGNA 62308 [3081051] CIGNA STATE OF WYOMING [308105107] 419.65 percent of total billed charges 328.6 503.5 Technical (Hospital) Services ZOLEDRONIC ACID 4 MG/5 ML INTRAVENOUS SOLUTION RX-35640 CDM J3489 HCPCS 636 RC 25021-0801-66 NDC inpatient 5 ML 530 530 UNITED HEALTHCARE (COMMERCIAL) [3081199] UNITED HEALTHCARE 87726 [308119901] 328.6 percent of total billed charges 328.6 503.5 Technical (Hospital) Services ZOLEDRONIC ACID 4 MG/5 ML INTRAVENOUS SOLUTION RX-35640 CDM J3489 HCPCS 636 RC 25021-0801-66 NDC inpatient 5 ML 530 530 BLUE CROSS BLUE SHIELD WELLMARK SB889 [3081026] BCBS WYOMING [308102603] 503.5 percent of total billed charges 328.6 503.5 Technical (Hospital) Services ZOLEDRONIC ACID 4 MG/5 ML INTRAVENOUS SOLUTION RX-35640 CDM J3489 HCPCS 636 RC 25021-0801-66 NDC inpatient 5 ML 530 530 HEALTHPARTNERS SX009 HEALTHPARTNERS 419.65 percent of total billed charges 328.6 503.5 Technical (Hospital) Services ZOLEDRONIC ACID 4 MG/5 ML INTRAVENOUS SOLUTION RX-35640 CDM J3489 HCPCS 636 RC 25021-0801-66 NDC inpatient 5 ML 530 530 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES EPO [308136803] 419.65 percent of total billed charges 328.6 503.5 Technical (Hospital) Services ZOLEDRONIC ACID 4 MG/5 ML INTRAVENOUS SOLUTION RX-35640 CDM J3489 HCPCS 636 RC 25021-0801-66 NDC inpatient 5 ML 530 530 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES HDHP [308136802] 419.65 percent of total billed charges 328.6 503.5 Technical (Hospital) Services ZOLEDRONIC ACID 4 MG/5 ML INTRAVENOUS SOLUTION RX-35640 CDM J3489 HCPCS 636 RC 25021-0801-66 NDC inpatient 5 ML 530 530 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES PPO [308136801] 419.65 percent of total billed charges 328.6 503.5 Technical (Hospital) Services ZOLEDRONIC ACID 5 MG/100 ML IN MANNITOL 5 %-WATER INTRAVENOUS PIGGYBCK RX-81434 CDM J3489 HCPCS 636 RC 70860-0802-82 NDC inpatient 100 ML 370.8 370.8 MEDICA (COMMERCIAL) 94265 [3081118] MEDICA CLAIMS [308111801] 333.72 percent of total billed charges 229.9 352.26 Technical (Hospital) Services ZOLEDRONIC ACID 5 MG/100 ML IN MANNITOL 5 %-WATER INTRAVENOUS PIGGYBCK RX-81434 CDM J3489 HCPCS 636 RC 70860-0802-82 NDC inpatient 100 ML 370.8 370.8 MULTIPLAN INC 34080 [3081285] MULTIPLAN INC [308128501] 352.26 percent of total billed charges 229.9 352.26 Technical (Hospital) Services ZOLEDRONIC ACID 5 MG/100 ML IN MANNITOL 5 %-WATER INTRAVENOUS PIGGYBCK RX-81434 CDM J3489 HCPCS 636 RC 70860-0802-82 NDC inpatient 100 ML 370.8 370.8 HEALTHPARTNERS SX009 HEALTHPARTNERS 293.6 percent of total billed charges 229.9 352.26 Technical (Hospital) Services ZOLEDRONIC ACID 5 MG/100 ML IN MANNITOL 5 %-WATER INTRAVENOUS PIGGYBCK RX-81434 CDM J3489 HCPCS 636 RC 70860-0802-82 NDC inpatient 100 ML 370.8 370.8 UNITED HEALTHCARE (COMMERCIAL) [3081199] UNITED HEALTHCARE 87726 [308119901] 229.9 percent of total billed charges 229.9 352.26 Technical (Hospital) Services ZOLEDRONIC ACID 5 MG/100 ML IN MANNITOL 5 %-WATER INTRAVENOUS PIGGYBCK RX-81434 CDM J3489 HCPCS 636 RC 70860-0802-82 NDC inpatient 100 ML 370.8 370.8 BLUE CROSS BLUE SHIELD WELLMARK SB889 [3081026] BCBS WYOMING [308102603] 352.26 percent of total billed charges 229.9 352.26 Technical (Hospital) Services ZOLEDRONIC ACID 5 MG/100 ML IN MANNITOL 5 %-WATER INTRAVENOUS PIGGYBCK RX-81434 CDM J3489 HCPCS 636 RC 70860-0802-82 NDC inpatient 100 ML 370.8 370.8 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES EPO [308136803] 293.6 percent of total billed charges 229.9 352.26 Technical (Hospital) Services ZOLEDRONIC ACID 5 MG/100 ML IN MANNITOL 5 %-WATER INTRAVENOUS PIGGYBCK RX-81434 CDM J3489 HCPCS 636 RC 70860-0802-82 NDC inpatient 100 ML 370.8 370.8 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES HDHP [308136802] 293.6 percent of total billed charges 229.9 352.26 Technical (Hospital) Services ZOLEDRONIC ACID 5 MG/100 ML IN MANNITOL 5 %-WATER INTRAVENOUS PIGGYBCK RX-81434 CDM J3489 HCPCS 636 RC 70860-0802-82 NDC inpatient 100 ML 370.8 370.8 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES PPO [308136801] 293.6 percent of total billed charges 229.9 352.26 Technical (Hospital) Services ZOLEDRONIC ACID 5 MG/100 ML IN MANNITOL 5 %-WATER INTRAVENOUS PIGGYBCK RX-81434 CDM J3489 HCPCS 636 RC 70860-0802-82 NDC inpatient 100 ML 370.8 370.8 CIGNA 62308 [3081051] CIGNA 62308 [308105105] 293.6 percent of total billed charges 229.9 352.26 Technical (Hospital) Services ZOLEDRONIC ACID 5 MG/100 ML IN MANNITOL 5 %-WATER INTRAVENOUS PIGGYBCK RX-81434 CDM J3489 HCPCS 636 RC 70860-0802-82 NDC inpatient 100 ML 370.8 370.8 CIGNA 62308 [3081051] CIGNA STATE OF WYOMING [308105107] 293.6 percent of total billed charges 229.9 352.26 Technical (Hospital) Services ZOLEDRONIC ACID 5 MG/100 ML IN MANNITOL 5 %-WATER INTRAVENOUS PIGGYBCK RX-81434 CDM J3489 HCPCS 636 RC 70860-0802-82 NDC outpatient 100 ML 370.8 370.8 CIGNA 62308 [3081051] CIGNA 62308 [308105105] 296.64 percent of total billed charges 229.9 352.26 Technical (Hospital) Services ZOLEDRONIC ACID 5 MG/100 ML IN MANNITOL 5 %-WATER INTRAVENOUS PIGGYBCK RX-81434 CDM J3489 HCPCS 636 RC 70860-0802-82 NDC outpatient 100 ML 370.8 370.8 CIGNA 62308 [3081051] CIGNA STATE OF WYOMING [308105107] 296.64 percent of total billed charges 229.9 352.26 Technical (Hospital) Services ZOLEDRONIC ACID 5 MG/100 ML IN MANNITOL 5 %-WATER INTRAVENOUS PIGGYBCK RX-81434 CDM J3489 HCPCS 636 RC 70860-0802-82 NDC outpatient 100 ML 370.8 370.8 MEDICA (COMMERCIAL) 94265 [3081118] MEDICA CLAIMS [308111801] 333.72 percent of total billed charges 229.9 352.26 Technical (Hospital) Services ZOLEDRONIC ACID 5 MG/100 ML IN MANNITOL 5 %-WATER INTRAVENOUS PIGGYBCK RX-81434 CDM J3489 HCPCS 636 RC 70860-0802-82 NDC outpatient 100 ML 370.8 370.8 MULTIPLAN INC 34080 [3081285] MULTIPLAN INC [308128501] 352.26 percent of total billed charges 229.9 352.26 Technical (Hospital) Services ZOLEDRONIC ACID 5 MG/100 ML IN MANNITOL 5 %-WATER INTRAVENOUS PIGGYBCK RX-81434 CDM J3489 HCPCS 636 RC 70860-0802-82 NDC outpatient 100 ML 370.8 370.8 BLUE CROSS BLUE SHIELD WELLMARK SB889 [3081026] BCBS WYOMING [308102603] 352.26 percent of total billed charges 229.9 352.26 Technical (Hospital) Services ZOLEDRONIC ACID 5 MG/100 ML IN MANNITOL 5 %-WATER INTRAVENOUS PIGGYBCK RX-81434 CDM J3489 HCPCS 636 RC 70860-0802-82 NDC outpatient 100 ML 370.8 370.8 HEALTHPARTNERS SX009 HEALTHPARTNERS 296.64 percent of total billed charges 229.9 352.26 Technical (Hospital) Services ZOLEDRONIC ACID 5 MG/100 ML IN MANNITOL 5 %-WATER INTRAVENOUS PIGGYBCK RX-81434 CDM J3489 HCPCS 636 RC 70860-0802-82 NDC outpatient 100 ML 370.8 370.8 UNITED HEALTHCARE (COMMERCIAL) [3081199] UNITED HEALTHCARE 87726 [308119901] 229.9 percent of total billed charges 229.9 352.26 Technical (Hospital) Services ZOLEDRONIC ACID 5 MG/100 ML IN MANNITOL 5 %-WATER INTRAVENOUS PIGGYBCK RX-81434 CDM J3489 HCPCS 636 RC 70860-0802-82 NDC outpatient 100 ML 370.8 370.8 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES EPO [308136803] 296.64 percent of total billed charges 229.9 352.26 Technical (Hospital) Services ZOLEDRONIC ACID 5 MG/100 ML IN MANNITOL 5 %-WATER INTRAVENOUS PIGGYBCK RX-81434 CDM J3489 HCPCS 636 RC 70860-0802-82 NDC outpatient 100 ML 370.8 370.8 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES HDHP [308136802] 296.64 percent of total billed charges 229.9 352.26 Technical (Hospital) Services ZOLEDRONIC ACID 5 MG/100 ML IN MANNITOL 5 %-WATER INTRAVENOUS PIGGYBCK RX-81434 CDM J3489 HCPCS 636 RC 70860-0802-82 NDC outpatient 100 ML 370.8 370.8 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES PPO [308136801] 296.64 percent of total billed charges 229.9 352.26 Technical (Hospital) Services ZIPRASIDONE 20 MG/ML (FINAL CONCENTRATION) INTRAMUSCULAR SOLUTION RX-33175 CDM J3486 HCPCS 636 RC 43598-0848-11 NDC inpatient 10 ME 146 146 HEALTHPARTNERS SX009 HEALTHPARTNERS 115.6 percent of total billed charges 90.52 138.7 Technical (Hospital) Services ZIPRASIDONE 20 MG/ML (FINAL CONCENTRATION) INTRAMUSCULAR SOLUTION RX-33175 CDM J3486 HCPCS 636 RC 43598-0848-11 NDC inpatient 10 ME 146 146 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES PPO [308136801] 115.6 percent of total billed charges 90.52 138.7 Technical (Hospital) Services ZIPRASIDONE 20 MG/ML (FINAL CONCENTRATION) INTRAMUSCULAR SOLUTION RX-33175 CDM J3486 HCPCS 636 RC 43598-0848-11 NDC inpatient 10 ME 146 146 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES EPO [308136803] 115.6 percent of total billed charges 90.52 138.7 Technical (Hospital) Services ZIPRASIDONE 20 MG/ML (FINAL CONCENTRATION) INTRAMUSCULAR SOLUTION RX-33175 CDM J3486 HCPCS 636 RC 43598-0848-11 NDC inpatient 10 ME 146 146 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES HDHP [308136802] 115.6 percent of total billed charges 90.52 138.7 Technical (Hospital) Services ZIPRASIDONE 20 MG/ML (FINAL CONCENTRATION) INTRAMUSCULAR SOLUTION RX-33175 CDM J3486 HCPCS 636 RC 43598-0848-11 NDC inpatient 10 ME 146 146 CIGNA 62308 [3081051] CIGNA 62308 [308105105] 115.6 percent of total billed charges 90.52 138.7 Technical (Hospital) Services ZIPRASIDONE 20 MG/ML (FINAL CONCENTRATION) INTRAMUSCULAR SOLUTION RX-33175 CDM J3486 HCPCS 636 RC 43598-0848-11 NDC inpatient 10 ME 146 146 CIGNA 62308 [3081051] CIGNA STATE OF WYOMING [308105107] 115.6 percent of total billed charges 90.52 138.7 Technical (Hospital) Services ZIPRASIDONE 20 MG/ML (FINAL CONCENTRATION) INTRAMUSCULAR SOLUTION RX-33175 CDM J3486 HCPCS 636 RC 43598-0848-11 NDC inpatient 10 ME 146 146 BLUE CROSS BLUE SHIELD WELLMARK SB889 [3081026] BCBS WYOMING [308102603] 138.7 percent of total billed charges 90.52 138.7 Technical (Hospital) Services ZIPRASIDONE 20 MG/ML (FINAL CONCENTRATION) INTRAMUSCULAR SOLUTION RX-33175 CDM J3486 HCPCS 636 RC 43598-0848-11 NDC inpatient 10 ME 146 146 UNITED HEALTHCARE (COMMERCIAL) [3081199] UNITED HEALTHCARE 87726 [308119901] 90.52 percent of total billed charges 90.52 138.7 Technical (Hospital) Services ZIPRASIDONE 20 MG/ML (FINAL CONCENTRATION) INTRAMUSCULAR SOLUTION RX-33175 CDM J3486 HCPCS 636 RC 43598-0848-11 NDC inpatient 10 ME 146 146 MEDICA (COMMERCIAL) 94265 [3081118] MEDICA CLAIMS [308111801] 131.4 percent of total billed charges 90.52 138.7 Technical (Hospital) Services ZIPRASIDONE 20 MG/ML (FINAL CONCENTRATION) INTRAMUSCULAR SOLUTION RX-33175 CDM J3486 HCPCS 636 RC 43598-0848-11 NDC inpatient 10 ME 146 146 MULTIPLAN INC 34080 [3081285] MULTIPLAN INC [308128501] 138.7 percent of total billed charges 90.52 138.7 Technical (Hospital) Services ZIPRASIDONE 20 MG/ML (FINAL CONCENTRATION) INTRAMUSCULAR SOLUTION RX-33175 CDM J3486 HCPCS 636 RC 43598-0848-11 NDC outpatient 10 ME 146 146 MULTIPLAN INC 34080 [3081285] MULTIPLAN INC [308128501] 138.7 percent of total billed charges 90.52 138.7 Technical (Hospital) Services ZIPRASIDONE 20 MG/ML (FINAL CONCENTRATION) INTRAMUSCULAR SOLUTION RX-33175 CDM J3486 HCPCS 636 RC 43598-0848-11 NDC outpatient 10 ME 146 146 MEDICA (COMMERCIAL) 94265 [3081118] MEDICA CLAIMS [308111801] 131.4 percent of total billed charges 90.52 138.7 Technical (Hospital) Services ZIPRASIDONE 20 MG/ML (FINAL CONCENTRATION) INTRAMUSCULAR SOLUTION RX-33175 CDM J3486 HCPCS 636 RC 43598-0848-11 NDC outpatient 10 ME 146 146 HEALTHPARTNERS SX009 HEALTHPARTNERS 116.8 percent of total billed charges 90.52 138.7 Technical (Hospital) Services ZIPRASIDONE 20 MG/ML (FINAL CONCENTRATION) INTRAMUSCULAR SOLUTION RX-33175 CDM J3486 HCPCS 636 RC 43598-0848-11 NDC outpatient 10 ME 146 146 UNITED HEALTHCARE (COMMERCIAL) [3081199] UNITED HEALTHCARE 87726 [308119901] 90.52 percent of total billed charges 90.52 138.7 Technical (Hospital) Services ZIPRASIDONE 20 MG/ML (FINAL CONCENTRATION) INTRAMUSCULAR SOLUTION RX-33175 CDM J3486 HCPCS 636 RC 43598-0848-11 NDC outpatient 10 ME 146 146 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES PPO [308136801] 116.8 percent of total billed charges 90.52 138.7 Technical (Hospital) Services ZIPRASIDONE 20 MG/ML (FINAL CONCENTRATION) INTRAMUSCULAR SOLUTION RX-33175 CDM J3486 HCPCS 636 RC 43598-0848-11 NDC outpatient 10 ME 146 146 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES EPO [308136803] 116.8 percent of total billed charges 90.52 138.7 Technical (Hospital) Services ZIPRASIDONE 20 MG/ML (FINAL CONCENTRATION) INTRAMUSCULAR SOLUTION RX-33175 CDM J3486 HCPCS 636 RC 43598-0848-11 NDC outpatient 10 ME 146 146 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES HDHP [308136802] 116.8 percent of total billed charges 90.52 138.7 Technical (Hospital) Services ZIPRASIDONE 20 MG/ML (FINAL CONCENTRATION) INTRAMUSCULAR SOLUTION RX-33175 CDM J3486 HCPCS 636 RC 43598-0848-11 NDC outpatient 10 ME 146 146 BLUE CROSS BLUE SHIELD WELLMARK SB889 [3081026] BCBS WYOMING [308102603] 138.7 percent of total billed charges 90.52 138.7 Technical (Hospital) Services ZIPRASIDONE 20 MG/ML (FINAL CONCENTRATION) INTRAMUSCULAR SOLUTION RX-33175 CDM J3486 HCPCS 636 RC 43598-0848-11 NDC outpatient 10 ME 146 146 CIGNA 62308 [3081051] CIGNA 62308 [308105105] 116.8 percent of total billed charges 90.52 138.7 Technical (Hospital) Services ZIPRASIDONE 20 MG/ML (FINAL CONCENTRATION) INTRAMUSCULAR SOLUTION RX-33175 CDM J3486 HCPCS 636 RC 43598-0848-11 NDC outpatient 10 ME 146 146 CIGNA 62308 [3081051] CIGNA STATE OF WYOMING [308105107] 116.8 percent of total billed charges 90.52 138.7 Technical (Hospital) Services POTASSIUM CHLORIDE 20 MEQ/L IN 0.9 % SODIUM CHLORIDE INTRAVENOUS RX-11081 CDM J3480 HCPCS 250 RC 00338-0691-04 NDC inpatient 1000 ML 81 BLUE CROSS BLUE SHIELD WELLMARK SB889 [3081026] BCBS WYOMING [308102603] 76.95 percent of total billed charges 76.95 76.95 Technical (Hospital) Services POTASSIUM CHLORIDE 20 MEQ/L IN 0.9 % SODIUM CHLORIDE INTRAVENOUS RX-11081 CDM J3480 HCPCS 250 RC 00338-0691-04 NDC outpatient 1000 ML 81 BLUE CROSS BLUE SHIELD WELLMARK SB889 [3081026] BCBS WYOMING [308102603] 76.95 percent of total billed charges 76.95 76.95 Technical (Hospital) Services POTASSIUM CHLORIDE 20 MEQ/L IN 0.9 % SODIUM CHLORIDE IV BOLUS RX-4080030100 CDM J3480 HCPCS 250 RC 00338-0691-04 NDC outpatient 1000 ML 81 BLUE CROSS BLUE SHIELD WELLMARK SB889 [3081026] BCBS WYOMING [308102603] 76.95 percent of total billed charges 76.95 76.95 Technical (Hospital) Services POTASSIUM CHLORIDE 20 MEQ/L IN 0.9 % SODIUM CHLORIDE IV BOLUS RX-4080030100 CDM J3480 HCPCS 250 RC 00338-0691-04 NDC inpatient 1000 ML 81 BLUE CROSS BLUE SHIELD WELLMARK SB889 [3081026] BCBS WYOMING [308102603] 76.95 percent of total billed charges 76.95 76.95 Technical (Hospital) Services POTASSIUM CHLORIDE 20 MEQ/L IN D5-0.9 % SODIUM CHLORIDE INTRAVENOUS RX-9795 CDM J3480 HCPCS 250 RC 00338-0803-04 NDC inpatient 1000 ML 81 BLUE CROSS BLUE SHIELD WELLMARK SB889 [3081026] BCBS WYOMING [308102603] 76.95 percent of total billed charges 76.95 76.95 Technical (Hospital) Services POTASSIUM CHLORIDE 20 MEQ/L IN D5-0.9 % SODIUM CHLORIDE INTRAVENOUS RX-9795 CDM J3480 HCPCS 250 RC 00338-0803-04 NDC outpatient 1000 ML 81 BLUE CROSS BLUE SHIELD WELLMARK SB889 [3081026] BCBS WYOMING [308102603] 76.95 percent of total billed charges 76.95 76.95 Technical (Hospital) Services POTASSIUM CHLORIDE 20 MEQ/L IN 0.9 % SODIUM CHLORIDE INTRAVENOUS RX-11081 CDM J3480 HCPCS 258 RC 00338-0691-04 NDC outpatient 1000 ML 81 81 HEALTHPARTNERS SX009 HEALTHPARTNERS 64.8 percent of total billed charges 50.22 76.95 Technical (Hospital) Services POTASSIUM CHLORIDE 20 MEQ/L IN 0.9 % SODIUM CHLORIDE INTRAVENOUS RX-11081 CDM J3480 HCPCS 258 RC 00338-0691-04 NDC outpatient 1000 ML 81 81 UNITED HEALTHCARE (COMMERCIAL) [3081199] UNITED HEALTHCARE 87726 [308119901] 50.22 percent of total billed charges 50.22 76.95 Technical (Hospital) Services POTASSIUM CHLORIDE 20 MEQ/L IN 0.9 % SODIUM CHLORIDE INTRAVENOUS RX-11081 CDM J3480 HCPCS 258 RC 00338-0691-04 NDC outpatient 1000 ML 81 81 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES EPO [308136803] 64.8 percent of total billed charges 50.22 76.95 Technical (Hospital) Services POTASSIUM CHLORIDE 20 MEQ/L IN 0.9 % SODIUM CHLORIDE INTRAVENOUS RX-11081 CDM J3480 HCPCS 258 RC 00338-0691-04 NDC outpatient 1000 ML 81 81 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES HDHP [308136802] 64.8 percent of total billed charges 50.22 76.95 Technical (Hospital) Services POTASSIUM CHLORIDE 20 MEQ/L IN 0.9 % SODIUM CHLORIDE INTRAVENOUS RX-11081 CDM J3480 HCPCS 258 RC 00338-0691-04 NDC outpatient 1000 ML 81 81 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES PPO [308136801] 64.8 percent of total billed charges 50.22 76.95 Technical (Hospital) Services POTASSIUM CHLORIDE 20 MEQ/L IN 0.9 % SODIUM CHLORIDE INTRAVENOUS RX-11081 CDM J3480 HCPCS 258 RC 00338-0691-04 NDC outpatient 1000 ML 81 81 MEDICA (COMMERCIAL) 94265 [3081118] MEDICA CLAIMS [308111801] 72.9 percent of total billed charges 50.22 76.95 Technical (Hospital) Services POTASSIUM CHLORIDE 20 MEQ/L IN 0.9 % SODIUM CHLORIDE INTRAVENOUS RX-11081 CDM J3480 HCPCS 258 RC 00338-0691-04 NDC outpatient 1000 ML 81 81 MULTIPLAN INC 34080 [3081285] MULTIPLAN INC [308128501] 76.95 percent of total billed charges 50.22 76.95 Technical (Hospital) Services POTASSIUM CHLORIDE 20 MEQ/L IN 0.9 % SODIUM CHLORIDE INTRAVENOUS RX-11081 CDM J3480 HCPCS 258 RC 00338-0691-04 NDC outpatient 1000 ML 81 81 CIGNA 62308 [3081051] CIGNA 62308 [308105105] 64.8 percent of total billed charges 50.22 76.95 Technical (Hospital) Services POTASSIUM CHLORIDE 20 MEQ/L IN 0.9 % SODIUM CHLORIDE INTRAVENOUS RX-11081 CDM J3480 HCPCS 258 RC 00338-0691-04 NDC outpatient 1000 ML 81 81 CIGNA 62308 [3081051] CIGNA STATE OF WYOMING [308105107] 64.8 percent of total billed charges 50.22 76.95 Technical (Hospital) Services POTASSIUM CHLORIDE 20 MEQ/L IN 0.9 % SODIUM CHLORIDE INTRAVENOUS RX-11081 CDM J3480 HCPCS 258 RC 00338-0691-04 NDC inpatient 1000 ML 81 81 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES PPO [308136801] 64.14 percent of total billed charges 50.22 76.95 Technical (Hospital) Services POTASSIUM CHLORIDE 20 MEQ/L IN 0.9 % SODIUM CHLORIDE INTRAVENOUS RX-11081 CDM J3480 HCPCS 258 RC 00338-0691-04 NDC inpatient 1000 ML 81 81 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES EPO [308136803] 64.14 percent of total billed charges 50.22 76.95 Technical (Hospital) Services POTASSIUM CHLORIDE 20 MEQ/L IN 0.9 % SODIUM CHLORIDE INTRAVENOUS RX-11081 CDM J3480 HCPCS 258 RC 00338-0691-04 NDC inpatient 1000 ML 81 81 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES HDHP [308136802] 64.14 percent of total billed charges 50.22 76.95 Technical (Hospital) Services POTASSIUM CHLORIDE 20 MEQ/L IN 0.9 % SODIUM CHLORIDE INTRAVENOUS RX-11081 CDM J3480 HCPCS 258 RC 00338-0691-04 NDC inpatient 1000 ML 81 81 CIGNA 62308 [3081051] CIGNA 62308 [308105105] 64.14 percent of total billed charges 50.22 76.95 Technical (Hospital) Services POTASSIUM CHLORIDE 20 MEQ/L IN 0.9 % SODIUM CHLORIDE INTRAVENOUS RX-11081 CDM J3480 HCPCS 258 RC 00338-0691-04 NDC inpatient 1000 ML 81 81 CIGNA 62308 [3081051] CIGNA STATE OF WYOMING [308105107] 64.14 percent of total billed charges 50.22 76.95 Technical (Hospital) Services POTASSIUM CHLORIDE 20 MEQ/L IN 0.9 % SODIUM CHLORIDE INTRAVENOUS RX-11081 CDM J3480 HCPCS 258 RC 00338-0691-04 NDC inpatient 1000 ML 81 81 HEALTHPARTNERS SX009 HEALTHPARTNERS 64.14 percent of total billed charges 50.22 76.95 Technical (Hospital) Services POTASSIUM CHLORIDE 20 MEQ/L IN 0.9 % SODIUM CHLORIDE INTRAVENOUS RX-11081 CDM J3480 HCPCS 258 RC 00338-0691-04 NDC inpatient 1000 ML 81 81 MULTIPLAN INC 34080 [3081285] MULTIPLAN INC [308128501] 76.95 percent of total billed charges 50.22 76.95 Technical (Hospital) Services POTASSIUM CHLORIDE 20 MEQ/L IN 0.9 % SODIUM CHLORIDE INTRAVENOUS RX-11081 CDM J3480 HCPCS 258 RC 00338-0691-04 NDC inpatient 1000 ML 81 81 MEDICA (COMMERCIAL) 94265 [3081118] MEDICA CLAIMS [308111801] 72.9 percent of total billed charges 50.22 76.95 Technical (Hospital) Services POTASSIUM CHLORIDE 20 MEQ/L IN 0.9 % SODIUM CHLORIDE INTRAVENOUS RX-11081 CDM J3480 HCPCS 258 RC 00338-0691-04 NDC inpatient 1000 ML 81 81 UNITED HEALTHCARE (COMMERCIAL) [3081199] UNITED HEALTHCARE 87726 [308119901] 50.22 percent of total billed charges 50.22 76.95 Technical (Hospital) Services POTASSIUM CHLORIDE 20 MEQ/L IN 0.9 % SODIUM CHLORIDE IV BOLUS RX-4080030100 CDM J3480 HCPCS 258 RC 00338-0691-04 NDC inpatient 1000 ML 81 81 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES PPO [308136801] 64.14 percent of total billed charges 50.22 76.95 Technical (Hospital) Services POTASSIUM CHLORIDE 20 MEQ/L IN 0.9 % SODIUM CHLORIDE IV BOLUS RX-4080030100 CDM J3480 HCPCS 258 RC 00338-0691-04 NDC inpatient 1000 ML 81 81 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES EPO [308136803] 64.14 percent of total billed charges 50.22 76.95 Technical (Hospital) Services POTASSIUM CHLORIDE 20 MEQ/L IN 0.9 % SODIUM CHLORIDE IV BOLUS RX-4080030100 CDM J3480 HCPCS 258 RC 00338-0691-04 NDC inpatient 1000 ML 81 81 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES HDHP [308136802] 64.14 percent of total billed charges 50.22 76.95 Technical (Hospital) Services POTASSIUM CHLORIDE 20 MEQ/L IN 0.9 % SODIUM CHLORIDE IV BOLUS RX-4080030100 CDM J3480 HCPCS 258 RC 00338-0691-04 NDC inpatient 1000 ML 81 81 CIGNA 62308 [3081051] CIGNA 62308 [308105105] 64.14 percent of total billed charges 50.22 76.95 Technical (Hospital) Services POTASSIUM CHLORIDE 20 MEQ/L IN 0.9 % SODIUM CHLORIDE IV BOLUS RX-4080030100 CDM J3480 HCPCS 258 RC 00338-0691-04 NDC inpatient 1000 ML 81 81 CIGNA 62308 [3081051] CIGNA STATE OF WYOMING [308105107] 64.14 percent of total billed charges 50.22 76.95 Technical (Hospital) Services POTASSIUM CHLORIDE 20 MEQ/L IN 0.9 % SODIUM CHLORIDE IV BOLUS RX-4080030100 CDM J3480 HCPCS 258 RC 00338-0691-04 NDC inpatient 1000 ML 81 81 MEDICA (COMMERCIAL) 94265 [3081118] MEDICA CLAIMS [308111801] 72.9 percent of total billed charges 50.22 76.95 Technical (Hospital) Services POTASSIUM CHLORIDE 20 MEQ/L IN 0.9 % SODIUM CHLORIDE IV BOLUS RX-4080030100 CDM J3480 HCPCS 258 RC 00338-0691-04 NDC inpatient 1000 ML 81 81 MULTIPLAN INC 34080 [3081285] MULTIPLAN INC [308128501] 76.95 percent of total billed charges 50.22 76.95 Technical (Hospital) Services POTASSIUM CHLORIDE 20 MEQ/L IN 0.9 % SODIUM CHLORIDE IV BOLUS RX-4080030100 CDM J3480 HCPCS 258 RC 00338-0691-04 NDC inpatient 1000 ML 81 81 HEALTHPARTNERS SX009 HEALTHPARTNERS 64.14 percent of total billed charges 50.22 76.95 Technical (Hospital) Services POTASSIUM CHLORIDE 20 MEQ/L IN 0.9 % SODIUM CHLORIDE IV BOLUS RX-4080030100 CDM J3480 HCPCS 258 RC 00338-0691-04 NDC inpatient 1000 ML 81 81 UNITED HEALTHCARE (COMMERCIAL) [3081199] UNITED HEALTHCARE 87726 [308119901] 50.22 percent of total billed charges 50.22 76.95 Technical (Hospital) Services POTASSIUM CHLORIDE 20 MEQ/L IN 0.9 % SODIUM CHLORIDE IV BOLUS RX-4080030100 CDM J3480 HCPCS 258 RC 00338-0691-04 NDC outpatient 1000 ML 81 81 UNITED HEALTHCARE (COMMERCIAL) [3081199] UNITED HEALTHCARE 87726 [308119901] 50.22 percent of total billed charges 50.22 76.95 Technical (Hospital) Services POTASSIUM CHLORIDE 20 MEQ/L IN 0.9 % SODIUM CHLORIDE IV BOLUS RX-4080030100 CDM J3480 HCPCS 258 RC 00338-0691-04 NDC outpatient 1000 ML 81 81 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES HDHP [308136802] 64.8 percent of total billed charges 50.22 76.95 Technical (Hospital) Services POTASSIUM CHLORIDE 20 MEQ/L IN 0.9 % SODIUM CHLORIDE IV BOLUS RX-4080030100 CDM J3480 HCPCS 258 RC 00338-0691-04 NDC outpatient 1000 ML 81 81 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES PPO [308136801] 64.8 percent of total billed charges 50.22 76.95 Technical (Hospital) Services POTASSIUM CHLORIDE 20 MEQ/L IN 0.9 % SODIUM CHLORIDE IV BOLUS RX-4080030100 CDM J3480 HCPCS 258 RC 00338-0691-04 NDC outpatient 1000 ML 81 81 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES EPO [308136803] 64.8 percent of total billed charges 50.22 76.95 Technical (Hospital) Services POTASSIUM CHLORIDE 20 MEQ/L IN 0.9 % SODIUM CHLORIDE IV BOLUS RX-4080030100 CDM J3480 HCPCS 258 RC 00338-0691-04 NDC outpatient 1000 ML 81 81 HEALTHPARTNERS SX009 HEALTHPARTNERS 64.8 percent of total billed charges 50.22 76.95 Technical (Hospital) Services POTASSIUM CHLORIDE 20 MEQ/L IN 0.9 % SODIUM CHLORIDE IV BOLUS RX-4080030100 CDM J3480 HCPCS 258 RC 00338-0691-04 NDC outpatient 1000 ML 81 81 MULTIPLAN INC 34080 [3081285] MULTIPLAN INC [308128501] 76.95 percent of total billed charges 50.22 76.95 Technical (Hospital) Services POTASSIUM CHLORIDE 20 MEQ/L IN 0.9 % SODIUM CHLORIDE IV BOLUS RX-4080030100 CDM J3480 HCPCS 258 RC 00338-0691-04 NDC outpatient 1000 ML 81 81 MEDICA (COMMERCIAL) 94265 [3081118] MEDICA CLAIMS [308111801] 72.9 percent of total billed charges 50.22 76.95 Technical (Hospital) Services POTASSIUM CHLORIDE 20 MEQ/L IN 0.9 % SODIUM CHLORIDE IV BOLUS RX-4080030100 CDM J3480 HCPCS 258 RC 00338-0691-04 NDC outpatient 1000 ML 81 81 CIGNA 62308 [3081051] CIGNA 62308 [308105105] 64.8 percent of total billed charges 50.22 76.95 Technical (Hospital) Services POTASSIUM CHLORIDE 20 MEQ/L IN 0.9 % SODIUM CHLORIDE IV BOLUS RX-4080030100 CDM J3480 HCPCS 258 RC 00338-0691-04 NDC outpatient 1000 ML 81 81 CIGNA 62308 [3081051] CIGNA STATE OF WYOMING [308105107] 64.8 percent of total billed charges 50.22 76.95 Technical (Hospital) Services POTASSIUM CHLORIDE 20 MEQ/L IN D5-0.9 % SODIUM CHLORIDE INTRAVENOUS RX-9795 CDM J3480 HCPCS 258 RC 00338-0803-04 NDC inpatient 1000 ML 81 81 CIGNA 62308 [3081051] CIGNA 62308 [308105105] 64.14 percent of total billed charges 50.22 76.95 Technical (Hospital) Services POTASSIUM CHLORIDE 20 MEQ/L IN D5-0.9 % SODIUM CHLORIDE INTRAVENOUS RX-9795 CDM J3480 HCPCS 258 RC 00338-0803-04 NDC inpatient 1000 ML 81 81 CIGNA 62308 [3081051] CIGNA STATE OF WYOMING [308105107] 64.14 percent of total billed charges 50.22 76.95 Technical (Hospital) Services POTASSIUM CHLORIDE 20 MEQ/L IN D5-0.9 % SODIUM CHLORIDE INTRAVENOUS RX-9795 CDM J3480 HCPCS 258 RC 00338-0803-04 NDC inpatient 1000 ML 81 81 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES EPO [308136803] 64.14 percent of total billed charges 50.22 76.95 Technical (Hospital) Services POTASSIUM CHLORIDE 20 MEQ/L IN D5-0.9 % SODIUM CHLORIDE INTRAVENOUS RX-9795 CDM J3480 HCPCS 258 RC 00338-0803-04 NDC inpatient 1000 ML 81 81 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES HDHP [308136802] 64.14 percent of total billed charges 50.22 76.95 Technical (Hospital) Services POTASSIUM CHLORIDE 20 MEQ/L IN D5-0.9 % SODIUM CHLORIDE INTRAVENOUS RX-9795 CDM J3480 HCPCS 258 RC 00338-0803-04 NDC inpatient 1000 ML 81 81 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES PPO [308136801] 64.14 percent of total billed charges 50.22 76.95 Technical (Hospital) Services POTASSIUM CHLORIDE 20 MEQ/L IN D5-0.9 % SODIUM CHLORIDE INTRAVENOUS RX-9795 CDM J3480 HCPCS 258 RC 00338-0803-04 NDC inpatient 1000 ML 81 81 MULTIPLAN INC 34080 [3081285] MULTIPLAN INC [308128501] 76.95 percent of total billed charges 50.22 76.95 Technical (Hospital) Services POTASSIUM CHLORIDE 20 MEQ/L IN D5-0.9 % SODIUM CHLORIDE INTRAVENOUS RX-9795 CDM J3480 HCPCS 258 RC 00338-0803-04 NDC inpatient 1000 ML 81 81 MEDICA (COMMERCIAL) 94265 [3081118] MEDICA CLAIMS [308111801] 72.9 percent of total billed charges 50.22 76.95 Technical (Hospital) Services POTASSIUM CHLORIDE 20 MEQ/L IN D5-0.9 % SODIUM CHLORIDE INTRAVENOUS RX-9795 CDM J3480 HCPCS 258 RC 00338-0803-04 NDC inpatient 1000 ML 81 81 HEALTHPARTNERS SX009 HEALTHPARTNERS 64.14 percent of total billed charges 50.22 76.95 Technical (Hospital) Services POTASSIUM CHLORIDE 20 MEQ/L IN D5-0.9 % SODIUM CHLORIDE INTRAVENOUS RX-9795 CDM J3480 HCPCS 258 RC 00338-0803-04 NDC inpatient 1000 ML 81 81 UNITED HEALTHCARE (COMMERCIAL) [3081199] UNITED HEALTHCARE 87726 [308119901] 50.22 percent of total billed charges 50.22 76.95 Technical (Hospital) Services POTASSIUM CHLORIDE 20 MEQ/L IN D5-0.9 % SODIUM CHLORIDE INTRAVENOUS RX-9795 CDM J3480 HCPCS 258 RC 00338-0803-04 NDC outpatient 1000 ML 81 81 HEALTHPARTNERS SX009 HEALTHPARTNERS 64.8 percent of total billed charges 50.22 76.95 Technical (Hospital) Services POTASSIUM CHLORIDE 20 MEQ/L IN D5-0.9 % SODIUM CHLORIDE INTRAVENOUS RX-9795 CDM J3480 HCPCS 258 RC 00338-0803-04 NDC outpatient 1000 ML 81 81 UNITED HEALTHCARE (COMMERCIAL) [3081199] UNITED HEALTHCARE 87726 [308119901] 50.22 percent of total billed charges 50.22 76.95 Technical (Hospital) Services POTASSIUM CHLORIDE 20 MEQ/L IN D5-0.9 % SODIUM CHLORIDE INTRAVENOUS RX-9795 CDM J3480 HCPCS 258 RC 00338-0803-04 NDC outpatient 1000 ML 81 81 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES HDHP [308136802] 64.8 percent of total billed charges 50.22 76.95 Technical (Hospital) Services POTASSIUM CHLORIDE 20 MEQ/L IN D5-0.9 % SODIUM CHLORIDE INTRAVENOUS RX-9795 CDM J3480 HCPCS 258 RC 00338-0803-04 NDC outpatient 1000 ML 81 81 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES EPO [308136803] 64.8 percent of total billed charges 50.22 76.95 Technical (Hospital) Services POTASSIUM CHLORIDE 20 MEQ/L IN D5-0.9 % SODIUM CHLORIDE INTRAVENOUS RX-9795 CDM J3480 HCPCS 258 RC 00338-0803-04 NDC outpatient 1000 ML 81 81 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES PPO [308136801] 64.8 percent of total billed charges 50.22 76.95 Technical (Hospital) Services POTASSIUM CHLORIDE 20 MEQ/L IN D5-0.9 % SODIUM CHLORIDE INTRAVENOUS RX-9795 CDM J3480 HCPCS 258 RC 00338-0803-04 NDC outpatient 1000 ML 81 81 MEDICA (COMMERCIAL) 94265 [3081118] MEDICA CLAIMS [308111801] 72.9 percent of total billed charges 50.22 76.95 Technical (Hospital) Services POTASSIUM CHLORIDE 20 MEQ/L IN D5-0.9 % SODIUM CHLORIDE INTRAVENOUS RX-9795 CDM J3480 HCPCS 258 RC 00338-0803-04 NDC outpatient 1000 ML 81 81 MULTIPLAN INC 34080 [3081285] MULTIPLAN INC [308128501] 76.95 percent of total billed charges 50.22 76.95 Technical (Hospital) Services POTASSIUM CHLORIDE 20 MEQ/L IN D5-0.9 % SODIUM CHLORIDE INTRAVENOUS RX-9795 CDM J3480 HCPCS 258 RC 00338-0803-04 NDC outpatient 1000 ML 81 81 CIGNA 62308 [3081051] CIGNA 62308 [308105105] 64.8 percent of total billed charges 50.22 76.95 Technical (Hospital) Services POTASSIUM CHLORIDE 20 MEQ/L IN D5-0.9 % SODIUM CHLORIDE INTRAVENOUS RX-9795 CDM J3480 HCPCS 258 RC 00338-0803-04 NDC outpatient 1000 ML 81 81 CIGNA 62308 [3081051] CIGNA STATE OF WYOMING [308105107] 64.8 percent of total billed charges 50.22 76.95 Technical (Hospital) Services POTASSIUM CHLORIDE 10 MEQ/100ML IN STERILE WATER INTRAVENOUS PIGGYBACK RX-11074 CDM J3480 HCPCS 636 RC 00338-0709-48 NDC outpatient 100 ML 62.2 62.2 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES HDHP [308136802] 49.76 percent of total billed charges 38.56 59.09 Technical (Hospital) Services POTASSIUM CHLORIDE 10 MEQ/100ML IN STERILE WATER INTRAVENOUS PIGGYBACK RX-11074 CDM J3480 HCPCS 636 RC 00338-0709-48 NDC outpatient 100 ML 62.2 62.2 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES EPO [308136803] 49.76 percent of total billed charges 38.56 59.09 Technical (Hospital) Services POTASSIUM CHLORIDE 10 MEQ/100ML IN STERILE WATER INTRAVENOUS PIGGYBACK RX-11074 CDM J3480 HCPCS 636 RC 00338-0709-48 NDC outpatient 100 ML 62.2 62.2 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES PPO [308136801] 49.76 percent of total billed charges 38.56 59.09 Technical (Hospital) Services POTASSIUM CHLORIDE 10 MEQ/100ML IN STERILE WATER INTRAVENOUS PIGGYBACK RX-11074 CDM J3480 HCPCS 636 RC 00338-0709-48 NDC outpatient 100 ML 62.2 62.2 BLUE CROSS BLUE SHIELD WELLMARK SB889 [3081026] BCBS WYOMING [308102603] 59.09 percent of total billed charges 38.56 59.09 Technical (Hospital) Services POTASSIUM CHLORIDE 10 MEQ/100ML IN STERILE WATER INTRAVENOUS PIGGYBACK RX-11074 CDM J3480 HCPCS 636 RC 00338-0709-48 NDC outpatient 100 ML 62.2 62.2 HEALTHPARTNERS SX009 HEALTHPARTNERS 49.76 percent of total billed charges 38.56 59.09 Technical (Hospital) Services POTASSIUM CHLORIDE 10 MEQ/100ML IN STERILE WATER INTRAVENOUS PIGGYBACK RX-11074 CDM J3480 HCPCS 636 RC 00338-0709-48 NDC outpatient 100 ML 62.2 62.2 UNITED HEALTHCARE (COMMERCIAL) [3081199] UNITED HEALTHCARE 87726 [308119901] 38.56 percent of total billed charges 38.56 59.09 Technical (Hospital) Services POTASSIUM CHLORIDE 10 MEQ/100ML IN STERILE WATER INTRAVENOUS PIGGYBACK RX-11074 CDM J3480 HCPCS 636 RC 00338-0709-48 NDC outpatient 100 ML 62.2 62.2 CIGNA 62308 [3081051] CIGNA 62308 [308105105] 49.76 percent of total billed charges 38.56 59.09 Technical (Hospital) Services POTASSIUM CHLORIDE 10 MEQ/100ML IN STERILE WATER INTRAVENOUS PIGGYBACK RX-11074 CDM J3480 HCPCS 636 RC 00338-0709-48 NDC outpatient 100 ML 62.2 62.2 CIGNA 62308 [3081051] CIGNA STATE OF WYOMING [308105107] 49.76 percent of total billed charges 38.56 59.09 Technical (Hospital) Services POTASSIUM CHLORIDE 10 MEQ/100ML IN STERILE WATER INTRAVENOUS PIGGYBACK RX-11074 CDM J3480 HCPCS 636 RC 00338-0709-48 NDC outpatient 100 ML 62.2 62.2 MEDICA (COMMERCIAL) 94265 [3081118] MEDICA CLAIMS [308111801] 55.98 percent of total billed charges 38.56 59.09 Technical (Hospital) Services POTASSIUM CHLORIDE 10 MEQ/100ML IN STERILE WATER INTRAVENOUS PIGGYBACK RX-11074 CDM J3480 HCPCS 636 RC 00338-0709-48 NDC outpatient 100 ML 62.2 62.2 MULTIPLAN INC 34080 [3081285] MULTIPLAN INC [308128501] 59.09 percent of total billed charges 38.56 59.09 Technical (Hospital) Services POTASSIUM CHLORIDE 10 MEQ/100ML IN STERILE WATER INTRAVENOUS PIGGYBACK RX-11074 CDM J3480 HCPCS 636 RC 00338-0709-48 NDC inpatient 100 ML 62.2 62.2 HEALTHPARTNERS SX009 HEALTHPARTNERS 49.25 percent of total billed charges 38.56 59.09 Technical (Hospital) Services POTASSIUM CHLORIDE 10 MEQ/100ML IN STERILE WATER INTRAVENOUS PIGGYBACK RX-11074 CDM J3480 HCPCS 636 RC 00338-0709-48 NDC inpatient 100 ML 62.2 62.2 MEDICA (COMMERCIAL) 94265 [3081118] MEDICA CLAIMS [308111801] 55.98 percent of total billed charges 38.56 59.09 Technical (Hospital) Services POTASSIUM CHLORIDE 10 MEQ/100ML IN STERILE WATER INTRAVENOUS PIGGYBACK RX-11074 CDM J3480 HCPCS 636 RC 00338-0709-48 NDC inpatient 100 ML 62.2 62.2 MULTIPLAN INC 34080 [3081285] MULTIPLAN INC [308128501] 59.09 percent of total billed charges 38.56 59.09 Technical (Hospital) Services POTASSIUM CHLORIDE 10 MEQ/100ML IN STERILE WATER INTRAVENOUS PIGGYBACK RX-11074 CDM J3480 HCPCS 636 RC 00338-0709-48 NDC inpatient 100 ML 62.2 62.2 BLUE CROSS BLUE SHIELD WELLMARK SB889 [3081026] BCBS WYOMING [308102603] 59.09 percent of total billed charges 38.56 59.09 Technical (Hospital) Services POTASSIUM CHLORIDE 10 MEQ/100ML IN STERILE WATER INTRAVENOUS PIGGYBACK RX-11074 CDM J3480 HCPCS 636 RC 00338-0709-48 NDC inpatient 100 ML 62.2 62.2 UNITED HEALTHCARE (COMMERCIAL) [3081199] UNITED HEALTHCARE 87726 [308119901] 38.56 percent of total billed charges 38.56 59.09 Technical (Hospital) Services POTASSIUM CHLORIDE 10 MEQ/100ML IN STERILE WATER INTRAVENOUS PIGGYBACK RX-11074 CDM J3480 HCPCS 636 RC 00338-0709-48 NDC inpatient 100 ML 62.2 62.2 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES EPO [308136803] 49.25 percent of total billed charges 38.56 59.09 Technical (Hospital) Services POTASSIUM CHLORIDE 10 MEQ/100ML IN STERILE WATER INTRAVENOUS PIGGYBACK RX-11074 CDM J3480 HCPCS 636 RC 00338-0709-48 NDC inpatient 100 ML 62.2 62.2 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES PPO [308136801] 49.25 percent of total billed charges 38.56 59.09 Technical (Hospital) Services POTASSIUM CHLORIDE 10 MEQ/100ML IN STERILE WATER INTRAVENOUS PIGGYBACK RX-11074 CDM J3480 HCPCS 636 RC 00338-0709-48 NDC inpatient 100 ML 62.2 62.2 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES HDHP [308136802] 49.25 percent of total billed charges 38.56 59.09 Technical (Hospital) Services POTASSIUM CHLORIDE 10 MEQ/100ML IN STERILE WATER INTRAVENOUS PIGGYBACK RX-11074 CDM J3480 HCPCS 636 RC 00338-0709-48 NDC inpatient 100 ML 62.2 62.2 CIGNA 62308 [3081051] CIGNA 62308 [308105105] 49.25 percent of total billed charges 38.56 59.09 Technical (Hospital) Services POTASSIUM CHLORIDE 10 MEQ/100ML IN STERILE WATER INTRAVENOUS PIGGYBACK RX-11074 CDM J3480 HCPCS 636 RC 00338-0709-48 NDC inpatient 100 ML 62.2 62.2 CIGNA 62308 [3081051] CIGNA STATE OF WYOMING [308105107] 49.25 percent of total billed charges 38.56 59.09 Technical (Hospital) Services POTASSIUM CHLORIDE 2 MEQ/ML INTRAVENOUS SOLUTION RX-6429 CDM J3480 HCPCS 636 RC 00409-6653-05 NDC outpatient 20 ML 69.56 69.56 MEDICA (COMMERCIAL) 94265 [3081118] MEDICA CLAIMS [308111801] 62.6 percent of total billed charges 43.13 66.08 Technical (Hospital) Services POTASSIUM CHLORIDE 2 MEQ/ML INTRAVENOUS SOLUTION RX-6429 CDM J3480 HCPCS 636 RC 00409-6653-05 NDC outpatient 20 ML 69.56 69.56 HEALTHPARTNERS SX009 HEALTHPARTNERS 55.65 percent of total billed charges 43.13 66.08 Technical (Hospital) Services POTASSIUM CHLORIDE 2 MEQ/ML INTRAVENOUS SOLUTION RX-6429 CDM J3480 HCPCS 636 RC 00409-6653-05 NDC outpatient 20 ML 69.56 69.56 UNITED HEALTHCARE (COMMERCIAL) [3081199] UNITED HEALTHCARE 87726 [308119901] 43.13 percent of total billed charges 43.13 66.08 Technical (Hospital) Services POTASSIUM CHLORIDE 2 MEQ/ML INTRAVENOUS SOLUTION RX-6429 CDM J3480 HCPCS 636 RC 00409-6653-05 NDC outpatient 20 ML 69.56 69.56 BLUE CROSS BLUE SHIELD WELLMARK SB889 [3081026] BCBS WYOMING [308102603] 66.08 percent of total billed charges 43.13 66.08 Technical (Hospital) Services POTASSIUM CHLORIDE 2 MEQ/ML INTRAVENOUS SOLUTION RX-6429 CDM J3480 HCPCS 636 RC 00409-6653-05 NDC outpatient 20 ML 69.56 69.56 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES EPO [308136803] 55.65 percent of total billed charges 43.13 66.08 Technical (Hospital) Services POTASSIUM CHLORIDE 2 MEQ/ML INTRAVENOUS SOLUTION RX-6429 CDM J3480 HCPCS 636 RC 00409-6653-05 NDC outpatient 20 ML 69.56 69.56 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES HDHP [308136802] 55.65 percent of total billed charges 43.13 66.08 Technical (Hospital) Services POTASSIUM CHLORIDE 2 MEQ/ML INTRAVENOUS SOLUTION RX-6429 CDM J3480 HCPCS 636 RC 00409-6653-05 NDC outpatient 20 ML 69.56 69.56 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES PPO [308136801] 55.65 percent of total billed charges 43.13 66.08 Technical (Hospital) Services POTASSIUM CHLORIDE 2 MEQ/ML INTRAVENOUS SOLUTION RX-6429 CDM J3480 HCPCS 636 RC 00409-6653-05 NDC outpatient 20 ML 69.56 69.56 MULTIPLAN INC 34080 [3081285] MULTIPLAN INC [308128501] 66.08 percent of total billed charges 43.13 66.08 Technical (Hospital) Services POTASSIUM CHLORIDE 2 MEQ/ML INTRAVENOUS SOLUTION RX-6429 CDM J3480 HCPCS 636 RC 00409-6653-05 NDC outpatient 20 ML 69.56 69.56 CIGNA 62308 [3081051] CIGNA 62308 [308105105] 55.65 percent of total billed charges 43.13 66.08 Technical (Hospital) Services POTASSIUM CHLORIDE 2 MEQ/ML INTRAVENOUS SOLUTION RX-6429 CDM J3480 HCPCS 636 RC 00409-6653-05 NDC outpatient 20 ML 69.56 69.56 CIGNA 62308 [3081051] CIGNA STATE OF WYOMING [308105107] 55.65 percent of total billed charges 43.13 66.08 Technical (Hospital) Services POTASSIUM CHLORIDE 2 MEQ/ML INTRAVENOUS SOLUTION RX-6429 CDM J3480 HCPCS 636 RC 00409-6653-05 NDC inpatient 20 ML 69.56 69.56 MEDICA (COMMERCIAL) 94265 [3081118] MEDICA CLAIMS [308111801] 62.6 percent of total billed charges 43.13 66.08 Technical (Hospital) Services POTASSIUM CHLORIDE 2 MEQ/ML INTRAVENOUS SOLUTION RX-6429 CDM J3480 HCPCS 636 RC 00409-6653-05 NDC inpatient 20 ML 69.56 69.56 MULTIPLAN INC 34080 [3081285] MULTIPLAN INC [308128501] 66.08 percent of total billed charges 43.13 66.08 Technical (Hospital) Services POTASSIUM CHLORIDE 2 MEQ/ML INTRAVENOUS SOLUTION RX-6429 CDM J3480 HCPCS 636 RC 00409-6653-05 NDC inpatient 20 ML 69.56 69.56 UNITED HEALTHCARE (COMMERCIAL) [3081199] UNITED HEALTHCARE 87726 [308119901] 43.13 percent of total billed charges 43.13 66.08 Technical (Hospital) Services POTASSIUM CHLORIDE 2 MEQ/ML INTRAVENOUS SOLUTION RX-6429 CDM J3480 HCPCS 636 RC 00409-6653-05 NDC inpatient 20 ML 69.56 69.56 BLUE CROSS BLUE SHIELD WELLMARK SB889 [3081026] BCBS WYOMING [308102603] 66.08 percent of total billed charges 43.13 66.08 Technical (Hospital) Services POTASSIUM CHLORIDE 2 MEQ/ML INTRAVENOUS SOLUTION RX-6429 CDM J3480 HCPCS 636 RC 00409-6653-05 NDC inpatient 20 ML 69.56 69.56 HEALTHPARTNERS SX009 HEALTHPARTNERS 55.08 percent of total billed charges 43.13 66.08 Technical (Hospital) Services POTASSIUM CHLORIDE 2 MEQ/ML INTRAVENOUS SOLUTION RX-6429 CDM J3480 HCPCS 636 RC 00409-6653-05 NDC inpatient 20 ML 69.56 69.56 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES EPO [308136803] 55.08 percent of total billed charges 43.13 66.08 Technical (Hospital) Services POTASSIUM CHLORIDE 2 MEQ/ML INTRAVENOUS SOLUTION RX-6429 CDM J3480 HCPCS 636 RC 00409-6653-05 NDC inpatient 20 ML 69.56 69.56 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES HDHP [308136802] 55.08 percent of total billed charges 43.13 66.08 Technical (Hospital) Services POTASSIUM CHLORIDE 2 MEQ/ML INTRAVENOUS SOLUTION RX-6429 CDM J3480 HCPCS 636 RC 00409-6653-05 NDC inpatient 20 ML 69.56 69.56 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES PPO [308136801] 55.08 percent of total billed charges 43.13 66.08 Technical (Hospital) Services POTASSIUM CHLORIDE 2 MEQ/ML INTRAVENOUS SOLUTION RX-6429 CDM J3480 HCPCS 636 RC 00409-6653-05 NDC inpatient 20 ML 69.56 69.56 CIGNA 62308 [3081051] CIGNA 62308 [308105105] 55.08 percent of total billed charges 43.13 66.08 Technical (Hospital) Services POTASSIUM CHLORIDE 2 MEQ/ML INTRAVENOUS SOLUTION RX-6429 CDM J3480 HCPCS 636 RC 00409-6653-05 NDC inpatient 20 ML 69.56 69.56 CIGNA 62308 [3081051] CIGNA STATE OF WYOMING [308105107] 55.08 percent of total billed charges 43.13 66.08 Technical (Hospital) Services MAGNESIUM SULFATE 2 GRAM/50 ML (4 %) IN WATER INTRAVENOUS PIGGYBACK RX-129651 CDM J3475 HCPCS 636 RC 63323-0106-05 NDC inpatient 50 ML 106 106 CIGNA 62308 [3081051] CIGNA 62308 [308105105] 83.93 percent of total billed charges 65.72 100.7 Technical (Hospital) Services MAGNESIUM SULFATE 2 GRAM/50 ML (4 %) IN WATER INTRAVENOUS PIGGYBACK RX-129651 CDM J3475 HCPCS 636 RC 63323-0106-05 NDC inpatient 50 ML 106 106 CIGNA 62308 [3081051] CIGNA STATE OF WYOMING [308105107] 83.93 percent of total billed charges 65.72 100.7 Technical (Hospital) Services MAGNESIUM SULFATE 2 GRAM/50 ML (4 %) IN WATER INTRAVENOUS PIGGYBACK RX-129651 CDM J3475 HCPCS 636 RC 63323-0106-05 NDC inpatient 50 ML 106 106 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES EPO [308136803] 83.93 percent of total billed charges 65.72 100.7 Technical (Hospital) Services MAGNESIUM SULFATE 2 GRAM/50 ML (4 %) IN WATER INTRAVENOUS PIGGYBACK RX-129651 CDM J3475 HCPCS 636 RC 63323-0106-05 NDC inpatient 50 ML 106 106 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES HDHP [308136802] 83.93 percent of total billed charges 65.72 100.7 Technical (Hospital) Services MAGNESIUM SULFATE 2 GRAM/50 ML (4 %) IN WATER INTRAVENOUS PIGGYBACK RX-129651 CDM J3475 HCPCS 636 RC 63323-0106-05 NDC inpatient 50 ML 106 106 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES PPO [308136801] 83.93 percent of total billed charges 65.72 100.7 Technical (Hospital) Services MAGNESIUM SULFATE 2 GRAM/50 ML (4 %) IN WATER INTRAVENOUS PIGGYBACK RX-129651 CDM J3475 HCPCS 636 RC 63323-0106-05 NDC inpatient 50 ML 106 106 BLUE CROSS BLUE SHIELD WELLMARK SB889 [3081026] BCBS WYOMING [308102603] 100.7 percent of total billed charges 65.72 100.7 Technical (Hospital) Services MAGNESIUM SULFATE 2 GRAM/50 ML (4 %) IN WATER INTRAVENOUS PIGGYBACK RX-129651 CDM J3475 HCPCS 636 RC 63323-0106-05 NDC inpatient 50 ML 106 106 UNITED HEALTHCARE (COMMERCIAL) [3081199] UNITED HEALTHCARE 87726 [308119901] 65.72 percent of total billed charges 65.72 100.7 Technical (Hospital) Services MAGNESIUM SULFATE 2 GRAM/50 ML (4 %) IN WATER INTRAVENOUS PIGGYBACK RX-129651 CDM J3475 HCPCS 636 RC 63323-0106-05 NDC inpatient 50 ML 106 106 MULTIPLAN INC 34080 [3081285] MULTIPLAN INC [308128501] 100.7 percent of total billed charges 65.72 100.7 Technical (Hospital) Services MAGNESIUM SULFATE 2 GRAM/50 ML (4 %) IN WATER INTRAVENOUS PIGGYBACK RX-129651 CDM J3475 HCPCS 636 RC 63323-0106-05 NDC inpatient 50 ML 106 106 MEDICA (COMMERCIAL) 94265 [3081118] MEDICA CLAIMS [308111801] 95.4 percent of total billed charges 65.72 100.7 Technical (Hospital) Services MAGNESIUM SULFATE 2 GRAM/50 ML (4 %) IN WATER INTRAVENOUS PIGGYBACK RX-129651 CDM J3475 HCPCS 636 RC 63323-0106-05 NDC inpatient 50 ML 106 106 HEALTHPARTNERS SX009 HEALTHPARTNERS 83.93 percent of total billed charges 65.72 100.7 Technical (Hospital) Services MAGNESIUM SULFATE 2 GRAM/50 ML (4 %) IN WATER INTRAVENOUS PIGGYBACK RX-129651 CDM J3475 HCPCS 636 RC 63323-0106-05 NDC outpatient 50 ML 106 106 BLUE CROSS BLUE SHIELD WELLMARK SB889 [3081026] BCBS WYOMING [308102603] 100.7 percent of total billed charges 65.72 100.7 Technical (Hospital) Services MAGNESIUM SULFATE 2 GRAM/50 ML (4 %) IN WATER INTRAVENOUS PIGGYBACK RX-129651 CDM J3475 HCPCS 636 RC 63323-0106-05 NDC outpatient 50 ML 106 106 HEALTHPARTNERS SX009 HEALTHPARTNERS 84.8 percent of total billed charges 65.72 100.7 Technical (Hospital) Services MAGNESIUM SULFATE 2 GRAM/50 ML (4 %) IN WATER INTRAVENOUS PIGGYBACK RX-129651 CDM J3475 HCPCS 636 RC 63323-0106-05 NDC outpatient 50 ML 106 106 UNITED HEALTHCARE (COMMERCIAL) [3081199] UNITED HEALTHCARE 87726 [308119901] 65.72 percent of total billed charges 65.72 100.7 Technical (Hospital) Services MAGNESIUM SULFATE 2 GRAM/50 ML (4 %) IN WATER INTRAVENOUS PIGGYBACK RX-129651 CDM J3475 HCPCS 636 RC 63323-0106-05 NDC outpatient 50 ML 106 106 MEDICA (COMMERCIAL) 94265 [3081118] MEDICA CLAIMS [308111801] 95.4 percent of total billed charges 65.72 100.7 Technical (Hospital) Services MAGNESIUM SULFATE 2 GRAM/50 ML (4 %) IN WATER INTRAVENOUS PIGGYBACK RX-129651 CDM J3475 HCPCS 636 RC 63323-0106-05 NDC outpatient 50 ML 106 106 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES EPO [308136803] 84.8 percent of total billed charges 65.72 100.7 Technical (Hospital) Services MAGNESIUM SULFATE 2 GRAM/50 ML (4 %) IN WATER INTRAVENOUS PIGGYBACK RX-129651 CDM J3475 HCPCS 636 RC 63323-0106-05 NDC outpatient 50 ML 106 106 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES PPO [308136801] 84.8 percent of total billed charges 65.72 100.7 Technical (Hospital) Services MAGNESIUM SULFATE 2 GRAM/50 ML (4 %) IN WATER INTRAVENOUS PIGGYBACK RX-129651 CDM J3475 HCPCS 636 RC 63323-0106-05 NDC outpatient 50 ML 106 106 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES HDHP [308136802] 84.8 percent of total billed charges 65.72 100.7 Technical (Hospital) Services MAGNESIUM SULFATE 2 GRAM/50 ML (4 %) IN WATER INTRAVENOUS PIGGYBACK RX-129651 CDM J3475 HCPCS 636 RC 63323-0106-05 NDC outpatient 50 ML 106 106 MULTIPLAN INC 34080 [3081285] MULTIPLAN INC [308128501] 100.7 percent of total billed charges 65.72 100.7 Technical (Hospital) Services MAGNESIUM SULFATE 2 GRAM/50 ML (4 %) IN WATER INTRAVENOUS PIGGYBACK RX-129651 CDM J3475 HCPCS 636 RC 63323-0106-05 NDC outpatient 50 ML 106 106 CIGNA 62308 [3081051] CIGNA 62308 [308105105] 84.8 percent of total billed charges 65.72 100.7 Technical (Hospital) Services MAGNESIUM SULFATE 2 GRAM/50 ML (4 %) IN WATER INTRAVENOUS PIGGYBACK RX-129651 CDM J3475 HCPCS 636 RC 63323-0106-05 NDC outpatient 50 ML 106 106 CIGNA 62308 [3081051] CIGNA STATE OF WYOMING [308105107] 84.8 percent of total billed charges 65.72 100.7 Technical (Hospital) Services MAGNESIUM SULFATE 500 MG/ML (50 %) INJECTION SOLUTION RX-4720 CDM J3475 HCPCS 636 RC 63323-0064-03 NDC outpatient 2 ML 60.57 60.57 HEALTHPARTNERS SX009 HEALTHPARTNERS 48.46 percent of total billed charges 37.55 57.54 Technical (Hospital) Services MAGNESIUM SULFATE 500 MG/ML (50 %) INJECTION SOLUTION RX-4720 CDM J3475 HCPCS 636 RC 63323-0064-03 NDC outpatient 2 ML 60.57 60.57 UNITED HEALTHCARE (COMMERCIAL) [3081199] UNITED HEALTHCARE 87726 [308119901] 37.55 percent of total billed charges 37.55 57.54 Technical (Hospital) Services MAGNESIUM SULFATE 500 MG/ML (50 %) INJECTION SOLUTION RX-4720 CDM J3475 HCPCS 636 RC 63323-0064-03 NDC outpatient 2 ML 60.57 60.57 CIGNA 62308 [3081051] CIGNA 62308 [308105105] 48.46 percent of total billed charges 37.55 57.54 Technical (Hospital) Services MAGNESIUM SULFATE 500 MG/ML (50 %) INJECTION SOLUTION RX-4720 CDM J3475 HCPCS 636 RC 63323-0064-03 NDC outpatient 2 ML 60.57 60.57 CIGNA 62308 [3081051] CIGNA STATE OF WYOMING [308105107] 48.46 percent of total billed charges 37.55 57.54 Technical (Hospital) Services MAGNESIUM SULFATE 500 MG/ML (50 %) INJECTION SOLUTION RX-4720 CDM J3475 HCPCS 636 RC 63323-0064-03 NDC outpatient 2 ML 60.57 60.57 MULTIPLAN INC 34080 [3081285] MULTIPLAN INC [308128501] 57.54 percent of total billed charges 37.55 57.54 Technical (Hospital) Services MAGNESIUM SULFATE 500 MG/ML (50 %) INJECTION SOLUTION RX-4720 CDM J3475 HCPCS 636 RC 63323-0064-03 NDC outpatient 2 ML 60.57 60.57 MEDICA (COMMERCIAL) 94265 [3081118] MEDICA CLAIMS [308111801] 54.51 percent of total billed charges 37.55 57.54 Technical (Hospital) Services MAGNESIUM SULFATE 500 MG/ML (50 %) INJECTION SOLUTION RX-4720 CDM J3475 HCPCS 636 RC 63323-0064-03 NDC outpatient 2 ML 60.57 60.57 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES HDHP [308136802] 48.46 percent of total billed charges 37.55 57.54 Technical (Hospital) Services MAGNESIUM SULFATE 500 MG/ML (50 %) INJECTION SOLUTION RX-4720 CDM J3475 HCPCS 636 RC 63323-0064-03 NDC outpatient 2 ML 60.57 60.57 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES EPO [308136803] 48.46 percent of total billed charges 37.55 57.54 Technical (Hospital) Services MAGNESIUM SULFATE 500 MG/ML (50 %) INJECTION SOLUTION RX-4720 CDM J3475 HCPCS 636 RC 63323-0064-03 NDC outpatient 2 ML 60.57 60.57 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES PPO [308136801] 48.46 percent of total billed charges 37.55 57.54 Technical (Hospital) Services MAGNESIUM SULFATE 500 MG/ML (50 %) INJECTION SOLUTION RX-4720 CDM J3475 HCPCS 636 RC 63323-0064-03 NDC outpatient 2 ML 60.57 60.57 BLUE CROSS BLUE SHIELD WELLMARK SB889 [3081026] BCBS WYOMING [308102603] 57.54 percent of total billed charges 37.55 57.54 Technical (Hospital) Services MAGNESIUM SULFATE 500 MG/ML (50 %) INJECTION SOLUTION RX-4720 CDM J3475 HCPCS 636 RC 63323-0064-03 NDC inpatient 2 ML 60.57 60.57 MULTIPLAN INC 34080 [3081285] MULTIPLAN INC [308128501] 57.54 percent of total billed charges 37.55 57.54 Technical (Hospital) Services MAGNESIUM SULFATE 500 MG/ML (50 %) INJECTION SOLUTION RX-4720 CDM J3475 HCPCS 636 RC 63323-0064-03 NDC inpatient 2 ML 60.57 60.57 MEDICA (COMMERCIAL) 94265 [3081118] MEDICA CLAIMS [308111801] 54.51 percent of total billed charges 37.55 57.54 Technical (Hospital) Services MAGNESIUM SULFATE 500 MG/ML (50 %) INJECTION SOLUTION RX-4720 CDM J3475 HCPCS 636 RC 63323-0064-03 NDC inpatient 2 ML 60.57 60.57 UNITED HEALTHCARE (COMMERCIAL) [3081199] UNITED HEALTHCARE 87726 [308119901] 37.55 percent of total billed charges 37.55 57.54 Technical (Hospital) Services MAGNESIUM SULFATE 500 MG/ML (50 %) INJECTION SOLUTION RX-4720 CDM J3475 HCPCS 636 RC 63323-0064-03 NDC inpatient 2 ML 60.57 60.57 BLUE CROSS BLUE SHIELD WELLMARK SB889 [3081026] BCBS WYOMING [308102603] 57.54 percent of total billed charges 37.55 57.54 Technical (Hospital) Services MAGNESIUM SULFATE 500 MG/ML (50 %) INJECTION SOLUTION RX-4720 CDM J3475 HCPCS 636 RC 63323-0064-03 NDC inpatient 2 ML 60.57 60.57 CIGNA 62308 [3081051] CIGNA 62308 [308105105] 47.96 percent of total billed charges 37.55 57.54 Technical (Hospital) Services MAGNESIUM SULFATE 500 MG/ML (50 %) INJECTION SOLUTION RX-4720 CDM J3475 HCPCS 636 RC 63323-0064-03 NDC inpatient 2 ML 60.57 60.57 CIGNA 62308 [3081051] CIGNA STATE OF WYOMING [308105107] 47.96 percent of total billed charges 37.55 57.54 Technical (Hospital) Services MAGNESIUM SULFATE 500 MG/ML (50 %) INJECTION SOLUTION RX-4720 CDM J3475 HCPCS 636 RC 63323-0064-03 NDC inpatient 2 ML 60.57 60.57 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES HDHP [308136802] 47.96 percent of total billed charges 37.55 57.54 Technical (Hospital) Services MAGNESIUM SULFATE 500 MG/ML (50 %) INJECTION SOLUTION RX-4720 CDM J3475 HCPCS 636 RC 63323-0064-03 NDC inpatient 2 ML 60.57 60.57 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES PPO [308136801] 47.96 percent of total billed charges 37.55 57.54 Technical (Hospital) Services MAGNESIUM SULFATE 500 MG/ML (50 %) INJECTION SOLUTION RX-4720 CDM J3475 HCPCS 636 RC 63323-0064-03 NDC inpatient 2 ML 60.57 60.57 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES EPO [308136803] 47.96 percent of total billed charges 37.55 57.54 Technical (Hospital) Services MAGNESIUM SULFATE 500 MG/ML (50 %) INJECTION SOLUTION RX-4720 CDM J3475 HCPCS 636 RC 63323-0064-03 NDC inpatient 2 ML 60.57 60.57 HEALTHPARTNERS SX009 HEALTHPARTNERS 47.96 percent of total billed charges 37.55 57.54 Technical (Hospital) Services PHYTONADIONE (VITAMIN K1) 10 MG/ML INJECTION SOLUTION RX-11023 CDM J3430 HCPCS 636 RC 00409-9158-01 NDC outpatient 0.2 ML 74.29 74.29 HEALTHPARTNERS SX009 HEALTHPARTNERS 59.43 percent of total billed charges 46.06 70.58 Technical (Hospital) Services PHYTONADIONE (VITAMIN K1) 10 MG/ML INJECTION SOLUTION RX-11023 CDM J3430 HCPCS 636 RC 00409-9158-01 NDC outpatient 0.2 ML 74.29 74.29 BLUE CROSS BLUE SHIELD WELLMARK SB889 [3081026] BCBS WYOMING [308102603] 70.58 percent of total billed charges 46.06 70.58 Technical (Hospital) Services PHYTONADIONE (VITAMIN K1) 10 MG/ML INJECTION SOLUTION RX-11023 CDM J3430 HCPCS 636 RC 00409-9158-01 NDC outpatient 0.2 ML 74.29 74.29 UNITED HEALTHCARE (COMMERCIAL) [3081199] UNITED HEALTHCARE 87726 [308119901] 46.06 percent of total billed charges 46.06 70.58 Technical (Hospital) Services PHYTONADIONE (VITAMIN K1) 10 MG/ML INJECTION SOLUTION RX-11023 CDM J3430 HCPCS 636 RC 00409-9158-01 NDC outpatient 0.2 ML 74.29 74.29 CIGNA 62308 [3081051] CIGNA 62308 [308105105] 59.43 percent of total billed charges 46.06 70.58 Technical (Hospital) Services PHYTONADIONE (VITAMIN K1) 10 MG/ML INJECTION SOLUTION RX-11023 CDM J3430 HCPCS 636 RC 00409-9158-01 NDC outpatient 0.2 ML 74.29 74.29 CIGNA 62308 [3081051] CIGNA STATE OF WYOMING [308105107] 59.43 percent of total billed charges 46.06 70.58 Technical (Hospital) Services PHYTONADIONE (VITAMIN K1) 10 MG/ML INJECTION SOLUTION RX-11023 CDM J3430 HCPCS 636 RC 00409-9158-01 NDC outpatient 0.2 ML 74.29 74.29 MULTIPLAN INC 34080 [3081285] MULTIPLAN INC [308128501] 70.58 percent of total billed charges 46.06 70.58 Technical (Hospital) Services PHYTONADIONE (VITAMIN K1) 10 MG/ML INJECTION SOLUTION RX-11023 CDM J3430 HCPCS 636 RC 00409-9158-01 NDC outpatient 0.2 ML 74.29 74.29 MEDICA (COMMERCIAL) 94265 [3081118] MEDICA CLAIMS [308111801] 66.86 percent of total billed charges 46.06 70.58 Technical (Hospital) Services PHYTONADIONE (VITAMIN K1) 10 MG/ML INJECTION SOLUTION RX-11023 CDM J3430 HCPCS 636 RC 00409-9158-01 NDC outpatient 0.2 ML 74.29 74.29 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES EPO [308136803] 59.43 percent of total billed charges 46.06 70.58 Technical (Hospital) Services PHYTONADIONE (VITAMIN K1) 10 MG/ML INJECTION SOLUTION RX-11023 CDM J3430 HCPCS 636 RC 00409-9158-01 NDC outpatient 0.2 ML 74.29 74.29 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES HDHP [308136802] 59.43 percent of total billed charges 46.06 70.58 Technical (Hospital) Services PHYTONADIONE (VITAMIN K1) 10 MG/ML INJECTION SOLUTION RX-11023 CDM J3430 HCPCS 636 RC 00409-9158-01 NDC outpatient 0.2 ML 74.29 74.29 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES PPO [308136801] 59.43 percent of total billed charges 46.06 70.58 Technical (Hospital) Services PHYTONADIONE (VITAMIN K1) 10 MG/ML INJECTION SOLUTION RX-11023 CDM J3430 HCPCS 636 RC 00409-9158-01 NDC inpatient 0.2 ML 74.29 74.29 MULTIPLAN INC 34080 [3081285] MULTIPLAN INC [308128501] 70.58 percent of total billed charges 46.06 70.58 Technical (Hospital) Services PHYTONADIONE (VITAMIN K1) 10 MG/ML INJECTION SOLUTION RX-11023 CDM J3430 HCPCS 636 RC 00409-9158-01 NDC inpatient 0.2 ML 74.29 74.29 HEALTHPARTNERS SX009 HEALTHPARTNERS 58.82 percent of total billed charges 46.06 70.58 Technical (Hospital) Services PHYTONADIONE (VITAMIN K1) 10 MG/ML INJECTION SOLUTION RX-11023 CDM J3430 HCPCS 636 RC 00409-9158-01 NDC inpatient 0.2 ML 74.29 74.29 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES EPO [308136803] 58.82 percent of total billed charges 46.06 70.58 Technical (Hospital) Services PHYTONADIONE (VITAMIN K1) 10 MG/ML INJECTION SOLUTION RX-11023 CDM J3430 HCPCS 636 RC 00409-9158-01 NDC inpatient 0.2 ML 74.29 74.29 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES HDHP [308136802] 58.82 percent of total billed charges 46.06 70.58 Technical (Hospital) Services PHYTONADIONE (VITAMIN K1) 10 MG/ML INJECTION SOLUTION RX-11023 CDM J3430 HCPCS 636 RC 00409-9158-01 NDC inpatient 0.2 ML 74.29 74.29 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES PPO [308136801] 58.82 percent of total billed charges 46.06 70.58 Technical (Hospital) Services PHYTONADIONE (VITAMIN K1) 10 MG/ML INJECTION SOLUTION RX-11023 CDM J3430 HCPCS 636 RC 00409-9158-01 NDC inpatient 0.2 ML 74.29 74.29 MEDICA (COMMERCIAL) 94265 [3081118] MEDICA CLAIMS [308111801] 66.86 percent of total billed charges 46.06 70.58 Technical (Hospital) Services PHYTONADIONE (VITAMIN K1) 10 MG/ML INJECTION SOLUTION RX-11023 CDM J3430 HCPCS 636 RC 00409-9158-01 NDC inpatient 0.2 ML 74.29 74.29 UNITED HEALTHCARE (COMMERCIAL) [3081199] UNITED HEALTHCARE 87726 [308119901] 46.06 percent of total billed charges 46.06 70.58 Technical (Hospital) Services PHYTONADIONE (VITAMIN K1) 10 MG/ML INJECTION SOLUTION RX-11023 CDM J3430 HCPCS 636 RC 00409-9158-01 NDC inpatient 0.2 ML 74.29 74.29 CIGNA 62308 [3081051] CIGNA 62308 [308105105] 58.82 percent of total billed charges 46.06 70.58 Technical (Hospital) Services PHYTONADIONE (VITAMIN K1) 10 MG/ML INJECTION SOLUTION RX-11023 CDM J3430 HCPCS 636 RC 00409-9158-01 NDC inpatient 0.2 ML 74.29 74.29 CIGNA 62308 [3081051] CIGNA STATE OF WYOMING [308105107] 58.82 percent of total billed charges 46.06 70.58 Technical (Hospital) Services PHYTONADIONE (VITAMIN K1) 10 MG/ML INJECTION SOLUTION RX-11023 CDM J3430 HCPCS 636 RC 00409-9158-01 NDC inpatient 0.2 ML 74.29 74.29 BLUE CROSS BLUE SHIELD WELLMARK SB889 [3081026] BCBS WYOMING [308102603] 70.58 percent of total billed charges 46.06 70.58 Technical (Hospital) Services "CYANOCOBALAMIN (VIT B-12) 1,000 MCG/ML INJECTION SOLUTION" RX-2007 CDM J3420 HCPCS 636 RC 63323-0044-00 NDC outpatient 0.1 ML 58.99 58.99 HEALTHPARTNERS SX009 HEALTHPARTNERS 47.19 percent of total billed charges 36.57 56.04 Technical (Hospital) Services "CYANOCOBALAMIN (VIT B-12) 1,000 MCG/ML INJECTION SOLUTION" RX-2007 CDM J3420 HCPCS 636 RC 63323-0044-00 NDC outpatient 0.1 ML 58.99 58.99 BLUE CROSS BLUE SHIELD WELLMARK SB889 [3081026] BCBS WYOMING [308102603] 56.04 percent of total billed charges 36.57 56.04 Technical (Hospital) Services "CYANOCOBALAMIN (VIT B-12) 1,000 MCG/ML INJECTION SOLUTION" RX-2007 CDM J3420 HCPCS 636 RC 63323-0044-00 NDC outpatient 0.1 ML 58.99 58.99 UNITED HEALTHCARE (COMMERCIAL) [3081199] UNITED HEALTHCARE 87726 [308119901] 36.57 percent of total billed charges 36.57 56.04 Technical (Hospital) Services "CYANOCOBALAMIN (VIT B-12) 1,000 MCG/ML INJECTION SOLUTION" RX-2007 CDM J3420 HCPCS 636 RC 63323-0044-00 NDC outpatient 0.1 ML 58.99 58.99 MULTIPLAN INC 34080 [3081285] MULTIPLAN INC [308128501] 56.04 percent of total billed charges 36.57 56.04 Technical (Hospital) Services "CYANOCOBALAMIN (VIT B-12) 1,000 MCG/ML INJECTION SOLUTION" RX-2007 CDM J3420 HCPCS 636 RC 63323-0044-00 NDC outpatient 0.1 ML 58.99 58.99 CIGNA 62308 [3081051] CIGNA 62308 [308105105] 47.19 percent of total billed charges 36.57 56.04 Technical (Hospital) Services "CYANOCOBALAMIN (VIT B-12) 1,000 MCG/ML INJECTION SOLUTION" RX-2007 CDM J3420 HCPCS 636 RC 63323-0044-00 NDC outpatient 0.1 ML 58.99 58.99 CIGNA 62308 [3081051] CIGNA STATE OF WYOMING [308105107] 47.19 percent of total billed charges 36.57 56.04 Technical (Hospital) Services "CYANOCOBALAMIN (VIT B-12) 1,000 MCG/ML INJECTION SOLUTION" RX-2007 CDM J3420 HCPCS 636 RC 63323-0044-00 NDC outpatient 0.1 ML 58.99 58.99 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES EPO [308136803] 47.19 percent of total billed charges 36.57 56.04 Technical (Hospital) Services "CYANOCOBALAMIN (VIT B-12) 1,000 MCG/ML INJECTION SOLUTION" RX-2007 CDM J3420 HCPCS 636 RC 63323-0044-00 NDC outpatient 0.1 ML 58.99 58.99 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES HDHP [308136802] 47.19 percent of total billed charges 36.57 56.04 Technical (Hospital) Services "CYANOCOBALAMIN (VIT B-12) 1,000 MCG/ML INJECTION SOLUTION" RX-2007 CDM J3420 HCPCS 636 RC 63323-0044-00 NDC outpatient 0.1 ML 58.99 58.99 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES PPO [308136801] 47.19 percent of total billed charges 36.57 56.04 Technical (Hospital) Services "CYANOCOBALAMIN (VIT B-12) 1,000 MCG/ML INJECTION SOLUTION" RX-2007 CDM J3420 HCPCS 636 RC 63323-0044-00 NDC outpatient 0.1 ML 58.99 58.99 MEDICA (COMMERCIAL) 94265 [3081118] MEDICA CLAIMS [308111801] 53.09 percent of total billed charges 36.57 56.04 Technical (Hospital) Services "CYANOCOBALAMIN (VIT B-12) 1,000 MCG/ML INJECTION SOLUTION" RX-2007 CDM J3420 HCPCS 636 RC 63323-0044-00 NDC inpatient 0.1 ML 58.99 58.99 UNITED HEALTHCARE (COMMERCIAL) [3081199] UNITED HEALTHCARE 87726 [308119901] 36.57 percent of total billed charges 36.57 56.04 Technical (Hospital) Services "CYANOCOBALAMIN (VIT B-12) 1,000 MCG/ML INJECTION SOLUTION" RX-2007 CDM J3420 HCPCS 636 RC 63323-0044-00 NDC inpatient 0.1 ML 58.99 58.99 CIGNA 62308 [3081051] CIGNA 62308 [308105105] 46.71 percent of total billed charges 36.57 56.04 Technical (Hospital) Services "CYANOCOBALAMIN (VIT B-12) 1,000 MCG/ML INJECTION SOLUTION" RX-2007 CDM J3420 HCPCS 636 RC 63323-0044-00 NDC inpatient 0.1 ML 58.99 58.99 CIGNA 62308 [3081051] CIGNA STATE OF WYOMING [308105107] 46.71 percent of total billed charges 36.57 56.04 Technical (Hospital) Services "CYANOCOBALAMIN (VIT B-12) 1,000 MCG/ML INJECTION SOLUTION" RX-2007 CDM J3420 HCPCS 636 RC 63323-0044-00 NDC inpatient 0.1 ML 58.99 58.99 BLUE CROSS BLUE SHIELD WELLMARK SB889 [3081026] BCBS WYOMING [308102603] 56.04 percent of total billed charges 36.57 56.04 Technical (Hospital) Services "CYANOCOBALAMIN (VIT B-12) 1,000 MCG/ML INJECTION SOLUTION" RX-2007 CDM J3420 HCPCS 636 RC 63323-0044-00 NDC inpatient 0.1 ML 58.99 58.99 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES EPO [308136803] 46.71 percent of total billed charges 36.57 56.04 Technical (Hospital) Services "CYANOCOBALAMIN (VIT B-12) 1,000 MCG/ML INJECTION SOLUTION" RX-2007 CDM J3420 HCPCS 636 RC 63323-0044-00 NDC inpatient 0.1 ML 58.99 58.99 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES HDHP [308136802] 46.71 percent of total billed charges 36.57 56.04 Technical (Hospital) Services "CYANOCOBALAMIN (VIT B-12) 1,000 MCG/ML INJECTION SOLUTION" RX-2007 CDM J3420 HCPCS 636 RC 63323-0044-00 NDC inpatient 0.1 ML 58.99 58.99 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES PPO [308136801] 46.71 percent of total billed charges 36.57 56.04 Technical (Hospital) Services "CYANOCOBALAMIN (VIT B-12) 1,000 MCG/ML INJECTION SOLUTION" RX-2007 CDM J3420 HCPCS 636 RC 63323-0044-00 NDC inpatient 0.1 ML 58.99 58.99 HEALTHPARTNERS SX009 HEALTHPARTNERS 46.71 percent of total billed charges 36.57 56.04 Technical (Hospital) Services "CYANOCOBALAMIN (VIT B-12) 1,000 MCG/ML INJECTION SOLUTION" RX-2007 CDM J3420 HCPCS 636 RC 63323-0044-00 NDC inpatient 0.1 ML 58.99 58.99 MEDICA (COMMERCIAL) 94265 [3081118] MEDICA CLAIMS [308111801] 53.09 percent of total billed charges 36.57 56.04 Technical (Hospital) Services "CYANOCOBALAMIN (VIT B-12) 1,000 MCG/ML INJECTION SOLUTION" RX-2007 CDM J3420 HCPCS 636 RC 63323-0044-00 NDC inpatient 0.1 ML 58.99 58.99 MULTIPLAN INC 34080 [3081285] MULTIPLAN INC [308128501] 56.04 percent of total billed charges 36.57 56.04 Technical (Hospital) Services THIAMINE HCL (VITAMIN B1) 100 MG/ML INJECTION SOLUTION RX-7876 CDM J3411 HCPCS 636 RC 63323-0013-02 NDC inpatient 0.5 ML 60.79 60.79 UNITED HEALTHCARE (COMMERCIAL) [3081199] UNITED HEALTHCARE 87726 [308119901] 37.69 percent of total billed charges 37.69 57.75 Technical (Hospital) Services THIAMINE HCL (VITAMIN B1) 100 MG/ML INJECTION SOLUTION RX-7876 CDM J3411 HCPCS 636 RC 63323-0013-02 NDC inpatient 0.5 ML 60.79 60.79 BLUE CROSS BLUE SHIELD WELLMARK SB889 [3081026] BCBS WYOMING [308102603] 57.75 percent of total billed charges 37.69 57.75 Technical (Hospital) Services THIAMINE HCL (VITAMIN B1) 100 MG/ML INJECTION SOLUTION RX-7876 CDM J3411 HCPCS 636 RC 63323-0013-02 NDC inpatient 0.5 ML 60.79 60.79 CIGNA 62308 [3081051] CIGNA 62308 [308105105] 48.13 percent of total billed charges 37.69 57.75 Technical (Hospital) Services THIAMINE HCL (VITAMIN B1) 100 MG/ML INJECTION SOLUTION RX-7876 CDM J3411 HCPCS 636 RC 63323-0013-02 NDC inpatient 0.5 ML 60.79 60.79 CIGNA 62308 [3081051] CIGNA STATE OF WYOMING [308105107] 48.13 percent of total billed charges 37.69 57.75 Technical (Hospital) Services THIAMINE HCL (VITAMIN B1) 100 MG/ML INJECTION SOLUTION RX-7876 CDM J3411 HCPCS 636 RC 63323-0013-02 NDC inpatient 0.5 ML 60.79 60.79 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES PPO [308136801] 48.13 percent of total billed charges 37.69 57.75 Technical (Hospital) Services THIAMINE HCL (VITAMIN B1) 100 MG/ML INJECTION SOLUTION RX-7876 CDM J3411 HCPCS 636 RC 63323-0013-02 NDC inpatient 0.5 ML 60.79 60.79 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES HDHP [308136802] 48.13 percent of total billed charges 37.69 57.75 Technical (Hospital) Services THIAMINE HCL (VITAMIN B1) 100 MG/ML INJECTION SOLUTION RX-7876 CDM J3411 HCPCS 636 RC 63323-0013-02 NDC inpatient 0.5 ML 60.79 60.79 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES EPO [308136803] 48.13 percent of total billed charges 37.69 57.75 Technical (Hospital) Services THIAMINE HCL (VITAMIN B1) 100 MG/ML INJECTION SOLUTION RX-7876 CDM J3411 HCPCS 636 RC 63323-0013-02 NDC inpatient 0.5 ML 60.79 60.79 MEDICA (COMMERCIAL) 94265 [3081118] MEDICA CLAIMS [308111801] 54.71 percent of total billed charges 37.69 57.75 Technical (Hospital) Services THIAMINE HCL (VITAMIN B1) 100 MG/ML INJECTION SOLUTION RX-7876 CDM J3411 HCPCS 636 RC 63323-0013-02 NDC inpatient 0.5 ML 60.79 60.79 MULTIPLAN INC 34080 [3081285] MULTIPLAN INC [308128501] 57.75 percent of total billed charges 37.69 57.75 Technical (Hospital) Services THIAMINE HCL (VITAMIN B1) 100 MG/ML INJECTION SOLUTION RX-7876 CDM J3411 HCPCS 636 RC 63323-0013-02 NDC inpatient 0.5 ML 60.79 60.79 HEALTHPARTNERS SX009 HEALTHPARTNERS 48.13 percent of total billed charges 37.69 57.75 Technical (Hospital) Services THIAMINE HCL (VITAMIN B1) 100 MG/ML INJECTION SOLUTION RX-7876 CDM J3411 HCPCS 636 RC 63323-0013-02 NDC outpatient 0.5 ML 60.79 60.79 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES PPO [308136801] 48.63 percent of total billed charges 37.69 57.75 Technical (Hospital) Services THIAMINE HCL (VITAMIN B1) 100 MG/ML INJECTION SOLUTION RX-7876 CDM J3411 HCPCS 636 RC 63323-0013-02 NDC outpatient 0.5 ML 60.79 60.79 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES HDHP [308136802] 48.63 percent of total billed charges 37.69 57.75 Technical (Hospital) Services THIAMINE HCL (VITAMIN B1) 100 MG/ML INJECTION SOLUTION RX-7876 CDM J3411 HCPCS 636 RC 63323-0013-02 NDC outpatient 0.5 ML 60.79 60.79 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES EPO [308136803] 48.63 percent of total billed charges 37.69 57.75 Technical (Hospital) Services THIAMINE HCL (VITAMIN B1) 100 MG/ML INJECTION SOLUTION RX-7876 CDM J3411 HCPCS 636 RC 63323-0013-02 NDC outpatient 0.5 ML 60.79 60.79 MEDICA (COMMERCIAL) 94265 [3081118] MEDICA CLAIMS [308111801] 54.71 percent of total billed charges 37.69 57.75 Technical (Hospital) Services THIAMINE HCL (VITAMIN B1) 100 MG/ML INJECTION SOLUTION RX-7876 CDM J3411 HCPCS 636 RC 63323-0013-02 NDC outpatient 0.5 ML 60.79 60.79 UNITED HEALTHCARE (COMMERCIAL) [3081199] UNITED HEALTHCARE 87726 [308119901] 37.69 percent of total billed charges 37.69 57.75 Technical (Hospital) Services THIAMINE HCL (VITAMIN B1) 100 MG/ML INJECTION SOLUTION RX-7876 CDM J3411 HCPCS 636 RC 63323-0013-02 NDC outpatient 0.5 ML 60.79 60.79 MULTIPLAN INC 34080 [3081285] MULTIPLAN INC [308128501] 57.75 percent of total billed charges 37.69 57.75 Technical (Hospital) Services THIAMINE HCL (VITAMIN B1) 100 MG/ML INJECTION SOLUTION RX-7876 CDM J3411 HCPCS 636 RC 63323-0013-02 NDC outpatient 0.5 ML 60.79 60.79 CIGNA 62308 [3081051] CIGNA 62308 [308105105] 48.63 percent of total billed charges 37.69 57.75 Technical (Hospital) Services THIAMINE HCL (VITAMIN B1) 100 MG/ML INJECTION SOLUTION RX-7876 CDM J3411 HCPCS 636 RC 63323-0013-02 NDC outpatient 0.5 ML 60.79 60.79 CIGNA 62308 [3081051] CIGNA STATE OF WYOMING [308105107] 48.63 percent of total billed charges 37.69 57.75 Technical (Hospital) Services THIAMINE HCL (VITAMIN B1) 100 MG/ML INJECTION SOLUTION RX-7876 CDM J3411 HCPCS 636 RC 63323-0013-02 NDC outpatient 0.5 ML 60.79 60.79 HEALTHPARTNERS SX009 HEALTHPARTNERS 48.63 percent of total billed charges 37.69 57.75 Technical (Hospital) Services THIAMINE HCL (VITAMIN B1) 100 MG/ML INJECTION SOLUTION RX-7876 CDM J3411 HCPCS 636 RC 63323-0013-02 NDC outpatient 0.5 ML 60.79 60.79 BLUE CROSS BLUE SHIELD WELLMARK SB889 [3081026] BCBS WYOMING [308102603] 57.75 percent of total billed charges 37.69 57.75 Technical (Hospital) Services HYDROXYZINE HCL 50 MG/ML INTRAMUSCULAR SOLUTION RX-3770 CDM J3410 HCPCS 636 RC 00517-5601-25 NDC outpatient 1 ML 153.37 153.37 CIGNA 62308 [3081051] CIGNA 62308 [308105105] 122.7 percent of total billed charges 95.09 145.7 Technical (Hospital) Services HYDROXYZINE HCL 50 MG/ML INTRAMUSCULAR SOLUTION RX-3770 CDM J3410 HCPCS 636 RC 00517-5601-25 NDC outpatient 1 ML 153.37 153.37 CIGNA 62308 [3081051] CIGNA STATE OF WYOMING [308105107] 122.7 percent of total billed charges 95.09 145.7 Technical (Hospital) Services HYDROXYZINE HCL 50 MG/ML INTRAMUSCULAR SOLUTION RX-3770 CDM J3410 HCPCS 636 RC 00517-5601-25 NDC outpatient 1 ML 153.37 153.37 MEDICA (COMMERCIAL) 94265 [3081118] MEDICA CLAIMS [308111801] 138.03 percent of total billed charges 95.09 145.7 Technical (Hospital) Services HYDROXYZINE HCL 50 MG/ML INTRAMUSCULAR SOLUTION RX-3770 CDM J3410 HCPCS 636 RC 00517-5601-25 NDC outpatient 1 ML 153.37 153.37 UNITED HEALTHCARE (COMMERCIAL) [3081199] UNITED HEALTHCARE 87726 [308119901] 95.09 percent of total billed charges 95.09 145.7 Technical (Hospital) Services HYDROXYZINE HCL 50 MG/ML INTRAMUSCULAR SOLUTION RX-3770 CDM J3410 HCPCS 636 RC 00517-5601-25 NDC outpatient 1 ML 153.37 153.37 MULTIPLAN INC 34080 [3081285] MULTIPLAN INC [308128501] 145.7 percent of total billed charges 95.09 145.7 Technical (Hospital) Services HYDROXYZINE HCL 50 MG/ML INTRAMUSCULAR SOLUTION RX-3770 CDM J3410 HCPCS 636 RC 00517-5601-25 NDC outpatient 1 ML 153.37 153.37 HEALTHPARTNERS SX009 HEALTHPARTNERS 122.7 percent of total billed charges 95.09 145.7 Technical (Hospital) Services HYDROXYZINE HCL 50 MG/ML INTRAMUSCULAR SOLUTION RX-3770 CDM J3410 HCPCS 636 RC 00517-5601-25 NDC outpatient 1 ML 153.37 153.37 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES PPO [308136801] 122.7 percent of total billed charges 95.09 145.7 Technical (Hospital) Services HYDROXYZINE HCL 50 MG/ML INTRAMUSCULAR SOLUTION RX-3770 CDM J3410 HCPCS 636 RC 00517-5601-25 NDC outpatient 1 ML 153.37 153.37 BLUE CROSS BLUE SHIELD WELLMARK SB889 [3081026] BCBS WYOMING [308102603] 145.7 percent of total billed charges 95.09 145.7 Technical (Hospital) Services HYDROXYZINE HCL 50 MG/ML INTRAMUSCULAR SOLUTION RX-3770 CDM J3410 HCPCS 636 RC 00517-5601-25 NDC outpatient 1 ML 153.37 153.37 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES EPO [308136803] 122.7 percent of total billed charges 95.09 145.7 Technical (Hospital) Services HYDROXYZINE HCL 50 MG/ML INTRAMUSCULAR SOLUTION RX-3770 CDM J3410 HCPCS 636 RC 00517-5601-25 NDC outpatient 1 ML 153.37 153.37 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES HDHP [308136802] 122.7 percent of total billed charges 95.09 145.7 Technical (Hospital) Services HYDROXYZINE HCL 50 MG/ML INTRAMUSCULAR SOLUTION RX-3770 CDM J3410 HCPCS 636 RC 00517-5601-25 NDC inpatient 1 ML 153.37 153.37 MULTIPLAN INC 34080 [3081285] MULTIPLAN INC [308128501] 145.7 percent of total billed charges 95.09 145.7 Technical (Hospital) Services HYDROXYZINE HCL 50 MG/ML INTRAMUSCULAR SOLUTION RX-3770 CDM J3410 HCPCS 636 RC 00517-5601-25 NDC inpatient 1 ML 153.37 153.37 MEDICA (COMMERCIAL) 94265 [3081118] MEDICA CLAIMS [308111801] 138.03 percent of total billed charges 95.09 145.7 Technical (Hospital) Services HYDROXYZINE HCL 50 MG/ML INTRAMUSCULAR SOLUTION RX-3770 CDM J3410 HCPCS 636 RC 00517-5601-25 NDC inpatient 1 ML 153.37 153.37 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES PPO [308136801] 121.44 percent of total billed charges 95.09 145.7 Technical (Hospital) Services HYDROXYZINE HCL 50 MG/ML INTRAMUSCULAR SOLUTION RX-3770 CDM J3410 HCPCS 636 RC 00517-5601-25 NDC inpatient 1 ML 153.37 153.37 HEALTHPARTNERS SX009 HEALTHPARTNERS 121.44 percent of total billed charges 95.09 145.7 Technical (Hospital) Services HYDROXYZINE HCL 50 MG/ML INTRAMUSCULAR SOLUTION RX-3770 CDM J3410 HCPCS 636 RC 00517-5601-25 NDC inpatient 1 ML 153.37 153.37 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES HDHP [308136802] 121.44 percent of total billed charges 95.09 145.7 Technical (Hospital) Services HYDROXYZINE HCL 50 MG/ML INTRAMUSCULAR SOLUTION RX-3770 CDM J3410 HCPCS 636 RC 00517-5601-25 NDC inpatient 1 ML 153.37 153.37 CIGNA 62308 [3081051] CIGNA 62308 [308105105] 121.44 percent of total billed charges 95.09 145.7 Technical (Hospital) Services HYDROXYZINE HCL 50 MG/ML INTRAMUSCULAR SOLUTION RX-3770 CDM J3410 HCPCS 636 RC 00517-5601-25 NDC inpatient 1 ML 153.37 153.37 CIGNA 62308 [3081051] CIGNA STATE OF WYOMING [308105107] 121.44 percent of total billed charges 95.09 145.7 Technical (Hospital) Services HYDROXYZINE HCL 50 MG/ML INTRAMUSCULAR SOLUTION RX-3770 CDM J3410 HCPCS 636 RC 00517-5601-25 NDC inpatient 1 ML 153.37 153.37 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES EPO [308136803] 121.44 percent of total billed charges 95.09 145.7 Technical (Hospital) Services HYDROXYZINE HCL 50 MG/ML INTRAMUSCULAR SOLUTION RX-3770 CDM J3410 HCPCS 636 RC 00517-5601-25 NDC inpatient 1 ML 153.37 153.37 UNITED HEALTHCARE (COMMERCIAL) [3081199] UNITED HEALTHCARE 87726 [308119901] 95.09 percent of total billed charges 95.09 145.7 Technical (Hospital) Services HYDROXYZINE HCL 50 MG/ML INTRAMUSCULAR SOLUTION RX-3770 CDM J3410 HCPCS 636 RC 00517-5601-25 NDC inpatient 1 ML 153.37 153.37 BLUE CROSS BLUE SHIELD WELLMARK SB889 [3081026] BCBS WYOMING [308102603] 145.7 percent of total billed charges 95.09 145.7 Technical (Hospital) Services VEDOLIZUMAB 300 MG INTRAVENOUS SOLUTION RX-126219 CDM J3380 HCPCS 636 RC 64764-0300-20 NDC outpatient 5 ML 13916.58 13916.58 CIGNA 62308 [3081051] CIGNA 62308 [308105105] 11133.26 percent of total billed charges 8628.28 13220.75 Technical (Hospital) Services VEDOLIZUMAB 300 MG INTRAVENOUS SOLUTION RX-126219 CDM J3380 HCPCS 636 RC 64764-0300-20 NDC outpatient 5 ML 13916.58 13916.58 CIGNA 62308 [3081051] CIGNA STATE OF WYOMING [308105107] 11133.26 percent of total billed charges 8628.28 13220.75 Technical (Hospital) Services VEDOLIZUMAB 300 MG INTRAVENOUS SOLUTION RX-126219 CDM J3380 HCPCS 636 RC 64764-0300-20 NDC outpatient 5 ML 13916.58 13916.58 BLUE CROSS BLUE SHIELD WELLMARK SB889 [3081026] BCBS WYOMING [308102603] 13220.75 percent of total billed charges 8628.28 13220.75 Technical (Hospital) Services VEDOLIZUMAB 300 MG INTRAVENOUS SOLUTION RX-126219 CDM J3380 HCPCS 636 RC 64764-0300-20 NDC outpatient 5 ML 13916.58 13916.58 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES EPO [308136803] 11133.26 percent of total billed charges 8628.28 13220.75 Technical (Hospital) Services VEDOLIZUMAB 300 MG INTRAVENOUS SOLUTION RX-126219 CDM J3380 HCPCS 636 RC 64764-0300-20 NDC outpatient 5 ML 13916.58 13916.58 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES PPO [308136801] 11133.26 percent of total billed charges 8628.28 13220.75 Technical (Hospital) Services VEDOLIZUMAB 300 MG INTRAVENOUS SOLUTION RX-126219 CDM J3380 HCPCS 636 RC 64764-0300-20 NDC outpatient 5 ML 13916.58 13916.58 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES HDHP [308136802] 11133.26 percent of total billed charges 8628.28 13220.75 Technical (Hospital) Services VEDOLIZUMAB 300 MG INTRAVENOUS SOLUTION RX-126219 CDM J3380 HCPCS 636 RC 64764-0300-20 NDC outpatient 5 ML 13916.58 13916.58 MULTIPLAN INC 34080 [3081285] MULTIPLAN INC [308128501] 13220.75 percent of total billed charges 8628.28 13220.75 Technical (Hospital) Services VEDOLIZUMAB 300 MG INTRAVENOUS SOLUTION RX-126219 CDM J3380 HCPCS 636 RC 64764-0300-20 NDC outpatient 5 ML 13916.58 13916.58 MEDICA (COMMERCIAL) 94265 [3081118] MEDICA CLAIMS [308111801] 12524.92 percent of total billed charges 8628.28 13220.75 Technical (Hospital) Services VEDOLIZUMAB 300 MG INTRAVENOUS SOLUTION RX-126219 CDM J3380 HCPCS 636 RC 64764-0300-20 NDC outpatient 5 ML 13916.58 13916.58 UNITED HEALTHCARE (COMMERCIAL) [3081199] UNITED HEALTHCARE 87726 [308119901] 8628.28 percent of total billed charges 8628.28 13220.75 Technical (Hospital) Services VEDOLIZUMAB 300 MG INTRAVENOUS SOLUTION RX-126219 CDM J3380 HCPCS 636 RC 64764-0300-20 NDC outpatient 5 ML 13916.58 13916.58 HEALTHPARTNERS SX009 HEALTHPARTNERS 11133.26 percent of total billed charges 8628.28 13220.75 Technical (Hospital) Services VEDOLIZUMAB 300 MG INTRAVENOUS SOLUTION RX-126219 CDM J3380 HCPCS 636 RC 64764-0300-20 NDC inpatient 5 ML 13916.58 13916.58 MEDICA (COMMERCIAL) 94265 [3081118] MEDICA CLAIMS [308111801] 12524.92 percent of total billed charges 8628.28 13220.75 Technical (Hospital) Services VEDOLIZUMAB 300 MG INTRAVENOUS SOLUTION RX-126219 CDM J3380 HCPCS 636 RC 64764-0300-20 NDC inpatient 5 ML 13916.58 13916.58 MULTIPLAN INC 34080 [3081285] MULTIPLAN INC [308128501] 13220.75 percent of total billed charges 8628.28 13220.75 Technical (Hospital) Services VEDOLIZUMAB 300 MG INTRAVENOUS SOLUTION RX-126219 CDM J3380 HCPCS 636 RC 64764-0300-20 NDC inpatient 5 ML 13916.58 13916.58 BLUE CROSS BLUE SHIELD WELLMARK SB889 [3081026] BCBS WYOMING [308102603] 13220.75 percent of total billed charges 8628.28 13220.75 Technical (Hospital) Services VEDOLIZUMAB 300 MG INTRAVENOUS SOLUTION RX-126219 CDM J3380 HCPCS 636 RC 64764-0300-20 NDC inpatient 5 ML 13916.58 13916.58 UNITED HEALTHCARE (COMMERCIAL) [3081199] UNITED HEALTHCARE 87726 [308119901] 8628.28 percent of total billed charges 8628.28 13220.75 Technical (Hospital) Services VEDOLIZUMAB 300 MG INTRAVENOUS SOLUTION RX-126219 CDM J3380 HCPCS 636 RC 64764-0300-20 NDC inpatient 5 ML 13916.58 13916.58 CIGNA 62308 [3081051] CIGNA 62308 [308105105] 11019.15 percent of total billed charges 8628.28 13220.75 Technical (Hospital) Services VEDOLIZUMAB 300 MG INTRAVENOUS SOLUTION RX-126219 CDM J3380 HCPCS 636 RC 64764-0300-20 NDC inpatient 5 ML 13916.58 13916.58 CIGNA 62308 [3081051] CIGNA STATE OF WYOMING [308105107] 11019.15 percent of total billed charges 8628.28 13220.75 Technical (Hospital) Services VEDOLIZUMAB 300 MG INTRAVENOUS SOLUTION RX-126219 CDM J3380 HCPCS 636 RC 64764-0300-20 NDC inpatient 5 ML 13916.58 13916.58 HEALTHPARTNERS SX009 HEALTHPARTNERS 11019.15 percent of total billed charges 8628.28 13220.75 Technical (Hospital) Services VEDOLIZUMAB 300 MG INTRAVENOUS SOLUTION RX-126219 CDM J3380 HCPCS 636 RC 64764-0300-20 NDC inpatient 5 ML 13916.58 13916.58 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES EPO [308136803] 11019.15 percent of total billed charges 8628.28 13220.75 Technical (Hospital) Services VEDOLIZUMAB 300 MG INTRAVENOUS SOLUTION RX-126219 CDM J3380 HCPCS 636 RC 64764-0300-20 NDC inpatient 5 ML 13916.58 13916.58 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES PPO [308136801] 11019.15 percent of total billed charges 8628.28 13220.75 Technical (Hospital) Services VEDOLIZUMAB 300 MG INTRAVENOUS SOLUTION RX-126219 CDM J3380 HCPCS 636 RC 64764-0300-20 NDC inpatient 5 ML 13916.58 13916.58 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES HDHP [308136802] 11019.15 percent of total billed charges 8628.28 13220.75 Technical (Hospital) Services VANCOMYCIN 1 GRAM/200 ML IN DILUENT COMBINATION IV PIGGYBACK RX-175567 CDM J3372 HCPCS 636 RC 70594-0042-01 NDC inpatient 200 ML 104.5 104.5 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES HDHP [308136802] 82.74 percent of total billed charges 64.79 99.28 Technical (Hospital) Services VANCOMYCIN 1 GRAM/200 ML IN DILUENT COMBINATION IV PIGGYBACK RX-175567 CDM J3372 HCPCS 636 RC 70594-0042-01 NDC inpatient 200 ML 104.5 104.5 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES EPO [308136803] 82.74 percent of total billed charges 64.79 99.28 Technical (Hospital) Services VANCOMYCIN 1 GRAM/200 ML IN DILUENT COMBINATION IV PIGGYBACK RX-175567 CDM J3372 HCPCS 636 RC 70594-0042-01 NDC inpatient 200 ML 104.5 104.5 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES PPO [308136801] 82.74 percent of total billed charges 64.79 99.28 Technical (Hospital) Services VANCOMYCIN 1 GRAM/200 ML IN DILUENT COMBINATION IV PIGGYBACK RX-175567 CDM J3372 HCPCS 636 RC 70594-0042-01 NDC inpatient 200 ML 104.5 104.5 CIGNA 62308 [3081051] CIGNA 62308 [308105105] 82.74 percent of total billed charges 64.79 99.28 Technical (Hospital) Services VANCOMYCIN 1 GRAM/200 ML IN DILUENT COMBINATION IV PIGGYBACK RX-175567 CDM J3372 HCPCS 636 RC 70594-0042-01 NDC inpatient 200 ML 104.5 104.5 CIGNA 62308 [3081051] CIGNA STATE OF WYOMING [308105107] 82.74 percent of total billed charges 64.79 99.28 Technical (Hospital) Services VANCOMYCIN 1 GRAM/200 ML IN DILUENT COMBINATION IV PIGGYBACK RX-175567 CDM J3372 HCPCS 636 RC 70594-0042-01 NDC inpatient 200 ML 104.5 104.5 HEALTHPARTNERS SX009 HEALTHPARTNERS 82.74 percent of total billed charges 64.79 99.28 Technical (Hospital) Services VANCOMYCIN 1 GRAM/200 ML IN DILUENT COMBINATION IV PIGGYBACK RX-175567 CDM J3372 HCPCS 636 RC 70594-0042-01 NDC inpatient 200 ML 104.5 104.5 MULTIPLAN INC 34080 [3081285] MULTIPLAN INC [308128501] 99.28 percent of total billed charges 64.79 99.28 Technical (Hospital) Services VANCOMYCIN 1 GRAM/200 ML IN DILUENT COMBINATION IV PIGGYBACK RX-175567 CDM J3372 HCPCS 636 RC 70594-0042-01 NDC inpatient 200 ML 104.5 104.5 MEDICA (COMMERCIAL) 94265 [3081118] MEDICA CLAIMS [308111801] 94.05 percent of total billed charges 64.79 99.28 Technical (Hospital) Services VANCOMYCIN 1 GRAM/200 ML IN DILUENT COMBINATION IV PIGGYBACK RX-175567 CDM J3372 HCPCS 636 RC 70594-0042-01 NDC inpatient 200 ML 104.5 104.5 BLUE CROSS BLUE SHIELD WELLMARK SB889 [3081026] BCBS WYOMING [308102603] 99.28 percent of total billed charges 64.79 99.28 Technical (Hospital) Services VANCOMYCIN 1 GRAM/200 ML IN DILUENT COMBINATION IV PIGGYBACK RX-175567 CDM J3372 HCPCS 636 RC 70594-0042-01 NDC inpatient 200 ML 104.5 104.5 UNITED HEALTHCARE (COMMERCIAL) [3081199] UNITED HEALTHCARE 87726 [308119901] 64.79 percent of total billed charges 64.79 99.28 Technical (Hospital) Services VANCOMYCIN 1 GRAM/200 ML IN DILUENT COMBINATION IV PIGGYBACK RX-175567 CDM J3372 HCPCS 636 RC 70594-0042-01 NDC outpatient 200 ML 104.5 104.5 HEALTHPARTNERS SX009 HEALTHPARTNERS 83.6 percent of total billed charges 64.79 99.28 Technical (Hospital) Services VANCOMYCIN 1 GRAM/200 ML IN DILUENT COMBINATION IV PIGGYBACK RX-175567 CDM J3372 HCPCS 636 RC 70594-0042-01 NDC outpatient 200 ML 104.5 104.5 UNITED HEALTHCARE (COMMERCIAL) [3081199] UNITED HEALTHCARE 87726 [308119901] 64.79 percent of total billed charges 64.79 99.28 Technical (Hospital) Services VANCOMYCIN 1 GRAM/200 ML IN DILUENT COMBINATION IV PIGGYBACK RX-175567 CDM J3372 HCPCS 636 RC 70594-0042-01 NDC outpatient 200 ML 104.5 104.5 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES EPO [308136803] 83.6 percent of total billed charges 64.79 99.28 Technical (Hospital) Services VANCOMYCIN 1 GRAM/200 ML IN DILUENT COMBINATION IV PIGGYBACK RX-175567 CDM J3372 HCPCS 636 RC 70594-0042-01 NDC outpatient 200 ML 104.5 104.5 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES HDHP [308136802] 83.6 percent of total billed charges 64.79 99.28 Technical (Hospital) Services VANCOMYCIN 1 GRAM/200 ML IN DILUENT COMBINATION IV PIGGYBACK RX-175567 CDM J3372 HCPCS 636 RC 70594-0042-01 NDC outpatient 200 ML 104.5 104.5 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES PPO [308136801] 83.6 percent of total billed charges 64.79 99.28 Technical (Hospital) Services VANCOMYCIN 1 GRAM/200 ML IN DILUENT COMBINATION IV PIGGYBACK RX-175567 CDM J3372 HCPCS 636 RC 70594-0042-01 NDC outpatient 200 ML 104.5 104.5 BLUE CROSS BLUE SHIELD WELLMARK SB889 [3081026] BCBS WYOMING [308102603] 99.28 percent of total billed charges 64.79 99.28 Technical (Hospital) Services VANCOMYCIN 1 GRAM/200 ML IN DILUENT COMBINATION IV PIGGYBACK RX-175567 CDM J3372 HCPCS 636 RC 70594-0042-01 NDC outpatient 200 ML 104.5 104.5 MULTIPLAN INC 34080 [3081285] MULTIPLAN INC [308128501] 99.28 percent of total billed charges 64.79 99.28 Technical (Hospital) Services VANCOMYCIN 1 GRAM/200 ML IN DILUENT COMBINATION IV PIGGYBACK RX-175567 CDM J3372 HCPCS 636 RC 70594-0042-01 NDC outpatient 200 ML 104.5 104.5 MEDICA (COMMERCIAL) 94265 [3081118] MEDICA CLAIMS [308111801] 94.05 percent of total billed charges 64.79 99.28 Technical (Hospital) Services VANCOMYCIN 1 GRAM/200 ML IN DILUENT COMBINATION IV PIGGYBACK RX-175567 CDM J3372 HCPCS 636 RC 70594-0042-01 NDC outpatient 200 ML 104.5 104.5 CIGNA 62308 [3081051] CIGNA STATE OF WYOMING [308105107] 83.6 percent of total billed charges 64.79 99.28 Technical (Hospital) Services VANCOMYCIN 1 GRAM/200 ML IN DILUENT COMBINATION IV PIGGYBACK RX-175567 CDM J3372 HCPCS 636 RC 70594-0042-01 NDC outpatient 200 ML 104.5 104.5 CIGNA 62308 [3081051] CIGNA 62308 [308105105] 83.6 percent of total billed charges 64.79 99.28 Technical (Hospital) Services VANCOMYCIN 2 GRAM/400 ML IN DILUENT COMBINATION IV PIGGYBACK RX-177337 CDM J3372 HCPCS 636 RC 70594-0044-02 NDC inpatient 400 ML 150.5 150.5 MULTIPLAN INC 34080 [3081285] MULTIPLAN INC [308128501] 142.98 percent of total billed charges 93.31 142.98 Technical (Hospital) Services VANCOMYCIN 2 GRAM/400 ML IN DILUENT COMBINATION IV PIGGYBACK RX-177337 CDM J3372 HCPCS 636 RC 70594-0044-02 NDC inpatient 400 ML 150.5 150.5 MEDICA (COMMERCIAL) 94265 [3081118] MEDICA CLAIMS [308111801] 135.45 percent of total billed charges 93.31 142.98 Technical (Hospital) Services VANCOMYCIN 2 GRAM/400 ML IN DILUENT COMBINATION IV PIGGYBACK RX-177337 CDM J3372 HCPCS 636 RC 70594-0044-02 NDC inpatient 400 ML 150.5 150.5 HEALTHPARTNERS SX009 HEALTHPARTNERS 119.17 percent of total billed charges 93.31 142.98 Technical (Hospital) Services VANCOMYCIN 2 GRAM/400 ML IN DILUENT COMBINATION IV PIGGYBACK RX-177337 CDM J3372 HCPCS 636 RC 70594-0044-02 NDC inpatient 400 ML 150.5 150.5 BLUE CROSS BLUE SHIELD WELLMARK SB889 [3081026] BCBS WYOMING [308102603] 142.98 percent of total billed charges 93.31 142.98 Technical (Hospital) Services VANCOMYCIN 2 GRAM/400 ML IN DILUENT COMBINATION IV PIGGYBACK RX-177337 CDM J3372 HCPCS 636 RC 70594-0044-02 NDC inpatient 400 ML 150.5 150.5 UNITED HEALTHCARE (COMMERCIAL) [3081199] UNITED HEALTHCARE 87726 [308119901] 93.31 percent of total billed charges 93.31 142.98 Technical (Hospital) Services VANCOMYCIN 2 GRAM/400 ML IN DILUENT COMBINATION IV PIGGYBACK RX-177337 CDM J3372 HCPCS 636 RC 70594-0044-02 NDC inpatient 400 ML 150.5 150.5 CIGNA 62308 [3081051] CIGNA 62308 [308105105] 119.17 percent of total billed charges 93.31 142.98 Technical (Hospital) Services VANCOMYCIN 2 GRAM/400 ML IN DILUENT COMBINATION IV PIGGYBACK RX-177337 CDM J3372 HCPCS 636 RC 70594-0044-02 NDC inpatient 400 ML 150.5 150.5 CIGNA 62308 [3081051] CIGNA STATE OF WYOMING [308105107] 119.17 percent of total billed charges 93.31 142.98 Technical (Hospital) Services VANCOMYCIN 2 GRAM/400 ML IN DILUENT COMBINATION IV PIGGYBACK RX-177337 CDM J3372 HCPCS 636 RC 70594-0044-02 NDC inpatient 400 ML 150.5 150.5 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES EPO [308136803] 119.17 percent of total billed charges 93.31 142.98 Technical (Hospital) Services VANCOMYCIN 2 GRAM/400 ML IN DILUENT COMBINATION IV PIGGYBACK RX-177337 CDM J3372 HCPCS 636 RC 70594-0044-02 NDC inpatient 400 ML 150.5 150.5 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES HDHP [308136802] 119.17 percent of total billed charges 93.31 142.98 Technical (Hospital) Services VANCOMYCIN 2 GRAM/400 ML IN DILUENT COMBINATION IV PIGGYBACK RX-177337 CDM J3372 HCPCS 636 RC 70594-0044-02 NDC inpatient 400 ML 150.5 150.5 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES PPO [308136801] 119.17 percent of total billed charges 93.31 142.98 Technical (Hospital) Services VANCOMYCIN 2 GRAM/400 ML IN DILUENT COMBINATION IV PIGGYBACK RX-177337 CDM J3372 HCPCS 636 RC 70594-0044-02 NDC outpatient 400 ML 150.5 150.5 BLUE CROSS BLUE SHIELD WELLMARK SB889 [3081026] BCBS WYOMING [308102603] 142.98 percent of total billed charges 93.31 142.98 Technical (Hospital) Services VANCOMYCIN 2 GRAM/400 ML IN DILUENT COMBINATION IV PIGGYBACK RX-177337 CDM J3372 HCPCS 636 RC 70594-0044-02 NDC outpatient 400 ML 150.5 150.5 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES PPO [308136801] 120.4 percent of total billed charges 93.31 142.98 Technical (Hospital) Services VANCOMYCIN 2 GRAM/400 ML IN DILUENT COMBINATION IV PIGGYBACK RX-177337 CDM J3372 HCPCS 636 RC 70594-0044-02 NDC outpatient 400 ML 150.5 150.5 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES HDHP [308136802] 120.4 percent of total billed charges 93.31 142.98 Technical (Hospital) Services VANCOMYCIN 2 GRAM/400 ML IN DILUENT COMBINATION IV PIGGYBACK RX-177337 CDM J3372 HCPCS 636 RC 70594-0044-02 NDC outpatient 400 ML 150.5 150.5 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES EPO [308136803] 120.4 percent of total billed charges 93.31 142.98 Technical (Hospital) Services VANCOMYCIN 2 GRAM/400 ML IN DILUENT COMBINATION IV PIGGYBACK RX-177337 CDM J3372 HCPCS 636 RC 70594-0044-02 NDC outpatient 400 ML 150.5 150.5 MULTIPLAN INC 34080 [3081285] MULTIPLAN INC [308128501] 142.98 percent of total billed charges 93.31 142.98 Technical (Hospital) Services VANCOMYCIN 2 GRAM/400 ML IN DILUENT COMBINATION IV PIGGYBACK RX-177337 CDM J3372 HCPCS 636 RC 70594-0044-02 NDC outpatient 400 ML 150.5 150.5 MEDICA (COMMERCIAL) 94265 [3081118] MEDICA CLAIMS [308111801] 135.45 percent of total billed charges 93.31 142.98 Technical (Hospital) Services VANCOMYCIN 2 GRAM/400 ML IN DILUENT COMBINATION IV PIGGYBACK RX-177337 CDM J3372 HCPCS 636 RC 70594-0044-02 NDC outpatient 400 ML 150.5 150.5 HEALTHPARTNERS SX009 HEALTHPARTNERS 120.4 percent of total billed charges 93.31 142.98 Technical (Hospital) Services VANCOMYCIN 2 GRAM/400 ML IN DILUENT COMBINATION IV PIGGYBACK RX-177337 CDM J3372 HCPCS 636 RC 70594-0044-02 NDC outpatient 400 ML 150.5 150.5 UNITED HEALTHCARE (COMMERCIAL) [3081199] UNITED HEALTHCARE 87726 [308119901] 93.31 percent of total billed charges 93.31 142.98 Technical (Hospital) Services VANCOMYCIN 2 GRAM/400 ML IN DILUENT COMBINATION IV PIGGYBACK RX-177337 CDM J3372 HCPCS 636 RC 70594-0044-02 NDC outpatient 400 ML 150.5 150.5 CIGNA 62308 [3081051] CIGNA 62308 [308105105] 120.4 percent of total billed charges 93.31 142.98 Technical (Hospital) Services VANCOMYCIN 2 GRAM/400 ML IN DILUENT COMBINATION IV PIGGYBACK RX-177337 CDM J3372 HCPCS 636 RC 70594-0044-02 NDC outpatient 400 ML 150.5 150.5 CIGNA 62308 [3081051] CIGNA STATE OF WYOMING [308105107] 120.4 percent of total billed charges 93.31 142.98 Technical (Hospital) Services VANCOMYCIN 500 MG INTRAVENOUS SOLUTION RX-8443 CDM J3370 HCPCS 636 RC 70436-0020-82 NDC outpatient 5 ML 61.3 61.3 UNITED HEALTHCARE (COMMERCIAL) [3081199] UNITED HEALTHCARE 87726 [308119901] 38.01 percent of total billed charges 38.01 58.24 Technical (Hospital) Services VANCOMYCIN 500 MG INTRAVENOUS SOLUTION RX-8443 CDM J3370 HCPCS 636 RC 70436-0020-82 NDC outpatient 5 ML 61.3 61.3 HEALTHPARTNERS SX009 HEALTHPARTNERS 49.04 percent of total billed charges 38.01 58.24 Technical (Hospital) Services VANCOMYCIN 500 MG INTRAVENOUS SOLUTION RX-8443 CDM J3370 HCPCS 636 RC 70436-0020-82 NDC outpatient 5 ML 61.3 61.3 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES PPO [308136801] 49.04 percent of total billed charges 38.01 58.24 Technical (Hospital) Services VANCOMYCIN 500 MG INTRAVENOUS SOLUTION RX-8443 CDM J3370 HCPCS 636 RC 70436-0020-82 NDC outpatient 5 ML 61.3 61.3 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES EPO [308136803] 49.04 percent of total billed charges 38.01 58.24 Technical (Hospital) Services VANCOMYCIN 500 MG INTRAVENOUS SOLUTION RX-8443 CDM J3370 HCPCS 636 RC 70436-0020-82 NDC outpatient 5 ML 61.3 61.3 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES HDHP [308136802] 49.04 percent of total billed charges 38.01 58.24 Technical (Hospital) Services VANCOMYCIN 500 MG INTRAVENOUS SOLUTION RX-8443 CDM J3370 HCPCS 636 RC 70436-0020-82 NDC outpatient 5 ML 61.3 61.3 BLUE CROSS BLUE SHIELD WELLMARK SB889 [3081026] BCBS WYOMING [308102603] 58.24 percent of total billed charges 38.01 58.24 Technical (Hospital) Services VANCOMYCIN 500 MG INTRAVENOUS SOLUTION RX-8443 CDM J3370 HCPCS 636 RC 70436-0020-82 NDC outpatient 5 ML 61.3 61.3 CIGNA 62308 [3081051] CIGNA 62308 [308105105] 49.04 percent of total billed charges 38.01 58.24 Technical (Hospital) Services VANCOMYCIN 500 MG INTRAVENOUS SOLUTION RX-8443 CDM J3370 HCPCS 636 RC 70436-0020-82 NDC outpatient 5 ML 61.3 61.3 CIGNA 62308 [3081051] CIGNA STATE OF WYOMING [308105107] 49.04 percent of total billed charges 38.01 58.24 Technical (Hospital) Services VANCOMYCIN 500 MG INTRAVENOUS SOLUTION RX-8443 CDM J3370 HCPCS 636 RC 70436-0020-82 NDC outpatient 5 ML 61.3 61.3 MEDICA (COMMERCIAL) 94265 [3081118] MEDICA CLAIMS [308111801] 55.17 percent of total billed charges 38.01 58.24 Technical (Hospital) Services VANCOMYCIN 500 MG INTRAVENOUS SOLUTION RX-8443 CDM J3370 HCPCS 636 RC 70436-0020-82 NDC outpatient 5 ML 61.3 61.3 MULTIPLAN INC 34080 [3081285] MULTIPLAN INC [308128501] 58.24 percent of total billed charges 38.01 58.24 Technical (Hospital) Services VANCOMYCIN 500 MG INTRAVENOUS SOLUTION RX-8443 CDM J3370 HCPCS 636 RC 70436-0020-82 NDC inpatient 5 ML 61.3 61.3 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES EPO [308136803] 48.54 percent of total billed charges 38.01 58.24 Technical (Hospital) Services VANCOMYCIN 500 MG INTRAVENOUS SOLUTION RX-8443 CDM J3370 HCPCS 636 RC 70436-0020-82 NDC inpatient 5 ML 61.3 61.3 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES PPO [308136801] 48.54 percent of total billed charges 38.01 58.24 Technical (Hospital) Services VANCOMYCIN 500 MG INTRAVENOUS SOLUTION RX-8443 CDM J3370 HCPCS 636 RC 70436-0020-82 NDC inpatient 5 ML 61.3 61.3 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES HDHP [308136802] 48.54 percent of total billed charges 38.01 58.24 Technical (Hospital) Services VANCOMYCIN 500 MG INTRAVENOUS SOLUTION RX-8443 CDM J3370 HCPCS 636 RC 70436-0020-82 NDC inpatient 5 ML 61.3 61.3 HEALTHPARTNERS SX009 HEALTHPARTNERS 48.54 percent of total billed charges 38.01 58.24 Technical (Hospital) Services VANCOMYCIN 500 MG INTRAVENOUS SOLUTION RX-8443 CDM J3370 HCPCS 636 RC 70436-0020-82 NDC inpatient 5 ML 61.3 61.3 UNITED HEALTHCARE (COMMERCIAL) [3081199] UNITED HEALTHCARE 87726 [308119901] 38.01 percent of total billed charges 38.01 58.24 Technical (Hospital) Services VANCOMYCIN 500 MG INTRAVENOUS SOLUTION RX-8443 CDM J3370 HCPCS 636 RC 70436-0020-82 NDC inpatient 5 ML 61.3 61.3 BLUE CROSS BLUE SHIELD WELLMARK SB889 [3081026] BCBS WYOMING [308102603] 58.24 percent of total billed charges 38.01 58.24 Technical (Hospital) Services VANCOMYCIN 500 MG INTRAVENOUS SOLUTION RX-8443 CDM J3370 HCPCS 636 RC 70436-0020-82 NDC inpatient 5 ML 61.3 61.3 CIGNA 62308 [3081051] CIGNA 62308 [308105105] 48.54 percent of total billed charges 38.01 58.24 Technical (Hospital) Services VANCOMYCIN 500 MG INTRAVENOUS SOLUTION RX-8443 CDM J3370 HCPCS 636 RC 70436-0020-82 NDC inpatient 5 ML 61.3 61.3 CIGNA 62308 [3081051] CIGNA STATE OF WYOMING [308105107] 48.54 percent of total billed charges 38.01 58.24 Technical (Hospital) Services VANCOMYCIN 500 MG INTRAVENOUS SOLUTION RX-8443 CDM J3370 HCPCS 636 RC 70436-0020-82 NDC inpatient 5 ML 61.3 61.3 MULTIPLAN INC 34080 [3081285] MULTIPLAN INC [308128501] 58.24 percent of total billed charges 38.01 58.24 Technical (Hospital) Services VANCOMYCIN 500 MG INTRAVENOUS SOLUTION RX-8443 CDM J3370 HCPCS 636 RC 70436-0020-82 NDC inpatient 5 ML 61.3 61.3 MEDICA (COMMERCIAL) 94265 [3081118] MEDICA CLAIMS [308111801] 55.17 percent of total billed charges 38.01 58.24 Technical (Hospital) Services DIAZEPAM 5 MG/ML INJECTION SYRINGE RX-106278 CDM J3360 HCPCS 636 RC 00409-1273-32 NDC outpatient 10 ME 170.66 170.66 BLUE CROSS BLUE SHIELD WELLMARK SB889 [3081026] BCBS WYOMING [308102603] 162.13 percent of total billed charges 105.81 162.13 Technical (Hospital) Services DIAZEPAM 5 MG/ML INJECTION SYRINGE RX-106278 CDM J3360 HCPCS 636 RC 00409-1273-32 NDC outpatient 10 ME 170.66 170.66 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES PPO [308136801] 136.53 percent of total billed charges 105.81 162.13 Technical (Hospital) Services DIAZEPAM 5 MG/ML INJECTION SYRINGE RX-106278 CDM J3360 HCPCS 636 RC 00409-1273-32 NDC outpatient 10 ME 170.66 170.66 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES HDHP [308136802] 136.53 percent of total billed charges 105.81 162.13 Technical (Hospital) Services DIAZEPAM 5 MG/ML INJECTION SYRINGE RX-106278 CDM J3360 HCPCS 636 RC 00409-1273-32 NDC outpatient 10 ME 170.66 170.66 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES EPO [308136803] 136.53 percent of total billed charges 105.81 162.13 Technical (Hospital) Services DIAZEPAM 5 MG/ML INJECTION SYRINGE RX-106278 CDM J3360 HCPCS 636 RC 00409-1273-32 NDC outpatient 10 ME 170.66 170.66 MEDICA (COMMERCIAL) 94265 [3081118] MEDICA CLAIMS [308111801] 153.59 percent of total billed charges 105.81 162.13 Technical (Hospital) Services DIAZEPAM 5 MG/ML INJECTION SYRINGE RX-106278 CDM J3360 HCPCS 636 RC 00409-1273-32 NDC outpatient 10 ME 170.66 170.66 MULTIPLAN INC 34080 [3081285] MULTIPLAN INC [308128501] 162.13 percent of total billed charges 105.81 162.13 Technical (Hospital) Services DIAZEPAM 5 MG/ML INJECTION SYRINGE RX-106278 CDM J3360 HCPCS 636 RC 00409-1273-32 NDC outpatient 10 ME 170.66 170.66 UNITED HEALTHCARE (COMMERCIAL) [3081199] UNITED HEALTHCARE 87726 [308119901] 105.81 percent of total billed charges 105.81 162.13 Technical (Hospital) Services DIAZEPAM 5 MG/ML INJECTION SYRINGE RX-106278 CDM J3360 HCPCS 636 RC 00409-1273-32 NDC outpatient 10 ME 170.66 170.66 HEALTHPARTNERS SX009 HEALTHPARTNERS 136.53 percent of total billed charges 105.81 162.13 Technical (Hospital) Services DIAZEPAM 5 MG/ML INJECTION SYRINGE RX-106278 CDM J3360 HCPCS 636 RC 00409-1273-32 NDC outpatient 10 ME 170.66 170.66 CIGNA 62308 [3081051] CIGNA 62308 [308105105] 136.53 percent of total billed charges 105.81 162.13 Technical (Hospital) Services DIAZEPAM 5 MG/ML INJECTION SYRINGE RX-106278 CDM J3360 HCPCS 636 RC 00409-1273-32 NDC outpatient 10 ME 170.66 170.66 CIGNA 62308 [3081051] CIGNA STATE OF WYOMING [308105107] 136.53 percent of total billed charges 105.81 162.13 Technical (Hospital) Services DIAZEPAM 5 MG/ML INJECTION SYRINGE RX-106278 CDM J3360 HCPCS 636 RC 00409-1273-32 NDC inpatient 10 ME 170.66 170.66 HEALTHPARTNERS SX009 HEALTHPARTNERS 135.13 percent of total billed charges 105.81 162.13 Technical (Hospital) Services DIAZEPAM 5 MG/ML INJECTION SYRINGE RX-106278 CDM J3360 HCPCS 636 RC 00409-1273-32 NDC inpatient 10 ME 170.66 170.66 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES EPO [308136803] 135.13 percent of total billed charges 105.81 162.13 Technical (Hospital) Services DIAZEPAM 5 MG/ML INJECTION SYRINGE RX-106278 CDM J3360 HCPCS 636 RC 00409-1273-32 NDC inpatient 10 ME 170.66 170.66 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES HDHP [308136802] 135.13 percent of total billed charges 105.81 162.13 Technical (Hospital) Services DIAZEPAM 5 MG/ML INJECTION SYRINGE RX-106278 CDM J3360 HCPCS 636 RC 00409-1273-32 NDC inpatient 10 ME 170.66 170.66 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES PPO [308136801] 135.13 percent of total billed charges 105.81 162.13 Technical (Hospital) Services DIAZEPAM 5 MG/ML INJECTION SYRINGE RX-106278 CDM J3360 HCPCS 636 RC 00409-1273-32 NDC inpatient 10 ME 170.66 170.66 CIGNA 62308 [3081051] CIGNA 62308 [308105105] 135.13 percent of total billed charges 105.81 162.13 Technical (Hospital) Services DIAZEPAM 5 MG/ML INJECTION SYRINGE RX-106278 CDM J3360 HCPCS 636 RC 00409-1273-32 NDC inpatient 10 ME 170.66 170.66 CIGNA 62308 [3081051] CIGNA STATE OF WYOMING [308105107] 135.13 percent of total billed charges 105.81 162.13 Technical (Hospital) Services DIAZEPAM 5 MG/ML INJECTION SYRINGE RX-106278 CDM J3360 HCPCS 636 RC 00409-1273-32 NDC inpatient 10 ME 170.66 170.66 UNITED HEALTHCARE (COMMERCIAL) [3081199] UNITED HEALTHCARE 87726 [308119901] 105.81 percent of total billed charges 105.81 162.13 Technical (Hospital) Services DIAZEPAM 5 MG/ML INJECTION SYRINGE RX-106278 CDM J3360 HCPCS 636 RC 00409-1273-32 NDC inpatient 10 ME 170.66 170.66 BLUE CROSS BLUE SHIELD WELLMARK SB889 [3081026] BCBS WYOMING [308102603] 162.13 percent of total billed charges 105.81 162.13 Technical (Hospital) Services DIAZEPAM 5 MG/ML INJECTION SYRINGE RX-106278 CDM J3360 HCPCS 636 RC 00409-1273-32 NDC inpatient 10 ME 170.66 170.66 MULTIPLAN INC 34080 [3081285] MULTIPLAN INC [308128501] 162.13 percent of total billed charges 105.81 162.13 Technical (Hospital) Services DIAZEPAM 5 MG/ML INJECTION SYRINGE RX-106278 CDM J3360 HCPCS 636 RC 00409-1273-32 NDC inpatient 10 ME 170.66 170.66 MEDICA (COMMERCIAL) 94265 [3081118] MEDICA CLAIMS [308111801] 153.59 percent of total billed charges 105.81 162.13 Technical (Hospital) Services DIAZEPAM 5 MG/ML INJECTION SOLUTION RX-2401 CDM J3360 HCPCS 636 RC 00409-3213-12 NDC outpatient 10 ML 232.11 232.11 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES HDHP [308136802] 185.69 percent of total billed charges 143.91 220.5 Technical (Hospital) Services DIAZEPAM 5 MG/ML INJECTION SOLUTION RX-2401 CDM J3360 HCPCS 636 RC 00409-3213-12 NDC outpatient 10 ML 232.11 232.11 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES EPO [308136803] 185.69 percent of total billed charges 143.91 220.5 Technical (Hospital) Services DIAZEPAM 5 MG/ML INJECTION SOLUTION RX-2401 CDM J3360 HCPCS 636 RC 00409-3213-12 NDC outpatient 10 ML 232.11 232.11 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES PPO [308136801] 185.69 percent of total billed charges 143.91 220.5 Technical (Hospital) Services DIAZEPAM 5 MG/ML INJECTION SOLUTION RX-2401 CDM J3360 HCPCS 636 RC 00409-3213-12 NDC outpatient 10 ML 232.11 232.11 UNITED HEALTHCARE (COMMERCIAL) [3081199] UNITED HEALTHCARE 87726 [308119901] 143.91 percent of total billed charges 143.91 220.5 Technical (Hospital) Services DIAZEPAM 5 MG/ML INJECTION SOLUTION RX-2401 CDM J3360 HCPCS 636 RC 00409-3213-12 NDC outpatient 10 ML 232.11 232.11 HEALTHPARTNERS SX009 HEALTHPARTNERS 185.69 percent of total billed charges 143.91 220.5 Technical (Hospital) Services DIAZEPAM 5 MG/ML INJECTION SOLUTION RX-2401 CDM J3360 HCPCS 636 RC 00409-3213-12 NDC inpatient 10 ML 232.11 232.11 BLUE CROSS BLUE SHIELD WELLMARK SB889 [3081026] BCBS WYOMING [308102603] 220.5 percent of total billed charges 143.91 220.5 Technical (Hospital) Services DIAZEPAM 5 MG/ML INJECTION SOLUTION RX-2401 CDM J3360 HCPCS 636 RC 00409-3213-12 NDC inpatient 10 ML 232.11 232.11 CIGNA 62308 [3081051] CIGNA 62308 [308105105] 183.78 percent of total billed charges 143.91 220.5 Technical (Hospital) Services DIAZEPAM 5 MG/ML INJECTION SOLUTION RX-2401 CDM J3360 HCPCS 636 RC 00409-3213-12 NDC inpatient 10 ML 232.11 232.11 CIGNA 62308 [3081051] CIGNA STATE OF WYOMING [308105107] 183.78 percent of total billed charges 143.91 220.5 Technical (Hospital) Services DIAZEPAM 5 MG/ML INJECTION SOLUTION RX-2401 CDM J3360 HCPCS 636 RC 00409-3213-12 NDC inpatient 10 ML 232.11 232.11 UNITED HEALTHCARE (COMMERCIAL) [3081199] UNITED HEALTHCARE 87726 [308119901] 143.91 percent of total billed charges 143.91 220.5 Technical (Hospital) Services DIAZEPAM 5 MG/ML INJECTION SOLUTION RX-2401 CDM J3360 HCPCS 636 RC 00409-3213-12 NDC inpatient 10 ML 232.11 232.11 MEDICA (COMMERCIAL) 94265 [3081118] MEDICA CLAIMS [308111801] 208.9 percent of total billed charges 143.91 220.5 Technical (Hospital) Services DIAZEPAM 5 MG/ML INJECTION SOLUTION RX-2401 CDM J3360 HCPCS 636 RC 00409-3213-12 NDC inpatient 10 ML 232.11 232.11 MULTIPLAN INC 34080 [3081285] MULTIPLAN INC [308128501] 220.5 percent of total billed charges 143.91 220.5 Technical (Hospital) Services DIAZEPAM 5 MG/ML INJECTION SOLUTION RX-2401 CDM J3360 HCPCS 636 RC 00409-3213-12 NDC inpatient 10 ML 232.11 232.11 HEALTHPARTNERS SX009 HEALTHPARTNERS 183.78 percent of total billed charges 143.91 220.5 Technical (Hospital) Services DIAZEPAM 5 MG/ML INJECTION SOLUTION RX-2401 CDM J3360 HCPCS 636 RC 00409-3213-12 NDC inpatient 10 ML 232.11 232.11 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES EPO [308136803] 183.78 percent of total billed charges 143.91 220.5 Technical (Hospital) Services DIAZEPAM 5 MG/ML INJECTION SOLUTION RX-2401 CDM J3360 HCPCS 636 RC 00409-3213-12 NDC inpatient 10 ML 232.11 232.11 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES PPO [308136801] 183.78 percent of total billed charges 143.91 220.5 Technical (Hospital) Services DIAZEPAM 5 MG/ML INJECTION SOLUTION RX-2401 CDM J3360 HCPCS 636 RC 00409-3213-12 NDC inpatient 10 ML 232.11 232.11 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES HDHP [308136802] 183.78 percent of total billed charges 143.91 220.5 Technical (Hospital) Services DIAZEPAM 5 MG/ML INJECTION SOLUTION RX-2401 CDM J3360 HCPCS 636 RC 00409-3213-12 NDC outpatient 10 ML 232.11 232.11 BLUE CROSS BLUE SHIELD WELLMARK SB889 [3081026] BCBS WYOMING [308102603] 220.5 percent of total billed charges 143.91 220.5 Technical (Hospital) Services DIAZEPAM 5 MG/ML INJECTION SOLUTION RX-2401 CDM J3360 HCPCS 636 RC 00409-3213-12 NDC outpatient 10 ML 232.11 232.11 CIGNA 62308 [3081051] CIGNA 62308 [308105105] 185.69 percent of total billed charges 143.91 220.5 Technical (Hospital) Services DIAZEPAM 5 MG/ML INJECTION SOLUTION RX-2401 CDM J3360 HCPCS 636 RC 00409-3213-12 NDC outpatient 10 ML 232.11 232.11 CIGNA 62308 [3081051] CIGNA STATE OF WYOMING [308105107] 185.69 percent of total billed charges 143.91 220.5 Technical (Hospital) Services DIAZEPAM 5 MG/ML INJECTION SOLUTION RX-2401 CDM J3360 HCPCS 636 RC 00409-3213-12 NDC outpatient 10 ML 232.11 232.11 MULTIPLAN INC 34080 [3081285] MULTIPLAN INC [308128501] 220.5 percent of total billed charges 143.91 220.5 Technical (Hospital) Services DIAZEPAM 5 MG/ML INJECTION SOLUTION RX-2401 CDM J3360 HCPCS 636 RC 00409-3213-12 NDC outpatient 10 ML 232.11 232.11 MEDICA (COMMERCIAL) 94265 [3081118] MEDICA CLAIMS [308111801] 208.9 percent of total billed charges 143.91 220.5 Technical (Hospital) Services TRIAMCINOLONE ACETONIDE 40 MG/ML SUSPENSION FOR INJECTION RX-8120 CDM J3301 HCPCS 636 RC 70121-1168-01 NDC inpatient 1 ML 73.17 73.17 BLUE CROSS BLUE SHIELD WELLMARK SB889 [3081026] BCBS WYOMING [308102603] 69.51 percent of total billed charges 45.37 69.51 Technical (Hospital) Services TRIAMCINOLONE ACETONIDE 40 MG/ML SUSPENSION FOR INJECTION RX-8120 CDM J3301 HCPCS 636 RC 70121-1168-01 NDC inpatient 1 ML 73.17 73.17 UNITED HEALTHCARE (COMMERCIAL) [3081199] UNITED HEALTHCARE 87726 [308119901] 45.37 percent of total billed charges 45.37 69.51 Technical (Hospital) Services TRIAMCINOLONE ACETONIDE 40 MG/ML SUSPENSION FOR INJECTION RX-8120 CDM J3301 HCPCS 636 RC 70121-1168-01 NDC inpatient 1 ML 73.17 73.17 CIGNA 62308 [3081051] CIGNA 62308 [308105105] 57.94 percent of total billed charges 45.37 69.51 Technical (Hospital) Services TRIAMCINOLONE ACETONIDE 40 MG/ML SUSPENSION FOR INJECTION RX-8120 CDM J3301 HCPCS 636 RC 70121-1168-01 NDC inpatient 1 ML 73.17 73.17 CIGNA 62308 [3081051] CIGNA STATE OF WYOMING [308105107] 57.94 percent of total billed charges 45.37 69.51 Technical (Hospital) Services TRIAMCINOLONE ACETONIDE 40 MG/ML SUSPENSION FOR INJECTION RX-8120 CDM J3301 HCPCS 636 RC 70121-1168-01 NDC inpatient 1 ML 73.17 73.17 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES EPO [308136803] 57.94 percent of total billed charges 45.37 69.51 Technical (Hospital) Services TRIAMCINOLONE ACETONIDE 40 MG/ML SUSPENSION FOR INJECTION RX-8120 CDM J3301 HCPCS 636 RC 70121-1168-01 NDC inpatient 1 ML 73.17 73.17 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES PPO [308136801] 57.94 percent of total billed charges 45.37 69.51 Technical (Hospital) Services TRIAMCINOLONE ACETONIDE 40 MG/ML SUSPENSION FOR INJECTION RX-8120 CDM J3301 HCPCS 636 RC 70121-1168-01 NDC inpatient 1 ML 73.17 73.17 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES HDHP [308136802] 57.94 percent of total billed charges 45.37 69.51 Technical (Hospital) Services TRIAMCINOLONE ACETONIDE 40 MG/ML SUSPENSION FOR INJECTION RX-8120 CDM J3301 HCPCS 636 RC 70121-1168-01 NDC inpatient 1 ML 73.17 73.17 HEALTHPARTNERS SX009 HEALTHPARTNERS 57.94 percent of total billed charges 45.37 69.51 Technical (Hospital) Services TRIAMCINOLONE ACETONIDE 40 MG/ML SUSPENSION FOR INJECTION RX-8120 CDM J3301 HCPCS 636 RC 70121-1168-01 NDC inpatient 1 ML 73.17 73.17 MEDICA (COMMERCIAL) 94265 [3081118] MEDICA CLAIMS [308111801] 65.85 percent of total billed charges 45.37 69.51 Technical (Hospital) Services TRIAMCINOLONE ACETONIDE 40 MG/ML SUSPENSION FOR INJECTION RX-8120 CDM J3301 HCPCS 636 RC 70121-1168-01 NDC inpatient 1 ML 73.17 73.17 MULTIPLAN INC 34080 [3081285] MULTIPLAN INC [308128501] 69.51 percent of total billed charges 45.37 69.51 Technical (Hospital) Services TRIAMCINOLONE ACETONIDE 40 MG/ML SUSPENSION FOR INJECTION RX-8120 CDM J3301 HCPCS 636 RC 70121-1168-01 NDC outpatient 1 ML 73.17 73.17 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES HDHP [308136802] 58.54 percent of total billed charges 45.37 69.51 Technical (Hospital) Services TRIAMCINOLONE ACETONIDE 40 MG/ML SUSPENSION FOR INJECTION RX-8120 CDM J3301 HCPCS 636 RC 70121-1168-01 NDC outpatient 1 ML 73.17 73.17 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES EPO [308136803] 58.54 percent of total billed charges 45.37 69.51 Technical (Hospital) Services TRIAMCINOLONE ACETONIDE 40 MG/ML SUSPENSION FOR INJECTION RX-8120 CDM J3301 HCPCS 636 RC 70121-1168-01 NDC outpatient 1 ML 73.17 73.17 BLUE CROSS BLUE SHIELD WELLMARK SB889 [3081026] BCBS WYOMING [308102603] 69.51 percent of total billed charges 45.37 69.51 Technical (Hospital) Services TRIAMCINOLONE ACETONIDE 40 MG/ML SUSPENSION FOR INJECTION RX-8120 CDM J3301 HCPCS 636 RC 70121-1168-01 NDC outpatient 1 ML 73.17 73.17 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES PPO [308136801] 58.54 percent of total billed charges 45.37 69.51 Technical (Hospital) Services TRIAMCINOLONE ACETONIDE 40 MG/ML SUSPENSION FOR INJECTION RX-8120 CDM J3301 HCPCS 636 RC 70121-1168-01 NDC outpatient 1 ML 73.17 73.17 CIGNA 62308 [3081051] CIGNA 62308 [308105105] 58.54 percent of total billed charges 45.37 69.51 Technical (Hospital) Services TRIAMCINOLONE ACETONIDE 40 MG/ML SUSPENSION FOR INJECTION RX-8120 CDM J3301 HCPCS 636 RC 70121-1168-01 NDC outpatient 1 ML 73.17 73.17 CIGNA 62308 [3081051] CIGNA STATE OF WYOMING [308105107] 58.54 percent of total billed charges 45.37 69.51 Technical (Hospital) Services TRIAMCINOLONE ACETONIDE 40 MG/ML SUSPENSION FOR INJECTION RX-8120 CDM J3301 HCPCS 636 RC 70121-1168-01 NDC outpatient 1 ML 73.17 73.17 MEDICA (COMMERCIAL) 94265 [3081118] MEDICA CLAIMS [308111801] 65.85 percent of total billed charges 45.37 69.51 Technical (Hospital) Services TRIAMCINOLONE ACETONIDE 40 MG/ML SUSPENSION FOR INJECTION RX-8120 CDM J3301 HCPCS 636 RC 70121-1168-01 NDC outpatient 1 ML 73.17 73.17 UNITED HEALTHCARE (COMMERCIAL) [3081199] UNITED HEALTHCARE 87726 [308119901] 45.37 percent of total billed charges 45.37 69.51 Technical (Hospital) Services TRIAMCINOLONE ACETONIDE 40 MG/ML SUSPENSION FOR INJECTION RX-8120 CDM J3301 HCPCS 636 RC 70121-1168-01 NDC outpatient 1 ML 73.17 73.17 MULTIPLAN INC 34080 [3081285] MULTIPLAN INC [308128501] 69.51 percent of total billed charges 45.37 69.51 Technical (Hospital) Services TRIAMCINOLONE ACETONIDE 40 MG/ML SUSPENSION FOR INJECTION RX-8120 CDM J3301 HCPCS 636 RC 70121-1168-01 NDC outpatient 1 ML 73.17 73.17 HEALTHPARTNERS SX009 HEALTHPARTNERS 58.54 percent of total billed charges 45.37 69.51 Technical (Hospital) Services CHLORPROMAZINE 25 MG/ML INJECTION SOLUTION RX-129677 CDM J3230 HCPCS 636 RC 00641-1398-35 NDC outpatient 2 ML 170.1 170.1 MEDICA (COMMERCIAL) 94265 [3081118] MEDICA CLAIMS [308111801] 153.09 percent of total billed charges 105.46 161.6 Technical (Hospital) Services CHLORPROMAZINE 25 MG/ML INJECTION SOLUTION RX-129677 CDM J3230 HCPCS 636 RC 00641-1398-35 NDC outpatient 2 ML 170.1 170.1 CIGNA 62308 [3081051] CIGNA 62308 [308105105] 136.08 percent of total billed charges 105.46 161.6 Technical (Hospital) Services CHLORPROMAZINE 25 MG/ML INJECTION SOLUTION RX-129677 CDM J3230 HCPCS 636 RC 00641-1398-35 NDC outpatient 2 ML 170.1 170.1 CIGNA 62308 [3081051] CIGNA STATE OF WYOMING [308105107] 136.08 percent of total billed charges 105.46 161.6 Technical (Hospital) Services CHLORPROMAZINE 25 MG/ML INJECTION SOLUTION RX-129677 CDM J3230 HCPCS 636 RC 00641-1398-35 NDC outpatient 2 ML 170.1 170.1 MULTIPLAN INC 34080 [3081285] MULTIPLAN INC [308128501] 161.6 percent of total billed charges 105.46 161.6 Technical (Hospital) Services CHLORPROMAZINE 25 MG/ML INJECTION SOLUTION RX-129677 CDM J3230 HCPCS 636 RC 00641-1398-35 NDC outpatient 2 ML 170.1 170.1 UNITED HEALTHCARE (COMMERCIAL) [3081199] UNITED HEALTHCARE 87726 [308119901] 105.46 percent of total billed charges 105.46 161.6 Technical (Hospital) Services CHLORPROMAZINE 25 MG/ML INJECTION SOLUTION RX-129677 CDM J3230 HCPCS 636 RC 00641-1398-35 NDC outpatient 2 ML 170.1 170.1 HEALTHPARTNERS SX009 HEALTHPARTNERS 136.08 percent of total billed charges 105.46 161.6 Technical (Hospital) Services CHLORPROMAZINE 25 MG/ML INJECTION SOLUTION RX-129677 CDM J3230 HCPCS 636 RC 00641-1398-35 NDC outpatient 2 ML 170.1 170.1 BLUE CROSS BLUE SHIELD WELLMARK SB889 [3081026] BCBS WYOMING [308102603] 161.6 percent of total billed charges 105.46 161.6 Technical (Hospital) Services CHLORPROMAZINE 25 MG/ML INJECTION SOLUTION RX-129677 CDM J3230 HCPCS 636 RC 00641-1398-35 NDC outpatient 2 ML 170.1 170.1 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES EPO [308136803] 136.08 percent of total billed charges 105.46 161.6 Technical (Hospital) Services CHLORPROMAZINE 25 MG/ML INJECTION SOLUTION RX-129677 CDM J3230 HCPCS 636 RC 00641-1398-35 NDC outpatient 2 ML 170.1 170.1 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES HDHP [308136802] 136.08 percent of total billed charges 105.46 161.6 Technical (Hospital) Services CHLORPROMAZINE 25 MG/ML INJECTION SOLUTION RX-129677 CDM J3230 HCPCS 636 RC 00641-1398-35 NDC outpatient 2 ML 170.1 170.1 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES PPO [308136801] 136.08 percent of total billed charges 105.46 161.6 Technical (Hospital) Services CHLORPROMAZINE 25 MG/ML INJECTION SOLUTION RX-129677 CDM J3230 HCPCS 636 RC 00641-1398-35 NDC inpatient 2 ML 170.1 170.1 HEALTHPARTNERS SX009 HEALTHPARTNERS 134.69 percent of total billed charges 105.46 161.6 Technical (Hospital) Services CHLORPROMAZINE 25 MG/ML INJECTION SOLUTION RX-129677 CDM J3230 HCPCS 636 RC 00641-1398-35 NDC inpatient 2 ML 170.1 170.1 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES EPO [308136803] 134.69 percent of total billed charges 105.46 161.6 Technical (Hospital) Services CHLORPROMAZINE 25 MG/ML INJECTION SOLUTION RX-129677 CDM J3230 HCPCS 636 RC 00641-1398-35 NDC inpatient 2 ML 170.1 170.1 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES HDHP [308136802] 134.69 percent of total billed charges 105.46 161.6 Technical (Hospital) Services CHLORPROMAZINE 25 MG/ML INJECTION SOLUTION RX-129677 CDM J3230 HCPCS 636 RC 00641-1398-35 NDC inpatient 2 ML 170.1 170.1 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES PPO [308136801] 134.69 percent of total billed charges 105.46 161.6 Technical (Hospital) Services CHLORPROMAZINE 25 MG/ML INJECTION SOLUTION RX-129677 CDM J3230 HCPCS 636 RC 00641-1398-35 NDC inpatient 2 ML 170.1 170.1 BLUE CROSS BLUE SHIELD WELLMARK SB889 [3081026] BCBS WYOMING [308102603] 161.6 percent of total billed charges 105.46 161.6 Technical (Hospital) Services CHLORPROMAZINE 25 MG/ML INJECTION SOLUTION RX-129677 CDM J3230 HCPCS 636 RC 00641-1398-35 NDC inpatient 2 ML 170.1 170.1 UNITED HEALTHCARE (COMMERCIAL) [3081199] UNITED HEALTHCARE 87726 [308119901] 105.46 percent of total billed charges 105.46 161.6 Technical (Hospital) Services CHLORPROMAZINE 25 MG/ML INJECTION SOLUTION RX-129677 CDM J3230 HCPCS 636 RC 00641-1398-35 NDC inpatient 2 ML 170.1 170.1 CIGNA 62308 [3081051] CIGNA 62308 [308105105] 134.69 percent of total billed charges 105.46 161.6 Technical (Hospital) Services CHLORPROMAZINE 25 MG/ML INJECTION SOLUTION RX-129677 CDM J3230 HCPCS 636 RC 00641-1398-35 NDC inpatient 2 ML 170.1 170.1 CIGNA 62308 [3081051] CIGNA STATE OF WYOMING [308105107] 134.69 percent of total billed charges 105.46 161.6 Technical (Hospital) Services CHLORPROMAZINE 25 MG/ML INJECTION SOLUTION RX-129677 CDM J3230 HCPCS 636 RC 00641-1398-35 NDC inpatient 2 ML 170.1 170.1 MULTIPLAN INC 34080 [3081285] MULTIPLAN INC [308128501] 161.6 percent of total billed charges 105.46 161.6 Technical (Hospital) Services CHLORPROMAZINE 25 MG/ML INJECTION SOLUTION RX-129677 CDM J3230 HCPCS 636 RC 00641-1398-35 NDC inpatient 2 ML 170.1 170.1 MEDICA (COMMERCIAL) 94265 [3081118] MEDICA CLAIMS [308111801] 153.09 percent of total billed charges 105.46 161.6 Technical (Hospital) Services ROMOSOZUMAB-AQQG 210 MG/2.34 ML(105 MG/1.17 ML X2)SUBCUTANEOUS SYRINGE RX-176681 CDM J3111 HCPCS 636 RC 55513-0880-02 NDC outpatient 2.34 ML 4953.74 4953.74 CIGNA 62308 [3081051] CIGNA 62308 [308105105] 3962.99 percent of total billed charges 3071.32 4706.05 Technical (Hospital) Services ROMOSOZUMAB-AQQG 210 MG/2.34 ML(105 MG/1.17 ML X2)SUBCUTANEOUS SYRINGE RX-176681 CDM J3111 HCPCS 636 RC 55513-0880-02 NDC outpatient 2.34 ML 4953.74 4953.74 CIGNA 62308 [3081051] CIGNA STATE OF WYOMING [308105107] 3962.99 percent of total billed charges 3071.32 4706.05 Technical (Hospital) Services ROMOSOZUMAB-AQQG 210 MG/2.34 ML(105 MG/1.17 ML X2)SUBCUTANEOUS SYRINGE RX-176681 CDM J3111 HCPCS 636 RC 55513-0880-02 NDC outpatient 2.34 ML 4953.74 4953.74 MULTIPLAN INC 34080 [3081285] MULTIPLAN INC [308128501] 4706.05 percent of total billed charges 3071.32 4706.05 Technical (Hospital) Services ROMOSOZUMAB-AQQG 210 MG/2.34 ML(105 MG/1.17 ML X2)SUBCUTANEOUS SYRINGE RX-176681 CDM J3111 HCPCS 636 RC 55513-0880-02 NDC outpatient 2.34 ML 4953.74 4953.74 MEDICA (COMMERCIAL) 94265 [3081118] MEDICA CLAIMS [308111801] 4458.37 percent of total billed charges 3071.32 4706.05 Technical (Hospital) Services ROMOSOZUMAB-AQQG 210 MG/2.34 ML(105 MG/1.17 ML X2)SUBCUTANEOUS SYRINGE RX-176681 CDM J3111 HCPCS 636 RC 55513-0880-02 NDC outpatient 2.34 ML 4953.74 4953.74 HEALTHPARTNERS SX009 HEALTHPARTNERS 3962.99 percent of total billed charges 3071.32 4706.05 Technical (Hospital) Services ROMOSOZUMAB-AQQG 210 MG/2.34 ML(105 MG/1.17 ML X2)SUBCUTANEOUS SYRINGE RX-176681 CDM J3111 HCPCS 636 RC 55513-0880-02 NDC outpatient 2.34 ML 4953.74 4953.74 UNITED HEALTHCARE (COMMERCIAL) [3081199] UNITED HEALTHCARE 87726 [308119901] 3071.32 percent of total billed charges 3071.32 4706.05 Technical (Hospital) Services ROMOSOZUMAB-AQQG 210 MG/2.34 ML(105 MG/1.17 ML X2)SUBCUTANEOUS SYRINGE RX-176681 CDM J3111 HCPCS 636 RC 55513-0880-02 NDC outpatient 2.34 ML 4953.74 4953.74 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES EPO [308136803] 3962.99 percent of total billed charges 3071.32 4706.05 Technical (Hospital) Services ROMOSOZUMAB-AQQG 210 MG/2.34 ML(105 MG/1.17 ML X2)SUBCUTANEOUS SYRINGE RX-176681 CDM J3111 HCPCS 636 RC 55513-0880-02 NDC outpatient 2.34 ML 4953.74 4953.74 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES HDHP [308136802] 3962.99 percent of total billed charges 3071.32 4706.05 Technical (Hospital) Services ROMOSOZUMAB-AQQG 210 MG/2.34 ML(105 MG/1.17 ML X2)SUBCUTANEOUS SYRINGE RX-176681 CDM J3111 HCPCS 636 RC 55513-0880-02 NDC outpatient 2.34 ML 4953.74 4953.74 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES PPO [308136801] 3962.99 percent of total billed charges 3071.32 4706.05 Technical (Hospital) Services ROMOSOZUMAB-AQQG 210 MG/2.34 ML(105 MG/1.17 ML X2)SUBCUTANEOUS SYRINGE RX-176681 CDM J3111 HCPCS 636 RC 55513-0880-02 NDC outpatient 2.34 ML 4953.74 4953.74 BLUE CROSS BLUE SHIELD WELLMARK SB889 [3081026] BCBS WYOMING [308102603] 4706.05 percent of total billed charges 3071.32 4706.05 Technical (Hospital) Services ROMOSOZUMAB-AQQG 210 MG/2.34 ML(105 MG/1.17 ML X2)SUBCUTANEOUS SYRINGE RX-176681 CDM J3111 HCPCS 636 RC 55513-0880-02 NDC inpatient 2.34 ML 4953.74 4953.74 HEALTHPARTNERS SX009 HEALTHPARTNERS 3922.37 percent of total billed charges 3071.32 4706.05 Technical (Hospital) Services ROMOSOZUMAB-AQQG 210 MG/2.34 ML(105 MG/1.17 ML X2)SUBCUTANEOUS SYRINGE RX-176681 CDM J3111 HCPCS 636 RC 55513-0880-02 NDC inpatient 2.34 ML 4953.74 4953.74 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES EPO [308136803] 3922.37 percent of total billed charges 3071.32 4706.05 Technical (Hospital) Services ROMOSOZUMAB-AQQG 210 MG/2.34 ML(105 MG/1.17 ML X2)SUBCUTANEOUS SYRINGE RX-176681 CDM J3111 HCPCS 636 RC 55513-0880-02 NDC inpatient 2.34 ML 4953.74 4953.74 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES HDHP [308136802] 3922.37 percent of total billed charges 3071.32 4706.05 Technical (Hospital) Services ROMOSOZUMAB-AQQG 210 MG/2.34 ML(105 MG/1.17 ML X2)SUBCUTANEOUS SYRINGE RX-176681 CDM J3111 HCPCS 636 RC 55513-0880-02 NDC inpatient 2.34 ML 4953.74 4953.74 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES PPO [308136801] 3922.37 percent of total billed charges 3071.32 4706.05 Technical (Hospital) Services ROMOSOZUMAB-AQQG 210 MG/2.34 ML(105 MG/1.17 ML X2)SUBCUTANEOUS SYRINGE RX-176681 CDM J3111 HCPCS 636 RC 55513-0880-02 NDC inpatient 2.34 ML 4953.74 4953.74 CIGNA 62308 [3081051] CIGNA 62308 [308105105] 3922.37 percent of total billed charges 3071.32 4706.05 Technical (Hospital) Services ROMOSOZUMAB-AQQG 210 MG/2.34 ML(105 MG/1.17 ML X2)SUBCUTANEOUS SYRINGE RX-176681 CDM J3111 HCPCS 636 RC 55513-0880-02 NDC inpatient 2.34 ML 4953.74 4953.74 CIGNA 62308 [3081051] CIGNA STATE OF WYOMING [308105107] 3922.37 percent of total billed charges 3071.32 4706.05 Technical (Hospital) Services ROMOSOZUMAB-AQQG 210 MG/2.34 ML(105 MG/1.17 ML X2)SUBCUTANEOUS SYRINGE RX-176681 CDM J3111 HCPCS 636 RC 55513-0880-02 NDC inpatient 2.34 ML 4953.74 4953.74 BLUE CROSS BLUE SHIELD WELLMARK SB889 [3081026] BCBS WYOMING [308102603] 4706.05 percent of total billed charges 3071.32 4706.05 Technical (Hospital) Services ROMOSOZUMAB-AQQG 210 MG/2.34 ML(105 MG/1.17 ML X2)SUBCUTANEOUS SYRINGE RX-176681 CDM J3111 HCPCS 636 RC 55513-0880-02 NDC inpatient 2.34 ML 4953.74 4953.74 UNITED HEALTHCARE (COMMERCIAL) [3081199] UNITED HEALTHCARE 87726 [308119901] 3071.32 percent of total billed charges 3071.32 4706.05 Technical (Hospital) Services ROMOSOZUMAB-AQQG 210 MG/2.34 ML(105 MG/1.17 ML X2)SUBCUTANEOUS SYRINGE RX-176681 CDM J3111 HCPCS 636 RC 55513-0880-02 NDC inpatient 2.34 ML 4953.74 4953.74 MEDICA (COMMERCIAL) 94265 [3081118] MEDICA CLAIMS [308111801] 4458.37 percent of total billed charges 3071.32 4706.05 Technical (Hospital) Services ROMOSOZUMAB-AQQG 210 MG/2.34 ML(105 MG/1.17 ML X2)SUBCUTANEOUS SYRINGE RX-176681 CDM J3111 HCPCS 636 RC 55513-0880-02 NDC inpatient 2.34 ML 4953.74 4953.74 MULTIPLAN INC 34080 [3081285] MULTIPLAN INC [308128501] 4706.05 percent of total billed charges 3071.32 4706.05 Technical (Hospital) Services TERBUTALINE 1 MG/ML SUBCUTANEOUS SOLUTION RX-11507 CDM J3105 HCPCS 636 RC 00143-9746-10 NDC inpatient 1 ML 68.5 68.5 BLUE CROSS BLUE SHIELD WELLMARK SB889 [3081026] BCBS WYOMING [308102603] 65.08 percent of total billed charges 42.47 65.08 Technical (Hospital) Services TERBUTALINE 1 MG/ML SUBCUTANEOUS SOLUTION RX-11507 CDM J3105 HCPCS 636 RC 00143-9746-10 NDC inpatient 1 ML 68.5 68.5 UNITED HEALTHCARE (COMMERCIAL) [3081199] UNITED HEALTHCARE 87726 [308119901] 42.47 percent of total billed charges 42.47 65.08 Technical (Hospital) Services TERBUTALINE 1 MG/ML SUBCUTANEOUS SOLUTION RX-11507 CDM J3105 HCPCS 636 RC 00143-9746-10 NDC inpatient 1 ML 68.5 68.5 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES EPO [308136803] 54.24 percent of total billed charges 42.47 65.08 Technical (Hospital) Services TERBUTALINE 1 MG/ML SUBCUTANEOUS SOLUTION RX-11507 CDM J3105 HCPCS 636 RC 00143-9746-10 NDC inpatient 1 ML 68.5 68.5 CIGNA 62308 [3081051] CIGNA 62308 [308105105] 54.24 percent of total billed charges 42.47 65.08 Technical (Hospital) Services TERBUTALINE 1 MG/ML SUBCUTANEOUS SOLUTION RX-11507 CDM J3105 HCPCS 636 RC 00143-9746-10 NDC inpatient 1 ML 68.5 68.5 CIGNA 62308 [3081051] CIGNA STATE OF WYOMING [308105107] 54.24 percent of total billed charges 42.47 65.08 Technical (Hospital) Services TERBUTALINE 1 MG/ML SUBCUTANEOUS SOLUTION RX-11507 CDM J3105 HCPCS 636 RC 00143-9746-10 NDC inpatient 1 ML 68.5 68.5 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES HDHP [308136802] 54.24 percent of total billed charges 42.47 65.08 Technical (Hospital) Services TERBUTALINE 1 MG/ML SUBCUTANEOUS SOLUTION RX-11507 CDM J3105 HCPCS 636 RC 00143-9746-10 NDC inpatient 1 ML 68.5 68.5 HEALTHPARTNERS SX009 HEALTHPARTNERS 54.24 percent of total billed charges 42.47 65.08 Technical (Hospital) Services TERBUTALINE 1 MG/ML SUBCUTANEOUS SOLUTION RX-11507 CDM J3105 HCPCS 636 RC 00143-9746-10 NDC inpatient 1 ML 68.5 68.5 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES PPO [308136801] 54.24 percent of total billed charges 42.47 65.08 Technical (Hospital) Services TERBUTALINE 1 MG/ML SUBCUTANEOUS SOLUTION RX-11507 CDM J3105 HCPCS 636 RC 00143-9746-10 NDC inpatient 1 ML 68.5 68.5 MEDICA (COMMERCIAL) 94265 [3081118] MEDICA CLAIMS [308111801] 61.65 percent of total billed charges 42.47 65.08 Technical (Hospital) Services TERBUTALINE 1 MG/ML SUBCUTANEOUS SOLUTION RX-11507 CDM J3105 HCPCS 636 RC 00143-9746-10 NDC inpatient 1 ML 68.5 68.5 MULTIPLAN INC 34080 [3081285] MULTIPLAN INC [308128501] 65.08 percent of total billed charges 42.47 65.08 Technical (Hospital) Services TERBUTALINE 1 MG/ML SUBCUTANEOUS SOLUTION RX-11507 CDM J3105 HCPCS 636 RC 00143-9746-10 NDC outpatient 1 ML 68.5 68.5 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES HDHP [308136802] 54.8 percent of total billed charges 42.47 65.08 Technical (Hospital) Services TERBUTALINE 1 MG/ML SUBCUTANEOUS SOLUTION RX-11507 CDM J3105 HCPCS 636 RC 00143-9746-10 NDC outpatient 1 ML 68.5 68.5 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES EPO [308136803] 54.8 percent of total billed charges 42.47 65.08 Technical (Hospital) Services TERBUTALINE 1 MG/ML SUBCUTANEOUS SOLUTION RX-11507 CDM J3105 HCPCS 636 RC 00143-9746-10 NDC outpatient 1 ML 68.5 68.5 HEALTHPARTNERS SX009 HEALTHPARTNERS 54.8 percent of total billed charges 42.47 65.08 Technical (Hospital) Services TERBUTALINE 1 MG/ML SUBCUTANEOUS SOLUTION RX-11507 CDM J3105 HCPCS 636 RC 00143-9746-10 NDC outpatient 1 ML 68.5 68.5 UNITED HEALTHCARE (COMMERCIAL) [3081199] UNITED HEALTHCARE 87726 [308119901] 42.47 percent of total billed charges 42.47 65.08 Technical (Hospital) Services TERBUTALINE 1 MG/ML SUBCUTANEOUS SOLUTION RX-11507 CDM J3105 HCPCS 636 RC 00143-9746-10 NDC outpatient 1 ML 68.5 68.5 MULTIPLAN INC 34080 [3081285] MULTIPLAN INC [308128501] 65.08 percent of total billed charges 42.47 65.08 Technical (Hospital) Services TERBUTALINE 1 MG/ML SUBCUTANEOUS SOLUTION RX-11507 CDM J3105 HCPCS 636 RC 00143-9746-10 NDC outpatient 1 ML 68.5 68.5 MEDICA (COMMERCIAL) 94265 [3081118] MEDICA CLAIMS [308111801] 61.65 percent of total billed charges 42.47 65.08 Technical (Hospital) Services TERBUTALINE 1 MG/ML SUBCUTANEOUS SOLUTION RX-11507 CDM J3105 HCPCS 636 RC 00143-9746-10 NDC outpatient 1 ML 68.5 68.5 CIGNA 62308 [3081051] CIGNA 62308 [308105105] 54.8 percent of total billed charges 42.47 65.08 Technical (Hospital) Services TERBUTALINE 1 MG/ML SUBCUTANEOUS SOLUTION RX-11507 CDM J3105 HCPCS 636 RC 00143-9746-10 NDC outpatient 1 ML 68.5 68.5 CIGNA 62308 [3081051] CIGNA STATE OF WYOMING [308105107] 54.8 percent of total billed charges 42.47 65.08 Technical (Hospital) Services TERBUTALINE 1 MG/ML SUBCUTANEOUS SOLUTION RX-11507 CDM J3105 HCPCS 636 RC 00143-9746-10 NDC outpatient 1 ML 68.5 68.5 BLUE CROSS BLUE SHIELD WELLMARK SB889 [3081026] BCBS WYOMING [308102603] 65.08 percent of total billed charges 42.47 65.08 Technical (Hospital) Services TERBUTALINE 1 MG/ML SUBCUTANEOUS SOLUTION RX-11507 CDM J3105 HCPCS 636 RC 00143-9746-10 NDC outpatient 1 ML 68.5 68.5 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES PPO [308136801] 54.8 percent of total billed charges 42.47 65.08 Technical (Hospital) Services TENECTEPLASE 50 MG INTRAVENOUS SOLUTION - MI RX-173231 CDM J3101 HCPCS 636 RC 50242-0120-47 NDC outpatient 6 ML 7146.56 7146.56 MULTIPLAN INC 34080 [3081285] MULTIPLAN INC [308128501] 6789.23 percent of total billed charges 4430.87 6789.23 Technical (Hospital) Services TENECTEPLASE 50 MG INTRAVENOUS SOLUTION - MI RX-173231 CDM J3101 HCPCS 636 RC 50242-0120-47 NDC outpatient 6 ML 7146.56 7146.56 MEDICA (COMMERCIAL) 94265 [3081118] MEDICA CLAIMS [308111801] 6431.9 percent of total billed charges 4430.87 6789.23 Technical (Hospital) Services TENECTEPLASE 50 MG INTRAVENOUS SOLUTION - MI RX-173231 CDM J3101 HCPCS 636 RC 50242-0120-47 NDC outpatient 6 ML 7146.56 7146.56 CIGNA 62308 [3081051] CIGNA STATE OF WYOMING [308105107] 5717.25 percent of total billed charges 4430.87 6789.23 Technical (Hospital) Services TENECTEPLASE 50 MG INTRAVENOUS SOLUTION - MI RX-173231 CDM J3101 HCPCS 636 RC 50242-0120-47 NDC outpatient 6 ML 7146.56 7146.56 CIGNA 62308 [3081051] CIGNA 62308 [308105105] 5717.25 percent of total billed charges 4430.87 6789.23 Technical (Hospital) Services TENECTEPLASE 50 MG INTRAVENOUS SOLUTION - MI RX-173231 CDM J3101 HCPCS 636 RC 50242-0120-47 NDC outpatient 6 ML 7146.56 7146.56 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES EPO [308136803] 5717.25 percent of total billed charges 4430.87 6789.23 Technical (Hospital) Services TENECTEPLASE 50 MG INTRAVENOUS SOLUTION - MI RX-173231 CDM J3101 HCPCS 636 RC 50242-0120-47 NDC outpatient 6 ML 7146.56 7146.56 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES HDHP [308136802] 5717.25 percent of total billed charges 4430.87 6789.23 Technical (Hospital) Services TENECTEPLASE 50 MG INTRAVENOUS SOLUTION - MI RX-173231 CDM J3101 HCPCS 636 RC 50242-0120-47 NDC outpatient 6 ML 7146.56 7146.56 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES PPO [308136801] 5717.25 percent of total billed charges 4430.87 6789.23 Technical (Hospital) Services TENECTEPLASE 50 MG INTRAVENOUS SOLUTION - MI RX-173231 CDM J3101 HCPCS 636 RC 50242-0120-47 NDC outpatient 6 ML 7146.56 7146.56 BLUE CROSS BLUE SHIELD WELLMARK SB889 [3081026] BCBS WYOMING [308102603] 6789.23 percent of total billed charges 4430.87 6789.23 Technical (Hospital) Services TENECTEPLASE 50 MG INTRAVENOUS SOLUTION - MI RX-173231 CDM J3101 HCPCS 636 RC 50242-0120-47 NDC outpatient 6 ML 7146.56 7146.56 UNITED HEALTHCARE (COMMERCIAL) [3081199] UNITED HEALTHCARE 87726 [308119901] 4430.87 percent of total billed charges 4430.87 6789.23 Technical (Hospital) Services TENECTEPLASE 50 MG INTRAVENOUS SOLUTION - MI RX-173231 CDM J3101 HCPCS 636 RC 50242-0120-47 NDC outpatient 6 ML 7146.56 7146.56 HEALTHPARTNERS SX009 HEALTHPARTNERS 5717.25 percent of total billed charges 4430.87 6789.23 Technical (Hospital) Services TENECTEPLASE 50 MG INTRAVENOUS SOLUTION - MI RX-173231 CDM J3101 HCPCS 636 RC 50242-0120-47 NDC inpatient 6 ML 7146.56 7146.56 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES EPO [308136803] 5658.65 percent of total billed charges 4430.87 6789.23 Technical (Hospital) Services TENECTEPLASE 50 MG INTRAVENOUS SOLUTION - MI RX-173231 CDM J3101 HCPCS 636 RC 50242-0120-47 NDC inpatient 6 ML 7146.56 7146.56 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES HDHP [308136802] 5658.65 percent of total billed charges 4430.87 6789.23 Technical (Hospital) Services TENECTEPLASE 50 MG INTRAVENOUS SOLUTION - MI RX-173231 CDM J3101 HCPCS 636 RC 50242-0120-47 NDC inpatient 6 ML 7146.56 7146.56 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES PPO [308136801] 5658.65 percent of total billed charges 4430.87 6789.23 Technical (Hospital) Services TENECTEPLASE 50 MG INTRAVENOUS SOLUTION - MI RX-173231 CDM J3101 HCPCS 636 RC 50242-0120-47 NDC inpatient 6 ML 7146.56 7146.56 HEALTHPARTNERS SX009 HEALTHPARTNERS 5658.65 percent of total billed charges 4430.87 6789.23 Technical (Hospital) Services TENECTEPLASE 50 MG INTRAVENOUS SOLUTION - MI RX-173231 CDM J3101 HCPCS 636 RC 50242-0120-47 NDC inpatient 6 ML 7146.56 7146.56 UNITED HEALTHCARE (COMMERCIAL) [3081199] UNITED HEALTHCARE 87726 [308119901] 4430.87 percent of total billed charges 4430.87 6789.23 Technical (Hospital) Services TENECTEPLASE 50 MG INTRAVENOUS SOLUTION - MI RX-173231 CDM J3101 HCPCS 636 RC 50242-0120-47 NDC inpatient 6 ML 7146.56 7146.56 BLUE CROSS BLUE SHIELD WELLMARK SB889 [3081026] BCBS WYOMING [308102603] 6789.23 percent of total billed charges 4430.87 6789.23 Technical (Hospital) Services TENECTEPLASE 50 MG INTRAVENOUS SOLUTION - MI RX-173231 CDM J3101 HCPCS 636 RC 50242-0120-47 NDC inpatient 6 ML 7146.56 7146.56 CIGNA 62308 [3081051] CIGNA 62308 [308105105] 5658.65 percent of total billed charges 4430.87 6789.23 Technical (Hospital) Services TENECTEPLASE 50 MG INTRAVENOUS SOLUTION - MI RX-173231 CDM J3101 HCPCS 636 RC 50242-0120-47 NDC inpatient 6 ML 7146.56 7146.56 CIGNA 62308 [3081051] CIGNA STATE OF WYOMING [308105107] 5658.65 percent of total billed charges 4430.87 6789.23 Technical (Hospital) Services TENECTEPLASE 50 MG INTRAVENOUS SOLUTION - MI RX-173231 CDM J3101 HCPCS 636 RC 50242-0120-47 NDC inpatient 6 ML 7146.56 7146.56 MULTIPLAN INC 34080 [3081285] MULTIPLAN INC [308128501] 6789.23 percent of total billed charges 4430.87 6789.23 Technical (Hospital) Services TENECTEPLASE 50 MG INTRAVENOUS SOLUTION - MI RX-173231 CDM J3101 HCPCS 636 RC 50242-0120-47 NDC inpatient 6 ML 7146.56 7146.56 MEDICA (COMMERCIAL) 94265 [3081118] MEDICA CLAIMS [308111801] 6431.9 percent of total billed charges 4430.87 6789.23 Technical (Hospital) Services TENECTEPLASE 50 MG INTRAVENOUS SOLUTION - STROKE RX-4080030162 CDM J3101 HCPCS 636 RC 50242-0037-06 NDC inpatient 10 ML 13077.6 13077.6 BLUE CROSS BLUE SHIELD WELLMARK SB889 [3081026] BCBS WYOMING [308102603] 12423.72 percent of total billed charges 8108.11 12423.72 Technical (Hospital) Services TENECTEPLASE 50 MG INTRAVENOUS SOLUTION - STROKE RX-4080030162 CDM J3101 HCPCS 636 RC 50242-0037-06 NDC inpatient 10 ML 13077.6 13077.6 UNITED HEALTHCARE (COMMERCIAL) [3081199] UNITED HEALTHCARE 87726 [308119901] 8108.11 percent of total billed charges 8108.11 12423.72 Technical (Hospital) Services TENECTEPLASE 50 MG INTRAVENOUS SOLUTION - STROKE RX-4080030162 CDM J3101 HCPCS 636 RC 50242-0037-06 NDC inpatient 10 ML 13077.6 13077.6 CIGNA 62308 [3081051] CIGNA 62308 [308105105] 10354.84 percent of total billed charges 8108.11 12423.72 Technical (Hospital) Services TENECTEPLASE 50 MG INTRAVENOUS SOLUTION - STROKE RX-4080030162 CDM J3101 HCPCS 636 RC 50242-0037-06 NDC inpatient 10 ML 13077.6 13077.6 CIGNA 62308 [3081051] CIGNA STATE OF WYOMING [308105107] 10354.84 percent of total billed charges 8108.11 12423.72 Technical (Hospital) Services TENECTEPLASE 50 MG INTRAVENOUS SOLUTION - STROKE RX-4080030162 CDM J3101 HCPCS 636 RC 50242-0037-06 NDC inpatient 10 ML 13077.6 13077.6 MULTIPLAN INC 34080 [3081285] MULTIPLAN INC [308128501] 12423.72 percent of total billed charges 8108.11 12423.72 Technical (Hospital) Services TENECTEPLASE 50 MG INTRAVENOUS SOLUTION - STROKE RX-4080030162 CDM J3101 HCPCS 636 RC 50242-0037-06 NDC inpatient 10 ML 13077.6 13077.6 MEDICA (COMMERCIAL) 94265 [3081118] MEDICA CLAIMS [308111801] 11769.84 percent of total billed charges 8108.11 12423.72 Technical (Hospital) Services TENECTEPLASE 50 MG INTRAVENOUS SOLUTION - STROKE RX-4080030162 CDM J3101 HCPCS 636 RC 50242-0037-06 NDC inpatient 10 ML 13077.6 13077.6 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES HDHP [308136802] 10354.84 percent of total billed charges 8108.11 12423.72 Technical (Hospital) Services TENECTEPLASE 50 MG INTRAVENOUS SOLUTION - STROKE RX-4080030162 CDM J3101 HCPCS 636 RC 50242-0037-06 NDC inpatient 10 ML 13077.6 13077.6 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES EPO [308136803] 10354.84 percent of total billed charges 8108.11 12423.72 Technical (Hospital) Services TENECTEPLASE 50 MG INTRAVENOUS SOLUTION - STROKE RX-4080030162 CDM J3101 HCPCS 636 RC 50242-0037-06 NDC inpatient 10 ML 13077.6 13077.6 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES PPO [308136801] 10354.84 percent of total billed charges 8108.11 12423.72 Technical (Hospital) Services TENECTEPLASE 50 MG INTRAVENOUS SOLUTION - STROKE RX-4080030162 CDM J3101 HCPCS 636 RC 50242-0037-06 NDC inpatient 10 ML 13077.6 13077.6 HEALTHPARTNERS SX009 HEALTHPARTNERS 10354.84 percent of total billed charges 8108.11 12423.72 Technical (Hospital) Services TENECTEPLASE 50 MG INTRAVENOUS SOLUTION - STROKE RX-4080030162 CDM J3101 HCPCS 636 RC 50242-0037-06 NDC outpatient 10 ML 13077.6 13077.6 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES PPO [308136801] 10462.08 percent of total billed charges 8108.11 12423.72 Technical (Hospital) Services TENECTEPLASE 50 MG INTRAVENOUS SOLUTION - STROKE RX-4080030162 CDM J3101 HCPCS 636 RC 50242-0037-06 NDC outpatient 10 ML 13077.6 13077.6 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES HDHP [308136802] 10462.08 percent of total billed charges 8108.11 12423.72 Technical (Hospital) Services TENECTEPLASE 50 MG INTRAVENOUS SOLUTION - STROKE RX-4080030162 CDM J3101 HCPCS 636 RC 50242-0037-06 NDC outpatient 10 ML 13077.6 13077.6 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES EPO [308136803] 10462.08 percent of total billed charges 8108.11 12423.72 Technical (Hospital) Services TENECTEPLASE 50 MG INTRAVENOUS SOLUTION - STROKE RX-4080030162 CDM J3101 HCPCS 636 RC 50242-0037-06 NDC outpatient 10 ML 13077.6 13077.6 BLUE CROSS BLUE SHIELD WELLMARK SB889 [3081026] BCBS WYOMING [308102603] 12423.72 percent of total billed charges 8108.11 12423.72 Technical (Hospital) Services TENECTEPLASE 50 MG INTRAVENOUS SOLUTION - STROKE RX-4080030162 CDM J3101 HCPCS 636 RC 50242-0037-06 NDC outpatient 10 ML 13077.6 13077.6 HEALTHPARTNERS SX009 HEALTHPARTNERS 10462.08 percent of total billed charges 8108.11 12423.72 Technical (Hospital) Services TENECTEPLASE 50 MG INTRAVENOUS SOLUTION - STROKE RX-4080030162 CDM J3101 HCPCS 636 RC 50242-0037-06 NDC outpatient 10 ML 13077.6 13077.6 UNITED HEALTHCARE (COMMERCIAL) [3081199] UNITED HEALTHCARE 87726 [308119901] 8108.11 percent of total billed charges 8108.11 12423.72 Technical (Hospital) Services TENECTEPLASE 50 MG INTRAVENOUS SOLUTION - STROKE RX-4080030162 CDM J3101 HCPCS 636 RC 50242-0037-06 NDC outpatient 10 ML 13077.6 13077.6 CIGNA 62308 [3081051] CIGNA 62308 [308105105] 10462.08 percent of total billed charges 8108.11 12423.72 Technical (Hospital) Services TENECTEPLASE 50 MG INTRAVENOUS SOLUTION - STROKE RX-4080030162 CDM J3101 HCPCS 636 RC 50242-0037-06 NDC outpatient 10 ML 13077.6 13077.6 CIGNA 62308 [3081051] CIGNA STATE OF WYOMING [308105107] 10462.08 percent of total billed charges 8108.11 12423.72 Technical (Hospital) Services TENECTEPLASE 50 MG INTRAVENOUS SOLUTION - STROKE RX-4080030162 CDM J3101 HCPCS 636 RC 50242-0037-06 NDC outpatient 10 ML 13077.6 13077.6 MULTIPLAN INC 34080 [3081285] MULTIPLAN INC [308128501] 12423.72 percent of total billed charges 8108.11 12423.72 Technical (Hospital) Services TENECTEPLASE 50 MG INTRAVENOUS SOLUTION - STROKE RX-4080030162 CDM J3101 HCPCS 636 RC 50242-0037-06 NDC outpatient 10 ML 13077.6 13077.6 MEDICA (COMMERCIAL) 94265 [3081118] MEDICA CLAIMS [308111801] 11769.84 percent of total billed charges 8108.11 12423.72 Technical (Hospital) Services FENTANYL (PF) 50 MCG/ML INTRAVENOUS WRAPPER RX-4080030024 CDM J3010 HCPCS 636 RC 00409-9094-25 NDC inpatient 5 ML 60.61 60.61 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES PPO [308136801] 47.99 percent of total billed charges 37.58 57.58 Technical (Hospital) Services FENTANYL (PF) 50 MCG/ML INTRAVENOUS WRAPPER RX-4080030024 CDM J3010 HCPCS 636 RC 00409-9094-25 NDC inpatient 5 ML 60.61 60.61 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES EPO [308136803] 47.99 percent of total billed charges 37.58 57.58 Technical (Hospital) Services FENTANYL (PF) 50 MCG/ML INTRAVENOUS WRAPPER RX-4080030024 CDM J3010 HCPCS 636 RC 00409-9094-25 NDC inpatient 5 ML 60.61 60.61 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES HDHP [308136802] 47.99 percent of total billed charges 37.58 57.58 Technical (Hospital) Services FENTANYL (PF) 50 MCG/ML INTRAVENOUS WRAPPER RX-4080030024 CDM J3010 HCPCS 636 RC 00409-9094-25 NDC inpatient 5 ML 60.61 60.61 HEALTHPARTNERS SX009 HEALTHPARTNERS 47.99 percent of total billed charges 37.58 57.58 Technical (Hospital) Services FENTANYL (PF) 50 MCG/ML INTRAVENOUS WRAPPER RX-4080030024 CDM J3010 HCPCS 636 RC 00409-9094-25 NDC inpatient 5 ML 60.61 60.61 UNITED HEALTHCARE (COMMERCIAL) [3081199] UNITED HEALTHCARE 87726 [308119901] 37.58 percent of total billed charges 37.58 57.58 Technical (Hospital) Services FENTANYL (PF) 50 MCG/ML INTRAVENOUS WRAPPER RX-4080030024 CDM J3010 HCPCS 636 RC 00409-9094-25 NDC inpatient 5 ML 60.61 60.61 BLUE CROSS BLUE SHIELD WELLMARK SB889 [3081026] BCBS WYOMING [308102603] 57.58 percent of total billed charges 37.58 57.58 Technical (Hospital) Services FENTANYL (PF) 50 MCG/ML INTRAVENOUS WRAPPER RX-4080030024 CDM J3010 HCPCS 636 RC 00409-9094-25 NDC inpatient 5 ML 60.61 60.61 CIGNA 62308 [3081051] CIGNA 62308 [308105105] 47.99 percent of total billed charges 37.58 57.58 Technical (Hospital) Services FENTANYL (PF) 50 MCG/ML INTRAVENOUS WRAPPER RX-4080030024 CDM J3010 HCPCS 636 RC 00409-9094-25 NDC inpatient 5 ML 60.61 60.61 CIGNA 62308 [3081051] CIGNA STATE OF WYOMING [308105107] 47.99 percent of total billed charges 37.58 57.58 Technical (Hospital) Services FENTANYL (PF) 50 MCG/ML INTRAVENOUS WRAPPER RX-4080030024 CDM J3010 HCPCS 636 RC 00409-9094-25 NDC inpatient 5 ML 60.61 60.61 MEDICA (COMMERCIAL) 94265 [3081118] MEDICA CLAIMS [308111801] 54.55 percent of total billed charges 37.58 57.58 Technical (Hospital) Services FENTANYL (PF) 50 MCG/ML INTRAVENOUS WRAPPER RX-4080030024 CDM J3010 HCPCS 636 RC 00409-9094-25 NDC inpatient 5 ML 60.61 60.61 MULTIPLAN INC 34080 [3081285] MULTIPLAN INC [308128501] 57.58 percent of total billed charges 37.58 57.58 Technical (Hospital) Services FENTANYL (PF) 50 MCG/ML INTRAVENOUS WRAPPER RX-4080030024 CDM J3010 HCPCS 636 RC 00409-9094-25 NDC outpatient 5 ML 60.61 60.61 UNITED HEALTHCARE (COMMERCIAL) [3081199] UNITED HEALTHCARE 87726 [308119901] 37.58 percent of total billed charges 37.58 57.58 Technical (Hospital) Services FENTANYL (PF) 50 MCG/ML INTRAVENOUS WRAPPER RX-4080030024 CDM J3010 HCPCS 636 RC 00409-9094-25 NDC outpatient 5 ML 60.61 60.61 HEALTHPARTNERS SX009 HEALTHPARTNERS 48.49 percent of total billed charges 37.58 57.58 Technical (Hospital) Services FENTANYL (PF) 50 MCG/ML INTRAVENOUS WRAPPER RX-4080030024 CDM J3010 HCPCS 636 RC 00409-9094-25 NDC outpatient 5 ML 60.61 60.61 BLUE CROSS BLUE SHIELD WELLMARK SB889 [3081026] BCBS WYOMING [308102603] 57.58 percent of total billed charges 37.58 57.58 Technical (Hospital) Services FENTANYL (PF) 50 MCG/ML INTRAVENOUS WRAPPER RX-4080030024 CDM J3010 HCPCS 636 RC 00409-9094-25 NDC outpatient 5 ML 60.61 60.61 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES EPO [308136803] 48.49 percent of total billed charges 37.58 57.58 Technical (Hospital) Services FENTANYL (PF) 50 MCG/ML INTRAVENOUS WRAPPER RX-4080030024 CDM J3010 HCPCS 636 RC 00409-9094-25 NDC outpatient 5 ML 60.61 60.61 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES HDHP [308136802] 48.49 percent of total billed charges 37.58 57.58 Technical (Hospital) Services FENTANYL (PF) 50 MCG/ML INTRAVENOUS WRAPPER RX-4080030024 CDM J3010 HCPCS 636 RC 00409-9094-25 NDC outpatient 5 ML 60.61 60.61 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES PPO [308136801] 48.49 percent of total billed charges 37.58 57.58 Technical (Hospital) Services FENTANYL (PF) 50 MCG/ML INTRAVENOUS WRAPPER RX-4080030024 CDM J3010 HCPCS 636 RC 00409-9094-25 NDC outpatient 5 ML 60.61 60.61 MEDICA (COMMERCIAL) 94265 [3081118] MEDICA CLAIMS [308111801] 54.55 percent of total billed charges 37.58 57.58 Technical (Hospital) Services FENTANYL (PF) 50 MCG/ML INTRAVENOUS WRAPPER RX-4080030024 CDM J3010 HCPCS 636 RC 00409-9094-25 NDC outpatient 5 ML 60.61 60.61 MULTIPLAN INC 34080 [3081285] MULTIPLAN INC [308128501] 57.58 percent of total billed charges 37.58 57.58 Technical (Hospital) Services FENTANYL (PF) 50 MCG/ML INTRAVENOUS WRAPPER RX-4080030024 CDM J3010 HCPCS 636 RC 00409-9094-25 NDC outpatient 5 ML 60.61 60.61 CIGNA 62308 [3081051] CIGNA 62308 [308105105] 48.49 percent of total billed charges 37.58 57.58 Technical (Hospital) Services FENTANYL (PF) 50 MCG/ML INTRAVENOUS WRAPPER RX-4080030024 CDM J3010 HCPCS 636 RC 00409-9094-25 NDC outpatient 5 ML 60.61 60.61 CIGNA 62308 [3081051] CIGNA STATE OF WYOMING [308105107] 48.49 percent of total billed charges 37.58 57.58 Technical (Hospital) Services ALTEPLASE 2 MG INTRA-CATHETER SOLUTION RX-31310 CDM J2997 HCPCS 636 RC 50242-0041-64 NDC outpatient 2 ML 526.35 526.35 UNITED HEALTHCARE (COMMERCIAL) [3081199] UNITED HEALTHCARE 87726 [308119901] 326.34 percent of total billed charges 326.34 500.03 Technical (Hospital) Services ALTEPLASE 2 MG INTRA-CATHETER SOLUTION RX-31310 CDM J2997 HCPCS 636 RC 50242-0041-64 NDC outpatient 2 ML 526.35 526.35 HEALTHPARTNERS SX009 HEALTHPARTNERS 421.08 percent of total billed charges 326.34 500.03 Technical (Hospital) Services ALTEPLASE 2 MG INTRA-CATHETER SOLUTION RX-31310 CDM J2997 HCPCS 636 RC 50242-0041-64 NDC outpatient 2 ML 526.35 526.35 CIGNA 62308 [3081051] CIGNA 62308 [308105105] 421.08 percent of total billed charges 326.34 500.03 Technical (Hospital) Services ALTEPLASE 2 MG INTRA-CATHETER SOLUTION RX-31310 CDM J2997 HCPCS 636 RC 50242-0041-64 NDC outpatient 2 ML 526.35 526.35 CIGNA 62308 [3081051] CIGNA STATE OF WYOMING [308105107] 421.08 percent of total billed charges 326.34 500.03 Technical (Hospital) Services ALTEPLASE 2 MG INTRA-CATHETER SOLUTION RX-31310 CDM J2997 HCPCS 636 RC 50242-0041-64 NDC outpatient 2 ML 526.35 526.35 MULTIPLAN INC 34080 [3081285] MULTIPLAN INC [308128501] 500.03 percent of total billed charges 326.34 500.03 Technical (Hospital) Services ALTEPLASE 2 MG INTRA-CATHETER SOLUTION RX-31310 CDM J2997 HCPCS 636 RC 50242-0041-64 NDC outpatient 2 ML 526.35 526.35 BLUE CROSS BLUE SHIELD WELLMARK SB889 [3081026] BCBS WYOMING [308102603] 500.03 percent of total billed charges 326.34 500.03 Technical (Hospital) Services ALTEPLASE 2 MG INTRA-CATHETER SOLUTION RX-31310 CDM J2997 HCPCS 636 RC 50242-0041-64 NDC outpatient 2 ML 526.35 526.35 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES EPO [308136803] 421.08 percent of total billed charges 326.34 500.03 Technical (Hospital) Services ALTEPLASE 2 MG INTRA-CATHETER SOLUTION RX-31310 CDM J2997 HCPCS 636 RC 50242-0041-64 NDC outpatient 2 ML 526.35 526.35 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES HDHP [308136802] 421.08 percent of total billed charges 326.34 500.03 Technical (Hospital) Services ALTEPLASE 2 MG INTRA-CATHETER SOLUTION RX-31310 CDM J2997 HCPCS 636 RC 50242-0041-64 NDC outpatient 2 ML 526.35 526.35 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES PPO [308136801] 421.08 percent of total billed charges 326.34 500.03 Technical (Hospital) Services ALTEPLASE 2 MG INTRA-CATHETER SOLUTION RX-31310 CDM J2997 HCPCS 636 RC 50242-0041-64 NDC outpatient 2 ML 526.35 526.35 MEDICA (COMMERCIAL) 94265 [3081118] MEDICA CLAIMS [308111801] 473.72 percent of total billed charges 326.34 500.03 Technical (Hospital) Services ALTEPLASE 2 MG INTRA-CATHETER SOLUTION RX-31310 CDM J2997 HCPCS 636 RC 50242-0041-64 NDC inpatient 2 ML 526.35 526.35 HEALTHPARTNERS SX009 HEALTHPARTNERS 416.76 percent of total billed charges 326.34 500.03 Technical (Hospital) Services ALTEPLASE 2 MG INTRA-CATHETER SOLUTION RX-31310 CDM J2997 HCPCS 636 RC 50242-0041-64 NDC inpatient 2 ML 526.35 526.35 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES HDHP [308136802] 416.76 percent of total billed charges 326.34 500.03 Technical (Hospital) Services ALTEPLASE 2 MG INTRA-CATHETER SOLUTION RX-31310 CDM J2997 HCPCS 636 RC 50242-0041-64 NDC inpatient 2 ML 526.35 526.35 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES PPO [308136801] 416.76 percent of total billed charges 326.34 500.03 Technical (Hospital) Services ALTEPLASE 2 MG INTRA-CATHETER SOLUTION RX-31310 CDM J2997 HCPCS 636 RC 50242-0041-64 NDC inpatient 2 ML 526.35 526.35 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES EPO [308136803] 416.76 percent of total billed charges 326.34 500.03 Technical (Hospital) Services ALTEPLASE 2 MG INTRA-CATHETER SOLUTION RX-31310 CDM J2997 HCPCS 636 RC 50242-0041-64 NDC inpatient 2 ML 526.35 526.35 MULTIPLAN INC 34080 [3081285] MULTIPLAN INC [308128501] 500.03 percent of total billed charges 326.34 500.03 Technical (Hospital) Services ALTEPLASE 2 MG INTRA-CATHETER SOLUTION RX-31310 CDM J2997 HCPCS 636 RC 50242-0041-64 NDC inpatient 2 ML 526.35 526.35 MEDICA (COMMERCIAL) 94265 [3081118] MEDICA CLAIMS [308111801] 473.72 percent of total billed charges 326.34 500.03 Technical (Hospital) Services ALTEPLASE 2 MG INTRA-CATHETER SOLUTION RX-31310 CDM J2997 HCPCS 636 RC 50242-0041-64 NDC inpatient 2 ML 526.35 526.35 UNITED HEALTHCARE (COMMERCIAL) [3081199] UNITED HEALTHCARE 87726 [308119901] 326.34 percent of total billed charges 326.34 500.03 Technical (Hospital) Services ALTEPLASE 2 MG INTRA-CATHETER SOLUTION RX-31310 CDM J2997 HCPCS 636 RC 50242-0041-64 NDC inpatient 2 ML 526.35 526.35 BLUE CROSS BLUE SHIELD WELLMARK SB889 [3081026] BCBS WYOMING [308102603] 500.03 percent of total billed charges 326.34 500.03 Technical (Hospital) Services ALTEPLASE 2 MG INTRA-CATHETER SOLUTION RX-31310 CDM J2997 HCPCS 636 RC 50242-0041-64 NDC inpatient 2 ML 526.35 526.35 CIGNA 62308 [3081051] CIGNA 62308 [308105105] 416.76 percent of total billed charges 326.34 500.03 Technical (Hospital) Services ALTEPLASE 2 MG INTRA-CATHETER SOLUTION RX-31310 CDM J2997 HCPCS 636 RC 50242-0041-64 NDC inpatient 2 ML 526.35 526.35 CIGNA 62308 [3081051] CIGNA STATE OF WYOMING [308105107] 416.76 percent of total billed charges 326.34 500.03 Technical (Hospital) Services ALTEPLASE 100 MG INTRAVENOUS SOLUTION RX-9002 CDM J2997 HCPCS 636 RC 50242-0085-25 NDC outpatient 100 ML 14050.36 14050.36 MULTIPLAN INC 34080 [3081285] MULTIPLAN INC [308128501] 13347.84 percent of total billed charges 8711.22 13347.84 Technical (Hospital) Services ALTEPLASE 100 MG INTRAVENOUS SOLUTION RX-9002 CDM J2997 HCPCS 636 RC 50242-0085-25 NDC outpatient 100 ML 14050.36 14050.36 MEDICA (COMMERCIAL) 94265 [3081118] MEDICA CLAIMS [308111801] 12645.32 percent of total billed charges 8711.22 13347.84 Technical (Hospital) Services ALTEPLASE 100 MG INTRAVENOUS SOLUTION RX-9002 CDM J2997 HCPCS 636 RC 50242-0085-25 NDC outpatient 100 ML 14050.36 14050.36 UNITED HEALTHCARE (COMMERCIAL) [3081199] UNITED HEALTHCARE 87726 [308119901] 8711.22 percent of total billed charges 8711.22 13347.84 Technical (Hospital) Services ALTEPLASE 100 MG INTRAVENOUS SOLUTION RX-9002 CDM J2997 HCPCS 636 RC 50242-0085-25 NDC outpatient 100 ML 14050.36 14050.36 BLUE CROSS BLUE SHIELD WELLMARK SB889 [3081026] BCBS WYOMING [308102603] 13347.84 percent of total billed charges 8711.22 13347.84 Technical (Hospital) Services ALTEPLASE 100 MG INTRAVENOUS SOLUTION RX-9002 CDM J2997 HCPCS 636 RC 50242-0085-25 NDC outpatient 100 ML 14050.36 14050.36 HEALTHPARTNERS SX009 HEALTHPARTNERS 11240.29 percent of total billed charges 8711.22 13347.84 Technical (Hospital) Services ALTEPLASE 100 MG INTRAVENOUS SOLUTION RX-9002 CDM J2997 HCPCS 636 RC 50242-0085-25 NDC outpatient 100 ML 14050.36 14050.36 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES EPO [308136803] 11240.29 percent of total billed charges 8711.22 13347.84 Technical (Hospital) Services ALTEPLASE 100 MG INTRAVENOUS SOLUTION RX-9002 CDM J2997 HCPCS 636 RC 50242-0085-25 NDC outpatient 100 ML 14050.36 14050.36 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES HDHP [308136802] 11240.29 percent of total billed charges 8711.22 13347.84 Technical (Hospital) Services ALTEPLASE 100 MG INTRAVENOUS SOLUTION RX-9002 CDM J2997 HCPCS 636 RC 50242-0085-25 NDC outpatient 100 ML 14050.36 14050.36 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES PPO [308136801] 11240.29 percent of total billed charges 8711.22 13347.84 Technical (Hospital) Services ALTEPLASE 100 MG INTRAVENOUS SOLUTION RX-9002 CDM J2997 HCPCS 636 RC 50242-0085-25 NDC outpatient 100 ML 14050.36 14050.36 CIGNA 62308 [3081051] CIGNA 62308 [308105105] 11240.29 percent of total billed charges 8711.22 13347.84 Technical (Hospital) Services ALTEPLASE 100 MG INTRAVENOUS SOLUTION RX-9002 CDM J2997 HCPCS 636 RC 50242-0085-25 NDC outpatient 100 ML 14050.36 14050.36 CIGNA 62308 [3081051] CIGNA STATE OF WYOMING [308105107] 11240.29 percent of total billed charges 8711.22 13347.84 Technical (Hospital) Services ALTEPLASE 100 MG INTRAVENOUS SOLUTION RX-9002 CDM J2997 HCPCS 636 RC 50242-0085-25 NDC inpatient 100 ML 14050.36 14050.36 BLUE CROSS BLUE SHIELD WELLMARK SB889 [3081026] BCBS WYOMING [308102603] 13347.84 percent of total billed charges 8711.22 13347.84 Technical (Hospital) Services ALTEPLASE 100 MG INTRAVENOUS SOLUTION RX-9002 CDM J2997 HCPCS 636 RC 50242-0085-25 NDC inpatient 100 ML 14050.36 14050.36 UNITED HEALTHCARE (COMMERCIAL) [3081199] UNITED HEALTHCARE 87726 [308119901] 8711.22 percent of total billed charges 8711.22 13347.84 Technical (Hospital) Services ALTEPLASE 100 MG INTRAVENOUS SOLUTION RX-9002 CDM J2997 HCPCS 636 RC 50242-0085-25 NDC inpatient 100 ML 14050.36 14050.36 MEDICA (COMMERCIAL) 94265 [3081118] MEDICA CLAIMS [308111801] 12645.32 percent of total billed charges 8711.22 13347.84 Technical (Hospital) Services ALTEPLASE 100 MG INTRAVENOUS SOLUTION RX-9002 CDM J2997 HCPCS 636 RC 50242-0085-25 NDC inpatient 100 ML 14050.36 14050.36 MULTIPLAN INC 34080 [3081285] MULTIPLAN INC [308128501] 13347.84 percent of total billed charges 8711.22 13347.84 Technical (Hospital) Services ALTEPLASE 100 MG INTRAVENOUS SOLUTION RX-9002 CDM J2997 HCPCS 636 RC 50242-0085-25 NDC inpatient 100 ML 14050.36 14050.36 HEALTHPARTNERS SX009 HEALTHPARTNERS 11125.08 percent of total billed charges 8711.22 13347.84 Technical (Hospital) Services ALTEPLASE 100 MG INTRAVENOUS SOLUTION RX-9002 CDM J2997 HCPCS 636 RC 50242-0085-25 NDC inpatient 100 ML 14050.36 14050.36 CIGNA 62308 [3081051] CIGNA 62308 [308105105] 11125.08 percent of total billed charges 8711.22 13347.84 Technical (Hospital) Services ALTEPLASE 100 MG INTRAVENOUS SOLUTION RX-9002 CDM J2997 HCPCS 636 RC 50242-0085-25 NDC inpatient 100 ML 14050.36 14050.36 CIGNA 62308 [3081051] CIGNA STATE OF WYOMING [308105107] 11125.08 percent of total billed charges 8711.22 13347.84 Technical (Hospital) Services ALTEPLASE 100 MG INTRAVENOUS SOLUTION RX-9002 CDM J2997 HCPCS 636 RC 50242-0085-25 NDC inpatient 100 ML 14050.36 14050.36 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES EPO [308136803] 11125.08 percent of total billed charges 8711.22 13347.84 Technical (Hospital) Services ALTEPLASE 100 MG INTRAVENOUS SOLUTION RX-9002 CDM J2997 HCPCS 636 RC 50242-0085-25 NDC inpatient 100 ML 14050.36 14050.36 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES HDHP [308136802] 11125.08 percent of total billed charges 8711.22 13347.84 Technical (Hospital) Services ALTEPLASE 100 MG INTRAVENOUS SOLUTION RX-9002 CDM J2997 HCPCS 636 RC 50242-0085-25 NDC inpatient 100 ML 14050.36 14050.36 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES PPO [308136801] 11125.08 percent of total billed charges 8711.22 13347.84 Technical (Hospital) Services METHYLPREDNISOLONE SODIUM SUCCINATE 125 MG SOLUTION FOR INJECTION RX-10578 CDM J2919 HCPCS 636 RC 63323-0258-03 NDC inpatient 125 ME 81.65 81.65 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES EPO [308136803] 64.65 percent of total billed charges 50.62 77.57 Technical (Hospital) Services METHYLPREDNISOLONE SODIUM SUCCINATE 125 MG SOLUTION FOR INJECTION RX-10578 CDM J2919 HCPCS 636 RC 63323-0258-03 NDC inpatient 125 ME 81.65 81.65 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES HDHP [308136802] 64.65 percent of total billed charges 50.62 77.57 Technical (Hospital) Services METHYLPREDNISOLONE SODIUM SUCCINATE 125 MG SOLUTION FOR INJECTION RX-10578 CDM J2919 HCPCS 636 RC 63323-0258-03 NDC inpatient 125 ME 81.65 81.65 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES PPO [308136801] 64.65 percent of total billed charges 50.62 77.57 Technical (Hospital) Services METHYLPREDNISOLONE SODIUM SUCCINATE 125 MG SOLUTION FOR INJECTION RX-10578 CDM J2919 HCPCS 636 RC 63323-0258-03 NDC inpatient 125 ME 81.65 81.65 CIGNA 62308 [3081051] CIGNA 62308 [308105105] 64.65 percent of total billed charges 50.62 77.57 Technical (Hospital) Services METHYLPREDNISOLONE SODIUM SUCCINATE 125 MG SOLUTION FOR INJECTION RX-10578 CDM J2919 HCPCS 636 RC 63323-0258-03 NDC inpatient 125 ME 81.65 81.65 CIGNA 62308 [3081051] CIGNA STATE OF WYOMING [308105107] 64.65 percent of total billed charges 50.62 77.57 Technical (Hospital) Services METHYLPREDNISOLONE SODIUM SUCCINATE 125 MG SOLUTION FOR INJECTION RX-10578 CDM J2919 HCPCS 636 RC 63323-0258-03 NDC inpatient 125 ME 81.65 81.65 BLUE CROSS BLUE SHIELD WELLMARK SB889 [3081026] BCBS WYOMING [308102603] 77.57 percent of total billed charges 50.62 77.57 Technical (Hospital) Services METHYLPREDNISOLONE SODIUM SUCCINATE 125 MG SOLUTION FOR INJECTION RX-10578 CDM J2919 HCPCS 636 RC 63323-0258-03 NDC inpatient 125 ME 81.65 81.65 UNITED HEALTHCARE (COMMERCIAL) [3081199] UNITED HEALTHCARE 87726 [308119901] 50.62 percent of total billed charges 50.62 77.57 Technical (Hospital) Services METHYLPREDNISOLONE SODIUM SUCCINATE 125 MG SOLUTION FOR INJECTION RX-10578 CDM J2919 HCPCS 636 RC 63323-0258-03 NDC inpatient 125 ME 81.65 81.65 MEDICA (COMMERCIAL) 94265 [3081118] MEDICA CLAIMS [308111801] 73.49 percent of total billed charges 50.62 77.57 Technical (Hospital) Services METHYLPREDNISOLONE SODIUM SUCCINATE 125 MG SOLUTION FOR INJECTION RX-10578 CDM J2919 HCPCS 636 RC 63323-0258-03 NDC inpatient 125 ME 81.65 81.65 MULTIPLAN INC 34080 [3081285] MULTIPLAN INC [308128501] 77.57 percent of total billed charges 50.62 77.57 Technical (Hospital) Services METHYLPREDNISOLONE SODIUM SUCCINATE 125 MG SOLUTION FOR INJECTION RX-10578 CDM J2919 HCPCS 636 RC 63323-0258-03 NDC inpatient 125 ME 81.65 81.65 HEALTHPARTNERS SX009 HEALTHPARTNERS 64.65 percent of total billed charges 50.62 77.57 Technical (Hospital) Services METHYLPREDNISOLONE SODIUM SUCCINATE 125 MG SOLUTION FOR INJECTION RX-10578 CDM J2919 HCPCS 636 RC 63323-0258-03 NDC outpatient 125 ME 81.65 81.65 MEDICA (COMMERCIAL) 94265 [3081118] MEDICA CLAIMS [308111801] 73.49 percent of total billed charges 50.62 77.57 Technical (Hospital) Services METHYLPREDNISOLONE SODIUM SUCCINATE 125 MG SOLUTION FOR INJECTION RX-10578 CDM J2919 HCPCS 636 RC 63323-0258-03 NDC outpatient 125 ME 81.65 81.65 MULTIPLAN INC 34080 [3081285] MULTIPLAN INC [308128501] 77.57 percent of total billed charges 50.62 77.57 Technical (Hospital) Services METHYLPREDNISOLONE SODIUM SUCCINATE 125 MG SOLUTION FOR INJECTION RX-10578 CDM J2919 HCPCS 636 RC 63323-0258-03 NDC outpatient 125 ME 81.65 81.65 CIGNA 62308 [3081051] CIGNA 62308 [308105105] 65.32 percent of total billed charges 50.62 77.57 Technical (Hospital) Services METHYLPREDNISOLONE SODIUM SUCCINATE 125 MG SOLUTION FOR INJECTION RX-10578 CDM J2919 HCPCS 636 RC 63323-0258-03 NDC outpatient 125 ME 81.65 81.65 CIGNA 62308 [3081051] CIGNA STATE OF WYOMING [308105107] 65.32 percent of total billed charges 50.62 77.57 Technical (Hospital) Services METHYLPREDNISOLONE SODIUM SUCCINATE 125 MG SOLUTION FOR INJECTION RX-10578 CDM J2919 HCPCS 636 RC 63323-0258-03 NDC outpatient 125 ME 81.65 81.65 BLUE CROSS BLUE SHIELD WELLMARK SB889 [3081026] BCBS WYOMING [308102603] 77.57 percent of total billed charges 50.62 77.57 Technical (Hospital) Services METHYLPREDNISOLONE SODIUM SUCCINATE 125 MG SOLUTION FOR INJECTION RX-10578 CDM J2919 HCPCS 636 RC 63323-0258-03 NDC outpatient 125 ME 81.65 81.65 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES EPO [308136803] 65.32 percent of total billed charges 50.62 77.57 Technical (Hospital) Services METHYLPREDNISOLONE SODIUM SUCCINATE 125 MG SOLUTION FOR INJECTION RX-10578 CDM J2919 HCPCS 636 RC 63323-0258-03 NDC outpatient 125 ME 81.65 81.65 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES HDHP [308136802] 65.32 percent of total billed charges 50.62 77.57 Technical (Hospital) Services METHYLPREDNISOLONE SODIUM SUCCINATE 125 MG SOLUTION FOR INJECTION RX-10578 CDM J2919 HCPCS 636 RC 63323-0258-03 NDC outpatient 125 ME 81.65 81.65 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES PPO [308136801] 65.32 percent of total billed charges 50.62 77.57 Technical (Hospital) Services METHYLPREDNISOLONE SODIUM SUCCINATE 125 MG SOLUTION FOR INJECTION RX-10578 CDM J2919 HCPCS 636 RC 63323-0258-03 NDC outpatient 125 ME 81.65 81.65 UNITED HEALTHCARE (COMMERCIAL) [3081199] UNITED HEALTHCARE 87726 [308119901] 50.62 percent of total billed charges 50.62 77.57 Technical (Hospital) Services METHYLPREDNISOLONE SODIUM SUCCINATE 125 MG SOLUTION FOR INJECTION RX-10578 CDM J2919 HCPCS 636 RC 63323-0258-03 NDC outpatient 125 ME 81.65 81.65 HEALTHPARTNERS SX009 HEALTHPARTNERS 65.32 percent of total billed charges 50.62 77.57 Technical (Hospital) Services METHYLPREDNISOLONE SODIUM SUCCINATE 500 MG INTRAVENOUS SOLUTION RX-10581 CDM J2919 HCPCS 636 RC 00009-0758-01 NDC inpatient 500 ME 146.78 146.78 MEDICA (COMMERCIAL) 94265 [3081118] MEDICA CLAIMS [308111801] 132.1 percent of total billed charges 91 139.44 Technical (Hospital) Services METHYLPREDNISOLONE SODIUM SUCCINATE 500 MG INTRAVENOUS SOLUTION RX-10581 CDM J2919 HCPCS 636 RC 00009-0758-01 NDC inpatient 500 ME 146.78 146.78 MULTIPLAN INC 34080 [3081285] MULTIPLAN INC [308128501] 139.44 percent of total billed charges 91 139.44 Technical (Hospital) Services METHYLPREDNISOLONE SODIUM SUCCINATE 500 MG INTRAVENOUS SOLUTION RX-10581 CDM J2919 HCPCS 636 RC 00009-0758-01 NDC inpatient 500 ME 146.78 146.78 HEALTHPARTNERS SX009 HEALTHPARTNERS 116.22 percent of total billed charges 91 139.44 Technical (Hospital) Services METHYLPREDNISOLONE SODIUM SUCCINATE 500 MG INTRAVENOUS SOLUTION RX-10581 CDM J2919 HCPCS 636 RC 00009-0758-01 NDC inpatient 500 ME 146.78 146.78 BLUE CROSS BLUE SHIELD WELLMARK SB889 [3081026] BCBS WYOMING [308102603] 139.44 percent of total billed charges 91 139.44 Technical (Hospital) Services METHYLPREDNISOLONE SODIUM SUCCINATE 500 MG INTRAVENOUS SOLUTION RX-10581 CDM J2919 HCPCS 636 RC 00009-0758-01 NDC inpatient 500 ME 146.78 146.78 UNITED HEALTHCARE (COMMERCIAL) [3081199] UNITED HEALTHCARE 87726 [308119901] 91 percent of total billed charges 91 139.44 Technical (Hospital) Services METHYLPREDNISOLONE SODIUM SUCCINATE 500 MG INTRAVENOUS SOLUTION RX-10581 CDM J2919 HCPCS 636 RC 00009-0758-01 NDC inpatient 500 ME 146.78 146.78 CIGNA 62308 [3081051] CIGNA STATE OF WYOMING [308105107] 116.22 percent of total billed charges 91 139.44 Technical (Hospital) Services METHYLPREDNISOLONE SODIUM SUCCINATE 500 MG INTRAVENOUS SOLUTION RX-10581 CDM J2919 HCPCS 636 RC 00009-0758-01 NDC inpatient 500 ME 146.78 146.78 CIGNA 62308 [3081051] CIGNA 62308 [308105105] 116.22 percent of total billed charges 91 139.44 Technical (Hospital) Services METHYLPREDNISOLONE SODIUM SUCCINATE 500 MG INTRAVENOUS SOLUTION RX-10581 CDM J2919 HCPCS 636 RC 00009-0758-01 NDC inpatient 500 ME 146.78 146.78 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES PPO [308136801] 116.22 percent of total billed charges 91 139.44 Technical (Hospital) Services METHYLPREDNISOLONE SODIUM SUCCINATE 500 MG INTRAVENOUS SOLUTION RX-10581 CDM J2919 HCPCS 636 RC 00009-0758-01 NDC inpatient 500 ME 146.78 146.78 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES EPO [308136803] 116.22 percent of total billed charges 91 139.44 Technical (Hospital) Services METHYLPREDNISOLONE SODIUM SUCCINATE 500 MG INTRAVENOUS SOLUTION RX-10581 CDM J2919 HCPCS 636 RC 00009-0758-01 NDC inpatient 500 ME 146.78 146.78 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES HDHP [308136802] 116.22 percent of total billed charges 91 139.44 Technical (Hospital) Services METHYLPREDNISOLONE SODIUM SUCCINATE 500 MG INTRAVENOUS SOLUTION RX-10581 CDM J2919 HCPCS 636 RC 00009-0758-01 NDC outpatient 500 ME 146.78 146.78 MULTIPLAN INC 34080 [3081285] MULTIPLAN INC [308128501] 139.44 percent of total billed charges 91 139.44 Technical (Hospital) Services METHYLPREDNISOLONE SODIUM SUCCINATE 500 MG INTRAVENOUS SOLUTION RX-10581 CDM J2919 HCPCS 636 RC 00009-0758-01 NDC outpatient 500 ME 146.78 146.78 MEDICA (COMMERCIAL) 94265 [3081118] MEDICA CLAIMS [308111801] 132.1 percent of total billed charges 91 139.44 Technical (Hospital) Services METHYLPREDNISOLONE SODIUM SUCCINATE 500 MG INTRAVENOUS SOLUTION RX-10581 CDM J2919 HCPCS 636 RC 00009-0758-01 NDC outpatient 500 ME 146.78 146.78 CIGNA 62308 [3081051] CIGNA 62308 [308105105] 117.42 percent of total billed charges 91 139.44 Technical (Hospital) Services METHYLPREDNISOLONE SODIUM SUCCINATE 500 MG INTRAVENOUS SOLUTION RX-10581 CDM J2919 HCPCS 636 RC 00009-0758-01 NDC outpatient 500 ME 146.78 146.78 CIGNA 62308 [3081051] CIGNA STATE OF WYOMING [308105107] 117.42 percent of total billed charges 91 139.44 Technical (Hospital) Services METHYLPREDNISOLONE SODIUM SUCCINATE 500 MG INTRAVENOUS SOLUTION RX-10581 CDM J2919 HCPCS 636 RC 00009-0758-01 NDC outpatient 500 ME 146.78 146.78 HEALTHPARTNERS SX009 HEALTHPARTNERS 117.42 percent of total billed charges 91 139.44 Technical (Hospital) Services METHYLPREDNISOLONE SODIUM SUCCINATE 500 MG INTRAVENOUS SOLUTION RX-10581 CDM J2919 HCPCS 636 RC 00009-0758-01 NDC outpatient 500 ME 146.78 146.78 BLUE CROSS BLUE SHIELD WELLMARK SB889 [3081026] BCBS WYOMING [308102603] 139.44 percent of total billed charges 91 139.44 Technical (Hospital) Services METHYLPREDNISOLONE SODIUM SUCCINATE 500 MG INTRAVENOUS SOLUTION RX-10581 CDM J2919 HCPCS 636 RC 00009-0758-01 NDC outpatient 500 ME 146.78 146.78 UNITED HEALTHCARE (COMMERCIAL) [3081199] UNITED HEALTHCARE 87726 [308119901] 91 percent of total billed charges 91 139.44 Technical (Hospital) Services METHYLPREDNISOLONE SODIUM SUCCINATE 500 MG INTRAVENOUS SOLUTION RX-10581 CDM J2919 HCPCS 636 RC 00009-0758-01 NDC outpatient 500 ME 146.78 146.78 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES EPO [308136803] 117.42 percent of total billed charges 91 139.44 Technical (Hospital) Services METHYLPREDNISOLONE SODIUM SUCCINATE 500 MG INTRAVENOUS SOLUTION RX-10581 CDM J2919 HCPCS 636 RC 00009-0758-01 NDC outpatient 500 ME 146.78 146.78 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES HDHP [308136802] 117.42 percent of total billed charges 91 139.44 Technical (Hospital) Services METHYLPREDNISOLONE SODIUM SUCCINATE 500 MG INTRAVENOUS SOLUTION RX-10581 CDM J2919 HCPCS 636 RC 00009-0758-01 NDC outpatient 500 ME 146.78 146.78 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES PPO [308136801] 117.42 percent of total billed charges 91 139.44 Technical (Hospital) Services METHYLPREDNISOLONE SOD SUCC (PF) 125 MG/2 ML SOLUTION FOR INJECTION RX-129397 CDM J2919 HCPCS 636 RC 00009-0047-04 NDC outpatient 2 ML 80.88 80.88 UNITED HEALTHCARE (COMMERCIAL) [3081199] UNITED HEALTHCARE 87726 [308119901] 50.15 percent of total billed charges 50.15 76.84 Technical (Hospital) Services METHYLPREDNISOLONE SOD SUCC (PF) 125 MG/2 ML SOLUTION FOR INJECTION RX-129397 CDM J2919 HCPCS 636 RC 00009-0047-04 NDC outpatient 2 ML 80.88 80.88 HEALTHPARTNERS SX009 HEALTHPARTNERS 64.7 percent of total billed charges 50.15 76.84 Technical (Hospital) Services METHYLPREDNISOLONE SOD SUCC (PF) 125 MG/2 ML SOLUTION FOR INJECTION RX-129397 CDM J2919 HCPCS 636 RC 00009-0047-04 NDC outpatient 2 ML 80.88 80.88 MULTIPLAN INC 34080 [3081285] MULTIPLAN INC [308128501] 76.84 percent of total billed charges 50.15 76.84 Technical (Hospital) Services METHYLPREDNISOLONE SOD SUCC (PF) 125 MG/2 ML SOLUTION FOR INJECTION RX-129397 CDM J2919 HCPCS 636 RC 00009-0047-04 NDC outpatient 2 ML 80.88 80.88 CIGNA 62308 [3081051] CIGNA 62308 [308105105] 64.7 percent of total billed charges 50.15 76.84 Technical (Hospital) Services METHYLPREDNISOLONE SOD SUCC (PF) 125 MG/2 ML SOLUTION FOR INJECTION RX-129397 CDM J2919 HCPCS 636 RC 00009-0047-04 NDC outpatient 2 ML 80.88 80.88 CIGNA 62308 [3081051] CIGNA STATE OF WYOMING [308105107] 64.7 percent of total billed charges 50.15 76.84 Technical (Hospital) Services METHYLPREDNISOLONE SOD SUCC (PF) 125 MG/2 ML SOLUTION FOR INJECTION RX-129397 CDM J2919 HCPCS 636 RC 00009-0047-04 NDC outpatient 2 ML 80.88 80.88 MEDICA (COMMERCIAL) 94265 [3081118] MEDICA CLAIMS [308111801] 72.79 percent of total billed charges 50.15 76.84 Technical (Hospital) Services METHYLPREDNISOLONE SOD SUCC (PF) 125 MG/2 ML SOLUTION FOR INJECTION RX-129397 CDM J2919 HCPCS 636 RC 00009-0047-04 NDC outpatient 2 ML 80.88 80.88 BLUE CROSS BLUE SHIELD WELLMARK SB889 [3081026] BCBS WYOMING [308102603] 76.84 percent of total billed charges 50.15 76.84 Technical (Hospital) Services METHYLPREDNISOLONE SOD SUCC (PF) 125 MG/2 ML SOLUTION FOR INJECTION RX-129397 CDM J2919 HCPCS 636 RC 00009-0047-04 NDC outpatient 2 ML 80.88 80.88 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES PPO [308136801] 64.7 percent of total billed charges 50.15 76.84 Technical (Hospital) Services METHYLPREDNISOLONE SOD SUCC (PF) 125 MG/2 ML SOLUTION FOR INJECTION RX-129397 CDM J2919 HCPCS 636 RC 00009-0047-04 NDC outpatient 2 ML 80.88 80.88 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES HDHP [308136802] 64.7 percent of total billed charges 50.15 76.84 Technical (Hospital) Services METHYLPREDNISOLONE SOD SUCC (PF) 125 MG/2 ML SOLUTION FOR INJECTION RX-129397 CDM J2919 HCPCS 636 RC 00009-0047-04 NDC outpatient 2 ML 80.88 80.88 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES EPO [308136803] 64.7 percent of total billed charges 50.15 76.84 Technical (Hospital) Services METHYLPREDNISOLONE SOD SUCC (PF) 125 MG/2 ML SOLUTION FOR INJECTION RX-129397 CDM J2919 HCPCS 636 RC 00009-0047-04 NDC inpatient 2 ML 80.88 80.88 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES EPO [308136803] 64.04 percent of total billed charges 50.15 76.84 Technical (Hospital) Services METHYLPREDNISOLONE SOD SUCC (PF) 125 MG/2 ML SOLUTION FOR INJECTION RX-129397 CDM J2919 HCPCS 636 RC 00009-0047-04 NDC inpatient 2 ML 80.88 80.88 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES HDHP [308136802] 64.04 percent of total billed charges 50.15 76.84 Technical (Hospital) Services METHYLPREDNISOLONE SOD SUCC (PF) 125 MG/2 ML SOLUTION FOR INJECTION RX-129397 CDM J2919 HCPCS 636 RC 00009-0047-04 NDC inpatient 2 ML 80.88 80.88 HEALTHPARTNERS SX009 HEALTHPARTNERS 64.04 percent of total billed charges 50.15 76.84 Technical (Hospital) Services METHYLPREDNISOLONE SOD SUCC (PF) 125 MG/2 ML SOLUTION FOR INJECTION RX-129397 CDM J2919 HCPCS 636 RC 00009-0047-04 NDC inpatient 2 ML 80.88 80.88 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES PPO [308136801] 64.04 percent of total billed charges 50.15 76.84 Technical (Hospital) Services METHYLPREDNISOLONE SOD SUCC (PF) 125 MG/2 ML SOLUTION FOR INJECTION RX-129397 CDM J2919 HCPCS 636 RC 00009-0047-04 NDC inpatient 2 ML 80.88 80.88 MULTIPLAN INC 34080 [3081285] MULTIPLAN INC [308128501] 76.84 percent of total billed charges 50.15 76.84 Technical (Hospital) Services METHYLPREDNISOLONE SOD SUCC (PF) 125 MG/2 ML SOLUTION FOR INJECTION RX-129397 CDM J2919 HCPCS 636 RC 00009-0047-04 NDC inpatient 2 ML 80.88 80.88 MEDICA (COMMERCIAL) 94265 [3081118] MEDICA CLAIMS [308111801] 72.79 percent of total billed charges 50.15 76.84 Technical (Hospital) Services METHYLPREDNISOLONE SOD SUCC (PF) 125 MG/2 ML SOLUTION FOR INJECTION RX-129397 CDM J2919 HCPCS 636 RC 00009-0047-04 NDC inpatient 2 ML 80.88 80.88 UNITED HEALTHCARE (COMMERCIAL) [3081199] UNITED HEALTHCARE 87726 [308119901] 50.15 percent of total billed charges 50.15 76.84 Technical (Hospital) Services METHYLPREDNISOLONE SOD SUCC (PF) 125 MG/2 ML SOLUTION FOR INJECTION RX-129397 CDM J2919 HCPCS 636 RC 00009-0047-04 NDC inpatient 2 ML 80.88 80.88 BLUE CROSS BLUE SHIELD WELLMARK SB889 [3081026] BCBS WYOMING [308102603] 76.84 percent of total billed charges 50.15 76.84 Technical (Hospital) Services METHYLPREDNISOLONE SOD SUCC (PF) 125 MG/2 ML SOLUTION FOR INJECTION RX-129397 CDM J2919 HCPCS 636 RC 00009-0047-04 NDC inpatient 2 ML 80.88 80.88 CIGNA 62308 [3081051] CIGNA 62308 [308105105] 64.04 percent of total billed charges 50.15 76.84 Technical (Hospital) Services METHYLPREDNISOLONE SOD SUCC (PF) 125 MG/2 ML SOLUTION FOR INJECTION RX-129397 CDM J2919 HCPCS 636 RC 00009-0047-04 NDC inpatient 2 ML 80.88 80.88 CIGNA 62308 [3081051] CIGNA STATE OF WYOMING [308105107] 64.04 percent of total billed charges 50.15 76.84 Technical (Hospital) Services METHYLPREDNISOLONE SOD SUCC (PF) 500 MG/4 ML INTRAVENOUS SOLUTION RX-129398 CDM J2919 HCPCS 636 RC 00009-0003-02 NDC inpatient 4 ML 229.38 229.38 CIGNA 62308 [3081051] CIGNA 62308 [308105105] 181.62 percent of total billed charges 142.22 217.91 Technical (Hospital) Services METHYLPREDNISOLONE SOD SUCC (PF) 500 MG/4 ML INTRAVENOUS SOLUTION RX-129398 CDM J2919 HCPCS 636 RC 00009-0003-02 NDC inpatient 4 ML 229.38 229.38 CIGNA 62308 [3081051] CIGNA STATE OF WYOMING [308105107] 181.62 percent of total billed charges 142.22 217.91 Technical (Hospital) Services METHYLPREDNISOLONE SOD SUCC (PF) 500 MG/4 ML INTRAVENOUS SOLUTION RX-129398 CDM J2919 HCPCS 636 RC 00009-0003-02 NDC inpatient 4 ML 229.38 229.38 BLUE CROSS BLUE SHIELD WELLMARK SB889 [3081026] BCBS WYOMING [308102603] 217.91 percent of total billed charges 142.22 217.91 Technical (Hospital) Services METHYLPREDNISOLONE SOD SUCC (PF) 500 MG/4 ML INTRAVENOUS SOLUTION RX-129398 CDM J2919 HCPCS 636 RC 00009-0003-02 NDC inpatient 4 ML 229.38 229.38 UNITED HEALTHCARE (COMMERCIAL) [3081199] UNITED HEALTHCARE 87726 [308119901] 142.22 percent of total billed charges 142.22 217.91 Technical (Hospital) Services METHYLPREDNISOLONE SOD SUCC (PF) 500 MG/4 ML INTRAVENOUS SOLUTION RX-129398 CDM J2919 HCPCS 636 RC 00009-0003-02 NDC inpatient 4 ML 229.38 229.38 MULTIPLAN INC 34080 [3081285] MULTIPLAN INC [308128501] 217.91 percent of total billed charges 142.22 217.91 Technical (Hospital) Services METHYLPREDNISOLONE SOD SUCC (PF) 500 MG/4 ML INTRAVENOUS SOLUTION RX-129398 CDM J2919 HCPCS 636 RC 00009-0003-02 NDC inpatient 4 ML 229.38 229.38 MEDICA (COMMERCIAL) 94265 [3081118] MEDICA CLAIMS [308111801] 206.44 percent of total billed charges 142.22 217.91 Technical (Hospital) Services METHYLPREDNISOLONE SOD SUCC (PF) 500 MG/4 ML INTRAVENOUS SOLUTION RX-129398 CDM J2919 HCPCS 636 RC 00009-0003-02 NDC inpatient 4 ML 229.38 229.38 HEALTHPARTNERS SX009 HEALTHPARTNERS 181.62 percent of total billed charges 142.22 217.91 Technical (Hospital) Services METHYLPREDNISOLONE SOD SUCC (PF) 500 MG/4 ML INTRAVENOUS SOLUTION RX-129398 CDM J2919 HCPCS 636 RC 00009-0003-02 NDC inpatient 4 ML 229.38 229.38 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES PPO [308136801] 181.62 percent of total billed charges 142.22 217.91 Technical (Hospital) Services METHYLPREDNISOLONE SOD SUCC (PF) 500 MG/4 ML INTRAVENOUS SOLUTION RX-129398 CDM J2919 HCPCS 636 RC 00009-0003-02 NDC inpatient 4 ML 229.38 229.38 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES EPO [308136803] 181.62 percent of total billed charges 142.22 217.91 Technical (Hospital) Services METHYLPREDNISOLONE SOD SUCC (PF) 500 MG/4 ML INTRAVENOUS SOLUTION RX-129398 CDM J2919 HCPCS 636 RC 00009-0003-02 NDC inpatient 4 ML 229.38 229.38 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES HDHP [308136802] 181.62 percent of total billed charges 142.22 217.91 Technical (Hospital) Services METHYLPREDNISOLONE SOD SUCC (PF) 500 MG/4 ML INTRAVENOUS SOLUTION RX-129398 CDM J2919 HCPCS 636 RC 00009-0003-02 NDC outpatient 4 ML 229.38 229.38 CIGNA 62308 [3081051] CIGNA 62308 [308105105] 183.5 percent of total billed charges 142.22 217.91 Technical (Hospital) Services METHYLPREDNISOLONE SOD SUCC (PF) 500 MG/4 ML INTRAVENOUS SOLUTION RX-129398 CDM J2919 HCPCS 636 RC 00009-0003-02 NDC outpatient 4 ML 229.38 229.38 CIGNA 62308 [3081051] CIGNA STATE OF WYOMING [308105107] 183.5 percent of total billed charges 142.22 217.91 Technical (Hospital) Services METHYLPREDNISOLONE SOD SUCC (PF) 500 MG/4 ML INTRAVENOUS SOLUTION RX-129398 CDM J2919 HCPCS 636 RC 00009-0003-02 NDC outpatient 4 ML 229.38 229.38 UNITED HEALTHCARE (COMMERCIAL) [3081199] UNITED HEALTHCARE 87726 [308119901] 142.22 percent of total billed charges 142.22 217.91 Technical (Hospital) Services METHYLPREDNISOLONE SOD SUCC (PF) 500 MG/4 ML INTRAVENOUS SOLUTION RX-129398 CDM J2919 HCPCS 636 RC 00009-0003-02 NDC outpatient 4 ML 229.38 229.38 HEALTHPARTNERS SX009 HEALTHPARTNERS 183.5 percent of total billed charges 142.22 217.91 Technical (Hospital) Services METHYLPREDNISOLONE SOD SUCC (PF) 500 MG/4 ML INTRAVENOUS SOLUTION RX-129398 CDM J2919 HCPCS 636 RC 00009-0003-02 NDC outpatient 4 ML 229.38 229.38 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES EPO [308136803] 183.5 percent of total billed charges 142.22 217.91 Technical (Hospital) Services METHYLPREDNISOLONE SOD SUCC (PF) 500 MG/4 ML INTRAVENOUS SOLUTION RX-129398 CDM J2919 HCPCS 636 RC 00009-0003-02 NDC outpatient 4 ML 229.38 229.38 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES HDHP [308136802] 183.5 percent of total billed charges 142.22 217.91 Technical (Hospital) Services METHYLPREDNISOLONE SOD SUCC (PF) 500 MG/4 ML INTRAVENOUS SOLUTION RX-129398 CDM J2919 HCPCS 636 RC 00009-0003-02 NDC outpatient 4 ML 229.38 229.38 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES PPO [308136801] 183.5 percent of total billed charges 142.22 217.91 Technical (Hospital) Services METHYLPREDNISOLONE SOD SUCC (PF) 500 MG/4 ML INTRAVENOUS SOLUTION RX-129398 CDM J2919 HCPCS 636 RC 00009-0003-02 NDC outpatient 4 ML 229.38 229.38 BLUE CROSS BLUE SHIELD WELLMARK SB889 [3081026] BCBS WYOMING [308102603] 217.91 percent of total billed charges 142.22 217.91 Technical (Hospital) Services METHYLPREDNISOLONE SOD SUCC (PF) 500 MG/4 ML INTRAVENOUS SOLUTION RX-129398 CDM J2919 HCPCS 636 RC 00009-0003-02 NDC outpatient 4 ML 229.38 229.38 MULTIPLAN INC 34080 [3081285] MULTIPLAN INC [308128501] 217.91 percent of total billed charges 142.22 217.91 Technical (Hospital) Services METHYLPREDNISOLONE SOD SUCC (PF) 500 MG/4 ML INTRAVENOUS SOLUTION RX-129398 CDM J2919 HCPCS 636 RC 00009-0003-02 NDC outpatient 4 ML 229.38 229.38 MEDICA (COMMERCIAL) 94265 [3081118] MEDICA CLAIMS [308111801] 206.44 percent of total billed charges 142.22 217.91 Technical (Hospital) Services "METHYLPREDNISOLONE SOD SUCC (PF) 1,000 MG/8 ML INTRAVENOUS SOLUTION" RX-129399 CDM J2919 HCPCS 636 RC 00009-0018-20 NDC inpatient 8 ML 330.92 330.92 BLUE CROSS BLUE SHIELD WELLMARK SB889 [3081026] BCBS WYOMING [308102603] 314.37 percent of total billed charges 205.17 314.37 Technical (Hospital) Services "METHYLPREDNISOLONE SOD SUCC (PF) 1,000 MG/8 ML INTRAVENOUS SOLUTION" RX-129399 CDM J2919 HCPCS 636 RC 00009-0018-20 NDC inpatient 8 ML 330.92 330.92 UNITED HEALTHCARE (COMMERCIAL) [3081199] UNITED HEALTHCARE 87726 [308119901] 205.17 percent of total billed charges 205.17 314.37 Technical (Hospital) Services "METHYLPREDNISOLONE SOD SUCC (PF) 1,000 MG/8 ML INTRAVENOUS SOLUTION" RX-129399 CDM J2919 HCPCS 636 RC 00009-0018-20 NDC inpatient 8 ML 330.92 330.92 CIGNA 62308 [3081051] CIGNA 62308 [308105105] 262.02 percent of total billed charges 205.17 314.37 Technical (Hospital) Services "METHYLPREDNISOLONE SOD SUCC (PF) 1,000 MG/8 ML INTRAVENOUS SOLUTION" RX-129399 CDM J2919 HCPCS 636 RC 00009-0018-20 NDC inpatient 8 ML 330.92 330.92 CIGNA 62308 [3081051] CIGNA STATE OF WYOMING [308105107] 262.02 percent of total billed charges 205.17 314.37 Technical (Hospital) Services "METHYLPREDNISOLONE SOD SUCC (PF) 1,000 MG/8 ML INTRAVENOUS SOLUTION" RX-129399 CDM J2919 HCPCS 636 RC 00009-0018-20 NDC inpatient 8 ML 330.92 330.92 MULTIPLAN INC 34080 [3081285] MULTIPLAN INC [308128501] 314.37 percent of total billed charges 205.17 314.37 Technical (Hospital) Services "METHYLPREDNISOLONE SOD SUCC (PF) 1,000 MG/8 ML INTRAVENOUS SOLUTION" RX-129399 CDM J2919 HCPCS 636 RC 00009-0018-20 NDC inpatient 8 ML 330.92 330.92 MEDICA (COMMERCIAL) 94265 [3081118] MEDICA CLAIMS [308111801] 297.83 percent of total billed charges 205.17 314.37 Technical (Hospital) Services "METHYLPREDNISOLONE SOD SUCC (PF) 1,000 MG/8 ML INTRAVENOUS SOLUTION" RX-129399 CDM J2919 HCPCS 636 RC 00009-0018-20 NDC inpatient 8 ML 330.92 330.92 HEALTHPARTNERS SX009 HEALTHPARTNERS 262.02 percent of total billed charges 205.17 314.37 Technical (Hospital) Services "METHYLPREDNISOLONE SOD SUCC (PF) 1,000 MG/8 ML INTRAVENOUS SOLUTION" RX-129399 CDM J2919 HCPCS 636 RC 00009-0018-20 NDC inpatient 8 ML 330.92 330.92 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES EPO [308136803] 262.02 percent of total billed charges 205.17 314.37 Technical (Hospital) Services "METHYLPREDNISOLONE SOD SUCC (PF) 1,000 MG/8 ML INTRAVENOUS SOLUTION" RX-129399 CDM J2919 HCPCS 636 RC 00009-0018-20 NDC inpatient 8 ML 330.92 330.92 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES HDHP [308136802] 262.02 percent of total billed charges 205.17 314.37 Technical (Hospital) Services "METHYLPREDNISOLONE SOD SUCC (PF) 1,000 MG/8 ML INTRAVENOUS SOLUTION" RX-129399 CDM J2919 HCPCS 636 RC 00009-0018-20 NDC inpatient 8 ML 330.92 330.92 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES PPO [308136801] 262.02 percent of total billed charges 205.17 314.37 Technical (Hospital) Services "METHYLPREDNISOLONE SOD SUCC (PF) 1,000 MG/8 ML INTRAVENOUS SOLUTION" RX-129399 CDM J2919 HCPCS 636 RC 00009-0018-20 NDC outpatient 8 ML 330.92 330.92 HEALTHPARTNERS SX009 HEALTHPARTNERS 264.74 percent of total billed charges 205.17 314.37 Technical (Hospital) Services "METHYLPREDNISOLONE SOD SUCC (PF) 1,000 MG/8 ML INTRAVENOUS SOLUTION" RX-129399 CDM J2919 HCPCS 636 RC 00009-0018-20 NDC outpatient 8 ML 330.92 330.92 UNITED HEALTHCARE (COMMERCIAL) [3081199] UNITED HEALTHCARE 87726 [308119901] 205.17 percent of total billed charges 205.17 314.37 Technical (Hospital) Services "METHYLPREDNISOLONE SOD SUCC (PF) 1,000 MG/8 ML INTRAVENOUS SOLUTION" RX-129399 CDM J2919 HCPCS 636 RC 00009-0018-20 NDC outpatient 8 ML 330.92 330.92 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES HDHP [308136802] 264.74 percent of total billed charges 205.17 314.37 Technical (Hospital) Services "METHYLPREDNISOLONE SOD SUCC (PF) 1,000 MG/8 ML INTRAVENOUS SOLUTION" RX-129399 CDM J2919 HCPCS 636 RC 00009-0018-20 NDC outpatient 8 ML 330.92 330.92 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES PPO [308136801] 264.74 percent of total billed charges 205.17 314.37 Technical (Hospital) Services "METHYLPREDNISOLONE SOD SUCC (PF) 1,000 MG/8 ML INTRAVENOUS SOLUTION" RX-129399 CDM J2919 HCPCS 636 RC 00009-0018-20 NDC outpatient 8 ML 330.92 330.92 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES EPO [308136803] 264.74 percent of total billed charges 205.17 314.37 Technical (Hospital) Services "METHYLPREDNISOLONE SOD SUCC (PF) 1,000 MG/8 ML INTRAVENOUS SOLUTION" RX-129399 CDM J2919 HCPCS 636 RC 00009-0018-20 NDC outpatient 8 ML 330.92 330.92 BLUE CROSS BLUE SHIELD WELLMARK SB889 [3081026] BCBS WYOMING [308102603] 314.37 percent of total billed charges 205.17 314.37 Technical (Hospital) Services "METHYLPREDNISOLONE SOD SUCC (PF) 1,000 MG/8 ML INTRAVENOUS SOLUTION" RX-129399 CDM J2919 HCPCS 636 RC 00009-0018-20 NDC outpatient 8 ML 330.92 330.92 MEDICA (COMMERCIAL) 94265 [3081118] MEDICA CLAIMS [308111801] 297.83 percent of total billed charges 205.17 314.37 Technical (Hospital) Services "METHYLPREDNISOLONE SOD SUCC (PF) 1,000 MG/8 ML INTRAVENOUS SOLUTION" RX-129399 CDM J2919 HCPCS 636 RC 00009-0018-20 NDC outpatient 8 ML 330.92 330.92 MULTIPLAN INC 34080 [3081285] MULTIPLAN INC [308128501] 314.37 percent of total billed charges 205.17 314.37 Technical (Hospital) Services "METHYLPREDNISOLONE SOD SUCC (PF) 1,000 MG/8 ML INTRAVENOUS SOLUTION" RX-129399 CDM J2919 HCPCS 636 RC 00009-0018-20 NDC outpatient 8 ML 330.92 330.92 CIGNA 62308 [3081051] CIGNA 62308 [308105105] 264.74 percent of total billed charges 205.17 314.37 Technical (Hospital) Services "METHYLPREDNISOLONE SOD SUCC (PF) 1,000 MG/8 ML INTRAVENOUS SOLUTION" RX-129399 CDM J2919 HCPCS 636 RC 00009-0018-20 NDC outpatient 8 ML 330.92 330.92 CIGNA 62308 [3081051] CIGNA STATE OF WYOMING [308105107] 264.74 percent of total billed charges 205.17 314.37 Technical (Hospital) Services SODIUM FERRIC GLUCONATE COMPLEX IN SUCROSE 62.5 MG/5 ML INTRAVENOUS RX-24932 CDM J2916 HCPCS 636 RC 00024-2794-10 NDC outpatient 5 ML 154.3 154.3 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES PPO [308136801] 123.44 percent of total billed charges 95.67 146.59 Technical (Hospital) Services SODIUM FERRIC GLUCONATE COMPLEX IN SUCROSE 62.5 MG/5 ML INTRAVENOUS RX-24932 CDM J2916 HCPCS 636 RC 00024-2794-10 NDC outpatient 5 ML 154.3 154.3 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES HDHP [308136802] 123.44 percent of total billed charges 95.67 146.59 Technical (Hospital) Services SODIUM FERRIC GLUCONATE COMPLEX IN SUCROSE 62.5 MG/5 ML INTRAVENOUS RX-24932 CDM J2916 HCPCS 636 RC 00024-2794-10 NDC outpatient 5 ML 154.3 154.3 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES EPO [308136803] 123.44 percent of total billed charges 95.67 146.59 Technical (Hospital) Services SODIUM FERRIC GLUCONATE COMPLEX IN SUCROSE 62.5 MG/5 ML INTRAVENOUS RX-24932 CDM J2916 HCPCS 636 RC 00024-2794-10 NDC outpatient 5 ML 154.3 154.3 BLUE CROSS BLUE SHIELD WELLMARK SB889 [3081026] BCBS WYOMING [308102603] 146.59 percent of total billed charges 95.67 146.59 Technical (Hospital) Services SODIUM FERRIC GLUCONATE COMPLEX IN SUCROSE 62.5 MG/5 ML INTRAVENOUS RX-24932 CDM J2916 HCPCS 636 RC 00024-2794-10 NDC outpatient 5 ML 154.3 154.3 UNITED HEALTHCARE (COMMERCIAL) [3081199] UNITED HEALTHCARE 87726 [308119901] 95.67 percent of total billed charges 95.67 146.59 Technical (Hospital) Services SODIUM FERRIC GLUCONATE COMPLEX IN SUCROSE 62.5 MG/5 ML INTRAVENOUS RX-24932 CDM J2916 HCPCS 636 RC 00024-2794-10 NDC outpatient 5 ML 154.3 154.3 HEALTHPARTNERS SX009 HEALTHPARTNERS 123.44 percent of total billed charges 95.67 146.59 Technical (Hospital) Services SODIUM FERRIC GLUCONATE COMPLEX IN SUCROSE 62.5 MG/5 ML INTRAVENOUS RX-24932 CDM J2916 HCPCS 636 RC 00024-2794-10 NDC outpatient 5 ML 154.3 154.3 CIGNA 62308 [3081051] CIGNA 62308 [308105105] 123.44 percent of total billed charges 95.67 146.59 Technical (Hospital) Services SODIUM FERRIC GLUCONATE COMPLEX IN SUCROSE 62.5 MG/5 ML INTRAVENOUS RX-24932 CDM J2916 HCPCS 636 RC 00024-2794-10 NDC outpatient 5 ML 154.3 154.3 CIGNA 62308 [3081051] CIGNA STATE OF WYOMING [308105107] 123.44 percent of total billed charges 95.67 146.59 Technical (Hospital) Services SODIUM FERRIC GLUCONATE COMPLEX IN SUCROSE 62.5 MG/5 ML INTRAVENOUS RX-24932 CDM J2916 HCPCS 636 RC 00024-2794-10 NDC outpatient 5 ML 154.3 154.3 MULTIPLAN INC 34080 [3081285] MULTIPLAN INC [308128501] 146.59 percent of total billed charges 95.67 146.59 Technical (Hospital) Services SODIUM FERRIC GLUCONATE COMPLEX IN SUCROSE 62.5 MG/5 ML INTRAVENOUS RX-24932 CDM J2916 HCPCS 636 RC 00024-2794-10 NDC outpatient 5 ML 154.3 154.3 MEDICA (COMMERCIAL) 94265 [3081118] MEDICA CLAIMS [308111801] 138.87 percent of total billed charges 95.67 146.59 Technical (Hospital) Services SODIUM FERRIC GLUCONATE COMPLEX IN SUCROSE 62.5 MG/5 ML INTRAVENOUS RX-24932 CDM J2916 HCPCS 636 RC 00024-2794-10 NDC inpatient 5 ML 154.3 154.3 HEALTHPARTNERS SX009 HEALTHPARTNERS 122.17 percent of total billed charges 95.67 146.59 Technical (Hospital) Services SODIUM FERRIC GLUCONATE COMPLEX IN SUCROSE 62.5 MG/5 ML INTRAVENOUS RX-24932 CDM J2916 HCPCS 636 RC 00024-2794-10 NDC inpatient 5 ML 154.3 154.3 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES EPO [308136803] 122.17 percent of total billed charges 95.67 146.59 Technical (Hospital) Services SODIUM FERRIC GLUCONATE COMPLEX IN SUCROSE 62.5 MG/5 ML INTRAVENOUS RX-24932 CDM J2916 HCPCS 636 RC 00024-2794-10 NDC inpatient 5 ML 154.3 154.3 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES HDHP [308136802] 122.17 percent of total billed charges 95.67 146.59 Technical (Hospital) Services SODIUM FERRIC GLUCONATE COMPLEX IN SUCROSE 62.5 MG/5 ML INTRAVENOUS RX-24932 CDM J2916 HCPCS 636 RC 00024-2794-10 NDC inpatient 5 ML 154.3 154.3 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES PPO [308136801] 122.17 percent of total billed charges 95.67 146.59 Technical (Hospital) Services SODIUM FERRIC GLUCONATE COMPLEX IN SUCROSE 62.5 MG/5 ML INTRAVENOUS RX-24932 CDM J2916 HCPCS 636 RC 00024-2794-10 NDC inpatient 5 ML 154.3 154.3 MULTIPLAN INC 34080 [3081285] MULTIPLAN INC [308128501] 146.59 percent of total billed charges 95.67 146.59 Technical (Hospital) Services SODIUM FERRIC GLUCONATE COMPLEX IN SUCROSE 62.5 MG/5 ML INTRAVENOUS RX-24932 CDM J2916 HCPCS 636 RC 00024-2794-10 NDC inpatient 5 ML 154.3 154.3 MEDICA (COMMERCIAL) 94265 [3081118] MEDICA CLAIMS [308111801] 138.87 percent of total billed charges 95.67 146.59 Technical (Hospital) Services SODIUM FERRIC GLUCONATE COMPLEX IN SUCROSE 62.5 MG/5 ML INTRAVENOUS RX-24932 CDM J2916 HCPCS 636 RC 00024-2794-10 NDC inpatient 5 ML 154.3 154.3 BLUE CROSS BLUE SHIELD WELLMARK SB889 [3081026] BCBS WYOMING [308102603] 146.59 percent of total billed charges 95.67 146.59 Technical (Hospital) Services SODIUM FERRIC GLUCONATE COMPLEX IN SUCROSE 62.5 MG/5 ML INTRAVENOUS RX-24932 CDM J2916 HCPCS 636 RC 00024-2794-10 NDC inpatient 5 ML 154.3 154.3 CIGNA 62308 [3081051] CIGNA 62308 [308105105] 122.17 percent of total billed charges 95.67 146.59 Technical (Hospital) Services SODIUM FERRIC GLUCONATE COMPLEX IN SUCROSE 62.5 MG/5 ML INTRAVENOUS RX-24932 CDM J2916 HCPCS 636 RC 00024-2794-10 NDC inpatient 5 ML 154.3 154.3 CIGNA 62308 [3081051] CIGNA STATE OF WYOMING [308105107] 122.17 percent of total billed charges 95.67 146.59 Technical (Hospital) Services SODIUM FERRIC GLUCONATE COMPLEX IN SUCROSE 62.5 MG/5 ML INTRAVENOUS RX-24932 CDM J2916 HCPCS 636 RC 00024-2794-10 NDC inpatient 5 ML 154.3 154.3 UNITED HEALTHCARE (COMMERCIAL) [3081199] UNITED HEALTHCARE 87726 [308119901] 95.67 percent of total billed charges 95.67 146.59 Technical (Hospital) Services ROMIPLOSTIM 250 MCG SUBCUTANEOUS SOLUTION RX-93566 CDM J2796 HCPCS 636 RC 55513-0221-01 NDC inpatient 0.5 ML 5071.92 5071.92 UNITED HEALTHCARE (COMMERCIAL) [3081199] UNITED HEALTHCARE 87726 [308119901] 3144.59 percent of total billed charges 3144.59 4818.32 Technical (Hospital) Services ROMIPLOSTIM 250 MCG SUBCUTANEOUS SOLUTION RX-93566 CDM J2796 HCPCS 636 RC 55513-0221-01 NDC inpatient 0.5 ML 5071.92 5071.92 BLUE CROSS BLUE SHIELD WELLMARK SB889 [3081026] BCBS WYOMING [308102603] 4818.32 percent of total billed charges 3144.59 4818.32 Technical (Hospital) Services ROMIPLOSTIM 250 MCG SUBCUTANEOUS SOLUTION RX-93566 CDM J2796 HCPCS 636 RC 55513-0221-01 NDC inpatient 0.5 ML 5071.92 5071.92 CIGNA 62308 [3081051] CIGNA 62308 [308105105] 4015.95 percent of total billed charges 3144.59 4818.32 Technical (Hospital) Services ROMIPLOSTIM 250 MCG SUBCUTANEOUS SOLUTION RX-93566 CDM J2796 HCPCS 636 RC 55513-0221-01 NDC inpatient 0.5 ML 5071.92 5071.92 CIGNA 62308 [3081051] CIGNA STATE OF WYOMING [308105107] 4015.95 percent of total billed charges 3144.59 4818.32 Technical (Hospital) Services ROMIPLOSTIM 250 MCG SUBCUTANEOUS SOLUTION RX-93566 CDM J2796 HCPCS 636 RC 55513-0221-01 NDC inpatient 0.5 ML 5071.92 5071.92 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES PPO [308136801] 4015.95 percent of total billed charges 3144.59 4818.32 Technical (Hospital) Services ROMIPLOSTIM 250 MCG SUBCUTANEOUS SOLUTION RX-93566 CDM J2796 HCPCS 636 RC 55513-0221-01 NDC inpatient 0.5 ML 5071.92 5071.92 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES EPO [308136803] 4015.95 percent of total billed charges 3144.59 4818.32 Technical (Hospital) Services ROMIPLOSTIM 250 MCG SUBCUTANEOUS SOLUTION RX-93566 CDM J2796 HCPCS 636 RC 55513-0221-01 NDC inpatient 0.5 ML 5071.92 5071.92 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES HDHP [308136802] 4015.95 percent of total billed charges 3144.59 4818.32 Technical (Hospital) Services ROMIPLOSTIM 250 MCG SUBCUTANEOUS SOLUTION RX-93566 CDM J2796 HCPCS 636 RC 55513-0221-01 NDC inpatient 0.5 ML 5071.92 5071.92 HEALTHPARTNERS SX009 HEALTHPARTNERS 4015.95 percent of total billed charges 3144.59 4818.32 Technical (Hospital) Services ROMIPLOSTIM 250 MCG SUBCUTANEOUS SOLUTION RX-93566 CDM J2796 HCPCS 636 RC 55513-0221-01 NDC inpatient 0.5 ML 5071.92 5071.92 MEDICA (COMMERCIAL) 94265 [3081118] MEDICA CLAIMS [308111801] 4564.73 percent of total billed charges 3144.59 4818.32 Technical (Hospital) Services ROMIPLOSTIM 250 MCG SUBCUTANEOUS SOLUTION RX-93566 CDM J2796 HCPCS 636 RC 55513-0221-01 NDC inpatient 0.5 ML 5071.92 5071.92 MULTIPLAN INC 34080 [3081285] MULTIPLAN INC [308128501] 4818.32 percent of total billed charges 3144.59 4818.32 Technical (Hospital) Services ROMIPLOSTIM 250 MCG SUBCUTANEOUS SOLUTION RX-93566 CDM J2796 HCPCS 636 RC 55513-0221-01 NDC outpatient 0.5 ML 5071.92 5071.92 HEALTHPARTNERS SX009 HEALTHPARTNERS 4057.54 percent of total billed charges 3144.59 4818.32 Technical (Hospital) Services ROMIPLOSTIM 250 MCG SUBCUTANEOUS SOLUTION RX-93566 CDM J2796 HCPCS 636 RC 55513-0221-01 NDC outpatient 0.5 ML 5071.92 5071.92 BLUE CROSS BLUE SHIELD WELLMARK SB889 [3081026] BCBS WYOMING [308102603] 4818.32 percent of total billed charges 3144.59 4818.32 Technical (Hospital) Services ROMIPLOSTIM 250 MCG SUBCUTANEOUS SOLUTION RX-93566 CDM J2796 HCPCS 636 RC 55513-0221-01 NDC outpatient 0.5 ML 5071.92 5071.92 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES HDHP [308136802] 4057.54 percent of total billed charges 3144.59 4818.32 Technical (Hospital) Services ROMIPLOSTIM 250 MCG SUBCUTANEOUS SOLUTION RX-93566 CDM J2796 HCPCS 636 RC 55513-0221-01 NDC outpatient 0.5 ML 5071.92 5071.92 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES PPO [308136801] 4057.54 percent of total billed charges 3144.59 4818.32 Technical (Hospital) Services ROMIPLOSTIM 250 MCG SUBCUTANEOUS SOLUTION RX-93566 CDM J2796 HCPCS 636 RC 55513-0221-01 NDC outpatient 0.5 ML 5071.92 5071.92 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES EPO [308136803] 4057.54 percent of total billed charges 3144.59 4818.32 Technical (Hospital) Services ROMIPLOSTIM 250 MCG SUBCUTANEOUS SOLUTION RX-93566 CDM J2796 HCPCS 636 RC 55513-0221-01 NDC outpatient 0.5 ML 5071.92 5071.92 MEDICA (COMMERCIAL) 94265 [3081118] MEDICA CLAIMS [308111801] 4564.73 percent of total billed charges 3144.59 4818.32 Technical (Hospital) Services ROMIPLOSTIM 250 MCG SUBCUTANEOUS SOLUTION RX-93566 CDM J2796 HCPCS 636 RC 55513-0221-01 NDC outpatient 0.5 ML 5071.92 5071.92 MULTIPLAN INC 34080 [3081285] MULTIPLAN INC [308128501] 4818.32 percent of total billed charges 3144.59 4818.32 Technical (Hospital) Services ROMIPLOSTIM 250 MCG SUBCUTANEOUS SOLUTION RX-93566 CDM J2796 HCPCS 636 RC 55513-0221-01 NDC outpatient 0.5 ML 5071.92 5071.92 CIGNA 62308 [3081051] CIGNA 62308 [308105105] 4057.54 percent of total billed charges 3144.59 4818.32 Technical (Hospital) Services ROMIPLOSTIM 250 MCG SUBCUTANEOUS SOLUTION RX-93566 CDM J2796 HCPCS 636 RC 55513-0221-01 NDC outpatient 0.5 ML 5071.92 5071.92 CIGNA 62308 [3081051] CIGNA STATE OF WYOMING [308105107] 4057.54 percent of total billed charges 3144.59 4818.32 Technical (Hospital) Services ROMIPLOSTIM 250 MCG SUBCUTANEOUS SOLUTION RX-93566 CDM J2796 HCPCS 636 RC 55513-0221-01 NDC outpatient 0.5 ML 5071.92 5071.92 UNITED HEALTHCARE (COMMERCIAL) [3081199] UNITED HEALTHCARE 87726 [308119901] 3144.59 percent of total billed charges 3144.59 4818.32 Technical (Hospital) Services ROMIPLOSTIM 500 MCG SUBCUTANEOUS SOLUTION RX-93567 CDM J2796 HCPCS 636 RC 55513-0222-01 NDC inpatient 1 ML 8993.83 8993.83 UNITED HEALTHCARE (COMMERCIAL) [3081199] UNITED HEALTHCARE 87726 [308119901] 5576.17 percent of total billed charges 5576.17 8544.14 Technical (Hospital) Services ROMIPLOSTIM 500 MCG SUBCUTANEOUS SOLUTION RX-93567 CDM J2796 HCPCS 636 RC 55513-0222-01 NDC inpatient 1 ML 8993.83 8993.83 BLUE CROSS BLUE SHIELD WELLMARK SB889 [3081026] BCBS WYOMING [308102603] 8544.14 percent of total billed charges 5576.17 8544.14 Technical (Hospital) Services ROMIPLOSTIM 500 MCG SUBCUTANEOUS SOLUTION RX-93567 CDM J2796 HCPCS 636 RC 55513-0222-01 NDC inpatient 1 ML 8993.83 8993.83 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES EPO [308136803] 7121.31 percent of total billed charges 5576.17 8544.14 Technical (Hospital) Services ROMIPLOSTIM 500 MCG SUBCUTANEOUS SOLUTION RX-93567 CDM J2796 HCPCS 636 RC 55513-0222-01 NDC inpatient 1 ML 8993.83 8993.83 CIGNA 62308 [3081051] CIGNA 62308 [308105105] 7121.31 percent of total billed charges 5576.17 8544.14 Technical (Hospital) Services ROMIPLOSTIM 500 MCG SUBCUTANEOUS SOLUTION RX-93567 CDM J2796 HCPCS 636 RC 55513-0222-01 NDC inpatient 1 ML 8993.83 8993.83 CIGNA 62308 [3081051] CIGNA STATE OF WYOMING [308105107] 7121.31 percent of total billed charges 5576.17 8544.14 Technical (Hospital) Services ROMIPLOSTIM 500 MCG SUBCUTANEOUS SOLUTION RX-93567 CDM J2796 HCPCS 636 RC 55513-0222-01 NDC inpatient 1 ML 8993.83 8993.83 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES HDHP [308136802] 7121.31 percent of total billed charges 5576.17 8544.14 Technical (Hospital) Services ROMIPLOSTIM 500 MCG SUBCUTANEOUS SOLUTION RX-93567 CDM J2796 HCPCS 636 RC 55513-0222-01 NDC inpatient 1 ML 8993.83 8993.83 HEALTHPARTNERS SX009 HEALTHPARTNERS 7121.31 percent of total billed charges 5576.17 8544.14 Technical (Hospital) Services ROMIPLOSTIM 500 MCG SUBCUTANEOUS SOLUTION RX-93567 CDM J2796 HCPCS 636 RC 55513-0222-01 NDC inpatient 1 ML 8993.83 8993.83 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES PPO [308136801] 7121.31 percent of total billed charges 5576.17 8544.14 Technical (Hospital) Services ROMIPLOSTIM 500 MCG SUBCUTANEOUS SOLUTION RX-93567 CDM J2796 HCPCS 636 RC 55513-0222-01 NDC inpatient 1 ML 8993.83 8993.83 MULTIPLAN INC 34080 [3081285] MULTIPLAN INC [308128501] 8544.14 percent of total billed charges 5576.17 8544.14 Technical (Hospital) Services ROMIPLOSTIM 500 MCG SUBCUTANEOUS SOLUTION RX-93567 CDM J2796 HCPCS 636 RC 55513-0222-01 NDC inpatient 1 ML 8993.83 8993.83 MEDICA (COMMERCIAL) 94265 [3081118] MEDICA CLAIMS [308111801] 8094.45 percent of total billed charges 5576.17 8544.14 Technical (Hospital) Services ROMIPLOSTIM 500 MCG SUBCUTANEOUS SOLUTION RX-93567 CDM J2796 HCPCS 636 RC 55513-0222-01 NDC outpatient 1 ML 8993.83 8993.83 HEALTHPARTNERS SX009 HEALTHPARTNERS 7195.06 percent of total billed charges 5576.17 8544.14 Technical (Hospital) Services ROMIPLOSTIM 500 MCG SUBCUTANEOUS SOLUTION RX-93567 CDM J2796 HCPCS 636 RC 55513-0222-01 NDC outpatient 1 ML 8993.83 8993.83 MULTIPLAN INC 34080 [3081285] MULTIPLAN INC [308128501] 8544.14 percent of total billed charges 5576.17 8544.14 Technical (Hospital) Services ROMIPLOSTIM 500 MCG SUBCUTANEOUS SOLUTION RX-93567 CDM J2796 HCPCS 636 RC 55513-0222-01 NDC outpatient 1 ML 8993.83 8993.83 UNITED HEALTHCARE (COMMERCIAL) [3081199] UNITED HEALTHCARE 87726 [308119901] 5576.17 percent of total billed charges 5576.17 8544.14 Technical (Hospital) Services ROMIPLOSTIM 500 MCG SUBCUTANEOUS SOLUTION RX-93567 CDM J2796 HCPCS 636 RC 55513-0222-01 NDC outpatient 1 ML 8993.83 8993.83 CIGNA 62308 [3081051] CIGNA 62308 [308105105] 7195.06 percent of total billed charges 5576.17 8544.14 Technical (Hospital) Services ROMIPLOSTIM 500 MCG SUBCUTANEOUS SOLUTION RX-93567 CDM J2796 HCPCS 636 RC 55513-0222-01 NDC outpatient 1 ML 8993.83 8993.83 CIGNA 62308 [3081051] CIGNA STATE OF WYOMING [308105107] 7195.06 percent of total billed charges 5576.17 8544.14 Technical (Hospital) Services ROMIPLOSTIM 500 MCG SUBCUTANEOUS SOLUTION RX-93567 CDM J2796 HCPCS 636 RC 55513-0222-01 NDC outpatient 1 ML 8993.83 8993.83 MEDICA (COMMERCIAL) 94265 [3081118] MEDICA CLAIMS [308111801] 8094.45 percent of total billed charges 5576.17 8544.14 Technical (Hospital) Services ROMIPLOSTIM 500 MCG SUBCUTANEOUS SOLUTION RX-93567 CDM J2796 HCPCS 636 RC 55513-0222-01 NDC outpatient 1 ML 8993.83 8993.83 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES PPO [308136801] 7195.06 percent of total billed charges 5576.17 8544.14 Technical (Hospital) Services ROMIPLOSTIM 500 MCG SUBCUTANEOUS SOLUTION RX-93567 CDM J2796 HCPCS 636 RC 55513-0222-01 NDC outpatient 1 ML 8993.83 8993.83 BLUE CROSS BLUE SHIELD WELLMARK SB889 [3081026] BCBS WYOMING [308102603] 8544.14 percent of total billed charges 5576.17 8544.14 Technical (Hospital) Services ROMIPLOSTIM 500 MCG SUBCUTANEOUS SOLUTION RX-93567 CDM J2796 HCPCS 636 RC 55513-0222-01 NDC outpatient 1 ML 8993.83 8993.83 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES HDHP [308136802] 7195.06 percent of total billed charges 5576.17 8544.14 Technical (Hospital) Services ROMIPLOSTIM 500 MCG SUBCUTANEOUS SOLUTION RX-93567 CDM J2796 HCPCS 636 RC 55513-0222-01 NDC outpatient 1 ML 8993.83 8993.83 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES EPO [308136803] 7195.06 percent of total billed charges 5576.17 8544.14 Technical (Hospital) Services "RHO(D) IMMUNE GLOBULIN 1,500 UNIT (300 MCG)/2 ML INJECTION SYRINGE" RX-127772 CDM J2791 HCPCS 636 RC 44206-0300-01 NDC inpatient 2 ML 515.19 515.19 UNITED HEALTHCARE (COMMERCIAL) [3081199] UNITED HEALTHCARE 87726 [308119901] 319.42 percent of total billed charges 319.42 489.43 Technical (Hospital) Services "RHO(D) IMMUNE GLOBULIN 1,500 UNIT (300 MCG)/2 ML INJECTION SYRINGE" RX-127772 CDM J2791 HCPCS 636 RC 44206-0300-01 NDC inpatient 2 ML 515.19 515.19 BLUE CROSS BLUE SHIELD WELLMARK SB889 [3081026] BCBS WYOMING [308102603] 489.43 percent of total billed charges 319.42 489.43 Technical (Hospital) Services "RHO(D) IMMUNE GLOBULIN 1,500 UNIT (300 MCG)/2 ML INJECTION SYRINGE" RX-127772 CDM J2791 HCPCS 636 RC 44206-0300-01 NDC inpatient 2 ML 515.19 515.19 CIGNA 62308 [3081051] CIGNA 62308 [308105105] 407.93 percent of total billed charges 319.42 489.43 Technical (Hospital) Services "RHO(D) IMMUNE GLOBULIN 1,500 UNIT (300 MCG)/2 ML INJECTION SYRINGE" RX-127772 CDM J2791 HCPCS 636 RC 44206-0300-01 NDC inpatient 2 ML 515.19 515.19 CIGNA 62308 [3081051] CIGNA STATE OF WYOMING [308105107] 407.93 percent of total billed charges 319.42 489.43 Technical (Hospital) Services "RHO(D) IMMUNE GLOBULIN 1,500 UNIT (300 MCG)/2 ML INJECTION SYRINGE" RX-127772 CDM J2791 HCPCS 636 RC 44206-0300-01 NDC inpatient 2 ML 515.19 515.19 MULTIPLAN INC 34080 [3081285] MULTIPLAN INC [308128501] 489.43 percent of total billed charges 319.42 489.43 Technical (Hospital) Services "RHO(D) IMMUNE GLOBULIN 1,500 UNIT (300 MCG)/2 ML INJECTION SYRINGE" RX-127772 CDM J2791 HCPCS 636 RC 44206-0300-01 NDC inpatient 2 ML 515.19 515.19 MEDICA (COMMERCIAL) 94265 [3081118] MEDICA CLAIMS [308111801] 463.67 percent of total billed charges 319.42 489.43 Technical (Hospital) Services "RHO(D) IMMUNE GLOBULIN 1,500 UNIT (300 MCG)/2 ML INJECTION SYRINGE" RX-127772 CDM J2791 HCPCS 636 RC 44206-0300-01 NDC inpatient 2 ML 515.19 515.19 HEALTHPARTNERS SX009 HEALTHPARTNERS 407.93 percent of total billed charges 319.42 489.43 Technical (Hospital) Services "RHO(D) IMMUNE GLOBULIN 1,500 UNIT (300 MCG)/2 ML INJECTION SYRINGE" RX-127772 CDM J2791 HCPCS 636 RC 44206-0300-01 NDC inpatient 2 ML 515.19 515.19 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES HDHP [308136802] 407.93 percent of total billed charges 319.42 489.43 Technical (Hospital) Services "RHO(D) IMMUNE GLOBULIN 1,500 UNIT (300 MCG)/2 ML INJECTION SYRINGE" RX-127772 CDM J2791 HCPCS 636 RC 44206-0300-01 NDC inpatient 2 ML 515.19 515.19 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES EPO [308136803] 407.93 percent of total billed charges 319.42 489.43 Technical (Hospital) Services "RHO(D) IMMUNE GLOBULIN 1,500 UNIT (300 MCG)/2 ML INJECTION SYRINGE" RX-127772 CDM J2791 HCPCS 636 RC 44206-0300-01 NDC inpatient 2 ML 515.19 515.19 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES PPO [308136801] 407.93 percent of total billed charges 319.42 489.43 Technical (Hospital) Services "RHO(D) IMMUNE GLOBULIN 1,500 UNIT (300 MCG)/2 ML INJECTION SYRINGE" RX-127772 CDM J2791 HCPCS 636 RC 44206-0300-01 NDC outpatient 2 ML 515.19 515.19 MEDICA (COMMERCIAL) 94265 [3081118] MEDICA CLAIMS [308111801] 463.67 percent of total billed charges 319.42 489.43 Technical (Hospital) Services "RHO(D) IMMUNE GLOBULIN 1,500 UNIT (300 MCG)/2 ML INJECTION SYRINGE" RX-127772 CDM J2791 HCPCS 636 RC 44206-0300-01 NDC outpatient 2 ML 515.19 515.19 BLUE CROSS BLUE SHIELD WELLMARK SB889 [3081026] BCBS WYOMING [308102603] 489.43 percent of total billed charges 319.42 489.43 Technical (Hospital) Services "RHO(D) IMMUNE GLOBULIN 1,500 UNIT (300 MCG)/2 ML INJECTION SYRINGE" RX-127772 CDM J2791 HCPCS 636 RC 44206-0300-01 NDC outpatient 2 ML 515.19 515.19 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES PPO [308136801] 412.15 percent of total billed charges 319.42 489.43 Technical (Hospital) Services "RHO(D) IMMUNE GLOBULIN 1,500 UNIT (300 MCG)/2 ML INJECTION SYRINGE" RX-127772 CDM J2791 HCPCS 636 RC 44206-0300-01 NDC outpatient 2 ML 515.19 515.19 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES HDHP [308136802] 412.15 percent of total billed charges 319.42 489.43 Technical (Hospital) Services "RHO(D) IMMUNE GLOBULIN 1,500 UNIT (300 MCG)/2 ML INJECTION SYRINGE" RX-127772 CDM J2791 HCPCS 636 RC 44206-0300-01 NDC outpatient 2 ML 515.19 515.19 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES EPO [308136803] 412.15 percent of total billed charges 319.42 489.43 Technical (Hospital) Services "RHO(D) IMMUNE GLOBULIN 1,500 UNIT (300 MCG)/2 ML INJECTION SYRINGE" RX-127772 CDM J2791 HCPCS 636 RC 44206-0300-01 NDC outpatient 2 ML 515.19 515.19 CIGNA 62308 [3081051] CIGNA 62308 [308105105] 412.15 percent of total billed charges 319.42 489.43 Technical (Hospital) Services "RHO(D) IMMUNE GLOBULIN 1,500 UNIT (300 MCG)/2 ML INJECTION SYRINGE" RX-127772 CDM J2791 HCPCS 636 RC 44206-0300-01 NDC outpatient 2 ML 515.19 515.19 CIGNA 62308 [3081051] CIGNA STATE OF WYOMING [308105107] 412.15 percent of total billed charges 319.42 489.43 Technical (Hospital) Services "RHO(D) IMMUNE GLOBULIN 1,500 UNIT (300 MCG)/2 ML INJECTION SYRINGE" RX-127772 CDM J2791 HCPCS 636 RC 44206-0300-01 NDC outpatient 2 ML 515.19 515.19 UNITED HEALTHCARE (COMMERCIAL) [3081199] UNITED HEALTHCARE 87726 [308119901] 319.42 percent of total billed charges 319.42 489.43 Technical (Hospital) Services "RHO(D) IMMUNE GLOBULIN 1,500 UNIT (300 MCG)/2 ML INJECTION SYRINGE" RX-127772 CDM J2791 HCPCS 636 RC 44206-0300-01 NDC outpatient 2 ML 515.19 515.19 MULTIPLAN INC 34080 [3081285] MULTIPLAN INC [308128501] 489.43 percent of total billed charges 319.42 489.43 Technical (Hospital) Services "RHO(D) IMMUNE GLOBULIN 1,500 UNIT (300 MCG)/2 ML INJECTION SYRINGE" RX-127772 CDM J2791 HCPCS 636 RC 44206-0300-01 NDC outpatient 2 ML 515.19 515.19 HEALTHPARTNERS SX009 HEALTHPARTNERS 412.15 percent of total billed charges 319.42 489.43 Technical (Hospital) Services METOCLOPRAMIDE 5 MG/ML INJECTION SOLUTION RX-5002 CDM J2765 HCPCS 636 RC 23155-0240-41 NDC outpatient 1 ML 59.4 59.4 HEALTHPARTNERS SX009 HEALTHPARTNERS 47.52 percent of total billed charges 36.83 56.43 Technical (Hospital) Services METOCLOPRAMIDE 5 MG/ML INJECTION SOLUTION RX-5002 CDM J2765 HCPCS 636 RC 23155-0240-41 NDC outpatient 1 ML 59.4 59.4 MULTIPLAN INC 34080 [3081285] MULTIPLAN INC [308128501] 56.43 percent of total billed charges 36.83 56.43 Technical (Hospital) Services METOCLOPRAMIDE 5 MG/ML INJECTION SOLUTION RX-5002 CDM J2765 HCPCS 636 RC 23155-0240-41 NDC outpatient 1 ML 59.4 59.4 UNITED HEALTHCARE (COMMERCIAL) [3081199] UNITED HEALTHCARE 87726 [308119901] 36.83 percent of total billed charges 36.83 56.43 Technical (Hospital) Services METOCLOPRAMIDE 5 MG/ML INJECTION SOLUTION RX-5002 CDM J2765 HCPCS 636 RC 23155-0240-41 NDC outpatient 1 ML 59.4 59.4 CIGNA 62308 [3081051] CIGNA 62308 [308105105] 47.52 percent of total billed charges 36.83 56.43 Technical (Hospital) Services METOCLOPRAMIDE 5 MG/ML INJECTION SOLUTION RX-5002 CDM J2765 HCPCS 636 RC 23155-0240-41 NDC outpatient 1 ML 59.4 59.4 CIGNA 62308 [3081051] CIGNA STATE OF WYOMING [308105107] 47.52 percent of total billed charges 36.83 56.43 Technical (Hospital) Services METOCLOPRAMIDE 5 MG/ML INJECTION SOLUTION RX-5002 CDM J2765 HCPCS 636 RC 23155-0240-41 NDC outpatient 1 ML 59.4 59.4 MEDICA (COMMERCIAL) 94265 [3081118] MEDICA CLAIMS [308111801] 53.46 percent of total billed charges 36.83 56.43 Technical (Hospital) Services METOCLOPRAMIDE 5 MG/ML INJECTION SOLUTION RX-5002 CDM J2765 HCPCS 636 RC 23155-0240-41 NDC outpatient 1 ML 59.4 59.4 BLUE CROSS BLUE SHIELD WELLMARK SB889 [3081026] BCBS WYOMING [308102603] 56.43 percent of total billed charges 36.83 56.43 Technical (Hospital) Services METOCLOPRAMIDE 5 MG/ML INJECTION SOLUTION RX-5002 CDM J2765 HCPCS 636 RC 23155-0240-41 NDC outpatient 1 ML 59.4 59.4 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES PPO [308136801] 47.52 percent of total billed charges 36.83 56.43 Technical (Hospital) Services METOCLOPRAMIDE 5 MG/ML INJECTION SOLUTION RX-5002 CDM J2765 HCPCS 636 RC 23155-0240-41 NDC outpatient 1 ML 59.4 59.4 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES HDHP [308136802] 47.52 percent of total billed charges 36.83 56.43 Technical (Hospital) Services METOCLOPRAMIDE 5 MG/ML INJECTION SOLUTION RX-5002 CDM J2765 HCPCS 636 RC 23155-0240-41 NDC outpatient 1 ML 59.4 59.4 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES EPO [308136803] 47.52 percent of total billed charges 36.83 56.43 Technical (Hospital) Services METOCLOPRAMIDE 5 MG/ML INJECTION SOLUTION RX-5002 CDM J2765 HCPCS 636 RC 23155-0240-41 NDC inpatient 1 ML 59.4 59.4 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES PPO [308136801] 47.03 percent of total billed charges 36.83 56.43 Technical (Hospital) Services METOCLOPRAMIDE 5 MG/ML INJECTION SOLUTION RX-5002 CDM J2765 HCPCS 636 RC 23155-0240-41 NDC inpatient 1 ML 59.4 59.4 HEALTHPARTNERS SX009 HEALTHPARTNERS 47.03 percent of total billed charges 36.83 56.43 Technical (Hospital) Services METOCLOPRAMIDE 5 MG/ML INJECTION SOLUTION RX-5002 CDM J2765 HCPCS 636 RC 23155-0240-41 NDC inpatient 1 ML 59.4 59.4 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES HDHP [308136802] 47.03 percent of total billed charges 36.83 56.43 Technical (Hospital) Services METOCLOPRAMIDE 5 MG/ML INJECTION SOLUTION RX-5002 CDM J2765 HCPCS 636 RC 23155-0240-41 NDC inpatient 1 ML 59.4 59.4 MULTIPLAN INC 34080 [3081285] MULTIPLAN INC [308128501] 56.43 percent of total billed charges 36.83 56.43 Technical (Hospital) Services METOCLOPRAMIDE 5 MG/ML INJECTION SOLUTION RX-5002 CDM J2765 HCPCS 636 RC 23155-0240-41 NDC inpatient 1 ML 59.4 59.4 MEDICA (COMMERCIAL) 94265 [3081118] MEDICA CLAIMS [308111801] 53.46 percent of total billed charges 36.83 56.43 Technical (Hospital) Services METOCLOPRAMIDE 5 MG/ML INJECTION SOLUTION RX-5002 CDM J2765 HCPCS 636 RC 23155-0240-41 NDC inpatient 1 ML 59.4 59.4 CIGNA 62308 [3081051] CIGNA 62308 [308105105] 47.03 percent of total billed charges 36.83 56.43 Technical (Hospital) Services METOCLOPRAMIDE 5 MG/ML INJECTION SOLUTION RX-5002 CDM J2765 HCPCS 636 RC 23155-0240-41 NDC inpatient 1 ML 59.4 59.4 CIGNA 62308 [3081051] CIGNA STATE OF WYOMING [308105107] 47.03 percent of total billed charges 36.83 56.43 Technical (Hospital) Services METOCLOPRAMIDE 5 MG/ML INJECTION SOLUTION RX-5002 CDM J2765 HCPCS 636 RC 23155-0240-41 NDC inpatient 1 ML 59.4 59.4 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES EPO [308136803] 47.03 percent of total billed charges 36.83 56.43 Technical (Hospital) Services METOCLOPRAMIDE 5 MG/ML INJECTION SOLUTION RX-5002 CDM J2765 HCPCS 636 RC 23155-0240-41 NDC inpatient 1 ML 59.4 59.4 UNITED HEALTHCARE (COMMERCIAL) [3081199] UNITED HEALTHCARE 87726 [308119901] 36.83 percent of total billed charges 36.83 56.43 Technical (Hospital) Services METOCLOPRAMIDE 5 MG/ML INJECTION SOLUTION RX-5002 CDM J2765 HCPCS 636 RC 23155-0240-41 NDC inpatient 1 ML 59.4 59.4 BLUE CROSS BLUE SHIELD WELLMARK SB889 [3081026] BCBS WYOMING [308102603] 56.43 percent of total billed charges 36.83 56.43 Technical (Hospital) Services PROTAMINE 10 MG/ML INTRAVENOUS SOLUTION RX-6677 CDM J2720 HCPCS 636 RC 63323-0229-30 NDC outpatient 25 ML 234.9 234.9 CIGNA 62308 [3081051] CIGNA 62308 [308105105] 187.92 percent of total billed charges 145.64 223.16 Technical (Hospital) Services PROTAMINE 10 MG/ML INTRAVENOUS SOLUTION RX-6677 CDM J2720 HCPCS 636 RC 63323-0229-30 NDC outpatient 25 ML 234.9 234.9 CIGNA 62308 [3081051] CIGNA STATE OF WYOMING [308105107] 187.92 percent of total billed charges 145.64 223.16 Technical (Hospital) Services PROTAMINE 10 MG/ML INTRAVENOUS SOLUTION RX-6677 CDM J2720 HCPCS 636 RC 63323-0229-30 NDC outpatient 25 ML 234.9 234.9 MULTIPLAN INC 34080 [3081285] MULTIPLAN INC [308128501] 223.16 percent of total billed charges 145.64 223.16 Technical (Hospital) Services PROTAMINE 10 MG/ML INTRAVENOUS SOLUTION RX-6677 CDM J2720 HCPCS 636 RC 63323-0229-30 NDC outpatient 25 ML 234.9 234.9 BLUE CROSS BLUE SHIELD WELLMARK SB889 [3081026] BCBS WYOMING [308102603] 223.16 percent of total billed charges 145.64 223.16 Technical (Hospital) Services PROTAMINE 10 MG/ML INTRAVENOUS SOLUTION RX-6677 CDM J2720 HCPCS 636 RC 63323-0229-30 NDC outpatient 25 ML 234.9 234.9 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES EPO [308136803] 187.92 percent of total billed charges 145.64 223.16 Technical (Hospital) Services PROTAMINE 10 MG/ML INTRAVENOUS SOLUTION RX-6677 CDM J2720 HCPCS 636 RC 63323-0229-30 NDC outpatient 25 ML 234.9 234.9 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES HDHP [308136802] 187.92 percent of total billed charges 145.64 223.16 Technical (Hospital) Services PROTAMINE 10 MG/ML INTRAVENOUS SOLUTION RX-6677 CDM J2720 HCPCS 636 RC 63323-0229-30 NDC outpatient 25 ML 234.9 234.9 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES PPO [308136801] 187.92 percent of total billed charges 145.64 223.16 Technical (Hospital) Services PROTAMINE 10 MG/ML INTRAVENOUS SOLUTION RX-6677 CDM J2720 HCPCS 636 RC 63323-0229-30 NDC outpatient 25 ML 234.9 234.9 HEALTHPARTNERS SX009 HEALTHPARTNERS 187.92 percent of total billed charges 145.64 223.16 Technical (Hospital) Services PROTAMINE 10 MG/ML INTRAVENOUS SOLUTION RX-6677 CDM J2720 HCPCS 636 RC 63323-0229-30 NDC outpatient 25 ML 234.9 234.9 UNITED HEALTHCARE (COMMERCIAL) [3081199] UNITED HEALTHCARE 87726 [308119901] 145.64 percent of total billed charges 145.64 223.16 Technical (Hospital) Services PROTAMINE 10 MG/ML INTRAVENOUS SOLUTION RX-6677 CDM J2720 HCPCS 636 RC 63323-0229-30 NDC outpatient 25 ML 234.9 234.9 MEDICA (COMMERCIAL) 94265 [3081118] MEDICA CLAIMS [308111801] 211.41 percent of total billed charges 145.64 223.16 Technical (Hospital) Services PROTAMINE 10 MG/ML INTRAVENOUS SOLUTION RX-6677 CDM J2720 HCPCS 636 RC 63323-0229-30 NDC inpatient 25 ML 234.9 234.9 UNITED HEALTHCARE (COMMERCIAL) [3081199] UNITED HEALTHCARE 87726 [308119901] 145.64 percent of total billed charges 145.64 223.16 Technical (Hospital) Services PROTAMINE 10 MG/ML INTRAVENOUS SOLUTION RX-6677 CDM J2720 HCPCS 636 RC 63323-0229-30 NDC inpatient 25 ML 234.9 234.9 BLUE CROSS BLUE SHIELD WELLMARK SB889 [3081026] BCBS WYOMING [308102603] 223.16 percent of total billed charges 145.64 223.16 Technical (Hospital) Services PROTAMINE 10 MG/ML INTRAVENOUS SOLUTION RX-6677 CDM J2720 HCPCS 636 RC 63323-0229-30 NDC inpatient 25 ML 234.9 234.9 MEDICA (COMMERCIAL) 94265 [3081118] MEDICA CLAIMS [308111801] 211.41 percent of total billed charges 145.64 223.16 Technical (Hospital) Services PROTAMINE 10 MG/ML INTRAVENOUS SOLUTION RX-6677 CDM J2720 HCPCS 636 RC 63323-0229-30 NDC inpatient 25 ML 234.9 234.9 MULTIPLAN INC 34080 [3081285] MULTIPLAN INC [308128501] 223.16 percent of total billed charges 145.64 223.16 Technical (Hospital) Services PROTAMINE 10 MG/ML INTRAVENOUS SOLUTION RX-6677 CDM J2720 HCPCS 636 RC 63323-0229-30 NDC inpatient 25 ML 234.9 234.9 CIGNA 62308 [3081051] CIGNA 62308 [308105105] 185.99 percent of total billed charges 145.64 223.16 Technical (Hospital) Services PROTAMINE 10 MG/ML INTRAVENOUS SOLUTION RX-6677 CDM J2720 HCPCS 636 RC 63323-0229-30 NDC inpatient 25 ML 234.9 234.9 CIGNA 62308 [3081051] CIGNA STATE OF WYOMING [308105107] 185.99 percent of total billed charges 145.64 223.16 Technical (Hospital) Services PROTAMINE 10 MG/ML INTRAVENOUS SOLUTION RX-6677 CDM J2720 HCPCS 636 RC 63323-0229-30 NDC inpatient 25 ML 234.9 234.9 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES EPO [308136803] 185.99 percent of total billed charges 145.64 223.16 Technical (Hospital) Services PROTAMINE 10 MG/ML INTRAVENOUS SOLUTION RX-6677 CDM J2720 HCPCS 636 RC 63323-0229-30 NDC inpatient 25 ML 234.9 234.9 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES HDHP [308136802] 185.99 percent of total billed charges 145.64 223.16 Technical (Hospital) Services PROTAMINE 10 MG/ML INTRAVENOUS SOLUTION RX-6677 CDM J2720 HCPCS 636 RC 63323-0229-30 NDC inpatient 25 ML 234.9 234.9 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES PPO [308136801] 185.99 percent of total billed charges 145.64 223.16 Technical (Hospital) Services PROTAMINE 10 MG/ML INTRAVENOUS SOLUTION RX-6677 CDM J2720 HCPCS 636 RC 63323-0229-30 NDC inpatient 25 ML 234.9 234.9 HEALTHPARTNERS SX009 HEALTHPARTNERS 185.99 percent of total billed charges 145.64 223.16 Technical (Hospital) Services PROPOFOL 10 MG/ML INTRAVENOUS EMULSION RX-11150 CDM J2704 HCPCS 636 RC 00409-4699-54 NDC outpatient 100 ML 110.1 110.1 UNITED HEALTHCARE (COMMERCIAL) [3081199] UNITED HEALTHCARE 87726 [308119901] 68.26 percent of total billed charges 68.26 104.6 Technical (Hospital) Services PROPOFOL 10 MG/ML INTRAVENOUS EMULSION RX-11150 CDM J2704 HCPCS 636 RC 00409-4699-54 NDC outpatient 100 ML 110.1 110.1 BLUE CROSS BLUE SHIELD WELLMARK SB889 [3081026] BCBS WYOMING [308102603] 104.6 percent of total billed charges 68.26 104.6 Technical (Hospital) Services PROPOFOL 10 MG/ML INTRAVENOUS EMULSION RX-11150 CDM J2704 HCPCS 636 RC 00409-4699-54 NDC outpatient 100 ML 110.1 110.1 HEALTHPARTNERS SX009 HEALTHPARTNERS 88.08 percent of total billed charges 68.26 104.6 Technical (Hospital) Services PROPOFOL 10 MG/ML INTRAVENOUS EMULSION RX-11150 CDM J2704 HCPCS 636 RC 00409-4699-54 NDC outpatient 100 ML 110.1 110.1 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES EPO [308136803] 88.08 percent of total billed charges 68.26 104.6 Technical (Hospital) Services PROPOFOL 10 MG/ML INTRAVENOUS EMULSION RX-11150 CDM J2704 HCPCS 636 RC 00409-4699-54 NDC outpatient 100 ML 110.1 110.1 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES HDHP [308136802] 88.08 percent of total billed charges 68.26 104.6 Technical (Hospital) Services PROPOFOL 10 MG/ML INTRAVENOUS EMULSION RX-11150 CDM J2704 HCPCS 636 RC 00409-4699-54 NDC outpatient 100 ML 110.1 110.1 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES PPO [308136801] 88.08 percent of total billed charges 68.26 104.6 Technical (Hospital) Services PROPOFOL 10 MG/ML INTRAVENOUS EMULSION RX-11150 CDM J2704 HCPCS 636 RC 00409-4699-54 NDC outpatient 100 ML 110.1 110.1 MULTIPLAN INC 34080 [3081285] MULTIPLAN INC [308128501] 104.6 percent of total billed charges 68.26 104.6 Technical (Hospital) Services PROPOFOL 10 MG/ML INTRAVENOUS EMULSION RX-11150 CDM J2704 HCPCS 636 RC 00409-4699-54 NDC outpatient 100 ML 110.1 110.1 MEDICA (COMMERCIAL) 94265 [3081118] MEDICA CLAIMS [308111801] 99.09 percent of total billed charges 68.26 104.6 Technical (Hospital) Services PROPOFOL 10 MG/ML INTRAVENOUS EMULSION RX-11150 CDM J2704 HCPCS 636 RC 00409-4699-54 NDC outpatient 100 ML 110.1 110.1 CIGNA 62308 [3081051] CIGNA 62308 [308105105] 88.08 percent of total billed charges 68.26 104.6 Technical (Hospital) Services PROPOFOL 10 MG/ML INTRAVENOUS EMULSION RX-11150 CDM J2704 HCPCS 636 RC 00409-4699-54 NDC outpatient 100 ML 110.1 110.1 CIGNA 62308 [3081051] CIGNA STATE OF WYOMING [308105107] 88.08 percent of total billed charges 68.26 104.6 Technical (Hospital) Services PROPOFOL 10 MG/ML INTRAVENOUS EMULSION RX-11150 CDM J2704 HCPCS 636 RC 00409-4699-54 NDC inpatient 100 ML 110.1 110.1 UNITED HEALTHCARE (COMMERCIAL) [3081199] UNITED HEALTHCARE 87726 [308119901] 68.26 percent of total billed charges 68.26 104.6 Technical (Hospital) Services PROPOFOL 10 MG/ML INTRAVENOUS EMULSION RX-11150 CDM J2704 HCPCS 636 RC 00409-4699-54 NDC inpatient 100 ML 110.1 110.1 BLUE CROSS BLUE SHIELD WELLMARK SB889 [3081026] BCBS WYOMING [308102603] 104.6 percent of total billed charges 68.26 104.6 Technical (Hospital) Services PROPOFOL 10 MG/ML INTRAVENOUS EMULSION RX-11150 CDM J2704 HCPCS 636 RC 00409-4699-54 NDC inpatient 100 ML 110.1 110.1 MULTIPLAN INC 34080 [3081285] MULTIPLAN INC [308128501] 104.6 percent of total billed charges 68.26 104.6 Technical (Hospital) Services PROPOFOL 10 MG/ML INTRAVENOUS EMULSION RX-11150 CDM J2704 HCPCS 636 RC 00409-4699-54 NDC inpatient 100 ML 110.1 110.1 HEALTHPARTNERS SX009 HEALTHPARTNERS 87.18 percent of total billed charges 68.26 104.6 Technical (Hospital) Services PROPOFOL 10 MG/ML INTRAVENOUS EMULSION RX-11150 CDM J2704 HCPCS 636 RC 00409-4699-54 NDC inpatient 100 ML 110.1 110.1 MEDICA (COMMERCIAL) 94265 [3081118] MEDICA CLAIMS [308111801] 99.09 percent of total billed charges 68.26 104.6 Technical (Hospital) Services PROPOFOL 10 MG/ML INTRAVENOUS EMULSION RX-11150 CDM J2704 HCPCS 636 RC 00409-4699-54 NDC inpatient 100 ML 110.1 110.1 CIGNA 62308 [3081051] CIGNA 62308 [308105105] 87.18 percent of total billed charges 68.26 104.6 Technical (Hospital) Services PROPOFOL 10 MG/ML INTRAVENOUS EMULSION RX-11150 CDM J2704 HCPCS 636 RC 00409-4699-54 NDC inpatient 100 ML 110.1 110.1 CIGNA 62308 [3081051] CIGNA STATE OF WYOMING [308105107] 87.18 percent of total billed charges 68.26 104.6 Technical (Hospital) Services PROPOFOL 10 MG/ML INTRAVENOUS EMULSION RX-11150 CDM J2704 HCPCS 636 RC 00409-4699-54 NDC inpatient 100 ML 110.1 110.1 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES EPO [308136803] 87.18 percent of total billed charges 68.26 104.6 Technical (Hospital) Services PROPOFOL 10 MG/ML INTRAVENOUS EMULSION RX-11150 CDM J2704 HCPCS 636 RC 00409-4699-54 NDC inpatient 100 ML 110.1 110.1 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES HDHP [308136802] 87.18 percent of total billed charges 68.26 104.6 Technical (Hospital) Services PROPOFOL 10 MG/ML INTRAVENOUS EMULSION RX-11150 CDM J2704 HCPCS 636 RC 00409-4699-54 NDC inpatient 100 ML 110.1 110.1 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES PPO [308136801] 87.18 percent of total billed charges 68.26 104.6 Technical (Hospital) Services PROPOFOL 10 MG/ML INTRAVENOUS EMULSION RX-11150 CDM J2704 HCPCS 636 RC 25021-0608-50 NDC inpatient 50 ML 84.6 84.6 BLUE CROSS BLUE SHIELD WELLMARK SB889 [3081026] BCBS WYOMING [308102603] 80.37 percent of total billed charges 52.45 80.37 Technical (Hospital) Services PROPOFOL 10 MG/ML INTRAVENOUS EMULSION RX-11150 CDM J2704 HCPCS 636 RC 25021-0608-50 NDC inpatient 50 ML 84.6 84.6 UNITED HEALTHCARE (COMMERCIAL) [3081199] UNITED HEALTHCARE 87726 [308119901] 52.45 percent of total billed charges 52.45 80.37 Technical (Hospital) Services PROPOFOL 10 MG/ML INTRAVENOUS EMULSION RX-11150 CDM J2704 HCPCS 636 RC 25021-0608-50 NDC inpatient 50 ML 84.6 84.6 MEDICA (COMMERCIAL) 94265 [3081118] MEDICA CLAIMS [308111801] 76.14 percent of total billed charges 52.45 80.37 Technical (Hospital) Services PROPOFOL 10 MG/ML INTRAVENOUS EMULSION RX-11150 CDM J2704 HCPCS 636 RC 25021-0608-50 NDC inpatient 50 ML 84.6 84.6 MULTIPLAN INC 34080 [3081285] MULTIPLAN INC [308128501] 80.37 percent of total billed charges 52.45 80.37 Technical (Hospital) Services PROPOFOL 10 MG/ML INTRAVENOUS EMULSION RX-11150 CDM J2704 HCPCS 636 RC 25021-0608-50 NDC inpatient 50 ML 84.6 84.6 HEALTHPARTNERS SX009 HEALTHPARTNERS 66.99 percent of total billed charges 52.45 80.37 Technical (Hospital) Services PROPOFOL 10 MG/ML INTRAVENOUS EMULSION RX-11150 CDM J2704 HCPCS 636 RC 25021-0608-50 NDC inpatient 50 ML 84.6 84.6 CIGNA 62308 [3081051] CIGNA 62308 [308105105] 66.99 percent of total billed charges 52.45 80.37 Technical (Hospital) Services PROPOFOL 10 MG/ML INTRAVENOUS EMULSION RX-11150 CDM J2704 HCPCS 636 RC 25021-0608-50 NDC inpatient 50 ML 84.6 84.6 CIGNA 62308 [3081051] CIGNA STATE OF WYOMING [308105107] 66.99 percent of total billed charges 52.45 80.37 Technical (Hospital) Services PROPOFOL 10 MG/ML INTRAVENOUS EMULSION RX-11150 CDM J2704 HCPCS 636 RC 25021-0608-50 NDC inpatient 50 ML 84.6 84.6 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES EPO [308136803] 66.99 percent of total billed charges 52.45 80.37 Technical (Hospital) Services PROPOFOL 10 MG/ML INTRAVENOUS EMULSION RX-11150 CDM J2704 HCPCS 636 RC 25021-0608-50 NDC inpatient 50 ML 84.6 84.6 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES HDHP [308136802] 66.99 percent of total billed charges 52.45 80.37 Technical (Hospital) Services PROPOFOL 10 MG/ML INTRAVENOUS EMULSION RX-11150 CDM J2704 HCPCS 636 RC 25021-0608-50 NDC inpatient 50 ML 84.6 84.6 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES PPO [308136801] 66.99 percent of total billed charges 52.45 80.37 Technical (Hospital) Services PROPOFOL 10 MG/ML INTRAVENOUS EMULSION RX-11150 CDM J2704 HCPCS 636 RC 25021-0608-50 NDC outpatient 50 ML 84.6 84.6 UNITED HEALTHCARE (COMMERCIAL) [3081199] UNITED HEALTHCARE 87726 [308119901] 52.45 percent of total billed charges 52.45 80.37 Technical (Hospital) Services PROPOFOL 10 MG/ML INTRAVENOUS EMULSION RX-11150 CDM J2704 HCPCS 636 RC 25021-0608-50 NDC outpatient 50 ML 84.6 84.6 BLUE CROSS BLUE SHIELD WELLMARK SB889 [3081026] BCBS WYOMING [308102603] 80.37 percent of total billed charges 52.45 80.37 Technical (Hospital) Services PROPOFOL 10 MG/ML INTRAVENOUS EMULSION RX-11150 CDM J2704 HCPCS 636 RC 25021-0608-50 NDC outpatient 50 ML 84.6 84.6 HEALTHPARTNERS SX009 HEALTHPARTNERS 67.68 percent of total billed charges 52.45 80.37 Technical (Hospital) Services PROPOFOL 10 MG/ML INTRAVENOUS EMULSION RX-11150 CDM J2704 HCPCS 636 RC 25021-0608-50 NDC outpatient 50 ML 84.6 84.6 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES PPO [308136801] 67.68 percent of total billed charges 52.45 80.37 Technical (Hospital) Services PROPOFOL 10 MG/ML INTRAVENOUS EMULSION RX-11150 CDM J2704 HCPCS 636 RC 25021-0608-50 NDC outpatient 50 ML 84.6 84.6 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES HDHP [308136802] 67.68 percent of total billed charges 52.45 80.37 Technical (Hospital) Services PROPOFOL 10 MG/ML INTRAVENOUS EMULSION RX-11150 CDM J2704 HCPCS 636 RC 25021-0608-50 NDC outpatient 50 ML 84.6 84.6 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES EPO [308136803] 67.68 percent of total billed charges 52.45 80.37 Technical (Hospital) Services PROPOFOL 10 MG/ML INTRAVENOUS EMULSION RX-11150 CDM J2704 HCPCS 636 RC 25021-0608-50 NDC outpatient 50 ML 84.6 84.6 MEDICA (COMMERCIAL) 94265 [3081118] MEDICA CLAIMS [308111801] 76.14 percent of total billed charges 52.45 80.37 Technical (Hospital) Services PROPOFOL 10 MG/ML INTRAVENOUS EMULSION RX-11150 CDM J2704 HCPCS 636 RC 25021-0608-50 NDC outpatient 50 ML 84.6 84.6 MULTIPLAN INC 34080 [3081285] MULTIPLAN INC [308128501] 80.37 percent of total billed charges 52.45 80.37 Technical (Hospital) Services PROPOFOL 10 MG/ML INTRAVENOUS EMULSION RX-11150 CDM J2704 HCPCS 636 RC 25021-0608-50 NDC outpatient 50 ML 84.6 84.6 CIGNA 62308 [3081051] CIGNA 62308 [308105105] 67.68 percent of total billed charges 52.45 80.37 Technical (Hospital) Services PROPOFOL 10 MG/ML INTRAVENOUS EMULSION RX-11150 CDM J2704 HCPCS 636 RC 25021-0608-50 NDC outpatient 50 ML 84.6 84.6 CIGNA 62308 [3081051] CIGNA STATE OF WYOMING [308105107] 67.68 percent of total billed charges 52.45 80.37 Technical (Hospital) Services OXYTOCIN 10 UNIT/ML INJECTION SOLUTION RX-5944 CDM J2590 HCPCS 636 RC 42023-0116-25 NDC inpatient 0.3 ML 59.38 59.38 MULTIPLAN INC 34080 [3081285] MULTIPLAN INC [308128501] 56.41 percent of total billed charges 36.82 56.41 Technical (Hospital) Services OXYTOCIN 10 UNIT/ML INJECTION SOLUTION RX-5944 CDM J2590 HCPCS 636 RC 42023-0116-25 NDC inpatient 0.3 ML 59.38 59.38 HEALTHPARTNERS SX009 HEALTHPARTNERS 47.02 percent of total billed charges 36.82 56.41 Technical (Hospital) Services OXYTOCIN 10 UNIT/ML INJECTION SOLUTION RX-5944 CDM J2590 HCPCS 636 RC 42023-0116-25 NDC inpatient 0.3 ML 59.38 59.38 MEDICA (COMMERCIAL) 94265 [3081118] MEDICA CLAIMS [308111801] 53.44 percent of total billed charges 36.82 56.41 Technical (Hospital) Services OXYTOCIN 10 UNIT/ML INJECTION SOLUTION RX-5944 CDM J2590 HCPCS 636 RC 42023-0116-25 NDC inpatient 0.3 ML 59.38 59.38 CIGNA 62308 [3081051] CIGNA STATE OF WYOMING [308105107] 47.02 percent of total billed charges 36.82 56.41 Technical (Hospital) Services OXYTOCIN 10 UNIT/ML INJECTION SOLUTION RX-5944 CDM J2590 HCPCS 636 RC 42023-0116-25 NDC inpatient 0.3 ML 59.38 59.38 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES EPO [308136803] 47.02 percent of total billed charges 36.82 56.41 Technical (Hospital) Services OXYTOCIN 10 UNIT/ML INJECTION SOLUTION RX-5944 CDM J2590 HCPCS 636 RC 42023-0116-25 NDC inpatient 0.3 ML 59.38 59.38 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES HDHP [308136802] 47.02 percent of total billed charges 36.82 56.41 Technical (Hospital) Services OXYTOCIN 10 UNIT/ML INJECTION SOLUTION RX-5944 CDM J2590 HCPCS 636 RC 42023-0116-25 NDC inpatient 0.3 ML 59.38 59.38 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES PPO [308136801] 47.02 percent of total billed charges 36.82 56.41 Technical (Hospital) Services OXYTOCIN 10 UNIT/ML INJECTION SOLUTION RX-5944 CDM J2590 HCPCS 636 RC 42023-0116-25 NDC inpatient 0.3 ML 59.38 59.38 CIGNA 62308 [3081051] CIGNA 62308 [308105105] 47.02 percent of total billed charges 36.82 56.41 Technical (Hospital) Services OXYTOCIN 10 UNIT/ML INJECTION SOLUTION RX-5944 CDM J2590 HCPCS 636 RC 42023-0116-25 NDC inpatient 0.3 ML 59.38 59.38 BLUE CROSS BLUE SHIELD WELLMARK SB889 [3081026] BCBS WYOMING [308102603] 56.41 percent of total billed charges 36.82 56.41 Technical (Hospital) Services OXYTOCIN 10 UNIT/ML INJECTION SOLUTION RX-5944 CDM J2590 HCPCS 636 RC 42023-0116-25 NDC inpatient 0.3 ML 59.38 59.38 UNITED HEALTHCARE (COMMERCIAL) [3081199] UNITED HEALTHCARE 87726 [308119901] 36.82 percent of total billed charges 36.82 56.41 Technical (Hospital) Services OXYTOCIN 10 UNIT/ML INJECTION SOLUTION RX-5944 CDM J2590 HCPCS 636 RC 42023-0116-25 NDC outpatient 0.3 ML 59.38 59.38 MEDICA (COMMERCIAL) 94265 [3081118] MEDICA CLAIMS [308111801] 53.44 percent of total billed charges 36.82 56.41 Technical (Hospital) Services OXYTOCIN 10 UNIT/ML INJECTION SOLUTION RX-5944 CDM J2590 HCPCS 636 RC 42023-0116-25 NDC outpatient 0.3 ML 59.38 59.38 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES PPO [308136801] 47.5 percent of total billed charges 36.82 56.41 Technical (Hospital) Services OXYTOCIN 10 UNIT/ML INJECTION SOLUTION RX-5944 CDM J2590 HCPCS 636 RC 42023-0116-25 NDC outpatient 0.3 ML 59.38 59.38 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES HDHP [308136802] 47.5 percent of total billed charges 36.82 56.41 Technical (Hospital) Services OXYTOCIN 10 UNIT/ML INJECTION SOLUTION RX-5944 CDM J2590 HCPCS 636 RC 42023-0116-25 NDC outpatient 0.3 ML 59.38 59.38 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES EPO [308136803] 47.5 percent of total billed charges 36.82 56.41 Technical (Hospital) Services OXYTOCIN 10 UNIT/ML INJECTION SOLUTION RX-5944 CDM J2590 HCPCS 636 RC 42023-0116-25 NDC outpatient 0.3 ML 59.38 59.38 UNITED HEALTHCARE (COMMERCIAL) [3081199] UNITED HEALTHCARE 87726 [308119901] 36.82 percent of total billed charges 36.82 56.41 Technical (Hospital) Services OXYTOCIN 10 UNIT/ML INJECTION SOLUTION RX-5944 CDM J2590 HCPCS 636 RC 42023-0116-25 NDC outpatient 0.3 ML 59.38 59.38 MULTIPLAN INC 34080 [3081285] MULTIPLAN INC [308128501] 56.41 percent of total billed charges 36.82 56.41 Technical (Hospital) Services OXYTOCIN 10 UNIT/ML INJECTION SOLUTION RX-5944 CDM J2590 HCPCS 636 RC 42023-0116-25 NDC outpatient 0.3 ML 59.38 59.38 CIGNA 62308 [3081051] CIGNA 62308 [308105105] 47.5 percent of total billed charges 36.82 56.41 Technical (Hospital) Services OXYTOCIN 10 UNIT/ML INJECTION SOLUTION RX-5944 CDM J2590 HCPCS 636 RC 42023-0116-25 NDC outpatient 0.3 ML 59.38 59.38 CIGNA 62308 [3081051] CIGNA STATE OF WYOMING [308105107] 47.5 percent of total billed charges 36.82 56.41 Technical (Hospital) Services OXYTOCIN 10 UNIT/ML INJECTION SOLUTION RX-5944 CDM J2590 HCPCS 636 RC 42023-0116-25 NDC outpatient 0.3 ML 59.38 59.38 HEALTHPARTNERS SX009 HEALTHPARTNERS 47.5 percent of total billed charges 36.82 56.41 Technical (Hospital) Services OXYTOCIN 10 UNIT/ML INJECTION SOLUTION RX-5944 CDM J2590 HCPCS 636 RC 42023-0116-25 NDC outpatient 0.3 ML 59.38 59.38 BLUE CROSS BLUE SHIELD WELLMARK SB889 [3081026] BCBS WYOMING [308102603] 56.41 percent of total billed charges 36.82 56.41 Technical (Hospital) Services PHENOBARBITAL SODIUM 130 MG/ML INJECTION SOLUTION RX-6221 CDM J2560 HCPCS 636 RC 54288-0137-10 NDC inpatient 1 ML 151.5 151.5 MULTIPLAN INC 34080 [3081285] MULTIPLAN INC [308128501] 143.93 percent of total billed charges 93.93 143.93 Technical (Hospital) Services PHENOBARBITAL SODIUM 130 MG/ML INJECTION SOLUTION RX-6221 CDM J2560 HCPCS 636 RC 54288-0137-10 NDC inpatient 1 ML 151.5 151.5 MEDICA (COMMERCIAL) 94265 [3081118] MEDICA CLAIMS [308111801] 136.35 percent of total billed charges 93.93 143.93 Technical (Hospital) Services PHENOBARBITAL SODIUM 130 MG/ML INJECTION SOLUTION RX-6221 CDM J2560 HCPCS 636 RC 54288-0137-10 NDC inpatient 1 ML 151.5 151.5 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES PPO [308136801] 119.96 percent of total billed charges 93.93 143.93 Technical (Hospital) Services PHENOBARBITAL SODIUM 130 MG/ML INJECTION SOLUTION RX-6221 CDM J2560 HCPCS 636 RC 54288-0137-10 NDC inpatient 1 ML 151.5 151.5 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES HDHP [308136802] 119.96 percent of total billed charges 93.93 143.93 Technical (Hospital) Services PHENOBARBITAL SODIUM 130 MG/ML INJECTION SOLUTION RX-6221 CDM J2560 HCPCS 636 RC 54288-0137-10 NDC inpatient 1 ML 151.5 151.5 HEALTHPARTNERS SX009 HEALTHPARTNERS 119.96 percent of total billed charges 93.93 143.93 Technical (Hospital) Services PHENOBARBITAL SODIUM 130 MG/ML INJECTION SOLUTION RX-6221 CDM J2560 HCPCS 636 RC 54288-0137-10 NDC inpatient 1 ML 151.5 151.5 CIGNA 62308 [3081051] CIGNA 62308 [308105105] 119.96 percent of total billed charges 93.93 143.93 Technical (Hospital) Services PHENOBARBITAL SODIUM 130 MG/ML INJECTION SOLUTION RX-6221 CDM J2560 HCPCS 636 RC 54288-0137-10 NDC inpatient 1 ML 151.5 151.5 CIGNA 62308 [3081051] CIGNA STATE OF WYOMING [308105107] 119.96 percent of total billed charges 93.93 143.93 Technical (Hospital) Services PHENOBARBITAL SODIUM 130 MG/ML INJECTION SOLUTION RX-6221 CDM J2560 HCPCS 636 RC 54288-0137-10 NDC inpatient 1 ML 151.5 151.5 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES EPO [308136803] 119.96 percent of total billed charges 93.93 143.93 Technical (Hospital) Services PHENOBARBITAL SODIUM 130 MG/ML INJECTION SOLUTION RX-6221 CDM J2560 HCPCS 636 RC 54288-0137-10 NDC inpatient 1 ML 151.5 151.5 UNITED HEALTHCARE (COMMERCIAL) [3081199] UNITED HEALTHCARE 87726 [308119901] 93.93 percent of total billed charges 93.93 143.93 Technical (Hospital) Services PHENOBARBITAL SODIUM 130 MG/ML INJECTION SOLUTION RX-6221 CDM J2560 HCPCS 636 RC 54288-0137-10 NDC inpatient 1 ML 151.5 151.5 BLUE CROSS BLUE SHIELD WELLMARK SB889 [3081026] BCBS WYOMING [308102603] 143.93 percent of total billed charges 93.93 143.93 Technical (Hospital) Services PHENOBARBITAL SODIUM 130 MG/ML INJECTION SOLUTION RX-6221 CDM J2560 HCPCS 636 RC 54288-0137-10 NDC outpatient 1 ML 151.5 151.5 HEALTHPARTNERS SX009 HEALTHPARTNERS 121.2 percent of total billed charges 93.93 143.93 Technical (Hospital) Services PHENOBARBITAL SODIUM 130 MG/ML INJECTION SOLUTION RX-6221 CDM J2560 HCPCS 636 RC 54288-0137-10 NDC outpatient 1 ML 151.5 151.5 UNITED HEALTHCARE (COMMERCIAL) [3081199] UNITED HEALTHCARE 87726 [308119901] 93.93 percent of total billed charges 93.93 143.93 Technical (Hospital) Services PHENOBARBITAL SODIUM 130 MG/ML INJECTION SOLUTION RX-6221 CDM J2560 HCPCS 636 RC 54288-0137-10 NDC outpatient 1 ML 151.5 151.5 MULTIPLAN INC 34080 [3081285] MULTIPLAN INC [308128501] 143.93 percent of total billed charges 93.93 143.93 Technical (Hospital) Services PHENOBARBITAL SODIUM 130 MG/ML INJECTION SOLUTION RX-6221 CDM J2560 HCPCS 636 RC 54288-0137-10 NDC outpatient 1 ML 151.5 151.5 CIGNA 62308 [3081051] CIGNA 62308 [308105105] 121.2 percent of total billed charges 93.93 143.93 Technical (Hospital) Services PHENOBARBITAL SODIUM 130 MG/ML INJECTION SOLUTION RX-6221 CDM J2560 HCPCS 636 RC 54288-0137-10 NDC outpatient 1 ML 151.5 151.5 CIGNA 62308 [3081051] CIGNA STATE OF WYOMING [308105107] 121.2 percent of total billed charges 93.93 143.93 Technical (Hospital) Services PHENOBARBITAL SODIUM 130 MG/ML INJECTION SOLUTION RX-6221 CDM J2560 HCPCS 636 RC 54288-0137-10 NDC outpatient 1 ML 151.5 151.5 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES PPO [308136801] 121.2 percent of total billed charges 93.93 143.93 Technical (Hospital) Services PHENOBARBITAL SODIUM 130 MG/ML INJECTION SOLUTION RX-6221 CDM J2560 HCPCS 636 RC 54288-0137-10 NDC outpatient 1 ML 151.5 151.5 BLUE CROSS BLUE SHIELD WELLMARK SB889 [3081026] BCBS WYOMING [308102603] 143.93 percent of total billed charges 93.93 143.93 Technical (Hospital) Services PHENOBARBITAL SODIUM 130 MG/ML INJECTION SOLUTION RX-6221 CDM J2560 HCPCS 636 RC 54288-0137-10 NDC outpatient 1 ML 151.5 151.5 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES EPO [308136803] 121.2 percent of total billed charges 93.93 143.93 Technical (Hospital) Services PHENOBARBITAL SODIUM 130 MG/ML INJECTION SOLUTION RX-6221 CDM J2560 HCPCS 636 RC 54288-0137-10 NDC outpatient 1 ML 151.5 151.5 MEDICA (COMMERCIAL) 94265 [3081118] MEDICA CLAIMS [308111801] 136.35 percent of total billed charges 93.93 143.93 Technical (Hospital) Services PHENOBARBITAL SODIUM 130 MG/ML INJECTION SOLUTION RX-6221 CDM J2560 HCPCS 636 RC 54288-0137-10 NDC outpatient 1 ML 151.5 151.5 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES HDHP [308136802] 121.2 percent of total billed charges 93.93 143.93 Technical (Hospital) Services PROMETHAZINE 25 MG/ML INJECTION SOLUTION RX-6618 CDM J2550 HCPCS 636 RC 00641-0928-25 NDC outpatient 1 ML 60.15 60.15 UNITED HEALTHCARE (COMMERCIAL) [3081199] UNITED HEALTHCARE 87726 [308119901] 37.29 percent of total billed charges 37.29 57.14 Technical (Hospital) Services PROMETHAZINE 25 MG/ML INJECTION SOLUTION RX-6618 CDM J2550 HCPCS 636 RC 00641-0928-25 NDC outpatient 1 ML 60.15 60.15 MULTIPLAN INC 34080 [3081285] MULTIPLAN INC [308128501] 57.14 percent of total billed charges 37.29 57.14 Technical (Hospital) Services PROMETHAZINE 25 MG/ML INJECTION SOLUTION RX-6618 CDM J2550 HCPCS 636 RC 00641-0928-25 NDC outpatient 1 ML 60.15 60.15 HEALTHPARTNERS SX009 HEALTHPARTNERS 48.12 percent of total billed charges 37.29 57.14 Technical (Hospital) Services PROMETHAZINE 25 MG/ML INJECTION SOLUTION RX-6618 CDM J2550 HCPCS 636 RC 00641-0928-25 NDC outpatient 1 ML 60.15 60.15 MEDICA (COMMERCIAL) 94265 [3081118] MEDICA CLAIMS [308111801] 54.14 percent of total billed charges 37.29 57.14 Technical (Hospital) Services PROMETHAZINE 25 MG/ML INJECTION SOLUTION RX-6618 CDM J2550 HCPCS 636 RC 00641-0928-25 NDC outpatient 1 ML 60.15 60.15 CIGNA 62308 [3081051] CIGNA 62308 [308105105] 48.12 percent of total billed charges 37.29 57.14 Technical (Hospital) Services PROMETHAZINE 25 MG/ML INJECTION SOLUTION RX-6618 CDM J2550 HCPCS 636 RC 00641-0928-25 NDC outpatient 1 ML 60.15 60.15 CIGNA 62308 [3081051] CIGNA STATE OF WYOMING [308105107] 48.12 percent of total billed charges 37.29 57.14 Technical (Hospital) Services PROMETHAZINE 25 MG/ML INJECTION SOLUTION RX-6618 CDM J2550 HCPCS 636 RC 00641-0928-25 NDC outpatient 1 ML 60.15 60.15 BLUE CROSS BLUE SHIELD WELLMARK SB889 [3081026] BCBS WYOMING [308102603] 57.14 percent of total billed charges 37.29 57.14 Technical (Hospital) Services PROMETHAZINE 25 MG/ML INJECTION SOLUTION RX-6618 CDM J2550 HCPCS 636 RC 00641-0928-25 NDC outpatient 1 ML 60.15 60.15 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES PPO [308136801] 48.12 percent of total billed charges 37.29 57.14 Technical (Hospital) Services PROMETHAZINE 25 MG/ML INJECTION SOLUTION RX-6618 CDM J2550 HCPCS 636 RC 00641-0928-25 NDC outpatient 1 ML 60.15 60.15 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES HDHP [308136802] 48.12 percent of total billed charges 37.29 57.14 Technical (Hospital) Services PROMETHAZINE 25 MG/ML INJECTION SOLUTION RX-6618 CDM J2550 HCPCS 636 RC 00641-0928-25 NDC outpatient 1 ML 60.15 60.15 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES EPO [308136803] 48.12 percent of total billed charges 37.29 57.14 Technical (Hospital) Services PROMETHAZINE 25 MG/ML INJECTION SOLUTION RX-6618 CDM J2550 HCPCS 636 RC 00641-0928-25 NDC inpatient 1 ML 60.15 60.15 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES PPO [308136801] 47.63 percent of total billed charges 37.29 57.14 Technical (Hospital) Services PROMETHAZINE 25 MG/ML INJECTION SOLUTION RX-6618 CDM J2550 HCPCS 636 RC 00641-0928-25 NDC inpatient 1 ML 60.15 60.15 HEALTHPARTNERS SX009 HEALTHPARTNERS 47.63 percent of total billed charges 37.29 57.14 Technical (Hospital) Services PROMETHAZINE 25 MG/ML INJECTION SOLUTION RX-6618 CDM J2550 HCPCS 636 RC 00641-0928-25 NDC inpatient 1 ML 60.15 60.15 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES HDHP [308136802] 47.63 percent of total billed charges 37.29 57.14 Technical (Hospital) Services PROMETHAZINE 25 MG/ML INJECTION SOLUTION RX-6618 CDM J2550 HCPCS 636 RC 00641-0928-25 NDC inpatient 1 ML 60.15 60.15 MULTIPLAN INC 34080 [3081285] MULTIPLAN INC [308128501] 57.14 percent of total billed charges 37.29 57.14 Technical (Hospital) Services PROMETHAZINE 25 MG/ML INJECTION SOLUTION RX-6618 CDM J2550 HCPCS 636 RC 00641-0928-25 NDC inpatient 1 ML 60.15 60.15 MEDICA (COMMERCIAL) 94265 [3081118] MEDICA CLAIMS [308111801] 54.14 percent of total billed charges 37.29 57.14 Technical (Hospital) Services PROMETHAZINE 25 MG/ML INJECTION SOLUTION RX-6618 CDM J2550 HCPCS 636 RC 00641-0928-25 NDC inpatient 1 ML 60.15 60.15 CIGNA 62308 [3081051] CIGNA 62308 [308105105] 47.63 percent of total billed charges 37.29 57.14 Technical (Hospital) Services PROMETHAZINE 25 MG/ML INJECTION SOLUTION RX-6618 CDM J2550 HCPCS 636 RC 00641-0928-25 NDC inpatient 1 ML 60.15 60.15 CIGNA 62308 [3081051] CIGNA STATE OF WYOMING [308105107] 47.63 percent of total billed charges 37.29 57.14 Technical (Hospital) Services PROMETHAZINE 25 MG/ML INJECTION SOLUTION RX-6618 CDM J2550 HCPCS 636 RC 00641-0928-25 NDC inpatient 1 ML 60.15 60.15 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES EPO [308136803] 47.63 percent of total billed charges 37.29 57.14 Technical (Hospital) Services PROMETHAZINE 25 MG/ML INJECTION SOLUTION RX-6618 CDM J2550 HCPCS 636 RC 00641-0928-25 NDC inpatient 1 ML 60.15 60.15 UNITED HEALTHCARE (COMMERCIAL) [3081199] UNITED HEALTHCARE 87726 [308119901] 37.29 percent of total billed charges 37.29 57.14 Technical (Hospital) Services PROMETHAZINE 25 MG/ML INJECTION SOLUTION RX-6618 CDM J2550 HCPCS 636 RC 00641-0928-25 NDC inpatient 1 ML 60.15 60.15 BLUE CROSS BLUE SHIELD WELLMARK SB889 [3081026] BCBS WYOMING [308102603] 57.14 percent of total billed charges 37.29 57.14 Technical (Hospital) Services PROMETHAZINE 50 MG/ML INJECTION SOLUTION RX-6619 CDM J2550 HCPCS 636 RC 00641-1496-31 NDC inpatient 1 ML 60.89 60.89 HEALTHPARTNERS SX009 HEALTHPARTNERS 48.21 percent of total billed charges 37.75 57.85 Technical (Hospital) Services PROMETHAZINE 50 MG/ML INJECTION SOLUTION RX-6619 CDM J2550 HCPCS 636 RC 00641-1496-31 NDC inpatient 1 ML 60.89 60.89 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES PPO [308136801] 48.21 percent of total billed charges 37.75 57.85 Technical (Hospital) Services PROMETHAZINE 50 MG/ML INJECTION SOLUTION RX-6619 CDM J2550 HCPCS 636 RC 00641-1496-31 NDC inpatient 1 ML 60.89 60.89 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES HDHP [308136802] 48.21 percent of total billed charges 37.75 57.85 Technical (Hospital) Services PROMETHAZINE 50 MG/ML INJECTION SOLUTION RX-6619 CDM J2550 HCPCS 636 RC 00641-1496-31 NDC inpatient 1 ML 60.89 60.89 MULTIPLAN INC 34080 [3081285] MULTIPLAN INC [308128501] 57.85 percent of total billed charges 37.75 57.85 Technical (Hospital) Services PROMETHAZINE 50 MG/ML INJECTION SOLUTION RX-6619 CDM J2550 HCPCS 636 RC 00641-1496-31 NDC inpatient 1 ML 60.89 60.89 MEDICA (COMMERCIAL) 94265 [3081118] MEDICA CLAIMS [308111801] 54.8 percent of total billed charges 37.75 57.85 Technical (Hospital) Services PROMETHAZINE 50 MG/ML INJECTION SOLUTION RX-6619 CDM J2550 HCPCS 636 RC 00641-1496-31 NDC inpatient 1 ML 60.89 60.89 UNITED HEALTHCARE (COMMERCIAL) [3081199] UNITED HEALTHCARE 87726 [308119901] 37.75 percent of total billed charges 37.75 57.85 Technical (Hospital) Services PROMETHAZINE 50 MG/ML INJECTION SOLUTION RX-6619 CDM J2550 HCPCS 636 RC 00641-1496-31 NDC inpatient 1 ML 60.89 60.89 BLUE CROSS BLUE SHIELD WELLMARK SB889 [3081026] BCBS WYOMING [308102603] 57.85 percent of total billed charges 37.75 57.85 Technical (Hospital) Services PROMETHAZINE 50 MG/ML INJECTION SOLUTION RX-6619 CDM J2550 HCPCS 636 RC 00641-1496-31 NDC inpatient 1 ML 60.89 60.89 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES EPO [308136803] 48.21 percent of total billed charges 37.75 57.85 Technical (Hospital) Services PROMETHAZINE 50 MG/ML INJECTION SOLUTION RX-6619 CDM J2550 HCPCS 636 RC 00641-1496-31 NDC inpatient 1 ML 60.89 60.89 CIGNA 62308 [3081051] CIGNA 62308 [308105105] 48.21 percent of total billed charges 37.75 57.85 Technical (Hospital) Services PROMETHAZINE 50 MG/ML INJECTION SOLUTION RX-6619 CDM J2550 HCPCS 636 RC 00641-1496-31 NDC inpatient 1 ML 60.89 60.89 CIGNA 62308 [3081051] CIGNA STATE OF WYOMING [308105107] 48.21 percent of total billed charges 37.75 57.85 Technical (Hospital) Services PROMETHAZINE 50 MG/ML INJECTION SOLUTION RX-6619 CDM J2550 HCPCS 636 RC 00641-1496-31 NDC outpatient 1 ML 60.89 60.89 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES EPO [308136803] 48.71 percent of total billed charges 37.75 57.85 Technical (Hospital) Services PROMETHAZINE 50 MG/ML INJECTION SOLUTION RX-6619 CDM J2550 HCPCS 636 RC 00641-1496-31 NDC outpatient 1 ML 60.89 60.89 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES HDHP [308136802] 48.71 percent of total billed charges 37.75 57.85 Technical (Hospital) Services PROMETHAZINE 50 MG/ML INJECTION SOLUTION RX-6619 CDM J2550 HCPCS 636 RC 00641-1496-31 NDC outpatient 1 ML 60.89 60.89 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES PPO [308136801] 48.71 percent of total billed charges 37.75 57.85 Technical (Hospital) Services PROMETHAZINE 50 MG/ML INJECTION SOLUTION RX-6619 CDM J2550 HCPCS 636 RC 00641-1496-31 NDC outpatient 1 ML 60.89 60.89 BLUE CROSS BLUE SHIELD WELLMARK SB889 [3081026] BCBS WYOMING [308102603] 57.85 percent of total billed charges 37.75 57.85 Technical (Hospital) Services PROMETHAZINE 50 MG/ML INJECTION SOLUTION RX-6619 CDM J2550 HCPCS 636 RC 00641-1496-31 NDC outpatient 1 ML 60.89 60.89 CIGNA 62308 [3081051] CIGNA 62308 [308105105] 48.71 percent of total billed charges 37.75 57.85 Technical (Hospital) Services PROMETHAZINE 50 MG/ML INJECTION SOLUTION RX-6619 CDM J2550 HCPCS 636 RC 00641-1496-31 NDC outpatient 1 ML 60.89 60.89 CIGNA 62308 [3081051] CIGNA STATE OF WYOMING [308105107] 48.71 percent of total billed charges 37.75 57.85 Technical (Hospital) Services PROMETHAZINE 50 MG/ML INJECTION SOLUTION RX-6619 CDM J2550 HCPCS 636 RC 00641-1496-31 NDC outpatient 1 ML 60.89 60.89 MEDICA (COMMERCIAL) 94265 [3081118] MEDICA CLAIMS [308111801] 54.8 percent of total billed charges 37.75 57.85 Technical (Hospital) Services PROMETHAZINE 50 MG/ML INJECTION SOLUTION RX-6619 CDM J2550 HCPCS 636 RC 00641-1496-31 NDC outpatient 1 ML 60.89 60.89 HEALTHPARTNERS SX009 HEALTHPARTNERS 48.71 percent of total billed charges 37.75 57.85 Technical (Hospital) Services PROMETHAZINE 50 MG/ML INJECTION SOLUTION RX-6619 CDM J2550 HCPCS 636 RC 00641-1496-31 NDC outpatient 1 ML 60.89 60.89 MULTIPLAN INC 34080 [3081285] MULTIPLAN INC [308128501] 57.85 percent of total billed charges 37.75 57.85 Technical (Hospital) Services PROMETHAZINE 50 MG/ML INJECTION SOLUTION RX-6619 CDM J2550 HCPCS 636 RC 00641-1496-31 NDC outpatient 1 ML 60.89 60.89 UNITED HEALTHCARE (COMMERCIAL) [3081199] UNITED HEALTHCARE 87726 [308119901] 37.75 percent of total billed charges 37.75 57.85 Technical (Hospital) Services PENTAMIDINE 300 MG SOLUTION FOR INHALATION RX-28235 CDM J2545 HCPCS 636 RC 13925-0522-01 NDC outpatient 300 ME 584.5 584.5 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES PPO [308136801] 467.6 percent of total billed charges 362.39 555.28 Technical (Hospital) Services PENTAMIDINE 300 MG SOLUTION FOR INHALATION RX-28235 CDM J2545 HCPCS 636 RC 13925-0522-01 NDC outpatient 300 ME 584.5 584.5 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES EPO [308136803] 467.6 percent of total billed charges 362.39 555.28 Technical (Hospital) Services PENTAMIDINE 300 MG SOLUTION FOR INHALATION RX-28235 CDM J2545 HCPCS 636 RC 13925-0522-01 NDC outpatient 300 ME 584.5 584.5 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES HDHP [308136802] 467.6 percent of total billed charges 362.39 555.28 Technical (Hospital) Services PENTAMIDINE 300 MG SOLUTION FOR INHALATION RX-28235 CDM J2545 HCPCS 636 RC 13925-0522-01 NDC outpatient 300 ME 584.5 584.5 BLUE CROSS BLUE SHIELD WELLMARK SB889 [3081026] BCBS WYOMING [308102603] 555.28 percent of total billed charges 362.39 555.28 Technical (Hospital) Services PENTAMIDINE 300 MG SOLUTION FOR INHALATION RX-28235 CDM J2545 HCPCS 636 RC 13925-0522-01 NDC outpatient 300 ME 584.5 584.5 HEALTHPARTNERS SX009 HEALTHPARTNERS 467.6 percent of total billed charges 362.39 555.28 Technical (Hospital) Services PENTAMIDINE 300 MG SOLUTION FOR INHALATION RX-28235 CDM J2545 HCPCS 636 RC 13925-0522-01 NDC outpatient 300 ME 584.5 584.5 UNITED HEALTHCARE (COMMERCIAL) [3081199] UNITED HEALTHCARE 87726 [308119901] 362.39 percent of total billed charges 362.39 555.28 Technical (Hospital) Services PENTAMIDINE 300 MG SOLUTION FOR INHALATION RX-28235 CDM J2545 HCPCS 636 RC 13925-0522-01 NDC outpatient 300 ME 584.5 584.5 CIGNA 62308 [3081051] CIGNA 62308 [308105105] 467.6 percent of total billed charges 362.39 555.28 Technical (Hospital) Services PENTAMIDINE 300 MG SOLUTION FOR INHALATION RX-28235 CDM J2545 HCPCS 636 RC 13925-0522-01 NDC outpatient 300 ME 584.5 584.5 CIGNA 62308 [3081051] CIGNA STATE OF WYOMING [308105107] 467.6 percent of total billed charges 362.39 555.28 Technical (Hospital) Services PENTAMIDINE 300 MG SOLUTION FOR INHALATION RX-28235 CDM J2545 HCPCS 636 RC 13925-0522-01 NDC outpatient 300 ME 584.5 584.5 MEDICA (COMMERCIAL) 94265 [3081118] MEDICA CLAIMS [308111801] 526.05 percent of total billed charges 362.39 555.28 Technical (Hospital) Services PENTAMIDINE 300 MG SOLUTION FOR INHALATION RX-28235 CDM J2545 HCPCS 636 RC 13925-0522-01 NDC outpatient 300 ME 584.5 584.5 MULTIPLAN INC 34080 [3081285] MULTIPLAN INC [308128501] 555.28 percent of total billed charges 362.39 555.28 Technical (Hospital) Services PENTAMIDINE 300 MG SOLUTION FOR INHALATION RX-28235 CDM J2545 HCPCS 636 RC 13925-0522-01 NDC inpatient 300 ME 584.5 584.5 BLUE CROSS BLUE SHIELD WELLMARK SB889 [3081026] BCBS WYOMING [308102603] 555.28 percent of total billed charges 362.39 555.28 Technical (Hospital) Services PENTAMIDINE 300 MG SOLUTION FOR INHALATION RX-28235 CDM J2545 HCPCS 636 RC 13925-0522-01 NDC inpatient 300 ME 584.5 584.5 UNITED HEALTHCARE (COMMERCIAL) [3081199] UNITED HEALTHCARE 87726 [308119901] 362.39 percent of total billed charges 362.39 555.28 Technical (Hospital) Services PENTAMIDINE 300 MG SOLUTION FOR INHALATION RX-28235 CDM J2545 HCPCS 636 RC 13925-0522-01 NDC inpatient 300 ME 584.5 584.5 HEALTHPARTNERS SX009 HEALTHPARTNERS 462.81 percent of total billed charges 362.39 555.28 Technical (Hospital) Services PENTAMIDINE 300 MG SOLUTION FOR INHALATION RX-28235 CDM J2545 HCPCS 636 RC 13925-0522-01 NDC inpatient 300 ME 584.5 584.5 MULTIPLAN INC 34080 [3081285] MULTIPLAN INC [308128501] 555.28 percent of total billed charges 362.39 555.28 Technical (Hospital) Services PENTAMIDINE 300 MG SOLUTION FOR INHALATION RX-28235 CDM J2545 HCPCS 636 RC 13925-0522-01 NDC inpatient 300 ME 584.5 584.5 MEDICA (COMMERCIAL) 94265 [3081118] MEDICA CLAIMS [308111801] 526.05 percent of total billed charges 362.39 555.28 Technical (Hospital) Services PENTAMIDINE 300 MG SOLUTION FOR INHALATION RX-28235 CDM J2545 HCPCS 636 RC 13925-0522-01 NDC inpatient 300 ME 584.5 584.5 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES EPO [308136803] 462.81 percent of total billed charges 362.39 555.28 Technical (Hospital) Services PENTAMIDINE 300 MG SOLUTION FOR INHALATION RX-28235 CDM J2545 HCPCS 636 RC 13925-0522-01 NDC inpatient 300 ME 584.5 584.5 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES HDHP [308136802] 462.81 percent of total billed charges 362.39 555.28 Technical (Hospital) Services PENTAMIDINE 300 MG SOLUTION FOR INHALATION RX-28235 CDM J2545 HCPCS 636 RC 13925-0522-01 NDC inpatient 300 ME 584.5 584.5 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES PPO [308136801] 462.81 percent of total billed charges 362.39 555.28 Technical (Hospital) Services PENTAMIDINE 300 MG SOLUTION FOR INHALATION RX-28235 CDM J2545 HCPCS 636 RC 13925-0522-01 NDC inpatient 300 ME 584.5 584.5 CIGNA 62308 [3081051] CIGNA 62308 [308105105] 462.81 percent of total billed charges 362.39 555.28 Technical (Hospital) Services PENTAMIDINE 300 MG SOLUTION FOR INHALATION RX-28235 CDM J2545 HCPCS 636 RC 13925-0522-01 NDC inpatient 300 ME 584.5 584.5 CIGNA 62308 [3081051] CIGNA STATE OF WYOMING [308105107] 462.81 percent of total billed charges 362.39 555.28 Technical (Hospital) Services PIPERACILLIN-TAZOBACTAM 4.5 GRAM INTRAVENOUS SOLUTION RX-18302 CDM J2543 HCPCS 636 RC 64679-0012-01 NDC outpatient 22.2 ML 84.6 84.6 MULTIPLAN INC 34080 [3081285] MULTIPLAN INC [308128501] 80.37 percent of total billed charges 52.45 80.37 Technical (Hospital) Services PIPERACILLIN-TAZOBACTAM 4.5 GRAM INTRAVENOUS SOLUTION RX-18302 CDM J2543 HCPCS 636 RC 64679-0012-01 NDC outpatient 22.2 ML 84.6 84.6 MEDICA (COMMERCIAL) 94265 [3081118] MEDICA CLAIMS [308111801] 76.14 percent of total billed charges 52.45 80.37 Technical (Hospital) Services PIPERACILLIN-TAZOBACTAM 4.5 GRAM INTRAVENOUS SOLUTION RX-18302 CDM J2543 HCPCS 636 RC 64679-0012-01 NDC outpatient 22.2 ML 84.6 84.6 CIGNA 62308 [3081051] CIGNA 62308 [308105105] 67.68 percent of total billed charges 52.45 80.37 Technical (Hospital) Services PIPERACILLIN-TAZOBACTAM 4.5 GRAM INTRAVENOUS SOLUTION RX-18302 CDM J2543 HCPCS 636 RC 64679-0012-01 NDC outpatient 22.2 ML 84.6 84.6 CIGNA 62308 [3081051] CIGNA STATE OF WYOMING [308105107] 67.68 percent of total billed charges 52.45 80.37 Technical (Hospital) Services PIPERACILLIN-TAZOBACTAM 4.5 GRAM INTRAVENOUS SOLUTION RX-18302 CDM J2543 HCPCS 636 RC 64679-0012-01 NDC outpatient 22.2 ML 84.6 84.6 UNITED HEALTHCARE (COMMERCIAL) [3081199] UNITED HEALTHCARE 87726 [308119901] 52.45 percent of total billed charges 52.45 80.37 Technical (Hospital) Services PIPERACILLIN-TAZOBACTAM 4.5 GRAM INTRAVENOUS SOLUTION RX-18302 CDM J2543 HCPCS 636 RC 64679-0012-01 NDC outpatient 22.2 ML 84.6 84.6 HEALTHPARTNERS SX009 HEALTHPARTNERS 67.68 percent of total billed charges 52.45 80.37 Technical (Hospital) Services PIPERACILLIN-TAZOBACTAM 4.5 GRAM INTRAVENOUS SOLUTION RX-18302 CDM J2543 HCPCS 636 RC 64679-0012-01 NDC outpatient 22.2 ML 84.6 84.6 BLUE CROSS BLUE SHIELD WELLMARK SB889 [3081026] BCBS WYOMING [308102603] 80.37 percent of total billed charges 52.45 80.37 Technical (Hospital) Services PIPERACILLIN-TAZOBACTAM 4.5 GRAM INTRAVENOUS SOLUTION RX-18302 CDM J2543 HCPCS 636 RC 64679-0012-01 NDC outpatient 22.2 ML 84.6 84.6 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES EPO [308136803] 67.68 percent of total billed charges 52.45 80.37 Technical (Hospital) Services PIPERACILLIN-TAZOBACTAM 4.5 GRAM INTRAVENOUS SOLUTION RX-18302 CDM J2543 HCPCS 636 RC 64679-0012-01 NDC outpatient 22.2 ML 84.6 84.6 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES HDHP [308136802] 67.68 percent of total billed charges 52.45 80.37 Technical (Hospital) Services PIPERACILLIN-TAZOBACTAM 4.5 GRAM INTRAVENOUS SOLUTION RX-18302 CDM J2543 HCPCS 636 RC 64679-0012-01 NDC outpatient 22.2 ML 84.6 84.6 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES PPO [308136801] 67.68 percent of total billed charges 52.45 80.37 Technical (Hospital) Services PIPERACILLIN-TAZOBACTAM 4.5 GRAM INTRAVENOUS SOLUTION RX-18302 CDM J2543 HCPCS 636 RC 64679-0012-01 NDC inpatient 22.2 ML 84.6 84.6 HEALTHPARTNERS SX009 HEALTHPARTNERS 66.99 percent of total billed charges 52.45 80.37 Technical (Hospital) Services PIPERACILLIN-TAZOBACTAM 4.5 GRAM INTRAVENOUS SOLUTION RX-18302 CDM J2543 HCPCS 636 RC 64679-0012-01 NDC inpatient 22.2 ML 84.6 84.6 CIGNA 62308 [3081051] CIGNA 62308 [308105105] 66.99 percent of total billed charges 52.45 80.37 Technical (Hospital) Services PIPERACILLIN-TAZOBACTAM 4.5 GRAM INTRAVENOUS SOLUTION RX-18302 CDM J2543 HCPCS 636 RC 64679-0012-01 NDC inpatient 22.2 ML 84.6 84.6 CIGNA 62308 [3081051] CIGNA STATE OF WYOMING [308105107] 66.99 percent of total billed charges 52.45 80.37 Technical (Hospital) Services PIPERACILLIN-TAZOBACTAM 4.5 GRAM INTRAVENOUS SOLUTION RX-18302 CDM J2543 HCPCS 636 RC 64679-0012-01 NDC inpatient 22.2 ML 84.6 84.6 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES EPO [308136803] 66.99 percent of total billed charges 52.45 80.37 Technical (Hospital) Services PIPERACILLIN-TAZOBACTAM 4.5 GRAM INTRAVENOUS SOLUTION RX-18302 CDM J2543 HCPCS 636 RC 64679-0012-01 NDC inpatient 22.2 ML 84.6 84.6 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES HDHP [308136802] 66.99 percent of total billed charges 52.45 80.37 Technical (Hospital) Services PIPERACILLIN-TAZOBACTAM 4.5 GRAM INTRAVENOUS SOLUTION RX-18302 CDM J2543 HCPCS 636 RC 64679-0012-01 NDC inpatient 22.2 ML 84.6 84.6 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES PPO [308136801] 66.99 percent of total billed charges 52.45 80.37 Technical (Hospital) Services PIPERACILLIN-TAZOBACTAM 4.5 GRAM INTRAVENOUS SOLUTION RX-18302 CDM J2543 HCPCS 636 RC 64679-0012-01 NDC inpatient 22.2 ML 84.6 84.6 UNITED HEALTHCARE (COMMERCIAL) [3081199] UNITED HEALTHCARE 87726 [308119901] 52.45 percent of total billed charges 52.45 80.37 Technical (Hospital) Services PIPERACILLIN-TAZOBACTAM 4.5 GRAM INTRAVENOUS SOLUTION RX-18302 CDM J2543 HCPCS 636 RC 64679-0012-01 NDC inpatient 22.2 ML 84.6 84.6 BLUE CROSS BLUE SHIELD WELLMARK SB889 [3081026] BCBS WYOMING [308102603] 80.37 percent of total billed charges 52.45 80.37 Technical (Hospital) Services PIPERACILLIN-TAZOBACTAM 4.5 GRAM INTRAVENOUS SOLUTION RX-18302 CDM J2543 HCPCS 636 RC 64679-0012-01 NDC inpatient 22.2 ML 84.6 84.6 MULTIPLAN INC 34080 [3081285] MULTIPLAN INC [308128501] 80.37 percent of total billed charges 52.45 80.37 Technical (Hospital) Services PIPERACILLIN-TAZOBACTAM 4.5 GRAM INTRAVENOUS SOLUTION RX-18302 CDM J2543 HCPCS 636 RC 64679-0012-01 NDC inpatient 22.2 ML 84.6 84.6 MEDICA (COMMERCIAL) 94265 [3081118] MEDICA CLAIMS [308111801] 76.14 percent of total billed charges 52.45 80.37 Technical (Hospital) Services PIPERACILLIN-TAZOBACTAM 3.375 GRAM INTRAVENOUS SOLUTION RX-18303 CDM J2543 HCPCS 636 RC 63323-0983-53 NDC inpatient 16.7 ML 61.3 61.3 MEDICA (COMMERCIAL) 94265 [3081118] MEDICA CLAIMS [308111801] 55.17 percent of total billed charges 38.01 58.24 Technical (Hospital) Services PIPERACILLIN-TAZOBACTAM 3.375 GRAM INTRAVENOUS SOLUTION RX-18303 CDM J2543 HCPCS 636 RC 63323-0983-53 NDC inpatient 16.7 ML 61.3 61.3 MULTIPLAN INC 34080 [3081285] MULTIPLAN INC [308128501] 58.24 percent of total billed charges 38.01 58.24 Technical (Hospital) Services PIPERACILLIN-TAZOBACTAM 3.375 GRAM INTRAVENOUS SOLUTION RX-18303 CDM J2543 HCPCS 636 RC 63323-0983-53 NDC inpatient 16.7 ML 61.3 61.3 BLUE CROSS BLUE SHIELD WELLMARK SB889 [3081026] BCBS WYOMING [308102603] 58.24 percent of total billed charges 38.01 58.24 Technical (Hospital) Services PIPERACILLIN-TAZOBACTAM 3.375 GRAM INTRAVENOUS SOLUTION RX-18303 CDM J2543 HCPCS 636 RC 63323-0983-53 NDC inpatient 16.7 ML 61.3 61.3 UNITED HEALTHCARE (COMMERCIAL) [3081199] UNITED HEALTHCARE 87726 [308119901] 38.01 percent of total billed charges 38.01 58.24 Technical (Hospital) Services PIPERACILLIN-TAZOBACTAM 3.375 GRAM INTRAVENOUS SOLUTION RX-18303 CDM J2543 HCPCS 636 RC 63323-0983-53 NDC inpatient 16.7 ML 61.3 61.3 CIGNA 62308 [3081051] CIGNA 62308 [308105105] 48.54 percent of total billed charges 38.01 58.24 Technical (Hospital) Services PIPERACILLIN-TAZOBACTAM 3.375 GRAM INTRAVENOUS SOLUTION RX-18303 CDM J2543 HCPCS 636 RC 63323-0983-53 NDC inpatient 16.7 ML 61.3 61.3 CIGNA 62308 [3081051] CIGNA STATE OF WYOMING [308105107] 48.54 percent of total billed charges 38.01 58.24 Technical (Hospital) Services PIPERACILLIN-TAZOBACTAM 3.375 GRAM INTRAVENOUS SOLUTION RX-18303 CDM J2543 HCPCS 636 RC 63323-0983-53 NDC inpatient 16.7 ML 61.3 61.3 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES EPO [308136803] 48.54 percent of total billed charges 38.01 58.24 Technical (Hospital) Services PIPERACILLIN-TAZOBACTAM 3.375 GRAM INTRAVENOUS SOLUTION RX-18303 CDM J2543 HCPCS 636 RC 63323-0983-53 NDC inpatient 16.7 ML 61.3 61.3 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES HDHP [308136802] 48.54 percent of total billed charges 38.01 58.24 Technical (Hospital) Services PIPERACILLIN-TAZOBACTAM 3.375 GRAM INTRAVENOUS SOLUTION RX-18303 CDM J2543 HCPCS 636 RC 63323-0983-53 NDC inpatient 16.7 ML 61.3 61.3 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES PPO [308136801] 48.54 percent of total billed charges 38.01 58.24 Technical (Hospital) Services PIPERACILLIN-TAZOBACTAM 3.375 GRAM INTRAVENOUS SOLUTION RX-18303 CDM J2543 HCPCS 636 RC 63323-0983-53 NDC inpatient 16.7 ML 61.3 61.3 HEALTHPARTNERS SX009 HEALTHPARTNERS 48.54 percent of total billed charges 38.01 58.24 Technical (Hospital) Services PIPERACILLIN-TAZOBACTAM 3.375 GRAM INTRAVENOUS SOLUTION RX-18303 CDM J2543 HCPCS 636 RC 63323-0983-53 NDC outpatient 16.7 ML 61.3 61.3 CIGNA 62308 [3081051] CIGNA STATE OF WYOMING [308105107] 49.04 percent of total billed charges 38.01 58.24 Technical (Hospital) Services PIPERACILLIN-TAZOBACTAM 3.375 GRAM INTRAVENOUS SOLUTION RX-18303 CDM J2543 HCPCS 636 RC 63323-0983-53 NDC outpatient 16.7 ML 61.3 61.3 CIGNA 62308 [3081051] CIGNA 62308 [308105105] 49.04 percent of total billed charges 38.01 58.24 Technical (Hospital) Services PIPERACILLIN-TAZOBACTAM 3.375 GRAM INTRAVENOUS SOLUTION RX-18303 CDM J2543 HCPCS 636 RC 63323-0983-53 NDC outpatient 16.7 ML 61.3 61.3 UNITED HEALTHCARE (COMMERCIAL) [3081199] UNITED HEALTHCARE 87726 [308119901] 38.01 percent of total billed charges 38.01 58.24 Technical (Hospital) Services PIPERACILLIN-TAZOBACTAM 3.375 GRAM INTRAVENOUS SOLUTION RX-18303 CDM J2543 HCPCS 636 RC 63323-0983-53 NDC outpatient 16.7 ML 61.3 61.3 HEALTHPARTNERS SX009 HEALTHPARTNERS 49.04 percent of total billed charges 38.01 58.24 Technical (Hospital) Services PIPERACILLIN-TAZOBACTAM 3.375 GRAM INTRAVENOUS SOLUTION RX-18303 CDM J2543 HCPCS 636 RC 63323-0983-53 NDC outpatient 16.7 ML 61.3 61.3 MEDICA (COMMERCIAL) 94265 [3081118] MEDICA CLAIMS [308111801] 55.17 percent of total billed charges 38.01 58.24 Technical (Hospital) Services PIPERACILLIN-TAZOBACTAM 3.375 GRAM INTRAVENOUS SOLUTION RX-18303 CDM J2543 HCPCS 636 RC 63323-0983-53 NDC outpatient 16.7 ML 61.3 61.3 MULTIPLAN INC 34080 [3081285] MULTIPLAN INC [308128501] 58.24 percent of total billed charges 38.01 58.24 Technical (Hospital) Services PIPERACILLIN-TAZOBACTAM 3.375 GRAM INTRAVENOUS SOLUTION RX-18303 CDM J2543 HCPCS 636 RC 63323-0983-53 NDC outpatient 16.7 ML 61.3 61.3 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES EPO [308136803] 49.04 percent of total billed charges 38.01 58.24 Technical (Hospital) Services PIPERACILLIN-TAZOBACTAM 3.375 GRAM INTRAVENOUS SOLUTION RX-18303 CDM J2543 HCPCS 636 RC 63323-0983-53 NDC outpatient 16.7 ML 61.3 61.3 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES HDHP [308136802] 49.04 percent of total billed charges 38.01 58.24 Technical (Hospital) Services PIPERACILLIN-TAZOBACTAM 3.375 GRAM INTRAVENOUS SOLUTION RX-18303 CDM J2543 HCPCS 636 RC 63323-0983-53 NDC outpatient 16.7 ML 61.3 61.3 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES PPO [308136801] 49.04 percent of total billed charges 38.01 58.24 Technical (Hospital) Services PIPERACILLIN-TAZOBACTAM 3.375 GRAM INTRAVENOUS SOLUTION RX-18303 CDM J2543 HCPCS 636 RC 63323-0983-53 NDC outpatient 16.7 ML 61.3 61.3 BLUE CROSS BLUE SHIELD WELLMARK SB889 [3081026] BCBS WYOMING [308102603] 58.24 percent of total billed charges 38.01 58.24 Technical (Hospital) Services PHENOBARBITAL SODIUM 65 MG/ML INJECTION SOLUTION RX-6224 CDM J2515 HCPCS 636 RC 54288-0136-10 NDC inpatient 1 ML 104.5 104.5 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES EPO [308136803] 82.74 percent of total billed charges 64.79 99.28 Technical (Hospital) Services PHENOBARBITAL SODIUM 65 MG/ML INJECTION SOLUTION RX-6224 CDM J2515 HCPCS 636 RC 54288-0136-10 NDC inpatient 1 ML 104.5 104.5 UNITED HEALTHCARE (COMMERCIAL) [3081199] UNITED HEALTHCARE 87726 [308119901] 64.79 percent of total billed charges 64.79 99.28 Technical (Hospital) Services PHENOBARBITAL SODIUM 65 MG/ML INJECTION SOLUTION RX-6224 CDM J2515 HCPCS 636 RC 54288-0136-10 NDC inpatient 1 ML 104.5 104.5 BLUE CROSS BLUE SHIELD WELLMARK SB889 [3081026] BCBS WYOMING [308102603] 99.28 percent of total billed charges 64.79 99.28 Technical (Hospital) Services PHENOBARBITAL SODIUM 65 MG/ML INJECTION SOLUTION RX-6224 CDM J2515 HCPCS 636 RC 54288-0136-10 NDC inpatient 1 ML 104.5 104.5 CIGNA 62308 [3081051] CIGNA 62308 [308105105] 82.74 percent of total billed charges 64.79 99.28 Technical (Hospital) Services PHENOBARBITAL SODIUM 65 MG/ML INJECTION SOLUTION RX-6224 CDM J2515 HCPCS 636 RC 54288-0136-10 NDC inpatient 1 ML 104.5 104.5 CIGNA 62308 [3081051] CIGNA STATE OF WYOMING [308105107] 82.74 percent of total billed charges 64.79 99.28 Technical (Hospital) Services PHENOBARBITAL SODIUM 65 MG/ML INJECTION SOLUTION RX-6224 CDM J2515 HCPCS 636 RC 54288-0136-10 NDC inpatient 1 ML 104.5 104.5 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES PPO [308136801] 82.74 percent of total billed charges 64.79 99.28 Technical (Hospital) Services PHENOBARBITAL SODIUM 65 MG/ML INJECTION SOLUTION RX-6224 CDM J2515 HCPCS 636 RC 54288-0136-10 NDC inpatient 1 ML 104.5 104.5 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES HDHP [308136802] 82.74 percent of total billed charges 64.79 99.28 Technical (Hospital) Services PHENOBARBITAL SODIUM 65 MG/ML INJECTION SOLUTION RX-6224 CDM J2515 HCPCS 636 RC 54288-0136-10 NDC inpatient 1 ML 104.5 104.5 HEALTHPARTNERS SX009 HEALTHPARTNERS 82.74 percent of total billed charges 64.79 99.28 Technical (Hospital) Services PHENOBARBITAL SODIUM 65 MG/ML INJECTION SOLUTION RX-6224 CDM J2515 HCPCS 636 RC 54288-0136-10 NDC inpatient 1 ML 104.5 104.5 MULTIPLAN INC 34080 [3081285] MULTIPLAN INC [308128501] 99.28 percent of total billed charges 64.79 99.28 Technical (Hospital) Services PHENOBARBITAL SODIUM 65 MG/ML INJECTION SOLUTION RX-6224 CDM J2515 HCPCS 636 RC 54288-0136-10 NDC inpatient 1 ML 104.5 104.5 MEDICA (COMMERCIAL) 94265 [3081118] MEDICA CLAIMS [308111801] 94.05 percent of total billed charges 64.79 99.28 Technical (Hospital) Services PHENOBARBITAL SODIUM 65 MG/ML INJECTION SOLUTION RX-6224 CDM J2515 HCPCS 636 RC 54288-0136-10 NDC outpatient 1 ML 104.5 104.5 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES PPO [308136801] 83.6 percent of total billed charges 64.79 99.28 Technical (Hospital) Services PHENOBARBITAL SODIUM 65 MG/ML INJECTION SOLUTION RX-6224 CDM J2515 HCPCS 636 RC 54288-0136-10 NDC outpatient 1 ML 104.5 104.5 BLUE CROSS BLUE SHIELD WELLMARK SB889 [3081026] BCBS WYOMING [308102603] 99.28 percent of total billed charges 64.79 99.28 Technical (Hospital) Services PHENOBARBITAL SODIUM 65 MG/ML INJECTION SOLUTION RX-6224 CDM J2515 HCPCS 636 RC 54288-0136-10 NDC outpatient 1 ML 104.5 104.5 UNITED HEALTHCARE (COMMERCIAL) [3081199] UNITED HEALTHCARE 87726 [308119901] 64.79 percent of total billed charges 64.79 99.28 Technical (Hospital) Services PHENOBARBITAL SODIUM 65 MG/ML INJECTION SOLUTION RX-6224 CDM J2515 HCPCS 636 RC 54288-0136-10 NDC outpatient 1 ML 104.5 104.5 MULTIPLAN INC 34080 [3081285] MULTIPLAN INC [308128501] 99.28 percent of total billed charges 64.79 99.28 Technical (Hospital) Services PHENOBARBITAL SODIUM 65 MG/ML INJECTION SOLUTION RX-6224 CDM J2515 HCPCS 636 RC 54288-0136-10 NDC outpatient 1 ML 104.5 104.5 HEALTHPARTNERS SX009 HEALTHPARTNERS 83.6 percent of total billed charges 64.79 99.28 Technical (Hospital) Services PHENOBARBITAL SODIUM 65 MG/ML INJECTION SOLUTION RX-6224 CDM J2515 HCPCS 636 RC 54288-0136-10 NDC outpatient 1 ML 104.5 104.5 CIGNA 62308 [3081051] CIGNA 62308 [308105105] 83.6 percent of total billed charges 64.79 99.28 Technical (Hospital) Services PHENOBARBITAL SODIUM 65 MG/ML INJECTION SOLUTION RX-6224 CDM J2515 HCPCS 636 RC 54288-0136-10 NDC outpatient 1 ML 104.5 104.5 CIGNA 62308 [3081051] CIGNA STATE OF WYOMING [308105107] 83.6 percent of total billed charges 64.79 99.28 Technical (Hospital) Services PHENOBARBITAL SODIUM 65 MG/ML INJECTION SOLUTION RX-6224 CDM J2515 HCPCS 636 RC 54288-0136-10 NDC outpatient 1 ML 104.5 104.5 MEDICA (COMMERCIAL) 94265 [3081118] MEDICA CLAIMS [308111801] 94.05 percent of total billed charges 64.79 99.28 Technical (Hospital) Services PHENOBARBITAL SODIUM 65 MG/ML INJECTION SOLUTION RX-6224 CDM J2515 HCPCS 636 RC 54288-0136-10 NDC outpatient 1 ML 104.5 104.5 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES HDHP [308136802] 83.6 percent of total billed charges 64.79 99.28 Technical (Hospital) Services PHENOBARBITAL SODIUM 65 MG/ML INJECTION SOLUTION RX-6224 CDM J2515 HCPCS 636 RC 54288-0136-10 NDC outpatient 1 ML 104.5 104.5 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES EPO [308136803] 83.6 percent of total billed charges 64.79 99.28 Technical (Hospital) Services PEGFILGRASTIM 6 MG/0.6 ML SUBCUTANEOUS SYRINGE RX-129657 CDM J2506 HCPCS 636 RC 55513-0190-01 NDC outpatient 0.6 ML 10167.99 10167.99 BLUE CROSS BLUE SHIELD WELLMARK SB889 [3081026] BCBS WYOMING [308102603] 9659.59 percent of total billed charges 6304.15 9659.59 Technical (Hospital) Services PEGFILGRASTIM 6 MG/0.6 ML SUBCUTANEOUS SYRINGE RX-129657 CDM J2506 HCPCS 636 RC 55513-0190-01 NDC outpatient 0.6 ML 10167.99 10167.99 HEALTHPARTNERS SX009 HEALTHPARTNERS 8134.39 percent of total billed charges 6304.15 9659.59 Technical (Hospital) Services PEGFILGRASTIM 6 MG/0.6 ML SUBCUTANEOUS SYRINGE RX-129657 CDM J2506 HCPCS 636 RC 55513-0190-01 NDC outpatient 0.6 ML 10167.99 10167.99 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES HDHP [308136802] 8134.39 percent of total billed charges 6304.15 9659.59 Technical (Hospital) Services PEGFILGRASTIM 6 MG/0.6 ML SUBCUTANEOUS SYRINGE RX-129657 CDM J2506 HCPCS 636 RC 55513-0190-01 NDC outpatient 0.6 ML 10167.99 10167.99 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES PPO [308136801] 8134.39 percent of total billed charges 6304.15 9659.59 Technical (Hospital) Services PEGFILGRASTIM 6 MG/0.6 ML SUBCUTANEOUS SYRINGE RX-129657 CDM J2506 HCPCS 636 RC 55513-0190-01 NDC outpatient 0.6 ML 10167.99 10167.99 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES EPO [308136803] 8134.39 percent of total billed charges 6304.15 9659.59 Technical (Hospital) Services PEGFILGRASTIM 6 MG/0.6 ML SUBCUTANEOUS SYRINGE RX-129657 CDM J2506 HCPCS 636 RC 55513-0190-01 NDC outpatient 0.6 ML 10167.99 10167.99 MEDICA (COMMERCIAL) 94265 [3081118] MEDICA CLAIMS [308111801] 9151.19 percent of total billed charges 6304.15 9659.59 Technical (Hospital) Services PEGFILGRASTIM 6 MG/0.6 ML SUBCUTANEOUS SYRINGE RX-129657 CDM J2506 HCPCS 636 RC 55513-0190-01 NDC outpatient 0.6 ML 10167.99 10167.99 MULTIPLAN INC 34080 [3081285] MULTIPLAN INC [308128501] 9659.59 percent of total billed charges 6304.15 9659.59 Technical (Hospital) Services PEGFILGRASTIM 6 MG/0.6 ML SUBCUTANEOUS SYRINGE RX-129657 CDM J2506 HCPCS 636 RC 55513-0190-01 NDC outpatient 0.6 ML 10167.99 10167.99 CIGNA 62308 [3081051] CIGNA 62308 [308105105] 8134.39 percent of total billed charges 6304.15 9659.59 Technical (Hospital) Services PEGFILGRASTIM 6 MG/0.6 ML SUBCUTANEOUS SYRINGE RX-129657 CDM J2506 HCPCS 636 RC 55513-0190-01 NDC outpatient 0.6 ML 10167.99 10167.99 CIGNA 62308 [3081051] CIGNA STATE OF WYOMING [308105107] 8134.39 percent of total billed charges 6304.15 9659.59 Technical (Hospital) Services PEGFILGRASTIM 6 MG/0.6 ML SUBCUTANEOUS SYRINGE RX-129657 CDM J2506 HCPCS 636 RC 55513-0190-01 NDC outpatient 0.6 ML 10167.99 10167.99 UNITED HEALTHCARE (COMMERCIAL) [3081199] UNITED HEALTHCARE 87726 [308119901] 6304.15 percent of total billed charges 6304.15 9659.59 Technical (Hospital) Services PEGFILGRASTIM 6 MG/0.6 ML SUBCUTANEOUS SYRINGE RX-129657 CDM J2506 HCPCS 636 RC 55513-0190-01 NDC inpatient 0.6 ML 10167.99 10167.99 MEDICA (COMMERCIAL) 94265 [3081118] MEDICA CLAIMS [308111801] 9151.19 percent of total billed charges 6304.15 9659.59 Technical (Hospital) Services PEGFILGRASTIM 6 MG/0.6 ML SUBCUTANEOUS SYRINGE RX-129657 CDM J2506 HCPCS 636 RC 55513-0190-01 NDC inpatient 0.6 ML 10167.99 10167.99 HEALTHPARTNERS SX009 HEALTHPARTNERS 8051.01 percent of total billed charges 6304.15 9659.59 Technical (Hospital) Services PEGFILGRASTIM 6 MG/0.6 ML SUBCUTANEOUS SYRINGE RX-129657 CDM J2506 HCPCS 636 RC 55513-0190-01 NDC inpatient 0.6 ML 10167.99 10167.99 MULTIPLAN INC 34080 [3081285] MULTIPLAN INC [308128501] 9659.59 percent of total billed charges 6304.15 9659.59 Technical (Hospital) Services PEGFILGRASTIM 6 MG/0.6 ML SUBCUTANEOUS SYRINGE RX-129657 CDM J2506 HCPCS 636 RC 55513-0190-01 NDC inpatient 0.6 ML 10167.99 10167.99 UNITED HEALTHCARE (COMMERCIAL) [3081199] UNITED HEALTHCARE 87726 [308119901] 6304.15 percent of total billed charges 6304.15 9659.59 Technical (Hospital) Services PEGFILGRASTIM 6 MG/0.6 ML SUBCUTANEOUS SYRINGE RX-129657 CDM J2506 HCPCS 636 RC 55513-0190-01 NDC inpatient 0.6 ML 10167.99 10167.99 BLUE CROSS BLUE SHIELD WELLMARK SB889 [3081026] BCBS WYOMING [308102603] 9659.59 percent of total billed charges 6304.15 9659.59 Technical (Hospital) Services PEGFILGRASTIM 6 MG/0.6 ML SUBCUTANEOUS SYRINGE RX-129657 CDM J2506 HCPCS 636 RC 55513-0190-01 NDC inpatient 0.6 ML 10167.99 10167.99 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES EPO [308136803] 8051.01 percent of total billed charges 6304.15 9659.59 Technical (Hospital) Services PEGFILGRASTIM 6 MG/0.6 ML SUBCUTANEOUS SYRINGE RX-129657 CDM J2506 HCPCS 636 RC 55513-0190-01 NDC inpatient 0.6 ML 10167.99 10167.99 CIGNA 62308 [3081051] CIGNA 62308 [308105105] 8051.01 percent of total billed charges 6304.15 9659.59 Technical (Hospital) Services PEGFILGRASTIM 6 MG/0.6 ML SUBCUTANEOUS SYRINGE RX-129657 CDM J2506 HCPCS 636 RC 55513-0190-01 NDC inpatient 0.6 ML 10167.99 10167.99 CIGNA 62308 [3081051] CIGNA STATE OF WYOMING [308105107] 8051.01 percent of total billed charges 6304.15 9659.59 Technical (Hospital) Services PEGFILGRASTIM 6 MG/0.6 ML SUBCUTANEOUS SYRINGE RX-129657 CDM J2506 HCPCS 636 RC 55513-0190-01 NDC inpatient 0.6 ML 10167.99 10167.99 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES HDHP [308136802] 8051.01 percent of total billed charges 6304.15 9659.59 Technical (Hospital) Services PEGFILGRASTIM 6 MG/0.6 ML SUBCUTANEOUS SYRINGE RX-129657 CDM J2506 HCPCS 636 RC 55513-0190-01 NDC inpatient 0.6 ML 10167.99 10167.99 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES PPO [308136801] 8051.01 percent of total billed charges 6304.15 9659.59 Technical (Hospital) Services PANTOPRAZOLE 40 MG INTRAVENOUS SOLUTION RX-26226 CDM J2470 HCPCS 636 RC 55150-0202-00 NDC outpatient 10 ML 69.5 69.5 CIGNA 62308 [3081051] CIGNA 62308 [308105105] 55.6 percent of total billed charges 43.09 66.03 Technical (Hospital) Services PANTOPRAZOLE 40 MG INTRAVENOUS SOLUTION RX-26226 CDM J2470 HCPCS 636 RC 55150-0202-00 NDC outpatient 10 ML 69.5 69.5 CIGNA 62308 [3081051] CIGNA STATE OF WYOMING [308105107] 55.6 percent of total billed charges 43.09 66.03 Technical (Hospital) Services PANTOPRAZOLE 40 MG INTRAVENOUS SOLUTION RX-26226 CDM J2470 HCPCS 636 RC 55150-0202-00 NDC outpatient 10 ML 69.5 69.5 HEALTHPARTNERS SX009 HEALTHPARTNERS 55.6 percent of total billed charges 43.09 66.03 Technical (Hospital) Services PANTOPRAZOLE 40 MG INTRAVENOUS SOLUTION RX-26226 CDM J2470 HCPCS 636 RC 55150-0202-00 NDC outpatient 10 ML 69.5 69.5 UNITED HEALTHCARE (COMMERCIAL) [3081199] UNITED HEALTHCARE 87726 [308119901] 43.09 percent of total billed charges 43.09 66.03 Technical (Hospital) Services PANTOPRAZOLE 40 MG INTRAVENOUS SOLUTION RX-26226 CDM J2470 HCPCS 636 RC 55150-0202-00 NDC outpatient 10 ML 69.5 69.5 MEDICA (COMMERCIAL) 94265 [3081118] MEDICA CLAIMS [308111801] 62.55 percent of total billed charges 43.09 66.03 Technical (Hospital) Services PANTOPRAZOLE 40 MG INTRAVENOUS SOLUTION RX-26226 CDM J2470 HCPCS 636 RC 55150-0202-00 NDC outpatient 10 ML 69.5 69.5 MULTIPLAN INC 34080 [3081285] MULTIPLAN INC [308128501] 66.03 percent of total billed charges 43.09 66.03 Technical (Hospital) Services PANTOPRAZOLE 40 MG INTRAVENOUS SOLUTION RX-26226 CDM J2470 HCPCS 636 RC 55150-0202-00 NDC outpatient 10 ML 69.5 69.5 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES PPO [308136801] 55.6 percent of total billed charges 43.09 66.03 Technical (Hospital) Services PANTOPRAZOLE 40 MG INTRAVENOUS SOLUTION RX-26226 CDM J2470 HCPCS 636 RC 55150-0202-00 NDC outpatient 10 ML 69.5 69.5 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES EPO [308136803] 55.6 percent of total billed charges 43.09 66.03 Technical (Hospital) Services PANTOPRAZOLE 40 MG INTRAVENOUS SOLUTION RX-26226 CDM J2470 HCPCS 636 RC 55150-0202-00 NDC outpatient 10 ML 69.5 69.5 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES HDHP [308136802] 55.6 percent of total billed charges 43.09 66.03 Technical (Hospital) Services PANTOPRAZOLE 40 MG INTRAVENOUS SOLUTION RX-26226 CDM J2470 HCPCS 636 RC 55150-0202-00 NDC outpatient 10 ML 69.5 69.5 BLUE CROSS BLUE SHIELD WELLMARK SB889 [3081026] BCBS WYOMING [308102603] 66.03 percent of total billed charges 43.09 66.03 Technical (Hospital) Services PANTOPRAZOLE 40 MG INTRAVENOUS SOLUTION RX-26226 CDM J2470 HCPCS 636 RC 55150-0202-00 NDC inpatient 10 ML 69.5 69.5 MULTIPLAN INC 34080 [3081285] MULTIPLAN INC [308128501] 66.03 percent of total billed charges 43.09 66.03 Technical (Hospital) Services PANTOPRAZOLE 40 MG INTRAVENOUS SOLUTION RX-26226 CDM J2470 HCPCS 636 RC 55150-0202-00 NDC inpatient 10 ML 69.5 69.5 MEDICA (COMMERCIAL) 94265 [3081118] MEDICA CLAIMS [308111801] 62.55 percent of total billed charges 43.09 66.03 Technical (Hospital) Services PANTOPRAZOLE 40 MG INTRAVENOUS SOLUTION RX-26226 CDM J2470 HCPCS 636 RC 55150-0202-00 NDC inpatient 10 ML 69.5 69.5 BLUE CROSS BLUE SHIELD WELLMARK SB889 [3081026] BCBS WYOMING [308102603] 66.03 percent of total billed charges 43.09 66.03 Technical (Hospital) Services PANTOPRAZOLE 40 MG INTRAVENOUS SOLUTION RX-26226 CDM J2470 HCPCS 636 RC 55150-0202-00 NDC inpatient 10 ML 69.5 69.5 CIGNA 62308 [3081051] CIGNA 62308 [308105105] 55.03 percent of total billed charges 43.09 66.03 Technical (Hospital) Services PANTOPRAZOLE 40 MG INTRAVENOUS SOLUTION RX-26226 CDM J2470 HCPCS 636 RC 55150-0202-00 NDC inpatient 10 ML 69.5 69.5 CIGNA 62308 [3081051] CIGNA STATE OF WYOMING [308105107] 55.03 percent of total billed charges 43.09 66.03 Technical (Hospital) Services PANTOPRAZOLE 40 MG INTRAVENOUS SOLUTION RX-26226 CDM J2470 HCPCS 636 RC 55150-0202-00 NDC inpatient 10 ML 69.5 69.5 UNITED HEALTHCARE (COMMERCIAL) [3081199] UNITED HEALTHCARE 87726 [308119901] 43.09 percent of total billed charges 43.09 66.03 Technical (Hospital) Services PANTOPRAZOLE 40 MG INTRAVENOUS SOLUTION RX-26226 CDM J2470 HCPCS 636 RC 55150-0202-00 NDC inpatient 10 ML 69.5 69.5 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES HDHP [308136802] 55.03 percent of total billed charges 43.09 66.03 Technical (Hospital) Services PANTOPRAZOLE 40 MG INTRAVENOUS SOLUTION RX-26226 CDM J2470 HCPCS 636 RC 55150-0202-00 NDC inpatient 10 ML 69.5 69.5 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES PPO [308136801] 55.03 percent of total billed charges 43.09 66.03 Technical (Hospital) Services PANTOPRAZOLE 40 MG INTRAVENOUS SOLUTION RX-26226 CDM J2470 HCPCS 636 RC 55150-0202-00 NDC inpatient 10 ML 69.5 69.5 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES EPO [308136803] 55.03 percent of total billed charges 43.09 66.03 Technical (Hospital) Services PANTOPRAZOLE 40 MG INTRAVENOUS SOLUTION RX-26226 CDM J2470 HCPCS 636 RC 55150-0202-00 NDC inpatient 10 ML 69.5 69.5 HEALTHPARTNERS SX009 HEALTHPARTNERS 55.03 percent of total billed charges 43.09 66.03 Technical (Hospital) Services PAMIDRONATE 30 MG/10 ML (3 MG/ML) INTRAVENOUS SOLUTION RX-32589 CDM J2430 HCPCS 636 RC 67457-0430-10 NDC outpatient 10 ML 149.5 149.5 BLUE CROSS BLUE SHIELD WELLMARK SB889 [3081026] BCBS WYOMING [308102603] 142.03 percent of total billed charges 92.69 142.03 Technical (Hospital) Services PAMIDRONATE 30 MG/10 ML (3 MG/ML) INTRAVENOUS SOLUTION RX-32589 CDM J2430 HCPCS 636 RC 67457-0430-10 NDC outpatient 10 ML 149.5 149.5 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES EPO [308136803] 119.6 percent of total billed charges 92.69 142.03 Technical (Hospital) Services PAMIDRONATE 30 MG/10 ML (3 MG/ML) INTRAVENOUS SOLUTION RX-32589 CDM J2430 HCPCS 636 RC 67457-0430-10 NDC outpatient 10 ML 149.5 149.5 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES PPO [308136801] 119.6 percent of total billed charges 92.69 142.03 Technical (Hospital) Services PAMIDRONATE 30 MG/10 ML (3 MG/ML) INTRAVENOUS SOLUTION RX-32589 CDM J2430 HCPCS 636 RC 67457-0430-10 NDC outpatient 10 ML 149.5 149.5 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES HDHP [308136802] 119.6 percent of total billed charges 92.69 142.03 Technical (Hospital) Services PAMIDRONATE 30 MG/10 ML (3 MG/ML) INTRAVENOUS SOLUTION RX-32589 CDM J2430 HCPCS 636 RC 67457-0430-10 NDC outpatient 10 ML 149.5 149.5 HEALTHPARTNERS SX009 HEALTHPARTNERS 119.6 percent of total billed charges 92.69 142.03 Technical (Hospital) Services PAMIDRONATE 30 MG/10 ML (3 MG/ML) INTRAVENOUS SOLUTION RX-32589 CDM J2430 HCPCS 636 RC 67457-0430-10 NDC outpatient 10 ML 149.5 149.5 UNITED HEALTHCARE (COMMERCIAL) [3081199] UNITED HEALTHCARE 87726 [308119901] 92.69 percent of total billed charges 92.69 142.03 Technical (Hospital) Services PAMIDRONATE 30 MG/10 ML (3 MG/ML) INTRAVENOUS SOLUTION RX-32589 CDM J2430 HCPCS 636 RC 67457-0430-10 NDC outpatient 10 ML 149.5 149.5 MEDICA (COMMERCIAL) 94265 [3081118] MEDICA CLAIMS [308111801] 134.55 percent of total billed charges 92.69 142.03 Technical (Hospital) Services PAMIDRONATE 30 MG/10 ML (3 MG/ML) INTRAVENOUS SOLUTION RX-32589 CDM J2430 HCPCS 636 RC 67457-0430-10 NDC outpatient 10 ML 149.5 149.5 MULTIPLAN INC 34080 [3081285] MULTIPLAN INC [308128501] 142.03 percent of total billed charges 92.69 142.03 Technical (Hospital) Services PAMIDRONATE 30 MG/10 ML (3 MG/ML) INTRAVENOUS SOLUTION RX-32589 CDM J2430 HCPCS 636 RC 67457-0430-10 NDC outpatient 10 ML 149.5 149.5 CIGNA 62308 [3081051] CIGNA 62308 [308105105] 119.6 percent of total billed charges 92.69 142.03 Technical (Hospital) Services PAMIDRONATE 30 MG/10 ML (3 MG/ML) INTRAVENOUS SOLUTION RX-32589 CDM J2430 HCPCS 636 RC 67457-0430-10 NDC outpatient 10 ML 149.5 149.5 CIGNA 62308 [3081051] CIGNA STATE OF WYOMING [308105107] 119.6 percent of total billed charges 92.69 142.03 Technical (Hospital) Services PAMIDRONATE 30 MG/10 ML (3 MG/ML) INTRAVENOUS SOLUTION RX-32589 CDM J2430 HCPCS 636 RC 67457-0430-10 NDC inpatient 10 ML 149.5 149.5 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES EPO [308136803] 118.37 percent of total billed charges 92.69 142.03 Technical (Hospital) Services PAMIDRONATE 30 MG/10 ML (3 MG/ML) INTRAVENOUS SOLUTION RX-32589 CDM J2430 HCPCS 636 RC 67457-0430-10 NDC inpatient 10 ML 149.5 149.5 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES PPO [308136801] 118.37 percent of total billed charges 92.69 142.03 Technical (Hospital) Services PAMIDRONATE 30 MG/10 ML (3 MG/ML) INTRAVENOUS SOLUTION RX-32589 CDM J2430 HCPCS 636 RC 67457-0430-10 NDC inpatient 10 ML 149.5 149.5 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES HDHP [308136802] 118.37 percent of total billed charges 92.69 142.03 Technical (Hospital) Services PAMIDRONATE 30 MG/10 ML (3 MG/ML) INTRAVENOUS SOLUTION RX-32589 CDM J2430 HCPCS 636 RC 67457-0430-10 NDC inpatient 10 ML 149.5 149.5 HEALTHPARTNERS SX009 HEALTHPARTNERS 118.37 percent of total billed charges 92.69 142.03 Technical (Hospital) Services PAMIDRONATE 30 MG/10 ML (3 MG/ML) INTRAVENOUS SOLUTION RX-32589 CDM J2430 HCPCS 636 RC 67457-0430-10 NDC inpatient 10 ML 149.5 149.5 MULTIPLAN INC 34080 [3081285] MULTIPLAN INC [308128501] 142.03 percent of total billed charges 92.69 142.03 Technical (Hospital) Services PAMIDRONATE 30 MG/10 ML (3 MG/ML) INTRAVENOUS SOLUTION RX-32589 CDM J2430 HCPCS 636 RC 67457-0430-10 NDC inpatient 10 ML 149.5 149.5 MEDICA (COMMERCIAL) 94265 [3081118] MEDICA CLAIMS [308111801] 134.55 percent of total billed charges 92.69 142.03 Technical (Hospital) Services PAMIDRONATE 30 MG/10 ML (3 MG/ML) INTRAVENOUS SOLUTION RX-32589 CDM J2430 HCPCS 636 RC 67457-0430-10 NDC inpatient 10 ML 149.5 149.5 CIGNA 62308 [3081051] CIGNA 62308 [308105105] 118.37 percent of total billed charges 92.69 142.03 Technical (Hospital) Services PAMIDRONATE 30 MG/10 ML (3 MG/ML) INTRAVENOUS SOLUTION RX-32589 CDM J2430 HCPCS 636 RC 67457-0430-10 NDC inpatient 10 ML 149.5 149.5 CIGNA 62308 [3081051] CIGNA STATE OF WYOMING [308105107] 118.37 percent of total billed charges 92.69 142.03 Technical (Hospital) Services PAMIDRONATE 30 MG/10 ML (3 MG/ML) INTRAVENOUS SOLUTION RX-32589 CDM J2430 HCPCS 636 RC 67457-0430-10 NDC inpatient 10 ML 149.5 149.5 UNITED HEALTHCARE (COMMERCIAL) [3081199] UNITED HEALTHCARE 87726 [308119901] 92.69 percent of total billed charges 92.69 142.03 Technical (Hospital) Services PAMIDRONATE 30 MG/10 ML (3 MG/ML) INTRAVENOUS SOLUTION RX-32589 CDM J2430 HCPCS 636 RC 67457-0430-10 NDC inpatient 10 ML 149.5 149.5 BLUE CROSS BLUE SHIELD WELLMARK SB889 [3081026] BCBS WYOMING [308102603] 142.03 percent of total billed charges 92.69 142.03 Technical (Hospital) Services ONDANSETRON HCL (PF) 4 MG/2 ML INJECTION SOLUTION RX-106348 CDM J2405 HCPCS 636 RC 23155-0548-31 NDC inpatient 2 ML 60.8 60.8 MEDICA (COMMERCIAL) 94265 [3081118] MEDICA CLAIMS [308111801] 54.72 percent of total billed charges 37.7 57.76 Technical (Hospital) Services ONDANSETRON HCL (PF) 4 MG/2 ML INJECTION SOLUTION RX-106348 CDM J2405 HCPCS 636 RC 23155-0548-31 NDC inpatient 2 ML 60.8 60.8 MULTIPLAN INC 34080 [3081285] MULTIPLAN INC [308128501] 57.76 percent of total billed charges 37.7 57.76 Technical (Hospital) Services ONDANSETRON HCL (PF) 4 MG/2 ML INJECTION SOLUTION RX-106348 CDM J2405 HCPCS 636 RC 23155-0548-31 NDC inpatient 2 ML 60.8 60.8 CIGNA 62308 [3081051] CIGNA 62308 [308105105] 48.14 percent of total billed charges 37.7 57.76 Technical (Hospital) Services ONDANSETRON HCL (PF) 4 MG/2 ML INJECTION SOLUTION RX-106348 CDM J2405 HCPCS 636 RC 23155-0548-31 NDC inpatient 2 ML 60.8 60.8 CIGNA 62308 [3081051] CIGNA STATE OF WYOMING [308105107] 48.14 percent of total billed charges 37.7 57.76 Technical (Hospital) Services ONDANSETRON HCL (PF) 4 MG/2 ML INJECTION SOLUTION RX-106348 CDM J2405 HCPCS 636 RC 23155-0548-31 NDC inpatient 2 ML 60.8 60.8 UNITED HEALTHCARE (COMMERCIAL) [3081199] UNITED HEALTHCARE 87726 [308119901] 37.7 percent of total billed charges 37.7 57.76 Technical (Hospital) Services ONDANSETRON HCL (PF) 4 MG/2 ML INJECTION SOLUTION RX-106348 CDM J2405 HCPCS 636 RC 23155-0548-31 NDC inpatient 2 ML 60.8 60.8 BLUE CROSS BLUE SHIELD WELLMARK SB889 [3081026] BCBS WYOMING [308102603] 57.76 percent of total billed charges 37.7 57.76 Technical (Hospital) Services ONDANSETRON HCL (PF) 4 MG/2 ML INJECTION SOLUTION RX-106348 CDM J2405 HCPCS 636 RC 23155-0548-31 NDC inpatient 2 ML 60.8 60.8 HEALTHPARTNERS SX009 HEALTHPARTNERS 48.14 percent of total billed charges 37.7 57.76 Technical (Hospital) Services ONDANSETRON HCL (PF) 4 MG/2 ML INJECTION SOLUTION RX-106348 CDM J2405 HCPCS 636 RC 23155-0548-31 NDC inpatient 2 ML 60.8 60.8 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES EPO [308136803] 48.14 percent of total billed charges 37.7 57.76 Technical (Hospital) Services ONDANSETRON HCL (PF) 4 MG/2 ML INJECTION SOLUTION RX-106348 CDM J2405 HCPCS 636 RC 23155-0548-31 NDC inpatient 2 ML 60.8 60.8 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES HDHP [308136802] 48.14 percent of total billed charges 37.7 57.76 Technical (Hospital) Services ONDANSETRON HCL (PF) 4 MG/2 ML INJECTION SOLUTION RX-106348 CDM J2405 HCPCS 636 RC 23155-0548-31 NDC inpatient 2 ML 60.8 60.8 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES PPO [308136801] 48.14 percent of total billed charges 37.7 57.76 Technical (Hospital) Services ONDANSETRON HCL (PF) 4 MG/2 ML INJECTION SOLUTION RX-106348 CDM J2405 HCPCS 636 RC 23155-0548-31 NDC outpatient 2 ML 60.8 60.8 HEALTHPARTNERS SX009 HEALTHPARTNERS 48.64 percent of total billed charges 37.7 57.76 Technical (Hospital) Services ONDANSETRON HCL (PF) 4 MG/2 ML INJECTION SOLUTION RX-106348 CDM J2405 HCPCS 636 RC 23155-0548-31 NDC outpatient 2 ML 60.8 60.8 UNITED HEALTHCARE (COMMERCIAL) [3081199] UNITED HEALTHCARE 87726 [308119901] 37.7 percent of total billed charges 37.7 57.76 Technical (Hospital) Services ONDANSETRON HCL (PF) 4 MG/2 ML INJECTION SOLUTION RX-106348 CDM J2405 HCPCS 636 RC 23155-0548-31 NDC outpatient 2 ML 60.8 60.8 MULTIPLAN INC 34080 [3081285] MULTIPLAN INC [308128501] 57.76 percent of total billed charges 37.7 57.76 Technical (Hospital) Services ONDANSETRON HCL (PF) 4 MG/2 ML INJECTION SOLUTION RX-106348 CDM J2405 HCPCS 636 RC 23155-0548-31 NDC outpatient 2 ML 60.8 60.8 CIGNA 62308 [3081051] CIGNA 62308 [308105105] 48.64 percent of total billed charges 37.7 57.76 Technical (Hospital) Services ONDANSETRON HCL (PF) 4 MG/2 ML INJECTION SOLUTION RX-106348 CDM J2405 HCPCS 636 RC 23155-0548-31 NDC outpatient 2 ML 60.8 60.8 CIGNA 62308 [3081051] CIGNA STATE OF WYOMING [308105107] 48.64 percent of total billed charges 37.7 57.76 Technical (Hospital) Services ONDANSETRON HCL (PF) 4 MG/2 ML INJECTION SOLUTION RX-106348 CDM J2405 HCPCS 636 RC 23155-0548-31 NDC outpatient 2 ML 60.8 60.8 MEDICA (COMMERCIAL) 94265 [3081118] MEDICA CLAIMS [308111801] 54.72 percent of total billed charges 37.7 57.76 Technical (Hospital) Services ONDANSETRON HCL (PF) 4 MG/2 ML INJECTION SOLUTION RX-106348 CDM J2405 HCPCS 636 RC 23155-0548-31 NDC outpatient 2 ML 60.8 60.8 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES EPO [308136803] 48.64 percent of total billed charges 37.7 57.76 Technical (Hospital) Services ONDANSETRON HCL (PF) 4 MG/2 ML INJECTION SOLUTION RX-106348 CDM J2405 HCPCS 636 RC 23155-0548-31 NDC outpatient 2 ML 60.8 60.8 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES HDHP [308136802] 48.64 percent of total billed charges 37.7 57.76 Technical (Hospital) Services ONDANSETRON HCL (PF) 4 MG/2 ML INJECTION SOLUTION RX-106348 CDM J2405 HCPCS 636 RC 23155-0548-31 NDC outpatient 2 ML 60.8 60.8 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES PPO [308136801] 48.64 percent of total billed charges 37.7 57.76 Technical (Hospital) Services ONDANSETRON HCL (PF) 4 MG/2 ML INJECTION SOLUTION RX-106348 CDM J2405 HCPCS 636 RC 23155-0548-31 NDC outpatient 2 ML 60.8 60.8 BLUE CROSS BLUE SHIELD WELLMARK SB889 [3081026] BCBS WYOMING [308102603] 57.76 percent of total billed charges 37.7 57.76 Technical (Hospital) Services ONDANSETRON HCL 2 MG/ML INTRAVENOUS SOLUTION RX-106349 CDM J2405 HCPCS 636 RC 23155-0550-31 NDC outpatient 1 ML 58.55 58.55 BLUE CROSS BLUE SHIELD WELLMARK SB889 [3081026] BCBS WYOMING [308102603] 55.62 percent of total billed charges 36.3 55.62 Technical (Hospital) Services ONDANSETRON HCL 2 MG/ML INTRAVENOUS SOLUTION RX-106349 CDM J2405 HCPCS 636 RC 23155-0550-31 NDC outpatient 1 ML 58.55 58.55 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES PPO [308136801] 46.84 percent of total billed charges 36.3 55.62 Technical (Hospital) Services ONDANSETRON HCL 2 MG/ML INTRAVENOUS SOLUTION RX-106349 CDM J2405 HCPCS 636 RC 23155-0550-31 NDC outpatient 1 ML 58.55 58.55 CIGNA 62308 [3081051] CIGNA 62308 [308105105] 46.84 percent of total billed charges 36.3 55.62 Technical (Hospital) Services ONDANSETRON HCL 2 MG/ML INTRAVENOUS SOLUTION RX-106349 CDM J2405 HCPCS 636 RC 23155-0550-31 NDC outpatient 1 ML 58.55 58.55 CIGNA 62308 [3081051] CIGNA STATE OF WYOMING [308105107] 46.84 percent of total billed charges 36.3 55.62 Technical (Hospital) Services ONDANSETRON HCL 2 MG/ML INTRAVENOUS SOLUTION RX-106349 CDM J2405 HCPCS 636 RC 23155-0550-31 NDC outpatient 1 ML 58.55 58.55 MEDICA (COMMERCIAL) 94265 [3081118] MEDICA CLAIMS [308111801] 52.7 percent of total billed charges 36.3 55.62 Technical (Hospital) Services ONDANSETRON HCL 2 MG/ML INTRAVENOUS SOLUTION RX-106349 CDM J2405 HCPCS 636 RC 23155-0550-31 NDC outpatient 1 ML 58.55 58.55 MULTIPLAN INC 34080 [3081285] MULTIPLAN INC [308128501] 55.62 percent of total billed charges 36.3 55.62 Technical (Hospital) Services ONDANSETRON HCL 2 MG/ML INTRAVENOUS SOLUTION RX-106349 CDM J2405 HCPCS 636 RC 23155-0550-31 NDC outpatient 1 ML 58.55 58.55 UNITED HEALTHCARE (COMMERCIAL) [3081199] UNITED HEALTHCARE 87726 [308119901] 36.3 percent of total billed charges 36.3 55.62 Technical (Hospital) Services ONDANSETRON HCL 2 MG/ML INTRAVENOUS SOLUTION RX-106349 CDM J2405 HCPCS 636 RC 23155-0550-31 NDC outpatient 1 ML 58.55 58.55 HEALTHPARTNERS SX009 HEALTHPARTNERS 46.84 percent of total billed charges 36.3 55.62 Technical (Hospital) Services ONDANSETRON HCL 2 MG/ML INTRAVENOUS SOLUTION RX-106349 CDM J2405 HCPCS 636 RC 23155-0550-31 NDC outpatient 1 ML 58.55 58.55 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES EPO [308136803] 46.84 percent of total billed charges 36.3 55.62 Technical (Hospital) Services ONDANSETRON HCL 2 MG/ML INTRAVENOUS SOLUTION RX-106349 CDM J2405 HCPCS 636 RC 23155-0550-31 NDC outpatient 1 ML 58.55 58.55 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES HDHP [308136802] 46.84 percent of total billed charges 36.3 55.62 Technical (Hospital) Services ONDANSETRON HCL 2 MG/ML INTRAVENOUS SOLUTION RX-106349 CDM J2405 HCPCS 636 RC 23155-0550-31 NDC inpatient 1 ML 58.55 58.55 CIGNA 62308 [3081051] CIGNA 62308 [308105105] 46.36 percent of total billed charges 36.3 55.62 Technical (Hospital) Services ONDANSETRON HCL 2 MG/ML INTRAVENOUS SOLUTION RX-106349 CDM J2405 HCPCS 636 RC 23155-0550-31 NDC inpatient 1 ML 58.55 58.55 CIGNA 62308 [3081051] CIGNA STATE OF WYOMING [308105107] 46.36 percent of total billed charges 36.3 55.62 Technical (Hospital) Services ONDANSETRON HCL 2 MG/ML INTRAVENOUS SOLUTION RX-106349 CDM J2405 HCPCS 636 RC 23155-0550-31 NDC inpatient 1 ML 58.55 58.55 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES HDHP [308136802] 46.36 percent of total billed charges 36.3 55.62 Technical (Hospital) Services ONDANSETRON HCL 2 MG/ML INTRAVENOUS SOLUTION RX-106349 CDM J2405 HCPCS 636 RC 23155-0550-31 NDC inpatient 1 ML 58.55 58.55 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES EPO [308136803] 46.36 percent of total billed charges 36.3 55.62 Technical (Hospital) Services ONDANSETRON HCL 2 MG/ML INTRAVENOUS SOLUTION RX-106349 CDM J2405 HCPCS 636 RC 23155-0550-31 NDC inpatient 1 ML 58.55 58.55 UNITED HEALTHCARE (COMMERCIAL) [3081199] UNITED HEALTHCARE 87726 [308119901] 36.3 percent of total billed charges 36.3 55.62 Technical (Hospital) Services ONDANSETRON HCL 2 MG/ML INTRAVENOUS SOLUTION RX-106349 CDM J2405 HCPCS 636 RC 23155-0550-31 NDC inpatient 1 ML 58.55 58.55 BLUE CROSS BLUE SHIELD WELLMARK SB889 [3081026] BCBS WYOMING [308102603] 55.62 percent of total billed charges 36.3 55.62 Technical (Hospital) Services ONDANSETRON HCL 2 MG/ML INTRAVENOUS SOLUTION RX-106349 CDM J2405 HCPCS 636 RC 23155-0550-31 NDC inpatient 1 ML 58.55 58.55 MEDICA (COMMERCIAL) 94265 [3081118] MEDICA CLAIMS [308111801] 52.7 percent of total billed charges 36.3 55.62 Technical (Hospital) Services ONDANSETRON HCL 2 MG/ML INTRAVENOUS SOLUTION RX-106349 CDM J2405 HCPCS 636 RC 23155-0550-31 NDC inpatient 1 ML 58.55 58.55 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES PPO [308136801] 46.36 percent of total billed charges 36.3 55.62 Technical (Hospital) Services ONDANSETRON HCL 2 MG/ML INTRAVENOUS SOLUTION RX-106349 CDM J2405 HCPCS 636 RC 23155-0550-31 NDC inpatient 1 ML 58.55 58.55 HEALTHPARTNERS SX009 HEALTHPARTNERS 46.36 percent of total billed charges 36.3 55.62 Technical (Hospital) Services ONDANSETRON HCL 2 MG/ML INTRAVENOUS SOLUTION RX-106349 CDM J2405 HCPCS 636 RC 23155-0550-31 NDC inpatient 1 ML 58.55 58.55 MULTIPLAN INC 34080 [3081285] MULTIPLAN INC [308128501] 55.62 percent of total billed charges 36.3 55.62 Technical (Hospital) Services NICARDIPINE 25 MG/10 ML INTRAVENOUS SOLUTION RX-12370 CDM J2404 HCPCS 250 RC 00143-9689-10 NDC inpatient 10 ML 148.02 148.02 MULTIPLAN INC 34080 [3081285] MULTIPLAN INC [308128501] 140.62 percent of total billed charges 91.77 140.62 Technical (Hospital) Services NICARDIPINE 25 MG/10 ML INTRAVENOUS SOLUTION RX-12370 CDM J2404 HCPCS 250 RC 00143-9689-10 NDC inpatient 10 ML 148.02 148.02 MEDICA (COMMERCIAL) 94265 [3081118] MEDICA CLAIMS [308111801] 133.22 percent of total billed charges 91.77 140.62 Technical (Hospital) Services NICARDIPINE 25 MG/10 ML INTRAVENOUS SOLUTION RX-12370 CDM J2404 HCPCS 250 RC 00143-9689-10 NDC inpatient 10 ML 148.02 148.02 CIGNA 62308 [3081051] CIGNA STATE OF WYOMING [308105107] 117.2 percent of total billed charges 91.77 140.62 Technical (Hospital) Services NICARDIPINE 25 MG/10 ML INTRAVENOUS SOLUTION RX-12370 CDM J2404 HCPCS 250 RC 00143-9689-10 NDC inpatient 10 ML 148.02 148.02 CIGNA 62308 [3081051] CIGNA 62308 [308105105] 117.2 percent of total billed charges 91.77 140.62 Technical (Hospital) Services NICARDIPINE 25 MG/10 ML INTRAVENOUS SOLUTION RX-12370 CDM J2404 HCPCS 250 RC 00143-9689-10 NDC inpatient 10 ML 148.02 148.02 UNITED HEALTHCARE (COMMERCIAL) [3081199] UNITED HEALTHCARE 87726 [308119901] 91.77 percent of total billed charges 91.77 140.62 Technical (Hospital) Services NICARDIPINE 25 MG/10 ML INTRAVENOUS SOLUTION RX-12370 CDM J2404 HCPCS 250 RC 00143-9689-10 NDC inpatient 10 ML 148.02 148.02 BLUE CROSS BLUE SHIELD WELLMARK SB889 [3081026] BCBS WYOMING [308102603] 140.62 percent of total billed charges 91.77 140.62 Technical (Hospital) Services NICARDIPINE 25 MG/10 ML INTRAVENOUS SOLUTION RX-12370 CDM J2404 HCPCS 250 RC 00143-9689-10 NDC inpatient 10 ML 148.02 148.02 HEALTHPARTNERS SX009 HEALTHPARTNERS 117.2 percent of total billed charges 91.77 140.62 Technical (Hospital) Services NICARDIPINE 25 MG/10 ML INTRAVENOUS SOLUTION RX-12370 CDM J2404 HCPCS 250 RC 00143-9689-10 NDC inpatient 10 ML 148.02 148.02 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES HDHP [308136802] 117.2 percent of total billed charges 91.77 140.62 Technical (Hospital) Services NICARDIPINE 25 MG/10 ML INTRAVENOUS SOLUTION RX-12370 CDM J2404 HCPCS 250 RC 00143-9689-10 NDC inpatient 10 ML 148.02 148.02 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES PPO [308136801] 117.2 percent of total billed charges 91.77 140.62 Technical (Hospital) Services NICARDIPINE 25 MG/10 ML INTRAVENOUS SOLUTION RX-12370 CDM J2404 HCPCS 250 RC 00143-9689-10 NDC inpatient 10 ML 148.02 148.02 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES EPO [308136803] 117.2 percent of total billed charges 91.77 140.62 Technical (Hospital) Services NICARDIPINE 25 MG/10 ML INTRAVENOUS SOLUTION RX-12370 CDM J2404 HCPCS 250 RC 00143-9689-10 NDC outpatient 10 ML 148.02 148.02 BLUE CROSS BLUE SHIELD WELLMARK SB889 [3081026] BCBS WYOMING [308102603] 140.62 percent of total billed charges 91.77 140.62 Technical (Hospital) Services NICARDIPINE 25 MG/10 ML INTRAVENOUS SOLUTION RX-12370 CDM J2404 HCPCS 250 RC 00143-9689-10 NDC outpatient 10 ML 148.02 148.02 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES EPO [308136803] 118.42 percent of total billed charges 91.77 140.62 Technical (Hospital) Services NICARDIPINE 25 MG/10 ML INTRAVENOUS SOLUTION RX-12370 CDM J2404 HCPCS 250 RC 00143-9689-10 NDC outpatient 10 ML 148.02 148.02 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES PPO [308136801] 118.42 percent of total billed charges 91.77 140.62 Technical (Hospital) Services NICARDIPINE 25 MG/10 ML INTRAVENOUS SOLUTION RX-12370 CDM J2404 HCPCS 250 RC 00143-9689-10 NDC outpatient 10 ML 148.02 148.02 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES HDHP [308136802] 118.42 percent of total billed charges 91.77 140.62 Technical (Hospital) Services NICARDIPINE 25 MG/10 ML INTRAVENOUS SOLUTION RX-12370 CDM J2404 HCPCS 250 RC 00143-9689-10 NDC outpatient 10 ML 148.02 148.02 UNITED HEALTHCARE (COMMERCIAL) [3081199] UNITED HEALTHCARE 87726 [308119901] 91.77 percent of total billed charges 91.77 140.62 Technical (Hospital) Services NICARDIPINE 25 MG/10 ML INTRAVENOUS SOLUTION RX-12370 CDM J2404 HCPCS 250 RC 00143-9689-10 NDC outpatient 10 ML 148.02 148.02 HEALTHPARTNERS SX009 HEALTHPARTNERS 118.42 percent of total billed charges 91.77 140.62 Technical (Hospital) Services NICARDIPINE 25 MG/10 ML INTRAVENOUS SOLUTION RX-12370 CDM J2404 HCPCS 250 RC 00143-9689-10 NDC outpatient 10 ML 148.02 148.02 CIGNA 62308 [3081051] CIGNA 62308 [308105105] 118.42 percent of total billed charges 91.77 140.62 Technical (Hospital) Services NICARDIPINE 25 MG/10 ML INTRAVENOUS SOLUTION RX-12370 CDM J2404 HCPCS 250 RC 00143-9689-10 NDC outpatient 10 ML 148.02 148.02 CIGNA 62308 [3081051] CIGNA STATE OF WYOMING [308105107] 118.42 percent of total billed charges 91.77 140.62 Technical (Hospital) Services NICARDIPINE 25 MG/10 ML INTRAVENOUS SOLUTION RX-12370 CDM J2404 HCPCS 250 RC 00143-9689-10 NDC outpatient 10 ML 148.02 148.02 MEDICA (COMMERCIAL) 94265 [3081118] MEDICA CLAIMS [308111801] 133.22 percent of total billed charges 91.77 140.62 Technical (Hospital) Services NICARDIPINE 25 MG/10 ML INTRAVENOUS SOLUTION RX-12370 CDM J2404 HCPCS 250 RC 00143-9689-10 NDC outpatient 10 ML 148.02 148.02 MULTIPLAN INC 34080 [3081285] MULTIPLAN INC [308128501] 140.62 percent of total billed charges 91.77 140.62 Technical (Hospital) Services PHENYLEPHRINE 10 MG/ML INJECTION SOLUTION RX-6242 CDM J2371 HCPCS 636 RC 00641-6142-25 NDC inpatient 1 ML 68.5 68.5 CIGNA 62308 [3081051] CIGNA 62308 [308105105] 54.24 percent of total billed charges 42.47 65.08 Technical (Hospital) Services PHENYLEPHRINE 10 MG/ML INJECTION SOLUTION RX-6242 CDM J2371 HCPCS 636 RC 00641-6142-25 NDC inpatient 1 ML 68.5 68.5 CIGNA 62308 [3081051] CIGNA STATE OF WYOMING [308105107] 54.24 percent of total billed charges 42.47 65.08 Technical (Hospital) Services PHENYLEPHRINE 10 MG/ML INJECTION SOLUTION RX-6242 CDM J2371 HCPCS 636 RC 00641-6142-25 NDC inpatient 1 ML 68.5 68.5 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES EPO [308136803] 54.24 percent of total billed charges 42.47 65.08 Technical (Hospital) Services PHENYLEPHRINE 10 MG/ML INJECTION SOLUTION RX-6242 CDM J2371 HCPCS 636 RC 00641-6142-25 NDC inpatient 1 ML 68.5 68.5 UNITED HEALTHCARE (COMMERCIAL) [3081199] UNITED HEALTHCARE 87726 [308119901] 42.47 percent of total billed charges 42.47 65.08 Technical (Hospital) Services PHENYLEPHRINE 10 MG/ML INJECTION SOLUTION RX-6242 CDM J2371 HCPCS 636 RC 00641-6142-25 NDC inpatient 1 ML 68.5 68.5 BLUE CROSS BLUE SHIELD WELLMARK SB889 [3081026] BCBS WYOMING [308102603] 65.08 percent of total billed charges 42.47 65.08 Technical (Hospital) Services PHENYLEPHRINE 10 MG/ML INJECTION SOLUTION RX-6242 CDM J2371 HCPCS 636 RC 00641-6142-25 NDC inpatient 1 ML 68.5 68.5 HEALTHPARTNERS SX009 HEALTHPARTNERS 54.24 percent of total billed charges 42.47 65.08 Technical (Hospital) Services PHENYLEPHRINE 10 MG/ML INJECTION SOLUTION RX-6242 CDM J2371 HCPCS 636 RC 00641-6142-25 NDC inpatient 1 ML 68.5 68.5 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES PPO [308136801] 54.24 percent of total billed charges 42.47 65.08 Technical (Hospital) Services PHENYLEPHRINE 10 MG/ML INJECTION SOLUTION RX-6242 CDM J2371 HCPCS 636 RC 00641-6142-25 NDC inpatient 1 ML 68.5 68.5 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES HDHP [308136802] 54.24 percent of total billed charges 42.47 65.08 Technical (Hospital) Services PHENYLEPHRINE 10 MG/ML INJECTION SOLUTION RX-6242 CDM J2371 HCPCS 636 RC 00641-6142-25 NDC inpatient 1 ML 68.5 68.5 MEDICA (COMMERCIAL) 94265 [3081118] MEDICA CLAIMS [308111801] 61.65 percent of total billed charges 42.47 65.08 Technical (Hospital) Services PHENYLEPHRINE 10 MG/ML INJECTION SOLUTION RX-6242 CDM J2371 HCPCS 636 RC 00641-6142-25 NDC inpatient 1 ML 68.5 68.5 MULTIPLAN INC 34080 [3081285] MULTIPLAN INC [308128501] 65.08 percent of total billed charges 42.47 65.08 Technical (Hospital) Services PHENYLEPHRINE 10 MG/ML INJECTION SOLUTION RX-6242 CDM J2371 HCPCS 636 RC 00641-6142-25 NDC outpatient 1 ML 68.5 68.5 BLUE CROSS BLUE SHIELD WELLMARK SB889 [3081026] BCBS WYOMING [308102603] 65.08 percent of total billed charges 42.47 65.08 Technical (Hospital) Services PHENYLEPHRINE 10 MG/ML INJECTION SOLUTION RX-6242 CDM J2371 HCPCS 636 RC 00641-6142-25 NDC outpatient 1 ML 68.5 68.5 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES PPO [308136801] 54.8 percent of total billed charges 42.47 65.08 Technical (Hospital) Services PHENYLEPHRINE 10 MG/ML INJECTION SOLUTION RX-6242 CDM J2371 HCPCS 636 RC 00641-6142-25 NDC outpatient 1 ML 68.5 68.5 UNITED HEALTHCARE (COMMERCIAL) [3081199] UNITED HEALTHCARE 87726 [308119901] 42.47 percent of total billed charges 42.47 65.08 Technical (Hospital) Services PHENYLEPHRINE 10 MG/ML INJECTION SOLUTION RX-6242 CDM J2371 HCPCS 636 RC 00641-6142-25 NDC outpatient 1 ML 68.5 68.5 MULTIPLAN INC 34080 [3081285] MULTIPLAN INC [308128501] 65.08 percent of total billed charges 42.47 65.08 Technical (Hospital) Services PHENYLEPHRINE 10 MG/ML INJECTION SOLUTION RX-6242 CDM J2371 HCPCS 636 RC 00641-6142-25 NDC outpatient 1 ML 68.5 68.5 HEALTHPARTNERS SX009 HEALTHPARTNERS 54.8 percent of total billed charges 42.47 65.08 Technical (Hospital) Services PHENYLEPHRINE 10 MG/ML INJECTION SOLUTION RX-6242 CDM J2371 HCPCS 636 RC 00641-6142-25 NDC outpatient 1 ML 68.5 68.5 CIGNA 62308 [3081051] CIGNA 62308 [308105105] 54.8 percent of total billed charges 42.47 65.08 Technical (Hospital) Services PHENYLEPHRINE 10 MG/ML INJECTION SOLUTION RX-6242 CDM J2371 HCPCS 636 RC 00641-6142-25 NDC outpatient 1 ML 68.5 68.5 CIGNA 62308 [3081051] CIGNA STATE OF WYOMING [308105107] 54.8 percent of total billed charges 42.47 65.08 Technical (Hospital) Services PHENYLEPHRINE 10 MG/ML INJECTION SOLUTION RX-6242 CDM J2371 HCPCS 636 RC 00641-6142-25 NDC outpatient 1 ML 68.5 68.5 MEDICA (COMMERCIAL) 94265 [3081118] MEDICA CLAIMS [308111801] 61.65 percent of total billed charges 42.47 65.08 Technical (Hospital) Services PHENYLEPHRINE 10 MG/ML INJECTION SOLUTION RX-6242 CDM J2371 HCPCS 636 RC 00641-6142-25 NDC outpatient 1 ML 68.5 68.5 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES HDHP [308136802] 54.8 percent of total billed charges 42.47 65.08 Technical (Hospital) Services PHENYLEPHRINE 10 MG/ML INJECTION SOLUTION RX-6242 CDM J2371 HCPCS 636 RC 00641-6142-25 NDC outpatient 1 ML 68.5 68.5 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES EPO [308136803] 54.8 percent of total billed charges 42.47 65.08 Technical (Hospital) Services ORPHENADRINE CITRATE 30 MG/ML INJECTION SOLUTION RX-5886 CDM J2360 HCPCS 636 RC 00641-6182-10 NDC inpatient 2 ML 85.6 85.6 HEALTHPARTNERS SX009 HEALTHPARTNERS 67.78 percent of total billed charges 53.07 81.32 Technical (Hospital) Services ORPHENADRINE CITRATE 30 MG/ML INJECTION SOLUTION RX-5886 CDM J2360 HCPCS 636 RC 00641-6182-10 NDC inpatient 2 ML 85.6 85.6 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES EPO [308136803] 67.78 percent of total billed charges 53.07 81.32 Technical (Hospital) Services ORPHENADRINE CITRATE 30 MG/ML INJECTION SOLUTION RX-5886 CDM J2360 HCPCS 636 RC 00641-6182-10 NDC inpatient 2 ML 85.6 85.6 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES PPO [308136801] 67.78 percent of total billed charges 53.07 81.32 Technical (Hospital) Services ORPHENADRINE CITRATE 30 MG/ML INJECTION SOLUTION RX-5886 CDM J2360 HCPCS 636 RC 00641-6182-10 NDC inpatient 2 ML 85.6 85.6 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES HDHP [308136802] 67.78 percent of total billed charges 53.07 81.32 Technical (Hospital) Services ORPHENADRINE CITRATE 30 MG/ML INJECTION SOLUTION RX-5886 CDM J2360 HCPCS 636 RC 00641-6182-10 NDC inpatient 2 ML 85.6 85.6 CIGNA 62308 [3081051] CIGNA 62308 [308105105] 67.78 percent of total billed charges 53.07 81.32 Technical (Hospital) Services ORPHENADRINE CITRATE 30 MG/ML INJECTION SOLUTION RX-5886 CDM J2360 HCPCS 636 RC 00641-6182-10 NDC inpatient 2 ML 85.6 85.6 CIGNA 62308 [3081051] CIGNA STATE OF WYOMING [308105107] 67.78 percent of total billed charges 53.07 81.32 Technical (Hospital) Services ORPHENADRINE CITRATE 30 MG/ML INJECTION SOLUTION RX-5886 CDM J2360 HCPCS 636 RC 00641-6182-10 NDC inpatient 2 ML 85.6 85.6 UNITED HEALTHCARE (COMMERCIAL) [3081199] UNITED HEALTHCARE 87726 [308119901] 53.07 percent of total billed charges 53.07 81.32 Technical (Hospital) Services ORPHENADRINE CITRATE 30 MG/ML INJECTION SOLUTION RX-5886 CDM J2360 HCPCS 636 RC 00641-6182-10 NDC inpatient 2 ML 85.6 85.6 BLUE CROSS BLUE SHIELD WELLMARK SB889 [3081026] BCBS WYOMING [308102603] 81.32 percent of total billed charges 53.07 81.32 Technical (Hospital) Services ORPHENADRINE CITRATE 30 MG/ML INJECTION SOLUTION RX-5886 CDM J2360 HCPCS 636 RC 00641-6182-10 NDC inpatient 2 ML 85.6 85.6 MULTIPLAN INC 34080 [3081285] MULTIPLAN INC [308128501] 81.32 percent of total billed charges 53.07 81.32 Technical (Hospital) Services ORPHENADRINE CITRATE 30 MG/ML INJECTION SOLUTION RX-5886 CDM J2360 HCPCS 636 RC 00641-6182-10 NDC inpatient 2 ML 85.6 85.6 MEDICA (COMMERCIAL) 94265 [3081118] MEDICA CLAIMS [308111801] 77.04 percent of total billed charges 53.07 81.32 Technical (Hospital) Services ORPHENADRINE CITRATE 30 MG/ML INJECTION SOLUTION RX-5886 CDM J2360 HCPCS 636 RC 00641-6182-10 NDC outpatient 2 ML 85.6 85.6 MEDICA (COMMERCIAL) 94265 [3081118] MEDICA CLAIMS [308111801] 77.04 percent of total billed charges 53.07 81.32 Technical (Hospital) Services ORPHENADRINE CITRATE 30 MG/ML INJECTION SOLUTION RX-5886 CDM J2360 HCPCS 636 RC 00641-6182-10 NDC outpatient 2 ML 85.6 85.6 HEALTHPARTNERS SX009 HEALTHPARTNERS 68.48 percent of total billed charges 53.07 81.32 Technical (Hospital) Services ORPHENADRINE CITRATE 30 MG/ML INJECTION SOLUTION RX-5886 CDM J2360 HCPCS 636 RC 00641-6182-10 NDC outpatient 2 ML 85.6 85.6 UNITED HEALTHCARE (COMMERCIAL) [3081199] UNITED HEALTHCARE 87726 [308119901] 53.07 percent of total billed charges 53.07 81.32 Technical (Hospital) Services ORPHENADRINE CITRATE 30 MG/ML INJECTION SOLUTION RX-5886 CDM J2360 HCPCS 636 RC 00641-6182-10 NDC outpatient 2 ML 85.6 85.6 MULTIPLAN INC 34080 [3081285] MULTIPLAN INC [308128501] 81.32 percent of total billed charges 53.07 81.32 Technical (Hospital) Services ORPHENADRINE CITRATE 30 MG/ML INJECTION SOLUTION RX-5886 CDM J2360 HCPCS 636 RC 00641-6182-10 NDC outpatient 2 ML 85.6 85.6 CIGNA 62308 [3081051] CIGNA 62308 [308105105] 68.48 percent of total billed charges 53.07 81.32 Technical (Hospital) Services ORPHENADRINE CITRATE 30 MG/ML INJECTION SOLUTION RX-5886 CDM J2360 HCPCS 636 RC 00641-6182-10 NDC outpatient 2 ML 85.6 85.6 CIGNA 62308 [3081051] CIGNA STATE OF WYOMING [308105107] 68.48 percent of total billed charges 53.07 81.32 Technical (Hospital) Services ORPHENADRINE CITRATE 30 MG/ML INJECTION SOLUTION RX-5886 CDM J2360 HCPCS 636 RC 00641-6182-10 NDC outpatient 2 ML 85.6 85.6 BLUE CROSS BLUE SHIELD WELLMARK SB889 [3081026] BCBS WYOMING [308102603] 81.32 percent of total billed charges 53.07 81.32 Technical (Hospital) Services ORPHENADRINE CITRATE 30 MG/ML INJECTION SOLUTION RX-5886 CDM J2360 HCPCS 636 RC 00641-6182-10 NDC outpatient 2 ML 85.6 85.6 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES PPO [308136801] 68.48 percent of total billed charges 53.07 81.32 Technical (Hospital) Services ORPHENADRINE CITRATE 30 MG/ML INJECTION SOLUTION RX-5886 CDM J2360 HCPCS 636 RC 00641-6182-10 NDC outpatient 2 ML 85.6 85.6 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES HDHP [308136802] 68.48 percent of total billed charges 53.07 81.32 Technical (Hospital) Services ORPHENADRINE CITRATE 30 MG/ML INJECTION SOLUTION RX-5886 CDM J2360 HCPCS 636 RC 00641-6182-10 NDC outpatient 2 ML 85.6 85.6 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES EPO [308136803] 68.48 percent of total billed charges 53.07 81.32 Technical (Hospital) Services OMALIZUMAB 150 MG/ML SUBCUTANEOUS SYRINGE RX-175587 CDM J2357 HCPCS 636 RC 50242-0215-01 NDC outpatient 1 ML 2609.96 2609.96 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES EPO [308136803] 2087.97 percent of total billed charges 1618.18 2479.46 Technical (Hospital) Services OMALIZUMAB 150 MG/ML SUBCUTANEOUS SYRINGE RX-175587 CDM J2357 HCPCS 636 RC 50242-0215-01 NDC outpatient 1 ML 2609.96 2609.96 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES HDHP [308136802] 2087.97 percent of total billed charges 1618.18 2479.46 Technical (Hospital) Services OMALIZUMAB 150 MG/ML SUBCUTANEOUS SYRINGE RX-175587 CDM J2357 HCPCS 636 RC 50242-0215-01 NDC outpatient 1 ML 2609.96 2609.96 BLUE CROSS BLUE SHIELD WELLMARK SB889 [3081026] BCBS WYOMING [308102603] 2479.46 percent of total billed charges 1618.18 2479.46 Technical (Hospital) Services OMALIZUMAB 150 MG/ML SUBCUTANEOUS SYRINGE RX-175587 CDM J2357 HCPCS 636 RC 50242-0215-01 NDC outpatient 1 ML 2609.96 2609.96 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES PPO [308136801] 2087.97 percent of total billed charges 1618.18 2479.46 Technical (Hospital) Services OMALIZUMAB 150 MG/ML SUBCUTANEOUS SYRINGE RX-175587 CDM J2357 HCPCS 636 RC 50242-0215-01 NDC outpatient 1 ML 2609.96 2609.96 CIGNA 62308 [3081051] CIGNA 62308 [308105105] 2087.97 percent of total billed charges 1618.18 2479.46 Technical (Hospital) Services OMALIZUMAB 150 MG/ML SUBCUTANEOUS SYRINGE RX-175587 CDM J2357 HCPCS 636 RC 50242-0215-01 NDC outpatient 1 ML 2609.96 2609.96 CIGNA 62308 [3081051] CIGNA STATE OF WYOMING [308105107] 2087.97 percent of total billed charges 1618.18 2479.46 Technical (Hospital) Services OMALIZUMAB 150 MG/ML SUBCUTANEOUS SYRINGE RX-175587 CDM J2357 HCPCS 636 RC 50242-0215-01 NDC outpatient 1 ML 2609.96 2609.96 MEDICA (COMMERCIAL) 94265 [3081118] MEDICA CLAIMS [308111801] 2348.96 percent of total billed charges 1618.18 2479.46 Technical (Hospital) Services OMALIZUMAB 150 MG/ML SUBCUTANEOUS SYRINGE RX-175587 CDM J2357 HCPCS 636 RC 50242-0215-01 NDC outpatient 1 ML 2609.96 2609.96 UNITED HEALTHCARE (COMMERCIAL) [3081199] UNITED HEALTHCARE 87726 [308119901] 1618.18 percent of total billed charges 1618.18 2479.46 Technical (Hospital) Services OMALIZUMAB 150 MG/ML SUBCUTANEOUS SYRINGE RX-175587 CDM J2357 HCPCS 636 RC 50242-0215-01 NDC outpatient 1 ML 2609.96 2609.96 MULTIPLAN INC 34080 [3081285] MULTIPLAN INC [308128501] 2479.46 percent of total billed charges 1618.18 2479.46 Technical (Hospital) Services OMALIZUMAB 150 MG/ML SUBCUTANEOUS SYRINGE RX-175587 CDM J2357 HCPCS 636 RC 50242-0215-01 NDC outpatient 1 ML 2609.96 2609.96 HEALTHPARTNERS SX009 HEALTHPARTNERS 2087.97 percent of total billed charges 1618.18 2479.46 Technical (Hospital) Services OMALIZUMAB 150 MG/ML SUBCUTANEOUS SYRINGE RX-175587 CDM J2357 HCPCS 636 RC 50242-0215-01 NDC inpatient 1 ML 2609.96 2609.96 MULTIPLAN INC 34080 [3081285] MULTIPLAN INC [308128501] 2479.46 percent of total billed charges 1618.18 2479.46 Technical (Hospital) Services OMALIZUMAB 150 MG/ML SUBCUTANEOUS SYRINGE RX-175587 CDM J2357 HCPCS 636 RC 50242-0215-01 NDC inpatient 1 ML 2609.96 2609.96 HEALTHPARTNERS SX009 HEALTHPARTNERS 2066.57 percent of total billed charges 1618.18 2479.46 Technical (Hospital) Services OMALIZUMAB 150 MG/ML SUBCUTANEOUS SYRINGE RX-175587 CDM J2357 HCPCS 636 RC 50242-0215-01 NDC inpatient 1 ML 2609.96 2609.96 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES PPO [308136801] 2066.57 percent of total billed charges 1618.18 2479.46 Technical (Hospital) Services OMALIZUMAB 150 MG/ML SUBCUTANEOUS SYRINGE RX-175587 CDM J2357 HCPCS 636 RC 50242-0215-01 NDC inpatient 1 ML 2609.96 2609.96 MEDICA (COMMERCIAL) 94265 [3081118] MEDICA CLAIMS [308111801] 2348.96 percent of total billed charges 1618.18 2479.46 Technical (Hospital) Services OMALIZUMAB 150 MG/ML SUBCUTANEOUS SYRINGE RX-175587 CDM J2357 HCPCS 636 RC 50242-0215-01 NDC inpatient 1 ML 2609.96 2609.96 BLUE CROSS BLUE SHIELD WELLMARK SB889 [3081026] BCBS WYOMING [308102603] 2479.46 percent of total billed charges 1618.18 2479.46 Technical (Hospital) Services OMALIZUMAB 150 MG/ML SUBCUTANEOUS SYRINGE RX-175587 CDM J2357 HCPCS 636 RC 50242-0215-01 NDC inpatient 1 ML 2609.96 2609.96 UNITED HEALTHCARE (COMMERCIAL) [3081199] UNITED HEALTHCARE 87726 [308119901] 1618.18 percent of total billed charges 1618.18 2479.46 Technical (Hospital) Services OMALIZUMAB 150 MG/ML SUBCUTANEOUS SYRINGE RX-175587 CDM J2357 HCPCS 636 RC 50242-0215-01 NDC inpatient 1 ML 2609.96 2609.96 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES EPO [308136803] 2066.57 percent of total billed charges 1618.18 2479.46 Technical (Hospital) Services OMALIZUMAB 150 MG/ML SUBCUTANEOUS SYRINGE RX-175587 CDM J2357 HCPCS 636 RC 50242-0215-01 NDC inpatient 1 ML 2609.96 2609.96 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES HDHP [308136802] 2066.57 percent of total billed charges 1618.18 2479.46 Technical (Hospital) Services OMALIZUMAB 150 MG/ML SUBCUTANEOUS SYRINGE RX-175587 CDM J2357 HCPCS 636 RC 50242-0215-01 NDC inpatient 1 ML 2609.96 2609.96 CIGNA 62308 [3081051] CIGNA 62308 [308105105] 2066.57 percent of total billed charges 1618.18 2479.46 Technical (Hospital) Services OMALIZUMAB 150 MG/ML SUBCUTANEOUS SYRINGE RX-175587 CDM J2357 HCPCS 636 RC 50242-0215-01 NDC inpatient 1 ML 2609.96 2609.96 CIGNA 62308 [3081051] CIGNA STATE OF WYOMING [308105107] 2066.57 percent of total billed charges 1618.18 2479.46 Technical (Hospital) Services OCRELIZUMAB 30 MG/ML INTRAVENOUS SOLUTION RX-169251 CDM J2350 HCPCS 636 RC 50242-0150-01 NDC inpatient 10 ML 27839.38 27839.38 HEALTHPARTNERS SX009 HEALTHPARTNERS 22043.22 percent of total billed charges 17260.42 26447.41 Technical (Hospital) Services OCRELIZUMAB 30 MG/ML INTRAVENOUS SOLUTION RX-169251 CDM J2350 HCPCS 636 RC 50242-0150-01 NDC inpatient 10 ML 27839.38 27839.38 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES HDHP [308136802] 22043.22 percent of total billed charges 17260.42 26447.41 Technical (Hospital) Services OCRELIZUMAB 30 MG/ML INTRAVENOUS SOLUTION RX-169251 CDM J2350 HCPCS 636 RC 50242-0150-01 NDC inpatient 10 ML 27839.38 27839.38 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES EPO [308136803] 22043.22 percent of total billed charges 17260.42 26447.41 Technical (Hospital) Services OCRELIZUMAB 30 MG/ML INTRAVENOUS SOLUTION RX-169251 CDM J2350 HCPCS 636 RC 50242-0150-01 NDC inpatient 10 ML 27839.38 27839.38 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES PPO [308136801] 22043.22 percent of total billed charges 17260.42 26447.41 Technical (Hospital) Services OCRELIZUMAB 30 MG/ML INTRAVENOUS SOLUTION RX-169251 CDM J2350 HCPCS 636 RC 50242-0150-01 NDC inpatient 10 ML 27839.38 27839.38 MEDICA (COMMERCIAL) 94265 [3081118] MEDICA CLAIMS [308111801] 25055.44 percent of total billed charges 17260.42 26447.41 Technical (Hospital) Services OCRELIZUMAB 30 MG/ML INTRAVENOUS SOLUTION RX-169251 CDM J2350 HCPCS 636 RC 50242-0150-01 NDC inpatient 10 ML 27839.38 27839.38 MULTIPLAN INC 34080 [3081285] MULTIPLAN INC [308128501] 26447.41 percent of total billed charges 17260.42 26447.41 Technical (Hospital) Services OCRELIZUMAB 30 MG/ML INTRAVENOUS SOLUTION RX-169251 CDM J2350 HCPCS 636 RC 50242-0150-01 NDC inpatient 10 ML 27839.38 27839.38 BLUE CROSS BLUE SHIELD WELLMARK SB889 [3081026] BCBS WYOMING [308102603] 26447.41 percent of total billed charges 17260.42 26447.41 Technical (Hospital) Services OCRELIZUMAB 30 MG/ML INTRAVENOUS SOLUTION RX-169251 CDM J2350 HCPCS 636 RC 50242-0150-01 NDC inpatient 10 ML 27839.38 27839.38 UNITED HEALTHCARE (COMMERCIAL) [3081199] UNITED HEALTHCARE 87726 [308119901] 17260.42 percent of total billed charges 17260.42 26447.41 Technical (Hospital) Services OCRELIZUMAB 30 MG/ML INTRAVENOUS SOLUTION RX-169251 CDM J2350 HCPCS 636 RC 50242-0150-01 NDC inpatient 10 ML 27839.38 27839.38 CIGNA 62308 [3081051] CIGNA 62308 [308105105] 22043.22 percent of total billed charges 17260.42 26447.41 Technical (Hospital) Services OCRELIZUMAB 30 MG/ML INTRAVENOUS SOLUTION RX-169251 CDM J2350 HCPCS 636 RC 50242-0150-01 NDC inpatient 10 ML 27839.38 27839.38 CIGNA 62308 [3081051] CIGNA STATE OF WYOMING [308105107] 22043.22 percent of total billed charges 17260.42 26447.41 Technical (Hospital) Services OCRELIZUMAB 30 MG/ML INTRAVENOUS SOLUTION RX-169251 CDM J2350 HCPCS 636 RC 50242-0150-01 NDC outpatient 10 ML 27839.38 27839.38 MULTIPLAN INC 34080 [3081285] MULTIPLAN INC [308128501] 26447.41 percent of total billed charges 17260.42 26447.41 Technical (Hospital) Services OCRELIZUMAB 30 MG/ML INTRAVENOUS SOLUTION RX-169251 CDM J2350 HCPCS 636 RC 50242-0150-01 NDC outpatient 10 ML 27839.38 27839.38 MEDICA (COMMERCIAL) 94265 [3081118] MEDICA CLAIMS [308111801] 25055.44 percent of total billed charges 17260.42 26447.41 Technical (Hospital) Services OCRELIZUMAB 30 MG/ML INTRAVENOUS SOLUTION RX-169251 CDM J2350 HCPCS 636 RC 50242-0150-01 NDC outpatient 10 ML 27839.38 27839.38 CIGNA 62308 [3081051] CIGNA 62308 [308105105] 22271.5 percent of total billed charges 17260.42 26447.41 Technical (Hospital) Services OCRELIZUMAB 30 MG/ML INTRAVENOUS SOLUTION RX-169251 CDM J2350 HCPCS 636 RC 50242-0150-01 NDC outpatient 10 ML 27839.38 27839.38 CIGNA 62308 [3081051] CIGNA STATE OF WYOMING [308105107] 22271.5 percent of total billed charges 17260.42 26447.41 Technical (Hospital) Services OCRELIZUMAB 30 MG/ML INTRAVENOUS SOLUTION RX-169251 CDM J2350 HCPCS 636 RC 50242-0150-01 NDC outpatient 10 ML 27839.38 27839.38 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES EPO [308136803] 22271.5 percent of total billed charges 17260.42 26447.41 Technical (Hospital) Services OCRELIZUMAB 30 MG/ML INTRAVENOUS SOLUTION RX-169251 CDM J2350 HCPCS 636 RC 50242-0150-01 NDC outpatient 10 ML 27839.38 27839.38 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES HDHP [308136802] 22271.5 percent of total billed charges 17260.42 26447.41 Technical (Hospital) Services OCRELIZUMAB 30 MG/ML INTRAVENOUS SOLUTION RX-169251 CDM J2350 HCPCS 636 RC 50242-0150-01 NDC outpatient 10 ML 27839.38 27839.38 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES PPO [308136801] 22271.5 percent of total billed charges 17260.42 26447.41 Technical (Hospital) Services OCRELIZUMAB 30 MG/ML INTRAVENOUS SOLUTION RX-169251 CDM J2350 HCPCS 636 RC 50242-0150-01 NDC outpatient 10 ML 27839.38 27839.38 UNITED HEALTHCARE (COMMERCIAL) [3081199] UNITED HEALTHCARE 87726 [308119901] 17260.42 percent of total billed charges 17260.42 26447.41 Technical (Hospital) Services OCRELIZUMAB 30 MG/ML INTRAVENOUS SOLUTION RX-169251 CDM J2350 HCPCS 636 RC 50242-0150-01 NDC outpatient 10 ML 27839.38 27839.38 HEALTHPARTNERS SX009 HEALTHPARTNERS 22271.5 percent of total billed charges 17260.42 26447.41 Technical (Hospital) Services OCRELIZUMAB 30 MG/ML INTRAVENOUS SOLUTION RX-169251 CDM J2350 HCPCS 636 RC 50242-0150-01 NDC outpatient 10 ML 27839.38 27839.38 BLUE CROSS BLUE SHIELD WELLMARK SB889 [3081026] BCBS WYOMING [308102603] 26447.41 percent of total billed charges 17260.42 26447.41 Technical (Hospital) Services NATALIZUMAB 300 MG/15 ML INTRAVENOUS SOLUTION RX-40120 CDM J2323 HCPCS 636 RC 64406-0008-01 NDC outpatient 15 ML 13459.35 13459.35 MULTIPLAN INC 34080 [3081285] MULTIPLAN INC [308128501] 12786.38 percent of total billed charges 8344.8 12786.38 Technical (Hospital) Services NATALIZUMAB 300 MG/15 ML INTRAVENOUS SOLUTION RX-40120 CDM J2323 HCPCS 636 RC 64406-0008-01 NDC outpatient 15 ML 13459.35 13459.35 MEDICA (COMMERCIAL) 94265 [3081118] MEDICA CLAIMS [308111801] 12113.42 percent of total billed charges 8344.8 12786.38 Technical (Hospital) Services NATALIZUMAB 300 MG/15 ML INTRAVENOUS SOLUTION RX-40120 CDM J2323 HCPCS 636 RC 64406-0008-01 NDC outpatient 15 ML 13459.35 13459.35 CIGNA 62308 [3081051] CIGNA 62308 [308105105] 10767.48 percent of total billed charges 8344.8 12786.38 Technical (Hospital) Services NATALIZUMAB 300 MG/15 ML INTRAVENOUS SOLUTION RX-40120 CDM J2323 HCPCS 636 RC 64406-0008-01 NDC outpatient 15 ML 13459.35 13459.35 CIGNA 62308 [3081051] CIGNA STATE OF WYOMING [308105107] 10767.48 percent of total billed charges 8344.8 12786.38 Technical (Hospital) Services NATALIZUMAB 300 MG/15 ML INTRAVENOUS SOLUTION RX-40120 CDM J2323 HCPCS 636 RC 64406-0008-01 NDC outpatient 15 ML 13459.35 13459.35 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES EPO [308136803] 10767.48 percent of total billed charges 8344.8 12786.38 Technical (Hospital) Services NATALIZUMAB 300 MG/15 ML INTRAVENOUS SOLUTION RX-40120 CDM J2323 HCPCS 636 RC 64406-0008-01 NDC outpatient 15 ML 13459.35 13459.35 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES PPO [308136801] 10767.48 percent of total billed charges 8344.8 12786.38 Technical (Hospital) Services NATALIZUMAB 300 MG/15 ML INTRAVENOUS SOLUTION RX-40120 CDM J2323 HCPCS 636 RC 64406-0008-01 NDC outpatient 15 ML 13459.35 13459.35 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES HDHP [308136802] 10767.48 percent of total billed charges 8344.8 12786.38 Technical (Hospital) Services NATALIZUMAB 300 MG/15 ML INTRAVENOUS SOLUTION RX-40120 CDM J2323 HCPCS 636 RC 64406-0008-01 NDC outpatient 15 ML 13459.35 13459.35 BLUE CROSS BLUE SHIELD WELLMARK SB889 [3081026] BCBS WYOMING [308102603] 12786.38 percent of total billed charges 8344.8 12786.38 Technical (Hospital) Services NATALIZUMAB 300 MG/15 ML INTRAVENOUS SOLUTION RX-40120 CDM J2323 HCPCS 636 RC 64406-0008-01 NDC outpatient 15 ML 13459.35 13459.35 UNITED HEALTHCARE (COMMERCIAL) [3081199] UNITED HEALTHCARE 87726 [308119901] 8344.8 percent of total billed charges 8344.8 12786.38 Technical (Hospital) Services NATALIZUMAB 300 MG/15 ML INTRAVENOUS SOLUTION RX-40120 CDM J2323 HCPCS 636 RC 64406-0008-01 NDC outpatient 15 ML 13459.35 13459.35 HEALTHPARTNERS SX009 HEALTHPARTNERS 10767.48 percent of total billed charges 8344.8 12786.38 Technical (Hospital) Services NATALIZUMAB 300 MG/15 ML INTRAVENOUS SOLUTION RX-40120 CDM J2323 HCPCS 636 RC 64406-0008-01 NDC inpatient 15 ML 13459.35 13459.35 BLUE CROSS BLUE SHIELD WELLMARK SB889 [3081026] BCBS WYOMING [308102603] 12786.38 percent of total billed charges 8344.8 12786.38 Technical (Hospital) Services NATALIZUMAB 300 MG/15 ML INTRAVENOUS SOLUTION RX-40120 CDM J2323 HCPCS 636 RC 64406-0008-01 NDC inpatient 15 ML 13459.35 13459.35 UNITED HEALTHCARE (COMMERCIAL) [3081199] UNITED HEALTHCARE 87726 [308119901] 8344.8 percent of total billed charges 8344.8 12786.38 Technical (Hospital) Services NATALIZUMAB 300 MG/15 ML INTRAVENOUS SOLUTION RX-40120 CDM J2323 HCPCS 636 RC 64406-0008-01 NDC inpatient 15 ML 13459.35 13459.35 MEDICA (COMMERCIAL) 94265 [3081118] MEDICA CLAIMS [308111801] 12113.42 percent of total billed charges 8344.8 12786.38 Technical (Hospital) Services NATALIZUMAB 300 MG/15 ML INTRAVENOUS SOLUTION RX-40120 CDM J2323 HCPCS 636 RC 64406-0008-01 NDC inpatient 15 ML 13459.35 13459.35 MULTIPLAN INC 34080 [3081285] MULTIPLAN INC [308128501] 12786.38 percent of total billed charges 8344.8 12786.38 Technical (Hospital) Services NATALIZUMAB 300 MG/15 ML INTRAVENOUS SOLUTION RX-40120 CDM J2323 HCPCS 636 RC 64406-0008-01 NDC inpatient 15 ML 13459.35 13459.35 HEALTHPARTNERS SX009 HEALTHPARTNERS 10657.11 percent of total billed charges 8344.8 12786.38 Technical (Hospital) Services NATALIZUMAB 300 MG/15 ML INTRAVENOUS SOLUTION RX-40120 CDM J2323 HCPCS 636 RC 64406-0008-01 NDC inpatient 15 ML 13459.35 13459.35 CIGNA 62308 [3081051] CIGNA 62308 [308105105] 10657.11 percent of total billed charges 8344.8 12786.38 Technical (Hospital) Services NATALIZUMAB 300 MG/15 ML INTRAVENOUS SOLUTION RX-40120 CDM J2323 HCPCS 636 RC 64406-0008-01 NDC inpatient 15 ML 13459.35 13459.35 CIGNA 62308 [3081051] CIGNA STATE OF WYOMING [308105107] 10657.11 percent of total billed charges 8344.8 12786.38 Technical (Hospital) Services NATALIZUMAB 300 MG/15 ML INTRAVENOUS SOLUTION RX-40120 CDM J2323 HCPCS 636 RC 64406-0008-01 NDC inpatient 15 ML 13459.35 13459.35 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES EPO [308136803] 10657.11 percent of total billed charges 8344.8 12786.38 Technical (Hospital) Services NATALIZUMAB 300 MG/15 ML INTRAVENOUS SOLUTION RX-40120 CDM J2323 HCPCS 636 RC 64406-0008-01 NDC inpatient 15 ML 13459.35 13459.35 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES HDHP [308136802] 10657.11 percent of total billed charges 8344.8 12786.38 Technical (Hospital) Services NATALIZUMAB 300 MG/15 ML INTRAVENOUS SOLUTION RX-40120 CDM J2323 HCPCS 636 RC 64406-0008-01 NDC inpatient 15 ML 13459.35 13459.35 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES PPO [308136801] 10657.11 percent of total billed charges 8344.8 12786.38 Technical (Hospital) Services NALOXONE 1 MG/ML INJECTION SYRINGE RX-5374 CDM J2310 HCPCS 636 RC 76329-3469-01 NDC outpatient 2 ML 170 170 MEDICA (COMMERCIAL) 94265 [3081118] MEDICA CLAIMS [308111801] 153 percent of total billed charges 105.4 161.5 Technical (Hospital) Services NALOXONE 1 MG/ML INJECTION SYRINGE RX-5374 CDM J2310 HCPCS 636 RC 76329-3469-01 NDC outpatient 2 ML 170 170 CIGNA 62308 [3081051] CIGNA 62308 [308105105] 136 percent of total billed charges 105.4 161.5 Technical (Hospital) Services NALOXONE 1 MG/ML INJECTION SYRINGE RX-5374 CDM J2310 HCPCS 636 RC 76329-3469-01 NDC outpatient 2 ML 170 170 CIGNA 62308 [3081051] CIGNA STATE OF WYOMING [308105107] 136 percent of total billed charges 105.4 161.5 Technical (Hospital) Services NALOXONE 1 MG/ML INJECTION SYRINGE RX-5374 CDM J2310 HCPCS 636 RC 76329-3469-01 NDC outpatient 2 ML 170 170 MULTIPLAN INC 34080 [3081285] MULTIPLAN INC [308128501] 161.5 percent of total billed charges 105.4 161.5 Technical (Hospital) Services NALOXONE 1 MG/ML INJECTION SYRINGE RX-5374 CDM J2310 HCPCS 636 RC 76329-3469-01 NDC outpatient 2 ML 170 170 HEALTHPARTNERS SX009 HEALTHPARTNERS 136 percent of total billed charges 105.4 161.5 Technical (Hospital) Services NALOXONE 1 MG/ML INJECTION SYRINGE RX-5374 CDM J2310 HCPCS 636 RC 76329-3469-01 NDC outpatient 2 ML 170 170 UNITED HEALTHCARE (COMMERCIAL) [3081199] UNITED HEALTHCARE 87726 [308119901] 105.4 percent of total billed charges 105.4 161.5 Technical (Hospital) Services NALOXONE 1 MG/ML INJECTION SYRINGE RX-5374 CDM J2310 HCPCS 636 RC 76329-3469-01 NDC outpatient 2 ML 170 170 BLUE CROSS BLUE SHIELD WELLMARK SB889 [3081026] BCBS WYOMING [308102603] 161.5 percent of total billed charges 105.4 161.5 Technical (Hospital) Services NALOXONE 1 MG/ML INJECTION SYRINGE RX-5374 CDM J2310 HCPCS 636 RC 76329-3469-01 NDC outpatient 2 ML 170 170 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES HDHP [308136802] 136 percent of total billed charges 105.4 161.5 Technical (Hospital) Services NALOXONE 1 MG/ML INJECTION SYRINGE RX-5374 CDM J2310 HCPCS 636 RC 76329-3469-01 NDC outpatient 2 ML 170 170 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES EPO [308136803] 136 percent of total billed charges 105.4 161.5 Technical (Hospital) Services NALOXONE 1 MG/ML INJECTION SYRINGE RX-5374 CDM J2310 HCPCS 636 RC 76329-3469-01 NDC outpatient 2 ML 170 170 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES PPO [308136801] 136 percent of total billed charges 105.4 161.5 Technical (Hospital) Services NALOXONE 1 MG/ML INJECTION SYRINGE RX-5374 CDM J2310 HCPCS 636 RC 76329-3469-01 NDC inpatient 2 ML 170 170 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES EPO [308136803] 134.61 percent of total billed charges 105.4 161.5 Technical (Hospital) Services NALOXONE 1 MG/ML INJECTION SYRINGE RX-5374 CDM J2310 HCPCS 636 RC 76329-3469-01 NDC inpatient 2 ML 170 170 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES HDHP [308136802] 134.61 percent of total billed charges 105.4 161.5 Technical (Hospital) Services NALOXONE 1 MG/ML INJECTION SYRINGE RX-5374 CDM J2310 HCPCS 636 RC 76329-3469-01 NDC inpatient 2 ML 170 170 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES PPO [308136801] 134.61 percent of total billed charges 105.4 161.5 Technical (Hospital) Services NALOXONE 1 MG/ML INJECTION SYRINGE RX-5374 CDM J2310 HCPCS 636 RC 76329-3469-01 NDC inpatient 2 ML 170 170 HEALTHPARTNERS SX009 HEALTHPARTNERS 134.61 percent of total billed charges 105.4 161.5 Technical (Hospital) Services NALOXONE 1 MG/ML INJECTION SYRINGE RX-5374 CDM J2310 HCPCS 636 RC 76329-3469-01 NDC inpatient 2 ML 170 170 MEDICA (COMMERCIAL) 94265 [3081118] MEDICA CLAIMS [308111801] 153 percent of total billed charges 105.4 161.5 Technical (Hospital) Services NALOXONE 1 MG/ML INJECTION SYRINGE RX-5374 CDM J2310 HCPCS 636 RC 76329-3469-01 NDC inpatient 2 ML 170 170 MULTIPLAN INC 34080 [3081285] MULTIPLAN INC [308128501] 161.5 percent of total billed charges 105.4 161.5 Technical (Hospital) Services NALOXONE 1 MG/ML INJECTION SYRINGE RX-5374 CDM J2310 HCPCS 636 RC 76329-3469-01 NDC inpatient 2 ML 170 170 CIGNA 62308 [3081051] CIGNA 62308 [308105105] 134.61 percent of total billed charges 105.4 161.5 Technical (Hospital) Services NALOXONE 1 MG/ML INJECTION SYRINGE RX-5374 CDM J2310 HCPCS 636 RC 76329-3469-01 NDC inpatient 2 ML 170 170 CIGNA 62308 [3081051] CIGNA STATE OF WYOMING [308105107] 134.61 percent of total billed charges 105.4 161.5 Technical (Hospital) Services NALOXONE 1 MG/ML INJECTION SYRINGE RX-5374 CDM J2310 HCPCS 636 RC 76329-3469-01 NDC inpatient 2 ML 170 170 BLUE CROSS BLUE SHIELD WELLMARK SB889 [3081026] BCBS WYOMING [308102603] 161.5 percent of total billed charges 105.4 161.5 Technical (Hospital) Services NALOXONE 1 MG/ML INJECTION SYRINGE RX-5374 CDM J2310 HCPCS 636 RC 76329-3469-01 NDC inpatient 2 ML 170 170 UNITED HEALTHCARE (COMMERCIAL) [3081199] UNITED HEALTHCARE 87726 [308119901] 105.4 percent of total billed charges 105.4 161.5 Technical (Hospital) Services NALBUPHINE 10 MG/ML INJECTION SOLUTION RX-5339 CDM J2300 HCPCS 636 RC 00409-1464-01 NDC outpatient 10 ML 176.23 176.23 CIGNA 62308 [3081051] CIGNA 62308 [308105105] 140.98 percent of total billed charges 109.26 167.42 Technical (Hospital) Services NALBUPHINE 10 MG/ML INJECTION SOLUTION RX-5339 CDM J2300 HCPCS 636 RC 00409-1464-01 NDC outpatient 10 ML 176.23 176.23 CIGNA 62308 [3081051] CIGNA STATE OF WYOMING [308105107] 140.98 percent of total billed charges 109.26 167.42 Technical (Hospital) Services NALBUPHINE 10 MG/ML INJECTION SOLUTION RX-5339 CDM J2300 HCPCS 636 RC 00409-1464-01 NDC outpatient 10 ML 176.23 176.23 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES PPO [308136801] 140.98 percent of total billed charges 109.26 167.42 Technical (Hospital) Services NALBUPHINE 10 MG/ML INJECTION SOLUTION RX-5339 CDM J2300 HCPCS 636 RC 00409-1464-01 NDC outpatient 10 ML 176.23 176.23 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES EPO [308136803] 140.98 percent of total billed charges 109.26 167.42 Technical (Hospital) Services NALBUPHINE 10 MG/ML INJECTION SOLUTION RX-5339 CDM J2300 HCPCS 636 RC 00409-1464-01 NDC outpatient 10 ML 176.23 176.23 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES HDHP [308136802] 140.98 percent of total billed charges 109.26 167.42 Technical (Hospital) Services NALBUPHINE 10 MG/ML INJECTION SOLUTION RX-5339 CDM J2300 HCPCS 636 RC 00409-1464-01 NDC outpatient 10 ML 176.23 176.23 BLUE CROSS BLUE SHIELD WELLMARK SB889 [3081026] BCBS WYOMING [308102603] 167.42 percent of total billed charges 109.26 167.42 Technical (Hospital) Services NALBUPHINE 10 MG/ML INJECTION SOLUTION RX-5339 CDM J2300 HCPCS 636 RC 00409-1464-01 NDC outpatient 10 ML 176.23 176.23 UNITED HEALTHCARE (COMMERCIAL) [3081199] UNITED HEALTHCARE 87726 [308119901] 109.26 percent of total billed charges 109.26 167.42 Technical (Hospital) Services NALBUPHINE 10 MG/ML INJECTION SOLUTION RX-5339 CDM J2300 HCPCS 636 RC 00409-1464-01 NDC outpatient 10 ML 176.23 176.23 HEALTHPARTNERS SX009 HEALTHPARTNERS 140.98 percent of total billed charges 109.26 167.42 Technical (Hospital) Services NALBUPHINE 10 MG/ML INJECTION SOLUTION RX-5339 CDM J2300 HCPCS 636 RC 00409-1464-01 NDC outpatient 10 ML 176.23 176.23 MEDICA (COMMERCIAL) 94265 [3081118] MEDICA CLAIMS [308111801] 158.61 percent of total billed charges 109.26 167.42 Technical (Hospital) Services NALBUPHINE 10 MG/ML INJECTION SOLUTION RX-5339 CDM J2300 HCPCS 636 RC 00409-1464-01 NDC outpatient 10 ML 176.23 176.23 MULTIPLAN INC 34080 [3081285] MULTIPLAN INC [308128501] 167.42 percent of total billed charges 109.26 167.42 Technical (Hospital) Services NALBUPHINE 10 MG/ML INJECTION SOLUTION RX-5339 CDM J2300 HCPCS 636 RC 00409-1464-01 NDC inpatient 10 ML 176.23 176.23 MULTIPLAN INC 34080 [3081285] MULTIPLAN INC [308128501] 167.42 percent of total billed charges 109.26 167.42 Technical (Hospital) Services NALBUPHINE 10 MG/ML INJECTION SOLUTION RX-5339 CDM J2300 HCPCS 636 RC 00409-1464-01 NDC inpatient 10 ML 176.23 176.23 MEDICA (COMMERCIAL) 94265 [3081118] MEDICA CLAIMS [308111801] 158.61 percent of total billed charges 109.26 167.42 Technical (Hospital) Services NALBUPHINE 10 MG/ML INJECTION SOLUTION RX-5339 CDM J2300 HCPCS 636 RC 00409-1464-01 NDC inpatient 10 ML 176.23 176.23 CIGNA 62308 [3081051] CIGNA 62308 [308105105] 139.54 percent of total billed charges 109.26 167.42 Technical (Hospital) Services NALBUPHINE 10 MG/ML INJECTION SOLUTION RX-5339 CDM J2300 HCPCS 636 RC 00409-1464-01 NDC inpatient 10 ML 176.23 176.23 CIGNA 62308 [3081051] CIGNA STATE OF WYOMING [308105107] 139.54 percent of total billed charges 109.26 167.42 Technical (Hospital) Services NALBUPHINE 10 MG/ML INJECTION SOLUTION RX-5339 CDM J2300 HCPCS 636 RC 00409-1464-01 NDC inpatient 10 ML 176.23 176.23 UNITED HEALTHCARE (COMMERCIAL) [3081199] UNITED HEALTHCARE 87726 [308119901] 109.26 percent of total billed charges 109.26 167.42 Technical (Hospital) Services NALBUPHINE 10 MG/ML INJECTION SOLUTION RX-5339 CDM J2300 HCPCS 636 RC 00409-1464-01 NDC inpatient 10 ML 176.23 176.23 BLUE CROSS BLUE SHIELD WELLMARK SB889 [3081026] BCBS WYOMING [308102603] 167.42 percent of total billed charges 109.26 167.42 Technical (Hospital) Services NALBUPHINE 10 MG/ML INJECTION SOLUTION RX-5339 CDM J2300 HCPCS 636 RC 00409-1464-01 NDC inpatient 10 ML 176.23 176.23 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES EPO [308136803] 139.54 percent of total billed charges 109.26 167.42 Technical (Hospital) Services NALBUPHINE 10 MG/ML INJECTION SOLUTION RX-5339 CDM J2300 HCPCS 636 RC 00409-1464-01 NDC inpatient 10 ML 176.23 176.23 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES HDHP [308136802] 139.54 percent of total billed charges 109.26 167.42 Technical (Hospital) Services NALBUPHINE 10 MG/ML INJECTION SOLUTION RX-5339 CDM J2300 HCPCS 636 RC 00409-1464-01 NDC inpatient 10 ML 176.23 176.23 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES PPO [308136801] 139.54 percent of total billed charges 109.26 167.42 Technical (Hospital) Services NALBUPHINE 10 MG/ML INJECTION SOLUTION RX-5339 CDM J2300 HCPCS 636 RC 00409-1464-01 NDC inpatient 10 ML 176.23 176.23 HEALTHPARTNERS SX009 HEALTHPARTNERS 139.54 percent of total billed charges 109.26 167.42 Technical (Hospital) Services MORPHINE (PF) 1 MG/ML INJECTION SOLUTION RX-15852 CDM J2274 HCPCS 636 RC 00641-6019-10 NDC outpatient 10 ML 151.46 151.46 BLUE CROSS BLUE SHIELD WELLMARK SB889 [3081026] BCBS WYOMING [308102603] 143.89 percent of total billed charges 93.91 143.89 Technical (Hospital) Services MORPHINE (PF) 1 MG/ML INJECTION SOLUTION RX-15852 CDM J2274 HCPCS 636 RC 00641-6019-10 NDC outpatient 10 ML 151.46 151.46 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES EPO [308136803] 121.17 percent of total billed charges 93.91 143.89 Technical (Hospital) Services MORPHINE (PF) 1 MG/ML INJECTION SOLUTION RX-15852 CDM J2274 HCPCS 636 RC 00641-6019-10 NDC outpatient 10 ML 151.46 151.46 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES HDHP [308136802] 121.17 percent of total billed charges 93.91 143.89 Technical (Hospital) Services MORPHINE (PF) 1 MG/ML INJECTION SOLUTION RX-15852 CDM J2274 HCPCS 636 RC 00641-6019-10 NDC outpatient 10 ML 151.46 151.46 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES PPO [308136801] 121.17 percent of total billed charges 93.91 143.89 Technical (Hospital) Services MORPHINE (PF) 1 MG/ML INJECTION SOLUTION RX-15852 CDM J2274 HCPCS 636 RC 00641-6019-10 NDC outpatient 10 ML 151.46 151.46 MULTIPLAN INC 34080 [3081285] MULTIPLAN INC [308128501] 143.89 percent of total billed charges 93.91 143.89 Technical (Hospital) Services MORPHINE (PF) 1 MG/ML INJECTION SOLUTION RX-15852 CDM J2274 HCPCS 636 RC 00641-6019-10 NDC outpatient 10 ML 151.46 151.46 MEDICA (COMMERCIAL) 94265 [3081118] MEDICA CLAIMS [308111801] 136.31 percent of total billed charges 93.91 143.89 Technical (Hospital) Services MORPHINE (PF) 1 MG/ML INJECTION SOLUTION RX-15852 CDM J2274 HCPCS 636 RC 00641-6019-10 NDC outpatient 10 ML 151.46 151.46 UNITED HEALTHCARE (COMMERCIAL) [3081199] UNITED HEALTHCARE 87726 [308119901] 93.91 percent of total billed charges 93.91 143.89 Technical (Hospital) Services MORPHINE (PF) 1 MG/ML INJECTION SOLUTION RX-15852 CDM J2274 HCPCS 636 RC 00641-6019-10 NDC outpatient 10 ML 151.46 151.46 HEALTHPARTNERS SX009 HEALTHPARTNERS 121.17 percent of total billed charges 93.91 143.89 Technical (Hospital) Services MORPHINE (PF) 1 MG/ML INJECTION SOLUTION RX-15852 CDM J2274 HCPCS 636 RC 00641-6019-10 NDC outpatient 10 ML 151.46 151.46 CIGNA 62308 [3081051] CIGNA 62308 [308105105] 121.17 percent of total billed charges 93.91 143.89 Technical (Hospital) Services MORPHINE (PF) 1 MG/ML INJECTION SOLUTION RX-15852 CDM J2274 HCPCS 636 RC 00641-6019-10 NDC outpatient 10 ML 151.46 151.46 CIGNA 62308 [3081051] CIGNA STATE OF WYOMING [308105107] 121.17 percent of total billed charges 93.91 143.89 Technical (Hospital) Services MORPHINE (PF) 1 MG/ML INJECTION SOLUTION RX-15852 CDM J2274 HCPCS 636 RC 00641-6019-10 NDC inpatient 10 ML 151.46 151.46 UNITED HEALTHCARE (COMMERCIAL) [3081199] UNITED HEALTHCARE 87726 [308119901] 93.91 percent of total billed charges 93.91 143.89 Technical (Hospital) Services MORPHINE (PF) 1 MG/ML INJECTION SOLUTION RX-15852 CDM J2274 HCPCS 636 RC 00641-6019-10 NDC inpatient 10 ML 151.46 151.46 BLUE CROSS BLUE SHIELD WELLMARK SB889 [3081026] BCBS WYOMING [308102603] 143.89 percent of total billed charges 93.91 143.89 Technical (Hospital) Services MORPHINE (PF) 1 MG/ML INJECTION SOLUTION RX-15852 CDM J2274 HCPCS 636 RC 00641-6019-10 NDC inpatient 10 ML 151.46 151.46 CIGNA 62308 [3081051] CIGNA 62308 [308105105] 119.93 percent of total billed charges 93.91 143.89 Technical (Hospital) Services MORPHINE (PF) 1 MG/ML INJECTION SOLUTION RX-15852 CDM J2274 HCPCS 636 RC 00641-6019-10 NDC inpatient 10 ML 151.46 151.46 CIGNA 62308 [3081051] CIGNA STATE OF WYOMING [308105107] 119.93 percent of total billed charges 93.91 143.89 Technical (Hospital) Services MORPHINE (PF) 1 MG/ML INJECTION SOLUTION RX-15852 CDM J2274 HCPCS 636 RC 00641-6019-10 NDC inpatient 10 ML 151.46 151.46 MULTIPLAN INC 34080 [3081285] MULTIPLAN INC [308128501] 143.89 percent of total billed charges 93.91 143.89 Technical (Hospital) Services MORPHINE (PF) 1 MG/ML INJECTION SOLUTION RX-15852 CDM J2274 HCPCS 636 RC 00641-6019-10 NDC inpatient 10 ML 151.46 151.46 MEDICA (COMMERCIAL) 94265 [3081118] MEDICA CLAIMS [308111801] 136.31 percent of total billed charges 93.91 143.89 Technical (Hospital) Services MORPHINE (PF) 1 MG/ML INJECTION SOLUTION RX-15852 CDM J2274 HCPCS 636 RC 00641-6019-10 NDC inpatient 10 ML 151.46 151.46 HEALTHPARTNERS SX009 HEALTHPARTNERS 119.93 percent of total billed charges 93.91 143.89 Technical (Hospital) Services MORPHINE (PF) 1 MG/ML INJECTION SOLUTION RX-15852 CDM J2274 HCPCS 636 RC 00641-6019-10 NDC inpatient 10 ML 151.46 151.46 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES HDHP [308136802] 119.93 percent of total billed charges 93.91 143.89 Technical (Hospital) Services MORPHINE (PF) 1 MG/ML INJECTION SOLUTION RX-15852 CDM J2274 HCPCS 636 RC 00641-6019-10 NDC inpatient 10 ML 151.46 151.46 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES PPO [308136801] 119.93 percent of total billed charges 93.91 143.89 Technical (Hospital) Services MORPHINE (PF) 1 MG/ML INJECTION SOLUTION RX-15852 CDM J2274 HCPCS 636 RC 00641-6019-10 NDC inpatient 10 ML 151.46 151.46 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES EPO [308136803] 119.93 percent of total billed charges 93.91 143.89 Technical (Hospital) Services MORPHINE 10 MG/ML INTRAVENOUS SOLUTION RX-27390 CDM J2270 HCPCS 636 RC 00641-6127-25 NDC outpatient 1 ML 60.85 60.85 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES EPO [308136803] 48.68 percent of total billed charges 37.73 57.81 Technical (Hospital) Services MORPHINE 10 MG/ML INTRAVENOUS SOLUTION RX-27390 CDM J2270 HCPCS 636 RC 00641-6127-25 NDC outpatient 1 ML 60.85 60.85 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES HDHP [308136802] 48.68 percent of total billed charges 37.73 57.81 Technical (Hospital) Services MORPHINE 10 MG/ML INTRAVENOUS SOLUTION RX-27390 CDM J2270 HCPCS 636 RC 00641-6127-25 NDC outpatient 1 ML 60.85 60.85 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES PPO [308136801] 48.68 percent of total billed charges 37.73 57.81 Technical (Hospital) Services MORPHINE 10 MG/ML INTRAVENOUS SOLUTION RX-27390 CDM J2270 HCPCS 636 RC 00641-6127-25 NDC outpatient 1 ML 60.85 60.85 BLUE CROSS BLUE SHIELD WELLMARK SB889 [3081026] BCBS WYOMING [308102603] 57.81 percent of total billed charges 37.73 57.81 Technical (Hospital) Services MORPHINE 10 MG/ML INTRAVENOUS SOLUTION RX-27390 CDM J2270 HCPCS 636 RC 00641-6127-25 NDC outpatient 1 ML 60.85 60.85 MEDICA (COMMERCIAL) 94265 [3081118] MEDICA CLAIMS [308111801] 54.77 percent of total billed charges 37.73 57.81 Technical (Hospital) Services MORPHINE 10 MG/ML INTRAVENOUS SOLUTION RX-27390 CDM J2270 HCPCS 636 RC 00641-6127-25 NDC outpatient 1 ML 60.85 60.85 CIGNA 62308 [3081051] CIGNA 62308 [308105105] 48.68 percent of total billed charges 37.73 57.81 Technical (Hospital) Services MORPHINE 10 MG/ML INTRAVENOUS SOLUTION RX-27390 CDM J2270 HCPCS 636 RC 00641-6127-25 NDC outpatient 1 ML 60.85 60.85 CIGNA 62308 [3081051] CIGNA STATE OF WYOMING [308105107] 48.68 percent of total billed charges 37.73 57.81 Technical (Hospital) Services MORPHINE 10 MG/ML INTRAVENOUS SOLUTION RX-27390 CDM J2270 HCPCS 636 RC 00641-6127-25 NDC outpatient 1 ML 60.85 60.85 MULTIPLAN INC 34080 [3081285] MULTIPLAN INC [308128501] 57.81 percent of total billed charges 37.73 57.81 Technical (Hospital) Services MORPHINE 10 MG/ML INTRAVENOUS SOLUTION RX-27390 CDM J2270 HCPCS 636 RC 00641-6127-25 NDC outpatient 1 ML 60.85 60.85 UNITED HEALTHCARE (COMMERCIAL) [3081199] UNITED HEALTHCARE 87726 [308119901] 37.73 percent of total billed charges 37.73 57.81 Technical (Hospital) Services MORPHINE 10 MG/ML INTRAVENOUS SOLUTION RX-27390 CDM J2270 HCPCS 636 RC 00641-6127-25 NDC outpatient 1 ML 60.85 60.85 HEALTHPARTNERS SX009 HEALTHPARTNERS 48.68 percent of total billed charges 37.73 57.81 Technical (Hospital) Services MORPHINE 10 MG/ML INTRAVENOUS SOLUTION RX-27390 CDM J2270 HCPCS 636 RC 00641-6127-25 NDC inpatient 1 ML 60.85 60.85 MEDICA (COMMERCIAL) 94265 [3081118] MEDICA CLAIMS [308111801] 54.77 percent of total billed charges 37.73 57.81 Technical (Hospital) Services MORPHINE 10 MG/ML INTRAVENOUS SOLUTION RX-27390 CDM J2270 HCPCS 636 RC 00641-6127-25 NDC inpatient 1 ML 60.85 60.85 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES PPO [308136801] 48.18 percent of total billed charges 37.73 57.81 Technical (Hospital) Services MORPHINE 10 MG/ML INTRAVENOUS SOLUTION RX-27390 CDM J2270 HCPCS 636 RC 00641-6127-25 NDC inpatient 1 ML 60.85 60.85 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES HDHP [308136802] 48.18 percent of total billed charges 37.73 57.81 Technical (Hospital) Services MORPHINE 10 MG/ML INTRAVENOUS SOLUTION RX-27390 CDM J2270 HCPCS 636 RC 00641-6127-25 NDC inpatient 1 ML 60.85 60.85 HEALTHPARTNERS SX009 HEALTHPARTNERS 48.18 percent of total billed charges 37.73 57.81 Technical (Hospital) Services MORPHINE 10 MG/ML INTRAVENOUS SOLUTION RX-27390 CDM J2270 HCPCS 636 RC 00641-6127-25 NDC inpatient 1 ML 60.85 60.85 MULTIPLAN INC 34080 [3081285] MULTIPLAN INC [308128501] 57.81 percent of total billed charges 37.73 57.81 Technical (Hospital) Services MORPHINE 10 MG/ML INTRAVENOUS SOLUTION RX-27390 CDM J2270 HCPCS 636 RC 00641-6127-25 NDC inpatient 1 ML 60.85 60.85 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES EPO [308136803] 48.18 percent of total billed charges 37.73 57.81 Technical (Hospital) Services MORPHINE 10 MG/ML INTRAVENOUS SOLUTION RX-27390 CDM J2270 HCPCS 636 RC 00641-6127-25 NDC inpatient 1 ML 60.85 60.85 CIGNA 62308 [3081051] CIGNA 62308 [308105105] 48.18 percent of total billed charges 37.73 57.81 Technical (Hospital) Services MORPHINE 10 MG/ML INTRAVENOUS SOLUTION RX-27390 CDM J2270 HCPCS 636 RC 00641-6127-25 NDC inpatient 1 ML 60.85 60.85 CIGNA 62308 [3081051] CIGNA STATE OF WYOMING [308105107] 48.18 percent of total billed charges 37.73 57.81 Technical (Hospital) Services MORPHINE 10 MG/ML INTRAVENOUS SOLUTION RX-27390 CDM J2270 HCPCS 636 RC 00641-6127-25 NDC inpatient 1 ML 60.85 60.85 BLUE CROSS BLUE SHIELD WELLMARK SB889 [3081026] BCBS WYOMING [308102603] 57.81 percent of total billed charges 37.73 57.81 Technical (Hospital) Services MORPHINE 10 MG/ML INTRAVENOUS SOLUTION RX-27390 CDM J2270 HCPCS 636 RC 00641-6127-25 NDC inpatient 1 ML 60.85 60.85 UNITED HEALTHCARE (COMMERCIAL) [3081199] UNITED HEALTHCARE 87726 [308119901] 37.73 percent of total billed charges 37.73 57.81 Technical (Hospital) Services MORPHINE 4 MG/ML INJECTION WRAPPER RX-4080050003 CDM J2270 HCPCS 636 RC 00641-6125-25 NDC inpatient 1 ML 60.8 60.8 BLUE CROSS BLUE SHIELD WELLMARK SB889 [3081026] BCBS WYOMING [308102603] 57.76 percent of total billed charges 37.7 57.76 Technical (Hospital) Services MORPHINE 4 MG/ML INJECTION WRAPPER RX-4080050003 CDM J2270 HCPCS 636 RC 00641-6125-25 NDC inpatient 1 ML 60.8 60.8 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES EPO [308136803] 48.14 percent of total billed charges 37.7 57.76 Technical (Hospital) Services MORPHINE 4 MG/ML INJECTION WRAPPER RX-4080050003 CDM J2270 HCPCS 636 RC 00641-6125-25 NDC inpatient 1 ML 60.8 60.8 UNITED HEALTHCARE (COMMERCIAL) [3081199] UNITED HEALTHCARE 87726 [308119901] 37.7 percent of total billed charges 37.7 57.76 Technical (Hospital) Services MORPHINE 4 MG/ML INJECTION WRAPPER RX-4080050003 CDM J2270 HCPCS 636 RC 00641-6125-25 NDC inpatient 1 ML 60.8 60.8 CIGNA 62308 [3081051] CIGNA 62308 [308105105] 48.14 percent of total billed charges 37.7 57.76 Technical (Hospital) Services MORPHINE 4 MG/ML INJECTION WRAPPER RX-4080050003 CDM J2270 HCPCS 636 RC 00641-6125-25 NDC inpatient 1 ML 60.8 60.8 CIGNA 62308 [3081051] CIGNA STATE OF WYOMING [308105107] 48.14 percent of total billed charges 37.7 57.76 Technical (Hospital) Services MORPHINE 4 MG/ML INJECTION WRAPPER RX-4080050003 CDM J2270 HCPCS 636 RC 00641-6125-25 NDC inpatient 1 ML 60.8 60.8 MULTIPLAN INC 34080 [3081285] MULTIPLAN INC [308128501] 57.76 percent of total billed charges 37.7 57.76 Technical (Hospital) Services MORPHINE 4 MG/ML INJECTION WRAPPER RX-4080050003 CDM J2270 HCPCS 636 RC 00641-6125-25 NDC inpatient 1 ML 60.8 60.8 MEDICA (COMMERCIAL) 94265 [3081118] MEDICA CLAIMS [308111801] 54.72 percent of total billed charges 37.7 57.76 Technical (Hospital) Services MORPHINE 4 MG/ML INJECTION WRAPPER RX-4080050003 CDM J2270 HCPCS 636 RC 00641-6125-25 NDC inpatient 1 ML 60.8 60.8 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES PPO [308136801] 48.14 percent of total billed charges 37.7 57.76 Technical (Hospital) Services MORPHINE 4 MG/ML INJECTION WRAPPER RX-4080050003 CDM J2270 HCPCS 636 RC 00641-6125-25 NDC inpatient 1 ML 60.8 60.8 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES HDHP [308136802] 48.14 percent of total billed charges 37.7 57.76 Technical (Hospital) Services MORPHINE 4 MG/ML INJECTION WRAPPER RX-4080050003 CDM J2270 HCPCS 636 RC 00641-6125-25 NDC inpatient 1 ML 60.8 60.8 HEALTHPARTNERS SX009 HEALTHPARTNERS 48.14 percent of total billed charges 37.7 57.76 Technical (Hospital) Services MORPHINE 4 MG/ML INJECTION WRAPPER RX-4080050003 CDM J2270 HCPCS 636 RC 00641-6125-25 NDC outpatient 1 ML 60.8 60.8 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES HDHP [308136802] 48.64 percent of total billed charges 37.7 57.76 Technical (Hospital) Services MORPHINE 4 MG/ML INJECTION WRAPPER RX-4080050003 CDM J2270 HCPCS 636 RC 00641-6125-25 NDC outpatient 1 ML 60.8 60.8 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES EPO [308136803] 48.64 percent of total billed charges 37.7 57.76 Technical (Hospital) Services MORPHINE 4 MG/ML INJECTION WRAPPER RX-4080050003 CDM J2270 HCPCS 636 RC 00641-6125-25 NDC outpatient 1 ML 60.8 60.8 MEDICA (COMMERCIAL) 94265 [3081118] MEDICA CLAIMS [308111801] 54.72 percent of total billed charges 37.7 57.76 Technical (Hospital) Services MORPHINE 4 MG/ML INJECTION WRAPPER RX-4080050003 CDM J2270 HCPCS 636 RC 00641-6125-25 NDC outpatient 1 ML 60.8 60.8 BLUE CROSS BLUE SHIELD WELLMARK SB889 [3081026] BCBS WYOMING [308102603] 57.76 percent of total billed charges 37.7 57.76 Technical (Hospital) Services MORPHINE 4 MG/ML INJECTION WRAPPER RX-4080050003 CDM J2270 HCPCS 636 RC 00641-6125-25 NDC outpatient 1 ML 60.8 60.8 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES PPO [308136801] 48.64 percent of total billed charges 37.7 57.76 Technical (Hospital) Services MORPHINE 4 MG/ML INJECTION WRAPPER RX-4080050003 CDM J2270 HCPCS 636 RC 00641-6125-25 NDC outpatient 1 ML 60.8 60.8 HEALTHPARTNERS SX009 HEALTHPARTNERS 48.64 percent of total billed charges 37.7 57.76 Technical (Hospital) Services MORPHINE 4 MG/ML INJECTION WRAPPER RX-4080050003 CDM J2270 HCPCS 636 RC 00641-6125-25 NDC outpatient 1 ML 60.8 60.8 UNITED HEALTHCARE (COMMERCIAL) [3081199] UNITED HEALTHCARE 87726 [308119901] 37.7 percent of total billed charges 37.7 57.76 Technical (Hospital) Services MORPHINE 4 MG/ML INJECTION WRAPPER RX-4080050003 CDM J2270 HCPCS 636 RC 00641-6125-25 NDC outpatient 1 ML 60.8 60.8 MULTIPLAN INC 34080 [3081285] MULTIPLAN INC [308128501] 57.76 percent of total billed charges 37.7 57.76 Technical (Hospital) Services MORPHINE 4 MG/ML INJECTION WRAPPER RX-4080050003 CDM J2270 HCPCS 636 RC 00641-6125-25 NDC outpatient 1 ML 60.8 60.8 CIGNA 62308 [3081051] CIGNA 62308 [308105105] 48.64 percent of total billed charges 37.7 57.76 Technical (Hospital) Services MORPHINE 4 MG/ML INJECTION WRAPPER RX-4080050003 CDM J2270 HCPCS 636 RC 00641-6125-25 NDC outpatient 1 ML 60.8 60.8 CIGNA 62308 [3081051] CIGNA STATE OF WYOMING [308105107] 48.64 percent of total billed charges 37.7 57.76 Technical (Hospital) Services MIDAZOLAM (PF & NON-PF) 1 MG/ML INJECTION SOLUTION WRAPPER RX-4080030046 CDM J2250 HCPCS 636 RC 00409-2305-16 NDC inpatient 2 ML 59.37 59.37 CIGNA 62308 [3081051] CIGNA 62308 [308105105] 47.01 percent of total billed charges 36.81 56.4 Technical (Hospital) Services MIDAZOLAM (PF & NON-PF) 1 MG/ML INJECTION SOLUTION WRAPPER RX-4080030046 CDM J2250 HCPCS 636 RC 00409-2305-16 NDC inpatient 2 ML 59.37 59.37 CIGNA 62308 [3081051] CIGNA STATE OF WYOMING [308105107] 47.01 percent of total billed charges 36.81 56.4 Technical (Hospital) Services MIDAZOLAM (PF & NON-PF) 1 MG/ML INJECTION SOLUTION WRAPPER RX-4080030046 CDM J2250 HCPCS 636 RC 00409-2305-16 NDC inpatient 2 ML 59.37 59.37 BLUE CROSS BLUE SHIELD WELLMARK SB889 [3081026] BCBS WYOMING [308102603] 56.4 percent of total billed charges 36.81 56.4 Technical (Hospital) Services MIDAZOLAM (PF & NON-PF) 1 MG/ML INJECTION SOLUTION WRAPPER RX-4080030046 CDM J2250 HCPCS 636 RC 00409-2305-16 NDC inpatient 2 ML 59.37 59.37 UNITED HEALTHCARE (COMMERCIAL) [3081199] UNITED HEALTHCARE 87726 [308119901] 36.81 percent of total billed charges 36.81 56.4 Technical (Hospital) Services MIDAZOLAM (PF & NON-PF) 1 MG/ML INJECTION SOLUTION WRAPPER RX-4080030046 CDM J2250 HCPCS 636 RC 00409-2305-16 NDC inpatient 2 ML 59.37 59.37 MEDICA (COMMERCIAL) 94265 [3081118] MEDICA CLAIMS [308111801] 53.43 percent of total billed charges 36.81 56.4 Technical (Hospital) Services MIDAZOLAM (PF & NON-PF) 1 MG/ML INJECTION SOLUTION WRAPPER RX-4080030046 CDM J2250 HCPCS 636 RC 00409-2305-16 NDC inpatient 2 ML 59.37 59.37 MULTIPLAN INC 34080 [3081285] MULTIPLAN INC [308128501] 56.4 percent of total billed charges 36.81 56.4 Technical (Hospital) Services MIDAZOLAM (PF & NON-PF) 1 MG/ML INJECTION SOLUTION WRAPPER RX-4080030046 CDM J2250 HCPCS 636 RC 00409-2305-16 NDC inpatient 2 ML 59.37 59.37 HEALTHPARTNERS SX009 HEALTHPARTNERS 47.01 percent of total billed charges 36.81 56.4 Technical (Hospital) Services MIDAZOLAM (PF & NON-PF) 1 MG/ML INJECTION SOLUTION WRAPPER RX-4080030046 CDM J2250 HCPCS 636 RC 00409-2305-16 NDC inpatient 2 ML 59.37 59.37 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES PPO [308136801] 47.01 percent of total billed charges 36.81 56.4 Technical (Hospital) Services MIDAZOLAM (PF & NON-PF) 1 MG/ML INJECTION SOLUTION WRAPPER RX-4080030046 CDM J2250 HCPCS 636 RC 00409-2305-16 NDC inpatient 2 ML 59.37 59.37 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES HDHP [308136802] 47.01 percent of total billed charges 36.81 56.4 Technical (Hospital) Services MIDAZOLAM (PF & NON-PF) 1 MG/ML INJECTION SOLUTION WRAPPER RX-4080030046 CDM J2250 HCPCS 636 RC 00409-2305-16 NDC inpatient 2 ML 59.37 59.37 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES EPO [308136803] 47.01 percent of total billed charges 36.81 56.4 Technical (Hospital) Services MIDAZOLAM (PF & NON-PF) 1 MG/ML INJECTION SOLUTION WRAPPER RX-4080030046 CDM J2250 HCPCS 636 RC 00409-2305-16 NDC outpatient 2 ML 59.37 59.37 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES EPO [308136803] 47.5 percent of total billed charges 36.81 56.4 Technical (Hospital) Services MIDAZOLAM (PF & NON-PF) 1 MG/ML INJECTION SOLUTION WRAPPER RX-4080030046 CDM J2250 HCPCS 636 RC 00409-2305-16 NDC outpatient 2 ML 59.37 59.37 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES PPO [308136801] 47.5 percent of total billed charges 36.81 56.4 Technical (Hospital) Services MIDAZOLAM (PF & NON-PF) 1 MG/ML INJECTION SOLUTION WRAPPER RX-4080030046 CDM J2250 HCPCS 636 RC 00409-2305-16 NDC outpatient 2 ML 59.37 59.37 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES HDHP [308136802] 47.5 percent of total billed charges 36.81 56.4 Technical (Hospital) Services MIDAZOLAM (PF & NON-PF) 1 MG/ML INJECTION SOLUTION WRAPPER RX-4080030046 CDM J2250 HCPCS 636 RC 00409-2305-16 NDC outpatient 2 ML 59.37 59.37 BLUE CROSS BLUE SHIELD WELLMARK SB889 [3081026] BCBS WYOMING [308102603] 56.4 percent of total billed charges 36.81 56.4 Technical (Hospital) Services MIDAZOLAM (PF & NON-PF) 1 MG/ML INJECTION SOLUTION WRAPPER RX-4080030046 CDM J2250 HCPCS 636 RC 00409-2305-16 NDC outpatient 2 ML 59.37 59.37 UNITED HEALTHCARE (COMMERCIAL) [3081199] UNITED HEALTHCARE 87726 [308119901] 36.81 percent of total billed charges 36.81 56.4 Technical (Hospital) Services MIDAZOLAM (PF & NON-PF) 1 MG/ML INJECTION SOLUTION WRAPPER RX-4080030046 CDM J2250 HCPCS 636 RC 00409-2305-16 NDC outpatient 2 ML 59.37 59.37 HEALTHPARTNERS SX009 HEALTHPARTNERS 47.5 percent of total billed charges 36.81 56.4 Technical (Hospital) Services MIDAZOLAM (PF & NON-PF) 1 MG/ML INJECTION SOLUTION WRAPPER RX-4080030046 CDM J2250 HCPCS 636 RC 00409-2305-16 NDC outpatient 2 ML 59.37 59.37 MULTIPLAN INC 34080 [3081285] MULTIPLAN INC [308128501] 56.4 percent of total billed charges 36.81 56.4 Technical (Hospital) Services MIDAZOLAM (PF & NON-PF) 1 MG/ML INJECTION SOLUTION WRAPPER RX-4080030046 CDM J2250 HCPCS 636 RC 00409-2305-16 NDC outpatient 2 ML 59.37 59.37 CIGNA 62308 [3081051] CIGNA 62308 [308105105] 47.5 percent of total billed charges 36.81 56.4 Technical (Hospital) Services MIDAZOLAM (PF & NON-PF) 1 MG/ML INJECTION SOLUTION WRAPPER RX-4080030046 CDM J2250 HCPCS 636 RC 00409-2305-16 NDC outpatient 2 ML 59.37 59.37 CIGNA 62308 [3081051] CIGNA STATE OF WYOMING [308105107] 47.5 percent of total billed charges 36.81 56.4 Technical (Hospital) Services MIDAZOLAM (PF & NON-PF) 1 MG/ML INJECTION SOLUTION WRAPPER RX-4080030046 CDM J2250 HCPCS 636 RC 00409-2305-16 NDC outpatient 2 ML 59.37 59.37 MEDICA (COMMERCIAL) 94265 [3081118] MEDICA CLAIMS [308111801] 53.43 percent of total billed charges 36.81 56.4 Technical (Hospital) Services MIDAZOLAM (PF & NON-PF) 5 MG/ML INJECTION SOLUTION WRAPPER RX-4080070036 CDM J2250 HCPCS 636 RC 00409-2308-01 NDC inpatient 1 ML 59.46 59.46 MEDICA (COMMERCIAL) 94265 [3081118] MEDICA CLAIMS [308111801] 53.51 percent of total billed charges 36.87 56.49 Technical (Hospital) Services MIDAZOLAM (PF & NON-PF) 5 MG/ML INJECTION SOLUTION WRAPPER RX-4080070036 CDM J2250 HCPCS 636 RC 00409-2308-01 NDC inpatient 1 ML 59.46 59.46 MULTIPLAN INC 34080 [3081285] MULTIPLAN INC [308128501] 56.49 percent of total billed charges 36.87 56.49 Technical (Hospital) Services MIDAZOLAM (PF & NON-PF) 5 MG/ML INJECTION SOLUTION WRAPPER RX-4080070036 CDM J2250 HCPCS 636 RC 00409-2308-01 NDC inpatient 1 ML 59.46 59.46 HEALTHPARTNERS SX009 HEALTHPARTNERS 47.08 percent of total billed charges 36.87 56.49 Technical (Hospital) Services MIDAZOLAM (PF & NON-PF) 5 MG/ML INJECTION SOLUTION WRAPPER RX-4080070036 CDM J2250 HCPCS 636 RC 00409-2308-01 NDC inpatient 1 ML 59.46 59.46 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES PPO [308136801] 47.08 percent of total billed charges 36.87 56.49 Technical (Hospital) Services MIDAZOLAM (PF & NON-PF) 5 MG/ML INJECTION SOLUTION WRAPPER RX-4080070036 CDM J2250 HCPCS 636 RC 00409-2308-01 NDC inpatient 1 ML 59.46 59.46 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES HDHP [308136802] 47.08 percent of total billed charges 36.87 56.49 Technical (Hospital) Services MIDAZOLAM (PF & NON-PF) 5 MG/ML INJECTION SOLUTION WRAPPER RX-4080070036 CDM J2250 HCPCS 636 RC 00409-2308-01 NDC inpatient 1 ML 59.46 59.46 BLUE CROSS BLUE SHIELD WELLMARK SB889 [3081026] BCBS WYOMING [308102603] 56.49 percent of total billed charges 36.87 56.49 Technical (Hospital) Services MIDAZOLAM (PF & NON-PF) 5 MG/ML INJECTION SOLUTION WRAPPER RX-4080070036 CDM J2250 HCPCS 636 RC 00409-2308-01 NDC inpatient 1 ML 59.46 59.46 UNITED HEALTHCARE (COMMERCIAL) [3081199] UNITED HEALTHCARE 87726 [308119901] 36.87 percent of total billed charges 36.87 56.49 Technical (Hospital) Services MIDAZOLAM (PF & NON-PF) 5 MG/ML INJECTION SOLUTION WRAPPER RX-4080070036 CDM J2250 HCPCS 636 RC 00409-2308-01 NDC inpatient 1 ML 59.46 59.46 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES EPO [308136803] 47.08 percent of total billed charges 36.87 56.49 Technical (Hospital) Services MIDAZOLAM (PF & NON-PF) 5 MG/ML INJECTION SOLUTION WRAPPER RX-4080070036 CDM J2250 HCPCS 636 RC 00409-2308-01 NDC inpatient 1 ML 59.46 59.46 CIGNA 62308 [3081051] CIGNA 62308 [308105105] 47.08 percent of total billed charges 36.87 56.49 Technical (Hospital) Services MIDAZOLAM (PF & NON-PF) 5 MG/ML INJECTION SOLUTION WRAPPER RX-4080070036 CDM J2250 HCPCS 636 RC 00409-2308-01 NDC inpatient 1 ML 59.46 59.46 CIGNA 62308 [3081051] CIGNA STATE OF WYOMING [308105107] 47.08 percent of total billed charges 36.87 56.49 Technical (Hospital) Services MIDAZOLAM (PF & NON-PF) 5 MG/ML INJECTION SOLUTION WRAPPER RX-4080070036 CDM J2250 HCPCS 636 RC 00409-2308-01 NDC outpatient 1 ML 59.46 59.46 CIGNA 62308 [3081051] CIGNA 62308 [308105105] 47.57 percent of total billed charges 36.87 56.49 Technical (Hospital) Services MIDAZOLAM (PF & NON-PF) 5 MG/ML INJECTION SOLUTION WRAPPER RX-4080070036 CDM J2250 HCPCS 636 RC 00409-2308-01 NDC outpatient 1 ML 59.46 59.46 CIGNA 62308 [3081051] CIGNA STATE OF WYOMING [308105107] 47.57 percent of total billed charges 36.87 56.49 Technical (Hospital) Services MIDAZOLAM (PF & NON-PF) 5 MG/ML INJECTION SOLUTION WRAPPER RX-4080070036 CDM J2250 HCPCS 636 RC 00409-2308-01 NDC outpatient 1 ML 59.46 59.46 MULTIPLAN INC 34080 [3081285] MULTIPLAN INC [308128501] 56.49 percent of total billed charges 36.87 56.49 Technical (Hospital) Services MIDAZOLAM (PF & NON-PF) 5 MG/ML INJECTION SOLUTION WRAPPER RX-4080070036 CDM J2250 HCPCS 636 RC 00409-2308-01 NDC outpatient 1 ML 59.46 59.46 UNITED HEALTHCARE (COMMERCIAL) [3081199] UNITED HEALTHCARE 87726 [308119901] 36.87 percent of total billed charges 36.87 56.49 Technical (Hospital) Services MIDAZOLAM (PF & NON-PF) 5 MG/ML INJECTION SOLUTION WRAPPER RX-4080070036 CDM J2250 HCPCS 636 RC 00409-2308-01 NDC outpatient 1 ML 59.46 59.46 HEALTHPARTNERS SX009 HEALTHPARTNERS 47.57 percent of total billed charges 36.87 56.49 Technical (Hospital) Services MIDAZOLAM (PF & NON-PF) 5 MG/ML INJECTION SOLUTION WRAPPER RX-4080070036 CDM J2250 HCPCS 636 RC 00409-2308-01 NDC outpatient 1 ML 59.46 59.46 BLUE CROSS BLUE SHIELD WELLMARK SB889 [3081026] BCBS WYOMING [308102603] 56.49 percent of total billed charges 36.87 56.49 Technical (Hospital) Services MIDAZOLAM (PF & NON-PF) 5 MG/ML INJECTION SOLUTION WRAPPER RX-4080070036 CDM J2250 HCPCS 636 RC 00409-2308-01 NDC outpatient 1 ML 59.46 59.46 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES PPO [308136801] 47.57 percent of total billed charges 36.87 56.49 Technical (Hospital) Services MIDAZOLAM (PF & NON-PF) 5 MG/ML INJECTION SOLUTION WRAPPER RX-4080070036 CDM J2250 HCPCS 636 RC 00409-2308-01 NDC outpatient 1 ML 59.46 59.46 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES EPO [308136803] 47.57 percent of total billed charges 36.87 56.49 Technical (Hospital) Services MIDAZOLAM (PF & NON-PF) 5 MG/ML INJECTION SOLUTION WRAPPER RX-4080070036 CDM J2250 HCPCS 636 RC 00409-2308-01 NDC outpatient 1 ML 59.46 59.46 MEDICA (COMMERCIAL) 94265 [3081118] MEDICA CLAIMS [308111801] 53.51 percent of total billed charges 36.87 56.49 Technical (Hospital) Services MIDAZOLAM (PF & NON-PF) 5 MG/ML INJECTION SOLUTION WRAPPER RX-4080070036 CDM J2250 HCPCS 636 RC 00409-2308-01 NDC outpatient 1 ML 59.46 59.46 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES HDHP [308136802] 47.57 percent of total billed charges 36.87 56.49 Technical (Hospital) Services METHYLERGONOVINE 0.2 MG/ML (1 ML) INJECTION SOLUTION RX-10571 CDM J2210 HCPCS 636 RC 51991-0144-99 NDC outpatient 1 ML 108.26 108.26 BLUE CROSS BLUE SHIELD WELLMARK SB889 [3081026] BCBS WYOMING [308102603] 102.85 percent of total billed charges 67.12 102.85 Technical (Hospital) Services METHYLERGONOVINE 0.2 MG/ML (1 ML) INJECTION SOLUTION RX-10571 CDM J2210 HCPCS 636 RC 51991-0144-99 NDC outpatient 1 ML 108.26 108.26 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES PPO [308136801] 86.61 percent of total billed charges 67.12 102.85 Technical (Hospital) Services METHYLERGONOVINE 0.2 MG/ML (1 ML) INJECTION SOLUTION RX-10571 CDM J2210 HCPCS 636 RC 51991-0144-99 NDC outpatient 1 ML 108.26 108.26 MEDICA (COMMERCIAL) 94265 [3081118] MEDICA CLAIMS [308111801] 97.43 percent of total billed charges 67.12 102.85 Technical (Hospital) Services METHYLERGONOVINE 0.2 MG/ML (1 ML) INJECTION SOLUTION RX-10571 CDM J2210 HCPCS 636 RC 51991-0144-99 NDC outpatient 1 ML 108.26 108.26 CIGNA 62308 [3081051] CIGNA 62308 [308105105] 86.61 percent of total billed charges 67.12 102.85 Technical (Hospital) Services METHYLERGONOVINE 0.2 MG/ML (1 ML) INJECTION SOLUTION RX-10571 CDM J2210 HCPCS 636 RC 51991-0144-99 NDC outpatient 1 ML 108.26 108.26 CIGNA 62308 [3081051] CIGNA STATE OF WYOMING [308105107] 86.61 percent of total billed charges 67.12 102.85 Technical (Hospital) Services METHYLERGONOVINE 0.2 MG/ML (1 ML) INJECTION SOLUTION RX-10571 CDM J2210 HCPCS 636 RC 51991-0144-99 NDC outpatient 1 ML 108.26 108.26 HEALTHPARTNERS SX009 HEALTHPARTNERS 86.61 percent of total billed charges 67.12 102.85 Technical (Hospital) Services METHYLERGONOVINE 0.2 MG/ML (1 ML) INJECTION SOLUTION RX-10571 CDM J2210 HCPCS 636 RC 51991-0144-99 NDC outpatient 1 ML 108.26 108.26 UNITED HEALTHCARE (COMMERCIAL) [3081199] UNITED HEALTHCARE 87726 [308119901] 67.12 percent of total billed charges 67.12 102.85 Technical (Hospital) Services METHYLERGONOVINE 0.2 MG/ML (1 ML) INJECTION SOLUTION RX-10571 CDM J2210 HCPCS 636 RC 51991-0144-99 NDC outpatient 1 ML 108.26 108.26 MULTIPLAN INC 34080 [3081285] MULTIPLAN INC [308128501] 102.85 percent of total billed charges 67.12 102.85 Technical (Hospital) Services METHYLERGONOVINE 0.2 MG/ML (1 ML) INJECTION SOLUTION RX-10571 CDM J2210 HCPCS 636 RC 51991-0144-99 NDC outpatient 1 ML 108.26 108.26 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES HDHP [308136802] 86.61 percent of total billed charges 67.12 102.85 Technical (Hospital) Services METHYLERGONOVINE 0.2 MG/ML (1 ML) INJECTION SOLUTION RX-10571 CDM J2210 HCPCS 636 RC 51991-0144-99 NDC outpatient 1 ML 108.26 108.26 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES EPO [308136803] 86.61 percent of total billed charges 67.12 102.85 Technical (Hospital) Services METHYLERGONOVINE 0.2 MG/ML (1 ML) INJECTION SOLUTION RX-10571 CDM J2210 HCPCS 636 RC 51991-0144-99 NDC inpatient 1 ML 108.26 108.26 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES EPO [308136803] 85.72 percent of total billed charges 67.12 102.85 Technical (Hospital) Services METHYLERGONOVINE 0.2 MG/ML (1 ML) INJECTION SOLUTION RX-10571 CDM J2210 HCPCS 636 RC 51991-0144-99 NDC inpatient 1 ML 108.26 108.26 UNITED HEALTHCARE (COMMERCIAL) [3081199] UNITED HEALTHCARE 87726 [308119901] 67.12 percent of total billed charges 67.12 102.85 Technical (Hospital) Services METHYLERGONOVINE 0.2 MG/ML (1 ML) INJECTION SOLUTION RX-10571 CDM J2210 HCPCS 636 RC 51991-0144-99 NDC inpatient 1 ML 108.26 108.26 BLUE CROSS BLUE SHIELD WELLMARK SB889 [3081026] BCBS WYOMING [308102603] 102.85 percent of total billed charges 67.12 102.85 Technical (Hospital) Services METHYLERGONOVINE 0.2 MG/ML (1 ML) INJECTION SOLUTION RX-10571 CDM J2210 HCPCS 636 RC 51991-0144-99 NDC inpatient 1 ML 108.26 108.26 CIGNA 62308 [3081051] CIGNA 62308 [308105105] 85.72 percent of total billed charges 67.12 102.85 Technical (Hospital) Services METHYLERGONOVINE 0.2 MG/ML (1 ML) INJECTION SOLUTION RX-10571 CDM J2210 HCPCS 636 RC 51991-0144-99 NDC inpatient 1 ML 108.26 108.26 CIGNA 62308 [3081051] CIGNA STATE OF WYOMING [308105107] 85.72 percent of total billed charges 67.12 102.85 Technical (Hospital) Services METHYLERGONOVINE 0.2 MG/ML (1 ML) INJECTION SOLUTION RX-10571 CDM J2210 HCPCS 636 RC 51991-0144-99 NDC inpatient 1 ML 108.26 108.26 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES HDHP [308136802] 85.72 percent of total billed charges 67.12 102.85 Technical (Hospital) Services METHYLERGONOVINE 0.2 MG/ML (1 ML) INJECTION SOLUTION RX-10571 CDM J2210 HCPCS 636 RC 51991-0144-99 NDC inpatient 1 ML 108.26 108.26 MULTIPLAN INC 34080 [3081285] MULTIPLAN INC [308128501] 102.85 percent of total billed charges 67.12 102.85 Technical (Hospital) Services METHYLERGONOVINE 0.2 MG/ML (1 ML) INJECTION SOLUTION RX-10571 CDM J2210 HCPCS 636 RC 51991-0144-99 NDC inpatient 1 ML 108.26 108.26 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES PPO [308136801] 85.72 percent of total billed charges 67.12 102.85 Technical (Hospital) Services METHYLERGONOVINE 0.2 MG/ML (1 ML) INJECTION SOLUTION RX-10571 CDM J2210 HCPCS 636 RC 51991-0144-99 NDC inpatient 1 ML 108.26 108.26 HEALTHPARTNERS SX009 HEALTHPARTNERS 85.72 percent of total billed charges 67.12 102.85 Technical (Hospital) Services METHYLERGONOVINE 0.2 MG/ML (1 ML) INJECTION SOLUTION RX-10571 CDM J2210 HCPCS 636 RC 51991-0144-99 NDC inpatient 1 ML 108.26 108.26 MEDICA (COMMERCIAL) 94265 [3081118] MEDICA CLAIMS [308111801] 97.43 percent of total billed charges 67.12 102.85 Technical (Hospital) Services MEROPENEM 1 GRAM INTRAVENOUS SOLUTION RX-17380 CDM J2185 HCPCS 636 RC 63323-0508-25 NDC outpatient 20 ML 70.4 70.4 BLUE CROSS BLUE SHIELD WELLMARK SB889 [3081026] BCBS WYOMING [308102603] 66.88 percent of total billed charges 43.65 66.88 Technical (Hospital) Services MEROPENEM 1 GRAM INTRAVENOUS SOLUTION RX-17380 CDM J2185 HCPCS 636 RC 63323-0508-25 NDC outpatient 20 ML 70.4 70.4 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES HDHP [308136802] 56.32 percent of total billed charges 43.65 66.88 Technical (Hospital) Services MEROPENEM 1 GRAM INTRAVENOUS SOLUTION RX-17380 CDM J2185 HCPCS 636 RC 63323-0508-25 NDC outpatient 20 ML 70.4 70.4 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES EPO [308136803] 56.32 percent of total billed charges 43.65 66.88 Technical (Hospital) Services MEROPENEM 1 GRAM INTRAVENOUS SOLUTION RX-17380 CDM J2185 HCPCS 636 RC 63323-0508-25 NDC outpatient 20 ML 70.4 70.4 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES PPO [308136801] 56.32 percent of total billed charges 43.65 66.88 Technical (Hospital) Services MEROPENEM 1 GRAM INTRAVENOUS SOLUTION RX-17380 CDM J2185 HCPCS 636 RC 63323-0508-25 NDC outpatient 20 ML 70.4 70.4 MULTIPLAN INC 34080 [3081285] MULTIPLAN INC [308128501] 66.88 percent of total billed charges 43.65 66.88 Technical (Hospital) Services MEROPENEM 1 GRAM INTRAVENOUS SOLUTION RX-17380 CDM J2185 HCPCS 636 RC 63323-0508-25 NDC outpatient 20 ML 70.4 70.4 MEDICA (COMMERCIAL) 94265 [3081118] MEDICA CLAIMS [308111801] 63.36 percent of total billed charges 43.65 66.88 Technical (Hospital) Services MEROPENEM 1 GRAM INTRAVENOUS SOLUTION RX-17380 CDM J2185 HCPCS 636 RC 63323-0508-25 NDC outpatient 20 ML 70.4 70.4 UNITED HEALTHCARE (COMMERCIAL) [3081199] UNITED HEALTHCARE 87726 [308119901] 43.65 percent of total billed charges 43.65 66.88 Technical (Hospital) Services MEROPENEM 1 GRAM INTRAVENOUS SOLUTION RX-17380 CDM J2185 HCPCS 636 RC 63323-0508-25 NDC outpatient 20 ML 70.4 70.4 HEALTHPARTNERS SX009 HEALTHPARTNERS 56.32 percent of total billed charges 43.65 66.88 Technical (Hospital) Services MEROPENEM 1 GRAM INTRAVENOUS SOLUTION RX-17380 CDM J2185 HCPCS 636 RC 63323-0508-25 NDC outpatient 20 ML 70.4 70.4 CIGNA 62308 [3081051] CIGNA STATE OF WYOMING [308105107] 56.32 percent of total billed charges 43.65 66.88 Technical (Hospital) Services MEROPENEM 1 GRAM INTRAVENOUS SOLUTION RX-17380 CDM J2185 HCPCS 636 RC 63323-0508-25 NDC outpatient 20 ML 70.4 70.4 CIGNA 62308 [3081051] CIGNA 62308 [308105105] 56.32 percent of total billed charges 43.65 66.88 Technical (Hospital) Services MEROPENEM 1 GRAM INTRAVENOUS SOLUTION RX-17380 CDM J2185 HCPCS 636 RC 63323-0508-25 NDC inpatient 20 ML 70.4 70.4 MEDICA (COMMERCIAL) 94265 [3081118] MEDICA CLAIMS [308111801] 63.36 percent of total billed charges 43.65 66.88 Technical (Hospital) Services MEROPENEM 1 GRAM INTRAVENOUS SOLUTION RX-17380 CDM J2185 HCPCS 636 RC 63323-0508-25 NDC inpatient 20 ML 70.4 70.4 MULTIPLAN INC 34080 [3081285] MULTIPLAN INC [308128501] 66.88 percent of total billed charges 43.65 66.88 Technical (Hospital) Services MEROPENEM 1 GRAM INTRAVENOUS SOLUTION RX-17380 CDM J2185 HCPCS 636 RC 63323-0508-25 NDC inpatient 20 ML 70.4 70.4 UNITED HEALTHCARE (COMMERCIAL) [3081199] UNITED HEALTHCARE 87726 [308119901] 43.65 percent of total billed charges 43.65 66.88 Technical (Hospital) Services MEROPENEM 1 GRAM INTRAVENOUS SOLUTION RX-17380 CDM J2185 HCPCS 636 RC 63323-0508-25 NDC inpatient 20 ML 70.4 70.4 BLUE CROSS BLUE SHIELD WELLMARK SB889 [3081026] BCBS WYOMING [308102603] 66.88 percent of total billed charges 43.65 66.88 Technical (Hospital) Services MEROPENEM 1 GRAM INTRAVENOUS SOLUTION RX-17380 CDM J2185 HCPCS 636 RC 63323-0508-25 NDC inpatient 20 ML 70.4 70.4 CIGNA 62308 [3081051] CIGNA 62308 [308105105] 55.74 percent of total billed charges 43.65 66.88 Technical (Hospital) Services MEROPENEM 1 GRAM INTRAVENOUS SOLUTION RX-17380 CDM J2185 HCPCS 636 RC 63323-0508-25 NDC inpatient 20 ML 70.4 70.4 CIGNA 62308 [3081051] CIGNA STATE OF WYOMING [308105107] 55.74 percent of total billed charges 43.65 66.88 Technical (Hospital) Services MEROPENEM 1 GRAM INTRAVENOUS SOLUTION RX-17380 CDM J2185 HCPCS 636 RC 63323-0508-25 NDC inpatient 20 ML 70.4 70.4 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES HDHP [308136802] 55.74 percent of total billed charges 43.65 66.88 Technical (Hospital) Services MEROPENEM 1 GRAM INTRAVENOUS SOLUTION RX-17380 CDM J2185 HCPCS 636 RC 63323-0508-25 NDC inpatient 20 ML 70.4 70.4 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES EPO [308136803] 55.74 percent of total billed charges 43.65 66.88 Technical (Hospital) Services MEROPENEM 1 GRAM INTRAVENOUS SOLUTION RX-17380 CDM J2185 HCPCS 636 RC 63323-0508-25 NDC inpatient 20 ML 70.4 70.4 HEALTHPARTNERS SX009 HEALTHPARTNERS 55.74 percent of total billed charges 43.65 66.88 Technical (Hospital) Services MEROPENEM 1 GRAM INTRAVENOUS SOLUTION RX-17380 CDM J2185 HCPCS 636 RC 63323-0508-25 NDC inpatient 20 ML 70.4 70.4 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES PPO [308136801] 55.74 percent of total billed charges 43.65 66.88 Technical (Hospital) Services MEPOLIZUMAB 100 MG SUBCUTANEOUS SOLUTION RX-133919 CDM J2182 HCPCS 636 RC 00173-0881-01 NDC inpatient 1 ML 5912.92 5912.92 UNITED HEALTHCARE (COMMERCIAL) [3081199] UNITED HEALTHCARE 87726 [308119901] 3666.01 percent of total billed charges 3666.01 5617.27 Technical (Hospital) Services MEPOLIZUMAB 100 MG SUBCUTANEOUS SOLUTION RX-133919 CDM J2182 HCPCS 636 RC 00173-0881-01 NDC inpatient 1 ML 5912.92 5912.92 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES EPO [308136803] 4681.85 percent of total billed charges 3666.01 5617.27 Technical (Hospital) Services MEPOLIZUMAB 100 MG SUBCUTANEOUS SOLUTION RX-133919 CDM J2182 HCPCS 636 RC 00173-0881-01 NDC inpatient 1 ML 5912.92 5912.92 BLUE CROSS BLUE SHIELD WELLMARK SB889 [3081026] BCBS WYOMING [308102603] 5617.27 percent of total billed charges 3666.01 5617.27 Technical (Hospital) Services MEPOLIZUMAB 100 MG SUBCUTANEOUS SOLUTION RX-133919 CDM J2182 HCPCS 636 RC 00173-0881-01 NDC inpatient 1 ML 5912.92 5912.92 CIGNA 62308 [3081051] CIGNA 62308 [308105105] 4681.85 percent of total billed charges 3666.01 5617.27 Technical (Hospital) Services MEPOLIZUMAB 100 MG SUBCUTANEOUS SOLUTION RX-133919 CDM J2182 HCPCS 636 RC 00173-0881-01 NDC inpatient 1 ML 5912.92 5912.92 CIGNA 62308 [3081051] CIGNA STATE OF WYOMING [308105107] 4681.85 percent of total billed charges 3666.01 5617.27 Technical (Hospital) Services MEPOLIZUMAB 100 MG SUBCUTANEOUS SOLUTION RX-133919 CDM J2182 HCPCS 636 RC 00173-0881-01 NDC inpatient 1 ML 5912.92 5912.92 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES HDHP [308136802] 4681.85 percent of total billed charges 3666.01 5617.27 Technical (Hospital) Services MEPOLIZUMAB 100 MG SUBCUTANEOUS SOLUTION RX-133919 CDM J2182 HCPCS 636 RC 00173-0881-01 NDC inpatient 1 ML 5912.92 5912.92 HEALTHPARTNERS SX009 HEALTHPARTNERS 4681.85 percent of total billed charges 3666.01 5617.27 Technical (Hospital) Services MEPOLIZUMAB 100 MG SUBCUTANEOUS SOLUTION RX-133919 CDM J2182 HCPCS 636 RC 00173-0881-01 NDC inpatient 1 ML 5912.92 5912.92 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES PPO [308136801] 4681.85 percent of total billed charges 3666.01 5617.27 Technical (Hospital) Services MEPOLIZUMAB 100 MG SUBCUTANEOUS SOLUTION RX-133919 CDM J2182 HCPCS 636 RC 00173-0881-01 NDC inpatient 1 ML 5912.92 5912.92 MEDICA (COMMERCIAL) 94265 [3081118] MEDICA CLAIMS [308111801] 5321.63 percent of total billed charges 3666.01 5617.27 Technical (Hospital) Services MEPOLIZUMAB 100 MG SUBCUTANEOUS SOLUTION RX-133919 CDM J2182 HCPCS 636 RC 00173-0881-01 NDC inpatient 1 ML 5912.92 5912.92 MULTIPLAN INC 34080 [3081285] MULTIPLAN INC [308128501] 5617.27 percent of total billed charges 3666.01 5617.27 Technical (Hospital) Services MEPOLIZUMAB 100 MG SUBCUTANEOUS SOLUTION RX-133919 CDM J2182 HCPCS 636 RC 00173-0881-01 NDC outpatient 1 ML 5912.92 5912.92 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES HDHP [308136802] 4730.34 percent of total billed charges 3666.01 5617.27 Technical (Hospital) Services MEPOLIZUMAB 100 MG SUBCUTANEOUS SOLUTION RX-133919 CDM J2182 HCPCS 636 RC 00173-0881-01 NDC outpatient 1 ML 5912.92 5912.92 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES EPO [308136803] 4730.34 percent of total billed charges 3666.01 5617.27 Technical (Hospital) Services MEPOLIZUMAB 100 MG SUBCUTANEOUS SOLUTION RX-133919 CDM J2182 HCPCS 636 RC 00173-0881-01 NDC outpatient 1 ML 5912.92 5912.92 MEDICA (COMMERCIAL) 94265 [3081118] MEDICA CLAIMS [308111801] 5321.63 percent of total billed charges 3666.01 5617.27 Technical (Hospital) Services MEPOLIZUMAB 100 MG SUBCUTANEOUS SOLUTION RX-133919 CDM J2182 HCPCS 636 RC 00173-0881-01 NDC outpatient 1 ML 5912.92 5912.92 BLUE CROSS BLUE SHIELD WELLMARK SB889 [3081026] BCBS WYOMING [308102603] 5617.27 percent of total billed charges 3666.01 5617.27 Technical (Hospital) Services MEPOLIZUMAB 100 MG SUBCUTANEOUS SOLUTION RX-133919 CDM J2182 HCPCS 636 RC 00173-0881-01 NDC outpatient 1 ML 5912.92 5912.92 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES PPO [308136801] 4730.34 percent of total billed charges 3666.01 5617.27 Technical (Hospital) Services MEPOLIZUMAB 100 MG SUBCUTANEOUS SOLUTION RX-133919 CDM J2182 HCPCS 636 RC 00173-0881-01 NDC outpatient 1 ML 5912.92 5912.92 HEALTHPARTNERS SX009 HEALTHPARTNERS 4730.34 percent of total billed charges 3666.01 5617.27 Technical (Hospital) Services MEPOLIZUMAB 100 MG SUBCUTANEOUS SOLUTION RX-133919 CDM J2182 HCPCS 636 RC 00173-0881-01 NDC outpatient 1 ML 5912.92 5912.92 MULTIPLAN INC 34080 [3081285] MULTIPLAN INC [308128501] 5617.27 percent of total billed charges 3666.01 5617.27 Technical (Hospital) Services MEPOLIZUMAB 100 MG SUBCUTANEOUS SOLUTION RX-133919 CDM J2182 HCPCS 636 RC 00173-0881-01 NDC outpatient 1 ML 5912.92 5912.92 UNITED HEALTHCARE (COMMERCIAL) [3081199] UNITED HEALTHCARE 87726 [308119901] 3666.01 percent of total billed charges 3666.01 5617.27 Technical (Hospital) Services MEPOLIZUMAB 100 MG SUBCUTANEOUS SOLUTION RX-133919 CDM J2182 HCPCS 636 RC 00173-0881-01 NDC outpatient 1 ML 5912.92 5912.92 CIGNA 62308 [3081051] CIGNA 62308 [308105105] 4730.34 percent of total billed charges 3666.01 5617.27 Technical (Hospital) Services MEPOLIZUMAB 100 MG SUBCUTANEOUS SOLUTION RX-133919 CDM J2182 HCPCS 636 RC 00173-0881-01 NDC outpatient 1 ML 5912.92 5912.92 CIGNA 62308 [3081051] CIGNA STATE OF WYOMING [308105107] 4730.34 percent of total billed charges 3666.01 5617.27 Technical (Hospital) Services MANNITOL 20 % INTRAVENOUS SOLUTION RX-4749 CDM J2150 HCPCS 636 RC 00338-0357-03 NDC outpatient 32 ML 68.53 68.53 CIGNA 62308 [3081051] CIGNA 62308 [308105105] 54.82 percent of total billed charges 42.49 65.1 Technical (Hospital) Services MANNITOL 20 % INTRAVENOUS SOLUTION RX-4749 CDM J2150 HCPCS 636 RC 00338-0357-03 NDC outpatient 32 ML 68.53 68.53 CIGNA 62308 [3081051] CIGNA STATE OF WYOMING [308105107] 54.82 percent of total billed charges 42.49 65.1 Technical (Hospital) Services MANNITOL 20 % INTRAVENOUS SOLUTION RX-4749 CDM J2150 HCPCS 636 RC 00338-0357-03 NDC outpatient 32 ML 68.53 68.53 MEDICA (COMMERCIAL) 94265 [3081118] MEDICA CLAIMS [308111801] 61.68 percent of total billed charges 42.49 65.1 Technical (Hospital) Services MANNITOL 20 % INTRAVENOUS SOLUTION RX-4749 CDM J2150 HCPCS 636 RC 00338-0357-03 NDC outpatient 32 ML 68.53 68.53 MULTIPLAN INC 34080 [3081285] MULTIPLAN INC [308128501] 65.1 percent of total billed charges 42.49 65.1 Technical (Hospital) Services MANNITOL 20 % INTRAVENOUS SOLUTION RX-4749 CDM J2150 HCPCS 636 RC 00338-0357-03 NDC outpatient 32 ML 68.53 68.53 HEALTHPARTNERS SX009 HEALTHPARTNERS 54.82 percent of total billed charges 42.49 65.1 Technical (Hospital) Services MANNITOL 20 % INTRAVENOUS SOLUTION RX-4749 CDM J2150 HCPCS 636 RC 00338-0357-03 NDC outpatient 32 ML 68.53 68.53 BLUE CROSS BLUE SHIELD WELLMARK SB889 [3081026] BCBS WYOMING [308102603] 65.1 percent of total billed charges 42.49 65.1 Technical (Hospital) Services MANNITOL 20 % INTRAVENOUS SOLUTION RX-4749 CDM J2150 HCPCS 636 RC 00338-0357-03 NDC outpatient 32 ML 68.53 68.53 UNITED HEALTHCARE (COMMERCIAL) [3081199] UNITED HEALTHCARE 87726 [308119901] 42.49 percent of total billed charges 42.49 65.1 Technical (Hospital) Services MANNITOL 20 % INTRAVENOUS SOLUTION RX-4749 CDM J2150 HCPCS 636 RC 00338-0357-03 NDC outpatient 32 ML 68.53 68.53 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES EPO [308136803] 54.82 percent of total billed charges 42.49 65.1 Technical (Hospital) Services MANNITOL 20 % INTRAVENOUS SOLUTION RX-4749 CDM J2150 HCPCS 636 RC 00338-0357-03 NDC outpatient 32 ML 68.53 68.53 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES HDHP [308136802] 54.82 percent of total billed charges 42.49 65.1 Technical (Hospital) Services MANNITOL 20 % INTRAVENOUS SOLUTION RX-4749 CDM J2150 HCPCS 636 RC 00338-0357-03 NDC outpatient 32 ML 68.53 68.53 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES PPO [308136801] 54.82 percent of total billed charges 42.49 65.1 Technical (Hospital) Services MANNITOL 20 % INTRAVENOUS SOLUTION RX-4749 CDM J2150 HCPCS 636 RC 00338-0357-03 NDC inpatient 32 ML 68.53 68.53 CIGNA 62308 [3081051] CIGNA 62308 [308105105] 54.26 percent of total billed charges 42.49 65.1 Technical (Hospital) Services MANNITOL 20 % INTRAVENOUS SOLUTION RX-4749 CDM J2150 HCPCS 636 RC 00338-0357-03 NDC inpatient 32 ML 68.53 68.53 CIGNA 62308 [3081051] CIGNA STATE OF WYOMING [308105107] 54.26 percent of total billed charges 42.49 65.1 Technical (Hospital) Services MANNITOL 20 % INTRAVENOUS SOLUTION RX-4749 CDM J2150 HCPCS 636 RC 00338-0357-03 NDC inpatient 32 ML 68.53 68.53 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES EPO [308136803] 54.26 percent of total billed charges 42.49 65.1 Technical (Hospital) Services MANNITOL 20 % INTRAVENOUS SOLUTION RX-4749 CDM J2150 HCPCS 636 RC 00338-0357-03 NDC inpatient 32 ML 68.53 68.53 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES HDHP [308136802] 54.26 percent of total billed charges 42.49 65.1 Technical (Hospital) Services MANNITOL 20 % INTRAVENOUS SOLUTION RX-4749 CDM J2150 HCPCS 636 RC 00338-0357-03 NDC inpatient 32 ML 68.53 68.53 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES PPO [308136801] 54.26 percent of total billed charges 42.49 65.1 Technical (Hospital) Services MANNITOL 20 % INTRAVENOUS SOLUTION RX-4749 CDM J2150 HCPCS 636 RC 00338-0357-03 NDC inpatient 32 ML 68.53 68.53 BLUE CROSS BLUE SHIELD WELLMARK SB889 [3081026] BCBS WYOMING [308102603] 65.1 percent of total billed charges 42.49 65.1 Technical (Hospital) Services MANNITOL 20 % INTRAVENOUS SOLUTION RX-4749 CDM J2150 HCPCS 636 RC 00338-0357-03 NDC inpatient 32 ML 68.53 68.53 UNITED HEALTHCARE (COMMERCIAL) [3081199] UNITED HEALTHCARE 87726 [308119901] 42.49 percent of total billed charges 42.49 65.1 Technical (Hospital) Services MANNITOL 20 % INTRAVENOUS SOLUTION RX-4749 CDM J2150 HCPCS 636 RC 00338-0357-03 NDC inpatient 32 ML 68.53 68.53 MEDICA (COMMERCIAL) 94265 [3081118] MEDICA CLAIMS [308111801] 61.68 percent of total billed charges 42.49 65.1 Technical (Hospital) Services MANNITOL 20 % INTRAVENOUS SOLUTION RX-4749 CDM J2150 HCPCS 636 RC 00338-0357-03 NDC inpatient 32 ML 68.53 68.53 HEALTHPARTNERS SX009 HEALTHPARTNERS 54.26 percent of total billed charges 42.49 65.1 Technical (Hospital) Services MANNITOL 20 % INTRAVENOUS SOLUTION RX-4749 CDM J2150 HCPCS 636 RC 00338-0357-03 NDC inpatient 32 ML 68.53 68.53 MULTIPLAN INC 34080 [3081285] MULTIPLAN INC [308128501] 65.1 percent of total billed charges 42.49 65.1 Technical (Hospital) Services LORAZEPAM 2 MG/ML INJECTION (WRAPPER) RX-4080030012 CDM J2060 HCPCS 636 RC 00409-1985-30 NDC outpatient 1 ML 61.89 61.89 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES EPO [308136803] 49.51 percent of total billed charges 38.37 58.8 Technical (Hospital) Services LORAZEPAM 2 MG/ML INJECTION (WRAPPER) RX-4080030012 CDM J2060 HCPCS 636 RC 00409-1985-30 NDC outpatient 1 ML 61.89 61.89 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES HDHP [308136802] 49.51 percent of total billed charges 38.37 58.8 Technical (Hospital) Services LORAZEPAM 2 MG/ML INJECTION (WRAPPER) RX-4080030012 CDM J2060 HCPCS 636 RC 00409-1985-30 NDC outpatient 1 ML 61.89 61.89 BLUE CROSS BLUE SHIELD WELLMARK SB889 [3081026] BCBS WYOMING [308102603] 58.8 percent of total billed charges 38.37 58.8 Technical (Hospital) Services LORAZEPAM 2 MG/ML INJECTION (WRAPPER) RX-4080030012 CDM J2060 HCPCS 636 RC 00409-1985-30 NDC outpatient 1 ML 61.89 61.89 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES PPO [308136801] 49.51 percent of total billed charges 38.37 58.8 Technical (Hospital) Services LORAZEPAM 2 MG/ML INJECTION (WRAPPER) RX-4080030012 CDM J2060 HCPCS 636 RC 00409-1985-30 NDC outpatient 1 ML 61.89 61.89 MULTIPLAN INC 34080 [3081285] MULTIPLAN INC [308128501] 58.8 percent of total billed charges 38.37 58.8 Technical (Hospital) Services LORAZEPAM 2 MG/ML INJECTION (WRAPPER) RX-4080030012 CDM J2060 HCPCS 636 RC 00409-1985-30 NDC outpatient 1 ML 61.89 61.89 UNITED HEALTHCARE (COMMERCIAL) [3081199] UNITED HEALTHCARE 87726 [308119901] 38.37 percent of total billed charges 38.37 58.8 Technical (Hospital) Services LORAZEPAM 2 MG/ML INJECTION (WRAPPER) RX-4080030012 CDM J2060 HCPCS 636 RC 00409-1985-30 NDC outpatient 1 ML 61.89 61.89 HEALTHPARTNERS SX009 HEALTHPARTNERS 49.51 percent of total billed charges 38.37 58.8 Technical (Hospital) Services LORAZEPAM 2 MG/ML INJECTION (WRAPPER) RX-4080030012 CDM J2060 HCPCS 636 RC 00409-1985-30 NDC outpatient 1 ML 61.89 61.89 MEDICA (COMMERCIAL) 94265 [3081118] MEDICA CLAIMS [308111801] 55.7 percent of total billed charges 38.37 58.8 Technical (Hospital) Services LORAZEPAM 2 MG/ML INJECTION (WRAPPER) RX-4080030012 CDM J2060 HCPCS 636 RC 00409-1985-30 NDC outpatient 1 ML 61.89 61.89 CIGNA 62308 [3081051] CIGNA 62308 [308105105] 49.51 percent of total billed charges 38.37 58.8 Technical (Hospital) Services LORAZEPAM 2 MG/ML INJECTION (WRAPPER) RX-4080030012 CDM J2060 HCPCS 636 RC 00409-1985-30 NDC outpatient 1 ML 61.89 61.89 CIGNA 62308 [3081051] CIGNA STATE OF WYOMING [308105107] 49.51 percent of total billed charges 38.37 58.8 Technical (Hospital) Services LORAZEPAM 2 MG/ML INJECTION (WRAPPER) RX-4080030012 CDM J2060 HCPCS 636 RC 00409-1985-30 NDC inpatient 1 ML 61.89 61.89 MULTIPLAN INC 34080 [3081285] MULTIPLAN INC [308128501] 58.8 percent of total billed charges 38.37 58.8 Technical (Hospital) Services LORAZEPAM 2 MG/ML INJECTION (WRAPPER) RX-4080030012 CDM J2060 HCPCS 636 RC 00409-1985-30 NDC inpatient 1 ML 61.89 61.89 MEDICA (COMMERCIAL) 94265 [3081118] MEDICA CLAIMS [308111801] 55.7 percent of total billed charges 38.37 58.8 Technical (Hospital) Services LORAZEPAM 2 MG/ML INJECTION (WRAPPER) RX-4080030012 CDM J2060 HCPCS 636 RC 00409-1985-30 NDC inpatient 1 ML 61.89 61.89 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES HDHP [308136802] 49 percent of total billed charges 38.37 58.8 Technical (Hospital) Services LORAZEPAM 2 MG/ML INJECTION (WRAPPER) RX-4080030012 CDM J2060 HCPCS 636 RC 00409-1985-30 NDC inpatient 1 ML 61.89 61.89 HEALTHPARTNERS SX009 HEALTHPARTNERS 49 percent of total billed charges 38.37 58.8 Technical (Hospital) Services LORAZEPAM 2 MG/ML INJECTION (WRAPPER) RX-4080030012 CDM J2060 HCPCS 636 RC 00409-1985-30 NDC inpatient 1 ML 61.89 61.89 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES PPO [308136801] 49 percent of total billed charges 38.37 58.8 Technical (Hospital) Services LORAZEPAM 2 MG/ML INJECTION (WRAPPER) RX-4080030012 CDM J2060 HCPCS 636 RC 00409-1985-30 NDC inpatient 1 ML 61.89 61.89 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES EPO [308136803] 49 percent of total billed charges 38.37 58.8 Technical (Hospital) Services LORAZEPAM 2 MG/ML INJECTION (WRAPPER) RX-4080030012 CDM J2060 HCPCS 636 RC 00409-1985-30 NDC inpatient 1 ML 61.89 61.89 CIGNA 62308 [3081051] CIGNA 62308 [308105105] 49 percent of total billed charges 38.37 58.8 Technical (Hospital) Services LORAZEPAM 2 MG/ML INJECTION (WRAPPER) RX-4080030012 CDM J2060 HCPCS 636 RC 00409-1985-30 NDC inpatient 1 ML 61.89 61.89 CIGNA 62308 [3081051] CIGNA STATE OF WYOMING [308105107] 49 percent of total billed charges 38.37 58.8 Technical (Hospital) Services LORAZEPAM 2 MG/ML INJECTION (WRAPPER) RX-4080030012 CDM J2060 HCPCS 636 RC 00409-1985-30 NDC inpatient 1 ML 61.89 61.89 UNITED HEALTHCARE (COMMERCIAL) [3081199] UNITED HEALTHCARE 87726 [308119901] 38.37 percent of total billed charges 38.37 58.8 Technical (Hospital) Services LORAZEPAM 2 MG/ML INJECTION (WRAPPER) RX-4080030012 CDM J2060 HCPCS 636 RC 00409-1985-30 NDC inpatient 1 ML 61.89 61.89 BLUE CROSS BLUE SHIELD WELLMARK SB889 [3081026] BCBS WYOMING [308102603] 58.8 percent of total billed charges 38.37 58.8 Technical (Hospital) Services LIDOCAINE (PF) 4 MG/ML (0.4 %) IN 5 % DEXTROSE INTRAVENOUS SOLUTION RX-14868 CDM J2002 HCPCS 636 RC 00264-9594-20 NDC inpatient 250 ML 72 72 HEALTHPARTNERS SX009 HEALTHPARTNERS 57.01 percent of total billed charges 44.64 68.4 Technical (Hospital) Services LIDOCAINE (PF) 4 MG/ML (0.4 %) IN 5 % DEXTROSE INTRAVENOUS SOLUTION RX-14868 CDM J2002 HCPCS 636 RC 00264-9594-20 NDC inpatient 250 ML 72 72 MULTIPLAN INC 34080 [3081285] MULTIPLAN INC [308128501] 68.4 percent of total billed charges 44.64 68.4 Technical (Hospital) Services LIDOCAINE (PF) 4 MG/ML (0.4 %) IN 5 % DEXTROSE INTRAVENOUS SOLUTION RX-14868 CDM J2002 HCPCS 636 RC 00264-9594-20 NDC inpatient 250 ML 72 72 MEDICA (COMMERCIAL) 94265 [3081118] MEDICA CLAIMS [308111801] 64.8 percent of total billed charges 44.64 68.4 Technical (Hospital) Services LIDOCAINE (PF) 4 MG/ML (0.4 %) IN 5 % DEXTROSE INTRAVENOUS SOLUTION RX-14868 CDM J2002 HCPCS 636 RC 00264-9594-20 NDC inpatient 250 ML 72 72 UNITED HEALTHCARE (COMMERCIAL) [3081199] UNITED HEALTHCARE 87726 [308119901] 44.64 percent of total billed charges 44.64 68.4 Technical (Hospital) Services LIDOCAINE (PF) 4 MG/ML (0.4 %) IN 5 % DEXTROSE INTRAVENOUS SOLUTION RX-14868 CDM J2002 HCPCS 636 RC 00264-9594-20 NDC inpatient 250 ML 72 72 BLUE CROSS BLUE SHIELD WELLMARK SB889 [3081026] BCBS WYOMING [308102603] 68.4 percent of total billed charges 44.64 68.4 Technical (Hospital) Services LIDOCAINE (PF) 4 MG/ML (0.4 %) IN 5 % DEXTROSE INTRAVENOUS SOLUTION RX-14868 CDM J2002 HCPCS 636 RC 00264-9594-20 NDC inpatient 250 ML 72 72 CIGNA 62308 [3081051] CIGNA 62308 [308105105] 57.01 percent of total billed charges 44.64 68.4 Technical (Hospital) Services LIDOCAINE (PF) 4 MG/ML (0.4 %) IN 5 % DEXTROSE INTRAVENOUS SOLUTION RX-14868 CDM J2002 HCPCS 636 RC 00264-9594-20 NDC inpatient 250 ML 72 72 CIGNA 62308 [3081051] CIGNA STATE OF WYOMING [308105107] 57.01 percent of total billed charges 44.64 68.4 Technical (Hospital) Services LIDOCAINE (PF) 4 MG/ML (0.4 %) IN 5 % DEXTROSE INTRAVENOUS SOLUTION RX-14868 CDM J2002 HCPCS 636 RC 00264-9594-20 NDC inpatient 250 ML 72 72 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES PPO [308136801] 57.01 percent of total billed charges 44.64 68.4 Technical (Hospital) Services LIDOCAINE (PF) 4 MG/ML (0.4 %) IN 5 % DEXTROSE INTRAVENOUS SOLUTION RX-14868 CDM J2002 HCPCS 636 RC 00264-9594-20 NDC inpatient 250 ML 72 72 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES HDHP [308136802] 57.01 percent of total billed charges 44.64 68.4 Technical (Hospital) Services LIDOCAINE (PF) 4 MG/ML (0.4 %) IN 5 % DEXTROSE INTRAVENOUS SOLUTION RX-14868 CDM J2002 HCPCS 636 RC 00264-9594-20 NDC inpatient 250 ML 72 72 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES EPO [308136803] 57.01 percent of total billed charges 44.64 68.4 Technical (Hospital) Services LIDOCAINE (PF) 4 MG/ML (0.4 %) IN 5 % DEXTROSE INTRAVENOUS SOLUTION RX-14868 CDM J2002 HCPCS 636 RC 00264-9594-20 NDC outpatient 250 ML 72 72 MEDICA (COMMERCIAL) 94265 [3081118] MEDICA CLAIMS [308111801] 64.8 percent of total billed charges 44.64 68.4 Technical (Hospital) Services LIDOCAINE (PF) 4 MG/ML (0.4 %) IN 5 % DEXTROSE INTRAVENOUS SOLUTION RX-14868 CDM J2002 HCPCS 636 RC 00264-9594-20 NDC outpatient 250 ML 72 72 MULTIPLAN INC 34080 [3081285] MULTIPLAN INC [308128501] 68.4 percent of total billed charges 44.64 68.4 Technical (Hospital) Services LIDOCAINE (PF) 4 MG/ML (0.4 %) IN 5 % DEXTROSE INTRAVENOUS SOLUTION RX-14868 CDM J2002 HCPCS 636 RC 00264-9594-20 NDC outpatient 250 ML 72 72 CIGNA 62308 [3081051] CIGNA 62308 [308105105] 57.6 percent of total billed charges 44.64 68.4 Technical (Hospital) Services LIDOCAINE (PF) 4 MG/ML (0.4 %) IN 5 % DEXTROSE INTRAVENOUS SOLUTION RX-14868 CDM J2002 HCPCS 636 RC 00264-9594-20 NDC outpatient 250 ML 72 72 CIGNA 62308 [3081051] CIGNA STATE OF WYOMING [308105107] 57.6 percent of total billed charges 44.64 68.4 Technical (Hospital) Services LIDOCAINE (PF) 4 MG/ML (0.4 %) IN 5 % DEXTROSE INTRAVENOUS SOLUTION RX-14868 CDM J2002 HCPCS 636 RC 00264-9594-20 NDC outpatient 250 ML 72 72 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES EPO [308136803] 57.6 percent of total billed charges 44.64 68.4 Technical (Hospital) Services LIDOCAINE (PF) 4 MG/ML (0.4 %) IN 5 % DEXTROSE INTRAVENOUS SOLUTION RX-14868 CDM J2002 HCPCS 636 RC 00264-9594-20 NDC outpatient 250 ML 72 72 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES HDHP [308136802] 57.6 percent of total billed charges 44.64 68.4 Technical (Hospital) Services LIDOCAINE (PF) 4 MG/ML (0.4 %) IN 5 % DEXTROSE INTRAVENOUS SOLUTION RX-14868 CDM J2002 HCPCS 636 RC 00264-9594-20 NDC outpatient 250 ML 72 72 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES PPO [308136801] 57.6 percent of total billed charges 44.64 68.4 Technical (Hospital) Services LIDOCAINE (PF) 4 MG/ML (0.4 %) IN 5 % DEXTROSE INTRAVENOUS SOLUTION RX-14868 CDM J2002 HCPCS 636 RC 00264-9594-20 NDC outpatient 250 ML 72 72 BLUE CROSS BLUE SHIELD WELLMARK SB889 [3081026] BCBS WYOMING [308102603] 68.4 percent of total billed charges 44.64 68.4 Technical (Hospital) Services LIDOCAINE (PF) 4 MG/ML (0.4 %) IN 5 % DEXTROSE INTRAVENOUS SOLUTION RX-14868 CDM J2002 HCPCS 636 RC 00264-9594-20 NDC outpatient 250 ML 72 72 HEALTHPARTNERS SX009 HEALTHPARTNERS 57.6 percent of total billed charges 44.64 68.4 Technical (Hospital) Services LIDOCAINE (PF) 4 MG/ML (0.4 %) IN 5 % DEXTROSE INTRAVENOUS SOLUTION RX-14868 CDM J2002 HCPCS 636 RC 00264-9594-20 NDC outpatient 250 ML 72 72 UNITED HEALTHCARE (COMMERCIAL) [3081199] UNITED HEALTHCARE 87726 [308119901] 44.64 percent of total billed charges 44.64 68.4 Technical (Hospital) Services LIDOCAINE (PF) 10 MG/ML (1 %) INJECTION SOLUTION RX-104207 CDM J2001 HCPCS 636 RC 63323-0492-57 NDC inpatient 5 ML 18.83 18.83 CIGNA 62308 [3081051] CIGNA 62308 [308105105] 14.91 percent of total billed charges 11.67 17.89 Technical (Hospital) Services LIDOCAINE (PF) 10 MG/ML (1 %) INJECTION SOLUTION RX-104207 CDM J2001 HCPCS 636 RC 63323-0492-57 NDC inpatient 5 ML 18.83 18.83 CIGNA 62308 [3081051] CIGNA STATE OF WYOMING [308105107] 14.91 percent of total billed charges 11.67 17.89 Technical (Hospital) Services LIDOCAINE (PF) 10 MG/ML (1 %) INJECTION SOLUTION RX-104207 CDM J2001 HCPCS 636 RC 63323-0492-57 NDC inpatient 5 ML 18.83 18.83 UNITED HEALTHCARE (COMMERCIAL) [3081199] UNITED HEALTHCARE 87726 [308119901] 11.67 percent of total billed charges 11.67 17.89 Technical (Hospital) Services LIDOCAINE (PF) 10 MG/ML (1 %) INJECTION SOLUTION RX-104207 CDM J2001 HCPCS 636 RC 63323-0492-57 NDC inpatient 5 ML 18.83 18.83 BLUE CROSS BLUE SHIELD WELLMARK SB889 [3081026] BCBS WYOMING [308102603] 17.89 percent of total billed charges 11.67 17.89 Technical (Hospital) Services LIDOCAINE (PF) 10 MG/ML (1 %) INJECTION SOLUTION RX-104207 CDM J2001 HCPCS 636 RC 63323-0492-57 NDC inpatient 5 ML 18.83 18.83 MULTIPLAN INC 34080 [3081285] MULTIPLAN INC [308128501] 17.89 percent of total billed charges 11.67 17.89 Technical (Hospital) Services LIDOCAINE (PF) 10 MG/ML (1 %) INJECTION SOLUTION RX-104207 CDM J2001 HCPCS 636 RC 63323-0492-57 NDC inpatient 5 ML 18.83 18.83 MEDICA (COMMERCIAL) 94265 [3081118] MEDICA CLAIMS [308111801] 16.95 percent of total billed charges 11.67 17.89 Technical (Hospital) Services LIDOCAINE (PF) 10 MG/ML (1 %) INJECTION SOLUTION RX-104207 CDM J2001 HCPCS 636 RC 63323-0492-57 NDC inpatient 5 ML 18.83 18.83 HEALTHPARTNERS SX009 HEALTHPARTNERS 14.91 percent of total billed charges 11.67 17.89 Technical (Hospital) Services LIDOCAINE (PF) 10 MG/ML (1 %) INJECTION SOLUTION RX-104207 CDM J2001 HCPCS 636 RC 63323-0492-57 NDC inpatient 5 ML 18.83 18.83 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES PPO [308136801] 14.91 percent of total billed charges 11.67 17.89 Technical (Hospital) Services LIDOCAINE (PF) 10 MG/ML (1 %) INJECTION SOLUTION RX-104207 CDM J2001 HCPCS 636 RC 63323-0492-57 NDC inpatient 5 ML 18.83 18.83 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES HDHP [308136802] 14.91 percent of total billed charges 11.67 17.89 Technical (Hospital) Services LIDOCAINE (PF) 10 MG/ML (1 %) INJECTION SOLUTION RX-104207 CDM J2001 HCPCS 636 RC 63323-0492-57 NDC inpatient 5 ML 18.83 18.83 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES EPO [308136803] 14.91 percent of total billed charges 11.67 17.89 Technical (Hospital) Services LIDOCAINE (PF) 10 MG/ML (1 %) INJECTION SOLUTION RX-104207 CDM J2001 HCPCS 636 RC 63323-0492-57 NDC outpatient 5 ML 18.83 18.83 UNITED HEALTHCARE (COMMERCIAL) [3081199] UNITED HEALTHCARE 87726 [308119901] 11.67 percent of total billed charges 11.67 17.89 Technical (Hospital) Services LIDOCAINE (PF) 10 MG/ML (1 %) INJECTION SOLUTION RX-104207 CDM J2001 HCPCS 636 RC 63323-0492-57 NDC outpatient 5 ML 18.83 18.83 BLUE CROSS BLUE SHIELD WELLMARK SB889 [3081026] BCBS WYOMING [308102603] 17.89 percent of total billed charges 11.67 17.89 Technical (Hospital) Services LIDOCAINE (PF) 10 MG/ML (1 %) INJECTION SOLUTION RX-104207 CDM J2001 HCPCS 636 RC 63323-0492-57 NDC outpatient 5 ML 18.83 18.83 HEALTHPARTNERS SX009 HEALTHPARTNERS 15.06 percent of total billed charges 11.67 17.89 Technical (Hospital) Services LIDOCAINE (PF) 10 MG/ML (1 %) INJECTION SOLUTION RX-104207 CDM J2001 HCPCS 636 RC 63323-0492-57 NDC outpatient 5 ML 18.83 18.83 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES EPO [308136803] 15.06 percent of total billed charges 11.67 17.89 Technical (Hospital) Services LIDOCAINE (PF) 10 MG/ML (1 %) INJECTION SOLUTION RX-104207 CDM J2001 HCPCS 636 RC 63323-0492-57 NDC outpatient 5 ML 18.83 18.83 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES HDHP [308136802] 15.06 percent of total billed charges 11.67 17.89 Technical (Hospital) Services LIDOCAINE (PF) 10 MG/ML (1 %) INJECTION SOLUTION RX-104207 CDM J2001 HCPCS 636 RC 63323-0492-57 NDC outpatient 5 ML 18.83 18.83 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES PPO [308136801] 15.06 percent of total billed charges 11.67 17.89 Technical (Hospital) Services LIDOCAINE (PF) 10 MG/ML (1 %) INJECTION SOLUTION RX-104207 CDM J2001 HCPCS 636 RC 63323-0492-57 NDC outpatient 5 ML 18.83 18.83 CIGNA 62308 [3081051] CIGNA 62308 [308105105] 15.06 percent of total billed charges 11.67 17.89 Technical (Hospital) Services LIDOCAINE (PF) 10 MG/ML (1 %) INJECTION SOLUTION RX-104207 CDM J2001 HCPCS 636 RC 63323-0492-57 NDC outpatient 5 ML 18.83 18.83 CIGNA 62308 [3081051] CIGNA STATE OF WYOMING [308105107] 15.06 percent of total billed charges 11.67 17.89 Technical (Hospital) Services LIDOCAINE (PF) 10 MG/ML (1 %) INJECTION SOLUTION RX-104207 CDM J2001 HCPCS 636 RC 63323-0492-57 NDC outpatient 5 ML 18.83 18.83 MEDICA (COMMERCIAL) 94265 [3081118] MEDICA CLAIMS [308111801] 16.95 percent of total billed charges 11.67 17.89 Technical (Hospital) Services LIDOCAINE (PF) 10 MG/ML (1 %) INJECTION SOLUTION RX-104207 CDM J2001 HCPCS 636 RC 63323-0492-57 NDC outpatient 5 ML 18.83 18.83 MULTIPLAN INC 34080 [3081285] MULTIPLAN INC [308128501] 17.89 percent of total billed charges 11.67 17.89 Technical (Hospital) Services LIDOCAINE (PF) 20 MG/ML (2 %) INJECTION SOLUTION RX-104208 CDM J2001 HCPCS 636 RC 63323-0495-07 NDC outpatient 5 ML 15.59 15.59 HEALTHPARTNERS SX009 HEALTHPARTNERS 12.47 percent of total billed charges 9.67 14.81 Technical (Hospital) Services LIDOCAINE (PF) 20 MG/ML (2 %) INJECTION SOLUTION RX-104208 CDM J2001 HCPCS 636 RC 63323-0495-07 NDC outpatient 5 ML 15.59 15.59 UNITED HEALTHCARE (COMMERCIAL) [3081199] UNITED HEALTHCARE 87726 [308119901] 9.67 percent of total billed charges 9.67 14.81 Technical (Hospital) Services LIDOCAINE (PF) 20 MG/ML (2 %) INJECTION SOLUTION RX-104208 CDM J2001 HCPCS 636 RC 63323-0495-07 NDC outpatient 5 ML 15.59 15.59 MEDICA (COMMERCIAL) 94265 [3081118] MEDICA CLAIMS [308111801] 14.03 percent of total billed charges 9.67 14.81 Technical (Hospital) Services LIDOCAINE (PF) 20 MG/ML (2 %) INJECTION SOLUTION RX-104208 CDM J2001 HCPCS 636 RC 63323-0495-07 NDC outpatient 5 ML 15.59 15.59 MULTIPLAN INC 34080 [3081285] MULTIPLAN INC [308128501] 14.81 percent of total billed charges 9.67 14.81 Technical (Hospital) Services LIDOCAINE (PF) 20 MG/ML (2 %) INJECTION SOLUTION RX-104208 CDM J2001 HCPCS 636 RC 63323-0495-07 NDC outpatient 5 ML 15.59 15.59 BLUE CROSS BLUE SHIELD WELLMARK SB889 [3081026] BCBS WYOMING [308102603] 14.81 percent of total billed charges 9.67 14.81 Technical (Hospital) Services LIDOCAINE (PF) 20 MG/ML (2 %) INJECTION SOLUTION RX-104208 CDM J2001 HCPCS 636 RC 63323-0495-07 NDC outpatient 5 ML 15.59 15.59 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES EPO [308136803] 12.47 percent of total billed charges 9.67 14.81 Technical (Hospital) Services LIDOCAINE (PF) 20 MG/ML (2 %) INJECTION SOLUTION RX-104208 CDM J2001 HCPCS 636 RC 63323-0495-07 NDC outpatient 5 ML 15.59 15.59 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES HDHP [308136802] 12.47 percent of total billed charges 9.67 14.81 Technical (Hospital) Services LIDOCAINE (PF) 20 MG/ML (2 %) INJECTION SOLUTION RX-104208 CDM J2001 HCPCS 636 RC 63323-0495-07 NDC outpatient 5 ML 15.59 15.59 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES PPO [308136801] 12.47 percent of total billed charges 9.67 14.81 Technical (Hospital) Services LIDOCAINE (PF) 20 MG/ML (2 %) INJECTION SOLUTION RX-104208 CDM J2001 HCPCS 636 RC 63323-0495-07 NDC outpatient 5 ML 15.59 15.59 CIGNA 62308 [3081051] CIGNA 62308 [308105105] 12.47 percent of total billed charges 9.67 14.81 Technical (Hospital) Services LIDOCAINE (PF) 20 MG/ML (2 %) INJECTION SOLUTION RX-104208 CDM J2001 HCPCS 636 RC 63323-0495-07 NDC outpatient 5 ML 15.59 15.59 CIGNA 62308 [3081051] CIGNA STATE OF WYOMING [308105107] 12.47 percent of total billed charges 9.67 14.81 Technical (Hospital) Services LIDOCAINE (PF) 20 MG/ML (2 %) INJECTION SOLUTION RX-104208 CDM J2001 HCPCS 636 RC 63323-0495-07 NDC inpatient 5 ML 15.59 15.59 HEALTHPARTNERS SX009 HEALTHPARTNERS 12.34 percent of total billed charges 9.67 14.81 Technical (Hospital) Services LIDOCAINE (PF) 20 MG/ML (2 %) INJECTION SOLUTION RX-104208 CDM J2001 HCPCS 636 RC 63323-0495-07 NDC inpatient 5 ML 15.59 15.59 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES EPO [308136803] 12.34 percent of total billed charges 9.67 14.81 Technical (Hospital) Services LIDOCAINE (PF) 20 MG/ML (2 %) INJECTION SOLUTION RX-104208 CDM J2001 HCPCS 636 RC 63323-0495-07 NDC inpatient 5 ML 15.59 15.59 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES HDHP [308136802] 12.34 percent of total billed charges 9.67 14.81 Technical (Hospital) Services LIDOCAINE (PF) 20 MG/ML (2 %) INJECTION SOLUTION RX-104208 CDM J2001 HCPCS 636 RC 63323-0495-07 NDC inpatient 5 ML 15.59 15.59 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES PPO [308136801] 12.34 percent of total billed charges 9.67 14.81 Technical (Hospital) Services LIDOCAINE (PF) 20 MG/ML (2 %) INJECTION SOLUTION RX-104208 CDM J2001 HCPCS 636 RC 63323-0495-07 NDC inpatient 5 ML 15.59 15.59 UNITED HEALTHCARE (COMMERCIAL) [3081199] UNITED HEALTHCARE 87726 [308119901] 9.67 percent of total billed charges 9.67 14.81 Technical (Hospital) Services LIDOCAINE (PF) 20 MG/ML (2 %) INJECTION SOLUTION RX-104208 CDM J2001 HCPCS 636 RC 63323-0495-07 NDC inpatient 5 ML 15.59 15.59 BLUE CROSS BLUE SHIELD WELLMARK SB889 [3081026] BCBS WYOMING [308102603] 14.81 percent of total billed charges 9.67 14.81 Technical (Hospital) Services LIDOCAINE (PF) 20 MG/ML (2 %) INJECTION SOLUTION RX-104208 CDM J2001 HCPCS 636 RC 63323-0495-07 NDC inpatient 5 ML 15.59 15.59 CIGNA 62308 [3081051] CIGNA 62308 [308105105] 12.34 percent of total billed charges 9.67 14.81 Technical (Hospital) Services LIDOCAINE (PF) 20 MG/ML (2 %) INJECTION SOLUTION RX-104208 CDM J2001 HCPCS 636 RC 63323-0495-07 NDC inpatient 5 ML 15.59 15.59 CIGNA 62308 [3081051] CIGNA STATE OF WYOMING [308105107] 12.34 percent of total billed charges 9.67 14.81 Technical (Hospital) Services LIDOCAINE (PF) 20 MG/ML (2 %) INJECTION SOLUTION RX-104208 CDM J2001 HCPCS 636 RC 63323-0495-07 NDC inpatient 5 ML 15.59 15.59 MEDICA (COMMERCIAL) 94265 [3081118] MEDICA CLAIMS [308111801] 14.03 percent of total billed charges 9.67 14.81 Technical (Hospital) Services LIDOCAINE (PF) 20 MG/ML (2 %) INJECTION SOLUTION RX-104208 CDM J2001 HCPCS 636 RC 63323-0495-07 NDC inpatient 5 ML 15.59 15.59 MULTIPLAN INC 34080 [3081285] MULTIPLAN INC [308128501] 14.81 percent of total billed charges 9.67 14.81 Technical (Hospital) Services LIDOCAINE (PF) 40 MG/ML (4 %) INJECTION SOLUTION RX-4455 CDM J2001 HCPCS 636 RC 00409-4283-25 NDC inpatient 5 ML 69.34 69.34 MULTIPLAN INC 34080 [3081285] MULTIPLAN INC [308128501] 65.87 percent of total billed charges 42.99 65.87 Technical (Hospital) Services LIDOCAINE (PF) 40 MG/ML (4 %) INJECTION SOLUTION RX-4455 CDM J2001 HCPCS 636 RC 00409-4283-25 NDC inpatient 5 ML 69.34 69.34 MEDICA (COMMERCIAL) 94265 [3081118] MEDICA CLAIMS [308111801] 62.41 percent of total billed charges 42.99 65.87 Technical (Hospital) Services LIDOCAINE (PF) 40 MG/ML (4 %) INJECTION SOLUTION RX-4455 CDM J2001 HCPCS 636 RC 00409-4283-25 NDC inpatient 5 ML 69.34 69.34 BLUE CROSS BLUE SHIELD WELLMARK SB889 [3081026] BCBS WYOMING [308102603] 65.87 percent of total billed charges 42.99 65.87 Technical (Hospital) Services LIDOCAINE (PF) 40 MG/ML (4 %) INJECTION SOLUTION RX-4455 CDM J2001 HCPCS 636 RC 00409-4283-25 NDC outpatient 5 ML 69.34 69.34 CIGNA 62308 [3081051] CIGNA 62308 [308105105] 55.47 percent of total billed charges 42.99 65.87 Technical (Hospital) Services LIDOCAINE (PF) 40 MG/ML (4 %) INJECTION SOLUTION RX-4455 CDM J2001 HCPCS 636 RC 00409-4283-25 NDC outpatient 5 ML 69.34 69.34 CIGNA 62308 [3081051] CIGNA STATE OF WYOMING [308105107] 55.47 percent of total billed charges 42.99 65.87 Technical (Hospital) Services LIDOCAINE (PF) 40 MG/ML (4 %) INJECTION SOLUTION RX-4455 CDM J2001 HCPCS 636 RC 00409-4283-25 NDC outpatient 5 ML 69.34 69.34 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES EPO [308136803] 55.47 percent of total billed charges 42.99 65.87 Technical (Hospital) Services LIDOCAINE (PF) 40 MG/ML (4 %) INJECTION SOLUTION RX-4455 CDM J2001 HCPCS 636 RC 00409-4283-25 NDC outpatient 5 ML 69.34 69.34 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES HDHP [308136802] 55.47 percent of total billed charges 42.99 65.87 Technical (Hospital) Services LIDOCAINE (PF) 40 MG/ML (4 %) INJECTION SOLUTION RX-4455 CDM J2001 HCPCS 636 RC 00409-4283-25 NDC outpatient 5 ML 69.34 69.34 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES PPO [308136801] 55.47 percent of total billed charges 42.99 65.87 Technical (Hospital) Services LIDOCAINE (PF) 40 MG/ML (4 %) INJECTION SOLUTION RX-4455 CDM J2001 HCPCS 636 RC 00409-4283-25 NDC outpatient 5 ML 69.34 69.34 BLUE CROSS BLUE SHIELD WELLMARK SB889 [3081026] BCBS WYOMING [308102603] 65.87 percent of total billed charges 42.99 65.87 Technical (Hospital) Services LIDOCAINE (PF) 40 MG/ML (4 %) INJECTION SOLUTION RX-4455 CDM J2001 HCPCS 636 RC 00409-4283-25 NDC outpatient 5 ML 69.34 69.34 MULTIPLAN INC 34080 [3081285] MULTIPLAN INC [308128501] 65.87 percent of total billed charges 42.99 65.87 Technical (Hospital) Services LIDOCAINE (PF) 40 MG/ML (4 %) INJECTION SOLUTION RX-4455 CDM J2001 HCPCS 636 RC 00409-4283-25 NDC outpatient 5 ML 69.34 69.34 MEDICA (COMMERCIAL) 94265 [3081118] MEDICA CLAIMS [308111801] 62.41 percent of total billed charges 42.99 65.87 Technical (Hospital) Services LIDOCAINE (PF) 40 MG/ML (4 %) INJECTION SOLUTION RX-4455 CDM J2001 HCPCS 636 RC 00409-4283-25 NDC outpatient 5 ML 69.34 69.34 UNITED HEALTHCARE (COMMERCIAL) [3081199] UNITED HEALTHCARE 87726 [308119901] 42.99 percent of total billed charges 42.99 65.87 Technical (Hospital) Services LIDOCAINE (PF) 40 MG/ML (4 %) INJECTION SOLUTION RX-4455 CDM J2001 HCPCS 636 RC 00409-4283-25 NDC outpatient 5 ML 69.34 69.34 HEALTHPARTNERS SX009 HEALTHPARTNERS 55.47 percent of total billed charges 42.99 65.87 Technical (Hospital) Services LIDOCAINE (PF) 40 MG/ML (4 %) INJECTION SOLUTION RX-4455 CDM J2001 HCPCS 636 RC 00409-4283-25 NDC inpatient 5 ML 69.34 69.34 UNITED HEALTHCARE (COMMERCIAL) [3081199] UNITED HEALTHCARE 87726 [308119901] 42.99 percent of total billed charges 42.99 65.87 Technical (Hospital) Services LIDOCAINE (PF) 40 MG/ML (4 %) INJECTION SOLUTION RX-4455 CDM J2001 HCPCS 636 RC 00409-4283-25 NDC inpatient 5 ML 69.34 69.34 CIGNA 62308 [3081051] CIGNA 62308 [308105105] 54.9 percent of total billed charges 42.99 65.87 Technical (Hospital) Services LIDOCAINE (PF) 40 MG/ML (4 %) INJECTION SOLUTION RX-4455 CDM J2001 HCPCS 636 RC 00409-4283-25 NDC inpatient 5 ML 69.34 69.34 CIGNA 62308 [3081051] CIGNA STATE OF WYOMING [308105107] 54.9 percent of total billed charges 42.99 65.87 Technical (Hospital) Services LIDOCAINE (PF) 40 MG/ML (4 %) INJECTION SOLUTION RX-4455 CDM J2001 HCPCS 636 RC 00409-4283-25 NDC inpatient 5 ML 69.34 69.34 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES EPO [308136803] 54.9 percent of total billed charges 42.99 65.87 Technical (Hospital) Services LIDOCAINE (PF) 40 MG/ML (4 %) INJECTION SOLUTION RX-4455 CDM J2001 HCPCS 636 RC 00409-4283-25 NDC inpatient 5 ML 69.34 69.34 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES PPO [308136801] 54.9 percent of total billed charges 42.99 65.87 Technical (Hospital) Services LIDOCAINE (PF) 40 MG/ML (4 %) INJECTION SOLUTION RX-4455 CDM J2001 HCPCS 636 RC 00409-4283-25 NDC inpatient 5 ML 69.34 69.34 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES HDHP [308136802] 54.9 percent of total billed charges 42.99 65.87 Technical (Hospital) Services LIDOCAINE (PF) 40 MG/ML (4 %) INJECTION SOLUTION RX-4455 CDM J2001 HCPCS 636 RC 00409-4283-25 NDC inpatient 5 ML 69.34 69.34 HEALTHPARTNERS SX009 HEALTHPARTNERS 54.9 percent of total billed charges 42.99 65.87 Technical (Hospital) Services LIDOCAINE (PF) 100 MG/5 ML (2 %) INTRAVENOUS SYRINGE RX-4459 CDM J2001 HCPCS 636 RC 00409-1323-05 NDC outpatient 5 ML 70.51 70.51 CIGNA 62308 [3081051] CIGNA 62308 [308105105] 56.41 percent of total billed charges 43.72 66.98 Technical (Hospital) Services LIDOCAINE (PF) 100 MG/5 ML (2 %) INTRAVENOUS SYRINGE RX-4459 CDM J2001 HCPCS 636 RC 00409-1323-05 NDC outpatient 5 ML 70.51 70.51 CIGNA 62308 [3081051] CIGNA STATE OF WYOMING [308105107] 56.41 percent of total billed charges 43.72 66.98 Technical (Hospital) Services LIDOCAINE (PF) 100 MG/5 ML (2 %) INTRAVENOUS SYRINGE RX-4459 CDM J2001 HCPCS 636 RC 00409-1323-05 NDC outpatient 5 ML 70.51 70.51 MEDICA (COMMERCIAL) 94265 [3081118] MEDICA CLAIMS [308111801] 63.46 percent of total billed charges 43.72 66.98 Technical (Hospital) Services LIDOCAINE (PF) 100 MG/5 ML (2 %) INTRAVENOUS SYRINGE RX-4459 CDM J2001 HCPCS 636 RC 00409-1323-05 NDC outpatient 5 ML 70.51 70.51 MULTIPLAN INC 34080 [3081285] MULTIPLAN INC [308128501] 66.98 percent of total billed charges 43.72 66.98 Technical (Hospital) Services LIDOCAINE (PF) 100 MG/5 ML (2 %) INTRAVENOUS SYRINGE RX-4459 CDM J2001 HCPCS 636 RC 00409-1323-05 NDC outpatient 5 ML 70.51 70.51 UNITED HEALTHCARE (COMMERCIAL) [3081199] UNITED HEALTHCARE 87726 [308119901] 43.72 percent of total billed charges 43.72 66.98 Technical (Hospital) Services LIDOCAINE (PF) 100 MG/5 ML (2 %) INTRAVENOUS SYRINGE RX-4459 CDM J2001 HCPCS 636 RC 00409-1323-05 NDC outpatient 5 ML 70.51 70.51 HEALTHPARTNERS SX009 HEALTHPARTNERS 56.41 percent of total billed charges 43.72 66.98 Technical (Hospital) Services LIDOCAINE (PF) 100 MG/5 ML (2 %) INTRAVENOUS SYRINGE RX-4459 CDM J2001 HCPCS 636 RC 00409-1323-05 NDC outpatient 5 ML 70.51 70.51 BLUE CROSS BLUE SHIELD WELLMARK SB889 [3081026] BCBS WYOMING [308102603] 66.98 percent of total billed charges 43.72 66.98 Technical (Hospital) Services LIDOCAINE (PF) 100 MG/5 ML (2 %) INTRAVENOUS SYRINGE RX-4459 CDM J2001 HCPCS 636 RC 00409-1323-05 NDC outpatient 5 ML 70.51 70.51 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES EPO [308136803] 56.41 percent of total billed charges 43.72 66.98 Technical (Hospital) Services LIDOCAINE (PF) 100 MG/5 ML (2 %) INTRAVENOUS SYRINGE RX-4459 CDM J2001 HCPCS 636 RC 00409-1323-05 NDC outpatient 5 ML 70.51 70.51 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES HDHP [308136802] 56.41 percent of total billed charges 43.72 66.98 Technical (Hospital) Services LIDOCAINE (PF) 100 MG/5 ML (2 %) INTRAVENOUS SYRINGE RX-4459 CDM J2001 HCPCS 636 RC 00409-1323-05 NDC outpatient 5 ML 70.51 70.51 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES PPO [308136801] 56.41 percent of total billed charges 43.72 66.98 Technical (Hospital) Services LIDOCAINE (PF) 100 MG/5 ML (2 %) INTRAVENOUS SYRINGE RX-4459 CDM J2001 HCPCS 636 RC 00409-1323-05 NDC inpatient 5 ML 70.51 70.51 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES PPO [308136801] 55.83 percent of total billed charges 43.72 66.98 Technical (Hospital) Services LIDOCAINE (PF) 100 MG/5 ML (2 %) INTRAVENOUS SYRINGE RX-4459 CDM J2001 HCPCS 636 RC 00409-1323-05 NDC inpatient 5 ML 70.51 70.51 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES HDHP [308136802] 55.83 percent of total billed charges 43.72 66.98 Technical (Hospital) Services LIDOCAINE (PF) 100 MG/5 ML (2 %) INTRAVENOUS SYRINGE RX-4459 CDM J2001 HCPCS 636 RC 00409-1323-05 NDC inpatient 5 ML 70.51 70.51 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES EPO [308136803] 55.83 percent of total billed charges 43.72 66.98 Technical (Hospital) Services LIDOCAINE (PF) 100 MG/5 ML (2 %) INTRAVENOUS SYRINGE RX-4459 CDM J2001 HCPCS 636 RC 00409-1323-05 NDC inpatient 5 ML 70.51 70.51 HEALTHPARTNERS SX009 HEALTHPARTNERS 55.83 percent of total billed charges 43.72 66.98 Technical (Hospital) Services LIDOCAINE (PF) 100 MG/5 ML (2 %) INTRAVENOUS SYRINGE RX-4459 CDM J2001 HCPCS 636 RC 00409-1323-05 NDC inpatient 5 ML 70.51 70.51 MEDICA (COMMERCIAL) 94265 [3081118] MEDICA CLAIMS [308111801] 63.46 percent of total billed charges 43.72 66.98 Technical (Hospital) Services LIDOCAINE (PF) 100 MG/5 ML (2 %) INTRAVENOUS SYRINGE RX-4459 CDM J2001 HCPCS 636 RC 00409-1323-05 NDC inpatient 5 ML 70.51 70.51 MULTIPLAN INC 34080 [3081285] MULTIPLAN INC [308128501] 66.98 percent of total billed charges 43.72 66.98 Technical (Hospital) Services LIDOCAINE (PF) 100 MG/5 ML (2 %) INTRAVENOUS SYRINGE RX-4459 CDM J2001 HCPCS 636 RC 00409-1323-05 NDC inpatient 5 ML 70.51 70.51 BLUE CROSS BLUE SHIELD WELLMARK SB889 [3081026] BCBS WYOMING [308102603] 66.98 percent of total billed charges 43.72 66.98 Technical (Hospital) Services LIDOCAINE (PF) 100 MG/5 ML (2 %) INTRAVENOUS SYRINGE RX-4459 CDM J2001 HCPCS 636 RC 00409-1323-05 NDC inpatient 5 ML 70.51 70.51 UNITED HEALTHCARE (COMMERCIAL) [3081199] UNITED HEALTHCARE 87726 [308119901] 43.72 percent of total billed charges 43.72 66.98 Technical (Hospital) Services LIDOCAINE (PF) 100 MG/5 ML (2 %) INTRAVENOUS SYRINGE RX-4459 CDM J2001 HCPCS 636 RC 00409-1323-05 NDC inpatient 5 ML 70.51 70.51 CIGNA 62308 [3081051] CIGNA 62308 [308105105] 55.83 percent of total billed charges 43.72 66.98 Technical (Hospital) Services LIDOCAINE (PF) 100 MG/5 ML (2 %) INTRAVENOUS SYRINGE RX-4459 CDM J2001 HCPCS 636 RC 00409-1323-05 NDC inpatient 5 ML 70.51 70.51 CIGNA 62308 [3081051] CIGNA STATE OF WYOMING [308105107] 55.83 percent of total billed charges 43.72 66.98 Technical (Hospital) Services LEVOFLOXACIN 500 MG/100 ML IN 5 % DEXTROSE INTRAVENOUS PIGGYBACK RX-108119 CDM J1956 HCPCS 636 RC 25021-0132-82 NDC inpatient 100 ML 81 81 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES EPO [308136803] 64.14 percent of total billed charges 50.22 76.95 Technical (Hospital) Services LEVOFLOXACIN 500 MG/100 ML IN 5 % DEXTROSE INTRAVENOUS PIGGYBACK RX-108119 CDM J1956 HCPCS 636 RC 25021-0132-82 NDC inpatient 100 ML 81 81 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES HDHP [308136802] 64.14 percent of total billed charges 50.22 76.95 Technical (Hospital) Services LEVOFLOXACIN 500 MG/100 ML IN 5 % DEXTROSE INTRAVENOUS PIGGYBACK RX-108119 CDM J1956 HCPCS 636 RC 25021-0132-82 NDC inpatient 100 ML 81 81 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES PPO [308136801] 64.14 percent of total billed charges 50.22 76.95 Technical (Hospital) Services LEVOFLOXACIN 500 MG/100 ML IN 5 % DEXTROSE INTRAVENOUS PIGGYBACK RX-108119 CDM J1956 HCPCS 636 RC 25021-0132-82 NDC inpatient 100 ML 81 81 CIGNA 62308 [3081051] CIGNA 62308 [308105105] 64.14 percent of total billed charges 50.22 76.95 Technical (Hospital) Services LEVOFLOXACIN 500 MG/100 ML IN 5 % DEXTROSE INTRAVENOUS PIGGYBACK RX-108119 CDM J1956 HCPCS 636 RC 25021-0132-82 NDC inpatient 100 ML 81 81 CIGNA 62308 [3081051] CIGNA STATE OF WYOMING [308105107] 64.14 percent of total billed charges 50.22 76.95 Technical (Hospital) Services LEVOFLOXACIN 500 MG/100 ML IN 5 % DEXTROSE INTRAVENOUS PIGGYBACK RX-108119 CDM J1956 HCPCS 636 RC 25021-0132-82 NDC inpatient 100 ML 81 81 BLUE CROSS BLUE SHIELD WELLMARK SB889 [3081026] BCBS WYOMING [308102603] 76.95 percent of total billed charges 50.22 76.95 Technical (Hospital) Services LEVOFLOXACIN 500 MG/100 ML IN 5 % DEXTROSE INTRAVENOUS PIGGYBACK RX-108119 CDM J1956 HCPCS 636 RC 25021-0132-82 NDC inpatient 100 ML 81 81 UNITED HEALTHCARE (COMMERCIAL) [3081199] UNITED HEALTHCARE 87726 [308119901] 50.22 percent of total billed charges 50.22 76.95 Technical (Hospital) Services LEVOFLOXACIN 500 MG/100 ML IN 5 % DEXTROSE INTRAVENOUS PIGGYBACK RX-108119 CDM J1956 HCPCS 636 RC 25021-0132-82 NDC inpatient 100 ML 81 81 MEDICA (COMMERCIAL) 94265 [3081118] MEDICA CLAIMS [308111801] 72.9 percent of total billed charges 50.22 76.95 Technical (Hospital) Services LEVOFLOXACIN 500 MG/100 ML IN 5 % DEXTROSE INTRAVENOUS PIGGYBACK RX-108119 CDM J1956 HCPCS 636 RC 25021-0132-82 NDC inpatient 100 ML 81 81 MULTIPLAN INC 34080 [3081285] MULTIPLAN INC [308128501] 76.95 percent of total billed charges 50.22 76.95 Technical (Hospital) Services LEVOFLOXACIN 500 MG/100 ML IN 5 % DEXTROSE INTRAVENOUS PIGGYBACK RX-108119 CDM J1956 HCPCS 636 RC 25021-0132-82 NDC inpatient 100 ML 81 81 HEALTHPARTNERS SX009 HEALTHPARTNERS 64.14 percent of total billed charges 50.22 76.95 Technical (Hospital) Services LEVOFLOXACIN 500 MG/100 ML IN 5 % DEXTROSE INTRAVENOUS PIGGYBACK RX-108119 CDM J1956 HCPCS 636 RC 25021-0132-82 NDC outpatient 100 ML 81 81 MEDICA (COMMERCIAL) 94265 [3081118] MEDICA CLAIMS [308111801] 72.9 percent of total billed charges 50.22 76.95 Technical (Hospital) Services LEVOFLOXACIN 500 MG/100 ML IN 5 % DEXTROSE INTRAVENOUS PIGGYBACK RX-108119 CDM J1956 HCPCS 636 RC 25021-0132-82 NDC outpatient 100 ML 81 81 MULTIPLAN INC 34080 [3081285] MULTIPLAN INC [308128501] 76.95 percent of total billed charges 50.22 76.95 Technical (Hospital) Services LEVOFLOXACIN 500 MG/100 ML IN 5 % DEXTROSE INTRAVENOUS PIGGYBACK RX-108119 CDM J1956 HCPCS 636 RC 25021-0132-82 NDC outpatient 100 ML 81 81 CIGNA 62308 [3081051] CIGNA 62308 [308105105] 64.8 percent of total billed charges 50.22 76.95 Technical (Hospital) Services LEVOFLOXACIN 500 MG/100 ML IN 5 % DEXTROSE INTRAVENOUS PIGGYBACK RX-108119 CDM J1956 HCPCS 636 RC 25021-0132-82 NDC outpatient 100 ML 81 81 CIGNA 62308 [3081051] CIGNA STATE OF WYOMING [308105107] 64.8 percent of total billed charges 50.22 76.95 Technical (Hospital) Services LEVOFLOXACIN 500 MG/100 ML IN 5 % DEXTROSE INTRAVENOUS PIGGYBACK RX-108119 CDM J1956 HCPCS 636 RC 25021-0132-82 NDC outpatient 100 ML 81 81 BLUE CROSS BLUE SHIELD WELLMARK SB889 [3081026] BCBS WYOMING [308102603] 76.95 percent of total billed charges 50.22 76.95 Technical (Hospital) Services LEVOFLOXACIN 500 MG/100 ML IN 5 % DEXTROSE INTRAVENOUS PIGGYBACK RX-108119 CDM J1956 HCPCS 636 RC 25021-0132-82 NDC outpatient 100 ML 81 81 HEALTHPARTNERS SX009 HEALTHPARTNERS 64.8 percent of total billed charges 50.22 76.95 Technical (Hospital) Services LEVOFLOXACIN 500 MG/100 ML IN 5 % DEXTROSE INTRAVENOUS PIGGYBACK RX-108119 CDM J1956 HCPCS 636 RC 25021-0132-82 NDC outpatient 100 ML 81 81 UNITED HEALTHCARE (COMMERCIAL) [3081199] UNITED HEALTHCARE 87726 [308119901] 50.22 percent of total billed charges 50.22 76.95 Technical (Hospital) Services LEVOFLOXACIN 500 MG/100 ML IN 5 % DEXTROSE INTRAVENOUS PIGGYBACK RX-108119 CDM J1956 HCPCS 636 RC 25021-0132-82 NDC outpatient 100 ML 81 81 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES PPO [308136801] 64.8 percent of total billed charges 50.22 76.95 Technical (Hospital) Services LEVOFLOXACIN 500 MG/100 ML IN 5 % DEXTROSE INTRAVENOUS PIGGYBACK RX-108119 CDM J1956 HCPCS 636 RC 25021-0132-82 NDC outpatient 100 ML 81 81 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES HDHP [308136802] 64.8 percent of total billed charges 50.22 76.95 Technical (Hospital) Services LEVOFLOXACIN 500 MG/100 ML IN 5 % DEXTROSE INTRAVENOUS PIGGYBACK RX-108119 CDM J1956 HCPCS 636 RC 25021-0132-82 NDC outpatient 100 ML 81 81 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES EPO [308136803] 64.8 percent of total billed charges 50.22 76.95 Technical (Hospital) Services LEVOFLOXACIN 750 MG/150 ML IN 5 % DEXTROSE INTRAVENOUS PIGGYBACK RX-108120 CDM J1956 HCPCS 636 RC 63323-0355-60 NDC outpatient 150 ML 83.05 83.05 CIGNA 62308 [3081051] CIGNA 62308 [308105105] 66.44 percent of total billed charges 51.49 78.9 Technical (Hospital) Services LEVOFLOXACIN 750 MG/150 ML IN 5 % DEXTROSE INTRAVENOUS PIGGYBACK RX-108120 CDM J1956 HCPCS 636 RC 63323-0355-60 NDC outpatient 150 ML 83.05 83.05 CIGNA 62308 [3081051] CIGNA STATE OF WYOMING [308105107] 66.44 percent of total billed charges 51.49 78.9 Technical (Hospital) Services LEVOFLOXACIN 750 MG/150 ML IN 5 % DEXTROSE INTRAVENOUS PIGGYBACK RX-108120 CDM J1956 HCPCS 636 RC 63323-0355-60 NDC outpatient 150 ML 83.05 83.05 MEDICA (COMMERCIAL) 94265 [3081118] MEDICA CLAIMS [308111801] 74.75 percent of total billed charges 51.49 78.9 Technical (Hospital) Services LEVOFLOXACIN 750 MG/150 ML IN 5 % DEXTROSE INTRAVENOUS PIGGYBACK RX-108120 CDM J1956 HCPCS 636 RC 63323-0355-60 NDC outpatient 150 ML 83.05 83.05 MULTIPLAN INC 34080 [3081285] MULTIPLAN INC [308128501] 78.9 percent of total billed charges 51.49 78.9 Technical (Hospital) Services LEVOFLOXACIN 750 MG/150 ML IN 5 % DEXTROSE INTRAVENOUS PIGGYBACK RX-108120 CDM J1956 HCPCS 636 RC 63323-0355-60 NDC outpatient 150 ML 83.05 83.05 UNITED HEALTHCARE (COMMERCIAL) [3081199] UNITED HEALTHCARE 87726 [308119901] 51.49 percent of total billed charges 51.49 78.9 Technical (Hospital) Services LEVOFLOXACIN 750 MG/150 ML IN 5 % DEXTROSE INTRAVENOUS PIGGYBACK RX-108120 CDM J1956 HCPCS 636 RC 63323-0355-60 NDC outpatient 150 ML 83.05 83.05 HEALTHPARTNERS SX009 HEALTHPARTNERS 66.44 percent of total billed charges 51.49 78.9 Technical (Hospital) Services LEVOFLOXACIN 750 MG/150 ML IN 5 % DEXTROSE INTRAVENOUS PIGGYBACK RX-108120 CDM J1956 HCPCS 636 RC 63323-0355-60 NDC outpatient 150 ML 83.05 83.05 BLUE CROSS BLUE SHIELD WELLMARK SB889 [3081026] BCBS WYOMING [308102603] 78.9 percent of total billed charges 51.49 78.9 Technical (Hospital) Services LEVOFLOXACIN 750 MG/150 ML IN 5 % DEXTROSE INTRAVENOUS PIGGYBACK RX-108120 CDM J1956 HCPCS 636 RC 63323-0355-60 NDC outpatient 150 ML 83.05 83.05 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES EPO [308136803] 66.44 percent of total billed charges 51.49 78.9 Technical (Hospital) Services LEVOFLOXACIN 750 MG/150 ML IN 5 % DEXTROSE INTRAVENOUS PIGGYBACK RX-108120 CDM J1956 HCPCS 636 RC 63323-0355-60 NDC outpatient 150 ML 83.05 83.05 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES HDHP [308136802] 66.44 percent of total billed charges 51.49 78.9 Technical (Hospital) Services LEVOFLOXACIN 750 MG/150 ML IN 5 % DEXTROSE INTRAVENOUS PIGGYBACK RX-108120 CDM J1956 HCPCS 636 RC 63323-0355-60 NDC outpatient 150 ML 83.05 83.05 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES PPO [308136801] 66.44 percent of total billed charges 51.49 78.9 Technical (Hospital) Services LEVOFLOXACIN 750 MG/150 ML IN 5 % DEXTROSE INTRAVENOUS PIGGYBACK RX-108120 CDM J1956 HCPCS 636 RC 63323-0355-60 NDC inpatient 150 ML 83.05 83.05 CIGNA 62308 [3081051] CIGNA 62308 [308105105] 65.76 percent of total billed charges 51.49 78.9 Technical (Hospital) Services LEVOFLOXACIN 750 MG/150 ML IN 5 % DEXTROSE INTRAVENOUS PIGGYBACK RX-108120 CDM J1956 HCPCS 636 RC 63323-0355-60 NDC inpatient 150 ML 83.05 83.05 CIGNA 62308 [3081051] CIGNA STATE OF WYOMING [308105107] 65.76 percent of total billed charges 51.49 78.9 Technical (Hospital) Services LEVOFLOXACIN 750 MG/150 ML IN 5 % DEXTROSE INTRAVENOUS PIGGYBACK RX-108120 CDM J1956 HCPCS 636 RC 63323-0355-60 NDC inpatient 150 ML 83.05 83.05 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES EPO [308136803] 65.76 percent of total billed charges 51.49 78.9 Technical (Hospital) Services LEVOFLOXACIN 750 MG/150 ML IN 5 % DEXTROSE INTRAVENOUS PIGGYBACK RX-108120 CDM J1956 HCPCS 636 RC 63323-0355-60 NDC inpatient 150 ML 83.05 83.05 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES HDHP [308136802] 65.76 percent of total billed charges 51.49 78.9 Technical (Hospital) Services LEVOFLOXACIN 750 MG/150 ML IN 5 % DEXTROSE INTRAVENOUS PIGGYBACK RX-108120 CDM J1956 HCPCS 636 RC 63323-0355-60 NDC inpatient 150 ML 83.05 83.05 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES PPO [308136801] 65.76 percent of total billed charges 51.49 78.9 Technical (Hospital) Services LEVOFLOXACIN 750 MG/150 ML IN 5 % DEXTROSE INTRAVENOUS PIGGYBACK RX-108120 CDM J1956 HCPCS 636 RC 63323-0355-60 NDC inpatient 150 ML 83.05 83.05 BLUE CROSS BLUE SHIELD WELLMARK SB889 [3081026] BCBS WYOMING [308102603] 78.9 percent of total billed charges 51.49 78.9 Technical (Hospital) Services LEVOFLOXACIN 750 MG/150 ML IN 5 % DEXTROSE INTRAVENOUS PIGGYBACK RX-108120 CDM J1956 HCPCS 636 RC 63323-0355-60 NDC inpatient 150 ML 83.05 83.05 UNITED HEALTHCARE (COMMERCIAL) [3081199] UNITED HEALTHCARE 87726 [308119901] 51.49 percent of total billed charges 51.49 78.9 Technical (Hospital) Services LEVOFLOXACIN 750 MG/150 ML IN 5 % DEXTROSE INTRAVENOUS PIGGYBACK RX-108120 CDM J1956 HCPCS 636 RC 63323-0355-60 NDC inpatient 150 ML 83.05 83.05 MEDICA (COMMERCIAL) 94265 [3081118] MEDICA CLAIMS [308111801] 74.75 percent of total billed charges 51.49 78.9 Technical (Hospital) Services LEVOFLOXACIN 750 MG/150 ML IN 5 % DEXTROSE INTRAVENOUS PIGGYBACK RX-108120 CDM J1956 HCPCS 636 RC 63323-0355-60 NDC inpatient 150 ML 83.05 83.05 MULTIPLAN INC 34080 [3081285] MULTIPLAN INC [308128501] 78.9 percent of total billed charges 51.49 78.9 Technical (Hospital) Services LEVOFLOXACIN 750 MG/150 ML IN 5 % DEXTROSE INTRAVENOUS PIGGYBACK RX-108120 CDM J1956 HCPCS 636 RC 63323-0355-60 NDC inpatient 150 ML 83.05 83.05 HEALTHPARTNERS SX009 HEALTHPARTNERS 65.76 percent of total billed charges 51.49 78.9 Technical (Hospital) Services LEVETIRACETAM 500 MG/5 ML INTRAVENOUS SOLUTION RX-77195 CDM J1953 HCPCS 636 RC 63323-0400-05 NDC outpatient 5 ML 72.39 72.39 CIGNA 62308 [3081051] CIGNA 62308 [308105105] 57.91 percent of total billed charges 44.88 68.77 Technical (Hospital) Services LEVETIRACETAM 500 MG/5 ML INTRAVENOUS SOLUTION RX-77195 CDM J1953 HCPCS 636 RC 63323-0400-05 NDC outpatient 5 ML 72.39 72.39 CIGNA 62308 [3081051] CIGNA STATE OF WYOMING [308105107] 57.91 percent of total billed charges 44.88 68.77 Technical (Hospital) Services LEVETIRACETAM 500 MG/5 ML INTRAVENOUS SOLUTION RX-77195 CDM J1953 HCPCS 636 RC 63323-0400-05 NDC outpatient 5 ML 72.39 72.39 BLUE CROSS BLUE SHIELD WELLMARK SB889 [3081026] BCBS WYOMING [308102603] 68.77 percent of total billed charges 44.88 68.77 Technical (Hospital) Services LEVETIRACETAM 500 MG/5 ML INTRAVENOUS SOLUTION RX-77195 CDM J1953 HCPCS 636 RC 63323-0400-05 NDC outpatient 5 ML 72.39 72.39 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES PPO [308136801] 57.91 percent of total billed charges 44.88 68.77 Technical (Hospital) Services LEVETIRACETAM 500 MG/5 ML INTRAVENOUS SOLUTION RX-77195 CDM J1953 HCPCS 636 RC 63323-0400-05 NDC outpatient 5 ML 72.39 72.39 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES HDHP [308136802] 57.91 percent of total billed charges 44.88 68.77 Technical (Hospital) Services LEVETIRACETAM 500 MG/5 ML INTRAVENOUS SOLUTION RX-77195 CDM J1953 HCPCS 636 RC 63323-0400-05 NDC outpatient 5 ML 72.39 72.39 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES EPO [308136803] 57.91 percent of total billed charges 44.88 68.77 Technical (Hospital) Services LEVETIRACETAM 500 MG/5 ML INTRAVENOUS SOLUTION RX-77195 CDM J1953 HCPCS 636 RC 63323-0400-05 NDC outpatient 5 ML 72.39 72.39 UNITED HEALTHCARE (COMMERCIAL) [3081199] UNITED HEALTHCARE 87726 [308119901] 44.88 percent of total billed charges 44.88 68.77 Technical (Hospital) Services LEVETIRACETAM 500 MG/5 ML INTRAVENOUS SOLUTION RX-77195 CDM J1953 HCPCS 636 RC 63323-0400-05 NDC outpatient 5 ML 72.39 72.39 HEALTHPARTNERS SX009 HEALTHPARTNERS 57.91 percent of total billed charges 44.88 68.77 Technical (Hospital) Services LEVETIRACETAM 500 MG/5 ML INTRAVENOUS SOLUTION RX-77195 CDM J1953 HCPCS 636 RC 63323-0400-05 NDC outpatient 5 ML 72.39 72.39 MULTIPLAN INC 34080 [3081285] MULTIPLAN INC [308128501] 68.77 percent of total billed charges 44.88 68.77 Technical (Hospital) Services LEVETIRACETAM 500 MG/5 ML INTRAVENOUS SOLUTION RX-77195 CDM J1953 HCPCS 636 RC 63323-0400-05 NDC outpatient 5 ML 72.39 72.39 MEDICA (COMMERCIAL) 94265 [3081118] MEDICA CLAIMS [308111801] 65.15 percent of total billed charges 44.88 68.77 Technical (Hospital) Services LEVETIRACETAM 500 MG/5 ML INTRAVENOUS SOLUTION RX-77195 CDM J1953 HCPCS 636 RC 63323-0400-05 NDC inpatient 5 ML 72.39 72.39 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES HDHP [308136802] 57.32 percent of total billed charges 44.88 68.77 Technical (Hospital) Services LEVETIRACETAM 500 MG/5 ML INTRAVENOUS SOLUTION RX-77195 CDM J1953 HCPCS 636 RC 63323-0400-05 NDC inpatient 5 ML 72.39 72.39 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES PPO [308136801] 57.32 percent of total billed charges 44.88 68.77 Technical (Hospital) Services LEVETIRACETAM 500 MG/5 ML INTRAVENOUS SOLUTION RX-77195 CDM J1953 HCPCS 636 RC 63323-0400-05 NDC inpatient 5 ML 72.39 72.39 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES EPO [308136803] 57.32 percent of total billed charges 44.88 68.77 Technical (Hospital) Services LEVETIRACETAM 500 MG/5 ML INTRAVENOUS SOLUTION RX-77195 CDM J1953 HCPCS 636 RC 63323-0400-05 NDC inpatient 5 ML 72.39 72.39 HEALTHPARTNERS SX009 HEALTHPARTNERS 57.32 percent of total billed charges 44.88 68.77 Technical (Hospital) Services LEVETIRACETAM 500 MG/5 ML INTRAVENOUS SOLUTION RX-77195 CDM J1953 HCPCS 636 RC 63323-0400-05 NDC inpatient 5 ML 72.39 72.39 UNITED HEALTHCARE (COMMERCIAL) [3081199] UNITED HEALTHCARE 87726 [308119901] 44.88 percent of total billed charges 44.88 68.77 Technical (Hospital) Services LEVETIRACETAM 500 MG/5 ML INTRAVENOUS SOLUTION RX-77195 CDM J1953 HCPCS 636 RC 63323-0400-05 NDC inpatient 5 ML 72.39 72.39 BLUE CROSS BLUE SHIELD WELLMARK SB889 [3081026] BCBS WYOMING [308102603] 68.77 percent of total billed charges 44.88 68.77 Technical (Hospital) Services LEVETIRACETAM 500 MG/5 ML INTRAVENOUS SOLUTION RX-77195 CDM J1953 HCPCS 636 RC 63323-0400-05 NDC inpatient 5 ML 72.39 72.39 CIGNA 62308 [3081051] CIGNA 62308 [308105105] 57.32 percent of total billed charges 44.88 68.77 Technical (Hospital) Services LEVETIRACETAM 500 MG/5 ML INTRAVENOUS SOLUTION RX-77195 CDM J1953 HCPCS 636 RC 63323-0400-05 NDC inpatient 5 ML 72.39 72.39 CIGNA 62308 [3081051] CIGNA STATE OF WYOMING [308105107] 57.32 percent of total billed charges 44.88 68.77 Technical (Hospital) Services LEVETIRACETAM 500 MG/5 ML INTRAVENOUS SOLUTION RX-77195 CDM J1953 HCPCS 636 RC 63323-0400-05 NDC inpatient 5 ML 72.39 72.39 MULTIPLAN INC 34080 [3081285] MULTIPLAN INC [308128501] 68.77 percent of total billed charges 44.88 68.77 Technical (Hospital) Services LEVETIRACETAM 500 MG/5 ML INTRAVENOUS SOLUTION RX-77195 CDM J1953 HCPCS 636 RC 63323-0400-05 NDC inpatient 5 ML 72.39 72.39 MEDICA (COMMERCIAL) 94265 [3081118] MEDICA CLAIMS [308111801] 65.15 percent of total billed charges 44.88 68.77 Technical (Hospital) Services FUROSEMIDE 10 MG/ML INJECTION SOLUTION RX-3291 CDM J1940 HCPCS 636 RC 63323-0280-26 NDC inpatient 2 ML 58.8 58.8 MEDICA (COMMERCIAL) 94265 [3081118] MEDICA CLAIMS [308111801] 52.92 percent of total billed charges 36.46 55.86 Technical (Hospital) Services FUROSEMIDE 10 MG/ML INJECTION SOLUTION RX-3291 CDM J1940 HCPCS 636 RC 63323-0280-26 NDC inpatient 2 ML 58.8 58.8 MULTIPLAN INC 34080 [3081285] MULTIPLAN INC [308128501] 55.86 percent of total billed charges 36.46 55.86 Technical (Hospital) Services FUROSEMIDE 10 MG/ML INJECTION SOLUTION RX-3291 CDM J1940 HCPCS 636 RC 63323-0280-26 NDC inpatient 2 ML 58.8 58.8 CIGNA 62308 [3081051] CIGNA 62308 [308105105] 46.56 percent of total billed charges 36.46 55.86 Technical (Hospital) Services FUROSEMIDE 10 MG/ML INJECTION SOLUTION RX-3291 CDM J1940 HCPCS 636 RC 63323-0280-26 NDC inpatient 2 ML 58.8 58.8 CIGNA 62308 [3081051] CIGNA STATE OF WYOMING [308105107] 46.56 percent of total billed charges 36.46 55.86 Technical (Hospital) Services FUROSEMIDE 10 MG/ML INJECTION SOLUTION RX-3291 CDM J1940 HCPCS 636 RC 63323-0280-26 NDC inpatient 2 ML 58.8 58.8 UNITED HEALTHCARE (COMMERCIAL) [3081199] UNITED HEALTHCARE 87726 [308119901] 36.46 percent of total billed charges 36.46 55.86 Technical (Hospital) Services FUROSEMIDE 10 MG/ML INJECTION SOLUTION RX-3291 CDM J1940 HCPCS 636 RC 63323-0280-26 NDC inpatient 2 ML 58.8 58.8 BLUE CROSS BLUE SHIELD WELLMARK SB889 [3081026] BCBS WYOMING [308102603] 55.86 percent of total billed charges 36.46 55.86 Technical (Hospital) Services FUROSEMIDE 10 MG/ML INJECTION SOLUTION RX-3291 CDM J1940 HCPCS 636 RC 63323-0280-26 NDC inpatient 2 ML 58.8 58.8 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES HDHP [308136802] 46.56 percent of total billed charges 36.46 55.86 Technical (Hospital) Services FUROSEMIDE 10 MG/ML INJECTION SOLUTION RX-3291 CDM J1940 HCPCS 636 RC 63323-0280-26 NDC inpatient 2 ML 58.8 58.8 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES EPO [308136803] 46.56 percent of total billed charges 36.46 55.86 Technical (Hospital) Services FUROSEMIDE 10 MG/ML INJECTION SOLUTION RX-3291 CDM J1940 HCPCS 636 RC 63323-0280-26 NDC inpatient 2 ML 58.8 58.8 HEALTHPARTNERS SX009 HEALTHPARTNERS 46.56 percent of total billed charges 36.46 55.86 Technical (Hospital) Services FUROSEMIDE 10 MG/ML INJECTION SOLUTION RX-3291 CDM J1940 HCPCS 636 RC 63323-0280-26 NDC inpatient 2 ML 58.8 58.8 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES PPO [308136801] 46.56 percent of total billed charges 36.46 55.86 Technical (Hospital) Services FUROSEMIDE 10 MG/ML INJECTION SOLUTION RX-3291 CDM J1940 HCPCS 636 RC 63323-0280-26 NDC outpatient 2 ML 58.8 58.8 HEALTHPARTNERS SX009 HEALTHPARTNERS 47.04 percent of total billed charges 36.46 55.86 Technical (Hospital) Services FUROSEMIDE 10 MG/ML INJECTION SOLUTION RX-3291 CDM J1940 HCPCS 636 RC 63323-0280-26 NDC outpatient 2 ML 58.8 58.8 UNITED HEALTHCARE (COMMERCIAL) [3081199] UNITED HEALTHCARE 87726 [308119901] 36.46 percent of total billed charges 36.46 55.86 Technical (Hospital) Services FUROSEMIDE 10 MG/ML INJECTION SOLUTION RX-3291 CDM J1940 HCPCS 636 RC 63323-0280-26 NDC outpatient 2 ML 58.8 58.8 MULTIPLAN INC 34080 [3081285] MULTIPLAN INC [308128501] 55.86 percent of total billed charges 36.46 55.86 Technical (Hospital) Services FUROSEMIDE 10 MG/ML INJECTION SOLUTION RX-3291 CDM J1940 HCPCS 636 RC 63323-0280-26 NDC outpatient 2 ML 58.8 58.8 CIGNA 62308 [3081051] CIGNA 62308 [308105105] 47.04 percent of total billed charges 36.46 55.86 Technical (Hospital) Services FUROSEMIDE 10 MG/ML INJECTION SOLUTION RX-3291 CDM J1940 HCPCS 636 RC 63323-0280-26 NDC outpatient 2 ML 58.8 58.8 CIGNA 62308 [3081051] CIGNA STATE OF WYOMING [308105107] 47.04 percent of total billed charges 36.46 55.86 Technical (Hospital) Services FUROSEMIDE 10 MG/ML INJECTION SOLUTION RX-3291 CDM J1940 HCPCS 636 RC 63323-0280-26 NDC outpatient 2 ML 58.8 58.8 MEDICA (COMMERCIAL) 94265 [3081118] MEDICA CLAIMS [308111801] 52.92 percent of total billed charges 36.46 55.86 Technical (Hospital) Services FUROSEMIDE 10 MG/ML INJECTION SOLUTION RX-3291 CDM J1940 HCPCS 636 RC 63323-0280-26 NDC outpatient 2 ML 58.8 58.8 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES HDHP [308136802] 47.04 percent of total billed charges 36.46 55.86 Technical (Hospital) Services FUROSEMIDE 10 MG/ML INJECTION SOLUTION RX-3291 CDM J1940 HCPCS 636 RC 63323-0280-26 NDC outpatient 2 ML 58.8 58.8 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES EPO [308136803] 47.04 percent of total billed charges 36.46 55.86 Technical (Hospital) Services FUROSEMIDE 10 MG/ML INJECTION SOLUTION RX-3291 CDM J1940 HCPCS 636 RC 63323-0280-26 NDC outpatient 2 ML 58.8 58.8 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES PPO [308136801] 47.04 percent of total billed charges 36.46 55.86 Technical (Hospital) Services FUROSEMIDE 10 MG/ML INJECTION SOLUTION RX-3291 CDM J1940 HCPCS 636 RC 63323-0280-26 NDC outpatient 2 ML 58.8 58.8 BLUE CROSS BLUE SHIELD WELLMARK SB889 [3081026] BCBS WYOMING [308102603] 55.86 percent of total billed charges 36.46 55.86 Technical (Hospital) Services BUMETANIDE 0.25 MG/ML INJECTION SOLUTION RX-9308 CDM J1939 HCPCS 636 RC 00641-6008-10 NDC outpatient 4 ML 61.32 61.32 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES EPO [308136803] 49.06 percent of total billed charges 38.02 58.25 Technical (Hospital) Services BUMETANIDE 0.25 MG/ML INJECTION SOLUTION RX-9308 CDM J1939 HCPCS 636 RC 00641-6008-10 NDC outpatient 4 ML 61.32 61.32 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES HDHP [308136802] 49.06 percent of total billed charges 38.02 58.25 Technical (Hospital) Services BUMETANIDE 0.25 MG/ML INJECTION SOLUTION RX-9308 CDM J1939 HCPCS 636 RC 00641-6008-10 NDC outpatient 4 ML 61.32 61.32 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES PPO [308136801] 49.06 percent of total billed charges 38.02 58.25 Technical (Hospital) Services BUMETANIDE 0.25 MG/ML INJECTION SOLUTION RX-9308 CDM J1939 HCPCS 636 RC 00641-6008-10 NDC inpatient 4 ML 61.32 61.32 MULTIPLAN INC 34080 [3081285] MULTIPLAN INC [308128501] 58.25 percent of total billed charges 38.02 58.25 Technical (Hospital) Services BUMETANIDE 0.25 MG/ML INJECTION SOLUTION RX-9308 CDM J1939 HCPCS 636 RC 00641-6008-10 NDC inpatient 4 ML 61.32 61.32 MEDICA (COMMERCIAL) 94265 [3081118] MEDICA CLAIMS [308111801] 55.19 percent of total billed charges 38.02 58.25 Technical (Hospital) Services BUMETANIDE 0.25 MG/ML INJECTION SOLUTION RX-9308 CDM J1939 HCPCS 636 RC 00641-6008-10 NDC inpatient 4 ML 61.32 61.32 BLUE CROSS BLUE SHIELD WELLMARK SB889 [3081026] BCBS WYOMING [308102603] 58.25 percent of total billed charges 38.02 58.25 Technical (Hospital) Services BUMETANIDE 0.25 MG/ML INJECTION SOLUTION RX-9308 CDM J1939 HCPCS 636 RC 00641-6008-10 NDC inpatient 4 ML 61.32 61.32 UNITED HEALTHCARE (COMMERCIAL) [3081199] UNITED HEALTHCARE 87726 [308119901] 38.02 percent of total billed charges 38.02 58.25 Technical (Hospital) Services BUMETANIDE 0.25 MG/ML INJECTION SOLUTION RX-9308 CDM J1939 HCPCS 636 RC 00641-6008-10 NDC inpatient 4 ML 61.32 61.32 CIGNA 62308 [3081051] CIGNA 62308 [308105105] 48.55 percent of total billed charges 38.02 58.25 Technical (Hospital) Services BUMETANIDE 0.25 MG/ML INJECTION SOLUTION RX-9308 CDM J1939 HCPCS 636 RC 00641-6008-10 NDC inpatient 4 ML 61.32 61.32 CIGNA 62308 [3081051] CIGNA STATE OF WYOMING [308105107] 48.55 percent of total billed charges 38.02 58.25 Technical (Hospital) Services BUMETANIDE 0.25 MG/ML INJECTION SOLUTION RX-9308 CDM J1939 HCPCS 636 RC 00641-6008-10 NDC inpatient 4 ML 61.32 61.32 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES EPO [308136803] 48.55 percent of total billed charges 38.02 58.25 Technical (Hospital) Services BUMETANIDE 0.25 MG/ML INJECTION SOLUTION RX-9308 CDM J1939 HCPCS 636 RC 00641-6008-10 NDC inpatient 4 ML 61.32 61.32 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES HDHP [308136802] 48.55 percent of total billed charges 38.02 58.25 Technical (Hospital) Services BUMETANIDE 0.25 MG/ML INJECTION SOLUTION RX-9308 CDM J1939 HCPCS 636 RC 00641-6008-10 NDC outpatient 4 ML 61.32 61.32 BLUE CROSS BLUE SHIELD WELLMARK SB889 [3081026] BCBS WYOMING [308102603] 58.25 percent of total billed charges 38.02 58.25 Technical (Hospital) Services BUMETANIDE 0.25 MG/ML INJECTION SOLUTION RX-9308 CDM J1939 HCPCS 636 RC 00641-6008-10 NDC outpatient 4 ML 61.32 61.32 UNITED HEALTHCARE (COMMERCIAL) [3081199] UNITED HEALTHCARE 87726 [308119901] 38.02 percent of total billed charges 38.02 58.25 Technical (Hospital) Services BUMETANIDE 0.25 MG/ML INJECTION SOLUTION RX-9308 CDM J1939 HCPCS 636 RC 00641-6008-10 NDC outpatient 4 ML 61.32 61.32 HEALTHPARTNERS SX009 HEALTHPARTNERS 49.06 percent of total billed charges 38.02 58.25 Technical (Hospital) Services BUMETANIDE 0.25 MG/ML INJECTION SOLUTION RX-9308 CDM J1939 HCPCS 636 RC 00641-6008-10 NDC outpatient 4 ML 61.32 61.32 CIGNA 62308 [3081051] CIGNA 62308 [308105105] 49.06 percent of total billed charges 38.02 58.25 Technical (Hospital) Services BUMETANIDE 0.25 MG/ML INJECTION SOLUTION RX-9308 CDM J1939 HCPCS 636 RC 00641-6008-10 NDC outpatient 4 ML 61.32 61.32 CIGNA 62308 [3081051] CIGNA STATE OF WYOMING [308105107] 49.06 percent of total billed charges 38.02 58.25 Technical (Hospital) Services BUMETANIDE 0.25 MG/ML INJECTION SOLUTION RX-9308 CDM J1939 HCPCS 636 RC 00641-6008-10 NDC outpatient 4 ML 61.32 61.32 MEDICA (COMMERCIAL) 94265 [3081118] MEDICA CLAIMS [308111801] 55.19 percent of total billed charges 38.02 58.25 Technical (Hospital) Services BUMETANIDE 0.25 MG/ML INJECTION SOLUTION RX-9308 CDM J1939 HCPCS 636 RC 00641-6008-10 NDC outpatient 4 ML 61.32 61.32 MULTIPLAN INC 34080 [3081285] MULTIPLAN INC [308128501] 58.25 percent of total billed charges 38.02 58.25 Technical (Hospital) Services BUMETANIDE 0.25 MG/ML INJECTION SOLUTION RX-9308 CDM J1939 HCPCS 636 RC 00641-6008-10 NDC inpatient 4 ML 61.32 61.32 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES PPO [308136801] 48.55 percent of total billed charges 38.02 58.25 Technical (Hospital) Services BUMETANIDE 0.25 MG/ML INJECTION SOLUTION RX-9308 CDM J1939 HCPCS 636 RC 00641-6008-10 NDC inpatient 4 ML 61.32 61.32 HEALTHPARTNERS SX009 HEALTHPARTNERS 48.55 percent of total billed charges 38.02 58.25 Technical (Hospital) Services KETOROLAC 30 MG/ML (1 ML) INJECTION SOLUTION RX-22473 CDM J1885 HCPCS 636 RC 63323-0162-16 NDC inpatient 1 ML 59.23 59.23 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES EPO [308136803] 46.9 percent of total billed charges 36.72 56.27 Technical (Hospital) Services KETOROLAC 30 MG/ML (1 ML) INJECTION SOLUTION RX-22473 CDM J1885 HCPCS 636 RC 63323-0162-16 NDC inpatient 1 ML 59.23 59.23 CIGNA 62308 [3081051] CIGNA 62308 [308105105] 46.9 percent of total billed charges 36.72 56.27 Technical (Hospital) Services KETOROLAC 30 MG/ML (1 ML) INJECTION SOLUTION RX-22473 CDM J1885 HCPCS 636 RC 63323-0162-16 NDC inpatient 1 ML 59.23 59.23 CIGNA 62308 [3081051] CIGNA STATE OF WYOMING [308105107] 46.9 percent of total billed charges 36.72 56.27 Technical (Hospital) Services KETOROLAC 30 MG/ML (1 ML) INJECTION SOLUTION RX-22473 CDM J1885 HCPCS 636 RC 63323-0162-16 NDC inpatient 1 ML 59.23 59.23 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES HDHP [308136802] 46.9 percent of total billed charges 36.72 56.27 Technical (Hospital) Services KETOROLAC 30 MG/ML (1 ML) INJECTION SOLUTION RX-22473 CDM J1885 HCPCS 636 RC 63323-0162-16 NDC inpatient 1 ML 59.23 59.23 UNITED HEALTHCARE (COMMERCIAL) [3081199] UNITED HEALTHCARE 87726 [308119901] 36.72 percent of total billed charges 36.72 56.27 Technical (Hospital) Services KETOROLAC 30 MG/ML (1 ML) INJECTION SOLUTION RX-22473 CDM J1885 HCPCS 636 RC 63323-0162-16 NDC inpatient 1 ML 59.23 59.23 BLUE CROSS BLUE SHIELD WELLMARK SB889 [3081026] BCBS WYOMING [308102603] 56.27 percent of total billed charges 36.72 56.27 Technical (Hospital) Services KETOROLAC 30 MG/ML (1 ML) INJECTION SOLUTION RX-22473 CDM J1885 HCPCS 636 RC 63323-0162-16 NDC inpatient 1 ML 59.23 59.23 MULTIPLAN INC 34080 [3081285] MULTIPLAN INC [308128501] 56.27 percent of total billed charges 36.72 56.27 Technical (Hospital) Services KETOROLAC 30 MG/ML (1 ML) INJECTION SOLUTION RX-22473 CDM J1885 HCPCS 636 RC 63323-0162-16 NDC inpatient 1 ML 59.23 59.23 HEALTHPARTNERS SX009 HEALTHPARTNERS 46.9 percent of total billed charges 36.72 56.27 Technical (Hospital) Services KETOROLAC 30 MG/ML (1 ML) INJECTION SOLUTION RX-22473 CDM J1885 HCPCS 636 RC 63323-0162-16 NDC inpatient 1 ML 59.23 59.23 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES PPO [308136801] 46.9 percent of total billed charges 36.72 56.27 Technical (Hospital) Services KETOROLAC 30 MG/ML (1 ML) INJECTION SOLUTION RX-22473 CDM J1885 HCPCS 636 RC 63323-0162-16 NDC inpatient 1 ML 59.23 59.23 MEDICA (COMMERCIAL) 94265 [3081118] MEDICA CLAIMS [308111801] 53.31 percent of total billed charges 36.72 56.27 Technical (Hospital) Services KETOROLAC 30 MG/ML (1 ML) INJECTION SOLUTION RX-22473 CDM J1885 HCPCS 636 RC 63323-0162-16 NDC outpatient 1 ML 59.23 59.23 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES HDHP [308136802] 47.38 percent of total billed charges 36.72 56.27 Technical (Hospital) Services KETOROLAC 30 MG/ML (1 ML) INJECTION SOLUTION RX-22473 CDM J1885 HCPCS 636 RC 63323-0162-16 NDC outpatient 1 ML 59.23 59.23 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES EPO [308136803] 47.38 percent of total billed charges 36.72 56.27 Technical (Hospital) Services KETOROLAC 30 MG/ML (1 ML) INJECTION SOLUTION RX-22473 CDM J1885 HCPCS 636 RC 63323-0162-16 NDC outpatient 1 ML 59.23 59.23 HEALTHPARTNERS SX009 HEALTHPARTNERS 47.38 percent of total billed charges 36.72 56.27 Technical (Hospital) Services KETOROLAC 30 MG/ML (1 ML) INJECTION SOLUTION RX-22473 CDM J1885 HCPCS 636 RC 63323-0162-16 NDC outpatient 1 ML 59.23 59.23 MULTIPLAN INC 34080 [3081285] MULTIPLAN INC [308128501] 56.27 percent of total billed charges 36.72 56.27 Technical (Hospital) Services KETOROLAC 30 MG/ML (1 ML) INJECTION SOLUTION RX-22473 CDM J1885 HCPCS 636 RC 63323-0162-16 NDC outpatient 1 ML 59.23 59.23 UNITED HEALTHCARE (COMMERCIAL) [3081199] UNITED HEALTHCARE 87726 [308119901] 36.72 percent of total billed charges 36.72 56.27 Technical (Hospital) Services KETOROLAC 30 MG/ML (1 ML) INJECTION SOLUTION RX-22473 CDM J1885 HCPCS 636 RC 63323-0162-16 NDC outpatient 1 ML 59.23 59.23 MEDICA (COMMERCIAL) 94265 [3081118] MEDICA CLAIMS [308111801] 53.31 percent of total billed charges 36.72 56.27 Technical (Hospital) Services KETOROLAC 30 MG/ML (1 ML) INJECTION SOLUTION RX-22473 CDM J1885 HCPCS 636 RC 63323-0162-16 NDC outpatient 1 ML 59.23 59.23 CIGNA 62308 [3081051] CIGNA 62308 [308105105] 47.38 percent of total billed charges 36.72 56.27 Technical (Hospital) Services KETOROLAC 30 MG/ML (1 ML) INJECTION SOLUTION RX-22473 CDM J1885 HCPCS 636 RC 63323-0162-16 NDC outpatient 1 ML 59.23 59.23 CIGNA 62308 [3081051] CIGNA STATE OF WYOMING [308105107] 47.38 percent of total billed charges 36.72 56.27 Technical (Hospital) Services KETOROLAC 30 MG/ML (1 ML) INJECTION SOLUTION RX-22473 CDM J1885 HCPCS 636 RC 63323-0162-16 NDC outpatient 1 ML 59.23 59.23 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES PPO [308136801] 47.38 percent of total billed charges 36.72 56.27 Technical (Hospital) Services KETOROLAC 30 MG/ML (1 ML) INJECTION SOLUTION RX-22473 CDM J1885 HCPCS 636 RC 63323-0162-16 NDC outpatient 1 ML 59.23 59.23 BLUE CROSS BLUE SHIELD WELLMARK SB889 [3081026] BCBS WYOMING [308102603] 56.27 percent of total billed charges 36.72 56.27 Technical (Hospital) Services PROPRANOLOL 1 MG/ML INTRAVENOUS SOLUTION RX-29335 CDM J1800 HCPCS 636 RC 00143-9872-01 NDC inpatient 1 ML 72.5 72.5 MEDICA (COMMERCIAL) 94265 [3081118] MEDICA CLAIMS [308111801] 65.25 percent of total billed charges 44.95 68.88 Technical (Hospital) Services PROPRANOLOL 1 MG/ML INTRAVENOUS SOLUTION RX-29335 CDM J1800 HCPCS 636 RC 00143-9872-01 NDC inpatient 1 ML 72.5 72.5 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES PPO [308136801] 57.41 percent of total billed charges 44.95 68.88 Technical (Hospital) Services PROPRANOLOL 1 MG/ML INTRAVENOUS SOLUTION RX-29335 CDM J1800 HCPCS 636 RC 00143-9872-01 NDC inpatient 1 ML 72.5 72.5 HEALTHPARTNERS SX009 HEALTHPARTNERS 57.41 percent of total billed charges 44.95 68.88 Technical (Hospital) Services PROPRANOLOL 1 MG/ML INTRAVENOUS SOLUTION RX-29335 CDM J1800 HCPCS 636 RC 00143-9872-01 NDC inpatient 1 ML 72.5 72.5 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES HDHP [308136802] 57.41 percent of total billed charges 44.95 68.88 Technical (Hospital) Services PROPRANOLOL 1 MG/ML INTRAVENOUS SOLUTION RX-29335 CDM J1800 HCPCS 636 RC 00143-9872-01 NDC inpatient 1 ML 72.5 72.5 MULTIPLAN INC 34080 [3081285] MULTIPLAN INC [308128501] 68.88 percent of total billed charges 44.95 68.88 Technical (Hospital) Services PROPRANOLOL 1 MG/ML INTRAVENOUS SOLUTION RX-29335 CDM J1800 HCPCS 636 RC 00143-9872-01 NDC inpatient 1 ML 72.5 72.5 BLUE CROSS BLUE SHIELD WELLMARK SB889 [3081026] BCBS WYOMING [308102603] 68.88 percent of total billed charges 44.95 68.88 Technical (Hospital) Services PROPRANOLOL 1 MG/ML INTRAVENOUS SOLUTION RX-29335 CDM J1800 HCPCS 636 RC 00143-9872-01 NDC inpatient 1 ML 72.5 72.5 UNITED HEALTHCARE (COMMERCIAL) [3081199] UNITED HEALTHCARE 87726 [308119901] 44.95 percent of total billed charges 44.95 68.88 Technical (Hospital) Services PROPRANOLOL 1 MG/ML INTRAVENOUS SOLUTION RX-29335 CDM J1800 HCPCS 636 RC 00143-9872-01 NDC inpatient 1 ML 72.5 72.5 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES EPO [308136803] 57.41 percent of total billed charges 44.95 68.88 Technical (Hospital) Services PROPRANOLOL 1 MG/ML INTRAVENOUS SOLUTION RX-29335 CDM J1800 HCPCS 636 RC 00143-9872-01 NDC inpatient 1 ML 72.5 72.5 CIGNA 62308 [3081051] CIGNA 62308 [308105105] 57.41 percent of total billed charges 44.95 68.88 Technical (Hospital) Services PROPRANOLOL 1 MG/ML INTRAVENOUS SOLUTION RX-29335 CDM J1800 HCPCS 636 RC 00143-9872-01 NDC inpatient 1 ML 72.5 72.5 CIGNA 62308 [3081051] CIGNA STATE OF WYOMING [308105107] 57.41 percent of total billed charges 44.95 68.88 Technical (Hospital) Services PROPRANOLOL 1 MG/ML INTRAVENOUS SOLUTION RX-29335 CDM J1800 HCPCS 636 RC 00143-9872-01 NDC outpatient 1 ML 72.5 72.5 CIGNA 62308 [3081051] CIGNA 62308 [308105105] 58 percent of total billed charges 44.95 68.88 Technical (Hospital) Services PROPRANOLOL 1 MG/ML INTRAVENOUS SOLUTION RX-29335 CDM J1800 HCPCS 636 RC 00143-9872-01 NDC outpatient 1 ML 72.5 72.5 CIGNA 62308 [3081051] CIGNA STATE OF WYOMING [308105107] 58 percent of total billed charges 44.95 68.88 Technical (Hospital) Services PROPRANOLOL 1 MG/ML INTRAVENOUS SOLUTION RX-29335 CDM J1800 HCPCS 636 RC 00143-9872-01 NDC outpatient 1 ML 72.5 72.5 MEDICA (COMMERCIAL) 94265 [3081118] MEDICA CLAIMS [308111801] 65.25 percent of total billed charges 44.95 68.88 Technical (Hospital) Services PROPRANOLOL 1 MG/ML INTRAVENOUS SOLUTION RX-29335 CDM J1800 HCPCS 636 RC 00143-9872-01 NDC outpatient 1 ML 72.5 72.5 UNITED HEALTHCARE (COMMERCIAL) [3081199] UNITED HEALTHCARE 87726 [308119901] 44.95 percent of total billed charges 44.95 68.88 Technical (Hospital) Services PROPRANOLOL 1 MG/ML INTRAVENOUS SOLUTION RX-29335 CDM J1800 HCPCS 636 RC 00143-9872-01 NDC outpatient 1 ML 72.5 72.5 MULTIPLAN INC 34080 [3081285] MULTIPLAN INC [308128501] 68.88 percent of total billed charges 44.95 68.88 Technical (Hospital) Services PROPRANOLOL 1 MG/ML INTRAVENOUS SOLUTION RX-29335 CDM J1800 HCPCS 636 RC 00143-9872-01 NDC outpatient 1 ML 72.5 72.5 HEALTHPARTNERS SX009 HEALTHPARTNERS 58 percent of total billed charges 44.95 68.88 Technical (Hospital) Services PROPRANOLOL 1 MG/ML INTRAVENOUS SOLUTION RX-29335 CDM J1800 HCPCS 636 RC 00143-9872-01 NDC outpatient 1 ML 72.5 72.5 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES PPO [308136801] 58 percent of total billed charges 44.95 68.88 Technical (Hospital) Services PROPRANOLOL 1 MG/ML INTRAVENOUS SOLUTION RX-29335 CDM J1800 HCPCS 636 RC 00143-9872-01 NDC outpatient 1 ML 72.5 72.5 BLUE CROSS BLUE SHIELD WELLMARK SB889 [3081026] BCBS WYOMING [308102603] 68.88 percent of total billed charges 44.95 68.88 Technical (Hospital) Services PROPRANOLOL 1 MG/ML INTRAVENOUS SOLUTION RX-29335 CDM J1800 HCPCS 636 RC 00143-9872-01 NDC outpatient 1 ML 72.5 72.5 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES HDHP [308136802] 58 percent of total billed charges 44.95 68.88 Technical (Hospital) Services PROPRANOLOL 1 MG/ML INTRAVENOUS SOLUTION RX-29335 CDM J1800 HCPCS 636 RC 00143-9872-01 NDC outpatient 1 ML 72.5 72.5 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES EPO [308136803] 58 percent of total billed charges 44.95 68.88 Technical (Hospital) Services DROPERIDOL 2.5 MG/ML INJECTION SOLUTION RX-2654 CDM J1790 HCPCS 636 RC 00517-9702-01 NDC inpatient 0.5 ML 60.72 60.72 CIGNA 62308 [3081051] CIGNA 62308 [308105105] 48.08 percent of total billed charges 37.65 57.68 Technical (Hospital) Services DROPERIDOL 2.5 MG/ML INJECTION SOLUTION RX-2654 CDM J1790 HCPCS 636 RC 00517-9702-01 NDC inpatient 0.5 ML 60.72 60.72 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES HDHP [308136802] 48.08 percent of total billed charges 37.65 57.68 Technical (Hospital) Services DROPERIDOL 2.5 MG/ML INJECTION SOLUTION RX-2654 CDM J1790 HCPCS 636 RC 00517-9702-01 NDC inpatient 0.5 ML 60.72 60.72 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES PPO [308136801] 48.08 percent of total billed charges 37.65 57.68 Technical (Hospital) Services DROPERIDOL 2.5 MG/ML INJECTION SOLUTION RX-2654 CDM J1790 HCPCS 636 RC 00517-9702-01 NDC inpatient 0.5 ML 60.72 60.72 CIGNA 62308 [3081051] CIGNA STATE OF WYOMING [308105107] 48.08 percent of total billed charges 37.65 57.68 Technical (Hospital) Services DROPERIDOL 2.5 MG/ML INJECTION SOLUTION RX-2654 CDM J1790 HCPCS 636 RC 00517-9702-01 NDC inpatient 0.5 ML 60.72 60.72 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES EPO [308136803] 48.08 percent of total billed charges 37.65 57.68 Technical (Hospital) Services DROPERIDOL 2.5 MG/ML INJECTION SOLUTION RX-2654 CDM J1790 HCPCS 636 RC 00517-9702-01 NDC inpatient 0.5 ML 60.72 60.72 MEDICA (COMMERCIAL) 94265 [3081118] MEDICA CLAIMS [308111801] 54.65 percent of total billed charges 37.65 57.68 Technical (Hospital) Services DROPERIDOL 2.5 MG/ML INJECTION SOLUTION RX-2654 CDM J1790 HCPCS 636 RC 00517-9702-01 NDC inpatient 0.5 ML 60.72 60.72 UNITED HEALTHCARE (COMMERCIAL) [3081199] UNITED HEALTHCARE 87726 [308119901] 37.65 percent of total billed charges 37.65 57.68 Technical (Hospital) Services DROPERIDOL 2.5 MG/ML INJECTION SOLUTION RX-2654 CDM J1790 HCPCS 636 RC 00517-9702-01 NDC inpatient 0.5 ML 60.72 60.72 BLUE CROSS BLUE SHIELD WELLMARK SB889 [3081026] BCBS WYOMING [308102603] 57.68 percent of total billed charges 37.65 57.68 Technical (Hospital) Services DROPERIDOL 2.5 MG/ML INJECTION SOLUTION RX-2654 CDM J1790 HCPCS 636 RC 00517-9702-01 NDC inpatient 0.5 ML 60.72 60.72 HEALTHPARTNERS SX009 HEALTHPARTNERS 48.08 percent of total billed charges 37.65 57.68 Technical (Hospital) Services DROPERIDOL 2.5 MG/ML INJECTION SOLUTION RX-2654 CDM J1790 HCPCS 636 RC 00517-9702-01 NDC inpatient 0.5 ML 60.72 60.72 MULTIPLAN INC 34080 [3081285] MULTIPLAN INC [308128501] 57.68 percent of total billed charges 37.65 57.68 Technical (Hospital) Services DROPERIDOL 2.5 MG/ML INJECTION SOLUTION RX-2654 CDM J1790 HCPCS 636 RC 00517-9702-01 NDC outpatient 0.5 ML 60.72 60.72 HEALTHPARTNERS SX009 HEALTHPARTNERS 48.58 percent of total billed charges 37.65 57.68 Technical (Hospital) Services DROPERIDOL 2.5 MG/ML INJECTION SOLUTION RX-2654 CDM J1790 HCPCS 636 RC 00517-9702-01 NDC outpatient 0.5 ML 60.72 60.72 BLUE CROSS BLUE SHIELD WELLMARK SB889 [3081026] BCBS WYOMING [308102603] 57.68 percent of total billed charges 37.65 57.68 Technical (Hospital) Services DROPERIDOL 2.5 MG/ML INJECTION SOLUTION RX-2654 CDM J1790 HCPCS 636 RC 00517-9702-01 NDC outpatient 0.5 ML 60.72 60.72 MULTIPLAN INC 34080 [3081285] MULTIPLAN INC [308128501] 57.68 percent of total billed charges 37.65 57.68 Technical (Hospital) Services DROPERIDOL 2.5 MG/ML INJECTION SOLUTION RX-2654 CDM J1790 HCPCS 636 RC 00517-9702-01 NDC outpatient 0.5 ML 60.72 60.72 CIGNA 62308 [3081051] CIGNA 62308 [308105105] 48.58 percent of total billed charges 37.65 57.68 Technical (Hospital) Services DROPERIDOL 2.5 MG/ML INJECTION SOLUTION RX-2654 CDM J1790 HCPCS 636 RC 00517-9702-01 NDC outpatient 0.5 ML 60.72 60.72 CIGNA 62308 [3081051] CIGNA STATE OF WYOMING [308105107] 48.58 percent of total billed charges 37.65 57.68 Technical (Hospital) Services DROPERIDOL 2.5 MG/ML INJECTION SOLUTION RX-2654 CDM J1790 HCPCS 636 RC 00517-9702-01 NDC outpatient 0.5 ML 60.72 60.72 UNITED HEALTHCARE (COMMERCIAL) [3081199] UNITED HEALTHCARE 87726 [308119901] 37.65 percent of total billed charges 37.65 57.68 Technical (Hospital) Services DROPERIDOL 2.5 MG/ML INJECTION SOLUTION RX-2654 CDM J1790 HCPCS 636 RC 00517-9702-01 NDC outpatient 0.5 ML 60.72 60.72 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES EPO [308136803] 48.58 percent of total billed charges 37.65 57.68 Technical (Hospital) Services DROPERIDOL 2.5 MG/ML INJECTION SOLUTION RX-2654 CDM J1790 HCPCS 636 RC 00517-9702-01 NDC outpatient 0.5 ML 60.72 60.72 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES HDHP [308136802] 48.58 percent of total billed charges 37.65 57.68 Technical (Hospital) Services DROPERIDOL 2.5 MG/ML INJECTION SOLUTION RX-2654 CDM J1790 HCPCS 636 RC 00517-9702-01 NDC outpatient 0.5 ML 60.72 60.72 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES PPO [308136801] 48.58 percent of total billed charges 37.65 57.68 Technical (Hospital) Services DROPERIDOL 2.5 MG/ML INJECTION SOLUTION RX-2654 CDM J1790 HCPCS 636 RC 00517-9702-01 NDC outpatient 0.5 ML 60.72 60.72 MEDICA (COMMERCIAL) 94265 [3081118] MEDICA CLAIMS [308111801] 54.65 percent of total billed charges 37.65 57.68 Technical (Hospital) Services IRON SUCROSE 200 MG IRON/10 ML INTRAVENOUS SOLUTION RX-130638 CDM J1756 HCPCS 636 RC 00517-2310-01 NDC inpatient 10 ML 384.43 384.43 HEALTHPARTNERS SX009 HEALTHPARTNERS 304.39 percent of total billed charges 238.35 365.21 Technical (Hospital) Services IRON SUCROSE 200 MG IRON/10 ML INTRAVENOUS SOLUTION RX-130638 CDM J1756 HCPCS 636 RC 00517-2310-01 NDC inpatient 10 ML 384.43 384.43 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES EPO [308136803] 304.39 percent of total billed charges 238.35 365.21 Technical (Hospital) Services IRON SUCROSE 200 MG IRON/10 ML INTRAVENOUS SOLUTION RX-130638 CDM J1756 HCPCS 636 RC 00517-2310-01 NDC inpatient 10 ML 384.43 384.43 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES PPO [308136801] 304.39 percent of total billed charges 238.35 365.21 Technical (Hospital) Services IRON SUCROSE 200 MG IRON/10 ML INTRAVENOUS SOLUTION RX-130638 CDM J1756 HCPCS 636 RC 00517-2310-01 NDC inpatient 10 ML 384.43 384.43 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES HDHP [308136802] 304.39 percent of total billed charges 238.35 365.21 Technical (Hospital) Services IRON SUCROSE 200 MG IRON/10 ML INTRAVENOUS SOLUTION RX-130638 CDM J1756 HCPCS 636 RC 00517-2310-01 NDC inpatient 10 ML 384.43 384.43 CIGNA 62308 [3081051] CIGNA 62308 [308105105] 304.39 percent of total billed charges 238.35 365.21 Technical (Hospital) Services IRON SUCROSE 200 MG IRON/10 ML INTRAVENOUS SOLUTION RX-130638 CDM J1756 HCPCS 636 RC 00517-2310-01 NDC inpatient 10 ML 384.43 384.43 CIGNA 62308 [3081051] CIGNA STATE OF WYOMING [308105107] 304.39 percent of total billed charges 238.35 365.21 Technical (Hospital) Services IRON SUCROSE 200 MG IRON/10 ML INTRAVENOUS SOLUTION RX-130638 CDM J1756 HCPCS 636 RC 00517-2310-01 NDC inpatient 10 ML 384.43 384.43 UNITED HEALTHCARE (COMMERCIAL) [3081199] UNITED HEALTHCARE 87726 [308119901] 238.35 percent of total billed charges 238.35 365.21 Technical (Hospital) Services IRON SUCROSE 200 MG IRON/10 ML INTRAVENOUS SOLUTION RX-130638 CDM J1756 HCPCS 636 RC 00517-2310-01 NDC inpatient 10 ML 384.43 384.43 BLUE CROSS BLUE SHIELD WELLMARK SB889 [3081026] BCBS WYOMING [308102603] 365.21 percent of total billed charges 238.35 365.21 Technical (Hospital) Services IRON SUCROSE 200 MG IRON/10 ML INTRAVENOUS SOLUTION RX-130638 CDM J1756 HCPCS 636 RC 00517-2310-01 NDC inpatient 10 ML 384.43 384.43 MEDICA (COMMERCIAL) 94265 [3081118] MEDICA CLAIMS [308111801] 345.99 percent of total billed charges 238.35 365.21 Technical (Hospital) Services IRON SUCROSE 200 MG IRON/10 ML INTRAVENOUS SOLUTION RX-130638 CDM J1756 HCPCS 636 RC 00517-2310-01 NDC inpatient 10 ML 384.43 384.43 MULTIPLAN INC 34080 [3081285] MULTIPLAN INC [308128501] 365.21 percent of total billed charges 238.35 365.21 Technical (Hospital) Services IRON SUCROSE 200 MG IRON/10 ML INTRAVENOUS SOLUTION RX-130638 CDM J1756 HCPCS 636 RC 00517-2310-01 NDC outpatient 10 ML 384.43 384.43 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES PPO [308136801] 307.54 percent of total billed charges 238.35 365.21 Technical (Hospital) Services IRON SUCROSE 200 MG IRON/10 ML INTRAVENOUS SOLUTION RX-130638 CDM J1756 HCPCS 636 RC 00517-2310-01 NDC outpatient 10 ML 384.43 384.43 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES HDHP [308136802] 307.54 percent of total billed charges 238.35 365.21 Technical (Hospital) Services IRON SUCROSE 200 MG IRON/10 ML INTRAVENOUS SOLUTION RX-130638 CDM J1756 HCPCS 636 RC 00517-2310-01 NDC outpatient 10 ML 384.43 384.43 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES EPO [308136803] 307.54 percent of total billed charges 238.35 365.21 Technical (Hospital) Services IRON SUCROSE 200 MG IRON/10 ML INTRAVENOUS SOLUTION RX-130638 CDM J1756 HCPCS 636 RC 00517-2310-01 NDC outpatient 10 ML 384.43 384.43 BLUE CROSS BLUE SHIELD WELLMARK SB889 [3081026] BCBS WYOMING [308102603] 365.21 percent of total billed charges 238.35 365.21 Technical (Hospital) Services IRON SUCROSE 200 MG IRON/10 ML INTRAVENOUS SOLUTION RX-130638 CDM J1756 HCPCS 636 RC 00517-2310-01 NDC outpatient 10 ML 384.43 384.43 MEDICA (COMMERCIAL) 94265 [3081118] MEDICA CLAIMS [308111801] 345.99 percent of total billed charges 238.35 365.21 Technical (Hospital) Services IRON SUCROSE 200 MG IRON/10 ML INTRAVENOUS SOLUTION RX-130638 CDM J1756 HCPCS 636 RC 00517-2310-01 NDC outpatient 10 ML 384.43 384.43 MULTIPLAN INC 34080 [3081285] MULTIPLAN INC [308128501] 365.21 percent of total billed charges 238.35 365.21 Technical (Hospital) Services IRON SUCROSE 200 MG IRON/10 ML INTRAVENOUS SOLUTION RX-130638 CDM J1756 HCPCS 636 RC 00517-2310-01 NDC outpatient 10 ML 384.43 384.43 HEALTHPARTNERS SX009 HEALTHPARTNERS 307.54 percent of total billed charges 238.35 365.21 Technical (Hospital) Services IRON SUCROSE 200 MG IRON/10 ML INTRAVENOUS SOLUTION RX-130638 CDM J1756 HCPCS 636 RC 00517-2310-01 NDC outpatient 10 ML 384.43 384.43 UNITED HEALTHCARE (COMMERCIAL) [3081199] UNITED HEALTHCARE 87726 [308119901] 238.35 percent of total billed charges 238.35 365.21 Technical (Hospital) Services IRON SUCROSE 200 MG IRON/10 ML INTRAVENOUS SOLUTION RX-130638 CDM J1756 HCPCS 636 RC 00517-2310-01 NDC outpatient 10 ML 384.43 384.43 CIGNA 62308 [3081051] CIGNA 62308 [308105105] 307.54 percent of total billed charges 238.35 365.21 Technical (Hospital) Services IRON SUCROSE 200 MG IRON/10 ML INTRAVENOUS SOLUTION RX-130638 CDM J1756 HCPCS 636 RC 00517-2310-01 NDC outpatient 10 ML 384.43 384.43 CIGNA 62308 [3081051] CIGNA STATE OF WYOMING [308105107] 307.54 percent of total billed charges 238.35 365.21 Technical (Hospital) Services IRON SUCROSE 100 MG IRON/5 ML INTRAVENOUS SOLUTION RX-29132 CDM J1756 HCPCS 636 RC 00517-2340-99 NDC inpatient 5 ML 247 247 MULTIPLAN INC 34080 [3081285] MULTIPLAN INC [308128501] 234.65 percent of total billed charges 153.14 234.65 Technical (Hospital) Services IRON SUCROSE 100 MG IRON/5 ML INTRAVENOUS SOLUTION RX-29132 CDM J1756 HCPCS 636 RC 00517-2340-99 NDC inpatient 5 ML 247 247 MEDICA (COMMERCIAL) 94265 [3081118] MEDICA CLAIMS [308111801] 222.3 percent of total billed charges 153.14 234.65 Technical (Hospital) Services IRON SUCROSE 100 MG IRON/5 ML INTRAVENOUS SOLUTION RX-29132 CDM J1756 HCPCS 636 RC 00517-2340-99 NDC inpatient 5 ML 247 247 BLUE CROSS BLUE SHIELD WELLMARK SB889 [3081026] BCBS WYOMING [308102603] 234.65 percent of total billed charges 153.14 234.65 Technical (Hospital) Services IRON SUCROSE 100 MG IRON/5 ML INTRAVENOUS SOLUTION RX-29132 CDM J1756 HCPCS 636 RC 00517-2340-99 NDC inpatient 5 ML 247 247 UNITED HEALTHCARE (COMMERCIAL) [3081199] UNITED HEALTHCARE 87726 [308119901] 153.14 percent of total billed charges 153.14 234.65 Technical (Hospital) Services IRON SUCROSE 100 MG IRON/5 ML INTRAVENOUS SOLUTION RX-29132 CDM J1756 HCPCS 636 RC 00517-2340-99 NDC inpatient 5 ML 247 247 CIGNA 62308 [3081051] CIGNA 62308 [308105105] 195.57 percent of total billed charges 153.14 234.65 Technical (Hospital) Services IRON SUCROSE 100 MG IRON/5 ML INTRAVENOUS SOLUTION RX-29132 CDM J1756 HCPCS 636 RC 00517-2340-99 NDC inpatient 5 ML 247 247 CIGNA 62308 [3081051] CIGNA STATE OF WYOMING [308105107] 195.57 percent of total billed charges 153.14 234.65 Technical (Hospital) Services IRON SUCROSE 100 MG IRON/5 ML INTRAVENOUS SOLUTION RX-29132 CDM J1756 HCPCS 636 RC 00517-2340-99 NDC inpatient 5 ML 247 247 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES EPO [308136803] 195.57 percent of total billed charges 153.14 234.65 Technical (Hospital) Services IRON SUCROSE 100 MG IRON/5 ML INTRAVENOUS SOLUTION RX-29132 CDM J1756 HCPCS 636 RC 00517-2340-99 NDC inpatient 5 ML 247 247 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES HDHP [308136802] 195.57 percent of total billed charges 153.14 234.65 Technical (Hospital) Services IRON SUCROSE 100 MG IRON/5 ML INTRAVENOUS SOLUTION RX-29132 CDM J1756 HCPCS 636 RC 00517-2340-99 NDC inpatient 5 ML 247 247 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES PPO [308136801] 195.57 percent of total billed charges 153.14 234.65 Technical (Hospital) Services IRON SUCROSE 100 MG IRON/5 ML INTRAVENOUS SOLUTION RX-29132 CDM J1756 HCPCS 636 RC 00517-2340-99 NDC inpatient 5 ML 247 247 HEALTHPARTNERS SX009 HEALTHPARTNERS 195.57 percent of total billed charges 153.14 234.65 Technical (Hospital) Services IRON SUCROSE 100 MG IRON/5 ML INTRAVENOUS SOLUTION RX-29132 CDM J1756 HCPCS 636 RC 00517-2340-99 NDC outpatient 5 ML 247 247 CIGNA 62308 [3081051] CIGNA 62308 [308105105] 197.6 percent of total billed charges 153.14 234.65 Technical (Hospital) Services IRON SUCROSE 100 MG IRON/5 ML INTRAVENOUS SOLUTION RX-29132 CDM J1756 HCPCS 636 RC 00517-2340-99 NDC outpatient 5 ML 247 247 CIGNA 62308 [3081051] CIGNA STATE OF WYOMING [308105107] 197.6 percent of total billed charges 153.14 234.65 Technical (Hospital) Services IRON SUCROSE 100 MG IRON/5 ML INTRAVENOUS SOLUTION RX-29132 CDM J1756 HCPCS 636 RC 00517-2340-99 NDC outpatient 5 ML 247 247 BLUE CROSS BLUE SHIELD WELLMARK SB889 [3081026] BCBS WYOMING [308102603] 234.65 percent of total billed charges 153.14 234.65 Technical (Hospital) Services IRON SUCROSE 100 MG IRON/5 ML INTRAVENOUS SOLUTION RX-29132 CDM J1756 HCPCS 636 RC 00517-2340-99 NDC outpatient 5 ML 247 247 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES HDHP [308136802] 197.6 percent of total billed charges 153.14 234.65 Technical (Hospital) Services IRON SUCROSE 100 MG IRON/5 ML INTRAVENOUS SOLUTION RX-29132 CDM J1756 HCPCS 636 RC 00517-2340-99 NDC outpatient 5 ML 247 247 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES PPO [308136801] 197.6 percent of total billed charges 153.14 234.65 Technical (Hospital) Services IRON SUCROSE 100 MG IRON/5 ML INTRAVENOUS SOLUTION RX-29132 CDM J1756 HCPCS 636 RC 00517-2340-99 NDC outpatient 5 ML 247 247 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES EPO [308136803] 197.6 percent of total billed charges 153.14 234.65 Technical (Hospital) Services IRON SUCROSE 100 MG IRON/5 ML INTRAVENOUS SOLUTION RX-29132 CDM J1756 HCPCS 636 RC 00517-2340-99 NDC outpatient 5 ML 247 247 HEALTHPARTNERS SX009 HEALTHPARTNERS 197.6 percent of total billed charges 153.14 234.65 Technical (Hospital) Services IRON SUCROSE 100 MG IRON/5 ML INTRAVENOUS SOLUTION RX-29132 CDM J1756 HCPCS 636 RC 00517-2340-99 NDC outpatient 5 ML 247 247 UNITED HEALTHCARE (COMMERCIAL) [3081199] UNITED HEALTHCARE 87726 [308119901] 153.14 percent of total billed charges 153.14 234.65 Technical (Hospital) Services IRON SUCROSE 100 MG IRON/5 ML INTRAVENOUS SOLUTION RX-29132 CDM J1756 HCPCS 636 RC 00517-2340-99 NDC outpatient 5 ML 247 247 MEDICA (COMMERCIAL) 94265 [3081118] MEDICA CLAIMS [308111801] 222.3 percent of total billed charges 153.14 234.65 Technical (Hospital) Services IRON SUCROSE 100 MG IRON/5 ML INTRAVENOUS SOLUTION RX-29132 CDM J1756 HCPCS 636 RC 00517-2340-99 NDC outpatient 5 ML 247 247 MULTIPLAN INC 34080 [3081285] MULTIPLAN INC [308128501] 234.65 percent of total billed charges 153.14 234.65 Technical (Hospital) Services INFLIXIMAB 100 MG INTRAVENOUS SOLUTION RX-23796 CDM J1745 HCPCS 636 RC 57894-0030-01 NDC inpatient 10 ML 2392.82 2392.82 BLUE CROSS BLUE SHIELD WELLMARK SB889 [3081026] BCBS WYOMING [308102603] 2273.18 percent of total billed charges 1483.55 2273.18 Technical (Hospital) Services INFLIXIMAB 100 MG INTRAVENOUS SOLUTION RX-23796 CDM J1745 HCPCS 636 RC 57894-0030-01 NDC inpatient 10 ML 2392.82 2392.82 UNITED HEALTHCARE (COMMERCIAL) [3081199] UNITED HEALTHCARE 87726 [308119901] 1483.55 percent of total billed charges 1483.55 2273.18 Technical (Hospital) Services INFLIXIMAB 100 MG INTRAVENOUS SOLUTION RX-23796 CDM J1745 HCPCS 636 RC 57894-0030-01 NDC inpatient 10 ML 2392.82 2392.82 CIGNA 62308 [3081051] CIGNA 62308 [308105105] 1894.63 percent of total billed charges 1483.55 2273.18 Technical (Hospital) Services INFLIXIMAB 100 MG INTRAVENOUS SOLUTION RX-23796 CDM J1745 HCPCS 636 RC 57894-0030-01 NDC inpatient 10 ML 2392.82 2392.82 CIGNA 62308 [3081051] CIGNA STATE OF WYOMING [308105107] 1894.63 percent of total billed charges 1483.55 2273.18 Technical (Hospital) Services INFLIXIMAB 100 MG INTRAVENOUS SOLUTION RX-23796 CDM J1745 HCPCS 636 RC 57894-0030-01 NDC inpatient 10 ML 2392.82 2392.82 MEDICA (COMMERCIAL) 94265 [3081118] MEDICA CLAIMS [308111801] 2153.54 percent of total billed charges 1483.55 2273.18 Technical (Hospital) Services INFLIXIMAB 100 MG INTRAVENOUS SOLUTION RX-23796 CDM J1745 HCPCS 636 RC 57894-0030-01 NDC inpatient 10 ML 2392.82 2392.82 MULTIPLAN INC 34080 [3081285] MULTIPLAN INC [308128501] 2273.18 percent of total billed charges 1483.55 2273.18 Technical (Hospital) Services INFLIXIMAB 100 MG INTRAVENOUS SOLUTION RX-23796 CDM J1745 HCPCS 636 RC 57894-0030-01 NDC inpatient 10 ML 2392.82 2392.82 HEALTHPARTNERS SX009 HEALTHPARTNERS 1894.63 percent of total billed charges 1483.55 2273.18 Technical (Hospital) Services INFLIXIMAB 100 MG INTRAVENOUS SOLUTION RX-23796 CDM J1745 HCPCS 636 RC 57894-0030-01 NDC inpatient 10 ML 2392.82 2392.82 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES EPO [308136803] 1894.63 percent of total billed charges 1483.55 2273.18 Technical (Hospital) Services INFLIXIMAB 100 MG INTRAVENOUS SOLUTION RX-23796 CDM J1745 HCPCS 636 RC 57894-0030-01 NDC inpatient 10 ML 2392.82 2392.82 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES HDHP [308136802] 1894.63 percent of total billed charges 1483.55 2273.18 Technical (Hospital) Services INFLIXIMAB 100 MG INTRAVENOUS SOLUTION RX-23796 CDM J1745 HCPCS 636 RC 57894-0030-01 NDC inpatient 10 ML 2392.82 2392.82 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES PPO [308136801] 1894.63 percent of total billed charges 1483.55 2273.18 Technical (Hospital) Services INFLIXIMAB 100 MG INTRAVENOUS SOLUTION RX-23796 CDM J1745 HCPCS 636 RC 57894-0030-01 NDC outpatient 10 ML 2392.82 2392.82 UNITED HEALTHCARE (COMMERCIAL) [3081199] UNITED HEALTHCARE 87726 [308119901] 1483.55 percent of total billed charges 1483.55 2273.18 Technical (Hospital) Services INFLIXIMAB 100 MG INTRAVENOUS SOLUTION RX-23796 CDM J1745 HCPCS 636 RC 57894-0030-01 NDC outpatient 10 ML 2392.82 2392.82 HEALTHPARTNERS SX009 HEALTHPARTNERS 1914.26 percent of total billed charges 1483.55 2273.18 Technical (Hospital) Services INFLIXIMAB 100 MG INTRAVENOUS SOLUTION RX-23796 CDM J1745 HCPCS 636 RC 57894-0030-01 NDC outpatient 10 ML 2392.82 2392.82 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES PPO [308136801] 1914.26 percent of total billed charges 1483.55 2273.18 Technical (Hospital) Services INFLIXIMAB 100 MG INTRAVENOUS SOLUTION RX-23796 CDM J1745 HCPCS 636 RC 57894-0030-01 NDC outpatient 10 ML 2392.82 2392.82 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES EPO [308136803] 1914.26 percent of total billed charges 1483.55 2273.18 Technical (Hospital) Services INFLIXIMAB 100 MG INTRAVENOUS SOLUTION RX-23796 CDM J1745 HCPCS 636 RC 57894-0030-01 NDC outpatient 10 ML 2392.82 2392.82 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES HDHP [308136802] 1914.26 percent of total billed charges 1483.55 2273.18 Technical (Hospital) Services INFLIXIMAB 100 MG INTRAVENOUS SOLUTION RX-23796 CDM J1745 HCPCS 636 RC 57894-0030-01 NDC outpatient 10 ML 2392.82 2392.82 BLUE CROSS BLUE SHIELD WELLMARK SB889 [3081026] BCBS WYOMING [308102603] 2273.18 percent of total billed charges 1483.55 2273.18 Technical (Hospital) Services INFLIXIMAB 100 MG INTRAVENOUS SOLUTION RX-23796 CDM J1745 HCPCS 636 RC 57894-0030-01 NDC outpatient 10 ML 2392.82 2392.82 MEDICA (COMMERCIAL) 94265 [3081118] MEDICA CLAIMS [308111801] 2153.54 percent of total billed charges 1483.55 2273.18 Technical (Hospital) Services INFLIXIMAB 100 MG INTRAVENOUS SOLUTION RX-23796 CDM J1745 HCPCS 636 RC 57894-0030-01 NDC outpatient 10 ML 2392.82 2392.82 MULTIPLAN INC 34080 [3081285] MULTIPLAN INC [308128501] 2273.18 percent of total billed charges 1483.55 2273.18 Technical (Hospital) Services INFLIXIMAB 100 MG INTRAVENOUS SOLUTION RX-23796 CDM J1745 HCPCS 636 RC 57894-0030-01 NDC outpatient 10 ML 2392.82 2392.82 CIGNA 62308 [3081051] CIGNA 62308 [308105105] 1914.26 percent of total billed charges 1483.55 2273.18 Technical (Hospital) Services INFLIXIMAB 100 MG INTRAVENOUS SOLUTION RX-23796 CDM J1745 HCPCS 636 RC 57894-0030-01 NDC outpatient 10 ML 2392.82 2392.82 CIGNA 62308 [3081051] CIGNA STATE OF WYOMING [308105107] 1914.26 percent of total billed charges 1483.55 2273.18 Technical (Hospital) Services IBANDRONATE 3 MG/3 ML INTRAVENOUS SYRINGE RX-110306 CDM J1740 HCPCS 636 RC 60505-6097-00 NDC inpatient 3 ML 640 640 BLUE CROSS BLUE SHIELD WELLMARK SB889 [3081026] BCBS WYOMING [308102603] 608 percent of total billed charges 396.8 608 Technical (Hospital) Services IBANDRONATE 3 MG/3 ML INTRAVENOUS SYRINGE RX-110306 CDM J1740 HCPCS 636 RC 60505-6097-00 NDC inpatient 3 ML 640 640 UNITED HEALTHCARE (COMMERCIAL) [3081199] UNITED HEALTHCARE 87726 [308119901] 396.8 percent of total billed charges 396.8 608 Technical (Hospital) Services IBANDRONATE 3 MG/3 ML INTRAVENOUS SYRINGE RX-110306 CDM J1740 HCPCS 636 RC 60505-6097-00 NDC inpatient 3 ML 640 640 CIGNA 62308 [3081051] CIGNA 62308 [308105105] 506.75 percent of total billed charges 396.8 608 Technical (Hospital) Services IBANDRONATE 3 MG/3 ML INTRAVENOUS SYRINGE RX-110306 CDM J1740 HCPCS 636 RC 60505-6097-00 NDC inpatient 3 ML 640 640 CIGNA 62308 [3081051] CIGNA STATE OF WYOMING [308105107] 506.75 percent of total billed charges 396.8 608 Technical (Hospital) Services IBANDRONATE 3 MG/3 ML INTRAVENOUS SYRINGE RX-110306 CDM J1740 HCPCS 636 RC 60505-6097-00 NDC inpatient 3 ML 640 640 MULTIPLAN INC 34080 [3081285] MULTIPLAN INC [308128501] 608 percent of total billed charges 396.8 608 Technical (Hospital) Services IBANDRONATE 3 MG/3 ML INTRAVENOUS SYRINGE RX-110306 CDM J1740 HCPCS 636 RC 60505-6097-00 NDC inpatient 3 ML 640 640 MEDICA (COMMERCIAL) 94265 [3081118] MEDICA CLAIMS [308111801] 576 percent of total billed charges 396.8 608 Technical (Hospital) Services IBANDRONATE 3 MG/3 ML INTRAVENOUS SYRINGE RX-110306 CDM J1740 HCPCS 636 RC 60505-6097-00 NDC inpatient 3 ML 640 640 HEALTHPARTNERS SX009 HEALTHPARTNERS 506.75 percent of total billed charges 396.8 608 Technical (Hospital) Services IBANDRONATE 3 MG/3 ML INTRAVENOUS SYRINGE RX-110306 CDM J1740 HCPCS 636 RC 60505-6097-00 NDC inpatient 3 ML 640 640 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES EPO [308136803] 506.75 percent of total billed charges 396.8 608 Technical (Hospital) Services IBANDRONATE 3 MG/3 ML INTRAVENOUS SYRINGE RX-110306 CDM J1740 HCPCS 636 RC 60505-6097-00 NDC inpatient 3 ML 640 640 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES PPO [308136801] 506.75 percent of total billed charges 396.8 608 Technical (Hospital) Services IBANDRONATE 3 MG/3 ML INTRAVENOUS SYRINGE RX-110306 CDM J1740 HCPCS 636 RC 60505-6097-00 NDC inpatient 3 ML 640 640 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES HDHP [308136802] 506.75 percent of total billed charges 396.8 608 Technical (Hospital) Services IBANDRONATE 3 MG/3 ML INTRAVENOUS SYRINGE RX-110306 CDM J1740 HCPCS 636 RC 60505-6097-00 NDC outpatient 3 ML 640 640 BLUE CROSS BLUE SHIELD WELLMARK SB889 [3081026] BCBS WYOMING [308102603] 608 percent of total billed charges 396.8 608 Technical (Hospital) Services IBANDRONATE 3 MG/3 ML INTRAVENOUS SYRINGE RX-110306 CDM J1740 HCPCS 636 RC 60505-6097-00 NDC outpatient 3 ML 640 640 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES EPO [308136803] 512 percent of total billed charges 396.8 608 Technical (Hospital) Services IBANDRONATE 3 MG/3 ML INTRAVENOUS SYRINGE RX-110306 CDM J1740 HCPCS 636 RC 60505-6097-00 NDC outpatient 3 ML 640 640 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES HDHP [308136802] 512 percent of total billed charges 396.8 608 Technical (Hospital) Services IBANDRONATE 3 MG/3 ML INTRAVENOUS SYRINGE RX-110306 CDM J1740 HCPCS 636 RC 60505-6097-00 NDC outpatient 3 ML 640 640 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES PPO [308136801] 512 percent of total billed charges 396.8 608 Technical (Hospital) Services IBANDRONATE 3 MG/3 ML INTRAVENOUS SYRINGE RX-110306 CDM J1740 HCPCS 636 RC 60505-6097-00 NDC outpatient 3 ML 640 640 MEDICA (COMMERCIAL) 94265 [3081118] MEDICA CLAIMS [308111801] 576 percent of total billed charges 396.8 608 Technical (Hospital) Services IBANDRONATE 3 MG/3 ML INTRAVENOUS SYRINGE RX-110306 CDM J1740 HCPCS 636 RC 60505-6097-00 NDC outpatient 3 ML 640 640 MULTIPLAN INC 34080 [3081285] MULTIPLAN INC [308128501] 608 percent of total billed charges 396.8 608 Technical (Hospital) Services IBANDRONATE 3 MG/3 ML INTRAVENOUS SYRINGE RX-110306 CDM J1740 HCPCS 636 RC 60505-6097-00 NDC outpatient 3 ML 640 640 CIGNA 62308 [3081051] CIGNA 62308 [308105105] 512 percent of total billed charges 396.8 608 Technical (Hospital) Services IBANDRONATE 3 MG/3 ML INTRAVENOUS SYRINGE RX-110306 CDM J1740 HCPCS 636 RC 60505-6097-00 NDC outpatient 3 ML 640 640 CIGNA 62308 [3081051] CIGNA STATE OF WYOMING [308105107] 512 percent of total billed charges 396.8 608 Technical (Hospital) Services IBANDRONATE 3 MG/3 ML INTRAVENOUS SYRINGE RX-110306 CDM J1740 HCPCS 636 RC 60505-6097-00 NDC outpatient 3 ML 640 640 UNITED HEALTHCARE (COMMERCIAL) [3081199] UNITED HEALTHCARE 87726 [308119901] 396.8 percent of total billed charges 396.8 608 Technical (Hospital) Services IBANDRONATE 3 MG/3 ML INTRAVENOUS SYRINGE RX-110306 CDM J1740 HCPCS 636 RC 60505-6097-00 NDC outpatient 3 ML 640 640 HEALTHPARTNERS SX009 HEALTHPARTNERS 512 percent of total billed charges 396.8 608 Technical (Hospital) Services HYDROCORTISONE SODIUM SUCCINATE 100 MG SOLUTION FOR INJECTION RX-121934 CDM J1720 HCPCS 636 RC 00009-0825-01 NDC inpatient 2 ML 85.86 85.86 MEDICA (COMMERCIAL) 94265 [3081118] MEDICA CLAIMS [308111801] 77.27 percent of total billed charges 53.23 81.57 Technical (Hospital) Services HYDROCORTISONE SODIUM SUCCINATE 100 MG SOLUTION FOR INJECTION RX-121934 CDM J1720 HCPCS 636 RC 00009-0825-01 NDC inpatient 2 ML 85.86 85.86 MULTIPLAN INC 34080 [3081285] MULTIPLAN INC [308128501] 81.57 percent of total billed charges 53.23 81.57 Technical (Hospital) Services HYDROCORTISONE SODIUM SUCCINATE 100 MG SOLUTION FOR INJECTION RX-121934 CDM J1720 HCPCS 636 RC 00009-0825-01 NDC inpatient 2 ML 85.86 85.86 CIGNA 62308 [3081051] CIGNA 62308 [308105105] 67.98 percent of total billed charges 53.23 81.57 Technical (Hospital) Services HYDROCORTISONE SODIUM SUCCINATE 100 MG SOLUTION FOR INJECTION RX-121934 CDM J1720 HCPCS 636 RC 00009-0825-01 NDC inpatient 2 ML 85.86 85.86 CIGNA 62308 [3081051] CIGNA STATE OF WYOMING [308105107] 67.98 percent of total billed charges 53.23 81.57 Technical (Hospital) Services HYDROCORTISONE SODIUM SUCCINATE 100 MG SOLUTION FOR INJECTION RX-121934 CDM J1720 HCPCS 636 RC 00009-0825-01 NDC inpatient 2 ML 85.86 85.86 UNITED HEALTHCARE (COMMERCIAL) [3081199] UNITED HEALTHCARE 87726 [308119901] 53.23 percent of total billed charges 53.23 81.57 Technical (Hospital) Services HYDROCORTISONE SODIUM SUCCINATE 100 MG SOLUTION FOR INJECTION RX-121934 CDM J1720 HCPCS 636 RC 00009-0825-01 NDC inpatient 2 ML 85.86 85.86 BLUE CROSS BLUE SHIELD WELLMARK SB889 [3081026] BCBS WYOMING [308102603] 81.57 percent of total billed charges 53.23 81.57 Technical (Hospital) Services HYDROCORTISONE SODIUM SUCCINATE 100 MG SOLUTION FOR INJECTION RX-121934 CDM J1720 HCPCS 636 RC 00009-0825-01 NDC inpatient 2 ML 85.86 85.86 HEALTHPARTNERS SX009 HEALTHPARTNERS 67.98 percent of total billed charges 53.23 81.57 Technical (Hospital) Services HYDROCORTISONE SODIUM SUCCINATE 100 MG SOLUTION FOR INJECTION RX-121934 CDM J1720 HCPCS 636 RC 00009-0825-01 NDC inpatient 2 ML 85.86 85.86 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES PPO [308136801] 67.98 percent of total billed charges 53.23 81.57 Technical (Hospital) Services HYDROCORTISONE SODIUM SUCCINATE 100 MG SOLUTION FOR INJECTION RX-121934 CDM J1720 HCPCS 636 RC 00009-0825-01 NDC inpatient 2 ML 85.86 85.86 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES HDHP [308136802] 67.98 percent of total billed charges 53.23 81.57 Technical (Hospital) Services HYDROCORTISONE SODIUM SUCCINATE 100 MG SOLUTION FOR INJECTION RX-121934 CDM J1720 HCPCS 636 RC 00009-0825-01 NDC inpatient 2 ML 85.86 85.86 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES EPO [308136803] 67.98 percent of total billed charges 53.23 81.57 Technical (Hospital) Services HYDROCORTISONE SODIUM SUCCINATE 100 MG SOLUTION FOR INJECTION RX-121934 CDM J1720 HCPCS 636 RC 00009-0825-01 NDC outpatient 2 ML 85.86 85.86 HEALTHPARTNERS SX009 HEALTHPARTNERS 68.69 percent of total billed charges 53.23 81.57 Technical (Hospital) Services HYDROCORTISONE SODIUM SUCCINATE 100 MG SOLUTION FOR INJECTION RX-121934 CDM J1720 HCPCS 636 RC 00009-0825-01 NDC outpatient 2 ML 85.86 85.86 UNITED HEALTHCARE (COMMERCIAL) [3081199] UNITED HEALTHCARE 87726 [308119901] 53.23 percent of total billed charges 53.23 81.57 Technical (Hospital) Services HYDROCORTISONE SODIUM SUCCINATE 100 MG SOLUTION FOR INJECTION RX-121934 CDM J1720 HCPCS 636 RC 00009-0825-01 NDC outpatient 2 ML 85.86 85.86 MULTIPLAN INC 34080 [3081285] MULTIPLAN INC [308128501] 81.57 percent of total billed charges 53.23 81.57 Technical (Hospital) Services HYDROCORTISONE SODIUM SUCCINATE 100 MG SOLUTION FOR INJECTION RX-121934 CDM J1720 HCPCS 636 RC 00009-0825-01 NDC outpatient 2 ML 85.86 85.86 CIGNA 62308 [3081051] CIGNA 62308 [308105105] 68.69 percent of total billed charges 53.23 81.57 Technical (Hospital) Services HYDROCORTISONE SODIUM SUCCINATE 100 MG SOLUTION FOR INJECTION RX-121934 CDM J1720 HCPCS 636 RC 00009-0825-01 NDC outpatient 2 ML 85.86 85.86 CIGNA 62308 [3081051] CIGNA STATE OF WYOMING [308105107] 68.69 percent of total billed charges 53.23 81.57 Technical (Hospital) Services HYDROCORTISONE SODIUM SUCCINATE 100 MG SOLUTION FOR INJECTION RX-121934 CDM J1720 HCPCS 636 RC 00009-0825-01 NDC outpatient 2 ML 85.86 85.86 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES HDHP [308136802] 68.69 percent of total billed charges 53.23 81.57 Technical (Hospital) Services HYDROCORTISONE SODIUM SUCCINATE 100 MG SOLUTION FOR INJECTION RX-121934 CDM J1720 HCPCS 636 RC 00009-0825-01 NDC outpatient 2 ML 85.86 85.86 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES PPO [308136801] 68.69 percent of total billed charges 53.23 81.57 Technical (Hospital) Services HYDROCORTISONE SODIUM SUCCINATE 100 MG SOLUTION FOR INJECTION RX-121934 CDM J1720 HCPCS 636 RC 00009-0825-01 NDC outpatient 2 ML 85.86 85.86 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES EPO [308136803] 68.69 percent of total billed charges 53.23 81.57 Technical (Hospital) Services HYDROCORTISONE SODIUM SUCCINATE 100 MG SOLUTION FOR INJECTION RX-121934 CDM J1720 HCPCS 636 RC 00009-0825-01 NDC outpatient 2 ML 85.86 85.86 BLUE CROSS BLUE SHIELD WELLMARK SB889 [3081026] BCBS WYOMING [308102603] 81.57 percent of total billed charges 53.23 81.57 Technical (Hospital) Services HYDROCORTISONE SODIUM SUCCINATE 100 MG SOLUTION FOR INJECTION RX-121934 CDM J1720 HCPCS 636 RC 00009-0825-01 NDC outpatient 2 ML 85.86 85.86 MEDICA (COMMERCIAL) 94265 [3081118] MEDICA CLAIMS [308111801] 77.27 percent of total billed charges 53.23 81.57 Technical (Hospital) Services HYDROCORTISONE SOD SUCCINATE (PF) 100 MG/2 ML SOLUTION - WRAPPER RX-4080030022 CDM J1720 HCPCS 636 RC 00009-0825-01 NDC inpatient 2 ML 85.86 85.86 HEALTHPARTNERS SX009 HEALTHPARTNERS 67.98 percent of total billed charges 53.23 81.57 Technical (Hospital) Services HYDROCORTISONE SOD SUCCINATE (PF) 100 MG/2 ML SOLUTION - WRAPPER RX-4080030022 CDM J1720 HCPCS 636 RC 00009-0825-01 NDC inpatient 2 ML 85.86 85.86 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES EPO [308136803] 67.98 percent of total billed charges 53.23 81.57 Technical (Hospital) Services HYDROCORTISONE SOD SUCCINATE (PF) 100 MG/2 ML SOLUTION - WRAPPER RX-4080030022 CDM J1720 HCPCS 636 RC 00009-0825-01 NDC inpatient 2 ML 85.86 85.86 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES HDHP [308136802] 67.98 percent of total billed charges 53.23 81.57 Technical (Hospital) Services HYDROCORTISONE SOD SUCCINATE (PF) 100 MG/2 ML SOLUTION - WRAPPER RX-4080030022 CDM J1720 HCPCS 636 RC 00009-0825-01 NDC inpatient 2 ML 85.86 85.86 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES PPO [308136801] 67.98 percent of total billed charges 53.23 81.57 Technical (Hospital) Services HYDROCORTISONE SOD SUCCINATE (PF) 100 MG/2 ML SOLUTION - WRAPPER RX-4080030022 CDM J1720 HCPCS 636 RC 00009-0825-01 NDC inpatient 2 ML 85.86 85.86 MULTIPLAN INC 34080 [3081285] MULTIPLAN INC [308128501] 81.57 percent of total billed charges 53.23 81.57 Technical (Hospital) Services HYDROCORTISONE SOD SUCCINATE (PF) 100 MG/2 ML SOLUTION - WRAPPER RX-4080030022 CDM J1720 HCPCS 636 RC 00009-0825-01 NDC inpatient 2 ML 85.86 85.86 MEDICA (COMMERCIAL) 94265 [3081118] MEDICA CLAIMS [308111801] 77.27 percent of total billed charges 53.23 81.57 Technical (Hospital) Services HYDROCORTISONE SOD SUCCINATE (PF) 100 MG/2 ML SOLUTION - WRAPPER RX-4080030022 CDM J1720 HCPCS 636 RC 00009-0825-01 NDC inpatient 2 ML 85.86 85.86 CIGNA 62308 [3081051] CIGNA 62308 [308105105] 67.98 percent of total billed charges 53.23 81.57 Technical (Hospital) Services HYDROCORTISONE SOD SUCCINATE (PF) 100 MG/2 ML SOLUTION - WRAPPER RX-4080030022 CDM J1720 HCPCS 636 RC 00009-0825-01 NDC inpatient 2 ML 85.86 85.86 CIGNA 62308 [3081051] CIGNA STATE OF WYOMING [308105107] 67.98 percent of total billed charges 53.23 81.57 Technical (Hospital) Services HYDROCORTISONE SOD SUCCINATE (PF) 100 MG/2 ML SOLUTION - WRAPPER RX-4080030022 CDM J1720 HCPCS 636 RC 00009-0825-01 NDC inpatient 2 ML 85.86 85.86 UNITED HEALTHCARE (COMMERCIAL) [3081199] UNITED HEALTHCARE 87726 [308119901] 53.23 percent of total billed charges 53.23 81.57 Technical (Hospital) Services HYDROCORTISONE SOD SUCCINATE (PF) 100 MG/2 ML SOLUTION - WRAPPER RX-4080030022 CDM J1720 HCPCS 636 RC 00009-0825-01 NDC inpatient 2 ML 85.86 85.86 BLUE CROSS BLUE SHIELD WELLMARK SB889 [3081026] BCBS WYOMING [308102603] 81.57 percent of total billed charges 53.23 81.57 Technical (Hospital) Services HYDROCORTISONE SOD SUCCINATE (PF) 100 MG/2 ML SOLUTION - WRAPPER RX-4080030022 CDM J1720 HCPCS 636 RC 00009-0825-01 NDC outpatient 2 ML 85.86 85.86 CIGNA 62308 [3081051] CIGNA 62308 [308105105] 68.69 percent of total billed charges 53.23 81.57 Technical (Hospital) Services HYDROCORTISONE SOD SUCCINATE (PF) 100 MG/2 ML SOLUTION - WRAPPER RX-4080030022 CDM J1720 HCPCS 636 RC 00009-0825-01 NDC outpatient 2 ML 85.86 85.86 CIGNA 62308 [3081051] CIGNA STATE OF WYOMING [308105107] 68.69 percent of total billed charges 53.23 81.57 Technical (Hospital) Services HYDROCORTISONE SOD SUCCINATE (PF) 100 MG/2 ML SOLUTION - WRAPPER RX-4080030022 CDM J1720 HCPCS 636 RC 00009-0825-01 NDC outpatient 2 ML 85.86 85.86 MULTIPLAN INC 34080 [3081285] MULTIPLAN INC [308128501] 81.57 percent of total billed charges 53.23 81.57 Technical (Hospital) Services HYDROCORTISONE SOD SUCCINATE (PF) 100 MG/2 ML SOLUTION - WRAPPER RX-4080030022 CDM J1720 HCPCS 636 RC 00009-0825-01 NDC outpatient 2 ML 85.86 85.86 UNITED HEALTHCARE (COMMERCIAL) [3081199] UNITED HEALTHCARE 87726 [308119901] 53.23 percent of total billed charges 53.23 81.57 Technical (Hospital) Services HYDROCORTISONE SOD SUCCINATE (PF) 100 MG/2 ML SOLUTION - WRAPPER RX-4080030022 CDM J1720 HCPCS 636 RC 00009-0825-01 NDC outpatient 2 ML 85.86 85.86 HEALTHPARTNERS SX009 HEALTHPARTNERS 68.69 percent of total billed charges 53.23 81.57 Technical (Hospital) Services HYDROCORTISONE SOD SUCCINATE (PF) 100 MG/2 ML SOLUTION - WRAPPER RX-4080030022 CDM J1720 HCPCS 636 RC 00009-0825-01 NDC outpatient 2 ML 85.86 85.86 BLUE CROSS BLUE SHIELD WELLMARK SB889 [3081026] BCBS WYOMING [308102603] 81.57 percent of total billed charges 53.23 81.57 Technical (Hospital) Services HYDROCORTISONE SOD SUCCINATE (PF) 100 MG/2 ML SOLUTION - WRAPPER RX-4080030022 CDM J1720 HCPCS 636 RC 00009-0825-01 NDC outpatient 2 ML 85.86 85.86 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES PPO [308136801] 68.69 percent of total billed charges 53.23 81.57 Technical (Hospital) Services HYDROCORTISONE SOD SUCCINATE (PF) 100 MG/2 ML SOLUTION - WRAPPER RX-4080030022 CDM J1720 HCPCS 636 RC 00009-0825-01 NDC outpatient 2 ML 85.86 85.86 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES EPO [308136803] 68.69 percent of total billed charges 53.23 81.57 Technical (Hospital) Services HYDROCORTISONE SOD SUCCINATE (PF) 100 MG/2 ML SOLUTION - WRAPPER RX-4080030022 CDM J1720 HCPCS 636 RC 00009-0825-01 NDC outpatient 2 ML 85.86 85.86 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES HDHP [308136802] 68.69 percent of total billed charges 53.23 81.57 Technical (Hospital) Services HYDROCORTISONE SOD SUCCINATE (PF) 100 MG/2 ML SOLUTION - WRAPPER RX-4080030022 CDM J1720 HCPCS 636 RC 00009-0825-01 NDC outpatient 2 ML 85.86 85.86 MEDICA (COMMERCIAL) 94265 [3081118] MEDICA CLAIMS [308111801] 77.27 percent of total billed charges 53.23 81.57 Technical (Hospital) Services ENOXAPARIN 30 MG/0.3 ML SUBCUTANEOUS SYRINGE RX-105899 CDM J1650 HCPCS 636 RC 00955-1003-10 NDC outpatient 0.3 ML 70.92 70.92 UNITED HEALTHCARE (COMMERCIAL) [3081199] UNITED HEALTHCARE 87726 [308119901] 43.97 percent of total billed charges 43.97 67.37 Technical (Hospital) Services ENOXAPARIN 30 MG/0.3 ML SUBCUTANEOUS SYRINGE RX-105899 CDM J1650 HCPCS 636 RC 00955-1003-10 NDC outpatient 0.3 ML 70.92 70.92 MULTIPLAN INC 34080 [3081285] MULTIPLAN INC [308128501] 67.37 percent of total billed charges 43.97 67.37 Technical (Hospital) Services ENOXAPARIN 30 MG/0.3 ML SUBCUTANEOUS SYRINGE RX-105899 CDM J1650 HCPCS 636 RC 00955-1003-10 NDC outpatient 0.3 ML 70.92 70.92 CIGNA 62308 [3081051] CIGNA 62308 [308105105] 56.74 percent of total billed charges 43.97 67.37 Technical (Hospital) Services ENOXAPARIN 30 MG/0.3 ML SUBCUTANEOUS SYRINGE RX-105899 CDM J1650 HCPCS 636 RC 00955-1003-10 NDC outpatient 0.3 ML 70.92 70.92 CIGNA 62308 [3081051] CIGNA STATE OF WYOMING [308105107] 56.74 percent of total billed charges 43.97 67.37 Technical (Hospital) Services ENOXAPARIN 30 MG/0.3 ML SUBCUTANEOUS SYRINGE RX-105899 CDM J1650 HCPCS 636 RC 00955-1003-10 NDC outpatient 0.3 ML 70.92 70.92 MEDICA (COMMERCIAL) 94265 [3081118] MEDICA CLAIMS [308111801] 63.83 percent of total billed charges 43.97 67.37 Technical (Hospital) Services ENOXAPARIN 30 MG/0.3 ML SUBCUTANEOUS SYRINGE RX-105899 CDM J1650 HCPCS 636 RC 00955-1003-10 NDC outpatient 0.3 ML 70.92 70.92 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES EPO [308136803] 56.74 percent of total billed charges 43.97 67.37 Technical (Hospital) Services ENOXAPARIN 30 MG/0.3 ML SUBCUTANEOUS SYRINGE RX-105899 CDM J1650 HCPCS 636 RC 00955-1003-10 NDC outpatient 0.3 ML 70.92 70.92 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES HDHP [308136802] 56.74 percent of total billed charges 43.97 67.37 Technical (Hospital) Services ENOXAPARIN 30 MG/0.3 ML SUBCUTANEOUS SYRINGE RX-105899 CDM J1650 HCPCS 636 RC 00955-1003-10 NDC outpatient 0.3 ML 70.92 70.92 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES PPO [308136801] 56.74 percent of total billed charges 43.97 67.37 Technical (Hospital) Services ENOXAPARIN 30 MG/0.3 ML SUBCUTANEOUS SYRINGE RX-105899 CDM J1650 HCPCS 636 RC 00955-1003-10 NDC outpatient 0.3 ML 70.92 70.92 HEALTHPARTNERS SX009 HEALTHPARTNERS 56.74 percent of total billed charges 43.97 67.37 Technical (Hospital) Services ENOXAPARIN 30 MG/0.3 ML SUBCUTANEOUS SYRINGE RX-105899 CDM J1650 HCPCS 636 RC 00955-1003-10 NDC outpatient 0.3 ML 70.92 70.92 BLUE CROSS BLUE SHIELD WELLMARK SB889 [3081026] BCBS WYOMING [308102603] 67.37 percent of total billed charges 43.97 67.37 Technical (Hospital) Services ENOXAPARIN 30 MG/0.3 ML SUBCUTANEOUS SYRINGE RX-105899 CDM J1650 HCPCS 636 RC 00955-1003-10 NDC inpatient 0.3 ML 70.92 70.92 HEALTHPARTNERS SX009 HEALTHPARTNERS 56.15 percent of total billed charges 43.97 67.37 Technical (Hospital) Services ENOXAPARIN 30 MG/0.3 ML SUBCUTANEOUS SYRINGE RX-105899 CDM J1650 HCPCS 636 RC 00955-1003-10 NDC inpatient 0.3 ML 70.92 70.92 MEDICA (COMMERCIAL) 94265 [3081118] MEDICA CLAIMS [308111801] 63.83 percent of total billed charges 43.97 67.37 Technical (Hospital) Services ENOXAPARIN 30 MG/0.3 ML SUBCUTANEOUS SYRINGE RX-105899 CDM J1650 HCPCS 636 RC 00955-1003-10 NDC inpatient 0.3 ML 70.92 70.92 MULTIPLAN INC 34080 [3081285] MULTIPLAN INC [308128501] 67.37 percent of total billed charges 43.97 67.37 Technical (Hospital) Services ENOXAPARIN 30 MG/0.3 ML SUBCUTANEOUS SYRINGE RX-105899 CDM J1650 HCPCS 636 RC 00955-1003-10 NDC inpatient 0.3 ML 70.92 70.92 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES EPO [308136803] 56.15 percent of total billed charges 43.97 67.37 Technical (Hospital) Services ENOXAPARIN 30 MG/0.3 ML SUBCUTANEOUS SYRINGE RX-105899 CDM J1650 HCPCS 636 RC 00955-1003-10 NDC inpatient 0.3 ML 70.92 70.92 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES HDHP [308136802] 56.15 percent of total billed charges 43.97 67.37 Technical (Hospital) Services ENOXAPARIN 30 MG/0.3 ML SUBCUTANEOUS SYRINGE RX-105899 CDM J1650 HCPCS 636 RC 00955-1003-10 NDC inpatient 0.3 ML 70.92 70.92 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES PPO [308136801] 56.15 percent of total billed charges 43.97 67.37 Technical (Hospital) Services ENOXAPARIN 30 MG/0.3 ML SUBCUTANEOUS SYRINGE RX-105899 CDM J1650 HCPCS 636 RC 00955-1003-10 NDC inpatient 0.3 ML 70.92 70.92 UNITED HEALTHCARE (COMMERCIAL) [3081199] UNITED HEALTHCARE 87726 [308119901] 43.97 percent of total billed charges 43.97 67.37 Technical (Hospital) Services ENOXAPARIN 30 MG/0.3 ML SUBCUTANEOUS SYRINGE RX-105899 CDM J1650 HCPCS 636 RC 00955-1003-10 NDC inpatient 0.3 ML 70.92 70.92 CIGNA 62308 [3081051] CIGNA 62308 [308105105] 56.15 percent of total billed charges 43.97 67.37 Technical (Hospital) Services ENOXAPARIN 30 MG/0.3 ML SUBCUTANEOUS SYRINGE RX-105899 CDM J1650 HCPCS 636 RC 00955-1003-10 NDC inpatient 0.3 ML 70.92 70.92 CIGNA 62308 [3081051] CIGNA STATE OF WYOMING [308105107] 56.15 percent of total billed charges 43.97 67.37 Technical (Hospital) Services ENOXAPARIN 30 MG/0.3 ML SUBCUTANEOUS SYRINGE RX-105899 CDM J1650 HCPCS 636 RC 00955-1003-10 NDC inpatient 0.3 ML 70.92 70.92 BLUE CROSS BLUE SHIELD WELLMARK SB889 [3081026] BCBS WYOMING [308102603] 67.37 percent of total billed charges 43.97 67.37 Technical (Hospital) Services ENOXAPARIN 40 MG/0.4 ML SUBCUTANEOUS SYRINGE RX-105900 CDM J1650 HCPCS 636 RC 00955-1004-10 NDC outpatient 0.4 ML 73.04 73.04 HEALTHPARTNERS SX009 HEALTHPARTNERS 58.43 percent of total billed charges 45.28 69.39 Technical (Hospital) Services ENOXAPARIN 40 MG/0.4 ML SUBCUTANEOUS SYRINGE RX-105900 CDM J1650 HCPCS 636 RC 00955-1004-10 NDC outpatient 0.4 ML 73.04 73.04 BLUE CROSS BLUE SHIELD WELLMARK SB889 [3081026] BCBS WYOMING [308102603] 69.39 percent of total billed charges 45.28 69.39 Technical (Hospital) Services ENOXAPARIN 40 MG/0.4 ML SUBCUTANEOUS SYRINGE RX-105900 CDM J1650 HCPCS 636 RC 00955-1004-10 NDC outpatient 0.4 ML 73.04 73.04 CIGNA 62308 [3081051] CIGNA 62308 [308105105] 58.43 percent of total billed charges 45.28 69.39 Technical (Hospital) Services ENOXAPARIN 40 MG/0.4 ML SUBCUTANEOUS SYRINGE RX-105900 CDM J1650 HCPCS 636 RC 00955-1004-10 NDC outpatient 0.4 ML 73.04 73.04 CIGNA 62308 [3081051] CIGNA STATE OF WYOMING [308105107] 58.43 percent of total billed charges 45.28 69.39 Technical (Hospital) Services ENOXAPARIN 40 MG/0.4 ML SUBCUTANEOUS SYRINGE RX-105900 CDM J1650 HCPCS 636 RC 00955-1004-10 NDC outpatient 0.4 ML 73.04 73.04 MULTIPLAN INC 34080 [3081285] MULTIPLAN INC [308128501] 69.39 percent of total billed charges 45.28 69.39 Technical (Hospital) Services ENOXAPARIN 40 MG/0.4 ML SUBCUTANEOUS SYRINGE RX-105900 CDM J1650 HCPCS 636 RC 00955-1004-10 NDC outpatient 0.4 ML 73.04 73.04 UNITED HEALTHCARE (COMMERCIAL) [3081199] UNITED HEALTHCARE 87726 [308119901] 45.28 percent of total billed charges 45.28 69.39 Technical (Hospital) Services ENOXAPARIN 40 MG/0.4 ML SUBCUTANEOUS SYRINGE RX-105900 CDM J1650 HCPCS 636 RC 00955-1004-10 NDC outpatient 0.4 ML 73.04 73.04 MEDICA (COMMERCIAL) 94265 [3081118] MEDICA CLAIMS [308111801] 65.74 percent of total billed charges 45.28 69.39 Technical (Hospital) Services ENOXAPARIN 40 MG/0.4 ML SUBCUTANEOUS SYRINGE RX-105900 CDM J1650 HCPCS 636 RC 00955-1004-10 NDC outpatient 0.4 ML 73.04 73.04 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES EPO [308136803] 58.43 percent of total billed charges 45.28 69.39 Technical (Hospital) Services ENOXAPARIN 40 MG/0.4 ML SUBCUTANEOUS SYRINGE RX-105900 CDM J1650 HCPCS 636 RC 00955-1004-10 NDC outpatient 0.4 ML 73.04 73.04 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES HDHP [308136802] 58.43 percent of total billed charges 45.28 69.39 Technical (Hospital) Services ENOXAPARIN 40 MG/0.4 ML SUBCUTANEOUS SYRINGE RX-105900 CDM J1650 HCPCS 636 RC 00955-1004-10 NDC outpatient 0.4 ML 73.04 73.04 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES PPO [308136801] 58.43 percent of total billed charges 45.28 69.39 Technical (Hospital) Services ENOXAPARIN 40 MG/0.4 ML SUBCUTANEOUS SYRINGE RX-105900 CDM J1650 HCPCS 636 RC 00955-1004-10 NDC inpatient 0.4 ML 73.04 73.04 UNITED HEALTHCARE (COMMERCIAL) [3081199] UNITED HEALTHCARE 87726 [308119901] 45.28 percent of total billed charges 45.28 69.39 Technical (Hospital) Services ENOXAPARIN 40 MG/0.4 ML SUBCUTANEOUS SYRINGE RX-105900 CDM J1650 HCPCS 636 RC 00955-1004-10 NDC inpatient 0.4 ML 73.04 73.04 BLUE CROSS BLUE SHIELD WELLMARK SB889 [3081026] BCBS WYOMING [308102603] 69.39 percent of total billed charges 45.28 69.39 Technical (Hospital) Services ENOXAPARIN 40 MG/0.4 ML SUBCUTANEOUS SYRINGE RX-105900 CDM J1650 HCPCS 636 RC 00955-1004-10 NDC inpatient 0.4 ML 73.04 73.04 HEALTHPARTNERS SX009 HEALTHPARTNERS 57.83 percent of total billed charges 45.28 69.39 Technical (Hospital) Services ENOXAPARIN 40 MG/0.4 ML SUBCUTANEOUS SYRINGE RX-105900 CDM J1650 HCPCS 636 RC 00955-1004-10 NDC inpatient 0.4 ML 73.04 73.04 MEDICA (COMMERCIAL) 94265 [3081118] MEDICA CLAIMS [308111801] 65.74 percent of total billed charges 45.28 69.39 Technical (Hospital) Services ENOXAPARIN 40 MG/0.4 ML SUBCUTANEOUS SYRINGE RX-105900 CDM J1650 HCPCS 636 RC 00955-1004-10 NDC inpatient 0.4 ML 73.04 73.04 CIGNA 62308 [3081051] CIGNA 62308 [308105105] 57.83 percent of total billed charges 45.28 69.39 Technical (Hospital) Services ENOXAPARIN 40 MG/0.4 ML SUBCUTANEOUS SYRINGE RX-105900 CDM J1650 HCPCS 636 RC 00955-1004-10 NDC inpatient 0.4 ML 73.04 73.04 CIGNA 62308 [3081051] CIGNA STATE OF WYOMING [308105107] 57.83 percent of total billed charges 45.28 69.39 Technical (Hospital) Services ENOXAPARIN 40 MG/0.4 ML SUBCUTANEOUS SYRINGE RX-105900 CDM J1650 HCPCS 636 RC 00955-1004-10 NDC inpatient 0.4 ML 73.04 73.04 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES EPO [308136803] 57.83 percent of total billed charges 45.28 69.39 Technical (Hospital) Services ENOXAPARIN 40 MG/0.4 ML SUBCUTANEOUS SYRINGE RX-105900 CDM J1650 HCPCS 636 RC 00955-1004-10 NDC inpatient 0.4 ML 73.04 73.04 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES HDHP [308136802] 57.83 percent of total billed charges 45.28 69.39 Technical (Hospital) Services ENOXAPARIN 40 MG/0.4 ML SUBCUTANEOUS SYRINGE RX-105900 CDM J1650 HCPCS 636 RC 00955-1004-10 NDC inpatient 0.4 ML 73.04 73.04 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES PPO [308136801] 57.83 percent of total billed charges 45.28 69.39 Technical (Hospital) Services ENOXAPARIN 40 MG/0.4 ML SUBCUTANEOUS SYRINGE RX-105900 CDM J1650 HCPCS 636 RC 00955-1004-10 NDC inpatient 0.4 ML 73.04 73.04 MULTIPLAN INC 34080 [3081285] MULTIPLAN INC [308128501] 69.39 percent of total billed charges 45.28 69.39 Technical (Hospital) Services ENOXAPARIN 60 MG/0.6 ML SUBCUTANEOUS SYRINGE RX-105901 CDM J1650 HCPCS 636 RC 00955-1006-10 NDC outpatient 0.6 ML 82.82 82.82 CIGNA 62308 [3081051] CIGNA 62308 [308105105] 66.26 percent of total billed charges 51.35 78.68 Technical (Hospital) Services ENOXAPARIN 60 MG/0.6 ML SUBCUTANEOUS SYRINGE RX-105901 CDM J1650 HCPCS 636 RC 00955-1006-10 NDC outpatient 0.6 ML 82.82 82.82 CIGNA 62308 [3081051] CIGNA STATE OF WYOMING [308105107] 66.26 percent of total billed charges 51.35 78.68 Technical (Hospital) Services ENOXAPARIN 60 MG/0.6 ML SUBCUTANEOUS SYRINGE RX-105901 CDM J1650 HCPCS 636 RC 00955-1006-10 NDC outpatient 0.6 ML 82.82 82.82 MULTIPLAN INC 34080 [3081285] MULTIPLAN INC [308128501] 78.68 percent of total billed charges 51.35 78.68 Technical (Hospital) Services ENOXAPARIN 60 MG/0.6 ML SUBCUTANEOUS SYRINGE RX-105901 CDM J1650 HCPCS 636 RC 00955-1006-10 NDC outpatient 0.6 ML 82.82 82.82 UNITED HEALTHCARE (COMMERCIAL) [3081199] UNITED HEALTHCARE 87726 [308119901] 51.35 percent of total billed charges 51.35 78.68 Technical (Hospital) Services ENOXAPARIN 60 MG/0.6 ML SUBCUTANEOUS SYRINGE RX-105901 CDM J1650 HCPCS 636 RC 00955-1006-10 NDC outpatient 0.6 ML 82.82 82.82 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES EPO [308136803] 66.26 percent of total billed charges 51.35 78.68 Technical (Hospital) Services ENOXAPARIN 60 MG/0.6 ML SUBCUTANEOUS SYRINGE RX-105901 CDM J1650 HCPCS 636 RC 00955-1006-10 NDC outpatient 0.6 ML 82.82 82.82 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES HDHP [308136802] 66.26 percent of total billed charges 51.35 78.68 Technical (Hospital) Services ENOXAPARIN 60 MG/0.6 ML SUBCUTANEOUS SYRINGE RX-105901 CDM J1650 HCPCS 636 RC 00955-1006-10 NDC outpatient 0.6 ML 82.82 82.82 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES PPO [308136801] 66.26 percent of total billed charges 51.35 78.68 Technical (Hospital) Services ENOXAPARIN 60 MG/0.6 ML SUBCUTANEOUS SYRINGE RX-105901 CDM J1650 HCPCS 636 RC 00955-1006-10 NDC outpatient 0.6 ML 82.82 82.82 MEDICA (COMMERCIAL) 94265 [3081118] MEDICA CLAIMS [308111801] 74.54 percent of total billed charges 51.35 78.68 Technical (Hospital) Services ENOXAPARIN 60 MG/0.6 ML SUBCUTANEOUS SYRINGE RX-105901 CDM J1650 HCPCS 636 RC 00955-1006-10 NDC outpatient 0.6 ML 82.82 82.82 HEALTHPARTNERS SX009 HEALTHPARTNERS 66.26 percent of total billed charges 51.35 78.68 Technical (Hospital) Services ENOXAPARIN 60 MG/0.6 ML SUBCUTANEOUS SYRINGE RX-105901 CDM J1650 HCPCS 636 RC 00955-1006-10 NDC outpatient 0.6 ML 82.82 82.82 BLUE CROSS BLUE SHIELD WELLMARK SB889 [3081026] BCBS WYOMING [308102603] 78.68 percent of total billed charges 51.35 78.68 Technical (Hospital) Services ENOXAPARIN 60 MG/0.6 ML SUBCUTANEOUS SYRINGE RX-105901 CDM J1650 HCPCS 636 RC 00955-1006-10 NDC inpatient 0.6 ML 82.82 82.82 MULTIPLAN INC 34080 [3081285] MULTIPLAN INC [308128501] 78.68 percent of total billed charges 51.35 78.68 Technical (Hospital) Services ENOXAPARIN 60 MG/0.6 ML SUBCUTANEOUS SYRINGE RX-105901 CDM J1650 HCPCS 636 RC 00955-1006-10 NDC inpatient 0.6 ML 82.82 82.82 HEALTHPARTNERS SX009 HEALTHPARTNERS 65.58 percent of total billed charges 51.35 78.68 Technical (Hospital) Services ENOXAPARIN 60 MG/0.6 ML SUBCUTANEOUS SYRINGE RX-105901 CDM J1650 HCPCS 636 RC 00955-1006-10 NDC inpatient 0.6 ML 82.82 82.82 MEDICA (COMMERCIAL) 94265 [3081118] MEDICA CLAIMS [308111801] 74.54 percent of total billed charges 51.35 78.68 Technical (Hospital) Services ENOXAPARIN 60 MG/0.6 ML SUBCUTANEOUS SYRINGE RX-105901 CDM J1650 HCPCS 636 RC 00955-1006-10 NDC inpatient 0.6 ML 82.82 82.82 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES PPO [308136801] 65.58 percent of total billed charges 51.35 78.68 Technical (Hospital) Services ENOXAPARIN 60 MG/0.6 ML SUBCUTANEOUS SYRINGE RX-105901 CDM J1650 HCPCS 636 RC 00955-1006-10 NDC inpatient 0.6 ML 82.82 82.82 CIGNA 62308 [3081051] CIGNA 62308 [308105105] 65.58 percent of total billed charges 51.35 78.68 Technical (Hospital) Services ENOXAPARIN 60 MG/0.6 ML SUBCUTANEOUS SYRINGE RX-105901 CDM J1650 HCPCS 636 RC 00955-1006-10 NDC inpatient 0.6 ML 82.82 82.82 CIGNA 62308 [3081051] CIGNA STATE OF WYOMING [308105107] 65.58 percent of total billed charges 51.35 78.68 Technical (Hospital) Services ENOXAPARIN 60 MG/0.6 ML SUBCUTANEOUS SYRINGE RX-105901 CDM J1650 HCPCS 636 RC 00955-1006-10 NDC inpatient 0.6 ML 82.82 82.82 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES EPO [308136803] 65.58 percent of total billed charges 51.35 78.68 Technical (Hospital) Services ENOXAPARIN 60 MG/0.6 ML SUBCUTANEOUS SYRINGE RX-105901 CDM J1650 HCPCS 636 RC 00955-1006-10 NDC inpatient 0.6 ML 82.82 82.82 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES HDHP [308136802] 65.58 percent of total billed charges 51.35 78.68 Technical (Hospital) Services ENOXAPARIN 60 MG/0.6 ML SUBCUTANEOUS SYRINGE RX-105901 CDM J1650 HCPCS 636 RC 00955-1006-10 NDC inpatient 0.6 ML 82.82 82.82 UNITED HEALTHCARE (COMMERCIAL) [3081199] UNITED HEALTHCARE 87726 [308119901] 51.35 percent of total billed charges 51.35 78.68 Technical (Hospital) Services ENOXAPARIN 60 MG/0.6 ML SUBCUTANEOUS SYRINGE RX-105901 CDM J1650 HCPCS 636 RC 00955-1006-10 NDC inpatient 0.6 ML 82.82 82.82 BLUE CROSS BLUE SHIELD WELLMARK SB889 [3081026] BCBS WYOMING [308102603] 78.68 percent of total billed charges 51.35 78.68 Technical (Hospital) Services ENOXAPARIN 100 MG/ML SUBCUTANEOUS SYRINGE RX-105903 CDM J1650 HCPCS 636 RC 00955-1010-10 NDC outpatient 1 ML 109.87 109.87 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES EPO [308136803] 87.9 percent of total billed charges 68.12 104.38 Technical (Hospital) Services ENOXAPARIN 100 MG/ML SUBCUTANEOUS SYRINGE RX-105903 CDM J1650 HCPCS 636 RC 00955-1010-10 NDC outpatient 1 ML 109.87 109.87 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES HDHP [308136802] 87.9 percent of total billed charges 68.12 104.38 Technical (Hospital) Services ENOXAPARIN 100 MG/ML SUBCUTANEOUS SYRINGE RX-105903 CDM J1650 HCPCS 636 RC 00955-1010-10 NDC outpatient 1 ML 109.87 109.87 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES PPO [308136801] 87.9 percent of total billed charges 68.12 104.38 Technical (Hospital) Services ENOXAPARIN 100 MG/ML SUBCUTANEOUS SYRINGE RX-105903 CDM J1650 HCPCS 636 RC 00955-1010-10 NDC outpatient 1 ML 109.87 109.87 BLUE CROSS BLUE SHIELD WELLMARK SB889 [3081026] BCBS WYOMING [308102603] 104.38 percent of total billed charges 68.12 104.38 Technical (Hospital) Services ENOXAPARIN 100 MG/ML SUBCUTANEOUS SYRINGE RX-105903 CDM J1650 HCPCS 636 RC 00955-1010-10 NDC outpatient 1 ML 109.87 109.87 CIGNA 62308 [3081051] CIGNA 62308 [308105105] 87.9 percent of total billed charges 68.12 104.38 Technical (Hospital) Services ENOXAPARIN 100 MG/ML SUBCUTANEOUS SYRINGE RX-105903 CDM J1650 HCPCS 636 RC 00955-1010-10 NDC outpatient 1 ML 109.87 109.87 CIGNA 62308 [3081051] CIGNA STATE OF WYOMING [308105107] 87.9 percent of total billed charges 68.12 104.38 Technical (Hospital) Services ENOXAPARIN 100 MG/ML SUBCUTANEOUS SYRINGE RX-105903 CDM J1650 HCPCS 636 RC 00955-1010-10 NDC outpatient 1 ML 109.87 109.87 MEDICA (COMMERCIAL) 94265 [3081118] MEDICA CLAIMS [308111801] 98.88 percent of total billed charges 68.12 104.38 Technical (Hospital) Services ENOXAPARIN 100 MG/ML SUBCUTANEOUS SYRINGE RX-105903 CDM J1650 HCPCS 636 RC 00955-1010-10 NDC outpatient 1 ML 109.87 109.87 UNITED HEALTHCARE (COMMERCIAL) [3081199] UNITED HEALTHCARE 87726 [308119901] 68.12 percent of total billed charges 68.12 104.38 Technical (Hospital) Services ENOXAPARIN 100 MG/ML SUBCUTANEOUS SYRINGE RX-105903 CDM J1650 HCPCS 636 RC 00955-1010-10 NDC outpatient 1 ML 109.87 109.87 MULTIPLAN INC 34080 [3081285] MULTIPLAN INC [308128501] 104.38 percent of total billed charges 68.12 104.38 Technical (Hospital) Services ENOXAPARIN 100 MG/ML SUBCUTANEOUS SYRINGE RX-105903 CDM J1650 HCPCS 636 RC 00955-1010-10 NDC outpatient 1 ML 109.87 109.87 HEALTHPARTNERS SX009 HEALTHPARTNERS 87.9 percent of total billed charges 68.12 104.38 Technical (Hospital) Services ENOXAPARIN 100 MG/ML SUBCUTANEOUS SYRINGE RX-105903 CDM J1650 HCPCS 636 RC 00955-1010-10 NDC inpatient 1 ML 109.87 109.87 BLUE CROSS BLUE SHIELD WELLMARK SB889 [3081026] BCBS WYOMING [308102603] 104.38 percent of total billed charges 68.12 104.38 Technical (Hospital) Services ENOXAPARIN 100 MG/ML SUBCUTANEOUS SYRINGE RX-105903 CDM J1650 HCPCS 636 RC 00955-1010-10 NDC inpatient 1 ML 109.87 109.87 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES HDHP [308136802] 87 percent of total billed charges 68.12 104.38 Technical (Hospital) Services ENOXAPARIN 100 MG/ML SUBCUTANEOUS SYRINGE RX-105903 CDM J1650 HCPCS 636 RC 00955-1010-10 NDC inpatient 1 ML 109.87 109.87 UNITED HEALTHCARE (COMMERCIAL) [3081199] UNITED HEALTHCARE 87726 [308119901] 68.12 percent of total billed charges 68.12 104.38 Technical (Hospital) Services ENOXAPARIN 100 MG/ML SUBCUTANEOUS SYRINGE RX-105903 CDM J1650 HCPCS 636 RC 00955-1010-10 NDC inpatient 1 ML 109.87 109.87 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES EPO [308136803] 87 percent of total billed charges 68.12 104.38 Technical (Hospital) Services ENOXAPARIN 100 MG/ML SUBCUTANEOUS SYRINGE RX-105903 CDM J1650 HCPCS 636 RC 00955-1010-10 NDC inpatient 1 ML 109.87 109.87 CIGNA 62308 [3081051] CIGNA 62308 [308105105] 87 percent of total billed charges 68.12 104.38 Technical (Hospital) Services ENOXAPARIN 100 MG/ML SUBCUTANEOUS SYRINGE RX-105903 CDM J1650 HCPCS 636 RC 00955-1010-10 NDC inpatient 1 ML 109.87 109.87 CIGNA 62308 [3081051] CIGNA STATE OF WYOMING [308105107] 87 percent of total billed charges 68.12 104.38 Technical (Hospital) Services ENOXAPARIN 100 MG/ML SUBCUTANEOUS SYRINGE RX-105903 CDM J1650 HCPCS 636 RC 00955-1010-10 NDC inpatient 1 ML 109.87 109.87 MEDICA (COMMERCIAL) 94265 [3081118] MEDICA CLAIMS [308111801] 98.88 percent of total billed charges 68.12 104.38 Technical (Hospital) Services ENOXAPARIN 100 MG/ML SUBCUTANEOUS SYRINGE RX-105903 CDM J1650 HCPCS 636 RC 00955-1010-10 NDC inpatient 1 ML 109.87 109.87 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES PPO [308136801] 87 percent of total billed charges 68.12 104.38 Technical (Hospital) Services ENOXAPARIN 100 MG/ML SUBCUTANEOUS SYRINGE RX-105903 CDM J1650 HCPCS 636 RC 00955-1010-10 NDC inpatient 1 ML 109.87 109.87 HEALTHPARTNERS SX009 HEALTHPARTNERS 87 percent of total billed charges 68.12 104.38 Technical (Hospital) Services ENOXAPARIN 100 MG/ML SUBCUTANEOUS SYRINGE RX-105903 CDM J1650 HCPCS 636 RC 00955-1010-10 NDC inpatient 1 ML 109.87 109.87 MULTIPLAN INC 34080 [3081285] MULTIPLAN INC [308128501] 104.38 percent of total billed charges 68.12 104.38 Technical (Hospital) Services "HEPARIN (PORCINE) 10,000 UNIT/ML INJECTION SOLUTION" RX-10177 CDM J1644 HCPCS 636 RC 67457-0602-02 NDC outpatient 1 ML 69.1 69.1 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES PPO [308136801] 55.28 percent of total billed charges 42.84 65.65 Technical (Hospital) Services "HEPARIN (PORCINE) 10,000 UNIT/ML INJECTION SOLUTION" RX-10177 CDM J1644 HCPCS 636 RC 67457-0602-02 NDC outpatient 1 ML 69.1 69.1 BLUE CROSS BLUE SHIELD WELLMARK SB889 [3081026] BCBS WYOMING [308102603] 65.65 percent of total billed charges 42.84 65.65 Technical (Hospital) Services "HEPARIN (PORCINE) 10,000 UNIT/ML INJECTION SOLUTION" RX-10177 CDM J1644 HCPCS 636 RC 67457-0602-02 NDC outpatient 1 ML 69.1 69.1 HEALTHPARTNERS SX009 HEALTHPARTNERS 55.28 percent of total billed charges 42.84 65.65 Technical (Hospital) Services "HEPARIN (PORCINE) 10,000 UNIT/ML INJECTION SOLUTION" RX-10177 CDM J1644 HCPCS 636 RC 67457-0602-02 NDC outpatient 1 ML 69.1 69.1 MULTIPLAN INC 34080 [3081285] MULTIPLAN INC [308128501] 65.65 percent of total billed charges 42.84 65.65 Technical (Hospital) Services "HEPARIN (PORCINE) 10,000 UNIT/ML INJECTION SOLUTION" RX-10177 CDM J1644 HCPCS 636 RC 67457-0602-02 NDC outpatient 1 ML 69.1 69.1 UNITED HEALTHCARE (COMMERCIAL) [3081199] UNITED HEALTHCARE 87726 [308119901] 42.84 percent of total billed charges 42.84 65.65 Technical (Hospital) Services "HEPARIN (PORCINE) 10,000 UNIT/ML INJECTION SOLUTION" RX-10177 CDM J1644 HCPCS 636 RC 67457-0602-02 NDC outpatient 1 ML 69.1 69.1 MEDICA (COMMERCIAL) 94265 [3081118] MEDICA CLAIMS [308111801] 62.19 percent of total billed charges 42.84 65.65 Technical (Hospital) Services "HEPARIN (PORCINE) 10,000 UNIT/ML INJECTION SOLUTION" RX-10177 CDM J1644 HCPCS 636 RC 67457-0602-02 NDC outpatient 1 ML 69.1 69.1 CIGNA 62308 [3081051] CIGNA 62308 [308105105] 55.28 percent of total billed charges 42.84 65.65 Technical (Hospital) Services "HEPARIN (PORCINE) 10,000 UNIT/ML INJECTION SOLUTION" RX-10177 CDM J1644 HCPCS 636 RC 67457-0602-02 NDC outpatient 1 ML 69.1 69.1 CIGNA 62308 [3081051] CIGNA STATE OF WYOMING [308105107] 55.28 percent of total billed charges 42.84 65.65 Technical (Hospital) Services "HEPARIN (PORCINE) 10,000 UNIT/ML INJECTION SOLUTION" RX-10177 CDM J1644 HCPCS 636 RC 67457-0602-02 NDC outpatient 1 ML 69.1 69.1 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES HDHP [308136802] 55.28 percent of total billed charges 42.84 65.65 Technical (Hospital) Services "HEPARIN (PORCINE) 10,000 UNIT/ML INJECTION SOLUTION" RX-10177 CDM J1644 HCPCS 636 RC 67457-0602-02 NDC outpatient 1 ML 69.1 69.1 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES EPO [308136803] 55.28 percent of total billed charges 42.84 65.65 Technical (Hospital) Services "HEPARIN (PORCINE) 10,000 UNIT/ML INJECTION SOLUTION" RX-10177 CDM J1644 HCPCS 636 RC 67457-0602-02 NDC inpatient 1 ML 69.1 69.1 BLUE CROSS BLUE SHIELD WELLMARK SB889 [3081026] BCBS WYOMING [308102603] 65.65 percent of total billed charges 42.84 65.65 Technical (Hospital) Services "HEPARIN (PORCINE) 10,000 UNIT/ML INJECTION SOLUTION" RX-10177 CDM J1644 HCPCS 636 RC 67457-0602-02 NDC inpatient 1 ML 69.1 69.1 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES HDHP [308136802] 54.71 percent of total billed charges 42.84 65.65 Technical (Hospital) Services "HEPARIN (PORCINE) 10,000 UNIT/ML INJECTION SOLUTION" RX-10177 CDM J1644 HCPCS 636 RC 67457-0602-02 NDC inpatient 1 ML 69.1 69.1 CIGNA 62308 [3081051] CIGNA 62308 [308105105] 54.71 percent of total billed charges 42.84 65.65 Technical (Hospital) Services "HEPARIN (PORCINE) 10,000 UNIT/ML INJECTION SOLUTION" RX-10177 CDM J1644 HCPCS 636 RC 67457-0602-02 NDC inpatient 1 ML 69.1 69.1 CIGNA 62308 [3081051] CIGNA STATE OF WYOMING [308105107] 54.71 percent of total billed charges 42.84 65.65 Technical (Hospital) Services "HEPARIN (PORCINE) 10,000 UNIT/ML INJECTION SOLUTION" RX-10177 CDM J1644 HCPCS 636 RC 67457-0602-02 NDC inpatient 1 ML 69.1 69.1 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES EPO [308136803] 54.71 percent of total billed charges 42.84 65.65 Technical (Hospital) Services "HEPARIN (PORCINE) 10,000 UNIT/ML INJECTION SOLUTION" RX-10177 CDM J1644 HCPCS 636 RC 67457-0602-02 NDC inpatient 1 ML 69.1 69.1 UNITED HEALTHCARE (COMMERCIAL) [3081199] UNITED HEALTHCARE 87726 [308119901] 42.84 percent of total billed charges 42.84 65.65 Technical (Hospital) Services "HEPARIN (PORCINE) 10,000 UNIT/ML INJECTION SOLUTION" RX-10177 CDM J1644 HCPCS 636 RC 67457-0602-02 NDC inpatient 1 ML 69.1 69.1 MULTIPLAN INC 34080 [3081285] MULTIPLAN INC [308128501] 65.65 percent of total billed charges 42.84 65.65 Technical (Hospital) Services "HEPARIN (PORCINE) 10,000 UNIT/ML INJECTION SOLUTION" RX-10177 CDM J1644 HCPCS 636 RC 67457-0602-02 NDC inpatient 1 ML 69.1 69.1 MEDICA (COMMERCIAL) 94265 [3081118] MEDICA CLAIMS [308111801] 62.19 percent of total billed charges 42.84 65.65 Technical (Hospital) Services "HEPARIN (PORCINE) 10,000 UNIT/ML INJECTION SOLUTION" RX-10177 CDM J1644 HCPCS 636 RC 67457-0602-02 NDC inpatient 1 ML 69.1 69.1 HEALTHPARTNERS SX009 HEALTHPARTNERS 54.71 percent of total billed charges 42.84 65.65 Technical (Hospital) Services "HEPARIN (PORCINE) 10,000 UNIT/ML INJECTION SOLUTION" RX-10177 CDM J1644 HCPCS 636 RC 67457-0602-02 NDC inpatient 1 ML 69.1 69.1 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES PPO [308136801] 54.71 percent of total billed charges 42.84 65.65 Technical (Hospital) Services "HEPARIN (PORCINE) 5,000 UNIT/ML INJECTION SOLUTION INTRAVENOUS" RX-10181 CDM J1644 HCPCS 636 RC 71288-0403-01 NDC outpatient 1 ML 60.2 60.2 MEDICA (COMMERCIAL) 94265 [3081118] MEDICA CLAIMS [308111801] 54.18 percent of total billed charges 37.32 57.19 Technical (Hospital) Services "HEPARIN (PORCINE) 5,000 UNIT/ML INJECTION SOLUTION INTRAVENOUS" RX-10181 CDM J1644 HCPCS 636 RC 71288-0403-01 NDC outpatient 1 ML 60.2 60.2 CIGNA 62308 [3081051] CIGNA 62308 [308105105] 48.16 percent of total billed charges 37.32 57.19 Technical (Hospital) Services "HEPARIN (PORCINE) 5,000 UNIT/ML INJECTION SOLUTION INTRAVENOUS" RX-10181 CDM J1644 HCPCS 636 RC 71288-0403-01 NDC outpatient 1 ML 60.2 60.2 CIGNA 62308 [3081051] CIGNA STATE OF WYOMING [308105107] 48.16 percent of total billed charges 37.32 57.19 Technical (Hospital) Services "HEPARIN (PORCINE) 5,000 UNIT/ML INJECTION SOLUTION INTRAVENOUS" RX-10181 CDM J1644 HCPCS 636 RC 71288-0403-01 NDC outpatient 1 ML 60.2 60.2 MULTIPLAN INC 34080 [3081285] MULTIPLAN INC [308128501] 57.19 percent of total billed charges 37.32 57.19 Technical (Hospital) Services "HEPARIN (PORCINE) 5,000 UNIT/ML INJECTION SOLUTION INTRAVENOUS" RX-10181 CDM J1644 HCPCS 636 RC 71288-0403-01 NDC outpatient 1 ML 60.2 60.2 UNITED HEALTHCARE (COMMERCIAL) [3081199] UNITED HEALTHCARE 87726 [308119901] 37.32 percent of total billed charges 37.32 57.19 Technical (Hospital) Services "HEPARIN (PORCINE) 5,000 UNIT/ML INJECTION SOLUTION INTRAVENOUS" RX-10181 CDM J1644 HCPCS 636 RC 71288-0403-01 NDC outpatient 1 ML 60.2 60.2 HEALTHPARTNERS SX009 HEALTHPARTNERS 48.16 percent of total billed charges 37.32 57.19 Technical (Hospital) Services "HEPARIN (PORCINE) 5,000 UNIT/ML INJECTION SOLUTION INTRAVENOUS" RX-10181 CDM J1644 HCPCS 636 RC 71288-0403-01 NDC outpatient 1 ML 60.2 60.2 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES PPO [308136801] 48.16 percent of total billed charges 37.32 57.19 Technical (Hospital) Services "HEPARIN (PORCINE) 5,000 UNIT/ML INJECTION SOLUTION INTRAVENOUS" RX-10181 CDM J1644 HCPCS 636 RC 71288-0403-01 NDC outpatient 1 ML 60.2 60.2 BLUE CROSS BLUE SHIELD WELLMARK SB889 [3081026] BCBS WYOMING [308102603] 57.19 percent of total billed charges 37.32 57.19 Technical (Hospital) Services "HEPARIN (PORCINE) 5,000 UNIT/ML INJECTION SOLUTION INTRAVENOUS" RX-10181 CDM J1644 HCPCS 636 RC 71288-0403-01 NDC outpatient 1 ML 60.2 60.2 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES HDHP [308136802] 48.16 percent of total billed charges 37.32 57.19 Technical (Hospital) Services "HEPARIN (PORCINE) 5,000 UNIT/ML INJECTION SOLUTION INTRAVENOUS" RX-10181 CDM J1644 HCPCS 636 RC 71288-0403-01 NDC outpatient 1 ML 60.2 60.2 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES EPO [308136803] 48.16 percent of total billed charges 37.32 57.19 Technical (Hospital) Services "HEPARIN (PORCINE) 5,000 UNIT/ML INJECTION SOLUTION INTRAVENOUS" RX-10181 CDM J1644 HCPCS 636 RC 71288-0403-01 NDC inpatient 1 ML 60.2 60.2 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES EPO [308136803] 47.67 percent of total billed charges 37.32 57.19 Technical (Hospital) Services "HEPARIN (PORCINE) 5,000 UNIT/ML INJECTION SOLUTION INTRAVENOUS" RX-10181 CDM J1644 HCPCS 636 RC 71288-0403-01 NDC inpatient 1 ML 60.2 60.2 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES HDHP [308136802] 47.67 percent of total billed charges 37.32 57.19 Technical (Hospital) Services "HEPARIN (PORCINE) 5,000 UNIT/ML INJECTION SOLUTION INTRAVENOUS" RX-10181 CDM J1644 HCPCS 636 RC 71288-0403-01 NDC inpatient 1 ML 60.2 60.2 CIGNA 62308 [3081051] CIGNA STATE OF WYOMING [308105107] 47.67 percent of total billed charges 37.32 57.19 Technical (Hospital) Services "HEPARIN (PORCINE) 5,000 UNIT/ML INJECTION SOLUTION INTRAVENOUS" RX-10181 CDM J1644 HCPCS 636 RC 71288-0403-01 NDC inpatient 1 ML 60.2 60.2 CIGNA 62308 [3081051] CIGNA 62308 [308105105] 47.67 percent of total billed charges 37.32 57.19 Technical (Hospital) Services "HEPARIN (PORCINE) 5,000 UNIT/ML INJECTION SOLUTION INTRAVENOUS" RX-10181 CDM J1644 HCPCS 636 RC 71288-0403-01 NDC inpatient 1 ML 60.2 60.2 UNITED HEALTHCARE (COMMERCIAL) [3081199] UNITED HEALTHCARE 87726 [308119901] 37.32 percent of total billed charges 37.32 57.19 Technical (Hospital) Services "HEPARIN (PORCINE) 5,000 UNIT/ML INJECTION SOLUTION INTRAVENOUS" RX-10181 CDM J1644 HCPCS 636 RC 71288-0403-01 NDC inpatient 1 ML 60.2 60.2 BLUE CROSS BLUE SHIELD WELLMARK SB889 [3081026] BCBS WYOMING [308102603] 57.19 percent of total billed charges 37.32 57.19 Technical (Hospital) Services "HEPARIN (PORCINE) 5,000 UNIT/ML INJECTION SOLUTION INTRAVENOUS" RX-10181 CDM J1644 HCPCS 636 RC 71288-0403-01 NDC inpatient 1 ML 60.2 60.2 HEALTHPARTNERS SX009 HEALTHPARTNERS 47.67 percent of total billed charges 37.32 57.19 Technical (Hospital) Services "HEPARIN (PORCINE) 5,000 UNIT/ML INJECTION SOLUTION INTRAVENOUS" RX-10181 CDM J1644 HCPCS 636 RC 71288-0403-01 NDC inpatient 1 ML 60.2 60.2 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES PPO [308136801] 47.67 percent of total billed charges 37.32 57.19 Technical (Hospital) Services "HEPARIN (PORCINE) 5,000 UNIT/ML INJECTION SOLUTION INTRAVENOUS" RX-10181 CDM J1644 HCPCS 636 RC 71288-0403-01 NDC inpatient 1 ML 60.2 60.2 MEDICA (COMMERCIAL) 94265 [3081118] MEDICA CLAIMS [308111801] 54.18 percent of total billed charges 37.32 57.19 Technical (Hospital) Services "HEPARIN (PORCINE) 5,000 UNIT/ML INJECTION SOLUTION INTRAVENOUS" RX-10181 CDM J1644 HCPCS 636 RC 71288-0403-01 NDC inpatient 1 ML 60.2 60.2 MULTIPLAN INC 34080 [3081285] MULTIPLAN INC [308128501] 57.19 percent of total billed charges 37.32 57.19 Technical (Hospital) Services "HEPARIN (PORCINE) 25,000 UNIT/250 ML (100 UNIT/ML) IN DEXTROSE 5 % IV" RX-24329 CDM J1644 HCPCS 636 RC 63323-0523-01 NDC inpatient 250 ML 74 74 CIGNA 62308 [3081051] CIGNA 62308 [308105105] 58.59 percent of total billed charges 45.88 70.3 Technical (Hospital) Services "HEPARIN (PORCINE) 25,000 UNIT/250 ML (100 UNIT/ML) IN DEXTROSE 5 % IV" RX-24329 CDM J1644 HCPCS 636 RC 63323-0523-01 NDC inpatient 250 ML 74 74 CIGNA 62308 [3081051] CIGNA STATE OF WYOMING [308105107] 58.59 percent of total billed charges 45.88 70.3 Technical (Hospital) Services "HEPARIN (PORCINE) 25,000 UNIT/250 ML (100 UNIT/ML) IN DEXTROSE 5 % IV" RX-24329 CDM J1644 HCPCS 636 RC 63323-0523-01 NDC inpatient 250 ML 74 74 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES EPO [308136803] 58.59 percent of total billed charges 45.88 70.3 Technical (Hospital) Services "HEPARIN (PORCINE) 25,000 UNIT/250 ML (100 UNIT/ML) IN DEXTROSE 5 % IV" RX-24329 CDM J1644 HCPCS 636 RC 63323-0523-01 NDC inpatient 250 ML 74 74 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES HDHP [308136802] 58.59 percent of total billed charges 45.88 70.3 Technical (Hospital) Services "HEPARIN (PORCINE) 25,000 UNIT/250 ML (100 UNIT/ML) IN DEXTROSE 5 % IV" RX-24329 CDM J1644 HCPCS 636 RC 63323-0523-01 NDC inpatient 250 ML 74 74 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES PPO [308136801] 58.59 percent of total billed charges 45.88 70.3 Technical (Hospital) Services "HEPARIN (PORCINE) 25,000 UNIT/250 ML (100 UNIT/ML) IN DEXTROSE 5 % IV" RX-24329 CDM J1644 HCPCS 636 RC 63323-0523-01 NDC inpatient 250 ML 74 74 BLUE CROSS BLUE SHIELD WELLMARK SB889 [3081026] BCBS WYOMING [308102603] 70.3 percent of total billed charges 45.88 70.3 Technical (Hospital) Services "HEPARIN (PORCINE) 25,000 UNIT/250 ML (100 UNIT/ML) IN DEXTROSE 5 % IV" RX-24329 CDM J1644 HCPCS 636 RC 63323-0523-01 NDC inpatient 250 ML 74 74 UNITED HEALTHCARE (COMMERCIAL) [3081199] UNITED HEALTHCARE 87726 [308119901] 45.88 percent of total billed charges 45.88 70.3 Technical (Hospital) Services "HEPARIN (PORCINE) 25,000 UNIT/250 ML (100 UNIT/ML) IN DEXTROSE 5 % IV" RX-24329 CDM J1644 HCPCS 636 RC 63323-0523-01 NDC inpatient 250 ML 74 74 MULTIPLAN INC 34080 [3081285] MULTIPLAN INC [308128501] 70.3 percent of total billed charges 45.88 70.3 Technical (Hospital) Services "HEPARIN (PORCINE) 25,000 UNIT/250 ML (100 UNIT/ML) IN DEXTROSE 5 % IV" RX-24329 CDM J1644 HCPCS 636 RC 63323-0523-01 NDC inpatient 250 ML 74 74 MEDICA (COMMERCIAL) 94265 [3081118] MEDICA CLAIMS [308111801] 66.6 percent of total billed charges 45.88 70.3 Technical (Hospital) Services "HEPARIN (PORCINE) 25,000 UNIT/250 ML (100 UNIT/ML) IN DEXTROSE 5 % IV" RX-24329 CDM J1644 HCPCS 636 RC 63323-0523-01 NDC inpatient 250 ML 74 74 HEALTHPARTNERS SX009 HEALTHPARTNERS 58.59 percent of total billed charges 45.88 70.3 Technical (Hospital) Services "HEPARIN (PORCINE) 25,000 UNIT/250 ML (100 UNIT/ML) IN DEXTROSE 5 % IV" RX-24329 CDM J1644 HCPCS 636 RC 63323-0523-01 NDC outpatient 250 ML 74 74 CIGNA 62308 [3081051] CIGNA 62308 [308105105] 59.2 percent of total billed charges 45.88 70.3 Technical (Hospital) Services "HEPARIN (PORCINE) 25,000 UNIT/250 ML (100 UNIT/ML) IN DEXTROSE 5 % IV" RX-24329 CDM J1644 HCPCS 636 RC 63323-0523-01 NDC outpatient 250 ML 74 74 CIGNA 62308 [3081051] CIGNA STATE OF WYOMING [308105107] 59.2 percent of total billed charges 45.88 70.3 Technical (Hospital) Services "HEPARIN (PORCINE) 25,000 UNIT/250 ML (100 UNIT/ML) IN DEXTROSE 5 % IV" RX-24329 CDM J1644 HCPCS 636 RC 63323-0523-01 NDC outpatient 250 ML 74 74 MEDICA (COMMERCIAL) 94265 [3081118] MEDICA CLAIMS [308111801] 66.6 percent of total billed charges 45.88 70.3 Technical (Hospital) Services "HEPARIN (PORCINE) 25,000 UNIT/250 ML (100 UNIT/ML) IN DEXTROSE 5 % IV" RX-24329 CDM J1644 HCPCS 636 RC 63323-0523-01 NDC outpatient 250 ML 74 74 MULTIPLAN INC 34080 [3081285] MULTIPLAN INC [308128501] 70.3 percent of total billed charges 45.88 70.3 Technical (Hospital) Services "HEPARIN (PORCINE) 25,000 UNIT/250 ML (100 UNIT/ML) IN DEXTROSE 5 % IV" RX-24329 CDM J1644 HCPCS 636 RC 63323-0523-01 NDC outpatient 250 ML 74 74 HEALTHPARTNERS SX009 HEALTHPARTNERS 59.2 percent of total billed charges 45.88 70.3 Technical (Hospital) Services "HEPARIN (PORCINE) 25,000 UNIT/250 ML (100 UNIT/ML) IN DEXTROSE 5 % IV" RX-24329 CDM J1644 HCPCS 636 RC 63323-0523-01 NDC outpatient 250 ML 74 74 UNITED HEALTHCARE (COMMERCIAL) [3081199] UNITED HEALTHCARE 87726 [308119901] 45.88 percent of total billed charges 45.88 70.3 Technical (Hospital) Services "HEPARIN (PORCINE) 25,000 UNIT/250 ML (100 UNIT/ML) IN DEXTROSE 5 % IV" RX-24329 CDM J1644 HCPCS 636 RC 63323-0523-01 NDC outpatient 250 ML 74 74 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES EPO [308136803] 59.2 percent of total billed charges 45.88 70.3 Technical (Hospital) Services "HEPARIN (PORCINE) 25,000 UNIT/250 ML (100 UNIT/ML) IN DEXTROSE 5 % IV" RX-24329 CDM J1644 HCPCS 636 RC 63323-0523-01 NDC outpatient 250 ML 74 74 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES HDHP [308136802] 59.2 percent of total billed charges 45.88 70.3 Technical (Hospital) Services "HEPARIN (PORCINE) 25,000 UNIT/250 ML (100 UNIT/ML) IN DEXTROSE 5 % IV" RX-24329 CDM J1644 HCPCS 636 RC 63323-0523-01 NDC outpatient 250 ML 74 74 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES PPO [308136801] 59.2 percent of total billed charges 45.88 70.3 Technical (Hospital) Services "HEPARIN (PORCINE) 25,000 UNIT/250 ML (100 UNIT/ML) IN DEXTROSE 5 % IV" RX-24329 CDM J1644 HCPCS 636 RC 63323-0523-01 NDC outpatient 250 ML 74 74 BLUE CROSS BLUE SHIELD WELLMARK SB889 [3081026] BCBS WYOMING [308102603] 70.3 percent of total billed charges 45.88 70.3 Technical (Hospital) Services "HEPARIN, PORCINE (PF) 100 UNIT/ML INTRAVENOUS SYRINGE" RX-125932 CDM J1642 HCPCS 636 RC 64253-0333-35 NDC inpatient 5 ML 58.88 58.88 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES PPO [308136801] 46.62 percent of total billed charges 36.51 55.94 Technical (Hospital) Services "HEPARIN, PORCINE (PF) 100 UNIT/ML INTRAVENOUS SYRINGE" RX-125932 CDM J1642 HCPCS 636 RC 64253-0333-35 NDC inpatient 5 ML 58.88 58.88 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES HDHP [308136802] 46.62 percent of total billed charges 36.51 55.94 Technical (Hospital) Services "HEPARIN, PORCINE (PF) 100 UNIT/ML INTRAVENOUS SYRINGE" RX-125932 CDM J1642 HCPCS 636 RC 64253-0333-35 NDC inpatient 5 ML 58.88 58.88 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES EPO [308136803] 46.62 percent of total billed charges 36.51 55.94 Technical (Hospital) Services "HEPARIN, PORCINE (PF) 100 UNIT/ML INTRAVENOUS SYRINGE" RX-125932 CDM J1642 HCPCS 636 RC 64253-0333-35 NDC inpatient 5 ML 58.88 58.88 HEALTHPARTNERS SX009 HEALTHPARTNERS 46.62 percent of total billed charges 36.51 55.94 Technical (Hospital) Services "HEPARIN, PORCINE (PF) 100 UNIT/ML INTRAVENOUS SYRINGE" RX-125932 CDM J1642 HCPCS 636 RC 64253-0333-35 NDC inpatient 5 ML 58.88 58.88 BLUE CROSS BLUE SHIELD WELLMARK SB889 [3081026] BCBS WYOMING [308102603] 55.94 percent of total billed charges 36.51 55.94 Technical (Hospital) Services "HEPARIN, PORCINE (PF) 100 UNIT/ML INTRAVENOUS SYRINGE" RX-125932 CDM J1642 HCPCS 636 RC 64253-0333-35 NDC inpatient 5 ML 58.88 58.88 CIGNA 62308 [3081051] CIGNA 62308 [308105105] 46.62 percent of total billed charges 36.51 55.94 Technical (Hospital) Services "HEPARIN, PORCINE (PF) 100 UNIT/ML INTRAVENOUS SYRINGE" RX-125932 CDM J1642 HCPCS 636 RC 64253-0333-35 NDC inpatient 5 ML 58.88 58.88 CIGNA 62308 [3081051] CIGNA STATE OF WYOMING [308105107] 46.62 percent of total billed charges 36.51 55.94 Technical (Hospital) Services "HEPARIN, PORCINE (PF) 100 UNIT/ML INTRAVENOUS SYRINGE" RX-125932 CDM J1642 HCPCS 636 RC 64253-0333-35 NDC inpatient 5 ML 58.88 58.88 UNITED HEALTHCARE (COMMERCIAL) [3081199] UNITED HEALTHCARE 87726 [308119901] 36.51 percent of total billed charges 36.51 55.94 Technical (Hospital) Services "HEPARIN, PORCINE (PF) 100 UNIT/ML INTRAVENOUS SYRINGE" RX-125932 CDM J1642 HCPCS 636 RC 64253-0333-35 NDC inpatient 5 ML 58.88 58.88 MEDICA (COMMERCIAL) 94265 [3081118] MEDICA CLAIMS [308111801] 52.99 percent of total billed charges 36.51 55.94 Technical (Hospital) Services "HEPARIN, PORCINE (PF) 100 UNIT/ML INTRAVENOUS SYRINGE" RX-125932 CDM J1642 HCPCS 636 RC 64253-0333-35 NDC inpatient 5 ML 58.88 58.88 MULTIPLAN INC 34080 [3081285] MULTIPLAN INC [308128501] 55.94 percent of total billed charges 36.51 55.94 Technical (Hospital) Services "HEPARIN, PORCINE (PF) 100 UNIT/ML INTRAVENOUS SYRINGE" RX-125932 CDM J1642 HCPCS 636 RC 64253-0333-35 NDC outpatient 5 ML 58.88 58.88 CIGNA 62308 [3081051] CIGNA 62308 [308105105] 47.1 percent of total billed charges 36.51 55.94 Technical (Hospital) Services "HEPARIN, PORCINE (PF) 100 UNIT/ML INTRAVENOUS SYRINGE" RX-125932 CDM J1642 HCPCS 636 RC 64253-0333-35 NDC outpatient 5 ML 58.88 58.88 CIGNA 62308 [3081051] CIGNA STATE OF WYOMING [308105107] 47.1 percent of total billed charges 36.51 55.94 Technical (Hospital) Services "HEPARIN, PORCINE (PF) 100 UNIT/ML INTRAVENOUS SYRINGE" RX-125932 CDM J1642 HCPCS 636 RC 64253-0333-35 NDC outpatient 5 ML 58.88 58.88 MEDICA (COMMERCIAL) 94265 [3081118] MEDICA CLAIMS [308111801] 52.99 percent of total billed charges 36.51 55.94 Technical (Hospital) Services "HEPARIN, PORCINE (PF) 100 UNIT/ML INTRAVENOUS SYRINGE" RX-125932 CDM J1642 HCPCS 636 RC 64253-0333-35 NDC outpatient 5 ML 58.88 58.88 MULTIPLAN INC 34080 [3081285] MULTIPLAN INC [308128501] 55.94 percent of total billed charges 36.51 55.94 Technical (Hospital) Services "HEPARIN, PORCINE (PF) 100 UNIT/ML INTRAVENOUS SYRINGE" RX-125932 CDM J1642 HCPCS 636 RC 64253-0333-35 NDC outpatient 5 ML 58.88 58.88 UNITED HEALTHCARE (COMMERCIAL) [3081199] UNITED HEALTHCARE 87726 [308119901] 36.51 percent of total billed charges 36.51 55.94 Technical (Hospital) Services "HEPARIN, PORCINE (PF) 100 UNIT/ML INTRAVENOUS SYRINGE" RX-125932 CDM J1642 HCPCS 636 RC 64253-0333-35 NDC outpatient 5 ML 58.88 58.88 BLUE CROSS BLUE SHIELD WELLMARK SB889 [3081026] BCBS WYOMING [308102603] 55.94 percent of total billed charges 36.51 55.94 Technical (Hospital) Services "HEPARIN, PORCINE (PF) 100 UNIT/ML INTRAVENOUS SYRINGE" RX-125932 CDM J1642 HCPCS 636 RC 64253-0333-35 NDC outpatient 5 ML 58.88 58.88 HEALTHPARTNERS SX009 HEALTHPARTNERS 47.1 percent of total billed charges 36.51 55.94 Technical (Hospital) Services "HEPARIN, PORCINE (PF) 100 UNIT/ML INTRAVENOUS SYRINGE" RX-125932 CDM J1642 HCPCS 636 RC 64253-0333-35 NDC outpatient 5 ML 58.88 58.88 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES EPO [308136803] 47.1 percent of total billed charges 36.51 55.94 Technical (Hospital) Services "HEPARIN, PORCINE (PF) 100 UNIT/ML INTRAVENOUS SYRINGE" RX-125932 CDM J1642 HCPCS 636 RC 64253-0333-35 NDC outpatient 5 ML 58.88 58.88 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES PPO [308136801] 47.1 percent of total billed charges 36.51 55.94 Technical (Hospital) Services "HEPARIN, PORCINE (PF) 100 UNIT/ML INTRAVENOUS SYRINGE" RX-125932 CDM J1642 HCPCS 636 RC 64253-0333-35 NDC outpatient 5 ML 58.88 58.88 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES HDHP [308136802] 47.1 percent of total billed charges 36.51 55.94 Technical (Hospital) Services HALOPERIDOL LACTATE 5 MG/ML INJECTION SOLUTION RX-3584 CDM J1630 HCPCS 636 RC 00143-9501-25 NDC inpatient 0.4 ML 58.94 58.94 HEALTHPARTNERS SX009 HEALTHPARTNERS 46.67 percent of total billed charges 36.54 55.99 Technical (Hospital) Services HALOPERIDOL LACTATE 5 MG/ML INJECTION SOLUTION RX-3584 CDM J1630 HCPCS 636 RC 00143-9501-25 NDC inpatient 0.4 ML 58.94 58.94 MEDICA (COMMERCIAL) 94265 [3081118] MEDICA CLAIMS [308111801] 53.05 percent of total billed charges 36.54 55.99 Technical (Hospital) Services HALOPERIDOL LACTATE 5 MG/ML INJECTION SOLUTION RX-3584 CDM J1630 HCPCS 636 RC 00143-9501-25 NDC inpatient 0.4 ML 58.94 58.94 MULTIPLAN INC 34080 [3081285] MULTIPLAN INC [308128501] 55.99 percent of total billed charges 36.54 55.99 Technical (Hospital) Services HALOPERIDOL LACTATE 5 MG/ML INJECTION SOLUTION RX-3584 CDM J1630 HCPCS 636 RC 00143-9501-25 NDC inpatient 0.4 ML 58.94 58.94 BLUE CROSS BLUE SHIELD WELLMARK SB889 [3081026] BCBS WYOMING [308102603] 55.99 percent of total billed charges 36.54 55.99 Technical (Hospital) Services HALOPERIDOL LACTATE 5 MG/ML INJECTION SOLUTION RX-3584 CDM J1630 HCPCS 636 RC 00143-9501-25 NDC inpatient 0.4 ML 58.94 58.94 UNITED HEALTHCARE (COMMERCIAL) [3081199] UNITED HEALTHCARE 87726 [308119901] 36.54 percent of total billed charges 36.54 55.99 Technical (Hospital) Services HALOPERIDOL LACTATE 5 MG/ML INJECTION SOLUTION RX-3584 CDM J1630 HCPCS 636 RC 00143-9501-25 NDC inpatient 0.4 ML 58.94 58.94 CIGNA 62308 [3081051] CIGNA 62308 [308105105] 46.67 percent of total billed charges 36.54 55.99 Technical (Hospital) Services HALOPERIDOL LACTATE 5 MG/ML INJECTION SOLUTION RX-3584 CDM J1630 HCPCS 636 RC 00143-9501-25 NDC inpatient 0.4 ML 58.94 58.94 CIGNA 62308 [3081051] CIGNA STATE OF WYOMING [308105107] 46.67 percent of total billed charges 36.54 55.99 Technical (Hospital) Services HALOPERIDOL LACTATE 5 MG/ML INJECTION SOLUTION RX-3584 CDM J1630 HCPCS 636 RC 00143-9501-25 NDC inpatient 0.4 ML 58.94 58.94 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES HDHP [308136802] 46.67 percent of total billed charges 36.54 55.99 Technical (Hospital) Services HALOPERIDOL LACTATE 5 MG/ML INJECTION SOLUTION RX-3584 CDM J1630 HCPCS 636 RC 00143-9501-25 NDC inpatient 0.4 ML 58.94 58.94 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES PPO [308136801] 46.67 percent of total billed charges 36.54 55.99 Technical (Hospital) Services HALOPERIDOL LACTATE 5 MG/ML INJECTION SOLUTION RX-3584 CDM J1630 HCPCS 636 RC 00143-9501-25 NDC inpatient 0.4 ML 58.94 58.94 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES EPO [308136803] 46.67 percent of total billed charges 36.54 55.99 Technical (Hospital) Services HALOPERIDOL LACTATE 5 MG/ML INJECTION SOLUTION RX-3584 CDM J1630 HCPCS 636 RC 00143-9501-25 NDC outpatient 0.4 ML 58.94 58.94 MULTIPLAN INC 34080 [3081285] MULTIPLAN INC [308128501] 55.99 percent of total billed charges 36.54 55.99 Technical (Hospital) Services HALOPERIDOL LACTATE 5 MG/ML INJECTION SOLUTION RX-3584 CDM J1630 HCPCS 636 RC 00143-9501-25 NDC outpatient 0.4 ML 58.94 58.94 CIGNA 62308 [3081051] CIGNA 62308 [308105105] 47.15 percent of total billed charges 36.54 55.99 Technical (Hospital) Services HALOPERIDOL LACTATE 5 MG/ML INJECTION SOLUTION RX-3584 CDM J1630 HCPCS 636 RC 00143-9501-25 NDC outpatient 0.4 ML 58.94 58.94 CIGNA 62308 [3081051] CIGNA STATE OF WYOMING [308105107] 47.15 percent of total billed charges 36.54 55.99 Technical (Hospital) Services HALOPERIDOL LACTATE 5 MG/ML INJECTION SOLUTION RX-3584 CDM J1630 HCPCS 636 RC 00143-9501-25 NDC outpatient 0.4 ML 58.94 58.94 UNITED HEALTHCARE (COMMERCIAL) [3081199] UNITED HEALTHCARE 87726 [308119901] 36.54 percent of total billed charges 36.54 55.99 Technical (Hospital) Services HALOPERIDOL LACTATE 5 MG/ML INJECTION SOLUTION RX-3584 CDM J1630 HCPCS 636 RC 00143-9501-25 NDC outpatient 0.4 ML 58.94 58.94 MEDICA (COMMERCIAL) 94265 [3081118] MEDICA CLAIMS [308111801] 53.05 percent of total billed charges 36.54 55.99 Technical (Hospital) Services HALOPERIDOL LACTATE 5 MG/ML INJECTION SOLUTION RX-3584 CDM J1630 HCPCS 636 RC 00143-9501-25 NDC outpatient 0.4 ML 58.94 58.94 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES EPO [308136803] 47.15 percent of total billed charges 36.54 55.99 Technical (Hospital) Services HALOPERIDOL LACTATE 5 MG/ML INJECTION SOLUTION RX-3584 CDM J1630 HCPCS 636 RC 00143-9501-25 NDC outpatient 0.4 ML 58.94 58.94 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES HDHP [308136802] 47.15 percent of total billed charges 36.54 55.99 Technical (Hospital) Services HALOPERIDOL LACTATE 5 MG/ML INJECTION SOLUTION RX-3584 CDM J1630 HCPCS 636 RC 00143-9501-25 NDC outpatient 0.4 ML 58.94 58.94 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES PPO [308136801] 47.15 percent of total billed charges 36.54 55.99 Technical (Hospital) Services HALOPERIDOL LACTATE 5 MG/ML INJECTION SOLUTION RX-3584 CDM J1630 HCPCS 636 RC 00143-9501-25 NDC outpatient 0.4 ML 58.94 58.94 HEALTHPARTNERS SX009 HEALTHPARTNERS 47.15 percent of total billed charges 36.54 55.99 Technical (Hospital) Services HALOPERIDOL LACTATE 5 MG/ML INJECTION SOLUTION RX-3584 CDM J1630 HCPCS 636 RC 00143-9501-25 NDC outpatient 0.4 ML 58.94 58.94 BLUE CROSS BLUE SHIELD WELLMARK SB889 [3081026] BCBS WYOMING [308102603] 55.99 percent of total billed charges 36.54 55.99 Technical (Hospital) Services GLUCAGON HCL 1 MG SOLUTION FOR INJECTION RX-179123 CDM J1610 HCPCS 636 RC 63323-0582-82 NDC outpatient 1 ME 679.8 679.8 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES EPO [308136803] 543.84 percent of total billed charges 421.48 645.81 Technical (Hospital) Services GLUCAGON HCL 1 MG SOLUTION FOR INJECTION RX-179123 CDM J1610 HCPCS 636 RC 63323-0582-82 NDC outpatient 1 ME 679.8 679.8 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES HDHP [308136802] 543.84 percent of total billed charges 421.48 645.81 Technical (Hospital) Services GLUCAGON HCL 1 MG SOLUTION FOR INJECTION RX-179123 CDM J1610 HCPCS 636 RC 63323-0582-82 NDC outpatient 1 ME 679.8 679.8 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES PPO [308136801] 543.84 percent of total billed charges 421.48 645.81 Technical (Hospital) Services GLUCAGON HCL 1 MG SOLUTION FOR INJECTION RX-179123 CDM J1610 HCPCS 636 RC 63323-0582-82 NDC outpatient 1 ME 679.8 679.8 BLUE CROSS BLUE SHIELD WELLMARK SB889 [3081026] BCBS WYOMING [308102603] 645.81 percent of total billed charges 421.48 645.81 Technical (Hospital) Services GLUCAGON HCL 1 MG SOLUTION FOR INJECTION RX-179123 CDM J1610 HCPCS 636 RC 63323-0582-82 NDC outpatient 1 ME 679.8 679.8 CIGNA 62308 [3081051] CIGNA 62308 [308105105] 543.84 percent of total billed charges 421.48 645.81 Technical (Hospital) Services GLUCAGON HCL 1 MG SOLUTION FOR INJECTION RX-179123 CDM J1610 HCPCS 636 RC 63323-0582-82 NDC outpatient 1 ME 679.8 679.8 CIGNA 62308 [3081051] CIGNA STATE OF WYOMING [308105107] 543.84 percent of total billed charges 421.48 645.81 Technical (Hospital) Services GLUCAGON HCL 1 MG SOLUTION FOR INJECTION RX-179123 CDM J1610 HCPCS 636 RC 63323-0582-82 NDC outpatient 1 ME 679.8 679.8 MEDICA (COMMERCIAL) 94265 [3081118] MEDICA CLAIMS [308111801] 611.82 percent of total billed charges 421.48 645.81 Technical (Hospital) Services GLUCAGON HCL 1 MG SOLUTION FOR INJECTION RX-179123 CDM J1610 HCPCS 636 RC 63323-0582-82 NDC outpatient 1 ME 679.8 679.8 MULTIPLAN INC 34080 [3081285] MULTIPLAN INC [308128501] 645.81 percent of total billed charges 421.48 645.81 Technical (Hospital) Services GLUCAGON HCL 1 MG SOLUTION FOR INJECTION RX-179123 CDM J1610 HCPCS 636 RC 63323-0582-82 NDC outpatient 1 ME 679.8 679.8 UNITED HEALTHCARE (COMMERCIAL) [3081199] UNITED HEALTHCARE 87726 [308119901] 421.48 percent of total billed charges 421.48 645.81 Technical (Hospital) Services GLUCAGON HCL 1 MG SOLUTION FOR INJECTION RX-179123 CDM J1610 HCPCS 636 RC 63323-0582-82 NDC outpatient 1 ME 679.8 679.8 HEALTHPARTNERS SX009 HEALTHPARTNERS 543.84 percent of total billed charges 421.48 645.81 Technical (Hospital) Services GLUCAGON HCL 1 MG SOLUTION FOR INJECTION RX-179123 CDM J1610 HCPCS 636 RC 63323-0582-82 NDC inpatient 1 ME 679.8 679.8 BLUE CROSS BLUE SHIELD WELLMARK SB889 [3081026] BCBS WYOMING [308102603] 645.81 percent of total billed charges 421.48 645.81 Technical (Hospital) Services GLUCAGON HCL 1 MG SOLUTION FOR INJECTION RX-179123 CDM J1610 HCPCS 636 RC 63323-0582-82 NDC inpatient 1 ME 679.8 679.8 UNITED HEALTHCARE (COMMERCIAL) [3081199] UNITED HEALTHCARE 87726 [308119901] 421.48 percent of total billed charges 421.48 645.81 Technical (Hospital) Services GLUCAGON HCL 1 MG SOLUTION FOR INJECTION RX-179123 CDM J1610 HCPCS 636 RC 63323-0582-82 NDC inpatient 1 ME 679.8 679.8 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES HDHP [308136802] 538.27 percent of total billed charges 421.48 645.81 Technical (Hospital) Services GLUCAGON HCL 1 MG SOLUTION FOR INJECTION RX-179123 CDM J1610 HCPCS 636 RC 63323-0582-82 NDC inpatient 1 ME 679.8 679.8 CIGNA 62308 [3081051] CIGNA 62308 [308105105] 538.27 percent of total billed charges 421.48 645.81 Technical (Hospital) Services GLUCAGON HCL 1 MG SOLUTION FOR INJECTION RX-179123 CDM J1610 HCPCS 636 RC 63323-0582-82 NDC inpatient 1 ME 679.8 679.8 CIGNA 62308 [3081051] CIGNA STATE OF WYOMING [308105107] 538.27 percent of total billed charges 421.48 645.81 Technical (Hospital) Services GLUCAGON HCL 1 MG SOLUTION FOR INJECTION RX-179123 CDM J1610 HCPCS 636 RC 63323-0582-82 NDC inpatient 1 ME 679.8 679.8 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES EPO [308136803] 538.27 percent of total billed charges 421.48 645.81 Technical (Hospital) Services GLUCAGON HCL 1 MG SOLUTION FOR INJECTION RX-179123 CDM J1610 HCPCS 636 RC 63323-0582-82 NDC inpatient 1 ME 679.8 679.8 MULTIPLAN INC 34080 [3081285] MULTIPLAN INC [308128501] 645.81 percent of total billed charges 421.48 645.81 Technical (Hospital) Services GLUCAGON HCL 1 MG SOLUTION FOR INJECTION RX-179123 CDM J1610 HCPCS 636 RC 63323-0582-82 NDC inpatient 1 ME 679.8 679.8 MEDICA (COMMERCIAL) 94265 [3081118] MEDICA CLAIMS [308111801] 611.82 percent of total billed charges 421.48 645.81 Technical (Hospital) Services GLUCAGON HCL 1 MG SOLUTION FOR INJECTION RX-179123 CDM J1610 HCPCS 636 RC 63323-0582-82 NDC inpatient 1 ME 679.8 679.8 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES PPO [308136801] 538.27 percent of total billed charges 421.48 645.81 Technical (Hospital) Services GLUCAGON HCL 1 MG SOLUTION FOR INJECTION RX-179123 CDM J1610 HCPCS 636 RC 63323-0582-82 NDC inpatient 1 ME 679.8 679.8 HEALTHPARTNERS SX009 HEALTHPARTNERS 538.27 percent of total billed charges 421.48 645.81 Technical (Hospital) Services GOLIMUMAB 12.5 MG/ML INTRAVENOUS SOLUTION RX-122614 CDM J1602 HCPCS 636 RC 57894-0350-01 NDC inpatient 4 ML 4449.19 4449.19 BLUE CROSS BLUE SHIELD WELLMARK SB889 [3081026] BCBS WYOMING [308102603] 4226.73 percent of total billed charges 2758.5 4226.73 Technical (Hospital) Services GOLIMUMAB 12.5 MG/ML INTRAVENOUS SOLUTION RX-122614 CDM J1602 HCPCS 636 RC 57894-0350-01 NDC inpatient 4 ML 4449.19 4449.19 UNITED HEALTHCARE (COMMERCIAL) [3081199] UNITED HEALTHCARE 87726 [308119901] 2758.5 percent of total billed charges 2758.5 4226.73 Technical (Hospital) Services GOLIMUMAB 12.5 MG/ML INTRAVENOUS SOLUTION RX-122614 CDM J1602 HCPCS 636 RC 57894-0350-01 NDC inpatient 4 ML 4449.19 4449.19 CIGNA 62308 [3081051] CIGNA 62308 [308105105] 3522.87 percent of total billed charges 2758.5 4226.73 Technical (Hospital) Services GOLIMUMAB 12.5 MG/ML INTRAVENOUS SOLUTION RX-122614 CDM J1602 HCPCS 636 RC 57894-0350-01 NDC inpatient 4 ML 4449.19 4449.19 CIGNA 62308 [3081051] CIGNA STATE OF WYOMING [308105107] 3522.87 percent of total billed charges 2758.5 4226.73 Technical (Hospital) Services GOLIMUMAB 12.5 MG/ML INTRAVENOUS SOLUTION RX-122614 CDM J1602 HCPCS 636 RC 57894-0350-01 NDC inpatient 4 ML 4449.19 4449.19 MEDICA (COMMERCIAL) 94265 [3081118] MEDICA CLAIMS [308111801] 4004.27 percent of total billed charges 2758.5 4226.73 Technical (Hospital) Services GOLIMUMAB 12.5 MG/ML INTRAVENOUS SOLUTION RX-122614 CDM J1602 HCPCS 636 RC 57894-0350-01 NDC inpatient 4 ML 4449.19 4449.19 MULTIPLAN INC 34080 [3081285] MULTIPLAN INC [308128501] 4226.73 percent of total billed charges 2758.5 4226.73 Technical (Hospital) Services GOLIMUMAB 12.5 MG/ML INTRAVENOUS SOLUTION RX-122614 CDM J1602 HCPCS 636 RC 57894-0350-01 NDC inpatient 4 ML 4449.19 4449.19 HEALTHPARTNERS SX009 HEALTHPARTNERS 3522.87 percent of total billed charges 2758.5 4226.73 Technical (Hospital) Services GOLIMUMAB 12.5 MG/ML INTRAVENOUS SOLUTION RX-122614 CDM J1602 HCPCS 636 RC 57894-0350-01 NDC inpatient 4 ML 4449.19 4449.19 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES EPO [308136803] 3522.87 percent of total billed charges 2758.5 4226.73 Technical (Hospital) Services GOLIMUMAB 12.5 MG/ML INTRAVENOUS SOLUTION RX-122614 CDM J1602 HCPCS 636 RC 57894-0350-01 NDC inpatient 4 ML 4449.19 4449.19 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES HDHP [308136802] 3522.87 percent of total billed charges 2758.5 4226.73 Technical (Hospital) Services GOLIMUMAB 12.5 MG/ML INTRAVENOUS SOLUTION RX-122614 CDM J1602 HCPCS 636 RC 57894-0350-01 NDC inpatient 4 ML 4449.19 4449.19 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES PPO [308136801] 3522.87 percent of total billed charges 2758.5 4226.73 Technical (Hospital) Services GOLIMUMAB 12.5 MG/ML INTRAVENOUS SOLUTION RX-122614 CDM J1602 HCPCS 636 RC 57894-0350-01 NDC outpatient 4 ML 4449.19 4449.19 BLUE CROSS BLUE SHIELD WELLMARK SB889 [3081026] BCBS WYOMING [308102603] 4226.73 percent of total billed charges 2758.5 4226.73 Technical (Hospital) Services GOLIMUMAB 12.5 MG/ML INTRAVENOUS SOLUTION RX-122614 CDM J1602 HCPCS 636 RC 57894-0350-01 NDC outpatient 4 ML 4449.19 4449.19 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES PPO [308136801] 3559.35 percent of total billed charges 2758.5 4226.73 Technical (Hospital) Services GOLIMUMAB 12.5 MG/ML INTRAVENOUS SOLUTION RX-122614 CDM J1602 HCPCS 636 RC 57894-0350-01 NDC outpatient 4 ML 4449.19 4449.19 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES HDHP [308136802] 3559.35 percent of total billed charges 2758.5 4226.73 Technical (Hospital) Services GOLIMUMAB 12.5 MG/ML INTRAVENOUS SOLUTION RX-122614 CDM J1602 HCPCS 636 RC 57894-0350-01 NDC outpatient 4 ML 4449.19 4449.19 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES EPO [308136803] 3559.35 percent of total billed charges 2758.5 4226.73 Technical (Hospital) Services GOLIMUMAB 12.5 MG/ML INTRAVENOUS SOLUTION RX-122614 CDM J1602 HCPCS 636 RC 57894-0350-01 NDC outpatient 4 ML 4449.19 4449.19 MULTIPLAN INC 34080 [3081285] MULTIPLAN INC [308128501] 4226.73 percent of total billed charges 2758.5 4226.73 Technical (Hospital) Services GOLIMUMAB 12.5 MG/ML INTRAVENOUS SOLUTION RX-122614 CDM J1602 HCPCS 636 RC 57894-0350-01 NDC outpatient 4 ML 4449.19 4449.19 MEDICA (COMMERCIAL) 94265 [3081118] MEDICA CLAIMS [308111801] 4004.27 percent of total billed charges 2758.5 4226.73 Technical (Hospital) Services GOLIMUMAB 12.5 MG/ML INTRAVENOUS SOLUTION RX-122614 CDM J1602 HCPCS 636 RC 57894-0350-01 NDC outpatient 4 ML 4449.19 4449.19 CIGNA 62308 [3081051] CIGNA 62308 [308105105] 3559.35 percent of total billed charges 2758.5 4226.73 Technical (Hospital) Services GOLIMUMAB 12.5 MG/ML INTRAVENOUS SOLUTION RX-122614 CDM J1602 HCPCS 636 RC 57894-0350-01 NDC outpatient 4 ML 4449.19 4449.19 CIGNA 62308 [3081051] CIGNA STATE OF WYOMING [308105107] 3559.35 percent of total billed charges 2758.5 4226.73 Technical (Hospital) Services GOLIMUMAB 12.5 MG/ML INTRAVENOUS SOLUTION RX-122614 CDM J1602 HCPCS 636 RC 57894-0350-01 NDC outpatient 4 ML 4449.19 4449.19 UNITED HEALTHCARE (COMMERCIAL) [3081199] UNITED HEALTHCARE 87726 [308119901] 2758.5 percent of total billed charges 2758.5 4226.73 Technical (Hospital) Services GOLIMUMAB 12.5 MG/ML INTRAVENOUS SOLUTION RX-122614 CDM J1602 HCPCS 636 RC 57894-0350-01 NDC outpatient 4 ML 4449.19 4449.19 HEALTHPARTNERS SX009 HEALTHPARTNERS 3559.35 percent of total billed charges 2758.5 4226.73 Technical (Hospital) Services GENTAMICIN 40 MG/ML INJECTION SOLUTION RX-3426 CDM J1580 HCPCS 636 RC 63323-0010-94 NDC outpatient 2 ML 59.51 59.51 HEALTHPARTNERS SX009 HEALTHPARTNERS 47.61 percent of total billed charges 36.9 56.53 Technical (Hospital) Services GENTAMICIN 40 MG/ML INJECTION SOLUTION RX-3426 CDM J1580 HCPCS 636 RC 63323-0010-94 NDC outpatient 2 ML 59.51 59.51 CIGNA 62308 [3081051] CIGNA 62308 [308105105] 47.61 percent of total billed charges 36.9 56.53 Technical (Hospital) Services GENTAMICIN 40 MG/ML INJECTION SOLUTION RX-3426 CDM J1580 HCPCS 636 RC 63323-0010-94 NDC outpatient 2 ML 59.51 59.51 CIGNA 62308 [3081051] CIGNA STATE OF WYOMING [308105107] 47.61 percent of total billed charges 36.9 56.53 Technical (Hospital) Services GENTAMICIN 40 MG/ML INJECTION SOLUTION RX-3426 CDM J1580 HCPCS 636 RC 63323-0010-94 NDC outpatient 2 ML 59.51 59.51 UNITED HEALTHCARE (COMMERCIAL) [3081199] UNITED HEALTHCARE 87726 [308119901] 36.9 percent of total billed charges 36.9 56.53 Technical (Hospital) Services GENTAMICIN 40 MG/ML INJECTION SOLUTION RX-3426 CDM J1580 HCPCS 636 RC 63323-0010-94 NDC outpatient 2 ML 59.51 59.51 MULTIPLAN INC 34080 [3081285] MULTIPLAN INC [308128501] 56.53 percent of total billed charges 36.9 56.53 Technical (Hospital) Services GENTAMICIN 40 MG/ML INJECTION SOLUTION RX-3426 CDM J1580 HCPCS 636 RC 63323-0010-94 NDC outpatient 2 ML 59.51 59.51 BLUE CROSS BLUE SHIELD WELLMARK SB889 [3081026] BCBS WYOMING [308102603] 56.53 percent of total billed charges 36.9 56.53 Technical (Hospital) Services GENTAMICIN 40 MG/ML INJECTION SOLUTION RX-3426 CDM J1580 HCPCS 636 RC 63323-0010-94 NDC outpatient 2 ML 59.51 59.51 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES HDHP [308136802] 47.61 percent of total billed charges 36.9 56.53 Technical (Hospital) Services GENTAMICIN 40 MG/ML INJECTION SOLUTION RX-3426 CDM J1580 HCPCS 636 RC 63323-0010-94 NDC outpatient 2 ML 59.51 59.51 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES EPO [308136803] 47.61 percent of total billed charges 36.9 56.53 Technical (Hospital) Services GENTAMICIN 40 MG/ML INJECTION SOLUTION RX-3426 CDM J1580 HCPCS 636 RC 63323-0010-94 NDC outpatient 2 ML 59.51 59.51 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES PPO [308136801] 47.61 percent of total billed charges 36.9 56.53 Technical (Hospital) Services GENTAMICIN 40 MG/ML INJECTION SOLUTION RX-3426 CDM J1580 HCPCS 636 RC 63323-0010-94 NDC outpatient 2 ML 59.51 59.51 MEDICA (COMMERCIAL) 94265 [3081118] MEDICA CLAIMS [308111801] 53.56 percent of total billed charges 36.9 56.53 Technical (Hospital) Services GENTAMICIN 40 MG/ML INJECTION SOLUTION RX-3426 CDM J1580 HCPCS 636 RC 63323-0010-94 NDC inpatient 2 ML 59.51 59.51 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES EPO [308136803] 47.12 percent of total billed charges 36.9 56.53 Technical (Hospital) Services GENTAMICIN 40 MG/ML INJECTION SOLUTION RX-3426 CDM J1580 HCPCS 636 RC 63323-0010-94 NDC inpatient 2 ML 59.51 59.51 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES PPO [308136801] 47.12 percent of total billed charges 36.9 56.53 Technical (Hospital) Services GENTAMICIN 40 MG/ML INJECTION SOLUTION RX-3426 CDM J1580 HCPCS 636 RC 63323-0010-94 NDC inpatient 2 ML 59.51 59.51 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES HDHP [308136802] 47.12 percent of total billed charges 36.9 56.53 Technical (Hospital) Services GENTAMICIN 40 MG/ML INJECTION SOLUTION RX-3426 CDM J1580 HCPCS 636 RC 63323-0010-94 NDC inpatient 2 ML 59.51 59.51 HEALTHPARTNERS SX009 HEALTHPARTNERS 47.12 percent of total billed charges 36.9 56.53 Technical (Hospital) Services GENTAMICIN 40 MG/ML INJECTION SOLUTION RX-3426 CDM J1580 HCPCS 636 RC 63323-0010-94 NDC inpatient 2 ML 59.51 59.51 UNITED HEALTHCARE (COMMERCIAL) [3081199] UNITED HEALTHCARE 87726 [308119901] 36.9 percent of total billed charges 36.9 56.53 Technical (Hospital) Services GENTAMICIN 40 MG/ML INJECTION SOLUTION RX-3426 CDM J1580 HCPCS 636 RC 63323-0010-94 NDC inpatient 2 ML 59.51 59.51 BLUE CROSS BLUE SHIELD WELLMARK SB889 [3081026] BCBS WYOMING [308102603] 56.53 percent of total billed charges 36.9 56.53 Technical (Hospital) Services GENTAMICIN 40 MG/ML INJECTION SOLUTION RX-3426 CDM J1580 HCPCS 636 RC 63323-0010-94 NDC inpatient 2 ML 59.51 59.51 CIGNA 62308 [3081051] CIGNA 62308 [308105105] 47.12 percent of total billed charges 36.9 56.53 Technical (Hospital) Services GENTAMICIN 40 MG/ML INJECTION SOLUTION RX-3426 CDM J1580 HCPCS 636 RC 63323-0010-94 NDC inpatient 2 ML 59.51 59.51 CIGNA 62308 [3081051] CIGNA STATE OF WYOMING [308105107] 47.12 percent of total billed charges 36.9 56.53 Technical (Hospital) Services GENTAMICIN 40 MG/ML INJECTION SOLUTION RX-3426 CDM J1580 HCPCS 636 RC 63323-0010-94 NDC inpatient 2 ML 59.51 59.51 MULTIPLAN INC 34080 [3081285] MULTIPLAN INC [308128501] 56.53 percent of total billed charges 36.9 56.53 Technical (Hospital) Services GENTAMICIN 40 MG/ML INJECTION SOLUTION RX-3426 CDM J1580 HCPCS 636 RC 63323-0010-94 NDC inpatient 2 ML 59.51 59.51 MEDICA (COMMERCIAL) 94265 [3081118] MEDICA CLAIMS [308111801] 53.56 percent of total billed charges 36.9 56.53 Technical (Hospital) Services IMMUNE GLOBULIN (HUMAN) (GAMMAGARD) 10% INJECTION SOLUTION RX-111197 CDM J1569 HCPCS 636 RC 00944-2700-05 NDC inpatient 100 ML 4145.2 4145.2 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES PPO [308136801] 3282.17 percent of total billed charges 2570.02 3937.94 Technical (Hospital) Services IMMUNE GLOBULIN (HUMAN) (GAMMAGARD) 10% INJECTION SOLUTION RX-111197 CDM J1569 HCPCS 636 RC 00944-2700-05 NDC inpatient 100 ML 4145.2 4145.2 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES EPO [308136803] 3282.17 percent of total billed charges 2570.02 3937.94 Technical (Hospital) Services IMMUNE GLOBULIN (HUMAN) (GAMMAGARD) 10% INJECTION SOLUTION RX-111197 CDM J1569 HCPCS 636 RC 00944-2700-05 NDC inpatient 100 ML 4145.2 4145.2 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES HDHP [308136802] 3282.17 percent of total billed charges 2570.02 3937.94 Technical (Hospital) Services IMMUNE GLOBULIN (HUMAN) (GAMMAGARD) 10% INJECTION SOLUTION RX-111197 CDM J1569 HCPCS 636 RC 00944-2700-05 NDC inpatient 100 ML 4145.2 4145.2 CIGNA 62308 [3081051] CIGNA 62308 [308105105] 3282.17 percent of total billed charges 2570.02 3937.94 Technical (Hospital) Services IMMUNE GLOBULIN (HUMAN) (GAMMAGARD) 10% INJECTION SOLUTION RX-111197 CDM J1569 HCPCS 636 RC 00944-2700-05 NDC inpatient 100 ML 4145.2 4145.2 CIGNA 62308 [3081051] CIGNA STATE OF WYOMING [308105107] 3282.17 percent of total billed charges 2570.02 3937.94 Technical (Hospital) Services IMMUNE GLOBULIN (HUMAN) (GAMMAGARD) 10% INJECTION SOLUTION RX-111197 CDM J1569 HCPCS 636 RC 00944-2700-05 NDC inpatient 100 ML 4145.2 4145.2 MEDICA (COMMERCIAL) 94265 [3081118] MEDICA CLAIMS [308111801] 3730.68 percent of total billed charges 2570.02 3937.94 Technical (Hospital) Services IMMUNE GLOBULIN (HUMAN) (GAMMAGARD) 10% INJECTION SOLUTION RX-111197 CDM J1569 HCPCS 636 RC 00944-2700-05 NDC inpatient 100 ML 4145.2 4145.2 MULTIPLAN INC 34080 [3081285] MULTIPLAN INC [308128501] 3937.94 percent of total billed charges 2570.02 3937.94 Technical (Hospital) Services IMMUNE GLOBULIN (HUMAN) (GAMMAGARD) 10% INJECTION SOLUTION RX-111197 CDM J1569 HCPCS 636 RC 00944-2700-05 NDC inpatient 100 ML 4145.2 4145.2 HEALTHPARTNERS SX009 HEALTHPARTNERS 3282.17 percent of total billed charges 2570.02 3937.94 Technical (Hospital) Services IMMUNE GLOBULIN (HUMAN) (GAMMAGARD) 10% INJECTION SOLUTION RX-111197 CDM J1569 HCPCS 636 RC 00944-2700-05 NDC inpatient 100 ML 4145.2 4145.2 BLUE CROSS BLUE SHIELD WELLMARK SB889 [3081026] BCBS WYOMING [308102603] 3937.94 percent of total billed charges 2570.02 3937.94 Technical (Hospital) Services IMMUNE GLOBULIN (HUMAN) (GAMMAGARD) 10% INJECTION SOLUTION RX-111197 CDM J1569 HCPCS 636 RC 00944-2700-05 NDC inpatient 100 ML 4145.2 4145.2 UNITED HEALTHCARE (COMMERCIAL) [3081199] UNITED HEALTHCARE 87726 [308119901] 2570.02 percent of total billed charges 2570.02 3937.94 Technical (Hospital) Services IMMUNE GLOBULIN (HUMAN) (GAMMAGARD) 10% INJECTION SOLUTION RX-111197 CDM J1569 HCPCS 636 RC 00944-2700-05 NDC outpatient 100 ML 4145.2 4145.2 CIGNA 62308 [3081051] CIGNA 62308 [308105105] 3316.16 percent of total billed charges 2570.02 3937.94 Technical (Hospital) Services IMMUNE GLOBULIN (HUMAN) (GAMMAGARD) 10% INJECTION SOLUTION RX-111197 CDM J1569 HCPCS 636 RC 00944-2700-05 NDC outpatient 100 ML 4145.2 4145.2 CIGNA 62308 [3081051] CIGNA STATE OF WYOMING [308105107] 3316.16 percent of total billed charges 2570.02 3937.94 Technical (Hospital) Services IMMUNE GLOBULIN (HUMAN) (GAMMAGARD) 10% INJECTION SOLUTION RX-111197 CDM J1569 HCPCS 636 RC 00944-2700-05 NDC outpatient 100 ML 4145.2 4145.2 UNITED HEALTHCARE (COMMERCIAL) [3081199] UNITED HEALTHCARE 87726 [308119901] 2570.02 percent of total billed charges 2570.02 3937.94 Technical (Hospital) Services IMMUNE GLOBULIN (HUMAN) (GAMMAGARD) 10% INJECTION SOLUTION RX-111197 CDM J1569 HCPCS 636 RC 00944-2700-05 NDC outpatient 100 ML 4145.2 4145.2 BLUE CROSS BLUE SHIELD WELLMARK SB889 [3081026] BCBS WYOMING [308102603] 3937.94 percent of total billed charges 2570.02 3937.94 Technical (Hospital) Services IMMUNE GLOBULIN (HUMAN) (GAMMAGARD) 10% INJECTION SOLUTION RX-111197 CDM J1569 HCPCS 636 RC 00944-2700-05 NDC outpatient 100 ML 4145.2 4145.2 HEALTHPARTNERS SX009 HEALTHPARTNERS 3316.16 percent of total billed charges 2570.02 3937.94 Technical (Hospital) Services IMMUNE GLOBULIN (HUMAN) (GAMMAGARD) 10% INJECTION SOLUTION RX-111197 CDM J1569 HCPCS 636 RC 00944-2700-05 NDC outpatient 100 ML 4145.2 4145.2 MULTIPLAN INC 34080 [3081285] MULTIPLAN INC [308128501] 3937.94 percent of total billed charges 2570.02 3937.94 Technical (Hospital) Services IMMUNE GLOBULIN (HUMAN) (GAMMAGARD) 10% INJECTION SOLUTION RX-111197 CDM J1569 HCPCS 636 RC 00944-2700-05 NDC outpatient 100 ML 4145.2 4145.2 MEDICA (COMMERCIAL) 94265 [3081118] MEDICA CLAIMS [308111801] 3730.68 percent of total billed charges 2570.02 3937.94 Technical (Hospital) Services IMMUNE GLOBULIN (HUMAN) (GAMMAGARD) 10% INJECTION SOLUTION RX-111197 CDM J1569 HCPCS 636 RC 00944-2700-05 NDC outpatient 100 ML 4145.2 4145.2 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES HDHP [308136802] 3316.16 percent of total billed charges 2570.02 3937.94 Technical (Hospital) Services IMMUNE GLOBULIN (HUMAN) (GAMMAGARD) 10% INJECTION SOLUTION RX-111197 CDM J1569 HCPCS 636 RC 00944-2700-05 NDC outpatient 100 ML 4145.2 4145.2 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES EPO [308136803] 3316.16 percent of total billed charges 2570.02 3937.94 Technical (Hospital) Services IMMUNE GLOBULIN (HUMAN) (GAMMAGARD) 10% INJECTION SOLUTION RX-111197 CDM J1569 HCPCS 636 RC 00944-2700-05 NDC outpatient 100 ML 4145.2 4145.2 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES PPO [308136801] 3316.16 percent of total billed charges 2570.02 3937.94 Technical (Hospital) Services IMMUNE GLOBU G 1 GRAM/10 ML(10 %)-GLY-IGA AVE 46 MCG/ML INJECTION SOLN RX-107750 CDM J1561 HCPCS 636 RC 13533-0800-12 NDC inpatient 10 ML 403.75 403.75 BLUE CROSS BLUE SHIELD WELLMARK SB889 [3081026] BCBS WYOMING [308102603] 383.56 percent of total billed charges 250.33 383.56 Technical (Hospital) Services IMMUNE GLOBU G 1 GRAM/10 ML(10 %)-GLY-IGA AVE 46 MCG/ML INJECTION SOLN RX-107750 CDM J1561 HCPCS 636 RC 13533-0800-12 NDC inpatient 10 ML 403.75 403.75 UNITED HEALTHCARE (COMMERCIAL) [3081199] UNITED HEALTHCARE 87726 [308119901] 250.33 percent of total billed charges 250.33 383.56 Technical (Hospital) Services IMMUNE GLOBU G 1 GRAM/10 ML(10 %)-GLY-IGA AVE 46 MCG/ML INJECTION SOLN RX-107750 CDM J1561 HCPCS 636 RC 13533-0800-12 NDC inpatient 10 ML 403.75 403.75 CIGNA 62308 [3081051] CIGNA 62308 [308105105] 319.69 percent of total billed charges 250.33 383.56 Technical (Hospital) Services IMMUNE GLOBU G 1 GRAM/10 ML(10 %)-GLY-IGA AVE 46 MCG/ML INJECTION SOLN RX-107750 CDM J1561 HCPCS 636 RC 13533-0800-12 NDC inpatient 10 ML 403.75 403.75 CIGNA 62308 [3081051] CIGNA STATE OF WYOMING [308105107] 319.69 percent of total billed charges 250.33 383.56 Technical (Hospital) Services IMMUNE GLOBU G 1 GRAM/10 ML(10 %)-GLY-IGA AVE 46 MCG/ML INJECTION SOLN RX-107750 CDM J1561 HCPCS 636 RC 13533-0800-12 NDC inpatient 10 ML 403.75 403.75 MULTIPLAN INC 34080 [3081285] MULTIPLAN INC [308128501] 383.56 percent of total billed charges 250.33 383.56 Technical (Hospital) Services IMMUNE GLOBU G 1 GRAM/10 ML(10 %)-GLY-IGA AVE 46 MCG/ML INJECTION SOLN RX-107750 CDM J1561 HCPCS 636 RC 13533-0800-12 NDC inpatient 10 ML 403.75 403.75 MEDICA (COMMERCIAL) 94265 [3081118] MEDICA CLAIMS [308111801] 363.38 percent of total billed charges 250.33 383.56 Technical (Hospital) Services IMMUNE GLOBU G 1 GRAM/10 ML(10 %)-GLY-IGA AVE 46 MCG/ML INJECTION SOLN RX-107750 CDM J1561 HCPCS 636 RC 13533-0800-12 NDC inpatient 10 ML 403.75 403.75 HEALTHPARTNERS SX009 HEALTHPARTNERS 319.69 percent of total billed charges 250.33 383.56 Technical (Hospital) Services IMMUNE GLOBU G 1 GRAM/10 ML(10 %)-GLY-IGA AVE 46 MCG/ML INJECTION SOLN RX-107750 CDM J1561 HCPCS 636 RC 13533-0800-12 NDC inpatient 10 ML 403.75 403.75 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES EPO [308136803] 319.69 percent of total billed charges 250.33 383.56 Technical (Hospital) Services IMMUNE GLOBU G 1 GRAM/10 ML(10 %)-GLY-IGA AVE 46 MCG/ML INJECTION SOLN RX-107750 CDM J1561 HCPCS 636 RC 13533-0800-12 NDC inpatient 10 ML 403.75 403.75 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES HDHP [308136802] 319.69 percent of total billed charges 250.33 383.56 Technical (Hospital) Services IMMUNE GLOBU G 1 GRAM/10 ML(10 %)-GLY-IGA AVE 46 MCG/ML INJECTION SOLN RX-107750 CDM J1561 HCPCS 636 RC 13533-0800-12 NDC inpatient 10 ML 403.75 403.75 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES PPO [308136801] 319.69 percent of total billed charges 250.33 383.56 Technical (Hospital) Services IMMUNE GLOBU G 1 GRAM/10 ML(10 %)-GLY-IGA AVE 46 MCG/ML INJECTION SOLN RX-107750 CDM J1561 HCPCS 636 RC 13533-0800-12 NDC outpatient 10 ML 403.75 403.75 CIGNA 62308 [3081051] CIGNA 62308 [308105105] 323 percent of total billed charges 250.33 383.56 Technical (Hospital) Services IMMUNE GLOBU G 1 GRAM/10 ML(10 %)-GLY-IGA AVE 46 MCG/ML INJECTION SOLN RX-107750 CDM J1561 HCPCS 636 RC 13533-0800-12 NDC outpatient 10 ML 403.75 403.75 CIGNA 62308 [3081051] CIGNA STATE OF WYOMING [308105107] 323 percent of total billed charges 250.33 383.56 Technical (Hospital) Services IMMUNE GLOBU G 1 GRAM/10 ML(10 %)-GLY-IGA AVE 46 MCG/ML INJECTION SOLN RX-107750 CDM J1561 HCPCS 636 RC 13533-0800-12 NDC outpatient 10 ML 403.75 403.75 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES EPO [308136803] 323 percent of total billed charges 250.33 383.56 Technical (Hospital) Services IMMUNE GLOBU G 1 GRAM/10 ML(10 %)-GLY-IGA AVE 46 MCG/ML INJECTION SOLN RX-107750 CDM J1561 HCPCS 636 RC 13533-0800-12 NDC outpatient 10 ML 403.75 403.75 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES PPO [308136801] 323 percent of total billed charges 250.33 383.56 Technical (Hospital) Services IMMUNE GLOBU G 1 GRAM/10 ML(10 %)-GLY-IGA AVE 46 MCG/ML INJECTION SOLN RX-107750 CDM J1561 HCPCS 636 RC 13533-0800-12 NDC outpatient 10 ML 403.75 403.75 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES HDHP [308136802] 323 percent of total billed charges 250.33 383.56 Technical (Hospital) Services IMMUNE GLOBU G 1 GRAM/10 ML(10 %)-GLY-IGA AVE 46 MCG/ML INJECTION SOLN RX-107750 CDM J1561 HCPCS 636 RC 13533-0800-12 NDC outpatient 10 ML 403.75 403.75 BLUE CROSS BLUE SHIELD WELLMARK SB889 [3081026] BCBS WYOMING [308102603] 383.56 percent of total billed charges 250.33 383.56 Technical (Hospital) Services IMMUNE GLOBU G 1 GRAM/10 ML(10 %)-GLY-IGA AVE 46 MCG/ML INJECTION SOLN RX-107750 CDM J1561 HCPCS 636 RC 13533-0800-12 NDC outpatient 10 ML 403.75 403.75 MEDICA (COMMERCIAL) 94265 [3081118] MEDICA CLAIMS [308111801] 363.38 percent of total billed charges 250.33 383.56 Technical (Hospital) Services IMMUNE GLOBU G 1 GRAM/10 ML(10 %)-GLY-IGA AVE 46 MCG/ML INJECTION SOLN RX-107750 CDM J1561 HCPCS 636 RC 13533-0800-12 NDC outpatient 10 ML 403.75 403.75 MULTIPLAN INC 34080 [3081285] MULTIPLAN INC [308128501] 383.56 percent of total billed charges 250.33 383.56 Technical (Hospital) Services IMMUNE GLOBU G 1 GRAM/10 ML(10 %)-GLY-IGA AVE 46 MCG/ML INJECTION SOLN RX-107750 CDM J1561 HCPCS 636 RC 13533-0800-12 NDC outpatient 10 ML 403.75 403.75 UNITED HEALTHCARE (COMMERCIAL) [3081199] UNITED HEALTHCARE 87726 [308119901] 250.33 percent of total billed charges 250.33 383.56 Technical (Hospital) Services IMMUNE GLOBU G 1 GRAM/10 ML(10 %)-GLY-IGA AVE 46 MCG/ML INJECTION SOLN RX-107750 CDM J1561 HCPCS 636 RC 13533-0800-12 NDC outpatient 10 ML 403.75 403.75 HEALTHPARTNERS SX009 HEALTHPARTNERS 323 percent of total billed charges 250.33 383.56 Technical (Hospital) Services IMMUNE GLOB G 20 GRAM/200 ML(10%)-GLY-IGA AVE 46 MCG/ML INJECTION SOLN RX-107754 CDM J1561 HCPCS 636 RC 13533-0800-25 NDC inpatient 200 ML 5285 5285 BLUE CROSS BLUE SHIELD WELLMARK SB889 [3081026] BCBS WYOMING [308102603] 5020.75 percent of total billed charges 3276.7 5020.75 Technical (Hospital) Services IMMUNE GLOB G 20 GRAM/200 ML(10%)-GLY-IGA AVE 46 MCG/ML INJECTION SOLN RX-107754 CDM J1561 HCPCS 636 RC 13533-0800-25 NDC inpatient 200 ML 5285 5285 UNITED HEALTHCARE (COMMERCIAL) [3081199] UNITED HEALTHCARE 87726 [308119901] 3276.7 percent of total billed charges 3276.7 5020.75 Technical (Hospital) Services IMMUNE GLOB G 20 GRAM/200 ML(10%)-GLY-IGA AVE 46 MCG/ML INJECTION SOLN RX-107754 CDM J1561 HCPCS 636 RC 13533-0800-25 NDC inpatient 200 ML 5285 5285 MEDICA (COMMERCIAL) 94265 [3081118] MEDICA CLAIMS [308111801] 4756.5 percent of total billed charges 3276.7 5020.75 Technical (Hospital) Services IMMUNE GLOB G 20 GRAM/200 ML(10%)-GLY-IGA AVE 46 MCG/ML INJECTION SOLN RX-107754 CDM J1561 HCPCS 636 RC 13533-0800-25 NDC inpatient 200 ML 5285 5285 MULTIPLAN INC 34080 [3081285] MULTIPLAN INC [308128501] 5020.75 percent of total billed charges 3276.7 5020.75 Technical (Hospital) Services IMMUNE GLOB G 20 GRAM/200 ML(10%)-GLY-IGA AVE 46 MCG/ML INJECTION SOLN RX-107754 CDM J1561 HCPCS 636 RC 13533-0800-25 NDC inpatient 200 ML 5285 5285 HEALTHPARTNERS SX009 HEALTHPARTNERS 4184.66 percent of total billed charges 3276.7 5020.75 Technical (Hospital) Services IMMUNE GLOB G 20 GRAM/200 ML(10%)-GLY-IGA AVE 46 MCG/ML INJECTION SOLN RX-107754 CDM J1561 HCPCS 636 RC 13533-0800-25 NDC inpatient 200 ML 5285 5285 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES PPO [308136801] 4184.66 percent of total billed charges 3276.7 5020.75 Technical (Hospital) Services IMMUNE GLOB G 20 GRAM/200 ML(10%)-GLY-IGA AVE 46 MCG/ML INJECTION SOLN RX-107754 CDM J1561 HCPCS 636 RC 13533-0800-25 NDC inpatient 200 ML 5285 5285 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES HDHP [308136802] 4184.66 percent of total billed charges 3276.7 5020.75 Technical (Hospital) Services IMMUNE GLOB G 20 GRAM/200 ML(10%)-GLY-IGA AVE 46 MCG/ML INJECTION SOLN RX-107754 CDM J1561 HCPCS 636 RC 13533-0800-25 NDC inpatient 200 ML 5285 5285 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES EPO [308136803] 4184.66 percent of total billed charges 3276.7 5020.75 Technical (Hospital) Services IMMUNE GLOB G 20 GRAM/200 ML(10%)-GLY-IGA AVE 46 MCG/ML INJECTION SOLN RX-107754 CDM J1561 HCPCS 636 RC 13533-0800-25 NDC inpatient 200 ML 5285 5285 CIGNA 62308 [3081051] CIGNA 62308 [308105105] 4184.66 percent of total billed charges 3276.7 5020.75 Technical (Hospital) Services IMMUNE GLOB G 20 GRAM/200 ML(10%)-GLY-IGA AVE 46 MCG/ML INJECTION SOLN RX-107754 CDM J1561 HCPCS 636 RC 13533-0800-25 NDC inpatient 200 ML 5285 5285 CIGNA 62308 [3081051] CIGNA STATE OF WYOMING [308105107] 4184.66 percent of total billed charges 3276.7 5020.75 Technical (Hospital) Services IMMUNE GLOB G 20 GRAM/200 ML(10%)-GLY-IGA AVE 46 MCG/ML INJECTION SOLN RX-107754 CDM J1561 HCPCS 636 RC 13533-0800-25 NDC outpatient 200 ML 5285 5285 CIGNA 62308 [3081051] CIGNA 62308 [308105105] 4228 percent of total billed charges 3276.7 5020.75 Technical (Hospital) Services IMMUNE GLOB G 20 GRAM/200 ML(10%)-GLY-IGA AVE 46 MCG/ML INJECTION SOLN RX-107754 CDM J1561 HCPCS 636 RC 13533-0800-25 NDC outpatient 200 ML 5285 5285 CIGNA 62308 [3081051] CIGNA STATE OF WYOMING [308105107] 4228 percent of total billed charges 3276.7 5020.75 Technical (Hospital) Services IMMUNE GLOB G 20 GRAM/200 ML(10%)-GLY-IGA AVE 46 MCG/ML INJECTION SOLN RX-107754 CDM J1561 HCPCS 636 RC 13533-0800-25 NDC outpatient 200 ML 5285 5285 MEDICA (COMMERCIAL) 94265 [3081118] MEDICA CLAIMS [308111801] 4756.5 percent of total billed charges 3276.7 5020.75 Technical (Hospital) Services IMMUNE GLOB G 20 GRAM/200 ML(10%)-GLY-IGA AVE 46 MCG/ML INJECTION SOLN RX-107754 CDM J1561 HCPCS 636 RC 13533-0800-25 NDC outpatient 200 ML 5285 5285 MULTIPLAN INC 34080 [3081285] MULTIPLAN INC [308128501] 5020.75 percent of total billed charges 3276.7 5020.75 Technical (Hospital) Services IMMUNE GLOB G 20 GRAM/200 ML(10%)-GLY-IGA AVE 46 MCG/ML INJECTION SOLN RX-107754 CDM J1561 HCPCS 636 RC 13533-0800-25 NDC outpatient 200 ML 5285 5285 BLUE CROSS BLUE SHIELD WELLMARK SB889 [3081026] BCBS WYOMING [308102603] 5020.75 percent of total billed charges 3276.7 5020.75 Technical (Hospital) Services IMMUNE GLOB G 20 GRAM/200 ML(10%)-GLY-IGA AVE 46 MCG/ML INJECTION SOLN RX-107754 CDM J1561 HCPCS 636 RC 13533-0800-25 NDC outpatient 200 ML 5285 5285 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES EPO [308136803] 4228 percent of total billed charges 3276.7 5020.75 Technical (Hospital) Services IMMUNE GLOB G 20 GRAM/200 ML(10%)-GLY-IGA AVE 46 MCG/ML INJECTION SOLN RX-107754 CDM J1561 HCPCS 636 RC 13533-0800-25 NDC outpatient 200 ML 5285 5285 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES HDHP [308136802] 4228 percent of total billed charges 3276.7 5020.75 Technical (Hospital) Services IMMUNE GLOB G 20 GRAM/200 ML(10%)-GLY-IGA AVE 46 MCG/ML INJECTION SOLN RX-107754 CDM J1561 HCPCS 636 RC 13533-0800-25 NDC outpatient 200 ML 5285 5285 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES PPO [308136801] 4228 percent of total billed charges 3276.7 5020.75 Technical (Hospital) Services IMMUNE GLOB G 20 GRAM/200 ML(10%)-GLY-IGA AVE 46 MCG/ML INJECTION SOLN RX-107754 CDM J1561 HCPCS 636 RC 13533-0800-25 NDC outpatient 200 ML 5285 5285 UNITED HEALTHCARE (COMMERCIAL) [3081199] UNITED HEALTHCARE 87726 [308119901] 3276.7 percent of total billed charges 3276.7 5020.75 Technical (Hospital) Services IMMUNE GLOB G 20 GRAM/200 ML(10%)-GLY-IGA AVE 46 MCG/ML INJECTION SOLN RX-107754 CDM J1561 HCPCS 636 RC 13533-0800-25 NDC outpatient 200 ML 5285 5285 HEALTHPARTNERS SX009 HEALTHPARTNERS 4228 percent of total billed charges 3276.7 5020.75 Technical (Hospital) Services IMMUNE GLOB G 40 GRAM/400 ML(10%)-GLY-IGA AVE 46 MCG/ML INJECTION SOLN RX-127559 CDM J1561 HCPCS 636 RC 13533-0800-40 NDC inpatient 400 ML 9420 9420 CIGNA 62308 [3081051] CIGNA 62308 [308105105] 7458.76 percent of total billed charges 5840.4 8949 Technical (Hospital) Services IMMUNE GLOB G 40 GRAM/400 ML(10%)-GLY-IGA AVE 46 MCG/ML INJECTION SOLN RX-127559 CDM J1561 HCPCS 636 RC 13533-0800-40 NDC inpatient 400 ML 9420 9420 CIGNA 62308 [3081051] CIGNA STATE OF WYOMING [308105107] 7458.76 percent of total billed charges 5840.4 8949 Technical (Hospital) Services IMMUNE GLOB G 40 GRAM/400 ML(10%)-GLY-IGA AVE 46 MCG/ML INJECTION SOLN RX-127559 CDM J1561 HCPCS 636 RC 13533-0800-40 NDC inpatient 400 ML 9420 9420 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES EPO [308136803] 7458.76 percent of total billed charges 5840.4 8949 Technical (Hospital) Services IMMUNE GLOB G 40 GRAM/400 ML(10%)-GLY-IGA AVE 46 MCG/ML INJECTION SOLN RX-127559 CDM J1561 HCPCS 636 RC 13533-0800-40 NDC inpatient 400 ML 9420 9420 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES HDHP [308136802] 7458.76 percent of total billed charges 5840.4 8949 Technical (Hospital) Services IMMUNE GLOB G 40 GRAM/400 ML(10%)-GLY-IGA AVE 46 MCG/ML INJECTION SOLN RX-127559 CDM J1561 HCPCS 636 RC 13533-0800-40 NDC inpatient 400 ML 9420 9420 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES PPO [308136801] 7458.76 percent of total billed charges 5840.4 8949 Technical (Hospital) Services IMMUNE GLOB G 40 GRAM/400 ML(10%)-GLY-IGA AVE 46 MCG/ML INJECTION SOLN RX-127559 CDM J1561 HCPCS 636 RC 13533-0800-40 NDC inpatient 400 ML 9420 9420 HEALTHPARTNERS SX009 HEALTHPARTNERS 7458.76 percent of total billed charges 5840.4 8949 Technical (Hospital) Services IMMUNE GLOB G 40 GRAM/400 ML(10%)-GLY-IGA AVE 46 MCG/ML INJECTION SOLN RX-127559 CDM J1561 HCPCS 636 RC 13533-0800-40 NDC inpatient 400 ML 9420 9420 MULTIPLAN INC 34080 [3081285] MULTIPLAN INC [308128501] 8949 percent of total billed charges 5840.4 8949 Technical (Hospital) Services IMMUNE GLOB G 40 GRAM/400 ML(10%)-GLY-IGA AVE 46 MCG/ML INJECTION SOLN RX-127559 CDM J1561 HCPCS 636 RC 13533-0800-40 NDC inpatient 400 ML 9420 9420 MEDICA (COMMERCIAL) 94265 [3081118] MEDICA CLAIMS [308111801] 8478 percent of total billed charges 5840.4 8949 Technical (Hospital) Services IMMUNE GLOB G 40 GRAM/400 ML(10%)-GLY-IGA AVE 46 MCG/ML INJECTION SOLN RX-127559 CDM J1561 HCPCS 636 RC 13533-0800-40 NDC inpatient 400 ML 9420 9420 UNITED HEALTHCARE (COMMERCIAL) [3081199] UNITED HEALTHCARE 87726 [308119901] 5840.4 percent of total billed charges 5840.4 8949 Technical (Hospital) Services IMMUNE GLOB G 40 GRAM/400 ML(10%)-GLY-IGA AVE 46 MCG/ML INJECTION SOLN RX-127559 CDM J1561 HCPCS 636 RC 13533-0800-40 NDC inpatient 400 ML 9420 9420 BLUE CROSS BLUE SHIELD WELLMARK SB889 [3081026] BCBS WYOMING [308102603] 8949 percent of total billed charges 5840.4 8949 Technical (Hospital) Services IMMUNE GLOB G 40 GRAM/400 ML(10%)-GLY-IGA AVE 46 MCG/ML INJECTION SOLN RX-127559 CDM J1561 HCPCS 636 RC 13533-0800-40 NDC outpatient 400 ML 9420 9420 UNITED HEALTHCARE (COMMERCIAL) [3081199] UNITED HEALTHCARE 87726 [308119901] 5840.4 percent of total billed charges 5840.4 8949 Technical (Hospital) Services IMMUNE GLOB G 40 GRAM/400 ML(10%)-GLY-IGA AVE 46 MCG/ML INJECTION SOLN RX-127559 CDM J1561 HCPCS 636 RC 13533-0800-40 NDC outpatient 400 ML 9420 9420 HEALTHPARTNERS SX009 HEALTHPARTNERS 7536 percent of total billed charges 5840.4 8949 Technical (Hospital) Services IMMUNE GLOB G 40 GRAM/400 ML(10%)-GLY-IGA AVE 46 MCG/ML INJECTION SOLN RX-127559 CDM J1561 HCPCS 636 RC 13533-0800-40 NDC outpatient 400 ML 9420 9420 MEDICA (COMMERCIAL) 94265 [3081118] MEDICA CLAIMS [308111801] 8478 percent of total billed charges 5840.4 8949 Technical (Hospital) Services IMMUNE GLOB G 40 GRAM/400 ML(10%)-GLY-IGA AVE 46 MCG/ML INJECTION SOLN RX-127559 CDM J1561 HCPCS 636 RC 13533-0800-40 NDC outpatient 400 ML 9420 9420 MULTIPLAN INC 34080 [3081285] MULTIPLAN INC [308128501] 8949 percent of total billed charges 5840.4 8949 Technical (Hospital) Services IMMUNE GLOB G 40 GRAM/400 ML(10%)-GLY-IGA AVE 46 MCG/ML INJECTION SOLN RX-127559 CDM J1561 HCPCS 636 RC 13533-0800-40 NDC outpatient 400 ML 9420 9420 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES PPO [308136801] 7536 percent of total billed charges 5840.4 8949 Technical (Hospital) Services IMMUNE GLOB G 40 GRAM/400 ML(10%)-GLY-IGA AVE 46 MCG/ML INJECTION SOLN RX-127559 CDM J1561 HCPCS 636 RC 13533-0800-40 NDC outpatient 400 ML 9420 9420 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES EPO [308136803] 7536 percent of total billed charges 5840.4 8949 Technical (Hospital) Services IMMUNE GLOB G 40 GRAM/400 ML(10%)-GLY-IGA AVE 46 MCG/ML INJECTION SOLN RX-127559 CDM J1561 HCPCS 636 RC 13533-0800-40 NDC outpatient 400 ML 9420 9420 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES HDHP [308136802] 7536 percent of total billed charges 5840.4 8949 Technical (Hospital) Services IMMUNE GLOB G 40 GRAM/400 ML(10%)-GLY-IGA AVE 46 MCG/ML INJECTION SOLN RX-127559 CDM J1561 HCPCS 636 RC 13533-0800-40 NDC outpatient 400 ML 9420 9420 BLUE CROSS BLUE SHIELD WELLMARK SB889 [3081026] BCBS WYOMING [308102603] 8949 percent of total billed charges 5840.4 8949 Technical (Hospital) Services IMMUNE GLOB G 40 GRAM/400 ML(10%)-GLY-IGA AVE 46 MCG/ML INJECTION SOLN RX-127559 CDM J1561 HCPCS 636 RC 13533-0800-40 NDC outpatient 400 ML 9420 9420 CIGNA 62308 [3081051] CIGNA 62308 [308105105] 7536 percent of total billed charges 5840.4 8949 Technical (Hospital) Services IMMUNE GLOB G 40 GRAM/400 ML(10%)-GLY-IGA AVE 46 MCG/ML INJECTION SOLN RX-127559 CDM J1561 HCPCS 636 RC 13533-0800-40 NDC outpatient 400 ML 9420 9420 CIGNA 62308 [3081051] CIGNA STATE OF WYOMING [308105107] 7536 percent of total billed charges 5840.4 8949 Technical (Hospital) Services FILGRASTIM 480 MCG/1.6 ML INJECTION SOLUTION RX-108074 CDM J1442 HCPCS 636 RC 55513-0546-01 NDC outpatient 1.6 ML 1151.33 1151.33 BLUE CROSS BLUE SHIELD WELLMARK SB889 [3081026] BCBS WYOMING [308102603] 1093.76 percent of total billed charges 713.82 1093.76 Technical (Hospital) Services FILGRASTIM 480 MCG/1.6 ML INJECTION SOLUTION RX-108074 CDM J1442 HCPCS 636 RC 55513-0546-01 NDC outpatient 1.6 ML 1151.33 1151.33 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES EPO [308136803] 921.06 percent of total billed charges 713.82 1093.76 Technical (Hospital) Services FILGRASTIM 480 MCG/1.6 ML INJECTION SOLUTION RX-108074 CDM J1442 HCPCS 636 RC 55513-0546-01 NDC outpatient 1.6 ML 1151.33 1151.33 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES HDHP [308136802] 921.06 percent of total billed charges 713.82 1093.76 Technical (Hospital) Services FILGRASTIM 480 MCG/1.6 ML INJECTION SOLUTION RX-108074 CDM J1442 HCPCS 636 RC 55513-0546-01 NDC outpatient 1.6 ML 1151.33 1151.33 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES PPO [308136801] 921.06 percent of total billed charges 713.82 1093.76 Technical (Hospital) Services FILGRASTIM 480 MCG/1.6 ML INJECTION SOLUTION RX-108074 CDM J1442 HCPCS 636 RC 55513-0546-01 NDC outpatient 1.6 ML 1151.33 1151.33 MEDICA (COMMERCIAL) 94265 [3081118] MEDICA CLAIMS [308111801] 1036.2 percent of total billed charges 713.82 1093.76 Technical (Hospital) Services FILGRASTIM 480 MCG/1.6 ML INJECTION SOLUTION RX-108074 CDM J1442 HCPCS 636 RC 55513-0546-01 NDC outpatient 1.6 ML 1151.33 1151.33 MULTIPLAN INC 34080 [3081285] MULTIPLAN INC [308128501] 1093.76 percent of total billed charges 713.82 1093.76 Technical (Hospital) Services FILGRASTIM 480 MCG/1.6 ML INJECTION SOLUTION RX-108074 CDM J1442 HCPCS 636 RC 55513-0546-01 NDC outpatient 1.6 ML 1151.33 1151.33 CIGNA 62308 [3081051] CIGNA 62308 [308105105] 921.06 percent of total billed charges 713.82 1093.76 Technical (Hospital) Services FILGRASTIM 480 MCG/1.6 ML INJECTION SOLUTION RX-108074 CDM J1442 HCPCS 636 RC 55513-0546-01 NDC outpatient 1.6 ML 1151.33 1151.33 CIGNA 62308 [3081051] CIGNA STATE OF WYOMING [308105107] 921.06 percent of total billed charges 713.82 1093.76 Technical (Hospital) Services FILGRASTIM 480 MCG/1.6 ML INJECTION SOLUTION RX-108074 CDM J1442 HCPCS 636 RC 55513-0546-01 NDC inpatient 1.6 ML 1151.33 1151.33 HEALTHPARTNERS SX009 HEALTHPARTNERS 911.62 percent of total billed charges 713.82 1093.76 Technical (Hospital) Services FILGRASTIM 480 MCG/1.6 ML INJECTION SOLUTION RX-108074 CDM J1442 HCPCS 636 RC 55513-0546-01 NDC outpatient 1.6 ML 1151.33 1151.33 HEALTHPARTNERS SX009 HEALTHPARTNERS 921.06 percent of total billed charges 713.82 1093.76 Technical (Hospital) Services FILGRASTIM 480 MCG/1.6 ML INJECTION SOLUTION RX-108074 CDM J1442 HCPCS 636 RC 55513-0546-01 NDC outpatient 1.6 ML 1151.33 1151.33 UNITED HEALTHCARE (COMMERCIAL) [3081199] UNITED HEALTHCARE 87726 [308119901] 713.82 percent of total billed charges 713.82 1093.76 Technical (Hospital) Services FILGRASTIM 480 MCG/1.6 ML INJECTION SOLUTION RX-108074 CDM J1442 HCPCS 636 RC 55513-0546-01 NDC inpatient 1.6 ML 1151.33 1151.33 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES EPO [308136803] 911.62 percent of total billed charges 713.82 1093.76 Technical (Hospital) Services FILGRASTIM 480 MCG/1.6 ML INJECTION SOLUTION RX-108074 CDM J1442 HCPCS 636 RC 55513-0546-01 NDC inpatient 1.6 ML 1151.33 1151.33 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES HDHP [308136802] 911.62 percent of total billed charges 713.82 1093.76 Technical (Hospital) Services FILGRASTIM 480 MCG/1.6 ML INJECTION SOLUTION RX-108074 CDM J1442 HCPCS 636 RC 55513-0546-01 NDC inpatient 1.6 ML 1151.33 1151.33 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES PPO [308136801] 911.62 percent of total billed charges 713.82 1093.76 Technical (Hospital) Services FILGRASTIM 480 MCG/1.6 ML INJECTION SOLUTION RX-108074 CDM J1442 HCPCS 636 RC 55513-0546-01 NDC inpatient 1.6 ML 1151.33 1151.33 MEDICA (COMMERCIAL) 94265 [3081118] MEDICA CLAIMS [308111801] 1036.2 percent of total billed charges 713.82 1093.76 Technical (Hospital) Services FILGRASTIM 480 MCG/1.6 ML INJECTION SOLUTION RX-108074 CDM J1442 HCPCS 636 RC 55513-0546-01 NDC inpatient 1.6 ML 1151.33 1151.33 CIGNA 62308 [3081051] CIGNA 62308 [308105105] 911.62 percent of total billed charges 713.82 1093.76 Technical (Hospital) Services FILGRASTIM 480 MCG/1.6 ML INJECTION SOLUTION RX-108074 CDM J1442 HCPCS 636 RC 55513-0546-01 NDC inpatient 1.6 ML 1151.33 1151.33 CIGNA 62308 [3081051] CIGNA STATE OF WYOMING [308105107] 911.62 percent of total billed charges 713.82 1093.76 Technical (Hospital) Services FILGRASTIM 480 MCG/1.6 ML INJECTION SOLUTION RX-108074 CDM J1442 HCPCS 636 RC 55513-0546-01 NDC inpatient 1.6 ML 1151.33 1151.33 BLUE CROSS BLUE SHIELD WELLMARK SB889 [3081026] BCBS WYOMING [308102603] 1093.76 percent of total billed charges 713.82 1093.76 Technical (Hospital) Services FILGRASTIM 480 MCG/1.6 ML INJECTION SOLUTION RX-108074 CDM J1442 HCPCS 636 RC 55513-0546-01 NDC inpatient 1.6 ML 1151.33 1151.33 UNITED HEALTHCARE (COMMERCIAL) [3081199] UNITED HEALTHCARE 87726 [308119901] 713.82 percent of total billed charges 713.82 1093.76 Technical (Hospital) Services FILGRASTIM 480 MCG/1.6 ML INJECTION SOLUTION RX-108074 CDM J1442 HCPCS 636 RC 55513-0546-01 NDC inpatient 1.6 ML 1151.33 1151.33 MULTIPLAN INC 34080 [3081285] MULTIPLAN INC [308128501] 1093.76 percent of total billed charges 713.82 1093.76 Technical (Hospital) Services FILGRASTIM 300 MCG/0.5 ML INJECTION SYRINGE RX-129689 CDM J1442 HCPCS 636 RC 55513-0924-91 NDC inpatient 0.5 ML 808.7 808.7 HEALTHPARTNERS SX009 HEALTHPARTNERS 640.33 percent of total billed charges 501.39 768.27 Technical (Hospital) Services FILGRASTIM 300 MCG/0.5 ML INJECTION SYRINGE RX-129689 CDM J1442 HCPCS 636 RC 55513-0924-91 NDC inpatient 0.5 ML 808.7 808.7 MEDICA (COMMERCIAL) 94265 [3081118] MEDICA CLAIMS [308111801] 727.83 percent of total billed charges 501.39 768.27 Technical (Hospital) Services FILGRASTIM 300 MCG/0.5 ML INJECTION SYRINGE RX-129689 CDM J1442 HCPCS 636 RC 55513-0924-91 NDC inpatient 0.5 ML 808.7 808.7 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES EPO [308136803] 640.33 percent of total billed charges 501.39 768.27 Technical (Hospital) Services FILGRASTIM 300 MCG/0.5 ML INJECTION SYRINGE RX-129689 CDM J1442 HCPCS 636 RC 55513-0924-91 NDC inpatient 0.5 ML 808.7 808.7 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES HDHP [308136802] 640.33 percent of total billed charges 501.39 768.27 Technical (Hospital) Services FILGRASTIM 300 MCG/0.5 ML INJECTION SYRINGE RX-129689 CDM J1442 HCPCS 636 RC 55513-0924-91 NDC inpatient 0.5 ML 808.7 808.7 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES PPO [308136801] 640.33 percent of total billed charges 501.39 768.27 Technical (Hospital) Services FILGRASTIM 300 MCG/0.5 ML INJECTION SYRINGE RX-129689 CDM J1442 HCPCS 636 RC 55513-0924-91 NDC inpatient 0.5 ML 808.7 808.7 CIGNA 62308 [3081051] CIGNA 62308 [308105105] 640.33 percent of total billed charges 501.39 768.27 Technical (Hospital) Services FILGRASTIM 300 MCG/0.5 ML INJECTION SYRINGE RX-129689 CDM J1442 HCPCS 636 RC 55513-0924-91 NDC inpatient 0.5 ML 808.7 808.7 CIGNA 62308 [3081051] CIGNA STATE OF WYOMING [308105107] 640.33 percent of total billed charges 501.39 768.27 Technical (Hospital) Services FILGRASTIM 300 MCG/0.5 ML INJECTION SYRINGE RX-129689 CDM J1442 HCPCS 636 RC 55513-0924-91 NDC inpatient 0.5 ML 808.7 808.7 UNITED HEALTHCARE (COMMERCIAL) [3081199] UNITED HEALTHCARE 87726 [308119901] 501.39 percent of total billed charges 501.39 768.27 Technical (Hospital) Services FILGRASTIM 300 MCG/0.5 ML INJECTION SYRINGE RX-129689 CDM J1442 HCPCS 636 RC 55513-0924-91 NDC inpatient 0.5 ML 808.7 808.7 BLUE CROSS BLUE SHIELD WELLMARK SB889 [3081026] BCBS WYOMING [308102603] 768.27 percent of total billed charges 501.39 768.27 Technical (Hospital) Services FILGRASTIM 300 MCG/0.5 ML INJECTION SYRINGE RX-129689 CDM J1442 HCPCS 636 RC 55513-0924-91 NDC inpatient 0.5 ML 808.7 808.7 MULTIPLAN INC 34080 [3081285] MULTIPLAN INC [308128501] 768.27 percent of total billed charges 501.39 768.27 Technical (Hospital) Services FILGRASTIM 300 MCG/0.5 ML INJECTION SYRINGE RX-129689 CDM J1442 HCPCS 636 RC 55513-0924-91 NDC outpatient 0.5 ML 808.7 808.7 BLUE CROSS BLUE SHIELD WELLMARK SB889 [3081026] BCBS WYOMING [308102603] 768.27 percent of total billed charges 501.39 768.27 Technical (Hospital) Services FILGRASTIM 300 MCG/0.5 ML INJECTION SYRINGE RX-129689 CDM J1442 HCPCS 636 RC 55513-0924-91 NDC outpatient 0.5 ML 808.7 808.7 HEALTHPARTNERS SX009 HEALTHPARTNERS 646.96 percent of total billed charges 501.39 768.27 Technical (Hospital) Services FILGRASTIM 300 MCG/0.5 ML INJECTION SYRINGE RX-129689 CDM J1442 HCPCS 636 RC 55513-0924-91 NDC outpatient 0.5 ML 808.7 808.7 MULTIPLAN INC 34080 [3081285] MULTIPLAN INC [308128501] 768.27 percent of total billed charges 501.39 768.27 Technical (Hospital) Services FILGRASTIM 300 MCG/0.5 ML INJECTION SYRINGE RX-129689 CDM J1442 HCPCS 636 RC 55513-0924-91 NDC outpatient 0.5 ML 808.7 808.7 CIGNA 62308 [3081051] CIGNA 62308 [308105105] 646.96 percent of total billed charges 501.39 768.27 Technical (Hospital) Services FILGRASTIM 300 MCG/0.5 ML INJECTION SYRINGE RX-129689 CDM J1442 HCPCS 636 RC 55513-0924-91 NDC outpatient 0.5 ML 808.7 808.7 CIGNA 62308 [3081051] CIGNA STATE OF WYOMING [308105107] 646.96 percent of total billed charges 501.39 768.27 Technical (Hospital) Services FILGRASTIM 300 MCG/0.5 ML INJECTION SYRINGE RX-129689 CDM J1442 HCPCS 636 RC 55513-0924-91 NDC outpatient 0.5 ML 808.7 808.7 UNITED HEALTHCARE (COMMERCIAL) [3081199] UNITED HEALTHCARE 87726 [308119901] 501.39 percent of total billed charges 501.39 768.27 Technical (Hospital) Services FILGRASTIM 300 MCG/0.5 ML INJECTION SYRINGE RX-129689 CDM J1442 HCPCS 636 RC 55513-0924-91 NDC outpatient 0.5 ML 808.7 808.7 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES EPO [308136803] 646.96 percent of total billed charges 501.39 768.27 Technical (Hospital) Services FILGRASTIM 300 MCG/0.5 ML INJECTION SYRINGE RX-129689 CDM J1442 HCPCS 636 RC 55513-0924-91 NDC outpatient 0.5 ML 808.7 808.7 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES PPO [308136801] 646.96 percent of total billed charges 501.39 768.27 Technical (Hospital) Services FILGRASTIM 300 MCG/0.5 ML INJECTION SYRINGE RX-129689 CDM J1442 HCPCS 636 RC 55513-0924-91 NDC outpatient 0.5 ML 808.7 808.7 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES HDHP [308136802] 646.96 percent of total billed charges 501.39 768.27 Technical (Hospital) Services FILGRASTIM 300 MCG/0.5 ML INJECTION SYRINGE RX-129689 CDM J1442 HCPCS 636 RC 55513-0924-91 NDC outpatient 0.5 ML 808.7 808.7 MEDICA (COMMERCIAL) 94265 [3081118] MEDICA CLAIMS [308111801] 727.83 percent of total billed charges 501.39 768.27 Technical (Hospital) Services FERRIC CARBOXYMALTOSE 50 MG IRON/ML INTRAVENOUS SOLUTION RX-122648 CDM J1439 HCPCS 636 RC 00517-0650-01 NDC inpatient 15 ML 3879.7 3879.7 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES EPO [308136803] 3071.95 percent of total billed charges 2405.41 3685.72 Technical (Hospital) Services FERRIC CARBOXYMALTOSE 50 MG IRON/ML INTRAVENOUS SOLUTION RX-122648 CDM J1439 HCPCS 636 RC 00517-0650-01 NDC inpatient 15 ML 3879.7 3879.7 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES HDHP [308136802] 3071.95 percent of total billed charges 2405.41 3685.72 Technical (Hospital) Services FERRIC CARBOXYMALTOSE 50 MG IRON/ML INTRAVENOUS SOLUTION RX-122648 CDM J1439 HCPCS 636 RC 00517-0650-01 NDC inpatient 15 ML 3879.7 3879.7 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES PPO [308136801] 3071.95 percent of total billed charges 2405.41 3685.72 Technical (Hospital) Services FERRIC CARBOXYMALTOSE 50 MG IRON/ML INTRAVENOUS SOLUTION RX-122648 CDM J1439 HCPCS 636 RC 00517-0650-01 NDC inpatient 15 ML 3879.7 3879.7 HEALTHPARTNERS SX009 HEALTHPARTNERS 3071.95 percent of total billed charges 2405.41 3685.72 Technical (Hospital) Services FERRIC CARBOXYMALTOSE 50 MG IRON/ML INTRAVENOUS SOLUTION RX-122648 CDM J1439 HCPCS 636 RC 00517-0650-01 NDC inpatient 15 ML 3879.7 3879.7 CIGNA 62308 [3081051] CIGNA 62308 [308105105] 3071.95 percent of total billed charges 2405.41 3685.72 Technical (Hospital) Services FERRIC CARBOXYMALTOSE 50 MG IRON/ML INTRAVENOUS SOLUTION RX-122648 CDM J1439 HCPCS 636 RC 00517-0650-01 NDC inpatient 15 ML 3879.7 3879.7 CIGNA 62308 [3081051] CIGNA STATE OF WYOMING [308105107] 3071.95 percent of total billed charges 2405.41 3685.72 Technical (Hospital) Services FERRIC CARBOXYMALTOSE 50 MG IRON/ML INTRAVENOUS SOLUTION RX-122648 CDM J1439 HCPCS 636 RC 00517-0650-01 NDC inpatient 15 ML 3879.7 3879.7 BLUE CROSS BLUE SHIELD WELLMARK SB889 [3081026] BCBS WYOMING [308102603] 3685.72 percent of total billed charges 2405.41 3685.72 Technical (Hospital) Services FERRIC CARBOXYMALTOSE 50 MG IRON/ML INTRAVENOUS SOLUTION RX-122648 CDM J1439 HCPCS 636 RC 00517-0650-01 NDC inpatient 15 ML 3879.7 3879.7 UNITED HEALTHCARE (COMMERCIAL) [3081199] UNITED HEALTHCARE 87726 [308119901] 2405.41 percent of total billed charges 2405.41 3685.72 Technical (Hospital) Services FERRIC CARBOXYMALTOSE 50 MG IRON/ML INTRAVENOUS SOLUTION RX-122648 CDM J1439 HCPCS 636 RC 00517-0650-01 NDC inpatient 15 ML 3879.7 3879.7 MEDICA (COMMERCIAL) 94265 [3081118] MEDICA CLAIMS [308111801] 3491.73 percent of total billed charges 2405.41 3685.72 Technical (Hospital) Services FERRIC CARBOXYMALTOSE 50 MG IRON/ML INTRAVENOUS SOLUTION RX-122648 CDM J1439 HCPCS 636 RC 00517-0650-01 NDC inpatient 15 ML 3879.7 3879.7 MULTIPLAN INC 34080 [3081285] MULTIPLAN INC [308128501] 3685.72 percent of total billed charges 2405.41 3685.72 Technical (Hospital) Services FERRIC CARBOXYMALTOSE 50 MG IRON/ML INTRAVENOUS SOLUTION RX-122648 CDM J1439 HCPCS 636 RC 00517-0650-01 NDC outpatient 15 ML 3879.7 3879.7 UNITED HEALTHCARE (COMMERCIAL) [3081199] UNITED HEALTHCARE 87726 [308119901] 2405.41 percent of total billed charges 2405.41 3685.72 Technical (Hospital) Services FERRIC CARBOXYMALTOSE 50 MG IRON/ML INTRAVENOUS SOLUTION RX-122648 CDM J1439 HCPCS 636 RC 00517-0650-01 NDC outpatient 15 ML 3879.7 3879.7 HEALTHPARTNERS SX009 HEALTHPARTNERS 3103.76 percent of total billed charges 2405.41 3685.72 Technical (Hospital) Services FERRIC CARBOXYMALTOSE 50 MG IRON/ML INTRAVENOUS SOLUTION RX-122648 CDM J1439 HCPCS 636 RC 00517-0650-01 NDC outpatient 15 ML 3879.7 3879.7 BLUE CROSS BLUE SHIELD WELLMARK SB889 [3081026] BCBS WYOMING [308102603] 3685.72 percent of total billed charges 2405.41 3685.72 Technical (Hospital) Services FERRIC CARBOXYMALTOSE 50 MG IRON/ML INTRAVENOUS SOLUTION RX-122648 CDM J1439 HCPCS 636 RC 00517-0650-01 NDC outpatient 15 ML 3879.7 3879.7 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES EPO [308136803] 3103.76 percent of total billed charges 2405.41 3685.72 Technical (Hospital) Services FERRIC CARBOXYMALTOSE 50 MG IRON/ML INTRAVENOUS SOLUTION RX-122648 CDM J1439 HCPCS 636 RC 00517-0650-01 NDC outpatient 15 ML 3879.7 3879.7 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES HDHP [308136802] 3103.76 percent of total billed charges 2405.41 3685.72 Technical (Hospital) Services FERRIC CARBOXYMALTOSE 50 MG IRON/ML INTRAVENOUS SOLUTION RX-122648 CDM J1439 HCPCS 636 RC 00517-0650-01 NDC outpatient 15 ML 3879.7 3879.7 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES PPO [308136801] 3103.76 percent of total billed charges 2405.41 3685.72 Technical (Hospital) Services FERRIC CARBOXYMALTOSE 50 MG IRON/ML INTRAVENOUS SOLUTION RX-122648 CDM J1439 HCPCS 636 RC 00517-0650-01 NDC outpatient 15 ML 3879.7 3879.7 MULTIPLAN INC 34080 [3081285] MULTIPLAN INC [308128501] 3685.72 percent of total billed charges 2405.41 3685.72 Technical (Hospital) Services FERRIC CARBOXYMALTOSE 50 MG IRON/ML INTRAVENOUS SOLUTION RX-122648 CDM J1439 HCPCS 636 RC 00517-0650-01 NDC outpatient 15 ML 3879.7 3879.7 MEDICA (COMMERCIAL) 94265 [3081118] MEDICA CLAIMS [308111801] 3491.73 percent of total billed charges 2405.41 3685.72 Technical (Hospital) Services FERRIC CARBOXYMALTOSE 50 MG IRON/ML INTRAVENOUS SOLUTION RX-122648 CDM J1439 HCPCS 636 RC 00517-0650-01 NDC outpatient 15 ML 3879.7 3879.7 CIGNA 62308 [3081051] CIGNA 62308 [308105105] 3103.76 percent of total billed charges 2405.41 3685.72 Technical (Hospital) Services FERRIC CARBOXYMALTOSE 50 MG IRON/ML INTRAVENOUS SOLUTION RX-122648 CDM J1439 HCPCS 636 RC 00517-0650-01 NDC outpatient 15 ML 3879.7 3879.7 CIGNA 62308 [3081051] CIGNA STATE OF WYOMING [308105107] 3103.76 percent of total billed charges 2405.41 3685.72 Technical (Hospital) Services ERTAPENEM 1 GRAM SOLUTION FOR INJECTION RX-31922 CDM J1335 HCPCS 636 RC 42023-0221-10 NDC inpatient 10 ML 379.07 379.07 HEALTHPARTNERS SX009 HEALTHPARTNERS 300.15 percent of total billed charges 235.02 360.12 Technical (Hospital) Services ERTAPENEM 1 GRAM SOLUTION FOR INJECTION RX-31922 CDM J1335 HCPCS 636 RC 42023-0221-10 NDC inpatient 10 ML 379.07 379.07 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES HDHP [308136802] 300.15 percent of total billed charges 235.02 360.12 Technical (Hospital) Services ERTAPENEM 1 GRAM SOLUTION FOR INJECTION RX-31922 CDM J1335 HCPCS 636 RC 42023-0221-10 NDC inpatient 10 ML 379.07 379.07 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES EPO [308136803] 300.15 percent of total billed charges 235.02 360.12 Technical (Hospital) Services ERTAPENEM 1 GRAM SOLUTION FOR INJECTION RX-31922 CDM J1335 HCPCS 636 RC 42023-0221-10 NDC inpatient 10 ML 379.07 379.07 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES PPO [308136801] 300.15 percent of total billed charges 235.02 360.12 Technical (Hospital) Services ERTAPENEM 1 GRAM SOLUTION FOR INJECTION RX-31922 CDM J1335 HCPCS 636 RC 42023-0221-10 NDC inpatient 10 ML 379.07 379.07 CIGNA 62308 [3081051] CIGNA 62308 [308105105] 300.15 percent of total billed charges 235.02 360.12 Technical (Hospital) Services ERTAPENEM 1 GRAM SOLUTION FOR INJECTION RX-31922 CDM J1335 HCPCS 636 RC 42023-0221-10 NDC inpatient 10 ML 379.07 379.07 CIGNA 62308 [3081051] CIGNA STATE OF WYOMING [308105107] 300.15 percent of total billed charges 235.02 360.12 Technical (Hospital) Services ERTAPENEM 1 GRAM SOLUTION FOR INJECTION RX-31922 CDM J1335 HCPCS 636 RC 42023-0221-10 NDC inpatient 10 ML 379.07 379.07 UNITED HEALTHCARE (COMMERCIAL) [3081199] UNITED HEALTHCARE 87726 [308119901] 235.02 percent of total billed charges 235.02 360.12 Technical (Hospital) Services ERTAPENEM 1 GRAM SOLUTION FOR INJECTION RX-31922 CDM J1335 HCPCS 636 RC 42023-0221-10 NDC inpatient 10 ML 379.07 379.07 BLUE CROSS BLUE SHIELD WELLMARK SB889 [3081026] BCBS WYOMING [308102603] 360.12 percent of total billed charges 235.02 360.12 Technical (Hospital) Services ERTAPENEM 1 GRAM SOLUTION FOR INJECTION RX-31922 CDM J1335 HCPCS 636 RC 42023-0221-10 NDC inpatient 10 ML 379.07 379.07 MULTIPLAN INC 34080 [3081285] MULTIPLAN INC [308128501] 360.12 percent of total billed charges 235.02 360.12 Technical (Hospital) Services ERTAPENEM 1 GRAM SOLUTION FOR INJECTION RX-31922 CDM J1335 HCPCS 636 RC 42023-0221-10 NDC inpatient 10 ML 379.07 379.07 MEDICA (COMMERCIAL) 94265 [3081118] MEDICA CLAIMS [308111801] 341.16 percent of total billed charges 235.02 360.12 Technical (Hospital) Services ERTAPENEM 1 GRAM SOLUTION FOR INJECTION RX-31922 CDM J1335 HCPCS 636 RC 42023-0221-10 NDC outpatient 10 ML 379.07 379.07 CIGNA 62308 [3081051] CIGNA STATE OF WYOMING [308105107] 303.26 percent of total billed charges 235.02 360.12 Technical (Hospital) Services ERTAPENEM 1 GRAM SOLUTION FOR INJECTION RX-31922 CDM J1335 HCPCS 636 RC 42023-0221-10 NDC outpatient 10 ML 379.07 379.07 CIGNA 62308 [3081051] CIGNA 62308 [308105105] 303.26 percent of total billed charges 235.02 360.12 Technical (Hospital) Services ERTAPENEM 1 GRAM SOLUTION FOR INJECTION RX-31922 CDM J1335 HCPCS 636 RC 42023-0221-10 NDC outpatient 10 ML 379.07 379.07 UNITED HEALTHCARE (COMMERCIAL) [3081199] UNITED HEALTHCARE 87726 [308119901] 235.02 percent of total billed charges 235.02 360.12 Technical (Hospital) Services ERTAPENEM 1 GRAM SOLUTION FOR INJECTION RX-31922 CDM J1335 HCPCS 636 RC 42023-0221-10 NDC outpatient 10 ML 379.07 379.07 HEALTHPARTNERS SX009 HEALTHPARTNERS 303.26 percent of total billed charges 235.02 360.12 Technical (Hospital) Services ERTAPENEM 1 GRAM SOLUTION FOR INJECTION RX-31922 CDM J1335 HCPCS 636 RC 42023-0221-10 NDC outpatient 10 ML 379.07 379.07 MULTIPLAN INC 34080 [3081285] MULTIPLAN INC [308128501] 360.12 percent of total billed charges 235.02 360.12 Technical (Hospital) Services ERTAPENEM 1 GRAM SOLUTION FOR INJECTION RX-31922 CDM J1335 HCPCS 636 RC 42023-0221-10 NDC outpatient 10 ML 379.07 379.07 MEDICA (COMMERCIAL) 94265 [3081118] MEDICA CLAIMS [308111801] 341.16 percent of total billed charges 235.02 360.12 Technical (Hospital) Services ERTAPENEM 1 GRAM SOLUTION FOR INJECTION RX-31922 CDM J1335 HCPCS 636 RC 42023-0221-10 NDC outpatient 10 ML 379.07 379.07 BLUE CROSS BLUE SHIELD WELLMARK SB889 [3081026] BCBS WYOMING [308102603] 360.12 percent of total billed charges 235.02 360.12 Technical (Hospital) Services ERTAPENEM 1 GRAM SOLUTION FOR INJECTION RX-31922 CDM J1335 HCPCS 636 RC 42023-0221-10 NDC outpatient 10 ML 379.07 379.07 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES EPO [308136803] 303.26 percent of total billed charges 235.02 360.12 Technical (Hospital) Services ERTAPENEM 1 GRAM SOLUTION FOR INJECTION RX-31922 CDM J1335 HCPCS 636 RC 42023-0221-10 NDC outpatient 10 ML 379.07 379.07 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES PPO [308136801] 303.26 percent of total billed charges 235.02 360.12 Technical (Hospital) Services ERTAPENEM 1 GRAM SOLUTION FOR INJECTION RX-31922 CDM J1335 HCPCS 636 RC 42023-0221-10 NDC outpatient 10 ML 379.07 379.07 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES HDHP [308136802] 303.26 percent of total billed charges 235.02 360.12 Technical (Hospital) Services EPTIFIBATIDE 0.75 MG/ML INTRAVENOUS SOLUTION RX-23123 CDM J1327 HCPCS 636 RC 70436-0163-80 NDC outpatient 100 ML 682 682 BLUE CROSS BLUE SHIELD WELLMARK SB889 [3081026] BCBS WYOMING [308102603] 647.9 percent of total billed charges 422.84 647.9 Technical (Hospital) Services EPTIFIBATIDE 0.75 MG/ML INTRAVENOUS SOLUTION RX-23123 CDM J1327 HCPCS 636 RC 70436-0163-80 NDC outpatient 100 ML 682 682 HEALTHPARTNERS SX009 HEALTHPARTNERS 545.6 percent of total billed charges 422.84 647.9 Technical (Hospital) Services EPTIFIBATIDE 0.75 MG/ML INTRAVENOUS SOLUTION RX-23123 CDM J1327 HCPCS 636 RC 70436-0163-80 NDC outpatient 100 ML 682 682 UNITED HEALTHCARE (COMMERCIAL) [3081199] UNITED HEALTHCARE 87726 [308119901] 422.84 percent of total billed charges 422.84 647.9 Technical (Hospital) Services EPTIFIBATIDE 0.75 MG/ML INTRAVENOUS SOLUTION RX-23123 CDM J1327 HCPCS 636 RC 70436-0163-80 NDC outpatient 100 ML 682 682 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES PPO [308136801] 545.6 percent of total billed charges 422.84 647.9 Technical (Hospital) Services EPTIFIBATIDE 0.75 MG/ML INTRAVENOUS SOLUTION RX-23123 CDM J1327 HCPCS 636 RC 70436-0163-80 NDC outpatient 100 ML 682 682 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES EPO [308136803] 545.6 percent of total billed charges 422.84 647.9 Technical (Hospital) Services EPTIFIBATIDE 0.75 MG/ML INTRAVENOUS SOLUTION RX-23123 CDM J1327 HCPCS 636 RC 70436-0163-80 NDC outpatient 100 ML 682 682 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES HDHP [308136802] 545.6 percent of total billed charges 422.84 647.9 Technical (Hospital) Services EPTIFIBATIDE 0.75 MG/ML INTRAVENOUS SOLUTION RX-23123 CDM J1327 HCPCS 636 RC 70436-0163-80 NDC outpatient 100 ML 682 682 CIGNA 62308 [3081051] CIGNA 62308 [308105105] 545.6 percent of total billed charges 422.84 647.9 Technical (Hospital) Services EPTIFIBATIDE 0.75 MG/ML INTRAVENOUS SOLUTION RX-23123 CDM J1327 HCPCS 636 RC 70436-0163-80 NDC outpatient 100 ML 682 682 CIGNA 62308 [3081051] CIGNA STATE OF WYOMING [308105107] 545.6 percent of total billed charges 422.84 647.9 Technical (Hospital) Services EPTIFIBATIDE 0.75 MG/ML INTRAVENOUS SOLUTION RX-23123 CDM J1327 HCPCS 636 RC 70436-0163-80 NDC outpatient 100 ML 682 682 MULTIPLAN INC 34080 [3081285] MULTIPLAN INC [308128501] 647.9 percent of total billed charges 422.84 647.9 Technical (Hospital) Services EPTIFIBATIDE 0.75 MG/ML INTRAVENOUS SOLUTION RX-23123 CDM J1327 HCPCS 636 RC 70436-0163-80 NDC outpatient 100 ML 682 682 MEDICA (COMMERCIAL) 94265 [3081118] MEDICA CLAIMS [308111801] 613.8 percent of total billed charges 422.84 647.9 Technical (Hospital) Services EPTIFIBATIDE 0.75 MG/ML INTRAVENOUS SOLUTION RX-23123 CDM J1327 HCPCS 636 RC 70436-0163-80 NDC inpatient 100 ML 682 682 BLUE CROSS BLUE SHIELD WELLMARK SB889 [3081026] BCBS WYOMING [308102603] 647.9 percent of total billed charges 422.84 647.9 Technical (Hospital) Services EPTIFIBATIDE 0.75 MG/ML INTRAVENOUS SOLUTION RX-23123 CDM J1327 HCPCS 636 RC 70436-0163-80 NDC inpatient 100 ML 682 682 UNITED HEALTHCARE (COMMERCIAL) [3081199] UNITED HEALTHCARE 87726 [308119901] 422.84 percent of total billed charges 422.84 647.9 Technical (Hospital) Services EPTIFIBATIDE 0.75 MG/ML INTRAVENOUS SOLUTION RX-23123 CDM J1327 HCPCS 636 RC 70436-0163-80 NDC inpatient 100 ML 682 682 MULTIPLAN INC 34080 [3081285] MULTIPLAN INC [308128501] 647.9 percent of total billed charges 422.84 647.9 Technical (Hospital) Services EPTIFIBATIDE 0.75 MG/ML INTRAVENOUS SOLUTION RX-23123 CDM J1327 HCPCS 636 RC 70436-0163-80 NDC inpatient 100 ML 682 682 MEDICA (COMMERCIAL) 94265 [3081118] MEDICA CLAIMS [308111801] 613.8 percent of total billed charges 422.84 647.9 Technical (Hospital) Services EPTIFIBATIDE 0.75 MG/ML INTRAVENOUS SOLUTION RX-23123 CDM J1327 HCPCS 636 RC 70436-0163-80 NDC inpatient 100 ML 682 682 HEALTHPARTNERS SX009 HEALTHPARTNERS 540.01 percent of total billed charges 422.84 647.9 Technical (Hospital) Services EPTIFIBATIDE 0.75 MG/ML INTRAVENOUS SOLUTION RX-23123 CDM J1327 HCPCS 636 RC 70436-0163-80 NDC inpatient 100 ML 682 682 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES PPO [308136801] 540.01 percent of total billed charges 422.84 647.9 Technical (Hospital) Services EPTIFIBATIDE 0.75 MG/ML INTRAVENOUS SOLUTION RX-23123 CDM J1327 HCPCS 636 RC 70436-0163-80 NDC inpatient 100 ML 682 682 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES HDHP [308136802] 540.01 percent of total billed charges 422.84 647.9 Technical (Hospital) Services EPTIFIBATIDE 0.75 MG/ML INTRAVENOUS SOLUTION RX-23123 CDM J1327 HCPCS 636 RC 70436-0163-80 NDC inpatient 100 ML 682 682 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES EPO [308136803] 540.01 percent of total billed charges 422.84 647.9 Technical (Hospital) Services EPTIFIBATIDE 0.75 MG/ML INTRAVENOUS SOLUTION RX-23123 CDM J1327 HCPCS 636 RC 70436-0163-80 NDC inpatient 100 ML 682 682 CIGNA 62308 [3081051] CIGNA 62308 [308105105] 540.01 percent of total billed charges 422.84 647.9 Technical (Hospital) Services EPTIFIBATIDE 0.75 MG/ML INTRAVENOUS SOLUTION RX-23123 CDM J1327 HCPCS 636 RC 70436-0163-80 NDC inpatient 100 ML 682 682 CIGNA 62308 [3081051] CIGNA STATE OF WYOMING [308105107] 540.01 percent of total billed charges 422.84 647.9 Technical (Hospital) Services "DOPAMINE 800 MG/250 ML (3,200 MCG/ML) IN 5 % DEXTROSE INTRAVENOUS SOLN" RX-14846 CDM J1265 HCPCS 636 RC 00338-1009-02 NDC inpatient 250 ML 108.25 108.25 CIGNA 62308 [3081051] CIGNA 62308 [308105105] 85.71 percent of total billed charges 67.12 102.84 Technical (Hospital) Services "DOPAMINE 800 MG/250 ML (3,200 MCG/ML) IN 5 % DEXTROSE INTRAVENOUS SOLN" RX-14846 CDM J1265 HCPCS 636 RC 00338-1009-02 NDC inpatient 250 ML 108.25 108.25 CIGNA 62308 [3081051] CIGNA STATE OF WYOMING [308105107] 85.71 percent of total billed charges 67.12 102.84 Technical (Hospital) Services "DOPAMINE 800 MG/250 ML (3,200 MCG/ML) IN 5 % DEXTROSE INTRAVENOUS SOLN" RX-14846 CDM J1265 HCPCS 636 RC 00338-1009-02 NDC inpatient 250 ML 108.25 108.25 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES EPO [308136803] 85.71 percent of total billed charges 67.12 102.84 Technical (Hospital) Services "DOPAMINE 800 MG/250 ML (3,200 MCG/ML) IN 5 % DEXTROSE INTRAVENOUS SOLN" RX-14846 CDM J1265 HCPCS 636 RC 00338-1009-02 NDC inpatient 250 ML 108.25 108.25 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES HDHP [308136802] 85.71 percent of total billed charges 67.12 102.84 Technical (Hospital) Services "DOPAMINE 800 MG/250 ML (3,200 MCG/ML) IN 5 % DEXTROSE INTRAVENOUS SOLN" RX-14846 CDM J1265 HCPCS 636 RC 00338-1009-02 NDC inpatient 250 ML 108.25 108.25 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES PPO [308136801] 85.71 percent of total billed charges 67.12 102.84 Technical (Hospital) Services "DOPAMINE 800 MG/250 ML (3,200 MCG/ML) IN 5 % DEXTROSE INTRAVENOUS SOLN" RX-14846 CDM J1265 HCPCS 636 RC 00338-1009-02 NDC inpatient 250 ML 108.25 108.25 HEALTHPARTNERS SX009 HEALTHPARTNERS 85.71 percent of total billed charges 67.12 102.84 Technical (Hospital) Services "DOPAMINE 800 MG/250 ML (3,200 MCG/ML) IN 5 % DEXTROSE INTRAVENOUS SOLN" RX-14846 CDM J1265 HCPCS 636 RC 00338-1009-02 NDC inpatient 250 ML 108.25 108.25 MEDICA (COMMERCIAL) 94265 [3081118] MEDICA CLAIMS [308111801] 97.43 percent of total billed charges 67.12 102.84 Technical (Hospital) Services "DOPAMINE 800 MG/250 ML (3,200 MCG/ML) IN 5 % DEXTROSE INTRAVENOUS SOLN" RX-14846 CDM J1265 HCPCS 636 RC 00338-1009-02 NDC inpatient 250 ML 108.25 108.25 MULTIPLAN INC 34080 [3081285] MULTIPLAN INC [308128501] 102.84 percent of total billed charges 67.12 102.84 Technical (Hospital) Services "DOPAMINE 800 MG/250 ML (3,200 MCG/ML) IN 5 % DEXTROSE INTRAVENOUS SOLN" RX-14846 CDM J1265 HCPCS 636 RC 00338-1009-02 NDC inpatient 250 ML 108.25 108.25 UNITED HEALTHCARE (COMMERCIAL) [3081199] UNITED HEALTHCARE 87726 [308119901] 67.12 percent of total billed charges 67.12 102.84 Technical (Hospital) Services "DOPAMINE 800 MG/250 ML (3,200 MCG/ML) IN 5 % DEXTROSE INTRAVENOUS SOLN" RX-14846 CDM J1265 HCPCS 636 RC 00338-1009-02 NDC inpatient 250 ML 108.25 108.25 BLUE CROSS BLUE SHIELD WELLMARK SB889 [3081026] BCBS WYOMING [308102603] 102.84 percent of total billed charges 67.12 102.84 Technical (Hospital) Services "DOPAMINE 800 MG/250 ML (3,200 MCG/ML) IN 5 % DEXTROSE INTRAVENOUS SOLN" RX-14846 CDM J1265 HCPCS 636 RC 00338-1009-02 NDC outpatient 250 ML 108.25 108.25 HEALTHPARTNERS SX009 HEALTHPARTNERS 86.6 percent of total billed charges 67.12 102.84 Technical (Hospital) Services "DOPAMINE 800 MG/250 ML (3,200 MCG/ML) IN 5 % DEXTROSE INTRAVENOUS SOLN" RX-14846 CDM J1265 HCPCS 636 RC 00338-1009-02 NDC outpatient 250 ML 108.25 108.25 UNITED HEALTHCARE (COMMERCIAL) [3081199] UNITED HEALTHCARE 87726 [308119901] 67.12 percent of total billed charges 67.12 102.84 Technical (Hospital) Services "DOPAMINE 800 MG/250 ML (3,200 MCG/ML) IN 5 % DEXTROSE INTRAVENOUS SOLN" RX-14846 CDM J1265 HCPCS 636 RC 00338-1009-02 NDC outpatient 250 ML 108.25 108.25 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES EPO [308136803] 86.6 percent of total billed charges 67.12 102.84 Technical (Hospital) Services "DOPAMINE 800 MG/250 ML (3,200 MCG/ML) IN 5 % DEXTROSE INTRAVENOUS SOLN" RX-14846 CDM J1265 HCPCS 636 RC 00338-1009-02 NDC outpatient 250 ML 108.25 108.25 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES HDHP [308136802] 86.6 percent of total billed charges 67.12 102.84 Technical (Hospital) Services "DOPAMINE 800 MG/250 ML (3,200 MCG/ML) IN 5 % DEXTROSE INTRAVENOUS SOLN" RX-14846 CDM J1265 HCPCS 636 RC 00338-1009-02 NDC outpatient 250 ML 108.25 108.25 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES PPO [308136801] 86.6 percent of total billed charges 67.12 102.84 Technical (Hospital) Services "DOPAMINE 800 MG/250 ML (3,200 MCG/ML) IN 5 % DEXTROSE INTRAVENOUS SOLN" RX-14846 CDM J1265 HCPCS 636 RC 00338-1009-02 NDC outpatient 250 ML 108.25 108.25 BLUE CROSS BLUE SHIELD WELLMARK SB889 [3081026] BCBS WYOMING [308102603] 102.84 percent of total billed charges 67.12 102.84 Technical (Hospital) Services "DOPAMINE 800 MG/250 ML (3,200 MCG/ML) IN 5 % DEXTROSE INTRAVENOUS SOLN" RX-14846 CDM J1265 HCPCS 636 RC 00338-1009-02 NDC outpatient 250 ML 108.25 108.25 CIGNA 62308 [3081051] CIGNA 62308 [308105105] 86.6 percent of total billed charges 67.12 102.84 Technical (Hospital) Services "DOPAMINE 800 MG/250 ML (3,200 MCG/ML) IN 5 % DEXTROSE INTRAVENOUS SOLN" RX-14846 CDM J1265 HCPCS 636 RC 00338-1009-02 NDC outpatient 250 ML 108.25 108.25 CIGNA 62308 [3081051] CIGNA STATE OF WYOMING [308105107] 86.6 percent of total billed charges 67.12 102.84 Technical (Hospital) Services "DOPAMINE 800 MG/250 ML (3,200 MCG/ML) IN 5 % DEXTROSE INTRAVENOUS SOLN" RX-14846 CDM J1265 HCPCS 636 RC 00338-1009-02 NDC outpatient 250 ML 108.25 108.25 MEDICA (COMMERCIAL) 94265 [3081118] MEDICA CLAIMS [308111801] 97.43 percent of total billed charges 67.12 102.84 Technical (Hospital) Services "DOPAMINE 800 MG/250 ML (3,200 MCG/ML) IN 5 % DEXTROSE INTRAVENOUS SOLN" RX-14846 CDM J1265 HCPCS 636 RC 00338-1009-02 NDC outpatient 250 ML 108.25 108.25 MULTIPLAN INC 34080 [3081285] MULTIPLAN INC [308128501] 102.84 percent of total billed charges 67.12 102.84 Technical (Hospital) Services "DOBUTAMINE 500 MG/250 ML (2,000 MCG/ML) IN 5 % DEXTROSE IV" RX-18315 CDM J1250 HCPCS 636 RC 00409-2347-32 NDC inpatient 250 ML 85.5 85.5 BLUE CROSS BLUE SHIELD WELLMARK SB889 [3081026] BCBS WYOMING [308102603] 81.23 percent of total billed charges 53.01 81.23 Technical (Hospital) Services "DOBUTAMINE 500 MG/250 ML (2,000 MCG/ML) IN 5 % DEXTROSE IV" RX-18315 CDM J1250 HCPCS 636 RC 00409-2347-32 NDC inpatient 250 ML 85.5 85.5 UNITED HEALTHCARE (COMMERCIAL) [3081199] UNITED HEALTHCARE 87726 [308119901] 53.01 percent of total billed charges 53.01 81.23 Technical (Hospital) Services "DOBUTAMINE 500 MG/250 ML (2,000 MCG/ML) IN 5 % DEXTROSE IV" RX-18315 CDM J1250 HCPCS 636 RC 00409-2347-32 NDC inpatient 250 ML 85.5 85.5 MEDICA (COMMERCIAL) 94265 [3081118] MEDICA CLAIMS [308111801] 76.95 percent of total billed charges 53.01 81.23 Technical (Hospital) Services "DOBUTAMINE 500 MG/250 ML (2,000 MCG/ML) IN 5 % DEXTROSE IV" RX-18315 CDM J1250 HCPCS 636 RC 00409-2347-32 NDC inpatient 250 ML 85.5 85.5 HEALTHPARTNERS SX009 HEALTHPARTNERS 67.7 percent of total billed charges 53.01 81.23 Technical (Hospital) Services "DOBUTAMINE 500 MG/250 ML (2,000 MCG/ML) IN 5 % DEXTROSE IV" RX-18315 CDM J1250 HCPCS 636 RC 00409-2347-32 NDC inpatient 250 ML 85.5 85.5 MULTIPLAN INC 34080 [3081285] MULTIPLAN INC [308128501] 81.23 percent of total billed charges 53.01 81.23 Technical (Hospital) Services "DOBUTAMINE 500 MG/250 ML (2,000 MCG/ML) IN 5 % DEXTROSE IV" RX-18315 CDM J1250 HCPCS 636 RC 00409-2347-32 NDC inpatient 250 ML 85.5 85.5 CIGNA 62308 [3081051] CIGNA 62308 [308105105] 67.7 percent of total billed charges 53.01 81.23 Technical (Hospital) Services "DOBUTAMINE 500 MG/250 ML (2,000 MCG/ML) IN 5 % DEXTROSE IV" RX-18315 CDM J1250 HCPCS 636 RC 00409-2347-32 NDC inpatient 250 ML 85.5 85.5 CIGNA 62308 [3081051] CIGNA STATE OF WYOMING [308105107] 67.7 percent of total billed charges 53.01 81.23 Technical (Hospital) Services "DOBUTAMINE 500 MG/250 ML (2,000 MCG/ML) IN 5 % DEXTROSE IV" RX-18315 CDM J1250 HCPCS 636 RC 00409-2347-32 NDC inpatient 250 ML 85.5 85.5 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES HDHP [308136802] 67.7 percent of total billed charges 53.01 81.23 Technical (Hospital) Services "DOBUTAMINE 500 MG/250 ML (2,000 MCG/ML) IN 5 % DEXTROSE IV" RX-18315 CDM J1250 HCPCS 636 RC 00409-2347-32 NDC inpatient 250 ML 85.5 85.5 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES PPO [308136801] 67.7 percent of total billed charges 53.01 81.23 Technical (Hospital) Services "DOBUTAMINE 500 MG/250 ML (2,000 MCG/ML) IN 5 % DEXTROSE IV" RX-18315 CDM J1250 HCPCS 636 RC 00409-2347-32 NDC inpatient 250 ML 85.5 85.5 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES EPO [308136803] 67.7 percent of total billed charges 53.01 81.23 Technical (Hospital) Services "DOBUTAMINE 500 MG/250 ML (2,000 MCG/ML) IN 5 % DEXTROSE IV" RX-18315 CDM J1250 HCPCS 636 RC 00409-2347-32 NDC outpatient 250 ML 85.5 85.5 BLUE CROSS BLUE SHIELD WELLMARK SB889 [3081026] BCBS WYOMING [308102603] 81.23 percent of total billed charges 53.01 81.23 Technical (Hospital) Services "DOBUTAMINE 500 MG/250 ML (2,000 MCG/ML) IN 5 % DEXTROSE IV" RX-18315 CDM J1250 HCPCS 636 RC 00409-2347-32 NDC outpatient 250 ML 85.5 85.5 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES PPO [308136801] 68.4 percent of total billed charges 53.01 81.23 Technical (Hospital) Services "DOBUTAMINE 500 MG/250 ML (2,000 MCG/ML) IN 5 % DEXTROSE IV" RX-18315 CDM J1250 HCPCS 636 RC 00409-2347-32 NDC outpatient 250 ML 85.5 85.5 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES HDHP [308136802] 68.4 percent of total billed charges 53.01 81.23 Technical (Hospital) Services "DOBUTAMINE 500 MG/250 ML (2,000 MCG/ML) IN 5 % DEXTROSE IV" RX-18315 CDM J1250 HCPCS 636 RC 00409-2347-32 NDC outpatient 250 ML 85.5 85.5 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES EPO [308136803] 68.4 percent of total billed charges 53.01 81.23 Technical (Hospital) Services "DOBUTAMINE 500 MG/250 ML (2,000 MCG/ML) IN 5 % DEXTROSE IV" RX-18315 CDM J1250 HCPCS 636 RC 00409-2347-32 NDC outpatient 250 ML 85.5 85.5 HEALTHPARTNERS SX009 HEALTHPARTNERS 68.4 percent of total billed charges 53.01 81.23 Technical (Hospital) Services "DOBUTAMINE 500 MG/250 ML (2,000 MCG/ML) IN 5 % DEXTROSE IV" RX-18315 CDM J1250 HCPCS 636 RC 00409-2347-32 NDC outpatient 250 ML 85.5 85.5 UNITED HEALTHCARE (COMMERCIAL) [3081199] UNITED HEALTHCARE 87726 [308119901] 53.01 percent of total billed charges 53.01 81.23 Technical (Hospital) Services "DOBUTAMINE 500 MG/250 ML (2,000 MCG/ML) IN 5 % DEXTROSE IV" RX-18315 CDM J1250 HCPCS 636 RC 00409-2347-32 NDC outpatient 250 ML 85.5 85.5 CIGNA 62308 [3081051] CIGNA 62308 [308105105] 68.4 percent of total billed charges 53.01 81.23 Technical (Hospital) Services "DOBUTAMINE 500 MG/250 ML (2,000 MCG/ML) IN 5 % DEXTROSE IV" RX-18315 CDM J1250 HCPCS 636 RC 00409-2347-32 NDC outpatient 250 ML 85.5 85.5 CIGNA 62308 [3081051] CIGNA STATE OF WYOMING [308105107] 68.4 percent of total billed charges 53.01 81.23 Technical (Hospital) Services "DOBUTAMINE 500 MG/250 ML (2,000 MCG/ML) IN 5 % DEXTROSE IV" RX-18315 CDM J1250 HCPCS 636 RC 00409-2347-32 NDC outpatient 250 ML 85.5 85.5 MULTIPLAN INC 34080 [3081285] MULTIPLAN INC [308128501] 81.23 percent of total billed charges 53.01 81.23 Technical (Hospital) Services "DOBUTAMINE 500 MG/250 ML (2,000 MCG/ML) IN 5 % DEXTROSE IV" RX-18315 CDM J1250 HCPCS 636 RC 00409-2347-32 NDC outpatient 250 ML 85.5 85.5 MEDICA (COMMERCIAL) 94265 [3081118] MEDICA CLAIMS [308111801] 76.95 percent of total billed charges 53.01 81.23 Technical (Hospital) Services DIMETHYL SULFOXIDE 50 % INTRAVESICAL SOLUTION RX-128753 CDM J1212 HCPCS 636 RC 67457-0177-50 NDC inpatient 50 ML 1595 1595 UNITED HEALTHCARE (COMMERCIAL) [3081199] UNITED HEALTHCARE 87726 [308119901] 988.9 percent of total billed charges 988.9 1515.25 Technical (Hospital) Services DIMETHYL SULFOXIDE 50 % INTRAVESICAL SOLUTION RX-128753 CDM J1212 HCPCS 636 RC 67457-0177-50 NDC inpatient 50 ML 1595 1595 BLUE CROSS BLUE SHIELD WELLMARK SB889 [3081026] BCBS WYOMING [308102603] 1515.25 percent of total billed charges 988.9 1515.25 Technical (Hospital) Services DIMETHYL SULFOXIDE 50 % INTRAVESICAL SOLUTION RX-128753 CDM J1212 HCPCS 636 RC 67457-0177-50 NDC inpatient 50 ML 1595 1595 MULTIPLAN INC 34080 [3081285] MULTIPLAN INC [308128501] 1515.25 percent of total billed charges 988.9 1515.25 Technical (Hospital) Services DIMETHYL SULFOXIDE 50 % INTRAVESICAL SOLUTION RX-128753 CDM J1212 HCPCS 636 RC 67457-0177-50 NDC inpatient 50 ML 1595 1595 MEDICA (COMMERCIAL) 94265 [3081118] MEDICA CLAIMS [308111801] 1435.5 percent of total billed charges 988.9 1515.25 Technical (Hospital) Services DIMETHYL SULFOXIDE 50 % INTRAVESICAL SOLUTION RX-128753 CDM J1212 HCPCS 636 RC 67457-0177-50 NDC inpatient 50 ML 1595 1595 HEALTHPARTNERS SX009 HEALTHPARTNERS 1262.92 percent of total billed charges 988.9 1515.25 Technical (Hospital) Services DIMETHYL SULFOXIDE 50 % INTRAVESICAL SOLUTION RX-128753 CDM J1212 HCPCS 636 RC 67457-0177-50 NDC inpatient 50 ML 1595 1595 CIGNA 62308 [3081051] CIGNA 62308 [308105105] 1262.92 percent of total billed charges 988.9 1515.25 Technical (Hospital) Services DIMETHYL SULFOXIDE 50 % INTRAVESICAL SOLUTION RX-128753 CDM J1212 HCPCS 636 RC 67457-0177-50 NDC inpatient 50 ML 1595 1595 CIGNA 62308 [3081051] CIGNA STATE OF WYOMING [308105107] 1262.92 percent of total billed charges 988.9 1515.25 Technical (Hospital) Services DIMETHYL SULFOXIDE 50 % INTRAVESICAL SOLUTION RX-128753 CDM J1212 HCPCS 636 RC 67457-0177-50 NDC inpatient 50 ML 1595 1595 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES HDHP [308136802] 1262.92 percent of total billed charges 988.9 1515.25 Technical (Hospital) Services DIMETHYL SULFOXIDE 50 % INTRAVESICAL SOLUTION RX-128753 CDM J1212 HCPCS 636 RC 67457-0177-50 NDC inpatient 50 ML 1595 1595 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES PPO [308136801] 1262.92 percent of total billed charges 988.9 1515.25 Technical (Hospital) Services DIMETHYL SULFOXIDE 50 % INTRAVESICAL SOLUTION RX-128753 CDM J1212 HCPCS 636 RC 67457-0177-50 NDC inpatient 50 ML 1595 1595 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES EPO [308136803] 1262.92 percent of total billed charges 988.9 1515.25 Technical (Hospital) Services DIMETHYL SULFOXIDE 50 % INTRAVESICAL SOLUTION RX-128753 CDM J1212 HCPCS 636 RC 67457-0177-50 NDC outpatient 50 ML 1595 1595 MULTIPLAN INC 34080 [3081285] MULTIPLAN INC [308128501] 1515.25 percent of total billed charges 988.9 1515.25 Technical (Hospital) Services DIMETHYL SULFOXIDE 50 % INTRAVESICAL SOLUTION RX-128753 CDM J1212 HCPCS 636 RC 67457-0177-50 NDC outpatient 50 ML 1595 1595 MEDICA (COMMERCIAL) 94265 [3081118] MEDICA CLAIMS [308111801] 1435.5 percent of total billed charges 988.9 1515.25 Technical (Hospital) Services DIMETHYL SULFOXIDE 50 % INTRAVESICAL SOLUTION RX-128753 CDM J1212 HCPCS 636 RC 67457-0177-50 NDC outpatient 50 ML 1595 1595 UNITED HEALTHCARE (COMMERCIAL) [3081199] UNITED HEALTHCARE 87726 [308119901] 988.9 percent of total billed charges 988.9 1515.25 Technical (Hospital) Services DIMETHYL SULFOXIDE 50 % INTRAVESICAL SOLUTION RX-128753 CDM J1212 HCPCS 636 RC 67457-0177-50 NDC outpatient 50 ML 1595 1595 HEALTHPARTNERS SX009 HEALTHPARTNERS 1276 percent of total billed charges 988.9 1515.25 Technical (Hospital) Services DIMETHYL SULFOXIDE 50 % INTRAVESICAL SOLUTION RX-128753 CDM J1212 HCPCS 636 RC 67457-0177-50 NDC outpatient 50 ML 1595 1595 BLUE CROSS BLUE SHIELD WELLMARK SB889 [3081026] BCBS WYOMING [308102603] 1515.25 percent of total billed charges 988.9 1515.25 Technical (Hospital) Services DIMETHYL SULFOXIDE 50 % INTRAVESICAL SOLUTION RX-128753 CDM J1212 HCPCS 636 RC 67457-0177-50 NDC outpatient 50 ML 1595 1595 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES EPO [308136803] 1276 percent of total billed charges 988.9 1515.25 Technical (Hospital) Services DIMETHYL SULFOXIDE 50 % INTRAVESICAL SOLUTION RX-128753 CDM J1212 HCPCS 636 RC 67457-0177-50 NDC outpatient 50 ML 1595 1595 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES PPO [308136801] 1276 percent of total billed charges 988.9 1515.25 Technical (Hospital) Services DIMETHYL SULFOXIDE 50 % INTRAVESICAL SOLUTION RX-128753 CDM J1212 HCPCS 636 RC 67457-0177-50 NDC outpatient 50 ML 1595 1595 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES HDHP [308136802] 1276 percent of total billed charges 988.9 1515.25 Technical (Hospital) Services DIMETHYL SULFOXIDE 50 % INTRAVESICAL SOLUTION RX-128753 CDM J1212 HCPCS 636 RC 67457-0177-50 NDC outpatient 50 ML 1595 1595 CIGNA 62308 [3081051] CIGNA 62308 [308105105] 1276 percent of total billed charges 988.9 1515.25 Technical (Hospital) Services DIMETHYL SULFOXIDE 50 % INTRAVESICAL SOLUTION RX-128753 CDM J1212 HCPCS 636 RC 67457-0177-50 NDC outpatient 50 ML 1595 1595 CIGNA 62308 [3081051] CIGNA STATE OF WYOMING [308105107] 1276 percent of total billed charges 988.9 1515.25 Technical (Hospital) Services DIPHENHYDRAMINE 50 MG/ML INJECTION SOLUTION RX-2508 CDM J1200 HCPCS 636 RC 63323-0664-01 NDC outpatient 1 ML 61.31 61.31 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES HDHP [308136802] 49.05 percent of total billed charges 38.01 58.24 Technical (Hospital) Services DIPHENHYDRAMINE 50 MG/ML INJECTION SOLUTION RX-2508 CDM J1200 HCPCS 636 RC 63323-0664-01 NDC outpatient 1 ML 61.31 61.31 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES EPO [308136803] 49.05 percent of total billed charges 38.01 58.24 Technical (Hospital) Services DIPHENHYDRAMINE 50 MG/ML INJECTION SOLUTION RX-2508 CDM J1200 HCPCS 636 RC 63323-0664-01 NDC outpatient 1 ML 61.31 61.31 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES PPO [308136801] 49.05 percent of total billed charges 38.01 58.24 Technical (Hospital) Services DIPHENHYDRAMINE 50 MG/ML INJECTION SOLUTION RX-2508 CDM J1200 HCPCS 636 RC 63323-0664-01 NDC outpatient 1 ML 61.31 61.31 BLUE CROSS BLUE SHIELD WELLMARK SB889 [3081026] BCBS WYOMING [308102603] 58.24 percent of total billed charges 38.01 58.24 Technical (Hospital) Services DIPHENHYDRAMINE 50 MG/ML INJECTION SOLUTION RX-2508 CDM J1200 HCPCS 636 RC 63323-0664-01 NDC outpatient 1 ML 61.31 61.31 CIGNA 62308 [3081051] CIGNA 62308 [308105105] 49.05 percent of total billed charges 38.01 58.24 Technical (Hospital) Services DIPHENHYDRAMINE 50 MG/ML INJECTION SOLUTION RX-2508 CDM J1200 HCPCS 636 RC 63323-0664-01 NDC outpatient 1 ML 61.31 61.31 CIGNA 62308 [3081051] CIGNA STATE OF WYOMING [308105107] 49.05 percent of total billed charges 38.01 58.24 Technical (Hospital) Services DIPHENHYDRAMINE 50 MG/ML INJECTION SOLUTION RX-2508 CDM J1200 HCPCS 636 RC 63323-0664-01 NDC outpatient 1 ML 61.31 61.31 MEDICA (COMMERCIAL) 94265 [3081118] MEDICA CLAIMS [308111801] 55.18 percent of total billed charges 38.01 58.24 Technical (Hospital) Services DIPHENHYDRAMINE 50 MG/ML INJECTION SOLUTION RX-2508 CDM J1200 HCPCS 636 RC 63323-0664-01 NDC outpatient 1 ML 61.31 61.31 HEALTHPARTNERS SX009 HEALTHPARTNERS 49.05 percent of total billed charges 38.01 58.24 Technical (Hospital) Services DIPHENHYDRAMINE 50 MG/ML INJECTION SOLUTION RX-2508 CDM J1200 HCPCS 636 RC 63323-0664-01 NDC outpatient 1 ML 61.31 61.31 MULTIPLAN INC 34080 [3081285] MULTIPLAN INC [308128501] 58.24 percent of total billed charges 38.01 58.24 Technical (Hospital) Services DIPHENHYDRAMINE 50 MG/ML INJECTION SOLUTION RX-2508 CDM J1200 HCPCS 636 RC 63323-0664-01 NDC outpatient 1 ML 61.31 61.31 UNITED HEALTHCARE (COMMERCIAL) [3081199] UNITED HEALTHCARE 87726 [308119901] 38.01 percent of total billed charges 38.01 58.24 Technical (Hospital) Services DIPHENHYDRAMINE 50 MG/ML INJECTION SOLUTION RX-2508 CDM J1200 HCPCS 636 RC 63323-0664-01 NDC inpatient 1 ML 61.31 61.31 BLUE CROSS BLUE SHIELD WELLMARK SB889 [3081026] BCBS WYOMING [308102603] 58.24 percent of total billed charges 38.01 58.24 Technical (Hospital) Services DIPHENHYDRAMINE 50 MG/ML INJECTION SOLUTION RX-2508 CDM J1200 HCPCS 636 RC 63323-0664-01 NDC inpatient 1 ML 61.31 61.31 UNITED HEALTHCARE (COMMERCIAL) [3081199] UNITED HEALTHCARE 87726 [308119901] 38.01 percent of total billed charges 38.01 58.24 Technical (Hospital) Services DIPHENHYDRAMINE 50 MG/ML INJECTION SOLUTION RX-2508 CDM J1200 HCPCS 636 RC 63323-0664-01 NDC inpatient 1 ML 61.31 61.31 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES EPO [308136803] 48.55 percent of total billed charges 38.01 58.24 Technical (Hospital) Services DIPHENHYDRAMINE 50 MG/ML INJECTION SOLUTION RX-2508 CDM J1200 HCPCS 636 RC 63323-0664-01 NDC inpatient 1 ML 61.31 61.31 CIGNA 62308 [3081051] CIGNA 62308 [308105105] 48.55 percent of total billed charges 38.01 58.24 Technical (Hospital) Services DIPHENHYDRAMINE 50 MG/ML INJECTION SOLUTION RX-2508 CDM J1200 HCPCS 636 RC 63323-0664-01 NDC inpatient 1 ML 61.31 61.31 CIGNA 62308 [3081051] CIGNA STATE OF WYOMING [308105107] 48.55 percent of total billed charges 38.01 58.24 Technical (Hospital) Services DIPHENHYDRAMINE 50 MG/ML INJECTION SOLUTION RX-2508 CDM J1200 HCPCS 636 RC 63323-0664-01 NDC inpatient 1 ML 61.31 61.31 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES HDHP [308136802] 48.55 percent of total billed charges 38.01 58.24 Technical (Hospital) Services DIPHENHYDRAMINE 50 MG/ML INJECTION SOLUTION RX-2508 CDM J1200 HCPCS 636 RC 63323-0664-01 NDC inpatient 1 ML 61.31 61.31 MULTIPLAN INC 34080 [3081285] MULTIPLAN INC [308128501] 58.24 percent of total billed charges 38.01 58.24 Technical (Hospital) Services DIPHENHYDRAMINE 50 MG/ML INJECTION SOLUTION RX-2508 CDM J1200 HCPCS 636 RC 63323-0664-01 NDC inpatient 1 ML 61.31 61.31 HEALTHPARTNERS SX009 HEALTHPARTNERS 48.55 percent of total billed charges 38.01 58.24 Technical (Hospital) Services DIPHENHYDRAMINE 50 MG/ML INJECTION SOLUTION RX-2508 CDM J1200 HCPCS 636 RC 63323-0664-01 NDC inpatient 1 ML 61.31 61.31 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES PPO [308136801] 48.55 percent of total billed charges 38.01 58.24 Technical (Hospital) Services DIPHENHYDRAMINE 50 MG/ML INJECTION SOLUTION RX-2508 CDM J1200 HCPCS 636 RC 63323-0664-01 NDC inpatient 1 ML 61.31 61.31 MEDICA (COMMERCIAL) 94265 [3081118] MEDICA CLAIMS [308111801] 55.18 percent of total billed charges 38.01 58.24 Technical (Hospital) Services HYDROMORPHONE 2 MG/ML INJECTION SYRINGE RX-122895 CDM J1170 HCPCS 636 RC 00409-1312-36 NDC outpatient 2 ME 71.07 71.07 HEALTHPARTNERS SX009 HEALTHPARTNERS 56.86 percent of total billed charges 44.06 67.52 Technical (Hospital) Services HYDROMORPHONE 2 MG/ML INJECTION SYRINGE RX-122895 CDM J1170 HCPCS 636 RC 00409-1312-36 NDC outpatient 2 ME 71.07 71.07 UNITED HEALTHCARE (COMMERCIAL) [3081199] UNITED HEALTHCARE 87726 [308119901] 44.06 percent of total billed charges 44.06 67.52 Technical (Hospital) Services HYDROMORPHONE 2 MG/ML INJECTION SYRINGE RX-122895 CDM J1170 HCPCS 636 RC 00409-1312-36 NDC outpatient 2 ME 71.07 71.07 MULTIPLAN INC 34080 [3081285] MULTIPLAN INC [308128501] 67.52 percent of total billed charges 44.06 67.52 Technical (Hospital) Services HYDROMORPHONE 2 MG/ML INJECTION SYRINGE RX-122895 CDM J1170 HCPCS 636 RC 00409-1312-36 NDC outpatient 2 ME 71.07 71.07 CIGNA 62308 [3081051] CIGNA 62308 [308105105] 56.86 percent of total billed charges 44.06 67.52 Technical (Hospital) Services HYDROMORPHONE 2 MG/ML INJECTION SYRINGE RX-122895 CDM J1170 HCPCS 636 RC 00409-1312-36 NDC outpatient 2 ME 71.07 71.07 CIGNA 62308 [3081051] CIGNA STATE OF WYOMING [308105107] 56.86 percent of total billed charges 44.06 67.52 Technical (Hospital) Services HYDROMORPHONE 2 MG/ML INJECTION SYRINGE RX-122895 CDM J1170 HCPCS 636 RC 00409-1312-36 NDC outpatient 2 ME 71.07 71.07 MEDICA (COMMERCIAL) 94265 [3081118] MEDICA CLAIMS [308111801] 63.96 percent of total billed charges 44.06 67.52 Technical (Hospital) Services HYDROMORPHONE 2 MG/ML INJECTION SYRINGE RX-122895 CDM J1170 HCPCS 636 RC 00409-1312-36 NDC outpatient 2 ME 71.07 71.07 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES PPO [308136801] 56.86 percent of total billed charges 44.06 67.52 Technical (Hospital) Services HYDROMORPHONE 2 MG/ML INJECTION SYRINGE RX-122895 CDM J1170 HCPCS 636 RC 00409-1312-36 NDC outpatient 2 ME 71.07 71.07 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES HDHP [308136802] 56.86 percent of total billed charges 44.06 67.52 Technical (Hospital) Services HYDROMORPHONE 2 MG/ML INJECTION SYRINGE RX-122895 CDM J1170 HCPCS 636 RC 00409-1312-36 NDC outpatient 2 ME 71.07 71.07 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES EPO [308136803] 56.86 percent of total billed charges 44.06 67.52 Technical (Hospital) Services HYDROMORPHONE 2 MG/ML INJECTION SYRINGE RX-122895 CDM J1170 HCPCS 636 RC 00409-1312-36 NDC outpatient 2 ME 71.07 71.07 BLUE CROSS BLUE SHIELD WELLMARK SB889 [3081026] BCBS WYOMING [308102603] 67.52 percent of total billed charges 44.06 67.52 Technical (Hospital) Services HYDROMORPHONE 2 MG/ML INJECTION SYRINGE RX-122895 CDM J1170 HCPCS 636 RC 00409-1312-36 NDC inpatient 2 ME 71.07 71.07 UNITED HEALTHCARE (COMMERCIAL) [3081199] UNITED HEALTHCARE 87726 [308119901] 44.06 percent of total billed charges 44.06 67.52 Technical (Hospital) Services HYDROMORPHONE 2 MG/ML INJECTION SYRINGE RX-122895 CDM J1170 HCPCS 636 RC 00409-1312-36 NDC inpatient 2 ME 71.07 71.07 BLUE CROSS BLUE SHIELD WELLMARK SB889 [3081026] BCBS WYOMING [308102603] 67.52 percent of total billed charges 44.06 67.52 Technical (Hospital) Services HYDROMORPHONE 2 MG/ML INJECTION SYRINGE RX-122895 CDM J1170 HCPCS 636 RC 00409-1312-36 NDC inpatient 2 ME 71.07 71.07 CIGNA 62308 [3081051] CIGNA 62308 [308105105] 56.27 percent of total billed charges 44.06 67.52 Technical (Hospital) Services HYDROMORPHONE 2 MG/ML INJECTION SYRINGE RX-122895 CDM J1170 HCPCS 636 RC 00409-1312-36 NDC inpatient 2 ME 71.07 71.07 CIGNA 62308 [3081051] CIGNA STATE OF WYOMING [308105107] 56.27 percent of total billed charges 44.06 67.52 Technical (Hospital) Services HYDROMORPHONE 2 MG/ML INJECTION SYRINGE RX-122895 CDM J1170 HCPCS 636 RC 00409-1312-36 NDC inpatient 2 ME 71.07 71.07 MULTIPLAN INC 34080 [3081285] MULTIPLAN INC [308128501] 67.52 percent of total billed charges 44.06 67.52 Technical (Hospital) Services HYDROMORPHONE 2 MG/ML INJECTION SYRINGE RX-122895 CDM J1170 HCPCS 636 RC 00409-1312-36 NDC inpatient 2 ME 71.07 71.07 MEDICA (COMMERCIAL) 94265 [3081118] MEDICA CLAIMS [308111801] 63.96 percent of total billed charges 44.06 67.52 Technical (Hospital) Services HYDROMORPHONE 2 MG/ML INJECTION SYRINGE RX-122895 CDM J1170 HCPCS 636 RC 00409-1312-36 NDC inpatient 2 ME 71.07 71.07 HEALTHPARTNERS SX009 HEALTHPARTNERS 56.27 percent of total billed charges 44.06 67.52 Technical (Hospital) Services HYDROMORPHONE 2 MG/ML INJECTION SYRINGE RX-122895 CDM J1170 HCPCS 636 RC 00409-1312-36 NDC inpatient 2 ME 71.07 71.07 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES HDHP [308136802] 56.27 percent of total billed charges 44.06 67.52 Technical (Hospital) Services HYDROMORPHONE 2 MG/ML INJECTION SYRINGE RX-122895 CDM J1170 HCPCS 636 RC 00409-1312-36 NDC inpatient 2 ME 71.07 71.07 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES EPO [308136803] 56.27 percent of total billed charges 44.06 67.52 Technical (Hospital) Services HYDROMORPHONE 2 MG/ML INJECTION SYRINGE RX-122895 CDM J1170 HCPCS 636 RC 00409-1312-36 NDC inpatient 2 ME 71.07 71.07 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES PPO [308136801] 56.27 percent of total billed charges 44.06 67.52 Technical (Hospital) Services HYDROMORPHONE 2 MG/ML INJECTION SOLUTION RX-3758 CDM J1170 HCPCS 636 RC 00409-3365-11 NDC inpatient 1 ML 59.87 59.87 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES HDHP [308136802] 47.41 percent of total billed charges 37.12 56.88 Technical (Hospital) Services HYDROMORPHONE 2 MG/ML INJECTION SOLUTION RX-3758 CDM J1170 HCPCS 636 RC 00409-3365-11 NDC inpatient 1 ML 59.87 59.87 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES PPO [308136801] 47.41 percent of total billed charges 37.12 56.88 Technical (Hospital) Services HYDROMORPHONE 2 MG/ML INJECTION SOLUTION RX-3758 CDM J1170 HCPCS 636 RC 00409-3365-11 NDC inpatient 1 ML 59.87 59.87 HEALTHPARTNERS SX009 HEALTHPARTNERS 47.41 percent of total billed charges 37.12 56.88 Technical (Hospital) Services HYDROMORPHONE 2 MG/ML INJECTION SOLUTION RX-3758 CDM J1170 HCPCS 636 RC 00409-3365-11 NDC inpatient 1 ML 59.87 59.87 MEDICA (COMMERCIAL) 94265 [3081118] MEDICA CLAIMS [308111801] 53.88 percent of total billed charges 37.12 56.88 Technical (Hospital) Services HYDROMORPHONE 2 MG/ML INJECTION SOLUTION RX-3758 CDM J1170 HCPCS 636 RC 00409-3365-11 NDC inpatient 1 ML 59.87 59.87 MULTIPLAN INC 34080 [3081285] MULTIPLAN INC [308128501] 56.88 percent of total billed charges 37.12 56.88 Technical (Hospital) Services HYDROMORPHONE 2 MG/ML INJECTION SOLUTION RX-3758 CDM J1170 HCPCS 636 RC 00409-3365-11 NDC inpatient 1 ML 59.87 59.87 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES EPO [308136803] 47.41 percent of total billed charges 37.12 56.88 Technical (Hospital) Services HYDROMORPHONE 2 MG/ML INJECTION SOLUTION RX-3758 CDM J1170 HCPCS 636 RC 00409-3365-11 NDC inpatient 1 ML 59.87 59.87 CIGNA 62308 [3081051] CIGNA 62308 [308105105] 47.41 percent of total billed charges 37.12 56.88 Technical (Hospital) Services HYDROMORPHONE 2 MG/ML INJECTION SOLUTION RX-3758 CDM J1170 HCPCS 636 RC 00409-3365-11 NDC inpatient 1 ML 59.87 59.87 CIGNA 62308 [3081051] CIGNA STATE OF WYOMING [308105107] 47.41 percent of total billed charges 37.12 56.88 Technical (Hospital) Services HYDROMORPHONE 2 MG/ML INJECTION SOLUTION RX-3758 CDM J1170 HCPCS 636 RC 00409-3365-11 NDC inpatient 1 ML 59.87 59.87 UNITED HEALTHCARE (COMMERCIAL) [3081199] UNITED HEALTHCARE 87726 [308119901] 37.12 percent of total billed charges 37.12 56.88 Technical (Hospital) Services HYDROMORPHONE 2 MG/ML INJECTION SOLUTION RX-3758 CDM J1170 HCPCS 636 RC 00409-3365-11 NDC inpatient 1 ML 59.87 59.87 BLUE CROSS BLUE SHIELD WELLMARK SB889 [3081026] BCBS WYOMING [308102603] 56.88 percent of total billed charges 37.12 56.88 Technical (Hospital) Services HYDROMORPHONE 2 MG/ML INJECTION SOLUTION RX-3758 CDM J1170 HCPCS 636 RC 00409-3365-11 NDC outpatient 1 ML 59.87 59.87 HEALTHPARTNERS SX009 HEALTHPARTNERS 47.9 percent of total billed charges 37.12 56.88 Technical (Hospital) Services HYDROMORPHONE 2 MG/ML INJECTION SOLUTION RX-3758 CDM J1170 HCPCS 636 RC 00409-3365-11 NDC outpatient 1 ML 59.87 59.87 UNITED HEALTHCARE (COMMERCIAL) [3081199] UNITED HEALTHCARE 87726 [308119901] 37.12 percent of total billed charges 37.12 56.88 Technical (Hospital) Services HYDROMORPHONE 2 MG/ML INJECTION SOLUTION RX-3758 CDM J1170 HCPCS 636 RC 00409-3365-11 NDC outpatient 1 ML 59.87 59.87 MULTIPLAN INC 34080 [3081285] MULTIPLAN INC [308128501] 56.88 percent of total billed charges 37.12 56.88 Technical (Hospital) Services HYDROMORPHONE 2 MG/ML INJECTION SOLUTION RX-3758 CDM J1170 HCPCS 636 RC 00409-3365-11 NDC outpatient 1 ML 59.87 59.87 CIGNA 62308 [3081051] CIGNA 62308 [308105105] 47.9 percent of total billed charges 37.12 56.88 Technical (Hospital) Services HYDROMORPHONE 2 MG/ML INJECTION SOLUTION RX-3758 CDM J1170 HCPCS 636 RC 00409-3365-11 NDC outpatient 1 ML 59.87 59.87 CIGNA 62308 [3081051] CIGNA STATE OF WYOMING [308105107] 47.9 percent of total billed charges 37.12 56.88 Technical (Hospital) Services HYDROMORPHONE 2 MG/ML INJECTION SOLUTION RX-3758 CDM J1170 HCPCS 636 RC 00409-3365-11 NDC outpatient 1 ML 59.87 59.87 BLUE CROSS BLUE SHIELD WELLMARK SB889 [3081026] BCBS WYOMING [308102603] 56.88 percent of total billed charges 37.12 56.88 Technical (Hospital) Services HYDROMORPHONE 2 MG/ML INJECTION SOLUTION RX-3758 CDM J1170 HCPCS 636 RC 00409-3365-11 NDC outpatient 1 ML 59.87 59.87 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES PPO [308136801] 47.9 percent of total billed charges 37.12 56.88 Technical (Hospital) Services HYDROMORPHONE 2 MG/ML INJECTION SOLUTION RX-3758 CDM J1170 HCPCS 636 RC 00409-3365-11 NDC outpatient 1 ML 59.87 59.87 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES HDHP [308136802] 47.9 percent of total billed charges 37.12 56.88 Technical (Hospital) Services HYDROMORPHONE 2 MG/ML INJECTION SOLUTION RX-3758 CDM J1170 HCPCS 636 RC 00409-3365-11 NDC outpatient 1 ML 59.87 59.87 MEDICA (COMMERCIAL) 94265 [3081118] MEDICA CLAIMS [308111801] 53.88 percent of total billed charges 37.12 56.88 Technical (Hospital) Services HYDROMORPHONE 2 MG/ML INJECTION SOLUTION RX-3758 CDM J1170 HCPCS 636 RC 00409-3365-11 NDC outpatient 1 ML 59.87 59.87 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES EPO [308136803] 47.9 percent of total billed charges 37.12 56.88 Technical (Hospital) Services PHENYTOIN SODIUM 50 MG/ML INTRAVENOUS SOLUTION RX-6256 CDM J1165 HCPCS 636 RC 00641-2555-45 NDC inpatient 5 ML 60.3 60.3 MULTIPLAN INC 34080 [3081285] MULTIPLAN INC [308128501] 57.29 percent of total billed charges 37.39 57.29 Technical (Hospital) Services PHENYTOIN SODIUM 50 MG/ML INTRAVENOUS SOLUTION RX-6256 CDM J1165 HCPCS 636 RC 00641-2555-45 NDC inpatient 5 ML 60.3 60.3 MEDICA (COMMERCIAL) 94265 [3081118] MEDICA CLAIMS [308111801] 54.27 percent of total billed charges 37.39 57.29 Technical (Hospital) Services PHENYTOIN SODIUM 50 MG/ML INTRAVENOUS SOLUTION RX-6256 CDM J1165 HCPCS 636 RC 00641-2555-45 NDC inpatient 5 ML 60.3 60.3 BLUE CROSS BLUE SHIELD WELLMARK SB889 [3081026] BCBS WYOMING [308102603] 57.29 percent of total billed charges 37.39 57.29 Technical (Hospital) Services PHENYTOIN SODIUM 50 MG/ML INTRAVENOUS SOLUTION RX-6256 CDM J1165 HCPCS 636 RC 00641-2555-45 NDC inpatient 5 ML 60.3 60.3 UNITED HEALTHCARE (COMMERCIAL) [3081199] UNITED HEALTHCARE 87726 [308119901] 37.39 percent of total billed charges 37.39 57.29 Technical (Hospital) Services PHENYTOIN SODIUM 50 MG/ML INTRAVENOUS SOLUTION RX-6256 CDM J1165 HCPCS 636 RC 00641-2555-45 NDC inpatient 5 ML 60.3 60.3 CIGNA 62308 [3081051] CIGNA 62308 [308105105] 47.75 percent of total billed charges 37.39 57.29 Technical (Hospital) Services PHENYTOIN SODIUM 50 MG/ML INTRAVENOUS SOLUTION RX-6256 CDM J1165 HCPCS 636 RC 00641-2555-45 NDC inpatient 5 ML 60.3 60.3 CIGNA 62308 [3081051] CIGNA STATE OF WYOMING [308105107] 47.75 percent of total billed charges 37.39 57.29 Technical (Hospital) Services PHENYTOIN SODIUM 50 MG/ML INTRAVENOUS SOLUTION RX-6256 CDM J1165 HCPCS 636 RC 00641-2555-45 NDC inpatient 5 ML 60.3 60.3 HEALTHPARTNERS SX009 HEALTHPARTNERS 47.75 percent of total billed charges 37.39 57.29 Technical (Hospital) Services PHENYTOIN SODIUM 50 MG/ML INTRAVENOUS SOLUTION RX-6256 CDM J1165 HCPCS 636 RC 00641-2555-45 NDC inpatient 5 ML 60.3 60.3 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES EPO [308136803] 47.75 percent of total billed charges 37.39 57.29 Technical (Hospital) Services PHENYTOIN SODIUM 50 MG/ML INTRAVENOUS SOLUTION RX-6256 CDM J1165 HCPCS 636 RC 00641-2555-45 NDC inpatient 5 ML 60.3 60.3 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES HDHP [308136802] 47.75 percent of total billed charges 37.39 57.29 Technical (Hospital) Services PHENYTOIN SODIUM 50 MG/ML INTRAVENOUS SOLUTION RX-6256 CDM J1165 HCPCS 636 RC 00641-2555-45 NDC inpatient 5 ML 60.3 60.3 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES PPO [308136801] 47.75 percent of total billed charges 37.39 57.29 Technical (Hospital) Services PHENYTOIN SODIUM 50 MG/ML INTRAVENOUS SOLUTION RX-6256 CDM J1165 HCPCS 636 RC 00641-2555-45 NDC outpatient 5 ML 60.3 60.3 MEDICA (COMMERCIAL) 94265 [3081118] MEDICA CLAIMS [308111801] 54.27 percent of total billed charges 37.39 57.29 Technical (Hospital) Services PHENYTOIN SODIUM 50 MG/ML INTRAVENOUS SOLUTION RX-6256 CDM J1165 HCPCS 636 RC 00641-2555-45 NDC outpatient 5 ML 60.3 60.3 MULTIPLAN INC 34080 [3081285] MULTIPLAN INC [308128501] 57.29 percent of total billed charges 37.39 57.29 Technical (Hospital) Services PHENYTOIN SODIUM 50 MG/ML INTRAVENOUS SOLUTION RX-6256 CDM J1165 HCPCS 636 RC 00641-2555-45 NDC outpatient 5 ML 60.3 60.3 CIGNA 62308 [3081051] CIGNA 62308 [308105105] 48.24 percent of total billed charges 37.39 57.29 Technical (Hospital) Services PHENYTOIN SODIUM 50 MG/ML INTRAVENOUS SOLUTION RX-6256 CDM J1165 HCPCS 636 RC 00641-2555-45 NDC outpatient 5 ML 60.3 60.3 CIGNA 62308 [3081051] CIGNA STATE OF WYOMING [308105107] 48.24 percent of total billed charges 37.39 57.29 Technical (Hospital) Services PHENYTOIN SODIUM 50 MG/ML INTRAVENOUS SOLUTION RX-6256 CDM J1165 HCPCS 636 RC 00641-2555-45 NDC outpatient 5 ML 60.3 60.3 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES HDHP [308136802] 48.24 percent of total billed charges 37.39 57.29 Technical (Hospital) Services PHENYTOIN SODIUM 50 MG/ML INTRAVENOUS SOLUTION RX-6256 CDM J1165 HCPCS 636 RC 00641-2555-45 NDC outpatient 5 ML 60.3 60.3 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES EPO [308136803] 48.24 percent of total billed charges 37.39 57.29 Technical (Hospital) Services PHENYTOIN SODIUM 50 MG/ML INTRAVENOUS SOLUTION RX-6256 CDM J1165 HCPCS 636 RC 00641-2555-45 NDC outpatient 5 ML 60.3 60.3 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES PPO [308136801] 48.24 percent of total billed charges 37.39 57.29 Technical (Hospital) Services PHENYTOIN SODIUM 50 MG/ML INTRAVENOUS SOLUTION RX-6256 CDM J1165 HCPCS 636 RC 00641-2555-45 NDC outpatient 5 ML 60.3 60.3 UNITED HEALTHCARE (COMMERCIAL) [3081199] UNITED HEALTHCARE 87726 [308119901] 37.39 percent of total billed charges 37.39 57.29 Technical (Hospital) Services PHENYTOIN SODIUM 50 MG/ML INTRAVENOUS SOLUTION RX-6256 CDM J1165 HCPCS 636 RC 00641-2555-45 NDC outpatient 5 ML 60.3 60.3 BLUE CROSS BLUE SHIELD WELLMARK SB889 [3081026] BCBS WYOMING [308102603] 57.29 percent of total billed charges 37.39 57.29 Technical (Hospital) Services PHENYTOIN SODIUM 50 MG/ML INTRAVENOUS SOLUTION RX-6256 CDM J1165 HCPCS 636 RC 00641-2555-45 NDC outpatient 5 ML 60.3 60.3 HEALTHPARTNERS SX009 HEALTHPARTNERS 48.24 percent of total billed charges 37.39 57.29 Technical (Hospital) Services DIGOXIN 250 MCG/ML (0.25 MG/ML) INJECTION SOLUTION RX-121798 CDM J1160 HCPCS 636 RC 00641-1410-35 NDC outpatient 2 ML 70 70 BLUE CROSS BLUE SHIELD WELLMARK SB889 [3081026] BCBS WYOMING [308102603] 66.5 percent of total billed charges 43.4 66.5 Technical (Hospital) Services DIGOXIN 250 MCG/ML (0.25 MG/ML) INJECTION SOLUTION RX-121798 CDM J1160 HCPCS 636 RC 00641-1410-35 NDC outpatient 2 ML 70 70 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES EPO [308136803] 56 percent of total billed charges 43.4 66.5 Technical (Hospital) Services DIGOXIN 250 MCG/ML (0.25 MG/ML) INJECTION SOLUTION RX-121798 CDM J1160 HCPCS 636 RC 00641-1410-35 NDC outpatient 2 ML 70 70 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES PPO [308136801] 56 percent of total billed charges 43.4 66.5 Technical (Hospital) Services DIGOXIN 250 MCG/ML (0.25 MG/ML) INJECTION SOLUTION RX-121798 CDM J1160 HCPCS 636 RC 00641-1410-35 NDC outpatient 2 ML 70 70 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES HDHP [308136802] 56 percent of total billed charges 43.4 66.5 Technical (Hospital) Services DIGOXIN 250 MCG/ML (0.25 MG/ML) INJECTION SOLUTION RX-121798 CDM J1160 HCPCS 636 RC 00641-1410-35 NDC outpatient 2 ML 70 70 MULTIPLAN INC 34080 [3081285] MULTIPLAN INC [308128501] 66.5 percent of total billed charges 43.4 66.5 Technical (Hospital) Services DIGOXIN 250 MCG/ML (0.25 MG/ML) INJECTION SOLUTION RX-121798 CDM J1160 HCPCS 636 RC 00641-1410-35 NDC outpatient 2 ML 70 70 CIGNA 62308 [3081051] CIGNA 62308 [308105105] 56 percent of total billed charges 43.4 66.5 Technical (Hospital) Services DIGOXIN 250 MCG/ML (0.25 MG/ML) INJECTION SOLUTION RX-121798 CDM J1160 HCPCS 636 RC 00641-1410-35 NDC outpatient 2 ML 70 70 CIGNA 62308 [3081051] CIGNA STATE OF WYOMING [308105107] 56 percent of total billed charges 43.4 66.5 Technical (Hospital) Services DIGOXIN 250 MCG/ML (0.25 MG/ML) INJECTION SOLUTION RX-121798 CDM J1160 HCPCS 636 RC 00641-1410-35 NDC outpatient 2 ML 70 70 MEDICA (COMMERCIAL) 94265 [3081118] MEDICA CLAIMS [308111801] 63 percent of total billed charges 43.4 66.5 Technical (Hospital) Services DIGOXIN 250 MCG/ML (0.25 MG/ML) INJECTION SOLUTION RX-121798 CDM J1160 HCPCS 636 RC 00641-1410-35 NDC outpatient 2 ML 70 70 UNITED HEALTHCARE (COMMERCIAL) [3081199] UNITED HEALTHCARE 87726 [308119901] 43.4 percent of total billed charges 43.4 66.5 Technical (Hospital) Services DIGOXIN 250 MCG/ML (0.25 MG/ML) INJECTION SOLUTION RX-121798 CDM J1160 HCPCS 636 RC 00641-1410-35 NDC outpatient 2 ML 70 70 HEALTHPARTNERS SX009 HEALTHPARTNERS 56 percent of total billed charges 43.4 66.5 Technical (Hospital) Services DIGOXIN 250 MCG/ML (0.25 MG/ML) INJECTION SOLUTION RX-121798 CDM J1160 HCPCS 636 RC 00641-1410-35 NDC inpatient 2 ML 70 70 UNITED HEALTHCARE (COMMERCIAL) [3081199] UNITED HEALTHCARE 87726 [308119901] 43.4 percent of total billed charges 43.4 66.5 Technical (Hospital) Services DIGOXIN 250 MCG/ML (0.25 MG/ML) INJECTION SOLUTION RX-121798 CDM J1160 HCPCS 636 RC 00641-1410-35 NDC inpatient 2 ML 70 70 BLUE CROSS BLUE SHIELD WELLMARK SB889 [3081026] BCBS WYOMING [308102603] 66.5 percent of total billed charges 43.4 66.5 Technical (Hospital) Services DIGOXIN 250 MCG/ML (0.25 MG/ML) INJECTION SOLUTION RX-121798 CDM J1160 HCPCS 636 RC 00641-1410-35 NDC inpatient 2 ML 70 70 CIGNA 62308 [3081051] CIGNA 62308 [308105105] 55.43 percent of total billed charges 43.4 66.5 Technical (Hospital) Services DIGOXIN 250 MCG/ML (0.25 MG/ML) INJECTION SOLUTION RX-121798 CDM J1160 HCPCS 636 RC 00641-1410-35 NDC inpatient 2 ML 70 70 CIGNA 62308 [3081051] CIGNA STATE OF WYOMING [308105107] 55.43 percent of total billed charges 43.4 66.5 Technical (Hospital) Services DIGOXIN 250 MCG/ML (0.25 MG/ML) INJECTION SOLUTION RX-121798 CDM J1160 HCPCS 636 RC 00641-1410-35 NDC inpatient 2 ML 70 70 MEDICA (COMMERCIAL) 94265 [3081118] MEDICA CLAIMS [308111801] 63 percent of total billed charges 43.4 66.5 Technical (Hospital) Services DIGOXIN 250 MCG/ML (0.25 MG/ML) INJECTION SOLUTION RX-121798 CDM J1160 HCPCS 636 RC 00641-1410-35 NDC inpatient 2 ML 70 70 MULTIPLAN INC 34080 [3081285] MULTIPLAN INC [308128501] 66.5 percent of total billed charges 43.4 66.5 Technical (Hospital) Services DIGOXIN 250 MCG/ML (0.25 MG/ML) INJECTION SOLUTION RX-121798 CDM J1160 HCPCS 636 RC 00641-1410-35 NDC inpatient 2 ML 70 70 HEALTHPARTNERS SX009 HEALTHPARTNERS 55.43 percent of total billed charges 43.4 66.5 Technical (Hospital) Services DIGOXIN 250 MCG/ML (0.25 MG/ML) INJECTION SOLUTION RX-121798 CDM J1160 HCPCS 636 RC 00641-1410-35 NDC inpatient 2 ML 70 70 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES PPO [308136801] 55.43 percent of total billed charges 43.4 66.5 Technical (Hospital) Services DIGOXIN 250 MCG/ML (0.25 MG/ML) INJECTION SOLUTION RX-121798 CDM J1160 HCPCS 636 RC 00641-1410-35 NDC inpatient 2 ML 70 70 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES HDHP [308136802] 55.43 percent of total billed charges 43.4 66.5 Technical (Hospital) Services DIGOXIN 250 MCG/ML (0.25 MG/ML) INJECTION SOLUTION RX-121798 CDM J1160 HCPCS 636 RC 00641-1410-35 NDC inpatient 2 ML 70 70 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES EPO [308136803] 55.43 percent of total billed charges 43.4 66.5 Technical (Hospital) Services DEXAMETHASONE SODIUM PHOSPHATE (PF) 10 MG/ML INJECTION SOLUTION RX-116345 CDM J1100 HCPCS 636 RC 63323-0506-01 NDC inpatient 1 ML 72 72 HEALTHPARTNERS SX009 HEALTHPARTNERS 57.01 percent of total billed charges 44.64 68.4 Technical (Hospital) Services DEXAMETHASONE SODIUM PHOSPHATE (PF) 10 MG/ML INJECTION SOLUTION RX-116345 CDM J1100 HCPCS 636 RC 63323-0506-01 NDC inpatient 1 ML 72 72 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES PPO [308136801] 57.01 percent of total billed charges 44.64 68.4 Technical (Hospital) Services DEXAMETHASONE SODIUM PHOSPHATE (PF) 10 MG/ML INJECTION SOLUTION RX-116345 CDM J1100 HCPCS 636 RC 63323-0506-01 NDC inpatient 1 ML 72 72 MEDICA (COMMERCIAL) 94265 [3081118] MEDICA CLAIMS [308111801] 64.8 percent of total billed charges 44.64 68.4 Technical (Hospital) Services DEXAMETHASONE SODIUM PHOSPHATE (PF) 10 MG/ML INJECTION SOLUTION RX-116345 CDM J1100 HCPCS 636 RC 63323-0506-01 NDC inpatient 1 ML 72 72 MULTIPLAN INC 34080 [3081285] MULTIPLAN INC [308128501] 68.4 percent of total billed charges 44.64 68.4 Technical (Hospital) Services DEXAMETHASONE SODIUM PHOSPHATE (PF) 10 MG/ML INJECTION SOLUTION RX-116345 CDM J1100 HCPCS 636 RC 63323-0506-01 NDC inpatient 1 ML 72 72 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES EPO [308136803] 57.01 percent of total billed charges 44.64 68.4 Technical (Hospital) Services DEXAMETHASONE SODIUM PHOSPHATE (PF) 10 MG/ML INJECTION SOLUTION RX-116345 CDM J1100 HCPCS 636 RC 63323-0506-01 NDC inpatient 1 ML 72 72 CIGNA 62308 [3081051] CIGNA 62308 [308105105] 57.01 percent of total billed charges 44.64 68.4 Technical (Hospital) Services DEXAMETHASONE SODIUM PHOSPHATE (PF) 10 MG/ML INJECTION SOLUTION RX-116345 CDM J1100 HCPCS 636 RC 63323-0506-01 NDC inpatient 1 ML 72 72 CIGNA 62308 [3081051] CIGNA STATE OF WYOMING [308105107] 57.01 percent of total billed charges 44.64 68.4 Technical (Hospital) Services DEXAMETHASONE SODIUM PHOSPHATE (PF) 10 MG/ML INJECTION SOLUTION RX-116345 CDM J1100 HCPCS 636 RC 63323-0506-01 NDC inpatient 1 ML 72 72 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES HDHP [308136802] 57.01 percent of total billed charges 44.64 68.4 Technical (Hospital) Services DEXAMETHASONE SODIUM PHOSPHATE (PF) 10 MG/ML INJECTION SOLUTION RX-116345 CDM J1100 HCPCS 636 RC 63323-0506-01 NDC inpatient 1 ML 72 72 UNITED HEALTHCARE (COMMERCIAL) [3081199] UNITED HEALTHCARE 87726 [308119901] 44.64 percent of total billed charges 44.64 68.4 Technical (Hospital) Services DEXAMETHASONE SODIUM PHOSPHATE (PF) 10 MG/ML INJECTION SOLUTION RX-116345 CDM J1100 HCPCS 636 RC 63323-0506-01 NDC inpatient 1 ML 72 72 BLUE CROSS BLUE SHIELD WELLMARK SB889 [3081026] BCBS WYOMING [308102603] 68.4 percent of total billed charges 44.64 68.4 Technical (Hospital) Services DEXAMETHASONE SODIUM PHOSPHATE (PF) 10 MG/ML INJECTION SOLUTION RX-116345 CDM J1100 HCPCS 636 RC 63323-0506-01 NDC outpatient 1 ML 72 72 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES HDHP [308136802] 57.6 percent of total billed charges 44.64 68.4 Technical (Hospital) Services DEXAMETHASONE SODIUM PHOSPHATE (PF) 10 MG/ML INJECTION SOLUTION RX-116345 CDM J1100 HCPCS 636 RC 63323-0506-01 NDC outpatient 1 ML 72 72 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES EPO [308136803] 57.6 percent of total billed charges 44.64 68.4 Technical (Hospital) Services DEXAMETHASONE SODIUM PHOSPHATE (PF) 10 MG/ML INJECTION SOLUTION RX-116345 CDM J1100 HCPCS 636 RC 63323-0506-01 NDC outpatient 1 ML 72 72 CIGNA 62308 [3081051] CIGNA 62308 [308105105] 57.6 percent of total billed charges 44.64 68.4 Technical (Hospital) Services DEXAMETHASONE SODIUM PHOSPHATE (PF) 10 MG/ML INJECTION SOLUTION RX-116345 CDM J1100 HCPCS 636 RC 63323-0506-01 NDC outpatient 1 ML 72 72 CIGNA 62308 [3081051] CIGNA STATE OF WYOMING [308105107] 57.6 percent of total billed charges 44.64 68.4 Technical (Hospital) Services DEXAMETHASONE SODIUM PHOSPHATE (PF) 10 MG/ML INJECTION SOLUTION RX-116345 CDM J1100 HCPCS 636 RC 63323-0506-01 NDC outpatient 1 ML 72 72 MEDICA (COMMERCIAL) 94265 [3081118] MEDICA CLAIMS [308111801] 64.8 percent of total billed charges 44.64 68.4 Technical (Hospital) Services DEXAMETHASONE SODIUM PHOSPHATE (PF) 10 MG/ML INJECTION SOLUTION RX-116345 CDM J1100 HCPCS 636 RC 63323-0506-01 NDC outpatient 1 ML 72 72 UNITED HEALTHCARE (COMMERCIAL) [3081199] UNITED HEALTHCARE 87726 [308119901] 44.64 percent of total billed charges 44.64 68.4 Technical (Hospital) Services DEXAMETHASONE SODIUM PHOSPHATE (PF) 10 MG/ML INJECTION SOLUTION RX-116345 CDM J1100 HCPCS 636 RC 63323-0506-01 NDC outpatient 1 ML 72 72 MULTIPLAN INC 34080 [3081285] MULTIPLAN INC [308128501] 68.4 percent of total billed charges 44.64 68.4 Technical (Hospital) Services DEXAMETHASONE SODIUM PHOSPHATE (PF) 10 MG/ML INJECTION SOLUTION RX-116345 CDM J1100 HCPCS 636 RC 63323-0506-01 NDC outpatient 1 ML 72 72 HEALTHPARTNERS SX009 HEALTHPARTNERS 57.6 percent of total billed charges 44.64 68.4 Technical (Hospital) Services DEXAMETHASONE SODIUM PHOSPHATE (PF) 10 MG/ML INJECTION SOLUTION RX-116345 CDM J1100 HCPCS 636 RC 63323-0506-01 NDC outpatient 1 ML 72 72 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES PPO [308136801] 57.6 percent of total billed charges 44.64 68.4 Technical (Hospital) Services DEXAMETHASONE SODIUM PHOSPHATE (PF) 10 MG/ML INJECTION SOLUTION RX-116345 CDM J1100 HCPCS 636 RC 63323-0506-01 NDC outpatient 1 ML 72 72 BLUE CROSS BLUE SHIELD WELLMARK SB889 [3081026] BCBS WYOMING [308102603] 68.4 percent of total billed charges 44.64 68.4 Technical (Hospital) Services DEXAMETHASONE SODIUM PHOSPHATE 10 MG/ML INJECTION SOLUTION RX-2331 CDM J1100 HCPCS 636 RC 00641-0367-21 NDC outpatient 1 ML 59.73 59.73 HEALTHPARTNERS SX009 HEALTHPARTNERS 47.78 percent of total billed charges 37.03 56.74 Technical (Hospital) Services DEXAMETHASONE SODIUM PHOSPHATE 10 MG/ML INJECTION SOLUTION RX-2331 CDM J1100 HCPCS 636 RC 00641-0367-21 NDC outpatient 1 ML 59.73 59.73 UNITED HEALTHCARE (COMMERCIAL) [3081199] UNITED HEALTHCARE 87726 [308119901] 37.03 percent of total billed charges 37.03 56.74 Technical (Hospital) Services DEXAMETHASONE SODIUM PHOSPHATE 10 MG/ML INJECTION SOLUTION RX-2331 CDM J1100 HCPCS 636 RC 00641-0367-21 NDC outpatient 1 ML 59.73 59.73 MULTIPLAN INC 34080 [3081285] MULTIPLAN INC [308128501] 56.74 percent of total billed charges 37.03 56.74 Technical (Hospital) Services DEXAMETHASONE SODIUM PHOSPHATE 10 MG/ML INJECTION SOLUTION RX-2331 CDM J1100 HCPCS 636 RC 00641-0367-21 NDC outpatient 1 ML 59.73 59.73 MEDICA (COMMERCIAL) 94265 [3081118] MEDICA CLAIMS [308111801] 53.76 percent of total billed charges 37.03 56.74 Technical (Hospital) Services DEXAMETHASONE SODIUM PHOSPHATE 10 MG/ML INJECTION SOLUTION RX-2331 CDM J1100 HCPCS 636 RC 00641-0367-21 NDC outpatient 1 ML 59.73 59.73 CIGNA 62308 [3081051] CIGNA 62308 [308105105] 47.78 percent of total billed charges 37.03 56.74 Technical (Hospital) Services DEXAMETHASONE SODIUM PHOSPHATE 10 MG/ML INJECTION SOLUTION RX-2331 CDM J1100 HCPCS 636 RC 00641-0367-21 NDC outpatient 1 ML 59.73 59.73 CIGNA 62308 [3081051] CIGNA STATE OF WYOMING [308105107] 47.78 percent of total billed charges 37.03 56.74 Technical (Hospital) Services DEXAMETHASONE SODIUM PHOSPHATE 10 MG/ML INJECTION SOLUTION RX-2331 CDM J1100 HCPCS 636 RC 00641-0367-21 NDC outpatient 1 ML 59.73 59.73 BLUE CROSS BLUE SHIELD WELLMARK SB889 [3081026] BCBS WYOMING [308102603] 56.74 percent of total billed charges 37.03 56.74 Technical (Hospital) Services DEXAMETHASONE SODIUM PHOSPHATE 10 MG/ML INJECTION SOLUTION RX-2331 CDM J1100 HCPCS 636 RC 00641-0367-21 NDC outpatient 1 ML 59.73 59.73 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES PPO [308136801] 47.78 percent of total billed charges 37.03 56.74 Technical (Hospital) Services DEXAMETHASONE SODIUM PHOSPHATE 10 MG/ML INJECTION SOLUTION RX-2331 CDM J1100 HCPCS 636 RC 00641-0367-21 NDC outpatient 1 ML 59.73 59.73 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES EPO [308136803] 47.78 percent of total billed charges 37.03 56.74 Technical (Hospital) Services DEXAMETHASONE SODIUM PHOSPHATE 10 MG/ML INJECTION SOLUTION RX-2331 CDM J1100 HCPCS 636 RC 00641-0367-21 NDC outpatient 1 ML 59.73 59.73 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES HDHP [308136802] 47.78 percent of total billed charges 37.03 56.74 Technical (Hospital) Services DEXAMETHASONE SODIUM PHOSPHATE 10 MG/ML INJECTION SOLUTION RX-2331 CDM J1100 HCPCS 636 RC 00641-0367-21 NDC inpatient 1 ML 59.73 59.73 MEDICA (COMMERCIAL) 94265 [3081118] MEDICA CLAIMS [308111801] 53.76 percent of total billed charges 37.03 56.74 Technical (Hospital) Services DEXAMETHASONE SODIUM PHOSPHATE 10 MG/ML INJECTION SOLUTION RX-2331 CDM J1100 HCPCS 636 RC 00641-0367-21 NDC inpatient 1 ML 59.73 59.73 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES PPO [308136801] 47.29 percent of total billed charges 37.03 56.74 Technical (Hospital) Services DEXAMETHASONE SODIUM PHOSPHATE 10 MG/ML INJECTION SOLUTION RX-2331 CDM J1100 HCPCS 636 RC 00641-0367-21 NDC inpatient 1 ML 59.73 59.73 HEALTHPARTNERS SX009 HEALTHPARTNERS 47.29 percent of total billed charges 37.03 56.74 Technical (Hospital) Services DEXAMETHASONE SODIUM PHOSPHATE 10 MG/ML INJECTION SOLUTION RX-2331 CDM J1100 HCPCS 636 RC 00641-0367-21 NDC inpatient 1 ML 59.73 59.73 MULTIPLAN INC 34080 [3081285] MULTIPLAN INC [308128501] 56.74 percent of total billed charges 37.03 56.74 Technical (Hospital) Services DEXAMETHASONE SODIUM PHOSPHATE 10 MG/ML INJECTION SOLUTION RX-2331 CDM J1100 HCPCS 636 RC 00641-0367-21 NDC inpatient 1 ML 59.73 59.73 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES HDHP [308136802] 47.29 percent of total billed charges 37.03 56.74 Technical (Hospital) Services DEXAMETHASONE SODIUM PHOSPHATE 10 MG/ML INJECTION SOLUTION RX-2331 CDM J1100 HCPCS 636 RC 00641-0367-21 NDC inpatient 1 ML 59.73 59.73 CIGNA 62308 [3081051] CIGNA 62308 [308105105] 47.29 percent of total billed charges 37.03 56.74 Technical (Hospital) Services DEXAMETHASONE SODIUM PHOSPHATE 10 MG/ML INJECTION SOLUTION RX-2331 CDM J1100 HCPCS 636 RC 00641-0367-21 NDC inpatient 1 ML 59.73 59.73 CIGNA 62308 [3081051] CIGNA STATE OF WYOMING [308105107] 47.29 percent of total billed charges 37.03 56.74 Technical (Hospital) Services DEXAMETHASONE SODIUM PHOSPHATE 10 MG/ML INJECTION SOLUTION RX-2331 CDM J1100 HCPCS 636 RC 00641-0367-21 NDC inpatient 1 ML 59.73 59.73 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES EPO [308136803] 47.29 percent of total billed charges 37.03 56.74 Technical (Hospital) Services DEXAMETHASONE SODIUM PHOSPHATE 10 MG/ML INJECTION SOLUTION RX-2331 CDM J1100 HCPCS 636 RC 00641-0367-21 NDC inpatient 1 ML 59.73 59.73 BLUE CROSS BLUE SHIELD WELLMARK SB889 [3081026] BCBS WYOMING [308102603] 56.74 percent of total billed charges 37.03 56.74 Technical (Hospital) Services DEXAMETHASONE SODIUM PHOSPHATE 10 MG/ML INJECTION SOLUTION RX-2331 CDM J1100 HCPCS 636 RC 00641-0367-21 NDC inpatient 1 ML 59.73 59.73 UNITED HEALTHCARE (COMMERCIAL) [3081199] UNITED HEALTHCARE 87726 [308119901] 37.03 percent of total billed charges 37.03 56.74 Technical (Hospital) Services DEXAMETHASONE SODIUM PHOSPHATE 4 MG/ML INJECTION SOLUTION RX-2332 CDM J1100 HCPCS 636 RC 63323-0165-16 NDC inpatient 1 ML 59.16 59.16 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES PPO [308136801] 46.84 percent of total billed charges 36.68 56.2 Technical (Hospital) Services DEXAMETHASONE SODIUM PHOSPHATE 4 MG/ML INJECTION SOLUTION RX-2332 CDM J1100 HCPCS 636 RC 63323-0165-16 NDC inpatient 1 ML 59.16 59.16 HEALTHPARTNERS SX009 HEALTHPARTNERS 46.84 percent of total billed charges 36.68 56.2 Technical (Hospital) Services DEXAMETHASONE SODIUM PHOSPHATE 4 MG/ML INJECTION SOLUTION RX-2332 CDM J1100 HCPCS 636 RC 63323-0165-16 NDC inpatient 1 ML 59.16 59.16 MEDICA (COMMERCIAL) 94265 [3081118] MEDICA CLAIMS [308111801] 53.24 percent of total billed charges 36.68 56.2 Technical (Hospital) Services DEXAMETHASONE SODIUM PHOSPHATE 4 MG/ML INJECTION SOLUTION RX-2332 CDM J1100 HCPCS 636 RC 63323-0165-16 NDC inpatient 1 ML 59.16 59.16 MULTIPLAN INC 34080 [3081285] MULTIPLAN INC [308128501] 56.2 percent of total billed charges 36.68 56.2 Technical (Hospital) Services DEXAMETHASONE SODIUM PHOSPHATE 4 MG/ML INJECTION SOLUTION RX-2332 CDM J1100 HCPCS 636 RC 63323-0165-16 NDC inpatient 1 ML 59.16 59.16 CIGNA 62308 [3081051] CIGNA 62308 [308105105] 46.84 percent of total billed charges 36.68 56.2 Technical (Hospital) Services DEXAMETHASONE SODIUM PHOSPHATE 4 MG/ML INJECTION SOLUTION RX-2332 CDM J1100 HCPCS 636 RC 63323-0165-16 NDC inpatient 1 ML 59.16 59.16 CIGNA 62308 [3081051] CIGNA STATE OF WYOMING [308105107] 46.84 percent of total billed charges 36.68 56.2 Technical (Hospital) Services DEXAMETHASONE SODIUM PHOSPHATE 4 MG/ML INJECTION SOLUTION RX-2332 CDM J1100 HCPCS 636 RC 63323-0165-16 NDC inpatient 1 ML 59.16 59.16 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES HDHP [308136802] 46.84 percent of total billed charges 36.68 56.2 Technical (Hospital) Services DEXAMETHASONE SODIUM PHOSPHATE 4 MG/ML INJECTION SOLUTION RX-2332 CDM J1100 HCPCS 636 RC 63323-0165-16 NDC inpatient 1 ML 59.16 59.16 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES EPO [308136803] 46.84 percent of total billed charges 36.68 56.2 Technical (Hospital) Services DEXAMETHASONE SODIUM PHOSPHATE 4 MG/ML INJECTION SOLUTION RX-2332 CDM J1100 HCPCS 636 RC 63323-0165-16 NDC inpatient 1 ML 59.16 59.16 UNITED HEALTHCARE (COMMERCIAL) [3081199] UNITED HEALTHCARE 87726 [308119901] 36.68 percent of total billed charges 36.68 56.2 Technical (Hospital) Services DEXAMETHASONE SODIUM PHOSPHATE 4 MG/ML INJECTION SOLUTION RX-2332 CDM J1100 HCPCS 636 RC 63323-0165-16 NDC inpatient 1 ML 59.16 59.16 BLUE CROSS BLUE SHIELD WELLMARK SB889 [3081026] BCBS WYOMING [308102603] 56.2 percent of total billed charges 36.68 56.2 Technical (Hospital) Services DEXAMETHASONE SODIUM PHOSPHATE 4 MG/ML INJECTION SOLUTION RX-2332 CDM J1100 HCPCS 636 RC 63323-0165-16 NDC outpatient 1 ML 59.16 59.16 BLUE CROSS BLUE SHIELD WELLMARK SB889 [3081026] BCBS WYOMING [308102603] 56.2 percent of total billed charges 36.68 56.2 Technical (Hospital) Services DEXAMETHASONE SODIUM PHOSPHATE 4 MG/ML INJECTION SOLUTION RX-2332 CDM J1100 HCPCS 636 RC 63323-0165-16 NDC outpatient 1 ML 59.16 59.16 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES PPO [308136801] 47.33 percent of total billed charges 36.68 56.2 Technical (Hospital) Services DEXAMETHASONE SODIUM PHOSPHATE 4 MG/ML INJECTION SOLUTION RX-2332 CDM J1100 HCPCS 636 RC 63323-0165-16 NDC outpatient 1 ML 59.16 59.16 HEALTHPARTNERS SX009 HEALTHPARTNERS 47.33 percent of total billed charges 36.68 56.2 Technical (Hospital) Services DEXAMETHASONE SODIUM PHOSPHATE 4 MG/ML INJECTION SOLUTION RX-2332 CDM J1100 HCPCS 636 RC 63323-0165-16 NDC outpatient 1 ML 59.16 59.16 MULTIPLAN INC 34080 [3081285] MULTIPLAN INC [308128501] 56.2 percent of total billed charges 36.68 56.2 Technical (Hospital) Services DEXAMETHASONE SODIUM PHOSPHATE 4 MG/ML INJECTION SOLUTION RX-2332 CDM J1100 HCPCS 636 RC 63323-0165-16 NDC outpatient 1 ML 59.16 59.16 UNITED HEALTHCARE (COMMERCIAL) [3081199] UNITED HEALTHCARE 87726 [308119901] 36.68 percent of total billed charges 36.68 56.2 Technical (Hospital) Services DEXAMETHASONE SODIUM PHOSPHATE 4 MG/ML INJECTION SOLUTION RX-2332 CDM J1100 HCPCS 636 RC 63323-0165-16 NDC outpatient 1 ML 59.16 59.16 MEDICA (COMMERCIAL) 94265 [3081118] MEDICA CLAIMS [308111801] 53.24 percent of total billed charges 36.68 56.2 Technical (Hospital) Services DEXAMETHASONE SODIUM PHOSPHATE 4 MG/ML INJECTION SOLUTION RX-2332 CDM J1100 HCPCS 636 RC 63323-0165-16 NDC outpatient 1 ML 59.16 59.16 CIGNA 62308 [3081051] CIGNA 62308 [308105105] 47.33 percent of total billed charges 36.68 56.2 Technical (Hospital) Services DEXAMETHASONE SODIUM PHOSPHATE 4 MG/ML INJECTION SOLUTION RX-2332 CDM J1100 HCPCS 636 RC 63323-0165-16 NDC outpatient 1 ML 59.16 59.16 CIGNA 62308 [3081051] CIGNA STATE OF WYOMING [308105107] 47.33 percent of total billed charges 36.68 56.2 Technical (Hospital) Services DEXAMETHASONE SODIUM PHOSPHATE 4 MG/ML INJECTION SOLUTION RX-2332 CDM J1100 HCPCS 636 RC 63323-0165-16 NDC outpatient 1 ML 59.16 59.16 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES EPO [308136803] 47.33 percent of total billed charges 36.68 56.2 Technical (Hospital) Services DEXAMETHASONE SODIUM PHOSPHATE 4 MG/ML INJECTION SOLUTION RX-2332 CDM J1100 HCPCS 636 RC 63323-0165-16 NDC outpatient 1 ML 59.16 59.16 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES HDHP [308136802] 47.33 percent of total billed charges 36.68 56.2 Technical (Hospital) Services METHYLPREDNISOLONE ACETATE 80 MG/ML SUSPENSION FOR INJECTION RX-4996 CDM J1010 HCPCS 636 RC 00009-3475-01 NDC inpatient 1 ML 106.93 106.93 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES PPO [308136801] 84.67 percent of total billed charges 66.3 101.58 Technical (Hospital) Services METHYLPREDNISOLONE ACETATE 80 MG/ML SUSPENSION FOR INJECTION RX-4996 CDM J1010 HCPCS 636 RC 00009-3475-01 NDC inpatient 1 ML 106.93 106.93 HEALTHPARTNERS SX009 HEALTHPARTNERS 84.67 percent of total billed charges 66.3 101.58 Technical (Hospital) Services METHYLPREDNISOLONE ACETATE 80 MG/ML SUSPENSION FOR INJECTION RX-4996 CDM J1010 HCPCS 636 RC 00009-3475-01 NDC inpatient 1 ML 106.93 106.93 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES HDHP [308136802] 84.67 percent of total billed charges 66.3 101.58 Technical (Hospital) Services METHYLPREDNISOLONE ACETATE 80 MG/ML SUSPENSION FOR INJECTION RX-4996 CDM J1010 HCPCS 636 RC 00009-3475-01 NDC inpatient 1 ML 106.93 106.93 MULTIPLAN INC 34080 [3081285] MULTIPLAN INC [308128501] 101.58 percent of total billed charges 66.3 101.58 Technical (Hospital) Services METHYLPREDNISOLONE ACETATE 80 MG/ML SUSPENSION FOR INJECTION RX-4996 CDM J1010 HCPCS 636 RC 00009-3475-01 NDC inpatient 1 ML 106.93 106.93 MEDICA (COMMERCIAL) 94265 [3081118] MEDICA CLAIMS [308111801] 96.24 percent of total billed charges 66.3 101.58 Technical (Hospital) Services METHYLPREDNISOLONE ACETATE 80 MG/ML SUSPENSION FOR INJECTION RX-4996 CDM J1010 HCPCS 636 RC 00009-3475-01 NDC inpatient 1 ML 106.93 106.93 UNITED HEALTHCARE (COMMERCIAL) [3081199] UNITED HEALTHCARE 87726 [308119901] 66.3 percent of total billed charges 66.3 101.58 Technical (Hospital) Services METHYLPREDNISOLONE ACETATE 80 MG/ML SUSPENSION FOR INJECTION RX-4996 CDM J1010 HCPCS 636 RC 00009-3475-01 NDC inpatient 1 ML 106.93 106.93 BLUE CROSS BLUE SHIELD WELLMARK SB889 [3081026] BCBS WYOMING [308102603] 101.58 percent of total billed charges 66.3 101.58 Technical (Hospital) Services METHYLPREDNISOLONE ACETATE 80 MG/ML SUSPENSION FOR INJECTION RX-4996 CDM J1010 HCPCS 636 RC 00009-3475-01 NDC inpatient 1 ML 106.93 106.93 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES EPO [308136803] 84.67 percent of total billed charges 66.3 101.58 Technical (Hospital) Services METHYLPREDNISOLONE ACETATE 80 MG/ML SUSPENSION FOR INJECTION RX-4996 CDM J1010 HCPCS 636 RC 00009-3475-01 NDC inpatient 1 ML 106.93 106.93 CIGNA 62308 [3081051] CIGNA 62308 [308105105] 84.67 percent of total billed charges 66.3 101.58 Technical (Hospital) Services METHYLPREDNISOLONE ACETATE 80 MG/ML SUSPENSION FOR INJECTION RX-4996 CDM J1010 HCPCS 636 RC 00009-3475-01 NDC inpatient 1 ML 106.93 106.93 CIGNA 62308 [3081051] CIGNA STATE OF WYOMING [308105107] 84.67 percent of total billed charges 66.3 101.58 Technical (Hospital) Services METHYLPREDNISOLONE ACETATE 80 MG/ML SUSPENSION FOR INJECTION RX-4996 CDM J1010 HCPCS 636 RC 00009-3475-01 NDC outpatient 1 ML 106.93 106.93 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES HDHP [308136802] 85.54 percent of total billed charges 66.3 101.58 Technical (Hospital) Services METHYLPREDNISOLONE ACETATE 80 MG/ML SUSPENSION FOR INJECTION RX-4996 CDM J1010 HCPCS 636 RC 00009-3475-01 NDC outpatient 1 ML 106.93 106.93 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES EPO [308136803] 85.54 percent of total billed charges 66.3 101.58 Technical (Hospital) Services METHYLPREDNISOLONE ACETATE 80 MG/ML SUSPENSION FOR INJECTION RX-4996 CDM J1010 HCPCS 636 RC 00009-3475-01 NDC outpatient 1 ML 106.93 106.93 MEDICA (COMMERCIAL) 94265 [3081118] MEDICA CLAIMS [308111801] 96.24 percent of total billed charges 66.3 101.58 Technical (Hospital) Services METHYLPREDNISOLONE ACETATE 80 MG/ML SUSPENSION FOR INJECTION RX-4996 CDM J1010 HCPCS 636 RC 00009-3475-01 NDC outpatient 1 ML 106.93 106.93 BLUE CROSS BLUE SHIELD WELLMARK SB889 [3081026] BCBS WYOMING [308102603] 101.58 percent of total billed charges 66.3 101.58 Technical (Hospital) Services METHYLPREDNISOLONE ACETATE 80 MG/ML SUSPENSION FOR INJECTION RX-4996 CDM J1010 HCPCS 636 RC 00009-3475-01 NDC outpatient 1 ML 106.93 106.93 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES PPO [308136801] 85.54 percent of total billed charges 66.3 101.58 Technical (Hospital) Services METHYLPREDNISOLONE ACETATE 80 MG/ML SUSPENSION FOR INJECTION RX-4996 CDM J1010 HCPCS 636 RC 00009-3475-01 NDC outpatient 1 ML 106.93 106.93 HEALTHPARTNERS SX009 HEALTHPARTNERS 85.54 percent of total billed charges 66.3 101.58 Technical (Hospital) Services METHYLPREDNISOLONE ACETATE 80 MG/ML SUSPENSION FOR INJECTION RX-4996 CDM J1010 HCPCS 636 RC 00009-3475-01 NDC outpatient 1 ML 106.93 106.93 UNITED HEALTHCARE (COMMERCIAL) [3081199] UNITED HEALTHCARE 87726 [308119901] 66.3 percent of total billed charges 66.3 101.58 Technical (Hospital) Services METHYLPREDNISOLONE ACETATE 80 MG/ML SUSPENSION FOR INJECTION RX-4996 CDM J1010 HCPCS 636 RC 00009-3475-01 NDC outpatient 1 ML 106.93 106.93 MULTIPLAN INC 34080 [3081285] MULTIPLAN INC [308128501] 101.58 percent of total billed charges 66.3 101.58 Technical (Hospital) Services METHYLPREDNISOLONE ACETATE 80 MG/ML SUSPENSION FOR INJECTION RX-4996 CDM J1010 HCPCS 636 RC 00009-3475-01 NDC outpatient 1 ML 106.93 106.93 CIGNA 62308 [3081051] CIGNA 62308 [308105105] 85.54 percent of total billed charges 66.3 101.58 Technical (Hospital) Services METHYLPREDNISOLONE ACETATE 80 MG/ML SUSPENSION FOR INJECTION RX-4996 CDM J1010 HCPCS 636 RC 00009-3475-01 NDC outpatient 1 ML 106.93 106.93 CIGNA 62308 [3081051] CIGNA STATE OF WYOMING [308105107] 85.54 percent of total billed charges 66.3 101.58 Technical (Hospital) Services DENOSUMAB 60 MG/ML SUBCUTANEOUS SYRINGE RX-105502 CDM J0897 HCPCS 636 RC 55513-0710-01 NDC inpatient 1 ML 4236.12 4236.12 HEALTHPARTNERS SX009 HEALTHPARTNERS 3354.16 percent of total billed charges 2626.39 4024.31 Technical (Hospital) Services DENOSUMAB 60 MG/ML SUBCUTANEOUS SYRINGE RX-105502 CDM J0897 HCPCS 636 RC 55513-0710-01 NDC inpatient 1 ML 4236.12 4236.12 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES HDHP [308136802] 3354.16 percent of total billed charges 2626.39 4024.31 Technical (Hospital) Services DENOSUMAB 60 MG/ML SUBCUTANEOUS SYRINGE RX-105502 CDM J0897 HCPCS 636 RC 55513-0710-01 NDC inpatient 1 ML 4236.12 4236.12 CIGNA 62308 [3081051] CIGNA 62308 [308105105] 3354.16 percent of total billed charges 2626.39 4024.31 Technical (Hospital) Services DENOSUMAB 60 MG/ML SUBCUTANEOUS SYRINGE RX-105502 CDM J0897 HCPCS 636 RC 55513-0710-01 NDC inpatient 1 ML 4236.12 4236.12 CIGNA 62308 [3081051] CIGNA STATE OF WYOMING [308105107] 3354.16 percent of total billed charges 2626.39 4024.31 Technical (Hospital) Services DENOSUMAB 60 MG/ML SUBCUTANEOUS SYRINGE RX-105502 CDM J0897 HCPCS 636 RC 55513-0710-01 NDC inpatient 1 ML 4236.12 4236.12 BLUE CROSS BLUE SHIELD WELLMARK SB889 [3081026] BCBS WYOMING [308102603] 4024.31 percent of total billed charges 2626.39 4024.31 Technical (Hospital) Services DENOSUMAB 60 MG/ML SUBCUTANEOUS SYRINGE RX-105502 CDM J0897 HCPCS 636 RC 55513-0710-01 NDC inpatient 1 ML 4236.12 4236.12 UNITED HEALTHCARE (COMMERCIAL) [3081199] UNITED HEALTHCARE 87726 [308119901] 2626.39 percent of total billed charges 2626.39 4024.31 Technical (Hospital) Services DENOSUMAB 60 MG/ML SUBCUTANEOUS SYRINGE RX-105502 CDM J0897 HCPCS 636 RC 55513-0710-01 NDC inpatient 1 ML 4236.12 4236.12 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES EPO [308136803] 3354.16 percent of total billed charges 2626.39 4024.31 Technical (Hospital) Services DENOSUMAB 60 MG/ML SUBCUTANEOUS SYRINGE RX-105502 CDM J0897 HCPCS 636 RC 55513-0710-01 NDC inpatient 1 ML 4236.12 4236.12 MULTIPLAN INC 34080 [3081285] MULTIPLAN INC [308128501] 4024.31 percent of total billed charges 2626.39 4024.31 Technical (Hospital) Services DENOSUMAB 60 MG/ML SUBCUTANEOUS SYRINGE RX-105502 CDM J0897 HCPCS 636 RC 55513-0710-01 NDC inpatient 1 ML 4236.12 4236.12 MEDICA (COMMERCIAL) 94265 [3081118] MEDICA CLAIMS [308111801] 3812.51 percent of total billed charges 2626.39 4024.31 Technical (Hospital) Services DENOSUMAB 60 MG/ML SUBCUTANEOUS SYRINGE RX-105502 CDM J0897 HCPCS 636 RC 55513-0710-01 NDC inpatient 1 ML 4236.12 4236.12 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES PPO [308136801] 3354.16 percent of total billed charges 2626.39 4024.31 Technical (Hospital) Services DENOSUMAB 60 MG/ML SUBCUTANEOUS SYRINGE RX-105502 CDM J0897 HCPCS 636 RC 55513-0710-01 NDC outpatient 1 ML 4236.12 4236.12 BLUE CROSS BLUE SHIELD WELLMARK SB889 [3081026] BCBS WYOMING [308102603] 4024.31 percent of total billed charges 2626.39 4024.31 Technical (Hospital) Services DENOSUMAB 60 MG/ML SUBCUTANEOUS SYRINGE RX-105502 CDM J0897 HCPCS 636 RC 55513-0710-01 NDC outpatient 1 ML 4236.12 4236.12 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES PPO [308136801] 3388.9 percent of total billed charges 2626.39 4024.31 Technical (Hospital) Services DENOSUMAB 60 MG/ML SUBCUTANEOUS SYRINGE RX-105502 CDM J0897 HCPCS 636 RC 55513-0710-01 NDC outpatient 1 ML 4236.12 4236.12 UNITED HEALTHCARE (COMMERCIAL) [3081199] UNITED HEALTHCARE 87726 [308119901] 2626.39 percent of total billed charges 2626.39 4024.31 Technical (Hospital) Services DENOSUMAB 60 MG/ML SUBCUTANEOUS SYRINGE RX-105502 CDM J0897 HCPCS 636 RC 55513-0710-01 NDC outpatient 1 ML 4236.12 4236.12 MULTIPLAN INC 34080 [3081285] MULTIPLAN INC [308128501] 4024.31 percent of total billed charges 2626.39 4024.31 Technical (Hospital) Services DENOSUMAB 60 MG/ML SUBCUTANEOUS SYRINGE RX-105502 CDM J0897 HCPCS 636 RC 55513-0710-01 NDC outpatient 1 ML 4236.12 4236.12 HEALTHPARTNERS SX009 HEALTHPARTNERS 3388.9 percent of total billed charges 2626.39 4024.31 Technical (Hospital) Services DENOSUMAB 60 MG/ML SUBCUTANEOUS SYRINGE RX-105502 CDM J0897 HCPCS 636 RC 55513-0710-01 NDC outpatient 1 ML 4236.12 4236.12 CIGNA 62308 [3081051] CIGNA 62308 [308105105] 3388.9 percent of total billed charges 2626.39 4024.31 Technical (Hospital) Services DENOSUMAB 60 MG/ML SUBCUTANEOUS SYRINGE RX-105502 CDM J0897 HCPCS 636 RC 55513-0710-01 NDC outpatient 1 ML 4236.12 4236.12 CIGNA 62308 [3081051] CIGNA STATE OF WYOMING [308105107] 3388.9 percent of total billed charges 2626.39 4024.31 Technical (Hospital) Services DENOSUMAB 60 MG/ML SUBCUTANEOUS SYRINGE RX-105502 CDM J0897 HCPCS 636 RC 55513-0710-01 NDC outpatient 1 ML 4236.12 4236.12 MEDICA (COMMERCIAL) 94265 [3081118] MEDICA CLAIMS [308111801] 3812.51 percent of total billed charges 2626.39 4024.31 Technical (Hospital) Services DENOSUMAB 60 MG/ML SUBCUTANEOUS SYRINGE RX-105502 CDM J0897 HCPCS 636 RC 55513-0710-01 NDC outpatient 1 ML 4236.12 4236.12 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES EPO [308136803] 3388.9 percent of total billed charges 2626.39 4024.31 Technical (Hospital) Services DENOSUMAB 60 MG/ML SUBCUTANEOUS SYRINGE RX-105502 CDM J0897 HCPCS 636 RC 55513-0710-01 NDC outpatient 1 ML 4236.12 4236.12 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES HDHP [308136802] 3388.9 percent of total billed charges 2626.39 4024.31 Technical (Hospital) Services "EPOETIN BETA, METHOXY PEG 30 MCG/0.3 ML INJECTION SYRINGE" RX-167304 CDM J0888 HCPCS 636 RC 59353-0400-09 NDC inpatient 0.3 ML 348.54 348.54 HEALTHPARTNERS SX009 HEALTHPARTNERS 275.97 percent of total billed charges 216.09 331.11 Technical (Hospital) Services "EPOETIN BETA, METHOXY PEG 30 MCG/0.3 ML INJECTION SYRINGE" RX-167304 CDM J0888 HCPCS 636 RC 59353-0400-09 NDC inpatient 0.3 ML 348.54 348.54 MULTIPLAN INC 34080 [3081285] MULTIPLAN INC [308128501] 331.11 percent of total billed charges 216.09 331.11 Technical (Hospital) Services "EPOETIN BETA, METHOXY PEG 30 MCG/0.3 ML INJECTION SYRINGE" RX-167304 CDM J0888 HCPCS 636 RC 59353-0400-09 NDC inpatient 0.3 ML 348.54 348.54 CIGNA 62308 [3081051] CIGNA 62308 [308105105] 275.97 percent of total billed charges 216.09 331.11 Technical (Hospital) Services "EPOETIN BETA, METHOXY PEG 30 MCG/0.3 ML INJECTION SYRINGE" RX-167304 CDM J0888 HCPCS 636 RC 59353-0400-09 NDC inpatient 0.3 ML 348.54 348.54 CIGNA 62308 [3081051] CIGNA STATE OF WYOMING [308105107] 275.97 percent of total billed charges 216.09 331.11 Technical (Hospital) Services "EPOETIN BETA, METHOXY PEG 30 MCG/0.3 ML INJECTION SYRINGE" RX-167304 CDM J0888 HCPCS 636 RC 59353-0400-09 NDC inpatient 0.3 ML 348.54 348.54 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES EPO [308136803] 275.97 percent of total billed charges 216.09 331.11 Technical (Hospital) Services "EPOETIN BETA, METHOXY PEG 30 MCG/0.3 ML INJECTION SYRINGE" RX-167304 CDM J0888 HCPCS 636 RC 59353-0400-09 NDC inpatient 0.3 ML 348.54 348.54 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES HDHP [308136802] 275.97 percent of total billed charges 216.09 331.11 Technical (Hospital) Services "EPOETIN BETA, METHOXY PEG 30 MCG/0.3 ML INJECTION SYRINGE" RX-167304 CDM J0888 HCPCS 636 RC 59353-0400-09 NDC inpatient 0.3 ML 348.54 348.54 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES PPO [308136801] 275.97 percent of total billed charges 216.09 331.11 Technical (Hospital) Services "EPOETIN BETA, METHOXY PEG 30 MCG/0.3 ML INJECTION SYRINGE" RX-167304 CDM J0888 HCPCS 636 RC 59353-0400-09 NDC inpatient 0.3 ML 348.54 348.54 MEDICA (COMMERCIAL) 94265 [3081118] MEDICA CLAIMS [308111801] 313.69 percent of total billed charges 216.09 331.11 Technical (Hospital) Services "EPOETIN BETA, METHOXY PEG 30 MCG/0.3 ML INJECTION SYRINGE" RX-167304 CDM J0888 HCPCS 636 RC 59353-0400-09 NDC inpatient 0.3 ML 348.54 348.54 BLUE CROSS BLUE SHIELD WELLMARK SB889 [3081026] BCBS WYOMING [308102603] 331.11 percent of total billed charges 216.09 331.11 Technical (Hospital) Services "EPOETIN BETA, METHOXY PEG 30 MCG/0.3 ML INJECTION SYRINGE" RX-167304 CDM J0888 HCPCS 636 RC 59353-0400-09 NDC inpatient 0.3 ML 348.54 348.54 UNITED HEALTHCARE (COMMERCIAL) [3081199] UNITED HEALTHCARE 87726 [308119901] 216.09 percent of total billed charges 216.09 331.11 Technical (Hospital) Services "EPOETIN BETA, METHOXY PEG 30 MCG/0.3 ML INJECTION SYRINGE" RX-167304 CDM J0888 HCPCS 636 RC 59353-0400-09 NDC outpatient 0.3 ML 348.54 348.54 HEALTHPARTNERS SX009 HEALTHPARTNERS 278.83 percent of total billed charges 216.09 331.11 Technical (Hospital) Services "EPOETIN BETA, METHOXY PEG 30 MCG/0.3 ML INJECTION SYRINGE" RX-167304 CDM J0888 HCPCS 636 RC 59353-0400-09 NDC outpatient 0.3 ML 348.54 348.54 BLUE CROSS BLUE SHIELD WELLMARK SB889 [3081026] BCBS WYOMING [308102603] 331.11 percent of total billed charges 216.09 331.11 Technical (Hospital) Services "EPOETIN BETA, METHOXY PEG 30 MCG/0.3 ML INJECTION SYRINGE" RX-167304 CDM J0888 HCPCS 636 RC 59353-0400-09 NDC outpatient 0.3 ML 348.54 348.54 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES EPO [308136803] 278.83 percent of total billed charges 216.09 331.11 Technical (Hospital) Services "EPOETIN BETA, METHOXY PEG 30 MCG/0.3 ML INJECTION SYRINGE" RX-167304 CDM J0888 HCPCS 636 RC 59353-0400-09 NDC outpatient 0.3 ML 348.54 348.54 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES HDHP [308136802] 278.83 percent of total billed charges 216.09 331.11 Technical (Hospital) Services "EPOETIN BETA, METHOXY PEG 30 MCG/0.3 ML INJECTION SYRINGE" RX-167304 CDM J0888 HCPCS 636 RC 59353-0400-09 NDC outpatient 0.3 ML 348.54 348.54 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES PPO [308136801] 278.83 percent of total billed charges 216.09 331.11 Technical (Hospital) Services "EPOETIN BETA, METHOXY PEG 30 MCG/0.3 ML INJECTION SYRINGE" RX-167304 CDM J0888 HCPCS 636 RC 59353-0400-09 NDC outpatient 0.3 ML 348.54 348.54 MEDICA (COMMERCIAL) 94265 [3081118] MEDICA CLAIMS [308111801] 313.69 percent of total billed charges 216.09 331.11 Technical (Hospital) Services "EPOETIN BETA, METHOXY PEG 30 MCG/0.3 ML INJECTION SYRINGE" RX-167304 CDM J0888 HCPCS 636 RC 59353-0400-09 NDC outpatient 0.3 ML 348.54 348.54 CIGNA 62308 [3081051] CIGNA 62308 [308105105] 278.83 percent of total billed charges 216.09 331.11 Technical (Hospital) Services "EPOETIN BETA, METHOXY PEG 30 MCG/0.3 ML INJECTION SYRINGE" RX-167304 CDM J0888 HCPCS 636 RC 59353-0400-09 NDC outpatient 0.3 ML 348.54 348.54 CIGNA 62308 [3081051] CIGNA STATE OF WYOMING [308105107] 278.83 percent of total billed charges 216.09 331.11 Technical (Hospital) Services "EPOETIN BETA, METHOXY PEG 30 MCG/0.3 ML INJECTION SYRINGE" RX-167304 CDM J0888 HCPCS 636 RC 59353-0400-09 NDC outpatient 0.3 ML 348.54 348.54 MULTIPLAN INC 34080 [3081285] MULTIPLAN INC [308128501] 331.11 percent of total billed charges 216.09 331.11 Technical (Hospital) Services "EPOETIN BETA, METHOXY PEG 30 MCG/0.3 ML INJECTION SYRINGE" RX-167304 CDM J0888 HCPCS 636 RC 59353-0400-09 NDC outpatient 0.3 ML 348.54 348.54 UNITED HEALTHCARE (COMMERCIAL) [3081199] UNITED HEALTHCARE 87726 [308119901] 216.09 percent of total billed charges 216.09 331.11 Technical (Hospital) Services "EPOETIN ALFA 20,000 UNIT/ML INJECTION SOLUTION" RX-14643 CDM J0885 HCPCS 636 RC 55513-0478-10 NDC inpatient 1 ML 806.6 806.6 BLUE CROSS BLUE SHIELD WELLMARK SB889 [3081026] BCBS WYOMING [308102603] 766.27 percent of total billed charges 500.09 766.27 Technical (Hospital) Services "EPOETIN ALFA 20,000 UNIT/ML INJECTION SOLUTION" RX-14643 CDM J0885 HCPCS 636 RC 55513-0478-10 NDC inpatient 1 ML 806.6 806.6 UNITED HEALTHCARE (COMMERCIAL) [3081199] UNITED HEALTHCARE 87726 [308119901] 500.09 percent of total billed charges 500.09 766.27 Technical (Hospital) Services "EPOETIN ALFA 20,000 UNIT/ML INJECTION SOLUTION" RX-14643 CDM J0885 HCPCS 636 RC 55513-0478-10 NDC inpatient 1 ML 806.6 806.6 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES EPO [308136803] 638.67 percent of total billed charges 500.09 766.27 Technical (Hospital) Services "EPOETIN ALFA 20,000 UNIT/ML INJECTION SOLUTION" RX-14643 CDM J0885 HCPCS 636 RC 55513-0478-10 NDC inpatient 1 ML 806.6 806.6 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES HDHP [308136802] 638.67 percent of total billed charges 500.09 766.27 Technical (Hospital) Services "EPOETIN ALFA 20,000 UNIT/ML INJECTION SOLUTION" RX-14643 CDM J0885 HCPCS 636 RC 55513-0478-10 NDC inpatient 1 ML 806.6 806.6 CIGNA 62308 [3081051] CIGNA 62308 [308105105] 638.67 percent of total billed charges 500.09 766.27 Technical (Hospital) Services "EPOETIN ALFA 20,000 UNIT/ML INJECTION SOLUTION" RX-14643 CDM J0885 HCPCS 636 RC 55513-0478-10 NDC inpatient 1 ML 806.6 806.6 CIGNA 62308 [3081051] CIGNA STATE OF WYOMING [308105107] 638.67 percent of total billed charges 500.09 766.27 Technical (Hospital) Services "EPOETIN ALFA 20,000 UNIT/ML INJECTION SOLUTION" RX-14643 CDM J0885 HCPCS 636 RC 55513-0478-10 NDC inpatient 1 ML 806.6 806.6 MEDICA (COMMERCIAL) 94265 [3081118] MEDICA CLAIMS [308111801] 725.94 percent of total billed charges 500.09 766.27 Technical (Hospital) Services "EPOETIN ALFA 20,000 UNIT/ML INJECTION SOLUTION" RX-14643 CDM J0885 HCPCS 636 RC 55513-0478-10 NDC inpatient 1 ML 806.6 806.6 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES PPO [308136801] 638.67 percent of total billed charges 500.09 766.27 Technical (Hospital) Services "EPOETIN ALFA 20,000 UNIT/ML INJECTION SOLUTION" RX-14643 CDM J0885 HCPCS 636 RC 55513-0478-10 NDC inpatient 1 ML 806.6 806.6 HEALTHPARTNERS SX009 HEALTHPARTNERS 638.67 percent of total billed charges 500.09 766.27 Technical (Hospital) Services "EPOETIN ALFA 20,000 UNIT/ML INJECTION SOLUTION" RX-14643 CDM J0885 HCPCS 636 RC 55513-0478-10 NDC inpatient 1 ML 806.6 806.6 MULTIPLAN INC 34080 [3081285] MULTIPLAN INC [308128501] 766.27 percent of total billed charges 500.09 766.27 Technical (Hospital) Services "EPOETIN ALFA 20,000 UNIT/ML INJECTION SOLUTION" RX-14643 CDM J0885 HCPCS 636 RC 55513-0478-10 NDC outpatient 1 ML 806.6 806.6 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES EPO [308136803] 645.28 percent of total billed charges 500.09 766.27 Technical (Hospital) Services "EPOETIN ALFA 20,000 UNIT/ML INJECTION SOLUTION" RX-14643 CDM J0885 HCPCS 636 RC 55513-0478-10 NDC outpatient 1 ML 806.6 806.6 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES HDHP [308136802] 645.28 percent of total billed charges 500.09 766.27 Technical (Hospital) Services "EPOETIN ALFA 20,000 UNIT/ML INJECTION SOLUTION" RX-14643 CDM J0885 HCPCS 636 RC 55513-0478-10 NDC outpatient 1 ML 806.6 806.6 BLUE CROSS BLUE SHIELD WELLMARK SB889 [3081026] BCBS WYOMING [308102603] 766.27 percent of total billed charges 500.09 766.27 Technical (Hospital) Services "EPOETIN ALFA 20,000 UNIT/ML INJECTION SOLUTION" RX-14643 CDM J0885 HCPCS 636 RC 55513-0478-10 NDC outpatient 1 ML 806.6 806.6 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES PPO [308136801] 645.28 percent of total billed charges 500.09 766.27 Technical (Hospital) Services "EPOETIN ALFA 20,000 UNIT/ML INJECTION SOLUTION" RX-14643 CDM J0885 HCPCS 636 RC 55513-0478-10 NDC outpatient 1 ML 806.6 806.6 MEDICA (COMMERCIAL) 94265 [3081118] MEDICA CLAIMS [308111801] 725.94 percent of total billed charges 500.09 766.27 Technical (Hospital) Services "EPOETIN ALFA 20,000 UNIT/ML INJECTION SOLUTION" RX-14643 CDM J0885 HCPCS 636 RC 55513-0478-10 NDC outpatient 1 ML 806.6 806.6 CIGNA 62308 [3081051] CIGNA 62308 [308105105] 645.28 percent of total billed charges 500.09 766.27 Technical (Hospital) Services "EPOETIN ALFA 20,000 UNIT/ML INJECTION SOLUTION" RX-14643 CDM J0885 HCPCS 636 RC 55513-0478-10 NDC outpatient 1 ML 806.6 806.6 CIGNA 62308 [3081051] CIGNA STATE OF WYOMING [308105107] 645.28 percent of total billed charges 500.09 766.27 Technical (Hospital) Services "EPOETIN ALFA 20,000 UNIT/ML INJECTION SOLUTION" RX-14643 CDM J0885 HCPCS 636 RC 55513-0478-10 NDC outpatient 1 ML 806.6 806.6 UNITED HEALTHCARE (COMMERCIAL) [3081199] UNITED HEALTHCARE 87726 [308119901] 500.09 percent of total billed charges 500.09 766.27 Technical (Hospital) Services "EPOETIN ALFA 20,000 UNIT/ML INJECTION SOLUTION" RX-14643 CDM J0885 HCPCS 636 RC 55513-0478-10 NDC outpatient 1 ML 806.6 806.6 MULTIPLAN INC 34080 [3081285] MULTIPLAN INC [308128501] 766.27 percent of total billed charges 500.09 766.27 Technical (Hospital) Services "EPOETIN ALFA 20,000 UNIT/ML INJECTION SOLUTION" RX-14643 CDM J0885 HCPCS 636 RC 55513-0478-10 NDC outpatient 1 ML 806.6 806.6 HEALTHPARTNERS SX009 HEALTHPARTNERS 645.28 percent of total billed charges 500.09 766.27 Technical (Hospital) Services "EPOETIN ALFA 10,000 UNIT/ML INJECTION SOLUTION" RX-9938 CDM J0885 HCPCS 636 RC 59676-0310-01 NDC inpatient 1 ML 667.25 667.25 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES EPO [308136803] 528.33 percent of total billed charges 413.7 633.89 Technical (Hospital) Services "EPOETIN ALFA 10,000 UNIT/ML INJECTION SOLUTION" RX-9938 CDM J0885 HCPCS 636 RC 59676-0310-01 NDC inpatient 1 ML 667.25 667.25 CIGNA 62308 [3081051] CIGNA 62308 [308105105] 528.33 percent of total billed charges 413.7 633.89 Technical (Hospital) Services "EPOETIN ALFA 10,000 UNIT/ML INJECTION SOLUTION" RX-9938 CDM J0885 HCPCS 636 RC 59676-0310-01 NDC inpatient 1 ML 667.25 667.25 CIGNA 62308 [3081051] CIGNA STATE OF WYOMING [308105107] 528.33 percent of total billed charges 413.7 633.89 Technical (Hospital) Services "EPOETIN ALFA 10,000 UNIT/ML INJECTION SOLUTION" RX-9938 CDM J0885 HCPCS 636 RC 59676-0310-01 NDC inpatient 1 ML 667.25 667.25 UNITED HEALTHCARE (COMMERCIAL) [3081199] UNITED HEALTHCARE 87726 [308119901] 413.7 percent of total billed charges 413.7 633.89 Technical (Hospital) Services "EPOETIN ALFA 10,000 UNIT/ML INJECTION SOLUTION" RX-9938 CDM J0885 HCPCS 636 RC 59676-0310-01 NDC inpatient 1 ML 667.25 667.25 BLUE CROSS BLUE SHIELD WELLMARK SB889 [3081026] BCBS WYOMING [308102603] 633.89 percent of total billed charges 413.7 633.89 Technical (Hospital) Services "EPOETIN ALFA 10,000 UNIT/ML INJECTION SOLUTION" RX-9938 CDM J0885 HCPCS 636 RC 59676-0310-01 NDC inpatient 1 ML 667.25 667.25 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES PPO [308136801] 528.33 percent of total billed charges 413.7 633.89 Technical (Hospital) Services "EPOETIN ALFA 10,000 UNIT/ML INJECTION SOLUTION" RX-9938 CDM J0885 HCPCS 636 RC 59676-0310-01 NDC inpatient 1 ML 667.25 667.25 HEALTHPARTNERS SX009 HEALTHPARTNERS 528.33 percent of total billed charges 413.7 633.89 Technical (Hospital) Services "EPOETIN ALFA 10,000 UNIT/ML INJECTION SOLUTION" RX-9938 CDM J0885 HCPCS 636 RC 59676-0310-01 NDC inpatient 1 ML 667.25 667.25 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES HDHP [308136802] 528.33 percent of total billed charges 413.7 633.89 Technical (Hospital) Services "EPOETIN ALFA 10,000 UNIT/ML INJECTION SOLUTION" RX-9938 CDM J0885 HCPCS 636 RC 59676-0310-01 NDC inpatient 1 ML 667.25 667.25 MULTIPLAN INC 34080 [3081285] MULTIPLAN INC [308128501] 633.89 percent of total billed charges 413.7 633.89 Technical (Hospital) Services "EPOETIN ALFA 10,000 UNIT/ML INJECTION SOLUTION" RX-9938 CDM J0885 HCPCS 636 RC 59676-0310-01 NDC inpatient 1 ML 667.25 667.25 MEDICA (COMMERCIAL) 94265 [3081118] MEDICA CLAIMS [308111801] 600.53 percent of total billed charges 413.7 633.89 Technical (Hospital) Services "EPOETIN ALFA 10,000 UNIT/ML INJECTION SOLUTION" RX-9938 CDM J0885 HCPCS 636 RC 59676-0310-01 NDC outpatient 1 ML 667.25 667.25 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES HDHP [308136802] 533.8 percent of total billed charges 413.7 633.89 Technical (Hospital) Services "EPOETIN ALFA 10,000 UNIT/ML INJECTION SOLUTION" RX-9938 CDM J0885 HCPCS 636 RC 59676-0310-01 NDC outpatient 1 ML 667.25 667.25 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES EPO [308136803] 533.8 percent of total billed charges 413.7 633.89 Technical (Hospital) Services "EPOETIN ALFA 10,000 UNIT/ML INJECTION SOLUTION" RX-9938 CDM J0885 HCPCS 636 RC 59676-0310-01 NDC outpatient 1 ML 667.25 667.25 HEALTHPARTNERS SX009 HEALTHPARTNERS 533.8 percent of total billed charges 413.7 633.89 Technical (Hospital) Services "EPOETIN ALFA 10,000 UNIT/ML INJECTION SOLUTION" RX-9938 CDM J0885 HCPCS 636 RC 59676-0310-01 NDC outpatient 1 ML 667.25 667.25 MULTIPLAN INC 34080 [3081285] MULTIPLAN INC [308128501] 633.89 percent of total billed charges 413.7 633.89 Technical (Hospital) Services "EPOETIN ALFA 10,000 UNIT/ML INJECTION SOLUTION" RX-9938 CDM J0885 HCPCS 636 RC 59676-0310-01 NDC outpatient 1 ML 667.25 667.25 UNITED HEALTHCARE (COMMERCIAL) [3081199] UNITED HEALTHCARE 87726 [308119901] 413.7 percent of total billed charges 413.7 633.89 Technical (Hospital) Services "EPOETIN ALFA 10,000 UNIT/ML INJECTION SOLUTION" RX-9938 CDM J0885 HCPCS 636 RC 59676-0310-01 NDC outpatient 1 ML 667.25 667.25 MEDICA (COMMERCIAL) 94265 [3081118] MEDICA CLAIMS [308111801] 600.53 percent of total billed charges 413.7 633.89 Technical (Hospital) Services "EPOETIN ALFA 10,000 UNIT/ML INJECTION SOLUTION" RX-9938 CDM J0885 HCPCS 636 RC 59676-0310-01 NDC outpatient 1 ML 667.25 667.25 CIGNA 62308 [3081051] CIGNA 62308 [308105105] 533.8 percent of total billed charges 413.7 633.89 Technical (Hospital) Services "EPOETIN ALFA 10,000 UNIT/ML INJECTION SOLUTION" RX-9938 CDM J0885 HCPCS 636 RC 59676-0310-01 NDC outpatient 1 ML 667.25 667.25 CIGNA 62308 [3081051] CIGNA STATE OF WYOMING [308105107] 533.8 percent of total billed charges 413.7 633.89 Technical (Hospital) Services "EPOETIN ALFA 10,000 UNIT/ML INJECTION SOLUTION" RX-9938 CDM J0885 HCPCS 636 RC 59676-0310-01 NDC outpatient 1 ML 667.25 667.25 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES PPO [308136801] 533.8 percent of total billed charges 413.7 633.89 Technical (Hospital) Services "EPOETIN ALFA 10,000 UNIT/ML INJECTION SOLUTION" RX-9938 CDM J0885 HCPCS 636 RC 59676-0310-01 NDC outpatient 1 ML 667.25 667.25 BLUE CROSS BLUE SHIELD WELLMARK SB889 [3081026] BCBS WYOMING [308102603] 633.89 percent of total billed charges 413.7 633.89 Technical (Hospital) Services "EPOETIN ALFA 4,000 UNIT/ML INJECTION SOLUTION" RX-9941 CDM J0885 HCPCS 636 RC 55513-0148-01 NDC inpatient 1 ML 328.32 328.32 CIGNA 62308 [3081051] CIGNA 62308 [308105105] 259.96 percent of total billed charges 203.56 311.9 Technical (Hospital) Services "EPOETIN ALFA 4,000 UNIT/ML INJECTION SOLUTION" RX-9941 CDM J0885 HCPCS 636 RC 55513-0148-01 NDC inpatient 1 ML 328.32 328.32 CIGNA 62308 [3081051] CIGNA STATE OF WYOMING [308105107] 259.96 percent of total billed charges 203.56 311.9 Technical (Hospital) Services "EPOETIN ALFA 4,000 UNIT/ML INJECTION SOLUTION" RX-9941 CDM J0885 HCPCS 636 RC 55513-0148-01 NDC inpatient 1 ML 328.32 328.32 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES EPO [308136803] 259.96 percent of total billed charges 203.56 311.9 Technical (Hospital) Services "EPOETIN ALFA 4,000 UNIT/ML INJECTION SOLUTION" RX-9941 CDM J0885 HCPCS 636 RC 55513-0148-01 NDC inpatient 1 ML 328.32 328.32 UNITED HEALTHCARE (COMMERCIAL) [3081199] UNITED HEALTHCARE 87726 [308119901] 203.56 percent of total billed charges 203.56 311.9 Technical (Hospital) Services "EPOETIN ALFA 4,000 UNIT/ML INJECTION SOLUTION" RX-9941 CDM J0885 HCPCS 636 RC 55513-0148-01 NDC inpatient 1 ML 328.32 328.32 BLUE CROSS BLUE SHIELD WELLMARK SB889 [3081026] BCBS WYOMING [308102603] 311.9 percent of total billed charges 203.56 311.9 Technical (Hospital) Services "EPOETIN ALFA 4,000 UNIT/ML INJECTION SOLUTION" RX-9941 CDM J0885 HCPCS 636 RC 55513-0148-01 NDC inpatient 1 ML 328.32 328.32 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES HDHP [308136802] 259.96 percent of total billed charges 203.56 311.9 Technical (Hospital) Services "EPOETIN ALFA 4,000 UNIT/ML INJECTION SOLUTION" RX-9941 CDM J0885 HCPCS 636 RC 55513-0148-01 NDC inpatient 1 ML 328.32 328.32 HEALTHPARTNERS SX009 HEALTHPARTNERS 259.96 percent of total billed charges 203.56 311.9 Technical (Hospital) Services "EPOETIN ALFA 4,000 UNIT/ML INJECTION SOLUTION" RX-9941 CDM J0885 HCPCS 636 RC 55513-0148-01 NDC inpatient 1 ML 328.32 328.32 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES PPO [308136801] 259.96 percent of total billed charges 203.56 311.9 Technical (Hospital) Services "EPOETIN ALFA 4,000 UNIT/ML INJECTION SOLUTION" RX-9941 CDM J0885 HCPCS 636 RC 55513-0148-01 NDC inpatient 1 ML 328.32 328.32 MULTIPLAN INC 34080 [3081285] MULTIPLAN INC [308128501] 311.9 percent of total billed charges 203.56 311.9 Technical (Hospital) Services "EPOETIN ALFA 4,000 UNIT/ML INJECTION SOLUTION" RX-9941 CDM J0885 HCPCS 636 RC 55513-0148-01 NDC inpatient 1 ML 328.32 328.32 MEDICA (COMMERCIAL) 94265 [3081118] MEDICA CLAIMS [308111801] 295.49 percent of total billed charges 203.56 311.9 Technical (Hospital) Services "EPOETIN ALFA 4,000 UNIT/ML INJECTION SOLUTION" RX-9941 CDM J0885 HCPCS 636 RC 55513-0148-01 NDC outpatient 1 ML 328.32 328.32 BLUE CROSS BLUE SHIELD WELLMARK SB889 [3081026] BCBS WYOMING [308102603] 311.9 percent of total billed charges 203.56 311.9 Technical (Hospital) Services "EPOETIN ALFA 4,000 UNIT/ML INJECTION SOLUTION" RX-9941 CDM J0885 HCPCS 636 RC 55513-0148-01 NDC outpatient 1 ML 328.32 328.32 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES PPO [308136801] 262.66 percent of total billed charges 203.56 311.9 Technical (Hospital) Services "EPOETIN ALFA 4,000 UNIT/ML INJECTION SOLUTION" RX-9941 CDM J0885 HCPCS 636 RC 55513-0148-01 NDC outpatient 1 ML 328.32 328.32 CIGNA 62308 [3081051] CIGNA 62308 [308105105] 262.66 percent of total billed charges 203.56 311.9 Technical (Hospital) Services "EPOETIN ALFA 4,000 UNIT/ML INJECTION SOLUTION" RX-9941 CDM J0885 HCPCS 636 RC 55513-0148-01 NDC outpatient 1 ML 328.32 328.32 CIGNA 62308 [3081051] CIGNA STATE OF WYOMING [308105107] 262.66 percent of total billed charges 203.56 311.9 Technical (Hospital) Services "EPOETIN ALFA 4,000 UNIT/ML INJECTION SOLUTION" RX-9941 CDM J0885 HCPCS 636 RC 55513-0148-01 NDC outpatient 1 ML 328.32 328.32 MEDICA (COMMERCIAL) 94265 [3081118] MEDICA CLAIMS [308111801] 295.49 percent of total billed charges 203.56 311.9 Technical (Hospital) Services "EPOETIN ALFA 4,000 UNIT/ML INJECTION SOLUTION" RX-9941 CDM J0885 HCPCS 636 RC 55513-0148-01 NDC outpatient 1 ML 328.32 328.32 HEALTHPARTNERS SX009 HEALTHPARTNERS 262.66 percent of total billed charges 203.56 311.9 Technical (Hospital) Services "EPOETIN ALFA 4,000 UNIT/ML INJECTION SOLUTION" RX-9941 CDM J0885 HCPCS 636 RC 55513-0148-01 NDC outpatient 1 ML 328.32 328.32 UNITED HEALTHCARE (COMMERCIAL) [3081199] UNITED HEALTHCARE 87726 [308119901] 203.56 percent of total billed charges 203.56 311.9 Technical (Hospital) Services "EPOETIN ALFA 4,000 UNIT/ML INJECTION SOLUTION" RX-9941 CDM J0885 HCPCS 636 RC 55513-0148-01 NDC outpatient 1 ML 328.32 328.32 MULTIPLAN INC 34080 [3081285] MULTIPLAN INC [308128501] 311.9 percent of total billed charges 203.56 311.9 Technical (Hospital) Services "EPOETIN ALFA 4,000 UNIT/ML INJECTION SOLUTION" RX-9941 CDM J0885 HCPCS 636 RC 55513-0148-01 NDC outpatient 1 ML 328.32 328.32 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES HDHP [308136802] 262.66 percent of total billed charges 203.56 311.9 Technical (Hospital) Services "EPOETIN ALFA 4,000 UNIT/ML INJECTION SOLUTION" RX-9941 CDM J0885 HCPCS 636 RC 55513-0148-01 NDC outpatient 1 ML 328.32 328.32 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES EPO [308136803] 262.66 percent of total billed charges 203.56 311.9 Technical (Hospital) Services DARBEPOETIN ALFA 25 MCG/0.42 ML IN POLYSORBATE INJECTION SYRINGE RX-129764 CDM J0881 HCPCS 636 RC 55513-0057-04 NDC inpatient 0.42 ML 543.5 543.5 BLUE CROSS BLUE SHIELD WELLMARK SB889 [3081026] BCBS WYOMING [308102603] 516.33 percent of total billed charges 336.97 516.33 Technical (Hospital) Services DARBEPOETIN ALFA 25 MCG/0.42 ML IN POLYSORBATE INJECTION SYRINGE RX-129764 CDM J0881 HCPCS 636 RC 55513-0057-04 NDC inpatient 0.42 ML 543.5 543.5 UNITED HEALTHCARE (COMMERCIAL) [3081199] UNITED HEALTHCARE 87726 [308119901] 336.97 percent of total billed charges 336.97 516.33 Technical (Hospital) Services DARBEPOETIN ALFA 25 MCG/0.42 ML IN POLYSORBATE INJECTION SYRINGE RX-129764 CDM J0881 HCPCS 636 RC 55513-0057-04 NDC inpatient 0.42 ML 543.5 543.5 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES EPO [308136803] 430.34 percent of total billed charges 336.97 516.33 Technical (Hospital) Services DARBEPOETIN ALFA 25 MCG/0.42 ML IN POLYSORBATE INJECTION SYRINGE RX-129764 CDM J0881 HCPCS 636 RC 55513-0057-04 NDC inpatient 0.42 ML 543.5 543.5 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES HDHP [308136802] 430.34 percent of total billed charges 336.97 516.33 Technical (Hospital) Services DARBEPOETIN ALFA 25 MCG/0.42 ML IN POLYSORBATE INJECTION SYRINGE RX-129764 CDM J0881 HCPCS 636 RC 55513-0057-04 NDC outpatient 0.42 ML 543.5 543.5 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES EPO [308136803] 434.8 percent of total billed charges 336.97 516.33 Technical (Hospital) Services DARBEPOETIN ALFA 25 MCG/0.42 ML IN POLYSORBATE INJECTION SYRINGE RX-129764 CDM J0881 HCPCS 636 RC 55513-0057-04 NDC outpatient 0.42 ML 543.5 543.5 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES HDHP [308136802] 434.8 percent of total billed charges 336.97 516.33 Technical (Hospital) Services DARBEPOETIN ALFA 25 MCG/0.42 ML IN POLYSORBATE INJECTION SYRINGE RX-129764 CDM J0881 HCPCS 636 RC 55513-0057-04 NDC outpatient 0.42 ML 543.5 543.5 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES PPO [308136801] 434.8 percent of total billed charges 336.97 516.33 Technical (Hospital) Services DARBEPOETIN ALFA 25 MCG/0.42 ML IN POLYSORBATE INJECTION SYRINGE RX-129764 CDM J0881 HCPCS 636 RC 55513-0057-04 NDC outpatient 0.42 ML 543.5 543.5 UNITED HEALTHCARE (COMMERCIAL) [3081199] UNITED HEALTHCARE 87726 [308119901] 336.97 percent of total billed charges 336.97 516.33 Technical (Hospital) Services DARBEPOETIN ALFA 25 MCG/0.42 ML IN POLYSORBATE INJECTION SYRINGE RX-129764 CDM J0881 HCPCS 636 RC 55513-0057-04 NDC outpatient 0.42 ML 543.5 543.5 MULTIPLAN INC 34080 [3081285] MULTIPLAN INC [308128501] 516.33 percent of total billed charges 336.97 516.33 Technical (Hospital) Services DARBEPOETIN ALFA 25 MCG/0.42 ML IN POLYSORBATE INJECTION SYRINGE RX-129764 CDM J0881 HCPCS 636 RC 55513-0057-04 NDC inpatient 0.42 ML 543.5 543.5 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES PPO [308136801] 430.34 percent of total billed charges 336.97 516.33 Technical (Hospital) Services DARBEPOETIN ALFA 25 MCG/0.42 ML IN POLYSORBATE INJECTION SYRINGE RX-129764 CDM J0881 HCPCS 636 RC 55513-0057-04 NDC inpatient 0.42 ML 543.5 543.5 CIGNA 62308 [3081051] CIGNA 62308 [308105105] 430.34 percent of total billed charges 336.97 516.33 Technical (Hospital) Services DARBEPOETIN ALFA 25 MCG/0.42 ML IN POLYSORBATE INJECTION SYRINGE RX-129764 CDM J0881 HCPCS 636 RC 55513-0057-04 NDC inpatient 0.42 ML 543.5 543.5 CIGNA 62308 [3081051] CIGNA STATE OF WYOMING [308105107] 430.34 percent of total billed charges 336.97 516.33 Technical (Hospital) Services DARBEPOETIN ALFA 25 MCG/0.42 ML IN POLYSORBATE INJECTION SYRINGE RX-129764 CDM J0881 HCPCS 636 RC 55513-0057-04 NDC inpatient 0.42 ML 543.5 543.5 HEALTHPARTNERS SX009 HEALTHPARTNERS 430.34 percent of total billed charges 336.97 516.33 Technical (Hospital) Services DARBEPOETIN ALFA 25 MCG/0.42 ML IN POLYSORBATE INJECTION SYRINGE RX-129764 CDM J0881 HCPCS 636 RC 55513-0057-04 NDC inpatient 0.42 ML 543.5 543.5 MEDICA (COMMERCIAL) 94265 [3081118] MEDICA CLAIMS [308111801] 489.15 percent of total billed charges 336.97 516.33 Technical (Hospital) Services DARBEPOETIN ALFA 25 MCG/0.42 ML IN POLYSORBATE INJECTION SYRINGE RX-129764 CDM J0881 HCPCS 636 RC 55513-0057-04 NDC inpatient 0.42 ML 543.5 543.5 MULTIPLAN INC 34080 [3081285] MULTIPLAN INC [308128501] 516.33 percent of total billed charges 336.97 516.33 Technical (Hospital) Services DARBEPOETIN ALFA 25 MCG/0.42 ML IN POLYSORBATE INJECTION SYRINGE RX-129764 CDM J0881 HCPCS 636 RC 55513-0057-04 NDC outpatient 0.42 ML 543.5 543.5 CIGNA 62308 [3081051] CIGNA 62308 [308105105] 434.8 percent of total billed charges 336.97 516.33 Technical (Hospital) Services DARBEPOETIN ALFA 25 MCG/0.42 ML IN POLYSORBATE INJECTION SYRINGE RX-129764 CDM J0881 HCPCS 636 RC 55513-0057-04 NDC outpatient 0.42 ML 543.5 543.5 CIGNA 62308 [3081051] CIGNA STATE OF WYOMING [308105107] 434.8 percent of total billed charges 336.97 516.33 Technical (Hospital) Services DARBEPOETIN ALFA 25 MCG/0.42 ML IN POLYSORBATE INJECTION SYRINGE RX-129764 CDM J0881 HCPCS 636 RC 55513-0057-04 NDC outpatient 0.42 ML 543.5 543.5 MEDICA (COMMERCIAL) 94265 [3081118] MEDICA CLAIMS [308111801] 489.15 percent of total billed charges 336.97 516.33 Technical (Hospital) Services DARBEPOETIN ALFA 25 MCG/0.42 ML IN POLYSORBATE INJECTION SYRINGE RX-129764 CDM J0881 HCPCS 636 RC 55513-0057-04 NDC outpatient 0.42 ML 543.5 543.5 BLUE CROSS BLUE SHIELD WELLMARK SB889 [3081026] BCBS WYOMING [308102603] 516.33 percent of total billed charges 336.97 516.33 Technical (Hospital) Services DARBEPOETIN ALFA 25 MCG/0.42 ML IN POLYSORBATE INJECTION SYRINGE RX-129764 CDM J0881 HCPCS 636 RC 55513-0057-04 NDC outpatient 0.42 ML 543.5 543.5 HEALTHPARTNERS SX009 HEALTHPARTNERS 434.8 percent of total billed charges 336.97 516.33 Technical (Hospital) Services ANTIVENIN CROTALIDAE (EQUINE) SOLUTION FOR INJECTION RX-175240 CDM J0841 HCPCS 636 RC 66621-0790-02 NDC outpatient 10 ML 2545 2545 MEDICA (COMMERCIAL) 94265 [3081118] MEDICA CLAIMS [308111801] 2290.5 percent of total billed charges 1577.9 2417.75 Technical (Hospital) Services ANTIVENIN CROTALIDAE (EQUINE) SOLUTION FOR INJECTION RX-175240 CDM J0841 HCPCS 636 RC 66621-0790-02 NDC outpatient 10 ML 2545 2545 MULTIPLAN INC 34080 [3081285] MULTIPLAN INC [308128501] 2417.75 percent of total billed charges 1577.9 2417.75 Technical (Hospital) Services ANTIVENIN CROTALIDAE (EQUINE) SOLUTION FOR INJECTION RX-175240 CDM J0841 HCPCS 636 RC 66621-0790-02 NDC outpatient 10 ML 2545 2545 HEALTHPARTNERS SX009 HEALTHPARTNERS 2036 percent of total billed charges 1577.9 2417.75 Technical (Hospital) Services ANTIVENIN CROTALIDAE (EQUINE) SOLUTION FOR INJECTION RX-175240 CDM J0841 HCPCS 636 RC 66621-0790-02 NDC outpatient 10 ML 2545 2545 UNITED HEALTHCARE (COMMERCIAL) [3081199] UNITED HEALTHCARE 87726 [308119901] 1577.9 percent of total billed charges 1577.9 2417.75 Technical (Hospital) Services ANTIVENIN CROTALIDAE (EQUINE) SOLUTION FOR INJECTION RX-175240 CDM J0841 HCPCS 636 RC 66621-0790-02 NDC outpatient 10 ML 2545 2545 BLUE CROSS BLUE SHIELD WELLMARK SB889 [3081026] BCBS WYOMING [308102603] 2417.75 percent of total billed charges 1577.9 2417.75 Technical (Hospital) Services ANTIVENIN CROTALIDAE (EQUINE) SOLUTION FOR INJECTION RX-175240 CDM J0841 HCPCS 636 RC 66621-0790-02 NDC outpatient 10 ML 2545 2545 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES EPO [308136803] 2036 percent of total billed charges 1577.9 2417.75 Technical (Hospital) Services ANTIVENIN CROTALIDAE (EQUINE) SOLUTION FOR INJECTION RX-175240 CDM J0841 HCPCS 636 RC 66621-0790-02 NDC outpatient 10 ML 2545 2545 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES HDHP [308136802] 2036 percent of total billed charges 1577.9 2417.75 Technical (Hospital) Services ANTIVENIN CROTALIDAE (EQUINE) SOLUTION FOR INJECTION RX-175240 CDM J0841 HCPCS 636 RC 66621-0790-02 NDC outpatient 10 ML 2545 2545 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES PPO [308136801] 2036 percent of total billed charges 1577.9 2417.75 Technical (Hospital) Services ANTIVENIN CROTALIDAE (EQUINE) SOLUTION FOR INJECTION RX-175240 CDM J0841 HCPCS 636 RC 66621-0790-02 NDC outpatient 10 ML 2545 2545 CIGNA 62308 [3081051] CIGNA 62308 [308105105] 2036 percent of total billed charges 1577.9 2417.75 Technical (Hospital) Services ANTIVENIN CROTALIDAE (EQUINE) SOLUTION FOR INJECTION RX-175240 CDM J0841 HCPCS 636 RC 66621-0790-02 NDC outpatient 10 ML 2545 2545 CIGNA 62308 [3081051] CIGNA STATE OF WYOMING [308105107] 2036 percent of total billed charges 1577.9 2417.75 Technical (Hospital) Services ANTIVENIN CROTALIDAE (EQUINE) SOLUTION FOR INJECTION RX-175240 CDM J0841 HCPCS 636 RC 66621-0790-02 NDC inpatient 10 ML 2545 2545 CIGNA 62308 [3081051] CIGNA 62308 [308105105] 2015.13 percent of total billed charges 1577.9 2417.75 Technical (Hospital) Services ANTIVENIN CROTALIDAE (EQUINE) SOLUTION FOR INJECTION RX-175240 CDM J0841 HCPCS 636 RC 66621-0790-02 NDC inpatient 10 ML 2545 2545 CIGNA 62308 [3081051] CIGNA STATE OF WYOMING [308105107] 2015.13 percent of total billed charges 1577.9 2417.75 Technical (Hospital) Services ANTIVENIN CROTALIDAE (EQUINE) SOLUTION FOR INJECTION RX-175240 CDM J0841 HCPCS 636 RC 66621-0790-02 NDC inpatient 10 ML 2545 2545 BLUE CROSS BLUE SHIELD WELLMARK SB889 [3081026] BCBS WYOMING [308102603] 2417.75 percent of total billed charges 1577.9 2417.75 Technical (Hospital) Services ANTIVENIN CROTALIDAE (EQUINE) SOLUTION FOR INJECTION RX-175240 CDM J0841 HCPCS 636 RC 66621-0790-02 NDC inpatient 10 ML 2545 2545 UNITED HEALTHCARE (COMMERCIAL) [3081199] UNITED HEALTHCARE 87726 [308119901] 1577.9 percent of total billed charges 1577.9 2417.75 Technical (Hospital) Services ANTIVENIN CROTALIDAE (EQUINE) SOLUTION FOR INJECTION RX-175240 CDM J0841 HCPCS 636 RC 66621-0790-02 NDC inpatient 10 ML 2545 2545 MEDICA (COMMERCIAL) 94265 [3081118] MEDICA CLAIMS [308111801] 2290.5 percent of total billed charges 1577.9 2417.75 Technical (Hospital) Services ANTIVENIN CROTALIDAE (EQUINE) SOLUTION FOR INJECTION RX-175240 CDM J0841 HCPCS 636 RC 66621-0790-02 NDC inpatient 10 ML 2545 2545 MULTIPLAN INC 34080 [3081285] MULTIPLAN INC [308128501] 2417.75 percent of total billed charges 1577.9 2417.75 Technical (Hospital) Services ANTIVENIN CROTALIDAE (EQUINE) SOLUTION FOR INJECTION RX-175240 CDM J0841 HCPCS 636 RC 66621-0790-02 NDC inpatient 10 ML 2545 2545 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES EPO [308136803] 2015.13 percent of total billed charges 1577.9 2417.75 Technical (Hospital) Services ANTIVENIN CROTALIDAE (EQUINE) SOLUTION FOR INJECTION RX-175240 CDM J0841 HCPCS 636 RC 66621-0790-02 NDC inpatient 10 ML 2545 2545 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES HDHP [308136802] 2015.13 percent of total billed charges 1577.9 2417.75 Technical (Hospital) Services ANTIVENIN CROTALIDAE (EQUINE) SOLUTION FOR INJECTION RX-175240 CDM J0841 HCPCS 636 RC 66621-0790-02 NDC inpatient 10 ML 2545 2545 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES PPO [308136801] 2015.13 percent of total billed charges 1577.9 2417.75 Technical (Hospital) Services ANTIVENIN CROTALIDAE (EQUINE) SOLUTION FOR INJECTION RX-175240 CDM J0841 HCPCS 636 RC 66621-0790-02 NDC inpatient 10 ML 2545 2545 HEALTHPARTNERS SX009 HEALTHPARTNERS 2015.13 percent of total billed charges 1577.9 2417.75 Technical (Hospital) Services PROCHLORPERAZINE EDISYLATE 10 MG/2 ML (5 MG/ML) INJECTION SOLUTION RX-6580 CDM J0780 HCPCS 636 RC 23155-0523-41 NDC inpatient 2 ML 69.13 69.13 MEDICA (COMMERCIAL) 94265 [3081118] MEDICA CLAIMS [308111801] 62.22 percent of total billed charges 42.86 65.67 Technical (Hospital) Services PROCHLORPERAZINE EDISYLATE 10 MG/2 ML (5 MG/ML) INJECTION SOLUTION RX-6580 CDM J0780 HCPCS 636 RC 23155-0523-41 NDC inpatient 2 ML 69.13 69.13 MULTIPLAN INC 34080 [3081285] MULTIPLAN INC [308128501] 65.67 percent of total billed charges 42.86 65.67 Technical (Hospital) Services PROCHLORPERAZINE EDISYLATE 10 MG/2 ML (5 MG/ML) INJECTION SOLUTION RX-6580 CDM J0780 HCPCS 636 RC 23155-0523-41 NDC inpatient 2 ML 69.13 69.13 BLUE CROSS BLUE SHIELD WELLMARK SB889 [3081026] BCBS WYOMING [308102603] 65.67 percent of total billed charges 42.86 65.67 Technical (Hospital) Services PROCHLORPERAZINE EDISYLATE 10 MG/2 ML (5 MG/ML) INJECTION SOLUTION RX-6580 CDM J0780 HCPCS 636 RC 23155-0523-41 NDC inpatient 2 ML 69.13 69.13 UNITED HEALTHCARE (COMMERCIAL) [3081199] UNITED HEALTHCARE 87726 [308119901] 42.86 percent of total billed charges 42.86 65.67 Technical (Hospital) Services PROCHLORPERAZINE EDISYLATE 10 MG/2 ML (5 MG/ML) INJECTION SOLUTION RX-6580 CDM J0780 HCPCS 636 RC 23155-0523-41 NDC inpatient 2 ML 69.13 69.13 CIGNA 62308 [3081051] CIGNA 62308 [308105105] 54.74 percent of total billed charges 42.86 65.67 Technical (Hospital) Services PROCHLORPERAZINE EDISYLATE 10 MG/2 ML (5 MG/ML) INJECTION SOLUTION RX-6580 CDM J0780 HCPCS 636 RC 23155-0523-41 NDC inpatient 2 ML 69.13 69.13 CIGNA 62308 [3081051] CIGNA STATE OF WYOMING [308105107] 54.74 percent of total billed charges 42.86 65.67 Technical (Hospital) Services PROCHLORPERAZINE EDISYLATE 10 MG/2 ML (5 MG/ML) INJECTION SOLUTION RX-6580 CDM J0780 HCPCS 636 RC 23155-0523-41 NDC inpatient 2 ML 69.13 69.13 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES HDHP [308136802] 54.74 percent of total billed charges 42.86 65.67 Technical (Hospital) Services PROCHLORPERAZINE EDISYLATE 10 MG/2 ML (5 MG/ML) INJECTION SOLUTION RX-6580 CDM J0780 HCPCS 636 RC 23155-0523-41 NDC inpatient 2 ML 69.13 69.13 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES PPO [308136801] 54.74 percent of total billed charges 42.86 65.67 Technical (Hospital) Services PROCHLORPERAZINE EDISYLATE 10 MG/2 ML (5 MG/ML) INJECTION SOLUTION RX-6580 CDM J0780 HCPCS 636 RC 23155-0523-41 NDC inpatient 2 ML 69.13 69.13 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES EPO [308136803] 54.74 percent of total billed charges 42.86 65.67 Technical (Hospital) Services PROCHLORPERAZINE EDISYLATE 10 MG/2 ML (5 MG/ML) INJECTION SOLUTION RX-6580 CDM J0780 HCPCS 636 RC 23155-0523-41 NDC inpatient 2 ML 69.13 69.13 HEALTHPARTNERS SX009 HEALTHPARTNERS 54.74 percent of total billed charges 42.86 65.67 Technical (Hospital) Services PROCHLORPERAZINE EDISYLATE 10 MG/2 ML (5 MG/ML) INJECTION SOLUTION RX-6580 CDM J0780 HCPCS 636 RC 23155-0523-41 NDC outpatient 2 ML 69.13 69.13 MEDICA (COMMERCIAL) 94265 [3081118] MEDICA CLAIMS [308111801] 62.22 percent of total billed charges 42.86 65.67 Technical (Hospital) Services PROCHLORPERAZINE EDISYLATE 10 MG/2 ML (5 MG/ML) INJECTION SOLUTION RX-6580 CDM J0780 HCPCS 636 RC 23155-0523-41 NDC outpatient 2 ML 69.13 69.13 BLUE CROSS BLUE SHIELD WELLMARK SB889 [3081026] BCBS WYOMING [308102603] 65.67 percent of total billed charges 42.86 65.67 Technical (Hospital) Services PROCHLORPERAZINE EDISYLATE 10 MG/2 ML (5 MG/ML) INJECTION SOLUTION RX-6580 CDM J0780 HCPCS 636 RC 23155-0523-41 NDC outpatient 2 ML 69.13 69.13 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES EPO [308136803] 55.3 percent of total billed charges 42.86 65.67 Technical (Hospital) Services PROCHLORPERAZINE EDISYLATE 10 MG/2 ML (5 MG/ML) INJECTION SOLUTION RX-6580 CDM J0780 HCPCS 636 RC 23155-0523-41 NDC outpatient 2 ML 69.13 69.13 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES HDHP [308136802] 55.3 percent of total billed charges 42.86 65.67 Technical (Hospital) Services PROCHLORPERAZINE EDISYLATE 10 MG/2 ML (5 MG/ML) INJECTION SOLUTION RX-6580 CDM J0780 HCPCS 636 RC 23155-0523-41 NDC outpatient 2 ML 69.13 69.13 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES PPO [308136801] 55.3 percent of total billed charges 42.86 65.67 Technical (Hospital) Services PROCHLORPERAZINE EDISYLATE 10 MG/2 ML (5 MG/ML) INJECTION SOLUTION RX-6580 CDM J0780 HCPCS 636 RC 23155-0523-41 NDC outpatient 2 ML 69.13 69.13 HEALTHPARTNERS SX009 HEALTHPARTNERS 55.3 percent of total billed charges 42.86 65.67 Technical (Hospital) Services PROCHLORPERAZINE EDISYLATE 10 MG/2 ML (5 MG/ML) INJECTION SOLUTION RX-6580 CDM J0780 HCPCS 636 RC 23155-0523-41 NDC outpatient 2 ML 69.13 69.13 MULTIPLAN INC 34080 [3081285] MULTIPLAN INC [308128501] 65.67 percent of total billed charges 42.86 65.67 Technical (Hospital) Services PROCHLORPERAZINE EDISYLATE 10 MG/2 ML (5 MG/ML) INJECTION SOLUTION RX-6580 CDM J0780 HCPCS 636 RC 23155-0523-41 NDC outpatient 2 ML 69.13 69.13 UNITED HEALTHCARE (COMMERCIAL) [3081199] UNITED HEALTHCARE 87726 [308119901] 42.86 percent of total billed charges 42.86 65.67 Technical (Hospital) Services PROCHLORPERAZINE EDISYLATE 10 MG/2 ML (5 MG/ML) INJECTION SOLUTION RX-6580 CDM J0780 HCPCS 636 RC 23155-0523-41 NDC outpatient 2 ML 69.13 69.13 CIGNA 62308 [3081051] CIGNA 62308 [308105105] 55.3 percent of total billed charges 42.86 65.67 Technical (Hospital) Services PROCHLORPERAZINE EDISYLATE 10 MG/2 ML (5 MG/ML) INJECTION SOLUTION RX-6580 CDM J0780 HCPCS 636 RC 23155-0523-41 NDC outpatient 2 ML 69.13 69.13 CIGNA 62308 [3081051] CIGNA STATE OF WYOMING [308105107] 55.3 percent of total billed charges 42.86 65.67 Technical (Hospital) Services IMIPENEM-CILASTATIN 500 MG INTRAVENOUS SOLUTION RX-9603 CDM J0743 HCPCS 636 RC 63323-0322-94 NDC inpatient 10 ML 82.5 82.5 HEALTHPARTNERS SX009 HEALTHPARTNERS 65.32 percent of total billed charges 51.15 78.38 Technical (Hospital) Services IMIPENEM-CILASTATIN 500 MG INTRAVENOUS SOLUTION RX-9603 CDM J0743 HCPCS 636 RC 63323-0322-94 NDC inpatient 10 ML 82.5 82.5 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES HDHP [308136802] 65.32 percent of total billed charges 51.15 78.38 Technical (Hospital) Services IMIPENEM-CILASTATIN 500 MG INTRAVENOUS SOLUTION RX-9603 CDM J0743 HCPCS 636 RC 63323-0322-94 NDC inpatient 10 ML 82.5 82.5 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES EPO [308136803] 65.32 percent of total billed charges 51.15 78.38 Technical (Hospital) Services IMIPENEM-CILASTATIN 500 MG INTRAVENOUS SOLUTION RX-9603 CDM J0743 HCPCS 636 RC 63323-0322-94 NDC inpatient 10 ML 82.5 82.5 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES PPO [308136801] 65.32 percent of total billed charges 51.15 78.38 Technical (Hospital) Services IMIPENEM-CILASTATIN 500 MG INTRAVENOUS SOLUTION RX-9603 CDM J0743 HCPCS 636 RC 63323-0322-94 NDC inpatient 10 ML 82.5 82.5 MEDICA (COMMERCIAL) 94265 [3081118] MEDICA CLAIMS [308111801] 74.25 percent of total billed charges 51.15 78.38 Technical (Hospital) Services IMIPENEM-CILASTATIN 500 MG INTRAVENOUS SOLUTION RX-9603 CDM J0743 HCPCS 636 RC 63323-0322-94 NDC inpatient 10 ML 82.5 82.5 MULTIPLAN INC 34080 [3081285] MULTIPLAN INC [308128501] 78.38 percent of total billed charges 51.15 78.38 Technical (Hospital) Services IMIPENEM-CILASTATIN 500 MG INTRAVENOUS SOLUTION RX-9603 CDM J0743 HCPCS 636 RC 63323-0322-94 NDC inpatient 10 ML 82.5 82.5 BLUE CROSS BLUE SHIELD WELLMARK SB889 [3081026] BCBS WYOMING [308102603] 78.38 percent of total billed charges 51.15 78.38 Technical (Hospital) Services IMIPENEM-CILASTATIN 500 MG INTRAVENOUS SOLUTION RX-9603 CDM J0743 HCPCS 636 RC 63323-0322-94 NDC inpatient 10 ML 82.5 82.5 CIGNA 62308 [3081051] CIGNA STATE OF WYOMING [308105107] 65.32 percent of total billed charges 51.15 78.38 Technical (Hospital) Services IMIPENEM-CILASTATIN 500 MG INTRAVENOUS SOLUTION RX-9603 CDM J0743 HCPCS 636 RC 63323-0322-94 NDC inpatient 10 ML 82.5 82.5 CIGNA 62308 [3081051] CIGNA 62308 [308105105] 65.32 percent of total billed charges 51.15 78.38 Technical (Hospital) Services IMIPENEM-CILASTATIN 500 MG INTRAVENOUS SOLUTION RX-9603 CDM J0743 HCPCS 636 RC 63323-0322-94 NDC inpatient 10 ML 82.5 82.5 UNITED HEALTHCARE (COMMERCIAL) [3081199] UNITED HEALTHCARE 87726 [308119901] 51.15 percent of total billed charges 51.15 78.38 Technical (Hospital) Services IMIPENEM-CILASTATIN 500 MG INTRAVENOUS SOLUTION RX-9603 CDM J0743 HCPCS 636 RC 63323-0322-94 NDC outpatient 10 ML 82.5 82.5 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES EPO [308136803] 66 percent of total billed charges 51.15 78.38 Technical (Hospital) Services IMIPENEM-CILASTATIN 500 MG INTRAVENOUS SOLUTION RX-9603 CDM J0743 HCPCS 636 RC 63323-0322-94 NDC outpatient 10 ML 82.5 82.5 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES PPO [308136801] 66 percent of total billed charges 51.15 78.38 Technical (Hospital) Services IMIPENEM-CILASTATIN 500 MG INTRAVENOUS SOLUTION RX-9603 CDM J0743 HCPCS 636 RC 63323-0322-94 NDC outpatient 10 ML 82.5 82.5 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES HDHP [308136802] 66 percent of total billed charges 51.15 78.38 Technical (Hospital) Services IMIPENEM-CILASTATIN 500 MG INTRAVENOUS SOLUTION RX-9603 CDM J0743 HCPCS 636 RC 63323-0322-94 NDC outpatient 10 ML 82.5 82.5 HEALTHPARTNERS SX009 HEALTHPARTNERS 66 percent of total billed charges 51.15 78.38 Technical (Hospital) Services IMIPENEM-CILASTATIN 500 MG INTRAVENOUS SOLUTION RX-9603 CDM J0743 HCPCS 636 RC 63323-0322-94 NDC outpatient 10 ML 82.5 82.5 BLUE CROSS BLUE SHIELD WELLMARK SB889 [3081026] BCBS WYOMING [308102603] 78.38 percent of total billed charges 51.15 78.38 Technical (Hospital) Services IMIPENEM-CILASTATIN 500 MG INTRAVENOUS SOLUTION RX-9603 CDM J0743 HCPCS 636 RC 63323-0322-94 NDC outpatient 10 ML 82.5 82.5 UNITED HEALTHCARE (COMMERCIAL) [3081199] UNITED HEALTHCARE 87726 [308119901] 51.15 percent of total billed charges 51.15 78.38 Technical (Hospital) Services IMIPENEM-CILASTATIN 500 MG INTRAVENOUS SOLUTION RX-9603 CDM J0743 HCPCS 636 RC 63323-0322-94 NDC outpatient 10 ML 82.5 82.5 MULTIPLAN INC 34080 [3081285] MULTIPLAN INC [308128501] 78.38 percent of total billed charges 51.15 78.38 Technical (Hospital) Services IMIPENEM-CILASTATIN 500 MG INTRAVENOUS SOLUTION RX-9603 CDM J0743 HCPCS 636 RC 63323-0322-94 NDC outpatient 10 ML 82.5 82.5 MEDICA (COMMERCIAL) 94265 [3081118] MEDICA CLAIMS [308111801] 74.25 percent of total billed charges 51.15 78.38 Technical (Hospital) Services IMIPENEM-CILASTATIN 500 MG INTRAVENOUS SOLUTION RX-9603 CDM J0743 HCPCS 636 RC 63323-0322-94 NDC outpatient 10 ML 82.5 82.5 CIGNA 62308 [3081051] CIGNA 62308 [308105105] 66 percent of total billed charges 51.15 78.38 Technical (Hospital) Services IMIPENEM-CILASTATIN 500 MG INTRAVENOUS SOLUTION RX-9603 CDM J0743 HCPCS 636 RC 63323-0322-94 NDC outpatient 10 ML 82.5 82.5 CIGNA 62308 [3081051] CIGNA STATE OF WYOMING [308105107] 66 percent of total billed charges 51.15 78.38 Technical (Hospital) Services CERTOLIZUMAB PEGOL 400 MG (200 MG X 2 VIALS) LYPHOLIZED POWDER RX-91495 CDM J0717 HCPCS 636 RC 50474-0700-62 NDC inpatient 1 ML 5309.6 5309.6 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES EPO [308136803] 4204.14 percent of total billed charges 3291.95 5044.12 Technical (Hospital) Services CERTOLIZUMAB PEGOL 400 MG (200 MG X 2 VIALS) LYPHOLIZED POWDER RX-91495 CDM J0717 HCPCS 636 RC 50474-0700-62 NDC inpatient 1 ML 5309.6 5309.6 CIGNA 62308 [3081051] CIGNA 62308 [308105105] 4204.14 percent of total billed charges 3291.95 5044.12 Technical (Hospital) Services CERTOLIZUMAB PEGOL 400 MG (200 MG X 2 VIALS) LYPHOLIZED POWDER RX-91495 CDM J0717 HCPCS 636 RC 50474-0700-62 NDC inpatient 1 ML 5309.6 5309.6 CIGNA 62308 [3081051] CIGNA STATE OF WYOMING [308105107] 4204.14 percent of total billed charges 3291.95 5044.12 Technical (Hospital) Services CERTOLIZUMAB PEGOL 400 MG (200 MG X 2 VIALS) LYPHOLIZED POWDER RX-91495 CDM J0717 HCPCS 636 RC 50474-0700-62 NDC inpatient 1 ML 5309.6 5309.6 UNITED HEALTHCARE (COMMERCIAL) [3081199] UNITED HEALTHCARE 87726 [308119901] 3291.95 percent of total billed charges 3291.95 5044.12 Technical (Hospital) Services CERTOLIZUMAB PEGOL 400 MG (200 MG X 2 VIALS) LYPHOLIZED POWDER RX-91495 CDM J0717 HCPCS 636 RC 50474-0700-62 NDC inpatient 1 ML 5309.6 5309.6 BLUE CROSS BLUE SHIELD WELLMARK SB889 [3081026] BCBS WYOMING [308102603] 5044.12 percent of total billed charges 3291.95 5044.12 Technical (Hospital) Services CERTOLIZUMAB PEGOL 400 MG (200 MG X 2 VIALS) LYPHOLIZED POWDER RX-91495 CDM J0717 HCPCS 636 RC 50474-0700-62 NDC inpatient 1 ML 5309.6 5309.6 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES PPO [308136801] 4204.14 percent of total billed charges 3291.95 5044.12 Technical (Hospital) Services CERTOLIZUMAB PEGOL 400 MG (200 MG X 2 VIALS) LYPHOLIZED POWDER RX-91495 CDM J0717 HCPCS 636 RC 50474-0700-62 NDC inpatient 1 ML 5309.6 5309.6 HEALTHPARTNERS SX009 HEALTHPARTNERS 4204.14 percent of total billed charges 3291.95 5044.12 Technical (Hospital) Services CERTOLIZUMAB PEGOL 400 MG (200 MG X 2 VIALS) LYPHOLIZED POWDER RX-91495 CDM J0717 HCPCS 636 RC 50474-0700-62 NDC inpatient 1 ML 5309.6 5309.6 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES HDHP [308136802] 4204.14 percent of total billed charges 3291.95 5044.12 Technical (Hospital) Services CERTOLIZUMAB PEGOL 400 MG (200 MG X 2 VIALS) LYPHOLIZED POWDER RX-91495 CDM J0717 HCPCS 636 RC 50474-0700-62 NDC inpatient 1 ML 5309.6 5309.6 MEDICA (COMMERCIAL) 94265 [3081118] MEDICA CLAIMS [308111801] 4778.64 percent of total billed charges 3291.95 5044.12 Technical (Hospital) Services CERTOLIZUMAB PEGOL 400 MG (200 MG X 2 VIALS) LYPHOLIZED POWDER RX-91495 CDM J0717 HCPCS 636 RC 50474-0700-62 NDC inpatient 1 ML 5309.6 5309.6 MULTIPLAN INC 34080 [3081285] MULTIPLAN INC [308128501] 5044.12 percent of total billed charges 3291.95 5044.12 Technical (Hospital) Services CERTOLIZUMAB PEGOL 400 MG (200 MG X 2 VIALS) LYPHOLIZED POWDER RX-91495 CDM J0717 HCPCS 636 RC 50474-0700-62 NDC outpatient 1 ML 5309.6 5309.6 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES HDHP [308136802] 4247.68 percent of total billed charges 3291.95 5044.12 Technical (Hospital) Services CERTOLIZUMAB PEGOL 400 MG (200 MG X 2 VIALS) LYPHOLIZED POWDER RX-91495 CDM J0717 HCPCS 636 RC 50474-0700-62 NDC outpatient 1 ML 5309.6 5309.6 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES EPO [308136803] 4247.68 percent of total billed charges 3291.95 5044.12 Technical (Hospital) Services CERTOLIZUMAB PEGOL 400 MG (200 MG X 2 VIALS) LYPHOLIZED POWDER RX-91495 CDM J0717 HCPCS 636 RC 50474-0700-62 NDC outpatient 1 ML 5309.6 5309.6 HEALTHPARTNERS SX009 HEALTHPARTNERS 4247.68 percent of total billed charges 3291.95 5044.12 Technical (Hospital) Services CERTOLIZUMAB PEGOL 400 MG (200 MG X 2 VIALS) LYPHOLIZED POWDER RX-91495 CDM J0717 HCPCS 636 RC 50474-0700-62 NDC outpatient 1 ML 5309.6 5309.6 MULTIPLAN INC 34080 [3081285] MULTIPLAN INC [308128501] 5044.12 percent of total billed charges 3291.95 5044.12 Technical (Hospital) Services CERTOLIZUMAB PEGOL 400 MG (200 MG X 2 VIALS) LYPHOLIZED POWDER RX-91495 CDM J0717 HCPCS 636 RC 50474-0700-62 NDC outpatient 1 ML 5309.6 5309.6 UNITED HEALTHCARE (COMMERCIAL) [3081199] UNITED HEALTHCARE 87726 [308119901] 3291.95 percent of total billed charges 3291.95 5044.12 Technical (Hospital) Services CERTOLIZUMAB PEGOL 400 MG (200 MG X 2 VIALS) LYPHOLIZED POWDER RX-91495 CDM J0717 HCPCS 636 RC 50474-0700-62 NDC outpatient 1 ML 5309.6 5309.6 CIGNA 62308 [3081051] CIGNA 62308 [308105105] 4247.68 percent of total billed charges 3291.95 5044.12 Technical (Hospital) Services CERTOLIZUMAB PEGOL 400 MG (200 MG X 2 VIALS) LYPHOLIZED POWDER RX-91495 CDM J0717 HCPCS 636 RC 50474-0700-62 NDC outpatient 1 ML 5309.6 5309.6 CIGNA 62308 [3081051] CIGNA STATE OF WYOMING [308105107] 4247.68 percent of total billed charges 3291.95 5044.12 Technical (Hospital) Services CERTOLIZUMAB PEGOL 400 MG (200 MG X 2 VIALS) LYPHOLIZED POWDER RX-91495 CDM J0717 HCPCS 636 RC 50474-0700-62 NDC outpatient 1 ML 5309.6 5309.6 MEDICA (COMMERCIAL) 94265 [3081118] MEDICA CLAIMS [308111801] 4778.64 percent of total billed charges 3291.95 5044.12 Technical (Hospital) Services CERTOLIZUMAB PEGOL 400 MG (200 MG X 2 VIALS) LYPHOLIZED POWDER RX-91495 CDM J0717 HCPCS 636 RC 50474-0700-62 NDC outpatient 1 ML 5309.6 5309.6 BLUE CROSS BLUE SHIELD WELLMARK SB889 [3081026] BCBS WYOMING [308102603] 5044.12 percent of total billed charges 3291.95 5044.12 Technical (Hospital) Services CERTOLIZUMAB PEGOL 400 MG (200 MG X 2 VIALS) LYPHOLIZED POWDER RX-91495 CDM J0717 HCPCS 636 RC 50474-0700-62 NDC outpatient 1 ML 5309.6 5309.6 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES PPO [308136801] 4247.68 percent of total billed charges 3291.95 5044.12 Technical (Hospital) Services CERTOLIZUMAB PEGOL 400 MG/2 ML (200 MG/ML X2) SUBCUTANEOUS SYRINGE KIT RX-97853 CDM J0717 HCPCS 636 RC 50474-0710-79 NDC inpatient 1 ML 5309.6 5309.6 CIGNA 62308 [3081051] CIGNA 62308 [308105105] 4204.14 percent of total billed charges 3291.95 5044.12 Technical (Hospital) Services CERTOLIZUMAB PEGOL 400 MG/2 ML (200 MG/ML X2) SUBCUTANEOUS SYRINGE KIT RX-97853 CDM J0717 HCPCS 636 RC 50474-0710-79 NDC inpatient 1 ML 5309.6 5309.6 CIGNA 62308 [3081051] CIGNA STATE OF WYOMING [308105107] 4204.14 percent of total billed charges 3291.95 5044.12 Technical (Hospital) Services CERTOLIZUMAB PEGOL 400 MG/2 ML (200 MG/ML X2) SUBCUTANEOUS SYRINGE KIT RX-97853 CDM J0717 HCPCS 636 RC 50474-0710-79 NDC inpatient 1 ML 5309.6 5309.6 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES EPO [308136803] 4204.14 percent of total billed charges 3291.95 5044.12 Technical (Hospital) Services CERTOLIZUMAB PEGOL 400 MG/2 ML (200 MG/ML X2) SUBCUTANEOUS SYRINGE KIT RX-97853 CDM J0717 HCPCS 636 RC 50474-0710-79 NDC inpatient 1 ML 5309.6 5309.6 UNITED HEALTHCARE (COMMERCIAL) [3081199] UNITED HEALTHCARE 87726 [308119901] 3291.95 percent of total billed charges 3291.95 5044.12 Technical (Hospital) Services CERTOLIZUMAB PEGOL 400 MG/2 ML (200 MG/ML X2) SUBCUTANEOUS SYRINGE KIT RX-97853 CDM J0717 HCPCS 636 RC 50474-0710-79 NDC inpatient 1 ML 5309.6 5309.6 BLUE CROSS BLUE SHIELD WELLMARK SB889 [3081026] BCBS WYOMING [308102603] 5044.12 percent of total billed charges 3291.95 5044.12 Technical (Hospital) Services CERTOLIZUMAB PEGOL 400 MG/2 ML (200 MG/ML X2) SUBCUTANEOUS SYRINGE KIT RX-97853 CDM J0717 HCPCS 636 RC 50474-0710-79 NDC inpatient 1 ML 5309.6 5309.6 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES PPO [308136801] 4204.14 percent of total billed charges 3291.95 5044.12 Technical (Hospital) Services CERTOLIZUMAB PEGOL 400 MG/2 ML (200 MG/ML X2) SUBCUTANEOUS SYRINGE KIT RX-97853 CDM J0717 HCPCS 636 RC 50474-0710-79 NDC inpatient 1 ML 5309.6 5309.6 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES HDHP [308136802] 4204.14 percent of total billed charges 3291.95 5044.12 Technical (Hospital) Services CERTOLIZUMAB PEGOL 400 MG/2 ML (200 MG/ML X2) SUBCUTANEOUS SYRINGE KIT RX-97853 CDM J0717 HCPCS 636 RC 50474-0710-79 NDC inpatient 1 ML 5309.6 5309.6 HEALTHPARTNERS SX009 HEALTHPARTNERS 4204.14 percent of total billed charges 3291.95 5044.12 Technical (Hospital) Services CERTOLIZUMAB PEGOL 400 MG/2 ML (200 MG/ML X2) SUBCUTANEOUS SYRINGE KIT RX-97853 CDM J0717 HCPCS 636 RC 50474-0710-79 NDC inpatient 1 ML 5309.6 5309.6 MULTIPLAN INC 34080 [3081285] MULTIPLAN INC [308128501] 5044.12 percent of total billed charges 3291.95 5044.12 Technical (Hospital) Services CERTOLIZUMAB PEGOL 400 MG/2 ML (200 MG/ML X2) SUBCUTANEOUS SYRINGE KIT RX-97853 CDM J0717 HCPCS 636 RC 50474-0710-79 NDC inpatient 1 ML 5309.6 5309.6 MEDICA (COMMERCIAL) 94265 [3081118] MEDICA CLAIMS [308111801] 4778.64 percent of total billed charges 3291.95 5044.12 Technical (Hospital) Services CERTOLIZUMAB PEGOL 400 MG/2 ML (200 MG/ML X2) SUBCUTANEOUS SYRINGE KIT RX-97853 CDM J0717 HCPCS 636 RC 50474-0710-79 NDC outpatient 1 ML 5309.6 5309.6 HEALTHPARTNERS SX009 HEALTHPARTNERS 4247.68 percent of total billed charges 3291.95 5044.12 Technical (Hospital) Services CERTOLIZUMAB PEGOL 400 MG/2 ML (200 MG/ML X2) SUBCUTANEOUS SYRINGE KIT RX-97853 CDM J0717 HCPCS 636 RC 50474-0710-79 NDC outpatient 1 ML 5309.6 5309.6 UNITED HEALTHCARE (COMMERCIAL) [3081199] UNITED HEALTHCARE 87726 [308119901] 3291.95 percent of total billed charges 3291.95 5044.12 Technical (Hospital) Services CERTOLIZUMAB PEGOL 400 MG/2 ML (200 MG/ML X2) SUBCUTANEOUS SYRINGE KIT RX-97853 CDM J0717 HCPCS 636 RC 50474-0710-79 NDC outpatient 1 ML 5309.6 5309.6 MULTIPLAN INC 34080 [3081285] MULTIPLAN INC [308128501] 5044.12 percent of total billed charges 3291.95 5044.12 Technical (Hospital) Services CERTOLIZUMAB PEGOL 400 MG/2 ML (200 MG/ML X2) SUBCUTANEOUS SYRINGE KIT RX-97853 CDM J0717 HCPCS 636 RC 50474-0710-79 NDC outpatient 1 ML 5309.6 5309.6 CIGNA 62308 [3081051] CIGNA 62308 [308105105] 4247.68 percent of total billed charges 3291.95 5044.12 Technical (Hospital) Services CERTOLIZUMAB PEGOL 400 MG/2 ML (200 MG/ML X2) SUBCUTANEOUS SYRINGE KIT RX-97853 CDM J0717 HCPCS 636 RC 50474-0710-79 NDC outpatient 1 ML 5309.6 5309.6 CIGNA 62308 [3081051] CIGNA STATE OF WYOMING [308105107] 4247.68 percent of total billed charges 3291.95 5044.12 Technical (Hospital) Services CERTOLIZUMAB PEGOL 400 MG/2 ML (200 MG/ML X2) SUBCUTANEOUS SYRINGE KIT RX-97853 CDM J0717 HCPCS 636 RC 50474-0710-79 NDC outpatient 1 ML 5309.6 5309.6 BLUE CROSS BLUE SHIELD WELLMARK SB889 [3081026] BCBS WYOMING [308102603] 5044.12 percent of total billed charges 3291.95 5044.12 Technical (Hospital) Services CERTOLIZUMAB PEGOL 400 MG/2 ML (200 MG/ML X2) SUBCUTANEOUS SYRINGE KIT RX-97853 CDM J0717 HCPCS 636 RC 50474-0710-79 NDC outpatient 1 ML 5309.6 5309.6 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES PPO [308136801] 4247.68 percent of total billed charges 3291.95 5044.12 Technical (Hospital) Services CERTOLIZUMAB PEGOL 400 MG/2 ML (200 MG/ML X2) SUBCUTANEOUS SYRINGE KIT RX-97853 CDM J0717 HCPCS 636 RC 50474-0710-79 NDC outpatient 1 ML 5309.6 5309.6 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES EPO [308136803] 4247.68 percent of total billed charges 3291.95 5044.12 Technical (Hospital) Services CERTOLIZUMAB PEGOL 400 MG/2 ML (200 MG/ML X2) SUBCUTANEOUS SYRINGE KIT RX-97853 CDM J0717 HCPCS 636 RC 50474-0710-79 NDC outpatient 1 ML 5309.6 5309.6 MEDICA (COMMERCIAL) 94265 [3081118] MEDICA CLAIMS [308111801] 4778.64 percent of total billed charges 3291.95 5044.12 Technical (Hospital) Services CERTOLIZUMAB PEGOL 400 MG/2 ML (200 MG/ML X2) SUBCUTANEOUS SYRINGE KIT RX-97853 CDM J0717 HCPCS 636 RC 50474-0710-79 NDC outpatient 1 ML 5309.6 5309.6 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES HDHP [308136802] 4247.68 percent of total billed charges 3291.95 5044.12 Technical (Hospital) Services CEFTAZIDIME 1 GRAM SOLUTION FOR INJECTION RX-9474 CDM J0713 HCPCS 636 RC 00409-5082-16 NDC inpatient 10 ML 68.76 68.76 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES EPO [308136803] 54.44 percent of total billed charges 42.63 65.32 Technical (Hospital) Services CEFTAZIDIME 1 GRAM SOLUTION FOR INJECTION RX-9474 CDM J0713 HCPCS 636 RC 00409-5082-16 NDC inpatient 10 ML 68.76 68.76 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES HDHP [308136802] 54.44 percent of total billed charges 42.63 65.32 Technical (Hospital) Services CEFTAZIDIME 1 GRAM SOLUTION FOR INJECTION RX-9474 CDM J0713 HCPCS 636 RC 00409-5082-16 NDC inpatient 10 ML 68.76 68.76 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES PPO [308136801] 54.44 percent of total billed charges 42.63 65.32 Technical (Hospital) Services CEFTAZIDIME 1 GRAM SOLUTION FOR INJECTION RX-9474 CDM J0713 HCPCS 636 RC 00409-5082-16 NDC inpatient 10 ML 68.76 68.76 HEALTHPARTNERS SX009 HEALTHPARTNERS 54.44 percent of total billed charges 42.63 65.32 Technical (Hospital) Services CEFTAZIDIME 1 GRAM SOLUTION FOR INJECTION RX-9474 CDM J0713 HCPCS 636 RC 00409-5082-16 NDC inpatient 10 ML 68.76 68.76 UNITED HEALTHCARE (COMMERCIAL) [3081199] UNITED HEALTHCARE 87726 [308119901] 42.63 percent of total billed charges 42.63 65.32 Technical (Hospital) Services CEFTAZIDIME 1 GRAM SOLUTION FOR INJECTION RX-9474 CDM J0713 HCPCS 636 RC 00409-5082-16 NDC inpatient 10 ML 68.76 68.76 CIGNA 62308 [3081051] CIGNA 62308 [308105105] 54.44 percent of total billed charges 42.63 65.32 Technical (Hospital) Services CEFTAZIDIME 1 GRAM SOLUTION FOR INJECTION RX-9474 CDM J0713 HCPCS 636 RC 00409-5082-16 NDC inpatient 10 ML 68.76 68.76 CIGNA 62308 [3081051] CIGNA STATE OF WYOMING [308105107] 54.44 percent of total billed charges 42.63 65.32 Technical (Hospital) Services CEFTAZIDIME 1 GRAM SOLUTION FOR INJECTION RX-9474 CDM J0713 HCPCS 636 RC 00409-5082-16 NDC inpatient 10 ML 68.76 68.76 BLUE CROSS BLUE SHIELD WELLMARK SB889 [3081026] BCBS WYOMING [308102603] 65.32 percent of total billed charges 42.63 65.32 Technical (Hospital) Services CEFTAZIDIME 1 GRAM SOLUTION FOR INJECTION RX-9474 CDM J0713 HCPCS 636 RC 00409-5082-16 NDC inpatient 10 ML 68.76 68.76 MEDICA (COMMERCIAL) 94265 [3081118] MEDICA CLAIMS [308111801] 61.88 percent of total billed charges 42.63 65.32 Technical (Hospital) Services CEFTAZIDIME 1 GRAM SOLUTION FOR INJECTION RX-9474 CDM J0713 HCPCS 636 RC 00409-5082-16 NDC inpatient 10 ML 68.76 68.76 MULTIPLAN INC 34080 [3081285] MULTIPLAN INC [308128501] 65.32 percent of total billed charges 42.63 65.32 Technical (Hospital) Services CEFTAZIDIME 1 GRAM SOLUTION FOR INJECTION RX-9474 CDM J0713 HCPCS 636 RC 00409-5082-16 NDC outpatient 10 ML 68.76 68.76 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES PPO [308136801] 55.01 percent of total billed charges 42.63 65.32 Technical (Hospital) Services CEFTAZIDIME 1 GRAM SOLUTION FOR INJECTION RX-9474 CDM J0713 HCPCS 636 RC 00409-5082-16 NDC outpatient 10 ML 68.76 68.76 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES EPO [308136803] 55.01 percent of total billed charges 42.63 65.32 Technical (Hospital) Services CEFTAZIDIME 1 GRAM SOLUTION FOR INJECTION RX-9474 CDM J0713 HCPCS 636 RC 00409-5082-16 NDC outpatient 10 ML 68.76 68.76 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES HDHP [308136802] 55.01 percent of total billed charges 42.63 65.32 Technical (Hospital) Services CEFTAZIDIME 1 GRAM SOLUTION FOR INJECTION RX-9474 CDM J0713 HCPCS 636 RC 00409-5082-16 NDC outpatient 10 ML 68.76 68.76 BLUE CROSS BLUE SHIELD WELLMARK SB889 [3081026] BCBS WYOMING [308102603] 65.32 percent of total billed charges 42.63 65.32 Technical (Hospital) Services CEFTAZIDIME 1 GRAM SOLUTION FOR INJECTION RX-9474 CDM J0713 HCPCS 636 RC 00409-5082-16 NDC outpatient 10 ML 68.76 68.76 HEALTHPARTNERS SX009 HEALTHPARTNERS 55.01 percent of total billed charges 42.63 65.32 Technical (Hospital) Services CEFTAZIDIME 1 GRAM SOLUTION FOR INJECTION RX-9474 CDM J0713 HCPCS 636 RC 00409-5082-16 NDC outpatient 10 ML 68.76 68.76 UNITED HEALTHCARE (COMMERCIAL) [3081199] UNITED HEALTHCARE 87726 [308119901] 42.63 percent of total billed charges 42.63 65.32 Technical (Hospital) Services CEFTAZIDIME 1 GRAM SOLUTION FOR INJECTION RX-9474 CDM J0713 HCPCS 636 RC 00409-5082-16 NDC outpatient 10 ML 68.76 68.76 CIGNA 62308 [3081051] CIGNA 62308 [308105105] 55.01 percent of total billed charges 42.63 65.32 Technical (Hospital) Services CEFTAZIDIME 1 GRAM SOLUTION FOR INJECTION RX-9474 CDM J0713 HCPCS 636 RC 00409-5082-16 NDC outpatient 10 ML 68.76 68.76 CIGNA 62308 [3081051] CIGNA STATE OF WYOMING [308105107] 55.01 percent of total billed charges 42.63 65.32 Technical (Hospital) Services CEFTAZIDIME 1 GRAM SOLUTION FOR INJECTION RX-9474 CDM J0713 HCPCS 636 RC 00409-5082-16 NDC outpatient 10 ML 68.76 68.76 MULTIPLAN INC 34080 [3081285] MULTIPLAN INC [308128501] 65.32 percent of total billed charges 42.63 65.32 Technical (Hospital) Services CEFTAZIDIME 1 GRAM SOLUTION FOR INJECTION RX-9474 CDM J0713 HCPCS 636 RC 00409-5082-16 NDC outpatient 10 ML 68.76 68.76 MEDICA (COMMERCIAL) 94265 [3081118] MEDICA CLAIMS [308111801] 61.88 percent of total billed charges 42.63 65.32 Technical (Hospital) Services CEFTAZIDIME 2 GRAM SOLUTION FOR INJECTION RX-9476 CDM J0713 HCPCS 636 RC 25021-0128-67 NDC inpatient 11.5 ML 108.47 108.47 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES EPO [308136803] 85.89 percent of total billed charges 67.25 103.05 Technical (Hospital) Services CEFTAZIDIME 2 GRAM SOLUTION FOR INJECTION RX-9476 CDM J0713 HCPCS 636 RC 25021-0128-67 NDC inpatient 11.5 ML 108.47 108.47 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES HDHP [308136802] 85.89 percent of total billed charges 67.25 103.05 Technical (Hospital) Services CEFTAZIDIME 2 GRAM SOLUTION FOR INJECTION RX-9476 CDM J0713 HCPCS 636 RC 25021-0128-67 NDC inpatient 11.5 ML 108.47 108.47 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES PPO [308136801] 85.89 percent of total billed charges 67.25 103.05 Technical (Hospital) Services CEFTAZIDIME 2 GRAM SOLUTION FOR INJECTION RX-9476 CDM J0713 HCPCS 636 RC 25021-0128-67 NDC inpatient 11.5 ML 108.47 108.47 CIGNA 62308 [3081051] CIGNA 62308 [308105105] 85.89 percent of total billed charges 67.25 103.05 Technical (Hospital) Services CEFTAZIDIME 2 GRAM SOLUTION FOR INJECTION RX-9476 CDM J0713 HCPCS 636 RC 25021-0128-67 NDC inpatient 11.5 ML 108.47 108.47 CIGNA 62308 [3081051] CIGNA STATE OF WYOMING [308105107] 85.89 percent of total billed charges 67.25 103.05 Technical (Hospital) Services CEFTAZIDIME 2 GRAM SOLUTION FOR INJECTION RX-9476 CDM J0713 HCPCS 636 RC 25021-0128-67 NDC inpatient 11.5 ML 108.47 108.47 HEALTHPARTNERS SX009 HEALTHPARTNERS 85.89 percent of total billed charges 67.25 103.05 Technical (Hospital) Services CEFTAZIDIME 2 GRAM SOLUTION FOR INJECTION RX-9476 CDM J0713 HCPCS 636 RC 25021-0128-67 NDC inpatient 11.5 ML 108.47 108.47 MULTIPLAN INC 34080 [3081285] MULTIPLAN INC [308128501] 103.05 percent of total billed charges 67.25 103.05 Technical (Hospital) Services CEFTAZIDIME 2 GRAM SOLUTION FOR INJECTION RX-9476 CDM J0713 HCPCS 636 RC 25021-0128-67 NDC inpatient 11.5 ML 108.47 108.47 MEDICA (COMMERCIAL) 94265 [3081118] MEDICA CLAIMS [308111801] 97.62 percent of total billed charges 67.25 103.05 Technical (Hospital) Services CEFTAZIDIME 2 GRAM SOLUTION FOR INJECTION RX-9476 CDM J0713 HCPCS 636 RC 25021-0128-67 NDC inpatient 11.5 ML 108.47 108.47 UNITED HEALTHCARE (COMMERCIAL) [3081199] UNITED HEALTHCARE 87726 [308119901] 67.25 percent of total billed charges 67.25 103.05 Technical (Hospital) Services CEFTAZIDIME 2 GRAM SOLUTION FOR INJECTION RX-9476 CDM J0713 HCPCS 636 RC 25021-0128-67 NDC inpatient 11.5 ML 108.47 108.47 BLUE CROSS BLUE SHIELD WELLMARK SB889 [3081026] BCBS WYOMING [308102603] 103.05 percent of total billed charges 67.25 103.05 Technical (Hospital) Services CEFTAZIDIME 2 GRAM SOLUTION FOR INJECTION RX-9476 CDM J0713 HCPCS 636 RC 25021-0128-67 NDC outpatient 11.5 ML 108.47 108.47 BLUE CROSS BLUE SHIELD WELLMARK SB889 [3081026] BCBS WYOMING [308102603] 103.05 percent of total billed charges 67.25 103.05 Technical (Hospital) Services CEFTAZIDIME 2 GRAM SOLUTION FOR INJECTION RX-9476 CDM J0713 HCPCS 636 RC 25021-0128-67 NDC outpatient 11.5 ML 108.47 108.47 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES EPO [308136803] 86.78 percent of total billed charges 67.25 103.05 Technical (Hospital) Services CEFTAZIDIME 2 GRAM SOLUTION FOR INJECTION RX-9476 CDM J0713 HCPCS 636 RC 25021-0128-67 NDC outpatient 11.5 ML 108.47 108.47 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES HDHP [308136802] 86.78 percent of total billed charges 67.25 103.05 Technical (Hospital) Services CEFTAZIDIME 2 GRAM SOLUTION FOR INJECTION RX-9476 CDM J0713 HCPCS 636 RC 25021-0128-67 NDC outpatient 11.5 ML 108.47 108.47 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES PPO [308136801] 86.78 percent of total billed charges 67.25 103.05 Technical (Hospital) Services CEFTAZIDIME 2 GRAM SOLUTION FOR INJECTION RX-9476 CDM J0713 HCPCS 636 RC 25021-0128-67 NDC outpatient 11.5 ML 108.47 108.47 HEALTHPARTNERS SX009 HEALTHPARTNERS 86.78 percent of total billed charges 67.25 103.05 Technical (Hospital) Services CEFTAZIDIME 2 GRAM SOLUTION FOR INJECTION RX-9476 CDM J0713 HCPCS 636 RC 25021-0128-67 NDC outpatient 11.5 ML 108.47 108.47 UNITED HEALTHCARE (COMMERCIAL) [3081199] UNITED HEALTHCARE 87726 [308119901] 67.25 percent of total billed charges 67.25 103.05 Technical (Hospital) Services CEFTAZIDIME 2 GRAM SOLUTION FOR INJECTION RX-9476 CDM J0713 HCPCS 636 RC 25021-0128-67 NDC outpatient 11.5 ML 108.47 108.47 MEDICA (COMMERCIAL) 94265 [3081118] MEDICA CLAIMS [308111801] 97.62 percent of total billed charges 67.25 103.05 Technical (Hospital) Services CEFTAZIDIME 2 GRAM SOLUTION FOR INJECTION RX-9476 CDM J0713 HCPCS 636 RC 25021-0128-67 NDC outpatient 11.5 ML 108.47 108.47 MULTIPLAN INC 34080 [3081285] MULTIPLAN INC [308128501] 103.05 percent of total billed charges 67.25 103.05 Technical (Hospital) Services CEFTAZIDIME 2 GRAM SOLUTION FOR INJECTION RX-9476 CDM J0713 HCPCS 636 RC 25021-0128-67 NDC outpatient 11.5 ML 108.47 108.47 CIGNA 62308 [3081051] CIGNA 62308 [308105105] 86.78 percent of total billed charges 67.25 103.05 Technical (Hospital) Services CEFTAZIDIME 2 GRAM SOLUTION FOR INJECTION RX-9476 CDM J0713 HCPCS 636 RC 25021-0128-67 NDC outpatient 11.5 ML 108.47 108.47 CIGNA 62308 [3081051] CIGNA STATE OF WYOMING [308105107] 86.78 percent of total billed charges 67.25 103.05 Technical (Hospital) Services BETAMETHASONE ACETATE AND SODIUM PHOS 6 MG/ML SUSPENSION FOR INJECTION RX-9266 CDM J0702 HCPCS 636 RC 00517-0720-01 NDC inpatient 5 ML 247.03 247.03 HEALTHPARTNERS SX009 HEALTHPARTNERS 195.6 percent of total billed charges 153.16 234.68 Technical (Hospital) Services BETAMETHASONE ACETATE AND SODIUM PHOS 6 MG/ML SUSPENSION FOR INJECTION RX-9266 CDM J0702 HCPCS 636 RC 00517-0720-01 NDC inpatient 5 ML 247.03 247.03 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES EPO [308136803] 195.6 percent of total billed charges 153.16 234.68 Technical (Hospital) Services BETAMETHASONE ACETATE AND SODIUM PHOS 6 MG/ML SUSPENSION FOR INJECTION RX-9266 CDM J0702 HCPCS 636 RC 00517-0720-01 NDC inpatient 5 ML 247.03 247.03 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES HDHP [308136802] 195.6 percent of total billed charges 153.16 234.68 Technical (Hospital) Services BETAMETHASONE ACETATE AND SODIUM PHOS 6 MG/ML SUSPENSION FOR INJECTION RX-9266 CDM J0702 HCPCS 636 RC 00517-0720-01 NDC inpatient 5 ML 247.03 247.03 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES PPO [308136801] 195.6 percent of total billed charges 153.16 234.68 Technical (Hospital) Services BETAMETHASONE ACETATE AND SODIUM PHOS 6 MG/ML SUSPENSION FOR INJECTION RX-9266 CDM J0702 HCPCS 636 RC 00517-0720-01 NDC inpatient 5 ML 247.03 247.03 MULTIPLAN INC 34080 [3081285] MULTIPLAN INC [308128501] 234.68 percent of total billed charges 153.16 234.68 Technical (Hospital) Services BETAMETHASONE ACETATE AND SODIUM PHOS 6 MG/ML SUSPENSION FOR INJECTION RX-9266 CDM J0702 HCPCS 636 RC 00517-0720-01 NDC inpatient 5 ML 247.03 247.03 MEDICA (COMMERCIAL) 94265 [3081118] MEDICA CLAIMS [308111801] 222.33 percent of total billed charges 153.16 234.68 Technical (Hospital) Services BETAMETHASONE ACETATE AND SODIUM PHOS 6 MG/ML SUSPENSION FOR INJECTION RX-9266 CDM J0702 HCPCS 636 RC 00517-0720-01 NDC inpatient 5 ML 247.03 247.03 UNITED HEALTHCARE (COMMERCIAL) [3081199] UNITED HEALTHCARE 87726 [308119901] 153.16 percent of total billed charges 153.16 234.68 Technical (Hospital) Services BETAMETHASONE ACETATE AND SODIUM PHOS 6 MG/ML SUSPENSION FOR INJECTION RX-9266 CDM J0702 HCPCS 636 RC 00517-0720-01 NDC inpatient 5 ML 247.03 247.03 BLUE CROSS BLUE SHIELD WELLMARK SB889 [3081026] BCBS WYOMING [308102603] 234.68 percent of total billed charges 153.16 234.68 Technical (Hospital) Services BETAMETHASONE ACETATE AND SODIUM PHOS 6 MG/ML SUSPENSION FOR INJECTION RX-9266 CDM J0702 HCPCS 636 RC 00517-0720-01 NDC inpatient 5 ML 247.03 247.03 CIGNA 62308 [3081051] CIGNA 62308 [308105105] 195.6 percent of total billed charges 153.16 234.68 Technical (Hospital) Services BETAMETHASONE ACETATE AND SODIUM PHOS 6 MG/ML SUSPENSION FOR INJECTION RX-9266 CDM J0702 HCPCS 636 RC 00517-0720-01 NDC inpatient 5 ML 247.03 247.03 CIGNA 62308 [3081051] CIGNA STATE OF WYOMING [308105107] 195.6 percent of total billed charges 153.16 234.68 Technical (Hospital) Services BETAMETHASONE ACETATE AND SODIUM PHOS 6 MG/ML SUSPENSION FOR INJECTION RX-9266 CDM J0702 HCPCS 636 RC 00517-0720-01 NDC outpatient 5 ML 247.03 247.03 BLUE CROSS BLUE SHIELD WELLMARK SB889 [3081026] BCBS WYOMING [308102603] 234.68 percent of total billed charges 153.16 234.68 Technical (Hospital) Services BETAMETHASONE ACETATE AND SODIUM PHOS 6 MG/ML SUSPENSION FOR INJECTION RX-9266 CDM J0702 HCPCS 636 RC 00517-0720-01 NDC outpatient 5 ML 247.03 247.03 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES PPO [308136801] 197.62 percent of total billed charges 153.16 234.68 Technical (Hospital) Services BETAMETHASONE ACETATE AND SODIUM PHOS 6 MG/ML SUSPENSION FOR INJECTION RX-9266 CDM J0702 HCPCS 636 RC 00517-0720-01 NDC outpatient 5 ML 247.03 247.03 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES EPO [308136803] 197.62 percent of total billed charges 153.16 234.68 Technical (Hospital) Services BETAMETHASONE ACETATE AND SODIUM PHOS 6 MG/ML SUSPENSION FOR INJECTION RX-9266 CDM J0702 HCPCS 636 RC 00517-0720-01 NDC outpatient 5 ML 247.03 247.03 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES HDHP [308136802] 197.62 percent of total billed charges 153.16 234.68 Technical (Hospital) Services BETAMETHASONE ACETATE AND SODIUM PHOS 6 MG/ML SUSPENSION FOR INJECTION RX-9266 CDM J0702 HCPCS 636 RC 00517-0720-01 NDC outpatient 5 ML 247.03 247.03 UNITED HEALTHCARE (COMMERCIAL) [3081199] UNITED HEALTHCARE 87726 [308119901] 153.16 percent of total billed charges 153.16 234.68 Technical (Hospital) Services BETAMETHASONE ACETATE AND SODIUM PHOS 6 MG/ML SUSPENSION FOR INJECTION RX-9266 CDM J0702 HCPCS 636 RC 00517-0720-01 NDC outpatient 5 ML 247.03 247.03 HEALTHPARTNERS SX009 HEALTHPARTNERS 197.62 percent of total billed charges 153.16 234.68 Technical (Hospital) Services BETAMETHASONE ACETATE AND SODIUM PHOS 6 MG/ML SUSPENSION FOR INJECTION RX-9266 CDM J0702 HCPCS 636 RC 00517-0720-01 NDC outpatient 5 ML 247.03 247.03 MEDICA (COMMERCIAL) 94265 [3081118] MEDICA CLAIMS [308111801] 222.33 percent of total billed charges 153.16 234.68 Technical (Hospital) Services BETAMETHASONE ACETATE AND SODIUM PHOS 6 MG/ML SUSPENSION FOR INJECTION RX-9266 CDM J0702 HCPCS 636 RC 00517-0720-01 NDC outpatient 5 ML 247.03 247.03 MULTIPLAN INC 34080 [3081285] MULTIPLAN INC [308128501] 234.68 percent of total billed charges 153.16 234.68 Technical (Hospital) Services BETAMETHASONE ACETATE AND SODIUM PHOS 6 MG/ML SUSPENSION FOR INJECTION RX-9266 CDM J0702 HCPCS 636 RC 00517-0720-01 NDC outpatient 5 ML 247.03 247.03 CIGNA 62308 [3081051] CIGNA 62308 [308105105] 197.62 percent of total billed charges 153.16 234.68 Technical (Hospital) Services BETAMETHASONE ACETATE AND SODIUM PHOS 6 MG/ML SUSPENSION FOR INJECTION RX-9266 CDM J0702 HCPCS 636 RC 00517-0720-01 NDC outpatient 5 ML 247.03 247.03 CIGNA 62308 [3081051] CIGNA STATE OF WYOMING [308105107] 197.62 percent of total billed charges 153.16 234.68 Technical (Hospital) Services CEFTRIAXONE 1 GRAM SOLUTION FOR IM RX-4080049487 CDM J0696 HCPCS 636 RC 00409-7332-01 NDC inpatient 3 ML 106.88 106.88 HEALTHPARTNERS SX009 HEALTHPARTNERS 84.63 percent of total billed charges 66.27 101.54 Technical (Hospital) Services CEFTRIAXONE 1 GRAM SOLUTION FOR IM RX-4080049487 CDM J0696 HCPCS 636 RC 00409-7332-01 NDC inpatient 3 ML 106.88 106.88 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES EPO [308136803] 84.63 percent of total billed charges 66.27 101.54 Technical (Hospital) Services CEFTRIAXONE 1 GRAM SOLUTION FOR IM RX-4080049487 CDM J0696 HCPCS 636 RC 00409-7332-01 NDC inpatient 3 ML 106.88 106.88 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES HDHP [308136802] 84.63 percent of total billed charges 66.27 101.54 Technical (Hospital) Services CEFTRIAXONE 1 GRAM SOLUTION FOR IM RX-4080049487 CDM J0696 HCPCS 636 RC 00409-7332-01 NDC inpatient 3 ML 106.88 106.88 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES PPO [308136801] 84.63 percent of total billed charges 66.27 101.54 Technical (Hospital) Services CEFTRIAXONE 1 GRAM SOLUTION FOR IM RX-4080049487 CDM J0696 HCPCS 636 RC 00409-7332-01 NDC inpatient 3 ML 106.88 106.88 MULTIPLAN INC 34080 [3081285] MULTIPLAN INC [308128501] 101.54 percent of total billed charges 66.27 101.54 Technical (Hospital) Services CEFTRIAXONE 1 GRAM SOLUTION FOR IM RX-4080049487 CDM J0696 HCPCS 636 RC 00409-7332-01 NDC inpatient 3 ML 106.88 106.88 MEDICA (COMMERCIAL) 94265 [3081118] MEDICA CLAIMS [308111801] 96.19 percent of total billed charges 66.27 101.54 Technical (Hospital) Services CEFTRIAXONE 1 GRAM SOLUTION FOR IM RX-4080049487 CDM J0696 HCPCS 636 RC 00409-7332-01 NDC inpatient 3 ML 106.88 106.88 UNITED HEALTHCARE (COMMERCIAL) [3081199] UNITED HEALTHCARE 87726 [308119901] 66.27 percent of total billed charges 66.27 101.54 Technical (Hospital) Services CEFTRIAXONE 1 GRAM SOLUTION FOR IM RX-4080049487 CDM J0696 HCPCS 636 RC 00409-7332-01 NDC inpatient 3 ML 106.88 106.88 BLUE CROSS BLUE SHIELD WELLMARK SB889 [3081026] BCBS WYOMING [308102603] 101.54 percent of total billed charges 66.27 101.54 Technical (Hospital) Services CEFTRIAXONE 1 GRAM SOLUTION FOR IM RX-4080049487 CDM J0696 HCPCS 636 RC 00409-7332-01 NDC inpatient 3 ML 106.88 106.88 CIGNA 62308 [3081051] CIGNA STATE OF WYOMING [308105107] 84.63 percent of total billed charges 66.27 101.54 Technical (Hospital) Services CEFTRIAXONE 1 GRAM SOLUTION FOR IM RX-4080049487 CDM J0696 HCPCS 636 RC 00409-7332-01 NDC inpatient 3 ML 106.88 106.88 CIGNA 62308 [3081051] CIGNA 62308 [308105105] 84.63 percent of total billed charges 66.27 101.54 Technical (Hospital) Services CEFTRIAXONE 1 GRAM SOLUTION FOR IM RX-4080049487 CDM J0696 HCPCS 636 RC 00409-7332-01 NDC outpatient 3 ML 106.88 106.88 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES EPO [308136803] 85.5 percent of total billed charges 66.27 101.54 Technical (Hospital) Services CEFTRIAXONE 1 GRAM SOLUTION FOR IM RX-4080049487 CDM J0696 HCPCS 636 RC 00409-7332-01 NDC outpatient 3 ML 106.88 106.88 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES HDHP [308136802] 85.5 percent of total billed charges 66.27 101.54 Technical (Hospital) Services CEFTRIAXONE 1 GRAM SOLUTION FOR IM RX-4080049487 CDM J0696 HCPCS 636 RC 00409-7332-01 NDC outpatient 3 ML 106.88 106.88 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES PPO [308136801] 85.5 percent of total billed charges 66.27 101.54 Technical (Hospital) Services CEFTRIAXONE 1 GRAM SOLUTION FOR IM RX-4080049487 CDM J0696 HCPCS 636 RC 00409-7332-01 NDC outpatient 3 ML 106.88 106.88 BLUE CROSS BLUE SHIELD WELLMARK SB889 [3081026] BCBS WYOMING [308102603] 101.54 percent of total billed charges 66.27 101.54 Technical (Hospital) Services CEFTRIAXONE 1 GRAM SOLUTION FOR IM RX-4080049487 CDM J0696 HCPCS 636 RC 00409-7332-01 NDC outpatient 3 ML 106.88 106.88 CIGNA 62308 [3081051] CIGNA 62308 [308105105] 85.5 percent of total billed charges 66.27 101.54 Technical (Hospital) Services CEFTRIAXONE 1 GRAM SOLUTION FOR IM RX-4080049487 CDM J0696 HCPCS 636 RC 00409-7332-01 NDC outpatient 3 ML 106.88 106.88 CIGNA 62308 [3081051] CIGNA STATE OF WYOMING [308105107] 85.5 percent of total billed charges 66.27 101.54 Technical (Hospital) Services CEFTRIAXONE 1 GRAM SOLUTION FOR IM RX-4080049487 CDM J0696 HCPCS 636 RC 00409-7332-01 NDC outpatient 3 ML 106.88 106.88 MULTIPLAN INC 34080 [3081285] MULTIPLAN INC [308128501] 101.54 percent of total billed charges 66.27 101.54 Technical (Hospital) Services CEFTRIAXONE 1 GRAM SOLUTION FOR IM RX-4080049487 CDM J0696 HCPCS 636 RC 00409-7332-01 NDC outpatient 3 ML 106.88 106.88 MEDICA (COMMERCIAL) 94265 [3081118] MEDICA CLAIMS [308111801] 96.19 percent of total billed charges 66.27 101.54 Technical (Hospital) Services CEFTRIAXONE 1 GRAM SOLUTION FOR IM RX-4080049487 CDM J0696 HCPCS 636 RC 00409-7332-01 NDC outpatient 3 ML 106.88 106.88 HEALTHPARTNERS SX009 HEALTHPARTNERS 85.5 percent of total billed charges 66.27 101.54 Technical (Hospital) Services CEFTRIAXONE 1 GRAM SOLUTION FOR IM RX-4080049487 CDM J0696 HCPCS 636 RC 00409-7332-01 NDC outpatient 3 ML 106.88 106.88 UNITED HEALTHCARE (COMMERCIAL) [3081199] UNITED HEALTHCARE 87726 [308119901] 66.27 percent of total billed charges 66.27 101.54 Technical (Hospital) Services CEFTRIAXONE 1 GRAM SOLUTION FOR IV PUSH RX-9487 CDM J0696 HCPCS 636 RC 00409-7332-01 NDC outpatient 10 ML 106 106 BLUE CROSS BLUE SHIELD WELLMARK SB889 [3081026] BCBS WYOMING [308102603] 100.7 percent of total billed charges 65.72 100.7 Technical (Hospital) Services CEFTRIAXONE 1 GRAM SOLUTION FOR IV PUSH RX-9487 CDM J0696 HCPCS 636 RC 00409-7332-01 NDC outpatient 10 ML 106 106 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES EPO [308136803] 84.8 percent of total billed charges 65.72 100.7 Technical (Hospital) Services CEFTRIAXONE 1 GRAM SOLUTION FOR IV PUSH RX-9487 CDM J0696 HCPCS 636 RC 00409-7332-01 NDC outpatient 10 ML 106 106 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES PPO [308136801] 84.8 percent of total billed charges 65.72 100.7 Technical (Hospital) Services CEFTRIAXONE 1 GRAM SOLUTION FOR IV PUSH RX-9487 CDM J0696 HCPCS 636 RC 00409-7332-01 NDC outpatient 10 ML 106 106 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES HDHP [308136802] 84.8 percent of total billed charges 65.72 100.7 Technical (Hospital) Services CEFTRIAXONE 1 GRAM SOLUTION FOR IV PUSH RX-9487 CDM J0696 HCPCS 636 RC 00409-7332-01 NDC outpatient 10 ML 106 106 UNITED HEALTHCARE (COMMERCIAL) [3081199] UNITED HEALTHCARE 87726 [308119901] 65.72 percent of total billed charges 65.72 100.7 Technical (Hospital) Services CEFTRIAXONE 1 GRAM SOLUTION FOR IV PUSH RX-9487 CDM J0696 HCPCS 636 RC 00409-7332-01 NDC outpatient 10 ML 106 106 HEALTHPARTNERS SX009 HEALTHPARTNERS 84.8 percent of total billed charges 65.72 100.7 Technical (Hospital) Services CEFTRIAXONE 1 GRAM SOLUTION FOR IV PUSH RX-9487 CDM J0696 HCPCS 636 RC 00409-7332-01 NDC outpatient 10 ML 106 106 MEDICA (COMMERCIAL) 94265 [3081118] MEDICA CLAIMS [308111801] 95.4 percent of total billed charges 65.72 100.7 Technical (Hospital) Services CEFTRIAXONE 1 GRAM SOLUTION FOR IV PUSH RX-9487 CDM J0696 HCPCS 636 RC 00409-7332-01 NDC outpatient 10 ML 106 106 MULTIPLAN INC 34080 [3081285] MULTIPLAN INC [308128501] 100.7 percent of total billed charges 65.72 100.7 Technical (Hospital) Services CEFTRIAXONE 1 GRAM SOLUTION FOR IV PUSH RX-9487 CDM J0696 HCPCS 636 RC 00409-7332-01 NDC outpatient 10 ML 106 106 CIGNA 62308 [3081051] CIGNA 62308 [308105105] 84.8 percent of total billed charges 65.72 100.7 Technical (Hospital) Services CEFTRIAXONE 1 GRAM SOLUTION FOR IV PUSH RX-9487 CDM J0696 HCPCS 636 RC 00409-7332-01 NDC outpatient 10 ML 106 106 CIGNA 62308 [3081051] CIGNA STATE OF WYOMING [308105107] 84.8 percent of total billed charges 65.72 100.7 Technical (Hospital) Services CEFTRIAXONE 1 GRAM SOLUTION FOR IV PUSH RX-9487 CDM J0696 HCPCS 636 RC 00409-7332-01 NDC inpatient 10 ML 106 106 HEALTHPARTNERS SX009 HEALTHPARTNERS 83.93 percent of total billed charges 65.72 100.7 Technical (Hospital) Services CEFTRIAXONE 1 GRAM SOLUTION FOR IV PUSH RX-9487 CDM J0696 HCPCS 636 RC 00409-7332-01 NDC inpatient 10 ML 106 106 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES PPO [308136801] 83.93 percent of total billed charges 65.72 100.7 Technical (Hospital) Services CEFTRIAXONE 1 GRAM SOLUTION FOR IV PUSH RX-9487 CDM J0696 HCPCS 636 RC 00409-7332-01 NDC inpatient 10 ML 106 106 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES HDHP [308136802] 83.93 percent of total billed charges 65.72 100.7 Technical (Hospital) Services CEFTRIAXONE 1 GRAM SOLUTION FOR IV PUSH RX-9487 CDM J0696 HCPCS 636 RC 00409-7332-01 NDC inpatient 10 ML 106 106 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES EPO [308136803] 83.93 percent of total billed charges 65.72 100.7 Technical (Hospital) Services CEFTRIAXONE 1 GRAM SOLUTION FOR IV PUSH RX-9487 CDM J0696 HCPCS 636 RC 00409-7332-01 NDC inpatient 10 ML 106 106 BLUE CROSS BLUE SHIELD WELLMARK SB889 [3081026] BCBS WYOMING [308102603] 100.7 percent of total billed charges 65.72 100.7 Technical (Hospital) Services CEFTRIAXONE 1 GRAM SOLUTION FOR IV PUSH RX-9487 CDM J0696 HCPCS 636 RC 00409-7332-01 NDC inpatient 10 ML 106 106 CIGNA 62308 [3081051] CIGNA 62308 [308105105] 83.93 percent of total billed charges 65.72 100.7 Technical (Hospital) Services CEFTRIAXONE 1 GRAM SOLUTION FOR IV PUSH RX-9487 CDM J0696 HCPCS 636 RC 00409-7332-01 NDC inpatient 10 ML 106 106 CIGNA 62308 [3081051] CIGNA STATE OF WYOMING [308105107] 83.93 percent of total billed charges 65.72 100.7 Technical (Hospital) Services CEFTRIAXONE 1 GRAM SOLUTION FOR IV PUSH RX-9487 CDM J0696 HCPCS 636 RC 00409-7332-01 NDC inpatient 10 ML 106 106 UNITED HEALTHCARE (COMMERCIAL) [3081199] UNITED HEALTHCARE 87726 [308119901] 65.72 percent of total billed charges 65.72 100.7 Technical (Hospital) Services CEFTRIAXONE 1 GRAM SOLUTION FOR IV PUSH RX-9487 CDM J0696 HCPCS 636 RC 00409-7332-01 NDC inpatient 10 ML 106 106 MULTIPLAN INC 34080 [3081285] MULTIPLAN INC [308128501] 100.7 percent of total billed charges 65.72 100.7 Technical (Hospital) Services CEFTRIAXONE 1 GRAM SOLUTION FOR IV PUSH RX-9487 CDM J0696 HCPCS 636 RC 00409-7332-01 NDC inpatient 10 ML 106 106 MEDICA (COMMERCIAL) 94265 [3081118] MEDICA CLAIMS [308111801] 95.4 percent of total billed charges 65.72 100.7 Technical (Hospital) Services CEFTRIAXONE 2 GRAM SOLUTION FOR IV PUSH RX-9488 CDM J0696 HCPCS 636 RC 00409-7335-03 NDC outpatient 20 ML 153.75 153.75 CIGNA 62308 [3081051] CIGNA 62308 [308105105] 123 percent of total billed charges 95.33 146.06 Technical (Hospital) Services CEFTRIAXONE 2 GRAM SOLUTION FOR IV PUSH RX-9488 CDM J0696 HCPCS 636 RC 00409-7335-03 NDC outpatient 20 ML 153.75 153.75 CIGNA 62308 [3081051] CIGNA STATE OF WYOMING [308105107] 123 percent of total billed charges 95.33 146.06 Technical (Hospital) Services CEFTRIAXONE 2 GRAM SOLUTION FOR IV PUSH RX-9488 CDM J0696 HCPCS 636 RC 00409-7335-03 NDC outpatient 20 ML 153.75 153.75 MEDICA (COMMERCIAL) 94265 [3081118] MEDICA CLAIMS [308111801] 138.38 percent of total billed charges 95.33 146.06 Technical (Hospital) Services CEFTRIAXONE 2 GRAM SOLUTION FOR IV PUSH RX-9488 CDM J0696 HCPCS 636 RC 00409-7335-03 NDC outpatient 20 ML 153.75 153.75 MULTIPLAN INC 34080 [3081285] MULTIPLAN INC [308128501] 146.06 percent of total billed charges 95.33 146.06 Technical (Hospital) Services CEFTRIAXONE 2 GRAM SOLUTION FOR IV PUSH RX-9488 CDM J0696 HCPCS 636 RC 00409-7335-03 NDC outpatient 20 ML 153.75 153.75 UNITED HEALTHCARE (COMMERCIAL) [3081199] UNITED HEALTHCARE 87726 [308119901] 95.33 percent of total billed charges 95.33 146.06 Technical (Hospital) Services CEFTRIAXONE 2 GRAM SOLUTION FOR IV PUSH RX-9488 CDM J0696 HCPCS 636 RC 00409-7335-03 NDC outpatient 20 ML 153.75 153.75 HEALTHPARTNERS SX009 HEALTHPARTNERS 123 percent of total billed charges 95.33 146.06 Technical (Hospital) Services CEFTRIAXONE 2 GRAM SOLUTION FOR IV PUSH RX-9488 CDM J0696 HCPCS 636 RC 00409-7335-03 NDC outpatient 20 ML 153.75 153.75 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES EPO [308136803] 123 percent of total billed charges 95.33 146.06 Technical (Hospital) Services CEFTRIAXONE 2 GRAM SOLUTION FOR IV PUSH RX-9488 CDM J0696 HCPCS 636 RC 00409-7335-03 NDC outpatient 20 ML 153.75 153.75 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES HDHP [308136802] 123 percent of total billed charges 95.33 146.06 Technical (Hospital) Services CEFTRIAXONE 2 GRAM SOLUTION FOR IV PUSH RX-9488 CDM J0696 HCPCS 636 RC 00409-7335-03 NDC outpatient 20 ML 153.75 153.75 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES PPO [308136801] 123 percent of total billed charges 95.33 146.06 Technical (Hospital) Services CEFTRIAXONE 2 GRAM SOLUTION FOR IV PUSH RX-9488 CDM J0696 HCPCS 636 RC 00409-7335-03 NDC outpatient 20 ML 153.75 153.75 BLUE CROSS BLUE SHIELD WELLMARK SB889 [3081026] BCBS WYOMING [308102603] 146.06 percent of total billed charges 95.33 146.06 Technical (Hospital) Services CEFTRIAXONE 2 GRAM SOLUTION FOR IV PUSH RX-9488 CDM J0696 HCPCS 636 RC 00409-7335-03 NDC inpatient 20 ML 153.75 153.75 UNITED HEALTHCARE (COMMERCIAL) [3081199] UNITED HEALTHCARE 87726 [308119901] 95.33 percent of total billed charges 95.33 146.06 Technical (Hospital) Services CEFTRIAXONE 2 GRAM SOLUTION FOR IV PUSH RX-9488 CDM J0696 HCPCS 636 RC 00409-7335-03 NDC inpatient 20 ML 153.75 153.75 BLUE CROSS BLUE SHIELD WELLMARK SB889 [3081026] BCBS WYOMING [308102603] 146.06 percent of total billed charges 95.33 146.06 Technical (Hospital) Services CEFTRIAXONE 2 GRAM SOLUTION FOR IV PUSH RX-9488 CDM J0696 HCPCS 636 RC 00409-7335-03 NDC inpatient 20 ML 153.75 153.75 MULTIPLAN INC 34080 [3081285] MULTIPLAN INC [308128501] 146.06 percent of total billed charges 95.33 146.06 Technical (Hospital) Services CEFTRIAXONE 2 GRAM SOLUTION FOR IV PUSH RX-9488 CDM J0696 HCPCS 636 RC 00409-7335-03 NDC inpatient 20 ML 153.75 153.75 MEDICA (COMMERCIAL) 94265 [3081118] MEDICA CLAIMS [308111801] 138.38 percent of total billed charges 95.33 146.06 Technical (Hospital) Services CEFTRIAXONE 2 GRAM SOLUTION FOR IV PUSH RX-9488 CDM J0696 HCPCS 636 RC 00409-7335-03 NDC inpatient 20 ML 153.75 153.75 CIGNA 62308 [3081051] CIGNA 62308 [308105105] 121.74 percent of total billed charges 95.33 146.06 Technical (Hospital) Services CEFTRIAXONE 2 GRAM SOLUTION FOR IV PUSH RX-9488 CDM J0696 HCPCS 636 RC 00409-7335-03 NDC inpatient 20 ML 153.75 153.75 CIGNA 62308 [3081051] CIGNA STATE OF WYOMING [308105107] 121.74 percent of total billed charges 95.33 146.06 Technical (Hospital) Services CEFTRIAXONE 2 GRAM SOLUTION FOR IV PUSH RX-9488 CDM J0696 HCPCS 636 RC 00409-7335-03 NDC inpatient 20 ML 153.75 153.75 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES EPO [308136803] 121.74 percent of total billed charges 95.33 146.06 Technical (Hospital) Services CEFTRIAXONE 2 GRAM SOLUTION FOR IV PUSH RX-9488 CDM J0696 HCPCS 636 RC 00409-7335-03 NDC inpatient 20 ML 153.75 153.75 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES HDHP [308136802] 121.74 percent of total billed charges 95.33 146.06 Technical (Hospital) Services CEFTRIAXONE 2 GRAM SOLUTION FOR IV PUSH RX-9488 CDM J0696 HCPCS 636 RC 00409-7335-03 NDC inpatient 20 ML 153.75 153.75 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES PPO [308136801] 121.74 percent of total billed charges 95.33 146.06 Technical (Hospital) Services CEFTRIAXONE 2 GRAM SOLUTION FOR IV PUSH RX-9488 CDM J0696 HCPCS 636 RC 00409-7335-03 NDC inpatient 20 ML 153.75 153.75 HEALTHPARTNERS SX009 HEALTHPARTNERS 121.74 percent of total billed charges 95.33 146.06 Technical (Hospital) Services CEFTRIAXONE 1 GRAM/50 ML IN DEXTROSE (ISO-OSMOT) INTRAVENOUS PIGGYBACK RX-9492 CDM J0696 HCPCS 636 RC 00264-3153-11 NDC outpatient 50 ML 108.18 108.18 CIGNA 62308 [3081051] CIGNA 62308 [308105105] 86.54 percent of total billed charges 67.07 102.77 Technical (Hospital) Services CEFTRIAXONE 1 GRAM/50 ML IN DEXTROSE (ISO-OSMOT) INTRAVENOUS PIGGYBACK RX-9492 CDM J0696 HCPCS 636 RC 00264-3153-11 NDC outpatient 50 ML 108.18 108.18 CIGNA 62308 [3081051] CIGNA STATE OF WYOMING [308105107] 86.54 percent of total billed charges 67.07 102.77 Technical (Hospital) Services CEFTRIAXONE 1 GRAM/50 ML IN DEXTROSE (ISO-OSMOT) INTRAVENOUS PIGGYBACK RX-9492 CDM J0696 HCPCS 636 RC 00264-3153-11 NDC outpatient 50 ML 108.18 108.18 MEDICA (COMMERCIAL) 94265 [3081118] MEDICA CLAIMS [308111801] 97.36 percent of total billed charges 67.07 102.77 Technical (Hospital) Services CEFTRIAXONE 1 GRAM/50 ML IN DEXTROSE (ISO-OSMOT) INTRAVENOUS PIGGYBACK RX-9492 CDM J0696 HCPCS 636 RC 00264-3153-11 NDC outpatient 50 ML 108.18 108.18 MULTIPLAN INC 34080 [3081285] MULTIPLAN INC [308128501] 102.77 percent of total billed charges 67.07 102.77 Technical (Hospital) Services CEFTRIAXONE 1 GRAM/50 ML IN DEXTROSE (ISO-OSMOT) INTRAVENOUS PIGGYBACK RX-9492 CDM J0696 HCPCS 636 RC 00264-3153-11 NDC outpatient 50 ML 108.18 108.18 BLUE CROSS BLUE SHIELD WELLMARK SB889 [3081026] BCBS WYOMING [308102603] 102.77 percent of total billed charges 67.07 102.77 Technical (Hospital) Services CEFTRIAXONE 1 GRAM/50 ML IN DEXTROSE (ISO-OSMOT) INTRAVENOUS PIGGYBACK RX-9492 CDM J0696 HCPCS 636 RC 00264-3153-11 NDC outpatient 50 ML 108.18 108.18 HEALTHPARTNERS SX009 HEALTHPARTNERS 86.54 percent of total billed charges 67.07 102.77 Technical (Hospital) Services CEFTRIAXONE 1 GRAM/50 ML IN DEXTROSE (ISO-OSMOT) INTRAVENOUS PIGGYBACK RX-9492 CDM J0696 HCPCS 636 RC 00264-3153-11 NDC outpatient 50 ML 108.18 108.18 UNITED HEALTHCARE (COMMERCIAL) [3081199] UNITED HEALTHCARE 87726 [308119901] 67.07 percent of total billed charges 67.07 102.77 Technical (Hospital) Services CEFTRIAXONE 1 GRAM/50 ML IN DEXTROSE (ISO-OSMOT) INTRAVENOUS PIGGYBACK RX-9492 CDM J0696 HCPCS 636 RC 00264-3153-11 NDC outpatient 50 ML 108.18 108.18 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES EPO [308136803] 86.54 percent of total billed charges 67.07 102.77 Technical (Hospital) Services CEFTRIAXONE 1 GRAM/50 ML IN DEXTROSE (ISO-OSMOT) INTRAVENOUS PIGGYBACK RX-9492 CDM J0696 HCPCS 636 RC 00264-3153-11 NDC outpatient 50 ML 108.18 108.18 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES HDHP [308136802] 86.54 percent of total billed charges 67.07 102.77 Technical (Hospital) Services CEFTRIAXONE 1 GRAM/50 ML IN DEXTROSE (ISO-OSMOT) INTRAVENOUS PIGGYBACK RX-9492 CDM J0696 HCPCS 636 RC 00264-3153-11 NDC outpatient 50 ML 108.18 108.18 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES PPO [308136801] 86.54 percent of total billed charges 67.07 102.77 Technical (Hospital) Services CEFTRIAXONE 1 GRAM/50 ML IN DEXTROSE (ISO-OSMOT) INTRAVENOUS PIGGYBACK RX-9492 CDM J0696 HCPCS 636 RC 00264-3153-11 NDC inpatient 50 ML 108.18 108.18 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES EPO [308136803] 85.66 percent of total billed charges 67.07 102.77 Technical (Hospital) Services CEFTRIAXONE 1 GRAM/50 ML IN DEXTROSE (ISO-OSMOT) INTRAVENOUS PIGGYBACK RX-9492 CDM J0696 HCPCS 636 RC 00264-3153-11 NDC inpatient 50 ML 108.18 108.18 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES HDHP [308136802] 85.66 percent of total billed charges 67.07 102.77 Technical (Hospital) Services CEFTRIAXONE 1 GRAM/50 ML IN DEXTROSE (ISO-OSMOT) INTRAVENOUS PIGGYBACK RX-9492 CDM J0696 HCPCS 636 RC 00264-3153-11 NDC inpatient 50 ML 108.18 108.18 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES PPO [308136801] 85.66 percent of total billed charges 67.07 102.77 Technical (Hospital) Services CEFTRIAXONE 1 GRAM/50 ML IN DEXTROSE (ISO-OSMOT) INTRAVENOUS PIGGYBACK RX-9492 CDM J0696 HCPCS 636 RC 00264-3153-11 NDC inpatient 50 ML 108.18 108.18 CIGNA 62308 [3081051] CIGNA 62308 [308105105] 85.66 percent of total billed charges 67.07 102.77 Technical (Hospital) Services CEFTRIAXONE 1 GRAM/50 ML IN DEXTROSE (ISO-OSMOT) INTRAVENOUS PIGGYBACK RX-9492 CDM J0696 HCPCS 636 RC 00264-3153-11 NDC inpatient 50 ML 108.18 108.18 CIGNA 62308 [3081051] CIGNA STATE OF WYOMING [308105107] 85.66 percent of total billed charges 67.07 102.77 Technical (Hospital) Services CEFTRIAXONE 1 GRAM/50 ML IN DEXTROSE (ISO-OSMOT) INTRAVENOUS PIGGYBACK RX-9492 CDM J0696 HCPCS 636 RC 00264-3153-11 NDC inpatient 50 ML 108.18 108.18 MEDICA (COMMERCIAL) 94265 [3081118] MEDICA CLAIMS [308111801] 97.36 percent of total billed charges 67.07 102.77 Technical (Hospital) Services CEFTRIAXONE 1 GRAM/50 ML IN DEXTROSE (ISO-OSMOT) INTRAVENOUS PIGGYBACK RX-9492 CDM J0696 HCPCS 636 RC 00264-3153-11 NDC inpatient 50 ML 108.18 108.18 MULTIPLAN INC 34080 [3081285] MULTIPLAN INC [308128501] 102.77 percent of total billed charges 67.07 102.77 Technical (Hospital) Services CEFTRIAXONE 1 GRAM/50 ML IN DEXTROSE (ISO-OSMOT) INTRAVENOUS PIGGYBACK RX-9492 CDM J0696 HCPCS 636 RC 00264-3153-11 NDC inpatient 50 ML 108.18 108.18 HEALTHPARTNERS SX009 HEALTHPARTNERS 85.66 percent of total billed charges 67.07 102.77 Technical (Hospital) Services CEFTRIAXONE 1 GRAM/50 ML IN DEXTROSE (ISO-OSMOT) INTRAVENOUS PIGGYBACK RX-9492 CDM J0696 HCPCS 636 RC 00264-3153-11 NDC inpatient 50 ML 108.18 108.18 UNITED HEALTHCARE (COMMERCIAL) [3081199] UNITED HEALTHCARE 87726 [308119901] 67.07 percent of total billed charges 67.07 102.77 Technical (Hospital) Services CEFTRIAXONE 1 GRAM/50 ML IN DEXTROSE (ISO-OSMOT) INTRAVENOUS PIGGYBACK RX-9492 CDM J0696 HCPCS 636 RC 00264-3153-11 NDC inpatient 50 ML 108.18 108.18 BLUE CROSS BLUE SHIELD WELLMARK SB889 [3081026] BCBS WYOMING [308102603] 102.77 percent of total billed charges 67.07 102.77 Technical (Hospital) Services CEFTRIAXONE 2 GRAM/50 ML IN DEXTROSE (ISO-OSM) INTRAVENOUS PIGGYBACK RX-9493 CDM J0696 HCPCS 636 RC 00264-3155-11 NDC outpatient 50 ML 148.74 148.74 UNITED HEALTHCARE (COMMERCIAL) [3081199] UNITED HEALTHCARE 87726 [308119901] 92.22 percent of total billed charges 92.22 141.3 Technical (Hospital) Services CEFTRIAXONE 2 GRAM/50 ML IN DEXTROSE (ISO-OSM) INTRAVENOUS PIGGYBACK RX-9493 CDM J0696 HCPCS 636 RC 00264-3155-11 NDC outpatient 50 ML 148.74 148.74 HEALTHPARTNERS SX009 HEALTHPARTNERS 118.99 percent of total billed charges 92.22 141.3 Technical (Hospital) Services CEFTRIAXONE 2 GRAM/50 ML IN DEXTROSE (ISO-OSM) INTRAVENOUS PIGGYBACK RX-9493 CDM J0696 HCPCS 636 RC 00264-3155-11 NDC outpatient 50 ML 148.74 148.74 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES EPO [308136803] 118.99 percent of total billed charges 92.22 141.3 Technical (Hospital) Services CEFTRIAXONE 2 GRAM/50 ML IN DEXTROSE (ISO-OSM) INTRAVENOUS PIGGYBACK RX-9493 CDM J0696 HCPCS 636 RC 00264-3155-11 NDC outpatient 50 ML 148.74 148.74 BLUE CROSS BLUE SHIELD WELLMARK SB889 [3081026] BCBS WYOMING [308102603] 141.3 percent of total billed charges 92.22 141.3 Technical (Hospital) Services CEFTRIAXONE 2 GRAM/50 ML IN DEXTROSE (ISO-OSM) INTRAVENOUS PIGGYBACK RX-9493 CDM J0696 HCPCS 636 RC 00264-3155-11 NDC outpatient 50 ML 148.74 148.74 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES PPO [308136801] 118.99 percent of total billed charges 92.22 141.3 Technical (Hospital) Services CEFTRIAXONE 2 GRAM/50 ML IN DEXTROSE (ISO-OSM) INTRAVENOUS PIGGYBACK RX-9493 CDM J0696 HCPCS 636 RC 00264-3155-11 NDC outpatient 50 ML 148.74 148.74 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES HDHP [308136802] 118.99 percent of total billed charges 92.22 141.3 Technical (Hospital) Services CEFTRIAXONE 2 GRAM/50 ML IN DEXTROSE (ISO-OSM) INTRAVENOUS PIGGYBACK RX-9493 CDM J0696 HCPCS 636 RC 00264-3155-11 NDC outpatient 50 ML 148.74 148.74 CIGNA 62308 [3081051] CIGNA 62308 [308105105] 118.99 percent of total billed charges 92.22 141.3 Technical (Hospital) Services CEFTRIAXONE 2 GRAM/50 ML IN DEXTROSE (ISO-OSM) INTRAVENOUS PIGGYBACK RX-9493 CDM J0696 HCPCS 636 RC 00264-3155-11 NDC outpatient 50 ML 148.74 148.74 CIGNA 62308 [3081051] CIGNA STATE OF WYOMING [308105107] 118.99 percent of total billed charges 92.22 141.3 Technical (Hospital) Services CEFTRIAXONE 2 GRAM/50 ML IN DEXTROSE (ISO-OSM) INTRAVENOUS PIGGYBACK RX-9493 CDM J0696 HCPCS 636 RC 00264-3155-11 NDC outpatient 50 ML 148.74 148.74 MEDICA (COMMERCIAL) 94265 [3081118] MEDICA CLAIMS [308111801] 133.87 percent of total billed charges 92.22 141.3 Technical (Hospital) Services CEFTRIAXONE 2 GRAM/50 ML IN DEXTROSE (ISO-OSM) INTRAVENOUS PIGGYBACK RX-9493 CDM J0696 HCPCS 636 RC 00264-3155-11 NDC outpatient 50 ML 148.74 148.74 MULTIPLAN INC 34080 [3081285] MULTIPLAN INC [308128501] 141.3 percent of total billed charges 92.22 141.3 Technical (Hospital) Services CEFTRIAXONE 2 GRAM/50 ML IN DEXTROSE (ISO-OSM) INTRAVENOUS PIGGYBACK RX-9493 CDM J0696 HCPCS 636 RC 00264-3155-11 NDC inpatient 50 ML 148.74 148.74 MULTIPLAN INC 34080 [3081285] MULTIPLAN INC [308128501] 141.3 percent of total billed charges 92.22 141.3 Technical (Hospital) Services CEFTRIAXONE 2 GRAM/50 ML IN DEXTROSE (ISO-OSM) INTRAVENOUS PIGGYBACK RX-9493 CDM J0696 HCPCS 636 RC 00264-3155-11 NDC inpatient 50 ML 148.74 148.74 MEDICA (COMMERCIAL) 94265 [3081118] MEDICA CLAIMS [308111801] 133.87 percent of total billed charges 92.22 141.3 Technical (Hospital) Services CEFTRIAXONE 2 GRAM/50 ML IN DEXTROSE (ISO-OSM) INTRAVENOUS PIGGYBACK RX-9493 CDM J0696 HCPCS 636 RC 00264-3155-11 NDC inpatient 50 ML 148.74 148.74 HEALTHPARTNERS SX009 HEALTHPARTNERS 117.77 percent of total billed charges 92.22 141.3 Technical (Hospital) Services CEFTRIAXONE 2 GRAM/50 ML IN DEXTROSE (ISO-OSM) INTRAVENOUS PIGGYBACK RX-9493 CDM J0696 HCPCS 636 RC 00264-3155-11 NDC inpatient 50 ML 148.74 148.74 UNITED HEALTHCARE (COMMERCIAL) [3081199] UNITED HEALTHCARE 87726 [308119901] 92.22 percent of total billed charges 92.22 141.3 Technical (Hospital) Services CEFTRIAXONE 2 GRAM/50 ML IN DEXTROSE (ISO-OSM) INTRAVENOUS PIGGYBACK RX-9493 CDM J0696 HCPCS 636 RC 00264-3155-11 NDC inpatient 50 ML 148.74 148.74 BLUE CROSS BLUE SHIELD WELLMARK SB889 [3081026] BCBS WYOMING [308102603] 141.3 percent of total billed charges 92.22 141.3 Technical (Hospital) Services CEFTRIAXONE 2 GRAM/50 ML IN DEXTROSE (ISO-OSM) INTRAVENOUS PIGGYBACK RX-9493 CDM J0696 HCPCS 636 RC 00264-3155-11 NDC inpatient 50 ML 148.74 148.74 CIGNA 62308 [3081051] CIGNA 62308 [308105105] 117.77 percent of total billed charges 92.22 141.3 Technical (Hospital) Services CEFTRIAXONE 2 GRAM/50 ML IN DEXTROSE (ISO-OSM) INTRAVENOUS PIGGYBACK RX-9493 CDM J0696 HCPCS 636 RC 00264-3155-11 NDC inpatient 50 ML 148.74 148.74 CIGNA 62308 [3081051] CIGNA STATE OF WYOMING [308105107] 117.77 percent of total billed charges 92.22 141.3 Technical (Hospital) Services CEFTRIAXONE 2 GRAM/50 ML IN DEXTROSE (ISO-OSM) INTRAVENOUS PIGGYBACK RX-9493 CDM J0696 HCPCS 636 RC 00264-3155-11 NDC inpatient 50 ML 148.74 148.74 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES EPO [308136803] 117.77 percent of total billed charges 92.22 141.3 Technical (Hospital) Services CEFTRIAXONE 2 GRAM/50 ML IN DEXTROSE (ISO-OSM) INTRAVENOUS PIGGYBACK RX-9493 CDM J0696 HCPCS 636 RC 00264-3155-11 NDC inpatient 50 ML 148.74 148.74 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES HDHP [308136802] 117.77 percent of total billed charges 92.22 141.3 Technical (Hospital) Services CEFTRIAXONE 2 GRAM/50 ML IN DEXTROSE (ISO-OSM) INTRAVENOUS PIGGYBACK RX-9493 CDM J0696 HCPCS 636 RC 00264-3155-11 NDC inpatient 50 ML 148.74 148.74 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES PPO [308136801] 117.77 percent of total billed charges 92.22 141.3 Technical (Hospital) Services CEFOXITIN 1 GRAM INTRAVENOUS SOLUTION RX-9461 CDM J0694 HCPCS 636 RC 25021-0109-10 NDC inpatient 10.53 ML 81.23 81.23 HEALTHPARTNERS SX009 HEALTHPARTNERS 64.32 percent of total billed charges 50.36 77.17 Technical (Hospital) Services CEFOXITIN 1 GRAM INTRAVENOUS SOLUTION RX-9461 CDM J0694 HCPCS 636 RC 25021-0109-10 NDC inpatient 10.53 ML 81.23 81.23 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES EPO [308136803] 64.32 percent of total billed charges 50.36 77.17 Technical (Hospital) Services CEFOXITIN 1 GRAM INTRAVENOUS SOLUTION RX-9461 CDM J0694 HCPCS 636 RC 25021-0109-10 NDC inpatient 10.53 ML 81.23 81.23 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES HDHP [308136802] 64.32 percent of total billed charges 50.36 77.17 Technical (Hospital) Services CEFOXITIN 1 GRAM INTRAVENOUS SOLUTION RX-9461 CDM J0694 HCPCS 636 RC 25021-0109-10 NDC inpatient 10.53 ML 81.23 81.23 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES PPO [308136801] 64.32 percent of total billed charges 50.36 77.17 Technical (Hospital) Services CEFOXITIN 1 GRAM INTRAVENOUS SOLUTION RX-9461 CDM J0694 HCPCS 636 RC 25021-0109-10 NDC inpatient 10.53 ML 81.23 81.23 MULTIPLAN INC 34080 [3081285] MULTIPLAN INC [308128501] 77.17 percent of total billed charges 50.36 77.17 Technical (Hospital) Services CEFOXITIN 1 GRAM INTRAVENOUS SOLUTION RX-9461 CDM J0694 HCPCS 636 RC 25021-0109-10 NDC inpatient 10.53 ML 81.23 81.23 MEDICA (COMMERCIAL) 94265 [3081118] MEDICA CLAIMS [308111801] 73.11 percent of total billed charges 50.36 77.17 Technical (Hospital) Services CEFOXITIN 1 GRAM INTRAVENOUS SOLUTION RX-9461 CDM J0694 HCPCS 636 RC 25021-0109-10 NDC inpatient 10.53 ML 81.23 81.23 UNITED HEALTHCARE (COMMERCIAL) [3081199] UNITED HEALTHCARE 87726 [308119901] 50.36 percent of total billed charges 50.36 77.17 Technical (Hospital) Services CEFOXITIN 1 GRAM INTRAVENOUS SOLUTION RX-9461 CDM J0694 HCPCS 636 RC 25021-0109-10 NDC inpatient 10.53 ML 81.23 81.23 CIGNA 62308 [3081051] CIGNA 62308 [308105105] 64.32 percent of total billed charges 50.36 77.17 Technical (Hospital) Services CEFOXITIN 1 GRAM INTRAVENOUS SOLUTION RX-9461 CDM J0694 HCPCS 636 RC 25021-0109-10 NDC inpatient 10.53 ML 81.23 81.23 CIGNA 62308 [3081051] CIGNA STATE OF WYOMING [308105107] 64.32 percent of total billed charges 50.36 77.17 Technical (Hospital) Services CEFOXITIN 1 GRAM INTRAVENOUS SOLUTION RX-9461 CDM J0694 HCPCS 636 RC 25021-0109-10 NDC inpatient 10.53 ML 81.23 81.23 BLUE CROSS BLUE SHIELD WELLMARK SB889 [3081026] BCBS WYOMING [308102603] 77.17 percent of total billed charges 50.36 77.17 Technical (Hospital) Services CEFOXITIN 1 GRAM INTRAVENOUS SOLUTION RX-9461 CDM J0694 HCPCS 636 RC 25021-0109-10 NDC outpatient 10.53 ML 81.23 81.23 MEDICA (COMMERCIAL) 94265 [3081118] MEDICA CLAIMS [308111801] 73.11 percent of total billed charges 50.36 77.17 Technical (Hospital) Services CEFOXITIN 1 GRAM INTRAVENOUS SOLUTION RX-9461 CDM J0694 HCPCS 636 RC 25021-0109-10 NDC outpatient 10.53 ML 81.23 81.23 MULTIPLAN INC 34080 [3081285] MULTIPLAN INC [308128501] 77.17 percent of total billed charges 50.36 77.17 Technical (Hospital) Services CEFOXITIN 1 GRAM INTRAVENOUS SOLUTION RX-9461 CDM J0694 HCPCS 636 RC 25021-0109-10 NDC outpatient 10.53 ML 81.23 81.23 CIGNA 62308 [3081051] CIGNA 62308 [308105105] 64.98 percent of total billed charges 50.36 77.17 Technical (Hospital) Services CEFOXITIN 1 GRAM INTRAVENOUS SOLUTION RX-9461 CDM J0694 HCPCS 636 RC 25021-0109-10 NDC outpatient 10.53 ML 81.23 81.23 CIGNA 62308 [3081051] CIGNA STATE OF WYOMING [308105107] 64.98 percent of total billed charges 50.36 77.17 Technical (Hospital) Services CEFOXITIN 1 GRAM INTRAVENOUS SOLUTION RX-9461 CDM J0694 HCPCS 636 RC 25021-0109-10 NDC outpatient 10.53 ML 81.23 81.23 HEALTHPARTNERS SX009 HEALTHPARTNERS 64.98 percent of total billed charges 50.36 77.17 Technical (Hospital) Services CEFOXITIN 1 GRAM INTRAVENOUS SOLUTION RX-9461 CDM J0694 HCPCS 636 RC 25021-0109-10 NDC outpatient 10.53 ML 81.23 81.23 UNITED HEALTHCARE (COMMERCIAL) [3081199] UNITED HEALTHCARE 87726 [308119901] 50.36 percent of total billed charges 50.36 77.17 Technical (Hospital) Services CEFOXITIN 1 GRAM INTRAVENOUS SOLUTION RX-9461 CDM J0694 HCPCS 636 RC 25021-0109-10 NDC outpatient 10.53 ML 81.23 81.23 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES EPO [308136803] 64.98 percent of total billed charges 50.36 77.17 Technical (Hospital) Services CEFOXITIN 1 GRAM INTRAVENOUS SOLUTION RX-9461 CDM J0694 HCPCS 636 RC 25021-0109-10 NDC outpatient 10.53 ML 81.23 81.23 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES HDHP [308136802] 64.98 percent of total billed charges 50.36 77.17 Technical (Hospital) Services CEFOXITIN 1 GRAM INTRAVENOUS SOLUTION RX-9461 CDM J0694 HCPCS 636 RC 25021-0109-10 NDC outpatient 10.53 ML 81.23 81.23 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES PPO [308136801] 64.98 percent of total billed charges 50.36 77.17 Technical (Hospital) Services CEFOXITIN 1 GRAM INTRAVENOUS SOLUTION RX-9461 CDM J0694 HCPCS 636 RC 25021-0109-10 NDC outpatient 10.53 ML 81.23 81.23 BLUE CROSS BLUE SHIELD WELLMARK SB889 [3081026] BCBS WYOMING [308102603] 77.17 percent of total billed charges 50.36 77.17 Technical (Hospital) Services CEFEPIME 1 GRAM SOLUTION FOR INJECTION RX-16369 CDM J0692 HCPCS 636 RC 25021-0121-66 NDC inpatient 10 ML 61.44 61.44 HEALTHPARTNERS SX009 HEALTHPARTNERS 48.65 percent of total billed charges 38.09 58.37 Technical (Hospital) Services CEFEPIME 1 GRAM SOLUTION FOR INJECTION RX-16369 CDM J0692 HCPCS 636 RC 25021-0121-66 NDC inpatient 10 ML 61.44 61.44 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES HDHP [308136802] 48.65 percent of total billed charges 38.09 58.37 Technical (Hospital) Services CEFEPIME 1 GRAM SOLUTION FOR INJECTION RX-16369 CDM J0692 HCPCS 636 RC 25021-0121-66 NDC inpatient 10 ML 61.44 61.44 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES PPO [308136801] 48.65 percent of total billed charges 38.09 58.37 Technical (Hospital) Services CEFEPIME 1 GRAM SOLUTION FOR INJECTION RX-16369 CDM J0692 HCPCS 636 RC 25021-0121-66 NDC inpatient 10 ML 61.44 61.44 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES EPO [308136803] 48.65 percent of total billed charges 38.09 58.37 Technical (Hospital) Services CEFEPIME 1 GRAM SOLUTION FOR INJECTION RX-16369 CDM J0692 HCPCS 636 RC 25021-0121-66 NDC inpatient 10 ML 61.44 61.44 MULTIPLAN INC 34080 [3081285] MULTIPLAN INC [308128501] 58.37 percent of total billed charges 38.09 58.37 Technical (Hospital) Services CEFEPIME 1 GRAM SOLUTION FOR INJECTION RX-16369 CDM J0692 HCPCS 636 RC 25021-0121-66 NDC inpatient 10 ML 61.44 61.44 MEDICA (COMMERCIAL) 94265 [3081118] MEDICA CLAIMS [308111801] 55.3 percent of total billed charges 38.09 58.37 Technical (Hospital) Services CEFEPIME 1 GRAM SOLUTION FOR INJECTION RX-16369 CDM J0692 HCPCS 636 RC 25021-0121-66 NDC inpatient 10 ML 61.44 61.44 CIGNA 62308 [3081051] CIGNA 62308 [308105105] 48.65 percent of total billed charges 38.09 58.37 Technical (Hospital) Services CEFEPIME 1 GRAM SOLUTION FOR INJECTION RX-16369 CDM J0692 HCPCS 636 RC 25021-0121-66 NDC inpatient 10 ML 61.44 61.44 CIGNA 62308 [3081051] CIGNA STATE OF WYOMING [308105107] 48.65 percent of total billed charges 38.09 58.37 Technical (Hospital) Services CEFEPIME 1 GRAM SOLUTION FOR INJECTION RX-16369 CDM J0692 HCPCS 636 RC 25021-0121-66 NDC inpatient 10 ML 61.44 61.44 UNITED HEALTHCARE (COMMERCIAL) [3081199] UNITED HEALTHCARE 87726 [308119901] 38.09 percent of total billed charges 38.09 58.37 Technical (Hospital) Services CEFEPIME 1 GRAM SOLUTION FOR INJECTION RX-16369 CDM J0692 HCPCS 636 RC 25021-0121-66 NDC inpatient 10 ML 61.44 61.44 BLUE CROSS BLUE SHIELD WELLMARK SB889 [3081026] BCBS WYOMING [308102603] 58.37 percent of total billed charges 38.09 58.37 Technical (Hospital) Services CEFEPIME 1 GRAM SOLUTION FOR INJECTION RX-16369 CDM J0692 HCPCS 636 RC 25021-0121-66 NDC outpatient 10 ML 61.44 61.44 HEALTHPARTNERS SX009 HEALTHPARTNERS 49.15 percent of total billed charges 38.09 58.37 Technical (Hospital) Services CEFEPIME 1 GRAM SOLUTION FOR INJECTION RX-16369 CDM J0692 HCPCS 636 RC 25021-0121-66 NDC outpatient 10 ML 61.44 61.44 UNITED HEALTHCARE (COMMERCIAL) [3081199] UNITED HEALTHCARE 87726 [308119901] 38.09 percent of total billed charges 38.09 58.37 Technical (Hospital) Services CEFEPIME 1 GRAM SOLUTION FOR INJECTION RX-16369 CDM J0692 HCPCS 636 RC 25021-0121-66 NDC outpatient 10 ML 61.44 61.44 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES PPO [308136801] 49.15 percent of total billed charges 38.09 58.37 Technical (Hospital) Services CEFEPIME 1 GRAM SOLUTION FOR INJECTION RX-16369 CDM J0692 HCPCS 636 RC 25021-0121-66 NDC outpatient 10 ML 61.44 61.44 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES EPO [308136803] 49.15 percent of total billed charges 38.09 58.37 Technical (Hospital) Services CEFEPIME 1 GRAM SOLUTION FOR INJECTION RX-16369 CDM J0692 HCPCS 636 RC 25021-0121-66 NDC outpatient 10 ML 61.44 61.44 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES HDHP [308136802] 49.15 percent of total billed charges 38.09 58.37 Technical (Hospital) Services CEFEPIME 1 GRAM SOLUTION FOR INJECTION RX-16369 CDM J0692 HCPCS 636 RC 25021-0121-66 NDC outpatient 10 ML 61.44 61.44 BLUE CROSS BLUE SHIELD WELLMARK SB889 [3081026] BCBS WYOMING [308102603] 58.37 percent of total billed charges 38.09 58.37 Technical (Hospital) Services CEFEPIME 1 GRAM SOLUTION FOR INJECTION RX-16369 CDM J0692 HCPCS 636 RC 25021-0121-66 NDC outpatient 10 ML 61.44 61.44 CIGNA 62308 [3081051] CIGNA 62308 [308105105] 49.15 percent of total billed charges 38.09 58.37 Technical (Hospital) Services CEFEPIME 1 GRAM SOLUTION FOR INJECTION RX-16369 CDM J0692 HCPCS 636 RC 25021-0121-66 NDC outpatient 10 ML 61.44 61.44 CIGNA 62308 [3081051] CIGNA STATE OF WYOMING [308105107] 49.15 percent of total billed charges 38.09 58.37 Technical (Hospital) Services CEFEPIME 1 GRAM SOLUTION FOR INJECTION RX-16369 CDM J0692 HCPCS 636 RC 25021-0121-66 NDC outpatient 10 ML 61.44 61.44 MULTIPLAN INC 34080 [3081285] MULTIPLAN INC [308128501] 58.37 percent of total billed charges 38.09 58.37 Technical (Hospital) Services CEFEPIME 1 GRAM SOLUTION FOR INJECTION RX-16369 CDM J0692 HCPCS 636 RC 25021-0121-66 NDC outpatient 10 ML 61.44 61.44 MEDICA (COMMERCIAL) 94265 [3081118] MEDICA CLAIMS [308111801] 55.3 percent of total billed charges 38.09 58.37 Technical (Hospital) Services CEFEPIME 2 GRAM SOLUTION FOR INJECTION RX-16371 CDM J0692 HCPCS 636 RC 25021-0122-67 NDC outpatient 1 UN 70.2 70.2 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES HDHP [308136802] 56.16 percent of total billed charges 43.52 66.69 Technical (Hospital) Services CEFEPIME 2 GRAM SOLUTION FOR INJECTION RX-16371 CDM J0692 HCPCS 636 RC 25021-0122-67 NDC outpatient 1 UN 70.2 70.2 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES EPO [308136803] 56.16 percent of total billed charges 43.52 66.69 Technical (Hospital) Services CEFEPIME 2 GRAM SOLUTION FOR INJECTION RX-16371 CDM J0692 HCPCS 636 RC 25021-0122-67 NDC outpatient 1 UN 70.2 70.2 MEDICA (COMMERCIAL) 94265 [3081118] MEDICA CLAIMS [308111801] 63.18 percent of total billed charges 43.52 66.69 Technical (Hospital) Services CEFEPIME 2 GRAM SOLUTION FOR INJECTION RX-16371 CDM J0692 HCPCS 636 RC 25021-0122-67 NDC outpatient 1 UN 70.2 70.2 CIGNA 62308 [3081051] CIGNA 62308 [308105105] 56.16 percent of total billed charges 43.52 66.69 Technical (Hospital) Services CEFEPIME 2 GRAM SOLUTION FOR INJECTION RX-16371 CDM J0692 HCPCS 636 RC 25021-0122-67 NDC outpatient 1 UN 70.2 70.2 CIGNA 62308 [3081051] CIGNA STATE OF WYOMING [308105107] 56.16 percent of total billed charges 43.52 66.69 Technical (Hospital) Services CEFEPIME 2 GRAM SOLUTION FOR INJECTION RX-16371 CDM J0692 HCPCS 636 RC 25021-0122-67 NDC outpatient 1 UN 70.2 70.2 HEALTHPARTNERS SX009 HEALTHPARTNERS 56.16 percent of total billed charges 43.52 66.69 Technical (Hospital) Services CEFEPIME 2 GRAM SOLUTION FOR INJECTION RX-16371 CDM J0692 HCPCS 636 RC 25021-0122-67 NDC outpatient 1 UN 70.2 70.2 UNITED HEALTHCARE (COMMERCIAL) [3081199] UNITED HEALTHCARE 87726 [308119901] 43.52 percent of total billed charges 43.52 66.69 Technical (Hospital) Services CEFEPIME 2 GRAM SOLUTION FOR INJECTION RX-16371 CDM J0692 HCPCS 636 RC 25021-0122-67 NDC outpatient 1 UN 70.2 70.2 MULTIPLAN INC 34080 [3081285] MULTIPLAN INC [308128501] 66.69 percent of total billed charges 43.52 66.69 Technical (Hospital) Services CEFEPIME 2 GRAM SOLUTION FOR INJECTION RX-16371 CDM J0692 HCPCS 636 RC 25021-0122-67 NDC outpatient 1 UN 70.2 70.2 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES PPO [308136801] 56.16 percent of total billed charges 43.52 66.69 Technical (Hospital) Services CEFEPIME 2 GRAM SOLUTION FOR INJECTION RX-16371 CDM J0692 HCPCS 636 RC 25021-0122-67 NDC outpatient 1 UN 70.2 70.2 BLUE CROSS BLUE SHIELD WELLMARK SB889 [3081026] BCBS WYOMING [308102603] 66.69 percent of total billed charges 43.52 66.69 Technical (Hospital) Services CEFEPIME 2 GRAM SOLUTION FOR INJECTION RX-16371 CDM J0692 HCPCS 636 RC 25021-0122-67 NDC inpatient 1 UN 70.2 70.2 BLUE CROSS BLUE SHIELD WELLMARK SB889 [3081026] BCBS WYOMING [308102603] 66.69 percent of total billed charges 43.52 66.69 Technical (Hospital) Services CEFEPIME 2 GRAM SOLUTION FOR INJECTION RX-16371 CDM J0692 HCPCS 636 RC 25021-0122-67 NDC inpatient 1 UN 70.2 70.2 UNITED HEALTHCARE (COMMERCIAL) [3081199] UNITED HEALTHCARE 87726 [308119901] 43.52 percent of total billed charges 43.52 66.69 Technical (Hospital) Services CEFEPIME 2 GRAM SOLUTION FOR INJECTION RX-16371 CDM J0692 HCPCS 636 RC 25021-0122-67 NDC inpatient 1 UN 70.2 70.2 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES EPO [308136803] 55.58 percent of total billed charges 43.52 66.69 Technical (Hospital) Services CEFEPIME 2 GRAM SOLUTION FOR INJECTION RX-16371 CDM J0692 HCPCS 636 RC 25021-0122-67 NDC inpatient 1 UN 70.2 70.2 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES HDHP [308136802] 55.58 percent of total billed charges 43.52 66.69 Technical (Hospital) Services CEFEPIME 2 GRAM SOLUTION FOR INJECTION RX-16371 CDM J0692 HCPCS 636 RC 25021-0122-67 NDC inpatient 1 UN 70.2 70.2 CIGNA 62308 [3081051] CIGNA 62308 [308105105] 55.58 percent of total billed charges 43.52 66.69 Technical (Hospital) Services CEFEPIME 2 GRAM SOLUTION FOR INJECTION RX-16371 CDM J0692 HCPCS 636 RC 25021-0122-67 NDC inpatient 1 UN 70.2 70.2 CIGNA 62308 [3081051] CIGNA STATE OF WYOMING [308105107] 55.58 percent of total billed charges 43.52 66.69 Technical (Hospital) Services CEFEPIME 2 GRAM SOLUTION FOR INJECTION RX-16371 CDM J0692 HCPCS 636 RC 25021-0122-67 NDC inpatient 1 UN 70.2 70.2 HEALTHPARTNERS SX009 HEALTHPARTNERS 55.58 percent of total billed charges 43.52 66.69 Technical (Hospital) Services CEFEPIME 2 GRAM SOLUTION FOR INJECTION RX-16371 CDM J0692 HCPCS 636 RC 25021-0122-67 NDC inpatient 1 UN 70.2 70.2 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES PPO [308136801] 55.58 percent of total billed charges 43.52 66.69 Technical (Hospital) Services CEFEPIME 2 GRAM SOLUTION FOR INJECTION RX-16371 CDM J0692 HCPCS 636 RC 25021-0122-67 NDC inpatient 1 UN 70.2 70.2 MEDICA (COMMERCIAL) 94265 [3081118] MEDICA CLAIMS [308111801] 63.18 percent of total billed charges 43.52 66.69 Technical (Hospital) Services CEFEPIME 2 GRAM SOLUTION FOR INJECTION RX-16371 CDM J0692 HCPCS 636 RC 25021-0122-67 NDC inpatient 1 UN 70.2 70.2 MULTIPLAN INC 34080 [3081285] MULTIPLAN INC [308128501] 66.69 percent of total billed charges 43.52 66.69 Technical (Hospital) Services CEFEPIME 2 G WET VIAL 160 MG/ML RX-4080030195 CDM J0692 HCPCS 636 RC 25021-0122-67 NDC outpatient 12.5 ML 70.2 70.2 BLUE CROSS BLUE SHIELD WELLMARK SB889 [3081026] BCBS WYOMING [308102603] 66.69 percent of total billed charges 43.52 66.69 Technical (Hospital) Services CEFEPIME 2 G WET VIAL 160 MG/ML RX-4080030195 CDM J0692 HCPCS 636 RC 25021-0122-67 NDC outpatient 12.5 ML 70.2 70.2 HEALTHPARTNERS SX009 HEALTHPARTNERS 56.16 percent of total billed charges 43.52 66.69 Technical (Hospital) Services CEFEPIME 2 G WET VIAL 160 MG/ML RX-4080030195 CDM J0692 HCPCS 636 RC 25021-0122-67 NDC outpatient 12.5 ML 70.2 70.2 UNITED HEALTHCARE (COMMERCIAL) [3081199] UNITED HEALTHCARE 87726 [308119901] 43.52 percent of total billed charges 43.52 66.69 Technical (Hospital) Services CEFEPIME 2 G WET VIAL 160 MG/ML RX-4080030195 CDM J0692 HCPCS 636 RC 25021-0122-67 NDC outpatient 12.5 ML 70.2 70.2 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES EPO [308136803] 56.16 percent of total billed charges 43.52 66.69 Technical (Hospital) Services CEFEPIME 2 G WET VIAL 160 MG/ML RX-4080030195 CDM J0692 HCPCS 636 RC 25021-0122-67 NDC outpatient 12.5 ML 70.2 70.2 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES HDHP [308136802] 56.16 percent of total billed charges 43.52 66.69 Technical (Hospital) Services CEFEPIME 2 G WET VIAL 160 MG/ML RX-4080030195 CDM J0692 HCPCS 636 RC 25021-0122-67 NDC outpatient 12.5 ML 70.2 70.2 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES PPO [308136801] 56.16 percent of total billed charges 43.52 66.69 Technical (Hospital) Services CEFEPIME 2 G WET VIAL 160 MG/ML RX-4080030195 CDM J0692 HCPCS 636 RC 25021-0122-67 NDC outpatient 12.5 ML 70.2 70.2 MEDICA (COMMERCIAL) 94265 [3081118] MEDICA CLAIMS [308111801] 63.18 percent of total billed charges 43.52 66.69 Technical (Hospital) Services CEFEPIME 2 G WET VIAL 160 MG/ML RX-4080030195 CDM J0692 HCPCS 636 RC 25021-0122-67 NDC outpatient 12.5 ML 70.2 70.2 MULTIPLAN INC 34080 [3081285] MULTIPLAN INC [308128501] 66.69 percent of total billed charges 43.52 66.69 Technical (Hospital) Services CEFEPIME 2 G WET VIAL 160 MG/ML RX-4080030195 CDM J0692 HCPCS 636 RC 25021-0122-67 NDC outpatient 12.5 ML 70.2 70.2 CIGNA 62308 [3081051] CIGNA 62308 [308105105] 56.16 percent of total billed charges 43.52 66.69 Technical (Hospital) Services CEFEPIME 2 G WET VIAL 160 MG/ML RX-4080030195 CDM J0692 HCPCS 636 RC 25021-0122-67 NDC outpatient 12.5 ML 70.2 70.2 CIGNA 62308 [3081051] CIGNA STATE OF WYOMING [308105107] 56.16 percent of total billed charges 43.52 66.69 Technical (Hospital) Services CEFEPIME 2 G WET VIAL 160 MG/ML RX-4080030195 CDM J0692 HCPCS 636 RC 25021-0122-67 NDC inpatient 12.5 ML 70.2 70.2 MEDICA (COMMERCIAL) 94265 [3081118] MEDICA CLAIMS [308111801] 63.18 percent of total billed charges 43.52 66.69 Technical (Hospital) Services CEFEPIME 2 G WET VIAL 160 MG/ML RX-4080030195 CDM J0692 HCPCS 636 RC 25021-0122-67 NDC inpatient 12.5 ML 70.2 70.2 MULTIPLAN INC 34080 [3081285] MULTIPLAN INC [308128501] 66.69 percent of total billed charges 43.52 66.69 Technical (Hospital) Services CEFEPIME 2 G WET VIAL 160 MG/ML RX-4080030195 CDM J0692 HCPCS 636 RC 25021-0122-67 NDC inpatient 12.5 ML 70.2 70.2 UNITED HEALTHCARE (COMMERCIAL) [3081199] UNITED HEALTHCARE 87726 [308119901] 43.52 percent of total billed charges 43.52 66.69 Technical (Hospital) Services CEFEPIME 2 G WET VIAL 160 MG/ML RX-4080030195 CDM J0692 HCPCS 636 RC 25021-0122-67 NDC inpatient 12.5 ML 70.2 70.2 BLUE CROSS BLUE SHIELD WELLMARK SB889 [3081026] BCBS WYOMING [308102603] 66.69 percent of total billed charges 43.52 66.69 Technical (Hospital) Services CEFEPIME 2 G WET VIAL 160 MG/ML RX-4080030195 CDM J0692 HCPCS 636 RC 25021-0122-67 NDC inpatient 12.5 ML 70.2 70.2 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES EPO [308136803] 55.58 percent of total billed charges 43.52 66.69 Technical (Hospital) Services CEFEPIME 2 G WET VIAL 160 MG/ML RX-4080030195 CDM J0692 HCPCS 636 RC 25021-0122-67 NDC inpatient 12.5 ML 70.2 70.2 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES HDHP [308136802] 55.58 percent of total billed charges 43.52 66.69 Technical (Hospital) Services CEFEPIME 2 G WET VIAL 160 MG/ML RX-4080030195 CDM J0692 HCPCS 636 RC 25021-0122-67 NDC inpatient 12.5 ML 70.2 70.2 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES PPO [308136801] 55.58 percent of total billed charges 43.52 66.69 Technical (Hospital) Services CEFEPIME 2 G WET VIAL 160 MG/ML RX-4080030195 CDM J0692 HCPCS 636 RC 25021-0122-67 NDC inpatient 12.5 ML 70.2 70.2 HEALTHPARTNERS SX009 HEALTHPARTNERS 55.58 percent of total billed charges 43.52 66.69 Technical (Hospital) Services CEFEPIME 2 G WET VIAL 160 MG/ML RX-4080030195 CDM J0692 HCPCS 636 RC 25021-0122-67 NDC inpatient 12.5 ML 70.2 70.2 CIGNA 62308 [3081051] CIGNA 62308 [308105105] 55.58 percent of total billed charges 43.52 66.69 Technical (Hospital) Services CEFEPIME 2 G WET VIAL 160 MG/ML RX-4080030195 CDM J0692 HCPCS 636 RC 25021-0122-67 NDC inpatient 12.5 ML 70.2 70.2 CIGNA 62308 [3081051] CIGNA STATE OF WYOMING [308105107] 55.58 percent of total billed charges 43.52 66.69 Technical (Hospital) Services CEFAZOLIN 2 GRAM/50 ML IN DEXTROSE (ISO-OSMOTIC) INTRAVENOUS PIGGYBACK (30 MIN) RX-113850 CDM J0690 HCPCS 636 RC 00264-3105-11 NDC outpatient 50 ML 84.76 84.76 HEALTHPARTNERS SX009 HEALTHPARTNERS 67.81 percent of total billed charges 52.55 80.52 Technical (Hospital) Services CEFAZOLIN 2 GRAM/50 ML IN DEXTROSE (ISO-OSMOTIC) INTRAVENOUS PIGGYBACK (30 MIN) RX-113850 CDM J0690 HCPCS 636 RC 00264-3105-11 NDC outpatient 50 ML 84.76 84.76 UNITED HEALTHCARE (COMMERCIAL) [3081199] UNITED HEALTHCARE 87726 [308119901] 52.55 percent of total billed charges 52.55 80.52 Technical (Hospital) Services CEFAZOLIN 2 GRAM/50 ML IN DEXTROSE (ISO-OSMOTIC) INTRAVENOUS PIGGYBACK (30 MIN) RX-113850 CDM J0690 HCPCS 636 RC 00264-3105-11 NDC outpatient 50 ML 84.76 84.76 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES PPO [308136801] 67.81 percent of total billed charges 52.55 80.52 Technical (Hospital) Services CEFAZOLIN 2 GRAM/50 ML IN DEXTROSE (ISO-OSMOTIC) INTRAVENOUS PIGGYBACK (30 MIN) RX-113850 CDM J0690 HCPCS 636 RC 00264-3105-11 NDC outpatient 50 ML 84.76 84.76 BLUE CROSS BLUE SHIELD WELLMARK SB889 [3081026] BCBS WYOMING [308102603] 80.52 percent of total billed charges 52.55 80.52 Technical (Hospital) Services CEFAZOLIN 2 GRAM/50 ML IN DEXTROSE (ISO-OSMOTIC) INTRAVENOUS PIGGYBACK (30 MIN) RX-113850 CDM J0690 HCPCS 636 RC 00264-3105-11 NDC outpatient 50 ML 84.76 84.76 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES HDHP [308136802] 67.81 percent of total billed charges 52.55 80.52 Technical (Hospital) Services CEFAZOLIN 2 GRAM/50 ML IN DEXTROSE (ISO-OSMOTIC) INTRAVENOUS PIGGYBACK (30 MIN) RX-113850 CDM J0690 HCPCS 636 RC 00264-3105-11 NDC outpatient 50 ML 84.76 84.76 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES EPO [308136803] 67.81 percent of total billed charges 52.55 80.52 Technical (Hospital) Services CEFAZOLIN 2 GRAM/50 ML IN DEXTROSE (ISO-OSMOTIC) INTRAVENOUS PIGGYBACK (30 MIN) RX-113850 CDM J0690 HCPCS 636 RC 00264-3105-11 NDC outpatient 50 ML 84.76 84.76 CIGNA 62308 [3081051] CIGNA STATE OF WYOMING [308105107] 67.81 percent of total billed charges 52.55 80.52 Technical (Hospital) Services CEFAZOLIN 2 GRAM/50 ML IN DEXTROSE (ISO-OSMOTIC) INTRAVENOUS PIGGYBACK (30 MIN) RX-113850 CDM J0690 HCPCS 636 RC 00264-3105-11 NDC outpatient 50 ML 84.76 84.76 CIGNA 62308 [3081051] CIGNA 62308 [308105105] 67.81 percent of total billed charges 52.55 80.52 Technical (Hospital) Services CEFAZOLIN 2 GRAM/50 ML IN DEXTROSE (ISO-OSMOTIC) INTRAVENOUS PIGGYBACK (30 MIN) RX-113850 CDM J0690 HCPCS 636 RC 00264-3105-11 NDC outpatient 50 ML 84.76 84.76 MEDICA (COMMERCIAL) 94265 [3081118] MEDICA CLAIMS [308111801] 76.28 percent of total billed charges 52.55 80.52 Technical (Hospital) Services CEFAZOLIN 2 GRAM/50 ML IN DEXTROSE (ISO-OSMOTIC) INTRAVENOUS PIGGYBACK (30 MIN) RX-113850 CDM J0690 HCPCS 636 RC 00264-3105-11 NDC outpatient 50 ML 84.76 84.76 MULTIPLAN INC 34080 [3081285] MULTIPLAN INC [308128501] 80.52 percent of total billed charges 52.55 80.52 Technical (Hospital) Services CEFAZOLIN 2 GRAM/50 ML IN DEXTROSE (ISO-OSMOTIC) INTRAVENOUS PIGGYBACK (30 MIN) RX-113850 CDM J0690 HCPCS 636 RC 00264-3105-11 NDC inpatient 50 ML 84.76 84.76 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES HDHP [308136802] 67.11 percent of total billed charges 52.55 80.52 Technical (Hospital) Services CEFAZOLIN 2 GRAM/50 ML IN DEXTROSE (ISO-OSMOTIC) INTRAVENOUS PIGGYBACK (30 MIN) RX-113850 CDM J0690 HCPCS 636 RC 00264-3105-11 NDC inpatient 50 ML 84.76 84.76 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES PPO [308136801] 67.11 percent of total billed charges 52.55 80.52 Technical (Hospital) Services CEFAZOLIN 2 GRAM/50 ML IN DEXTROSE (ISO-OSMOTIC) INTRAVENOUS PIGGYBACK (30 MIN) RX-113850 CDM J0690 HCPCS 636 RC 00264-3105-11 NDC inpatient 50 ML 84.76 84.76 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES EPO [308136803] 67.11 percent of total billed charges 52.55 80.52 Technical (Hospital) Services CEFAZOLIN 2 GRAM/50 ML IN DEXTROSE (ISO-OSMOTIC) INTRAVENOUS PIGGYBACK (30 MIN) RX-113850 CDM J0690 HCPCS 636 RC 00264-3105-11 NDC inpatient 50 ML 84.76 84.76 CIGNA 62308 [3081051] CIGNA 62308 [308105105] 67.11 percent of total billed charges 52.55 80.52 Technical (Hospital) Services CEFAZOLIN 2 GRAM/50 ML IN DEXTROSE (ISO-OSMOTIC) INTRAVENOUS PIGGYBACK (30 MIN) RX-113850 CDM J0690 HCPCS 636 RC 00264-3105-11 NDC inpatient 50 ML 84.76 84.76 CIGNA 62308 [3081051] CIGNA STATE OF WYOMING [308105107] 67.11 percent of total billed charges 52.55 80.52 Technical (Hospital) Services CEFAZOLIN 2 GRAM/50 ML IN DEXTROSE (ISO-OSMOTIC) INTRAVENOUS PIGGYBACK (30 MIN) RX-113850 CDM J0690 HCPCS 636 RC 00264-3105-11 NDC inpatient 50 ML 84.76 84.76 MULTIPLAN INC 34080 [3081285] MULTIPLAN INC [308128501] 80.52 percent of total billed charges 52.55 80.52 Technical (Hospital) Services CEFAZOLIN 2 GRAM/50 ML IN DEXTROSE (ISO-OSMOTIC) INTRAVENOUS PIGGYBACK (30 MIN) RX-113850 CDM J0690 HCPCS 636 RC 00264-3105-11 NDC inpatient 50 ML 84.76 84.76 MEDICA (COMMERCIAL) 94265 [3081118] MEDICA CLAIMS [308111801] 76.28 percent of total billed charges 52.55 80.52 Technical (Hospital) Services CEFAZOLIN 2 GRAM/50 ML IN DEXTROSE (ISO-OSMOTIC) INTRAVENOUS PIGGYBACK (30 MIN) RX-113850 CDM J0690 HCPCS 636 RC 00264-3105-11 NDC inpatient 50 ML 84.76 84.76 HEALTHPARTNERS SX009 HEALTHPARTNERS 67.11 percent of total billed charges 52.55 80.52 Technical (Hospital) Services CEFAZOLIN 2 GRAM/50 ML IN DEXTROSE (ISO-OSMOTIC) INTRAVENOUS PIGGYBACK (30 MIN) RX-113850 CDM J0690 HCPCS 636 RC 00264-3105-11 NDC inpatient 50 ML 84.76 84.76 UNITED HEALTHCARE (COMMERCIAL) [3081199] UNITED HEALTHCARE 87726 [308119901] 52.55 percent of total billed charges 52.55 80.52 Technical (Hospital) Services CEFAZOLIN 2 GRAM/50 ML IN DEXTROSE (ISO-OSMOTIC) INTRAVENOUS PIGGYBACK (30 MIN) RX-113850 CDM J0690 HCPCS 636 RC 00264-3105-11 NDC inpatient 50 ML 84.76 84.76 BLUE CROSS BLUE SHIELD WELLMARK SB889 [3081026] BCBS WYOMING [308102603] 80.52 percent of total billed charges 52.55 80.52 Technical (Hospital) Services CEFAZOLIN 1 GRAM SOLUTION FOR INJECTION RX-1445 CDM J0690 HCPCS 636 RC 44567-0707-25 NDC outpatient 3 ML 59.95 59.95 MULTIPLAN INC 34080 [3081285] MULTIPLAN INC [308128501] 56.95 percent of total billed charges 37.17 56.95 Technical (Hospital) Services CEFAZOLIN 1 GRAM SOLUTION FOR INJECTION RX-1445 CDM J0690 HCPCS 636 RC 44567-0707-25 NDC outpatient 3 ML 59.95 59.95 MEDICA (COMMERCIAL) 94265 [3081118] MEDICA CLAIMS [308111801] 53.96 percent of total billed charges 37.17 56.95 Technical (Hospital) Services CEFAZOLIN 1 GRAM SOLUTION FOR INJECTION RX-1445 CDM J0690 HCPCS 636 RC 44567-0707-25 NDC outpatient 3 ML 59.95 59.95 CIGNA 62308 [3081051] CIGNA 62308 [308105105] 47.96 percent of total billed charges 37.17 56.95 Technical (Hospital) Services CEFAZOLIN 1 GRAM SOLUTION FOR INJECTION RX-1445 CDM J0690 HCPCS 636 RC 44567-0707-25 NDC outpatient 3 ML 59.95 59.95 CIGNA 62308 [3081051] CIGNA STATE OF WYOMING [308105107] 47.96 percent of total billed charges 37.17 56.95 Technical (Hospital) Services CEFAZOLIN 1 GRAM SOLUTION FOR INJECTION RX-1445 CDM J0690 HCPCS 636 RC 44567-0707-25 NDC outpatient 3 ML 59.95 59.95 UNITED HEALTHCARE (COMMERCIAL) [3081199] UNITED HEALTHCARE 87726 [308119901] 37.17 percent of total billed charges 37.17 56.95 Technical (Hospital) Services CEFAZOLIN 1 GRAM SOLUTION FOR INJECTION RX-1445 CDM J0690 HCPCS 636 RC 44567-0707-25 NDC outpatient 3 ML 59.95 59.95 HEALTHPARTNERS SX009 HEALTHPARTNERS 47.96 percent of total billed charges 37.17 56.95 Technical (Hospital) Services CEFAZOLIN 1 GRAM SOLUTION FOR INJECTION RX-1445 CDM J0690 HCPCS 636 RC 44567-0707-25 NDC outpatient 3 ML 59.95 59.95 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES PPO [308136801] 47.96 percent of total billed charges 37.17 56.95 Technical (Hospital) Services CEFAZOLIN 1 GRAM SOLUTION FOR INJECTION RX-1445 CDM J0690 HCPCS 636 RC 44567-0707-25 NDC outpatient 3 ML 59.95 59.95 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES HDHP [308136802] 47.96 percent of total billed charges 37.17 56.95 Technical (Hospital) Services CEFAZOLIN 1 GRAM SOLUTION FOR INJECTION RX-1445 CDM J0690 HCPCS 636 RC 44567-0707-25 NDC outpatient 3 ML 59.95 59.95 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES EPO [308136803] 47.96 percent of total billed charges 37.17 56.95 Technical (Hospital) Services CEFAZOLIN 1 GRAM SOLUTION FOR INJECTION RX-1445 CDM J0690 HCPCS 636 RC 44567-0707-25 NDC outpatient 3 ML 59.95 59.95 BLUE CROSS BLUE SHIELD WELLMARK SB889 [3081026] BCBS WYOMING [308102603] 56.95 percent of total billed charges 37.17 56.95 Technical (Hospital) Services CEFAZOLIN 1 GRAM SOLUTION FOR INJECTION RX-1445 CDM J0690 HCPCS 636 RC 44567-0707-25 NDC inpatient 3 ML 59.95 59.95 HEALTHPARTNERS SX009 HEALTHPARTNERS 47.47 percent of total billed charges 37.17 56.95 Technical (Hospital) Services CEFAZOLIN 1 GRAM SOLUTION FOR INJECTION RX-1445 CDM J0690 HCPCS 636 RC 44567-0707-25 NDC inpatient 3 ML 59.95 59.95 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES EPO [308136803] 47.47 percent of total billed charges 37.17 56.95 Technical (Hospital) Services CEFAZOLIN 1 GRAM SOLUTION FOR INJECTION RX-1445 CDM J0690 HCPCS 636 RC 44567-0707-25 NDC inpatient 3 ML 59.95 59.95 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES PPO [308136801] 47.47 percent of total billed charges 37.17 56.95 Technical (Hospital) Services CEFAZOLIN 1 GRAM SOLUTION FOR INJECTION RX-1445 CDM J0690 HCPCS 636 RC 44567-0707-25 NDC inpatient 3 ML 59.95 59.95 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES HDHP [308136802] 47.47 percent of total billed charges 37.17 56.95 Technical (Hospital) Services CEFAZOLIN 1 GRAM SOLUTION FOR INJECTION RX-1445 CDM J0690 HCPCS 636 RC 44567-0707-25 NDC inpatient 3 ML 59.95 59.95 BLUE CROSS BLUE SHIELD WELLMARK SB889 [3081026] BCBS WYOMING [308102603] 56.95 percent of total billed charges 37.17 56.95 Technical (Hospital) Services CEFAZOLIN 1 GRAM SOLUTION FOR INJECTION RX-1445 CDM J0690 HCPCS 636 RC 44567-0707-25 NDC inpatient 3 ML 59.95 59.95 UNITED HEALTHCARE (COMMERCIAL) [3081199] UNITED HEALTHCARE 87726 [308119901] 37.17 percent of total billed charges 37.17 56.95 Technical (Hospital) Services CEFAZOLIN 1 GRAM SOLUTION FOR INJECTION RX-1445 CDM J0690 HCPCS 636 RC 44567-0707-25 NDC inpatient 3 ML 59.95 59.95 CIGNA 62308 [3081051] CIGNA 62308 [308105105] 47.47 percent of total billed charges 37.17 56.95 Technical (Hospital) Services CEFAZOLIN 1 GRAM SOLUTION FOR INJECTION RX-1445 CDM J0690 HCPCS 636 RC 44567-0707-25 NDC inpatient 3 ML 59.95 59.95 CIGNA 62308 [3081051] CIGNA STATE OF WYOMING [308105107] 47.47 percent of total billed charges 37.17 56.95 Technical (Hospital) Services CEFAZOLIN 1 GRAM SOLUTION FOR INJECTION RX-1445 CDM J0690 HCPCS 636 RC 44567-0707-25 NDC inpatient 3 ML 59.95 59.95 MEDICA (COMMERCIAL) 94265 [3081118] MEDICA CLAIMS [308111801] 53.96 percent of total billed charges 37.17 56.95 Technical (Hospital) Services CEFAZOLIN 1 GRAM SOLUTION FOR INJECTION RX-1445 CDM J0690 HCPCS 636 RC 44567-0707-25 NDC inpatient 3 ML 59.95 59.95 MULTIPLAN INC 34080 [3081285] MULTIPLAN INC [308128501] 56.95 percent of total billed charges 37.17 56.95 Technical (Hospital) Services CALCIUM GLUCONATE 100 MG/ML (10 %) INTRAVENOUS SOLUTION RX-1312 CDM J0612 HCPCS 636 RC 63323-0360-01 NDC outpatient 5 ML 69.51 69.51 UNITED HEALTHCARE (COMMERCIAL) [3081199] UNITED HEALTHCARE 87726 [308119901] 43.1 percent of total billed charges 43.1 66.03 Technical (Hospital) Services CALCIUM GLUCONATE 100 MG/ML (10 %) INTRAVENOUS SOLUTION RX-1312 CDM J0612 HCPCS 636 RC 63323-0360-01 NDC outpatient 5 ML 69.51 69.51 HEALTHPARTNERS SX009 HEALTHPARTNERS 55.61 percent of total billed charges 43.1 66.03 Technical (Hospital) Services CALCIUM GLUCONATE 100 MG/ML (10 %) INTRAVENOUS SOLUTION RX-1312 CDM J0612 HCPCS 636 RC 63323-0360-01 NDC outpatient 5 ML 69.51 69.51 MULTIPLAN INC 34080 [3081285] MULTIPLAN INC [308128501] 66.03 percent of total billed charges 43.1 66.03 Technical (Hospital) Services CALCIUM GLUCONATE 100 MG/ML (10 %) INTRAVENOUS SOLUTION RX-1312 CDM J0612 HCPCS 636 RC 63323-0360-01 NDC outpatient 5 ML 69.51 69.51 MEDICA (COMMERCIAL) 94265 [3081118] MEDICA CLAIMS [308111801] 62.56 percent of total billed charges 43.1 66.03 Technical (Hospital) Services CALCIUM GLUCONATE 100 MG/ML (10 %) INTRAVENOUS SOLUTION RX-1312 CDM J0612 HCPCS 636 RC 63323-0360-01 NDC outpatient 5 ML 69.51 69.51 BLUE CROSS BLUE SHIELD WELLMARK SB889 [3081026] BCBS WYOMING [308102603] 66.03 percent of total billed charges 43.1 66.03 Technical (Hospital) Services CALCIUM GLUCONATE 100 MG/ML (10 %) INTRAVENOUS SOLUTION RX-1312 CDM J0612 HCPCS 636 RC 63323-0360-01 NDC outpatient 5 ML 69.51 69.51 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES HDHP [308136802] 55.61 percent of total billed charges 43.1 66.03 Technical (Hospital) Services CALCIUM GLUCONATE 100 MG/ML (10 %) INTRAVENOUS SOLUTION RX-1312 CDM J0612 HCPCS 636 RC 63323-0360-01 NDC outpatient 5 ML 69.51 69.51 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES PPO [308136801] 55.61 percent of total billed charges 43.1 66.03 Technical (Hospital) Services CALCIUM GLUCONATE 100 MG/ML (10 %) INTRAVENOUS SOLUTION RX-1312 CDM J0612 HCPCS 636 RC 63323-0360-01 NDC outpatient 5 ML 69.51 69.51 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES EPO [308136803] 55.61 percent of total billed charges 43.1 66.03 Technical (Hospital) Services CALCIUM GLUCONATE 100 MG/ML (10 %) INTRAVENOUS SOLUTION RX-1312 CDM J0612 HCPCS 636 RC 63323-0360-01 NDC outpatient 5 ML 69.51 69.51 CIGNA 62308 [3081051] CIGNA 62308 [308105105] 55.61 percent of total billed charges 43.1 66.03 Technical (Hospital) Services CALCIUM GLUCONATE 100 MG/ML (10 %) INTRAVENOUS SOLUTION RX-1312 CDM J0612 HCPCS 636 RC 63323-0360-01 NDC outpatient 5 ML 69.51 69.51 CIGNA 62308 [3081051] CIGNA STATE OF WYOMING [308105107] 55.61 percent of total billed charges 43.1 66.03 Technical (Hospital) Services CALCIUM GLUCONATE 100 MG/ML (10 %) INTRAVENOUS SOLUTION RX-1312 CDM J0612 HCPCS 636 RC 63323-0360-01 NDC inpatient 5 ML 69.51 69.51 BLUE CROSS BLUE SHIELD WELLMARK SB889 [3081026] BCBS WYOMING [308102603] 66.03 percent of total billed charges 43.1 66.03 Technical (Hospital) Services CALCIUM GLUCONATE 100 MG/ML (10 %) INTRAVENOUS SOLUTION RX-1312 CDM J0612 HCPCS 636 RC 63323-0360-01 NDC inpatient 5 ML 69.51 69.51 UNITED HEALTHCARE (COMMERCIAL) [3081199] UNITED HEALTHCARE 87726 [308119901] 43.1 percent of total billed charges 43.1 66.03 Technical (Hospital) Services CALCIUM GLUCONATE 100 MG/ML (10 %) INTRAVENOUS SOLUTION RX-1312 CDM J0612 HCPCS 636 RC 63323-0360-01 NDC inpatient 5 ML 69.51 69.51 CIGNA 62308 [3081051] CIGNA 62308 [308105105] 55.04 percent of total billed charges 43.1 66.03 Technical (Hospital) Services CALCIUM GLUCONATE 100 MG/ML (10 %) INTRAVENOUS SOLUTION RX-1312 CDM J0612 HCPCS 636 RC 63323-0360-01 NDC inpatient 5 ML 69.51 69.51 CIGNA 62308 [3081051] CIGNA STATE OF WYOMING [308105107] 55.04 percent of total billed charges 43.1 66.03 Technical (Hospital) Services CALCIUM GLUCONATE 100 MG/ML (10 %) INTRAVENOUS SOLUTION RX-1312 CDM J0612 HCPCS 636 RC 63323-0360-01 NDC inpatient 5 ML 69.51 69.51 MEDICA (COMMERCIAL) 94265 [3081118] MEDICA CLAIMS [308111801] 62.56 percent of total billed charges 43.1 66.03 Technical (Hospital) Services CALCIUM GLUCONATE 100 MG/ML (10 %) INTRAVENOUS SOLUTION RX-1312 CDM J0612 HCPCS 636 RC 63323-0360-01 NDC inpatient 5 ML 69.51 69.51 MULTIPLAN INC 34080 [3081285] MULTIPLAN INC [308128501] 66.03 percent of total billed charges 43.1 66.03 Technical (Hospital) Services CALCIUM GLUCONATE 100 MG/ML (10 %) INTRAVENOUS SOLUTION RX-1312 CDM J0612 HCPCS 636 RC 63323-0360-01 NDC inpatient 5 ML 69.51 69.51 HEALTHPARTNERS SX009 HEALTHPARTNERS 55.04 percent of total billed charges 43.1 66.03 Technical (Hospital) Services CALCIUM GLUCONATE 100 MG/ML (10 %) INTRAVENOUS SOLUTION RX-1312 CDM J0612 HCPCS 636 RC 63323-0360-01 NDC inpatient 5 ML 69.51 69.51 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES EPO [308136803] 55.04 percent of total billed charges 43.1 66.03 Technical (Hospital) Services CALCIUM GLUCONATE 100 MG/ML (10 %) INTRAVENOUS SOLUTION RX-1312 CDM J0612 HCPCS 636 RC 63323-0360-01 NDC inpatient 5 ML 69.51 69.51 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES HDHP [308136802] 55.04 percent of total billed charges 43.1 66.03 Technical (Hospital) Services CALCIUM GLUCONATE 100 MG/ML (10 %) INTRAVENOUS SOLUTION RX-1312 CDM J0612 HCPCS 636 RC 63323-0360-01 NDC inpatient 5 ML 69.51 69.51 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES PPO [308136801] 55.04 percent of total billed charges 43.1 66.03 Technical (Hospital) Services CINACALCET 60 MG TABLET RX-38101 CDM J0604 HCPCS 250 RC 55513-0074-30 NDC outpatient 1 UN 193.78 193.78 MULTIPLAN INC 34080 [3081285] MULTIPLAN INC [308128501] 184.09 percent of total billed charges 120.14 184.09 Technical (Hospital) Services CINACALCET 60 MG TABLET RX-38101 CDM J0604 HCPCS 250 RC 55513-0074-30 NDC outpatient 1 UN 193.78 193.78 UNITED HEALTHCARE (COMMERCIAL) [3081199] UNITED HEALTHCARE 87726 [308119901] 120.14 percent of total billed charges 120.14 184.09 Technical (Hospital) Services CINACALCET 60 MG TABLET RX-38101 CDM J0604 HCPCS 250 RC 55513-0074-30 NDC outpatient 1 UN 193.78 193.78 HEALTHPARTNERS SX009 HEALTHPARTNERS 155.02 percent of total billed charges 120.14 184.09 Technical (Hospital) Services CINACALCET 60 MG TABLET RX-38101 CDM J0604 HCPCS 250 RC 55513-0074-30 NDC outpatient 1 UN 193.78 193.78 CIGNA 62308 [3081051] CIGNA 62308 [308105105] 155.02 percent of total billed charges 120.14 184.09 Technical (Hospital) Services CINACALCET 60 MG TABLET RX-38101 CDM J0604 HCPCS 250 RC 55513-0074-30 NDC outpatient 1 UN 193.78 193.78 CIGNA 62308 [3081051] CIGNA STATE OF WYOMING [308105107] 155.02 percent of total billed charges 120.14 184.09 Technical (Hospital) Services CINACALCET 60 MG TABLET RX-38101 CDM J0604 HCPCS 250 RC 55513-0074-30 NDC outpatient 1 UN 193.78 193.78 MEDICA (COMMERCIAL) 94265 [3081118] MEDICA CLAIMS [308111801] 174.4 percent of total billed charges 120.14 184.09 Technical (Hospital) Services CINACALCET 60 MG TABLET RX-38101 CDM J0604 HCPCS 250 RC 55513-0074-30 NDC outpatient 1 UN 193.78 193.78 BLUE CROSS BLUE SHIELD WELLMARK SB889 [3081026] BCBS WYOMING [308102603] 184.09 percent of total billed charges 120.14 184.09 Technical (Hospital) Services CINACALCET 60 MG TABLET RX-38101 CDM J0604 HCPCS 250 RC 55513-0074-30 NDC outpatient 1 UN 193.78 193.78 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES EPO [308136803] 155.02 percent of total billed charges 120.14 184.09 Technical (Hospital) Services CINACALCET 60 MG TABLET RX-38101 CDM J0604 HCPCS 250 RC 55513-0074-30 NDC outpatient 1 UN 193.78 193.78 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES HDHP [308136802] 155.02 percent of total billed charges 120.14 184.09 Technical (Hospital) Services CINACALCET 60 MG TABLET RX-38101 CDM J0604 HCPCS 250 RC 55513-0074-30 NDC outpatient 1 UN 193.78 193.78 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES PPO [308136801] 155.02 percent of total billed charges 120.14 184.09 Technical (Hospital) Services CINACALCET 60 MG TABLET RX-38101 CDM J0604 HCPCS 250 RC 55513-0074-30 NDC inpatient 1 UN 193.78 193.78 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES PPO [308136801] 153.44 percent of total billed charges 120.14 184.09 Technical (Hospital) Services CINACALCET 60 MG TABLET RX-38101 CDM J0604 HCPCS 250 RC 55513-0074-30 NDC inpatient 1 UN 193.78 193.78 MEDICA (COMMERCIAL) 94265 [3081118] MEDICA CLAIMS [308111801] 174.4 percent of total billed charges 120.14 184.09 Technical (Hospital) Services CINACALCET 60 MG TABLET RX-38101 CDM J0604 HCPCS 250 RC 55513-0074-30 NDC inpatient 1 UN 193.78 193.78 MULTIPLAN INC 34080 [3081285] MULTIPLAN INC [308128501] 184.09 percent of total billed charges 120.14 184.09 Technical (Hospital) Services CINACALCET 60 MG TABLET RX-38101 CDM J0604 HCPCS 250 RC 55513-0074-30 NDC inpatient 1 UN 193.78 193.78 HEALTHPARTNERS SX009 HEALTHPARTNERS 153.44 percent of total billed charges 120.14 184.09 Technical (Hospital) Services CINACALCET 60 MG TABLET RX-38101 CDM J0604 HCPCS 250 RC 55513-0074-30 NDC inpatient 1 UN 193.78 193.78 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES HDHP [308136802] 153.44 percent of total billed charges 120.14 184.09 Technical (Hospital) Services CINACALCET 60 MG TABLET RX-38101 CDM J0604 HCPCS 250 RC 55513-0074-30 NDC inpatient 1 UN 193.78 193.78 CIGNA 62308 [3081051] CIGNA 62308 [308105105] 153.44 percent of total billed charges 120.14 184.09 Technical (Hospital) Services CINACALCET 60 MG TABLET RX-38101 CDM J0604 HCPCS 250 RC 55513-0074-30 NDC inpatient 1 UN 193.78 193.78 CIGNA 62308 [3081051] CIGNA STATE OF WYOMING [308105107] 153.44 percent of total billed charges 120.14 184.09 Technical (Hospital) Services CINACALCET 60 MG TABLET RX-38101 CDM J0604 HCPCS 250 RC 55513-0074-30 NDC inpatient 1 UN 193.78 193.78 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES EPO [308136803] 153.44 percent of total billed charges 120.14 184.09 Technical (Hospital) Services CINACALCET 60 MG TABLET RX-38101 CDM J0604 HCPCS 250 RC 55513-0074-30 NDC inpatient 1 UN 193.78 193.78 UNITED HEALTHCARE (COMMERCIAL) [3081199] UNITED HEALTHCARE 87726 [308119901] 120.14 percent of total billed charges 120.14 184.09 Technical (Hospital) Services CINACALCET 60 MG TABLET RX-38101 CDM J0604 HCPCS 250 RC 55513-0074-30 NDC inpatient 1 UN 193.78 193.78 BLUE CROSS BLUE SHIELD WELLMARK SB889 [3081026] BCBS WYOMING [308102603] 184.09 percent of total billed charges 120.14 184.09 Technical (Hospital) Services "PENICILLIN G BENZATHINE 1,200,000 UNIT/2 ML INTRAMUSCULAR SYRINGE" RX-108049 CDM J0561 HCPCS 636 RC 60793-0701-02 NDC outpatient 2 ML 779.99 779.99 HEALTHPARTNERS SX009 HEALTHPARTNERS 623.99 percent of total billed charges 483.59 740.99 Technical (Hospital) Services "PENICILLIN G BENZATHINE 1,200,000 UNIT/2 ML INTRAMUSCULAR SYRINGE" RX-108049 CDM J0561 HCPCS 636 RC 60793-0701-02 NDC outpatient 2 ML 779.99 779.99 UNITED HEALTHCARE (COMMERCIAL) [3081199] UNITED HEALTHCARE 87726 [308119901] 483.59 percent of total billed charges 483.59 740.99 Technical (Hospital) Services "PENICILLIN G BENZATHINE 1,200,000 UNIT/2 ML INTRAMUSCULAR SYRINGE" RX-108049 CDM J0561 HCPCS 636 RC 60793-0701-02 NDC outpatient 2 ML 779.99 779.99 CIGNA 62308 [3081051] CIGNA 62308 [308105105] 623.99 percent of total billed charges 483.59 740.99 Technical (Hospital) Services "PENICILLIN G BENZATHINE 1,200,000 UNIT/2 ML INTRAMUSCULAR SYRINGE" RX-108049 CDM J0561 HCPCS 636 RC 60793-0701-02 NDC outpatient 2 ML 779.99 779.99 CIGNA 62308 [3081051] CIGNA STATE OF WYOMING [308105107] 623.99 percent of total billed charges 483.59 740.99 Technical (Hospital) Services "PENICILLIN G BENZATHINE 1,200,000 UNIT/2 ML INTRAMUSCULAR SYRINGE" RX-108049 CDM J0561 HCPCS 636 RC 60793-0701-02 NDC outpatient 2 ML 779.99 779.99 MULTIPLAN INC 34080 [3081285] MULTIPLAN INC [308128501] 740.99 percent of total billed charges 483.59 740.99 Technical (Hospital) Services "PENICILLIN G BENZATHINE 1,200,000 UNIT/2 ML INTRAMUSCULAR SYRINGE" RX-108049 CDM J0561 HCPCS 636 RC 60793-0701-02 NDC outpatient 2 ML 779.99 779.99 MEDICA (COMMERCIAL) 94265 [3081118] MEDICA CLAIMS [308111801] 701.99 percent of total billed charges 483.59 740.99 Technical (Hospital) Services "PENICILLIN G BENZATHINE 1,200,000 UNIT/2 ML INTRAMUSCULAR SYRINGE" RX-108049 CDM J0561 HCPCS 636 RC 60793-0701-02 NDC outpatient 2 ML 779.99 779.99 BLUE CROSS BLUE SHIELD WELLMARK SB889 [3081026] BCBS WYOMING [308102603] 740.99 percent of total billed charges 483.59 740.99 Technical (Hospital) Services "PENICILLIN G BENZATHINE 1,200,000 UNIT/2 ML INTRAMUSCULAR SYRINGE" RX-108049 CDM J0561 HCPCS 636 RC 60793-0701-02 NDC outpatient 2 ML 779.99 779.99 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES EPO [308136803] 623.99 percent of total billed charges 483.59 740.99 Technical (Hospital) Services "PENICILLIN G BENZATHINE 1,200,000 UNIT/2 ML INTRAMUSCULAR SYRINGE" RX-108049 CDM J0561 HCPCS 636 RC 60793-0701-02 NDC outpatient 2 ML 779.99 779.99 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES HDHP [308136802] 623.99 percent of total billed charges 483.59 740.99 Technical (Hospital) Services "PENICILLIN G BENZATHINE 1,200,000 UNIT/2 ML INTRAMUSCULAR SYRINGE" RX-108049 CDM J0561 HCPCS 636 RC 60793-0701-02 NDC outpatient 2 ML 779.99 779.99 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES PPO [308136801] 623.99 percent of total billed charges 483.59 740.99 Technical (Hospital) Services "PENICILLIN G BENZATHINE 1,200,000 UNIT/2 ML INTRAMUSCULAR SYRINGE" RX-108049 CDM J0561 HCPCS 636 RC 60793-0701-02 NDC inpatient 2 ML 779.99 779.99 MEDICA (COMMERCIAL) 94265 [3081118] MEDICA CLAIMS [308111801] 701.99 percent of total billed charges 483.59 740.99 Technical (Hospital) Services "PENICILLIN G BENZATHINE 1,200,000 UNIT/2 ML INTRAMUSCULAR SYRINGE" RX-108049 CDM J0561 HCPCS 636 RC 60793-0701-02 NDC inpatient 2 ML 779.99 779.99 MULTIPLAN INC 34080 [3081285] MULTIPLAN INC [308128501] 740.99 percent of total billed charges 483.59 740.99 Technical (Hospital) Services "PENICILLIN G BENZATHINE 1,200,000 UNIT/2 ML INTRAMUSCULAR SYRINGE" RX-108049 CDM J0561 HCPCS 636 RC 60793-0701-02 NDC inpatient 2 ML 779.99 779.99 UNITED HEALTHCARE (COMMERCIAL) [3081199] UNITED HEALTHCARE 87726 [308119901] 483.59 percent of total billed charges 483.59 740.99 Technical (Hospital) Services "PENICILLIN G BENZATHINE 1,200,000 UNIT/2 ML INTRAMUSCULAR SYRINGE" RX-108049 CDM J0561 HCPCS 636 RC 60793-0701-02 NDC inpatient 2 ML 779.99 779.99 BLUE CROSS BLUE SHIELD WELLMARK SB889 [3081026] BCBS WYOMING [308102603] 740.99 percent of total billed charges 483.59 740.99 Technical (Hospital) Services "PENICILLIN G BENZATHINE 1,200,000 UNIT/2 ML INTRAMUSCULAR SYRINGE" RX-108049 CDM J0561 HCPCS 636 RC 60793-0701-02 NDC inpatient 2 ML 779.99 779.99 CIGNA 62308 [3081051] CIGNA 62308 [308105105] 617.6 percent of total billed charges 483.59 740.99 Technical (Hospital) Services "PENICILLIN G BENZATHINE 1,200,000 UNIT/2 ML INTRAMUSCULAR SYRINGE" RX-108049 CDM J0561 HCPCS 636 RC 60793-0701-02 NDC inpatient 2 ML 779.99 779.99 CIGNA 62308 [3081051] CIGNA STATE OF WYOMING [308105107] 617.6 percent of total billed charges 483.59 740.99 Technical (Hospital) Services "PENICILLIN G BENZATHINE 1,200,000 UNIT/2 ML INTRAMUSCULAR SYRINGE" RX-108049 CDM J0561 HCPCS 636 RC 60793-0701-02 NDC inpatient 2 ML 779.99 779.99 HEALTHPARTNERS SX009 HEALTHPARTNERS 617.6 percent of total billed charges 483.59 740.99 Technical (Hospital) Services "PENICILLIN G BENZATHINE 1,200,000 UNIT/2 ML INTRAMUSCULAR SYRINGE" RX-108049 CDM J0561 HCPCS 636 RC 60793-0701-02 NDC inpatient 2 ML 779.99 779.99 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES HDHP [308136802] 617.6 percent of total billed charges 483.59 740.99 Technical (Hospital) Services "PENICILLIN G BENZATHINE 1,200,000 UNIT/2 ML INTRAMUSCULAR SYRINGE" RX-108049 CDM J0561 HCPCS 636 RC 60793-0701-02 NDC inpatient 2 ML 779.99 779.99 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES PPO [308136801] 617.6 percent of total billed charges 483.59 740.99 Technical (Hospital) Services "PENICILLIN G BENZATHINE 1,200,000 UNIT/2 ML INTRAMUSCULAR SYRINGE" RX-108049 CDM J0561 HCPCS 636 RC 60793-0701-02 NDC inpatient 2 ML 779.99 779.99 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES EPO [308136803] 617.6 percent of total billed charges 483.59 740.99 Technical (Hospital) Services DICYCLOMINE 10 MG/ML INTRAMUSCULAR SOLUTION RX-2417 CDM J0500 HCPCS 636 RC 31722-0963-31 NDC outpatient 1 ML 106 106 CIGNA 62308 [3081051] CIGNA 62308 [308105105] 84.8 percent of total billed charges 65.72 100.7 Technical (Hospital) Services DICYCLOMINE 10 MG/ML INTRAMUSCULAR SOLUTION RX-2417 CDM J0500 HCPCS 636 RC 31722-0963-31 NDC outpatient 1 ML 106 106 CIGNA 62308 [3081051] CIGNA STATE OF WYOMING [308105107] 84.8 percent of total billed charges 65.72 100.7 Technical (Hospital) Services DICYCLOMINE 10 MG/ML INTRAMUSCULAR SOLUTION RX-2417 CDM J0500 HCPCS 636 RC 31722-0963-31 NDC outpatient 1 ML 106 106 MEDICA (COMMERCIAL) 94265 [3081118] MEDICA CLAIMS [308111801] 95.4 percent of total billed charges 65.72 100.7 Technical (Hospital) Services DICYCLOMINE 10 MG/ML INTRAMUSCULAR SOLUTION RX-2417 CDM J0500 HCPCS 636 RC 31722-0963-31 NDC outpatient 1 ML 106 106 MULTIPLAN INC 34080 [3081285] MULTIPLAN INC [308128501] 100.7 percent of total billed charges 65.72 100.7 Technical (Hospital) Services DICYCLOMINE 10 MG/ML INTRAMUSCULAR SOLUTION RX-2417 CDM J0500 HCPCS 636 RC 31722-0963-31 NDC outpatient 1 ML 106 106 UNITED HEALTHCARE (COMMERCIAL) [3081199] UNITED HEALTHCARE 87726 [308119901] 65.72 percent of total billed charges 65.72 100.7 Technical (Hospital) Services DICYCLOMINE 10 MG/ML INTRAMUSCULAR SOLUTION RX-2417 CDM J0500 HCPCS 636 RC 31722-0963-31 NDC outpatient 1 ML 106 106 HEALTHPARTNERS SX009 HEALTHPARTNERS 84.8 percent of total billed charges 65.72 100.7 Technical (Hospital) Services DICYCLOMINE 10 MG/ML INTRAMUSCULAR SOLUTION RX-2417 CDM J0500 HCPCS 636 RC 31722-0963-31 NDC outpatient 1 ML 106 106 BLUE CROSS BLUE SHIELD WELLMARK SB889 [3081026] BCBS WYOMING [308102603] 100.7 percent of total billed charges 65.72 100.7 Technical (Hospital) Services DICYCLOMINE 10 MG/ML INTRAMUSCULAR SOLUTION RX-2417 CDM J0500 HCPCS 636 RC 31722-0963-31 NDC outpatient 1 ML 106 106 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES PPO [308136801] 84.8 percent of total billed charges 65.72 100.7 Technical (Hospital) Services DICYCLOMINE 10 MG/ML INTRAMUSCULAR SOLUTION RX-2417 CDM J0500 HCPCS 636 RC 31722-0963-31 NDC outpatient 1 ML 106 106 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES HDHP [308136802] 84.8 percent of total billed charges 65.72 100.7 Technical (Hospital) Services DICYCLOMINE 10 MG/ML INTRAMUSCULAR SOLUTION RX-2417 CDM J0500 HCPCS 636 RC 31722-0963-31 NDC outpatient 1 ML 106 106 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES EPO [308136803] 84.8 percent of total billed charges 65.72 100.7 Technical (Hospital) Services DICYCLOMINE 10 MG/ML INTRAMUSCULAR SOLUTION RX-2417 CDM J0500 HCPCS 636 RC 31722-0963-31 NDC inpatient 1 ML 106 106 MULTIPLAN INC 34080 [3081285] MULTIPLAN INC [308128501] 100.7 percent of total billed charges 65.72 100.7 Technical (Hospital) Services DICYCLOMINE 10 MG/ML INTRAMUSCULAR SOLUTION RX-2417 CDM J0500 HCPCS 636 RC 31722-0963-31 NDC inpatient 1 ML 106 106 MEDICA (COMMERCIAL) 94265 [3081118] MEDICA CLAIMS [308111801] 95.4 percent of total billed charges 65.72 100.7 Technical (Hospital) Services DICYCLOMINE 10 MG/ML INTRAMUSCULAR SOLUTION RX-2417 CDM J0500 HCPCS 636 RC 31722-0963-31 NDC inpatient 1 ML 106 106 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES PPO [308136801] 83.93 percent of total billed charges 65.72 100.7 Technical (Hospital) Services DICYCLOMINE 10 MG/ML INTRAMUSCULAR SOLUTION RX-2417 CDM J0500 HCPCS 636 RC 31722-0963-31 NDC inpatient 1 ML 106 106 HEALTHPARTNERS SX009 HEALTHPARTNERS 83.93 percent of total billed charges 65.72 100.7 Technical (Hospital) Services DICYCLOMINE 10 MG/ML INTRAMUSCULAR SOLUTION RX-2417 CDM J0500 HCPCS 636 RC 31722-0963-31 NDC inpatient 1 ML 106 106 BLUE CROSS BLUE SHIELD WELLMARK SB889 [3081026] BCBS WYOMING [308102603] 100.7 percent of total billed charges 65.72 100.7 Technical (Hospital) Services DICYCLOMINE 10 MG/ML INTRAMUSCULAR SOLUTION RX-2417 CDM J0500 HCPCS 636 RC 31722-0963-31 NDC inpatient 1 ML 106 106 UNITED HEALTHCARE (COMMERCIAL) [3081199] UNITED HEALTHCARE 87726 [308119901] 65.72 percent of total billed charges 65.72 100.7 Technical (Hospital) Services DICYCLOMINE 10 MG/ML INTRAMUSCULAR SOLUTION RX-2417 CDM J0500 HCPCS 636 RC 31722-0963-31 NDC inpatient 1 ML 106 106 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES EPO [308136803] 83.93 percent of total billed charges 65.72 100.7 Technical (Hospital) Services DICYCLOMINE 10 MG/ML INTRAMUSCULAR SOLUTION RX-2417 CDM J0500 HCPCS 636 RC 31722-0963-31 NDC inpatient 1 ML 106 106 CIGNA 62308 [3081051] CIGNA 62308 [308105105] 83.93 percent of total billed charges 65.72 100.7 Technical (Hospital) Services DICYCLOMINE 10 MG/ML INTRAMUSCULAR SOLUTION RX-2417 CDM J0500 HCPCS 636 RC 31722-0963-31 NDC inpatient 1 ML 106 106 CIGNA 62308 [3081051] CIGNA STATE OF WYOMING [308105107] 83.93 percent of total billed charges 65.72 100.7 Technical (Hospital) Services DICYCLOMINE 10 MG/ML INTRAMUSCULAR SOLUTION RX-2417 CDM J0500 HCPCS 636 RC 31722-0963-31 NDC inpatient 1 ML 106 106 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES HDHP [308136802] 83.93 percent of total billed charges 65.72 100.7 Technical (Hospital) Services ATROPINE 0.1 MG/ML INJECTION SYRINGE RX-730 CDM J0461 HCPCS 636 RC 00409-1630-10 NDC inpatient 10 ML 80.27 80.27 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES HDHP [308136802] 63.56 percent of total billed charges 49.77 76.26 Technical (Hospital) Services ATROPINE 0.1 MG/ML INJECTION SYRINGE RX-730 CDM J0461 HCPCS 636 RC 00409-1630-10 NDC inpatient 10 ML 80.27 80.27 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES PPO [308136801] 63.56 percent of total billed charges 49.77 76.26 Technical (Hospital) Services ATROPINE 0.1 MG/ML INJECTION SYRINGE RX-730 CDM J0461 HCPCS 636 RC 00409-1630-10 NDC inpatient 10 ML 80.27 80.27 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES EPO [308136803] 63.56 percent of total billed charges 49.77 76.26 Technical (Hospital) Services ATROPINE 0.1 MG/ML INJECTION SYRINGE RX-730 CDM J0461 HCPCS 636 RC 00409-1630-10 NDC inpatient 10 ML 80.27 80.27 HEALTHPARTNERS SX009 HEALTHPARTNERS 63.56 percent of total billed charges 49.77 76.26 Technical (Hospital) Services ATROPINE 0.1 MG/ML INJECTION SYRINGE RX-730 CDM J0461 HCPCS 636 RC 00409-1630-10 NDC inpatient 10 ML 80.27 80.27 MEDICA (COMMERCIAL) 94265 [3081118] MEDICA CLAIMS [308111801] 72.24 percent of total billed charges 49.77 76.26 Technical (Hospital) Services ATROPINE 0.1 MG/ML INJECTION SYRINGE RX-730 CDM J0461 HCPCS 636 RC 00409-1630-10 NDC inpatient 10 ML 80.27 80.27 MULTIPLAN INC 34080 [3081285] MULTIPLAN INC [308128501] 76.26 percent of total billed charges 49.77 76.26 Technical (Hospital) Services ATROPINE 0.1 MG/ML INJECTION SYRINGE RX-730 CDM J0461 HCPCS 636 RC 00409-1630-10 NDC inpatient 10 ML 80.27 80.27 UNITED HEALTHCARE (COMMERCIAL) [3081199] UNITED HEALTHCARE 87726 [308119901] 49.77 percent of total billed charges 49.77 76.26 Technical (Hospital) Services ATROPINE 0.1 MG/ML INJECTION SYRINGE RX-730 CDM J0461 HCPCS 636 RC 00409-1630-10 NDC inpatient 10 ML 80.27 80.27 BLUE CROSS BLUE SHIELD WELLMARK SB889 [3081026] BCBS WYOMING [308102603] 76.26 percent of total billed charges 49.77 76.26 Technical (Hospital) Services ATROPINE 0.1 MG/ML INJECTION SYRINGE RX-730 CDM J0461 HCPCS 636 RC 00409-1630-10 NDC inpatient 10 ML 80.27 80.27 CIGNA 62308 [3081051] CIGNA 62308 [308105105] 63.56 percent of total billed charges 49.77 76.26 Technical (Hospital) Services ATROPINE 0.1 MG/ML INJECTION SYRINGE RX-730 CDM J0461 HCPCS 636 RC 00409-1630-10 NDC inpatient 10 ML 80.27 80.27 CIGNA 62308 [3081051] CIGNA STATE OF WYOMING [308105107] 63.56 percent of total billed charges 49.77 76.26 Technical (Hospital) Services ATROPINE 0.1 MG/ML INJECTION SYRINGE RX-730 CDM J0461 HCPCS 636 RC 00409-1630-10 NDC outpatient 10 ML 80.27 80.27 MEDICA (COMMERCIAL) 94265 [3081118] MEDICA CLAIMS [308111801] 72.24 percent of total billed charges 49.77 76.26 Technical (Hospital) Services ATROPINE 0.1 MG/ML INJECTION SYRINGE RX-730 CDM J0461 HCPCS 636 RC 00409-1630-10 NDC outpatient 10 ML 80.27 80.27 MULTIPLAN INC 34080 [3081285] MULTIPLAN INC [308128501] 76.26 percent of total billed charges 49.77 76.26 Technical (Hospital) Services ATROPINE 0.1 MG/ML INJECTION SYRINGE RX-730 CDM J0461 HCPCS 636 RC 00409-1630-10 NDC outpatient 10 ML 80.27 80.27 CIGNA 62308 [3081051] CIGNA 62308 [308105105] 64.22 percent of total billed charges 49.77 76.26 Technical (Hospital) Services ATROPINE 0.1 MG/ML INJECTION SYRINGE RX-730 CDM J0461 HCPCS 636 RC 00409-1630-10 NDC outpatient 10 ML 80.27 80.27 CIGNA 62308 [3081051] CIGNA STATE OF WYOMING [308105107] 64.22 percent of total billed charges 49.77 76.26 Technical (Hospital) Services ATROPINE 0.1 MG/ML INJECTION SYRINGE RX-730 CDM J0461 HCPCS 636 RC 00409-1630-10 NDC outpatient 10 ML 80.27 80.27 BLUE CROSS BLUE SHIELD WELLMARK SB889 [3081026] BCBS WYOMING [308102603] 76.26 percent of total billed charges 49.77 76.26 Technical (Hospital) Services ATROPINE 0.1 MG/ML INJECTION SYRINGE RX-730 CDM J0461 HCPCS 636 RC 00409-1630-10 NDC outpatient 10 ML 80.27 80.27 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES HDHP [308136802] 64.22 percent of total billed charges 49.77 76.26 Technical (Hospital) Services ATROPINE 0.1 MG/ML INJECTION SYRINGE RX-730 CDM J0461 HCPCS 636 RC 00409-1630-10 NDC outpatient 10 ML 80.27 80.27 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES EPO [308136803] 64.22 percent of total billed charges 49.77 76.26 Technical (Hospital) Services ATROPINE 0.1 MG/ML INJECTION SYRINGE RX-730 CDM J0461 HCPCS 636 RC 00409-1630-10 NDC outpatient 10 ML 80.27 80.27 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES PPO [308136801] 64.22 percent of total billed charges 49.77 76.26 Technical (Hospital) Services ATROPINE 0.1 MG/ML INJECTION SYRINGE RX-730 CDM J0461 HCPCS 636 RC 00409-1630-10 NDC outpatient 10 ML 80.27 80.27 UNITED HEALTHCARE (COMMERCIAL) [3081199] UNITED HEALTHCARE 87726 [308119901] 49.77 percent of total billed charges 49.77 76.26 Technical (Hospital) Services ATROPINE 0.1 MG/ML INJECTION SYRINGE RX-730 CDM J0461 HCPCS 636 RC 00409-1630-10 NDC outpatient 10 ML 80.27 80.27 HEALTHPARTNERS SX009 HEALTHPARTNERS 64.22 percent of total billed charges 49.77 76.26 Technical (Hospital) Services AZTREONAM 1 GRAM SOLUTION FOR INJECTION RX-9185 CDM J0457 HCPCS 636 RC 63323-0401-20 NDC outpatient 10 ML 173.08 173.08 CIGNA 62308 [3081051] CIGNA 62308 [308105105] 138.46 percent of total billed charges 107.31 164.43 Technical (Hospital) Services AZTREONAM 1 GRAM SOLUTION FOR INJECTION RX-9185 CDM J0457 HCPCS 636 RC 63323-0401-20 NDC outpatient 10 ML 173.08 173.08 CIGNA 62308 [3081051] CIGNA STATE OF WYOMING [308105107] 138.46 percent of total billed charges 107.31 164.43 Technical (Hospital) Services AZTREONAM 1 GRAM SOLUTION FOR INJECTION RX-9185 CDM J0457 HCPCS 636 RC 63323-0401-20 NDC outpatient 10 ML 173.08 173.08 BLUE CROSS BLUE SHIELD WELLMARK SB889 [3081026] BCBS WYOMING [308102603] 164.43 percent of total billed charges 107.31 164.43 Technical (Hospital) Services AZTREONAM 1 GRAM SOLUTION FOR INJECTION RX-9185 CDM J0457 HCPCS 636 RC 63323-0401-20 NDC outpatient 10 ML 173.08 173.08 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES PPO [308136801] 138.46 percent of total billed charges 107.31 164.43 Technical (Hospital) Services AZTREONAM 1 GRAM SOLUTION FOR INJECTION RX-9185 CDM J0457 HCPCS 636 RC 63323-0401-20 NDC outpatient 10 ML 173.08 173.08 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES HDHP [308136802] 138.46 percent of total billed charges 107.31 164.43 Technical (Hospital) Services AZTREONAM 1 GRAM SOLUTION FOR INJECTION RX-9185 CDM J0457 HCPCS 636 RC 63323-0401-20 NDC outpatient 10 ML 173.08 173.08 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES EPO [308136803] 138.46 percent of total billed charges 107.31 164.43 Technical (Hospital) Services AZTREONAM 1 GRAM SOLUTION FOR INJECTION RX-9185 CDM J0457 HCPCS 636 RC 63323-0401-20 NDC outpatient 10 ML 173.08 173.08 UNITED HEALTHCARE (COMMERCIAL) [3081199] UNITED HEALTHCARE 87726 [308119901] 107.31 percent of total billed charges 107.31 164.43 Technical (Hospital) Services AZTREONAM 1 GRAM SOLUTION FOR INJECTION RX-9185 CDM J0457 HCPCS 636 RC 63323-0401-20 NDC outpatient 10 ML 173.08 173.08 HEALTHPARTNERS SX009 HEALTHPARTNERS 138.46 percent of total billed charges 107.31 164.43 Technical (Hospital) Services AZTREONAM 1 GRAM SOLUTION FOR INJECTION RX-9185 CDM J0457 HCPCS 636 RC 63323-0401-20 NDC outpatient 10 ML 173.08 173.08 MULTIPLAN INC 34080 [3081285] MULTIPLAN INC [308128501] 164.43 percent of total billed charges 107.31 164.43 Technical (Hospital) Services AZTREONAM 1 GRAM SOLUTION FOR INJECTION RX-9185 CDM J0457 HCPCS 636 RC 63323-0401-20 NDC outpatient 10 ML 173.08 173.08 MEDICA (COMMERCIAL) 94265 [3081118] MEDICA CLAIMS [308111801] 155.77 percent of total billed charges 107.31 164.43 Technical (Hospital) Services AZTREONAM 1 GRAM SOLUTION FOR INJECTION RX-9185 CDM J0457 HCPCS 636 RC 63323-0401-20 NDC inpatient 10 ML 173.08 173.08 BLUE CROSS BLUE SHIELD WELLMARK SB889 [3081026] BCBS WYOMING [308102603] 164.43 percent of total billed charges 107.31 164.43 Technical (Hospital) Services AZTREONAM 1 GRAM SOLUTION FOR INJECTION RX-9185 CDM J0457 HCPCS 636 RC 63323-0401-20 NDC inpatient 10 ML 173.08 173.08 UNITED HEALTHCARE (COMMERCIAL) [3081199] UNITED HEALTHCARE 87726 [308119901] 107.31 percent of total billed charges 107.31 164.43 Technical (Hospital) Services AZTREONAM 1 GRAM SOLUTION FOR INJECTION RX-9185 CDM J0457 HCPCS 636 RC 63323-0401-20 NDC inpatient 10 ML 173.08 173.08 CIGNA 62308 [3081051] CIGNA 62308 [308105105] 137.04 percent of total billed charges 107.31 164.43 Technical (Hospital) Services AZTREONAM 1 GRAM SOLUTION FOR INJECTION RX-9185 CDM J0457 HCPCS 636 RC 63323-0401-20 NDC inpatient 10 ML 173.08 173.08 CIGNA 62308 [3081051] CIGNA STATE OF WYOMING [308105107] 137.04 percent of total billed charges 107.31 164.43 Technical (Hospital) Services AZTREONAM 1 GRAM SOLUTION FOR INJECTION RX-9185 CDM J0457 HCPCS 636 RC 63323-0401-20 NDC inpatient 10 ML 173.08 173.08 MEDICA (COMMERCIAL) 94265 [3081118] MEDICA CLAIMS [308111801] 155.77 percent of total billed charges 107.31 164.43 Technical (Hospital) Services AZTREONAM 1 GRAM SOLUTION FOR INJECTION RX-9185 CDM J0457 HCPCS 636 RC 63323-0401-20 NDC inpatient 10 ML 173.08 173.08 MULTIPLAN INC 34080 [3081285] MULTIPLAN INC [308128501] 164.43 percent of total billed charges 107.31 164.43 Technical (Hospital) Services AZTREONAM 1 GRAM SOLUTION FOR INJECTION RX-9185 CDM J0457 HCPCS 636 RC 63323-0401-20 NDC inpatient 10 ML 173.08 173.08 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES PPO [308136801] 137.04 percent of total billed charges 107.31 164.43 Technical (Hospital) Services AZTREONAM 1 GRAM SOLUTION FOR INJECTION RX-9185 CDM J0457 HCPCS 636 RC 63323-0401-20 NDC inpatient 10 ML 173.08 173.08 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES HDHP [308136802] 137.04 percent of total billed charges 107.31 164.43 Technical (Hospital) Services AZTREONAM 1 GRAM SOLUTION FOR INJECTION RX-9185 CDM J0457 HCPCS 636 RC 63323-0401-20 NDC inpatient 10 ML 173.08 173.08 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES EPO [308136803] 137.04 percent of total billed charges 107.31 164.43 Technical (Hospital) Services AZTREONAM 1 GRAM SOLUTION FOR INJECTION RX-9185 CDM J0457 HCPCS 636 RC 63323-0401-20 NDC inpatient 10 ML 173.08 173.08 HEALTHPARTNERS SX009 HEALTHPARTNERS 137.04 percent of total billed charges 107.31 164.43 Technical (Hospital) Services AZITHROMYCIN 500 MG INTRAVENOUS SOLUTION RX-21063 CDM J0456 HCPCS 636 RC 63323-0398-14 NDC outpatient 5 ML 71.7 71.7 MEDICA (COMMERCIAL) 94265 [3081118] MEDICA CLAIMS [308111801] 64.53 percent of total billed charges 44.45 68.12 Technical (Hospital) Services AZITHROMYCIN 500 MG INTRAVENOUS SOLUTION RX-21063 CDM J0456 HCPCS 636 RC 63323-0398-14 NDC outpatient 5 ML 71.7 71.7 MULTIPLAN INC 34080 [3081285] MULTIPLAN INC [308128501] 68.12 percent of total billed charges 44.45 68.12 Technical (Hospital) Services AZITHROMYCIN 500 MG INTRAVENOUS SOLUTION RX-21063 CDM J0456 HCPCS 636 RC 63323-0398-14 NDC outpatient 5 ML 71.7 71.7 CIGNA 62308 [3081051] CIGNA 62308 [308105105] 57.36 percent of total billed charges 44.45 68.12 Technical (Hospital) Services AZITHROMYCIN 500 MG INTRAVENOUS SOLUTION RX-21063 CDM J0456 HCPCS 636 RC 63323-0398-14 NDC outpatient 5 ML 71.7 71.7 CIGNA 62308 [3081051] CIGNA STATE OF WYOMING [308105107] 57.36 percent of total billed charges 44.45 68.12 Technical (Hospital) Services AZITHROMYCIN 500 MG INTRAVENOUS SOLUTION RX-21063 CDM J0456 HCPCS 636 RC 63323-0398-14 NDC outpatient 5 ML 71.7 71.7 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES PPO [308136801] 57.36 percent of total billed charges 44.45 68.12 Technical (Hospital) Services AZITHROMYCIN 500 MG INTRAVENOUS SOLUTION RX-21063 CDM J0456 HCPCS 636 RC 63323-0398-14 NDC outpatient 5 ML 71.7 71.7 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES EPO [308136803] 57.36 percent of total billed charges 44.45 68.12 Technical (Hospital) Services AZITHROMYCIN 500 MG INTRAVENOUS SOLUTION RX-21063 CDM J0456 HCPCS 636 RC 63323-0398-14 NDC outpatient 5 ML 71.7 71.7 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES HDHP [308136802] 57.36 percent of total billed charges 44.45 68.12 Technical (Hospital) Services AZITHROMYCIN 500 MG INTRAVENOUS SOLUTION RX-21063 CDM J0456 HCPCS 636 RC 63323-0398-14 NDC outpatient 5 ML 71.7 71.7 UNITED HEALTHCARE (COMMERCIAL) [3081199] UNITED HEALTHCARE 87726 [308119901] 44.45 percent of total billed charges 44.45 68.12 Technical (Hospital) Services AZITHROMYCIN 500 MG INTRAVENOUS SOLUTION RX-21063 CDM J0456 HCPCS 636 RC 63323-0398-14 NDC outpatient 5 ML 71.7 71.7 BLUE CROSS BLUE SHIELD WELLMARK SB889 [3081026] BCBS WYOMING [308102603] 68.12 percent of total billed charges 44.45 68.12 Technical (Hospital) Services AZITHROMYCIN 500 MG INTRAVENOUS SOLUTION RX-21063 CDM J0456 HCPCS 636 RC 63323-0398-14 NDC outpatient 5 ML 71.7 71.7 HEALTHPARTNERS SX009 HEALTHPARTNERS 57.36 percent of total billed charges 44.45 68.12 Technical (Hospital) Services AZITHROMYCIN 500 MG INTRAVENOUS SOLUTION RX-21063 CDM J0456 HCPCS 636 RC 63323-0398-14 NDC inpatient 5 ML 71.7 71.7 MEDICA (COMMERCIAL) 94265 [3081118] MEDICA CLAIMS [308111801] 64.53 percent of total billed charges 44.45 68.12 Technical (Hospital) Services AZITHROMYCIN 500 MG INTRAVENOUS SOLUTION RX-21063 CDM J0456 HCPCS 636 RC 63323-0398-14 NDC inpatient 5 ML 71.7 71.7 MULTIPLAN INC 34080 [3081285] MULTIPLAN INC [308128501] 68.12 percent of total billed charges 44.45 68.12 Technical (Hospital) Services AZITHROMYCIN 500 MG INTRAVENOUS SOLUTION RX-21063 CDM J0456 HCPCS 636 RC 63323-0398-14 NDC inpatient 5 ML 71.7 71.7 BLUE CROSS BLUE SHIELD WELLMARK SB889 [3081026] BCBS WYOMING [308102603] 68.12 percent of total billed charges 44.45 68.12 Technical (Hospital) Services AZITHROMYCIN 500 MG INTRAVENOUS SOLUTION RX-21063 CDM J0456 HCPCS 636 RC 63323-0398-14 NDC inpatient 5 ML 71.7 71.7 UNITED HEALTHCARE (COMMERCIAL) [3081199] UNITED HEALTHCARE 87726 [308119901] 44.45 percent of total billed charges 44.45 68.12 Technical (Hospital) Services AZITHROMYCIN 500 MG INTRAVENOUS SOLUTION RX-21063 CDM J0456 HCPCS 636 RC 63323-0398-14 NDC inpatient 5 ML 71.7 71.7 CIGNA 62308 [3081051] CIGNA 62308 [308105105] 56.77 percent of total billed charges 44.45 68.12 Technical (Hospital) Services AZITHROMYCIN 500 MG INTRAVENOUS SOLUTION RX-21063 CDM J0456 HCPCS 636 RC 63323-0398-14 NDC inpatient 5 ML 71.7 71.7 CIGNA 62308 [3081051] CIGNA STATE OF WYOMING [308105107] 56.77 percent of total billed charges 44.45 68.12 Technical (Hospital) Services AZITHROMYCIN 500 MG INTRAVENOUS SOLUTION RX-21063 CDM J0456 HCPCS 636 RC 63323-0398-14 NDC inpatient 5 ML 71.7 71.7 HEALTHPARTNERS SX009 HEALTHPARTNERS 56.77 percent of total billed charges 44.45 68.12 Technical (Hospital) Services AZITHROMYCIN 500 MG INTRAVENOUS SOLUTION RX-21063 CDM J0456 HCPCS 636 RC 63323-0398-14 NDC inpatient 5 ML 71.7 71.7 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES EPO [308136803] 56.77 percent of total billed charges 44.45 68.12 Technical (Hospital) Services AZITHROMYCIN 500 MG INTRAVENOUS SOLUTION RX-21063 CDM J0456 HCPCS 636 RC 63323-0398-14 NDC inpatient 5 ML 71.7 71.7 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES HDHP [308136802] 56.77 percent of total billed charges 44.45 68.12 Technical (Hospital) Services AZITHROMYCIN 500 MG INTRAVENOUS SOLUTION RX-21063 CDM J0456 HCPCS 636 RC 63323-0398-14 NDC inpatient 5 ML 71.7 71.7 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES PPO [308136801] 56.77 percent of total billed charges 44.45 68.12 Technical (Hospital) Services HYDRALAZINE 20 MG/ML INJECTION SOLUTION RX-3697 CDM J0360 HCPCS 636 RC 63323-0614-01 NDC outpatient 1 ML 334.6 334.6 BLUE CROSS BLUE SHIELD WELLMARK SB889 [3081026] BCBS WYOMING [308102603] 317.87 percent of total billed charges 207.45 317.87 Technical (Hospital) Services HYDRALAZINE 20 MG/ML INJECTION SOLUTION RX-3697 CDM J0360 HCPCS 636 RC 63323-0614-01 NDC outpatient 1 ML 334.6 334.6 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES PPO [308136801] 267.68 percent of total billed charges 207.45 317.87 Technical (Hospital) Services HYDRALAZINE 20 MG/ML INJECTION SOLUTION RX-3697 CDM J0360 HCPCS 636 RC 63323-0614-01 NDC outpatient 1 ML 334.6 334.6 HEALTHPARTNERS SX009 HEALTHPARTNERS 267.68 percent of total billed charges 207.45 317.87 Technical (Hospital) Services HYDRALAZINE 20 MG/ML INJECTION SOLUTION RX-3697 CDM J0360 HCPCS 636 RC 63323-0614-01 NDC outpatient 1 ML 334.6 334.6 UNITED HEALTHCARE (COMMERCIAL) [3081199] UNITED HEALTHCARE 87726 [308119901] 207.45 percent of total billed charges 207.45 317.87 Technical (Hospital) Services HYDRALAZINE 20 MG/ML INJECTION SOLUTION RX-3697 CDM J0360 HCPCS 636 RC 63323-0614-01 NDC outpatient 1 ML 334.6 334.6 MULTIPLAN INC 34080 [3081285] MULTIPLAN INC [308128501] 317.87 percent of total billed charges 207.45 317.87 Technical (Hospital) Services HYDRALAZINE 20 MG/ML INJECTION SOLUTION RX-3697 CDM J0360 HCPCS 636 RC 63323-0614-01 NDC outpatient 1 ML 334.6 334.6 CIGNA 62308 [3081051] CIGNA 62308 [308105105] 267.68 percent of total billed charges 207.45 317.87 Technical (Hospital) Services HYDRALAZINE 20 MG/ML INJECTION SOLUTION RX-3697 CDM J0360 HCPCS 636 RC 63323-0614-01 NDC outpatient 1 ML 334.6 334.6 CIGNA 62308 [3081051] CIGNA STATE OF WYOMING [308105107] 267.68 percent of total billed charges 207.45 317.87 Technical (Hospital) Services HYDRALAZINE 20 MG/ML INJECTION SOLUTION RX-3697 CDM J0360 HCPCS 636 RC 63323-0614-01 NDC outpatient 1 ML 334.6 334.6 MEDICA (COMMERCIAL) 94265 [3081118] MEDICA CLAIMS [308111801] 301.14 percent of total billed charges 207.45 317.87 Technical (Hospital) Services HYDRALAZINE 20 MG/ML INJECTION SOLUTION RX-3697 CDM J0360 HCPCS 636 RC 63323-0614-01 NDC outpatient 1 ML 334.6 334.6 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES EPO [308136803] 267.68 percent of total billed charges 207.45 317.87 Technical (Hospital) Services HYDRALAZINE 20 MG/ML INJECTION SOLUTION RX-3697 CDM J0360 HCPCS 636 RC 63323-0614-01 NDC outpatient 1 ML 334.6 334.6 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES HDHP [308136802] 267.68 percent of total billed charges 207.45 317.87 Technical (Hospital) Services HYDRALAZINE 20 MG/ML INJECTION SOLUTION RX-3697 CDM J0360 HCPCS 636 RC 63323-0614-01 NDC inpatient 1 ML 334.6 334.6 MEDICA (COMMERCIAL) 94265 [3081118] MEDICA CLAIMS [308111801] 301.14 percent of total billed charges 207.45 317.87 Technical (Hospital) Services HYDRALAZINE 20 MG/ML INJECTION SOLUTION RX-3697 CDM J0360 HCPCS 636 RC 63323-0614-01 NDC inpatient 1 ML 334.6 334.6 MULTIPLAN INC 34080 [3081285] MULTIPLAN INC [308128501] 317.87 percent of total billed charges 207.45 317.87 Technical (Hospital) Services HYDRALAZINE 20 MG/ML INJECTION SOLUTION RX-3697 CDM J0360 HCPCS 636 RC 63323-0614-01 NDC inpatient 1 ML 334.6 334.6 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES PPO [308136801] 264.94 percent of total billed charges 207.45 317.87 Technical (Hospital) Services HYDRALAZINE 20 MG/ML INJECTION SOLUTION RX-3697 CDM J0360 HCPCS 636 RC 63323-0614-01 NDC inpatient 1 ML 334.6 334.6 HEALTHPARTNERS SX009 HEALTHPARTNERS 264.94 percent of total billed charges 207.45 317.87 Technical (Hospital) Services HYDRALAZINE 20 MG/ML INJECTION SOLUTION RX-3697 CDM J0360 HCPCS 636 RC 63323-0614-01 NDC inpatient 1 ML 334.6 334.6 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES HDHP [308136802] 264.94 percent of total billed charges 207.45 317.87 Technical (Hospital) Services HYDRALAZINE 20 MG/ML INJECTION SOLUTION RX-3697 CDM J0360 HCPCS 636 RC 63323-0614-01 NDC inpatient 1 ML 334.6 334.6 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES EPO [308136803] 264.94 percent of total billed charges 207.45 317.87 Technical (Hospital) Services HYDRALAZINE 20 MG/ML INJECTION SOLUTION RX-3697 CDM J0360 HCPCS 636 RC 63323-0614-01 NDC inpatient 1 ML 334.6 334.6 CIGNA 62308 [3081051] CIGNA 62308 [308105105] 264.94 percent of total billed charges 207.45 317.87 Technical (Hospital) Services HYDRALAZINE 20 MG/ML INJECTION SOLUTION RX-3697 CDM J0360 HCPCS 636 RC 63323-0614-01 NDC inpatient 1 ML 334.6 334.6 CIGNA 62308 [3081051] CIGNA STATE OF WYOMING [308105107] 264.94 percent of total billed charges 207.45 317.87 Technical (Hospital) Services HYDRALAZINE 20 MG/ML INJECTION SOLUTION RX-3697 CDM J0360 HCPCS 636 RC 63323-0614-01 NDC inpatient 1 ML 334.6 334.6 BLUE CROSS BLUE SHIELD WELLMARK SB889 [3081026] BCBS WYOMING [308102603] 317.87 percent of total billed charges 207.45 317.87 Technical (Hospital) Services HYDRALAZINE 20 MG/ML INJECTION SOLUTION RX-3697 CDM J0360 HCPCS 636 RC 63323-0614-01 NDC inpatient 1 ML 334.6 334.6 UNITED HEALTHCARE (COMMERCIAL) [3081199] UNITED HEALTHCARE 87726 [308119901] 207.45 percent of total billed charges 207.45 317.87 Technical (Hospital) Services SUCCINYLCHOLINE CHLORIDE 20 MG/ML INJECTION SOLUTION RX-7536 CDM J0330 HCPCS 636 RC 70710-1377-02 NDC inpatient 10 ML 74.09 74.09 HEALTHPARTNERS SX009 HEALTHPARTNERS 58.66 percent of total billed charges 45.94 70.39 Technical (Hospital) Services SUCCINYLCHOLINE CHLORIDE 20 MG/ML INJECTION SOLUTION RX-7536 CDM J0330 HCPCS 636 RC 70710-1377-02 NDC inpatient 10 ML 74.09 74.09 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES PPO [308136801] 58.66 percent of total billed charges 45.94 70.39 Technical (Hospital) Services SUCCINYLCHOLINE CHLORIDE 20 MG/ML INJECTION SOLUTION RX-7536 CDM J0330 HCPCS 636 RC 70710-1377-02 NDC inpatient 10 ML 74.09 74.09 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES HDHP [308136802] 58.66 percent of total billed charges 45.94 70.39 Technical (Hospital) Services SUCCINYLCHOLINE CHLORIDE 20 MG/ML INJECTION SOLUTION RX-7536 CDM J0330 HCPCS 636 RC 70710-1377-02 NDC inpatient 10 ML 74.09 74.09 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES EPO [308136803] 58.66 percent of total billed charges 45.94 70.39 Technical (Hospital) Services SUCCINYLCHOLINE CHLORIDE 20 MG/ML INJECTION SOLUTION RX-7536 CDM J0330 HCPCS 636 RC 70710-1377-02 NDC inpatient 10 ML 74.09 74.09 MEDICA (COMMERCIAL) 94265 [3081118] MEDICA CLAIMS [308111801] 66.68 percent of total billed charges 45.94 70.39 Technical (Hospital) Services SUCCINYLCHOLINE CHLORIDE 20 MG/ML INJECTION SOLUTION RX-7536 CDM J0330 HCPCS 636 RC 70710-1377-02 NDC inpatient 10 ML 74.09 74.09 MULTIPLAN INC 34080 [3081285] MULTIPLAN INC [308128501] 70.39 percent of total billed charges 45.94 70.39 Technical (Hospital) Services SUCCINYLCHOLINE CHLORIDE 20 MG/ML INJECTION SOLUTION RX-7536 CDM J0330 HCPCS 636 RC 70710-1377-02 NDC inpatient 10 ML 74.09 74.09 CIGNA 62308 [3081051] CIGNA 62308 [308105105] 58.66 percent of total billed charges 45.94 70.39 Technical (Hospital) Services SUCCINYLCHOLINE CHLORIDE 20 MG/ML INJECTION SOLUTION RX-7536 CDM J0330 HCPCS 636 RC 70710-1377-02 NDC inpatient 10 ML 74.09 74.09 CIGNA 62308 [3081051] CIGNA STATE OF WYOMING [308105107] 58.66 percent of total billed charges 45.94 70.39 Technical (Hospital) Services SUCCINYLCHOLINE CHLORIDE 20 MG/ML INJECTION SOLUTION RX-7536 CDM J0330 HCPCS 636 RC 70710-1377-02 NDC inpatient 10 ML 74.09 74.09 UNITED HEALTHCARE (COMMERCIAL) [3081199] UNITED HEALTHCARE 87726 [308119901] 45.94 percent of total billed charges 45.94 70.39 Technical (Hospital) Services SUCCINYLCHOLINE CHLORIDE 20 MG/ML INJECTION SOLUTION RX-7536 CDM J0330 HCPCS 636 RC 70710-1377-02 NDC inpatient 10 ML 74.09 74.09 BLUE CROSS BLUE SHIELD WELLMARK SB889 [3081026] BCBS WYOMING [308102603] 70.39 percent of total billed charges 45.94 70.39 Technical (Hospital) Services SUCCINYLCHOLINE CHLORIDE 20 MG/ML INJECTION SOLUTION RX-7536 CDM J0330 HCPCS 636 RC 70710-1377-02 NDC outpatient 10 ML 74.09 74.09 HEALTHPARTNERS SX009 HEALTHPARTNERS 59.27 percent of total billed charges 45.94 70.39 Technical (Hospital) Services SUCCINYLCHOLINE CHLORIDE 20 MG/ML INJECTION SOLUTION RX-7536 CDM J0330 HCPCS 636 RC 70710-1377-02 NDC outpatient 10 ML 74.09 74.09 UNITED HEALTHCARE (COMMERCIAL) [3081199] UNITED HEALTHCARE 87726 [308119901] 45.94 percent of total billed charges 45.94 70.39 Technical (Hospital) Services SUCCINYLCHOLINE CHLORIDE 20 MG/ML INJECTION SOLUTION RX-7536 CDM J0330 HCPCS 636 RC 70710-1377-02 NDC outpatient 10 ML 74.09 74.09 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES EPO [308136803] 59.27 percent of total billed charges 45.94 70.39 Technical (Hospital) Services SUCCINYLCHOLINE CHLORIDE 20 MG/ML INJECTION SOLUTION RX-7536 CDM J0330 HCPCS 636 RC 70710-1377-02 NDC outpatient 10 ML 74.09 74.09 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES HDHP [308136802] 59.27 percent of total billed charges 45.94 70.39 Technical (Hospital) Services SUCCINYLCHOLINE CHLORIDE 20 MG/ML INJECTION SOLUTION RX-7536 CDM J0330 HCPCS 636 RC 70710-1377-02 NDC outpatient 10 ML 74.09 74.09 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES PPO [308136801] 59.27 percent of total billed charges 45.94 70.39 Technical (Hospital) Services SUCCINYLCHOLINE CHLORIDE 20 MG/ML INJECTION SOLUTION RX-7536 CDM J0330 HCPCS 636 RC 70710-1377-02 NDC outpatient 10 ML 74.09 74.09 BLUE CROSS BLUE SHIELD WELLMARK SB889 [3081026] BCBS WYOMING [308102603] 70.39 percent of total billed charges 45.94 70.39 Technical (Hospital) Services SUCCINYLCHOLINE CHLORIDE 20 MG/ML INJECTION SOLUTION RX-7536 CDM J0330 HCPCS 636 RC 70710-1377-02 NDC outpatient 10 ML 74.09 74.09 CIGNA 62308 [3081051] CIGNA 62308 [308105105] 59.27 percent of total billed charges 45.94 70.39 Technical (Hospital) Services SUCCINYLCHOLINE CHLORIDE 20 MG/ML INJECTION SOLUTION RX-7536 CDM J0330 HCPCS 636 RC 70710-1377-02 NDC outpatient 10 ML 74.09 74.09 CIGNA 62308 [3081051] CIGNA STATE OF WYOMING [308105107] 59.27 percent of total billed charges 45.94 70.39 Technical (Hospital) Services SUCCINYLCHOLINE CHLORIDE 20 MG/ML INJECTION SOLUTION RX-7536 CDM J0330 HCPCS 636 RC 70710-1377-02 NDC outpatient 10 ML 74.09 74.09 MEDICA (COMMERCIAL) 94265 [3081118] MEDICA CLAIMS [308111801] 66.68 percent of total billed charges 45.94 70.39 Technical (Hospital) Services SUCCINYLCHOLINE CHLORIDE 20 MG/ML INJECTION SOLUTION RX-7536 CDM J0330 HCPCS 636 RC 70710-1377-02 NDC outpatient 10 ML 74.09 74.09 MULTIPLAN INC 34080 [3081285] MULTIPLAN INC [308128501] 70.39 percent of total billed charges 45.94 70.39 Technical (Hospital) Services AMPICILLIN-SULBACTAM 1.5 GRAM SOLUTION FOR INJECTION RX-9083 CDM J0295 HCPCS 636 RC 00049-0013-81 NDC inpatient 4 ML 72.21 72.21 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES EPO [308136803] 57.18 percent of total billed charges 44.77 68.6 Technical (Hospital) Services AMPICILLIN-SULBACTAM 1.5 GRAM SOLUTION FOR INJECTION RX-9083 CDM J0295 HCPCS 636 RC 00049-0013-81 NDC outpatient 4 ML 72.21 72.21 HEALTHPARTNERS SX009 HEALTHPARTNERS 57.77 percent of total billed charges 44.77 68.6 Technical (Hospital) Services AMPICILLIN-SULBACTAM 1.5 GRAM SOLUTION FOR INJECTION RX-9083 CDM J0295 HCPCS 636 RC 00049-0013-81 NDC outpatient 4 ML 72.21 72.21 UNITED HEALTHCARE (COMMERCIAL) [3081199] UNITED HEALTHCARE 87726 [308119901] 44.77 percent of total billed charges 44.77 68.6 Technical (Hospital) Services AMPICILLIN-SULBACTAM 1.5 GRAM SOLUTION FOR INJECTION RX-9083 CDM J0295 HCPCS 636 RC 00049-0013-81 NDC inpatient 4 ML 72.21 72.21 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES HDHP [308136802] 57.18 percent of total billed charges 44.77 68.6 Technical (Hospital) Services AMPICILLIN-SULBACTAM 1.5 GRAM SOLUTION FOR INJECTION RX-9083 CDM J0295 HCPCS 636 RC 00049-0013-81 NDC inpatient 4 ML 72.21 72.21 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES PPO [308136801] 57.18 percent of total billed charges 44.77 68.6 Technical (Hospital) Services AMPICILLIN-SULBACTAM 1.5 GRAM SOLUTION FOR INJECTION RX-9083 CDM J0295 HCPCS 636 RC 00049-0013-81 NDC inpatient 4 ML 72.21 72.21 HEALTHPARTNERS SX009 HEALTHPARTNERS 57.18 percent of total billed charges 44.77 68.6 Technical (Hospital) Services AMPICILLIN-SULBACTAM 1.5 GRAM SOLUTION FOR INJECTION RX-9083 CDM J0295 HCPCS 636 RC 00049-0013-81 NDC inpatient 4 ML 72.21 72.21 BLUE CROSS BLUE SHIELD WELLMARK SB889 [3081026] BCBS WYOMING [308102603] 68.6 percent of total billed charges 44.77 68.6 Technical (Hospital) Services AMPICILLIN-SULBACTAM 1.5 GRAM SOLUTION FOR INJECTION RX-9083 CDM J0295 HCPCS 636 RC 00049-0013-81 NDC inpatient 4 ML 72.21 72.21 UNITED HEALTHCARE (COMMERCIAL) [3081199] UNITED HEALTHCARE 87726 [308119901] 44.77 percent of total billed charges 44.77 68.6 Technical (Hospital) Services AMPICILLIN-SULBACTAM 1.5 GRAM SOLUTION FOR INJECTION RX-9083 CDM J0295 HCPCS 636 RC 00049-0013-81 NDC inpatient 4 ML 72.21 72.21 CIGNA 62308 [3081051] CIGNA 62308 [308105105] 57.18 percent of total billed charges 44.77 68.6 Technical (Hospital) Services AMPICILLIN-SULBACTAM 1.5 GRAM SOLUTION FOR INJECTION RX-9083 CDM J0295 HCPCS 636 RC 00049-0013-81 NDC inpatient 4 ML 72.21 72.21 CIGNA 62308 [3081051] CIGNA STATE OF WYOMING [308105107] 57.18 percent of total billed charges 44.77 68.6 Technical (Hospital) Services AMPICILLIN-SULBACTAM 1.5 GRAM SOLUTION FOR INJECTION RX-9083 CDM J0295 HCPCS 636 RC 00049-0013-81 NDC inpatient 4 ML 72.21 72.21 MEDICA (COMMERCIAL) 94265 [3081118] MEDICA CLAIMS [308111801] 64.99 percent of total billed charges 44.77 68.6 Technical (Hospital) Services AMPICILLIN-SULBACTAM 1.5 GRAM SOLUTION FOR INJECTION RX-9083 CDM J0295 HCPCS 636 RC 00049-0013-81 NDC outpatient 4 ML 72.21 72.21 MEDICA (COMMERCIAL) 94265 [3081118] MEDICA CLAIMS [308111801] 64.99 percent of total billed charges 44.77 68.6 Technical (Hospital) Services AMPICILLIN-SULBACTAM 1.5 GRAM SOLUTION FOR INJECTION RX-9083 CDM J0295 HCPCS 636 RC 00049-0013-81 NDC outpatient 4 ML 72.21 72.21 MULTIPLAN INC 34080 [3081285] MULTIPLAN INC [308128501] 68.6 percent of total billed charges 44.77 68.6 Technical (Hospital) Services AMPICILLIN-SULBACTAM 1.5 GRAM SOLUTION FOR INJECTION RX-9083 CDM J0295 HCPCS 636 RC 00049-0013-81 NDC outpatient 4 ML 72.21 72.21 CIGNA 62308 [3081051] CIGNA 62308 [308105105] 57.77 percent of total billed charges 44.77 68.6 Technical (Hospital) Services AMPICILLIN-SULBACTAM 1.5 GRAM SOLUTION FOR INJECTION RX-9083 CDM J0295 HCPCS 636 RC 00049-0013-81 NDC outpatient 4 ML 72.21 72.21 CIGNA 62308 [3081051] CIGNA STATE OF WYOMING [308105107] 57.77 percent of total billed charges 44.77 68.6 Technical (Hospital) Services AMPICILLIN-SULBACTAM 1.5 GRAM SOLUTION FOR INJECTION RX-9083 CDM J0295 HCPCS 636 RC 00049-0013-81 NDC outpatient 4 ML 72.21 72.21 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES PPO [308136801] 57.77 percent of total billed charges 44.77 68.6 Technical (Hospital) Services AMPICILLIN-SULBACTAM 1.5 GRAM SOLUTION FOR INJECTION RX-9083 CDM J0295 HCPCS 636 RC 00049-0013-81 NDC outpatient 4 ML 72.21 72.21 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES EPO [308136803] 57.77 percent of total billed charges 44.77 68.6 Technical (Hospital) Services AMPICILLIN-SULBACTAM 1.5 GRAM SOLUTION FOR INJECTION RX-9083 CDM J0295 HCPCS 636 RC 00049-0013-81 NDC outpatient 4 ML 72.21 72.21 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES HDHP [308136802] 57.77 percent of total billed charges 44.77 68.6 Technical (Hospital) Services AMPICILLIN-SULBACTAM 1.5 GRAM SOLUTION FOR INJECTION RX-9083 CDM J0295 HCPCS 636 RC 00049-0013-81 NDC outpatient 4 ML 72.21 72.21 BLUE CROSS BLUE SHIELD WELLMARK SB889 [3081026] BCBS WYOMING [308102603] 68.6 percent of total billed charges 44.77 68.6 Technical (Hospital) Services AMPICILLIN-SULBACTAM 1.5 GRAM SOLUTION FOR INJECTION RX-9083 CDM J0295 HCPCS 636 RC 00049-0013-81 NDC inpatient 4 ML 72.21 72.21 MULTIPLAN INC 34080 [3081285] MULTIPLAN INC [308128501] 68.6 percent of total billed charges 44.77 68.6 Technical (Hospital) Services AMPICILLIN 2 GRAM SOLUTION FOR INJECTION RX-472 CDM J0290 HCPCS 636 RC 00781-9273-95 NDC outpatient 8 ML 83.4 83.4 MEDICA (COMMERCIAL) 94265 [3081118] MEDICA CLAIMS [308111801] 75.06 percent of total billed charges 51.71 79.23 Technical (Hospital) Services AMPICILLIN 2 GRAM SOLUTION FOR INJECTION RX-472 CDM J0290 HCPCS 636 RC 00781-9273-95 NDC outpatient 8 ML 83.4 83.4 MULTIPLAN INC 34080 [3081285] MULTIPLAN INC [308128501] 79.23 percent of total billed charges 51.71 79.23 Technical (Hospital) Services AMPICILLIN 2 GRAM SOLUTION FOR INJECTION RX-472 CDM J0290 HCPCS 636 RC 00781-9273-95 NDC outpatient 8 ML 83.4 83.4 HEALTHPARTNERS SX009 HEALTHPARTNERS 66.72 percent of total billed charges 51.71 79.23 Technical (Hospital) Services AMPICILLIN 2 GRAM SOLUTION FOR INJECTION RX-472 CDM J0290 HCPCS 636 RC 00781-9273-95 NDC outpatient 8 ML 83.4 83.4 UNITED HEALTHCARE (COMMERCIAL) [3081199] UNITED HEALTHCARE 87726 [308119901] 51.71 percent of total billed charges 51.71 79.23 Technical (Hospital) Services AMPICILLIN 2 GRAM SOLUTION FOR INJECTION RX-472 CDM J0290 HCPCS 636 RC 00781-9273-95 NDC outpatient 8 ML 83.4 83.4 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES HDHP [308136802] 66.72 percent of total billed charges 51.71 79.23 Technical (Hospital) Services AMPICILLIN 2 GRAM SOLUTION FOR INJECTION RX-472 CDM J0290 HCPCS 636 RC 00781-9273-95 NDC outpatient 8 ML 83.4 83.4 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES PPO [308136801] 66.72 percent of total billed charges 51.71 79.23 Technical (Hospital) Services AMPICILLIN 2 GRAM SOLUTION FOR INJECTION RX-472 CDM J0290 HCPCS 636 RC 00781-9273-95 NDC outpatient 8 ML 83.4 83.4 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES EPO [308136803] 66.72 percent of total billed charges 51.71 79.23 Technical (Hospital) Services AMPICILLIN 2 GRAM SOLUTION FOR INJECTION RX-472 CDM J0290 HCPCS 636 RC 00781-9273-95 NDC inpatient 8 ML 83.4 83.4 CIGNA 62308 [3081051] CIGNA 62308 [308105105] 66.04 percent of total billed charges 51.71 79.23 Technical (Hospital) Services AMPICILLIN 2 GRAM SOLUTION FOR INJECTION RX-472 CDM J0290 HCPCS 636 RC 00781-9273-95 NDC inpatient 8 ML 83.4 83.4 CIGNA 62308 [3081051] CIGNA STATE OF WYOMING [308105107] 66.04 percent of total billed charges 51.71 79.23 Technical (Hospital) Services AMPICILLIN 2 GRAM SOLUTION FOR INJECTION RX-472 CDM J0290 HCPCS 636 RC 00781-9273-95 NDC inpatient 8 ML 83.4 83.4 UNITED HEALTHCARE (COMMERCIAL) [3081199] UNITED HEALTHCARE 87726 [308119901] 51.71 percent of total billed charges 51.71 79.23 Technical (Hospital) Services AMPICILLIN 2 GRAM SOLUTION FOR INJECTION RX-472 CDM J0290 HCPCS 636 RC 00781-9273-95 NDC inpatient 8 ML 83.4 83.4 BLUE CROSS BLUE SHIELD WELLMARK SB889 [3081026] BCBS WYOMING [308102603] 79.23 percent of total billed charges 51.71 79.23 Technical (Hospital) Services AMPICILLIN 2 GRAM SOLUTION FOR INJECTION RX-472 CDM J0290 HCPCS 636 RC 00781-9273-95 NDC outpatient 8 ML 83.4 83.4 BLUE CROSS BLUE SHIELD WELLMARK SB889 [3081026] BCBS WYOMING [308102603] 79.23 percent of total billed charges 51.71 79.23 Technical (Hospital) Services AMPICILLIN 2 GRAM SOLUTION FOR INJECTION RX-472 CDM J0290 HCPCS 636 RC 00781-9273-95 NDC outpatient 8 ML 83.4 83.4 CIGNA 62308 [3081051] CIGNA 62308 [308105105] 66.72 percent of total billed charges 51.71 79.23 Technical (Hospital) Services AMPICILLIN 2 GRAM SOLUTION FOR INJECTION RX-472 CDM J0290 HCPCS 636 RC 00781-9273-95 NDC outpatient 8 ML 83.4 83.4 CIGNA 62308 [3081051] CIGNA STATE OF WYOMING [308105107] 66.72 percent of total billed charges 51.71 79.23 Technical (Hospital) Services AMPICILLIN 2 GRAM SOLUTION FOR INJECTION RX-472 CDM J0290 HCPCS 636 RC 00781-9273-95 NDC inpatient 8 ML 83.4 83.4 MULTIPLAN INC 34080 [3081285] MULTIPLAN INC [308128501] 79.23 percent of total billed charges 51.71 79.23 Technical (Hospital) Services AMPICILLIN 2 GRAM SOLUTION FOR INJECTION RX-472 CDM J0290 HCPCS 636 RC 00781-9273-95 NDC inpatient 8 ML 83.4 83.4 MEDICA (COMMERCIAL) 94265 [3081118] MEDICA CLAIMS [308111801] 75.06 percent of total billed charges 51.71 79.23 Technical (Hospital) Services AMPICILLIN 2 GRAM SOLUTION FOR INJECTION RX-472 CDM J0290 HCPCS 636 RC 00781-9273-95 NDC inpatient 8 ML 83.4 83.4 HEALTHPARTNERS SX009 HEALTHPARTNERS 66.04 percent of total billed charges 51.71 79.23 Technical (Hospital) Services AMPICILLIN 2 GRAM SOLUTION FOR INJECTION RX-472 CDM J0290 HCPCS 636 RC 00781-9273-95 NDC inpatient 8 ML 83.4 83.4 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES EPO [308136803] 66.04 percent of total billed charges 51.71 79.23 Technical (Hospital) Services AMPICILLIN 2 GRAM SOLUTION FOR INJECTION RX-472 CDM J0290 HCPCS 636 RC 00781-9273-95 NDC inpatient 8 ML 83.4 83.4 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES HDHP [308136802] 66.04 percent of total billed charges 51.71 79.23 Technical (Hospital) Services AMPICILLIN 2 GRAM SOLUTION FOR INJECTION RX-472 CDM J0290 HCPCS 636 RC 00781-9273-95 NDC inpatient 8 ML 83.4 83.4 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES PPO [308136801] 66.04 percent of total billed charges 51.71 79.23 Technical (Hospital) Services AMPHOTERICIN B LIPOSOME 50 MG INTRAVENOUS SUSPENSION RX-21900 CDM J0289 HCPCS 636 RC 00469-3051-30 NDC inpatient 12.5 ML 784.04 784.04 MULTIPLAN INC 34080 [3081285] MULTIPLAN INC [308128501] 744.84 percent of total billed charges 486.1 744.84 Technical (Hospital) Services AMPHOTERICIN B LIPOSOME 50 MG INTRAVENOUS SUSPENSION RX-21900 CDM J0289 HCPCS 636 RC 00469-3051-30 NDC inpatient 12.5 ML 784.04 784.04 MEDICA (COMMERCIAL) 94265 [3081118] MEDICA CLAIMS [308111801] 705.64 percent of total billed charges 486.1 744.84 Technical (Hospital) Services AMPHOTERICIN B LIPOSOME 50 MG INTRAVENOUS SUSPENSION RX-21900 CDM J0289 HCPCS 636 RC 00469-3051-30 NDC inpatient 12.5 ML 784.04 784.04 UNITED HEALTHCARE (COMMERCIAL) [3081199] UNITED HEALTHCARE 87726 [308119901] 486.1 percent of total billed charges 486.1 744.84 Technical (Hospital) Services AMPHOTERICIN B LIPOSOME 50 MG INTRAVENOUS SUSPENSION RX-21900 CDM J0289 HCPCS 636 RC 00469-3051-30 NDC outpatient 12.5 ML 784.04 784.04 CIGNA 62308 [3081051] CIGNA 62308 [308105105] 627.23 percent of total billed charges 486.1 744.84 Technical (Hospital) Services AMPHOTERICIN B LIPOSOME 50 MG INTRAVENOUS SUSPENSION RX-21900 CDM J0289 HCPCS 636 RC 00469-3051-30 NDC outpatient 12.5 ML 784.04 784.04 CIGNA 62308 [3081051] CIGNA STATE OF WYOMING [308105107] 627.23 percent of total billed charges 486.1 744.84 Technical (Hospital) Services AMPHOTERICIN B LIPOSOME 50 MG INTRAVENOUS SUSPENSION RX-21900 CDM J0289 HCPCS 636 RC 00469-3051-30 NDC outpatient 12.5 ML 784.04 784.04 MULTIPLAN INC 34080 [3081285] MULTIPLAN INC [308128501] 744.84 percent of total billed charges 486.1 744.84 Technical (Hospital) Services AMPHOTERICIN B LIPOSOME 50 MG INTRAVENOUS SUSPENSION RX-21900 CDM J0289 HCPCS 636 RC 00469-3051-30 NDC outpatient 12.5 ML 784.04 784.04 BLUE CROSS BLUE SHIELD WELLMARK SB889 [3081026] BCBS WYOMING [308102603] 744.84 percent of total billed charges 486.1 744.84 Technical (Hospital) Services AMPHOTERICIN B LIPOSOME 50 MG INTRAVENOUS SUSPENSION RX-21900 CDM J0289 HCPCS 636 RC 00469-3051-30 NDC inpatient 12.5 ML 784.04 784.04 BLUE CROSS BLUE SHIELD WELLMARK SB889 [3081026] BCBS WYOMING [308102603] 744.84 percent of total billed charges 486.1 744.84 Technical (Hospital) Services AMPHOTERICIN B LIPOSOME 50 MG INTRAVENOUS SUSPENSION RX-21900 CDM J0289 HCPCS 636 RC 00469-3051-30 NDC inpatient 12.5 ML 784.04 784.04 CIGNA 62308 [3081051] CIGNA STATE OF WYOMING [308105107] 620.8 percent of total billed charges 486.1 744.84 Technical (Hospital) Services AMPHOTERICIN B LIPOSOME 50 MG INTRAVENOUS SUSPENSION RX-21900 CDM J0289 HCPCS 636 RC 00469-3051-30 NDC inpatient 12.5 ML 784.04 784.04 CIGNA 62308 [3081051] CIGNA 62308 [308105105] 620.8 percent of total billed charges 486.1 744.84 Technical (Hospital) Services AMPHOTERICIN B LIPOSOME 50 MG INTRAVENOUS SUSPENSION RX-21900 CDM J0289 HCPCS 636 RC 00469-3051-30 NDC inpatient 12.5 ML 784.04 784.04 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES PPO [308136801] 620.8 percent of total billed charges 486.1 744.84 Technical (Hospital) Services AMPHOTERICIN B LIPOSOME 50 MG INTRAVENOUS SUSPENSION RX-21900 CDM J0289 HCPCS 636 RC 00469-3051-30 NDC inpatient 12.5 ML 784.04 784.04 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES EPO [308136803] 620.8 percent of total billed charges 486.1 744.84 Technical (Hospital) Services AMPHOTERICIN B LIPOSOME 50 MG INTRAVENOUS SUSPENSION RX-21900 CDM J0289 HCPCS 636 RC 00469-3051-30 NDC inpatient 12.5 ML 784.04 784.04 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES HDHP [308136802] 620.8 percent of total billed charges 486.1 744.84 Technical (Hospital) Services AMPHOTERICIN B LIPOSOME 50 MG INTRAVENOUS SUSPENSION RX-21900 CDM J0289 HCPCS 636 RC 00469-3051-30 NDC inpatient 12.5 ML 784.04 784.04 HEALTHPARTNERS SX009 HEALTHPARTNERS 620.8 percent of total billed charges 486.1 744.84 Technical (Hospital) Services AMPHOTERICIN B LIPOSOME 50 MG INTRAVENOUS SUSPENSION RX-21900 CDM J0289 HCPCS 636 RC 00469-3051-30 NDC outpatient 12.5 ML 784.04 784.04 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES EPO [308136803] 627.23 percent of total billed charges 486.1 744.84 Technical (Hospital) Services AMPHOTERICIN B LIPOSOME 50 MG INTRAVENOUS SUSPENSION RX-21900 CDM J0289 HCPCS 636 RC 00469-3051-30 NDC outpatient 12.5 ML 784.04 784.04 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES HDHP [308136802] 627.23 percent of total billed charges 486.1 744.84 Technical (Hospital) Services AMPHOTERICIN B LIPOSOME 50 MG INTRAVENOUS SUSPENSION RX-21900 CDM J0289 HCPCS 636 RC 00469-3051-30 NDC outpatient 12.5 ML 784.04 784.04 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES PPO [308136801] 627.23 percent of total billed charges 486.1 744.84 Technical (Hospital) Services AMPHOTERICIN B LIPOSOME 50 MG INTRAVENOUS SUSPENSION RX-21900 CDM J0289 HCPCS 636 RC 00469-3051-30 NDC outpatient 12.5 ML 784.04 784.04 MEDICA (COMMERCIAL) 94265 [3081118] MEDICA CLAIMS [308111801] 705.64 percent of total billed charges 486.1 744.84 Technical (Hospital) Services AMPHOTERICIN B LIPOSOME 50 MG INTRAVENOUS SUSPENSION RX-21900 CDM J0289 HCPCS 636 RC 00469-3051-30 NDC outpatient 12.5 ML 784.04 784.04 UNITED HEALTHCARE (COMMERCIAL) [3081199] UNITED HEALTHCARE 87726 [308119901] 486.1 percent of total billed charges 486.1 744.84 Technical (Hospital) Services AMPHOTERICIN B LIPOSOME 50 MG INTRAVENOUS SUSPENSION RX-21900 CDM J0289 HCPCS 636 RC 00469-3051-30 NDC outpatient 12.5 ML 784.04 784.04 HEALTHPARTNERS SX009 HEALTHPARTNERS 627.23 percent of total billed charges 486.1 744.84 Technical (Hospital) Services AMIODARONE 50 MG/ML INTRAVENOUS SOLUTION WRAPPER RX-4080030050 CDM J0282 HCPCS 636 RC 00143-9875-01 NDC inpatient 3 ML 60.3 60.3 HEALTHPARTNERS SX009 HEALTHPARTNERS 47.75 percent of total billed charges 37.39 57.29 Technical (Hospital) Services AMIODARONE 50 MG/ML INTRAVENOUS SOLUTION WRAPPER RX-4080030050 CDM J0282 HCPCS 636 RC 00143-9875-01 NDC outpatient 3 ML 60.3 60.3 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES EPO [308136803] 48.24 percent of total billed charges 37.39 57.29 Technical (Hospital) Services AMIODARONE 50 MG/ML INTRAVENOUS SOLUTION WRAPPER RX-4080030050 CDM J0282 HCPCS 636 RC 00143-9875-01 NDC outpatient 3 ML 60.3 60.3 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES HDHP [308136802] 48.24 percent of total billed charges 37.39 57.29 Technical (Hospital) Services AMIODARONE 50 MG/ML INTRAVENOUS SOLUTION WRAPPER RX-4080030050 CDM J0282 HCPCS 636 RC 00143-9875-01 NDC inpatient 3 ML 60.3 60.3 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES EPO [308136803] 47.75 percent of total billed charges 37.39 57.29 Technical (Hospital) Services AMIODARONE 50 MG/ML INTRAVENOUS SOLUTION WRAPPER RX-4080030050 CDM J0282 HCPCS 636 RC 00143-9875-01 NDC inpatient 3 ML 60.3 60.3 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES HDHP [308136802] 47.75 percent of total billed charges 37.39 57.29 Technical (Hospital) Services AMIODARONE 50 MG/ML INTRAVENOUS SOLUTION WRAPPER RX-4080030050 CDM J0282 HCPCS 636 RC 00143-9875-01 NDC inpatient 3 ML 60.3 60.3 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES PPO [308136801] 47.75 percent of total billed charges 37.39 57.29 Technical (Hospital) Services AMIODARONE 50 MG/ML INTRAVENOUS SOLUTION WRAPPER RX-4080030050 CDM J0282 HCPCS 636 RC 00143-9875-01 NDC inpatient 3 ML 60.3 60.3 MULTIPLAN INC 34080 [3081285] MULTIPLAN INC [308128501] 57.29 percent of total billed charges 37.39 57.29 Technical (Hospital) Services AMIODARONE 50 MG/ML INTRAVENOUS SOLUTION WRAPPER RX-4080030050 CDM J0282 HCPCS 636 RC 00143-9875-01 NDC inpatient 3 ML 60.3 60.3 MEDICA (COMMERCIAL) 94265 [3081118] MEDICA CLAIMS [308111801] 54.27 percent of total billed charges 37.39 57.29 Technical (Hospital) Services AMIODARONE 50 MG/ML INTRAVENOUS SOLUTION WRAPPER RX-4080030050 CDM J0282 HCPCS 636 RC 00143-9875-01 NDC inpatient 3 ML 60.3 60.3 CIGNA 62308 [3081051] CIGNA 62308 [308105105] 47.75 percent of total billed charges 37.39 57.29 Technical (Hospital) Services AMIODARONE 50 MG/ML INTRAVENOUS SOLUTION WRAPPER RX-4080030050 CDM J0282 HCPCS 636 RC 00143-9875-01 NDC inpatient 3 ML 60.3 60.3 CIGNA 62308 [3081051] CIGNA STATE OF WYOMING [308105107] 47.75 percent of total billed charges 37.39 57.29 Technical (Hospital) Services AMIODARONE 50 MG/ML INTRAVENOUS SOLUTION WRAPPER RX-4080030050 CDM J0282 HCPCS 636 RC 00143-9875-01 NDC inpatient 3 ML 60.3 60.3 BLUE CROSS BLUE SHIELD WELLMARK SB889 [3081026] BCBS WYOMING [308102603] 57.29 percent of total billed charges 37.39 57.29 Technical (Hospital) Services AMIODARONE 50 MG/ML INTRAVENOUS SOLUTION WRAPPER RX-4080030050 CDM J0282 HCPCS 636 RC 00143-9875-01 NDC outpatient 3 ML 60.3 60.3 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES PPO [308136801] 48.24 percent of total billed charges 37.39 57.29 Technical (Hospital) Services AMIODARONE 50 MG/ML INTRAVENOUS SOLUTION WRAPPER RX-4080030050 CDM J0282 HCPCS 636 RC 00143-9875-01 NDC outpatient 3 ML 60.3 60.3 BLUE CROSS BLUE SHIELD WELLMARK SB889 [3081026] BCBS WYOMING [308102603] 57.29 percent of total billed charges 37.39 57.29 Technical (Hospital) Services AMIODARONE 50 MG/ML INTRAVENOUS SOLUTION WRAPPER RX-4080030050 CDM J0282 HCPCS 636 RC 00143-9875-01 NDC outpatient 3 ML 60.3 60.3 HEALTHPARTNERS SX009 HEALTHPARTNERS 48.24 percent of total billed charges 37.39 57.29 Technical (Hospital) Services AMIODARONE 50 MG/ML INTRAVENOUS SOLUTION WRAPPER RX-4080030050 CDM J0282 HCPCS 636 RC 00143-9875-01 NDC outpatient 3 ML 60.3 60.3 UNITED HEALTHCARE (COMMERCIAL) [3081199] UNITED HEALTHCARE 87726 [308119901] 37.39 percent of total billed charges 37.39 57.29 Technical (Hospital) Services AMIODARONE 50 MG/ML INTRAVENOUS SOLUTION WRAPPER RX-4080030050 CDM J0282 HCPCS 636 RC 00143-9875-01 NDC outpatient 3 ML 60.3 60.3 CIGNA 62308 [3081051] CIGNA 62308 [308105105] 48.24 percent of total billed charges 37.39 57.29 Technical (Hospital) Services AMIODARONE 50 MG/ML INTRAVENOUS SOLUTION WRAPPER RX-4080030050 CDM J0282 HCPCS 636 RC 00143-9875-01 NDC outpatient 3 ML 60.3 60.3 CIGNA 62308 [3081051] CIGNA STATE OF WYOMING [308105107] 48.24 percent of total billed charges 37.39 57.29 Technical (Hospital) Services AMIODARONE 50 MG/ML INTRAVENOUS SOLUTION WRAPPER RX-4080030050 CDM J0282 HCPCS 636 RC 00143-9875-01 NDC outpatient 3 ML 60.3 60.3 MEDICA (COMMERCIAL) 94265 [3081118] MEDICA CLAIMS [308111801] 54.27 percent of total billed charges 37.39 57.29 Technical (Hospital) Services AMIODARONE 50 MG/ML INTRAVENOUS SOLUTION WRAPPER RX-4080030050 CDM J0282 HCPCS 636 RC 00143-9875-01 NDC outpatient 3 ML 60.3 60.3 MULTIPLAN INC 34080 [3081285] MULTIPLAN INC [308128501] 57.29 percent of total billed charges 37.39 57.29 Technical (Hospital) Services AMIODARONE 50 MG/ML INTRAVENOUS SOLUTION WRAPPER RX-4080030050 CDM J0282 HCPCS 636 RC 00143-9875-01 NDC inpatient 3 ML 60.3 60.3 UNITED HEALTHCARE (COMMERCIAL) [3081199] UNITED HEALTHCARE 87726 [308119901] 37.39 percent of total billed charges 37.39 57.29 Technical (Hospital) Services AMINOPHYLLINE 250 MG/10 ML INTRAVENOUS SOLUTION RX-407 CDM J0280 HCPCS 636 RC 00409-5921-01 NDC outpatient 10 ML 105.02 105.02 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES EPO [308136803] 84.02 percent of total billed charges 65.11 99.77 Technical (Hospital) Services AMINOPHYLLINE 250 MG/10 ML INTRAVENOUS SOLUTION RX-407 CDM J0280 HCPCS 636 RC 00409-5921-01 NDC outpatient 10 ML 105.02 105.02 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES HDHP [308136802] 84.02 percent of total billed charges 65.11 99.77 Technical (Hospital) Services AMINOPHYLLINE 250 MG/10 ML INTRAVENOUS SOLUTION RX-407 CDM J0280 HCPCS 636 RC 00409-5921-01 NDC outpatient 10 ML 105.02 105.02 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES PPO [308136801] 84.02 percent of total billed charges 65.11 99.77 Technical (Hospital) Services AMINOPHYLLINE 250 MG/10 ML INTRAVENOUS SOLUTION RX-407 CDM J0280 HCPCS 636 RC 00409-5921-01 NDC outpatient 10 ML 105.02 105.02 UNITED HEALTHCARE (COMMERCIAL) [3081199] UNITED HEALTHCARE 87726 [308119901] 65.11 percent of total billed charges 65.11 99.77 Technical (Hospital) Services AMINOPHYLLINE 250 MG/10 ML INTRAVENOUS SOLUTION RX-407 CDM J0280 HCPCS 636 RC 00409-5921-01 NDC outpatient 10 ML 105.02 105.02 HEALTHPARTNERS SX009 HEALTHPARTNERS 84.02 percent of total billed charges 65.11 99.77 Technical (Hospital) Services AMINOPHYLLINE 250 MG/10 ML INTRAVENOUS SOLUTION RX-407 CDM J0280 HCPCS 636 RC 00409-5921-01 NDC outpatient 10 ML 105.02 105.02 BLUE CROSS BLUE SHIELD WELLMARK SB889 [3081026] BCBS WYOMING [308102603] 99.77 percent of total billed charges 65.11 99.77 Technical (Hospital) Services AMINOPHYLLINE 250 MG/10 ML INTRAVENOUS SOLUTION RX-407 CDM J0280 HCPCS 636 RC 00409-5921-01 NDC outpatient 10 ML 105.02 105.02 MEDICA (COMMERCIAL) 94265 [3081118] MEDICA CLAIMS [308111801] 94.52 percent of total billed charges 65.11 99.77 Technical (Hospital) Services AMINOPHYLLINE 250 MG/10 ML INTRAVENOUS SOLUTION RX-407 CDM J0280 HCPCS 636 RC 00409-5921-01 NDC outpatient 10 ML 105.02 105.02 MULTIPLAN INC 34080 [3081285] MULTIPLAN INC [308128501] 99.77 percent of total billed charges 65.11 99.77 Technical (Hospital) Services AMINOPHYLLINE 250 MG/10 ML INTRAVENOUS SOLUTION RX-407 CDM J0280 HCPCS 636 RC 00409-5921-01 NDC outpatient 10 ML 105.02 105.02 CIGNA 62308 [3081051] CIGNA 62308 [308105105] 84.02 percent of total billed charges 65.11 99.77 Technical (Hospital) Services AMINOPHYLLINE 250 MG/10 ML INTRAVENOUS SOLUTION RX-407 CDM J0280 HCPCS 636 RC 00409-5921-01 NDC outpatient 10 ML 105.02 105.02 CIGNA 62308 [3081051] CIGNA STATE OF WYOMING [308105107] 84.02 percent of total billed charges 65.11 99.77 Technical (Hospital) Services AMINOPHYLLINE 250 MG/10 ML INTRAVENOUS SOLUTION RX-407 CDM J0280 HCPCS 636 RC 00409-5921-01 NDC inpatient 10 ML 105.02 105.02 UNITED HEALTHCARE (COMMERCIAL) [3081199] UNITED HEALTHCARE 87726 [308119901] 65.11 percent of total billed charges 65.11 99.77 Technical (Hospital) Services AMINOPHYLLINE 250 MG/10 ML INTRAVENOUS SOLUTION RX-407 CDM J0280 HCPCS 636 RC 00409-5921-01 NDC inpatient 10 ML 105.02 105.02 BLUE CROSS BLUE SHIELD WELLMARK SB889 [3081026] BCBS WYOMING [308102603] 99.77 percent of total billed charges 65.11 99.77 Technical (Hospital) Services AMINOPHYLLINE 250 MG/10 ML INTRAVENOUS SOLUTION RX-407 CDM J0280 HCPCS 636 RC 00409-5921-01 NDC inpatient 10 ML 105.02 105.02 CIGNA 62308 [3081051] CIGNA 62308 [308105105] 83.15 percent of total billed charges 65.11 99.77 Technical (Hospital) Services AMINOPHYLLINE 250 MG/10 ML INTRAVENOUS SOLUTION RX-407 CDM J0280 HCPCS 636 RC 00409-5921-01 NDC inpatient 10 ML 105.02 105.02 CIGNA 62308 [3081051] CIGNA STATE OF WYOMING [308105107] 83.15 percent of total billed charges 65.11 99.77 Technical (Hospital) Services AMINOPHYLLINE 250 MG/10 ML INTRAVENOUS SOLUTION RX-407 CDM J0280 HCPCS 636 RC 00409-5921-01 NDC inpatient 10 ML 105.02 105.02 MEDICA (COMMERCIAL) 94265 [3081118] MEDICA CLAIMS [308111801] 94.52 percent of total billed charges 65.11 99.77 Technical (Hospital) Services AMINOPHYLLINE 250 MG/10 ML INTRAVENOUS SOLUTION RX-407 CDM J0280 HCPCS 636 RC 00409-5921-01 NDC inpatient 10 ML 105.02 105.02 MULTIPLAN INC 34080 [3081285] MULTIPLAN INC [308128501] 99.77 percent of total billed charges 65.11 99.77 Technical (Hospital) Services AMINOPHYLLINE 250 MG/10 ML INTRAVENOUS SOLUTION RX-407 CDM J0280 HCPCS 636 RC 00409-5921-01 NDC inpatient 10 ML 105.02 105.02 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES EPO [308136803] 83.15 percent of total billed charges 65.11 99.77 Technical (Hospital) Services AMINOPHYLLINE 250 MG/10 ML INTRAVENOUS SOLUTION RX-407 CDM J0280 HCPCS 636 RC 00409-5921-01 NDC inpatient 10 ML 105.02 105.02 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES PPO [308136801] 83.15 percent of total billed charges 65.11 99.77 Technical (Hospital) Services AMINOPHYLLINE 250 MG/10 ML INTRAVENOUS SOLUTION RX-407 CDM J0280 HCPCS 636 RC 00409-5921-01 NDC inpatient 10 ML 105.02 105.02 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES HDHP [308136802] 83.15 percent of total billed charges 65.11 99.77 Technical (Hospital) Services AMINOPHYLLINE 250 MG/10 ML INTRAVENOUS SOLUTION RX-407 CDM J0280 HCPCS 636 RC 00409-5921-01 NDC inpatient 10 ML 105.02 105.02 HEALTHPARTNERS SX009 HEALTHPARTNERS 83.15 percent of total billed charges 65.11 99.77 Technical (Hospital) Services SODIUM THIOSULFATE 12.5 GRAM/50 ML (250 MG/ML) INTRAVENOUS SOLUTION RX-7364 CDM J0209 HCPCS 250 RC 60267-0705-50 NDC inpatient 50 ML 378 378 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES EPO [308136803] 299.3 percent of total billed charges 234.36 359.1 Technical (Hospital) Services SODIUM THIOSULFATE 12.5 GRAM/50 ML (250 MG/ML) INTRAVENOUS SOLUTION RX-7364 CDM J0209 HCPCS 250 RC 60267-0705-50 NDC inpatient 50 ML 378 378 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES PPO [308136801] 299.3 percent of total billed charges 234.36 359.1 Technical (Hospital) Services SODIUM THIOSULFATE 12.5 GRAM/50 ML (250 MG/ML) INTRAVENOUS SOLUTION RX-7364 CDM J0209 HCPCS 250 RC 60267-0705-50 NDC inpatient 50 ML 378 378 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES HDHP [308136802] 299.3 percent of total billed charges 234.36 359.1 Technical (Hospital) Services SODIUM THIOSULFATE 12.5 GRAM/50 ML (250 MG/ML) INTRAVENOUS SOLUTION RX-7364 CDM J0209 HCPCS 250 RC 60267-0705-50 NDC inpatient 50 ML 378 378 CIGNA 62308 [3081051] CIGNA 62308 [308105105] 299.3 percent of total billed charges 234.36 359.1 Technical (Hospital) Services SODIUM THIOSULFATE 12.5 GRAM/50 ML (250 MG/ML) INTRAVENOUS SOLUTION RX-7364 CDM J0209 HCPCS 250 RC 60267-0705-50 NDC inpatient 50 ML 378 378 CIGNA 62308 [3081051] CIGNA STATE OF WYOMING [308105107] 299.3 percent of total billed charges 234.36 359.1 Technical (Hospital) Services SODIUM THIOSULFATE 12.5 GRAM/50 ML (250 MG/ML) INTRAVENOUS SOLUTION RX-7364 CDM J0209 HCPCS 250 RC 60267-0705-50 NDC inpatient 50 ML 378 378 HEALTHPARTNERS SX009 HEALTHPARTNERS 299.3 percent of total billed charges 234.36 359.1 Technical (Hospital) Services SODIUM THIOSULFATE 12.5 GRAM/50 ML (250 MG/ML) INTRAVENOUS SOLUTION RX-7364 CDM J0209 HCPCS 250 RC 60267-0705-50 NDC inpatient 50 ML 378 378 MULTIPLAN INC 34080 [3081285] MULTIPLAN INC [308128501] 359.1 percent of total billed charges 234.36 359.1 Technical (Hospital) Services SODIUM THIOSULFATE 12.5 GRAM/50 ML (250 MG/ML) INTRAVENOUS SOLUTION RX-7364 CDM J0209 HCPCS 250 RC 60267-0705-50 NDC inpatient 50 ML 378 378 MEDICA (COMMERCIAL) 94265 [3081118] MEDICA CLAIMS [308111801] 340.2 percent of total billed charges 234.36 359.1 Technical (Hospital) Services SODIUM THIOSULFATE 12.5 GRAM/50 ML (250 MG/ML) INTRAVENOUS SOLUTION RX-7364 CDM J0209 HCPCS 250 RC 60267-0705-50 NDC inpatient 50 ML 378 378 BLUE CROSS BLUE SHIELD WELLMARK SB889 [3081026] BCBS WYOMING [308102603] 359.1 percent of total billed charges 234.36 359.1 Technical (Hospital) Services SODIUM THIOSULFATE 12.5 GRAM/50 ML (250 MG/ML) INTRAVENOUS SOLUTION RX-7364 CDM J0209 HCPCS 250 RC 60267-0705-50 NDC inpatient 50 ML 378 378 UNITED HEALTHCARE (COMMERCIAL) [3081199] UNITED HEALTHCARE 87726 [308119901] 234.36 percent of total billed charges 234.36 359.1 Technical (Hospital) Services SODIUM THIOSULFATE 12.5 GRAM/50 ML (250 MG/ML) INTRAVENOUS SOLUTION RX-7364 CDM J0209 HCPCS 250 RC 60267-0705-50 NDC outpatient 50 ML 378 378 UNITED HEALTHCARE (COMMERCIAL) [3081199] UNITED HEALTHCARE 87726 [308119901] 234.36 percent of total billed charges 234.36 359.1 Technical (Hospital) Services SODIUM THIOSULFATE 12.5 GRAM/50 ML (250 MG/ML) INTRAVENOUS SOLUTION RX-7364 CDM J0209 HCPCS 250 RC 60267-0705-50 NDC outpatient 50 ML 378 378 BLUE CROSS BLUE SHIELD WELLMARK SB889 [3081026] BCBS WYOMING [308102603] 359.1 percent of total billed charges 234.36 359.1 Technical (Hospital) Services SODIUM THIOSULFATE 12.5 GRAM/50 ML (250 MG/ML) INTRAVENOUS SOLUTION RX-7364 CDM J0209 HCPCS 250 RC 60267-0705-50 NDC outpatient 50 ML 378 378 HEALTHPARTNERS SX009 HEALTHPARTNERS 302.4 percent of total billed charges 234.36 359.1 Technical (Hospital) Services SODIUM THIOSULFATE 12.5 GRAM/50 ML (250 MG/ML) INTRAVENOUS SOLUTION RX-7364 CDM J0209 HCPCS 250 RC 60267-0705-50 NDC outpatient 50 ML 378 378 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES PPO [308136801] 302.4 percent of total billed charges 234.36 359.1 Technical (Hospital) Services SODIUM THIOSULFATE 12.5 GRAM/50 ML (250 MG/ML) INTRAVENOUS SOLUTION RX-7364 CDM J0209 HCPCS 250 RC 60267-0705-50 NDC outpatient 50 ML 378 378 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES EPO [308136803] 302.4 percent of total billed charges 234.36 359.1 Technical (Hospital) Services SODIUM THIOSULFATE 12.5 GRAM/50 ML (250 MG/ML) INTRAVENOUS SOLUTION RX-7364 CDM J0209 HCPCS 250 RC 60267-0705-50 NDC outpatient 50 ML 378 378 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES HDHP [308136802] 302.4 percent of total billed charges 234.36 359.1 Technical (Hospital) Services SODIUM THIOSULFATE 12.5 GRAM/50 ML (250 MG/ML) INTRAVENOUS SOLUTION RX-7364 CDM J0209 HCPCS 250 RC 60267-0705-50 NDC outpatient 50 ML 378 378 CIGNA 62308 [3081051] CIGNA STATE OF WYOMING [308105107] 302.4 percent of total billed charges 234.36 359.1 Technical (Hospital) Services SODIUM THIOSULFATE 12.5 GRAM/50 ML (250 MG/ML) INTRAVENOUS SOLUTION RX-7364 CDM J0209 HCPCS 250 RC 60267-0705-50 NDC outpatient 50 ML 378 378 CIGNA 62308 [3081051] CIGNA 62308 [308105105] 302.4 percent of total billed charges 234.36 359.1 Technical (Hospital) Services SODIUM THIOSULFATE 12.5 GRAM/50 ML (250 MG/ML) INTRAVENOUS SOLUTION RX-7364 CDM J0209 HCPCS 250 RC 60267-0705-50 NDC outpatient 50 ML 378 378 MULTIPLAN INC 34080 [3081285] MULTIPLAN INC [308128501] 359.1 percent of total billed charges 234.36 359.1 Technical (Hospital) Services SODIUM THIOSULFATE 12.5 GRAM/50 ML (250 MG/ML) INTRAVENOUS SOLUTION RX-7364 CDM J0209 HCPCS 250 RC 60267-0705-50 NDC outpatient 50 ML 378 378 MEDICA (COMMERCIAL) 94265 [3081118] MEDICA CLAIMS [308111801] 340.2 percent of total billed charges 234.36 359.1 Technical (Hospital) Services EPINEPHRINE 1 MG/ML (1 ML) INJECTION SOLUTION RX-2850 CDM J0171 HCPCS 636 RC 42023-0159-01 NDC inpatient 1 ML 84.96 84.96 CIGNA 62308 [3081051] CIGNA 62308 [308105105] 67.27 percent of total billed charges 52.68 80.71 Technical (Hospital) Services EPINEPHRINE 1 MG/ML (1 ML) INJECTION SOLUTION RX-2850 CDM J0171 HCPCS 636 RC 42023-0159-01 NDC inpatient 1 ML 84.96 84.96 CIGNA 62308 [3081051] CIGNA STATE OF WYOMING [308105107] 67.27 percent of total billed charges 52.68 80.71 Technical (Hospital) Services EPINEPHRINE 1 MG/ML (1 ML) INJECTION SOLUTION RX-2850 CDM J0171 HCPCS 636 RC 42023-0159-01 NDC inpatient 1 ML 84.96 84.96 UNITED HEALTHCARE (COMMERCIAL) [3081199] UNITED HEALTHCARE 87726 [308119901] 52.68 percent of total billed charges 52.68 80.71 Technical (Hospital) Services EPINEPHRINE 1 MG/ML (1 ML) INJECTION SOLUTION RX-2850 CDM J0171 HCPCS 636 RC 42023-0159-01 NDC inpatient 1 ML 84.96 84.96 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES EPO [308136803] 67.27 percent of total billed charges 52.68 80.71 Technical (Hospital) Services EPINEPHRINE 1 MG/ML (1 ML) INJECTION SOLUTION RX-2850 CDM J0171 HCPCS 636 RC 42023-0159-01 NDC inpatient 1 ML 84.96 84.96 BLUE CROSS BLUE SHIELD WELLMARK SB889 [3081026] BCBS WYOMING [308102603] 80.71 percent of total billed charges 52.68 80.71 Technical (Hospital) Services EPINEPHRINE 1 MG/ML (1 ML) INJECTION SOLUTION RX-2850 CDM J0171 HCPCS 636 RC 42023-0159-01 NDC inpatient 1 ML 84.96 84.96 MULTIPLAN INC 34080 [3081285] MULTIPLAN INC [308128501] 80.71 percent of total billed charges 52.68 80.71 Technical (Hospital) Services EPINEPHRINE 1 MG/ML (1 ML) INJECTION SOLUTION RX-2850 CDM J0171 HCPCS 636 RC 42023-0159-01 NDC inpatient 1 ML 84.96 84.96 MEDICA (COMMERCIAL) 94265 [3081118] MEDICA CLAIMS [308111801] 76.46 percent of total billed charges 52.68 80.71 Technical (Hospital) Services EPINEPHRINE 1 MG/ML (1 ML) INJECTION SOLUTION RX-2850 CDM J0171 HCPCS 636 RC 42023-0159-01 NDC inpatient 1 ML 84.96 84.96 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES PPO [308136801] 67.27 percent of total billed charges 52.68 80.71 Technical (Hospital) Services EPINEPHRINE 1 MG/ML (1 ML) INJECTION SOLUTION RX-2850 CDM J0171 HCPCS 636 RC 42023-0159-01 NDC inpatient 1 ML 84.96 84.96 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES HDHP [308136802] 67.27 percent of total billed charges 52.68 80.71 Technical (Hospital) Services EPINEPHRINE 1 MG/ML (1 ML) INJECTION SOLUTION RX-2850 CDM J0171 HCPCS 636 RC 42023-0159-01 NDC inpatient 1 ML 84.96 84.96 HEALTHPARTNERS SX009 HEALTHPARTNERS 67.27 percent of total billed charges 52.68 80.71 Technical (Hospital) Services EPINEPHRINE 1 MG/ML (1 ML) INJECTION SOLUTION RX-2850 CDM J0171 HCPCS 636 RC 42023-0159-01 NDC outpatient 1 ML 84.96 84.96 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES EPO [308136803] 67.97 percent of total billed charges 52.68 80.71 Technical (Hospital) Services EPINEPHRINE 1 MG/ML (1 ML) INJECTION SOLUTION RX-2850 CDM J0171 HCPCS 636 RC 42023-0159-01 NDC outpatient 1 ML 84.96 84.96 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES HDHP [308136802] 67.97 percent of total billed charges 52.68 80.71 Technical (Hospital) Services EPINEPHRINE 1 MG/ML (1 ML) INJECTION SOLUTION RX-2850 CDM J0171 HCPCS 636 RC 42023-0159-01 NDC outpatient 1 ML 84.96 84.96 HEALTHPARTNERS SX009 HEALTHPARTNERS 67.97 percent of total billed charges 52.68 80.71 Technical (Hospital) Services EPINEPHRINE 1 MG/ML (1 ML) INJECTION SOLUTION RX-2850 CDM J0171 HCPCS 636 RC 42023-0159-01 NDC outpatient 1 ML 84.96 84.96 MULTIPLAN INC 34080 [3081285] MULTIPLAN INC [308128501] 80.71 percent of total billed charges 52.68 80.71 Technical (Hospital) Services EPINEPHRINE 1 MG/ML (1 ML) INJECTION SOLUTION RX-2850 CDM J0171 HCPCS 636 RC 42023-0159-01 NDC outpatient 1 ML 84.96 84.96 UNITED HEALTHCARE (COMMERCIAL) [3081199] UNITED HEALTHCARE 87726 [308119901] 52.68 percent of total billed charges 52.68 80.71 Technical (Hospital) Services EPINEPHRINE 1 MG/ML (1 ML) INJECTION SOLUTION RX-2850 CDM J0171 HCPCS 636 RC 42023-0159-01 NDC outpatient 1 ML 84.96 84.96 CIGNA 62308 [3081051] CIGNA 62308 [308105105] 67.97 percent of total billed charges 52.68 80.71 Technical (Hospital) Services EPINEPHRINE 1 MG/ML (1 ML) INJECTION SOLUTION RX-2850 CDM J0171 HCPCS 636 RC 42023-0159-01 NDC outpatient 1 ML 84.96 84.96 CIGNA 62308 [3081051] CIGNA STATE OF WYOMING [308105107] 67.97 percent of total billed charges 52.68 80.71 Technical (Hospital) Services EPINEPHRINE 1 MG/ML (1 ML) INJECTION SOLUTION RX-2850 CDM J0171 HCPCS 636 RC 42023-0159-01 NDC outpatient 1 ML 84.96 84.96 MEDICA (COMMERCIAL) 94265 [3081118] MEDICA CLAIMS [308111801] 76.46 percent of total billed charges 52.68 80.71 Technical (Hospital) Services EPINEPHRINE 1 MG/ML (1 ML) INJECTION SOLUTION RX-2850 CDM J0171 HCPCS 636 RC 42023-0159-01 NDC outpatient 1 ML 84.96 84.96 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES PPO [308136801] 67.97 percent of total billed charges 52.68 80.71 Technical (Hospital) Services EPINEPHRINE 1 MG/ML (1 ML) INJECTION SOLUTION RX-2850 CDM J0171 HCPCS 636 RC 42023-0159-01 NDC outpatient 1 ML 84.96 84.96 BLUE CROSS BLUE SHIELD WELLMARK SB889 [3081026] BCBS WYOMING [308102603] 80.71 percent of total billed charges 52.68 80.71 Technical (Hospital) Services EPINEPHRINE 1 MG/ML INJECTION SOLUTION RX-97788 CDM J0171 HCPCS 636 RC 42023-0168-01 NDC outpatient 30 ML 650.56 650.56 BLUE CROSS BLUE SHIELD WELLMARK SB889 [3081026] BCBS WYOMING [308102603] 618.03 percent of total billed charges 403.35 618.03 Technical (Hospital) Services EPINEPHRINE 1 MG/ML INJECTION SOLUTION RX-97788 CDM J0171 HCPCS 636 RC 42023-0168-01 NDC outpatient 30 ML 650.56 650.56 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES PPO [308136801] 520.45 percent of total billed charges 403.35 618.03 Technical (Hospital) Services EPINEPHRINE 1 MG/ML INJECTION SOLUTION RX-97788 CDM J0171 HCPCS 636 RC 42023-0168-01 NDC outpatient 30 ML 650.56 650.56 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES HDHP [308136802] 520.45 percent of total billed charges 403.35 618.03 Technical (Hospital) Services EPINEPHRINE 1 MG/ML INJECTION SOLUTION RX-97788 CDM J0171 HCPCS 636 RC 42023-0168-01 NDC outpatient 30 ML 650.56 650.56 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES EPO [308136803] 520.45 percent of total billed charges 403.35 618.03 Technical (Hospital) Services EPINEPHRINE 1 MG/ML INJECTION SOLUTION RX-97788 CDM J0171 HCPCS 636 RC 42023-0168-01 NDC outpatient 30 ML 650.56 650.56 MEDICA (COMMERCIAL) 94265 [3081118] MEDICA CLAIMS [308111801] 585.5 percent of total billed charges 403.35 618.03 Technical (Hospital) Services EPINEPHRINE 1 MG/ML INJECTION SOLUTION RX-97788 CDM J0171 HCPCS 636 RC 42023-0168-01 NDC outpatient 30 ML 650.56 650.56 MULTIPLAN INC 34080 [3081285] MULTIPLAN INC [308128501] 618.03 percent of total billed charges 403.35 618.03 Technical (Hospital) Services EPINEPHRINE 1 MG/ML INJECTION SOLUTION RX-97788 CDM J0171 HCPCS 636 RC 42023-0168-01 NDC outpatient 30 ML 650.56 650.56 UNITED HEALTHCARE (COMMERCIAL) [3081199] UNITED HEALTHCARE 87726 [308119901] 403.35 percent of total billed charges 403.35 618.03 Technical (Hospital) Services EPINEPHRINE 1 MG/ML INJECTION SOLUTION RX-97788 CDM J0171 HCPCS 636 RC 42023-0168-01 NDC outpatient 30 ML 650.56 650.56 HEALTHPARTNERS SX009 HEALTHPARTNERS 520.45 percent of total billed charges 403.35 618.03 Technical (Hospital) Services EPINEPHRINE 1 MG/ML INJECTION SOLUTION RX-97788 CDM J0171 HCPCS 636 RC 42023-0168-01 NDC outpatient 30 ML 650.56 650.56 CIGNA 62308 [3081051] CIGNA 62308 [308105105] 520.45 percent of total billed charges 403.35 618.03 Technical (Hospital) Services EPINEPHRINE 1 MG/ML INJECTION SOLUTION RX-97788 CDM J0171 HCPCS 636 RC 42023-0168-01 NDC outpatient 30 ML 650.56 650.56 CIGNA 62308 [3081051] CIGNA STATE OF WYOMING [308105107] 520.45 percent of total billed charges 403.35 618.03 Technical (Hospital) Services EPINEPHRINE 1 MG/ML INJECTION SOLUTION RX-97788 CDM J0171 HCPCS 636 RC 42023-0168-01 NDC inpatient 30 ML 650.56 650.56 MULTIPLAN INC 34080 [3081285] MULTIPLAN INC [308128501] 618.03 percent of total billed charges 403.35 618.03 Technical (Hospital) Services EPINEPHRINE 1 MG/ML INJECTION SOLUTION RX-97788 CDM J0171 HCPCS 636 RC 42023-0168-01 NDC inpatient 30 ML 650.56 650.56 MEDICA (COMMERCIAL) 94265 [3081118] MEDICA CLAIMS [308111801] 585.5 percent of total billed charges 403.35 618.03 Technical (Hospital) Services EPINEPHRINE 1 MG/ML INJECTION SOLUTION RX-97788 CDM J0171 HCPCS 636 RC 42023-0168-01 NDC inpatient 30 ML 650.56 650.56 HEALTHPARTNERS SX009 HEALTHPARTNERS 515.11 percent of total billed charges 403.35 618.03 Technical (Hospital) Services EPINEPHRINE 1 MG/ML INJECTION SOLUTION RX-97788 CDM J0171 HCPCS 636 RC 42023-0168-01 NDC inpatient 30 ML 650.56 650.56 BLUE CROSS BLUE SHIELD WELLMARK SB889 [3081026] BCBS WYOMING [308102603] 618.03 percent of total billed charges 403.35 618.03 Technical (Hospital) Services EPINEPHRINE 1 MG/ML INJECTION SOLUTION RX-97788 CDM J0171 HCPCS 636 RC 42023-0168-01 NDC inpatient 30 ML 650.56 650.56 UNITED HEALTHCARE (COMMERCIAL) [3081199] UNITED HEALTHCARE 87726 [308119901] 403.35 percent of total billed charges 403.35 618.03 Technical (Hospital) Services EPINEPHRINE 1 MG/ML INJECTION SOLUTION RX-97788 CDM J0171 HCPCS 636 RC 42023-0168-01 NDC inpatient 30 ML 650.56 650.56 CIGNA 62308 [3081051] CIGNA 62308 [308105105] 515.11 percent of total billed charges 403.35 618.03 Technical (Hospital) Services EPINEPHRINE 1 MG/ML INJECTION SOLUTION RX-97788 CDM J0171 HCPCS 636 RC 42023-0168-01 NDC inpatient 30 ML 650.56 650.56 CIGNA 62308 [3081051] CIGNA STATE OF WYOMING [308105107] 515.11 percent of total billed charges 403.35 618.03 Technical (Hospital) Services EPINEPHRINE 1 MG/ML INJECTION SOLUTION RX-97788 CDM J0171 HCPCS 636 RC 42023-0168-01 NDC inpatient 30 ML 650.56 650.56 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES EPO [308136803] 515.11 percent of total billed charges 403.35 618.03 Technical (Hospital) Services EPINEPHRINE 1 MG/ML INJECTION SOLUTION RX-97788 CDM J0171 HCPCS 636 RC 42023-0168-01 NDC inpatient 30 ML 650.56 650.56 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES HDHP [308136802] 515.11 percent of total billed charges 403.35 618.03 Technical (Hospital) Services EPINEPHRINE 1 MG/ML INJECTION SOLUTION RX-97788 CDM J0171 HCPCS 636 RC 42023-0168-01 NDC inpatient 30 ML 650.56 650.56 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES PPO [308136801] 515.11 percent of total billed charges 403.35 618.03 Technical (Hospital) Services ADENOSINE 3 MG/ML INTRAVENOUS SYRINGE RX-123122 CDM J0153 HCPCS 636 RC 25021-0301-67 NDC outpatient 2 ML 104.5 104.5 UNITED HEALTHCARE (COMMERCIAL) [3081199] UNITED HEALTHCARE 87726 [308119901] 64.79 percent of total billed charges 64.79 99.28 Technical (Hospital) Services ADENOSINE 3 MG/ML INTRAVENOUS SYRINGE RX-123122 CDM J0153 HCPCS 636 RC 25021-0301-67 NDC outpatient 2 ML 104.5 104.5 HEALTHPARTNERS SX009 HEALTHPARTNERS 83.6 percent of total billed charges 64.79 99.28 Technical (Hospital) Services ADENOSINE 3 MG/ML INTRAVENOUS SYRINGE RX-123122 CDM J0153 HCPCS 636 RC 25021-0301-67 NDC outpatient 2 ML 104.5 104.5 MULTIPLAN INC 34080 [3081285] MULTIPLAN INC [308128501] 99.28 percent of total billed charges 64.79 99.28 Technical (Hospital) Services ADENOSINE 3 MG/ML INTRAVENOUS SYRINGE RX-123122 CDM J0153 HCPCS 636 RC 25021-0301-67 NDC outpatient 2 ML 104.5 104.5 MEDICA (COMMERCIAL) 94265 [3081118] MEDICA CLAIMS [308111801] 94.05 percent of total billed charges 64.79 99.28 Technical (Hospital) Services ADENOSINE 3 MG/ML INTRAVENOUS SYRINGE RX-123122 CDM J0153 HCPCS 636 RC 25021-0301-67 NDC outpatient 2 ML 104.5 104.5 CIGNA 62308 [3081051] CIGNA 62308 [308105105] 83.6 percent of total billed charges 64.79 99.28 Technical (Hospital) Services ADENOSINE 3 MG/ML INTRAVENOUS SYRINGE RX-123122 CDM J0153 HCPCS 636 RC 25021-0301-67 NDC outpatient 2 ML 104.5 104.5 CIGNA 62308 [3081051] CIGNA STATE OF WYOMING [308105107] 83.6 percent of total billed charges 64.79 99.28 Technical (Hospital) Services ADENOSINE 3 MG/ML INTRAVENOUS SYRINGE RX-123122 CDM J0153 HCPCS 636 RC 25021-0301-67 NDC outpatient 2 ML 104.5 104.5 BLUE CROSS BLUE SHIELD WELLMARK SB889 [3081026] BCBS WYOMING [308102603] 99.28 percent of total billed charges 64.79 99.28 Technical (Hospital) Services ADENOSINE 3 MG/ML INTRAVENOUS SYRINGE RX-123122 CDM J0153 HCPCS 636 RC 25021-0301-67 NDC outpatient 2 ML 104.5 104.5 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES HDHP [308136802] 83.6 percent of total billed charges 64.79 99.28 Technical (Hospital) Services ADENOSINE 3 MG/ML INTRAVENOUS SYRINGE RX-123122 CDM J0153 HCPCS 636 RC 25021-0301-67 NDC outpatient 2 ML 104.5 104.5 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES PPO [308136801] 83.6 percent of total billed charges 64.79 99.28 Technical (Hospital) Services ADENOSINE 3 MG/ML INTRAVENOUS SYRINGE RX-123122 CDM J0153 HCPCS 636 RC 25021-0301-67 NDC outpatient 2 ML 104.5 104.5 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES EPO [308136803] 83.6 percent of total billed charges 64.79 99.28 Technical (Hospital) Services ADENOSINE 3 MG/ML INTRAVENOUS SYRINGE RX-123122 CDM J0153 HCPCS 636 RC 25021-0301-67 NDC inpatient 2 ML 104.5 104.5 CIGNA 62308 [3081051] CIGNA 62308 [308105105] 82.74 percent of total billed charges 64.79 99.28 Technical (Hospital) Services ADENOSINE 3 MG/ML INTRAVENOUS SYRINGE RX-123122 CDM J0153 HCPCS 636 RC 25021-0301-67 NDC inpatient 2 ML 104.5 104.5 CIGNA 62308 [3081051] CIGNA STATE OF WYOMING [308105107] 82.74 percent of total billed charges 64.79 99.28 Technical (Hospital) Services ADENOSINE 3 MG/ML INTRAVENOUS SYRINGE RX-123122 CDM J0153 HCPCS 636 RC 25021-0301-67 NDC inpatient 2 ML 104.5 104.5 BLUE CROSS BLUE SHIELD WELLMARK SB889 [3081026] BCBS WYOMING [308102603] 99.28 percent of total billed charges 64.79 99.28 Technical (Hospital) Services ADENOSINE 3 MG/ML INTRAVENOUS SYRINGE RX-123122 CDM J0153 HCPCS 636 RC 25021-0301-67 NDC inpatient 2 ML 104.5 104.5 UNITED HEALTHCARE (COMMERCIAL) [3081199] UNITED HEALTHCARE 87726 [308119901] 64.79 percent of total billed charges 64.79 99.28 Technical (Hospital) Services ADENOSINE 3 MG/ML INTRAVENOUS SYRINGE RX-123122 CDM J0153 HCPCS 636 RC 25021-0301-67 NDC inpatient 2 ML 104.5 104.5 MULTIPLAN INC 34080 [3081285] MULTIPLAN INC [308128501] 99.28 percent of total billed charges 64.79 99.28 Technical (Hospital) Services ADENOSINE 3 MG/ML INTRAVENOUS SYRINGE RX-123122 CDM J0153 HCPCS 636 RC 25021-0301-67 NDC inpatient 2 ML 104.5 104.5 MEDICA (COMMERCIAL) 94265 [3081118] MEDICA CLAIMS [308111801] 94.05 percent of total billed charges 64.79 99.28 Technical (Hospital) Services ADENOSINE 3 MG/ML INTRAVENOUS SYRINGE RX-123122 CDM J0153 HCPCS 636 RC 25021-0301-67 NDC inpatient 2 ML 104.5 104.5 HEALTHPARTNERS SX009 HEALTHPARTNERS 82.74 percent of total billed charges 64.79 99.28 Technical (Hospital) Services ADENOSINE 3 MG/ML INTRAVENOUS SYRINGE RX-123122 CDM J0153 HCPCS 636 RC 25021-0301-67 NDC inpatient 2 ML 104.5 104.5 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES EPO [308136803] 82.74 percent of total billed charges 64.79 99.28 Technical (Hospital) Services ADENOSINE 3 MG/ML INTRAVENOUS SYRINGE RX-123122 CDM J0153 HCPCS 636 RC 25021-0301-67 NDC inpatient 2 ML 104.5 104.5 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES HDHP [308136802] 82.74 percent of total billed charges 64.79 99.28 Technical (Hospital) Services ADENOSINE 3 MG/ML INTRAVENOUS SYRINGE RX-123122 CDM J0153 HCPCS 636 RC 25021-0301-67 NDC inpatient 2 ML 104.5 104.5 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES PPO [308136801] 82.74 percent of total billed charges 64.79 99.28 Technical (Hospital) Services ADENOSINE 3 MG/ML INTRAVENOUS SOLUTION RX-38703 CDM J0153 HCPCS 636 RC 63323-0651-02 NDC outpatient 2 ML 80.95 80.95 BLUE CROSS BLUE SHIELD WELLMARK SB889 [3081026] BCBS WYOMING [308102603] 76.9 percent of total billed charges 50.19 76.9 Technical (Hospital) Services ADENOSINE 3 MG/ML INTRAVENOUS SOLUTION RX-38703 CDM J0153 HCPCS 636 RC 63323-0651-02 NDC outpatient 2 ML 80.95 80.95 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES EPO [308136803] 64.76 percent of total billed charges 50.19 76.9 Technical (Hospital) Services ADENOSINE 3 MG/ML INTRAVENOUS SOLUTION RX-38703 CDM J0153 HCPCS 636 RC 63323-0651-02 NDC outpatient 2 ML 80.95 80.95 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES HDHP [308136802] 64.76 percent of total billed charges 50.19 76.9 Technical (Hospital) Services ADENOSINE 3 MG/ML INTRAVENOUS SOLUTION RX-38703 CDM J0153 HCPCS 636 RC 63323-0651-02 NDC outpatient 2 ML 80.95 80.95 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES PPO [308136801] 64.76 percent of total billed charges 50.19 76.9 Technical (Hospital) Services ADENOSINE 3 MG/ML INTRAVENOUS SOLUTION RX-38703 CDM J0153 HCPCS 636 RC 63323-0651-02 NDC outpatient 2 ML 80.95 80.95 UNITED HEALTHCARE (COMMERCIAL) [3081199] UNITED HEALTHCARE 87726 [308119901] 50.19 percent of total billed charges 50.19 76.9 Technical (Hospital) Services ADENOSINE 3 MG/ML INTRAVENOUS SOLUTION RX-38703 CDM J0153 HCPCS 636 RC 63323-0651-02 NDC outpatient 2 ML 80.95 80.95 HEALTHPARTNERS SX009 HEALTHPARTNERS 64.76 percent of total billed charges 50.19 76.9 Technical (Hospital) Services ADENOSINE 3 MG/ML INTRAVENOUS SOLUTION RX-38703 CDM J0153 HCPCS 636 RC 63323-0651-02 NDC inpatient 2 ML 80.95 80.95 CIGNA 62308 [3081051] CIGNA 62308 [308105105] 64.1 percent of total billed charges 50.19 76.9 Technical (Hospital) Services ADENOSINE 3 MG/ML INTRAVENOUS SOLUTION RX-38703 CDM J0153 HCPCS 636 RC 63323-0651-02 NDC inpatient 2 ML 80.95 80.95 CIGNA 62308 [3081051] CIGNA STATE OF WYOMING [308105107] 64.1 percent of total billed charges 50.19 76.9 Technical (Hospital) Services ADENOSINE 3 MG/ML INTRAVENOUS SOLUTION RX-38703 CDM J0153 HCPCS 636 RC 63323-0651-02 NDC inpatient 2 ML 80.95 80.95 BLUE CROSS BLUE SHIELD WELLMARK SB889 [3081026] BCBS WYOMING [308102603] 76.9 percent of total billed charges 50.19 76.9 Technical (Hospital) Services ADENOSINE 3 MG/ML INTRAVENOUS SOLUTION RX-38703 CDM J0153 HCPCS 636 RC 63323-0651-02 NDC inpatient 2 ML 80.95 80.95 UNITED HEALTHCARE (COMMERCIAL) [3081199] UNITED HEALTHCARE 87726 [308119901] 50.19 percent of total billed charges 50.19 76.9 Technical (Hospital) Services ADENOSINE 3 MG/ML INTRAVENOUS SOLUTION RX-38703 CDM J0153 HCPCS 636 RC 63323-0651-02 NDC inpatient 2 ML 80.95 80.95 MULTIPLAN INC 34080 [3081285] MULTIPLAN INC [308128501] 76.9 percent of total billed charges 50.19 76.9 Technical (Hospital) Services ADENOSINE 3 MG/ML INTRAVENOUS SOLUTION RX-38703 CDM J0153 HCPCS 636 RC 63323-0651-02 NDC inpatient 2 ML 80.95 80.95 MEDICA (COMMERCIAL) 94265 [3081118] MEDICA CLAIMS [308111801] 72.86 percent of total billed charges 50.19 76.9 Technical (Hospital) Services ADENOSINE 3 MG/ML INTRAVENOUS SOLUTION RX-38703 CDM J0153 HCPCS 636 RC 63323-0651-02 NDC inpatient 2 ML 80.95 80.95 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES EPO [308136803] 64.1 percent of total billed charges 50.19 76.9 Technical (Hospital) Services ADENOSINE 3 MG/ML INTRAVENOUS SOLUTION RX-38703 CDM J0153 HCPCS 636 RC 63323-0651-02 NDC inpatient 2 ML 80.95 80.95 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES HDHP [308136802] 64.1 percent of total billed charges 50.19 76.9 Technical (Hospital) Services ADENOSINE 3 MG/ML INTRAVENOUS SOLUTION RX-38703 CDM J0153 HCPCS 636 RC 63323-0651-02 NDC inpatient 2 ML 80.95 80.95 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES PPO [308136801] 64.1 percent of total billed charges 50.19 76.9 Technical (Hospital) Services ADENOSINE 3 MG/ML INTRAVENOUS SOLUTION RX-38703 CDM J0153 HCPCS 636 RC 63323-0651-02 NDC inpatient 2 ML 80.95 80.95 HEALTHPARTNERS SX009 HEALTHPARTNERS 64.1 percent of total billed charges 50.19 76.9 Technical (Hospital) Services ADENOSINE 3 MG/ML INTRAVENOUS SOLUTION RX-38703 CDM J0153 HCPCS 636 RC 63323-0651-02 NDC outpatient 2 ML 80.95 80.95 MEDICA (COMMERCIAL) 94265 [3081118] MEDICA CLAIMS [308111801] 72.86 percent of total billed charges 50.19 76.9 Technical (Hospital) Services ADENOSINE 3 MG/ML INTRAVENOUS SOLUTION RX-38703 CDM J0153 HCPCS 636 RC 63323-0651-02 NDC outpatient 2 ML 80.95 80.95 CIGNA 62308 [3081051] CIGNA 62308 [308105105] 64.76 percent of total billed charges 50.19 76.9 Technical (Hospital) Services ADENOSINE 3 MG/ML INTRAVENOUS SOLUTION RX-38703 CDM J0153 HCPCS 636 RC 63323-0651-02 NDC outpatient 2 ML 80.95 80.95 CIGNA 62308 [3081051] CIGNA STATE OF WYOMING [308105107] 64.76 percent of total billed charges 50.19 76.9 Technical (Hospital) Services ADENOSINE 3 MG/ML INTRAVENOUS SOLUTION RX-38703 CDM J0153 HCPCS 636 RC 63323-0651-02 NDC outpatient 2 ML 80.95 80.95 MULTIPLAN INC 34080 [3081285] MULTIPLAN INC [308128501] 76.9 percent of total billed charges 50.19 76.9 Technical (Hospital) Services ACETYLCYSTEINE 200 MG/ML (20 %) INTRAVENOUS SOLUTION RX-38303 CDM J0132 HCPCS 636 RC 63323-0963-21 NDC inpatient 3 ML 107.3 107.3 MULTIPLAN INC 34080 [3081285] MULTIPLAN INC [308128501] 101.94 percent of total billed charges 66.53 101.94 Technical (Hospital) Services ACETYLCYSTEINE 200 MG/ML (20 %) INTRAVENOUS SOLUTION RX-38303 CDM J0132 HCPCS 636 RC 63323-0963-21 NDC inpatient 3 ML 107.3 107.3 MEDICA (COMMERCIAL) 94265 [3081118] MEDICA CLAIMS [308111801] 96.57 percent of total billed charges 66.53 101.94 Technical (Hospital) Services ACETYLCYSTEINE 200 MG/ML (20 %) INTRAVENOUS SOLUTION RX-38303 CDM J0132 HCPCS 636 RC 63323-0963-21 NDC inpatient 3 ML 107.3 107.3 BLUE CROSS BLUE SHIELD WELLMARK SB889 [3081026] BCBS WYOMING [308102603] 101.94 percent of total billed charges 66.53 101.94 Technical (Hospital) Services ACETYLCYSTEINE 200 MG/ML (20 %) INTRAVENOUS SOLUTION RX-38303 CDM J0132 HCPCS 636 RC 63323-0963-21 NDC inpatient 3 ML 107.3 107.3 UNITED HEALTHCARE (COMMERCIAL) [3081199] UNITED HEALTHCARE 87726 [308119901] 66.53 percent of total billed charges 66.53 101.94 Technical (Hospital) Services ACETYLCYSTEINE 200 MG/ML (20 %) INTRAVENOUS SOLUTION RX-38303 CDM J0132 HCPCS 636 RC 63323-0963-21 NDC inpatient 3 ML 107.3 107.3 CIGNA 62308 [3081051] CIGNA 62308 [308105105] 84.96 percent of total billed charges 66.53 101.94 Technical (Hospital) Services ACETYLCYSTEINE 200 MG/ML (20 %) INTRAVENOUS SOLUTION RX-38303 CDM J0132 HCPCS 636 RC 63323-0963-21 NDC inpatient 3 ML 107.3 107.3 CIGNA 62308 [3081051] CIGNA STATE OF WYOMING [308105107] 84.96 percent of total billed charges 66.53 101.94 Technical (Hospital) Services ACETYLCYSTEINE 200 MG/ML (20 %) INTRAVENOUS SOLUTION RX-38303 CDM J0132 HCPCS 636 RC 63323-0963-21 NDC inpatient 3 ML 107.3 107.3 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES EPO [308136803] 84.96 percent of total billed charges 66.53 101.94 Technical (Hospital) Services ACETYLCYSTEINE 200 MG/ML (20 %) INTRAVENOUS SOLUTION RX-38303 CDM J0132 HCPCS 636 RC 63323-0963-21 NDC inpatient 3 ML 107.3 107.3 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES HDHP [308136802] 84.96 percent of total billed charges 66.53 101.94 Technical (Hospital) Services ACETYLCYSTEINE 200 MG/ML (20 %) INTRAVENOUS SOLUTION RX-38303 CDM J0132 HCPCS 636 RC 63323-0963-21 NDC inpatient 3 ML 107.3 107.3 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES PPO [308136801] 84.96 percent of total billed charges 66.53 101.94 Technical (Hospital) Services ACETYLCYSTEINE 200 MG/ML (20 %) INTRAVENOUS SOLUTION RX-38303 CDM J0132 HCPCS 636 RC 63323-0963-21 NDC inpatient 3 ML 107.3 107.3 HEALTHPARTNERS SX009 HEALTHPARTNERS 84.96 percent of total billed charges 66.53 101.94 Technical (Hospital) Services ACETYLCYSTEINE 200 MG/ML (20 %) INTRAVENOUS SOLUTION RX-38303 CDM J0132 HCPCS 636 RC 63323-0963-21 NDC outpatient 3 ML 107.3 107.3 MEDICA (COMMERCIAL) 94265 [3081118] MEDICA CLAIMS [308111801] 96.57 percent of total billed charges 66.53 101.94 Technical (Hospital) Services ACETYLCYSTEINE 200 MG/ML (20 %) INTRAVENOUS SOLUTION RX-38303 CDM J0132 HCPCS 636 RC 63323-0963-21 NDC outpatient 3 ML 107.3 107.3 MULTIPLAN INC 34080 [3081285] MULTIPLAN INC [308128501] 101.94 percent of total billed charges 66.53 101.94 Technical (Hospital) Services ACETYLCYSTEINE 200 MG/ML (20 %) INTRAVENOUS SOLUTION RX-38303 CDM J0132 HCPCS 636 RC 63323-0963-21 NDC outpatient 3 ML 107.3 107.3 CIGNA 62308 [3081051] CIGNA 62308 [308105105] 85.84 percent of total billed charges 66.53 101.94 Technical (Hospital) Services ACETYLCYSTEINE 200 MG/ML (20 %) INTRAVENOUS SOLUTION RX-38303 CDM J0132 HCPCS 636 RC 63323-0963-21 NDC outpatient 3 ML 107.3 107.3 CIGNA 62308 [3081051] CIGNA STATE OF WYOMING [308105107] 85.84 percent of total billed charges 66.53 101.94 Technical (Hospital) Services ACETYLCYSTEINE 200 MG/ML (20 %) INTRAVENOUS SOLUTION RX-38303 CDM J0132 HCPCS 636 RC 63323-0963-21 NDC outpatient 3 ML 107.3 107.3 UNITED HEALTHCARE (COMMERCIAL) [3081199] UNITED HEALTHCARE 87726 [308119901] 66.53 percent of total billed charges 66.53 101.94 Technical (Hospital) Services ACETYLCYSTEINE 200 MG/ML (20 %) INTRAVENOUS SOLUTION RX-38303 CDM J0132 HCPCS 636 RC 63323-0963-21 NDC outpatient 3 ML 107.3 107.3 HEALTHPARTNERS SX009 HEALTHPARTNERS 85.84 percent of total billed charges 66.53 101.94 Technical (Hospital) Services ACETYLCYSTEINE 200 MG/ML (20 %) INTRAVENOUS SOLUTION RX-38303 CDM J0132 HCPCS 636 RC 63323-0963-21 NDC outpatient 3 ML 107.3 107.3 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES EPO [308136803] 85.84 percent of total billed charges 66.53 101.94 Technical (Hospital) Services ACETYLCYSTEINE 200 MG/ML (20 %) INTRAVENOUS SOLUTION RX-38303 CDM J0132 HCPCS 636 RC 63323-0963-21 NDC outpatient 3 ML 107.3 107.3 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES HDHP [308136802] 85.84 percent of total billed charges 66.53 101.94 Technical (Hospital) Services ACETYLCYSTEINE 200 MG/ML (20 %) INTRAVENOUS SOLUTION RX-38303 CDM J0132 HCPCS 636 RC 63323-0963-21 NDC outpatient 3 ML 107.3 107.3 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES PPO [308136801] 85.84 percent of total billed charges 66.53 101.94 Technical (Hospital) Services ACETYLCYSTEINE 200 MG/ML (20 %) INTRAVENOUS SOLUTION RX-38303 CDM J0132 HCPCS 636 RC 63323-0963-21 NDC outpatient 3 ML 107.3 107.3 BLUE CROSS BLUE SHIELD WELLMARK SB889 [3081026] BCBS WYOMING [308102603] 101.94 percent of total billed charges 66.53 101.94 Technical (Hospital) Services Trauma Resp W Activation Sprh PX-6840039000 CDM G0390 HCPCS 684 RC inpatient 1957 1957 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES PPO [308136801] 1549.55 percent of total billed charges 1213.34 1859.15 Technical (Hospital) Services Trauma Resp W Activation Sprh PX-6840039000 CDM G0390 HCPCS 684 RC inpatient 1957 1957 UNITED HEALTHCARE (COMMERCIAL) [3081199] UNITED HEALTHCARE 87726 [308119901] 1213.34 percent of total billed charges 1213.34 1859.15 Technical (Hospital) Services Trauma Resp W Activation Sprh PX-6840039000 CDM G0390 HCPCS 684 RC inpatient 1957 1957 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES HDHP [308136802] 1549.55 percent of total billed charges 1213.34 1859.15 Technical (Hospital) Services Trauma Resp W Activation Sprh PX-6840039000 CDM G0390 HCPCS 684 RC inpatient 1957 1957 BLUE CROSS BLUE SHIELD WELLMARK SB889 [3081026] BCBS WYOMING [308102603] 1859.15 percent of total billed charges 1213.34 1859.15 Technical (Hospital) Services Trauma Resp W Activation Sprh PX-6840039000 CDM G0390 HCPCS 684 RC inpatient 1957 1957 HEALTHPARTNERS SX009 HEALTHPARTNERS 1549.55 percent of total billed charges 1213.34 1859.15 Technical (Hospital) Services Trauma Resp W Activation Sprh PX-6840039000 CDM G0390 HCPCS 684 RC inpatient 1957 1957 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES EPO [308136803] 1549.55 percent of total billed charges 1213.34 1859.15 Technical (Hospital) Services Trauma Resp W Activation Sprh PX-6840039000 CDM G0390 HCPCS 684 RC inpatient 1957 1957 MEDICA (COMMERCIAL) 94265 [3081118] MEDICA CLAIMS [308111801] 1761.3 percent of total billed charges 1213.34 1859.15 Technical (Hospital) Services Trauma Resp W Activation Sprh PX-6840039000 CDM G0390 HCPCS 684 RC inpatient 1957 1957 MULTIPLAN INC 34080 [3081285] MULTIPLAN INC [308128501] 1859.15 percent of total billed charges 1213.34 1859.15 Technical (Hospital) Services Trauma Resp W Activation Sprh PX-6840039000 CDM G0390 HCPCS 684 RC inpatient 1957 1957 CIGNA 62308 [3081051] CIGNA 62308 [308105105] 1549.55 percent of total billed charges 1213.34 1859.15 Technical (Hospital) Services Trauma Resp W Activation Sprh PX-6840039000 CDM G0390 HCPCS 684 RC inpatient 1957 1957 CIGNA 62308 [3081051] CIGNA STATE OF WYOMING [308105107] 1549.55 percent of total billed charges 1213.34 1859.15 Technical (Hospital) Services Trauma Resp W Activation Sprh PX-6840039000 CDM G0390 HCPCS 684 RC outpatient 1957 1957 BLUE CROSS BLUE SHIELD WELLMARK SB889 [3081026] BCBS WYOMING [308102603] 1859.15 percent of total billed charges 1213.34 1859.15 Technical (Hospital) Services Trauma Resp W Activation Sprh PX-6840039000 CDM G0390 HCPCS 684 RC outpatient 1957 1957 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES HDHP [308136802] 1565.6 percent of total billed charges 1213.34 1859.15 Technical (Hospital) Services Trauma Resp W Activation Sprh PX-6840039000 CDM G0390 HCPCS 684 RC outpatient 1957 1957 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES EPO [308136803] 1565.6 percent of total billed charges 1213.34 1859.15 Technical (Hospital) Services Trauma Resp W Activation Sprh PX-6840039000 CDM G0390 HCPCS 684 RC outpatient 1957 1957 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES PPO [308136801] 1565.6 percent of total billed charges 1213.34 1859.15 Technical (Hospital) Services Trauma Resp W Activation Sprh PX-6840039000 CDM G0390 HCPCS 684 RC outpatient 1957 1957 HEALTHPARTNERS SX009 HEALTHPARTNERS 1565.6 percent of total billed charges 1213.34 1859.15 Technical (Hospital) Services Trauma Resp W Activation Sprh PX-6840039000 CDM G0390 HCPCS 684 RC outpatient 1957 1957 UNITED HEALTHCARE (COMMERCIAL) [3081199] UNITED HEALTHCARE 87726 [308119901] 1213.34 percent of total billed charges 1213.34 1859.15 Technical (Hospital) Services Trauma Resp W Activation Sprh PX-6840039000 CDM G0390 HCPCS 684 RC outpatient 1957 1957 MULTIPLAN INC 34080 [3081285] MULTIPLAN INC [308128501] 1859.15 percent of total billed charges 1213.34 1859.15 Technical (Hospital) Services Trauma Resp W Activation Sprh PX-6840039000 CDM G0390 HCPCS 684 RC outpatient 1957 1957 CIGNA 62308 [3081051] CIGNA 62308 [308105105] 1565.6 percent of total billed charges 1213.34 1859.15 Technical (Hospital) Services Trauma Resp W Activation Sprh PX-6840039000 CDM G0390 HCPCS 684 RC outpatient 1957 1957 CIGNA 62308 [3081051] CIGNA STATE OF WYOMING [308105107] 1565.6 percent of total billed charges 1213.34 1859.15 Technical (Hospital) Services Trauma Resp W Activation Sprh PX-6840039000 CDM G0390 HCPCS 684 RC outpatient 1957 1957 MEDICA (COMMERCIAL) 94265 [3081118] MEDICA CLAIMS [308111801] 1761.3 percent of total billed charges 1213.34 1859.15 Technical (Hospital) Services Sso Direct Admit PX-7620000500 CDM G0379 HCPCS 762 RC outpatient 500 500 CIGNA 62308 [3081051] CIGNA 62308 [308105105] 400 percent of total billed charges 310 475 Technical (Hospital) Services Sso Direct Admit PX-7620000500 CDM G0379 HCPCS 762 RC outpatient 500 500 CIGNA 62308 [3081051] CIGNA STATE OF WYOMING [308105107] 400 percent of total billed charges 310 475 Technical (Hospital) Services Sso Direct Admit PX-7620000500 CDM G0379 HCPCS 762 RC outpatient 500 500 MEDICA (COMMERCIAL) 94265 [3081118] MEDICA CLAIMS [308111801] 450 percent of total billed charges 310 475 Technical (Hospital) Services Sso Direct Admit PX-7620000500 CDM G0379 HCPCS 762 RC outpatient 500 500 MULTIPLAN INC 34080 [3081285] MULTIPLAN INC [308128501] 475 percent of total billed charges 310 475 Technical (Hospital) Services Sso Direct Admit PX-7620000500 CDM G0379 HCPCS 762 RC outpatient 500 500 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES PPO [308136801] 400 percent of total billed charges 310 475 Technical (Hospital) Services Sso Direct Admit PX-7620000500 CDM G0379 HCPCS 762 RC outpatient 500 500 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES HDHP [308136802] 400 percent of total billed charges 310 475 Technical (Hospital) Services Sso Direct Admit PX-7620000500 CDM G0379 HCPCS 762 RC outpatient 500 500 BLUE CROSS BLUE SHIELD WELLMARK SB889 [3081026] BCBS WYOMING [308102603] 475 percent of total billed charges 310 475 Technical (Hospital) Services Sso Direct Admit PX-7620000500 CDM G0379 HCPCS 762 RC outpatient 500 500 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES EPO [308136803] 400 percent of total billed charges 310 475 Technical (Hospital) Services Sso Direct Admit PX-7620000500 CDM G0379 HCPCS 762 RC outpatient 500 500 UNITED HEALTHCARE (COMMERCIAL) [3081199] UNITED HEALTHCARE 87726 [308119901] 310 percent of total billed charges 310 475 Technical (Hospital) Services Sso Direct Admit PX-7620000500 CDM G0379 HCPCS 762 RC outpatient 500 500 HEALTHPARTNERS SX009 HEALTHPARTNERS 400 percent of total billed charges 310 475 Technical (Hospital) Services Sso Direct Admit PX-7620000500 CDM G0379 HCPCS 762 RC inpatient 500 500 CIGNA 62308 [3081051] CIGNA 62308 [308105105] 395.9 percent of total billed charges 310 475 Technical (Hospital) Services Sso Direct Admit PX-7620000500 CDM G0379 HCPCS 762 RC inpatient 500 500 CIGNA 62308 [3081051] CIGNA STATE OF WYOMING [308105107] 395.9 percent of total billed charges 310 475 Technical (Hospital) Services Sso Direct Admit PX-7620000500 CDM G0379 HCPCS 762 RC inpatient 500 500 BLUE CROSS BLUE SHIELD WELLMARK SB889 [3081026] BCBS WYOMING [308102603] 475 percent of total billed charges 310 475 Technical (Hospital) Services Sso Direct Admit PX-7620000500 CDM G0379 HCPCS 762 RC inpatient 500 500 UNITED HEALTHCARE (COMMERCIAL) [3081199] UNITED HEALTHCARE 87726 [308119901] 310 percent of total billed charges 310 475 Technical (Hospital) Services Sso Direct Admit PX-7620000500 CDM G0379 HCPCS 762 RC inpatient 500 500 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES PPO [308136801] 395.9 percent of total billed charges 310 475 Technical (Hospital) Services Sso Direct Admit PX-7620000500 CDM G0379 HCPCS 762 RC inpatient 500 500 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES EPO [308136803] 395.9 percent of total billed charges 310 475 Technical (Hospital) Services Sso Direct Admit PX-7620000500 CDM G0379 HCPCS 762 RC inpatient 500 500 HEALTHPARTNERS SX009 HEALTHPARTNERS 395.9 percent of total billed charges 310 475 Technical (Hospital) Services Sso Direct Admit PX-7620000500 CDM G0379 HCPCS 762 RC inpatient 500 500 MULTIPLAN INC 34080 [3081285] MULTIPLAN INC [308128501] 475 percent of total billed charges 310 475 Technical (Hospital) Services Sso Direct Admit PX-7620000500 CDM G0379 HCPCS 762 RC inpatient 500 500 MEDICA (COMMERCIAL) 94265 [3081118] MEDICA CLAIMS [308111801] 450 percent of total billed charges 310 475 Technical (Hospital) Services Sso Direct Admit PX-7620000500 CDM G0379 HCPCS 762 RC inpatient 500 500 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES HDHP [308136802] 395.9 percent of total billed charges 310 475 Technical (Hospital) Services Sso per Hour PX-7620000100 CDM G0378 HCPCS 762 RC inpatient 135 135 BLUE CROSS BLUE SHIELD WELLMARK SB889 [3081026] BCBS WYOMING [308102603] 128.25 percent of total billed charges 83.7 128.25 Technical (Hospital) Services Sso per Hour PX-7620000100 CDM G0378 HCPCS 762 RC inpatient 135 135 UNITED HEALTHCARE (COMMERCIAL) [3081199] UNITED HEALTHCARE 87726 [308119901] 83.7 percent of total billed charges 83.7 128.25 Technical (Hospital) Services Sso per Hour PX-7620000100 CDM G0378 HCPCS 762 RC inpatient 135 135 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES PPO [308136801] 106.89 percent of total billed charges 83.7 128.25 Technical (Hospital) Services Sso per Hour PX-7620000100 CDM G0378 HCPCS 762 RC inpatient 135 135 MULTIPLAN INC 34080 [3081285] MULTIPLAN INC [308128501] 128.25 percent of total billed charges 83.7 128.25 Technical (Hospital) Services Sso per Hour PX-7620000100 CDM G0378 HCPCS 762 RC inpatient 135 135 MEDICA (COMMERCIAL) 94265 [3081118] MEDICA CLAIMS [308111801] 121.5 percent of total billed charges 83.7 128.25 Technical (Hospital) Services Sso per Hour PX-7620000100 CDM G0378 HCPCS 762 RC inpatient 135 135 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES HDHP [308136802] 106.89 percent of total billed charges 83.7 128.25 Technical (Hospital) Services Sso per Hour PX-7620000100 CDM G0378 HCPCS 762 RC inpatient 135 135 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES EPO [308136803] 106.89 percent of total billed charges 83.7 128.25 Technical (Hospital) Services Sso per Hour PX-7620000100 CDM G0378 HCPCS 762 RC inpatient 135 135 HEALTHPARTNERS SX009 HEALTHPARTNERS 106.89 percent of total billed charges 83.7 128.25 Technical (Hospital) Services Sso per Hour PX-7620000100 CDM G0378 HCPCS 762 RC inpatient 135 135 CIGNA 62308 [3081051] CIGNA 62308 [308105105] 106.89 percent of total billed charges 83.7 128.25 Technical (Hospital) Services Sso per Hour PX-7620000100 CDM G0378 HCPCS 762 RC inpatient 135 135 CIGNA 62308 [3081051] CIGNA STATE OF WYOMING [308105107] 106.89 percent of total billed charges 83.7 128.25 Technical (Hospital) Services Sso per Hour PX-7620000100 CDM G0378 HCPCS 762 RC outpatient 135 135 CIGNA 62308 [3081051] CIGNA STATE OF WYOMING [308105107] 108 percent of total billed charges 83.7 128.25 Technical (Hospital) Services Sso per Hour PX-7620000100 CDM G0378 HCPCS 762 RC outpatient 135 135 CIGNA 62308 [3081051] CIGNA 62308 [308105105] 108 percent of total billed charges 83.7 128.25 Technical (Hospital) Services Sso per Hour PX-7620000100 CDM G0378 HCPCS 762 RC outpatient 135 135 MEDICA (COMMERCIAL) 94265 [3081118] MEDICA CLAIMS [308111801] 121.5 percent of total billed charges 83.7 128.25 Technical (Hospital) Services Sso per Hour PX-7620000100 CDM G0378 HCPCS 762 RC outpatient 135 135 MULTIPLAN INC 34080 [3081285] MULTIPLAN INC [308128501] 128.25 percent of total billed charges 83.7 128.25 Technical (Hospital) Services Sso per Hour PX-7620000100 CDM G0378 HCPCS 762 RC outpatient 135 135 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES PPO [308136801] 108 percent of total billed charges 83.7 128.25 Technical (Hospital) Services Sso per Hour PX-7620000100 CDM G0378 HCPCS 762 RC outpatient 135 135 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES HDHP [308136802] 108 percent of total billed charges 83.7 128.25 Technical (Hospital) Services Sso per Hour PX-7620000100 CDM G0378 HCPCS 762 RC outpatient 135 135 BLUE CROSS BLUE SHIELD WELLMARK SB889 [3081026] BCBS WYOMING [308102603] 128.25 percent of total billed charges 83.7 128.25 Technical (Hospital) Services Sso per Hour PX-7620000100 CDM G0378 HCPCS 762 RC outpatient 135 135 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES EPO [308136803] 108 percent of total billed charges 83.7 128.25 Technical (Hospital) Services Sso per Hour PX-7620000100 CDM G0378 HCPCS 762 RC outpatient 135 135 UNITED HEALTHCARE (COMMERCIAL) [3081199] UNITED HEALTHCARE 87726 [308119901] 83.7 percent of total billed charges 83.7 128.25 Technical (Hospital) Services Sso per Hour PX-7620000100 CDM G0378 HCPCS 762 RC outpatient 135 135 HEALTHPARTNERS SX009 HEALTHPARTNERS 108 percent of total billed charges 83.7 128.25 Technical (Hospital) Services Sso Increased Acuity per Hour PX-7620000200 CDM G0378 HCPCS 762 RC inpatient 160 160 CIGNA 62308 [3081051] CIGNA 62308 [308105105] 126.69 percent of total billed charges 99.2 152 Technical (Hospital) Services Sso Increased Acuity per Hour PX-7620000200 CDM G0378 HCPCS 762 RC inpatient 160 160 CIGNA 62308 [3081051] CIGNA STATE OF WYOMING [308105107] 126.69 percent of total billed charges 99.2 152 Technical (Hospital) Services Sso Increased Acuity per Hour PX-7620000200 CDM G0378 HCPCS 762 RC inpatient 160 160 HEALTHPARTNERS SX009 HEALTHPARTNERS 126.69 percent of total billed charges 99.2 152 Technical (Hospital) Services Sso Increased Acuity per Hour PX-7620000200 CDM G0378 HCPCS 762 RC inpatient 160 160 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES EPO [308136803] 126.69 percent of total billed charges 99.2 152 Technical (Hospital) Services Sso Increased Acuity per Hour PX-7620000200 CDM G0378 HCPCS 762 RC inpatient 160 160 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES HDHP [308136802] 126.69 percent of total billed charges 99.2 152 Technical (Hospital) Services Sso Increased Acuity per Hour PX-7620000200 CDM G0378 HCPCS 762 RC inpatient 160 160 MEDICA (COMMERCIAL) 94265 [3081118] MEDICA CLAIMS [308111801] 144 percent of total billed charges 99.2 152 Technical (Hospital) Services Sso Increased Acuity per Hour PX-7620000200 CDM G0378 HCPCS 762 RC inpatient 160 160 MULTIPLAN INC 34080 [3081285] MULTIPLAN INC [308128501] 152 percent of total billed charges 99.2 152 Technical (Hospital) Services Sso Increased Acuity per Hour PX-7620000200 CDM G0378 HCPCS 762 RC inpatient 160 160 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES PPO [308136801] 126.69 percent of total billed charges 99.2 152 Technical (Hospital) Services Sso Increased Acuity per Hour PX-7620000200 CDM G0378 HCPCS 762 RC inpatient 160 160 UNITED HEALTHCARE (COMMERCIAL) [3081199] UNITED HEALTHCARE 87726 [308119901] 99.2 percent of total billed charges 99.2 152 Technical (Hospital) Services Sso Increased Acuity per Hour PX-7620000200 CDM G0378 HCPCS 762 RC inpatient 160 160 BLUE CROSS BLUE SHIELD WELLMARK SB889 [3081026] BCBS WYOMING [308102603] 152 percent of total billed charges 99.2 152 Technical (Hospital) Services Sso Increased Acuity per Hour PX-7620000200 CDM G0378 HCPCS 762 RC outpatient 160 160 HEALTHPARTNERS SX009 HEALTHPARTNERS 128 percent of total billed charges 99.2 152 Technical (Hospital) Services Sso Increased Acuity per Hour PX-7620000200 CDM G0378 HCPCS 762 RC outpatient 160 160 UNITED HEALTHCARE (COMMERCIAL) [3081199] UNITED HEALTHCARE 87726 [308119901] 99.2 percent of total billed charges 99.2 152 Technical (Hospital) Services Sso Increased Acuity per Hour PX-7620000200 CDM G0378 HCPCS 762 RC outpatient 160 160 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES EPO [308136803] 128 percent of total billed charges 99.2 152 Technical (Hospital) Services Sso Increased Acuity per Hour PX-7620000200 CDM G0378 HCPCS 762 RC outpatient 160 160 BLUE CROSS BLUE SHIELD WELLMARK SB889 [3081026] BCBS WYOMING [308102603] 152 percent of total billed charges 99.2 152 Technical (Hospital) Services Sso Increased Acuity per Hour PX-7620000200 CDM G0378 HCPCS 762 RC outpatient 160 160 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES HDHP [308136802] 128 percent of total billed charges 99.2 152 Technical (Hospital) Services Sso Increased Acuity per Hour PX-7620000200 CDM G0378 HCPCS 762 RC outpatient 160 160 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES PPO [308136801] 128 percent of total billed charges 99.2 152 Technical (Hospital) Services Sso Increased Acuity per Hour PX-7620000200 CDM G0378 HCPCS 762 RC outpatient 160 160 MULTIPLAN INC 34080 [3081285] MULTIPLAN INC [308128501] 152 percent of total billed charges 99.2 152 Technical (Hospital) Services Sso Increased Acuity per Hour PX-7620000200 CDM G0378 HCPCS 762 RC outpatient 160 160 MEDICA (COMMERCIAL) 94265 [3081118] MEDICA CLAIMS [308111801] 144 percent of total billed charges 99.2 152 Technical (Hospital) Services Sso Increased Acuity per Hour PX-7620000200 CDM G0378 HCPCS 762 RC outpatient 160 160 CIGNA 62308 [3081051] CIGNA 62308 [308105105] 128 percent of total billed charges 99.2 152 Technical (Hospital) Services Sso Increased Acuity per Hour PX-7620000200 CDM G0378 HCPCS 762 RC outpatient 160 160 CIGNA 62308 [3081051] CIGNA STATE OF WYOMING [308105107] 128 percent of total billed charges 99.2 152 Technical (Hospital) Services Sso Carve Out PX-7620000300 CDM G0378 HCPCS 762 RC inpatient 135 135 CIGNA 62308 [3081051] CIGNA 62308 [308105105] 106.89 percent of total billed charges 83.7 128.25 Technical (Hospital) Services Sso Carve Out PX-7620000300 CDM G0378 HCPCS 762 RC inpatient 135 135 CIGNA 62308 [3081051] CIGNA STATE OF WYOMING [308105107] 106.89 percent of total billed charges 83.7 128.25 Technical (Hospital) Services Sso Carve Out PX-7620000300 CDM G0378 HCPCS 762 RC inpatient 135 135 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES EPO [308136803] 106.89 percent of total billed charges 83.7 128.25 Technical (Hospital) Services Sso Carve Out PX-7620000300 CDM G0378 HCPCS 762 RC inpatient 135 135 HEALTHPARTNERS SX009 HEALTHPARTNERS 106.89 percent of total billed charges 83.7 128.25 Technical (Hospital) Services Sso Carve Out PX-7620000300 CDM G0378 HCPCS 762 RC inpatient 135 135 MEDICA (COMMERCIAL) 94265 [3081118] MEDICA CLAIMS [308111801] 121.5 percent of total billed charges 83.7 128.25 Technical (Hospital) Services Sso Carve Out PX-7620000300 CDM G0378 HCPCS 762 RC inpatient 135 135 MULTIPLAN INC 34080 [3081285] MULTIPLAN INC [308128501] 128.25 percent of total billed charges 83.7 128.25 Technical (Hospital) Services Sso Carve Out PX-7620000300 CDM G0378 HCPCS 762 RC inpatient 135 135 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES PPO [308136801] 106.89 percent of total billed charges 83.7 128.25 Technical (Hospital) Services Sso Carve Out PX-7620000300 CDM G0378 HCPCS 762 RC inpatient 135 135 UNITED HEALTHCARE (COMMERCIAL) [3081199] UNITED HEALTHCARE 87726 [308119901] 83.7 percent of total billed charges 83.7 128.25 Technical (Hospital) Services Sso Carve Out PX-7620000300 CDM G0378 HCPCS 762 RC inpatient 135 135 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES HDHP [308136802] 106.89 percent of total billed charges 83.7 128.25 Technical (Hospital) Services Sso Carve Out PX-7620000300 CDM G0378 HCPCS 762 RC inpatient 135 135 BLUE CROSS BLUE SHIELD WELLMARK SB889 [3081026] BCBS WYOMING [308102603] 128.25 percent of total billed charges 83.7 128.25 Technical (Hospital) Services Sso Carve Out PX-7620000300 CDM G0378 HCPCS 762 RC outpatient 135 135 BLUE CROSS BLUE SHIELD WELLMARK SB889 [3081026] BCBS WYOMING [308102603] 128.25 percent of total billed charges 83.7 128.25 Technical (Hospital) Services Sso Carve Out PX-7620000300 CDM G0378 HCPCS 762 RC outpatient 135 135 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES HDHP [308136802] 108 percent of total billed charges 83.7 128.25 Technical (Hospital) Services Sso Carve Out PX-7620000300 CDM G0378 HCPCS 762 RC outpatient 135 135 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES PPO [308136801] 108 percent of total billed charges 83.7 128.25 Technical (Hospital) Services Sso Carve Out PX-7620000300 CDM G0378 HCPCS 762 RC outpatient 135 135 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES EPO [308136803] 108 percent of total billed charges 83.7 128.25 Technical (Hospital) Services Sso Carve Out PX-7620000300 CDM G0378 HCPCS 762 RC outpatient 135 135 UNITED HEALTHCARE (COMMERCIAL) [3081199] UNITED HEALTHCARE 87726 [308119901] 83.7 percent of total billed charges 83.7 128.25 Technical (Hospital) Services Sso Carve Out PX-7620000300 CDM G0378 HCPCS 762 RC outpatient 135 135 HEALTHPARTNERS SX009 HEALTHPARTNERS 108 percent of total billed charges 83.7 128.25 Technical (Hospital) Services Sso Carve Out PX-7620000300 CDM G0378 HCPCS 762 RC outpatient 135 135 MEDICA (COMMERCIAL) 94265 [3081118] MEDICA CLAIMS [308111801] 121.5 percent of total billed charges 83.7 128.25 Technical (Hospital) Services Sso Carve Out PX-7620000300 CDM G0378 HCPCS 762 RC outpatient 135 135 MULTIPLAN INC 34080 [3081285] MULTIPLAN INC [308128501] 128.25 percent of total billed charges 83.7 128.25 Technical (Hospital) Services Sso Carve Out PX-7620000300 CDM G0378 HCPCS 762 RC outpatient 135 135 CIGNA 62308 [3081051] CIGNA 62308 [308105105] 108 percent of total billed charges 83.7 128.25 Technical (Hospital) Services Sso Carve Out PX-7620000300 CDM G0378 HCPCS 762 RC outpatient 135 135 CIGNA 62308 [3081051] CIGNA STATE OF WYOMING [308105107] 108 percent of total billed charges 83.7 128.25 Technical (Hospital) Services Sso Increased Acuity Carve Out PX-7620000400 CDM G0378 HCPCS 762 RC inpatient 160 160 BLUE CROSS BLUE SHIELD WELLMARK SB889 [3081026] BCBS WYOMING [308102603] 152 percent of total billed charges 99.2 152 Technical (Hospital) Services Sso Increased Acuity Carve Out PX-7620000400 CDM G0378 HCPCS 762 RC inpatient 160 160 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES PPO [308136801] 126.69 percent of total billed charges 99.2 152 Technical (Hospital) Services Sso Increased Acuity Carve Out PX-7620000400 CDM G0378 HCPCS 762 RC inpatient 160 160 UNITED HEALTHCARE (COMMERCIAL) [3081199] UNITED HEALTHCARE 87726 [308119901] 99.2 percent of total billed charges 99.2 152 Technical (Hospital) Services Sso Increased Acuity Carve Out PX-7620000400 CDM G0378 HCPCS 762 RC inpatient 160 160 MULTIPLAN INC 34080 [3081285] MULTIPLAN INC [308128501] 152 percent of total billed charges 99.2 152 Technical (Hospital) Services Sso Increased Acuity Carve Out PX-7620000400 CDM G0378 HCPCS 762 RC inpatient 160 160 MEDICA (COMMERCIAL) 94265 [3081118] MEDICA CLAIMS [308111801] 144 percent of total billed charges 99.2 152 Technical (Hospital) Services Sso Increased Acuity Carve Out PX-7620000400 CDM G0378 HCPCS 762 RC inpatient 160 160 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES HDHP [308136802] 126.69 percent of total billed charges 99.2 152 Technical (Hospital) Services Sso Increased Acuity Carve Out PX-7620000400 CDM G0378 HCPCS 762 RC inpatient 160 160 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES EPO [308136803] 126.69 percent of total billed charges 99.2 152 Technical (Hospital) Services Sso Increased Acuity Carve Out PX-7620000400 CDM G0378 HCPCS 762 RC inpatient 160 160 HEALTHPARTNERS SX009 HEALTHPARTNERS 126.69 percent of total billed charges 99.2 152 Technical (Hospital) Services Sso Increased Acuity Carve Out PX-7620000400 CDM G0378 HCPCS 762 RC inpatient 160 160 CIGNA 62308 [3081051] CIGNA 62308 [308105105] 126.69 percent of total billed charges 99.2 152 Technical (Hospital) Services Sso Increased Acuity Carve Out PX-7620000400 CDM G0378 HCPCS 762 RC inpatient 160 160 CIGNA 62308 [3081051] CIGNA STATE OF WYOMING [308105107] 126.69 percent of total billed charges 99.2 152 Technical (Hospital) Services Sso Increased Acuity Carve Out PX-7620000400 CDM G0378 HCPCS 762 RC outpatient 160 160 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES EPO [308136803] 128 percent of total billed charges 99.2 152 Technical (Hospital) Services Sso Increased Acuity Carve Out PX-7620000400 CDM G0378 HCPCS 762 RC outpatient 160 160 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES PPO [308136801] 128 percent of total billed charges 99.2 152 Technical (Hospital) Services Sso Increased Acuity Carve Out PX-7620000400 CDM G0378 HCPCS 762 RC outpatient 160 160 BLUE CROSS BLUE SHIELD WELLMARK SB889 [3081026] BCBS WYOMING [308102603] 152 percent of total billed charges 99.2 152 Technical (Hospital) Services Sso Increased Acuity Carve Out PX-7620000400 CDM G0378 HCPCS 762 RC outpatient 160 160 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES HDHP [308136802] 128 percent of total billed charges 99.2 152 Technical (Hospital) Services Sso Increased Acuity Carve Out PX-7620000400 CDM G0378 HCPCS 762 RC outpatient 160 160 MULTIPLAN INC 34080 [3081285] MULTIPLAN INC [308128501] 152 percent of total billed charges 99.2 152 Technical (Hospital) Services Sso Increased Acuity Carve Out PX-7620000400 CDM G0378 HCPCS 762 RC outpatient 160 160 UNITED HEALTHCARE (COMMERCIAL) [3081199] UNITED HEALTHCARE 87726 [308119901] 99.2 percent of total billed charges 99.2 152 Technical (Hospital) Services Sso Increased Acuity Carve Out PX-7620000400 CDM G0378 HCPCS 762 RC outpatient 160 160 HEALTHPARTNERS SX009 HEALTHPARTNERS 128 percent of total billed charges 99.2 152 Technical (Hospital) Services Sso Increased Acuity Carve Out PX-7620000400 CDM G0378 HCPCS 762 RC outpatient 160 160 CIGNA 62308 [3081051] CIGNA 62308 [308105105] 128 percent of total billed charges 99.2 152 Technical (Hospital) Services Sso Increased Acuity Carve Out PX-7620000400 CDM G0378 HCPCS 762 RC outpatient 160 160 CIGNA 62308 [3081051] CIGNA STATE OF WYOMING [308105107] 128 percent of total billed charges 99.2 152 Technical (Hospital) Services Sso Increased Acuity Carve Out PX-7620000400 CDM G0378 HCPCS 762 RC outpatient 160 160 MEDICA (COMMERCIAL) 94265 [3081118] MEDICA CLAIMS [308111801] 144 percent of total billed charges 99.2 152 Technical (Hospital) Services "Other Resp Proc to Improve Function or Strength, Group" PX-4100023900 CDM G0239 HCPCS 410 RC inpatient 37 37 MEDICA (COMMERCIAL) 94265 [3081118] MEDICA CLAIMS [308111801] 33.3 percent of total billed charges 22.94 35.15 Technical (Hospital) Services "Other Resp Proc to Improve Function or Strength, Group" PX-4100023900 CDM G0239 HCPCS 410 RC inpatient 37 37 MULTIPLAN INC 34080 [3081285] MULTIPLAN INC [308128501] 35.15 percent of total billed charges 22.94 35.15 Technical (Hospital) Services "Other Resp Proc to Improve Function or Strength, Group" PX-4100023900 CDM G0239 HCPCS 410 RC inpatient 37 37 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES HDHP [308136802] 29.3 percent of total billed charges 22.94 35.15 Technical (Hospital) Services "Other Resp Proc to Improve Function or Strength, Group" PX-4100023900 CDM G0239 HCPCS 410 RC inpatient 37 37 HEALTHPARTNERS SX009 HEALTHPARTNERS 29.3 percent of total billed charges 22.94 35.15 Technical (Hospital) Services "Other Resp Proc to Improve Function or Strength, Group" PX-4100023900 CDM G0239 HCPCS 410 RC inpatient 37 37 UNITED HEALTHCARE (COMMERCIAL) [3081199] UNITED HEALTHCARE 87726 [308119901] 22.94 percent of total billed charges 22.94 35.15 Technical (Hospital) Services "Other Resp Proc to Improve Function or Strength, Group" PX-4100023900 CDM G0239 HCPCS 410 RC inpatient 37 37 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES PPO [308136801] 29.3 percent of total billed charges 22.94 35.15 Technical (Hospital) Services "Other Resp Proc to Improve Function or Strength, Group" PX-4100023900 CDM G0239 HCPCS 410 RC inpatient 37 37 BLUE CROSS BLUE SHIELD WELLMARK SB889 [3081026] BCBS WYOMING [308102603] 35.15 percent of total billed charges 22.94 35.15 Technical (Hospital) Services "Other Resp Proc to Improve Function or Strength, Group" PX-4100023900 CDM G0239 HCPCS 410 RC inpatient 37 37 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES EPO [308136803] 29.3 percent of total billed charges 22.94 35.15 Technical (Hospital) Services "Other Resp Proc to Improve Function or Strength, Group" PX-4100023900 CDM G0239 HCPCS 410 RC inpatient 37 37 CIGNA 62308 [3081051] CIGNA 62308 [308105105] 29.3 percent of total billed charges 22.94 35.15 Technical (Hospital) Services "Other Resp Proc to Improve Function or Strength, Group" PX-4100023900 CDM G0239 HCPCS 410 RC inpatient 37 37 CIGNA 62308 [3081051] CIGNA STATE OF WYOMING [308105107] 29.3 percent of total billed charges 22.94 35.15 Technical (Hospital) Services "Other Resp Proc to Improve Function or Strength, Group" PX-4100023900 CDM G0239 HCPCS 410 RC outpatient 37 37 MULTIPLAN INC 34080 [3081285] MULTIPLAN INC [308128501] 35.15 percent of total billed charges 22.94 35.15 Technical (Hospital) Services "Other Resp Proc to Improve Function or Strength, Group" PX-4100023900 CDM G0239 HCPCS 410 RC outpatient 37 37 CIGNA 62308 [3081051] CIGNA 62308 [308105105] 29.6 percent of total billed charges 22.94 35.15 Technical (Hospital) Services "Other Resp Proc to Improve Function or Strength, Group" PX-4100023900 CDM G0239 HCPCS 410 RC outpatient 37 37 CIGNA 62308 [3081051] CIGNA STATE OF WYOMING [308105107] 29.6 percent of total billed charges 22.94 35.15 Technical (Hospital) Services "Other Resp Proc to Improve Function or Strength, Group" PX-4100023900 CDM G0239 HCPCS 410 RC outpatient 37 37 UNITED HEALTHCARE (COMMERCIAL) [3081199] UNITED HEALTHCARE 87726 [308119901] 22.94 percent of total billed charges 22.94 35.15 Technical (Hospital) Services "Other Resp Proc to Improve Function or Strength, Group" PX-4100023900 CDM G0239 HCPCS 410 RC outpatient 37 37 HEALTHPARTNERS SX009 HEALTHPARTNERS 29.6 percent of total billed charges 22.94 35.15 Technical (Hospital) Services "Other Resp Proc to Improve Function or Strength, Group" PX-4100023900 CDM G0239 HCPCS 410 RC outpatient 37 37 MEDICA (COMMERCIAL) 94265 [3081118] MEDICA CLAIMS [308111801] 33.3 percent of total billed charges 22.94 35.15 Technical (Hospital) Services "Other Resp Proc to Improve Function or Strength, Group" PX-4100023900 CDM G0239 HCPCS 410 RC outpatient 37 37 BLUE CROSS BLUE SHIELD WELLMARK SB889 [3081026] BCBS WYOMING [308102603] 35.15 percent of total billed charges 22.94 35.15 Technical (Hospital) Services "Other Resp Proc to Improve Function or Strength, Group" PX-4100023900 CDM G0239 HCPCS 410 RC outpatient 37 37 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES HDHP [308136802] 29.6 percent of total billed charges 22.94 35.15 Technical (Hospital) Services "Other Resp Proc to Improve Function or Strength, Group" PX-4100023900 CDM G0239 HCPCS 410 RC outpatient 37 37 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES PPO [308136801] 29.6 percent of total billed charges 22.94 35.15 Technical (Hospital) Services "Other Resp Proc to Improve Function or Strength, Group" PX-4100023900 CDM G0239 HCPCS 410 RC outpatient 37 37 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES EPO [308136803] 29.6 percent of total billed charges 22.94 35.15 Technical (Hospital) Services HC/HH Wch Supp Mask Aerosal Adult__001206 PX-2705000001 CDM E0601 HCPCS 270 RC outpatient 5 5 MEDICA (COMMERCIAL) 94265 [3081118] MEDICA CLAIMS [308111801] 4.5 percent of total billed charges 3.1 4.75 Technical (Hospital) Services HC/HH Wch Supp Mask Aerosal Adult__001206 PX-2705000001 CDM E0601 HCPCS 270 RC outpatient 5 5 MULTIPLAN INC 34080 [3081285] MULTIPLAN INC [308128501] 4.75 percent of total billed charges 3.1 4.75 Technical (Hospital) Services HC/HH Wch Supp Mask Aerosal Adult__001206 PX-2705000001 CDM E0601 HCPCS 270 RC outpatient 5 5 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES HDHP [308136802] 4 percent of total billed charges 3.1 4.75 Technical (Hospital) Services HC/HH Wch Supp Mask Aerosal Adult__001206 PX-2705000001 CDM E0601 HCPCS 270 RC outpatient 5 5 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES EPO [308136803] 4 percent of total billed charges 3.1 4.75 Technical (Hospital) Services HC/HH Wch Supp Mask Aerosal Adult__001206 PX-2705000001 CDM E0601 HCPCS 270 RC outpatient 5 5 BLUE CROSS BLUE SHIELD WELLMARK SB889 [3081026] BCBS WYOMING [308102603] 4.75 percent of total billed charges 3.1 4.75 Technical (Hospital) Services HC/HH Wch Supp Mask Aerosal Adult__001206 PX-2705000001 CDM E0601 HCPCS 270 RC outpatient 5 5 CIGNA 62308 [3081051] CIGNA 62308 [308105105] 4 percent of total billed charges 3.1 4.75 Technical (Hospital) Services HC/HH Wch Supp Mask Aerosal Adult__001206 PX-2705000001 CDM E0601 HCPCS 270 RC outpatient 5 5 CIGNA 62308 [3081051] CIGNA STATE OF WYOMING [308105107] 4 percent of total billed charges 3.1 4.75 Technical (Hospital) Services HC/HH Wch Supp Mask Aerosal Adult__001206 PX-2705000001 CDM E0601 HCPCS 270 RC outpatient 5 5 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES PPO [308136801] 4 percent of total billed charges 3.1 4.75 Technical (Hospital) Services HC/HH Wch Supp Mask Aerosal Adult__001206 PX-2705000001 CDM E0601 HCPCS 270 RC outpatient 5 5 UNITED HEALTHCARE (COMMERCIAL) [3081199] UNITED HEALTHCARE 87726 [308119901] 3.1 percent of total billed charges 3.1 4.75 Technical (Hospital) Services HC/HH Wch Supp Mask Aerosal Adult__001206 PX-2705000001 CDM E0601 HCPCS 270 RC outpatient 5 5 HEALTHPARTNERS SX009 HEALTHPARTNERS 4 percent of total billed charges 3.1 4.75 Technical (Hospital) Services HC/HH Wch Supp Mask Aerosal Adult__001206 PX-2705000001 CDM E0601 HCPCS 270 RC inpatient 5 5 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES PPO [308136801] 3.96 percent of total billed charges 3.1 4.75 Technical (Hospital) Services HC/HH Wch Supp Mask Aerosal Adult__001206 PX-2705000001 CDM E0601 HCPCS 270 RC inpatient 5 5 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES HDHP [308136802] 3.96 percent of total billed charges 3.1 4.75 Technical (Hospital) Services HC/HH Wch Supp Mask Aerosal Adult__001206 PX-2705000001 CDM E0601 HCPCS 270 RC inpatient 5 5 UNITED HEALTHCARE (COMMERCIAL) [3081199] UNITED HEALTHCARE 87726 [308119901] 3.1 percent of total billed charges 3.1 4.75 Technical (Hospital) Services HC/HH Wch Supp Mask Aerosal Adult__001206 PX-2705000001 CDM E0601 HCPCS 270 RC inpatient 5 5 MEDICA (COMMERCIAL) 94265 [3081118] MEDICA CLAIMS [308111801] 4.5 percent of total billed charges 3.1 4.75 Technical (Hospital) Services HC/HH Wch Supp Mask Aerosal Adult__001206 PX-2705000001 CDM E0601 HCPCS 270 RC inpatient 5 5 MULTIPLAN INC 34080 [3081285] MULTIPLAN INC [308128501] 4.75 percent of total billed charges 3.1 4.75 Technical (Hospital) Services HC/HH Wch Supp Mask Aerosal Adult__001206 PX-2705000001 CDM E0601 HCPCS 270 RC inpatient 5 5 BLUE CROSS BLUE SHIELD WELLMARK SB889 [3081026] BCBS WYOMING [308102603] 4.75 percent of total billed charges 3.1 4.75 Technical (Hospital) Services HC/HH Wch Supp Mask Aerosal Adult__001206 PX-2705000001 CDM E0601 HCPCS 270 RC inpatient 5 5 CIGNA 62308 [3081051] CIGNA 62308 [308105105] 3.96 percent of total billed charges 3.1 4.75 Technical (Hospital) Services HC/HH Wch Supp Mask Aerosal Adult__001206 PX-2705000001 CDM E0601 HCPCS 270 RC inpatient 5 5 CIGNA 62308 [3081051] CIGNA STATE OF WYOMING [308105107] 3.96 percent of total billed charges 3.1 4.75 Technical (Hospital) Services HC/HH Wch Supp Mask Aerosal Adult__001206 PX-2705000001 CDM E0601 HCPCS 270 RC inpatient 5 5 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES EPO [308136803] 3.96 percent of total billed charges 3.1 4.75 Technical (Hospital) Services HC/HH Wch Supp Mask Aerosal Adult__001206 PX-2705000001 CDM E0601 HCPCS 270 RC inpatient 5 5 HEALTHPARTNERS SX009 HEALTHPARTNERS 3.96 percent of total billed charges 3.1 4.75 Technical (Hospital) Services "Hospital Outpatient Clinic Visit Specimen Collection for Severe Acute Respiratory Syndrome Coronavirus 2 Sars-Cov-2 Coronavirus Disease Covid-19, Any Specimen Source)" PX-3000980300 CDM C9803 HCPCS 300 RC inpatient 60 60 UNITED HEALTHCARE (COMMERCIAL) [3081199] UNITED HEALTHCARE 87726 [308119901] 37.2 percent of total billed charges 37.2 57 Technical (Hospital) Services "Hospital Outpatient Clinic Visit Specimen Collection for Severe Acute Respiratory Syndrome Coronavirus 2 Sars-Cov-2 Coronavirus Disease Covid-19, Any Specimen Source)" PX-3000980300 CDM C9803 HCPCS 300 RC inpatient 60 60 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES PPO [308136801] 47.51 percent of total billed charges 37.2 57 Technical (Hospital) Services "Hospital Outpatient Clinic Visit Specimen Collection for Severe Acute Respiratory Syndrome Coronavirus 2 Sars-Cov-2 Coronavirus Disease Covid-19, Any Specimen Source)" PX-3000980300 CDM C9803 HCPCS 300 RC inpatient 60 60 BLUE CROSS BLUE SHIELD WELLMARK SB889 [3081026] BCBS WYOMING [308102603] 57 percent of total billed charges 37.2 57 Technical (Hospital) Services "Hospital Outpatient Clinic Visit Specimen Collection for Severe Acute Respiratory Syndrome Coronavirus 2 Sars-Cov-2 Coronavirus Disease Covid-19, Any Specimen Source)" PX-3000980300 CDM C9803 HCPCS 300 RC inpatient 60 60 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES EPO [308136803] 47.51 percent of total billed charges 37.2 57 Technical (Hospital) Services "Hospital Outpatient Clinic Visit Specimen Collection for Severe Acute Respiratory Syndrome Coronavirus 2 Sars-Cov-2 Coronavirus Disease Covid-19, Any Specimen Source)" PX-3000980300 CDM C9803 HCPCS 300 RC inpatient 60 60 HEALTHPARTNERS SX009 HEALTHPARTNERS 47.51 percent of total billed charges 37.2 57 Technical (Hospital) Services "Hospital Outpatient Clinic Visit Specimen Collection for Severe Acute Respiratory Syndrome Coronavirus 2 Sars-Cov-2 Coronavirus Disease Covid-19, Any Specimen Source)" PX-3000980300 CDM C9803 HCPCS 300 RC inpatient 60 60 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES HDHP [308136802] 47.51 percent of total billed charges 37.2 57 Technical (Hospital) Services "Hospital Outpatient Clinic Visit Specimen Collection for Severe Acute Respiratory Syndrome Coronavirus 2 Sars-Cov-2 Coronavirus Disease Covid-19, Any Specimen Source)" PX-3000980300 CDM C9803 HCPCS 300 RC inpatient 60 60 MEDICA (COMMERCIAL) 94265 [3081118] MEDICA CLAIMS [308111801] 54 percent of total billed charges 37.2 57 Technical (Hospital) Services "Hospital Outpatient Clinic Visit Specimen Collection for Severe Acute Respiratory Syndrome Coronavirus 2 Sars-Cov-2 Coronavirus Disease Covid-19, Any Specimen Source)" PX-3000980300 CDM C9803 HCPCS 300 RC inpatient 60 60 MULTIPLAN INC 34080 [3081285] MULTIPLAN INC [308128501] 57 percent of total billed charges 37.2 57 Technical (Hospital) Services "Hospital Outpatient Clinic Visit Specimen Collection for Severe Acute Respiratory Syndrome Coronavirus 2 Sars-Cov-2 Coronavirus Disease Covid-19, Any Specimen Source)" PX-3000980300 CDM C9803 HCPCS 300 RC inpatient 60 60 CIGNA 62308 [3081051] CIGNA 62308 [308105105] 47.51 percent of total billed charges 37.2 57 Technical (Hospital) Services "Hospital Outpatient Clinic Visit Specimen Collection for Severe Acute Respiratory Syndrome Coronavirus 2 Sars-Cov-2 Coronavirus Disease Covid-19, Any Specimen Source)" PX-3000980300 CDM C9803 HCPCS 300 RC inpatient 60 60 CIGNA 62308 [3081051] CIGNA STATE OF WYOMING [308105107] 47.51 percent of total billed charges 37.2 57 Technical (Hospital) Services "Hospital Outpatient Clinic Visit Specimen Collection for Severe Acute Respiratory Syndrome Coronavirus 2 Sars-Cov-2 Coronavirus Disease Covid-19, Any Specimen Source)" PX-3000980300 CDM C9803 HCPCS 300 RC outpatient 60 60 UNITED HEALTHCARE (COMMERCIAL) [3081199] UNITED HEALTHCARE 87726 [308119901] 37.2 percent of total billed charges 37.2 57 Technical (Hospital) Services "Hospital Outpatient Clinic Visit Specimen Collection for Severe Acute Respiratory Syndrome Coronavirus 2 Sars-Cov-2 Coronavirus Disease Covid-19, Any Specimen Source)" PX-3000980300 CDM C9803 HCPCS 300 RC outpatient 60 60 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES EPO [308136803] 48 percent of total billed charges 37.2 57 Technical (Hospital) Services "Hospital Outpatient Clinic Visit Specimen Collection for Severe Acute Respiratory Syndrome Coronavirus 2 Sars-Cov-2 Coronavirus Disease Covid-19, Any Specimen Source)" PX-3000980300 CDM C9803 HCPCS 300 RC outpatient 60 60 HEALTHPARTNERS SX009 HEALTHPARTNERS 48 percent of total billed charges 37.2 57 Technical (Hospital) Services "Hospital Outpatient Clinic Visit Specimen Collection for Severe Acute Respiratory Syndrome Coronavirus 2 Sars-Cov-2 Coronavirus Disease Covid-19, Any Specimen Source)" PX-3000980300 CDM C9803 HCPCS 300 RC outpatient 60 60 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES PPO [308136801] 48 percent of total billed charges 37.2 57 Technical (Hospital) Services "Hospital Outpatient Clinic Visit Specimen Collection for Severe Acute Respiratory Syndrome Coronavirus 2 Sars-Cov-2 Coronavirus Disease Covid-19, Any Specimen Source)" PX-3000980300 CDM C9803 HCPCS 300 RC outpatient 60 60 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES HDHP [308136802] 48 percent of total billed charges 37.2 57 Technical (Hospital) Services "Hospital Outpatient Clinic Visit Specimen Collection for Severe Acute Respiratory Syndrome Coronavirus 2 Sars-Cov-2 Coronavirus Disease Covid-19, Any Specimen Source)" PX-3000980300 CDM C9803 HCPCS 300 RC outpatient 60 60 BLUE CROSS BLUE SHIELD WELLMARK SB889 [3081026] BCBS WYOMING [308102603] 57 percent of total billed charges 37.2 57 Technical (Hospital) Services "Hospital Outpatient Clinic Visit Specimen Collection for Severe Acute Respiratory Syndrome Coronavirus 2 Sars-Cov-2 Coronavirus Disease Covid-19, Any Specimen Source)" PX-3000980300 CDM C9803 HCPCS 300 RC outpatient 60 60 MULTIPLAN INC 34080 [3081285] MULTIPLAN INC [308128501] 57 percent of total billed charges 37.2 57 Technical (Hospital) Services "Hospital Outpatient Clinic Visit Specimen Collection for Severe Acute Respiratory Syndrome Coronavirus 2 Sars-Cov-2 Coronavirus Disease Covid-19, Any Specimen Source)" PX-3000980300 CDM C9803 HCPCS 300 RC outpatient 60 60 MEDICA (COMMERCIAL) 94265 [3081118] MEDICA CLAIMS [308111801] 54 percent of total billed charges 37.2 57 Technical (Hospital) Services "Hospital Outpatient Clinic Visit Specimen Collection for Severe Acute Respiratory Syndrome Coronavirus 2 Sars-Cov-2 Coronavirus Disease Covid-19, Any Specimen Source)" PX-3000980300 CDM C9803 HCPCS 300 RC outpatient 60 60 CIGNA 62308 [3081051] CIGNA 62308 [308105105] 48 percent of total billed charges 37.2 57 Technical (Hospital) Services "Hospital Outpatient Clinic Visit Specimen Collection for Severe Acute Respiratory Syndrome Coronavirus 2 Sars-Cov-2 Coronavirus Disease Covid-19, Any Specimen Source)" PX-3000980300 CDM C9803 HCPCS 300 RC outpatient 60 60 CIGNA 62308 [3081051] CIGNA STATE OF WYOMING [308105107] 48 percent of total billed charges 37.2 57 Technical (Hospital) Services HC/HH Wch Supp Cath Kit Central Venous__M3720hkic PX-2725000006 CDM C1751 HCPCS 272 RC inpatient 155 155 MEDICA (COMMERCIAL) 94265 [3081118] MEDICA CLAIMS [308111801] 139.5 percent of total billed charges 96.1 147.25 Technical (Hospital) Services HC/HH Wch Supp Cath Kit Central Venous__M3720hkic PX-2725000006 CDM C1751 HCPCS 272 RC inpatient 155 155 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES PPO [308136801] 122.73 percent of total billed charges 96.1 147.25 Technical (Hospital) Services HC/HH Wch Supp Cath Kit Central Venous__M3720hkic PX-2725000006 CDM C1751 HCPCS 272 RC inpatient 155 155 UNITED HEALTHCARE (COMMERCIAL) [3081199] UNITED HEALTHCARE 87726 [308119901] 96.1 percent of total billed charges 96.1 147.25 Technical (Hospital) Services HC/HH Wch Supp Cath Kit Central Venous__M3720hkic PX-2725000006 CDM C1751 HCPCS 272 RC inpatient 155 155 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES HDHP [308136802] 122.73 percent of total billed charges 96.1 147.25 Technical (Hospital) Services HC/HH Wch Supp Cath Kit Central Venous__M3720hkic PX-2725000006 CDM C1751 HCPCS 272 RC inpatient 155 155 CIGNA 62308 [3081051] CIGNA 62308 [308105105] 122.73 percent of total billed charges 96.1 147.25 Technical (Hospital) Services HC/HH Wch Supp Cath Kit Central Venous__M3720hkic PX-2725000006 CDM C1751 HCPCS 272 RC inpatient 155 155 CIGNA 62308 [3081051] CIGNA STATE OF WYOMING [308105107] 122.73 percent of total billed charges 96.1 147.25 Technical (Hospital) Services HC/HH Wch Supp Cath Kit Central Venous__M3720hkic PX-2725000006 CDM C1751 HCPCS 272 RC inpatient 155 155 BLUE CROSS BLUE SHIELD WELLMARK SB889 [3081026] BCBS WYOMING [308102603] 147.25 percent of total billed charges 96.1 147.25 Technical (Hospital) Services HC/HH Wch Supp Cath Kit Central Venous__M3720hkic PX-2725000006 CDM C1751 HCPCS 272 RC inpatient 155 155 MULTIPLAN INC 34080 [3081285] MULTIPLAN INC [308128501] 147.25 percent of total billed charges 96.1 147.25 Technical (Hospital) Services HC/HH Wch Supp Cath Kit Central Venous__M3720hkic PX-2725000006 CDM C1751 HCPCS 272 RC inpatient 155 155 HEALTHPARTNERS SX009 HEALTHPARTNERS 122.73 percent of total billed charges 96.1 147.25 Technical (Hospital) Services HC/HH Wch Supp Cath Kit Central Venous__M3720hkic PX-2725000006 CDM C1751 HCPCS 272 RC inpatient 155 155 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES EPO [308136803] 122.73 percent of total billed charges 96.1 147.25 Technical (Hospital) Services HC/HH Wch Supp Cath Kit Central Venous__M3720hkic PX-2725000006 CDM C1751 HCPCS 272 RC outpatient 155 155 MULTIPLAN INC 34080 [3081285] MULTIPLAN INC [308128501] 147.25 percent of total billed charges 96.1 147.25 Technical (Hospital) Services HC/HH Wch Supp Cath Kit Central Venous__M3720hkic PX-2725000006 CDM C1751 HCPCS 272 RC outpatient 155 155 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES PPO [308136801] 124 percent of total billed charges 96.1 147.25 Technical (Hospital) Services HC/HH Wch Supp Cath Kit Central Venous__M3720hkic PX-2725000006 CDM C1751 HCPCS 272 RC outpatient 155 155 MEDICA (COMMERCIAL) 94265 [3081118] MEDICA CLAIMS [308111801] 139.5 percent of total billed charges 96.1 147.25 Technical (Hospital) Services HC/HH Wch Supp Cath Kit Central Venous__M3720hkic PX-2725000006 CDM C1751 HCPCS 272 RC outpatient 155 155 CIGNA 62308 [3081051] CIGNA STATE OF WYOMING [308105107] 124 percent of total billed charges 96.1 147.25 Technical (Hospital) Services HC/HH Wch Supp Cath Kit Central Venous__M3720hkic PX-2725000006 CDM C1751 HCPCS 272 RC outpatient 155 155 CIGNA 62308 [3081051] CIGNA 62308 [308105105] 124 percent of total billed charges 96.1 147.25 Technical (Hospital) Services HC/HH Wch Supp Cath Kit Central Venous__M3720hkic PX-2725000006 CDM C1751 HCPCS 272 RC outpatient 155 155 UNITED HEALTHCARE (COMMERCIAL) [3081199] UNITED HEALTHCARE 87726 [308119901] 96.1 percent of total billed charges 96.1 147.25 Technical (Hospital) Services HC/HH Wch Supp Cath Kit Central Venous__M3720hkic PX-2725000006 CDM C1751 HCPCS 272 RC outpatient 155 155 HEALTHPARTNERS SX009 HEALTHPARTNERS 124 percent of total billed charges 96.1 147.25 Technical (Hospital) Services HC/HH Wch Supp Cath Kit Central Venous__M3720hkic PX-2725000006 CDM C1751 HCPCS 272 RC outpatient 155 155 BLUE CROSS BLUE SHIELD WELLMARK SB889 [3081026] BCBS WYOMING [308102603] 147.25 percent of total billed charges 96.1 147.25 Technical (Hospital) Services HC/HH Wch Supp Cath Kit Central Venous__M3720hkic PX-2725000006 CDM C1751 HCPCS 272 RC outpatient 155 155 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES EPO [308136803] 124 percent of total billed charges 96.1 147.25 Technical (Hospital) Services HC/HH Wch Supp Cath Kit Central Venous__M3720hkic PX-2725000006 CDM C1751 HCPCS 272 RC outpatient 155 155 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES HDHP [308136802] 124 percent of total billed charges 96.1 147.25 Technical (Hospital) Services HC/HH Wch Supp Padding Cast Synthetic 4x4__Cmw04 PX-2705000112 CDM A9999 HCPCS 270 RC inpatient 9 9 CIGNA 62308 [3081051] CIGNA 62308 [308105105] 7.13 percent of total billed charges 5.58 8.55 Technical (Hospital) Services HC/HH Wch Supp Padding Cast Synthetic 4x4__Cmw04 PX-2705000112 CDM A9999 HCPCS 270 RC inpatient 9 9 CIGNA 62308 [3081051] CIGNA STATE OF WYOMING [308105107] 7.13 percent of total billed charges 5.58 8.55 Technical (Hospital) Services HC/HH Wch Supp Padding Cast Synthetic 4x4__Cmw04 PX-2705000112 CDM A9999 HCPCS 270 RC inpatient 9 9 BLUE CROSS BLUE SHIELD WELLMARK SB889 [3081026] BCBS WYOMING [308102603] 8.55 percent of total billed charges 5.58 8.55 Technical (Hospital) Services HC/HH Wch Supp Padding Cast Synthetic 4x4__Cmw04 PX-2705000112 CDM A9999 HCPCS 270 RC inpatient 9 9 MULTIPLAN INC 34080 [3081285] MULTIPLAN INC [308128501] 8.55 percent of total billed charges 5.58 8.55 Technical (Hospital) Services HC/HH Wch Supp Padding Cast Synthetic 4x4__Cmw04 PX-2705000112 CDM A9999 HCPCS 270 RC inpatient 9 9 HEALTHPARTNERS SX009 HEALTHPARTNERS 7.13 percent of total billed charges 5.58 8.55 Technical (Hospital) Services HC/HH Wch Supp Padding Cast Synthetic 4x4__Cmw04 PX-2705000112 CDM A9999 HCPCS 270 RC inpatient 9 9 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES EPO [308136803] 7.13 percent of total billed charges 5.58 8.55 Technical (Hospital) Services HC/HH Wch Supp Padding Cast Synthetic 4x4__Cmw04 PX-2705000112 CDM A9999 HCPCS 270 RC inpatient 9 9 MEDICA (COMMERCIAL) 94265 [3081118] MEDICA CLAIMS [308111801] 8.1 percent of total billed charges 5.58 8.55 Technical (Hospital) Services HC/HH Wch Supp Padding Cast Synthetic 4x4__Cmw04 PX-2705000112 CDM A9999 HCPCS 270 RC inpatient 9 9 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES HDHP [308136802] 7.13 percent of total billed charges 5.58 8.55 Technical (Hospital) Services HC/HH Wch Supp Padding Cast Synthetic 4x4__Cmw04 PX-2705000112 CDM A9999 HCPCS 270 RC inpatient 9 9 UNITED HEALTHCARE (COMMERCIAL) [3081199] UNITED HEALTHCARE 87726 [308119901] 5.58 percent of total billed charges 5.58 8.55 Technical (Hospital) Services HC/HH Wch Supp Padding Cast Synthetic 4x4__Cmw04 PX-2705000112 CDM A9999 HCPCS 270 RC inpatient 9 9 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES PPO [308136801] 7.13 percent of total billed charges 5.58 8.55 Technical (Hospital) Services HC/HH Wch Supp Padding Cast Synthetic 4x4__Cmw04 PX-2705000112 CDM A9999 HCPCS 270 RC outpatient 9 9 CIGNA 62308 [3081051] CIGNA 62308 [308105105] 7.2 percent of total billed charges 5.58 8.55 Technical (Hospital) Services HC/HH Wch Supp Padding Cast Synthetic 4x4__Cmw04 PX-2705000112 CDM A9999 HCPCS 270 RC outpatient 9 9 CIGNA 62308 [3081051] CIGNA STATE OF WYOMING [308105107] 7.2 percent of total billed charges 5.58 8.55 Technical (Hospital) Services HC/HH Wch Supp Padding Cast Synthetic 4x4__Cmw04 PX-2705000112 CDM A9999 HCPCS 270 RC outpatient 9 9 BLUE CROSS BLUE SHIELD WELLMARK SB889 [3081026] BCBS WYOMING [308102603] 8.55 percent of total billed charges 5.58 8.55 Technical (Hospital) Services HC/HH Wch Supp Padding Cast Synthetic 4x4__Cmw04 PX-2705000112 CDM A9999 HCPCS 270 RC outpatient 9 9 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES EPO [308136803] 7.2 percent of total billed charges 5.58 8.55 Technical (Hospital) Services HC/HH Wch Supp Padding Cast Synthetic 4x4__Cmw04 PX-2705000112 CDM A9999 HCPCS 270 RC outpatient 9 9 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES HDHP [308136802] 7.2 percent of total billed charges 5.58 8.55 Technical (Hospital) Services HC/HH Wch Supp Padding Cast Synthetic 4x4__Cmw04 PX-2705000112 CDM A9999 HCPCS 270 RC outpatient 9 9 HEALTHPARTNERS SX009 HEALTHPARTNERS 7.2 percent of total billed charges 5.58 8.55 Technical (Hospital) Services HC/HH Wch Supp Padding Cast Synthetic 4x4__Cmw04 PX-2705000112 CDM A9999 HCPCS 270 RC outpatient 9 9 UNITED HEALTHCARE (COMMERCIAL) [3081199] UNITED HEALTHCARE 87726 [308119901] 5.58 percent of total billed charges 5.58 8.55 Technical (Hospital) Services HC/HH Wch Supp Padding Cast Synthetic 4x4__Cmw04 PX-2705000112 CDM A9999 HCPCS 270 RC outpatient 9 9 MEDICA (COMMERCIAL) 94265 [3081118] MEDICA CLAIMS [308111801] 8.1 percent of total billed charges 5.58 8.55 Technical (Hospital) Services HC/HH Wch Supp Padding Cast Synthetic 4x4__Cmw04 PX-2705000112 CDM A9999 HCPCS 270 RC outpatient 9 9 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES PPO [308136801] 7.2 percent of total billed charges 5.58 8.55 Technical (Hospital) Services HC/HH Wch Supp Padding Cast Synthetic 4x4__Cmw04 PX-2705000112 CDM A9999 HCPCS 270 RC outpatient 9 9 MULTIPLAN INC 34080 [3081285] MULTIPLAN INC [308128501] 8.55 percent of total billed charges 5.58 8.55 Technical (Hospital) Services HC/HH Wch Supp Syringe Ecc Tip 10cc__305482 PX-2705000173 CDM A9999 HCPCS 270 RC inpatient 5 5 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES PPO [308136801] 3.96 percent of total billed charges 3.1 4.75 Technical (Hospital) Services HC/HH Wch Supp Syringe Ecc Tip 10cc__305482 PX-2705000173 CDM A9999 HCPCS 270 RC inpatient 5 5 MEDICA (COMMERCIAL) 94265 [3081118] MEDICA CLAIMS [308111801] 4.5 percent of total billed charges 3.1 4.75 Technical (Hospital) Services HC/HH Wch Supp Syringe Ecc Tip 10cc__305482 PX-2705000173 CDM A9999 HCPCS 270 RC inpatient 5 5 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES HDHP [308136802] 3.96 percent of total billed charges 3.1 4.75 Technical (Hospital) Services HC/HH Wch Supp Syringe Ecc Tip 10cc__305482 PX-2705000173 CDM A9999 HCPCS 270 RC inpatient 5 5 UNITED HEALTHCARE (COMMERCIAL) [3081199] UNITED HEALTHCARE 87726 [308119901] 3.1 percent of total billed charges 3.1 4.75 Technical (Hospital) Services HC/HH Wch Supp Syringe Ecc Tip 10cc__305482 PX-2705000173 CDM A9999 HCPCS 270 RC inpatient 5 5 BLUE CROSS BLUE SHIELD WELLMARK SB889 [3081026] BCBS WYOMING [308102603] 4.75 percent of total billed charges 3.1 4.75 Technical (Hospital) Services HC/HH Wch Supp Syringe Ecc Tip 10cc__305482 PX-2705000173 CDM A9999 HCPCS 270 RC inpatient 5 5 MULTIPLAN INC 34080 [3081285] MULTIPLAN INC [308128501] 4.75 percent of total billed charges 3.1 4.75 Technical (Hospital) Services HC/HH Wch Supp Syringe Ecc Tip 10cc__305482 PX-2705000173 CDM A9999 HCPCS 270 RC inpatient 5 5 CIGNA 62308 [3081051] CIGNA 62308 [308105105] 3.96 percent of total billed charges 3.1 4.75 Technical (Hospital) Services HC/HH Wch Supp Syringe Ecc Tip 10cc__305482 PX-2705000173 CDM A9999 HCPCS 270 RC inpatient 5 5 CIGNA 62308 [3081051] CIGNA STATE OF WYOMING [308105107] 3.96 percent of total billed charges 3.1 4.75 Technical (Hospital) Services HC/HH Wch Supp Syringe Ecc Tip 10cc__305482 PX-2705000173 CDM A9999 HCPCS 270 RC inpatient 5 5 HEALTHPARTNERS SX009 HEALTHPARTNERS 3.96 percent of total billed charges 3.1 4.75 Technical (Hospital) Services HC/HH Wch Supp Syringe Ecc Tip 10cc__305482 PX-2705000173 CDM A9999 HCPCS 270 RC inpatient 5 5 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES EPO [308136803] 3.96 percent of total billed charges 3.1 4.75 Technical (Hospital) Services HC/HH Wch Supp Syringe Ecc Tip 10cc__305482 PX-2705000173 CDM A9999 HCPCS 270 RC outpatient 5 5 MULTIPLAN INC 34080 [3081285] MULTIPLAN INC [308128501] 4.75 percent of total billed charges 3.1 4.75 Technical (Hospital) Services HC/HH Wch Supp Syringe Ecc Tip 10cc__305482 PX-2705000173 CDM A9999 HCPCS 270 RC outpatient 5 5 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES PPO [308136801] 4 percent of total billed charges 3.1 4.75 Technical (Hospital) Services HC/HH Wch Supp Syringe Ecc Tip 10cc__305482 PX-2705000173 CDM A9999 HCPCS 270 RC outpatient 5 5 MEDICA (COMMERCIAL) 94265 [3081118] MEDICA CLAIMS [308111801] 4.5 percent of total billed charges 3.1 4.75 Technical (Hospital) Services HC/HH Wch Supp Syringe Ecc Tip 10cc__305482 PX-2705000173 CDM A9999 HCPCS 270 RC outpatient 5 5 HEALTHPARTNERS SX009 HEALTHPARTNERS 4 percent of total billed charges 3.1 4.75 Technical (Hospital) Services HC/HH Wch Supp Syringe Ecc Tip 10cc__305482 PX-2705000173 CDM A9999 HCPCS 270 RC outpatient 5 5 UNITED HEALTHCARE (COMMERCIAL) [3081199] UNITED HEALTHCARE 87726 [308119901] 3.1 percent of total billed charges 3.1 4.75 Technical (Hospital) Services HC/HH Wch Supp Syringe Ecc Tip 10cc__305482 PX-2705000173 CDM A9999 HCPCS 270 RC outpatient 5 5 CIGNA 62308 [3081051] CIGNA 62308 [308105105] 4 percent of total billed charges 3.1 4.75 Technical (Hospital) Services HC/HH Wch Supp Syringe Ecc Tip 10cc__305482 PX-2705000173 CDM A9999 HCPCS 270 RC outpatient 5 5 CIGNA 62308 [3081051] CIGNA STATE OF WYOMING [308105107] 4 percent of total billed charges 3.1 4.75 Technical (Hospital) Services HC/HH Wch Supp Syringe Ecc Tip 10cc__305482 PX-2705000173 CDM A9999 HCPCS 270 RC outpatient 5 5 BLUE CROSS BLUE SHIELD WELLMARK SB889 [3081026] BCBS WYOMING [308102603] 4.75 percent of total billed charges 3.1 4.75 Technical (Hospital) Services HC/HH Wch Supp Syringe Ecc Tip 10cc__305482 PX-2705000173 CDM A9999 HCPCS 270 RC outpatient 5 5 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES EPO [308136803] 4 percent of total billed charges 3.1 4.75 Technical (Hospital) Services HC/HH Wch Supp Syringe Ecc Tip 10cc__305482 PX-2705000173 CDM A9999 HCPCS 270 RC outpatient 5 5 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES HDHP [308136802] 4 percent of total billed charges 3.1 4.75 Technical (Hospital) Services HC/HH Wch Supp Coban 2 Layer Lite PX-2705000242 CDM A6442 HCPCS 270 RC outpatient 50 50 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES EPO [308136803] 40 percent of total billed charges 31 47.5 Technical (Hospital) Services HC/HH Wch Supp Coban 2 Layer Lite PX-2705000242 CDM A6442 HCPCS 270 RC outpatient 50 50 BLUE CROSS BLUE SHIELD WELLMARK SB889 [3081026] BCBS WYOMING [308102603] 47.5 percent of total billed charges 31 47.5 Technical (Hospital) Services HC/HH Wch Supp Coban 2 Layer Lite PX-2705000242 CDM A6442 HCPCS 270 RC outpatient 50 50 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES HDHP [308136802] 40 percent of total billed charges 31 47.5 Technical (Hospital) Services HC/HH Wch Supp Coban 2 Layer Lite PX-2705000242 CDM A6442 HCPCS 270 RC outpatient 50 50 UNITED HEALTHCARE (COMMERCIAL) [3081199] UNITED HEALTHCARE 87726 [308119901] 31 percent of total billed charges 31 47.5 Technical (Hospital) Services HC/HH Wch Supp Coban 2 Layer Lite PX-2705000242 CDM A6442 HCPCS 270 RC outpatient 50 50 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES PPO [308136801] 40 percent of total billed charges 31 47.5 Technical (Hospital) Services HC/HH Wch Supp Coban 2 Layer Lite PX-2705000242 CDM A6442 HCPCS 270 RC outpatient 50 50 HEALTHPARTNERS SX009 HEALTHPARTNERS 40 percent of total billed charges 31 47.5 Technical (Hospital) Services HC/HH Wch Supp Coban 2 Layer Lite PX-2705000242 CDM A6442 HCPCS 270 RC outpatient 50 50 MULTIPLAN INC 34080 [3081285] MULTIPLAN INC [308128501] 47.5 percent of total billed charges 31 47.5 Technical (Hospital) Services HC/HH Wch Supp Coban 2 Layer Lite PX-2705000242 CDM A6442 HCPCS 270 RC outpatient 50 50 CIGNA 62308 [3081051] CIGNA 62308 [308105105] 40 percent of total billed charges 31 47.5 Technical (Hospital) Services HC/HH Wch Supp Coban 2 Layer Lite PX-2705000242 CDM A6442 HCPCS 270 RC outpatient 50 50 CIGNA 62308 [3081051] CIGNA STATE OF WYOMING [308105107] 40 percent of total billed charges 31 47.5 Technical (Hospital) Services HC/HH Wch Supp Coban 2 Layer Lite PX-2705000242 CDM A6442 HCPCS 270 RC outpatient 50 50 MEDICA (COMMERCIAL) 94265 [3081118] MEDICA CLAIMS [308111801] 45 percent of total billed charges 31 47.5 Technical (Hospital) Services HC/HH Wch Supp Coban 2 Layer Lite PX-2705000242 CDM A6442 HCPCS 270 RC inpatient 50 50 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES PPO [308136801] 39.59 percent of total billed charges 31 47.5 Technical (Hospital) Services HC/HH Wch Supp Coban 2 Layer Lite PX-2705000242 CDM A6442 HCPCS 270 RC inpatient 50 50 MEDICA (COMMERCIAL) 94265 [3081118] MEDICA CLAIMS [308111801] 45 percent of total billed charges 31 47.5 Technical (Hospital) Services HC/HH Wch Supp Coban 2 Layer Lite PX-2705000242 CDM A6442 HCPCS 270 RC inpatient 50 50 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES HDHP [308136802] 39.59 percent of total billed charges 31 47.5 Technical (Hospital) Services HC/HH Wch Supp Coban 2 Layer Lite PX-2705000242 CDM A6442 HCPCS 270 RC inpatient 50 50 UNITED HEALTHCARE (COMMERCIAL) [3081199] UNITED HEALTHCARE 87726 [308119901] 31 percent of total billed charges 31 47.5 Technical (Hospital) Services HC/HH Wch Supp Coban 2 Layer Lite PX-2705000242 CDM A6442 HCPCS 270 RC inpatient 50 50 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES EPO [308136803] 39.59 percent of total billed charges 31 47.5 Technical (Hospital) Services HC/HH Wch Supp Coban 2 Layer Lite PX-2705000242 CDM A6442 HCPCS 270 RC inpatient 50 50 MULTIPLAN INC 34080 [3081285] MULTIPLAN INC [308128501] 47.5 percent of total billed charges 31 47.5 Technical (Hospital) Services HC/HH Wch Supp Coban 2 Layer Lite PX-2705000242 CDM A6442 HCPCS 270 RC inpatient 50 50 BLUE CROSS BLUE SHIELD WELLMARK SB889 [3081026] BCBS WYOMING [308102603] 47.5 percent of total billed charges 31 47.5 Technical (Hospital) Services HC/HH Wch Supp Coban 2 Layer Lite PX-2705000242 CDM A6442 HCPCS 270 RC inpatient 50 50 HEALTHPARTNERS SX009 HEALTHPARTNERS 39.59 percent of total billed charges 31 47.5 Technical (Hospital) Services HC/HH Wch Supp Coban 2 Layer Lite PX-2705000242 CDM A6442 HCPCS 270 RC inpatient 50 50 CIGNA 62308 [3081051] CIGNA 62308 [308105105] 39.59 percent of total billed charges 31 47.5 Technical (Hospital) Services HC/HH Wch Supp Coban 2 Layer Lite PX-2705000242 CDM A6442 HCPCS 270 RC inpatient 50 50 CIGNA 62308 [3081051] CIGNA STATE OF WYOMING [308105107] 39.59 percent of total billed charges 31 47.5 Technical (Hospital) Services HC/HH Wch Supp Bndg Cnfrm Stretch St 2x75__2231 PX-2725000005 CDM A6442 HCPCS 272 RC inpatient 5 5 UNITED HEALTHCARE (COMMERCIAL) [3081199] UNITED HEALTHCARE 87726 [308119901] 3.1 percent of total billed charges 3.1 4.75 Technical (Hospital) Services HC/HH Wch Supp Bndg Cnfrm Stretch St 2x75__2231 PX-2725000005 CDM A6442 HCPCS 272 RC inpatient 5 5 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES HDHP [308136802] 3.96 percent of total billed charges 3.1 4.75 Technical (Hospital) Services HC/HH Wch Supp Bndg Cnfrm Stretch St 2x75__2231 PX-2725000005 CDM A6442 HCPCS 272 RC inpatient 5 5 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES PPO [308136801] 3.96 percent of total billed charges 3.1 4.75 Technical (Hospital) Services HC/HH Wch Supp Bndg Cnfrm Stretch St 2x75__2231 PX-2725000005 CDM A6442 HCPCS 272 RC inpatient 5 5 MEDICA (COMMERCIAL) 94265 [3081118] MEDICA CLAIMS [308111801] 4.5 percent of total billed charges 3.1 4.75 Technical (Hospital) Services HC/HH Wch Supp Bndg Cnfrm Stretch St 2x75__2231 PX-2725000005 CDM A6442 HCPCS 272 RC inpatient 5 5 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES EPO [308136803] 3.96 percent of total billed charges 3.1 4.75 Technical (Hospital) Services HC/HH Wch Supp Bndg Cnfrm Stretch St 2x75__2231 PX-2725000005 CDM A6442 HCPCS 272 RC inpatient 5 5 HEALTHPARTNERS SX009 HEALTHPARTNERS 3.96 percent of total billed charges 3.1 4.75 Technical (Hospital) Services HC/HH Wch Supp Bndg Cnfrm Stretch St 2x75__2231 PX-2725000005 CDM A6442 HCPCS 272 RC inpatient 5 5 BLUE CROSS BLUE SHIELD WELLMARK SB889 [3081026] BCBS WYOMING [308102603] 4.75 percent of total billed charges 3.1 4.75 Technical (Hospital) Services HC/HH Wch Supp Bndg Cnfrm Stretch St 2x75__2231 PX-2725000005 CDM A6442 HCPCS 272 RC inpatient 5 5 MULTIPLAN INC 34080 [3081285] MULTIPLAN INC [308128501] 4.75 percent of total billed charges 3.1 4.75 Technical (Hospital) Services HC/HH Wch Supp Bndg Cnfrm Stretch St 2x75__2231 PX-2725000005 CDM A6442 HCPCS 272 RC inpatient 5 5 CIGNA 62308 [3081051] CIGNA 62308 [308105105] 3.96 percent of total billed charges 3.1 4.75 Technical (Hospital) Services HC/HH Wch Supp Bndg Cnfrm Stretch St 2x75__2231 PX-2725000005 CDM A6442 HCPCS 272 RC inpatient 5 5 CIGNA 62308 [3081051] CIGNA STATE OF WYOMING [308105107] 3.96 percent of total billed charges 3.1 4.75 Technical (Hospital) Services HC/HH Wch Supp Bndg Cnfrm Stretch St 2x75__2231 PX-2725000005 CDM A6442 HCPCS 272 RC outpatient 5 5 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES HDHP [308136802] 4 percent of total billed charges 3.1 4.75 Technical (Hospital) Services HC/HH Wch Supp Bndg Cnfrm Stretch St 2x75__2231 PX-2725000005 CDM A6442 HCPCS 272 RC outpatient 5 5 BLUE CROSS BLUE SHIELD WELLMARK SB889 [3081026] BCBS WYOMING [308102603] 4.75 percent of total billed charges 3.1 4.75 Technical (Hospital) Services HC/HH Wch Supp Bndg Cnfrm Stretch St 2x75__2231 PX-2725000005 CDM A6442 HCPCS 272 RC outpatient 5 5 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES EPO [308136803] 4 percent of total billed charges 3.1 4.75 Technical (Hospital) Services HC/HH Wch Supp Bndg Cnfrm Stretch St 2x75__2231 PX-2725000005 CDM A6442 HCPCS 272 RC outpatient 5 5 UNITED HEALTHCARE (COMMERCIAL) [3081199] UNITED HEALTHCARE 87726 [308119901] 3.1 percent of total billed charges 3.1 4.75 Technical (Hospital) Services HC/HH Wch Supp Bndg Cnfrm Stretch St 2x75__2231 PX-2725000005 CDM A6442 HCPCS 272 RC outpatient 5 5 HEALTHPARTNERS SX009 HEALTHPARTNERS 4 percent of total billed charges 3.1 4.75 Technical (Hospital) Services HC/HH Wch Supp Bndg Cnfrm Stretch St 2x75__2231 PX-2725000005 CDM A6442 HCPCS 272 RC outpatient 5 5 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES PPO [308136801] 4 percent of total billed charges 3.1 4.75 Technical (Hospital) Services HC/HH Wch Supp Bndg Cnfrm Stretch St 2x75__2231 PX-2725000005 CDM A6442 HCPCS 272 RC outpatient 5 5 CIGNA 62308 [3081051] CIGNA 62308 [308105105] 4 percent of total billed charges 3.1 4.75 Technical (Hospital) Services HC/HH Wch Supp Bndg Cnfrm Stretch St 2x75__2231 PX-2725000005 CDM A6442 HCPCS 272 RC outpatient 5 5 CIGNA 62308 [3081051] CIGNA STATE OF WYOMING [308105107] 4 percent of total billed charges 3.1 4.75 Technical (Hospital) Services HC/HH Wch Supp Bndg Cnfrm Stretch St 2x75__2231 PX-2725000005 CDM A6442 HCPCS 272 RC outpatient 5 5 MEDICA (COMMERCIAL) 94265 [3081118] MEDICA CLAIMS [308111801] 4.5 percent of total billed charges 3.1 4.75 Technical (Hospital) Services HC/HH Wch Supp Bndg Cnfrm Stretch St 2x75__2231 PX-2725000005 CDM A6442 HCPCS 272 RC outpatient 5 5 MULTIPLAN INC 34080 [3081285] MULTIPLAN INC [308128501] 4.75 percent of total billed charges 3.1 4.75 Technical (Hospital) Services HC/HH Wch Supp Gauze Sterile 4x4 Tray (12ply)__6939 PX-2725000003 CDM A6402 HCPCS 272 RC outpatient 7 7 MEDICA (COMMERCIAL) 94265 [3081118] MEDICA CLAIMS [308111801] 6.3 percent of total billed charges 4.34 6.65 Technical (Hospital) Services HC/HH Wch Supp Gauze Sterile 4x4 Tray (12ply)__6939 PX-2725000003 CDM A6402 HCPCS 272 RC outpatient 7 7 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES PPO [308136801] 5.6 percent of total billed charges 4.34 6.65 Technical (Hospital) Services HC/HH Wch Supp Gauze Sterile 4x4 Tray (12ply)__6939 PX-2725000003 CDM A6402 HCPCS 272 RC outpatient 7 7 HEALTHPARTNERS SX009 HEALTHPARTNERS 5.6 percent of total billed charges 4.34 6.65 Technical (Hospital) Services HC/HH Wch Supp Gauze Sterile 4x4 Tray (12ply)__6939 PX-2725000003 CDM A6402 HCPCS 272 RC outpatient 7 7 MULTIPLAN INC 34080 [3081285] MULTIPLAN INC [308128501] 6.65 percent of total billed charges 4.34 6.65 Technical (Hospital) Services HC/HH Wch Supp Gauze Sterile 4x4 Tray (12ply)__6939 PX-2725000003 CDM A6402 HCPCS 272 RC outpatient 7 7 UNITED HEALTHCARE (COMMERCIAL) [3081199] UNITED HEALTHCARE 87726 [308119901] 4.34 percent of total billed charges 4.34 6.65 Technical (Hospital) Services HC/HH Wch Supp Gauze Sterile 4x4 Tray (12ply)__6939 PX-2725000003 CDM A6402 HCPCS 272 RC outpatient 7 7 CIGNA 62308 [3081051] CIGNA 62308 [308105105] 5.6 percent of total billed charges 4.34 6.65 Technical (Hospital) Services HC/HH Wch Supp Gauze Sterile 4x4 Tray (12ply)__6939 PX-2725000003 CDM A6402 HCPCS 272 RC outpatient 7 7 CIGNA 62308 [3081051] CIGNA STATE OF WYOMING [308105107] 5.6 percent of total billed charges 4.34 6.65 Technical (Hospital) Services HC/HH Wch Supp Gauze Sterile 4x4 Tray (12ply)__6939 PX-2725000003 CDM A6402 HCPCS 272 RC outpatient 7 7 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES HDHP [308136802] 5.6 percent of total billed charges 4.34 6.65 Technical (Hospital) Services HC/HH Wch Supp Gauze Sterile 4x4 Tray (12ply)__6939 PX-2725000003 CDM A6402 HCPCS 272 RC outpatient 7 7 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES EPO [308136803] 5.6 percent of total billed charges 4.34 6.65 Technical (Hospital) Services HC/HH Wch Supp Gauze Sterile 4x4 Tray (12ply)__6939 PX-2725000003 CDM A6402 HCPCS 272 RC outpatient 7 7 BLUE CROSS BLUE SHIELD WELLMARK SB889 [3081026] BCBS WYOMING [308102603] 6.65 percent of total billed charges 4.34 6.65 Technical (Hospital) Services HC/HH Wch Supp Gauze Sterile 4x4 Tray (12ply)__6939 PX-2725000003 CDM A6402 HCPCS 272 RC inpatient 7 7 CIGNA 62308 [3081051] CIGNA STATE OF WYOMING [308105107] 5.54 percent of total billed charges 4.34 6.65 Technical (Hospital) Services HC/HH Wch Supp Gauze Sterile 4x4 Tray (12ply)__6939 PX-2725000003 CDM A6402 HCPCS 272 RC inpatient 7 7 CIGNA 62308 [3081051] CIGNA 62308 [308105105] 5.54 percent of total billed charges 4.34 6.65 Technical (Hospital) Services HC/HH Wch Supp Gauze Sterile 4x4 Tray (12ply)__6939 PX-2725000003 CDM A6402 HCPCS 272 RC inpatient 7 7 HEALTHPARTNERS SX009 HEALTHPARTNERS 5.54 percent of total billed charges 4.34 6.65 Technical (Hospital) Services HC/HH Wch Supp Gauze Sterile 4x4 Tray (12ply)__6939 PX-2725000003 CDM A6402 HCPCS 272 RC inpatient 7 7 BLUE CROSS BLUE SHIELD WELLMARK SB889 [3081026] BCBS WYOMING [308102603] 6.65 percent of total billed charges 4.34 6.65 Technical (Hospital) Services HC/HH Wch Supp Gauze Sterile 4x4 Tray (12ply)__6939 PX-2725000003 CDM A6402 HCPCS 272 RC inpatient 7 7 MULTIPLAN INC 34080 [3081285] MULTIPLAN INC [308128501] 6.65 percent of total billed charges 4.34 6.65 Technical (Hospital) Services HC/HH Wch Supp Gauze Sterile 4x4 Tray (12ply)__6939 PX-2725000003 CDM A6402 HCPCS 272 RC inpatient 7 7 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES EPO [308136803] 5.54 percent of total billed charges 4.34 6.65 Technical (Hospital) Services HC/HH Wch Supp Gauze Sterile 4x4 Tray (12ply)__6939 PX-2725000003 CDM A6402 HCPCS 272 RC inpatient 7 7 MEDICA (COMMERCIAL) 94265 [3081118] MEDICA CLAIMS [308111801] 6.3 percent of total billed charges 4.34 6.65 Technical (Hospital) Services HC/HH Wch Supp Gauze Sterile 4x4 Tray (12ply)__6939 PX-2725000003 CDM A6402 HCPCS 272 RC inpatient 7 7 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES HDHP [308136802] 5.54 percent of total billed charges 4.34 6.65 Technical (Hospital) Services HC/HH Wch Supp Gauze Sterile 4x4 Tray (12ply)__6939 PX-2725000003 CDM A6402 HCPCS 272 RC inpatient 7 7 UNITED HEALTHCARE (COMMERCIAL) [3081199] UNITED HEALTHCARE 87726 [308119901] 4.34 percent of total billed charges 4.34 6.65 Technical (Hospital) Services HC/HH Wch Supp Gauze Sterile 4x4 Tray (12ply)__6939 PX-2725000003 CDM A6402 HCPCS 272 RC inpatient 7 7 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES PPO [308136801] 5.54 percent of total billed charges 4.34 6.65 Technical (Hospital) Services HC/HH Wch Supp Sponge Sterile 4x4 2pk__3033 PX-2725000004 CDM A6402 HCPCS 272 RC inpatient 6 6 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES PPO [308136801] 4.75 percent of total billed charges 3.72 5.7 Technical (Hospital) Services HC/HH Wch Supp Sponge Sterile 4x4 2pk__3033 PX-2725000004 CDM A6402 HCPCS 272 RC inpatient 6 6 MEDICA (COMMERCIAL) 94265 [3081118] MEDICA CLAIMS [308111801] 5.4 percent of total billed charges 3.72 5.7 Technical (Hospital) Services HC/HH Wch Supp Sponge Sterile 4x4 2pk__3033 PX-2725000004 CDM A6402 HCPCS 272 RC inpatient 6 6 UNITED HEALTHCARE (COMMERCIAL) [3081199] UNITED HEALTHCARE 87726 [308119901] 3.72 percent of total billed charges 3.72 5.7 Technical (Hospital) Services HC/HH Wch Supp Sponge Sterile 4x4 2pk__3033 PX-2725000004 CDM A6402 HCPCS 272 RC inpatient 6 6 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES HDHP [308136802] 4.75 percent of total billed charges 3.72 5.7 Technical (Hospital) Services HC/HH Wch Supp Sponge Sterile 4x4 2pk__3033 PX-2725000004 CDM A6402 HCPCS 272 RC inpatient 6 6 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES EPO [308136803] 4.75 percent of total billed charges 3.72 5.7 Technical (Hospital) Services HC/HH Wch Supp Sponge Sterile 4x4 2pk__3033 PX-2725000004 CDM A6402 HCPCS 272 RC inpatient 6 6 HEALTHPARTNERS SX009 HEALTHPARTNERS 4.75 percent of total billed charges 3.72 5.7 Technical (Hospital) Services HC/HH Wch Supp Sponge Sterile 4x4 2pk__3033 PX-2725000004 CDM A6402 HCPCS 272 RC inpatient 6 6 BLUE CROSS BLUE SHIELD WELLMARK SB889 [3081026] BCBS WYOMING [308102603] 5.7 percent of total billed charges 3.72 5.7 Technical (Hospital) Services HC/HH Wch Supp Sponge Sterile 4x4 2pk__3033 PX-2725000004 CDM A6402 HCPCS 272 RC inpatient 6 6 MULTIPLAN INC 34080 [3081285] MULTIPLAN INC [308128501] 5.7 percent of total billed charges 3.72 5.7 Technical (Hospital) Services HC/HH Wch Supp Sponge Sterile 4x4 2pk__3033 PX-2725000004 CDM A6402 HCPCS 272 RC inpatient 6 6 CIGNA 62308 [3081051] CIGNA 62308 [308105105] 4.75 percent of total billed charges 3.72 5.7 Technical (Hospital) Services HC/HH Wch Supp Sponge Sterile 4x4 2pk__3033 PX-2725000004 CDM A6402 HCPCS 272 RC inpatient 6 6 CIGNA 62308 [3081051] CIGNA STATE OF WYOMING [308105107] 4.75 percent of total billed charges 3.72 5.7 Technical (Hospital) Services HC/HH Wch Supp Sponge Sterile 4x4 2pk__3033 PX-2725000004 CDM A6402 HCPCS 272 RC outpatient 6 6 UNITED HEALTHCARE (COMMERCIAL) [3081199] UNITED HEALTHCARE 87726 [308119901] 3.72 percent of total billed charges 3.72 5.7 Technical (Hospital) Services HC/HH Wch Supp Sponge Sterile 4x4 2pk__3033 PX-2725000004 CDM A6402 HCPCS 272 RC outpatient 6 6 CIGNA 62308 [3081051] CIGNA 62308 [308105105] 4.8 percent of total billed charges 3.72 5.7 Technical (Hospital) Services HC/HH Wch Supp Sponge Sterile 4x4 2pk__3033 PX-2725000004 CDM A6402 HCPCS 272 RC outpatient 6 6 CIGNA 62308 [3081051] CIGNA STATE OF WYOMING [308105107] 4.8 percent of total billed charges 3.72 5.7 Technical (Hospital) Services HC/HH Wch Supp Sponge Sterile 4x4 2pk__3033 PX-2725000004 CDM A6402 HCPCS 272 RC outpatient 6 6 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES HDHP [308136802] 4.8 percent of total billed charges 3.72 5.7 Technical (Hospital) Services HC/HH Wch Supp Sponge Sterile 4x4 2pk__3033 PX-2725000004 CDM A6402 HCPCS 272 RC outpatient 6 6 BLUE CROSS BLUE SHIELD WELLMARK SB889 [3081026] BCBS WYOMING [308102603] 5.7 percent of total billed charges 3.72 5.7 Technical (Hospital) Services HC/HH Wch Supp Sponge Sterile 4x4 2pk__3033 PX-2725000004 CDM A6402 HCPCS 272 RC outpatient 6 6 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES EPO [308136803] 4.8 percent of total billed charges 3.72 5.7 Technical (Hospital) Services HC/HH Wch Supp Sponge Sterile 4x4 2pk__3033 PX-2725000004 CDM A6402 HCPCS 272 RC outpatient 6 6 MEDICA (COMMERCIAL) 94265 [3081118] MEDICA CLAIMS [308111801] 5.4 percent of total billed charges 3.72 5.7 Technical (Hospital) Services HC/HH Wch Supp Sponge Sterile 4x4 2pk__3033 PX-2725000004 CDM A6402 HCPCS 272 RC outpatient 6 6 HEALTHPARTNERS SX009 HEALTHPARTNERS 4.8 percent of total billed charges 3.72 5.7 Technical (Hospital) Services HC/HH Wch Supp Sponge Sterile 4x4 2pk__3033 PX-2725000004 CDM A6402 HCPCS 272 RC outpatient 6 6 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES PPO [308136801] 4.8 percent of total billed charges 3.72 5.7 Technical (Hospital) Services HC/HH Wch Supp Sponge Sterile 4x4 2pk__3033 PX-2725000004 CDM A6402 HCPCS 272 RC outpatient 6 6 MULTIPLAN INC 34080 [3081285] MULTIPLAN INC [308128501] 5.7 percent of total billed charges 3.72 5.7 Technical (Hospital) Services HC/HH Wch Supp Suture Remover Kit__723 PX-2725000002 CDM A4649 HCPCS 272 RC inpatient 7 7 CIGNA 62308 [3081051] CIGNA 62308 [308105105] 5.54 percent of total billed charges 4.34 6.65 Technical (Hospital) Services HC/HH Wch Supp Suture Remover Kit__723 PX-2725000002 CDM A4649 HCPCS 272 RC inpatient 7 7 CIGNA 62308 [3081051] CIGNA STATE OF WYOMING [308105107] 5.54 percent of total billed charges 4.34 6.65 Technical (Hospital) Services HC/HH Wch Supp Suture Remover Kit__723 PX-2725000002 CDM A4649 HCPCS 272 RC inpatient 7 7 BLUE CROSS BLUE SHIELD WELLMARK SB889 [3081026] BCBS WYOMING [308102603] 6.65 percent of total billed charges 4.34 6.65 Technical (Hospital) Services HC/HH Wch Supp Suture Remover Kit__723 PX-2725000002 CDM A4649 HCPCS 272 RC inpatient 7 7 MULTIPLAN INC 34080 [3081285] MULTIPLAN INC [308128501] 6.65 percent of total billed charges 4.34 6.65 Technical (Hospital) Services HC/HH Wch Supp Suture Remover Kit__723 PX-2725000002 CDM A4649 HCPCS 272 RC inpatient 7 7 HEALTHPARTNERS SX009 HEALTHPARTNERS 5.54 percent of total billed charges 4.34 6.65 Technical (Hospital) Services HC/HH Wch Supp Suture Remover Kit__723 PX-2725000002 CDM A4649 HCPCS 272 RC inpatient 7 7 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES EPO [308136803] 5.54 percent of total billed charges 4.34 6.65 Technical (Hospital) Services HC/HH Wch Supp Suture Remover Kit__723 PX-2725000002 CDM A4649 HCPCS 272 RC inpatient 7 7 MEDICA (COMMERCIAL) 94265 [3081118] MEDICA CLAIMS [308111801] 6.3 percent of total billed charges 4.34 6.65 Technical (Hospital) Services HC/HH Wch Supp Suture Remover Kit__723 PX-2725000002 CDM A4649 HCPCS 272 RC inpatient 7 7 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES PPO [308136801] 5.54 percent of total billed charges 4.34 6.65 Technical (Hospital) Services HC/HH Wch Supp Suture Remover Kit__723 PX-2725000002 CDM A4649 HCPCS 272 RC inpatient 7 7 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES HDHP [308136802] 5.54 percent of total billed charges 4.34 6.65 Technical (Hospital) Services HC/HH Wch Supp Suture Remover Kit__723 PX-2725000002 CDM A4649 HCPCS 272 RC inpatient 7 7 UNITED HEALTHCARE (COMMERCIAL) [3081199] UNITED HEALTHCARE 87726 [308119901] 4.34 percent of total billed charges 4.34 6.65 Technical (Hospital) Services HC/HH Wch Supp Suture Remover Kit__723 PX-2725000002 CDM A4649 HCPCS 272 RC outpatient 7 7 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES HDHP [308136802] 5.6 percent of total billed charges 4.34 6.65 Technical (Hospital) Services HC/HH Wch Supp Suture Remover Kit__723 PX-2725000002 CDM A4649 HCPCS 272 RC outpatient 7 7 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES EPO [308136803] 5.6 percent of total billed charges 4.34 6.65 Technical (Hospital) Services HC/HH Wch Supp Suture Remover Kit__723 PX-2725000002 CDM A4649 HCPCS 272 RC outpatient 7 7 BLUE CROSS BLUE SHIELD WELLMARK SB889 [3081026] BCBS WYOMING [308102603] 6.65 percent of total billed charges 4.34 6.65 Technical (Hospital) Services HC/HH Wch Supp Suture Remover Kit__723 PX-2725000002 CDM A4649 HCPCS 272 RC outpatient 7 7 CIGNA 62308 [3081051] CIGNA 62308 [308105105] 5.6 percent of total billed charges 4.34 6.65 Technical (Hospital) Services HC/HH Wch Supp Suture Remover Kit__723 PX-2725000002 CDM A4649 HCPCS 272 RC outpatient 7 7 CIGNA 62308 [3081051] CIGNA STATE OF WYOMING [308105107] 5.6 percent of total billed charges 4.34 6.65 Technical (Hospital) Services HC/HH Wch Supp Suture Remover Kit__723 PX-2725000002 CDM A4649 HCPCS 272 RC outpatient 7 7 UNITED HEALTHCARE (COMMERCIAL) [3081199] UNITED HEALTHCARE 87726 [308119901] 4.34 percent of total billed charges 4.34 6.65 Technical (Hospital) Services HC/HH Wch Supp Suture Remover Kit__723 PX-2725000002 CDM A4649 HCPCS 272 RC outpatient 7 7 HEALTHPARTNERS SX009 HEALTHPARTNERS 5.6 percent of total billed charges 4.34 6.65 Technical (Hospital) Services HC/HH Wch Supp Suture Remover Kit__723 PX-2725000002 CDM A4649 HCPCS 272 RC outpatient 7 7 MEDICA (COMMERCIAL) 94265 [3081118] MEDICA CLAIMS [308111801] 6.3 percent of total billed charges 4.34 6.65 Technical (Hospital) Services HC/HH Wch Supp Suture Remover Kit__723 PX-2725000002 CDM A4649 HCPCS 272 RC outpatient 7 7 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES PPO [308136801] 5.6 percent of total billed charges 4.34 6.65 Technical (Hospital) Services HC/HH Wch Supp Suture Remover Kit__723 PX-2725000002 CDM A4649 HCPCS 272 RC outpatient 7 7 MULTIPLAN INC 34080 [3081285] MULTIPLAN INC [308128501] 6.65 percent of total billed charges 4.34 6.65 Technical (Hospital) Services HC/HH Wch Supp Safe-T-Centesis Tray__Pig1260t PX-2725000001 CDM A4550 HCPCS 272 RC inpatient 152 152 MEDICA (COMMERCIAL) 94265 [3081118] MEDICA CLAIMS [308111801] 136.8 percent of total billed charges 94.24 144.4 Technical (Hospital) Services HC/HH Wch Supp Safe-T-Centesis Tray__Pig1260t PX-2725000001 CDM A4550 HCPCS 272 RC inpatient 152 152 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES PPO [308136801] 120.35 percent of total billed charges 94.24 144.4 Technical (Hospital) Services HC/HH Wch Supp Safe-T-Centesis Tray__Pig1260t PX-2725000001 CDM A4550 HCPCS 272 RC inpatient 152 152 UNITED HEALTHCARE (COMMERCIAL) [3081199] UNITED HEALTHCARE 87726 [308119901] 94.24 percent of total billed charges 94.24 144.4 Technical (Hospital) Services HC/HH Wch Supp Safe-T-Centesis Tray__Pig1260t PX-2725000001 CDM A4550 HCPCS 272 RC inpatient 152 152 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES HDHP [308136802] 120.35 percent of total billed charges 94.24 144.4 Technical (Hospital) Services HC/HH Wch Supp Safe-T-Centesis Tray__Pig1260t PX-2725000001 CDM A4550 HCPCS 272 RC inpatient 152 152 BLUE CROSS BLUE SHIELD WELLMARK SB889 [3081026] BCBS WYOMING [308102603] 144.4 percent of total billed charges 94.24 144.4 Technical (Hospital) Services HC/HH Wch Supp Safe-T-Centesis Tray__Pig1260t PX-2725000001 CDM A4550 HCPCS 272 RC inpatient 152 152 MULTIPLAN INC 34080 [3081285] MULTIPLAN INC [308128501] 144.4 percent of total billed charges 94.24 144.4 Technical (Hospital) Services HC/HH Wch Supp Safe-T-Centesis Tray__Pig1260t PX-2725000001 CDM A4550 HCPCS 272 RC inpatient 152 152 CIGNA 62308 [3081051] CIGNA 62308 [308105105] 120.35 percent of total billed charges 94.24 144.4 Technical (Hospital) Services HC/HH Wch Supp Safe-T-Centesis Tray__Pig1260t PX-2725000001 CDM A4550 HCPCS 272 RC inpatient 152 152 CIGNA 62308 [3081051] CIGNA STATE OF WYOMING [308105107] 120.35 percent of total billed charges 94.24 144.4 Technical (Hospital) Services HC/HH Wch Supp Safe-T-Centesis Tray__Pig1260t PX-2725000001 CDM A4550 HCPCS 272 RC inpatient 152 152 HEALTHPARTNERS SX009 HEALTHPARTNERS 120.35 percent of total billed charges 94.24 144.4 Technical (Hospital) Services HC/HH Wch Supp Safe-T-Centesis Tray__Pig1260t PX-2725000001 CDM A4550 HCPCS 272 RC inpatient 152 152 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES EPO [308136803] 120.35 percent of total billed charges 94.24 144.4 Technical (Hospital) Services HC/HH Wch Supp Safe-T-Centesis Tray__Pig1260t PX-2725000001 CDM A4550 HCPCS 272 RC outpatient 152 152 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES HDHP [308136802] 121.6 percent of total billed charges 94.24 144.4 Technical (Hospital) Services HC/HH Wch Supp Safe-T-Centesis Tray__Pig1260t PX-2725000001 CDM A4550 HCPCS 272 RC outpatient 152 152 BLUE CROSS BLUE SHIELD WELLMARK SB889 [3081026] BCBS WYOMING [308102603] 144.4 percent of total billed charges 94.24 144.4 Technical (Hospital) Services HC/HH Wch Supp Safe-T-Centesis Tray__Pig1260t PX-2725000001 CDM A4550 HCPCS 272 RC outpatient 152 152 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES EPO [308136803] 121.6 percent of total billed charges 94.24 144.4 Technical (Hospital) Services HC/HH Wch Supp Safe-T-Centesis Tray__Pig1260t PX-2725000001 CDM A4550 HCPCS 272 RC outpatient 152 152 CIGNA 62308 [3081051] CIGNA 62308 [308105105] 121.6 percent of total billed charges 94.24 144.4 Technical (Hospital) Services HC/HH Wch Supp Safe-T-Centesis Tray__Pig1260t PX-2725000001 CDM A4550 HCPCS 272 RC outpatient 152 152 CIGNA 62308 [3081051] CIGNA STATE OF WYOMING [308105107] 121.6 percent of total billed charges 94.24 144.4 Technical (Hospital) Services HC/HH Wch Supp Safe-T-Centesis Tray__Pig1260t PX-2725000001 CDM A4550 HCPCS 272 RC outpatient 152 152 HEALTHPARTNERS SX009 HEALTHPARTNERS 121.6 percent of total billed charges 94.24 144.4 Technical (Hospital) Services HC/HH Wch Supp Safe-T-Centesis Tray__Pig1260t PX-2725000001 CDM A4550 HCPCS 272 RC outpatient 152 152 UNITED HEALTHCARE (COMMERCIAL) [3081199] UNITED HEALTHCARE 87726 [308119901] 94.24 percent of total billed charges 94.24 144.4 Technical (Hospital) Services HC/HH Wch Supp Safe-T-Centesis Tray__Pig1260t PX-2725000001 CDM A4550 HCPCS 272 RC outpatient 152 152 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES PPO [308136801] 121.6 percent of total billed charges 94.24 144.4 Technical (Hospital) Services HC/HH Wch Supp Safe-T-Centesis Tray__Pig1260t PX-2725000001 CDM A4550 HCPCS 272 RC outpatient 152 152 MULTIPLAN INC 34080 [3081285] MULTIPLAN INC [308128501] 144.4 percent of total billed charges 94.24 144.4 Technical (Hospital) Services HC/HH Wch Supp Safe-T-Centesis Tray__Pig1260t PX-2725000001 CDM A4550 HCPCS 272 RC outpatient 152 152 MEDICA (COMMERCIAL) 94265 [3081118] MEDICA CLAIMS [308111801] 136.8 percent of total billed charges 94.24 144.4 Technical (Hospital) Services HC/HH Wch Supp Spray No Sting Barrier__3346 PX-2705000159 CDM A4369 HCPCS 270 RC inpatient 62 62 CIGNA 62308 [3081051] CIGNA 62308 [308105105] 49.09 percent of total billed charges 38.44 58.9 Technical (Hospital) Services HC/HH Wch Supp Spray No Sting Barrier__3346 PX-2705000159 CDM A4369 HCPCS 270 RC inpatient 62 62 CIGNA 62308 [3081051] CIGNA STATE OF WYOMING [308105107] 49.09 percent of total billed charges 38.44 58.9 Technical (Hospital) Services HC/HH Wch Supp Spray No Sting Barrier__3346 PX-2705000159 CDM A4369 HCPCS 270 RC inpatient 62 62 MULTIPLAN INC 34080 [3081285] MULTIPLAN INC [308128501] 58.9 percent of total billed charges 38.44 58.9 Technical (Hospital) Services HC/HH Wch Supp Spray No Sting Barrier__3346 PX-2705000159 CDM A4369 HCPCS 270 RC inpatient 62 62 BLUE CROSS BLUE SHIELD WELLMARK SB889 [3081026] BCBS WYOMING [308102603] 58.9 percent of total billed charges 38.44 58.9 Technical (Hospital) Services HC/HH Wch Supp Spray No Sting Barrier__3346 PX-2705000159 CDM A4369 HCPCS 270 RC inpatient 62 62 HEALTHPARTNERS SX009 HEALTHPARTNERS 49.09 percent of total billed charges 38.44 58.9 Technical (Hospital) Services HC/HH Wch Supp Spray No Sting Barrier__3346 PX-2705000159 CDM A4369 HCPCS 270 RC inpatient 62 62 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES EPO [308136803] 49.09 percent of total billed charges 38.44 58.9 Technical (Hospital) Services HC/HH Wch Supp Spray No Sting Barrier__3346 PX-2705000159 CDM A4369 HCPCS 270 RC inpatient 62 62 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES HDHP [308136802] 49.09 percent of total billed charges 38.44 58.9 Technical (Hospital) Services HC/HH Wch Supp Spray No Sting Barrier__3346 PX-2705000159 CDM A4369 HCPCS 270 RC inpatient 62 62 UNITED HEALTHCARE (COMMERCIAL) [3081199] UNITED HEALTHCARE 87726 [308119901] 38.44 percent of total billed charges 38.44 58.9 Technical (Hospital) Services HC/HH Wch Supp Spray No Sting Barrier__3346 PX-2705000159 CDM A4369 HCPCS 270 RC inpatient 62 62 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES PPO [308136801] 49.09 percent of total billed charges 38.44 58.9 Technical (Hospital) Services HC/HH Wch Supp Spray No Sting Barrier__3346 PX-2705000159 CDM A4369 HCPCS 270 RC inpatient 62 62 MEDICA (COMMERCIAL) 94265 [3081118] MEDICA CLAIMS [308111801] 55.8 percent of total billed charges 38.44 58.9 Technical (Hospital) Services HC/HH Wch Supp Spray No Sting Barrier__3346 PX-2705000159 CDM A4369 HCPCS 270 RC outpatient 62 62 BLUE CROSS BLUE SHIELD WELLMARK SB889 [3081026] BCBS WYOMING [308102603] 58.9 percent of total billed charges 38.44 58.9 Technical (Hospital) Services HC/HH Wch Supp Spray No Sting Barrier__3346 PX-2705000159 CDM A4369 HCPCS 270 RC outpatient 62 62 CIGNA 62308 [3081051] CIGNA 62308 [308105105] 49.6 percent of total billed charges 38.44 58.9 Technical (Hospital) Services HC/HH Wch Supp Spray No Sting Barrier__3346 PX-2705000159 CDM A4369 HCPCS 270 RC outpatient 62 62 CIGNA 62308 [3081051] CIGNA STATE OF WYOMING [308105107] 49.6 percent of total billed charges 38.44 58.9 Technical (Hospital) Services HC/HH Wch Supp Spray No Sting Barrier__3346 PX-2705000159 CDM A4369 HCPCS 270 RC outpatient 62 62 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES EPO [308136803] 49.6 percent of total billed charges 38.44 58.9 Technical (Hospital) Services HC/HH Wch Supp Spray No Sting Barrier__3346 PX-2705000159 CDM A4369 HCPCS 270 RC outpatient 62 62 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES HDHP [308136802] 49.6 percent of total billed charges 38.44 58.9 Technical (Hospital) Services HC/HH Wch Supp Spray No Sting Barrier__3346 PX-2705000159 CDM A4369 HCPCS 270 RC outpatient 62 62 UNITED HEALTHCARE (COMMERCIAL) [3081199] UNITED HEALTHCARE 87726 [308119901] 38.44 percent of total billed charges 38.44 58.9 Technical (Hospital) Services HC/HH Wch Supp Spray No Sting Barrier__3346 PX-2705000159 CDM A4369 HCPCS 270 RC outpatient 62 62 HEALTHPARTNERS SX009 HEALTHPARTNERS 49.6 percent of total billed charges 38.44 58.9 Technical (Hospital) Services HC/HH Wch Supp Spray No Sting Barrier__3346 PX-2705000159 CDM A4369 HCPCS 270 RC outpatient 62 62 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES PPO [308136801] 49.6 percent of total billed charges 38.44 58.9 Technical (Hospital) Services HC/HH Wch Supp Spray No Sting Barrier__3346 PX-2705000159 CDM A4369 HCPCS 270 RC outpatient 62 62 MULTIPLAN INC 34080 [3081285] MULTIPLAN INC [308128501] 58.9 percent of total billed charges 38.44 58.9 Technical (Hospital) Services HC/HH Wch Supp Spray No Sting Barrier__3346 PX-2705000159 CDM A4369 HCPCS 270 RC outpatient 62 62 MEDICA (COMMERCIAL) 94265 [3081118] MEDICA CLAIMS [308111801] 55.8 percent of total billed charges 38.44 58.9 Technical (Hospital) Services HC/HH Wch Supp Urine Drain Bag 2000__154102 PX-2725000131 CDM A4357 HCPCS 272 RC inpatient 34 34 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES EPO [308136803] 26.92 percent of total billed charges 21.08 32.3 Technical (Hospital) Services HC/HH Wch Supp Urine Drain Bag 2000__154102 PX-2725000131 CDM A4357 HCPCS 272 RC inpatient 34 34 HEALTHPARTNERS SX009 HEALTHPARTNERS 26.92 percent of total billed charges 21.08 32.3 Technical (Hospital) Services HC/HH Wch Supp Urine Drain Bag 2000__154102 PX-2725000131 CDM A4357 HCPCS 272 RC inpatient 34 34 MULTIPLAN INC 34080 [3081285] MULTIPLAN INC [308128501] 32.3 percent of total billed charges 21.08 32.3 Technical (Hospital) Services HC/HH Wch Supp Urine Drain Bag 2000__154102 PX-2725000131 CDM A4357 HCPCS 272 RC inpatient 34 34 BLUE CROSS BLUE SHIELD WELLMARK SB889 [3081026] BCBS WYOMING [308102603] 32.3 percent of total billed charges 21.08 32.3 Technical (Hospital) Services HC/HH Wch Supp Urine Drain Bag 2000__154102 PX-2725000131 CDM A4357 HCPCS 272 RC inpatient 34 34 UNITED HEALTHCARE (COMMERCIAL) [3081199] UNITED HEALTHCARE 87726 [308119901] 21.08 percent of total billed charges 21.08 32.3 Technical (Hospital) Services HC/HH Wch Supp Urine Drain Bag 2000__154102 PX-2725000131 CDM A4357 HCPCS 272 RC inpatient 34 34 CIGNA 62308 [3081051] CIGNA 62308 [308105105] 26.92 percent of total billed charges 21.08 32.3 Technical (Hospital) Services HC/HH Wch Supp Urine Drain Bag 2000__154102 PX-2725000131 CDM A4357 HCPCS 272 RC inpatient 34 34 CIGNA 62308 [3081051] CIGNA STATE OF WYOMING [308105107] 26.92 percent of total billed charges 21.08 32.3 Technical (Hospital) Services HC/HH Wch Supp Urine Drain Bag 2000__154102 PX-2725000131 CDM A4357 HCPCS 272 RC inpatient 34 34 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES HDHP [308136802] 26.92 percent of total billed charges 21.08 32.3 Technical (Hospital) Services HC/HH Wch Supp Urine Drain Bag 2000__154102 PX-2725000131 CDM A4357 HCPCS 272 RC inpatient 34 34 MEDICA (COMMERCIAL) 94265 [3081118] MEDICA CLAIMS [308111801] 30.6 percent of total billed charges 21.08 32.3 Technical (Hospital) Services HC/HH Wch Supp Urine Drain Bag 2000__154102 PX-2725000131 CDM A4357 HCPCS 272 RC inpatient 34 34 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES PPO [308136801] 26.92 percent of total billed charges 21.08 32.3 Technical (Hospital) Services HC/HH Wch Supp Urine Drain Bag 2000__154102 PX-2725000131 CDM A4357 HCPCS 272 RC outpatient 34 34 CIGNA 62308 [3081051] CIGNA 62308 [308105105] 27.2 percent of total billed charges 21.08 32.3 Technical (Hospital) Services HC/HH Wch Supp Urine Drain Bag 2000__154102 PX-2725000131 CDM A4357 HCPCS 272 RC outpatient 34 34 CIGNA 62308 [3081051] CIGNA STATE OF WYOMING [308105107] 27.2 percent of total billed charges 21.08 32.3 Technical (Hospital) Services HC/HH Wch Supp Urine Drain Bag 2000__154102 PX-2725000131 CDM A4357 HCPCS 272 RC outpatient 34 34 UNITED HEALTHCARE (COMMERCIAL) [3081199] UNITED HEALTHCARE 87726 [308119901] 21.08 percent of total billed charges 21.08 32.3 Technical (Hospital) Services HC/HH Wch Supp Urine Drain Bag 2000__154102 PX-2725000131 CDM A4357 HCPCS 272 RC outpatient 34 34 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES PPO [308136801] 27.2 percent of total billed charges 21.08 32.3 Technical (Hospital) Services HC/HH Wch Supp Urine Drain Bag 2000__154102 PX-2725000131 CDM A4357 HCPCS 272 RC outpatient 34 34 HEALTHPARTNERS SX009 HEALTHPARTNERS 27.2 percent of total billed charges 21.08 32.3 Technical (Hospital) Services HC/HH Wch Supp Urine Drain Bag 2000__154102 PX-2725000131 CDM A4357 HCPCS 272 RC outpatient 34 34 MULTIPLAN INC 34080 [3081285] MULTIPLAN INC [308128501] 32.3 percent of total billed charges 21.08 32.3 Technical (Hospital) Services HC/HH Wch Supp Urine Drain Bag 2000__154102 PX-2725000131 CDM A4357 HCPCS 272 RC outpatient 34 34 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES HDHP [308136802] 27.2 percent of total billed charges 21.08 32.3 Technical (Hospital) Services HC/HH Wch Supp Urine Drain Bag 2000__154102 PX-2725000131 CDM A4357 HCPCS 272 RC outpatient 34 34 BLUE CROSS BLUE SHIELD WELLMARK SB889 [3081026] BCBS WYOMING [308102603] 32.3 percent of total billed charges 21.08 32.3 Technical (Hospital) Services HC/HH Wch Supp Urine Drain Bag 2000__154102 PX-2725000131 CDM A4357 HCPCS 272 RC outpatient 34 34 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES EPO [308136803] 27.2 percent of total billed charges 21.08 32.3 Technical (Hospital) Services HC/HH Wch Supp Urine Drain Bag 2000__154102 PX-2725000131 CDM A4357 HCPCS 272 RC outpatient 34 34 MEDICA (COMMERCIAL) 94265 [3081118] MEDICA CLAIMS [308111801] 30.6 percent of total billed charges 21.08 32.3 Technical (Hospital) Services FAMOTIDINE 20 MG TABLET RX-10011 CDM 6370000100 HCPCS 250 RC 00904-7193-61 NDC outpatient 1 UN 5.7 5.7 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES HDHP [308136802] 4.56 percent of total billed charges 3.53 5.42 Technical (Hospital) Services FAMOTIDINE 20 MG TABLET RX-10011 CDM 6370000100 HCPCS 250 RC 00904-7193-61 NDC outpatient 1 UN 5.7 5.7 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES PPO [308136801] 4.56 percent of total billed charges 3.53 5.42 Technical (Hospital) Services FAMOTIDINE 20 MG TABLET RX-10011 CDM 6370000100 HCPCS 250 RC 00904-7193-61 NDC outpatient 1 UN 5.7 5.7 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES EPO [308136803] 4.56 percent of total billed charges 3.53 5.42 Technical (Hospital) Services FAMOTIDINE 20 MG TABLET RX-10011 CDM 6370000100 HCPCS 250 RC 00904-7193-61 NDC outpatient 1 UN 5.7 5.7 MEDICA (COMMERCIAL) 94265 [3081118] MEDICA CLAIMS [308111801] 5.13 percent of total billed charges 3.53 5.42 Technical (Hospital) Services FAMOTIDINE 20 MG TABLET RX-10011 CDM 6370000100 HCPCS 250 RC 00904-7193-61 NDC outpatient 1 UN 5.7 5.7 CIGNA 62308 [3081051] CIGNA 62308 [308105105] 4.56 percent of total billed charges 3.53 5.42 Technical (Hospital) Services FAMOTIDINE 20 MG TABLET RX-10011 CDM 6370000100 HCPCS 250 RC 00904-7193-61 NDC outpatient 1 UN 5.7 5.7 CIGNA 62308 [3081051] CIGNA STATE OF WYOMING [308105107] 4.56 percent of total billed charges 3.53 5.42 Technical (Hospital) Services FAMOTIDINE 20 MG TABLET RX-10011 CDM 6370000100 HCPCS 250 RC 00904-7193-61 NDC outpatient 1 UN 5.7 5.7 MULTIPLAN INC 34080 [3081285] MULTIPLAN INC [308128501] 5.42 percent of total billed charges 3.53 5.42 Technical (Hospital) Services FAMOTIDINE 20 MG TABLET RX-10011 CDM 6370000100 HCPCS 250 RC 00904-7193-61 NDC outpatient 1 UN 5.7 5.7 UNITED HEALTHCARE (COMMERCIAL) [3081199] UNITED HEALTHCARE 87726 [308119901] 3.53 percent of total billed charges 3.53 5.42 Technical (Hospital) Services FAMOTIDINE 20 MG TABLET RX-10011 CDM 6370000100 HCPCS 250 RC 00904-7193-61 NDC outpatient 1 UN 5.7 5.7 HEALTHPARTNERS SX009 HEALTHPARTNERS 4.56 percent of total billed charges 3.53 5.42 Technical (Hospital) Services FAMOTIDINE 20 MG TABLET RX-10011 CDM 6370000100 HCPCS 250 RC 00904-7193-61 NDC outpatient 1 UN 5.7 5.7 BLUE CROSS BLUE SHIELD WELLMARK SB889 [3081026] BCBS WYOMING [308102603] 5.42 percent of total billed charges 3.53 5.42 Technical (Hospital) Services FAMOTIDINE 20 MG TABLET RX-10011 CDM 6370000100 HCPCS 250 RC 00904-7193-61 NDC inpatient 1 UN 5.7 5.7 MULTIPLAN INC 34080 [3081285] MULTIPLAN INC [308128501] 5.42 percent of total billed charges 3.53 5.42 Technical (Hospital) Services FAMOTIDINE 20 MG TABLET RX-10011 CDM 6370000100 HCPCS 250 RC 00904-7193-61 NDC inpatient 1 UN 5.7 5.7 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES PPO [308136801] 4.51 percent of total billed charges 3.53 5.42 Technical (Hospital) Services FAMOTIDINE 20 MG TABLET RX-10011 CDM 6370000100 HCPCS 250 RC 00904-7193-61 NDC inpatient 1 UN 5.7 5.7 MEDICA (COMMERCIAL) 94265 [3081118] MEDICA CLAIMS [308111801] 5.13 percent of total billed charges 3.53 5.42 Technical (Hospital) Services FAMOTIDINE 20 MG TABLET RX-10011 CDM 6370000100 HCPCS 250 RC 00904-7193-61 NDC inpatient 1 UN 5.7 5.7 HEALTHPARTNERS SX009 HEALTHPARTNERS 4.51 percent of total billed charges 3.53 5.42 Technical (Hospital) Services FAMOTIDINE 20 MG TABLET RX-10011 CDM 6370000100 HCPCS 250 RC 00904-7193-61 NDC inpatient 1 UN 5.7 5.7 UNITED HEALTHCARE (COMMERCIAL) [3081199] UNITED HEALTHCARE 87726 [308119901] 3.53 percent of total billed charges 3.53 5.42 Technical (Hospital) Services FAMOTIDINE 20 MG TABLET RX-10011 CDM 6370000100 HCPCS 250 RC 00904-7193-61 NDC inpatient 1 UN 5.7 5.7 BLUE CROSS BLUE SHIELD WELLMARK SB889 [3081026] BCBS WYOMING [308102603] 5.42 percent of total billed charges 3.53 5.42 Technical (Hospital) Services FAMOTIDINE 20 MG TABLET RX-10011 CDM 6370000100 HCPCS 250 RC 00904-7193-61 NDC inpatient 1 UN 5.7 5.7 CIGNA 62308 [3081051] CIGNA 62308 [308105105] 4.51 percent of total billed charges 3.53 5.42 Technical (Hospital) Services FAMOTIDINE 20 MG TABLET RX-10011 CDM 6370000100 HCPCS 250 RC 00904-7193-61 NDC inpatient 1 UN 5.7 5.7 CIGNA 62308 [3081051] CIGNA STATE OF WYOMING [308105107] 4.51 percent of total billed charges 3.53 5.42 Technical (Hospital) Services FAMOTIDINE 20 MG TABLET RX-10011 CDM 6370000100 HCPCS 250 RC 00904-7193-61 NDC inpatient 1 UN 5.7 5.7 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES EPO [308136803] 4.51 percent of total billed charges 3.53 5.42 Technical (Hospital) Services FAMOTIDINE 20 MG TABLET RX-10011 CDM 6370000100 HCPCS 250 RC 00904-7193-61 NDC inpatient 1 UN 5.7 5.7 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES HDHP [308136802] 4.51 percent of total billed charges 3.53 5.42 Technical (Hospital) Services FINASTERIDE 5 MG TABLET RX-10037 CDM 6370000100 HCPCS 250 RC 50268-0314-15 NDC inpatient 1 UN 6.19 6.19 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES EPO [308136803] 4.9 percent of total billed charges 3.84 5.88 Technical (Hospital) Services FINASTERIDE 5 MG TABLET RX-10037 CDM 6370000100 HCPCS 250 RC 50268-0314-15 NDC inpatient 1 UN 6.19 6.19 CIGNA 62308 [3081051] CIGNA 62308 [308105105] 4.9 percent of total billed charges 3.84 5.88 Technical (Hospital) Services FINASTERIDE 5 MG TABLET RX-10037 CDM 6370000100 HCPCS 250 RC 50268-0314-15 NDC inpatient 1 UN 6.19 6.19 CIGNA 62308 [3081051] CIGNA STATE OF WYOMING [308105107] 4.9 percent of total billed charges 3.84 5.88 Technical (Hospital) Services FINASTERIDE 5 MG TABLET RX-10037 CDM 6370000100 HCPCS 250 RC 50268-0314-15 NDC inpatient 1 UN 6.19 6.19 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES HDHP [308136802] 4.9 percent of total billed charges 3.84 5.88 Technical (Hospital) Services FINASTERIDE 5 MG TABLET RX-10037 CDM 6370000100 HCPCS 250 RC 50268-0314-15 NDC inpatient 1 UN 6.19 6.19 BLUE CROSS BLUE SHIELD WELLMARK SB889 [3081026] BCBS WYOMING [308102603] 5.88 percent of total billed charges 3.84 5.88 Technical (Hospital) Services FINASTERIDE 5 MG TABLET RX-10037 CDM 6370000100 HCPCS 250 RC 50268-0314-15 NDC inpatient 1 UN 6.19 6.19 UNITED HEALTHCARE (COMMERCIAL) [3081199] UNITED HEALTHCARE 87726 [308119901] 3.84 percent of total billed charges 3.84 5.88 Technical (Hospital) Services FINASTERIDE 5 MG TABLET RX-10037 CDM 6370000100 HCPCS 250 RC 50268-0314-15 NDC inpatient 1 UN 6.19 6.19 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES PPO [308136801] 4.9 percent of total billed charges 3.84 5.88 Technical (Hospital) Services FINASTERIDE 5 MG TABLET RX-10037 CDM 6370000100 HCPCS 250 RC 50268-0314-15 NDC inpatient 1 UN 6.19 6.19 MEDICA (COMMERCIAL) 94265 [3081118] MEDICA CLAIMS [308111801] 5.57 percent of total billed charges 3.84 5.88 Technical (Hospital) Services FINASTERIDE 5 MG TABLET RX-10037 CDM 6370000100 HCPCS 250 RC 50268-0314-15 NDC inpatient 1 UN 6.19 6.19 HEALTHPARTNERS SX009 HEALTHPARTNERS 4.9 percent of total billed charges 3.84 5.88 Technical (Hospital) Services FINASTERIDE 5 MG TABLET RX-10037 CDM 6370000100 HCPCS 250 RC 50268-0314-15 NDC inpatient 1 UN 6.19 6.19 MULTIPLAN INC 34080 [3081285] MULTIPLAN INC [308128501] 5.88 percent of total billed charges 3.84 5.88 Technical (Hospital) Services FINASTERIDE 5 MG TABLET RX-10037 CDM 6370000100 HCPCS 250 RC 50268-0314-15 NDC outpatient 1 UN 6.19 6.19 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES HDHP [308136802] 4.95 percent of total billed charges 3.84 5.88 Technical (Hospital) Services FINASTERIDE 5 MG TABLET RX-10037 CDM 6370000100 HCPCS 250 RC 50268-0314-15 NDC outpatient 1 UN 6.19 6.19 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES PPO [308136801] 4.95 percent of total billed charges 3.84 5.88 Technical (Hospital) Services FINASTERIDE 5 MG TABLET RX-10037 CDM 6370000100 HCPCS 250 RC 50268-0314-15 NDC outpatient 1 UN 6.19 6.19 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES EPO [308136803] 4.95 percent of total billed charges 3.84 5.88 Technical (Hospital) Services FINASTERIDE 5 MG TABLET RX-10037 CDM 6370000100 HCPCS 250 RC 50268-0314-15 NDC outpatient 1 UN 6.19 6.19 MEDICA (COMMERCIAL) 94265 [3081118] MEDICA CLAIMS [308111801] 5.57 percent of total billed charges 3.84 5.88 Technical (Hospital) Services FINASTERIDE 5 MG TABLET RX-10037 CDM 6370000100 HCPCS 250 RC 50268-0314-15 NDC outpatient 1 UN 6.19 6.19 CIGNA 62308 [3081051] CIGNA 62308 [308105105] 4.95 percent of total billed charges 3.84 5.88 Technical (Hospital) Services FINASTERIDE 5 MG TABLET RX-10037 CDM 6370000100 HCPCS 250 RC 50268-0314-15 NDC outpatient 1 UN 6.19 6.19 CIGNA 62308 [3081051] CIGNA STATE OF WYOMING [308105107] 4.95 percent of total billed charges 3.84 5.88 Technical (Hospital) Services FINASTERIDE 5 MG TABLET RX-10037 CDM 6370000100 HCPCS 250 RC 50268-0314-15 NDC outpatient 1 UN 6.19 6.19 UNITED HEALTHCARE (COMMERCIAL) [3081199] UNITED HEALTHCARE 87726 [308119901] 3.84 percent of total billed charges 3.84 5.88 Technical (Hospital) Services FINASTERIDE 5 MG TABLET RX-10037 CDM 6370000100 HCPCS 250 RC 50268-0314-15 NDC outpatient 1 UN 6.19 6.19 MULTIPLAN INC 34080 [3081285] MULTIPLAN INC [308128501] 5.88 percent of total billed charges 3.84 5.88 Technical (Hospital) Services FINASTERIDE 5 MG TABLET RX-10037 CDM 6370000100 HCPCS 250 RC 50268-0314-15 NDC outpatient 1 UN 6.19 6.19 BLUE CROSS BLUE SHIELD WELLMARK SB889 [3081026] BCBS WYOMING [308102603] 5.88 percent of total billed charges 3.84 5.88 Technical (Hospital) Services FINASTERIDE 5 MG TABLET RX-10037 CDM 6370000100 HCPCS 250 RC 50268-0314-15 NDC outpatient 1 UN 6.19 6.19 HEALTHPARTNERS SX009 HEALTHPARTNERS 4.95 percent of total billed charges 3.84 5.88 Technical (Hospital) Services FLECAINIDE 50 MG TABLET RX-10043 CDM 6370000100 HCPCS 250 RC 00054-0010-25 NDC outpatient 1 UN 6.19 6.19 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES HDHP [308136802] 4.95 percent of total billed charges 3.84 5.88 Technical (Hospital) Services FLECAINIDE 50 MG TABLET RX-10043 CDM 6370000100 HCPCS 250 RC 00054-0010-25 NDC outpatient 1 UN 6.19 6.19 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES PPO [308136801] 4.95 percent of total billed charges 3.84 5.88 Technical (Hospital) Services FLECAINIDE 50 MG TABLET RX-10043 CDM 6370000100 HCPCS 250 RC 00054-0010-25 NDC outpatient 1 UN 6.19 6.19 BLUE CROSS BLUE SHIELD WELLMARK SB889 [3081026] BCBS WYOMING [308102603] 5.88 percent of total billed charges 3.84 5.88 Technical (Hospital) Services FLECAINIDE 50 MG TABLET RX-10043 CDM 6370000100 HCPCS 250 RC 00054-0010-25 NDC outpatient 1 UN 6.19 6.19 HEALTHPARTNERS SX009 HEALTHPARTNERS 4.95 percent of total billed charges 3.84 5.88 Technical (Hospital) Services FLECAINIDE 50 MG TABLET RX-10043 CDM 6370000100 HCPCS 250 RC 00054-0010-25 NDC outpatient 1 UN 6.19 6.19 MULTIPLAN INC 34080 [3081285] MULTIPLAN INC [308128501] 5.88 percent of total billed charges 3.84 5.88 Technical (Hospital) Services FLECAINIDE 50 MG TABLET RX-10043 CDM 6370000100 HCPCS 250 RC 00054-0010-25 NDC outpatient 1 UN 6.19 6.19 CIGNA 62308 [3081051] CIGNA 62308 [308105105] 4.95 percent of total billed charges 3.84 5.88 Technical (Hospital) Services FLECAINIDE 50 MG TABLET RX-10043 CDM 6370000100 HCPCS 250 RC 00054-0010-25 NDC outpatient 1 UN 6.19 6.19 CIGNA 62308 [3081051] CIGNA STATE OF WYOMING [308105107] 4.95 percent of total billed charges 3.84 5.88 Technical (Hospital) Services FLECAINIDE 50 MG TABLET RX-10043 CDM 6370000100 HCPCS 250 RC 00054-0010-25 NDC outpatient 1 UN 6.19 6.19 UNITED HEALTHCARE (COMMERCIAL) [3081199] UNITED HEALTHCARE 87726 [308119901] 3.84 percent of total billed charges 3.84 5.88 Technical (Hospital) Services FLECAINIDE 50 MG TABLET RX-10043 CDM 6370000100 HCPCS 250 RC 00054-0010-25 NDC outpatient 1 UN 6.19 6.19 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES EPO [308136803] 4.95 percent of total billed charges 3.84 5.88 Technical (Hospital) Services FLECAINIDE 50 MG TABLET RX-10043 CDM 6370000100 HCPCS 250 RC 00054-0010-25 NDC outpatient 1 UN 6.19 6.19 MEDICA (COMMERCIAL) 94265 [3081118] MEDICA CLAIMS [308111801] 5.57 percent of total billed charges 3.84 5.88 Technical (Hospital) Services FLECAINIDE 50 MG TABLET RX-10043 CDM 6370000100 HCPCS 250 RC 00054-0010-25 NDC inpatient 1 UN 6.19 6.19 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES HDHP [308136802] 4.9 percent of total billed charges 3.84 5.88 Technical (Hospital) Services FLECAINIDE 50 MG TABLET RX-10043 CDM 6370000100 HCPCS 250 RC 00054-0010-25 NDC inpatient 1 UN 6.19 6.19 MEDICA (COMMERCIAL) 94265 [3081118] MEDICA CLAIMS [308111801] 5.57 percent of total billed charges 3.84 5.88 Technical (Hospital) Services FLECAINIDE 50 MG TABLET RX-10043 CDM 6370000100 HCPCS 250 RC 00054-0010-25 NDC inpatient 1 UN 6.19 6.19 HEALTHPARTNERS SX009 HEALTHPARTNERS 4.9 percent of total billed charges 3.84 5.88 Technical (Hospital) Services FLECAINIDE 50 MG TABLET RX-10043 CDM 6370000100 HCPCS 250 RC 00054-0010-25 NDC inpatient 1 UN 6.19 6.19 CIGNA 62308 [3081051] CIGNA 62308 [308105105] 4.9 percent of total billed charges 3.84 5.88 Technical (Hospital) Services FLECAINIDE 50 MG TABLET RX-10043 CDM 6370000100 HCPCS 250 RC 00054-0010-25 NDC inpatient 1 UN 6.19 6.19 CIGNA 62308 [3081051] CIGNA STATE OF WYOMING [308105107] 4.9 percent of total billed charges 3.84 5.88 Technical (Hospital) Services FLECAINIDE 50 MG TABLET RX-10043 CDM 6370000100 HCPCS 250 RC 00054-0010-25 NDC inpatient 1 UN 6.19 6.19 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES EPO [308136803] 4.9 percent of total billed charges 3.84 5.88 Technical (Hospital) Services FLECAINIDE 50 MG TABLET RX-10043 CDM 6370000100 HCPCS 250 RC 00054-0010-25 NDC inpatient 1 UN 6.19 6.19 BLUE CROSS BLUE SHIELD WELLMARK SB889 [3081026] BCBS WYOMING [308102603] 5.88 percent of total billed charges 3.84 5.88 Technical (Hospital) Services FLECAINIDE 50 MG TABLET RX-10043 CDM 6370000100 HCPCS 250 RC 00054-0010-25 NDC inpatient 1 UN 6.19 6.19 UNITED HEALTHCARE (COMMERCIAL) [3081199] UNITED HEALTHCARE 87726 [308119901] 3.84 percent of total billed charges 3.84 5.88 Technical (Hospital) Services FLECAINIDE 50 MG TABLET RX-10043 CDM 6370000100 HCPCS 250 RC 00054-0010-25 NDC inpatient 1 UN 6.19 6.19 MULTIPLAN INC 34080 [3081285] MULTIPLAN INC [308128501] 5.88 percent of total billed charges 3.84 5.88 Technical (Hospital) Services FLECAINIDE 50 MG TABLET RX-10043 CDM 6370000100 HCPCS 250 RC 00054-0010-25 NDC inpatient 1 UN 6.19 6.19 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES PPO [308136801] 4.9 percent of total billed charges 3.84 5.88 Technical (Hospital) Services FLUDROCORTISONE 0.1 MG TABLET RX-10054 CDM 6370000100 HCPCS 250 RC 00115-7033-01 NDC inpatient 1 UN 6.21 6.21 CIGNA 62308 [3081051] CIGNA 62308 [308105105] 4.92 percent of total billed charges 3.85 5.9 Technical (Hospital) Services FLUDROCORTISONE 0.1 MG TABLET RX-10054 CDM 6370000100 HCPCS 250 RC 00115-7033-01 NDC inpatient 1 UN 6.21 6.21 CIGNA 62308 [3081051] CIGNA STATE OF WYOMING [308105107] 4.92 percent of total billed charges 3.85 5.9 Technical (Hospital) Services FLUDROCORTISONE 0.1 MG TABLET RX-10054 CDM 6370000100 HCPCS 250 RC 00115-7033-01 NDC inpatient 1 UN 6.21 6.21 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES EPO [308136803] 4.92 percent of total billed charges 3.85 5.9 Technical (Hospital) Services FLUDROCORTISONE 0.1 MG TABLET RX-10054 CDM 6370000100 HCPCS 250 RC 00115-7033-01 NDC inpatient 1 UN 6.21 6.21 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES HDHP [308136802] 4.92 percent of total billed charges 3.85 5.9 Technical (Hospital) Services FLUDROCORTISONE 0.1 MG TABLET RX-10054 CDM 6370000100 HCPCS 250 RC 00115-7033-01 NDC inpatient 1 UN 6.21 6.21 BLUE CROSS BLUE SHIELD WELLMARK SB889 [3081026] BCBS WYOMING [308102603] 5.9 percent of total billed charges 3.85 5.9 Technical (Hospital) Services FLUDROCORTISONE 0.1 MG TABLET RX-10054 CDM 6370000100 HCPCS 250 RC 00115-7033-01 NDC inpatient 1 UN 6.21 6.21 UNITED HEALTHCARE (COMMERCIAL) [3081199] UNITED HEALTHCARE 87726 [308119901] 3.85 percent of total billed charges 3.85 5.9 Technical (Hospital) Services FLUDROCORTISONE 0.1 MG TABLET RX-10054 CDM 6370000100 HCPCS 250 RC 00115-7033-01 NDC inpatient 1 UN 6.21 6.21 HEALTHPARTNERS SX009 HEALTHPARTNERS 4.92 percent of total billed charges 3.85 5.9 Technical (Hospital) Services FLUDROCORTISONE 0.1 MG TABLET RX-10054 CDM 6370000100 HCPCS 250 RC 00115-7033-01 NDC inpatient 1 UN 6.21 6.21 MEDICA (COMMERCIAL) 94265 [3081118] MEDICA CLAIMS [308111801] 5.59 percent of total billed charges 3.85 5.9 Technical (Hospital) Services FLUDROCORTISONE 0.1 MG TABLET RX-10054 CDM 6370000100 HCPCS 250 RC 00115-7033-01 NDC inpatient 1 UN 6.21 6.21 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES PPO [308136801] 4.92 percent of total billed charges 3.85 5.9 Technical (Hospital) Services FLUDROCORTISONE 0.1 MG TABLET RX-10054 CDM 6370000100 HCPCS 250 RC 00115-7033-01 NDC inpatient 1 UN 6.21 6.21 MULTIPLAN INC 34080 [3081285] MULTIPLAN INC [308128501] 5.9 percent of total billed charges 3.85 5.9 Technical (Hospital) Services FLUDROCORTISONE 0.1 MG TABLET RX-10054 CDM 6370000100 HCPCS 250 RC 00115-7033-01 NDC outpatient 1 UN 6.21 6.21 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES PPO [308136801] 4.97 percent of total billed charges 3.85 5.9 Technical (Hospital) Services FLUDROCORTISONE 0.1 MG TABLET RX-10054 CDM 6370000100 HCPCS 250 RC 00115-7033-01 NDC outpatient 1 UN 6.21 6.21 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES HDHP [308136802] 4.97 percent of total billed charges 3.85 5.9 Technical (Hospital) Services FLUDROCORTISONE 0.1 MG TABLET RX-10054 CDM 6370000100 HCPCS 250 RC 00115-7033-01 NDC outpatient 1 UN 6.21 6.21 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES EPO [308136803] 4.97 percent of total billed charges 3.85 5.9 Technical (Hospital) Services FLUDROCORTISONE 0.1 MG TABLET RX-10054 CDM 6370000100 HCPCS 250 RC 00115-7033-01 NDC outpatient 1 UN 6.21 6.21 BLUE CROSS BLUE SHIELD WELLMARK SB889 [3081026] BCBS WYOMING [308102603] 5.9 percent of total billed charges 3.85 5.9 Technical (Hospital) Services FLUDROCORTISONE 0.1 MG TABLET RX-10054 CDM 6370000100 HCPCS 250 RC 00115-7033-01 NDC outpatient 1 UN 6.21 6.21 HEALTHPARTNERS SX009 HEALTHPARTNERS 4.97 percent of total billed charges 3.85 5.9 Technical (Hospital) Services FLUDROCORTISONE 0.1 MG TABLET RX-10054 CDM 6370000100 HCPCS 250 RC 00115-7033-01 NDC outpatient 1 UN 6.21 6.21 MULTIPLAN INC 34080 [3081285] MULTIPLAN INC [308128501] 5.9 percent of total billed charges 3.85 5.9 Technical (Hospital) Services FLUDROCORTISONE 0.1 MG TABLET RX-10054 CDM 6370000100 HCPCS 250 RC 00115-7033-01 NDC outpatient 1 UN 6.21 6.21 CIGNA 62308 [3081051] CIGNA 62308 [308105105] 4.97 percent of total billed charges 3.85 5.9 Technical (Hospital) Services FLUDROCORTISONE 0.1 MG TABLET RX-10054 CDM 6370000100 HCPCS 250 RC 00115-7033-01 NDC outpatient 1 UN 6.21 6.21 CIGNA 62308 [3081051] CIGNA STATE OF WYOMING [308105107] 4.97 percent of total billed charges 3.85 5.9 Technical (Hospital) Services FLUDROCORTISONE 0.1 MG TABLET RX-10054 CDM 6370000100 HCPCS 250 RC 00115-7033-01 NDC outpatient 1 UN 6.21 6.21 MEDICA (COMMERCIAL) 94265 [3081118] MEDICA CLAIMS [308111801] 5.59 percent of total billed charges 3.85 5.9 Technical (Hospital) Services FLUDROCORTISONE 0.1 MG TABLET RX-10054 CDM 6370000100 HCPCS 250 RC 00115-7033-01 NDC outpatient 1 UN 6.21 6.21 UNITED HEALTHCARE (COMMERCIAL) [3081199] UNITED HEALTHCARE 87726 [308119901] 3.85 percent of total billed charges 3.85 5.9 Technical (Hospital) Services FLUOXETINE 10 MG CAPSULE RX-10069 CDM 6370000100 HCPCS 250 RC 50111-0647-01 NDC outpatient 1 UN 5.68 5.68 MULTIPLAN INC 34080 [3081285] MULTIPLAN INC [308128501] 5.4 percent of total billed charges 3.52 5.4 Technical (Hospital) Services FLUOXETINE 10 MG CAPSULE RX-10069 CDM 6370000100 HCPCS 250 RC 50111-0647-01 NDC outpatient 1 UN 5.68 5.68 CIGNA 62308 [3081051] CIGNA 62308 [308105105] 4.54 percent of total billed charges 3.52 5.4 Technical (Hospital) Services FLUOXETINE 10 MG CAPSULE RX-10069 CDM 6370000100 HCPCS 250 RC 50111-0647-01 NDC outpatient 1 UN 5.68 5.68 CIGNA 62308 [3081051] CIGNA STATE OF WYOMING [308105107] 4.54 percent of total billed charges 3.52 5.4 Technical (Hospital) Services FLUOXETINE 10 MG CAPSULE RX-10069 CDM 6370000100 HCPCS 250 RC 50111-0647-01 NDC outpatient 1 UN 5.68 5.68 UNITED HEALTHCARE (COMMERCIAL) [3081199] UNITED HEALTHCARE 87726 [308119901] 3.52 percent of total billed charges 3.52 5.4 Technical (Hospital) Services FLUOXETINE 10 MG CAPSULE RX-10069 CDM 6370000100 HCPCS 250 RC 50111-0647-01 NDC outpatient 1 UN 5.68 5.68 MEDICA (COMMERCIAL) 94265 [3081118] MEDICA CLAIMS [308111801] 5.11 percent of total billed charges 3.52 5.4 Technical (Hospital) Services FLUOXETINE 10 MG CAPSULE RX-10069 CDM 6370000100 HCPCS 250 RC 50111-0647-01 NDC outpatient 1 UN 5.68 5.68 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES EPO [308136803] 4.54 percent of total billed charges 3.52 5.4 Technical (Hospital) Services FLUOXETINE 10 MG CAPSULE RX-10069 CDM 6370000100 HCPCS 250 RC 50111-0647-01 NDC outpatient 1 UN 5.68 5.68 BLUE CROSS BLUE SHIELD WELLMARK SB889 [3081026] BCBS WYOMING [308102603] 5.4 percent of total billed charges 3.52 5.4 Technical (Hospital) Services FLUOXETINE 10 MG CAPSULE RX-10069 CDM 6370000100 HCPCS 250 RC 50111-0647-01 NDC outpatient 1 UN 5.68 5.68 HEALTHPARTNERS SX009 HEALTHPARTNERS 4.54 percent of total billed charges 3.52 5.4 Technical (Hospital) Services FLUOXETINE 10 MG CAPSULE RX-10069 CDM 6370000100 HCPCS 250 RC 50111-0647-01 NDC outpatient 1 UN 5.68 5.68 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES HDHP [308136802] 4.54 percent of total billed charges 3.52 5.4 Technical (Hospital) Services FLUOXETINE 10 MG CAPSULE RX-10069 CDM 6370000100 HCPCS 250 RC 50111-0647-01 NDC outpatient 1 UN 5.68 5.68 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES PPO [308136801] 4.54 percent of total billed charges 3.52 5.4 Technical (Hospital) Services FLUOXETINE 10 MG CAPSULE RX-10069 CDM 6370000100 HCPCS 250 RC 50111-0647-01 NDC inpatient 1 UN 5.68 5.68 MULTIPLAN INC 34080 [3081285] MULTIPLAN INC [308128501] 5.4 percent of total billed charges 3.52 5.4 Technical (Hospital) Services FLUOXETINE 10 MG CAPSULE RX-10069 CDM 6370000100 HCPCS 250 RC 50111-0647-01 NDC inpatient 1 UN 5.68 5.68 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES PPO [308136801] 4.5 percent of total billed charges 3.52 5.4 Technical (Hospital) Services FLUOXETINE 10 MG CAPSULE RX-10069 CDM 6370000100 HCPCS 250 RC 50111-0647-01 NDC inpatient 1 UN 5.68 5.68 UNITED HEALTHCARE (COMMERCIAL) [3081199] UNITED HEALTHCARE 87726 [308119901] 3.52 percent of total billed charges 3.52 5.4 Technical (Hospital) Services FLUOXETINE 10 MG CAPSULE RX-10069 CDM 6370000100 HCPCS 250 RC 50111-0647-01 NDC inpatient 1 UN 5.68 5.68 BLUE CROSS BLUE SHIELD WELLMARK SB889 [3081026] BCBS WYOMING [308102603] 5.4 percent of total billed charges 3.52 5.4 Technical (Hospital) Services FLUOXETINE 10 MG CAPSULE RX-10069 CDM 6370000100 HCPCS 250 RC 50111-0647-01 NDC inpatient 1 UN 5.68 5.68 CIGNA 62308 [3081051] CIGNA 62308 [308105105] 4.5 percent of total billed charges 3.52 5.4 Technical (Hospital) Services FLUOXETINE 10 MG CAPSULE RX-10069 CDM 6370000100 HCPCS 250 RC 50111-0647-01 NDC inpatient 1 UN 5.68 5.68 CIGNA 62308 [3081051] CIGNA STATE OF WYOMING [308105107] 4.5 percent of total billed charges 3.52 5.4 Technical (Hospital) Services FLUOXETINE 10 MG CAPSULE RX-10069 CDM 6370000100 HCPCS 250 RC 50111-0647-01 NDC inpatient 1 UN 5.68 5.68 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES EPO [308136803] 4.5 percent of total billed charges 3.52 5.4 Technical (Hospital) Services FLUOXETINE 10 MG CAPSULE RX-10069 CDM 6370000100 HCPCS 250 RC 50111-0647-01 NDC inpatient 1 UN 5.68 5.68 MEDICA (COMMERCIAL) 94265 [3081118] MEDICA CLAIMS [308111801] 5.11 percent of total billed charges 3.52 5.4 Technical (Hospital) Services FLUOXETINE 10 MG CAPSULE RX-10069 CDM 6370000100 HCPCS 250 RC 50111-0647-01 NDC inpatient 1 UN 5.68 5.68 HEALTHPARTNERS SX009 HEALTHPARTNERS 4.5 percent of total billed charges 3.52 5.4 Technical (Hospital) Services FLUOXETINE 10 MG CAPSULE RX-10069 CDM 6370000100 HCPCS 250 RC 50111-0647-01 NDC inpatient 1 UN 5.68 5.68 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES HDHP [308136802] 4.5 percent of total billed charges 3.52 5.4 Technical (Hospital) Services FLUOXETINE 20 MG CAPSULE RX-10070 CDM 6370000100 HCPCS 250 RC 50111-0648-01 NDC inpatient 1 UN 5.68 5.68 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES PPO [308136801] 4.5 percent of total billed charges 3.52 5.4 Technical (Hospital) Services FLUOXETINE 20 MG CAPSULE RX-10070 CDM 6370000100 HCPCS 250 RC 50111-0648-01 NDC inpatient 1 UN 5.68 5.68 HEALTHPARTNERS SX009 HEALTHPARTNERS 4.5 percent of total billed charges 3.52 5.4 Technical (Hospital) Services FLUOXETINE 20 MG CAPSULE RX-10070 CDM 6370000100 HCPCS 250 RC 50111-0648-01 NDC inpatient 1 UN 5.68 5.68 MEDICA (COMMERCIAL) 94265 [3081118] MEDICA CLAIMS [308111801] 5.11 percent of total billed charges 3.52 5.4 Technical (Hospital) Services FLUOXETINE 20 MG CAPSULE RX-10070 CDM 6370000100 HCPCS 250 RC 50111-0648-01 NDC inpatient 1 UN 5.68 5.68 MULTIPLAN INC 34080 [3081285] MULTIPLAN INC [308128501] 5.4 percent of total billed charges 3.52 5.4 Technical (Hospital) Services FLUOXETINE 20 MG CAPSULE RX-10070 CDM 6370000100 HCPCS 250 RC 50111-0648-01 NDC inpatient 1 UN 5.68 5.68 BLUE CROSS BLUE SHIELD WELLMARK SB889 [3081026] BCBS WYOMING [308102603] 5.4 percent of total billed charges 3.52 5.4 Technical (Hospital) Services FLUOXETINE 20 MG CAPSULE RX-10070 CDM 6370000100 HCPCS 250 RC 50111-0648-01 NDC inpatient 1 UN 5.68 5.68 UNITED HEALTHCARE (COMMERCIAL) [3081199] UNITED HEALTHCARE 87726 [308119901] 3.52 percent of total billed charges 3.52 5.4 Technical (Hospital) Services FLUOXETINE 20 MG CAPSULE RX-10070 CDM 6370000100 HCPCS 250 RC 50111-0648-01 NDC inpatient 1 UN 5.68 5.68 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES HDHP [308136802] 4.5 percent of total billed charges 3.52 5.4 Technical (Hospital) Services FLUOXETINE 20 MG CAPSULE RX-10070 CDM 6370000100 HCPCS 250 RC 50111-0648-01 NDC inpatient 1 UN 5.68 5.68 CIGNA 62308 [3081051] CIGNA 62308 [308105105] 4.5 percent of total billed charges 3.52 5.4 Technical (Hospital) Services FLUOXETINE 20 MG CAPSULE RX-10070 CDM 6370000100 HCPCS 250 RC 50111-0648-01 NDC inpatient 1 UN 5.68 5.68 CIGNA 62308 [3081051] CIGNA STATE OF WYOMING [308105107] 4.5 percent of total billed charges 3.52 5.4 Technical (Hospital) Services FLUOXETINE 20 MG CAPSULE RX-10070 CDM 6370000100 HCPCS 250 RC 50111-0648-01 NDC inpatient 1 UN 5.68 5.68 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES EPO [308136803] 4.5 percent of total billed charges 3.52 5.4 Technical (Hospital) Services FLUOXETINE 20 MG CAPSULE RX-10070 CDM 6370000100 HCPCS 250 RC 50111-0648-01 NDC outpatient 1 UN 5.68 5.68 MEDICA (COMMERCIAL) 94265 [3081118] MEDICA CLAIMS [308111801] 5.11 percent of total billed charges 3.52 5.4 Technical (Hospital) Services FLUOXETINE 20 MG CAPSULE RX-10070 CDM 6370000100 HCPCS 250 RC 50111-0648-01 NDC outpatient 1 UN 5.68 5.68 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES EPO [308136803] 4.54 percent of total billed charges 3.52 5.4 Technical (Hospital) Services FLUOXETINE 20 MG CAPSULE RX-10070 CDM 6370000100 HCPCS 250 RC 50111-0648-01 NDC outpatient 1 UN 5.68 5.68 CIGNA 62308 [3081051] CIGNA 62308 [308105105] 4.54 percent of total billed charges 3.52 5.4 Technical (Hospital) Services FLUOXETINE 20 MG CAPSULE RX-10070 CDM 6370000100 HCPCS 250 RC 50111-0648-01 NDC outpatient 1 UN 5.68 5.68 CIGNA 62308 [3081051] CIGNA STATE OF WYOMING [308105107] 4.54 percent of total billed charges 3.52 5.4 Technical (Hospital) Services FLUOXETINE 20 MG CAPSULE RX-10070 CDM 6370000100 HCPCS 250 RC 50111-0648-01 NDC outpatient 1 UN 5.68 5.68 MULTIPLAN INC 34080 [3081285] MULTIPLAN INC [308128501] 5.4 percent of total billed charges 3.52 5.4 Technical (Hospital) Services FLUOXETINE 20 MG CAPSULE RX-10070 CDM 6370000100 HCPCS 250 RC 50111-0648-01 NDC outpatient 1 UN 5.68 5.68 UNITED HEALTHCARE (COMMERCIAL) [3081199] UNITED HEALTHCARE 87726 [308119901] 3.52 percent of total billed charges 3.52 5.4 Technical (Hospital) Services FLUOXETINE 20 MG CAPSULE RX-10070 CDM 6370000100 HCPCS 250 RC 50111-0648-01 NDC outpatient 1 UN 5.68 5.68 HEALTHPARTNERS SX009 HEALTHPARTNERS 4.54 percent of total billed charges 3.52 5.4 Technical (Hospital) Services FLUOXETINE 20 MG CAPSULE RX-10070 CDM 6370000100 HCPCS 250 RC 50111-0648-01 NDC outpatient 1 UN 5.68 5.68 BLUE CROSS BLUE SHIELD WELLMARK SB889 [3081026] BCBS WYOMING [308102603] 5.4 percent of total billed charges 3.52 5.4 Technical (Hospital) Services FLUOXETINE 20 MG CAPSULE RX-10070 CDM 6370000100 HCPCS 250 RC 50111-0648-01 NDC outpatient 1 UN 5.68 5.68 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES HDHP [308136802] 4.54 percent of total billed charges 3.52 5.4 Technical (Hospital) Services FLUOXETINE 20 MG CAPSULE RX-10070 CDM 6370000100 HCPCS 250 RC 50111-0648-01 NDC outpatient 1 UN 5.68 5.68 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES PPO [308136801] 4.54 percent of total billed charges 3.52 5.4 Technical (Hospital) Services LACTOBACIL RHAMNOSUS GG 10 BILLION CELL-INULIN 200 MG SPRINKLE CAPSULE RX-100735 CDM 6370000100 HCPCS 250 RC 49100-0400-09 NDC outpatient 1 UN 6.12 6.12 UNITED HEALTHCARE (COMMERCIAL) [3081199] UNITED HEALTHCARE 87726 [308119901] 3.79 percent of total billed charges 3.79 5.81 Technical (Hospital) Services LACTOBACIL RHAMNOSUS GG 10 BILLION CELL-INULIN 200 MG SPRINKLE CAPSULE RX-100735 CDM 6370000100 HCPCS 250 RC 49100-0400-09 NDC outpatient 1 UN 6.12 6.12 MULTIPLAN INC 34080 [3081285] MULTIPLAN INC [308128501] 5.81 percent of total billed charges 3.79 5.81 Technical (Hospital) Services LACTOBACIL RHAMNOSUS GG 10 BILLION CELL-INULIN 200 MG SPRINKLE CAPSULE RX-100735 CDM 6370000100 HCPCS 250 RC 49100-0400-09 NDC outpatient 1 UN 6.12 6.12 CIGNA 62308 [3081051] CIGNA 62308 [308105105] 4.9 percent of total billed charges 3.79 5.81 Technical (Hospital) Services LACTOBACIL RHAMNOSUS GG 10 BILLION CELL-INULIN 200 MG SPRINKLE CAPSULE RX-100735 CDM 6370000100 HCPCS 250 RC 49100-0400-09 NDC outpatient 1 UN 6.12 6.12 CIGNA 62308 [3081051] CIGNA STATE OF WYOMING [308105107] 4.9 percent of total billed charges 3.79 5.81 Technical (Hospital) Services LACTOBACIL RHAMNOSUS GG 10 BILLION CELL-INULIN 200 MG SPRINKLE CAPSULE RX-100735 CDM 6370000100 HCPCS 250 RC 49100-0400-09 NDC outpatient 1 UN 6.12 6.12 MEDICA (COMMERCIAL) 94265 [3081118] MEDICA CLAIMS [308111801] 5.51 percent of total billed charges 3.79 5.81 Technical (Hospital) Services LACTOBACIL RHAMNOSUS GG 10 BILLION CELL-INULIN 200 MG SPRINKLE CAPSULE RX-100735 CDM 6370000100 HCPCS 250 RC 49100-0400-09 NDC outpatient 1 UN 6.12 6.12 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES EPO [308136803] 4.9 percent of total billed charges 3.79 5.81 Technical (Hospital) Services LACTOBACIL RHAMNOSUS GG 10 BILLION CELL-INULIN 200 MG SPRINKLE CAPSULE RX-100735 CDM 6370000100 HCPCS 250 RC 49100-0400-09 NDC outpatient 1 UN 6.12 6.12 BLUE CROSS BLUE SHIELD WELLMARK SB889 [3081026] BCBS WYOMING [308102603] 5.81 percent of total billed charges 3.79 5.81 Technical (Hospital) Services LACTOBACIL RHAMNOSUS GG 10 BILLION CELL-INULIN 200 MG SPRINKLE CAPSULE RX-100735 CDM 6370000100 HCPCS 250 RC 49100-0400-09 NDC outpatient 1 UN 6.12 6.12 HEALTHPARTNERS SX009 HEALTHPARTNERS 4.9 percent of total billed charges 3.79 5.81 Technical (Hospital) Services LACTOBACIL RHAMNOSUS GG 10 BILLION CELL-INULIN 200 MG SPRINKLE CAPSULE RX-100735 CDM 6370000100 HCPCS 250 RC 49100-0400-09 NDC outpatient 1 UN 6.12 6.12 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES PPO [308136801] 4.9 percent of total billed charges 3.79 5.81 Technical (Hospital) Services LACTOBACIL RHAMNOSUS GG 10 BILLION CELL-INULIN 200 MG SPRINKLE CAPSULE RX-100735 CDM 6370000100 HCPCS 250 RC 49100-0400-09 NDC outpatient 1 UN 6.12 6.12 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES HDHP [308136802] 4.9 percent of total billed charges 3.79 5.81 Technical (Hospital) Services LACTOBACIL RHAMNOSUS GG 10 BILLION CELL-INULIN 200 MG SPRINKLE CAPSULE RX-100735 CDM 6370000100 HCPCS 250 RC 49100-0400-09 NDC inpatient 1 UN 6.12 6.12 HEALTHPARTNERS SX009 HEALTHPARTNERS 4.85 percent of total billed charges 3.79 5.81 Technical (Hospital) Services LACTOBACIL RHAMNOSUS GG 10 BILLION CELL-INULIN 200 MG SPRINKLE CAPSULE RX-100735 CDM 6370000100 HCPCS 250 RC 49100-0400-09 NDC inpatient 1 UN 6.12 6.12 MEDICA (COMMERCIAL) 94265 [3081118] MEDICA CLAIMS [308111801] 5.51 percent of total billed charges 3.79 5.81 Technical (Hospital) Services LACTOBACIL RHAMNOSUS GG 10 BILLION CELL-INULIN 200 MG SPRINKLE CAPSULE RX-100735 CDM 6370000100 HCPCS 250 RC 49100-0400-09 NDC inpatient 1 UN 6.12 6.12 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES PPO [308136801] 4.85 percent of total billed charges 3.79 5.81 Technical (Hospital) Services LACTOBACIL RHAMNOSUS GG 10 BILLION CELL-INULIN 200 MG SPRINKLE CAPSULE RX-100735 CDM 6370000100 HCPCS 250 RC 49100-0400-09 NDC inpatient 1 UN 6.12 6.12 MULTIPLAN INC 34080 [3081285] MULTIPLAN INC [308128501] 5.81 percent of total billed charges 3.79 5.81 Technical (Hospital) Services LACTOBACIL RHAMNOSUS GG 10 BILLION CELL-INULIN 200 MG SPRINKLE CAPSULE RX-100735 CDM 6370000100 HCPCS 250 RC 49100-0400-09 NDC inpatient 1 UN 6.12 6.12 UNITED HEALTHCARE (COMMERCIAL) [3081199] UNITED HEALTHCARE 87726 [308119901] 3.79 percent of total billed charges 3.79 5.81 Technical (Hospital) Services LACTOBACIL RHAMNOSUS GG 10 BILLION CELL-INULIN 200 MG SPRINKLE CAPSULE RX-100735 CDM 6370000100 HCPCS 250 RC 49100-0400-09 NDC inpatient 1 UN 6.12 6.12 BLUE CROSS BLUE SHIELD WELLMARK SB889 [3081026] BCBS WYOMING [308102603] 5.81 percent of total billed charges 3.79 5.81 Technical (Hospital) Services LACTOBACIL RHAMNOSUS GG 10 BILLION CELL-INULIN 200 MG SPRINKLE CAPSULE RX-100735 CDM 6370000100 HCPCS 250 RC 49100-0400-09 NDC inpatient 1 UN 6.12 6.12 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES HDHP [308136802] 4.85 percent of total billed charges 3.79 5.81 Technical (Hospital) Services LACTOBACIL RHAMNOSUS GG 10 BILLION CELL-INULIN 200 MG SPRINKLE CAPSULE RX-100735 CDM 6370000100 HCPCS 250 RC 49100-0400-09 NDC inpatient 1 UN 6.12 6.12 CIGNA 62308 [3081051] CIGNA 62308 [308105105] 4.85 percent of total billed charges 3.79 5.81 Technical (Hospital) Services LACTOBACIL RHAMNOSUS GG 10 BILLION CELL-INULIN 200 MG SPRINKLE CAPSULE RX-100735 CDM 6370000100 HCPCS 250 RC 49100-0400-09 NDC inpatient 1 UN 6.12 6.12 CIGNA 62308 [3081051] CIGNA STATE OF WYOMING [308105107] 4.85 percent of total billed charges 3.79 5.81 Technical (Hospital) Services LACTOBACIL RHAMNOSUS GG 10 BILLION CELL-INULIN 200 MG SPRINKLE CAPSULE RX-100735 CDM 6370000100 HCPCS 250 RC 49100-0400-09 NDC inpatient 1 UN 6.12 6.12 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES EPO [308136803] 4.85 percent of total billed charges 3.79 5.81 Technical (Hospital) Services ESTRADIOL 10 MCG VAGINAL TABLET RX-100745 CDM 6370000100 HCPCS 250 RC 65162-0226-23 NDC outpatient 1 UN 67.4 67.4 BLUE CROSS BLUE SHIELD WELLMARK SB889 [3081026] BCBS WYOMING [308102603] 64.03 percent of total billed charges 41.79 64.03 Technical (Hospital) Services ESTRADIOL 10 MCG VAGINAL TABLET RX-100745 CDM 6370000100 HCPCS 250 RC 65162-0226-23 NDC outpatient 1 UN 67.4 67.4 HEALTHPARTNERS SX009 HEALTHPARTNERS 53.92 percent of total billed charges 41.79 64.03 Technical (Hospital) Services ESTRADIOL 10 MCG VAGINAL TABLET RX-100745 CDM 6370000100 HCPCS 250 RC 65162-0226-23 NDC outpatient 1 UN 67.4 67.4 UNITED HEALTHCARE (COMMERCIAL) [3081199] UNITED HEALTHCARE 87726 [308119901] 41.79 percent of total billed charges 41.79 64.03 Technical (Hospital) Services ESTRADIOL 10 MCG VAGINAL TABLET RX-100745 CDM 6370000100 HCPCS 250 RC 65162-0226-23 NDC outpatient 1 UN 67.4 67.4 CIGNA 62308 [3081051] CIGNA 62308 [308105105] 53.92 percent of total billed charges 41.79 64.03 Technical (Hospital) Services ESTRADIOL 10 MCG VAGINAL TABLET RX-100745 CDM 6370000100 HCPCS 250 RC 65162-0226-23 NDC outpatient 1 UN 67.4 67.4 CIGNA 62308 [3081051] CIGNA STATE OF WYOMING [308105107] 53.92 percent of total billed charges 41.79 64.03 Technical (Hospital) Services ESTRADIOL 10 MCG VAGINAL TABLET RX-100745 CDM 6370000100 HCPCS 250 RC 65162-0226-23 NDC outpatient 1 UN 67.4 67.4 MULTIPLAN INC 34080 [3081285] MULTIPLAN INC [308128501] 64.03 percent of total billed charges 41.79 64.03 Technical (Hospital) Services ESTRADIOL 10 MCG VAGINAL TABLET RX-100745 CDM 6370000100 HCPCS 250 RC 65162-0226-23 NDC outpatient 1 UN 67.4 67.4 MEDICA (COMMERCIAL) 94265 [3081118] MEDICA CLAIMS [308111801] 60.66 percent of total billed charges 41.79 64.03 Technical (Hospital) Services ESTRADIOL 10 MCG VAGINAL TABLET RX-100745 CDM 6370000100 HCPCS 250 RC 65162-0226-23 NDC outpatient 1 UN 67.4 67.4 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES EPO [308136803] 53.92 percent of total billed charges 41.79 64.03 Technical (Hospital) Services ESTRADIOL 10 MCG VAGINAL TABLET RX-100745 CDM 6370000100 HCPCS 250 RC 65162-0226-23 NDC outpatient 1 UN 67.4 67.4 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES HDHP [308136802] 53.92 percent of total billed charges 41.79 64.03 Technical (Hospital) Services ESTRADIOL 10 MCG VAGINAL TABLET RX-100745 CDM 6370000100 HCPCS 250 RC 65162-0226-23 NDC outpatient 1 UN 67.4 67.4 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES PPO [308136801] 53.92 percent of total billed charges 41.79 64.03 Technical (Hospital) Services ESTRADIOL 10 MCG VAGINAL TABLET RX-100745 CDM 6370000100 HCPCS 250 RC 65162-0226-23 NDC inpatient 1 UN 67.4 67.4 MULTIPLAN INC 34080 [3081285] MULTIPLAN INC [308128501] 64.03 percent of total billed charges 41.79 64.03 Technical (Hospital) Services ESTRADIOL 10 MCG VAGINAL TABLET RX-100745 CDM 6370000100 HCPCS 250 RC 65162-0226-23 NDC inpatient 1 UN 67.4 67.4 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES PPO [308136801] 53.37 percent of total billed charges 41.79 64.03 Technical (Hospital) Services ESTRADIOL 10 MCG VAGINAL TABLET RX-100745 CDM 6370000100 HCPCS 250 RC 65162-0226-23 NDC inpatient 1 UN 67.4 67.4 HEALTHPARTNERS SX009 HEALTHPARTNERS 53.37 percent of total billed charges 41.79 64.03 Technical (Hospital) Services ESTRADIOL 10 MCG VAGINAL TABLET RX-100745 CDM 6370000100 HCPCS 250 RC 65162-0226-23 NDC inpatient 1 UN 67.4 67.4 MEDICA (COMMERCIAL) 94265 [3081118] MEDICA CLAIMS [308111801] 60.66 percent of total billed charges 41.79 64.03 Technical (Hospital) Services ESTRADIOL 10 MCG VAGINAL TABLET RX-100745 CDM 6370000100 HCPCS 250 RC 65162-0226-23 NDC inpatient 1 UN 67.4 67.4 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES EPO [308136803] 53.37 percent of total billed charges 41.79 64.03 Technical (Hospital) Services ESTRADIOL 10 MCG VAGINAL TABLET RX-100745 CDM 6370000100 HCPCS 250 RC 65162-0226-23 NDC inpatient 1 UN 67.4 67.4 CIGNA 62308 [3081051] CIGNA 62308 [308105105] 53.37 percent of total billed charges 41.79 64.03 Technical (Hospital) Services ESTRADIOL 10 MCG VAGINAL TABLET RX-100745 CDM 6370000100 HCPCS 250 RC 65162-0226-23 NDC inpatient 1 UN 67.4 67.4 CIGNA 62308 [3081051] CIGNA STATE OF WYOMING [308105107] 53.37 percent of total billed charges 41.79 64.03 Technical (Hospital) Services ESTRADIOL 10 MCG VAGINAL TABLET RX-100745 CDM 6370000100 HCPCS 250 RC 65162-0226-23 NDC inpatient 1 UN 67.4 67.4 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES HDHP [308136802] 53.37 percent of total billed charges 41.79 64.03 Technical (Hospital) Services ESTRADIOL 10 MCG VAGINAL TABLET RX-100745 CDM 6370000100 HCPCS 250 RC 65162-0226-23 NDC inpatient 1 UN 67.4 67.4 BLUE CROSS BLUE SHIELD WELLMARK SB889 [3081026] BCBS WYOMING [308102603] 64.03 percent of total billed charges 41.79 64.03 Technical (Hospital) Services ESTRADIOL 10 MCG VAGINAL TABLET RX-100745 CDM 6370000100 HCPCS 250 RC 65162-0226-23 NDC inpatient 1 UN 67.4 67.4 UNITED HEALTHCARE (COMMERCIAL) [3081199] UNITED HEALTHCARE 87726 [308119901] 41.79 percent of total billed charges 41.79 64.03 Technical (Hospital) Services GLIPIZIDE 5 MG TABLET RX-10117 CDM 6370000100 HCPCS 250 RC 00904-6637-61 NDC inpatient 1 UN 5.95 5.95 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES PPO [308136801] 4.71 percent of total billed charges 3.69 5.65 Technical (Hospital) Services GLIPIZIDE 5 MG TABLET RX-10117 CDM 6370000100 HCPCS 250 RC 00904-6637-61 NDC inpatient 1 UN 5.95 5.95 HEALTHPARTNERS SX009 HEALTHPARTNERS 4.71 percent of total billed charges 3.69 5.65 Technical (Hospital) Services GLIPIZIDE 5 MG TABLET RX-10117 CDM 6370000100 HCPCS 250 RC 00904-6637-61 NDC inpatient 1 UN 5.95 5.95 MEDICA (COMMERCIAL) 94265 [3081118] MEDICA CLAIMS [308111801] 5.36 percent of total billed charges 3.69 5.65 Technical (Hospital) Services GLIPIZIDE 5 MG TABLET RX-10117 CDM 6370000100 HCPCS 250 RC 00904-6637-61 NDC inpatient 1 UN 5.95 5.95 MULTIPLAN INC 34080 [3081285] MULTIPLAN INC [308128501] 5.65 percent of total billed charges 3.69 5.65 Technical (Hospital) Services GLIPIZIDE 5 MG TABLET RX-10117 CDM 6370000100 HCPCS 250 RC 00904-6637-61 NDC inpatient 1 UN 5.95 5.95 UNITED HEALTHCARE (COMMERCIAL) [3081199] UNITED HEALTHCARE 87726 [308119901] 3.69 percent of total billed charges 3.69 5.65 Technical (Hospital) Services GLIPIZIDE 5 MG TABLET RX-10117 CDM 6370000100 HCPCS 250 RC 00904-6637-61 NDC inpatient 1 UN 5.95 5.95 BLUE CROSS BLUE SHIELD WELLMARK SB889 [3081026] BCBS WYOMING [308102603] 5.65 percent of total billed charges 3.69 5.65 Technical (Hospital) Services GLIPIZIDE 5 MG TABLET RX-10117 CDM 6370000100 HCPCS 250 RC 00904-6637-61 NDC inpatient 1 UN 5.95 5.95 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES EPO [308136803] 4.71 percent of total billed charges 3.69 5.65 Technical (Hospital) Services GLIPIZIDE 5 MG TABLET RX-10117 CDM 6370000100 HCPCS 250 RC 00904-6637-61 NDC inpatient 1 UN 5.95 5.95 CIGNA 62308 [3081051] CIGNA 62308 [308105105] 4.71 percent of total billed charges 3.69 5.65 Technical (Hospital) Services GLIPIZIDE 5 MG TABLET RX-10117 CDM 6370000100 HCPCS 250 RC 00904-6637-61 NDC inpatient 1 UN 5.95 5.95 CIGNA 62308 [3081051] CIGNA STATE OF WYOMING [308105107] 4.71 percent of total billed charges 3.69 5.65 Technical (Hospital) Services GLIPIZIDE 5 MG TABLET RX-10117 CDM 6370000100 HCPCS 250 RC 00904-6637-61 NDC inpatient 1 UN 5.95 5.95 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES HDHP [308136802] 4.71 percent of total billed charges 3.69 5.65 Technical (Hospital) Services GLIPIZIDE 5 MG TABLET RX-10117 CDM 6370000100 HCPCS 250 RC 00904-6637-61 NDC outpatient 1 UN 5.95 5.95 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES PPO [308136801] 4.76 percent of total billed charges 3.69 5.65 Technical (Hospital) Services GLIPIZIDE 5 MG TABLET RX-10117 CDM 6370000100 HCPCS 250 RC 00904-6637-61 NDC outpatient 1 UN 5.95 5.95 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES HDHP [308136802] 4.76 percent of total billed charges 3.69 5.65 Technical (Hospital) Services GLIPIZIDE 5 MG TABLET RX-10117 CDM 6370000100 HCPCS 250 RC 00904-6637-61 NDC outpatient 1 UN 5.95 5.95 CIGNA 62308 [3081051] CIGNA 62308 [308105105] 4.76 percent of total billed charges 3.69 5.65 Technical (Hospital) Services GLIPIZIDE 5 MG TABLET RX-10117 CDM 6370000100 HCPCS 250 RC 00904-6637-61 NDC outpatient 1 UN 5.95 5.95 CIGNA 62308 [3081051] CIGNA STATE OF WYOMING [308105107] 4.76 percent of total billed charges 3.69 5.65 Technical (Hospital) Services GLIPIZIDE 5 MG TABLET RX-10117 CDM 6370000100 HCPCS 250 RC 00904-6637-61 NDC outpatient 1 UN 5.95 5.95 MEDICA (COMMERCIAL) 94265 [3081118] MEDICA CLAIMS [308111801] 5.36 percent of total billed charges 3.69 5.65 Technical (Hospital) Services GLIPIZIDE 5 MG TABLET RX-10117 CDM 6370000100 HCPCS 250 RC 00904-6637-61 NDC outpatient 1 UN 5.95 5.95 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES EPO [308136803] 4.76 percent of total billed charges 3.69 5.65 Technical (Hospital) Services GLIPIZIDE 5 MG TABLET RX-10117 CDM 6370000100 HCPCS 250 RC 00904-6637-61 NDC outpatient 1 UN 5.95 5.95 MULTIPLAN INC 34080 [3081285] MULTIPLAN INC [308128501] 5.65 percent of total billed charges 3.69 5.65 Technical (Hospital) Services GLIPIZIDE 5 MG TABLET RX-10117 CDM 6370000100 HCPCS 250 RC 00904-6637-61 NDC outpatient 1 UN 5.95 5.95 UNITED HEALTHCARE (COMMERCIAL) [3081199] UNITED HEALTHCARE 87726 [308119901] 3.69 percent of total billed charges 3.69 5.65 Technical (Hospital) Services GLIPIZIDE 5 MG TABLET RX-10117 CDM 6370000100 HCPCS 250 RC 00904-6637-61 NDC outpatient 1 UN 5.95 5.95 HEALTHPARTNERS SX009 HEALTHPARTNERS 4.76 percent of total billed charges 3.69 5.65 Technical (Hospital) Services GLIPIZIDE 5 MG TABLET RX-10117 CDM 6370000100 HCPCS 250 RC 00904-6637-61 NDC outpatient 1 UN 5.95 5.95 BLUE CROSS BLUE SHIELD WELLMARK SB889 [3081026] BCBS WYOMING [308102603] 5.65 percent of total billed charges 3.69 5.65 Technical (Hospital) Services GLYCOPYRROLATE 1 MG TABLET RX-10130 CDM 6370000100 HCPCS 250 RC 23155-0606-01 NDC inpatient 1 UN 5.74 5.74 CIGNA 62308 [3081051] CIGNA 62308 [308105105] 4.54 percent of total billed charges 3.56 5.45 Technical (Hospital) Services GLYCOPYRROLATE 1 MG TABLET RX-10130 CDM 6370000100 HCPCS 250 RC 23155-0606-01 NDC inpatient 1 UN 5.74 5.74 CIGNA 62308 [3081051] CIGNA STATE OF WYOMING [308105107] 4.54 percent of total billed charges 3.56 5.45 Technical (Hospital) Services GLYCOPYRROLATE 1 MG TABLET RX-10130 CDM 6370000100 HCPCS 250 RC 23155-0606-01 NDC inpatient 1 UN 5.74 5.74 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES EPO [308136803] 4.54 percent of total billed charges 3.56 5.45 Technical (Hospital) Services GLYCOPYRROLATE 1 MG TABLET RX-10130 CDM 6370000100 HCPCS 250 RC 23155-0606-01 NDC inpatient 1 UN 5.74 5.74 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES HDHP [308136802] 4.54 percent of total billed charges 3.56 5.45 Technical (Hospital) Services GLYCOPYRROLATE 1 MG TABLET RX-10130 CDM 6370000100 HCPCS 250 RC 23155-0606-01 NDC inpatient 1 UN 5.74 5.74 MEDICA (COMMERCIAL) 94265 [3081118] MEDICA CLAIMS [308111801] 5.17 percent of total billed charges 3.56 5.45 Technical (Hospital) Services GLYCOPYRROLATE 1 MG TABLET RX-10130 CDM 6370000100 HCPCS 250 RC 23155-0606-01 NDC inpatient 1 UN 5.74 5.74 HEALTHPARTNERS SX009 HEALTHPARTNERS 4.54 percent of total billed charges 3.56 5.45 Technical (Hospital) Services GLYCOPYRROLATE 1 MG TABLET RX-10130 CDM 6370000100 HCPCS 250 RC 23155-0606-01 NDC inpatient 1 UN 5.74 5.74 BLUE CROSS BLUE SHIELD WELLMARK SB889 [3081026] BCBS WYOMING [308102603] 5.45 percent of total billed charges 3.56 5.45 Technical (Hospital) Services GLYCOPYRROLATE 1 MG TABLET RX-10130 CDM 6370000100 HCPCS 250 RC 23155-0606-01 NDC inpatient 1 UN 5.74 5.74 UNITED HEALTHCARE (COMMERCIAL) [3081199] UNITED HEALTHCARE 87726 [308119901] 3.56 percent of total billed charges 3.56 5.45 Technical (Hospital) Services GLYCOPYRROLATE 1 MG TABLET RX-10130 CDM 6370000100 HCPCS 250 RC 23155-0606-01 NDC inpatient 1 UN 5.74 5.74 MULTIPLAN INC 34080 [3081285] MULTIPLAN INC [308128501] 5.45 percent of total billed charges 3.56 5.45 Technical (Hospital) Services GLYCOPYRROLATE 1 MG TABLET RX-10130 CDM 6370000100 HCPCS 250 RC 23155-0606-01 NDC inpatient 1 UN 5.74 5.74 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES PPO [308136801] 4.54 percent of total billed charges 3.56 5.45 Technical (Hospital) Services GLYCOPYRROLATE 1 MG TABLET RX-10130 CDM 6370000100 HCPCS 250 RC 23155-0606-01 NDC outpatient 1 UN 5.74 5.74 MEDICA (COMMERCIAL) 94265 [3081118] MEDICA CLAIMS [308111801] 5.17 percent of total billed charges 3.56 5.45 Technical (Hospital) Services GLYCOPYRROLATE 1 MG TABLET RX-10130 CDM 6370000100 HCPCS 250 RC 23155-0606-01 NDC outpatient 1 UN 5.74 5.74 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES EPO [308136803] 4.59 percent of total billed charges 3.56 5.45 Technical (Hospital) Services GLYCOPYRROLATE 1 MG TABLET RX-10130 CDM 6370000100 HCPCS 250 RC 23155-0606-01 NDC outpatient 1 UN 5.74 5.74 MULTIPLAN INC 34080 [3081285] MULTIPLAN INC [308128501] 5.45 percent of total billed charges 3.56 5.45 Technical (Hospital) Services GLYCOPYRROLATE 1 MG TABLET RX-10130 CDM 6370000100 HCPCS 250 RC 23155-0606-01 NDC outpatient 1 UN 5.74 5.74 CIGNA 62308 [3081051] CIGNA 62308 [308105105] 4.59 percent of total billed charges 3.56 5.45 Technical (Hospital) Services GLYCOPYRROLATE 1 MG TABLET RX-10130 CDM 6370000100 HCPCS 250 RC 23155-0606-01 NDC outpatient 1 UN 5.74 5.74 CIGNA 62308 [3081051] CIGNA STATE OF WYOMING [308105107] 4.59 percent of total billed charges 3.56 5.45 Technical (Hospital) Services GLYCOPYRROLATE 1 MG TABLET RX-10130 CDM 6370000100 HCPCS 250 RC 23155-0606-01 NDC outpatient 1 UN 5.74 5.74 UNITED HEALTHCARE (COMMERCIAL) [3081199] UNITED HEALTHCARE 87726 [308119901] 3.56 percent of total billed charges 3.56 5.45 Technical (Hospital) Services GLYCOPYRROLATE 1 MG TABLET RX-10130 CDM 6370000100 HCPCS 250 RC 23155-0606-01 NDC outpatient 1 UN 5.74 5.74 HEALTHPARTNERS SX009 HEALTHPARTNERS 4.59 percent of total billed charges 3.56 5.45 Technical (Hospital) Services GLYCOPYRROLATE 1 MG TABLET RX-10130 CDM 6370000100 HCPCS 250 RC 23155-0606-01 NDC outpatient 1 UN 5.74 5.74 BLUE CROSS BLUE SHIELD WELLMARK SB889 [3081026] BCBS WYOMING [308102603] 5.45 percent of total billed charges 3.56 5.45 Technical (Hospital) Services GLYCOPYRROLATE 1 MG TABLET RX-10130 CDM 6370000100 HCPCS 250 RC 23155-0606-01 NDC outpatient 1 UN 5.74 5.74 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES HDHP [308136802] 4.59 percent of total billed charges 3.56 5.45 Technical (Hospital) Services GLYCOPYRROLATE 1 MG TABLET RX-10130 CDM 6370000100 HCPCS 250 RC 23155-0606-01 NDC outpatient 1 UN 5.74 5.74 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES PPO [308136801] 4.59 percent of total billed charges 3.56 5.45 Technical (Hospital) Services HYDROCORTISONE 5 MG TABLET RX-10209 CDM 6370000100 HCPCS 250 RC 59762-0073-01 NDC inpatient 1 UN 5.79 5.79 MULTIPLAN INC 34080 [3081285] MULTIPLAN INC [308128501] 5.5 percent of total billed charges 3.59 5.5 Technical (Hospital) Services HYDROCORTISONE 5 MG TABLET RX-10209 CDM 6370000100 HCPCS 250 RC 59762-0073-01 NDC inpatient 1 UN 5.79 5.79 MEDICA (COMMERCIAL) 94265 [3081118] MEDICA CLAIMS [308111801] 5.21 percent of total billed charges 3.59 5.5 Technical (Hospital) Services HYDROCORTISONE 5 MG TABLET RX-10209 CDM 6370000100 HCPCS 250 RC 59762-0073-01 NDC inpatient 1 UN 5.79 5.79 HEALTHPARTNERS SX009 HEALTHPARTNERS 4.58 percent of total billed charges 3.59 5.5 Technical (Hospital) Services HYDROCORTISONE 5 MG TABLET RX-10209 CDM 6370000100 HCPCS 250 RC 59762-0073-01 NDC inpatient 1 UN 5.79 5.79 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES PPO [308136801] 4.58 percent of total billed charges 3.59 5.5 Technical (Hospital) Services HYDROCORTISONE 5 MG TABLET RX-10209 CDM 6370000100 HCPCS 250 RC 59762-0073-01 NDC inpatient 1 UN 5.79 5.79 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES EPO [308136803] 4.58 percent of total billed charges 3.59 5.5 Technical (Hospital) Services HYDROCORTISONE 5 MG TABLET RX-10209 CDM 6370000100 HCPCS 250 RC 59762-0073-01 NDC inpatient 1 UN 5.79 5.79 CIGNA 62308 [3081051] CIGNA 62308 [308105105] 4.58 percent of total billed charges 3.59 5.5 Technical (Hospital) Services HYDROCORTISONE 5 MG TABLET RX-10209 CDM 6370000100 HCPCS 250 RC 59762-0073-01 NDC inpatient 1 UN 5.79 5.79 CIGNA 62308 [3081051] CIGNA STATE OF WYOMING [308105107] 4.58 percent of total billed charges 3.59 5.5 Technical (Hospital) Services HYDROCORTISONE 5 MG TABLET RX-10209 CDM 6370000100 HCPCS 250 RC 59762-0073-01 NDC inpatient 1 UN 5.79 5.79 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES HDHP [308136802] 4.58 percent of total billed charges 3.59 5.5 Technical (Hospital) Services HYDROCORTISONE 5 MG TABLET RX-10209 CDM 6370000100 HCPCS 250 RC 59762-0073-01 NDC inpatient 1 UN 5.79 5.79 BLUE CROSS BLUE SHIELD WELLMARK SB889 [3081026] BCBS WYOMING [308102603] 5.5 percent of total billed charges 3.59 5.5 Technical (Hospital) Services HYDROCORTISONE 5 MG TABLET RX-10209 CDM 6370000100 HCPCS 250 RC 59762-0073-01 NDC inpatient 1 UN 5.79 5.79 UNITED HEALTHCARE (COMMERCIAL) [3081199] UNITED HEALTHCARE 87726 [308119901] 3.59 percent of total billed charges 3.59 5.5 Technical (Hospital) Services HYDROCORTISONE 5 MG TABLET RX-10209 CDM 6370000100 HCPCS 250 RC 59762-0073-01 NDC outpatient 1 UN 5.79 5.79 MULTIPLAN INC 34080 [3081285] MULTIPLAN INC [308128501] 5.5 percent of total billed charges 3.59 5.5 Technical (Hospital) Services HYDROCORTISONE 5 MG TABLET RX-10209 CDM 6370000100 HCPCS 250 RC 59762-0073-01 NDC outpatient 1 UN 5.79 5.79 UNITED HEALTHCARE (COMMERCIAL) [3081199] UNITED HEALTHCARE 87726 [308119901] 3.59 percent of total billed charges 3.59 5.5 Technical (Hospital) Services HYDROCORTISONE 5 MG TABLET RX-10209 CDM 6370000100 HCPCS 250 RC 59762-0073-01 NDC outpatient 1 UN 5.79 5.79 CIGNA 62308 [3081051] CIGNA 62308 [308105105] 4.63 percent of total billed charges 3.59 5.5 Technical (Hospital) Services HYDROCORTISONE 5 MG TABLET RX-10209 CDM 6370000100 HCPCS 250 RC 59762-0073-01 NDC outpatient 1 UN 5.79 5.79 CIGNA 62308 [3081051] CIGNA STATE OF WYOMING [308105107] 4.63 percent of total billed charges 3.59 5.5 Technical (Hospital) Services HYDROCORTISONE 5 MG TABLET RX-10209 CDM 6370000100 HCPCS 250 RC 59762-0073-01 NDC outpatient 1 UN 5.79 5.79 MEDICA (COMMERCIAL) 94265 [3081118] MEDICA CLAIMS [308111801] 5.21 percent of total billed charges 3.59 5.5 Technical (Hospital) Services HYDROCORTISONE 5 MG TABLET RX-10209 CDM 6370000100 HCPCS 250 RC 59762-0073-01 NDC outpatient 1 UN 5.79 5.79 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES EPO [308136803] 4.63 percent of total billed charges 3.59 5.5 Technical (Hospital) Services HYDROCORTISONE 5 MG TABLET RX-10209 CDM 6370000100 HCPCS 250 RC 59762-0073-01 NDC outpatient 1 UN 5.79 5.79 HEALTHPARTNERS SX009 HEALTHPARTNERS 4.63 percent of total billed charges 3.59 5.5 Technical (Hospital) Services HYDROCORTISONE 5 MG TABLET RX-10209 CDM 6370000100 HCPCS 250 RC 59762-0073-01 NDC outpatient 1 UN 5.79 5.79 BLUE CROSS BLUE SHIELD WELLMARK SB889 [3081026] BCBS WYOMING [308102603] 5.5 percent of total billed charges 3.59 5.5 Technical (Hospital) Services HYDROCORTISONE 5 MG TABLET RX-10209 CDM 6370000100 HCPCS 250 RC 59762-0073-01 NDC outpatient 1 UN 5.79 5.79 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES HDHP [308136802] 4.63 percent of total billed charges 3.59 5.5 Technical (Hospital) Services HYDROCORTISONE 5 MG TABLET RX-10209 CDM 6370000100 HCPCS 250 RC 59762-0073-01 NDC outpatient 1 UN 5.79 5.79 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES PPO [308136801] 4.63 percent of total billed charges 3.59 5.5 Technical (Hospital) Services INSULIN NPH ISOPHANE U-100 HUMAN 100 UNIT/ML SUBCUTANEOUS SUSPENSION RX-10284 CDM 6370000100 HCPCS 250 RC 00002-8315-01 NDC inpatient 10 ML 204.61 204.61 MULTIPLAN INC 34080 [3081285] MULTIPLAN INC [308128501] 194.38 percent of total billed charges 126.86 194.38 Technical (Hospital) Services INSULIN NPH ISOPHANE U-100 HUMAN 100 UNIT/ML SUBCUTANEOUS SUSPENSION RX-10284 CDM 6370000100 HCPCS 250 RC 00002-8315-01 NDC inpatient 10 ML 204.61 204.61 MEDICA (COMMERCIAL) 94265 [3081118] MEDICA CLAIMS [308111801] 184.15 percent of total billed charges 126.86 194.38 Technical (Hospital) Services INSULIN NPH ISOPHANE U-100 HUMAN 100 UNIT/ML SUBCUTANEOUS SUSPENSION RX-10284 CDM 6370000100 HCPCS 250 RC 00002-8315-01 NDC inpatient 10 ML 204.61 204.61 CIGNA 62308 [3081051] CIGNA 62308 [308105105] 162.01 percent of total billed charges 126.86 194.38 Technical (Hospital) Services INSULIN NPH ISOPHANE U-100 HUMAN 100 UNIT/ML SUBCUTANEOUS SUSPENSION RX-10284 CDM 6370000100 HCPCS 250 RC 00002-8315-01 NDC inpatient 10 ML 204.61 204.61 CIGNA 62308 [3081051] CIGNA STATE OF WYOMING [308105107] 162.01 percent of total billed charges 126.86 194.38 Technical (Hospital) Services INSULIN NPH ISOPHANE U-100 HUMAN 100 UNIT/ML SUBCUTANEOUS SUSPENSION RX-10284 CDM 6370000100 HCPCS 250 RC 00002-8315-01 NDC inpatient 10 ML 204.61 204.61 UNITED HEALTHCARE (COMMERCIAL) [3081199] UNITED HEALTHCARE 87726 [308119901] 126.86 percent of total billed charges 126.86 194.38 Technical (Hospital) Services INSULIN NPH ISOPHANE U-100 HUMAN 100 UNIT/ML SUBCUTANEOUS SUSPENSION RX-10284 CDM 6370000100 HCPCS 250 RC 00002-8315-01 NDC inpatient 10 ML 204.61 204.61 BLUE CROSS BLUE SHIELD WELLMARK SB889 [3081026] BCBS WYOMING [308102603] 194.38 percent of total billed charges 126.86 194.38 Technical (Hospital) Services INSULIN NPH ISOPHANE U-100 HUMAN 100 UNIT/ML SUBCUTANEOUS SUSPENSION RX-10284 CDM 6370000100 HCPCS 250 RC 00002-8315-01 NDC inpatient 10 ML 204.61 204.61 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES PPO [308136801] 162.01 percent of total billed charges 126.86 194.38 Technical (Hospital) Services INSULIN NPH ISOPHANE U-100 HUMAN 100 UNIT/ML SUBCUTANEOUS SUSPENSION RX-10284 CDM 6370000100 HCPCS 250 RC 00002-8315-01 NDC inpatient 10 ML 204.61 204.61 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES HDHP [308136802] 162.01 percent of total billed charges 126.86 194.38 Technical (Hospital) Services INSULIN NPH ISOPHANE U-100 HUMAN 100 UNIT/ML SUBCUTANEOUS SUSPENSION RX-10284 CDM 6370000100 HCPCS 250 RC 00002-8315-01 NDC inpatient 10 ML 204.61 204.61 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES EPO [308136803] 162.01 percent of total billed charges 126.86 194.38 Technical (Hospital) Services INSULIN NPH ISOPHANE U-100 HUMAN 100 UNIT/ML SUBCUTANEOUS SUSPENSION RX-10284 CDM 6370000100 HCPCS 250 RC 00002-8315-01 NDC inpatient 10 ML 204.61 204.61 HEALTHPARTNERS SX009 HEALTHPARTNERS 162.01 percent of total billed charges 126.86 194.38 Technical (Hospital) Services INSULIN NPH ISOPHANE U-100 HUMAN 100 UNIT/ML SUBCUTANEOUS SUSPENSION RX-10284 CDM 6370000100 HCPCS 250 RC 00002-8315-01 NDC outpatient 10 ML 204.61 204.61 MULTIPLAN INC 34080 [3081285] MULTIPLAN INC [308128501] 194.38 percent of total billed charges 126.86 194.38 Technical (Hospital) Services INSULIN NPH ISOPHANE U-100 HUMAN 100 UNIT/ML SUBCUTANEOUS SUSPENSION RX-10284 CDM 6370000100 HCPCS 250 RC 00002-8315-01 NDC outpatient 10 ML 204.61 204.61 MEDICA (COMMERCIAL) 94265 [3081118] MEDICA CLAIMS [308111801] 184.15 percent of total billed charges 126.86 194.38 Technical (Hospital) Services INSULIN NPH ISOPHANE U-100 HUMAN 100 UNIT/ML SUBCUTANEOUS SUSPENSION RX-10284 CDM 6370000100 HCPCS 250 RC 00002-8315-01 NDC outpatient 10 ML 204.61 204.61 CIGNA 62308 [3081051] CIGNA 62308 [308105105] 163.69 percent of total billed charges 126.86 194.38 Technical (Hospital) Services INSULIN NPH ISOPHANE U-100 HUMAN 100 UNIT/ML SUBCUTANEOUS SUSPENSION RX-10284 CDM 6370000100 HCPCS 250 RC 00002-8315-01 NDC outpatient 10 ML 204.61 204.61 CIGNA 62308 [3081051] CIGNA STATE OF WYOMING [308105107] 163.69 percent of total billed charges 126.86 194.38 Technical (Hospital) Services INSULIN NPH ISOPHANE U-100 HUMAN 100 UNIT/ML SUBCUTANEOUS SUSPENSION RX-10284 CDM 6370000100 HCPCS 250 RC 00002-8315-01 NDC outpatient 10 ML 204.61 204.61 UNITED HEALTHCARE (COMMERCIAL) [3081199] UNITED HEALTHCARE 87726 [308119901] 126.86 percent of total billed charges 126.86 194.38 Technical (Hospital) Services INSULIN NPH ISOPHANE U-100 HUMAN 100 UNIT/ML SUBCUTANEOUS SUSPENSION RX-10284 CDM 6370000100 HCPCS 250 RC 00002-8315-01 NDC outpatient 10 ML 204.61 204.61 BLUE CROSS BLUE SHIELD WELLMARK SB889 [3081026] BCBS WYOMING [308102603] 194.38 percent of total billed charges 126.86 194.38 Technical (Hospital) Services INSULIN NPH ISOPHANE U-100 HUMAN 100 UNIT/ML SUBCUTANEOUS SUSPENSION RX-10284 CDM 6370000100 HCPCS 250 RC 00002-8315-01 NDC outpatient 10 ML 204.61 204.61 HEALTHPARTNERS SX009 HEALTHPARTNERS 163.69 percent of total billed charges 126.86 194.38 Technical (Hospital) Services INSULIN NPH ISOPHANE U-100 HUMAN 100 UNIT/ML SUBCUTANEOUS SUSPENSION RX-10284 CDM 6370000100 HCPCS 250 RC 00002-8315-01 NDC outpatient 10 ML 204.61 204.61 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES PPO [308136801] 163.69 percent of total billed charges 126.86 194.38 Technical (Hospital) Services INSULIN NPH ISOPHANE U-100 HUMAN 100 UNIT/ML SUBCUTANEOUS SUSPENSION RX-10284 CDM 6370000100 HCPCS 250 RC 00002-8315-01 NDC outpatient 10 ML 204.61 204.61 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES HDHP [308136802] 163.69 percent of total billed charges 126.86 194.38 Technical (Hospital) Services INSULIN NPH ISOPHANE U-100 HUMAN 100 UNIT/ML SUBCUTANEOUS SUSPENSION RX-10284 CDM 6370000100 HCPCS 250 RC 00002-8315-01 NDC outpatient 10 ML 204.61 204.61 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES EPO [308136803] 163.69 percent of total billed charges 126.86 194.38 Technical (Hospital) Services INSULIN HUMAN U-100 NPH-REGULR 70-30 MIX 100 UNIT/ML SUBCUTANEOUS SUSP RX-10286 CDM 6370000100 HCPCS 250 RC 00002-8715-17 NDC inpatient 3 ML 83.38 83.38 MULTIPLAN INC 34080 [3081285] MULTIPLAN INC [308128501] 79.21 percent of total billed charges 51.7 79.21 Technical (Hospital) Services INSULIN HUMAN U-100 NPH-REGULR 70-30 MIX 100 UNIT/ML SUBCUTANEOUS SUSP RX-10286 CDM 6370000100 HCPCS 250 RC 00002-8715-17 NDC inpatient 3 ML 83.38 83.38 MEDICA (COMMERCIAL) 94265 [3081118] MEDICA CLAIMS [308111801] 75.04 percent of total billed charges 51.7 79.21 Technical (Hospital) Services INSULIN HUMAN U-100 NPH-REGULR 70-30 MIX 100 UNIT/ML SUBCUTANEOUS SUSP RX-10286 CDM 6370000100 HCPCS 250 RC 00002-8715-17 NDC inpatient 3 ML 83.38 83.38 UNITED HEALTHCARE (COMMERCIAL) [3081199] UNITED HEALTHCARE 87726 [308119901] 51.7 percent of total billed charges 51.7 79.21 Technical (Hospital) Services INSULIN HUMAN U-100 NPH-REGULR 70-30 MIX 100 UNIT/ML SUBCUTANEOUS SUSP RX-10286 CDM 6370000100 HCPCS 250 RC 00002-8715-17 NDC inpatient 3 ML 83.38 83.38 BLUE CROSS BLUE SHIELD WELLMARK SB889 [3081026] BCBS WYOMING [308102603] 79.21 percent of total billed charges 51.7 79.21 Technical (Hospital) Services INSULIN HUMAN U-100 NPH-REGULR 70-30 MIX 100 UNIT/ML SUBCUTANEOUS SUSP RX-10286 CDM 6370000100 HCPCS 250 RC 00002-8715-17 NDC inpatient 3 ML 83.38 83.38 CIGNA 62308 [3081051] CIGNA 62308 [308105105] 66.02 percent of total billed charges 51.7 79.21 Technical (Hospital) Services INSULIN HUMAN U-100 NPH-REGULR 70-30 MIX 100 UNIT/ML SUBCUTANEOUS SUSP RX-10286 CDM 6370000100 HCPCS 250 RC 00002-8715-17 NDC inpatient 3 ML 83.38 83.38 CIGNA 62308 [3081051] CIGNA STATE OF WYOMING [308105107] 66.02 percent of total billed charges 51.7 79.21 Technical (Hospital) Services INSULIN HUMAN U-100 NPH-REGULR 70-30 MIX 100 UNIT/ML SUBCUTANEOUS SUSP RX-10286 CDM 6370000100 HCPCS 250 RC 00002-8715-17 NDC inpatient 3 ML 83.38 83.38 HEALTHPARTNERS SX009 HEALTHPARTNERS 66.02 percent of total billed charges 51.7 79.21 Technical (Hospital) Services INSULIN HUMAN U-100 NPH-REGULR 70-30 MIX 100 UNIT/ML SUBCUTANEOUS SUSP RX-10286 CDM 6370000100 HCPCS 250 RC 00002-8715-17 NDC inpatient 3 ML 83.38 83.38 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES EPO [308136803] 66.02 percent of total billed charges 51.7 79.21 Technical (Hospital) Services INSULIN HUMAN U-100 NPH-REGULR 70-30 MIX 100 UNIT/ML SUBCUTANEOUS SUSP RX-10286 CDM 6370000100 HCPCS 250 RC 00002-8715-17 NDC inpatient 3 ML 83.38 83.38 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES PPO [308136801] 66.02 percent of total billed charges 51.7 79.21 Technical (Hospital) Services INSULIN HUMAN U-100 NPH-REGULR 70-30 MIX 100 UNIT/ML SUBCUTANEOUS SUSP RX-10286 CDM 6370000100 HCPCS 250 RC 00002-8715-17 NDC inpatient 3 ML 83.38 83.38 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES HDHP [308136802] 66.02 percent of total billed charges 51.7 79.21 Technical (Hospital) Services INSULIN HUMAN U-100 NPH-REGULR 70-30 MIX 100 UNIT/ML SUBCUTANEOUS SUSP RX-10286 CDM 6370000100 HCPCS 250 RC 00002-8715-17 NDC outpatient 3 ML 83.38 83.38 HEALTHPARTNERS SX009 HEALTHPARTNERS 66.7 percent of total billed charges 51.7 79.21 Technical (Hospital) Services INSULIN HUMAN U-100 NPH-REGULR 70-30 MIX 100 UNIT/ML SUBCUTANEOUS SUSP RX-10286 CDM 6370000100 HCPCS 250 RC 00002-8715-17 NDC outpatient 3 ML 83.38 83.38 UNITED HEALTHCARE (COMMERCIAL) [3081199] UNITED HEALTHCARE 87726 [308119901] 51.7 percent of total billed charges 51.7 79.21 Technical (Hospital) Services INSULIN HUMAN U-100 NPH-REGULR 70-30 MIX 100 UNIT/ML SUBCUTANEOUS SUSP RX-10286 CDM 6370000100 HCPCS 250 RC 00002-8715-17 NDC outpatient 3 ML 83.38 83.38 CIGNA 62308 [3081051] CIGNA 62308 [308105105] 66.7 percent of total billed charges 51.7 79.21 Technical (Hospital) Services INSULIN HUMAN U-100 NPH-REGULR 70-30 MIX 100 UNIT/ML SUBCUTANEOUS SUSP RX-10286 CDM 6370000100 HCPCS 250 RC 00002-8715-17 NDC outpatient 3 ML 83.38 83.38 CIGNA 62308 [3081051] CIGNA STATE OF WYOMING [308105107] 66.7 percent of total billed charges 51.7 79.21 Technical (Hospital) Services INSULIN HUMAN U-100 NPH-REGULR 70-30 MIX 100 UNIT/ML SUBCUTANEOUS SUSP RX-10286 CDM 6370000100 HCPCS 250 RC 00002-8715-17 NDC outpatient 3 ML 83.38 83.38 MULTIPLAN INC 34080 [3081285] MULTIPLAN INC [308128501] 79.21 percent of total billed charges 51.7 79.21 Technical (Hospital) Services INSULIN HUMAN U-100 NPH-REGULR 70-30 MIX 100 UNIT/ML SUBCUTANEOUS SUSP RX-10286 CDM 6370000100 HCPCS 250 RC 00002-8715-17 NDC outpatient 3 ML 83.38 83.38 MEDICA (COMMERCIAL) 94265 [3081118] MEDICA CLAIMS [308111801] 75.04 percent of total billed charges 51.7 79.21 Technical (Hospital) Services INSULIN HUMAN U-100 NPH-REGULR 70-30 MIX 100 UNIT/ML SUBCUTANEOUS SUSP RX-10286 CDM 6370000100 HCPCS 250 RC 00002-8715-17 NDC outpatient 3 ML 83.38 83.38 BLUE CROSS BLUE SHIELD WELLMARK SB889 [3081026] BCBS WYOMING [308102603] 79.21 percent of total billed charges 51.7 79.21 Technical (Hospital) Services INSULIN HUMAN U-100 NPH-REGULR 70-30 MIX 100 UNIT/ML SUBCUTANEOUS SUSP RX-10286 CDM 6370000100 HCPCS 250 RC 00002-8715-17 NDC outpatient 3 ML 83.38 83.38 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES EPO [308136803] 66.7 percent of total billed charges 51.7 79.21 Technical (Hospital) Services INSULIN HUMAN U-100 NPH-REGULR 70-30 MIX 100 UNIT/ML SUBCUTANEOUS SUSP RX-10286 CDM 6370000100 HCPCS 250 RC 00002-8715-17 NDC outpatient 3 ML 83.38 83.38 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES HDHP [308136802] 66.7 percent of total billed charges 51.7 79.21 Technical (Hospital) Services INSULIN HUMAN U-100 NPH-REGULR 70-30 MIX 100 UNIT/ML SUBCUTANEOUS SUSP RX-10286 CDM 6370000100 HCPCS 250 RC 00002-8715-17 NDC outpatient 3 ML 83.38 83.38 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES PPO [308136801] 66.7 percent of total billed charges 51.7 79.21 Technical (Hospital) Services KETOCONAZOLE 2 % TOPICAL CREAM RX-10368 CDM 6370000100 HCPCS 250 RC 51672-1298-02 NDC inpatient 1 GR 6.89 6.89 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES HDHP [308136802] 5.46 percent of total billed charges 4.27 6.55 Technical (Hospital) Services KETOCONAZOLE 2 % TOPICAL CREAM RX-10368 CDM 6370000100 HCPCS 250 RC 51672-1298-02 NDC inpatient 1 GR 6.89 6.89 MEDICA (COMMERCIAL) 94265 [3081118] MEDICA CLAIMS [308111801] 6.2 percent of total billed charges 4.27 6.55 Technical (Hospital) Services KETOCONAZOLE 2 % TOPICAL CREAM RX-10368 CDM 6370000100 HCPCS 250 RC 51672-1298-02 NDC inpatient 1 GR 6.89 6.89 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES EPO [308136803] 5.46 percent of total billed charges 4.27 6.55 Technical (Hospital) Services KETOCONAZOLE 2 % TOPICAL CREAM RX-10368 CDM 6370000100 HCPCS 250 RC 51672-1298-02 NDC inpatient 1 GR 6.89 6.89 CIGNA 62308 [3081051] CIGNA 62308 [308105105] 5.46 percent of total billed charges 4.27 6.55 Technical (Hospital) Services KETOCONAZOLE 2 % TOPICAL CREAM RX-10368 CDM 6370000100 HCPCS 250 RC 51672-1298-02 NDC inpatient 1 GR 6.89 6.89 CIGNA 62308 [3081051] CIGNA STATE OF WYOMING [308105107] 5.46 percent of total billed charges 4.27 6.55 Technical (Hospital) Services KETOCONAZOLE 2 % TOPICAL CREAM RX-10368 CDM 6370000100 HCPCS 250 RC 51672-1298-02 NDC inpatient 1 GR 6.89 6.89 BLUE CROSS BLUE SHIELD WELLMARK SB889 [3081026] BCBS WYOMING [308102603] 6.55 percent of total billed charges 4.27 6.55 Technical (Hospital) Services KETOCONAZOLE 2 % TOPICAL CREAM RX-10368 CDM 6370000100 HCPCS 250 RC 51672-1298-02 NDC inpatient 1 GR 6.89 6.89 UNITED HEALTHCARE (COMMERCIAL) [3081199] UNITED HEALTHCARE 87726 [308119901] 4.27 percent of total billed charges 4.27 6.55 Technical (Hospital) Services KETOCONAZOLE 2 % TOPICAL CREAM RX-10368 CDM 6370000100 HCPCS 250 RC 51672-1298-02 NDC inpatient 1 GR 6.89 6.89 MULTIPLAN INC 34080 [3081285] MULTIPLAN INC [308128501] 6.55 percent of total billed charges 4.27 6.55 Technical (Hospital) Services KETOCONAZOLE 2 % TOPICAL CREAM RX-10368 CDM 6370000100 HCPCS 250 RC 51672-1298-02 NDC inpatient 1 GR 6.89 6.89 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES PPO [308136801] 5.46 percent of total billed charges 4.27 6.55 Technical (Hospital) Services KETOCONAZOLE 2 % TOPICAL CREAM RX-10368 CDM 6370000100 HCPCS 250 RC 51672-1298-02 NDC inpatient 1 GR 6.89 6.89 HEALTHPARTNERS SX009 HEALTHPARTNERS 5.46 percent of total billed charges 4.27 6.55 Technical (Hospital) Services KETOCONAZOLE 2 % TOPICAL CREAM RX-10368 CDM 6370000100 HCPCS 250 RC 51672-1298-02 NDC outpatient 1 GR 6.89 6.89 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES PPO [308136801] 5.51 percent of total billed charges 4.27 6.55 Technical (Hospital) Services KETOCONAZOLE 2 % TOPICAL CREAM RX-10368 CDM 6370000100 HCPCS 250 RC 51672-1298-02 NDC outpatient 1 GR 6.89 6.89 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES HDHP [308136802] 5.51 percent of total billed charges 4.27 6.55 Technical (Hospital) Services KETOCONAZOLE 2 % TOPICAL CREAM RX-10368 CDM 6370000100 HCPCS 250 RC 51672-1298-02 NDC outpatient 1 GR 6.89 6.89 MEDICA (COMMERCIAL) 94265 [3081118] MEDICA CLAIMS [308111801] 6.2 percent of total billed charges 4.27 6.55 Technical (Hospital) Services KETOCONAZOLE 2 % TOPICAL CREAM RX-10368 CDM 6370000100 HCPCS 250 RC 51672-1298-02 NDC outpatient 1 GR 6.89 6.89 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES EPO [308136803] 5.51 percent of total billed charges 4.27 6.55 Technical (Hospital) Services KETOCONAZOLE 2 % TOPICAL CREAM RX-10368 CDM 6370000100 HCPCS 250 RC 51672-1298-02 NDC outpatient 1 GR 6.89 6.89 UNITED HEALTHCARE (COMMERCIAL) [3081199] UNITED HEALTHCARE 87726 [308119901] 4.27 percent of total billed charges 4.27 6.55 Technical (Hospital) Services KETOCONAZOLE 2 % TOPICAL CREAM RX-10368 CDM 6370000100 HCPCS 250 RC 51672-1298-02 NDC outpatient 1 GR 6.89 6.89 MULTIPLAN INC 34080 [3081285] MULTIPLAN INC [308128501] 6.55 percent of total billed charges 4.27 6.55 Technical (Hospital) Services KETOCONAZOLE 2 % TOPICAL CREAM RX-10368 CDM 6370000100 HCPCS 250 RC 51672-1298-02 NDC outpatient 1 GR 6.89 6.89 CIGNA 62308 [3081051] CIGNA 62308 [308105105] 5.51 percent of total billed charges 4.27 6.55 Technical (Hospital) Services KETOCONAZOLE 2 % TOPICAL CREAM RX-10368 CDM 6370000100 HCPCS 250 RC 51672-1298-02 NDC outpatient 1 GR 6.89 6.89 CIGNA 62308 [3081051] CIGNA STATE OF WYOMING [308105107] 5.51 percent of total billed charges 4.27 6.55 Technical (Hospital) Services KETOCONAZOLE 2 % TOPICAL CREAM RX-10368 CDM 6370000100 HCPCS 250 RC 51672-1298-02 NDC outpatient 1 GR 6.89 6.89 BLUE CROSS BLUE SHIELD WELLMARK SB889 [3081026] BCBS WYOMING [308102603] 6.55 percent of total billed charges 4.27 6.55 Technical (Hospital) Services KETOCONAZOLE 2 % TOPICAL CREAM RX-10368 CDM 6370000100 HCPCS 250 RC 51672-1298-02 NDC outpatient 1 GR 6.89 6.89 HEALTHPARTNERS SX009 HEALTHPARTNERS 5.51 percent of total billed charges 4.27 6.55 Technical (Hospital) Services KETOROLAC 10 MG TABLET RX-10371 CDM 6370000100 HCPCS 250 RC 00093-0314-01 NDC inpatient 1 UN 6.7 6.7 HEALTHPARTNERS SX009 HEALTHPARTNERS 5.31 percent of total billed charges 4.15 6.37 Technical (Hospital) Services KETOROLAC 10 MG TABLET RX-10371 CDM 6370000100 HCPCS 250 RC 00093-0314-01 NDC inpatient 1 UN 6.7 6.7 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES PPO [308136801] 5.31 percent of total billed charges 4.15 6.37 Technical (Hospital) Services KETOROLAC 10 MG TABLET RX-10371 CDM 6370000100 HCPCS 250 RC 00093-0314-01 NDC inpatient 1 UN 6.7 6.7 MULTIPLAN INC 34080 [3081285] MULTIPLAN INC [308128501] 6.37 percent of total billed charges 4.15 6.37 Technical (Hospital) Services KETOROLAC 10 MG TABLET RX-10371 CDM 6370000100 HCPCS 250 RC 00093-0314-01 NDC inpatient 1 UN 6.7 6.7 UNITED HEALTHCARE (COMMERCIAL) [3081199] UNITED HEALTHCARE 87726 [308119901] 4.15 percent of total billed charges 4.15 6.37 Technical (Hospital) Services KETOROLAC 10 MG TABLET RX-10371 CDM 6370000100 HCPCS 250 RC 00093-0314-01 NDC inpatient 1 UN 6.7 6.7 BLUE CROSS BLUE SHIELD WELLMARK SB889 [3081026] BCBS WYOMING [308102603] 6.37 percent of total billed charges 4.15 6.37 Technical (Hospital) Services KETOROLAC 10 MG TABLET RX-10371 CDM 6370000100 HCPCS 250 RC 00093-0314-01 NDC inpatient 1 UN 6.7 6.7 CIGNA 62308 [3081051] CIGNA 62308 [308105105] 5.31 percent of total billed charges 4.15 6.37 Technical (Hospital) Services KETOROLAC 10 MG TABLET RX-10371 CDM 6370000100 HCPCS 250 RC 00093-0314-01 NDC inpatient 1 UN 6.7 6.7 CIGNA 62308 [3081051] CIGNA STATE OF WYOMING [308105107] 5.31 percent of total billed charges 4.15 6.37 Technical (Hospital) Services KETOROLAC 10 MG TABLET RX-10371 CDM 6370000100 HCPCS 250 RC 00093-0314-01 NDC inpatient 1 UN 6.7 6.7 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES EPO [308136803] 5.31 percent of total billed charges 4.15 6.37 Technical (Hospital) Services KETOROLAC 10 MG TABLET RX-10371 CDM 6370000100 HCPCS 250 RC 00093-0314-01 NDC inpatient 1 UN 6.7 6.7 MEDICA (COMMERCIAL) 94265 [3081118] MEDICA CLAIMS [308111801] 6.03 percent of total billed charges 4.15 6.37 Technical (Hospital) Services KETOROLAC 10 MG TABLET RX-10371 CDM 6370000100 HCPCS 250 RC 00093-0314-01 NDC inpatient 1 UN 6.7 6.7 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES HDHP [308136802] 5.31 percent of total billed charges 4.15 6.37 Technical (Hospital) Services KETOROLAC 10 MG TABLET RX-10371 CDM 6370000100 HCPCS 250 RC 00093-0314-01 NDC outpatient 1 UN 6.7 6.7 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES PPO [308136801] 5.36 percent of total billed charges 4.15 6.37 Technical (Hospital) Services KETOROLAC 10 MG TABLET RX-10371 CDM 6370000100 HCPCS 250 RC 00093-0314-01 NDC outpatient 1 UN 6.7 6.7 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES HDHP [308136802] 5.36 percent of total billed charges 4.15 6.37 Technical (Hospital) Services KETOROLAC 10 MG TABLET RX-10371 CDM 6370000100 HCPCS 250 RC 00093-0314-01 NDC outpatient 1 UN 6.7 6.7 UNITED HEALTHCARE (COMMERCIAL) [3081199] UNITED HEALTHCARE 87726 [308119901] 4.15 percent of total billed charges 4.15 6.37 Technical (Hospital) Services KETOROLAC 10 MG TABLET RX-10371 CDM 6370000100 HCPCS 250 RC 00093-0314-01 NDC outpatient 1 UN 6.7 6.7 MULTIPLAN INC 34080 [3081285] MULTIPLAN INC [308128501] 6.37 percent of total billed charges 4.15 6.37 Technical (Hospital) Services KETOROLAC 10 MG TABLET RX-10371 CDM 6370000100 HCPCS 250 RC 00093-0314-01 NDC outpatient 1 UN 6.7 6.7 CIGNA 62308 [3081051] CIGNA 62308 [308105105] 5.36 percent of total billed charges 4.15 6.37 Technical (Hospital) Services KETOROLAC 10 MG TABLET RX-10371 CDM 6370000100 HCPCS 250 RC 00093-0314-01 NDC outpatient 1 UN 6.7 6.7 CIGNA 62308 [3081051] CIGNA STATE OF WYOMING [308105107] 5.36 percent of total billed charges 4.15 6.37 Technical (Hospital) Services KETOROLAC 10 MG TABLET RX-10371 CDM 6370000100 HCPCS 250 RC 00093-0314-01 NDC outpatient 1 UN 6.7 6.7 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES EPO [308136803] 5.36 percent of total billed charges 4.15 6.37 Technical (Hospital) Services KETOROLAC 10 MG TABLET RX-10371 CDM 6370000100 HCPCS 250 RC 00093-0314-01 NDC outpatient 1 UN 6.7 6.7 MEDICA (COMMERCIAL) 94265 [3081118] MEDICA CLAIMS [308111801] 6.03 percent of total billed charges 4.15 6.37 Technical (Hospital) Services KETOROLAC 10 MG TABLET RX-10371 CDM 6370000100 HCPCS 250 RC 00093-0314-01 NDC outpatient 1 UN 6.7 6.7 HEALTHPARTNERS SX009 HEALTHPARTNERS 5.36 percent of total billed charges 4.15 6.37 Technical (Hospital) Services KETOROLAC 10 MG TABLET RX-10371 CDM 6370000100 HCPCS 250 RC 00093-0314-01 NDC outpatient 1 UN 6.7 6.7 BLUE CROSS BLUE SHIELD WELLMARK SB889 [3081026] BCBS WYOMING [308102603] 6.37 percent of total billed charges 4.15 6.37 Technical (Hospital) Services LABETALOL 100 MG TABLET RX-10373 CDM 6370000100 HCPCS 250 RC 68382-0798-01 NDC outpatient 1 UN 5.82 5.82 BLUE CROSS BLUE SHIELD WELLMARK SB889 [3081026] BCBS WYOMING [308102603] 5.53 percent of total billed charges 3.61 5.53 Technical (Hospital) Services LABETALOL 100 MG TABLET RX-10373 CDM 6370000100 HCPCS 250 RC 68382-0798-01 NDC outpatient 1 UN 5.82 5.82 HEALTHPARTNERS SX009 HEALTHPARTNERS 4.66 percent of total billed charges 3.61 5.53 Technical (Hospital) Services LABETALOL 100 MG TABLET RX-10373 CDM 6370000100 HCPCS 250 RC 68382-0798-01 NDC outpatient 1 UN 5.82 5.82 MEDICA (COMMERCIAL) 94265 [3081118] MEDICA CLAIMS [308111801] 5.24 percent of total billed charges 3.61 5.53 Technical (Hospital) Services LABETALOL 100 MG TABLET RX-10373 CDM 6370000100 HCPCS 250 RC 68382-0798-01 NDC outpatient 1 UN 5.82 5.82 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES EPO [308136803] 4.66 percent of total billed charges 3.61 5.53 Technical (Hospital) Services LABETALOL 100 MG TABLET RX-10373 CDM 6370000100 HCPCS 250 RC 68382-0798-01 NDC outpatient 1 UN 5.82 5.82 UNITED HEALTHCARE (COMMERCIAL) [3081199] UNITED HEALTHCARE 87726 [308119901] 3.61 percent of total billed charges 3.61 5.53 Technical (Hospital) Services LABETALOL 100 MG TABLET RX-10373 CDM 6370000100 HCPCS 250 RC 68382-0798-01 NDC outpatient 1 UN 5.82 5.82 CIGNA 62308 [3081051] CIGNA 62308 [308105105] 4.66 percent of total billed charges 3.61 5.53 Technical (Hospital) Services LABETALOL 100 MG TABLET RX-10373 CDM 6370000100 HCPCS 250 RC 68382-0798-01 NDC outpatient 1 UN 5.82 5.82 CIGNA 62308 [3081051] CIGNA STATE OF WYOMING [308105107] 4.66 percent of total billed charges 3.61 5.53 Technical (Hospital) Services LABETALOL 100 MG TABLET RX-10373 CDM 6370000100 HCPCS 250 RC 68382-0798-01 NDC outpatient 1 UN 5.82 5.82 MULTIPLAN INC 34080 [3081285] MULTIPLAN INC [308128501] 5.53 percent of total billed charges 3.61 5.53 Technical (Hospital) Services LABETALOL 100 MG TABLET RX-10373 CDM 6370000100 HCPCS 250 RC 68382-0798-01 NDC outpatient 1 UN 5.82 5.82 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES PPO [308136801] 4.66 percent of total billed charges 3.61 5.53 Technical (Hospital) Services LABETALOL 100 MG TABLET RX-10373 CDM 6370000100 HCPCS 250 RC 68382-0798-01 NDC outpatient 1 UN 5.82 5.82 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES HDHP [308136802] 4.66 percent of total billed charges 3.61 5.53 Technical (Hospital) Services LABETALOL 100 MG TABLET RX-10373 CDM 6370000100 HCPCS 250 RC 68382-0798-01 NDC inpatient 1 UN 5.82 5.82 MULTIPLAN INC 34080 [3081285] MULTIPLAN INC [308128501] 5.53 percent of total billed charges 3.61 5.53 Technical (Hospital) Services LABETALOL 100 MG TABLET RX-10373 CDM 6370000100 HCPCS 250 RC 68382-0798-01 NDC inpatient 1 UN 5.82 5.82 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES PPO [308136801] 4.61 percent of total billed charges 3.61 5.53 Technical (Hospital) Services LABETALOL 100 MG TABLET RX-10373 CDM 6370000100 HCPCS 250 RC 68382-0798-01 NDC inpatient 1 UN 5.82 5.82 MEDICA (COMMERCIAL) 94265 [3081118] MEDICA CLAIMS [308111801] 5.24 percent of total billed charges 3.61 5.53 Technical (Hospital) Services LABETALOL 100 MG TABLET RX-10373 CDM 6370000100 HCPCS 250 RC 68382-0798-01 NDC inpatient 1 UN 5.82 5.82 HEALTHPARTNERS SX009 HEALTHPARTNERS 4.61 percent of total billed charges 3.61 5.53 Technical (Hospital) Services LABETALOL 100 MG TABLET RX-10373 CDM 6370000100 HCPCS 250 RC 68382-0798-01 NDC inpatient 1 UN 5.82 5.82 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES HDHP [308136802] 4.61 percent of total billed charges 3.61 5.53 Technical (Hospital) Services LABETALOL 100 MG TABLET RX-10373 CDM 6370000100 HCPCS 250 RC 68382-0798-01 NDC inpatient 1 UN 5.82 5.82 CIGNA 62308 [3081051] CIGNA 62308 [308105105] 4.61 percent of total billed charges 3.61 5.53 Technical (Hospital) Services LABETALOL 100 MG TABLET RX-10373 CDM 6370000100 HCPCS 250 RC 68382-0798-01 NDC inpatient 1 UN 5.82 5.82 CIGNA 62308 [3081051] CIGNA STATE OF WYOMING [308105107] 4.61 percent of total billed charges 3.61 5.53 Technical (Hospital) Services LABETALOL 100 MG TABLET RX-10373 CDM 6370000100 HCPCS 250 RC 68382-0798-01 NDC inpatient 1 UN 5.82 5.82 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES EPO [308136803] 4.61 percent of total billed charges 3.61 5.53 Technical (Hospital) Services LABETALOL 100 MG TABLET RX-10373 CDM 6370000100 HCPCS 250 RC 68382-0798-01 NDC inpatient 1 UN 5.82 5.82 BLUE CROSS BLUE SHIELD WELLMARK SB889 [3081026] BCBS WYOMING [308102603] 5.53 percent of total billed charges 3.61 5.53 Technical (Hospital) Services LABETALOL 100 MG TABLET RX-10373 CDM 6370000100 HCPCS 250 RC 68382-0798-01 NDC inpatient 1 UN 5.82 5.82 UNITED HEALTHCARE (COMMERCIAL) [3081199] UNITED HEALTHCARE 87726 [308119901] 3.61 percent of total billed charges 3.61 5.53 Technical (Hospital) Services AMMONIUM LACTATE 12 % LOTION RX-10380 CDM 6370000100 HCPCS 250 RC 45802-0525-26 NDC inpatient 1 GR 5.66 5.66 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES PPO [308136801] 4.48 percent of total billed charges 3.51 5.38 Technical (Hospital) Services AMMONIUM LACTATE 12 % LOTION RX-10380 CDM 6370000100 HCPCS 250 RC 45802-0525-26 NDC inpatient 1 GR 5.66 5.66 MEDICA (COMMERCIAL) 94265 [3081118] MEDICA CLAIMS [308111801] 5.09 percent of total billed charges 3.51 5.38 Technical (Hospital) Services AMMONIUM LACTATE 12 % LOTION RX-10380 CDM 6370000100 HCPCS 250 RC 45802-0525-26 NDC inpatient 1 GR 5.66 5.66 HEALTHPARTNERS SX009 HEALTHPARTNERS 4.48 percent of total billed charges 3.51 5.38 Technical (Hospital) Services AMMONIUM LACTATE 12 % LOTION RX-10380 CDM 6370000100 HCPCS 250 RC 45802-0525-26 NDC inpatient 1 GR 5.66 5.66 MULTIPLAN INC 34080 [3081285] MULTIPLAN INC [308128501] 5.38 percent of total billed charges 3.51 5.38 Technical (Hospital) Services AMMONIUM LACTATE 12 % LOTION RX-10380 CDM 6370000100 HCPCS 250 RC 45802-0525-26 NDC inpatient 1 GR 5.66 5.66 BLUE CROSS BLUE SHIELD WELLMARK SB889 [3081026] BCBS WYOMING [308102603] 5.38 percent of total billed charges 3.51 5.38 Technical (Hospital) Services AMMONIUM LACTATE 12 % LOTION RX-10380 CDM 6370000100 HCPCS 250 RC 45802-0525-26 NDC inpatient 1 GR 5.66 5.66 UNITED HEALTHCARE (COMMERCIAL) [3081199] UNITED HEALTHCARE 87726 [308119901] 3.51 percent of total billed charges 3.51 5.38 Technical (Hospital) Services AMMONIUM LACTATE 12 % LOTION RX-10380 CDM 6370000100 HCPCS 250 RC 45802-0525-26 NDC inpatient 1 GR 5.66 5.66 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES HDHP [308136802] 4.48 percent of total billed charges 3.51 5.38 Technical (Hospital) Services AMMONIUM LACTATE 12 % LOTION RX-10380 CDM 6370000100 HCPCS 250 RC 45802-0525-26 NDC inpatient 1 GR 5.66 5.66 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES EPO [308136803] 4.48 percent of total billed charges 3.51 5.38 Technical (Hospital) Services AMMONIUM LACTATE 12 % LOTION RX-10380 CDM 6370000100 HCPCS 250 RC 45802-0525-26 NDC inpatient 1 GR 5.66 5.66 CIGNA 62308 [3081051] CIGNA 62308 [308105105] 4.48 percent of total billed charges 3.51 5.38 Technical (Hospital) Services AMMONIUM LACTATE 12 % LOTION RX-10380 CDM 6370000100 HCPCS 250 RC 45802-0525-26 NDC inpatient 1 GR 5.66 5.66 CIGNA 62308 [3081051] CIGNA STATE OF WYOMING [308105107] 4.48 percent of total billed charges 3.51 5.38 Technical (Hospital) Services AMMONIUM LACTATE 12 % LOTION RX-10380 CDM 6370000100 HCPCS 250 RC 45802-0525-26 NDC outpatient 1 GR 5.66 5.66 UNITED HEALTHCARE (COMMERCIAL) [3081199] UNITED HEALTHCARE 87726 [308119901] 3.51 percent of total billed charges 3.51 5.38 Technical (Hospital) Services AMMONIUM LACTATE 12 % LOTION RX-10380 CDM 6370000100 HCPCS 250 RC 45802-0525-26 NDC outpatient 1 GR 5.66 5.66 MULTIPLAN INC 34080 [3081285] MULTIPLAN INC [308128501] 5.38 percent of total billed charges 3.51 5.38 Technical (Hospital) Services AMMONIUM LACTATE 12 % LOTION RX-10380 CDM 6370000100 HCPCS 250 RC 45802-0525-26 NDC outpatient 1 GR 5.66 5.66 CIGNA 62308 [3081051] CIGNA STATE OF WYOMING [308105107] 4.53 percent of total billed charges 3.51 5.38 Technical (Hospital) Services AMMONIUM LACTATE 12 % LOTION RX-10380 CDM 6370000100 HCPCS 250 RC 45802-0525-26 NDC outpatient 1 GR 5.66 5.66 CIGNA 62308 [3081051] CIGNA 62308 [308105105] 4.53 percent of total billed charges 3.51 5.38 Technical (Hospital) Services AMMONIUM LACTATE 12 % LOTION RX-10380 CDM 6370000100 HCPCS 250 RC 45802-0525-26 NDC outpatient 1 GR 5.66 5.66 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES EPO [308136803] 4.53 percent of total billed charges 3.51 5.38 Technical (Hospital) Services AMMONIUM LACTATE 12 % LOTION RX-10380 CDM 6370000100 HCPCS 250 RC 45802-0525-26 NDC outpatient 1 GR 5.66 5.66 MEDICA (COMMERCIAL) 94265 [3081118] MEDICA CLAIMS [308111801] 5.09 percent of total billed charges 3.51 5.38 Technical (Hospital) Services AMMONIUM LACTATE 12 % LOTION RX-10380 CDM 6370000100 HCPCS 250 RC 45802-0525-26 NDC outpatient 1 GR 5.66 5.66 HEALTHPARTNERS SX009 HEALTHPARTNERS 4.53 percent of total billed charges 3.51 5.38 Technical (Hospital) Services AMMONIUM LACTATE 12 % LOTION RX-10380 CDM 6370000100 HCPCS 250 RC 45802-0525-26 NDC outpatient 1 GR 5.66 5.66 BLUE CROSS BLUE SHIELD WELLMARK SB889 [3081026] BCBS WYOMING [308102603] 5.38 percent of total billed charges 3.51 5.38 Technical (Hospital) Services AMMONIUM LACTATE 12 % LOTION RX-10380 CDM 6370000100 HCPCS 250 RC 45802-0525-26 NDC outpatient 1 GR 5.66 5.66 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES PPO [308136801] 4.53 percent of total billed charges 3.51 5.38 Technical (Hospital) Services AMMONIUM LACTATE 12 % LOTION RX-10380 CDM 6370000100 HCPCS 250 RC 45802-0525-26 NDC outpatient 1 GR 5.66 5.66 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES HDHP [308136802] 4.53 percent of total billed charges 3.51 5.38 Technical (Hospital) Services TAMSULOSIN 0.4 MG CAPSULE RX-103890 CDM 6370000100 HCPCS 250 RC 65862-0598-01 NDC outpatient 1 UN 5.75 5.75 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES PPO [308136801] 4.6 percent of total billed charges 3.57 5.46 Technical (Hospital) Services TAMSULOSIN 0.4 MG CAPSULE RX-103890 CDM 6370000100 HCPCS 250 RC 65862-0598-01 NDC outpatient 1 UN 5.75 5.75 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES HDHP [308136802] 4.6 percent of total billed charges 3.57 5.46 Technical (Hospital) Services TAMSULOSIN 0.4 MG CAPSULE RX-103890 CDM 6370000100 HCPCS 250 RC 65862-0598-01 NDC outpatient 1 UN 5.75 5.75 HEALTHPARTNERS SX009 HEALTHPARTNERS 4.6 percent of total billed charges 3.57 5.46 Technical (Hospital) Services TAMSULOSIN 0.4 MG CAPSULE RX-103890 CDM 6370000100 HCPCS 250 RC 65862-0598-01 NDC outpatient 1 UN 5.75 5.75 BLUE CROSS BLUE SHIELD WELLMARK SB889 [3081026] BCBS WYOMING [308102603] 5.46 percent of total billed charges 3.57 5.46 Technical (Hospital) Services TAMSULOSIN 0.4 MG CAPSULE RX-103890 CDM 6370000100 HCPCS 250 RC 65862-0598-01 NDC outpatient 1 UN 5.75 5.75 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES EPO [308136803] 4.6 percent of total billed charges 3.57 5.46 Technical (Hospital) Services TAMSULOSIN 0.4 MG CAPSULE RX-103890 CDM 6370000100 HCPCS 250 RC 65862-0598-01 NDC outpatient 1 UN 5.75 5.75 MEDICA (COMMERCIAL) 94265 [3081118] MEDICA CLAIMS [308111801] 5.18 percent of total billed charges 3.57 5.46 Technical (Hospital) Services TAMSULOSIN 0.4 MG CAPSULE RX-103890 CDM 6370000100 HCPCS 250 RC 65862-0598-01 NDC outpatient 1 UN 5.75 5.75 MULTIPLAN INC 34080 [3081285] MULTIPLAN INC [308128501] 5.46 percent of total billed charges 3.57 5.46 Technical (Hospital) Services TAMSULOSIN 0.4 MG CAPSULE RX-103890 CDM 6370000100 HCPCS 250 RC 65862-0598-01 NDC outpatient 1 UN 5.75 5.75 CIGNA 62308 [3081051] CIGNA 62308 [308105105] 4.6 percent of total billed charges 3.57 5.46 Technical (Hospital) Services TAMSULOSIN 0.4 MG CAPSULE RX-103890 CDM 6370000100 HCPCS 250 RC 65862-0598-01 NDC outpatient 1 UN 5.75 5.75 CIGNA 62308 [3081051] CIGNA STATE OF WYOMING [308105107] 4.6 percent of total billed charges 3.57 5.46 Technical (Hospital) Services TAMSULOSIN 0.4 MG CAPSULE RX-103890 CDM 6370000100 HCPCS 250 RC 65862-0598-01 NDC outpatient 1 UN 5.75 5.75 UNITED HEALTHCARE (COMMERCIAL) [3081199] UNITED HEALTHCARE 87726 [308119901] 3.57 percent of total billed charges 3.57 5.46 Technical (Hospital) Services TAMSULOSIN 0.4 MG CAPSULE RX-103890 CDM 6370000100 HCPCS 250 RC 65862-0598-01 NDC inpatient 1 UN 5.75 5.75 HEALTHPARTNERS SX009 HEALTHPARTNERS 4.55 percent of total billed charges 3.57 5.46 Technical (Hospital) Services TAMSULOSIN 0.4 MG CAPSULE RX-103890 CDM 6370000100 HCPCS 250 RC 65862-0598-01 NDC inpatient 1 UN 5.75 5.75 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES PPO [308136801] 4.55 percent of total billed charges 3.57 5.46 Technical (Hospital) Services TAMSULOSIN 0.4 MG CAPSULE RX-103890 CDM 6370000100 HCPCS 250 RC 65862-0598-01 NDC inpatient 1 UN 5.75 5.75 MULTIPLAN INC 34080 [3081285] MULTIPLAN INC [308128501] 5.46 percent of total billed charges 3.57 5.46 Technical (Hospital) Services TAMSULOSIN 0.4 MG CAPSULE RX-103890 CDM 6370000100 HCPCS 250 RC 65862-0598-01 NDC inpatient 1 UN 5.75 5.75 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES EPO [308136803] 4.55 percent of total billed charges 3.57 5.46 Technical (Hospital) Services TAMSULOSIN 0.4 MG CAPSULE RX-103890 CDM 6370000100 HCPCS 250 RC 65862-0598-01 NDC inpatient 1 UN 5.75 5.75 CIGNA 62308 [3081051] CIGNA 62308 [308105105] 4.55 percent of total billed charges 3.57 5.46 Technical (Hospital) Services TAMSULOSIN 0.4 MG CAPSULE RX-103890 CDM 6370000100 HCPCS 250 RC 65862-0598-01 NDC inpatient 1 UN 5.75 5.75 CIGNA 62308 [3081051] CIGNA STATE OF WYOMING [308105107] 4.55 percent of total billed charges 3.57 5.46 Technical (Hospital) Services TAMSULOSIN 0.4 MG CAPSULE RX-103890 CDM 6370000100 HCPCS 250 RC 65862-0598-01 NDC inpatient 1 UN 5.75 5.75 MEDICA (COMMERCIAL) 94265 [3081118] MEDICA CLAIMS [308111801] 5.18 percent of total billed charges 3.57 5.46 Technical (Hospital) Services TAMSULOSIN 0.4 MG CAPSULE RX-103890 CDM 6370000100 HCPCS 250 RC 65862-0598-01 NDC inpatient 1 UN 5.75 5.75 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES HDHP [308136802] 4.55 percent of total billed charges 3.57 5.46 Technical (Hospital) Services TAMSULOSIN 0.4 MG CAPSULE RX-103890 CDM 6370000100 HCPCS 250 RC 65862-0598-01 NDC inpatient 1 UN 5.75 5.75 BLUE CROSS BLUE SHIELD WELLMARK SB889 [3081026] BCBS WYOMING [308102603] 5.46 percent of total billed charges 3.57 5.46 Technical (Hospital) Services TAMSULOSIN 0.4 MG CAPSULE RX-103890 CDM 6370000100 HCPCS 250 RC 65862-0598-01 NDC inpatient 1 UN 5.75 5.75 UNITED HEALTHCARE (COMMERCIAL) [3081199] UNITED HEALTHCARE 87726 [308119901] 3.57 percent of total billed charges 3.57 5.46 Technical (Hospital) Services LEVOTHYROXINE 175 MCG TABLET RX-10406 CDM 6370000100 HCPCS 250 RC 00074-7070-90 NDC inpatient 1 UN 7.2 7.2 BLUE CROSS BLUE SHIELD WELLMARK SB889 [3081026] BCBS WYOMING [308102603] 6.84 percent of total billed charges 4.46 6.84 Technical (Hospital) Services LEVOTHYROXINE 175 MCG TABLET RX-10406 CDM 6370000100 HCPCS 250 RC 00074-7070-90 NDC inpatient 1 UN 7.2 7.2 UNITED HEALTHCARE (COMMERCIAL) [3081199] UNITED HEALTHCARE 87726 [308119901] 4.46 percent of total billed charges 4.46 6.84 Technical (Hospital) Services LEVOTHYROXINE 175 MCG TABLET RX-10406 CDM 6370000100 HCPCS 250 RC 00074-7070-90 NDC inpatient 1 UN 7.2 7.2 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES EPO [308136803] 5.7 percent of total billed charges 4.46 6.84 Technical (Hospital) Services LEVOTHYROXINE 175 MCG TABLET RX-10406 CDM 6370000100 HCPCS 250 RC 00074-7070-90 NDC inpatient 1 UN 7.2 7.2 CIGNA 62308 [3081051] CIGNA 62308 [308105105] 5.7 percent of total billed charges 4.46 6.84 Technical (Hospital) Services LEVOTHYROXINE 175 MCG TABLET RX-10406 CDM 6370000100 HCPCS 250 RC 00074-7070-90 NDC inpatient 1 UN 7.2 7.2 CIGNA 62308 [3081051] CIGNA STATE OF WYOMING [308105107] 5.7 percent of total billed charges 4.46 6.84 Technical (Hospital) Services LEVOTHYROXINE 175 MCG TABLET RX-10406 CDM 6370000100 HCPCS 250 RC 00074-7070-90 NDC inpatient 1 UN 7.2 7.2 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES HDHP [308136802] 5.7 percent of total billed charges 4.46 6.84 Technical (Hospital) Services LEVOTHYROXINE 175 MCG TABLET RX-10406 CDM 6370000100 HCPCS 250 RC 00074-7070-90 NDC inpatient 1 UN 7.2 7.2 MEDICA (COMMERCIAL) 94265 [3081118] MEDICA CLAIMS [308111801] 6.48 percent of total billed charges 4.46 6.84 Technical (Hospital) Services LEVOTHYROXINE 175 MCG TABLET RX-10406 CDM 6370000100 HCPCS 250 RC 00074-7070-90 NDC inpatient 1 UN 7.2 7.2 HEALTHPARTNERS SX009 HEALTHPARTNERS 5.7 percent of total billed charges 4.46 6.84 Technical (Hospital) Services LEVOTHYROXINE 175 MCG TABLET RX-10406 CDM 6370000100 HCPCS 250 RC 00074-7070-90 NDC inpatient 1 UN 7.2 7.2 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES PPO [308136801] 5.7 percent of total billed charges 4.46 6.84 Technical (Hospital) Services LEVOTHYROXINE 175 MCG TABLET RX-10406 CDM 6370000100 HCPCS 250 RC 00074-7070-90 NDC inpatient 1 UN 7.2 7.2 MULTIPLAN INC 34080 [3081285] MULTIPLAN INC [308128501] 6.84 percent of total billed charges 4.46 6.84 Technical (Hospital) Services LEVOTHYROXINE 175 MCG TABLET RX-10406 CDM 6370000100 HCPCS 250 RC 00074-7070-90 NDC outpatient 1 UN 7.2 7.2 CIGNA 62308 [3081051] CIGNA 62308 [308105105] 5.76 percent of total billed charges 4.46 6.84 Technical (Hospital) Services LEVOTHYROXINE 175 MCG TABLET RX-10406 CDM 6370000100 HCPCS 250 RC 00074-7070-90 NDC outpatient 1 UN 7.2 7.2 CIGNA 62308 [3081051] CIGNA STATE OF WYOMING [308105107] 5.76 percent of total billed charges 4.46 6.84 Technical (Hospital) Services LEVOTHYROXINE 175 MCG TABLET RX-10406 CDM 6370000100 HCPCS 250 RC 00074-7070-90 NDC outpatient 1 UN 7.2 7.2 MULTIPLAN INC 34080 [3081285] MULTIPLAN INC [308128501] 6.84 percent of total billed charges 4.46 6.84 Technical (Hospital) Services LEVOTHYROXINE 175 MCG TABLET RX-10406 CDM 6370000100 HCPCS 250 RC 00074-7070-90 NDC outpatient 1 UN 7.2 7.2 MEDICA (COMMERCIAL) 94265 [3081118] MEDICA CLAIMS [308111801] 6.48 percent of total billed charges 4.46 6.84 Technical (Hospital) Services LEVOTHYROXINE 175 MCG TABLET RX-10406 CDM 6370000100 HCPCS 250 RC 00074-7070-90 NDC outpatient 1 UN 7.2 7.2 UNITED HEALTHCARE (COMMERCIAL) [3081199] UNITED HEALTHCARE 87726 [308119901] 4.46 percent of total billed charges 4.46 6.84 Technical (Hospital) Services LEVOTHYROXINE 175 MCG TABLET RX-10406 CDM 6370000100 HCPCS 250 RC 00074-7070-90 NDC outpatient 1 UN 7.2 7.2 HEALTHPARTNERS SX009 HEALTHPARTNERS 5.76 percent of total billed charges 4.46 6.84 Technical (Hospital) Services LEVOTHYROXINE 175 MCG TABLET RX-10406 CDM 6370000100 HCPCS 250 RC 00074-7070-90 NDC outpatient 1 UN 7.2 7.2 BLUE CROSS BLUE SHIELD WELLMARK SB889 [3081026] BCBS WYOMING [308102603] 6.84 percent of total billed charges 4.46 6.84 Technical (Hospital) Services LEVOTHYROXINE 175 MCG TABLET RX-10406 CDM 6370000100 HCPCS 250 RC 00074-7070-90 NDC outpatient 1 UN 7.2 7.2 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES PPO [308136801] 5.76 percent of total billed charges 4.46 6.84 Technical (Hospital) Services LEVOTHYROXINE 175 MCG TABLET RX-10406 CDM 6370000100 HCPCS 250 RC 00074-7070-90 NDC outpatient 1 UN 7.2 7.2 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES EPO [308136803] 5.76 percent of total billed charges 4.46 6.84 Technical (Hospital) Services LEVOTHYROXINE 175 MCG TABLET RX-10406 CDM 6370000100 HCPCS 250 RC 00074-7070-90 NDC outpatient 1 UN 7.2 7.2 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES HDHP [308136802] 5.76 percent of total billed charges 4.46 6.84 Technical (Hospital) Services LIDOCAINE-PRILOCAINE 2.5 %-2.5 % TOPICAL CREAM RX-10434 CDM 6370000100 HCPCS 250 RC 00168-0357-05 NDC inpatient 3 GR 23.66 23.66 MEDICA (COMMERCIAL) 94265 [3081118] MEDICA CLAIMS [308111801] 21.29 percent of total billed charges 14.67 22.48 Technical (Hospital) Services LIDOCAINE-PRILOCAINE 2.5 %-2.5 % TOPICAL CREAM RX-10434 CDM 6370000100 HCPCS 250 RC 00168-0357-05 NDC inpatient 3 GR 23.66 23.66 MULTIPLAN INC 34080 [3081285] MULTIPLAN INC [308128501] 22.48 percent of total billed charges 14.67 22.48 Technical (Hospital) Services LIDOCAINE-PRILOCAINE 2.5 %-2.5 % TOPICAL CREAM RX-10434 CDM 6370000100 HCPCS 250 RC 00168-0357-05 NDC inpatient 3 GR 23.66 23.66 BLUE CROSS BLUE SHIELD WELLMARK SB889 [3081026] BCBS WYOMING [308102603] 22.48 percent of total billed charges 14.67 22.48 Technical (Hospital) Services LIDOCAINE-PRILOCAINE 2.5 %-2.5 % TOPICAL CREAM RX-10434 CDM 6370000100 HCPCS 250 RC 00168-0357-05 NDC inpatient 3 GR 23.66 23.66 UNITED HEALTHCARE (COMMERCIAL) [3081199] UNITED HEALTHCARE 87726 [308119901] 14.67 percent of total billed charges 14.67 22.48 Technical (Hospital) Services LIDOCAINE-PRILOCAINE 2.5 %-2.5 % TOPICAL CREAM RX-10434 CDM 6370000100 HCPCS 250 RC 00168-0357-05 NDC inpatient 3 GR 23.66 23.66 CIGNA 62308 [3081051] CIGNA 62308 [308105105] 18.73 percent of total billed charges 14.67 22.48 Technical (Hospital) Services LIDOCAINE-PRILOCAINE 2.5 %-2.5 % TOPICAL CREAM RX-10434 CDM 6370000100 HCPCS 250 RC 00168-0357-05 NDC inpatient 3 GR 23.66 23.66 CIGNA 62308 [3081051] CIGNA STATE OF WYOMING [308105107] 18.73 percent of total billed charges 14.67 22.48 Technical (Hospital) Services LIDOCAINE-PRILOCAINE 2.5 %-2.5 % TOPICAL CREAM RX-10434 CDM 6370000100 HCPCS 250 RC 00168-0357-05 NDC inpatient 3 GR 23.66 23.66 HEALTHPARTNERS SX009 HEALTHPARTNERS 18.73 percent of total billed charges 14.67 22.48 Technical (Hospital) Services LIDOCAINE-PRILOCAINE 2.5 %-2.5 % TOPICAL CREAM RX-10434 CDM 6370000100 HCPCS 250 RC 00168-0357-05 NDC inpatient 3 GR 23.66 23.66 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES EPO [308136803] 18.73 percent of total billed charges 14.67 22.48 Technical (Hospital) Services LIDOCAINE-PRILOCAINE 2.5 %-2.5 % TOPICAL CREAM RX-10434 CDM 6370000100 HCPCS 250 RC 00168-0357-05 NDC inpatient 3 GR 23.66 23.66 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES HDHP [308136802] 18.73 percent of total billed charges 14.67 22.48 Technical (Hospital) Services LIDOCAINE-PRILOCAINE 2.5 %-2.5 % TOPICAL CREAM RX-10434 CDM 6370000100 HCPCS 250 RC 00168-0357-05 NDC inpatient 3 GR 23.66 23.66 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES PPO [308136801] 18.73 percent of total billed charges 14.67 22.48 Technical (Hospital) Services LIDOCAINE-PRILOCAINE 2.5 %-2.5 % TOPICAL CREAM RX-10434 CDM 6370000100 HCPCS 250 RC 00168-0357-05 NDC outpatient 3 GR 23.66 23.66 BLUE CROSS BLUE SHIELD WELLMARK SB889 [3081026] BCBS WYOMING [308102603] 22.48 percent of total billed charges 14.67 22.48 Technical (Hospital) Services LIDOCAINE-PRILOCAINE 2.5 %-2.5 % TOPICAL CREAM RX-10434 CDM 6370000100 HCPCS 250 RC 00168-0357-05 NDC outpatient 3 GR 23.66 23.66 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES HDHP [308136802] 18.93 percent of total billed charges 14.67 22.48 Technical (Hospital) Services LIDOCAINE-PRILOCAINE 2.5 %-2.5 % TOPICAL CREAM RX-10434 CDM 6370000100 HCPCS 250 RC 00168-0357-05 NDC outpatient 3 GR 23.66 23.66 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES PPO [308136801] 18.93 percent of total billed charges 14.67 22.48 Technical (Hospital) Services LIDOCAINE-PRILOCAINE 2.5 %-2.5 % TOPICAL CREAM RX-10434 CDM 6370000100 HCPCS 250 RC 00168-0357-05 NDC outpatient 3 GR 23.66 23.66 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES EPO [308136803] 18.93 percent of total billed charges 14.67 22.48 Technical (Hospital) Services LIDOCAINE-PRILOCAINE 2.5 %-2.5 % TOPICAL CREAM RX-10434 CDM 6370000100 HCPCS 250 RC 00168-0357-05 NDC outpatient 3 GR 23.66 23.66 HEALTHPARTNERS SX009 HEALTHPARTNERS 18.93 percent of total billed charges 14.67 22.48 Technical (Hospital) Services LIDOCAINE-PRILOCAINE 2.5 %-2.5 % TOPICAL CREAM RX-10434 CDM 6370000100 HCPCS 250 RC 00168-0357-05 NDC outpatient 3 GR 23.66 23.66 UNITED HEALTHCARE (COMMERCIAL) [3081199] UNITED HEALTHCARE 87726 [308119901] 14.67 percent of total billed charges 14.67 22.48 Technical (Hospital) Services LIDOCAINE-PRILOCAINE 2.5 %-2.5 % TOPICAL CREAM RX-10434 CDM 6370000100 HCPCS 250 RC 00168-0357-05 NDC outpatient 3 GR 23.66 23.66 CIGNA 62308 [3081051] CIGNA 62308 [308105105] 18.93 percent of total billed charges 14.67 22.48 Technical (Hospital) Services LIDOCAINE-PRILOCAINE 2.5 %-2.5 % TOPICAL CREAM RX-10434 CDM 6370000100 HCPCS 250 RC 00168-0357-05 NDC outpatient 3 GR 23.66 23.66 CIGNA 62308 [3081051] CIGNA STATE OF WYOMING [308105107] 18.93 percent of total billed charges 14.67 22.48 Technical (Hospital) Services LIDOCAINE-PRILOCAINE 2.5 %-2.5 % TOPICAL CREAM RX-10434 CDM 6370000100 HCPCS 250 RC 00168-0357-05 NDC outpatient 3 GR 23.66 23.66 MEDICA (COMMERCIAL) 94265 [3081118] MEDICA CLAIMS [308111801] 21.29 percent of total billed charges 14.67 22.48 Technical (Hospital) Services LIDOCAINE-PRILOCAINE 2.5 %-2.5 % TOPICAL CREAM RX-10434 CDM 6370000100 HCPCS 250 RC 00168-0357-05 NDC outpatient 3 GR 23.66 23.66 MULTIPLAN INC 34080 [3081285] MULTIPLAN INC [308128501] 22.48 percent of total billed charges 14.67 22.48 Technical (Hospital) Services LISINOPRIL 10 MG TABLET RX-10449 CDM 6370000100 HCPCS 250 RC 68180-0980-01 NDC inpatient 1 UN 5.67 5.67 MEDICA (COMMERCIAL) 94265 [3081118] MEDICA CLAIMS [308111801] 5.1 percent of total billed charges 3.52 5.39 Technical (Hospital) Services LISINOPRIL 10 MG TABLET RX-10449 CDM 6370000100 HCPCS 250 RC 68180-0980-01 NDC inpatient 1 UN 5.67 5.67 HEALTHPARTNERS SX009 HEALTHPARTNERS 4.49 percent of total billed charges 3.52 5.39 Technical (Hospital) Services LISINOPRIL 10 MG TABLET RX-10449 CDM 6370000100 HCPCS 250 RC 68180-0980-01 NDC inpatient 1 UN 5.67 5.67 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES PPO [308136801] 4.49 percent of total billed charges 3.52 5.39 Technical (Hospital) Services LISINOPRIL 10 MG TABLET RX-10449 CDM 6370000100 HCPCS 250 RC 68180-0980-01 NDC inpatient 1 UN 5.67 5.67 MULTIPLAN INC 34080 [3081285] MULTIPLAN INC [308128501] 5.39 percent of total billed charges 3.52 5.39 Technical (Hospital) Services LISINOPRIL 10 MG TABLET RX-10449 CDM 6370000100 HCPCS 250 RC 68180-0980-01 NDC inpatient 1 UN 5.67 5.67 BLUE CROSS BLUE SHIELD WELLMARK SB889 [3081026] BCBS WYOMING [308102603] 5.39 percent of total billed charges 3.52 5.39 Technical (Hospital) Services LISINOPRIL 10 MG TABLET RX-10449 CDM 6370000100 HCPCS 250 RC 68180-0980-01 NDC inpatient 1 UN 5.67 5.67 UNITED HEALTHCARE (COMMERCIAL) [3081199] UNITED HEALTHCARE 87726 [308119901] 3.52 percent of total billed charges 3.52 5.39 Technical (Hospital) Services LISINOPRIL 10 MG TABLET RX-10449 CDM 6370000100 HCPCS 250 RC 68180-0980-01 NDC inpatient 1 UN 5.67 5.67 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES EPO [308136803] 4.49 percent of total billed charges 3.52 5.39 Technical (Hospital) Services LISINOPRIL 10 MG TABLET RX-10449 CDM 6370000100 HCPCS 250 RC 68180-0980-01 NDC inpatient 1 UN 5.67 5.67 CIGNA 62308 [3081051] CIGNA 62308 [308105105] 4.49 percent of total billed charges 3.52 5.39 Technical (Hospital) Services LISINOPRIL 10 MG TABLET RX-10449 CDM 6370000100 HCPCS 250 RC 68180-0980-01 NDC inpatient 1 UN 5.67 5.67 CIGNA 62308 [3081051] CIGNA STATE OF WYOMING [308105107] 4.49 percent of total billed charges 3.52 5.39 Technical (Hospital) Services LISINOPRIL 10 MG TABLET RX-10449 CDM 6370000100 HCPCS 250 RC 68180-0980-01 NDC inpatient 1 UN 5.67 5.67 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES HDHP [308136802] 4.49 percent of total billed charges 3.52 5.39 Technical (Hospital) Services LISINOPRIL 10 MG TABLET RX-10449 CDM 6370000100 HCPCS 250 RC 68180-0980-01 NDC outpatient 1 UN 5.67 5.67 UNITED HEALTHCARE (COMMERCIAL) [3081199] UNITED HEALTHCARE 87726 [308119901] 3.52 percent of total billed charges 3.52 5.39 Technical (Hospital) Services LISINOPRIL 10 MG TABLET RX-10449 CDM 6370000100 HCPCS 250 RC 68180-0980-01 NDC outpatient 1 UN 5.67 5.67 MEDICA (COMMERCIAL) 94265 [3081118] MEDICA CLAIMS [308111801] 5.1 percent of total billed charges 3.52 5.39 Technical (Hospital) Services LISINOPRIL 10 MG TABLET RX-10449 CDM 6370000100 HCPCS 250 RC 68180-0980-01 NDC outpatient 1 UN 5.67 5.67 MULTIPLAN INC 34080 [3081285] MULTIPLAN INC [308128501] 5.39 percent of total billed charges 3.52 5.39 Technical (Hospital) Services LISINOPRIL 10 MG TABLET RX-10449 CDM 6370000100 HCPCS 250 RC 68180-0980-01 NDC outpatient 1 UN 5.67 5.67 CIGNA 62308 [3081051] CIGNA 62308 [308105105] 4.54 percent of total billed charges 3.52 5.39 Technical (Hospital) Services LISINOPRIL 10 MG TABLET RX-10449 CDM 6370000100 HCPCS 250 RC 68180-0980-01 NDC outpatient 1 UN 5.67 5.67 CIGNA 62308 [3081051] CIGNA STATE OF WYOMING [308105107] 4.54 percent of total billed charges 3.52 5.39 Technical (Hospital) Services LISINOPRIL 10 MG TABLET RX-10449 CDM 6370000100 HCPCS 250 RC 68180-0980-01 NDC outpatient 1 UN 5.67 5.67 BLUE CROSS BLUE SHIELD WELLMARK SB889 [3081026] BCBS WYOMING [308102603] 5.39 percent of total billed charges 3.52 5.39 Technical (Hospital) Services LISINOPRIL 10 MG TABLET RX-10449 CDM 6370000100 HCPCS 250 RC 68180-0980-01 NDC outpatient 1 UN 5.67 5.67 HEALTHPARTNERS SX009 HEALTHPARTNERS 4.54 percent of total billed charges 3.52 5.39 Technical (Hospital) Services LISINOPRIL 10 MG TABLET RX-10449 CDM 6370000100 HCPCS 250 RC 68180-0980-01 NDC outpatient 1 UN 5.67 5.67 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES EPO [308136803] 4.54 percent of total billed charges 3.52 5.39 Technical (Hospital) Services LISINOPRIL 10 MG TABLET RX-10449 CDM 6370000100 HCPCS 250 RC 68180-0980-01 NDC outpatient 1 UN 5.67 5.67 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES HDHP [308136802] 4.54 percent of total billed charges 3.52 5.39 Technical (Hospital) Services LISINOPRIL 10 MG TABLET RX-10449 CDM 6370000100 HCPCS 250 RC 68180-0980-01 NDC outpatient 1 UN 5.67 5.67 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES PPO [308136801] 4.54 percent of total billed charges 3.52 5.39 Technical (Hospital) Services LISINOPRIL 5 MG TABLET RX-10451 CDM 6370000100 HCPCS 250 RC 00904-6797-61 NDC inpatient 1 UN 5.69 5.69 BLUE CROSS BLUE SHIELD WELLMARK SB889 [3081026] BCBS WYOMING [308102603] 5.41 percent of total billed charges 3.53 5.41 Technical (Hospital) Services LISINOPRIL 5 MG TABLET RX-10451 CDM 6370000100 HCPCS 250 RC 00904-6797-61 NDC inpatient 1 UN 5.69 5.69 UNITED HEALTHCARE (COMMERCIAL) [3081199] UNITED HEALTHCARE 87726 [308119901] 3.53 percent of total billed charges 3.53 5.41 Technical (Hospital) Services LISINOPRIL 5 MG TABLET RX-10451 CDM 6370000100 HCPCS 250 RC 00904-6797-61 NDC inpatient 1 UN 5.69 5.69 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES HDHP [308136802] 4.51 percent of total billed charges 3.53 5.41 Technical (Hospital) Services LISINOPRIL 5 MG TABLET RX-10451 CDM 6370000100 HCPCS 250 RC 00904-6797-61 NDC inpatient 1 UN 5.69 5.69 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES EPO [308136803] 4.51 percent of total billed charges 3.53 5.41 Technical (Hospital) Services LISINOPRIL 5 MG TABLET RX-10451 CDM 6370000100 HCPCS 250 RC 00904-6797-61 NDC inpatient 1 UN 5.69 5.69 CIGNA 62308 [3081051] CIGNA 62308 [308105105] 4.51 percent of total billed charges 3.53 5.41 Technical (Hospital) Services LISINOPRIL 5 MG TABLET RX-10451 CDM 6370000100 HCPCS 250 RC 00904-6797-61 NDC inpatient 1 UN 5.69 5.69 CIGNA 62308 [3081051] CIGNA STATE OF WYOMING [308105107] 4.51 percent of total billed charges 3.53 5.41 Technical (Hospital) Services LISINOPRIL 5 MG TABLET RX-10451 CDM 6370000100 HCPCS 250 RC 00904-6797-61 NDC inpatient 1 UN 5.69 5.69 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES PPO [308136801] 4.51 percent of total billed charges 3.53 5.41 Technical (Hospital) Services LISINOPRIL 5 MG TABLET RX-10451 CDM 6370000100 HCPCS 250 RC 00904-6797-61 NDC inpatient 1 UN 5.69 5.69 HEALTHPARTNERS SX009 HEALTHPARTNERS 4.51 percent of total billed charges 3.53 5.41 Technical (Hospital) Services LISINOPRIL 5 MG TABLET RX-10451 CDM 6370000100 HCPCS 250 RC 00904-6797-61 NDC inpatient 1 UN 5.69 5.69 MEDICA (COMMERCIAL) 94265 [3081118] MEDICA CLAIMS [308111801] 5.12 percent of total billed charges 3.53 5.41 Technical (Hospital) Services LISINOPRIL 5 MG TABLET RX-10451 CDM 6370000100 HCPCS 250 RC 00904-6797-61 NDC inpatient 1 UN 5.69 5.69 MULTIPLAN INC 34080 [3081285] MULTIPLAN INC [308128501] 5.41 percent of total billed charges 3.53 5.41 Technical (Hospital) Services LISINOPRIL 5 MG TABLET RX-10451 CDM 6370000100 HCPCS 250 RC 00904-6797-61 NDC outpatient 1 UN 5.69 5.69 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES PPO [308136801] 4.55 percent of total billed charges 3.53 5.41 Technical (Hospital) Services LISINOPRIL 5 MG TABLET RX-10451 CDM 6370000100 HCPCS 250 RC 00904-6797-61 NDC outpatient 1 UN 5.69 5.69 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES HDHP [308136802] 4.55 percent of total billed charges 3.53 5.41 Technical (Hospital) Services LISINOPRIL 5 MG TABLET RX-10451 CDM 6370000100 HCPCS 250 RC 00904-6797-61 NDC outpatient 1 UN 5.69 5.69 HEALTHPARTNERS SX009 HEALTHPARTNERS 4.55 percent of total billed charges 3.53 5.41 Technical (Hospital) Services LISINOPRIL 5 MG TABLET RX-10451 CDM 6370000100 HCPCS 250 RC 00904-6797-61 NDC outpatient 1 UN 5.69 5.69 BLUE CROSS BLUE SHIELD WELLMARK SB889 [3081026] BCBS WYOMING [308102603] 5.41 percent of total billed charges 3.53 5.41 Technical (Hospital) Services LISINOPRIL 5 MG TABLET RX-10451 CDM 6370000100 HCPCS 250 RC 00904-6797-61 NDC outpatient 1 UN 5.69 5.69 UNITED HEALTHCARE (COMMERCIAL) [3081199] UNITED HEALTHCARE 87726 [308119901] 3.53 percent of total billed charges 3.53 5.41 Technical (Hospital) Services LISINOPRIL 5 MG TABLET RX-10451 CDM 6370000100 HCPCS 250 RC 00904-6797-61 NDC outpatient 1 UN 5.69 5.69 CIGNA 62308 [3081051] CIGNA 62308 [308105105] 4.55 percent of total billed charges 3.53 5.41 Technical (Hospital) Services LISINOPRIL 5 MG TABLET RX-10451 CDM 6370000100 HCPCS 250 RC 00904-6797-61 NDC outpatient 1 UN 5.69 5.69 CIGNA 62308 [3081051] CIGNA STATE OF WYOMING [308105107] 4.55 percent of total billed charges 3.53 5.41 Technical (Hospital) Services LISINOPRIL 5 MG TABLET RX-10451 CDM 6370000100 HCPCS 250 RC 00904-6797-61 NDC outpatient 1 UN 5.69 5.69 MULTIPLAN INC 34080 [3081285] MULTIPLAN INC [308128501] 5.41 percent of total billed charges 3.53 5.41 Technical (Hospital) Services LISINOPRIL 5 MG TABLET RX-10451 CDM 6370000100 HCPCS 250 RC 00904-6797-61 NDC outpatient 1 UN 5.69 5.69 MEDICA (COMMERCIAL) 94265 [3081118] MEDICA CLAIMS [308111801] 5.12 percent of total billed charges 3.53 5.41 Technical (Hospital) Services LISINOPRIL 5 MG TABLET RX-10451 CDM 6370000100 HCPCS 250 RC 00904-6797-61 NDC outpatient 1 UN 5.69 5.69 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES EPO [308136803] 4.55 percent of total billed charges 3.53 5.41 Technical (Hospital) Services FLUTICASONE 100 MCG-SALMETEROL 50 MCG/DOSE BLISTR POWDR FOR INHALATION RX-104564 CDM 6370000100 HCPCS 250 RC 00173-0695-04 NDC inpatient 1 UN 145.51 145.51 MULTIPLAN INC 34080 [3081285] MULTIPLAN INC [308128501] 138.23 percent of total billed charges 90.22 138.23 Technical (Hospital) Services FLUTICASONE 100 MCG-SALMETEROL 50 MCG/DOSE BLISTR POWDR FOR INHALATION RX-104564 CDM 6370000100 HCPCS 250 RC 00173-0695-04 NDC inpatient 1 UN 145.51 145.51 HEALTHPARTNERS SX009 HEALTHPARTNERS 115.21 percent of total billed charges 90.22 138.23 Technical (Hospital) Services FLUTICASONE 100 MCG-SALMETEROL 50 MCG/DOSE BLISTR POWDR FOR INHALATION RX-104564 CDM 6370000100 HCPCS 250 RC 00173-0695-04 NDC inpatient 1 UN 145.51 145.51 MEDICA (COMMERCIAL) 94265 [3081118] MEDICA CLAIMS [308111801] 130.96 percent of total billed charges 90.22 138.23 Technical (Hospital) Services FLUTICASONE 100 MCG-SALMETEROL 50 MCG/DOSE BLISTR POWDR FOR INHALATION RX-104564 CDM 6370000100 HCPCS 250 RC 00173-0695-04 NDC inpatient 1 UN 145.51 145.51 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES PPO [308136801] 115.21 percent of total billed charges 90.22 138.23 Technical (Hospital) Services FLUTICASONE 100 MCG-SALMETEROL 50 MCG/DOSE BLISTR POWDR FOR INHALATION RX-104564 CDM 6370000100 HCPCS 250 RC 00173-0695-04 NDC inpatient 1 UN 145.51 145.51 UNITED HEALTHCARE (COMMERCIAL) [3081199] UNITED HEALTHCARE 87726 [308119901] 90.22 percent of total billed charges 90.22 138.23 Technical (Hospital) Services FLUTICASONE 100 MCG-SALMETEROL 50 MCG/DOSE BLISTR POWDR FOR INHALATION RX-104564 CDM 6370000100 HCPCS 250 RC 00173-0695-04 NDC inpatient 1 UN 145.51 145.51 BLUE CROSS BLUE SHIELD WELLMARK SB889 [3081026] BCBS WYOMING [308102603] 138.23 percent of total billed charges 90.22 138.23 Technical (Hospital) Services FLUTICASONE 100 MCG-SALMETEROL 50 MCG/DOSE BLISTR POWDR FOR INHALATION RX-104564 CDM 6370000100 HCPCS 250 RC 00173-0695-04 NDC inpatient 1 UN 145.51 145.51 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES EPO [308136803] 115.21 percent of total billed charges 90.22 138.23 Technical (Hospital) Services FLUTICASONE 100 MCG-SALMETEROL 50 MCG/DOSE BLISTR POWDR FOR INHALATION RX-104564 CDM 6370000100 HCPCS 250 RC 00173-0695-04 NDC inpatient 1 UN 145.51 145.51 CIGNA 62308 [3081051] CIGNA 62308 [308105105] 115.21 percent of total billed charges 90.22 138.23 Technical (Hospital) Services FLUTICASONE 100 MCG-SALMETEROL 50 MCG/DOSE BLISTR POWDR FOR INHALATION RX-104564 CDM 6370000100 HCPCS 250 RC 00173-0695-04 NDC inpatient 1 UN 145.51 145.51 CIGNA 62308 [3081051] CIGNA STATE OF WYOMING [308105107] 115.21 percent of total billed charges 90.22 138.23 Technical (Hospital) Services FLUTICASONE 100 MCG-SALMETEROL 50 MCG/DOSE BLISTR POWDR FOR INHALATION RX-104564 CDM 6370000100 HCPCS 250 RC 00173-0695-04 NDC inpatient 1 UN 145.51 145.51 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES HDHP [308136802] 115.21 percent of total billed charges 90.22 138.23 Technical (Hospital) Services FLUTICASONE 100 MCG-SALMETEROL 50 MCG/DOSE BLISTR POWDR FOR INHALATION RX-104564 CDM 6370000100 HCPCS 250 RC 00173-0695-04 NDC outpatient 1 UN 145.51 145.51 MEDICA (COMMERCIAL) 94265 [3081118] MEDICA CLAIMS [308111801] 130.96 percent of total billed charges 90.22 138.23 Technical (Hospital) Services FLUTICASONE 100 MCG-SALMETEROL 50 MCG/DOSE BLISTR POWDR FOR INHALATION RX-104564 CDM 6370000100 HCPCS 250 RC 00173-0695-04 NDC outpatient 1 UN 145.51 145.51 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES EPO [308136803] 116.41 percent of total billed charges 90.22 138.23 Technical (Hospital) Services FLUTICASONE 100 MCG-SALMETEROL 50 MCG/DOSE BLISTR POWDR FOR INHALATION RX-104564 CDM 6370000100 HCPCS 250 RC 00173-0695-04 NDC outpatient 1 UN 145.51 145.51 CIGNA 62308 [3081051] CIGNA 62308 [308105105] 116.41 percent of total billed charges 90.22 138.23 Technical (Hospital) Services FLUTICASONE 100 MCG-SALMETEROL 50 MCG/DOSE BLISTR POWDR FOR INHALATION RX-104564 CDM 6370000100 HCPCS 250 RC 00173-0695-04 NDC outpatient 1 UN 145.51 145.51 CIGNA 62308 [3081051] CIGNA STATE OF WYOMING [308105107] 116.41 percent of total billed charges 90.22 138.23 Technical (Hospital) Services FLUTICASONE 100 MCG-SALMETEROL 50 MCG/DOSE BLISTR POWDR FOR INHALATION RX-104564 CDM 6370000100 HCPCS 250 RC 00173-0695-04 NDC outpatient 1 UN 145.51 145.51 MULTIPLAN INC 34080 [3081285] MULTIPLAN INC [308128501] 138.23 percent of total billed charges 90.22 138.23 Technical (Hospital) Services FLUTICASONE 100 MCG-SALMETEROL 50 MCG/DOSE BLISTR POWDR FOR INHALATION RX-104564 CDM 6370000100 HCPCS 250 RC 00173-0695-04 NDC outpatient 1 UN 145.51 145.51 UNITED HEALTHCARE (COMMERCIAL) [3081199] UNITED HEALTHCARE 87726 [308119901] 90.22 percent of total billed charges 90.22 138.23 Technical (Hospital) Services FLUTICASONE 100 MCG-SALMETEROL 50 MCG/DOSE BLISTR POWDR FOR INHALATION RX-104564 CDM 6370000100 HCPCS 250 RC 00173-0695-04 NDC outpatient 1 UN 145.51 145.51 BLUE CROSS BLUE SHIELD WELLMARK SB889 [3081026] BCBS WYOMING [308102603] 138.23 percent of total billed charges 90.22 138.23 Technical (Hospital) Services FLUTICASONE 100 MCG-SALMETEROL 50 MCG/DOSE BLISTR POWDR FOR INHALATION RX-104564 CDM 6370000100 HCPCS 250 RC 00173-0695-04 NDC outpatient 1 UN 145.51 145.51 HEALTHPARTNERS SX009 HEALTHPARTNERS 116.41 percent of total billed charges 90.22 138.23 Technical (Hospital) Services FLUTICASONE 100 MCG-SALMETEROL 50 MCG/DOSE BLISTR POWDR FOR INHALATION RX-104564 CDM 6370000100 HCPCS 250 RC 00173-0695-04 NDC outpatient 1 UN 145.51 145.51 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES HDHP [308136802] 116.41 percent of total billed charges 90.22 138.23 Technical (Hospital) Services FLUTICASONE 100 MCG-SALMETEROL 50 MCG/DOSE BLISTR POWDR FOR INHALATION RX-104564 CDM 6370000100 HCPCS 250 RC 00173-0695-04 NDC outpatient 1 UN 145.51 145.51 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES PPO [308136801] 116.41 percent of total billed charges 90.22 138.23 Technical (Hospital) Services FLUTICASONE 250 MCG-SALMETEROL 50 MCG/DOSE BLISTR POWDR FOR INHALATION RX-104565 CDM 6370000100 HCPCS 250 RC 00173-0696-04 NDC inpatient 1 UN 145.51 145.51 HEALTHPARTNERS SX009 HEALTHPARTNERS 115.21 percent of total billed charges 90.22 138.23 Technical (Hospital) Services FLUTICASONE 250 MCG-SALMETEROL 50 MCG/DOSE BLISTR POWDR FOR INHALATION RX-104565 CDM 6370000100 HCPCS 250 RC 00173-0696-04 NDC inpatient 1 UN 145.51 145.51 MEDICA (COMMERCIAL) 94265 [3081118] MEDICA CLAIMS [308111801] 130.96 percent of total billed charges 90.22 138.23 Technical (Hospital) Services FLUTICASONE 250 MCG-SALMETEROL 50 MCG/DOSE BLISTR POWDR FOR INHALATION RX-104565 CDM 6370000100 HCPCS 250 RC 00173-0696-04 NDC inpatient 1 UN 145.51 145.51 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES EPO [308136803] 115.21 percent of total billed charges 90.22 138.23 Technical (Hospital) Services FLUTICASONE 250 MCG-SALMETEROL 50 MCG/DOSE BLISTR POWDR FOR INHALATION RX-104565 CDM 6370000100 HCPCS 250 RC 00173-0696-04 NDC inpatient 1 UN 145.51 145.51 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES HDHP [308136802] 115.21 percent of total billed charges 90.22 138.23 Technical (Hospital) Services FLUTICASONE 250 MCG-SALMETEROL 50 MCG/DOSE BLISTR POWDR FOR INHALATION RX-104565 CDM 6370000100 HCPCS 250 RC 00173-0696-04 NDC inpatient 1 UN 145.51 145.51 CIGNA 62308 [3081051] CIGNA 62308 [308105105] 115.21 percent of total billed charges 90.22 138.23 Technical (Hospital) Services FLUTICASONE 250 MCG-SALMETEROL 50 MCG/DOSE BLISTR POWDR FOR INHALATION RX-104565 CDM 6370000100 HCPCS 250 RC 00173-0696-04 NDC inpatient 1 UN 145.51 145.51 CIGNA 62308 [3081051] CIGNA STATE OF WYOMING [308105107] 115.21 percent of total billed charges 90.22 138.23 Technical (Hospital) Services FLUTICASONE 250 MCG-SALMETEROL 50 MCG/DOSE BLISTR POWDR FOR INHALATION RX-104565 CDM 6370000100 HCPCS 250 RC 00173-0696-04 NDC inpatient 1 UN 145.51 145.51 UNITED HEALTHCARE (COMMERCIAL) [3081199] UNITED HEALTHCARE 87726 [308119901] 90.22 percent of total billed charges 90.22 138.23 Technical (Hospital) Services FLUTICASONE 250 MCG-SALMETEROL 50 MCG/DOSE BLISTR POWDR FOR INHALATION RX-104565 CDM 6370000100 HCPCS 250 RC 00173-0696-04 NDC inpatient 1 UN 145.51 145.51 BLUE CROSS BLUE SHIELD WELLMARK SB889 [3081026] BCBS WYOMING [308102603] 138.23 percent of total billed charges 90.22 138.23 Technical (Hospital) Services FLUTICASONE 250 MCG-SALMETEROL 50 MCG/DOSE BLISTR POWDR FOR INHALATION RX-104565 CDM 6370000100 HCPCS 250 RC 00173-0696-04 NDC inpatient 1 UN 145.51 145.51 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES PPO [308136801] 115.21 percent of total billed charges 90.22 138.23 Technical (Hospital) Services FLUTICASONE 250 MCG-SALMETEROL 50 MCG/DOSE BLISTR POWDR FOR INHALATION RX-104565 CDM 6370000100 HCPCS 250 RC 00173-0696-04 NDC inpatient 1 UN 145.51 145.51 MULTIPLAN INC 34080 [3081285] MULTIPLAN INC [308128501] 138.23 percent of total billed charges 90.22 138.23 Technical (Hospital) Services FLUTICASONE 250 MCG-SALMETEROL 50 MCG/DOSE BLISTR POWDR FOR INHALATION RX-104565 CDM 6370000100 HCPCS 250 RC 00173-0696-04 NDC outpatient 1 UN 145.51 145.51 BLUE CROSS BLUE SHIELD WELLMARK SB889 [3081026] BCBS WYOMING [308102603] 138.23 percent of total billed charges 90.22 138.23 Technical (Hospital) Services FLUTICASONE 250 MCG-SALMETEROL 50 MCG/DOSE BLISTR POWDR FOR INHALATION RX-104565 CDM 6370000100 HCPCS 250 RC 00173-0696-04 NDC outpatient 1 UN 145.51 145.51 HEALTHPARTNERS SX009 HEALTHPARTNERS 116.41 percent of total billed charges 90.22 138.23 Technical (Hospital) Services FLUTICASONE 250 MCG-SALMETEROL 50 MCG/DOSE BLISTR POWDR FOR INHALATION RX-104565 CDM 6370000100 HCPCS 250 RC 00173-0696-04 NDC outpatient 1 UN 145.51 145.51 MEDICA (COMMERCIAL) 94265 [3081118] MEDICA CLAIMS [308111801] 130.96 percent of total billed charges 90.22 138.23 Technical (Hospital) Services FLUTICASONE 250 MCG-SALMETEROL 50 MCG/DOSE BLISTR POWDR FOR INHALATION RX-104565 CDM 6370000100 HCPCS 250 RC 00173-0696-04 NDC outpatient 1 UN 145.51 145.51 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES EPO [308136803] 116.41 percent of total billed charges 90.22 138.23 Technical (Hospital) Services FLUTICASONE 250 MCG-SALMETEROL 50 MCG/DOSE BLISTR POWDR FOR INHALATION RX-104565 CDM 6370000100 HCPCS 250 RC 00173-0696-04 NDC outpatient 1 UN 145.51 145.51 CIGNA 62308 [3081051] CIGNA 62308 [308105105] 116.41 percent of total billed charges 90.22 138.23 Technical (Hospital) Services FLUTICASONE 250 MCG-SALMETEROL 50 MCG/DOSE BLISTR POWDR FOR INHALATION RX-104565 CDM 6370000100 HCPCS 250 RC 00173-0696-04 NDC outpatient 1 UN 145.51 145.51 CIGNA 62308 [3081051] CIGNA STATE OF WYOMING [308105107] 116.41 percent of total billed charges 90.22 138.23 Technical (Hospital) Services FLUTICASONE 250 MCG-SALMETEROL 50 MCG/DOSE BLISTR POWDR FOR INHALATION RX-104565 CDM 6370000100 HCPCS 250 RC 00173-0696-04 NDC outpatient 1 UN 145.51 145.51 MULTIPLAN INC 34080 [3081285] MULTIPLAN INC [308128501] 138.23 percent of total billed charges 90.22 138.23 Technical (Hospital) Services FLUTICASONE 250 MCG-SALMETEROL 50 MCG/DOSE BLISTR POWDR FOR INHALATION RX-104565 CDM 6370000100 HCPCS 250 RC 00173-0696-04 NDC outpatient 1 UN 145.51 145.51 UNITED HEALTHCARE (COMMERCIAL) [3081199] UNITED HEALTHCARE 87726 [308119901] 90.22 percent of total billed charges 90.22 138.23 Technical (Hospital) Services FLUTICASONE 250 MCG-SALMETEROL 50 MCG/DOSE BLISTR POWDR FOR INHALATION RX-104565 CDM 6370000100 HCPCS 250 RC 00173-0696-04 NDC outpatient 1 UN 145.51 145.51 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES HDHP [308136802] 116.41 percent of total billed charges 90.22 138.23 Technical (Hospital) Services FLUTICASONE 250 MCG-SALMETEROL 50 MCG/DOSE BLISTR POWDR FOR INHALATION RX-104565 CDM 6370000100 HCPCS 250 RC 00173-0696-04 NDC outpatient 1 UN 145.51 145.51 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES PPO [308136801] 116.41 percent of total billed charges 90.22 138.23 Technical (Hospital) Services FLUTICASONE 500 MCG-SALMETEROL 50 MCG/DOSE BLISTR POWDR FOR INHALATION RX-104566 CDM 6370000100 HCPCS 250 RC 00054-0328-56 NDC inpatient 1 UN 593.12 593.12 MULTIPLAN INC 34080 [3081285] MULTIPLAN INC [308128501] 563.46 percent of total billed charges 367.73 563.46 Technical (Hospital) Services FLUTICASONE 500 MCG-SALMETEROL 50 MCG/DOSE BLISTR POWDR FOR INHALATION RX-104566 CDM 6370000100 HCPCS 250 RC 00054-0328-56 NDC inpatient 1 UN 593.12 593.12 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES PPO [308136801] 469.63 percent of total billed charges 367.73 563.46 Technical (Hospital) Services FLUTICASONE 500 MCG-SALMETEROL 50 MCG/DOSE BLISTR POWDR FOR INHALATION RX-104566 CDM 6370000100 HCPCS 250 RC 00054-0328-56 NDC inpatient 1 UN 593.12 593.12 BLUE CROSS BLUE SHIELD WELLMARK SB889 [3081026] BCBS WYOMING [308102603] 563.46 percent of total billed charges 367.73 563.46 Technical (Hospital) Services FLUTICASONE 500 MCG-SALMETEROL 50 MCG/DOSE BLISTR POWDR FOR INHALATION RX-104566 CDM 6370000100 HCPCS 250 RC 00054-0328-56 NDC inpatient 1 UN 593.12 593.12 UNITED HEALTHCARE (COMMERCIAL) [3081199] UNITED HEALTHCARE 87726 [308119901] 367.73 percent of total billed charges 367.73 563.46 Technical (Hospital) Services FLUTICASONE 500 MCG-SALMETEROL 50 MCG/DOSE BLISTR POWDR FOR INHALATION RX-104566 CDM 6370000100 HCPCS 250 RC 00054-0328-56 NDC inpatient 1 UN 593.12 593.12 CIGNA 62308 [3081051] CIGNA 62308 [308105105] 469.63 percent of total billed charges 367.73 563.46 Technical (Hospital) Services FLUTICASONE 500 MCG-SALMETEROL 50 MCG/DOSE BLISTR POWDR FOR INHALATION RX-104566 CDM 6370000100 HCPCS 250 RC 00054-0328-56 NDC inpatient 1 UN 593.12 593.12 CIGNA 62308 [3081051] CIGNA STATE OF WYOMING [308105107] 469.63 percent of total billed charges 367.73 563.46 Technical (Hospital) Services FLUTICASONE 500 MCG-SALMETEROL 50 MCG/DOSE BLISTR POWDR FOR INHALATION RX-104566 CDM 6370000100 HCPCS 250 RC 00054-0328-56 NDC inpatient 1 UN 593.12 593.12 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES HDHP [308136802] 469.63 percent of total billed charges 367.73 563.46 Technical (Hospital) Services FLUTICASONE 500 MCG-SALMETEROL 50 MCG/DOSE BLISTR POWDR FOR INHALATION RX-104566 CDM 6370000100 HCPCS 250 RC 00054-0328-56 NDC outpatient 1 UN 593.12 593.12 MULTIPLAN INC 34080 [3081285] MULTIPLAN INC [308128501] 563.46 percent of total billed charges 367.73 563.46 Technical (Hospital) Services FLUTICASONE 500 MCG-SALMETEROL 50 MCG/DOSE BLISTR POWDR FOR INHALATION RX-104566 CDM 6370000100 HCPCS 250 RC 00054-0328-56 NDC outpatient 1 UN 593.12 593.12 UNITED HEALTHCARE (COMMERCIAL) [3081199] UNITED HEALTHCARE 87726 [308119901] 367.73 percent of total billed charges 367.73 563.46 Technical (Hospital) Services FLUTICASONE 500 MCG-SALMETEROL 50 MCG/DOSE BLISTR POWDR FOR INHALATION RX-104566 CDM 6370000100 HCPCS 250 RC 00054-0328-56 NDC outpatient 1 UN 593.12 593.12 CIGNA 62308 [3081051] CIGNA 62308 [308105105] 474.5 percent of total billed charges 367.73 563.46 Technical (Hospital) Services FLUTICASONE 500 MCG-SALMETEROL 50 MCG/DOSE BLISTR POWDR FOR INHALATION RX-104566 CDM 6370000100 HCPCS 250 RC 00054-0328-56 NDC outpatient 1 UN 593.12 593.12 CIGNA 62308 [3081051] CIGNA STATE OF WYOMING [308105107] 474.5 percent of total billed charges 367.73 563.46 Technical (Hospital) Services FLUTICASONE 500 MCG-SALMETEROL 50 MCG/DOSE BLISTR POWDR FOR INHALATION RX-104566 CDM 6370000100 HCPCS 250 RC 00054-0328-56 NDC inpatient 1 UN 593.12 593.12 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES EPO [308136803] 469.63 percent of total billed charges 367.73 563.46 Technical (Hospital) Services FLUTICASONE 500 MCG-SALMETEROL 50 MCG/DOSE BLISTR POWDR FOR INHALATION RX-104566 CDM 6370000100 HCPCS 250 RC 00054-0328-56 NDC inpatient 1 UN 593.12 593.12 HEALTHPARTNERS SX009 HEALTHPARTNERS 469.63 percent of total billed charges 367.73 563.46 Technical (Hospital) Services FLUTICASONE 500 MCG-SALMETEROL 50 MCG/DOSE BLISTR POWDR FOR INHALATION RX-104566 CDM 6370000100 HCPCS 250 RC 00054-0328-56 NDC inpatient 1 UN 593.12 593.12 MEDICA (COMMERCIAL) 94265 [3081118] MEDICA CLAIMS [308111801] 533.81 percent of total billed charges 367.73 563.46 Technical (Hospital) Services FLUTICASONE 500 MCG-SALMETEROL 50 MCG/DOSE BLISTR POWDR FOR INHALATION RX-104566 CDM 6370000100 HCPCS 250 RC 00054-0328-56 NDC outpatient 1 UN 593.12 593.12 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES EPO [308136803] 474.5 percent of total billed charges 367.73 563.46 Technical (Hospital) Services FLUTICASONE 500 MCG-SALMETEROL 50 MCG/DOSE BLISTR POWDR FOR INHALATION RX-104566 CDM 6370000100 HCPCS 250 RC 00054-0328-56 NDC outpatient 1 UN 593.12 593.12 MEDICA (COMMERCIAL) 94265 [3081118] MEDICA CLAIMS [308111801] 533.81 percent of total billed charges 367.73 563.46 Technical (Hospital) Services FLUTICASONE 500 MCG-SALMETEROL 50 MCG/DOSE BLISTR POWDR FOR INHALATION RX-104566 CDM 6370000100 HCPCS 250 RC 00054-0328-56 NDC outpatient 1 UN 593.12 593.12 HEALTHPARTNERS SX009 HEALTHPARTNERS 474.5 percent of total billed charges 367.73 563.46 Technical (Hospital) Services FLUTICASONE 500 MCG-SALMETEROL 50 MCG/DOSE BLISTR POWDR FOR INHALATION RX-104566 CDM 6370000100 HCPCS 250 RC 00054-0328-56 NDC outpatient 1 UN 593.12 593.12 BLUE CROSS BLUE SHIELD WELLMARK SB889 [3081026] BCBS WYOMING [308102603] 563.46 percent of total billed charges 367.73 563.46 Technical (Hospital) Services FLUTICASONE 500 MCG-SALMETEROL 50 MCG/DOSE BLISTR POWDR FOR INHALATION RX-104566 CDM 6370000100 HCPCS 250 RC 00054-0328-56 NDC outpatient 1 UN 593.12 593.12 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES HDHP [308136802] 474.5 percent of total billed charges 367.73 563.46 Technical (Hospital) Services FLUTICASONE 500 MCG-SALMETEROL 50 MCG/DOSE BLISTR POWDR FOR INHALATION RX-104566 CDM 6370000100 HCPCS 250 RC 00054-0328-56 NDC outpatient 1 UN 593.12 593.12 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES PPO [308136801] 474.5 percent of total billed charges 367.73 563.46 Technical (Hospital) Services BETHANECHOL CHLORIDE 50 MG TABLET RX-1046 CDM 6370000100 HCPCS 250 RC 51293-0648-01 NDC outpatient 1 UN 6.37 6.37 BLUE CROSS BLUE SHIELD WELLMARK SB889 [3081026] BCBS WYOMING [308102603] 6.05 percent of total billed charges 3.95 6.05 Technical (Hospital) Services BETHANECHOL CHLORIDE 50 MG TABLET RX-1046 CDM 6370000100 HCPCS 250 RC 51293-0648-01 NDC outpatient 1 UN 6.37 6.37 HEALTHPARTNERS SX009 HEALTHPARTNERS 5.1 percent of total billed charges 3.95 6.05 Technical (Hospital) Services BETHANECHOL CHLORIDE 50 MG TABLET RX-1046 CDM 6370000100 HCPCS 250 RC 51293-0648-01 NDC outpatient 1 UN 6.37 6.37 UNITED HEALTHCARE (COMMERCIAL) [3081199] UNITED HEALTHCARE 87726 [308119901] 3.95 percent of total billed charges 3.95 6.05 Technical (Hospital) Services BETHANECHOL CHLORIDE 50 MG TABLET RX-1046 CDM 6370000100 HCPCS 250 RC 51293-0648-01 NDC outpatient 1 UN 6.37 6.37 MULTIPLAN INC 34080 [3081285] MULTIPLAN INC [308128501] 6.05 percent of total billed charges 3.95 6.05 Technical (Hospital) Services BETHANECHOL CHLORIDE 50 MG TABLET RX-1046 CDM 6370000100 HCPCS 250 RC 51293-0648-01 NDC outpatient 1 UN 6.37 6.37 CIGNA 62308 [3081051] CIGNA 62308 [308105105] 5.1 percent of total billed charges 3.95 6.05 Technical (Hospital) Services BETHANECHOL CHLORIDE 50 MG TABLET RX-1046 CDM 6370000100 HCPCS 250 RC 51293-0648-01 NDC outpatient 1 UN 6.37 6.37 CIGNA 62308 [3081051] CIGNA STATE OF WYOMING [308105107] 5.1 percent of total billed charges 3.95 6.05 Technical (Hospital) Services BETHANECHOL CHLORIDE 50 MG TABLET RX-1046 CDM 6370000100 HCPCS 250 RC 51293-0648-01 NDC outpatient 1 UN 6.37 6.37 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES EPO [308136803] 5.1 percent of total billed charges 3.95 6.05 Technical (Hospital) Services BETHANECHOL CHLORIDE 50 MG TABLET RX-1046 CDM 6370000100 HCPCS 250 RC 51293-0648-01 NDC outpatient 1 UN 6.37 6.37 MEDICA (COMMERCIAL) 94265 [3081118] MEDICA CLAIMS [308111801] 5.73 percent of total billed charges 3.95 6.05 Technical (Hospital) Services BETHANECHOL CHLORIDE 50 MG TABLET RX-1046 CDM 6370000100 HCPCS 250 RC 51293-0648-01 NDC outpatient 1 UN 6.37 6.37 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES HDHP [308136802] 5.1 percent of total billed charges 3.95 6.05 Technical (Hospital) Services BETHANECHOL CHLORIDE 50 MG TABLET RX-1046 CDM 6370000100 HCPCS 250 RC 51293-0648-01 NDC outpatient 1 UN 6.37 6.37 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES PPO [308136801] 5.1 percent of total billed charges 3.95 6.05 Technical (Hospital) Services BETHANECHOL CHLORIDE 50 MG TABLET RX-1046 CDM 6370000100 HCPCS 250 RC 51293-0648-01 NDC inpatient 1 UN 6.37 6.37 MEDICA (COMMERCIAL) 94265 [3081118] MEDICA CLAIMS [308111801] 5.73 percent of total billed charges 3.95 6.05 Technical (Hospital) Services BETHANECHOL CHLORIDE 50 MG TABLET RX-1046 CDM 6370000100 HCPCS 250 RC 51293-0648-01 NDC inpatient 1 UN 6.37 6.37 HEALTHPARTNERS SX009 HEALTHPARTNERS 5.04 percent of total billed charges 3.95 6.05 Technical (Hospital) Services BETHANECHOL CHLORIDE 50 MG TABLET RX-1046 CDM 6370000100 HCPCS 250 RC 51293-0648-01 NDC inpatient 1 UN 6.37 6.37 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES PPO [308136801] 5.04 percent of total billed charges 3.95 6.05 Technical (Hospital) Services BETHANECHOL CHLORIDE 50 MG TABLET RX-1046 CDM 6370000100 HCPCS 250 RC 51293-0648-01 NDC inpatient 1 UN 6.37 6.37 MULTIPLAN INC 34080 [3081285] MULTIPLAN INC [308128501] 6.05 percent of total billed charges 3.95 6.05 Technical (Hospital) Services BETHANECHOL CHLORIDE 50 MG TABLET RX-1046 CDM 6370000100 HCPCS 250 RC 51293-0648-01 NDC inpatient 1 UN 6.37 6.37 BLUE CROSS BLUE SHIELD WELLMARK SB889 [3081026] BCBS WYOMING [308102603] 6.05 percent of total billed charges 3.95 6.05 Technical (Hospital) Services BETHANECHOL CHLORIDE 50 MG TABLET RX-1046 CDM 6370000100 HCPCS 250 RC 51293-0648-01 NDC inpatient 1 UN 6.37 6.37 UNITED HEALTHCARE (COMMERCIAL) [3081199] UNITED HEALTHCARE 87726 [308119901] 3.95 percent of total billed charges 3.95 6.05 Technical (Hospital) Services BETHANECHOL CHLORIDE 50 MG TABLET RX-1046 CDM 6370000100 HCPCS 250 RC 51293-0648-01 NDC inpatient 1 UN 6.37 6.37 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES EPO [308136803] 5.04 percent of total billed charges 3.95 6.05 Technical (Hospital) Services BETHANECHOL CHLORIDE 50 MG TABLET RX-1046 CDM 6370000100 HCPCS 250 RC 51293-0648-01 NDC inpatient 1 UN 6.37 6.37 CIGNA 62308 [3081051] CIGNA 62308 [308105105] 5.04 percent of total billed charges 3.95 6.05 Technical (Hospital) Services BETHANECHOL CHLORIDE 50 MG TABLET RX-1046 CDM 6370000100 HCPCS 250 RC 51293-0648-01 NDC inpatient 1 UN 6.37 6.37 CIGNA 62308 [3081051] CIGNA STATE OF WYOMING [308105107] 5.04 percent of total billed charges 3.95 6.05 Technical (Hospital) Services BETHANECHOL CHLORIDE 50 MG TABLET RX-1046 CDM 6370000100 HCPCS 250 RC 51293-0648-01 NDC inpatient 1 UN 6.37 6.37 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES HDHP [308136802] 5.04 percent of total billed charges 3.95 6.05 Technical (Hospital) Services RIFAXIMIN 550 MG TABLET RX-104604 CDM 6370000100 HCPCS 250 RC 65649-0303-02 NDC inpatient 1 UN 194.45 194.45 MULTIPLAN INC 34080 [3081285] MULTIPLAN INC [308128501] 184.73 percent of total billed charges 120.56 184.73 Technical (Hospital) Services RIFAXIMIN 550 MG TABLET RX-104604 CDM 6370000100 HCPCS 250 RC 65649-0303-02 NDC inpatient 1 UN 194.45 194.45 HEALTHPARTNERS SX009 HEALTHPARTNERS 153.97 percent of total billed charges 120.56 184.73 Technical (Hospital) Services RIFAXIMIN 550 MG TABLET RX-104604 CDM 6370000100 HCPCS 250 RC 65649-0303-02 NDC inpatient 1 UN 194.45 194.45 MEDICA (COMMERCIAL) 94265 [3081118] MEDICA CLAIMS [308111801] 175.01 percent of total billed charges 120.56 184.73 Technical (Hospital) Services RIFAXIMIN 550 MG TABLET RX-104604 CDM 6370000100 HCPCS 250 RC 65649-0303-02 NDC inpatient 1 UN 194.45 194.45 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES PPO [308136801] 153.97 percent of total billed charges 120.56 184.73 Technical (Hospital) Services RIFAXIMIN 550 MG TABLET RX-104604 CDM 6370000100 HCPCS 250 RC 65649-0303-02 NDC inpatient 1 UN 194.45 194.45 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES HDHP [308136802] 153.97 percent of total billed charges 120.56 184.73 Technical (Hospital) Services RIFAXIMIN 550 MG TABLET RX-104604 CDM 6370000100 HCPCS 250 RC 65649-0303-02 NDC inpatient 1 UN 194.45 194.45 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES EPO [308136803] 153.97 percent of total billed charges 120.56 184.73 Technical (Hospital) Services RIFAXIMIN 550 MG TABLET RX-104604 CDM 6370000100 HCPCS 250 RC 65649-0303-02 NDC inpatient 1 UN 194.45 194.45 CIGNA 62308 [3081051] CIGNA 62308 [308105105] 153.97 percent of total billed charges 120.56 184.73 Technical (Hospital) Services RIFAXIMIN 550 MG TABLET RX-104604 CDM 6370000100 HCPCS 250 RC 65649-0303-02 NDC inpatient 1 UN 194.45 194.45 CIGNA 62308 [3081051] CIGNA STATE OF WYOMING [308105107] 153.97 percent of total billed charges 120.56 184.73 Technical (Hospital) Services RIFAXIMIN 550 MG TABLET RX-104604 CDM 6370000100 HCPCS 250 RC 65649-0303-02 NDC inpatient 1 UN 194.45 194.45 UNITED HEALTHCARE (COMMERCIAL) [3081199] UNITED HEALTHCARE 87726 [308119901] 120.56 percent of total billed charges 120.56 184.73 Technical (Hospital) Services RIFAXIMIN 550 MG TABLET RX-104604 CDM 6370000100 HCPCS 250 RC 65649-0303-02 NDC inpatient 1 UN 194.45 194.45 BLUE CROSS BLUE SHIELD WELLMARK SB889 [3081026] BCBS WYOMING [308102603] 184.73 percent of total billed charges 120.56 184.73 Technical (Hospital) Services RIFAXIMIN 550 MG TABLET RX-104604 CDM 6370000100 HCPCS 250 RC 65649-0303-02 NDC outpatient 1 UN 194.45 194.45 HEALTHPARTNERS SX009 HEALTHPARTNERS 155.56 percent of total billed charges 120.56 184.73 Technical (Hospital) Services RIFAXIMIN 550 MG TABLET RX-104604 CDM 6370000100 HCPCS 250 RC 65649-0303-02 NDC outpatient 1 UN 194.45 194.45 UNITED HEALTHCARE (COMMERCIAL) [3081199] UNITED HEALTHCARE 87726 [308119901] 120.56 percent of total billed charges 120.56 184.73 Technical (Hospital) Services RIFAXIMIN 550 MG TABLET RX-104604 CDM 6370000100 HCPCS 250 RC 65649-0303-02 NDC outpatient 1 UN 194.45 194.45 CIGNA 62308 [3081051] CIGNA 62308 [308105105] 155.56 percent of total billed charges 120.56 184.73 Technical (Hospital) Services RIFAXIMIN 550 MG TABLET RX-104604 CDM 6370000100 HCPCS 250 RC 65649-0303-02 NDC outpatient 1 UN 194.45 194.45 CIGNA 62308 [3081051] CIGNA STATE OF WYOMING [308105107] 155.56 percent of total billed charges 120.56 184.73 Technical (Hospital) Services RIFAXIMIN 550 MG TABLET RX-104604 CDM 6370000100 HCPCS 250 RC 65649-0303-02 NDC outpatient 1 UN 194.45 194.45 MULTIPLAN INC 34080 [3081285] MULTIPLAN INC [308128501] 184.73 percent of total billed charges 120.56 184.73 Technical (Hospital) Services RIFAXIMIN 550 MG TABLET RX-104604 CDM 6370000100 HCPCS 250 RC 65649-0303-02 NDC outpatient 1 UN 194.45 194.45 MEDICA (COMMERCIAL) 94265 [3081118] MEDICA CLAIMS [308111801] 175.01 percent of total billed charges 120.56 184.73 Technical (Hospital) Services RIFAXIMIN 550 MG TABLET RX-104604 CDM 6370000100 HCPCS 250 RC 65649-0303-02 NDC outpatient 1 UN 194.45 194.45 BLUE CROSS BLUE SHIELD WELLMARK SB889 [3081026] BCBS WYOMING [308102603] 184.73 percent of total billed charges 120.56 184.73 Technical (Hospital) Services RIFAXIMIN 550 MG TABLET RX-104604 CDM 6370000100 HCPCS 250 RC 65649-0303-02 NDC outpatient 1 UN 194.45 194.45 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES EPO [308136803] 155.56 percent of total billed charges 120.56 184.73 Technical (Hospital) Services RIFAXIMIN 550 MG TABLET RX-104604 CDM 6370000100 HCPCS 250 RC 65649-0303-02 NDC outpatient 1 UN 194.45 194.45 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES HDHP [308136802] 155.56 percent of total billed charges 120.56 184.73 Technical (Hospital) Services RIFAXIMIN 550 MG TABLET RX-104604 CDM 6370000100 HCPCS 250 RC 65649-0303-02 NDC outpatient 1 UN 194.45 194.45 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES PPO [308136801] 155.56 percent of total billed charges 120.56 184.73 Technical (Hospital) Services LORATADINE 10 MG TABLET RX-10466 CDM 6370000100 HCPCS 250 RC 45802-0650-78 NDC inpatient 1 UN 5.92 5.92 UNITED HEALTHCARE (COMMERCIAL) [3081199] UNITED HEALTHCARE 87726 [308119901] 3.67 percent of total billed charges 3.67 5.62 Technical (Hospital) Services LORATADINE 10 MG TABLET RX-10466 CDM 6370000100 HCPCS 250 RC 45802-0650-78 NDC inpatient 1 UN 5.92 5.92 BLUE CROSS BLUE SHIELD WELLMARK SB889 [3081026] BCBS WYOMING [308102603] 5.62 percent of total billed charges 3.67 5.62 Technical (Hospital) Services LORATADINE 10 MG TABLET RX-10466 CDM 6370000100 HCPCS 250 RC 45802-0650-78 NDC inpatient 1 UN 5.92 5.92 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES EPO [308136803] 4.69 percent of total billed charges 3.67 5.62 Technical (Hospital) Services LORATADINE 10 MG TABLET RX-10466 CDM 6370000100 HCPCS 250 RC 45802-0650-78 NDC inpatient 1 UN 5.92 5.92 CIGNA 62308 [3081051] CIGNA 62308 [308105105] 4.69 percent of total billed charges 3.67 5.62 Technical (Hospital) Services LORATADINE 10 MG TABLET RX-10466 CDM 6370000100 HCPCS 250 RC 45802-0650-78 NDC inpatient 1 UN 5.92 5.92 CIGNA 62308 [3081051] CIGNA STATE OF WYOMING [308105107] 4.69 percent of total billed charges 3.67 5.62 Technical (Hospital) Services LORATADINE 10 MG TABLET RX-10466 CDM 6370000100 HCPCS 250 RC 45802-0650-78 NDC inpatient 1 UN 5.92 5.92 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES HDHP [308136802] 4.69 percent of total billed charges 3.67 5.62 Technical (Hospital) Services LORATADINE 10 MG TABLET RX-10466 CDM 6370000100 HCPCS 250 RC 45802-0650-78 NDC inpatient 1 UN 5.92 5.92 HEALTHPARTNERS SX009 HEALTHPARTNERS 4.69 percent of total billed charges 3.67 5.62 Technical (Hospital) Services LORATADINE 10 MG TABLET RX-10466 CDM 6370000100 HCPCS 250 RC 45802-0650-78 NDC inpatient 1 UN 5.92 5.92 MEDICA (COMMERCIAL) 94265 [3081118] MEDICA CLAIMS [308111801] 5.33 percent of total billed charges 3.67 5.62 Technical (Hospital) Services LORATADINE 10 MG TABLET RX-10466 CDM 6370000100 HCPCS 250 RC 45802-0650-78 NDC inpatient 1 UN 5.92 5.92 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES PPO [308136801] 4.69 percent of total billed charges 3.67 5.62 Technical (Hospital) Services LORATADINE 10 MG TABLET RX-10466 CDM 6370000100 HCPCS 250 RC 45802-0650-78 NDC inpatient 1 UN 5.92 5.92 MULTIPLAN INC 34080 [3081285] MULTIPLAN INC [308128501] 5.62 percent of total billed charges 3.67 5.62 Technical (Hospital) Services LORATADINE 10 MG TABLET RX-10466 CDM 6370000100 HCPCS 250 RC 45802-0650-78 NDC outpatient 1 UN 5.92 5.92 CIGNA 62308 [3081051] CIGNA 62308 [308105105] 4.74 percent of total billed charges 3.67 5.62 Technical (Hospital) Services LORATADINE 10 MG TABLET RX-10466 CDM 6370000100 HCPCS 250 RC 45802-0650-78 NDC outpatient 1 UN 5.92 5.92 CIGNA 62308 [3081051] CIGNA STATE OF WYOMING [308105107] 4.74 percent of total billed charges 3.67 5.62 Technical (Hospital) Services LORATADINE 10 MG TABLET RX-10466 CDM 6370000100 HCPCS 250 RC 45802-0650-78 NDC outpatient 1 UN 5.92 5.92 MULTIPLAN INC 34080 [3081285] MULTIPLAN INC [308128501] 5.62 percent of total billed charges 3.67 5.62 Technical (Hospital) Services LORATADINE 10 MG TABLET RX-10466 CDM 6370000100 HCPCS 250 RC 45802-0650-78 NDC outpatient 1 UN 5.92 5.92 UNITED HEALTHCARE (COMMERCIAL) [3081199] UNITED HEALTHCARE 87726 [308119901] 3.67 percent of total billed charges 3.67 5.62 Technical (Hospital) Services LORATADINE 10 MG TABLET RX-10466 CDM 6370000100 HCPCS 250 RC 45802-0650-78 NDC outpatient 1 UN 5.92 5.92 MEDICA (COMMERCIAL) 94265 [3081118] MEDICA CLAIMS [308111801] 5.33 percent of total billed charges 3.67 5.62 Technical (Hospital) Services LORATADINE 10 MG TABLET RX-10466 CDM 6370000100 HCPCS 250 RC 45802-0650-78 NDC outpatient 1 UN 5.92 5.92 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES EPO [308136803] 4.74 percent of total billed charges 3.67 5.62 Technical (Hospital) Services LORATADINE 10 MG TABLET RX-10466 CDM 6370000100 HCPCS 250 RC 45802-0650-78 NDC outpatient 1 UN 5.92 5.92 HEALTHPARTNERS SX009 HEALTHPARTNERS 4.74 percent of total billed charges 3.67 5.62 Technical (Hospital) Services LORATADINE 10 MG TABLET RX-10466 CDM 6370000100 HCPCS 250 RC 45802-0650-78 NDC outpatient 1 UN 5.92 5.92 BLUE CROSS BLUE SHIELD WELLMARK SB889 [3081026] BCBS WYOMING [308102603] 5.62 percent of total billed charges 3.67 5.62 Technical (Hospital) Services LORATADINE 10 MG TABLET RX-10466 CDM 6370000100 HCPCS 250 RC 45802-0650-78 NDC outpatient 1 UN 5.92 5.92 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES HDHP [308136802] 4.74 percent of total billed charges 3.67 5.62 Technical (Hospital) Services LORATADINE 10 MG TABLET RX-10466 CDM 6370000100 HCPCS 250 RC 45802-0650-78 NDC outpatient 1 UN 5.92 5.92 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES PPO [308136801] 4.74 percent of total billed charges 3.67 5.62 Technical (Hospital) Services BUTALBITAL-ACETAMINOPHEN-CAFFEINE 50 MG-300 MG-40 MG CAPSULE RX-104993 CDM 6370000100 HCPCS 250 RC 70010-0044-01 NDC outpatient 1 UN 6.5 6.5 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES PPO [308136801] 5.2 percent of total billed charges 4.03 6.18 Technical (Hospital) Services BUTALBITAL-ACETAMINOPHEN-CAFFEINE 50 MG-300 MG-40 MG CAPSULE RX-104993 CDM 6370000100 HCPCS 250 RC 70010-0044-01 NDC outpatient 1 UN 6.5 6.5 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES HDHP [308136802] 5.2 percent of total billed charges 4.03 6.18 Technical (Hospital) Services BUTALBITAL-ACETAMINOPHEN-CAFFEINE 50 MG-300 MG-40 MG CAPSULE RX-104993 CDM 6370000100 HCPCS 250 RC 70010-0044-01 NDC outpatient 1 UN 6.5 6.5 BLUE CROSS BLUE SHIELD WELLMARK SB889 [3081026] BCBS WYOMING [308102603] 6.18 percent of total billed charges 4.03 6.18 Technical (Hospital) Services BUTALBITAL-ACETAMINOPHEN-CAFFEINE 50 MG-300 MG-40 MG CAPSULE RX-104993 CDM 6370000100 HCPCS 250 RC 70010-0044-01 NDC outpatient 1 UN 6.5 6.5 HEALTHPARTNERS SX009 HEALTHPARTNERS 5.2 percent of total billed charges 4.03 6.18 Technical (Hospital) Services BUTALBITAL-ACETAMINOPHEN-CAFFEINE 50 MG-300 MG-40 MG CAPSULE RX-104993 CDM 6370000100 HCPCS 250 RC 70010-0044-01 NDC outpatient 1 UN 6.5 6.5 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES EPO [308136803] 5.2 percent of total billed charges 4.03 6.18 Technical (Hospital) Services BUTALBITAL-ACETAMINOPHEN-CAFFEINE 50 MG-300 MG-40 MG CAPSULE RX-104993 CDM 6370000100 HCPCS 250 RC 70010-0044-01 NDC outpatient 1 UN 6.5 6.5 MEDICA (COMMERCIAL) 94265 [3081118] MEDICA CLAIMS [308111801] 5.85 percent of total billed charges 4.03 6.18 Technical (Hospital) Services BUTALBITAL-ACETAMINOPHEN-CAFFEINE 50 MG-300 MG-40 MG CAPSULE RX-104993 CDM 6370000100 HCPCS 250 RC 70010-0044-01 NDC outpatient 1 UN 6.5 6.5 CIGNA 62308 [3081051] CIGNA 62308 [308105105] 5.2 percent of total billed charges 4.03 6.18 Technical (Hospital) Services BUTALBITAL-ACETAMINOPHEN-CAFFEINE 50 MG-300 MG-40 MG CAPSULE RX-104993 CDM 6370000100 HCPCS 250 RC 70010-0044-01 NDC outpatient 1 UN 6.5 6.5 CIGNA 62308 [3081051] CIGNA STATE OF WYOMING [308105107] 5.2 percent of total billed charges 4.03 6.18 Technical (Hospital) Services BUTALBITAL-ACETAMINOPHEN-CAFFEINE 50 MG-300 MG-40 MG CAPSULE RX-104993 CDM 6370000100 HCPCS 250 RC 70010-0044-01 NDC outpatient 1 UN 6.5 6.5 MULTIPLAN INC 34080 [3081285] MULTIPLAN INC [308128501] 6.18 percent of total billed charges 4.03 6.18 Technical (Hospital) Services BUTALBITAL-ACETAMINOPHEN-CAFFEINE 50 MG-300 MG-40 MG CAPSULE RX-104993 CDM 6370000100 HCPCS 250 RC 70010-0044-01 NDC outpatient 1 UN 6.5 6.5 UNITED HEALTHCARE (COMMERCIAL) [3081199] UNITED HEALTHCARE 87726 [308119901] 4.03 percent of total billed charges 4.03 6.18 Technical (Hospital) Services BUTALBITAL-ACETAMINOPHEN-CAFFEINE 50 MG-300 MG-40 MG CAPSULE RX-104993 CDM 6370000100 HCPCS 250 RC 70010-0044-01 NDC inpatient 1 UN 6.5 6.5 BLUE CROSS BLUE SHIELD WELLMARK SB889 [3081026] BCBS WYOMING [308102603] 6.18 percent of total billed charges 4.03 6.18 Technical (Hospital) Services BUTALBITAL-ACETAMINOPHEN-CAFFEINE 50 MG-300 MG-40 MG CAPSULE RX-104993 CDM 6370000100 HCPCS 250 RC 70010-0044-01 NDC inpatient 1 UN 6.5 6.5 UNITED HEALTHCARE (COMMERCIAL) [3081199] UNITED HEALTHCARE 87726 [308119901] 4.03 percent of total billed charges 4.03 6.18 Technical (Hospital) Services BUTALBITAL-ACETAMINOPHEN-CAFFEINE 50 MG-300 MG-40 MG CAPSULE RX-104993 CDM 6370000100 HCPCS 250 RC 70010-0044-01 NDC inpatient 1 UN 6.5 6.5 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES HDHP [308136802] 5.15 percent of total billed charges 4.03 6.18 Technical (Hospital) Services BUTALBITAL-ACETAMINOPHEN-CAFFEINE 50 MG-300 MG-40 MG CAPSULE RX-104993 CDM 6370000100 HCPCS 250 RC 70010-0044-01 NDC inpatient 1 UN 6.5 6.5 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES EPO [308136803] 5.15 percent of total billed charges 4.03 6.18 Technical (Hospital) Services BUTALBITAL-ACETAMINOPHEN-CAFFEINE 50 MG-300 MG-40 MG CAPSULE RX-104993 CDM 6370000100 HCPCS 250 RC 70010-0044-01 NDC inpatient 1 UN 6.5 6.5 CIGNA 62308 [3081051] CIGNA 62308 [308105105] 5.15 percent of total billed charges 4.03 6.18 Technical (Hospital) Services BUTALBITAL-ACETAMINOPHEN-CAFFEINE 50 MG-300 MG-40 MG CAPSULE RX-104993 CDM 6370000100 HCPCS 250 RC 70010-0044-01 NDC inpatient 1 UN 6.5 6.5 CIGNA 62308 [3081051] CIGNA STATE OF WYOMING [308105107] 5.15 percent of total billed charges 4.03 6.18 Technical (Hospital) Services BUTALBITAL-ACETAMINOPHEN-CAFFEINE 50 MG-300 MG-40 MG CAPSULE RX-104993 CDM 6370000100 HCPCS 250 RC 70010-0044-01 NDC inpatient 1 UN 6.5 6.5 HEALTHPARTNERS SX009 HEALTHPARTNERS 5.15 percent of total billed charges 4.03 6.18 Technical (Hospital) Services BUTALBITAL-ACETAMINOPHEN-CAFFEINE 50 MG-300 MG-40 MG CAPSULE RX-104993 CDM 6370000100 HCPCS 250 RC 70010-0044-01 NDC inpatient 1 UN 6.5 6.5 MEDICA (COMMERCIAL) 94265 [3081118] MEDICA CLAIMS [308111801] 5.85 percent of total billed charges 4.03 6.18 Technical (Hospital) Services BUTALBITAL-ACETAMINOPHEN-CAFFEINE 50 MG-300 MG-40 MG CAPSULE RX-104993 CDM 6370000100 HCPCS 250 RC 70010-0044-01 NDC inpatient 1 UN 6.5 6.5 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES PPO [308136801] 5.15 percent of total billed charges 4.03 6.18 Technical (Hospital) Services BUTALBITAL-ACETAMINOPHEN-CAFFEINE 50 MG-300 MG-40 MG CAPSULE RX-104993 CDM 6370000100 HCPCS 250 RC 70010-0044-01 NDC inpatient 1 UN 6.5 6.5 MULTIPLAN INC 34080 [3081285] MULTIPLAN INC [308128501] 6.18 percent of total billed charges 4.03 6.18 Technical (Hospital) Services METFORMIN 500 MG TABLET RX-10544 CDM 6370000100 HCPCS 250 RC 23155-0102-01 NDC inpatient 1 UN 5.66 5.66 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES HDHP [308136802] 4.48 percent of total billed charges 3.51 5.38 Technical (Hospital) Services METFORMIN 500 MG TABLET RX-10544 CDM 6370000100 HCPCS 250 RC 23155-0102-01 NDC inpatient 1 UN 5.66 5.66 CIGNA 62308 [3081051] CIGNA 62308 [308105105] 4.48 percent of total billed charges 3.51 5.38 Technical (Hospital) Services METFORMIN 500 MG TABLET RX-10544 CDM 6370000100 HCPCS 250 RC 23155-0102-01 NDC inpatient 1 UN 5.66 5.66 CIGNA 62308 [3081051] CIGNA STATE OF WYOMING [308105107] 4.48 percent of total billed charges 3.51 5.38 Technical (Hospital) Services METFORMIN 500 MG TABLET RX-10544 CDM 6370000100 HCPCS 250 RC 23155-0102-01 NDC inpatient 1 UN 5.66 5.66 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES EPO [308136803] 4.48 percent of total billed charges 3.51 5.38 Technical (Hospital) Services METFORMIN 500 MG TABLET RX-10544 CDM 6370000100 HCPCS 250 RC 23155-0102-01 NDC inpatient 1 UN 5.66 5.66 BLUE CROSS BLUE SHIELD WELLMARK SB889 [3081026] BCBS WYOMING [308102603] 5.38 percent of total billed charges 3.51 5.38 Technical (Hospital) Services METFORMIN 500 MG TABLET RX-10544 CDM 6370000100 HCPCS 250 RC 23155-0102-01 NDC inpatient 1 UN 5.66 5.66 UNITED HEALTHCARE (COMMERCIAL) [3081199] UNITED HEALTHCARE 87726 [308119901] 3.51 percent of total billed charges 3.51 5.38 Technical (Hospital) Services METFORMIN 500 MG TABLET RX-10544 CDM 6370000100 HCPCS 250 RC 23155-0102-01 NDC inpatient 1 UN 5.66 5.66 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES PPO [308136801] 4.48 percent of total billed charges 3.51 5.38 Technical (Hospital) Services METFORMIN 500 MG TABLET RX-10544 CDM 6370000100 HCPCS 250 RC 23155-0102-01 NDC inpatient 1 UN 5.66 5.66 HEALTHPARTNERS SX009 HEALTHPARTNERS 4.48 percent of total billed charges 3.51 5.38 Technical (Hospital) Services METFORMIN 500 MG TABLET RX-10544 CDM 6370000100 HCPCS 250 RC 23155-0102-01 NDC inpatient 1 UN 5.66 5.66 MEDICA (COMMERCIAL) 94265 [3081118] MEDICA CLAIMS [308111801] 5.09 percent of total billed charges 3.51 5.38 Technical (Hospital) Services METFORMIN 500 MG TABLET RX-10544 CDM 6370000100 HCPCS 250 RC 23155-0102-01 NDC inpatient 1 UN 5.66 5.66 MULTIPLAN INC 34080 [3081285] MULTIPLAN INC [308128501] 5.38 percent of total billed charges 3.51 5.38 Technical (Hospital) Services METFORMIN 500 MG TABLET RX-10544 CDM 6370000100 HCPCS 250 RC 23155-0102-01 NDC outpatient 1 UN 5.66 5.66 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES HDHP [308136802] 4.53 percent of total billed charges 3.51 5.38 Technical (Hospital) Services METFORMIN 500 MG TABLET RX-10544 CDM 6370000100 HCPCS 250 RC 23155-0102-01 NDC outpatient 1 UN 5.66 5.66 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES PPO [308136801] 4.53 percent of total billed charges 3.51 5.38 Technical (Hospital) Services METFORMIN 500 MG TABLET RX-10544 CDM 6370000100 HCPCS 250 RC 23155-0102-01 NDC outpatient 1 UN 5.66 5.66 HEALTHPARTNERS SX009 HEALTHPARTNERS 4.53 percent of total billed charges 3.51 5.38 Technical (Hospital) Services METFORMIN 500 MG TABLET RX-10544 CDM 6370000100 HCPCS 250 RC 23155-0102-01 NDC outpatient 1 UN 5.66 5.66 BLUE CROSS BLUE SHIELD WELLMARK SB889 [3081026] BCBS WYOMING [308102603] 5.38 percent of total billed charges 3.51 5.38 Technical (Hospital) Services METFORMIN 500 MG TABLET RX-10544 CDM 6370000100 HCPCS 250 RC 23155-0102-01 NDC outpatient 1 UN 5.66 5.66 CIGNA 62308 [3081051] CIGNA 62308 [308105105] 4.53 percent of total billed charges 3.51 5.38 Technical (Hospital) Services METFORMIN 500 MG TABLET RX-10544 CDM 6370000100 HCPCS 250 RC 23155-0102-01 NDC outpatient 1 UN 5.66 5.66 CIGNA 62308 [3081051] CIGNA STATE OF WYOMING [308105107] 4.53 percent of total billed charges 3.51 5.38 Technical (Hospital) Services METFORMIN 500 MG TABLET RX-10544 CDM 6370000100 HCPCS 250 RC 23155-0102-01 NDC outpatient 1 UN 5.66 5.66 MULTIPLAN INC 34080 [3081285] MULTIPLAN INC [308128501] 5.38 percent of total billed charges 3.51 5.38 Technical (Hospital) Services METFORMIN 500 MG TABLET RX-10544 CDM 6370000100 HCPCS 250 RC 23155-0102-01 NDC outpatient 1 UN 5.66 5.66 UNITED HEALTHCARE (COMMERCIAL) [3081199] UNITED HEALTHCARE 87726 [308119901] 3.51 percent of total billed charges 3.51 5.38 Technical (Hospital) Services METFORMIN 500 MG TABLET RX-10544 CDM 6370000100 HCPCS 250 RC 23155-0102-01 NDC outpatient 1 UN 5.66 5.66 MEDICA (COMMERCIAL) 94265 [3081118] MEDICA CLAIMS [308111801] 5.09 percent of total billed charges 3.51 5.38 Technical (Hospital) Services METFORMIN 500 MG TABLET RX-10544 CDM 6370000100 HCPCS 250 RC 23155-0102-01 NDC outpatient 1 UN 5.66 5.66 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES EPO [308136803] 4.53 percent of total billed charges 3.51 5.38 Technical (Hospital) Services METHIMAZOLE 5 MG TABLET RX-10553 CDM 6370000100 HCPCS 250 RC 23155-0070-01 NDC inpatient 1 UN 5.77 5.77 MULTIPLAN INC 34080 [3081285] MULTIPLAN INC [308128501] 5.48 percent of total billed charges 3.58 5.48 Technical (Hospital) Services METHIMAZOLE 5 MG TABLET RX-10553 CDM 6370000100 HCPCS 250 RC 23155-0070-01 NDC inpatient 1 UN 5.77 5.77 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES PPO [308136801] 4.57 percent of total billed charges 3.58 5.48 Technical (Hospital) Services METHIMAZOLE 5 MG TABLET RX-10553 CDM 6370000100 HCPCS 250 RC 23155-0070-01 NDC inpatient 1 UN 5.77 5.77 HEALTHPARTNERS SX009 HEALTHPARTNERS 4.57 percent of total billed charges 3.58 5.48 Technical (Hospital) Services METHIMAZOLE 5 MG TABLET RX-10553 CDM 6370000100 HCPCS 250 RC 23155-0070-01 NDC inpatient 1 UN 5.77 5.77 MEDICA (COMMERCIAL) 94265 [3081118] MEDICA CLAIMS [308111801] 5.19 percent of total billed charges 3.58 5.48 Technical (Hospital) Services METHIMAZOLE 5 MG TABLET RX-10553 CDM 6370000100 HCPCS 250 RC 23155-0070-01 NDC inpatient 1 UN 5.77 5.77 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES HDHP [308136802] 4.57 percent of total billed charges 3.58 5.48 Technical (Hospital) Services METHIMAZOLE 5 MG TABLET RX-10553 CDM 6370000100 HCPCS 250 RC 23155-0070-01 NDC inpatient 1 UN 5.77 5.77 CIGNA 62308 [3081051] CIGNA 62308 [308105105] 4.57 percent of total billed charges 3.58 5.48 Technical (Hospital) Services METHIMAZOLE 5 MG TABLET RX-10553 CDM 6370000100 HCPCS 250 RC 23155-0070-01 NDC inpatient 1 UN 5.77 5.77 CIGNA 62308 [3081051] CIGNA STATE OF WYOMING [308105107] 4.57 percent of total billed charges 3.58 5.48 Technical (Hospital) Services METHIMAZOLE 5 MG TABLET RX-10553 CDM 6370000100 HCPCS 250 RC 23155-0070-01 NDC inpatient 1 UN 5.77 5.77 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES EPO [308136803] 4.57 percent of total billed charges 3.58 5.48 Technical (Hospital) Services METHIMAZOLE 5 MG TABLET RX-10553 CDM 6370000100 HCPCS 250 RC 23155-0070-01 NDC inpatient 1 UN 5.77 5.77 UNITED HEALTHCARE (COMMERCIAL) [3081199] UNITED HEALTHCARE 87726 [308119901] 3.58 percent of total billed charges 3.58 5.48 Technical (Hospital) Services METHIMAZOLE 5 MG TABLET RX-10553 CDM 6370000100 HCPCS 250 RC 23155-0070-01 NDC inpatient 1 UN 5.77 5.77 BLUE CROSS BLUE SHIELD WELLMARK SB889 [3081026] BCBS WYOMING [308102603] 5.48 percent of total billed charges 3.58 5.48 Technical (Hospital) Services METHIMAZOLE 5 MG TABLET RX-10553 CDM 6370000100 HCPCS 250 RC 23155-0070-01 NDC outpatient 1 UN 5.77 5.77 BLUE CROSS BLUE SHIELD WELLMARK SB889 [3081026] BCBS WYOMING [308102603] 5.48 percent of total billed charges 3.58 5.48 Technical (Hospital) Services METHIMAZOLE 5 MG TABLET RX-10553 CDM 6370000100 HCPCS 250 RC 23155-0070-01 NDC outpatient 1 UN 5.77 5.77 UNITED HEALTHCARE (COMMERCIAL) [3081199] UNITED HEALTHCARE 87726 [308119901] 3.58 percent of total billed charges 3.58 5.48 Technical (Hospital) Services METHIMAZOLE 5 MG TABLET RX-10553 CDM 6370000100 HCPCS 250 RC 23155-0070-01 NDC outpatient 1 UN 5.77 5.77 HEALTHPARTNERS SX009 HEALTHPARTNERS 4.62 percent of total billed charges 3.58 5.48 Technical (Hospital) Services METHIMAZOLE 5 MG TABLET RX-10553 CDM 6370000100 HCPCS 250 RC 23155-0070-01 NDC outpatient 1 UN 5.77 5.77 MULTIPLAN INC 34080 [3081285] MULTIPLAN INC [308128501] 5.48 percent of total billed charges 3.58 5.48 Technical (Hospital) Services METHIMAZOLE 5 MG TABLET RX-10553 CDM 6370000100 HCPCS 250 RC 23155-0070-01 NDC outpatient 1 UN 5.77 5.77 CIGNA 62308 [3081051] CIGNA 62308 [308105105] 4.62 percent of total billed charges 3.58 5.48 Technical (Hospital) Services METHIMAZOLE 5 MG TABLET RX-10553 CDM 6370000100 HCPCS 250 RC 23155-0070-01 NDC outpatient 1 UN 5.77 5.77 CIGNA 62308 [3081051] CIGNA STATE OF WYOMING [308105107] 4.62 percent of total billed charges 3.58 5.48 Technical (Hospital) Services METHIMAZOLE 5 MG TABLET RX-10553 CDM 6370000100 HCPCS 250 RC 23155-0070-01 NDC outpatient 1 UN 5.77 5.77 MEDICA (COMMERCIAL) 94265 [3081118] MEDICA CLAIMS [308111801] 5.19 percent of total billed charges 3.58 5.48 Technical (Hospital) Services METHIMAZOLE 5 MG TABLET RX-10553 CDM 6370000100 HCPCS 250 RC 23155-0070-01 NDC outpatient 1 UN 5.77 5.77 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES EPO [308136803] 4.62 percent of total billed charges 3.58 5.48 Technical (Hospital) Services METHIMAZOLE 5 MG TABLET RX-10553 CDM 6370000100 HCPCS 250 RC 23155-0070-01 NDC outpatient 1 UN 5.77 5.77 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES HDHP [308136802] 4.62 percent of total billed charges 3.58 5.48 Technical (Hospital) Services METHIMAZOLE 5 MG TABLET RX-10553 CDM 6370000100 HCPCS 250 RC 23155-0070-01 NDC outpatient 1 UN 5.77 5.77 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES PPO [308136801] 4.62 percent of total billed charges 3.58 5.48 Technical (Hospital) Services METOLAZONE 2.5 MG TABLET RX-10587 CDM 6370000100 HCPCS 250 RC 00378-6172-01 NDC inpatient 1 UN 7.42 7.42 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES PPO [308136801] 5.88 percent of total billed charges 4.6 7.05 Technical (Hospital) Services METOLAZONE 2.5 MG TABLET RX-10587 CDM 6370000100 HCPCS 250 RC 00378-6172-01 NDC inpatient 1 UN 7.42 7.42 MULTIPLAN INC 34080 [3081285] MULTIPLAN INC [308128501] 7.05 percent of total billed charges 4.6 7.05 Technical (Hospital) Services METOLAZONE 2.5 MG TABLET RX-10587 CDM 6370000100 HCPCS 250 RC 00378-6172-01 NDC inpatient 1 UN 7.42 7.42 UNITED HEALTHCARE (COMMERCIAL) [3081199] UNITED HEALTHCARE 87726 [308119901] 4.6 percent of total billed charges 4.6 7.05 Technical (Hospital) Services METOLAZONE 2.5 MG TABLET RX-10587 CDM 6370000100 HCPCS 250 RC 00378-6172-01 NDC inpatient 1 UN 7.42 7.42 BLUE CROSS BLUE SHIELD WELLMARK SB889 [3081026] BCBS WYOMING [308102603] 7.05 percent of total billed charges 4.6 7.05 Technical (Hospital) Services METOLAZONE 2.5 MG TABLET RX-10587 CDM 6370000100 HCPCS 250 RC 00378-6172-01 NDC inpatient 1 UN 7.42 7.42 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES HDHP [308136802] 5.88 percent of total billed charges 4.6 7.05 Technical (Hospital) Services METOLAZONE 2.5 MG TABLET RX-10587 CDM 6370000100 HCPCS 250 RC 00378-6172-01 NDC inpatient 1 UN 7.42 7.42 HEALTHPARTNERS SX009 HEALTHPARTNERS 5.88 percent of total billed charges 4.6 7.05 Technical (Hospital) Services METOLAZONE 2.5 MG TABLET RX-10587 CDM 6370000100 HCPCS 250 RC 00378-6172-01 NDC inpatient 1 UN 7.42 7.42 MEDICA (COMMERCIAL) 94265 [3081118] MEDICA CLAIMS [308111801] 6.68 percent of total billed charges 4.6 7.05 Technical (Hospital) Services METOLAZONE 2.5 MG TABLET RX-10587 CDM 6370000100 HCPCS 250 RC 00378-6172-01 NDC inpatient 1 UN 7.42 7.42 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES EPO [308136803] 5.88 percent of total billed charges 4.6 7.05 Technical (Hospital) Services METOLAZONE 2.5 MG TABLET RX-10587 CDM 6370000100 HCPCS 250 RC 00378-6172-01 NDC inpatient 1 UN 7.42 7.42 CIGNA 62308 [3081051] CIGNA 62308 [308105105] 5.88 percent of total billed charges 4.6 7.05 Technical (Hospital) Services METOLAZONE 2.5 MG TABLET RX-10587 CDM 6370000100 HCPCS 250 RC 00378-6172-01 NDC inpatient 1 UN 7.42 7.42 CIGNA 62308 [3081051] CIGNA STATE OF WYOMING [308105107] 5.88 percent of total billed charges 4.6 7.05 Technical (Hospital) Services METOLAZONE 2.5 MG TABLET RX-10587 CDM 6370000100 HCPCS 250 RC 00378-6172-01 NDC outpatient 1 UN 7.42 7.42 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES HDHP [308136802] 5.94 percent of total billed charges 4.6 7.05 Technical (Hospital) Services METOLAZONE 2.5 MG TABLET RX-10587 CDM 6370000100 HCPCS 250 RC 00378-6172-01 NDC outpatient 1 UN 7.42 7.42 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES PPO [308136801] 5.94 percent of total billed charges 4.6 7.05 Technical (Hospital) Services METOLAZONE 2.5 MG TABLET RX-10587 CDM 6370000100 HCPCS 250 RC 00378-6172-01 NDC outpatient 1 UN 7.42 7.42 BLUE CROSS BLUE SHIELD WELLMARK SB889 [3081026] BCBS WYOMING [308102603] 7.05 percent of total billed charges 4.6 7.05 Technical (Hospital) Services METOLAZONE 2.5 MG TABLET RX-10587 CDM 6370000100 HCPCS 250 RC 00378-6172-01 NDC outpatient 1 UN 7.42 7.42 HEALTHPARTNERS SX009 HEALTHPARTNERS 5.94 percent of total billed charges 4.6 7.05 Technical (Hospital) Services METOLAZONE 2.5 MG TABLET RX-10587 CDM 6370000100 HCPCS 250 RC 00378-6172-01 NDC outpatient 1 UN 7.42 7.42 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES EPO [308136803] 5.94 percent of total billed charges 4.6 7.05 Technical (Hospital) Services METOLAZONE 2.5 MG TABLET RX-10587 CDM 6370000100 HCPCS 250 RC 00378-6172-01 NDC outpatient 1 UN 7.42 7.42 MEDICA (COMMERCIAL) 94265 [3081118] MEDICA CLAIMS [308111801] 6.68 percent of total billed charges 4.6 7.05 Technical (Hospital) Services METOLAZONE 2.5 MG TABLET RX-10587 CDM 6370000100 HCPCS 250 RC 00378-6172-01 NDC outpatient 1 UN 7.42 7.42 MULTIPLAN INC 34080 [3081285] MULTIPLAN INC [308128501] 7.05 percent of total billed charges 4.6 7.05 Technical (Hospital) Services METOLAZONE 2.5 MG TABLET RX-10587 CDM 6370000100 HCPCS 250 RC 00378-6172-01 NDC outpatient 1 UN 7.42 7.42 CIGNA 62308 [3081051] CIGNA 62308 [308105105] 5.94 percent of total billed charges 4.6 7.05 Technical (Hospital) Services METOLAZONE 2.5 MG TABLET RX-10587 CDM 6370000100 HCPCS 250 RC 00378-6172-01 NDC outpatient 1 UN 7.42 7.42 CIGNA 62308 [3081051] CIGNA STATE OF WYOMING [308105107] 5.94 percent of total billed charges 4.6 7.05 Technical (Hospital) Services METOLAZONE 2.5 MG TABLET RX-10587 CDM 6370000100 HCPCS 250 RC 00378-6172-01 NDC outpatient 1 UN 7.42 7.42 UNITED HEALTHCARE (COMMERCIAL) [3081199] UNITED HEALTHCARE 87726 [308119901] 4.6 percent of total billed charges 4.6 7.05 Technical (Hospital) Services MIDODRINE 5 MG TABLET RX-10610 CDM 6370000100 HCPCS 250 RC 60505-1321-01 NDC outpatient 1 UN 6.35 6.35 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES PPO [308136801] 5.08 percent of total billed charges 3.94 6.03 Technical (Hospital) Services MIDODRINE 5 MG TABLET RX-10610 CDM 6370000100 HCPCS 250 RC 60505-1321-01 NDC outpatient 1 UN 6.35 6.35 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES HDHP [308136802] 5.08 percent of total billed charges 3.94 6.03 Technical (Hospital) Services MIDODRINE 5 MG TABLET RX-10610 CDM 6370000100 HCPCS 250 RC 60505-1321-01 NDC outpatient 1 UN 6.35 6.35 UNITED HEALTHCARE (COMMERCIAL) [3081199] UNITED HEALTHCARE 87726 [308119901] 3.94 percent of total billed charges 3.94 6.03 Technical (Hospital) Services MIDODRINE 5 MG TABLET RX-10610 CDM 6370000100 HCPCS 250 RC 60505-1321-01 NDC outpatient 1 UN 6.35 6.35 MULTIPLAN INC 34080 [3081285] MULTIPLAN INC [308128501] 6.03 percent of total billed charges 3.94 6.03 Technical (Hospital) Services MIDODRINE 5 MG TABLET RX-10610 CDM 6370000100 HCPCS 250 RC 60505-1321-01 NDC outpatient 1 UN 6.35 6.35 CIGNA 62308 [3081051] CIGNA 62308 [308105105] 5.08 percent of total billed charges 3.94 6.03 Technical (Hospital) Services MIDODRINE 5 MG TABLET RX-10610 CDM 6370000100 HCPCS 250 RC 60505-1321-01 NDC outpatient 1 UN 6.35 6.35 CIGNA 62308 [3081051] CIGNA STATE OF WYOMING [308105107] 5.08 percent of total billed charges 3.94 6.03 Technical (Hospital) Services MIDODRINE 5 MG TABLET RX-10610 CDM 6370000100 HCPCS 250 RC 60505-1321-01 NDC outpatient 1 UN 6.35 6.35 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES EPO [308136803] 5.08 percent of total billed charges 3.94 6.03 Technical (Hospital) Services MIDODRINE 5 MG TABLET RX-10610 CDM 6370000100 HCPCS 250 RC 60505-1321-01 NDC outpatient 1 UN 6.35 6.35 MEDICA (COMMERCIAL) 94265 [3081118] MEDICA CLAIMS [308111801] 5.72 percent of total billed charges 3.94 6.03 Technical (Hospital) Services MIDODRINE 5 MG TABLET RX-10610 CDM 6370000100 HCPCS 250 RC 60505-1321-01 NDC outpatient 1 UN 6.35 6.35 BLUE CROSS BLUE SHIELD WELLMARK SB889 [3081026] BCBS WYOMING [308102603] 6.03 percent of total billed charges 3.94 6.03 Technical (Hospital) Services MIDODRINE 5 MG TABLET RX-10610 CDM 6370000100 HCPCS 250 RC 60505-1321-01 NDC outpatient 1 UN 6.35 6.35 HEALTHPARTNERS SX009 HEALTHPARTNERS 5.08 percent of total billed charges 3.94 6.03 Technical (Hospital) Services MIDODRINE 5 MG TABLET RX-10610 CDM 6370000100 HCPCS 250 RC 60505-1321-01 NDC inpatient 1 UN 6.35 6.35 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES HDHP [308136802] 5.03 percent of total billed charges 3.94 6.03 Technical (Hospital) Services MIDODRINE 5 MG TABLET RX-10610 CDM 6370000100 HCPCS 250 RC 60505-1321-01 NDC inpatient 1 UN 6.35 6.35 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES EPO [308136803] 5.03 percent of total billed charges 3.94 6.03 Technical (Hospital) Services MIDODRINE 5 MG TABLET RX-10610 CDM 6370000100 HCPCS 250 RC 60505-1321-01 NDC inpatient 1 UN 6.35 6.35 CIGNA 62308 [3081051] CIGNA 62308 [308105105] 5.03 percent of total billed charges 3.94 6.03 Technical (Hospital) Services MIDODRINE 5 MG TABLET RX-10610 CDM 6370000100 HCPCS 250 RC 60505-1321-01 NDC inpatient 1 UN 6.35 6.35 CIGNA 62308 [3081051] CIGNA STATE OF WYOMING [308105107] 5.03 percent of total billed charges 3.94 6.03 Technical (Hospital) Services MIDODRINE 5 MG TABLET RX-10610 CDM 6370000100 HCPCS 250 RC 60505-1321-01 NDC inpatient 1 UN 6.35 6.35 UNITED HEALTHCARE (COMMERCIAL) [3081199] UNITED HEALTHCARE 87726 [308119901] 3.94 percent of total billed charges 3.94 6.03 Technical (Hospital) Services MIDODRINE 5 MG TABLET RX-10610 CDM 6370000100 HCPCS 250 RC 60505-1321-01 NDC inpatient 1 UN 6.35 6.35 BLUE CROSS BLUE SHIELD WELLMARK SB889 [3081026] BCBS WYOMING [308102603] 6.03 percent of total billed charges 3.94 6.03 Technical (Hospital) Services MIDODRINE 5 MG TABLET RX-10610 CDM 6370000100 HCPCS 250 RC 60505-1321-01 NDC inpatient 1 UN 6.35 6.35 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES PPO [308136801] 5.03 percent of total billed charges 3.94 6.03 Technical (Hospital) Services MIDODRINE 5 MG TABLET RX-10610 CDM 6370000100 HCPCS 250 RC 60505-1321-01 NDC inpatient 1 UN 6.35 6.35 MEDICA (COMMERCIAL) 94265 [3081118] MEDICA CLAIMS [308111801] 5.72 percent of total billed charges 3.94 6.03 Technical (Hospital) Services MIDODRINE 5 MG TABLET RX-10610 CDM 6370000100 HCPCS 250 RC 60505-1321-01 NDC inpatient 1 UN 6.35 6.35 HEALTHPARTNERS SX009 HEALTHPARTNERS 5.03 percent of total billed charges 3.94 6.03 Technical (Hospital) Services MIDODRINE 5 MG TABLET RX-10610 CDM 6370000100 HCPCS 250 RC 60505-1321-01 NDC inpatient 1 UN 6.35 6.35 MULTIPLAN INC 34080 [3081285] MULTIPLAN INC [308128501] 6.03 percent of total billed charges 3.94 6.03 Technical (Hospital) Services "NEOMYCIN 3.5 MG/G-POLYMYXIN B 10,000 UNIT/G-DEXAMETH 0.1 % EYE OINT" RX-106249 CDM 6370000100 HCPCS 250 RC 00574-4160-35 NDC outpatient 4 GR 107.76 107.76 MEDICA (COMMERCIAL) 94265 [3081118] MEDICA CLAIMS [308111801] 96.98 percent of total billed charges 66.81 102.37 Technical (Hospital) Services "NEOMYCIN 3.5 MG/G-POLYMYXIN B 10,000 UNIT/G-DEXAMETH 0.1 % EYE OINT" RX-106249 CDM 6370000100 HCPCS 250 RC 00574-4160-35 NDC outpatient 4 GR 107.76 107.76 MULTIPLAN INC 34080 [3081285] MULTIPLAN INC [308128501] 102.37 percent of total billed charges 66.81 102.37 Technical (Hospital) Services "NEOMYCIN 3.5 MG/G-POLYMYXIN B 10,000 UNIT/G-DEXAMETH 0.1 % EYE OINT" RX-106249 CDM 6370000100 HCPCS 250 RC 00574-4160-35 NDC outpatient 4 GR 107.76 107.76 HEALTHPARTNERS SX009 HEALTHPARTNERS 86.21 percent of total billed charges 66.81 102.37 Technical (Hospital) Services "NEOMYCIN 3.5 MG/G-POLYMYXIN B 10,000 UNIT/G-DEXAMETH 0.1 % EYE OINT" RX-106249 CDM 6370000100 HCPCS 250 RC 00574-4160-35 NDC outpatient 4 GR 107.76 107.76 UNITED HEALTHCARE (COMMERCIAL) [3081199] UNITED HEALTHCARE 87726 [308119901] 66.81 percent of total billed charges 66.81 102.37 Technical (Hospital) Services "NEOMYCIN 3.5 MG/G-POLYMYXIN B 10,000 UNIT/G-DEXAMETH 0.1 % EYE OINT" RX-106249 CDM 6370000100 HCPCS 250 RC 00574-4160-35 NDC outpatient 4 GR 107.76 107.76 CIGNA 62308 [3081051] CIGNA 62308 [308105105] 86.21 percent of total billed charges 66.81 102.37 Technical (Hospital) Services "NEOMYCIN 3.5 MG/G-POLYMYXIN B 10,000 UNIT/G-DEXAMETH 0.1 % EYE OINT" RX-106249 CDM 6370000100 HCPCS 250 RC 00574-4160-35 NDC outpatient 4 GR 107.76 107.76 CIGNA 62308 [3081051] CIGNA STATE OF WYOMING [308105107] 86.21 percent of total billed charges 66.81 102.37 Technical (Hospital) Services "NEOMYCIN 3.5 MG/G-POLYMYXIN B 10,000 UNIT/G-DEXAMETH 0.1 % EYE OINT" RX-106249 CDM 6370000100 HCPCS 250 RC 00574-4160-35 NDC outpatient 4 GR 107.76 107.76 BLUE CROSS BLUE SHIELD WELLMARK SB889 [3081026] BCBS WYOMING [308102603] 102.37 percent of total billed charges 66.81 102.37 Technical (Hospital) Services "NEOMYCIN 3.5 MG/G-POLYMYXIN B 10,000 UNIT/G-DEXAMETH 0.1 % EYE OINT" RX-106249 CDM 6370000100 HCPCS 250 RC 00574-4160-35 NDC outpatient 4 GR 107.76 107.76 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES HDHP [308136802] 86.21 percent of total billed charges 66.81 102.37 Technical (Hospital) Services "NEOMYCIN 3.5 MG/G-POLYMYXIN B 10,000 UNIT/G-DEXAMETH 0.1 % EYE OINT" RX-106249 CDM 6370000100 HCPCS 250 RC 00574-4160-35 NDC outpatient 4 GR 107.76 107.76 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES EPO [308136803] 86.21 percent of total billed charges 66.81 102.37 Technical (Hospital) Services "NEOMYCIN 3.5 MG/G-POLYMYXIN B 10,000 UNIT/G-DEXAMETH 0.1 % EYE OINT" RX-106249 CDM 6370000100 HCPCS 250 RC 00574-4160-35 NDC inpatient 4 GR 107.76 107.76 BLUE CROSS BLUE SHIELD WELLMARK SB889 [3081026] BCBS WYOMING [308102603] 102.37 percent of total billed charges 66.81 102.37 Technical (Hospital) Services "NEOMYCIN 3.5 MG/G-POLYMYXIN B 10,000 UNIT/G-DEXAMETH 0.1 % EYE OINT" RX-106249 CDM 6370000100 HCPCS 250 RC 00574-4160-35 NDC inpatient 4 GR 107.76 107.76 CIGNA 62308 [3081051] CIGNA 62308 [308105105] 85.32 percent of total billed charges 66.81 102.37 Technical (Hospital) Services "NEOMYCIN 3.5 MG/G-POLYMYXIN B 10,000 UNIT/G-DEXAMETH 0.1 % EYE OINT" RX-106249 CDM 6370000100 HCPCS 250 RC 00574-4160-35 NDC inpatient 4 GR 107.76 107.76 CIGNA 62308 [3081051] CIGNA STATE OF WYOMING [308105107] 85.32 percent of total billed charges 66.81 102.37 Technical (Hospital) Services "NEOMYCIN 3.5 MG/G-POLYMYXIN B 10,000 UNIT/G-DEXAMETH 0.1 % EYE OINT" RX-106249 CDM 6370000100 HCPCS 250 RC 00574-4160-35 NDC inpatient 4 GR 107.76 107.76 UNITED HEALTHCARE (COMMERCIAL) [3081199] UNITED HEALTHCARE 87726 [308119901] 66.81 percent of total billed charges 66.81 102.37 Technical (Hospital) Services "NEOMYCIN 3.5 MG/G-POLYMYXIN B 10,000 UNIT/G-DEXAMETH 0.1 % EYE OINT" RX-106249 CDM 6370000100 HCPCS 250 RC 00574-4160-35 NDC inpatient 4 GR 107.76 107.76 MEDICA (COMMERCIAL) 94265 [3081118] MEDICA CLAIMS [308111801] 96.98 percent of total billed charges 66.81 102.37 Technical (Hospital) Services "NEOMYCIN 3.5 MG/G-POLYMYXIN B 10,000 UNIT/G-DEXAMETH 0.1 % EYE OINT" RX-106249 CDM 6370000100 HCPCS 250 RC 00574-4160-35 NDC inpatient 4 GR 107.76 107.76 MULTIPLAN INC 34080 [3081285] MULTIPLAN INC [308128501] 102.37 percent of total billed charges 66.81 102.37 Technical (Hospital) Services "NEOMYCIN 3.5 MG/G-POLYMYXIN B 10,000 UNIT/G-DEXAMETH 0.1 % EYE OINT" RX-106249 CDM 6370000100 HCPCS 250 RC 00574-4160-35 NDC inpatient 4 GR 107.76 107.76 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES EPO [308136803] 85.32 percent of total billed charges 66.81 102.37 Technical (Hospital) Services "NEOMYCIN 3.5 MG/G-POLYMYXIN B 10,000 UNIT/G-DEXAMETH 0.1 % EYE OINT" RX-106249 CDM 6370000100 HCPCS 250 RC 00574-4160-35 NDC inpatient 4 GR 107.76 107.76 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES PPO [308136801] 85.32 percent of total billed charges 66.81 102.37 Technical (Hospital) Services "NEOMYCIN 3.5 MG/G-POLYMYXIN B 10,000 UNIT/G-DEXAMETH 0.1 % EYE OINT" RX-106249 CDM 6370000100 HCPCS 250 RC 00574-4160-35 NDC outpatient 4 GR 107.76 107.76 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES PPO [308136801] 86.21 percent of total billed charges 66.81 102.37 Technical (Hospital) Services "NEOMYCIN 3.5 MG/G-POLYMYXIN B 10,000 UNIT/G-DEXAMETH 0.1 % EYE OINT" RX-106249 CDM 6370000100 HCPCS 250 RC 00574-4160-35 NDC inpatient 4 GR 107.76 107.76 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES HDHP [308136802] 85.32 percent of total billed charges 66.81 102.37 Technical (Hospital) Services "NEOMYCIN 3.5 MG/G-POLYMYXIN B 10,000 UNIT/G-DEXAMETH 0.1 % EYE OINT" RX-106249 CDM 6370000100 HCPCS 250 RC 00574-4160-35 NDC inpatient 4 GR 107.76 107.76 HEALTHPARTNERS SX009 HEALTHPARTNERS 85.32 percent of total billed charges 66.81 102.37 Technical (Hospital) Services HYDROCODONE 10 MG-CHLORPHENIRAMINE 8 MG/5 ML ORAL SUSP EXTEND.REL 12HR RX-106413 CDM 6370000100 HCPCS 250 RC 27808-0086-01 NDC inpatient 2.5 ML 6.85 6.85 MULTIPLAN INC 34080 [3081285] MULTIPLAN INC [308128501] 6.51 percent of total billed charges 4.25 6.51 Technical (Hospital) Services HYDROCODONE 10 MG-CHLORPHENIRAMINE 8 MG/5 ML ORAL SUSP EXTEND.REL 12HR RX-106413 CDM 6370000100 HCPCS 250 RC 27808-0086-01 NDC inpatient 2.5 ML 6.85 6.85 MEDICA (COMMERCIAL) 94265 [3081118] MEDICA CLAIMS [308111801] 6.17 percent of total billed charges 4.25 6.51 Technical (Hospital) Services HYDROCODONE 10 MG-CHLORPHENIRAMINE 8 MG/5 ML ORAL SUSP EXTEND.REL 12HR RX-106413 CDM 6370000100 HCPCS 250 RC 27808-0086-01 NDC inpatient 2.5 ML 6.85 6.85 UNITED HEALTHCARE (COMMERCIAL) [3081199] UNITED HEALTHCARE 87726 [308119901] 4.25 percent of total billed charges 4.25 6.51 Technical (Hospital) Services HYDROCODONE 10 MG-CHLORPHENIRAMINE 8 MG/5 ML ORAL SUSP EXTEND.REL 12HR RX-106413 CDM 6370000100 HCPCS 250 RC 27808-0086-01 NDC inpatient 2.5 ML 6.85 6.85 BLUE CROSS BLUE SHIELD WELLMARK SB889 [3081026] BCBS WYOMING [308102603] 6.51 percent of total billed charges 4.25 6.51 Technical (Hospital) Services HYDROCODONE 10 MG-CHLORPHENIRAMINE 8 MG/5 ML ORAL SUSP EXTEND.REL 12HR RX-106413 CDM 6370000100 HCPCS 250 RC 27808-0086-01 NDC inpatient 2.5 ML 6.85 6.85 CIGNA 62308 [3081051] CIGNA 62308 [308105105] 5.42 percent of total billed charges 4.25 6.51 Technical (Hospital) Services HYDROCODONE 10 MG-CHLORPHENIRAMINE 8 MG/5 ML ORAL SUSP EXTEND.REL 12HR RX-106413 CDM 6370000100 HCPCS 250 RC 27808-0086-01 NDC inpatient 2.5 ML 6.85 6.85 CIGNA 62308 [3081051] CIGNA STATE OF WYOMING [308105107] 5.42 percent of total billed charges 4.25 6.51 Technical (Hospital) Services HYDROCODONE 10 MG-CHLORPHENIRAMINE 8 MG/5 ML ORAL SUSP EXTEND.REL 12HR RX-106413 CDM 6370000100 HCPCS 250 RC 27808-0086-01 NDC inpatient 2.5 ML 6.85 6.85 HEALTHPARTNERS SX009 HEALTHPARTNERS 5.42 percent of total billed charges 4.25 6.51 Technical (Hospital) Services HYDROCODONE 10 MG-CHLORPHENIRAMINE 8 MG/5 ML ORAL SUSP EXTEND.REL 12HR RX-106413 CDM 6370000100 HCPCS 250 RC 27808-0086-01 NDC inpatient 2.5 ML 6.85 6.85 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES EPO [308136803] 5.42 percent of total billed charges 4.25 6.51 Technical (Hospital) Services HYDROCODONE 10 MG-CHLORPHENIRAMINE 8 MG/5 ML ORAL SUSP EXTEND.REL 12HR RX-106413 CDM 6370000100 HCPCS 250 RC 27808-0086-01 NDC inpatient 2.5 ML 6.85 6.85 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES HDHP [308136802] 5.42 percent of total billed charges 4.25 6.51 Technical (Hospital) Services HYDROCODONE 10 MG-CHLORPHENIRAMINE 8 MG/5 ML ORAL SUSP EXTEND.REL 12HR RX-106413 CDM 6370000100 HCPCS 250 RC 27808-0086-01 NDC inpatient 2.5 ML 6.85 6.85 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES PPO [308136801] 5.42 percent of total billed charges 4.25 6.51 Technical (Hospital) Services HYDROCODONE 10 MG-CHLORPHENIRAMINE 8 MG/5 ML ORAL SUSP EXTEND.REL 12HR RX-106413 CDM 6370000100 HCPCS 250 RC 27808-0086-01 NDC outpatient 2.5 ML 6.85 6.85 MEDICA (COMMERCIAL) 94265 [3081118] MEDICA CLAIMS [308111801] 6.17 percent of total billed charges 4.25 6.51 Technical (Hospital) Services HYDROCODONE 10 MG-CHLORPHENIRAMINE 8 MG/5 ML ORAL SUSP EXTEND.REL 12HR RX-106413 CDM 6370000100 HCPCS 250 RC 27808-0086-01 NDC outpatient 2.5 ML 6.85 6.85 MULTIPLAN INC 34080 [3081285] MULTIPLAN INC [308128501] 6.51 percent of total billed charges 4.25 6.51 Technical (Hospital) Services HYDROCODONE 10 MG-CHLORPHENIRAMINE 8 MG/5 ML ORAL SUSP EXTEND.REL 12HR RX-106413 CDM 6370000100 HCPCS 250 RC 27808-0086-01 NDC outpatient 2.5 ML 6.85 6.85 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES EPO [308136803] 5.48 percent of total billed charges 4.25 6.51 Technical (Hospital) Services HYDROCODONE 10 MG-CHLORPHENIRAMINE 8 MG/5 ML ORAL SUSP EXTEND.REL 12HR RX-106413 CDM 6370000100 HCPCS 250 RC 27808-0086-01 NDC outpatient 2.5 ML 6.85 6.85 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES HDHP [308136802] 5.48 percent of total billed charges 4.25 6.51 Technical (Hospital) Services HYDROCODONE 10 MG-CHLORPHENIRAMINE 8 MG/5 ML ORAL SUSP EXTEND.REL 12HR RX-106413 CDM 6370000100 HCPCS 250 RC 27808-0086-01 NDC outpatient 2.5 ML 6.85 6.85 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES PPO [308136801] 5.48 percent of total billed charges 4.25 6.51 Technical (Hospital) Services HYDROCODONE 10 MG-CHLORPHENIRAMINE 8 MG/5 ML ORAL SUSP EXTEND.REL 12HR RX-106413 CDM 6370000100 HCPCS 250 RC 27808-0086-01 NDC outpatient 2.5 ML 6.85 6.85 BLUE CROSS BLUE SHIELD WELLMARK SB889 [3081026] BCBS WYOMING [308102603] 6.51 percent of total billed charges 4.25 6.51 Technical (Hospital) Services HYDROCODONE 10 MG-CHLORPHENIRAMINE 8 MG/5 ML ORAL SUSP EXTEND.REL 12HR RX-106413 CDM 6370000100 HCPCS 250 RC 27808-0086-01 NDC outpatient 2.5 ML 6.85 6.85 CIGNA 62308 [3081051] CIGNA 62308 [308105105] 5.48 percent of total billed charges 4.25 6.51 Technical (Hospital) Services HYDROCODONE 10 MG-CHLORPHENIRAMINE 8 MG/5 ML ORAL SUSP EXTEND.REL 12HR RX-106413 CDM 6370000100 HCPCS 250 RC 27808-0086-01 NDC outpatient 2.5 ML 6.85 6.85 CIGNA 62308 [3081051] CIGNA STATE OF WYOMING [308105107] 5.48 percent of total billed charges 4.25 6.51 Technical (Hospital) Services HYDROCODONE 10 MG-CHLORPHENIRAMINE 8 MG/5 ML ORAL SUSP EXTEND.REL 12HR RX-106413 CDM 6370000100 HCPCS 250 RC 27808-0086-01 NDC outpatient 2.5 ML 6.85 6.85 HEALTHPARTNERS SX009 HEALTHPARTNERS 5.48 percent of total billed charges 4.25 6.51 Technical (Hospital) Services HYDROCODONE 10 MG-CHLORPHENIRAMINE 8 MG/5 ML ORAL SUSP EXTEND.REL 12HR RX-106413 CDM 6370000100 HCPCS 250 RC 27808-0086-01 NDC outpatient 2.5 ML 6.85 6.85 UNITED HEALTHCARE (COMMERCIAL) [3081199] UNITED HEALTHCARE 87726 [308119901] 4.25 percent of total billed charges 4.25 6.51 Technical (Hospital) Services DABIGATRAN ETEXILATE 75 MG CAPSULE RX-106490 CDM 6370000100 HCPCS 250 RC 00597-0355-56 NDC outpatient 1 UN 15.31 15.31 MEDICA (COMMERCIAL) 94265 [3081118] MEDICA CLAIMS [308111801] 13.78 percent of total billed charges 9.49 14.54 Technical (Hospital) Services DABIGATRAN ETEXILATE 75 MG CAPSULE RX-106490 CDM 6370000100 HCPCS 250 RC 00597-0355-56 NDC outpatient 1 UN 15.31 15.31 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES EPO [308136803] 12.25 percent of total billed charges 9.49 14.54 Technical (Hospital) Services DABIGATRAN ETEXILATE 75 MG CAPSULE RX-106490 CDM 6370000100 HCPCS 250 RC 00597-0355-56 NDC outpatient 1 UN 15.31 15.31 CIGNA 62308 [3081051] CIGNA 62308 [308105105] 12.25 percent of total billed charges 9.49 14.54 Technical (Hospital) Services DABIGATRAN ETEXILATE 75 MG CAPSULE RX-106490 CDM 6370000100 HCPCS 250 RC 00597-0355-56 NDC outpatient 1 UN 15.31 15.31 CIGNA 62308 [3081051] CIGNA STATE OF WYOMING [308105107] 12.25 percent of total billed charges 9.49 14.54 Technical (Hospital) Services DABIGATRAN ETEXILATE 75 MG CAPSULE RX-106490 CDM 6370000100 HCPCS 250 RC 00597-0355-56 NDC outpatient 1 UN 15.31 15.31 UNITED HEALTHCARE (COMMERCIAL) [3081199] UNITED HEALTHCARE 87726 [308119901] 9.49 percent of total billed charges 9.49 14.54 Technical (Hospital) Services DABIGATRAN ETEXILATE 75 MG CAPSULE RX-106490 CDM 6370000100 HCPCS 250 RC 00597-0355-56 NDC outpatient 1 UN 15.31 15.31 MULTIPLAN INC 34080 [3081285] MULTIPLAN INC [308128501] 14.54 percent of total billed charges 9.49 14.54 Technical (Hospital) Services DABIGATRAN ETEXILATE 75 MG CAPSULE RX-106490 CDM 6370000100 HCPCS 250 RC 00597-0355-56 NDC outpatient 1 UN 15.31 15.31 BLUE CROSS BLUE SHIELD WELLMARK SB889 [3081026] BCBS WYOMING [308102603] 14.54 percent of total billed charges 9.49 14.54 Technical (Hospital) Services DABIGATRAN ETEXILATE 75 MG CAPSULE RX-106490 CDM 6370000100 HCPCS 250 RC 00597-0355-56 NDC outpatient 1 UN 15.31 15.31 HEALTHPARTNERS SX009 HEALTHPARTNERS 12.25 percent of total billed charges 9.49 14.54 Technical (Hospital) Services DABIGATRAN ETEXILATE 75 MG CAPSULE RX-106490 CDM 6370000100 HCPCS 250 RC 00597-0355-56 NDC outpatient 1 UN 15.31 15.31 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES HDHP [308136802] 12.25 percent of total billed charges 9.49 14.54 Technical (Hospital) Services DABIGATRAN ETEXILATE 75 MG CAPSULE RX-106490 CDM 6370000100 HCPCS 250 RC 00597-0355-56 NDC outpatient 1 UN 15.31 15.31 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES PPO [308136801] 12.25 percent of total billed charges 9.49 14.54 Technical (Hospital) Services DABIGATRAN ETEXILATE 75 MG CAPSULE RX-106490 CDM 6370000100 HCPCS 250 RC 00597-0355-56 NDC inpatient 1 UN 15.31 15.31 MULTIPLAN INC 34080 [3081285] MULTIPLAN INC [308128501] 14.54 percent of total billed charges 9.49 14.54 Technical (Hospital) Services DABIGATRAN ETEXILATE 75 MG CAPSULE RX-106490 CDM 6370000100 HCPCS 250 RC 00597-0355-56 NDC inpatient 1 UN 15.31 15.31 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES PPO [308136801] 12.12 percent of total billed charges 9.49 14.54 Technical (Hospital) Services DABIGATRAN ETEXILATE 75 MG CAPSULE RX-106490 CDM 6370000100 HCPCS 250 RC 00597-0355-56 NDC inpatient 1 UN 15.31 15.31 HEALTHPARTNERS SX009 HEALTHPARTNERS 12.12 percent of total billed charges 9.49 14.54 Technical (Hospital) Services DABIGATRAN ETEXILATE 75 MG CAPSULE RX-106490 CDM 6370000100 HCPCS 250 RC 00597-0355-56 NDC inpatient 1 UN 15.31 15.31 MEDICA (COMMERCIAL) 94265 [3081118] MEDICA CLAIMS [308111801] 13.78 percent of total billed charges 9.49 14.54 Technical (Hospital) Services DABIGATRAN ETEXILATE 75 MG CAPSULE RX-106490 CDM 6370000100 HCPCS 250 RC 00597-0355-56 NDC inpatient 1 UN 15.31 15.31 CIGNA 62308 [3081051] CIGNA 62308 [308105105] 12.12 percent of total billed charges 9.49 14.54 Technical (Hospital) Services DABIGATRAN ETEXILATE 75 MG CAPSULE RX-106490 CDM 6370000100 HCPCS 250 RC 00597-0355-56 NDC inpatient 1 UN 15.31 15.31 CIGNA 62308 [3081051] CIGNA STATE OF WYOMING [308105107] 12.12 percent of total billed charges 9.49 14.54 Technical (Hospital) Services DABIGATRAN ETEXILATE 75 MG CAPSULE RX-106490 CDM 6370000100 HCPCS 250 RC 00597-0355-56 NDC inpatient 1 UN 15.31 15.31 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES HDHP [308136802] 12.12 percent of total billed charges 9.49 14.54 Technical (Hospital) Services DABIGATRAN ETEXILATE 75 MG CAPSULE RX-106490 CDM 6370000100 HCPCS 250 RC 00597-0355-56 NDC inpatient 1 UN 15.31 15.31 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES EPO [308136803] 12.12 percent of total billed charges 9.49 14.54 Technical (Hospital) Services DABIGATRAN ETEXILATE 75 MG CAPSULE RX-106490 CDM 6370000100 HCPCS 250 RC 00597-0355-56 NDC inpatient 1 UN 15.31 15.31 UNITED HEALTHCARE (COMMERCIAL) [3081199] UNITED HEALTHCARE 87726 [308119901] 9.49 percent of total billed charges 9.49 14.54 Technical (Hospital) Services DABIGATRAN ETEXILATE 75 MG CAPSULE RX-106490 CDM 6370000100 HCPCS 250 RC 00597-0355-56 NDC inpatient 1 UN 15.31 15.31 BLUE CROSS BLUE SHIELD WELLMARK SB889 [3081026] BCBS WYOMING [308102603] 14.54 percent of total billed charges 9.49 14.54 Technical (Hospital) Services MUPIROCIN 2 % TOPICAL OINTMENT RX-10674 CDM 6370000100 HCPCS 250 RC 45802-0112-22 NDC inpatient 22 GR 37.4 37.4 MULTIPLAN INC 34080 [3081285] MULTIPLAN INC [308128501] 35.53 percent of total billed charges 23.19 35.53 Technical (Hospital) Services MUPIROCIN 2 % TOPICAL OINTMENT RX-10674 CDM 6370000100 HCPCS 250 RC 45802-0112-22 NDC inpatient 22 GR 37.4 37.4 MEDICA (COMMERCIAL) 94265 [3081118] MEDICA CLAIMS [308111801] 33.66 percent of total billed charges 23.19 35.53 Technical (Hospital) Services MUPIROCIN 2 % TOPICAL OINTMENT RX-10674 CDM 6370000100 HCPCS 250 RC 45802-0112-22 NDC inpatient 22 GR 37.4 37.4 UNITED HEALTHCARE (COMMERCIAL) [3081199] UNITED HEALTHCARE 87726 [308119901] 23.19 percent of total billed charges 23.19 35.53 Technical (Hospital) Services MUPIROCIN 2 % TOPICAL OINTMENT RX-10674 CDM 6370000100 HCPCS 250 RC 45802-0112-22 NDC inpatient 22 GR 37.4 37.4 BLUE CROSS BLUE SHIELD WELLMARK SB889 [3081026] BCBS WYOMING [308102603] 35.53 percent of total billed charges 23.19 35.53 Technical (Hospital) Services MUPIROCIN 2 % TOPICAL OINTMENT RX-10674 CDM 6370000100 HCPCS 250 RC 45802-0112-22 NDC inpatient 22 GR 37.4 37.4 CIGNA 62308 [3081051] CIGNA 62308 [308105105] 29.61 percent of total billed charges 23.19 35.53 Technical (Hospital) Services MUPIROCIN 2 % TOPICAL OINTMENT RX-10674 CDM 6370000100 HCPCS 250 RC 45802-0112-22 NDC inpatient 22 GR 37.4 37.4 CIGNA 62308 [3081051] CIGNA STATE OF WYOMING [308105107] 29.61 percent of total billed charges 23.19 35.53 Technical (Hospital) Services MUPIROCIN 2 % TOPICAL OINTMENT RX-10674 CDM 6370000100 HCPCS 250 RC 45802-0112-22 NDC inpatient 22 GR 37.4 37.4 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES EPO [308136803] 29.61 percent of total billed charges 23.19 35.53 Technical (Hospital) Services MUPIROCIN 2 % TOPICAL OINTMENT RX-10674 CDM 6370000100 HCPCS 250 RC 45802-0112-22 NDC inpatient 22 GR 37.4 37.4 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES HDHP [308136802] 29.61 percent of total billed charges 23.19 35.53 Technical (Hospital) Services MUPIROCIN 2 % TOPICAL OINTMENT RX-10674 CDM 6370000100 HCPCS 250 RC 45802-0112-22 NDC inpatient 22 GR 37.4 37.4 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES PPO [308136801] 29.61 percent of total billed charges 23.19 35.53 Technical (Hospital) Services MUPIROCIN 2 % TOPICAL OINTMENT RX-10674 CDM 6370000100 HCPCS 250 RC 45802-0112-22 NDC inpatient 22 GR 37.4 37.4 HEALTHPARTNERS SX009 HEALTHPARTNERS 29.61 percent of total billed charges 23.19 35.53 Technical (Hospital) Services MUPIROCIN 2 % TOPICAL OINTMENT RX-10674 CDM 6370000100 HCPCS 250 RC 45802-0112-22 NDC outpatient 22 GR 37.4 37.4 CIGNA 62308 [3081051] CIGNA 62308 [308105105] 29.92 percent of total billed charges 23.19 35.53 Technical (Hospital) Services MUPIROCIN 2 % TOPICAL OINTMENT RX-10674 CDM 6370000100 HCPCS 250 RC 45802-0112-22 NDC outpatient 22 GR 37.4 37.4 CIGNA 62308 [3081051] CIGNA STATE OF WYOMING [308105107] 29.92 percent of total billed charges 23.19 35.53 Technical (Hospital) Services MUPIROCIN 2 % TOPICAL OINTMENT RX-10674 CDM 6370000100 HCPCS 250 RC 45802-0112-22 NDC outpatient 22 GR 37.4 37.4 HEALTHPARTNERS SX009 HEALTHPARTNERS 29.92 percent of total billed charges 23.19 35.53 Technical (Hospital) Services MUPIROCIN 2 % TOPICAL OINTMENT RX-10674 CDM 6370000100 HCPCS 250 RC 45802-0112-22 NDC outpatient 22 GR 37.4 37.4 UNITED HEALTHCARE (COMMERCIAL) [3081199] UNITED HEALTHCARE 87726 [308119901] 23.19 percent of total billed charges 23.19 35.53 Technical (Hospital) Services MUPIROCIN 2 % TOPICAL OINTMENT RX-10674 CDM 6370000100 HCPCS 250 RC 45802-0112-22 NDC outpatient 22 GR 37.4 37.4 MULTIPLAN INC 34080 [3081285] MULTIPLAN INC [308128501] 35.53 percent of total billed charges 23.19 35.53 Technical (Hospital) Services MUPIROCIN 2 % TOPICAL OINTMENT RX-10674 CDM 6370000100 HCPCS 250 RC 45802-0112-22 NDC outpatient 22 GR 37.4 37.4 MEDICA (COMMERCIAL) 94265 [3081118] MEDICA CLAIMS [308111801] 33.66 percent of total billed charges 23.19 35.53 Technical (Hospital) Services MUPIROCIN 2 % TOPICAL OINTMENT RX-10674 CDM 6370000100 HCPCS 250 RC 45802-0112-22 NDC outpatient 22 GR 37.4 37.4 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES EPO [308136803] 29.92 percent of total billed charges 23.19 35.53 Technical (Hospital) Services MUPIROCIN 2 % TOPICAL OINTMENT RX-10674 CDM 6370000100 HCPCS 250 RC 45802-0112-22 NDC outpatient 22 GR 37.4 37.4 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES HDHP [308136802] 29.92 percent of total billed charges 23.19 35.53 Technical (Hospital) Services MUPIROCIN 2 % TOPICAL OINTMENT RX-10674 CDM 6370000100 HCPCS 250 RC 45802-0112-22 NDC outpatient 22 GR 37.4 37.4 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES PPO [308136801] 29.92 percent of total billed charges 23.19 35.53 Technical (Hospital) Services MUPIROCIN 2 % TOPICAL OINTMENT RX-10674 CDM 6370000100 HCPCS 250 RC 45802-0112-22 NDC outpatient 22 GR 37.4 37.4 BLUE CROSS BLUE SHIELD WELLMARK SB889 [3081026] BCBS WYOMING [308102603] 35.53 percent of total billed charges 23.19 35.53 Technical (Hospital) Services NITROFURANTOIN MONOHYDRATE/MACROCRYSTALS 100 MG CAPSULE RX-10724 CDM 6370000100 HCPCS 250 RC 00185-0122-01 NDC outpatient 1 UN 6.12 6.12 MEDICA (COMMERCIAL) 94265 [3081118] MEDICA CLAIMS [308111801] 5.51 percent of total billed charges 3.79 5.81 Technical (Hospital) Services NITROFURANTOIN MONOHYDRATE/MACROCRYSTALS 100 MG CAPSULE RX-10724 CDM 6370000100 HCPCS 250 RC 00185-0122-01 NDC outpatient 1 UN 6.12 6.12 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES EPO [308136803] 4.9 percent of total billed charges 3.79 5.81 Technical (Hospital) Services NITROFURANTOIN MONOHYDRATE/MACROCRYSTALS 100 MG CAPSULE RX-10724 CDM 6370000100 HCPCS 250 RC 00185-0122-01 NDC outpatient 1 UN 6.12 6.12 CIGNA 62308 [3081051] CIGNA 62308 [308105105] 4.9 percent of total billed charges 3.79 5.81 Technical (Hospital) Services NITROFURANTOIN MONOHYDRATE/MACROCRYSTALS 100 MG CAPSULE RX-10724 CDM 6370000100 HCPCS 250 RC 00185-0122-01 NDC outpatient 1 UN 6.12 6.12 CIGNA 62308 [3081051] CIGNA STATE OF WYOMING [308105107] 4.9 percent of total billed charges 3.79 5.81 Technical (Hospital) Services NITROFURANTOIN MONOHYDRATE/MACROCRYSTALS 100 MG CAPSULE RX-10724 CDM 6370000100 HCPCS 250 RC 00185-0122-01 NDC outpatient 1 UN 6.12 6.12 MULTIPLAN INC 34080 [3081285] MULTIPLAN INC [308128501] 5.81 percent of total billed charges 3.79 5.81 Technical (Hospital) Services NITROFURANTOIN MONOHYDRATE/MACROCRYSTALS 100 MG CAPSULE RX-10724 CDM 6370000100 HCPCS 250 RC 00185-0122-01 NDC outpatient 1 UN 6.12 6.12 UNITED HEALTHCARE (COMMERCIAL) [3081199] UNITED HEALTHCARE 87726 [308119901] 3.79 percent of total billed charges 3.79 5.81 Technical (Hospital) Services NITROFURANTOIN MONOHYDRATE/MACROCRYSTALS 100 MG CAPSULE RX-10724 CDM 6370000100 HCPCS 250 RC 00185-0122-01 NDC outpatient 1 UN 6.12 6.12 HEALTHPARTNERS SX009 HEALTHPARTNERS 4.9 percent of total billed charges 3.79 5.81 Technical (Hospital) Services NITROFURANTOIN MONOHYDRATE/MACROCRYSTALS 100 MG CAPSULE RX-10724 CDM 6370000100 HCPCS 250 RC 00185-0122-01 NDC outpatient 1 UN 6.12 6.12 BLUE CROSS BLUE SHIELD WELLMARK SB889 [3081026] BCBS WYOMING [308102603] 5.81 percent of total billed charges 3.79 5.81 Technical (Hospital) Services NITROFURANTOIN MONOHYDRATE/MACROCRYSTALS 100 MG CAPSULE RX-10724 CDM 6370000100 HCPCS 250 RC 00185-0122-01 NDC outpatient 1 UN 6.12 6.12 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES PPO [308136801] 4.9 percent of total billed charges 3.79 5.81 Technical (Hospital) Services NITROFURANTOIN MONOHYDRATE/MACROCRYSTALS 100 MG CAPSULE RX-10724 CDM 6370000100 HCPCS 250 RC 00185-0122-01 NDC outpatient 1 UN 6.12 6.12 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES HDHP [308136802] 4.9 percent of total billed charges 3.79 5.81 Technical (Hospital) Services NITROFURANTOIN MONOHYDRATE/MACROCRYSTALS 100 MG CAPSULE RX-10724 CDM 6370000100 HCPCS 250 RC 00185-0122-01 NDC inpatient 1 UN 6.12 6.12 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES PPO [308136801] 4.85 percent of total billed charges 3.79 5.81 Technical (Hospital) Services NITROFURANTOIN MONOHYDRATE/MACROCRYSTALS 100 MG CAPSULE RX-10724 CDM 6370000100 HCPCS 250 RC 00185-0122-01 NDC inpatient 1 UN 6.12 6.12 HEALTHPARTNERS SX009 HEALTHPARTNERS 4.85 percent of total billed charges 3.79 5.81 Technical (Hospital) Services NITROFURANTOIN MONOHYDRATE/MACROCRYSTALS 100 MG CAPSULE RX-10724 CDM 6370000100 HCPCS 250 RC 00185-0122-01 NDC inpatient 1 UN 6.12 6.12 MEDICA (COMMERCIAL) 94265 [3081118] MEDICA CLAIMS [308111801] 5.51 percent of total billed charges 3.79 5.81 Technical (Hospital) Services NITROFURANTOIN MONOHYDRATE/MACROCRYSTALS 100 MG CAPSULE RX-10724 CDM 6370000100 HCPCS 250 RC 00185-0122-01 NDC inpatient 1 UN 6.12 6.12 MULTIPLAN INC 34080 [3081285] MULTIPLAN INC [308128501] 5.81 percent of total billed charges 3.79 5.81 Technical (Hospital) Services NITROFURANTOIN MONOHYDRATE/MACROCRYSTALS 100 MG CAPSULE RX-10724 CDM 6370000100 HCPCS 250 RC 00185-0122-01 NDC inpatient 1 UN 6.12 6.12 BLUE CROSS BLUE SHIELD WELLMARK SB889 [3081026] BCBS WYOMING [308102603] 5.81 percent of total billed charges 3.79 5.81 Technical (Hospital) Services NITROFURANTOIN MONOHYDRATE/MACROCRYSTALS 100 MG CAPSULE RX-10724 CDM 6370000100 HCPCS 250 RC 00185-0122-01 NDC inpatient 1 UN 6.12 6.12 UNITED HEALTHCARE (COMMERCIAL) [3081199] UNITED HEALTHCARE 87726 [308119901] 3.79 percent of total billed charges 3.79 5.81 Technical (Hospital) Services NITROFURANTOIN MONOHYDRATE/MACROCRYSTALS 100 MG CAPSULE RX-10724 CDM 6370000100 HCPCS 250 RC 00185-0122-01 NDC inpatient 1 UN 6.12 6.12 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES HDHP [308136802] 4.85 percent of total billed charges 3.79 5.81 Technical (Hospital) Services NITROFURANTOIN MONOHYDRATE/MACROCRYSTALS 100 MG CAPSULE RX-10724 CDM 6370000100 HCPCS 250 RC 00185-0122-01 NDC inpatient 1 UN 6.12 6.12 CIGNA 62308 [3081051] CIGNA 62308 [308105105] 4.85 percent of total billed charges 3.79 5.81 Technical (Hospital) Services NITROFURANTOIN MONOHYDRATE/MACROCRYSTALS 100 MG CAPSULE RX-10724 CDM 6370000100 HCPCS 250 RC 00185-0122-01 NDC inpatient 1 UN 6.12 6.12 CIGNA 62308 [3081051] CIGNA STATE OF WYOMING [308105107] 4.85 percent of total billed charges 3.79 5.81 Technical (Hospital) Services NITROFURANTOIN MONOHYDRATE/MACROCRYSTALS 100 MG CAPSULE RX-10724 CDM 6370000100 HCPCS 250 RC 00185-0122-01 NDC inpatient 1 UN 6.12 6.12 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES EPO [308136803] 4.85 percent of total billed charges 3.79 5.81 Technical (Hospital) Services "OMEGA-3 FATTY ACIDS-FISH OIL 300 MG-1,000 MG CAPSULE" RX-10774 CDM 6370000100 HCPCS 250 RC 40985-0228-72 NDC inpatient 1 UN 5.67 5.67 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES EPO [308136803] 4.49 percent of total billed charges 3.52 5.39 Technical (Hospital) Services "OMEGA-3 FATTY ACIDS-FISH OIL 300 MG-1,000 MG CAPSULE" RX-10774 CDM 6370000100 HCPCS 250 RC 40985-0228-72 NDC inpatient 1 UN 5.67 5.67 CIGNA 62308 [3081051] CIGNA 62308 [308105105] 4.49 percent of total billed charges 3.52 5.39 Technical (Hospital) Services "OMEGA-3 FATTY ACIDS-FISH OIL 300 MG-1,000 MG CAPSULE" RX-10774 CDM 6370000100 HCPCS 250 RC 40985-0228-72 NDC inpatient 1 UN 5.67 5.67 CIGNA 62308 [3081051] CIGNA STATE OF WYOMING [308105107] 4.49 percent of total billed charges 3.52 5.39 Technical (Hospital) Services "OMEGA-3 FATTY ACIDS-FISH OIL 300 MG-1,000 MG CAPSULE" RX-10774 CDM 6370000100 HCPCS 250 RC 40985-0228-72 NDC inpatient 1 UN 5.67 5.67 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES HDHP [308136802] 4.49 percent of total billed charges 3.52 5.39 Technical (Hospital) Services "OMEGA-3 FATTY ACIDS-FISH OIL 300 MG-1,000 MG CAPSULE" RX-10774 CDM 6370000100 HCPCS 250 RC 40985-0228-72 NDC inpatient 1 UN 5.67 5.67 UNITED HEALTHCARE (COMMERCIAL) [3081199] UNITED HEALTHCARE 87726 [308119901] 3.52 percent of total billed charges 3.52 5.39 Technical (Hospital) Services "OMEGA-3 FATTY ACIDS-FISH OIL 300 MG-1,000 MG CAPSULE" RX-10774 CDM 6370000100 HCPCS 250 RC 40985-0228-72 NDC inpatient 1 UN 5.67 5.67 BLUE CROSS BLUE SHIELD WELLMARK SB889 [3081026] BCBS WYOMING [308102603] 5.39 percent of total billed charges 3.52 5.39 Technical (Hospital) Services "OMEGA-3 FATTY ACIDS-FISH OIL 300 MG-1,000 MG CAPSULE" RX-10774 CDM 6370000100 HCPCS 250 RC 40985-0228-72 NDC inpatient 1 UN 5.67 5.67 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES PPO [308136801] 4.49 percent of total billed charges 3.52 5.39 Technical (Hospital) Services "OMEGA-3 FATTY ACIDS-FISH OIL 300 MG-1,000 MG CAPSULE" RX-10774 CDM 6370000100 HCPCS 250 RC 40985-0228-72 NDC inpatient 1 UN 5.67 5.67 MEDICA (COMMERCIAL) 94265 [3081118] MEDICA CLAIMS [308111801] 5.1 percent of total billed charges 3.52 5.39 Technical (Hospital) Services "OMEGA-3 FATTY ACIDS-FISH OIL 300 MG-1,000 MG CAPSULE" RX-10774 CDM 6370000100 HCPCS 250 RC 40985-0228-72 NDC inpatient 1 UN 5.67 5.67 HEALTHPARTNERS SX009 HEALTHPARTNERS 4.49 percent of total billed charges 3.52 5.39 Technical (Hospital) Services "OMEGA-3 FATTY ACIDS-FISH OIL 300 MG-1,000 MG CAPSULE" RX-10774 CDM 6370000100 HCPCS 250 RC 40985-0228-72 NDC inpatient 1 UN 5.67 5.67 MULTIPLAN INC 34080 [3081285] MULTIPLAN INC [308128501] 5.39 percent of total billed charges 3.52 5.39 Technical (Hospital) Services "OMEGA-3 FATTY ACIDS-FISH OIL 300 MG-1,000 MG CAPSULE" RX-10774 CDM 6370000100 HCPCS 250 RC 40985-0228-72 NDC outpatient 1 UN 5.67 5.67 HEALTHPARTNERS SX009 HEALTHPARTNERS 4.54 percent of total billed charges 3.52 5.39 Technical (Hospital) Services "OMEGA-3 FATTY ACIDS-FISH OIL 300 MG-1,000 MG CAPSULE" RX-10774 CDM 6370000100 HCPCS 250 RC 40985-0228-72 NDC outpatient 1 UN 5.67 5.67 UNITED HEALTHCARE (COMMERCIAL) [3081199] UNITED HEALTHCARE 87726 [308119901] 3.52 percent of total billed charges 3.52 5.39 Technical (Hospital) Services "OMEGA-3 FATTY ACIDS-FISH OIL 300 MG-1,000 MG CAPSULE" RX-10774 CDM 6370000100 HCPCS 250 RC 40985-0228-72 NDC outpatient 1 UN 5.67 5.67 MULTIPLAN INC 34080 [3081285] MULTIPLAN INC [308128501] 5.39 percent of total billed charges 3.52 5.39 Technical (Hospital) Services "OMEGA-3 FATTY ACIDS-FISH OIL 300 MG-1,000 MG CAPSULE" RX-10774 CDM 6370000100 HCPCS 250 RC 40985-0228-72 NDC outpatient 1 UN 5.67 5.67 CIGNA 62308 [3081051] CIGNA 62308 [308105105] 4.54 percent of total billed charges 3.52 5.39 Technical (Hospital) Services "OMEGA-3 FATTY ACIDS-FISH OIL 300 MG-1,000 MG CAPSULE" RX-10774 CDM 6370000100 HCPCS 250 RC 40985-0228-72 NDC outpatient 1 UN 5.67 5.67 CIGNA 62308 [3081051] CIGNA STATE OF WYOMING [308105107] 4.54 percent of total billed charges 3.52 5.39 Technical (Hospital) Services "OMEGA-3 FATTY ACIDS-FISH OIL 300 MG-1,000 MG CAPSULE" RX-10774 CDM 6370000100 HCPCS 250 RC 40985-0228-72 NDC outpatient 1 UN 5.67 5.67 MEDICA (COMMERCIAL) 94265 [3081118] MEDICA CLAIMS [308111801] 5.1 percent of total billed charges 3.52 5.39 Technical (Hospital) Services "OMEGA-3 FATTY ACIDS-FISH OIL 300 MG-1,000 MG CAPSULE" RX-10774 CDM 6370000100 HCPCS 250 RC 40985-0228-72 NDC outpatient 1 UN 5.67 5.67 BLUE CROSS BLUE SHIELD WELLMARK SB889 [3081026] BCBS WYOMING [308102603] 5.39 percent of total billed charges 3.52 5.39 Technical (Hospital) Services "OMEGA-3 FATTY ACIDS-FISH OIL 300 MG-1,000 MG CAPSULE" RX-10774 CDM 6370000100 HCPCS 250 RC 40985-0228-72 NDC outpatient 1 UN 5.67 5.67 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES HDHP [308136802] 4.54 percent of total billed charges 3.52 5.39 Technical (Hospital) Services "OMEGA-3 FATTY ACIDS-FISH OIL 300 MG-1,000 MG CAPSULE" RX-10774 CDM 6370000100 HCPCS 250 RC 40985-0228-72 NDC outpatient 1 UN 5.67 5.67 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES EPO [308136803] 4.54 percent of total billed charges 3.52 5.39 Technical (Hospital) Services "OMEGA-3 FATTY ACIDS-FISH OIL 300 MG-1,000 MG CAPSULE" RX-10774 CDM 6370000100 HCPCS 250 RC 40985-0228-72 NDC outpatient 1 UN 5.67 5.67 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES PPO [308136801] 4.54 percent of total billed charges 3.52 5.39 Technical (Hospital) Services ELECTROLYTES-DEXTROSE ORAL SOLUTION RX-10784 CDM 6370000100 HCPCS 250 RC 70074-0803-65 NDC outpatient 120 ML 6.22 6.22 CIGNA 62308 [3081051] CIGNA 62308 [308105105] 4.98 percent of total billed charges 3.86 5.91 Technical (Hospital) Services ELECTROLYTES-DEXTROSE ORAL SOLUTION RX-10784 CDM 6370000100 HCPCS 250 RC 70074-0803-65 NDC outpatient 120 ML 6.22 6.22 CIGNA 62308 [3081051] CIGNA STATE OF WYOMING [308105107] 4.98 percent of total billed charges 3.86 5.91 Technical (Hospital) Services ELECTROLYTES-DEXTROSE ORAL SOLUTION RX-10784 CDM 6370000100 HCPCS 250 RC 70074-0803-65 NDC outpatient 120 ML 6.22 6.22 BLUE CROSS BLUE SHIELD WELLMARK SB889 [3081026] BCBS WYOMING [308102603] 5.91 percent of total billed charges 3.86 5.91 Technical (Hospital) Services ELECTROLYTES-DEXTROSE ORAL SOLUTION RX-10784 CDM 6370000100 HCPCS 250 RC 70074-0803-65 NDC outpatient 120 ML 6.22 6.22 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES HDHP [308136802] 4.98 percent of total billed charges 3.86 5.91 Technical (Hospital) Services ELECTROLYTES-DEXTROSE ORAL SOLUTION RX-10784 CDM 6370000100 HCPCS 250 RC 70074-0803-65 NDC outpatient 120 ML 6.22 6.22 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES EPO [308136803] 4.98 percent of total billed charges 3.86 5.91 Technical (Hospital) Services ELECTROLYTES-DEXTROSE ORAL SOLUTION RX-10784 CDM 6370000100 HCPCS 250 RC 70074-0803-65 NDC outpatient 120 ML 6.22 6.22 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES PPO [308136801] 4.98 percent of total billed charges 3.86 5.91 Technical (Hospital) Services ELECTROLYTES-DEXTROSE ORAL SOLUTION RX-10784 CDM 6370000100 HCPCS 250 RC 70074-0803-65 NDC outpatient 120 ML 6.22 6.22 MULTIPLAN INC 34080 [3081285] MULTIPLAN INC [308128501] 5.91 percent of total billed charges 3.86 5.91 Technical (Hospital) Services ELECTROLYTES-DEXTROSE ORAL SOLUTION RX-10784 CDM 6370000100 HCPCS 250 RC 70074-0803-65 NDC outpatient 120 ML 6.22 6.22 MEDICA (COMMERCIAL) 94265 [3081118] MEDICA CLAIMS [308111801] 5.6 percent of total billed charges 3.86 5.91 Technical (Hospital) Services ELECTROLYTES-DEXTROSE ORAL SOLUTION RX-10784 CDM 6370000100 HCPCS 250 RC 70074-0803-65 NDC outpatient 120 ML 6.22 6.22 HEALTHPARTNERS SX009 HEALTHPARTNERS 4.98 percent of total billed charges 3.86 5.91 Technical (Hospital) Services ELECTROLYTES-DEXTROSE ORAL SOLUTION RX-10784 CDM 6370000100 HCPCS 250 RC 70074-0803-65 NDC outpatient 120 ML 6.22 6.22 UNITED HEALTHCARE (COMMERCIAL) [3081199] UNITED HEALTHCARE 87726 [308119901] 3.86 percent of total billed charges 3.86 5.91 Technical (Hospital) Services ELECTROLYTES-DEXTROSE ORAL SOLUTION RX-10784 CDM 6370000100 HCPCS 250 RC 70074-0803-65 NDC inpatient 120 ML 6.22 6.22 MEDICA (COMMERCIAL) 94265 [3081118] MEDICA CLAIMS [308111801] 5.6 percent of total billed charges 3.86 5.91 Technical (Hospital) Services ELECTROLYTES-DEXTROSE ORAL SOLUTION RX-10784 CDM 6370000100 HCPCS 250 RC 70074-0803-65 NDC inpatient 120 ML 6.22 6.22 MULTIPLAN INC 34080 [3081285] MULTIPLAN INC [308128501] 5.91 percent of total billed charges 3.86 5.91 Technical (Hospital) Services ELECTROLYTES-DEXTROSE ORAL SOLUTION RX-10784 CDM 6370000100 HCPCS 250 RC 70074-0803-65 NDC inpatient 120 ML 6.22 6.22 HEALTHPARTNERS SX009 HEALTHPARTNERS 4.92 percent of total billed charges 3.86 5.91 Technical (Hospital) Services ELECTROLYTES-DEXTROSE ORAL SOLUTION RX-10784 CDM 6370000100 HCPCS 250 RC 70074-0803-65 NDC inpatient 120 ML 6.22 6.22 BLUE CROSS BLUE SHIELD WELLMARK SB889 [3081026] BCBS WYOMING [308102603] 5.91 percent of total billed charges 3.86 5.91 Technical (Hospital) Services ELECTROLYTES-DEXTROSE ORAL SOLUTION RX-10784 CDM 6370000100 HCPCS 250 RC 70074-0803-65 NDC inpatient 120 ML 6.22 6.22 UNITED HEALTHCARE (COMMERCIAL) [3081199] UNITED HEALTHCARE 87726 [308119901] 3.86 percent of total billed charges 3.86 5.91 Technical (Hospital) Services ELECTROLYTES-DEXTROSE ORAL SOLUTION RX-10784 CDM 6370000100 HCPCS 250 RC 70074-0803-65 NDC inpatient 120 ML 6.22 6.22 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES PPO [308136801] 4.92 percent of total billed charges 3.86 5.91 Technical (Hospital) Services ELECTROLYTES-DEXTROSE ORAL SOLUTION RX-10784 CDM 6370000100 HCPCS 250 RC 70074-0803-65 NDC inpatient 120 ML 6.22 6.22 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES EPO [308136803] 4.92 percent of total billed charges 3.86 5.91 Technical (Hospital) Services ELECTROLYTES-DEXTROSE ORAL SOLUTION RX-10784 CDM 6370000100 HCPCS 250 RC 70074-0803-65 NDC inpatient 120 ML 6.22 6.22 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES HDHP [308136802] 4.92 percent of total billed charges 3.86 5.91 Technical (Hospital) Services ELECTROLYTES-DEXTROSE ORAL SOLUTION RX-10784 CDM 6370000100 HCPCS 250 RC 70074-0803-65 NDC inpatient 120 ML 6.22 6.22 CIGNA 62308 [3081051] CIGNA 62308 [308105105] 4.92 percent of total billed charges 3.86 5.91 Technical (Hospital) Services ELECTROLYTES-DEXTROSE ORAL SOLUTION RX-10784 CDM 6370000100 HCPCS 250 RC 70074-0803-65 NDC inpatient 120 ML 6.22 6.22 CIGNA 62308 [3081051] CIGNA STATE OF WYOMING [308105107] 4.92 percent of total billed charges 3.86 5.91 Technical (Hospital) Services OXYCODONE 5 MG TABLET RX-10814 CDM 6370000100 HCPCS 250 RC 42806-0005-01 NDC inpatient 1 UN 5.8 5.8 UNITED HEALTHCARE (COMMERCIAL) [3081199] UNITED HEALTHCARE 87726 [308119901] 3.6 percent of total billed charges 3.6 5.51 Technical (Hospital) Services OXYCODONE 5 MG TABLET RX-10814 CDM 6370000100 HCPCS 250 RC 42806-0005-01 NDC inpatient 1 UN 5.8 5.8 BLUE CROSS BLUE SHIELD WELLMARK SB889 [3081026] BCBS WYOMING [308102603] 5.51 percent of total billed charges 3.6 5.51 Technical (Hospital) Services OXYCODONE 5 MG TABLET RX-10814 CDM 6370000100 HCPCS 250 RC 42806-0005-01 NDC inpatient 1 UN 5.8 5.8 HEALTHPARTNERS SX009 HEALTHPARTNERS 4.59 percent of total billed charges 3.6 5.51 Technical (Hospital) Services OXYCODONE 5 MG TABLET RX-10814 CDM 6370000100 HCPCS 250 RC 42806-0005-01 NDC inpatient 1 UN 5.8 5.8 MEDICA (COMMERCIAL) 94265 [3081118] MEDICA CLAIMS [308111801] 5.22 percent of total billed charges 3.6 5.51 Technical (Hospital) Services OXYCODONE 5 MG TABLET RX-10814 CDM 6370000100 HCPCS 250 RC 42806-0005-01 NDC inpatient 1 UN 5.8 5.8 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES EPO [308136803] 4.59 percent of total billed charges 3.6 5.51 Technical (Hospital) Services OXYCODONE 5 MG TABLET RX-10814 CDM 6370000100 HCPCS 250 RC 42806-0005-01 NDC inpatient 1 UN 5.8 5.8 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES HDHP [308136802] 4.59 percent of total billed charges 3.6 5.51 Technical (Hospital) Services OXYCODONE 5 MG TABLET RX-10814 CDM 6370000100 HCPCS 250 RC 42806-0005-01 NDC inpatient 1 UN 5.8 5.8 CIGNA 62308 [3081051] CIGNA 62308 [308105105] 4.59 percent of total billed charges 3.6 5.51 Technical (Hospital) Services OXYCODONE 5 MG TABLET RX-10814 CDM 6370000100 HCPCS 250 RC 42806-0005-01 NDC inpatient 1 UN 5.8 5.8 CIGNA 62308 [3081051] CIGNA STATE OF WYOMING [308105107] 4.59 percent of total billed charges 3.6 5.51 Technical (Hospital) Services OXYCODONE 5 MG TABLET RX-10814 CDM 6370000100 HCPCS 250 RC 42806-0005-01 NDC inpatient 1 UN 5.8 5.8 MULTIPLAN INC 34080 [3081285] MULTIPLAN INC [308128501] 5.51 percent of total billed charges 3.6 5.51 Technical (Hospital) Services OXYCODONE 5 MG TABLET RX-10814 CDM 6370000100 HCPCS 250 RC 42806-0005-01 NDC inpatient 1 UN 5.8 5.8 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES PPO [308136801] 4.59 percent of total billed charges 3.6 5.51 Technical (Hospital) Services OXYCODONE 5 MG TABLET RX-10814 CDM 6370000100 HCPCS 250 RC 42806-0005-01 NDC outpatient 1 UN 5.8 5.8 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES HDHP [308136802] 4.64 percent of total billed charges 3.6 5.51 Technical (Hospital) Services OXYCODONE 5 MG TABLET RX-10814 CDM 6370000100 HCPCS 250 RC 42806-0005-01 NDC outpatient 1 UN 5.8 5.8 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES PPO [308136801] 4.64 percent of total billed charges 3.6 5.51 Technical (Hospital) Services OXYCODONE 5 MG TABLET RX-10814 CDM 6370000100 HCPCS 250 RC 42806-0005-01 NDC outpatient 1 UN 5.8 5.8 CIGNA 62308 [3081051] CIGNA 62308 [308105105] 4.64 percent of total billed charges 3.6 5.51 Technical (Hospital) Services OXYCODONE 5 MG TABLET RX-10814 CDM 6370000100 HCPCS 250 RC 42806-0005-01 NDC outpatient 1 UN 5.8 5.8 CIGNA 62308 [3081051] CIGNA STATE OF WYOMING [308105107] 4.64 percent of total billed charges 3.6 5.51 Technical (Hospital) Services OXYCODONE 5 MG TABLET RX-10814 CDM 6370000100 HCPCS 250 RC 42806-0005-01 NDC outpatient 1 UN 5.8 5.8 MEDICA (COMMERCIAL) 94265 [3081118] MEDICA CLAIMS [308111801] 5.22 percent of total billed charges 3.6 5.51 Technical (Hospital) Services OXYCODONE 5 MG TABLET RX-10814 CDM 6370000100 HCPCS 250 RC 42806-0005-01 NDC outpatient 1 UN 5.8 5.8 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES EPO [308136803] 4.64 percent of total billed charges 3.6 5.51 Technical (Hospital) Services OXYCODONE 5 MG TABLET RX-10814 CDM 6370000100 HCPCS 250 RC 42806-0005-01 NDC outpatient 1 UN 5.8 5.8 UNITED HEALTHCARE (COMMERCIAL) [3081199] UNITED HEALTHCARE 87726 [308119901] 3.6 percent of total billed charges 3.6 5.51 Technical (Hospital) Services OXYCODONE 5 MG TABLET RX-10814 CDM 6370000100 HCPCS 250 RC 42806-0005-01 NDC outpatient 1 UN 5.8 5.8 MULTIPLAN INC 34080 [3081285] MULTIPLAN INC [308128501] 5.51 percent of total billed charges 3.6 5.51 Technical (Hospital) Services OXYCODONE 5 MG TABLET RX-10814 CDM 6370000100 HCPCS 250 RC 42806-0005-01 NDC outpatient 1 UN 5.8 5.8 BLUE CROSS BLUE SHIELD WELLMARK SB889 [3081026] BCBS WYOMING [308102603] 5.51 percent of total billed charges 3.6 5.51 Technical (Hospital) Services OXYCODONE 5 MG TABLET RX-10814 CDM 6370000100 HCPCS 250 RC 42806-0005-01 NDC outpatient 1 UN 5.8 5.8 HEALTHPARTNERS SX009 HEALTHPARTNERS 4.64 percent of total billed charges 3.6 5.51 Technical (Hospital) Services PEG 3350-ELECTROLYTES 236 GRAM-22.74 GRAM-6.74 GRAM-5.86 GRAM SOLUTION RX-10839 CDM 6370000100 HCPCS 250 RC 43386-0090-19 NDC inpatient 4000 ML 106.5 106.5 BLUE CROSS BLUE SHIELD WELLMARK SB889 [3081026] BCBS WYOMING [308102603] 101.18 percent of total billed charges 66.03 101.18 Technical (Hospital) Services PEG 3350-ELECTROLYTES 236 GRAM-22.74 GRAM-6.74 GRAM-5.86 GRAM SOLUTION RX-10839 CDM 6370000100 HCPCS 250 RC 43386-0090-19 NDC inpatient 4000 ML 106.5 106.5 UNITED HEALTHCARE (COMMERCIAL) [3081199] UNITED HEALTHCARE 87726 [308119901] 66.03 percent of total billed charges 66.03 101.18 Technical (Hospital) Services PEG 3350-ELECTROLYTES 236 GRAM-22.74 GRAM-6.74 GRAM-5.86 GRAM SOLUTION RX-10839 CDM 6370000100 HCPCS 250 RC 43386-0090-19 NDC inpatient 4000 ML 106.5 106.5 HEALTHPARTNERS SX009 HEALTHPARTNERS 84.33 percent of total billed charges 66.03 101.18 Technical (Hospital) Services PEG 3350-ELECTROLYTES 236 GRAM-22.74 GRAM-6.74 GRAM-5.86 GRAM SOLUTION RX-10839 CDM 6370000100 HCPCS 250 RC 43386-0090-19 NDC inpatient 4000 ML 106.5 106.5 MULTIPLAN INC 34080 [3081285] MULTIPLAN INC [308128501] 101.18 percent of total billed charges 66.03 101.18 Technical (Hospital) Services PEG 3350-ELECTROLYTES 236 GRAM-22.74 GRAM-6.74 GRAM-5.86 GRAM SOLUTION RX-10839 CDM 6370000100 HCPCS 250 RC 43386-0090-19 NDC inpatient 4000 ML 106.5 106.5 MEDICA (COMMERCIAL) 94265 [3081118] MEDICA CLAIMS [308111801] 95.85 percent of total billed charges 66.03 101.18 Technical (Hospital) Services PEG 3350-ELECTROLYTES 236 GRAM-22.74 GRAM-6.74 GRAM-5.86 GRAM SOLUTION RX-10839 CDM 6370000100 HCPCS 250 RC 43386-0090-19 NDC inpatient 4000 ML 106.5 106.5 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES EPO [308136803] 84.33 percent of total billed charges 66.03 101.18 Technical (Hospital) Services PEG 3350-ELECTROLYTES 236 GRAM-22.74 GRAM-6.74 GRAM-5.86 GRAM SOLUTION RX-10839 CDM 6370000100 HCPCS 250 RC 43386-0090-19 NDC inpatient 4000 ML 106.5 106.5 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES HDHP [308136802] 84.33 percent of total billed charges 66.03 101.18 Technical (Hospital) Services PEG 3350-ELECTROLYTES 236 GRAM-22.74 GRAM-6.74 GRAM-5.86 GRAM SOLUTION RX-10839 CDM 6370000100 HCPCS 250 RC 43386-0090-19 NDC inpatient 4000 ML 106.5 106.5 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES PPO [308136801] 84.33 percent of total billed charges 66.03 101.18 Technical (Hospital) Services PEG 3350-ELECTROLYTES 236 GRAM-22.74 GRAM-6.74 GRAM-5.86 GRAM SOLUTION RX-10839 CDM 6370000100 HCPCS 250 RC 43386-0090-19 NDC inpatient 4000 ML 106.5 106.5 CIGNA 62308 [3081051] CIGNA 62308 [308105105] 84.33 percent of total billed charges 66.03 101.18 Technical (Hospital) Services PEG 3350-ELECTROLYTES 236 GRAM-22.74 GRAM-6.74 GRAM-5.86 GRAM SOLUTION RX-10839 CDM 6370000100 HCPCS 250 RC 43386-0090-19 NDC inpatient 4000 ML 106.5 106.5 CIGNA 62308 [3081051] CIGNA STATE OF WYOMING [308105107] 84.33 percent of total billed charges 66.03 101.18 Technical (Hospital) Services PEG 3350-ELECTROLYTES 236 GRAM-22.74 GRAM-6.74 GRAM-5.86 GRAM SOLUTION RX-10839 CDM 6370000100 HCPCS 250 RC 43386-0090-19 NDC outpatient 4000 ML 106.5 106.5 CIGNA 62308 [3081051] CIGNA 62308 [308105105] 85.2 percent of total billed charges 66.03 101.18 Technical (Hospital) Services PEG 3350-ELECTROLYTES 236 GRAM-22.74 GRAM-6.74 GRAM-5.86 GRAM SOLUTION RX-10839 CDM 6370000100 HCPCS 250 RC 43386-0090-19 NDC outpatient 4000 ML 106.5 106.5 CIGNA 62308 [3081051] CIGNA STATE OF WYOMING [308105107] 85.2 percent of total billed charges 66.03 101.18 Technical (Hospital) Services PEG 3350-ELECTROLYTES 236 GRAM-22.74 GRAM-6.74 GRAM-5.86 GRAM SOLUTION RX-10839 CDM 6370000100 HCPCS 250 RC 43386-0090-19 NDC outpatient 4000 ML 106.5 106.5 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES EPO [308136803] 85.2 percent of total billed charges 66.03 101.18 Technical (Hospital) Services PEG 3350-ELECTROLYTES 236 GRAM-22.74 GRAM-6.74 GRAM-5.86 GRAM SOLUTION RX-10839 CDM 6370000100 HCPCS 250 RC 43386-0090-19 NDC outpatient 4000 ML 106.5 106.5 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES HDHP [308136802] 85.2 percent of total billed charges 66.03 101.18 Technical (Hospital) Services PEG 3350-ELECTROLYTES 236 GRAM-22.74 GRAM-6.74 GRAM-5.86 GRAM SOLUTION RX-10839 CDM 6370000100 HCPCS 250 RC 43386-0090-19 NDC outpatient 4000 ML 106.5 106.5 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES PPO [308136801] 85.2 percent of total billed charges 66.03 101.18 Technical (Hospital) Services PEG 3350-ELECTROLYTES 236 GRAM-22.74 GRAM-6.74 GRAM-5.86 GRAM SOLUTION RX-10839 CDM 6370000100 HCPCS 250 RC 43386-0090-19 NDC outpatient 4000 ML 106.5 106.5 BLUE CROSS BLUE SHIELD WELLMARK SB889 [3081026] BCBS WYOMING [308102603] 101.18 percent of total billed charges 66.03 101.18 Technical (Hospital) Services PEG 3350-ELECTROLYTES 236 GRAM-22.74 GRAM-6.74 GRAM-5.86 GRAM SOLUTION RX-10839 CDM 6370000100 HCPCS 250 RC 43386-0090-19 NDC outpatient 4000 ML 106.5 106.5 UNITED HEALTHCARE (COMMERCIAL) [3081199] UNITED HEALTHCARE 87726 [308119901] 66.03 percent of total billed charges 66.03 101.18 Technical (Hospital) Services PEG 3350-ELECTROLYTES 236 GRAM-22.74 GRAM-6.74 GRAM-5.86 GRAM SOLUTION RX-10839 CDM 6370000100 HCPCS 250 RC 43386-0090-19 NDC outpatient 4000 ML 106.5 106.5 MULTIPLAN INC 34080 [3081285] MULTIPLAN INC [308128501] 101.18 percent of total billed charges 66.03 101.18 Technical (Hospital) Services PEG 3350-ELECTROLYTES 236 GRAM-22.74 GRAM-6.74 GRAM-5.86 GRAM SOLUTION RX-10839 CDM 6370000100 HCPCS 250 RC 43386-0090-19 NDC outpatient 4000 ML 106.5 106.5 MEDICA (COMMERCIAL) 94265 [3081118] MEDICA CLAIMS [308111801] 95.85 percent of total billed charges 66.03 101.18 Technical (Hospital) Services PEG 3350-ELECTROLYTES 236 GRAM-22.74 GRAM-6.74 GRAM-5.86 GRAM SOLUTION RX-10839 CDM 6370000100 HCPCS 250 RC 43386-0090-19 NDC outpatient 4000 ML 106.5 106.5 HEALTHPARTNERS SX009 HEALTHPARTNERS 85.2 percent of total billed charges 66.03 101.18 Technical (Hospital) Services PAROXETINE 20 MG TABLET RX-10855 CDM 6370000100 HCPCS 250 RC 00904-5677-61 NDC outpatient 1 UN 5.87 5.87 HEALTHPARTNERS SX009 HEALTHPARTNERS 4.7 percent of total billed charges 3.64 5.58 Technical (Hospital) Services PAROXETINE 20 MG TABLET RX-10855 CDM 6370000100 HCPCS 250 RC 00904-5677-61 NDC outpatient 1 UN 5.87 5.87 BLUE CROSS BLUE SHIELD WELLMARK SB889 [3081026] BCBS WYOMING [308102603] 5.58 percent of total billed charges 3.64 5.58 Technical (Hospital) Services PAROXETINE 20 MG TABLET RX-10855 CDM 6370000100 HCPCS 250 RC 00904-5677-61 NDC outpatient 1 UN 5.87 5.87 UNITED HEALTHCARE (COMMERCIAL) [3081199] UNITED HEALTHCARE 87726 [308119901] 3.64 percent of total billed charges 3.64 5.58 Technical (Hospital) Services PAROXETINE 20 MG TABLET RX-10855 CDM 6370000100 HCPCS 250 RC 00904-5677-61 NDC outpatient 1 UN 5.87 5.87 MULTIPLAN INC 34080 [3081285] MULTIPLAN INC [308128501] 5.58 percent of total billed charges 3.64 5.58 Technical (Hospital) Services PAROXETINE 20 MG TABLET RX-10855 CDM 6370000100 HCPCS 250 RC 00904-5677-61 NDC outpatient 1 UN 5.87 5.87 CIGNA 62308 [3081051] CIGNA 62308 [308105105] 4.7 percent of total billed charges 3.64 5.58 Technical (Hospital) Services PAROXETINE 20 MG TABLET RX-10855 CDM 6370000100 HCPCS 250 RC 00904-5677-61 NDC outpatient 1 UN 5.87 5.87 CIGNA 62308 [3081051] CIGNA STATE OF WYOMING [308105107] 4.7 percent of total billed charges 3.64 5.58 Technical (Hospital) Services PAROXETINE 20 MG TABLET RX-10855 CDM 6370000100 HCPCS 250 RC 00904-5677-61 NDC outpatient 1 UN 5.87 5.87 MEDICA (COMMERCIAL) 94265 [3081118] MEDICA CLAIMS [308111801] 5.28 percent of total billed charges 3.64 5.58 Technical (Hospital) Services PAROXETINE 20 MG TABLET RX-10855 CDM 6370000100 HCPCS 250 RC 00904-5677-61 NDC outpatient 1 UN 5.87 5.87 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES EPO [308136803] 4.7 percent of total billed charges 3.64 5.58 Technical (Hospital) Services PAROXETINE 20 MG TABLET RX-10855 CDM 6370000100 HCPCS 250 RC 00904-5677-61 NDC outpatient 1 UN 5.87 5.87 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES PPO [308136801] 4.7 percent of total billed charges 3.64 5.58 Technical (Hospital) Services PAROXETINE 20 MG TABLET RX-10855 CDM 6370000100 HCPCS 250 RC 00904-5677-61 NDC outpatient 1 UN 5.87 5.87 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES HDHP [308136802] 4.7 percent of total billed charges 3.64 5.58 Technical (Hospital) Services PAROXETINE 20 MG TABLET RX-10855 CDM 6370000100 HCPCS 250 RC 00904-5677-61 NDC inpatient 1 UN 5.87 5.87 UNITED HEALTHCARE (COMMERCIAL) [3081199] UNITED HEALTHCARE 87726 [308119901] 3.64 percent of total billed charges 3.64 5.58 Technical (Hospital) Services PAROXETINE 20 MG TABLET RX-10855 CDM 6370000100 HCPCS 250 RC 00904-5677-61 NDC inpatient 1 UN 5.87 5.87 BLUE CROSS BLUE SHIELD WELLMARK SB889 [3081026] BCBS WYOMING [308102603] 5.58 percent of total billed charges 3.64 5.58 Technical (Hospital) Services PAROXETINE 20 MG TABLET RX-10855 CDM 6370000100 HCPCS 250 RC 00904-5677-61 NDC inpatient 1 UN 5.87 5.87 MEDICA (COMMERCIAL) 94265 [3081118] MEDICA CLAIMS [308111801] 5.28 percent of total billed charges 3.64 5.58 Technical (Hospital) Services PAROXETINE 20 MG TABLET RX-10855 CDM 6370000100 HCPCS 250 RC 00904-5677-61 NDC inpatient 1 UN 5.87 5.87 HEALTHPARTNERS SX009 HEALTHPARTNERS 4.65 percent of total billed charges 3.64 5.58 Technical (Hospital) Services PAROXETINE 20 MG TABLET RX-10855 CDM 6370000100 HCPCS 250 RC 00904-5677-61 NDC inpatient 1 UN 5.87 5.87 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES HDHP [308136802] 4.65 percent of total billed charges 3.64 5.58 Technical (Hospital) Services PAROXETINE 20 MG TABLET RX-10855 CDM 6370000100 HCPCS 250 RC 00904-5677-61 NDC inpatient 1 UN 5.87 5.87 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES EPO [308136803] 4.65 percent of total billed charges 3.64 5.58 Technical (Hospital) Services PAROXETINE 20 MG TABLET RX-10855 CDM 6370000100 HCPCS 250 RC 00904-5677-61 NDC inpatient 1 UN 5.87 5.87 CIGNA 62308 [3081051] CIGNA 62308 [308105105] 4.65 percent of total billed charges 3.64 5.58 Technical (Hospital) Services PAROXETINE 20 MG TABLET RX-10855 CDM 6370000100 HCPCS 250 RC 00904-5677-61 NDC inpatient 1 UN 5.87 5.87 CIGNA 62308 [3081051] CIGNA STATE OF WYOMING [308105107] 4.65 percent of total billed charges 3.64 5.58 Technical (Hospital) Services PAROXETINE 20 MG TABLET RX-10855 CDM 6370000100 HCPCS 250 RC 00904-5677-61 NDC inpatient 1 UN 5.87 5.87 MULTIPLAN INC 34080 [3081285] MULTIPLAN INC [308128501] 5.58 percent of total billed charges 3.64 5.58 Technical (Hospital) Services PAROXETINE 20 MG TABLET RX-10855 CDM 6370000100 HCPCS 250 RC 00904-5677-61 NDC inpatient 1 UN 5.87 5.87 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES PPO [308136801] 4.65 percent of total billed charges 3.64 5.58 Technical (Hospital) Services PAROXETINE 30 MG TABLET RX-10856 CDM 6370000100 HCPCS 250 RC 00378-7003-93 NDC inpatient 1 UN 5.81 5.81 BLUE CROSS BLUE SHIELD WELLMARK SB889 [3081026] BCBS WYOMING [308102603] 5.52 percent of total billed charges 3.6 5.52 Technical (Hospital) Services PAROXETINE 30 MG TABLET RX-10856 CDM 6370000100 HCPCS 250 RC 00378-7003-93 NDC inpatient 1 UN 5.81 5.81 UNITED HEALTHCARE (COMMERCIAL) [3081199] UNITED HEALTHCARE 87726 [308119901] 3.6 percent of total billed charges 3.6 5.52 Technical (Hospital) Services PAROXETINE 30 MG TABLET RX-10856 CDM 6370000100 HCPCS 250 RC 00378-7003-93 NDC inpatient 1 UN 5.81 5.81 CIGNA 62308 [3081051] CIGNA 62308 [308105105] 4.6 percent of total billed charges 3.6 5.52 Technical (Hospital) Services PAROXETINE 30 MG TABLET RX-10856 CDM 6370000100 HCPCS 250 RC 00378-7003-93 NDC inpatient 1 UN 5.81 5.81 CIGNA 62308 [3081051] CIGNA STATE OF WYOMING [308105107] 4.6 percent of total billed charges 3.6 5.52 Technical (Hospital) Services PAROXETINE 30 MG TABLET RX-10856 CDM 6370000100 HCPCS 250 RC 00378-7003-93 NDC inpatient 1 UN 5.81 5.81 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES EPO [308136803] 4.6 percent of total billed charges 3.6 5.52 Technical (Hospital) Services PAROXETINE 30 MG TABLET RX-10856 CDM 6370000100 HCPCS 250 RC 00378-7003-93 NDC inpatient 1 UN 5.81 5.81 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES HDHP [308136802] 4.6 percent of total billed charges 3.6 5.52 Technical (Hospital) Services PAROXETINE 30 MG TABLET RX-10856 CDM 6370000100 HCPCS 250 RC 00378-7003-93 NDC inpatient 1 UN 5.81 5.81 MULTIPLAN INC 34080 [3081285] MULTIPLAN INC [308128501] 5.52 percent of total billed charges 3.6 5.52 Technical (Hospital) Services PAROXETINE 30 MG TABLET RX-10856 CDM 6370000100 HCPCS 250 RC 00378-7003-93 NDC inpatient 1 UN 5.81 5.81 MEDICA (COMMERCIAL) 94265 [3081118] MEDICA CLAIMS [308111801] 5.23 percent of total billed charges 3.6 5.52 Technical (Hospital) Services PAROXETINE 30 MG TABLET RX-10856 CDM 6370000100 HCPCS 250 RC 00378-7003-93 NDC inpatient 1 UN 5.81 5.81 HEALTHPARTNERS SX009 HEALTHPARTNERS 4.6 percent of total billed charges 3.6 5.52 Technical (Hospital) Services PAROXETINE 30 MG TABLET RX-10856 CDM 6370000100 HCPCS 250 RC 00378-7003-93 NDC inpatient 1 UN 5.81 5.81 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES PPO [308136801] 4.6 percent of total billed charges 3.6 5.52 Technical (Hospital) Services PAROXETINE 30 MG TABLET RX-10856 CDM 6370000100 HCPCS 250 RC 00378-7003-93 NDC outpatient 1 UN 5.81 5.81 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES HDHP [308136802] 4.65 percent of total billed charges 3.6 5.52 Technical (Hospital) Services PAROXETINE 30 MG TABLET RX-10856 CDM 6370000100 HCPCS 250 RC 00378-7003-93 NDC outpatient 1 UN 5.81 5.81 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES PPO [308136801] 4.65 percent of total billed charges 3.6 5.52 Technical (Hospital) Services PAROXETINE 30 MG TABLET RX-10856 CDM 6370000100 HCPCS 250 RC 00378-7003-93 NDC outpatient 1 UN 5.81 5.81 MEDICA (COMMERCIAL) 94265 [3081118] MEDICA CLAIMS [308111801] 5.23 percent of total billed charges 3.6 5.52 Technical (Hospital) Services PAROXETINE 30 MG TABLET RX-10856 CDM 6370000100 HCPCS 250 RC 00378-7003-93 NDC outpatient 1 UN 5.81 5.81 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES EPO [308136803] 4.65 percent of total billed charges 3.6 5.52 Technical (Hospital) Services PAROXETINE 30 MG TABLET RX-10856 CDM 6370000100 HCPCS 250 RC 00378-7003-93 NDC outpatient 1 UN 5.81 5.81 MULTIPLAN INC 34080 [3081285] MULTIPLAN INC [308128501] 5.52 percent of total billed charges 3.6 5.52 Technical (Hospital) Services PAROXETINE 30 MG TABLET RX-10856 CDM 6370000100 HCPCS 250 RC 00378-7003-93 NDC outpatient 1 UN 5.81 5.81 CIGNA 62308 [3081051] CIGNA 62308 [308105105] 4.65 percent of total billed charges 3.6 5.52 Technical (Hospital) Services PAROXETINE 30 MG TABLET RX-10856 CDM 6370000100 HCPCS 250 RC 00378-7003-93 NDC outpatient 1 UN 5.81 5.81 CIGNA 62308 [3081051] CIGNA STATE OF WYOMING [308105107] 4.65 percent of total billed charges 3.6 5.52 Technical (Hospital) Services PAROXETINE 30 MG TABLET RX-10856 CDM 6370000100 HCPCS 250 RC 00378-7003-93 NDC outpatient 1 UN 5.81 5.81 UNITED HEALTHCARE (COMMERCIAL) [3081199] UNITED HEALTHCARE 87726 [308119901] 3.6 percent of total billed charges 3.6 5.52 Technical (Hospital) Services PAROXETINE 30 MG TABLET RX-10856 CDM 6370000100 HCPCS 250 RC 00378-7003-93 NDC outpatient 1 UN 5.81 5.81 BLUE CROSS BLUE SHIELD WELLMARK SB889 [3081026] BCBS WYOMING [308102603] 5.52 percent of total billed charges 3.6 5.52 Technical (Hospital) Services PAROXETINE 30 MG TABLET RX-10856 CDM 6370000100 HCPCS 250 RC 00378-7003-93 NDC outpatient 1 UN 5.81 5.81 HEALTHPARTNERS SX009 HEALTHPARTNERS 4.65 percent of total billed charges 3.6 5.52 Technical (Hospital) Services ROFLUMILAST 500 MCG TABLET RX-109401 CDM 6370000100 HCPCS 250 RC 72205-0200-30 NDC outpatient 1 UN 6.22 6.22 BLUE CROSS BLUE SHIELD WELLMARK SB889 [3081026] BCBS WYOMING [308102603] 5.91 percent of total billed charges 3.86 5.91 Technical (Hospital) Services ROFLUMILAST 500 MCG TABLET RX-109401 CDM 6370000100 HCPCS 250 RC 72205-0200-30 NDC outpatient 1 UN 6.22 6.22 UNITED HEALTHCARE (COMMERCIAL) [3081199] UNITED HEALTHCARE 87726 [308119901] 3.86 percent of total billed charges 3.86 5.91 Technical (Hospital) Services ROFLUMILAST 500 MCG TABLET RX-109401 CDM 6370000100 HCPCS 250 RC 72205-0200-30 NDC outpatient 1 UN 6.22 6.22 HEALTHPARTNERS SX009 HEALTHPARTNERS 4.98 percent of total billed charges 3.86 5.91 Technical (Hospital) Services ROFLUMILAST 500 MCG TABLET RX-109401 CDM 6370000100 HCPCS 250 RC 72205-0200-30 NDC outpatient 1 UN 6.22 6.22 MEDICA (COMMERCIAL) 94265 [3081118] MEDICA CLAIMS [308111801] 5.6 percent of total billed charges 3.86 5.91 Technical (Hospital) Services ROFLUMILAST 500 MCG TABLET RX-109401 CDM 6370000100 HCPCS 250 RC 72205-0200-30 NDC outpatient 1 UN 6.22 6.22 CIGNA 62308 [3081051] CIGNA 62308 [308105105] 4.98 percent of total billed charges 3.86 5.91 Technical (Hospital) Services ROFLUMILAST 500 MCG TABLET RX-109401 CDM 6370000100 HCPCS 250 RC 72205-0200-30 NDC outpatient 1 UN 6.22 6.22 CIGNA 62308 [3081051] CIGNA STATE OF WYOMING [308105107] 4.98 percent of total billed charges 3.86 5.91 Technical (Hospital) Services ROFLUMILAST 500 MCG TABLET RX-109401 CDM 6370000100 HCPCS 250 RC 72205-0200-30 NDC outpatient 1 UN 6.22 6.22 MULTIPLAN INC 34080 [3081285] MULTIPLAN INC [308128501] 5.91 percent of total billed charges 3.86 5.91 Technical (Hospital) Services ROFLUMILAST 500 MCG TABLET RX-109401 CDM 6370000100 HCPCS 250 RC 72205-0200-30 NDC outpatient 1 UN 6.22 6.22 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES HDHP [308136802] 4.98 percent of total billed charges 3.86 5.91 Technical (Hospital) Services ROFLUMILAST 500 MCG TABLET RX-109401 CDM 6370000100 HCPCS 250 RC 72205-0200-30 NDC outpatient 1 UN 6.22 6.22 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES EPO [308136803] 4.98 percent of total billed charges 3.86 5.91 Technical (Hospital) Services ROFLUMILAST 500 MCG TABLET RX-109401 CDM 6370000100 HCPCS 250 RC 72205-0200-30 NDC outpatient 1 UN 6.22 6.22 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES PPO [308136801] 4.98 percent of total billed charges 3.86 5.91 Technical (Hospital) Services ROFLUMILAST 500 MCG TABLET RX-109401 CDM 6370000100 HCPCS 250 RC 72205-0200-30 NDC inpatient 1 UN 6.22 6.22 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES PPO [308136801] 4.92 percent of total billed charges 3.86 5.91 Technical (Hospital) Services ROFLUMILAST 500 MCG TABLET RX-109401 CDM 6370000100 HCPCS 250 RC 72205-0200-30 NDC inpatient 1 UN 6.22 6.22 MEDICA (COMMERCIAL) 94265 [3081118] MEDICA CLAIMS [308111801] 5.6 percent of total billed charges 3.86 5.91 Technical (Hospital) Services ROFLUMILAST 500 MCG TABLET RX-109401 CDM 6370000100 HCPCS 250 RC 72205-0200-30 NDC inpatient 1 UN 6.22 6.22 HEALTHPARTNERS SX009 HEALTHPARTNERS 4.92 percent of total billed charges 3.86 5.91 Technical (Hospital) Services ROFLUMILAST 500 MCG TABLET RX-109401 CDM 6370000100 HCPCS 250 RC 72205-0200-30 NDC inpatient 1 UN 6.22 6.22 MULTIPLAN INC 34080 [3081285] MULTIPLAN INC [308128501] 5.91 percent of total billed charges 3.86 5.91 Technical (Hospital) Services ROFLUMILAST 500 MCG TABLET RX-109401 CDM 6370000100 HCPCS 250 RC 72205-0200-30 NDC inpatient 1 UN 6.22 6.22 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES HDHP [308136802] 4.92 percent of total billed charges 3.86 5.91 Technical (Hospital) Services ROFLUMILAST 500 MCG TABLET RX-109401 CDM 6370000100 HCPCS 250 RC 72205-0200-30 NDC inpatient 1 UN 6.22 6.22 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES EPO [308136803] 4.92 percent of total billed charges 3.86 5.91 Technical (Hospital) Services ROFLUMILAST 500 MCG TABLET RX-109401 CDM 6370000100 HCPCS 250 RC 72205-0200-30 NDC inpatient 1 UN 6.22 6.22 CIGNA 62308 [3081051] CIGNA 62308 [308105105] 4.92 percent of total billed charges 3.86 5.91 Technical (Hospital) Services ROFLUMILAST 500 MCG TABLET RX-109401 CDM 6370000100 HCPCS 250 RC 72205-0200-30 NDC inpatient 1 UN 6.22 6.22 CIGNA 62308 [3081051] CIGNA STATE OF WYOMING [308105107] 4.92 percent of total billed charges 3.86 5.91 Technical (Hospital) Services ROFLUMILAST 500 MCG TABLET RX-109401 CDM 6370000100 HCPCS 250 RC 72205-0200-30 NDC inpatient 1 UN 6.22 6.22 BLUE CROSS BLUE SHIELD WELLMARK SB889 [3081026] BCBS WYOMING [308102603] 5.91 percent of total billed charges 3.86 5.91 Technical (Hospital) Services ROFLUMILAST 500 MCG TABLET RX-109401 CDM 6370000100 HCPCS 250 RC 72205-0200-30 NDC inpatient 1 UN 6.22 6.22 UNITED HEALTHCARE (COMMERCIAL) [3081199] UNITED HEALTHCARE 87726 [308119901] 3.86 percent of total billed charges 3.86 5.91 Technical (Hospital) Services LINAGLIPTIN 5 MG TABLET RX-109773 CDM 6370000100 HCPCS 250 RC 00597-0140-30 NDC outpatient 1 UN 65.5 65.5 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES HDHP [308136802] 52.4 percent of total billed charges 40.61 62.23 Technical (Hospital) Services LINAGLIPTIN 5 MG TABLET RX-109773 CDM 6370000100 HCPCS 250 RC 00597-0140-30 NDC outpatient 1 UN 65.5 65.5 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES PPO [308136801] 52.4 percent of total billed charges 40.61 62.23 Technical (Hospital) Services LINAGLIPTIN 5 MG TABLET RX-109773 CDM 6370000100 HCPCS 250 RC 00597-0140-30 NDC outpatient 1 UN 65.5 65.5 MULTIPLAN INC 34080 [3081285] MULTIPLAN INC [308128501] 62.23 percent of total billed charges 40.61 62.23 Technical (Hospital) Services LINAGLIPTIN 5 MG TABLET RX-109773 CDM 6370000100 HCPCS 250 RC 00597-0140-30 NDC outpatient 1 UN 65.5 65.5 CIGNA 62308 [3081051] CIGNA 62308 [308105105] 52.4 percent of total billed charges 40.61 62.23 Technical (Hospital) Services LINAGLIPTIN 5 MG TABLET RX-109773 CDM 6370000100 HCPCS 250 RC 00597-0140-30 NDC outpatient 1 UN 65.5 65.5 CIGNA 62308 [3081051] CIGNA STATE OF WYOMING [308105107] 52.4 percent of total billed charges 40.61 62.23 Technical (Hospital) Services LINAGLIPTIN 5 MG TABLET RX-109773 CDM 6370000100 HCPCS 250 RC 00597-0140-30 NDC outpatient 1 UN 65.5 65.5 UNITED HEALTHCARE (COMMERCIAL) [3081199] UNITED HEALTHCARE 87726 [308119901] 40.61 percent of total billed charges 40.61 62.23 Technical (Hospital) Services LINAGLIPTIN 5 MG TABLET RX-109773 CDM 6370000100 HCPCS 250 RC 00597-0140-30 NDC outpatient 1 UN 65.5 65.5 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES EPO [308136803] 52.4 percent of total billed charges 40.61 62.23 Technical (Hospital) Services LINAGLIPTIN 5 MG TABLET RX-109773 CDM 6370000100 HCPCS 250 RC 00597-0140-30 NDC outpatient 1 UN 65.5 65.5 MEDICA (COMMERCIAL) 94265 [3081118] MEDICA CLAIMS [308111801] 58.95 percent of total billed charges 40.61 62.23 Technical (Hospital) Services LINAGLIPTIN 5 MG TABLET RX-109773 CDM 6370000100 HCPCS 250 RC 00597-0140-30 NDC outpatient 1 UN 65.5 65.5 HEALTHPARTNERS SX009 HEALTHPARTNERS 52.4 percent of total billed charges 40.61 62.23 Technical (Hospital) Services LINAGLIPTIN 5 MG TABLET RX-109773 CDM 6370000100 HCPCS 250 RC 00597-0140-30 NDC outpatient 1 UN 65.5 65.5 BLUE CROSS BLUE SHIELD WELLMARK SB889 [3081026] BCBS WYOMING [308102603] 62.23 percent of total billed charges 40.61 62.23 Technical (Hospital) Services LINAGLIPTIN 5 MG TABLET RX-109773 CDM 6370000100 HCPCS 250 RC 00597-0140-30 NDC inpatient 1 UN 65.5 65.5 MEDICA (COMMERCIAL) 94265 [3081118] MEDICA CLAIMS [308111801] 58.95 percent of total billed charges 40.61 62.23 Technical (Hospital) Services LINAGLIPTIN 5 MG TABLET RX-109773 CDM 6370000100 HCPCS 250 RC 00597-0140-30 NDC inpatient 1 UN 65.5 65.5 HEALTHPARTNERS SX009 HEALTHPARTNERS 51.86 percent of total billed charges 40.61 62.23 Technical (Hospital) Services LINAGLIPTIN 5 MG TABLET RX-109773 CDM 6370000100 HCPCS 250 RC 00597-0140-30 NDC inpatient 1 UN 65.5 65.5 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES PPO [308136801] 51.86 percent of total billed charges 40.61 62.23 Technical (Hospital) Services LINAGLIPTIN 5 MG TABLET RX-109773 CDM 6370000100 HCPCS 250 RC 00597-0140-30 NDC inpatient 1 UN 65.5 65.5 MULTIPLAN INC 34080 [3081285] MULTIPLAN INC [308128501] 62.23 percent of total billed charges 40.61 62.23 Technical (Hospital) Services LINAGLIPTIN 5 MG TABLET RX-109773 CDM 6370000100 HCPCS 250 RC 00597-0140-30 NDC inpatient 1 UN 65.5 65.5 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES HDHP [308136802] 51.86 percent of total billed charges 40.61 62.23 Technical (Hospital) Services LINAGLIPTIN 5 MG TABLET RX-109773 CDM 6370000100 HCPCS 250 RC 00597-0140-30 NDC inpatient 1 UN 65.5 65.5 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES EPO [308136803] 51.86 percent of total billed charges 40.61 62.23 Technical (Hospital) Services LINAGLIPTIN 5 MG TABLET RX-109773 CDM 6370000100 HCPCS 250 RC 00597-0140-30 NDC inpatient 1 UN 65.5 65.5 CIGNA 62308 [3081051] CIGNA 62308 [308105105] 51.86 percent of total billed charges 40.61 62.23 Technical (Hospital) Services LINAGLIPTIN 5 MG TABLET RX-109773 CDM 6370000100 HCPCS 250 RC 00597-0140-30 NDC inpatient 1 UN 65.5 65.5 CIGNA 62308 [3081051] CIGNA STATE OF WYOMING [308105107] 51.86 percent of total billed charges 40.61 62.23 Technical (Hospital) Services LINAGLIPTIN 5 MG TABLET RX-109773 CDM 6370000100 HCPCS 250 RC 00597-0140-30 NDC inpatient 1 UN 65.5 65.5 UNITED HEALTHCARE (COMMERCIAL) [3081199] UNITED HEALTHCARE 87726 [308119901] 40.61 percent of total billed charges 40.61 62.23 Technical (Hospital) Services LINAGLIPTIN 5 MG TABLET RX-109773 CDM 6370000100 HCPCS 250 RC 00597-0140-30 NDC inpatient 1 UN 65.5 65.5 BLUE CROSS BLUE SHIELD WELLMARK SB889 [3081026] BCBS WYOMING [308102603] 62.23 percent of total billed charges 40.61 62.23 Technical (Hospital) Services RIVAROXABAN 10 MG TABLET RX-110250 CDM 6370000100 HCPCS 250 RC 50458-0580-30 NDC outpatient 1 UN 66.99 66.99 BLUE CROSS BLUE SHIELD WELLMARK SB889 [3081026] BCBS WYOMING [308102603] 63.64 percent of total billed charges 41.53 63.64 Technical (Hospital) Services RIVAROXABAN 10 MG TABLET RX-110250 CDM 6370000100 HCPCS 250 RC 50458-0580-30 NDC outpatient 1 UN 66.99 66.99 HEALTHPARTNERS SX009 HEALTHPARTNERS 53.59 percent of total billed charges 41.53 63.64 Technical (Hospital) Services RIVAROXABAN 10 MG TABLET RX-110250 CDM 6370000100 HCPCS 250 RC 50458-0580-30 NDC outpatient 1 UN 66.99 66.99 MULTIPLAN INC 34080 [3081285] MULTIPLAN INC [308128501] 63.64 percent of total billed charges 41.53 63.64 Technical (Hospital) Services RIVAROXABAN 10 MG TABLET RX-110250 CDM 6370000100 HCPCS 250 RC 50458-0580-30 NDC outpatient 1 UN 66.99 66.99 CIGNA 62308 [3081051] CIGNA 62308 [308105105] 53.59 percent of total billed charges 41.53 63.64 Technical (Hospital) Services RIVAROXABAN 10 MG TABLET RX-110250 CDM 6370000100 HCPCS 250 RC 50458-0580-30 NDC outpatient 1 UN 66.99 66.99 CIGNA 62308 [3081051] CIGNA STATE OF WYOMING [308105107] 53.59 percent of total billed charges 41.53 63.64 Technical (Hospital) Services RIVAROXABAN 10 MG TABLET RX-110250 CDM 6370000100 HCPCS 250 RC 50458-0580-30 NDC outpatient 1 UN 66.99 66.99 UNITED HEALTHCARE (COMMERCIAL) [3081199] UNITED HEALTHCARE 87726 [308119901] 41.53 percent of total billed charges 41.53 63.64 Technical (Hospital) Services RIVAROXABAN 10 MG TABLET RX-110250 CDM 6370000100 HCPCS 250 RC 50458-0580-30 NDC outpatient 1 UN 66.99 66.99 MEDICA (COMMERCIAL) 94265 [3081118] MEDICA CLAIMS [308111801] 60.29 percent of total billed charges 41.53 63.64 Technical (Hospital) Services RIVAROXABAN 10 MG TABLET RX-110250 CDM 6370000100 HCPCS 250 RC 50458-0580-30 NDC outpatient 1 UN 66.99 66.99 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES EPO [308136803] 53.59 percent of total billed charges 41.53 63.64 Technical (Hospital) Services RIVAROXABAN 10 MG TABLET RX-110250 CDM 6370000100 HCPCS 250 RC 50458-0580-30 NDC outpatient 1 UN 66.99 66.99 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES HDHP [308136802] 53.59 percent of total billed charges 41.53 63.64 Technical (Hospital) Services RIVAROXABAN 10 MG TABLET RX-110250 CDM 6370000100 HCPCS 250 RC 50458-0580-30 NDC outpatient 1 UN 66.99 66.99 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES PPO [308136801] 53.59 percent of total billed charges 41.53 63.64 Technical (Hospital) Services RIVAROXABAN 10 MG TABLET RX-110250 CDM 6370000100 HCPCS 250 RC 50458-0580-30 NDC inpatient 1 UN 66.99 66.99 UNITED HEALTHCARE (COMMERCIAL) [3081199] UNITED HEALTHCARE 87726 [308119901] 41.53 percent of total billed charges 41.53 63.64 Technical (Hospital) Services RIVAROXABAN 10 MG TABLET RX-110250 CDM 6370000100 HCPCS 250 RC 50458-0580-30 NDC inpatient 1 UN 66.99 66.99 BLUE CROSS BLUE SHIELD WELLMARK SB889 [3081026] BCBS WYOMING [308102603] 63.64 percent of total billed charges 41.53 63.64 Technical (Hospital) Services RIVAROXABAN 10 MG TABLET RX-110250 CDM 6370000100 HCPCS 250 RC 50458-0580-30 NDC inpatient 1 UN 66.99 66.99 CIGNA 62308 [3081051] CIGNA STATE OF WYOMING [308105107] 53.04 percent of total billed charges 41.53 63.64 Technical (Hospital) Services RIVAROXABAN 10 MG TABLET RX-110250 CDM 6370000100 HCPCS 250 RC 50458-0580-30 NDC inpatient 1 UN 66.99 66.99 CIGNA 62308 [3081051] CIGNA 62308 [308105105] 53.04 percent of total billed charges 41.53 63.64 Technical (Hospital) Services RIVAROXABAN 10 MG TABLET RX-110250 CDM 6370000100 HCPCS 250 RC 50458-0580-30 NDC inpatient 1 UN 66.99 66.99 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES EPO [308136803] 53.04 percent of total billed charges 41.53 63.64 Technical (Hospital) Services RIVAROXABAN 10 MG TABLET RX-110250 CDM 6370000100 HCPCS 250 RC 50458-0580-30 NDC inpatient 1 UN 66.99 66.99 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES HDHP [308136802] 53.04 percent of total billed charges 41.53 63.64 Technical (Hospital) Services RIVAROXABAN 10 MG TABLET RX-110250 CDM 6370000100 HCPCS 250 RC 50458-0580-30 NDC inpatient 1 UN 66.99 66.99 MULTIPLAN INC 34080 [3081285] MULTIPLAN INC [308128501] 63.64 percent of total billed charges 41.53 63.64 Technical (Hospital) Services RIVAROXABAN 10 MG TABLET RX-110250 CDM 6370000100 HCPCS 250 RC 50458-0580-30 NDC inpatient 1 UN 66.99 66.99 HEALTHPARTNERS SX009 HEALTHPARTNERS 53.04 percent of total billed charges 41.53 63.64 Technical (Hospital) Services RIVAROXABAN 10 MG TABLET RX-110250 CDM 6370000100 HCPCS 250 RC 50458-0580-30 NDC inpatient 1 UN 66.99 66.99 MEDICA (COMMERCIAL) 94265 [3081118] MEDICA CLAIMS [308111801] 60.29 percent of total billed charges 41.53 63.64 Technical (Hospital) Services RIVAROXABAN 10 MG TABLET RX-110250 CDM 6370000100 HCPCS 250 RC 50458-0580-30 NDC inpatient 1 UN 66.99 66.99 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES PPO [308136801] 53.04 percent of total billed charges 41.53 63.64 Technical (Hospital) Services CALCIUM POLYCARBOPHIL 625 MG TABLET RX-11046 CDM 6370000100 HCPCS 250 RC 00536-4306-05 NDC outpatient 1 UN 5.67 5.67 HEALTHPARTNERS SX009 HEALTHPARTNERS 4.54 percent of total billed charges 3.52 5.39 Technical (Hospital) Services CALCIUM POLYCARBOPHIL 625 MG TABLET RX-11046 CDM 6370000100 HCPCS 250 RC 00536-4306-05 NDC outpatient 1 UN 5.67 5.67 UNITED HEALTHCARE (COMMERCIAL) [3081199] UNITED HEALTHCARE 87726 [308119901] 3.52 percent of total billed charges 3.52 5.39 Technical (Hospital) Services CALCIUM POLYCARBOPHIL 625 MG TABLET RX-11046 CDM 6370000100 HCPCS 250 RC 00536-4306-05 NDC outpatient 1 UN 5.67 5.67 MULTIPLAN INC 34080 [3081285] MULTIPLAN INC [308128501] 5.39 percent of total billed charges 3.52 5.39 Technical (Hospital) Services CALCIUM POLYCARBOPHIL 625 MG TABLET RX-11046 CDM 6370000100 HCPCS 250 RC 00536-4306-05 NDC outpatient 1 UN 5.67 5.67 CIGNA 62308 [3081051] CIGNA 62308 [308105105] 4.54 percent of total billed charges 3.52 5.39 Technical (Hospital) Services CALCIUM POLYCARBOPHIL 625 MG TABLET RX-11046 CDM 6370000100 HCPCS 250 RC 00536-4306-05 NDC outpatient 1 UN 5.67 5.67 CIGNA 62308 [3081051] CIGNA STATE OF WYOMING [308105107] 4.54 percent of total billed charges 3.52 5.39 Technical (Hospital) Services CALCIUM POLYCARBOPHIL 625 MG TABLET RX-11046 CDM 6370000100 HCPCS 250 RC 00536-4306-05 NDC outpatient 1 UN 5.67 5.67 MEDICA (COMMERCIAL) 94265 [3081118] MEDICA CLAIMS [308111801] 5.1 percent of total billed charges 3.52 5.39 Technical (Hospital) Services CALCIUM POLYCARBOPHIL 625 MG TABLET RX-11046 CDM 6370000100 HCPCS 250 RC 00536-4306-05 NDC outpatient 1 UN 5.67 5.67 BLUE CROSS BLUE SHIELD WELLMARK SB889 [3081026] BCBS WYOMING [308102603] 5.39 percent of total billed charges 3.52 5.39 Technical (Hospital) Services CALCIUM POLYCARBOPHIL 625 MG TABLET RX-11046 CDM 6370000100 HCPCS 250 RC 00536-4306-05 NDC outpatient 1 UN 5.67 5.67 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES HDHP [308136802] 4.54 percent of total billed charges 3.52 5.39 Technical (Hospital) Services CALCIUM POLYCARBOPHIL 625 MG TABLET RX-11046 CDM 6370000100 HCPCS 250 RC 00536-4306-05 NDC outpatient 1 UN 5.67 5.67 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES EPO [308136803] 4.54 percent of total billed charges 3.52 5.39 Technical (Hospital) Services CALCIUM POLYCARBOPHIL 625 MG TABLET RX-11046 CDM 6370000100 HCPCS 250 RC 00536-4306-05 NDC outpatient 1 UN 5.67 5.67 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES PPO [308136801] 4.54 percent of total billed charges 3.52 5.39 Technical (Hospital) Services CALCIUM POLYCARBOPHIL 625 MG TABLET RX-11046 CDM 6370000100 HCPCS 250 RC 00536-4306-05 NDC inpatient 1 UN 5.67 5.67 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES PPO [308136801] 4.49 percent of total billed charges 3.52 5.39 Technical (Hospital) Services CALCIUM POLYCARBOPHIL 625 MG TABLET RX-11046 CDM 6370000100 HCPCS 250 RC 00536-4306-05 NDC inpatient 1 UN 5.67 5.67 MEDICA (COMMERCIAL) 94265 [3081118] MEDICA CLAIMS [308111801] 5.1 percent of total billed charges 3.52 5.39 Technical (Hospital) Services CALCIUM POLYCARBOPHIL 625 MG TABLET RX-11046 CDM 6370000100 HCPCS 250 RC 00536-4306-05 NDC inpatient 1 UN 5.67 5.67 HEALTHPARTNERS SX009 HEALTHPARTNERS 4.49 percent of total billed charges 3.52 5.39 Technical (Hospital) Services CALCIUM POLYCARBOPHIL 625 MG TABLET RX-11046 CDM 6370000100 HCPCS 250 RC 00536-4306-05 NDC inpatient 1 UN 5.67 5.67 MULTIPLAN INC 34080 [3081285] MULTIPLAN INC [308128501] 5.39 percent of total billed charges 3.52 5.39 Technical (Hospital) Services CALCIUM POLYCARBOPHIL 625 MG TABLET RX-11046 CDM 6370000100 HCPCS 250 RC 00536-4306-05 NDC inpatient 1 UN 5.67 5.67 UNITED HEALTHCARE (COMMERCIAL) [3081199] UNITED HEALTHCARE 87726 [308119901] 3.52 percent of total billed charges 3.52 5.39 Technical (Hospital) Services CALCIUM POLYCARBOPHIL 625 MG TABLET RX-11046 CDM 6370000100 HCPCS 250 RC 00536-4306-05 NDC inpatient 1 UN 5.67 5.67 BLUE CROSS BLUE SHIELD WELLMARK SB889 [3081026] BCBS WYOMING [308102603] 5.39 percent of total billed charges 3.52 5.39 Technical (Hospital) Services CALCIUM POLYCARBOPHIL 625 MG TABLET RX-11046 CDM 6370000100 HCPCS 250 RC 00536-4306-05 NDC inpatient 1 UN 5.67 5.67 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES HDHP [308136802] 4.49 percent of total billed charges 3.52 5.39 Technical (Hospital) Services CALCIUM POLYCARBOPHIL 625 MG TABLET RX-11046 CDM 6370000100 HCPCS 250 RC 00536-4306-05 NDC inpatient 1 UN 5.67 5.67 CIGNA 62308 [3081051] CIGNA 62308 [308105105] 4.49 percent of total billed charges 3.52 5.39 Technical (Hospital) Services CALCIUM POLYCARBOPHIL 625 MG TABLET RX-11046 CDM 6370000100 HCPCS 250 RC 00536-4306-05 NDC inpatient 1 UN 5.67 5.67 CIGNA 62308 [3081051] CIGNA STATE OF WYOMING [308105107] 4.49 percent of total billed charges 3.52 5.39 Technical (Hospital) Services CALCIUM POLYCARBOPHIL 625 MG TABLET RX-11046 CDM 6370000100 HCPCS 250 RC 00536-4306-05 NDC inpatient 1 UN 5.67 5.67 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES EPO [308136803] 4.49 percent of total billed charges 3.52 5.39 Technical (Hospital) Services "POTASSIUM PHOSPHATE, MONOBASIC 500 MG SOLUBLE TABLET" RX-11087 CDM 6370000100 HCPCS 250 RC 00486-1111-01 NDC outpatient 1 UN 6.11 6.11 HEALTHPARTNERS SX009 HEALTHPARTNERS 4.89 percent of total billed charges 3.79 5.8 Technical (Hospital) Services "POTASSIUM PHOSPHATE, MONOBASIC 500 MG SOLUBLE TABLET" RX-11087 CDM 6370000100 HCPCS 250 RC 00486-1111-01 NDC outpatient 1 UN 6.11 6.11 BLUE CROSS BLUE SHIELD WELLMARK SB889 [3081026] BCBS WYOMING [308102603] 5.8 percent of total billed charges 3.79 5.8 Technical (Hospital) Services "POTASSIUM PHOSPHATE, MONOBASIC 500 MG SOLUBLE TABLET" RX-11087 CDM 6370000100 HCPCS 250 RC 00486-1111-01 NDC outpatient 1 UN 6.11 6.11 UNITED HEALTHCARE (COMMERCIAL) [3081199] UNITED HEALTHCARE 87726 [308119901] 3.79 percent of total billed charges 3.79 5.8 Technical (Hospital) Services "POTASSIUM PHOSPHATE, MONOBASIC 500 MG SOLUBLE TABLET" RX-11087 CDM 6370000100 HCPCS 250 RC 00486-1111-01 NDC outpatient 1 UN 6.11 6.11 MULTIPLAN INC 34080 [3081285] MULTIPLAN INC [308128501] 5.8 percent of total billed charges 3.79 5.8 Technical (Hospital) Services "POTASSIUM PHOSPHATE, MONOBASIC 500 MG SOLUBLE TABLET" RX-11087 CDM 6370000100 HCPCS 250 RC 00486-1111-01 NDC outpatient 1 UN 6.11 6.11 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES EPO [308136803] 4.89 percent of total billed charges 3.79 5.8 Technical (Hospital) Services "POTASSIUM PHOSPHATE, MONOBASIC 500 MG SOLUBLE TABLET" RX-11087 CDM 6370000100 HCPCS 250 RC 00486-1111-01 NDC outpatient 1 UN 6.11 6.11 MEDICA (COMMERCIAL) 94265 [3081118] MEDICA CLAIMS [308111801] 5.5 percent of total billed charges 3.79 5.8 Technical (Hospital) Services "POTASSIUM PHOSPHATE, MONOBASIC 500 MG SOLUBLE TABLET" RX-11087 CDM 6370000100 HCPCS 250 RC 00486-1111-01 NDC outpatient 1 UN 6.11 6.11 CIGNA 62308 [3081051] CIGNA 62308 [308105105] 4.89 percent of total billed charges 3.79 5.8 Technical (Hospital) Services "POTASSIUM PHOSPHATE, MONOBASIC 500 MG SOLUBLE TABLET" RX-11087 CDM 6370000100 HCPCS 250 RC 00486-1111-01 NDC outpatient 1 UN 6.11 6.11 CIGNA 62308 [3081051] CIGNA STATE OF WYOMING [308105107] 4.89 percent of total billed charges 3.79 5.8 Technical (Hospital) Services "POTASSIUM PHOSPHATE, MONOBASIC 500 MG SOLUBLE TABLET" RX-11087 CDM 6370000100 HCPCS 250 RC 00486-1111-01 NDC outpatient 1 UN 6.11 6.11 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES PPO [308136801] 4.89 percent of total billed charges 3.79 5.8 Technical (Hospital) Services "POTASSIUM PHOSPHATE, MONOBASIC 500 MG SOLUBLE TABLET" RX-11087 CDM 6370000100 HCPCS 250 RC 00486-1111-01 NDC outpatient 1 UN 6.11 6.11 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES HDHP [308136802] 4.89 percent of total billed charges 3.79 5.8 Technical (Hospital) Services "POTASSIUM PHOSPHATE, MONOBASIC 500 MG SOLUBLE TABLET" RX-11087 CDM 6370000100 HCPCS 250 RC 00486-1111-01 NDC inpatient 1 UN 6.11 6.11 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES EPO [308136803] 4.84 percent of total billed charges 3.79 5.8 Technical (Hospital) Services "POTASSIUM PHOSPHATE, MONOBASIC 500 MG SOLUBLE TABLET" RX-11087 CDM 6370000100 HCPCS 250 RC 00486-1111-01 NDC inpatient 1 UN 6.11 6.11 CIGNA 62308 [3081051] CIGNA 62308 [308105105] 4.84 percent of total billed charges 3.79 5.8 Technical (Hospital) Services "POTASSIUM PHOSPHATE, MONOBASIC 500 MG SOLUBLE TABLET" RX-11087 CDM 6370000100 HCPCS 250 RC 00486-1111-01 NDC inpatient 1 UN 6.11 6.11 CIGNA 62308 [3081051] CIGNA STATE OF WYOMING [308105107] 4.84 percent of total billed charges 3.79 5.8 Technical (Hospital) Services "POTASSIUM PHOSPHATE, MONOBASIC 500 MG SOLUBLE TABLET" RX-11087 CDM 6370000100 HCPCS 250 RC 00486-1111-01 NDC inpatient 1 UN 6.11 6.11 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES HDHP [308136802] 4.84 percent of total billed charges 3.79 5.8 Technical (Hospital) Services "POTASSIUM PHOSPHATE, MONOBASIC 500 MG SOLUBLE TABLET" RX-11087 CDM 6370000100 HCPCS 250 RC 00486-1111-01 NDC inpatient 1 UN 6.11 6.11 UNITED HEALTHCARE (COMMERCIAL) [3081199] UNITED HEALTHCARE 87726 [308119901] 3.79 percent of total billed charges 3.79 5.8 Technical (Hospital) Services "POTASSIUM PHOSPHATE, MONOBASIC 500 MG SOLUBLE TABLET" RX-11087 CDM 6370000100 HCPCS 250 RC 00486-1111-01 NDC inpatient 1 UN 6.11 6.11 BLUE CROSS BLUE SHIELD WELLMARK SB889 [3081026] BCBS WYOMING [308102603] 5.8 percent of total billed charges 3.79 5.8 Technical (Hospital) Services "POTASSIUM PHOSPHATE, MONOBASIC 500 MG SOLUBLE TABLET" RX-11087 CDM 6370000100 HCPCS 250 RC 00486-1111-01 NDC inpatient 1 UN 6.11 6.11 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES PPO [308136801] 4.84 percent of total billed charges 3.79 5.8 Technical (Hospital) Services "POTASSIUM PHOSPHATE, MONOBASIC 500 MG SOLUBLE TABLET" RX-11087 CDM 6370000100 HCPCS 250 RC 00486-1111-01 NDC inpatient 1 UN 6.11 6.11 HEALTHPARTNERS SX009 HEALTHPARTNERS 4.84 percent of total billed charges 3.79 5.8 Technical (Hospital) Services "POTASSIUM PHOSPHATE, MONOBASIC 500 MG SOLUBLE TABLET" RX-11087 CDM 6370000100 HCPCS 250 RC 00486-1111-01 NDC inpatient 1 UN 6.11 6.11 MEDICA (COMMERCIAL) 94265 [3081118] MEDICA CLAIMS [308111801] 5.5 percent of total billed charges 3.79 5.8 Technical (Hospital) Services "POTASSIUM PHOSPHATE, MONOBASIC 500 MG SOLUBLE TABLET" RX-11087 CDM 6370000100 HCPCS 250 RC 00486-1111-01 NDC inpatient 1 UN 6.11 6.11 MULTIPLAN INC 34080 [3081285] MULTIPLAN INC [308128501] 5.8 percent of total billed charges 3.79 5.8 Technical (Hospital) Services OSELTAMIVIR 6 MG/ML ORAL SUSPENSION RX-110998 CDM 6370000100 HCPCS 250 RC 00004-0822-05 NDC inpatient 3.34 ML 33.95 33.95 MULTIPLAN INC 34080 [3081285] MULTIPLAN INC [308128501] 32.25 percent of total billed charges 21.05 32.25 Technical (Hospital) Services OSELTAMIVIR 6 MG/ML ORAL SUSPENSION RX-110998 CDM 6370000100 HCPCS 250 RC 00004-0822-05 NDC inpatient 3.34 ML 33.95 33.95 MEDICA (COMMERCIAL) 94265 [3081118] MEDICA CLAIMS [308111801] 30.56 percent of total billed charges 21.05 32.25 Technical (Hospital) Services OSELTAMIVIR 6 MG/ML ORAL SUSPENSION RX-110998 CDM 6370000100 HCPCS 250 RC 00004-0822-05 NDC inpatient 3.34 ML 33.95 33.95 CIGNA 62308 [3081051] CIGNA 62308 [308105105] 26.88 percent of total billed charges 21.05 32.25 Technical (Hospital) Services OSELTAMIVIR 6 MG/ML ORAL SUSPENSION RX-110998 CDM 6370000100 HCPCS 250 RC 00004-0822-05 NDC inpatient 3.34 ML 33.95 33.95 CIGNA 62308 [3081051] CIGNA STATE OF WYOMING [308105107] 26.88 percent of total billed charges 21.05 32.25 Technical (Hospital) Services OSELTAMIVIR 6 MG/ML ORAL SUSPENSION RX-110998 CDM 6370000100 HCPCS 250 RC 00004-0822-05 NDC inpatient 3.34 ML 33.95 33.95 UNITED HEALTHCARE (COMMERCIAL) [3081199] UNITED HEALTHCARE 87726 [308119901] 21.05 percent of total billed charges 21.05 32.25 Technical (Hospital) Services OSELTAMIVIR 6 MG/ML ORAL SUSPENSION RX-110998 CDM 6370000100 HCPCS 250 RC 00004-0822-05 NDC inpatient 3.34 ML 33.95 33.95 BLUE CROSS BLUE SHIELD WELLMARK SB889 [3081026] BCBS WYOMING [308102603] 32.25 percent of total billed charges 21.05 32.25 Technical (Hospital) Services OSELTAMIVIR 6 MG/ML ORAL SUSPENSION RX-110998 CDM 6370000100 HCPCS 250 RC 00004-0822-05 NDC inpatient 3.34 ML 33.95 33.95 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES EPO [308136803] 26.88 percent of total billed charges 21.05 32.25 Technical (Hospital) Services OSELTAMIVIR 6 MG/ML ORAL SUSPENSION RX-110998 CDM 6370000100 HCPCS 250 RC 00004-0822-05 NDC inpatient 3.34 ML 33.95 33.95 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES HDHP [308136802] 26.88 percent of total billed charges 21.05 32.25 Technical (Hospital) Services OSELTAMIVIR 6 MG/ML ORAL SUSPENSION RX-110998 CDM 6370000100 HCPCS 250 RC 00004-0822-05 NDC inpatient 3.34 ML 33.95 33.95 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES PPO [308136801] 26.88 percent of total billed charges 21.05 32.25 Technical (Hospital) Services OSELTAMIVIR 6 MG/ML ORAL SUSPENSION RX-110998 CDM 6370000100 HCPCS 250 RC 00004-0822-05 NDC inpatient 3.34 ML 33.95 33.95 HEALTHPARTNERS SX009 HEALTHPARTNERS 26.88 percent of total billed charges 21.05 32.25 Technical (Hospital) Services OSELTAMIVIR 6 MG/ML ORAL SUSPENSION RX-110998 CDM 6370000100 HCPCS 250 RC 00004-0822-05 NDC outpatient 3.34 ML 33.95 33.95 HEALTHPARTNERS SX009 HEALTHPARTNERS 27.16 percent of total billed charges 21.05 32.25 Technical (Hospital) Services OSELTAMIVIR 6 MG/ML ORAL SUSPENSION RX-110998 CDM 6370000100 HCPCS 250 RC 00004-0822-05 NDC outpatient 3.34 ML 33.95 33.95 UNITED HEALTHCARE (COMMERCIAL) [3081199] UNITED HEALTHCARE 87726 [308119901] 21.05 percent of total billed charges 21.05 32.25 Technical (Hospital) Services OSELTAMIVIR 6 MG/ML ORAL SUSPENSION RX-110998 CDM 6370000100 HCPCS 250 RC 00004-0822-05 NDC outpatient 3.34 ML 33.95 33.95 CIGNA 62308 [3081051] CIGNA 62308 [308105105] 27.16 percent of total billed charges 21.05 32.25 Technical (Hospital) Services OSELTAMIVIR 6 MG/ML ORAL SUSPENSION RX-110998 CDM 6370000100 HCPCS 250 RC 00004-0822-05 NDC outpatient 3.34 ML 33.95 33.95 CIGNA 62308 [3081051] CIGNA STATE OF WYOMING [308105107] 27.16 percent of total billed charges 21.05 32.25 Technical (Hospital) Services OSELTAMIVIR 6 MG/ML ORAL SUSPENSION RX-110998 CDM 6370000100 HCPCS 250 RC 00004-0822-05 NDC outpatient 3.34 ML 33.95 33.95 BLUE CROSS BLUE SHIELD WELLMARK SB889 [3081026] BCBS WYOMING [308102603] 32.25 percent of total billed charges 21.05 32.25 Technical (Hospital) Services OSELTAMIVIR 6 MG/ML ORAL SUSPENSION RX-110998 CDM 6370000100 HCPCS 250 RC 00004-0822-05 NDC outpatient 3.34 ML 33.95 33.95 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES EPO [308136803] 27.16 percent of total billed charges 21.05 32.25 Technical (Hospital) Services OSELTAMIVIR 6 MG/ML ORAL SUSPENSION RX-110998 CDM 6370000100 HCPCS 250 RC 00004-0822-05 NDC outpatient 3.34 ML 33.95 33.95 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES HDHP [308136802] 27.16 percent of total billed charges 21.05 32.25 Technical (Hospital) Services OSELTAMIVIR 6 MG/ML ORAL SUSPENSION RX-110998 CDM 6370000100 HCPCS 250 RC 00004-0822-05 NDC outpatient 3.34 ML 33.95 33.95 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES PPO [308136801] 27.16 percent of total billed charges 21.05 32.25 Technical (Hospital) Services OSELTAMIVIR 6 MG/ML ORAL SUSPENSION RX-110998 CDM 6370000100 HCPCS 250 RC 00004-0822-05 NDC outpatient 3.34 ML 33.95 33.95 MEDICA (COMMERCIAL) 94265 [3081118] MEDICA CLAIMS [308111801] 30.56 percent of total billed charges 21.05 32.25 Technical (Hospital) Services OSELTAMIVIR 6 MG/ML ORAL SUSPENSION RX-110998 CDM 6370000100 HCPCS 250 RC 00004-0822-05 NDC outpatient 3.34 ML 33.95 33.95 MULTIPLAN INC 34080 [3081285] MULTIPLAN INC [308128501] 32.25 percent of total billed charges 21.05 32.25 Technical (Hospital) Services PRAVASTATIN 10 MG TABLET RX-11110 CDM 6370000100 HCPCS 250 RC 68462-0195-90 NDC outpatient 1 UN 5.98 5.98 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES HDHP [308136802] 4.78 percent of total billed charges 3.71 5.68 Technical (Hospital) Services PRAVASTATIN 10 MG TABLET RX-11110 CDM 6370000100 HCPCS 250 RC 68462-0195-90 NDC outpatient 1 UN 5.98 5.98 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES PPO [308136801] 4.78 percent of total billed charges 3.71 5.68 Technical (Hospital) Services PRAVASTATIN 10 MG TABLET RX-11110 CDM 6370000100 HCPCS 250 RC 68462-0195-90 NDC outpatient 1 UN 5.98 5.98 CIGNA 62308 [3081051] CIGNA 62308 [308105105] 4.78 percent of total billed charges 3.71 5.68 Technical (Hospital) Services PRAVASTATIN 10 MG TABLET RX-11110 CDM 6370000100 HCPCS 250 RC 68462-0195-90 NDC outpatient 1 UN 5.98 5.98 CIGNA 62308 [3081051] CIGNA STATE OF WYOMING [308105107] 4.78 percent of total billed charges 3.71 5.68 Technical (Hospital) Services PRAVASTATIN 10 MG TABLET RX-11110 CDM 6370000100 HCPCS 250 RC 68462-0195-90 NDC outpatient 1 UN 5.98 5.98 MEDICA (COMMERCIAL) 94265 [3081118] MEDICA CLAIMS [308111801] 5.38 percent of total billed charges 3.71 5.68 Technical (Hospital) Services PRAVASTATIN 10 MG TABLET RX-11110 CDM 6370000100 HCPCS 250 RC 68462-0195-90 NDC outpatient 1 UN 5.98 5.98 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES EPO [308136803] 4.78 percent of total billed charges 3.71 5.68 Technical (Hospital) Services PRAVASTATIN 10 MG TABLET RX-11110 CDM 6370000100 HCPCS 250 RC 68462-0195-90 NDC outpatient 1 UN 5.98 5.98 MULTIPLAN INC 34080 [3081285] MULTIPLAN INC [308128501] 5.68 percent of total billed charges 3.71 5.68 Technical (Hospital) Services PRAVASTATIN 10 MG TABLET RX-11110 CDM 6370000100 HCPCS 250 RC 68462-0195-90 NDC outpatient 1 UN 5.98 5.98 UNITED HEALTHCARE (COMMERCIAL) [3081199] UNITED HEALTHCARE 87726 [308119901] 3.71 percent of total billed charges 3.71 5.68 Technical (Hospital) Services PRAVASTATIN 10 MG TABLET RX-11110 CDM 6370000100 HCPCS 250 RC 68462-0195-90 NDC outpatient 1 UN 5.98 5.98 HEALTHPARTNERS SX009 HEALTHPARTNERS 4.78 percent of total billed charges 3.71 5.68 Technical (Hospital) Services PRAVASTATIN 10 MG TABLET RX-11110 CDM 6370000100 HCPCS 250 RC 68462-0195-90 NDC outpatient 1 UN 5.98 5.98 BLUE CROSS BLUE SHIELD WELLMARK SB889 [3081026] BCBS WYOMING [308102603] 5.68 percent of total billed charges 3.71 5.68 Technical (Hospital) Services PRAVASTATIN 10 MG TABLET RX-11110 CDM 6370000100 HCPCS 250 RC 68462-0195-90 NDC inpatient 1 UN 5.98 5.98 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES PPO [308136801] 4.73 percent of total billed charges 3.71 5.68 Technical (Hospital) Services PRAVASTATIN 10 MG TABLET RX-11110 CDM 6370000100 HCPCS 250 RC 68462-0195-90 NDC inpatient 1 UN 5.98 5.98 HEALTHPARTNERS SX009 HEALTHPARTNERS 4.73 percent of total billed charges 3.71 5.68 Technical (Hospital) Services PRAVASTATIN 10 MG TABLET RX-11110 CDM 6370000100 HCPCS 250 RC 68462-0195-90 NDC inpatient 1 UN 5.98 5.98 MEDICA (COMMERCIAL) 94265 [3081118] MEDICA CLAIMS [308111801] 5.38 percent of total billed charges 3.71 5.68 Technical (Hospital) Services PRAVASTATIN 10 MG TABLET RX-11110 CDM 6370000100 HCPCS 250 RC 68462-0195-90 NDC inpatient 1 UN 5.98 5.98 MULTIPLAN INC 34080 [3081285] MULTIPLAN INC [308128501] 5.68 percent of total billed charges 3.71 5.68 Technical (Hospital) Services PRAVASTATIN 10 MG TABLET RX-11110 CDM 6370000100 HCPCS 250 RC 68462-0195-90 NDC inpatient 1 UN 5.98 5.98 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES EPO [308136803] 4.73 percent of total billed charges 3.71 5.68 Technical (Hospital) Services PRAVASTATIN 10 MG TABLET RX-11110 CDM 6370000100 HCPCS 250 RC 68462-0195-90 NDC inpatient 1 UN 5.98 5.98 CIGNA 62308 [3081051] CIGNA 62308 [308105105] 4.73 percent of total billed charges 3.71 5.68 Technical (Hospital) Services PRAVASTATIN 10 MG TABLET RX-11110 CDM 6370000100 HCPCS 250 RC 68462-0195-90 NDC inpatient 1 UN 5.98 5.98 CIGNA 62308 [3081051] CIGNA STATE OF WYOMING [308105107] 4.73 percent of total billed charges 3.71 5.68 Technical (Hospital) Services PRAVASTATIN 10 MG TABLET RX-11110 CDM 6370000100 HCPCS 250 RC 68462-0195-90 NDC inpatient 1 UN 5.98 5.98 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES HDHP [308136802] 4.73 percent of total billed charges 3.71 5.68 Technical (Hospital) Services PRAVASTATIN 10 MG TABLET RX-11110 CDM 6370000100 HCPCS 250 RC 68462-0195-90 NDC inpatient 1 UN 5.98 5.98 BLUE CROSS BLUE SHIELD WELLMARK SB889 [3081026] BCBS WYOMING [308102603] 5.68 percent of total billed charges 3.71 5.68 Technical (Hospital) Services PRAVASTATIN 10 MG TABLET RX-11110 CDM 6370000100 HCPCS 250 RC 68462-0195-90 NDC inpatient 1 UN 5.98 5.98 UNITED HEALTHCARE (COMMERCIAL) [3081199] UNITED HEALTHCARE 87726 [308119901] 3.71 percent of total billed charges 3.71 5.68 Technical (Hospital) Services PRAVASTATIN 40 MG TABLET RX-11112 CDM 6370000100 HCPCS 250 RC 42291-0668-90 NDC inpatient 1 UN 5.67 5.67 MULTIPLAN INC 34080 [3081285] MULTIPLAN INC [308128501] 5.39 percent of total billed charges 3.52 5.39 Technical (Hospital) Services PRAVASTATIN 40 MG TABLET RX-11112 CDM 6370000100 HCPCS 250 RC 42291-0668-90 NDC inpatient 1 UN 5.67 5.67 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES PPO [308136801] 4.49 percent of total billed charges 3.52 5.39 Technical (Hospital) Services PRAVASTATIN 40 MG TABLET RX-11112 CDM 6370000100 HCPCS 250 RC 42291-0668-90 NDC inpatient 1 UN 5.67 5.67 HEALTHPARTNERS SX009 HEALTHPARTNERS 4.49 percent of total billed charges 3.52 5.39 Technical (Hospital) Services PRAVASTATIN 40 MG TABLET RX-11112 CDM 6370000100 HCPCS 250 RC 42291-0668-90 NDC inpatient 1 UN 5.67 5.67 MEDICA (COMMERCIAL) 94265 [3081118] MEDICA CLAIMS [308111801] 5.1 percent of total billed charges 3.52 5.39 Technical (Hospital) Services PRAVASTATIN 40 MG TABLET RX-11112 CDM 6370000100 HCPCS 250 RC 42291-0668-90 NDC inpatient 1 UN 5.67 5.67 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES EPO [308136803] 4.49 percent of total billed charges 3.52 5.39 Technical (Hospital) Services PRAVASTATIN 40 MG TABLET RX-11112 CDM 6370000100 HCPCS 250 RC 42291-0668-90 NDC inpatient 1 UN 5.67 5.67 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES HDHP [308136802] 4.49 percent of total billed charges 3.52 5.39 Technical (Hospital) Services PRAVASTATIN 40 MG TABLET RX-11112 CDM 6370000100 HCPCS 250 RC 42291-0668-90 NDC inpatient 1 UN 5.67 5.67 CIGNA 62308 [3081051] CIGNA 62308 [308105105] 4.49 percent of total billed charges 3.52 5.39 Technical (Hospital) Services PRAVASTATIN 40 MG TABLET RX-11112 CDM 6370000100 HCPCS 250 RC 42291-0668-90 NDC inpatient 1 UN 5.67 5.67 CIGNA 62308 [3081051] CIGNA STATE OF WYOMING [308105107] 4.49 percent of total billed charges 3.52 5.39 Technical (Hospital) Services PRAVASTATIN 40 MG TABLET RX-11112 CDM 6370000100 HCPCS 250 RC 42291-0668-90 NDC inpatient 1 UN 5.67 5.67 BLUE CROSS BLUE SHIELD WELLMARK SB889 [3081026] BCBS WYOMING [308102603] 5.39 percent of total billed charges 3.52 5.39 Technical (Hospital) Services PRAVASTATIN 40 MG TABLET RX-11112 CDM 6370000100 HCPCS 250 RC 42291-0668-90 NDC inpatient 1 UN 5.67 5.67 UNITED HEALTHCARE (COMMERCIAL) [3081199] UNITED HEALTHCARE 87726 [308119901] 3.52 percent of total billed charges 3.52 5.39 Technical (Hospital) Services PRAVASTATIN 40 MG TABLET RX-11112 CDM 6370000100 HCPCS 250 RC 42291-0668-90 NDC outpatient 1 UN 5.67 5.67 HEALTHPARTNERS SX009 HEALTHPARTNERS 4.54 percent of total billed charges 3.52 5.39 Technical (Hospital) Services PRAVASTATIN 40 MG TABLET RX-11112 CDM 6370000100 HCPCS 250 RC 42291-0668-90 NDC outpatient 1 UN 5.67 5.67 BLUE CROSS BLUE SHIELD WELLMARK SB889 [3081026] BCBS WYOMING [308102603] 5.39 percent of total billed charges 3.52 5.39 Technical (Hospital) Services PRAVASTATIN 40 MG TABLET RX-11112 CDM 6370000100 HCPCS 250 RC 42291-0668-90 NDC outpatient 1 UN 5.67 5.67 MEDICA (COMMERCIAL) 94265 [3081118] MEDICA CLAIMS [308111801] 5.1 percent of total billed charges 3.52 5.39 Technical (Hospital) Services PRAVASTATIN 40 MG TABLET RX-11112 CDM 6370000100 HCPCS 250 RC 42291-0668-90 NDC outpatient 1 UN 5.67 5.67 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES EPO [308136803] 4.54 percent of total billed charges 3.52 5.39 Technical (Hospital) Services PRAVASTATIN 40 MG TABLET RX-11112 CDM 6370000100 HCPCS 250 RC 42291-0668-90 NDC outpatient 1 UN 5.67 5.67 MULTIPLAN INC 34080 [3081285] MULTIPLAN INC [308128501] 5.39 percent of total billed charges 3.52 5.39 Technical (Hospital) Services PRAVASTATIN 40 MG TABLET RX-11112 CDM 6370000100 HCPCS 250 RC 42291-0668-90 NDC outpatient 1 UN 5.67 5.67 CIGNA 62308 [3081051] CIGNA 62308 [308105105] 4.54 percent of total billed charges 3.52 5.39 Technical (Hospital) Services PRAVASTATIN 40 MG TABLET RX-11112 CDM 6370000100 HCPCS 250 RC 42291-0668-90 NDC outpatient 1 UN 5.67 5.67 CIGNA 62308 [3081051] CIGNA STATE OF WYOMING [308105107] 4.54 percent of total billed charges 3.52 5.39 Technical (Hospital) Services PRAVASTATIN 40 MG TABLET RX-11112 CDM 6370000100 HCPCS 250 RC 42291-0668-90 NDC outpatient 1 UN 5.67 5.67 UNITED HEALTHCARE (COMMERCIAL) [3081199] UNITED HEALTHCARE 87726 [308119901] 3.52 percent of total billed charges 3.52 5.39 Technical (Hospital) Services PRAVASTATIN 40 MG TABLET RX-11112 CDM 6370000100 HCPCS 250 RC 42291-0668-90 NDC outpatient 1 UN 5.67 5.67 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES PPO [308136801] 4.54 percent of total billed charges 3.52 5.39 Technical (Hospital) Services PRAVASTATIN 40 MG TABLET RX-11112 CDM 6370000100 HCPCS 250 RC 42291-0668-90 NDC outpatient 1 UN 5.67 5.67 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES HDHP [308136802] 4.54 percent of total billed charges 3.52 5.39 Technical (Hospital) Services PRIMIDONE 50 MG TABLET RX-11129 CDM 6370000100 HCPCS 250 RC 10135-0540-01 NDC outpatient 1 UN 5.72 5.72 HEALTHPARTNERS SX009 HEALTHPARTNERS 4.58 percent of total billed charges 3.55 5.43 Technical (Hospital) Services PRIMIDONE 50 MG TABLET RX-11129 CDM 6370000100 HCPCS 250 RC 10135-0540-01 NDC outpatient 1 UN 5.72 5.72 BLUE CROSS BLUE SHIELD WELLMARK SB889 [3081026] BCBS WYOMING [308102603] 5.43 percent of total billed charges 3.55 5.43 Technical (Hospital) Services PRIMIDONE 50 MG TABLET RX-11129 CDM 6370000100 HCPCS 250 RC 10135-0540-01 NDC outpatient 1 UN 5.72 5.72 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES EPO [308136803] 4.58 percent of total billed charges 3.55 5.43 Technical (Hospital) Services PRIMIDONE 50 MG TABLET RX-11129 CDM 6370000100 HCPCS 250 RC 10135-0540-01 NDC outpatient 1 UN 5.72 5.72 MEDICA (COMMERCIAL) 94265 [3081118] MEDICA CLAIMS [308111801] 5.15 percent of total billed charges 3.55 5.43 Technical (Hospital) Services PRIMIDONE 50 MG TABLET RX-11129 CDM 6370000100 HCPCS 250 RC 10135-0540-01 NDC outpatient 1 UN 5.72 5.72 CIGNA 62308 [3081051] CIGNA 62308 [308105105] 4.58 percent of total billed charges 3.55 5.43 Technical (Hospital) Services PRIMIDONE 50 MG TABLET RX-11129 CDM 6370000100 HCPCS 250 RC 10135-0540-01 NDC outpatient 1 UN 5.72 5.72 CIGNA 62308 [3081051] CIGNA STATE OF WYOMING [308105107] 4.58 percent of total billed charges 3.55 5.43 Technical (Hospital) Services PRIMIDONE 50 MG TABLET RX-11129 CDM 6370000100 HCPCS 250 RC 10135-0540-01 NDC outpatient 1 UN 5.72 5.72 MULTIPLAN INC 34080 [3081285] MULTIPLAN INC [308128501] 5.43 percent of total billed charges 3.55 5.43 Technical (Hospital) Services PRIMIDONE 50 MG TABLET RX-11129 CDM 6370000100 HCPCS 250 RC 10135-0540-01 NDC outpatient 1 UN 5.72 5.72 UNITED HEALTHCARE (COMMERCIAL) [3081199] UNITED HEALTHCARE 87726 [308119901] 3.55 percent of total billed charges 3.55 5.43 Technical (Hospital) Services PRIMIDONE 50 MG TABLET RX-11129 CDM 6370000100 HCPCS 250 RC 10135-0540-01 NDC outpatient 1 UN 5.72 5.72 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES PPO [308136801] 4.58 percent of total billed charges 3.55 5.43 Technical (Hospital) Services PRIMIDONE 50 MG TABLET RX-11129 CDM 6370000100 HCPCS 250 RC 10135-0540-01 NDC outpatient 1 UN 5.72 5.72 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES HDHP [308136802] 4.58 percent of total billed charges 3.55 5.43 Technical (Hospital) Services PRIMIDONE 50 MG TABLET RX-11129 CDM 6370000100 HCPCS 250 RC 10135-0540-01 NDC inpatient 1 UN 5.72 5.72 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES HDHP [308136802] 4.53 percent of total billed charges 3.55 5.43 Technical (Hospital) Services PRIMIDONE 50 MG TABLET RX-11129 CDM 6370000100 HCPCS 250 RC 10135-0540-01 NDC inpatient 1 UN 5.72 5.72 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES EPO [308136803] 4.53 percent of total billed charges 3.55 5.43 Technical (Hospital) Services PRIMIDONE 50 MG TABLET RX-11129 CDM 6370000100 HCPCS 250 RC 10135-0540-01 NDC inpatient 1 UN 5.72 5.72 CIGNA 62308 [3081051] CIGNA 62308 [308105105] 4.53 percent of total billed charges 3.55 5.43 Technical (Hospital) Services PRIMIDONE 50 MG TABLET RX-11129 CDM 6370000100 HCPCS 250 RC 10135-0540-01 NDC inpatient 1 UN 5.72 5.72 CIGNA 62308 [3081051] CIGNA STATE OF WYOMING [308105107] 4.53 percent of total billed charges 3.55 5.43 Technical (Hospital) Services PRIMIDONE 50 MG TABLET RX-11129 CDM 6370000100 HCPCS 250 RC 10135-0540-01 NDC inpatient 1 UN 5.72 5.72 BLUE CROSS BLUE SHIELD WELLMARK SB889 [3081026] BCBS WYOMING [308102603] 5.43 percent of total billed charges 3.55 5.43 Technical (Hospital) Services PRIMIDONE 50 MG TABLET RX-11129 CDM 6370000100 HCPCS 250 RC 10135-0540-01 NDC inpatient 1 UN 5.72 5.72 UNITED HEALTHCARE (COMMERCIAL) [3081199] UNITED HEALTHCARE 87726 [308119901] 3.55 percent of total billed charges 3.55 5.43 Technical (Hospital) Services PRIMIDONE 50 MG TABLET RX-11129 CDM 6370000100 HCPCS 250 RC 10135-0540-01 NDC inpatient 1 UN 5.72 5.72 MULTIPLAN INC 34080 [3081285] MULTIPLAN INC [308128501] 5.43 percent of total billed charges 3.55 5.43 Technical (Hospital) Services PRIMIDONE 50 MG TABLET RX-11129 CDM 6370000100 HCPCS 250 RC 10135-0540-01 NDC inpatient 1 UN 5.72 5.72 MEDICA (COMMERCIAL) 94265 [3081118] MEDICA CLAIMS [308111801] 5.15 percent of total billed charges 3.55 5.43 Technical (Hospital) Services PRIMIDONE 50 MG TABLET RX-11129 CDM 6370000100 HCPCS 250 RC 10135-0540-01 NDC inpatient 1 UN 5.72 5.72 HEALTHPARTNERS SX009 HEALTHPARTNERS 4.53 percent of total billed charges 3.55 5.43 Technical (Hospital) Services PRIMIDONE 50 MG TABLET RX-11129 CDM 6370000100 HCPCS 250 RC 10135-0540-01 NDC inpatient 1 UN 5.72 5.72 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES PPO [308136801] 4.53 percent of total billed charges 3.55 5.43 Technical (Hospital) Services PROCHLORPERAZINE 25 MG RECTAL SUPPOSITORY RX-11138 CDM 6370000100 HCPCS 250 RC 00713-0135-12 NDC inpatient 1 UN 37.11 37.11 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES PPO [308136801] 29.38 percent of total billed charges 23.01 35.25 Technical (Hospital) Services PROCHLORPERAZINE 25 MG RECTAL SUPPOSITORY RX-11138 CDM 6370000100 HCPCS 250 RC 00713-0135-12 NDC inpatient 1 UN 37.11 37.11 HEALTHPARTNERS SX009 HEALTHPARTNERS 29.38 percent of total billed charges 23.01 35.25 Technical (Hospital) Services PROCHLORPERAZINE 25 MG RECTAL SUPPOSITORY RX-11138 CDM 6370000100 HCPCS 250 RC 00713-0135-12 NDC inpatient 1 UN 37.11 37.11 MEDICA (COMMERCIAL) 94265 [3081118] MEDICA CLAIMS [308111801] 33.4 percent of total billed charges 23.01 35.25 Technical (Hospital) Services PROCHLORPERAZINE 25 MG RECTAL SUPPOSITORY RX-11138 CDM 6370000100 HCPCS 250 RC 00713-0135-12 NDC inpatient 1 UN 37.11 37.11 MULTIPLAN INC 34080 [3081285] MULTIPLAN INC [308128501] 35.25 percent of total billed charges 23.01 35.25 Technical (Hospital) Services PROCHLORPERAZINE 25 MG RECTAL SUPPOSITORY RX-11138 CDM 6370000100 HCPCS 250 RC 00713-0135-12 NDC inpatient 1 UN 37.11 37.11 BLUE CROSS BLUE SHIELD WELLMARK SB889 [3081026] BCBS WYOMING [308102603] 35.25 percent of total billed charges 23.01 35.25 Technical (Hospital) Services PROCHLORPERAZINE 25 MG RECTAL SUPPOSITORY RX-11138 CDM 6370000100 HCPCS 250 RC 00713-0135-12 NDC inpatient 1 UN 37.11 37.11 UNITED HEALTHCARE (COMMERCIAL) [3081199] UNITED HEALTHCARE 87726 [308119901] 23.01 percent of total billed charges 23.01 35.25 Technical (Hospital) Services PROCHLORPERAZINE 25 MG RECTAL SUPPOSITORY RX-11138 CDM 6370000100 HCPCS 250 RC 00713-0135-12 NDC inpatient 1 UN 37.11 37.11 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES EPO [308136803] 29.38 percent of total billed charges 23.01 35.25 Technical (Hospital) Services PROCHLORPERAZINE 25 MG RECTAL SUPPOSITORY RX-11138 CDM 6370000100 HCPCS 250 RC 00713-0135-12 NDC inpatient 1 UN 37.11 37.11 CIGNA 62308 [3081051] CIGNA 62308 [308105105] 29.38 percent of total billed charges 23.01 35.25 Technical (Hospital) Services PROCHLORPERAZINE 25 MG RECTAL SUPPOSITORY RX-11138 CDM 6370000100 HCPCS 250 RC 00713-0135-12 NDC inpatient 1 UN 37.11 37.11 CIGNA 62308 [3081051] CIGNA STATE OF WYOMING [308105107] 29.38 percent of total billed charges 23.01 35.25 Technical (Hospital) Services PROCHLORPERAZINE 25 MG RECTAL SUPPOSITORY RX-11138 CDM 6370000100 HCPCS 250 RC 00713-0135-12 NDC inpatient 1 UN 37.11 37.11 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES HDHP [308136802] 29.38 percent of total billed charges 23.01 35.25 Technical (Hospital) Services PROCHLORPERAZINE 25 MG RECTAL SUPPOSITORY RX-11138 CDM 6370000100 HCPCS 250 RC 00713-0135-12 NDC outpatient 1 UN 37.11 37.11 HEALTHPARTNERS SX009 HEALTHPARTNERS 29.69 percent of total billed charges 23.01 35.25 Technical (Hospital) Services PROCHLORPERAZINE 25 MG RECTAL SUPPOSITORY RX-11138 CDM 6370000100 HCPCS 250 RC 00713-0135-12 NDC outpatient 1 UN 37.11 37.11 BLUE CROSS BLUE SHIELD WELLMARK SB889 [3081026] BCBS WYOMING [308102603] 35.25 percent of total billed charges 23.01 35.25 Technical (Hospital) Services PROCHLORPERAZINE 25 MG RECTAL SUPPOSITORY RX-11138 CDM 6370000100 HCPCS 250 RC 00713-0135-12 NDC outpatient 1 UN 37.11 37.11 UNITED HEALTHCARE (COMMERCIAL) [3081199] UNITED HEALTHCARE 87726 [308119901] 23.01 percent of total billed charges 23.01 35.25 Technical (Hospital) Services PROCHLORPERAZINE 25 MG RECTAL SUPPOSITORY RX-11138 CDM 6370000100 HCPCS 250 RC 00713-0135-12 NDC outpatient 1 UN 37.11 37.11 CIGNA 62308 [3081051] CIGNA 62308 [308105105] 29.69 percent of total billed charges 23.01 35.25 Technical (Hospital) Services PROCHLORPERAZINE 25 MG RECTAL SUPPOSITORY RX-11138 CDM 6370000100 HCPCS 250 RC 00713-0135-12 NDC outpatient 1 UN 37.11 37.11 CIGNA 62308 [3081051] CIGNA STATE OF WYOMING [308105107] 29.69 percent of total billed charges 23.01 35.25 Technical (Hospital) Services PROCHLORPERAZINE 25 MG RECTAL SUPPOSITORY RX-11138 CDM 6370000100 HCPCS 250 RC 00713-0135-12 NDC outpatient 1 UN 37.11 37.11 MULTIPLAN INC 34080 [3081285] MULTIPLAN INC [308128501] 35.25 percent of total billed charges 23.01 35.25 Technical (Hospital) Services PROCHLORPERAZINE 25 MG RECTAL SUPPOSITORY RX-11138 CDM 6370000100 HCPCS 250 RC 00713-0135-12 NDC outpatient 1 UN 37.11 37.11 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES EPO [308136803] 29.69 percent of total billed charges 23.01 35.25 Technical (Hospital) Services PROCHLORPERAZINE 25 MG RECTAL SUPPOSITORY RX-11138 CDM 6370000100 HCPCS 250 RC 00713-0135-12 NDC outpatient 1 UN 37.11 37.11 MEDICA (COMMERCIAL) 94265 [3081118] MEDICA CLAIMS [308111801] 33.4 percent of total billed charges 23.01 35.25 Technical (Hospital) Services PROCHLORPERAZINE 25 MG RECTAL SUPPOSITORY RX-11138 CDM 6370000100 HCPCS 250 RC 00713-0135-12 NDC outpatient 1 UN 37.11 37.11 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES HDHP [308136802] 29.69 percent of total billed charges 23.01 35.25 Technical (Hospital) Services PROCHLORPERAZINE 25 MG RECTAL SUPPOSITORY RX-11138 CDM 6370000100 HCPCS 250 RC 00713-0135-12 NDC outpatient 1 UN 37.11 37.11 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES PPO [308136801] 29.69 percent of total billed charges 23.01 35.25 Technical (Hospital) Services PROMETHAZINE 12.5 MG RECTAL SUPPOSITORY RX-11143 CDM 6370000100 HCPCS 250 RC 00713-0536-12 NDC inpatient 1 UN 38.15 38.15 UNITED HEALTHCARE (COMMERCIAL) [3081199] UNITED HEALTHCARE 87726 [308119901] 23.65 percent of total billed charges 23.65 36.24 Technical (Hospital) Services PROMETHAZINE 12.5 MG RECTAL SUPPOSITORY RX-11143 CDM 6370000100 HCPCS 250 RC 00713-0536-12 NDC inpatient 1 UN 38.15 38.15 BLUE CROSS BLUE SHIELD WELLMARK SB889 [3081026] BCBS WYOMING [308102603] 36.24 percent of total billed charges 23.65 36.24 Technical (Hospital) Services PROMETHAZINE 12.5 MG RECTAL SUPPOSITORY RX-11143 CDM 6370000100 HCPCS 250 RC 00713-0536-12 NDC inpatient 1 UN 38.15 38.15 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES EPO [308136803] 30.21 percent of total billed charges 23.65 36.24 Technical (Hospital) Services PROMETHAZINE 12.5 MG RECTAL SUPPOSITORY RX-11143 CDM 6370000100 HCPCS 250 RC 00713-0536-12 NDC inpatient 1 UN 38.15 38.15 CIGNA 62308 [3081051] CIGNA 62308 [308105105] 30.21 percent of total billed charges 23.65 36.24 Technical (Hospital) Services PROMETHAZINE 12.5 MG RECTAL SUPPOSITORY RX-11143 CDM 6370000100 HCPCS 250 RC 00713-0536-12 NDC inpatient 1 UN 38.15 38.15 CIGNA 62308 [3081051] CIGNA STATE OF WYOMING [308105107] 30.21 percent of total billed charges 23.65 36.24 Technical (Hospital) Services PROMETHAZINE 12.5 MG RECTAL SUPPOSITORY RX-11143 CDM 6370000100 HCPCS 250 RC 00713-0536-12 NDC inpatient 1 UN 38.15 38.15 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES HDHP [308136802] 30.21 percent of total billed charges 23.65 36.24 Technical (Hospital) Services PROMETHAZINE 12.5 MG RECTAL SUPPOSITORY RX-11143 CDM 6370000100 HCPCS 250 RC 00713-0536-12 NDC inpatient 1 UN 38.15 38.15 MEDICA (COMMERCIAL) 94265 [3081118] MEDICA CLAIMS [308111801] 34.34 percent of total billed charges 23.65 36.24 Technical (Hospital) Services PROMETHAZINE 12.5 MG RECTAL SUPPOSITORY RX-11143 CDM 6370000100 HCPCS 250 RC 00713-0536-12 NDC inpatient 1 UN 38.15 38.15 HEALTHPARTNERS SX009 HEALTHPARTNERS 30.21 percent of total billed charges 23.65 36.24 Technical (Hospital) Services PROMETHAZINE 12.5 MG RECTAL SUPPOSITORY RX-11143 CDM 6370000100 HCPCS 250 RC 00713-0536-12 NDC inpatient 1 UN 38.15 38.15 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES PPO [308136801] 30.21 percent of total billed charges 23.65 36.24 Technical (Hospital) Services PROMETHAZINE 12.5 MG RECTAL SUPPOSITORY RX-11143 CDM 6370000100 HCPCS 250 RC 00713-0536-12 NDC inpatient 1 UN 38.15 38.15 MULTIPLAN INC 34080 [3081285] MULTIPLAN INC [308128501] 36.24 percent of total billed charges 23.65 36.24 Technical (Hospital) Services PROMETHAZINE 12.5 MG RECTAL SUPPOSITORY RX-11143 CDM 6370000100 HCPCS 250 RC 00713-0536-12 NDC outpatient 1 UN 38.15 38.15 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES PPO [308136801] 30.52 percent of total billed charges 23.65 36.24 Technical (Hospital) Services PROMETHAZINE 12.5 MG RECTAL SUPPOSITORY RX-11143 CDM 6370000100 HCPCS 250 RC 00713-0536-12 NDC outpatient 1 UN 38.15 38.15 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES HDHP [308136802] 30.52 percent of total billed charges 23.65 36.24 Technical (Hospital) Services PROMETHAZINE 12.5 MG RECTAL SUPPOSITORY RX-11143 CDM 6370000100 HCPCS 250 RC 00713-0536-12 NDC outpatient 1 UN 38.15 38.15 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES EPO [308136803] 30.52 percent of total billed charges 23.65 36.24 Technical (Hospital) Services PROMETHAZINE 12.5 MG RECTAL SUPPOSITORY RX-11143 CDM 6370000100 HCPCS 250 RC 00713-0536-12 NDC outpatient 1 UN 38.15 38.15 BLUE CROSS BLUE SHIELD WELLMARK SB889 [3081026] BCBS WYOMING [308102603] 36.24 percent of total billed charges 23.65 36.24 Technical (Hospital) Services PROMETHAZINE 12.5 MG RECTAL SUPPOSITORY RX-11143 CDM 6370000100 HCPCS 250 RC 00713-0536-12 NDC outpatient 1 UN 38.15 38.15 UNITED HEALTHCARE (COMMERCIAL) [3081199] UNITED HEALTHCARE 87726 [308119901] 23.65 percent of total billed charges 23.65 36.24 Technical (Hospital) Services PROMETHAZINE 12.5 MG RECTAL SUPPOSITORY RX-11143 CDM 6370000100 HCPCS 250 RC 00713-0536-12 NDC outpatient 1 UN 38.15 38.15 HEALTHPARTNERS SX009 HEALTHPARTNERS 30.52 percent of total billed charges 23.65 36.24 Technical (Hospital) Services PROMETHAZINE 12.5 MG RECTAL SUPPOSITORY RX-11143 CDM 6370000100 HCPCS 250 RC 00713-0536-12 NDC outpatient 1 UN 38.15 38.15 MULTIPLAN INC 34080 [3081285] MULTIPLAN INC [308128501] 36.24 percent of total billed charges 23.65 36.24 Technical (Hospital) Services PROMETHAZINE 12.5 MG RECTAL SUPPOSITORY RX-11143 CDM 6370000100 HCPCS 250 RC 00713-0536-12 NDC outpatient 1 UN 38.15 38.15 CIGNA 62308 [3081051] CIGNA 62308 [308105105] 30.52 percent of total billed charges 23.65 36.24 Technical (Hospital) Services PROMETHAZINE 12.5 MG RECTAL SUPPOSITORY RX-11143 CDM 6370000100 HCPCS 250 RC 00713-0536-12 NDC outpatient 1 UN 38.15 38.15 CIGNA 62308 [3081051] CIGNA STATE OF WYOMING [308105107] 30.52 percent of total billed charges 23.65 36.24 Technical (Hospital) Services PROMETHAZINE 12.5 MG RECTAL SUPPOSITORY RX-11143 CDM 6370000100 HCPCS 250 RC 00713-0536-12 NDC outpatient 1 UN 38.15 38.15 MEDICA (COMMERCIAL) 94265 [3081118] MEDICA CLAIMS [308111801] 34.34 percent of total billed charges 23.65 36.24 Technical (Hospital) Services PROMETHAZINE 25 MG RECTAL SUPPOSITORY RX-11144 CDM 6370000100 HCPCS 250 RC 00713-0526-12 NDC outpatient 1 UN 38.15 38.15 BLUE CROSS BLUE SHIELD WELLMARK SB889 [3081026] BCBS WYOMING [308102603] 36.24 percent of total billed charges 23.65 36.24 Technical (Hospital) Services PROMETHAZINE 25 MG RECTAL SUPPOSITORY RX-11144 CDM 6370000100 HCPCS 250 RC 00713-0526-12 NDC outpatient 1 UN 38.15 38.15 HEALTHPARTNERS SX009 HEALTHPARTNERS 30.52 percent of total billed charges 23.65 36.24 Technical (Hospital) Services PROMETHAZINE 25 MG RECTAL SUPPOSITORY RX-11144 CDM 6370000100 HCPCS 250 RC 00713-0526-12 NDC outpatient 1 UN 38.15 38.15 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES EPO [308136803] 30.52 percent of total billed charges 23.65 36.24 Technical (Hospital) Services PROMETHAZINE 25 MG RECTAL SUPPOSITORY RX-11144 CDM 6370000100 HCPCS 250 RC 00713-0526-12 NDC outpatient 1 UN 38.15 38.15 MEDICA (COMMERCIAL) 94265 [3081118] MEDICA CLAIMS [308111801] 34.34 percent of total billed charges 23.65 36.24 Technical (Hospital) Services PROMETHAZINE 25 MG RECTAL SUPPOSITORY RX-11144 CDM 6370000100 HCPCS 250 RC 00713-0526-12 NDC outpatient 1 UN 38.15 38.15 CIGNA 62308 [3081051] CIGNA 62308 [308105105] 30.52 percent of total billed charges 23.65 36.24 Technical (Hospital) Services PROMETHAZINE 25 MG RECTAL SUPPOSITORY RX-11144 CDM 6370000100 HCPCS 250 RC 00713-0526-12 NDC outpatient 1 UN 38.15 38.15 CIGNA 62308 [3081051] CIGNA STATE OF WYOMING [308105107] 30.52 percent of total billed charges 23.65 36.24 Technical (Hospital) Services PROMETHAZINE 25 MG RECTAL SUPPOSITORY RX-11144 CDM 6370000100 HCPCS 250 RC 00713-0526-12 NDC outpatient 1 UN 38.15 38.15 UNITED HEALTHCARE (COMMERCIAL) [3081199] UNITED HEALTHCARE 87726 [308119901] 23.65 percent of total billed charges 23.65 36.24 Technical (Hospital) Services PROMETHAZINE 25 MG RECTAL SUPPOSITORY RX-11144 CDM 6370000100 HCPCS 250 RC 00713-0526-12 NDC outpatient 1 UN 38.15 38.15 MULTIPLAN INC 34080 [3081285] MULTIPLAN INC [308128501] 36.24 percent of total billed charges 23.65 36.24 Technical (Hospital) Services PROMETHAZINE 25 MG RECTAL SUPPOSITORY RX-11144 CDM 6370000100 HCPCS 250 RC 00713-0526-12 NDC outpatient 1 UN 38.15 38.15 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES PPO [308136801] 30.52 percent of total billed charges 23.65 36.24 Technical (Hospital) Services PROMETHAZINE 25 MG RECTAL SUPPOSITORY RX-11144 CDM 6370000100 HCPCS 250 RC 00713-0526-12 NDC outpatient 1 UN 38.15 38.15 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES HDHP [308136802] 30.52 percent of total billed charges 23.65 36.24 Technical (Hospital) Services PROMETHAZINE 25 MG RECTAL SUPPOSITORY RX-11144 CDM 6370000100 HCPCS 250 RC 00713-0526-12 NDC inpatient 1 UN 38.15 38.15 UNITED HEALTHCARE (COMMERCIAL) [3081199] UNITED HEALTHCARE 87726 [308119901] 23.65 percent of total billed charges 23.65 36.24 Technical (Hospital) Services PROMETHAZINE 25 MG RECTAL SUPPOSITORY RX-11144 CDM 6370000100 HCPCS 250 RC 00713-0526-12 NDC inpatient 1 UN 38.15 38.15 BLUE CROSS BLUE SHIELD WELLMARK SB889 [3081026] BCBS WYOMING [308102603] 36.24 percent of total billed charges 23.65 36.24 Technical (Hospital) Services PROMETHAZINE 25 MG RECTAL SUPPOSITORY RX-11144 CDM 6370000100 HCPCS 250 RC 00713-0526-12 NDC inpatient 1 UN 38.15 38.15 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES HDHP [308136802] 30.21 percent of total billed charges 23.65 36.24 Technical (Hospital) Services PROMETHAZINE 25 MG RECTAL SUPPOSITORY RX-11144 CDM 6370000100 HCPCS 250 RC 00713-0526-12 NDC inpatient 1 UN 38.15 38.15 HEALTHPARTNERS SX009 HEALTHPARTNERS 30.21 percent of total billed charges 23.65 36.24 Technical (Hospital) Services PROMETHAZINE 25 MG RECTAL SUPPOSITORY RX-11144 CDM 6370000100 HCPCS 250 RC 00713-0526-12 NDC inpatient 1 UN 38.15 38.15 MEDICA (COMMERCIAL) 94265 [3081118] MEDICA CLAIMS [308111801] 34.34 percent of total billed charges 23.65 36.24 Technical (Hospital) Services PROMETHAZINE 25 MG RECTAL SUPPOSITORY RX-11144 CDM 6370000100 HCPCS 250 RC 00713-0526-12 NDC inpatient 1 UN 38.15 38.15 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES EPO [308136803] 30.21 percent of total billed charges 23.65 36.24 Technical (Hospital) Services PROMETHAZINE 25 MG RECTAL SUPPOSITORY RX-11144 CDM 6370000100 HCPCS 250 RC 00713-0526-12 NDC inpatient 1 UN 38.15 38.15 CIGNA 62308 [3081051] CIGNA 62308 [308105105] 30.21 percent of total billed charges 23.65 36.24 Technical (Hospital) Services PROMETHAZINE 25 MG RECTAL SUPPOSITORY RX-11144 CDM 6370000100 HCPCS 250 RC 00713-0526-12 NDC inpatient 1 UN 38.15 38.15 CIGNA 62308 [3081051] CIGNA STATE OF WYOMING [308105107] 30.21 percent of total billed charges 23.65 36.24 Technical (Hospital) Services PROMETHAZINE 25 MG RECTAL SUPPOSITORY RX-11144 CDM 6370000100 HCPCS 250 RC 00713-0526-12 NDC inpatient 1 UN 38.15 38.15 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES PPO [308136801] 30.21 percent of total billed charges 23.65 36.24 Technical (Hospital) Services PROMETHAZINE 25 MG RECTAL SUPPOSITORY RX-11144 CDM 6370000100 HCPCS 250 RC 00713-0526-12 NDC inpatient 1 UN 38.15 38.15 MULTIPLAN INC 34080 [3081285] MULTIPLAN INC [308128501] 36.24 percent of total billed charges 23.65 36.24 Technical (Hospital) Services RAMIPRIL 10 MG CAPSULE RX-11259 CDM 6370000100 HCPCS 250 RC 65862-0477-01 NDC inpatient 1 UN 5.83 5.83 MULTIPLAN INC 34080 [3081285] MULTIPLAN INC [308128501] 5.54 percent of total billed charges 3.61 5.54 Technical (Hospital) Services RAMIPRIL 10 MG CAPSULE RX-11259 CDM 6370000100 HCPCS 250 RC 65862-0477-01 NDC inpatient 1 UN 5.83 5.83 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES PPO [308136801] 4.62 percent of total billed charges 3.61 5.54 Technical (Hospital) Services RAMIPRIL 10 MG CAPSULE RX-11259 CDM 6370000100 HCPCS 250 RC 65862-0477-01 NDC inpatient 1 UN 5.83 5.83 MEDICA (COMMERCIAL) 94265 [3081118] MEDICA CLAIMS [308111801] 5.25 percent of total billed charges 3.61 5.54 Technical (Hospital) Services RAMIPRIL 10 MG CAPSULE RX-11259 CDM 6370000100 HCPCS 250 RC 65862-0477-01 NDC inpatient 1 UN 5.83 5.83 HEALTHPARTNERS SX009 HEALTHPARTNERS 4.62 percent of total billed charges 3.61 5.54 Technical (Hospital) Services RAMIPRIL 10 MG CAPSULE RX-11259 CDM 6370000100 HCPCS 250 RC 65862-0477-01 NDC inpatient 1 UN 5.83 5.83 UNITED HEALTHCARE (COMMERCIAL) [3081199] UNITED HEALTHCARE 87726 [308119901] 3.61 percent of total billed charges 3.61 5.54 Technical (Hospital) Services RAMIPRIL 10 MG CAPSULE RX-11259 CDM 6370000100 HCPCS 250 RC 65862-0477-01 NDC inpatient 1 UN 5.83 5.83 BLUE CROSS BLUE SHIELD WELLMARK SB889 [3081026] BCBS WYOMING [308102603] 5.54 percent of total billed charges 3.61 5.54 Technical (Hospital) Services RAMIPRIL 10 MG CAPSULE RX-11259 CDM 6370000100 HCPCS 250 RC 65862-0477-01 NDC inpatient 1 UN 5.83 5.83 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES HDHP [308136802] 4.62 percent of total billed charges 3.61 5.54 Technical (Hospital) Services RAMIPRIL 10 MG CAPSULE RX-11259 CDM 6370000100 HCPCS 250 RC 65862-0477-01 NDC inpatient 1 UN 5.83 5.83 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES EPO [308136803] 4.62 percent of total billed charges 3.61 5.54 Technical (Hospital) Services RAMIPRIL 10 MG CAPSULE RX-11259 CDM 6370000100 HCPCS 250 RC 65862-0477-01 NDC inpatient 1 UN 5.83 5.83 CIGNA 62308 [3081051] CIGNA 62308 [308105105] 4.62 percent of total billed charges 3.61 5.54 Technical (Hospital) Services RAMIPRIL 10 MG CAPSULE RX-11259 CDM 6370000100 HCPCS 250 RC 65862-0477-01 NDC inpatient 1 UN 5.83 5.83 CIGNA 62308 [3081051] CIGNA STATE OF WYOMING [308105107] 4.62 percent of total billed charges 3.61 5.54 Technical (Hospital) Services RAMIPRIL 10 MG CAPSULE RX-11259 CDM 6370000100 HCPCS 250 RC 65862-0477-01 NDC outpatient 1 UN 5.83 5.83 UNITED HEALTHCARE (COMMERCIAL) [3081199] UNITED HEALTHCARE 87726 [308119901] 3.61 percent of total billed charges 3.61 5.54 Technical (Hospital) Services RAMIPRIL 10 MG CAPSULE RX-11259 CDM 6370000100 HCPCS 250 RC 65862-0477-01 NDC outpatient 1 UN 5.83 5.83 HEALTHPARTNERS SX009 HEALTHPARTNERS 4.66 percent of total billed charges 3.61 5.54 Technical (Hospital) Services RAMIPRIL 10 MG CAPSULE RX-11259 CDM 6370000100 HCPCS 250 RC 65862-0477-01 NDC outpatient 1 UN 5.83 5.83 CIGNA 62308 [3081051] CIGNA STATE OF WYOMING [308105107] 4.66 percent of total billed charges 3.61 5.54 Technical (Hospital) Services RAMIPRIL 10 MG CAPSULE RX-11259 CDM 6370000100 HCPCS 250 RC 65862-0477-01 NDC outpatient 1 UN 5.83 5.83 MULTIPLAN INC 34080 [3081285] MULTIPLAN INC [308128501] 5.54 percent of total billed charges 3.61 5.54 Technical (Hospital) Services RAMIPRIL 10 MG CAPSULE RX-11259 CDM 6370000100 HCPCS 250 RC 65862-0477-01 NDC outpatient 1 UN 5.83 5.83 CIGNA 62308 [3081051] CIGNA 62308 [308105105] 4.66 percent of total billed charges 3.61 5.54 Technical (Hospital) Services RAMIPRIL 10 MG CAPSULE RX-11259 CDM 6370000100 HCPCS 250 RC 65862-0477-01 NDC outpatient 1 UN 5.83 5.83 MEDICA (COMMERCIAL) 94265 [3081118] MEDICA CLAIMS [308111801] 5.25 percent of total billed charges 3.61 5.54 Technical (Hospital) Services RAMIPRIL 10 MG CAPSULE RX-11259 CDM 6370000100 HCPCS 250 RC 65862-0477-01 NDC outpatient 1 UN 5.83 5.83 BLUE CROSS BLUE SHIELD WELLMARK SB889 [3081026] BCBS WYOMING [308102603] 5.54 percent of total billed charges 3.61 5.54 Technical (Hospital) Services RAMIPRIL 10 MG CAPSULE RX-11259 CDM 6370000100 HCPCS 250 RC 65862-0477-01 NDC outpatient 1 UN 5.83 5.83 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES EPO [308136803] 4.66 percent of total billed charges 3.61 5.54 Technical (Hospital) Services RAMIPRIL 10 MG CAPSULE RX-11259 CDM 6370000100 HCPCS 250 RC 65862-0477-01 NDC outpatient 1 UN 5.83 5.83 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES HDHP [308136802] 4.66 percent of total billed charges 3.61 5.54 Technical (Hospital) Services RAMIPRIL 10 MG CAPSULE RX-11259 CDM 6370000100 HCPCS 250 RC 65862-0477-01 NDC outpatient 1 UN 5.83 5.83 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES PPO [308136801] 4.66 percent of total billed charges 3.61 5.54 Technical (Hospital) Services RAMIPRIL 2.5 MG CAPSULE RX-11260 CDM 6370000100 HCPCS 250 RC 65862-0475-01 NDC inpatient 1 UN 5.81 5.81 UNITED HEALTHCARE (COMMERCIAL) [3081199] UNITED HEALTHCARE 87726 [308119901] 3.6 percent of total billed charges 3.6 5.52 Technical (Hospital) Services RAMIPRIL 2.5 MG CAPSULE RX-11260 CDM 6370000100 HCPCS 250 RC 65862-0475-01 NDC inpatient 1 UN 5.81 5.81 BLUE CROSS BLUE SHIELD WELLMARK SB889 [3081026] BCBS WYOMING [308102603] 5.52 percent of total billed charges 3.6 5.52 Technical (Hospital) Services RAMIPRIL 2.5 MG CAPSULE RX-11260 CDM 6370000100 HCPCS 250 RC 65862-0475-01 NDC inpatient 1 UN 5.81 5.81 CIGNA 62308 [3081051] CIGNA 62308 [308105105] 4.6 percent of total billed charges 3.6 5.52 Technical (Hospital) Services RAMIPRIL 2.5 MG CAPSULE RX-11260 CDM 6370000100 HCPCS 250 RC 65862-0475-01 NDC inpatient 1 UN 5.81 5.81 CIGNA 62308 [3081051] CIGNA STATE OF WYOMING [308105107] 4.6 percent of total billed charges 3.6 5.52 Technical (Hospital) Services RAMIPRIL 2.5 MG CAPSULE RX-11260 CDM 6370000100 HCPCS 250 RC 65862-0475-01 NDC inpatient 1 UN 5.81 5.81 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES EPO [308136803] 4.6 percent of total billed charges 3.6 5.52 Technical (Hospital) Services RAMIPRIL 2.5 MG CAPSULE RX-11260 CDM 6370000100 HCPCS 250 RC 65862-0475-01 NDC inpatient 1 UN 5.81 5.81 MEDICA (COMMERCIAL) 94265 [3081118] MEDICA CLAIMS [308111801] 5.23 percent of total billed charges 3.6 5.52 Technical (Hospital) Services RAMIPRIL 2.5 MG CAPSULE RX-11260 CDM 6370000100 HCPCS 250 RC 65862-0475-01 NDC inpatient 1 UN 5.81 5.81 HEALTHPARTNERS SX009 HEALTHPARTNERS 4.6 percent of total billed charges 3.6 5.52 Technical (Hospital) Services RAMIPRIL 2.5 MG CAPSULE RX-11260 CDM 6370000100 HCPCS 250 RC 65862-0475-01 NDC inpatient 1 UN 5.81 5.81 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES HDHP [308136802] 4.6 percent of total billed charges 3.6 5.52 Technical (Hospital) Services RAMIPRIL 2.5 MG CAPSULE RX-11260 CDM 6370000100 HCPCS 250 RC 65862-0475-01 NDC inpatient 1 UN 5.81 5.81 MULTIPLAN INC 34080 [3081285] MULTIPLAN INC [308128501] 5.52 percent of total billed charges 3.6 5.52 Technical (Hospital) Services RAMIPRIL 2.5 MG CAPSULE RX-11260 CDM 6370000100 HCPCS 250 RC 65862-0475-01 NDC inpatient 1 UN 5.81 5.81 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES PPO [308136801] 4.6 percent of total billed charges 3.6 5.52 Technical (Hospital) Services RAMIPRIL 2.5 MG CAPSULE RX-11260 CDM 6370000100 HCPCS 250 RC 65862-0475-01 NDC outpatient 1 UN 5.81 5.81 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES HDHP [308136802] 4.65 percent of total billed charges 3.6 5.52 Technical (Hospital) Services RAMIPRIL 2.5 MG CAPSULE RX-11260 CDM 6370000100 HCPCS 250 RC 65862-0475-01 NDC outpatient 1 UN 5.81 5.81 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES PPO [308136801] 4.65 percent of total billed charges 3.6 5.52 Technical (Hospital) Services RAMIPRIL 2.5 MG CAPSULE RX-11260 CDM 6370000100 HCPCS 250 RC 65862-0475-01 NDC outpatient 1 UN 5.81 5.81 MEDICA (COMMERCIAL) 94265 [3081118] MEDICA CLAIMS [308111801] 5.23 percent of total billed charges 3.6 5.52 Technical (Hospital) Services RAMIPRIL 2.5 MG CAPSULE RX-11260 CDM 6370000100 HCPCS 250 RC 65862-0475-01 NDC outpatient 1 UN 5.81 5.81 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES EPO [308136803] 4.65 percent of total billed charges 3.6 5.52 Technical (Hospital) Services RAMIPRIL 2.5 MG CAPSULE RX-11260 CDM 6370000100 HCPCS 250 RC 65862-0475-01 NDC outpatient 1 UN 5.81 5.81 MULTIPLAN INC 34080 [3081285] MULTIPLAN INC [308128501] 5.52 percent of total billed charges 3.6 5.52 Technical (Hospital) Services RAMIPRIL 2.5 MG CAPSULE RX-11260 CDM 6370000100 HCPCS 250 RC 65862-0475-01 NDC outpatient 1 UN 5.81 5.81 CIGNA 62308 [3081051] CIGNA 62308 [308105105] 4.65 percent of total billed charges 3.6 5.52 Technical (Hospital) Services RAMIPRIL 2.5 MG CAPSULE RX-11260 CDM 6370000100 HCPCS 250 RC 65862-0475-01 NDC outpatient 1 UN 5.81 5.81 CIGNA 62308 [3081051] CIGNA STATE OF WYOMING [308105107] 4.65 percent of total billed charges 3.6 5.52 Technical (Hospital) Services RAMIPRIL 2.5 MG CAPSULE RX-11260 CDM 6370000100 HCPCS 250 RC 65862-0475-01 NDC outpatient 1 UN 5.81 5.81 UNITED HEALTHCARE (COMMERCIAL) [3081199] UNITED HEALTHCARE 87726 [308119901] 3.6 percent of total billed charges 3.6 5.52 Technical (Hospital) Services RAMIPRIL 2.5 MG CAPSULE RX-11260 CDM 6370000100 HCPCS 250 RC 65862-0475-01 NDC outpatient 1 UN 5.81 5.81 HEALTHPARTNERS SX009 HEALTHPARTNERS 4.65 percent of total billed charges 3.6 5.52 Technical (Hospital) Services RAMIPRIL 2.5 MG CAPSULE RX-11260 CDM 6370000100 HCPCS 250 RC 65862-0475-01 NDC outpatient 1 UN 5.81 5.81 BLUE CROSS BLUE SHIELD WELLMARK SB889 [3081026] BCBS WYOMING [308102603] 5.52 percent of total billed charges 3.6 5.52 Technical (Hospital) Services RIVAROXABAN 15 MG TABLET RX-112834 CDM 6370000100 HCPCS 250 RC 50458-0578-30 NDC outpatient 1 UN 66.99 66.99 HEALTHPARTNERS SX009 HEALTHPARTNERS 53.59 percent of total billed charges 41.53 63.64 Technical (Hospital) Services RIVAROXABAN 15 MG TABLET RX-112834 CDM 6370000100 HCPCS 250 RC 50458-0578-30 NDC outpatient 1 UN 66.99 66.99 BLUE CROSS BLUE SHIELD WELLMARK SB889 [3081026] BCBS WYOMING [308102603] 63.64 percent of total billed charges 41.53 63.64 Technical (Hospital) Services RIVAROXABAN 15 MG TABLET RX-112834 CDM 6370000100 HCPCS 250 RC 50458-0578-30 NDC outpatient 1 UN 66.99 66.99 MULTIPLAN INC 34080 [3081285] MULTIPLAN INC [308128501] 63.64 percent of total billed charges 41.53 63.64 Technical (Hospital) Services RIVAROXABAN 15 MG TABLET RX-112834 CDM 6370000100 HCPCS 250 RC 50458-0578-30 NDC outpatient 1 UN 66.99 66.99 UNITED HEALTHCARE (COMMERCIAL) [3081199] UNITED HEALTHCARE 87726 [308119901] 41.53 percent of total billed charges 41.53 63.64 Technical (Hospital) Services RIVAROXABAN 15 MG TABLET RX-112834 CDM 6370000100 HCPCS 250 RC 50458-0578-30 NDC outpatient 1 UN 66.99 66.99 CIGNA 62308 [3081051] CIGNA 62308 [308105105] 53.59 percent of total billed charges 41.53 63.64 Technical (Hospital) Services RIVAROXABAN 15 MG TABLET RX-112834 CDM 6370000100 HCPCS 250 RC 50458-0578-30 NDC outpatient 1 UN 66.99 66.99 CIGNA 62308 [3081051] CIGNA STATE OF WYOMING [308105107] 53.59 percent of total billed charges 41.53 63.64 Technical (Hospital) Services RIVAROXABAN 15 MG TABLET RX-112834 CDM 6370000100 HCPCS 250 RC 50458-0578-30 NDC outpatient 1 UN 66.99 66.99 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES EPO [308136803] 53.59 percent of total billed charges 41.53 63.64 Technical (Hospital) Services RIVAROXABAN 15 MG TABLET RX-112834 CDM 6370000100 HCPCS 250 RC 50458-0578-30 NDC outpatient 1 UN 66.99 66.99 MEDICA (COMMERCIAL) 94265 [3081118] MEDICA CLAIMS [308111801] 60.29 percent of total billed charges 41.53 63.64 Technical (Hospital) Services RIVAROXABAN 15 MG TABLET RX-112834 CDM 6370000100 HCPCS 250 RC 50458-0578-30 NDC outpatient 1 UN 66.99 66.99 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES HDHP [308136802] 53.59 percent of total billed charges 41.53 63.64 Technical (Hospital) Services RIVAROXABAN 15 MG TABLET RX-112834 CDM 6370000100 HCPCS 250 RC 50458-0578-30 NDC outpatient 1 UN 66.99 66.99 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES PPO [308136801] 53.59 percent of total billed charges 41.53 63.64 Technical (Hospital) Services RIVAROXABAN 15 MG TABLET RX-112834 CDM 6370000100 HCPCS 250 RC 50458-0578-30 NDC inpatient 1 UN 66.99 66.99 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES PPO [308136801] 53.04 percent of total billed charges 41.53 63.64 Technical (Hospital) Services RIVAROXABAN 15 MG TABLET RX-112834 CDM 6370000100 HCPCS 250 RC 50458-0578-30 NDC inpatient 1 UN 66.99 66.99 HEALTHPARTNERS SX009 HEALTHPARTNERS 53.04 percent of total billed charges 41.53 63.64 Technical (Hospital) Services RIVAROXABAN 15 MG TABLET RX-112834 CDM 6370000100 HCPCS 250 RC 50458-0578-30 NDC inpatient 1 UN 66.99 66.99 MEDICA (COMMERCIAL) 94265 [3081118] MEDICA CLAIMS [308111801] 60.29 percent of total billed charges 41.53 63.64 Technical (Hospital) Services RIVAROXABAN 15 MG TABLET RX-112834 CDM 6370000100 HCPCS 250 RC 50458-0578-30 NDC inpatient 1 UN 66.99 66.99 MULTIPLAN INC 34080 [3081285] MULTIPLAN INC [308128501] 63.64 percent of total billed charges 41.53 63.64 Technical (Hospital) Services RIVAROXABAN 15 MG TABLET RX-112834 CDM 6370000100 HCPCS 250 RC 50458-0578-30 NDC inpatient 1 UN 66.99 66.99 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES HDHP [308136802] 53.04 percent of total billed charges 41.53 63.64 Technical (Hospital) Services RIVAROXABAN 15 MG TABLET RX-112834 CDM 6370000100 HCPCS 250 RC 50458-0578-30 NDC inpatient 1 UN 66.99 66.99 CIGNA 62308 [3081051] CIGNA 62308 [308105105] 53.04 percent of total billed charges 41.53 63.64 Technical (Hospital) Services RIVAROXABAN 15 MG TABLET RX-112834 CDM 6370000100 HCPCS 250 RC 50458-0578-30 NDC inpatient 1 UN 66.99 66.99 CIGNA 62308 [3081051] CIGNA STATE OF WYOMING [308105107] 53.04 percent of total billed charges 41.53 63.64 Technical (Hospital) Services RIVAROXABAN 15 MG TABLET RX-112834 CDM 6370000100 HCPCS 250 RC 50458-0578-30 NDC inpatient 1 UN 66.99 66.99 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES EPO [308136803] 53.04 percent of total billed charges 41.53 63.64 Technical (Hospital) Services RIVAROXABAN 15 MG TABLET RX-112834 CDM 6370000100 HCPCS 250 RC 50458-0578-30 NDC inpatient 1 UN 66.99 66.99 BLUE CROSS BLUE SHIELD WELLMARK SB889 [3081026] BCBS WYOMING [308102603] 63.64 percent of total billed charges 41.53 63.64 Technical (Hospital) Services RIVAROXABAN 15 MG TABLET RX-112834 CDM 6370000100 HCPCS 250 RC 50458-0578-30 NDC inpatient 1 UN 66.99 66.99 UNITED HEALTHCARE (COMMERCIAL) [3081199] UNITED HEALTHCARE 87726 [308119901] 41.53 percent of total billed charges 41.53 63.64 Technical (Hospital) Services RIVAROXABAN 20 MG TABLET RX-112835 CDM 6370000100 HCPCS 250 RC 50458-0579-90 NDC inpatient 1 UN 66.99 66.99 MULTIPLAN INC 34080 [3081285] MULTIPLAN INC [308128501] 63.64 percent of total billed charges 41.53 63.64 Technical (Hospital) Services RIVAROXABAN 20 MG TABLET RX-112835 CDM 6370000100 HCPCS 250 RC 50458-0579-90 NDC inpatient 1 UN 66.99 66.99 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES PPO [308136801] 53.04 percent of total billed charges 41.53 63.64 Technical (Hospital) Services RIVAROXABAN 20 MG TABLET RX-112835 CDM 6370000100 HCPCS 250 RC 50458-0579-90 NDC inpatient 1 UN 66.99 66.99 MEDICA (COMMERCIAL) 94265 [3081118] MEDICA CLAIMS [308111801] 60.29 percent of total billed charges 41.53 63.64 Technical (Hospital) Services RIVAROXABAN 20 MG TABLET RX-112835 CDM 6370000100 HCPCS 250 RC 50458-0579-90 NDC inpatient 1 UN 66.99 66.99 HEALTHPARTNERS SX009 HEALTHPARTNERS 53.04 percent of total billed charges 41.53 63.64 Technical (Hospital) Services RIVAROXABAN 20 MG TABLET RX-112835 CDM 6370000100 HCPCS 250 RC 50458-0579-90 NDC inpatient 1 UN 66.99 66.99 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES HDHP [308136802] 53.04 percent of total billed charges 41.53 63.64 Technical (Hospital) Services RIVAROXABAN 20 MG TABLET RX-112835 CDM 6370000100 HCPCS 250 RC 50458-0579-90 NDC inpatient 1 UN 66.99 66.99 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES EPO [308136803] 53.04 percent of total billed charges 41.53 63.64 Technical (Hospital) Services RIVAROXABAN 20 MG TABLET RX-112835 CDM 6370000100 HCPCS 250 RC 50458-0579-90 NDC inpatient 1 UN 66.99 66.99 CIGNA 62308 [3081051] CIGNA 62308 [308105105] 53.04 percent of total billed charges 41.53 63.64 Technical (Hospital) Services RIVAROXABAN 20 MG TABLET RX-112835 CDM 6370000100 HCPCS 250 RC 50458-0579-90 NDC inpatient 1 UN 66.99 66.99 CIGNA 62308 [3081051] CIGNA STATE OF WYOMING [308105107] 53.04 percent of total billed charges 41.53 63.64 Technical (Hospital) Services RIVAROXABAN 20 MG TABLET RX-112835 CDM 6370000100 HCPCS 250 RC 50458-0579-90 NDC inpatient 1 UN 66.99 66.99 BLUE CROSS BLUE SHIELD WELLMARK SB889 [3081026] BCBS WYOMING [308102603] 63.64 percent of total billed charges 41.53 63.64 Technical (Hospital) Services RIVAROXABAN 20 MG TABLET RX-112835 CDM 6370000100 HCPCS 250 RC 50458-0579-90 NDC inpatient 1 UN 66.99 66.99 UNITED HEALTHCARE (COMMERCIAL) [3081199] UNITED HEALTHCARE 87726 [308119901] 41.53 percent of total billed charges 41.53 63.64 Technical (Hospital) Services RIVAROXABAN 20 MG TABLET RX-112835 CDM 6370000100 HCPCS 250 RC 50458-0579-90 NDC outpatient 1 UN 66.99 66.99 BLUE CROSS BLUE SHIELD WELLMARK SB889 [3081026] BCBS WYOMING [308102603] 63.64 percent of total billed charges 41.53 63.64 Technical (Hospital) Services RIVAROXABAN 20 MG TABLET RX-112835 CDM 6370000100 HCPCS 250 RC 50458-0579-90 NDC outpatient 1 UN 66.99 66.99 HEALTHPARTNERS SX009 HEALTHPARTNERS 53.59 percent of total billed charges 41.53 63.64 Technical (Hospital) Services RIVAROXABAN 20 MG TABLET RX-112835 CDM 6370000100 HCPCS 250 RC 50458-0579-90 NDC outpatient 1 UN 66.99 66.99 MULTIPLAN INC 34080 [3081285] MULTIPLAN INC [308128501] 63.64 percent of total billed charges 41.53 63.64 Technical (Hospital) Services RIVAROXABAN 20 MG TABLET RX-112835 CDM 6370000100 HCPCS 250 RC 50458-0579-90 NDC outpatient 1 UN 66.99 66.99 CIGNA 62308 [3081051] CIGNA 62308 [308105105] 53.59 percent of total billed charges 41.53 63.64 Technical (Hospital) Services RIVAROXABAN 20 MG TABLET RX-112835 CDM 6370000100 HCPCS 250 RC 50458-0579-90 NDC outpatient 1 UN 66.99 66.99 CIGNA 62308 [3081051] CIGNA STATE OF WYOMING [308105107] 53.59 percent of total billed charges 41.53 63.64 Technical (Hospital) Services RIVAROXABAN 20 MG TABLET RX-112835 CDM 6370000100 HCPCS 250 RC 50458-0579-90 NDC outpatient 1 UN 66.99 66.99 UNITED HEALTHCARE (COMMERCIAL) [3081199] UNITED HEALTHCARE 87726 [308119901] 41.53 percent of total billed charges 41.53 63.64 Technical (Hospital) Services RIVAROXABAN 20 MG TABLET RX-112835 CDM 6370000100 HCPCS 250 RC 50458-0579-90 NDC outpatient 1 UN 66.99 66.99 MEDICA (COMMERCIAL) 94265 [3081118] MEDICA CLAIMS [308111801] 60.29 percent of total billed charges 41.53 63.64 Technical (Hospital) Services RIVAROXABAN 20 MG TABLET RX-112835 CDM 6370000100 HCPCS 250 RC 50458-0579-90 NDC outpatient 1 UN 66.99 66.99 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES EPO [308136803] 53.59 percent of total billed charges 41.53 63.64 Technical (Hospital) Services RIVAROXABAN 20 MG TABLET RX-112835 CDM 6370000100 HCPCS 250 RC 50458-0579-90 NDC outpatient 1 UN 66.99 66.99 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES HDHP [308136802] 53.59 percent of total billed charges 41.53 63.64 Technical (Hospital) Services RIVAROXABAN 20 MG TABLET RX-112835 CDM 6370000100 HCPCS 250 RC 50458-0579-90 NDC outpatient 1 UN 66.99 66.99 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES PPO [308136801] 53.59 percent of total billed charges 41.53 63.64 Technical (Hospital) Services RIFAMPIN 300 MG CAPSULE RX-11293 CDM 6370000100 HCPCS 250 RC 68180-0659-06 NDC inpatient 1 UN 18.57 18.57 MULTIPLAN INC 34080 [3081285] MULTIPLAN INC [308128501] 17.64 percent of total billed charges 11.51 17.64 Technical (Hospital) Services RIFAMPIN 300 MG CAPSULE RX-11293 CDM 6370000100 HCPCS 250 RC 68180-0659-06 NDC inpatient 1 UN 18.57 18.57 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES PPO [308136801] 14.7 percent of total billed charges 11.51 17.64 Technical (Hospital) Services RIFAMPIN 300 MG CAPSULE RX-11293 CDM 6370000100 HCPCS 250 RC 68180-0659-06 NDC inpatient 1 UN 18.57 18.57 BLUE CROSS BLUE SHIELD WELLMARK SB889 [3081026] BCBS WYOMING [308102603] 17.64 percent of total billed charges 11.51 17.64 Technical (Hospital) Services RIFAMPIN 300 MG CAPSULE RX-11293 CDM 6370000100 HCPCS 250 RC 68180-0659-06 NDC inpatient 1 UN 18.57 18.57 UNITED HEALTHCARE (COMMERCIAL) [3081199] UNITED HEALTHCARE 87726 [308119901] 11.51 percent of total billed charges 11.51 17.64 Technical (Hospital) Services RIFAMPIN 300 MG CAPSULE RX-11293 CDM 6370000100 HCPCS 250 RC 68180-0659-06 NDC inpatient 1 UN 18.57 18.57 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES HDHP [308136802] 14.7 percent of total billed charges 11.51 17.64 Technical (Hospital) Services RIFAMPIN 300 MG CAPSULE RX-11293 CDM 6370000100 HCPCS 250 RC 68180-0659-06 NDC inpatient 1 UN 18.57 18.57 HEALTHPARTNERS SX009 HEALTHPARTNERS 14.7 percent of total billed charges 11.51 17.64 Technical (Hospital) Services RIFAMPIN 300 MG CAPSULE RX-11293 CDM 6370000100 HCPCS 250 RC 68180-0659-06 NDC inpatient 1 UN 18.57 18.57 MEDICA (COMMERCIAL) 94265 [3081118] MEDICA CLAIMS [308111801] 16.71 percent of total billed charges 11.51 17.64 Technical (Hospital) Services RIFAMPIN 300 MG CAPSULE RX-11293 CDM 6370000100 HCPCS 250 RC 68180-0659-06 NDC inpatient 1 UN 18.57 18.57 CIGNA 62308 [3081051] CIGNA 62308 [308105105] 14.7 percent of total billed charges 11.51 17.64 Technical (Hospital) Services RIFAMPIN 300 MG CAPSULE RX-11293 CDM 6370000100 HCPCS 250 RC 68180-0659-06 NDC inpatient 1 UN 18.57 18.57 CIGNA 62308 [3081051] CIGNA STATE OF WYOMING [308105107] 14.7 percent of total billed charges 11.51 17.64 Technical (Hospital) Services RIFAMPIN 300 MG CAPSULE RX-11293 CDM 6370000100 HCPCS 250 RC 68180-0659-06 NDC inpatient 1 UN 18.57 18.57 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES EPO [308136803] 14.7 percent of total billed charges 11.51 17.64 Technical (Hospital) Services RIFAMPIN 300 MG CAPSULE RX-11293 CDM 6370000100 HCPCS 250 RC 68180-0659-06 NDC outpatient 1 UN 18.57 18.57 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES PPO [308136801] 14.86 percent of total billed charges 11.51 17.64 Technical (Hospital) Services RIFAMPIN 300 MG CAPSULE RX-11293 CDM 6370000100 HCPCS 250 RC 68180-0659-06 NDC outpatient 1 UN 18.57 18.57 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES HDHP [308136802] 14.86 percent of total billed charges 11.51 17.64 Technical (Hospital) Services RIFAMPIN 300 MG CAPSULE RX-11293 CDM 6370000100 HCPCS 250 RC 68180-0659-06 NDC outpatient 1 UN 18.57 18.57 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES EPO [308136803] 14.86 percent of total billed charges 11.51 17.64 Technical (Hospital) Services RIFAMPIN 300 MG CAPSULE RX-11293 CDM 6370000100 HCPCS 250 RC 68180-0659-06 NDC outpatient 1 UN 18.57 18.57 MEDICA (COMMERCIAL) 94265 [3081118] MEDICA CLAIMS [308111801] 16.71 percent of total billed charges 11.51 17.64 Technical (Hospital) Services RIFAMPIN 300 MG CAPSULE RX-11293 CDM 6370000100 HCPCS 250 RC 68180-0659-06 NDC outpatient 1 UN 18.57 18.57 UNITED HEALTHCARE (COMMERCIAL) [3081199] UNITED HEALTHCARE 87726 [308119901] 11.51 percent of total billed charges 11.51 17.64 Technical (Hospital) Services RIFAMPIN 300 MG CAPSULE RX-11293 CDM 6370000100 HCPCS 250 RC 68180-0659-06 NDC outpatient 1 UN 18.57 18.57 CIGNA 62308 [3081051] CIGNA 62308 [308105105] 14.86 percent of total billed charges 11.51 17.64 Technical (Hospital) Services RIFAMPIN 300 MG CAPSULE RX-11293 CDM 6370000100 HCPCS 250 RC 68180-0659-06 NDC outpatient 1 UN 18.57 18.57 CIGNA 62308 [3081051] CIGNA STATE OF WYOMING [308105107] 14.86 percent of total billed charges 11.51 17.64 Technical (Hospital) Services RIFAMPIN 300 MG CAPSULE RX-11293 CDM 6370000100 HCPCS 250 RC 68180-0659-06 NDC outpatient 1 UN 18.57 18.57 MULTIPLAN INC 34080 [3081285] MULTIPLAN INC [308128501] 17.64 percent of total billed charges 11.51 17.64 Technical (Hospital) Services RIFAMPIN 300 MG CAPSULE RX-11293 CDM 6370000100 HCPCS 250 RC 68180-0659-06 NDC outpatient 1 UN 18.57 18.57 BLUE CROSS BLUE SHIELD WELLMARK SB889 [3081026] BCBS WYOMING [308102603] 17.64 percent of total billed charges 11.51 17.64 Technical (Hospital) Services RIFAMPIN 300 MG CAPSULE RX-11293 CDM 6370000100 HCPCS 250 RC 68180-0659-06 NDC outpatient 1 UN 18.57 18.57 HEALTHPARTNERS SX009 HEALTHPARTNERS 14.86 percent of total billed charges 11.51 17.64 Technical (Hospital) Services ACETAZOLAMIDE 250 MG TABLET RX-113 CDM 6370000100 HCPCS 250 RC 23155-0288-01 NDC inpatient 1 UN 5.97 5.97 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES PPO [308136801] 4.73 percent of total billed charges 3.7 5.67 Technical (Hospital) Services ACETAZOLAMIDE 250 MG TABLET RX-113 CDM 6370000100 HCPCS 250 RC 23155-0288-01 NDC inpatient 1 UN 5.97 5.97 MEDICA (COMMERCIAL) 94265 [3081118] MEDICA CLAIMS [308111801] 5.37 percent of total billed charges 3.7 5.67 Technical (Hospital) Services ACETAZOLAMIDE 250 MG TABLET RX-113 CDM 6370000100 HCPCS 250 RC 23155-0288-01 NDC inpatient 1 UN 5.97 5.97 HEALTHPARTNERS SX009 HEALTHPARTNERS 4.73 percent of total billed charges 3.7 5.67 Technical (Hospital) Services ACETAZOLAMIDE 250 MG TABLET RX-113 CDM 6370000100 HCPCS 250 RC 23155-0288-01 NDC inpatient 1 UN 5.97 5.97 MULTIPLAN INC 34080 [3081285] MULTIPLAN INC [308128501] 5.67 percent of total billed charges 3.7 5.67 Technical (Hospital) Services ACETAZOLAMIDE 250 MG TABLET RX-113 CDM 6370000100 HCPCS 250 RC 23155-0288-01 NDC inpatient 1 UN 5.97 5.97 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES HDHP [308136802] 4.73 percent of total billed charges 3.7 5.67 Technical (Hospital) Services ACETAZOLAMIDE 250 MG TABLET RX-113 CDM 6370000100 HCPCS 250 RC 23155-0288-01 NDC inpatient 1 UN 5.97 5.97 CIGNA 62308 [3081051] CIGNA 62308 [308105105] 4.73 percent of total billed charges 3.7 5.67 Technical (Hospital) Services ACETAZOLAMIDE 250 MG TABLET RX-113 CDM 6370000100 HCPCS 250 RC 23155-0288-01 NDC inpatient 1 UN 5.97 5.97 CIGNA 62308 [3081051] CIGNA STATE OF WYOMING [308105107] 4.73 percent of total billed charges 3.7 5.67 Technical (Hospital) Services ACETAZOLAMIDE 250 MG TABLET RX-113 CDM 6370000100 HCPCS 250 RC 23155-0288-01 NDC inpatient 1 UN 5.97 5.97 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES EPO [308136803] 4.73 percent of total billed charges 3.7 5.67 Technical (Hospital) Services ACETAZOLAMIDE 250 MG TABLET RX-113 CDM 6370000100 HCPCS 250 RC 23155-0288-01 NDC inpatient 1 UN 5.97 5.97 BLUE CROSS BLUE SHIELD WELLMARK SB889 [3081026] BCBS WYOMING [308102603] 5.67 percent of total billed charges 3.7 5.67 Technical (Hospital) Services ACETAZOLAMIDE 250 MG TABLET RX-113 CDM 6370000100 HCPCS 250 RC 23155-0288-01 NDC inpatient 1 UN 5.97 5.97 UNITED HEALTHCARE (COMMERCIAL) [3081199] UNITED HEALTHCARE 87726 [308119901] 3.7 percent of total billed charges 3.7 5.67 Technical (Hospital) Services ACETAZOLAMIDE 250 MG TABLET RX-113 CDM 6370000100 HCPCS 250 RC 23155-0288-01 NDC outpatient 1 UN 5.97 5.97 BLUE CROSS BLUE SHIELD WELLMARK SB889 [3081026] BCBS WYOMING [308102603] 5.67 percent of total billed charges 3.7 5.67 Technical (Hospital) Services ACETAZOLAMIDE 250 MG TABLET RX-113 CDM 6370000100 HCPCS 250 RC 23155-0288-01 NDC outpatient 1 UN 5.97 5.97 HEALTHPARTNERS SX009 HEALTHPARTNERS 4.78 percent of total billed charges 3.7 5.67 Technical (Hospital) Services ACETAZOLAMIDE 250 MG TABLET RX-113 CDM 6370000100 HCPCS 250 RC 23155-0288-01 NDC outpatient 1 UN 5.97 5.97 MULTIPLAN INC 34080 [3081285] MULTIPLAN INC [308128501] 5.67 percent of total billed charges 3.7 5.67 Technical (Hospital) Services ACETAZOLAMIDE 250 MG TABLET RX-113 CDM 6370000100 HCPCS 250 RC 23155-0288-01 NDC outpatient 1 UN 5.97 5.97 CIGNA 62308 [3081051] CIGNA 62308 [308105105] 4.78 percent of total billed charges 3.7 5.67 Technical (Hospital) Services ACETAZOLAMIDE 250 MG TABLET RX-113 CDM 6370000100 HCPCS 250 RC 23155-0288-01 NDC outpatient 1 UN 5.97 5.97 CIGNA 62308 [3081051] CIGNA STATE OF WYOMING [308105107] 4.78 percent of total billed charges 3.7 5.67 Technical (Hospital) Services ACETAZOLAMIDE 250 MG TABLET RX-113 CDM 6370000100 HCPCS 250 RC 23155-0288-01 NDC outpatient 1 UN 5.97 5.97 UNITED HEALTHCARE (COMMERCIAL) [3081199] UNITED HEALTHCARE 87726 [308119901] 3.7 percent of total billed charges 3.7 5.67 Technical (Hospital) Services ACETAZOLAMIDE 250 MG TABLET RX-113 CDM 6370000100 HCPCS 250 RC 23155-0288-01 NDC outpatient 1 UN 5.97 5.97 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES EPO [308136803] 4.78 percent of total billed charges 3.7 5.67 Technical (Hospital) Services ACETAZOLAMIDE 250 MG TABLET RX-113 CDM 6370000100 HCPCS 250 RC 23155-0288-01 NDC outpatient 1 UN 5.97 5.97 MEDICA (COMMERCIAL) 94265 [3081118] MEDICA CLAIMS [308111801] 5.37 percent of total billed charges 3.7 5.67 Technical (Hospital) Services ACETAZOLAMIDE 250 MG TABLET RX-113 CDM 6370000100 HCPCS 250 RC 23155-0288-01 NDC outpatient 1 UN 5.97 5.97 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES HDHP [308136802] 4.78 percent of total billed charges 3.7 5.67 Technical (Hospital) Services ACETAZOLAMIDE 250 MG TABLET RX-113 CDM 6370000100 HCPCS 250 RC 23155-0288-01 NDC outpatient 1 UN 5.97 5.97 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES PPO [308136801] 4.78 percent of total billed charges 3.7 5.67 Technical (Hospital) Services SERTRALINE 100 MG TABLET RX-11350 CDM 6370000100 HCPCS 250 RC 68180-0353-02 NDC outpatient 1 UN 5.72 5.72 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES HDHP [308136802] 4.58 percent of total billed charges 3.55 5.43 Technical (Hospital) Services SERTRALINE 100 MG TABLET RX-11350 CDM 6370000100 HCPCS 250 RC 68180-0353-02 NDC outpatient 1 UN 5.72 5.72 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES PPO [308136801] 4.58 percent of total billed charges 3.55 5.43 Technical (Hospital) Services SERTRALINE 100 MG TABLET RX-11350 CDM 6370000100 HCPCS 250 RC 68180-0353-02 NDC outpatient 1 UN 5.72 5.72 UNITED HEALTHCARE (COMMERCIAL) [3081199] UNITED HEALTHCARE 87726 [308119901] 3.55 percent of total billed charges 3.55 5.43 Technical (Hospital) Services SERTRALINE 100 MG TABLET RX-11350 CDM 6370000100 HCPCS 250 RC 68180-0353-02 NDC outpatient 1 UN 5.72 5.72 MULTIPLAN INC 34080 [3081285] MULTIPLAN INC [308128501] 5.43 percent of total billed charges 3.55 5.43 Technical (Hospital) Services SERTRALINE 100 MG TABLET RX-11350 CDM 6370000100 HCPCS 250 RC 68180-0353-02 NDC outpatient 1 UN 5.72 5.72 CIGNA 62308 [3081051] CIGNA 62308 [308105105] 4.58 percent of total billed charges 3.55 5.43 Technical (Hospital) Services SERTRALINE 100 MG TABLET RX-11350 CDM 6370000100 HCPCS 250 RC 68180-0353-02 NDC outpatient 1 UN 5.72 5.72 CIGNA 62308 [3081051] CIGNA STATE OF WYOMING [308105107] 4.58 percent of total billed charges 3.55 5.43 Technical (Hospital) Services SERTRALINE 100 MG TABLET RX-11350 CDM 6370000100 HCPCS 250 RC 68180-0353-02 NDC outpatient 1 UN 5.72 5.72 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES EPO [308136803] 4.58 percent of total billed charges 3.55 5.43 Technical (Hospital) Services SERTRALINE 100 MG TABLET RX-11350 CDM 6370000100 HCPCS 250 RC 68180-0353-02 NDC outpatient 1 UN 5.72 5.72 MEDICA (COMMERCIAL) 94265 [3081118] MEDICA CLAIMS [308111801] 5.15 percent of total billed charges 3.55 5.43 Technical (Hospital) Services SERTRALINE 100 MG TABLET RX-11350 CDM 6370000100 HCPCS 250 RC 68180-0353-02 NDC outpatient 1 UN 5.72 5.72 BLUE CROSS BLUE SHIELD WELLMARK SB889 [3081026] BCBS WYOMING [308102603] 5.43 percent of total billed charges 3.55 5.43 Technical (Hospital) Services SERTRALINE 100 MG TABLET RX-11350 CDM 6370000100 HCPCS 250 RC 68180-0353-02 NDC outpatient 1 UN 5.72 5.72 HEALTHPARTNERS SX009 HEALTHPARTNERS 4.58 percent of total billed charges 3.55 5.43 Technical (Hospital) Services SERTRALINE 100 MG TABLET RX-11350 CDM 6370000100 HCPCS 250 RC 68180-0353-02 NDC inpatient 1 UN 5.72 5.72 BLUE CROSS BLUE SHIELD WELLMARK SB889 [3081026] BCBS WYOMING [308102603] 5.43 percent of total billed charges 3.55 5.43 Technical (Hospital) Services SERTRALINE 100 MG TABLET RX-11350 CDM 6370000100 HCPCS 250 RC 68180-0353-02 NDC inpatient 1 UN 5.72 5.72 UNITED HEALTHCARE (COMMERCIAL) [3081199] UNITED HEALTHCARE 87726 [308119901] 3.55 percent of total billed charges 3.55 5.43 Technical (Hospital) Services SERTRALINE 100 MG TABLET RX-11350 CDM 6370000100 HCPCS 250 RC 68180-0353-02 NDC inpatient 1 UN 5.72 5.72 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES HDHP [308136802] 4.53 percent of total billed charges 3.55 5.43 Technical (Hospital) Services SERTRALINE 100 MG TABLET RX-11350 CDM 6370000100 HCPCS 250 RC 68180-0353-02 NDC inpatient 1 UN 5.72 5.72 HEALTHPARTNERS SX009 HEALTHPARTNERS 4.53 percent of total billed charges 3.55 5.43 Technical (Hospital) Services SERTRALINE 100 MG TABLET RX-11350 CDM 6370000100 HCPCS 250 RC 68180-0353-02 NDC inpatient 1 UN 5.72 5.72 MEDICA (COMMERCIAL) 94265 [3081118] MEDICA CLAIMS [308111801] 5.15 percent of total billed charges 3.55 5.43 Technical (Hospital) Services SERTRALINE 100 MG TABLET RX-11350 CDM 6370000100 HCPCS 250 RC 68180-0353-02 NDC inpatient 1 UN 5.72 5.72 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES EPO [308136803] 4.53 percent of total billed charges 3.55 5.43 Technical (Hospital) Services SERTRALINE 100 MG TABLET RX-11350 CDM 6370000100 HCPCS 250 RC 68180-0353-02 NDC inpatient 1 UN 5.72 5.72 CIGNA 62308 [3081051] CIGNA 62308 [308105105] 4.53 percent of total billed charges 3.55 5.43 Technical (Hospital) Services SERTRALINE 100 MG TABLET RX-11350 CDM 6370000100 HCPCS 250 RC 68180-0353-02 NDC inpatient 1 UN 5.72 5.72 CIGNA 62308 [3081051] CIGNA STATE OF WYOMING [308105107] 4.53 percent of total billed charges 3.55 5.43 Technical (Hospital) Services SERTRALINE 100 MG TABLET RX-11350 CDM 6370000100 HCPCS 250 RC 68180-0353-02 NDC inpatient 1 UN 5.72 5.72 MULTIPLAN INC 34080 [3081285] MULTIPLAN INC [308128501] 5.43 percent of total billed charges 3.55 5.43 Technical (Hospital) Services SERTRALINE 100 MG TABLET RX-11350 CDM 6370000100 HCPCS 250 RC 68180-0353-02 NDC inpatient 1 UN 5.72 5.72 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES PPO [308136801] 4.53 percent of total billed charges 3.55 5.43 Technical (Hospital) Services SERTRALINE 50 MG TABLET RX-11351 CDM 6370000100 HCPCS 250 RC 68180-0352-02 NDC inpatient 1 UN 5.72 5.72 MULTIPLAN INC 34080 [3081285] MULTIPLAN INC [308128501] 5.43 percent of total billed charges 3.55 5.43 Technical (Hospital) Services SERTRALINE 50 MG TABLET RX-11351 CDM 6370000100 HCPCS 250 RC 68180-0352-02 NDC inpatient 1 UN 5.72 5.72 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES PPO [308136801] 4.53 percent of total billed charges 3.55 5.43 Technical (Hospital) Services SERTRALINE 50 MG TABLET RX-11351 CDM 6370000100 HCPCS 250 RC 68180-0352-02 NDC inpatient 1 UN 5.72 5.72 BLUE CROSS BLUE SHIELD WELLMARK SB889 [3081026] BCBS WYOMING [308102603] 5.43 percent of total billed charges 3.55 5.43 Technical (Hospital) Services SERTRALINE 50 MG TABLET RX-11351 CDM 6370000100 HCPCS 250 RC 68180-0352-02 NDC inpatient 1 UN 5.72 5.72 UNITED HEALTHCARE (COMMERCIAL) [3081199] UNITED HEALTHCARE 87726 [308119901] 3.55 percent of total billed charges 3.55 5.43 Technical (Hospital) Services SERTRALINE 50 MG TABLET RX-11351 CDM 6370000100 HCPCS 250 RC 68180-0352-02 NDC inpatient 1 UN 5.72 5.72 MEDICA (COMMERCIAL) 94265 [3081118] MEDICA CLAIMS [308111801] 5.15 percent of total billed charges 3.55 5.43 Technical (Hospital) Services SERTRALINE 50 MG TABLET RX-11351 CDM 6370000100 HCPCS 250 RC 68180-0352-02 NDC inpatient 1 UN 5.72 5.72 HEALTHPARTNERS SX009 HEALTHPARTNERS 4.53 percent of total billed charges 3.55 5.43 Technical (Hospital) Services SERTRALINE 50 MG TABLET RX-11351 CDM 6370000100 HCPCS 250 RC 68180-0352-02 NDC inpatient 1 UN 5.72 5.72 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES HDHP [308136802] 4.53 percent of total billed charges 3.55 5.43 Technical (Hospital) Services SERTRALINE 50 MG TABLET RX-11351 CDM 6370000100 HCPCS 250 RC 68180-0352-02 NDC inpatient 1 UN 5.72 5.72 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES EPO [308136803] 4.53 percent of total billed charges 3.55 5.43 Technical (Hospital) Services SERTRALINE 50 MG TABLET RX-11351 CDM 6370000100 HCPCS 250 RC 68180-0352-02 NDC inpatient 1 UN 5.72 5.72 CIGNA 62308 [3081051] CIGNA 62308 [308105105] 4.53 percent of total billed charges 3.55 5.43 Technical (Hospital) Services SERTRALINE 50 MG TABLET RX-11351 CDM 6370000100 HCPCS 250 RC 68180-0352-02 NDC inpatient 1 UN 5.72 5.72 CIGNA 62308 [3081051] CIGNA STATE OF WYOMING [308105107] 4.53 percent of total billed charges 3.55 5.43 Technical (Hospital) Services SERTRALINE 50 MG TABLET RX-11351 CDM 6370000100 HCPCS 250 RC 68180-0352-02 NDC outpatient 1 UN 5.72 5.72 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES PPO [308136801] 4.58 percent of total billed charges 3.55 5.43 Technical (Hospital) Services SERTRALINE 50 MG TABLET RX-11351 CDM 6370000100 HCPCS 250 RC 68180-0352-02 NDC outpatient 1 UN 5.72 5.72 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES HDHP [308136802] 4.58 percent of total billed charges 3.55 5.43 Technical (Hospital) Services SERTRALINE 50 MG TABLET RX-11351 CDM 6370000100 HCPCS 250 RC 68180-0352-02 NDC outpatient 1 UN 5.72 5.72 CIGNA 62308 [3081051] CIGNA 62308 [308105105] 4.58 percent of total billed charges 3.55 5.43 Technical (Hospital) Services SERTRALINE 50 MG TABLET RX-11351 CDM 6370000100 HCPCS 250 RC 68180-0352-02 NDC outpatient 1 UN 5.72 5.72 CIGNA 62308 [3081051] CIGNA STATE OF WYOMING [308105107] 4.58 percent of total billed charges 3.55 5.43 Technical (Hospital) Services SERTRALINE 50 MG TABLET RX-11351 CDM 6370000100 HCPCS 250 RC 68180-0352-02 NDC outpatient 1 UN 5.72 5.72 MULTIPLAN INC 34080 [3081285] MULTIPLAN INC [308128501] 5.43 percent of total billed charges 3.55 5.43 Technical (Hospital) Services SERTRALINE 50 MG TABLET RX-11351 CDM 6370000100 HCPCS 250 RC 68180-0352-02 NDC outpatient 1 UN 5.72 5.72 UNITED HEALTHCARE (COMMERCIAL) [3081199] UNITED HEALTHCARE 87726 [308119901] 3.55 percent of total billed charges 3.55 5.43 Technical (Hospital) Services SERTRALINE 50 MG TABLET RX-11351 CDM 6370000100 HCPCS 250 RC 68180-0352-02 NDC outpatient 1 UN 5.72 5.72 MEDICA (COMMERCIAL) 94265 [3081118] MEDICA CLAIMS [308111801] 5.15 percent of total billed charges 3.55 5.43 Technical (Hospital) Services SERTRALINE 50 MG TABLET RX-11351 CDM 6370000100 HCPCS 250 RC 68180-0352-02 NDC outpatient 1 UN 5.72 5.72 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES EPO [308136803] 4.58 percent of total billed charges 3.55 5.43 Technical (Hospital) Services SERTRALINE 50 MG TABLET RX-11351 CDM 6370000100 HCPCS 250 RC 68180-0352-02 NDC outpatient 1 UN 5.72 5.72 BLUE CROSS BLUE SHIELD WELLMARK SB889 [3081026] BCBS WYOMING [308102603] 5.43 percent of total billed charges 3.55 5.43 Technical (Hospital) Services SERTRALINE 50 MG TABLET RX-11351 CDM 6370000100 HCPCS 250 RC 68180-0352-02 NDC outpatient 1 UN 5.72 5.72 HEALTHPARTNERS SX009 HEALTHPARTNERS 4.58 percent of total billed charges 3.55 5.43 Technical (Hospital) Services SIMVASTATIN 10 MG TABLET RX-11364 CDM 6370000100 HCPCS 250 RC 16729-0004-15 NDC inpatient 1 UN 5.67 5.67 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES EPO [308136803] 4.49 percent of total billed charges 3.52 5.39 Technical (Hospital) Services SIMVASTATIN 10 MG TABLET RX-11364 CDM 6370000100 HCPCS 250 RC 16729-0004-15 NDC inpatient 1 UN 5.67 5.67 CIGNA 62308 [3081051] CIGNA 62308 [308105105] 4.49 percent of total billed charges 3.52 5.39 Technical (Hospital) Services SIMVASTATIN 10 MG TABLET RX-11364 CDM 6370000100 HCPCS 250 RC 16729-0004-15 NDC inpatient 1 UN 5.67 5.67 CIGNA 62308 [3081051] CIGNA STATE OF WYOMING [308105107] 4.49 percent of total billed charges 3.52 5.39 Technical (Hospital) Services SIMVASTATIN 10 MG TABLET RX-11364 CDM 6370000100 HCPCS 250 RC 16729-0004-15 NDC inpatient 1 UN 5.67 5.67 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES HDHP [308136802] 4.49 percent of total billed charges 3.52 5.39 Technical (Hospital) Services SIMVASTATIN 10 MG TABLET RX-11364 CDM 6370000100 HCPCS 250 RC 16729-0004-15 NDC inpatient 1 UN 5.67 5.67 HEALTHPARTNERS SX009 HEALTHPARTNERS 4.49 percent of total billed charges 3.52 5.39 Technical (Hospital) Services SIMVASTATIN 10 MG TABLET RX-11364 CDM 6370000100 HCPCS 250 RC 16729-0004-15 NDC inpatient 1 UN 5.67 5.67 MEDICA (COMMERCIAL) 94265 [3081118] MEDICA CLAIMS [308111801] 5.1 percent of total billed charges 3.52 5.39 Technical (Hospital) Services SIMVASTATIN 10 MG TABLET RX-11364 CDM 6370000100 HCPCS 250 RC 16729-0004-15 NDC inpatient 1 UN 5.67 5.67 BLUE CROSS BLUE SHIELD WELLMARK SB889 [3081026] BCBS WYOMING [308102603] 5.39 percent of total billed charges 3.52 5.39 Technical (Hospital) Services SIMVASTATIN 10 MG TABLET RX-11364 CDM 6370000100 HCPCS 250 RC 16729-0004-15 NDC inpatient 1 UN 5.67 5.67 UNITED HEALTHCARE (COMMERCIAL) [3081199] UNITED HEALTHCARE 87726 [308119901] 3.52 percent of total billed charges 3.52 5.39 Technical (Hospital) Services SIMVASTATIN 10 MG TABLET RX-11364 CDM 6370000100 HCPCS 250 RC 16729-0004-15 NDC inpatient 1 UN 5.67 5.67 MULTIPLAN INC 34080 [3081285] MULTIPLAN INC [308128501] 5.39 percent of total billed charges 3.52 5.39 Technical (Hospital) Services SIMVASTATIN 10 MG TABLET RX-11364 CDM 6370000100 HCPCS 250 RC 16729-0004-15 NDC inpatient 1 UN 5.67 5.67 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES PPO [308136801] 4.49 percent of total billed charges 3.52 5.39 Technical (Hospital) Services SIMVASTATIN 10 MG TABLET RX-11364 CDM 6370000100 HCPCS 250 RC 16729-0004-15 NDC outpatient 1 UN 5.67 5.67 BLUE CROSS BLUE SHIELD WELLMARK SB889 [3081026] BCBS WYOMING [308102603] 5.39 percent of total billed charges 3.52 5.39 Technical (Hospital) Services SIMVASTATIN 10 MG TABLET RX-11364 CDM 6370000100 HCPCS 250 RC 16729-0004-15 NDC outpatient 1 UN 5.67 5.67 HEALTHPARTNERS SX009 HEALTHPARTNERS 4.54 percent of total billed charges 3.52 5.39 Technical (Hospital) Services SIMVASTATIN 10 MG TABLET RX-11364 CDM 6370000100 HCPCS 250 RC 16729-0004-15 NDC outpatient 1 UN 5.67 5.67 UNITED HEALTHCARE (COMMERCIAL) [3081199] UNITED HEALTHCARE 87726 [308119901] 3.52 percent of total billed charges 3.52 5.39 Technical (Hospital) Services SIMVASTATIN 10 MG TABLET RX-11364 CDM 6370000100 HCPCS 250 RC 16729-0004-15 NDC outpatient 1 UN 5.67 5.67 MULTIPLAN INC 34080 [3081285] MULTIPLAN INC [308128501] 5.39 percent of total billed charges 3.52 5.39 Technical (Hospital) Services SIMVASTATIN 10 MG TABLET RX-11364 CDM 6370000100 HCPCS 250 RC 16729-0004-15 NDC outpatient 1 UN 5.67 5.67 CIGNA 62308 [3081051] CIGNA 62308 [308105105] 4.54 percent of total billed charges 3.52 5.39 Technical (Hospital) Services SIMVASTATIN 10 MG TABLET RX-11364 CDM 6370000100 HCPCS 250 RC 16729-0004-15 NDC outpatient 1 UN 5.67 5.67 CIGNA 62308 [3081051] CIGNA STATE OF WYOMING [308105107] 4.54 percent of total billed charges 3.52 5.39 Technical (Hospital) Services SIMVASTATIN 10 MG TABLET RX-11364 CDM 6370000100 HCPCS 250 RC 16729-0004-15 NDC outpatient 1 UN 5.67 5.67 MEDICA (COMMERCIAL) 94265 [3081118] MEDICA CLAIMS [308111801] 5.1 percent of total billed charges 3.52 5.39 Technical (Hospital) Services SIMVASTATIN 10 MG TABLET RX-11364 CDM 6370000100 HCPCS 250 RC 16729-0004-15 NDC outpatient 1 UN 5.67 5.67 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES PPO [308136801] 4.54 percent of total billed charges 3.52 5.39 Technical (Hospital) Services SIMVASTATIN 10 MG TABLET RX-11364 CDM 6370000100 HCPCS 250 RC 16729-0004-15 NDC outpatient 1 UN 5.67 5.67 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES EPO [308136803] 4.54 percent of total billed charges 3.52 5.39 Technical (Hospital) Services SIMVASTATIN 10 MG TABLET RX-11364 CDM 6370000100 HCPCS 250 RC 16729-0004-15 NDC outpatient 1 UN 5.67 5.67 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES HDHP [308136802] 4.54 percent of total billed charges 3.52 5.39 Technical (Hospital) Services SIMVASTATIN 20 MG TABLET RX-11365 CDM 6370000100 HCPCS 250 RC 70377-0003-14 NDC inpatient 1 UN 5.73 5.73 UNITED HEALTHCARE (COMMERCIAL) [3081199] UNITED HEALTHCARE 87726 [308119901] 3.55 percent of total billed charges 3.55 5.44 Technical (Hospital) Services SIMVASTATIN 20 MG TABLET RX-11365 CDM 6370000100 HCPCS 250 RC 70377-0003-14 NDC inpatient 1 UN 5.73 5.73 BLUE CROSS BLUE SHIELD WELLMARK SB889 [3081026] BCBS WYOMING [308102603] 5.44 percent of total billed charges 3.55 5.44 Technical (Hospital) Services SIMVASTATIN 20 MG TABLET RX-11365 CDM 6370000100 HCPCS 250 RC 70377-0003-14 NDC inpatient 1 UN 5.73 5.73 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES HDHP [308136802] 4.54 percent of total billed charges 3.55 5.44 Technical (Hospital) Services SIMVASTATIN 20 MG TABLET RX-11365 CDM 6370000100 HCPCS 250 RC 70377-0003-14 NDC inpatient 1 UN 5.73 5.73 CIGNA 62308 [3081051] CIGNA 62308 [308105105] 4.54 percent of total billed charges 3.55 5.44 Technical (Hospital) Services SIMVASTATIN 20 MG TABLET RX-11365 CDM 6370000100 HCPCS 250 RC 70377-0003-14 NDC inpatient 1 UN 5.73 5.73 CIGNA 62308 [3081051] CIGNA STATE OF WYOMING [308105107] 4.54 percent of total billed charges 3.55 5.44 Technical (Hospital) Services SIMVASTATIN 20 MG TABLET RX-11365 CDM 6370000100 HCPCS 250 RC 70377-0003-14 NDC inpatient 1 UN 5.73 5.73 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES EPO [308136803] 4.54 percent of total billed charges 3.55 5.44 Technical (Hospital) Services SIMVASTATIN 20 MG TABLET RX-11365 CDM 6370000100 HCPCS 250 RC 70377-0003-14 NDC inpatient 1 UN 5.73 5.73 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES PPO [308136801] 4.54 percent of total billed charges 3.55 5.44 Technical (Hospital) Services SIMVASTATIN 20 MG TABLET RX-11365 CDM 6370000100 HCPCS 250 RC 70377-0003-14 NDC inpatient 1 UN 5.73 5.73 MEDICA (COMMERCIAL) 94265 [3081118] MEDICA CLAIMS [308111801] 5.16 percent of total billed charges 3.55 5.44 Technical (Hospital) Services SIMVASTATIN 20 MG TABLET RX-11365 CDM 6370000100 HCPCS 250 RC 70377-0003-14 NDC inpatient 1 UN 5.73 5.73 HEALTHPARTNERS SX009 HEALTHPARTNERS 4.54 percent of total billed charges 3.55 5.44 Technical (Hospital) Services SIMVASTATIN 20 MG TABLET RX-11365 CDM 6370000100 HCPCS 250 RC 70377-0003-14 NDC inpatient 1 UN 5.73 5.73 MULTIPLAN INC 34080 [3081285] MULTIPLAN INC [308128501] 5.44 percent of total billed charges 3.55 5.44 Technical (Hospital) Services SIMVASTATIN 20 MG TABLET RX-11365 CDM 6370000100 HCPCS 250 RC 70377-0003-14 NDC outpatient 1 UN 5.73 5.73 BLUE CROSS BLUE SHIELD WELLMARK SB889 [3081026] BCBS WYOMING [308102603] 5.44 percent of total billed charges 3.55 5.44 Technical (Hospital) Services SIMVASTATIN 20 MG TABLET RX-11365 CDM 6370000100 HCPCS 250 RC 70377-0003-14 NDC outpatient 1 UN 5.73 5.73 HEALTHPARTNERS SX009 HEALTHPARTNERS 4.58 percent of total billed charges 3.55 5.44 Technical (Hospital) Services SIMVASTATIN 20 MG TABLET RX-11365 CDM 6370000100 HCPCS 250 RC 70377-0003-14 NDC outpatient 1 UN 5.73 5.73 UNITED HEALTHCARE (COMMERCIAL) [3081199] UNITED HEALTHCARE 87726 [308119901] 3.55 percent of total billed charges 3.55 5.44 Technical (Hospital) Services SIMVASTATIN 20 MG TABLET RX-11365 CDM 6370000100 HCPCS 250 RC 70377-0003-14 NDC outpatient 1 UN 5.73 5.73 CIGNA 62308 [3081051] CIGNA 62308 [308105105] 4.58 percent of total billed charges 3.55 5.44 Technical (Hospital) Services SIMVASTATIN 20 MG TABLET RX-11365 CDM 6370000100 HCPCS 250 RC 70377-0003-14 NDC outpatient 1 UN 5.73 5.73 CIGNA 62308 [3081051] CIGNA STATE OF WYOMING [308105107] 4.58 percent of total billed charges 3.55 5.44 Technical (Hospital) Services SIMVASTATIN 20 MG TABLET RX-11365 CDM 6370000100 HCPCS 250 RC 70377-0003-14 NDC outpatient 1 UN 5.73 5.73 MULTIPLAN INC 34080 [3081285] MULTIPLAN INC [308128501] 5.44 percent of total billed charges 3.55 5.44 Technical (Hospital) Services SIMVASTATIN 20 MG TABLET RX-11365 CDM 6370000100 HCPCS 250 RC 70377-0003-14 NDC outpatient 1 UN 5.73 5.73 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES EPO [308136803] 4.58 percent of total billed charges 3.55 5.44 Technical (Hospital) Services SIMVASTATIN 20 MG TABLET RX-11365 CDM 6370000100 HCPCS 250 RC 70377-0003-14 NDC outpatient 1 UN 5.73 5.73 MEDICA (COMMERCIAL) 94265 [3081118] MEDICA CLAIMS [308111801] 5.16 percent of total billed charges 3.55 5.44 Technical (Hospital) Services SIMVASTATIN 20 MG TABLET RX-11365 CDM 6370000100 HCPCS 250 RC 70377-0003-14 NDC outpatient 1 UN 5.73 5.73 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES HDHP [308136802] 4.58 percent of total billed charges 3.55 5.44 Technical (Hospital) Services SIMVASTATIN 20 MG TABLET RX-11365 CDM 6370000100 HCPCS 250 RC 70377-0003-14 NDC outpatient 1 UN 5.73 5.73 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES PPO [308136801] 4.58 percent of total billed charges 3.55 5.44 Technical (Hospital) Services SODIUM PHOSPHATE 19 GRAM-7 GRAM/118 ML ENEMA RX-11395 CDM 6370000100 HCPCS 250 RC 00132-0201-40 NDC outpatient 1 UN 6.55 6.55 MULTIPLAN INC 34080 [3081285] MULTIPLAN INC [308128501] 6.22 percent of total billed charges 4.06 6.22 Technical (Hospital) Services SODIUM PHOSPHATE 19 GRAM-7 GRAM/118 ML ENEMA RX-11395 CDM 6370000100 HCPCS 250 RC 00132-0201-40 NDC outpatient 1 UN 6.55 6.55 CIGNA 62308 [3081051] CIGNA 62308 [308105105] 5.24 percent of total billed charges 4.06 6.22 Technical (Hospital) Services SODIUM PHOSPHATE 19 GRAM-7 GRAM/118 ML ENEMA RX-11395 CDM 6370000100 HCPCS 250 RC 00132-0201-40 NDC outpatient 1 UN 6.55 6.55 CIGNA 62308 [3081051] CIGNA STATE OF WYOMING [308105107] 5.24 percent of total billed charges 4.06 6.22 Technical (Hospital) Services SODIUM PHOSPHATE 19 GRAM-7 GRAM/118 ML ENEMA RX-11395 CDM 6370000100 HCPCS 250 RC 00132-0201-40 NDC outpatient 1 UN 6.55 6.55 MEDICA (COMMERCIAL) 94265 [3081118] MEDICA CLAIMS [308111801] 5.9 percent of total billed charges 4.06 6.22 Technical (Hospital) Services SODIUM PHOSPHATE 19 GRAM-7 GRAM/118 ML ENEMA RX-11395 CDM 6370000100 HCPCS 250 RC 00132-0201-40 NDC outpatient 1 UN 6.55 6.55 HEALTHPARTNERS SX009 HEALTHPARTNERS 5.24 percent of total billed charges 4.06 6.22 Technical (Hospital) Services SODIUM PHOSPHATE 19 GRAM-7 GRAM/118 ML ENEMA RX-11395 CDM 6370000100 HCPCS 250 RC 00132-0201-40 NDC outpatient 1 UN 6.55 6.55 UNITED HEALTHCARE (COMMERCIAL) [3081199] UNITED HEALTHCARE 87726 [308119901] 4.06 percent of total billed charges 4.06 6.22 Technical (Hospital) Services SODIUM PHOSPHATE 19 GRAM-7 GRAM/118 ML ENEMA RX-11395 CDM 6370000100 HCPCS 250 RC 00132-0201-40 NDC outpatient 1 UN 6.55 6.55 BLUE CROSS BLUE SHIELD WELLMARK SB889 [3081026] BCBS WYOMING [308102603] 6.22 percent of total billed charges 4.06 6.22 Technical (Hospital) Services SODIUM PHOSPHATE 19 GRAM-7 GRAM/118 ML ENEMA RX-11395 CDM 6370000100 HCPCS 250 RC 00132-0201-40 NDC outpatient 1 UN 6.55 6.55 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES HDHP [308136802] 5.24 percent of total billed charges 4.06 6.22 Technical (Hospital) Services SODIUM PHOSPHATE 19 GRAM-7 GRAM/118 ML ENEMA RX-11395 CDM 6370000100 HCPCS 250 RC 00132-0201-40 NDC outpatient 1 UN 6.55 6.55 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES EPO [308136803] 5.24 percent of total billed charges 4.06 6.22 Technical (Hospital) Services SODIUM PHOSPHATE 19 GRAM-7 GRAM/118 ML ENEMA RX-11395 CDM 6370000100 HCPCS 250 RC 00132-0201-40 NDC outpatient 1 UN 6.55 6.55 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES PPO [308136801] 5.24 percent of total billed charges 4.06 6.22 Technical (Hospital) Services SODIUM PHOSPHATE 19 GRAM-7 GRAM/118 ML ENEMA RX-11395 CDM 6370000100 HCPCS 250 RC 00132-0201-40 NDC inpatient 1 UN 6.55 6.55 BLUE CROSS BLUE SHIELD WELLMARK SB889 [3081026] BCBS WYOMING [308102603] 6.22 percent of total billed charges 4.06 6.22 Technical (Hospital) Services SODIUM PHOSPHATE 19 GRAM-7 GRAM/118 ML ENEMA RX-11395 CDM 6370000100 HCPCS 250 RC 00132-0201-40 NDC inpatient 1 UN 6.55 6.55 UNITED HEALTHCARE (COMMERCIAL) [3081199] UNITED HEALTHCARE 87726 [308119901] 4.06 percent of total billed charges 4.06 6.22 Technical (Hospital) Services SODIUM PHOSPHATE 19 GRAM-7 GRAM/118 ML ENEMA RX-11395 CDM 6370000100 HCPCS 250 RC 00132-0201-40 NDC inpatient 1 UN 6.55 6.55 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES HDHP [308136802] 5.19 percent of total billed charges 4.06 6.22 Technical (Hospital) Services SODIUM PHOSPHATE 19 GRAM-7 GRAM/118 ML ENEMA RX-11395 CDM 6370000100 HCPCS 250 RC 00132-0201-40 NDC inpatient 1 UN 6.55 6.55 HEALTHPARTNERS SX009 HEALTHPARTNERS 5.19 percent of total billed charges 4.06 6.22 Technical (Hospital) Services SODIUM PHOSPHATE 19 GRAM-7 GRAM/118 ML ENEMA RX-11395 CDM 6370000100 HCPCS 250 RC 00132-0201-40 NDC inpatient 1 UN 6.55 6.55 MEDICA (COMMERCIAL) 94265 [3081118] MEDICA CLAIMS [308111801] 5.9 percent of total billed charges 4.06 6.22 Technical (Hospital) Services SODIUM PHOSPHATE 19 GRAM-7 GRAM/118 ML ENEMA RX-11395 CDM 6370000100 HCPCS 250 RC 00132-0201-40 NDC inpatient 1 UN 6.55 6.55 CIGNA 62308 [3081051] CIGNA 62308 [308105105] 5.19 percent of total billed charges 4.06 6.22 Technical (Hospital) Services SODIUM PHOSPHATE 19 GRAM-7 GRAM/118 ML ENEMA RX-11395 CDM 6370000100 HCPCS 250 RC 00132-0201-40 NDC inpatient 1 UN 6.55 6.55 CIGNA 62308 [3081051] CIGNA STATE OF WYOMING [308105107] 5.19 percent of total billed charges 4.06 6.22 Technical (Hospital) Services SODIUM PHOSPHATE 19 GRAM-7 GRAM/118 ML ENEMA RX-11395 CDM 6370000100 HCPCS 250 RC 00132-0201-40 NDC inpatient 1 UN 6.55 6.55 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES EPO [308136803] 5.19 percent of total billed charges 4.06 6.22 Technical (Hospital) Services SODIUM PHOSPHATE 19 GRAM-7 GRAM/118 ML ENEMA RX-11395 CDM 6370000100 HCPCS 250 RC 00132-0201-40 NDC inpatient 1 UN 6.55 6.55 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES PPO [308136801] 5.19 percent of total billed charges 4.06 6.22 Technical (Hospital) Services SODIUM PHOSPHATE 19 GRAM-7 GRAM/118 ML ENEMA RX-11395 CDM 6370000100 HCPCS 250 RC 00132-0201-40 NDC inpatient 1 UN 6.55 6.55 MULTIPLAN INC 34080 [3081285] MULTIPLAN INC [308128501] 6.22 percent of total billed charges 4.06 6.22 Technical (Hospital) Services SOTALOL 80 MG TABLET RX-11421 CDM 6370000100 HCPCS 250 RC 60505-0080-00 NDC outpatient 1 UN 5.71 5.71 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES PPO [308136801] 4.57 percent of total billed charges 3.54 5.42 Technical (Hospital) Services SOTALOL 80 MG TABLET RX-11421 CDM 6370000100 HCPCS 250 RC 60505-0080-00 NDC outpatient 1 UN 5.71 5.71 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES HDHP [308136802] 4.57 percent of total billed charges 3.54 5.42 Technical (Hospital) Services SOTALOL 80 MG TABLET RX-11421 CDM 6370000100 HCPCS 250 RC 60505-0080-00 NDC outpatient 1 UN 5.71 5.71 HEALTHPARTNERS SX009 HEALTHPARTNERS 4.57 percent of total billed charges 3.54 5.42 Technical (Hospital) Services SOTALOL 80 MG TABLET RX-11421 CDM 6370000100 HCPCS 250 RC 60505-0080-00 NDC outpatient 1 UN 5.71 5.71 BLUE CROSS BLUE SHIELD WELLMARK SB889 [3081026] BCBS WYOMING [308102603] 5.42 percent of total billed charges 3.54 5.42 Technical (Hospital) Services SOTALOL 80 MG TABLET RX-11421 CDM 6370000100 HCPCS 250 RC 60505-0080-00 NDC outpatient 1 UN 5.71 5.71 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES EPO [308136803] 4.57 percent of total billed charges 3.54 5.42 Technical (Hospital) Services SOTALOL 80 MG TABLET RX-11421 CDM 6370000100 HCPCS 250 RC 60505-0080-00 NDC outpatient 1 UN 5.71 5.71 MEDICA (COMMERCIAL) 94265 [3081118] MEDICA CLAIMS [308111801] 5.14 percent of total billed charges 3.54 5.42 Technical (Hospital) Services SOTALOL 80 MG TABLET RX-11421 CDM 6370000100 HCPCS 250 RC 60505-0080-00 NDC outpatient 1 UN 5.71 5.71 CIGNA 62308 [3081051] CIGNA 62308 [308105105] 4.57 percent of total billed charges 3.54 5.42 Technical (Hospital) Services SOTALOL 80 MG TABLET RX-11421 CDM 6370000100 HCPCS 250 RC 60505-0080-00 NDC outpatient 1 UN 5.71 5.71 CIGNA 62308 [3081051] CIGNA STATE OF WYOMING [308105107] 4.57 percent of total billed charges 3.54 5.42 Technical (Hospital) Services SOTALOL 80 MG TABLET RX-11421 CDM 6370000100 HCPCS 250 RC 60505-0080-00 NDC outpatient 1 UN 5.71 5.71 MULTIPLAN INC 34080 [3081285] MULTIPLAN INC [308128501] 5.42 percent of total billed charges 3.54 5.42 Technical (Hospital) Services SOTALOL 80 MG TABLET RX-11421 CDM 6370000100 HCPCS 250 RC 60505-0080-00 NDC outpatient 1 UN 5.71 5.71 UNITED HEALTHCARE (COMMERCIAL) [3081199] UNITED HEALTHCARE 87726 [308119901] 3.54 percent of total billed charges 3.54 5.42 Technical (Hospital) Services SOTALOL 80 MG TABLET RX-11421 CDM 6370000100 HCPCS 250 RC 60505-0080-00 NDC inpatient 1 UN 5.71 5.71 MULTIPLAN INC 34080 [3081285] MULTIPLAN INC [308128501] 5.42 percent of total billed charges 3.54 5.42 Technical (Hospital) Services SOTALOL 80 MG TABLET RX-11421 CDM 6370000100 HCPCS 250 RC 60505-0080-00 NDC inpatient 1 UN 5.71 5.71 HEALTHPARTNERS SX009 HEALTHPARTNERS 4.52 percent of total billed charges 3.54 5.42 Technical (Hospital) Services SOTALOL 80 MG TABLET RX-11421 CDM 6370000100 HCPCS 250 RC 60505-0080-00 NDC inpatient 1 UN 5.71 5.71 MEDICA (COMMERCIAL) 94265 [3081118] MEDICA CLAIMS [308111801] 5.14 percent of total billed charges 3.54 5.42 Technical (Hospital) Services SOTALOL 80 MG TABLET RX-11421 CDM 6370000100 HCPCS 250 RC 60505-0080-00 NDC inpatient 1 UN 5.71 5.71 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES PPO [308136801] 4.52 percent of total billed charges 3.54 5.42 Technical (Hospital) Services SOTALOL 80 MG TABLET RX-11421 CDM 6370000100 HCPCS 250 RC 60505-0080-00 NDC inpatient 1 UN 5.71 5.71 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES HDHP [308136802] 4.52 percent of total billed charges 3.54 5.42 Technical (Hospital) Services SOTALOL 80 MG TABLET RX-11421 CDM 6370000100 HCPCS 250 RC 60505-0080-00 NDC inpatient 1 UN 5.71 5.71 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES EPO [308136803] 4.52 percent of total billed charges 3.54 5.42 Technical (Hospital) Services SOTALOL 80 MG TABLET RX-11421 CDM 6370000100 HCPCS 250 RC 60505-0080-00 NDC inpatient 1 UN 5.71 5.71 CIGNA 62308 [3081051] CIGNA 62308 [308105105] 4.52 percent of total billed charges 3.54 5.42 Technical (Hospital) Services SOTALOL 80 MG TABLET RX-11421 CDM 6370000100 HCPCS 250 RC 60505-0080-00 NDC inpatient 1 UN 5.71 5.71 CIGNA 62308 [3081051] CIGNA STATE OF WYOMING [308105107] 4.52 percent of total billed charges 3.54 5.42 Technical (Hospital) Services SOTALOL 80 MG TABLET RX-11421 CDM 6370000100 HCPCS 250 RC 60505-0080-00 NDC inpatient 1 UN 5.71 5.71 BLUE CROSS BLUE SHIELD WELLMARK SB889 [3081026] BCBS WYOMING [308102603] 5.42 percent of total billed charges 3.54 5.42 Technical (Hospital) Services SOTALOL 80 MG TABLET RX-11421 CDM 6370000100 HCPCS 250 RC 60505-0080-00 NDC inpatient 1 UN 5.71 5.71 UNITED HEALTHCARE (COMMERCIAL) [3081199] UNITED HEALTHCARE 87726 [308119901] 3.54 percent of total billed charges 3.54 5.42 Technical (Hospital) Services SPIRONOLACTONE 50 MG TABLET RX-11426 CDM 6370000100 HCPCS 250 RC 60687-0476-01 NDC inpatient 1 UN 6.08 6.08 MULTIPLAN INC 34080 [3081285] MULTIPLAN INC [308128501] 5.78 percent of total billed charges 3.77 5.78 Technical (Hospital) Services SPIRONOLACTONE 50 MG TABLET RX-11426 CDM 6370000100 HCPCS 250 RC 60687-0476-01 NDC inpatient 1 UN 6.08 6.08 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES PPO [308136801] 4.81 percent of total billed charges 3.77 5.78 Technical (Hospital) Services SPIRONOLACTONE 50 MG TABLET RX-11426 CDM 6370000100 HCPCS 250 RC 60687-0476-01 NDC inpatient 1 UN 6.08 6.08 HEALTHPARTNERS SX009 HEALTHPARTNERS 4.81 percent of total billed charges 3.77 5.78 Technical (Hospital) Services SPIRONOLACTONE 50 MG TABLET RX-11426 CDM 6370000100 HCPCS 250 RC 60687-0476-01 NDC inpatient 1 UN 6.08 6.08 MEDICA (COMMERCIAL) 94265 [3081118] MEDICA CLAIMS [308111801] 5.47 percent of total billed charges 3.77 5.78 Technical (Hospital) Services SPIRONOLACTONE 50 MG TABLET RX-11426 CDM 6370000100 HCPCS 250 RC 60687-0476-01 NDC inpatient 1 UN 6.08 6.08 UNITED HEALTHCARE (COMMERCIAL) [3081199] UNITED HEALTHCARE 87726 [308119901] 3.77 percent of total billed charges 3.77 5.78 Technical (Hospital) Services SPIRONOLACTONE 50 MG TABLET RX-11426 CDM 6370000100 HCPCS 250 RC 60687-0476-01 NDC inpatient 1 UN 6.08 6.08 BLUE CROSS BLUE SHIELD WELLMARK SB889 [3081026] BCBS WYOMING [308102603] 5.78 percent of total billed charges 3.77 5.78 Technical (Hospital) Services SPIRONOLACTONE 50 MG TABLET RX-11426 CDM 6370000100 HCPCS 250 RC 60687-0476-01 NDC inpatient 1 UN 6.08 6.08 CIGNA 62308 [3081051] CIGNA 62308 [308105105] 4.81 percent of total billed charges 3.77 5.78 Technical (Hospital) Services SPIRONOLACTONE 50 MG TABLET RX-11426 CDM 6370000100 HCPCS 250 RC 60687-0476-01 NDC inpatient 1 UN 6.08 6.08 CIGNA 62308 [3081051] CIGNA STATE OF WYOMING [308105107] 4.81 percent of total billed charges 3.77 5.78 Technical (Hospital) Services SPIRONOLACTONE 50 MG TABLET RX-11426 CDM 6370000100 HCPCS 250 RC 60687-0476-01 NDC inpatient 1 UN 6.08 6.08 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES EPO [308136803] 4.81 percent of total billed charges 3.77 5.78 Technical (Hospital) Services SPIRONOLACTONE 50 MG TABLET RX-11426 CDM 6370000100 HCPCS 250 RC 60687-0476-01 NDC inpatient 1 UN 6.08 6.08 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES HDHP [308136802] 4.81 percent of total billed charges 3.77 5.78 Technical (Hospital) Services SPIRONOLACTONE 50 MG TABLET RX-11426 CDM 6370000100 HCPCS 250 RC 60687-0476-01 NDC outpatient 1 UN 6.08 6.08 CIGNA 62308 [3081051] CIGNA 62308 [308105105] 4.86 percent of total billed charges 3.77 5.78 Technical (Hospital) Services SPIRONOLACTONE 50 MG TABLET RX-11426 CDM 6370000100 HCPCS 250 RC 60687-0476-01 NDC outpatient 1 UN 6.08 6.08 CIGNA 62308 [3081051] CIGNA STATE OF WYOMING [308105107] 4.86 percent of total billed charges 3.77 5.78 Technical (Hospital) Services SPIRONOLACTONE 50 MG TABLET RX-11426 CDM 6370000100 HCPCS 250 RC 60687-0476-01 NDC outpatient 1 UN 6.08 6.08 MULTIPLAN INC 34080 [3081285] MULTIPLAN INC [308128501] 5.78 percent of total billed charges 3.77 5.78 Technical (Hospital) Services SPIRONOLACTONE 50 MG TABLET RX-11426 CDM 6370000100 HCPCS 250 RC 60687-0476-01 NDC outpatient 1 UN 6.08 6.08 MEDICA (COMMERCIAL) 94265 [3081118] MEDICA CLAIMS [308111801] 5.47 percent of total billed charges 3.77 5.78 Technical (Hospital) Services SPIRONOLACTONE 50 MG TABLET RX-11426 CDM 6370000100 HCPCS 250 RC 60687-0476-01 NDC outpatient 1 UN 6.08 6.08 UNITED HEALTHCARE (COMMERCIAL) [3081199] UNITED HEALTHCARE 87726 [308119901] 3.77 percent of total billed charges 3.77 5.78 Technical (Hospital) Services SPIRONOLACTONE 50 MG TABLET RX-11426 CDM 6370000100 HCPCS 250 RC 60687-0476-01 NDC outpatient 1 UN 6.08 6.08 HEALTHPARTNERS SX009 HEALTHPARTNERS 4.86 percent of total billed charges 3.77 5.78 Technical (Hospital) Services SPIRONOLACTONE 50 MG TABLET RX-11426 CDM 6370000100 HCPCS 250 RC 60687-0476-01 NDC outpatient 1 UN 6.08 6.08 BLUE CROSS BLUE SHIELD WELLMARK SB889 [3081026] BCBS WYOMING [308102603] 5.78 percent of total billed charges 3.77 5.78 Technical (Hospital) Services SPIRONOLACTONE 50 MG TABLET RX-11426 CDM 6370000100 HCPCS 250 RC 60687-0476-01 NDC outpatient 1 UN 6.08 6.08 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES EPO [308136803] 4.86 percent of total billed charges 3.77 5.78 Technical (Hospital) Services SPIRONOLACTONE 50 MG TABLET RX-11426 CDM 6370000100 HCPCS 250 RC 60687-0476-01 NDC outpatient 1 UN 6.08 6.08 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES HDHP [308136802] 4.86 percent of total billed charges 3.77 5.78 Technical (Hospital) Services SPIRONOLACTONE 50 MG TABLET RX-11426 CDM 6370000100 HCPCS 250 RC 60687-0476-01 NDC outpatient 1 UN 6.08 6.08 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES PPO [308136801] 4.86 percent of total billed charges 3.77 5.78 Technical (Hospital) Services SUCRALFATE 1 GRAM TABLET RX-11442 CDM 6370000100 HCPCS 250 RC 00093-2210-05 NDC outpatient 1 UN 5.86 5.86 UNITED HEALTHCARE (COMMERCIAL) [3081199] UNITED HEALTHCARE 87726 [308119901] 3.63 percent of total billed charges 3.63 5.57 Technical (Hospital) Services SUCRALFATE 1 GRAM TABLET RX-11442 CDM 6370000100 HCPCS 250 RC 00093-2210-05 NDC outpatient 1 UN 5.86 5.86 MULTIPLAN INC 34080 [3081285] MULTIPLAN INC [308128501] 5.57 percent of total billed charges 3.63 5.57 Technical (Hospital) Services SUCRALFATE 1 GRAM TABLET RX-11442 CDM 6370000100 HCPCS 250 RC 00093-2210-05 NDC outpatient 1 UN 5.86 5.86 CIGNA 62308 [3081051] CIGNA 62308 [308105105] 4.69 percent of total billed charges 3.63 5.57 Technical (Hospital) Services SUCRALFATE 1 GRAM TABLET RX-11442 CDM 6370000100 HCPCS 250 RC 00093-2210-05 NDC outpatient 1 UN 5.86 5.86 CIGNA 62308 [3081051] CIGNA STATE OF WYOMING [308105107] 4.69 percent of total billed charges 3.63 5.57 Technical (Hospital) Services SUCRALFATE 1 GRAM TABLET RX-11442 CDM 6370000100 HCPCS 250 RC 00093-2210-05 NDC outpatient 1 UN 5.86 5.86 MEDICA (COMMERCIAL) 94265 [3081118] MEDICA CLAIMS [308111801] 5.27 percent of total billed charges 3.63 5.57 Technical (Hospital) Services SUCRALFATE 1 GRAM TABLET RX-11442 CDM 6370000100 HCPCS 250 RC 00093-2210-05 NDC outpatient 1 UN 5.86 5.86 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES EPO [308136803] 4.69 percent of total billed charges 3.63 5.57 Technical (Hospital) Services SUCRALFATE 1 GRAM TABLET RX-11442 CDM 6370000100 HCPCS 250 RC 00093-2210-05 NDC outpatient 1 UN 5.86 5.86 HEALTHPARTNERS SX009 HEALTHPARTNERS 4.69 percent of total billed charges 3.63 5.57 Technical (Hospital) Services SUCRALFATE 1 GRAM TABLET RX-11442 CDM 6370000100 HCPCS 250 RC 00093-2210-05 NDC outpatient 1 UN 5.86 5.86 BLUE CROSS BLUE SHIELD WELLMARK SB889 [3081026] BCBS WYOMING [308102603] 5.57 percent of total billed charges 3.63 5.57 Technical (Hospital) Services SUCRALFATE 1 GRAM TABLET RX-11442 CDM 6370000100 HCPCS 250 RC 00093-2210-05 NDC outpatient 1 UN 5.86 5.86 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES HDHP [308136802] 4.69 percent of total billed charges 3.63 5.57 Technical (Hospital) Services SUCRALFATE 1 GRAM TABLET RX-11442 CDM 6370000100 HCPCS 250 RC 00093-2210-05 NDC outpatient 1 UN 5.86 5.86 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES PPO [308136801] 4.69 percent of total billed charges 3.63 5.57 Technical (Hospital) Services SUCRALFATE 1 GRAM TABLET RX-11442 CDM 6370000100 HCPCS 250 RC 00093-2210-05 NDC inpatient 1 UN 5.86 5.86 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES EPO [308136803] 4.64 percent of total billed charges 3.63 5.57 Technical (Hospital) Services SUCRALFATE 1 GRAM TABLET RX-11442 CDM 6370000100 HCPCS 250 RC 00093-2210-05 NDC inpatient 1 UN 5.86 5.86 CIGNA 62308 [3081051] CIGNA 62308 [308105105] 4.64 percent of total billed charges 3.63 5.57 Technical (Hospital) Services SUCRALFATE 1 GRAM TABLET RX-11442 CDM 6370000100 HCPCS 250 RC 00093-2210-05 NDC inpatient 1 UN 5.86 5.86 CIGNA 62308 [3081051] CIGNA STATE OF WYOMING [308105107] 4.64 percent of total billed charges 3.63 5.57 Technical (Hospital) Services SUCRALFATE 1 GRAM TABLET RX-11442 CDM 6370000100 HCPCS 250 RC 00093-2210-05 NDC inpatient 1 UN 5.86 5.86 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES HDHP [308136802] 4.64 percent of total billed charges 3.63 5.57 Technical (Hospital) Services SUCRALFATE 1 GRAM TABLET RX-11442 CDM 6370000100 HCPCS 250 RC 00093-2210-05 NDC inpatient 1 UN 5.86 5.86 UNITED HEALTHCARE (COMMERCIAL) [3081199] UNITED HEALTHCARE 87726 [308119901] 3.63 percent of total billed charges 3.63 5.57 Technical (Hospital) Services SUCRALFATE 1 GRAM TABLET RX-11442 CDM 6370000100 HCPCS 250 RC 00093-2210-05 NDC inpatient 1 UN 5.86 5.86 BLUE CROSS BLUE SHIELD WELLMARK SB889 [3081026] BCBS WYOMING [308102603] 5.57 percent of total billed charges 3.63 5.57 Technical (Hospital) Services SUCRALFATE 1 GRAM TABLET RX-11442 CDM 6370000100 HCPCS 250 RC 00093-2210-05 NDC inpatient 1 UN 5.86 5.86 MEDICA (COMMERCIAL) 94265 [3081118] MEDICA CLAIMS [308111801] 5.27 percent of total billed charges 3.63 5.57 Technical (Hospital) Services SUCRALFATE 1 GRAM TABLET RX-11442 CDM 6370000100 HCPCS 250 RC 00093-2210-05 NDC inpatient 1 UN 5.86 5.86 HEALTHPARTNERS SX009 HEALTHPARTNERS 4.64 percent of total billed charges 3.63 5.57 Technical (Hospital) Services SUCRALFATE 1 GRAM TABLET RX-11442 CDM 6370000100 HCPCS 250 RC 00093-2210-05 NDC inpatient 1 UN 5.86 5.86 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES PPO [308136801] 4.64 percent of total billed charges 3.63 5.57 Technical (Hospital) Services SUCRALFATE 1 GRAM TABLET RX-11442 CDM 6370000100 HCPCS 250 RC 00093-2210-05 NDC inpatient 1 UN 5.86 5.86 MULTIPLAN INC 34080 [3081285] MULTIPLAN INC [308128501] 5.57 percent of total billed charges 3.63 5.57 Technical (Hospital) Services "MAGNESIUM 64 MG (MAGNESIUM CHLORIDE) TABLET,DELAYED RELEASE" RX-114555 CDM 6370000100 HCPCS 250 RC 68585-0005-75 NDC outpatient 1 UN 5.7 5.7 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES EPO [308136803] 4.56 percent of total billed charges 3.53 5.42 Technical (Hospital) Services "MAGNESIUM 64 MG (MAGNESIUM CHLORIDE) TABLET,DELAYED RELEASE" RX-114555 CDM 6370000100 HCPCS 250 RC 68585-0005-75 NDC outpatient 1 UN 5.7 5.7 MEDICA (COMMERCIAL) 94265 [3081118] MEDICA CLAIMS [308111801] 5.13 percent of total billed charges 3.53 5.42 Technical (Hospital) Services "MAGNESIUM 64 MG (MAGNESIUM CHLORIDE) TABLET,DELAYED RELEASE" RX-114555 CDM 6370000100 HCPCS 250 RC 68585-0005-75 NDC outpatient 1 UN 5.7 5.7 UNITED HEALTHCARE (COMMERCIAL) [3081199] UNITED HEALTHCARE 87726 [308119901] 3.53 percent of total billed charges 3.53 5.42 Technical (Hospital) Services "MAGNESIUM 64 MG (MAGNESIUM CHLORIDE) TABLET,DELAYED RELEASE" RX-114555 CDM 6370000100 HCPCS 250 RC 68585-0005-75 NDC outpatient 1 UN 5.7 5.7 CIGNA 62308 [3081051] CIGNA 62308 [308105105] 4.56 percent of total billed charges 3.53 5.42 Technical (Hospital) Services "MAGNESIUM 64 MG (MAGNESIUM CHLORIDE) TABLET,DELAYED RELEASE" RX-114555 CDM 6370000100 HCPCS 250 RC 68585-0005-75 NDC outpatient 1 UN 5.7 5.7 CIGNA 62308 [3081051] CIGNA STATE OF WYOMING [308105107] 4.56 percent of total billed charges 3.53 5.42 Technical (Hospital) Services "MAGNESIUM 64 MG (MAGNESIUM CHLORIDE) TABLET,DELAYED RELEASE" RX-114555 CDM 6370000100 HCPCS 250 RC 68585-0005-75 NDC outpatient 1 UN 5.7 5.7 MULTIPLAN INC 34080 [3081285] MULTIPLAN INC [308128501] 5.42 percent of total billed charges 3.53 5.42 Technical (Hospital) Services "MAGNESIUM 64 MG (MAGNESIUM CHLORIDE) TABLET,DELAYED RELEASE" RX-114555 CDM 6370000100 HCPCS 250 RC 68585-0005-75 NDC outpatient 1 UN 5.7 5.7 BLUE CROSS BLUE SHIELD WELLMARK SB889 [3081026] BCBS WYOMING [308102603] 5.42 percent of total billed charges 3.53 5.42 Technical (Hospital) Services "MAGNESIUM 64 MG (MAGNESIUM CHLORIDE) TABLET,DELAYED RELEASE" RX-114555 CDM 6370000100 HCPCS 250 RC 68585-0005-75 NDC outpatient 1 UN 5.7 5.7 HEALTHPARTNERS SX009 HEALTHPARTNERS 4.56 percent of total billed charges 3.53 5.42 Technical (Hospital) Services "MAGNESIUM 64 MG (MAGNESIUM CHLORIDE) TABLET,DELAYED RELEASE" RX-114555 CDM 6370000100 HCPCS 250 RC 68585-0005-75 NDC outpatient 1 UN 5.7 5.7 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES HDHP [308136802] 4.56 percent of total billed charges 3.53 5.42 Technical (Hospital) Services "MAGNESIUM 64 MG (MAGNESIUM CHLORIDE) TABLET,DELAYED RELEASE" RX-114555 CDM 6370000100 HCPCS 250 RC 68585-0005-75 NDC outpatient 1 UN 5.7 5.7 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES PPO [308136801] 4.56 percent of total billed charges 3.53 5.42 Technical (Hospital) Services "MAGNESIUM 64 MG (MAGNESIUM CHLORIDE) TABLET,DELAYED RELEASE" RX-114555 CDM 6370000100 HCPCS 250 RC 68585-0005-75 NDC inpatient 1 UN 5.7 5.7 MULTIPLAN INC 34080 [3081285] MULTIPLAN INC [308128501] 5.42 percent of total billed charges 3.53 5.42 Technical (Hospital) Services "MAGNESIUM 64 MG (MAGNESIUM CHLORIDE) TABLET,DELAYED RELEASE" RX-114555 CDM 6370000100 HCPCS 250 RC 68585-0005-75 NDC inpatient 1 UN 5.7 5.7 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES PPO [308136801] 4.51 percent of total billed charges 3.53 5.42 Technical (Hospital) Services "MAGNESIUM 64 MG (MAGNESIUM CHLORIDE) TABLET,DELAYED RELEASE" RX-114555 CDM 6370000100 HCPCS 250 RC 68585-0005-75 NDC inpatient 1 UN 5.7 5.7 MEDICA (COMMERCIAL) 94265 [3081118] MEDICA CLAIMS [308111801] 5.13 percent of total billed charges 3.53 5.42 Technical (Hospital) Services "MAGNESIUM 64 MG (MAGNESIUM CHLORIDE) TABLET,DELAYED RELEASE" RX-114555 CDM 6370000100 HCPCS 250 RC 68585-0005-75 NDC inpatient 1 UN 5.7 5.7 HEALTHPARTNERS SX009 HEALTHPARTNERS 4.51 percent of total billed charges 3.53 5.42 Technical (Hospital) Services "MAGNESIUM 64 MG (MAGNESIUM CHLORIDE) TABLET,DELAYED RELEASE" RX-114555 CDM 6370000100 HCPCS 250 RC 68585-0005-75 NDC inpatient 1 UN 5.7 5.7 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES HDHP [308136802] 4.51 percent of total billed charges 3.53 5.42 Technical (Hospital) Services "MAGNESIUM 64 MG (MAGNESIUM CHLORIDE) TABLET,DELAYED RELEASE" RX-114555 CDM 6370000100 HCPCS 250 RC 68585-0005-75 NDC inpatient 1 UN 5.7 5.7 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES EPO [308136803] 4.51 percent of total billed charges 3.53 5.42 Technical (Hospital) Services "MAGNESIUM 64 MG (MAGNESIUM CHLORIDE) TABLET,DELAYED RELEASE" RX-114555 CDM 6370000100 HCPCS 250 RC 68585-0005-75 NDC inpatient 1 UN 5.7 5.7 CIGNA 62308 [3081051] CIGNA 62308 [308105105] 4.51 percent of total billed charges 3.53 5.42 Technical (Hospital) Services "MAGNESIUM 64 MG (MAGNESIUM CHLORIDE) TABLET,DELAYED RELEASE" RX-114555 CDM 6370000100 HCPCS 250 RC 68585-0005-75 NDC inpatient 1 UN 5.7 5.7 CIGNA 62308 [3081051] CIGNA STATE OF WYOMING [308105107] 4.51 percent of total billed charges 3.53 5.42 Technical (Hospital) Services "MAGNESIUM 64 MG (MAGNESIUM CHLORIDE) TABLET,DELAYED RELEASE" RX-114555 CDM 6370000100 HCPCS 250 RC 68585-0005-75 NDC inpatient 1 UN 5.7 5.7 BLUE CROSS BLUE SHIELD WELLMARK SB889 [3081026] BCBS WYOMING [308102603] 5.42 percent of total billed charges 3.53 5.42 Technical (Hospital) Services "MAGNESIUM 64 MG (MAGNESIUM CHLORIDE) TABLET,DELAYED RELEASE" RX-114555 CDM 6370000100 HCPCS 250 RC 68585-0005-75 NDC inpatient 1 UN 5.7 5.7 UNITED HEALTHCARE (COMMERCIAL) [3081199] UNITED HEALTHCARE 87726 [308119901] 3.53 percent of total billed charges 3.53 5.42 Technical (Hospital) Services TAMOXIFEN 20 MG TABLET RX-11498 CDM 6370000100 HCPCS 250 RC 00378-0274-93 NDC inpatient 1 UN 6.38 6.38 HEALTHPARTNERS SX009 HEALTHPARTNERS 5.05 percent of total billed charges 3.96 6.06 Technical (Hospital) Services TAMOXIFEN 20 MG TABLET RX-11498 CDM 6370000100 HCPCS 250 RC 00378-0274-93 NDC inpatient 1 UN 6.38 6.38 MEDICA (COMMERCIAL) 94265 [3081118] MEDICA CLAIMS [308111801] 5.74 percent of total billed charges 3.96 6.06 Technical (Hospital) Services TAMOXIFEN 20 MG TABLET RX-11498 CDM 6370000100 HCPCS 250 RC 00378-0274-93 NDC inpatient 1 UN 6.38 6.38 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES PPO [308136801] 5.05 percent of total billed charges 3.96 6.06 Technical (Hospital) Services TAMOXIFEN 20 MG TABLET RX-11498 CDM 6370000100 HCPCS 250 RC 00378-0274-93 NDC inpatient 1 UN 6.38 6.38 MULTIPLAN INC 34080 [3081285] MULTIPLAN INC [308128501] 6.06 percent of total billed charges 3.96 6.06 Technical (Hospital) Services TAMOXIFEN 20 MG TABLET RX-11498 CDM 6370000100 HCPCS 250 RC 00378-0274-93 NDC inpatient 1 UN 6.38 6.38 UNITED HEALTHCARE (COMMERCIAL) [3081199] UNITED HEALTHCARE 87726 [308119901] 3.96 percent of total billed charges 3.96 6.06 Technical (Hospital) Services TAMOXIFEN 20 MG TABLET RX-11498 CDM 6370000100 HCPCS 250 RC 00378-0274-93 NDC inpatient 1 UN 6.38 6.38 BLUE CROSS BLUE SHIELD WELLMARK SB889 [3081026] BCBS WYOMING [308102603] 6.06 percent of total billed charges 3.96 6.06 Technical (Hospital) Services TAMOXIFEN 20 MG TABLET RX-11498 CDM 6370000100 HCPCS 250 RC 00378-0274-93 NDC inpatient 1 UN 6.38 6.38 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES HDHP [308136802] 5.05 percent of total billed charges 3.96 6.06 Technical (Hospital) Services TAMOXIFEN 20 MG TABLET RX-11498 CDM 6370000100 HCPCS 250 RC 00378-0274-93 NDC inpatient 1 UN 6.38 6.38 CIGNA 62308 [3081051] CIGNA 62308 [308105105] 5.05 percent of total billed charges 3.96 6.06 Technical (Hospital) Services TAMOXIFEN 20 MG TABLET RX-11498 CDM 6370000100 HCPCS 250 RC 00378-0274-93 NDC inpatient 1 UN 6.38 6.38 CIGNA 62308 [3081051] CIGNA STATE OF WYOMING [308105107] 5.05 percent of total billed charges 3.96 6.06 Technical (Hospital) Services TAMOXIFEN 20 MG TABLET RX-11498 CDM 6370000100 HCPCS 250 RC 00378-0274-93 NDC inpatient 1 UN 6.38 6.38 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES EPO [308136803] 5.05 percent of total billed charges 3.96 6.06 Technical (Hospital) Services TAMOXIFEN 20 MG TABLET RX-11498 CDM 6370000100 HCPCS 250 RC 00378-0274-93 NDC outpatient 1 UN 6.38 6.38 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES HDHP [308136802] 5.1 percent of total billed charges 3.96 6.06 Technical (Hospital) Services TAMOXIFEN 20 MG TABLET RX-11498 CDM 6370000100 HCPCS 250 RC 00378-0274-93 NDC outpatient 1 UN 6.38 6.38 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES PPO [308136801] 5.1 percent of total billed charges 3.96 6.06 Technical (Hospital) Services TAMOXIFEN 20 MG TABLET RX-11498 CDM 6370000100 HCPCS 250 RC 00378-0274-93 NDC outpatient 1 UN 6.38 6.38 MULTIPLAN INC 34080 [3081285] MULTIPLAN INC [308128501] 6.06 percent of total billed charges 3.96 6.06 Technical (Hospital) Services TAMOXIFEN 20 MG TABLET RX-11498 CDM 6370000100 HCPCS 250 RC 00378-0274-93 NDC outpatient 1 UN 6.38 6.38 CIGNA 62308 [3081051] CIGNA 62308 [308105105] 5.1 percent of total billed charges 3.96 6.06 Technical (Hospital) Services TAMOXIFEN 20 MG TABLET RX-11498 CDM 6370000100 HCPCS 250 RC 00378-0274-93 NDC outpatient 1 UN 6.38 6.38 CIGNA 62308 [3081051] CIGNA STATE OF WYOMING [308105107] 5.1 percent of total billed charges 3.96 6.06 Technical (Hospital) Services TAMOXIFEN 20 MG TABLET RX-11498 CDM 6370000100 HCPCS 250 RC 00378-0274-93 NDC outpatient 1 UN 6.38 6.38 MEDICA (COMMERCIAL) 94265 [3081118] MEDICA CLAIMS [308111801] 5.74 percent of total billed charges 3.96 6.06 Technical (Hospital) Services TAMOXIFEN 20 MG TABLET RX-11498 CDM 6370000100 HCPCS 250 RC 00378-0274-93 NDC outpatient 1 UN 6.38 6.38 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES EPO [308136803] 5.1 percent of total billed charges 3.96 6.06 Technical (Hospital) Services TAMOXIFEN 20 MG TABLET RX-11498 CDM 6370000100 HCPCS 250 RC 00378-0274-93 NDC outpatient 1 UN 6.38 6.38 UNITED HEALTHCARE (COMMERCIAL) [3081199] UNITED HEALTHCARE 87726 [308119901] 3.96 percent of total billed charges 3.96 6.06 Technical (Hospital) Services TAMOXIFEN 20 MG TABLET RX-11498 CDM 6370000100 HCPCS 250 RC 00378-0274-93 NDC outpatient 1 UN 6.38 6.38 BLUE CROSS BLUE SHIELD WELLMARK SB889 [3081026] BCBS WYOMING [308102603] 6.06 percent of total billed charges 3.96 6.06 Technical (Hospital) Services TAMOXIFEN 20 MG TABLET RX-11498 CDM 6370000100 HCPCS 250 RC 00378-0274-93 NDC outpatient 1 UN 6.38 6.38 HEALTHPARTNERS SX009 HEALTHPARTNERS 5.1 percent of total billed charges 3.96 6.06 Technical (Hospital) Services TIMOLOL MALEATE 0.25 % EYE DROPS RX-11561 CDM 6370000100 HCPCS 250 RC 64980-0513-01 NDC outpatient 10 ML 52.96 52.96 CIGNA 62308 [3081051] CIGNA STATE OF WYOMING [308105107] 42.37 percent of total billed charges 32.84 50.31 Technical (Hospital) Services TIMOLOL MALEATE 0.25 % EYE DROPS RX-11561 CDM 6370000100 HCPCS 250 RC 64980-0513-01 NDC outpatient 10 ML 52.96 52.96 MEDICA (COMMERCIAL) 94265 [3081118] MEDICA CLAIMS [308111801] 47.66 percent of total billed charges 32.84 50.31 Technical (Hospital) Services TIMOLOL MALEATE 0.25 % EYE DROPS RX-11561 CDM 6370000100 HCPCS 250 RC 64980-0513-01 NDC outpatient 10 ML 52.96 52.96 MULTIPLAN INC 34080 [3081285] MULTIPLAN INC [308128501] 50.31 percent of total billed charges 32.84 50.31 Technical (Hospital) Services TIMOLOL MALEATE 0.25 % EYE DROPS RX-11561 CDM 6370000100 HCPCS 250 RC 64980-0513-01 NDC outpatient 10 ML 52.96 52.96 CIGNA 62308 [3081051] CIGNA 62308 [308105105] 42.37 percent of total billed charges 32.84 50.31 Technical (Hospital) Services TIMOLOL MALEATE 0.25 % EYE DROPS RX-11561 CDM 6370000100 HCPCS 250 RC 64980-0513-01 NDC outpatient 10 ML 52.96 52.96 UNITED HEALTHCARE (COMMERCIAL) [3081199] UNITED HEALTHCARE 87726 [308119901] 32.84 percent of total billed charges 32.84 50.31 Technical (Hospital) Services TIMOLOL MALEATE 0.25 % EYE DROPS RX-11561 CDM 6370000100 HCPCS 250 RC 64980-0513-01 NDC outpatient 10 ML 52.96 52.96 HEALTHPARTNERS SX009 HEALTHPARTNERS 42.37 percent of total billed charges 32.84 50.31 Technical (Hospital) Services TIMOLOL MALEATE 0.25 % EYE DROPS RX-11561 CDM 6370000100 HCPCS 250 RC 64980-0513-01 NDC outpatient 10 ML 52.96 52.96 BLUE CROSS BLUE SHIELD WELLMARK SB889 [3081026] BCBS WYOMING [308102603] 50.31 percent of total billed charges 32.84 50.31 Technical (Hospital) Services TIMOLOL MALEATE 0.25 % EYE DROPS RX-11561 CDM 6370000100 HCPCS 250 RC 64980-0513-01 NDC outpatient 10 ML 52.96 52.96 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES PPO [308136801] 42.37 percent of total billed charges 32.84 50.31 Technical (Hospital) Services TIMOLOL MALEATE 0.25 % EYE DROPS RX-11561 CDM 6370000100 HCPCS 250 RC 64980-0513-01 NDC outpatient 10 ML 52.96 52.96 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES HDHP [308136802] 42.37 percent of total billed charges 32.84 50.31 Technical (Hospital) Services TIMOLOL MALEATE 0.25 % EYE DROPS RX-11561 CDM 6370000100 HCPCS 250 RC 64980-0513-01 NDC outpatient 10 ML 52.96 52.96 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES EPO [308136803] 42.37 percent of total billed charges 32.84 50.31 Technical (Hospital) Services TIMOLOL MALEATE 0.25 % EYE DROPS RX-11561 CDM 6370000100 HCPCS 250 RC 64980-0513-01 NDC inpatient 10 ML 52.96 52.96 HEALTHPARTNERS SX009 HEALTHPARTNERS 41.93 percent of total billed charges 32.84 50.31 Technical (Hospital) Services TIMOLOL MALEATE 0.25 % EYE DROPS RX-11561 CDM 6370000100 HCPCS 250 RC 64980-0513-01 NDC inpatient 10 ML 52.96 52.96 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES HDHP [308136802] 41.93 percent of total billed charges 32.84 50.31 Technical (Hospital) Services TIMOLOL MALEATE 0.25 % EYE DROPS RX-11561 CDM 6370000100 HCPCS 250 RC 64980-0513-01 NDC inpatient 10 ML 52.96 52.96 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES PPO [308136801] 41.93 percent of total billed charges 32.84 50.31 Technical (Hospital) Services TIMOLOL MALEATE 0.25 % EYE DROPS RX-11561 CDM 6370000100 HCPCS 250 RC 64980-0513-01 NDC inpatient 10 ML 52.96 52.96 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES EPO [308136803] 41.93 percent of total billed charges 32.84 50.31 Technical (Hospital) Services TIMOLOL MALEATE 0.25 % EYE DROPS RX-11561 CDM 6370000100 HCPCS 250 RC 64980-0513-01 NDC inpatient 10 ML 52.96 52.96 MULTIPLAN INC 34080 [3081285] MULTIPLAN INC [308128501] 50.31 percent of total billed charges 32.84 50.31 Technical (Hospital) Services TIMOLOL MALEATE 0.25 % EYE DROPS RX-11561 CDM 6370000100 HCPCS 250 RC 64980-0513-01 NDC inpatient 10 ML 52.96 52.96 MEDICA (COMMERCIAL) 94265 [3081118] MEDICA CLAIMS [308111801] 47.66 percent of total billed charges 32.84 50.31 Technical (Hospital) Services TIMOLOL MALEATE 0.25 % EYE DROPS RX-11561 CDM 6370000100 HCPCS 250 RC 64980-0513-01 NDC inpatient 10 ML 52.96 52.96 BLUE CROSS BLUE SHIELD WELLMARK SB889 [3081026] BCBS WYOMING [308102603] 50.31 percent of total billed charges 32.84 50.31 Technical (Hospital) Services TIMOLOL MALEATE 0.25 % EYE DROPS RX-11561 CDM 6370000100 HCPCS 250 RC 64980-0513-01 NDC inpatient 10 ML 52.96 52.96 UNITED HEALTHCARE (COMMERCIAL) [3081199] UNITED HEALTHCARE 87726 [308119901] 32.84 percent of total billed charges 32.84 50.31 Technical (Hospital) Services TIMOLOL MALEATE 0.25 % EYE DROPS RX-11561 CDM 6370000100 HCPCS 250 RC 64980-0513-01 NDC inpatient 10 ML 52.96 52.96 CIGNA 62308 [3081051] CIGNA 62308 [308105105] 41.93 percent of total billed charges 32.84 50.31 Technical (Hospital) Services TIMOLOL MALEATE 0.25 % EYE DROPS RX-11561 CDM 6370000100 HCPCS 250 RC 64980-0513-01 NDC inpatient 10 ML 52.96 52.96 CIGNA 62308 [3081051] CIGNA STATE OF WYOMING [308105107] 41.93 percent of total billed charges 32.84 50.31 Technical (Hospital) Services TIMOLOL MALEATE 0.5 % EYE DROPS RX-11562 CDM 6370000100 HCPCS 250 RC 61314-0227-05 NDC outpatient 5 ML 38.05 38.05 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES HDHP [308136802] 30.44 percent of total billed charges 23.59 36.15 Technical (Hospital) Services TIMOLOL MALEATE 0.5 % EYE DROPS RX-11562 CDM 6370000100 HCPCS 250 RC 61314-0227-05 NDC outpatient 5 ML 38.05 38.05 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES PPO [308136801] 30.44 percent of total billed charges 23.59 36.15 Technical (Hospital) Services TIMOLOL MALEATE 0.5 % EYE DROPS RX-11562 CDM 6370000100 HCPCS 250 RC 61314-0227-05 NDC outpatient 5 ML 38.05 38.05 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES EPO [308136803] 30.44 percent of total billed charges 23.59 36.15 Technical (Hospital) Services TIMOLOL MALEATE 0.5 % EYE DROPS RX-11562 CDM 6370000100 HCPCS 250 RC 61314-0227-05 NDC outpatient 5 ML 38.05 38.05 BLUE CROSS BLUE SHIELD WELLMARK SB889 [3081026] BCBS WYOMING [308102603] 36.15 percent of total billed charges 23.59 36.15 Technical (Hospital) Services TIMOLOL MALEATE 0.5 % EYE DROPS RX-11562 CDM 6370000100 HCPCS 250 RC 61314-0227-05 NDC outpatient 5 ML 38.05 38.05 HEALTHPARTNERS SX009 HEALTHPARTNERS 30.44 percent of total billed charges 23.59 36.15 Technical (Hospital) Services TIMOLOL MALEATE 0.5 % EYE DROPS RX-11562 CDM 6370000100 HCPCS 250 RC 61314-0227-05 NDC outpatient 5 ML 38.05 38.05 UNITED HEALTHCARE (COMMERCIAL) [3081199] UNITED HEALTHCARE 87726 [308119901] 23.59 percent of total billed charges 23.59 36.15 Technical (Hospital) Services TIMOLOL MALEATE 0.5 % EYE DROPS RX-11562 CDM 6370000100 HCPCS 250 RC 61314-0227-05 NDC outpatient 5 ML 38.05 38.05 CIGNA 62308 [3081051] CIGNA 62308 [308105105] 30.44 percent of total billed charges 23.59 36.15 Technical (Hospital) Services TIMOLOL MALEATE 0.5 % EYE DROPS RX-11562 CDM 6370000100 HCPCS 250 RC 61314-0227-05 NDC outpatient 5 ML 38.05 38.05 CIGNA 62308 [3081051] CIGNA STATE OF WYOMING [308105107] 30.44 percent of total billed charges 23.59 36.15 Technical (Hospital) Services TIMOLOL MALEATE 0.5 % EYE DROPS RX-11562 CDM 6370000100 HCPCS 250 RC 61314-0227-05 NDC outpatient 5 ML 38.05 38.05 MULTIPLAN INC 34080 [3081285] MULTIPLAN INC [308128501] 36.15 percent of total billed charges 23.59 36.15 Technical (Hospital) Services TIMOLOL MALEATE 0.5 % EYE DROPS RX-11562 CDM 6370000100 HCPCS 250 RC 61314-0227-05 NDC outpatient 5 ML 38.05 38.05 MEDICA (COMMERCIAL) 94265 [3081118] MEDICA CLAIMS [308111801] 34.25 percent of total billed charges 23.59 36.15 Technical (Hospital) Services TIMOLOL MALEATE 0.5 % EYE DROPS RX-11562 CDM 6370000100 HCPCS 250 RC 61314-0227-05 NDC inpatient 5 ML 38.05 38.05 HEALTHPARTNERS SX009 HEALTHPARTNERS 30.13 percent of total billed charges 23.59 36.15 Technical (Hospital) Services TIMOLOL MALEATE 0.5 % EYE DROPS RX-11562 CDM 6370000100 HCPCS 250 RC 61314-0227-05 NDC inpatient 5 ML 38.05 38.05 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES PPO [308136801] 30.13 percent of total billed charges 23.59 36.15 Technical (Hospital) Services TIMOLOL MALEATE 0.5 % EYE DROPS RX-11562 CDM 6370000100 HCPCS 250 RC 61314-0227-05 NDC inpatient 5 ML 38.05 38.05 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES EPO [308136803] 30.13 percent of total billed charges 23.59 36.15 Technical (Hospital) Services TIMOLOL MALEATE 0.5 % EYE DROPS RX-11562 CDM 6370000100 HCPCS 250 RC 61314-0227-05 NDC inpatient 5 ML 38.05 38.05 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES HDHP [308136802] 30.13 percent of total billed charges 23.59 36.15 Technical (Hospital) Services TIMOLOL MALEATE 0.5 % EYE DROPS RX-11562 CDM 6370000100 HCPCS 250 RC 61314-0227-05 NDC inpatient 5 ML 38.05 38.05 CIGNA 62308 [3081051] CIGNA 62308 [308105105] 30.13 percent of total billed charges 23.59 36.15 Technical (Hospital) Services TIMOLOL MALEATE 0.5 % EYE DROPS RX-11562 CDM 6370000100 HCPCS 250 RC 61314-0227-05 NDC inpatient 5 ML 38.05 38.05 CIGNA 62308 [3081051] CIGNA STATE OF WYOMING [308105107] 30.13 percent of total billed charges 23.59 36.15 Technical (Hospital) Services TIMOLOL MALEATE 0.5 % EYE DROPS RX-11562 CDM 6370000100 HCPCS 250 RC 61314-0227-05 NDC inpatient 5 ML 38.05 38.05 BLUE CROSS BLUE SHIELD WELLMARK SB889 [3081026] BCBS WYOMING [308102603] 36.15 percent of total billed charges 23.59 36.15 Technical (Hospital) Services TIMOLOL MALEATE 0.5 % EYE DROPS RX-11562 CDM 6370000100 HCPCS 250 RC 61314-0227-05 NDC inpatient 5 ML 38.05 38.05 UNITED HEALTHCARE (COMMERCIAL) [3081199] UNITED HEALTHCARE 87726 [308119901] 23.59 percent of total billed charges 23.59 36.15 Technical (Hospital) Services TIMOLOL MALEATE 0.5 % EYE DROPS RX-11562 CDM 6370000100 HCPCS 250 RC 61314-0227-05 NDC inpatient 5 ML 38.05 38.05 MULTIPLAN INC 34080 [3081285] MULTIPLAN INC [308128501] 36.15 percent of total billed charges 23.59 36.15 Technical (Hospital) Services TIMOLOL MALEATE 0.5 % EYE DROPS RX-11562 CDM 6370000100 HCPCS 250 RC 61314-0227-05 NDC inpatient 5 ML 38.05 38.05 MEDICA (COMMERCIAL) 94265 [3081118] MEDICA CLAIMS [308111801] 34.25 percent of total billed charges 23.59 36.15 Technical (Hospital) Services "TOBRAMYCIN 0.3 %-DEXAMETHASONE 0.1 % EYE DROPS,SUSPENSION" RX-11567 CDM 6370000100 HCPCS 250 RC 24208-0295-05 NDC inpatient 5 ML 332.9 332.9 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES EPO [308136803] 263.59 percent of total billed charges 206.4 316.26 Technical (Hospital) Services "TOBRAMYCIN 0.3 %-DEXAMETHASONE 0.1 % EYE DROPS,SUSPENSION" RX-11567 CDM 6370000100 HCPCS 250 RC 24208-0295-05 NDC inpatient 5 ML 332.9 332.9 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES HDHP [308136802] 263.59 percent of total billed charges 206.4 316.26 Technical (Hospital) Services "TOBRAMYCIN 0.3 %-DEXAMETHASONE 0.1 % EYE DROPS,SUSPENSION" RX-11567 CDM 6370000100 HCPCS 250 RC 24208-0295-05 NDC inpatient 5 ML 332.9 332.9 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES PPO [308136801] 263.59 percent of total billed charges 206.4 316.26 Technical (Hospital) Services "TOBRAMYCIN 0.3 %-DEXAMETHASONE 0.1 % EYE DROPS,SUSPENSION" RX-11567 CDM 6370000100 HCPCS 250 RC 24208-0295-05 NDC inpatient 5 ML 332.9 332.9 HEALTHPARTNERS SX009 HEALTHPARTNERS 263.59 percent of total billed charges 206.4 316.26 Technical (Hospital) Services "TOBRAMYCIN 0.3 %-DEXAMETHASONE 0.1 % EYE DROPS,SUSPENSION" RX-11567 CDM 6370000100 HCPCS 250 RC 24208-0295-05 NDC inpatient 5 ML 332.9 332.9 MEDICA (COMMERCIAL) 94265 [3081118] MEDICA CLAIMS [308111801] 299.61 percent of total billed charges 206.4 316.26 Technical (Hospital) Services "TOBRAMYCIN 0.3 %-DEXAMETHASONE 0.1 % EYE DROPS,SUSPENSION" RX-11567 CDM 6370000100 HCPCS 250 RC 24208-0295-05 NDC inpatient 5 ML 332.9 332.9 MULTIPLAN INC 34080 [3081285] MULTIPLAN INC [308128501] 316.26 percent of total billed charges 206.4 316.26 Technical (Hospital) Services "TOBRAMYCIN 0.3 %-DEXAMETHASONE 0.1 % EYE DROPS,SUSPENSION" RX-11567 CDM 6370000100 HCPCS 250 RC 24208-0295-05 NDC inpatient 5 ML 332.9 332.9 BLUE CROSS BLUE SHIELD WELLMARK SB889 [3081026] BCBS WYOMING [308102603] 316.26 percent of total billed charges 206.4 316.26 Technical (Hospital) Services "TOBRAMYCIN 0.3 %-DEXAMETHASONE 0.1 % EYE DROPS,SUSPENSION" RX-11567 CDM 6370000100 HCPCS 250 RC 24208-0295-05 NDC inpatient 5 ML 332.9 332.9 UNITED HEALTHCARE (COMMERCIAL) [3081199] UNITED HEALTHCARE 87726 [308119901] 206.4 percent of total billed charges 206.4 316.26 Technical (Hospital) Services "TOBRAMYCIN 0.3 %-DEXAMETHASONE 0.1 % EYE DROPS,SUSPENSION" RX-11567 CDM 6370000100 HCPCS 250 RC 24208-0295-05 NDC inpatient 5 ML 332.9 332.9 CIGNA 62308 [3081051] CIGNA 62308 [308105105] 263.59 percent of total billed charges 206.4 316.26 Technical (Hospital) Services "TOBRAMYCIN 0.3 %-DEXAMETHASONE 0.1 % EYE DROPS,SUSPENSION" RX-11567 CDM 6370000100 HCPCS 250 RC 24208-0295-05 NDC inpatient 5 ML 332.9 332.9 CIGNA 62308 [3081051] CIGNA STATE OF WYOMING [308105107] 263.59 percent of total billed charges 206.4 316.26 Technical (Hospital) Services "TOBRAMYCIN 0.3 %-DEXAMETHASONE 0.1 % EYE DROPS,SUSPENSION" RX-11567 CDM 6370000100 HCPCS 250 RC 24208-0295-05 NDC outpatient 5 ML 332.9 332.9 MEDICA (COMMERCIAL) 94265 [3081118] MEDICA CLAIMS [308111801] 299.61 percent of total billed charges 206.4 316.26 Technical (Hospital) Services "TOBRAMYCIN 0.3 %-DEXAMETHASONE 0.1 % EYE DROPS,SUSPENSION" RX-11567 CDM 6370000100 HCPCS 250 RC 24208-0295-05 NDC outpatient 5 ML 332.9 332.9 MULTIPLAN INC 34080 [3081285] MULTIPLAN INC [308128501] 316.26 percent of total billed charges 206.4 316.26 Technical (Hospital) Services "TOBRAMYCIN 0.3 %-DEXAMETHASONE 0.1 % EYE DROPS,SUSPENSION" RX-11567 CDM 6370000100 HCPCS 250 RC 24208-0295-05 NDC outpatient 5 ML 332.9 332.9 CIGNA 62308 [3081051] CIGNA 62308 [308105105] 266.32 percent of total billed charges 206.4 316.26 Technical (Hospital) Services "TOBRAMYCIN 0.3 %-DEXAMETHASONE 0.1 % EYE DROPS,SUSPENSION" RX-11567 CDM 6370000100 HCPCS 250 RC 24208-0295-05 NDC outpatient 5 ML 332.9 332.9 CIGNA 62308 [3081051] CIGNA STATE OF WYOMING [308105107] 266.32 percent of total billed charges 206.4 316.26 Technical (Hospital) Services "TOBRAMYCIN 0.3 %-DEXAMETHASONE 0.1 % EYE DROPS,SUSPENSION" RX-11567 CDM 6370000100 HCPCS 250 RC 24208-0295-05 NDC outpatient 5 ML 332.9 332.9 UNITED HEALTHCARE (COMMERCIAL) [3081199] UNITED HEALTHCARE 87726 [308119901] 206.4 percent of total billed charges 206.4 316.26 Technical (Hospital) Services "TOBRAMYCIN 0.3 %-DEXAMETHASONE 0.1 % EYE DROPS,SUSPENSION" RX-11567 CDM 6370000100 HCPCS 250 RC 24208-0295-05 NDC outpatient 5 ML 332.9 332.9 HEALTHPARTNERS SX009 HEALTHPARTNERS 266.32 percent of total billed charges 206.4 316.26 Technical (Hospital) Services "TOBRAMYCIN 0.3 %-DEXAMETHASONE 0.1 % EYE DROPS,SUSPENSION" RX-11567 CDM 6370000100 HCPCS 250 RC 24208-0295-05 NDC outpatient 5 ML 332.9 332.9 BLUE CROSS BLUE SHIELD WELLMARK SB889 [3081026] BCBS WYOMING [308102603] 316.26 percent of total billed charges 206.4 316.26 Technical (Hospital) Services "TOBRAMYCIN 0.3 %-DEXAMETHASONE 0.1 % EYE DROPS,SUSPENSION" RX-11567 CDM 6370000100 HCPCS 250 RC 24208-0295-05 NDC outpatient 5 ML 332.9 332.9 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES HDHP [308136802] 266.32 percent of total billed charges 206.4 316.26 Technical (Hospital) Services "TOBRAMYCIN 0.3 %-DEXAMETHASONE 0.1 % EYE DROPS,SUSPENSION" RX-11567 CDM 6370000100 HCPCS 250 RC 24208-0295-05 NDC outpatient 5 ML 332.9 332.9 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES EPO [308136803] 266.32 percent of total billed charges 206.4 316.26 Technical (Hospital) Services "TOBRAMYCIN 0.3 %-DEXAMETHASONE 0.1 % EYE DROPS,SUSPENSION" RX-11567 CDM 6370000100 HCPCS 250 RC 24208-0295-05 NDC outpatient 5 ML 332.9 332.9 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES PPO [308136801] 266.32 percent of total billed charges 206.4 316.26 Technical (Hospital) Services SULFAMETHOXAZOLE 800 MG-TRIMETHOPRIM 160 MG TABLET RX-11599 CDM 6370000100 HCPCS 250 RC 65862-0420-01 NDC inpatient 1 UN 5.68 5.68 MEDICA (COMMERCIAL) 94265 [3081118] MEDICA CLAIMS [308111801] 5.11 percent of total billed charges 3.52 5.4 Technical (Hospital) Services SULFAMETHOXAZOLE 800 MG-TRIMETHOPRIM 160 MG TABLET RX-11599 CDM 6370000100 HCPCS 250 RC 65862-0420-01 NDC inpatient 1 UN 5.68 5.68 HEALTHPARTNERS SX009 HEALTHPARTNERS 4.5 percent of total billed charges 3.52 5.4 Technical (Hospital) Services SULFAMETHOXAZOLE 800 MG-TRIMETHOPRIM 160 MG TABLET RX-11599 CDM 6370000100 HCPCS 250 RC 65862-0420-01 NDC inpatient 1 UN 5.68 5.68 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES PPO [308136801] 4.5 percent of total billed charges 3.52 5.4 Technical (Hospital) Services SULFAMETHOXAZOLE 800 MG-TRIMETHOPRIM 160 MG TABLET RX-11599 CDM 6370000100 HCPCS 250 RC 65862-0420-01 NDC inpatient 1 UN 5.68 5.68 MULTIPLAN INC 34080 [3081285] MULTIPLAN INC [308128501] 5.4 percent of total billed charges 3.52 5.4 Technical (Hospital) Services SULFAMETHOXAZOLE 800 MG-TRIMETHOPRIM 160 MG TABLET RX-11599 CDM 6370000100 HCPCS 250 RC 65862-0420-01 NDC inpatient 1 UN 5.68 5.68 BLUE CROSS BLUE SHIELD WELLMARK SB889 [3081026] BCBS WYOMING [308102603] 5.4 percent of total billed charges 3.52 5.4 Technical (Hospital) Services SULFAMETHOXAZOLE 800 MG-TRIMETHOPRIM 160 MG TABLET RX-11599 CDM 6370000100 HCPCS 250 RC 65862-0420-01 NDC inpatient 1 UN 5.68 5.68 UNITED HEALTHCARE (COMMERCIAL) [3081199] UNITED HEALTHCARE 87726 [308119901] 3.52 percent of total billed charges 3.52 5.4 Technical (Hospital) Services SULFAMETHOXAZOLE 800 MG-TRIMETHOPRIM 160 MG TABLET RX-11599 CDM 6370000100 HCPCS 250 RC 65862-0420-01 NDC inpatient 1 UN 5.68 5.68 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES EPO [308136803] 4.5 percent of total billed charges 3.52 5.4 Technical (Hospital) Services SULFAMETHOXAZOLE 800 MG-TRIMETHOPRIM 160 MG TABLET RX-11599 CDM 6370000100 HCPCS 250 RC 65862-0420-01 NDC inpatient 1 UN 5.68 5.68 CIGNA 62308 [3081051] CIGNA 62308 [308105105] 4.5 percent of total billed charges 3.52 5.4 Technical (Hospital) Services SULFAMETHOXAZOLE 800 MG-TRIMETHOPRIM 160 MG TABLET RX-11599 CDM 6370000100 HCPCS 250 RC 65862-0420-01 NDC inpatient 1 UN 5.68 5.68 CIGNA 62308 [3081051] CIGNA STATE OF WYOMING [308105107] 4.5 percent of total billed charges 3.52 5.4 Technical (Hospital) Services SULFAMETHOXAZOLE 800 MG-TRIMETHOPRIM 160 MG TABLET RX-11599 CDM 6370000100 HCPCS 250 RC 65862-0420-01 NDC inpatient 1 UN 5.68 5.68 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES HDHP [308136802] 4.5 percent of total billed charges 3.52 5.4 Technical (Hospital) Services SULFAMETHOXAZOLE 800 MG-TRIMETHOPRIM 160 MG TABLET RX-11599 CDM 6370000100 HCPCS 250 RC 65862-0420-01 NDC outpatient 1 UN 5.68 5.68 HEALTHPARTNERS SX009 HEALTHPARTNERS 4.54 percent of total billed charges 3.52 5.4 Technical (Hospital) Services SULFAMETHOXAZOLE 800 MG-TRIMETHOPRIM 160 MG TABLET RX-11599 CDM 6370000100 HCPCS 250 RC 65862-0420-01 NDC outpatient 1 UN 5.68 5.68 BLUE CROSS BLUE SHIELD WELLMARK SB889 [3081026] BCBS WYOMING [308102603] 5.4 percent of total billed charges 3.52 5.4 Technical (Hospital) Services SULFAMETHOXAZOLE 800 MG-TRIMETHOPRIM 160 MG TABLET RX-11599 CDM 6370000100 HCPCS 250 RC 65862-0420-01 NDC outpatient 1 UN 5.68 5.68 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES EPO [308136803] 4.54 percent of total billed charges 3.52 5.4 Technical (Hospital) Services SULFAMETHOXAZOLE 800 MG-TRIMETHOPRIM 160 MG TABLET RX-11599 CDM 6370000100 HCPCS 250 RC 65862-0420-01 NDC outpatient 1 UN 5.68 5.68 MEDICA (COMMERCIAL) 94265 [3081118] MEDICA CLAIMS [308111801] 5.11 percent of total billed charges 3.52 5.4 Technical (Hospital) Services SULFAMETHOXAZOLE 800 MG-TRIMETHOPRIM 160 MG TABLET RX-11599 CDM 6370000100 HCPCS 250 RC 65862-0420-01 NDC outpatient 1 UN 5.68 5.68 MULTIPLAN INC 34080 [3081285] MULTIPLAN INC [308128501] 5.4 percent of total billed charges 3.52 5.4 Technical (Hospital) Services SULFAMETHOXAZOLE 800 MG-TRIMETHOPRIM 160 MG TABLET RX-11599 CDM 6370000100 HCPCS 250 RC 65862-0420-01 NDC outpatient 1 UN 5.68 5.68 CIGNA 62308 [3081051] CIGNA 62308 [308105105] 4.54 percent of total billed charges 3.52 5.4 Technical (Hospital) Services SULFAMETHOXAZOLE 800 MG-TRIMETHOPRIM 160 MG TABLET RX-11599 CDM 6370000100 HCPCS 250 RC 65862-0420-01 NDC outpatient 1 UN 5.68 5.68 CIGNA 62308 [3081051] CIGNA STATE OF WYOMING [308105107] 4.54 percent of total billed charges 3.52 5.4 Technical (Hospital) Services SULFAMETHOXAZOLE 800 MG-TRIMETHOPRIM 160 MG TABLET RX-11599 CDM 6370000100 HCPCS 250 RC 65862-0420-01 NDC outpatient 1 UN 5.68 5.68 UNITED HEALTHCARE (COMMERCIAL) [3081199] UNITED HEALTHCARE 87726 [308119901] 3.52 percent of total billed charges 3.52 5.4 Technical (Hospital) Services SULFAMETHOXAZOLE 800 MG-TRIMETHOPRIM 160 MG TABLET RX-11599 CDM 6370000100 HCPCS 250 RC 65862-0420-01 NDC outpatient 1 UN 5.68 5.68 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES PPO [308136801] 4.54 percent of total billed charges 3.52 5.4 Technical (Hospital) Services SULFAMETHOXAZOLE 800 MG-TRIMETHOPRIM 160 MG TABLET RX-11599 CDM 6370000100 HCPCS 250 RC 65862-0420-01 NDC outpatient 1 UN 5.68 5.68 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES HDHP [308136802] 4.54 percent of total billed charges 3.52 5.4 Technical (Hospital) Services VANCOMYCIN 125 MG CAPSULE RX-11628 CDM 6370000100 HCPCS 250 RC 68180-0166-13 NDC outpatient 1 UN 8.12 8.12 CIGNA 62308 [3081051] CIGNA 62308 [308105105] 6.5 percent of total billed charges 5.03 7.71 Technical (Hospital) Services VANCOMYCIN 125 MG CAPSULE RX-11628 CDM 6370000100 HCPCS 250 RC 68180-0166-13 NDC outpatient 1 UN 8.12 8.12 CIGNA 62308 [3081051] CIGNA STATE OF WYOMING [308105107] 6.5 percent of total billed charges 5.03 7.71 Technical (Hospital) Services VANCOMYCIN 125 MG CAPSULE RX-11628 CDM 6370000100 HCPCS 250 RC 68180-0166-13 NDC outpatient 1 UN 8.12 8.12 MEDICA (COMMERCIAL) 94265 [3081118] MEDICA CLAIMS [308111801] 7.31 percent of total billed charges 5.03 7.71 Technical (Hospital) Services VANCOMYCIN 125 MG CAPSULE RX-11628 CDM 6370000100 HCPCS 250 RC 68180-0166-13 NDC outpatient 1 UN 8.12 8.12 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES EPO [308136803] 6.5 percent of total billed charges 5.03 7.71 Technical (Hospital) Services VANCOMYCIN 125 MG CAPSULE RX-11628 CDM 6370000100 HCPCS 250 RC 68180-0166-13 NDC outpatient 1 UN 8.12 8.12 MULTIPLAN INC 34080 [3081285] MULTIPLAN INC [308128501] 7.71 percent of total billed charges 5.03 7.71 Technical (Hospital) Services VANCOMYCIN 125 MG CAPSULE RX-11628 CDM 6370000100 HCPCS 250 RC 68180-0166-13 NDC outpatient 1 UN 8.12 8.12 UNITED HEALTHCARE (COMMERCIAL) [3081199] UNITED HEALTHCARE 87726 [308119901] 5.03 percent of total billed charges 5.03 7.71 Technical (Hospital) Services VANCOMYCIN 125 MG CAPSULE RX-11628 CDM 6370000100 HCPCS 250 RC 68180-0166-13 NDC outpatient 1 UN 8.12 8.12 HEALTHPARTNERS SX009 HEALTHPARTNERS 6.5 percent of total billed charges 5.03 7.71 Technical (Hospital) Services VANCOMYCIN 125 MG CAPSULE RX-11628 CDM 6370000100 HCPCS 250 RC 68180-0166-13 NDC outpatient 1 UN 8.12 8.12 BLUE CROSS BLUE SHIELD WELLMARK SB889 [3081026] BCBS WYOMING [308102603] 7.71 percent of total billed charges 5.03 7.71 Technical (Hospital) Services VANCOMYCIN 125 MG CAPSULE RX-11628 CDM 6370000100 HCPCS 250 RC 68180-0166-13 NDC outpatient 1 UN 8.12 8.12 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES HDHP [308136802] 6.5 percent of total billed charges 5.03 7.71 Technical (Hospital) Services VANCOMYCIN 125 MG CAPSULE RX-11628 CDM 6370000100 HCPCS 250 RC 68180-0166-13 NDC outpatient 1 UN 8.12 8.12 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES PPO [308136801] 6.5 percent of total billed charges 5.03 7.71 Technical (Hospital) Services VANCOMYCIN 125 MG CAPSULE RX-11628 CDM 6370000100 HCPCS 250 RC 68180-0166-13 NDC inpatient 1 UN 8.12 8.12 HEALTHPARTNERS SX009 HEALTHPARTNERS 6.43 percent of total billed charges 5.03 7.71 Technical (Hospital) Services VANCOMYCIN 125 MG CAPSULE RX-11628 CDM 6370000100 HCPCS 250 RC 68180-0166-13 NDC inpatient 1 UN 8.12 8.12 MEDICA (COMMERCIAL) 94265 [3081118] MEDICA CLAIMS [308111801] 7.31 percent of total billed charges 5.03 7.71 Technical (Hospital) Services VANCOMYCIN 125 MG CAPSULE RX-11628 CDM 6370000100 HCPCS 250 RC 68180-0166-13 NDC inpatient 1 UN 8.12 8.12 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES PPO [308136801] 6.43 percent of total billed charges 5.03 7.71 Technical (Hospital) Services VANCOMYCIN 125 MG CAPSULE RX-11628 CDM 6370000100 HCPCS 250 RC 68180-0166-13 NDC inpatient 1 UN 8.12 8.12 MULTIPLAN INC 34080 [3081285] MULTIPLAN INC [308128501] 7.71 percent of total billed charges 5.03 7.71 Technical (Hospital) Services VANCOMYCIN 125 MG CAPSULE RX-11628 CDM 6370000100 HCPCS 250 RC 68180-0166-13 NDC inpatient 1 UN 8.12 8.12 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES EPO [308136803] 6.43 percent of total billed charges 5.03 7.71 Technical (Hospital) Services VANCOMYCIN 125 MG CAPSULE RX-11628 CDM 6370000100 HCPCS 250 RC 68180-0166-13 NDC inpatient 1 UN 8.12 8.12 CIGNA 62308 [3081051] CIGNA STATE OF WYOMING [308105107] 6.43 percent of total billed charges 5.03 7.71 Technical (Hospital) Services VANCOMYCIN 125 MG CAPSULE RX-11628 CDM 6370000100 HCPCS 250 RC 68180-0166-13 NDC inpatient 1 UN 8.12 8.12 CIGNA 62308 [3081051] CIGNA 62308 [308105105] 6.43 percent of total billed charges 5.03 7.71 Technical (Hospital) Services VANCOMYCIN 125 MG CAPSULE RX-11628 CDM 6370000100 HCPCS 250 RC 68180-0166-13 NDC inpatient 1 UN 8.12 8.12 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES HDHP [308136802] 6.43 percent of total billed charges 5.03 7.71 Technical (Hospital) Services VANCOMYCIN 125 MG CAPSULE RX-11628 CDM 6370000100 HCPCS 250 RC 68180-0166-13 NDC inpatient 1 UN 8.12 8.12 UNITED HEALTHCARE (COMMERCIAL) [3081199] UNITED HEALTHCARE 87726 [308119901] 5.03 percent of total billed charges 5.03 7.71 Technical (Hospital) Services VANCOMYCIN 125 MG CAPSULE RX-11628 CDM 6370000100 HCPCS 250 RC 68180-0166-13 NDC inpatient 1 UN 8.12 8.12 BLUE CROSS BLUE SHIELD WELLMARK SB889 [3081026] BCBS WYOMING [308102603] 7.71 percent of total billed charges 5.03 7.71 Technical (Hospital) Services WARFARIN 1 MG TABLET RX-11664 CDM 6370000100 HCPCS 250 RC 00093-1712-01 NDC inpatient 1 UN 5.84 5.84 MULTIPLAN INC 34080 [3081285] MULTIPLAN INC [308128501] 5.55 percent of total billed charges 3.62 5.55 Technical (Hospital) Services WARFARIN 1 MG TABLET RX-11664 CDM 6370000100 HCPCS 250 RC 00093-1712-01 NDC inpatient 1 UN 5.84 5.84 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES PPO [308136801] 4.62 percent of total billed charges 3.62 5.55 Technical (Hospital) Services WARFARIN 1 MG TABLET RX-11664 CDM 6370000100 HCPCS 250 RC 00093-1712-01 NDC inpatient 1 UN 5.84 5.84 CIGNA 62308 [3081051] CIGNA 62308 [308105105] 4.62 percent of total billed charges 3.62 5.55 Technical (Hospital) Services WARFARIN 1 MG TABLET RX-11664 CDM 6370000100 HCPCS 250 RC 00093-1712-01 NDC inpatient 1 UN 5.84 5.84 CIGNA 62308 [3081051] CIGNA STATE OF WYOMING [308105107] 4.62 percent of total billed charges 3.62 5.55 Technical (Hospital) Services WARFARIN 1 MG TABLET RX-11664 CDM 6370000100 HCPCS 250 RC 00093-1712-01 NDC inpatient 1 UN 5.84 5.84 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES EPO [308136803] 4.62 percent of total billed charges 3.62 5.55 Technical (Hospital) Services WARFARIN 1 MG TABLET RX-11664 CDM 6370000100 HCPCS 250 RC 00093-1712-01 NDC inpatient 1 UN 5.84 5.84 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES HDHP [308136802] 4.62 percent of total billed charges 3.62 5.55 Technical (Hospital) Services WARFARIN 1 MG TABLET RX-11664 CDM 6370000100 HCPCS 250 RC 00093-1712-01 NDC inpatient 1 UN 5.84 5.84 HEALTHPARTNERS SX009 HEALTHPARTNERS 4.62 percent of total billed charges 3.62 5.55 Technical (Hospital) Services WARFARIN 1 MG TABLET RX-11664 CDM 6370000100 HCPCS 250 RC 00093-1712-01 NDC inpatient 1 UN 5.84 5.84 MEDICA (COMMERCIAL) 94265 [3081118] MEDICA CLAIMS [308111801] 5.26 percent of total billed charges 3.62 5.55 Technical (Hospital) Services WARFARIN 1 MG TABLET RX-11664 CDM 6370000100 HCPCS 250 RC 00093-1712-01 NDC inpatient 1 UN 5.84 5.84 UNITED HEALTHCARE (COMMERCIAL) [3081199] UNITED HEALTHCARE 87726 [308119901] 3.62 percent of total billed charges 3.62 5.55 Technical (Hospital) Services WARFARIN 1 MG TABLET RX-11664 CDM 6370000100 HCPCS 250 RC 00093-1712-01 NDC inpatient 1 UN 5.84 5.84 BLUE CROSS BLUE SHIELD WELLMARK SB889 [3081026] BCBS WYOMING [308102603] 5.55 percent of total billed charges 3.62 5.55 Technical (Hospital) Services WARFARIN 1 MG TABLET RX-11664 CDM 6370000100 HCPCS 250 RC 00093-1712-01 NDC outpatient 1 UN 5.84 5.84 HEALTHPARTNERS SX009 HEALTHPARTNERS 4.67 percent of total billed charges 3.62 5.55 Technical (Hospital) Services WARFARIN 1 MG TABLET RX-11664 CDM 6370000100 HCPCS 250 RC 00093-1712-01 NDC outpatient 1 UN 5.84 5.84 BLUE CROSS BLUE SHIELD WELLMARK SB889 [3081026] BCBS WYOMING [308102603] 5.55 percent of total billed charges 3.62 5.55 Technical (Hospital) Services WARFARIN 1 MG TABLET RX-11664 CDM 6370000100 HCPCS 250 RC 00093-1712-01 NDC outpatient 1 UN 5.84 5.84 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES EPO [308136803] 4.67 percent of total billed charges 3.62 5.55 Technical (Hospital) Services WARFARIN 1 MG TABLET RX-11664 CDM 6370000100 HCPCS 250 RC 00093-1712-01 NDC outpatient 1 UN 5.84 5.84 MEDICA (COMMERCIAL) 94265 [3081118] MEDICA CLAIMS [308111801] 5.26 percent of total billed charges 3.62 5.55 Technical (Hospital) Services WARFARIN 1 MG TABLET RX-11664 CDM 6370000100 HCPCS 250 RC 00093-1712-01 NDC outpatient 1 UN 5.84 5.84 MULTIPLAN INC 34080 [3081285] MULTIPLAN INC [308128501] 5.55 percent of total billed charges 3.62 5.55 Technical (Hospital) Services WARFARIN 1 MG TABLET RX-11664 CDM 6370000100 HCPCS 250 RC 00093-1712-01 NDC outpatient 1 UN 5.84 5.84 CIGNA 62308 [3081051] CIGNA 62308 [308105105] 4.67 percent of total billed charges 3.62 5.55 Technical (Hospital) Services WARFARIN 1 MG TABLET RX-11664 CDM 6370000100 HCPCS 250 RC 00093-1712-01 NDC outpatient 1 UN 5.84 5.84 CIGNA 62308 [3081051] CIGNA STATE OF WYOMING [308105107] 4.67 percent of total billed charges 3.62 5.55 Technical (Hospital) Services WARFARIN 1 MG TABLET RX-11664 CDM 6370000100 HCPCS 250 RC 00093-1712-01 NDC outpatient 1 UN 5.84 5.84 UNITED HEALTHCARE (COMMERCIAL) [3081199] UNITED HEALTHCARE 87726 [308119901] 3.62 percent of total billed charges 3.62 5.55 Technical (Hospital) Services WARFARIN 1 MG TABLET RX-11664 CDM 6370000100 HCPCS 250 RC 00093-1712-01 NDC outpatient 1 UN 5.84 5.84 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES HDHP [308136802] 4.67 percent of total billed charges 3.62 5.55 Technical (Hospital) Services WARFARIN 1 MG TABLET RX-11664 CDM 6370000100 HCPCS 250 RC 00093-1712-01 NDC outpatient 1 UN 5.84 5.84 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES PPO [308136801] 4.67 percent of total billed charges 3.62 5.55 Technical (Hospital) Services IPRATROPIUM 20 MCG-ALBUTEROL 100 MCG/ACTUATION MIST FOR INHALATION RX-116728 CDM 6370000100 HCPCS 250 RC 00597-0024-02 NDC outpatient 4 GR 1124.34 1124.34 MULTIPLAN INC 34080 [3081285] MULTIPLAN INC [308128501] 1068.12 percent of total billed charges 697.09 1068.12 Technical (Hospital) Services IPRATROPIUM 20 MCG-ALBUTEROL 100 MCG/ACTUATION MIST FOR INHALATION RX-116728 CDM 6370000100 HCPCS 250 RC 00597-0024-02 NDC outpatient 4 GR 1124.34 1124.34 MEDICA (COMMERCIAL) 94265 [3081118] MEDICA CLAIMS [308111801] 1011.91 percent of total billed charges 697.09 1068.12 Technical (Hospital) Services IPRATROPIUM 20 MCG-ALBUTEROL 100 MCG/ACTUATION MIST FOR INHALATION RX-116728 CDM 6370000100 HCPCS 250 RC 00597-0024-02 NDC outpatient 4 GR 1124.34 1124.34 CIGNA 62308 [3081051] CIGNA 62308 [308105105] 899.47 percent of total billed charges 697.09 1068.12 Technical (Hospital) Services IPRATROPIUM 20 MCG-ALBUTEROL 100 MCG/ACTUATION MIST FOR INHALATION RX-116728 CDM 6370000100 HCPCS 250 RC 00597-0024-02 NDC outpatient 4 GR 1124.34 1124.34 CIGNA 62308 [3081051] CIGNA STATE OF WYOMING [308105107] 899.47 percent of total billed charges 697.09 1068.12 Technical (Hospital) Services IPRATROPIUM 20 MCG-ALBUTEROL 100 MCG/ACTUATION MIST FOR INHALATION RX-116728 CDM 6370000100 HCPCS 250 RC 00597-0024-02 NDC outpatient 4 GR 1124.34 1124.34 HEALTHPARTNERS SX009 HEALTHPARTNERS 899.47 percent of total billed charges 697.09 1068.12 Technical (Hospital) Services IPRATROPIUM 20 MCG-ALBUTEROL 100 MCG/ACTUATION MIST FOR INHALATION RX-116728 CDM 6370000100 HCPCS 250 RC 00597-0024-02 NDC outpatient 4 GR 1124.34 1124.34 UNITED HEALTHCARE (COMMERCIAL) [3081199] UNITED HEALTHCARE 87726 [308119901] 697.09 percent of total billed charges 697.09 1068.12 Technical (Hospital) Services IPRATROPIUM 20 MCG-ALBUTEROL 100 MCG/ACTUATION MIST FOR INHALATION RX-116728 CDM 6370000100 HCPCS 250 RC 00597-0024-02 NDC outpatient 4 GR 1124.34 1124.34 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES EPO [308136803] 899.47 percent of total billed charges 697.09 1068.12 Technical (Hospital) Services IPRATROPIUM 20 MCG-ALBUTEROL 100 MCG/ACTUATION MIST FOR INHALATION RX-116728 CDM 6370000100 HCPCS 250 RC 00597-0024-02 NDC outpatient 4 GR 1124.34 1124.34 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES HDHP [308136802] 899.47 percent of total billed charges 697.09 1068.12 Technical (Hospital) Services IPRATROPIUM 20 MCG-ALBUTEROL 100 MCG/ACTUATION MIST FOR INHALATION RX-116728 CDM 6370000100 HCPCS 250 RC 00597-0024-02 NDC outpatient 4 GR 1124.34 1124.34 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES PPO [308136801] 899.47 percent of total billed charges 697.09 1068.12 Technical (Hospital) Services IPRATROPIUM 20 MCG-ALBUTEROL 100 MCG/ACTUATION MIST FOR INHALATION RX-116728 CDM 6370000100 HCPCS 250 RC 00597-0024-02 NDC outpatient 4 GR 1124.34 1124.34 BLUE CROSS BLUE SHIELD WELLMARK SB889 [3081026] BCBS WYOMING [308102603] 1068.12 percent of total billed charges 697.09 1068.12 Technical (Hospital) Services IPRATROPIUM 20 MCG-ALBUTEROL 100 MCG/ACTUATION MIST FOR INHALATION RX-116728 CDM 6370000100 HCPCS 250 RC 00597-0024-02 NDC inpatient 4 GR 1124.34 1124.34 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES HDHP [308136802] 890.25 percent of total billed charges 697.09 1068.12 Technical (Hospital) Services IPRATROPIUM 20 MCG-ALBUTEROL 100 MCG/ACTUATION MIST FOR INHALATION RX-116728 CDM 6370000100 HCPCS 250 RC 00597-0024-02 NDC inpatient 4 GR 1124.34 1124.34 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES PPO [308136801] 890.25 percent of total billed charges 697.09 1068.12 Technical (Hospital) Services IPRATROPIUM 20 MCG-ALBUTEROL 100 MCG/ACTUATION MIST FOR INHALATION RX-116728 CDM 6370000100 HCPCS 250 RC 00597-0024-02 NDC inpatient 4 GR 1124.34 1124.34 HEALTHPARTNERS SX009 HEALTHPARTNERS 890.25 percent of total billed charges 697.09 1068.12 Technical (Hospital) Services IPRATROPIUM 20 MCG-ALBUTEROL 100 MCG/ACTUATION MIST FOR INHALATION RX-116728 CDM 6370000100 HCPCS 250 RC 00597-0024-02 NDC inpatient 4 GR 1124.34 1124.34 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES EPO [308136803] 890.25 percent of total billed charges 697.09 1068.12 Technical (Hospital) Services IPRATROPIUM 20 MCG-ALBUTEROL 100 MCG/ACTUATION MIST FOR INHALATION RX-116728 CDM 6370000100 HCPCS 250 RC 00597-0024-02 NDC inpatient 4 GR 1124.34 1124.34 UNITED HEALTHCARE (COMMERCIAL) [3081199] UNITED HEALTHCARE 87726 [308119901] 697.09 percent of total billed charges 697.09 1068.12 Technical (Hospital) Services IPRATROPIUM 20 MCG-ALBUTEROL 100 MCG/ACTUATION MIST FOR INHALATION RX-116728 CDM 6370000100 HCPCS 250 RC 00597-0024-02 NDC inpatient 4 GR 1124.34 1124.34 BLUE CROSS BLUE SHIELD WELLMARK SB889 [3081026] BCBS WYOMING [308102603] 1068.12 percent of total billed charges 697.09 1068.12 Technical (Hospital) Services IPRATROPIUM 20 MCG-ALBUTEROL 100 MCG/ACTUATION MIST FOR INHALATION RX-116728 CDM 6370000100 HCPCS 250 RC 00597-0024-02 NDC inpatient 4 GR 1124.34 1124.34 CIGNA 62308 [3081051] CIGNA 62308 [308105105] 890.25 percent of total billed charges 697.09 1068.12 Technical (Hospital) Services IPRATROPIUM 20 MCG-ALBUTEROL 100 MCG/ACTUATION MIST FOR INHALATION RX-116728 CDM 6370000100 HCPCS 250 RC 00597-0024-02 NDC inpatient 4 GR 1124.34 1124.34 CIGNA 62308 [3081051] CIGNA STATE OF WYOMING [308105107] 890.25 percent of total billed charges 697.09 1068.12 Technical (Hospital) Services IPRATROPIUM 20 MCG-ALBUTEROL 100 MCG/ACTUATION MIST FOR INHALATION RX-116728 CDM 6370000100 HCPCS 250 RC 00597-0024-02 NDC inpatient 4 GR 1124.34 1124.34 MEDICA (COMMERCIAL) 94265 [3081118] MEDICA CLAIMS [308111801] 1011.91 percent of total billed charges 697.09 1068.12 Technical (Hospital) Services IPRATROPIUM 20 MCG-ALBUTEROL 100 MCG/ACTUATION MIST FOR INHALATION RX-116728 CDM 6370000100 HCPCS 250 RC 00597-0024-02 NDC inpatient 4 GR 1124.34 1124.34 MULTIPLAN INC 34080 [3081285] MULTIPLAN INC [308128501] 1068.12 percent of total billed charges 697.09 1068.12 Technical (Hospital) Services "MIRABEGRON ER 25 MG TABLET,EXTENDED RELEASE 24 HR" RX-116842 CDM 6370000100 HCPCS 250 RC 00469-2601-90 NDC outpatient 1 UN 54.34 54.34 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES HDHP [308136802] 43.47 percent of total billed charges 33.69 51.62 Technical (Hospital) Services "MIRABEGRON ER 25 MG TABLET,EXTENDED RELEASE 24 HR" RX-116842 CDM 6370000100 HCPCS 250 RC 00469-2601-90 NDC outpatient 1 UN 54.34 54.34 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES PPO [308136801] 43.47 percent of total billed charges 33.69 51.62 Technical (Hospital) Services "MIRABEGRON ER 25 MG TABLET,EXTENDED RELEASE 24 HR" RX-116842 CDM 6370000100 HCPCS 250 RC 00469-2601-90 NDC outpatient 1 UN 54.34 54.34 HEALTHPARTNERS SX009 HEALTHPARTNERS 43.47 percent of total billed charges 33.69 51.62 Technical (Hospital) Services "MIRABEGRON ER 25 MG TABLET,EXTENDED RELEASE 24 HR" RX-116842 CDM 6370000100 HCPCS 250 RC 00469-2601-90 NDC outpatient 1 UN 54.34 54.34 BLUE CROSS BLUE SHIELD WELLMARK SB889 [3081026] BCBS WYOMING [308102603] 51.62 percent of total billed charges 33.69 51.62 Technical (Hospital) Services "MIRABEGRON ER 25 MG TABLET,EXTENDED RELEASE 24 HR" RX-116842 CDM 6370000100 HCPCS 250 RC 00469-2601-90 NDC outpatient 1 UN 54.34 54.34 MEDICA (COMMERCIAL) 94265 [3081118] MEDICA CLAIMS [308111801] 48.91 percent of total billed charges 33.69 51.62 Technical (Hospital) Services "MIRABEGRON ER 25 MG TABLET,EXTENDED RELEASE 24 HR" RX-116842 CDM 6370000100 HCPCS 250 RC 00469-2601-90 NDC outpatient 1 UN 54.34 54.34 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES EPO [308136803] 43.47 percent of total billed charges 33.69 51.62 Technical (Hospital) Services "MIRABEGRON ER 25 MG TABLET,EXTENDED RELEASE 24 HR" RX-116842 CDM 6370000100 HCPCS 250 RC 00469-2601-90 NDC outpatient 1 UN 54.34 54.34 CIGNA 62308 [3081051] CIGNA 62308 [308105105] 43.47 percent of total billed charges 33.69 51.62 Technical (Hospital) Services "MIRABEGRON ER 25 MG TABLET,EXTENDED RELEASE 24 HR" RX-116842 CDM 6370000100 HCPCS 250 RC 00469-2601-90 NDC outpatient 1 UN 54.34 54.34 CIGNA 62308 [3081051] CIGNA STATE OF WYOMING [308105107] 43.47 percent of total billed charges 33.69 51.62 Technical (Hospital) Services "MIRABEGRON ER 25 MG TABLET,EXTENDED RELEASE 24 HR" RX-116842 CDM 6370000100 HCPCS 250 RC 00469-2601-90 NDC outpatient 1 UN 54.34 54.34 MULTIPLAN INC 34080 [3081285] MULTIPLAN INC [308128501] 51.62 percent of total billed charges 33.69 51.62 Technical (Hospital) Services "MIRABEGRON ER 25 MG TABLET,EXTENDED RELEASE 24 HR" RX-116842 CDM 6370000100 HCPCS 250 RC 00469-2601-90 NDC outpatient 1 UN 54.34 54.34 UNITED HEALTHCARE (COMMERCIAL) [3081199] UNITED HEALTHCARE 87726 [308119901] 33.69 percent of total billed charges 33.69 51.62 Technical (Hospital) Services "MIRABEGRON ER 25 MG TABLET,EXTENDED RELEASE 24 HR" RX-116842 CDM 6370000100 HCPCS 250 RC 00469-2601-90 NDC inpatient 1 UN 54.34 54.34 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES EPO [308136803] 43.03 percent of total billed charges 33.69 51.62 Technical (Hospital) Services "MIRABEGRON ER 25 MG TABLET,EXTENDED RELEASE 24 HR" RX-116842 CDM 6370000100 HCPCS 250 RC 00469-2601-90 NDC inpatient 1 UN 54.34 54.34 CIGNA 62308 [3081051] CIGNA 62308 [308105105] 43.03 percent of total billed charges 33.69 51.62 Technical (Hospital) Services "MIRABEGRON ER 25 MG TABLET,EXTENDED RELEASE 24 HR" RX-116842 CDM 6370000100 HCPCS 250 RC 00469-2601-90 NDC inpatient 1 UN 54.34 54.34 CIGNA 62308 [3081051] CIGNA STATE OF WYOMING [308105107] 43.03 percent of total billed charges 33.69 51.62 Technical (Hospital) Services "MIRABEGRON ER 25 MG TABLET,EXTENDED RELEASE 24 HR" RX-116842 CDM 6370000100 HCPCS 250 RC 00469-2601-90 NDC inpatient 1 UN 54.34 54.34 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES HDHP [308136802] 43.03 percent of total billed charges 33.69 51.62 Technical (Hospital) Services "MIRABEGRON ER 25 MG TABLET,EXTENDED RELEASE 24 HR" RX-116842 CDM 6370000100 HCPCS 250 RC 00469-2601-90 NDC inpatient 1 UN 54.34 54.34 BLUE CROSS BLUE SHIELD WELLMARK SB889 [3081026] BCBS WYOMING [308102603] 51.62 percent of total billed charges 33.69 51.62 Technical (Hospital) Services "MIRABEGRON ER 25 MG TABLET,EXTENDED RELEASE 24 HR" RX-116842 CDM 6370000100 HCPCS 250 RC 00469-2601-90 NDC inpatient 1 UN 54.34 54.34 UNITED HEALTHCARE (COMMERCIAL) [3081199] UNITED HEALTHCARE 87726 [308119901] 33.69 percent of total billed charges 33.69 51.62 Technical (Hospital) Services "MIRABEGRON ER 25 MG TABLET,EXTENDED RELEASE 24 HR" RX-116842 CDM 6370000100 HCPCS 250 RC 00469-2601-90 NDC inpatient 1 UN 54.34 54.34 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES PPO [308136801] 43.03 percent of total billed charges 33.69 51.62 Technical (Hospital) Services "MIRABEGRON ER 25 MG TABLET,EXTENDED RELEASE 24 HR" RX-116842 CDM 6370000100 HCPCS 250 RC 00469-2601-90 NDC inpatient 1 UN 54.34 54.34 MEDICA (COMMERCIAL) 94265 [3081118] MEDICA CLAIMS [308111801] 48.91 percent of total billed charges 33.69 51.62 Technical (Hospital) Services "MIRABEGRON ER 25 MG TABLET,EXTENDED RELEASE 24 HR" RX-116842 CDM 6370000100 HCPCS 250 RC 00469-2601-90 NDC inpatient 1 UN 54.34 54.34 HEALTHPARTNERS SX009 HEALTHPARTNERS 43.03 percent of total billed charges 33.69 51.62 Technical (Hospital) Services "MIRABEGRON ER 25 MG TABLET,EXTENDED RELEASE 24 HR" RX-116842 CDM 6370000100 HCPCS 250 RC 00469-2601-90 NDC inpatient 1 UN 54.34 54.34 MULTIPLAN INC 34080 [3081285] MULTIPLAN INC [308128501] 51.62 percent of total billed charges 33.69 51.62 Technical (Hospital) Services ZOLPIDEM 5 MG TABLET RX-11701 CDM 6370000100 HCPCS 250 RC 00781-5317-01 NDC inpatient 1 UN 5.69 5.69 UNITED HEALTHCARE (COMMERCIAL) [3081199] UNITED HEALTHCARE 87726 [308119901] 3.53 percent of total billed charges 3.53 5.41 Technical (Hospital) Services ZOLPIDEM 5 MG TABLET RX-11701 CDM 6370000100 HCPCS 250 RC 00781-5317-01 NDC inpatient 1 UN 5.69 5.69 BLUE CROSS BLUE SHIELD WELLMARK SB889 [3081026] BCBS WYOMING [308102603] 5.41 percent of total billed charges 3.53 5.41 Technical (Hospital) Services ZOLPIDEM 5 MG TABLET RX-11701 CDM 6370000100 HCPCS 250 RC 00781-5317-01 NDC inpatient 1 UN 5.69 5.69 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES HDHP [308136802] 4.51 percent of total billed charges 3.53 5.41 Technical (Hospital) Services ZOLPIDEM 5 MG TABLET RX-11701 CDM 6370000100 HCPCS 250 RC 00781-5317-01 NDC inpatient 1 UN 5.69 5.69 CIGNA 62308 [3081051] CIGNA 62308 [308105105] 4.51 percent of total billed charges 3.53 5.41 Technical (Hospital) Services ZOLPIDEM 5 MG TABLET RX-11701 CDM 6370000100 HCPCS 250 RC 00781-5317-01 NDC inpatient 1 UN 5.69 5.69 CIGNA 62308 [3081051] CIGNA STATE OF WYOMING [308105107] 4.51 percent of total billed charges 3.53 5.41 Technical (Hospital) Services ZOLPIDEM 5 MG TABLET RX-11701 CDM 6370000100 HCPCS 250 RC 00781-5317-01 NDC inpatient 1 UN 5.69 5.69 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES EPO [308136803] 4.51 percent of total billed charges 3.53 5.41 Technical (Hospital) Services ZOLPIDEM 5 MG TABLET RX-11701 CDM 6370000100 HCPCS 250 RC 00781-5317-01 NDC inpatient 1 UN 5.69 5.69 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES PPO [308136801] 4.51 percent of total billed charges 3.53 5.41 Technical (Hospital) Services ZOLPIDEM 5 MG TABLET RX-11701 CDM 6370000100 HCPCS 250 RC 00781-5317-01 NDC inpatient 1 UN 5.69 5.69 HEALTHPARTNERS SX009 HEALTHPARTNERS 4.51 percent of total billed charges 3.53 5.41 Technical (Hospital) Services ZOLPIDEM 5 MG TABLET RX-11701 CDM 6370000100 HCPCS 250 RC 00781-5317-01 NDC inpatient 1 UN 5.69 5.69 MEDICA (COMMERCIAL) 94265 [3081118] MEDICA CLAIMS [308111801] 5.12 percent of total billed charges 3.53 5.41 Technical (Hospital) Services ZOLPIDEM 5 MG TABLET RX-11701 CDM 6370000100 HCPCS 250 RC 00781-5317-01 NDC inpatient 1 UN 5.69 5.69 MULTIPLAN INC 34080 [3081285] MULTIPLAN INC [308128501] 5.41 percent of total billed charges 3.53 5.41 Technical (Hospital) Services ZOLPIDEM 5 MG TABLET RX-11701 CDM 6370000100 HCPCS 250 RC 00781-5317-01 NDC outpatient 1 UN 5.69 5.69 BLUE CROSS BLUE SHIELD WELLMARK SB889 [3081026] BCBS WYOMING [308102603] 5.41 percent of total billed charges 3.53 5.41 Technical (Hospital) Services ZOLPIDEM 5 MG TABLET RX-11701 CDM 6370000100 HCPCS 250 RC 00781-5317-01 NDC outpatient 1 UN 5.69 5.69 HEALTHPARTNERS SX009 HEALTHPARTNERS 4.55 percent of total billed charges 3.53 5.41 Technical (Hospital) Services ZOLPIDEM 5 MG TABLET RX-11701 CDM 6370000100 HCPCS 250 RC 00781-5317-01 NDC outpatient 1 UN 5.69 5.69 CIGNA 62308 [3081051] CIGNA 62308 [308105105] 4.55 percent of total billed charges 3.53 5.41 Technical (Hospital) Services ZOLPIDEM 5 MG TABLET RX-11701 CDM 6370000100 HCPCS 250 RC 00781-5317-01 NDC outpatient 1 UN 5.69 5.69 CIGNA 62308 [3081051] CIGNA STATE OF WYOMING [308105107] 4.55 percent of total billed charges 3.53 5.41 Technical (Hospital) Services ZOLPIDEM 5 MG TABLET RX-11701 CDM 6370000100 HCPCS 250 RC 00781-5317-01 NDC outpatient 1 UN 5.69 5.69 MULTIPLAN INC 34080 [3081285] MULTIPLAN INC [308128501] 5.41 percent of total billed charges 3.53 5.41 Technical (Hospital) Services ZOLPIDEM 5 MG TABLET RX-11701 CDM 6370000100 HCPCS 250 RC 00781-5317-01 NDC outpatient 1 UN 5.69 5.69 MEDICA (COMMERCIAL) 94265 [3081118] MEDICA CLAIMS [308111801] 5.12 percent of total billed charges 3.53 5.41 Technical (Hospital) Services ZOLPIDEM 5 MG TABLET RX-11701 CDM 6370000100 HCPCS 250 RC 00781-5317-01 NDC outpatient 1 UN 5.69 5.69 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES EPO [308136803] 4.55 percent of total billed charges 3.53 5.41 Technical (Hospital) Services ZOLPIDEM 5 MG TABLET RX-11701 CDM 6370000100 HCPCS 250 RC 00781-5317-01 NDC outpatient 1 UN 5.69 5.69 UNITED HEALTHCARE (COMMERCIAL) [3081199] UNITED HEALTHCARE 87726 [308119901] 3.53 percent of total billed charges 3.53 5.41 Technical (Hospital) Services ZOLPIDEM 5 MG TABLET RX-11701 CDM 6370000100 HCPCS 250 RC 00781-5317-01 NDC outpatient 1 UN 5.69 5.69 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES PPO [308136801] 4.55 percent of total billed charges 3.53 5.41 Technical (Hospital) Services ZOLPIDEM 5 MG TABLET RX-11701 CDM 6370000100 HCPCS 250 RC 00781-5317-01 NDC outpatient 1 UN 5.69 5.69 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES HDHP [308136802] 4.55 percent of total billed charges 3.53 5.41 Technical (Hospital) Services "MORPHINE ER 30 MG TABLET,EXTENDED RELEASE" RX-119007 CDM 6370000100 HCPCS 250 RC 00904-6558-61 NDC inpatient 1 UN 6.87 6.87 CIGNA 62308 [3081051] CIGNA 62308 [308105105] 5.44 percent of total billed charges 4.26 6.53 Technical (Hospital) Services "MORPHINE ER 30 MG TABLET,EXTENDED RELEASE" RX-119007 CDM 6370000100 HCPCS 250 RC 00904-6558-61 NDC inpatient 1 UN 6.87 6.87 CIGNA 62308 [3081051] CIGNA STATE OF WYOMING [308105107] 5.44 percent of total billed charges 4.26 6.53 Technical (Hospital) Services "MORPHINE ER 30 MG TABLET,EXTENDED RELEASE" RX-119007 CDM 6370000100 HCPCS 250 RC 00904-6558-61 NDC inpatient 1 UN 6.87 6.87 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES EPO [308136803] 5.44 percent of total billed charges 4.26 6.53 Technical (Hospital) Services "MORPHINE ER 30 MG TABLET,EXTENDED RELEASE" RX-119007 CDM 6370000100 HCPCS 250 RC 00904-6558-61 NDC inpatient 1 UN 6.87 6.87 MEDICA (COMMERCIAL) 94265 [3081118] MEDICA CLAIMS [308111801] 6.18 percent of total billed charges 4.26 6.53 Technical (Hospital) Services "MORPHINE ER 30 MG TABLET,EXTENDED RELEASE" RX-119007 CDM 6370000100 HCPCS 250 RC 00904-6558-61 NDC inpatient 1 UN 6.87 6.87 HEALTHPARTNERS SX009 HEALTHPARTNERS 5.44 percent of total billed charges 4.26 6.53 Technical (Hospital) Services "MORPHINE ER 30 MG TABLET,EXTENDED RELEASE" RX-119007 CDM 6370000100 HCPCS 250 RC 00904-6558-61 NDC inpatient 1 UN 6.87 6.87 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES HDHP [308136802] 5.44 percent of total billed charges 4.26 6.53 Technical (Hospital) Services "MORPHINE ER 30 MG TABLET,EXTENDED RELEASE" RX-119007 CDM 6370000100 HCPCS 250 RC 00904-6558-61 NDC inpatient 1 UN 6.87 6.87 BLUE CROSS BLUE SHIELD WELLMARK SB889 [3081026] BCBS WYOMING [308102603] 6.53 percent of total billed charges 4.26 6.53 Technical (Hospital) Services "MORPHINE ER 30 MG TABLET,EXTENDED RELEASE" RX-119007 CDM 6370000100 HCPCS 250 RC 00904-6558-61 NDC inpatient 1 UN 6.87 6.87 UNITED HEALTHCARE (COMMERCIAL) [3081199] UNITED HEALTHCARE 87726 [308119901] 4.26 percent of total billed charges 4.26 6.53 Technical (Hospital) Services "MORPHINE ER 30 MG TABLET,EXTENDED RELEASE" RX-119007 CDM 6370000100 HCPCS 250 RC 00904-6558-61 NDC inpatient 1 UN 6.87 6.87 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES PPO [308136801] 5.44 percent of total billed charges 4.26 6.53 Technical (Hospital) Services "MORPHINE ER 30 MG TABLET,EXTENDED RELEASE" RX-119007 CDM 6370000100 HCPCS 250 RC 00904-6558-61 NDC inpatient 1 UN 6.87 6.87 MULTIPLAN INC 34080 [3081285] MULTIPLAN INC [308128501] 6.53 percent of total billed charges 4.26 6.53 Technical (Hospital) Services "MORPHINE ER 30 MG TABLET,EXTENDED RELEASE" RX-119007 CDM 6370000100 HCPCS 250 RC 00904-6558-61 NDC outpatient 1 UN 6.87 6.87 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES EPO [308136803] 5.5 percent of total billed charges 4.26 6.53 Technical (Hospital) Services "MORPHINE ER 30 MG TABLET,EXTENDED RELEASE" RX-119007 CDM 6370000100 HCPCS 250 RC 00904-6558-61 NDC outpatient 1 UN 6.87 6.87 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES HDHP [308136802] 5.5 percent of total billed charges 4.26 6.53 Technical (Hospital) Services "MORPHINE ER 30 MG TABLET,EXTENDED RELEASE" RX-119007 CDM 6370000100 HCPCS 250 RC 00904-6558-61 NDC outpatient 1 UN 6.87 6.87 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES PPO [308136801] 5.5 percent of total billed charges 4.26 6.53 Technical (Hospital) Services "MORPHINE ER 30 MG TABLET,EXTENDED RELEASE" RX-119007 CDM 6370000100 HCPCS 250 RC 00904-6558-61 NDC outpatient 1 UN 6.87 6.87 BLUE CROSS BLUE SHIELD WELLMARK SB889 [3081026] BCBS WYOMING [308102603] 6.53 percent of total billed charges 4.26 6.53 Technical (Hospital) Services "MORPHINE ER 30 MG TABLET,EXTENDED RELEASE" RX-119007 CDM 6370000100 HCPCS 250 RC 00904-6558-61 NDC outpatient 1 UN 6.87 6.87 MEDICA (COMMERCIAL) 94265 [3081118] MEDICA CLAIMS [308111801] 6.18 percent of total billed charges 4.26 6.53 Technical (Hospital) Services "MORPHINE ER 30 MG TABLET,EXTENDED RELEASE" RX-119007 CDM 6370000100 HCPCS 250 RC 00904-6558-61 NDC outpatient 1 UN 6.87 6.87 CIGNA 62308 [3081051] CIGNA 62308 [308105105] 5.5 percent of total billed charges 4.26 6.53 Technical (Hospital) Services "MORPHINE ER 30 MG TABLET,EXTENDED RELEASE" RX-119007 CDM 6370000100 HCPCS 250 RC 00904-6558-61 NDC outpatient 1 UN 6.87 6.87 CIGNA 62308 [3081051] CIGNA STATE OF WYOMING [308105107] 5.5 percent of total billed charges 4.26 6.53 Technical (Hospital) Services "MORPHINE ER 30 MG TABLET,EXTENDED RELEASE" RX-119007 CDM 6370000100 HCPCS 250 RC 00904-6558-61 NDC outpatient 1 UN 6.87 6.87 MULTIPLAN INC 34080 [3081285] MULTIPLAN INC [308128501] 6.53 percent of total billed charges 4.26 6.53 Technical (Hospital) Services "MORPHINE ER 30 MG TABLET,EXTENDED RELEASE" RX-119007 CDM 6370000100 HCPCS 250 RC 00904-6558-61 NDC outpatient 1 UN 6.87 6.87 HEALTHPARTNERS SX009 HEALTHPARTNERS 5.5 percent of total billed charges 4.26 6.53 Technical (Hospital) Services "MORPHINE ER 30 MG TABLET,EXTENDED RELEASE" RX-119007 CDM 6370000100 HCPCS 250 RC 00904-6558-61 NDC outpatient 1 UN 6.87 6.87 UNITED HEALTHCARE (COMMERCIAL) [3081199] UNITED HEALTHCARE 87726 [308119901] 4.26 percent of total billed charges 4.26 6.53 Technical (Hospital) Services "DICLOFENAC 50 MG-MISOPROSTOL 200 MCG TABLET,IMMED.AND DELAYED RELEASE" RX-119012 CDM 6370000100 HCPCS 250 RC 59762-0028-02 NDC inpatient 1 UN 14.68 14.68 CIGNA 62308 [3081051] CIGNA 62308 [308105105] 11.62 percent of total billed charges 9.1 13.95 Technical (Hospital) Services "DICLOFENAC 50 MG-MISOPROSTOL 200 MCG TABLET,IMMED.AND DELAYED RELEASE" RX-119012 CDM 6370000100 HCPCS 250 RC 59762-0028-02 NDC inpatient 1 UN 14.68 14.68 CIGNA 62308 [3081051] CIGNA STATE OF WYOMING [308105107] 11.62 percent of total billed charges 9.1 13.95 Technical (Hospital) Services "DICLOFENAC 50 MG-MISOPROSTOL 200 MCG TABLET,IMMED.AND DELAYED RELEASE" RX-119012 CDM 6370000100 HCPCS 250 RC 59762-0028-02 NDC inpatient 1 UN 14.68 14.68 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES EPO [308136803] 11.62 percent of total billed charges 9.1 13.95 Technical (Hospital) Services "DICLOFENAC 50 MG-MISOPROSTOL 200 MCG TABLET,IMMED.AND DELAYED RELEASE" RX-119012 CDM 6370000100 HCPCS 250 RC 59762-0028-02 NDC inpatient 1 UN 14.68 14.68 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES HDHP [308136802] 11.62 percent of total billed charges 9.1 13.95 Technical (Hospital) Services "DICLOFENAC 50 MG-MISOPROSTOL 200 MCG TABLET,IMMED.AND DELAYED RELEASE" RX-119012 CDM 6370000100 HCPCS 250 RC 59762-0028-02 NDC inpatient 1 UN 14.68 14.68 HEALTHPARTNERS SX009 HEALTHPARTNERS 11.62 percent of total billed charges 9.1 13.95 Technical (Hospital) Services "DICLOFENAC 50 MG-MISOPROSTOL 200 MCG TABLET,IMMED.AND DELAYED RELEASE" RX-119012 CDM 6370000100 HCPCS 250 RC 59762-0028-02 NDC inpatient 1 UN 14.68 14.68 MEDICA (COMMERCIAL) 94265 [3081118] MEDICA CLAIMS [308111801] 13.21 percent of total billed charges 9.1 13.95 Technical (Hospital) Services "DICLOFENAC 50 MG-MISOPROSTOL 200 MCG TABLET,IMMED.AND DELAYED RELEASE" RX-119012 CDM 6370000100 HCPCS 250 RC 59762-0028-02 NDC inpatient 1 UN 14.68 14.68 UNITED HEALTHCARE (COMMERCIAL) [3081199] UNITED HEALTHCARE 87726 [308119901] 9.1 percent of total billed charges 9.1 13.95 Technical (Hospital) Services "DICLOFENAC 50 MG-MISOPROSTOL 200 MCG TABLET,IMMED.AND DELAYED RELEASE" RX-119012 CDM 6370000100 HCPCS 250 RC 59762-0028-02 NDC inpatient 1 UN 14.68 14.68 BLUE CROSS BLUE SHIELD WELLMARK SB889 [3081026] BCBS WYOMING [308102603] 13.95 percent of total billed charges 9.1 13.95 Technical (Hospital) Services "DICLOFENAC 50 MG-MISOPROSTOL 200 MCG TABLET,IMMED.AND DELAYED RELEASE" RX-119012 CDM 6370000100 HCPCS 250 RC 59762-0028-02 NDC inpatient 1 UN 14.68 14.68 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES PPO [308136801] 11.62 percent of total billed charges 9.1 13.95 Technical (Hospital) Services "DICLOFENAC 50 MG-MISOPROSTOL 200 MCG TABLET,IMMED.AND DELAYED RELEASE" RX-119012 CDM 6370000100 HCPCS 250 RC 59762-0028-02 NDC inpatient 1 UN 14.68 14.68 MULTIPLAN INC 34080 [3081285] MULTIPLAN INC [308128501] 13.95 percent of total billed charges 9.1 13.95 Technical (Hospital) Services "DICLOFENAC 50 MG-MISOPROSTOL 200 MCG TABLET,IMMED.AND DELAYED RELEASE" RX-119012 CDM 6370000100 HCPCS 250 RC 59762-0028-02 NDC outpatient 1 UN 14.68 14.68 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES PPO [308136801] 11.74 percent of total billed charges 9.1 13.95 Technical (Hospital) Services "DICLOFENAC 50 MG-MISOPROSTOL 200 MCG TABLET,IMMED.AND DELAYED RELEASE" RX-119012 CDM 6370000100 HCPCS 250 RC 59762-0028-02 NDC outpatient 1 UN 14.68 14.68 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES HDHP [308136802] 11.74 percent of total billed charges 9.1 13.95 Technical (Hospital) Services "DICLOFENAC 50 MG-MISOPROSTOL 200 MCG TABLET,IMMED.AND DELAYED RELEASE" RX-119012 CDM 6370000100 HCPCS 250 RC 59762-0028-02 NDC outpatient 1 UN 14.68 14.68 BLUE CROSS BLUE SHIELD WELLMARK SB889 [3081026] BCBS WYOMING [308102603] 13.95 percent of total billed charges 9.1 13.95 Technical (Hospital) Services "DICLOFENAC 50 MG-MISOPROSTOL 200 MCG TABLET,IMMED.AND DELAYED RELEASE" RX-119012 CDM 6370000100 HCPCS 250 RC 59762-0028-02 NDC outpatient 1 UN 14.68 14.68 HEALTHPARTNERS SX009 HEALTHPARTNERS 11.74 percent of total billed charges 9.1 13.95 Technical (Hospital) Services "DICLOFENAC 50 MG-MISOPROSTOL 200 MCG TABLET,IMMED.AND DELAYED RELEASE" RX-119012 CDM 6370000100 HCPCS 250 RC 59762-0028-02 NDC outpatient 1 UN 14.68 14.68 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES EPO [308136803] 11.74 percent of total billed charges 9.1 13.95 Technical (Hospital) Services "DICLOFENAC 50 MG-MISOPROSTOL 200 MCG TABLET,IMMED.AND DELAYED RELEASE" RX-119012 CDM 6370000100 HCPCS 250 RC 59762-0028-02 NDC outpatient 1 UN 14.68 14.68 MEDICA (COMMERCIAL) 94265 [3081118] MEDICA CLAIMS [308111801] 13.21 percent of total billed charges 9.1 13.95 Technical (Hospital) Services "DICLOFENAC 50 MG-MISOPROSTOL 200 MCG TABLET,IMMED.AND DELAYED RELEASE" RX-119012 CDM 6370000100 HCPCS 250 RC 59762-0028-02 NDC outpatient 1 UN 14.68 14.68 UNITED HEALTHCARE (COMMERCIAL) [3081199] UNITED HEALTHCARE 87726 [308119901] 9.1 percent of total billed charges 9.1 13.95 Technical (Hospital) Services "DICLOFENAC 50 MG-MISOPROSTOL 200 MCG TABLET,IMMED.AND DELAYED RELEASE" RX-119012 CDM 6370000100 HCPCS 250 RC 59762-0028-02 NDC outpatient 1 UN 14.68 14.68 CIGNA 62308 [3081051] CIGNA 62308 [308105105] 11.74 percent of total billed charges 9.1 13.95 Technical (Hospital) Services "DICLOFENAC 50 MG-MISOPROSTOL 200 MCG TABLET,IMMED.AND DELAYED RELEASE" RX-119012 CDM 6370000100 HCPCS 250 RC 59762-0028-02 NDC outpatient 1 UN 14.68 14.68 CIGNA 62308 [3081051] CIGNA STATE OF WYOMING [308105107] 11.74 percent of total billed charges 9.1 13.95 Technical (Hospital) Services "DICLOFENAC 50 MG-MISOPROSTOL 200 MCG TABLET,IMMED.AND DELAYED RELEASE" RX-119012 CDM 6370000100 HCPCS 250 RC 59762-0028-02 NDC outpatient 1 UN 14.68 14.68 MULTIPLAN INC 34080 [3081285] MULTIPLAN INC [308128501] 13.95 percent of total billed charges 9.1 13.95 Technical (Hospital) Services APIXABAN 2.5 MG TABLET RX-119040 CDM 6370000100 HCPCS 250 RC 00003-0893-31 NDC outpatient 1 UN 38.31 38.31 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES PPO [308136801] 30.65 percent of total billed charges 23.75 36.39 Technical (Hospital) Services APIXABAN 2.5 MG TABLET RX-119040 CDM 6370000100 HCPCS 250 RC 00003-0893-31 NDC outpatient 1 UN 38.31 38.31 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES HDHP [308136802] 30.65 percent of total billed charges 23.75 36.39 Technical (Hospital) Services APIXABAN 2.5 MG TABLET RX-119040 CDM 6370000100 HCPCS 250 RC 00003-0893-31 NDC outpatient 1 UN 38.31 38.31 BLUE CROSS BLUE SHIELD WELLMARK SB889 [3081026] BCBS WYOMING [308102603] 36.39 percent of total billed charges 23.75 36.39 Technical (Hospital) Services APIXABAN 2.5 MG TABLET RX-119040 CDM 6370000100 HCPCS 250 RC 00003-0893-31 NDC outpatient 1 UN 38.31 38.31 HEALTHPARTNERS SX009 HEALTHPARTNERS 30.65 percent of total billed charges 23.75 36.39 Technical (Hospital) Services APIXABAN 2.5 MG TABLET RX-119040 CDM 6370000100 HCPCS 250 RC 00003-0893-31 NDC outpatient 1 UN 38.31 38.31 MULTIPLAN INC 34080 [3081285] MULTIPLAN INC [308128501] 36.39 percent of total billed charges 23.75 36.39 Technical (Hospital) Services APIXABAN 2.5 MG TABLET RX-119040 CDM 6370000100 HCPCS 250 RC 00003-0893-31 NDC outpatient 1 UN 38.31 38.31 CIGNA 62308 [3081051] CIGNA 62308 [308105105] 30.65 percent of total billed charges 23.75 36.39 Technical (Hospital) Services APIXABAN 2.5 MG TABLET RX-119040 CDM 6370000100 HCPCS 250 RC 00003-0893-31 NDC outpatient 1 UN 38.31 38.31 CIGNA 62308 [3081051] CIGNA STATE OF WYOMING [308105107] 30.65 percent of total billed charges 23.75 36.39 Technical (Hospital) Services APIXABAN 2.5 MG TABLET RX-119040 CDM 6370000100 HCPCS 250 RC 00003-0893-31 NDC outpatient 1 UN 38.31 38.31 UNITED HEALTHCARE (COMMERCIAL) [3081199] UNITED HEALTHCARE 87726 [308119901] 23.75 percent of total billed charges 23.75 36.39 Technical (Hospital) Services APIXABAN 2.5 MG TABLET RX-119040 CDM 6370000100 HCPCS 250 RC 00003-0893-31 NDC outpatient 1 UN 38.31 38.31 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES EPO [308136803] 30.65 percent of total billed charges 23.75 36.39 Technical (Hospital) Services APIXABAN 2.5 MG TABLET RX-119040 CDM 6370000100 HCPCS 250 RC 00003-0893-31 NDC outpatient 1 UN 38.31 38.31 MEDICA (COMMERCIAL) 94265 [3081118] MEDICA CLAIMS [308111801] 34.48 percent of total billed charges 23.75 36.39 Technical (Hospital) Services APIXABAN 2.5 MG TABLET RX-119040 CDM 6370000100 HCPCS 250 RC 00003-0893-31 NDC inpatient 1 UN 38.31 38.31 CIGNA 62308 [3081051] CIGNA 62308 [308105105] 30.33 percent of total billed charges 23.75 36.39 Technical (Hospital) Services APIXABAN 2.5 MG TABLET RX-119040 CDM 6370000100 HCPCS 250 RC 00003-0893-31 NDC inpatient 1 UN 38.31 38.31 CIGNA 62308 [3081051] CIGNA STATE OF WYOMING [308105107] 30.33 percent of total billed charges 23.75 36.39 Technical (Hospital) Services APIXABAN 2.5 MG TABLET RX-119040 CDM 6370000100 HCPCS 250 RC 00003-0893-31 NDC inpatient 1 UN 38.31 38.31 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES EPO [308136803] 30.33 percent of total billed charges 23.75 36.39 Technical (Hospital) Services APIXABAN 2.5 MG TABLET RX-119040 CDM 6370000100 HCPCS 250 RC 00003-0893-31 NDC inpatient 1 UN 38.31 38.31 HEALTHPARTNERS SX009 HEALTHPARTNERS 30.33 percent of total billed charges 23.75 36.39 Technical (Hospital) Services APIXABAN 2.5 MG TABLET RX-119040 CDM 6370000100 HCPCS 250 RC 00003-0893-31 NDC inpatient 1 UN 38.31 38.31 MEDICA (COMMERCIAL) 94265 [3081118] MEDICA CLAIMS [308111801] 34.48 percent of total billed charges 23.75 36.39 Technical (Hospital) Services APIXABAN 2.5 MG TABLET RX-119040 CDM 6370000100 HCPCS 250 RC 00003-0893-31 NDC inpatient 1 UN 38.31 38.31 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES HDHP [308136802] 30.33 percent of total billed charges 23.75 36.39 Technical (Hospital) Services APIXABAN 2.5 MG TABLET RX-119040 CDM 6370000100 HCPCS 250 RC 00003-0893-31 NDC inpatient 1 UN 38.31 38.31 UNITED HEALTHCARE (COMMERCIAL) [3081199] UNITED HEALTHCARE 87726 [308119901] 23.75 percent of total billed charges 23.75 36.39 Technical (Hospital) Services APIXABAN 2.5 MG TABLET RX-119040 CDM 6370000100 HCPCS 250 RC 00003-0893-31 NDC inpatient 1 UN 38.31 38.31 BLUE CROSS BLUE SHIELD WELLMARK SB889 [3081026] BCBS WYOMING [308102603] 36.39 percent of total billed charges 23.75 36.39 Technical (Hospital) Services APIXABAN 2.5 MG TABLET RX-119040 CDM 6370000100 HCPCS 250 RC 00003-0893-31 NDC inpatient 1 UN 38.31 38.31 MULTIPLAN INC 34080 [3081285] MULTIPLAN INC [308128501] 36.39 percent of total billed charges 23.75 36.39 Technical (Hospital) Services APIXABAN 2.5 MG TABLET RX-119040 CDM 6370000100 HCPCS 250 RC 00003-0893-31 NDC inpatient 1 UN 38.31 38.31 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES PPO [308136801] 30.33 percent of total billed charges 23.75 36.39 Technical (Hospital) Services TOFACITINIB 5 MG TABLET RX-119109 CDM 6370000100 HCPCS 250 RC 00069-1001-01 NDC inpatient 1 UN 327.9 327.9 MEDICA (COMMERCIAL) 94265 [3081118] MEDICA CLAIMS [308111801] 295.11 percent of total billed charges 203.3 311.51 Technical (Hospital) Services TOFACITINIB 5 MG TABLET RX-119109 CDM 6370000100 HCPCS 250 RC 00069-1001-01 NDC inpatient 1 UN 327.9 327.9 HEALTHPARTNERS SX009 HEALTHPARTNERS 259.63 percent of total billed charges 203.3 311.51 Technical (Hospital) Services TOFACITINIB 5 MG TABLET RX-119109 CDM 6370000100 HCPCS 250 RC 00069-1001-01 NDC inpatient 1 UN 327.9 327.9 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES PPO [308136801] 259.63 percent of total billed charges 203.3 311.51 Technical (Hospital) Services TOFACITINIB 5 MG TABLET RX-119109 CDM 6370000100 HCPCS 250 RC 00069-1001-01 NDC inpatient 1 UN 327.9 327.9 MULTIPLAN INC 34080 [3081285] MULTIPLAN INC [308128501] 311.51 percent of total billed charges 203.3 311.51 Technical (Hospital) Services TOFACITINIB 5 MG TABLET RX-119109 CDM 6370000100 HCPCS 250 RC 00069-1001-01 NDC inpatient 1 UN 327.9 327.9 BLUE CROSS BLUE SHIELD WELLMARK SB889 [3081026] BCBS WYOMING [308102603] 311.51 percent of total billed charges 203.3 311.51 Technical (Hospital) Services TOFACITINIB 5 MG TABLET RX-119109 CDM 6370000100 HCPCS 250 RC 00069-1001-01 NDC inpatient 1 UN 327.9 327.9 UNITED HEALTHCARE (COMMERCIAL) [3081199] UNITED HEALTHCARE 87726 [308119901] 203.3 percent of total billed charges 203.3 311.51 Technical (Hospital) Services TOFACITINIB 5 MG TABLET RX-119109 CDM 6370000100 HCPCS 250 RC 00069-1001-01 NDC inpatient 1 UN 327.9 327.9 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES EPO [308136803] 259.63 percent of total billed charges 203.3 311.51 Technical (Hospital) Services TOFACITINIB 5 MG TABLET RX-119109 CDM 6370000100 HCPCS 250 RC 00069-1001-01 NDC inpatient 1 UN 327.9 327.9 CIGNA 62308 [3081051] CIGNA 62308 [308105105] 259.63 percent of total billed charges 203.3 311.51 Technical (Hospital) Services TOFACITINIB 5 MG TABLET RX-119109 CDM 6370000100 HCPCS 250 RC 00069-1001-01 NDC inpatient 1 UN 327.9 327.9 CIGNA 62308 [3081051] CIGNA STATE OF WYOMING [308105107] 259.63 percent of total billed charges 203.3 311.51 Technical (Hospital) Services TOFACITINIB 5 MG TABLET RX-119109 CDM 6370000100 HCPCS 250 RC 00069-1001-01 NDC inpatient 1 UN 327.9 327.9 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES HDHP [308136802] 259.63 percent of total billed charges 203.3 311.51 Technical (Hospital) Services TOFACITINIB 5 MG TABLET RX-119109 CDM 6370000100 HCPCS 250 RC 00069-1001-01 NDC outpatient 1 UN 327.9 327.9 CIGNA 62308 [3081051] CIGNA 62308 [308105105] 262.32 percent of total billed charges 203.3 311.51 Technical (Hospital) Services TOFACITINIB 5 MG TABLET RX-119109 CDM 6370000100 HCPCS 250 RC 00069-1001-01 NDC outpatient 1 UN 327.9 327.9 CIGNA 62308 [3081051] CIGNA STATE OF WYOMING [308105107] 262.32 percent of total billed charges 203.3 311.51 Technical (Hospital) Services TOFACITINIB 5 MG TABLET RX-119109 CDM 6370000100 HCPCS 250 RC 00069-1001-01 NDC outpatient 1 UN 327.9 327.9 MEDICA (COMMERCIAL) 94265 [3081118] MEDICA CLAIMS [308111801] 295.11 percent of total billed charges 203.3 311.51 Technical (Hospital) Services TOFACITINIB 5 MG TABLET RX-119109 CDM 6370000100 HCPCS 250 RC 00069-1001-01 NDC outpatient 1 UN 327.9 327.9 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES EPO [308136803] 262.32 percent of total billed charges 203.3 311.51 Technical (Hospital) Services TOFACITINIB 5 MG TABLET RX-119109 CDM 6370000100 HCPCS 250 RC 00069-1001-01 NDC outpatient 1 UN 327.9 327.9 MULTIPLAN INC 34080 [3081285] MULTIPLAN INC [308128501] 311.51 percent of total billed charges 203.3 311.51 Technical (Hospital) Services TOFACITINIB 5 MG TABLET RX-119109 CDM 6370000100 HCPCS 250 RC 00069-1001-01 NDC outpatient 1 UN 327.9 327.9 UNITED HEALTHCARE (COMMERCIAL) [3081199] UNITED HEALTHCARE 87726 [308119901] 203.3 percent of total billed charges 203.3 311.51 Technical (Hospital) Services TOFACITINIB 5 MG TABLET RX-119109 CDM 6370000100 HCPCS 250 RC 00069-1001-01 NDC outpatient 1 UN 327.9 327.9 BLUE CROSS BLUE SHIELD WELLMARK SB889 [3081026] BCBS WYOMING [308102603] 311.51 percent of total billed charges 203.3 311.51 Technical (Hospital) Services TOFACITINIB 5 MG TABLET RX-119109 CDM 6370000100 HCPCS 250 RC 00069-1001-01 NDC outpatient 1 UN 327.9 327.9 HEALTHPARTNERS SX009 HEALTHPARTNERS 262.32 percent of total billed charges 203.3 311.51 Technical (Hospital) Services TOFACITINIB 5 MG TABLET RX-119109 CDM 6370000100 HCPCS 250 RC 00069-1001-01 NDC outpatient 1 UN 327.9 327.9 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES HDHP [308136802] 262.32 percent of total billed charges 203.3 311.51 Technical (Hospital) Services TOFACITINIB 5 MG TABLET RX-119109 CDM 6370000100 HCPCS 250 RC 00069-1001-01 NDC outpatient 1 UN 327.9 327.9 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES PPO [308136801] 262.32 percent of total billed charges 203.3 311.51 Technical (Hospital) Services "MORPHINE ER 15 MG TABLET,EXTENDED RELEASE" RX-119246 CDM 6370000100 HCPCS 250 RC 00228-4270-11 NDC outpatient 1 UN 6.29 6.29 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES PPO [308136801] 5.03 percent of total billed charges 3.9 5.98 Technical (Hospital) Services "MORPHINE ER 15 MG TABLET,EXTENDED RELEASE" RX-119246 CDM 6370000100 HCPCS 250 RC 00228-4270-11 NDC outpatient 1 UN 6.29 6.29 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES HDHP [308136802] 5.03 percent of total billed charges 3.9 5.98 Technical (Hospital) Services "MORPHINE ER 15 MG TABLET,EXTENDED RELEASE" RX-119246 CDM 6370000100 HCPCS 250 RC 00228-4270-11 NDC outpatient 1 UN 6.29 6.29 BLUE CROSS BLUE SHIELD WELLMARK SB889 [3081026] BCBS WYOMING [308102603] 5.98 percent of total billed charges 3.9 5.98 Technical (Hospital) Services "MORPHINE ER 15 MG TABLET,EXTENDED RELEASE" RX-119246 CDM 6370000100 HCPCS 250 RC 00228-4270-11 NDC outpatient 1 UN 6.29 6.29 HEALTHPARTNERS SX009 HEALTHPARTNERS 5.03 percent of total billed charges 3.9 5.98 Technical (Hospital) Services "MORPHINE ER 15 MG TABLET,EXTENDED RELEASE" RX-119246 CDM 6370000100 HCPCS 250 RC 00228-4270-11 NDC outpatient 1 UN 6.29 6.29 MEDICA (COMMERCIAL) 94265 [3081118] MEDICA CLAIMS [308111801] 5.66 percent of total billed charges 3.9 5.98 Technical (Hospital) Services "MORPHINE ER 15 MG TABLET,EXTENDED RELEASE" RX-119246 CDM 6370000100 HCPCS 250 RC 00228-4270-11 NDC outpatient 1 UN 6.29 6.29 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES EPO [308136803] 5.03 percent of total billed charges 3.9 5.98 Technical (Hospital) Services "MORPHINE ER 15 MG TABLET,EXTENDED RELEASE" RX-119246 CDM 6370000100 HCPCS 250 RC 00228-4270-11 NDC outpatient 1 UN 6.29 6.29 UNITED HEALTHCARE (COMMERCIAL) [3081199] UNITED HEALTHCARE 87726 [308119901] 3.9 percent of total billed charges 3.9 5.98 Technical (Hospital) Services "MORPHINE ER 15 MG TABLET,EXTENDED RELEASE" RX-119246 CDM 6370000100 HCPCS 250 RC 00228-4270-11 NDC outpatient 1 UN 6.29 6.29 MULTIPLAN INC 34080 [3081285] MULTIPLAN INC [308128501] 5.98 percent of total billed charges 3.9 5.98 Technical (Hospital) Services "MORPHINE ER 15 MG TABLET,EXTENDED RELEASE" RX-119246 CDM 6370000100 HCPCS 250 RC 00228-4270-11 NDC outpatient 1 UN 6.29 6.29 CIGNA 62308 [3081051] CIGNA 62308 [308105105] 5.03 percent of total billed charges 3.9 5.98 Technical (Hospital) Services "MORPHINE ER 15 MG TABLET,EXTENDED RELEASE" RX-119246 CDM 6370000100 HCPCS 250 RC 00228-4270-11 NDC outpatient 1 UN 6.29 6.29 CIGNA 62308 [3081051] CIGNA STATE OF WYOMING [308105107] 5.03 percent of total billed charges 3.9 5.98 Technical (Hospital) Services "MORPHINE ER 15 MG TABLET,EXTENDED RELEASE" RX-119246 CDM 6370000100 HCPCS 250 RC 00228-4270-11 NDC inpatient 1 UN 6.29 6.29 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES PPO [308136801] 4.98 percent of total billed charges 3.9 5.98 Technical (Hospital) Services "MORPHINE ER 15 MG TABLET,EXTENDED RELEASE" RX-119246 CDM 6370000100 HCPCS 250 RC 00228-4270-11 NDC inpatient 1 UN 6.29 6.29 MULTIPLAN INC 34080 [3081285] MULTIPLAN INC [308128501] 5.98 percent of total billed charges 3.9 5.98 Technical (Hospital) Services "MORPHINE ER 15 MG TABLET,EXTENDED RELEASE" RX-119246 CDM 6370000100 HCPCS 250 RC 00228-4270-11 NDC inpatient 1 UN 6.29 6.29 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES HDHP [308136802] 4.98 percent of total billed charges 3.9 5.98 Technical (Hospital) Services "MORPHINE ER 15 MG TABLET,EXTENDED RELEASE" RX-119246 CDM 6370000100 HCPCS 250 RC 00228-4270-11 NDC inpatient 1 UN 6.29 6.29 MEDICA (COMMERCIAL) 94265 [3081118] MEDICA CLAIMS [308111801] 5.66 percent of total billed charges 3.9 5.98 Technical (Hospital) Services "MORPHINE ER 15 MG TABLET,EXTENDED RELEASE" RX-119246 CDM 6370000100 HCPCS 250 RC 00228-4270-11 NDC inpatient 1 UN 6.29 6.29 HEALTHPARTNERS SX009 HEALTHPARTNERS 4.98 percent of total billed charges 3.9 5.98 Technical (Hospital) Services "MORPHINE ER 15 MG TABLET,EXTENDED RELEASE" RX-119246 CDM 6370000100 HCPCS 250 RC 00228-4270-11 NDC inpatient 1 UN 6.29 6.29 CIGNA 62308 [3081051] CIGNA 62308 [308105105] 4.98 percent of total billed charges 3.9 5.98 Technical (Hospital) Services "MORPHINE ER 15 MG TABLET,EXTENDED RELEASE" RX-119246 CDM 6370000100 HCPCS 250 RC 00228-4270-11 NDC inpatient 1 UN 6.29 6.29 CIGNA 62308 [3081051] CIGNA STATE OF WYOMING [308105107] 4.98 percent of total billed charges 3.9 5.98 Technical (Hospital) Services "MORPHINE ER 15 MG TABLET,EXTENDED RELEASE" RX-119246 CDM 6370000100 HCPCS 250 RC 00228-4270-11 NDC inpatient 1 UN 6.29 6.29 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES EPO [308136803] 4.98 percent of total billed charges 3.9 5.98 Technical (Hospital) Services "MORPHINE ER 15 MG TABLET,EXTENDED RELEASE" RX-119246 CDM 6370000100 HCPCS 250 RC 00228-4270-11 NDC inpatient 1 UN 6.29 6.29 BLUE CROSS BLUE SHIELD WELLMARK SB889 [3081026] BCBS WYOMING [308102603] 5.98 percent of total billed charges 3.9 5.98 Technical (Hospital) Services "MORPHINE ER 15 MG TABLET,EXTENDED RELEASE" RX-119246 CDM 6370000100 HCPCS 250 RC 00228-4270-11 NDC inpatient 1 UN 6.29 6.29 UNITED HEALTHCARE (COMMERCIAL) [3081199] UNITED HEALTHCARE 87726 [308119901] 3.9 percent of total billed charges 3.9 5.98 Technical (Hospital) Services "MORPHINE ER 60 MG TABLET,EXTENDED RELEASE" RX-119247 CDM 6370000100 HCPCS 250 RC 42858-0803-01 NDC outpatient 1 UN 6.49 6.49 MULTIPLAN INC 34080 [3081285] MULTIPLAN INC [308128501] 6.17 percent of total billed charges 4.02 6.17 Technical (Hospital) Services "MORPHINE ER 60 MG TABLET,EXTENDED RELEASE" RX-119247 CDM 6370000100 HCPCS 250 RC 42858-0803-01 NDC outpatient 1 UN 6.49 6.49 UNITED HEALTHCARE (COMMERCIAL) [3081199] UNITED HEALTHCARE 87726 [308119901] 4.02 percent of total billed charges 4.02 6.17 Technical (Hospital) Services "MORPHINE ER 60 MG TABLET,EXTENDED RELEASE" RX-119247 CDM 6370000100 HCPCS 250 RC 42858-0803-01 NDC outpatient 1 UN 6.49 6.49 CIGNA 62308 [3081051] CIGNA 62308 [308105105] 5.19 percent of total billed charges 4.02 6.17 Technical (Hospital) Services "MORPHINE ER 60 MG TABLET,EXTENDED RELEASE" RX-119247 CDM 6370000100 HCPCS 250 RC 42858-0803-01 NDC outpatient 1 UN 6.49 6.49 CIGNA 62308 [3081051] CIGNA STATE OF WYOMING [308105107] 5.19 percent of total billed charges 4.02 6.17 Technical (Hospital) Services "MORPHINE ER 60 MG TABLET,EXTENDED RELEASE" RX-119247 CDM 6370000100 HCPCS 250 RC 42858-0803-01 NDC outpatient 1 UN 6.49 6.49 MEDICA (COMMERCIAL) 94265 [3081118] MEDICA CLAIMS [308111801] 5.84 percent of total billed charges 4.02 6.17 Technical (Hospital) Services "MORPHINE ER 60 MG TABLET,EXTENDED RELEASE" RX-119247 CDM 6370000100 HCPCS 250 RC 42858-0803-01 NDC outpatient 1 UN 6.49 6.49 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES EPO [308136803] 5.19 percent of total billed charges 4.02 6.17 Technical (Hospital) Services "MORPHINE ER 60 MG TABLET,EXTENDED RELEASE" RX-119247 CDM 6370000100 HCPCS 250 RC 42858-0803-01 NDC outpatient 1 UN 6.49 6.49 BLUE CROSS BLUE SHIELD WELLMARK SB889 [3081026] BCBS WYOMING [308102603] 6.17 percent of total billed charges 4.02 6.17 Technical (Hospital) Services "MORPHINE ER 60 MG TABLET,EXTENDED RELEASE" RX-119247 CDM 6370000100 HCPCS 250 RC 42858-0803-01 NDC outpatient 1 UN 6.49 6.49 HEALTHPARTNERS SX009 HEALTHPARTNERS 5.19 percent of total billed charges 4.02 6.17 Technical (Hospital) Services "MORPHINE ER 60 MG TABLET,EXTENDED RELEASE" RX-119247 CDM 6370000100 HCPCS 250 RC 42858-0803-01 NDC outpatient 1 UN 6.49 6.49 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES HDHP [308136802] 5.19 percent of total billed charges 4.02 6.17 Technical (Hospital) Services "MORPHINE ER 60 MG TABLET,EXTENDED RELEASE" RX-119247 CDM 6370000100 HCPCS 250 RC 42858-0803-01 NDC outpatient 1 UN 6.49 6.49 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES PPO [308136801] 5.19 percent of total billed charges 4.02 6.17 Technical (Hospital) Services "MORPHINE ER 60 MG TABLET,EXTENDED RELEASE" RX-119247 CDM 6370000100 HCPCS 250 RC 42858-0803-01 NDC inpatient 1 UN 6.49 6.49 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES HDHP [308136802] 5.14 percent of total billed charges 4.02 6.17 Technical (Hospital) Services "MORPHINE ER 60 MG TABLET,EXTENDED RELEASE" RX-119247 CDM 6370000100 HCPCS 250 RC 42858-0803-01 NDC inpatient 1 UN 6.49 6.49 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES EPO [308136803] 5.14 percent of total billed charges 4.02 6.17 Technical (Hospital) Services "MORPHINE ER 60 MG TABLET,EXTENDED RELEASE" RX-119247 CDM 6370000100 HCPCS 250 RC 42858-0803-01 NDC inpatient 1 UN 6.49 6.49 CIGNA 62308 [3081051] CIGNA 62308 [308105105] 5.14 percent of total billed charges 4.02 6.17 Technical (Hospital) Services "MORPHINE ER 60 MG TABLET,EXTENDED RELEASE" RX-119247 CDM 6370000100 HCPCS 250 RC 42858-0803-01 NDC inpatient 1 UN 6.49 6.49 CIGNA 62308 [3081051] CIGNA STATE OF WYOMING [308105107] 5.14 percent of total billed charges 4.02 6.17 Technical (Hospital) Services "MORPHINE ER 60 MG TABLET,EXTENDED RELEASE" RX-119247 CDM 6370000100 HCPCS 250 RC 42858-0803-01 NDC inpatient 1 UN 6.49 6.49 BLUE CROSS BLUE SHIELD WELLMARK SB889 [3081026] BCBS WYOMING [308102603] 6.17 percent of total billed charges 4.02 6.17 Technical (Hospital) Services "MORPHINE ER 60 MG TABLET,EXTENDED RELEASE" RX-119247 CDM 6370000100 HCPCS 250 RC 42858-0803-01 NDC inpatient 1 UN 6.49 6.49 UNITED HEALTHCARE (COMMERCIAL) [3081199] UNITED HEALTHCARE 87726 [308119901] 4.02 percent of total billed charges 4.02 6.17 Technical (Hospital) Services "MORPHINE ER 60 MG TABLET,EXTENDED RELEASE" RX-119247 CDM 6370000100 HCPCS 250 RC 42858-0803-01 NDC inpatient 1 UN 6.49 6.49 MEDICA (COMMERCIAL) 94265 [3081118] MEDICA CLAIMS [308111801] 5.84 percent of total billed charges 4.02 6.17 Technical (Hospital) Services "MORPHINE ER 60 MG TABLET,EXTENDED RELEASE" RX-119247 CDM 6370000100 HCPCS 250 RC 42858-0803-01 NDC inpatient 1 UN 6.49 6.49 HEALTHPARTNERS SX009 HEALTHPARTNERS 5.14 percent of total billed charges 4.02 6.17 Technical (Hospital) Services "MORPHINE ER 60 MG TABLET,EXTENDED RELEASE" RX-119247 CDM 6370000100 HCPCS 250 RC 42858-0803-01 NDC inpatient 1 UN 6.49 6.49 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES PPO [308136801] 5.14 percent of total billed charges 4.02 6.17 Technical (Hospital) Services "MORPHINE ER 60 MG TABLET,EXTENDED RELEASE" RX-119247 CDM 6370000100 HCPCS 250 RC 42858-0803-01 NDC inpatient 1 UN 6.49 6.49 MULTIPLAN INC 34080 [3081285] MULTIPLAN INC [308128501] 6.17 percent of total billed charges 4.02 6.17 Technical (Hospital) Services "MORPHINE ER 100 MG TABLET,EXTENDED RELEASE" RX-119248 CDM 6370000100 HCPCS 250 RC 42858-0804-01 NDC outpatient 1 UN 6.55 6.55 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES PPO [308136801] 5.24 percent of total billed charges 4.06 6.22 Technical (Hospital) Services "MORPHINE ER 100 MG TABLET,EXTENDED RELEASE" RX-119248 CDM 6370000100 HCPCS 250 RC 42858-0804-01 NDC outpatient 1 UN 6.55 6.55 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES HDHP [308136802] 5.24 percent of total billed charges 4.06 6.22 Technical (Hospital) Services "MORPHINE ER 100 MG TABLET,EXTENDED RELEASE" RX-119248 CDM 6370000100 HCPCS 250 RC 42858-0804-01 NDC outpatient 1 UN 6.55 6.55 UNITED HEALTHCARE (COMMERCIAL) [3081199] UNITED HEALTHCARE 87726 [308119901] 4.06 percent of total billed charges 4.06 6.22 Technical (Hospital) Services "MORPHINE ER 100 MG TABLET,EXTENDED RELEASE" RX-119248 CDM 6370000100 HCPCS 250 RC 42858-0804-01 NDC outpatient 1 UN 6.55 6.55 MULTIPLAN INC 34080 [3081285] MULTIPLAN INC [308128501] 6.22 percent of total billed charges 4.06 6.22 Technical (Hospital) Services "MORPHINE ER 100 MG TABLET,EXTENDED RELEASE" RX-119248 CDM 6370000100 HCPCS 250 RC 42858-0804-01 NDC outpatient 1 UN 6.55 6.55 CIGNA 62308 [3081051] CIGNA 62308 [308105105] 5.24 percent of total billed charges 4.06 6.22 Technical (Hospital) Services "MORPHINE ER 100 MG TABLET,EXTENDED RELEASE" RX-119248 CDM 6370000100 HCPCS 250 RC 42858-0804-01 NDC outpatient 1 UN 6.55 6.55 CIGNA 62308 [3081051] CIGNA STATE OF WYOMING [308105107] 5.24 percent of total billed charges 4.06 6.22 Technical (Hospital) Services "MORPHINE ER 100 MG TABLET,EXTENDED RELEASE" RX-119248 CDM 6370000100 HCPCS 250 RC 42858-0804-01 NDC outpatient 1 UN 6.55 6.55 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES EPO [308136803] 5.24 percent of total billed charges 4.06 6.22 Technical (Hospital) Services "MORPHINE ER 100 MG TABLET,EXTENDED RELEASE" RX-119248 CDM 6370000100 HCPCS 250 RC 42858-0804-01 NDC outpatient 1 UN 6.55 6.55 MEDICA (COMMERCIAL) 94265 [3081118] MEDICA CLAIMS [308111801] 5.9 percent of total billed charges 4.06 6.22 Technical (Hospital) Services "MORPHINE ER 100 MG TABLET,EXTENDED RELEASE" RX-119248 CDM 6370000100 HCPCS 250 RC 42858-0804-01 NDC outpatient 1 UN 6.55 6.55 BLUE CROSS BLUE SHIELD WELLMARK SB889 [3081026] BCBS WYOMING [308102603] 6.22 percent of total billed charges 4.06 6.22 Technical (Hospital) Services "MORPHINE ER 100 MG TABLET,EXTENDED RELEASE" RX-119248 CDM 6370000100 HCPCS 250 RC 42858-0804-01 NDC outpatient 1 UN 6.55 6.55 HEALTHPARTNERS SX009 HEALTHPARTNERS 5.24 percent of total billed charges 4.06 6.22 Technical (Hospital) Services "MORPHINE ER 100 MG TABLET,EXTENDED RELEASE" RX-119248 CDM 6370000100 HCPCS 250 RC 42858-0804-01 NDC inpatient 1 UN 6.55 6.55 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES EPO [308136803] 5.19 percent of total billed charges 4.06 6.22 Technical (Hospital) Services "MORPHINE ER 100 MG TABLET,EXTENDED RELEASE" RX-119248 CDM 6370000100 HCPCS 250 RC 42858-0804-01 NDC inpatient 1 UN 6.55 6.55 CIGNA 62308 [3081051] CIGNA 62308 [308105105] 5.19 percent of total billed charges 4.06 6.22 Technical (Hospital) Services "MORPHINE ER 100 MG TABLET,EXTENDED RELEASE" RX-119248 CDM 6370000100 HCPCS 250 RC 42858-0804-01 NDC inpatient 1 UN 6.55 6.55 CIGNA 62308 [3081051] CIGNA STATE OF WYOMING [308105107] 5.19 percent of total billed charges 4.06 6.22 Technical (Hospital) Services "MORPHINE ER 100 MG TABLET,EXTENDED RELEASE" RX-119248 CDM 6370000100 HCPCS 250 RC 42858-0804-01 NDC inpatient 1 UN 6.55 6.55 MEDICA (COMMERCIAL) 94265 [3081118] MEDICA CLAIMS [308111801] 5.9 percent of total billed charges 4.06 6.22 Technical (Hospital) Services "MORPHINE ER 100 MG TABLET,EXTENDED RELEASE" RX-119248 CDM 6370000100 HCPCS 250 RC 42858-0804-01 NDC inpatient 1 UN 6.55 6.55 HEALTHPARTNERS SX009 HEALTHPARTNERS 5.19 percent of total billed charges 4.06 6.22 Technical (Hospital) Services "MORPHINE ER 100 MG TABLET,EXTENDED RELEASE" RX-119248 CDM 6370000100 HCPCS 250 RC 42858-0804-01 NDC inpatient 1 UN 6.55 6.55 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES HDHP [308136802] 5.19 percent of total billed charges 4.06 6.22 Technical (Hospital) Services "MORPHINE ER 100 MG TABLET,EXTENDED RELEASE" RX-119248 CDM 6370000100 HCPCS 250 RC 42858-0804-01 NDC inpatient 1 UN 6.55 6.55 BLUE CROSS BLUE SHIELD WELLMARK SB889 [3081026] BCBS WYOMING [308102603] 6.22 percent of total billed charges 4.06 6.22 Technical (Hospital) Services "MORPHINE ER 100 MG TABLET,EXTENDED RELEASE" RX-119248 CDM 6370000100 HCPCS 250 RC 42858-0804-01 NDC inpatient 1 UN 6.55 6.55 UNITED HEALTHCARE (COMMERCIAL) [3081199] UNITED HEALTHCARE 87726 [308119901] 4.06 percent of total billed charges 4.06 6.22 Technical (Hospital) Services "MORPHINE ER 100 MG TABLET,EXTENDED RELEASE" RX-119248 CDM 6370000100 HCPCS 250 RC 42858-0804-01 NDC inpatient 1 UN 6.55 6.55 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES PPO [308136801] 5.19 percent of total billed charges 4.06 6.22 Technical (Hospital) Services "MORPHINE ER 100 MG TABLET,EXTENDED RELEASE" RX-119248 CDM 6370000100 HCPCS 250 RC 42858-0804-01 NDC inpatient 1 UN 6.55 6.55 MULTIPLAN INC 34080 [3081285] MULTIPLAN INC [308128501] 6.22 percent of total billed charges 4.06 6.22 Technical (Hospital) Services APIXABAN 5 MG TABLET RX-119614 CDM 6370000100 HCPCS 250 RC 00003-0894-31 NDC inpatient 1 UN 38.31 38.31 UNITED HEALTHCARE (COMMERCIAL) [3081199] UNITED HEALTHCARE 87726 [308119901] 23.75 percent of total billed charges 23.75 36.39 Technical (Hospital) Services APIXABAN 5 MG TABLET RX-119614 CDM 6370000100 HCPCS 250 RC 00003-0894-31 NDC inpatient 1 UN 38.31 38.31 BLUE CROSS BLUE SHIELD WELLMARK SB889 [3081026] BCBS WYOMING [308102603] 36.39 percent of total billed charges 23.75 36.39 Technical (Hospital) Services APIXABAN 5 MG TABLET RX-119614 CDM 6370000100 HCPCS 250 RC 00003-0894-31 NDC inpatient 1 UN 38.31 38.31 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES EPO [308136803] 30.33 percent of total billed charges 23.75 36.39 Technical (Hospital) Services APIXABAN 5 MG TABLET RX-119614 CDM 6370000100 HCPCS 250 RC 00003-0894-31 NDC inpatient 1 UN 38.31 38.31 CIGNA 62308 [3081051] CIGNA 62308 [308105105] 30.33 percent of total billed charges 23.75 36.39 Technical (Hospital) Services APIXABAN 5 MG TABLET RX-119614 CDM 6370000100 HCPCS 250 RC 00003-0894-31 NDC inpatient 1 UN 38.31 38.31 CIGNA 62308 [3081051] CIGNA STATE OF WYOMING [308105107] 30.33 percent of total billed charges 23.75 36.39 Technical (Hospital) Services APIXABAN 5 MG TABLET RX-119614 CDM 6370000100 HCPCS 250 RC 00003-0894-31 NDC inpatient 1 UN 38.31 38.31 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES HDHP [308136802] 30.33 percent of total billed charges 23.75 36.39 Technical (Hospital) Services APIXABAN 5 MG TABLET RX-119614 CDM 6370000100 HCPCS 250 RC 00003-0894-31 NDC inpatient 1 UN 38.31 38.31 HEALTHPARTNERS SX009 HEALTHPARTNERS 30.33 percent of total billed charges 23.75 36.39 Technical (Hospital) Services APIXABAN 5 MG TABLET RX-119614 CDM 6370000100 HCPCS 250 RC 00003-0894-31 NDC inpatient 1 UN 38.31 38.31 MEDICA (COMMERCIAL) 94265 [3081118] MEDICA CLAIMS [308111801] 34.48 percent of total billed charges 23.75 36.39 Technical (Hospital) Services APIXABAN 5 MG TABLET RX-119614 CDM 6370000100 HCPCS 250 RC 00003-0894-31 NDC inpatient 1 UN 38.31 38.31 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES PPO [308136801] 30.33 percent of total billed charges 23.75 36.39 Technical (Hospital) Services APIXABAN 5 MG TABLET RX-119614 CDM 6370000100 HCPCS 250 RC 00003-0894-31 NDC inpatient 1 UN 38.31 38.31 MULTIPLAN INC 34080 [3081285] MULTIPLAN INC [308128501] 36.39 percent of total billed charges 23.75 36.39 Technical (Hospital) Services APIXABAN 5 MG TABLET RX-119614 CDM 6370000100 HCPCS 250 RC 00003-0894-31 NDC outpatient 1 UN 38.31 38.31 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES PPO [308136801] 30.65 percent of total billed charges 23.75 36.39 Technical (Hospital) Services APIXABAN 5 MG TABLET RX-119614 CDM 6370000100 HCPCS 250 RC 00003-0894-31 NDC outpatient 1 UN 38.31 38.31 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES HDHP [308136802] 30.65 percent of total billed charges 23.75 36.39 Technical (Hospital) Services APIXABAN 5 MG TABLET RX-119614 CDM 6370000100 HCPCS 250 RC 00003-0894-31 NDC outpatient 1 UN 38.31 38.31 HEALTHPARTNERS SX009 HEALTHPARTNERS 30.65 percent of total billed charges 23.75 36.39 Technical (Hospital) Services APIXABAN 5 MG TABLET RX-119614 CDM 6370000100 HCPCS 250 RC 00003-0894-31 NDC outpatient 1 UN 38.31 38.31 BLUE CROSS BLUE SHIELD WELLMARK SB889 [3081026] BCBS WYOMING [308102603] 36.39 percent of total billed charges 23.75 36.39 Technical (Hospital) Services APIXABAN 5 MG TABLET RX-119614 CDM 6370000100 HCPCS 250 RC 00003-0894-31 NDC outpatient 1 UN 38.31 38.31 MEDICA (COMMERCIAL) 94265 [3081118] MEDICA CLAIMS [308111801] 34.48 percent of total billed charges 23.75 36.39 Technical (Hospital) Services APIXABAN 5 MG TABLET RX-119614 CDM 6370000100 HCPCS 250 RC 00003-0894-31 NDC outpatient 1 UN 38.31 38.31 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES EPO [308136803] 30.65 percent of total billed charges 23.75 36.39 Technical (Hospital) Services APIXABAN 5 MG TABLET RX-119614 CDM 6370000100 HCPCS 250 RC 00003-0894-31 NDC outpatient 1 UN 38.31 38.31 MULTIPLAN INC 34080 [3081285] MULTIPLAN INC [308128501] 36.39 percent of total billed charges 23.75 36.39 Technical (Hospital) Services APIXABAN 5 MG TABLET RX-119614 CDM 6370000100 HCPCS 250 RC 00003-0894-31 NDC outpatient 1 UN 38.31 38.31 CIGNA 62308 [3081051] CIGNA 62308 [308105105] 30.65 percent of total billed charges 23.75 36.39 Technical (Hospital) Services APIXABAN 5 MG TABLET RX-119614 CDM 6370000100 HCPCS 250 RC 00003-0894-31 NDC outpatient 1 UN 38.31 38.31 CIGNA 62308 [3081051] CIGNA STATE OF WYOMING [308105107] 30.65 percent of total billed charges 23.75 36.39 Technical (Hospital) Services APIXABAN 5 MG TABLET RX-119614 CDM 6370000100 HCPCS 250 RC 00003-0894-31 NDC outpatient 1 UN 38.31 38.31 UNITED HEALTHCARE (COMMERCIAL) [3081199] UNITED HEALTHCARE 87726 [308119901] 23.75 percent of total billed charges 23.75 36.39 Technical (Hospital) Services MECLIZINE 12.5 MG TABLET RX-12024 CDM 6370000100 HCPCS 250 RC 00536-1297-01 NDC inpatient 1 UN 5.65 5.65 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES HDHP [308136802] 4.47 percent of total billed charges 3.5 5.37 Technical (Hospital) Services MECLIZINE 12.5 MG TABLET RX-12024 CDM 6370000100 HCPCS 250 RC 00536-1297-01 NDC inpatient 1 UN 5.65 5.65 CIGNA 62308 [3081051] CIGNA STATE OF WYOMING [308105107] 4.47 percent of total billed charges 3.5 5.37 Technical (Hospital) Services MECLIZINE 12.5 MG TABLET RX-12024 CDM 6370000100 HCPCS 250 RC 00536-1297-01 NDC inpatient 1 UN 5.65 5.65 CIGNA 62308 [3081051] CIGNA 62308 [308105105] 4.47 percent of total billed charges 3.5 5.37 Technical (Hospital) Services MECLIZINE 12.5 MG TABLET RX-12024 CDM 6370000100 HCPCS 250 RC 00536-1297-01 NDC inpatient 1 UN 5.65 5.65 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES EPO [308136803] 4.47 percent of total billed charges 3.5 5.37 Technical (Hospital) Services MECLIZINE 12.5 MG TABLET RX-12024 CDM 6370000100 HCPCS 250 RC 00536-1297-01 NDC inpatient 1 UN 5.65 5.65 UNITED HEALTHCARE (COMMERCIAL) [3081199] UNITED HEALTHCARE 87726 [308119901] 3.5 percent of total billed charges 3.5 5.37 Technical (Hospital) Services MECLIZINE 12.5 MG TABLET RX-12024 CDM 6370000100 HCPCS 250 RC 00536-1297-01 NDC inpatient 1 UN 5.65 5.65 BLUE CROSS BLUE SHIELD WELLMARK SB889 [3081026] BCBS WYOMING [308102603] 5.37 percent of total billed charges 3.5 5.37 Technical (Hospital) Services MECLIZINE 12.5 MG TABLET RX-12024 CDM 6370000100 HCPCS 250 RC 00536-1297-01 NDC inpatient 1 UN 5.65 5.65 HEALTHPARTNERS SX009 HEALTHPARTNERS 4.47 percent of total billed charges 3.5 5.37 Technical (Hospital) Services MECLIZINE 12.5 MG TABLET RX-12024 CDM 6370000100 HCPCS 250 RC 00536-1297-01 NDC inpatient 1 UN 5.65 5.65 MEDICA (COMMERCIAL) 94265 [3081118] MEDICA CLAIMS [308111801] 5.09 percent of total billed charges 3.5 5.37 Technical (Hospital) Services MECLIZINE 12.5 MG TABLET RX-12024 CDM 6370000100 HCPCS 250 RC 00536-1297-01 NDC inpatient 1 UN 5.65 5.65 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES PPO [308136801] 4.47 percent of total billed charges 3.5 5.37 Technical (Hospital) Services MECLIZINE 12.5 MG TABLET RX-12024 CDM 6370000100 HCPCS 250 RC 00536-1297-01 NDC inpatient 1 UN 5.65 5.65 MULTIPLAN INC 34080 [3081285] MULTIPLAN INC [308128501] 5.37 percent of total billed charges 3.5 5.37 Technical (Hospital) Services MECLIZINE 12.5 MG TABLET RX-12024 CDM 6370000100 HCPCS 250 RC 00536-1297-01 NDC outpatient 1 UN 5.65 5.65 CIGNA 62308 [3081051] CIGNA 62308 [308105105] 4.52 percent of total billed charges 3.5 5.37 Technical (Hospital) Services MECLIZINE 12.5 MG TABLET RX-12024 CDM 6370000100 HCPCS 250 RC 00536-1297-01 NDC outpatient 1 UN 5.65 5.65 CIGNA 62308 [3081051] CIGNA STATE OF WYOMING [308105107] 4.52 percent of total billed charges 3.5 5.37 Technical (Hospital) Services MECLIZINE 12.5 MG TABLET RX-12024 CDM 6370000100 HCPCS 250 RC 00536-1297-01 NDC outpatient 1 UN 5.65 5.65 MULTIPLAN INC 34080 [3081285] MULTIPLAN INC [308128501] 5.37 percent of total billed charges 3.5 5.37 Technical (Hospital) Services MECLIZINE 12.5 MG TABLET RX-12024 CDM 6370000100 HCPCS 250 RC 00536-1297-01 NDC outpatient 1 UN 5.65 5.65 UNITED HEALTHCARE (COMMERCIAL) [3081199] UNITED HEALTHCARE 87726 [308119901] 3.5 percent of total billed charges 3.5 5.37 Technical (Hospital) Services MECLIZINE 12.5 MG TABLET RX-12024 CDM 6370000100 HCPCS 250 RC 00536-1297-01 NDC outpatient 1 UN 5.65 5.65 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES EPO [308136803] 4.52 percent of total billed charges 3.5 5.37 Technical (Hospital) Services MECLIZINE 12.5 MG TABLET RX-12024 CDM 6370000100 HCPCS 250 RC 00536-1297-01 NDC outpatient 1 UN 5.65 5.65 MEDICA (COMMERCIAL) 94265 [3081118] MEDICA CLAIMS [308111801] 5.09 percent of total billed charges 3.5 5.37 Technical (Hospital) Services MECLIZINE 12.5 MG TABLET RX-12024 CDM 6370000100 HCPCS 250 RC 00536-1297-01 NDC outpatient 1 UN 5.65 5.65 HEALTHPARTNERS SX009 HEALTHPARTNERS 4.52 percent of total billed charges 3.5 5.37 Technical (Hospital) Services MECLIZINE 12.5 MG TABLET RX-12024 CDM 6370000100 HCPCS 250 RC 00536-1297-01 NDC outpatient 1 UN 5.65 5.65 BLUE CROSS BLUE SHIELD WELLMARK SB889 [3081026] BCBS WYOMING [308102603] 5.37 percent of total billed charges 3.5 5.37 Technical (Hospital) Services MECLIZINE 12.5 MG TABLET RX-12024 CDM 6370000100 HCPCS 250 RC 00536-1297-01 NDC outpatient 1 UN 5.65 5.65 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES PPO [308136801] 4.52 percent of total billed charges 3.5 5.37 Technical (Hospital) Services MECLIZINE 12.5 MG TABLET RX-12024 CDM 6370000100 HCPCS 250 RC 00536-1297-01 NDC outpatient 1 UN 5.65 5.65 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES HDHP [308136802] 4.52 percent of total billed charges 3.5 5.37 Technical (Hospital) Services "DOXYLAMINE 10 MG-PYRIDOXINE (VIT B6) 10 MG TABLET,DELAYED RELEASE" RX-121504 CDM 6370000100 HCPCS 250 RC 55494-0100-10 NDC outpatient 2 UN 28.52 28.52 BLUE CROSS BLUE SHIELD WELLMARK SB889 [3081026] BCBS WYOMING [308102603] 27.09 percent of total billed charges 17.68 27.09 Technical (Hospital) Services "DOXYLAMINE 10 MG-PYRIDOXINE (VIT B6) 10 MG TABLET,DELAYED RELEASE" RX-121504 CDM 6370000100 HCPCS 250 RC 55494-0100-10 NDC outpatient 2 UN 28.52 28.52 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES EPO [308136803] 22.82 percent of total billed charges 17.68 27.09 Technical (Hospital) Services "DOXYLAMINE 10 MG-PYRIDOXINE (VIT B6) 10 MG TABLET,DELAYED RELEASE" RX-121504 CDM 6370000100 HCPCS 250 RC 55494-0100-10 NDC outpatient 2 UN 28.52 28.52 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES PPO [308136801] 22.82 percent of total billed charges 17.68 27.09 Technical (Hospital) Services "DOXYLAMINE 10 MG-PYRIDOXINE (VIT B6) 10 MG TABLET,DELAYED RELEASE" RX-121504 CDM 6370000100 HCPCS 250 RC 55494-0100-10 NDC outpatient 2 UN 28.52 28.52 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES HDHP [308136802] 22.82 percent of total billed charges 17.68 27.09 Technical (Hospital) Services "DOXYLAMINE 10 MG-PYRIDOXINE (VIT B6) 10 MG TABLET,DELAYED RELEASE" RX-121504 CDM 6370000100 HCPCS 250 RC 55494-0100-10 NDC outpatient 2 UN 28.52 28.52 UNITED HEALTHCARE (COMMERCIAL) [3081199] UNITED HEALTHCARE 87726 [308119901] 17.68 percent of total billed charges 17.68 27.09 Technical (Hospital) Services "DOXYLAMINE 10 MG-PYRIDOXINE (VIT B6) 10 MG TABLET,DELAYED RELEASE" RX-121504 CDM 6370000100 HCPCS 250 RC 55494-0100-10 NDC outpatient 2 UN 28.52 28.52 HEALTHPARTNERS SX009 HEALTHPARTNERS 22.82 percent of total billed charges 17.68 27.09 Technical (Hospital) Services "DOXYLAMINE 10 MG-PYRIDOXINE (VIT B6) 10 MG TABLET,DELAYED RELEASE" RX-121504 CDM 6370000100 HCPCS 250 RC 55494-0100-10 NDC outpatient 2 UN 28.52 28.52 CIGNA 62308 [3081051] CIGNA 62308 [308105105] 22.82 percent of total billed charges 17.68 27.09 Technical (Hospital) Services "DOXYLAMINE 10 MG-PYRIDOXINE (VIT B6) 10 MG TABLET,DELAYED RELEASE" RX-121504 CDM 6370000100 HCPCS 250 RC 55494-0100-10 NDC outpatient 2 UN 28.52 28.52 CIGNA 62308 [3081051] CIGNA STATE OF WYOMING [308105107] 22.82 percent of total billed charges 17.68 27.09 Technical (Hospital) Services "DOXYLAMINE 10 MG-PYRIDOXINE (VIT B6) 10 MG TABLET,DELAYED RELEASE" RX-121504 CDM 6370000100 HCPCS 250 RC 55494-0100-10 NDC outpatient 2 UN 28.52 28.52 MULTIPLAN INC 34080 [3081285] MULTIPLAN INC [308128501] 27.09 percent of total billed charges 17.68 27.09 Technical (Hospital) Services "DOXYLAMINE 10 MG-PYRIDOXINE (VIT B6) 10 MG TABLET,DELAYED RELEASE" RX-121504 CDM 6370000100 HCPCS 250 RC 55494-0100-10 NDC outpatient 2 UN 28.52 28.52 MEDICA (COMMERCIAL) 94265 [3081118] MEDICA CLAIMS [308111801] 25.67 percent of total billed charges 17.68 27.09 Technical (Hospital) Services "DOXYLAMINE 10 MG-PYRIDOXINE (VIT B6) 10 MG TABLET,DELAYED RELEASE" RX-121504 CDM 6370000100 HCPCS 250 RC 55494-0100-10 NDC inpatient 2 UN 28.52 28.52 MEDICA (COMMERCIAL) 94265 [3081118] MEDICA CLAIMS [308111801] 25.67 percent of total billed charges 17.68 27.09 Technical (Hospital) Services "DOXYLAMINE 10 MG-PYRIDOXINE (VIT B6) 10 MG TABLET,DELAYED RELEASE" RX-121504 CDM 6370000100 HCPCS 250 RC 55494-0100-10 NDC inpatient 2 UN 28.52 28.52 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES HDHP [308136802] 22.58 percent of total billed charges 17.68 27.09 Technical (Hospital) Services "DOXYLAMINE 10 MG-PYRIDOXINE (VIT B6) 10 MG TABLET,DELAYED RELEASE" RX-121504 CDM 6370000100 HCPCS 250 RC 55494-0100-10 NDC inpatient 2 UN 28.52 28.52 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES PPO [308136801] 22.58 percent of total billed charges 17.68 27.09 Technical (Hospital) Services "DOXYLAMINE 10 MG-PYRIDOXINE (VIT B6) 10 MG TABLET,DELAYED RELEASE" RX-121504 CDM 6370000100 HCPCS 250 RC 55494-0100-10 NDC inpatient 2 UN 28.52 28.52 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES EPO [308136803] 22.58 percent of total billed charges 17.68 27.09 Technical (Hospital) Services "DOXYLAMINE 10 MG-PYRIDOXINE (VIT B6) 10 MG TABLET,DELAYED RELEASE" RX-121504 CDM 6370000100 HCPCS 250 RC 55494-0100-10 NDC inpatient 2 UN 28.52 28.52 HEALTHPARTNERS SX009 HEALTHPARTNERS 22.58 percent of total billed charges 17.68 27.09 Technical (Hospital) Services "DOXYLAMINE 10 MG-PYRIDOXINE (VIT B6) 10 MG TABLET,DELAYED RELEASE" RX-121504 CDM 6370000100 HCPCS 250 RC 55494-0100-10 NDC inpatient 2 UN 28.52 28.52 CIGNA 62308 [3081051] CIGNA 62308 [308105105] 22.58 percent of total billed charges 17.68 27.09 Technical (Hospital) Services "DOXYLAMINE 10 MG-PYRIDOXINE (VIT B6) 10 MG TABLET,DELAYED RELEASE" RX-121504 CDM 6370000100 HCPCS 250 RC 55494-0100-10 NDC inpatient 2 UN 28.52 28.52 CIGNA 62308 [3081051] CIGNA STATE OF WYOMING [308105107] 22.58 percent of total billed charges 17.68 27.09 Technical (Hospital) Services "DOXYLAMINE 10 MG-PYRIDOXINE (VIT B6) 10 MG TABLET,DELAYED RELEASE" RX-121504 CDM 6370000100 HCPCS 250 RC 55494-0100-10 NDC inpatient 2 UN 28.52 28.52 BLUE CROSS BLUE SHIELD WELLMARK SB889 [3081026] BCBS WYOMING [308102603] 27.09 percent of total billed charges 17.68 27.09 Technical (Hospital) Services "DOXYLAMINE 10 MG-PYRIDOXINE (VIT B6) 10 MG TABLET,DELAYED RELEASE" RX-121504 CDM 6370000100 HCPCS 250 RC 55494-0100-10 NDC inpatient 2 UN 28.52 28.52 UNITED HEALTHCARE (COMMERCIAL) [3081199] UNITED HEALTHCARE 87726 [308119901] 17.68 percent of total billed charges 17.68 27.09 Technical (Hospital) Services "DOXYLAMINE 10 MG-PYRIDOXINE (VIT B6) 10 MG TABLET,DELAYED RELEASE" RX-121504 CDM 6370000100 HCPCS 250 RC 55494-0100-10 NDC inpatient 2 UN 28.52 28.52 MULTIPLAN INC 34080 [3081285] MULTIPLAN INC [308128501] 27.09 percent of total billed charges 17.68 27.09 Technical (Hospital) Services CANAGLIFLOZIN 100 MG TABLET RX-121562 CDM 6370000100 HCPCS 250 RC 50458-0140-30 NDC inpatient 1 UN 67.95 67.95 MULTIPLAN INC 34080 [3081285] MULTIPLAN INC [308128501] 64.55 percent of total billed charges 42.13 64.55 Technical (Hospital) Services CANAGLIFLOZIN 100 MG TABLET RX-121562 CDM 6370000100 HCPCS 250 RC 50458-0140-30 NDC inpatient 1 UN 67.95 67.95 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES PPO [308136801] 53.8 percent of total billed charges 42.13 64.55 Technical (Hospital) Services CANAGLIFLOZIN 100 MG TABLET RX-121562 CDM 6370000100 HCPCS 250 RC 50458-0140-30 NDC inpatient 1 UN 67.95 67.95 BLUE CROSS BLUE SHIELD WELLMARK SB889 [3081026] BCBS WYOMING [308102603] 64.55 percent of total billed charges 42.13 64.55 Technical (Hospital) Services CANAGLIFLOZIN 100 MG TABLET RX-121562 CDM 6370000100 HCPCS 250 RC 50458-0140-30 NDC inpatient 1 UN 67.95 67.95 UNITED HEALTHCARE (COMMERCIAL) [3081199] UNITED HEALTHCARE 87726 [308119901] 42.13 percent of total billed charges 42.13 64.55 Technical (Hospital) Services CANAGLIFLOZIN 100 MG TABLET RX-121562 CDM 6370000100 HCPCS 250 RC 50458-0140-30 NDC inpatient 1 UN 67.95 67.95 MEDICA (COMMERCIAL) 94265 [3081118] MEDICA CLAIMS [308111801] 61.16 percent of total billed charges 42.13 64.55 Technical (Hospital) Services CANAGLIFLOZIN 100 MG TABLET RX-121562 CDM 6370000100 HCPCS 250 RC 50458-0140-30 NDC inpatient 1 UN 67.95 67.95 HEALTHPARTNERS SX009 HEALTHPARTNERS 53.8 percent of total billed charges 42.13 64.55 Technical (Hospital) Services CANAGLIFLOZIN 100 MG TABLET RX-121562 CDM 6370000100 HCPCS 250 RC 50458-0140-30 NDC inpatient 1 UN 67.95 67.95 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES HDHP [308136802] 53.8 percent of total billed charges 42.13 64.55 Technical (Hospital) Services CANAGLIFLOZIN 100 MG TABLET RX-121562 CDM 6370000100 HCPCS 250 RC 50458-0140-30 NDC inpatient 1 UN 67.95 67.95 CIGNA 62308 [3081051] CIGNA 62308 [308105105] 53.8 percent of total billed charges 42.13 64.55 Technical (Hospital) Services CANAGLIFLOZIN 100 MG TABLET RX-121562 CDM 6370000100 HCPCS 250 RC 50458-0140-30 NDC inpatient 1 UN 67.95 67.95 CIGNA 62308 [3081051] CIGNA STATE OF WYOMING [308105107] 53.8 percent of total billed charges 42.13 64.55 Technical (Hospital) Services CANAGLIFLOZIN 100 MG TABLET RX-121562 CDM 6370000100 HCPCS 250 RC 50458-0140-30 NDC inpatient 1 UN 67.95 67.95 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES EPO [308136803] 53.8 percent of total billed charges 42.13 64.55 Technical (Hospital) Services CANAGLIFLOZIN 100 MG TABLET RX-121562 CDM 6370000100 HCPCS 250 RC 50458-0140-30 NDC outpatient 1 UN 67.95 67.95 HEALTHPARTNERS SX009 HEALTHPARTNERS 54.36 percent of total billed charges 42.13 64.55 Technical (Hospital) Services CANAGLIFLOZIN 100 MG TABLET RX-121562 CDM 6370000100 HCPCS 250 RC 50458-0140-30 NDC outpatient 1 UN 67.95 67.95 UNITED HEALTHCARE (COMMERCIAL) [3081199] UNITED HEALTHCARE 87726 [308119901] 42.13 percent of total billed charges 42.13 64.55 Technical (Hospital) Services CANAGLIFLOZIN 100 MG TABLET RX-121562 CDM 6370000100 HCPCS 250 RC 50458-0140-30 NDC outpatient 1 UN 67.95 67.95 CIGNA 62308 [3081051] CIGNA 62308 [308105105] 54.36 percent of total billed charges 42.13 64.55 Technical (Hospital) Services CANAGLIFLOZIN 100 MG TABLET RX-121562 CDM 6370000100 HCPCS 250 RC 50458-0140-30 NDC outpatient 1 UN 67.95 67.95 CIGNA 62308 [3081051] CIGNA STATE OF WYOMING [308105107] 54.36 percent of total billed charges 42.13 64.55 Technical (Hospital) Services CANAGLIFLOZIN 100 MG TABLET RX-121562 CDM 6370000100 HCPCS 250 RC 50458-0140-30 NDC outpatient 1 UN 67.95 67.95 MULTIPLAN INC 34080 [3081285] MULTIPLAN INC [308128501] 64.55 percent of total billed charges 42.13 64.55 Technical (Hospital) Services CANAGLIFLOZIN 100 MG TABLET RX-121562 CDM 6370000100 HCPCS 250 RC 50458-0140-30 NDC outpatient 1 UN 67.95 67.95 MEDICA (COMMERCIAL) 94265 [3081118] MEDICA CLAIMS [308111801] 61.16 percent of total billed charges 42.13 64.55 Technical (Hospital) Services CANAGLIFLOZIN 100 MG TABLET RX-121562 CDM 6370000100 HCPCS 250 RC 50458-0140-30 NDC outpatient 1 UN 67.95 67.95 BLUE CROSS BLUE SHIELD WELLMARK SB889 [3081026] BCBS WYOMING [308102603] 64.55 percent of total billed charges 42.13 64.55 Technical (Hospital) Services CANAGLIFLOZIN 100 MG TABLET RX-121562 CDM 6370000100 HCPCS 250 RC 50458-0140-30 NDC outpatient 1 UN 67.95 67.95 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES HDHP [308136802] 54.36 percent of total billed charges 42.13 64.55 Technical (Hospital) Services CANAGLIFLOZIN 100 MG TABLET RX-121562 CDM 6370000100 HCPCS 250 RC 50458-0140-30 NDC outpatient 1 UN 67.95 67.95 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES EPO [308136803] 54.36 percent of total billed charges 42.13 64.55 Technical (Hospital) Services CANAGLIFLOZIN 100 MG TABLET RX-121562 CDM 6370000100 HCPCS 250 RC 50458-0140-30 NDC outpatient 1 UN 67.95 67.95 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES PPO [308136801] 54.36 percent of total billed charges 42.13 64.55 Technical (Hospital) Services MAGNESIUM HYDROXIDE 400 MG/5 ML ORAL SUSPENSION RX-121938 CDM 6370000100 HCPCS 250 RC 00121-0431-30 NDC inpatient 30 ML 7.57 7.57 HEALTHPARTNERS SX009 HEALTHPARTNERS 5.99 percent of total billed charges 4.69 7.19 Technical (Hospital) Services MAGNESIUM HYDROXIDE 400 MG/5 ML ORAL SUSPENSION RX-121938 CDM 6370000100 HCPCS 250 RC 00121-0431-30 NDC inpatient 30 ML 7.57 7.57 CIGNA 62308 [3081051] CIGNA 62308 [308105105] 5.99 percent of total billed charges 4.69 7.19 Technical (Hospital) Services MAGNESIUM HYDROXIDE 400 MG/5 ML ORAL SUSPENSION RX-121938 CDM 6370000100 HCPCS 250 RC 00121-0431-30 NDC inpatient 30 ML 7.57 7.57 CIGNA 62308 [3081051] CIGNA STATE OF WYOMING [308105107] 5.99 percent of total billed charges 4.69 7.19 Technical (Hospital) Services MAGNESIUM HYDROXIDE 400 MG/5 ML ORAL SUSPENSION RX-121938 CDM 6370000100 HCPCS 250 RC 00121-0431-30 NDC inpatient 30 ML 7.57 7.57 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES EPO [308136803] 5.99 percent of total billed charges 4.69 7.19 Technical (Hospital) Services MAGNESIUM HYDROXIDE 400 MG/5 ML ORAL SUSPENSION RX-121938 CDM 6370000100 HCPCS 250 RC 00121-0431-30 NDC inpatient 30 ML 7.57 7.57 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES PPO [308136801] 5.99 percent of total billed charges 4.69 7.19 Technical (Hospital) Services MAGNESIUM HYDROXIDE 400 MG/5 ML ORAL SUSPENSION RX-121938 CDM 6370000100 HCPCS 250 RC 00121-0431-30 NDC inpatient 30 ML 7.57 7.57 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES HDHP [308136802] 5.99 percent of total billed charges 4.69 7.19 Technical (Hospital) Services MAGNESIUM HYDROXIDE 400 MG/5 ML ORAL SUSPENSION RX-121938 CDM 6370000100 HCPCS 250 RC 00121-0431-30 NDC inpatient 30 ML 7.57 7.57 MULTIPLAN INC 34080 [3081285] MULTIPLAN INC [308128501] 7.19 percent of total billed charges 4.69 7.19 Technical (Hospital) Services MAGNESIUM HYDROXIDE 400 MG/5 ML ORAL SUSPENSION RX-121938 CDM 6370000100 HCPCS 250 RC 00121-0431-30 NDC inpatient 30 ML 7.57 7.57 MEDICA (COMMERCIAL) 94265 [3081118] MEDICA CLAIMS [308111801] 6.81 percent of total billed charges 4.69 7.19 Technical (Hospital) Services MAGNESIUM HYDROXIDE 400 MG/5 ML ORAL SUSPENSION RX-121938 CDM 6370000100 HCPCS 250 RC 00121-0431-30 NDC inpatient 30 ML 7.57 7.57 UNITED HEALTHCARE (COMMERCIAL) [3081199] UNITED HEALTHCARE 87726 [308119901] 4.69 percent of total billed charges 4.69 7.19 Technical (Hospital) Services MAGNESIUM HYDROXIDE 400 MG/5 ML ORAL SUSPENSION RX-121938 CDM 6370000100 HCPCS 250 RC 00121-0431-30 NDC inpatient 30 ML 7.57 7.57 BLUE CROSS BLUE SHIELD WELLMARK SB889 [3081026] BCBS WYOMING [308102603] 7.19 percent of total billed charges 4.69 7.19 Technical (Hospital) Services MAGNESIUM HYDROXIDE 400 MG/5 ML ORAL SUSPENSION RX-121938 CDM 6370000100 HCPCS 250 RC 00121-0431-30 NDC outpatient 30 ML 7.57 7.57 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES EPO [308136803] 6.06 percent of total billed charges 4.69 7.19 Technical (Hospital) Services MAGNESIUM HYDROXIDE 400 MG/5 ML ORAL SUSPENSION RX-121938 CDM 6370000100 HCPCS 250 RC 00121-0431-30 NDC outpatient 30 ML 7.57 7.57 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES PPO [308136801] 6.06 percent of total billed charges 4.69 7.19 Technical (Hospital) Services MAGNESIUM HYDROXIDE 400 MG/5 ML ORAL SUSPENSION RX-121938 CDM 6370000100 HCPCS 250 RC 00121-0431-30 NDC outpatient 30 ML 7.57 7.57 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES HDHP [308136802] 6.06 percent of total billed charges 4.69 7.19 Technical (Hospital) Services MAGNESIUM HYDROXIDE 400 MG/5 ML ORAL SUSPENSION RX-121938 CDM 6370000100 HCPCS 250 RC 00121-0431-30 NDC outpatient 30 ML 7.57 7.57 BLUE CROSS BLUE SHIELD WELLMARK SB889 [3081026] BCBS WYOMING [308102603] 7.19 percent of total billed charges 4.69 7.19 Technical (Hospital) Services MAGNESIUM HYDROXIDE 400 MG/5 ML ORAL SUSPENSION RX-121938 CDM 6370000100 HCPCS 250 RC 00121-0431-30 NDC outpatient 30 ML 7.57 7.57 HEALTHPARTNERS SX009 HEALTHPARTNERS 6.06 percent of total billed charges 4.69 7.19 Technical (Hospital) Services MAGNESIUM HYDROXIDE 400 MG/5 ML ORAL SUSPENSION RX-121938 CDM 6370000100 HCPCS 250 RC 00121-0431-30 NDC outpatient 30 ML 7.57 7.57 UNITED HEALTHCARE (COMMERCIAL) [3081199] UNITED HEALTHCARE 87726 [308119901] 4.69 percent of total billed charges 4.69 7.19 Technical (Hospital) Services MAGNESIUM HYDROXIDE 400 MG/5 ML ORAL SUSPENSION RX-121938 CDM 6370000100 HCPCS 250 RC 00121-0431-30 NDC outpatient 30 ML 7.57 7.57 CIGNA 62308 [3081051] CIGNA 62308 [308105105] 6.06 percent of total billed charges 4.69 7.19 Technical (Hospital) Services MAGNESIUM HYDROXIDE 400 MG/5 ML ORAL SUSPENSION RX-121938 CDM 6370000100 HCPCS 250 RC 00121-0431-30 NDC outpatient 30 ML 7.57 7.57 CIGNA 62308 [3081051] CIGNA STATE OF WYOMING [308105107] 6.06 percent of total billed charges 4.69 7.19 Technical (Hospital) Services MAGNESIUM HYDROXIDE 400 MG/5 ML ORAL SUSPENSION RX-121938 CDM 6370000100 HCPCS 250 RC 00121-0431-30 NDC outpatient 30 ML 7.57 7.57 MULTIPLAN INC 34080 [3081285] MULTIPLAN INC [308128501] 7.19 percent of total billed charges 4.69 7.19 Technical (Hospital) Services MAGNESIUM HYDROXIDE 400 MG/5 ML ORAL SUSPENSION RX-121938 CDM 6370000100 HCPCS 250 RC 00121-0431-30 NDC outpatient 30 ML 7.57 7.57 MEDICA (COMMERCIAL) 94265 [3081118] MEDICA CLAIMS [308111801] 6.81 percent of total billed charges 4.69 7.19 Technical (Hospital) Services VENLAFAXINE 100 MG TABLET RX-12205 CDM 6370000100 HCPCS 250 RC 57664-0396-88 NDC outpatient 1 UN 6 6 MULTIPLAN INC 34080 [3081285] MULTIPLAN INC [308128501] 5.7 percent of total billed charges 3.72 5.7 Technical (Hospital) Services VENLAFAXINE 100 MG TABLET RX-12205 CDM 6370000100 HCPCS 250 RC 57664-0396-88 NDC outpatient 1 UN 6 6 UNITED HEALTHCARE (COMMERCIAL) [3081199] UNITED HEALTHCARE 87726 [308119901] 3.72 percent of total billed charges 3.72 5.7 Technical (Hospital) Services VENLAFAXINE 100 MG TABLET RX-12205 CDM 6370000100 HCPCS 250 RC 57664-0396-88 NDC outpatient 1 UN 6 6 CIGNA 62308 [3081051] CIGNA 62308 [308105105] 4.8 percent of total billed charges 3.72 5.7 Technical (Hospital) Services VENLAFAXINE 100 MG TABLET RX-12205 CDM 6370000100 HCPCS 250 RC 57664-0396-88 NDC outpatient 1 UN 6 6 CIGNA 62308 [3081051] CIGNA STATE OF WYOMING [308105107] 4.8 percent of total billed charges 3.72 5.7 Technical (Hospital) Services VENLAFAXINE 100 MG TABLET RX-12205 CDM 6370000100 HCPCS 250 RC 57664-0396-88 NDC outpatient 1 UN 6 6 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES EPO [308136803] 4.8 percent of total billed charges 3.72 5.7 Technical (Hospital) Services VENLAFAXINE 100 MG TABLET RX-12205 CDM 6370000100 HCPCS 250 RC 57664-0396-88 NDC outpatient 1 UN 6 6 MEDICA (COMMERCIAL) 94265 [3081118] MEDICA CLAIMS [308111801] 5.4 percent of total billed charges 3.72 5.7 Technical (Hospital) Services VENLAFAXINE 100 MG TABLET RX-12205 CDM 6370000100 HCPCS 250 RC 57664-0396-88 NDC outpatient 1 UN 6 6 BLUE CROSS BLUE SHIELD WELLMARK SB889 [3081026] BCBS WYOMING [308102603] 5.7 percent of total billed charges 3.72 5.7 Technical (Hospital) Services VENLAFAXINE 100 MG TABLET RX-12205 CDM 6370000100 HCPCS 250 RC 57664-0396-88 NDC outpatient 1 UN 6 6 HEALTHPARTNERS SX009 HEALTHPARTNERS 4.8 percent of total billed charges 3.72 5.7 Technical (Hospital) Services VENLAFAXINE 100 MG TABLET RX-12205 CDM 6370000100 HCPCS 250 RC 57664-0396-88 NDC outpatient 1 UN 6 6 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES PPO [308136801] 4.8 percent of total billed charges 3.72 5.7 Technical (Hospital) Services VENLAFAXINE 100 MG TABLET RX-12205 CDM 6370000100 HCPCS 250 RC 57664-0396-88 NDC outpatient 1 UN 6 6 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES HDHP [308136802] 4.8 percent of total billed charges 3.72 5.7 Technical (Hospital) Services VENLAFAXINE 100 MG TABLET RX-12205 CDM 6370000100 HCPCS 250 RC 57664-0396-88 NDC inpatient 1 UN 6 6 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES PPO [308136801] 4.75 percent of total billed charges 3.72 5.7 Technical (Hospital) Services VENLAFAXINE 100 MG TABLET RX-12205 CDM 6370000100 HCPCS 250 RC 57664-0396-88 NDC inpatient 1 UN 6 6 MEDICA (COMMERCIAL) 94265 [3081118] MEDICA CLAIMS [308111801] 5.4 percent of total billed charges 3.72 5.7 Technical (Hospital) Services VENLAFAXINE 100 MG TABLET RX-12205 CDM 6370000100 HCPCS 250 RC 57664-0396-88 NDC inpatient 1 UN 6 6 HEALTHPARTNERS SX009 HEALTHPARTNERS 4.75 percent of total billed charges 3.72 5.7 Technical (Hospital) Services VENLAFAXINE 100 MG TABLET RX-12205 CDM 6370000100 HCPCS 250 RC 57664-0396-88 NDC inpatient 1 UN 6 6 MULTIPLAN INC 34080 [3081285] MULTIPLAN INC [308128501] 5.7 percent of total billed charges 3.72 5.7 Technical (Hospital) Services VENLAFAXINE 100 MG TABLET RX-12205 CDM 6370000100 HCPCS 250 RC 57664-0396-88 NDC inpatient 1 UN 6 6 BLUE CROSS BLUE SHIELD WELLMARK SB889 [3081026] BCBS WYOMING [308102603] 5.7 percent of total billed charges 3.72 5.7 Technical (Hospital) Services VENLAFAXINE 100 MG TABLET RX-12205 CDM 6370000100 HCPCS 250 RC 57664-0396-88 NDC inpatient 1 UN 6 6 UNITED HEALTHCARE (COMMERCIAL) [3081199] UNITED HEALTHCARE 87726 [308119901] 3.72 percent of total billed charges 3.72 5.7 Technical (Hospital) Services VENLAFAXINE 100 MG TABLET RX-12205 CDM 6370000100 HCPCS 250 RC 57664-0396-88 NDC inpatient 1 UN 6 6 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES HDHP [308136802] 4.75 percent of total billed charges 3.72 5.7 Technical (Hospital) Services VENLAFAXINE 100 MG TABLET RX-12205 CDM 6370000100 HCPCS 250 RC 57664-0396-88 NDC inpatient 1 UN 6 6 CIGNA 62308 [3081051] CIGNA 62308 [308105105] 4.75 percent of total billed charges 3.72 5.7 Technical (Hospital) Services VENLAFAXINE 100 MG TABLET RX-12205 CDM 6370000100 HCPCS 250 RC 57664-0396-88 NDC inpatient 1 UN 6 6 CIGNA 62308 [3081051] CIGNA STATE OF WYOMING [308105107] 4.75 percent of total billed charges 3.72 5.7 Technical (Hospital) Services VENLAFAXINE 100 MG TABLET RX-12205 CDM 6370000100 HCPCS 250 RC 57664-0396-88 NDC inpatient 1 UN 6 6 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES EPO [308136803] 4.75 percent of total billed charges 3.72 5.7 Technical (Hospital) Services VENLAFAXINE 75 MG TABLET RX-12206 CDM 6370000100 HCPCS 250 RC 57664-0395-88 NDC outpatient 1 UN 5.98 5.98 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES HDHP [308136802] 4.78 percent of total billed charges 3.71 5.68 Technical (Hospital) Services VENLAFAXINE 75 MG TABLET RX-12206 CDM 6370000100 HCPCS 250 RC 57664-0395-88 NDC outpatient 1 UN 5.98 5.98 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES PPO [308136801] 4.78 percent of total billed charges 3.71 5.68 Technical (Hospital) Services VENLAFAXINE 75 MG TABLET RX-12206 CDM 6370000100 HCPCS 250 RC 57664-0395-88 NDC outpatient 1 UN 5.98 5.98 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES EPO [308136803] 4.78 percent of total billed charges 3.71 5.68 Technical (Hospital) Services VENLAFAXINE 75 MG TABLET RX-12206 CDM 6370000100 HCPCS 250 RC 57664-0395-88 NDC outpatient 1 UN 5.98 5.98 MEDICA (COMMERCIAL) 94265 [3081118] MEDICA CLAIMS [308111801] 5.38 percent of total billed charges 3.71 5.68 Technical (Hospital) Services VENLAFAXINE 75 MG TABLET RX-12206 CDM 6370000100 HCPCS 250 RC 57664-0395-88 NDC outpatient 1 UN 5.98 5.98 MULTIPLAN INC 34080 [3081285] MULTIPLAN INC [308128501] 5.68 percent of total billed charges 3.71 5.68 Technical (Hospital) Services VENLAFAXINE 75 MG TABLET RX-12206 CDM 6370000100 HCPCS 250 RC 57664-0395-88 NDC outpatient 1 UN 5.98 5.98 CIGNA 62308 [3081051] CIGNA 62308 [308105105] 4.78 percent of total billed charges 3.71 5.68 Technical (Hospital) Services VENLAFAXINE 75 MG TABLET RX-12206 CDM 6370000100 HCPCS 250 RC 57664-0395-88 NDC outpatient 1 UN 5.98 5.98 CIGNA 62308 [3081051] CIGNA STATE OF WYOMING [308105107] 4.78 percent of total billed charges 3.71 5.68 Technical (Hospital) Services VENLAFAXINE 75 MG TABLET RX-12206 CDM 6370000100 HCPCS 250 RC 57664-0395-88 NDC outpatient 1 UN 5.98 5.98 UNITED HEALTHCARE (COMMERCIAL) [3081199] UNITED HEALTHCARE 87726 [308119901] 3.71 percent of total billed charges 3.71 5.68 Technical (Hospital) Services VENLAFAXINE 75 MG TABLET RX-12206 CDM 6370000100 HCPCS 250 RC 57664-0395-88 NDC outpatient 1 UN 5.98 5.98 BLUE CROSS BLUE SHIELD WELLMARK SB889 [3081026] BCBS WYOMING [308102603] 5.68 percent of total billed charges 3.71 5.68 Technical (Hospital) Services VENLAFAXINE 75 MG TABLET RX-12206 CDM 6370000100 HCPCS 250 RC 57664-0395-88 NDC outpatient 1 UN 5.98 5.98 HEALTHPARTNERS SX009 HEALTHPARTNERS 4.78 percent of total billed charges 3.71 5.68 Technical (Hospital) Services VENLAFAXINE 75 MG TABLET RX-12206 CDM 6370000100 HCPCS 250 RC 57664-0395-88 NDC inpatient 1 UN 5.98 5.98 BLUE CROSS BLUE SHIELD WELLMARK SB889 [3081026] BCBS WYOMING [308102603] 5.68 percent of total billed charges 3.71 5.68 Technical (Hospital) Services VENLAFAXINE 75 MG TABLET RX-12206 CDM 6370000100 HCPCS 250 RC 57664-0395-88 NDC inpatient 1 UN 5.98 5.98 UNITED HEALTHCARE (COMMERCIAL) [3081199] UNITED HEALTHCARE 87726 [308119901] 3.71 percent of total billed charges 3.71 5.68 Technical (Hospital) Services VENLAFAXINE 75 MG TABLET RX-12206 CDM 6370000100 HCPCS 250 RC 57664-0395-88 NDC inpatient 1 UN 5.98 5.98 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES HDHP [308136802] 4.73 percent of total billed charges 3.71 5.68 Technical (Hospital) Services VENLAFAXINE 75 MG TABLET RX-12206 CDM 6370000100 HCPCS 250 RC 57664-0395-88 NDC inpatient 1 UN 5.98 5.98 MEDICA (COMMERCIAL) 94265 [3081118] MEDICA CLAIMS [308111801] 5.38 percent of total billed charges 3.71 5.68 Technical (Hospital) Services VENLAFAXINE 75 MG TABLET RX-12206 CDM 6370000100 HCPCS 250 RC 57664-0395-88 NDC inpatient 1 UN 5.98 5.98 HEALTHPARTNERS SX009 HEALTHPARTNERS 4.73 percent of total billed charges 3.71 5.68 Technical (Hospital) Services VENLAFAXINE 75 MG TABLET RX-12206 CDM 6370000100 HCPCS 250 RC 57664-0395-88 NDC inpatient 1 UN 5.98 5.98 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES EPO [308136803] 4.73 percent of total billed charges 3.71 5.68 Technical (Hospital) Services VENLAFAXINE 75 MG TABLET RX-12206 CDM 6370000100 HCPCS 250 RC 57664-0395-88 NDC inpatient 1 UN 5.98 5.98 CIGNA 62308 [3081051] CIGNA 62308 [308105105] 4.73 percent of total billed charges 3.71 5.68 Technical (Hospital) Services VENLAFAXINE 75 MG TABLET RX-12206 CDM 6370000100 HCPCS 250 RC 57664-0395-88 NDC inpatient 1 UN 5.98 5.98 CIGNA 62308 [3081051] CIGNA STATE OF WYOMING [308105107] 4.73 percent of total billed charges 3.71 5.68 Technical (Hospital) Services VENLAFAXINE 75 MG TABLET RX-12206 CDM 6370000100 HCPCS 250 RC 57664-0395-88 NDC inpatient 1 UN 5.98 5.98 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES PPO [308136801] 4.73 percent of total billed charges 3.71 5.68 Technical (Hospital) Services VENLAFAXINE 75 MG TABLET RX-12206 CDM 6370000100 HCPCS 250 RC 57664-0395-88 NDC inpatient 1 UN 5.98 5.98 MULTIPLAN INC 34080 [3081285] MULTIPLAN INC [308128501] 5.68 percent of total billed charges 3.71 5.68 Technical (Hospital) Services VENLAFAXINE 37.5 MG TABLET RX-12207 CDM 6370000100 HCPCS 250 RC 57664-0393-88 NDC inpatient 1 UN 5.95 5.95 CIGNA 62308 [3081051] CIGNA 62308 [308105105] 4.71 percent of total billed charges 3.69 5.65 Technical (Hospital) Services VENLAFAXINE 37.5 MG TABLET RX-12207 CDM 6370000100 HCPCS 250 RC 57664-0393-88 NDC inpatient 1 UN 5.95 5.95 CIGNA 62308 [3081051] CIGNA STATE OF WYOMING [308105107] 4.71 percent of total billed charges 3.69 5.65 Technical (Hospital) Services VENLAFAXINE 37.5 MG TABLET RX-12207 CDM 6370000100 HCPCS 250 RC 57664-0393-88 NDC inpatient 1 UN 5.95 5.95 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES EPO [308136803] 4.71 percent of total billed charges 3.69 5.65 Technical (Hospital) Services VENLAFAXINE 37.5 MG TABLET RX-12207 CDM 6370000100 HCPCS 250 RC 57664-0393-88 NDC inpatient 1 UN 5.95 5.95 MEDICA (COMMERCIAL) 94265 [3081118] MEDICA CLAIMS [308111801] 5.36 percent of total billed charges 3.69 5.65 Technical (Hospital) Services VENLAFAXINE 37.5 MG TABLET RX-12207 CDM 6370000100 HCPCS 250 RC 57664-0393-88 NDC inpatient 1 UN 5.95 5.95 HEALTHPARTNERS SX009 HEALTHPARTNERS 4.71 percent of total billed charges 3.69 5.65 Technical (Hospital) Services VENLAFAXINE 37.5 MG TABLET RX-12207 CDM 6370000100 HCPCS 250 RC 57664-0393-88 NDC inpatient 1 UN 5.95 5.95 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES HDHP [308136802] 4.71 percent of total billed charges 3.69 5.65 Technical (Hospital) Services VENLAFAXINE 37.5 MG TABLET RX-12207 CDM 6370000100 HCPCS 250 RC 57664-0393-88 NDC inpatient 1 UN 5.95 5.95 BLUE CROSS BLUE SHIELD WELLMARK SB889 [3081026] BCBS WYOMING [308102603] 5.65 percent of total billed charges 3.69 5.65 Technical (Hospital) Services VENLAFAXINE 37.5 MG TABLET RX-12207 CDM 6370000100 HCPCS 250 RC 57664-0393-88 NDC inpatient 1 UN 5.95 5.95 UNITED HEALTHCARE (COMMERCIAL) [3081199] UNITED HEALTHCARE 87726 [308119901] 3.69 percent of total billed charges 3.69 5.65 Technical (Hospital) Services VENLAFAXINE 37.5 MG TABLET RX-12207 CDM 6370000100 HCPCS 250 RC 57664-0393-88 NDC inpatient 1 UN 5.95 5.95 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES PPO [308136801] 4.71 percent of total billed charges 3.69 5.65 Technical (Hospital) Services VENLAFAXINE 37.5 MG TABLET RX-12207 CDM 6370000100 HCPCS 250 RC 57664-0393-88 NDC inpatient 1 UN 5.95 5.95 MULTIPLAN INC 34080 [3081285] MULTIPLAN INC [308128501] 5.65 percent of total billed charges 3.69 5.65 Technical (Hospital) Services VENLAFAXINE 37.5 MG TABLET RX-12207 CDM 6370000100 HCPCS 250 RC 57664-0393-88 NDC outpatient 1 UN 5.95 5.95 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES PPO [308136801] 4.76 percent of total billed charges 3.69 5.65 Technical (Hospital) Services VENLAFAXINE 37.5 MG TABLET RX-12207 CDM 6370000100 HCPCS 250 RC 57664-0393-88 NDC outpatient 1 UN 5.95 5.95 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES HDHP [308136802] 4.76 percent of total billed charges 3.69 5.65 Technical (Hospital) Services VENLAFAXINE 37.5 MG TABLET RX-12207 CDM 6370000100 HCPCS 250 RC 57664-0393-88 NDC outpatient 1 UN 5.95 5.95 MULTIPLAN INC 34080 [3081285] MULTIPLAN INC [308128501] 5.65 percent of total billed charges 3.69 5.65 Technical (Hospital) Services VENLAFAXINE 37.5 MG TABLET RX-12207 CDM 6370000100 HCPCS 250 RC 57664-0393-88 NDC outpatient 1 UN 5.95 5.95 CIGNA 62308 [3081051] CIGNA 62308 [308105105] 4.76 percent of total billed charges 3.69 5.65 Technical (Hospital) Services VENLAFAXINE 37.5 MG TABLET RX-12207 CDM 6370000100 HCPCS 250 RC 57664-0393-88 NDC outpatient 1 UN 5.95 5.95 CIGNA 62308 [3081051] CIGNA STATE OF WYOMING [308105107] 4.76 percent of total billed charges 3.69 5.65 Technical (Hospital) Services VENLAFAXINE 37.5 MG TABLET RX-12207 CDM 6370000100 HCPCS 250 RC 57664-0393-88 NDC outpatient 1 UN 5.95 5.95 UNITED HEALTHCARE (COMMERCIAL) [3081199] UNITED HEALTHCARE 87726 [308119901] 3.69 percent of total billed charges 3.69 5.65 Technical (Hospital) Services VENLAFAXINE 37.5 MG TABLET RX-12207 CDM 6370000100 HCPCS 250 RC 57664-0393-88 NDC outpatient 1 UN 5.95 5.95 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES EPO [308136803] 4.76 percent of total billed charges 3.69 5.65 Technical (Hospital) Services VENLAFAXINE 37.5 MG TABLET RX-12207 CDM 6370000100 HCPCS 250 RC 57664-0393-88 NDC outpatient 1 UN 5.95 5.95 MEDICA (COMMERCIAL) 94265 [3081118] MEDICA CLAIMS [308111801] 5.36 percent of total billed charges 3.69 5.65 Technical (Hospital) Services VENLAFAXINE 37.5 MG TABLET RX-12207 CDM 6370000100 HCPCS 250 RC 57664-0393-88 NDC outpatient 1 UN 5.95 5.95 HEALTHPARTNERS SX009 HEALTHPARTNERS 4.76 percent of total billed charges 3.69 5.65 Technical (Hospital) Services VENLAFAXINE 37.5 MG TABLET RX-12207 CDM 6370000100 HCPCS 250 RC 57664-0393-88 NDC outpatient 1 UN 5.95 5.95 BLUE CROSS BLUE SHIELD WELLMARK SB889 [3081026] BCBS WYOMING [308102603] 5.65 percent of total billed charges 3.69 5.65 Technical (Hospital) Services "OXYCODONE ER 10 MG TABLET,CRUSH RESISTANT,EXTENDED RELEASE 12 HR" RX-122363 CDM 6370000100 HCPCS 250 RC 59011-0410-20 NDC inpatient 1 UN 24.18 24.18 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES PPO [308136801] 19.15 percent of total billed charges 14.99 22.97 Technical (Hospital) Services "OXYCODONE ER 10 MG TABLET,CRUSH RESISTANT,EXTENDED RELEASE 12 HR" RX-122363 CDM 6370000100 HCPCS 250 RC 59011-0410-20 NDC inpatient 1 UN 24.18 24.18 MULTIPLAN INC 34080 [3081285] MULTIPLAN INC [308128501] 22.97 percent of total billed charges 14.99 22.97 Technical (Hospital) Services "OXYCODONE ER 10 MG TABLET,CRUSH RESISTANT,EXTENDED RELEASE 12 HR" RX-122363 CDM 6370000100 HCPCS 250 RC 59011-0410-20 NDC inpatient 1 UN 24.18 24.18 CIGNA 62308 [3081051] CIGNA 62308 [308105105] 19.15 percent of total billed charges 14.99 22.97 Technical (Hospital) Services "OXYCODONE ER 10 MG TABLET,CRUSH RESISTANT,EXTENDED RELEASE 12 HR" RX-122363 CDM 6370000100 HCPCS 250 RC 59011-0410-20 NDC inpatient 1 UN 24.18 24.18 CIGNA 62308 [3081051] CIGNA STATE OF WYOMING [308105107] 19.15 percent of total billed charges 14.99 22.97 Technical (Hospital) Services "OXYCODONE ER 10 MG TABLET,CRUSH RESISTANT,EXTENDED RELEASE 12 HR" RX-122363 CDM 6370000100 HCPCS 250 RC 59011-0410-20 NDC inpatient 1 UN 24.18 24.18 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES EPO [308136803] 19.15 percent of total billed charges 14.99 22.97 Technical (Hospital) Services "OXYCODONE ER 10 MG TABLET,CRUSH RESISTANT,EXTENDED RELEASE 12 HR" RX-122363 CDM 6370000100 HCPCS 250 RC 59011-0410-20 NDC inpatient 1 UN 24.18 24.18 HEALTHPARTNERS SX009 HEALTHPARTNERS 19.15 percent of total billed charges 14.99 22.97 Technical (Hospital) Services "OXYCODONE ER 10 MG TABLET,CRUSH RESISTANT,EXTENDED RELEASE 12 HR" RX-122363 CDM 6370000100 HCPCS 250 RC 59011-0410-20 NDC inpatient 1 UN 24.18 24.18 MEDICA (COMMERCIAL) 94265 [3081118] MEDICA CLAIMS [308111801] 21.76 percent of total billed charges 14.99 22.97 Technical (Hospital) Services "OXYCODONE ER 10 MG TABLET,CRUSH RESISTANT,EXTENDED RELEASE 12 HR" RX-122363 CDM 6370000100 HCPCS 250 RC 59011-0410-20 NDC inpatient 1 UN 24.18 24.18 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES HDHP [308136802] 19.15 percent of total billed charges 14.99 22.97 Technical (Hospital) Services "OXYCODONE ER 10 MG TABLET,CRUSH RESISTANT,EXTENDED RELEASE 12 HR" RX-122363 CDM 6370000100 HCPCS 250 RC 59011-0410-20 NDC inpatient 1 UN 24.18 24.18 UNITED HEALTHCARE (COMMERCIAL) [3081199] UNITED HEALTHCARE 87726 [308119901] 14.99 percent of total billed charges 14.99 22.97 Technical (Hospital) Services "OXYCODONE ER 10 MG TABLET,CRUSH RESISTANT,EXTENDED RELEASE 12 HR" RX-122363 CDM 6370000100 HCPCS 250 RC 59011-0410-20 NDC inpatient 1 UN 24.18 24.18 BLUE CROSS BLUE SHIELD WELLMARK SB889 [3081026] BCBS WYOMING [308102603] 22.97 percent of total billed charges 14.99 22.97 Technical (Hospital) Services "OXYCODONE ER 10 MG TABLET,CRUSH RESISTANT,EXTENDED RELEASE 12 HR" RX-122363 CDM 6370000100 HCPCS 250 RC 59011-0410-20 NDC outpatient 1 UN 24.18 24.18 HEALTHPARTNERS SX009 HEALTHPARTNERS 19.34 percent of total billed charges 14.99 22.97 Technical (Hospital) Services "OXYCODONE ER 10 MG TABLET,CRUSH RESISTANT,EXTENDED RELEASE 12 HR" RX-122363 CDM 6370000100 HCPCS 250 RC 59011-0410-20 NDC outpatient 1 UN 24.18 24.18 BLUE CROSS BLUE SHIELD WELLMARK SB889 [3081026] BCBS WYOMING [308102603] 22.97 percent of total billed charges 14.99 22.97 Technical (Hospital) Services "OXYCODONE ER 10 MG TABLET,CRUSH RESISTANT,EXTENDED RELEASE 12 HR" RX-122363 CDM 6370000100 HCPCS 250 RC 59011-0410-20 NDC outpatient 1 UN 24.18 24.18 UNITED HEALTHCARE (COMMERCIAL) [3081199] UNITED HEALTHCARE 87726 [308119901] 14.99 percent of total billed charges 14.99 22.97 Technical (Hospital) Services "OXYCODONE ER 10 MG TABLET,CRUSH RESISTANT,EXTENDED RELEASE 12 HR" RX-122363 CDM 6370000100 HCPCS 250 RC 59011-0410-20 NDC outpatient 1 UN 24.18 24.18 MEDICA (COMMERCIAL) 94265 [3081118] MEDICA CLAIMS [308111801] 21.76 percent of total billed charges 14.99 22.97 Technical (Hospital) Services "OXYCODONE ER 10 MG TABLET,CRUSH RESISTANT,EXTENDED RELEASE 12 HR" RX-122363 CDM 6370000100 HCPCS 250 RC 59011-0410-20 NDC outpatient 1 UN 24.18 24.18 CIGNA 62308 [3081051] CIGNA 62308 [308105105] 19.34 percent of total billed charges 14.99 22.97 Technical (Hospital) Services "OXYCODONE ER 10 MG TABLET,CRUSH RESISTANT,EXTENDED RELEASE 12 HR" RX-122363 CDM 6370000100 HCPCS 250 RC 59011-0410-20 NDC outpatient 1 UN 24.18 24.18 CIGNA 62308 [3081051] CIGNA STATE OF WYOMING [308105107] 19.34 percent of total billed charges 14.99 22.97 Technical (Hospital) Services "OXYCODONE ER 10 MG TABLET,CRUSH RESISTANT,EXTENDED RELEASE 12 HR" RX-122363 CDM 6370000100 HCPCS 250 RC 59011-0410-20 NDC outpatient 1 UN 24.18 24.18 MULTIPLAN INC 34080 [3081285] MULTIPLAN INC [308128501] 22.97 percent of total billed charges 14.99 22.97 Technical (Hospital) Services "OXYCODONE ER 10 MG TABLET,CRUSH RESISTANT,EXTENDED RELEASE 12 HR" RX-122363 CDM 6370000100 HCPCS 250 RC 59011-0410-20 NDC outpatient 1 UN 24.18 24.18 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES PPO [308136801] 19.34 percent of total billed charges 14.99 22.97 Technical (Hospital) Services "OXYCODONE ER 10 MG TABLET,CRUSH RESISTANT,EXTENDED RELEASE 12 HR" RX-122363 CDM 6370000100 HCPCS 250 RC 59011-0410-20 NDC outpatient 1 UN 24.18 24.18 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES HDHP [308136802] 19.34 percent of total billed charges 14.99 22.97 Technical (Hospital) Services "OXYCODONE ER 10 MG TABLET,CRUSH RESISTANT,EXTENDED RELEASE 12 HR" RX-122363 CDM 6370000100 HCPCS 250 RC 59011-0410-20 NDC outpatient 1 UN 24.18 24.18 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES EPO [308136803] 19.34 percent of total billed charges 14.99 22.97 Technical (Hospital) Services "OXYCODONE ER 20 MG TABLET,CRUSH RESISTANT,EXTENDED RELEASE 12 HR" RX-122366 CDM 6370000100 HCPCS 250 RC 59011-0420-10 NDC outpatient 1 UN 38.34 38.34 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES HDHP [308136802] 30.67 percent of total billed charges 23.77 36.42 Technical (Hospital) Services "OXYCODONE ER 20 MG TABLET,CRUSH RESISTANT,EXTENDED RELEASE 12 HR" RX-122366 CDM 6370000100 HCPCS 250 RC 59011-0420-10 NDC outpatient 1 UN 38.34 38.34 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES PPO [308136801] 30.67 percent of total billed charges 23.77 36.42 Technical (Hospital) Services "OXYCODONE ER 20 MG TABLET,CRUSH RESISTANT,EXTENDED RELEASE 12 HR" RX-122366 CDM 6370000100 HCPCS 250 RC 59011-0420-10 NDC outpatient 1 UN 38.34 38.34 CIGNA 62308 [3081051] CIGNA 62308 [308105105] 30.67 percent of total billed charges 23.77 36.42 Technical (Hospital) Services "OXYCODONE ER 20 MG TABLET,CRUSH RESISTANT,EXTENDED RELEASE 12 HR" RX-122366 CDM 6370000100 HCPCS 250 RC 59011-0420-10 NDC outpatient 1 UN 38.34 38.34 CIGNA 62308 [3081051] CIGNA STATE OF WYOMING [308105107] 30.67 percent of total billed charges 23.77 36.42 Technical (Hospital) Services "OXYCODONE ER 20 MG TABLET,CRUSH RESISTANT,EXTENDED RELEASE 12 HR" RX-122366 CDM 6370000100 HCPCS 250 RC 59011-0420-10 NDC outpatient 1 UN 38.34 38.34 MEDICA (COMMERCIAL) 94265 [3081118] MEDICA CLAIMS [308111801] 34.51 percent of total billed charges 23.77 36.42 Technical (Hospital) Services "OXYCODONE ER 20 MG TABLET,CRUSH RESISTANT,EXTENDED RELEASE 12 HR" RX-122366 CDM 6370000100 HCPCS 250 RC 59011-0420-10 NDC outpatient 1 UN 38.34 38.34 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES EPO [308136803] 30.67 percent of total billed charges 23.77 36.42 Technical (Hospital) Services "OXYCODONE ER 20 MG TABLET,CRUSH RESISTANT,EXTENDED RELEASE 12 HR" RX-122366 CDM 6370000100 HCPCS 250 RC 59011-0420-10 NDC outpatient 1 UN 38.34 38.34 MULTIPLAN INC 34080 [3081285] MULTIPLAN INC [308128501] 36.42 percent of total billed charges 23.77 36.42 Technical (Hospital) Services "OXYCODONE ER 20 MG TABLET,CRUSH RESISTANT,EXTENDED RELEASE 12 HR" RX-122366 CDM 6370000100 HCPCS 250 RC 59011-0420-10 NDC outpatient 1 UN 38.34 38.34 UNITED HEALTHCARE (COMMERCIAL) [3081199] UNITED HEALTHCARE 87726 [308119901] 23.77 percent of total billed charges 23.77 36.42 Technical (Hospital) Services "OXYCODONE ER 20 MG TABLET,CRUSH RESISTANT,EXTENDED RELEASE 12 HR" RX-122366 CDM 6370000100 HCPCS 250 RC 59011-0420-10 NDC outpatient 1 UN 38.34 38.34 HEALTHPARTNERS SX009 HEALTHPARTNERS 30.67 percent of total billed charges 23.77 36.42 Technical (Hospital) Services "OXYCODONE ER 20 MG TABLET,CRUSH RESISTANT,EXTENDED RELEASE 12 HR" RX-122366 CDM 6370000100 HCPCS 250 RC 59011-0420-10 NDC outpatient 1 UN 38.34 38.34 BLUE CROSS BLUE SHIELD WELLMARK SB889 [3081026] BCBS WYOMING [308102603] 36.42 percent of total billed charges 23.77 36.42 Technical (Hospital) Services "OXYCODONE ER 20 MG TABLET,CRUSH RESISTANT,EXTENDED RELEASE 12 HR" RX-122366 CDM 6370000100 HCPCS 250 RC 59011-0420-10 NDC inpatient 1 UN 38.34 38.34 BLUE CROSS BLUE SHIELD WELLMARK SB889 [3081026] BCBS WYOMING [308102603] 36.42 percent of total billed charges 23.77 36.42 Technical (Hospital) Services "OXYCODONE ER 20 MG TABLET,CRUSH RESISTANT,EXTENDED RELEASE 12 HR" RX-122366 CDM 6370000100 HCPCS 250 RC 59011-0420-10 NDC inpatient 1 UN 38.34 38.34 UNITED HEALTHCARE (COMMERCIAL) [3081199] UNITED HEALTHCARE 87726 [308119901] 23.77 percent of total billed charges 23.77 36.42 Technical (Hospital) Services "OXYCODONE ER 20 MG TABLET,CRUSH RESISTANT,EXTENDED RELEASE 12 HR" RX-122366 CDM 6370000100 HCPCS 250 RC 59011-0420-10 NDC inpatient 1 UN 38.34 38.34 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES HDHP [308136802] 30.36 percent of total billed charges 23.77 36.42 Technical (Hospital) Services "OXYCODONE ER 20 MG TABLET,CRUSH RESISTANT,EXTENDED RELEASE 12 HR" RX-122366 CDM 6370000100 HCPCS 250 RC 59011-0420-10 NDC inpatient 1 UN 38.34 38.34 MEDICA (COMMERCIAL) 94265 [3081118] MEDICA CLAIMS [308111801] 34.51 percent of total billed charges 23.77 36.42 Technical (Hospital) Services "OXYCODONE ER 20 MG TABLET,CRUSH RESISTANT,EXTENDED RELEASE 12 HR" RX-122366 CDM 6370000100 HCPCS 250 RC 59011-0420-10 NDC inpatient 1 UN 38.34 38.34 HEALTHPARTNERS SX009 HEALTHPARTNERS 30.36 percent of total billed charges 23.77 36.42 Technical (Hospital) Services "OXYCODONE ER 20 MG TABLET,CRUSH RESISTANT,EXTENDED RELEASE 12 HR" RX-122366 CDM 6370000100 HCPCS 250 RC 59011-0420-10 NDC inpatient 1 UN 38.34 38.34 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES EPO [308136803] 30.36 percent of total billed charges 23.77 36.42 Technical (Hospital) Services "OXYCODONE ER 20 MG TABLET,CRUSH RESISTANT,EXTENDED RELEASE 12 HR" RX-122366 CDM 6370000100 HCPCS 250 RC 59011-0420-10 NDC inpatient 1 UN 38.34 38.34 CIGNA 62308 [3081051] CIGNA 62308 [308105105] 30.36 percent of total billed charges 23.77 36.42 Technical (Hospital) Services "OXYCODONE ER 20 MG TABLET,CRUSH RESISTANT,EXTENDED RELEASE 12 HR" RX-122366 CDM 6370000100 HCPCS 250 RC 59011-0420-10 NDC inpatient 1 UN 38.34 38.34 CIGNA 62308 [3081051] CIGNA STATE OF WYOMING [308105107] 30.36 percent of total billed charges 23.77 36.42 Technical (Hospital) Services "OXYCODONE ER 20 MG TABLET,CRUSH RESISTANT,EXTENDED RELEASE 12 HR" RX-122366 CDM 6370000100 HCPCS 250 RC 59011-0420-10 NDC inpatient 1 UN 38.34 38.34 MULTIPLAN INC 34080 [3081285] MULTIPLAN INC [308128501] 36.42 percent of total billed charges 23.77 36.42 Technical (Hospital) Services "OXYCODONE ER 20 MG TABLET,CRUSH RESISTANT,EXTENDED RELEASE 12 HR" RX-122366 CDM 6370000100 HCPCS 250 RC 59011-0420-10 NDC inpatient 1 UN 38.34 38.34 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES PPO [308136801] 30.36 percent of total billed charges 23.77 36.42 Technical (Hospital) Services CHOLESTYRAMINE-ASPARTAME 4 GRAM ORAL POWDER FOR SUSP IN A PACKET RX-123751 CDM 6370000100 HCPCS 250 RC 49884-0466-63 NDC outpatient 1 UN 7.67 7.67 BLUE CROSS BLUE SHIELD WELLMARK SB889 [3081026] BCBS WYOMING [308102603] 7.29 percent of total billed charges 4.76 7.29 Technical (Hospital) Services CHOLESTYRAMINE-ASPARTAME 4 GRAM ORAL POWDER FOR SUSP IN A PACKET RX-123751 CDM 6370000100 HCPCS 250 RC 49884-0466-63 NDC outpatient 1 UN 7.67 7.67 HEALTHPARTNERS SX009 HEALTHPARTNERS 6.14 percent of total billed charges 4.76 7.29 Technical (Hospital) Services CHOLESTYRAMINE-ASPARTAME 4 GRAM ORAL POWDER FOR SUSP IN A PACKET RX-123751 CDM 6370000100 HCPCS 250 RC 49884-0466-63 NDC outpatient 1 UN 7.67 7.67 UNITED HEALTHCARE (COMMERCIAL) [3081199] UNITED HEALTHCARE 87726 [308119901] 4.76 percent of total billed charges 4.76 7.29 Technical (Hospital) Services CHOLESTYRAMINE-ASPARTAME 4 GRAM ORAL POWDER FOR SUSP IN A PACKET RX-123751 CDM 6370000100 HCPCS 250 RC 49884-0466-63 NDC outpatient 1 UN 7.67 7.67 CIGNA 62308 [3081051] CIGNA 62308 [308105105] 6.14 percent of total billed charges 4.76 7.29 Technical (Hospital) Services CHOLESTYRAMINE-ASPARTAME 4 GRAM ORAL POWDER FOR SUSP IN A PACKET RX-123751 CDM 6370000100 HCPCS 250 RC 49884-0466-63 NDC outpatient 1 UN 7.67 7.67 CIGNA 62308 [3081051] CIGNA STATE OF WYOMING [308105107] 6.14 percent of total billed charges 4.76 7.29 Technical (Hospital) Services CHOLESTYRAMINE-ASPARTAME 4 GRAM ORAL POWDER FOR SUSP IN A PACKET RX-123751 CDM 6370000100 HCPCS 250 RC 49884-0466-63 NDC outpatient 1 UN 7.67 7.67 MULTIPLAN INC 34080 [3081285] MULTIPLAN INC [308128501] 7.29 percent of total billed charges 4.76 7.29 Technical (Hospital) Services CHOLESTYRAMINE-ASPARTAME 4 GRAM ORAL POWDER FOR SUSP IN A PACKET RX-123751 CDM 6370000100 HCPCS 250 RC 49884-0466-63 NDC outpatient 1 UN 7.67 7.67 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES EPO [308136803] 6.14 percent of total billed charges 4.76 7.29 Technical (Hospital) Services CHOLESTYRAMINE-ASPARTAME 4 GRAM ORAL POWDER FOR SUSP IN A PACKET RX-123751 CDM 6370000100 HCPCS 250 RC 49884-0466-63 NDC outpatient 1 UN 7.67 7.67 MEDICA (COMMERCIAL) 94265 [3081118] MEDICA CLAIMS [308111801] 6.9 percent of total billed charges 4.76 7.29 Technical (Hospital) Services CHOLESTYRAMINE-ASPARTAME 4 GRAM ORAL POWDER FOR SUSP IN A PACKET RX-123751 CDM 6370000100 HCPCS 250 RC 49884-0466-63 NDC outpatient 1 UN 7.67 7.67 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES PPO [308136801] 6.14 percent of total billed charges 4.76 7.29 Technical (Hospital) Services CHOLESTYRAMINE-ASPARTAME 4 GRAM ORAL POWDER FOR SUSP IN A PACKET RX-123751 CDM 6370000100 HCPCS 250 RC 49884-0466-63 NDC outpatient 1 UN 7.67 7.67 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES HDHP [308136802] 6.14 percent of total billed charges 4.76 7.29 Technical (Hospital) Services CHOLESTYRAMINE-ASPARTAME 4 GRAM ORAL POWDER FOR SUSP IN A PACKET RX-123751 CDM 6370000100 HCPCS 250 RC 49884-0466-63 NDC inpatient 1 UN 7.67 7.67 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES HDHP [308136802] 6.07 percent of total billed charges 4.76 7.29 Technical (Hospital) Services CHOLESTYRAMINE-ASPARTAME 4 GRAM ORAL POWDER FOR SUSP IN A PACKET RX-123751 CDM 6370000100 HCPCS 250 RC 49884-0466-63 NDC inpatient 1 UN 7.67 7.67 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES EPO [308136803] 6.07 percent of total billed charges 4.76 7.29 Technical (Hospital) Services CHOLESTYRAMINE-ASPARTAME 4 GRAM ORAL POWDER FOR SUSP IN A PACKET RX-123751 CDM 6370000100 HCPCS 250 RC 49884-0466-63 NDC inpatient 1 UN 7.67 7.67 CIGNA 62308 [3081051] CIGNA 62308 [308105105] 6.07 percent of total billed charges 4.76 7.29 Technical (Hospital) Services CHOLESTYRAMINE-ASPARTAME 4 GRAM ORAL POWDER FOR SUSP IN A PACKET RX-123751 CDM 6370000100 HCPCS 250 RC 49884-0466-63 NDC inpatient 1 UN 7.67 7.67 CIGNA 62308 [3081051] CIGNA STATE OF WYOMING [308105107] 6.07 percent of total billed charges 4.76 7.29 Technical (Hospital) Services CHOLESTYRAMINE-ASPARTAME 4 GRAM ORAL POWDER FOR SUSP IN A PACKET RX-123751 CDM 6370000100 HCPCS 250 RC 49884-0466-63 NDC inpatient 1 UN 7.67 7.67 BLUE CROSS BLUE SHIELD WELLMARK SB889 [3081026] BCBS WYOMING [308102603] 7.29 percent of total billed charges 4.76 7.29 Technical (Hospital) Services CHOLESTYRAMINE-ASPARTAME 4 GRAM ORAL POWDER FOR SUSP IN A PACKET RX-123751 CDM 6370000100 HCPCS 250 RC 49884-0466-63 NDC inpatient 1 UN 7.67 7.67 UNITED HEALTHCARE (COMMERCIAL) [3081199] UNITED HEALTHCARE 87726 [308119901] 4.76 percent of total billed charges 4.76 7.29 Technical (Hospital) Services CHOLESTYRAMINE-ASPARTAME 4 GRAM ORAL POWDER FOR SUSP IN A PACKET RX-123751 CDM 6370000100 HCPCS 250 RC 49884-0466-63 NDC inpatient 1 UN 7.67 7.67 MULTIPLAN INC 34080 [3081285] MULTIPLAN INC [308128501] 7.29 percent of total billed charges 4.76 7.29 Technical (Hospital) Services CHOLESTYRAMINE-ASPARTAME 4 GRAM ORAL POWDER FOR SUSP IN A PACKET RX-123751 CDM 6370000100 HCPCS 250 RC 49884-0466-63 NDC inpatient 1 UN 7.67 7.67 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES PPO [308136801] 6.07 percent of total billed charges 4.76 7.29 Technical (Hospital) Services CHOLESTYRAMINE-ASPARTAME 4 GRAM ORAL POWDER FOR SUSP IN A PACKET RX-123751 CDM 6370000100 HCPCS 250 RC 49884-0466-63 NDC inpatient 1 UN 7.67 7.67 MEDICA (COMMERCIAL) 94265 [3081118] MEDICA CLAIMS [308111801] 6.9 percent of total billed charges 4.76 7.29 Technical (Hospital) Services CHOLESTYRAMINE-ASPARTAME 4 GRAM ORAL POWDER FOR SUSP IN A PACKET RX-123751 CDM 6370000100 HCPCS 250 RC 49884-0466-63 NDC inpatient 1 UN 7.67 7.67 HEALTHPARTNERS SX009 HEALTHPARTNERS 6.07 percent of total billed charges 4.76 7.29 Technical (Hospital) Services FLUOCINONIDE-EMOLLIENT 0.05 % TOPICAL CREAM RX-124677 CDM 6370000100 HCPCS 250 RC 00093-0263-30 NDC inpatient 1 GR 8.19 8.19 MULTIPLAN INC 34080 [3081285] MULTIPLAN INC [308128501] 7.78 percent of total billed charges 5.08 7.78 Technical (Hospital) Services FLUOCINONIDE-EMOLLIENT 0.05 % TOPICAL CREAM RX-124677 CDM 6370000100 HCPCS 250 RC 00093-0263-30 NDC inpatient 1 GR 8.19 8.19 MEDICA (COMMERCIAL) 94265 [3081118] MEDICA CLAIMS [308111801] 7.37 percent of total billed charges 5.08 7.78 Technical (Hospital) Services FLUOCINONIDE-EMOLLIENT 0.05 % TOPICAL CREAM RX-124677 CDM 6370000100 HCPCS 250 RC 00093-0263-30 NDC inpatient 1 GR 8.19 8.19 HEALTHPARTNERS SX009 HEALTHPARTNERS 6.48 percent of total billed charges 5.08 7.78 Technical (Hospital) Services FLUOCINONIDE-EMOLLIENT 0.05 % TOPICAL CREAM RX-124677 CDM 6370000100 HCPCS 250 RC 00093-0263-30 NDC inpatient 1 GR 8.19 8.19 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES PPO [308136801] 6.48 percent of total billed charges 5.08 7.78 Technical (Hospital) Services FLUOCINONIDE-EMOLLIENT 0.05 % TOPICAL CREAM RX-124677 CDM 6370000100 HCPCS 250 RC 00093-0263-30 NDC inpatient 1 GR 8.19 8.19 UNITED HEALTHCARE (COMMERCIAL) [3081199] UNITED HEALTHCARE 87726 [308119901] 5.08 percent of total billed charges 5.08 7.78 Technical (Hospital) Services FLUOCINONIDE-EMOLLIENT 0.05 % TOPICAL CREAM RX-124677 CDM 6370000100 HCPCS 250 RC 00093-0263-30 NDC inpatient 1 GR 8.19 8.19 BLUE CROSS BLUE SHIELD WELLMARK SB889 [3081026] BCBS WYOMING [308102603] 7.78 percent of total billed charges 5.08 7.78 Technical (Hospital) Services FLUOCINONIDE-EMOLLIENT 0.05 % TOPICAL CREAM RX-124677 CDM 6370000100 HCPCS 250 RC 00093-0263-30 NDC inpatient 1 GR 8.19 8.19 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES HDHP [308136802] 6.48 percent of total billed charges 5.08 7.78 Technical (Hospital) Services FLUOCINONIDE-EMOLLIENT 0.05 % TOPICAL CREAM RX-124677 CDM 6370000100 HCPCS 250 RC 00093-0263-30 NDC inpatient 1 GR 8.19 8.19 CIGNA 62308 [3081051] CIGNA 62308 [308105105] 6.48 percent of total billed charges 5.08 7.78 Technical (Hospital) Services FLUOCINONIDE-EMOLLIENT 0.05 % TOPICAL CREAM RX-124677 CDM 6370000100 HCPCS 250 RC 00093-0263-30 NDC inpatient 1 GR 8.19 8.19 CIGNA 62308 [3081051] CIGNA STATE OF WYOMING [308105107] 6.48 percent of total billed charges 5.08 7.78 Technical (Hospital) Services FLUOCINONIDE-EMOLLIENT 0.05 % TOPICAL CREAM RX-124677 CDM 6370000100 HCPCS 250 RC 00093-0263-30 NDC inpatient 1 GR 8.19 8.19 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES EPO [308136803] 6.48 percent of total billed charges 5.08 7.78 Technical (Hospital) Services FLUOCINONIDE-EMOLLIENT 0.05 % TOPICAL CREAM RX-124677 CDM 6370000100 HCPCS 250 RC 00093-0263-30 NDC outpatient 1 GR 8.19 8.19 MEDICA (COMMERCIAL) 94265 [3081118] MEDICA CLAIMS [308111801] 7.37 percent of total billed charges 5.08 7.78 Technical (Hospital) Services FLUOCINONIDE-EMOLLIENT 0.05 % TOPICAL CREAM RX-124677 CDM 6370000100 HCPCS 250 RC 00093-0263-30 NDC outpatient 1 GR 8.19 8.19 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES EPO [308136803] 6.55 percent of total billed charges 5.08 7.78 Technical (Hospital) Services FLUOCINONIDE-EMOLLIENT 0.05 % TOPICAL CREAM RX-124677 CDM 6370000100 HCPCS 250 RC 00093-0263-30 NDC outpatient 1 GR 8.19 8.19 MULTIPLAN INC 34080 [3081285] MULTIPLAN INC [308128501] 7.78 percent of total billed charges 5.08 7.78 Technical (Hospital) Services FLUOCINONIDE-EMOLLIENT 0.05 % TOPICAL CREAM RX-124677 CDM 6370000100 HCPCS 250 RC 00093-0263-30 NDC outpatient 1 GR 8.19 8.19 CIGNA 62308 [3081051] CIGNA 62308 [308105105] 6.55 percent of total billed charges 5.08 7.78 Technical (Hospital) Services FLUOCINONIDE-EMOLLIENT 0.05 % TOPICAL CREAM RX-124677 CDM 6370000100 HCPCS 250 RC 00093-0263-30 NDC outpatient 1 GR 8.19 8.19 CIGNA 62308 [3081051] CIGNA STATE OF WYOMING [308105107] 6.55 percent of total billed charges 5.08 7.78 Technical (Hospital) Services FLUOCINONIDE-EMOLLIENT 0.05 % TOPICAL CREAM RX-124677 CDM 6370000100 HCPCS 250 RC 00093-0263-30 NDC outpatient 1 GR 8.19 8.19 UNITED HEALTHCARE (COMMERCIAL) [3081199] UNITED HEALTHCARE 87726 [308119901] 5.08 percent of total billed charges 5.08 7.78 Technical (Hospital) Services FLUOCINONIDE-EMOLLIENT 0.05 % TOPICAL CREAM RX-124677 CDM 6370000100 HCPCS 250 RC 00093-0263-30 NDC outpatient 1 GR 8.19 8.19 BLUE CROSS BLUE SHIELD WELLMARK SB889 [3081026] BCBS WYOMING [308102603] 7.78 percent of total billed charges 5.08 7.78 Technical (Hospital) Services FLUOCINONIDE-EMOLLIENT 0.05 % TOPICAL CREAM RX-124677 CDM 6370000100 HCPCS 250 RC 00093-0263-30 NDC outpatient 1 GR 8.19 8.19 HEALTHPARTNERS SX009 HEALTHPARTNERS 6.55 percent of total billed charges 5.08 7.78 Technical (Hospital) Services FLUOCINONIDE-EMOLLIENT 0.05 % TOPICAL CREAM RX-124677 CDM 6370000100 HCPCS 250 RC 00093-0263-30 NDC outpatient 1 GR 8.19 8.19 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES HDHP [308136802] 6.55 percent of total billed charges 5.08 7.78 Technical (Hospital) Services FLUOCINONIDE-EMOLLIENT 0.05 % TOPICAL CREAM RX-124677 CDM 6370000100 HCPCS 250 RC 00093-0263-30 NDC outpatient 1 GR 8.19 8.19 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES PPO [308136801] 6.55 percent of total billed charges 5.08 7.78 Technical (Hospital) Services ACTIVATED CHARCOAL 50 GRAM/240 ML ORAL SUSPENSION RX-124814 CDM 6370000100 HCPCS 250 RC 00574-0521-76 NDC outpatient 120 ML 37.88 37.88 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES EPO [308136803] 30.3 percent of total billed charges 23.49 35.99 Technical (Hospital) Services ACTIVATED CHARCOAL 50 GRAM/240 ML ORAL SUSPENSION RX-124814 CDM 6370000100 HCPCS 250 RC 00574-0521-76 NDC inpatient 120 ML 37.88 37.88 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES EPO [308136803] 29.99 percent of total billed charges 23.49 35.99 Technical (Hospital) Services ACTIVATED CHARCOAL 50 GRAM/240 ML ORAL SUSPENSION RX-124814 CDM 6370000100 HCPCS 250 RC 00574-0521-76 NDC inpatient 120 ML 37.88 37.88 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES PPO [308136801] 29.99 percent of total billed charges 23.49 35.99 Technical (Hospital) Services ACTIVATED CHARCOAL 50 GRAM/240 ML ORAL SUSPENSION RX-124814 CDM 6370000100 HCPCS 250 RC 00574-0521-76 NDC inpatient 120 ML 37.88 37.88 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES HDHP [308136802] 29.99 percent of total billed charges 23.49 35.99 Technical (Hospital) Services ACTIVATED CHARCOAL 50 GRAM/240 ML ORAL SUSPENSION RX-124814 CDM 6370000100 HCPCS 250 RC 00574-0521-76 NDC outpatient 120 ML 37.88 37.88 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES HDHP [308136802] 30.3 percent of total billed charges 23.49 35.99 Technical (Hospital) Services ACTIVATED CHARCOAL 50 GRAM/240 ML ORAL SUSPENSION RX-124814 CDM 6370000100 HCPCS 250 RC 00574-0521-76 NDC outpatient 120 ML 37.88 37.88 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES PPO [308136801] 30.3 percent of total billed charges 23.49 35.99 Technical (Hospital) Services ACTIVATED CHARCOAL 50 GRAM/240 ML ORAL SUSPENSION RX-124814 CDM 6370000100 HCPCS 250 RC 00574-0521-76 NDC outpatient 120 ML 37.88 37.88 BLUE CROSS BLUE SHIELD WELLMARK SB889 [3081026] BCBS WYOMING [308102603] 35.99 percent of total billed charges 23.49 35.99 Technical (Hospital) Services ACTIVATED CHARCOAL 50 GRAM/240 ML ORAL SUSPENSION RX-124814 CDM 6370000100 HCPCS 250 RC 00574-0521-76 NDC outpatient 120 ML 37.88 37.88 UNITED HEALTHCARE (COMMERCIAL) [3081199] UNITED HEALTHCARE 87726 [308119901] 23.49 percent of total billed charges 23.49 35.99 Technical (Hospital) Services ACTIVATED CHARCOAL 50 GRAM/240 ML ORAL SUSPENSION RX-124814 CDM 6370000100 HCPCS 250 RC 00574-0521-76 NDC outpatient 120 ML 37.88 37.88 HEALTHPARTNERS SX009 HEALTHPARTNERS 30.3 percent of total billed charges 23.49 35.99 Technical (Hospital) Services ACTIVATED CHARCOAL 50 GRAM/240 ML ORAL SUSPENSION RX-124814 CDM 6370000100 HCPCS 250 RC 00574-0521-76 NDC outpatient 120 ML 37.88 37.88 CIGNA 62308 [3081051] CIGNA 62308 [308105105] 30.3 percent of total billed charges 23.49 35.99 Technical (Hospital) Services ACTIVATED CHARCOAL 50 GRAM/240 ML ORAL SUSPENSION RX-124814 CDM 6370000100 HCPCS 250 RC 00574-0521-76 NDC outpatient 120 ML 37.88 37.88 CIGNA 62308 [3081051] CIGNA STATE OF WYOMING [308105107] 30.3 percent of total billed charges 23.49 35.99 Technical (Hospital) Services ACTIVATED CHARCOAL 50 GRAM/240 ML ORAL SUSPENSION RX-124814 CDM 6370000100 HCPCS 250 RC 00574-0521-76 NDC outpatient 120 ML 37.88 37.88 MEDICA (COMMERCIAL) 94265 [3081118] MEDICA CLAIMS [308111801] 34.09 percent of total billed charges 23.49 35.99 Technical (Hospital) Services ACTIVATED CHARCOAL 50 GRAM/240 ML ORAL SUSPENSION RX-124814 CDM 6370000100 HCPCS 250 RC 00574-0521-76 NDC inpatient 120 ML 37.88 37.88 CIGNA 62308 [3081051] CIGNA 62308 [308105105] 29.99 percent of total billed charges 23.49 35.99 Technical (Hospital) Services ACTIVATED CHARCOAL 50 GRAM/240 ML ORAL SUSPENSION RX-124814 CDM 6370000100 HCPCS 250 RC 00574-0521-76 NDC inpatient 120 ML 37.88 37.88 CIGNA 62308 [3081051] CIGNA STATE OF WYOMING [308105107] 29.99 percent of total billed charges 23.49 35.99 Technical (Hospital) Services ACTIVATED CHARCOAL 50 GRAM/240 ML ORAL SUSPENSION RX-124814 CDM 6370000100 HCPCS 250 RC 00574-0521-76 NDC inpatient 120 ML 37.88 37.88 UNITED HEALTHCARE (COMMERCIAL) [3081199] UNITED HEALTHCARE 87726 [308119901] 23.49 percent of total billed charges 23.49 35.99 Technical (Hospital) Services ACTIVATED CHARCOAL 50 GRAM/240 ML ORAL SUSPENSION RX-124814 CDM 6370000100 HCPCS 250 RC 00574-0521-76 NDC inpatient 120 ML 37.88 37.88 BLUE CROSS BLUE SHIELD WELLMARK SB889 [3081026] BCBS WYOMING [308102603] 35.99 percent of total billed charges 23.49 35.99 Technical (Hospital) Services ACTIVATED CHARCOAL 50 GRAM/240 ML ORAL SUSPENSION RX-124814 CDM 6370000100 HCPCS 250 RC 00574-0521-76 NDC inpatient 120 ML 37.88 37.88 MEDICA (COMMERCIAL) 94265 [3081118] MEDICA CLAIMS [308111801] 34.09 percent of total billed charges 23.49 35.99 Technical (Hospital) Services ACTIVATED CHARCOAL 50 GRAM/240 ML ORAL SUSPENSION RX-124814 CDM 6370000100 HCPCS 250 RC 00574-0521-76 NDC inpatient 120 ML 37.88 37.88 MULTIPLAN INC 34080 [3081285] MULTIPLAN INC [308128501] 35.99 percent of total billed charges 23.49 35.99 Technical (Hospital) Services ACTIVATED CHARCOAL 50 GRAM/240 ML ORAL SUSPENSION RX-124814 CDM 6370000100 HCPCS 250 RC 00574-0521-76 NDC inpatient 120 ML 37.88 37.88 HEALTHPARTNERS SX009 HEALTHPARTNERS 29.99 percent of total billed charges 23.49 35.99 Technical (Hospital) Services ACTIVATED CHARCOAL 50 GRAM/240 ML ORAL SUSPENSION RX-124814 CDM 6370000100 HCPCS 250 RC 00574-0521-76 NDC outpatient 120 ML 37.88 37.88 MULTIPLAN INC 34080 [3081285] MULTIPLAN INC [308128501] 35.99 percent of total billed charges 23.49 35.99 Technical (Hospital) Services INSULIN ASPART 100 UNIT/ML SUBCUTANEOUS PEN (CORRECTION DOSE) RX-124838 CDM 6370000100 HCPCS 250 RC 00169-6339-10 NDC inpatient 3 ML 137 137 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES PPO [308136801] 108.48 percent of total billed charges 84.94 130.15 Technical (Hospital) Services INSULIN ASPART 100 UNIT/ML SUBCUTANEOUS PEN (CORRECTION DOSE) RX-124838 CDM 6370000100 HCPCS 250 RC 00169-6339-10 NDC inpatient 3 ML 137 137 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES HDHP [308136802] 108.48 percent of total billed charges 84.94 130.15 Technical (Hospital) Services INSULIN ASPART 100 UNIT/ML SUBCUTANEOUS PEN (CORRECTION DOSE) RX-124838 CDM 6370000100 HCPCS 250 RC 00169-6339-10 NDC inpatient 3 ML 137 137 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES EPO [308136803] 108.48 percent of total billed charges 84.94 130.15 Technical (Hospital) Services INSULIN ASPART 100 UNIT/ML SUBCUTANEOUS PEN (CORRECTION DOSE) RX-124838 CDM 6370000100 HCPCS 250 RC 00169-6339-10 NDC inpatient 3 ML 137 137 HEALTHPARTNERS SX009 HEALTHPARTNERS 108.48 percent of total billed charges 84.94 130.15 Technical (Hospital) Services INSULIN ASPART 100 UNIT/ML SUBCUTANEOUS PEN (CORRECTION DOSE) RX-124838 CDM 6370000100 HCPCS 250 RC 00169-6339-10 NDC inpatient 3 ML 137 137 MULTIPLAN INC 34080 [3081285] MULTIPLAN INC [308128501] 130.15 percent of total billed charges 84.94 130.15 Technical (Hospital) Services INSULIN ASPART 100 UNIT/ML SUBCUTANEOUS PEN (CORRECTION DOSE) RX-124838 CDM 6370000100 HCPCS 250 RC 00169-6339-10 NDC inpatient 3 ML 137 137 MEDICA (COMMERCIAL) 94265 [3081118] MEDICA CLAIMS [308111801] 123.3 percent of total billed charges 84.94 130.15 Technical (Hospital) Services INSULIN ASPART 100 UNIT/ML SUBCUTANEOUS PEN (CORRECTION DOSE) RX-124838 CDM 6370000100 HCPCS 250 RC 00169-6339-10 NDC inpatient 3 ML 137 137 UNITED HEALTHCARE (COMMERCIAL) [3081199] UNITED HEALTHCARE 87726 [308119901] 84.94 percent of total billed charges 84.94 130.15 Technical (Hospital) Services INSULIN ASPART 100 UNIT/ML SUBCUTANEOUS PEN (CORRECTION DOSE) RX-124838 CDM 6370000100 HCPCS 250 RC 00169-6339-10 NDC inpatient 3 ML 137 137 BLUE CROSS BLUE SHIELD WELLMARK SB889 [3081026] BCBS WYOMING [308102603] 130.15 percent of total billed charges 84.94 130.15 Technical (Hospital) Services INSULIN ASPART 100 UNIT/ML SUBCUTANEOUS PEN (CORRECTION DOSE) RX-124838 CDM 6370000100 HCPCS 250 RC 00169-6339-10 NDC inpatient 3 ML 137 137 CIGNA 62308 [3081051] CIGNA 62308 [308105105] 108.48 percent of total billed charges 84.94 130.15 Technical (Hospital) Services INSULIN ASPART 100 UNIT/ML SUBCUTANEOUS PEN (CORRECTION DOSE) RX-124838 CDM 6370000100 HCPCS 250 RC 00169-6339-10 NDC inpatient 3 ML 137 137 CIGNA 62308 [3081051] CIGNA STATE OF WYOMING [308105107] 108.48 percent of total billed charges 84.94 130.15 Technical (Hospital) Services INSULIN ASPART 100 UNIT/ML SUBCUTANEOUS PEN (CORRECTION DOSE) RX-124838 CDM 6370000100 HCPCS 250 RC 00169-6339-10 NDC outpatient 3 ML 137 137 BLUE CROSS BLUE SHIELD WELLMARK SB889 [3081026] BCBS WYOMING [308102603] 130.15 percent of total billed charges 84.94 130.15 Technical (Hospital) Services INSULIN ASPART 100 UNIT/ML SUBCUTANEOUS PEN (CORRECTION DOSE) RX-124838 CDM 6370000100 HCPCS 250 RC 00169-6339-10 NDC outpatient 3 ML 137 137 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES EPO [308136803] 109.6 percent of total billed charges 84.94 130.15 Technical (Hospital) Services INSULIN ASPART 100 UNIT/ML SUBCUTANEOUS PEN (CORRECTION DOSE) RX-124838 CDM 6370000100 HCPCS 250 RC 00169-6339-10 NDC outpatient 3 ML 137 137 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES HDHP [308136802] 109.6 percent of total billed charges 84.94 130.15 Technical (Hospital) Services INSULIN ASPART 100 UNIT/ML SUBCUTANEOUS PEN (CORRECTION DOSE) RX-124838 CDM 6370000100 HCPCS 250 RC 00169-6339-10 NDC outpatient 3 ML 137 137 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES PPO [308136801] 109.6 percent of total billed charges 84.94 130.15 Technical (Hospital) Services INSULIN ASPART 100 UNIT/ML SUBCUTANEOUS PEN (CORRECTION DOSE) RX-124838 CDM 6370000100 HCPCS 250 RC 00169-6339-10 NDC outpatient 3 ML 137 137 HEALTHPARTNERS SX009 HEALTHPARTNERS 109.6 percent of total billed charges 84.94 130.15 Technical (Hospital) Services INSULIN ASPART 100 UNIT/ML SUBCUTANEOUS PEN (CORRECTION DOSE) RX-124838 CDM 6370000100 HCPCS 250 RC 00169-6339-10 NDC outpatient 3 ML 137 137 UNITED HEALTHCARE (COMMERCIAL) [3081199] UNITED HEALTHCARE 87726 [308119901] 84.94 percent of total billed charges 84.94 130.15 Technical (Hospital) Services INSULIN ASPART 100 UNIT/ML SUBCUTANEOUS PEN (CORRECTION DOSE) RX-124838 CDM 6370000100 HCPCS 250 RC 00169-6339-10 NDC outpatient 3 ML 137 137 CIGNA 62308 [3081051] CIGNA 62308 [308105105] 109.6 percent of total billed charges 84.94 130.15 Technical (Hospital) Services INSULIN ASPART 100 UNIT/ML SUBCUTANEOUS PEN (CORRECTION DOSE) RX-124838 CDM 6370000100 HCPCS 250 RC 00169-6339-10 NDC outpatient 3 ML 137 137 CIGNA 62308 [3081051] CIGNA STATE OF WYOMING [308105107] 109.6 percent of total billed charges 84.94 130.15 Technical (Hospital) Services INSULIN ASPART 100 UNIT/ML SUBCUTANEOUS PEN (CORRECTION DOSE) RX-124838 CDM 6370000100 HCPCS 250 RC 00169-6339-10 NDC outpatient 3 ML 137 137 MULTIPLAN INC 34080 [3081285] MULTIPLAN INC [308128501] 130.15 percent of total billed charges 84.94 130.15 Technical (Hospital) Services INSULIN ASPART 100 UNIT/ML SUBCUTANEOUS PEN (CORRECTION DOSE) RX-124838 CDM 6370000100 HCPCS 250 RC 00169-6339-10 NDC outpatient 3 ML 137 137 MEDICA (COMMERCIAL) 94265 [3081118] MEDICA CLAIMS [308111801] 123.3 percent of total billed charges 84.94 130.15 Technical (Hospital) Services INSULIN GLARGINE (U-100) 100 UNIT/ML (3 ML) SUBCUTANEOUS PEN RX-124840 CDM 6370000100 HCPCS 250 RC 00002-7715-59 NDC outpatient 3 ML 137 137 CIGNA 62308 [3081051] CIGNA 62308 [308105105] 109.6 percent of total billed charges 84.94 130.15 Technical (Hospital) Services INSULIN GLARGINE (U-100) 100 UNIT/ML (3 ML) SUBCUTANEOUS PEN RX-124840 CDM 6370000100 HCPCS 250 RC 00002-7715-59 NDC outpatient 3 ML 137 137 CIGNA 62308 [3081051] CIGNA STATE OF WYOMING [308105107] 109.6 percent of total billed charges 84.94 130.15 Technical (Hospital) Services INSULIN GLARGINE (U-100) 100 UNIT/ML (3 ML) SUBCUTANEOUS PEN RX-124840 CDM 6370000100 HCPCS 250 RC 00002-7715-59 NDC outpatient 3 ML 137 137 MULTIPLAN INC 34080 [3081285] MULTIPLAN INC [308128501] 130.15 percent of total billed charges 84.94 130.15 Technical (Hospital) Services INSULIN GLARGINE (U-100) 100 UNIT/ML (3 ML) SUBCUTANEOUS PEN RX-124840 CDM 6370000100 HCPCS 250 RC 00002-7715-59 NDC outpatient 3 ML 137 137 MEDICA (COMMERCIAL) 94265 [3081118] MEDICA CLAIMS [308111801] 123.3 percent of total billed charges 84.94 130.15 Technical (Hospital) Services INSULIN GLARGINE (U-100) 100 UNIT/ML (3 ML) SUBCUTANEOUS PEN RX-124840 CDM 6370000100 HCPCS 250 RC 00002-7715-59 NDC outpatient 3 ML 137 137 HEALTHPARTNERS SX009 HEALTHPARTNERS 109.6 percent of total billed charges 84.94 130.15 Technical (Hospital) Services INSULIN GLARGINE (U-100) 100 UNIT/ML (3 ML) SUBCUTANEOUS PEN RX-124840 CDM 6370000100 HCPCS 250 RC 00002-7715-59 NDC outpatient 3 ML 137 137 UNITED HEALTHCARE (COMMERCIAL) [3081199] UNITED HEALTHCARE 87726 [308119901] 84.94 percent of total billed charges 84.94 130.15 Technical (Hospital) Services INSULIN GLARGINE (U-100) 100 UNIT/ML (3 ML) SUBCUTANEOUS PEN RX-124840 CDM 6370000100 HCPCS 250 RC 00002-7715-59 NDC outpatient 3 ML 137 137 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES EPO [308136803] 109.6 percent of total billed charges 84.94 130.15 Technical (Hospital) Services INSULIN GLARGINE (U-100) 100 UNIT/ML (3 ML) SUBCUTANEOUS PEN RX-124840 CDM 6370000100 HCPCS 250 RC 00002-7715-59 NDC outpatient 3 ML 137 137 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES PPO [308136801] 109.6 percent of total billed charges 84.94 130.15 Technical (Hospital) Services INSULIN GLARGINE (U-100) 100 UNIT/ML (3 ML) SUBCUTANEOUS PEN RX-124840 CDM 6370000100 HCPCS 250 RC 00002-7715-59 NDC outpatient 3 ML 137 137 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES HDHP [308136802] 109.6 percent of total billed charges 84.94 130.15 Technical (Hospital) Services INSULIN GLARGINE (U-100) 100 UNIT/ML (3 ML) SUBCUTANEOUS PEN RX-124840 CDM 6370000100 HCPCS 250 RC 00002-7715-59 NDC outpatient 3 ML 137 137 BLUE CROSS BLUE SHIELD WELLMARK SB889 [3081026] BCBS WYOMING [308102603] 130.15 percent of total billed charges 84.94 130.15 Technical (Hospital) Services INSULIN GLARGINE (U-100) 100 UNIT/ML (3 ML) SUBCUTANEOUS PEN RX-124840 CDM 6370000100 HCPCS 250 RC 00002-7715-59 NDC inpatient 3 ML 137 137 MEDICA (COMMERCIAL) 94265 [3081118] MEDICA CLAIMS [308111801] 123.3 percent of total billed charges 84.94 130.15 Technical (Hospital) Services INSULIN GLARGINE (U-100) 100 UNIT/ML (3 ML) SUBCUTANEOUS PEN RX-124840 CDM 6370000100 HCPCS 250 RC 00002-7715-59 NDC inpatient 3 ML 137 137 MULTIPLAN INC 34080 [3081285] MULTIPLAN INC [308128501] 130.15 percent of total billed charges 84.94 130.15 Technical (Hospital) Services INSULIN GLARGINE (U-100) 100 UNIT/ML (3 ML) SUBCUTANEOUS PEN RX-124840 CDM 6370000100 HCPCS 250 RC 00002-7715-59 NDC inpatient 3 ML 137 137 BLUE CROSS BLUE SHIELD WELLMARK SB889 [3081026] BCBS WYOMING [308102603] 130.15 percent of total billed charges 84.94 130.15 Technical (Hospital) Services INSULIN GLARGINE (U-100) 100 UNIT/ML (3 ML) SUBCUTANEOUS PEN RX-124840 CDM 6370000100 HCPCS 250 RC 00002-7715-59 NDC inpatient 3 ML 137 137 CIGNA 62308 [3081051] CIGNA 62308 [308105105] 108.48 percent of total billed charges 84.94 130.15 Technical (Hospital) Services INSULIN GLARGINE (U-100) 100 UNIT/ML (3 ML) SUBCUTANEOUS PEN RX-124840 CDM 6370000100 HCPCS 250 RC 00002-7715-59 NDC inpatient 3 ML 137 137 CIGNA 62308 [3081051] CIGNA STATE OF WYOMING [308105107] 108.48 percent of total billed charges 84.94 130.15 Technical (Hospital) Services INSULIN GLARGINE (U-100) 100 UNIT/ML (3 ML) SUBCUTANEOUS PEN RX-124840 CDM 6370000100 HCPCS 250 RC 00002-7715-59 NDC inpatient 3 ML 137 137 UNITED HEALTHCARE (COMMERCIAL) [3081199] UNITED HEALTHCARE 87726 [308119901] 84.94 percent of total billed charges 84.94 130.15 Technical (Hospital) Services INSULIN GLARGINE (U-100) 100 UNIT/ML (3 ML) SUBCUTANEOUS PEN RX-124840 CDM 6370000100 HCPCS 250 RC 00002-7715-59 NDC inpatient 3 ML 137 137 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES EPO [308136803] 108.48 percent of total billed charges 84.94 130.15 Technical (Hospital) Services INSULIN GLARGINE (U-100) 100 UNIT/ML (3 ML) SUBCUTANEOUS PEN RX-124840 CDM 6370000100 HCPCS 250 RC 00002-7715-59 NDC inpatient 3 ML 137 137 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES PPO [308136801] 108.48 percent of total billed charges 84.94 130.15 Technical (Hospital) Services INSULIN GLARGINE (U-100) 100 UNIT/ML (3 ML) SUBCUTANEOUS PEN RX-124840 CDM 6370000100 HCPCS 250 RC 00002-7715-59 NDC inpatient 3 ML 137 137 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES HDHP [308136802] 108.48 percent of total billed charges 84.94 130.15 Technical (Hospital) Services INSULIN GLARGINE (U-100) 100 UNIT/ML (3 ML) SUBCUTANEOUS PEN RX-124840 CDM 6370000100 HCPCS 250 RC 00002-7715-59 NDC inpatient 3 ML 137 137 HEALTHPARTNERS SX009 HEALTHPARTNERS 108.48 percent of total billed charges 84.94 130.15 Technical (Hospital) Services INSULIN LISPRO (U-100) 100 UNIT/ML SUBCUTANEOUS PEN RX-124845 CDM 6370000100 HCPCS 250 RC 00002-8799-59 NDC inpatient 3 ML 137 137 UNITED HEALTHCARE (COMMERCIAL) [3081199] UNITED HEALTHCARE 87726 [308119901] 84.94 percent of total billed charges 84.94 130.15 Technical (Hospital) Services INSULIN LISPRO (U-100) 100 UNIT/ML SUBCUTANEOUS PEN RX-124845 CDM 6370000100 HCPCS 250 RC 00002-8799-59 NDC inpatient 3 ML 137 137 BLUE CROSS BLUE SHIELD WELLMARK SB889 [3081026] BCBS WYOMING [308102603] 130.15 percent of total billed charges 84.94 130.15 Technical (Hospital) Services INSULIN LISPRO (U-100) 100 UNIT/ML SUBCUTANEOUS PEN RX-124845 CDM 6370000100 HCPCS 250 RC 00002-8799-59 NDC inpatient 3 ML 137 137 CIGNA 62308 [3081051] CIGNA 62308 [308105105] 108.48 percent of total billed charges 84.94 130.15 Technical (Hospital) Services INSULIN LISPRO (U-100) 100 UNIT/ML SUBCUTANEOUS PEN RX-124845 CDM 6370000100 HCPCS 250 RC 00002-8799-59 NDC inpatient 3 ML 137 137 CIGNA 62308 [3081051] CIGNA STATE OF WYOMING [308105107] 108.48 percent of total billed charges 84.94 130.15 Technical (Hospital) Services INSULIN LISPRO (U-100) 100 UNIT/ML SUBCUTANEOUS PEN RX-124845 CDM 6370000100 HCPCS 250 RC 00002-8799-59 NDC inpatient 3 ML 137 137 MEDICA (COMMERCIAL) 94265 [3081118] MEDICA CLAIMS [308111801] 123.3 percent of total billed charges 84.94 130.15 Technical (Hospital) Services INSULIN LISPRO (U-100) 100 UNIT/ML SUBCUTANEOUS PEN RX-124845 CDM 6370000100 HCPCS 250 RC 00002-8799-59 NDC inpatient 3 ML 137 137 MULTIPLAN INC 34080 [3081285] MULTIPLAN INC [308128501] 130.15 percent of total billed charges 84.94 130.15 Technical (Hospital) Services INSULIN LISPRO (U-100) 100 UNIT/ML SUBCUTANEOUS PEN RX-124845 CDM 6370000100 HCPCS 250 RC 00002-8799-59 NDC inpatient 3 ML 137 137 HEALTHPARTNERS SX009 HEALTHPARTNERS 108.48 percent of total billed charges 84.94 130.15 Technical (Hospital) Services INSULIN LISPRO (U-100) 100 UNIT/ML SUBCUTANEOUS PEN RX-124845 CDM 6370000100 HCPCS 250 RC 00002-8799-59 NDC inpatient 3 ML 137 137 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES PPO [308136801] 108.48 percent of total billed charges 84.94 130.15 Technical (Hospital) Services INSULIN LISPRO (U-100) 100 UNIT/ML SUBCUTANEOUS PEN RX-124845 CDM 6370000100 HCPCS 250 RC 00002-8799-59 NDC inpatient 3 ML 137 137 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES HDHP [308136802] 108.48 percent of total billed charges 84.94 130.15 Technical (Hospital) Services INSULIN LISPRO (U-100) 100 UNIT/ML SUBCUTANEOUS PEN RX-124845 CDM 6370000100 HCPCS 250 RC 00002-8799-59 NDC inpatient 3 ML 137 137 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES EPO [308136803] 108.48 percent of total billed charges 84.94 130.15 Technical (Hospital) Services INSULIN LISPRO (U-100) 100 UNIT/ML SUBCUTANEOUS PEN RX-124845 CDM 6370000100 HCPCS 250 RC 00002-8799-59 NDC outpatient 3 ML 137 137 BLUE CROSS BLUE SHIELD WELLMARK SB889 [3081026] BCBS WYOMING [308102603] 130.15 percent of total billed charges 84.94 130.15 Technical (Hospital) Services INSULIN LISPRO (U-100) 100 UNIT/ML SUBCUTANEOUS PEN RX-124845 CDM 6370000100 HCPCS 250 RC 00002-8799-59 NDC outpatient 3 ML 137 137 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES HDHP [308136802] 109.6 percent of total billed charges 84.94 130.15 Technical (Hospital) Services INSULIN LISPRO (U-100) 100 UNIT/ML SUBCUTANEOUS PEN RX-124845 CDM 6370000100 HCPCS 250 RC 00002-8799-59 NDC outpatient 3 ML 137 137 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES PPO [308136801] 109.6 percent of total billed charges 84.94 130.15 Technical (Hospital) Services INSULIN LISPRO (U-100) 100 UNIT/ML SUBCUTANEOUS PEN RX-124845 CDM 6370000100 HCPCS 250 RC 00002-8799-59 NDC outpatient 3 ML 137 137 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES EPO [308136803] 109.6 percent of total billed charges 84.94 130.15 Technical (Hospital) Services INSULIN LISPRO (U-100) 100 UNIT/ML SUBCUTANEOUS PEN RX-124845 CDM 6370000100 HCPCS 250 RC 00002-8799-59 NDC outpatient 3 ML 137 137 MULTIPLAN INC 34080 [3081285] MULTIPLAN INC [308128501] 130.15 percent of total billed charges 84.94 130.15 Technical (Hospital) Services INSULIN LISPRO (U-100) 100 UNIT/ML SUBCUTANEOUS PEN RX-124845 CDM 6370000100 HCPCS 250 RC 00002-8799-59 NDC outpatient 3 ML 137 137 MEDICA (COMMERCIAL) 94265 [3081118] MEDICA CLAIMS [308111801] 123.3 percent of total billed charges 84.94 130.15 Technical (Hospital) Services INSULIN LISPRO (U-100) 100 UNIT/ML SUBCUTANEOUS PEN RX-124845 CDM 6370000100 HCPCS 250 RC 00002-8799-59 NDC outpatient 3 ML 137 137 CIGNA 62308 [3081051] CIGNA 62308 [308105105] 109.6 percent of total billed charges 84.94 130.15 Technical (Hospital) Services INSULIN LISPRO (U-100) 100 UNIT/ML SUBCUTANEOUS PEN RX-124845 CDM 6370000100 HCPCS 250 RC 00002-8799-59 NDC outpatient 3 ML 137 137 CIGNA 62308 [3081051] CIGNA STATE OF WYOMING [308105107] 109.6 percent of total billed charges 84.94 130.15 Technical (Hospital) Services INSULIN LISPRO (U-100) 100 UNIT/ML SUBCUTANEOUS PEN RX-124845 CDM 6370000100 HCPCS 250 RC 00002-8799-59 NDC outpatient 3 ML 137 137 HEALTHPARTNERS SX009 HEALTHPARTNERS 109.6 percent of total billed charges 84.94 130.15 Technical (Hospital) Services INSULIN LISPRO (U-100) 100 UNIT/ML SUBCUTANEOUS PEN RX-124845 CDM 6370000100 HCPCS 250 RC 00002-8799-59 NDC outpatient 3 ML 137 137 UNITED HEALTHCARE (COMMERCIAL) [3081199] UNITED HEALTHCARE 87726 [308119901] 84.94 percent of total billed charges 84.94 130.15 Technical (Hospital) Services INSULIN ASPAR PROT-INSULIN ASPART 100 UNIT/ML (70-30) SUBCUTANEOUS PEN RX-124856 CDM 6370000100 HCPCS 250 RC 00169-3696-19 NDC outpatient 3 ML 137 137 MEDICA (COMMERCIAL) 94265 [3081118] MEDICA CLAIMS [308111801] 123.3 percent of total billed charges 84.94 130.15 Technical (Hospital) Services INSULIN ASPAR PROT-INSULIN ASPART 100 UNIT/ML (70-30) SUBCUTANEOUS PEN RX-124856 CDM 6370000100 HCPCS 250 RC 00169-3696-19 NDC outpatient 3 ML 137 137 MULTIPLAN INC 34080 [3081285] MULTIPLAN INC [308128501] 130.15 percent of total billed charges 84.94 130.15 Technical (Hospital) Services INSULIN ASPAR PROT-INSULIN ASPART 100 UNIT/ML (70-30) SUBCUTANEOUS PEN RX-124856 CDM 6370000100 HCPCS 250 RC 00169-3696-19 NDC outpatient 3 ML 137 137 BLUE CROSS BLUE SHIELD WELLMARK SB889 [3081026] BCBS WYOMING [308102603] 130.15 percent of total billed charges 84.94 130.15 Technical (Hospital) Services INSULIN ASPAR PROT-INSULIN ASPART 100 UNIT/ML (70-30) SUBCUTANEOUS PEN RX-124856 CDM 6370000100 HCPCS 250 RC 00169-3696-19 NDC outpatient 3 ML 137 137 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES PPO [308136801] 109.6 percent of total billed charges 84.94 130.15 Technical (Hospital) Services INSULIN ASPAR PROT-INSULIN ASPART 100 UNIT/ML (70-30) SUBCUTANEOUS PEN RX-124856 CDM 6370000100 HCPCS 250 RC 00169-3696-19 NDC outpatient 3 ML 137 137 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES HDHP [308136802] 109.6 percent of total billed charges 84.94 130.15 Technical (Hospital) Services INSULIN ASPAR PROT-INSULIN ASPART 100 UNIT/ML (70-30) SUBCUTANEOUS PEN RX-124856 CDM 6370000100 HCPCS 250 RC 00169-3696-19 NDC outpatient 3 ML 137 137 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES EPO [308136803] 109.6 percent of total billed charges 84.94 130.15 Technical (Hospital) Services INSULIN ASPAR PROT-INSULIN ASPART 100 UNIT/ML (70-30) SUBCUTANEOUS PEN RX-124856 CDM 6370000100 HCPCS 250 RC 00169-3696-19 NDC outpatient 3 ML 137 137 UNITED HEALTHCARE (COMMERCIAL) [3081199] UNITED HEALTHCARE 87726 [308119901] 84.94 percent of total billed charges 84.94 130.15 Technical (Hospital) Services INSULIN ASPAR PROT-INSULIN ASPART 100 UNIT/ML (70-30) SUBCUTANEOUS PEN RX-124856 CDM 6370000100 HCPCS 250 RC 00169-3696-19 NDC outpatient 3 ML 137 137 HEALTHPARTNERS SX009 HEALTHPARTNERS 109.6 percent of total billed charges 84.94 130.15 Technical (Hospital) Services INSULIN ASPAR PROT-INSULIN ASPART 100 UNIT/ML (70-30) SUBCUTANEOUS PEN RX-124856 CDM 6370000100 HCPCS 250 RC 00169-3696-19 NDC outpatient 3 ML 137 137 CIGNA 62308 [3081051] CIGNA 62308 [308105105] 109.6 percent of total billed charges 84.94 130.15 Technical (Hospital) Services INSULIN ASPAR PROT-INSULIN ASPART 100 UNIT/ML (70-30) SUBCUTANEOUS PEN RX-124856 CDM 6370000100 HCPCS 250 RC 00169-3696-19 NDC outpatient 3 ML 137 137 CIGNA 62308 [3081051] CIGNA STATE OF WYOMING [308105107] 109.6 percent of total billed charges 84.94 130.15 Technical (Hospital) Services INSULIN ASPAR PROT-INSULIN ASPART 100 UNIT/ML (70-30) SUBCUTANEOUS PEN RX-124856 CDM 6370000100 HCPCS 250 RC 00169-3696-19 NDC inpatient 3 ML 137 137 MULTIPLAN INC 34080 [3081285] MULTIPLAN INC [308128501] 130.15 percent of total billed charges 84.94 130.15 Technical (Hospital) Services INSULIN ASPAR PROT-INSULIN ASPART 100 UNIT/ML (70-30) SUBCUTANEOUS PEN RX-124856 CDM 6370000100 HCPCS 250 RC 00169-3696-19 NDC inpatient 3 ML 137 137 MEDICA (COMMERCIAL) 94265 [3081118] MEDICA CLAIMS [308111801] 123.3 percent of total billed charges 84.94 130.15 Technical (Hospital) Services INSULIN ASPAR PROT-INSULIN ASPART 100 UNIT/ML (70-30) SUBCUTANEOUS PEN RX-124856 CDM 6370000100 HCPCS 250 RC 00169-3696-19 NDC inpatient 3 ML 137 137 BLUE CROSS BLUE SHIELD WELLMARK SB889 [3081026] BCBS WYOMING [308102603] 130.15 percent of total billed charges 84.94 130.15 Technical (Hospital) Services INSULIN ASPAR PROT-INSULIN ASPART 100 UNIT/ML (70-30) SUBCUTANEOUS PEN RX-124856 CDM 6370000100 HCPCS 250 RC 00169-3696-19 NDC inpatient 3 ML 137 137 UNITED HEALTHCARE (COMMERCIAL) [3081199] UNITED HEALTHCARE 87726 [308119901] 84.94 percent of total billed charges 84.94 130.15 Technical (Hospital) Services INSULIN ASPAR PROT-INSULIN ASPART 100 UNIT/ML (70-30) SUBCUTANEOUS PEN RX-124856 CDM 6370000100 HCPCS 250 RC 00169-3696-19 NDC inpatient 3 ML 137 137 CIGNA 62308 [3081051] CIGNA 62308 [308105105] 108.48 percent of total billed charges 84.94 130.15 Technical (Hospital) Services INSULIN ASPAR PROT-INSULIN ASPART 100 UNIT/ML (70-30) SUBCUTANEOUS PEN RX-124856 CDM 6370000100 HCPCS 250 RC 00169-3696-19 NDC inpatient 3 ML 137 137 CIGNA 62308 [3081051] CIGNA STATE OF WYOMING [308105107] 108.48 percent of total billed charges 84.94 130.15 Technical (Hospital) Services INSULIN ASPAR PROT-INSULIN ASPART 100 UNIT/ML (70-30) SUBCUTANEOUS PEN RX-124856 CDM 6370000100 HCPCS 250 RC 00169-3696-19 NDC inpatient 3 ML 137 137 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES EPO [308136803] 108.48 percent of total billed charges 84.94 130.15 Technical (Hospital) Services INSULIN ASPAR PROT-INSULIN ASPART 100 UNIT/ML (70-30) SUBCUTANEOUS PEN RX-124856 CDM 6370000100 HCPCS 250 RC 00169-3696-19 NDC inpatient 3 ML 137 137 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES HDHP [308136802] 108.48 percent of total billed charges 84.94 130.15 Technical (Hospital) Services INSULIN ASPAR PROT-INSULIN ASPART 100 UNIT/ML (70-30) SUBCUTANEOUS PEN RX-124856 CDM 6370000100 HCPCS 250 RC 00169-3696-19 NDC inpatient 3 ML 137 137 HEALTHPARTNERS SX009 HEALTHPARTNERS 108.48 percent of total billed charges 84.94 130.15 Technical (Hospital) Services INSULIN ASPAR PROT-INSULIN ASPART 100 UNIT/ML (70-30) SUBCUTANEOUS PEN RX-124856 CDM 6370000100 HCPCS 250 RC 00169-3696-19 NDC inpatient 3 ML 137 137 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES PPO [308136801] 108.48 percent of total billed charges 84.94 130.15 Technical (Hospital) Services LIRAGLUTIDE 0.6 MG/0.1 ML (18 MG/3 ML) SUBCUTANEOUS PEN INJECTOR RX-124865 CDM 6370000100 HCPCS 250 RC 00169-4060-13 NDC outpatient 0.1 ML 73.56 73.56 CIGNA 62308 [3081051] CIGNA 62308 [308105105] 58.85 percent of total billed charges 45.61 69.88 Technical (Hospital) Services LIRAGLUTIDE 0.6 MG/0.1 ML (18 MG/3 ML) SUBCUTANEOUS PEN INJECTOR RX-124865 CDM 6370000100 HCPCS 250 RC 00169-4060-13 NDC outpatient 0.1 ML 73.56 73.56 CIGNA 62308 [3081051] CIGNA STATE OF WYOMING [308105107] 58.85 percent of total billed charges 45.61 69.88 Technical (Hospital) Services LIRAGLUTIDE 0.6 MG/0.1 ML (18 MG/3 ML) SUBCUTANEOUS PEN INJECTOR RX-124865 CDM 6370000100 HCPCS 250 RC 00169-4060-13 NDC outpatient 0.1 ML 73.56 73.56 MULTIPLAN INC 34080 [3081285] MULTIPLAN INC [308128501] 69.88 percent of total billed charges 45.61 69.88 Technical (Hospital) Services LIRAGLUTIDE 0.6 MG/0.1 ML (18 MG/3 ML) SUBCUTANEOUS PEN INJECTOR RX-124865 CDM 6370000100 HCPCS 250 RC 00169-4060-13 NDC outpatient 0.1 ML 73.56 73.56 UNITED HEALTHCARE (COMMERCIAL) [3081199] UNITED HEALTHCARE 87726 [308119901] 45.61 percent of total billed charges 45.61 69.88 Technical (Hospital) Services LIRAGLUTIDE 0.6 MG/0.1 ML (18 MG/3 ML) SUBCUTANEOUS PEN INJECTOR RX-124865 CDM 6370000100 HCPCS 250 RC 00169-4060-13 NDC outpatient 0.1 ML 73.56 73.56 MEDICA (COMMERCIAL) 94265 [3081118] MEDICA CLAIMS [308111801] 66.2 percent of total billed charges 45.61 69.88 Technical (Hospital) Services LIRAGLUTIDE 0.6 MG/0.1 ML (18 MG/3 ML) SUBCUTANEOUS PEN INJECTOR RX-124865 CDM 6370000100 HCPCS 250 RC 00169-4060-13 NDC outpatient 0.1 ML 73.56 73.56 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES EPO [308136803] 58.85 percent of total billed charges 45.61 69.88 Technical (Hospital) Services LIRAGLUTIDE 0.6 MG/0.1 ML (18 MG/3 ML) SUBCUTANEOUS PEN INJECTOR RX-124865 CDM 6370000100 HCPCS 250 RC 00169-4060-13 NDC outpatient 0.1 ML 73.56 73.56 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES HDHP [308136802] 58.85 percent of total billed charges 45.61 69.88 Technical (Hospital) Services LIRAGLUTIDE 0.6 MG/0.1 ML (18 MG/3 ML) SUBCUTANEOUS PEN INJECTOR RX-124865 CDM 6370000100 HCPCS 250 RC 00169-4060-13 NDC outpatient 0.1 ML 73.56 73.56 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES PPO [308136801] 58.85 percent of total billed charges 45.61 69.88 Technical (Hospital) Services LIRAGLUTIDE 0.6 MG/0.1 ML (18 MG/3 ML) SUBCUTANEOUS PEN INJECTOR RX-124865 CDM 6370000100 HCPCS 250 RC 00169-4060-13 NDC outpatient 0.1 ML 73.56 73.56 HEALTHPARTNERS SX009 HEALTHPARTNERS 58.85 percent of total billed charges 45.61 69.88 Technical (Hospital) Services LIRAGLUTIDE 0.6 MG/0.1 ML (18 MG/3 ML) SUBCUTANEOUS PEN INJECTOR RX-124865 CDM 6370000100 HCPCS 250 RC 00169-4060-13 NDC outpatient 0.1 ML 73.56 73.56 BLUE CROSS BLUE SHIELD WELLMARK SB889 [3081026] BCBS WYOMING [308102603] 69.88 percent of total billed charges 45.61 69.88 Technical (Hospital) Services LIRAGLUTIDE 0.6 MG/0.1 ML (18 MG/3 ML) SUBCUTANEOUS PEN INJECTOR RX-124865 CDM 6370000100 HCPCS 250 RC 00169-4060-13 NDC inpatient 0.1 ML 73.56 73.56 MULTIPLAN INC 34080 [3081285] MULTIPLAN INC [308128501] 69.88 percent of total billed charges 45.61 69.88 Technical (Hospital) Services LIRAGLUTIDE 0.6 MG/0.1 ML (18 MG/3 ML) SUBCUTANEOUS PEN INJECTOR RX-124865 CDM 6370000100 HCPCS 250 RC 00169-4060-13 NDC inpatient 0.1 ML 73.56 73.56 HEALTHPARTNERS SX009 HEALTHPARTNERS 58.24 percent of total billed charges 45.61 69.88 Technical (Hospital) Services LIRAGLUTIDE 0.6 MG/0.1 ML (18 MG/3 ML) SUBCUTANEOUS PEN INJECTOR RX-124865 CDM 6370000100 HCPCS 250 RC 00169-4060-13 NDC inpatient 0.1 ML 73.56 73.56 MEDICA (COMMERCIAL) 94265 [3081118] MEDICA CLAIMS [308111801] 66.2 percent of total billed charges 45.61 69.88 Technical (Hospital) Services LIRAGLUTIDE 0.6 MG/0.1 ML (18 MG/3 ML) SUBCUTANEOUS PEN INJECTOR RX-124865 CDM 6370000100 HCPCS 250 RC 00169-4060-13 NDC inpatient 0.1 ML 73.56 73.56 CIGNA 62308 [3081051] CIGNA 62308 [308105105] 58.24 percent of total billed charges 45.61 69.88 Technical (Hospital) Services LIRAGLUTIDE 0.6 MG/0.1 ML (18 MG/3 ML) SUBCUTANEOUS PEN INJECTOR RX-124865 CDM 6370000100 HCPCS 250 RC 00169-4060-13 NDC inpatient 0.1 ML 73.56 73.56 CIGNA 62308 [3081051] CIGNA STATE OF WYOMING [308105107] 58.24 percent of total billed charges 45.61 69.88 Technical (Hospital) Services LIRAGLUTIDE 0.6 MG/0.1 ML (18 MG/3 ML) SUBCUTANEOUS PEN INJECTOR RX-124865 CDM 6370000100 HCPCS 250 RC 00169-4060-13 NDC inpatient 0.1 ML 73.56 73.56 BLUE CROSS BLUE SHIELD WELLMARK SB889 [3081026] BCBS WYOMING [308102603] 69.88 percent of total billed charges 45.61 69.88 Technical (Hospital) Services LIRAGLUTIDE 0.6 MG/0.1 ML (18 MG/3 ML) SUBCUTANEOUS PEN INJECTOR RX-124865 CDM 6370000100 HCPCS 250 RC 00169-4060-13 NDC inpatient 0.1 ML 73.56 73.56 UNITED HEALTHCARE (COMMERCIAL) [3081199] UNITED HEALTHCARE 87726 [308119901] 45.61 percent of total billed charges 45.61 69.88 Technical (Hospital) Services LIRAGLUTIDE 0.6 MG/0.1 ML (18 MG/3 ML) SUBCUTANEOUS PEN INJECTOR RX-124865 CDM 6370000100 HCPCS 250 RC 00169-4060-13 NDC inpatient 0.1 ML 73.56 73.56 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES EPO [308136803] 58.24 percent of total billed charges 45.61 69.88 Technical (Hospital) Services LIRAGLUTIDE 0.6 MG/0.1 ML (18 MG/3 ML) SUBCUTANEOUS PEN INJECTOR RX-124865 CDM 6370000100 HCPCS 250 RC 00169-4060-13 NDC inpatient 0.1 ML 73.56 73.56 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES HDHP [308136802] 58.24 percent of total billed charges 45.61 69.88 Technical (Hospital) Services LIRAGLUTIDE 0.6 MG/0.1 ML (18 MG/3 ML) SUBCUTANEOUS PEN INJECTOR RX-124865 CDM 6370000100 HCPCS 250 RC 00169-4060-13 NDC inpatient 0.1 ML 73.56 73.56 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES PPO [308136801] 58.24 percent of total billed charges 45.61 69.88 Technical (Hospital) Services ESTRADIOL 0.5 MG TABLET RX-12491 CDM 6370000100 HCPCS 250 RC 00555-0899-02 NDC inpatient 1 UN 5.89 5.89 HEALTHPARTNERS SX009 HEALTHPARTNERS 4.66 percent of total billed charges 3.65 5.6 Technical (Hospital) Services ESTRADIOL 0.5 MG TABLET RX-12491 CDM 6370000100 HCPCS 250 RC 00555-0899-02 NDC inpatient 1 UN 5.89 5.89 MEDICA (COMMERCIAL) 94265 [3081118] MEDICA CLAIMS [308111801] 5.3 percent of total billed charges 3.65 5.6 Technical (Hospital) Services ESTRADIOL 0.5 MG TABLET RX-12491 CDM 6370000100 HCPCS 250 RC 00555-0899-02 NDC inpatient 1 UN 5.89 5.89 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES PPO [308136801] 4.66 percent of total billed charges 3.65 5.6 Technical (Hospital) Services ESTRADIOL 0.5 MG TABLET RX-12491 CDM 6370000100 HCPCS 250 RC 00555-0899-02 NDC inpatient 1 UN 5.89 5.89 MULTIPLAN INC 34080 [3081285] MULTIPLAN INC [308128501] 5.6 percent of total billed charges 3.65 5.6 Technical (Hospital) Services ESTRADIOL 0.5 MG TABLET RX-12491 CDM 6370000100 HCPCS 250 RC 00555-0899-02 NDC inpatient 1 UN 5.89 5.89 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES EPO [308136803] 4.66 percent of total billed charges 3.65 5.6 Technical (Hospital) Services ESTRADIOL 0.5 MG TABLET RX-12491 CDM 6370000100 HCPCS 250 RC 00555-0899-02 NDC inpatient 1 UN 5.89 5.89 CIGNA 62308 [3081051] CIGNA 62308 [308105105] 4.66 percent of total billed charges 3.65 5.6 Technical (Hospital) Services ESTRADIOL 0.5 MG TABLET RX-12491 CDM 6370000100 HCPCS 250 RC 00555-0899-02 NDC inpatient 1 UN 5.89 5.89 CIGNA 62308 [3081051] CIGNA STATE OF WYOMING [308105107] 4.66 percent of total billed charges 3.65 5.6 Technical (Hospital) Services ESTRADIOL 0.5 MG TABLET RX-12491 CDM 6370000100 HCPCS 250 RC 00555-0899-02 NDC inpatient 1 UN 5.89 5.89 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES HDHP [308136802] 4.66 percent of total billed charges 3.65 5.6 Technical (Hospital) Services ESTRADIOL 0.5 MG TABLET RX-12491 CDM 6370000100 HCPCS 250 RC 00555-0899-02 NDC inpatient 1 UN 5.89 5.89 BLUE CROSS BLUE SHIELD WELLMARK SB889 [3081026] BCBS WYOMING [308102603] 5.6 percent of total billed charges 3.65 5.6 Technical (Hospital) Services ESTRADIOL 0.5 MG TABLET RX-12491 CDM 6370000100 HCPCS 250 RC 00555-0899-02 NDC inpatient 1 UN 5.89 5.89 UNITED HEALTHCARE (COMMERCIAL) [3081199] UNITED HEALTHCARE 87726 [308119901] 3.65 percent of total billed charges 3.65 5.6 Technical (Hospital) Services ESTRADIOL 0.5 MG TABLET RX-12491 CDM 6370000100 HCPCS 250 RC 00555-0899-02 NDC outpatient 1 UN 5.89 5.89 BLUE CROSS BLUE SHIELD WELLMARK SB889 [3081026] BCBS WYOMING [308102603] 5.6 percent of total billed charges 3.65 5.6 Technical (Hospital) Services ESTRADIOL 0.5 MG TABLET RX-12491 CDM 6370000100 HCPCS 250 RC 00555-0899-02 NDC outpatient 1 UN 5.89 5.89 CIGNA 62308 [3081051] CIGNA 62308 [308105105] 4.71 percent of total billed charges 3.65 5.6 Technical (Hospital) Services ESTRADIOL 0.5 MG TABLET RX-12491 CDM 6370000100 HCPCS 250 RC 00555-0899-02 NDC outpatient 1 UN 5.89 5.89 CIGNA 62308 [3081051] CIGNA STATE OF WYOMING [308105107] 4.71 percent of total billed charges 3.65 5.6 Technical (Hospital) Services ESTRADIOL 0.5 MG TABLET RX-12491 CDM 6370000100 HCPCS 250 RC 00555-0899-02 NDC outpatient 1 UN 5.89 5.89 MULTIPLAN INC 34080 [3081285] MULTIPLAN INC [308128501] 5.6 percent of total billed charges 3.65 5.6 Technical (Hospital) Services ESTRADIOL 0.5 MG TABLET RX-12491 CDM 6370000100 HCPCS 250 RC 00555-0899-02 NDC outpatient 1 UN 5.89 5.89 MEDICA (COMMERCIAL) 94265 [3081118] MEDICA CLAIMS [308111801] 5.3 percent of total billed charges 3.65 5.6 Technical (Hospital) Services ESTRADIOL 0.5 MG TABLET RX-12491 CDM 6370000100 HCPCS 250 RC 00555-0899-02 NDC outpatient 1 UN 5.89 5.89 UNITED HEALTHCARE (COMMERCIAL) [3081199] UNITED HEALTHCARE 87726 [308119901] 3.65 percent of total billed charges 3.65 5.6 Technical (Hospital) Services ESTRADIOL 0.5 MG TABLET RX-12491 CDM 6370000100 HCPCS 250 RC 00555-0899-02 NDC outpatient 1 UN 5.89 5.89 HEALTHPARTNERS SX009 HEALTHPARTNERS 4.71 percent of total billed charges 3.65 5.6 Technical (Hospital) Services ESTRADIOL 0.5 MG TABLET RX-12491 CDM 6370000100 HCPCS 250 RC 00555-0899-02 NDC outpatient 1 UN 5.89 5.89 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES PPO [308136801] 4.71 percent of total billed charges 3.65 5.6 Technical (Hospital) Services ESTRADIOL 0.5 MG TABLET RX-12491 CDM 6370000100 HCPCS 250 RC 00555-0899-02 NDC outpatient 1 UN 5.89 5.89 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES HDHP [308136802] 4.71 percent of total billed charges 3.65 5.6 Technical (Hospital) Services ESTRADIOL 0.5 MG TABLET RX-12491 CDM 6370000100 HCPCS 250 RC 00555-0899-02 NDC outpatient 1 UN 5.89 5.89 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES EPO [308136803] 4.71 percent of total billed charges 3.65 5.6 Technical (Hospital) Services DAPAGLIFLOZIN PROPANEDIOL 5 MG TABLET RX-125074 CDM 6370000100 HCPCS 250 RC 66993-0456-30 NDC inpatient 1 UN 51.62 51.62 UNITED HEALTHCARE (COMMERCIAL) [3081199] UNITED HEALTHCARE 87726 [308119901] 32 percent of total billed charges 32 49.04 Technical (Hospital) Services DAPAGLIFLOZIN PROPANEDIOL 5 MG TABLET RX-125074 CDM 6370000100 HCPCS 250 RC 66993-0456-30 NDC inpatient 1 UN 51.62 51.62 BLUE CROSS BLUE SHIELD WELLMARK SB889 [3081026] BCBS WYOMING [308102603] 49.04 percent of total billed charges 32 49.04 Technical (Hospital) Services DAPAGLIFLOZIN PROPANEDIOL 5 MG TABLET RX-125074 CDM 6370000100 HCPCS 250 RC 66993-0456-30 NDC inpatient 1 UN 51.62 51.62 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES HDHP [308136802] 40.87 percent of total billed charges 32 49.04 Technical (Hospital) Services DAPAGLIFLOZIN PROPANEDIOL 5 MG TABLET RX-125074 CDM 6370000100 HCPCS 250 RC 66993-0456-30 NDC inpatient 1 UN 51.62 51.62 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES EPO [308136803] 40.87 percent of total billed charges 32 49.04 Technical (Hospital) Services DAPAGLIFLOZIN PROPANEDIOL 5 MG TABLET RX-125074 CDM 6370000100 HCPCS 250 RC 66993-0456-30 NDC inpatient 1 UN 51.62 51.62 CIGNA 62308 [3081051] CIGNA 62308 [308105105] 40.87 percent of total billed charges 32 49.04 Technical (Hospital) Services DAPAGLIFLOZIN PROPANEDIOL 5 MG TABLET RX-125074 CDM 6370000100 HCPCS 250 RC 66993-0456-30 NDC inpatient 1 UN 51.62 51.62 CIGNA 62308 [3081051] CIGNA STATE OF WYOMING [308105107] 40.87 percent of total billed charges 32 49.04 Technical (Hospital) Services DAPAGLIFLOZIN PROPANEDIOL 5 MG TABLET RX-125074 CDM 6370000100 HCPCS 250 RC 66993-0456-30 NDC inpatient 1 UN 51.62 51.62 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES PPO [308136801] 40.87 percent of total billed charges 32 49.04 Technical (Hospital) Services DAPAGLIFLOZIN PROPANEDIOL 5 MG TABLET RX-125074 CDM 6370000100 HCPCS 250 RC 66993-0456-30 NDC inpatient 1 UN 51.62 51.62 HEALTHPARTNERS SX009 HEALTHPARTNERS 40.87 percent of total billed charges 32 49.04 Technical (Hospital) Services DAPAGLIFLOZIN PROPANEDIOL 5 MG TABLET RX-125074 CDM 6370000100 HCPCS 250 RC 66993-0456-30 NDC inpatient 1 UN 51.62 51.62 MEDICA (COMMERCIAL) 94265 [3081118] MEDICA CLAIMS [308111801] 46.46 percent of total billed charges 32 49.04 Technical (Hospital) Services DAPAGLIFLOZIN PROPANEDIOL 5 MG TABLET RX-125074 CDM 6370000100 HCPCS 250 RC 66993-0456-30 NDC inpatient 1 UN 51.62 51.62 MULTIPLAN INC 34080 [3081285] MULTIPLAN INC [308128501] 49.04 percent of total billed charges 32 49.04 Technical (Hospital) Services DAPAGLIFLOZIN PROPANEDIOL 5 MG TABLET RX-125074 CDM 6370000100 HCPCS 250 RC 66993-0456-30 NDC outpatient 1 UN 51.62 51.62 UNITED HEALTHCARE (COMMERCIAL) [3081199] UNITED HEALTHCARE 87726 [308119901] 32 percent of total billed charges 32 49.04 Technical (Hospital) Services DAPAGLIFLOZIN PROPANEDIOL 5 MG TABLET RX-125074 CDM 6370000100 HCPCS 250 RC 66993-0456-30 NDC outpatient 1 UN 51.62 51.62 CIGNA 62308 [3081051] CIGNA 62308 [308105105] 41.3 percent of total billed charges 32 49.04 Technical (Hospital) Services DAPAGLIFLOZIN PROPANEDIOL 5 MG TABLET RX-125074 CDM 6370000100 HCPCS 250 RC 66993-0456-30 NDC outpatient 1 UN 51.62 51.62 CIGNA 62308 [3081051] CIGNA STATE OF WYOMING [308105107] 41.3 percent of total billed charges 32 49.04 Technical (Hospital) Services DAPAGLIFLOZIN PROPANEDIOL 5 MG TABLET RX-125074 CDM 6370000100 HCPCS 250 RC 66993-0456-30 NDC outpatient 1 UN 51.62 51.62 MULTIPLAN INC 34080 [3081285] MULTIPLAN INC [308128501] 49.04 percent of total billed charges 32 49.04 Technical (Hospital) Services DAPAGLIFLOZIN PROPANEDIOL 5 MG TABLET RX-125074 CDM 6370000100 HCPCS 250 RC 66993-0456-30 NDC outpatient 1 UN 51.62 51.62 MEDICA (COMMERCIAL) 94265 [3081118] MEDICA CLAIMS [308111801] 46.46 percent of total billed charges 32 49.04 Technical (Hospital) Services DAPAGLIFLOZIN PROPANEDIOL 5 MG TABLET RX-125074 CDM 6370000100 HCPCS 250 RC 66993-0456-30 NDC outpatient 1 UN 51.62 51.62 BLUE CROSS BLUE SHIELD WELLMARK SB889 [3081026] BCBS WYOMING [308102603] 49.04 percent of total billed charges 32 49.04 Technical (Hospital) Services DAPAGLIFLOZIN PROPANEDIOL 5 MG TABLET RX-125074 CDM 6370000100 HCPCS 250 RC 66993-0456-30 NDC outpatient 1 UN 51.62 51.62 HEALTHPARTNERS SX009 HEALTHPARTNERS 41.3 percent of total billed charges 32 49.04 Technical (Hospital) Services DAPAGLIFLOZIN PROPANEDIOL 5 MG TABLET RX-125074 CDM 6370000100 HCPCS 250 RC 66993-0456-30 NDC outpatient 1 UN 51.62 51.62 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES HDHP [308136802] 41.3 percent of total billed charges 32 49.04 Technical (Hospital) Services DAPAGLIFLOZIN PROPANEDIOL 5 MG TABLET RX-125074 CDM 6370000100 HCPCS 250 RC 66993-0456-30 NDC outpatient 1 UN 51.62 51.62 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES PPO [308136801] 41.3 percent of total billed charges 32 49.04 Technical (Hospital) Services DAPAGLIFLOZIN PROPANEDIOL 5 MG TABLET RX-125074 CDM 6370000100 HCPCS 250 RC 66993-0456-30 NDC outpatient 1 UN 51.62 51.62 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES EPO [308136803] 41.3 percent of total billed charges 32 49.04 Technical (Hospital) Services SODIUM CHLORIDE-ALOE VERA NASAL GEL RX-125275 CDM 6370000100 HCPCS 250 RC 00225-0525-47 NDC inpatient 1 GR 5.82 5.82 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES EPO [308136803] 4.61 percent of total billed charges 3.61 5.53 Technical (Hospital) Services SODIUM CHLORIDE-ALOE VERA NASAL GEL RX-125275 CDM 6370000100 HCPCS 250 RC 00225-0525-47 NDC inpatient 1 GR 5.82 5.82 CIGNA 62308 [3081051] CIGNA 62308 [308105105] 4.61 percent of total billed charges 3.61 5.53 Technical (Hospital) Services SODIUM CHLORIDE-ALOE VERA NASAL GEL RX-125275 CDM 6370000100 HCPCS 250 RC 00225-0525-47 NDC inpatient 1 GR 5.82 5.82 CIGNA 62308 [3081051] CIGNA STATE OF WYOMING [308105107] 4.61 percent of total billed charges 3.61 5.53 Technical (Hospital) Services SODIUM CHLORIDE-ALOE VERA NASAL GEL RX-125275 CDM 6370000100 HCPCS 250 RC 00225-0525-47 NDC inpatient 1 GR 5.82 5.82 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES HDHP [308136802] 4.61 percent of total billed charges 3.61 5.53 Technical (Hospital) Services SODIUM CHLORIDE-ALOE VERA NASAL GEL RX-125275 CDM 6370000100 HCPCS 250 RC 00225-0525-47 NDC inpatient 1 GR 5.82 5.82 MEDICA (COMMERCIAL) 94265 [3081118] MEDICA CLAIMS [308111801] 5.24 percent of total billed charges 3.61 5.53 Technical (Hospital) Services SODIUM CHLORIDE-ALOE VERA NASAL GEL RX-125275 CDM 6370000100 HCPCS 250 RC 00225-0525-47 NDC inpatient 1 GR 5.82 5.82 HEALTHPARTNERS SX009 HEALTHPARTNERS 4.61 percent of total billed charges 3.61 5.53 Technical (Hospital) Services SODIUM CHLORIDE-ALOE VERA NASAL GEL RX-125275 CDM 6370000100 HCPCS 250 RC 00225-0525-47 NDC inpatient 1 GR 5.82 5.82 UNITED HEALTHCARE (COMMERCIAL) [3081199] UNITED HEALTHCARE 87726 [308119901] 3.61 percent of total billed charges 3.61 5.53 Technical (Hospital) Services SODIUM CHLORIDE-ALOE VERA NASAL GEL RX-125275 CDM 6370000100 HCPCS 250 RC 00225-0525-47 NDC inpatient 1 GR 5.82 5.82 BLUE CROSS BLUE SHIELD WELLMARK SB889 [3081026] BCBS WYOMING [308102603] 5.53 percent of total billed charges 3.61 5.53 Technical (Hospital) Services SODIUM CHLORIDE-ALOE VERA NASAL GEL RX-125275 CDM 6370000100 HCPCS 250 RC 00225-0525-47 NDC inpatient 1 GR 5.82 5.82 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES PPO [308136801] 4.61 percent of total billed charges 3.61 5.53 Technical (Hospital) Services SODIUM CHLORIDE-ALOE VERA NASAL GEL RX-125275 CDM 6370000100 HCPCS 250 RC 00225-0525-47 NDC inpatient 1 GR 5.82 5.82 MULTIPLAN INC 34080 [3081285] MULTIPLAN INC [308128501] 5.53 percent of total billed charges 3.61 5.53 Technical (Hospital) Services SODIUM CHLORIDE-ALOE VERA NASAL GEL RX-125275 CDM 6370000100 HCPCS 250 RC 00225-0525-47 NDC outpatient 1 GR 5.82 5.82 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES PPO [308136801] 4.66 percent of total billed charges 3.61 5.53 Technical (Hospital) Services SODIUM CHLORIDE-ALOE VERA NASAL GEL RX-125275 CDM 6370000100 HCPCS 250 RC 00225-0525-47 NDC outpatient 1 GR 5.82 5.82 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES HDHP [308136802] 4.66 percent of total billed charges 3.61 5.53 Technical (Hospital) Services SODIUM CHLORIDE-ALOE VERA NASAL GEL RX-125275 CDM 6370000100 HCPCS 250 RC 00225-0525-47 NDC outpatient 1 GR 5.82 5.82 BLUE CROSS BLUE SHIELD WELLMARK SB889 [3081026] BCBS WYOMING [308102603] 5.53 percent of total billed charges 3.61 5.53 Technical (Hospital) Services SODIUM CHLORIDE-ALOE VERA NASAL GEL RX-125275 CDM 6370000100 HCPCS 250 RC 00225-0525-47 NDC outpatient 1 GR 5.82 5.82 HEALTHPARTNERS SX009 HEALTHPARTNERS 4.66 percent of total billed charges 3.61 5.53 Technical (Hospital) Services SODIUM CHLORIDE-ALOE VERA NASAL GEL RX-125275 CDM 6370000100 HCPCS 250 RC 00225-0525-47 NDC outpatient 1 GR 5.82 5.82 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES EPO [308136803] 4.66 percent of total billed charges 3.61 5.53 Technical (Hospital) Services SODIUM CHLORIDE-ALOE VERA NASAL GEL RX-125275 CDM 6370000100 HCPCS 250 RC 00225-0525-47 NDC outpatient 1 GR 5.82 5.82 MEDICA (COMMERCIAL) 94265 [3081118] MEDICA CLAIMS [308111801] 5.24 percent of total billed charges 3.61 5.53 Technical (Hospital) Services SODIUM CHLORIDE-ALOE VERA NASAL GEL RX-125275 CDM 6370000100 HCPCS 250 RC 00225-0525-47 NDC outpatient 1 GR 5.82 5.82 UNITED HEALTHCARE (COMMERCIAL) [3081199] UNITED HEALTHCARE 87726 [308119901] 3.61 percent of total billed charges 3.61 5.53 Technical (Hospital) Services SODIUM CHLORIDE-ALOE VERA NASAL GEL RX-125275 CDM 6370000100 HCPCS 250 RC 00225-0525-47 NDC outpatient 1 GR 5.82 5.82 CIGNA 62308 [3081051] CIGNA 62308 [308105105] 4.66 percent of total billed charges 3.61 5.53 Technical (Hospital) Services SODIUM CHLORIDE-ALOE VERA NASAL GEL RX-125275 CDM 6370000100 HCPCS 250 RC 00225-0525-47 NDC outpatient 1 GR 5.82 5.82 CIGNA 62308 [3081051] CIGNA STATE OF WYOMING [308105107] 4.66 percent of total billed charges 3.61 5.53 Technical (Hospital) Services SODIUM CHLORIDE-ALOE VERA NASAL GEL RX-125275 CDM 6370000100 HCPCS 250 RC 00225-0525-47 NDC outpatient 1 GR 5.82 5.82 MULTIPLAN INC 34080 [3081285] MULTIPLAN INC [308128501] 5.53 percent of total billed charges 3.61 5.53 Technical (Hospital) Services "ASPIRIN-SOD BICARB-CITRIC ACID 325 MG-1,916 MG-1,000 MG EFFERVES TAB" RX-125715 CDM 6370000100 HCPCS 250 RC 16500-0040-12 NDC inpatient 1 UN 5.73 5.73 UNITED HEALTHCARE (COMMERCIAL) [3081199] UNITED HEALTHCARE 87726 [308119901] 3.55 percent of total billed charges 3.55 5.44 Technical (Hospital) Services "ASPIRIN-SOD BICARB-CITRIC ACID 325 MG-1,916 MG-1,000 MG EFFERVES TAB" RX-125715 CDM 6370000100 HCPCS 250 RC 16500-0040-12 NDC inpatient 1 UN 5.73 5.73 BLUE CROSS BLUE SHIELD WELLMARK SB889 [3081026] BCBS WYOMING [308102603] 5.44 percent of total billed charges 3.55 5.44 Technical (Hospital) Services "ASPIRIN-SOD BICARB-CITRIC ACID 325 MG-1,916 MG-1,000 MG EFFERVES TAB" RX-125715 CDM 6370000100 HCPCS 250 RC 16500-0040-12 NDC inpatient 1 UN 5.73 5.73 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES HDHP [308136802] 4.54 percent of total billed charges 3.55 5.44 Technical (Hospital) Services "ASPIRIN-SOD BICARB-CITRIC ACID 325 MG-1,916 MG-1,000 MG EFFERVES TAB" RX-125715 CDM 6370000100 HCPCS 250 RC 16500-0040-12 NDC inpatient 1 UN 5.73 5.73 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES EPO [308136803] 4.54 percent of total billed charges 3.55 5.44 Technical (Hospital) Services "ASPIRIN-SOD BICARB-CITRIC ACID 325 MG-1,916 MG-1,000 MG EFFERVES TAB" RX-125715 CDM 6370000100 HCPCS 250 RC 16500-0040-12 NDC inpatient 1 UN 5.73 5.73 CIGNA 62308 [3081051] CIGNA 62308 [308105105] 4.54 percent of total billed charges 3.55 5.44 Technical (Hospital) Services "ASPIRIN-SOD BICARB-CITRIC ACID 325 MG-1,916 MG-1,000 MG EFFERVES TAB" RX-125715 CDM 6370000100 HCPCS 250 RC 16500-0040-12 NDC inpatient 1 UN 5.73 5.73 CIGNA 62308 [3081051] CIGNA STATE OF WYOMING [308105107] 4.54 percent of total billed charges 3.55 5.44 Technical (Hospital) Services "ASPIRIN-SOD BICARB-CITRIC ACID 325 MG-1,916 MG-1,000 MG EFFERVES TAB" RX-125715 CDM 6370000100 HCPCS 250 RC 16500-0040-12 NDC inpatient 1 UN 5.73 5.73 MULTIPLAN INC 34080 [3081285] MULTIPLAN INC [308128501] 5.44 percent of total billed charges 3.55 5.44 Technical (Hospital) Services "ASPIRIN-SOD BICARB-CITRIC ACID 325 MG-1,916 MG-1,000 MG EFFERVES TAB" RX-125715 CDM 6370000100 HCPCS 250 RC 16500-0040-12 NDC inpatient 1 UN 5.73 5.73 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES PPO [308136801] 4.54 percent of total billed charges 3.55 5.44 Technical (Hospital) Services "ASPIRIN-SOD BICARB-CITRIC ACID 325 MG-1,916 MG-1,000 MG EFFERVES TAB" RX-125715 CDM 6370000100 HCPCS 250 RC 16500-0040-12 NDC inpatient 1 UN 5.73 5.73 HEALTHPARTNERS SX009 HEALTHPARTNERS 4.54 percent of total billed charges 3.55 5.44 Technical (Hospital) Services "ASPIRIN-SOD BICARB-CITRIC ACID 325 MG-1,916 MG-1,000 MG EFFERVES TAB" RX-125715 CDM 6370000100 HCPCS 250 RC 16500-0040-12 NDC inpatient 1 UN 5.73 5.73 MEDICA (COMMERCIAL) 94265 [3081118] MEDICA CLAIMS [308111801] 5.16 percent of total billed charges 3.55 5.44 Technical (Hospital) Services "ASPIRIN-SOD BICARB-CITRIC ACID 325 MG-1,916 MG-1,000 MG EFFERVES TAB" RX-125715 CDM 6370000100 HCPCS 250 RC 16500-0040-12 NDC outpatient 1 UN 5.73 5.73 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES EPO [308136803] 4.58 percent of total billed charges 3.55 5.44 Technical (Hospital) Services "ASPIRIN-SOD BICARB-CITRIC ACID 325 MG-1,916 MG-1,000 MG EFFERVES TAB" RX-125715 CDM 6370000100 HCPCS 250 RC 16500-0040-12 NDC outpatient 1 UN 5.73 5.73 MEDICA (COMMERCIAL) 94265 [3081118] MEDICA CLAIMS [308111801] 5.16 percent of total billed charges 3.55 5.44 Technical (Hospital) Services "ASPIRIN-SOD BICARB-CITRIC ACID 325 MG-1,916 MG-1,000 MG EFFERVES TAB" RX-125715 CDM 6370000100 HCPCS 250 RC 16500-0040-12 NDC outpatient 1 UN 5.73 5.73 CIGNA 62308 [3081051] CIGNA 62308 [308105105] 4.58 percent of total billed charges 3.55 5.44 Technical (Hospital) Services "ASPIRIN-SOD BICARB-CITRIC ACID 325 MG-1,916 MG-1,000 MG EFFERVES TAB" RX-125715 CDM 6370000100 HCPCS 250 RC 16500-0040-12 NDC outpatient 1 UN 5.73 5.73 CIGNA 62308 [3081051] CIGNA STATE OF WYOMING [308105107] 4.58 percent of total billed charges 3.55 5.44 Technical (Hospital) Services "ASPIRIN-SOD BICARB-CITRIC ACID 325 MG-1,916 MG-1,000 MG EFFERVES TAB" RX-125715 CDM 6370000100 HCPCS 250 RC 16500-0040-12 NDC outpatient 1 UN 5.73 5.73 UNITED HEALTHCARE (COMMERCIAL) [3081199] UNITED HEALTHCARE 87726 [308119901] 3.55 percent of total billed charges 3.55 5.44 Technical (Hospital) Services "ASPIRIN-SOD BICARB-CITRIC ACID 325 MG-1,916 MG-1,000 MG EFFERVES TAB" RX-125715 CDM 6370000100 HCPCS 250 RC 16500-0040-12 NDC outpatient 1 UN 5.73 5.73 MULTIPLAN INC 34080 [3081285] MULTIPLAN INC [308128501] 5.44 percent of total billed charges 3.55 5.44 Technical (Hospital) Services "ASPIRIN-SOD BICARB-CITRIC ACID 325 MG-1,916 MG-1,000 MG EFFERVES TAB" RX-125715 CDM 6370000100 HCPCS 250 RC 16500-0040-12 NDC outpatient 1 UN 5.73 5.73 HEALTHPARTNERS SX009 HEALTHPARTNERS 4.58 percent of total billed charges 3.55 5.44 Technical (Hospital) Services "ASPIRIN-SOD BICARB-CITRIC ACID 325 MG-1,916 MG-1,000 MG EFFERVES TAB" RX-125715 CDM 6370000100 HCPCS 250 RC 16500-0040-12 NDC outpatient 1 UN 5.73 5.73 BLUE CROSS BLUE SHIELD WELLMARK SB889 [3081026] BCBS WYOMING [308102603] 5.44 percent of total billed charges 3.55 5.44 Technical (Hospital) Services "ASPIRIN-SOD BICARB-CITRIC ACID 325 MG-1,916 MG-1,000 MG EFFERVES TAB" RX-125715 CDM 6370000100 HCPCS 250 RC 16500-0040-12 NDC outpatient 1 UN 5.73 5.73 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES HDHP [308136802] 4.58 percent of total billed charges 3.55 5.44 Technical (Hospital) Services "ASPIRIN-SOD BICARB-CITRIC ACID 325 MG-1,916 MG-1,000 MG EFFERVES TAB" RX-125715 CDM 6370000100 HCPCS 250 RC 16500-0040-12 NDC outpatient 1 UN 5.73 5.73 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES PPO [308136801] 4.58 percent of total billed charges 3.55 5.44 Technical (Hospital) Services "SODIUM CHLORIDE 1,000 MG SOLUBLE TABLET" RX-125976 CDM 6370000100 HCPCS 250 RC 69367-0220-01 NDC outpatient 1 UN 5.7 5.7 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES PPO [308136801] 4.56 percent of total billed charges 3.53 5.42 Technical (Hospital) Services "SODIUM CHLORIDE 1,000 MG SOLUBLE TABLET" RX-125976 CDM 6370000100 HCPCS 250 RC 69367-0220-01 NDC outpatient 1 UN 5.7 5.7 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES HDHP [308136802] 4.56 percent of total billed charges 3.53 5.42 Technical (Hospital) Services "SODIUM CHLORIDE 1,000 MG SOLUBLE TABLET" RX-125976 CDM 6370000100 HCPCS 250 RC 69367-0220-01 NDC outpatient 1 UN 5.7 5.7 HEALTHPARTNERS SX009 HEALTHPARTNERS 4.56 percent of total billed charges 3.53 5.42 Technical (Hospital) Services "SODIUM CHLORIDE 1,000 MG SOLUBLE TABLET" RX-125976 CDM 6370000100 HCPCS 250 RC 69367-0220-01 NDC outpatient 1 UN 5.7 5.7 BLUE CROSS BLUE SHIELD WELLMARK SB889 [3081026] BCBS WYOMING [308102603] 5.42 percent of total billed charges 3.53 5.42 Technical (Hospital) Services "SODIUM CHLORIDE 1,000 MG SOLUBLE TABLET" RX-125976 CDM 6370000100 HCPCS 250 RC 69367-0220-01 NDC outpatient 1 UN 5.7 5.7 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES EPO [308136803] 4.56 percent of total billed charges 3.53 5.42 Technical (Hospital) Services "SODIUM CHLORIDE 1,000 MG SOLUBLE TABLET" RX-125976 CDM 6370000100 HCPCS 250 RC 69367-0220-01 NDC outpatient 1 UN 5.7 5.7 MEDICA (COMMERCIAL) 94265 [3081118] MEDICA CLAIMS [308111801] 5.13 percent of total billed charges 3.53 5.42 Technical (Hospital) Services "SODIUM CHLORIDE 1,000 MG SOLUBLE TABLET" RX-125976 CDM 6370000100 HCPCS 250 RC 69367-0220-01 NDC outpatient 1 UN 5.7 5.7 UNITED HEALTHCARE (COMMERCIAL) [3081199] UNITED HEALTHCARE 87726 [308119901] 3.53 percent of total billed charges 3.53 5.42 Technical (Hospital) Services "SODIUM CHLORIDE 1,000 MG SOLUBLE TABLET" RX-125976 CDM 6370000100 HCPCS 250 RC 69367-0220-01 NDC outpatient 1 UN 5.7 5.7 MULTIPLAN INC 34080 [3081285] MULTIPLAN INC [308128501] 5.42 percent of total billed charges 3.53 5.42 Technical (Hospital) Services "SODIUM CHLORIDE 1,000 MG SOLUBLE TABLET" RX-125976 CDM 6370000100 HCPCS 250 RC 69367-0220-01 NDC outpatient 1 UN 5.7 5.7 CIGNA 62308 [3081051] CIGNA 62308 [308105105] 4.56 percent of total billed charges 3.53 5.42 Technical (Hospital) Services "SODIUM CHLORIDE 1,000 MG SOLUBLE TABLET" RX-125976 CDM 6370000100 HCPCS 250 RC 69367-0220-01 NDC outpatient 1 UN 5.7 5.7 CIGNA 62308 [3081051] CIGNA STATE OF WYOMING [308105107] 4.56 percent of total billed charges 3.53 5.42 Technical (Hospital) Services "SODIUM CHLORIDE 1,000 MG SOLUBLE TABLET" RX-125976 CDM 6370000100 HCPCS 250 RC 69367-0220-01 NDC inpatient 1 UN 5.7 5.7 BLUE CROSS BLUE SHIELD WELLMARK SB889 [3081026] BCBS WYOMING [308102603] 5.42 percent of total billed charges 3.53 5.42 Technical (Hospital) Services "SODIUM CHLORIDE 1,000 MG SOLUBLE TABLET" RX-125976 CDM 6370000100 HCPCS 250 RC 69367-0220-01 NDC inpatient 1 UN 5.7 5.7 UNITED HEALTHCARE (COMMERCIAL) [3081199] UNITED HEALTHCARE 87726 [308119901] 3.53 percent of total billed charges 3.53 5.42 Technical (Hospital) Services "SODIUM CHLORIDE 1,000 MG SOLUBLE TABLET" RX-125976 CDM 6370000100 HCPCS 250 RC 69367-0220-01 NDC inpatient 1 UN 5.7 5.7 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES HDHP [308136802] 4.51 percent of total billed charges 3.53 5.42 Technical (Hospital) Services "SODIUM CHLORIDE 1,000 MG SOLUBLE TABLET" RX-125976 CDM 6370000100 HCPCS 250 RC 69367-0220-01 NDC inpatient 1 UN 5.7 5.7 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES EPO [308136803] 4.51 percent of total billed charges 3.53 5.42 Technical (Hospital) Services "SODIUM CHLORIDE 1,000 MG SOLUBLE TABLET" RX-125976 CDM 6370000100 HCPCS 250 RC 69367-0220-01 NDC inpatient 1 UN 5.7 5.7 CIGNA 62308 [3081051] CIGNA 62308 [308105105] 4.51 percent of total billed charges 3.53 5.42 Technical (Hospital) Services "SODIUM CHLORIDE 1,000 MG SOLUBLE TABLET" RX-125976 CDM 6370000100 HCPCS 250 RC 69367-0220-01 NDC inpatient 1 UN 5.7 5.7 CIGNA 62308 [3081051] CIGNA STATE OF WYOMING [308105107] 4.51 percent of total billed charges 3.53 5.42 Technical (Hospital) Services "SODIUM CHLORIDE 1,000 MG SOLUBLE TABLET" RX-125976 CDM 6370000100 HCPCS 250 RC 69367-0220-01 NDC inpatient 1 UN 5.7 5.7 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES PPO [308136801] 4.51 percent of total billed charges 3.53 5.42 Technical (Hospital) Services "SODIUM CHLORIDE 1,000 MG SOLUBLE TABLET" RX-125976 CDM 6370000100 HCPCS 250 RC 69367-0220-01 NDC inpatient 1 UN 5.7 5.7 HEALTHPARTNERS SX009 HEALTHPARTNERS 4.51 percent of total billed charges 3.53 5.42 Technical (Hospital) Services "SODIUM CHLORIDE 1,000 MG SOLUBLE TABLET" RX-125976 CDM 6370000100 HCPCS 250 RC 69367-0220-01 NDC inpatient 1 UN 5.7 5.7 MEDICA (COMMERCIAL) 94265 [3081118] MEDICA CLAIMS [308111801] 5.13 percent of total billed charges 3.53 5.42 Technical (Hospital) Services "SODIUM CHLORIDE 1,000 MG SOLUBLE TABLET" RX-125976 CDM 6370000100 HCPCS 250 RC 69367-0220-01 NDC inpatient 1 UN 5.7 5.7 MULTIPLAN INC 34080 [3081285] MULTIPLAN INC [308128501] 5.42 percent of total billed charges 3.53 5.42 Technical (Hospital) Services DROXIDOPA 100 MG CAPSULE RX-126113 CDM 6370000100 HCPCS 250 RC 67877-0704-90 NDC inpatient 1 UN 7.18 7.18 MEDICA (COMMERCIAL) 94265 [3081118] MEDICA CLAIMS [308111801] 6.46 percent of total billed charges 4.45 6.82 Technical (Hospital) Services DROXIDOPA 100 MG CAPSULE RX-126113 CDM 6370000100 HCPCS 250 RC 67877-0704-90 NDC inpatient 1 UN 7.18 7.18 HEALTHPARTNERS SX009 HEALTHPARTNERS 5.69 percent of total billed charges 4.45 6.82 Technical (Hospital) Services DROXIDOPA 100 MG CAPSULE RX-126113 CDM 6370000100 HCPCS 250 RC 67877-0704-90 NDC inpatient 1 UN 7.18 7.18 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES HDHP [308136802] 5.69 percent of total billed charges 4.45 6.82 Technical (Hospital) Services DROXIDOPA 100 MG CAPSULE RX-126113 CDM 6370000100 HCPCS 250 RC 67877-0704-90 NDC inpatient 1 UN 7.18 7.18 CIGNA 62308 [3081051] CIGNA 62308 [308105105] 5.69 percent of total billed charges 4.45 6.82 Technical (Hospital) Services DROXIDOPA 100 MG CAPSULE RX-126113 CDM 6370000100 HCPCS 250 RC 67877-0704-90 NDC inpatient 1 UN 7.18 7.18 CIGNA 62308 [3081051] CIGNA STATE OF WYOMING [308105107] 5.69 percent of total billed charges 4.45 6.82 Technical (Hospital) Services DROXIDOPA 100 MG CAPSULE RX-126113 CDM 6370000100 HCPCS 250 RC 67877-0704-90 NDC inpatient 1 UN 7.18 7.18 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES EPO [308136803] 5.69 percent of total billed charges 4.45 6.82 Technical (Hospital) Services DROXIDOPA 100 MG CAPSULE RX-126113 CDM 6370000100 HCPCS 250 RC 67877-0704-90 NDC inpatient 1 UN 7.18 7.18 BLUE CROSS BLUE SHIELD WELLMARK SB889 [3081026] BCBS WYOMING [308102603] 6.82 percent of total billed charges 4.45 6.82 Technical (Hospital) Services DROXIDOPA 100 MG CAPSULE RX-126113 CDM 6370000100 HCPCS 250 RC 67877-0704-90 NDC inpatient 1 UN 7.18 7.18 UNITED HEALTHCARE (COMMERCIAL) [3081199] UNITED HEALTHCARE 87726 [308119901] 4.45 percent of total billed charges 4.45 6.82 Technical (Hospital) Services DROXIDOPA 100 MG CAPSULE RX-126113 CDM 6370000100 HCPCS 250 RC 67877-0704-90 NDC inpatient 1 UN 7.18 7.18 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES PPO [308136801] 5.69 percent of total billed charges 4.45 6.82 Technical (Hospital) Services DROXIDOPA 100 MG CAPSULE RX-126113 CDM 6370000100 HCPCS 250 RC 67877-0704-90 NDC inpatient 1 UN 7.18 7.18 MULTIPLAN INC 34080 [3081285] MULTIPLAN INC [308128501] 6.82 percent of total billed charges 4.45 6.82 Technical (Hospital) Services DROXIDOPA 100 MG CAPSULE RX-126113 CDM 6370000100 HCPCS 250 RC 67877-0704-90 NDC outpatient 1 UN 7.18 7.18 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES PPO [308136801] 5.74 percent of total billed charges 4.45 6.82 Technical (Hospital) Services DROXIDOPA 100 MG CAPSULE RX-126113 CDM 6370000100 HCPCS 250 RC 67877-0704-90 NDC outpatient 1 UN 7.18 7.18 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES HDHP [308136802] 5.74 percent of total billed charges 4.45 6.82 Technical (Hospital) Services DROXIDOPA 100 MG CAPSULE RX-126113 CDM 6370000100 HCPCS 250 RC 67877-0704-90 NDC outpatient 1 UN 7.18 7.18 HEALTHPARTNERS SX009 HEALTHPARTNERS 5.74 percent of total billed charges 4.45 6.82 Technical (Hospital) Services DROXIDOPA 100 MG CAPSULE RX-126113 CDM 6370000100 HCPCS 250 RC 67877-0704-90 NDC outpatient 1 UN 7.18 7.18 BLUE CROSS BLUE SHIELD WELLMARK SB889 [3081026] BCBS WYOMING [308102603] 6.82 percent of total billed charges 4.45 6.82 Technical (Hospital) Services DROXIDOPA 100 MG CAPSULE RX-126113 CDM 6370000100 HCPCS 250 RC 67877-0704-90 NDC outpatient 1 UN 7.18 7.18 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES EPO [308136803] 5.74 percent of total billed charges 4.45 6.82 Technical (Hospital) Services DROXIDOPA 100 MG CAPSULE RX-126113 CDM 6370000100 HCPCS 250 RC 67877-0704-90 NDC outpatient 1 UN 7.18 7.18 MEDICA (COMMERCIAL) 94265 [3081118] MEDICA CLAIMS [308111801] 6.46 percent of total billed charges 4.45 6.82 Technical (Hospital) Services DROXIDOPA 100 MG CAPSULE RX-126113 CDM 6370000100 HCPCS 250 RC 67877-0704-90 NDC outpatient 1 UN 7.18 7.18 CIGNA 62308 [3081051] CIGNA 62308 [308105105] 5.74 percent of total billed charges 4.45 6.82 Technical (Hospital) Services DROXIDOPA 100 MG CAPSULE RX-126113 CDM 6370000100 HCPCS 250 RC 67877-0704-90 NDC outpatient 1 UN 7.18 7.18 CIGNA 62308 [3081051] CIGNA STATE OF WYOMING [308105107] 5.74 percent of total billed charges 4.45 6.82 Technical (Hospital) Services DROXIDOPA 100 MG CAPSULE RX-126113 CDM 6370000100 HCPCS 250 RC 67877-0704-90 NDC outpatient 1 UN 7.18 7.18 UNITED HEALTHCARE (COMMERCIAL) [3081199] UNITED HEALTHCARE 87726 [308119901] 4.45 percent of total billed charges 4.45 6.82 Technical (Hospital) Services DROXIDOPA 100 MG CAPSULE RX-126113 CDM 6370000100 HCPCS 250 RC 67877-0704-90 NDC outpatient 1 UN 7.18 7.18 MULTIPLAN INC 34080 [3081285] MULTIPLAN INC [308128501] 6.82 percent of total billed charges 4.45 6.82 Technical (Hospital) Services "CARBIDOPA ER 25 MG-LEVODOPA 100 MG TABLET,EXTENDED RELEASE" RX-126194 CDM 6370000100 HCPCS 250 RC 00378-0088-01 NDC inpatient 1 UN 6.31 6.31 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES PPO [308136801] 5 percent of total billed charges 3.91 5.99 Technical (Hospital) Services "CARBIDOPA ER 25 MG-LEVODOPA 100 MG TABLET,EXTENDED RELEASE" RX-126194 CDM 6370000100 HCPCS 250 RC 00378-0088-01 NDC inpatient 1 UN 6.31 6.31 HEALTHPARTNERS SX009 HEALTHPARTNERS 5 percent of total billed charges 3.91 5.99 Technical (Hospital) Services "CARBIDOPA ER 25 MG-LEVODOPA 100 MG TABLET,EXTENDED RELEASE" RX-126194 CDM 6370000100 HCPCS 250 RC 00378-0088-01 NDC inpatient 1 UN 6.31 6.31 MEDICA (COMMERCIAL) 94265 [3081118] MEDICA CLAIMS [308111801] 5.68 percent of total billed charges 3.91 5.99 Technical (Hospital) Services "CARBIDOPA ER 25 MG-LEVODOPA 100 MG TABLET,EXTENDED RELEASE" RX-126194 CDM 6370000100 HCPCS 250 RC 00378-0088-01 NDC inpatient 1 UN 6.31 6.31 MULTIPLAN INC 34080 [3081285] MULTIPLAN INC [308128501] 5.99 percent of total billed charges 3.91 5.99 Technical (Hospital) Services "CARBIDOPA ER 25 MG-LEVODOPA 100 MG TABLET,EXTENDED RELEASE" RX-126194 CDM 6370000100 HCPCS 250 RC 00378-0088-01 NDC inpatient 1 UN 6.31 6.31 BLUE CROSS BLUE SHIELD WELLMARK SB889 [3081026] BCBS WYOMING [308102603] 5.99 percent of total billed charges 3.91 5.99 Technical (Hospital) Services "CARBIDOPA ER 25 MG-LEVODOPA 100 MG TABLET,EXTENDED RELEASE" RX-126194 CDM 6370000100 HCPCS 250 RC 00378-0088-01 NDC inpatient 1 UN 6.31 6.31 UNITED HEALTHCARE (COMMERCIAL) [3081199] UNITED HEALTHCARE 87726 [308119901] 3.91 percent of total billed charges 3.91 5.99 Technical (Hospital) Services "CARBIDOPA ER 25 MG-LEVODOPA 100 MG TABLET,EXTENDED RELEASE" RX-126194 CDM 6370000100 HCPCS 250 RC 00378-0088-01 NDC inpatient 1 UN 6.31 6.31 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES HDHP [308136802] 5 percent of total billed charges 3.91 5.99 Technical (Hospital) Services "CARBIDOPA ER 25 MG-LEVODOPA 100 MG TABLET,EXTENDED RELEASE" RX-126194 CDM 6370000100 HCPCS 250 RC 00378-0088-01 NDC inpatient 1 UN 6.31 6.31 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES EPO [308136803] 5 percent of total billed charges 3.91 5.99 Technical (Hospital) Services "CARBIDOPA ER 25 MG-LEVODOPA 100 MG TABLET,EXTENDED RELEASE" RX-126194 CDM 6370000100 HCPCS 250 RC 00378-0088-01 NDC inpatient 1 UN 6.31 6.31 CIGNA 62308 [3081051] CIGNA 62308 [308105105] 5 percent of total billed charges 3.91 5.99 Technical (Hospital) Services "CARBIDOPA ER 25 MG-LEVODOPA 100 MG TABLET,EXTENDED RELEASE" RX-126194 CDM 6370000100 HCPCS 250 RC 00378-0088-01 NDC inpatient 1 UN 6.31 6.31 CIGNA 62308 [3081051] CIGNA STATE OF WYOMING [308105107] 5 percent of total billed charges 3.91 5.99 Technical (Hospital) Services "CARBIDOPA ER 25 MG-LEVODOPA 100 MG TABLET,EXTENDED RELEASE" RX-126194 CDM 6370000100 HCPCS 250 RC 00378-0088-01 NDC outpatient 1 UN 6.31 6.31 HEALTHPARTNERS SX009 HEALTHPARTNERS 5.05 percent of total billed charges 3.91 5.99 Technical (Hospital) Services "CARBIDOPA ER 25 MG-LEVODOPA 100 MG TABLET,EXTENDED RELEASE" RX-126194 CDM 6370000100 HCPCS 250 RC 00378-0088-01 NDC outpatient 1 UN 6.31 6.31 UNITED HEALTHCARE (COMMERCIAL) [3081199] UNITED HEALTHCARE 87726 [308119901] 3.91 percent of total billed charges 3.91 5.99 Technical (Hospital) Services "CARBIDOPA ER 25 MG-LEVODOPA 100 MG TABLET,EXTENDED RELEASE" RX-126194 CDM 6370000100 HCPCS 250 RC 00378-0088-01 NDC outpatient 1 UN 6.31 6.31 MEDICA (COMMERCIAL) 94265 [3081118] MEDICA CLAIMS [308111801] 5.68 percent of total billed charges 3.91 5.99 Technical (Hospital) Services "CARBIDOPA ER 25 MG-LEVODOPA 100 MG TABLET,EXTENDED RELEASE" RX-126194 CDM 6370000100 HCPCS 250 RC 00378-0088-01 NDC outpatient 1 UN 6.31 6.31 MULTIPLAN INC 34080 [3081285] MULTIPLAN INC [308128501] 5.99 percent of total billed charges 3.91 5.99 Technical (Hospital) Services "CARBIDOPA ER 25 MG-LEVODOPA 100 MG TABLET,EXTENDED RELEASE" RX-126194 CDM 6370000100 HCPCS 250 RC 00378-0088-01 NDC outpatient 1 UN 6.31 6.31 CIGNA 62308 [3081051] CIGNA 62308 [308105105] 5.05 percent of total billed charges 3.91 5.99 Technical (Hospital) Services "CARBIDOPA ER 25 MG-LEVODOPA 100 MG TABLET,EXTENDED RELEASE" RX-126194 CDM 6370000100 HCPCS 250 RC 00378-0088-01 NDC outpatient 1 UN 6.31 6.31 CIGNA 62308 [3081051] CIGNA STATE OF WYOMING [308105107] 5.05 percent of total billed charges 3.91 5.99 Technical (Hospital) Services "CARBIDOPA ER 25 MG-LEVODOPA 100 MG TABLET,EXTENDED RELEASE" RX-126194 CDM 6370000100 HCPCS 250 RC 00378-0088-01 NDC outpatient 1 UN 6.31 6.31 BLUE CROSS BLUE SHIELD WELLMARK SB889 [3081026] BCBS WYOMING [308102603] 5.99 percent of total billed charges 3.91 5.99 Technical (Hospital) Services "CARBIDOPA ER 25 MG-LEVODOPA 100 MG TABLET,EXTENDED RELEASE" RX-126194 CDM 6370000100 HCPCS 250 RC 00378-0088-01 NDC outpatient 1 UN 6.31 6.31 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES PPO [308136801] 5.05 percent of total billed charges 3.91 5.99 Technical (Hospital) Services "CARBIDOPA ER 25 MG-LEVODOPA 100 MG TABLET,EXTENDED RELEASE" RX-126194 CDM 6370000100 HCPCS 250 RC 00378-0088-01 NDC outpatient 1 UN 6.31 6.31 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES EPO [308136803] 5.05 percent of total billed charges 3.91 5.99 Technical (Hospital) Services "CARBIDOPA ER 25 MG-LEVODOPA 100 MG TABLET,EXTENDED RELEASE" RX-126194 CDM 6370000100 HCPCS 250 RC 00378-0088-01 NDC outpatient 1 UN 6.31 6.31 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES HDHP [308136802] 5.05 percent of total billed charges 3.91 5.99 Technical (Hospital) Services METHYL SALICYLATE 30 %-MENTHOL 10 % TOPICAL CREAM RX-126314 CDM 6370000100 HCPCS 250 RC 41167-0008-81 NDC outpatient 85 GR 23.46 23.46 CIGNA 62308 [3081051] CIGNA 62308 [308105105] 18.77 percent of total billed charges 14.55 22.29 Technical (Hospital) Services METHYL SALICYLATE 30 %-MENTHOL 10 % TOPICAL CREAM RX-126314 CDM 6370000100 HCPCS 250 RC 41167-0008-81 NDC outpatient 85 GR 23.46 23.46 CIGNA 62308 [3081051] CIGNA STATE OF WYOMING [308105107] 18.77 percent of total billed charges 14.55 22.29 Technical (Hospital) Services METHYL SALICYLATE 30 %-MENTHOL 10 % TOPICAL CREAM RX-126314 CDM 6370000100 HCPCS 250 RC 41167-0008-81 NDC outpatient 85 GR 23.46 23.46 UNITED HEALTHCARE (COMMERCIAL) [3081199] UNITED HEALTHCARE 87726 [308119901] 14.55 percent of total billed charges 14.55 22.29 Technical (Hospital) Services METHYL SALICYLATE 30 %-MENTHOL 10 % TOPICAL CREAM RX-126314 CDM 6370000100 HCPCS 250 RC 41167-0008-81 NDC outpatient 85 GR 23.46 23.46 HEALTHPARTNERS SX009 HEALTHPARTNERS 18.77 percent of total billed charges 14.55 22.29 Technical (Hospital) Services METHYL SALICYLATE 30 %-MENTHOL 10 % TOPICAL CREAM RX-126314 CDM 6370000100 HCPCS 250 RC 41167-0008-81 NDC outpatient 85 GR 23.46 23.46 MULTIPLAN INC 34080 [3081285] MULTIPLAN INC [308128501] 22.29 percent of total billed charges 14.55 22.29 Technical (Hospital) Services METHYL SALICYLATE 30 %-MENTHOL 10 % TOPICAL CREAM RX-126314 CDM 6370000100 HCPCS 250 RC 41167-0008-81 NDC outpatient 85 GR 23.46 23.46 MEDICA (COMMERCIAL) 94265 [3081118] MEDICA CLAIMS [308111801] 21.11 percent of total billed charges 14.55 22.29 Technical (Hospital) Services METHYL SALICYLATE 30 %-MENTHOL 10 % TOPICAL CREAM RX-126314 CDM 6370000100 HCPCS 250 RC 41167-0008-81 NDC outpatient 85 GR 23.46 23.46 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES EPO [308136803] 18.77 percent of total billed charges 14.55 22.29 Technical (Hospital) Services METHYL SALICYLATE 30 %-MENTHOL 10 % TOPICAL CREAM RX-126314 CDM 6370000100 HCPCS 250 RC 41167-0008-81 NDC outpatient 85 GR 23.46 23.46 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES HDHP [308136802] 18.77 percent of total billed charges 14.55 22.29 Technical (Hospital) Services METHYL SALICYLATE 30 %-MENTHOL 10 % TOPICAL CREAM RX-126314 CDM 6370000100 HCPCS 250 RC 41167-0008-81 NDC outpatient 85 GR 23.46 23.46 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES PPO [308136801] 18.77 percent of total billed charges 14.55 22.29 Technical (Hospital) Services METHYL SALICYLATE 30 %-MENTHOL 10 % TOPICAL CREAM RX-126314 CDM 6370000100 HCPCS 250 RC 41167-0008-81 NDC outpatient 85 GR 23.46 23.46 BLUE CROSS BLUE SHIELD WELLMARK SB889 [3081026] BCBS WYOMING [308102603] 22.29 percent of total billed charges 14.55 22.29 Technical (Hospital) Services METHYL SALICYLATE 30 %-MENTHOL 10 % TOPICAL CREAM RX-126314 CDM 6370000100 HCPCS 250 RC 41167-0008-81 NDC inpatient 85 GR 23.46 23.46 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES EPO [308136803] 18.58 percent of total billed charges 14.55 22.29 Technical (Hospital) Services METHYL SALICYLATE 30 %-MENTHOL 10 % TOPICAL CREAM RX-126314 CDM 6370000100 HCPCS 250 RC 41167-0008-81 NDC inpatient 85 GR 23.46 23.46 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES HDHP [308136802] 18.58 percent of total billed charges 14.55 22.29 Technical (Hospital) Services METHYL SALICYLATE 30 %-MENTHOL 10 % TOPICAL CREAM RX-126314 CDM 6370000100 HCPCS 250 RC 41167-0008-81 NDC inpatient 85 GR 23.46 23.46 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES PPO [308136801] 18.58 percent of total billed charges 14.55 22.29 Technical (Hospital) Services METHYL SALICYLATE 30 %-MENTHOL 10 % TOPICAL CREAM RX-126314 CDM 6370000100 HCPCS 250 RC 41167-0008-81 NDC inpatient 85 GR 23.46 23.46 CIGNA 62308 [3081051] CIGNA 62308 [308105105] 18.58 percent of total billed charges 14.55 22.29 Technical (Hospital) Services METHYL SALICYLATE 30 %-MENTHOL 10 % TOPICAL CREAM RX-126314 CDM 6370000100 HCPCS 250 RC 41167-0008-81 NDC inpatient 85 GR 23.46 23.46 CIGNA 62308 [3081051] CIGNA STATE OF WYOMING [308105107] 18.58 percent of total billed charges 14.55 22.29 Technical (Hospital) Services METHYL SALICYLATE 30 %-MENTHOL 10 % TOPICAL CREAM RX-126314 CDM 6370000100 HCPCS 250 RC 41167-0008-81 NDC inpatient 85 GR 23.46 23.46 MEDICA (COMMERCIAL) 94265 [3081118] MEDICA CLAIMS [308111801] 21.11 percent of total billed charges 14.55 22.29 Technical (Hospital) Services METHYL SALICYLATE 30 %-MENTHOL 10 % TOPICAL CREAM RX-126314 CDM 6370000100 HCPCS 250 RC 41167-0008-81 NDC inpatient 85 GR 23.46 23.46 MULTIPLAN INC 34080 [3081285] MULTIPLAN INC [308128501] 22.29 percent of total billed charges 14.55 22.29 Technical (Hospital) Services METHYL SALICYLATE 30 %-MENTHOL 10 % TOPICAL CREAM RX-126314 CDM 6370000100 HCPCS 250 RC 41167-0008-81 NDC inpatient 85 GR 23.46 23.46 HEALTHPARTNERS SX009 HEALTHPARTNERS 18.58 percent of total billed charges 14.55 22.29 Technical (Hospital) Services METHYL SALICYLATE 30 %-MENTHOL 10 % TOPICAL CREAM RX-126314 CDM 6370000100 HCPCS 250 RC 41167-0008-81 NDC inpatient 85 GR 23.46 23.46 BLUE CROSS BLUE SHIELD WELLMARK SB889 [3081026] BCBS WYOMING [308102603] 22.29 percent of total billed charges 14.55 22.29 Technical (Hospital) Services METHYL SALICYLATE 30 %-MENTHOL 10 % TOPICAL CREAM RX-126314 CDM 6370000100 HCPCS 250 RC 41167-0008-81 NDC inpatient 85 GR 23.46 23.46 UNITED HEALTHCARE (COMMERCIAL) [3081199] UNITED HEALTHCARE 87726 [308119901] 14.55 percent of total billed charges 14.55 22.29 Technical (Hospital) Services EMPAGLIFLOZIN 10 MG TABLET RX-126630 CDM 6370000100 HCPCS 250 RC 00597-0152-30 NDC outpatient 1 UN 81.87 81.87 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES HDHP [308136802] 65.5 percent of total billed charges 50.76 77.78 Technical (Hospital) Services EMPAGLIFLOZIN 10 MG TABLET RX-126630 CDM 6370000100 HCPCS 250 RC 00597-0152-30 NDC outpatient 1 UN 81.87 81.87 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES PPO [308136801] 65.5 percent of total billed charges 50.76 77.78 Technical (Hospital) Services EMPAGLIFLOZIN 10 MG TABLET RX-126630 CDM 6370000100 HCPCS 250 RC 00597-0152-30 NDC outpatient 1 UN 81.87 81.87 UNITED HEALTHCARE (COMMERCIAL) [3081199] UNITED HEALTHCARE 87726 [308119901] 50.76 percent of total billed charges 50.76 77.78 Technical (Hospital) Services EMPAGLIFLOZIN 10 MG TABLET RX-126630 CDM 6370000100 HCPCS 250 RC 00597-0152-30 NDC outpatient 1 UN 81.87 81.87 MULTIPLAN INC 34080 [3081285] MULTIPLAN INC [308128501] 77.78 percent of total billed charges 50.76 77.78 Technical (Hospital) Services EMPAGLIFLOZIN 10 MG TABLET RX-126630 CDM 6370000100 HCPCS 250 RC 00597-0152-30 NDC outpatient 1 UN 81.87 81.87 CIGNA 62308 [3081051] CIGNA 62308 [308105105] 65.5 percent of total billed charges 50.76 77.78 Technical (Hospital) Services EMPAGLIFLOZIN 10 MG TABLET RX-126630 CDM 6370000100 HCPCS 250 RC 00597-0152-30 NDC outpatient 1 UN 81.87 81.87 CIGNA 62308 [3081051] CIGNA STATE OF WYOMING [308105107] 65.5 percent of total billed charges 50.76 77.78 Technical (Hospital) Services EMPAGLIFLOZIN 10 MG TABLET RX-126630 CDM 6370000100 HCPCS 250 RC 00597-0152-30 NDC outpatient 1 UN 81.87 81.87 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES EPO [308136803] 65.5 percent of total billed charges 50.76 77.78 Technical (Hospital) Services EMPAGLIFLOZIN 10 MG TABLET RX-126630 CDM 6370000100 HCPCS 250 RC 00597-0152-30 NDC outpatient 1 UN 81.87 81.87 MEDICA (COMMERCIAL) 94265 [3081118] MEDICA CLAIMS [308111801] 73.68 percent of total billed charges 50.76 77.78 Technical (Hospital) Services EMPAGLIFLOZIN 10 MG TABLET RX-126630 CDM 6370000100 HCPCS 250 RC 00597-0152-30 NDC outpatient 1 UN 81.87 81.87 HEALTHPARTNERS SX009 HEALTHPARTNERS 65.5 percent of total billed charges 50.76 77.78 Technical (Hospital) Services EMPAGLIFLOZIN 10 MG TABLET RX-126630 CDM 6370000100 HCPCS 250 RC 00597-0152-30 NDC outpatient 1 UN 81.87 81.87 BLUE CROSS BLUE SHIELD WELLMARK SB889 [3081026] BCBS WYOMING [308102603] 77.78 percent of total billed charges 50.76 77.78 Technical (Hospital) Services EMPAGLIFLOZIN 10 MG TABLET RX-126630 CDM 6370000100 HCPCS 250 RC 00597-0152-30 NDC inpatient 1 UN 81.87 81.87 CIGNA 62308 [3081051] CIGNA 62308 [308105105] 64.82 percent of total billed charges 50.76 77.78 Technical (Hospital) Services EMPAGLIFLOZIN 10 MG TABLET RX-126630 CDM 6370000100 HCPCS 250 RC 00597-0152-30 NDC inpatient 1 UN 81.87 81.87 CIGNA 62308 [3081051] CIGNA STATE OF WYOMING [308105107] 64.82 percent of total billed charges 50.76 77.78 Technical (Hospital) Services EMPAGLIFLOZIN 10 MG TABLET RX-126630 CDM 6370000100 HCPCS 250 RC 00597-0152-30 NDC inpatient 1 UN 81.87 81.87 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES EPO [308136803] 64.82 percent of total billed charges 50.76 77.78 Technical (Hospital) Services EMPAGLIFLOZIN 10 MG TABLET RX-126630 CDM 6370000100 HCPCS 250 RC 00597-0152-30 NDC inpatient 1 UN 81.87 81.87 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES HDHP [308136802] 64.82 percent of total billed charges 50.76 77.78 Technical (Hospital) Services EMPAGLIFLOZIN 10 MG TABLET RX-126630 CDM 6370000100 HCPCS 250 RC 00597-0152-30 NDC inpatient 1 UN 81.87 81.87 BLUE CROSS BLUE SHIELD WELLMARK SB889 [3081026] BCBS WYOMING [308102603] 77.78 percent of total billed charges 50.76 77.78 Technical (Hospital) Services EMPAGLIFLOZIN 10 MG TABLET RX-126630 CDM 6370000100 HCPCS 250 RC 00597-0152-30 NDC inpatient 1 UN 81.87 81.87 UNITED HEALTHCARE (COMMERCIAL) [3081199] UNITED HEALTHCARE 87726 [308119901] 50.76 percent of total billed charges 50.76 77.78 Technical (Hospital) Services EMPAGLIFLOZIN 10 MG TABLET RX-126630 CDM 6370000100 HCPCS 250 RC 00597-0152-30 NDC inpatient 1 UN 81.87 81.87 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES PPO [308136801] 64.82 percent of total billed charges 50.76 77.78 Technical (Hospital) Services EMPAGLIFLOZIN 10 MG TABLET RX-126630 CDM 6370000100 HCPCS 250 RC 00597-0152-30 NDC inpatient 1 UN 81.87 81.87 HEALTHPARTNERS SX009 HEALTHPARTNERS 64.82 percent of total billed charges 50.76 77.78 Technical (Hospital) Services EMPAGLIFLOZIN 10 MG TABLET RX-126630 CDM 6370000100 HCPCS 250 RC 00597-0152-30 NDC inpatient 1 UN 81.87 81.87 MEDICA (COMMERCIAL) 94265 [3081118] MEDICA CLAIMS [308111801] 73.68 percent of total billed charges 50.76 77.78 Technical (Hospital) Services EMPAGLIFLOZIN 10 MG TABLET RX-126630 CDM 6370000100 HCPCS 250 RC 00597-0152-30 NDC inpatient 1 UN 81.87 81.87 MULTIPLAN INC 34080 [3081285] MULTIPLAN INC [308128501] 77.78 percent of total billed charges 50.76 77.78 Technical (Hospital) Services LACTOBAC NO.2-BIFIDOBAC NO.1-S. THERMO 112.5 BILLION CELL CAPSULE RX-126943 CDM 6370000100 HCPCS 250 RC 69355-0412-03 NDC inpatient 1 UN 6.35 6.35 MULTIPLAN INC 34080 [3081285] MULTIPLAN INC [308128501] 6.03 percent of total billed charges 3.94 6.03 Technical (Hospital) Services LACTOBAC NO.2-BIFIDOBAC NO.1-S. THERMO 112.5 BILLION CELL CAPSULE RX-126943 CDM 6370000100 HCPCS 250 RC 69355-0412-03 NDC inpatient 1 UN 6.35 6.35 HEALTHPARTNERS SX009 HEALTHPARTNERS 5.03 percent of total billed charges 3.94 6.03 Technical (Hospital) Services LACTOBAC NO.2-BIFIDOBAC NO.1-S. THERMO 112.5 BILLION CELL CAPSULE RX-126943 CDM 6370000100 HCPCS 250 RC 69355-0412-03 NDC inpatient 1 UN 6.35 6.35 MEDICA (COMMERCIAL) 94265 [3081118] MEDICA CLAIMS [308111801] 5.72 percent of total billed charges 3.94 6.03 Technical (Hospital) Services LACTOBAC NO.2-BIFIDOBAC NO.1-S. THERMO 112.5 BILLION CELL CAPSULE RX-126943 CDM 6370000100 HCPCS 250 RC 69355-0412-03 NDC inpatient 1 UN 6.35 6.35 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES PPO [308136801] 5.03 percent of total billed charges 3.94 6.03 Technical (Hospital) Services LACTOBAC NO.2-BIFIDOBAC NO.1-S. THERMO 112.5 BILLION CELL CAPSULE RX-126943 CDM 6370000100 HCPCS 250 RC 69355-0412-03 NDC inpatient 1 UN 6.35 6.35 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES HDHP [308136802] 5.03 percent of total billed charges 3.94 6.03 Technical (Hospital) Services LACTOBAC NO.2-BIFIDOBAC NO.1-S. THERMO 112.5 BILLION CELL CAPSULE RX-126943 CDM 6370000100 HCPCS 250 RC 69355-0412-03 NDC inpatient 1 UN 6.35 6.35 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES EPO [308136803] 5.03 percent of total billed charges 3.94 6.03 Technical (Hospital) Services LACTOBAC NO.2-BIFIDOBAC NO.1-S. THERMO 112.5 BILLION CELL CAPSULE RX-126943 CDM 6370000100 HCPCS 250 RC 69355-0412-03 NDC inpatient 1 UN 6.35 6.35 CIGNA 62308 [3081051] CIGNA 62308 [308105105] 5.03 percent of total billed charges 3.94 6.03 Technical (Hospital) Services LACTOBAC NO.2-BIFIDOBAC NO.1-S. THERMO 112.5 BILLION CELL CAPSULE RX-126943 CDM 6370000100 HCPCS 250 RC 69355-0412-03 NDC inpatient 1 UN 6.35 6.35 CIGNA 62308 [3081051] CIGNA STATE OF WYOMING [308105107] 5.03 percent of total billed charges 3.94 6.03 Technical (Hospital) Services LACTOBAC NO.2-BIFIDOBAC NO.1-S. THERMO 112.5 BILLION CELL CAPSULE RX-126943 CDM 6370000100 HCPCS 250 RC 69355-0412-03 NDC inpatient 1 UN 6.35 6.35 UNITED HEALTHCARE (COMMERCIAL) [3081199] UNITED HEALTHCARE 87726 [308119901] 3.94 percent of total billed charges 3.94 6.03 Technical (Hospital) Services LACTOBAC NO.2-BIFIDOBAC NO.1-S. THERMO 112.5 BILLION CELL CAPSULE RX-126943 CDM 6370000100 HCPCS 250 RC 69355-0412-03 NDC inpatient 1 UN 6.35 6.35 BLUE CROSS BLUE SHIELD WELLMARK SB889 [3081026] BCBS WYOMING [308102603] 6.03 percent of total billed charges 3.94 6.03 Technical (Hospital) Services LACTOBAC NO.2-BIFIDOBAC NO.1-S. THERMO 112.5 BILLION CELL CAPSULE RX-126943 CDM 6370000100 HCPCS 250 RC 69355-0412-03 NDC outpatient 1 UN 6.35 6.35 BLUE CROSS BLUE SHIELD WELLMARK SB889 [3081026] BCBS WYOMING [308102603] 6.03 percent of total billed charges 3.94 6.03 Technical (Hospital) Services LACTOBAC NO.2-BIFIDOBAC NO.1-S. THERMO 112.5 BILLION CELL CAPSULE RX-126943 CDM 6370000100 HCPCS 250 RC 69355-0412-03 NDC outpatient 1 UN 6.35 6.35 UNITED HEALTHCARE (COMMERCIAL) [3081199] UNITED HEALTHCARE 87726 [308119901] 3.94 percent of total billed charges 3.94 6.03 Technical (Hospital) Services LACTOBAC NO.2-BIFIDOBAC NO.1-S. THERMO 112.5 BILLION CELL CAPSULE RX-126943 CDM 6370000100 HCPCS 250 RC 69355-0412-03 NDC outpatient 1 UN 6.35 6.35 HEALTHPARTNERS SX009 HEALTHPARTNERS 5.08 percent of total billed charges 3.94 6.03 Technical (Hospital) Services LACTOBAC NO.2-BIFIDOBAC NO.1-S. THERMO 112.5 BILLION CELL CAPSULE RX-126943 CDM 6370000100 HCPCS 250 RC 69355-0412-03 NDC outpatient 1 UN 6.35 6.35 CIGNA 62308 [3081051] CIGNA 62308 [308105105] 5.08 percent of total billed charges 3.94 6.03 Technical (Hospital) Services LACTOBAC NO.2-BIFIDOBAC NO.1-S. THERMO 112.5 BILLION CELL CAPSULE RX-126943 CDM 6370000100 HCPCS 250 RC 69355-0412-03 NDC outpatient 1 UN 6.35 6.35 CIGNA 62308 [3081051] CIGNA STATE OF WYOMING [308105107] 5.08 percent of total billed charges 3.94 6.03 Technical (Hospital) Services LACTOBAC NO.2-BIFIDOBAC NO.1-S. THERMO 112.5 BILLION CELL CAPSULE RX-126943 CDM 6370000100 HCPCS 250 RC 69355-0412-03 NDC outpatient 1 UN 6.35 6.35 MULTIPLAN INC 34080 [3081285] MULTIPLAN INC [308128501] 6.03 percent of total billed charges 3.94 6.03 Technical (Hospital) Services LACTOBAC NO.2-BIFIDOBAC NO.1-S. THERMO 112.5 BILLION CELL CAPSULE RX-126943 CDM 6370000100 HCPCS 250 RC 69355-0412-03 NDC outpatient 1 UN 6.35 6.35 MEDICA (COMMERCIAL) 94265 [3081118] MEDICA CLAIMS [308111801] 5.72 percent of total billed charges 3.94 6.03 Technical (Hospital) Services LACTOBAC NO.2-BIFIDOBAC NO.1-S. THERMO 112.5 BILLION CELL CAPSULE RX-126943 CDM 6370000100 HCPCS 250 RC 69355-0412-03 NDC outpatient 1 UN 6.35 6.35 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES HDHP [308136802] 5.08 percent of total billed charges 3.94 6.03 Technical (Hospital) Services LACTOBAC NO.2-BIFIDOBAC NO.1-S. THERMO 112.5 BILLION CELL CAPSULE RX-126943 CDM 6370000100 HCPCS 250 RC 69355-0412-03 NDC outpatient 1 UN 6.35 6.35 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES EPO [308136803] 5.08 percent of total billed charges 3.94 6.03 Technical (Hospital) Services LACTOBAC NO.2-BIFIDOBAC NO.1-S. THERMO 112.5 BILLION CELL CAPSULE RX-126943 CDM 6370000100 HCPCS 250 RC 69355-0412-03 NDC outpatient 1 UN 6.35 6.35 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES PPO [308136801] 5.08 percent of total billed charges 3.94 6.03 Technical (Hospital) Services TERBINAFINE HCL 250 MG TABLET RX-12724 CDM 6370000100 HCPCS 250 RC 51991-0526-33 NDC inpatient 1 UN 5.76 5.76 CIGNA 62308 [3081051] CIGNA 62308 [308105105] 4.56 percent of total billed charges 3.57 5.47 Technical (Hospital) Services TERBINAFINE HCL 250 MG TABLET RX-12724 CDM 6370000100 HCPCS 250 RC 51991-0526-33 NDC inpatient 1 UN 5.76 5.76 CIGNA 62308 [3081051] CIGNA STATE OF WYOMING [308105107] 4.56 percent of total billed charges 3.57 5.47 Technical (Hospital) Services TERBINAFINE HCL 250 MG TABLET RX-12724 CDM 6370000100 HCPCS 250 RC 51991-0526-33 NDC inpatient 1 UN 5.76 5.76 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES EPO [308136803] 4.56 percent of total billed charges 3.57 5.47 Technical (Hospital) Services TERBINAFINE HCL 250 MG TABLET RX-12724 CDM 6370000100 HCPCS 250 RC 51991-0526-33 NDC inpatient 1 UN 5.76 5.76 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES HDHP [308136802] 4.56 percent of total billed charges 3.57 5.47 Technical (Hospital) Services TERBINAFINE HCL 250 MG TABLET RX-12724 CDM 6370000100 HCPCS 250 RC 51991-0526-33 NDC inpatient 1 UN 5.76 5.76 BLUE CROSS BLUE SHIELD WELLMARK SB889 [3081026] BCBS WYOMING [308102603] 5.47 percent of total billed charges 3.57 5.47 Technical (Hospital) Services TERBINAFINE HCL 250 MG TABLET RX-12724 CDM 6370000100 HCPCS 250 RC 51991-0526-33 NDC inpatient 1 UN 5.76 5.76 UNITED HEALTHCARE (COMMERCIAL) [3081199] UNITED HEALTHCARE 87726 [308119901] 3.57 percent of total billed charges 3.57 5.47 Technical (Hospital) Services TERBINAFINE HCL 250 MG TABLET RX-12724 CDM 6370000100 HCPCS 250 RC 51991-0526-33 NDC inpatient 1 UN 5.76 5.76 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES PPO [308136801] 4.56 percent of total billed charges 3.57 5.47 Technical (Hospital) Services TERBINAFINE HCL 250 MG TABLET RX-12724 CDM 6370000100 HCPCS 250 RC 51991-0526-33 NDC inpatient 1 UN 5.76 5.76 MEDICA (COMMERCIAL) 94265 [3081118] MEDICA CLAIMS [308111801] 5.18 percent of total billed charges 3.57 5.47 Technical (Hospital) Services TERBINAFINE HCL 250 MG TABLET RX-12724 CDM 6370000100 HCPCS 250 RC 51991-0526-33 NDC inpatient 1 UN 5.76 5.76 HEALTHPARTNERS SX009 HEALTHPARTNERS 4.56 percent of total billed charges 3.57 5.47 Technical (Hospital) Services TERBINAFINE HCL 250 MG TABLET RX-12724 CDM 6370000100 HCPCS 250 RC 51991-0526-33 NDC inpatient 1 UN 5.76 5.76 MULTIPLAN INC 34080 [3081285] MULTIPLAN INC [308128501] 5.47 percent of total billed charges 3.57 5.47 Technical (Hospital) Services TERBINAFINE HCL 250 MG TABLET RX-12724 CDM 6370000100 HCPCS 250 RC 51991-0526-33 NDC outpatient 1 UN 5.76 5.76 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES EPO [308136803] 4.61 percent of total billed charges 3.57 5.47 Technical (Hospital) Services TERBINAFINE HCL 250 MG TABLET RX-12724 CDM 6370000100 HCPCS 250 RC 51991-0526-33 NDC outpatient 1 UN 5.76 5.76 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES PPO [308136801] 4.61 percent of total billed charges 3.57 5.47 Technical (Hospital) Services TERBINAFINE HCL 250 MG TABLET RX-12724 CDM 6370000100 HCPCS 250 RC 51991-0526-33 NDC outpatient 1 UN 5.76 5.76 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES HDHP [308136802] 4.61 percent of total billed charges 3.57 5.47 Technical (Hospital) Services TERBINAFINE HCL 250 MG TABLET RX-12724 CDM 6370000100 HCPCS 250 RC 51991-0526-33 NDC outpatient 1 UN 5.76 5.76 UNITED HEALTHCARE (COMMERCIAL) [3081199] UNITED HEALTHCARE 87726 [308119901] 3.57 percent of total billed charges 3.57 5.47 Technical (Hospital) Services TERBINAFINE HCL 250 MG TABLET RX-12724 CDM 6370000100 HCPCS 250 RC 51991-0526-33 NDC outpatient 1 UN 5.76 5.76 MEDICA (COMMERCIAL) 94265 [3081118] MEDICA CLAIMS [308111801] 5.18 percent of total billed charges 3.57 5.47 Technical (Hospital) Services TERBINAFINE HCL 250 MG TABLET RX-12724 CDM 6370000100 HCPCS 250 RC 51991-0526-33 NDC outpatient 1 UN 5.76 5.76 CIGNA 62308 [3081051] CIGNA 62308 [308105105] 4.61 percent of total billed charges 3.57 5.47 Technical (Hospital) Services TERBINAFINE HCL 250 MG TABLET RX-12724 CDM 6370000100 HCPCS 250 RC 51991-0526-33 NDC outpatient 1 UN 5.76 5.76 CIGNA 62308 [3081051] CIGNA STATE OF WYOMING [308105107] 4.61 percent of total billed charges 3.57 5.47 Technical (Hospital) Services TERBINAFINE HCL 250 MG TABLET RX-12724 CDM 6370000100 HCPCS 250 RC 51991-0526-33 NDC outpatient 1 UN 5.76 5.76 MULTIPLAN INC 34080 [3081285] MULTIPLAN INC [308128501] 5.47 percent of total billed charges 3.57 5.47 Technical (Hospital) Services TERBINAFINE HCL 250 MG TABLET RX-12724 CDM 6370000100 HCPCS 250 RC 51991-0526-33 NDC outpatient 1 UN 5.76 5.76 HEALTHPARTNERS SX009 HEALTHPARTNERS 4.61 percent of total billed charges 3.57 5.47 Technical (Hospital) Services TERBINAFINE HCL 250 MG TABLET RX-12724 CDM 6370000100 HCPCS 250 RC 51991-0526-33 NDC outpatient 1 UN 5.76 5.76 BLUE CROSS BLUE SHIELD WELLMARK SB889 [3081026] BCBS WYOMING [308102603] 5.47 percent of total billed charges 3.57 5.47 Technical (Hospital) Services TIOTROPIUM BROMIDE 2.5 MCG/ACTUATION MIST FOR INHALATION RX-127331 CDM 6370000100 HCPCS 250 RC 00597-0100-61 NDC inpatient 4 GR 1162.39 1162.39 CIGNA 62308 [3081051] CIGNA 62308 [308105105] 920.38 percent of total billed charges 720.68 1104.27 Technical (Hospital) Services TIOTROPIUM BROMIDE 2.5 MCG/ACTUATION MIST FOR INHALATION RX-127331 CDM 6370000100 HCPCS 250 RC 00597-0100-61 NDC inpatient 4 GR 1162.39 1162.39 CIGNA 62308 [3081051] CIGNA STATE OF WYOMING [308105107] 920.38 percent of total billed charges 720.68 1104.27 Technical (Hospital) Services TIOTROPIUM BROMIDE 2.5 MCG/ACTUATION MIST FOR INHALATION RX-127331 CDM 6370000100 HCPCS 250 RC 00597-0100-61 NDC inpatient 4 GR 1162.39 1162.39 BLUE CROSS BLUE SHIELD WELLMARK SB889 [3081026] BCBS WYOMING [308102603] 1104.27 percent of total billed charges 720.68 1104.27 Technical (Hospital) Services TIOTROPIUM BROMIDE 2.5 MCG/ACTUATION MIST FOR INHALATION RX-127331 CDM 6370000100 HCPCS 250 RC 00597-0100-61 NDC inpatient 4 GR 1162.39 1162.39 UNITED HEALTHCARE (COMMERCIAL) [3081199] UNITED HEALTHCARE 87726 [308119901] 720.68 percent of total billed charges 720.68 1104.27 Technical (Hospital) Services TIOTROPIUM BROMIDE 2.5 MCG/ACTUATION MIST FOR INHALATION RX-127331 CDM 6370000100 HCPCS 250 RC 00597-0100-61 NDC inpatient 4 GR 1162.39 1162.39 MEDICA (COMMERCIAL) 94265 [3081118] MEDICA CLAIMS [308111801] 1046.15 percent of total billed charges 720.68 1104.27 Technical (Hospital) Services TIOTROPIUM BROMIDE 2.5 MCG/ACTUATION MIST FOR INHALATION RX-127331 CDM 6370000100 HCPCS 250 RC 00597-0100-61 NDC inpatient 4 GR 1162.39 1162.39 MULTIPLAN INC 34080 [3081285] MULTIPLAN INC [308128501] 1104.27 percent of total billed charges 720.68 1104.27 Technical (Hospital) Services TIOTROPIUM BROMIDE 2.5 MCG/ACTUATION MIST FOR INHALATION RX-127331 CDM 6370000100 HCPCS 250 RC 00597-0100-61 NDC inpatient 4 GR 1162.39 1162.39 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES EPO [308136803] 920.38 percent of total billed charges 720.68 1104.27 Technical (Hospital) Services TIOTROPIUM BROMIDE 2.5 MCG/ACTUATION MIST FOR INHALATION RX-127331 CDM 6370000100 HCPCS 250 RC 00597-0100-61 NDC inpatient 4 GR 1162.39 1162.39 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES HDHP [308136802] 920.38 percent of total billed charges 720.68 1104.27 Technical (Hospital) Services TIOTROPIUM BROMIDE 2.5 MCG/ACTUATION MIST FOR INHALATION RX-127331 CDM 6370000100 HCPCS 250 RC 00597-0100-61 NDC inpatient 4 GR 1162.39 1162.39 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES PPO [308136801] 920.38 percent of total billed charges 720.68 1104.27 Technical (Hospital) Services TIOTROPIUM BROMIDE 2.5 MCG/ACTUATION MIST FOR INHALATION RX-127331 CDM 6370000100 HCPCS 250 RC 00597-0100-61 NDC inpatient 4 GR 1162.39 1162.39 HEALTHPARTNERS SX009 HEALTHPARTNERS 920.38 percent of total billed charges 720.68 1104.27 Technical (Hospital) Services TIOTROPIUM BROMIDE 2.5 MCG/ACTUATION MIST FOR INHALATION RX-127331 CDM 6370000100 HCPCS 250 RC 00597-0100-61 NDC outpatient 4 GR 1162.39 1162.39 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES PPO [308136801] 929.91 percent of total billed charges 720.68 1104.27 Technical (Hospital) Services TIOTROPIUM BROMIDE 2.5 MCG/ACTUATION MIST FOR INHALATION RX-127331 CDM 6370000100 HCPCS 250 RC 00597-0100-61 NDC outpatient 4 GR 1162.39 1162.39 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES HDHP [308136802] 929.91 percent of total billed charges 720.68 1104.27 Technical (Hospital) Services TIOTROPIUM BROMIDE 2.5 MCG/ACTUATION MIST FOR INHALATION RX-127331 CDM 6370000100 HCPCS 250 RC 00597-0100-61 NDC outpatient 4 GR 1162.39 1162.39 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES EPO [308136803] 929.91 percent of total billed charges 720.68 1104.27 Technical (Hospital) Services TIOTROPIUM BROMIDE 2.5 MCG/ACTUATION MIST FOR INHALATION RX-127331 CDM 6370000100 HCPCS 250 RC 00597-0100-61 NDC outpatient 4 GR 1162.39 1162.39 BLUE CROSS BLUE SHIELD WELLMARK SB889 [3081026] BCBS WYOMING [308102603] 1104.27 percent of total billed charges 720.68 1104.27 Technical (Hospital) Services TIOTROPIUM BROMIDE 2.5 MCG/ACTUATION MIST FOR INHALATION RX-127331 CDM 6370000100 HCPCS 250 RC 00597-0100-61 NDC outpatient 4 GR 1162.39 1162.39 UNITED HEALTHCARE (COMMERCIAL) [3081199] UNITED HEALTHCARE 87726 [308119901] 720.68 percent of total billed charges 720.68 1104.27 Technical (Hospital) Services TIOTROPIUM BROMIDE 2.5 MCG/ACTUATION MIST FOR INHALATION RX-127331 CDM 6370000100 HCPCS 250 RC 00597-0100-61 NDC outpatient 4 GR 1162.39 1162.39 HEALTHPARTNERS SX009 HEALTHPARTNERS 929.91 percent of total billed charges 720.68 1104.27 Technical (Hospital) Services TIOTROPIUM BROMIDE 2.5 MCG/ACTUATION MIST FOR INHALATION RX-127331 CDM 6370000100 HCPCS 250 RC 00597-0100-61 NDC outpatient 4 GR 1162.39 1162.39 CIGNA 62308 [3081051] CIGNA 62308 [308105105] 929.91 percent of total billed charges 720.68 1104.27 Technical (Hospital) Services TIOTROPIUM BROMIDE 2.5 MCG/ACTUATION MIST FOR INHALATION RX-127331 CDM 6370000100 HCPCS 250 RC 00597-0100-61 NDC outpatient 4 GR 1162.39 1162.39 CIGNA 62308 [3081051] CIGNA STATE OF WYOMING [308105107] 929.91 percent of total billed charges 720.68 1104.27 Technical (Hospital) Services TIOTROPIUM BROMIDE 2.5 MCG/ACTUATION MIST FOR INHALATION RX-127331 CDM 6370000100 HCPCS 250 RC 00597-0100-61 NDC outpatient 4 GR 1162.39 1162.39 MEDICA (COMMERCIAL) 94265 [3081118] MEDICA CLAIMS [308111801] 1046.15 percent of total billed charges 720.68 1104.27 Technical (Hospital) Services TIOTROPIUM BROMIDE 2.5 MCG/ACTUATION MIST FOR INHALATION RX-127331 CDM 6370000100 HCPCS 250 RC 00597-0100-61 NDC outpatient 4 GR 1162.39 1162.39 MULTIPLAN INC 34080 [3081285] MULTIPLAN INC [308128501] 1104.27 percent of total billed charges 720.68 1104.27 Technical (Hospital) Services UMECLIDINIUM 62.5 MCG/ACTUATION BLISTER POWDER FOR INHALATION RX-127350 CDM 6370000100 HCPCS 250 RC 00173-0873-10 NDC outpatient 1 UN 47.4 47.4 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES HDHP [308136802] 37.92 percent of total billed charges 29.39 45.03 Technical (Hospital) Services UMECLIDINIUM 62.5 MCG/ACTUATION BLISTER POWDER FOR INHALATION RX-127350 CDM 6370000100 HCPCS 250 RC 00173-0873-10 NDC outpatient 1 UN 47.4 47.4 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES PPO [308136801] 37.92 percent of total billed charges 29.39 45.03 Technical (Hospital) Services UMECLIDINIUM 62.5 MCG/ACTUATION BLISTER POWDER FOR INHALATION RX-127350 CDM 6370000100 HCPCS 250 RC 00173-0873-10 NDC outpatient 1 UN 47.4 47.4 HEALTHPARTNERS SX009 HEALTHPARTNERS 37.92 percent of total billed charges 29.39 45.03 Technical (Hospital) Services UMECLIDINIUM 62.5 MCG/ACTUATION BLISTER POWDER FOR INHALATION RX-127350 CDM 6370000100 HCPCS 250 RC 00173-0873-10 NDC outpatient 1 UN 47.4 47.4 BLUE CROSS BLUE SHIELD WELLMARK SB889 [3081026] BCBS WYOMING [308102603] 45.03 percent of total billed charges 29.39 45.03 Technical (Hospital) Services UMECLIDINIUM 62.5 MCG/ACTUATION BLISTER POWDER FOR INHALATION RX-127350 CDM 6370000100 HCPCS 250 RC 00173-0873-10 NDC outpatient 1 UN 47.4 47.4 UNITED HEALTHCARE (COMMERCIAL) [3081199] UNITED HEALTHCARE 87726 [308119901] 29.39 percent of total billed charges 29.39 45.03 Technical (Hospital) Services UMECLIDINIUM 62.5 MCG/ACTUATION BLISTER POWDER FOR INHALATION RX-127350 CDM 6370000100 HCPCS 250 RC 00173-0873-10 NDC outpatient 1 UN 47.4 47.4 MULTIPLAN INC 34080 [3081285] MULTIPLAN INC [308128501] 45.03 percent of total billed charges 29.39 45.03 Technical (Hospital) Services UMECLIDINIUM 62.5 MCG/ACTUATION BLISTER POWDER FOR INHALATION RX-127350 CDM 6370000100 HCPCS 250 RC 00173-0873-10 NDC outpatient 1 UN 47.4 47.4 CIGNA 62308 [3081051] CIGNA 62308 [308105105] 37.92 percent of total billed charges 29.39 45.03 Technical (Hospital) Services UMECLIDINIUM 62.5 MCG/ACTUATION BLISTER POWDER FOR INHALATION RX-127350 CDM 6370000100 HCPCS 250 RC 00173-0873-10 NDC outpatient 1 UN 47.4 47.4 CIGNA 62308 [3081051] CIGNA STATE OF WYOMING [308105107] 37.92 percent of total billed charges 29.39 45.03 Technical (Hospital) Services UMECLIDINIUM 62.5 MCG/ACTUATION BLISTER POWDER FOR INHALATION RX-127350 CDM 6370000100 HCPCS 250 RC 00173-0873-10 NDC outpatient 1 UN 47.4 47.4 MEDICA (COMMERCIAL) 94265 [3081118] MEDICA CLAIMS [308111801] 42.66 percent of total billed charges 29.39 45.03 Technical (Hospital) Services UMECLIDINIUM 62.5 MCG/ACTUATION BLISTER POWDER FOR INHALATION RX-127350 CDM 6370000100 HCPCS 250 RC 00173-0873-10 NDC outpatient 1 UN 47.4 47.4 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES EPO [308136803] 37.92 percent of total billed charges 29.39 45.03 Technical (Hospital) Services UMECLIDINIUM 62.5 MCG/ACTUATION BLISTER POWDER FOR INHALATION RX-127350 CDM 6370000100 HCPCS 250 RC 00173-0873-10 NDC inpatient 1 UN 47.4 47.4 MULTIPLAN INC 34080 [3081285] MULTIPLAN INC [308128501] 45.03 percent of total billed charges 29.39 45.03 Technical (Hospital) Services UMECLIDINIUM 62.5 MCG/ACTUATION BLISTER POWDER FOR INHALATION RX-127350 CDM 6370000100 HCPCS 250 RC 00173-0873-10 NDC inpatient 1 UN 47.4 47.4 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES PPO [308136801] 37.53 percent of total billed charges 29.39 45.03 Technical (Hospital) Services UMECLIDINIUM 62.5 MCG/ACTUATION BLISTER POWDER FOR INHALATION RX-127350 CDM 6370000100 HCPCS 250 RC 00173-0873-10 NDC inpatient 1 UN 47.4 47.4 CIGNA 62308 [3081051] CIGNA 62308 [308105105] 37.53 percent of total billed charges 29.39 45.03 Technical (Hospital) Services UMECLIDINIUM 62.5 MCG/ACTUATION BLISTER POWDER FOR INHALATION RX-127350 CDM 6370000100 HCPCS 250 RC 00173-0873-10 NDC inpatient 1 UN 47.4 47.4 CIGNA 62308 [3081051] CIGNA STATE OF WYOMING [308105107] 37.53 percent of total billed charges 29.39 45.03 Technical (Hospital) Services UMECLIDINIUM 62.5 MCG/ACTUATION BLISTER POWDER FOR INHALATION RX-127350 CDM 6370000100 HCPCS 250 RC 00173-0873-10 NDC inpatient 1 UN 47.4 47.4 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES EPO [308136803] 37.53 percent of total billed charges 29.39 45.03 Technical (Hospital) Services UMECLIDINIUM 62.5 MCG/ACTUATION BLISTER POWDER FOR INHALATION RX-127350 CDM 6370000100 HCPCS 250 RC 00173-0873-10 NDC inpatient 1 UN 47.4 47.4 HEALTHPARTNERS SX009 HEALTHPARTNERS 37.53 percent of total billed charges 29.39 45.03 Technical (Hospital) Services UMECLIDINIUM 62.5 MCG/ACTUATION BLISTER POWDER FOR INHALATION RX-127350 CDM 6370000100 HCPCS 250 RC 00173-0873-10 NDC inpatient 1 UN 47.4 47.4 MEDICA (COMMERCIAL) 94265 [3081118] MEDICA CLAIMS [308111801] 42.66 percent of total billed charges 29.39 45.03 Technical (Hospital) Services UMECLIDINIUM 62.5 MCG/ACTUATION BLISTER POWDER FOR INHALATION RX-127350 CDM 6370000100 HCPCS 250 RC 00173-0873-10 NDC inpatient 1 UN 47.4 47.4 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES HDHP [308136802] 37.53 percent of total billed charges 29.39 45.03 Technical (Hospital) Services UMECLIDINIUM 62.5 MCG/ACTUATION BLISTER POWDER FOR INHALATION RX-127350 CDM 6370000100 HCPCS 250 RC 00173-0873-10 NDC inpatient 1 UN 47.4 47.4 UNITED HEALTHCARE (COMMERCIAL) [3081199] UNITED HEALTHCARE 87726 [308119901] 29.39 percent of total billed charges 29.39 45.03 Technical (Hospital) Services UMECLIDINIUM 62.5 MCG/ACTUATION BLISTER POWDER FOR INHALATION RX-127350 CDM 6370000100 HCPCS 250 RC 00173-0873-10 NDC inpatient 1 UN 47.4 47.4 BLUE CROSS BLUE SHIELD WELLMARK SB889 [3081026] BCBS WYOMING [308102603] 45.03 percent of total billed charges 29.39 45.03 Technical (Hospital) Services PENTOSAN POLYSULFATE SODIUM 100 MG CAPSULE RX-12912 CDM 6370000100 HCPCS 250 RC 50458-0098-01 NDC outpatient 1 UN 46.9 46.9 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES PPO [308136801] 37.52 percent of total billed charges 29.08 44.56 Technical (Hospital) Services PENTOSAN POLYSULFATE SODIUM 100 MG CAPSULE RX-12912 CDM 6370000100 HCPCS 250 RC 50458-0098-01 NDC outpatient 1 UN 46.9 46.9 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES HDHP [308136802] 37.52 percent of total billed charges 29.08 44.56 Technical (Hospital) Services PENTOSAN POLYSULFATE SODIUM 100 MG CAPSULE RX-12912 CDM 6370000100 HCPCS 250 RC 50458-0098-01 NDC outpatient 1 UN 46.9 46.9 MEDICA (COMMERCIAL) 94265 [3081118] MEDICA CLAIMS [308111801] 42.21 percent of total billed charges 29.08 44.56 Technical (Hospital) Services PENTOSAN POLYSULFATE SODIUM 100 MG CAPSULE RX-12912 CDM 6370000100 HCPCS 250 RC 50458-0098-01 NDC outpatient 1 UN 46.9 46.9 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES EPO [308136803] 37.52 percent of total billed charges 29.08 44.56 Technical (Hospital) Services PENTOSAN POLYSULFATE SODIUM 100 MG CAPSULE RX-12912 CDM 6370000100 HCPCS 250 RC 50458-0098-01 NDC outpatient 1 UN 46.9 46.9 CIGNA 62308 [3081051] CIGNA 62308 [308105105] 37.52 percent of total billed charges 29.08 44.56 Technical (Hospital) Services PENTOSAN POLYSULFATE SODIUM 100 MG CAPSULE RX-12912 CDM 6370000100 HCPCS 250 RC 50458-0098-01 NDC outpatient 1 UN 46.9 46.9 CIGNA 62308 [3081051] CIGNA STATE OF WYOMING [308105107] 37.52 percent of total billed charges 29.08 44.56 Technical (Hospital) Services PENTOSAN POLYSULFATE SODIUM 100 MG CAPSULE RX-12912 CDM 6370000100 HCPCS 250 RC 50458-0098-01 NDC outpatient 1 UN 46.9 46.9 MULTIPLAN INC 34080 [3081285] MULTIPLAN INC [308128501] 44.56 percent of total billed charges 29.08 44.56 Technical (Hospital) Services PENTOSAN POLYSULFATE SODIUM 100 MG CAPSULE RX-12912 CDM 6370000100 HCPCS 250 RC 50458-0098-01 NDC outpatient 1 UN 46.9 46.9 UNITED HEALTHCARE (COMMERCIAL) [3081199] UNITED HEALTHCARE 87726 [308119901] 29.08 percent of total billed charges 29.08 44.56 Technical (Hospital) Services PENTOSAN POLYSULFATE SODIUM 100 MG CAPSULE RX-12912 CDM 6370000100 HCPCS 250 RC 50458-0098-01 NDC outpatient 1 UN 46.9 46.9 BLUE CROSS BLUE SHIELD WELLMARK SB889 [3081026] BCBS WYOMING [308102603] 44.56 percent of total billed charges 29.08 44.56 Technical (Hospital) Services PENTOSAN POLYSULFATE SODIUM 100 MG CAPSULE RX-12912 CDM 6370000100 HCPCS 250 RC 50458-0098-01 NDC outpatient 1 UN 46.9 46.9 HEALTHPARTNERS SX009 HEALTHPARTNERS 37.52 percent of total billed charges 29.08 44.56 Technical (Hospital) Services PENTOSAN POLYSULFATE SODIUM 100 MG CAPSULE RX-12912 CDM 6370000100 HCPCS 250 RC 50458-0098-01 NDC inpatient 1 UN 46.9 46.9 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES PPO [308136801] 37.14 percent of total billed charges 29.08 44.56 Technical (Hospital) Services PENTOSAN POLYSULFATE SODIUM 100 MG CAPSULE RX-12912 CDM 6370000100 HCPCS 250 RC 50458-0098-01 NDC inpatient 1 UN 46.9 46.9 MEDICA (COMMERCIAL) 94265 [3081118] MEDICA CLAIMS [308111801] 42.21 percent of total billed charges 29.08 44.56 Technical (Hospital) Services PENTOSAN POLYSULFATE SODIUM 100 MG CAPSULE RX-12912 CDM 6370000100 HCPCS 250 RC 50458-0098-01 NDC inpatient 1 UN 46.9 46.9 HEALTHPARTNERS SX009 HEALTHPARTNERS 37.14 percent of total billed charges 29.08 44.56 Technical (Hospital) Services PENTOSAN POLYSULFATE SODIUM 100 MG CAPSULE RX-12912 CDM 6370000100 HCPCS 250 RC 50458-0098-01 NDC inpatient 1 UN 46.9 46.9 MULTIPLAN INC 34080 [3081285] MULTIPLAN INC [308128501] 44.56 percent of total billed charges 29.08 44.56 Technical (Hospital) Services PENTOSAN POLYSULFATE SODIUM 100 MG CAPSULE RX-12912 CDM 6370000100 HCPCS 250 RC 50458-0098-01 NDC inpatient 1 UN 46.9 46.9 BLUE CROSS BLUE SHIELD WELLMARK SB889 [3081026] BCBS WYOMING [308102603] 44.56 percent of total billed charges 29.08 44.56 Technical (Hospital) Services PENTOSAN POLYSULFATE SODIUM 100 MG CAPSULE RX-12912 CDM 6370000100 HCPCS 250 RC 50458-0098-01 NDC inpatient 1 UN 46.9 46.9 UNITED HEALTHCARE (COMMERCIAL) [3081199] UNITED HEALTHCARE 87726 [308119901] 29.08 percent of total billed charges 29.08 44.56 Technical (Hospital) Services PENTOSAN POLYSULFATE SODIUM 100 MG CAPSULE RX-12912 CDM 6370000100 HCPCS 250 RC 50458-0098-01 NDC inpatient 1 UN 46.9 46.9 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES HDHP [308136802] 37.14 percent of total billed charges 29.08 44.56 Technical (Hospital) Services PENTOSAN POLYSULFATE SODIUM 100 MG CAPSULE RX-12912 CDM 6370000100 HCPCS 250 RC 50458-0098-01 NDC inpatient 1 UN 46.9 46.9 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES EPO [308136803] 37.14 percent of total billed charges 29.08 44.56 Technical (Hospital) Services PENTOSAN POLYSULFATE SODIUM 100 MG CAPSULE RX-12912 CDM 6370000100 HCPCS 250 RC 50458-0098-01 NDC inpatient 1 UN 46.9 46.9 CIGNA 62308 [3081051] CIGNA 62308 [308105105] 37.14 percent of total billed charges 29.08 44.56 Technical (Hospital) Services PENTOSAN POLYSULFATE SODIUM 100 MG CAPSULE RX-12912 CDM 6370000100 HCPCS 250 RC 50458-0098-01 NDC inpatient 1 UN 46.9 46.9 CIGNA 62308 [3081051] CIGNA STATE OF WYOMING [308105107] 37.14 percent of total billed charges 29.08 44.56 Technical (Hospital) Services THYROID (PORK) 30 MG TABLET RX-129143 CDM 6370000100 HCPCS 250 RC 00456-0458-01 NDC inpatient 1 UN 6.58 6.58 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES EPO [308136803] 5.21 percent of total billed charges 4.08 6.25 Technical (Hospital) Services THYROID (PORK) 30 MG TABLET RX-129143 CDM 6370000100 HCPCS 250 RC 00456-0458-01 NDC inpatient 1 UN 6.58 6.58 CIGNA 62308 [3081051] CIGNA 62308 [308105105] 5.21 percent of total billed charges 4.08 6.25 Technical (Hospital) Services THYROID (PORK) 30 MG TABLET RX-129143 CDM 6370000100 HCPCS 250 RC 00456-0458-01 NDC inpatient 1 UN 6.58 6.58 CIGNA 62308 [3081051] CIGNA STATE OF WYOMING [308105107] 5.21 percent of total billed charges 4.08 6.25 Technical (Hospital) Services THYROID (PORK) 30 MG TABLET RX-129143 CDM 6370000100 HCPCS 250 RC 00456-0458-01 NDC inpatient 1 UN 6.58 6.58 MEDICA (COMMERCIAL) 94265 [3081118] MEDICA CLAIMS [308111801] 5.92 percent of total billed charges 4.08 6.25 Technical (Hospital) Services THYROID (PORK) 30 MG TABLET RX-129143 CDM 6370000100 HCPCS 250 RC 00456-0458-01 NDC inpatient 1 UN 6.58 6.58 HEALTHPARTNERS SX009 HEALTHPARTNERS 5.21 percent of total billed charges 4.08 6.25 Technical (Hospital) Services THYROID (PORK) 30 MG TABLET RX-129143 CDM 6370000100 HCPCS 250 RC 00456-0458-01 NDC inpatient 1 UN 6.58 6.58 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES HDHP [308136802] 5.21 percent of total billed charges 4.08 6.25 Technical (Hospital) Services THYROID (PORK) 30 MG TABLET RX-129143 CDM 6370000100 HCPCS 250 RC 00456-0458-01 NDC inpatient 1 UN 6.58 6.58 UNITED HEALTHCARE (COMMERCIAL) [3081199] UNITED HEALTHCARE 87726 [308119901] 4.08 percent of total billed charges 4.08 6.25 Technical (Hospital) Services THYROID (PORK) 30 MG TABLET RX-129143 CDM 6370000100 HCPCS 250 RC 00456-0458-01 NDC inpatient 1 UN 6.58 6.58 BLUE CROSS BLUE SHIELD WELLMARK SB889 [3081026] BCBS WYOMING [308102603] 6.25 percent of total billed charges 4.08 6.25 Technical (Hospital) Services THYROID (PORK) 30 MG TABLET RX-129143 CDM 6370000100 HCPCS 250 RC 00456-0458-01 NDC inpatient 1 UN 6.58 6.58 MULTIPLAN INC 34080 [3081285] MULTIPLAN INC [308128501] 6.25 percent of total billed charges 4.08 6.25 Technical (Hospital) Services THYROID (PORK) 30 MG TABLET RX-129143 CDM 6370000100 HCPCS 250 RC 00456-0458-01 NDC inpatient 1 UN 6.58 6.58 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES PPO [308136801] 5.21 percent of total billed charges 4.08 6.25 Technical (Hospital) Services THYROID (PORK) 30 MG TABLET RX-129143 CDM 6370000100 HCPCS 250 RC 00456-0458-01 NDC outpatient 1 UN 6.58 6.58 MEDICA (COMMERCIAL) 94265 [3081118] MEDICA CLAIMS [308111801] 5.92 percent of total billed charges 4.08 6.25 Technical (Hospital) Services THYROID (PORK) 30 MG TABLET RX-129143 CDM 6370000100 HCPCS 250 RC 00456-0458-01 NDC outpatient 1 UN 6.58 6.58 CIGNA 62308 [3081051] CIGNA STATE OF WYOMING [308105107] 5.26 percent of total billed charges 4.08 6.25 Technical (Hospital) Services THYROID (PORK) 30 MG TABLET RX-129143 CDM 6370000100 HCPCS 250 RC 00456-0458-01 NDC outpatient 1 UN 6.58 6.58 CIGNA 62308 [3081051] CIGNA 62308 [308105105] 5.26 percent of total billed charges 4.08 6.25 Technical (Hospital) Services THYROID (PORK) 30 MG TABLET RX-129143 CDM 6370000100 HCPCS 250 RC 00456-0458-01 NDC outpatient 1 UN 6.58 6.58 MULTIPLAN INC 34080 [3081285] MULTIPLAN INC [308128501] 6.25 percent of total billed charges 4.08 6.25 Technical (Hospital) Services THYROID (PORK) 30 MG TABLET RX-129143 CDM 6370000100 HCPCS 250 RC 00456-0458-01 NDC outpatient 1 UN 6.58 6.58 UNITED HEALTHCARE (COMMERCIAL) [3081199] UNITED HEALTHCARE 87726 [308119901] 4.08 percent of total billed charges 4.08 6.25 Technical (Hospital) Services THYROID (PORK) 30 MG TABLET RX-129143 CDM 6370000100 HCPCS 250 RC 00456-0458-01 NDC outpatient 1 UN 6.58 6.58 BLUE CROSS BLUE SHIELD WELLMARK SB889 [3081026] BCBS WYOMING [308102603] 6.25 percent of total billed charges 4.08 6.25 Technical (Hospital) Services THYROID (PORK) 30 MG TABLET RX-129143 CDM 6370000100 HCPCS 250 RC 00456-0458-01 NDC outpatient 1 UN 6.58 6.58 HEALTHPARTNERS SX009 HEALTHPARTNERS 5.26 percent of total billed charges 4.08 6.25 Technical (Hospital) Services THYROID (PORK) 30 MG TABLET RX-129143 CDM 6370000100 HCPCS 250 RC 00456-0458-01 NDC outpatient 1 UN 6.58 6.58 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES PPO [308136801] 5.26 percent of total billed charges 4.08 6.25 Technical (Hospital) Services THYROID (PORK) 30 MG TABLET RX-129143 CDM 6370000100 HCPCS 250 RC 00456-0458-01 NDC outpatient 1 UN 6.58 6.58 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES HDHP [308136802] 5.26 percent of total billed charges 4.08 6.25 Technical (Hospital) Services THYROID (PORK) 30 MG TABLET RX-129143 CDM 6370000100 HCPCS 250 RC 00456-0458-01 NDC outpatient 1 UN 6.58 6.58 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES EPO [308136803] 5.26 percent of total billed charges 4.08 6.25 Technical (Hospital) Services THYROID (PORK) 180 MG TABLET RX-129147 CDM 6370000100 HCPCS 250 RC 00456-0462-01 NDC outpatient 1 UN 7.09 7.09 MEDICA (COMMERCIAL) 94265 [3081118] MEDICA CLAIMS [308111801] 6.38 percent of total billed charges 4.4 6.74 Technical (Hospital) Services THYROID (PORK) 180 MG TABLET RX-129147 CDM 6370000100 HCPCS 250 RC 00456-0462-01 NDC outpatient 1 UN 7.09 7.09 CIGNA 62308 [3081051] CIGNA 62308 [308105105] 5.67 percent of total billed charges 4.4 6.74 Technical (Hospital) Services THYROID (PORK) 180 MG TABLET RX-129147 CDM 6370000100 HCPCS 250 RC 00456-0462-01 NDC outpatient 1 UN 7.09 7.09 CIGNA 62308 [3081051] CIGNA STATE OF WYOMING [308105107] 5.67 percent of total billed charges 4.4 6.74 Technical (Hospital) Services THYROID (PORK) 180 MG TABLET RX-129147 CDM 6370000100 HCPCS 250 RC 00456-0462-01 NDC outpatient 1 UN 7.09 7.09 UNITED HEALTHCARE (COMMERCIAL) [3081199] UNITED HEALTHCARE 87726 [308119901] 4.4 percent of total billed charges 4.4 6.74 Technical (Hospital) Services THYROID (PORK) 180 MG TABLET RX-129147 CDM 6370000100 HCPCS 250 RC 00456-0462-01 NDC outpatient 1 UN 7.09 7.09 MULTIPLAN INC 34080 [3081285] MULTIPLAN INC [308128501] 6.74 percent of total billed charges 4.4 6.74 Technical (Hospital) Services THYROID (PORK) 180 MG TABLET RX-129147 CDM 6370000100 HCPCS 250 RC 00456-0462-01 NDC outpatient 1 UN 7.09 7.09 HEALTHPARTNERS SX009 HEALTHPARTNERS 5.67 percent of total billed charges 4.4 6.74 Technical (Hospital) Services THYROID (PORK) 180 MG TABLET RX-129147 CDM 6370000100 HCPCS 250 RC 00456-0462-01 NDC outpatient 1 UN 7.09 7.09 BLUE CROSS BLUE SHIELD WELLMARK SB889 [3081026] BCBS WYOMING [308102603] 6.74 percent of total billed charges 4.4 6.74 Technical (Hospital) Services THYROID (PORK) 180 MG TABLET RX-129147 CDM 6370000100 HCPCS 250 RC 00456-0462-01 NDC outpatient 1 UN 7.09 7.09 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES PPO [308136801] 5.67 percent of total billed charges 4.4 6.74 Technical (Hospital) Services THYROID (PORK) 180 MG TABLET RX-129147 CDM 6370000100 HCPCS 250 RC 00456-0462-01 NDC outpatient 1 UN 7.09 7.09 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES EPO [308136803] 5.67 percent of total billed charges 4.4 6.74 Technical (Hospital) Services THYROID (PORK) 180 MG TABLET RX-129147 CDM 6370000100 HCPCS 250 RC 00456-0462-01 NDC outpatient 1 UN 7.09 7.09 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES HDHP [308136802] 5.67 percent of total billed charges 4.4 6.74 Technical (Hospital) Services THYROID (PORK) 180 MG TABLET RX-129147 CDM 6370000100 HCPCS 250 RC 00456-0462-01 NDC inpatient 1 UN 7.09 7.09 MULTIPLAN INC 34080 [3081285] MULTIPLAN INC [308128501] 6.74 percent of total billed charges 4.4 6.74 Technical (Hospital) Services THYROID (PORK) 180 MG TABLET RX-129147 CDM 6370000100 HCPCS 250 RC 00456-0462-01 NDC inpatient 1 UN 7.09 7.09 MEDICA (COMMERCIAL) 94265 [3081118] MEDICA CLAIMS [308111801] 6.38 percent of total billed charges 4.4 6.74 Technical (Hospital) Services THYROID (PORK) 180 MG TABLET RX-129147 CDM 6370000100 HCPCS 250 RC 00456-0462-01 NDC inpatient 1 UN 7.09 7.09 HEALTHPARTNERS SX009 HEALTHPARTNERS 5.61 percent of total billed charges 4.4 6.74 Technical (Hospital) Services THYROID (PORK) 180 MG TABLET RX-129147 CDM 6370000100 HCPCS 250 RC 00456-0462-01 NDC inpatient 1 UN 7.09 7.09 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES PPO [308136801] 5.61 percent of total billed charges 4.4 6.74 Technical (Hospital) Services THYROID (PORK) 180 MG TABLET RX-129147 CDM 6370000100 HCPCS 250 RC 00456-0462-01 NDC inpatient 1 UN 7.09 7.09 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES EPO [308136803] 5.61 percent of total billed charges 4.4 6.74 Technical (Hospital) Services THYROID (PORK) 180 MG TABLET RX-129147 CDM 6370000100 HCPCS 250 RC 00456-0462-01 NDC inpatient 1 UN 7.09 7.09 CIGNA 62308 [3081051] CIGNA 62308 [308105105] 5.61 percent of total billed charges 4.4 6.74 Technical (Hospital) Services THYROID (PORK) 180 MG TABLET RX-129147 CDM 6370000100 HCPCS 250 RC 00456-0462-01 NDC inpatient 1 UN 7.09 7.09 CIGNA 62308 [3081051] CIGNA STATE OF WYOMING [308105107] 5.61 percent of total billed charges 4.4 6.74 Technical (Hospital) Services THYROID (PORK) 180 MG TABLET RX-129147 CDM 6370000100 HCPCS 250 RC 00456-0462-01 NDC inpatient 1 UN 7.09 7.09 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES HDHP [308136802] 5.61 percent of total billed charges 4.4 6.74 Technical (Hospital) Services THYROID (PORK) 180 MG TABLET RX-129147 CDM 6370000100 HCPCS 250 RC 00456-0462-01 NDC inpatient 1 UN 7.09 7.09 UNITED HEALTHCARE (COMMERCIAL) [3081199] UNITED HEALTHCARE 87726 [308119901] 4.4 percent of total billed charges 4.4 6.74 Technical (Hospital) Services THYROID (PORK) 180 MG TABLET RX-129147 CDM 6370000100 HCPCS 250 RC 00456-0462-01 NDC inpatient 1 UN 7.09 7.09 BLUE CROSS BLUE SHIELD WELLMARK SB889 [3081026] BCBS WYOMING [308102603] 6.74 percent of total billed charges 4.4 6.74 Technical (Hospital) Services ACETAMINOPHEN 160 MG/5 ML (5 ML) ORAL SOLUTION RX-129286 CDM 6370000100 HCPCS 250 RC 81033-0002-05 NDC inpatient 5 ML 6.37 6.37 MEDICA (COMMERCIAL) 94265 [3081118] MEDICA CLAIMS [308111801] 5.73 percent of total billed charges 3.95 6.05 Technical (Hospital) Services ACETAMINOPHEN 160 MG/5 ML (5 ML) ORAL SOLUTION RX-129286 CDM 6370000100 HCPCS 250 RC 81033-0002-05 NDC inpatient 5 ML 6.37 6.37 MULTIPLAN INC 34080 [3081285] MULTIPLAN INC [308128501] 6.05 percent of total billed charges 3.95 6.05 Technical (Hospital) Services ACETAMINOPHEN 160 MG/5 ML (5 ML) ORAL SOLUTION RX-129286 CDM 6370000100 HCPCS 250 RC 81033-0002-05 NDC inpatient 5 ML 6.37 6.37 BLUE CROSS BLUE SHIELD WELLMARK SB889 [3081026] BCBS WYOMING [308102603] 6.05 percent of total billed charges 3.95 6.05 Technical (Hospital) Services ACETAMINOPHEN 160 MG/5 ML (5 ML) ORAL SOLUTION RX-129286 CDM 6370000100 HCPCS 250 RC 81033-0002-05 NDC inpatient 5 ML 6.37 6.37 UNITED HEALTHCARE (COMMERCIAL) [3081199] UNITED HEALTHCARE 87726 [308119901] 3.95 percent of total billed charges 3.95 6.05 Technical (Hospital) Services ACETAMINOPHEN 160 MG/5 ML (5 ML) ORAL SOLUTION RX-129286 CDM 6370000100 HCPCS 250 RC 81033-0002-05 NDC inpatient 5 ML 6.37 6.37 CIGNA 62308 [3081051] CIGNA 62308 [308105105] 5.04 percent of total billed charges 3.95 6.05 Technical (Hospital) Services ACETAMINOPHEN 160 MG/5 ML (5 ML) ORAL SOLUTION RX-129286 CDM 6370000100 HCPCS 250 RC 81033-0002-05 NDC inpatient 5 ML 6.37 6.37 CIGNA 62308 [3081051] CIGNA STATE OF WYOMING [308105107] 5.04 percent of total billed charges 3.95 6.05 Technical (Hospital) Services ACETAMINOPHEN 160 MG/5 ML (5 ML) ORAL SOLUTION RX-129286 CDM 6370000100 HCPCS 250 RC 81033-0002-05 NDC inpatient 5 ML 6.37 6.37 HEALTHPARTNERS SX009 HEALTHPARTNERS 5.04 percent of total billed charges 3.95 6.05 Technical (Hospital) Services ACETAMINOPHEN 160 MG/5 ML (5 ML) ORAL SOLUTION RX-129286 CDM 6370000100 HCPCS 250 RC 81033-0002-05 NDC inpatient 5 ML 6.37 6.37 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES EPO [308136803] 5.04 percent of total billed charges 3.95 6.05 Technical (Hospital) Services ACETAMINOPHEN 160 MG/5 ML (5 ML) ORAL SOLUTION RX-129286 CDM 6370000100 HCPCS 250 RC 81033-0002-05 NDC outpatient 5 ML 6.37 6.37 MEDICA (COMMERCIAL) 94265 [3081118] MEDICA CLAIMS [308111801] 5.73 percent of total billed charges 3.95 6.05 Technical (Hospital) Services ACETAMINOPHEN 160 MG/5 ML (5 ML) ORAL SOLUTION RX-129286 CDM 6370000100 HCPCS 250 RC 81033-0002-05 NDC outpatient 5 ML 6.37 6.37 MULTIPLAN INC 34080 [3081285] MULTIPLAN INC [308128501] 6.05 percent of total billed charges 3.95 6.05 Technical (Hospital) Services ACETAMINOPHEN 160 MG/5 ML (5 ML) ORAL SOLUTION RX-129286 CDM 6370000100 HCPCS 250 RC 81033-0002-05 NDC outpatient 5 ML 6.37 6.37 CIGNA 62308 [3081051] CIGNA 62308 [308105105] 5.1 percent of total billed charges 3.95 6.05 Technical (Hospital) Services ACETAMINOPHEN 160 MG/5 ML (5 ML) ORAL SOLUTION RX-129286 CDM 6370000100 HCPCS 250 RC 81033-0002-05 NDC outpatient 5 ML 6.37 6.37 CIGNA 62308 [3081051] CIGNA STATE OF WYOMING [308105107] 5.1 percent of total billed charges 3.95 6.05 Technical (Hospital) Services ACETAMINOPHEN 160 MG/5 ML (5 ML) ORAL SOLUTION RX-129286 CDM 6370000100 HCPCS 250 RC 81033-0002-05 NDC outpatient 5 ML 6.37 6.37 UNITED HEALTHCARE (COMMERCIAL) [3081199] UNITED HEALTHCARE 87726 [308119901] 3.95 percent of total billed charges 3.95 6.05 Technical (Hospital) Services ACETAMINOPHEN 160 MG/5 ML (5 ML) ORAL SOLUTION RX-129286 CDM 6370000100 HCPCS 250 RC 81033-0002-05 NDC outpatient 5 ML 6.37 6.37 HEALTHPARTNERS SX009 HEALTHPARTNERS 5.1 percent of total billed charges 3.95 6.05 Technical (Hospital) Services ACETAMINOPHEN 160 MG/5 ML (5 ML) ORAL SOLUTION RX-129286 CDM 6370000100 HCPCS 250 RC 81033-0002-05 NDC outpatient 5 ML 6.37 6.37 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES EPO [308136803] 5.1 percent of total billed charges 3.95 6.05 Technical (Hospital) Services ACETAMINOPHEN 160 MG/5 ML (5 ML) ORAL SOLUTION RX-129286 CDM 6370000100 HCPCS 250 RC 81033-0002-05 NDC inpatient 5 ML 6.37 6.37 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES HDHP [308136802] 5.04 percent of total billed charges 3.95 6.05 Technical (Hospital) Services ACETAMINOPHEN 160 MG/5 ML (5 ML) ORAL SOLUTION RX-129286 CDM 6370000100 HCPCS 250 RC 81033-0002-05 NDC inpatient 5 ML 6.37 6.37 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES PPO [308136801] 5.04 percent of total billed charges 3.95 6.05 Technical (Hospital) Services ACETAMINOPHEN 160 MG/5 ML (5 ML) ORAL SOLUTION RX-129286 CDM 6370000100 HCPCS 250 RC 81033-0002-05 NDC outpatient 5 ML 6.37 6.37 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES HDHP [308136802] 5.1 percent of total billed charges 3.95 6.05 Technical (Hospital) Services ACETAMINOPHEN 160 MG/5 ML (5 ML) ORAL SOLUTION RX-129286 CDM 6370000100 HCPCS 250 RC 81033-0002-05 NDC outpatient 5 ML 6.37 6.37 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES PPO [308136801] 5.1 percent of total billed charges 3.95 6.05 Technical (Hospital) Services ACETAMINOPHEN 160 MG/5 ML (5 ML) ORAL SOLUTION RX-129286 CDM 6370000100 HCPCS 250 RC 81033-0002-05 NDC outpatient 5 ML 6.37 6.37 BLUE CROSS BLUE SHIELD WELLMARK SB889 [3081026] BCBS WYOMING [308102603] 6.05 percent of total billed charges 3.95 6.05 Technical (Hospital) Services WITCH HAZEL 50 % TOPICAL PADS RX-129535 CDM 6370000100 HCPCS 250 RC 00573-0558-07 NDC inpatient 1 UN 5.89 5.89 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES HDHP [308136802] 4.66 percent of total billed charges 3.65 5.6 Technical (Hospital) Services WITCH HAZEL 50 % TOPICAL PADS RX-129535 CDM 6370000100 HCPCS 250 RC 00573-0558-07 NDC inpatient 1 UN 5.89 5.89 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES EPO [308136803] 4.66 percent of total billed charges 3.65 5.6 Technical (Hospital) Services WITCH HAZEL 50 % TOPICAL PADS RX-129535 CDM 6370000100 HCPCS 250 RC 00573-0558-07 NDC inpatient 1 UN 5.89 5.89 CIGNA 62308 [3081051] CIGNA 62308 [308105105] 4.66 percent of total billed charges 3.65 5.6 Technical (Hospital) Services WITCH HAZEL 50 % TOPICAL PADS RX-129535 CDM 6370000100 HCPCS 250 RC 00573-0558-07 NDC inpatient 1 UN 5.89 5.89 CIGNA 62308 [3081051] CIGNA STATE OF WYOMING [308105107] 4.66 percent of total billed charges 3.65 5.6 Technical (Hospital) Services WITCH HAZEL 50 % TOPICAL PADS RX-129535 CDM 6370000100 HCPCS 250 RC 00573-0558-07 NDC inpatient 1 UN 5.89 5.89 UNITED HEALTHCARE (COMMERCIAL) [3081199] UNITED HEALTHCARE 87726 [308119901] 3.65 percent of total billed charges 3.65 5.6 Technical (Hospital) Services WITCH HAZEL 50 % TOPICAL PADS RX-129535 CDM 6370000100 HCPCS 250 RC 00573-0558-07 NDC inpatient 1 UN 5.89 5.89 BLUE CROSS BLUE SHIELD WELLMARK SB889 [3081026] BCBS WYOMING [308102603] 5.6 percent of total billed charges 3.65 5.6 Technical (Hospital) Services WITCH HAZEL 50 % TOPICAL PADS RX-129535 CDM 6370000100 HCPCS 250 RC 00573-0558-07 NDC inpatient 1 UN 5.89 5.89 MULTIPLAN INC 34080 [3081285] MULTIPLAN INC [308128501] 5.6 percent of total billed charges 3.65 5.6 Technical (Hospital) Services WITCH HAZEL 50 % TOPICAL PADS RX-129535 CDM 6370000100 HCPCS 250 RC 00573-0558-07 NDC inpatient 1 UN 5.89 5.89 MEDICA (COMMERCIAL) 94265 [3081118] MEDICA CLAIMS [308111801] 5.3 percent of total billed charges 3.65 5.6 Technical (Hospital) Services WITCH HAZEL 50 % TOPICAL PADS RX-129535 CDM 6370000100 HCPCS 250 RC 00573-0558-07 NDC inpatient 1 UN 5.89 5.89 HEALTHPARTNERS SX009 HEALTHPARTNERS 4.66 percent of total billed charges 3.65 5.6 Technical (Hospital) Services WITCH HAZEL 50 % TOPICAL PADS RX-129535 CDM 6370000100 HCPCS 250 RC 00573-0558-07 NDC inpatient 1 UN 5.89 5.89 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES PPO [308136801] 4.66 percent of total billed charges 3.65 5.6 Technical (Hospital) Services WITCH HAZEL 50 % TOPICAL PADS RX-129535 CDM 6370000100 HCPCS 250 RC 00573-0558-07 NDC outpatient 1 UN 5.89 5.89 BLUE CROSS BLUE SHIELD WELLMARK SB889 [3081026] BCBS WYOMING [308102603] 5.6 percent of total billed charges 3.65 5.6 Technical (Hospital) Services WITCH HAZEL 50 % TOPICAL PADS RX-129535 CDM 6370000100 HCPCS 250 RC 00573-0558-07 NDC outpatient 1 UN 5.89 5.89 HEALTHPARTNERS SX009 HEALTHPARTNERS 4.71 percent of total billed charges 3.65 5.6 Technical (Hospital) Services WITCH HAZEL 50 % TOPICAL PADS RX-129535 CDM 6370000100 HCPCS 250 RC 00573-0558-07 NDC outpatient 1 UN 5.89 5.89 UNITED HEALTHCARE (COMMERCIAL) [3081199] UNITED HEALTHCARE 87726 [308119901] 3.65 percent of total billed charges 3.65 5.6 Technical (Hospital) Services WITCH HAZEL 50 % TOPICAL PADS RX-129535 CDM 6370000100 HCPCS 250 RC 00573-0558-07 NDC outpatient 1 UN 5.89 5.89 MEDICA (COMMERCIAL) 94265 [3081118] MEDICA CLAIMS [308111801] 5.3 percent of total billed charges 3.65 5.6 Technical (Hospital) Services WITCH HAZEL 50 % TOPICAL PADS RX-129535 CDM 6370000100 HCPCS 250 RC 00573-0558-07 NDC outpatient 1 UN 5.89 5.89 MULTIPLAN INC 34080 [3081285] MULTIPLAN INC [308128501] 5.6 percent of total billed charges 3.65 5.6 Technical (Hospital) Services WITCH HAZEL 50 % TOPICAL PADS RX-129535 CDM 6370000100 HCPCS 250 RC 00573-0558-07 NDC outpatient 1 UN 5.89 5.89 CIGNA 62308 [3081051] CIGNA 62308 [308105105] 4.71 percent of total billed charges 3.65 5.6 Technical (Hospital) Services WITCH HAZEL 50 % TOPICAL PADS RX-129535 CDM 6370000100 HCPCS 250 RC 00573-0558-07 NDC outpatient 1 UN 5.89 5.89 CIGNA 62308 [3081051] CIGNA STATE OF WYOMING [308105107] 4.71 percent of total billed charges 3.65 5.6 Technical (Hospital) Services WITCH HAZEL 50 % TOPICAL PADS RX-129535 CDM 6370000100 HCPCS 250 RC 00573-0558-07 NDC outpatient 1 UN 5.89 5.89 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES PPO [308136801] 4.71 percent of total billed charges 3.65 5.6 Technical (Hospital) Services WITCH HAZEL 50 % TOPICAL PADS RX-129535 CDM 6370000100 HCPCS 250 RC 00573-0558-07 NDC outpatient 1 UN 5.89 5.89 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES EPO [308136803] 4.71 percent of total billed charges 3.65 5.6 Technical (Hospital) Services WITCH HAZEL 50 % TOPICAL PADS RX-129535 CDM 6370000100 HCPCS 250 RC 00573-0558-07 NDC outpatient 1 UN 5.89 5.89 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES HDHP [308136802] 4.71 percent of total billed charges 3.65 5.6 Technical (Hospital) Services TIOTROPIUM 2.5 MCG-OLODATEROL 2.5 MCG/ACTUATION MIST FOR INHALATION RX-129646 CDM 6370000100 HCPCS 250 RC 00597-0155-70 NDC inpatient 4 GR 306.5 306.5 HEALTHPARTNERS SX009 HEALTHPARTNERS 242.69 percent of total billed charges 190.03 291.18 Technical (Hospital) Services TIOTROPIUM 2.5 MCG-OLODATEROL 2.5 MCG/ACTUATION MIST FOR INHALATION RX-129646 CDM 6370000100 HCPCS 250 RC 00597-0155-70 NDC inpatient 4 GR 306.5 306.5 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES HDHP [308136802] 242.69 percent of total billed charges 190.03 291.18 Technical (Hospital) Services TIOTROPIUM 2.5 MCG-OLODATEROL 2.5 MCG/ACTUATION MIST FOR INHALATION RX-129646 CDM 6370000100 HCPCS 250 RC 00597-0155-70 NDC inpatient 4 GR 306.5 306.5 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES PPO [308136801] 242.69 percent of total billed charges 190.03 291.18 Technical (Hospital) Services TIOTROPIUM 2.5 MCG-OLODATEROL 2.5 MCG/ACTUATION MIST FOR INHALATION RX-129646 CDM 6370000100 HCPCS 250 RC 00597-0155-70 NDC inpatient 4 GR 306.5 306.5 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES EPO [308136803] 242.69 percent of total billed charges 190.03 291.18 Technical (Hospital) Services TIOTROPIUM 2.5 MCG-OLODATEROL 2.5 MCG/ACTUATION MIST FOR INHALATION RX-129646 CDM 6370000100 HCPCS 250 RC 00597-0155-70 NDC inpatient 4 GR 306.5 306.5 CIGNA 62308 [3081051] CIGNA 62308 [308105105] 242.69 percent of total billed charges 190.03 291.18 Technical (Hospital) Services TIOTROPIUM 2.5 MCG-OLODATEROL 2.5 MCG/ACTUATION MIST FOR INHALATION RX-129646 CDM 6370000100 HCPCS 250 RC 00597-0155-70 NDC inpatient 4 GR 306.5 306.5 CIGNA 62308 [3081051] CIGNA STATE OF WYOMING [308105107] 242.69 percent of total billed charges 190.03 291.18 Technical (Hospital) Services TIOTROPIUM 2.5 MCG-OLODATEROL 2.5 MCG/ACTUATION MIST FOR INHALATION RX-129646 CDM 6370000100 HCPCS 250 RC 00597-0155-70 NDC inpatient 4 GR 306.5 306.5 BLUE CROSS BLUE SHIELD WELLMARK SB889 [3081026] BCBS WYOMING [308102603] 291.18 percent of total billed charges 190.03 291.18 Technical (Hospital) Services TIOTROPIUM 2.5 MCG-OLODATEROL 2.5 MCG/ACTUATION MIST FOR INHALATION RX-129646 CDM 6370000100 HCPCS 250 RC 00597-0155-70 NDC inpatient 4 GR 306.5 306.5 UNITED HEALTHCARE (COMMERCIAL) [3081199] UNITED HEALTHCARE 87726 [308119901] 190.03 percent of total billed charges 190.03 291.18 Technical (Hospital) Services TIOTROPIUM 2.5 MCG-OLODATEROL 2.5 MCG/ACTUATION MIST FOR INHALATION RX-129646 CDM 6370000100 HCPCS 250 RC 00597-0155-70 NDC inpatient 4 GR 306.5 306.5 MULTIPLAN INC 34080 [3081285] MULTIPLAN INC [308128501] 291.18 percent of total billed charges 190.03 291.18 Technical (Hospital) Services TIOTROPIUM 2.5 MCG-OLODATEROL 2.5 MCG/ACTUATION MIST FOR INHALATION RX-129646 CDM 6370000100 HCPCS 250 RC 00597-0155-70 NDC inpatient 4 GR 306.5 306.5 MEDICA (COMMERCIAL) 94265 [3081118] MEDICA CLAIMS [308111801] 275.85 percent of total billed charges 190.03 291.18 Technical (Hospital) Services TIOTROPIUM 2.5 MCG-OLODATEROL 2.5 MCG/ACTUATION MIST FOR INHALATION RX-129646 CDM 6370000100 HCPCS 250 RC 00597-0155-70 NDC outpatient 4 GR 306.5 306.5 CIGNA 62308 [3081051] CIGNA 62308 [308105105] 245.2 percent of total billed charges 190.03 291.18 Technical (Hospital) Services TIOTROPIUM 2.5 MCG-OLODATEROL 2.5 MCG/ACTUATION MIST FOR INHALATION RX-129646 CDM 6370000100 HCPCS 250 RC 00597-0155-70 NDC outpatient 4 GR 306.5 306.5 CIGNA 62308 [3081051] CIGNA STATE OF WYOMING [308105107] 245.2 percent of total billed charges 190.03 291.18 Technical (Hospital) Services TIOTROPIUM 2.5 MCG-OLODATEROL 2.5 MCG/ACTUATION MIST FOR INHALATION RX-129646 CDM 6370000100 HCPCS 250 RC 00597-0155-70 NDC outpatient 4 GR 306.5 306.5 HEALTHPARTNERS SX009 HEALTHPARTNERS 245.2 percent of total billed charges 190.03 291.18 Technical (Hospital) Services TIOTROPIUM 2.5 MCG-OLODATEROL 2.5 MCG/ACTUATION MIST FOR INHALATION RX-129646 CDM 6370000100 HCPCS 250 RC 00597-0155-70 NDC outpatient 4 GR 306.5 306.5 UNITED HEALTHCARE (COMMERCIAL) [3081199] UNITED HEALTHCARE 87726 [308119901] 190.03 percent of total billed charges 190.03 291.18 Technical (Hospital) Services TIOTROPIUM 2.5 MCG-OLODATEROL 2.5 MCG/ACTUATION MIST FOR INHALATION RX-129646 CDM 6370000100 HCPCS 250 RC 00597-0155-70 NDC outpatient 4 GR 306.5 306.5 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES EPO [308136803] 245.2 percent of total billed charges 190.03 291.18 Technical (Hospital) Services TIOTROPIUM 2.5 MCG-OLODATEROL 2.5 MCG/ACTUATION MIST FOR INHALATION RX-129646 CDM 6370000100 HCPCS 250 RC 00597-0155-70 NDC outpatient 4 GR 306.5 306.5 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES HDHP [308136802] 245.2 percent of total billed charges 190.03 291.18 Technical (Hospital) Services TIOTROPIUM 2.5 MCG-OLODATEROL 2.5 MCG/ACTUATION MIST FOR INHALATION RX-129646 CDM 6370000100 HCPCS 250 RC 00597-0155-70 NDC outpatient 4 GR 306.5 306.5 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES PPO [308136801] 245.2 percent of total billed charges 190.03 291.18 Technical (Hospital) Services TIOTROPIUM 2.5 MCG-OLODATEROL 2.5 MCG/ACTUATION MIST FOR INHALATION RX-129646 CDM 6370000100 HCPCS 250 RC 00597-0155-70 NDC outpatient 4 GR 306.5 306.5 BLUE CROSS BLUE SHIELD WELLMARK SB889 [3081026] BCBS WYOMING [308102603] 291.18 percent of total billed charges 190.03 291.18 Technical (Hospital) Services TIOTROPIUM 2.5 MCG-OLODATEROL 2.5 MCG/ACTUATION MIST FOR INHALATION RX-129646 CDM 6370000100 HCPCS 250 RC 00597-0155-70 NDC outpatient 4 GR 306.5 306.5 MEDICA (COMMERCIAL) 94265 [3081118] MEDICA CLAIMS [308111801] 275.85 percent of total billed charges 190.03 291.18 Technical (Hospital) Services TIOTROPIUM 2.5 MCG-OLODATEROL 2.5 MCG/ACTUATION MIST FOR INHALATION RX-129646 CDM 6370000100 HCPCS 250 RC 00597-0155-70 NDC outpatient 4 GR 306.5 306.5 MULTIPLAN INC 34080 [3081285] MULTIPLAN INC [308128501] 291.18 percent of total billed charges 190.03 291.18 Technical (Hospital) Services SACUBITRIL 24 MG-VALSARTAN 26 MG TABLET RX-129911 CDM 6370000100 HCPCS 250 RC 00078-0659-20 NDC inpatient 1 UN 47.07 47.07 UNITED HEALTHCARE (COMMERCIAL) [3081199] UNITED HEALTHCARE 87726 [308119901] 29.18 percent of total billed charges 29.18 44.72 Technical (Hospital) Services SACUBITRIL 24 MG-VALSARTAN 26 MG TABLET RX-129911 CDM 6370000100 HCPCS 250 RC 00078-0659-20 NDC inpatient 1 UN 47.07 47.07 BLUE CROSS BLUE SHIELD WELLMARK SB889 [3081026] BCBS WYOMING [308102603] 44.72 percent of total billed charges 29.18 44.72 Technical (Hospital) Services SACUBITRIL 24 MG-VALSARTAN 26 MG TABLET RX-129911 CDM 6370000100 HCPCS 250 RC 00078-0659-20 NDC inpatient 1 UN 47.07 47.07 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES HDHP [308136802] 37.27 percent of total billed charges 29.18 44.72 Technical (Hospital) Services SACUBITRIL 24 MG-VALSARTAN 26 MG TABLET RX-129911 CDM 6370000100 HCPCS 250 RC 00078-0659-20 NDC inpatient 1 UN 47.07 47.07 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES EPO [308136803] 37.27 percent of total billed charges 29.18 44.72 Technical (Hospital) Services SACUBITRIL 24 MG-VALSARTAN 26 MG TABLET RX-129911 CDM 6370000100 HCPCS 250 RC 00078-0659-20 NDC inpatient 1 UN 47.07 47.07 CIGNA 62308 [3081051] CIGNA 62308 [308105105] 37.27 percent of total billed charges 29.18 44.72 Technical (Hospital) Services SACUBITRIL 24 MG-VALSARTAN 26 MG TABLET RX-129911 CDM 6370000100 HCPCS 250 RC 00078-0659-20 NDC inpatient 1 UN 47.07 47.07 CIGNA 62308 [3081051] CIGNA STATE OF WYOMING [308105107] 37.27 percent of total billed charges 29.18 44.72 Technical (Hospital) Services SACUBITRIL 24 MG-VALSARTAN 26 MG TABLET RX-129911 CDM 6370000100 HCPCS 250 RC 00078-0659-20 NDC inpatient 1 UN 47.07 47.07 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES PPO [308136801] 37.27 percent of total billed charges 29.18 44.72 Technical (Hospital) Services SACUBITRIL 24 MG-VALSARTAN 26 MG TABLET RX-129911 CDM 6370000100 HCPCS 250 RC 00078-0659-20 NDC inpatient 1 UN 47.07 47.07 HEALTHPARTNERS SX009 HEALTHPARTNERS 37.27 percent of total billed charges 29.18 44.72 Technical (Hospital) Services SACUBITRIL 24 MG-VALSARTAN 26 MG TABLET RX-129911 CDM 6370000100 HCPCS 250 RC 00078-0659-20 NDC inpatient 1 UN 47.07 47.07 MEDICA (COMMERCIAL) 94265 [3081118] MEDICA CLAIMS [308111801] 42.36 percent of total billed charges 29.18 44.72 Technical (Hospital) Services SACUBITRIL 24 MG-VALSARTAN 26 MG TABLET RX-129911 CDM 6370000100 HCPCS 250 RC 00078-0659-20 NDC inpatient 1 UN 47.07 47.07 MULTIPLAN INC 34080 [3081285] MULTIPLAN INC [308128501] 44.72 percent of total billed charges 29.18 44.72 Technical (Hospital) Services SACUBITRIL 24 MG-VALSARTAN 26 MG TABLET RX-129911 CDM 6370000100 HCPCS 250 RC 00078-0659-20 NDC outpatient 1 UN 47.07 47.07 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES PPO [308136801] 37.66 percent of total billed charges 29.18 44.72 Technical (Hospital) Services SACUBITRIL 24 MG-VALSARTAN 26 MG TABLET RX-129911 CDM 6370000100 HCPCS 250 RC 00078-0659-20 NDC outpatient 1 UN 47.07 47.07 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES EPO [308136803] 37.66 percent of total billed charges 29.18 44.72 Technical (Hospital) Services SACUBITRIL 24 MG-VALSARTAN 26 MG TABLET RX-129911 CDM 6370000100 HCPCS 250 RC 00078-0659-20 NDC outpatient 1 UN 47.07 47.07 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES HDHP [308136802] 37.66 percent of total billed charges 29.18 44.72 Technical (Hospital) Services SACUBITRIL 24 MG-VALSARTAN 26 MG TABLET RX-129911 CDM 6370000100 HCPCS 250 RC 00078-0659-20 NDC outpatient 1 UN 47.07 47.07 MEDICA (COMMERCIAL) 94265 [3081118] MEDICA CLAIMS [308111801] 42.36 percent of total billed charges 29.18 44.72 Technical (Hospital) Services SACUBITRIL 24 MG-VALSARTAN 26 MG TABLET RX-129911 CDM 6370000100 HCPCS 250 RC 00078-0659-20 NDC outpatient 1 UN 47.07 47.07 CIGNA 62308 [3081051] CIGNA 62308 [308105105] 37.66 percent of total billed charges 29.18 44.72 Technical (Hospital) Services SACUBITRIL 24 MG-VALSARTAN 26 MG TABLET RX-129911 CDM 6370000100 HCPCS 250 RC 00078-0659-20 NDC outpatient 1 UN 47.07 47.07 CIGNA 62308 [3081051] CIGNA STATE OF WYOMING [308105107] 37.66 percent of total billed charges 29.18 44.72 Technical (Hospital) Services SACUBITRIL 24 MG-VALSARTAN 26 MG TABLET RX-129911 CDM 6370000100 HCPCS 250 RC 00078-0659-20 NDC outpatient 1 UN 47.07 47.07 MULTIPLAN INC 34080 [3081285] MULTIPLAN INC [308128501] 44.72 percent of total billed charges 29.18 44.72 Technical (Hospital) Services SACUBITRIL 24 MG-VALSARTAN 26 MG TABLET RX-129911 CDM 6370000100 HCPCS 250 RC 00078-0659-20 NDC outpatient 1 UN 47.07 47.07 HEALTHPARTNERS SX009 HEALTHPARTNERS 37.66 percent of total billed charges 29.18 44.72 Technical (Hospital) Services SACUBITRIL 24 MG-VALSARTAN 26 MG TABLET RX-129911 CDM 6370000100 HCPCS 250 RC 00078-0659-20 NDC outpatient 1 UN 47.07 47.07 UNITED HEALTHCARE (COMMERCIAL) [3081199] UNITED HEALTHCARE 87726 [308119901] 29.18 percent of total billed charges 29.18 44.72 Technical (Hospital) Services SACUBITRIL 24 MG-VALSARTAN 26 MG TABLET RX-129911 CDM 6370000100 HCPCS 250 RC 00078-0659-20 NDC outpatient 1 UN 47.07 47.07 BLUE CROSS BLUE SHIELD WELLMARK SB889 [3081026] BCBS WYOMING [308102603] 44.72 percent of total billed charges 29.18 44.72 Technical (Hospital) Services SACUBITRIL 97 MG-VALSARTAN 103 MG TABLET RX-129913 CDM 6370000100 HCPCS 250 RC 00078-0696-20 NDC inpatient 1 UN 47.07 47.07 MULTIPLAN INC 34080 [3081285] MULTIPLAN INC [308128501] 44.72 percent of total billed charges 29.18 44.72 Technical (Hospital) Services SACUBITRIL 97 MG-VALSARTAN 103 MG TABLET RX-129913 CDM 6370000100 HCPCS 250 RC 00078-0696-20 NDC inpatient 1 UN 47.07 47.07 HEALTHPARTNERS SX009 HEALTHPARTNERS 37.27 percent of total billed charges 29.18 44.72 Technical (Hospital) Services SACUBITRIL 97 MG-VALSARTAN 103 MG TABLET RX-129913 CDM 6370000100 HCPCS 250 RC 00078-0696-20 NDC inpatient 1 UN 47.07 47.07 MEDICA (COMMERCIAL) 94265 [3081118] MEDICA CLAIMS [308111801] 42.36 percent of total billed charges 29.18 44.72 Technical (Hospital) Services SACUBITRIL 97 MG-VALSARTAN 103 MG TABLET RX-129913 CDM 6370000100 HCPCS 250 RC 00078-0696-20 NDC inpatient 1 UN 47.07 47.07 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES PPO [308136801] 37.27 percent of total billed charges 29.18 44.72 Technical (Hospital) Services SACUBITRIL 97 MG-VALSARTAN 103 MG TABLET RX-129913 CDM 6370000100 HCPCS 250 RC 00078-0696-20 NDC inpatient 1 UN 47.07 47.07 CIGNA 62308 [3081051] CIGNA STATE OF WYOMING [308105107] 37.27 percent of total billed charges 29.18 44.72 Technical (Hospital) Services SACUBITRIL 97 MG-VALSARTAN 103 MG TABLET RX-129913 CDM 6370000100 HCPCS 250 RC 00078-0696-20 NDC inpatient 1 UN 47.07 47.07 CIGNA 62308 [3081051] CIGNA 62308 [308105105] 37.27 percent of total billed charges 29.18 44.72 Technical (Hospital) Services SACUBITRIL 97 MG-VALSARTAN 103 MG TABLET RX-129913 CDM 6370000100 HCPCS 250 RC 00078-0696-20 NDC inpatient 1 UN 47.07 47.07 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES EPO [308136803] 37.27 percent of total billed charges 29.18 44.72 Technical (Hospital) Services SACUBITRIL 97 MG-VALSARTAN 103 MG TABLET RX-129913 CDM 6370000100 HCPCS 250 RC 00078-0696-20 NDC inpatient 1 UN 47.07 47.07 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES HDHP [308136802] 37.27 percent of total billed charges 29.18 44.72 Technical (Hospital) Services SACUBITRIL 97 MG-VALSARTAN 103 MG TABLET RX-129913 CDM 6370000100 HCPCS 250 RC 00078-0696-20 NDC inpatient 1 UN 47.07 47.07 UNITED HEALTHCARE (COMMERCIAL) [3081199] UNITED HEALTHCARE 87726 [308119901] 29.18 percent of total billed charges 29.18 44.72 Technical (Hospital) Services SACUBITRIL 97 MG-VALSARTAN 103 MG TABLET RX-129913 CDM 6370000100 HCPCS 250 RC 00078-0696-20 NDC inpatient 1 UN 47.07 47.07 BLUE CROSS BLUE SHIELD WELLMARK SB889 [3081026] BCBS WYOMING [308102603] 44.72 percent of total billed charges 29.18 44.72 Technical (Hospital) Services SACUBITRIL 97 MG-VALSARTAN 103 MG TABLET RX-129913 CDM 6370000100 HCPCS 250 RC 00078-0696-20 NDC outpatient 1 UN 47.07 47.07 HEALTHPARTNERS SX009 HEALTHPARTNERS 37.66 percent of total billed charges 29.18 44.72 Technical (Hospital) Services SACUBITRIL 97 MG-VALSARTAN 103 MG TABLET RX-129913 CDM 6370000100 HCPCS 250 RC 00078-0696-20 NDC outpatient 1 UN 47.07 47.07 BLUE CROSS BLUE SHIELD WELLMARK SB889 [3081026] BCBS WYOMING [308102603] 44.72 percent of total billed charges 29.18 44.72 Technical (Hospital) Services SACUBITRIL 97 MG-VALSARTAN 103 MG TABLET RX-129913 CDM 6370000100 HCPCS 250 RC 00078-0696-20 NDC outpatient 1 UN 47.07 47.07 MEDICA (COMMERCIAL) 94265 [3081118] MEDICA CLAIMS [308111801] 42.36 percent of total billed charges 29.18 44.72 Technical (Hospital) Services SACUBITRIL 97 MG-VALSARTAN 103 MG TABLET RX-129913 CDM 6370000100 HCPCS 250 RC 00078-0696-20 NDC outpatient 1 UN 47.07 47.07 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES EPO [308136803] 37.66 percent of total billed charges 29.18 44.72 Technical (Hospital) Services SACUBITRIL 97 MG-VALSARTAN 103 MG TABLET RX-129913 CDM 6370000100 HCPCS 250 RC 00078-0696-20 NDC outpatient 1 UN 47.07 47.07 UNITED HEALTHCARE (COMMERCIAL) [3081199] UNITED HEALTHCARE 87726 [308119901] 29.18 percent of total billed charges 29.18 44.72 Technical (Hospital) Services SACUBITRIL 97 MG-VALSARTAN 103 MG TABLET RX-129913 CDM 6370000100 HCPCS 250 RC 00078-0696-20 NDC outpatient 1 UN 47.07 47.07 CIGNA 62308 [3081051] CIGNA 62308 [308105105] 37.66 percent of total billed charges 29.18 44.72 Technical (Hospital) Services SACUBITRIL 97 MG-VALSARTAN 103 MG TABLET RX-129913 CDM 6370000100 HCPCS 250 RC 00078-0696-20 NDC outpatient 1 UN 47.07 47.07 CIGNA 62308 [3081051] CIGNA STATE OF WYOMING [308105107] 37.66 percent of total billed charges 29.18 44.72 Technical (Hospital) Services SACUBITRIL 97 MG-VALSARTAN 103 MG TABLET RX-129913 CDM 6370000100 HCPCS 250 RC 00078-0696-20 NDC outpatient 1 UN 47.07 47.07 MULTIPLAN INC 34080 [3081285] MULTIPLAN INC [308128501] 44.72 percent of total billed charges 29.18 44.72 Technical (Hospital) Services SACUBITRIL 97 MG-VALSARTAN 103 MG TABLET RX-129913 CDM 6370000100 HCPCS 250 RC 00078-0696-20 NDC outpatient 1 UN 47.07 47.07 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES PPO [308136801] 37.66 percent of total billed charges 29.18 44.72 Technical (Hospital) Services SACUBITRIL 97 MG-VALSARTAN 103 MG TABLET RX-129913 CDM 6370000100 HCPCS 250 RC 00078-0696-20 NDC outpatient 1 UN 47.07 47.07 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES HDHP [308136802] 37.66 percent of total billed charges 29.18 44.72 Technical (Hospital) Services "CALCIUM 500 MG (AS CALCIUM CARBONATE 1,250 MG) TABLET" RX-1300 CDM 6370000100 HCPCS 250 RC 00904-1883-72 NDC inpatient 1 UN 5.64 5.64 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES EPO [308136803] 4.47 percent of total billed charges 3.5 5.36 Technical (Hospital) Services "CALCIUM 500 MG (AS CALCIUM CARBONATE 1,250 MG) TABLET" RX-1300 CDM 6370000100 HCPCS 250 RC 00904-1883-72 NDC inpatient 1 UN 5.64 5.64 CIGNA 62308 [3081051] CIGNA 62308 [308105105] 4.47 percent of total billed charges 3.5 5.36 Technical (Hospital) Services "CALCIUM 500 MG (AS CALCIUM CARBONATE 1,250 MG) TABLET" RX-1300 CDM 6370000100 HCPCS 250 RC 00904-1883-72 NDC inpatient 1 UN 5.64 5.64 CIGNA 62308 [3081051] CIGNA STATE OF WYOMING [308105107] 4.47 percent of total billed charges 3.5 5.36 Technical (Hospital) Services "CALCIUM 500 MG (AS CALCIUM CARBONATE 1,250 MG) TABLET" RX-1300 CDM 6370000100 HCPCS 250 RC 00904-1883-72 NDC inpatient 1 UN 5.64 5.64 MEDICA (COMMERCIAL) 94265 [3081118] MEDICA CLAIMS [308111801] 5.08 percent of total billed charges 3.5 5.36 Technical (Hospital) Services "CALCIUM 500 MG (AS CALCIUM CARBONATE 1,250 MG) TABLET" RX-1300 CDM 6370000100 HCPCS 250 RC 00904-1883-72 NDC inpatient 1 UN 5.64 5.64 HEALTHPARTNERS SX009 HEALTHPARTNERS 4.47 percent of total billed charges 3.5 5.36 Technical (Hospital) Services "CALCIUM 500 MG (AS CALCIUM CARBONATE 1,250 MG) TABLET" RX-1300 CDM 6370000100 HCPCS 250 RC 00904-1883-72 NDC inpatient 1 UN 5.64 5.64 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES HDHP [308136802] 4.47 percent of total billed charges 3.5 5.36 Technical (Hospital) Services "CALCIUM 500 MG (AS CALCIUM CARBONATE 1,250 MG) TABLET" RX-1300 CDM 6370000100 HCPCS 250 RC 00904-1883-72 NDC inpatient 1 UN 5.64 5.64 UNITED HEALTHCARE (COMMERCIAL) [3081199] UNITED HEALTHCARE 87726 [308119901] 3.5 percent of total billed charges 3.5 5.36 Technical (Hospital) Services "CALCIUM 500 MG (AS CALCIUM CARBONATE 1,250 MG) TABLET" RX-1300 CDM 6370000100 HCPCS 250 RC 00904-1883-72 NDC inpatient 1 UN 5.64 5.64 BLUE CROSS BLUE SHIELD WELLMARK SB889 [3081026] BCBS WYOMING [308102603] 5.36 percent of total billed charges 3.5 5.36 Technical (Hospital) Services "CALCIUM 500 MG (AS CALCIUM CARBONATE 1,250 MG) TABLET" RX-1300 CDM 6370000100 HCPCS 250 RC 00904-1883-72 NDC inpatient 1 UN 5.64 5.64 MULTIPLAN INC 34080 [3081285] MULTIPLAN INC [308128501] 5.36 percent of total billed charges 3.5 5.36 Technical (Hospital) Services "CALCIUM 500 MG (AS CALCIUM CARBONATE 1,250 MG) TABLET" RX-1300 CDM 6370000100 HCPCS 250 RC 00904-1883-72 NDC inpatient 1 UN 5.64 5.64 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES PPO [308136801] 4.47 percent of total billed charges 3.5 5.36 Technical (Hospital) Services "CALCIUM 500 MG (AS CALCIUM CARBONATE 1,250 MG) TABLET" RX-1300 CDM 6370000100 HCPCS 250 RC 00904-1883-72 NDC outpatient 1 UN 5.64 5.64 UNITED HEALTHCARE (COMMERCIAL) [3081199] UNITED HEALTHCARE 87726 [308119901] 3.5 percent of total billed charges 3.5 5.36 Technical (Hospital) Services "CALCIUM 500 MG (AS CALCIUM CARBONATE 1,250 MG) TABLET" RX-1300 CDM 6370000100 HCPCS 250 RC 00904-1883-72 NDC outpatient 1 UN 5.64 5.64 MEDICA (COMMERCIAL) 94265 [3081118] MEDICA CLAIMS [308111801] 5.08 percent of total billed charges 3.5 5.36 Technical (Hospital) Services "CALCIUM 500 MG (AS CALCIUM CARBONATE 1,250 MG) TABLET" RX-1300 CDM 6370000100 HCPCS 250 RC 00904-1883-72 NDC outpatient 1 UN 5.64 5.64 CIGNA 62308 [3081051] CIGNA 62308 [308105105] 4.51 percent of total billed charges 3.5 5.36 Technical (Hospital) Services "CALCIUM 500 MG (AS CALCIUM CARBONATE 1,250 MG) TABLET" RX-1300 CDM 6370000100 HCPCS 250 RC 00904-1883-72 NDC outpatient 1 UN 5.64 5.64 CIGNA 62308 [3081051] CIGNA STATE OF WYOMING [308105107] 4.51 percent of total billed charges 3.5 5.36 Technical (Hospital) Services "CALCIUM 500 MG (AS CALCIUM CARBONATE 1,250 MG) TABLET" RX-1300 CDM 6370000100 HCPCS 250 RC 00904-1883-72 NDC outpatient 1 UN 5.64 5.64 MULTIPLAN INC 34080 [3081285] MULTIPLAN INC [308128501] 5.36 percent of total billed charges 3.5 5.36 Technical (Hospital) Services "CALCIUM 500 MG (AS CALCIUM CARBONATE 1,250 MG) TABLET" RX-1300 CDM 6370000100 HCPCS 250 RC 00904-1883-72 NDC outpatient 1 UN 5.64 5.64 BLUE CROSS BLUE SHIELD WELLMARK SB889 [3081026] BCBS WYOMING [308102603] 5.36 percent of total billed charges 3.5 5.36 Technical (Hospital) Services "CALCIUM 500 MG (AS CALCIUM CARBONATE 1,250 MG) TABLET" RX-1300 CDM 6370000100 HCPCS 250 RC 00904-1883-72 NDC outpatient 1 UN 5.64 5.64 HEALTHPARTNERS SX009 HEALTHPARTNERS 4.51 percent of total billed charges 3.5 5.36 Technical (Hospital) Services "CALCIUM 500 MG (AS CALCIUM CARBONATE 1,250 MG) TABLET" RX-1300 CDM 6370000100 HCPCS 250 RC 00904-1883-72 NDC outpatient 1 UN 5.64 5.64 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES EPO [308136803] 4.51 percent of total billed charges 3.5 5.36 Technical (Hospital) Services "CALCIUM 500 MG (AS CALCIUM CARBONATE 1,250 MG) TABLET" RX-1300 CDM 6370000100 HCPCS 250 RC 00904-1883-72 NDC outpatient 1 UN 5.64 5.64 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES PPO [308136801] 4.51 percent of total billed charges 3.5 5.36 Technical (Hospital) Services "CALCIUM 500 MG (AS CALCIUM CARBONATE 1,250 MG) TABLET" RX-1300 CDM 6370000100 HCPCS 250 RC 00904-1883-72 NDC outpatient 1 UN 5.64 5.64 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES HDHP [308136802] 4.51 percent of total billed charges 3.5 5.36 Technical (Hospital) Services THIAMINE MONONITRATE (VITAMIN B1) 100 MG TABLET RX-130049 CDM 6370000100 HCPCS 250 RC 50268-0851-11 NDC outpatient 1 UN 5.79 5.79 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES PPO [308136801] 4.63 percent of total billed charges 3.59 5.5 Technical (Hospital) Services THIAMINE MONONITRATE (VITAMIN B1) 100 MG TABLET RX-130049 CDM 6370000100 HCPCS 250 RC 50268-0851-11 NDC outpatient 1 UN 5.79 5.79 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES HDHP [308136802] 4.63 percent of total billed charges 3.59 5.5 Technical (Hospital) Services THIAMINE MONONITRATE (VITAMIN B1) 100 MG TABLET RX-130049 CDM 6370000100 HCPCS 250 RC 50268-0851-11 NDC outpatient 1 UN 5.79 5.79 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES EPO [308136803] 4.63 percent of total billed charges 3.59 5.5 Technical (Hospital) Services THIAMINE MONONITRATE (VITAMIN B1) 100 MG TABLET RX-130049 CDM 6370000100 HCPCS 250 RC 50268-0851-11 NDC outpatient 1 UN 5.79 5.79 UNITED HEALTHCARE (COMMERCIAL) [3081199] UNITED HEALTHCARE 87726 [308119901] 3.59 percent of total billed charges 3.59 5.5 Technical (Hospital) Services THIAMINE MONONITRATE (VITAMIN B1) 100 MG TABLET RX-130049 CDM 6370000100 HCPCS 250 RC 50268-0851-11 NDC outpatient 1 UN 5.79 5.79 CIGNA 62308 [3081051] CIGNA 62308 [308105105] 4.63 percent of total billed charges 3.59 5.5 Technical (Hospital) Services THIAMINE MONONITRATE (VITAMIN B1) 100 MG TABLET RX-130049 CDM 6370000100 HCPCS 250 RC 50268-0851-11 NDC outpatient 1 UN 5.79 5.79 CIGNA 62308 [3081051] CIGNA STATE OF WYOMING [308105107] 4.63 percent of total billed charges 3.59 5.5 Technical (Hospital) Services THIAMINE MONONITRATE (VITAMIN B1) 100 MG TABLET RX-130049 CDM 6370000100 HCPCS 250 RC 50268-0851-11 NDC outpatient 1 UN 5.79 5.79 MULTIPLAN INC 34080 [3081285] MULTIPLAN INC [308128501] 5.5 percent of total billed charges 3.59 5.5 Technical (Hospital) Services THIAMINE MONONITRATE (VITAMIN B1) 100 MG TABLET RX-130049 CDM 6370000100 HCPCS 250 RC 50268-0851-11 NDC outpatient 1 UN 5.79 5.79 MEDICA (COMMERCIAL) 94265 [3081118] MEDICA CLAIMS [308111801] 5.21 percent of total billed charges 3.59 5.5 Technical (Hospital) Services THIAMINE MONONITRATE (VITAMIN B1) 100 MG TABLET RX-130049 CDM 6370000100 HCPCS 250 RC 50268-0851-11 NDC outpatient 1 UN 5.79 5.79 BLUE CROSS BLUE SHIELD WELLMARK SB889 [3081026] BCBS WYOMING [308102603] 5.5 percent of total billed charges 3.59 5.5 Technical (Hospital) Services THIAMINE MONONITRATE (VITAMIN B1) 100 MG TABLET RX-130049 CDM 6370000100 HCPCS 250 RC 50268-0851-11 NDC outpatient 1 UN 5.79 5.79 HEALTHPARTNERS SX009 HEALTHPARTNERS 4.63 percent of total billed charges 3.59 5.5 Technical (Hospital) Services THIAMINE MONONITRATE (VITAMIN B1) 100 MG TABLET RX-130049 CDM 6370000100 HCPCS 250 RC 50268-0851-11 NDC inpatient 1 UN 5.79 5.79 BLUE CROSS BLUE SHIELD WELLMARK SB889 [3081026] BCBS WYOMING [308102603] 5.5 percent of total billed charges 3.59 5.5 Technical (Hospital) Services THIAMINE MONONITRATE (VITAMIN B1) 100 MG TABLET RX-130049 CDM 6370000100 HCPCS 250 RC 50268-0851-11 NDC inpatient 1 UN 5.79 5.79 UNITED HEALTHCARE (COMMERCIAL) [3081199] UNITED HEALTHCARE 87726 [308119901] 3.59 percent of total billed charges 3.59 5.5 Technical (Hospital) Services THIAMINE MONONITRATE (VITAMIN B1) 100 MG TABLET RX-130049 CDM 6370000100 HCPCS 250 RC 50268-0851-11 NDC inpatient 1 UN 5.79 5.79 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES HDHP [308136802] 4.58 percent of total billed charges 3.59 5.5 Technical (Hospital) Services THIAMINE MONONITRATE (VITAMIN B1) 100 MG TABLET RX-130049 CDM 6370000100 HCPCS 250 RC 50268-0851-11 NDC inpatient 1 UN 5.79 5.79 CIGNA 62308 [3081051] CIGNA 62308 [308105105] 4.58 percent of total billed charges 3.59 5.5 Technical (Hospital) Services THIAMINE MONONITRATE (VITAMIN B1) 100 MG TABLET RX-130049 CDM 6370000100 HCPCS 250 RC 50268-0851-11 NDC inpatient 1 UN 5.79 5.79 CIGNA 62308 [3081051] CIGNA STATE OF WYOMING [308105107] 4.58 percent of total billed charges 3.59 5.5 Technical (Hospital) Services THIAMINE MONONITRATE (VITAMIN B1) 100 MG TABLET RX-130049 CDM 6370000100 HCPCS 250 RC 50268-0851-11 NDC inpatient 1 UN 5.79 5.79 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES EPO [308136803] 4.58 percent of total billed charges 3.59 5.5 Technical (Hospital) Services THIAMINE MONONITRATE (VITAMIN B1) 100 MG TABLET RX-130049 CDM 6370000100 HCPCS 250 RC 50268-0851-11 NDC inpatient 1 UN 5.79 5.79 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES PPO [308136801] 4.58 percent of total billed charges 3.59 5.5 Technical (Hospital) Services THIAMINE MONONITRATE (VITAMIN B1) 100 MG TABLET RX-130049 CDM 6370000100 HCPCS 250 RC 50268-0851-11 NDC inpatient 1 UN 5.79 5.79 HEALTHPARTNERS SX009 HEALTHPARTNERS 4.58 percent of total billed charges 3.59 5.5 Technical (Hospital) Services THIAMINE MONONITRATE (VITAMIN B1) 100 MG TABLET RX-130049 CDM 6370000100 HCPCS 250 RC 50268-0851-11 NDC inpatient 1 UN 5.79 5.79 MEDICA (COMMERCIAL) 94265 [3081118] MEDICA CLAIMS [308111801] 5.21 percent of total billed charges 3.59 5.5 Technical (Hospital) Services THIAMINE MONONITRATE (VITAMIN B1) 100 MG TABLET RX-130049 CDM 6370000100 HCPCS 250 RC 50268-0851-11 NDC inpatient 1 UN 5.79 5.79 MULTIPLAN INC 34080 [3081285] MULTIPLAN INC [308128501] 5.5 percent of total billed charges 3.59 5.5 Technical (Hospital) Services "NIACIN ER 1,000 MG TABLET,EXTENDED RELEASE" RX-130636 CDM 6370000100 HCPCS 250 RC 00536-7038-01 NDC outpatient 1 UN 5.68 5.68 BLUE CROSS BLUE SHIELD WELLMARK SB889 [3081026] BCBS WYOMING [308102603] 5.4 percent of total billed charges 3.52 5.4 Technical (Hospital) Services "NIACIN ER 1,000 MG TABLET,EXTENDED RELEASE" RX-130636 CDM 6370000100 HCPCS 250 RC 00536-7038-01 NDC outpatient 1 UN 5.68 5.68 HEALTHPARTNERS SX009 HEALTHPARTNERS 4.54 percent of total billed charges 3.52 5.4 Technical (Hospital) Services "NIACIN ER 1,000 MG TABLET,EXTENDED RELEASE" RX-130636 CDM 6370000100 HCPCS 250 RC 00536-7038-01 NDC outpatient 1 UN 5.68 5.68 CIGNA 62308 [3081051] CIGNA 62308 [308105105] 4.54 percent of total billed charges 3.52 5.4 Technical (Hospital) Services "NIACIN ER 1,000 MG TABLET,EXTENDED RELEASE" RX-130636 CDM 6370000100 HCPCS 250 RC 00536-7038-01 NDC outpatient 1 UN 5.68 5.68 CIGNA 62308 [3081051] CIGNA STATE OF WYOMING [308105107] 4.54 percent of total billed charges 3.52 5.4 Technical (Hospital) Services "NIACIN ER 1,000 MG TABLET,EXTENDED RELEASE" RX-130636 CDM 6370000100 HCPCS 250 RC 00536-7038-01 NDC outpatient 1 UN 5.68 5.68 MEDICA (COMMERCIAL) 94265 [3081118] MEDICA CLAIMS [308111801] 5.11 percent of total billed charges 3.52 5.4 Technical (Hospital) Services "NIACIN ER 1,000 MG TABLET,EXTENDED RELEASE" RX-130636 CDM 6370000100 HCPCS 250 RC 00536-7038-01 NDC outpatient 1 UN 5.68 5.68 MULTIPLAN INC 34080 [3081285] MULTIPLAN INC [308128501] 5.4 percent of total billed charges 3.52 5.4 Technical (Hospital) Services "NIACIN ER 1,000 MG TABLET,EXTENDED RELEASE" RX-130636 CDM 6370000100 HCPCS 250 RC 00536-7038-01 NDC outpatient 1 UN 5.68 5.68 UNITED HEALTHCARE (COMMERCIAL) [3081199] UNITED HEALTHCARE 87726 [308119901] 3.52 percent of total billed charges 3.52 5.4 Technical (Hospital) Services "NIACIN ER 1,000 MG TABLET,EXTENDED RELEASE" RX-130636 CDM 6370000100 HCPCS 250 RC 00536-7038-01 NDC outpatient 1 UN 5.68 5.68 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES HDHP [308136802] 4.54 percent of total billed charges 3.52 5.4 Technical (Hospital) Services "NIACIN ER 1,000 MG TABLET,EXTENDED RELEASE" RX-130636 CDM 6370000100 HCPCS 250 RC 00536-7038-01 NDC outpatient 1 UN 5.68 5.68 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES EPO [308136803] 4.54 percent of total billed charges 3.52 5.4 Technical (Hospital) Services "NIACIN ER 1,000 MG TABLET,EXTENDED RELEASE" RX-130636 CDM 6370000100 HCPCS 250 RC 00536-7038-01 NDC outpatient 1 UN 5.68 5.68 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES PPO [308136801] 4.54 percent of total billed charges 3.52 5.4 Technical (Hospital) Services "NIACIN ER 1,000 MG TABLET,EXTENDED RELEASE" RX-130636 CDM 6370000100 HCPCS 250 RC 00536-7038-01 NDC inpatient 1 UN 5.68 5.68 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES HDHP [308136802] 4.5 percent of total billed charges 3.52 5.4 Technical (Hospital) Services "NIACIN ER 1,000 MG TABLET,EXTENDED RELEASE" RX-130636 CDM 6370000100 HCPCS 250 RC 00536-7038-01 NDC inpatient 1 UN 5.68 5.68 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES EPO [308136803] 4.5 percent of total billed charges 3.52 5.4 Technical (Hospital) Services "NIACIN ER 1,000 MG TABLET,EXTENDED RELEASE" RX-130636 CDM 6370000100 HCPCS 250 RC 00536-7038-01 NDC inpatient 1 UN 5.68 5.68 CIGNA 62308 [3081051] CIGNA 62308 [308105105] 4.5 percent of total billed charges 3.52 5.4 Technical (Hospital) Services "NIACIN ER 1,000 MG TABLET,EXTENDED RELEASE" RX-130636 CDM 6370000100 HCPCS 250 RC 00536-7038-01 NDC inpatient 1 UN 5.68 5.68 CIGNA 62308 [3081051] CIGNA STATE OF WYOMING [308105107] 4.5 percent of total billed charges 3.52 5.4 Technical (Hospital) Services "NIACIN ER 1,000 MG TABLET,EXTENDED RELEASE" RX-130636 CDM 6370000100 HCPCS 250 RC 00536-7038-01 NDC inpatient 1 UN 5.68 5.68 BLUE CROSS BLUE SHIELD WELLMARK SB889 [3081026] BCBS WYOMING [308102603] 5.4 percent of total billed charges 3.52 5.4 Technical (Hospital) Services "NIACIN ER 1,000 MG TABLET,EXTENDED RELEASE" RX-130636 CDM 6370000100 HCPCS 250 RC 00536-7038-01 NDC inpatient 1 UN 5.68 5.68 UNITED HEALTHCARE (COMMERCIAL) [3081199] UNITED HEALTHCARE 87726 [308119901] 3.52 percent of total billed charges 3.52 5.4 Technical (Hospital) Services "NIACIN ER 1,000 MG TABLET,EXTENDED RELEASE" RX-130636 CDM 6370000100 HCPCS 250 RC 00536-7038-01 NDC inpatient 1 UN 5.68 5.68 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES PPO [308136801] 4.5 percent of total billed charges 3.52 5.4 Technical (Hospital) Services "NIACIN ER 1,000 MG TABLET,EXTENDED RELEASE" RX-130636 CDM 6370000100 HCPCS 250 RC 00536-7038-01 NDC inpatient 1 UN 5.68 5.68 MEDICA (COMMERCIAL) 94265 [3081118] MEDICA CLAIMS [308111801] 5.11 percent of total billed charges 3.52 5.4 Technical (Hospital) Services "NIACIN ER 1,000 MG TABLET,EXTENDED RELEASE" RX-130636 CDM 6370000100 HCPCS 250 RC 00536-7038-01 NDC inpatient 1 UN 5.68 5.68 HEALTHPARTNERS SX009 HEALTHPARTNERS 4.5 percent of total billed charges 3.52 5.4 Technical (Hospital) Services "NIACIN ER 1,000 MG TABLET,EXTENDED RELEASE" RX-130636 CDM 6370000100 HCPCS 250 RC 00536-7038-01 NDC inpatient 1 UN 5.68 5.68 MULTIPLAN INC 34080 [3081285] MULTIPLAN INC [308128501] 5.4 percent of total billed charges 3.52 5.4 Technical (Hospital) Services "VERAPAMIL ER (SR) 240 MG TABLET,EXTENDED RELEASE" RX-13073 CDM 6370000100 HCPCS 250 RC 68462-0260-01 NDC outpatient 1 UN 5.93 5.93 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES HDHP [308136802] 4.74 percent of total billed charges 3.68 5.63 Technical (Hospital) Services "VERAPAMIL ER (SR) 240 MG TABLET,EXTENDED RELEASE" RX-13073 CDM 6370000100 HCPCS 250 RC 68462-0260-01 NDC outpatient 1 UN 5.93 5.93 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES EPO [308136803] 4.74 percent of total billed charges 3.68 5.63 Technical (Hospital) Services "VERAPAMIL ER (SR) 240 MG TABLET,EXTENDED RELEASE" RX-13073 CDM 6370000100 HCPCS 250 RC 68462-0260-01 NDC outpatient 1 UN 5.93 5.93 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES PPO [308136801] 4.74 percent of total billed charges 3.68 5.63 Technical (Hospital) Services "VERAPAMIL ER (SR) 240 MG TABLET,EXTENDED RELEASE" RX-13073 CDM 6370000100 HCPCS 250 RC 68462-0260-01 NDC outpatient 1 UN 5.93 5.93 HEALTHPARTNERS SX009 HEALTHPARTNERS 4.74 percent of total billed charges 3.68 5.63 Technical (Hospital) Services "VERAPAMIL ER (SR) 240 MG TABLET,EXTENDED RELEASE" RX-13073 CDM 6370000100 HCPCS 250 RC 68462-0260-01 NDC outpatient 1 UN 5.93 5.93 BLUE CROSS BLUE SHIELD WELLMARK SB889 [3081026] BCBS WYOMING [308102603] 5.63 percent of total billed charges 3.68 5.63 Technical (Hospital) Services "VERAPAMIL ER (SR) 240 MG TABLET,EXTENDED RELEASE" RX-13073 CDM 6370000100 HCPCS 250 RC 68462-0260-01 NDC outpatient 1 UN 5.93 5.93 MEDICA (COMMERCIAL) 94265 [3081118] MEDICA CLAIMS [308111801] 5.34 percent of total billed charges 3.68 5.63 Technical (Hospital) Services "VERAPAMIL ER (SR) 240 MG TABLET,EXTENDED RELEASE" RX-13073 CDM 6370000100 HCPCS 250 RC 68462-0260-01 NDC outpatient 1 UN 5.93 5.93 CIGNA 62308 [3081051] CIGNA 62308 [308105105] 4.74 percent of total billed charges 3.68 5.63 Technical (Hospital) Services "VERAPAMIL ER (SR) 240 MG TABLET,EXTENDED RELEASE" RX-13073 CDM 6370000100 HCPCS 250 RC 68462-0260-01 NDC outpatient 1 UN 5.93 5.93 CIGNA 62308 [3081051] CIGNA STATE OF WYOMING [308105107] 4.74 percent of total billed charges 3.68 5.63 Technical (Hospital) Services "VERAPAMIL ER (SR) 240 MG TABLET,EXTENDED RELEASE" RX-13073 CDM 6370000100 HCPCS 250 RC 68462-0260-01 NDC outpatient 1 UN 5.93 5.93 UNITED HEALTHCARE (COMMERCIAL) [3081199] UNITED HEALTHCARE 87726 [308119901] 3.68 percent of total billed charges 3.68 5.63 Technical (Hospital) Services "VERAPAMIL ER (SR) 240 MG TABLET,EXTENDED RELEASE" RX-13073 CDM 6370000100 HCPCS 250 RC 68462-0260-01 NDC outpatient 1 UN 5.93 5.93 MULTIPLAN INC 34080 [3081285] MULTIPLAN INC [308128501] 5.63 percent of total billed charges 3.68 5.63 Technical (Hospital) Services "VERAPAMIL ER (SR) 240 MG TABLET,EXTENDED RELEASE" RX-13073 CDM 6370000100 HCPCS 250 RC 68462-0260-01 NDC inpatient 1 UN 5.93 5.93 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES PPO [308136801] 4.7 percent of total billed charges 3.68 5.63 Technical (Hospital) Services "VERAPAMIL ER (SR) 240 MG TABLET,EXTENDED RELEASE" RX-13073 CDM 6370000100 HCPCS 250 RC 68462-0260-01 NDC inpatient 1 UN 5.93 5.93 HEALTHPARTNERS SX009 HEALTHPARTNERS 4.7 percent of total billed charges 3.68 5.63 Technical (Hospital) Services "VERAPAMIL ER (SR) 240 MG TABLET,EXTENDED RELEASE" RX-13073 CDM 6370000100 HCPCS 250 RC 68462-0260-01 NDC inpatient 1 UN 5.93 5.93 MEDICA (COMMERCIAL) 94265 [3081118] MEDICA CLAIMS [308111801] 5.34 percent of total billed charges 3.68 5.63 Technical (Hospital) Services "VERAPAMIL ER (SR) 240 MG TABLET,EXTENDED RELEASE" RX-13073 CDM 6370000100 HCPCS 250 RC 68462-0260-01 NDC inpatient 1 UN 5.93 5.93 MULTIPLAN INC 34080 [3081285] MULTIPLAN INC [308128501] 5.63 percent of total billed charges 3.68 5.63 Technical (Hospital) Services "VERAPAMIL ER (SR) 240 MG TABLET,EXTENDED RELEASE" RX-13073 CDM 6370000100 HCPCS 250 RC 68462-0260-01 NDC inpatient 1 UN 5.93 5.93 BLUE CROSS BLUE SHIELD WELLMARK SB889 [3081026] BCBS WYOMING [308102603] 5.63 percent of total billed charges 3.68 5.63 Technical (Hospital) Services "VERAPAMIL ER (SR) 240 MG TABLET,EXTENDED RELEASE" RX-13073 CDM 6370000100 HCPCS 250 RC 68462-0260-01 NDC inpatient 1 UN 5.93 5.93 UNITED HEALTHCARE (COMMERCIAL) [3081199] UNITED HEALTHCARE 87726 [308119901] 3.68 percent of total billed charges 3.68 5.63 Technical (Hospital) Services "VERAPAMIL ER (SR) 240 MG TABLET,EXTENDED RELEASE" RX-13073 CDM 6370000100 HCPCS 250 RC 68462-0260-01 NDC inpatient 1 UN 5.93 5.93 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES HDHP [308136802] 4.7 percent of total billed charges 3.68 5.63 Technical (Hospital) Services "VERAPAMIL ER (SR) 240 MG TABLET,EXTENDED RELEASE" RX-13073 CDM 6370000100 HCPCS 250 RC 68462-0260-01 NDC inpatient 1 UN 5.93 5.93 CIGNA 62308 [3081051] CIGNA 62308 [308105105] 4.7 percent of total billed charges 3.68 5.63 Technical (Hospital) Services "VERAPAMIL ER (SR) 240 MG TABLET,EXTENDED RELEASE" RX-13073 CDM 6370000100 HCPCS 250 RC 68462-0260-01 NDC inpatient 1 UN 5.93 5.93 CIGNA 62308 [3081051] CIGNA STATE OF WYOMING [308105107] 4.7 percent of total billed charges 3.68 5.63 Technical (Hospital) Services "VERAPAMIL ER (SR) 240 MG TABLET,EXTENDED RELEASE" RX-13073 CDM 6370000100 HCPCS 250 RC 68462-0260-01 NDC inpatient 1 UN 5.93 5.93 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES EPO [308136803] 4.7 percent of total billed charges 3.68 5.63 Technical (Hospital) Services "ACIDOPHILUS 100 MILLION CELL-PECTIN, CITRUS 10 MG CAPSULE" RX-130793 CDM 6370000100 HCPCS 250 RC 96295-0127-75 NDC outpatient 1 UN 5.77 5.77 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES HDHP [308136802] 4.62 percent of total billed charges 3.58 5.48 Technical (Hospital) Services "ACIDOPHILUS 100 MILLION CELL-PECTIN, CITRUS 10 MG CAPSULE" RX-130793 CDM 6370000100 HCPCS 250 RC 96295-0127-75 NDC outpatient 1 UN 5.77 5.77 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES EPO [308136803] 4.62 percent of total billed charges 3.58 5.48 Technical (Hospital) Services "ACIDOPHILUS 100 MILLION CELL-PECTIN, CITRUS 10 MG CAPSULE" RX-130793 CDM 6370000100 HCPCS 250 RC 96295-0127-75 NDC outpatient 1 UN 5.77 5.77 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES PPO [308136801] 4.62 percent of total billed charges 3.58 5.48 Technical (Hospital) Services "ACIDOPHILUS 100 MILLION CELL-PECTIN, CITRUS 10 MG CAPSULE" RX-130793 CDM 6370000100 HCPCS 250 RC 96295-0127-75 NDC outpatient 1 UN 5.77 5.77 MEDICA (COMMERCIAL) 94265 [3081118] MEDICA CLAIMS [308111801] 5.19 percent of total billed charges 3.58 5.48 Technical (Hospital) Services "ACIDOPHILUS 100 MILLION CELL-PECTIN, CITRUS 10 MG CAPSULE" RX-130793 CDM 6370000100 HCPCS 250 RC 96295-0127-75 NDC outpatient 1 UN 5.77 5.77 MULTIPLAN INC 34080 [3081285] MULTIPLAN INC [308128501] 5.48 percent of total billed charges 3.58 5.48 Technical (Hospital) Services "ACIDOPHILUS 100 MILLION CELL-PECTIN, CITRUS 10 MG CAPSULE" RX-130793 CDM 6370000100 HCPCS 250 RC 96295-0127-75 NDC outpatient 1 UN 5.77 5.77 CIGNA 62308 [3081051] CIGNA 62308 [308105105] 4.62 percent of total billed charges 3.58 5.48 Technical (Hospital) Services "ACIDOPHILUS 100 MILLION CELL-PECTIN, CITRUS 10 MG CAPSULE" RX-130793 CDM 6370000100 HCPCS 250 RC 96295-0127-75 NDC outpatient 1 UN 5.77 5.77 CIGNA 62308 [3081051] CIGNA STATE OF WYOMING [308105107] 4.62 percent of total billed charges 3.58 5.48 Technical (Hospital) Services "ACIDOPHILUS 100 MILLION CELL-PECTIN, CITRUS 10 MG CAPSULE" RX-130793 CDM 6370000100 HCPCS 250 RC 96295-0127-75 NDC outpatient 1 UN 5.77 5.77 UNITED HEALTHCARE (COMMERCIAL) [3081199] UNITED HEALTHCARE 87726 [308119901] 3.58 percent of total billed charges 3.58 5.48 Technical (Hospital) Services "ACIDOPHILUS 100 MILLION CELL-PECTIN, CITRUS 10 MG CAPSULE" RX-130793 CDM 6370000100 HCPCS 250 RC 96295-0127-75 NDC outpatient 1 UN 5.77 5.77 HEALTHPARTNERS SX009 HEALTHPARTNERS 4.62 percent of total billed charges 3.58 5.48 Technical (Hospital) Services "ACIDOPHILUS 100 MILLION CELL-PECTIN, CITRUS 10 MG CAPSULE" RX-130793 CDM 6370000100 HCPCS 250 RC 96295-0127-75 NDC outpatient 1 UN 5.77 5.77 BLUE CROSS BLUE SHIELD WELLMARK SB889 [3081026] BCBS WYOMING [308102603] 5.48 percent of total billed charges 3.58 5.48 Technical (Hospital) Services "ACIDOPHILUS 100 MILLION CELL-PECTIN, CITRUS 10 MG CAPSULE" RX-130793 CDM 6370000100 HCPCS 250 RC 96295-0127-75 NDC inpatient 1 UN 5.77 5.77 BLUE CROSS BLUE SHIELD WELLMARK SB889 [3081026] BCBS WYOMING [308102603] 5.48 percent of total billed charges 3.58 5.48 Technical (Hospital) Services "ACIDOPHILUS 100 MILLION CELL-PECTIN, CITRUS 10 MG CAPSULE" RX-130793 CDM 6370000100 HCPCS 250 RC 96295-0127-75 NDC inpatient 1 UN 5.77 5.77 UNITED HEALTHCARE (COMMERCIAL) [3081199] UNITED HEALTHCARE 87726 [308119901] 3.58 percent of total billed charges 3.58 5.48 Technical (Hospital) Services "ACIDOPHILUS 100 MILLION CELL-PECTIN, CITRUS 10 MG CAPSULE" RX-130793 CDM 6370000100 HCPCS 250 RC 96295-0127-75 NDC inpatient 1 UN 5.77 5.77 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES EPO [308136803] 4.57 percent of total billed charges 3.58 5.48 Technical (Hospital) Services "ACIDOPHILUS 100 MILLION CELL-PECTIN, CITRUS 10 MG CAPSULE" RX-130793 CDM 6370000100 HCPCS 250 RC 96295-0127-75 NDC inpatient 1 UN 5.77 5.77 CIGNA 62308 [3081051] CIGNA 62308 [308105105] 4.57 percent of total billed charges 3.58 5.48 Technical (Hospital) Services "ACIDOPHILUS 100 MILLION CELL-PECTIN, CITRUS 10 MG CAPSULE" RX-130793 CDM 6370000100 HCPCS 250 RC 96295-0127-75 NDC inpatient 1 UN 5.77 5.77 CIGNA 62308 [3081051] CIGNA STATE OF WYOMING [308105107] 4.57 percent of total billed charges 3.58 5.48 Technical (Hospital) Services "ACIDOPHILUS 100 MILLION CELL-PECTIN, CITRUS 10 MG CAPSULE" RX-130793 CDM 6370000100 HCPCS 250 RC 96295-0127-75 NDC inpatient 1 UN 5.77 5.77 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES HDHP [308136802] 4.57 percent of total billed charges 3.58 5.48 Technical (Hospital) Services "ACIDOPHILUS 100 MILLION CELL-PECTIN, CITRUS 10 MG CAPSULE" RX-130793 CDM 6370000100 HCPCS 250 RC 96295-0127-75 NDC inpatient 1 UN 5.77 5.77 HEALTHPARTNERS SX009 HEALTHPARTNERS 4.57 percent of total billed charges 3.58 5.48 Technical (Hospital) Services "ACIDOPHILUS 100 MILLION CELL-PECTIN, CITRUS 10 MG CAPSULE" RX-130793 CDM 6370000100 HCPCS 250 RC 96295-0127-75 NDC inpatient 1 UN 5.77 5.77 MEDICA (COMMERCIAL) 94265 [3081118] MEDICA CLAIMS [308111801] 5.19 percent of total billed charges 3.58 5.48 Technical (Hospital) Services "ACIDOPHILUS 100 MILLION CELL-PECTIN, CITRUS 10 MG CAPSULE" RX-130793 CDM 6370000100 HCPCS 250 RC 96295-0127-75 NDC inpatient 1 UN 5.77 5.77 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES PPO [308136801] 4.57 percent of total billed charges 3.58 5.48 Technical (Hospital) Services "ACIDOPHILUS 100 MILLION CELL-PECTIN, CITRUS 10 MG CAPSULE" RX-130793 CDM 6370000100 HCPCS 250 RC 96295-0127-75 NDC inpatient 1 UN 5.77 5.77 MULTIPLAN INC 34080 [3081285] MULTIPLAN INC [308128501] 5.48 percent of total billed charges 3.58 5.48 Technical (Hospital) Services LISINOPRIL 2.5 MG TABLET RX-13089 CDM 6370000100 HCPCS 250 RC 68180-0512-01 NDC outpatient 1 UN 5.65 5.65 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES EPO [308136803] 4.52 percent of total billed charges 3.5 5.37 Technical (Hospital) Services LISINOPRIL 2.5 MG TABLET RX-13089 CDM 6370000100 HCPCS 250 RC 68180-0512-01 NDC outpatient 1 UN 5.65 5.65 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES HDHP [308136802] 4.52 percent of total billed charges 3.5 5.37 Technical (Hospital) Services LISINOPRIL 2.5 MG TABLET RX-13089 CDM 6370000100 HCPCS 250 RC 68180-0512-01 NDC outpatient 1 UN 5.65 5.65 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES PPO [308136801] 4.52 percent of total billed charges 3.5 5.37 Technical (Hospital) Services LISINOPRIL 2.5 MG TABLET RX-13089 CDM 6370000100 HCPCS 250 RC 68180-0512-01 NDC outpatient 1 UN 5.65 5.65 HEALTHPARTNERS SX009 HEALTHPARTNERS 4.52 percent of total billed charges 3.5 5.37 Technical (Hospital) Services LISINOPRIL 2.5 MG TABLET RX-13089 CDM 6370000100 HCPCS 250 RC 68180-0512-01 NDC outpatient 1 UN 5.65 5.65 BLUE CROSS BLUE SHIELD WELLMARK SB889 [3081026] BCBS WYOMING [308102603] 5.37 percent of total billed charges 3.5 5.37 Technical (Hospital) Services LISINOPRIL 2.5 MG TABLET RX-13089 CDM 6370000100 HCPCS 250 RC 68180-0512-01 NDC outpatient 1 UN 5.65 5.65 MULTIPLAN INC 34080 [3081285] MULTIPLAN INC [308128501] 5.37 percent of total billed charges 3.5 5.37 Technical (Hospital) Services LISINOPRIL 2.5 MG TABLET RX-13089 CDM 6370000100 HCPCS 250 RC 68180-0512-01 NDC outpatient 1 UN 5.65 5.65 CIGNA 62308 [3081051] CIGNA 62308 [308105105] 4.52 percent of total billed charges 3.5 5.37 Technical (Hospital) Services LISINOPRIL 2.5 MG TABLET RX-13089 CDM 6370000100 HCPCS 250 RC 68180-0512-01 NDC outpatient 1 UN 5.65 5.65 CIGNA 62308 [3081051] CIGNA STATE OF WYOMING [308105107] 4.52 percent of total billed charges 3.5 5.37 Technical (Hospital) Services LISINOPRIL 2.5 MG TABLET RX-13089 CDM 6370000100 HCPCS 250 RC 68180-0512-01 NDC outpatient 1 UN 5.65 5.65 UNITED HEALTHCARE (COMMERCIAL) [3081199] UNITED HEALTHCARE 87726 [308119901] 3.5 percent of total billed charges 3.5 5.37 Technical (Hospital) Services LISINOPRIL 2.5 MG TABLET RX-13089 CDM 6370000100 HCPCS 250 RC 68180-0512-01 NDC outpatient 1 UN 5.65 5.65 MEDICA (COMMERCIAL) 94265 [3081118] MEDICA CLAIMS [308111801] 5.09 percent of total billed charges 3.5 5.37 Technical (Hospital) Services LISINOPRIL 2.5 MG TABLET RX-13089 CDM 6370000100 HCPCS 250 RC 68180-0512-01 NDC inpatient 1 UN 5.65 5.65 BLUE CROSS BLUE SHIELD WELLMARK SB889 [3081026] BCBS WYOMING [308102603] 5.37 percent of total billed charges 3.5 5.37 Technical (Hospital) Services LISINOPRIL 2.5 MG TABLET RX-13089 CDM 6370000100 HCPCS 250 RC 68180-0512-01 NDC inpatient 1 UN 5.65 5.65 UNITED HEALTHCARE (COMMERCIAL) [3081199] UNITED HEALTHCARE 87726 [308119901] 3.5 percent of total billed charges 3.5 5.37 Technical (Hospital) Services LISINOPRIL 2.5 MG TABLET RX-13089 CDM 6370000100 HCPCS 250 RC 68180-0512-01 NDC inpatient 1 UN 5.65 5.65 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES HDHP [308136802] 4.47 percent of total billed charges 3.5 5.37 Technical (Hospital) Services LISINOPRIL 2.5 MG TABLET RX-13089 CDM 6370000100 HCPCS 250 RC 68180-0512-01 NDC inpatient 1 UN 5.65 5.65 CIGNA 62308 [3081051] CIGNA 62308 [308105105] 4.47 percent of total billed charges 3.5 5.37 Technical (Hospital) Services LISINOPRIL 2.5 MG TABLET RX-13089 CDM 6370000100 HCPCS 250 RC 68180-0512-01 NDC inpatient 1 UN 5.65 5.65 CIGNA 62308 [3081051] CIGNA STATE OF WYOMING [308105107] 4.47 percent of total billed charges 3.5 5.37 Technical (Hospital) Services LISINOPRIL 2.5 MG TABLET RX-13089 CDM 6370000100 HCPCS 250 RC 68180-0512-01 NDC inpatient 1 UN 5.65 5.65 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES EPO [308136803] 4.47 percent of total billed charges 3.5 5.37 Technical (Hospital) Services LISINOPRIL 2.5 MG TABLET RX-13089 CDM 6370000100 HCPCS 250 RC 68180-0512-01 NDC inpatient 1 UN 5.65 5.65 MULTIPLAN INC 34080 [3081285] MULTIPLAN INC [308128501] 5.37 percent of total billed charges 3.5 5.37 Technical (Hospital) Services LISINOPRIL 2.5 MG TABLET RX-13089 CDM 6370000100 HCPCS 250 RC 68180-0512-01 NDC inpatient 1 UN 5.65 5.65 MEDICA (COMMERCIAL) 94265 [3081118] MEDICA CLAIMS [308111801] 5.09 percent of total billed charges 3.5 5.37 Technical (Hospital) Services LISINOPRIL 2.5 MG TABLET RX-13089 CDM 6370000100 HCPCS 250 RC 68180-0512-01 NDC inpatient 1 UN 5.65 5.65 HEALTHPARTNERS SX009 HEALTHPARTNERS 4.47 percent of total billed charges 3.5 5.37 Technical (Hospital) Services LISINOPRIL 2.5 MG TABLET RX-13089 CDM 6370000100 HCPCS 250 RC 68180-0512-01 NDC inpatient 1 UN 5.65 5.65 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES PPO [308136801] 4.47 percent of total billed charges 3.5 5.37 Technical (Hospital) Services LACTULOSE 10 GRAM/15 ML ORAL SOLUTION (UNIT DOSE) RX-131110 CDM 6370000100 HCPCS 250 RC 00121-4577-15 NDC inpatient 15 ML 6.21 6.21 HEALTHPARTNERS SX009 HEALTHPARTNERS 4.92 percent of total billed charges 3.85 5.9 Technical (Hospital) Services LACTULOSE 10 GRAM/15 ML ORAL SOLUTION (UNIT DOSE) RX-131110 CDM 6370000100 HCPCS 250 RC 00121-4577-15 NDC inpatient 15 ML 6.21 6.21 CIGNA 62308 [3081051] CIGNA 62308 [308105105] 4.92 percent of total billed charges 3.85 5.9 Technical (Hospital) Services LACTULOSE 10 GRAM/15 ML ORAL SOLUTION (UNIT DOSE) RX-131110 CDM 6370000100 HCPCS 250 RC 00121-4577-15 NDC inpatient 15 ML 6.21 6.21 CIGNA 62308 [3081051] CIGNA STATE OF WYOMING [308105107] 4.92 percent of total billed charges 3.85 5.9 Technical (Hospital) Services LACTULOSE 10 GRAM/15 ML ORAL SOLUTION (UNIT DOSE) RX-131110 CDM 6370000100 HCPCS 250 RC 00121-4577-15 NDC inpatient 15 ML 6.21 6.21 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES HDHP [308136802] 4.92 percent of total billed charges 3.85 5.9 Technical (Hospital) Services LACTULOSE 10 GRAM/15 ML ORAL SOLUTION (UNIT DOSE) RX-131110 CDM 6370000100 HCPCS 250 RC 00121-4577-15 NDC inpatient 15 ML 6.21 6.21 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES PPO [308136801] 4.92 percent of total billed charges 3.85 5.9 Technical (Hospital) Services LACTULOSE 10 GRAM/15 ML ORAL SOLUTION (UNIT DOSE) RX-131110 CDM 6370000100 HCPCS 250 RC 00121-4577-15 NDC inpatient 15 ML 6.21 6.21 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES EPO [308136803] 4.92 percent of total billed charges 3.85 5.9 Technical (Hospital) Services LACTULOSE 10 GRAM/15 ML ORAL SOLUTION (UNIT DOSE) RX-131110 CDM 6370000100 HCPCS 250 RC 00121-4577-15 NDC inpatient 15 ML 6.21 6.21 MEDICA (COMMERCIAL) 94265 [3081118] MEDICA CLAIMS [308111801] 5.59 percent of total billed charges 3.85 5.9 Technical (Hospital) Services LACTULOSE 10 GRAM/15 ML ORAL SOLUTION (UNIT DOSE) RX-131110 CDM 6370000100 HCPCS 250 RC 00121-4577-15 NDC inpatient 15 ML 6.21 6.21 MULTIPLAN INC 34080 [3081285] MULTIPLAN INC [308128501] 5.9 percent of total billed charges 3.85 5.9 Technical (Hospital) Services LACTULOSE 10 GRAM/15 ML ORAL SOLUTION (UNIT DOSE) RX-131110 CDM 6370000100 HCPCS 250 RC 00121-4577-15 NDC inpatient 15 ML 6.21 6.21 UNITED HEALTHCARE (COMMERCIAL) [3081199] UNITED HEALTHCARE 87726 [308119901] 3.85 percent of total billed charges 3.85 5.9 Technical (Hospital) Services LACTULOSE 10 GRAM/15 ML ORAL SOLUTION (UNIT DOSE) RX-131110 CDM 6370000100 HCPCS 250 RC 00121-4577-15 NDC inpatient 15 ML 6.21 6.21 BLUE CROSS BLUE SHIELD WELLMARK SB889 [3081026] BCBS WYOMING [308102603] 5.9 percent of total billed charges 3.85 5.9 Technical (Hospital) Services LACTULOSE 10 GRAM/15 ML ORAL SOLUTION (UNIT DOSE) RX-131110 CDM 6370000100 HCPCS 250 RC 00121-4577-15 NDC outpatient 15 ML 6.21 6.21 CIGNA 62308 [3081051] CIGNA 62308 [308105105] 4.97 percent of total billed charges 3.85 5.9 Technical (Hospital) Services LACTULOSE 10 GRAM/15 ML ORAL SOLUTION (UNIT DOSE) RX-131110 CDM 6370000100 HCPCS 250 RC 00121-4577-15 NDC outpatient 15 ML 6.21 6.21 CIGNA 62308 [3081051] CIGNA STATE OF WYOMING [308105107] 4.97 percent of total billed charges 3.85 5.9 Technical (Hospital) Services LACTULOSE 10 GRAM/15 ML ORAL SOLUTION (UNIT DOSE) RX-131110 CDM 6370000100 HCPCS 250 RC 00121-4577-15 NDC outpatient 15 ML 6.21 6.21 MEDICA (COMMERCIAL) 94265 [3081118] MEDICA CLAIMS [308111801] 5.59 percent of total billed charges 3.85 5.9 Technical (Hospital) Services LACTULOSE 10 GRAM/15 ML ORAL SOLUTION (UNIT DOSE) RX-131110 CDM 6370000100 HCPCS 250 RC 00121-4577-15 NDC outpatient 15 ML 6.21 6.21 MULTIPLAN INC 34080 [3081285] MULTIPLAN INC [308128501] 5.9 percent of total billed charges 3.85 5.9 Technical (Hospital) Services LACTULOSE 10 GRAM/15 ML ORAL SOLUTION (UNIT DOSE) RX-131110 CDM 6370000100 HCPCS 250 RC 00121-4577-15 NDC outpatient 15 ML 6.21 6.21 UNITED HEALTHCARE (COMMERCIAL) [3081199] UNITED HEALTHCARE 87726 [308119901] 3.85 percent of total billed charges 3.85 5.9 Technical (Hospital) Services LACTULOSE 10 GRAM/15 ML ORAL SOLUTION (UNIT DOSE) RX-131110 CDM 6370000100 HCPCS 250 RC 00121-4577-15 NDC outpatient 15 ML 6.21 6.21 BLUE CROSS BLUE SHIELD WELLMARK SB889 [3081026] BCBS WYOMING [308102603] 5.9 percent of total billed charges 3.85 5.9 Technical (Hospital) Services LACTULOSE 10 GRAM/15 ML ORAL SOLUTION (UNIT DOSE) RX-131110 CDM 6370000100 HCPCS 250 RC 00121-4577-15 NDC outpatient 15 ML 6.21 6.21 HEALTHPARTNERS SX009 HEALTHPARTNERS 4.97 percent of total billed charges 3.85 5.9 Technical (Hospital) Services LACTULOSE 10 GRAM/15 ML ORAL SOLUTION (UNIT DOSE) RX-131110 CDM 6370000100 HCPCS 250 RC 00121-4577-15 NDC outpatient 15 ML 6.21 6.21 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES EPO [308136803] 4.97 percent of total billed charges 3.85 5.9 Technical (Hospital) Services LACTULOSE 10 GRAM/15 ML ORAL SOLUTION (UNIT DOSE) RX-131110 CDM 6370000100 HCPCS 250 RC 00121-4577-15 NDC outpatient 15 ML 6.21 6.21 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES HDHP [308136802] 4.97 percent of total billed charges 3.85 5.9 Technical (Hospital) Services LACTULOSE 10 GRAM/15 ML ORAL SOLUTION (UNIT DOSE) RX-131110 CDM 6370000100 HCPCS 250 RC 00121-4577-15 NDC outpatient 15 ML 6.21 6.21 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES PPO [308136801] 4.97 percent of total billed charges 3.85 5.9 Technical (Hospital) Services METHYLNALTREXONE 12 MG/0.6 ML SUBCUTANEOUS SYRINGE RX-131225 CDM 6370000100 HCPCS 250 RC 65649-0551-07 NDC inpatient 0.6 ML 510.31 510.31 MULTIPLAN INC 34080 [3081285] MULTIPLAN INC [308128501] 484.79 percent of total billed charges 316.39 484.79 Technical (Hospital) Services METHYLNALTREXONE 12 MG/0.6 ML SUBCUTANEOUS SYRINGE RX-131225 CDM 6370000100 HCPCS 250 RC 65649-0551-07 NDC inpatient 0.6 ML 510.31 510.31 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES PPO [308136801] 404.06 percent of total billed charges 316.39 484.79 Technical (Hospital) Services METHYLNALTREXONE 12 MG/0.6 ML SUBCUTANEOUS SYRINGE RX-131225 CDM 6370000100 HCPCS 250 RC 65649-0551-07 NDC inpatient 0.6 ML 510.31 510.31 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES EPO [308136803] 404.06 percent of total billed charges 316.39 484.79 Technical (Hospital) Services METHYLNALTREXONE 12 MG/0.6 ML SUBCUTANEOUS SYRINGE RX-131225 CDM 6370000100 HCPCS 250 RC 65649-0551-07 NDC inpatient 0.6 ML 510.31 510.31 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES HDHP [308136802] 404.06 percent of total billed charges 316.39 484.79 Technical (Hospital) Services METHYLNALTREXONE 12 MG/0.6 ML SUBCUTANEOUS SYRINGE RX-131225 CDM 6370000100 HCPCS 250 RC 65649-0551-07 NDC inpatient 0.6 ML 510.31 510.31 CIGNA 62308 [3081051] CIGNA 62308 [308105105] 404.06 percent of total billed charges 316.39 484.79 Technical (Hospital) Services METHYLNALTREXONE 12 MG/0.6 ML SUBCUTANEOUS SYRINGE RX-131225 CDM 6370000100 HCPCS 250 RC 65649-0551-07 NDC inpatient 0.6 ML 510.31 510.31 CIGNA 62308 [3081051] CIGNA STATE OF WYOMING [308105107] 404.06 percent of total billed charges 316.39 484.79 Technical (Hospital) Services METHYLNALTREXONE 12 MG/0.6 ML SUBCUTANEOUS SYRINGE RX-131225 CDM 6370000100 HCPCS 250 RC 65649-0551-07 NDC inpatient 0.6 ML 510.31 510.31 HEALTHPARTNERS SX009 HEALTHPARTNERS 404.06 percent of total billed charges 316.39 484.79 Technical (Hospital) Services METHYLNALTREXONE 12 MG/0.6 ML SUBCUTANEOUS SYRINGE RX-131225 CDM 6370000100 HCPCS 250 RC 65649-0551-07 NDC inpatient 0.6 ML 510.31 510.31 MEDICA (COMMERCIAL) 94265 [3081118] MEDICA CLAIMS [308111801] 459.28 percent of total billed charges 316.39 484.79 Technical (Hospital) Services METHYLNALTREXONE 12 MG/0.6 ML SUBCUTANEOUS SYRINGE RX-131225 CDM 6370000100 HCPCS 250 RC 65649-0551-07 NDC inpatient 0.6 ML 510.31 510.31 BLUE CROSS BLUE SHIELD WELLMARK SB889 [3081026] BCBS WYOMING [308102603] 484.79 percent of total billed charges 316.39 484.79 Technical (Hospital) Services METHYLNALTREXONE 12 MG/0.6 ML SUBCUTANEOUS SYRINGE RX-131225 CDM 6370000100 HCPCS 250 RC 65649-0551-07 NDC inpatient 0.6 ML 510.31 510.31 UNITED HEALTHCARE (COMMERCIAL) [3081199] UNITED HEALTHCARE 87726 [308119901] 316.39 percent of total billed charges 316.39 484.79 Technical (Hospital) Services METHYLNALTREXONE 12 MG/0.6 ML SUBCUTANEOUS SYRINGE RX-131225 CDM 6370000100 HCPCS 250 RC 65649-0551-07 NDC outpatient 0.6 ML 510.31 510.31 HEALTHPARTNERS SX009 HEALTHPARTNERS 408.25 percent of total billed charges 316.39 484.79 Technical (Hospital) Services METHYLNALTREXONE 12 MG/0.6 ML SUBCUTANEOUS SYRINGE RX-131225 CDM 6370000100 HCPCS 250 RC 65649-0551-07 NDC outpatient 0.6 ML 510.31 510.31 BLUE CROSS BLUE SHIELD WELLMARK SB889 [3081026] BCBS WYOMING [308102603] 484.79 percent of total billed charges 316.39 484.79 Technical (Hospital) Services METHYLNALTREXONE 12 MG/0.6 ML SUBCUTANEOUS SYRINGE RX-131225 CDM 6370000100 HCPCS 250 RC 65649-0551-07 NDC outpatient 0.6 ML 510.31 510.31 MEDICA (COMMERCIAL) 94265 [3081118] MEDICA CLAIMS [308111801] 459.28 percent of total billed charges 316.39 484.79 Technical (Hospital) Services METHYLNALTREXONE 12 MG/0.6 ML SUBCUTANEOUS SYRINGE RX-131225 CDM 6370000100 HCPCS 250 RC 65649-0551-07 NDC outpatient 0.6 ML 510.31 510.31 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES PPO [308136801] 408.25 percent of total billed charges 316.39 484.79 Technical (Hospital) Services METHYLNALTREXONE 12 MG/0.6 ML SUBCUTANEOUS SYRINGE RX-131225 CDM 6370000100 HCPCS 250 RC 65649-0551-07 NDC outpatient 0.6 ML 510.31 510.31 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES HDHP [308136802] 408.25 percent of total billed charges 316.39 484.79 Technical (Hospital) Services METHYLNALTREXONE 12 MG/0.6 ML SUBCUTANEOUS SYRINGE RX-131225 CDM 6370000100 HCPCS 250 RC 65649-0551-07 NDC outpatient 0.6 ML 510.31 510.31 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES EPO [308136803] 408.25 percent of total billed charges 316.39 484.79 Technical (Hospital) Services METHYLNALTREXONE 12 MG/0.6 ML SUBCUTANEOUS SYRINGE RX-131225 CDM 6370000100 HCPCS 250 RC 65649-0551-07 NDC outpatient 0.6 ML 510.31 510.31 MULTIPLAN INC 34080 [3081285] MULTIPLAN INC [308128501] 484.79 percent of total billed charges 316.39 484.79 Technical (Hospital) Services METHYLNALTREXONE 12 MG/0.6 ML SUBCUTANEOUS SYRINGE RX-131225 CDM 6370000100 HCPCS 250 RC 65649-0551-07 NDC outpatient 0.6 ML 510.31 510.31 CIGNA 62308 [3081051] CIGNA 62308 [308105105] 408.25 percent of total billed charges 316.39 484.79 Technical (Hospital) Services METHYLNALTREXONE 12 MG/0.6 ML SUBCUTANEOUS SYRINGE RX-131225 CDM 6370000100 HCPCS 250 RC 65649-0551-07 NDC outpatient 0.6 ML 510.31 510.31 CIGNA 62308 [3081051] CIGNA STATE OF WYOMING [308105107] 408.25 percent of total billed charges 316.39 484.79 Technical (Hospital) Services METHYLNALTREXONE 12 MG/0.6 ML SUBCUTANEOUS SYRINGE RX-131225 CDM 6370000100 HCPCS 250 RC 65649-0551-07 NDC outpatient 0.6 ML 510.31 510.31 UNITED HEALTHCARE (COMMERCIAL) [3081199] UNITED HEALTHCARE 87726 [308119901] 316.39 percent of total billed charges 316.39 484.79 Technical (Hospital) Services VALACYCLOVIR 1 GRAM TABLET RX-13132 CDM 6370000100 HCPCS 250 RC 59746-0325-30 NDC inpatient 1 UN 6.78 6.78 UNITED HEALTHCARE (COMMERCIAL) [3081199] UNITED HEALTHCARE 87726 [308119901] 4.2 percent of total billed charges 4.2 6.44 Technical (Hospital) Services VALACYCLOVIR 1 GRAM TABLET RX-13132 CDM 6370000100 HCPCS 250 RC 59746-0325-30 NDC inpatient 1 UN 6.78 6.78 BLUE CROSS BLUE SHIELD WELLMARK SB889 [3081026] BCBS WYOMING [308102603] 6.44 percent of total billed charges 4.2 6.44 Technical (Hospital) Services VALACYCLOVIR 1 GRAM TABLET RX-13132 CDM 6370000100 HCPCS 250 RC 59746-0325-30 NDC inpatient 1 UN 6.78 6.78 HEALTHPARTNERS SX009 HEALTHPARTNERS 5.37 percent of total billed charges 4.2 6.44 Technical (Hospital) Services VALACYCLOVIR 1 GRAM TABLET RX-13132 CDM 6370000100 HCPCS 250 RC 59746-0325-30 NDC inpatient 1 UN 6.78 6.78 MEDICA (COMMERCIAL) 94265 [3081118] MEDICA CLAIMS [308111801] 6.1 percent of total billed charges 4.2 6.44 Technical (Hospital) Services VALACYCLOVIR 1 GRAM TABLET RX-13132 CDM 6370000100 HCPCS 250 RC 59746-0325-30 NDC inpatient 1 UN 6.78 6.78 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES HDHP [308136802] 5.37 percent of total billed charges 4.2 6.44 Technical (Hospital) Services VALACYCLOVIR 1 GRAM TABLET RX-13132 CDM 6370000100 HCPCS 250 RC 59746-0325-30 NDC inpatient 1 UN 6.78 6.78 CIGNA 62308 [3081051] CIGNA 62308 [308105105] 5.37 percent of total billed charges 4.2 6.44 Technical (Hospital) Services VALACYCLOVIR 1 GRAM TABLET RX-13132 CDM 6370000100 HCPCS 250 RC 59746-0325-30 NDC inpatient 1 UN 6.78 6.78 CIGNA 62308 [3081051] CIGNA STATE OF WYOMING [308105107] 5.37 percent of total billed charges 4.2 6.44 Technical (Hospital) Services VALACYCLOVIR 1 GRAM TABLET RX-13132 CDM 6370000100 HCPCS 250 RC 59746-0325-30 NDC inpatient 1 UN 6.78 6.78 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES EPO [308136803] 5.37 percent of total billed charges 4.2 6.44 Technical (Hospital) Services VALACYCLOVIR 1 GRAM TABLET RX-13132 CDM 6370000100 HCPCS 250 RC 59746-0325-30 NDC inpatient 1 UN 6.78 6.78 MULTIPLAN INC 34080 [3081285] MULTIPLAN INC [308128501] 6.44 percent of total billed charges 4.2 6.44 Technical (Hospital) Services VALACYCLOVIR 1 GRAM TABLET RX-13132 CDM 6370000100 HCPCS 250 RC 59746-0325-30 NDC inpatient 1 UN 6.78 6.78 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES PPO [308136801] 5.37 percent of total billed charges 4.2 6.44 Technical (Hospital) Services VALACYCLOVIR 1 GRAM TABLET RX-13132 CDM 6370000100 HCPCS 250 RC 59746-0325-30 NDC outpatient 1 UN 6.78 6.78 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES EPO [308136803] 5.42 percent of total billed charges 4.2 6.44 Technical (Hospital) Services VALACYCLOVIR 1 GRAM TABLET RX-13132 CDM 6370000100 HCPCS 250 RC 59746-0325-30 NDC outpatient 1 UN 6.78 6.78 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES HDHP [308136802] 5.42 percent of total billed charges 4.2 6.44 Technical (Hospital) Services VALACYCLOVIR 1 GRAM TABLET RX-13132 CDM 6370000100 HCPCS 250 RC 59746-0325-30 NDC outpatient 1 UN 6.78 6.78 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES PPO [308136801] 5.42 percent of total billed charges 4.2 6.44 Technical (Hospital) Services VALACYCLOVIR 1 GRAM TABLET RX-13132 CDM 6370000100 HCPCS 250 RC 59746-0325-30 NDC outpatient 1 UN 6.78 6.78 CIGNA 62308 [3081051] CIGNA 62308 [308105105] 5.42 percent of total billed charges 4.2 6.44 Technical (Hospital) Services VALACYCLOVIR 1 GRAM TABLET RX-13132 CDM 6370000100 HCPCS 250 RC 59746-0325-30 NDC outpatient 1 UN 6.78 6.78 CIGNA 62308 [3081051] CIGNA STATE OF WYOMING [308105107] 5.42 percent of total billed charges 4.2 6.44 Technical (Hospital) Services VALACYCLOVIR 1 GRAM TABLET RX-13132 CDM 6370000100 HCPCS 250 RC 59746-0325-30 NDC outpatient 1 UN 6.78 6.78 MULTIPLAN INC 34080 [3081285] MULTIPLAN INC [308128501] 6.44 percent of total billed charges 4.2 6.44 Technical (Hospital) Services VALACYCLOVIR 1 GRAM TABLET RX-13132 CDM 6370000100 HCPCS 250 RC 59746-0325-30 NDC outpatient 1 UN 6.78 6.78 UNITED HEALTHCARE (COMMERCIAL) [3081199] UNITED HEALTHCARE 87726 [308119901] 4.2 percent of total billed charges 4.2 6.44 Technical (Hospital) Services VALACYCLOVIR 1 GRAM TABLET RX-13132 CDM 6370000100 HCPCS 250 RC 59746-0325-30 NDC outpatient 1 UN 6.78 6.78 MEDICA (COMMERCIAL) 94265 [3081118] MEDICA CLAIMS [308111801] 6.1 percent of total billed charges 4.2 6.44 Technical (Hospital) Services VALACYCLOVIR 1 GRAM TABLET RX-13132 CDM 6370000100 HCPCS 250 RC 59746-0325-30 NDC outpatient 1 UN 6.78 6.78 HEALTHPARTNERS SX009 HEALTHPARTNERS 5.42 percent of total billed charges 4.2 6.44 Technical (Hospital) Services VALACYCLOVIR 1 GRAM TABLET RX-13132 CDM 6370000100 HCPCS 250 RC 59746-0325-30 NDC outpatient 1 UN 6.78 6.78 BLUE CROSS BLUE SHIELD WELLMARK SB889 [3081026] BCBS WYOMING [308102603] 6.44 percent of total billed charges 4.2 6.44 Technical (Hospital) Services VALACYCLOVIR 500 MG TABLET RX-13133 CDM 6370000100 HCPCS 250 RC 51079-0093-01 NDC outpatient 1 UN 15.05 15.05 HEALTHPARTNERS SX009 HEALTHPARTNERS 12.04 percent of total billed charges 9.33 14.3 Technical (Hospital) Services VALACYCLOVIR 500 MG TABLET RX-13133 CDM 6370000100 HCPCS 250 RC 51079-0093-01 NDC outpatient 1 UN 15.05 15.05 BLUE CROSS BLUE SHIELD WELLMARK SB889 [3081026] BCBS WYOMING [308102603] 14.3 percent of total billed charges 9.33 14.3 Technical (Hospital) Services VALACYCLOVIR 500 MG TABLET RX-13133 CDM 6370000100 HCPCS 250 RC 51079-0093-01 NDC outpatient 1 UN 15.05 15.05 MULTIPLAN INC 34080 [3081285] MULTIPLAN INC [308128501] 14.3 percent of total billed charges 9.33 14.3 Technical (Hospital) Services VALACYCLOVIR 500 MG TABLET RX-13133 CDM 6370000100 HCPCS 250 RC 51079-0093-01 NDC outpatient 1 UN 15.05 15.05 UNITED HEALTHCARE (COMMERCIAL) [3081199] UNITED HEALTHCARE 87726 [308119901] 9.33 percent of total billed charges 9.33 14.3 Technical (Hospital) Services VALACYCLOVIR 500 MG TABLET RX-13133 CDM 6370000100 HCPCS 250 RC 51079-0093-01 NDC outpatient 1 UN 15.05 15.05 CIGNA 62308 [3081051] CIGNA 62308 [308105105] 12.04 percent of total billed charges 9.33 14.3 Technical (Hospital) Services VALACYCLOVIR 500 MG TABLET RX-13133 CDM 6370000100 HCPCS 250 RC 51079-0093-01 NDC outpatient 1 UN 15.05 15.05 CIGNA 62308 [3081051] CIGNA STATE OF WYOMING [308105107] 12.04 percent of total billed charges 9.33 14.3 Technical (Hospital) Services VALACYCLOVIR 500 MG TABLET RX-13133 CDM 6370000100 HCPCS 250 RC 51079-0093-01 NDC outpatient 1 UN 15.05 15.05 MEDICA (COMMERCIAL) 94265 [3081118] MEDICA CLAIMS [308111801] 13.55 percent of total billed charges 9.33 14.3 Technical (Hospital) Services VALACYCLOVIR 500 MG TABLET RX-13133 CDM 6370000100 HCPCS 250 RC 51079-0093-01 NDC outpatient 1 UN 15.05 15.05 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES HDHP [308136802] 12.04 percent of total billed charges 9.33 14.3 Technical (Hospital) Services VALACYCLOVIR 500 MG TABLET RX-13133 CDM 6370000100 HCPCS 250 RC 51079-0093-01 NDC outpatient 1 UN 15.05 15.05 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES EPO [308136803] 12.04 percent of total billed charges 9.33 14.3 Technical (Hospital) Services VALACYCLOVIR 500 MG TABLET RX-13133 CDM 6370000100 HCPCS 250 RC 51079-0093-01 NDC outpatient 1 UN 15.05 15.05 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES PPO [308136801] 12.04 percent of total billed charges 9.33 14.3 Technical (Hospital) Services VALACYCLOVIR 500 MG TABLET RX-13133 CDM 6370000100 HCPCS 250 RC 51079-0093-01 NDC inpatient 1 UN 15.05 15.05 MEDICA (COMMERCIAL) 94265 [3081118] MEDICA CLAIMS [308111801] 13.55 percent of total billed charges 9.33 14.3 Technical (Hospital) Services VALACYCLOVIR 500 MG TABLET RX-13133 CDM 6370000100 HCPCS 250 RC 51079-0093-01 NDC inpatient 1 UN 15.05 15.05 HEALTHPARTNERS SX009 HEALTHPARTNERS 11.92 percent of total billed charges 9.33 14.3 Technical (Hospital) Services VALACYCLOVIR 500 MG TABLET RX-13133 CDM 6370000100 HCPCS 250 RC 51079-0093-01 NDC inpatient 1 UN 15.05 15.05 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES PPO [308136801] 11.92 percent of total billed charges 9.33 14.3 Technical (Hospital) Services VALACYCLOVIR 500 MG TABLET RX-13133 CDM 6370000100 HCPCS 250 RC 51079-0093-01 NDC inpatient 1 UN 15.05 15.05 MULTIPLAN INC 34080 [3081285] MULTIPLAN INC [308128501] 14.3 percent of total billed charges 9.33 14.3 Technical (Hospital) Services VALACYCLOVIR 500 MG TABLET RX-13133 CDM 6370000100 HCPCS 250 RC 51079-0093-01 NDC inpatient 1 UN 15.05 15.05 CIGNA 62308 [3081051] CIGNA 62308 [308105105] 11.92 percent of total billed charges 9.33 14.3 Technical (Hospital) Services VALACYCLOVIR 500 MG TABLET RX-13133 CDM 6370000100 HCPCS 250 RC 51079-0093-01 NDC inpatient 1 UN 15.05 15.05 CIGNA 62308 [3081051] CIGNA STATE OF WYOMING [308105107] 11.92 percent of total billed charges 9.33 14.3 Technical (Hospital) Services VALACYCLOVIR 500 MG TABLET RX-13133 CDM 6370000100 HCPCS 250 RC 51079-0093-01 NDC inpatient 1 UN 15.05 15.05 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES EPO [308136803] 11.92 percent of total billed charges 9.33 14.3 Technical (Hospital) Services VALACYCLOVIR 500 MG TABLET RX-13133 CDM 6370000100 HCPCS 250 RC 51079-0093-01 NDC inpatient 1 UN 15.05 15.05 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES HDHP [308136802] 11.92 percent of total billed charges 9.33 14.3 Technical (Hospital) Services VALACYCLOVIR 500 MG TABLET RX-13133 CDM 6370000100 HCPCS 250 RC 51079-0093-01 NDC inpatient 1 UN 15.05 15.05 BLUE CROSS BLUE SHIELD WELLMARK SB889 [3081026] BCBS WYOMING [308102603] 14.3 percent of total billed charges 9.33 14.3 Technical (Hospital) Services VALACYCLOVIR 500 MG TABLET RX-13133 CDM 6370000100 HCPCS 250 RC 51079-0093-01 NDC inpatient 1 UN 15.05 15.05 UNITED HEALTHCARE (COMMERCIAL) [3081199] UNITED HEALTHCARE 87726 [308119901] 9.33 percent of total billed charges 9.33 14.3 Technical (Hospital) Services PHENOBARB-HYOSCYAMN-ATROPINE-SCOP 16.2 MG-0.1037 MG/5 ML (5 ML) ELIXIR RX-131833 CDM 6370000100 HCPCS 250 RC 66689-0063-01 NDC inpatient 5 ML 137.8 137.8 MULTIPLAN INC 34080 [3081285] MULTIPLAN INC [308128501] 130.91 percent of total billed charges 85.44 130.91 Technical (Hospital) Services PHENOBARB-HYOSCYAMN-ATROPINE-SCOP 16.2 MG-0.1037 MG/5 ML (5 ML) ELIXIR RX-131833 CDM 6370000100 HCPCS 250 RC 66689-0063-01 NDC inpatient 5 ML 137.8 137.8 MEDICA (COMMERCIAL) 94265 [3081118] MEDICA CLAIMS [308111801] 124.02 percent of total billed charges 85.44 130.91 Technical (Hospital) Services PHENOBARB-HYOSCYAMN-ATROPINE-SCOP 16.2 MG-0.1037 MG/5 ML (5 ML) ELIXIR RX-131833 CDM 6370000100 HCPCS 250 RC 66689-0063-01 NDC inpatient 5 ML 137.8 137.8 CIGNA 62308 [3081051] CIGNA 62308 [308105105] 109.11 percent of total billed charges 85.44 130.91 Technical (Hospital) Services PHENOBARB-HYOSCYAMN-ATROPINE-SCOP 16.2 MG-0.1037 MG/5 ML (5 ML) ELIXIR RX-131833 CDM 6370000100 HCPCS 250 RC 66689-0063-01 NDC inpatient 5 ML 137.8 137.8 CIGNA 62308 [3081051] CIGNA STATE OF WYOMING [308105107] 109.11 percent of total billed charges 85.44 130.91 Technical (Hospital) Services PHENOBARB-HYOSCYAMN-ATROPINE-SCOP 16.2 MG-0.1037 MG/5 ML (5 ML) ELIXIR RX-131833 CDM 6370000100 HCPCS 250 RC 66689-0063-01 NDC inpatient 5 ML 137.8 137.8 UNITED HEALTHCARE (COMMERCIAL) [3081199] UNITED HEALTHCARE 87726 [308119901] 85.44 percent of total billed charges 85.44 130.91 Technical (Hospital) Services PHENOBARB-HYOSCYAMN-ATROPINE-SCOP 16.2 MG-0.1037 MG/5 ML (5 ML) ELIXIR RX-131833 CDM 6370000100 HCPCS 250 RC 66689-0063-01 NDC inpatient 5 ML 137.8 137.8 BLUE CROSS BLUE SHIELD WELLMARK SB889 [3081026] BCBS WYOMING [308102603] 130.91 percent of total billed charges 85.44 130.91 Technical (Hospital) Services PHENOBARB-HYOSCYAMN-ATROPINE-SCOP 16.2 MG-0.1037 MG/5 ML (5 ML) ELIXIR RX-131833 CDM 6370000100 HCPCS 250 RC 66689-0063-01 NDC inpatient 5 ML 137.8 137.8 HEALTHPARTNERS SX009 HEALTHPARTNERS 109.11 percent of total billed charges 85.44 130.91 Technical (Hospital) Services PHENOBARB-HYOSCYAMN-ATROPINE-SCOP 16.2 MG-0.1037 MG/5 ML (5 ML) ELIXIR RX-131833 CDM 6370000100 HCPCS 250 RC 66689-0063-01 NDC inpatient 5 ML 137.8 137.8 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES PPO [308136801] 109.11 percent of total billed charges 85.44 130.91 Technical (Hospital) Services PHENOBARB-HYOSCYAMN-ATROPINE-SCOP 16.2 MG-0.1037 MG/5 ML (5 ML) ELIXIR RX-131833 CDM 6370000100 HCPCS 250 RC 66689-0063-01 NDC inpatient 5 ML 137.8 137.8 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES HDHP [308136802] 109.11 percent of total billed charges 85.44 130.91 Technical (Hospital) Services PHENOBARB-HYOSCYAMN-ATROPINE-SCOP 16.2 MG-0.1037 MG/5 ML (5 ML) ELIXIR RX-131833 CDM 6370000100 HCPCS 250 RC 66689-0063-01 NDC inpatient 5 ML 137.8 137.8 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES EPO [308136803] 109.11 percent of total billed charges 85.44 130.91 Technical (Hospital) Services PHENOBARB-HYOSCYAMN-ATROPINE-SCOP 16.2 MG-0.1037 MG/5 ML (5 ML) ELIXIR RX-131833 CDM 6370000100 HCPCS 250 RC 66689-0063-01 NDC outpatient 5 ML 137.8 137.8 MULTIPLAN INC 34080 [3081285] MULTIPLAN INC [308128501] 130.91 percent of total billed charges 85.44 130.91 Technical (Hospital) Services PHENOBARB-HYOSCYAMN-ATROPINE-SCOP 16.2 MG-0.1037 MG/5 ML (5 ML) ELIXIR RX-131833 CDM 6370000100 HCPCS 250 RC 66689-0063-01 NDC outpatient 5 ML 137.8 137.8 MEDICA (COMMERCIAL) 94265 [3081118] MEDICA CLAIMS [308111801] 124.02 percent of total billed charges 85.44 130.91 Technical (Hospital) Services PHENOBARB-HYOSCYAMN-ATROPINE-SCOP 16.2 MG-0.1037 MG/5 ML (5 ML) ELIXIR RX-131833 CDM 6370000100 HCPCS 250 RC 66689-0063-01 NDC outpatient 5 ML 137.8 137.8 CIGNA 62308 [3081051] CIGNA 62308 [308105105] 110.24 percent of total billed charges 85.44 130.91 Technical (Hospital) Services PHENOBARB-HYOSCYAMN-ATROPINE-SCOP 16.2 MG-0.1037 MG/5 ML (5 ML) ELIXIR RX-131833 CDM 6370000100 HCPCS 250 RC 66689-0063-01 NDC outpatient 5 ML 137.8 137.8 CIGNA 62308 [3081051] CIGNA STATE OF WYOMING [308105107] 110.24 percent of total billed charges 85.44 130.91 Technical (Hospital) Services PHENOBARB-HYOSCYAMN-ATROPINE-SCOP 16.2 MG-0.1037 MG/5 ML (5 ML) ELIXIR RX-131833 CDM 6370000100 HCPCS 250 RC 66689-0063-01 NDC outpatient 5 ML 137.8 137.8 UNITED HEALTHCARE (COMMERCIAL) [3081199] UNITED HEALTHCARE 87726 [308119901] 85.44 percent of total billed charges 85.44 130.91 Technical (Hospital) Services PHENOBARB-HYOSCYAMN-ATROPINE-SCOP 16.2 MG-0.1037 MG/5 ML (5 ML) ELIXIR RX-131833 CDM 6370000100 HCPCS 250 RC 66689-0063-01 NDC outpatient 5 ML 137.8 137.8 HEALTHPARTNERS SX009 HEALTHPARTNERS 110.24 percent of total billed charges 85.44 130.91 Technical (Hospital) Services PHENOBARB-HYOSCYAMN-ATROPINE-SCOP 16.2 MG-0.1037 MG/5 ML (5 ML) ELIXIR RX-131833 CDM 6370000100 HCPCS 250 RC 66689-0063-01 NDC outpatient 5 ML 137.8 137.8 BLUE CROSS BLUE SHIELD WELLMARK SB889 [3081026] BCBS WYOMING [308102603] 130.91 percent of total billed charges 85.44 130.91 Technical (Hospital) Services PHENOBARB-HYOSCYAMN-ATROPINE-SCOP 16.2 MG-0.1037 MG/5 ML (5 ML) ELIXIR RX-131833 CDM 6370000100 HCPCS 250 RC 66689-0063-01 NDC outpatient 5 ML 137.8 137.8 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES HDHP [308136802] 110.24 percent of total billed charges 85.44 130.91 Technical (Hospital) Services PHENOBARB-HYOSCYAMN-ATROPINE-SCOP 16.2 MG-0.1037 MG/5 ML (5 ML) ELIXIR RX-131833 CDM 6370000100 HCPCS 250 RC 66689-0063-01 NDC outpatient 5 ML 137.8 137.8 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES PPO [308136801] 110.24 percent of total billed charges 85.44 130.91 Technical (Hospital) Services PHENOBARB-HYOSCYAMN-ATROPINE-SCOP 16.2 MG-0.1037 MG/5 ML (5 ML) ELIXIR RX-131833 CDM 6370000100 HCPCS 250 RC 66689-0063-01 NDC outpatient 5 ML 137.8 137.8 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES EPO [308136803] 110.24 percent of total billed charges 85.44 130.91 Technical (Hospital) Services "VERAPAMIL ER (SR) 120 MG TABLET,EXTENDED RELEASE" RX-13184 CDM 6370000100 HCPCS 250 RC 68462-0292-01 NDC outpatient 1 UN 6.22 6.22 HEALTHPARTNERS SX009 HEALTHPARTNERS 4.98 percent of total billed charges 3.86 5.91 Technical (Hospital) Services "VERAPAMIL ER (SR) 120 MG TABLET,EXTENDED RELEASE" RX-13184 CDM 6370000100 HCPCS 250 RC 68462-0292-01 NDC outpatient 1 UN 6.22 6.22 BLUE CROSS BLUE SHIELD WELLMARK SB889 [3081026] BCBS WYOMING [308102603] 5.91 percent of total billed charges 3.86 5.91 Technical (Hospital) Services "VERAPAMIL ER (SR) 120 MG TABLET,EXTENDED RELEASE" RX-13184 CDM 6370000100 HCPCS 250 RC 68462-0292-01 NDC outpatient 1 UN 6.22 6.22 MEDICA (COMMERCIAL) 94265 [3081118] MEDICA CLAIMS [308111801] 5.6 percent of total billed charges 3.86 5.91 Technical (Hospital) Services "VERAPAMIL ER (SR) 120 MG TABLET,EXTENDED RELEASE" RX-13184 CDM 6370000100 HCPCS 250 RC 68462-0292-01 NDC outpatient 1 UN 6.22 6.22 UNITED HEALTHCARE (COMMERCIAL) [3081199] UNITED HEALTHCARE 87726 [308119901] 3.86 percent of total billed charges 3.86 5.91 Technical (Hospital) Services "VERAPAMIL ER (SR) 120 MG TABLET,EXTENDED RELEASE" RX-13184 CDM 6370000100 HCPCS 250 RC 68462-0292-01 NDC outpatient 1 UN 6.22 6.22 CIGNA 62308 [3081051] CIGNA 62308 [308105105] 4.98 percent of total billed charges 3.86 5.91 Technical (Hospital) Services "VERAPAMIL ER (SR) 120 MG TABLET,EXTENDED RELEASE" RX-13184 CDM 6370000100 HCPCS 250 RC 68462-0292-01 NDC outpatient 1 UN 6.22 6.22 CIGNA 62308 [3081051] CIGNA STATE OF WYOMING [308105107] 4.98 percent of total billed charges 3.86 5.91 Technical (Hospital) Services "VERAPAMIL ER (SR) 120 MG TABLET,EXTENDED RELEASE" RX-13184 CDM 6370000100 HCPCS 250 RC 68462-0292-01 NDC outpatient 1 UN 6.22 6.22 MULTIPLAN INC 34080 [3081285] MULTIPLAN INC [308128501] 5.91 percent of total billed charges 3.86 5.91 Technical (Hospital) Services "VERAPAMIL ER (SR) 120 MG TABLET,EXTENDED RELEASE" RX-13184 CDM 6370000100 HCPCS 250 RC 68462-0292-01 NDC outpatient 1 UN 6.22 6.22 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES EPO [308136803] 4.98 percent of total billed charges 3.86 5.91 Technical (Hospital) Services "VERAPAMIL ER (SR) 120 MG TABLET,EXTENDED RELEASE" RX-13184 CDM 6370000100 HCPCS 250 RC 68462-0292-01 NDC outpatient 1 UN 6.22 6.22 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES HDHP [308136802] 4.98 percent of total billed charges 3.86 5.91 Technical (Hospital) Services "VERAPAMIL ER (SR) 120 MG TABLET,EXTENDED RELEASE" RX-13184 CDM 6370000100 HCPCS 250 RC 68462-0292-01 NDC outpatient 1 UN 6.22 6.22 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES PPO [308136801] 4.98 percent of total billed charges 3.86 5.91 Technical (Hospital) Services "VERAPAMIL ER (SR) 120 MG TABLET,EXTENDED RELEASE" RX-13184 CDM 6370000100 HCPCS 250 RC 68462-0292-01 NDC inpatient 1 UN 6.22 6.22 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES EPO [308136803] 4.92 percent of total billed charges 3.86 5.91 Technical (Hospital) Services "VERAPAMIL ER (SR) 120 MG TABLET,EXTENDED RELEASE" RX-13184 CDM 6370000100 HCPCS 250 RC 68462-0292-01 NDC inpatient 1 UN 6.22 6.22 CIGNA 62308 [3081051] CIGNA 62308 [308105105] 4.92 percent of total billed charges 3.86 5.91 Technical (Hospital) Services "VERAPAMIL ER (SR) 120 MG TABLET,EXTENDED RELEASE" RX-13184 CDM 6370000100 HCPCS 250 RC 68462-0292-01 NDC inpatient 1 UN 6.22 6.22 CIGNA 62308 [3081051] CIGNA STATE OF WYOMING [308105107] 4.92 percent of total billed charges 3.86 5.91 Technical (Hospital) Services "VERAPAMIL ER (SR) 120 MG TABLET,EXTENDED RELEASE" RX-13184 CDM 6370000100 HCPCS 250 RC 68462-0292-01 NDC inpatient 1 UN 6.22 6.22 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES HDHP [308136802] 4.92 percent of total billed charges 3.86 5.91 Technical (Hospital) Services "VERAPAMIL ER (SR) 120 MG TABLET,EXTENDED RELEASE" RX-13184 CDM 6370000100 HCPCS 250 RC 68462-0292-01 NDC inpatient 1 UN 6.22 6.22 UNITED HEALTHCARE (COMMERCIAL) [3081199] UNITED HEALTHCARE 87726 [308119901] 3.86 percent of total billed charges 3.86 5.91 Technical (Hospital) Services "VERAPAMIL ER (SR) 120 MG TABLET,EXTENDED RELEASE" RX-13184 CDM 6370000100 HCPCS 250 RC 68462-0292-01 NDC inpatient 1 UN 6.22 6.22 BLUE CROSS BLUE SHIELD WELLMARK SB889 [3081026] BCBS WYOMING [308102603] 5.91 percent of total billed charges 3.86 5.91 Technical (Hospital) Services "VERAPAMIL ER (SR) 120 MG TABLET,EXTENDED RELEASE" RX-13184 CDM 6370000100 HCPCS 250 RC 68462-0292-01 NDC inpatient 1 UN 6.22 6.22 MULTIPLAN INC 34080 [3081285] MULTIPLAN INC [308128501] 5.91 percent of total billed charges 3.86 5.91 Technical (Hospital) Services "VERAPAMIL ER (SR) 120 MG TABLET,EXTENDED RELEASE" RX-13184 CDM 6370000100 HCPCS 250 RC 68462-0292-01 NDC inpatient 1 UN 6.22 6.22 MEDICA (COMMERCIAL) 94265 [3081118] MEDICA CLAIMS [308111801] 5.6 percent of total billed charges 3.86 5.91 Technical (Hospital) Services "VERAPAMIL ER (SR) 120 MG TABLET,EXTENDED RELEASE" RX-13184 CDM 6370000100 HCPCS 250 RC 68462-0292-01 NDC inpatient 1 UN 6.22 6.22 HEALTHPARTNERS SX009 HEALTHPARTNERS 4.92 percent of total billed charges 3.86 5.91 Technical (Hospital) Services "VERAPAMIL ER (SR) 120 MG TABLET,EXTENDED RELEASE" RX-13184 CDM 6370000100 HCPCS 250 RC 68462-0292-01 NDC inpatient 1 UN 6.22 6.22 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES PPO [308136801] 4.92 percent of total billed charges 3.86 5.91 Technical (Hospital) Services HONEY 100 % TOPICAL PASTE RX-132171 CDM 6370000100 HCPCS 250 RC 09958-0033-61 NDC outpatient 44 ML 53.43 53.43 UNITED HEALTHCARE (COMMERCIAL) [3081199] UNITED HEALTHCARE 87726 [308119901] 33.13 percent of total billed charges 33.13 50.76 Technical (Hospital) Services HONEY 100 % TOPICAL PASTE RX-132171 CDM 6370000100 HCPCS 250 RC 09958-0033-61 NDC outpatient 44 ML 53.43 53.43 HEALTHPARTNERS SX009 HEALTHPARTNERS 42.74 percent of total billed charges 33.13 50.76 Technical (Hospital) Services HONEY 100 % TOPICAL PASTE RX-132171 CDM 6370000100 HCPCS 250 RC 09958-0033-61 NDC outpatient 44 ML 53.43 53.43 BLUE CROSS BLUE SHIELD WELLMARK SB889 [3081026] BCBS WYOMING [308102603] 50.76 percent of total billed charges 33.13 50.76 Technical (Hospital) Services HONEY 100 % TOPICAL PASTE RX-132171 CDM 6370000100 HCPCS 250 RC 09958-0033-61 NDC outpatient 44 ML 53.43 53.43 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES EPO [308136803] 42.74 percent of total billed charges 33.13 50.76 Technical (Hospital) Services HONEY 100 % TOPICAL PASTE RX-132171 CDM 6370000100 HCPCS 250 RC 09958-0033-61 NDC outpatient 44 ML 53.43 53.43 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES HDHP [308136802] 42.74 percent of total billed charges 33.13 50.76 Technical (Hospital) Services HONEY 100 % TOPICAL PASTE RX-132171 CDM 6370000100 HCPCS 250 RC 09958-0033-61 NDC outpatient 44 ML 53.43 53.43 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES PPO [308136801] 42.74 percent of total billed charges 33.13 50.76 Technical (Hospital) Services HONEY 100 % TOPICAL PASTE RX-132171 CDM 6370000100 HCPCS 250 RC 09958-0033-61 NDC outpatient 44 ML 53.43 53.43 CIGNA 62308 [3081051] CIGNA 62308 [308105105] 42.74 percent of total billed charges 33.13 50.76 Technical (Hospital) Services HONEY 100 % TOPICAL PASTE RX-132171 CDM 6370000100 HCPCS 250 RC 09958-0033-61 NDC outpatient 44 ML 53.43 53.43 CIGNA 62308 [3081051] CIGNA STATE OF WYOMING [308105107] 42.74 percent of total billed charges 33.13 50.76 Technical (Hospital) Services HONEY 100 % TOPICAL PASTE RX-132171 CDM 6370000100 HCPCS 250 RC 09958-0033-61 NDC outpatient 44 ML 53.43 53.43 MEDICA (COMMERCIAL) 94265 [3081118] MEDICA CLAIMS [308111801] 48.09 percent of total billed charges 33.13 50.76 Technical (Hospital) Services HONEY 100 % TOPICAL PASTE RX-132171 CDM 6370000100 HCPCS 250 RC 09958-0033-61 NDC outpatient 44 ML 53.43 53.43 MULTIPLAN INC 34080 [3081285] MULTIPLAN INC [308128501] 50.76 percent of total billed charges 33.13 50.76 Technical (Hospital) Services HONEY 100 % TOPICAL PASTE RX-132171 CDM 6370000100 HCPCS 250 RC 09958-0033-61 NDC inpatient 44 ML 53.43 53.43 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES EPO [308136803] 42.31 percent of total billed charges 33.13 50.76 Technical (Hospital) Services HONEY 100 % TOPICAL PASTE RX-132171 CDM 6370000100 HCPCS 250 RC 09958-0033-61 NDC inpatient 44 ML 53.43 53.43 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES HDHP [308136802] 42.31 percent of total billed charges 33.13 50.76 Technical (Hospital) Services HONEY 100 % TOPICAL PASTE RX-132171 CDM 6370000100 HCPCS 250 RC 09958-0033-61 NDC inpatient 44 ML 53.43 53.43 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES PPO [308136801] 42.31 percent of total billed charges 33.13 50.76 Technical (Hospital) Services HONEY 100 % TOPICAL PASTE RX-132171 CDM 6370000100 HCPCS 250 RC 09958-0033-61 NDC inpatient 44 ML 53.43 53.43 CIGNA 62308 [3081051] CIGNA 62308 [308105105] 42.31 percent of total billed charges 33.13 50.76 Technical (Hospital) Services HONEY 100 % TOPICAL PASTE RX-132171 CDM 6370000100 HCPCS 250 RC 09958-0033-61 NDC inpatient 44 ML 53.43 53.43 CIGNA 62308 [3081051] CIGNA STATE OF WYOMING [308105107] 42.31 percent of total billed charges 33.13 50.76 Technical (Hospital) Services HONEY 100 % TOPICAL PASTE RX-132171 CDM 6370000100 HCPCS 250 RC 09958-0033-61 NDC inpatient 44 ML 53.43 53.43 HEALTHPARTNERS SX009 HEALTHPARTNERS 42.31 percent of total billed charges 33.13 50.76 Technical (Hospital) Services HONEY 100 % TOPICAL PASTE RX-132171 CDM 6370000100 HCPCS 250 RC 09958-0033-61 NDC inpatient 44 ML 53.43 53.43 MULTIPLAN INC 34080 [3081285] MULTIPLAN INC [308128501] 50.76 percent of total billed charges 33.13 50.76 Technical (Hospital) Services HONEY 100 % TOPICAL PASTE RX-132171 CDM 6370000100 HCPCS 250 RC 09958-0033-61 NDC inpatient 44 ML 53.43 53.43 MEDICA (COMMERCIAL) 94265 [3081118] MEDICA CLAIMS [308111801] 48.09 percent of total billed charges 33.13 50.76 Technical (Hospital) Services HONEY 100 % TOPICAL PASTE RX-132171 CDM 6370000100 HCPCS 250 RC 09958-0033-61 NDC inpatient 44 ML 53.43 53.43 UNITED HEALTHCARE (COMMERCIAL) [3081199] UNITED HEALTHCARE 87726 [308119901] 33.13 percent of total billed charges 33.13 50.76 Technical (Hospital) Services HONEY 100 % TOPICAL PASTE RX-132171 CDM 6370000100 HCPCS 250 RC 09958-0033-61 NDC inpatient 44 ML 53.43 53.43 BLUE CROSS BLUE SHIELD WELLMARK SB889 [3081026] BCBS WYOMING [308102603] 50.76 percent of total billed charges 33.13 50.76 Technical (Hospital) Services SUMATRIPTAN 100 MG TABLET RX-13369 CDM 6370000100 HCPCS 250 RC 55111-0293-09 NDC inpatient 1 UN 7.39 7.39 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES HDHP [308136802] 5.85 percent of total billed charges 4.58 7.02 Technical (Hospital) Services SUMATRIPTAN 100 MG TABLET RX-13369 CDM 6370000100 HCPCS 250 RC 55111-0293-09 NDC inpatient 1 UN 7.39 7.39 HEALTHPARTNERS SX009 HEALTHPARTNERS 5.85 percent of total billed charges 4.58 7.02 Technical (Hospital) Services SUMATRIPTAN 100 MG TABLET RX-13369 CDM 6370000100 HCPCS 250 RC 55111-0293-09 NDC inpatient 1 UN 7.39 7.39 MEDICA (COMMERCIAL) 94265 [3081118] MEDICA CLAIMS [308111801] 6.65 percent of total billed charges 4.58 7.02 Technical (Hospital) Services SUMATRIPTAN 100 MG TABLET RX-13369 CDM 6370000100 HCPCS 250 RC 55111-0293-09 NDC inpatient 1 UN 7.39 7.39 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES EPO [308136803] 5.85 percent of total billed charges 4.58 7.02 Technical (Hospital) Services SUMATRIPTAN 100 MG TABLET RX-13369 CDM 6370000100 HCPCS 250 RC 55111-0293-09 NDC inpatient 1 UN 7.39 7.39 CIGNA 62308 [3081051] CIGNA 62308 [308105105] 5.85 percent of total billed charges 4.58 7.02 Technical (Hospital) Services SUMATRIPTAN 100 MG TABLET RX-13369 CDM 6370000100 HCPCS 250 RC 55111-0293-09 NDC inpatient 1 UN 7.39 7.39 CIGNA 62308 [3081051] CIGNA STATE OF WYOMING [308105107] 5.85 percent of total billed charges 4.58 7.02 Technical (Hospital) Services SUMATRIPTAN 100 MG TABLET RX-13369 CDM 6370000100 HCPCS 250 RC 55111-0293-09 NDC inpatient 1 UN 7.39 7.39 BLUE CROSS BLUE SHIELD WELLMARK SB889 [3081026] BCBS WYOMING [308102603] 7.02 percent of total billed charges 4.58 7.02 Technical (Hospital) Services SUMATRIPTAN 100 MG TABLET RX-13369 CDM 6370000100 HCPCS 250 RC 55111-0293-09 NDC inpatient 1 UN 7.39 7.39 UNITED HEALTHCARE (COMMERCIAL) [3081199] UNITED HEALTHCARE 87726 [308119901] 4.58 percent of total billed charges 4.58 7.02 Technical (Hospital) Services SUMATRIPTAN 100 MG TABLET RX-13369 CDM 6370000100 HCPCS 250 RC 55111-0293-09 NDC inpatient 1 UN 7.39 7.39 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES PPO [308136801] 5.85 percent of total billed charges 4.58 7.02 Technical (Hospital) Services SUMATRIPTAN 100 MG TABLET RX-13369 CDM 6370000100 HCPCS 250 RC 55111-0293-09 NDC inpatient 1 UN 7.39 7.39 MULTIPLAN INC 34080 [3081285] MULTIPLAN INC [308128501] 7.02 percent of total billed charges 4.58 7.02 Technical (Hospital) Services SUMATRIPTAN 100 MG TABLET RX-13369 CDM 6370000100 HCPCS 250 RC 55111-0293-09 NDC outpatient 1 UN 7.39 7.39 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES PPO [308136801] 5.91 percent of total billed charges 4.58 7.02 Technical (Hospital) Services SUMATRIPTAN 100 MG TABLET RX-13369 CDM 6370000100 HCPCS 250 RC 55111-0293-09 NDC outpatient 1 UN 7.39 7.39 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES EPO [308136803] 5.91 percent of total billed charges 4.58 7.02 Technical (Hospital) Services SUMATRIPTAN 100 MG TABLET RX-13369 CDM 6370000100 HCPCS 250 RC 55111-0293-09 NDC outpatient 1 UN 7.39 7.39 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES HDHP [308136802] 5.91 percent of total billed charges 4.58 7.02 Technical (Hospital) Services SUMATRIPTAN 100 MG TABLET RX-13369 CDM 6370000100 HCPCS 250 RC 55111-0293-09 NDC outpatient 1 UN 7.39 7.39 HEALTHPARTNERS SX009 HEALTHPARTNERS 5.91 percent of total billed charges 4.58 7.02 Technical (Hospital) Services SUMATRIPTAN 100 MG TABLET RX-13369 CDM 6370000100 HCPCS 250 RC 55111-0293-09 NDC outpatient 1 UN 7.39 7.39 BLUE CROSS BLUE SHIELD WELLMARK SB889 [3081026] BCBS WYOMING [308102603] 7.02 percent of total billed charges 4.58 7.02 Technical (Hospital) Services SUMATRIPTAN 100 MG TABLET RX-13369 CDM 6370000100 HCPCS 250 RC 55111-0293-09 NDC outpatient 1 UN 7.39 7.39 UNITED HEALTHCARE (COMMERCIAL) [3081199] UNITED HEALTHCARE 87726 [308119901] 4.58 percent of total billed charges 4.58 7.02 Technical (Hospital) Services SUMATRIPTAN 100 MG TABLET RX-13369 CDM 6370000100 HCPCS 250 RC 55111-0293-09 NDC outpatient 1 UN 7.39 7.39 CIGNA 62308 [3081051] CIGNA 62308 [308105105] 5.91 percent of total billed charges 4.58 7.02 Technical (Hospital) Services SUMATRIPTAN 100 MG TABLET RX-13369 CDM 6370000100 HCPCS 250 RC 55111-0293-09 NDC outpatient 1 UN 7.39 7.39 CIGNA 62308 [3081051] CIGNA STATE OF WYOMING [308105107] 5.91 percent of total billed charges 4.58 7.02 Technical (Hospital) Services SUMATRIPTAN 100 MG TABLET RX-13369 CDM 6370000100 HCPCS 250 RC 55111-0293-09 NDC outpatient 1 UN 7.39 7.39 MULTIPLAN INC 34080 [3081285] MULTIPLAN INC [308128501] 7.02 percent of total billed charges 4.58 7.02 Technical (Hospital) Services SUMATRIPTAN 100 MG TABLET RX-13369 CDM 6370000100 HCPCS 250 RC 55111-0293-09 NDC outpatient 1 UN 7.39 7.39 MEDICA (COMMERCIAL) 94265 [3081118] MEDICA CLAIMS [308111801] 6.65 percent of total billed charges 4.58 7.02 Technical (Hospital) Services PATIROMER CALCIUM SORBITEX 8.4 GRAM ORAL POWDER PACKET RX-133908 CDM 6370000100 HCPCS 250 RC 53436-0084-01 NDC outpatient 1 UN 116.66 116.66 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES HDHP [308136802] 93.33 percent of total billed charges 72.33 110.83 Technical (Hospital) Services PATIROMER CALCIUM SORBITEX 8.4 GRAM ORAL POWDER PACKET RX-133908 CDM 6370000100 HCPCS 250 RC 53436-0084-01 NDC outpatient 1 UN 116.66 116.66 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES EPO [308136803] 93.33 percent of total billed charges 72.33 110.83 Technical (Hospital) Services PATIROMER CALCIUM SORBITEX 8.4 GRAM ORAL POWDER PACKET RX-133908 CDM 6370000100 HCPCS 250 RC 53436-0084-01 NDC outpatient 1 UN 116.66 116.66 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES PPO [308136801] 93.33 percent of total billed charges 72.33 110.83 Technical (Hospital) Services PATIROMER CALCIUM SORBITEX 8.4 GRAM ORAL POWDER PACKET RX-133908 CDM 6370000100 HCPCS 250 RC 53436-0084-01 NDC outpatient 1 UN 116.66 116.66 MEDICA (COMMERCIAL) 94265 [3081118] MEDICA CLAIMS [308111801] 104.99 percent of total billed charges 72.33 110.83 Technical (Hospital) Services PATIROMER CALCIUM SORBITEX 8.4 GRAM ORAL POWDER PACKET RX-133908 CDM 6370000100 HCPCS 250 RC 53436-0084-01 NDC outpatient 1 UN 116.66 116.66 MULTIPLAN INC 34080 [3081285] MULTIPLAN INC [308128501] 110.83 percent of total billed charges 72.33 110.83 Technical (Hospital) Services PATIROMER CALCIUM SORBITEX 8.4 GRAM ORAL POWDER PACKET RX-133908 CDM 6370000100 HCPCS 250 RC 53436-0084-01 NDC outpatient 1 UN 116.66 116.66 CIGNA 62308 [3081051] CIGNA 62308 [308105105] 93.33 percent of total billed charges 72.33 110.83 Technical (Hospital) Services PATIROMER CALCIUM SORBITEX 8.4 GRAM ORAL POWDER PACKET RX-133908 CDM 6370000100 HCPCS 250 RC 53436-0084-01 NDC outpatient 1 UN 116.66 116.66 CIGNA 62308 [3081051] CIGNA STATE OF WYOMING [308105107] 93.33 percent of total billed charges 72.33 110.83 Technical (Hospital) Services PATIROMER CALCIUM SORBITEX 8.4 GRAM ORAL POWDER PACKET RX-133908 CDM 6370000100 HCPCS 250 RC 53436-0084-01 NDC outpatient 1 UN 116.66 116.66 UNITED HEALTHCARE (COMMERCIAL) [3081199] UNITED HEALTHCARE 87726 [308119901] 72.33 percent of total billed charges 72.33 110.83 Technical (Hospital) Services PATIROMER CALCIUM SORBITEX 8.4 GRAM ORAL POWDER PACKET RX-133908 CDM 6370000100 HCPCS 250 RC 53436-0084-01 NDC outpatient 1 UN 116.66 116.66 BLUE CROSS BLUE SHIELD WELLMARK SB889 [3081026] BCBS WYOMING [308102603] 110.83 percent of total billed charges 72.33 110.83 Technical (Hospital) Services PATIROMER CALCIUM SORBITEX 8.4 GRAM ORAL POWDER PACKET RX-133908 CDM 6370000100 HCPCS 250 RC 53436-0084-01 NDC outpatient 1 UN 116.66 116.66 HEALTHPARTNERS SX009 HEALTHPARTNERS 93.33 percent of total billed charges 72.33 110.83 Technical (Hospital) Services PATIROMER CALCIUM SORBITEX 8.4 GRAM ORAL POWDER PACKET RX-133908 CDM 6370000100 HCPCS 250 RC 53436-0084-01 NDC inpatient 1 UN 116.66 116.66 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES PPO [308136801] 92.37 percent of total billed charges 72.33 110.83 Technical (Hospital) Services PATIROMER CALCIUM SORBITEX 8.4 GRAM ORAL POWDER PACKET RX-133908 CDM 6370000100 HCPCS 250 RC 53436-0084-01 NDC inpatient 1 UN 116.66 116.66 MEDICA (COMMERCIAL) 94265 [3081118] MEDICA CLAIMS [308111801] 104.99 percent of total billed charges 72.33 110.83 Technical (Hospital) Services PATIROMER CALCIUM SORBITEX 8.4 GRAM ORAL POWDER PACKET RX-133908 CDM 6370000100 HCPCS 250 RC 53436-0084-01 NDC inpatient 1 UN 116.66 116.66 HEALTHPARTNERS SX009 HEALTHPARTNERS 92.37 percent of total billed charges 72.33 110.83 Technical (Hospital) Services PATIROMER CALCIUM SORBITEX 8.4 GRAM ORAL POWDER PACKET RX-133908 CDM 6370000100 HCPCS 250 RC 53436-0084-01 NDC inpatient 1 UN 116.66 116.66 MULTIPLAN INC 34080 [3081285] MULTIPLAN INC [308128501] 110.83 percent of total billed charges 72.33 110.83 Technical (Hospital) Services PATIROMER CALCIUM SORBITEX 8.4 GRAM ORAL POWDER PACKET RX-133908 CDM 6370000100 HCPCS 250 RC 53436-0084-01 NDC inpatient 1 UN 116.66 116.66 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES HDHP [308136802] 92.37 percent of total billed charges 72.33 110.83 Technical (Hospital) Services PATIROMER CALCIUM SORBITEX 8.4 GRAM ORAL POWDER PACKET RX-133908 CDM 6370000100 HCPCS 250 RC 53436-0084-01 NDC inpatient 1 UN 116.66 116.66 CIGNA 62308 [3081051] CIGNA 62308 [308105105] 92.37 percent of total billed charges 72.33 110.83 Technical (Hospital) Services PATIROMER CALCIUM SORBITEX 8.4 GRAM ORAL POWDER PACKET RX-133908 CDM 6370000100 HCPCS 250 RC 53436-0084-01 NDC inpatient 1 UN 116.66 116.66 CIGNA 62308 [3081051] CIGNA STATE OF WYOMING [308105107] 92.37 percent of total billed charges 72.33 110.83 Technical (Hospital) Services PATIROMER CALCIUM SORBITEX 8.4 GRAM ORAL POWDER PACKET RX-133908 CDM 6370000100 HCPCS 250 RC 53436-0084-01 NDC inpatient 1 UN 116.66 116.66 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES EPO [308136803] 92.37 percent of total billed charges 72.33 110.83 Technical (Hospital) Services PATIROMER CALCIUM SORBITEX 8.4 GRAM ORAL POWDER PACKET RX-133908 CDM 6370000100 HCPCS 250 RC 53436-0084-01 NDC inpatient 1 UN 116.66 116.66 BLUE CROSS BLUE SHIELD WELLMARK SB889 [3081026] BCBS WYOMING [308102603] 110.83 percent of total billed charges 72.33 110.83 Technical (Hospital) Services PATIROMER CALCIUM SORBITEX 8.4 GRAM ORAL POWDER PACKET RX-133908 CDM 6370000100 HCPCS 250 RC 53436-0084-01 NDC inpatient 1 UN 116.66 116.66 UNITED HEALTHCARE (COMMERCIAL) [3081199] UNITED HEALTHCARE 87726 [308119901] 72.33 percent of total billed charges 72.33 110.83 Technical (Hospital) Services CARBAMAZEPINE 100 MG CHEWABLE TABLET RX-1355 CDM 6370000100 HCPCS 250 RC 51672-4041-01 NDC outpatient 1 UN 6.02 6.02 MEDICA (COMMERCIAL) 94265 [3081118] MEDICA CLAIMS [308111801] 5.42 percent of total billed charges 3.73 5.72 Technical (Hospital) Services CARBAMAZEPINE 100 MG CHEWABLE TABLET RX-1355 CDM 6370000100 HCPCS 250 RC 51672-4041-01 NDC outpatient 1 UN 6.02 6.02 CIGNA 62308 [3081051] CIGNA 62308 [308105105] 4.82 percent of total billed charges 3.73 5.72 Technical (Hospital) Services CARBAMAZEPINE 100 MG CHEWABLE TABLET RX-1355 CDM 6370000100 HCPCS 250 RC 51672-4041-01 NDC outpatient 1 UN 6.02 6.02 CIGNA 62308 [3081051] CIGNA STATE OF WYOMING [308105107] 4.82 percent of total billed charges 3.73 5.72 Technical (Hospital) Services CARBAMAZEPINE 100 MG CHEWABLE TABLET RX-1355 CDM 6370000100 HCPCS 250 RC 51672-4041-01 NDC outpatient 1 UN 6.02 6.02 MULTIPLAN INC 34080 [3081285] MULTIPLAN INC [308128501] 5.72 percent of total billed charges 3.73 5.72 Technical (Hospital) Services CARBAMAZEPINE 100 MG CHEWABLE TABLET RX-1355 CDM 6370000100 HCPCS 250 RC 51672-4041-01 NDC outpatient 1 UN 6.02 6.02 UNITED HEALTHCARE (COMMERCIAL) [3081199] UNITED HEALTHCARE 87726 [308119901] 3.73 percent of total billed charges 3.73 5.72 Technical (Hospital) Services CARBAMAZEPINE 100 MG CHEWABLE TABLET RX-1355 CDM 6370000100 HCPCS 250 RC 51672-4041-01 NDC outpatient 1 UN 6.02 6.02 HEALTHPARTNERS SX009 HEALTHPARTNERS 4.82 percent of total billed charges 3.73 5.72 Technical (Hospital) Services CARBAMAZEPINE 100 MG CHEWABLE TABLET RX-1355 CDM 6370000100 HCPCS 250 RC 51672-4041-01 NDC outpatient 1 UN 6.02 6.02 BLUE CROSS BLUE SHIELD WELLMARK SB889 [3081026] BCBS WYOMING [308102603] 5.72 percent of total billed charges 3.73 5.72 Technical (Hospital) Services CARBAMAZEPINE 100 MG CHEWABLE TABLET RX-1355 CDM 6370000100 HCPCS 250 RC 51672-4041-01 NDC outpatient 1 UN 6.02 6.02 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES PPO [308136801] 4.82 percent of total billed charges 3.73 5.72 Technical (Hospital) Services CARBAMAZEPINE 100 MG CHEWABLE TABLET RX-1355 CDM 6370000100 HCPCS 250 RC 51672-4041-01 NDC outpatient 1 UN 6.02 6.02 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES HDHP [308136802] 4.82 percent of total billed charges 3.73 5.72 Technical (Hospital) Services CARBAMAZEPINE 100 MG CHEWABLE TABLET RX-1355 CDM 6370000100 HCPCS 250 RC 51672-4041-01 NDC outpatient 1 UN 6.02 6.02 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES EPO [308136803] 4.82 percent of total billed charges 3.73 5.72 Technical (Hospital) Services CARBAMAZEPINE 100 MG CHEWABLE TABLET RX-1355 CDM 6370000100 HCPCS 250 RC 51672-4041-01 NDC inpatient 1 UN 6.02 6.02 CIGNA 62308 [3081051] CIGNA 62308 [308105105] 4.77 percent of total billed charges 3.73 5.72 Technical (Hospital) Services CARBAMAZEPINE 100 MG CHEWABLE TABLET RX-1355 CDM 6370000100 HCPCS 250 RC 51672-4041-01 NDC inpatient 1 UN 6.02 6.02 CIGNA 62308 [3081051] CIGNA STATE OF WYOMING [308105107] 4.77 percent of total billed charges 3.73 5.72 Technical (Hospital) Services CARBAMAZEPINE 100 MG CHEWABLE TABLET RX-1355 CDM 6370000100 HCPCS 250 RC 51672-4041-01 NDC inpatient 1 UN 6.02 6.02 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES EPO [308136803] 4.77 percent of total billed charges 3.73 5.72 Technical (Hospital) Services CARBAMAZEPINE 100 MG CHEWABLE TABLET RX-1355 CDM 6370000100 HCPCS 250 RC 51672-4041-01 NDC inpatient 1 UN 6.02 6.02 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES HDHP [308136802] 4.77 percent of total billed charges 3.73 5.72 Technical (Hospital) Services CARBAMAZEPINE 100 MG CHEWABLE TABLET RX-1355 CDM 6370000100 HCPCS 250 RC 51672-4041-01 NDC inpatient 1 UN 6.02 6.02 BLUE CROSS BLUE SHIELD WELLMARK SB889 [3081026] BCBS WYOMING [308102603] 5.72 percent of total billed charges 3.73 5.72 Technical (Hospital) Services CARBAMAZEPINE 100 MG CHEWABLE TABLET RX-1355 CDM 6370000100 HCPCS 250 RC 51672-4041-01 NDC inpatient 1 UN 6.02 6.02 UNITED HEALTHCARE (COMMERCIAL) [3081199] UNITED HEALTHCARE 87726 [308119901] 3.73 percent of total billed charges 3.73 5.72 Technical (Hospital) Services CARBAMAZEPINE 100 MG CHEWABLE TABLET RX-1355 CDM 6370000100 HCPCS 250 RC 51672-4041-01 NDC inpatient 1 UN 6.02 6.02 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES PPO [308136801] 4.77 percent of total billed charges 3.73 5.72 Technical (Hospital) Services CARBAMAZEPINE 100 MG CHEWABLE TABLET RX-1355 CDM 6370000100 HCPCS 250 RC 51672-4041-01 NDC inpatient 1 UN 6.02 6.02 MEDICA (COMMERCIAL) 94265 [3081118] MEDICA CLAIMS [308111801] 5.42 percent of total billed charges 3.73 5.72 Technical (Hospital) Services CARBAMAZEPINE 100 MG CHEWABLE TABLET RX-1355 CDM 6370000100 HCPCS 250 RC 51672-4041-01 NDC inpatient 1 UN 6.02 6.02 HEALTHPARTNERS SX009 HEALTHPARTNERS 4.77 percent of total billed charges 3.73 5.72 Technical (Hospital) Services CARBAMAZEPINE 100 MG CHEWABLE TABLET RX-1355 CDM 6370000100 HCPCS 250 RC 51672-4041-01 NDC inpatient 1 UN 6.02 6.02 MULTIPLAN INC 34080 [3081285] MULTIPLAN INC [308128501] 5.72 percent of total billed charges 3.73 5.72 Technical (Hospital) Services CARBAMAZEPINE 200 MG TABLET RX-1357 CDM 6370000100 HCPCS 250 RC 75834-0221-01 NDC inpatient 1 UN 5.77 5.77 CIGNA 62308 [3081051] CIGNA 62308 [308105105] 4.57 percent of total billed charges 3.58 5.48 Technical (Hospital) Services CARBAMAZEPINE 200 MG TABLET RX-1357 CDM 6370000100 HCPCS 250 RC 75834-0221-01 NDC inpatient 1 UN 5.77 5.77 CIGNA 62308 [3081051] CIGNA STATE OF WYOMING [308105107] 4.57 percent of total billed charges 3.58 5.48 Technical (Hospital) Services CARBAMAZEPINE 200 MG TABLET RX-1357 CDM 6370000100 HCPCS 250 RC 75834-0221-01 NDC inpatient 1 UN 5.77 5.77 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES EPO [308136803] 4.57 percent of total billed charges 3.58 5.48 Technical (Hospital) Services CARBAMAZEPINE 200 MG TABLET RX-1357 CDM 6370000100 HCPCS 250 RC 75834-0221-01 NDC inpatient 1 UN 5.77 5.77 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES HDHP [308136802] 4.57 percent of total billed charges 3.58 5.48 Technical (Hospital) Services CARBAMAZEPINE 200 MG TABLET RX-1357 CDM 6370000100 HCPCS 250 RC 75834-0221-01 NDC inpatient 1 UN 5.77 5.77 BLUE CROSS BLUE SHIELD WELLMARK SB889 [3081026] BCBS WYOMING [308102603] 5.48 percent of total billed charges 3.58 5.48 Technical (Hospital) Services CARBAMAZEPINE 200 MG TABLET RX-1357 CDM 6370000100 HCPCS 250 RC 75834-0221-01 NDC inpatient 1 UN 5.77 5.77 UNITED HEALTHCARE (COMMERCIAL) [3081199] UNITED HEALTHCARE 87726 [308119901] 3.58 percent of total billed charges 3.58 5.48 Technical (Hospital) Services CARBAMAZEPINE 200 MG TABLET RX-1357 CDM 6370000100 HCPCS 250 RC 75834-0221-01 NDC inpatient 1 UN 5.77 5.77 MULTIPLAN INC 34080 [3081285] MULTIPLAN INC [308128501] 5.48 percent of total billed charges 3.58 5.48 Technical (Hospital) Services CARBAMAZEPINE 200 MG TABLET RX-1357 CDM 6370000100 HCPCS 250 RC 75834-0221-01 NDC inpatient 1 UN 5.77 5.77 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES PPO [308136801] 4.57 percent of total billed charges 3.58 5.48 Technical (Hospital) Services CARBAMAZEPINE 200 MG TABLET RX-1357 CDM 6370000100 HCPCS 250 RC 75834-0221-01 NDC inpatient 1 UN 5.77 5.77 HEALTHPARTNERS SX009 HEALTHPARTNERS 4.57 percent of total billed charges 3.58 5.48 Technical (Hospital) Services CARBAMAZEPINE 200 MG TABLET RX-1357 CDM 6370000100 HCPCS 250 RC 75834-0221-01 NDC inpatient 1 UN 5.77 5.77 MEDICA (COMMERCIAL) 94265 [3081118] MEDICA CLAIMS [308111801] 5.19 percent of total billed charges 3.58 5.48 Technical (Hospital) Services CARBAMAZEPINE 200 MG TABLET RX-1357 CDM 6370000100 HCPCS 250 RC 75834-0221-01 NDC outpatient 1 UN 5.77 5.77 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES EPO [308136803] 4.62 percent of total billed charges 3.58 5.48 Technical (Hospital) Services CARBAMAZEPINE 200 MG TABLET RX-1357 CDM 6370000100 HCPCS 250 RC 75834-0221-01 NDC outpatient 1 UN 5.77 5.77 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES HDHP [308136802] 4.62 percent of total billed charges 3.58 5.48 Technical (Hospital) Services CARBAMAZEPINE 200 MG TABLET RX-1357 CDM 6370000100 HCPCS 250 RC 75834-0221-01 NDC outpatient 1 UN 5.77 5.77 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES PPO [308136801] 4.62 percent of total billed charges 3.58 5.48 Technical (Hospital) Services CARBAMAZEPINE 200 MG TABLET RX-1357 CDM 6370000100 HCPCS 250 RC 75834-0221-01 NDC outpatient 1 UN 5.77 5.77 HEALTHPARTNERS SX009 HEALTHPARTNERS 4.62 percent of total billed charges 3.58 5.48 Technical (Hospital) Services CARBAMAZEPINE 200 MG TABLET RX-1357 CDM 6370000100 HCPCS 250 RC 75834-0221-01 NDC outpatient 1 UN 5.77 5.77 BLUE CROSS BLUE SHIELD WELLMARK SB889 [3081026] BCBS WYOMING [308102603] 5.48 percent of total billed charges 3.58 5.48 Technical (Hospital) Services CARBAMAZEPINE 200 MG TABLET RX-1357 CDM 6370000100 HCPCS 250 RC 75834-0221-01 NDC outpatient 1 UN 5.77 5.77 CIGNA 62308 [3081051] CIGNA 62308 [308105105] 4.62 percent of total billed charges 3.58 5.48 Technical (Hospital) Services CARBAMAZEPINE 200 MG TABLET RX-1357 CDM 6370000100 HCPCS 250 RC 75834-0221-01 NDC outpatient 1 UN 5.77 5.77 CIGNA 62308 [3081051] CIGNA STATE OF WYOMING [308105107] 4.62 percent of total billed charges 3.58 5.48 Technical (Hospital) Services CARBAMAZEPINE 200 MG TABLET RX-1357 CDM 6370000100 HCPCS 250 RC 75834-0221-01 NDC outpatient 1 UN 5.77 5.77 MULTIPLAN INC 34080 [3081285] MULTIPLAN INC [308128501] 5.48 percent of total billed charges 3.58 5.48 Technical (Hospital) Services CARBAMAZEPINE 200 MG TABLET RX-1357 CDM 6370000100 HCPCS 250 RC 75834-0221-01 NDC outpatient 1 UN 5.77 5.77 MEDICA (COMMERCIAL) 94265 [3081118] MEDICA CLAIMS [308111801] 5.19 percent of total billed charges 3.58 5.48 Technical (Hospital) Services CARBAMAZEPINE 200 MG TABLET RX-1357 CDM 6370000100 HCPCS 250 RC 75834-0221-01 NDC outpatient 1 UN 5.77 5.77 UNITED HEALTHCARE (COMMERCIAL) [3081199] UNITED HEALTHCARE 87726 [308119901] 3.58 percent of total billed charges 3.58 5.48 Technical (Hospital) Services FLUCONAZOLE 150 MG TABLET RX-13577 CDM 6370000100 HCPCS 250 RC 57237-0005-11 NDC inpatient 1 UN 6.75 6.75 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES HDHP [308136802] 5.34 percent of total billed charges 4.19 6.41 Technical (Hospital) Services FLUCONAZOLE 150 MG TABLET RX-13577 CDM 6370000100 HCPCS 250 RC 57237-0005-11 NDC inpatient 1 UN 6.75 6.75 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES EPO [308136803] 5.34 percent of total billed charges 4.19 6.41 Technical (Hospital) Services FLUCONAZOLE 150 MG TABLET RX-13577 CDM 6370000100 HCPCS 250 RC 57237-0005-11 NDC inpatient 1 UN 6.75 6.75 CIGNA 62308 [3081051] CIGNA 62308 [308105105] 5.34 percent of total billed charges 4.19 6.41 Technical (Hospital) Services FLUCONAZOLE 150 MG TABLET RX-13577 CDM 6370000100 HCPCS 250 RC 57237-0005-11 NDC inpatient 1 UN 6.75 6.75 CIGNA 62308 [3081051] CIGNA STATE OF WYOMING [308105107] 5.34 percent of total billed charges 4.19 6.41 Technical (Hospital) Services FLUCONAZOLE 150 MG TABLET RX-13577 CDM 6370000100 HCPCS 250 RC 57237-0005-11 NDC inpatient 1 UN 6.75 6.75 BLUE CROSS BLUE SHIELD WELLMARK SB889 [3081026] BCBS WYOMING [308102603] 6.41 percent of total billed charges 4.19 6.41 Technical (Hospital) Services FLUCONAZOLE 150 MG TABLET RX-13577 CDM 6370000100 HCPCS 250 RC 57237-0005-11 NDC inpatient 1 UN 6.75 6.75 UNITED HEALTHCARE (COMMERCIAL) [3081199] UNITED HEALTHCARE 87726 [308119901] 4.19 percent of total billed charges 4.19 6.41 Technical (Hospital) Services FLUCONAZOLE 150 MG TABLET RX-13577 CDM 6370000100 HCPCS 250 RC 57237-0005-11 NDC inpatient 1 UN 6.75 6.75 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES PPO [308136801] 5.34 percent of total billed charges 4.19 6.41 Technical (Hospital) Services FLUCONAZOLE 150 MG TABLET RX-13577 CDM 6370000100 HCPCS 250 RC 57237-0005-11 NDC inpatient 1 UN 6.75 6.75 MEDICA (COMMERCIAL) 94265 [3081118] MEDICA CLAIMS [308111801] 6.08 percent of total billed charges 4.19 6.41 Technical (Hospital) Services FLUCONAZOLE 150 MG TABLET RX-13577 CDM 6370000100 HCPCS 250 RC 57237-0005-11 NDC inpatient 1 UN 6.75 6.75 HEALTHPARTNERS SX009 HEALTHPARTNERS 5.34 percent of total billed charges 4.19 6.41 Technical (Hospital) Services FLUCONAZOLE 150 MG TABLET RX-13577 CDM 6370000100 HCPCS 250 RC 57237-0005-11 NDC inpatient 1 UN 6.75 6.75 MULTIPLAN INC 34080 [3081285] MULTIPLAN INC [308128501] 6.41 percent of total billed charges 4.19 6.41 Technical (Hospital) Services FLUCONAZOLE 150 MG TABLET RX-13577 CDM 6370000100 HCPCS 250 RC 57237-0005-11 NDC outpatient 1 UN 6.75 6.75 MEDICA (COMMERCIAL) 94265 [3081118] MEDICA CLAIMS [308111801] 6.08 percent of total billed charges 4.19 6.41 Technical (Hospital) Services FLUCONAZOLE 150 MG TABLET RX-13577 CDM 6370000100 HCPCS 250 RC 57237-0005-11 NDC outpatient 1 UN 6.75 6.75 MULTIPLAN INC 34080 [3081285] MULTIPLAN INC [308128501] 6.41 percent of total billed charges 4.19 6.41 Technical (Hospital) Services FLUCONAZOLE 150 MG TABLET RX-13577 CDM 6370000100 HCPCS 250 RC 57237-0005-11 NDC outpatient 1 UN 6.75 6.75 CIGNA 62308 [3081051] CIGNA 62308 [308105105] 5.4 percent of total billed charges 4.19 6.41 Technical (Hospital) Services FLUCONAZOLE 150 MG TABLET RX-13577 CDM 6370000100 HCPCS 250 RC 57237-0005-11 NDC outpatient 1 UN 6.75 6.75 CIGNA 62308 [3081051] CIGNA STATE OF WYOMING [308105107] 5.4 percent of total billed charges 4.19 6.41 Technical (Hospital) Services FLUCONAZOLE 150 MG TABLET RX-13577 CDM 6370000100 HCPCS 250 RC 57237-0005-11 NDC outpatient 1 UN 6.75 6.75 UNITED HEALTHCARE (COMMERCIAL) [3081199] UNITED HEALTHCARE 87726 [308119901] 4.19 percent of total billed charges 4.19 6.41 Technical (Hospital) Services FLUCONAZOLE 150 MG TABLET RX-13577 CDM 6370000100 HCPCS 250 RC 57237-0005-11 NDC outpatient 1 UN 6.75 6.75 BLUE CROSS BLUE SHIELD WELLMARK SB889 [3081026] BCBS WYOMING [308102603] 6.41 percent of total billed charges 4.19 6.41 Technical (Hospital) Services FLUCONAZOLE 150 MG TABLET RX-13577 CDM 6370000100 HCPCS 250 RC 57237-0005-11 NDC outpatient 1 UN 6.75 6.75 HEALTHPARTNERS SX009 HEALTHPARTNERS 5.4 percent of total billed charges 4.19 6.41 Technical (Hospital) Services FLUCONAZOLE 150 MG TABLET RX-13577 CDM 6370000100 HCPCS 250 RC 57237-0005-11 NDC outpatient 1 UN 6.75 6.75 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES PPO [308136801] 5.4 percent of total billed charges 4.19 6.41 Technical (Hospital) Services FLUCONAZOLE 150 MG TABLET RX-13577 CDM 6370000100 HCPCS 250 RC 57237-0005-11 NDC outpatient 1 UN 6.75 6.75 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES HDHP [308136802] 5.4 percent of total billed charges 4.19 6.41 Technical (Hospital) Services FLUCONAZOLE 150 MG TABLET RX-13577 CDM 6370000100 HCPCS 250 RC 57237-0005-11 NDC outpatient 1 UN 6.75 6.75 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES EPO [308136803] 5.4 percent of total billed charges 4.19 6.41 Technical (Hospital) Services "POTASSIUM CHLORIDE ER 10 MEQ CAPSULE,EXTENDED RELEASE" RX-13644 CDM 6370000100 HCPCS 250 RC 53746-0542-05 NDC outpatient 1 UN 5.87 5.87 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES PPO [308136801] 4.7 percent of total billed charges 3.64 5.58 Technical (Hospital) Services "POTASSIUM CHLORIDE ER 10 MEQ CAPSULE,EXTENDED RELEASE" RX-13644 CDM 6370000100 HCPCS 250 RC 53746-0542-05 NDC outpatient 1 UN 5.87 5.87 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES HDHP [308136802] 4.7 percent of total billed charges 3.64 5.58 Technical (Hospital) Services "POTASSIUM CHLORIDE ER 10 MEQ CAPSULE,EXTENDED RELEASE" RX-13644 CDM 6370000100 HCPCS 250 RC 53746-0542-05 NDC outpatient 1 UN 5.87 5.87 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES EPO [308136803] 4.7 percent of total billed charges 3.64 5.58 Technical (Hospital) Services "POTASSIUM CHLORIDE ER 10 MEQ CAPSULE,EXTENDED RELEASE" RX-13644 CDM 6370000100 HCPCS 250 RC 53746-0542-05 NDC outpatient 1 UN 5.87 5.87 HEALTHPARTNERS SX009 HEALTHPARTNERS 4.7 percent of total billed charges 3.64 5.58 Technical (Hospital) Services "POTASSIUM CHLORIDE ER 10 MEQ CAPSULE,EXTENDED RELEASE" RX-13644 CDM 6370000100 HCPCS 250 RC 53746-0542-05 NDC outpatient 1 UN 5.87 5.87 BLUE CROSS BLUE SHIELD WELLMARK SB889 [3081026] BCBS WYOMING [308102603] 5.58 percent of total billed charges 3.64 5.58 Technical (Hospital) Services "POTASSIUM CHLORIDE ER 10 MEQ CAPSULE,EXTENDED RELEASE" RX-13644 CDM 6370000100 HCPCS 250 RC 53746-0542-05 NDC outpatient 1 UN 5.87 5.87 UNITED HEALTHCARE (COMMERCIAL) [3081199] UNITED HEALTHCARE 87726 [308119901] 3.64 percent of total billed charges 3.64 5.58 Technical (Hospital) Services "POTASSIUM CHLORIDE ER 10 MEQ CAPSULE,EXTENDED RELEASE" RX-13644 CDM 6370000100 HCPCS 250 RC 53746-0542-05 NDC outpatient 1 UN 5.87 5.87 MULTIPLAN INC 34080 [3081285] MULTIPLAN INC [308128501] 5.58 percent of total billed charges 3.64 5.58 Technical (Hospital) Services "POTASSIUM CHLORIDE ER 10 MEQ CAPSULE,EXTENDED RELEASE" RX-13644 CDM 6370000100 HCPCS 250 RC 53746-0542-05 NDC outpatient 1 UN 5.87 5.87 CIGNA 62308 [3081051] CIGNA 62308 [308105105] 4.7 percent of total billed charges 3.64 5.58 Technical (Hospital) Services "POTASSIUM CHLORIDE ER 10 MEQ CAPSULE,EXTENDED RELEASE" RX-13644 CDM 6370000100 HCPCS 250 RC 53746-0542-05 NDC outpatient 1 UN 5.87 5.87 CIGNA 62308 [3081051] CIGNA STATE OF WYOMING [308105107] 4.7 percent of total billed charges 3.64 5.58 Technical (Hospital) Services "POTASSIUM CHLORIDE ER 10 MEQ CAPSULE,EXTENDED RELEASE" RX-13644 CDM 6370000100 HCPCS 250 RC 53746-0542-05 NDC outpatient 1 UN 5.87 5.87 MEDICA (COMMERCIAL) 94265 [3081118] MEDICA CLAIMS [308111801] 5.28 percent of total billed charges 3.64 5.58 Technical (Hospital) Services "POTASSIUM CHLORIDE ER 10 MEQ CAPSULE,EXTENDED RELEASE" RX-13644 CDM 6370000100 HCPCS 250 RC 53746-0542-05 NDC inpatient 1 UN 5.87 5.87 MULTIPLAN INC 34080 [3081285] MULTIPLAN INC [308128501] 5.58 percent of total billed charges 3.64 5.58 Technical (Hospital) Services "POTASSIUM CHLORIDE ER 10 MEQ CAPSULE,EXTENDED RELEASE" RX-13644 CDM 6370000100 HCPCS 250 RC 53746-0542-05 NDC inpatient 1 UN 5.87 5.87 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES PPO [308136801] 4.65 percent of total billed charges 3.64 5.58 Technical (Hospital) Services "POTASSIUM CHLORIDE ER 10 MEQ CAPSULE,EXTENDED RELEASE" RX-13644 CDM 6370000100 HCPCS 250 RC 53746-0542-05 NDC inpatient 1 UN 5.87 5.87 MEDICA (COMMERCIAL) 94265 [3081118] MEDICA CLAIMS [308111801] 5.28 percent of total billed charges 3.64 5.58 Technical (Hospital) Services "POTASSIUM CHLORIDE ER 10 MEQ CAPSULE,EXTENDED RELEASE" RX-13644 CDM 6370000100 HCPCS 250 RC 53746-0542-05 NDC inpatient 1 UN 5.87 5.87 HEALTHPARTNERS SX009 HEALTHPARTNERS 4.65 percent of total billed charges 3.64 5.58 Technical (Hospital) Services "POTASSIUM CHLORIDE ER 10 MEQ CAPSULE,EXTENDED RELEASE" RX-13644 CDM 6370000100 HCPCS 250 RC 53746-0542-05 NDC inpatient 1 UN 5.87 5.87 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES HDHP [308136802] 4.65 percent of total billed charges 3.64 5.58 Technical (Hospital) Services "POTASSIUM CHLORIDE ER 10 MEQ CAPSULE,EXTENDED RELEASE" RX-13644 CDM 6370000100 HCPCS 250 RC 53746-0542-05 NDC inpatient 1 UN 5.87 5.87 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES EPO [308136803] 4.65 percent of total billed charges 3.64 5.58 Technical (Hospital) Services "POTASSIUM CHLORIDE ER 10 MEQ CAPSULE,EXTENDED RELEASE" RX-13644 CDM 6370000100 HCPCS 250 RC 53746-0542-05 NDC inpatient 1 UN 5.87 5.87 CIGNA 62308 [3081051] CIGNA 62308 [308105105] 4.65 percent of total billed charges 3.64 5.58 Technical (Hospital) Services "POTASSIUM CHLORIDE ER 10 MEQ CAPSULE,EXTENDED RELEASE" RX-13644 CDM 6370000100 HCPCS 250 RC 53746-0542-05 NDC inpatient 1 UN 5.87 5.87 CIGNA 62308 [3081051] CIGNA STATE OF WYOMING [308105107] 4.65 percent of total billed charges 3.64 5.58 Technical (Hospital) Services "POTASSIUM CHLORIDE ER 10 MEQ CAPSULE,EXTENDED RELEASE" RX-13644 CDM 6370000100 HCPCS 250 RC 53746-0542-05 NDC inpatient 1 UN 5.87 5.87 BLUE CROSS BLUE SHIELD WELLMARK SB889 [3081026] BCBS WYOMING [308102603] 5.58 percent of total billed charges 3.64 5.58 Technical (Hospital) Services "POTASSIUM CHLORIDE ER 10 MEQ CAPSULE,EXTENDED RELEASE" RX-13644 CDM 6370000100 HCPCS 250 RC 53746-0542-05 NDC inpatient 1 UN 5.87 5.87 UNITED HEALTHCARE (COMMERCIAL) [3081199] UNITED HEALTHCARE 87726 [308119901] 3.64 percent of total billed charges 3.64 5.58 Technical (Hospital) Services LAMOTRIGINE 25 MG TABLET RX-13981 CDM 6370000100 HCPCS 250 RC 51672-4130-01 NDC inpatient 1 UN 5.68 5.68 CIGNA 62308 [3081051] CIGNA 62308 [308105105] 4.5 percent of total billed charges 3.52 5.4 Technical (Hospital) Services LAMOTRIGINE 25 MG TABLET RX-13981 CDM 6370000100 HCPCS 250 RC 51672-4130-01 NDC inpatient 1 UN 5.68 5.68 CIGNA 62308 [3081051] CIGNA STATE OF WYOMING [308105107] 4.5 percent of total billed charges 3.52 5.4 Technical (Hospital) Services LAMOTRIGINE 25 MG TABLET RX-13981 CDM 6370000100 HCPCS 250 RC 51672-4130-01 NDC inpatient 1 UN 5.68 5.68 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES EPO [308136803] 4.5 percent of total billed charges 3.52 5.4 Technical (Hospital) Services LAMOTRIGINE 25 MG TABLET RX-13981 CDM 6370000100 HCPCS 250 RC 51672-4130-01 NDC inpatient 1 UN 5.68 5.68 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES HDHP [308136802] 4.5 percent of total billed charges 3.52 5.4 Technical (Hospital) Services LAMOTRIGINE 25 MG TABLET RX-13981 CDM 6370000100 HCPCS 250 RC 51672-4130-01 NDC inpatient 1 UN 5.68 5.68 BLUE CROSS BLUE SHIELD WELLMARK SB889 [3081026] BCBS WYOMING [308102603] 5.4 percent of total billed charges 3.52 5.4 Technical (Hospital) Services LAMOTRIGINE 25 MG TABLET RX-13981 CDM 6370000100 HCPCS 250 RC 51672-4130-01 NDC inpatient 1 UN 5.68 5.68 UNITED HEALTHCARE (COMMERCIAL) [3081199] UNITED HEALTHCARE 87726 [308119901] 3.52 percent of total billed charges 3.52 5.4 Technical (Hospital) Services LAMOTRIGINE 25 MG TABLET RX-13981 CDM 6370000100 HCPCS 250 RC 51672-4130-01 NDC inpatient 1 UN 5.68 5.68 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES PPO [308136801] 4.5 percent of total billed charges 3.52 5.4 Technical (Hospital) Services LAMOTRIGINE 25 MG TABLET RX-13981 CDM 6370000100 HCPCS 250 RC 51672-4130-01 NDC inpatient 1 UN 5.68 5.68 HEALTHPARTNERS SX009 HEALTHPARTNERS 4.5 percent of total billed charges 3.52 5.4 Technical (Hospital) Services LAMOTRIGINE 25 MG TABLET RX-13981 CDM 6370000100 HCPCS 250 RC 51672-4130-01 NDC inpatient 1 UN 5.68 5.68 MEDICA (COMMERCIAL) 94265 [3081118] MEDICA CLAIMS [308111801] 5.11 percent of total billed charges 3.52 5.4 Technical (Hospital) Services LAMOTRIGINE 25 MG TABLET RX-13981 CDM 6370000100 HCPCS 250 RC 51672-4130-01 NDC inpatient 1 UN 5.68 5.68 MULTIPLAN INC 34080 [3081285] MULTIPLAN INC [308128501] 5.4 percent of total billed charges 3.52 5.4 Technical (Hospital) Services LAMOTRIGINE 25 MG TABLET RX-13981 CDM 6370000100 HCPCS 250 RC 51672-4130-01 NDC outpatient 1 UN 5.68 5.68 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES EPO [308136803] 4.54 percent of total billed charges 3.52 5.4 Technical (Hospital) Services LAMOTRIGINE 25 MG TABLET RX-13981 CDM 6370000100 HCPCS 250 RC 51672-4130-01 NDC outpatient 1 UN 5.68 5.68 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES HDHP [308136802] 4.54 percent of total billed charges 3.52 5.4 Technical (Hospital) Services LAMOTRIGINE 25 MG TABLET RX-13981 CDM 6370000100 HCPCS 250 RC 51672-4130-01 NDC outpatient 1 UN 5.68 5.68 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES PPO [308136801] 4.54 percent of total billed charges 3.52 5.4 Technical (Hospital) Services LAMOTRIGINE 25 MG TABLET RX-13981 CDM 6370000100 HCPCS 250 RC 51672-4130-01 NDC outpatient 1 UN 5.68 5.68 CIGNA 62308 [3081051] CIGNA 62308 [308105105] 4.54 percent of total billed charges 3.52 5.4 Technical (Hospital) Services LAMOTRIGINE 25 MG TABLET RX-13981 CDM 6370000100 HCPCS 250 RC 51672-4130-01 NDC outpatient 1 UN 5.68 5.68 CIGNA 62308 [3081051] CIGNA STATE OF WYOMING [308105107] 4.54 percent of total billed charges 3.52 5.4 Technical (Hospital) Services LAMOTRIGINE 25 MG TABLET RX-13981 CDM 6370000100 HCPCS 250 RC 51672-4130-01 NDC outpatient 1 UN 5.68 5.68 MULTIPLAN INC 34080 [3081285] MULTIPLAN INC [308128501] 5.4 percent of total billed charges 3.52 5.4 Technical (Hospital) Services LAMOTRIGINE 25 MG TABLET RX-13981 CDM 6370000100 HCPCS 250 RC 51672-4130-01 NDC outpatient 1 UN 5.68 5.68 MEDICA (COMMERCIAL) 94265 [3081118] MEDICA CLAIMS [308111801] 5.11 percent of total billed charges 3.52 5.4 Technical (Hospital) Services LAMOTRIGINE 25 MG TABLET RX-13981 CDM 6370000100 HCPCS 250 RC 51672-4130-01 NDC outpatient 1 UN 5.68 5.68 UNITED HEALTHCARE (COMMERCIAL) [3081199] UNITED HEALTHCARE 87726 [308119901] 3.52 percent of total billed charges 3.52 5.4 Technical (Hospital) Services LAMOTRIGINE 25 MG TABLET RX-13981 CDM 6370000100 HCPCS 250 RC 51672-4130-01 NDC outpatient 1 UN 5.68 5.68 HEALTHPARTNERS SX009 HEALTHPARTNERS 4.54 percent of total billed charges 3.52 5.4 Technical (Hospital) Services LAMOTRIGINE 25 MG TABLET RX-13981 CDM 6370000100 HCPCS 250 RC 51672-4130-01 NDC outpatient 1 UN 5.68 5.68 BLUE CROSS BLUE SHIELD WELLMARK SB889 [3081026] BCBS WYOMING [308102603] 5.4 percent of total billed charges 3.52 5.4 Technical (Hospital) Services LAMOTRIGINE 100 MG TABLET RX-13982 CDM 6370000100 HCPCS 250 RC 51672-4131-01 NDC outpatient 1 UN 5.69 5.69 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES EPO [308136803] 4.55 percent of total billed charges 3.53 5.41 Technical (Hospital) Services LAMOTRIGINE 100 MG TABLET RX-13982 CDM 6370000100 HCPCS 250 RC 51672-4131-01 NDC outpatient 1 UN 5.69 5.69 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES HDHP [308136802] 4.55 percent of total billed charges 3.53 5.41 Technical (Hospital) Services LAMOTRIGINE 100 MG TABLET RX-13982 CDM 6370000100 HCPCS 250 RC 51672-4131-01 NDC outpatient 1 UN 5.69 5.69 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES PPO [308136801] 4.55 percent of total billed charges 3.53 5.41 Technical (Hospital) Services LAMOTRIGINE 100 MG TABLET RX-13982 CDM 6370000100 HCPCS 250 RC 51672-4131-01 NDC outpatient 1 UN 5.69 5.69 MULTIPLAN INC 34080 [3081285] MULTIPLAN INC [308128501] 5.41 percent of total billed charges 3.53 5.41 Technical (Hospital) Services LAMOTRIGINE 100 MG TABLET RX-13982 CDM 6370000100 HCPCS 250 RC 51672-4131-01 NDC outpatient 1 UN 5.69 5.69 UNITED HEALTHCARE (COMMERCIAL) [3081199] UNITED HEALTHCARE 87726 [308119901] 3.53 percent of total billed charges 3.53 5.41 Technical (Hospital) Services LAMOTRIGINE 100 MG TABLET RX-13982 CDM 6370000100 HCPCS 250 RC 51672-4131-01 NDC outpatient 1 UN 5.69 5.69 CIGNA 62308 [3081051] CIGNA 62308 [308105105] 4.55 percent of total billed charges 3.53 5.41 Technical (Hospital) Services LAMOTRIGINE 100 MG TABLET RX-13982 CDM 6370000100 HCPCS 250 RC 51672-4131-01 NDC outpatient 1 UN 5.69 5.69 CIGNA 62308 [3081051] CIGNA STATE OF WYOMING [308105107] 4.55 percent of total billed charges 3.53 5.41 Technical (Hospital) Services LAMOTRIGINE 100 MG TABLET RX-13982 CDM 6370000100 HCPCS 250 RC 51672-4131-01 NDC outpatient 1 UN 5.69 5.69 MEDICA (COMMERCIAL) 94265 [3081118] MEDICA CLAIMS [308111801] 5.12 percent of total billed charges 3.53 5.41 Technical (Hospital) Services LAMOTRIGINE 100 MG TABLET RX-13982 CDM 6370000100 HCPCS 250 RC 51672-4131-01 NDC outpatient 1 UN 5.69 5.69 HEALTHPARTNERS SX009 HEALTHPARTNERS 4.55 percent of total billed charges 3.53 5.41 Technical (Hospital) Services LAMOTRIGINE 100 MG TABLET RX-13982 CDM 6370000100 HCPCS 250 RC 51672-4131-01 NDC outpatient 1 UN 5.69 5.69 BLUE CROSS BLUE SHIELD WELLMARK SB889 [3081026] BCBS WYOMING [308102603] 5.41 percent of total billed charges 3.53 5.41 Technical (Hospital) Services LAMOTRIGINE 100 MG TABLET RX-13982 CDM 6370000100 HCPCS 250 RC 51672-4131-01 NDC inpatient 1 UN 5.69 5.69 BLUE CROSS BLUE SHIELD WELLMARK SB889 [3081026] BCBS WYOMING [308102603] 5.41 percent of total billed charges 3.53 5.41 Technical (Hospital) Services LAMOTRIGINE 100 MG TABLET RX-13982 CDM 6370000100 HCPCS 250 RC 51672-4131-01 NDC inpatient 1 UN 5.69 5.69 UNITED HEALTHCARE (COMMERCIAL) [3081199] UNITED HEALTHCARE 87726 [308119901] 3.53 percent of total billed charges 3.53 5.41 Technical (Hospital) Services LAMOTRIGINE 100 MG TABLET RX-13982 CDM 6370000100 HCPCS 250 RC 51672-4131-01 NDC inpatient 1 UN 5.69 5.69 CIGNA 62308 [3081051] CIGNA 62308 [308105105] 4.51 percent of total billed charges 3.53 5.41 Technical (Hospital) Services LAMOTRIGINE 100 MG TABLET RX-13982 CDM 6370000100 HCPCS 250 RC 51672-4131-01 NDC inpatient 1 UN 5.69 5.69 CIGNA 62308 [3081051] CIGNA STATE OF WYOMING [308105107] 4.51 percent of total billed charges 3.53 5.41 Technical (Hospital) Services LAMOTRIGINE 100 MG TABLET RX-13982 CDM 6370000100 HCPCS 250 RC 51672-4131-01 NDC inpatient 1 UN 5.69 5.69 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES HDHP [308136802] 4.51 percent of total billed charges 3.53 5.41 Technical (Hospital) Services LAMOTRIGINE 100 MG TABLET RX-13982 CDM 6370000100 HCPCS 250 RC 51672-4131-01 NDC inpatient 1 UN 5.69 5.69 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES EPO [308136803] 4.51 percent of total billed charges 3.53 5.41 Technical (Hospital) Services LAMOTRIGINE 100 MG TABLET RX-13982 CDM 6370000100 HCPCS 250 RC 51672-4131-01 NDC inpatient 1 UN 5.69 5.69 MULTIPLAN INC 34080 [3081285] MULTIPLAN INC [308128501] 5.41 percent of total billed charges 3.53 5.41 Technical (Hospital) Services LAMOTRIGINE 100 MG TABLET RX-13982 CDM 6370000100 HCPCS 250 RC 51672-4131-01 NDC inpatient 1 UN 5.69 5.69 HEALTHPARTNERS SX009 HEALTHPARTNERS 4.51 percent of total billed charges 3.53 5.41 Technical (Hospital) Services LAMOTRIGINE 100 MG TABLET RX-13982 CDM 6370000100 HCPCS 250 RC 51672-4131-01 NDC inpatient 1 UN 5.69 5.69 MEDICA (COMMERCIAL) 94265 [3081118] MEDICA CLAIMS [308111801] 5.12 percent of total billed charges 3.53 5.41 Technical (Hospital) Services LAMOTRIGINE 100 MG TABLET RX-13982 CDM 6370000100 HCPCS 250 RC 51672-4131-01 NDC inpatient 1 UN 5.69 5.69 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES PPO [308136801] 4.51 percent of total billed charges 3.53 5.41 Technical (Hospital) Services "DILTIAZEM ER 60 MG CAPSULE,EXTENDED RELEASE 12 HR" RX-14100 CDM 6370000100 HCPCS 250 RC 00378-6060-01 NDC outpatient 1 UN 8.16 8.16 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES PPO [308136801] 6.53 percent of total billed charges 5.06 7.75 Technical (Hospital) Services "DILTIAZEM ER 60 MG CAPSULE,EXTENDED RELEASE 12 HR" RX-14100 CDM 6370000100 HCPCS 250 RC 00378-6060-01 NDC outpatient 1 UN 8.16 8.16 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES HDHP [308136802] 6.53 percent of total billed charges 5.06 7.75 Technical (Hospital) Services "DILTIAZEM ER 60 MG CAPSULE,EXTENDED RELEASE 12 HR" RX-14100 CDM 6370000100 HCPCS 250 RC 00378-6060-01 NDC outpatient 1 UN 8.16 8.16 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES EPO [308136803] 6.53 percent of total billed charges 5.06 7.75 Technical (Hospital) Services "DILTIAZEM ER 60 MG CAPSULE,EXTENDED RELEASE 12 HR" RX-14100 CDM 6370000100 HCPCS 250 RC 00378-6060-01 NDC outpatient 1 UN 8.16 8.16 BLUE CROSS BLUE SHIELD WELLMARK SB889 [3081026] BCBS WYOMING [308102603] 7.75 percent of total billed charges 5.06 7.75 Technical (Hospital) Services "DILTIAZEM ER 60 MG CAPSULE,EXTENDED RELEASE 12 HR" RX-14100 CDM 6370000100 HCPCS 250 RC 00378-6060-01 NDC outpatient 1 UN 8.16 8.16 HEALTHPARTNERS SX009 HEALTHPARTNERS 6.53 percent of total billed charges 5.06 7.75 Technical (Hospital) Services "DILTIAZEM ER 60 MG CAPSULE,EXTENDED RELEASE 12 HR" RX-14100 CDM 6370000100 HCPCS 250 RC 00378-6060-01 NDC outpatient 1 UN 8.16 8.16 MEDICA (COMMERCIAL) 94265 [3081118] MEDICA CLAIMS [308111801] 7.34 percent of total billed charges 5.06 7.75 Technical (Hospital) Services "DILTIAZEM ER 60 MG CAPSULE,EXTENDED RELEASE 12 HR" RX-14100 CDM 6370000100 HCPCS 250 RC 00378-6060-01 NDC outpatient 1 UN 8.16 8.16 CIGNA 62308 [3081051] CIGNA 62308 [308105105] 6.53 percent of total billed charges 5.06 7.75 Technical (Hospital) Services "DILTIAZEM ER 60 MG CAPSULE,EXTENDED RELEASE 12 HR" RX-14100 CDM 6370000100 HCPCS 250 RC 00378-6060-01 NDC outpatient 1 UN 8.16 8.16 CIGNA 62308 [3081051] CIGNA STATE OF WYOMING [308105107] 6.53 percent of total billed charges 5.06 7.75 Technical (Hospital) Services "DILTIAZEM ER 60 MG CAPSULE,EXTENDED RELEASE 12 HR" RX-14100 CDM 6370000100 HCPCS 250 RC 00378-6060-01 NDC outpatient 1 UN 8.16 8.16 MULTIPLAN INC 34080 [3081285] MULTIPLAN INC [308128501] 7.75 percent of total billed charges 5.06 7.75 Technical (Hospital) Services "DILTIAZEM ER 60 MG CAPSULE,EXTENDED RELEASE 12 HR" RX-14100 CDM 6370000100 HCPCS 250 RC 00378-6060-01 NDC outpatient 1 UN 8.16 8.16 UNITED HEALTHCARE (COMMERCIAL) [3081199] UNITED HEALTHCARE 87726 [308119901] 5.06 percent of total billed charges 5.06 7.75 Technical (Hospital) Services "DILTIAZEM ER 60 MG CAPSULE,EXTENDED RELEASE 12 HR" RX-14100 CDM 6370000100 HCPCS 250 RC 00378-6060-01 NDC inpatient 1 UN 8.16 8.16 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES PPO [308136801] 6.46 percent of total billed charges 5.06 7.75 Technical (Hospital) Services "DILTIAZEM ER 60 MG CAPSULE,EXTENDED RELEASE 12 HR" RX-14100 CDM 6370000100 HCPCS 250 RC 00378-6060-01 NDC inpatient 1 UN 8.16 8.16 MEDICA (COMMERCIAL) 94265 [3081118] MEDICA CLAIMS [308111801] 7.34 percent of total billed charges 5.06 7.75 Technical (Hospital) Services "DILTIAZEM ER 60 MG CAPSULE,EXTENDED RELEASE 12 HR" RX-14100 CDM 6370000100 HCPCS 250 RC 00378-6060-01 NDC inpatient 1 UN 8.16 8.16 HEALTHPARTNERS SX009 HEALTHPARTNERS 6.46 percent of total billed charges 5.06 7.75 Technical (Hospital) Services "DILTIAZEM ER 60 MG CAPSULE,EXTENDED RELEASE 12 HR" RX-14100 CDM 6370000100 HCPCS 250 RC 00378-6060-01 NDC inpatient 1 UN 8.16 8.16 MULTIPLAN INC 34080 [3081285] MULTIPLAN INC [308128501] 7.75 percent of total billed charges 5.06 7.75 Technical (Hospital) Services "DILTIAZEM ER 60 MG CAPSULE,EXTENDED RELEASE 12 HR" RX-14100 CDM 6370000100 HCPCS 250 RC 00378-6060-01 NDC inpatient 1 UN 8.16 8.16 BLUE CROSS BLUE SHIELD WELLMARK SB889 [3081026] BCBS WYOMING [308102603] 7.75 percent of total billed charges 5.06 7.75 Technical (Hospital) Services "DILTIAZEM ER 60 MG CAPSULE,EXTENDED RELEASE 12 HR" RX-14100 CDM 6370000100 HCPCS 250 RC 00378-6060-01 NDC inpatient 1 UN 8.16 8.16 UNITED HEALTHCARE (COMMERCIAL) [3081199] UNITED HEALTHCARE 87726 [308119901] 5.06 percent of total billed charges 5.06 7.75 Technical (Hospital) Services "DILTIAZEM ER 60 MG CAPSULE,EXTENDED RELEASE 12 HR" RX-14100 CDM 6370000100 HCPCS 250 RC 00378-6060-01 NDC inpatient 1 UN 8.16 8.16 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES HDHP [308136802] 6.46 percent of total billed charges 5.06 7.75 Technical (Hospital) Services "DILTIAZEM ER 60 MG CAPSULE,EXTENDED RELEASE 12 HR" RX-14100 CDM 6370000100 HCPCS 250 RC 00378-6060-01 NDC inpatient 1 UN 8.16 8.16 CIGNA 62308 [3081051] CIGNA STATE OF WYOMING [308105107] 6.46 percent of total billed charges 5.06 7.75 Technical (Hospital) Services "DILTIAZEM ER 60 MG CAPSULE,EXTENDED RELEASE 12 HR" RX-14100 CDM 6370000100 HCPCS 250 RC 00378-6060-01 NDC inpatient 1 UN 8.16 8.16 CIGNA 62308 [3081051] CIGNA 62308 [308105105] 6.46 percent of total billed charges 5.06 7.75 Technical (Hospital) Services "DILTIAZEM ER 60 MG CAPSULE,EXTENDED RELEASE 12 HR" RX-14100 CDM 6370000100 HCPCS 250 RC 00378-6060-01 NDC inpatient 1 UN 8.16 8.16 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES EPO [308136803] 6.46 percent of total billed charges 5.06 7.75 Technical (Hospital) Services TERAZOSIN 1 MG CAPSULE RX-14550 CDM 6370000100 HCPCS 250 RC 59746-0383-06 NDC outpatient 1 UN 5.8 5.8 UNITED HEALTHCARE (COMMERCIAL) [3081199] UNITED HEALTHCARE 87726 [308119901] 3.6 percent of total billed charges 3.6 5.51 Technical (Hospital) Services TERAZOSIN 1 MG CAPSULE RX-14550 CDM 6370000100 HCPCS 250 RC 59746-0383-06 NDC outpatient 1 UN 5.8 5.8 CIGNA 62308 [3081051] CIGNA 62308 [308105105] 4.64 percent of total billed charges 3.6 5.51 Technical (Hospital) Services TERAZOSIN 1 MG CAPSULE RX-14550 CDM 6370000100 HCPCS 250 RC 59746-0383-06 NDC outpatient 1 UN 5.8 5.8 CIGNA 62308 [3081051] CIGNA STATE OF WYOMING [308105107] 4.64 percent of total billed charges 3.6 5.51 Technical (Hospital) Services TERAZOSIN 1 MG CAPSULE RX-14550 CDM 6370000100 HCPCS 250 RC 59746-0383-06 NDC outpatient 1 UN 5.8 5.8 MULTIPLAN INC 34080 [3081285] MULTIPLAN INC [308128501] 5.51 percent of total billed charges 3.6 5.51 Technical (Hospital) Services TERAZOSIN 1 MG CAPSULE RX-14550 CDM 6370000100 HCPCS 250 RC 59746-0383-06 NDC outpatient 1 UN 5.8 5.8 MEDICA (COMMERCIAL) 94265 [3081118] MEDICA CLAIMS [308111801] 5.22 percent of total billed charges 3.6 5.51 Technical (Hospital) Services TERAZOSIN 1 MG CAPSULE RX-14550 CDM 6370000100 HCPCS 250 RC 59746-0383-06 NDC outpatient 1 UN 5.8 5.8 HEALTHPARTNERS SX009 HEALTHPARTNERS 4.64 percent of total billed charges 3.6 5.51 Technical (Hospital) Services TERAZOSIN 1 MG CAPSULE RX-14550 CDM 6370000100 HCPCS 250 RC 59746-0383-06 NDC outpatient 1 UN 5.8 5.8 BLUE CROSS BLUE SHIELD WELLMARK SB889 [3081026] BCBS WYOMING [308102603] 5.51 percent of total billed charges 3.6 5.51 Technical (Hospital) Services TERAZOSIN 1 MG CAPSULE RX-14550 CDM 6370000100 HCPCS 250 RC 59746-0383-06 NDC outpatient 1 UN 5.8 5.8 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES EPO [308136803] 4.64 percent of total billed charges 3.6 5.51 Technical (Hospital) Services TERAZOSIN 1 MG CAPSULE RX-14550 CDM 6370000100 HCPCS 250 RC 59746-0383-06 NDC outpatient 1 UN 5.8 5.8 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES HDHP [308136802] 4.64 percent of total billed charges 3.6 5.51 Technical (Hospital) Services TERAZOSIN 1 MG CAPSULE RX-14550 CDM 6370000100 HCPCS 250 RC 59746-0383-06 NDC outpatient 1 UN 5.8 5.8 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES PPO [308136801] 4.64 percent of total billed charges 3.6 5.51 Technical (Hospital) Services TERAZOSIN 1 MG CAPSULE RX-14550 CDM 6370000100 HCPCS 250 RC 59746-0383-06 NDC inpatient 1 UN 5.8 5.8 MEDICA (COMMERCIAL) 94265 [3081118] MEDICA CLAIMS [308111801] 5.22 percent of total billed charges 3.6 5.51 Technical (Hospital) Services TERAZOSIN 1 MG CAPSULE RX-14550 CDM 6370000100 HCPCS 250 RC 59746-0383-06 NDC inpatient 1 UN 5.8 5.8 HEALTHPARTNERS SX009 HEALTHPARTNERS 4.59 percent of total billed charges 3.6 5.51 Technical (Hospital) Services TERAZOSIN 1 MG CAPSULE RX-14550 CDM 6370000100 HCPCS 250 RC 59746-0383-06 NDC inpatient 1 UN 5.8 5.8 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES PPO [308136801] 4.59 percent of total billed charges 3.6 5.51 Technical (Hospital) Services TERAZOSIN 1 MG CAPSULE RX-14550 CDM 6370000100 HCPCS 250 RC 59746-0383-06 NDC inpatient 1 UN 5.8 5.8 MULTIPLAN INC 34080 [3081285] MULTIPLAN INC [308128501] 5.51 percent of total billed charges 3.6 5.51 Technical (Hospital) Services TERAZOSIN 1 MG CAPSULE RX-14550 CDM 6370000100 HCPCS 250 RC 59746-0383-06 NDC inpatient 1 UN 5.8 5.8 UNITED HEALTHCARE (COMMERCIAL) [3081199] UNITED HEALTHCARE 87726 [308119901] 3.6 percent of total billed charges 3.6 5.51 Technical (Hospital) Services TERAZOSIN 1 MG CAPSULE RX-14550 CDM 6370000100 HCPCS 250 RC 59746-0383-06 NDC inpatient 1 UN 5.8 5.8 BLUE CROSS BLUE SHIELD WELLMARK SB889 [3081026] BCBS WYOMING [308102603] 5.51 percent of total billed charges 3.6 5.51 Technical (Hospital) Services TERAZOSIN 1 MG CAPSULE RX-14550 CDM 6370000100 HCPCS 250 RC 59746-0383-06 NDC inpatient 1 UN 5.8 5.8 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES HDHP [308136802] 4.59 percent of total billed charges 3.6 5.51 Technical (Hospital) Services TERAZOSIN 1 MG CAPSULE RX-14550 CDM 6370000100 HCPCS 250 RC 59746-0383-06 NDC inpatient 1 UN 5.8 5.8 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES EPO [308136803] 4.59 percent of total billed charges 3.6 5.51 Technical (Hospital) Services TERAZOSIN 1 MG CAPSULE RX-14550 CDM 6370000100 HCPCS 250 RC 59746-0383-06 NDC inpatient 1 UN 5.8 5.8 CIGNA 62308 [3081051] CIGNA 62308 [308105105] 4.59 percent of total billed charges 3.6 5.51 Technical (Hospital) Services TERAZOSIN 1 MG CAPSULE RX-14550 CDM 6370000100 HCPCS 250 RC 59746-0383-06 NDC inpatient 1 UN 5.8 5.8 CIGNA 62308 [3081051] CIGNA STATE OF WYOMING [308105107] 4.59 percent of total billed charges 3.6 5.51 Technical (Hospital) Services TERAZOSIN 2 MG CAPSULE RX-14551 CDM 6370000100 HCPCS 250 RC 59746-0384-06 NDC inpatient 1 UN 5.8 5.8 MULTIPLAN INC 34080 [3081285] MULTIPLAN INC [308128501] 5.51 percent of total billed charges 3.6 5.51 Technical (Hospital) Services TERAZOSIN 2 MG CAPSULE RX-14551 CDM 6370000100 HCPCS 250 RC 59746-0384-06 NDC inpatient 1 UN 5.8 5.8 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES PPO [308136801] 4.59 percent of total billed charges 3.6 5.51 Technical (Hospital) Services TERAZOSIN 2 MG CAPSULE RX-14551 CDM 6370000100 HCPCS 250 RC 59746-0384-06 NDC inpatient 1 UN 5.8 5.8 BLUE CROSS BLUE SHIELD WELLMARK SB889 [3081026] BCBS WYOMING [308102603] 5.51 percent of total billed charges 3.6 5.51 Technical (Hospital) Services TERAZOSIN 2 MG CAPSULE RX-14551 CDM 6370000100 HCPCS 250 RC 59746-0384-06 NDC inpatient 1 UN 5.8 5.8 UNITED HEALTHCARE (COMMERCIAL) [3081199] UNITED HEALTHCARE 87726 [308119901] 3.6 percent of total billed charges 3.6 5.51 Technical (Hospital) Services TERAZOSIN 2 MG CAPSULE RX-14551 CDM 6370000100 HCPCS 250 RC 59746-0384-06 NDC inpatient 1 UN 5.8 5.8 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES HDHP [308136802] 4.59 percent of total billed charges 3.6 5.51 Technical (Hospital) Services TERAZOSIN 2 MG CAPSULE RX-14551 CDM 6370000100 HCPCS 250 RC 59746-0384-06 NDC inpatient 1 UN 5.8 5.8 MEDICA (COMMERCIAL) 94265 [3081118] MEDICA CLAIMS [308111801] 5.22 percent of total billed charges 3.6 5.51 Technical (Hospital) Services TERAZOSIN 2 MG CAPSULE RX-14551 CDM 6370000100 HCPCS 250 RC 59746-0384-06 NDC inpatient 1 UN 5.8 5.8 HEALTHPARTNERS SX009 HEALTHPARTNERS 4.59 percent of total billed charges 3.6 5.51 Technical (Hospital) Services TERAZOSIN 2 MG CAPSULE RX-14551 CDM 6370000100 HCPCS 250 RC 59746-0384-06 NDC inpatient 1 UN 5.8 5.8 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES EPO [308136803] 4.59 percent of total billed charges 3.6 5.51 Technical (Hospital) Services TERAZOSIN 2 MG CAPSULE RX-14551 CDM 6370000100 HCPCS 250 RC 59746-0384-06 NDC inpatient 1 UN 5.8 5.8 CIGNA 62308 [3081051] CIGNA 62308 [308105105] 4.59 percent of total billed charges 3.6 5.51 Technical (Hospital) Services TERAZOSIN 2 MG CAPSULE RX-14551 CDM 6370000100 HCPCS 250 RC 59746-0384-06 NDC inpatient 1 UN 5.8 5.8 CIGNA 62308 [3081051] CIGNA STATE OF WYOMING [308105107] 4.59 percent of total billed charges 3.6 5.51 Technical (Hospital) Services TERAZOSIN 2 MG CAPSULE RX-14551 CDM 6370000100 HCPCS 250 RC 59746-0384-06 NDC outpatient 1 UN 5.8 5.8 UNITED HEALTHCARE (COMMERCIAL) [3081199] UNITED HEALTHCARE 87726 [308119901] 3.6 percent of total billed charges 3.6 5.51 Technical (Hospital) Services TERAZOSIN 2 MG CAPSULE RX-14551 CDM 6370000100 HCPCS 250 RC 59746-0384-06 NDC outpatient 1 UN 5.8 5.8 HEALTHPARTNERS SX009 HEALTHPARTNERS 4.64 percent of total billed charges 3.6 5.51 Technical (Hospital) Services TERAZOSIN 2 MG CAPSULE RX-14551 CDM 6370000100 HCPCS 250 RC 59746-0384-06 NDC outpatient 1 UN 5.8 5.8 MULTIPLAN INC 34080 [3081285] MULTIPLAN INC [308128501] 5.51 percent of total billed charges 3.6 5.51 Technical (Hospital) Services TERAZOSIN 2 MG CAPSULE RX-14551 CDM 6370000100 HCPCS 250 RC 59746-0384-06 NDC outpatient 1 UN 5.8 5.8 CIGNA 62308 [3081051] CIGNA 62308 [308105105] 4.64 percent of total billed charges 3.6 5.51 Technical (Hospital) Services TERAZOSIN 2 MG CAPSULE RX-14551 CDM 6370000100 HCPCS 250 RC 59746-0384-06 NDC outpatient 1 UN 5.8 5.8 CIGNA 62308 [3081051] CIGNA STATE OF WYOMING [308105107] 4.64 percent of total billed charges 3.6 5.51 Technical (Hospital) Services TERAZOSIN 2 MG CAPSULE RX-14551 CDM 6370000100 HCPCS 250 RC 59746-0384-06 NDC outpatient 1 UN 5.8 5.8 MEDICA (COMMERCIAL) 94265 [3081118] MEDICA CLAIMS [308111801] 5.22 percent of total billed charges 3.6 5.51 Technical (Hospital) Services TERAZOSIN 2 MG CAPSULE RX-14551 CDM 6370000100 HCPCS 250 RC 59746-0384-06 NDC outpatient 1 UN 5.8 5.8 BLUE CROSS BLUE SHIELD WELLMARK SB889 [3081026] BCBS WYOMING [308102603] 5.51 percent of total billed charges 3.6 5.51 Technical (Hospital) Services TERAZOSIN 2 MG CAPSULE RX-14551 CDM 6370000100 HCPCS 250 RC 59746-0384-06 NDC outpatient 1 UN 5.8 5.8 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES EPO [308136803] 4.64 percent of total billed charges 3.6 5.51 Technical (Hospital) Services TERAZOSIN 2 MG CAPSULE RX-14551 CDM 6370000100 HCPCS 250 RC 59746-0384-06 NDC outpatient 1 UN 5.8 5.8 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES PPO [308136801] 4.64 percent of total billed charges 3.6 5.51 Technical (Hospital) Services TERAZOSIN 2 MG CAPSULE RX-14551 CDM 6370000100 HCPCS 250 RC 59746-0384-06 NDC outpatient 1 UN 5.8 5.8 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES HDHP [308136802] 4.64 percent of total billed charges 3.6 5.51 Technical (Hospital) Services TERAZOSIN 5 MG CAPSULE RX-14553 CDM 6370000100 HCPCS 250 RC 59746-0385-06 NDC inpatient 1 UN 5.8 5.8 CIGNA 62308 [3081051] CIGNA 62308 [308105105] 4.59 percent of total billed charges 3.6 5.51 Technical (Hospital) Services TERAZOSIN 5 MG CAPSULE RX-14553 CDM 6370000100 HCPCS 250 RC 59746-0385-06 NDC inpatient 1 UN 5.8 5.8 CIGNA 62308 [3081051] CIGNA STATE OF WYOMING [308105107] 4.59 percent of total billed charges 3.6 5.51 Technical (Hospital) Services TERAZOSIN 5 MG CAPSULE RX-14553 CDM 6370000100 HCPCS 250 RC 59746-0385-06 NDC inpatient 1 UN 5.8 5.8 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES EPO [308136803] 4.59 percent of total billed charges 3.6 5.51 Technical (Hospital) Services TERAZOSIN 5 MG CAPSULE RX-14553 CDM 6370000100 HCPCS 250 RC 59746-0385-06 NDC inpatient 1 UN 5.8 5.8 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES HDHP [308136802] 4.59 percent of total billed charges 3.6 5.51 Technical (Hospital) Services TERAZOSIN 5 MG CAPSULE RX-14553 CDM 6370000100 HCPCS 250 RC 59746-0385-06 NDC inpatient 1 UN 5.8 5.8 BLUE CROSS BLUE SHIELD WELLMARK SB889 [3081026] BCBS WYOMING [308102603] 5.51 percent of total billed charges 3.6 5.51 Technical (Hospital) Services TERAZOSIN 5 MG CAPSULE RX-14553 CDM 6370000100 HCPCS 250 RC 59746-0385-06 NDC inpatient 1 UN 5.8 5.8 UNITED HEALTHCARE (COMMERCIAL) [3081199] UNITED HEALTHCARE 87726 [308119901] 3.6 percent of total billed charges 3.6 5.51 Technical (Hospital) Services TERAZOSIN 5 MG CAPSULE RX-14553 CDM 6370000100 HCPCS 250 RC 59746-0385-06 NDC inpatient 1 UN 5.8 5.8 MULTIPLAN INC 34080 [3081285] MULTIPLAN INC [308128501] 5.51 percent of total billed charges 3.6 5.51 Technical (Hospital) Services TERAZOSIN 5 MG CAPSULE RX-14553 CDM 6370000100 HCPCS 250 RC 59746-0385-06 NDC inpatient 1 UN 5.8 5.8 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES PPO [308136801] 4.59 percent of total billed charges 3.6 5.51 Technical (Hospital) Services TERAZOSIN 5 MG CAPSULE RX-14553 CDM 6370000100 HCPCS 250 RC 59746-0385-06 NDC inpatient 1 UN 5.8 5.8 HEALTHPARTNERS SX009 HEALTHPARTNERS 4.59 percent of total billed charges 3.6 5.51 Technical (Hospital) Services TERAZOSIN 5 MG CAPSULE RX-14553 CDM 6370000100 HCPCS 250 RC 59746-0385-06 NDC inpatient 1 UN 5.8 5.8 MEDICA (COMMERCIAL) 94265 [3081118] MEDICA CLAIMS [308111801] 5.22 percent of total billed charges 3.6 5.51 Technical (Hospital) Services TERAZOSIN 5 MG CAPSULE RX-14553 CDM 6370000100 HCPCS 250 RC 59746-0385-06 NDC outpatient 1 UN 5.8 5.8 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES EPO [308136803] 4.64 percent of total billed charges 3.6 5.51 Technical (Hospital) Services TERAZOSIN 5 MG CAPSULE RX-14553 CDM 6370000100 HCPCS 250 RC 59746-0385-06 NDC outpatient 1 UN 5.8 5.8 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES PPO [308136801] 4.64 percent of total billed charges 3.6 5.51 Technical (Hospital) Services TERAZOSIN 5 MG CAPSULE RX-14553 CDM 6370000100 HCPCS 250 RC 59746-0385-06 NDC outpatient 1 UN 5.8 5.8 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES HDHP [308136802] 4.64 percent of total billed charges 3.6 5.51 Technical (Hospital) Services TERAZOSIN 5 MG CAPSULE RX-14553 CDM 6370000100 HCPCS 250 RC 59746-0385-06 NDC outpatient 1 UN 5.8 5.8 HEALTHPARTNERS SX009 HEALTHPARTNERS 4.64 percent of total billed charges 3.6 5.51 Technical (Hospital) Services TERAZOSIN 5 MG CAPSULE RX-14553 CDM 6370000100 HCPCS 250 RC 59746-0385-06 NDC outpatient 1 UN 5.8 5.8 BLUE CROSS BLUE SHIELD WELLMARK SB889 [3081026] BCBS WYOMING [308102603] 5.51 percent of total billed charges 3.6 5.51 Technical (Hospital) Services TERAZOSIN 5 MG CAPSULE RX-14553 CDM 6370000100 HCPCS 250 RC 59746-0385-06 NDC outpatient 1 UN 5.8 5.8 CIGNA 62308 [3081051] CIGNA 62308 [308105105] 4.64 percent of total billed charges 3.6 5.51 Technical (Hospital) Services TERAZOSIN 5 MG CAPSULE RX-14553 CDM 6370000100 HCPCS 250 RC 59746-0385-06 NDC outpatient 1 UN 5.8 5.8 CIGNA 62308 [3081051] CIGNA STATE OF WYOMING [308105107] 4.64 percent of total billed charges 3.6 5.51 Technical (Hospital) Services TERAZOSIN 5 MG CAPSULE RX-14553 CDM 6370000100 HCPCS 250 RC 59746-0385-06 NDC outpatient 1 UN 5.8 5.8 MULTIPLAN INC 34080 [3081285] MULTIPLAN INC [308128501] 5.51 percent of total billed charges 3.6 5.51 Technical (Hospital) Services TERAZOSIN 5 MG CAPSULE RX-14553 CDM 6370000100 HCPCS 250 RC 59746-0385-06 NDC outpatient 1 UN 5.8 5.8 MEDICA (COMMERCIAL) 94265 [3081118] MEDICA CLAIMS [308111801] 5.22 percent of total billed charges 3.6 5.51 Technical (Hospital) Services TERAZOSIN 5 MG CAPSULE RX-14553 CDM 6370000100 HCPCS 250 RC 59746-0385-06 NDC outpatient 1 UN 5.8 5.8 UNITED HEALTHCARE (COMMERCIAL) [3081199] UNITED HEALTHCARE 87726 [308119901] 3.6 percent of total billed charges 3.6 5.51 Technical (Hospital) Services TRAMADOL 50 MG TABLET RX-14632 CDM 6370000100 HCPCS 250 RC 57664-0377-18 NDC outpatient 1 UN 5.67 5.67 UNITED HEALTHCARE (COMMERCIAL) [3081199] UNITED HEALTHCARE 87726 [308119901] 3.52 percent of total billed charges 3.52 5.39 Technical (Hospital) Services TRAMADOL 50 MG TABLET RX-14632 CDM 6370000100 HCPCS 250 RC 57664-0377-18 NDC outpatient 1 UN 5.67 5.67 MULTIPLAN INC 34080 [3081285] MULTIPLAN INC [308128501] 5.39 percent of total billed charges 3.52 5.39 Technical (Hospital) Services TRAMADOL 50 MG TABLET RX-14632 CDM 6370000100 HCPCS 250 RC 57664-0377-18 NDC outpatient 1 UN 5.67 5.67 CIGNA 62308 [3081051] CIGNA 62308 [308105105] 4.54 percent of total billed charges 3.52 5.39 Technical (Hospital) Services TRAMADOL 50 MG TABLET RX-14632 CDM 6370000100 HCPCS 250 RC 57664-0377-18 NDC outpatient 1 UN 5.67 5.67 CIGNA 62308 [3081051] CIGNA STATE OF WYOMING [308105107] 4.54 percent of total billed charges 3.52 5.39 Technical (Hospital) Services TRAMADOL 50 MG TABLET RX-14632 CDM 6370000100 HCPCS 250 RC 57664-0377-18 NDC outpatient 1 UN 5.67 5.67 MEDICA (COMMERCIAL) 94265 [3081118] MEDICA CLAIMS [308111801] 5.1 percent of total billed charges 3.52 5.39 Technical (Hospital) Services TRAMADOL 50 MG TABLET RX-14632 CDM 6370000100 HCPCS 250 RC 57664-0377-18 NDC outpatient 1 UN 5.67 5.67 HEALTHPARTNERS SX009 HEALTHPARTNERS 4.54 percent of total billed charges 3.52 5.39 Technical (Hospital) Services TRAMADOL 50 MG TABLET RX-14632 CDM 6370000100 HCPCS 250 RC 57664-0377-18 NDC outpatient 1 UN 5.67 5.67 BLUE CROSS BLUE SHIELD WELLMARK SB889 [3081026] BCBS WYOMING [308102603] 5.39 percent of total billed charges 3.52 5.39 Technical (Hospital) Services TRAMADOL 50 MG TABLET RX-14632 CDM 6370000100 HCPCS 250 RC 57664-0377-18 NDC outpatient 1 UN 5.67 5.67 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES HDHP [308136802] 4.54 percent of total billed charges 3.52 5.39 Technical (Hospital) Services TRAMADOL 50 MG TABLET RX-14632 CDM 6370000100 HCPCS 250 RC 57664-0377-18 NDC outpatient 1 UN 5.67 5.67 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES EPO [308136803] 4.54 percent of total billed charges 3.52 5.39 Technical (Hospital) Services TRAMADOL 50 MG TABLET RX-14632 CDM 6370000100 HCPCS 250 RC 57664-0377-18 NDC outpatient 1 UN 5.67 5.67 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES PPO [308136801] 4.54 percent of total billed charges 3.52 5.39 Technical (Hospital) Services TRAMADOL 50 MG TABLET RX-14632 CDM 6370000100 HCPCS 250 RC 57664-0377-18 NDC inpatient 1 UN 5.67 5.67 MEDICA (COMMERCIAL) 94265 [3081118] MEDICA CLAIMS [308111801] 5.1 percent of total billed charges 3.52 5.39 Technical (Hospital) Services TRAMADOL 50 MG TABLET RX-14632 CDM 6370000100 HCPCS 250 RC 57664-0377-18 NDC inpatient 1 UN 5.67 5.67 HEALTHPARTNERS SX009 HEALTHPARTNERS 4.49 percent of total billed charges 3.52 5.39 Technical (Hospital) Services TRAMADOL 50 MG TABLET RX-14632 CDM 6370000100 HCPCS 250 RC 57664-0377-18 NDC inpatient 1 UN 5.67 5.67 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES PPO [308136801] 4.49 percent of total billed charges 3.52 5.39 Technical (Hospital) Services TRAMADOL 50 MG TABLET RX-14632 CDM 6370000100 HCPCS 250 RC 57664-0377-18 NDC inpatient 1 UN 5.67 5.67 MULTIPLAN INC 34080 [3081285] MULTIPLAN INC [308128501] 5.39 percent of total billed charges 3.52 5.39 Technical (Hospital) Services TRAMADOL 50 MG TABLET RX-14632 CDM 6370000100 HCPCS 250 RC 57664-0377-18 NDC inpatient 1 UN 5.67 5.67 UNITED HEALTHCARE (COMMERCIAL) [3081199] UNITED HEALTHCARE 87726 [308119901] 3.52 percent of total billed charges 3.52 5.39 Technical (Hospital) Services TRAMADOL 50 MG TABLET RX-14632 CDM 6370000100 HCPCS 250 RC 57664-0377-18 NDC inpatient 1 UN 5.67 5.67 BLUE CROSS BLUE SHIELD WELLMARK SB889 [3081026] BCBS WYOMING [308102603] 5.39 percent of total billed charges 3.52 5.39 Technical (Hospital) Services TRAMADOL 50 MG TABLET RX-14632 CDM 6370000100 HCPCS 250 RC 57664-0377-18 NDC inpatient 1 UN 5.67 5.67 CIGNA 62308 [3081051] CIGNA 62308 [308105105] 4.49 percent of total billed charges 3.52 5.39 Technical (Hospital) Services TRAMADOL 50 MG TABLET RX-14632 CDM 6370000100 HCPCS 250 RC 57664-0377-18 NDC inpatient 1 UN 5.67 5.67 CIGNA 62308 [3081051] CIGNA STATE OF WYOMING [308105107] 4.49 percent of total billed charges 3.52 5.39 Technical (Hospital) Services TRAMADOL 50 MG TABLET RX-14632 CDM 6370000100 HCPCS 250 RC 57664-0377-18 NDC inpatient 1 UN 5.67 5.67 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES EPO [308136803] 4.49 percent of total billed charges 3.52 5.39 Technical (Hospital) Services TRAMADOL 50 MG TABLET RX-14632 CDM 6370000100 HCPCS 250 RC 57664-0377-18 NDC inpatient 1 UN 5.67 5.67 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES HDHP [308136802] 4.49 percent of total billed charges 3.52 5.39 Technical (Hospital) Services METFORMIN 850 MG TABLET RX-14719 CDM 6370000100 HCPCS 250 RC 23155-0103-01 NDC outpatient 1 UN 5.68 5.68 HEALTHPARTNERS SX009 HEALTHPARTNERS 4.54 percent of total billed charges 3.52 5.4 Technical (Hospital) Services METFORMIN 850 MG TABLET RX-14719 CDM 6370000100 HCPCS 250 RC 23155-0103-01 NDC outpatient 1 UN 5.68 5.68 BLUE CROSS BLUE SHIELD WELLMARK SB889 [3081026] BCBS WYOMING [308102603] 5.4 percent of total billed charges 3.52 5.4 Technical (Hospital) Services METFORMIN 850 MG TABLET RX-14719 CDM 6370000100 HCPCS 250 RC 23155-0103-01 NDC outpatient 1 UN 5.68 5.68 UNITED HEALTHCARE (COMMERCIAL) [3081199] UNITED HEALTHCARE 87726 [308119901] 3.52 percent of total billed charges 3.52 5.4 Technical (Hospital) Services METFORMIN 850 MG TABLET RX-14719 CDM 6370000100 HCPCS 250 RC 23155-0103-01 NDC outpatient 1 UN 5.68 5.68 MULTIPLAN INC 34080 [3081285] MULTIPLAN INC [308128501] 5.4 percent of total billed charges 3.52 5.4 Technical (Hospital) Services METFORMIN 850 MG TABLET RX-14719 CDM 6370000100 HCPCS 250 RC 23155-0103-01 NDC outpatient 1 UN 5.68 5.68 CIGNA 62308 [3081051] CIGNA 62308 [308105105] 4.54 percent of total billed charges 3.52 5.4 Technical (Hospital) Services METFORMIN 850 MG TABLET RX-14719 CDM 6370000100 HCPCS 250 RC 23155-0103-01 NDC outpatient 1 UN 5.68 5.68 CIGNA 62308 [3081051] CIGNA STATE OF WYOMING [308105107] 4.54 percent of total billed charges 3.52 5.4 Technical (Hospital) Services METFORMIN 850 MG TABLET RX-14719 CDM 6370000100 HCPCS 250 RC 23155-0103-01 NDC outpatient 1 UN 5.68 5.68 MEDICA (COMMERCIAL) 94265 [3081118] MEDICA CLAIMS [308111801] 5.11 percent of total billed charges 3.52 5.4 Technical (Hospital) Services METFORMIN 850 MG TABLET RX-14719 CDM 6370000100 HCPCS 250 RC 23155-0103-01 NDC outpatient 1 UN 5.68 5.68 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES HDHP [308136802] 4.54 percent of total billed charges 3.52 5.4 Technical (Hospital) Services METFORMIN 850 MG TABLET RX-14719 CDM 6370000100 HCPCS 250 RC 23155-0103-01 NDC outpatient 1 UN 5.68 5.68 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES PPO [308136801] 4.54 percent of total billed charges 3.52 5.4 Technical (Hospital) Services METFORMIN 850 MG TABLET RX-14719 CDM 6370000100 HCPCS 250 RC 23155-0103-01 NDC outpatient 1 UN 5.68 5.68 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES EPO [308136803] 4.54 percent of total billed charges 3.52 5.4 Technical (Hospital) Services METFORMIN 850 MG TABLET RX-14719 CDM 6370000100 HCPCS 250 RC 23155-0103-01 NDC inpatient 1 UN 5.68 5.68 BLUE CROSS BLUE SHIELD WELLMARK SB889 [3081026] BCBS WYOMING [308102603] 5.4 percent of total billed charges 3.52 5.4 Technical (Hospital) Services METFORMIN 850 MG TABLET RX-14719 CDM 6370000100 HCPCS 250 RC 23155-0103-01 NDC inpatient 1 UN 5.68 5.68 UNITED HEALTHCARE (COMMERCIAL) [3081199] UNITED HEALTHCARE 87726 [308119901] 3.52 percent of total billed charges 3.52 5.4 Technical (Hospital) Services METFORMIN 850 MG TABLET RX-14719 CDM 6370000100 HCPCS 250 RC 23155-0103-01 NDC inpatient 1 UN 5.68 5.68 CIGNA 62308 [3081051] CIGNA 62308 [308105105] 4.5 percent of total billed charges 3.52 5.4 Technical (Hospital) Services METFORMIN 850 MG TABLET RX-14719 CDM 6370000100 HCPCS 250 RC 23155-0103-01 NDC inpatient 1 UN 5.68 5.68 CIGNA 62308 [3081051] CIGNA STATE OF WYOMING [308105107] 4.5 percent of total billed charges 3.52 5.4 Technical (Hospital) Services METFORMIN 850 MG TABLET RX-14719 CDM 6370000100 HCPCS 250 RC 23155-0103-01 NDC inpatient 1 UN 5.68 5.68 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES EPO [308136803] 4.5 percent of total billed charges 3.52 5.4 Technical (Hospital) Services METFORMIN 850 MG TABLET RX-14719 CDM 6370000100 HCPCS 250 RC 23155-0103-01 NDC inpatient 1 UN 5.68 5.68 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES HDHP [308136802] 4.5 percent of total billed charges 3.52 5.4 Technical (Hospital) Services METFORMIN 850 MG TABLET RX-14719 CDM 6370000100 HCPCS 250 RC 23155-0103-01 NDC inpatient 1 UN 5.68 5.68 MEDICA (COMMERCIAL) 94265 [3081118] MEDICA CLAIMS [308111801] 5.11 percent of total billed charges 3.52 5.4 Technical (Hospital) Services METFORMIN 850 MG TABLET RX-14719 CDM 6370000100 HCPCS 250 RC 23155-0103-01 NDC inpatient 1 UN 5.68 5.68 HEALTHPARTNERS SX009 HEALTHPARTNERS 4.5 percent of total billed charges 3.52 5.4 Technical (Hospital) Services METFORMIN 850 MG TABLET RX-14719 CDM 6370000100 HCPCS 250 RC 23155-0103-01 NDC inpatient 1 UN 5.68 5.68 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES PPO [308136801] 4.5 percent of total billed charges 3.52 5.4 Technical (Hospital) Services METFORMIN 850 MG TABLET RX-14719 CDM 6370000100 HCPCS 250 RC 23155-0103-01 NDC inpatient 1 UN 5.68 5.68 MULTIPLAN INC 34080 [3081285] MULTIPLAN INC [308128501] 5.4 percent of total billed charges 3.52 5.4 Technical (Hospital) Services TIZANIDINE 2 MG TABLET RX-14792 CDM 6370000100 HCPCS 250 RC 57664-0502-89 NDC inpatient 1 UN 5.7 5.7 BLUE CROSS BLUE SHIELD WELLMARK SB889 [3081026] BCBS WYOMING [308102603] 5.42 percent of total billed charges 3.53 5.42 Technical (Hospital) Services TIZANIDINE 2 MG TABLET RX-14792 CDM 6370000100 HCPCS 250 RC 57664-0502-89 NDC inpatient 1 UN 5.7 5.7 UNITED HEALTHCARE (COMMERCIAL) [3081199] UNITED HEALTHCARE 87726 [308119901] 3.53 percent of total billed charges 3.53 5.42 Technical (Hospital) Services TIZANIDINE 2 MG TABLET RX-14792 CDM 6370000100 HCPCS 250 RC 57664-0502-89 NDC inpatient 1 UN 5.7 5.7 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES EPO [308136803] 4.51 percent of total billed charges 3.53 5.42 Technical (Hospital) Services TIZANIDINE 2 MG TABLET RX-14792 CDM 6370000100 HCPCS 250 RC 57664-0502-89 NDC inpatient 1 UN 5.7 5.7 CIGNA 62308 [3081051] CIGNA 62308 [308105105] 4.51 percent of total billed charges 3.53 5.42 Technical (Hospital) Services TIZANIDINE 2 MG TABLET RX-14792 CDM 6370000100 HCPCS 250 RC 57664-0502-89 NDC inpatient 1 UN 5.7 5.7 CIGNA 62308 [3081051] CIGNA STATE OF WYOMING [308105107] 4.51 percent of total billed charges 3.53 5.42 Technical (Hospital) Services TIZANIDINE 2 MG TABLET RX-14792 CDM 6370000100 HCPCS 250 RC 57664-0502-89 NDC inpatient 1 UN 5.7 5.7 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES HDHP [308136802] 4.51 percent of total billed charges 3.53 5.42 Technical (Hospital) Services TIZANIDINE 2 MG TABLET RX-14792 CDM 6370000100 HCPCS 250 RC 57664-0502-89 NDC inpatient 1 UN 5.7 5.7 HEALTHPARTNERS SX009 HEALTHPARTNERS 4.51 percent of total billed charges 3.53 5.42 Technical (Hospital) Services TIZANIDINE 2 MG TABLET RX-14792 CDM 6370000100 HCPCS 250 RC 57664-0502-89 NDC inpatient 1 UN 5.7 5.7 MEDICA (COMMERCIAL) 94265 [3081118] MEDICA CLAIMS [308111801] 5.13 percent of total billed charges 3.53 5.42 Technical (Hospital) Services TIZANIDINE 2 MG TABLET RX-14792 CDM 6370000100 HCPCS 250 RC 57664-0502-89 NDC inpatient 1 UN 5.7 5.7 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES PPO [308136801] 4.51 percent of total billed charges 3.53 5.42 Technical (Hospital) Services TIZANIDINE 2 MG TABLET RX-14792 CDM 6370000100 HCPCS 250 RC 57664-0502-89 NDC inpatient 1 UN 5.7 5.7 MULTIPLAN INC 34080 [3081285] MULTIPLAN INC [308128501] 5.42 percent of total billed charges 3.53 5.42 Technical (Hospital) Services TIZANIDINE 2 MG TABLET RX-14792 CDM 6370000100 HCPCS 250 RC 57664-0502-89 NDC outpatient 1 UN 5.7 5.7 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES EPO [308136803] 4.56 percent of total billed charges 3.53 5.42 Technical (Hospital) Services TIZANIDINE 2 MG TABLET RX-14792 CDM 6370000100 HCPCS 250 RC 57664-0502-89 NDC outpatient 1 UN 5.7 5.7 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES HDHP [308136802] 4.56 percent of total billed charges 3.53 5.42 Technical (Hospital) Services TIZANIDINE 2 MG TABLET RX-14792 CDM 6370000100 HCPCS 250 RC 57664-0502-89 NDC outpatient 1 UN 5.7 5.7 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES PPO [308136801] 4.56 percent of total billed charges 3.53 5.42 Technical (Hospital) Services TIZANIDINE 2 MG TABLET RX-14792 CDM 6370000100 HCPCS 250 RC 57664-0502-89 NDC outpatient 1 UN 5.7 5.7 BLUE CROSS BLUE SHIELD WELLMARK SB889 [3081026] BCBS WYOMING [308102603] 5.42 percent of total billed charges 3.53 5.42 Technical (Hospital) Services TIZANIDINE 2 MG TABLET RX-14792 CDM 6370000100 HCPCS 250 RC 57664-0502-89 NDC outpatient 1 UN 5.7 5.7 HEALTHPARTNERS SX009 HEALTHPARTNERS 4.56 percent of total billed charges 3.53 5.42 Technical (Hospital) Services TIZANIDINE 2 MG TABLET RX-14792 CDM 6370000100 HCPCS 250 RC 57664-0502-89 NDC outpatient 1 UN 5.7 5.7 MULTIPLAN INC 34080 [3081285] MULTIPLAN INC [308128501] 5.42 percent of total billed charges 3.53 5.42 Technical (Hospital) Services TIZANIDINE 2 MG TABLET RX-14792 CDM 6370000100 HCPCS 250 RC 57664-0502-89 NDC outpatient 1 UN 5.7 5.7 UNITED HEALTHCARE (COMMERCIAL) [3081199] UNITED HEALTHCARE 87726 [308119901] 3.53 percent of total billed charges 3.53 5.42 Technical (Hospital) Services TIZANIDINE 2 MG TABLET RX-14792 CDM 6370000100 HCPCS 250 RC 57664-0502-89 NDC outpatient 1 UN 5.7 5.7 CIGNA 62308 [3081051] CIGNA 62308 [308105105] 4.56 percent of total billed charges 3.53 5.42 Technical (Hospital) Services TIZANIDINE 2 MG TABLET RX-14792 CDM 6370000100 HCPCS 250 RC 57664-0502-89 NDC outpatient 1 UN 5.7 5.7 CIGNA 62308 [3081051] CIGNA STATE OF WYOMING [308105107] 4.56 percent of total billed charges 3.53 5.42 Technical (Hospital) Services TIZANIDINE 2 MG TABLET RX-14792 CDM 6370000100 HCPCS 250 RC 57664-0502-89 NDC outpatient 1 UN 5.7 5.7 MEDICA (COMMERCIAL) 94265 [3081118] MEDICA CLAIMS [308111801] 5.13 percent of total billed charges 3.53 5.42 Technical (Hospital) Services TIZANIDINE 4 MG TABLET RX-14793 CDM 6370000100 HCPCS 250 RC 00904-6418-61 NDC inpatient 1 UN 6.15 6.15 MULTIPLAN INC 34080 [3081285] MULTIPLAN INC [308128501] 5.84 percent of total billed charges 3.81 5.84 Technical (Hospital) Services TIZANIDINE 4 MG TABLET RX-14793 CDM 6370000100 HCPCS 250 RC 00904-6418-61 NDC inpatient 1 UN 6.15 6.15 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES PPO [308136801] 4.87 percent of total billed charges 3.81 5.84 Technical (Hospital) Services TIZANIDINE 4 MG TABLET RX-14793 CDM 6370000100 HCPCS 250 RC 00904-6418-61 NDC inpatient 1 UN 6.15 6.15 MEDICA (COMMERCIAL) 94265 [3081118] MEDICA CLAIMS [308111801] 5.54 percent of total billed charges 3.81 5.84 Technical (Hospital) Services TIZANIDINE 4 MG TABLET RX-14793 CDM 6370000100 HCPCS 250 RC 00904-6418-61 NDC inpatient 1 UN 6.15 6.15 HEALTHPARTNERS SX009 HEALTHPARTNERS 4.87 percent of total billed charges 3.81 5.84 Technical (Hospital) Services TIZANIDINE 4 MG TABLET RX-14793 CDM 6370000100 HCPCS 250 RC 00904-6418-61 NDC inpatient 1 UN 6.15 6.15 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES HDHP [308136802] 4.87 percent of total billed charges 3.81 5.84 Technical (Hospital) Services TIZANIDINE 4 MG TABLET RX-14793 CDM 6370000100 HCPCS 250 RC 00904-6418-61 NDC inpatient 1 UN 6.15 6.15 CIGNA 62308 [3081051] CIGNA 62308 [308105105] 4.87 percent of total billed charges 3.81 5.84 Technical (Hospital) Services TIZANIDINE 4 MG TABLET RX-14793 CDM 6370000100 HCPCS 250 RC 00904-6418-61 NDC inpatient 1 UN 6.15 6.15 CIGNA 62308 [3081051] CIGNA STATE OF WYOMING [308105107] 4.87 percent of total billed charges 3.81 5.84 Technical (Hospital) Services TIZANIDINE 4 MG TABLET RX-14793 CDM 6370000100 HCPCS 250 RC 00904-6418-61 NDC inpatient 1 UN 6.15 6.15 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES EPO [308136803] 4.87 percent of total billed charges 3.81 5.84 Technical (Hospital) Services TIZANIDINE 4 MG TABLET RX-14793 CDM 6370000100 HCPCS 250 RC 00904-6418-61 NDC inpatient 1 UN 6.15 6.15 UNITED HEALTHCARE (COMMERCIAL) [3081199] UNITED HEALTHCARE 87726 [308119901] 3.81 percent of total billed charges 3.81 5.84 Technical (Hospital) Services TIZANIDINE 4 MG TABLET RX-14793 CDM 6370000100 HCPCS 250 RC 00904-6418-61 NDC inpatient 1 UN 6.15 6.15 BLUE CROSS BLUE SHIELD WELLMARK SB889 [3081026] BCBS WYOMING [308102603] 5.84 percent of total billed charges 3.81 5.84 Technical (Hospital) Services TIZANIDINE 4 MG TABLET RX-14793 CDM 6370000100 HCPCS 250 RC 00904-6418-61 NDC outpatient 1 UN 6.15 6.15 MEDICA (COMMERCIAL) 94265 [3081118] MEDICA CLAIMS [308111801] 5.54 percent of total billed charges 3.81 5.84 Technical (Hospital) Services TIZANIDINE 4 MG TABLET RX-14793 CDM 6370000100 HCPCS 250 RC 00904-6418-61 NDC outpatient 1 UN 6.15 6.15 CIGNA 62308 [3081051] CIGNA 62308 [308105105] 4.92 percent of total billed charges 3.81 5.84 Technical (Hospital) Services TIZANIDINE 4 MG TABLET RX-14793 CDM 6370000100 HCPCS 250 RC 00904-6418-61 NDC outpatient 1 UN 6.15 6.15 CIGNA 62308 [3081051] CIGNA STATE OF WYOMING [308105107] 4.92 percent of total billed charges 3.81 5.84 Technical (Hospital) Services TIZANIDINE 4 MG TABLET RX-14793 CDM 6370000100 HCPCS 250 RC 00904-6418-61 NDC outpatient 1 UN 6.15 6.15 UNITED HEALTHCARE (COMMERCIAL) [3081199] UNITED HEALTHCARE 87726 [308119901] 3.81 percent of total billed charges 3.81 5.84 Technical (Hospital) Services TIZANIDINE 4 MG TABLET RX-14793 CDM 6370000100 HCPCS 250 RC 00904-6418-61 NDC outpatient 1 UN 6.15 6.15 MULTIPLAN INC 34080 [3081285] MULTIPLAN INC [308128501] 5.84 percent of total billed charges 3.81 5.84 Technical (Hospital) Services TIZANIDINE 4 MG TABLET RX-14793 CDM 6370000100 HCPCS 250 RC 00904-6418-61 NDC outpatient 1 UN 6.15 6.15 HEALTHPARTNERS SX009 HEALTHPARTNERS 4.92 percent of total billed charges 3.81 5.84 Technical (Hospital) Services TIZANIDINE 4 MG TABLET RX-14793 CDM 6370000100 HCPCS 250 RC 00904-6418-61 NDC outpatient 1 UN 6.15 6.15 BLUE CROSS BLUE SHIELD WELLMARK SB889 [3081026] BCBS WYOMING [308102603] 5.84 percent of total billed charges 3.81 5.84 Technical (Hospital) Services TIZANIDINE 4 MG TABLET RX-14793 CDM 6370000100 HCPCS 250 RC 00904-6418-61 NDC outpatient 1 UN 6.15 6.15 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES EPO [308136803] 4.92 percent of total billed charges 3.81 5.84 Technical (Hospital) Services TIZANIDINE 4 MG TABLET RX-14793 CDM 6370000100 HCPCS 250 RC 00904-6418-61 NDC outpatient 1 UN 6.15 6.15 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES HDHP [308136802] 4.92 percent of total billed charges 3.81 5.84 Technical (Hospital) Services TIZANIDINE 4 MG TABLET RX-14793 CDM 6370000100 HCPCS 250 RC 00904-6418-61 NDC outpatient 1 UN 6.15 6.15 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES PPO [308136801] 4.92 percent of total billed charges 3.81 5.84 Technical (Hospital) Services LOSARTAN 25 MG TABLET RX-14823 CDM 6370000100 HCPCS 250 RC 65862-0201-90 NDC inpatient 1 UN 5.7 5.7 MEDICA (COMMERCIAL) 94265 [3081118] MEDICA CLAIMS [308111801] 5.13 percent of total billed charges 3.53 5.42 Technical (Hospital) Services LOSARTAN 25 MG TABLET RX-14823 CDM 6370000100 HCPCS 250 RC 65862-0201-90 NDC inpatient 1 UN 5.7 5.7 HEALTHPARTNERS SX009 HEALTHPARTNERS 4.51 percent of total billed charges 3.53 5.42 Technical (Hospital) Services LOSARTAN 25 MG TABLET RX-14823 CDM 6370000100 HCPCS 250 RC 65862-0201-90 NDC inpatient 1 UN 5.7 5.7 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES HDHP [308136802] 4.51 percent of total billed charges 3.53 5.42 Technical (Hospital) Services LOSARTAN 25 MG TABLET RX-14823 CDM 6370000100 HCPCS 250 RC 65862-0201-90 NDC inpatient 1 UN 5.7 5.7 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES EPO [308136803] 4.51 percent of total billed charges 3.53 5.42 Technical (Hospital) Services LOSARTAN 25 MG TABLET RX-14823 CDM 6370000100 HCPCS 250 RC 65862-0201-90 NDC inpatient 1 UN 5.7 5.7 CIGNA 62308 [3081051] CIGNA 62308 [308105105] 4.51 percent of total billed charges 3.53 5.42 Technical (Hospital) Services LOSARTAN 25 MG TABLET RX-14823 CDM 6370000100 HCPCS 250 RC 65862-0201-90 NDC inpatient 1 UN 5.7 5.7 CIGNA 62308 [3081051] CIGNA STATE OF WYOMING [308105107] 4.51 percent of total billed charges 3.53 5.42 Technical (Hospital) Services LOSARTAN 25 MG TABLET RX-14823 CDM 6370000100 HCPCS 250 RC 65862-0201-90 NDC inpatient 1 UN 5.7 5.7 BLUE CROSS BLUE SHIELD WELLMARK SB889 [3081026] BCBS WYOMING [308102603] 5.42 percent of total billed charges 3.53 5.42 Technical (Hospital) Services LOSARTAN 25 MG TABLET RX-14823 CDM 6370000100 HCPCS 250 RC 65862-0201-90 NDC inpatient 1 UN 5.7 5.7 UNITED HEALTHCARE (COMMERCIAL) [3081199] UNITED HEALTHCARE 87726 [308119901] 3.53 percent of total billed charges 3.53 5.42 Technical (Hospital) Services LOSARTAN 25 MG TABLET RX-14823 CDM 6370000100 HCPCS 250 RC 65862-0201-90 NDC inpatient 1 UN 5.7 5.7 MULTIPLAN INC 34080 [3081285] MULTIPLAN INC [308128501] 5.42 percent of total billed charges 3.53 5.42 Technical (Hospital) Services LOSARTAN 25 MG TABLET RX-14823 CDM 6370000100 HCPCS 250 RC 65862-0201-90 NDC inpatient 1 UN 5.7 5.7 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES PPO [308136801] 4.51 percent of total billed charges 3.53 5.42 Technical (Hospital) Services LOSARTAN 25 MG TABLET RX-14823 CDM 6370000100 HCPCS 250 RC 65862-0201-90 NDC outpatient 1 UN 5.7 5.7 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES EPO [308136803] 4.56 percent of total billed charges 3.53 5.42 Technical (Hospital) Services LOSARTAN 25 MG TABLET RX-14823 CDM 6370000100 HCPCS 250 RC 65862-0201-90 NDC outpatient 1 UN 5.7 5.7 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES HDHP [308136802] 4.56 percent of total billed charges 3.53 5.42 Technical (Hospital) Services LOSARTAN 25 MG TABLET RX-14823 CDM 6370000100 HCPCS 250 RC 65862-0201-90 NDC outpatient 1 UN 5.7 5.7 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES PPO [308136801] 4.56 percent of total billed charges 3.53 5.42 Technical (Hospital) Services LOSARTAN 25 MG TABLET RX-14823 CDM 6370000100 HCPCS 250 RC 65862-0201-90 NDC outpatient 1 UN 5.7 5.7 UNITED HEALTHCARE (COMMERCIAL) [3081199] UNITED HEALTHCARE 87726 [308119901] 3.53 percent of total billed charges 3.53 5.42 Technical (Hospital) Services LOSARTAN 25 MG TABLET RX-14823 CDM 6370000100 HCPCS 250 RC 65862-0201-90 NDC outpatient 1 UN 5.7 5.7 MULTIPLAN INC 34080 [3081285] MULTIPLAN INC [308128501] 5.42 percent of total billed charges 3.53 5.42 Technical (Hospital) Services LOSARTAN 25 MG TABLET RX-14823 CDM 6370000100 HCPCS 250 RC 65862-0201-90 NDC outpatient 1 UN 5.7 5.7 CIGNA 62308 [3081051] CIGNA 62308 [308105105] 4.56 percent of total billed charges 3.53 5.42 Technical (Hospital) Services LOSARTAN 25 MG TABLET RX-14823 CDM 6370000100 HCPCS 250 RC 65862-0201-90 NDC outpatient 1 UN 5.7 5.7 CIGNA 62308 [3081051] CIGNA STATE OF WYOMING [308105107] 4.56 percent of total billed charges 3.53 5.42 Technical (Hospital) Services LOSARTAN 25 MG TABLET RX-14823 CDM 6370000100 HCPCS 250 RC 65862-0201-90 NDC outpatient 1 UN 5.7 5.7 MEDICA (COMMERCIAL) 94265 [3081118] MEDICA CLAIMS [308111801] 5.13 percent of total billed charges 3.53 5.42 Technical (Hospital) Services LOSARTAN 25 MG TABLET RX-14823 CDM 6370000100 HCPCS 250 RC 65862-0201-90 NDC outpatient 1 UN 5.7 5.7 HEALTHPARTNERS SX009 HEALTHPARTNERS 4.56 percent of total billed charges 3.53 5.42 Technical (Hospital) Services LOSARTAN 25 MG TABLET RX-14823 CDM 6370000100 HCPCS 250 RC 65862-0201-90 NDC outpatient 1 UN 5.7 5.7 BLUE CROSS BLUE SHIELD WELLMARK SB889 [3081026] BCBS WYOMING [308102603] 5.42 percent of total billed charges 3.53 5.42 Technical (Hospital) Services LOSARTAN 50 MG TABLET RX-14824 CDM 6370000100 HCPCS 250 RC 65862-0202-90 NDC outpatient 1 UN 5.72 5.72 BLUE CROSS BLUE SHIELD WELLMARK SB889 [3081026] BCBS WYOMING [308102603] 5.43 percent of total billed charges 3.55 5.43 Technical (Hospital) Services LOSARTAN 50 MG TABLET RX-14824 CDM 6370000100 HCPCS 250 RC 65862-0202-90 NDC outpatient 1 UN 5.72 5.72 MULTIPLAN INC 34080 [3081285] MULTIPLAN INC [308128501] 5.43 percent of total billed charges 3.55 5.43 Technical (Hospital) Services LOSARTAN 50 MG TABLET RX-14824 CDM 6370000100 HCPCS 250 RC 65862-0202-90 NDC outpatient 1 UN 5.72 5.72 CIGNA 62308 [3081051] CIGNA 62308 [308105105] 4.58 percent of total billed charges 3.55 5.43 Technical (Hospital) Services LOSARTAN 50 MG TABLET RX-14824 CDM 6370000100 HCPCS 250 RC 65862-0202-90 NDC outpatient 1 UN 5.72 5.72 CIGNA 62308 [3081051] CIGNA STATE OF WYOMING [308105107] 4.58 percent of total billed charges 3.55 5.43 Technical (Hospital) Services LOSARTAN 50 MG TABLET RX-14824 CDM 6370000100 HCPCS 250 RC 65862-0202-90 NDC outpatient 1 UN 5.72 5.72 MEDICA (COMMERCIAL) 94265 [3081118] MEDICA CLAIMS [308111801] 5.15 percent of total billed charges 3.55 5.43 Technical (Hospital) Services LOSARTAN 50 MG TABLET RX-14824 CDM 6370000100 HCPCS 250 RC 65862-0202-90 NDC outpatient 1 UN 5.72 5.72 HEALTHPARTNERS SX009 HEALTHPARTNERS 4.58 percent of total billed charges 3.55 5.43 Technical (Hospital) Services LOSARTAN 50 MG TABLET RX-14824 CDM 6370000100 HCPCS 250 RC 65862-0202-90 NDC outpatient 1 UN 5.72 5.72 UNITED HEALTHCARE (COMMERCIAL) [3081199] UNITED HEALTHCARE 87726 [308119901] 3.55 percent of total billed charges 3.55 5.43 Technical (Hospital) Services LOSARTAN 50 MG TABLET RX-14824 CDM 6370000100 HCPCS 250 RC 65862-0202-90 NDC outpatient 1 UN 5.72 5.72 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES HDHP [308136802] 4.58 percent of total billed charges 3.55 5.43 Technical (Hospital) Services LOSARTAN 50 MG TABLET RX-14824 CDM 6370000100 HCPCS 250 RC 65862-0202-90 NDC outpatient 1 UN 5.72 5.72 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES PPO [308136801] 4.58 percent of total billed charges 3.55 5.43 Technical (Hospital) Services LOSARTAN 50 MG TABLET RX-14824 CDM 6370000100 HCPCS 250 RC 65862-0202-90 NDC outpatient 1 UN 5.72 5.72 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES EPO [308136803] 4.58 percent of total billed charges 3.55 5.43 Technical (Hospital) Services LOSARTAN 50 MG TABLET RX-14824 CDM 6370000100 HCPCS 250 RC 65862-0202-90 NDC inpatient 1 UN 5.72 5.72 MULTIPLAN INC 34080 [3081285] MULTIPLAN INC [308128501] 5.43 percent of total billed charges 3.55 5.43 Technical (Hospital) Services LOSARTAN 50 MG TABLET RX-14824 CDM 6370000100 HCPCS 250 RC 65862-0202-90 NDC inpatient 1 UN 5.72 5.72 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES PPO [308136801] 4.53 percent of total billed charges 3.55 5.43 Technical (Hospital) Services LOSARTAN 50 MG TABLET RX-14824 CDM 6370000100 HCPCS 250 RC 65862-0202-90 NDC inpatient 1 UN 5.72 5.72 HEALTHPARTNERS SX009 HEALTHPARTNERS 4.53 percent of total billed charges 3.55 5.43 Technical (Hospital) Services LOSARTAN 50 MG TABLET RX-14824 CDM 6370000100 HCPCS 250 RC 65862-0202-90 NDC inpatient 1 UN 5.72 5.72 MEDICA (COMMERCIAL) 94265 [3081118] MEDICA CLAIMS [308111801] 5.15 percent of total billed charges 3.55 5.43 Technical (Hospital) Services LOSARTAN 50 MG TABLET RX-14824 CDM 6370000100 HCPCS 250 RC 65862-0202-90 NDC inpatient 1 UN 5.72 5.72 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES EPO [308136803] 4.53 percent of total billed charges 3.55 5.43 Technical (Hospital) Services LOSARTAN 50 MG TABLET RX-14824 CDM 6370000100 HCPCS 250 RC 65862-0202-90 NDC inpatient 1 UN 5.72 5.72 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES HDHP [308136802] 4.53 percent of total billed charges 3.55 5.43 Technical (Hospital) Services LOSARTAN 50 MG TABLET RX-14824 CDM 6370000100 HCPCS 250 RC 65862-0202-90 NDC inpatient 1 UN 5.72 5.72 CIGNA 62308 [3081051] CIGNA 62308 [308105105] 4.53 percent of total billed charges 3.55 5.43 Technical (Hospital) Services LOSARTAN 50 MG TABLET RX-14824 CDM 6370000100 HCPCS 250 RC 65862-0202-90 NDC inpatient 1 UN 5.72 5.72 CIGNA 62308 [3081051] CIGNA STATE OF WYOMING [308105107] 4.53 percent of total billed charges 3.55 5.43 Technical (Hospital) Services LOSARTAN 50 MG TABLET RX-14824 CDM 6370000100 HCPCS 250 RC 65862-0202-90 NDC inpatient 1 UN 5.72 5.72 BLUE CROSS BLUE SHIELD WELLMARK SB889 [3081026] BCBS WYOMING [308102603] 5.43 percent of total billed charges 3.55 5.43 Technical (Hospital) Services LOSARTAN 50 MG TABLET RX-14824 CDM 6370000100 HCPCS 250 RC 65862-0202-90 NDC inpatient 1 UN 5.72 5.72 UNITED HEALTHCARE (COMMERCIAL) [3081199] UNITED HEALTHCARE 87726 [308119901] 3.55 percent of total billed charges 3.55 5.43 Technical (Hospital) Services ATOVAQUONE 750 MG/5 ML ORAL SUSPENSION RX-14953 CDM 6370000100 HCPCS 250 RC 00904-7459-41 NDC outpatient 5 ML 112.64 112.64 BLUE CROSS BLUE SHIELD WELLMARK SB889 [3081026] BCBS WYOMING [308102603] 107.01 percent of total billed charges 69.84 107.01 Technical (Hospital) Services ATOVAQUONE 750 MG/5 ML ORAL SUSPENSION RX-14953 CDM 6370000100 HCPCS 250 RC 00904-7459-41 NDC outpatient 5 ML 112.64 112.64 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES HDHP [308136802] 90.11 percent of total billed charges 69.84 107.01 Technical (Hospital) Services ATOVAQUONE 750 MG/5 ML ORAL SUSPENSION RX-14953 CDM 6370000100 HCPCS 250 RC 00904-7459-41 NDC outpatient 5 ML 112.64 112.64 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES PPO [308136801] 90.11 percent of total billed charges 69.84 107.01 Technical (Hospital) Services ATOVAQUONE 750 MG/5 ML ORAL SUSPENSION RX-14953 CDM 6370000100 HCPCS 250 RC 00904-7459-41 NDC outpatient 5 ML 112.64 112.64 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES EPO [308136803] 90.11 percent of total billed charges 69.84 107.01 Technical (Hospital) Services ATOVAQUONE 750 MG/5 ML ORAL SUSPENSION RX-14953 CDM 6370000100 HCPCS 250 RC 00904-7459-41 NDC outpatient 5 ML 112.64 112.64 CIGNA 62308 [3081051] CIGNA 62308 [308105105] 90.11 percent of total billed charges 69.84 107.01 Technical (Hospital) Services ATOVAQUONE 750 MG/5 ML ORAL SUSPENSION RX-14953 CDM 6370000100 HCPCS 250 RC 00904-7459-41 NDC outpatient 5 ML 112.64 112.64 CIGNA 62308 [3081051] CIGNA STATE OF WYOMING [308105107] 90.11 percent of total billed charges 69.84 107.01 Technical (Hospital) Services ATOVAQUONE 750 MG/5 ML ORAL SUSPENSION RX-14953 CDM 6370000100 HCPCS 250 RC 00904-7459-41 NDC outpatient 5 ML 112.64 112.64 HEALTHPARTNERS SX009 HEALTHPARTNERS 90.11 percent of total billed charges 69.84 107.01 Technical (Hospital) Services ATOVAQUONE 750 MG/5 ML ORAL SUSPENSION RX-14953 CDM 6370000100 HCPCS 250 RC 00904-7459-41 NDC outpatient 5 ML 112.64 112.64 UNITED HEALTHCARE (COMMERCIAL) [3081199] UNITED HEALTHCARE 87726 [308119901] 69.84 percent of total billed charges 69.84 107.01 Technical (Hospital) Services ATOVAQUONE 750 MG/5 ML ORAL SUSPENSION RX-14953 CDM 6370000100 HCPCS 250 RC 00904-7459-41 NDC outpatient 5 ML 112.64 112.64 MULTIPLAN INC 34080 [3081285] MULTIPLAN INC [308128501] 107.01 percent of total billed charges 69.84 107.01 Technical (Hospital) Services ATOVAQUONE 750 MG/5 ML ORAL SUSPENSION RX-14953 CDM 6370000100 HCPCS 250 RC 00904-7459-41 NDC outpatient 5 ML 112.64 112.64 MEDICA (COMMERCIAL) 94265 [3081118] MEDICA CLAIMS [308111801] 101.38 percent of total billed charges 69.84 107.01 Technical (Hospital) Services ATOVAQUONE 750 MG/5 ML ORAL SUSPENSION RX-14953 CDM 6370000100 HCPCS 250 RC 00904-7459-41 NDC inpatient 5 ML 112.64 112.64 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES HDHP [308136802] 89.19 percent of total billed charges 69.84 107.01 Technical (Hospital) Services ATOVAQUONE 750 MG/5 ML ORAL SUSPENSION RX-14953 CDM 6370000100 HCPCS 250 RC 00904-7459-41 NDC inpatient 5 ML 112.64 112.64 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES EPO [308136803] 89.19 percent of total billed charges 69.84 107.01 Technical (Hospital) Services ATOVAQUONE 750 MG/5 ML ORAL SUSPENSION RX-14953 CDM 6370000100 HCPCS 250 RC 00904-7459-41 NDC inpatient 5 ML 112.64 112.64 HEALTHPARTNERS SX009 HEALTHPARTNERS 89.19 percent of total billed charges 69.84 107.01 Technical (Hospital) Services ATOVAQUONE 750 MG/5 ML ORAL SUSPENSION RX-14953 CDM 6370000100 HCPCS 250 RC 00904-7459-41 NDC inpatient 5 ML 112.64 112.64 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES PPO [308136801] 89.19 percent of total billed charges 69.84 107.01 Technical (Hospital) Services ATOVAQUONE 750 MG/5 ML ORAL SUSPENSION RX-14953 CDM 6370000100 HCPCS 250 RC 00904-7459-41 NDC inpatient 5 ML 112.64 112.64 MULTIPLAN INC 34080 [3081285] MULTIPLAN INC [308128501] 107.01 percent of total billed charges 69.84 107.01 Technical (Hospital) Services ATOVAQUONE 750 MG/5 ML ORAL SUSPENSION RX-14953 CDM 6370000100 HCPCS 250 RC 00904-7459-41 NDC inpatient 5 ML 112.64 112.64 MEDICA (COMMERCIAL) 94265 [3081118] MEDICA CLAIMS [308111801] 101.38 percent of total billed charges 69.84 107.01 Technical (Hospital) Services ATOVAQUONE 750 MG/5 ML ORAL SUSPENSION RX-14953 CDM 6370000100 HCPCS 250 RC 00904-7459-41 NDC inpatient 5 ML 112.64 112.64 UNITED HEALTHCARE (COMMERCIAL) [3081199] UNITED HEALTHCARE 87726 [308119901] 69.84 percent of total billed charges 69.84 107.01 Technical (Hospital) Services ATOVAQUONE 750 MG/5 ML ORAL SUSPENSION RX-14953 CDM 6370000100 HCPCS 250 RC 00904-7459-41 NDC inpatient 5 ML 112.64 112.64 BLUE CROSS BLUE SHIELD WELLMARK SB889 [3081026] BCBS WYOMING [308102603] 107.01 percent of total billed charges 69.84 107.01 Technical (Hospital) Services ATOVAQUONE 750 MG/5 ML ORAL SUSPENSION RX-14953 CDM 6370000100 HCPCS 250 RC 00904-7459-41 NDC inpatient 5 ML 112.64 112.64 CIGNA 62308 [3081051] CIGNA 62308 [308105105] 89.19 percent of total billed charges 69.84 107.01 Technical (Hospital) Services ATOVAQUONE 750 MG/5 ML ORAL SUSPENSION RX-14953 CDM 6370000100 HCPCS 250 RC 00904-7459-41 NDC inpatient 5 ML 112.64 112.64 CIGNA 62308 [3081051] CIGNA STATE OF WYOMING [308105107] 89.19 percent of total billed charges 69.84 107.01 Technical (Hospital) Services SUMATRIPTAN 50 MG TABLET RX-15328 CDM 6370000100 HCPCS 250 RC 55111-0292-36 NDC inpatient 1 UN 7.39 7.39 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES PPO [308136801] 5.85 percent of total billed charges 4.58 7.02 Technical (Hospital) Services SUMATRIPTAN 50 MG TABLET RX-15328 CDM 6370000100 HCPCS 250 RC 55111-0292-36 NDC inpatient 1 UN 7.39 7.39 HEALTHPARTNERS SX009 HEALTHPARTNERS 5.85 percent of total billed charges 4.58 7.02 Technical (Hospital) Services SUMATRIPTAN 50 MG TABLET RX-15328 CDM 6370000100 HCPCS 250 RC 55111-0292-36 NDC inpatient 1 UN 7.39 7.39 MEDICA (COMMERCIAL) 94265 [3081118] MEDICA CLAIMS [308111801] 6.65 percent of total billed charges 4.58 7.02 Technical (Hospital) Services SUMATRIPTAN 50 MG TABLET RX-15328 CDM 6370000100 HCPCS 250 RC 55111-0292-36 NDC inpatient 1 UN 7.39 7.39 MULTIPLAN INC 34080 [3081285] MULTIPLAN INC [308128501] 7.02 percent of total billed charges 4.58 7.02 Technical (Hospital) Services SUMATRIPTAN 50 MG TABLET RX-15328 CDM 6370000100 HCPCS 250 RC 55111-0292-36 NDC inpatient 1 UN 7.39 7.39 BLUE CROSS BLUE SHIELD WELLMARK SB889 [3081026] BCBS WYOMING [308102603] 7.02 percent of total billed charges 4.58 7.02 Technical (Hospital) Services SUMATRIPTAN 50 MG TABLET RX-15328 CDM 6370000100 HCPCS 250 RC 55111-0292-36 NDC inpatient 1 UN 7.39 7.39 UNITED HEALTHCARE (COMMERCIAL) [3081199] UNITED HEALTHCARE 87726 [308119901] 4.58 percent of total billed charges 4.58 7.02 Technical (Hospital) Services SUMATRIPTAN 50 MG TABLET RX-15328 CDM 6370000100 HCPCS 250 RC 55111-0292-36 NDC inpatient 1 UN 7.39 7.39 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES HDHP [308136802] 5.85 percent of total billed charges 4.58 7.02 Technical (Hospital) Services SUMATRIPTAN 50 MG TABLET RX-15328 CDM 6370000100 HCPCS 250 RC 55111-0292-36 NDC inpatient 1 UN 7.39 7.39 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES EPO [308136803] 5.85 percent of total billed charges 4.58 7.02 Technical (Hospital) Services SUMATRIPTAN 50 MG TABLET RX-15328 CDM 6370000100 HCPCS 250 RC 55111-0292-36 NDC inpatient 1 UN 7.39 7.39 CIGNA 62308 [3081051] CIGNA 62308 [308105105] 5.85 percent of total billed charges 4.58 7.02 Technical (Hospital) Services SUMATRIPTAN 50 MG TABLET RX-15328 CDM 6370000100 HCPCS 250 RC 55111-0292-36 NDC inpatient 1 UN 7.39 7.39 CIGNA 62308 [3081051] CIGNA STATE OF WYOMING [308105107] 5.85 percent of total billed charges 4.58 7.02 Technical (Hospital) Services SUMATRIPTAN 50 MG TABLET RX-15328 CDM 6370000100 HCPCS 250 RC 55111-0292-36 NDC outpatient 1 UN 7.39 7.39 CIGNA 62308 [3081051] CIGNA 62308 [308105105] 5.91 percent of total billed charges 4.58 7.02 Technical (Hospital) Services SUMATRIPTAN 50 MG TABLET RX-15328 CDM 6370000100 HCPCS 250 RC 55111-0292-36 NDC outpatient 1 UN 7.39 7.39 CIGNA 62308 [3081051] CIGNA STATE OF WYOMING [308105107] 5.91 percent of total billed charges 4.58 7.02 Technical (Hospital) Services SUMATRIPTAN 50 MG TABLET RX-15328 CDM 6370000100 HCPCS 250 RC 55111-0292-36 NDC outpatient 1 UN 7.39 7.39 MULTIPLAN INC 34080 [3081285] MULTIPLAN INC [308128501] 7.02 percent of total billed charges 4.58 7.02 Technical (Hospital) Services SUMATRIPTAN 50 MG TABLET RX-15328 CDM 6370000100 HCPCS 250 RC 55111-0292-36 NDC outpatient 1 UN 7.39 7.39 MEDICA (COMMERCIAL) 94265 [3081118] MEDICA CLAIMS [308111801] 6.65 percent of total billed charges 4.58 7.02 Technical (Hospital) Services SUMATRIPTAN 50 MG TABLET RX-15328 CDM 6370000100 HCPCS 250 RC 55111-0292-36 NDC outpatient 1 UN 7.39 7.39 UNITED HEALTHCARE (COMMERCIAL) [3081199] UNITED HEALTHCARE 87726 [308119901] 4.58 percent of total billed charges 4.58 7.02 Technical (Hospital) Services SUMATRIPTAN 50 MG TABLET RX-15328 CDM 6370000100 HCPCS 250 RC 55111-0292-36 NDC outpatient 1 UN 7.39 7.39 HEALTHPARTNERS SX009 HEALTHPARTNERS 5.91 percent of total billed charges 4.58 7.02 Technical (Hospital) Services SUMATRIPTAN 50 MG TABLET RX-15328 CDM 6370000100 HCPCS 250 RC 55111-0292-36 NDC outpatient 1 UN 7.39 7.39 BLUE CROSS BLUE SHIELD WELLMARK SB889 [3081026] BCBS WYOMING [308102603] 7.02 percent of total billed charges 4.58 7.02 Technical (Hospital) Services SUMATRIPTAN 50 MG TABLET RX-15328 CDM 6370000100 HCPCS 250 RC 55111-0292-36 NDC outpatient 1 UN 7.39 7.39 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES EPO [308136803] 5.91 percent of total billed charges 4.58 7.02 Technical (Hospital) Services SUMATRIPTAN 50 MG TABLET RX-15328 CDM 6370000100 HCPCS 250 RC 55111-0292-36 NDC outpatient 1 UN 7.39 7.39 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES PPO [308136801] 5.91 percent of total billed charges 4.58 7.02 Technical (Hospital) Services SUMATRIPTAN 50 MG TABLET RX-15328 CDM 6370000100 HCPCS 250 RC 55111-0292-36 NDC outpatient 1 UN 7.39 7.39 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES HDHP [308136802] 5.91 percent of total billed charges 4.58 7.02 Technical (Hospital) Services "DICLOFENAC SODIUM 75 MG TABLET,DELAYED RELEASE" RX-15341 CDM 6370000100 HCPCS 250 RC 61442-0103-01 NDC outpatient 1 UN 5.89 5.89 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES EPO [308136803] 4.71 percent of total billed charges 3.65 5.6 Technical (Hospital) Services "DICLOFENAC SODIUM 75 MG TABLET,DELAYED RELEASE" RX-15341 CDM 6370000100 HCPCS 250 RC 61442-0103-01 NDC outpatient 1 UN 5.89 5.89 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES PPO [308136801] 4.71 percent of total billed charges 3.65 5.6 Technical (Hospital) Services "DICLOFENAC SODIUM 75 MG TABLET,DELAYED RELEASE" RX-15341 CDM 6370000100 HCPCS 250 RC 61442-0103-01 NDC outpatient 1 UN 5.89 5.89 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES HDHP [308136802] 4.71 percent of total billed charges 3.65 5.6 Technical (Hospital) Services "DICLOFENAC SODIUM 75 MG TABLET,DELAYED RELEASE" RX-15341 CDM 6370000100 HCPCS 250 RC 61442-0103-01 NDC outpatient 1 UN 5.89 5.89 BLUE CROSS BLUE SHIELD WELLMARK SB889 [3081026] BCBS WYOMING [308102603] 5.6 percent of total billed charges 3.65 5.6 Technical (Hospital) Services "DICLOFENAC SODIUM 75 MG TABLET,DELAYED RELEASE" RX-15341 CDM 6370000100 HCPCS 250 RC 61442-0103-01 NDC outpatient 1 UN 5.89 5.89 HEALTHPARTNERS SX009 HEALTHPARTNERS 4.71 percent of total billed charges 3.65 5.6 Technical (Hospital) Services "DICLOFENAC SODIUM 75 MG TABLET,DELAYED RELEASE" RX-15341 CDM 6370000100 HCPCS 250 RC 61442-0103-01 NDC outpatient 1 UN 5.89 5.89 UNITED HEALTHCARE (COMMERCIAL) [3081199] UNITED HEALTHCARE 87726 [308119901] 3.65 percent of total billed charges 3.65 5.6 Technical (Hospital) Services "DICLOFENAC SODIUM 75 MG TABLET,DELAYED RELEASE" RX-15341 CDM 6370000100 HCPCS 250 RC 61442-0103-01 NDC outpatient 1 UN 5.89 5.89 MULTIPLAN INC 34080 [3081285] MULTIPLAN INC [308128501] 5.6 percent of total billed charges 3.65 5.6 Technical (Hospital) Services "DICLOFENAC SODIUM 75 MG TABLET,DELAYED RELEASE" RX-15341 CDM 6370000100 HCPCS 250 RC 61442-0103-01 NDC outpatient 1 UN 5.89 5.89 CIGNA 62308 [3081051] CIGNA 62308 [308105105] 4.71 percent of total billed charges 3.65 5.6 Technical (Hospital) Services "DICLOFENAC SODIUM 75 MG TABLET,DELAYED RELEASE" RX-15341 CDM 6370000100 HCPCS 250 RC 61442-0103-01 NDC outpatient 1 UN 5.89 5.89 CIGNA 62308 [3081051] CIGNA STATE OF WYOMING [308105107] 4.71 percent of total billed charges 3.65 5.6 Technical (Hospital) Services "DICLOFENAC SODIUM 75 MG TABLET,DELAYED RELEASE" RX-15341 CDM 6370000100 HCPCS 250 RC 61442-0103-01 NDC outpatient 1 UN 5.89 5.89 MEDICA (COMMERCIAL) 94265 [3081118] MEDICA CLAIMS [308111801] 5.3 percent of total billed charges 3.65 5.6 Technical (Hospital) Services "DICLOFENAC SODIUM 75 MG TABLET,DELAYED RELEASE" RX-15341 CDM 6370000100 HCPCS 250 RC 61442-0103-01 NDC inpatient 1 UN 5.89 5.89 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES PPO [308136801] 4.66 percent of total billed charges 3.65 5.6 Technical (Hospital) Services "DICLOFENAC SODIUM 75 MG TABLET,DELAYED RELEASE" RX-15341 CDM 6370000100 HCPCS 250 RC 61442-0103-01 NDC inpatient 1 UN 5.89 5.89 HEALTHPARTNERS SX009 HEALTHPARTNERS 4.66 percent of total billed charges 3.65 5.6 Technical (Hospital) Services "DICLOFENAC SODIUM 75 MG TABLET,DELAYED RELEASE" RX-15341 CDM 6370000100 HCPCS 250 RC 61442-0103-01 NDC inpatient 1 UN 5.89 5.89 MEDICA (COMMERCIAL) 94265 [3081118] MEDICA CLAIMS [308111801] 5.3 percent of total billed charges 3.65 5.6 Technical (Hospital) Services "DICLOFENAC SODIUM 75 MG TABLET,DELAYED RELEASE" RX-15341 CDM 6370000100 HCPCS 250 RC 61442-0103-01 NDC inpatient 1 UN 5.89 5.89 MULTIPLAN INC 34080 [3081285] MULTIPLAN INC [308128501] 5.6 percent of total billed charges 3.65 5.6 Technical (Hospital) Services "DICLOFENAC SODIUM 75 MG TABLET,DELAYED RELEASE" RX-15341 CDM 6370000100 HCPCS 250 RC 61442-0103-01 NDC inpatient 1 UN 5.89 5.89 BLUE CROSS BLUE SHIELD WELLMARK SB889 [3081026] BCBS WYOMING [308102603] 5.6 percent of total billed charges 3.65 5.6 Technical (Hospital) Services "DICLOFENAC SODIUM 75 MG TABLET,DELAYED RELEASE" RX-15341 CDM 6370000100 HCPCS 250 RC 61442-0103-01 NDC inpatient 1 UN 5.89 5.89 UNITED HEALTHCARE (COMMERCIAL) [3081199] UNITED HEALTHCARE 87726 [308119901] 3.65 percent of total billed charges 3.65 5.6 Technical (Hospital) Services "DICLOFENAC SODIUM 75 MG TABLET,DELAYED RELEASE" RX-15341 CDM 6370000100 HCPCS 250 RC 61442-0103-01 NDC inpatient 1 UN 5.89 5.89 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES HDHP [308136802] 4.66 percent of total billed charges 3.65 5.6 Technical (Hospital) Services "DICLOFENAC SODIUM 75 MG TABLET,DELAYED RELEASE" RX-15341 CDM 6370000100 HCPCS 250 RC 61442-0103-01 NDC inpatient 1 UN 5.89 5.89 CIGNA 62308 [3081051] CIGNA 62308 [308105105] 4.66 percent of total billed charges 3.65 5.6 Technical (Hospital) Services "DICLOFENAC SODIUM 75 MG TABLET,DELAYED RELEASE" RX-15341 CDM 6370000100 HCPCS 250 RC 61442-0103-01 NDC inpatient 1 UN 5.89 5.89 CIGNA 62308 [3081051] CIGNA STATE OF WYOMING [308105107] 4.66 percent of total billed charges 3.65 5.6 Technical (Hospital) Services "DICLOFENAC SODIUM 75 MG TABLET,DELAYED RELEASE" RX-15341 CDM 6370000100 HCPCS 250 RC 61442-0103-01 NDC inpatient 1 UN 5.89 5.89 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES EPO [308136803] 4.66 percent of total billed charges 3.65 5.6 Technical (Hospital) Services CALCITONIN (SALMON) 200 UNIT/ACTUATION NASAL SPRAY RX-15738 CDM 6370000100 HCPCS 250 RC 49884-0161-11 NDC outpatient 0.09 ML 14.89 14.89 HEALTHPARTNERS SX009 HEALTHPARTNERS 11.91 percent of total billed charges 9.23 14.15 Technical (Hospital) Services CALCITONIN (SALMON) 200 UNIT/ACTUATION NASAL SPRAY RX-15738 CDM 6370000100 HCPCS 250 RC 49884-0161-11 NDC outpatient 0.09 ML 14.89 14.89 BLUE CROSS BLUE SHIELD WELLMARK SB889 [3081026] BCBS WYOMING [308102603] 14.15 percent of total billed charges 9.23 14.15 Technical (Hospital) Services CALCITONIN (SALMON) 200 UNIT/ACTUATION NASAL SPRAY RX-15738 CDM 6370000100 HCPCS 250 RC 49884-0161-11 NDC outpatient 0.09 ML 14.89 14.89 CIGNA 62308 [3081051] CIGNA 62308 [308105105] 11.91 percent of total billed charges 9.23 14.15 Technical (Hospital) Services CALCITONIN (SALMON) 200 UNIT/ACTUATION NASAL SPRAY RX-15738 CDM 6370000100 HCPCS 250 RC 49884-0161-11 NDC outpatient 0.09 ML 14.89 14.89 CIGNA 62308 [3081051] CIGNA STATE OF WYOMING [308105107] 11.91 percent of total billed charges 9.23 14.15 Technical (Hospital) Services CALCITONIN (SALMON) 200 UNIT/ACTUATION NASAL SPRAY RX-15738 CDM 6370000100 HCPCS 250 RC 49884-0161-11 NDC outpatient 0.09 ML 14.89 14.89 MULTIPLAN INC 34080 [3081285] MULTIPLAN INC [308128501] 14.15 percent of total billed charges 9.23 14.15 Technical (Hospital) Services CALCITONIN (SALMON) 200 UNIT/ACTUATION NASAL SPRAY RX-15738 CDM 6370000100 HCPCS 250 RC 49884-0161-11 NDC outpatient 0.09 ML 14.89 14.89 UNITED HEALTHCARE (COMMERCIAL) [3081199] UNITED HEALTHCARE 87726 [308119901] 9.23 percent of total billed charges 9.23 14.15 Technical (Hospital) Services CALCITONIN (SALMON) 200 UNIT/ACTUATION NASAL SPRAY RX-15738 CDM 6370000100 HCPCS 250 RC 49884-0161-11 NDC outpatient 0.09 ML 14.89 14.89 MEDICA (COMMERCIAL) 94265 [3081118] MEDICA CLAIMS [308111801] 13.4 percent of total billed charges 9.23 14.15 Technical (Hospital) Services CALCITONIN (SALMON) 200 UNIT/ACTUATION NASAL SPRAY RX-15738 CDM 6370000100 HCPCS 250 RC 49884-0161-11 NDC outpatient 0.09 ML 14.89 14.89 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES EPO [308136803] 11.91 percent of total billed charges 9.23 14.15 Technical (Hospital) Services CALCITONIN (SALMON) 200 UNIT/ACTUATION NASAL SPRAY RX-15738 CDM 6370000100 HCPCS 250 RC 49884-0161-11 NDC outpatient 0.09 ML 14.89 14.89 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES HDHP [308136802] 11.91 percent of total billed charges 9.23 14.15 Technical (Hospital) Services CALCITONIN (SALMON) 200 UNIT/ACTUATION NASAL SPRAY RX-15738 CDM 6370000100 HCPCS 250 RC 49884-0161-11 NDC outpatient 0.09 ML 14.89 14.89 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES PPO [308136801] 11.91 percent of total billed charges 9.23 14.15 Technical (Hospital) Services CALCITONIN (SALMON) 200 UNIT/ACTUATION NASAL SPRAY RX-15738 CDM 6370000100 HCPCS 250 RC 49884-0161-11 NDC inpatient 0.09 ML 14.89 14.89 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES EPO [308136803] 11.79 percent of total billed charges 9.23 14.15 Technical (Hospital) Services CALCITONIN (SALMON) 200 UNIT/ACTUATION NASAL SPRAY RX-15738 CDM 6370000100 HCPCS 250 RC 49884-0161-11 NDC inpatient 0.09 ML 14.89 14.89 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES HDHP [308136802] 11.79 percent of total billed charges 9.23 14.15 Technical (Hospital) Services CALCITONIN (SALMON) 200 UNIT/ACTUATION NASAL SPRAY RX-15738 CDM 6370000100 HCPCS 250 RC 49884-0161-11 NDC inpatient 0.09 ML 14.89 14.89 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES PPO [308136801] 11.79 percent of total billed charges 9.23 14.15 Technical (Hospital) Services CALCITONIN (SALMON) 200 UNIT/ACTUATION NASAL SPRAY RX-15738 CDM 6370000100 HCPCS 250 RC 49884-0161-11 NDC inpatient 0.09 ML 14.89 14.89 MEDICA (COMMERCIAL) 94265 [3081118] MEDICA CLAIMS [308111801] 13.4 percent of total billed charges 9.23 14.15 Technical (Hospital) Services CALCITONIN (SALMON) 200 UNIT/ACTUATION NASAL SPRAY RX-15738 CDM 6370000100 HCPCS 250 RC 49884-0161-11 NDC inpatient 0.09 ML 14.89 14.89 HEALTHPARTNERS SX009 HEALTHPARTNERS 11.79 percent of total billed charges 9.23 14.15 Technical (Hospital) Services CALCITONIN (SALMON) 200 UNIT/ACTUATION NASAL SPRAY RX-15738 CDM 6370000100 HCPCS 250 RC 49884-0161-11 NDC inpatient 0.09 ML 14.89 14.89 UNITED HEALTHCARE (COMMERCIAL) [3081199] UNITED HEALTHCARE 87726 [308119901] 9.23 percent of total billed charges 9.23 14.15 Technical (Hospital) Services CALCITONIN (SALMON) 200 UNIT/ACTUATION NASAL SPRAY RX-15738 CDM 6370000100 HCPCS 250 RC 49884-0161-11 NDC inpatient 0.09 ML 14.89 14.89 BLUE CROSS BLUE SHIELD WELLMARK SB889 [3081026] BCBS WYOMING [308102603] 14.15 percent of total billed charges 9.23 14.15 Technical (Hospital) Services CALCITONIN (SALMON) 200 UNIT/ACTUATION NASAL SPRAY RX-15738 CDM 6370000100 HCPCS 250 RC 49884-0161-11 NDC inpatient 0.09 ML 14.89 14.89 CIGNA 62308 [3081051] CIGNA 62308 [308105105] 11.79 percent of total billed charges 9.23 14.15 Technical (Hospital) Services CALCITONIN (SALMON) 200 UNIT/ACTUATION NASAL SPRAY RX-15738 CDM 6370000100 HCPCS 250 RC 49884-0161-11 NDC inpatient 0.09 ML 14.89 14.89 CIGNA 62308 [3081051] CIGNA STATE OF WYOMING [308105107] 11.79 percent of total billed charges 9.23 14.15 Technical (Hospital) Services CALCITONIN (SALMON) 200 UNIT/ACTUATION NASAL SPRAY RX-15738 CDM 6370000100 HCPCS 250 RC 49884-0161-11 NDC inpatient 0.09 ML 14.89 14.89 MULTIPLAN INC 34080 [3081285] MULTIPLAN INC [308128501] 14.15 percent of total billed charges 9.23 14.15 Technical (Hospital) Services CARVEDILOL 6.25 MG TABLET RX-15747 CDM 6370000100 HCPCS 250 RC 68382-0093-01 NDC outpatient 1 UN 5.67 5.67 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES EPO [308136803] 4.54 percent of total billed charges 3.52 5.39 Technical (Hospital) Services CARVEDILOL 6.25 MG TABLET RX-15747 CDM 6370000100 HCPCS 250 RC 68382-0093-01 NDC outpatient 1 UN 5.67 5.67 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES PPO [308136801] 4.54 percent of total billed charges 3.52 5.39 Technical (Hospital) Services CARVEDILOL 6.25 MG TABLET RX-15747 CDM 6370000100 HCPCS 250 RC 68382-0093-01 NDC outpatient 1 UN 5.67 5.67 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES HDHP [308136802] 4.54 percent of total billed charges 3.52 5.39 Technical (Hospital) Services CARVEDILOL 6.25 MG TABLET RX-15747 CDM 6370000100 HCPCS 250 RC 68382-0093-01 NDC outpatient 1 UN 5.67 5.67 HEALTHPARTNERS SX009 HEALTHPARTNERS 4.54 percent of total billed charges 3.52 5.39 Technical (Hospital) Services CARVEDILOL 6.25 MG TABLET RX-15747 CDM 6370000100 HCPCS 250 RC 68382-0093-01 NDC outpatient 1 UN 5.67 5.67 BLUE CROSS BLUE SHIELD WELLMARK SB889 [3081026] BCBS WYOMING [308102603] 5.39 percent of total billed charges 3.52 5.39 Technical (Hospital) Services CARVEDILOL 6.25 MG TABLET RX-15747 CDM 6370000100 HCPCS 250 RC 68382-0093-01 NDC outpatient 1 UN 5.67 5.67 CIGNA 62308 [3081051] CIGNA 62308 [308105105] 4.54 percent of total billed charges 3.52 5.39 Technical (Hospital) Services CARVEDILOL 6.25 MG TABLET RX-15747 CDM 6370000100 HCPCS 250 RC 68382-0093-01 NDC outpatient 1 UN 5.67 5.67 CIGNA 62308 [3081051] CIGNA STATE OF WYOMING [308105107] 4.54 percent of total billed charges 3.52 5.39 Technical (Hospital) Services CARVEDILOL 6.25 MG TABLET RX-15747 CDM 6370000100 HCPCS 250 RC 68382-0093-01 NDC outpatient 1 UN 5.67 5.67 MULTIPLAN INC 34080 [3081285] MULTIPLAN INC [308128501] 5.39 percent of total billed charges 3.52 5.39 Technical (Hospital) Services CARVEDILOL 6.25 MG TABLET RX-15747 CDM 6370000100 HCPCS 250 RC 68382-0093-01 NDC outpatient 1 UN 5.67 5.67 MEDICA (COMMERCIAL) 94265 [3081118] MEDICA CLAIMS [308111801] 5.1 percent of total billed charges 3.52 5.39 Technical (Hospital) Services CARVEDILOL 6.25 MG TABLET RX-15747 CDM 6370000100 HCPCS 250 RC 68382-0093-01 NDC outpatient 1 UN 5.67 5.67 UNITED HEALTHCARE (COMMERCIAL) [3081199] UNITED HEALTHCARE 87726 [308119901] 3.52 percent of total billed charges 3.52 5.39 Technical (Hospital) Services CARVEDILOL 6.25 MG TABLET RX-15747 CDM 6370000100 HCPCS 250 RC 68382-0093-01 NDC inpatient 1 UN 5.67 5.67 MULTIPLAN INC 34080 [3081285] MULTIPLAN INC [308128501] 5.39 percent of total billed charges 3.52 5.39 Technical (Hospital) Services CARVEDILOL 6.25 MG TABLET RX-15747 CDM 6370000100 HCPCS 250 RC 68382-0093-01 NDC inpatient 1 UN 5.67 5.67 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES PPO [308136801] 4.49 percent of total billed charges 3.52 5.39 Technical (Hospital) Services CARVEDILOL 6.25 MG TABLET RX-15747 CDM 6370000100 HCPCS 250 RC 68382-0093-01 NDC inpatient 1 UN 5.67 5.67 BLUE CROSS BLUE SHIELD WELLMARK SB889 [3081026] BCBS WYOMING [308102603] 5.39 percent of total billed charges 3.52 5.39 Technical (Hospital) Services CARVEDILOL 6.25 MG TABLET RX-15747 CDM 6370000100 HCPCS 250 RC 68382-0093-01 NDC inpatient 1 UN 5.67 5.67 UNITED HEALTHCARE (COMMERCIAL) [3081199] UNITED HEALTHCARE 87726 [308119901] 3.52 percent of total billed charges 3.52 5.39 Technical (Hospital) Services CARVEDILOL 6.25 MG TABLET RX-15747 CDM 6370000100 HCPCS 250 RC 68382-0093-01 NDC inpatient 1 UN 5.67 5.67 HEALTHPARTNERS SX009 HEALTHPARTNERS 4.49 percent of total billed charges 3.52 5.39 Technical (Hospital) Services CARVEDILOL 6.25 MG TABLET RX-15747 CDM 6370000100 HCPCS 250 RC 68382-0093-01 NDC inpatient 1 UN 5.67 5.67 MEDICA (COMMERCIAL) 94265 [3081118] MEDICA CLAIMS [308111801] 5.1 percent of total billed charges 3.52 5.39 Technical (Hospital) Services CARVEDILOL 6.25 MG TABLET RX-15747 CDM 6370000100 HCPCS 250 RC 68382-0093-01 NDC inpatient 1 UN 5.67 5.67 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES HDHP [308136802] 4.49 percent of total billed charges 3.52 5.39 Technical (Hospital) Services CARVEDILOL 6.25 MG TABLET RX-15747 CDM 6370000100 HCPCS 250 RC 68382-0093-01 NDC inpatient 1 UN 5.67 5.67 CIGNA 62308 [3081051] CIGNA 62308 [308105105] 4.49 percent of total billed charges 3.52 5.39 Technical (Hospital) Services CARVEDILOL 6.25 MG TABLET RX-15747 CDM 6370000100 HCPCS 250 RC 68382-0093-01 NDC inpatient 1 UN 5.67 5.67 CIGNA 62308 [3081051] CIGNA STATE OF WYOMING [308105107] 4.49 percent of total billed charges 3.52 5.39 Technical (Hospital) Services CARVEDILOL 6.25 MG TABLET RX-15747 CDM 6370000100 HCPCS 250 RC 68382-0093-01 NDC inpatient 1 UN 5.67 5.67 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES EPO [308136803] 4.49 percent of total billed charges 3.52 5.39 Technical (Hospital) Services CARVEDILOL 25 MG TABLET RX-15748 CDM 6370000100 HCPCS 250 RC 68382-0095-01 NDC outpatient 1 UN 5.67 5.67 HEALTHPARTNERS SX009 HEALTHPARTNERS 4.54 percent of total billed charges 3.52 5.39 Technical (Hospital) Services CARVEDILOL 25 MG TABLET RX-15748 CDM 6370000100 HCPCS 250 RC 68382-0095-01 NDC outpatient 1 UN 5.67 5.67 BLUE CROSS BLUE SHIELD WELLMARK SB889 [3081026] BCBS WYOMING [308102603] 5.39 percent of total billed charges 3.52 5.39 Technical (Hospital) Services CARVEDILOL 25 MG TABLET RX-15748 CDM 6370000100 HCPCS 250 RC 68382-0095-01 NDC outpatient 1 UN 5.67 5.67 MULTIPLAN INC 34080 [3081285] MULTIPLAN INC [308128501] 5.39 percent of total billed charges 3.52 5.39 Technical (Hospital) Services CARVEDILOL 25 MG TABLET RX-15748 CDM 6370000100 HCPCS 250 RC 68382-0095-01 NDC outpatient 1 UN 5.67 5.67 CIGNA 62308 [3081051] CIGNA 62308 [308105105] 4.54 percent of total billed charges 3.52 5.39 Technical (Hospital) Services CARVEDILOL 25 MG TABLET RX-15748 CDM 6370000100 HCPCS 250 RC 68382-0095-01 NDC outpatient 1 UN 5.67 5.67 CIGNA 62308 [3081051] CIGNA STATE OF WYOMING [308105107] 4.54 percent of total billed charges 3.52 5.39 Technical (Hospital) Services CARVEDILOL 25 MG TABLET RX-15748 CDM 6370000100 HCPCS 250 RC 68382-0095-01 NDC outpatient 1 UN 5.67 5.67 UNITED HEALTHCARE (COMMERCIAL) [3081199] UNITED HEALTHCARE 87726 [308119901] 3.52 percent of total billed charges 3.52 5.39 Technical (Hospital) Services CARVEDILOL 25 MG TABLET RX-15748 CDM 6370000100 HCPCS 250 RC 68382-0095-01 NDC outpatient 1 UN 5.67 5.67 MEDICA (COMMERCIAL) 94265 [3081118] MEDICA CLAIMS [308111801] 5.1 percent of total billed charges 3.52 5.39 Technical (Hospital) Services CARVEDILOL 25 MG TABLET RX-15748 CDM 6370000100 HCPCS 250 RC 68382-0095-01 NDC outpatient 1 UN 5.67 5.67 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES PPO [308136801] 4.54 percent of total billed charges 3.52 5.39 Technical (Hospital) Services CARVEDILOL 25 MG TABLET RX-15748 CDM 6370000100 HCPCS 250 RC 68382-0095-01 NDC outpatient 1 UN 5.67 5.67 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES HDHP [308136802] 4.54 percent of total billed charges 3.52 5.39 Technical (Hospital) Services CARVEDILOL 25 MG TABLET RX-15748 CDM 6370000100 HCPCS 250 RC 68382-0095-01 NDC outpatient 1 UN 5.67 5.67 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES EPO [308136803] 4.54 percent of total billed charges 3.52 5.39 Technical (Hospital) Services CARVEDILOL 25 MG TABLET RX-15748 CDM 6370000100 HCPCS 250 RC 68382-0095-01 NDC inpatient 1 UN 5.67 5.67 BLUE CROSS BLUE SHIELD WELLMARK SB889 [3081026] BCBS WYOMING [308102603] 5.39 percent of total billed charges 3.52 5.39 Technical (Hospital) Services CARVEDILOL 25 MG TABLET RX-15748 CDM 6370000100 HCPCS 250 RC 68382-0095-01 NDC inpatient 1 UN 5.67 5.67 UNITED HEALTHCARE (COMMERCIAL) [3081199] UNITED HEALTHCARE 87726 [308119901] 3.52 percent of total billed charges 3.52 5.39 Technical (Hospital) Services CARVEDILOL 25 MG TABLET RX-15748 CDM 6370000100 HCPCS 250 RC 68382-0095-01 NDC inpatient 1 UN 5.67 5.67 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES HDHP [308136802] 4.49 percent of total billed charges 3.52 5.39 Technical (Hospital) Services CARVEDILOL 25 MG TABLET RX-15748 CDM 6370000100 HCPCS 250 RC 68382-0095-01 NDC inpatient 1 UN 5.67 5.67 CIGNA 62308 [3081051] CIGNA 62308 [308105105] 4.49 percent of total billed charges 3.52 5.39 Technical (Hospital) Services CARVEDILOL 25 MG TABLET RX-15748 CDM 6370000100 HCPCS 250 RC 68382-0095-01 NDC inpatient 1 UN 5.67 5.67 CIGNA 62308 [3081051] CIGNA STATE OF WYOMING [308105107] 4.49 percent of total billed charges 3.52 5.39 Technical (Hospital) Services CARVEDILOL 25 MG TABLET RX-15748 CDM 6370000100 HCPCS 250 RC 68382-0095-01 NDC inpatient 1 UN 5.67 5.67 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES EPO [308136803] 4.49 percent of total billed charges 3.52 5.39 Technical (Hospital) Services CARVEDILOL 25 MG TABLET RX-15748 CDM 6370000100 HCPCS 250 RC 68382-0095-01 NDC inpatient 1 UN 5.67 5.67 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES PPO [308136801] 4.49 percent of total billed charges 3.52 5.39 Technical (Hospital) Services CARVEDILOL 25 MG TABLET RX-15748 CDM 6370000100 HCPCS 250 RC 68382-0095-01 NDC inpatient 1 UN 5.67 5.67 MEDICA (COMMERCIAL) 94265 [3081118] MEDICA CLAIMS [308111801] 5.1 percent of total billed charges 3.52 5.39 Technical (Hospital) Services CARVEDILOL 25 MG TABLET RX-15748 CDM 6370000100 HCPCS 250 RC 68382-0095-01 NDC inpatient 1 UN 5.67 5.67 HEALTHPARTNERS SX009 HEALTHPARTNERS 4.49 percent of total billed charges 3.52 5.39 Technical (Hospital) Services CARVEDILOL 25 MG TABLET RX-15748 CDM 6370000100 HCPCS 250 RC 68382-0095-01 NDC inpatient 1 UN 5.67 5.67 MULTIPLAN INC 34080 [3081285] MULTIPLAN INC [308128501] 5.39 percent of total billed charges 3.52 5.39 Technical (Hospital) Services CARVEDILOL 12.5 MG TABLET RX-15749 CDM 6370000100 HCPCS 250 RC 68382-0094-01 NDC inpatient 1 UN 5.67 5.67 CIGNA 62308 [3081051] CIGNA 62308 [308105105] 4.49 percent of total billed charges 3.52 5.39 Technical (Hospital) Services CARVEDILOL 12.5 MG TABLET RX-15749 CDM 6370000100 HCPCS 250 RC 68382-0094-01 NDC inpatient 1 UN 5.67 5.67 CIGNA 62308 [3081051] CIGNA STATE OF WYOMING [308105107] 4.49 percent of total billed charges 3.52 5.39 Technical (Hospital) Services CARVEDILOL 12.5 MG TABLET RX-15749 CDM 6370000100 HCPCS 250 RC 68382-0094-01 NDC inpatient 1 UN 5.67 5.67 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES EPO [308136803] 4.49 percent of total billed charges 3.52 5.39 Technical (Hospital) Services CARVEDILOL 12.5 MG TABLET RX-15749 CDM 6370000100 HCPCS 250 RC 68382-0094-01 NDC inpatient 1 UN 5.67 5.67 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES HDHP [308136802] 4.49 percent of total billed charges 3.52 5.39 Technical (Hospital) Services CARVEDILOL 12.5 MG TABLET RX-15749 CDM 6370000100 HCPCS 250 RC 68382-0094-01 NDC inpatient 1 UN 5.67 5.67 UNITED HEALTHCARE (COMMERCIAL) [3081199] UNITED HEALTHCARE 87726 [308119901] 3.52 percent of total billed charges 3.52 5.39 Technical (Hospital) Services CARVEDILOL 12.5 MG TABLET RX-15749 CDM 6370000100 HCPCS 250 RC 68382-0094-01 NDC inpatient 1 UN 5.67 5.67 BLUE CROSS BLUE SHIELD WELLMARK SB889 [3081026] BCBS WYOMING [308102603] 5.39 percent of total billed charges 3.52 5.39 Technical (Hospital) Services CARVEDILOL 12.5 MG TABLET RX-15749 CDM 6370000100 HCPCS 250 RC 68382-0094-01 NDC inpatient 1 UN 5.67 5.67 HEALTHPARTNERS SX009 HEALTHPARTNERS 4.49 percent of total billed charges 3.52 5.39 Technical (Hospital) Services CARVEDILOL 12.5 MG TABLET RX-15749 CDM 6370000100 HCPCS 250 RC 68382-0094-01 NDC inpatient 1 UN 5.67 5.67 MEDICA (COMMERCIAL) 94265 [3081118] MEDICA CLAIMS [308111801] 5.1 percent of total billed charges 3.52 5.39 Technical (Hospital) Services CARVEDILOL 12.5 MG TABLET RX-15749 CDM 6370000100 HCPCS 250 RC 68382-0094-01 NDC inpatient 1 UN 5.67 5.67 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES PPO [308136801] 4.49 percent of total billed charges 3.52 5.39 Technical (Hospital) Services CARVEDILOL 12.5 MG TABLET RX-15749 CDM 6370000100 HCPCS 250 RC 68382-0094-01 NDC inpatient 1 UN 5.67 5.67 MULTIPLAN INC 34080 [3081285] MULTIPLAN INC [308128501] 5.39 percent of total billed charges 3.52 5.39 Technical (Hospital) Services CARVEDILOL 12.5 MG TABLET RX-15749 CDM 6370000100 HCPCS 250 RC 68382-0094-01 NDC outpatient 1 UN 5.67 5.67 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES EPO [308136803] 4.54 percent of total billed charges 3.52 5.39 Technical (Hospital) Services CARVEDILOL 12.5 MG TABLET RX-15749 CDM 6370000100 HCPCS 250 RC 68382-0094-01 NDC outpatient 1 UN 5.67 5.67 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES PPO [308136801] 4.54 percent of total billed charges 3.52 5.39 Technical (Hospital) Services CARVEDILOL 12.5 MG TABLET RX-15749 CDM 6370000100 HCPCS 250 RC 68382-0094-01 NDC outpatient 1 UN 5.67 5.67 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES HDHP [308136802] 4.54 percent of total billed charges 3.52 5.39 Technical (Hospital) Services CARVEDILOL 12.5 MG TABLET RX-15749 CDM 6370000100 HCPCS 250 RC 68382-0094-01 NDC outpatient 1 UN 5.67 5.67 HEALTHPARTNERS SX009 HEALTHPARTNERS 4.54 percent of total billed charges 3.52 5.39 Technical (Hospital) Services CARVEDILOL 12.5 MG TABLET RX-15749 CDM 6370000100 HCPCS 250 RC 68382-0094-01 NDC outpatient 1 UN 5.67 5.67 UNITED HEALTHCARE (COMMERCIAL) [3081199] UNITED HEALTHCARE 87726 [308119901] 3.52 percent of total billed charges 3.52 5.39 Technical (Hospital) Services CARVEDILOL 12.5 MG TABLET RX-15749 CDM 6370000100 HCPCS 250 RC 68382-0094-01 NDC outpatient 1 UN 5.67 5.67 MEDICA (COMMERCIAL) 94265 [3081118] MEDICA CLAIMS [308111801] 5.1 percent of total billed charges 3.52 5.39 Technical (Hospital) Services CARVEDILOL 12.5 MG TABLET RX-15749 CDM 6370000100 HCPCS 250 RC 68382-0094-01 NDC outpatient 1 UN 5.67 5.67 MULTIPLAN INC 34080 [3081285] MULTIPLAN INC [308128501] 5.39 percent of total billed charges 3.52 5.39 Technical (Hospital) Services CARVEDILOL 12.5 MG TABLET RX-15749 CDM 6370000100 HCPCS 250 RC 68382-0094-01 NDC outpatient 1 UN 5.67 5.67 CIGNA 62308 [3081051] CIGNA 62308 [308105105] 4.54 percent of total billed charges 3.52 5.39 Technical (Hospital) Services CARVEDILOL 12.5 MG TABLET RX-15749 CDM 6370000100 HCPCS 250 RC 68382-0094-01 NDC outpatient 1 UN 5.67 5.67 CIGNA 62308 [3081051] CIGNA STATE OF WYOMING [308105107] 4.54 percent of total billed charges 3.52 5.39 Technical (Hospital) Services CARVEDILOL 12.5 MG TABLET RX-15749 CDM 6370000100 HCPCS 250 RC 68382-0094-01 NDC outpatient 1 UN 5.67 5.67 BLUE CROSS BLUE SHIELD WELLMARK SB889 [3081026] BCBS WYOMING [308102603] 5.39 percent of total billed charges 3.52 5.39 Technical (Hospital) Services AZITHROMYCIN 200 MG/5 ML ORAL SUSPENSION RX-15797 CDM 6370000100 HCPCS 250 RC 00093-2026-31 NDC outpatient 30 ML 108.66 108.66 MEDICA (COMMERCIAL) 94265 [3081118] MEDICA CLAIMS [308111801] 97.79 percent of total billed charges 67.37 103.23 Technical (Hospital) Services AZITHROMYCIN 200 MG/5 ML ORAL SUSPENSION RX-15797 CDM 6370000100 HCPCS 250 RC 00093-2026-31 NDC outpatient 30 ML 108.66 108.66 MULTIPLAN INC 34080 [3081285] MULTIPLAN INC [308128501] 103.23 percent of total billed charges 67.37 103.23 Technical (Hospital) Services AZITHROMYCIN 200 MG/5 ML ORAL SUSPENSION RX-15797 CDM 6370000100 HCPCS 250 RC 00093-2026-31 NDC outpatient 30 ML 108.66 108.66 CIGNA 62308 [3081051] CIGNA 62308 [308105105] 86.93 percent of total billed charges 67.37 103.23 Technical (Hospital) Services AZITHROMYCIN 200 MG/5 ML ORAL SUSPENSION RX-15797 CDM 6370000100 HCPCS 250 RC 00093-2026-31 NDC outpatient 30 ML 108.66 108.66 CIGNA 62308 [3081051] CIGNA STATE OF WYOMING [308105107] 86.93 percent of total billed charges 67.37 103.23 Technical (Hospital) Services AZITHROMYCIN 200 MG/5 ML ORAL SUSPENSION RX-15797 CDM 6370000100 HCPCS 250 RC 00093-2026-31 NDC outpatient 30 ML 108.66 108.66 HEALTHPARTNERS SX009 HEALTHPARTNERS 86.93 percent of total billed charges 67.37 103.23 Technical (Hospital) Services AZITHROMYCIN 200 MG/5 ML ORAL SUSPENSION RX-15797 CDM 6370000100 HCPCS 250 RC 00093-2026-31 NDC outpatient 30 ML 108.66 108.66 BLUE CROSS BLUE SHIELD WELLMARK SB889 [3081026] BCBS WYOMING [308102603] 103.23 percent of total billed charges 67.37 103.23 Technical (Hospital) Services AZITHROMYCIN 200 MG/5 ML ORAL SUSPENSION RX-15797 CDM 6370000100 HCPCS 250 RC 00093-2026-31 NDC outpatient 30 ML 108.66 108.66 UNITED HEALTHCARE (COMMERCIAL) [3081199] UNITED HEALTHCARE 87726 [308119901] 67.37 percent of total billed charges 67.37 103.23 Technical (Hospital) Services AZITHROMYCIN 200 MG/5 ML ORAL SUSPENSION RX-15797 CDM 6370000100 HCPCS 250 RC 00093-2026-31 NDC outpatient 30 ML 108.66 108.66 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES EPO [308136803] 86.93 percent of total billed charges 67.37 103.23 Technical (Hospital) Services AZITHROMYCIN 200 MG/5 ML ORAL SUSPENSION RX-15797 CDM 6370000100 HCPCS 250 RC 00093-2026-31 NDC outpatient 30 ML 108.66 108.66 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES HDHP [308136802] 86.93 percent of total billed charges 67.37 103.23 Technical (Hospital) Services AZITHROMYCIN 200 MG/5 ML ORAL SUSPENSION RX-15797 CDM 6370000100 HCPCS 250 RC 00093-2026-31 NDC outpatient 30 ML 108.66 108.66 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES PPO [308136801] 86.93 percent of total billed charges 67.37 103.23 Technical (Hospital) Services AZITHROMYCIN 200 MG/5 ML ORAL SUSPENSION RX-15797 CDM 6370000100 HCPCS 250 RC 00093-2026-31 NDC inpatient 30 ML 108.66 108.66 BLUE CROSS BLUE SHIELD WELLMARK SB889 [3081026] BCBS WYOMING [308102603] 103.23 percent of total billed charges 67.37 103.23 Technical (Hospital) Services AZITHROMYCIN 200 MG/5 ML ORAL SUSPENSION RX-15797 CDM 6370000100 HCPCS 250 RC 00093-2026-31 NDC inpatient 30 ML 108.66 108.66 UNITED HEALTHCARE (COMMERCIAL) [3081199] UNITED HEALTHCARE 87726 [308119901] 67.37 percent of total billed charges 67.37 103.23 Technical (Hospital) Services AZITHROMYCIN 200 MG/5 ML ORAL SUSPENSION RX-15797 CDM 6370000100 HCPCS 250 RC 00093-2026-31 NDC inpatient 30 ML 108.66 108.66 MEDICA (COMMERCIAL) 94265 [3081118] MEDICA CLAIMS [308111801] 97.79 percent of total billed charges 67.37 103.23 Technical (Hospital) Services AZITHROMYCIN 200 MG/5 ML ORAL SUSPENSION RX-15797 CDM 6370000100 HCPCS 250 RC 00093-2026-31 NDC inpatient 30 ML 108.66 108.66 MULTIPLAN INC 34080 [3081285] MULTIPLAN INC [308128501] 103.23 percent of total billed charges 67.37 103.23 Technical (Hospital) Services AZITHROMYCIN 200 MG/5 ML ORAL SUSPENSION RX-15797 CDM 6370000100 HCPCS 250 RC 00093-2026-31 NDC inpatient 30 ML 108.66 108.66 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES HDHP [308136802] 86.04 percent of total billed charges 67.37 103.23 Technical (Hospital) Services AZITHROMYCIN 200 MG/5 ML ORAL SUSPENSION RX-15797 CDM 6370000100 HCPCS 250 RC 00093-2026-31 NDC inpatient 30 ML 108.66 108.66 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES EPO [308136803] 86.04 percent of total billed charges 67.37 103.23 Technical (Hospital) Services AZITHROMYCIN 200 MG/5 ML ORAL SUSPENSION RX-15797 CDM 6370000100 HCPCS 250 RC 00093-2026-31 NDC inpatient 30 ML 108.66 108.66 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES PPO [308136801] 86.04 percent of total billed charges 67.37 103.23 Technical (Hospital) Services AZITHROMYCIN 200 MG/5 ML ORAL SUSPENSION RX-15797 CDM 6370000100 HCPCS 250 RC 00093-2026-31 NDC inpatient 30 ML 108.66 108.66 CIGNA 62308 [3081051] CIGNA 62308 [308105105] 86.04 percent of total billed charges 67.37 103.23 Technical (Hospital) Services AZITHROMYCIN 200 MG/5 ML ORAL SUSPENSION RX-15797 CDM 6370000100 HCPCS 250 RC 00093-2026-31 NDC inpatient 30 ML 108.66 108.66 CIGNA 62308 [3081051] CIGNA STATE OF WYOMING [308105107] 86.04 percent of total billed charges 67.37 103.23 Technical (Hospital) Services AZITHROMYCIN 200 MG/5 ML ORAL SUSPENSION RX-15797 CDM 6370000100 HCPCS 250 RC 00093-2026-31 NDC inpatient 30 ML 108.66 108.66 HEALTHPARTNERS SX009 HEALTHPARTNERS 86.04 percent of total billed charges 67.37 103.23 Technical (Hospital) Services DESMOPRESSIN 0.2 MG TABLET RX-16053 CDM 6370000100 HCPCS 250 RC 23155-0490-01 NDC outpatient 1 UN 6.8 6.8 UNITED HEALTHCARE (COMMERCIAL) [3081199] UNITED HEALTHCARE 87726 [308119901] 4.22 percent of total billed charges 4.22 6.46 Technical (Hospital) Services DESMOPRESSIN 0.2 MG TABLET RX-16053 CDM 6370000100 HCPCS 250 RC 23155-0490-01 NDC outpatient 1 UN 6.8 6.8 MEDICA (COMMERCIAL) 94265 [3081118] MEDICA CLAIMS [308111801] 6.12 percent of total billed charges 4.22 6.46 Technical (Hospital) Services DESMOPRESSIN 0.2 MG TABLET RX-16053 CDM 6370000100 HCPCS 250 RC 23155-0490-01 NDC outpatient 1 UN 6.8 6.8 MULTIPLAN INC 34080 [3081285] MULTIPLAN INC [308128501] 6.46 percent of total billed charges 4.22 6.46 Technical (Hospital) Services DESMOPRESSIN 0.2 MG TABLET RX-16053 CDM 6370000100 HCPCS 250 RC 23155-0490-01 NDC outpatient 1 UN 6.8 6.8 CIGNA 62308 [3081051] CIGNA 62308 [308105105] 5.44 percent of total billed charges 4.22 6.46 Technical (Hospital) Services DESMOPRESSIN 0.2 MG TABLET RX-16053 CDM 6370000100 HCPCS 250 RC 23155-0490-01 NDC outpatient 1 UN 6.8 6.8 CIGNA 62308 [3081051] CIGNA STATE OF WYOMING [308105107] 5.44 percent of total billed charges 4.22 6.46 Technical (Hospital) Services DESMOPRESSIN 0.2 MG TABLET RX-16053 CDM 6370000100 HCPCS 250 RC 23155-0490-01 NDC outpatient 1 UN 6.8 6.8 BLUE CROSS BLUE SHIELD WELLMARK SB889 [3081026] BCBS WYOMING [308102603] 6.46 percent of total billed charges 4.22 6.46 Technical (Hospital) Services DESMOPRESSIN 0.2 MG TABLET RX-16053 CDM 6370000100 HCPCS 250 RC 23155-0490-01 NDC outpatient 1 UN 6.8 6.8 HEALTHPARTNERS SX009 HEALTHPARTNERS 5.44 percent of total billed charges 4.22 6.46 Technical (Hospital) Services DESMOPRESSIN 0.2 MG TABLET RX-16053 CDM 6370000100 HCPCS 250 RC 23155-0490-01 NDC outpatient 1 UN 6.8 6.8 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES HDHP [308136802] 5.44 percent of total billed charges 4.22 6.46 Technical (Hospital) Services DESMOPRESSIN 0.2 MG TABLET RX-16053 CDM 6370000100 HCPCS 250 RC 23155-0490-01 NDC outpatient 1 UN 6.8 6.8 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES PPO [308136801] 5.44 percent of total billed charges 4.22 6.46 Technical (Hospital) Services DESMOPRESSIN 0.2 MG TABLET RX-16053 CDM 6370000100 HCPCS 250 RC 23155-0490-01 NDC outpatient 1 UN 6.8 6.8 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES EPO [308136803] 5.44 percent of total billed charges 4.22 6.46 Technical (Hospital) Services DESMOPRESSIN 0.2 MG TABLET RX-16053 CDM 6370000100 HCPCS 250 RC 23155-0490-01 NDC inpatient 1 UN 6.8 6.8 BLUE CROSS BLUE SHIELD WELLMARK SB889 [3081026] BCBS WYOMING [308102603] 6.46 percent of total billed charges 4.22 6.46 Technical (Hospital) Services DESMOPRESSIN 0.2 MG TABLET RX-16053 CDM 6370000100 HCPCS 250 RC 23155-0490-01 NDC inpatient 1 UN 6.8 6.8 UNITED HEALTHCARE (COMMERCIAL) [3081199] UNITED HEALTHCARE 87726 [308119901] 4.22 percent of total billed charges 4.22 6.46 Technical (Hospital) Services DESMOPRESSIN 0.2 MG TABLET RX-16053 CDM 6370000100 HCPCS 250 RC 23155-0490-01 NDC inpatient 1 UN 6.8 6.8 CIGNA 62308 [3081051] CIGNA 62308 [308105105] 5.38 percent of total billed charges 4.22 6.46 Technical (Hospital) Services DESMOPRESSIN 0.2 MG TABLET RX-16053 CDM 6370000100 HCPCS 250 RC 23155-0490-01 NDC inpatient 1 UN 6.8 6.8 CIGNA 62308 [3081051] CIGNA STATE OF WYOMING [308105107] 5.38 percent of total billed charges 4.22 6.46 Technical (Hospital) Services DESMOPRESSIN 0.2 MG TABLET RX-16053 CDM 6370000100 HCPCS 250 RC 23155-0490-01 NDC inpatient 1 UN 6.8 6.8 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES EPO [308136803] 5.38 percent of total billed charges 4.22 6.46 Technical (Hospital) Services DESMOPRESSIN 0.2 MG TABLET RX-16053 CDM 6370000100 HCPCS 250 RC 23155-0490-01 NDC inpatient 1 UN 6.8 6.8 HEALTHPARTNERS SX009 HEALTHPARTNERS 5.38 percent of total billed charges 4.22 6.46 Technical (Hospital) Services DESMOPRESSIN 0.2 MG TABLET RX-16053 CDM 6370000100 HCPCS 250 RC 23155-0490-01 NDC inpatient 1 UN 6.8 6.8 MEDICA (COMMERCIAL) 94265 [3081118] MEDICA CLAIMS [308111801] 6.12 percent of total billed charges 4.22 6.46 Technical (Hospital) Services DESMOPRESSIN 0.2 MG TABLET RX-16053 CDM 6370000100 HCPCS 250 RC 23155-0490-01 NDC inpatient 1 UN 6.8 6.8 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES HDHP [308136802] 5.38 percent of total billed charges 4.22 6.46 Technical (Hospital) Services DESMOPRESSIN 0.2 MG TABLET RX-16053 CDM 6370000100 HCPCS 250 RC 23155-0490-01 NDC inpatient 1 UN 6.8 6.8 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES PPO [308136801] 5.38 percent of total billed charges 4.22 6.46 Technical (Hospital) Services DESMOPRESSIN 0.2 MG TABLET RX-16053 CDM 6370000100 HCPCS 250 RC 23155-0490-01 NDC inpatient 1 UN 6.8 6.8 MULTIPLAN INC 34080 [3081285] MULTIPLAN INC [308128501] 6.46 percent of total billed charges 4.22 6.46 Technical (Hospital) Services IPRATROPIUM BROMIDE 21 MCG (0.03 %) NASAL SPRAY RX-16070 CDM 6370000100 HCPCS 250 RC 00054-0045-44 NDC inpatient 30 ML 118.5 118.5 MULTIPLAN INC 34080 [3081285] MULTIPLAN INC [308128501] 112.58 percent of total billed charges 73.47 112.58 Technical (Hospital) Services IPRATROPIUM BROMIDE 21 MCG (0.03 %) NASAL SPRAY RX-16070 CDM 6370000100 HCPCS 250 RC 00054-0045-44 NDC inpatient 30 ML 118.5 118.5 MEDICA (COMMERCIAL) 94265 [3081118] MEDICA CLAIMS [308111801] 106.65 percent of total billed charges 73.47 112.58 Technical (Hospital) Services IPRATROPIUM BROMIDE 21 MCG (0.03 %) NASAL SPRAY RX-16070 CDM 6370000100 HCPCS 250 RC 00054-0045-44 NDC inpatient 30 ML 118.5 118.5 UNITED HEALTHCARE (COMMERCIAL) [3081199] UNITED HEALTHCARE 87726 [308119901] 73.47 percent of total billed charges 73.47 112.58 Technical (Hospital) Services IPRATROPIUM BROMIDE 21 MCG (0.03 %) NASAL SPRAY RX-16070 CDM 6370000100 HCPCS 250 RC 00054-0045-44 NDC inpatient 30 ML 118.5 118.5 BLUE CROSS BLUE SHIELD WELLMARK SB889 [3081026] BCBS WYOMING [308102603] 112.58 percent of total billed charges 73.47 112.58 Technical (Hospital) Services IPRATROPIUM BROMIDE 21 MCG (0.03 %) NASAL SPRAY RX-16070 CDM 6370000100 HCPCS 250 RC 00054-0045-44 NDC inpatient 30 ML 118.5 118.5 CIGNA 62308 [3081051] CIGNA 62308 [308105105] 93.83 percent of total billed charges 73.47 112.58 Technical (Hospital) Services IPRATROPIUM BROMIDE 21 MCG (0.03 %) NASAL SPRAY RX-16070 CDM 6370000100 HCPCS 250 RC 00054-0045-44 NDC inpatient 30 ML 118.5 118.5 CIGNA 62308 [3081051] CIGNA STATE OF WYOMING [308105107] 93.83 percent of total billed charges 73.47 112.58 Technical (Hospital) Services IPRATROPIUM BROMIDE 21 MCG (0.03 %) NASAL SPRAY RX-16070 CDM 6370000100 HCPCS 250 RC 00054-0045-44 NDC inpatient 30 ML 118.5 118.5 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES HDHP [308136802] 93.83 percent of total billed charges 73.47 112.58 Technical (Hospital) Services IPRATROPIUM BROMIDE 21 MCG (0.03 %) NASAL SPRAY RX-16070 CDM 6370000100 HCPCS 250 RC 00054-0045-44 NDC inpatient 30 ML 118.5 118.5 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES EPO [308136803] 93.83 percent of total billed charges 73.47 112.58 Technical (Hospital) Services IPRATROPIUM BROMIDE 21 MCG (0.03 %) NASAL SPRAY RX-16070 CDM 6370000100 HCPCS 250 RC 00054-0045-44 NDC inpatient 30 ML 118.5 118.5 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES PPO [308136801] 93.83 percent of total billed charges 73.47 112.58 Technical (Hospital) Services IPRATROPIUM BROMIDE 21 MCG (0.03 %) NASAL SPRAY RX-16070 CDM 6370000100 HCPCS 250 RC 00054-0045-44 NDC inpatient 30 ML 118.5 118.5 HEALTHPARTNERS SX009 HEALTHPARTNERS 93.83 percent of total billed charges 73.47 112.58 Technical (Hospital) Services IPRATROPIUM BROMIDE 21 MCG (0.03 %) NASAL SPRAY RX-16070 CDM 6370000100 HCPCS 250 RC 00054-0045-44 NDC outpatient 30 ML 118.5 118.5 UNITED HEALTHCARE (COMMERCIAL) [3081199] UNITED HEALTHCARE 87726 [308119901] 73.47 percent of total billed charges 73.47 112.58 Technical (Hospital) Services IPRATROPIUM BROMIDE 21 MCG (0.03 %) NASAL SPRAY RX-16070 CDM 6370000100 HCPCS 250 RC 00054-0045-44 NDC outpatient 30 ML 118.5 118.5 HEALTHPARTNERS SX009 HEALTHPARTNERS 94.8 percent of total billed charges 73.47 112.58 Technical (Hospital) Services IPRATROPIUM BROMIDE 21 MCG (0.03 %) NASAL SPRAY RX-16070 CDM 6370000100 HCPCS 250 RC 00054-0045-44 NDC outpatient 30 ML 118.5 118.5 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES EPO [308136803] 94.8 percent of total billed charges 73.47 112.58 Technical (Hospital) Services IPRATROPIUM BROMIDE 21 MCG (0.03 %) NASAL SPRAY RX-16070 CDM 6370000100 HCPCS 250 RC 00054-0045-44 NDC outpatient 30 ML 118.5 118.5 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES HDHP [308136802] 94.8 percent of total billed charges 73.47 112.58 Technical (Hospital) Services IPRATROPIUM BROMIDE 21 MCG (0.03 %) NASAL SPRAY RX-16070 CDM 6370000100 HCPCS 250 RC 00054-0045-44 NDC outpatient 30 ML 118.5 118.5 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES PPO [308136801] 94.8 percent of total billed charges 73.47 112.58 Technical (Hospital) Services IPRATROPIUM BROMIDE 21 MCG (0.03 %) NASAL SPRAY RX-16070 CDM 6370000100 HCPCS 250 RC 00054-0045-44 NDC outpatient 30 ML 118.5 118.5 BLUE CROSS BLUE SHIELD WELLMARK SB889 [3081026] BCBS WYOMING [308102603] 112.58 percent of total billed charges 73.47 112.58 Technical (Hospital) Services IPRATROPIUM BROMIDE 21 MCG (0.03 %) NASAL SPRAY RX-16070 CDM 6370000100 HCPCS 250 RC 00054-0045-44 NDC outpatient 30 ML 118.5 118.5 MULTIPLAN INC 34080 [3081285] MULTIPLAN INC [308128501] 112.58 percent of total billed charges 73.47 112.58 Technical (Hospital) Services IPRATROPIUM BROMIDE 21 MCG (0.03 %) NASAL SPRAY RX-16070 CDM 6370000100 HCPCS 250 RC 00054-0045-44 NDC outpatient 30 ML 118.5 118.5 MEDICA (COMMERCIAL) 94265 [3081118] MEDICA CLAIMS [308111801] 106.65 percent of total billed charges 73.47 112.58 Technical (Hospital) Services IPRATROPIUM BROMIDE 21 MCG (0.03 %) NASAL SPRAY RX-16070 CDM 6370000100 HCPCS 250 RC 00054-0045-44 NDC outpatient 30 ML 118.5 118.5 CIGNA 62308 [3081051] CIGNA 62308 [308105105] 94.8 percent of total billed charges 73.47 112.58 Technical (Hospital) Services IPRATROPIUM BROMIDE 21 MCG (0.03 %) NASAL SPRAY RX-16070 CDM 6370000100 HCPCS 250 RC 00054-0045-44 NDC outpatient 30 ML 118.5 118.5 CIGNA 62308 [3081051] CIGNA STATE OF WYOMING [308105107] 94.8 percent of total billed charges 73.47 112.58 Technical (Hospital) Services CHLORDIAZEPOXIDE 10 MG CAPSULE RX-1622 CDM 6370000100 HCPCS 250 RC 00555-0033-02 NDC outpatient 1 UN 5.77 5.77 HEALTHPARTNERS SX009 HEALTHPARTNERS 4.62 percent of total billed charges 3.58 5.48 Technical (Hospital) Services CHLORDIAZEPOXIDE 10 MG CAPSULE RX-1622 CDM 6370000100 HCPCS 250 RC 00555-0033-02 NDC outpatient 1 UN 5.77 5.77 BLUE CROSS BLUE SHIELD WELLMARK SB889 [3081026] BCBS WYOMING [308102603] 5.48 percent of total billed charges 3.58 5.48 Technical (Hospital) Services CHLORDIAZEPOXIDE 10 MG CAPSULE RX-1622 CDM 6370000100 HCPCS 250 RC 00555-0033-02 NDC outpatient 1 UN 5.77 5.77 MEDICA (COMMERCIAL) 94265 [3081118] MEDICA CLAIMS [308111801] 5.19 percent of total billed charges 3.58 5.48 Technical (Hospital) Services CHLORDIAZEPOXIDE 10 MG CAPSULE RX-1622 CDM 6370000100 HCPCS 250 RC 00555-0033-02 NDC outpatient 1 UN 5.77 5.77 UNITED HEALTHCARE (COMMERCIAL) [3081199] UNITED HEALTHCARE 87726 [308119901] 3.58 percent of total billed charges 3.58 5.48 Technical (Hospital) Services CHLORDIAZEPOXIDE 10 MG CAPSULE RX-1622 CDM 6370000100 HCPCS 250 RC 00555-0033-02 NDC outpatient 1 UN 5.77 5.77 CIGNA 62308 [3081051] CIGNA 62308 [308105105] 4.62 percent of total billed charges 3.58 5.48 Technical (Hospital) Services CHLORDIAZEPOXIDE 10 MG CAPSULE RX-1622 CDM 6370000100 HCPCS 250 RC 00555-0033-02 NDC outpatient 1 UN 5.77 5.77 CIGNA 62308 [3081051] CIGNA STATE OF WYOMING [308105107] 4.62 percent of total billed charges 3.58 5.48 Technical (Hospital) Services CHLORDIAZEPOXIDE 10 MG CAPSULE RX-1622 CDM 6370000100 HCPCS 250 RC 00555-0033-02 NDC outpatient 1 UN 5.77 5.77 MULTIPLAN INC 34080 [3081285] MULTIPLAN INC [308128501] 5.48 percent of total billed charges 3.58 5.48 Technical (Hospital) Services CHLORDIAZEPOXIDE 10 MG CAPSULE RX-1622 CDM 6370000100 HCPCS 250 RC 00555-0033-02 NDC outpatient 1 UN 5.77 5.77 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES PPO [308136801] 4.62 percent of total billed charges 3.58 5.48 Technical (Hospital) Services CHLORDIAZEPOXIDE 10 MG CAPSULE RX-1622 CDM 6370000100 HCPCS 250 RC 00555-0033-02 NDC outpatient 1 UN 5.77 5.77 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES HDHP [308136802] 4.62 percent of total billed charges 3.58 5.48 Technical (Hospital) Services CHLORDIAZEPOXIDE 10 MG CAPSULE RX-1622 CDM 6370000100 HCPCS 250 RC 00555-0033-02 NDC outpatient 1 UN 5.77 5.77 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES EPO [308136803] 4.62 percent of total billed charges 3.58 5.48 Technical (Hospital) Services CHLORDIAZEPOXIDE 10 MG CAPSULE RX-1622 CDM 6370000100 HCPCS 250 RC 00555-0033-02 NDC inpatient 1 UN 5.77 5.77 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES PPO [308136801] 4.57 percent of total billed charges 3.58 5.48 Technical (Hospital) Services CHLORDIAZEPOXIDE 10 MG CAPSULE RX-1622 CDM 6370000100 HCPCS 250 RC 00555-0033-02 NDC inpatient 1 UN 5.77 5.77 MEDICA (COMMERCIAL) 94265 [3081118] MEDICA CLAIMS [308111801] 5.19 percent of total billed charges 3.58 5.48 Technical (Hospital) Services CHLORDIAZEPOXIDE 10 MG CAPSULE RX-1622 CDM 6370000100 HCPCS 250 RC 00555-0033-02 NDC inpatient 1 UN 5.77 5.77 HEALTHPARTNERS SX009 HEALTHPARTNERS 4.57 percent of total billed charges 3.58 5.48 Technical (Hospital) Services CHLORDIAZEPOXIDE 10 MG CAPSULE RX-1622 CDM 6370000100 HCPCS 250 RC 00555-0033-02 NDC inpatient 1 UN 5.77 5.77 MULTIPLAN INC 34080 [3081285] MULTIPLAN INC [308128501] 5.48 percent of total billed charges 3.58 5.48 Technical (Hospital) Services CHLORDIAZEPOXIDE 10 MG CAPSULE RX-1622 CDM 6370000100 HCPCS 250 RC 00555-0033-02 NDC inpatient 1 UN 5.77 5.77 BLUE CROSS BLUE SHIELD WELLMARK SB889 [3081026] BCBS WYOMING [308102603] 5.48 percent of total billed charges 3.58 5.48 Technical (Hospital) Services CHLORDIAZEPOXIDE 10 MG CAPSULE RX-1622 CDM 6370000100 HCPCS 250 RC 00555-0033-02 NDC inpatient 1 UN 5.77 5.77 UNITED HEALTHCARE (COMMERCIAL) [3081199] UNITED HEALTHCARE 87726 [308119901] 3.58 percent of total billed charges 3.58 5.48 Technical (Hospital) Services CHLORDIAZEPOXIDE 10 MG CAPSULE RX-1622 CDM 6370000100 HCPCS 250 RC 00555-0033-02 NDC inpatient 1 UN 5.77 5.77 CIGNA 62308 [3081051] CIGNA 62308 [308105105] 4.57 percent of total billed charges 3.58 5.48 Technical (Hospital) Services CHLORDIAZEPOXIDE 10 MG CAPSULE RX-1622 CDM 6370000100 HCPCS 250 RC 00555-0033-02 NDC inpatient 1 UN 5.77 5.77 CIGNA 62308 [3081051] CIGNA STATE OF WYOMING [308105107] 4.57 percent of total billed charges 3.58 5.48 Technical (Hospital) Services CHLORDIAZEPOXIDE 10 MG CAPSULE RX-1622 CDM 6370000100 HCPCS 250 RC 00555-0033-02 NDC inpatient 1 UN 5.77 5.77 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES EPO [308136803] 4.57 percent of total billed charges 3.58 5.48 Technical (Hospital) Services CHLORDIAZEPOXIDE 10 MG CAPSULE RX-1622 CDM 6370000100 HCPCS 250 RC 00555-0033-02 NDC inpatient 1 UN 5.77 5.77 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES HDHP [308136802] 4.57 percent of total billed charges 3.58 5.48 Technical (Hospital) Services CHLORDIAZEPOXIDE 25 MG CAPSULE RX-1623 CDM 6370000100 HCPCS 250 RC 00555-0159-02 NDC inpatient 1 UN 5.79 5.79 UNITED HEALTHCARE (COMMERCIAL) [3081199] UNITED HEALTHCARE 87726 [308119901] 3.59 percent of total billed charges 3.59 5.5 Technical (Hospital) Services CHLORDIAZEPOXIDE 25 MG CAPSULE RX-1623 CDM 6370000100 HCPCS 250 RC 00555-0159-02 NDC inpatient 1 UN 5.79 5.79 BLUE CROSS BLUE SHIELD WELLMARK SB889 [3081026] BCBS WYOMING [308102603] 5.5 percent of total billed charges 3.59 5.5 Technical (Hospital) Services CHLORDIAZEPOXIDE 25 MG CAPSULE RX-1623 CDM 6370000100 HCPCS 250 RC 00555-0159-02 NDC inpatient 1 UN 5.79 5.79 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES HDHP [308136802] 4.58 percent of total billed charges 3.59 5.5 Technical (Hospital) Services CHLORDIAZEPOXIDE 25 MG CAPSULE RX-1623 CDM 6370000100 HCPCS 250 RC 00555-0159-02 NDC inpatient 1 UN 5.79 5.79 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES EPO [308136803] 4.58 percent of total billed charges 3.59 5.5 Technical (Hospital) Services CHLORDIAZEPOXIDE 25 MG CAPSULE RX-1623 CDM 6370000100 HCPCS 250 RC 00555-0159-02 NDC inpatient 1 UN 5.79 5.79 CIGNA 62308 [3081051] CIGNA 62308 [308105105] 4.58 percent of total billed charges 3.59 5.5 Technical (Hospital) Services CHLORDIAZEPOXIDE 25 MG CAPSULE RX-1623 CDM 6370000100 HCPCS 250 RC 00555-0159-02 NDC inpatient 1 UN 5.79 5.79 CIGNA 62308 [3081051] CIGNA STATE OF WYOMING [308105107] 4.58 percent of total billed charges 3.59 5.5 Technical (Hospital) Services CHLORDIAZEPOXIDE 25 MG CAPSULE RX-1623 CDM 6370000100 HCPCS 250 RC 00555-0159-02 NDC outpatient 1 UN 5.79 5.79 MEDICA (COMMERCIAL) 94265 [3081118] MEDICA CLAIMS [308111801] 5.21 percent of total billed charges 3.59 5.5 Technical (Hospital) Services CHLORDIAZEPOXIDE 25 MG CAPSULE RX-1623 CDM 6370000100 HCPCS 250 RC 00555-0159-02 NDC outpatient 1 UN 5.79 5.79 CIGNA 62308 [3081051] CIGNA 62308 [308105105] 4.63 percent of total billed charges 3.59 5.5 Technical (Hospital) Services CHLORDIAZEPOXIDE 25 MG CAPSULE RX-1623 CDM 6370000100 HCPCS 250 RC 00555-0159-02 NDC outpatient 1 UN 5.79 5.79 CIGNA 62308 [3081051] CIGNA STATE OF WYOMING [308105107] 4.63 percent of total billed charges 3.59 5.5 Technical (Hospital) Services CHLORDIAZEPOXIDE 25 MG CAPSULE RX-1623 CDM 6370000100 HCPCS 250 RC 00555-0159-02 NDC outpatient 1 UN 5.79 5.79 MULTIPLAN INC 34080 [3081285] MULTIPLAN INC [308128501] 5.5 percent of total billed charges 3.59 5.5 Technical (Hospital) Services CHLORDIAZEPOXIDE 25 MG CAPSULE RX-1623 CDM 6370000100 HCPCS 250 RC 00555-0159-02 NDC outpatient 1 UN 5.79 5.79 UNITED HEALTHCARE (COMMERCIAL) [3081199] UNITED HEALTHCARE 87726 [308119901] 3.59 percent of total billed charges 3.59 5.5 Technical (Hospital) Services CHLORDIAZEPOXIDE 25 MG CAPSULE RX-1623 CDM 6370000100 HCPCS 250 RC 00555-0159-02 NDC outpatient 1 UN 5.79 5.79 HEALTHPARTNERS SX009 HEALTHPARTNERS 4.63 percent of total billed charges 3.59 5.5 Technical (Hospital) Services CHLORDIAZEPOXIDE 25 MG CAPSULE RX-1623 CDM 6370000100 HCPCS 250 RC 00555-0159-02 NDC inpatient 1 UN 5.79 5.79 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES PPO [308136801] 4.58 percent of total billed charges 3.59 5.5 Technical (Hospital) Services CHLORDIAZEPOXIDE 25 MG CAPSULE RX-1623 CDM 6370000100 HCPCS 250 RC 00555-0159-02 NDC inpatient 1 UN 5.79 5.79 HEALTHPARTNERS SX009 HEALTHPARTNERS 4.58 percent of total billed charges 3.59 5.5 Technical (Hospital) Services CHLORDIAZEPOXIDE 25 MG CAPSULE RX-1623 CDM 6370000100 HCPCS 250 RC 00555-0159-02 NDC inpatient 1 UN 5.79 5.79 MEDICA (COMMERCIAL) 94265 [3081118] MEDICA CLAIMS [308111801] 5.21 percent of total billed charges 3.59 5.5 Technical (Hospital) Services CHLORDIAZEPOXIDE 25 MG CAPSULE RX-1623 CDM 6370000100 HCPCS 250 RC 00555-0159-02 NDC inpatient 1 UN 5.79 5.79 MULTIPLAN INC 34080 [3081285] MULTIPLAN INC [308128501] 5.5 percent of total billed charges 3.59 5.5 Technical (Hospital) Services CHLORDIAZEPOXIDE 25 MG CAPSULE RX-1623 CDM 6370000100 HCPCS 250 RC 00555-0159-02 NDC outpatient 1 UN 5.79 5.79 BLUE CROSS BLUE SHIELD WELLMARK SB889 [3081026] BCBS WYOMING [308102603] 5.5 percent of total billed charges 3.59 5.5 Technical (Hospital) Services CHLORDIAZEPOXIDE 25 MG CAPSULE RX-1623 CDM 6370000100 HCPCS 250 RC 00555-0159-02 NDC outpatient 1 UN 5.79 5.79 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES PPO [308136801] 4.63 percent of total billed charges 3.59 5.5 Technical (Hospital) Services CHLORDIAZEPOXIDE 25 MG CAPSULE RX-1623 CDM 6370000100 HCPCS 250 RC 00555-0159-02 NDC outpatient 1 UN 5.79 5.79 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES HDHP [308136802] 4.63 percent of total billed charges 3.59 5.5 Technical (Hospital) Services CHLORDIAZEPOXIDE 25 MG CAPSULE RX-1623 CDM 6370000100 HCPCS 250 RC 00555-0159-02 NDC outpatient 1 UN 5.79 5.79 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES EPO [308136803] 4.63 percent of total billed charges 3.59 5.5 Technical (Hospital) Services CHLORDIAZEPOXIDE 5 MG CAPSULE RX-1624 CDM 6370000100 HCPCS 250 RC 51079-0374-01 NDC inpatient 1 UN 6.26 6.26 MULTIPLAN INC 34080 [3081285] MULTIPLAN INC [308128501] 5.95 percent of total billed charges 3.88 5.95 Technical (Hospital) Services CHLORDIAZEPOXIDE 5 MG CAPSULE RX-1624 CDM 6370000100 HCPCS 250 RC 51079-0374-01 NDC inpatient 1 UN 6.26 6.26 MEDICA (COMMERCIAL) 94265 [3081118] MEDICA CLAIMS [308111801] 5.63 percent of total billed charges 3.88 5.95 Technical (Hospital) Services CHLORDIAZEPOXIDE 5 MG CAPSULE RX-1624 CDM 6370000100 HCPCS 250 RC 51079-0374-01 NDC inpatient 1 UN 6.26 6.26 HEALTHPARTNERS SX009 HEALTHPARTNERS 4.96 percent of total billed charges 3.88 5.95 Technical (Hospital) Services CHLORDIAZEPOXIDE 5 MG CAPSULE RX-1624 CDM 6370000100 HCPCS 250 RC 51079-0374-01 NDC inpatient 1 UN 6.26 6.26 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES PPO [308136801] 4.96 percent of total billed charges 3.88 5.95 Technical (Hospital) Services CHLORDIAZEPOXIDE 5 MG CAPSULE RX-1624 CDM 6370000100 HCPCS 250 RC 51079-0374-01 NDC inpatient 1 UN 6.26 6.26 CIGNA 62308 [3081051] CIGNA 62308 [308105105] 4.96 percent of total billed charges 3.88 5.95 Technical (Hospital) Services CHLORDIAZEPOXIDE 5 MG CAPSULE RX-1624 CDM 6370000100 HCPCS 250 RC 51079-0374-01 NDC inpatient 1 UN 6.26 6.26 CIGNA 62308 [3081051] CIGNA STATE OF WYOMING [308105107] 4.96 percent of total billed charges 3.88 5.95 Technical (Hospital) Services CHLORDIAZEPOXIDE 5 MG CAPSULE RX-1624 CDM 6370000100 HCPCS 250 RC 51079-0374-01 NDC inpatient 1 UN 6.26 6.26 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES EPO [308136803] 4.96 percent of total billed charges 3.88 5.95 Technical (Hospital) Services CHLORDIAZEPOXIDE 5 MG CAPSULE RX-1624 CDM 6370000100 HCPCS 250 RC 51079-0374-01 NDC inpatient 1 UN 6.26 6.26 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES HDHP [308136802] 4.96 percent of total billed charges 3.88 5.95 Technical (Hospital) Services CHLORDIAZEPOXIDE 5 MG CAPSULE RX-1624 CDM 6370000100 HCPCS 250 RC 51079-0374-01 NDC inpatient 1 UN 6.26 6.26 BLUE CROSS BLUE SHIELD WELLMARK SB889 [3081026] BCBS WYOMING [308102603] 5.95 percent of total billed charges 3.88 5.95 Technical (Hospital) Services CHLORDIAZEPOXIDE 5 MG CAPSULE RX-1624 CDM 6370000100 HCPCS 250 RC 51079-0374-01 NDC inpatient 1 UN 6.26 6.26 UNITED HEALTHCARE (COMMERCIAL) [3081199] UNITED HEALTHCARE 87726 [308119901] 3.88 percent of total billed charges 3.88 5.95 Technical (Hospital) Services CHLORDIAZEPOXIDE 5 MG CAPSULE RX-1624 CDM 6370000100 HCPCS 250 RC 51079-0374-01 NDC outpatient 1 UN 6.26 6.26 CIGNA 62308 [3081051] CIGNA 62308 [308105105] 5.01 percent of total billed charges 3.88 5.95 Technical (Hospital) Services CHLORDIAZEPOXIDE 5 MG CAPSULE RX-1624 CDM 6370000100 HCPCS 250 RC 51079-0374-01 NDC outpatient 1 UN 6.26 6.26 CIGNA 62308 [3081051] CIGNA STATE OF WYOMING [308105107] 5.01 percent of total billed charges 3.88 5.95 Technical (Hospital) Services CHLORDIAZEPOXIDE 5 MG CAPSULE RX-1624 CDM 6370000100 HCPCS 250 RC 51079-0374-01 NDC outpatient 1 UN 6.26 6.26 MEDICA (COMMERCIAL) 94265 [3081118] MEDICA CLAIMS [308111801] 5.63 percent of total billed charges 3.88 5.95 Technical (Hospital) Services CHLORDIAZEPOXIDE 5 MG CAPSULE RX-1624 CDM 6370000100 HCPCS 250 RC 51079-0374-01 NDC outpatient 1 UN 6.26 6.26 UNITED HEALTHCARE (COMMERCIAL) [3081199] UNITED HEALTHCARE 87726 [308119901] 3.88 percent of total billed charges 3.88 5.95 Technical (Hospital) Services CHLORDIAZEPOXIDE 5 MG CAPSULE RX-1624 CDM 6370000100 HCPCS 250 RC 51079-0374-01 NDC outpatient 1 UN 6.26 6.26 MULTIPLAN INC 34080 [3081285] MULTIPLAN INC [308128501] 5.95 percent of total billed charges 3.88 5.95 Technical (Hospital) Services CHLORDIAZEPOXIDE 5 MG CAPSULE RX-1624 CDM 6370000100 HCPCS 250 RC 51079-0374-01 NDC outpatient 1 UN 6.26 6.26 HEALTHPARTNERS SX009 HEALTHPARTNERS 5.01 percent of total billed charges 3.88 5.95 Technical (Hospital) Services CHLORDIAZEPOXIDE 5 MG CAPSULE RX-1624 CDM 6370000100 HCPCS 250 RC 51079-0374-01 NDC outpatient 1 UN 6.26 6.26 BLUE CROSS BLUE SHIELD WELLMARK SB889 [3081026] BCBS WYOMING [308102603] 5.95 percent of total billed charges 3.88 5.95 Technical (Hospital) Services CHLORDIAZEPOXIDE 5 MG CAPSULE RX-1624 CDM 6370000100 HCPCS 250 RC 51079-0374-01 NDC outpatient 1 UN 6.26 6.26 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES HDHP [308136802] 5.01 percent of total billed charges 3.88 5.95 Technical (Hospital) Services CHLORDIAZEPOXIDE 5 MG CAPSULE RX-1624 CDM 6370000100 HCPCS 250 RC 51079-0374-01 NDC outpatient 1 UN 6.26 6.26 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES EPO [308136803] 5.01 percent of total billed charges 3.88 5.95 Technical (Hospital) Services CHLORDIAZEPOXIDE 5 MG CAPSULE RX-1624 CDM 6370000100 HCPCS 250 RC 51079-0374-01 NDC outpatient 1 UN 6.26 6.26 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES PPO [308136801] 5.01 percent of total billed charges 3.88 5.95 Technical (Hospital) Services GLIMEPIRIDE 2 MG TABLET RX-16356 CDM 6370000100 HCPCS 250 RC 68084-0326-11 NDC outpatient 1 UN 6.16 6.16 MULTIPLAN INC 34080 [3081285] MULTIPLAN INC [308128501] 5.85 percent of total billed charges 3.82 5.85 Technical (Hospital) Services GLIMEPIRIDE 2 MG TABLET RX-16356 CDM 6370000100 HCPCS 250 RC 68084-0326-11 NDC outpatient 1 UN 6.16 6.16 CIGNA 62308 [3081051] CIGNA 62308 [308105105] 4.93 percent of total billed charges 3.82 5.85 Technical (Hospital) Services GLIMEPIRIDE 2 MG TABLET RX-16356 CDM 6370000100 HCPCS 250 RC 68084-0326-11 NDC outpatient 1 UN 6.16 6.16 CIGNA 62308 [3081051] CIGNA STATE OF WYOMING [308105107] 4.93 percent of total billed charges 3.82 5.85 Technical (Hospital) Services GLIMEPIRIDE 2 MG TABLET RX-16356 CDM 6370000100 HCPCS 250 RC 68084-0326-11 NDC outpatient 1 UN 6.16 6.16 UNITED HEALTHCARE (COMMERCIAL) [3081199] UNITED HEALTHCARE 87726 [308119901] 3.82 percent of total billed charges 3.82 5.85 Technical (Hospital) Services GLIMEPIRIDE 2 MG TABLET RX-16356 CDM 6370000100 HCPCS 250 RC 68084-0326-11 NDC outpatient 1 UN 6.16 6.16 MEDICA (COMMERCIAL) 94265 [3081118] MEDICA CLAIMS [308111801] 5.54 percent of total billed charges 3.82 5.85 Technical (Hospital) Services GLIMEPIRIDE 2 MG TABLET RX-16356 CDM 6370000100 HCPCS 250 RC 68084-0326-11 NDC outpatient 1 UN 6.16 6.16 BLUE CROSS BLUE SHIELD WELLMARK SB889 [3081026] BCBS WYOMING [308102603] 5.85 percent of total billed charges 3.82 5.85 Technical (Hospital) Services GLIMEPIRIDE 2 MG TABLET RX-16356 CDM 6370000100 HCPCS 250 RC 68084-0326-11 NDC outpatient 1 UN 6.16 6.16 HEALTHPARTNERS SX009 HEALTHPARTNERS 4.93 percent of total billed charges 3.82 5.85 Technical (Hospital) Services GLIMEPIRIDE 2 MG TABLET RX-16356 CDM 6370000100 HCPCS 250 RC 68084-0326-11 NDC outpatient 1 UN 6.16 6.16 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES PPO [308136801] 4.93 percent of total billed charges 3.82 5.85 Technical (Hospital) Services GLIMEPIRIDE 2 MG TABLET RX-16356 CDM 6370000100 HCPCS 250 RC 68084-0326-11 NDC outpatient 1 UN 6.16 6.16 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES EPO [308136803] 4.93 percent of total billed charges 3.82 5.85 Technical (Hospital) Services GLIMEPIRIDE 2 MG TABLET RX-16356 CDM 6370000100 HCPCS 250 RC 68084-0326-11 NDC outpatient 1 UN 6.16 6.16 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES HDHP [308136802] 4.93 percent of total billed charges 3.82 5.85 Technical (Hospital) Services GLIMEPIRIDE 2 MG TABLET RX-16356 CDM 6370000100 HCPCS 250 RC 68084-0326-11 NDC inpatient 1 UN 6.16 6.16 MEDICA (COMMERCIAL) 94265 [3081118] MEDICA CLAIMS [308111801] 5.54 percent of total billed charges 3.82 5.85 Technical (Hospital) Services GLIMEPIRIDE 2 MG TABLET RX-16356 CDM 6370000100 HCPCS 250 RC 68084-0326-11 NDC inpatient 1 UN 6.16 6.16 HEALTHPARTNERS SX009 HEALTHPARTNERS 4.88 percent of total billed charges 3.82 5.85 Technical (Hospital) Services GLIMEPIRIDE 2 MG TABLET RX-16356 CDM 6370000100 HCPCS 250 RC 68084-0326-11 NDC inpatient 1 UN 6.16 6.16 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES PPO [308136801] 4.88 percent of total billed charges 3.82 5.85 Technical (Hospital) Services GLIMEPIRIDE 2 MG TABLET RX-16356 CDM 6370000100 HCPCS 250 RC 68084-0326-11 NDC inpatient 1 UN 6.16 6.16 MULTIPLAN INC 34080 [3081285] MULTIPLAN INC [308128501] 5.85 percent of total billed charges 3.82 5.85 Technical (Hospital) Services GLIMEPIRIDE 2 MG TABLET RX-16356 CDM 6370000100 HCPCS 250 RC 68084-0326-11 NDC inpatient 1 UN 6.16 6.16 BLUE CROSS BLUE SHIELD WELLMARK SB889 [3081026] BCBS WYOMING [308102603] 5.85 percent of total billed charges 3.82 5.85 Technical (Hospital) Services GLIMEPIRIDE 2 MG TABLET RX-16356 CDM 6370000100 HCPCS 250 RC 68084-0326-11 NDC inpatient 1 UN 6.16 6.16 UNITED HEALTHCARE (COMMERCIAL) [3081199] UNITED HEALTHCARE 87726 [308119901] 3.82 percent of total billed charges 3.82 5.85 Technical (Hospital) Services GLIMEPIRIDE 2 MG TABLET RX-16356 CDM 6370000100 HCPCS 250 RC 68084-0326-11 NDC inpatient 1 UN 6.16 6.16 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES HDHP [308136802] 4.88 percent of total billed charges 3.82 5.85 Technical (Hospital) Services GLIMEPIRIDE 2 MG TABLET RX-16356 CDM 6370000100 HCPCS 250 RC 68084-0326-11 NDC inpatient 1 UN 6.16 6.16 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES EPO [308136803] 4.88 percent of total billed charges 3.82 5.85 Technical (Hospital) Services GLIMEPIRIDE 2 MG TABLET RX-16356 CDM 6370000100 HCPCS 250 RC 68084-0326-11 NDC inpatient 1 UN 6.16 6.16 CIGNA 62308 [3081051] CIGNA 62308 [308105105] 4.88 percent of total billed charges 3.82 5.85 Technical (Hospital) Services GLIMEPIRIDE 2 MG TABLET RX-16356 CDM 6370000100 HCPCS 250 RC 68084-0326-11 NDC inpatient 1 UN 6.16 6.16 CIGNA 62308 [3081051] CIGNA STATE OF WYOMING [308105107] 4.88 percent of total billed charges 3.82 5.85 Technical (Hospital) Services GLIMEPIRIDE 4 MG TABLET RX-16357 CDM 6370000100 HCPCS 250 RC 16729-0003-01 NDC inpatient 1 UN 5.89 5.89 CIGNA 62308 [3081051] CIGNA 62308 [308105105] 4.66 percent of total billed charges 3.65 5.6 Technical (Hospital) Services GLIMEPIRIDE 4 MG TABLET RX-16357 CDM 6370000100 HCPCS 250 RC 16729-0003-01 NDC inpatient 1 UN 5.89 5.89 CIGNA 62308 [3081051] CIGNA STATE OF WYOMING [308105107] 4.66 percent of total billed charges 3.65 5.6 Technical (Hospital) Services GLIMEPIRIDE 4 MG TABLET RX-16357 CDM 6370000100 HCPCS 250 RC 16729-0003-01 NDC inpatient 1 UN 5.89 5.89 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES EPO [308136803] 4.66 percent of total billed charges 3.65 5.6 Technical (Hospital) Services GLIMEPIRIDE 4 MG TABLET RX-16357 CDM 6370000100 HCPCS 250 RC 16729-0003-01 NDC inpatient 1 UN 5.89 5.89 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES HDHP [308136802] 4.66 percent of total billed charges 3.65 5.6 Technical (Hospital) Services GLIMEPIRIDE 4 MG TABLET RX-16357 CDM 6370000100 HCPCS 250 RC 16729-0003-01 NDC inpatient 1 UN 5.89 5.89 BLUE CROSS BLUE SHIELD WELLMARK SB889 [3081026] BCBS WYOMING [308102603] 5.6 percent of total billed charges 3.65 5.6 Technical (Hospital) Services GLIMEPIRIDE 4 MG TABLET RX-16357 CDM 6370000100 HCPCS 250 RC 16729-0003-01 NDC inpatient 1 UN 5.89 5.89 UNITED HEALTHCARE (COMMERCIAL) [3081199] UNITED HEALTHCARE 87726 [308119901] 3.65 percent of total billed charges 3.65 5.6 Technical (Hospital) Services GLIMEPIRIDE 4 MG TABLET RX-16357 CDM 6370000100 HCPCS 250 RC 16729-0003-01 NDC inpatient 1 UN 5.89 5.89 HEALTHPARTNERS SX009 HEALTHPARTNERS 4.66 percent of total billed charges 3.65 5.6 Technical (Hospital) Services GLIMEPIRIDE 4 MG TABLET RX-16357 CDM 6370000100 HCPCS 250 RC 16729-0003-01 NDC inpatient 1 UN 5.89 5.89 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES PPO [308136801] 4.66 percent of total billed charges 3.65 5.6 Technical (Hospital) Services GLIMEPIRIDE 4 MG TABLET RX-16357 CDM 6370000100 HCPCS 250 RC 16729-0003-01 NDC inpatient 1 UN 5.89 5.89 MEDICA (COMMERCIAL) 94265 [3081118] MEDICA CLAIMS [308111801] 5.3 percent of total billed charges 3.65 5.6 Technical (Hospital) Services GLIMEPIRIDE 4 MG TABLET RX-16357 CDM 6370000100 HCPCS 250 RC 16729-0003-01 NDC inpatient 1 UN 5.89 5.89 MULTIPLAN INC 34080 [3081285] MULTIPLAN INC [308128501] 5.6 percent of total billed charges 3.65 5.6 Technical (Hospital) Services GLIMEPIRIDE 4 MG TABLET RX-16357 CDM 6370000100 HCPCS 250 RC 16729-0003-01 NDC outpatient 1 UN 5.89 5.89 MEDICA (COMMERCIAL) 94265 [3081118] MEDICA CLAIMS [308111801] 5.3 percent of total billed charges 3.65 5.6 Technical (Hospital) Services GLIMEPIRIDE 4 MG TABLET RX-16357 CDM 6370000100 HCPCS 250 RC 16729-0003-01 NDC outpatient 1 UN 5.89 5.89 MULTIPLAN INC 34080 [3081285] MULTIPLAN INC [308128501] 5.6 percent of total billed charges 3.65 5.6 Technical (Hospital) Services GLIMEPIRIDE 4 MG TABLET RX-16357 CDM 6370000100 HCPCS 250 RC 16729-0003-01 NDC outpatient 1 UN 5.89 5.89 CIGNA 62308 [3081051] CIGNA 62308 [308105105] 4.71 percent of total billed charges 3.65 5.6 Technical (Hospital) Services GLIMEPIRIDE 4 MG TABLET RX-16357 CDM 6370000100 HCPCS 250 RC 16729-0003-01 NDC outpatient 1 UN 5.89 5.89 CIGNA 62308 [3081051] CIGNA STATE OF WYOMING [308105107] 4.71 percent of total billed charges 3.65 5.6 Technical (Hospital) Services GLIMEPIRIDE 4 MG TABLET RX-16357 CDM 6370000100 HCPCS 250 RC 16729-0003-01 NDC outpatient 1 UN 5.89 5.89 UNITED HEALTHCARE (COMMERCIAL) [3081199] UNITED HEALTHCARE 87726 [308119901] 3.65 percent of total billed charges 3.65 5.6 Technical (Hospital) Services GLIMEPIRIDE 4 MG TABLET RX-16357 CDM 6370000100 HCPCS 250 RC 16729-0003-01 NDC outpatient 1 UN 5.89 5.89 HEALTHPARTNERS SX009 HEALTHPARTNERS 4.71 percent of total billed charges 3.65 5.6 Technical (Hospital) Services GLIMEPIRIDE 4 MG TABLET RX-16357 CDM 6370000100 HCPCS 250 RC 16729-0003-01 NDC outpatient 1 UN 5.89 5.89 BLUE CROSS BLUE SHIELD WELLMARK SB889 [3081026] BCBS WYOMING [308102603] 5.6 percent of total billed charges 3.65 5.6 Technical (Hospital) Services GLIMEPIRIDE 4 MG TABLET RX-16357 CDM 6370000100 HCPCS 250 RC 16729-0003-01 NDC outpatient 1 UN 5.89 5.89 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES PPO [308136801] 4.71 percent of total billed charges 3.65 5.6 Technical (Hospital) Services GLIMEPIRIDE 4 MG TABLET RX-16357 CDM 6370000100 HCPCS 250 RC 16729-0003-01 NDC outpatient 1 UN 5.89 5.89 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES HDHP [308136802] 4.71 percent of total billed charges 3.65 5.6 Technical (Hospital) Services GLIMEPIRIDE 4 MG TABLET RX-16357 CDM 6370000100 HCPCS 250 RC 16729-0003-01 NDC outpatient 1 UN 5.89 5.89 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES EPO [308136803] 4.71 percent of total billed charges 3.65 5.6 Technical (Hospital) Services CHLORTHALIDONE 25 MG TABLET RX-1661 CDM 6370000100 HCPCS 250 RC 60687-0317-25 NDC outpatient 1 UN 7.54 7.54 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES PPO [308136801] 6.03 percent of total billed charges 4.67 7.16 Technical (Hospital) Services CHLORTHALIDONE 25 MG TABLET RX-1661 CDM 6370000100 HCPCS 250 RC 60687-0317-25 NDC outpatient 1 UN 7.54 7.54 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES EPO [308136803] 6.03 percent of total billed charges 4.67 7.16 Technical (Hospital) Services CHLORTHALIDONE 25 MG TABLET RX-1661 CDM 6370000100 HCPCS 250 RC 60687-0317-25 NDC outpatient 1 UN 7.54 7.54 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES HDHP [308136802] 6.03 percent of total billed charges 4.67 7.16 Technical (Hospital) Services CHLORTHALIDONE 25 MG TABLET RX-1661 CDM 6370000100 HCPCS 250 RC 60687-0317-25 NDC outpatient 1 UN 7.54 7.54 UNITED HEALTHCARE (COMMERCIAL) [3081199] UNITED HEALTHCARE 87726 [308119901] 4.67 percent of total billed charges 4.67 7.16 Technical (Hospital) Services CHLORTHALIDONE 25 MG TABLET RX-1661 CDM 6370000100 HCPCS 250 RC 60687-0317-25 NDC outpatient 1 UN 7.54 7.54 MULTIPLAN INC 34080 [3081285] MULTIPLAN INC [308128501] 7.16 percent of total billed charges 4.67 7.16 Technical (Hospital) Services CHLORTHALIDONE 25 MG TABLET RX-1661 CDM 6370000100 HCPCS 250 RC 60687-0317-25 NDC outpatient 1 UN 7.54 7.54 CIGNA 62308 [3081051] CIGNA 62308 [308105105] 6.03 percent of total billed charges 4.67 7.16 Technical (Hospital) Services CHLORTHALIDONE 25 MG TABLET RX-1661 CDM 6370000100 HCPCS 250 RC 60687-0317-25 NDC outpatient 1 UN 7.54 7.54 CIGNA 62308 [3081051] CIGNA STATE OF WYOMING [308105107] 6.03 percent of total billed charges 4.67 7.16 Technical (Hospital) Services CHLORTHALIDONE 25 MG TABLET RX-1661 CDM 6370000100 HCPCS 250 RC 60687-0317-25 NDC outpatient 1 UN 7.54 7.54 MEDICA (COMMERCIAL) 94265 [3081118] MEDICA CLAIMS [308111801] 6.79 percent of total billed charges 4.67 7.16 Technical (Hospital) Services CHLORTHALIDONE 25 MG TABLET RX-1661 CDM 6370000100 HCPCS 250 RC 60687-0317-25 NDC outpatient 1 UN 7.54 7.54 BLUE CROSS BLUE SHIELD WELLMARK SB889 [3081026] BCBS WYOMING [308102603] 7.16 percent of total billed charges 4.67 7.16 Technical (Hospital) Services CHLORTHALIDONE 25 MG TABLET RX-1661 CDM 6370000100 HCPCS 250 RC 60687-0317-25 NDC outpatient 1 UN 7.54 7.54 HEALTHPARTNERS SX009 HEALTHPARTNERS 6.03 percent of total billed charges 4.67 7.16 Technical (Hospital) Services CHLORTHALIDONE 25 MG TABLET RX-1661 CDM 6370000100 HCPCS 250 RC 60687-0317-25 NDC inpatient 1 UN 7.54 7.54 UNITED HEALTHCARE (COMMERCIAL) [3081199] UNITED HEALTHCARE 87726 [308119901] 4.67 percent of total billed charges 4.67 7.16 Technical (Hospital) Services CHLORTHALIDONE 25 MG TABLET RX-1661 CDM 6370000100 HCPCS 250 RC 60687-0317-25 NDC inpatient 1 UN 7.54 7.54 BLUE CROSS BLUE SHIELD WELLMARK SB889 [3081026] BCBS WYOMING [308102603] 7.16 percent of total billed charges 4.67 7.16 Technical (Hospital) Services CHLORTHALIDONE 25 MG TABLET RX-1661 CDM 6370000100 HCPCS 250 RC 60687-0317-25 NDC inpatient 1 UN 7.54 7.54 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES EPO [308136803] 5.97 percent of total billed charges 4.67 7.16 Technical (Hospital) Services CHLORTHALIDONE 25 MG TABLET RX-1661 CDM 6370000100 HCPCS 250 RC 60687-0317-25 NDC inpatient 1 UN 7.54 7.54 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES HDHP [308136802] 5.97 percent of total billed charges 4.67 7.16 Technical (Hospital) Services CHLORTHALIDONE 25 MG TABLET RX-1661 CDM 6370000100 HCPCS 250 RC 60687-0317-25 NDC inpatient 1 UN 7.54 7.54 CIGNA 62308 [3081051] CIGNA 62308 [308105105] 5.97 percent of total billed charges 4.67 7.16 Technical (Hospital) Services CHLORTHALIDONE 25 MG TABLET RX-1661 CDM 6370000100 HCPCS 250 RC 60687-0317-25 NDC inpatient 1 UN 7.54 7.54 CIGNA 62308 [3081051] CIGNA STATE OF WYOMING [308105107] 5.97 percent of total billed charges 4.67 7.16 Technical (Hospital) Services CHLORTHALIDONE 25 MG TABLET RX-1661 CDM 6370000100 HCPCS 250 RC 60687-0317-25 NDC inpatient 1 UN 7.54 7.54 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES PPO [308136801] 5.97 percent of total billed charges 4.67 7.16 Technical (Hospital) Services CHLORTHALIDONE 25 MG TABLET RX-1661 CDM 6370000100 HCPCS 250 RC 60687-0317-25 NDC inpatient 1 UN 7.54 7.54 MEDICA (COMMERCIAL) 94265 [3081118] MEDICA CLAIMS [308111801] 6.79 percent of total billed charges 4.67 7.16 Technical (Hospital) Services CHLORTHALIDONE 25 MG TABLET RX-1661 CDM 6370000100 HCPCS 250 RC 60687-0317-25 NDC inpatient 1 UN 7.54 7.54 HEALTHPARTNERS SX009 HEALTHPARTNERS 5.97 percent of total billed charges 4.67 7.16 Technical (Hospital) Services CHLORTHALIDONE 25 MG TABLET RX-1661 CDM 6370000100 HCPCS 250 RC 60687-0317-25 NDC inpatient 1 UN 7.54 7.54 MULTIPLAN INC 34080 [3081285] MULTIPLAN INC [308128501] 7.16 percent of total billed charges 4.67 7.16 Technical (Hospital) Services PAROXETINE 10 MG TABLET RX-16632 CDM 6370000100 HCPCS 250 RC 00378-7001-93 NDC outpatient 1 UN 5.73 5.73 HEALTHPARTNERS SX009 HEALTHPARTNERS 4.58 percent of total billed charges 3.55 5.44 Technical (Hospital) Services PAROXETINE 10 MG TABLET RX-16632 CDM 6370000100 HCPCS 250 RC 00378-7001-93 NDC outpatient 1 UN 5.73 5.73 BLUE CROSS BLUE SHIELD WELLMARK SB889 [3081026] BCBS WYOMING [308102603] 5.44 percent of total billed charges 3.55 5.44 Technical (Hospital) Services PAROXETINE 10 MG TABLET RX-16632 CDM 6370000100 HCPCS 250 RC 00378-7001-93 NDC outpatient 1 UN 5.73 5.73 MULTIPLAN INC 34080 [3081285] MULTIPLAN INC [308128501] 5.44 percent of total billed charges 3.55 5.44 Technical (Hospital) Services PAROXETINE 10 MG TABLET RX-16632 CDM 6370000100 HCPCS 250 RC 00378-7001-93 NDC outpatient 1 UN 5.73 5.73 UNITED HEALTHCARE (COMMERCIAL) [3081199] UNITED HEALTHCARE 87726 [308119901] 3.55 percent of total billed charges 3.55 5.44 Technical (Hospital) Services PAROXETINE 10 MG TABLET RX-16632 CDM 6370000100 HCPCS 250 RC 00378-7001-93 NDC outpatient 1 UN 5.73 5.73 CIGNA 62308 [3081051] CIGNA 62308 [308105105] 4.58 percent of total billed charges 3.55 5.44 Technical (Hospital) Services PAROXETINE 10 MG TABLET RX-16632 CDM 6370000100 HCPCS 250 RC 00378-7001-93 NDC outpatient 1 UN 5.73 5.73 CIGNA 62308 [3081051] CIGNA STATE OF WYOMING [308105107] 4.58 percent of total billed charges 3.55 5.44 Technical (Hospital) Services PAROXETINE 10 MG TABLET RX-16632 CDM 6370000100 HCPCS 250 RC 00378-7001-93 NDC outpatient 1 UN 5.73 5.73 MEDICA (COMMERCIAL) 94265 [3081118] MEDICA CLAIMS [308111801] 5.16 percent of total billed charges 3.55 5.44 Technical (Hospital) Services PAROXETINE 10 MG TABLET RX-16632 CDM 6370000100 HCPCS 250 RC 00378-7001-93 NDC outpatient 1 UN 5.73 5.73 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES HDHP [308136802] 4.58 percent of total billed charges 3.55 5.44 Technical (Hospital) Services PAROXETINE 10 MG TABLET RX-16632 CDM 6370000100 HCPCS 250 RC 00378-7001-93 NDC outpatient 1 UN 5.73 5.73 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES EPO [308136803] 4.58 percent of total billed charges 3.55 5.44 Technical (Hospital) Services PAROXETINE 10 MG TABLET RX-16632 CDM 6370000100 HCPCS 250 RC 00378-7001-93 NDC outpatient 1 UN 5.73 5.73 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES PPO [308136801] 4.58 percent of total billed charges 3.55 5.44 Technical (Hospital) Services PAROXETINE 10 MG TABLET RX-16632 CDM 6370000100 HCPCS 250 RC 00378-7001-93 NDC inpatient 1 UN 5.73 5.73 UNITED HEALTHCARE (COMMERCIAL) [3081199] UNITED HEALTHCARE 87726 [308119901] 3.55 percent of total billed charges 3.55 5.44 Technical (Hospital) Services PAROXETINE 10 MG TABLET RX-16632 CDM 6370000100 HCPCS 250 RC 00378-7001-93 NDC inpatient 1 UN 5.73 5.73 BLUE CROSS BLUE SHIELD WELLMARK SB889 [3081026] BCBS WYOMING [308102603] 5.44 percent of total billed charges 3.55 5.44 Technical (Hospital) Services PAROXETINE 10 MG TABLET RX-16632 CDM 6370000100 HCPCS 250 RC 00378-7001-93 NDC inpatient 1 UN 5.73 5.73 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES HDHP [308136802] 4.54 percent of total billed charges 3.55 5.44 Technical (Hospital) Services PAROXETINE 10 MG TABLET RX-16632 CDM 6370000100 HCPCS 250 RC 00378-7001-93 NDC inpatient 1 UN 5.73 5.73 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES EPO [308136803] 4.54 percent of total billed charges 3.55 5.44 Technical (Hospital) Services PAROXETINE 10 MG TABLET RX-16632 CDM 6370000100 HCPCS 250 RC 00378-7001-93 NDC inpatient 1 UN 5.73 5.73 CIGNA 62308 [3081051] CIGNA 62308 [308105105] 4.54 percent of total billed charges 3.55 5.44 Technical (Hospital) Services PAROXETINE 10 MG TABLET RX-16632 CDM 6370000100 HCPCS 250 RC 00378-7001-93 NDC inpatient 1 UN 5.73 5.73 CIGNA 62308 [3081051] CIGNA STATE OF WYOMING [308105107] 4.54 percent of total billed charges 3.55 5.44 Technical (Hospital) Services PAROXETINE 10 MG TABLET RX-16632 CDM 6370000100 HCPCS 250 RC 00378-7001-93 NDC inpatient 1 UN 5.73 5.73 MULTIPLAN INC 34080 [3081285] MULTIPLAN INC [308128501] 5.44 percent of total billed charges 3.55 5.44 Technical (Hospital) Services PAROXETINE 10 MG TABLET RX-16632 CDM 6370000100 HCPCS 250 RC 00378-7001-93 NDC inpatient 1 UN 5.73 5.73 MEDICA (COMMERCIAL) 94265 [3081118] MEDICA CLAIMS [308111801] 5.16 percent of total billed charges 3.55 5.44 Technical (Hospital) Services PAROXETINE 10 MG TABLET RX-16632 CDM 6370000100 HCPCS 250 RC 00378-7001-93 NDC inpatient 1 UN 5.73 5.73 HEALTHPARTNERS SX009 HEALTHPARTNERS 4.54 percent of total billed charges 3.55 5.44 Technical (Hospital) Services PAROXETINE 10 MG TABLET RX-16632 CDM 6370000100 HCPCS 250 RC 00378-7001-93 NDC inpatient 1 UN 5.73 5.73 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES PPO [308136801] 4.54 percent of total billed charges 3.55 5.44 Technical (Hospital) Services PAROXETINE 40 MG TABLET RX-16633 CDM 6370000100 HCPCS 250 RC 00378-7004-93 NDC outpatient 1 UN 5.82 5.82 HEALTHPARTNERS SX009 HEALTHPARTNERS 4.66 percent of total billed charges 3.61 5.53 Technical (Hospital) Services PAROXETINE 40 MG TABLET RX-16633 CDM 6370000100 HCPCS 250 RC 00378-7004-93 NDC outpatient 1 UN 5.82 5.82 BLUE CROSS BLUE SHIELD WELLMARK SB889 [3081026] BCBS WYOMING [308102603] 5.53 percent of total billed charges 3.61 5.53 Technical (Hospital) Services PAROXETINE 40 MG TABLET RX-16633 CDM 6370000100 HCPCS 250 RC 00378-7004-93 NDC outpatient 1 UN 5.82 5.82 UNITED HEALTHCARE (COMMERCIAL) [3081199] UNITED HEALTHCARE 87726 [308119901] 3.61 percent of total billed charges 3.61 5.53 Technical (Hospital) Services PAROXETINE 40 MG TABLET RX-16633 CDM 6370000100 HCPCS 250 RC 00378-7004-93 NDC outpatient 1 UN 5.82 5.82 MEDICA (COMMERCIAL) 94265 [3081118] MEDICA CLAIMS [308111801] 5.24 percent of total billed charges 3.61 5.53 Technical (Hospital) Services PAROXETINE 40 MG TABLET RX-16633 CDM 6370000100 HCPCS 250 RC 00378-7004-93 NDC outpatient 1 UN 5.82 5.82 CIGNA 62308 [3081051] CIGNA 62308 [308105105] 4.66 percent of total billed charges 3.61 5.53 Technical (Hospital) Services PAROXETINE 40 MG TABLET RX-16633 CDM 6370000100 HCPCS 250 RC 00378-7004-93 NDC outpatient 1 UN 5.82 5.82 CIGNA 62308 [3081051] CIGNA STATE OF WYOMING [308105107] 4.66 percent of total billed charges 3.61 5.53 Technical (Hospital) Services PAROXETINE 40 MG TABLET RX-16633 CDM 6370000100 HCPCS 250 RC 00378-7004-93 NDC outpatient 1 UN 5.82 5.82 MULTIPLAN INC 34080 [3081285] MULTIPLAN INC [308128501] 5.53 percent of total billed charges 3.61 5.53 Technical (Hospital) Services PAROXETINE 40 MG TABLET RX-16633 CDM 6370000100 HCPCS 250 RC 00378-7004-93 NDC outpatient 1 UN 5.82 5.82 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES PPO [308136801] 4.66 percent of total billed charges 3.61 5.53 Technical (Hospital) Services PAROXETINE 40 MG TABLET RX-16633 CDM 6370000100 HCPCS 250 RC 00378-7004-93 NDC outpatient 1 UN 5.82 5.82 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES HDHP [308136802] 4.66 percent of total billed charges 3.61 5.53 Technical (Hospital) Services PAROXETINE 40 MG TABLET RX-16633 CDM 6370000100 HCPCS 250 RC 00378-7004-93 NDC outpatient 1 UN 5.82 5.82 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES EPO [308136803] 4.66 percent of total billed charges 3.61 5.53 Technical (Hospital) Services PAROXETINE 40 MG TABLET RX-16633 CDM 6370000100 HCPCS 250 RC 00378-7004-93 NDC inpatient 1 UN 5.82 5.82 MULTIPLAN INC 34080 [3081285] MULTIPLAN INC [308128501] 5.53 percent of total billed charges 3.61 5.53 Technical (Hospital) Services PAROXETINE 40 MG TABLET RX-16633 CDM 6370000100 HCPCS 250 RC 00378-7004-93 NDC inpatient 1 UN 5.82 5.82 MEDICA (COMMERCIAL) 94265 [3081118] MEDICA CLAIMS [308111801] 5.24 percent of total billed charges 3.61 5.53 Technical (Hospital) Services PAROXETINE 40 MG TABLET RX-16633 CDM 6370000100 HCPCS 250 RC 00378-7004-93 NDC inpatient 1 UN 5.82 5.82 HEALTHPARTNERS SX009 HEALTHPARTNERS 4.61 percent of total billed charges 3.61 5.53 Technical (Hospital) Services PAROXETINE 40 MG TABLET RX-16633 CDM 6370000100 HCPCS 250 RC 00378-7004-93 NDC inpatient 1 UN 5.82 5.82 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES PPO [308136801] 4.61 percent of total billed charges 3.61 5.53 Technical (Hospital) Services PAROXETINE 40 MG TABLET RX-16633 CDM 6370000100 HCPCS 250 RC 00378-7004-93 NDC inpatient 1 UN 5.82 5.82 UNITED HEALTHCARE (COMMERCIAL) [3081199] UNITED HEALTHCARE 87726 [308119901] 3.61 percent of total billed charges 3.61 5.53 Technical (Hospital) Services PAROXETINE 40 MG TABLET RX-16633 CDM 6370000100 HCPCS 250 RC 00378-7004-93 NDC inpatient 1 UN 5.82 5.82 BLUE CROSS BLUE SHIELD WELLMARK SB889 [3081026] BCBS WYOMING [308102603] 5.53 percent of total billed charges 3.61 5.53 Technical (Hospital) Services PAROXETINE 40 MG TABLET RX-16633 CDM 6370000100 HCPCS 250 RC 00378-7004-93 NDC inpatient 1 UN 5.82 5.82 CIGNA 62308 [3081051] CIGNA 62308 [308105105] 4.61 percent of total billed charges 3.61 5.53 Technical (Hospital) Services PAROXETINE 40 MG TABLET RX-16633 CDM 6370000100 HCPCS 250 RC 00378-7004-93 NDC inpatient 1 UN 5.82 5.82 CIGNA 62308 [3081051] CIGNA STATE OF WYOMING [308105107] 4.61 percent of total billed charges 3.61 5.53 Technical (Hospital) Services PAROXETINE 40 MG TABLET RX-16633 CDM 6370000100 HCPCS 250 RC 00378-7004-93 NDC inpatient 1 UN 5.82 5.82 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES HDHP [308136802] 4.61 percent of total billed charges 3.61 5.53 Technical (Hospital) Services PAROXETINE 40 MG TABLET RX-16633 CDM 6370000100 HCPCS 250 RC 00378-7004-93 NDC inpatient 1 UN 5.82 5.82 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES EPO [308136803] 4.61 percent of total billed charges 3.61 5.53 Technical (Hospital) Services LIDOCAINE 4 % TOPICAL PATCH RX-167271 CDM 6370000100 HCPCS 250 RC 46581-0830-06 NDC inpatient 1 UN 6.86 6.86 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES PPO [308136801] 5.43 percent of total billed charges 4.25 6.52 Technical (Hospital) Services LIDOCAINE 4 % TOPICAL PATCH RX-167271 CDM 6370000100 HCPCS 250 RC 46581-0830-06 NDC inpatient 1 UN 6.86 6.86 MULTIPLAN INC 34080 [3081285] MULTIPLAN INC [308128501] 6.52 percent of total billed charges 4.25 6.52 Technical (Hospital) Services LIDOCAINE 4 % TOPICAL PATCH RX-167271 CDM 6370000100 HCPCS 250 RC 46581-0830-06 NDC inpatient 1 UN 6.86 6.86 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES HDHP [308136802] 5.43 percent of total billed charges 4.25 6.52 Technical (Hospital) Services LIDOCAINE 4 % TOPICAL PATCH RX-167271 CDM 6370000100 HCPCS 250 RC 46581-0830-06 NDC inpatient 1 UN 6.86 6.86 MEDICA (COMMERCIAL) 94265 [3081118] MEDICA CLAIMS [308111801] 6.17 percent of total billed charges 4.25 6.52 Technical (Hospital) Services LIDOCAINE 4 % TOPICAL PATCH RX-167271 CDM 6370000100 HCPCS 250 RC 46581-0830-06 NDC inpatient 1 UN 6.86 6.86 HEALTHPARTNERS SX009 HEALTHPARTNERS 5.43 percent of total billed charges 4.25 6.52 Technical (Hospital) Services LIDOCAINE 4 % TOPICAL PATCH RX-167271 CDM 6370000100 HCPCS 250 RC 46581-0830-06 NDC inpatient 1 UN 6.86 6.86 CIGNA 62308 [3081051] CIGNA 62308 [308105105] 5.43 percent of total billed charges 4.25 6.52 Technical (Hospital) Services LIDOCAINE 4 % TOPICAL PATCH RX-167271 CDM 6370000100 HCPCS 250 RC 46581-0830-06 NDC inpatient 1 UN 6.86 6.86 CIGNA 62308 [3081051] CIGNA STATE OF WYOMING [308105107] 5.43 percent of total billed charges 4.25 6.52 Technical (Hospital) Services LIDOCAINE 4 % TOPICAL PATCH RX-167271 CDM 6370000100 HCPCS 250 RC 46581-0830-06 NDC inpatient 1 UN 6.86 6.86 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES EPO [308136803] 5.43 percent of total billed charges 4.25 6.52 Technical (Hospital) Services LIDOCAINE 4 % TOPICAL PATCH RX-167271 CDM 6370000100 HCPCS 250 RC 46581-0830-06 NDC inpatient 1 UN 6.86 6.86 UNITED HEALTHCARE (COMMERCIAL) [3081199] UNITED HEALTHCARE 87726 [308119901] 4.25 percent of total billed charges 4.25 6.52 Technical (Hospital) Services LIDOCAINE 4 % TOPICAL PATCH RX-167271 CDM 6370000100 HCPCS 250 RC 46581-0830-06 NDC inpatient 1 UN 6.86 6.86 BLUE CROSS BLUE SHIELD WELLMARK SB889 [3081026] BCBS WYOMING [308102603] 6.52 percent of total billed charges 4.25 6.52 Technical (Hospital) Services LIDOCAINE 4 % TOPICAL PATCH RX-167271 CDM 6370000100 HCPCS 250 RC 46581-0830-06 NDC outpatient 1 UN 6.86 6.86 MULTIPLAN INC 34080 [3081285] MULTIPLAN INC [308128501] 6.52 percent of total billed charges 4.25 6.52 Technical (Hospital) Services LIDOCAINE 4 % TOPICAL PATCH RX-167271 CDM 6370000100 HCPCS 250 RC 46581-0830-06 NDC outpatient 1 UN 6.86 6.86 CIGNA 62308 [3081051] CIGNA 62308 [308105105] 5.49 percent of total billed charges 4.25 6.52 Technical (Hospital) Services LIDOCAINE 4 % TOPICAL PATCH RX-167271 CDM 6370000100 HCPCS 250 RC 46581-0830-06 NDC outpatient 1 UN 6.86 6.86 CIGNA 62308 [3081051] CIGNA STATE OF WYOMING [308105107] 5.49 percent of total billed charges 4.25 6.52 Technical (Hospital) Services LIDOCAINE 4 % TOPICAL PATCH RX-167271 CDM 6370000100 HCPCS 250 RC 46581-0830-06 NDC outpatient 1 UN 6.86 6.86 MEDICA (COMMERCIAL) 94265 [3081118] MEDICA CLAIMS [308111801] 6.17 percent of total billed charges 4.25 6.52 Technical (Hospital) Services LIDOCAINE 4 % TOPICAL PATCH RX-167271 CDM 6370000100 HCPCS 250 RC 46581-0830-06 NDC outpatient 1 UN 6.86 6.86 UNITED HEALTHCARE (COMMERCIAL) [3081199] UNITED HEALTHCARE 87726 [308119901] 4.25 percent of total billed charges 4.25 6.52 Technical (Hospital) Services LIDOCAINE 4 % TOPICAL PATCH RX-167271 CDM 6370000100 HCPCS 250 RC 46581-0830-06 NDC outpatient 1 UN 6.86 6.86 HEALTHPARTNERS SX009 HEALTHPARTNERS 5.49 percent of total billed charges 4.25 6.52 Technical (Hospital) Services LIDOCAINE 4 % TOPICAL PATCH RX-167271 CDM 6370000100 HCPCS 250 RC 46581-0830-06 NDC outpatient 1 UN 6.86 6.86 BLUE CROSS BLUE SHIELD WELLMARK SB889 [3081026] BCBS WYOMING [308102603] 6.52 percent of total billed charges 4.25 6.52 Technical (Hospital) Services LIDOCAINE 4 % TOPICAL PATCH RX-167271 CDM 6370000100 HCPCS 250 RC 46581-0830-06 NDC outpatient 1 UN 6.86 6.86 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES PPO [308136801] 5.49 percent of total billed charges 4.25 6.52 Technical (Hospital) Services LIDOCAINE 4 % TOPICAL PATCH RX-167271 CDM 6370000100 HCPCS 250 RC 46581-0830-06 NDC outpatient 1 UN 6.86 6.86 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES HDHP [308136802] 5.49 percent of total billed charges 4.25 6.52 Technical (Hospital) Services LIDOCAINE 4 % TOPICAL PATCH RX-167271 CDM 6370000100 HCPCS 250 RC 46581-0830-06 NDC outpatient 1 UN 6.86 6.86 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES EPO [308136803] 5.49 percent of total billed charges 4.25 6.52 Technical (Hospital) Services "THEOPHYLLINE ER 400 MG TABLET,EXTENDED RELEASE 24 HR" RX-167272 CDM 6370000100 HCPCS 250 RC 68462-0380-01 NDC outpatient 1 UN 6.96 6.96 BLUE CROSS BLUE SHIELD WELLMARK SB889 [3081026] BCBS WYOMING [308102603] 6.61 percent of total billed charges 4.32 6.61 Technical (Hospital) Services "THEOPHYLLINE ER 400 MG TABLET,EXTENDED RELEASE 24 HR" RX-167272 CDM 6370000100 HCPCS 250 RC 68462-0380-01 NDC outpatient 1 UN 6.96 6.96 HEALTHPARTNERS SX009 HEALTHPARTNERS 5.57 percent of total billed charges 4.32 6.61 Technical (Hospital) Services "THEOPHYLLINE ER 400 MG TABLET,EXTENDED RELEASE 24 HR" RX-167272 CDM 6370000100 HCPCS 250 RC 68462-0380-01 NDC outpatient 1 UN 6.96 6.96 MEDICA (COMMERCIAL) 94265 [3081118] MEDICA CLAIMS [308111801] 6.26 percent of total billed charges 4.32 6.61 Technical (Hospital) Services "THEOPHYLLINE ER 400 MG TABLET,EXTENDED RELEASE 24 HR" RX-167272 CDM 6370000100 HCPCS 250 RC 68462-0380-01 NDC outpatient 1 UN 6.96 6.96 MULTIPLAN INC 34080 [3081285] MULTIPLAN INC [308128501] 6.61 percent of total billed charges 4.32 6.61 Technical (Hospital) Services "THEOPHYLLINE ER 400 MG TABLET,EXTENDED RELEASE 24 HR" RX-167272 CDM 6370000100 HCPCS 250 RC 68462-0380-01 NDC outpatient 1 UN 6.96 6.96 CIGNA 62308 [3081051] CIGNA 62308 [308105105] 5.57 percent of total billed charges 4.32 6.61 Technical (Hospital) Services "THEOPHYLLINE ER 400 MG TABLET,EXTENDED RELEASE 24 HR" RX-167272 CDM 6370000100 HCPCS 250 RC 68462-0380-01 NDC outpatient 1 UN 6.96 6.96 CIGNA 62308 [3081051] CIGNA STATE OF WYOMING [308105107] 5.57 percent of total billed charges 4.32 6.61 Technical (Hospital) Services "THEOPHYLLINE ER 400 MG TABLET,EXTENDED RELEASE 24 HR" RX-167272 CDM 6370000100 HCPCS 250 RC 68462-0380-01 NDC outpatient 1 UN 6.96 6.96 UNITED HEALTHCARE (COMMERCIAL) [3081199] UNITED HEALTHCARE 87726 [308119901] 4.32 percent of total billed charges 4.32 6.61 Technical (Hospital) Services "THEOPHYLLINE ER 400 MG TABLET,EXTENDED RELEASE 24 HR" RX-167272 CDM 6370000100 HCPCS 250 RC 68462-0380-01 NDC outpatient 1 UN 6.96 6.96 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES EPO [308136803] 5.57 percent of total billed charges 4.32 6.61 Technical (Hospital) Services "THEOPHYLLINE ER 400 MG TABLET,EXTENDED RELEASE 24 HR" RX-167272 CDM 6370000100 HCPCS 250 RC 68462-0380-01 NDC outpatient 1 UN 6.96 6.96 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES HDHP [308136802] 5.57 percent of total billed charges 4.32 6.61 Technical (Hospital) Services "THEOPHYLLINE ER 400 MG TABLET,EXTENDED RELEASE 24 HR" RX-167272 CDM 6370000100 HCPCS 250 RC 68462-0380-01 NDC outpatient 1 UN 6.96 6.96 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES PPO [308136801] 5.57 percent of total billed charges 4.32 6.61 Technical (Hospital) Services "THEOPHYLLINE ER 400 MG TABLET,EXTENDED RELEASE 24 HR" RX-167272 CDM 6370000100 HCPCS 250 RC 68462-0380-01 NDC inpatient 1 UN 6.96 6.96 UNITED HEALTHCARE (COMMERCIAL) [3081199] UNITED HEALTHCARE 87726 [308119901] 4.32 percent of total billed charges 4.32 6.61 Technical (Hospital) Services "THEOPHYLLINE ER 400 MG TABLET,EXTENDED RELEASE 24 HR" RX-167272 CDM 6370000100 HCPCS 250 RC 68462-0380-01 NDC inpatient 1 UN 6.96 6.96 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES EPO [308136803] 5.51 percent of total billed charges 4.32 6.61 Technical (Hospital) Services "THEOPHYLLINE ER 400 MG TABLET,EXTENDED RELEASE 24 HR" RX-167272 CDM 6370000100 HCPCS 250 RC 68462-0380-01 NDC inpatient 1 UN 6.96 6.96 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES HDHP [308136802] 5.51 percent of total billed charges 4.32 6.61 Technical (Hospital) Services "THEOPHYLLINE ER 400 MG TABLET,EXTENDED RELEASE 24 HR" RX-167272 CDM 6370000100 HCPCS 250 RC 68462-0380-01 NDC inpatient 1 UN 6.96 6.96 CIGNA 62308 [3081051] CIGNA 62308 [308105105] 5.51 percent of total billed charges 4.32 6.61 Technical (Hospital) Services "THEOPHYLLINE ER 400 MG TABLET,EXTENDED RELEASE 24 HR" RX-167272 CDM 6370000100 HCPCS 250 RC 68462-0380-01 NDC inpatient 1 UN 6.96 6.96 CIGNA 62308 [3081051] CIGNA STATE OF WYOMING [308105107] 5.51 percent of total billed charges 4.32 6.61 Technical (Hospital) Services "THEOPHYLLINE ER 400 MG TABLET,EXTENDED RELEASE 24 HR" RX-167272 CDM 6370000100 HCPCS 250 RC 68462-0380-01 NDC inpatient 1 UN 6.96 6.96 BLUE CROSS BLUE SHIELD WELLMARK SB889 [3081026] BCBS WYOMING [308102603] 6.61 percent of total billed charges 4.32 6.61 Technical (Hospital) Services "THEOPHYLLINE ER 400 MG TABLET,EXTENDED RELEASE 24 HR" RX-167272 CDM 6370000100 HCPCS 250 RC 68462-0380-01 NDC inpatient 1 UN 6.96 6.96 MEDICA (COMMERCIAL) 94265 [3081118] MEDICA CLAIMS [308111801] 6.26 percent of total billed charges 4.32 6.61 Technical (Hospital) Services "THEOPHYLLINE ER 400 MG TABLET,EXTENDED RELEASE 24 HR" RX-167272 CDM 6370000100 HCPCS 250 RC 68462-0380-01 NDC inpatient 1 UN 6.96 6.96 HEALTHPARTNERS SX009 HEALTHPARTNERS 5.51 percent of total billed charges 4.32 6.61 Technical (Hospital) Services "THEOPHYLLINE ER 400 MG TABLET,EXTENDED RELEASE 24 HR" RX-167272 CDM 6370000100 HCPCS 250 RC 68462-0380-01 NDC inpatient 1 UN 6.96 6.96 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES PPO [308136801] 5.51 percent of total billed charges 4.32 6.61 Technical (Hospital) Services "THEOPHYLLINE ER 400 MG TABLET,EXTENDED RELEASE 24 HR" RX-167272 CDM 6370000100 HCPCS 250 RC 68462-0380-01 NDC inpatient 1 UN 6.96 6.96 MULTIPLAN INC 34080 [3081285] MULTIPLAN INC [308128501] 6.61 percent of total billed charges 4.32 6.61 Technical (Hospital) Services SODIUM POLYSTYRENE SULFONATE 15 GRAM-SORBITOL 20 GRAM/60 ML ORAL SUSP RX-167371 CDM 6370000100 HCPCS 250 RC 46287-0006-60 NDC inpatient 60 ML 107.28 107.28 CIGNA 62308 [3081051] CIGNA 62308 [308105105] 84.94 percent of total billed charges 66.51 101.92 Technical (Hospital) Services SODIUM POLYSTYRENE SULFONATE 15 GRAM-SORBITOL 20 GRAM/60 ML ORAL SUSP RX-167371 CDM 6370000100 HCPCS 250 RC 46287-0006-60 NDC inpatient 60 ML 107.28 107.28 CIGNA 62308 [3081051] CIGNA STATE OF WYOMING [308105107] 84.94 percent of total billed charges 66.51 101.92 Technical (Hospital) Services SODIUM POLYSTYRENE SULFONATE 15 GRAM-SORBITOL 20 GRAM/60 ML ORAL SUSP RX-167371 CDM 6370000100 HCPCS 250 RC 46287-0006-60 NDC inpatient 60 ML 107.28 107.28 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES EPO [308136803] 84.94 percent of total billed charges 66.51 101.92 Technical (Hospital) Services SODIUM POLYSTYRENE SULFONATE 15 GRAM-SORBITOL 20 GRAM/60 ML ORAL SUSP RX-167371 CDM 6370000100 HCPCS 250 RC 46287-0006-60 NDC inpatient 60 ML 107.28 107.28 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES HDHP [308136802] 84.94 percent of total billed charges 66.51 101.92 Technical (Hospital) Services SODIUM POLYSTYRENE SULFONATE 15 GRAM-SORBITOL 20 GRAM/60 ML ORAL SUSP RX-167371 CDM 6370000100 HCPCS 250 RC 46287-0006-60 NDC inpatient 60 ML 107.28 107.28 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES PPO [308136801] 84.94 percent of total billed charges 66.51 101.92 Technical (Hospital) Services SODIUM POLYSTYRENE SULFONATE 15 GRAM-SORBITOL 20 GRAM/60 ML ORAL SUSP RX-167371 CDM 6370000100 HCPCS 250 RC 46287-0006-60 NDC inpatient 60 ML 107.28 107.28 MEDICA (COMMERCIAL) 94265 [3081118] MEDICA CLAIMS [308111801] 96.55 percent of total billed charges 66.51 101.92 Technical (Hospital) Services SODIUM POLYSTYRENE SULFONATE 15 GRAM-SORBITOL 20 GRAM/60 ML ORAL SUSP RX-167371 CDM 6370000100 HCPCS 250 RC 46287-0006-60 NDC inpatient 60 ML 107.28 107.28 MULTIPLAN INC 34080 [3081285] MULTIPLAN INC [308128501] 101.92 percent of total billed charges 66.51 101.92 Technical (Hospital) Services SODIUM POLYSTYRENE SULFONATE 15 GRAM-SORBITOL 20 GRAM/60 ML ORAL SUSP RX-167371 CDM 6370000100 HCPCS 250 RC 46287-0006-60 NDC inpatient 60 ML 107.28 107.28 HEALTHPARTNERS SX009 HEALTHPARTNERS 84.94 percent of total billed charges 66.51 101.92 Technical (Hospital) Services SODIUM POLYSTYRENE SULFONATE 15 GRAM-SORBITOL 20 GRAM/60 ML ORAL SUSP RX-167371 CDM 6370000100 HCPCS 250 RC 46287-0006-60 NDC inpatient 60 ML 107.28 107.28 BLUE CROSS BLUE SHIELD WELLMARK SB889 [3081026] BCBS WYOMING [308102603] 101.92 percent of total billed charges 66.51 101.92 Technical (Hospital) Services SODIUM POLYSTYRENE SULFONATE 15 GRAM-SORBITOL 20 GRAM/60 ML ORAL SUSP RX-167371 CDM 6370000100 HCPCS 250 RC 46287-0006-60 NDC inpatient 60 ML 107.28 107.28 UNITED HEALTHCARE (COMMERCIAL) [3081199] UNITED HEALTHCARE 87726 [308119901] 66.51 percent of total billed charges 66.51 101.92 Technical (Hospital) Services SODIUM POLYSTYRENE SULFONATE 15 GRAM-SORBITOL 20 GRAM/60 ML ORAL SUSP RX-167371 CDM 6370000100 HCPCS 250 RC 46287-0006-60 NDC outpatient 60 ML 107.28 107.28 UNITED HEALTHCARE (COMMERCIAL) [3081199] UNITED HEALTHCARE 87726 [308119901] 66.51 percent of total billed charges 66.51 101.92 Technical (Hospital) Services SODIUM POLYSTYRENE SULFONATE 15 GRAM-SORBITOL 20 GRAM/60 ML ORAL SUSP RX-167371 CDM 6370000100 HCPCS 250 RC 46287-0006-60 NDC outpatient 60 ML 107.28 107.28 BLUE CROSS BLUE SHIELD WELLMARK SB889 [3081026] BCBS WYOMING [308102603] 101.92 percent of total billed charges 66.51 101.92 Technical (Hospital) Services SODIUM POLYSTYRENE SULFONATE 15 GRAM-SORBITOL 20 GRAM/60 ML ORAL SUSP RX-167371 CDM 6370000100 HCPCS 250 RC 46287-0006-60 NDC outpatient 60 ML 107.28 107.28 HEALTHPARTNERS SX009 HEALTHPARTNERS 85.82 percent of total billed charges 66.51 101.92 Technical (Hospital) Services SODIUM POLYSTYRENE SULFONATE 15 GRAM-SORBITOL 20 GRAM/60 ML ORAL SUSP RX-167371 CDM 6370000100 HCPCS 250 RC 46287-0006-60 NDC outpatient 60 ML 107.28 107.28 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES EPO [308136803] 85.82 percent of total billed charges 66.51 101.92 Technical (Hospital) Services SODIUM POLYSTYRENE SULFONATE 15 GRAM-SORBITOL 20 GRAM/60 ML ORAL SUSP RX-167371 CDM 6370000100 HCPCS 250 RC 46287-0006-60 NDC outpatient 60 ML 107.28 107.28 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES HDHP [308136802] 85.82 percent of total billed charges 66.51 101.92 Technical (Hospital) Services SODIUM POLYSTYRENE SULFONATE 15 GRAM-SORBITOL 20 GRAM/60 ML ORAL SUSP RX-167371 CDM 6370000100 HCPCS 250 RC 46287-0006-60 NDC outpatient 60 ML 107.28 107.28 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES PPO [308136801] 85.82 percent of total billed charges 66.51 101.92 Technical (Hospital) Services SODIUM POLYSTYRENE SULFONATE 15 GRAM-SORBITOL 20 GRAM/60 ML ORAL SUSP RX-167371 CDM 6370000100 HCPCS 250 RC 46287-0006-60 NDC outpatient 60 ML 107.28 107.28 MEDICA (COMMERCIAL) 94265 [3081118] MEDICA CLAIMS [308111801] 96.55 percent of total billed charges 66.51 101.92 Technical (Hospital) Services SODIUM POLYSTYRENE SULFONATE 15 GRAM-SORBITOL 20 GRAM/60 ML ORAL SUSP RX-167371 CDM 6370000100 HCPCS 250 RC 46287-0006-60 NDC outpatient 60 ML 107.28 107.28 MULTIPLAN INC 34080 [3081285] MULTIPLAN INC [308128501] 101.92 percent of total billed charges 66.51 101.92 Technical (Hospital) Services SODIUM POLYSTYRENE SULFONATE 15 GRAM-SORBITOL 20 GRAM/60 ML ORAL SUSP RX-167371 CDM 6370000100 HCPCS 250 RC 46287-0006-60 NDC outpatient 60 ML 107.28 107.28 CIGNA 62308 [3081051] CIGNA 62308 [308105105] 85.82 percent of total billed charges 66.51 101.92 Technical (Hospital) Services SODIUM POLYSTYRENE SULFONATE 15 GRAM-SORBITOL 20 GRAM/60 ML ORAL SUSP RX-167371 CDM 6370000100 HCPCS 250 RC 46287-0006-60 NDC outpatient 60 ML 107.28 107.28 CIGNA 62308 [3081051] CIGNA STATE OF WYOMING [308105107] 85.82 percent of total billed charges 66.51 101.92 Technical (Hospital) Services LACTOBACILLUS ACIDOPHILUS 500 MILLION CELL CAPSULE RX-167980 CDM 6370000100 HCPCS 250 RC 00904-7260-06 NDC inpatient 1 UN 6.04 6.04 MEDICA (COMMERCIAL) 94265 [3081118] MEDICA CLAIMS [308111801] 5.44 percent of total billed charges 3.74 5.74 Technical (Hospital) Services LACTOBACILLUS ACIDOPHILUS 500 MILLION CELL CAPSULE RX-167980 CDM 6370000100 HCPCS 250 RC 00904-7260-06 NDC inpatient 1 UN 6.04 6.04 HEALTHPARTNERS SX009 HEALTHPARTNERS 4.78 percent of total billed charges 3.74 5.74 Technical (Hospital) Services LACTOBACILLUS ACIDOPHILUS 500 MILLION CELL CAPSULE RX-167980 CDM 6370000100 HCPCS 250 RC 00904-7260-06 NDC inpatient 1 UN 6.04 6.04 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES PPO [308136801] 4.78 percent of total billed charges 3.74 5.74 Technical (Hospital) Services LACTOBACILLUS ACIDOPHILUS 500 MILLION CELL CAPSULE RX-167980 CDM 6370000100 HCPCS 250 RC 00904-7260-06 NDC inpatient 1 UN 6.04 6.04 MULTIPLAN INC 34080 [3081285] MULTIPLAN INC [308128501] 5.74 percent of total billed charges 3.74 5.74 Technical (Hospital) Services LACTOBACILLUS ACIDOPHILUS 500 MILLION CELL CAPSULE RX-167980 CDM 6370000100 HCPCS 250 RC 00904-7260-06 NDC inpatient 1 UN 6.04 6.04 UNITED HEALTHCARE (COMMERCIAL) [3081199] UNITED HEALTHCARE 87726 [308119901] 3.74 percent of total billed charges 3.74 5.74 Technical (Hospital) Services LACTOBACILLUS ACIDOPHILUS 500 MILLION CELL CAPSULE RX-167980 CDM 6370000100 HCPCS 250 RC 00904-7260-06 NDC inpatient 1 UN 6.04 6.04 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES HDHP [308136802] 4.78 percent of total billed charges 3.74 5.74 Technical (Hospital) Services LACTOBACILLUS ACIDOPHILUS 500 MILLION CELL CAPSULE RX-167980 CDM 6370000100 HCPCS 250 RC 00904-7260-06 NDC inpatient 1 UN 6.04 6.04 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES EPO [308136803] 4.78 percent of total billed charges 3.74 5.74 Technical (Hospital) Services LACTOBACILLUS ACIDOPHILUS 500 MILLION CELL CAPSULE RX-167980 CDM 6370000100 HCPCS 250 RC 00904-7260-06 NDC inpatient 1 UN 6.04 6.04 CIGNA 62308 [3081051] CIGNA 62308 [308105105] 4.78 percent of total billed charges 3.74 5.74 Technical (Hospital) Services LACTOBACILLUS ACIDOPHILUS 500 MILLION CELL CAPSULE RX-167980 CDM 6370000100 HCPCS 250 RC 00904-7260-06 NDC inpatient 1 UN 6.04 6.04 CIGNA 62308 [3081051] CIGNA STATE OF WYOMING [308105107] 4.78 percent of total billed charges 3.74 5.74 Technical (Hospital) Services LACTOBACILLUS ACIDOPHILUS 500 MILLION CELL CAPSULE RX-167980 CDM 6370000100 HCPCS 250 RC 00904-7260-06 NDC inpatient 1 UN 6.04 6.04 BLUE CROSS BLUE SHIELD WELLMARK SB889 [3081026] BCBS WYOMING [308102603] 5.74 percent of total billed charges 3.74 5.74 Technical (Hospital) Services LACTOBACILLUS ACIDOPHILUS 500 MILLION CELL CAPSULE RX-167980 CDM 6370000100 HCPCS 250 RC 00904-7260-06 NDC outpatient 1 UN 6.04 6.04 HEALTHPARTNERS SX009 HEALTHPARTNERS 4.83 percent of total billed charges 3.74 5.74 Technical (Hospital) Services LACTOBACILLUS ACIDOPHILUS 500 MILLION CELL CAPSULE RX-167980 CDM 6370000100 HCPCS 250 RC 00904-7260-06 NDC outpatient 1 UN 6.04 6.04 UNITED HEALTHCARE (COMMERCIAL) [3081199] UNITED HEALTHCARE 87726 [308119901] 3.74 percent of total billed charges 3.74 5.74 Technical (Hospital) Services LACTOBACILLUS ACIDOPHILUS 500 MILLION CELL CAPSULE RX-167980 CDM 6370000100 HCPCS 250 RC 00904-7260-06 NDC outpatient 1 UN 6.04 6.04 MULTIPLAN INC 34080 [3081285] MULTIPLAN INC [308128501] 5.74 percent of total billed charges 3.74 5.74 Technical (Hospital) Services LACTOBACILLUS ACIDOPHILUS 500 MILLION CELL CAPSULE RX-167980 CDM 6370000100 HCPCS 250 RC 00904-7260-06 NDC outpatient 1 UN 6.04 6.04 CIGNA 62308 [3081051] CIGNA 62308 [308105105] 4.83 percent of total billed charges 3.74 5.74 Technical (Hospital) Services LACTOBACILLUS ACIDOPHILUS 500 MILLION CELL CAPSULE RX-167980 CDM 6370000100 HCPCS 250 RC 00904-7260-06 NDC outpatient 1 UN 6.04 6.04 CIGNA 62308 [3081051] CIGNA STATE OF WYOMING [308105107] 4.83 percent of total billed charges 3.74 5.74 Technical (Hospital) Services LACTOBACILLUS ACIDOPHILUS 500 MILLION CELL CAPSULE RX-167980 CDM 6370000100 HCPCS 250 RC 00904-7260-06 NDC outpatient 1 UN 6.04 6.04 MEDICA (COMMERCIAL) 94265 [3081118] MEDICA CLAIMS [308111801] 5.44 percent of total billed charges 3.74 5.74 Technical (Hospital) Services LACTOBACILLUS ACIDOPHILUS 500 MILLION CELL CAPSULE RX-167980 CDM 6370000100 HCPCS 250 RC 00904-7260-06 NDC outpatient 1 UN 6.04 6.04 BLUE CROSS BLUE SHIELD WELLMARK SB889 [3081026] BCBS WYOMING [308102603] 5.74 percent of total billed charges 3.74 5.74 Technical (Hospital) Services LACTOBACILLUS ACIDOPHILUS 500 MILLION CELL CAPSULE RX-167980 CDM 6370000100 HCPCS 250 RC 00904-7260-06 NDC outpatient 1 UN 6.04 6.04 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES EPO [308136803] 4.83 percent of total billed charges 3.74 5.74 Technical (Hospital) Services LACTOBACILLUS ACIDOPHILUS 500 MILLION CELL CAPSULE RX-167980 CDM 6370000100 HCPCS 250 RC 00904-7260-06 NDC outpatient 1 UN 6.04 6.04 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES PPO [308136801] 4.83 percent of total billed charges 3.74 5.74 Technical (Hospital) Services LACTOBACILLUS ACIDOPHILUS 500 MILLION CELL CAPSULE RX-167980 CDM 6370000100 HCPCS 250 RC 00904-7260-06 NDC outpatient 1 UN 6.04 6.04 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES HDHP [308136802] 4.83 percent of total billed charges 3.74 5.74 Technical (Hospital) Services MELATONIN 3 MG TABLET RX-16830 CDM 6370000100 HCPCS 250 RC 43292-0562-98 NDC outpatient 1 UN 5.65 5.65 HEALTHPARTNERS SX009 HEALTHPARTNERS 4.52 percent of total billed charges 3.5 5.37 Technical (Hospital) Services MELATONIN 3 MG TABLET RX-16830 CDM 6370000100 HCPCS 250 RC 43292-0562-98 NDC outpatient 1 UN 5.65 5.65 BLUE CROSS BLUE SHIELD WELLMARK SB889 [3081026] BCBS WYOMING [308102603] 5.37 percent of total billed charges 3.5 5.37 Technical (Hospital) Services MELATONIN 3 MG TABLET RX-16830 CDM 6370000100 HCPCS 250 RC 43292-0562-98 NDC outpatient 1 UN 5.65 5.65 MEDICA (COMMERCIAL) 94265 [3081118] MEDICA CLAIMS [308111801] 5.09 percent of total billed charges 3.5 5.37 Technical (Hospital) Services MELATONIN 3 MG TABLET RX-16830 CDM 6370000100 HCPCS 250 RC 43292-0562-98 NDC outpatient 1 UN 5.65 5.65 UNITED HEALTHCARE (COMMERCIAL) [3081199] UNITED HEALTHCARE 87726 [308119901] 3.5 percent of total billed charges 3.5 5.37 Technical (Hospital) Services MELATONIN 3 MG TABLET RX-16830 CDM 6370000100 HCPCS 250 RC 43292-0562-98 NDC outpatient 1 UN 5.65 5.65 MULTIPLAN INC 34080 [3081285] MULTIPLAN INC [308128501] 5.37 percent of total billed charges 3.5 5.37 Technical (Hospital) Services MELATONIN 3 MG TABLET RX-16830 CDM 6370000100 HCPCS 250 RC 43292-0562-98 NDC outpatient 1 UN 5.65 5.65 CIGNA 62308 [3081051] CIGNA 62308 [308105105] 4.52 percent of total billed charges 3.5 5.37 Technical (Hospital) Services MELATONIN 3 MG TABLET RX-16830 CDM 6370000100 HCPCS 250 RC 43292-0562-98 NDC outpatient 1 UN 5.65 5.65 CIGNA 62308 [3081051] CIGNA STATE OF WYOMING [308105107] 4.52 percent of total billed charges 3.5 5.37 Technical (Hospital) Services MELATONIN 3 MG TABLET RX-16830 CDM 6370000100 HCPCS 250 RC 43292-0562-98 NDC outpatient 1 UN 5.65 5.65 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES HDHP [308136802] 4.52 percent of total billed charges 3.5 5.37 Technical (Hospital) Services MELATONIN 3 MG TABLET RX-16830 CDM 6370000100 HCPCS 250 RC 43292-0562-98 NDC outpatient 1 UN 5.65 5.65 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES EPO [308136803] 4.52 percent of total billed charges 3.5 5.37 Technical (Hospital) Services MELATONIN 3 MG TABLET RX-16830 CDM 6370000100 HCPCS 250 RC 43292-0562-98 NDC outpatient 1 UN 5.65 5.65 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES PPO [308136801] 4.52 percent of total billed charges 3.5 5.37 Technical (Hospital) Services MELATONIN 3 MG TABLET RX-16830 CDM 6370000100 HCPCS 250 RC 43292-0562-98 NDC inpatient 1 UN 5.65 5.65 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES PPO [308136801] 4.47 percent of total billed charges 3.5 5.37 Technical (Hospital) Services MELATONIN 3 MG TABLET RX-16830 CDM 6370000100 HCPCS 250 RC 43292-0562-98 NDC inpatient 1 UN 5.65 5.65 MULTIPLAN INC 34080 [3081285] MULTIPLAN INC [308128501] 5.37 percent of total billed charges 3.5 5.37 Technical (Hospital) Services MELATONIN 3 MG TABLET RX-16830 CDM 6370000100 HCPCS 250 RC 43292-0562-98 NDC inpatient 1 UN 5.65 5.65 BLUE CROSS BLUE SHIELD WELLMARK SB889 [3081026] BCBS WYOMING [308102603] 5.37 percent of total billed charges 3.5 5.37 Technical (Hospital) Services MELATONIN 3 MG TABLET RX-16830 CDM 6370000100 HCPCS 250 RC 43292-0562-98 NDC inpatient 1 UN 5.65 5.65 UNITED HEALTHCARE (COMMERCIAL) [3081199] UNITED HEALTHCARE 87726 [308119901] 3.5 percent of total billed charges 3.5 5.37 Technical (Hospital) Services MELATONIN 3 MG TABLET RX-16830 CDM 6370000100 HCPCS 250 RC 43292-0562-98 NDC inpatient 1 UN 5.65 5.65 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES HDHP [308136802] 4.47 percent of total billed charges 3.5 5.37 Technical (Hospital) Services MELATONIN 3 MG TABLET RX-16830 CDM 6370000100 HCPCS 250 RC 43292-0562-98 NDC inpatient 1 UN 5.65 5.65 HEALTHPARTNERS SX009 HEALTHPARTNERS 4.47 percent of total billed charges 3.5 5.37 Technical (Hospital) Services MELATONIN 3 MG TABLET RX-16830 CDM 6370000100 HCPCS 250 RC 43292-0562-98 NDC inpatient 1 UN 5.65 5.65 MEDICA (COMMERCIAL) 94265 [3081118] MEDICA CLAIMS [308111801] 5.09 percent of total billed charges 3.5 5.37 Technical (Hospital) Services MELATONIN 3 MG TABLET RX-16830 CDM 6370000100 HCPCS 250 RC 43292-0562-98 NDC inpatient 1 UN 5.65 5.65 CIGNA 62308 [3081051] CIGNA 62308 [308105105] 4.47 percent of total billed charges 3.5 5.37 Technical (Hospital) Services MELATONIN 3 MG TABLET RX-16830 CDM 6370000100 HCPCS 250 RC 43292-0562-98 NDC inpatient 1 UN 5.65 5.65 CIGNA 62308 [3081051] CIGNA STATE OF WYOMING [308105107] 4.47 percent of total billed charges 3.5 5.37 Technical (Hospital) Services MELATONIN 3 MG TABLET RX-16830 CDM 6370000100 HCPCS 250 RC 43292-0562-98 NDC inpatient 1 UN 5.65 5.65 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES EPO [308136803] 4.47 percent of total billed charges 3.5 5.37 Technical (Hospital) Services HYOSCYAMINE 0.125 MG SUBLINGUAL TABLET RX-17023 CDM 6370000100 HCPCS 250 RC 70156-0105-01 NDC inpatient 1 UN 5.85 5.85 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES PPO [308136801] 4.63 percent of total billed charges 3.63 5.56 Technical (Hospital) Services HYOSCYAMINE 0.125 MG SUBLINGUAL TABLET RX-17023 CDM 6370000100 HCPCS 250 RC 70156-0105-01 NDC inpatient 1 UN 5.85 5.85 HEALTHPARTNERS SX009 HEALTHPARTNERS 4.63 percent of total billed charges 3.63 5.56 Technical (Hospital) Services HYOSCYAMINE 0.125 MG SUBLINGUAL TABLET RX-17023 CDM 6370000100 HCPCS 250 RC 70156-0105-01 NDC inpatient 1 UN 5.85 5.85 MEDICA (COMMERCIAL) 94265 [3081118] MEDICA CLAIMS [308111801] 5.27 percent of total billed charges 3.63 5.56 Technical (Hospital) Services HYOSCYAMINE 0.125 MG SUBLINGUAL TABLET RX-17023 CDM 6370000100 HCPCS 250 RC 70156-0105-01 NDC inpatient 1 UN 5.85 5.85 MULTIPLAN INC 34080 [3081285] MULTIPLAN INC [308128501] 5.56 percent of total billed charges 3.63 5.56 Technical (Hospital) Services HYOSCYAMINE 0.125 MG SUBLINGUAL TABLET RX-17023 CDM 6370000100 HCPCS 250 RC 70156-0105-01 NDC inpatient 1 UN 5.85 5.85 UNITED HEALTHCARE (COMMERCIAL) [3081199] UNITED HEALTHCARE 87726 [308119901] 3.63 percent of total billed charges 3.63 5.56 Technical (Hospital) Services HYOSCYAMINE 0.125 MG SUBLINGUAL TABLET RX-17023 CDM 6370000100 HCPCS 250 RC 70156-0105-01 NDC inpatient 1 UN 5.85 5.85 BLUE CROSS BLUE SHIELD WELLMARK SB889 [3081026] BCBS WYOMING [308102603] 5.56 percent of total billed charges 3.63 5.56 Technical (Hospital) Services HYOSCYAMINE 0.125 MG SUBLINGUAL TABLET RX-17023 CDM 6370000100 HCPCS 250 RC 70156-0105-01 NDC inpatient 1 UN 5.85 5.85 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES EPO [308136803] 4.63 percent of total billed charges 3.63 5.56 Technical (Hospital) Services HYOSCYAMINE 0.125 MG SUBLINGUAL TABLET RX-17023 CDM 6370000100 HCPCS 250 RC 70156-0105-01 NDC inpatient 1 UN 5.85 5.85 CIGNA 62308 [3081051] CIGNA 62308 [308105105] 4.63 percent of total billed charges 3.63 5.56 Technical (Hospital) Services HYOSCYAMINE 0.125 MG SUBLINGUAL TABLET RX-17023 CDM 6370000100 HCPCS 250 RC 70156-0105-01 NDC inpatient 1 UN 5.85 5.85 CIGNA 62308 [3081051] CIGNA STATE OF WYOMING [308105107] 4.63 percent of total billed charges 3.63 5.56 Technical (Hospital) Services HYOSCYAMINE 0.125 MG SUBLINGUAL TABLET RX-17023 CDM 6370000100 HCPCS 250 RC 70156-0105-01 NDC inpatient 1 UN 5.85 5.85 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES HDHP [308136802] 4.63 percent of total billed charges 3.63 5.56 Technical (Hospital) Services HYOSCYAMINE 0.125 MG SUBLINGUAL TABLET RX-17023 CDM 6370000100 HCPCS 250 RC 70156-0105-01 NDC outpatient 1 UN 5.85 5.85 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES EPO [308136803] 4.68 percent of total billed charges 3.63 5.56 Technical (Hospital) Services HYOSCYAMINE 0.125 MG SUBLINGUAL TABLET RX-17023 CDM 6370000100 HCPCS 250 RC 70156-0105-01 NDC outpatient 1 UN 5.85 5.85 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES HDHP [308136802] 4.68 percent of total billed charges 3.63 5.56 Technical (Hospital) Services HYOSCYAMINE 0.125 MG SUBLINGUAL TABLET RX-17023 CDM 6370000100 HCPCS 250 RC 70156-0105-01 NDC outpatient 1 UN 5.85 5.85 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES PPO [308136801] 4.68 percent of total billed charges 3.63 5.56 Technical (Hospital) Services HYOSCYAMINE 0.125 MG SUBLINGUAL TABLET RX-17023 CDM 6370000100 HCPCS 250 RC 70156-0105-01 NDC outpatient 1 UN 5.85 5.85 BLUE CROSS BLUE SHIELD WELLMARK SB889 [3081026] BCBS WYOMING [308102603] 5.56 percent of total billed charges 3.63 5.56 Technical (Hospital) Services HYOSCYAMINE 0.125 MG SUBLINGUAL TABLET RX-17023 CDM 6370000100 HCPCS 250 RC 70156-0105-01 NDC outpatient 1 UN 5.85 5.85 MEDICA (COMMERCIAL) 94265 [3081118] MEDICA CLAIMS [308111801] 5.27 percent of total billed charges 3.63 5.56 Technical (Hospital) Services HYOSCYAMINE 0.125 MG SUBLINGUAL TABLET RX-17023 CDM 6370000100 HCPCS 250 RC 70156-0105-01 NDC outpatient 1 UN 5.85 5.85 MULTIPLAN INC 34080 [3081285] MULTIPLAN INC [308128501] 5.56 percent of total billed charges 3.63 5.56 Technical (Hospital) Services HYOSCYAMINE 0.125 MG SUBLINGUAL TABLET RX-17023 CDM 6370000100 HCPCS 250 RC 70156-0105-01 NDC outpatient 1 UN 5.85 5.85 CIGNA 62308 [3081051] CIGNA 62308 [308105105] 4.68 percent of total billed charges 3.63 5.56 Technical (Hospital) Services HYOSCYAMINE 0.125 MG SUBLINGUAL TABLET RX-17023 CDM 6370000100 HCPCS 250 RC 70156-0105-01 NDC outpatient 1 UN 5.85 5.85 CIGNA 62308 [3081051] CIGNA STATE OF WYOMING [308105107] 4.68 percent of total billed charges 3.63 5.56 Technical (Hospital) Services HYOSCYAMINE 0.125 MG SUBLINGUAL TABLET RX-17023 CDM 6370000100 HCPCS 250 RC 70156-0105-01 NDC outpatient 1 UN 5.85 5.85 HEALTHPARTNERS SX009 HEALTHPARTNERS 4.68 percent of total billed charges 3.63 5.56 Technical (Hospital) Services HYOSCYAMINE 0.125 MG SUBLINGUAL TABLET RX-17023 CDM 6370000100 HCPCS 250 RC 70156-0105-01 NDC outpatient 1 UN 5.85 5.85 UNITED HEALTHCARE (COMMERCIAL) [3081199] UNITED HEALTHCARE 87726 [308119901] 3.63 percent of total billed charges 3.63 5.56 Technical (Hospital) Services GLECAPREVIR 100 MG-PIBRENTASVIR 40 MG TABLET RX-170905 CDM 6370000100 HCPCS 250 RC 00074-2625-28 NDC inpatient 3 UN 1106.43 1106.43 BLUE CROSS BLUE SHIELD WELLMARK SB889 [3081026] BCBS WYOMING [308102603] 1051.11 percent of total billed charges 685.99 1051.11 Technical (Hospital) Services GLECAPREVIR 100 MG-PIBRENTASVIR 40 MG TABLET RX-170905 CDM 6370000100 HCPCS 250 RC 00074-2625-28 NDC inpatient 3 UN 1106.43 1106.43 UNITED HEALTHCARE (COMMERCIAL) [3081199] UNITED HEALTHCARE 87726 [308119901] 685.99 percent of total billed charges 685.99 1051.11 Technical (Hospital) Services GLECAPREVIR 100 MG-PIBRENTASVIR 40 MG TABLET RX-170905 CDM 6370000100 HCPCS 250 RC 00074-2625-28 NDC inpatient 3 UN 1106.43 1106.43 CIGNA 62308 [3081051] CIGNA 62308 [308105105] 876.07 percent of total billed charges 685.99 1051.11 Technical (Hospital) Services GLECAPREVIR 100 MG-PIBRENTASVIR 40 MG TABLET RX-170905 CDM 6370000100 HCPCS 250 RC 00074-2625-28 NDC inpatient 3 UN 1106.43 1106.43 CIGNA 62308 [3081051] CIGNA STATE OF WYOMING [308105107] 876.07 percent of total billed charges 685.99 1051.11 Technical (Hospital) Services GLECAPREVIR 100 MG-PIBRENTASVIR 40 MG TABLET RX-170905 CDM 6370000100 HCPCS 250 RC 00074-2625-28 NDC inpatient 3 UN 1106.43 1106.43 MEDICA (COMMERCIAL) 94265 [3081118] MEDICA CLAIMS [308111801] 995.79 percent of total billed charges 685.99 1051.11 Technical (Hospital) Services GLECAPREVIR 100 MG-PIBRENTASVIR 40 MG TABLET RX-170905 CDM 6370000100 HCPCS 250 RC 00074-2625-28 NDC inpatient 3 UN 1106.43 1106.43 MULTIPLAN INC 34080 [3081285] MULTIPLAN INC [308128501] 1051.11 percent of total billed charges 685.99 1051.11 Technical (Hospital) Services GLECAPREVIR 100 MG-PIBRENTASVIR 40 MG TABLET RX-170905 CDM 6370000100 HCPCS 250 RC 00074-2625-28 NDC inpatient 3 UN 1106.43 1106.43 HEALTHPARTNERS SX009 HEALTHPARTNERS 876.07 percent of total billed charges 685.99 1051.11 Technical (Hospital) Services GLECAPREVIR 100 MG-PIBRENTASVIR 40 MG TABLET RX-170905 CDM 6370000100 HCPCS 250 RC 00074-2625-28 NDC inpatient 3 UN 1106.43 1106.43 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES EPO [308136803] 876.07 percent of total billed charges 685.99 1051.11 Technical (Hospital) Services GLECAPREVIR 100 MG-PIBRENTASVIR 40 MG TABLET RX-170905 CDM 6370000100 HCPCS 250 RC 00074-2625-28 NDC inpatient 3 UN 1106.43 1106.43 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES HDHP [308136802] 876.07 percent of total billed charges 685.99 1051.11 Technical (Hospital) Services GLECAPREVIR 100 MG-PIBRENTASVIR 40 MG TABLET RX-170905 CDM 6370000100 HCPCS 250 RC 00074-2625-28 NDC inpatient 3 UN 1106.43 1106.43 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES PPO [308136801] 876.07 percent of total billed charges 685.99 1051.11 Technical (Hospital) Services GLECAPREVIR 100 MG-PIBRENTASVIR 40 MG TABLET RX-170905 CDM 6370000100 HCPCS 250 RC 00074-2625-28 NDC outpatient 3 UN 1106.43 1106.43 BLUE CROSS BLUE SHIELD WELLMARK SB889 [3081026] BCBS WYOMING [308102603] 1051.11 percent of total billed charges 685.99 1051.11 Technical (Hospital) Services GLECAPREVIR 100 MG-PIBRENTASVIR 40 MG TABLET RX-170905 CDM 6370000100 HCPCS 250 RC 00074-2625-28 NDC outpatient 3 UN 1106.43 1106.43 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES PPO [308136801] 885.14 percent of total billed charges 685.99 1051.11 Technical (Hospital) Services GLECAPREVIR 100 MG-PIBRENTASVIR 40 MG TABLET RX-170905 CDM 6370000100 HCPCS 250 RC 00074-2625-28 NDC outpatient 3 UN 1106.43 1106.43 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES EPO [308136803] 885.14 percent of total billed charges 685.99 1051.11 Technical (Hospital) Services GLECAPREVIR 100 MG-PIBRENTASVIR 40 MG TABLET RX-170905 CDM 6370000100 HCPCS 250 RC 00074-2625-28 NDC outpatient 3 UN 1106.43 1106.43 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES HDHP [308136802] 885.14 percent of total billed charges 685.99 1051.11 Technical (Hospital) Services GLECAPREVIR 100 MG-PIBRENTASVIR 40 MG TABLET RX-170905 CDM 6370000100 HCPCS 250 RC 00074-2625-28 NDC outpatient 3 UN 1106.43 1106.43 CIGNA 62308 [3081051] CIGNA 62308 [308105105] 885.14 percent of total billed charges 685.99 1051.11 Technical (Hospital) Services GLECAPREVIR 100 MG-PIBRENTASVIR 40 MG TABLET RX-170905 CDM 6370000100 HCPCS 250 RC 00074-2625-28 NDC outpatient 3 UN 1106.43 1106.43 CIGNA 62308 [3081051] CIGNA STATE OF WYOMING [308105107] 885.14 percent of total billed charges 685.99 1051.11 Technical (Hospital) Services GLECAPREVIR 100 MG-PIBRENTASVIR 40 MG TABLET RX-170905 CDM 6370000100 HCPCS 250 RC 00074-2625-28 NDC outpatient 3 UN 1106.43 1106.43 MEDICA (COMMERCIAL) 94265 [3081118] MEDICA CLAIMS [308111801] 995.79 percent of total billed charges 685.99 1051.11 Technical (Hospital) Services GLECAPREVIR 100 MG-PIBRENTASVIR 40 MG TABLET RX-170905 CDM 6370000100 HCPCS 250 RC 00074-2625-28 NDC outpatient 3 UN 1106.43 1106.43 MULTIPLAN INC 34080 [3081285] MULTIPLAN INC [308128501] 1051.11 percent of total billed charges 685.99 1051.11 Technical (Hospital) Services GLECAPREVIR 100 MG-PIBRENTASVIR 40 MG TABLET RX-170905 CDM 6370000100 HCPCS 250 RC 00074-2625-28 NDC outpatient 3 UN 1106.43 1106.43 UNITED HEALTHCARE (COMMERCIAL) [3081199] UNITED HEALTHCARE 87726 [308119901] 685.99 percent of total billed charges 685.99 1051.11 Technical (Hospital) Services GLECAPREVIR 100 MG-PIBRENTASVIR 40 MG TABLET RX-170905 CDM 6370000100 HCPCS 250 RC 00074-2625-28 NDC outpatient 3 UN 1106.43 1106.43 HEALTHPARTNERS SX009 HEALTHPARTNERS 885.14 percent of total billed charges 685.99 1051.11 Technical (Hospital) Services EXENATIDE ER 2 MG/0.85 ML SUBCUTANEOUS AUTO-INJECTOR RX-172123 CDM 6370000100 HCPCS 250 RC 00310-6540-01 NDC inpatient 1 UN 606.86 606.86 MULTIPLAN INC 34080 [3081285] MULTIPLAN INC [308128501] 576.52 percent of total billed charges 376.25 576.52 Technical (Hospital) Services EXENATIDE ER 2 MG/0.85 ML SUBCUTANEOUS AUTO-INJECTOR RX-172123 CDM 6370000100 HCPCS 250 RC 00310-6540-01 NDC inpatient 1 UN 606.86 606.86 BLUE CROSS BLUE SHIELD WELLMARK SB889 [3081026] BCBS WYOMING [308102603] 576.52 percent of total billed charges 376.25 576.52 Technical (Hospital) Services EXENATIDE ER 2 MG/0.85 ML SUBCUTANEOUS AUTO-INJECTOR RX-172123 CDM 6370000100 HCPCS 250 RC 00310-6540-01 NDC inpatient 1 UN 606.86 606.86 UNITED HEALTHCARE (COMMERCIAL) [3081199] UNITED HEALTHCARE 87726 [308119901] 376.25 percent of total billed charges 376.25 576.52 Technical (Hospital) Services EXENATIDE ER 2 MG/0.85 ML SUBCUTANEOUS AUTO-INJECTOR RX-172123 CDM 6370000100 HCPCS 250 RC 00310-6540-01 NDC inpatient 1 UN 606.86 606.86 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES EPO [308136803] 480.51 percent of total billed charges 376.25 576.52 Technical (Hospital) Services EXENATIDE ER 2 MG/0.85 ML SUBCUTANEOUS AUTO-INJECTOR RX-172123 CDM 6370000100 HCPCS 250 RC 00310-6540-01 NDC inpatient 1 UN 606.86 606.86 CIGNA 62308 [3081051] CIGNA 62308 [308105105] 480.51 percent of total billed charges 376.25 576.52 Technical (Hospital) Services EXENATIDE ER 2 MG/0.85 ML SUBCUTANEOUS AUTO-INJECTOR RX-172123 CDM 6370000100 HCPCS 250 RC 00310-6540-01 NDC inpatient 1 UN 606.86 606.86 CIGNA 62308 [3081051] CIGNA STATE OF WYOMING [308105107] 480.51 percent of total billed charges 376.25 576.52 Technical (Hospital) Services EXENATIDE ER 2 MG/0.85 ML SUBCUTANEOUS AUTO-INJECTOR RX-172123 CDM 6370000100 HCPCS 250 RC 00310-6540-01 NDC inpatient 1 UN 606.86 606.86 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES HDHP [308136802] 480.51 percent of total billed charges 376.25 576.52 Technical (Hospital) Services EXENATIDE ER 2 MG/0.85 ML SUBCUTANEOUS AUTO-INJECTOR RX-172123 CDM 6370000100 HCPCS 250 RC 00310-6540-01 NDC inpatient 1 UN 606.86 606.86 HEALTHPARTNERS SX009 HEALTHPARTNERS 480.51 percent of total billed charges 376.25 576.52 Technical (Hospital) Services EXENATIDE ER 2 MG/0.85 ML SUBCUTANEOUS AUTO-INJECTOR RX-172123 CDM 6370000100 HCPCS 250 RC 00310-6540-01 NDC inpatient 1 UN 606.86 606.86 MEDICA (COMMERCIAL) 94265 [3081118] MEDICA CLAIMS [308111801] 546.17 percent of total billed charges 376.25 576.52 Technical (Hospital) Services EXENATIDE ER 2 MG/0.85 ML SUBCUTANEOUS AUTO-INJECTOR RX-172123 CDM 6370000100 HCPCS 250 RC 00310-6540-01 NDC inpatient 1 UN 606.86 606.86 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES PPO [308136801] 480.51 percent of total billed charges 376.25 576.52 Technical (Hospital) Services EXENATIDE ER 2 MG/0.85 ML SUBCUTANEOUS AUTO-INJECTOR RX-172123 CDM 6370000100 HCPCS 250 RC 00310-6540-01 NDC outpatient 1 UN 606.86 606.86 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES EPO [308136803] 485.49 percent of total billed charges 376.25 576.52 Technical (Hospital) Services EXENATIDE ER 2 MG/0.85 ML SUBCUTANEOUS AUTO-INJECTOR RX-172123 CDM 6370000100 HCPCS 250 RC 00310-6540-01 NDC outpatient 1 UN 606.86 606.86 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES HDHP [308136802] 485.49 percent of total billed charges 376.25 576.52 Technical (Hospital) Services EXENATIDE ER 2 MG/0.85 ML SUBCUTANEOUS AUTO-INJECTOR RX-172123 CDM 6370000100 HCPCS 250 RC 00310-6540-01 NDC outpatient 1 UN 606.86 606.86 MEDICA (COMMERCIAL) 94265 [3081118] MEDICA CLAIMS [308111801] 546.17 percent of total billed charges 376.25 576.52 Technical (Hospital) Services EXENATIDE ER 2 MG/0.85 ML SUBCUTANEOUS AUTO-INJECTOR RX-172123 CDM 6370000100 HCPCS 250 RC 00310-6540-01 NDC outpatient 1 UN 606.86 606.86 CIGNA 62308 [3081051] CIGNA 62308 [308105105] 485.49 percent of total billed charges 376.25 576.52 Technical (Hospital) Services EXENATIDE ER 2 MG/0.85 ML SUBCUTANEOUS AUTO-INJECTOR RX-172123 CDM 6370000100 HCPCS 250 RC 00310-6540-01 NDC outpatient 1 UN 606.86 606.86 CIGNA 62308 [3081051] CIGNA STATE OF WYOMING [308105107] 485.49 percent of total billed charges 376.25 576.52 Technical (Hospital) Services EXENATIDE ER 2 MG/0.85 ML SUBCUTANEOUS AUTO-INJECTOR RX-172123 CDM 6370000100 HCPCS 250 RC 00310-6540-01 NDC outpatient 1 UN 606.86 606.86 MULTIPLAN INC 34080 [3081285] MULTIPLAN INC [308128501] 576.52 percent of total billed charges 376.25 576.52 Technical (Hospital) Services EXENATIDE ER 2 MG/0.85 ML SUBCUTANEOUS AUTO-INJECTOR RX-172123 CDM 6370000100 HCPCS 250 RC 00310-6540-01 NDC outpatient 1 UN 606.86 606.86 UNITED HEALTHCARE (COMMERCIAL) [3081199] UNITED HEALTHCARE 87726 [308119901] 376.25 percent of total billed charges 376.25 576.52 Technical (Hospital) Services EXENATIDE ER 2 MG/0.85 ML SUBCUTANEOUS AUTO-INJECTOR RX-172123 CDM 6370000100 HCPCS 250 RC 00310-6540-01 NDC outpatient 1 UN 606.86 606.86 HEALTHPARTNERS SX009 HEALTHPARTNERS 485.49 percent of total billed charges 376.25 576.52 Technical (Hospital) Services EXENATIDE ER 2 MG/0.85 ML SUBCUTANEOUS AUTO-INJECTOR RX-172123 CDM 6370000100 HCPCS 250 RC 00310-6540-01 NDC outpatient 1 UN 606.86 606.86 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES PPO [308136801] 485.49 percent of total billed charges 376.25 576.52 Technical (Hospital) Services EXENATIDE ER 2 MG/0.85 ML SUBCUTANEOUS AUTO-INJECTOR RX-172123 CDM 6370000100 HCPCS 250 RC 00310-6540-01 NDC outpatient 1 UN 606.86 606.86 BLUE CROSS BLUE SHIELD WELLMARK SB889 [3081026] BCBS WYOMING [308102603] 576.52 percent of total billed charges 376.25 576.52 Technical (Hospital) Services CLINDAMYCIN HCL 150 MG CAPSULE RX-1740 CDM 6370000100 HCPCS 250 RC 63304-0692-01 NDC outpatient 1 UN 5.76 5.76 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES HDHP [308136802] 4.61 percent of total billed charges 3.57 5.47 Technical (Hospital) Services CLINDAMYCIN HCL 150 MG CAPSULE RX-1740 CDM 6370000100 HCPCS 250 RC 63304-0692-01 NDC outpatient 1 UN 5.76 5.76 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES EPO [308136803] 4.61 percent of total billed charges 3.57 5.47 Technical (Hospital) Services CLINDAMYCIN HCL 150 MG CAPSULE RX-1740 CDM 6370000100 HCPCS 250 RC 63304-0692-01 NDC outpatient 1 UN 5.76 5.76 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES PPO [308136801] 4.61 percent of total billed charges 3.57 5.47 Technical (Hospital) Services CLINDAMYCIN HCL 150 MG CAPSULE RX-1740 CDM 6370000100 HCPCS 250 RC 63304-0692-01 NDC outpatient 1 UN 5.76 5.76 MULTIPLAN INC 34080 [3081285] MULTIPLAN INC [308128501] 5.47 percent of total billed charges 3.57 5.47 Technical (Hospital) Services CLINDAMYCIN HCL 150 MG CAPSULE RX-1740 CDM 6370000100 HCPCS 250 RC 63304-0692-01 NDC outpatient 1 UN 5.76 5.76 CIGNA 62308 [3081051] CIGNA 62308 [308105105] 4.61 percent of total billed charges 3.57 5.47 Technical (Hospital) Services CLINDAMYCIN HCL 150 MG CAPSULE RX-1740 CDM 6370000100 HCPCS 250 RC 63304-0692-01 NDC outpatient 1 UN 5.76 5.76 CIGNA 62308 [3081051] CIGNA STATE OF WYOMING [308105107] 4.61 percent of total billed charges 3.57 5.47 Technical (Hospital) Services CLINDAMYCIN HCL 150 MG CAPSULE RX-1740 CDM 6370000100 HCPCS 250 RC 63304-0692-01 NDC outpatient 1 UN 5.76 5.76 UNITED HEALTHCARE (COMMERCIAL) [3081199] UNITED HEALTHCARE 87726 [308119901] 3.57 percent of total billed charges 3.57 5.47 Technical (Hospital) Services CLINDAMYCIN HCL 150 MG CAPSULE RX-1740 CDM 6370000100 HCPCS 250 RC 63304-0692-01 NDC outpatient 1 UN 5.76 5.76 MEDICA (COMMERCIAL) 94265 [3081118] MEDICA CLAIMS [308111801] 5.18 percent of total billed charges 3.57 5.47 Technical (Hospital) Services CLINDAMYCIN HCL 150 MG CAPSULE RX-1740 CDM 6370000100 HCPCS 250 RC 63304-0692-01 NDC outpatient 1 UN 5.76 5.76 BLUE CROSS BLUE SHIELD WELLMARK SB889 [3081026] BCBS WYOMING [308102603] 5.47 percent of total billed charges 3.57 5.47 Technical (Hospital) Services CLINDAMYCIN HCL 150 MG CAPSULE RX-1740 CDM 6370000100 HCPCS 250 RC 63304-0692-01 NDC outpatient 1 UN 5.76 5.76 HEALTHPARTNERS SX009 HEALTHPARTNERS 4.61 percent of total billed charges 3.57 5.47 Technical (Hospital) Services CLINDAMYCIN HCL 150 MG CAPSULE RX-1740 CDM 6370000100 HCPCS 250 RC 63304-0692-01 NDC inpatient 1 UN 5.76 5.76 MULTIPLAN INC 34080 [3081285] MULTIPLAN INC [308128501] 5.47 percent of total billed charges 3.57 5.47 Technical (Hospital) Services CLINDAMYCIN HCL 150 MG CAPSULE RX-1740 CDM 6370000100 HCPCS 250 RC 63304-0692-01 NDC inpatient 1 UN 5.76 5.76 MEDICA (COMMERCIAL) 94265 [3081118] MEDICA CLAIMS [308111801] 5.18 percent of total billed charges 3.57 5.47 Technical (Hospital) Services CLINDAMYCIN HCL 150 MG CAPSULE RX-1740 CDM 6370000100 HCPCS 250 RC 63304-0692-01 NDC inpatient 1 UN 5.76 5.76 HEALTHPARTNERS SX009 HEALTHPARTNERS 4.56 percent of total billed charges 3.57 5.47 Technical (Hospital) Services CLINDAMYCIN HCL 150 MG CAPSULE RX-1740 CDM 6370000100 HCPCS 250 RC 63304-0692-01 NDC inpatient 1 UN 5.76 5.76 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES PPO [308136801] 4.56 percent of total billed charges 3.57 5.47 Technical (Hospital) Services CLINDAMYCIN HCL 150 MG CAPSULE RX-1740 CDM 6370000100 HCPCS 250 RC 63304-0692-01 NDC inpatient 1 UN 5.76 5.76 CIGNA 62308 [3081051] CIGNA 62308 [308105105] 4.56 percent of total billed charges 3.57 5.47 Technical (Hospital) Services CLINDAMYCIN HCL 150 MG CAPSULE RX-1740 CDM 6370000100 HCPCS 250 RC 63304-0692-01 NDC inpatient 1 UN 5.76 5.76 CIGNA 62308 [3081051] CIGNA STATE OF WYOMING [308105107] 4.56 percent of total billed charges 3.57 5.47 Technical (Hospital) Services CLINDAMYCIN HCL 150 MG CAPSULE RX-1740 CDM 6370000100 HCPCS 250 RC 63304-0692-01 NDC inpatient 1 UN 5.76 5.76 BLUE CROSS BLUE SHIELD WELLMARK SB889 [3081026] BCBS WYOMING [308102603] 5.47 percent of total billed charges 3.57 5.47 Technical (Hospital) Services CLINDAMYCIN HCL 150 MG CAPSULE RX-1740 CDM 6370000100 HCPCS 250 RC 63304-0692-01 NDC inpatient 1 UN 5.76 5.76 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES EPO [308136803] 4.56 percent of total billed charges 3.57 5.47 Technical (Hospital) Services CLINDAMYCIN HCL 150 MG CAPSULE RX-1740 CDM 6370000100 HCPCS 250 RC 63304-0692-01 NDC inpatient 1 UN 5.76 5.76 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES HDHP [308136802] 4.56 percent of total billed charges 3.57 5.47 Technical (Hospital) Services CLINDAMYCIN HCL 150 MG CAPSULE RX-1740 CDM 6370000100 HCPCS 250 RC 63304-0692-01 NDC inpatient 1 UN 5.76 5.76 UNITED HEALTHCARE (COMMERCIAL) [3081199] UNITED HEALTHCARE 87726 [308119901] 3.57 percent of total billed charges 3.57 5.47 Technical (Hospital) Services MELATONIN 5 MG TABLET RX-17427 CDM 6370000100 HCPCS 250 RC 30768-0157-45 NDC outpatient 1 UN 5.67 5.67 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES HDHP [308136802] 4.54 percent of total billed charges 3.52 5.39 Technical (Hospital) Services MELATONIN 5 MG TABLET RX-17427 CDM 6370000100 HCPCS 250 RC 30768-0157-45 NDC outpatient 1 UN 5.67 5.67 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES EPO [308136803] 4.54 percent of total billed charges 3.52 5.39 Technical (Hospital) Services MELATONIN 5 MG TABLET RX-17427 CDM 6370000100 HCPCS 250 RC 30768-0157-45 NDC outpatient 1 UN 5.67 5.67 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES PPO [308136801] 4.54 percent of total billed charges 3.52 5.39 Technical (Hospital) Services MELATONIN 5 MG TABLET RX-17427 CDM 6370000100 HCPCS 250 RC 30768-0157-45 NDC outpatient 1 UN 5.67 5.67 HEALTHPARTNERS SX009 HEALTHPARTNERS 4.54 percent of total billed charges 3.52 5.39 Technical (Hospital) Services MELATONIN 5 MG TABLET RX-17427 CDM 6370000100 HCPCS 250 RC 30768-0157-45 NDC outpatient 1 UN 5.67 5.67 BLUE CROSS BLUE SHIELD WELLMARK SB889 [3081026] BCBS WYOMING [308102603] 5.39 percent of total billed charges 3.52 5.39 Technical (Hospital) Services MELATONIN 5 MG TABLET RX-17427 CDM 6370000100 HCPCS 250 RC 30768-0157-45 NDC outpatient 1 UN 5.67 5.67 MULTIPLAN INC 34080 [3081285] MULTIPLAN INC [308128501] 5.39 percent of total billed charges 3.52 5.39 Technical (Hospital) Services MELATONIN 5 MG TABLET RX-17427 CDM 6370000100 HCPCS 250 RC 30768-0157-45 NDC outpatient 1 UN 5.67 5.67 UNITED HEALTHCARE (COMMERCIAL) [3081199] UNITED HEALTHCARE 87726 [308119901] 3.52 percent of total billed charges 3.52 5.39 Technical (Hospital) Services MELATONIN 5 MG TABLET RX-17427 CDM 6370000100 HCPCS 250 RC 30768-0157-45 NDC outpatient 1 UN 5.67 5.67 CIGNA 62308 [3081051] CIGNA 62308 [308105105] 4.54 percent of total billed charges 3.52 5.39 Technical (Hospital) Services MELATONIN 5 MG TABLET RX-17427 CDM 6370000100 HCPCS 250 RC 30768-0157-45 NDC outpatient 1 UN 5.67 5.67 CIGNA 62308 [3081051] CIGNA STATE OF WYOMING [308105107] 4.54 percent of total billed charges 3.52 5.39 Technical (Hospital) Services MELATONIN 5 MG TABLET RX-17427 CDM 6370000100 HCPCS 250 RC 30768-0157-45 NDC outpatient 1 UN 5.67 5.67 MEDICA (COMMERCIAL) 94265 [3081118] MEDICA CLAIMS [308111801] 5.1 percent of total billed charges 3.52 5.39 Technical (Hospital) Services MELATONIN 5 MG TABLET RX-17427 CDM 6370000100 HCPCS 250 RC 30768-0157-45 NDC inpatient 1 UN 5.67 5.67 MULTIPLAN INC 34080 [3081285] MULTIPLAN INC [308128501] 5.39 percent of total billed charges 3.52 5.39 Technical (Hospital) Services MELATONIN 5 MG TABLET RX-17427 CDM 6370000100 HCPCS 250 RC 30768-0157-45 NDC inpatient 1 UN 5.67 5.67 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES PPO [308136801] 4.49 percent of total billed charges 3.52 5.39 Technical (Hospital) Services MELATONIN 5 MG TABLET RX-17427 CDM 6370000100 HCPCS 250 RC 30768-0157-45 NDC inpatient 1 UN 5.67 5.67 MEDICA (COMMERCIAL) 94265 [3081118] MEDICA CLAIMS [308111801] 5.1 percent of total billed charges 3.52 5.39 Technical (Hospital) Services MELATONIN 5 MG TABLET RX-17427 CDM 6370000100 HCPCS 250 RC 30768-0157-45 NDC inpatient 1 UN 5.67 5.67 HEALTHPARTNERS SX009 HEALTHPARTNERS 4.49 percent of total billed charges 3.52 5.39 Technical (Hospital) Services MELATONIN 5 MG TABLET RX-17427 CDM 6370000100 HCPCS 250 RC 30768-0157-45 NDC inpatient 1 UN 5.67 5.67 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES HDHP [308136802] 4.49 percent of total billed charges 3.52 5.39 Technical (Hospital) Services MELATONIN 5 MG TABLET RX-17427 CDM 6370000100 HCPCS 250 RC 30768-0157-45 NDC inpatient 1 UN 5.67 5.67 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES EPO [308136803] 4.49 percent of total billed charges 3.52 5.39 Technical (Hospital) Services MELATONIN 5 MG TABLET RX-17427 CDM 6370000100 HCPCS 250 RC 30768-0157-45 NDC inpatient 1 UN 5.67 5.67 BLUE CROSS BLUE SHIELD WELLMARK SB889 [3081026] BCBS WYOMING [308102603] 5.39 percent of total billed charges 3.52 5.39 Technical (Hospital) Services MELATONIN 5 MG TABLET RX-17427 CDM 6370000100 HCPCS 250 RC 30768-0157-45 NDC inpatient 1 UN 5.67 5.67 CIGNA 62308 [3081051] CIGNA 62308 [308105105] 4.49 percent of total billed charges 3.52 5.39 Technical (Hospital) Services MELATONIN 5 MG TABLET RX-17427 CDM 6370000100 HCPCS 250 RC 30768-0157-45 NDC inpatient 1 UN 5.67 5.67 CIGNA 62308 [3081051] CIGNA STATE OF WYOMING [308105107] 4.49 percent of total billed charges 3.52 5.39 Technical (Hospital) Services MELATONIN 5 MG TABLET RX-17427 CDM 6370000100 HCPCS 250 RC 30768-0157-45 NDC inpatient 1 UN 5.67 5.67 UNITED HEALTHCARE (COMMERCIAL) [3081199] UNITED HEALTHCARE 87726 [308119901] 3.52 percent of total billed charges 3.52 5.39 Technical (Hospital) Services SODIUM ZIRCONIUM CYCLOSILICATE 10 GRAM ORAL POWDER PACKET RX-174276 CDM 6370000100 HCPCS 250 RC 00310-1110-30 NDC inpatient 1 UN 109.85 109.85 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES EPO [308136803] 86.98 percent of total billed charges 68.11 104.36 Technical (Hospital) Services SODIUM ZIRCONIUM CYCLOSILICATE 10 GRAM ORAL POWDER PACKET RX-174276 CDM 6370000100 HCPCS 250 RC 00310-1110-30 NDC inpatient 1 UN 109.85 109.85 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES HDHP [308136802] 86.98 percent of total billed charges 68.11 104.36 Technical (Hospital) Services SODIUM ZIRCONIUM CYCLOSILICATE 10 GRAM ORAL POWDER PACKET RX-174276 CDM 6370000100 HCPCS 250 RC 00310-1110-30 NDC inpatient 1 UN 109.85 109.85 BLUE CROSS BLUE SHIELD WELLMARK SB889 [3081026] BCBS WYOMING [308102603] 104.36 percent of total billed charges 68.11 104.36 Technical (Hospital) Services SODIUM ZIRCONIUM CYCLOSILICATE 10 GRAM ORAL POWDER PACKET RX-174276 CDM 6370000100 HCPCS 250 RC 00310-1110-30 NDC inpatient 1 UN 109.85 109.85 CIGNA 62308 [3081051] CIGNA 62308 [308105105] 86.98 percent of total billed charges 68.11 104.36 Technical (Hospital) Services SODIUM ZIRCONIUM CYCLOSILICATE 10 GRAM ORAL POWDER PACKET RX-174276 CDM 6370000100 HCPCS 250 RC 00310-1110-30 NDC inpatient 1 UN 109.85 109.85 CIGNA 62308 [3081051] CIGNA STATE OF WYOMING [308105107] 86.98 percent of total billed charges 68.11 104.36 Technical (Hospital) Services SODIUM ZIRCONIUM CYCLOSILICATE 10 GRAM ORAL POWDER PACKET RX-174276 CDM 6370000100 HCPCS 250 RC 00310-1110-30 NDC inpatient 1 UN 109.85 109.85 UNITED HEALTHCARE (COMMERCIAL) [3081199] UNITED HEALTHCARE 87726 [308119901] 68.11 percent of total billed charges 68.11 104.36 Technical (Hospital) Services SODIUM ZIRCONIUM CYCLOSILICATE 10 GRAM ORAL POWDER PACKET RX-174276 CDM 6370000100 HCPCS 250 RC 00310-1110-30 NDC inpatient 1 UN 109.85 109.85 MEDICA (COMMERCIAL) 94265 [3081118] MEDICA CLAIMS [308111801] 98.87 percent of total billed charges 68.11 104.36 Technical (Hospital) Services SODIUM ZIRCONIUM CYCLOSILICATE 10 GRAM ORAL POWDER PACKET RX-174276 CDM 6370000100 HCPCS 250 RC 00310-1110-30 NDC inpatient 1 UN 109.85 109.85 HEALTHPARTNERS SX009 HEALTHPARTNERS 86.98 percent of total billed charges 68.11 104.36 Technical (Hospital) Services SODIUM ZIRCONIUM CYCLOSILICATE 10 GRAM ORAL POWDER PACKET RX-174276 CDM 6370000100 HCPCS 250 RC 00310-1110-30 NDC inpatient 1 UN 109.85 109.85 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES PPO [308136801] 86.98 percent of total billed charges 68.11 104.36 Technical (Hospital) Services SODIUM ZIRCONIUM CYCLOSILICATE 10 GRAM ORAL POWDER PACKET RX-174276 CDM 6370000100 HCPCS 250 RC 00310-1110-30 NDC inpatient 1 UN 109.85 109.85 MULTIPLAN INC 34080 [3081285] MULTIPLAN INC [308128501] 104.36 percent of total billed charges 68.11 104.36 Technical (Hospital) Services SODIUM ZIRCONIUM CYCLOSILICATE 10 GRAM ORAL POWDER PACKET RX-174276 CDM 6370000100 HCPCS 250 RC 00310-1110-30 NDC outpatient 1 UN 109.85 109.85 BLUE CROSS BLUE SHIELD WELLMARK SB889 [3081026] BCBS WYOMING [308102603] 104.36 percent of total billed charges 68.11 104.36 Technical (Hospital) Services SODIUM ZIRCONIUM CYCLOSILICATE 10 GRAM ORAL POWDER PACKET RX-174276 CDM 6370000100 HCPCS 250 RC 00310-1110-30 NDC outpatient 1 UN 109.85 109.85 MEDICA (COMMERCIAL) 94265 [3081118] MEDICA CLAIMS [308111801] 98.87 percent of total billed charges 68.11 104.36 Technical (Hospital) Services SODIUM ZIRCONIUM CYCLOSILICATE 10 GRAM ORAL POWDER PACKET RX-174276 CDM 6370000100 HCPCS 250 RC 00310-1110-30 NDC outpatient 1 UN 109.85 109.85 MULTIPLAN INC 34080 [3081285] MULTIPLAN INC [308128501] 104.36 percent of total billed charges 68.11 104.36 Technical (Hospital) Services SODIUM ZIRCONIUM CYCLOSILICATE 10 GRAM ORAL POWDER PACKET RX-174276 CDM 6370000100 HCPCS 250 RC 00310-1110-30 NDC outpatient 1 UN 109.85 109.85 CIGNA 62308 [3081051] CIGNA 62308 [308105105] 87.88 percent of total billed charges 68.11 104.36 Technical (Hospital) Services SODIUM ZIRCONIUM CYCLOSILICATE 10 GRAM ORAL POWDER PACKET RX-174276 CDM 6370000100 HCPCS 250 RC 00310-1110-30 NDC outpatient 1 UN 109.85 109.85 CIGNA 62308 [3081051] CIGNA STATE OF WYOMING [308105107] 87.88 percent of total billed charges 68.11 104.36 Technical (Hospital) Services SODIUM ZIRCONIUM CYCLOSILICATE 10 GRAM ORAL POWDER PACKET RX-174276 CDM 6370000100 HCPCS 250 RC 00310-1110-30 NDC outpatient 1 UN 109.85 109.85 HEALTHPARTNERS SX009 HEALTHPARTNERS 87.88 percent of total billed charges 68.11 104.36 Technical (Hospital) Services SODIUM ZIRCONIUM CYCLOSILICATE 10 GRAM ORAL POWDER PACKET RX-174276 CDM 6370000100 HCPCS 250 RC 00310-1110-30 NDC outpatient 1 UN 109.85 109.85 UNITED HEALTHCARE (COMMERCIAL) [3081199] UNITED HEALTHCARE 87726 [308119901] 68.11 percent of total billed charges 68.11 104.36 Technical (Hospital) Services SODIUM ZIRCONIUM CYCLOSILICATE 10 GRAM ORAL POWDER PACKET RX-174276 CDM 6370000100 HCPCS 250 RC 00310-1110-30 NDC outpatient 1 UN 109.85 109.85 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES EPO [308136803] 87.88 percent of total billed charges 68.11 104.36 Technical (Hospital) Services SODIUM ZIRCONIUM CYCLOSILICATE 10 GRAM ORAL POWDER PACKET RX-174276 CDM 6370000100 HCPCS 250 RC 00310-1110-30 NDC outpatient 1 UN 109.85 109.85 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES PPO [308136801] 87.88 percent of total billed charges 68.11 104.36 Technical (Hospital) Services SODIUM ZIRCONIUM CYCLOSILICATE 10 GRAM ORAL POWDER PACKET RX-174276 CDM 6370000100 HCPCS 250 RC 00310-1110-30 NDC outpatient 1 UN 109.85 109.85 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES HDHP [308136802] 87.88 percent of total billed charges 68.11 104.36 Technical (Hospital) Services PIMAVANSERIN 34 MG CAPSULE RX-174345 CDM 6370000100 HCPCS 250 RC 63090-0340-30 NDC outpatient 1 UN 606.5 606.5 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES PPO [308136801] 485.2 percent of total billed charges 376.03 576.18 Technical (Hospital) Services PIMAVANSERIN 34 MG CAPSULE RX-174345 CDM 6370000100 HCPCS 250 RC 63090-0340-30 NDC outpatient 1 UN 606.5 606.5 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES EPO [308136803] 485.2 percent of total billed charges 376.03 576.18 Technical (Hospital) Services PIMAVANSERIN 34 MG CAPSULE RX-174345 CDM 6370000100 HCPCS 250 RC 63090-0340-30 NDC outpatient 1 UN 606.5 606.5 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES HDHP [308136802] 485.2 percent of total billed charges 376.03 576.18 Technical (Hospital) Services PIMAVANSERIN 34 MG CAPSULE RX-174345 CDM 6370000100 HCPCS 250 RC 63090-0340-30 NDC outpatient 1 UN 606.5 606.5 BLUE CROSS BLUE SHIELD WELLMARK SB889 [3081026] BCBS WYOMING [308102603] 576.18 percent of total billed charges 376.03 576.18 Technical (Hospital) Services PIMAVANSERIN 34 MG CAPSULE RX-174345 CDM 6370000100 HCPCS 250 RC 63090-0340-30 NDC outpatient 1 UN 606.5 606.5 HEALTHPARTNERS SX009 HEALTHPARTNERS 485.2 percent of total billed charges 376.03 576.18 Technical (Hospital) Services PIMAVANSERIN 34 MG CAPSULE RX-174345 CDM 6370000100 HCPCS 250 RC 63090-0340-30 NDC outpatient 1 UN 606.5 606.5 MULTIPLAN INC 34080 [3081285] MULTIPLAN INC [308128501] 576.18 percent of total billed charges 376.03 576.18 Technical (Hospital) Services PIMAVANSERIN 34 MG CAPSULE RX-174345 CDM 6370000100 HCPCS 250 RC 63090-0340-30 NDC outpatient 1 UN 606.5 606.5 CIGNA 62308 [3081051] CIGNA 62308 [308105105] 485.2 percent of total billed charges 376.03 576.18 Technical (Hospital) Services PIMAVANSERIN 34 MG CAPSULE RX-174345 CDM 6370000100 HCPCS 250 RC 63090-0340-30 NDC outpatient 1 UN 606.5 606.5 CIGNA 62308 [3081051] CIGNA STATE OF WYOMING [308105107] 485.2 percent of total billed charges 376.03 576.18 Technical (Hospital) Services PIMAVANSERIN 34 MG CAPSULE RX-174345 CDM 6370000100 HCPCS 250 RC 63090-0340-30 NDC outpatient 1 UN 606.5 606.5 UNITED HEALTHCARE (COMMERCIAL) [3081199] UNITED HEALTHCARE 87726 [308119901] 376.03 percent of total billed charges 376.03 576.18 Technical (Hospital) Services PIMAVANSERIN 34 MG CAPSULE RX-174345 CDM 6370000100 HCPCS 250 RC 63090-0340-30 NDC outpatient 1 UN 606.5 606.5 MEDICA (COMMERCIAL) 94265 [3081118] MEDICA CLAIMS [308111801] 545.85 percent of total billed charges 376.03 576.18 Technical (Hospital) Services PIMAVANSERIN 34 MG CAPSULE RX-174345 CDM 6370000100 HCPCS 250 RC 63090-0340-30 NDC inpatient 1 UN 606.5 606.5 MULTIPLAN INC 34080 [3081285] MULTIPLAN INC [308128501] 576.18 percent of total billed charges 376.03 576.18 Technical (Hospital) Services PIMAVANSERIN 34 MG CAPSULE RX-174345 CDM 6370000100 HCPCS 250 RC 63090-0340-30 NDC inpatient 1 UN 606.5 606.5 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES PPO [308136801] 480.23 percent of total billed charges 376.03 576.18 Technical (Hospital) Services PIMAVANSERIN 34 MG CAPSULE RX-174345 CDM 6370000100 HCPCS 250 RC 63090-0340-30 NDC inpatient 1 UN 606.5 606.5 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES HDHP [308136802] 480.23 percent of total billed charges 376.03 576.18 Technical (Hospital) Services PIMAVANSERIN 34 MG CAPSULE RX-174345 CDM 6370000100 HCPCS 250 RC 63090-0340-30 NDC inpatient 1 UN 606.5 606.5 MEDICA (COMMERCIAL) 94265 [3081118] MEDICA CLAIMS [308111801] 545.85 percent of total billed charges 376.03 576.18 Technical (Hospital) Services PIMAVANSERIN 34 MG CAPSULE RX-174345 CDM 6370000100 HCPCS 250 RC 63090-0340-30 NDC inpatient 1 UN 606.5 606.5 HEALTHPARTNERS SX009 HEALTHPARTNERS 480.23 percent of total billed charges 376.03 576.18 Technical (Hospital) Services PIMAVANSERIN 34 MG CAPSULE RX-174345 CDM 6370000100 HCPCS 250 RC 63090-0340-30 NDC inpatient 1 UN 606.5 606.5 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES EPO [308136803] 480.23 percent of total billed charges 376.03 576.18 Technical (Hospital) Services PIMAVANSERIN 34 MG CAPSULE RX-174345 CDM 6370000100 HCPCS 250 RC 63090-0340-30 NDC inpatient 1 UN 606.5 606.5 CIGNA 62308 [3081051] CIGNA 62308 [308105105] 480.23 percent of total billed charges 376.03 576.18 Technical (Hospital) Services PIMAVANSERIN 34 MG CAPSULE RX-174345 CDM 6370000100 HCPCS 250 RC 63090-0340-30 NDC inpatient 1 UN 606.5 606.5 CIGNA 62308 [3081051] CIGNA STATE OF WYOMING [308105107] 480.23 percent of total billed charges 376.03 576.18 Technical (Hospital) Services PIMAVANSERIN 34 MG CAPSULE RX-174345 CDM 6370000100 HCPCS 250 RC 63090-0340-30 NDC inpatient 1 UN 606.5 606.5 UNITED HEALTHCARE (COMMERCIAL) [3081199] UNITED HEALTHCARE 87726 [308119901] 376.03 percent of total billed charges 376.03 576.18 Technical (Hospital) Services PIMAVANSERIN 34 MG CAPSULE RX-174345 CDM 6370000100 HCPCS 250 RC 63090-0340-30 NDC inpatient 1 UN 606.5 606.5 BLUE CROSS BLUE SHIELD WELLMARK SB889 [3081026] BCBS WYOMING [308102603] 576.18 percent of total billed charges 376.03 576.18 Technical (Hospital) Services BUSPIRONE 15 MG TABLET RX-17464 CDM 6370000100 HCPCS 250 RC 68382-0182-01 NDC outpatient 1 UN 5.71 5.71 UNITED HEALTHCARE (COMMERCIAL) [3081199] UNITED HEALTHCARE 87726 [308119901] 3.54 percent of total billed charges 3.54 5.42 Technical (Hospital) Services BUSPIRONE 15 MG TABLET RX-17464 CDM 6370000100 HCPCS 250 RC 68382-0182-01 NDC outpatient 1 UN 5.71 5.71 MULTIPLAN INC 34080 [3081285] MULTIPLAN INC [308128501] 5.42 percent of total billed charges 3.54 5.42 Technical (Hospital) Services BUSPIRONE 15 MG TABLET RX-17464 CDM 6370000100 HCPCS 250 RC 68382-0182-01 NDC outpatient 1 UN 5.71 5.71 CIGNA 62308 [3081051] CIGNA 62308 [308105105] 4.57 percent of total billed charges 3.54 5.42 Technical (Hospital) Services BUSPIRONE 15 MG TABLET RX-17464 CDM 6370000100 HCPCS 250 RC 68382-0182-01 NDC outpatient 1 UN 5.71 5.71 CIGNA 62308 [3081051] CIGNA STATE OF WYOMING [308105107] 4.57 percent of total billed charges 3.54 5.42 Technical (Hospital) Services BUSPIRONE 15 MG TABLET RX-17464 CDM 6370000100 HCPCS 250 RC 68382-0182-01 NDC outpatient 1 UN 5.71 5.71 MEDICA (COMMERCIAL) 94265 [3081118] MEDICA CLAIMS [308111801] 5.14 percent of total billed charges 3.54 5.42 Technical (Hospital) Services BUSPIRONE 15 MG TABLET RX-17464 CDM 6370000100 HCPCS 250 RC 68382-0182-01 NDC outpatient 1 UN 5.71 5.71 HEALTHPARTNERS SX009 HEALTHPARTNERS 4.57 percent of total billed charges 3.54 5.42 Technical (Hospital) Services BUSPIRONE 15 MG TABLET RX-17464 CDM 6370000100 HCPCS 250 RC 68382-0182-01 NDC outpatient 1 UN 5.71 5.71 BLUE CROSS BLUE SHIELD WELLMARK SB889 [3081026] BCBS WYOMING [308102603] 5.42 percent of total billed charges 3.54 5.42 Technical (Hospital) Services BUSPIRONE 15 MG TABLET RX-17464 CDM 6370000100 HCPCS 250 RC 68382-0182-01 NDC outpatient 1 UN 5.71 5.71 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES HDHP [308136802] 4.57 percent of total billed charges 3.54 5.42 Technical (Hospital) Services BUSPIRONE 15 MG TABLET RX-17464 CDM 6370000100 HCPCS 250 RC 68382-0182-01 NDC outpatient 1 UN 5.71 5.71 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES EPO [308136803] 4.57 percent of total billed charges 3.54 5.42 Technical (Hospital) Services BUSPIRONE 15 MG TABLET RX-17464 CDM 6370000100 HCPCS 250 RC 68382-0182-01 NDC outpatient 1 UN 5.71 5.71 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES PPO [308136801] 4.57 percent of total billed charges 3.54 5.42 Technical (Hospital) Services BUSPIRONE 15 MG TABLET RX-17464 CDM 6370000100 HCPCS 250 RC 68382-0182-01 NDC inpatient 1 UN 5.71 5.71 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES PPO [308136801] 4.52 percent of total billed charges 3.54 5.42 Technical (Hospital) Services BUSPIRONE 15 MG TABLET RX-17464 CDM 6370000100 HCPCS 250 RC 68382-0182-01 NDC inpatient 1 UN 5.71 5.71 HEALTHPARTNERS SX009 HEALTHPARTNERS 4.52 percent of total billed charges 3.54 5.42 Technical (Hospital) Services BUSPIRONE 15 MG TABLET RX-17464 CDM 6370000100 HCPCS 250 RC 68382-0182-01 NDC inpatient 1 UN 5.71 5.71 MEDICA (COMMERCIAL) 94265 [3081118] MEDICA CLAIMS [308111801] 5.14 percent of total billed charges 3.54 5.42 Technical (Hospital) Services BUSPIRONE 15 MG TABLET RX-17464 CDM 6370000100 HCPCS 250 RC 68382-0182-01 NDC inpatient 1 UN 5.71 5.71 MULTIPLAN INC 34080 [3081285] MULTIPLAN INC [308128501] 5.42 percent of total billed charges 3.54 5.42 Technical (Hospital) Services BUSPIRONE 15 MG TABLET RX-17464 CDM 6370000100 HCPCS 250 RC 68382-0182-01 NDC inpatient 1 UN 5.71 5.71 UNITED HEALTHCARE (COMMERCIAL) [3081199] UNITED HEALTHCARE 87726 [308119901] 3.54 percent of total billed charges 3.54 5.42 Technical (Hospital) Services BUSPIRONE 15 MG TABLET RX-17464 CDM 6370000100 HCPCS 250 RC 68382-0182-01 NDC inpatient 1 UN 5.71 5.71 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES EPO [308136803] 4.52 percent of total billed charges 3.54 5.42 Technical (Hospital) Services BUSPIRONE 15 MG TABLET RX-17464 CDM 6370000100 HCPCS 250 RC 68382-0182-01 NDC inpatient 1 UN 5.71 5.71 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES HDHP [308136802] 4.52 percent of total billed charges 3.54 5.42 Technical (Hospital) Services BUSPIRONE 15 MG TABLET RX-17464 CDM 6370000100 HCPCS 250 RC 68382-0182-01 NDC inpatient 1 UN 5.71 5.71 BLUE CROSS BLUE SHIELD WELLMARK SB889 [3081026] BCBS WYOMING [308102603] 5.42 percent of total billed charges 3.54 5.42 Technical (Hospital) Services BUSPIRONE 15 MG TABLET RX-17464 CDM 6370000100 HCPCS 250 RC 68382-0182-01 NDC inpatient 1 UN 5.71 5.71 CIGNA 62308 [3081051] CIGNA 62308 [308105105] 4.52 percent of total billed charges 3.54 5.42 Technical (Hospital) Services BUSPIRONE 15 MG TABLET RX-17464 CDM 6370000100 HCPCS 250 RC 68382-0182-01 NDC inpatient 1 UN 5.71 5.71 CIGNA 62308 [3081051] CIGNA STATE OF WYOMING [308105107] 4.52 percent of total billed charges 3.54 5.42 Technical (Hospital) Services BALSAM PERU-CASTOR OIL TOPICAL OINTMENT RX-175324 CDM 6370000100 HCPCS 250 RC 58980-0780-21 NDC outpatient 1 GR 6.15 6.15 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES PPO [308136801] 4.92 percent of total billed charges 3.81 5.84 Technical (Hospital) Services BALSAM PERU-CASTOR OIL TOPICAL OINTMENT RX-175324 CDM 6370000100 HCPCS 250 RC 58980-0780-21 NDC outpatient 1 GR 6.15 6.15 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES HDHP [308136802] 4.92 percent of total billed charges 3.81 5.84 Technical (Hospital) Services BALSAM PERU-CASTOR OIL TOPICAL OINTMENT RX-175324 CDM 6370000100 HCPCS 250 RC 58980-0780-21 NDC outpatient 1 GR 6.15 6.15 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES EPO [308136803] 4.92 percent of total billed charges 3.81 5.84 Technical (Hospital) Services BALSAM PERU-CASTOR OIL TOPICAL OINTMENT RX-175324 CDM 6370000100 HCPCS 250 RC 58980-0780-21 NDC outpatient 1 GR 6.15 6.15 BLUE CROSS BLUE SHIELD WELLMARK SB889 [3081026] BCBS WYOMING [308102603] 5.84 percent of total billed charges 3.81 5.84 Technical (Hospital) Services BALSAM PERU-CASTOR OIL TOPICAL OINTMENT RX-175324 CDM 6370000100 HCPCS 250 RC 58980-0780-21 NDC outpatient 1 GR 6.15 6.15 HEALTHPARTNERS SX009 HEALTHPARTNERS 4.92 percent of total billed charges 3.81 5.84 Technical (Hospital) Services BALSAM PERU-CASTOR OIL TOPICAL OINTMENT RX-175324 CDM 6370000100 HCPCS 250 RC 58980-0780-21 NDC outpatient 1 GR 6.15 6.15 CIGNA 62308 [3081051] CIGNA 62308 [308105105] 4.92 percent of total billed charges 3.81 5.84 Technical (Hospital) Services BALSAM PERU-CASTOR OIL TOPICAL OINTMENT RX-175324 CDM 6370000100 HCPCS 250 RC 58980-0780-21 NDC outpatient 1 GR 6.15 6.15 CIGNA 62308 [3081051] CIGNA STATE OF WYOMING [308105107] 4.92 percent of total billed charges 3.81 5.84 Technical (Hospital) Services BALSAM PERU-CASTOR OIL TOPICAL OINTMENT RX-175324 CDM 6370000100 HCPCS 250 RC 58980-0780-21 NDC outpatient 1 GR 6.15 6.15 MULTIPLAN INC 34080 [3081285] MULTIPLAN INC [308128501] 5.84 percent of total billed charges 3.81 5.84 Technical (Hospital) Services BALSAM PERU-CASTOR OIL TOPICAL OINTMENT RX-175324 CDM 6370000100 HCPCS 250 RC 58980-0780-21 NDC outpatient 1 GR 6.15 6.15 UNITED HEALTHCARE (COMMERCIAL) [3081199] UNITED HEALTHCARE 87726 [308119901] 3.81 percent of total billed charges 3.81 5.84 Technical (Hospital) Services BALSAM PERU-CASTOR OIL TOPICAL OINTMENT RX-175324 CDM 6370000100 HCPCS 250 RC 58980-0780-21 NDC outpatient 1 GR 6.15 6.15 MEDICA (COMMERCIAL) 94265 [3081118] MEDICA CLAIMS [308111801] 5.54 percent of total billed charges 3.81 5.84 Technical (Hospital) Services BALSAM PERU-CASTOR OIL TOPICAL OINTMENT RX-175324 CDM 6370000100 HCPCS 250 RC 58980-0780-21 NDC inpatient 1 GR 6.15 6.15 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES PPO [308136801] 4.87 percent of total billed charges 3.81 5.84 Technical (Hospital) Services BALSAM PERU-CASTOR OIL TOPICAL OINTMENT RX-175324 CDM 6370000100 HCPCS 250 RC 58980-0780-21 NDC inpatient 1 GR 6.15 6.15 MEDICA (COMMERCIAL) 94265 [3081118] MEDICA CLAIMS [308111801] 5.54 percent of total billed charges 3.81 5.84 Technical (Hospital) Services BALSAM PERU-CASTOR OIL TOPICAL OINTMENT RX-175324 CDM 6370000100 HCPCS 250 RC 58980-0780-21 NDC inpatient 1 GR 6.15 6.15 HEALTHPARTNERS SX009 HEALTHPARTNERS 4.87 percent of total billed charges 3.81 5.84 Technical (Hospital) Services BALSAM PERU-CASTOR OIL TOPICAL OINTMENT RX-175324 CDM 6370000100 HCPCS 250 RC 58980-0780-21 NDC inpatient 1 GR 6.15 6.15 MULTIPLAN INC 34080 [3081285] MULTIPLAN INC [308128501] 5.84 percent of total billed charges 3.81 5.84 Technical (Hospital) Services BALSAM PERU-CASTOR OIL TOPICAL OINTMENT RX-175324 CDM 6370000100 HCPCS 250 RC 58980-0780-21 NDC inpatient 1 GR 6.15 6.15 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES HDHP [308136802] 4.87 percent of total billed charges 3.81 5.84 Technical (Hospital) Services BALSAM PERU-CASTOR OIL TOPICAL OINTMENT RX-175324 CDM 6370000100 HCPCS 250 RC 58980-0780-21 NDC inpatient 1 GR 6.15 6.15 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES EPO [308136803] 4.87 percent of total billed charges 3.81 5.84 Technical (Hospital) Services BALSAM PERU-CASTOR OIL TOPICAL OINTMENT RX-175324 CDM 6370000100 HCPCS 250 RC 58980-0780-21 NDC inpatient 1 GR 6.15 6.15 CIGNA 62308 [3081051] CIGNA 62308 [308105105] 4.87 percent of total billed charges 3.81 5.84 Technical (Hospital) Services BALSAM PERU-CASTOR OIL TOPICAL OINTMENT RX-175324 CDM 6370000100 HCPCS 250 RC 58980-0780-21 NDC inpatient 1 GR 6.15 6.15 CIGNA 62308 [3081051] CIGNA STATE OF WYOMING [308105107] 4.87 percent of total billed charges 3.81 5.84 Technical (Hospital) Services BALSAM PERU-CASTOR OIL TOPICAL OINTMENT RX-175324 CDM 6370000100 HCPCS 250 RC 58980-0780-21 NDC inpatient 1 GR 6.15 6.15 BLUE CROSS BLUE SHIELD WELLMARK SB889 [3081026] BCBS WYOMING [308102603] 5.84 percent of total billed charges 3.81 5.84 Technical (Hospital) Services BALSAM PERU-CASTOR OIL TOPICAL OINTMENT RX-175324 CDM 6370000100 HCPCS 250 RC 58980-0780-21 NDC inpatient 1 GR 6.15 6.15 UNITED HEALTHCARE (COMMERCIAL) [3081199] UNITED HEALTHCARE 87726 [308119901] 3.81 percent of total billed charges 3.81 5.84 Technical (Hospital) Services CLONIDINE HCL 0.1 MG TABLET RX-1755 CDM 6370000100 HCPCS 250 RC 00228-2127-10 NDC inpatient 1 UN 5.66 5.66 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES PPO [308136801] 4.48 percent of total billed charges 3.51 5.38 Technical (Hospital) Services CLONIDINE HCL 0.1 MG TABLET RX-1755 CDM 6370000100 HCPCS 250 RC 00228-2127-10 NDC inpatient 1 UN 5.66 5.66 MEDICA (COMMERCIAL) 94265 [3081118] MEDICA CLAIMS [308111801] 5.09 percent of total billed charges 3.51 5.38 Technical (Hospital) Services CLONIDINE HCL 0.1 MG TABLET RX-1755 CDM 6370000100 HCPCS 250 RC 00228-2127-10 NDC inpatient 1 UN 5.66 5.66 HEALTHPARTNERS SX009 HEALTHPARTNERS 4.48 percent of total billed charges 3.51 5.38 Technical (Hospital) Services CLONIDINE HCL 0.1 MG TABLET RX-1755 CDM 6370000100 HCPCS 250 RC 00228-2127-10 NDC inpatient 1 UN 5.66 5.66 MULTIPLAN INC 34080 [3081285] MULTIPLAN INC [308128501] 5.38 percent of total billed charges 3.51 5.38 Technical (Hospital) Services CLONIDINE HCL 0.1 MG TABLET RX-1755 CDM 6370000100 HCPCS 250 RC 00228-2127-10 NDC inpatient 1 UN 5.66 5.66 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES HDHP [308136802] 4.48 percent of total billed charges 3.51 5.38 Technical (Hospital) Services CLONIDINE HCL 0.1 MG TABLET RX-1755 CDM 6370000100 HCPCS 250 RC 00228-2127-10 NDC inpatient 1 UN 5.66 5.66 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES EPO [308136803] 4.48 percent of total billed charges 3.51 5.38 Technical (Hospital) Services CLONIDINE HCL 0.1 MG TABLET RX-1755 CDM 6370000100 HCPCS 250 RC 00228-2127-10 NDC inpatient 1 UN 5.66 5.66 CIGNA 62308 [3081051] CIGNA 62308 [308105105] 4.48 percent of total billed charges 3.51 5.38 Technical (Hospital) Services CLONIDINE HCL 0.1 MG TABLET RX-1755 CDM 6370000100 HCPCS 250 RC 00228-2127-10 NDC inpatient 1 UN 5.66 5.66 CIGNA 62308 [3081051] CIGNA STATE OF WYOMING [308105107] 4.48 percent of total billed charges 3.51 5.38 Technical (Hospital) Services CLONIDINE HCL 0.1 MG TABLET RX-1755 CDM 6370000100 HCPCS 250 RC 00228-2127-10 NDC inpatient 1 UN 5.66 5.66 UNITED HEALTHCARE (COMMERCIAL) [3081199] UNITED HEALTHCARE 87726 [308119901] 3.51 percent of total billed charges 3.51 5.38 Technical (Hospital) Services CLONIDINE HCL 0.1 MG TABLET RX-1755 CDM 6370000100 HCPCS 250 RC 00228-2127-10 NDC inpatient 1 UN 5.66 5.66 BLUE CROSS BLUE SHIELD WELLMARK SB889 [3081026] BCBS WYOMING [308102603] 5.38 percent of total billed charges 3.51 5.38 Technical (Hospital) Services CLONIDINE HCL 0.1 MG TABLET RX-1755 CDM 6370000100 HCPCS 250 RC 00228-2127-10 NDC outpatient 1 UN 5.66 5.66 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES EPO [308136803] 4.53 percent of total billed charges 3.51 5.38 Technical (Hospital) Services CLONIDINE HCL 0.1 MG TABLET RX-1755 CDM 6370000100 HCPCS 250 RC 00228-2127-10 NDC outpatient 1 UN 5.66 5.66 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES HDHP [308136802] 4.53 percent of total billed charges 3.51 5.38 Technical (Hospital) Services CLONIDINE HCL 0.1 MG TABLET RX-1755 CDM 6370000100 HCPCS 250 RC 00228-2127-10 NDC outpatient 1 UN 5.66 5.66 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES PPO [308136801] 4.53 percent of total billed charges 3.51 5.38 Technical (Hospital) Services CLONIDINE HCL 0.1 MG TABLET RX-1755 CDM 6370000100 HCPCS 250 RC 00228-2127-10 NDC outpatient 1 UN 5.66 5.66 HEALTHPARTNERS SX009 HEALTHPARTNERS 4.53 percent of total billed charges 3.51 5.38 Technical (Hospital) Services CLONIDINE HCL 0.1 MG TABLET RX-1755 CDM 6370000100 HCPCS 250 RC 00228-2127-10 NDC outpatient 1 UN 5.66 5.66 BLUE CROSS BLUE SHIELD WELLMARK SB889 [3081026] BCBS WYOMING [308102603] 5.38 percent of total billed charges 3.51 5.38 Technical (Hospital) Services CLONIDINE HCL 0.1 MG TABLET RX-1755 CDM 6370000100 HCPCS 250 RC 00228-2127-10 NDC outpatient 1 UN 5.66 5.66 UNITED HEALTHCARE (COMMERCIAL) [3081199] UNITED HEALTHCARE 87726 [308119901] 3.51 percent of total billed charges 3.51 5.38 Technical (Hospital) Services CLONIDINE HCL 0.1 MG TABLET RX-1755 CDM 6370000100 HCPCS 250 RC 00228-2127-10 NDC outpatient 1 UN 5.66 5.66 MULTIPLAN INC 34080 [3081285] MULTIPLAN INC [308128501] 5.38 percent of total billed charges 3.51 5.38 Technical (Hospital) Services CLONIDINE HCL 0.1 MG TABLET RX-1755 CDM 6370000100 HCPCS 250 RC 00228-2127-10 NDC outpatient 1 UN 5.66 5.66 CIGNA 62308 [3081051] CIGNA 62308 [308105105] 4.53 percent of total billed charges 3.51 5.38 Technical (Hospital) Services CLONIDINE HCL 0.1 MG TABLET RX-1755 CDM 6370000100 HCPCS 250 RC 00228-2127-10 NDC outpatient 1 UN 5.66 5.66 CIGNA 62308 [3081051] CIGNA STATE OF WYOMING [308105107] 4.53 percent of total billed charges 3.51 5.38 Technical (Hospital) Services CLONIDINE HCL 0.1 MG TABLET RX-1755 CDM 6370000100 HCPCS 250 RC 00228-2127-10 NDC outpatient 1 UN 5.66 5.66 MEDICA (COMMERCIAL) 94265 [3081118] MEDICA CLAIMS [308111801] 5.09 percent of total billed charges 3.51 5.38 Technical (Hospital) Services "CALCIUM CIT 1,000 MG CALCIUM-VIT D3 10 MCG(400 UNIT)/30 ML ORAL LIQUID" RX-176144 CDM 6370000100 HCPCS 250 RC 79854-0078-82 NDC inpatient 15 ML 5.85 5.85 CIGNA 62308 [3081051] CIGNA 62308 [308105105] 4.63 percent of total billed charges 3.63 5.56 Technical (Hospital) Services "CALCIUM CIT 1,000 MG CALCIUM-VIT D3 10 MCG(400 UNIT)/30 ML ORAL LIQUID" RX-176144 CDM 6370000100 HCPCS 250 RC 79854-0078-82 NDC inpatient 15 ML 5.85 5.85 CIGNA 62308 [3081051] CIGNA STATE OF WYOMING [308105107] 4.63 percent of total billed charges 3.63 5.56 Technical (Hospital) Services "CALCIUM CIT 1,000 MG CALCIUM-VIT D3 10 MCG(400 UNIT)/30 ML ORAL LIQUID" RX-176144 CDM 6370000100 HCPCS 250 RC 79854-0078-82 NDC inpatient 15 ML 5.85 5.85 HEALTHPARTNERS SX009 HEALTHPARTNERS 4.63 percent of total billed charges 3.63 5.56 Technical (Hospital) Services "CALCIUM CIT 1,000 MG CALCIUM-VIT D3 10 MCG(400 UNIT)/30 ML ORAL LIQUID" RX-176144 CDM 6370000100 HCPCS 250 RC 79854-0078-82 NDC inpatient 15 ML 5.85 5.85 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES EPO [308136803] 4.63 percent of total billed charges 3.63 5.56 Technical (Hospital) Services "CALCIUM CIT 1,000 MG CALCIUM-VIT D3 10 MCG(400 UNIT)/30 ML ORAL LIQUID" RX-176144 CDM 6370000100 HCPCS 250 RC 79854-0078-82 NDC inpatient 15 ML 5.85 5.85 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES HDHP [308136802] 4.63 percent of total billed charges 3.63 5.56 Technical (Hospital) Services "CALCIUM CIT 1,000 MG CALCIUM-VIT D3 10 MCG(400 UNIT)/30 ML ORAL LIQUID" RX-176144 CDM 6370000100 HCPCS 250 RC 79854-0078-82 NDC inpatient 15 ML 5.85 5.85 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES PPO [308136801] 4.63 percent of total billed charges 3.63 5.56 Technical (Hospital) Services "CALCIUM CIT 1,000 MG CALCIUM-VIT D3 10 MCG(400 UNIT)/30 ML ORAL LIQUID" RX-176144 CDM 6370000100 HCPCS 250 RC 79854-0078-82 NDC inpatient 15 ML 5.85 5.85 MULTIPLAN INC 34080 [3081285] MULTIPLAN INC [308128501] 5.56 percent of total billed charges 3.63 5.56 Technical (Hospital) Services "CALCIUM CIT 1,000 MG CALCIUM-VIT D3 10 MCG(400 UNIT)/30 ML ORAL LIQUID" RX-176144 CDM 6370000100 HCPCS 250 RC 79854-0078-82 NDC inpatient 15 ML 5.85 5.85 MEDICA (COMMERCIAL) 94265 [3081118] MEDICA CLAIMS [308111801] 5.27 percent of total billed charges 3.63 5.56 Technical (Hospital) Services "CALCIUM CIT 1,000 MG CALCIUM-VIT D3 10 MCG(400 UNIT)/30 ML ORAL LIQUID" RX-176144 CDM 6370000100 HCPCS 250 RC 79854-0078-82 NDC inpatient 15 ML 5.85 5.85 UNITED HEALTHCARE (COMMERCIAL) [3081199] UNITED HEALTHCARE 87726 [308119901] 3.63 percent of total billed charges 3.63 5.56 Technical (Hospital) Services "CALCIUM CIT 1,000 MG CALCIUM-VIT D3 10 MCG(400 UNIT)/30 ML ORAL LIQUID" RX-176144 CDM 6370000100 HCPCS 250 RC 79854-0078-82 NDC inpatient 15 ML 5.85 5.85 BLUE CROSS BLUE SHIELD WELLMARK SB889 [3081026] BCBS WYOMING [308102603] 5.56 percent of total billed charges 3.63 5.56 Technical (Hospital) Services "CALCIUM CIT 1,000 MG CALCIUM-VIT D3 10 MCG(400 UNIT)/30 ML ORAL LIQUID" RX-176144 CDM 6370000100 HCPCS 250 RC 79854-0078-82 NDC outpatient 15 ML 5.85 5.85 UNITED HEALTHCARE (COMMERCIAL) [3081199] UNITED HEALTHCARE 87726 [308119901] 3.63 percent of total billed charges 3.63 5.56 Technical (Hospital) Services "CALCIUM CIT 1,000 MG CALCIUM-VIT D3 10 MCG(400 UNIT)/30 ML ORAL LIQUID" RX-176144 CDM 6370000100 HCPCS 250 RC 79854-0078-82 NDC outpatient 15 ML 5.85 5.85 HEALTHPARTNERS SX009 HEALTHPARTNERS 4.68 percent of total billed charges 3.63 5.56 Technical (Hospital) Services "CALCIUM CIT 1,000 MG CALCIUM-VIT D3 10 MCG(400 UNIT)/30 ML ORAL LIQUID" RX-176144 CDM 6370000100 HCPCS 250 RC 79854-0078-82 NDC outpatient 15 ML 5.85 5.85 MULTIPLAN INC 34080 [3081285] MULTIPLAN INC [308128501] 5.56 percent of total billed charges 3.63 5.56 Technical (Hospital) Services "CALCIUM CIT 1,000 MG CALCIUM-VIT D3 10 MCG(400 UNIT)/30 ML ORAL LIQUID" RX-176144 CDM 6370000100 HCPCS 250 RC 79854-0078-82 NDC outpatient 15 ML 5.85 5.85 MEDICA (COMMERCIAL) 94265 [3081118] MEDICA CLAIMS [308111801] 5.27 percent of total billed charges 3.63 5.56 Technical (Hospital) Services "CALCIUM CIT 1,000 MG CALCIUM-VIT D3 10 MCG(400 UNIT)/30 ML ORAL LIQUID" RX-176144 CDM 6370000100 HCPCS 250 RC 79854-0078-82 NDC outpatient 15 ML 5.85 5.85 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES EPO [308136803] 4.68 percent of total billed charges 3.63 5.56 Technical (Hospital) Services "CALCIUM CIT 1,000 MG CALCIUM-VIT D3 10 MCG(400 UNIT)/30 ML ORAL LIQUID" RX-176144 CDM 6370000100 HCPCS 250 RC 79854-0078-82 NDC outpatient 15 ML 5.85 5.85 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES HDHP [308136802] 4.68 percent of total billed charges 3.63 5.56 Technical (Hospital) Services "CALCIUM CIT 1,000 MG CALCIUM-VIT D3 10 MCG(400 UNIT)/30 ML ORAL LIQUID" RX-176144 CDM 6370000100 HCPCS 250 RC 79854-0078-82 NDC outpatient 15 ML 5.85 5.85 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES PPO [308136801] 4.68 percent of total billed charges 3.63 5.56 Technical (Hospital) Services "CALCIUM CIT 1,000 MG CALCIUM-VIT D3 10 MCG(400 UNIT)/30 ML ORAL LIQUID" RX-176144 CDM 6370000100 HCPCS 250 RC 79854-0078-82 NDC outpatient 15 ML 5.85 5.85 BLUE CROSS BLUE SHIELD WELLMARK SB889 [3081026] BCBS WYOMING [308102603] 5.56 percent of total billed charges 3.63 5.56 Technical (Hospital) Services "CALCIUM CIT 1,000 MG CALCIUM-VIT D3 10 MCG(400 UNIT)/30 ML ORAL LIQUID" RX-176144 CDM 6370000100 HCPCS 250 RC 79854-0078-82 NDC outpatient 15 ML 5.85 5.85 CIGNA 62308 [3081051] CIGNA 62308 [308105105] 4.68 percent of total billed charges 3.63 5.56 Technical (Hospital) Services "CALCIUM CIT 1,000 MG CALCIUM-VIT D3 10 MCG(400 UNIT)/30 ML ORAL LIQUID" RX-176144 CDM 6370000100 HCPCS 250 RC 79854-0078-82 NDC outpatient 15 ML 5.85 5.85 CIGNA 62308 [3081051] CIGNA STATE OF WYOMING [308105107] 4.68 percent of total billed charges 3.63 5.56 Technical (Hospital) Services BRIMONIDINE 0.2 % EYE DROPS RX-17881 CDM 6370000100 HCPCS 250 RC 61314-0143-10 NDC inpatient 10 ML 47.6 47.6 CIGNA 62308 [3081051] CIGNA 62308 [308105105] 37.69 percent of total billed charges 29.51 45.22 Technical (Hospital) Services BRIMONIDINE 0.2 % EYE DROPS RX-17881 CDM 6370000100 HCPCS 250 RC 61314-0143-10 NDC inpatient 10 ML 47.6 47.6 CIGNA 62308 [3081051] CIGNA STATE OF WYOMING [308105107] 37.69 percent of total billed charges 29.51 45.22 Technical (Hospital) Services BRIMONIDINE 0.2 % EYE DROPS RX-17881 CDM 6370000100 HCPCS 250 RC 61314-0143-10 NDC inpatient 10 ML 47.6 47.6 BLUE CROSS BLUE SHIELD WELLMARK SB889 [3081026] BCBS WYOMING [308102603] 45.22 percent of total billed charges 29.51 45.22 Technical (Hospital) Services BRIMONIDINE 0.2 % EYE DROPS RX-17881 CDM 6370000100 HCPCS 250 RC 61314-0143-10 NDC inpatient 10 ML 47.6 47.6 UNITED HEALTHCARE (COMMERCIAL) [3081199] UNITED HEALTHCARE 87726 [308119901] 29.51 percent of total billed charges 29.51 45.22 Technical (Hospital) Services BRIMONIDINE 0.2 % EYE DROPS RX-17881 CDM 6370000100 HCPCS 250 RC 61314-0143-10 NDC inpatient 10 ML 47.6 47.6 MEDICA (COMMERCIAL) 94265 [3081118] MEDICA CLAIMS [308111801] 42.84 percent of total billed charges 29.51 45.22 Technical (Hospital) Services BRIMONIDINE 0.2 % EYE DROPS RX-17881 CDM 6370000100 HCPCS 250 RC 61314-0143-10 NDC inpatient 10 ML 47.6 47.6 MULTIPLAN INC 34080 [3081285] MULTIPLAN INC [308128501] 45.22 percent of total billed charges 29.51 45.22 Technical (Hospital) Services BRIMONIDINE 0.2 % EYE DROPS RX-17881 CDM 6370000100 HCPCS 250 RC 61314-0143-10 NDC inpatient 10 ML 47.6 47.6 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES EPO [308136803] 37.69 percent of total billed charges 29.51 45.22 Technical (Hospital) Services BRIMONIDINE 0.2 % EYE DROPS RX-17881 CDM 6370000100 HCPCS 250 RC 61314-0143-10 NDC inpatient 10 ML 47.6 47.6 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES HDHP [308136802] 37.69 percent of total billed charges 29.51 45.22 Technical (Hospital) Services BRIMONIDINE 0.2 % EYE DROPS RX-17881 CDM 6370000100 HCPCS 250 RC 61314-0143-10 NDC inpatient 10 ML 47.6 47.6 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES PPO [308136801] 37.69 percent of total billed charges 29.51 45.22 Technical (Hospital) Services BRIMONIDINE 0.2 % EYE DROPS RX-17881 CDM 6370000100 HCPCS 250 RC 61314-0143-10 NDC inpatient 10 ML 47.6 47.6 HEALTHPARTNERS SX009 HEALTHPARTNERS 37.69 percent of total billed charges 29.51 45.22 Technical (Hospital) Services BRIMONIDINE 0.2 % EYE DROPS RX-17881 CDM 6370000100 HCPCS 250 RC 61314-0143-10 NDC outpatient 10 ML 47.6 47.6 MULTIPLAN INC 34080 [3081285] MULTIPLAN INC [308128501] 45.22 percent of total billed charges 29.51 45.22 Technical (Hospital) Services BRIMONIDINE 0.2 % EYE DROPS RX-17881 CDM 6370000100 HCPCS 250 RC 61314-0143-10 NDC outpatient 10 ML 47.6 47.6 MEDICA (COMMERCIAL) 94265 [3081118] MEDICA CLAIMS [308111801] 42.84 percent of total billed charges 29.51 45.22 Technical (Hospital) Services BRIMONIDINE 0.2 % EYE DROPS RX-17881 CDM 6370000100 HCPCS 250 RC 61314-0143-10 NDC outpatient 10 ML 47.6 47.6 CIGNA 62308 [3081051] CIGNA 62308 [308105105] 38.08 percent of total billed charges 29.51 45.22 Technical (Hospital) Services BRIMONIDINE 0.2 % EYE DROPS RX-17881 CDM 6370000100 HCPCS 250 RC 61314-0143-10 NDC outpatient 10 ML 47.6 47.6 CIGNA 62308 [3081051] CIGNA STATE OF WYOMING [308105107] 38.08 percent of total billed charges 29.51 45.22 Technical (Hospital) Services BRIMONIDINE 0.2 % EYE DROPS RX-17881 CDM 6370000100 HCPCS 250 RC 61314-0143-10 NDC outpatient 10 ML 47.6 47.6 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES HDHP [308136802] 38.08 percent of total billed charges 29.51 45.22 Technical (Hospital) Services BRIMONIDINE 0.2 % EYE DROPS RX-17881 CDM 6370000100 HCPCS 250 RC 61314-0143-10 NDC outpatient 10 ML 47.6 47.6 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES PPO [308136801] 38.08 percent of total billed charges 29.51 45.22 Technical (Hospital) Services BRIMONIDINE 0.2 % EYE DROPS RX-17881 CDM 6370000100 HCPCS 250 RC 61314-0143-10 NDC outpatient 10 ML 47.6 47.6 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES EPO [308136803] 38.08 percent of total billed charges 29.51 45.22 Technical (Hospital) Services BRIMONIDINE 0.2 % EYE DROPS RX-17881 CDM 6370000100 HCPCS 250 RC 61314-0143-10 NDC outpatient 10 ML 47.6 47.6 BLUE CROSS BLUE SHIELD WELLMARK SB889 [3081026] BCBS WYOMING [308102603] 45.22 percent of total billed charges 29.51 45.22 Technical (Hospital) Services BRIMONIDINE 0.2 % EYE DROPS RX-17881 CDM 6370000100 HCPCS 250 RC 61314-0143-10 NDC outpatient 10 ML 47.6 47.6 UNITED HEALTHCARE (COMMERCIAL) [3081199] UNITED HEALTHCARE 87726 [308119901] 29.51 percent of total billed charges 29.51 45.22 Technical (Hospital) Services BRIMONIDINE 0.2 % EYE DROPS RX-17881 CDM 6370000100 HCPCS 250 RC 61314-0143-10 NDC outpatient 10 ML 47.6 47.6 HEALTHPARTNERS SX009 HEALTHPARTNERS 38.08 percent of total billed charges 29.51 45.22 Technical (Hospital) Services UBROGEPANT 100 MG TABLET RX-179072 CDM 6370000100 HCPCS 250 RC 00023-6501-02 NDC inpatient 1 UN 334.82 334.82 UNITED HEALTHCARE (COMMERCIAL) [3081199] UNITED HEALTHCARE 87726 [308119901] 207.59 percent of total billed charges 207.59 318.08 Technical (Hospital) Services UBROGEPANT 100 MG TABLET RX-179072 CDM 6370000100 HCPCS 250 RC 00023-6501-02 NDC inpatient 1 UN 334.82 334.82 BLUE CROSS BLUE SHIELD WELLMARK SB889 [3081026] BCBS WYOMING [308102603] 318.08 percent of total billed charges 207.59 318.08 Technical (Hospital) Services UBROGEPANT 100 MG TABLET RX-179072 CDM 6370000100 HCPCS 250 RC 00023-6501-02 NDC inpatient 1 UN 334.82 334.82 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES EPO [308136803] 265.11 percent of total billed charges 207.59 318.08 Technical (Hospital) Services UBROGEPANT 100 MG TABLET RX-179072 CDM 6370000100 HCPCS 250 RC 00023-6501-02 NDC inpatient 1 UN 334.82 334.82 CIGNA 62308 [3081051] CIGNA 62308 [308105105] 265.11 percent of total billed charges 207.59 318.08 Technical (Hospital) Services UBROGEPANT 100 MG TABLET RX-179072 CDM 6370000100 HCPCS 250 RC 00023-6501-02 NDC inpatient 1 UN 334.82 334.82 CIGNA 62308 [3081051] CIGNA STATE OF WYOMING [308105107] 265.11 percent of total billed charges 207.59 318.08 Technical (Hospital) Services UBROGEPANT 100 MG TABLET RX-179072 CDM 6370000100 HCPCS 250 RC 00023-6501-02 NDC inpatient 1 UN 334.82 334.82 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES HDHP [308136802] 265.11 percent of total billed charges 207.59 318.08 Technical (Hospital) Services UBROGEPANT 100 MG TABLET RX-179072 CDM 6370000100 HCPCS 250 RC 00023-6501-02 NDC inpatient 1 UN 334.82 334.82 HEALTHPARTNERS SX009 HEALTHPARTNERS 265.11 percent of total billed charges 207.59 318.08 Technical (Hospital) Services UBROGEPANT 100 MG TABLET RX-179072 CDM 6370000100 HCPCS 250 RC 00023-6501-02 NDC inpatient 1 UN 334.82 334.82 MEDICA (COMMERCIAL) 94265 [3081118] MEDICA CLAIMS [308111801] 301.34 percent of total billed charges 207.59 318.08 Technical (Hospital) Services UBROGEPANT 100 MG TABLET RX-179072 CDM 6370000100 HCPCS 250 RC 00023-6501-02 NDC inpatient 1 UN 334.82 334.82 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES PPO [308136801] 265.11 percent of total billed charges 207.59 318.08 Technical (Hospital) Services UBROGEPANT 100 MG TABLET RX-179072 CDM 6370000100 HCPCS 250 RC 00023-6501-02 NDC inpatient 1 UN 334.82 334.82 MULTIPLAN INC 34080 [3081285] MULTIPLAN INC [308128501] 318.08 percent of total billed charges 207.59 318.08 Technical (Hospital) Services UBROGEPANT 100 MG TABLET RX-179072 CDM 6370000100 HCPCS 250 RC 00023-6501-02 NDC outpatient 1 UN 334.82 334.82 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES EPO [308136803] 267.86 percent of total billed charges 207.59 318.08 Technical (Hospital) Services UBROGEPANT 100 MG TABLET RX-179072 CDM 6370000100 HCPCS 250 RC 00023-6501-02 NDC outpatient 1 UN 334.82 334.82 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES HDHP [308136802] 267.86 percent of total billed charges 207.59 318.08 Technical (Hospital) Services UBROGEPANT 100 MG TABLET RX-179072 CDM 6370000100 HCPCS 250 RC 00023-6501-02 NDC outpatient 1 UN 334.82 334.82 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES PPO [308136801] 267.86 percent of total billed charges 207.59 318.08 Technical (Hospital) Services UBROGEPANT 100 MG TABLET RX-179072 CDM 6370000100 HCPCS 250 RC 00023-6501-02 NDC outpatient 1 UN 334.82 334.82 BLUE CROSS BLUE SHIELD WELLMARK SB889 [3081026] BCBS WYOMING [308102603] 318.08 percent of total billed charges 207.59 318.08 Technical (Hospital) Services UBROGEPANT 100 MG TABLET RX-179072 CDM 6370000100 HCPCS 250 RC 00023-6501-02 NDC outpatient 1 UN 334.82 334.82 HEALTHPARTNERS SX009 HEALTHPARTNERS 267.86 percent of total billed charges 207.59 318.08 Technical (Hospital) Services UBROGEPANT 100 MG TABLET RX-179072 CDM 6370000100 HCPCS 250 RC 00023-6501-02 NDC outpatient 1 UN 334.82 334.82 UNITED HEALTHCARE (COMMERCIAL) [3081199] UNITED HEALTHCARE 87726 [308119901] 207.59 percent of total billed charges 207.59 318.08 Technical (Hospital) Services UBROGEPANT 100 MG TABLET RX-179072 CDM 6370000100 HCPCS 250 RC 00023-6501-02 NDC outpatient 1 UN 334.82 334.82 MEDICA (COMMERCIAL) 94265 [3081118] MEDICA CLAIMS [308111801] 301.34 percent of total billed charges 207.59 318.08 Technical (Hospital) Services UBROGEPANT 100 MG TABLET RX-179072 CDM 6370000100 HCPCS 250 RC 00023-6501-02 NDC outpatient 1 UN 334.82 334.82 MULTIPLAN INC 34080 [3081285] MULTIPLAN INC [308128501] 318.08 percent of total billed charges 207.59 318.08 Technical (Hospital) Services UBROGEPANT 100 MG TABLET RX-179072 CDM 6370000100 HCPCS 250 RC 00023-6501-02 NDC outpatient 1 UN 334.82 334.82 CIGNA 62308 [3081051] CIGNA 62308 [308105105] 267.86 percent of total billed charges 207.59 318.08 Technical (Hospital) Services UBROGEPANT 100 MG TABLET RX-179072 CDM 6370000100 HCPCS 250 RC 00023-6501-02 NDC outpatient 1 UN 334.82 334.82 CIGNA 62308 [3081051] CIGNA STATE OF WYOMING [308105107] 267.86 percent of total billed charges 207.59 318.08 Technical (Hospital) Services OLANZAPINE 5 MG TABLET RX-17936 CDM 6370000100 HCPCS 250 RC 43598-0164-30 NDC outpatient 1 UN 5.85 5.85 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES HDHP [308136802] 4.68 percent of total billed charges 3.63 5.56 Technical (Hospital) Services OLANZAPINE 5 MG TABLET RX-17936 CDM 6370000100 HCPCS 250 RC 43598-0164-30 NDC outpatient 1 UN 5.85 5.85 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES EPO [308136803] 4.68 percent of total billed charges 3.63 5.56 Technical (Hospital) Services OLANZAPINE 5 MG TABLET RX-17936 CDM 6370000100 HCPCS 250 RC 43598-0164-30 NDC outpatient 1 UN 5.85 5.85 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES PPO [308136801] 4.68 percent of total billed charges 3.63 5.56 Technical (Hospital) Services OLANZAPINE 5 MG TABLET RX-17936 CDM 6370000100 HCPCS 250 RC 43598-0164-30 NDC outpatient 1 UN 5.85 5.85 UNITED HEALTHCARE (COMMERCIAL) [3081199] UNITED HEALTHCARE 87726 [308119901] 3.63 percent of total billed charges 3.63 5.56 Technical (Hospital) Services OLANZAPINE 5 MG TABLET RX-17936 CDM 6370000100 HCPCS 250 RC 43598-0164-30 NDC outpatient 1 UN 5.85 5.85 CIGNA 62308 [3081051] CIGNA 62308 [308105105] 4.68 percent of total billed charges 3.63 5.56 Technical (Hospital) Services OLANZAPINE 5 MG TABLET RX-17936 CDM 6370000100 HCPCS 250 RC 43598-0164-30 NDC outpatient 1 UN 5.85 5.85 CIGNA 62308 [3081051] CIGNA STATE OF WYOMING [308105107] 4.68 percent of total billed charges 3.63 5.56 Technical (Hospital) Services OLANZAPINE 5 MG TABLET RX-17936 CDM 6370000100 HCPCS 250 RC 43598-0164-30 NDC outpatient 1 UN 5.85 5.85 MULTIPLAN INC 34080 [3081285] MULTIPLAN INC [308128501] 5.56 percent of total billed charges 3.63 5.56 Technical (Hospital) Services OLANZAPINE 5 MG TABLET RX-17936 CDM 6370000100 HCPCS 250 RC 43598-0164-30 NDC outpatient 1 UN 5.85 5.85 MEDICA (COMMERCIAL) 94265 [3081118] MEDICA CLAIMS [308111801] 5.27 percent of total billed charges 3.63 5.56 Technical (Hospital) Services OLANZAPINE 5 MG TABLET RX-17936 CDM 6370000100 HCPCS 250 RC 43598-0164-30 NDC outpatient 1 UN 5.85 5.85 HEALTHPARTNERS SX009 HEALTHPARTNERS 4.68 percent of total billed charges 3.63 5.56 Technical (Hospital) Services OLANZAPINE 5 MG TABLET RX-17936 CDM 6370000100 HCPCS 250 RC 43598-0164-30 NDC outpatient 1 UN 5.85 5.85 BLUE CROSS BLUE SHIELD WELLMARK SB889 [3081026] BCBS WYOMING [308102603] 5.56 percent of total billed charges 3.63 5.56 Technical (Hospital) Services OLANZAPINE 5 MG TABLET RX-17936 CDM 6370000100 HCPCS 250 RC 43598-0164-30 NDC inpatient 1 UN 5.85 5.85 CIGNA 62308 [3081051] CIGNA STATE OF WYOMING [308105107] 4.63 percent of total billed charges 3.63 5.56 Technical (Hospital) Services OLANZAPINE 5 MG TABLET RX-17936 CDM 6370000100 HCPCS 250 RC 43598-0164-30 NDC inpatient 1 UN 5.85 5.85 CIGNA 62308 [3081051] CIGNA 62308 [308105105] 4.63 percent of total billed charges 3.63 5.56 Technical (Hospital) Services OLANZAPINE 5 MG TABLET RX-17936 CDM 6370000100 HCPCS 250 RC 43598-0164-30 NDC inpatient 1 UN 5.85 5.85 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES EPO [308136803] 4.63 percent of total billed charges 3.63 5.56 Technical (Hospital) Services OLANZAPINE 5 MG TABLET RX-17936 CDM 6370000100 HCPCS 250 RC 43598-0164-30 NDC inpatient 1 UN 5.85 5.85 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES HDHP [308136802] 4.63 percent of total billed charges 3.63 5.56 Technical (Hospital) Services OLANZAPINE 5 MG TABLET RX-17936 CDM 6370000100 HCPCS 250 RC 43598-0164-30 NDC inpatient 1 UN 5.85 5.85 UNITED HEALTHCARE (COMMERCIAL) [3081199] UNITED HEALTHCARE 87726 [308119901] 3.63 percent of total billed charges 3.63 5.56 Technical (Hospital) Services OLANZAPINE 5 MG TABLET RX-17936 CDM 6370000100 HCPCS 250 RC 43598-0164-30 NDC inpatient 1 UN 5.85 5.85 BLUE CROSS BLUE SHIELD WELLMARK SB889 [3081026] BCBS WYOMING [308102603] 5.56 percent of total billed charges 3.63 5.56 Technical (Hospital) Services OLANZAPINE 5 MG TABLET RX-17936 CDM 6370000100 HCPCS 250 RC 43598-0164-30 NDC inpatient 1 UN 5.85 5.85 MULTIPLAN INC 34080 [3081285] MULTIPLAN INC [308128501] 5.56 percent of total billed charges 3.63 5.56 Technical (Hospital) Services OLANZAPINE 5 MG TABLET RX-17936 CDM 6370000100 HCPCS 250 RC 43598-0164-30 NDC inpatient 1 UN 5.85 5.85 MEDICA (COMMERCIAL) 94265 [3081118] MEDICA CLAIMS [308111801] 5.27 percent of total billed charges 3.63 5.56 Technical (Hospital) Services OLANZAPINE 5 MG TABLET RX-17936 CDM 6370000100 HCPCS 250 RC 43598-0164-30 NDC inpatient 1 UN 5.85 5.85 HEALTHPARTNERS SX009 HEALTHPARTNERS 4.63 percent of total billed charges 3.63 5.56 Technical (Hospital) Services OLANZAPINE 5 MG TABLET RX-17936 CDM 6370000100 HCPCS 250 RC 43598-0164-30 NDC inpatient 1 UN 5.85 5.85 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES PPO [308136801] 4.63 percent of total billed charges 3.63 5.56 Technical (Hospital) Services OLANZAPINE 10 MG TABLET RX-17937 CDM 6370000100 HCPCS 250 RC 43598-0166-30 NDC outpatient 1 UN 5.97 5.97 BLUE CROSS BLUE SHIELD WELLMARK SB889 [3081026] BCBS WYOMING [308102603] 5.67 percent of total billed charges 3.7 5.67 Technical (Hospital) Services OLANZAPINE 10 MG TABLET RX-17937 CDM 6370000100 HCPCS 250 RC 43598-0166-30 NDC outpatient 1 UN 5.97 5.97 HEALTHPARTNERS SX009 HEALTHPARTNERS 4.78 percent of total billed charges 3.7 5.67 Technical (Hospital) Services OLANZAPINE 10 MG TABLET RX-17937 CDM 6370000100 HCPCS 250 RC 43598-0166-30 NDC outpatient 1 UN 5.97 5.97 UNITED HEALTHCARE (COMMERCIAL) [3081199] UNITED HEALTHCARE 87726 [308119901] 3.7 percent of total billed charges 3.7 5.67 Technical (Hospital) Services OLANZAPINE 10 MG TABLET RX-17937 CDM 6370000100 HCPCS 250 RC 43598-0166-30 NDC outpatient 1 UN 5.97 5.97 CIGNA 62308 [3081051] CIGNA 62308 [308105105] 4.78 percent of total billed charges 3.7 5.67 Technical (Hospital) Services OLANZAPINE 10 MG TABLET RX-17937 CDM 6370000100 HCPCS 250 RC 43598-0166-30 NDC outpatient 1 UN 5.97 5.97 CIGNA 62308 [3081051] CIGNA STATE OF WYOMING [308105107] 4.78 percent of total billed charges 3.7 5.67 Technical (Hospital) Services OLANZAPINE 10 MG TABLET RX-17937 CDM 6370000100 HCPCS 250 RC 43598-0166-30 NDC outpatient 1 UN 5.97 5.97 MULTIPLAN INC 34080 [3081285] MULTIPLAN INC [308128501] 5.67 percent of total billed charges 3.7 5.67 Technical (Hospital) Services OLANZAPINE 10 MG TABLET RX-17937 CDM 6370000100 HCPCS 250 RC 43598-0166-30 NDC outpatient 1 UN 5.97 5.97 MEDICA (COMMERCIAL) 94265 [3081118] MEDICA CLAIMS [308111801] 5.37 percent of total billed charges 3.7 5.67 Technical (Hospital) Services OLANZAPINE 10 MG TABLET RX-17937 CDM 6370000100 HCPCS 250 RC 43598-0166-30 NDC outpatient 1 UN 5.97 5.97 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES PPO [308136801] 4.78 percent of total billed charges 3.7 5.67 Technical (Hospital) Services OLANZAPINE 10 MG TABLET RX-17937 CDM 6370000100 HCPCS 250 RC 43598-0166-30 NDC outpatient 1 UN 5.97 5.97 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES EPO [308136803] 4.78 percent of total billed charges 3.7 5.67 Technical (Hospital) Services OLANZAPINE 10 MG TABLET RX-17937 CDM 6370000100 HCPCS 250 RC 43598-0166-30 NDC outpatient 1 UN 5.97 5.97 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES HDHP [308136802] 4.78 percent of total billed charges 3.7 5.67 Technical (Hospital) Services OLANZAPINE 10 MG TABLET RX-17937 CDM 6370000100 HCPCS 250 RC 43598-0166-30 NDC inpatient 1 UN 5.97 5.97 UNITED HEALTHCARE (COMMERCIAL) [3081199] UNITED HEALTHCARE 87726 [308119901] 3.7 percent of total billed charges 3.7 5.67 Technical (Hospital) Services OLANZAPINE 10 MG TABLET RX-17937 CDM 6370000100 HCPCS 250 RC 43598-0166-30 NDC inpatient 1 UN 5.97 5.97 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES HDHP [308136802] 4.73 percent of total billed charges 3.7 5.67 Technical (Hospital) Services OLANZAPINE 10 MG TABLET RX-17937 CDM 6370000100 HCPCS 250 RC 43598-0166-30 NDC inpatient 1 UN 5.97 5.97 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES EPO [308136803] 4.73 percent of total billed charges 3.7 5.67 Technical (Hospital) Services OLANZAPINE 10 MG TABLET RX-17937 CDM 6370000100 HCPCS 250 RC 43598-0166-30 NDC inpatient 1 UN 5.97 5.97 CIGNA 62308 [3081051] CIGNA 62308 [308105105] 4.73 percent of total billed charges 3.7 5.67 Technical (Hospital) Services OLANZAPINE 10 MG TABLET RX-17937 CDM 6370000100 HCPCS 250 RC 43598-0166-30 NDC inpatient 1 UN 5.97 5.97 CIGNA 62308 [3081051] CIGNA STATE OF WYOMING [308105107] 4.73 percent of total billed charges 3.7 5.67 Technical (Hospital) Services OLANZAPINE 10 MG TABLET RX-17937 CDM 6370000100 HCPCS 250 RC 43598-0166-30 NDC inpatient 1 UN 5.97 5.97 BLUE CROSS BLUE SHIELD WELLMARK SB889 [3081026] BCBS WYOMING [308102603] 5.67 percent of total billed charges 3.7 5.67 Technical (Hospital) Services OLANZAPINE 10 MG TABLET RX-17937 CDM 6370000100 HCPCS 250 RC 43598-0166-30 NDC inpatient 1 UN 5.97 5.97 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES PPO [308136801] 4.73 percent of total billed charges 3.7 5.67 Technical (Hospital) Services OLANZAPINE 10 MG TABLET RX-17937 CDM 6370000100 HCPCS 250 RC 43598-0166-30 NDC inpatient 1 UN 5.97 5.97 HEALTHPARTNERS SX009 HEALTHPARTNERS 4.73 percent of total billed charges 3.7 5.67 Technical (Hospital) Services OLANZAPINE 10 MG TABLET RX-17937 CDM 6370000100 HCPCS 250 RC 43598-0166-30 NDC inpatient 1 UN 5.97 5.97 MEDICA (COMMERCIAL) 94265 [3081118] MEDICA CLAIMS [308111801] 5.37 percent of total billed charges 3.7 5.67 Technical (Hospital) Services OLANZAPINE 10 MG TABLET RX-17937 CDM 6370000100 HCPCS 250 RC 43598-0166-30 NDC inpatient 1 UN 5.97 5.97 MULTIPLAN INC 34080 [3081285] MULTIPLAN INC [308128501] 5.67 percent of total billed charges 3.7 5.67 Technical (Hospital) Services COLCHICINE 0.6 MG TABLET RX-1821 CDM 6370000100 HCPCS 250 RC 64764-0119-07 NDC inpatient 1 UN 29.19 29.19 BLUE CROSS BLUE SHIELD WELLMARK SB889 [3081026] BCBS WYOMING [308102603] 27.73 percent of total billed charges 18.1 27.73 Technical (Hospital) Services COLCHICINE 0.6 MG TABLET RX-1821 CDM 6370000100 HCPCS 250 RC 64764-0119-07 NDC inpatient 1 UN 29.19 29.19 UNITED HEALTHCARE (COMMERCIAL) [3081199] UNITED HEALTHCARE 87726 [308119901] 18.1 percent of total billed charges 18.1 27.73 Technical (Hospital) Services COLCHICINE 0.6 MG TABLET RX-1821 CDM 6370000100 HCPCS 250 RC 64764-0119-07 NDC inpatient 1 UN 29.19 29.19 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES EPO [308136803] 23.11 percent of total billed charges 18.1 27.73 Technical (Hospital) Services COLCHICINE 0.6 MG TABLET RX-1821 CDM 6370000100 HCPCS 250 RC 64764-0119-07 NDC inpatient 1 UN 29.19 29.19 CIGNA 62308 [3081051] CIGNA 62308 [308105105] 23.11 percent of total billed charges 18.1 27.73 Technical (Hospital) Services COLCHICINE 0.6 MG TABLET RX-1821 CDM 6370000100 HCPCS 250 RC 64764-0119-07 NDC inpatient 1 UN 29.19 29.19 CIGNA 62308 [3081051] CIGNA STATE OF WYOMING [308105107] 23.11 percent of total billed charges 18.1 27.73 Technical (Hospital) Services COLCHICINE 0.6 MG TABLET RX-1821 CDM 6370000100 HCPCS 250 RC 64764-0119-07 NDC inpatient 1 UN 29.19 29.19 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES HDHP [308136802] 23.11 percent of total billed charges 18.1 27.73 Technical (Hospital) Services COLCHICINE 0.6 MG TABLET RX-1821 CDM 6370000100 HCPCS 250 RC 64764-0119-07 NDC inpatient 1 UN 29.19 29.19 HEALTHPARTNERS SX009 HEALTHPARTNERS 23.11 percent of total billed charges 18.1 27.73 Technical (Hospital) Services COLCHICINE 0.6 MG TABLET RX-1821 CDM 6370000100 HCPCS 250 RC 64764-0119-07 NDC inpatient 1 UN 29.19 29.19 MEDICA (COMMERCIAL) 94265 [3081118] MEDICA CLAIMS [308111801] 26.27 percent of total billed charges 18.1 27.73 Technical (Hospital) Services COLCHICINE 0.6 MG TABLET RX-1821 CDM 6370000100 HCPCS 250 RC 64764-0119-07 NDC inpatient 1 UN 29.19 29.19 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES PPO [308136801] 23.11 percent of total billed charges 18.1 27.73 Technical (Hospital) Services COLCHICINE 0.6 MG TABLET RX-1821 CDM 6370000100 HCPCS 250 RC 64764-0119-07 NDC inpatient 1 UN 29.19 29.19 MULTIPLAN INC 34080 [3081285] MULTIPLAN INC [308128501] 27.73 percent of total billed charges 18.1 27.73 Technical (Hospital) Services COLCHICINE 0.6 MG TABLET RX-1821 CDM 6370000100 HCPCS 250 RC 64764-0119-07 NDC outpatient 1 UN 29.19 29.19 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES EPO [308136803] 23.35 percent of total billed charges 18.1 27.73 Technical (Hospital) Services COLCHICINE 0.6 MG TABLET RX-1821 CDM 6370000100 HCPCS 250 RC 64764-0119-07 NDC outpatient 1 UN 29.19 29.19 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES PPO [308136801] 23.35 percent of total billed charges 18.1 27.73 Technical (Hospital) Services COLCHICINE 0.6 MG TABLET RX-1821 CDM 6370000100 HCPCS 250 RC 64764-0119-07 NDC outpatient 1 UN 29.19 29.19 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES HDHP [308136802] 23.35 percent of total billed charges 18.1 27.73 Technical (Hospital) Services COLCHICINE 0.6 MG TABLET RX-1821 CDM 6370000100 HCPCS 250 RC 64764-0119-07 NDC outpatient 1 UN 29.19 29.19 CIGNA 62308 [3081051] CIGNA 62308 [308105105] 23.35 percent of total billed charges 18.1 27.73 Technical (Hospital) Services COLCHICINE 0.6 MG TABLET RX-1821 CDM 6370000100 HCPCS 250 RC 64764-0119-07 NDC outpatient 1 UN 29.19 29.19 CIGNA 62308 [3081051] CIGNA STATE OF WYOMING [308105107] 23.35 percent of total billed charges 18.1 27.73 Technical (Hospital) Services COLCHICINE 0.6 MG TABLET RX-1821 CDM 6370000100 HCPCS 250 RC 64764-0119-07 NDC outpatient 1 UN 29.19 29.19 MEDICA (COMMERCIAL) 94265 [3081118] MEDICA CLAIMS [308111801] 26.27 percent of total billed charges 18.1 27.73 Technical (Hospital) Services COLCHICINE 0.6 MG TABLET RX-1821 CDM 6370000100 HCPCS 250 RC 64764-0119-07 NDC outpatient 1 UN 29.19 29.19 MULTIPLAN INC 34080 [3081285] MULTIPLAN INC [308128501] 27.73 percent of total billed charges 18.1 27.73 Technical (Hospital) Services COLCHICINE 0.6 MG TABLET RX-1821 CDM 6370000100 HCPCS 250 RC 64764-0119-07 NDC outpatient 1 UN 29.19 29.19 UNITED HEALTHCARE (COMMERCIAL) [3081199] UNITED HEALTHCARE 87726 [308119901] 18.1 percent of total billed charges 18.1 27.73 Technical (Hospital) Services COLCHICINE 0.6 MG TABLET RX-1821 CDM 6370000100 HCPCS 250 RC 64764-0119-07 NDC outpatient 1 UN 29.19 29.19 HEALTHPARTNERS SX009 HEALTHPARTNERS 23.35 percent of total billed charges 18.1 27.73 Technical (Hospital) Services COLCHICINE 0.6 MG TABLET RX-1821 CDM 6370000100 HCPCS 250 RC 64764-0119-07 NDC outpatient 1 UN 29.19 29.19 BLUE CROSS BLUE SHIELD WELLMARK SB889 [3081026] BCBS WYOMING [308102603] 27.73 percent of total billed charges 18.1 27.73 Technical (Hospital) Services LIDOCAINE 4 %-EPINEPHRINE 0.18 %-TETRACAINE 0.5 % TOPICAL GEL RX-182232 CDM 6370000100 HCPCS 250 RC 71266-6290-01 NDC outpatient 3 ML 65.7 65.7 MULTIPLAN INC 34080 [3081285] MULTIPLAN INC [308128501] 62.42 percent of total billed charges 40.73 62.42 Technical (Hospital) Services LIDOCAINE 4 %-EPINEPHRINE 0.18 %-TETRACAINE 0.5 % TOPICAL GEL RX-182232 CDM 6370000100 HCPCS 250 RC 71266-6290-01 NDC outpatient 3 ML 65.7 65.7 MEDICA (COMMERCIAL) 94265 [3081118] MEDICA CLAIMS [308111801] 59.13 percent of total billed charges 40.73 62.42 Technical (Hospital) Services LIDOCAINE 4 %-EPINEPHRINE 0.18 %-TETRACAINE 0.5 % TOPICAL GEL RX-182232 CDM 6370000100 HCPCS 250 RC 71266-6290-01 NDC outpatient 3 ML 65.7 65.7 CIGNA 62308 [3081051] CIGNA 62308 [308105105] 52.56 percent of total billed charges 40.73 62.42 Technical (Hospital) Services LIDOCAINE 4 %-EPINEPHRINE 0.18 %-TETRACAINE 0.5 % TOPICAL GEL RX-182232 CDM 6370000100 HCPCS 250 RC 71266-6290-01 NDC outpatient 3 ML 65.7 65.7 CIGNA 62308 [3081051] CIGNA STATE OF WYOMING [308105107] 52.56 percent of total billed charges 40.73 62.42 Technical (Hospital) Services LIDOCAINE 4 %-EPINEPHRINE 0.18 %-TETRACAINE 0.5 % TOPICAL GEL RX-182232 CDM 6370000100 HCPCS 250 RC 71266-6290-01 NDC outpatient 3 ML 65.7 65.7 UNITED HEALTHCARE (COMMERCIAL) [3081199] UNITED HEALTHCARE 87726 [308119901] 40.73 percent of total billed charges 40.73 62.42 Technical (Hospital) Services LIDOCAINE 4 %-EPINEPHRINE 0.18 %-TETRACAINE 0.5 % TOPICAL GEL RX-182232 CDM 6370000100 HCPCS 250 RC 71266-6290-01 NDC outpatient 3 ML 65.7 65.7 HEALTHPARTNERS SX009 HEALTHPARTNERS 52.56 percent of total billed charges 40.73 62.42 Technical (Hospital) Services LIDOCAINE 4 %-EPINEPHRINE 0.18 %-TETRACAINE 0.5 % TOPICAL GEL RX-182232 CDM 6370000100 HCPCS 250 RC 71266-6290-01 NDC outpatient 3 ML 65.7 65.7 BLUE CROSS BLUE SHIELD WELLMARK SB889 [3081026] BCBS WYOMING [308102603] 62.42 percent of total billed charges 40.73 62.42 Technical (Hospital) Services LIDOCAINE 4 %-EPINEPHRINE 0.18 %-TETRACAINE 0.5 % TOPICAL GEL RX-182232 CDM 6370000100 HCPCS 250 RC 71266-6290-01 NDC outpatient 3 ML 65.7 65.7 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES HDHP [308136802] 52.56 percent of total billed charges 40.73 62.42 Technical (Hospital) Services LIDOCAINE 4 %-EPINEPHRINE 0.18 %-TETRACAINE 0.5 % TOPICAL GEL RX-182232 CDM 6370000100 HCPCS 250 RC 71266-6290-01 NDC outpatient 3 ML 65.7 65.7 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES PPO [308136801] 52.56 percent of total billed charges 40.73 62.42 Technical (Hospital) Services LIDOCAINE 4 %-EPINEPHRINE 0.18 %-TETRACAINE 0.5 % TOPICAL GEL RX-182232 CDM 6370000100 HCPCS 250 RC 71266-6290-01 NDC outpatient 3 ML 65.7 65.7 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES EPO [308136803] 52.56 percent of total billed charges 40.73 62.42 Technical (Hospital) Services LIDOCAINE 4 %-EPINEPHRINE 0.18 %-TETRACAINE 0.5 % TOPICAL GEL RX-182232 CDM 6370000100 HCPCS 250 RC 71266-6290-01 NDC inpatient 3 ML 65.7 65.7 HEALTHPARTNERS SX009 HEALTHPARTNERS 52.02 percent of total billed charges 40.73 62.42 Technical (Hospital) Services LIDOCAINE 4 %-EPINEPHRINE 0.18 %-TETRACAINE 0.5 % TOPICAL GEL RX-182232 CDM 6370000100 HCPCS 250 RC 71266-6290-01 NDC inpatient 3 ML 65.7 65.7 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES HDHP [308136802] 52.02 percent of total billed charges 40.73 62.42 Technical (Hospital) Services LIDOCAINE 4 %-EPINEPHRINE 0.18 %-TETRACAINE 0.5 % TOPICAL GEL RX-182232 CDM 6370000100 HCPCS 250 RC 71266-6290-01 NDC inpatient 3 ML 65.7 65.7 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES PPO [308136801] 52.02 percent of total billed charges 40.73 62.42 Technical (Hospital) Services LIDOCAINE 4 %-EPINEPHRINE 0.18 %-TETRACAINE 0.5 % TOPICAL GEL RX-182232 CDM 6370000100 HCPCS 250 RC 71266-6290-01 NDC inpatient 3 ML 65.7 65.7 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES EPO [308136803] 52.02 percent of total billed charges 40.73 62.42 Technical (Hospital) Services LIDOCAINE 4 %-EPINEPHRINE 0.18 %-TETRACAINE 0.5 % TOPICAL GEL RX-182232 CDM 6370000100 HCPCS 250 RC 71266-6290-01 NDC inpatient 3 ML 65.7 65.7 MULTIPLAN INC 34080 [3081285] MULTIPLAN INC [308128501] 62.42 percent of total billed charges 40.73 62.42 Technical (Hospital) Services LIDOCAINE 4 %-EPINEPHRINE 0.18 %-TETRACAINE 0.5 % TOPICAL GEL RX-182232 CDM 6370000100 HCPCS 250 RC 71266-6290-01 NDC inpatient 3 ML 65.7 65.7 MEDICA (COMMERCIAL) 94265 [3081118] MEDICA CLAIMS [308111801] 59.13 percent of total billed charges 40.73 62.42 Technical (Hospital) Services LIDOCAINE 4 %-EPINEPHRINE 0.18 %-TETRACAINE 0.5 % TOPICAL GEL RX-182232 CDM 6370000100 HCPCS 250 RC 71266-6290-01 NDC inpatient 3 ML 65.7 65.7 BLUE CROSS BLUE SHIELD WELLMARK SB889 [3081026] BCBS WYOMING [308102603] 62.42 percent of total billed charges 40.73 62.42 Technical (Hospital) Services LIDOCAINE 4 %-EPINEPHRINE 0.18 %-TETRACAINE 0.5 % TOPICAL GEL RX-182232 CDM 6370000100 HCPCS 250 RC 71266-6290-01 NDC inpatient 3 ML 65.7 65.7 CIGNA 62308 [3081051] CIGNA 62308 [308105105] 52.02 percent of total billed charges 40.73 62.42 Technical (Hospital) Services LIDOCAINE 4 %-EPINEPHRINE 0.18 %-TETRACAINE 0.5 % TOPICAL GEL RX-182232 CDM 6370000100 HCPCS 250 RC 71266-6290-01 NDC inpatient 3 ML 65.7 65.7 CIGNA 62308 [3081051] CIGNA STATE OF WYOMING [308105107] 52.02 percent of total billed charges 40.73 62.42 Technical (Hospital) Services LIDOCAINE 4 %-EPINEPHRINE 0.18 %-TETRACAINE 0.5 % TOPICAL GEL RX-182232 CDM 6370000100 HCPCS 250 RC 71266-6290-01 NDC inpatient 3 ML 65.7 65.7 UNITED HEALTHCARE (COMMERCIAL) [3081199] UNITED HEALTHCARE 87726 [308119901] 40.73 percent of total billed charges 40.73 62.42 Technical (Hospital) Services BISOPROLOL 10 MG-HYDROCHLOROTHIAZIDE 6.25 MG TABLET RX-18289 CDM 6370000100 HCPCS 250 RC 29300-0189-13 NDC inpatient 1 UN 6.1 6.1 CIGNA 62308 [3081051] CIGNA 62308 [308105105] 4.83 percent of total billed charges 3.78 5.8 Technical (Hospital) Services BISOPROLOL 10 MG-HYDROCHLOROTHIAZIDE 6.25 MG TABLET RX-18289 CDM 6370000100 HCPCS 250 RC 29300-0189-13 NDC inpatient 1 UN 6.1 6.1 CIGNA 62308 [3081051] CIGNA STATE OF WYOMING [308105107] 4.83 percent of total billed charges 3.78 5.8 Technical (Hospital) Services BISOPROLOL 10 MG-HYDROCHLOROTHIAZIDE 6.25 MG TABLET RX-18289 CDM 6370000100 HCPCS 250 RC 29300-0189-13 NDC inpatient 1 UN 6.1 6.1 BLUE CROSS BLUE SHIELD WELLMARK SB889 [3081026] BCBS WYOMING [308102603] 5.8 percent of total billed charges 3.78 5.8 Technical (Hospital) Services BISOPROLOL 10 MG-HYDROCHLOROTHIAZIDE 6.25 MG TABLET RX-18289 CDM 6370000100 HCPCS 250 RC 29300-0189-13 NDC inpatient 1 UN 6.1 6.1 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES HDHP [308136802] 4.83 percent of total billed charges 3.78 5.8 Technical (Hospital) Services BISOPROLOL 10 MG-HYDROCHLOROTHIAZIDE 6.25 MG TABLET RX-18289 CDM 6370000100 HCPCS 250 RC 29300-0189-13 NDC inpatient 1 UN 6.1 6.1 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES EPO [308136803] 4.83 percent of total billed charges 3.78 5.8 Technical (Hospital) Services BISOPROLOL 10 MG-HYDROCHLOROTHIAZIDE 6.25 MG TABLET RX-18289 CDM 6370000100 HCPCS 250 RC 29300-0189-13 NDC inpatient 1 UN 6.1 6.1 UNITED HEALTHCARE (COMMERCIAL) [3081199] UNITED HEALTHCARE 87726 [308119901] 3.78 percent of total billed charges 3.78 5.8 Technical (Hospital) Services BISOPROLOL 10 MG-HYDROCHLOROTHIAZIDE 6.25 MG TABLET RX-18289 CDM 6370000100 HCPCS 250 RC 29300-0189-13 NDC inpatient 1 UN 6.1 6.1 MEDICA (COMMERCIAL) 94265 [3081118] MEDICA CLAIMS [308111801] 5.49 percent of total billed charges 3.78 5.8 Technical (Hospital) Services BISOPROLOL 10 MG-HYDROCHLOROTHIAZIDE 6.25 MG TABLET RX-18289 CDM 6370000100 HCPCS 250 RC 29300-0189-13 NDC inpatient 1 UN 6.1 6.1 HEALTHPARTNERS SX009 HEALTHPARTNERS 4.83 percent of total billed charges 3.78 5.8 Technical (Hospital) Services BISOPROLOL 10 MG-HYDROCHLOROTHIAZIDE 6.25 MG TABLET RX-18289 CDM 6370000100 HCPCS 250 RC 29300-0189-13 NDC inpatient 1 UN 6.1 6.1 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES PPO [308136801] 4.83 percent of total billed charges 3.78 5.8 Technical (Hospital) Services BISOPROLOL 10 MG-HYDROCHLOROTHIAZIDE 6.25 MG TABLET RX-18289 CDM 6370000100 HCPCS 250 RC 29300-0189-13 NDC inpatient 1 UN 6.1 6.1 MULTIPLAN INC 34080 [3081285] MULTIPLAN INC [308128501] 5.8 percent of total billed charges 3.78 5.8 Technical (Hospital) Services BISOPROLOL 10 MG-HYDROCHLOROTHIAZIDE 6.25 MG TABLET RX-18289 CDM 6370000100 HCPCS 250 RC 29300-0189-13 NDC outpatient 1 UN 6.1 6.1 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES HDHP [308136802] 4.88 percent of total billed charges 3.78 5.8 Technical (Hospital) Services BISOPROLOL 10 MG-HYDROCHLOROTHIAZIDE 6.25 MG TABLET RX-18289 CDM 6370000100 HCPCS 250 RC 29300-0189-13 NDC outpatient 1 UN 6.1 6.1 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES PPO [308136801] 4.88 percent of total billed charges 3.78 5.8 Technical (Hospital) Services BISOPROLOL 10 MG-HYDROCHLOROTHIAZIDE 6.25 MG TABLET RX-18289 CDM 6370000100 HCPCS 250 RC 29300-0189-13 NDC outpatient 1 UN 6.1 6.1 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES EPO [308136803] 4.88 percent of total billed charges 3.78 5.8 Technical (Hospital) Services BISOPROLOL 10 MG-HYDROCHLOROTHIAZIDE 6.25 MG TABLET RX-18289 CDM 6370000100 HCPCS 250 RC 29300-0189-13 NDC outpatient 1 UN 6.1 6.1 MEDICA (COMMERCIAL) 94265 [3081118] MEDICA CLAIMS [308111801] 5.49 percent of total billed charges 3.78 5.8 Technical (Hospital) Services BISOPROLOL 10 MG-HYDROCHLOROTHIAZIDE 6.25 MG TABLET RX-18289 CDM 6370000100 HCPCS 250 RC 29300-0189-13 NDC outpatient 1 UN 6.1 6.1 CIGNA 62308 [3081051] CIGNA 62308 [308105105] 4.88 percent of total billed charges 3.78 5.8 Technical (Hospital) Services BISOPROLOL 10 MG-HYDROCHLOROTHIAZIDE 6.25 MG TABLET RX-18289 CDM 6370000100 HCPCS 250 RC 29300-0189-13 NDC outpatient 1 UN 6.1 6.1 CIGNA 62308 [3081051] CIGNA STATE OF WYOMING [308105107] 4.88 percent of total billed charges 3.78 5.8 Technical (Hospital) Services BISOPROLOL 10 MG-HYDROCHLOROTHIAZIDE 6.25 MG TABLET RX-18289 CDM 6370000100 HCPCS 250 RC 29300-0189-13 NDC outpatient 1 UN 6.1 6.1 MULTIPLAN INC 34080 [3081285] MULTIPLAN INC [308128501] 5.8 percent of total billed charges 3.78 5.8 Technical (Hospital) Services BISOPROLOL 10 MG-HYDROCHLOROTHIAZIDE 6.25 MG TABLET RX-18289 CDM 6370000100 HCPCS 250 RC 29300-0189-13 NDC outpatient 1 UN 6.1 6.1 UNITED HEALTHCARE (COMMERCIAL) [3081199] UNITED HEALTHCARE 87726 [308119901] 3.78 percent of total billed charges 3.78 5.8 Technical (Hospital) Services BISOPROLOL 10 MG-HYDROCHLOROTHIAZIDE 6.25 MG TABLET RX-18289 CDM 6370000100 HCPCS 250 RC 29300-0189-13 NDC outpatient 1 UN 6.1 6.1 BLUE CROSS BLUE SHIELD WELLMARK SB889 [3081026] BCBS WYOMING [308102603] 5.8 percent of total billed charges 3.78 5.8 Technical (Hospital) Services BISOPROLOL 10 MG-HYDROCHLOROTHIAZIDE 6.25 MG TABLET RX-18289 CDM 6370000100 HCPCS 250 RC 29300-0189-13 NDC outpatient 1 UN 6.1 6.1 HEALTHPARTNERS SX009 HEALTHPARTNERS 4.88 percent of total billed charges 3.78 5.8 Technical (Hospital) Services TORSEMIDE 20 MG TABLET RX-18293 CDM 6370000100 HCPCS 250 RC 31722-0531-01 NDC inpatient 1 UN 5.83 5.83 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES HDHP [308136802] 4.62 percent of total billed charges 3.61 5.54 Technical (Hospital) Services TORSEMIDE 20 MG TABLET RX-18293 CDM 6370000100 HCPCS 250 RC 31722-0531-01 NDC inpatient 1 UN 5.83 5.83 CIGNA 62308 [3081051] CIGNA 62308 [308105105] 4.62 percent of total billed charges 3.61 5.54 Technical (Hospital) Services TORSEMIDE 20 MG TABLET RX-18293 CDM 6370000100 HCPCS 250 RC 31722-0531-01 NDC inpatient 1 UN 5.83 5.83 CIGNA 62308 [3081051] CIGNA STATE OF WYOMING [308105107] 4.62 percent of total billed charges 3.61 5.54 Technical (Hospital) Services TORSEMIDE 20 MG TABLET RX-18293 CDM 6370000100 HCPCS 250 RC 31722-0531-01 NDC inpatient 1 UN 5.83 5.83 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES EPO [308136803] 4.62 percent of total billed charges 3.61 5.54 Technical (Hospital) Services TORSEMIDE 20 MG TABLET RX-18293 CDM 6370000100 HCPCS 250 RC 31722-0531-01 NDC inpatient 1 UN 5.83 5.83 BLUE CROSS BLUE SHIELD WELLMARK SB889 [3081026] BCBS WYOMING [308102603] 5.54 percent of total billed charges 3.61 5.54 Technical (Hospital) Services TORSEMIDE 20 MG TABLET RX-18293 CDM 6370000100 HCPCS 250 RC 31722-0531-01 NDC inpatient 1 UN 5.83 5.83 UNITED HEALTHCARE (COMMERCIAL) [3081199] UNITED HEALTHCARE 87726 [308119901] 3.61 percent of total billed charges 3.61 5.54 Technical (Hospital) Services TORSEMIDE 20 MG TABLET RX-18293 CDM 6370000100 HCPCS 250 RC 31722-0531-01 NDC inpatient 1 UN 5.83 5.83 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES PPO [308136801] 4.62 percent of total billed charges 3.61 5.54 Technical (Hospital) Services TORSEMIDE 20 MG TABLET RX-18293 CDM 6370000100 HCPCS 250 RC 31722-0531-01 NDC inpatient 1 UN 5.83 5.83 HEALTHPARTNERS SX009 HEALTHPARTNERS 4.62 percent of total billed charges 3.61 5.54 Technical (Hospital) Services TORSEMIDE 20 MG TABLET RX-18293 CDM 6370000100 HCPCS 250 RC 31722-0531-01 NDC inpatient 1 UN 5.83 5.83 MEDICA (COMMERCIAL) 94265 [3081118] MEDICA CLAIMS [308111801] 5.25 percent of total billed charges 3.61 5.54 Technical (Hospital) Services TORSEMIDE 20 MG TABLET RX-18293 CDM 6370000100 HCPCS 250 RC 31722-0531-01 NDC inpatient 1 UN 5.83 5.83 MULTIPLAN INC 34080 [3081285] MULTIPLAN INC [308128501] 5.54 percent of total billed charges 3.61 5.54 Technical (Hospital) Services TORSEMIDE 20 MG TABLET RX-18293 CDM 6370000100 HCPCS 250 RC 31722-0531-01 NDC outpatient 1 UN 5.83 5.83 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES EPO [308136803] 4.66 percent of total billed charges 3.61 5.54 Technical (Hospital) Services TORSEMIDE 20 MG TABLET RX-18293 CDM 6370000100 HCPCS 250 RC 31722-0531-01 NDC outpatient 1 UN 5.83 5.83 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES PPO [308136801] 4.66 percent of total billed charges 3.61 5.54 Technical (Hospital) Services TORSEMIDE 20 MG TABLET RX-18293 CDM 6370000100 HCPCS 250 RC 31722-0531-01 NDC outpatient 1 UN 5.83 5.83 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES HDHP [308136802] 4.66 percent of total billed charges 3.61 5.54 Technical (Hospital) Services TORSEMIDE 20 MG TABLET RX-18293 CDM 6370000100 HCPCS 250 RC 31722-0531-01 NDC outpatient 1 UN 5.83 5.83 BLUE CROSS BLUE SHIELD WELLMARK SB889 [3081026] BCBS WYOMING [308102603] 5.54 percent of total billed charges 3.61 5.54 Technical (Hospital) Services TORSEMIDE 20 MG TABLET RX-18293 CDM 6370000100 HCPCS 250 RC 31722-0531-01 NDC outpatient 1 UN 5.83 5.83 UNITED HEALTHCARE (COMMERCIAL) [3081199] UNITED HEALTHCARE 87726 [308119901] 3.61 percent of total billed charges 3.61 5.54 Technical (Hospital) Services TORSEMIDE 20 MG TABLET RX-18293 CDM 6370000100 HCPCS 250 RC 31722-0531-01 NDC outpatient 1 UN 5.83 5.83 HEALTHPARTNERS SX009 HEALTHPARTNERS 4.66 percent of total billed charges 3.61 5.54 Technical (Hospital) Services TORSEMIDE 20 MG TABLET RX-18293 CDM 6370000100 HCPCS 250 RC 31722-0531-01 NDC outpatient 1 UN 5.83 5.83 MULTIPLAN INC 34080 [3081285] MULTIPLAN INC [308128501] 5.54 percent of total billed charges 3.61 5.54 Technical (Hospital) Services TORSEMIDE 20 MG TABLET RX-18293 CDM 6370000100 HCPCS 250 RC 31722-0531-01 NDC outpatient 1 UN 5.83 5.83 CIGNA 62308 [3081051] CIGNA 62308 [308105105] 4.66 percent of total billed charges 3.61 5.54 Technical (Hospital) Services TORSEMIDE 20 MG TABLET RX-18293 CDM 6370000100 HCPCS 250 RC 31722-0531-01 NDC outpatient 1 UN 5.83 5.83 CIGNA 62308 [3081051] CIGNA STATE OF WYOMING [308105107] 4.66 percent of total billed charges 3.61 5.54 Technical (Hospital) Services TORSEMIDE 20 MG TABLET RX-18293 CDM 6370000100 HCPCS 250 RC 31722-0531-01 NDC outpatient 1 UN 5.83 5.83 MEDICA (COMMERCIAL) 94265 [3081118] MEDICA CLAIMS [308111801] 5.25 percent of total billed charges 3.61 5.54 Technical (Hospital) Services GABAPENTIN 400 MG CAPSULE RX-18307 CDM 6370000100 HCPCS 250 RC 67877-0224-05 NDC inpatient 1 UN 5.68 5.68 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES HDHP [308136802] 4.5 percent of total billed charges 3.52 5.4 Technical (Hospital) Services GABAPENTIN 400 MG CAPSULE RX-18307 CDM 6370000100 HCPCS 250 RC 67877-0224-05 NDC inpatient 1 UN 5.68 5.68 BLUE CROSS BLUE SHIELD WELLMARK SB889 [3081026] BCBS WYOMING [308102603] 5.4 percent of total billed charges 3.52 5.4 Technical (Hospital) Services GABAPENTIN 400 MG CAPSULE RX-18307 CDM 6370000100 HCPCS 250 RC 67877-0224-05 NDC inpatient 1 UN 5.68 5.68 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES EPO [308136803] 4.5 percent of total billed charges 3.52 5.4 Technical (Hospital) Services GABAPENTIN 400 MG CAPSULE RX-18307 CDM 6370000100 HCPCS 250 RC 67877-0224-05 NDC inpatient 1 UN 5.68 5.68 CIGNA 62308 [3081051] CIGNA 62308 [308105105] 4.5 percent of total billed charges 3.52 5.4 Technical (Hospital) Services GABAPENTIN 400 MG CAPSULE RX-18307 CDM 6370000100 HCPCS 250 RC 67877-0224-05 NDC inpatient 1 UN 5.68 5.68 CIGNA 62308 [3081051] CIGNA STATE OF WYOMING [308105107] 4.5 percent of total billed charges 3.52 5.4 Technical (Hospital) Services GABAPENTIN 400 MG CAPSULE RX-18307 CDM 6370000100 HCPCS 250 RC 67877-0224-05 NDC inpatient 1 UN 5.68 5.68 UNITED HEALTHCARE (COMMERCIAL) [3081199] UNITED HEALTHCARE 87726 [308119901] 3.52 percent of total billed charges 3.52 5.4 Technical (Hospital) Services GABAPENTIN 400 MG CAPSULE RX-18307 CDM 6370000100 HCPCS 250 RC 67877-0224-05 NDC inpatient 1 UN 5.68 5.68 MULTIPLAN INC 34080 [3081285] MULTIPLAN INC [308128501] 5.4 percent of total billed charges 3.52 5.4 Technical (Hospital) Services GABAPENTIN 400 MG CAPSULE RX-18307 CDM 6370000100 HCPCS 250 RC 67877-0224-05 NDC inpatient 1 UN 5.68 5.68 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES PPO [308136801] 4.5 percent of total billed charges 3.52 5.4 Technical (Hospital) Services GABAPENTIN 400 MG CAPSULE RX-18307 CDM 6370000100 HCPCS 250 RC 67877-0224-05 NDC inpatient 1 UN 5.68 5.68 MEDICA (COMMERCIAL) 94265 [3081118] MEDICA CLAIMS [308111801] 5.11 percent of total billed charges 3.52 5.4 Technical (Hospital) Services GABAPENTIN 400 MG CAPSULE RX-18307 CDM 6370000100 HCPCS 250 RC 67877-0224-05 NDC inpatient 1 UN 5.68 5.68 HEALTHPARTNERS SX009 HEALTHPARTNERS 4.5 percent of total billed charges 3.52 5.4 Technical (Hospital) Services GABAPENTIN 400 MG CAPSULE RX-18307 CDM 6370000100 HCPCS 250 RC 67877-0224-05 NDC outpatient 1 UN 5.68 5.68 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES EPO [308136803] 4.54 percent of total billed charges 3.52 5.4 Technical (Hospital) Services GABAPENTIN 400 MG CAPSULE RX-18307 CDM 6370000100 HCPCS 250 RC 67877-0224-05 NDC outpatient 1 UN 5.68 5.68 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES PPO [308136801] 4.54 percent of total billed charges 3.52 5.4 Technical (Hospital) Services GABAPENTIN 400 MG CAPSULE RX-18307 CDM 6370000100 HCPCS 250 RC 67877-0224-05 NDC outpatient 1 UN 5.68 5.68 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES HDHP [308136802] 4.54 percent of total billed charges 3.52 5.4 Technical (Hospital) Services GABAPENTIN 400 MG CAPSULE RX-18307 CDM 6370000100 HCPCS 250 RC 67877-0224-05 NDC outpatient 1 UN 5.68 5.68 MULTIPLAN INC 34080 [3081285] MULTIPLAN INC [308128501] 5.4 percent of total billed charges 3.52 5.4 Technical (Hospital) Services GABAPENTIN 400 MG CAPSULE RX-18307 CDM 6370000100 HCPCS 250 RC 67877-0224-05 NDC outpatient 1 UN 5.68 5.68 UNITED HEALTHCARE (COMMERCIAL) [3081199] UNITED HEALTHCARE 87726 [308119901] 3.52 percent of total billed charges 3.52 5.4 Technical (Hospital) Services GABAPENTIN 400 MG CAPSULE RX-18307 CDM 6370000100 HCPCS 250 RC 67877-0224-05 NDC outpatient 1 UN 5.68 5.68 CIGNA 62308 [3081051] CIGNA 62308 [308105105] 4.54 percent of total billed charges 3.52 5.4 Technical (Hospital) Services GABAPENTIN 400 MG CAPSULE RX-18307 CDM 6370000100 HCPCS 250 RC 67877-0224-05 NDC outpatient 1 UN 5.68 5.68 CIGNA 62308 [3081051] CIGNA STATE OF WYOMING [308105107] 4.54 percent of total billed charges 3.52 5.4 Technical (Hospital) Services GABAPENTIN 400 MG CAPSULE RX-18307 CDM 6370000100 HCPCS 250 RC 67877-0224-05 NDC outpatient 1 UN 5.68 5.68 MEDICA (COMMERCIAL) 94265 [3081118] MEDICA CLAIMS [308111801] 5.11 percent of total billed charges 3.52 5.4 Technical (Hospital) Services GABAPENTIN 400 MG CAPSULE RX-18307 CDM 6370000100 HCPCS 250 RC 67877-0224-05 NDC outpatient 1 UN 5.68 5.68 HEALTHPARTNERS SX009 HEALTHPARTNERS 4.54 percent of total billed charges 3.52 5.4 Technical (Hospital) Services GABAPENTIN 400 MG CAPSULE RX-18307 CDM 6370000100 HCPCS 250 RC 67877-0224-05 NDC outpatient 1 UN 5.68 5.68 BLUE CROSS BLUE SHIELD WELLMARK SB889 [3081026] BCBS WYOMING [308102603] 5.4 percent of total billed charges 3.52 5.4 Technical (Hospital) Services GABAPENTIN 300 MG CAPSULE RX-18308 CDM 6370000100 HCPCS 250 RC 67877-0223-05 NDC inpatient 1 UN 5.67 5.67 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES EPO [308136803] 4.49 percent of total billed charges 3.52 5.39 Technical (Hospital) Services GABAPENTIN 300 MG CAPSULE RX-18308 CDM 6370000100 HCPCS 250 RC 67877-0223-05 NDC inpatient 1 UN 5.67 5.67 CIGNA 62308 [3081051] CIGNA STATE OF WYOMING [308105107] 4.49 percent of total billed charges 3.52 5.39 Technical (Hospital) Services GABAPENTIN 300 MG CAPSULE RX-18308 CDM 6370000100 HCPCS 250 RC 67877-0223-05 NDC inpatient 1 UN 5.67 5.67 CIGNA 62308 [3081051] CIGNA 62308 [308105105] 4.49 percent of total billed charges 3.52 5.39 Technical (Hospital) Services GABAPENTIN 300 MG CAPSULE RX-18308 CDM 6370000100 HCPCS 250 RC 67877-0223-05 NDC inpatient 1 UN 5.67 5.67 HEALTHPARTNERS SX009 HEALTHPARTNERS 4.49 percent of total billed charges 3.52 5.39 Technical (Hospital) Services GABAPENTIN 300 MG CAPSULE RX-18308 CDM 6370000100 HCPCS 250 RC 67877-0223-05 NDC inpatient 1 UN 5.67 5.67 MEDICA (COMMERCIAL) 94265 [3081118] MEDICA CLAIMS [308111801] 5.1 percent of total billed charges 3.52 5.39 Technical (Hospital) Services GABAPENTIN 300 MG CAPSULE RX-18308 CDM 6370000100 HCPCS 250 RC 67877-0223-05 NDC inpatient 1 UN 5.67 5.67 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES HDHP [308136802] 4.49 percent of total billed charges 3.52 5.39 Technical (Hospital) Services GABAPENTIN 300 MG CAPSULE RX-18308 CDM 6370000100 HCPCS 250 RC 67877-0223-05 NDC inpatient 1 UN 5.67 5.67 BLUE CROSS BLUE SHIELD WELLMARK SB889 [3081026] BCBS WYOMING [308102603] 5.39 percent of total billed charges 3.52 5.39 Technical (Hospital) Services GABAPENTIN 300 MG CAPSULE RX-18308 CDM 6370000100 HCPCS 250 RC 67877-0223-05 NDC inpatient 1 UN 5.67 5.67 UNITED HEALTHCARE (COMMERCIAL) [3081199] UNITED HEALTHCARE 87726 [308119901] 3.52 percent of total billed charges 3.52 5.39 Technical (Hospital) Services GABAPENTIN 300 MG CAPSULE RX-18308 CDM 6370000100 HCPCS 250 RC 67877-0223-05 NDC inpatient 1 UN 5.67 5.67 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES PPO [308136801] 4.49 percent of total billed charges 3.52 5.39 Technical (Hospital) Services GABAPENTIN 300 MG CAPSULE RX-18308 CDM 6370000100 HCPCS 250 RC 67877-0223-05 NDC inpatient 1 UN 5.67 5.67 MULTIPLAN INC 34080 [3081285] MULTIPLAN INC [308128501] 5.39 percent of total billed charges 3.52 5.39 Technical (Hospital) Services GABAPENTIN 300 MG CAPSULE RX-18308 CDM 6370000100 HCPCS 250 RC 67877-0223-05 NDC outpatient 1 UN 5.67 5.67 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES PPO [308136801] 4.54 percent of total billed charges 3.52 5.39 Technical (Hospital) Services GABAPENTIN 300 MG CAPSULE RX-18308 CDM 6370000100 HCPCS 250 RC 67877-0223-05 NDC outpatient 1 UN 5.67 5.67 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES EPO [308136803] 4.54 percent of total billed charges 3.52 5.39 Technical (Hospital) Services GABAPENTIN 300 MG CAPSULE RX-18308 CDM 6370000100 HCPCS 250 RC 67877-0223-05 NDC outpatient 1 UN 5.67 5.67 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES HDHP [308136802] 4.54 percent of total billed charges 3.52 5.39 Technical (Hospital) Services GABAPENTIN 300 MG CAPSULE RX-18308 CDM 6370000100 HCPCS 250 RC 67877-0223-05 NDC outpatient 1 UN 5.67 5.67 HEALTHPARTNERS SX009 HEALTHPARTNERS 4.54 percent of total billed charges 3.52 5.39 Technical (Hospital) Services GABAPENTIN 300 MG CAPSULE RX-18308 CDM 6370000100 HCPCS 250 RC 67877-0223-05 NDC outpatient 1 UN 5.67 5.67 BLUE CROSS BLUE SHIELD WELLMARK SB889 [3081026] BCBS WYOMING [308102603] 5.39 percent of total billed charges 3.52 5.39 Technical (Hospital) Services GABAPENTIN 300 MG CAPSULE RX-18308 CDM 6370000100 HCPCS 250 RC 67877-0223-05 NDC outpatient 1 UN 5.67 5.67 MEDICA (COMMERCIAL) 94265 [3081118] MEDICA CLAIMS [308111801] 5.1 percent of total billed charges 3.52 5.39 Technical (Hospital) Services GABAPENTIN 300 MG CAPSULE RX-18308 CDM 6370000100 HCPCS 250 RC 67877-0223-05 NDC outpatient 1 UN 5.67 5.67 UNITED HEALTHCARE (COMMERCIAL) [3081199] UNITED HEALTHCARE 87726 [308119901] 3.52 percent of total billed charges 3.52 5.39 Technical (Hospital) Services GABAPENTIN 300 MG CAPSULE RX-18308 CDM 6370000100 HCPCS 250 RC 67877-0223-05 NDC outpatient 1 UN 5.67 5.67 MULTIPLAN INC 34080 [3081285] MULTIPLAN INC [308128501] 5.39 percent of total billed charges 3.52 5.39 Technical (Hospital) Services GABAPENTIN 300 MG CAPSULE RX-18308 CDM 6370000100 HCPCS 250 RC 67877-0223-05 NDC outpatient 1 UN 5.67 5.67 CIGNA 62308 [3081051] CIGNA 62308 [308105105] 4.54 percent of total billed charges 3.52 5.39 Technical (Hospital) Services GABAPENTIN 300 MG CAPSULE RX-18308 CDM 6370000100 HCPCS 250 RC 67877-0223-05 NDC outpatient 1 UN 5.67 5.67 CIGNA 62308 [3081051] CIGNA STATE OF WYOMING [308105107] 4.54 percent of total billed charges 3.52 5.39 Technical (Hospital) Services GABAPENTIN 100 MG CAPSULE RX-18309 CDM 6370000100 HCPCS 250 RC 67877-0222-05 NDC inpatient 1 UN 5.66 5.66 CIGNA 62308 [3081051] CIGNA STATE OF WYOMING [308105107] 4.48 percent of total billed charges 3.51 5.38 Technical (Hospital) Services GABAPENTIN 100 MG CAPSULE RX-18309 CDM 6370000100 HCPCS 250 RC 67877-0222-05 NDC inpatient 1 UN 5.66 5.66 CIGNA 62308 [3081051] CIGNA 62308 [308105105] 4.48 percent of total billed charges 3.51 5.38 Technical (Hospital) Services GABAPENTIN 100 MG CAPSULE RX-18309 CDM 6370000100 HCPCS 250 RC 67877-0222-05 NDC inpatient 1 UN 5.66 5.66 BLUE CROSS BLUE SHIELD WELLMARK SB889 [3081026] BCBS WYOMING [308102603] 5.38 percent of total billed charges 3.51 5.38 Technical (Hospital) Services GABAPENTIN 100 MG CAPSULE RX-18309 CDM 6370000100 HCPCS 250 RC 67877-0222-05 NDC inpatient 1 UN 5.66 5.66 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES HDHP [308136802] 4.48 percent of total billed charges 3.51 5.38 Technical (Hospital) Services GABAPENTIN 100 MG CAPSULE RX-18309 CDM 6370000100 HCPCS 250 RC 67877-0222-05 NDC inpatient 1 UN 5.66 5.66 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES EPO [308136803] 4.48 percent of total billed charges 3.51 5.38 Technical (Hospital) Services GABAPENTIN 100 MG CAPSULE RX-18309 CDM 6370000100 HCPCS 250 RC 67877-0222-05 NDC inpatient 1 UN 5.66 5.66 UNITED HEALTHCARE (COMMERCIAL) [3081199] UNITED HEALTHCARE 87726 [308119901] 3.51 percent of total billed charges 3.51 5.38 Technical (Hospital) Services GABAPENTIN 100 MG CAPSULE RX-18309 CDM 6370000100 HCPCS 250 RC 67877-0222-05 NDC inpatient 1 UN 5.66 5.66 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES PPO [308136801] 4.48 percent of total billed charges 3.51 5.38 Technical (Hospital) Services GABAPENTIN 100 MG CAPSULE RX-18309 CDM 6370000100 HCPCS 250 RC 67877-0222-05 NDC inpatient 1 UN 5.66 5.66 HEALTHPARTNERS SX009 HEALTHPARTNERS 4.48 percent of total billed charges 3.51 5.38 Technical (Hospital) Services GABAPENTIN 100 MG CAPSULE RX-18309 CDM 6370000100 HCPCS 250 RC 67877-0222-05 NDC inpatient 1 UN 5.66 5.66 MEDICA (COMMERCIAL) 94265 [3081118] MEDICA CLAIMS [308111801] 5.09 percent of total billed charges 3.51 5.38 Technical (Hospital) Services GABAPENTIN 100 MG CAPSULE RX-18309 CDM 6370000100 HCPCS 250 RC 67877-0222-05 NDC inpatient 1 UN 5.66 5.66 MULTIPLAN INC 34080 [3081285] MULTIPLAN INC [308128501] 5.38 percent of total billed charges 3.51 5.38 Technical (Hospital) Services GABAPENTIN 100 MG CAPSULE RX-18309 CDM 6370000100 HCPCS 250 RC 67877-0222-05 NDC outpatient 1 UN 5.66 5.66 HEALTHPARTNERS SX009 HEALTHPARTNERS 4.53 percent of total billed charges 3.51 5.38 Technical (Hospital) Services GABAPENTIN 100 MG CAPSULE RX-18309 CDM 6370000100 HCPCS 250 RC 67877-0222-05 NDC outpatient 1 UN 5.66 5.66 UNITED HEALTHCARE (COMMERCIAL) [3081199] UNITED HEALTHCARE 87726 [308119901] 3.51 percent of total billed charges 3.51 5.38 Technical (Hospital) Services GABAPENTIN 100 MG CAPSULE RX-18309 CDM 6370000100 HCPCS 250 RC 67877-0222-05 NDC outpatient 1 UN 5.66 5.66 MULTIPLAN INC 34080 [3081285] MULTIPLAN INC [308128501] 5.38 percent of total billed charges 3.51 5.38 Technical (Hospital) Services GABAPENTIN 100 MG CAPSULE RX-18309 CDM 6370000100 HCPCS 250 RC 67877-0222-05 NDC outpatient 1 UN 5.66 5.66 CIGNA 62308 [3081051] CIGNA 62308 [308105105] 4.53 percent of total billed charges 3.51 5.38 Technical (Hospital) Services GABAPENTIN 100 MG CAPSULE RX-18309 CDM 6370000100 HCPCS 250 RC 67877-0222-05 NDC outpatient 1 UN 5.66 5.66 CIGNA 62308 [3081051] CIGNA STATE OF WYOMING [308105107] 4.53 percent of total billed charges 3.51 5.38 Technical (Hospital) Services GABAPENTIN 100 MG CAPSULE RX-18309 CDM 6370000100 HCPCS 250 RC 67877-0222-05 NDC outpatient 1 UN 5.66 5.66 MEDICA (COMMERCIAL) 94265 [3081118] MEDICA CLAIMS [308111801] 5.09 percent of total billed charges 3.51 5.38 Technical (Hospital) Services GABAPENTIN 100 MG CAPSULE RX-18309 CDM 6370000100 HCPCS 250 RC 67877-0222-05 NDC outpatient 1 UN 5.66 5.66 BLUE CROSS BLUE SHIELD WELLMARK SB889 [3081026] BCBS WYOMING [308102603] 5.38 percent of total billed charges 3.51 5.38 Technical (Hospital) Services GABAPENTIN 100 MG CAPSULE RX-18309 CDM 6370000100 HCPCS 250 RC 67877-0222-05 NDC outpatient 1 UN 5.66 5.66 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES EPO [308136803] 4.53 percent of total billed charges 3.51 5.38 Technical (Hospital) Services GABAPENTIN 100 MG CAPSULE RX-18309 CDM 6370000100 HCPCS 250 RC 67877-0222-05 NDC outpatient 1 UN 5.66 5.66 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES PPO [308136801] 4.53 percent of total billed charges 3.51 5.38 Technical (Hospital) Services GABAPENTIN 100 MG CAPSULE RX-18309 CDM 6370000100 HCPCS 250 RC 67877-0222-05 NDC outpatient 1 UN 5.66 5.66 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES HDHP [308136802] 4.53 percent of total billed charges 3.51 5.38 Technical (Hospital) Services BENZOCAINE 20 %-MENTHOL 0.26 %-ZINC CHLORIDE 0.15 % MUCOSAL GEL RX-184174 CDM 6370000100 HCPCS 250 RC 10310-0283-13 NDC outpatient 12 GR 47.36 47.36 HEALTHPARTNERS SX009 HEALTHPARTNERS 37.89 percent of total billed charges 29.36 44.99 Technical (Hospital) Services BENZOCAINE 20 %-MENTHOL 0.26 %-ZINC CHLORIDE 0.15 % MUCOSAL GEL RX-184174 CDM 6370000100 HCPCS 250 RC 10310-0283-13 NDC outpatient 12 GR 47.36 47.36 UNITED HEALTHCARE (COMMERCIAL) [3081199] UNITED HEALTHCARE 87726 [308119901] 29.36 percent of total billed charges 29.36 44.99 Technical (Hospital) Services BENZOCAINE 20 %-MENTHOL 0.26 %-ZINC CHLORIDE 0.15 % MUCOSAL GEL RX-184174 CDM 6370000100 HCPCS 250 RC 10310-0283-13 NDC outpatient 12 GR 47.36 47.36 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES EPO [308136803] 37.89 percent of total billed charges 29.36 44.99 Technical (Hospital) Services BENZOCAINE 20 %-MENTHOL 0.26 %-ZINC CHLORIDE 0.15 % MUCOSAL GEL RX-184174 CDM 6370000100 HCPCS 250 RC 10310-0283-13 NDC outpatient 12 GR 47.36 47.36 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES HDHP [308136802] 37.89 percent of total billed charges 29.36 44.99 Technical (Hospital) Services BENZOCAINE 20 %-MENTHOL 0.26 %-ZINC CHLORIDE 0.15 % MUCOSAL GEL RX-184174 CDM 6370000100 HCPCS 250 RC 10310-0283-13 NDC outpatient 12 GR 47.36 47.36 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES PPO [308136801] 37.89 percent of total billed charges 29.36 44.99 Technical (Hospital) Services BENZOCAINE 20 %-MENTHOL 0.26 %-ZINC CHLORIDE 0.15 % MUCOSAL GEL RX-184174 CDM 6370000100 HCPCS 250 RC 10310-0283-13 NDC outpatient 12 GR 47.36 47.36 BLUE CROSS BLUE SHIELD WELLMARK SB889 [3081026] BCBS WYOMING [308102603] 44.99 percent of total billed charges 29.36 44.99 Technical (Hospital) Services BENZOCAINE 20 %-MENTHOL 0.26 %-ZINC CHLORIDE 0.15 % MUCOSAL GEL RX-184174 CDM 6370000100 HCPCS 250 RC 10310-0283-13 NDC outpatient 12 GR 47.36 47.36 CIGNA 62308 [3081051] CIGNA 62308 [308105105] 37.89 percent of total billed charges 29.36 44.99 Technical (Hospital) Services BENZOCAINE 20 %-MENTHOL 0.26 %-ZINC CHLORIDE 0.15 % MUCOSAL GEL RX-184174 CDM 6370000100 HCPCS 250 RC 10310-0283-13 NDC outpatient 12 GR 47.36 47.36 CIGNA 62308 [3081051] CIGNA STATE OF WYOMING [308105107] 37.89 percent of total billed charges 29.36 44.99 Technical (Hospital) Services BENZOCAINE 20 %-MENTHOL 0.26 %-ZINC CHLORIDE 0.15 % MUCOSAL GEL RX-184174 CDM 6370000100 HCPCS 250 RC 10310-0283-13 NDC outpatient 12 GR 47.36 47.36 MULTIPLAN INC 34080 [3081285] MULTIPLAN INC [308128501] 44.99 percent of total billed charges 29.36 44.99 Technical (Hospital) Services BENZOCAINE 20 %-MENTHOL 0.26 %-ZINC CHLORIDE 0.15 % MUCOSAL GEL RX-184174 CDM 6370000100 HCPCS 250 RC 10310-0283-13 NDC outpatient 12 GR 47.36 47.36 MEDICA (COMMERCIAL) 94265 [3081118] MEDICA CLAIMS [308111801] 42.62 percent of total billed charges 29.36 44.99 Technical (Hospital) Services BENZOCAINE 20 %-MENTHOL 0.26 %-ZINC CHLORIDE 0.15 % MUCOSAL GEL RX-184174 CDM 6370000100 HCPCS 250 RC 10310-0283-13 NDC inpatient 12 GR 47.36 47.36 BLUE CROSS BLUE SHIELD WELLMARK SB889 [3081026] BCBS WYOMING [308102603] 44.99 percent of total billed charges 29.36 44.99 Technical (Hospital) Services BENZOCAINE 20 %-MENTHOL 0.26 %-ZINC CHLORIDE 0.15 % MUCOSAL GEL RX-184174 CDM 6370000100 HCPCS 250 RC 10310-0283-13 NDC inpatient 12 GR 47.36 47.36 UNITED HEALTHCARE (COMMERCIAL) [3081199] UNITED HEALTHCARE 87726 [308119901] 29.36 percent of total billed charges 29.36 44.99 Technical (Hospital) Services BENZOCAINE 20 %-MENTHOL 0.26 %-ZINC CHLORIDE 0.15 % MUCOSAL GEL RX-184174 CDM 6370000100 HCPCS 250 RC 10310-0283-13 NDC inpatient 12 GR 47.36 47.36 MEDICA (COMMERCIAL) 94265 [3081118] MEDICA CLAIMS [308111801] 42.62 percent of total billed charges 29.36 44.99 Technical (Hospital) Services BENZOCAINE 20 %-MENTHOL 0.26 %-ZINC CHLORIDE 0.15 % MUCOSAL GEL RX-184174 CDM 6370000100 HCPCS 250 RC 10310-0283-13 NDC inpatient 12 GR 47.36 47.36 MULTIPLAN INC 34080 [3081285] MULTIPLAN INC [308128501] 44.99 percent of total billed charges 29.36 44.99 Technical (Hospital) Services BENZOCAINE 20 %-MENTHOL 0.26 %-ZINC CHLORIDE 0.15 % MUCOSAL GEL RX-184174 CDM 6370000100 HCPCS 250 RC 10310-0283-13 NDC inpatient 12 GR 47.36 47.36 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES EPO [308136803] 37.5 percent of total billed charges 29.36 44.99 Technical (Hospital) Services BENZOCAINE 20 %-MENTHOL 0.26 %-ZINC CHLORIDE 0.15 % MUCOSAL GEL RX-184174 CDM 6370000100 HCPCS 250 RC 10310-0283-13 NDC inpatient 12 GR 47.36 47.36 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES HDHP [308136802] 37.5 percent of total billed charges 29.36 44.99 Technical (Hospital) Services BENZOCAINE 20 %-MENTHOL 0.26 %-ZINC CHLORIDE 0.15 % MUCOSAL GEL RX-184174 CDM 6370000100 HCPCS 250 RC 10310-0283-13 NDC inpatient 12 GR 47.36 47.36 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES PPO [308136801] 37.5 percent of total billed charges 29.36 44.99 Technical (Hospital) Services BENZOCAINE 20 %-MENTHOL 0.26 %-ZINC CHLORIDE 0.15 % MUCOSAL GEL RX-184174 CDM 6370000100 HCPCS 250 RC 10310-0283-13 NDC inpatient 12 GR 47.36 47.36 HEALTHPARTNERS SX009 HEALTHPARTNERS 37.5 percent of total billed charges 29.36 44.99 Technical (Hospital) Services BENZOCAINE 20 %-MENTHOL 0.26 %-ZINC CHLORIDE 0.15 % MUCOSAL GEL RX-184174 CDM 6370000100 HCPCS 250 RC 10310-0283-13 NDC inpatient 12 GR 47.36 47.36 CIGNA 62308 [3081051] CIGNA 62308 [308105105] 37.5 percent of total billed charges 29.36 44.99 Technical (Hospital) Services BENZOCAINE 20 %-MENTHOL 0.26 %-ZINC CHLORIDE 0.15 % MUCOSAL GEL RX-184174 CDM 6370000100 HCPCS 250 RC 10310-0283-13 NDC inpatient 12 GR 47.36 47.36 CIGNA 62308 [3081051] CIGNA STATE OF WYOMING [308105107] 37.5 percent of total billed charges 29.36 44.99 Technical (Hospital) Services "NIRMATRELVIR 300 MG (150 MG X2)-RITONAVIR 100 MG TABLET,DOSE PACK" RX-185163 CDM 6370000100 HCPCS 250 RC 00069-5321-30 NDC inpatient 30 UN 0.01 0.01 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES EPO [308136803] 0.01 percent of total billed charges 0.01 0.01 Technical (Hospital) Services "NIRMATRELVIR 300 MG (150 MG X2)-RITONAVIR 100 MG TABLET,DOSE PACK" RX-185163 CDM 6370000100 HCPCS 250 RC 00069-5321-30 NDC inpatient 30 UN 0.01 0.01 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES HDHP [308136802] 0.01 percent of total billed charges 0.01 0.01 Technical (Hospital) Services "NIRMATRELVIR 300 MG (150 MG X2)-RITONAVIR 100 MG TABLET,DOSE PACK" RX-185163 CDM 6370000100 HCPCS 250 RC 00069-5321-30 NDC inpatient 30 UN 0.01 0.01 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES PPO [308136801] 0.01 percent of total billed charges 0.01 0.01 Technical (Hospital) Services "NIRMATRELVIR 300 MG (150 MG X2)-RITONAVIR 100 MG TABLET,DOSE PACK" RX-185163 CDM 6370000100 HCPCS 250 RC 00069-5321-30 NDC inpatient 30 UN 0.01 0.01 HEALTHPARTNERS SX009 HEALTHPARTNERS 0.01 percent of total billed charges 0.01 0.01 Technical (Hospital) Services "NIRMATRELVIR 300 MG (150 MG X2)-RITONAVIR 100 MG TABLET,DOSE PACK" RX-185163 CDM 6370000100 HCPCS 250 RC 00069-5321-30 NDC inpatient 30 UN 0.01 0.01 CIGNA 62308 [3081051] CIGNA 62308 [308105105] 0.01 percent of total billed charges 0.01 0.01 Technical (Hospital) Services "NIRMATRELVIR 300 MG (150 MG X2)-RITONAVIR 100 MG TABLET,DOSE PACK" RX-185163 CDM 6370000100 HCPCS 250 RC 00069-5321-30 NDC inpatient 30 UN 0.01 0.01 CIGNA 62308 [3081051] CIGNA STATE OF WYOMING [308105107] 0.01 percent of total billed charges 0.01 0.01 Technical (Hospital) Services "NIRMATRELVIR 300 MG (150 MG X2)-RITONAVIR 100 MG TABLET,DOSE PACK" RX-185163 CDM 6370000100 HCPCS 250 RC 00069-5321-30 NDC inpatient 30 UN 0.01 0.01 BLUE CROSS BLUE SHIELD WELLMARK SB889 [3081026] BCBS WYOMING [308102603] 0.01 percent of total billed charges 0.01 0.01 Technical (Hospital) Services "NIRMATRELVIR 300 MG (150 MG X2)-RITONAVIR 100 MG TABLET,DOSE PACK" RX-185163 CDM 6370000100 HCPCS 250 RC 00069-5321-30 NDC inpatient 30 UN 0.01 0.01 UNITED HEALTHCARE (COMMERCIAL) [3081199] UNITED HEALTHCARE 87726 [308119901] 0.01 percent of total billed charges 0.01 0.01 Technical (Hospital) Services "NIRMATRELVIR 300 MG (150 MG X2)-RITONAVIR 100 MG TABLET,DOSE PACK" RX-185163 CDM 6370000100 HCPCS 250 RC 00069-5321-30 NDC inpatient 30 UN 0.01 0.01 MULTIPLAN INC 34080 [3081285] MULTIPLAN INC [308128501] 0.01 percent of total billed charges 0.01 0.01 Technical (Hospital) Services "NIRMATRELVIR 300 MG (150 MG X2)-RITONAVIR 100 MG TABLET,DOSE PACK" RX-185163 CDM 6370000100 HCPCS 250 RC 00069-5321-30 NDC inpatient 30 UN 0.01 0.01 MEDICA (COMMERCIAL) 94265 [3081118] MEDICA CLAIMS [308111801] 0.01 percent of total billed charges 0.01 0.01 Technical (Hospital) Services "NIRMATRELVIR 300 MG (150 MG X2)-RITONAVIR 100 MG TABLET,DOSE PACK" RX-185163 CDM 6370000100 HCPCS 250 RC 00069-5321-30 NDC outpatient 30 UN 0.01 0.01 BLUE CROSS BLUE SHIELD WELLMARK SB889 [3081026] BCBS WYOMING [308102603] 0.01 percent of total billed charges 0.01 0.01 Technical (Hospital) Services "NIRMATRELVIR 300 MG (150 MG X2)-RITONAVIR 100 MG TABLET,DOSE PACK" RX-185163 CDM 6370000100 HCPCS 250 RC 00069-5321-30 NDC outpatient 30 UN 0.01 0.01 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES PPO [308136801] 0.01 percent of total billed charges 0.01 0.01 Technical (Hospital) Services "NIRMATRELVIR 300 MG (150 MG X2)-RITONAVIR 100 MG TABLET,DOSE PACK" RX-185163 CDM 6370000100 HCPCS 250 RC 00069-5321-30 NDC outpatient 30 UN 0.01 0.01 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES HDHP [308136802] 0.01 percent of total billed charges 0.01 0.01 Technical (Hospital) Services "NIRMATRELVIR 300 MG (150 MG X2)-RITONAVIR 100 MG TABLET,DOSE PACK" RX-185163 CDM 6370000100 HCPCS 250 RC 00069-5321-30 NDC outpatient 30 UN 0.01 0.01 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES EPO [308136803] 0.01 percent of total billed charges 0.01 0.01 Technical (Hospital) Services "NIRMATRELVIR 300 MG (150 MG X2)-RITONAVIR 100 MG TABLET,DOSE PACK" RX-185163 CDM 6370000100 HCPCS 250 RC 00069-5321-30 NDC outpatient 30 UN 0.01 0.01 UNITED HEALTHCARE (COMMERCIAL) [3081199] UNITED HEALTHCARE 87726 [308119901] 0.01 percent of total billed charges 0.01 0.01 Technical (Hospital) Services "NIRMATRELVIR 300 MG (150 MG X2)-RITONAVIR 100 MG TABLET,DOSE PACK" RX-185163 CDM 6370000100 HCPCS 250 RC 00069-5321-30 NDC outpatient 30 UN 0.01 0.01 HEALTHPARTNERS SX009 HEALTHPARTNERS 0.01 percent of total billed charges 0.01 0.01 Technical (Hospital) Services "NIRMATRELVIR 300 MG (150 MG X2)-RITONAVIR 100 MG TABLET,DOSE PACK" RX-185163 CDM 6370000100 HCPCS 250 RC 00069-5321-30 NDC outpatient 30 UN 0.01 0.01 MULTIPLAN INC 34080 [3081285] MULTIPLAN INC [308128501] 0.01 percent of total billed charges 0.01 0.01 Technical (Hospital) Services "NIRMATRELVIR 300 MG (150 MG X2)-RITONAVIR 100 MG TABLET,DOSE PACK" RX-185163 CDM 6370000100 HCPCS 250 RC 00069-5321-30 NDC outpatient 30 UN 0.01 0.01 MEDICA (COMMERCIAL) 94265 [3081118] MEDICA CLAIMS [308111801] 0.01 percent of total billed charges 0.01 0.01 Technical (Hospital) Services "NIRMATRELVIR 300 MG (150 MG X2)-RITONAVIR 100 MG TABLET,DOSE PACK" RX-185163 CDM 6370000100 HCPCS 250 RC 00069-5321-30 NDC outpatient 30 UN 0.01 0.01 CIGNA 62308 [3081051] CIGNA 62308 [308105105] 0.01 percent of total billed charges 0.01 0.01 Technical (Hospital) Services "NIRMATRELVIR 300 MG (150 MG X2)-RITONAVIR 100 MG TABLET,DOSE PACK" RX-185163 CDM 6370000100 HCPCS 250 RC 00069-5321-30 NDC outpatient 30 UN 0.01 0.01 CIGNA 62308 [3081051] CIGNA STATE OF WYOMING [308105107] 0.01 percent of total billed charges 0.01 0.01 Technical (Hospital) Services LATANOPROST 0.005 % EYE DROPS RX-18621 CDM 6370000100 HCPCS 250 RC 61314-0547-01 NDC inpatient 0.05 ML 5.83 5.83 UNITED HEALTHCARE (COMMERCIAL) [3081199] UNITED HEALTHCARE 87726 [308119901] 3.61 percent of total billed charges 3.61 5.54 Technical (Hospital) Services LATANOPROST 0.005 % EYE DROPS RX-18621 CDM 6370000100 HCPCS 250 RC 61314-0547-01 NDC inpatient 0.05 ML 5.83 5.83 BLUE CROSS BLUE SHIELD WELLMARK SB889 [3081026] BCBS WYOMING [308102603] 5.54 percent of total billed charges 3.61 5.54 Technical (Hospital) Services LATANOPROST 0.005 % EYE DROPS RX-18621 CDM 6370000100 HCPCS 250 RC 61314-0547-01 NDC inpatient 0.05 ML 5.83 5.83 CIGNA 62308 [3081051] CIGNA 62308 [308105105] 4.62 percent of total billed charges 3.61 5.54 Technical (Hospital) Services LATANOPROST 0.005 % EYE DROPS RX-18621 CDM 6370000100 HCPCS 250 RC 61314-0547-01 NDC inpatient 0.05 ML 5.83 5.83 CIGNA 62308 [3081051] CIGNA STATE OF WYOMING [308105107] 4.62 percent of total billed charges 3.61 5.54 Technical (Hospital) Services LATANOPROST 0.005 % EYE DROPS RX-18621 CDM 6370000100 HCPCS 250 RC 61314-0547-01 NDC inpatient 0.05 ML 5.83 5.83 MEDICA (COMMERCIAL) 94265 [3081118] MEDICA CLAIMS [308111801] 5.25 percent of total billed charges 3.61 5.54 Technical (Hospital) Services LATANOPROST 0.005 % EYE DROPS RX-18621 CDM 6370000100 HCPCS 250 RC 61314-0547-01 NDC inpatient 0.05 ML 5.83 5.83 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES EPO [308136803] 4.62 percent of total billed charges 3.61 5.54 Technical (Hospital) Services LATANOPROST 0.005 % EYE DROPS RX-18621 CDM 6370000100 HCPCS 250 RC 61314-0547-01 NDC inpatient 0.05 ML 5.83 5.83 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES HDHP [308136802] 4.62 percent of total billed charges 3.61 5.54 Technical (Hospital) Services LATANOPROST 0.005 % EYE DROPS RX-18621 CDM 6370000100 HCPCS 250 RC 61314-0547-01 NDC inpatient 0.05 ML 5.83 5.83 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES PPO [308136801] 4.62 percent of total billed charges 3.61 5.54 Technical (Hospital) Services LATANOPROST 0.005 % EYE DROPS RX-18621 CDM 6370000100 HCPCS 250 RC 61314-0547-01 NDC inpatient 0.05 ML 5.83 5.83 HEALTHPARTNERS SX009 HEALTHPARTNERS 4.62 percent of total billed charges 3.61 5.54 Technical (Hospital) Services LATANOPROST 0.005 % EYE DROPS RX-18621 CDM 6370000100 HCPCS 250 RC 61314-0547-01 NDC inpatient 0.05 ML 5.83 5.83 MULTIPLAN INC 34080 [3081285] MULTIPLAN INC [308128501] 5.54 percent of total billed charges 3.61 5.54 Technical (Hospital) Services LATANOPROST 0.005 % EYE DROPS RX-18621 CDM 6370000100 HCPCS 250 RC 61314-0547-01 NDC outpatient 0.05 ML 5.83 5.83 UNITED HEALTHCARE (COMMERCIAL) [3081199] UNITED HEALTHCARE 87726 [308119901] 3.61 percent of total billed charges 3.61 5.54 Technical (Hospital) Services LATANOPROST 0.005 % EYE DROPS RX-18621 CDM 6370000100 HCPCS 250 RC 61314-0547-01 NDC outpatient 0.05 ML 5.83 5.83 MULTIPLAN INC 34080 [3081285] MULTIPLAN INC [308128501] 5.54 percent of total billed charges 3.61 5.54 Technical (Hospital) Services LATANOPROST 0.005 % EYE DROPS RX-18621 CDM 6370000100 HCPCS 250 RC 61314-0547-01 NDC outpatient 0.05 ML 5.83 5.83 CIGNA 62308 [3081051] CIGNA 62308 [308105105] 4.66 percent of total billed charges 3.61 5.54 Technical (Hospital) Services LATANOPROST 0.005 % EYE DROPS RX-18621 CDM 6370000100 HCPCS 250 RC 61314-0547-01 NDC outpatient 0.05 ML 5.83 5.83 CIGNA 62308 [3081051] CIGNA STATE OF WYOMING [308105107] 4.66 percent of total billed charges 3.61 5.54 Technical (Hospital) Services LATANOPROST 0.005 % EYE DROPS RX-18621 CDM 6370000100 HCPCS 250 RC 61314-0547-01 NDC outpatient 0.05 ML 5.83 5.83 MEDICA (COMMERCIAL) 94265 [3081118] MEDICA CLAIMS [308111801] 5.25 percent of total billed charges 3.61 5.54 Technical (Hospital) Services LATANOPROST 0.005 % EYE DROPS RX-18621 CDM 6370000100 HCPCS 250 RC 61314-0547-01 NDC outpatient 0.05 ML 5.83 5.83 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES EPO [308136803] 4.66 percent of total billed charges 3.61 5.54 Technical (Hospital) Services LATANOPROST 0.005 % EYE DROPS RX-18621 CDM 6370000100 HCPCS 250 RC 61314-0547-01 NDC outpatient 0.05 ML 5.83 5.83 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES HDHP [308136802] 4.66 percent of total billed charges 3.61 5.54 Technical (Hospital) Services LATANOPROST 0.005 % EYE DROPS RX-18621 CDM 6370000100 HCPCS 250 RC 61314-0547-01 NDC outpatient 0.05 ML 5.83 5.83 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES PPO [308136801] 4.66 percent of total billed charges 3.61 5.54 Technical (Hospital) Services LATANOPROST 0.005 % EYE DROPS RX-18621 CDM 6370000100 HCPCS 250 RC 61314-0547-01 NDC outpatient 0.05 ML 5.83 5.83 HEALTHPARTNERS SX009 HEALTHPARTNERS 4.66 percent of total billed charges 3.61 5.54 Technical (Hospital) Services LATANOPROST 0.005 % EYE DROPS RX-18621 CDM 6370000100 HCPCS 250 RC 61314-0547-01 NDC outpatient 0.05 ML 5.83 5.83 BLUE CROSS BLUE SHIELD WELLMARK SB889 [3081026] BCBS WYOMING [308102603] 5.54 percent of total billed charges 3.61 5.54 Technical (Hospital) Services DONEPEZIL 5 MG TABLET RX-18786 CDM 6370000100 HCPCS 250 RC 43547-0275-03 NDC outpatient 1 UN 5.79 5.79 MEDICA (COMMERCIAL) 94265 [3081118] MEDICA CLAIMS [308111801] 5.21 percent of total billed charges 3.59 5.5 Technical (Hospital) Services DONEPEZIL 5 MG TABLET RX-18786 CDM 6370000100 HCPCS 250 RC 43547-0275-03 NDC outpatient 1 UN 5.79 5.79 CIGNA 62308 [3081051] CIGNA 62308 [308105105] 4.63 percent of total billed charges 3.59 5.5 Technical (Hospital) Services DONEPEZIL 5 MG TABLET RX-18786 CDM 6370000100 HCPCS 250 RC 43547-0275-03 NDC outpatient 1 UN 5.79 5.79 CIGNA 62308 [3081051] CIGNA STATE OF WYOMING [308105107] 4.63 percent of total billed charges 3.59 5.5 Technical (Hospital) Services DONEPEZIL 5 MG TABLET RX-18786 CDM 6370000100 HCPCS 250 RC 43547-0275-03 NDC outpatient 1 UN 5.79 5.79 UNITED HEALTHCARE (COMMERCIAL) [3081199] UNITED HEALTHCARE 87726 [308119901] 3.59 percent of total billed charges 3.59 5.5 Technical (Hospital) Services DONEPEZIL 5 MG TABLET RX-18786 CDM 6370000100 HCPCS 250 RC 43547-0275-03 NDC outpatient 1 UN 5.79 5.79 MULTIPLAN INC 34080 [3081285] MULTIPLAN INC [308128501] 5.5 percent of total billed charges 3.59 5.5 Technical (Hospital) Services DONEPEZIL 5 MG TABLET RX-18786 CDM 6370000100 HCPCS 250 RC 43547-0275-03 NDC outpatient 1 UN 5.79 5.79 HEALTHPARTNERS SX009 HEALTHPARTNERS 4.63 percent of total billed charges 3.59 5.5 Technical (Hospital) Services DONEPEZIL 5 MG TABLET RX-18786 CDM 6370000100 HCPCS 250 RC 43547-0275-03 NDC outpatient 1 UN 5.79 5.79 BLUE CROSS BLUE SHIELD WELLMARK SB889 [3081026] BCBS WYOMING [308102603] 5.5 percent of total billed charges 3.59 5.5 Technical (Hospital) Services DONEPEZIL 5 MG TABLET RX-18786 CDM 6370000100 HCPCS 250 RC 43547-0275-03 NDC outpatient 1 UN 5.79 5.79 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES EPO [308136803] 4.63 percent of total billed charges 3.59 5.5 Technical (Hospital) Services DONEPEZIL 5 MG TABLET RX-18786 CDM 6370000100 HCPCS 250 RC 43547-0275-03 NDC outpatient 1 UN 5.79 5.79 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES HDHP [308136802] 4.63 percent of total billed charges 3.59 5.5 Technical (Hospital) Services DONEPEZIL 5 MG TABLET RX-18786 CDM 6370000100 HCPCS 250 RC 43547-0275-03 NDC outpatient 1 UN 5.79 5.79 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES PPO [308136801] 4.63 percent of total billed charges 3.59 5.5 Technical (Hospital) Services DONEPEZIL 5 MG TABLET RX-18786 CDM 6370000100 HCPCS 250 RC 43547-0275-03 NDC inpatient 1 UN 5.79 5.79 MULTIPLAN INC 34080 [3081285] MULTIPLAN INC [308128501] 5.5 percent of total billed charges 3.59 5.5 Technical (Hospital) Services DONEPEZIL 5 MG TABLET RX-18786 CDM 6370000100 HCPCS 250 RC 43547-0275-03 NDC inpatient 1 UN 5.79 5.79 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES PPO [308136801] 4.58 percent of total billed charges 3.59 5.5 Technical (Hospital) Services DONEPEZIL 5 MG TABLET RX-18786 CDM 6370000100 HCPCS 250 RC 43547-0275-03 NDC inpatient 1 UN 5.79 5.79 MEDICA (COMMERCIAL) 94265 [3081118] MEDICA CLAIMS [308111801] 5.21 percent of total billed charges 3.59 5.5 Technical (Hospital) Services DONEPEZIL 5 MG TABLET RX-18786 CDM 6370000100 HCPCS 250 RC 43547-0275-03 NDC inpatient 1 UN 5.79 5.79 HEALTHPARTNERS SX009 HEALTHPARTNERS 4.58 percent of total billed charges 3.59 5.5 Technical (Hospital) Services DONEPEZIL 5 MG TABLET RX-18786 CDM 6370000100 HCPCS 250 RC 43547-0275-03 NDC inpatient 1 UN 5.79 5.79 BLUE CROSS BLUE SHIELD WELLMARK SB889 [3081026] BCBS WYOMING [308102603] 5.5 percent of total billed charges 3.59 5.5 Technical (Hospital) Services DONEPEZIL 5 MG TABLET RX-18786 CDM 6370000100 HCPCS 250 RC 43547-0275-03 NDC inpatient 1 UN 5.79 5.79 CIGNA 62308 [3081051] CIGNA 62308 [308105105] 4.58 percent of total billed charges 3.59 5.5 Technical (Hospital) Services DONEPEZIL 5 MG TABLET RX-18786 CDM 6370000100 HCPCS 250 RC 43547-0275-03 NDC inpatient 1 UN 5.79 5.79 CIGNA 62308 [3081051] CIGNA STATE OF WYOMING [308105107] 4.58 percent of total billed charges 3.59 5.5 Technical (Hospital) Services DONEPEZIL 5 MG TABLET RX-18786 CDM 6370000100 HCPCS 250 RC 43547-0275-03 NDC inpatient 1 UN 5.79 5.79 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES EPO [308136803] 4.58 percent of total billed charges 3.59 5.5 Technical (Hospital) Services DONEPEZIL 5 MG TABLET RX-18786 CDM 6370000100 HCPCS 250 RC 43547-0275-03 NDC inpatient 1 UN 5.79 5.79 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES HDHP [308136802] 4.58 percent of total billed charges 3.59 5.5 Technical (Hospital) Services DONEPEZIL 5 MG TABLET RX-18786 CDM 6370000100 HCPCS 250 RC 43547-0275-03 NDC inpatient 1 UN 5.79 5.79 UNITED HEALTHCARE (COMMERCIAL) [3081199] UNITED HEALTHCARE 87726 [308119901] 3.59 percent of total billed charges 3.59 5.5 Technical (Hospital) Services DONEPEZIL 10 MG TABLET RX-18787 CDM 6370000100 HCPCS 250 RC 43547-0276-09 NDC outpatient 1 UN 5.79 5.79 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES EPO [308136803] 4.63 percent of total billed charges 3.59 5.5 Technical (Hospital) Services DONEPEZIL 10 MG TABLET RX-18787 CDM 6370000100 HCPCS 250 RC 43547-0276-09 NDC outpatient 1 UN 5.79 5.79 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES PPO [308136801] 4.63 percent of total billed charges 3.59 5.5 Technical (Hospital) Services DONEPEZIL 10 MG TABLET RX-18787 CDM 6370000100 HCPCS 250 RC 43547-0276-09 NDC outpatient 1 UN 5.79 5.79 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES HDHP [308136802] 4.63 percent of total billed charges 3.59 5.5 Technical (Hospital) Services DONEPEZIL 10 MG TABLET RX-18787 CDM 6370000100 HCPCS 250 RC 43547-0276-09 NDC outpatient 1 UN 5.79 5.79 MULTIPLAN INC 34080 [3081285] MULTIPLAN INC [308128501] 5.5 percent of total billed charges 3.59 5.5 Technical (Hospital) Services DONEPEZIL 10 MG TABLET RX-18787 CDM 6370000100 HCPCS 250 RC 43547-0276-09 NDC outpatient 1 UN 5.79 5.79 CIGNA 62308 [3081051] CIGNA 62308 [308105105] 4.63 percent of total billed charges 3.59 5.5 Technical (Hospital) Services DONEPEZIL 10 MG TABLET RX-18787 CDM 6370000100 HCPCS 250 RC 43547-0276-09 NDC outpatient 1 UN 5.79 5.79 CIGNA 62308 [3081051] CIGNA STATE OF WYOMING [308105107] 4.63 percent of total billed charges 3.59 5.5 Technical (Hospital) Services DONEPEZIL 10 MG TABLET RX-18787 CDM 6370000100 HCPCS 250 RC 43547-0276-09 NDC outpatient 1 UN 5.79 5.79 MEDICA (COMMERCIAL) 94265 [3081118] MEDICA CLAIMS [308111801] 5.21 percent of total billed charges 3.59 5.5 Technical (Hospital) Services DONEPEZIL 10 MG TABLET RX-18787 CDM 6370000100 HCPCS 250 RC 43547-0276-09 NDC outpatient 1 UN 5.79 5.79 UNITED HEALTHCARE (COMMERCIAL) [3081199] UNITED HEALTHCARE 87726 [308119901] 3.59 percent of total billed charges 3.59 5.5 Technical (Hospital) Services DONEPEZIL 10 MG TABLET RX-18787 CDM 6370000100 HCPCS 250 RC 43547-0276-09 NDC outpatient 1 UN 5.79 5.79 HEALTHPARTNERS SX009 HEALTHPARTNERS 4.63 percent of total billed charges 3.59 5.5 Technical (Hospital) Services DONEPEZIL 10 MG TABLET RX-18787 CDM 6370000100 HCPCS 250 RC 43547-0276-09 NDC outpatient 1 UN 5.79 5.79 BLUE CROSS BLUE SHIELD WELLMARK SB889 [3081026] BCBS WYOMING [308102603] 5.5 percent of total billed charges 3.59 5.5 Technical (Hospital) Services DONEPEZIL 10 MG TABLET RX-18787 CDM 6370000100 HCPCS 250 RC 43547-0276-09 NDC inpatient 1 UN 5.79 5.79 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES PPO [308136801] 4.58 percent of total billed charges 3.59 5.5 Technical (Hospital) Services DONEPEZIL 10 MG TABLET RX-18787 CDM 6370000100 HCPCS 250 RC 43547-0276-09 NDC inpatient 1 UN 5.79 5.79 MULTIPLAN INC 34080 [3081285] MULTIPLAN INC [308128501] 5.5 percent of total billed charges 3.59 5.5 Technical (Hospital) Services DONEPEZIL 10 MG TABLET RX-18787 CDM 6370000100 HCPCS 250 RC 43547-0276-09 NDC inpatient 1 UN 5.79 5.79 CIGNA 62308 [3081051] CIGNA 62308 [308105105] 4.58 percent of total billed charges 3.59 5.5 Technical (Hospital) Services DONEPEZIL 10 MG TABLET RX-18787 CDM 6370000100 HCPCS 250 RC 43547-0276-09 NDC inpatient 1 UN 5.79 5.79 CIGNA 62308 [3081051] CIGNA STATE OF WYOMING [308105107] 4.58 percent of total billed charges 3.59 5.5 Technical (Hospital) Services DONEPEZIL 10 MG TABLET RX-18787 CDM 6370000100 HCPCS 250 RC 43547-0276-09 NDC inpatient 1 UN 5.79 5.79 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES EPO [308136803] 4.58 percent of total billed charges 3.59 5.5 Technical (Hospital) Services DONEPEZIL 10 MG TABLET RX-18787 CDM 6370000100 HCPCS 250 RC 43547-0276-09 NDC inpatient 1 UN 5.79 5.79 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES HDHP [308136802] 4.58 percent of total billed charges 3.59 5.5 Technical (Hospital) Services DONEPEZIL 10 MG TABLET RX-18787 CDM 6370000100 HCPCS 250 RC 43547-0276-09 NDC inpatient 1 UN 5.79 5.79 MEDICA (COMMERCIAL) 94265 [3081118] MEDICA CLAIMS [308111801] 5.21 percent of total billed charges 3.59 5.5 Technical (Hospital) Services DONEPEZIL 10 MG TABLET RX-18787 CDM 6370000100 HCPCS 250 RC 43547-0276-09 NDC inpatient 1 UN 5.79 5.79 HEALTHPARTNERS SX009 HEALTHPARTNERS 4.58 percent of total billed charges 3.59 5.5 Technical (Hospital) Services DONEPEZIL 10 MG TABLET RX-18787 CDM 6370000100 HCPCS 250 RC 43547-0276-09 NDC inpatient 1 UN 5.79 5.79 BLUE CROSS BLUE SHIELD WELLMARK SB889 [3081026] BCBS WYOMING [308102603] 5.5 percent of total billed charges 3.59 5.5 Technical (Hospital) Services DONEPEZIL 10 MG TABLET RX-18787 CDM 6370000100 HCPCS 250 RC 43547-0276-09 NDC inpatient 1 UN 5.79 5.79 UNITED HEALTHCARE (COMMERCIAL) [3081199] UNITED HEALTHCARE 87726 [308119901] 3.59 percent of total billed charges 3.59 5.5 Technical (Hospital) Services LEVOFLOXACIN 500 MG TABLET RX-18919 CDM 6370000100 HCPCS 250 RC 55111-0280-50 NDC outpatient 1 UN 6.01 6.01 MEDICA (COMMERCIAL) 94265 [3081118] MEDICA CLAIMS [308111801] 5.41 percent of total billed charges 3.73 5.71 Technical (Hospital) Services LEVOFLOXACIN 500 MG TABLET RX-18919 CDM 6370000100 HCPCS 250 RC 55111-0280-50 NDC outpatient 1 UN 6.01 6.01 UNITED HEALTHCARE (COMMERCIAL) [3081199] UNITED HEALTHCARE 87726 [308119901] 3.73 percent of total billed charges 3.73 5.71 Technical (Hospital) Services LEVOFLOXACIN 500 MG TABLET RX-18919 CDM 6370000100 HCPCS 250 RC 55111-0280-50 NDC outpatient 1 UN 6.01 6.01 CIGNA 62308 [3081051] CIGNA 62308 [308105105] 4.81 percent of total billed charges 3.73 5.71 Technical (Hospital) Services LEVOFLOXACIN 500 MG TABLET RX-18919 CDM 6370000100 HCPCS 250 RC 55111-0280-50 NDC outpatient 1 UN 6.01 6.01 CIGNA 62308 [3081051] CIGNA STATE OF WYOMING [308105107] 4.81 percent of total billed charges 3.73 5.71 Technical (Hospital) Services LEVOFLOXACIN 500 MG TABLET RX-18919 CDM 6370000100 HCPCS 250 RC 55111-0280-50 NDC outpatient 1 UN 6.01 6.01 MULTIPLAN INC 34080 [3081285] MULTIPLAN INC [308128501] 5.71 percent of total billed charges 3.73 5.71 Technical (Hospital) Services LEVOFLOXACIN 500 MG TABLET RX-18919 CDM 6370000100 HCPCS 250 RC 55111-0280-50 NDC outpatient 1 UN 6.01 6.01 BLUE CROSS BLUE SHIELD WELLMARK SB889 [3081026] BCBS WYOMING [308102603] 5.71 percent of total billed charges 3.73 5.71 Technical (Hospital) Services LEVOFLOXACIN 500 MG TABLET RX-18919 CDM 6370000100 HCPCS 250 RC 55111-0280-50 NDC outpatient 1 UN 6.01 6.01 HEALTHPARTNERS SX009 HEALTHPARTNERS 4.81 percent of total billed charges 3.73 5.71 Technical (Hospital) Services LEVOFLOXACIN 500 MG TABLET RX-18919 CDM 6370000100 HCPCS 250 RC 55111-0280-50 NDC outpatient 1 UN 6.01 6.01 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES PPO [308136801] 4.81 percent of total billed charges 3.73 5.71 Technical (Hospital) Services LEVOFLOXACIN 500 MG TABLET RX-18919 CDM 6370000100 HCPCS 250 RC 55111-0280-50 NDC outpatient 1 UN 6.01 6.01 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES HDHP [308136802] 4.81 percent of total billed charges 3.73 5.71 Technical (Hospital) Services LEVOFLOXACIN 500 MG TABLET RX-18919 CDM 6370000100 HCPCS 250 RC 55111-0280-50 NDC outpatient 1 UN 6.01 6.01 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES EPO [308136803] 4.81 percent of total billed charges 3.73 5.71 Technical (Hospital) Services LEVOFLOXACIN 500 MG TABLET RX-18919 CDM 6370000100 HCPCS 250 RC 55111-0280-50 NDC inpatient 1 UN 6.01 6.01 BLUE CROSS BLUE SHIELD WELLMARK SB889 [3081026] BCBS WYOMING [308102603] 5.71 percent of total billed charges 3.73 5.71 Technical (Hospital) Services LEVOFLOXACIN 500 MG TABLET RX-18919 CDM 6370000100 HCPCS 250 RC 55111-0280-50 NDC inpatient 1 UN 6.01 6.01 UNITED HEALTHCARE (COMMERCIAL) [3081199] UNITED HEALTHCARE 87726 [308119901] 3.73 percent of total billed charges 3.73 5.71 Technical (Hospital) Services LEVOFLOXACIN 500 MG TABLET RX-18919 CDM 6370000100 HCPCS 250 RC 55111-0280-50 NDC inpatient 1 UN 6.01 6.01 CIGNA 62308 [3081051] CIGNA 62308 [308105105] 4.76 percent of total billed charges 3.73 5.71 Technical (Hospital) Services LEVOFLOXACIN 500 MG TABLET RX-18919 CDM 6370000100 HCPCS 250 RC 55111-0280-50 NDC inpatient 1 UN 6.01 6.01 CIGNA 62308 [3081051] CIGNA STATE OF WYOMING [308105107] 4.76 percent of total billed charges 3.73 5.71 Technical (Hospital) Services LEVOFLOXACIN 500 MG TABLET RX-18919 CDM 6370000100 HCPCS 250 RC 55111-0280-50 NDC inpatient 1 UN 6.01 6.01 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES EPO [308136803] 4.76 percent of total billed charges 3.73 5.71 Technical (Hospital) Services LEVOFLOXACIN 500 MG TABLET RX-18919 CDM 6370000100 HCPCS 250 RC 55111-0280-50 NDC inpatient 1 UN 6.01 6.01 MEDICA (COMMERCIAL) 94265 [3081118] MEDICA CLAIMS [308111801] 5.41 percent of total billed charges 3.73 5.71 Technical (Hospital) Services LEVOFLOXACIN 500 MG TABLET RX-18919 CDM 6370000100 HCPCS 250 RC 55111-0280-50 NDC inpatient 1 UN 6.01 6.01 HEALTHPARTNERS SX009 HEALTHPARTNERS 4.76 percent of total billed charges 3.73 5.71 Technical (Hospital) Services LEVOFLOXACIN 500 MG TABLET RX-18919 CDM 6370000100 HCPCS 250 RC 55111-0280-50 NDC inpatient 1 UN 6.01 6.01 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES HDHP [308136802] 4.76 percent of total billed charges 3.73 5.71 Technical (Hospital) Services LEVOFLOXACIN 500 MG TABLET RX-18919 CDM 6370000100 HCPCS 250 RC 55111-0280-50 NDC inpatient 1 UN 6.01 6.01 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES PPO [308136801] 4.76 percent of total billed charges 3.73 5.71 Technical (Hospital) Services LEVOFLOXACIN 500 MG TABLET RX-18919 CDM 6370000100 HCPCS 250 RC 55111-0280-50 NDC inpatient 1 UN 6.01 6.01 MULTIPLAN INC 34080 [3081285] MULTIPLAN INC [308128501] 5.71 percent of total billed charges 3.73 5.71 Technical (Hospital) Services TOPIRAMATE 25 MG TABLET RX-18920 CDM 6370000100 HCPCS 250 RC 68382-0138-14 NDC inpatient 1 UN 5.69 5.69 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES PPO [308136801] 4.51 percent of total billed charges 3.53 5.41 Technical (Hospital) Services TOPIRAMATE 25 MG TABLET RX-18920 CDM 6370000100 HCPCS 250 RC 68382-0138-14 NDC inpatient 1 UN 5.69 5.69 HEALTHPARTNERS SX009 HEALTHPARTNERS 4.51 percent of total billed charges 3.53 5.41 Technical (Hospital) Services TOPIRAMATE 25 MG TABLET RX-18920 CDM 6370000100 HCPCS 250 RC 68382-0138-14 NDC inpatient 1 UN 5.69 5.69 MEDICA (COMMERCIAL) 94265 [3081118] MEDICA CLAIMS [308111801] 5.12 percent of total billed charges 3.53 5.41 Technical (Hospital) Services TOPIRAMATE 25 MG TABLET RX-18920 CDM 6370000100 HCPCS 250 RC 68382-0138-14 NDC inpatient 1 UN 5.69 5.69 MULTIPLAN INC 34080 [3081285] MULTIPLAN INC [308128501] 5.41 percent of total billed charges 3.53 5.41 Technical (Hospital) Services TOPIRAMATE 25 MG TABLET RX-18920 CDM 6370000100 HCPCS 250 RC 68382-0138-14 NDC inpatient 1 UN 5.69 5.69 UNITED HEALTHCARE (COMMERCIAL) [3081199] UNITED HEALTHCARE 87726 [308119901] 3.53 percent of total billed charges 3.53 5.41 Technical (Hospital) Services TOPIRAMATE 25 MG TABLET RX-18920 CDM 6370000100 HCPCS 250 RC 68382-0138-14 NDC inpatient 1 UN 5.69 5.69 CIGNA 62308 [3081051] CIGNA 62308 [308105105] 4.51 percent of total billed charges 3.53 5.41 Technical (Hospital) Services TOPIRAMATE 25 MG TABLET RX-18920 CDM 6370000100 HCPCS 250 RC 68382-0138-14 NDC inpatient 1 UN 5.69 5.69 CIGNA 62308 [3081051] CIGNA STATE OF WYOMING [308105107] 4.51 percent of total billed charges 3.53 5.41 Technical (Hospital) Services TOPIRAMATE 25 MG TABLET RX-18920 CDM 6370000100 HCPCS 250 RC 68382-0138-14 NDC inpatient 1 UN 5.69 5.69 BLUE CROSS BLUE SHIELD WELLMARK SB889 [3081026] BCBS WYOMING [308102603] 5.41 percent of total billed charges 3.53 5.41 Technical (Hospital) Services TOPIRAMATE 25 MG TABLET RX-18920 CDM 6370000100 HCPCS 250 RC 68382-0138-14 NDC inpatient 1 UN 5.69 5.69 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES HDHP [308136802] 4.51 percent of total billed charges 3.53 5.41 Technical (Hospital) Services TOPIRAMATE 25 MG TABLET RX-18920 CDM 6370000100 HCPCS 250 RC 68382-0138-14 NDC inpatient 1 UN 5.69 5.69 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES EPO [308136803] 4.51 percent of total billed charges 3.53 5.41 Technical (Hospital) Services TOPIRAMATE 25 MG TABLET RX-18920 CDM 6370000100 HCPCS 250 RC 68382-0138-14 NDC outpatient 1 UN 5.69 5.69 MEDICA (COMMERCIAL) 94265 [3081118] MEDICA CLAIMS [308111801] 5.12 percent of total billed charges 3.53 5.41 Technical (Hospital) Services TOPIRAMATE 25 MG TABLET RX-18920 CDM 6370000100 HCPCS 250 RC 68382-0138-14 NDC outpatient 1 UN 5.69 5.69 MULTIPLAN INC 34080 [3081285] MULTIPLAN INC [308128501] 5.41 percent of total billed charges 3.53 5.41 Technical (Hospital) Services TOPIRAMATE 25 MG TABLET RX-18920 CDM 6370000100 HCPCS 250 RC 68382-0138-14 NDC outpatient 1 UN 5.69 5.69 CIGNA 62308 [3081051] CIGNA 62308 [308105105] 4.55 percent of total billed charges 3.53 5.41 Technical (Hospital) Services TOPIRAMATE 25 MG TABLET RX-18920 CDM 6370000100 HCPCS 250 RC 68382-0138-14 NDC outpatient 1 UN 5.69 5.69 CIGNA 62308 [3081051] CIGNA STATE OF WYOMING [308105107] 4.55 percent of total billed charges 3.53 5.41 Technical (Hospital) Services TOPIRAMATE 25 MG TABLET RX-18920 CDM 6370000100 HCPCS 250 RC 68382-0138-14 NDC outpatient 1 UN 5.69 5.69 HEALTHPARTNERS SX009 HEALTHPARTNERS 4.55 percent of total billed charges 3.53 5.41 Technical (Hospital) Services TOPIRAMATE 25 MG TABLET RX-18920 CDM 6370000100 HCPCS 250 RC 68382-0138-14 NDC outpatient 1 UN 5.69 5.69 UNITED HEALTHCARE (COMMERCIAL) [3081199] UNITED HEALTHCARE 87726 [308119901] 3.53 percent of total billed charges 3.53 5.41 Technical (Hospital) Services TOPIRAMATE 25 MG TABLET RX-18920 CDM 6370000100 HCPCS 250 RC 68382-0138-14 NDC outpatient 1 UN 5.69 5.69 BLUE CROSS BLUE SHIELD WELLMARK SB889 [3081026] BCBS WYOMING [308102603] 5.41 percent of total billed charges 3.53 5.41 Technical (Hospital) Services TOPIRAMATE 25 MG TABLET RX-18920 CDM 6370000100 HCPCS 250 RC 68382-0138-14 NDC outpatient 1 UN 5.69 5.69 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES HDHP [308136802] 4.55 percent of total billed charges 3.53 5.41 Technical (Hospital) Services TOPIRAMATE 25 MG TABLET RX-18920 CDM 6370000100 HCPCS 250 RC 68382-0138-14 NDC outpatient 1 UN 5.69 5.69 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES PPO [308136801] 4.55 percent of total billed charges 3.53 5.41 Technical (Hospital) Services TOPIRAMATE 25 MG TABLET RX-18920 CDM 6370000100 HCPCS 250 RC 68382-0138-14 NDC outpatient 1 UN 5.69 5.69 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES EPO [308136803] 4.55 percent of total billed charges 3.53 5.41 Technical (Hospital) Services HYDROCHLOROTHIAZIDE 12.5 MG CAPSULE RX-19146 CDM 6370000100 HCPCS 250 RC 00591-0347-01 NDC inpatient 1 UN 5.7 5.7 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES HDHP [308136802] 4.51 percent of total billed charges 3.53 5.42 Technical (Hospital) Services HYDROCHLOROTHIAZIDE 12.5 MG CAPSULE RX-19146 CDM 6370000100 HCPCS 250 RC 00591-0347-01 NDC inpatient 1 UN 5.7 5.7 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES EPO [308136803] 4.51 percent of total billed charges 3.53 5.42 Technical (Hospital) Services HYDROCHLOROTHIAZIDE 12.5 MG CAPSULE RX-19146 CDM 6370000100 HCPCS 250 RC 00591-0347-01 NDC inpatient 1 UN 5.7 5.7 CIGNA 62308 [3081051] CIGNA 62308 [308105105] 4.51 percent of total billed charges 3.53 5.42 Technical (Hospital) Services HYDROCHLOROTHIAZIDE 12.5 MG CAPSULE RX-19146 CDM 6370000100 HCPCS 250 RC 00591-0347-01 NDC inpatient 1 UN 5.7 5.7 CIGNA 62308 [3081051] CIGNA STATE OF WYOMING [308105107] 4.51 percent of total billed charges 3.53 5.42 Technical (Hospital) Services HYDROCHLOROTHIAZIDE 12.5 MG CAPSULE RX-19146 CDM 6370000100 HCPCS 250 RC 00591-0347-01 NDC inpatient 1 UN 5.7 5.7 UNITED HEALTHCARE (COMMERCIAL) [3081199] UNITED HEALTHCARE 87726 [308119901] 3.53 percent of total billed charges 3.53 5.42 Technical (Hospital) Services HYDROCHLOROTHIAZIDE 12.5 MG CAPSULE RX-19146 CDM 6370000100 HCPCS 250 RC 00591-0347-01 NDC inpatient 1 UN 5.7 5.7 BLUE CROSS BLUE SHIELD WELLMARK SB889 [3081026] BCBS WYOMING [308102603] 5.42 percent of total billed charges 3.53 5.42 Technical (Hospital) Services HYDROCHLOROTHIAZIDE 12.5 MG CAPSULE RX-19146 CDM 6370000100 HCPCS 250 RC 00591-0347-01 NDC inpatient 1 UN 5.7 5.7 MULTIPLAN INC 34080 [3081285] MULTIPLAN INC [308128501] 5.42 percent of total billed charges 3.53 5.42 Technical (Hospital) Services HYDROCHLOROTHIAZIDE 12.5 MG CAPSULE RX-19146 CDM 6370000100 HCPCS 250 RC 00591-0347-01 NDC inpatient 1 UN 5.7 5.7 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES PPO [308136801] 4.51 percent of total billed charges 3.53 5.42 Technical (Hospital) Services HYDROCHLOROTHIAZIDE 12.5 MG CAPSULE RX-19146 CDM 6370000100 HCPCS 250 RC 00591-0347-01 NDC inpatient 1 UN 5.7 5.7 MEDICA (COMMERCIAL) 94265 [3081118] MEDICA CLAIMS [308111801] 5.13 percent of total billed charges 3.53 5.42 Technical (Hospital) Services HYDROCHLOROTHIAZIDE 12.5 MG CAPSULE RX-19146 CDM 6370000100 HCPCS 250 RC 00591-0347-01 NDC inpatient 1 UN 5.7 5.7 HEALTHPARTNERS SX009 HEALTHPARTNERS 4.51 percent of total billed charges 3.53 5.42 Technical (Hospital) Services HYDROCHLOROTHIAZIDE 12.5 MG CAPSULE RX-19146 CDM 6370000100 HCPCS 250 RC 00591-0347-01 NDC outpatient 1 UN 5.7 5.7 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES EPO [308136803] 4.56 percent of total billed charges 3.53 5.42 Technical (Hospital) Services HYDROCHLOROTHIAZIDE 12.5 MG CAPSULE RX-19146 CDM 6370000100 HCPCS 250 RC 00591-0347-01 NDC outpatient 1 UN 5.7 5.7 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES PPO [308136801] 4.56 percent of total billed charges 3.53 5.42 Technical (Hospital) Services HYDROCHLOROTHIAZIDE 12.5 MG CAPSULE RX-19146 CDM 6370000100 HCPCS 250 RC 00591-0347-01 NDC outpatient 1 UN 5.7 5.7 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES HDHP [308136802] 4.56 percent of total billed charges 3.53 5.42 Technical (Hospital) Services HYDROCHLOROTHIAZIDE 12.5 MG CAPSULE RX-19146 CDM 6370000100 HCPCS 250 RC 00591-0347-01 NDC outpatient 1 UN 5.7 5.7 HEALTHPARTNERS SX009 HEALTHPARTNERS 4.56 percent of total billed charges 3.53 5.42 Technical (Hospital) Services HYDROCHLOROTHIAZIDE 12.5 MG CAPSULE RX-19146 CDM 6370000100 HCPCS 250 RC 00591-0347-01 NDC outpatient 1 UN 5.7 5.7 BLUE CROSS BLUE SHIELD WELLMARK SB889 [3081026] BCBS WYOMING [308102603] 5.42 percent of total billed charges 3.53 5.42 Technical (Hospital) Services HYDROCHLOROTHIAZIDE 12.5 MG CAPSULE RX-19146 CDM 6370000100 HCPCS 250 RC 00591-0347-01 NDC outpatient 1 UN 5.7 5.7 UNITED HEALTHCARE (COMMERCIAL) [3081199] UNITED HEALTHCARE 87726 [308119901] 3.53 percent of total billed charges 3.53 5.42 Technical (Hospital) Services HYDROCHLOROTHIAZIDE 12.5 MG CAPSULE RX-19146 CDM 6370000100 HCPCS 250 RC 00591-0347-01 NDC outpatient 1 UN 5.7 5.7 MULTIPLAN INC 34080 [3081285] MULTIPLAN INC [308128501] 5.42 percent of total billed charges 3.53 5.42 Technical (Hospital) Services HYDROCHLOROTHIAZIDE 12.5 MG CAPSULE RX-19146 CDM 6370000100 HCPCS 250 RC 00591-0347-01 NDC outpatient 1 UN 5.7 5.7 CIGNA 62308 [3081051] CIGNA 62308 [308105105] 4.56 percent of total billed charges 3.53 5.42 Technical (Hospital) Services HYDROCHLOROTHIAZIDE 12.5 MG CAPSULE RX-19146 CDM 6370000100 HCPCS 250 RC 00591-0347-01 NDC outpatient 1 UN 5.7 5.7 CIGNA 62308 [3081051] CIGNA STATE OF WYOMING [308105107] 4.56 percent of total billed charges 3.53 5.42 Technical (Hospital) Services HYDROCHLOROTHIAZIDE 12.5 MG CAPSULE RX-19146 CDM 6370000100 HCPCS 250 RC 00591-0347-01 NDC outpatient 1 UN 5.7 5.7 MEDICA (COMMERCIAL) 94265 [3081118] MEDICA CLAIMS [308111801] 5.13 percent of total billed charges 3.53 5.42 Technical (Hospital) Services ATORVASTATIN 10 MG TABLET RX-19176 CDM 6370000100 HCPCS 250 RC 00378-3950-77 NDC inpatient 1 UN 5.73 5.73 BLUE CROSS BLUE SHIELD WELLMARK SB889 [3081026] BCBS WYOMING [308102603] 5.44 percent of total billed charges 3.55 5.44 Technical (Hospital) Services ATORVASTATIN 10 MG TABLET RX-19176 CDM 6370000100 HCPCS 250 RC 00378-3950-77 NDC inpatient 1 UN 5.73 5.73 CIGNA 62308 [3081051] CIGNA 62308 [308105105] 4.54 percent of total billed charges 3.55 5.44 Technical (Hospital) Services ATORVASTATIN 10 MG TABLET RX-19176 CDM 6370000100 HCPCS 250 RC 00378-3950-77 NDC inpatient 1 UN 5.73 5.73 CIGNA 62308 [3081051] CIGNA STATE OF WYOMING [308105107] 4.54 percent of total billed charges 3.55 5.44 Technical (Hospital) Services ATORVASTATIN 10 MG TABLET RX-19176 CDM 6370000100 HCPCS 250 RC 00378-3950-77 NDC inpatient 1 UN 5.73 5.73 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES EPO [308136803] 4.54 percent of total billed charges 3.55 5.44 Technical (Hospital) Services ATORVASTATIN 10 MG TABLET RX-19176 CDM 6370000100 HCPCS 250 RC 00378-3950-77 NDC inpatient 1 UN 5.73 5.73 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES HDHP [308136802] 4.54 percent of total billed charges 3.55 5.44 Technical (Hospital) Services ATORVASTATIN 10 MG TABLET RX-19176 CDM 6370000100 HCPCS 250 RC 00378-3950-77 NDC inpatient 1 UN 5.73 5.73 UNITED HEALTHCARE (COMMERCIAL) [3081199] UNITED HEALTHCARE 87726 [308119901] 3.55 percent of total billed charges 3.55 5.44 Technical (Hospital) Services ATORVASTATIN 10 MG TABLET RX-19176 CDM 6370000100 HCPCS 250 RC 00378-3950-77 NDC inpatient 1 UN 5.73 5.73 MULTIPLAN INC 34080 [3081285] MULTIPLAN INC [308128501] 5.44 percent of total billed charges 3.55 5.44 Technical (Hospital) Services ATORVASTATIN 10 MG TABLET RX-19176 CDM 6370000100 HCPCS 250 RC 00378-3950-77 NDC inpatient 1 UN 5.73 5.73 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES PPO [308136801] 4.54 percent of total billed charges 3.55 5.44 Technical (Hospital) Services ATORVASTATIN 10 MG TABLET RX-19176 CDM 6370000100 HCPCS 250 RC 00378-3950-77 NDC inpatient 1 UN 5.73 5.73 HEALTHPARTNERS SX009 HEALTHPARTNERS 4.54 percent of total billed charges 3.55 5.44 Technical (Hospital) Services ATORVASTATIN 10 MG TABLET RX-19176 CDM 6370000100 HCPCS 250 RC 00378-3950-77 NDC inpatient 1 UN 5.73 5.73 MEDICA (COMMERCIAL) 94265 [3081118] MEDICA CLAIMS [308111801] 5.16 percent of total billed charges 3.55 5.44 Technical (Hospital) Services ATORVASTATIN 10 MG TABLET RX-19176 CDM 6370000100 HCPCS 250 RC 00378-3950-77 NDC outpatient 1 UN 5.73 5.73 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES EPO [308136803] 4.58 percent of total billed charges 3.55 5.44 Technical (Hospital) Services ATORVASTATIN 10 MG TABLET RX-19176 CDM 6370000100 HCPCS 250 RC 00378-3950-77 NDC outpatient 1 UN 5.73 5.73 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES PPO [308136801] 4.58 percent of total billed charges 3.55 5.44 Technical (Hospital) Services ATORVASTATIN 10 MG TABLET RX-19176 CDM 6370000100 HCPCS 250 RC 00378-3950-77 NDC outpatient 1 UN 5.73 5.73 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES HDHP [308136802] 4.58 percent of total billed charges 3.55 5.44 Technical (Hospital) Services ATORVASTATIN 10 MG TABLET RX-19176 CDM 6370000100 HCPCS 250 RC 00378-3950-77 NDC outpatient 1 UN 5.73 5.73 BLUE CROSS BLUE SHIELD WELLMARK SB889 [3081026] BCBS WYOMING [308102603] 5.44 percent of total billed charges 3.55 5.44 Technical (Hospital) Services ATORVASTATIN 10 MG TABLET RX-19176 CDM 6370000100 HCPCS 250 RC 00378-3950-77 NDC outpatient 1 UN 5.73 5.73 CIGNA 62308 [3081051] CIGNA 62308 [308105105] 4.58 percent of total billed charges 3.55 5.44 Technical (Hospital) Services ATORVASTATIN 10 MG TABLET RX-19176 CDM 6370000100 HCPCS 250 RC 00378-3950-77 NDC outpatient 1 UN 5.73 5.73 CIGNA 62308 [3081051] CIGNA STATE OF WYOMING [308105107] 4.58 percent of total billed charges 3.55 5.44 Technical (Hospital) Services ATORVASTATIN 10 MG TABLET RX-19176 CDM 6370000100 HCPCS 250 RC 00378-3950-77 NDC outpatient 1 UN 5.73 5.73 MULTIPLAN INC 34080 [3081285] MULTIPLAN INC [308128501] 5.44 percent of total billed charges 3.55 5.44 Technical (Hospital) Services ATORVASTATIN 10 MG TABLET RX-19176 CDM 6370000100 HCPCS 250 RC 00378-3950-77 NDC outpatient 1 UN 5.73 5.73 MEDICA (COMMERCIAL) 94265 [3081118] MEDICA CLAIMS [308111801] 5.16 percent of total billed charges 3.55 5.44 Technical (Hospital) Services ATORVASTATIN 10 MG TABLET RX-19176 CDM 6370000100 HCPCS 250 RC 00378-3950-77 NDC outpatient 1 UN 5.73 5.73 UNITED HEALTHCARE (COMMERCIAL) [3081199] UNITED HEALTHCARE 87726 [308119901] 3.55 percent of total billed charges 3.55 5.44 Technical (Hospital) Services ATORVASTATIN 10 MG TABLET RX-19176 CDM 6370000100 HCPCS 250 RC 00378-3950-77 NDC outpatient 1 UN 5.73 5.73 HEALTHPARTNERS SX009 HEALTHPARTNERS 4.58 percent of total billed charges 3.55 5.44 Technical (Hospital) Services ATORVASTATIN 40 MG TABLET RX-19177 CDM 6370000100 HCPCS 250 RC 00378-3952-77 NDC outpatient 1 UN 5.77 5.77 MEDICA (COMMERCIAL) 94265 [3081118] MEDICA CLAIMS [308111801] 5.19 percent of total billed charges 3.58 5.48 Technical (Hospital) Services ATORVASTATIN 40 MG TABLET RX-19177 CDM 6370000100 HCPCS 250 RC 00378-3952-77 NDC outpatient 1 UN 5.77 5.77 CIGNA 62308 [3081051] CIGNA 62308 [308105105] 4.62 percent of total billed charges 3.58 5.48 Technical (Hospital) Services ATORVASTATIN 40 MG TABLET RX-19177 CDM 6370000100 HCPCS 250 RC 00378-3952-77 NDC outpatient 1 UN 5.77 5.77 CIGNA 62308 [3081051] CIGNA STATE OF WYOMING [308105107] 4.62 percent of total billed charges 3.58 5.48 Technical (Hospital) Services ATORVASTATIN 40 MG TABLET RX-19177 CDM 6370000100 HCPCS 250 RC 00378-3952-77 NDC outpatient 1 UN 5.77 5.77 MULTIPLAN INC 34080 [3081285] MULTIPLAN INC [308128501] 5.48 percent of total billed charges 3.58 5.48 Technical (Hospital) Services ATORVASTATIN 40 MG TABLET RX-19177 CDM 6370000100 HCPCS 250 RC 00378-3952-77 NDC outpatient 1 UN 5.77 5.77 UNITED HEALTHCARE (COMMERCIAL) [3081199] UNITED HEALTHCARE 87726 [308119901] 3.58 percent of total billed charges 3.58 5.48 Technical (Hospital) Services ATORVASTATIN 40 MG TABLET RX-19177 CDM 6370000100 HCPCS 250 RC 00378-3952-77 NDC outpatient 1 UN 5.77 5.77 BLUE CROSS BLUE SHIELD WELLMARK SB889 [3081026] BCBS WYOMING [308102603] 5.48 percent of total billed charges 3.58 5.48 Technical (Hospital) Services ATORVASTATIN 40 MG TABLET RX-19177 CDM 6370000100 HCPCS 250 RC 00378-3952-77 NDC outpatient 1 UN 5.77 5.77 HEALTHPARTNERS SX009 HEALTHPARTNERS 4.62 percent of total billed charges 3.58 5.48 Technical (Hospital) Services ATORVASTATIN 40 MG TABLET RX-19177 CDM 6370000100 HCPCS 250 RC 00378-3952-77 NDC outpatient 1 UN 5.77 5.77 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES PPO [308136801] 4.62 percent of total billed charges 3.58 5.48 Technical (Hospital) Services ATORVASTATIN 40 MG TABLET RX-19177 CDM 6370000100 HCPCS 250 RC 00378-3952-77 NDC outpatient 1 UN 5.77 5.77 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES HDHP [308136802] 4.62 percent of total billed charges 3.58 5.48 Technical (Hospital) Services ATORVASTATIN 40 MG TABLET RX-19177 CDM 6370000100 HCPCS 250 RC 00378-3952-77 NDC outpatient 1 UN 5.77 5.77 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES EPO [308136803] 4.62 percent of total billed charges 3.58 5.48 Technical (Hospital) Services ATORVASTATIN 40 MG TABLET RX-19177 CDM 6370000100 HCPCS 250 RC 00378-3952-77 NDC inpatient 1 UN 5.77 5.77 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES HDHP [308136802] 4.57 percent of total billed charges 3.58 5.48 Technical (Hospital) Services ATORVASTATIN 40 MG TABLET RX-19177 CDM 6370000100 HCPCS 250 RC 00378-3952-77 NDC inpatient 1 UN 5.77 5.77 CIGNA 62308 [3081051] CIGNA 62308 [308105105] 4.57 percent of total billed charges 3.58 5.48 Technical (Hospital) Services ATORVASTATIN 40 MG TABLET RX-19177 CDM 6370000100 HCPCS 250 RC 00378-3952-77 NDC inpatient 1 UN 5.77 5.77 CIGNA 62308 [3081051] CIGNA STATE OF WYOMING [308105107] 4.57 percent of total billed charges 3.58 5.48 Technical (Hospital) Services ATORVASTATIN 40 MG TABLET RX-19177 CDM 6370000100 HCPCS 250 RC 00378-3952-77 NDC inpatient 1 UN 5.77 5.77 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES EPO [308136803] 4.57 percent of total billed charges 3.58 5.48 Technical (Hospital) Services ATORVASTATIN 40 MG TABLET RX-19177 CDM 6370000100 HCPCS 250 RC 00378-3952-77 NDC inpatient 1 UN 5.77 5.77 BLUE CROSS BLUE SHIELD WELLMARK SB889 [3081026] BCBS WYOMING [308102603] 5.48 percent of total billed charges 3.58 5.48 Technical (Hospital) Services ATORVASTATIN 40 MG TABLET RX-19177 CDM 6370000100 HCPCS 250 RC 00378-3952-77 NDC inpatient 1 UN 5.77 5.77 UNITED HEALTHCARE (COMMERCIAL) [3081199] UNITED HEALTHCARE 87726 [308119901] 3.58 percent of total billed charges 3.58 5.48 Technical (Hospital) Services ATORVASTATIN 40 MG TABLET RX-19177 CDM 6370000100 HCPCS 250 RC 00378-3952-77 NDC inpatient 1 UN 5.77 5.77 HEALTHPARTNERS SX009 HEALTHPARTNERS 4.57 percent of total billed charges 3.58 5.48 Technical (Hospital) Services ATORVASTATIN 40 MG TABLET RX-19177 CDM 6370000100 HCPCS 250 RC 00378-3952-77 NDC inpatient 1 UN 5.77 5.77 MEDICA (COMMERCIAL) 94265 [3081118] MEDICA CLAIMS [308111801] 5.19 percent of total billed charges 3.58 5.48 Technical (Hospital) Services ATORVASTATIN 40 MG TABLET RX-19177 CDM 6370000100 HCPCS 250 RC 00378-3952-77 NDC inpatient 1 UN 5.77 5.77 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES PPO [308136801] 4.57 percent of total billed charges 3.58 5.48 Technical (Hospital) Services ATORVASTATIN 40 MG TABLET RX-19177 CDM 6370000100 HCPCS 250 RC 00378-3952-77 NDC inpatient 1 UN 5.77 5.77 MULTIPLAN INC 34080 [3081285] MULTIPLAN INC [308128501] 5.48 percent of total billed charges 3.58 5.48 Technical (Hospital) Services ATORVASTATIN 20 MG TABLET RX-19178 CDM 6370000100 HCPCS 250 RC 00093-5059-98 NDC inpatient 1 UN 5.8 5.8 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES HDHP [308136802] 4.59 percent of total billed charges 3.6 5.51 Technical (Hospital) Services ATORVASTATIN 20 MG TABLET RX-19178 CDM 6370000100 HCPCS 250 RC 00093-5059-98 NDC inpatient 1 UN 5.8 5.8 HEALTHPARTNERS SX009 HEALTHPARTNERS 4.59 percent of total billed charges 3.6 5.51 Technical (Hospital) Services ATORVASTATIN 20 MG TABLET RX-19178 CDM 6370000100 HCPCS 250 RC 00093-5059-98 NDC inpatient 1 UN 5.8 5.8 MEDICA (COMMERCIAL) 94265 [3081118] MEDICA CLAIMS [308111801] 5.22 percent of total billed charges 3.6 5.51 Technical (Hospital) Services ATORVASTATIN 20 MG TABLET RX-19178 CDM 6370000100 HCPCS 250 RC 00093-5059-98 NDC inpatient 1 UN 5.8 5.8 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES EPO [308136803] 4.59 percent of total billed charges 3.6 5.51 Technical (Hospital) Services ATORVASTATIN 20 MG TABLET RX-19178 CDM 6370000100 HCPCS 250 RC 00093-5059-98 NDC inpatient 1 UN 5.8 5.8 CIGNA 62308 [3081051] CIGNA 62308 [308105105] 4.59 percent of total billed charges 3.6 5.51 Technical (Hospital) Services ATORVASTATIN 20 MG TABLET RX-19178 CDM 6370000100 HCPCS 250 RC 00093-5059-98 NDC inpatient 1 UN 5.8 5.8 CIGNA 62308 [3081051] CIGNA STATE OF WYOMING [308105107] 4.59 percent of total billed charges 3.6 5.51 Technical (Hospital) Services ATORVASTATIN 20 MG TABLET RX-19178 CDM 6370000100 HCPCS 250 RC 00093-5059-98 NDC inpatient 1 UN 5.8 5.8 UNITED HEALTHCARE (COMMERCIAL) [3081199] UNITED HEALTHCARE 87726 [308119901] 3.6 percent of total billed charges 3.6 5.51 Technical (Hospital) Services ATORVASTATIN 20 MG TABLET RX-19178 CDM 6370000100 HCPCS 250 RC 00093-5059-98 NDC inpatient 1 UN 5.8 5.8 BLUE CROSS BLUE SHIELD WELLMARK SB889 [3081026] BCBS WYOMING [308102603] 5.51 percent of total billed charges 3.6 5.51 Technical (Hospital) Services ATORVASTATIN 20 MG TABLET RX-19178 CDM 6370000100 HCPCS 250 RC 00093-5059-98 NDC inpatient 1 UN 5.8 5.8 MULTIPLAN INC 34080 [3081285] MULTIPLAN INC [308128501] 5.51 percent of total billed charges 3.6 5.51 Technical (Hospital) Services ATORVASTATIN 20 MG TABLET RX-19178 CDM 6370000100 HCPCS 250 RC 00093-5059-98 NDC inpatient 1 UN 5.8 5.8 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES PPO [308136801] 4.59 percent of total billed charges 3.6 5.51 Technical (Hospital) Services ATORVASTATIN 20 MG TABLET RX-19178 CDM 6370000100 HCPCS 250 RC 00093-5059-98 NDC outpatient 1 UN 5.8 5.8 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES EPO [308136803] 4.64 percent of total billed charges 3.6 5.51 Technical (Hospital) Services ATORVASTATIN 20 MG TABLET RX-19178 CDM 6370000100 HCPCS 250 RC 00093-5059-98 NDC outpatient 1 UN 5.8 5.8 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES HDHP [308136802] 4.64 percent of total billed charges 3.6 5.51 Technical (Hospital) Services ATORVASTATIN 20 MG TABLET RX-19178 CDM 6370000100 HCPCS 250 RC 00093-5059-98 NDC outpatient 1 UN 5.8 5.8 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES PPO [308136801] 4.64 percent of total billed charges 3.6 5.51 Technical (Hospital) Services ATORVASTATIN 20 MG TABLET RX-19178 CDM 6370000100 HCPCS 250 RC 00093-5059-98 NDC outpatient 1 UN 5.8 5.8 HEALTHPARTNERS SX009 HEALTHPARTNERS 4.64 percent of total billed charges 3.6 5.51 Technical (Hospital) Services ATORVASTATIN 20 MG TABLET RX-19178 CDM 6370000100 HCPCS 250 RC 00093-5059-98 NDC outpatient 1 UN 5.8 5.8 BLUE CROSS BLUE SHIELD WELLMARK SB889 [3081026] BCBS WYOMING [308102603] 5.51 percent of total billed charges 3.6 5.51 Technical (Hospital) Services ATORVASTATIN 20 MG TABLET RX-19178 CDM 6370000100 HCPCS 250 RC 00093-5059-98 NDC outpatient 1 UN 5.8 5.8 UNITED HEALTHCARE (COMMERCIAL) [3081199] UNITED HEALTHCARE 87726 [308119901] 3.6 percent of total billed charges 3.6 5.51 Technical (Hospital) Services ATORVASTATIN 20 MG TABLET RX-19178 CDM 6370000100 HCPCS 250 RC 00093-5059-98 NDC outpatient 1 UN 5.8 5.8 MULTIPLAN INC 34080 [3081285] MULTIPLAN INC [308128501] 5.51 percent of total billed charges 3.6 5.51 Technical (Hospital) Services ATORVASTATIN 20 MG TABLET RX-19178 CDM 6370000100 HCPCS 250 RC 00093-5059-98 NDC outpatient 1 UN 5.8 5.8 CIGNA 62308 [3081051] CIGNA 62308 [308105105] 4.64 percent of total billed charges 3.6 5.51 Technical (Hospital) Services ATORVASTATIN 20 MG TABLET RX-19178 CDM 6370000100 HCPCS 250 RC 00093-5059-98 NDC outpatient 1 UN 5.8 5.8 CIGNA 62308 [3081051] CIGNA STATE OF WYOMING [308105107] 4.64 percent of total billed charges 3.6 5.51 Technical (Hospital) Services ATORVASTATIN 20 MG TABLET RX-19178 CDM 6370000100 HCPCS 250 RC 00093-5059-98 NDC outpatient 1 UN 5.8 5.8 MEDICA (COMMERCIAL) 94265 [3081118] MEDICA CLAIMS [308111801] 5.22 percent of total billed charges 3.6 5.51 Technical (Hospital) Services WARFARIN 3 MG TABLET RX-19433 CDM 6370000100 HCPCS 250 RC 00093-1715-01 NDC inpatient 1 UN 5.86 5.86 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES PPO [308136801] 4.64 percent of total billed charges 3.63 5.57 Technical (Hospital) Services WARFARIN 3 MG TABLET RX-19433 CDM 6370000100 HCPCS 250 RC 00093-1715-01 NDC inpatient 1 UN 5.86 5.86 MEDICA (COMMERCIAL) 94265 [3081118] MEDICA CLAIMS [308111801] 5.27 percent of total billed charges 3.63 5.57 Technical (Hospital) Services WARFARIN 3 MG TABLET RX-19433 CDM 6370000100 HCPCS 250 RC 00093-1715-01 NDC inpatient 1 UN 5.86 5.86 HEALTHPARTNERS SX009 HEALTHPARTNERS 4.64 percent of total billed charges 3.63 5.57 Technical (Hospital) Services WARFARIN 3 MG TABLET RX-19433 CDM 6370000100 HCPCS 250 RC 00093-1715-01 NDC inpatient 1 UN 5.86 5.86 MULTIPLAN INC 34080 [3081285] MULTIPLAN INC [308128501] 5.57 percent of total billed charges 3.63 5.57 Technical (Hospital) Services WARFARIN 3 MG TABLET RX-19433 CDM 6370000100 HCPCS 250 RC 00093-1715-01 NDC inpatient 1 UN 5.86 5.86 UNITED HEALTHCARE (COMMERCIAL) [3081199] UNITED HEALTHCARE 87726 [308119901] 3.63 percent of total billed charges 3.63 5.57 Technical (Hospital) Services WARFARIN 3 MG TABLET RX-19433 CDM 6370000100 HCPCS 250 RC 00093-1715-01 NDC inpatient 1 UN 5.86 5.86 BLUE CROSS BLUE SHIELD WELLMARK SB889 [3081026] BCBS WYOMING [308102603] 5.57 percent of total billed charges 3.63 5.57 Technical (Hospital) Services WARFARIN 3 MG TABLET RX-19433 CDM 6370000100 HCPCS 250 RC 00093-1715-01 NDC inpatient 1 UN 5.86 5.86 CIGNA 62308 [3081051] CIGNA 62308 [308105105] 4.64 percent of total billed charges 3.63 5.57 Technical (Hospital) Services WARFARIN 3 MG TABLET RX-19433 CDM 6370000100 HCPCS 250 RC 00093-1715-01 NDC inpatient 1 UN 5.86 5.86 CIGNA 62308 [3081051] CIGNA STATE OF WYOMING [308105107] 4.64 percent of total billed charges 3.63 5.57 Technical (Hospital) Services WARFARIN 3 MG TABLET RX-19433 CDM 6370000100 HCPCS 250 RC 00093-1715-01 NDC inpatient 1 UN 5.86 5.86 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES EPO [308136803] 4.64 percent of total billed charges 3.63 5.57 Technical (Hospital) Services WARFARIN 3 MG TABLET RX-19433 CDM 6370000100 HCPCS 250 RC 00093-1715-01 NDC inpatient 1 UN 5.86 5.86 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES HDHP [308136802] 4.64 percent of total billed charges 3.63 5.57 Technical (Hospital) Services WARFARIN 3 MG TABLET RX-19433 CDM 6370000100 HCPCS 250 RC 00093-1715-01 NDC outpatient 1 UN 5.86 5.86 MULTIPLAN INC 34080 [3081285] MULTIPLAN INC [308128501] 5.57 percent of total billed charges 3.63 5.57 Technical (Hospital) Services WARFARIN 3 MG TABLET RX-19433 CDM 6370000100 HCPCS 250 RC 00093-1715-01 NDC outpatient 1 UN 5.86 5.86 CIGNA 62308 [3081051] CIGNA 62308 [308105105] 4.69 percent of total billed charges 3.63 5.57 Technical (Hospital) Services WARFARIN 3 MG TABLET RX-19433 CDM 6370000100 HCPCS 250 RC 00093-1715-01 NDC outpatient 1 UN 5.86 5.86 CIGNA 62308 [3081051] CIGNA STATE OF WYOMING [308105107] 4.69 percent of total billed charges 3.63 5.57 Technical (Hospital) Services WARFARIN 3 MG TABLET RX-19433 CDM 6370000100 HCPCS 250 RC 00093-1715-01 NDC outpatient 1 UN 5.86 5.86 MEDICA (COMMERCIAL) 94265 [3081118] MEDICA CLAIMS [308111801] 5.27 percent of total billed charges 3.63 5.57 Technical (Hospital) Services WARFARIN 3 MG TABLET RX-19433 CDM 6370000100 HCPCS 250 RC 00093-1715-01 NDC outpatient 1 UN 5.86 5.86 UNITED HEALTHCARE (COMMERCIAL) [3081199] UNITED HEALTHCARE 87726 [308119901] 3.63 percent of total billed charges 3.63 5.57 Technical (Hospital) Services WARFARIN 3 MG TABLET RX-19433 CDM 6370000100 HCPCS 250 RC 00093-1715-01 NDC outpatient 1 UN 5.86 5.86 BLUE CROSS BLUE SHIELD WELLMARK SB889 [3081026] BCBS WYOMING [308102603] 5.57 percent of total billed charges 3.63 5.57 Technical (Hospital) Services WARFARIN 3 MG TABLET RX-19433 CDM 6370000100 HCPCS 250 RC 00093-1715-01 NDC outpatient 1 UN 5.86 5.86 HEALTHPARTNERS SX009 HEALTHPARTNERS 4.69 percent of total billed charges 3.63 5.57 Technical (Hospital) Services WARFARIN 3 MG TABLET RX-19433 CDM 6370000100 HCPCS 250 RC 00093-1715-01 NDC outpatient 1 UN 5.86 5.86 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES EPO [308136803] 4.69 percent of total billed charges 3.63 5.57 Technical (Hospital) Services WARFARIN 3 MG TABLET RX-19433 CDM 6370000100 HCPCS 250 RC 00093-1715-01 NDC outpatient 1 UN 5.86 5.86 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES PPO [308136801] 4.69 percent of total billed charges 3.63 5.57 Technical (Hospital) Services WARFARIN 3 MG TABLET RX-19433 CDM 6370000100 HCPCS 250 RC 00093-1715-01 NDC outpatient 1 UN 5.86 5.86 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES HDHP [308136802] 4.69 percent of total billed charges 3.63 5.57 Technical (Hospital) Services "CALCIUM CARBONATE 500 MG (1,250 MG)-VITAMIN D3 200 UNIT (5 MCG) TABLET" RX-19483 CDM 6370000100 HCPCS 250 RC 37864-0000-32 NDC inpatient 1 UN 5.64 5.64 BLUE CROSS BLUE SHIELD WELLMARK SB889 [3081026] BCBS WYOMING [308102603] 5.36 percent of total billed charges 3.5 5.36 Technical (Hospital) Services "CALCIUM CARBONATE 500 MG (1,250 MG)-VITAMIN D3 200 UNIT (5 MCG) TABLET" RX-19483 CDM 6370000100 HCPCS 250 RC 37864-0000-32 NDC inpatient 1 UN 5.64 5.64 UNITED HEALTHCARE (COMMERCIAL) [3081199] UNITED HEALTHCARE 87726 [308119901] 3.5 percent of total billed charges 3.5 5.36 Technical (Hospital) Services "CALCIUM CARBONATE 500 MG (1,250 MG)-VITAMIN D3 200 UNIT (5 MCG) TABLET" RX-19483 CDM 6370000100 HCPCS 250 RC 37864-0000-32 NDC inpatient 1 UN 5.64 5.64 CIGNA 62308 [3081051] CIGNA 62308 [308105105] 4.47 percent of total billed charges 3.5 5.36 Technical (Hospital) Services "CALCIUM CARBONATE 500 MG (1,250 MG)-VITAMIN D3 200 UNIT (5 MCG) TABLET" RX-19483 CDM 6370000100 HCPCS 250 RC 37864-0000-32 NDC inpatient 1 UN 5.64 5.64 CIGNA 62308 [3081051] CIGNA STATE OF WYOMING [308105107] 4.47 percent of total billed charges 3.5 5.36 Technical (Hospital) Services "CALCIUM CARBONATE 500 MG (1,250 MG)-VITAMIN D3 200 UNIT (5 MCG) TABLET" RX-19483 CDM 6370000100 HCPCS 250 RC 37864-0000-32 NDC inpatient 1 UN 5.64 5.64 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES EPO [308136803] 4.47 percent of total billed charges 3.5 5.36 Technical (Hospital) Services "CALCIUM CARBONATE 500 MG (1,250 MG)-VITAMIN D3 200 UNIT (5 MCG) TABLET" RX-19483 CDM 6370000100 HCPCS 250 RC 37864-0000-32 NDC outpatient 1 UN 5.64 5.64 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES HDHP [308136802] 4.51 percent of total billed charges 3.5 5.36 Technical (Hospital) Services "CALCIUM CARBONATE 500 MG (1,250 MG)-VITAMIN D3 200 UNIT (5 MCG) TABLET" RX-19483 CDM 6370000100 HCPCS 250 RC 37864-0000-32 NDC outpatient 1 UN 5.64 5.64 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES PPO [308136801] 4.51 percent of total billed charges 3.5 5.36 Technical (Hospital) Services "CALCIUM CARBONATE 500 MG (1,250 MG)-VITAMIN D3 200 UNIT (5 MCG) TABLET" RX-19483 CDM 6370000100 HCPCS 250 RC 37864-0000-32 NDC outpatient 1 UN 5.64 5.64 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES EPO [308136803] 4.51 percent of total billed charges 3.5 5.36 Technical (Hospital) Services "CALCIUM CARBONATE 500 MG (1,250 MG)-VITAMIN D3 200 UNIT (5 MCG) TABLET" RX-19483 CDM 6370000100 HCPCS 250 RC 37864-0000-32 NDC outpatient 1 UN 5.64 5.64 BLUE CROSS BLUE SHIELD WELLMARK SB889 [3081026] BCBS WYOMING [308102603] 5.36 percent of total billed charges 3.5 5.36 Technical (Hospital) Services "CALCIUM CARBONATE 500 MG (1,250 MG)-VITAMIN D3 200 UNIT (5 MCG) TABLET" RX-19483 CDM 6370000100 HCPCS 250 RC 37864-0000-32 NDC outpatient 1 UN 5.64 5.64 MULTIPLAN INC 34080 [3081285] MULTIPLAN INC [308128501] 5.36 percent of total billed charges 3.5 5.36 Technical (Hospital) Services "CALCIUM CARBONATE 500 MG (1,250 MG)-VITAMIN D3 200 UNIT (5 MCG) TABLET" RX-19483 CDM 6370000100 HCPCS 250 RC 37864-0000-32 NDC outpatient 1 UN 5.64 5.64 CIGNA 62308 [3081051] CIGNA 62308 [308105105] 4.51 percent of total billed charges 3.5 5.36 Technical (Hospital) Services "CALCIUM CARBONATE 500 MG (1,250 MG)-VITAMIN D3 200 UNIT (5 MCG) TABLET" RX-19483 CDM 6370000100 HCPCS 250 RC 37864-0000-32 NDC outpatient 1 UN 5.64 5.64 CIGNA 62308 [3081051] CIGNA STATE OF WYOMING [308105107] 4.51 percent of total billed charges 3.5 5.36 Technical (Hospital) Services "CALCIUM CARBONATE 500 MG (1,250 MG)-VITAMIN D3 200 UNIT (5 MCG) TABLET" RX-19483 CDM 6370000100 HCPCS 250 RC 37864-0000-32 NDC outpatient 1 UN 5.64 5.64 MEDICA (COMMERCIAL) 94265 [3081118] MEDICA CLAIMS [308111801] 5.08 percent of total billed charges 3.5 5.36 Technical (Hospital) Services "CALCIUM CARBONATE 500 MG (1,250 MG)-VITAMIN D3 200 UNIT (5 MCG) TABLET" RX-19483 CDM 6370000100 HCPCS 250 RC 37864-0000-32 NDC outpatient 1 UN 5.64 5.64 UNITED HEALTHCARE (COMMERCIAL) [3081199] UNITED HEALTHCARE 87726 [308119901] 3.5 percent of total billed charges 3.5 5.36 Technical (Hospital) Services "CALCIUM CARBONATE 500 MG (1,250 MG)-VITAMIN D3 200 UNIT (5 MCG) TABLET" RX-19483 CDM 6370000100 HCPCS 250 RC 37864-0000-32 NDC outpatient 1 UN 5.64 5.64 HEALTHPARTNERS SX009 HEALTHPARTNERS 4.51 percent of total billed charges 3.5 5.36 Technical (Hospital) Services "CALCIUM CARBONATE 500 MG (1,250 MG)-VITAMIN D3 200 UNIT (5 MCG) TABLET" RX-19483 CDM 6370000100 HCPCS 250 RC 37864-0000-32 NDC inpatient 1 UN 5.64 5.64 MEDICA (COMMERCIAL) 94265 [3081118] MEDICA CLAIMS [308111801] 5.08 percent of total billed charges 3.5 5.36 Technical (Hospital) Services "CALCIUM CARBONATE 500 MG (1,250 MG)-VITAMIN D3 200 UNIT (5 MCG) TABLET" RX-19483 CDM 6370000100 HCPCS 250 RC 37864-0000-32 NDC inpatient 1 UN 5.64 5.64 HEALTHPARTNERS SX009 HEALTHPARTNERS 4.47 percent of total billed charges 3.5 5.36 Technical (Hospital) Services "CALCIUM CARBONATE 500 MG (1,250 MG)-VITAMIN D3 200 UNIT (5 MCG) TABLET" RX-19483 CDM 6370000100 HCPCS 250 RC 37864-0000-32 NDC inpatient 1 UN 5.64 5.64 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES HDHP [308136802] 4.47 percent of total billed charges 3.5 5.36 Technical (Hospital) Services "CALCIUM CARBONATE 500 MG (1,250 MG)-VITAMIN D3 200 UNIT (5 MCG) TABLET" RX-19483 CDM 6370000100 HCPCS 250 RC 37864-0000-32 NDC inpatient 1 UN 5.64 5.64 MULTIPLAN INC 34080 [3081285] MULTIPLAN INC [308128501] 5.36 percent of total billed charges 3.5 5.36 Technical (Hospital) Services "CALCIUM CARBONATE 500 MG (1,250 MG)-VITAMIN D3 200 UNIT (5 MCG) TABLET" RX-19483 CDM 6370000100 HCPCS 250 RC 37864-0000-32 NDC inpatient 1 UN 5.64 5.64 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES PPO [308136801] 4.47 percent of total billed charges 3.5 5.36 Technical (Hospital) Services CLINDAMYCIN 1 % LOTION RX-19711 CDM 6370000100 HCPCS 250 RC 00168-0203-60 NDC inpatient 1 ML 7.54 7.54 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES HDHP [308136802] 5.97 percent of total billed charges 4.67 7.16 Technical (Hospital) Services CLINDAMYCIN 1 % LOTION RX-19711 CDM 6370000100 HCPCS 250 RC 00168-0203-60 NDC inpatient 1 ML 7.54 7.54 CIGNA 62308 [3081051] CIGNA 62308 [308105105] 5.97 percent of total billed charges 4.67 7.16 Technical (Hospital) Services CLINDAMYCIN 1 % LOTION RX-19711 CDM 6370000100 HCPCS 250 RC 00168-0203-60 NDC inpatient 1 ML 7.54 7.54 CIGNA 62308 [3081051] CIGNA STATE OF WYOMING [308105107] 5.97 percent of total billed charges 4.67 7.16 Technical (Hospital) Services CLINDAMYCIN 1 % LOTION RX-19711 CDM 6370000100 HCPCS 250 RC 00168-0203-60 NDC inpatient 1 ML 7.54 7.54 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES EPO [308136803] 5.97 percent of total billed charges 4.67 7.16 Technical (Hospital) Services CLINDAMYCIN 1 % LOTION RX-19711 CDM 6370000100 HCPCS 250 RC 00168-0203-60 NDC inpatient 1 ML 7.54 7.54 BLUE CROSS BLUE SHIELD WELLMARK SB889 [3081026] BCBS WYOMING [308102603] 7.16 percent of total billed charges 4.67 7.16 Technical (Hospital) Services CLINDAMYCIN 1 % LOTION RX-19711 CDM 6370000100 HCPCS 250 RC 00168-0203-60 NDC inpatient 1 ML 7.54 7.54 UNITED HEALTHCARE (COMMERCIAL) [3081199] UNITED HEALTHCARE 87726 [308119901] 4.67 percent of total billed charges 4.67 7.16 Technical (Hospital) Services CLINDAMYCIN 1 % LOTION RX-19711 CDM 6370000100 HCPCS 250 RC 00168-0203-60 NDC inpatient 1 ML 7.54 7.54 HEALTHPARTNERS SX009 HEALTHPARTNERS 5.97 percent of total billed charges 4.67 7.16 Technical (Hospital) Services CLINDAMYCIN 1 % LOTION RX-19711 CDM 6370000100 HCPCS 250 RC 00168-0203-60 NDC inpatient 1 ML 7.54 7.54 MEDICA (COMMERCIAL) 94265 [3081118] MEDICA CLAIMS [308111801] 6.79 percent of total billed charges 4.67 7.16 Technical (Hospital) Services CLINDAMYCIN 1 % LOTION RX-19711 CDM 6370000100 HCPCS 250 RC 00168-0203-60 NDC inpatient 1 ML 7.54 7.54 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES PPO [308136801] 5.97 percent of total billed charges 4.67 7.16 Technical (Hospital) Services CLINDAMYCIN 1 % LOTION RX-19711 CDM 6370000100 HCPCS 250 RC 00168-0203-60 NDC inpatient 1 ML 7.54 7.54 MULTIPLAN INC 34080 [3081285] MULTIPLAN INC [308128501] 7.16 percent of total billed charges 4.67 7.16 Technical (Hospital) Services CLINDAMYCIN 1 % LOTION RX-19711 CDM 6370000100 HCPCS 250 RC 00168-0203-60 NDC outpatient 1 ML 7.54 7.54 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES EPO [308136803] 6.03 percent of total billed charges 4.67 7.16 Technical (Hospital) Services CLINDAMYCIN 1 % LOTION RX-19711 CDM 6370000100 HCPCS 250 RC 00168-0203-60 NDC outpatient 1 ML 7.54 7.54 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES PPO [308136801] 6.03 percent of total billed charges 4.67 7.16 Technical (Hospital) Services CLINDAMYCIN 1 % LOTION RX-19711 CDM 6370000100 HCPCS 250 RC 00168-0203-60 NDC outpatient 1 ML 7.54 7.54 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES HDHP [308136802] 6.03 percent of total billed charges 4.67 7.16 Technical (Hospital) Services CLINDAMYCIN 1 % LOTION RX-19711 CDM 6370000100 HCPCS 250 RC 00168-0203-60 NDC outpatient 1 ML 7.54 7.54 BLUE CROSS BLUE SHIELD WELLMARK SB889 [3081026] BCBS WYOMING [308102603] 7.16 percent of total billed charges 4.67 7.16 Technical (Hospital) Services CLINDAMYCIN 1 % LOTION RX-19711 CDM 6370000100 HCPCS 250 RC 00168-0203-60 NDC outpatient 1 ML 7.54 7.54 UNITED HEALTHCARE (COMMERCIAL) [3081199] UNITED HEALTHCARE 87726 [308119901] 4.67 percent of total billed charges 4.67 7.16 Technical (Hospital) Services CLINDAMYCIN 1 % LOTION RX-19711 CDM 6370000100 HCPCS 250 RC 00168-0203-60 NDC outpatient 1 ML 7.54 7.54 HEALTHPARTNERS SX009 HEALTHPARTNERS 6.03 percent of total billed charges 4.67 7.16 Technical (Hospital) Services CLINDAMYCIN 1 % LOTION RX-19711 CDM 6370000100 HCPCS 250 RC 00168-0203-60 NDC outpatient 1 ML 7.54 7.54 CIGNA 62308 [3081051] CIGNA 62308 [308105105] 6.03 percent of total billed charges 4.67 7.16 Technical (Hospital) Services CLINDAMYCIN 1 % LOTION RX-19711 CDM 6370000100 HCPCS 250 RC 00168-0203-60 NDC outpatient 1 ML 7.54 7.54 CIGNA 62308 [3081051] CIGNA STATE OF WYOMING [308105107] 6.03 percent of total billed charges 4.67 7.16 Technical (Hospital) Services CLINDAMYCIN 1 % LOTION RX-19711 CDM 6370000100 HCPCS 250 RC 00168-0203-60 NDC outpatient 1 ML 7.54 7.54 MULTIPLAN INC 34080 [3081285] MULTIPLAN INC [308128501] 7.16 percent of total billed charges 4.67 7.16 Technical (Hospital) Services CLINDAMYCIN 1 % LOTION RX-19711 CDM 6370000100 HCPCS 250 RC 00168-0203-60 NDC outpatient 1 ML 7.54 7.54 MEDICA (COMMERCIAL) 94265 [3081118] MEDICA CLAIMS [308111801] 6.79 percent of total billed charges 4.67 7.16 Technical (Hospital) Services OFLOXACIN 0.3 % EYE DROPS RX-19746 CDM 6370000100 HCPCS 250 RC 64980-0515-05 NDC outpatient 5 ML 54 54 CIGNA 62308 [3081051] CIGNA 62308 [308105105] 43.2 percent of total billed charges 33.48 51.3 Technical (Hospital) Services OFLOXACIN 0.3 % EYE DROPS RX-19746 CDM 6370000100 HCPCS 250 RC 64980-0515-05 NDC outpatient 5 ML 54 54 CIGNA 62308 [3081051] CIGNA STATE OF WYOMING [308105107] 43.2 percent of total billed charges 33.48 51.3 Technical (Hospital) Services OFLOXACIN 0.3 % EYE DROPS RX-19746 CDM 6370000100 HCPCS 250 RC 64980-0515-05 NDC outpatient 5 ML 54 54 MEDICA (COMMERCIAL) 94265 [3081118] MEDICA CLAIMS [308111801] 48.6 percent of total billed charges 33.48 51.3 Technical (Hospital) Services OFLOXACIN 0.3 % EYE DROPS RX-19746 CDM 6370000100 HCPCS 250 RC 64980-0515-05 NDC outpatient 5 ML 54 54 MULTIPLAN INC 34080 [3081285] MULTIPLAN INC [308128501] 51.3 percent of total billed charges 33.48 51.3 Technical (Hospital) Services OFLOXACIN 0.3 % EYE DROPS RX-19746 CDM 6370000100 HCPCS 250 RC 64980-0515-05 NDC outpatient 5 ML 54 54 UNITED HEALTHCARE (COMMERCIAL) [3081199] UNITED HEALTHCARE 87726 [308119901] 33.48 percent of total billed charges 33.48 51.3 Technical (Hospital) Services OFLOXACIN 0.3 % EYE DROPS RX-19746 CDM 6370000100 HCPCS 250 RC 64980-0515-05 NDC outpatient 5 ML 54 54 HEALTHPARTNERS SX009 HEALTHPARTNERS 43.2 percent of total billed charges 33.48 51.3 Technical (Hospital) Services OFLOXACIN 0.3 % EYE DROPS RX-19746 CDM 6370000100 HCPCS 250 RC 64980-0515-05 NDC outpatient 5 ML 54 54 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES HDHP [308136802] 43.2 percent of total billed charges 33.48 51.3 Technical (Hospital) Services OFLOXACIN 0.3 % EYE DROPS RX-19746 CDM 6370000100 HCPCS 250 RC 64980-0515-05 NDC outpatient 5 ML 54 54 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES PPO [308136801] 43.2 percent of total billed charges 33.48 51.3 Technical (Hospital) Services OFLOXACIN 0.3 % EYE DROPS RX-19746 CDM 6370000100 HCPCS 250 RC 64980-0515-05 NDC outpatient 5 ML 54 54 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES EPO [308136803] 43.2 percent of total billed charges 33.48 51.3 Technical (Hospital) Services OFLOXACIN 0.3 % EYE DROPS RX-19746 CDM 6370000100 HCPCS 250 RC 64980-0515-05 NDC outpatient 5 ML 54 54 BLUE CROSS BLUE SHIELD WELLMARK SB889 [3081026] BCBS WYOMING [308102603] 51.3 percent of total billed charges 33.48 51.3 Technical (Hospital) Services OFLOXACIN 0.3 % EYE DROPS RX-19746 CDM 6370000100 HCPCS 250 RC 64980-0515-05 NDC inpatient 5 ML 54 54 BLUE CROSS BLUE SHIELD WELLMARK SB889 [3081026] BCBS WYOMING [308102603] 51.3 percent of total billed charges 33.48 51.3 Technical (Hospital) Services OFLOXACIN 0.3 % EYE DROPS RX-19746 CDM 6370000100 HCPCS 250 RC 64980-0515-05 NDC inpatient 5 ML 54 54 UNITED HEALTHCARE (COMMERCIAL) [3081199] UNITED HEALTHCARE 87726 [308119901] 33.48 percent of total billed charges 33.48 51.3 Technical (Hospital) Services OFLOXACIN 0.3 % EYE DROPS RX-19746 CDM 6370000100 HCPCS 250 RC 64980-0515-05 NDC inpatient 5 ML 54 54 CIGNA 62308 [3081051] CIGNA 62308 [308105105] 42.76 percent of total billed charges 33.48 51.3 Technical (Hospital) Services OFLOXACIN 0.3 % EYE DROPS RX-19746 CDM 6370000100 HCPCS 250 RC 64980-0515-05 NDC inpatient 5 ML 54 54 CIGNA 62308 [3081051] CIGNA STATE OF WYOMING [308105107] 42.76 percent of total billed charges 33.48 51.3 Technical (Hospital) Services OFLOXACIN 0.3 % EYE DROPS RX-19746 CDM 6370000100 HCPCS 250 RC 64980-0515-05 NDC inpatient 5 ML 54 54 MEDICA (COMMERCIAL) 94265 [3081118] MEDICA CLAIMS [308111801] 48.6 percent of total billed charges 33.48 51.3 Technical (Hospital) Services OFLOXACIN 0.3 % EYE DROPS RX-19746 CDM 6370000100 HCPCS 250 RC 64980-0515-05 NDC inpatient 5 ML 54 54 MULTIPLAN INC 34080 [3081285] MULTIPLAN INC [308128501] 51.3 percent of total billed charges 33.48 51.3 Technical (Hospital) Services OFLOXACIN 0.3 % EYE DROPS RX-19746 CDM 6370000100 HCPCS 250 RC 64980-0515-05 NDC inpatient 5 ML 54 54 HEALTHPARTNERS SX009 HEALTHPARTNERS 42.76 percent of total billed charges 33.48 51.3 Technical (Hospital) Services OFLOXACIN 0.3 % EYE DROPS RX-19746 CDM 6370000100 HCPCS 250 RC 64980-0515-05 NDC inpatient 5 ML 54 54 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES HDHP [308136802] 42.76 percent of total billed charges 33.48 51.3 Technical (Hospital) Services OFLOXACIN 0.3 % EYE DROPS RX-19746 CDM 6370000100 HCPCS 250 RC 64980-0515-05 NDC inpatient 5 ML 54 54 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES PPO [308136801] 42.76 percent of total billed charges 33.48 51.3 Technical (Hospital) Services OFLOXACIN 0.3 % EYE DROPS RX-19746 CDM 6370000100 HCPCS 250 RC 64980-0515-05 NDC inpatient 5 ML 54 54 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES EPO [308136803] 42.76 percent of total billed charges 33.48 51.3 Technical (Hospital) Services SERTRALINE 25 MG TABLET RX-19882 CDM 6370000100 HCPCS 250 RC 68180-0351-09 NDC outpatient 1 UN 5.72 5.72 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES HDHP [308136802] 4.58 percent of total billed charges 3.55 5.43 Technical (Hospital) Services SERTRALINE 25 MG TABLET RX-19882 CDM 6370000100 HCPCS 250 RC 68180-0351-09 NDC outpatient 1 UN 5.72 5.72 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES PPO [308136801] 4.58 percent of total billed charges 3.55 5.43 Technical (Hospital) Services SERTRALINE 25 MG TABLET RX-19882 CDM 6370000100 HCPCS 250 RC 68180-0351-09 NDC outpatient 1 UN 5.72 5.72 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES EPO [308136803] 4.58 percent of total billed charges 3.55 5.43 Technical (Hospital) Services SERTRALINE 25 MG TABLET RX-19882 CDM 6370000100 HCPCS 250 RC 68180-0351-09 NDC outpatient 1 UN 5.72 5.72 UNITED HEALTHCARE (COMMERCIAL) [3081199] UNITED HEALTHCARE 87726 [308119901] 3.55 percent of total billed charges 3.55 5.43 Technical (Hospital) Services SERTRALINE 25 MG TABLET RX-19882 CDM 6370000100 HCPCS 250 RC 68180-0351-09 NDC outpatient 1 UN 5.72 5.72 CIGNA 62308 [3081051] CIGNA 62308 [308105105] 4.58 percent of total billed charges 3.55 5.43 Technical (Hospital) Services SERTRALINE 25 MG TABLET RX-19882 CDM 6370000100 HCPCS 250 RC 68180-0351-09 NDC outpatient 1 UN 5.72 5.72 CIGNA 62308 [3081051] CIGNA STATE OF WYOMING [308105107] 4.58 percent of total billed charges 3.55 5.43 Technical (Hospital) Services SERTRALINE 25 MG TABLET RX-19882 CDM 6370000100 HCPCS 250 RC 68180-0351-09 NDC outpatient 1 UN 5.72 5.72 MULTIPLAN INC 34080 [3081285] MULTIPLAN INC [308128501] 5.43 percent of total billed charges 3.55 5.43 Technical (Hospital) Services SERTRALINE 25 MG TABLET RX-19882 CDM 6370000100 HCPCS 250 RC 68180-0351-09 NDC outpatient 1 UN 5.72 5.72 MEDICA (COMMERCIAL) 94265 [3081118] MEDICA CLAIMS [308111801] 5.15 percent of total billed charges 3.55 5.43 Technical (Hospital) Services SERTRALINE 25 MG TABLET RX-19882 CDM 6370000100 HCPCS 250 RC 68180-0351-09 NDC outpatient 1 UN 5.72 5.72 BLUE CROSS BLUE SHIELD WELLMARK SB889 [3081026] BCBS WYOMING [308102603] 5.43 percent of total billed charges 3.55 5.43 Technical (Hospital) Services SERTRALINE 25 MG TABLET RX-19882 CDM 6370000100 HCPCS 250 RC 68180-0351-09 NDC outpatient 1 UN 5.72 5.72 HEALTHPARTNERS SX009 HEALTHPARTNERS 4.58 percent of total billed charges 3.55 5.43 Technical (Hospital) Services SERTRALINE 25 MG TABLET RX-19882 CDM 6370000100 HCPCS 250 RC 68180-0351-09 NDC inpatient 1 UN 5.72 5.72 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES PPO [308136801] 4.53 percent of total billed charges 3.55 5.43 Technical (Hospital) Services SERTRALINE 25 MG TABLET RX-19882 CDM 6370000100 HCPCS 250 RC 68180-0351-09 NDC inpatient 1 UN 5.72 5.72 MEDICA (COMMERCIAL) 94265 [3081118] MEDICA CLAIMS [308111801] 5.15 percent of total billed charges 3.55 5.43 Technical (Hospital) Services SERTRALINE 25 MG TABLET RX-19882 CDM 6370000100 HCPCS 250 RC 68180-0351-09 NDC inpatient 1 UN 5.72 5.72 HEALTHPARTNERS SX009 HEALTHPARTNERS 4.53 percent of total billed charges 3.55 5.43 Technical (Hospital) Services SERTRALINE 25 MG TABLET RX-19882 CDM 6370000100 HCPCS 250 RC 68180-0351-09 NDC inpatient 1 UN 5.72 5.72 MULTIPLAN INC 34080 [3081285] MULTIPLAN INC [308128501] 5.43 percent of total billed charges 3.55 5.43 Technical (Hospital) Services SERTRALINE 25 MG TABLET RX-19882 CDM 6370000100 HCPCS 250 RC 68180-0351-09 NDC inpatient 1 UN 5.72 5.72 CIGNA 62308 [3081051] CIGNA 62308 [308105105] 4.53 percent of total billed charges 3.55 5.43 Technical (Hospital) Services SERTRALINE 25 MG TABLET RX-19882 CDM 6370000100 HCPCS 250 RC 68180-0351-09 NDC inpatient 1 UN 5.72 5.72 CIGNA 62308 [3081051] CIGNA STATE OF WYOMING [308105107] 4.53 percent of total billed charges 3.55 5.43 Technical (Hospital) Services SERTRALINE 25 MG TABLET RX-19882 CDM 6370000100 HCPCS 250 RC 68180-0351-09 NDC inpatient 1 UN 5.72 5.72 BLUE CROSS BLUE SHIELD WELLMARK SB889 [3081026] BCBS WYOMING [308102603] 5.43 percent of total billed charges 3.55 5.43 Technical (Hospital) Services SERTRALINE 25 MG TABLET RX-19882 CDM 6370000100 HCPCS 250 RC 68180-0351-09 NDC inpatient 1 UN 5.72 5.72 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES EPO [308136803] 4.53 percent of total billed charges 3.55 5.43 Technical (Hospital) Services SERTRALINE 25 MG TABLET RX-19882 CDM 6370000100 HCPCS 250 RC 68180-0351-09 NDC inpatient 1 UN 5.72 5.72 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES HDHP [308136802] 4.53 percent of total billed charges 3.55 5.43 Technical (Hospital) Services SERTRALINE 25 MG TABLET RX-19882 CDM 6370000100 HCPCS 250 RC 68180-0351-09 NDC inpatient 1 UN 5.72 5.72 UNITED HEALTHCARE (COMMERCIAL) [3081199] UNITED HEALTHCARE 87726 [308119901] 3.55 percent of total billed charges 3.55 5.43 Technical (Hospital) Services CYANOCOBALAMIN (VIT B-12) 100 MCG TABLET RX-2008 CDM 6370000100 HCPCS 250 RC 80681-0071-00 NDC outpatient 1 UN 5.64 5.64 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES PPO [308136801] 4.51 percent of total billed charges 3.5 5.36 Technical (Hospital) Services CYANOCOBALAMIN (VIT B-12) 100 MCG TABLET RX-2008 CDM 6370000100 HCPCS 250 RC 80681-0071-00 NDC outpatient 1 UN 5.64 5.64 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES HDHP [308136802] 4.51 percent of total billed charges 3.5 5.36 Technical (Hospital) Services CYANOCOBALAMIN (VIT B-12) 100 MCG TABLET RX-2008 CDM 6370000100 HCPCS 250 RC 80681-0071-00 NDC outpatient 1 UN 5.64 5.64 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES EPO [308136803] 4.51 percent of total billed charges 3.5 5.36 Technical (Hospital) Services CYANOCOBALAMIN (VIT B-12) 100 MCG TABLET RX-2008 CDM 6370000100 HCPCS 250 RC 80681-0071-00 NDC outpatient 1 UN 5.64 5.64 MEDICA (COMMERCIAL) 94265 [3081118] MEDICA CLAIMS [308111801] 5.08 percent of total billed charges 3.5 5.36 Technical (Hospital) Services CYANOCOBALAMIN (VIT B-12) 100 MCG TABLET RX-2008 CDM 6370000100 HCPCS 250 RC 80681-0071-00 NDC outpatient 1 UN 5.64 5.64 UNITED HEALTHCARE (COMMERCIAL) [3081199] UNITED HEALTHCARE 87726 [308119901] 3.5 percent of total billed charges 3.5 5.36 Technical (Hospital) Services CYANOCOBALAMIN (VIT B-12) 100 MCG TABLET RX-2008 CDM 6370000100 HCPCS 250 RC 80681-0071-00 NDC outpatient 1 UN 5.64 5.64 CIGNA 62308 [3081051] CIGNA 62308 [308105105] 4.51 percent of total billed charges 3.5 5.36 Technical (Hospital) Services CYANOCOBALAMIN (VIT B-12) 100 MCG TABLET RX-2008 CDM 6370000100 HCPCS 250 RC 80681-0071-00 NDC outpatient 1 UN 5.64 5.64 CIGNA 62308 [3081051] CIGNA STATE OF WYOMING [308105107] 4.51 percent of total billed charges 3.5 5.36 Technical (Hospital) Services CYANOCOBALAMIN (VIT B-12) 100 MCG TABLET RX-2008 CDM 6370000100 HCPCS 250 RC 80681-0071-00 NDC outpatient 1 UN 5.64 5.64 MULTIPLAN INC 34080 [3081285] MULTIPLAN INC [308128501] 5.36 percent of total billed charges 3.5 5.36 Technical (Hospital) Services CYANOCOBALAMIN (VIT B-12) 100 MCG TABLET RX-2008 CDM 6370000100 HCPCS 250 RC 80681-0071-00 NDC outpatient 1 UN 5.64 5.64 BLUE CROSS BLUE SHIELD WELLMARK SB889 [3081026] BCBS WYOMING [308102603] 5.36 percent of total billed charges 3.5 5.36 Technical (Hospital) Services CYANOCOBALAMIN (VIT B-12) 100 MCG TABLET RX-2008 CDM 6370000100 HCPCS 250 RC 80681-0071-00 NDC outpatient 1 UN 5.64 5.64 HEALTHPARTNERS SX009 HEALTHPARTNERS 4.51 percent of total billed charges 3.5 5.36 Technical (Hospital) Services CYANOCOBALAMIN (VIT B-12) 100 MCG TABLET RX-2008 CDM 6370000100 HCPCS 250 RC 80681-0071-00 NDC inpatient 1 UN 5.64 5.64 MULTIPLAN INC 34080 [3081285] MULTIPLAN INC [308128501] 5.36 percent of total billed charges 3.5 5.36 Technical (Hospital) Services CYANOCOBALAMIN (VIT B-12) 100 MCG TABLET RX-2008 CDM 6370000100 HCPCS 250 RC 80681-0071-00 NDC inpatient 1 UN 5.64 5.64 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES PPO [308136801] 4.47 percent of total billed charges 3.5 5.36 Technical (Hospital) Services CYANOCOBALAMIN (VIT B-12) 100 MCG TABLET RX-2008 CDM 6370000100 HCPCS 250 RC 80681-0071-00 NDC inpatient 1 UN 5.64 5.64 MEDICA (COMMERCIAL) 94265 [3081118] MEDICA CLAIMS [308111801] 5.08 percent of total billed charges 3.5 5.36 Technical (Hospital) Services CYANOCOBALAMIN (VIT B-12) 100 MCG TABLET RX-2008 CDM 6370000100 HCPCS 250 RC 80681-0071-00 NDC inpatient 1 UN 5.64 5.64 HEALTHPARTNERS SX009 HEALTHPARTNERS 4.47 percent of total billed charges 3.5 5.36 Technical (Hospital) Services CYANOCOBALAMIN (VIT B-12) 100 MCG TABLET RX-2008 CDM 6370000100 HCPCS 250 RC 80681-0071-00 NDC inpatient 1 UN 5.64 5.64 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES HDHP [308136802] 4.47 percent of total billed charges 3.5 5.36 Technical (Hospital) Services CYANOCOBALAMIN (VIT B-12) 100 MCG TABLET RX-2008 CDM 6370000100 HCPCS 250 RC 80681-0071-00 NDC inpatient 1 UN 5.64 5.64 CIGNA 62308 [3081051] CIGNA 62308 [308105105] 4.47 percent of total billed charges 3.5 5.36 Technical (Hospital) Services CYANOCOBALAMIN (VIT B-12) 100 MCG TABLET RX-2008 CDM 6370000100 HCPCS 250 RC 80681-0071-00 NDC inpatient 1 UN 5.64 5.64 CIGNA 62308 [3081051] CIGNA STATE OF WYOMING [308105107] 4.47 percent of total billed charges 3.5 5.36 Technical (Hospital) Services CYANOCOBALAMIN (VIT B-12) 100 MCG TABLET RX-2008 CDM 6370000100 HCPCS 250 RC 80681-0071-00 NDC inpatient 1 UN 5.64 5.64 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES EPO [308136803] 4.47 percent of total billed charges 3.5 5.36 Technical (Hospital) Services CYANOCOBALAMIN (VIT B-12) 100 MCG TABLET RX-2008 CDM 6370000100 HCPCS 250 RC 80681-0071-00 NDC inpatient 1 UN 5.64 5.64 UNITED HEALTHCARE (COMMERCIAL) [3081199] UNITED HEALTHCARE 87726 [308119901] 3.5 percent of total billed charges 3.5 5.36 Technical (Hospital) Services CYANOCOBALAMIN (VIT B-12) 100 MCG TABLET RX-2008 CDM 6370000100 HCPCS 250 RC 80681-0071-00 NDC inpatient 1 UN 5.64 5.64 BLUE CROSS BLUE SHIELD WELLMARK SB889 [3081026] BCBS WYOMING [308102603] 5.36 percent of total billed charges 3.5 5.36 Technical (Hospital) Services CYANOCOBALAMIN (VIT B-12) 500 MCG TABLET RX-2012 CDM 6370000100 HCPCS 250 RC 79854-0200-60 NDC inpatient 1 UN 5.67 5.67 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES HDHP [308136802] 4.49 percent of total billed charges 3.52 5.39 Technical (Hospital) Services CYANOCOBALAMIN (VIT B-12) 500 MCG TABLET RX-2012 CDM 6370000100 HCPCS 250 RC 79854-0200-60 NDC inpatient 1 UN 5.67 5.67 HEALTHPARTNERS SX009 HEALTHPARTNERS 4.49 percent of total billed charges 3.52 5.39 Technical (Hospital) Services CYANOCOBALAMIN (VIT B-12) 500 MCG TABLET RX-2012 CDM 6370000100 HCPCS 250 RC 79854-0200-60 NDC inpatient 1 UN 5.67 5.67 MEDICA (COMMERCIAL) 94265 [3081118] MEDICA CLAIMS [308111801] 5.1 percent of total billed charges 3.52 5.39 Technical (Hospital) Services CYANOCOBALAMIN (VIT B-12) 500 MCG TABLET RX-2012 CDM 6370000100 HCPCS 250 RC 79854-0200-60 NDC inpatient 1 UN 5.67 5.67 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES EPO [308136803] 4.49 percent of total billed charges 3.52 5.39 Technical (Hospital) Services CYANOCOBALAMIN (VIT B-12) 500 MCG TABLET RX-2012 CDM 6370000100 HCPCS 250 RC 79854-0200-60 NDC inpatient 1 UN 5.67 5.67 CIGNA 62308 [3081051] CIGNA 62308 [308105105] 4.49 percent of total billed charges 3.52 5.39 Technical (Hospital) Services CYANOCOBALAMIN (VIT B-12) 500 MCG TABLET RX-2012 CDM 6370000100 HCPCS 250 RC 79854-0200-60 NDC inpatient 1 UN 5.67 5.67 CIGNA 62308 [3081051] CIGNA STATE OF WYOMING [308105107] 4.49 percent of total billed charges 3.52 5.39 Technical (Hospital) Services CYANOCOBALAMIN (VIT B-12) 500 MCG TABLET RX-2012 CDM 6370000100 HCPCS 250 RC 79854-0200-60 NDC outpatient 1 UN 5.67 5.67 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES PPO [308136801] 4.54 percent of total billed charges 3.52 5.39 Technical (Hospital) Services CYANOCOBALAMIN (VIT B-12) 500 MCG TABLET RX-2012 CDM 6370000100 HCPCS 250 RC 79854-0200-60 NDC outpatient 1 UN 5.67 5.67 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES HDHP [308136802] 4.54 percent of total billed charges 3.52 5.39 Technical (Hospital) Services CYANOCOBALAMIN (VIT B-12) 500 MCG TABLET RX-2012 CDM 6370000100 HCPCS 250 RC 79854-0200-60 NDC outpatient 1 UN 5.67 5.67 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES EPO [308136803] 4.54 percent of total billed charges 3.52 5.39 Technical (Hospital) Services CYANOCOBALAMIN (VIT B-12) 500 MCG TABLET RX-2012 CDM 6370000100 HCPCS 250 RC 79854-0200-60 NDC outpatient 1 UN 5.67 5.67 BLUE CROSS BLUE SHIELD WELLMARK SB889 [3081026] BCBS WYOMING [308102603] 5.39 percent of total billed charges 3.52 5.39 Technical (Hospital) Services CYANOCOBALAMIN (VIT B-12) 500 MCG TABLET RX-2012 CDM 6370000100 HCPCS 250 RC 79854-0200-60 NDC outpatient 1 UN 5.67 5.67 UNITED HEALTHCARE (COMMERCIAL) [3081199] UNITED HEALTHCARE 87726 [308119901] 3.52 percent of total billed charges 3.52 5.39 Technical (Hospital) Services CYANOCOBALAMIN (VIT B-12) 500 MCG TABLET RX-2012 CDM 6370000100 HCPCS 250 RC 79854-0200-60 NDC outpatient 1 UN 5.67 5.67 HEALTHPARTNERS SX009 HEALTHPARTNERS 4.54 percent of total billed charges 3.52 5.39 Technical (Hospital) Services CYANOCOBALAMIN (VIT B-12) 500 MCG TABLET RX-2012 CDM 6370000100 HCPCS 250 RC 79854-0200-60 NDC outpatient 1 UN 5.67 5.67 CIGNA 62308 [3081051] CIGNA 62308 [308105105] 4.54 percent of total billed charges 3.52 5.39 Technical (Hospital) Services CYANOCOBALAMIN (VIT B-12) 500 MCG TABLET RX-2012 CDM 6370000100 HCPCS 250 RC 79854-0200-60 NDC outpatient 1 UN 5.67 5.67 CIGNA 62308 [3081051] CIGNA STATE OF WYOMING [308105107] 4.54 percent of total billed charges 3.52 5.39 Technical (Hospital) Services CYANOCOBALAMIN (VIT B-12) 500 MCG TABLET RX-2012 CDM 6370000100 HCPCS 250 RC 79854-0200-60 NDC outpatient 1 UN 5.67 5.67 MULTIPLAN INC 34080 [3081285] MULTIPLAN INC [308128501] 5.39 percent of total billed charges 3.52 5.39 Technical (Hospital) Services CYANOCOBALAMIN (VIT B-12) 500 MCG TABLET RX-2012 CDM 6370000100 HCPCS 250 RC 79854-0200-60 NDC outpatient 1 UN 5.67 5.67 MEDICA (COMMERCIAL) 94265 [3081118] MEDICA CLAIMS [308111801] 5.1 percent of total billed charges 3.52 5.39 Technical (Hospital) Services CYANOCOBALAMIN (VIT B-12) 500 MCG TABLET RX-2012 CDM 6370000100 HCPCS 250 RC 79854-0200-60 NDC inpatient 1 UN 5.67 5.67 BLUE CROSS BLUE SHIELD WELLMARK SB889 [3081026] BCBS WYOMING [308102603] 5.39 percent of total billed charges 3.52 5.39 Technical (Hospital) Services CYANOCOBALAMIN (VIT B-12) 500 MCG TABLET RX-2012 CDM 6370000100 HCPCS 250 RC 79854-0200-60 NDC inpatient 1 UN 5.67 5.67 UNITED HEALTHCARE (COMMERCIAL) [3081199] UNITED HEALTHCARE 87726 [308119901] 3.52 percent of total billed charges 3.52 5.39 Technical (Hospital) Services CYANOCOBALAMIN (VIT B-12) 500 MCG TABLET RX-2012 CDM 6370000100 HCPCS 250 RC 79854-0200-60 NDC inpatient 1 UN 5.67 5.67 MULTIPLAN INC 34080 [3081285] MULTIPLAN INC [308128501] 5.39 percent of total billed charges 3.52 5.39 Technical (Hospital) Services CYANOCOBALAMIN (VIT B-12) 500 MCG TABLET RX-2012 CDM 6370000100 HCPCS 250 RC 79854-0200-60 NDC inpatient 1 UN 5.67 5.67 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES PPO [308136801] 4.49 percent of total billed charges 3.52 5.39 Technical (Hospital) Services CYCLOPENTOLATE 1 % EYE DROPS RX-2025 CDM 6370000100 HCPCS 250 RC 61314-0396-01 NDC outpatient 2 ML 47.55 47.55 BLUE CROSS BLUE SHIELD WELLMARK SB889 [3081026] BCBS WYOMING [308102603] 45.17 percent of total billed charges 29.48 45.17 Technical (Hospital) Services CYCLOPENTOLATE 1 % EYE DROPS RX-2025 CDM 6370000100 HCPCS 250 RC 61314-0396-01 NDC outpatient 2 ML 47.55 47.55 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES PPO [308136801] 38.04 percent of total billed charges 29.48 45.17 Technical (Hospital) Services CYCLOPENTOLATE 1 % EYE DROPS RX-2025 CDM 6370000100 HCPCS 250 RC 61314-0396-01 NDC outpatient 2 ML 47.55 47.55 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES EPO [308136803] 38.04 percent of total billed charges 29.48 45.17 Technical (Hospital) Services CYCLOPENTOLATE 1 % EYE DROPS RX-2025 CDM 6370000100 HCPCS 250 RC 61314-0396-01 NDC outpatient 2 ML 47.55 47.55 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES HDHP [308136802] 38.04 percent of total billed charges 29.48 45.17 Technical (Hospital) Services CYCLOPENTOLATE 1 % EYE DROPS RX-2025 CDM 6370000100 HCPCS 250 RC 61314-0396-01 NDC outpatient 2 ML 47.55 47.55 UNITED HEALTHCARE (COMMERCIAL) [3081199] UNITED HEALTHCARE 87726 [308119901] 29.48 percent of total billed charges 29.48 45.17 Technical (Hospital) Services CYCLOPENTOLATE 1 % EYE DROPS RX-2025 CDM 6370000100 HCPCS 250 RC 61314-0396-01 NDC outpatient 2 ML 47.55 47.55 HEALTHPARTNERS SX009 HEALTHPARTNERS 38.04 percent of total billed charges 29.48 45.17 Technical (Hospital) Services CYCLOPENTOLATE 1 % EYE DROPS RX-2025 CDM 6370000100 HCPCS 250 RC 61314-0396-01 NDC outpatient 2 ML 47.55 47.55 MEDICA (COMMERCIAL) 94265 [3081118] MEDICA CLAIMS [308111801] 42.8 percent of total billed charges 29.48 45.17 Technical (Hospital) Services CYCLOPENTOLATE 1 % EYE DROPS RX-2025 CDM 6370000100 HCPCS 250 RC 61314-0396-01 NDC outpatient 2 ML 47.55 47.55 MULTIPLAN INC 34080 [3081285] MULTIPLAN INC [308128501] 45.17 percent of total billed charges 29.48 45.17 Technical (Hospital) Services CYCLOPENTOLATE 1 % EYE DROPS RX-2025 CDM 6370000100 HCPCS 250 RC 61314-0396-01 NDC outpatient 2 ML 47.55 47.55 CIGNA 62308 [3081051] CIGNA 62308 [308105105] 38.04 percent of total billed charges 29.48 45.17 Technical (Hospital) Services CYCLOPENTOLATE 1 % EYE DROPS RX-2025 CDM 6370000100 HCPCS 250 RC 61314-0396-01 NDC outpatient 2 ML 47.55 47.55 CIGNA 62308 [3081051] CIGNA STATE OF WYOMING [308105107] 38.04 percent of total billed charges 29.48 45.17 Technical (Hospital) Services CYCLOPENTOLATE 1 % EYE DROPS RX-2025 CDM 6370000100 HCPCS 250 RC 61314-0396-01 NDC inpatient 2 ML 47.55 47.55 MULTIPLAN INC 34080 [3081285] MULTIPLAN INC [308128501] 45.17 percent of total billed charges 29.48 45.17 Technical (Hospital) Services CYCLOPENTOLATE 1 % EYE DROPS RX-2025 CDM 6370000100 HCPCS 250 RC 61314-0396-01 NDC inpatient 2 ML 47.55 47.55 UNITED HEALTHCARE (COMMERCIAL) [3081199] UNITED HEALTHCARE 87726 [308119901] 29.48 percent of total billed charges 29.48 45.17 Technical (Hospital) Services CYCLOPENTOLATE 1 % EYE DROPS RX-2025 CDM 6370000100 HCPCS 250 RC 61314-0396-01 NDC inpatient 2 ML 47.55 47.55 BLUE CROSS BLUE SHIELD WELLMARK SB889 [3081026] BCBS WYOMING [308102603] 45.17 percent of total billed charges 29.48 45.17 Technical (Hospital) Services CYCLOPENTOLATE 1 % EYE DROPS RX-2025 CDM 6370000100 HCPCS 250 RC 61314-0396-01 NDC inpatient 2 ML 47.55 47.55 CIGNA 62308 [3081051] CIGNA 62308 [308105105] 37.65 percent of total billed charges 29.48 45.17 Technical (Hospital) Services CYCLOPENTOLATE 1 % EYE DROPS RX-2025 CDM 6370000100 HCPCS 250 RC 61314-0396-01 NDC inpatient 2 ML 47.55 47.55 CIGNA 62308 [3081051] CIGNA STATE OF WYOMING [308105107] 37.65 percent of total billed charges 29.48 45.17 Technical (Hospital) Services CYCLOPENTOLATE 1 % EYE DROPS RX-2025 CDM 6370000100 HCPCS 250 RC 61314-0396-01 NDC inpatient 2 ML 47.55 47.55 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES EPO [308136803] 37.65 percent of total billed charges 29.48 45.17 Technical (Hospital) Services CYCLOPENTOLATE 1 % EYE DROPS RX-2025 CDM 6370000100 HCPCS 250 RC 61314-0396-01 NDC inpatient 2 ML 47.55 47.55 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES HDHP [308136802] 37.65 percent of total billed charges 29.48 45.17 Technical (Hospital) Services CYCLOPENTOLATE 1 % EYE DROPS RX-2025 CDM 6370000100 HCPCS 250 RC 61314-0396-01 NDC inpatient 2 ML 47.55 47.55 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES PPO [308136801] 37.65 percent of total billed charges 29.48 45.17 Technical (Hospital) Services CYCLOPENTOLATE 1 % EYE DROPS RX-2025 CDM 6370000100 HCPCS 250 RC 61314-0396-01 NDC inpatient 2 ML 47.55 47.55 HEALTHPARTNERS SX009 HEALTHPARTNERS 37.65 percent of total billed charges 29.48 45.17 Technical (Hospital) Services CYCLOPENTOLATE 1 % EYE DROPS RX-2025 CDM 6370000100 HCPCS 250 RC 61314-0396-01 NDC inpatient 2 ML 47.55 47.55 MEDICA (COMMERCIAL) 94265 [3081118] MEDICA CLAIMS [308111801] 42.8 percent of total billed charges 29.48 45.17 Technical (Hospital) Services MELOXICAM 7.5 MG TABLET RX-20566 CDM 6370000100 HCPCS 250 RC 69097-0158-07 NDC inpatient 1 UN 5.66 5.66 MULTIPLAN INC 34080 [3081285] MULTIPLAN INC [308128501] 5.38 percent of total billed charges 3.51 5.38 Technical (Hospital) Services MELOXICAM 7.5 MG TABLET RX-20566 CDM 6370000100 HCPCS 250 RC 69097-0158-07 NDC inpatient 1 UN 5.66 5.66 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES PPO [308136801] 4.48 percent of total billed charges 3.51 5.38 Technical (Hospital) Services MELOXICAM 7.5 MG TABLET RX-20566 CDM 6370000100 HCPCS 250 RC 69097-0158-07 NDC inpatient 1 UN 5.66 5.66 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES HDHP [308136802] 4.48 percent of total billed charges 3.51 5.38 Technical (Hospital) Services MELOXICAM 7.5 MG TABLET RX-20566 CDM 6370000100 HCPCS 250 RC 69097-0158-07 NDC inpatient 1 UN 5.66 5.66 MEDICA (COMMERCIAL) 94265 [3081118] MEDICA CLAIMS [308111801] 5.09 percent of total billed charges 3.51 5.38 Technical (Hospital) Services MELOXICAM 7.5 MG TABLET RX-20566 CDM 6370000100 HCPCS 250 RC 69097-0158-07 NDC inpatient 1 UN 5.66 5.66 HEALTHPARTNERS SX009 HEALTHPARTNERS 4.48 percent of total billed charges 3.51 5.38 Technical (Hospital) Services MELOXICAM 7.5 MG TABLET RX-20566 CDM 6370000100 HCPCS 250 RC 69097-0158-07 NDC inpatient 1 UN 5.66 5.66 CIGNA 62308 [3081051] CIGNA 62308 [308105105] 4.48 percent of total billed charges 3.51 5.38 Technical (Hospital) Services MELOXICAM 7.5 MG TABLET RX-20566 CDM 6370000100 HCPCS 250 RC 69097-0158-07 NDC inpatient 1 UN 5.66 5.66 CIGNA 62308 [3081051] CIGNA STATE OF WYOMING [308105107] 4.48 percent of total billed charges 3.51 5.38 Technical (Hospital) Services MELOXICAM 7.5 MG TABLET RX-20566 CDM 6370000100 HCPCS 250 RC 69097-0158-07 NDC inpatient 1 UN 5.66 5.66 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES EPO [308136803] 4.48 percent of total billed charges 3.51 5.38 Technical (Hospital) Services MELOXICAM 7.5 MG TABLET RX-20566 CDM 6370000100 HCPCS 250 RC 69097-0158-07 NDC inpatient 1 UN 5.66 5.66 UNITED HEALTHCARE (COMMERCIAL) [3081199] UNITED HEALTHCARE 87726 [308119901] 3.51 percent of total billed charges 3.51 5.38 Technical (Hospital) Services MELOXICAM 7.5 MG TABLET RX-20566 CDM 6370000100 HCPCS 250 RC 69097-0158-07 NDC inpatient 1 UN 5.66 5.66 BLUE CROSS BLUE SHIELD WELLMARK SB889 [3081026] BCBS WYOMING [308102603] 5.38 percent of total billed charges 3.51 5.38 Technical (Hospital) Services MELOXICAM 7.5 MG TABLET RX-20566 CDM 6370000100 HCPCS 250 RC 69097-0158-07 NDC outpatient 1 UN 5.66 5.66 UNITED HEALTHCARE (COMMERCIAL) [3081199] UNITED HEALTHCARE 87726 [308119901] 3.51 percent of total billed charges 3.51 5.38 Technical (Hospital) Services MELOXICAM 7.5 MG TABLET RX-20566 CDM 6370000100 HCPCS 250 RC 69097-0158-07 NDC outpatient 1 UN 5.66 5.66 MULTIPLAN INC 34080 [3081285] MULTIPLAN INC [308128501] 5.38 percent of total billed charges 3.51 5.38 Technical (Hospital) Services MELOXICAM 7.5 MG TABLET RX-20566 CDM 6370000100 HCPCS 250 RC 69097-0158-07 NDC outpatient 1 UN 5.66 5.66 CIGNA 62308 [3081051] CIGNA 62308 [308105105] 4.53 percent of total billed charges 3.51 5.38 Technical (Hospital) Services MELOXICAM 7.5 MG TABLET RX-20566 CDM 6370000100 HCPCS 250 RC 69097-0158-07 NDC outpatient 1 UN 5.66 5.66 CIGNA 62308 [3081051] CIGNA STATE OF WYOMING [308105107] 4.53 percent of total billed charges 3.51 5.38 Technical (Hospital) Services MELOXICAM 7.5 MG TABLET RX-20566 CDM 6370000100 HCPCS 250 RC 69097-0158-07 NDC outpatient 1 UN 5.66 5.66 MEDICA (COMMERCIAL) 94265 [3081118] MEDICA CLAIMS [308111801] 5.09 percent of total billed charges 3.51 5.38 Technical (Hospital) Services MELOXICAM 7.5 MG TABLET RX-20566 CDM 6370000100 HCPCS 250 RC 69097-0158-07 NDC outpatient 1 UN 5.66 5.66 HEALTHPARTNERS SX009 HEALTHPARTNERS 4.53 percent of total billed charges 3.51 5.38 Technical (Hospital) Services MELOXICAM 7.5 MG TABLET RX-20566 CDM 6370000100 HCPCS 250 RC 69097-0158-07 NDC outpatient 1 UN 5.66 5.66 BLUE CROSS BLUE SHIELD WELLMARK SB889 [3081026] BCBS WYOMING [308102603] 5.38 percent of total billed charges 3.51 5.38 Technical (Hospital) Services MELOXICAM 7.5 MG TABLET RX-20566 CDM 6370000100 HCPCS 250 RC 69097-0158-07 NDC outpatient 1 UN 5.66 5.66 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES PPO [308136801] 4.53 percent of total billed charges 3.51 5.38 Technical (Hospital) Services MELOXICAM 7.5 MG TABLET RX-20566 CDM 6370000100 HCPCS 250 RC 69097-0158-07 NDC outpatient 1 UN 5.66 5.66 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES EPO [308136803] 4.53 percent of total billed charges 3.51 5.38 Technical (Hospital) Services MELOXICAM 7.5 MG TABLET RX-20566 CDM 6370000100 HCPCS 250 RC 69097-0158-07 NDC outpatient 1 UN 5.66 5.66 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES HDHP [308136802] 4.53 percent of total billed charges 3.51 5.38 Technical (Hospital) Services IMIQUIMOD 5 % TOPICAL CREAM PACKET RX-20718 CDM 6370000100 HCPCS 250 RC 45802-0368-62 NDC outpatient 1 UN 7.7 7.7 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES PPO [308136801] 6.16 percent of total billed charges 4.77 7.32 Technical (Hospital) Services IMIQUIMOD 5 % TOPICAL CREAM PACKET RX-20718 CDM 6370000100 HCPCS 250 RC 45802-0368-62 NDC outpatient 1 UN 7.7 7.7 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES HDHP [308136802] 6.16 percent of total billed charges 4.77 7.32 Technical (Hospital) Services IMIQUIMOD 5 % TOPICAL CREAM PACKET RX-20718 CDM 6370000100 HCPCS 250 RC 45802-0368-62 NDC outpatient 1 UN 7.7 7.7 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES EPO [308136803] 6.16 percent of total billed charges 4.77 7.32 Technical (Hospital) Services IMIQUIMOD 5 % TOPICAL CREAM PACKET RX-20718 CDM 6370000100 HCPCS 250 RC 45802-0368-62 NDC outpatient 1 UN 7.7 7.7 HEALTHPARTNERS SX009 HEALTHPARTNERS 6.16 percent of total billed charges 4.77 7.32 Technical (Hospital) Services IMIQUIMOD 5 % TOPICAL CREAM PACKET RX-20718 CDM 6370000100 HCPCS 250 RC 45802-0368-62 NDC outpatient 1 UN 7.7 7.7 BLUE CROSS BLUE SHIELD WELLMARK SB889 [3081026] BCBS WYOMING [308102603] 7.32 percent of total billed charges 4.77 7.32 Technical (Hospital) Services IMIQUIMOD 5 % TOPICAL CREAM PACKET RX-20718 CDM 6370000100 HCPCS 250 RC 45802-0368-62 NDC outpatient 1 UN 7.7 7.7 MULTIPLAN INC 34080 [3081285] MULTIPLAN INC [308128501] 7.32 percent of total billed charges 4.77 7.32 Technical (Hospital) Services IMIQUIMOD 5 % TOPICAL CREAM PACKET RX-20718 CDM 6370000100 HCPCS 250 RC 45802-0368-62 NDC outpatient 1 UN 7.7 7.7 UNITED HEALTHCARE (COMMERCIAL) [3081199] UNITED HEALTHCARE 87726 [308119901] 4.77 percent of total billed charges 4.77 7.32 Technical (Hospital) Services IMIQUIMOD 5 % TOPICAL CREAM PACKET RX-20718 CDM 6370000100 HCPCS 250 RC 45802-0368-62 NDC outpatient 1 UN 7.7 7.7 CIGNA 62308 [3081051] CIGNA 62308 [308105105] 6.16 percent of total billed charges 4.77 7.32 Technical (Hospital) Services IMIQUIMOD 5 % TOPICAL CREAM PACKET RX-20718 CDM 6370000100 HCPCS 250 RC 45802-0368-62 NDC outpatient 1 UN 7.7 7.7 CIGNA 62308 [3081051] CIGNA STATE OF WYOMING [308105107] 6.16 percent of total billed charges 4.77 7.32 Technical (Hospital) Services IMIQUIMOD 5 % TOPICAL CREAM PACKET RX-20718 CDM 6370000100 HCPCS 250 RC 45802-0368-62 NDC outpatient 1 UN 7.7 7.7 MEDICA (COMMERCIAL) 94265 [3081118] MEDICA CLAIMS [308111801] 6.93 percent of total billed charges 4.77 7.32 Technical (Hospital) Services IMIQUIMOD 5 % TOPICAL CREAM PACKET RX-20718 CDM 6370000100 HCPCS 250 RC 45802-0368-62 NDC inpatient 1 UN 7.7 7.7 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES HDHP [308136802] 6.1 percent of total billed charges 4.77 7.32 Technical (Hospital) Services IMIQUIMOD 5 % TOPICAL CREAM PACKET RX-20718 CDM 6370000100 HCPCS 250 RC 45802-0368-62 NDC inpatient 1 UN 7.7 7.7 BLUE CROSS BLUE SHIELD WELLMARK SB889 [3081026] BCBS WYOMING [308102603] 7.32 percent of total billed charges 4.77 7.32 Technical (Hospital) Services IMIQUIMOD 5 % TOPICAL CREAM PACKET RX-20718 CDM 6370000100 HCPCS 250 RC 45802-0368-62 NDC inpatient 1 UN 7.7 7.7 CIGNA 62308 [3081051] CIGNA 62308 [308105105] 6.1 percent of total billed charges 4.77 7.32 Technical (Hospital) Services IMIQUIMOD 5 % TOPICAL CREAM PACKET RX-20718 CDM 6370000100 HCPCS 250 RC 45802-0368-62 NDC inpatient 1 UN 7.7 7.7 CIGNA 62308 [3081051] CIGNA STATE OF WYOMING [308105107] 6.1 percent of total billed charges 4.77 7.32 Technical (Hospital) Services IMIQUIMOD 5 % TOPICAL CREAM PACKET RX-20718 CDM 6370000100 HCPCS 250 RC 45802-0368-62 NDC inpatient 1 UN 7.7 7.7 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES EPO [308136803] 6.1 percent of total billed charges 4.77 7.32 Technical (Hospital) Services IMIQUIMOD 5 % TOPICAL CREAM PACKET RX-20718 CDM 6370000100 HCPCS 250 RC 45802-0368-62 NDC inpatient 1 UN 7.7 7.7 UNITED HEALTHCARE (COMMERCIAL) [3081199] UNITED HEALTHCARE 87726 [308119901] 4.77 percent of total billed charges 4.77 7.32 Technical (Hospital) Services IMIQUIMOD 5 % TOPICAL CREAM PACKET RX-20718 CDM 6370000100 HCPCS 250 RC 45802-0368-62 NDC inpatient 1 UN 7.7 7.7 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES PPO [308136801] 6.1 percent of total billed charges 4.77 7.32 Technical (Hospital) Services IMIQUIMOD 5 % TOPICAL CREAM PACKET RX-20718 CDM 6370000100 HCPCS 250 RC 45802-0368-62 NDC inpatient 1 UN 7.7 7.7 HEALTHPARTNERS SX009 HEALTHPARTNERS 6.1 percent of total billed charges 4.77 7.32 Technical (Hospital) Services IMIQUIMOD 5 % TOPICAL CREAM PACKET RX-20718 CDM 6370000100 HCPCS 250 RC 45802-0368-62 NDC inpatient 1 UN 7.7 7.7 MEDICA (COMMERCIAL) 94265 [3081118] MEDICA CLAIMS [308111801] 6.93 percent of total billed charges 4.77 7.32 Technical (Hospital) Services IMIQUIMOD 5 % TOPICAL CREAM PACKET RX-20718 CDM 6370000100 HCPCS 250 RC 45802-0368-62 NDC inpatient 1 UN 7.7 7.7 MULTIPLAN INC 34080 [3081285] MULTIPLAN INC [308128501] 7.32 percent of total billed charges 4.77 7.32 Technical (Hospital) Services AZITHROMYCIN 250 MG TABLET RX-20943 CDM 6370000100 HCPCS 250 RC 50111-0787-51 NDC inpatient 1 UN 8.12 8.12 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES HDHP [308136802] 6.43 percent of total billed charges 5.03 7.71 Technical (Hospital) Services AZITHROMYCIN 250 MG TABLET RX-20943 CDM 6370000100 HCPCS 250 RC 50111-0787-51 NDC inpatient 1 UN 8.12 8.12 MEDICA (COMMERCIAL) 94265 [3081118] MEDICA CLAIMS [308111801] 7.31 percent of total billed charges 5.03 7.71 Technical (Hospital) Services AZITHROMYCIN 250 MG TABLET RX-20943 CDM 6370000100 HCPCS 250 RC 50111-0787-51 NDC inpatient 1 UN 8.12 8.12 HEALTHPARTNERS SX009 HEALTHPARTNERS 6.43 percent of total billed charges 5.03 7.71 Technical (Hospital) Services AZITHROMYCIN 250 MG TABLET RX-20943 CDM 6370000100 HCPCS 250 RC 50111-0787-51 NDC inpatient 1 UN 8.12 8.12 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES EPO [308136803] 6.43 percent of total billed charges 5.03 7.71 Technical (Hospital) Services AZITHROMYCIN 250 MG TABLET RX-20943 CDM 6370000100 HCPCS 250 RC 50111-0787-51 NDC inpatient 1 UN 8.12 8.12 CIGNA 62308 [3081051] CIGNA 62308 [308105105] 6.43 percent of total billed charges 5.03 7.71 Technical (Hospital) Services AZITHROMYCIN 250 MG TABLET RX-20943 CDM 6370000100 HCPCS 250 RC 50111-0787-51 NDC inpatient 1 UN 8.12 8.12 CIGNA 62308 [3081051] CIGNA STATE OF WYOMING [308105107] 6.43 percent of total billed charges 5.03 7.71 Technical (Hospital) Services AZITHROMYCIN 250 MG TABLET RX-20943 CDM 6370000100 HCPCS 250 RC 50111-0787-51 NDC inpatient 1 UN 8.12 8.12 BLUE CROSS BLUE SHIELD WELLMARK SB889 [3081026] BCBS WYOMING [308102603] 7.71 percent of total billed charges 5.03 7.71 Technical (Hospital) Services AZITHROMYCIN 250 MG TABLET RX-20943 CDM 6370000100 HCPCS 250 RC 50111-0787-51 NDC inpatient 1 UN 8.12 8.12 UNITED HEALTHCARE (COMMERCIAL) [3081199] UNITED HEALTHCARE 87726 [308119901] 5.03 percent of total billed charges 5.03 7.71 Technical (Hospital) Services AZITHROMYCIN 250 MG TABLET RX-20943 CDM 6370000100 HCPCS 250 RC 50111-0787-51 NDC inpatient 1 UN 8.12 8.12 MULTIPLAN INC 34080 [3081285] MULTIPLAN INC [308128501] 7.71 percent of total billed charges 5.03 7.71 Technical (Hospital) Services AZITHROMYCIN 250 MG TABLET RX-20943 CDM 6370000100 HCPCS 250 RC 50111-0787-51 NDC inpatient 1 UN 8.12 8.12 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES PPO [308136801] 6.43 percent of total billed charges 5.03 7.71 Technical (Hospital) Services AZITHROMYCIN 250 MG TABLET RX-20943 CDM 6370000100 HCPCS 250 RC 50111-0787-51 NDC outpatient 1 UN 8.12 8.12 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES EPO [308136803] 6.5 percent of total billed charges 5.03 7.71 Technical (Hospital) Services AZITHROMYCIN 250 MG TABLET RX-20943 CDM 6370000100 HCPCS 250 RC 50111-0787-51 NDC outpatient 1 UN 8.12 8.12 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES HDHP [308136802] 6.5 percent of total billed charges 5.03 7.71 Technical (Hospital) Services AZITHROMYCIN 250 MG TABLET RX-20943 CDM 6370000100 HCPCS 250 RC 50111-0787-51 NDC outpatient 1 UN 8.12 8.12 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES PPO [308136801] 6.5 percent of total billed charges 5.03 7.71 Technical (Hospital) Services AZITHROMYCIN 250 MG TABLET RX-20943 CDM 6370000100 HCPCS 250 RC 50111-0787-51 NDC outpatient 1 UN 8.12 8.12 BLUE CROSS BLUE SHIELD WELLMARK SB889 [3081026] BCBS WYOMING [308102603] 7.71 percent of total billed charges 5.03 7.71 Technical (Hospital) Services AZITHROMYCIN 250 MG TABLET RX-20943 CDM 6370000100 HCPCS 250 RC 50111-0787-51 NDC outpatient 1 UN 8.12 8.12 HEALTHPARTNERS SX009 HEALTHPARTNERS 6.5 percent of total billed charges 5.03 7.71 Technical (Hospital) Services AZITHROMYCIN 250 MG TABLET RX-20943 CDM 6370000100 HCPCS 250 RC 50111-0787-51 NDC outpatient 1 UN 8.12 8.12 MEDICA (COMMERCIAL) 94265 [3081118] MEDICA CLAIMS [308111801] 7.31 percent of total billed charges 5.03 7.71 Technical (Hospital) Services AZITHROMYCIN 250 MG TABLET RX-20943 CDM 6370000100 HCPCS 250 RC 50111-0787-51 NDC outpatient 1 UN 8.12 8.12 CIGNA 62308 [3081051] CIGNA 62308 [308105105] 6.5 percent of total billed charges 5.03 7.71 Technical (Hospital) Services AZITHROMYCIN 250 MG TABLET RX-20943 CDM 6370000100 HCPCS 250 RC 50111-0787-51 NDC outpatient 1 UN 8.12 8.12 CIGNA 62308 [3081051] CIGNA STATE OF WYOMING [308105107] 6.5 percent of total billed charges 5.03 7.71 Technical (Hospital) Services AZITHROMYCIN 250 MG TABLET RX-20943 CDM 6370000100 HCPCS 250 RC 50111-0787-51 NDC outpatient 1 UN 8.12 8.12 MULTIPLAN INC 34080 [3081285] MULTIPLAN INC [308128501] 7.71 percent of total billed charges 5.03 7.71 Technical (Hospital) Services AZITHROMYCIN 250 MG TABLET RX-20943 CDM 6370000100 HCPCS 250 RC 50111-0787-51 NDC outpatient 1 UN 8.12 8.12 UNITED HEALTHCARE (COMMERCIAL) [3081199] UNITED HEALTHCARE 87726 [308119901] 5.03 percent of total billed charges 5.03 7.71 Technical (Hospital) Services OLANZAPINE 2.5 MG TABLET RX-21057 CDM 6370000100 HCPCS 250 RC 55111-0163-30 NDC outpatient 1 UN 5.82 5.82 BLUE CROSS BLUE SHIELD WELLMARK SB889 [3081026] BCBS WYOMING [308102603] 5.53 percent of total billed charges 3.61 5.53 Technical (Hospital) Services OLANZAPINE 2.5 MG TABLET RX-21057 CDM 6370000100 HCPCS 250 RC 55111-0163-30 NDC outpatient 1 UN 5.82 5.82 MEDICA (COMMERCIAL) 94265 [3081118] MEDICA CLAIMS [308111801] 5.24 percent of total billed charges 3.61 5.53 Technical (Hospital) Services OLANZAPINE 2.5 MG TABLET RX-21057 CDM 6370000100 HCPCS 250 RC 55111-0163-30 NDC outpatient 1 UN 5.82 5.82 CIGNA 62308 [3081051] CIGNA 62308 [308105105] 4.66 percent of total billed charges 3.61 5.53 Technical (Hospital) Services OLANZAPINE 2.5 MG TABLET RX-21057 CDM 6370000100 HCPCS 250 RC 55111-0163-30 NDC outpatient 1 UN 5.82 5.82 CIGNA 62308 [3081051] CIGNA STATE OF WYOMING [308105107] 4.66 percent of total billed charges 3.61 5.53 Technical (Hospital) Services OLANZAPINE 2.5 MG TABLET RX-21057 CDM 6370000100 HCPCS 250 RC 55111-0163-30 NDC outpatient 1 UN 5.82 5.82 MULTIPLAN INC 34080 [3081285] MULTIPLAN INC [308128501] 5.53 percent of total billed charges 3.61 5.53 Technical (Hospital) Services OLANZAPINE 2.5 MG TABLET RX-21057 CDM 6370000100 HCPCS 250 RC 55111-0163-30 NDC outpatient 1 UN 5.82 5.82 UNITED HEALTHCARE (COMMERCIAL) [3081199] UNITED HEALTHCARE 87726 [308119901] 3.61 percent of total billed charges 3.61 5.53 Technical (Hospital) Services OLANZAPINE 2.5 MG TABLET RX-21057 CDM 6370000100 HCPCS 250 RC 55111-0163-30 NDC outpatient 1 UN 5.82 5.82 HEALTHPARTNERS SX009 HEALTHPARTNERS 4.66 percent of total billed charges 3.61 5.53 Technical (Hospital) Services OLANZAPINE 2.5 MG TABLET RX-21057 CDM 6370000100 HCPCS 250 RC 55111-0163-30 NDC outpatient 1 UN 5.82 5.82 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES PPO [308136801] 4.66 percent of total billed charges 3.61 5.53 Technical (Hospital) Services OLANZAPINE 2.5 MG TABLET RX-21057 CDM 6370000100 HCPCS 250 RC 55111-0163-30 NDC outpatient 1 UN 5.82 5.82 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES HDHP [308136802] 4.66 percent of total billed charges 3.61 5.53 Technical (Hospital) Services OLANZAPINE 2.5 MG TABLET RX-21057 CDM 6370000100 HCPCS 250 RC 55111-0163-30 NDC outpatient 1 UN 5.82 5.82 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES EPO [308136803] 4.66 percent of total billed charges 3.61 5.53 Technical (Hospital) Services OLANZAPINE 2.5 MG TABLET RX-21057 CDM 6370000100 HCPCS 250 RC 55111-0163-30 NDC inpatient 1 UN 5.82 5.82 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES PPO [308136801] 4.61 percent of total billed charges 3.61 5.53 Technical (Hospital) Services OLANZAPINE 2.5 MG TABLET RX-21057 CDM 6370000100 HCPCS 250 RC 55111-0163-30 NDC inpatient 1 UN 5.82 5.82 HEALTHPARTNERS SX009 HEALTHPARTNERS 4.61 percent of total billed charges 3.61 5.53 Technical (Hospital) Services OLANZAPINE 2.5 MG TABLET RX-21057 CDM 6370000100 HCPCS 250 RC 55111-0163-30 NDC inpatient 1 UN 5.82 5.82 MEDICA (COMMERCIAL) 94265 [3081118] MEDICA CLAIMS [308111801] 5.24 percent of total billed charges 3.61 5.53 Technical (Hospital) Services OLANZAPINE 2.5 MG TABLET RX-21057 CDM 6370000100 HCPCS 250 RC 55111-0163-30 NDC inpatient 1 UN 5.82 5.82 MULTIPLAN INC 34080 [3081285] MULTIPLAN INC [308128501] 5.53 percent of total billed charges 3.61 5.53 Technical (Hospital) Services OLANZAPINE 2.5 MG TABLET RX-21057 CDM 6370000100 HCPCS 250 RC 55111-0163-30 NDC inpatient 1 UN 5.82 5.82 UNITED HEALTHCARE (COMMERCIAL) [3081199] UNITED HEALTHCARE 87726 [308119901] 3.61 percent of total billed charges 3.61 5.53 Technical (Hospital) Services OLANZAPINE 2.5 MG TABLET RX-21057 CDM 6370000100 HCPCS 250 RC 55111-0163-30 NDC inpatient 1 UN 5.82 5.82 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES HDHP [308136802] 4.61 percent of total billed charges 3.61 5.53 Technical (Hospital) Services OLANZAPINE 2.5 MG TABLET RX-21057 CDM 6370000100 HCPCS 250 RC 55111-0163-30 NDC inpatient 1 UN 5.82 5.82 CIGNA 62308 [3081051] CIGNA STATE OF WYOMING [308105107] 4.61 percent of total billed charges 3.61 5.53 Technical (Hospital) Services OLANZAPINE 2.5 MG TABLET RX-21057 CDM 6370000100 HCPCS 250 RC 55111-0163-30 NDC inpatient 1 UN 5.82 5.82 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES EPO [308136803] 4.61 percent of total billed charges 3.61 5.53 Technical (Hospital) Services OLANZAPINE 2.5 MG TABLET RX-21057 CDM 6370000100 HCPCS 250 RC 55111-0163-30 NDC inpatient 1 UN 5.82 5.82 CIGNA 62308 [3081051] CIGNA 62308 [308105105] 4.61 percent of total billed charges 3.61 5.53 Technical (Hospital) Services OLANZAPINE 2.5 MG TABLET RX-21057 CDM 6370000100 HCPCS 250 RC 55111-0163-30 NDC inpatient 1 UN 5.82 5.82 BLUE CROSS BLUE SHIELD WELLMARK SB889 [3081026] BCBS WYOMING [308102603] 5.53 percent of total billed charges 3.61 5.53 Technical (Hospital) Services CITALOPRAM 20 MG TABLET RX-21062 CDM 6370000100 HCPCS 250 RC 00378-6232-01 NDC outpatient 1 UN 5.7 5.7 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES EPO [308136803] 4.56 percent of total billed charges 3.53 5.42 Technical (Hospital) Services CITALOPRAM 20 MG TABLET RX-21062 CDM 6370000100 HCPCS 250 RC 00378-6232-01 NDC outpatient 1 UN 5.7 5.7 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES PPO [308136801] 4.56 percent of total billed charges 3.53 5.42 Technical (Hospital) Services CITALOPRAM 20 MG TABLET RX-21062 CDM 6370000100 HCPCS 250 RC 00378-6232-01 NDC outpatient 1 UN 5.7 5.7 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES HDHP [308136802] 4.56 percent of total billed charges 3.53 5.42 Technical (Hospital) Services CITALOPRAM 20 MG TABLET RX-21062 CDM 6370000100 HCPCS 250 RC 00378-6232-01 NDC outpatient 1 UN 5.7 5.7 HEALTHPARTNERS SX009 HEALTHPARTNERS 4.56 percent of total billed charges 3.53 5.42 Technical (Hospital) Services CITALOPRAM 20 MG TABLET RX-21062 CDM 6370000100 HCPCS 250 RC 00378-6232-01 NDC outpatient 1 UN 5.7 5.7 BLUE CROSS BLUE SHIELD WELLMARK SB889 [3081026] BCBS WYOMING [308102603] 5.42 percent of total billed charges 3.53 5.42 Technical (Hospital) Services CITALOPRAM 20 MG TABLET RX-21062 CDM 6370000100 HCPCS 250 RC 00378-6232-01 NDC outpatient 1 UN 5.7 5.7 UNITED HEALTHCARE (COMMERCIAL) [3081199] UNITED HEALTHCARE 87726 [308119901] 3.53 percent of total billed charges 3.53 5.42 Technical (Hospital) Services CITALOPRAM 20 MG TABLET RX-21062 CDM 6370000100 HCPCS 250 RC 00378-6232-01 NDC outpatient 1 UN 5.7 5.7 MEDICA (COMMERCIAL) 94265 [3081118] MEDICA CLAIMS [308111801] 5.13 percent of total billed charges 3.53 5.42 Technical (Hospital) Services CITALOPRAM 20 MG TABLET RX-21062 CDM 6370000100 HCPCS 250 RC 00378-6232-01 NDC outpatient 1 UN 5.7 5.7 MULTIPLAN INC 34080 [3081285] MULTIPLAN INC [308128501] 5.42 percent of total billed charges 3.53 5.42 Technical (Hospital) Services CITALOPRAM 20 MG TABLET RX-21062 CDM 6370000100 HCPCS 250 RC 00378-6232-01 NDC outpatient 1 UN 5.7 5.7 CIGNA 62308 [3081051] CIGNA 62308 [308105105] 4.56 percent of total billed charges 3.53 5.42 Technical (Hospital) Services CITALOPRAM 20 MG TABLET RX-21062 CDM 6370000100 HCPCS 250 RC 00378-6232-01 NDC outpatient 1 UN 5.7 5.7 CIGNA 62308 [3081051] CIGNA STATE OF WYOMING [308105107] 4.56 percent of total billed charges 3.53 5.42 Technical (Hospital) Services CITALOPRAM 20 MG TABLET RX-21062 CDM 6370000100 HCPCS 250 RC 00378-6232-01 NDC inpatient 1 UN 5.7 5.7 UNITED HEALTHCARE (COMMERCIAL) [3081199] UNITED HEALTHCARE 87726 [308119901] 3.53 percent of total billed charges 3.53 5.42 Technical (Hospital) Services CITALOPRAM 20 MG TABLET RX-21062 CDM 6370000100 HCPCS 250 RC 00378-6232-01 NDC inpatient 1 UN 5.7 5.7 BLUE CROSS BLUE SHIELD WELLMARK SB889 [3081026] BCBS WYOMING [308102603] 5.42 percent of total billed charges 3.53 5.42 Technical (Hospital) Services CITALOPRAM 20 MG TABLET RX-21062 CDM 6370000100 HCPCS 250 RC 00378-6232-01 NDC inpatient 1 UN 5.7 5.7 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES HDHP [308136802] 4.51 percent of total billed charges 3.53 5.42 Technical (Hospital) Services CITALOPRAM 20 MG TABLET RX-21062 CDM 6370000100 HCPCS 250 RC 00378-6232-01 NDC inpatient 1 UN 5.7 5.7 MEDICA (COMMERCIAL) 94265 [3081118] MEDICA CLAIMS [308111801] 5.13 percent of total billed charges 3.53 5.42 Technical (Hospital) Services CITALOPRAM 20 MG TABLET RX-21062 CDM 6370000100 HCPCS 250 RC 00378-6232-01 NDC inpatient 1 UN 5.7 5.7 HEALTHPARTNERS SX009 HEALTHPARTNERS 4.51 percent of total billed charges 3.53 5.42 Technical (Hospital) Services CITALOPRAM 20 MG TABLET RX-21062 CDM 6370000100 HCPCS 250 RC 00378-6232-01 NDC inpatient 1 UN 5.7 5.7 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES EPO [308136803] 4.51 percent of total billed charges 3.53 5.42 Technical (Hospital) Services CITALOPRAM 20 MG TABLET RX-21062 CDM 6370000100 HCPCS 250 RC 00378-6232-01 NDC inpatient 1 UN 5.7 5.7 CIGNA 62308 [3081051] CIGNA 62308 [308105105] 4.51 percent of total billed charges 3.53 5.42 Technical (Hospital) Services CITALOPRAM 20 MG TABLET RX-21062 CDM 6370000100 HCPCS 250 RC 00378-6232-01 NDC inpatient 1 UN 5.7 5.7 CIGNA 62308 [3081051] CIGNA STATE OF WYOMING [308105107] 4.51 percent of total billed charges 3.53 5.42 Technical (Hospital) Services CITALOPRAM 20 MG TABLET RX-21062 CDM 6370000100 HCPCS 250 RC 00378-6232-01 NDC inpatient 1 UN 5.7 5.7 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES PPO [308136801] 4.51 percent of total billed charges 3.53 5.42 Technical (Hospital) Services CITALOPRAM 20 MG TABLET RX-21062 CDM 6370000100 HCPCS 250 RC 00378-6232-01 NDC inpatient 1 UN 5.7 5.7 MULTIPLAN INC 34080 [3081285] MULTIPLAN INC [308128501] 5.42 percent of total billed charges 3.53 5.42 Technical (Hospital) Services PRAMIPEXOLE 0.125 MG TABLET RX-21287 CDM 6370000100 HCPCS 250 RC 68462-0330-90 NDC outpatient 1 UN 5.73 5.73 BLUE CROSS BLUE SHIELD WELLMARK SB889 [3081026] BCBS WYOMING [308102603] 5.44 percent of total billed charges 3.55 5.44 Technical (Hospital) Services PRAMIPEXOLE 0.125 MG TABLET RX-21287 CDM 6370000100 HCPCS 250 RC 68462-0330-90 NDC outpatient 1 UN 5.73 5.73 HEALTHPARTNERS SX009 HEALTHPARTNERS 4.58 percent of total billed charges 3.55 5.44 Technical (Hospital) Services PRAMIPEXOLE 0.125 MG TABLET RX-21287 CDM 6370000100 HCPCS 250 RC 68462-0330-90 NDC outpatient 1 UN 5.73 5.73 UNITED HEALTHCARE (COMMERCIAL) [3081199] UNITED HEALTHCARE 87726 [308119901] 3.55 percent of total billed charges 3.55 5.44 Technical (Hospital) Services PRAMIPEXOLE 0.125 MG TABLET RX-21287 CDM 6370000100 HCPCS 250 RC 68462-0330-90 NDC outpatient 1 UN 5.73 5.73 MULTIPLAN INC 34080 [3081285] MULTIPLAN INC [308128501] 5.44 percent of total billed charges 3.55 5.44 Technical (Hospital) Services PRAMIPEXOLE 0.125 MG TABLET RX-21287 CDM 6370000100 HCPCS 250 RC 68462-0330-90 NDC outpatient 1 UN 5.73 5.73 CIGNA 62308 [3081051] CIGNA 62308 [308105105] 4.58 percent of total billed charges 3.55 5.44 Technical (Hospital) Services PRAMIPEXOLE 0.125 MG TABLET RX-21287 CDM 6370000100 HCPCS 250 RC 68462-0330-90 NDC outpatient 1 UN 5.73 5.73 CIGNA 62308 [3081051] CIGNA STATE OF WYOMING [308105107] 4.58 percent of total billed charges 3.55 5.44 Technical (Hospital) Services PRAMIPEXOLE 0.125 MG TABLET RX-21287 CDM 6370000100 HCPCS 250 RC 68462-0330-90 NDC outpatient 1 UN 5.73 5.73 MEDICA (COMMERCIAL) 94265 [3081118] MEDICA CLAIMS [308111801] 5.16 percent of total billed charges 3.55 5.44 Technical (Hospital) Services PRAMIPEXOLE 0.125 MG TABLET RX-21287 CDM 6370000100 HCPCS 250 RC 68462-0330-90 NDC outpatient 1 UN 5.73 5.73 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES HDHP [308136802] 4.58 percent of total billed charges 3.55 5.44 Technical (Hospital) Services PRAMIPEXOLE 0.125 MG TABLET RX-21287 CDM 6370000100 HCPCS 250 RC 68462-0330-90 NDC outpatient 1 UN 5.73 5.73 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES EPO [308136803] 4.58 percent of total billed charges 3.55 5.44 Technical (Hospital) Services PRAMIPEXOLE 0.125 MG TABLET RX-21287 CDM 6370000100 HCPCS 250 RC 68462-0330-90 NDC outpatient 1 UN 5.73 5.73 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES PPO [308136801] 4.58 percent of total billed charges 3.55 5.44 Technical (Hospital) Services PRAMIPEXOLE 0.125 MG TABLET RX-21287 CDM 6370000100 HCPCS 250 RC 68462-0330-90 NDC inpatient 1 UN 5.73 5.73 UNITED HEALTHCARE (COMMERCIAL) [3081199] UNITED HEALTHCARE 87726 [308119901] 3.55 percent of total billed charges 3.55 5.44 Technical (Hospital) Services PRAMIPEXOLE 0.125 MG TABLET RX-21287 CDM 6370000100 HCPCS 250 RC 68462-0330-90 NDC inpatient 1 UN 5.73 5.73 BLUE CROSS BLUE SHIELD WELLMARK SB889 [3081026] BCBS WYOMING [308102603] 5.44 percent of total billed charges 3.55 5.44 Technical (Hospital) Services PRAMIPEXOLE 0.125 MG TABLET RX-21287 CDM 6370000100 HCPCS 250 RC 68462-0330-90 NDC inpatient 1 UN 5.73 5.73 CIGNA 62308 [3081051] CIGNA 62308 [308105105] 4.54 percent of total billed charges 3.55 5.44 Technical (Hospital) Services PRAMIPEXOLE 0.125 MG TABLET RX-21287 CDM 6370000100 HCPCS 250 RC 68462-0330-90 NDC inpatient 1 UN 5.73 5.73 CIGNA 62308 [3081051] CIGNA STATE OF WYOMING [308105107] 4.54 percent of total billed charges 3.55 5.44 Technical (Hospital) Services PRAMIPEXOLE 0.125 MG TABLET RX-21287 CDM 6370000100 HCPCS 250 RC 68462-0330-90 NDC inpatient 1 UN 5.73 5.73 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES EPO [308136803] 4.54 percent of total billed charges 3.55 5.44 Technical (Hospital) Services PRAMIPEXOLE 0.125 MG TABLET RX-21287 CDM 6370000100 HCPCS 250 RC 68462-0330-90 NDC inpatient 1 UN 5.73 5.73 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES HDHP [308136802] 4.54 percent of total billed charges 3.55 5.44 Technical (Hospital) Services PRAMIPEXOLE 0.125 MG TABLET RX-21287 CDM 6370000100 HCPCS 250 RC 68462-0330-90 NDC inpatient 1 UN 5.73 5.73 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES PPO [308136801] 4.54 percent of total billed charges 3.55 5.44 Technical (Hospital) Services PRAMIPEXOLE 0.125 MG TABLET RX-21287 CDM 6370000100 HCPCS 250 RC 68462-0330-90 NDC inpatient 1 UN 5.73 5.73 HEALTHPARTNERS SX009 HEALTHPARTNERS 4.54 percent of total billed charges 3.55 5.44 Technical (Hospital) Services PRAMIPEXOLE 0.125 MG TABLET RX-21287 CDM 6370000100 HCPCS 250 RC 68462-0330-90 NDC inpatient 1 UN 5.73 5.73 MEDICA (COMMERCIAL) 94265 [3081118] MEDICA CLAIMS [308111801] 5.16 percent of total billed charges 3.55 5.44 Technical (Hospital) Services PRAMIPEXOLE 0.125 MG TABLET RX-21287 CDM 6370000100 HCPCS 250 RC 68462-0330-90 NDC inpatient 1 UN 5.73 5.73 MULTIPLAN INC 34080 [3081285] MULTIPLAN INC [308128501] 5.44 percent of total billed charges 3.55 5.44 Technical (Hospital) Services PRAMIPEXOLE 0.25 MG TABLET RX-21290 CDM 6370000100 HCPCS 250 RC 65862-0605-99 NDC inpatient 1 UN 5.77 5.77 BLUE CROSS BLUE SHIELD WELLMARK SB889 [3081026] BCBS WYOMING [308102603] 5.48 percent of total billed charges 3.58 5.48 Technical (Hospital) Services PRAMIPEXOLE 0.25 MG TABLET RX-21290 CDM 6370000100 HCPCS 250 RC 65862-0605-99 NDC inpatient 1 UN 5.77 5.77 UNITED HEALTHCARE (COMMERCIAL) [3081199] UNITED HEALTHCARE 87726 [308119901] 3.58 percent of total billed charges 3.58 5.48 Technical (Hospital) Services PRAMIPEXOLE 0.25 MG TABLET RX-21290 CDM 6370000100 HCPCS 250 RC 65862-0605-99 NDC inpatient 1 UN 5.77 5.77 CIGNA 62308 [3081051] CIGNA 62308 [308105105] 4.57 percent of total billed charges 3.58 5.48 Technical (Hospital) Services PRAMIPEXOLE 0.25 MG TABLET RX-21290 CDM 6370000100 HCPCS 250 RC 65862-0605-99 NDC inpatient 1 UN 5.77 5.77 CIGNA 62308 [3081051] CIGNA STATE OF WYOMING [308105107] 4.57 percent of total billed charges 3.58 5.48 Technical (Hospital) Services PRAMIPEXOLE 0.25 MG TABLET RX-21290 CDM 6370000100 HCPCS 250 RC 65862-0605-99 NDC inpatient 1 UN 5.77 5.77 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES EPO [308136803] 4.57 percent of total billed charges 3.58 5.48 Technical (Hospital) Services PRAMIPEXOLE 0.25 MG TABLET RX-21290 CDM 6370000100 HCPCS 250 RC 65862-0605-99 NDC inpatient 1 UN 5.77 5.77 HEALTHPARTNERS SX009 HEALTHPARTNERS 4.57 percent of total billed charges 3.58 5.48 Technical (Hospital) Services PRAMIPEXOLE 0.25 MG TABLET RX-21290 CDM 6370000100 HCPCS 250 RC 65862-0605-99 NDC inpatient 1 UN 5.77 5.77 MEDICA (COMMERCIAL) 94265 [3081118] MEDICA CLAIMS [308111801] 5.19 percent of total billed charges 3.58 5.48 Technical (Hospital) Services PRAMIPEXOLE 0.25 MG TABLET RX-21290 CDM 6370000100 HCPCS 250 RC 65862-0605-99 NDC inpatient 1 UN 5.77 5.77 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES HDHP [308136802] 4.57 percent of total billed charges 3.58 5.48 Technical (Hospital) Services PRAMIPEXOLE 0.25 MG TABLET RX-21290 CDM 6370000100 HCPCS 250 RC 65862-0605-99 NDC inpatient 1 UN 5.77 5.77 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES PPO [308136801] 4.57 percent of total billed charges 3.58 5.48 Technical (Hospital) Services PRAMIPEXOLE 0.25 MG TABLET RX-21290 CDM 6370000100 HCPCS 250 RC 65862-0605-99 NDC inpatient 1 UN 5.77 5.77 MULTIPLAN INC 34080 [3081285] MULTIPLAN INC [308128501] 5.48 percent of total billed charges 3.58 5.48 Technical (Hospital) Services PRAMIPEXOLE 0.25 MG TABLET RX-21290 CDM 6370000100 HCPCS 250 RC 65862-0605-99 NDC outpatient 1 UN 5.77 5.77 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES EPO [308136803] 4.62 percent of total billed charges 3.58 5.48 Technical (Hospital) Services PRAMIPEXOLE 0.25 MG TABLET RX-21290 CDM 6370000100 HCPCS 250 RC 65862-0605-99 NDC outpatient 1 UN 5.77 5.77 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES PPO [308136801] 4.62 percent of total billed charges 3.58 5.48 Technical (Hospital) Services PRAMIPEXOLE 0.25 MG TABLET RX-21290 CDM 6370000100 HCPCS 250 RC 65862-0605-99 NDC outpatient 1 UN 5.77 5.77 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES HDHP [308136802] 4.62 percent of total billed charges 3.58 5.48 Technical (Hospital) Services PRAMIPEXOLE 0.25 MG TABLET RX-21290 CDM 6370000100 HCPCS 250 RC 65862-0605-99 NDC outpatient 1 UN 5.77 5.77 UNITED HEALTHCARE (COMMERCIAL) [3081199] UNITED HEALTHCARE 87726 [308119901] 3.58 percent of total billed charges 3.58 5.48 Technical (Hospital) Services PRAMIPEXOLE 0.25 MG TABLET RX-21290 CDM 6370000100 HCPCS 250 RC 65862-0605-99 NDC outpatient 1 UN 5.77 5.77 MULTIPLAN INC 34080 [3081285] MULTIPLAN INC [308128501] 5.48 percent of total billed charges 3.58 5.48 Technical (Hospital) Services PRAMIPEXOLE 0.25 MG TABLET RX-21290 CDM 6370000100 HCPCS 250 RC 65862-0605-99 NDC outpatient 1 UN 5.77 5.77 CIGNA 62308 [3081051] CIGNA 62308 [308105105] 4.62 percent of total billed charges 3.58 5.48 Technical (Hospital) Services PRAMIPEXOLE 0.25 MG TABLET RX-21290 CDM 6370000100 HCPCS 250 RC 65862-0605-99 NDC outpatient 1 UN 5.77 5.77 CIGNA 62308 [3081051] CIGNA STATE OF WYOMING [308105107] 4.62 percent of total billed charges 3.58 5.48 Technical (Hospital) Services PRAMIPEXOLE 0.25 MG TABLET RX-21290 CDM 6370000100 HCPCS 250 RC 65862-0605-99 NDC outpatient 1 UN 5.77 5.77 MEDICA (COMMERCIAL) 94265 [3081118] MEDICA CLAIMS [308111801] 5.19 percent of total billed charges 3.58 5.48 Technical (Hospital) Services PRAMIPEXOLE 0.25 MG TABLET RX-21290 CDM 6370000100 HCPCS 250 RC 65862-0605-99 NDC outpatient 1 UN 5.77 5.77 BLUE CROSS BLUE SHIELD WELLMARK SB889 [3081026] BCBS WYOMING [308102603] 5.48 percent of total billed charges 3.58 5.48 Technical (Hospital) Services PRAMIPEXOLE 0.25 MG TABLET RX-21290 CDM 6370000100 HCPCS 250 RC 65862-0605-99 NDC outpatient 1 UN 5.77 5.77 HEALTHPARTNERS SX009 HEALTHPARTNERS 4.62 percent of total billed charges 3.58 5.48 Technical (Hospital) Services DAPSONE 100 MG TABLET RX-2131 CDM 6370000100 HCPCS 250 RC 49938-0101-30 NDC inpatient 1 UN 14.8 14.8 UNITED HEALTHCARE (COMMERCIAL) [3081199] UNITED HEALTHCARE 87726 [308119901] 9.18 percent of total billed charges 9.18 14.06 Technical (Hospital) Services DAPSONE 100 MG TABLET RX-2131 CDM 6370000100 HCPCS 250 RC 49938-0101-30 NDC inpatient 1 UN 14.8 14.8 BLUE CROSS BLUE SHIELD WELLMARK SB889 [3081026] BCBS WYOMING [308102603] 14.06 percent of total billed charges 9.18 14.06 Technical (Hospital) Services DAPSONE 100 MG TABLET RX-2131 CDM 6370000100 HCPCS 250 RC 49938-0101-30 NDC inpatient 1 UN 14.8 14.8 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES EPO [308136803] 11.72 percent of total billed charges 9.18 14.06 Technical (Hospital) Services DAPSONE 100 MG TABLET RX-2131 CDM 6370000100 HCPCS 250 RC 49938-0101-30 NDC inpatient 1 UN 14.8 14.8 CIGNA 62308 [3081051] CIGNA 62308 [308105105] 11.72 percent of total billed charges 9.18 14.06 Technical (Hospital) Services DAPSONE 100 MG TABLET RX-2131 CDM 6370000100 HCPCS 250 RC 49938-0101-30 NDC inpatient 1 UN 14.8 14.8 CIGNA 62308 [3081051] CIGNA STATE OF WYOMING [308105107] 11.72 percent of total billed charges 9.18 14.06 Technical (Hospital) Services DAPSONE 100 MG TABLET RX-2131 CDM 6370000100 HCPCS 250 RC 49938-0101-30 NDC inpatient 1 UN 14.8 14.8 MEDICA (COMMERCIAL) 94265 [3081118] MEDICA CLAIMS [308111801] 13.32 percent of total billed charges 9.18 14.06 Technical (Hospital) Services DAPSONE 100 MG TABLET RX-2131 CDM 6370000100 HCPCS 250 RC 49938-0101-30 NDC inpatient 1 UN 14.8 14.8 HEALTHPARTNERS SX009 HEALTHPARTNERS 11.72 percent of total billed charges 9.18 14.06 Technical (Hospital) Services DAPSONE 100 MG TABLET RX-2131 CDM 6370000100 HCPCS 250 RC 49938-0101-30 NDC inpatient 1 UN 14.8 14.8 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES HDHP [308136802] 11.72 percent of total billed charges 9.18 14.06 Technical (Hospital) Services DAPSONE 100 MG TABLET RX-2131 CDM 6370000100 HCPCS 250 RC 49938-0101-30 NDC inpatient 1 UN 14.8 14.8 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES PPO [308136801] 11.72 percent of total billed charges 9.18 14.06 Technical (Hospital) Services DAPSONE 100 MG TABLET RX-2131 CDM 6370000100 HCPCS 250 RC 49938-0101-30 NDC inpatient 1 UN 14.8 14.8 MULTIPLAN INC 34080 [3081285] MULTIPLAN INC [308128501] 14.06 percent of total billed charges 9.18 14.06 Technical (Hospital) Services DAPSONE 100 MG TABLET RX-2131 CDM 6370000100 HCPCS 250 RC 49938-0101-30 NDC outpatient 1 UN 14.8 14.8 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES PPO [308136801] 11.84 percent of total billed charges 9.18 14.06 Technical (Hospital) Services DAPSONE 100 MG TABLET RX-2131 CDM 6370000100 HCPCS 250 RC 49938-0101-30 NDC outpatient 1 UN 14.8 14.8 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES EPO [308136803] 11.84 percent of total billed charges 9.18 14.06 Technical (Hospital) Services DAPSONE 100 MG TABLET RX-2131 CDM 6370000100 HCPCS 250 RC 49938-0101-30 NDC outpatient 1 UN 14.8 14.8 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES HDHP [308136802] 11.84 percent of total billed charges 9.18 14.06 Technical (Hospital) Services DAPSONE 100 MG TABLET RX-2131 CDM 6370000100 HCPCS 250 RC 49938-0101-30 NDC outpatient 1 UN 14.8 14.8 MEDICA (COMMERCIAL) 94265 [3081118] MEDICA CLAIMS [308111801] 13.32 percent of total billed charges 9.18 14.06 Technical (Hospital) Services DAPSONE 100 MG TABLET RX-2131 CDM 6370000100 HCPCS 250 RC 49938-0101-30 NDC outpatient 1 UN 14.8 14.8 UNITED HEALTHCARE (COMMERCIAL) [3081199] UNITED HEALTHCARE 87726 [308119901] 9.18 percent of total billed charges 9.18 14.06 Technical (Hospital) Services DAPSONE 100 MG TABLET RX-2131 CDM 6370000100 HCPCS 250 RC 49938-0101-30 NDC outpatient 1 UN 14.8 14.8 MULTIPLAN INC 34080 [3081285] MULTIPLAN INC [308128501] 14.06 percent of total billed charges 9.18 14.06 Technical (Hospital) Services DAPSONE 100 MG TABLET RX-2131 CDM 6370000100 HCPCS 250 RC 49938-0101-30 NDC outpatient 1 UN 14.8 14.8 CIGNA 62308 [3081051] CIGNA 62308 [308105105] 11.84 percent of total billed charges 9.18 14.06 Technical (Hospital) Services DAPSONE 100 MG TABLET RX-2131 CDM 6370000100 HCPCS 250 RC 49938-0101-30 NDC outpatient 1 UN 14.8 14.8 CIGNA 62308 [3081051] CIGNA STATE OF WYOMING [308105107] 11.84 percent of total billed charges 9.18 14.06 Technical (Hospital) Services DAPSONE 100 MG TABLET RX-2131 CDM 6370000100 HCPCS 250 RC 49938-0101-30 NDC outpatient 1 UN 14.8 14.8 HEALTHPARTNERS SX009 HEALTHPARTNERS 11.84 percent of total billed charges 9.18 14.06 Technical (Hospital) Services DAPSONE 100 MG TABLET RX-2131 CDM 6370000100 HCPCS 250 RC 49938-0101-30 NDC outpatient 1 UN 14.8 14.8 BLUE CROSS BLUE SHIELD WELLMARK SB889 [3081026] BCBS WYOMING [308102603] 14.06 percent of total billed charges 9.18 14.06 Technical (Hospital) Services WARFARIN 4 MG TABLET RX-21372 CDM 6370000100 HCPCS 250 RC 51672-4031-01 NDC inpatient 1 UN 5.86 5.86 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES EPO [308136803] 4.64 percent of total billed charges 3.63 5.57 Technical (Hospital) Services WARFARIN 4 MG TABLET RX-21372 CDM 6370000100 HCPCS 250 RC 51672-4031-01 NDC inpatient 1 UN 5.86 5.86 CIGNA 62308 [3081051] CIGNA 62308 [308105105] 4.64 percent of total billed charges 3.63 5.57 Technical (Hospital) Services WARFARIN 4 MG TABLET RX-21372 CDM 6370000100 HCPCS 250 RC 51672-4031-01 NDC inpatient 1 UN 5.86 5.86 CIGNA 62308 [3081051] CIGNA STATE OF WYOMING [308105107] 4.64 percent of total billed charges 3.63 5.57 Technical (Hospital) Services WARFARIN 4 MG TABLET RX-21372 CDM 6370000100 HCPCS 250 RC 51672-4031-01 NDC inpatient 1 UN 5.86 5.86 BLUE CROSS BLUE SHIELD WELLMARK SB889 [3081026] BCBS WYOMING [308102603] 5.57 percent of total billed charges 3.63 5.57 Technical (Hospital) Services WARFARIN 4 MG TABLET RX-21372 CDM 6370000100 HCPCS 250 RC 51672-4031-01 NDC inpatient 1 UN 5.86 5.86 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES HDHP [308136802] 4.64 percent of total billed charges 3.63 5.57 Technical (Hospital) Services WARFARIN 4 MG TABLET RX-21372 CDM 6370000100 HCPCS 250 RC 51672-4031-01 NDC inpatient 1 UN 5.86 5.86 UNITED HEALTHCARE (COMMERCIAL) [3081199] UNITED HEALTHCARE 87726 [308119901] 3.63 percent of total billed charges 3.63 5.57 Technical (Hospital) Services WARFARIN 4 MG TABLET RX-21372 CDM 6370000100 HCPCS 250 RC 51672-4031-01 NDC inpatient 1 UN 5.86 5.86 MEDICA (COMMERCIAL) 94265 [3081118] MEDICA CLAIMS [308111801] 5.27 percent of total billed charges 3.63 5.57 Technical (Hospital) Services WARFARIN 4 MG TABLET RX-21372 CDM 6370000100 HCPCS 250 RC 51672-4031-01 NDC inpatient 1 UN 5.86 5.86 HEALTHPARTNERS SX009 HEALTHPARTNERS 4.64 percent of total billed charges 3.63 5.57 Technical (Hospital) Services WARFARIN 4 MG TABLET RX-21372 CDM 6370000100 HCPCS 250 RC 51672-4031-01 NDC inpatient 1 UN 5.86 5.86 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES PPO [308136801] 4.64 percent of total billed charges 3.63 5.57 Technical (Hospital) Services WARFARIN 4 MG TABLET RX-21372 CDM 6370000100 HCPCS 250 RC 51672-4031-01 NDC inpatient 1 UN 5.86 5.86 MULTIPLAN INC 34080 [3081285] MULTIPLAN INC [308128501] 5.57 percent of total billed charges 3.63 5.57 Technical (Hospital) Services WARFARIN 4 MG TABLET RX-21372 CDM 6370000100 HCPCS 250 RC 51672-4031-01 NDC outpatient 1 UN 5.86 5.86 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES HDHP [308136802] 4.69 percent of total billed charges 3.63 5.57 Technical (Hospital) Services WARFARIN 4 MG TABLET RX-21372 CDM 6370000100 HCPCS 250 RC 51672-4031-01 NDC outpatient 1 UN 5.86 5.86 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES PPO [308136801] 4.69 percent of total billed charges 3.63 5.57 Technical (Hospital) Services WARFARIN 4 MG TABLET RX-21372 CDM 6370000100 HCPCS 250 RC 51672-4031-01 NDC outpatient 1 UN 5.86 5.86 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES EPO [308136803] 4.69 percent of total billed charges 3.63 5.57 Technical (Hospital) Services WARFARIN 4 MG TABLET RX-21372 CDM 6370000100 HCPCS 250 RC 51672-4031-01 NDC outpatient 1 UN 5.86 5.86 HEALTHPARTNERS SX009 HEALTHPARTNERS 4.69 percent of total billed charges 3.63 5.57 Technical (Hospital) Services WARFARIN 4 MG TABLET RX-21372 CDM 6370000100 HCPCS 250 RC 51672-4031-01 NDC outpatient 1 UN 5.86 5.86 BLUE CROSS BLUE SHIELD WELLMARK SB889 [3081026] BCBS WYOMING [308102603] 5.57 percent of total billed charges 3.63 5.57 Technical (Hospital) Services WARFARIN 4 MG TABLET RX-21372 CDM 6370000100 HCPCS 250 RC 51672-4031-01 NDC outpatient 1 UN 5.86 5.86 UNITED HEALTHCARE (COMMERCIAL) [3081199] UNITED HEALTHCARE 87726 [308119901] 3.63 percent of total billed charges 3.63 5.57 Technical (Hospital) Services WARFARIN 4 MG TABLET RX-21372 CDM 6370000100 HCPCS 250 RC 51672-4031-01 NDC outpatient 1 UN 5.86 5.86 MEDICA (COMMERCIAL) 94265 [3081118] MEDICA CLAIMS [308111801] 5.27 percent of total billed charges 3.63 5.57 Technical (Hospital) Services WARFARIN 4 MG TABLET RX-21372 CDM 6370000100 HCPCS 250 RC 51672-4031-01 NDC outpatient 1 UN 5.86 5.86 CIGNA 62308 [3081051] CIGNA 62308 [308105105] 4.69 percent of total billed charges 3.63 5.57 Technical (Hospital) Services WARFARIN 4 MG TABLET RX-21372 CDM 6370000100 HCPCS 250 RC 51672-4031-01 NDC outpatient 1 UN 5.86 5.86 CIGNA 62308 [3081051] CIGNA STATE OF WYOMING [308105107] 4.69 percent of total billed charges 3.63 5.57 Technical (Hospital) Services WARFARIN 4 MG TABLET RX-21372 CDM 6370000100 HCPCS 250 RC 51672-4031-01 NDC outpatient 1 UN 5.86 5.86 MULTIPLAN INC 34080 [3081285] MULTIPLAN INC [308128501] 5.57 percent of total billed charges 3.63 5.57 Technical (Hospital) Services LETROZOLE 2.5 MG TABLET RX-21509 CDM 6370000100 HCPCS 250 RC 50268-0476-11 NDC outpatient 1 UN 6.18 6.18 HEALTHPARTNERS SX009 HEALTHPARTNERS 4.94 percent of total billed charges 3.83 5.87 Technical (Hospital) Services LETROZOLE 2.5 MG TABLET RX-21509 CDM 6370000100 HCPCS 250 RC 50268-0476-11 NDC outpatient 1 UN 6.18 6.18 BLUE CROSS BLUE SHIELD WELLMARK SB889 [3081026] BCBS WYOMING [308102603] 5.87 percent of total billed charges 3.83 5.87 Technical (Hospital) Services LETROZOLE 2.5 MG TABLET RX-21509 CDM 6370000100 HCPCS 250 RC 50268-0476-11 NDC outpatient 1 UN 6.18 6.18 MEDICA (COMMERCIAL) 94265 [3081118] MEDICA CLAIMS [308111801] 5.56 percent of total billed charges 3.83 5.87 Technical (Hospital) Services LETROZOLE 2.5 MG TABLET RX-21509 CDM 6370000100 HCPCS 250 RC 50268-0476-11 NDC outpatient 1 UN 6.18 6.18 UNITED HEALTHCARE (COMMERCIAL) [3081199] UNITED HEALTHCARE 87726 [308119901] 3.83 percent of total billed charges 3.83 5.87 Technical (Hospital) Services LETROZOLE 2.5 MG TABLET RX-21509 CDM 6370000100 HCPCS 250 RC 50268-0476-11 NDC outpatient 1 UN 6.18 6.18 MULTIPLAN INC 34080 [3081285] MULTIPLAN INC [308128501] 5.87 percent of total billed charges 3.83 5.87 Technical (Hospital) Services LETROZOLE 2.5 MG TABLET RX-21509 CDM 6370000100 HCPCS 250 RC 50268-0476-11 NDC outpatient 1 UN 6.18 6.18 CIGNA 62308 [3081051] CIGNA 62308 [308105105] 4.94 percent of total billed charges 3.83 5.87 Technical (Hospital) Services LETROZOLE 2.5 MG TABLET RX-21509 CDM 6370000100 HCPCS 250 RC 50268-0476-11 NDC outpatient 1 UN 6.18 6.18 CIGNA 62308 [3081051] CIGNA STATE OF WYOMING [308105107] 4.94 percent of total billed charges 3.83 5.87 Technical (Hospital) Services LETROZOLE 2.5 MG TABLET RX-21509 CDM 6370000100 HCPCS 250 RC 50268-0476-11 NDC outpatient 1 UN 6.18 6.18 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES PPO [308136801] 4.94 percent of total billed charges 3.83 5.87 Technical (Hospital) Services LETROZOLE 2.5 MG TABLET RX-21509 CDM 6370000100 HCPCS 250 RC 50268-0476-11 NDC outpatient 1 UN 6.18 6.18 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES EPO [308136803] 4.94 percent of total billed charges 3.83 5.87 Technical (Hospital) Services LETROZOLE 2.5 MG TABLET RX-21509 CDM 6370000100 HCPCS 250 RC 50268-0476-11 NDC outpatient 1 UN 6.18 6.18 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES HDHP [308136802] 4.94 percent of total billed charges 3.83 5.87 Technical (Hospital) Services LETROZOLE 2.5 MG TABLET RX-21509 CDM 6370000100 HCPCS 250 RC 50268-0476-11 NDC inpatient 1 UN 6.18 6.18 UNITED HEALTHCARE (COMMERCIAL) [3081199] UNITED HEALTHCARE 87726 [308119901] 3.83 percent of total billed charges 3.83 5.87 Technical (Hospital) Services LETROZOLE 2.5 MG TABLET RX-21509 CDM 6370000100 HCPCS 250 RC 50268-0476-11 NDC inpatient 1 UN 6.18 6.18 CIGNA 62308 [3081051] CIGNA 62308 [308105105] 4.89 percent of total billed charges 3.83 5.87 Technical (Hospital) Services LETROZOLE 2.5 MG TABLET RX-21509 CDM 6370000100 HCPCS 250 RC 50268-0476-11 NDC inpatient 1 UN 6.18 6.18 CIGNA 62308 [3081051] CIGNA STATE OF WYOMING [308105107] 4.89 percent of total billed charges 3.83 5.87 Technical (Hospital) Services LETROZOLE 2.5 MG TABLET RX-21509 CDM 6370000100 HCPCS 250 RC 50268-0476-11 NDC inpatient 1 UN 6.18 6.18 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES EPO [308136803] 4.89 percent of total billed charges 3.83 5.87 Technical (Hospital) Services LETROZOLE 2.5 MG TABLET RX-21509 CDM 6370000100 HCPCS 250 RC 50268-0476-11 NDC inpatient 1 UN 6.18 6.18 BLUE CROSS BLUE SHIELD WELLMARK SB889 [3081026] BCBS WYOMING [308102603] 5.87 percent of total billed charges 3.83 5.87 Technical (Hospital) Services LETROZOLE 2.5 MG TABLET RX-21509 CDM 6370000100 HCPCS 250 RC 50268-0476-11 NDC inpatient 1 UN 6.18 6.18 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES HDHP [308136802] 4.89 percent of total billed charges 3.83 5.87 Technical (Hospital) Services LETROZOLE 2.5 MG TABLET RX-21509 CDM 6370000100 HCPCS 250 RC 50268-0476-11 NDC inpatient 1 UN 6.18 6.18 HEALTHPARTNERS SX009 HEALTHPARTNERS 4.89 percent of total billed charges 3.83 5.87 Technical (Hospital) Services LETROZOLE 2.5 MG TABLET RX-21509 CDM 6370000100 HCPCS 250 RC 50268-0476-11 NDC inpatient 1 UN 6.18 6.18 MEDICA (COMMERCIAL) 94265 [3081118] MEDICA CLAIMS [308111801] 5.56 percent of total billed charges 3.83 5.87 Technical (Hospital) Services LETROZOLE 2.5 MG TABLET RX-21509 CDM 6370000100 HCPCS 250 RC 50268-0476-11 NDC inpatient 1 UN 6.18 6.18 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES PPO [308136801] 4.89 percent of total billed charges 3.83 5.87 Technical (Hospital) Services LETROZOLE 2.5 MG TABLET RX-21509 CDM 6370000100 HCPCS 250 RC 50268-0476-11 NDC inpatient 1 UN 6.18 6.18 MULTIPLAN INC 34080 [3081285] MULTIPLAN INC [308128501] 5.87 percent of total billed charges 3.83 5.87 Technical (Hospital) Services ROPINIROLE 0.25 MG TABLET RX-21688 CDM 6370000100 HCPCS 250 RC 00904-6373-61 NDC inpatient 1 UN 6.11 6.11 MULTIPLAN INC 34080 [3081285] MULTIPLAN INC [308128501] 5.8 percent of total billed charges 3.79 5.8 Technical (Hospital) Services ROPINIROLE 0.25 MG TABLET RX-21688 CDM 6370000100 HCPCS 250 RC 00904-6373-61 NDC inpatient 1 UN 6.11 6.11 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES PPO [308136801] 4.84 percent of total billed charges 3.79 5.8 Technical (Hospital) Services ROPINIROLE 0.25 MG TABLET RX-21688 CDM 6370000100 HCPCS 250 RC 00904-6373-61 NDC inpatient 1 UN 6.11 6.11 MEDICA (COMMERCIAL) 94265 [3081118] MEDICA CLAIMS [308111801] 5.5 percent of total billed charges 3.79 5.8 Technical (Hospital) Services ROPINIROLE 0.25 MG TABLET RX-21688 CDM 6370000100 HCPCS 250 RC 00904-6373-61 NDC inpatient 1 UN 6.11 6.11 HEALTHPARTNERS SX009 HEALTHPARTNERS 4.84 percent of total billed charges 3.79 5.8 Technical (Hospital) Services ROPINIROLE 0.25 MG TABLET RX-21688 CDM 6370000100 HCPCS 250 RC 00904-6373-61 NDC inpatient 1 UN 6.11 6.11 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES HDHP [308136802] 4.84 percent of total billed charges 3.79 5.8 Technical (Hospital) Services ROPINIROLE 0.25 MG TABLET RX-21688 CDM 6370000100 HCPCS 250 RC 00904-6373-61 NDC inpatient 1 UN 6.11 6.11 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES EPO [308136803] 4.84 percent of total billed charges 3.79 5.8 Technical (Hospital) Services ROPINIROLE 0.25 MG TABLET RX-21688 CDM 6370000100 HCPCS 250 RC 00904-6373-61 NDC inpatient 1 UN 6.11 6.11 CIGNA 62308 [3081051] CIGNA 62308 [308105105] 4.84 percent of total billed charges 3.79 5.8 Technical (Hospital) Services ROPINIROLE 0.25 MG TABLET RX-21688 CDM 6370000100 HCPCS 250 RC 00904-6373-61 NDC inpatient 1 UN 6.11 6.11 CIGNA 62308 [3081051] CIGNA STATE OF WYOMING [308105107] 4.84 percent of total billed charges 3.79 5.8 Technical (Hospital) Services ROPINIROLE 0.25 MG TABLET RX-21688 CDM 6370000100 HCPCS 250 RC 00904-6373-61 NDC inpatient 1 UN 6.11 6.11 BLUE CROSS BLUE SHIELD WELLMARK SB889 [3081026] BCBS WYOMING [308102603] 5.8 percent of total billed charges 3.79 5.8 Technical (Hospital) Services ROPINIROLE 0.25 MG TABLET RX-21688 CDM 6370000100 HCPCS 250 RC 00904-6373-61 NDC inpatient 1 UN 6.11 6.11 UNITED HEALTHCARE (COMMERCIAL) [3081199] UNITED HEALTHCARE 87726 [308119901] 3.79 percent of total billed charges 3.79 5.8 Technical (Hospital) Services ROPINIROLE 0.25 MG TABLET RX-21688 CDM 6370000100 HCPCS 250 RC 00904-6373-61 NDC outpatient 1 UN 6.11 6.11 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES PPO [308136801] 4.89 percent of total billed charges 3.79 5.8 Technical (Hospital) Services ROPINIROLE 0.25 MG TABLET RX-21688 CDM 6370000100 HCPCS 250 RC 00904-6373-61 NDC outpatient 1 UN 6.11 6.11 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES EPO [308136803] 4.89 percent of total billed charges 3.79 5.8 Technical (Hospital) Services ROPINIROLE 0.25 MG TABLET RX-21688 CDM 6370000100 HCPCS 250 RC 00904-6373-61 NDC outpatient 1 UN 6.11 6.11 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES HDHP [308136802] 4.89 percent of total billed charges 3.79 5.8 Technical (Hospital) Services ROPINIROLE 0.25 MG TABLET RX-21688 CDM 6370000100 HCPCS 250 RC 00904-6373-61 NDC outpatient 1 UN 6.11 6.11 HEALTHPARTNERS SX009 HEALTHPARTNERS 4.89 percent of total billed charges 3.79 5.8 Technical (Hospital) Services ROPINIROLE 0.25 MG TABLET RX-21688 CDM 6370000100 HCPCS 250 RC 00904-6373-61 NDC outpatient 1 UN 6.11 6.11 BLUE CROSS BLUE SHIELD WELLMARK SB889 [3081026] BCBS WYOMING [308102603] 5.8 percent of total billed charges 3.79 5.8 Technical (Hospital) Services ROPINIROLE 0.25 MG TABLET RX-21688 CDM 6370000100 HCPCS 250 RC 00904-6373-61 NDC outpatient 1 UN 6.11 6.11 MEDICA (COMMERCIAL) 94265 [3081118] MEDICA CLAIMS [308111801] 5.5 percent of total billed charges 3.79 5.8 Technical (Hospital) Services ROPINIROLE 0.25 MG TABLET RX-21688 CDM 6370000100 HCPCS 250 RC 00904-6373-61 NDC outpatient 1 UN 6.11 6.11 UNITED HEALTHCARE (COMMERCIAL) [3081199] UNITED HEALTHCARE 87726 [308119901] 3.79 percent of total billed charges 3.79 5.8 Technical (Hospital) Services ROPINIROLE 0.25 MG TABLET RX-21688 CDM 6370000100 HCPCS 250 RC 00904-6373-61 NDC outpatient 1 UN 6.11 6.11 CIGNA 62308 [3081051] CIGNA 62308 [308105105] 4.89 percent of total billed charges 3.79 5.8 Technical (Hospital) Services ROPINIROLE 0.25 MG TABLET RX-21688 CDM 6370000100 HCPCS 250 RC 00904-6373-61 NDC outpatient 1 UN 6.11 6.11 CIGNA 62308 [3081051] CIGNA STATE OF WYOMING [308105107] 4.89 percent of total billed charges 3.79 5.8 Technical (Hospital) Services ROPINIROLE 0.25 MG TABLET RX-21688 CDM 6370000100 HCPCS 250 RC 00904-6373-61 NDC outpatient 1 UN 6.11 6.11 MULTIPLAN INC 34080 [3081285] MULTIPLAN INC [308128501] 5.8 percent of total billed charges 3.79 5.8 Technical (Hospital) Services ROPINIROLE 1 MG TABLET RX-21689 CDM 6370000100 HCPCS 250 RC 43547-0270-10 NDC inpatient 1 UN 5.74 5.74 BLUE CROSS BLUE SHIELD WELLMARK SB889 [3081026] BCBS WYOMING [308102603] 5.45 percent of total billed charges 3.56 5.45 Technical (Hospital) Services ROPINIROLE 1 MG TABLET RX-21689 CDM 6370000100 HCPCS 250 RC 43547-0270-10 NDC inpatient 1 UN 5.74 5.74 UNITED HEALTHCARE (COMMERCIAL) [3081199] UNITED HEALTHCARE 87726 [308119901] 3.56 percent of total billed charges 3.56 5.45 Technical (Hospital) Services ROPINIROLE 1 MG TABLET RX-21689 CDM 6370000100 HCPCS 250 RC 43547-0270-10 NDC inpatient 1 UN 5.74 5.74 CIGNA 62308 [3081051] CIGNA 62308 [308105105] 4.54 percent of total billed charges 3.56 5.45 Technical (Hospital) Services ROPINIROLE 1 MG TABLET RX-21689 CDM 6370000100 HCPCS 250 RC 43547-0270-10 NDC inpatient 1 UN 5.74 5.74 CIGNA 62308 [3081051] CIGNA STATE OF WYOMING [308105107] 4.54 percent of total billed charges 3.56 5.45 Technical (Hospital) Services ROPINIROLE 1 MG TABLET RX-21689 CDM 6370000100 HCPCS 250 RC 43547-0270-10 NDC inpatient 1 UN 5.74 5.74 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES EPO [308136803] 4.54 percent of total billed charges 3.56 5.45 Technical (Hospital) Services ROPINIROLE 1 MG TABLET RX-21689 CDM 6370000100 HCPCS 250 RC 43547-0270-10 NDC inpatient 1 UN 5.74 5.74 HEALTHPARTNERS SX009 HEALTHPARTNERS 4.54 percent of total billed charges 3.56 5.45 Technical (Hospital) Services ROPINIROLE 1 MG TABLET RX-21689 CDM 6370000100 HCPCS 250 RC 43547-0270-10 NDC inpatient 1 UN 5.74 5.74 MEDICA (COMMERCIAL) 94265 [3081118] MEDICA CLAIMS [308111801] 5.17 percent of total billed charges 3.56 5.45 Technical (Hospital) Services ROPINIROLE 1 MG TABLET RX-21689 CDM 6370000100 HCPCS 250 RC 43547-0270-10 NDC inpatient 1 UN 5.74 5.74 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES HDHP [308136802] 4.54 percent of total billed charges 3.56 5.45 Technical (Hospital) Services ROPINIROLE 1 MG TABLET RX-21689 CDM 6370000100 HCPCS 250 RC 43547-0270-10 NDC inpatient 1 UN 5.74 5.74 MULTIPLAN INC 34080 [3081285] MULTIPLAN INC [308128501] 5.45 percent of total billed charges 3.56 5.45 Technical (Hospital) Services ROPINIROLE 1 MG TABLET RX-21689 CDM 6370000100 HCPCS 250 RC 43547-0270-10 NDC inpatient 1 UN 5.74 5.74 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES PPO [308136801] 4.54 percent of total billed charges 3.56 5.45 Technical (Hospital) Services ROPINIROLE 1 MG TABLET RX-21689 CDM 6370000100 HCPCS 250 RC 43547-0270-10 NDC outpatient 1 UN 5.74 5.74 BLUE CROSS BLUE SHIELD WELLMARK SB889 [3081026] BCBS WYOMING [308102603] 5.45 percent of total billed charges 3.56 5.45 Technical (Hospital) Services ROPINIROLE 1 MG TABLET RX-21689 CDM 6370000100 HCPCS 250 RC 43547-0270-10 NDC outpatient 1 UN 5.74 5.74 HEALTHPARTNERS SX009 HEALTHPARTNERS 4.59 percent of total billed charges 3.56 5.45 Technical (Hospital) Services ROPINIROLE 1 MG TABLET RX-21689 CDM 6370000100 HCPCS 250 RC 43547-0270-10 NDC outpatient 1 UN 5.74 5.74 UNITED HEALTHCARE (COMMERCIAL) [3081199] UNITED HEALTHCARE 87726 [308119901] 3.56 percent of total billed charges 3.56 5.45 Technical (Hospital) Services ROPINIROLE 1 MG TABLET RX-21689 CDM 6370000100 HCPCS 250 RC 43547-0270-10 NDC outpatient 1 UN 5.74 5.74 MULTIPLAN INC 34080 [3081285] MULTIPLAN INC [308128501] 5.45 percent of total billed charges 3.56 5.45 Technical (Hospital) Services ROPINIROLE 1 MG TABLET RX-21689 CDM 6370000100 HCPCS 250 RC 43547-0270-10 NDC outpatient 1 UN 5.74 5.74 CIGNA 62308 [3081051] CIGNA 62308 [308105105] 4.59 percent of total billed charges 3.56 5.45 Technical (Hospital) Services ROPINIROLE 1 MG TABLET RX-21689 CDM 6370000100 HCPCS 250 RC 43547-0270-10 NDC outpatient 1 UN 5.74 5.74 CIGNA 62308 [3081051] CIGNA STATE OF WYOMING [308105107] 4.59 percent of total billed charges 3.56 5.45 Technical (Hospital) Services ROPINIROLE 1 MG TABLET RX-21689 CDM 6370000100 HCPCS 250 RC 43547-0270-10 NDC outpatient 1 UN 5.74 5.74 MEDICA (COMMERCIAL) 94265 [3081118] MEDICA CLAIMS [308111801] 5.17 percent of total billed charges 3.56 5.45 Technical (Hospital) Services ROPINIROLE 1 MG TABLET RX-21689 CDM 6370000100 HCPCS 250 RC 43547-0270-10 NDC outpatient 1 UN 5.74 5.74 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES EPO [308136803] 4.59 percent of total billed charges 3.56 5.45 Technical (Hospital) Services ROPINIROLE 1 MG TABLET RX-21689 CDM 6370000100 HCPCS 250 RC 43547-0270-10 NDC outpatient 1 UN 5.74 5.74 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES HDHP [308136802] 4.59 percent of total billed charges 3.56 5.45 Technical (Hospital) Services ROPINIROLE 1 MG TABLET RX-21689 CDM 6370000100 HCPCS 250 RC 43547-0270-10 NDC outpatient 1 UN 5.74 5.74 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES PPO [308136801] 4.59 percent of total billed charges 3.56 5.45 Technical (Hospital) Services ROPINIROLE 2 MG TABLET RX-21690 CDM 6370000100 HCPCS 250 RC 50268-0744-15 NDC outpatient 1 UN 6.08 6.08 CIGNA 62308 [3081051] CIGNA 62308 [308105105] 4.86 percent of total billed charges 3.77 5.78 Technical (Hospital) Services ROPINIROLE 2 MG TABLET RX-21690 CDM 6370000100 HCPCS 250 RC 50268-0744-15 NDC outpatient 1 UN 6.08 6.08 CIGNA 62308 [3081051] CIGNA STATE OF WYOMING [308105107] 4.86 percent of total billed charges 3.77 5.78 Technical (Hospital) Services ROPINIROLE 2 MG TABLET RX-21690 CDM 6370000100 HCPCS 250 RC 50268-0744-15 NDC outpatient 1 UN 6.08 6.08 MULTIPLAN INC 34080 [3081285] MULTIPLAN INC [308128501] 5.78 percent of total billed charges 3.77 5.78 Technical (Hospital) Services ROPINIROLE 2 MG TABLET RX-21690 CDM 6370000100 HCPCS 250 RC 50268-0744-15 NDC outpatient 1 UN 6.08 6.08 UNITED HEALTHCARE (COMMERCIAL) [3081199] UNITED HEALTHCARE 87726 [308119901] 3.77 percent of total billed charges 3.77 5.78 Technical (Hospital) Services ROPINIROLE 2 MG TABLET RX-21690 CDM 6370000100 HCPCS 250 RC 50268-0744-15 NDC outpatient 1 UN 6.08 6.08 MEDICA (COMMERCIAL) 94265 [3081118] MEDICA CLAIMS [308111801] 5.47 percent of total billed charges 3.77 5.78 Technical (Hospital) Services ROPINIROLE 2 MG TABLET RX-21690 CDM 6370000100 HCPCS 250 RC 50268-0744-15 NDC outpatient 1 UN 6.08 6.08 BLUE CROSS BLUE SHIELD WELLMARK SB889 [3081026] BCBS WYOMING [308102603] 5.78 percent of total billed charges 3.77 5.78 Technical (Hospital) Services ROPINIROLE 2 MG TABLET RX-21690 CDM 6370000100 HCPCS 250 RC 50268-0744-15 NDC outpatient 1 UN 6.08 6.08 HEALTHPARTNERS SX009 HEALTHPARTNERS 4.86 percent of total billed charges 3.77 5.78 Technical (Hospital) Services ROPINIROLE 2 MG TABLET RX-21690 CDM 6370000100 HCPCS 250 RC 50268-0744-15 NDC outpatient 1 UN 6.08 6.08 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES EPO [308136803] 4.86 percent of total billed charges 3.77 5.78 Technical (Hospital) Services ROPINIROLE 2 MG TABLET RX-21690 CDM 6370000100 HCPCS 250 RC 50268-0744-15 NDC outpatient 1 UN 6.08 6.08 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES HDHP [308136802] 4.86 percent of total billed charges 3.77 5.78 Technical (Hospital) Services ROPINIROLE 2 MG TABLET RX-21690 CDM 6370000100 HCPCS 250 RC 50268-0744-15 NDC outpatient 1 UN 6.08 6.08 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES PPO [308136801] 4.86 percent of total billed charges 3.77 5.78 Technical (Hospital) Services ROPINIROLE 2 MG TABLET RX-21690 CDM 6370000100 HCPCS 250 RC 50268-0744-15 NDC inpatient 1 UN 6.08 6.08 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES PPO [308136801] 4.81 percent of total billed charges 3.77 5.78 Technical (Hospital) Services ROPINIROLE 2 MG TABLET RX-21690 CDM 6370000100 HCPCS 250 RC 50268-0744-15 NDC inpatient 1 UN 6.08 6.08 MEDICA (COMMERCIAL) 94265 [3081118] MEDICA CLAIMS [308111801] 5.47 percent of total billed charges 3.77 5.78 Technical (Hospital) Services ROPINIROLE 2 MG TABLET RX-21690 CDM 6370000100 HCPCS 250 RC 50268-0744-15 NDC inpatient 1 UN 6.08 6.08 HEALTHPARTNERS SX009 HEALTHPARTNERS 4.81 percent of total billed charges 3.77 5.78 Technical (Hospital) Services ROPINIROLE 2 MG TABLET RX-21690 CDM 6370000100 HCPCS 250 RC 50268-0744-15 NDC inpatient 1 UN 6.08 6.08 MULTIPLAN INC 34080 [3081285] MULTIPLAN INC [308128501] 5.78 percent of total billed charges 3.77 5.78 Technical (Hospital) Services ROPINIROLE 2 MG TABLET RX-21690 CDM 6370000100 HCPCS 250 RC 50268-0744-15 NDC inpatient 1 UN 6.08 6.08 CIGNA 62308 [3081051] CIGNA 62308 [308105105] 4.81 percent of total billed charges 3.77 5.78 Technical (Hospital) Services ROPINIROLE 2 MG TABLET RX-21690 CDM 6370000100 HCPCS 250 RC 50268-0744-15 NDC inpatient 1 UN 6.08 6.08 CIGNA 62308 [3081051] CIGNA STATE OF WYOMING [308105107] 4.81 percent of total billed charges 3.77 5.78 Technical (Hospital) Services ROPINIROLE 2 MG TABLET RX-21690 CDM 6370000100 HCPCS 250 RC 50268-0744-15 NDC inpatient 1 UN 6.08 6.08 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES EPO [308136803] 4.81 percent of total billed charges 3.77 5.78 Technical (Hospital) Services ROPINIROLE 2 MG TABLET RX-21690 CDM 6370000100 HCPCS 250 RC 50268-0744-15 NDC inpatient 1 UN 6.08 6.08 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES HDHP [308136802] 4.81 percent of total billed charges 3.77 5.78 Technical (Hospital) Services ROPINIROLE 2 MG TABLET RX-21690 CDM 6370000100 HCPCS 250 RC 50268-0744-15 NDC inpatient 1 UN 6.08 6.08 BLUE CROSS BLUE SHIELD WELLMARK SB889 [3081026] BCBS WYOMING [308102603] 5.78 percent of total billed charges 3.77 5.78 Technical (Hospital) Services ROPINIROLE 2 MG TABLET RX-21690 CDM 6370000100 HCPCS 250 RC 50268-0744-15 NDC inpatient 1 UN 6.08 6.08 UNITED HEALTHCARE (COMMERCIAL) [3081199] UNITED HEALTHCARE 87726 [308119901] 3.77 percent of total billed charges 3.77 5.78 Technical (Hospital) Services ROPINIROLE 0.5 MG TABLET RX-21800 CDM 6370000100 HCPCS 250 RC 43547-0269-10 NDC inpatient 1 UN 5.74 5.74 BLUE CROSS BLUE SHIELD WELLMARK SB889 [3081026] BCBS WYOMING [308102603] 5.45 percent of total billed charges 3.56 5.45 Technical (Hospital) Services ROPINIROLE 0.5 MG TABLET RX-21800 CDM 6370000100 HCPCS 250 RC 43547-0269-10 NDC inpatient 1 UN 5.74 5.74 UNITED HEALTHCARE (COMMERCIAL) [3081199] UNITED HEALTHCARE 87726 [308119901] 3.56 percent of total billed charges 3.56 5.45 Technical (Hospital) Services ROPINIROLE 0.5 MG TABLET RX-21800 CDM 6370000100 HCPCS 250 RC 43547-0269-10 NDC inpatient 1 UN 5.74 5.74 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES EPO [308136803] 4.54 percent of total billed charges 3.56 5.45 Technical (Hospital) Services ROPINIROLE 0.5 MG TABLET RX-21800 CDM 6370000100 HCPCS 250 RC 43547-0269-10 NDC inpatient 1 UN 5.74 5.74 CIGNA 62308 [3081051] CIGNA 62308 [308105105] 4.54 percent of total billed charges 3.56 5.45 Technical (Hospital) Services ROPINIROLE 0.5 MG TABLET RX-21800 CDM 6370000100 HCPCS 250 RC 43547-0269-10 NDC inpatient 1 UN 5.74 5.74 CIGNA 62308 [3081051] CIGNA STATE OF WYOMING [308105107] 4.54 percent of total billed charges 3.56 5.45 Technical (Hospital) Services ROPINIROLE 0.5 MG TABLET RX-21800 CDM 6370000100 HCPCS 250 RC 43547-0269-10 NDC inpatient 1 UN 5.74 5.74 MEDICA (COMMERCIAL) 94265 [3081118] MEDICA CLAIMS [308111801] 5.17 percent of total billed charges 3.56 5.45 Technical (Hospital) Services ROPINIROLE 0.5 MG TABLET RX-21800 CDM 6370000100 HCPCS 250 RC 43547-0269-10 NDC inpatient 1 UN 5.74 5.74 HEALTHPARTNERS SX009 HEALTHPARTNERS 4.54 percent of total billed charges 3.56 5.45 Technical (Hospital) Services ROPINIROLE 0.5 MG TABLET RX-21800 CDM 6370000100 HCPCS 250 RC 43547-0269-10 NDC inpatient 1 UN 5.74 5.74 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES HDHP [308136802] 4.54 percent of total billed charges 3.56 5.45 Technical (Hospital) Services ROPINIROLE 0.5 MG TABLET RX-21800 CDM 6370000100 HCPCS 250 RC 43547-0269-10 NDC inpatient 1 UN 5.74 5.74 MULTIPLAN INC 34080 [3081285] MULTIPLAN INC [308128501] 5.45 percent of total billed charges 3.56 5.45 Technical (Hospital) Services ROPINIROLE 0.5 MG TABLET RX-21800 CDM 6370000100 HCPCS 250 RC 43547-0269-10 NDC inpatient 1 UN 5.74 5.74 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES PPO [308136801] 4.54 percent of total billed charges 3.56 5.45 Technical (Hospital) Services ROPINIROLE 0.5 MG TABLET RX-21800 CDM 6370000100 HCPCS 250 RC 43547-0269-10 NDC outpatient 1 UN 5.74 5.74 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES EPO [308136803] 4.59 percent of total billed charges 3.56 5.45 Technical (Hospital) Services ROPINIROLE 0.5 MG TABLET RX-21800 CDM 6370000100 HCPCS 250 RC 43547-0269-10 NDC outpatient 1 UN 5.74 5.74 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES HDHP [308136802] 4.59 percent of total billed charges 3.56 5.45 Technical (Hospital) Services ROPINIROLE 0.5 MG TABLET RX-21800 CDM 6370000100 HCPCS 250 RC 43547-0269-10 NDC outpatient 1 UN 5.74 5.74 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES PPO [308136801] 4.59 percent of total billed charges 3.56 5.45 Technical (Hospital) Services ROPINIROLE 0.5 MG TABLET RX-21800 CDM 6370000100 HCPCS 250 RC 43547-0269-10 NDC outpatient 1 UN 5.74 5.74 MEDICA (COMMERCIAL) 94265 [3081118] MEDICA CLAIMS [308111801] 5.17 percent of total billed charges 3.56 5.45 Technical (Hospital) Services ROPINIROLE 0.5 MG TABLET RX-21800 CDM 6370000100 HCPCS 250 RC 43547-0269-10 NDC outpatient 1 UN 5.74 5.74 UNITED HEALTHCARE (COMMERCIAL) [3081199] UNITED HEALTHCARE 87726 [308119901] 3.56 percent of total billed charges 3.56 5.45 Technical (Hospital) Services ROPINIROLE 0.5 MG TABLET RX-21800 CDM 6370000100 HCPCS 250 RC 43547-0269-10 NDC outpatient 1 UN 5.74 5.74 MULTIPLAN INC 34080 [3081285] MULTIPLAN INC [308128501] 5.45 percent of total billed charges 3.56 5.45 Technical (Hospital) Services ROPINIROLE 0.5 MG TABLET RX-21800 CDM 6370000100 HCPCS 250 RC 43547-0269-10 NDC outpatient 1 UN 5.74 5.74 CIGNA 62308 [3081051] CIGNA 62308 [308105105] 4.59 percent of total billed charges 3.56 5.45 Technical (Hospital) Services ROPINIROLE 0.5 MG TABLET RX-21800 CDM 6370000100 HCPCS 250 RC 43547-0269-10 NDC outpatient 1 UN 5.74 5.74 CIGNA 62308 [3081051] CIGNA STATE OF WYOMING [308105107] 4.59 percent of total billed charges 3.56 5.45 Technical (Hospital) Services ROPINIROLE 0.5 MG TABLET RX-21800 CDM 6370000100 HCPCS 250 RC 43547-0269-10 NDC outpatient 1 UN 5.74 5.74 HEALTHPARTNERS SX009 HEALTHPARTNERS 4.59 percent of total billed charges 3.56 5.45 Technical (Hospital) Services ROPINIROLE 0.5 MG TABLET RX-21800 CDM 6370000100 HCPCS 250 RC 43547-0269-10 NDC outpatient 1 UN 5.74 5.74 BLUE CROSS BLUE SHIELD WELLMARK SB889 [3081026] BCBS WYOMING [308102603] 5.45 percent of total billed charges 3.56 5.45 Technical (Hospital) Services QUETIAPINE 25 MG TABLET RX-21823 CDM 6370000100 HCPCS 250 RC 67877-0242-01 NDC outpatient 1 UN 5.66 5.66 HEALTHPARTNERS SX009 HEALTHPARTNERS 4.53 percent of total billed charges 3.51 5.38 Technical (Hospital) Services QUETIAPINE 25 MG TABLET RX-21823 CDM 6370000100 HCPCS 250 RC 67877-0242-01 NDC outpatient 1 UN 5.66 5.66 BLUE CROSS BLUE SHIELD WELLMARK SB889 [3081026] BCBS WYOMING [308102603] 5.38 percent of total billed charges 3.51 5.38 Technical (Hospital) Services QUETIAPINE 25 MG TABLET RX-21823 CDM 6370000100 HCPCS 250 RC 67877-0242-01 NDC outpatient 1 UN 5.66 5.66 MEDICA (COMMERCIAL) 94265 [3081118] MEDICA CLAIMS [308111801] 5.09 percent of total billed charges 3.51 5.38 Technical (Hospital) Services QUETIAPINE 25 MG TABLET RX-21823 CDM 6370000100 HCPCS 250 RC 67877-0242-01 NDC outpatient 1 UN 5.66 5.66 MULTIPLAN INC 34080 [3081285] MULTIPLAN INC [308128501] 5.38 percent of total billed charges 3.51 5.38 Technical (Hospital) Services QUETIAPINE 25 MG TABLET RX-21823 CDM 6370000100 HCPCS 250 RC 67877-0242-01 NDC outpatient 1 UN 5.66 5.66 CIGNA 62308 [3081051] CIGNA 62308 [308105105] 4.53 percent of total billed charges 3.51 5.38 Technical (Hospital) Services QUETIAPINE 25 MG TABLET RX-21823 CDM 6370000100 HCPCS 250 RC 67877-0242-01 NDC outpatient 1 UN 5.66 5.66 CIGNA 62308 [3081051] CIGNA STATE OF WYOMING [308105107] 4.53 percent of total billed charges 3.51 5.38 Technical (Hospital) Services QUETIAPINE 25 MG TABLET RX-21823 CDM 6370000100 HCPCS 250 RC 67877-0242-01 NDC outpatient 1 UN 5.66 5.66 UNITED HEALTHCARE (COMMERCIAL) [3081199] UNITED HEALTHCARE 87726 [308119901] 3.51 percent of total billed charges 3.51 5.38 Technical (Hospital) Services QUETIAPINE 25 MG TABLET RX-21823 CDM 6370000100 HCPCS 250 RC 67877-0242-01 NDC outpatient 1 UN 5.66 5.66 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES EPO [308136803] 4.53 percent of total billed charges 3.51 5.38 Technical (Hospital) Services QUETIAPINE 25 MG TABLET RX-21823 CDM 6370000100 HCPCS 250 RC 67877-0242-01 NDC outpatient 1 UN 5.66 5.66 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES HDHP [308136802] 4.53 percent of total billed charges 3.51 5.38 Technical (Hospital) Services QUETIAPINE 25 MG TABLET RX-21823 CDM 6370000100 HCPCS 250 RC 67877-0242-01 NDC outpatient 1 UN 5.66 5.66 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES PPO [308136801] 4.53 percent of total billed charges 3.51 5.38 Technical (Hospital) Services QUETIAPINE 25 MG TABLET RX-21823 CDM 6370000100 HCPCS 250 RC 67877-0242-01 NDC inpatient 1 UN 5.66 5.66 MULTIPLAN INC 34080 [3081285] MULTIPLAN INC [308128501] 5.38 percent of total billed charges 3.51 5.38 Technical (Hospital) Services QUETIAPINE 25 MG TABLET RX-21823 CDM 6370000100 HCPCS 250 RC 67877-0242-01 NDC inpatient 1 UN 5.66 5.66 MEDICA (COMMERCIAL) 94265 [3081118] MEDICA CLAIMS [308111801] 5.09 percent of total billed charges 3.51 5.38 Technical (Hospital) Services QUETIAPINE 25 MG TABLET RX-21823 CDM 6370000100 HCPCS 250 RC 67877-0242-01 NDC inpatient 1 UN 5.66 5.66 HEALTHPARTNERS SX009 HEALTHPARTNERS 4.48 percent of total billed charges 3.51 5.38 Technical (Hospital) Services QUETIAPINE 25 MG TABLET RX-21823 CDM 6370000100 HCPCS 250 RC 67877-0242-01 NDC inpatient 1 UN 5.66 5.66 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES PPO [308136801] 4.48 percent of total billed charges 3.51 5.38 Technical (Hospital) Services QUETIAPINE 25 MG TABLET RX-21823 CDM 6370000100 HCPCS 250 RC 67877-0242-01 NDC inpatient 1 UN 5.66 5.66 UNITED HEALTHCARE (COMMERCIAL) [3081199] UNITED HEALTHCARE 87726 [308119901] 3.51 percent of total billed charges 3.51 5.38 Technical (Hospital) Services QUETIAPINE 25 MG TABLET RX-21823 CDM 6370000100 HCPCS 250 RC 67877-0242-01 NDC inpatient 1 UN 5.66 5.66 CIGNA 62308 [3081051] CIGNA 62308 [308105105] 4.48 percent of total billed charges 3.51 5.38 Technical (Hospital) Services QUETIAPINE 25 MG TABLET RX-21823 CDM 6370000100 HCPCS 250 RC 67877-0242-01 NDC inpatient 1 UN 5.66 5.66 BLUE CROSS BLUE SHIELD WELLMARK SB889 [3081026] BCBS WYOMING [308102603] 5.38 percent of total billed charges 3.51 5.38 Technical (Hospital) Services QUETIAPINE 25 MG TABLET RX-21823 CDM 6370000100 HCPCS 250 RC 67877-0242-01 NDC inpatient 1 UN 5.66 5.66 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES HDHP [308136802] 4.48 percent of total billed charges 3.51 5.38 Technical (Hospital) Services QUETIAPINE 25 MG TABLET RX-21823 CDM 6370000100 HCPCS 250 RC 67877-0242-01 NDC inpatient 1 UN 5.66 5.66 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES EPO [308136803] 4.48 percent of total billed charges 3.51 5.38 Technical (Hospital) Services QUETIAPINE 25 MG TABLET RX-21823 CDM 6370000100 HCPCS 250 RC 67877-0242-01 NDC inpatient 1 UN 5.66 5.66 CIGNA 62308 [3081051] CIGNA STATE OF WYOMING [308105107] 4.48 percent of total billed charges 3.51 5.38 Technical (Hospital) Services QUETIAPINE 200 MG TABLET RX-21825 CDM 6370000100 HCPCS 250 RC 67877-0246-01 NDC outpatient 1 UN 5.74 5.74 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES PPO [308136801] 4.59 percent of total billed charges 3.56 5.45 Technical (Hospital) Services QUETIAPINE 200 MG TABLET RX-21825 CDM 6370000100 HCPCS 250 RC 67877-0246-01 NDC outpatient 1 UN 5.74 5.74 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES HDHP [308136802] 4.59 percent of total billed charges 3.56 5.45 Technical (Hospital) Services QUETIAPINE 200 MG TABLET RX-21825 CDM 6370000100 HCPCS 250 RC 67877-0246-01 NDC outpatient 1 UN 5.74 5.74 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES EPO [308136803] 4.59 percent of total billed charges 3.56 5.45 Technical (Hospital) Services QUETIAPINE 200 MG TABLET RX-21825 CDM 6370000100 HCPCS 250 RC 67877-0246-01 NDC outpatient 1 UN 5.74 5.74 HEALTHPARTNERS SX009 HEALTHPARTNERS 4.59 percent of total billed charges 3.56 5.45 Technical (Hospital) Services QUETIAPINE 200 MG TABLET RX-21825 CDM 6370000100 HCPCS 250 RC 67877-0246-01 NDC outpatient 1 UN 5.74 5.74 UNITED HEALTHCARE (COMMERCIAL) [3081199] UNITED HEALTHCARE 87726 [308119901] 3.56 percent of total billed charges 3.56 5.45 Technical (Hospital) Services QUETIAPINE 200 MG TABLET RX-21825 CDM 6370000100 HCPCS 250 RC 67877-0246-01 NDC outpatient 1 UN 5.74 5.74 MEDICA (COMMERCIAL) 94265 [3081118] MEDICA CLAIMS [308111801] 5.17 percent of total billed charges 3.56 5.45 Technical (Hospital) Services QUETIAPINE 200 MG TABLET RX-21825 CDM 6370000100 HCPCS 250 RC 67877-0246-01 NDC outpatient 1 UN 5.74 5.74 MULTIPLAN INC 34080 [3081285] MULTIPLAN INC [308128501] 5.45 percent of total billed charges 3.56 5.45 Technical (Hospital) Services QUETIAPINE 200 MG TABLET RX-21825 CDM 6370000100 HCPCS 250 RC 67877-0246-01 NDC outpatient 1 UN 5.74 5.74 CIGNA 62308 [3081051] CIGNA 62308 [308105105] 4.59 percent of total billed charges 3.56 5.45 Technical (Hospital) Services QUETIAPINE 200 MG TABLET RX-21825 CDM 6370000100 HCPCS 250 RC 67877-0246-01 NDC outpatient 1 UN 5.74 5.74 CIGNA 62308 [3081051] CIGNA STATE OF WYOMING [308105107] 4.59 percent of total billed charges 3.56 5.45 Technical (Hospital) Services QUETIAPINE 200 MG TABLET RX-21825 CDM 6370000100 HCPCS 250 RC 67877-0246-01 NDC outpatient 1 UN 5.74 5.74 BLUE CROSS BLUE SHIELD WELLMARK SB889 [3081026] BCBS WYOMING [308102603] 5.45 percent of total billed charges 3.56 5.45 Technical (Hospital) Services QUETIAPINE 200 MG TABLET RX-21825 CDM 6370000100 HCPCS 250 RC 67877-0246-01 NDC inpatient 1 UN 5.74 5.74 BLUE CROSS BLUE SHIELD WELLMARK SB889 [3081026] BCBS WYOMING [308102603] 5.45 percent of total billed charges 3.56 5.45 Technical (Hospital) Services QUETIAPINE 200 MG TABLET RX-21825 CDM 6370000100 HCPCS 250 RC 67877-0246-01 NDC inpatient 1 UN 5.74 5.74 UNITED HEALTHCARE (COMMERCIAL) [3081199] UNITED HEALTHCARE 87726 [308119901] 3.56 percent of total billed charges 3.56 5.45 Technical (Hospital) Services QUETIAPINE 200 MG TABLET RX-21825 CDM 6370000100 HCPCS 250 RC 67877-0246-01 NDC inpatient 1 UN 5.74 5.74 CIGNA 62308 [3081051] CIGNA 62308 [308105105] 4.54 percent of total billed charges 3.56 5.45 Technical (Hospital) Services QUETIAPINE 200 MG TABLET RX-21825 CDM 6370000100 HCPCS 250 RC 67877-0246-01 NDC inpatient 1 UN 5.74 5.74 CIGNA 62308 [3081051] CIGNA STATE OF WYOMING [308105107] 4.54 percent of total billed charges 3.56 5.45 Technical (Hospital) Services QUETIAPINE 200 MG TABLET RX-21825 CDM 6370000100 HCPCS 250 RC 67877-0246-01 NDC inpatient 1 UN 5.74 5.74 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES EPO [308136803] 4.54 percent of total billed charges 3.56 5.45 Technical (Hospital) Services QUETIAPINE 200 MG TABLET RX-21825 CDM 6370000100 HCPCS 250 RC 67877-0246-01 NDC inpatient 1 UN 5.74 5.74 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES HDHP [308136802] 4.54 percent of total billed charges 3.56 5.45 Technical (Hospital) Services QUETIAPINE 200 MG TABLET RX-21825 CDM 6370000100 HCPCS 250 RC 67877-0246-01 NDC inpatient 1 UN 5.74 5.74 HEALTHPARTNERS SX009 HEALTHPARTNERS 4.54 percent of total billed charges 3.56 5.45 Technical (Hospital) Services QUETIAPINE 200 MG TABLET RX-21825 CDM 6370000100 HCPCS 250 RC 67877-0246-01 NDC inpatient 1 UN 5.74 5.74 MEDICA (COMMERCIAL) 94265 [3081118] MEDICA CLAIMS [308111801] 5.17 percent of total billed charges 3.56 5.45 Technical (Hospital) Services QUETIAPINE 200 MG TABLET RX-21825 CDM 6370000100 HCPCS 250 RC 67877-0246-01 NDC inpatient 1 UN 5.74 5.74 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES PPO [308136801] 4.54 percent of total billed charges 3.56 5.45 Technical (Hospital) Services QUETIAPINE 200 MG TABLET RX-21825 CDM 6370000100 HCPCS 250 RC 67877-0246-01 NDC inpatient 1 UN 5.74 5.74 MULTIPLAN INC 34080 [3081285] MULTIPLAN INC [308128501] 5.45 percent of total billed charges 3.56 5.45 Technical (Hospital) Services IRBESARTAN 75 MG TABLET RX-21847 CDM 6370000100 HCPCS 250 RC 62332-0041-30 NDC inpatient 1 UN 5.97 5.97 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES HDHP [308136802] 4.73 percent of total billed charges 3.7 5.67 Technical (Hospital) Services IRBESARTAN 75 MG TABLET RX-21847 CDM 6370000100 HCPCS 250 RC 62332-0041-30 NDC inpatient 1 UN 5.97 5.97 CIGNA 62308 [3081051] CIGNA 62308 [308105105] 4.73 percent of total billed charges 3.7 5.67 Technical (Hospital) Services IRBESARTAN 75 MG TABLET RX-21847 CDM 6370000100 HCPCS 250 RC 62332-0041-30 NDC inpatient 1 UN 5.97 5.97 CIGNA 62308 [3081051] CIGNA STATE OF WYOMING [308105107] 4.73 percent of total billed charges 3.7 5.67 Technical (Hospital) Services IRBESARTAN 75 MG TABLET RX-21847 CDM 6370000100 HCPCS 250 RC 62332-0041-30 NDC inpatient 1 UN 5.97 5.97 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES EPO [308136803] 4.73 percent of total billed charges 3.7 5.67 Technical (Hospital) Services IRBESARTAN 75 MG TABLET RX-21847 CDM 6370000100 HCPCS 250 RC 62332-0041-30 NDC inpatient 1 UN 5.97 5.97 BLUE CROSS BLUE SHIELD WELLMARK SB889 [3081026] BCBS WYOMING [308102603] 5.67 percent of total billed charges 3.7 5.67 Technical (Hospital) Services IRBESARTAN 75 MG TABLET RX-21847 CDM 6370000100 HCPCS 250 RC 62332-0041-30 NDC inpatient 1 UN 5.97 5.97 UNITED HEALTHCARE (COMMERCIAL) [3081199] UNITED HEALTHCARE 87726 [308119901] 3.7 percent of total billed charges 3.7 5.67 Technical (Hospital) Services IRBESARTAN 75 MG TABLET RX-21847 CDM 6370000100 HCPCS 250 RC 62332-0041-30 NDC inpatient 1 UN 5.97 5.97 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES PPO [308136801] 4.73 percent of total billed charges 3.7 5.67 Technical (Hospital) Services IRBESARTAN 75 MG TABLET RX-21847 CDM 6370000100 HCPCS 250 RC 62332-0041-30 NDC inpatient 1 UN 5.97 5.97 HEALTHPARTNERS SX009 HEALTHPARTNERS 4.73 percent of total billed charges 3.7 5.67 Technical (Hospital) Services IRBESARTAN 75 MG TABLET RX-21847 CDM 6370000100 HCPCS 250 RC 62332-0041-30 NDC inpatient 1 UN 5.97 5.97 MEDICA (COMMERCIAL) 94265 [3081118] MEDICA CLAIMS [308111801] 5.37 percent of total billed charges 3.7 5.67 Technical (Hospital) Services IRBESARTAN 75 MG TABLET RX-21847 CDM 6370000100 HCPCS 250 RC 62332-0041-30 NDC inpatient 1 UN 5.97 5.97 MULTIPLAN INC 34080 [3081285] MULTIPLAN INC [308128501] 5.67 percent of total billed charges 3.7 5.67 Technical (Hospital) Services IRBESARTAN 75 MG TABLET RX-21847 CDM 6370000100 HCPCS 250 RC 62332-0041-30 NDC outpatient 1 UN 5.97 5.97 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES EPO [308136803] 4.78 percent of total billed charges 3.7 5.67 Technical (Hospital) Services IRBESARTAN 75 MG TABLET RX-21847 CDM 6370000100 HCPCS 250 RC 62332-0041-30 NDC outpatient 1 UN 5.97 5.97 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES HDHP [308136802] 4.78 percent of total billed charges 3.7 5.67 Technical (Hospital) Services IRBESARTAN 75 MG TABLET RX-21847 CDM 6370000100 HCPCS 250 RC 62332-0041-30 NDC outpatient 1 UN 5.97 5.97 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES PPO [308136801] 4.78 percent of total billed charges 3.7 5.67 Technical (Hospital) Services IRBESARTAN 75 MG TABLET RX-21847 CDM 6370000100 HCPCS 250 RC 62332-0041-30 NDC outpatient 1 UN 5.97 5.97 BLUE CROSS BLUE SHIELD WELLMARK SB889 [3081026] BCBS WYOMING [308102603] 5.67 percent of total billed charges 3.7 5.67 Technical (Hospital) Services IRBESARTAN 75 MG TABLET RX-21847 CDM 6370000100 HCPCS 250 RC 62332-0041-30 NDC outpatient 1 UN 5.97 5.97 HEALTHPARTNERS SX009 HEALTHPARTNERS 4.78 percent of total billed charges 3.7 5.67 Technical (Hospital) Services IRBESARTAN 75 MG TABLET RX-21847 CDM 6370000100 HCPCS 250 RC 62332-0041-30 NDC outpatient 1 UN 5.97 5.97 UNITED HEALTHCARE (COMMERCIAL) [3081199] UNITED HEALTHCARE 87726 [308119901] 3.7 percent of total billed charges 3.7 5.67 Technical (Hospital) Services IRBESARTAN 75 MG TABLET RX-21847 CDM 6370000100 HCPCS 250 RC 62332-0041-30 NDC outpatient 1 UN 5.97 5.97 CIGNA 62308 [3081051] CIGNA 62308 [308105105] 4.78 percent of total billed charges 3.7 5.67 Technical (Hospital) Services IRBESARTAN 75 MG TABLET RX-21847 CDM 6370000100 HCPCS 250 RC 62332-0041-30 NDC outpatient 1 UN 5.97 5.97 CIGNA 62308 [3081051] CIGNA STATE OF WYOMING [308105107] 4.78 percent of total billed charges 3.7 5.67 Technical (Hospital) Services IRBESARTAN 75 MG TABLET RX-21847 CDM 6370000100 HCPCS 250 RC 62332-0041-30 NDC outpatient 1 UN 5.97 5.97 MULTIPLAN INC 34080 [3081285] MULTIPLAN INC [308128501] 5.67 percent of total billed charges 3.7 5.67 Technical (Hospital) Services IRBESARTAN 75 MG TABLET RX-21847 CDM 6370000100 HCPCS 250 RC 62332-0041-30 NDC outpatient 1 UN 5.97 5.97 MEDICA (COMMERCIAL) 94265 [3081118] MEDICA CLAIMS [308111801] 5.37 percent of total billed charges 3.7 5.67 Technical (Hospital) Services CLOPIDOGREL 75 MG TABLET RX-22142 CDM 6370000100 HCPCS 250 RC 00904-6294-61 NDC outpatient 1 UN 5.86 5.86 HEALTHPARTNERS SX009 HEALTHPARTNERS 4.69 percent of total billed charges 3.63 5.57 Technical (Hospital) Services CLOPIDOGREL 75 MG TABLET RX-22142 CDM 6370000100 HCPCS 250 RC 00904-6294-61 NDC outpatient 1 UN 5.86 5.86 BLUE CROSS BLUE SHIELD WELLMARK SB889 [3081026] BCBS WYOMING [308102603] 5.57 percent of total billed charges 3.63 5.57 Technical (Hospital) Services CLOPIDOGREL 75 MG TABLET RX-22142 CDM 6370000100 HCPCS 250 RC 00904-6294-61 NDC outpatient 1 UN 5.86 5.86 CIGNA 62308 [3081051] CIGNA 62308 [308105105] 4.69 percent of total billed charges 3.63 5.57 Technical (Hospital) Services CLOPIDOGREL 75 MG TABLET RX-22142 CDM 6370000100 HCPCS 250 RC 00904-6294-61 NDC outpatient 1 UN 5.86 5.86 CIGNA 62308 [3081051] CIGNA STATE OF WYOMING [308105107] 4.69 percent of total billed charges 3.63 5.57 Technical (Hospital) Services CLOPIDOGREL 75 MG TABLET RX-22142 CDM 6370000100 HCPCS 250 RC 00904-6294-61 NDC outpatient 1 UN 5.86 5.86 MEDICA (COMMERCIAL) 94265 [3081118] MEDICA CLAIMS [308111801] 5.27 percent of total billed charges 3.63 5.57 Technical (Hospital) Services CLOPIDOGREL 75 MG TABLET RX-22142 CDM 6370000100 HCPCS 250 RC 00904-6294-61 NDC outpatient 1 UN 5.86 5.86 MULTIPLAN INC 34080 [3081285] MULTIPLAN INC [308128501] 5.57 percent of total billed charges 3.63 5.57 Technical (Hospital) Services CLOPIDOGREL 75 MG TABLET RX-22142 CDM 6370000100 HCPCS 250 RC 00904-6294-61 NDC outpatient 1 UN 5.86 5.86 UNITED HEALTHCARE (COMMERCIAL) [3081199] UNITED HEALTHCARE 87726 [308119901] 3.63 percent of total billed charges 3.63 5.57 Technical (Hospital) Services CLOPIDOGREL 75 MG TABLET RX-22142 CDM 6370000100 HCPCS 250 RC 00904-6294-61 NDC outpatient 1 UN 5.86 5.86 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES EPO [308136803] 4.69 percent of total billed charges 3.63 5.57 Technical (Hospital) Services CLOPIDOGREL 75 MG TABLET RX-22142 CDM 6370000100 HCPCS 250 RC 00904-6294-61 NDC outpatient 1 UN 5.86 5.86 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES HDHP [308136802] 4.69 percent of total billed charges 3.63 5.57 Technical (Hospital) Services CLOPIDOGREL 75 MG TABLET RX-22142 CDM 6370000100 HCPCS 250 RC 00904-6294-61 NDC outpatient 1 UN 5.86 5.86 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES PPO [308136801] 4.69 percent of total billed charges 3.63 5.57 Technical (Hospital) Services CLOPIDOGREL 75 MG TABLET RX-22142 CDM 6370000100 HCPCS 250 RC 00904-6294-61 NDC inpatient 1 UN 5.86 5.86 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES HDHP [308136802] 4.64 percent of total billed charges 3.63 5.57 Technical (Hospital) Services CLOPIDOGREL 75 MG TABLET RX-22142 CDM 6370000100 HCPCS 250 RC 00904-6294-61 NDC inpatient 1 UN 5.86 5.86 CIGNA 62308 [3081051] CIGNA 62308 [308105105] 4.64 percent of total billed charges 3.63 5.57 Technical (Hospital) Services CLOPIDOGREL 75 MG TABLET RX-22142 CDM 6370000100 HCPCS 250 RC 00904-6294-61 NDC inpatient 1 UN 5.86 5.86 CIGNA 62308 [3081051] CIGNA STATE OF WYOMING [308105107] 4.64 percent of total billed charges 3.63 5.57 Technical (Hospital) Services CLOPIDOGREL 75 MG TABLET RX-22142 CDM 6370000100 HCPCS 250 RC 00904-6294-61 NDC inpatient 1 UN 5.86 5.86 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES EPO [308136803] 4.64 percent of total billed charges 3.63 5.57 Technical (Hospital) Services CLOPIDOGREL 75 MG TABLET RX-22142 CDM 6370000100 HCPCS 250 RC 00904-6294-61 NDC inpatient 1 UN 5.86 5.86 BLUE CROSS BLUE SHIELD WELLMARK SB889 [3081026] BCBS WYOMING [308102603] 5.57 percent of total billed charges 3.63 5.57 Technical (Hospital) Services CLOPIDOGREL 75 MG TABLET RX-22142 CDM 6370000100 HCPCS 250 RC 00904-6294-61 NDC inpatient 1 UN 5.86 5.86 UNITED HEALTHCARE (COMMERCIAL) [3081199] UNITED HEALTHCARE 87726 [308119901] 3.63 percent of total billed charges 3.63 5.57 Technical (Hospital) Services CLOPIDOGREL 75 MG TABLET RX-22142 CDM 6370000100 HCPCS 250 RC 00904-6294-61 NDC inpatient 1 UN 5.86 5.86 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES PPO [308136801] 4.64 percent of total billed charges 3.63 5.57 Technical (Hospital) Services CLOPIDOGREL 75 MG TABLET RX-22142 CDM 6370000100 HCPCS 250 RC 00904-6294-61 NDC inpatient 1 UN 5.86 5.86 MEDICA (COMMERCIAL) 94265 [3081118] MEDICA CLAIMS [308111801] 5.27 percent of total billed charges 3.63 5.57 Technical (Hospital) Services CLOPIDOGREL 75 MG TABLET RX-22142 CDM 6370000100 HCPCS 250 RC 00904-6294-61 NDC inpatient 1 UN 5.86 5.86 HEALTHPARTNERS SX009 HEALTHPARTNERS 4.64 percent of total billed charges 3.63 5.57 Technical (Hospital) Services CLOPIDOGREL 75 MG TABLET RX-22142 CDM 6370000100 HCPCS 250 RC 00904-6294-61 NDC inpatient 1 UN 5.86 5.86 MULTIPLAN INC 34080 [3081285] MULTIPLAN INC [308128501] 5.57 percent of total billed charges 3.63 5.57 Technical (Hospital) Services OFLOXACIN 0.3 % EAR DROPS RX-22257 CDM 6370000100 HCPCS 250 RC 60505-0363-01 NDC inpatient 5 ML 245 245 BLUE CROSS BLUE SHIELD WELLMARK SB889 [3081026] BCBS WYOMING [308102603] 232.75 percent of total billed charges 151.9 232.75 Technical (Hospital) Services OFLOXACIN 0.3 % EAR DROPS RX-22257 CDM 6370000100 HCPCS 250 RC 60505-0363-01 NDC inpatient 5 ML 245 245 UNITED HEALTHCARE (COMMERCIAL) [3081199] UNITED HEALTHCARE 87726 [308119901] 151.9 percent of total billed charges 151.9 232.75 Technical (Hospital) Services OFLOXACIN 0.3 % EAR DROPS RX-22257 CDM 6370000100 HCPCS 250 RC 60505-0363-01 NDC inpatient 5 ML 245 245 CIGNA 62308 [3081051] CIGNA 62308 [308105105] 193.99 percent of total billed charges 151.9 232.75 Technical (Hospital) Services OFLOXACIN 0.3 % EAR DROPS RX-22257 CDM 6370000100 HCPCS 250 RC 60505-0363-01 NDC inpatient 5 ML 245 245 CIGNA 62308 [3081051] CIGNA STATE OF WYOMING [308105107] 193.99 percent of total billed charges 151.9 232.75 Technical (Hospital) Services OFLOXACIN 0.3 % EAR DROPS RX-22257 CDM 6370000100 HCPCS 250 RC 60505-0363-01 NDC inpatient 5 ML 245 245 MULTIPLAN INC 34080 [3081285] MULTIPLAN INC [308128501] 232.75 percent of total billed charges 151.9 232.75 Technical (Hospital) Services OFLOXACIN 0.3 % EAR DROPS RX-22257 CDM 6370000100 HCPCS 250 RC 60505-0363-01 NDC inpatient 5 ML 245 245 MEDICA (COMMERCIAL) 94265 [3081118] MEDICA CLAIMS [308111801] 220.5 percent of total billed charges 151.9 232.75 Technical (Hospital) Services OFLOXACIN 0.3 % EAR DROPS RX-22257 CDM 6370000100 HCPCS 250 RC 60505-0363-01 NDC inpatient 5 ML 245 245 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES EPO [308136803] 193.99 percent of total billed charges 151.9 232.75 Technical (Hospital) Services OFLOXACIN 0.3 % EAR DROPS RX-22257 CDM 6370000100 HCPCS 250 RC 60505-0363-01 NDC inpatient 5 ML 245 245 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES PPO [308136801] 193.99 percent of total billed charges 151.9 232.75 Technical (Hospital) Services OFLOXACIN 0.3 % EAR DROPS RX-22257 CDM 6370000100 HCPCS 250 RC 60505-0363-01 NDC inpatient 5 ML 245 245 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES HDHP [308136802] 193.99 percent of total billed charges 151.9 232.75 Technical (Hospital) Services OFLOXACIN 0.3 % EAR DROPS RX-22257 CDM 6370000100 HCPCS 250 RC 60505-0363-01 NDC inpatient 5 ML 245 245 HEALTHPARTNERS SX009 HEALTHPARTNERS 193.99 percent of total billed charges 151.9 232.75 Technical (Hospital) Services OFLOXACIN 0.3 % EAR DROPS RX-22257 CDM 6370000100 HCPCS 250 RC 60505-0363-01 NDC outpatient 5 ML 245 245 MULTIPLAN INC 34080 [3081285] MULTIPLAN INC [308128501] 232.75 percent of total billed charges 151.9 232.75 Technical (Hospital) Services OFLOXACIN 0.3 % EAR DROPS RX-22257 CDM 6370000100 HCPCS 250 RC 60505-0363-01 NDC outpatient 5 ML 245 245 MEDICA (COMMERCIAL) 94265 [3081118] MEDICA CLAIMS [308111801] 220.5 percent of total billed charges 151.9 232.75 Technical (Hospital) Services OFLOXACIN 0.3 % EAR DROPS RX-22257 CDM 6370000100 HCPCS 250 RC 60505-0363-01 NDC outpatient 5 ML 245 245 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES PPO [308136801] 196 percent of total billed charges 151.9 232.75 Technical (Hospital) Services OFLOXACIN 0.3 % EAR DROPS RX-22257 CDM 6370000100 HCPCS 250 RC 60505-0363-01 NDC outpatient 5 ML 245 245 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES HDHP [308136802] 196 percent of total billed charges 151.9 232.75 Technical (Hospital) Services OFLOXACIN 0.3 % EAR DROPS RX-22257 CDM 6370000100 HCPCS 250 RC 60505-0363-01 NDC outpatient 5 ML 245 245 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES EPO [308136803] 196 percent of total billed charges 151.9 232.75 Technical (Hospital) Services OFLOXACIN 0.3 % EAR DROPS RX-22257 CDM 6370000100 HCPCS 250 RC 60505-0363-01 NDC outpatient 5 ML 245 245 CIGNA 62308 [3081051] CIGNA 62308 [308105105] 196 percent of total billed charges 151.9 232.75 Technical (Hospital) Services OFLOXACIN 0.3 % EAR DROPS RX-22257 CDM 6370000100 HCPCS 250 RC 60505-0363-01 NDC outpatient 5 ML 245 245 CIGNA 62308 [3081051] CIGNA STATE OF WYOMING [308105107] 196 percent of total billed charges 151.9 232.75 Technical (Hospital) Services OFLOXACIN 0.3 % EAR DROPS RX-22257 CDM 6370000100 HCPCS 250 RC 60505-0363-01 NDC outpatient 5 ML 245 245 UNITED HEALTHCARE (COMMERCIAL) [3081199] UNITED HEALTHCARE 87726 [308119901] 151.9 percent of total billed charges 151.9 232.75 Technical (Hospital) Services OFLOXACIN 0.3 % EAR DROPS RX-22257 CDM 6370000100 HCPCS 250 RC 60505-0363-01 NDC outpatient 5 ML 245 245 BLUE CROSS BLUE SHIELD WELLMARK SB889 [3081026] BCBS WYOMING [308102603] 232.75 percent of total billed charges 151.9 232.75 Technical (Hospital) Services OFLOXACIN 0.3 % EAR DROPS RX-22257 CDM 6370000100 HCPCS 250 RC 60505-0363-01 NDC outpatient 5 ML 245 245 HEALTHPARTNERS SX009 HEALTHPARTNERS 196 percent of total billed charges 151.9 232.75 Technical (Hospital) Services MONTELUKAST 10 MG TABLET RX-22509 CDM 6370000100 HCPCS 250 RC 13668-0081-30 NDC inpatient 1 UN 5.85 5.85 MULTIPLAN INC 34080 [3081285] MULTIPLAN INC [308128501] 5.56 percent of total billed charges 3.63 5.56 Technical (Hospital) Services MONTELUKAST 10 MG TABLET RX-22509 CDM 6370000100 HCPCS 250 RC 13668-0081-30 NDC inpatient 1 UN 5.85 5.85 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES PPO [308136801] 4.63 percent of total billed charges 3.63 5.56 Technical (Hospital) Services MONTELUKAST 10 MG TABLET RX-22509 CDM 6370000100 HCPCS 250 RC 13668-0081-30 NDC inpatient 1 UN 5.85 5.85 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES EPO [308136803] 4.63 percent of total billed charges 3.63 5.56 Technical (Hospital) Services MONTELUKAST 10 MG TABLET RX-22509 CDM 6370000100 HCPCS 250 RC 13668-0081-30 NDC inpatient 1 UN 5.85 5.85 CIGNA 62308 [3081051] CIGNA 62308 [308105105] 4.63 percent of total billed charges 3.63 5.56 Technical (Hospital) Services MONTELUKAST 10 MG TABLET RX-22509 CDM 6370000100 HCPCS 250 RC 13668-0081-30 NDC inpatient 1 UN 5.85 5.85 CIGNA 62308 [3081051] CIGNA STATE OF WYOMING [308105107] 4.63 percent of total billed charges 3.63 5.56 Technical (Hospital) Services MONTELUKAST 10 MG TABLET RX-22509 CDM 6370000100 HCPCS 250 RC 13668-0081-30 NDC inpatient 1 UN 5.85 5.85 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES HDHP [308136802] 4.63 percent of total billed charges 3.63 5.56 Technical (Hospital) Services MONTELUKAST 10 MG TABLET RX-22509 CDM 6370000100 HCPCS 250 RC 13668-0081-30 NDC inpatient 1 UN 5.85 5.85 MEDICA (COMMERCIAL) 94265 [3081118] MEDICA CLAIMS [308111801] 5.27 percent of total billed charges 3.63 5.56 Technical (Hospital) Services MONTELUKAST 10 MG TABLET RX-22509 CDM 6370000100 HCPCS 250 RC 13668-0081-30 NDC inpatient 1 UN 5.85 5.85 HEALTHPARTNERS SX009 HEALTHPARTNERS 4.63 percent of total billed charges 3.63 5.56 Technical (Hospital) Services MONTELUKAST 10 MG TABLET RX-22509 CDM 6370000100 HCPCS 250 RC 13668-0081-30 NDC inpatient 1 UN 5.85 5.85 UNITED HEALTHCARE (COMMERCIAL) [3081199] UNITED HEALTHCARE 87726 [308119901] 3.63 percent of total billed charges 3.63 5.56 Technical (Hospital) Services MONTELUKAST 10 MG TABLET RX-22509 CDM 6370000100 HCPCS 250 RC 13668-0081-30 NDC inpatient 1 UN 5.85 5.85 BLUE CROSS BLUE SHIELD WELLMARK SB889 [3081026] BCBS WYOMING [308102603] 5.56 percent of total billed charges 3.63 5.56 Technical (Hospital) Services MONTELUKAST 10 MG TABLET RX-22509 CDM 6370000100 HCPCS 250 RC 13668-0081-30 NDC outpatient 1 UN 5.85 5.85 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES PPO [308136801] 4.68 percent of total billed charges 3.63 5.56 Technical (Hospital) Services MONTELUKAST 10 MG TABLET RX-22509 CDM 6370000100 HCPCS 250 RC 13668-0081-30 NDC outpatient 1 UN 5.85 5.85 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES HDHP [308136802] 4.68 percent of total billed charges 3.63 5.56 Technical (Hospital) Services MONTELUKAST 10 MG TABLET RX-22509 CDM 6370000100 HCPCS 250 RC 13668-0081-30 NDC outpatient 1 UN 5.85 5.85 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES EPO [308136803] 4.68 percent of total billed charges 3.63 5.56 Technical (Hospital) Services MONTELUKAST 10 MG TABLET RX-22509 CDM 6370000100 HCPCS 250 RC 13668-0081-30 NDC outpatient 1 UN 5.85 5.85 BLUE CROSS BLUE SHIELD WELLMARK SB889 [3081026] BCBS WYOMING [308102603] 5.56 percent of total billed charges 3.63 5.56 Technical (Hospital) Services MONTELUKAST 10 MG TABLET RX-22509 CDM 6370000100 HCPCS 250 RC 13668-0081-30 NDC outpatient 1 UN 5.85 5.85 HEALTHPARTNERS SX009 HEALTHPARTNERS 4.68 percent of total billed charges 3.63 5.56 Technical (Hospital) Services MONTELUKAST 10 MG TABLET RX-22509 CDM 6370000100 HCPCS 250 RC 13668-0081-30 NDC outpatient 1 UN 5.85 5.85 MEDICA (COMMERCIAL) 94265 [3081118] MEDICA CLAIMS [308111801] 5.27 percent of total billed charges 3.63 5.56 Technical (Hospital) Services MONTELUKAST 10 MG TABLET RX-22509 CDM 6370000100 HCPCS 250 RC 13668-0081-30 NDC outpatient 1 UN 5.85 5.85 MULTIPLAN INC 34080 [3081285] MULTIPLAN INC [308128501] 5.56 percent of total billed charges 3.63 5.56 Technical (Hospital) Services MONTELUKAST 10 MG TABLET RX-22509 CDM 6370000100 HCPCS 250 RC 13668-0081-30 NDC outpatient 1 UN 5.85 5.85 CIGNA 62308 [3081051] CIGNA 62308 [308105105] 4.68 percent of total billed charges 3.63 5.56 Technical (Hospital) Services MONTELUKAST 10 MG TABLET RX-22509 CDM 6370000100 HCPCS 250 RC 13668-0081-30 NDC outpatient 1 UN 5.85 5.85 CIGNA 62308 [3081051] CIGNA STATE OF WYOMING [308105107] 4.68 percent of total billed charges 3.63 5.56 Technical (Hospital) Services MONTELUKAST 10 MG TABLET RX-22509 CDM 6370000100 HCPCS 250 RC 13668-0081-30 NDC outpatient 1 UN 5.85 5.85 UNITED HEALTHCARE (COMMERCIAL) [3081199] UNITED HEALTHCARE 87726 [308119901] 3.63 percent of total billed charges 3.63 5.56 Technical (Hospital) Services SULFAMETHOXAZOLE 200 MG-TRIMETHOPRIM 40 MG/5 ML ORAL SUSPENSION RX-22560 CDM 6370000100 HCPCS 250 RC 65862-0496-47 NDC inpatient 473 ML 143.04 143.04 UNITED HEALTHCARE (COMMERCIAL) [3081199] UNITED HEALTHCARE 87726 [308119901] 88.68 percent of total billed charges 88.68 135.89 Technical (Hospital) Services SULFAMETHOXAZOLE 200 MG-TRIMETHOPRIM 40 MG/5 ML ORAL SUSPENSION RX-22560 CDM 6370000100 HCPCS 250 RC 65862-0496-47 NDC inpatient 473 ML 143.04 143.04 BLUE CROSS BLUE SHIELD WELLMARK SB889 [3081026] BCBS WYOMING [308102603] 135.89 percent of total billed charges 88.68 135.89 Technical (Hospital) Services SULFAMETHOXAZOLE 200 MG-TRIMETHOPRIM 40 MG/5 ML ORAL SUSPENSION RX-22560 CDM 6370000100 HCPCS 250 RC 65862-0496-47 NDC inpatient 473 ML 143.04 143.04 HEALTHPARTNERS SX009 HEALTHPARTNERS 113.26 percent of total billed charges 88.68 135.89 Technical (Hospital) Services SULFAMETHOXAZOLE 200 MG-TRIMETHOPRIM 40 MG/5 ML ORAL SUSPENSION RX-22560 CDM 6370000100 HCPCS 250 RC 65862-0496-47 NDC inpatient 473 ML 143.04 143.04 MEDICA (COMMERCIAL) 94265 [3081118] MEDICA CLAIMS [308111801] 128.74 percent of total billed charges 88.68 135.89 Technical (Hospital) Services SULFAMETHOXAZOLE 200 MG-TRIMETHOPRIM 40 MG/5 ML ORAL SUSPENSION RX-22560 CDM 6370000100 HCPCS 250 RC 65862-0496-47 NDC inpatient 473 ML 143.04 143.04 MULTIPLAN INC 34080 [3081285] MULTIPLAN INC [308128501] 135.89 percent of total billed charges 88.68 135.89 Technical (Hospital) Services SULFAMETHOXAZOLE 200 MG-TRIMETHOPRIM 40 MG/5 ML ORAL SUSPENSION RX-22560 CDM 6370000100 HCPCS 250 RC 65862-0496-47 NDC inpatient 473 ML 143.04 143.04 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES HDHP [308136802] 113.26 percent of total billed charges 88.68 135.89 Technical (Hospital) Services SULFAMETHOXAZOLE 200 MG-TRIMETHOPRIM 40 MG/5 ML ORAL SUSPENSION RX-22560 CDM 6370000100 HCPCS 250 RC 65862-0496-47 NDC inpatient 473 ML 143.04 143.04 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES PPO [308136801] 113.26 percent of total billed charges 88.68 135.89 Technical (Hospital) Services SULFAMETHOXAZOLE 200 MG-TRIMETHOPRIM 40 MG/5 ML ORAL SUSPENSION RX-22560 CDM 6370000100 HCPCS 250 RC 65862-0496-47 NDC inpatient 473 ML 143.04 143.04 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES EPO [308136803] 113.26 percent of total billed charges 88.68 135.89 Technical (Hospital) Services SULFAMETHOXAZOLE 200 MG-TRIMETHOPRIM 40 MG/5 ML ORAL SUSPENSION RX-22560 CDM 6370000100 HCPCS 250 RC 65862-0496-47 NDC inpatient 473 ML 143.04 143.04 CIGNA 62308 [3081051] CIGNA 62308 [308105105] 113.26 percent of total billed charges 88.68 135.89 Technical (Hospital) Services SULFAMETHOXAZOLE 200 MG-TRIMETHOPRIM 40 MG/5 ML ORAL SUSPENSION RX-22560 CDM 6370000100 HCPCS 250 RC 65862-0496-47 NDC inpatient 473 ML 143.04 143.04 CIGNA 62308 [3081051] CIGNA STATE OF WYOMING [308105107] 113.26 percent of total billed charges 88.68 135.89 Technical (Hospital) Services SULFAMETHOXAZOLE 200 MG-TRIMETHOPRIM 40 MG/5 ML ORAL SUSPENSION RX-22560 CDM 6370000100 HCPCS 250 RC 65862-0496-47 NDC outpatient 473 ML 143.04 143.04 CIGNA 62308 [3081051] CIGNA 62308 [308105105] 114.43 percent of total billed charges 88.68 135.89 Technical (Hospital) Services SULFAMETHOXAZOLE 200 MG-TRIMETHOPRIM 40 MG/5 ML ORAL SUSPENSION RX-22560 CDM 6370000100 HCPCS 250 RC 65862-0496-47 NDC outpatient 473 ML 143.04 143.04 CIGNA 62308 [3081051] CIGNA STATE OF WYOMING [308105107] 114.43 percent of total billed charges 88.68 135.89 Technical (Hospital) Services SULFAMETHOXAZOLE 200 MG-TRIMETHOPRIM 40 MG/5 ML ORAL SUSPENSION RX-22560 CDM 6370000100 HCPCS 250 RC 65862-0496-47 NDC outpatient 473 ML 143.04 143.04 MULTIPLAN INC 34080 [3081285] MULTIPLAN INC [308128501] 135.89 percent of total billed charges 88.68 135.89 Technical (Hospital) Services SULFAMETHOXAZOLE 200 MG-TRIMETHOPRIM 40 MG/5 ML ORAL SUSPENSION RX-22560 CDM 6370000100 HCPCS 250 RC 65862-0496-47 NDC outpatient 473 ML 143.04 143.04 MEDICA (COMMERCIAL) 94265 [3081118] MEDICA CLAIMS [308111801] 128.74 percent of total billed charges 88.68 135.89 Technical (Hospital) Services SULFAMETHOXAZOLE 200 MG-TRIMETHOPRIM 40 MG/5 ML ORAL SUSPENSION RX-22560 CDM 6370000100 HCPCS 250 RC 65862-0496-47 NDC outpatient 473 ML 143.04 143.04 HEALTHPARTNERS SX009 HEALTHPARTNERS 114.43 percent of total billed charges 88.68 135.89 Technical (Hospital) Services SULFAMETHOXAZOLE 200 MG-TRIMETHOPRIM 40 MG/5 ML ORAL SUSPENSION RX-22560 CDM 6370000100 HCPCS 250 RC 65862-0496-47 NDC outpatient 473 ML 143.04 143.04 UNITED HEALTHCARE (COMMERCIAL) [3081199] UNITED HEALTHCARE 87726 [308119901] 88.68 percent of total billed charges 88.68 135.89 Technical (Hospital) Services SULFAMETHOXAZOLE 200 MG-TRIMETHOPRIM 40 MG/5 ML ORAL SUSPENSION RX-22560 CDM 6370000100 HCPCS 250 RC 65862-0496-47 NDC outpatient 473 ML 143.04 143.04 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES HDHP [308136802] 114.43 percent of total billed charges 88.68 135.89 Technical (Hospital) Services SULFAMETHOXAZOLE 200 MG-TRIMETHOPRIM 40 MG/5 ML ORAL SUSPENSION RX-22560 CDM 6370000100 HCPCS 250 RC 65862-0496-47 NDC outpatient 473 ML 143.04 143.04 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES PPO [308136801] 114.43 percent of total billed charges 88.68 135.89 Technical (Hospital) Services SULFAMETHOXAZOLE 200 MG-TRIMETHOPRIM 40 MG/5 ML ORAL SUSPENSION RX-22560 CDM 6370000100 HCPCS 250 RC 65862-0496-47 NDC outpatient 473 ML 143.04 143.04 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES EPO [308136803] 114.43 percent of total billed charges 88.68 135.89 Technical (Hospital) Services SULFAMETHOXAZOLE 200 MG-TRIMETHOPRIM 40 MG/5 ML ORAL SUSPENSION RX-22560 CDM 6370000100 HCPCS 250 RC 65862-0496-47 NDC outpatient 473 ML 143.04 143.04 BLUE CROSS BLUE SHIELD WELLMARK SB889 [3081026] BCBS WYOMING [308102603] 135.89 percent of total billed charges 88.68 135.89 Technical (Hospital) Services LOSARTAN 100 MG TABLET RX-22588 CDM 6370000100 HCPCS 250 RC 65862-0203-90 NDC outpatient 1 UN 5.76 5.76 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES HDHP [308136802] 4.61 percent of total billed charges 3.57 5.47 Technical (Hospital) Services LOSARTAN 100 MG TABLET RX-22588 CDM 6370000100 HCPCS 250 RC 65862-0203-90 NDC outpatient 1 UN 5.76 5.76 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES EPO [308136803] 4.61 percent of total billed charges 3.57 5.47 Technical (Hospital) Services LOSARTAN 100 MG TABLET RX-22588 CDM 6370000100 HCPCS 250 RC 65862-0203-90 NDC outpatient 1 UN 5.76 5.76 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES PPO [308136801] 4.61 percent of total billed charges 3.57 5.47 Technical (Hospital) Services LOSARTAN 100 MG TABLET RX-22588 CDM 6370000100 HCPCS 250 RC 65862-0203-90 NDC outpatient 1 UN 5.76 5.76 BLUE CROSS BLUE SHIELD WELLMARK SB889 [3081026] BCBS WYOMING [308102603] 5.47 percent of total billed charges 3.57 5.47 Technical (Hospital) Services LOSARTAN 100 MG TABLET RX-22588 CDM 6370000100 HCPCS 250 RC 65862-0203-90 NDC outpatient 1 UN 5.76 5.76 HEALTHPARTNERS SX009 HEALTHPARTNERS 4.61 percent of total billed charges 3.57 5.47 Technical (Hospital) Services LOSARTAN 100 MG TABLET RX-22588 CDM 6370000100 HCPCS 250 RC 65862-0203-90 NDC outpatient 1 UN 5.76 5.76 MULTIPLAN INC 34080 [3081285] MULTIPLAN INC [308128501] 5.47 percent of total billed charges 3.57 5.47 Technical (Hospital) Services LOSARTAN 100 MG TABLET RX-22588 CDM 6370000100 HCPCS 250 RC 65862-0203-90 NDC outpatient 1 UN 5.76 5.76 CIGNA 62308 [3081051] CIGNA 62308 [308105105] 4.61 percent of total billed charges 3.57 5.47 Technical (Hospital) Services LOSARTAN 100 MG TABLET RX-22588 CDM 6370000100 HCPCS 250 RC 65862-0203-90 NDC outpatient 1 UN 5.76 5.76 CIGNA 62308 [3081051] CIGNA STATE OF WYOMING [308105107] 4.61 percent of total billed charges 3.57 5.47 Technical (Hospital) Services LOSARTAN 100 MG TABLET RX-22588 CDM 6370000100 HCPCS 250 RC 65862-0203-90 NDC outpatient 1 UN 5.76 5.76 UNITED HEALTHCARE (COMMERCIAL) [3081199] UNITED HEALTHCARE 87726 [308119901] 3.57 percent of total billed charges 3.57 5.47 Technical (Hospital) Services LOSARTAN 100 MG TABLET RX-22588 CDM 6370000100 HCPCS 250 RC 65862-0203-90 NDC outpatient 1 UN 5.76 5.76 MEDICA (COMMERCIAL) 94265 [3081118] MEDICA CLAIMS [308111801] 5.18 percent of total billed charges 3.57 5.47 Technical (Hospital) Services LOSARTAN 100 MG TABLET RX-22588 CDM 6370000100 HCPCS 250 RC 65862-0203-90 NDC inpatient 1 UN 5.76 5.76 UNITED HEALTHCARE (COMMERCIAL) [3081199] UNITED HEALTHCARE 87726 [308119901] 3.57 percent of total billed charges 3.57 5.47 Technical (Hospital) Services LOSARTAN 100 MG TABLET RX-22588 CDM 6370000100 HCPCS 250 RC 65862-0203-90 NDC inpatient 1 UN 5.76 5.76 BLUE CROSS BLUE SHIELD WELLMARK SB889 [3081026] BCBS WYOMING [308102603] 5.47 percent of total billed charges 3.57 5.47 Technical (Hospital) Services LOSARTAN 100 MG TABLET RX-22588 CDM 6370000100 HCPCS 250 RC 65862-0203-90 NDC inpatient 1 UN 5.76 5.76 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES HDHP [308136802] 4.56 percent of total billed charges 3.57 5.47 Technical (Hospital) Services LOSARTAN 100 MG TABLET RX-22588 CDM 6370000100 HCPCS 250 RC 65862-0203-90 NDC inpatient 1 UN 5.76 5.76 CIGNA 62308 [3081051] CIGNA 62308 [308105105] 4.56 percent of total billed charges 3.57 5.47 Technical (Hospital) Services LOSARTAN 100 MG TABLET RX-22588 CDM 6370000100 HCPCS 250 RC 65862-0203-90 NDC inpatient 1 UN 5.76 5.76 CIGNA 62308 [3081051] CIGNA STATE OF WYOMING [308105107] 4.56 percent of total billed charges 3.57 5.47 Technical (Hospital) Services LOSARTAN 100 MG TABLET RX-22588 CDM 6370000100 HCPCS 250 RC 65862-0203-90 NDC inpatient 1 UN 5.76 5.76 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES EPO [308136803] 4.56 percent of total billed charges 3.57 5.47 Technical (Hospital) Services LOSARTAN 100 MG TABLET RX-22588 CDM 6370000100 HCPCS 250 RC 65862-0203-90 NDC inpatient 1 UN 5.76 5.76 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES PPO [308136801] 4.56 percent of total billed charges 3.57 5.47 Technical (Hospital) Services LOSARTAN 100 MG TABLET RX-22588 CDM 6370000100 HCPCS 250 RC 65862-0203-90 NDC inpatient 1 UN 5.76 5.76 MEDICA (COMMERCIAL) 94265 [3081118] MEDICA CLAIMS [308111801] 5.18 percent of total billed charges 3.57 5.47 Technical (Hospital) Services LOSARTAN 100 MG TABLET RX-22588 CDM 6370000100 HCPCS 250 RC 65862-0203-90 NDC inpatient 1 UN 5.76 5.76 HEALTHPARTNERS SX009 HEALTHPARTNERS 4.56 percent of total billed charges 3.57 5.47 Technical (Hospital) Services LOSARTAN 100 MG TABLET RX-22588 CDM 6370000100 HCPCS 250 RC 65862-0203-90 NDC inpatient 1 UN 5.76 5.76 MULTIPLAN INC 34080 [3081285] MULTIPLAN INC [308128501] 5.47 percent of total billed charges 3.57 5.47 Technical (Hospital) Services URSODIOL 250 MG TABLET RX-22660 CDM 6370000100 HCPCS 250 RC 49884-0412-01 NDC inpatient 1 UN 7.77 7.77 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES HDHP [308136802] 6.15 percent of total billed charges 4.82 7.38 Technical (Hospital) Services URSODIOL 250 MG TABLET RX-22660 CDM 6370000100 HCPCS 250 RC 49884-0412-01 NDC inpatient 1 UN 7.77 7.77 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES EPO [308136803] 6.15 percent of total billed charges 4.82 7.38 Technical (Hospital) Services URSODIOL 250 MG TABLET RX-22660 CDM 6370000100 HCPCS 250 RC 49884-0412-01 NDC inpatient 1 UN 7.77 7.77 CIGNA 62308 [3081051] CIGNA 62308 [308105105] 6.15 percent of total billed charges 4.82 7.38 Technical (Hospital) Services URSODIOL 250 MG TABLET RX-22660 CDM 6370000100 HCPCS 250 RC 49884-0412-01 NDC inpatient 1 UN 7.77 7.77 CIGNA 62308 [3081051] CIGNA STATE OF WYOMING [308105107] 6.15 percent of total billed charges 4.82 7.38 Technical (Hospital) Services URSODIOL 250 MG TABLET RX-22660 CDM 6370000100 HCPCS 250 RC 49884-0412-01 NDC inpatient 1 UN 7.77 7.77 BLUE CROSS BLUE SHIELD WELLMARK SB889 [3081026] BCBS WYOMING [308102603] 7.38 percent of total billed charges 4.82 7.38 Technical (Hospital) Services URSODIOL 250 MG TABLET RX-22660 CDM 6370000100 HCPCS 250 RC 49884-0412-01 NDC inpatient 1 UN 7.77 7.77 UNITED HEALTHCARE (COMMERCIAL) [3081199] UNITED HEALTHCARE 87726 [308119901] 4.82 percent of total billed charges 4.82 7.38 Technical (Hospital) Services URSODIOL 250 MG TABLET RX-22660 CDM 6370000100 HCPCS 250 RC 49884-0412-01 NDC inpatient 1 UN 7.77 7.77 HEALTHPARTNERS SX009 HEALTHPARTNERS 6.15 percent of total billed charges 4.82 7.38 Technical (Hospital) Services URSODIOL 250 MG TABLET RX-22660 CDM 6370000100 HCPCS 250 RC 49884-0412-01 NDC inpatient 1 UN 7.77 7.77 MEDICA (COMMERCIAL) 94265 [3081118] MEDICA CLAIMS [308111801] 6.99 percent of total billed charges 4.82 7.38 Technical (Hospital) Services URSODIOL 250 MG TABLET RX-22660 CDM 6370000100 HCPCS 250 RC 49884-0412-01 NDC inpatient 1 UN 7.77 7.77 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES PPO [308136801] 6.15 percent of total billed charges 4.82 7.38 Technical (Hospital) Services URSODIOL 250 MG TABLET RX-22660 CDM 6370000100 HCPCS 250 RC 49884-0412-01 NDC inpatient 1 UN 7.77 7.77 MULTIPLAN INC 34080 [3081285] MULTIPLAN INC [308128501] 7.38 percent of total billed charges 4.82 7.38 Technical (Hospital) Services URSODIOL 250 MG TABLET RX-22660 CDM 6370000100 HCPCS 250 RC 49884-0412-01 NDC outpatient 1 UN 7.77 7.77 HEALTHPARTNERS SX009 HEALTHPARTNERS 6.22 percent of total billed charges 4.82 7.38 Technical (Hospital) Services URSODIOL 250 MG TABLET RX-22660 CDM 6370000100 HCPCS 250 RC 49884-0412-01 NDC outpatient 1 UN 7.77 7.77 BLUE CROSS BLUE SHIELD WELLMARK SB889 [3081026] BCBS WYOMING [308102603] 7.38 percent of total billed charges 4.82 7.38 Technical (Hospital) Services URSODIOL 250 MG TABLET RX-22660 CDM 6370000100 HCPCS 250 RC 49884-0412-01 NDC outpatient 1 UN 7.77 7.77 MEDICA (COMMERCIAL) 94265 [3081118] MEDICA CLAIMS [308111801] 6.99 percent of total billed charges 4.82 7.38 Technical (Hospital) Services URSODIOL 250 MG TABLET RX-22660 CDM 6370000100 HCPCS 250 RC 49884-0412-01 NDC outpatient 1 UN 7.77 7.77 UNITED HEALTHCARE (COMMERCIAL) [3081199] UNITED HEALTHCARE 87726 [308119901] 4.82 percent of total billed charges 4.82 7.38 Technical (Hospital) Services URSODIOL 250 MG TABLET RX-22660 CDM 6370000100 HCPCS 250 RC 49884-0412-01 NDC outpatient 1 UN 7.77 7.77 CIGNA 62308 [3081051] CIGNA 62308 [308105105] 6.22 percent of total billed charges 4.82 7.38 Technical (Hospital) Services URSODIOL 250 MG TABLET RX-22660 CDM 6370000100 HCPCS 250 RC 49884-0412-01 NDC outpatient 1 UN 7.77 7.77 CIGNA 62308 [3081051] CIGNA STATE OF WYOMING [308105107] 6.22 percent of total billed charges 4.82 7.38 Technical (Hospital) Services URSODIOL 250 MG TABLET RX-22660 CDM 6370000100 HCPCS 250 RC 49884-0412-01 NDC outpatient 1 UN 7.77 7.77 MULTIPLAN INC 34080 [3081285] MULTIPLAN INC [308128501] 7.38 percent of total billed charges 4.82 7.38 Technical (Hospital) Services URSODIOL 250 MG TABLET RX-22660 CDM 6370000100 HCPCS 250 RC 49884-0412-01 NDC outpatient 1 UN 7.77 7.77 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES PPO [308136801] 6.22 percent of total billed charges 4.82 7.38 Technical (Hospital) Services URSODIOL 250 MG TABLET RX-22660 CDM 6370000100 HCPCS 250 RC 49884-0412-01 NDC outpatient 1 UN 7.77 7.77 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES EPO [308136803] 6.22 percent of total billed charges 4.82 7.38 Technical (Hospital) Services URSODIOL 250 MG TABLET RX-22660 CDM 6370000100 HCPCS 250 RC 49884-0412-01 NDC outpatient 1 UN 7.77 7.77 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES HDHP [308136802] 6.22 percent of total billed charges 4.82 7.38 Technical (Hospital) Services TOLTERODINE 2 MG TABLET RX-22783 CDM 6370000100 HCPCS 250 RC 00093-0018-06 NDC inpatient 1 UN 14.72 14.72 MULTIPLAN INC 34080 [3081285] MULTIPLAN INC [308128501] 13.98 percent of total billed charges 9.13 13.98 Technical (Hospital) Services TOLTERODINE 2 MG TABLET RX-22783 CDM 6370000100 HCPCS 250 RC 00093-0018-06 NDC inpatient 1 UN 14.72 14.72 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES PPO [308136801] 11.66 percent of total billed charges 9.13 13.98 Technical (Hospital) Services TOLTERODINE 2 MG TABLET RX-22783 CDM 6370000100 HCPCS 250 RC 00093-0018-06 NDC inpatient 1 UN 14.72 14.72 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES HDHP [308136802] 11.66 percent of total billed charges 9.13 13.98 Technical (Hospital) Services TOLTERODINE 2 MG TABLET RX-22783 CDM 6370000100 HCPCS 250 RC 00093-0018-06 NDC inpatient 1 UN 14.72 14.72 HEALTHPARTNERS SX009 HEALTHPARTNERS 11.66 percent of total billed charges 9.13 13.98 Technical (Hospital) Services TOLTERODINE 2 MG TABLET RX-22783 CDM 6370000100 HCPCS 250 RC 00093-0018-06 NDC inpatient 1 UN 14.72 14.72 MEDICA (COMMERCIAL) 94265 [3081118] MEDICA CLAIMS [308111801] 13.25 percent of total billed charges 9.13 13.98 Technical (Hospital) Services TOLTERODINE 2 MG TABLET RX-22783 CDM 6370000100 HCPCS 250 RC 00093-0018-06 NDC inpatient 1 UN 14.72 14.72 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES EPO [308136803] 11.66 percent of total billed charges 9.13 13.98 Technical (Hospital) Services TOLTERODINE 2 MG TABLET RX-22783 CDM 6370000100 HCPCS 250 RC 00093-0018-06 NDC inpatient 1 UN 14.72 14.72 CIGNA 62308 [3081051] CIGNA STATE OF WYOMING [308105107] 11.66 percent of total billed charges 9.13 13.98 Technical (Hospital) Services TOLTERODINE 2 MG TABLET RX-22783 CDM 6370000100 HCPCS 250 RC 00093-0018-06 NDC inpatient 1 UN 14.72 14.72 CIGNA 62308 [3081051] CIGNA 62308 [308105105] 11.66 percent of total billed charges 9.13 13.98 Technical (Hospital) Services TOLTERODINE 2 MG TABLET RX-22783 CDM 6370000100 HCPCS 250 RC 00093-0018-06 NDC inpatient 1 UN 14.72 14.72 BLUE CROSS BLUE SHIELD WELLMARK SB889 [3081026] BCBS WYOMING [308102603] 13.98 percent of total billed charges 9.13 13.98 Technical (Hospital) Services TOLTERODINE 2 MG TABLET RX-22783 CDM 6370000100 HCPCS 250 RC 00093-0018-06 NDC inpatient 1 UN 14.72 14.72 UNITED HEALTHCARE (COMMERCIAL) [3081199] UNITED HEALTHCARE 87726 [308119901] 9.13 percent of total billed charges 9.13 13.98 Technical (Hospital) Services TOLTERODINE 2 MG TABLET RX-22783 CDM 6370000100 HCPCS 250 RC 00093-0018-06 NDC outpatient 1 UN 14.72 14.72 CIGNA 62308 [3081051] CIGNA 62308 [308105105] 11.78 percent of total billed charges 9.13 13.98 Technical (Hospital) Services TOLTERODINE 2 MG TABLET RX-22783 CDM 6370000100 HCPCS 250 RC 00093-0018-06 NDC outpatient 1 UN 14.72 14.72 CIGNA 62308 [3081051] CIGNA STATE OF WYOMING [308105107] 11.78 percent of total billed charges 9.13 13.98 Technical (Hospital) Services TOLTERODINE 2 MG TABLET RX-22783 CDM 6370000100 HCPCS 250 RC 00093-0018-06 NDC outpatient 1 UN 14.72 14.72 MULTIPLAN INC 34080 [3081285] MULTIPLAN INC [308128501] 13.98 percent of total billed charges 9.13 13.98 Technical (Hospital) Services TOLTERODINE 2 MG TABLET RX-22783 CDM 6370000100 HCPCS 250 RC 00093-0018-06 NDC outpatient 1 UN 14.72 14.72 MEDICA (COMMERCIAL) 94265 [3081118] MEDICA CLAIMS [308111801] 13.25 percent of total billed charges 9.13 13.98 Technical (Hospital) Services TOLTERODINE 2 MG TABLET RX-22783 CDM 6370000100 HCPCS 250 RC 00093-0018-06 NDC outpatient 1 UN 14.72 14.72 UNITED HEALTHCARE (COMMERCIAL) [3081199] UNITED HEALTHCARE 87726 [308119901] 9.13 percent of total billed charges 9.13 13.98 Technical (Hospital) Services TOLTERODINE 2 MG TABLET RX-22783 CDM 6370000100 HCPCS 250 RC 00093-0018-06 NDC outpatient 1 UN 14.72 14.72 HEALTHPARTNERS SX009 HEALTHPARTNERS 11.78 percent of total billed charges 9.13 13.98 Technical (Hospital) Services TOLTERODINE 2 MG TABLET RX-22783 CDM 6370000100 HCPCS 250 RC 00093-0018-06 NDC outpatient 1 UN 14.72 14.72 BLUE CROSS BLUE SHIELD WELLMARK SB889 [3081026] BCBS WYOMING [308102603] 13.98 percent of total billed charges 9.13 13.98 Technical (Hospital) Services TOLTERODINE 2 MG TABLET RX-22783 CDM 6370000100 HCPCS 250 RC 00093-0018-06 NDC outpatient 1 UN 14.72 14.72 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES EPO [308136803] 11.78 percent of total billed charges 9.13 13.98 Technical (Hospital) Services TOLTERODINE 2 MG TABLET RX-22783 CDM 6370000100 HCPCS 250 RC 00093-0018-06 NDC outpatient 1 UN 14.72 14.72 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES PPO [308136801] 11.78 percent of total billed charges 9.13 13.98 Technical (Hospital) Services TOLTERODINE 2 MG TABLET RX-22783 CDM 6370000100 HCPCS 250 RC 00093-0018-06 NDC outpatient 1 UN 14.72 14.72 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES HDHP [308136802] 11.78 percent of total billed charges 9.13 13.98 Technical (Hospital) Services CAMPHOR-MENTHOL 0.5 %-0.5 % LOTION RX-23063 CDM 6370000100 HCPCS 250 RC 00316-0229-75 NDC inpatient 1 ML 5.66 5.66 MULTIPLAN INC 34080 [3081285] MULTIPLAN INC [308128501] 5.38 percent of total billed charges 3.51 5.38 Technical (Hospital) Services CAMPHOR-MENTHOL 0.5 %-0.5 % LOTION RX-23063 CDM 6370000100 HCPCS 250 RC 00316-0229-75 NDC inpatient 1 ML 5.66 5.66 MEDICA (COMMERCIAL) 94265 [3081118] MEDICA CLAIMS [308111801] 5.09 percent of total billed charges 3.51 5.38 Technical (Hospital) Services CAMPHOR-MENTHOL 0.5 %-0.5 % LOTION RX-23063 CDM 6370000100 HCPCS 250 RC 00316-0229-75 NDC inpatient 1 ML 5.66 5.66 HEALTHPARTNERS SX009 HEALTHPARTNERS 4.48 percent of total billed charges 3.51 5.38 Technical (Hospital) Services CAMPHOR-MENTHOL 0.5 %-0.5 % LOTION RX-23063 CDM 6370000100 HCPCS 250 RC 00316-0229-75 NDC inpatient 1 ML 5.66 5.66 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES PPO [308136801] 4.48 percent of total billed charges 3.51 5.38 Technical (Hospital) Services CAMPHOR-MENTHOL 0.5 %-0.5 % LOTION RX-23063 CDM 6370000100 HCPCS 250 RC 00316-0229-75 NDC inpatient 1 ML 5.66 5.66 UNITED HEALTHCARE (COMMERCIAL) [3081199] UNITED HEALTHCARE 87726 [308119901] 3.51 percent of total billed charges 3.51 5.38 Technical (Hospital) Services CAMPHOR-MENTHOL 0.5 %-0.5 % LOTION RX-23063 CDM 6370000100 HCPCS 250 RC 00316-0229-75 NDC inpatient 1 ML 5.66 5.66 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES EPO [308136803] 4.48 percent of total billed charges 3.51 5.38 Technical (Hospital) Services CAMPHOR-MENTHOL 0.5 %-0.5 % LOTION RX-23063 CDM 6370000100 HCPCS 250 RC 00316-0229-75 NDC inpatient 1 ML 5.66 5.66 CIGNA 62308 [3081051] CIGNA 62308 [308105105] 4.48 percent of total billed charges 3.51 5.38 Technical (Hospital) Services CAMPHOR-MENTHOL 0.5 %-0.5 % LOTION RX-23063 CDM 6370000100 HCPCS 250 RC 00316-0229-75 NDC inpatient 1 ML 5.66 5.66 CIGNA 62308 [3081051] CIGNA STATE OF WYOMING [308105107] 4.48 percent of total billed charges 3.51 5.38 Technical (Hospital) Services CAMPHOR-MENTHOL 0.5 %-0.5 % LOTION RX-23063 CDM 6370000100 HCPCS 250 RC 00316-0229-75 NDC inpatient 1 ML 5.66 5.66 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES HDHP [308136802] 4.48 percent of total billed charges 3.51 5.38 Technical (Hospital) Services CAMPHOR-MENTHOL 0.5 %-0.5 % LOTION RX-23063 CDM 6370000100 HCPCS 250 RC 00316-0229-75 NDC inpatient 1 ML 5.66 5.66 BLUE CROSS BLUE SHIELD WELLMARK SB889 [3081026] BCBS WYOMING [308102603] 5.38 percent of total billed charges 3.51 5.38 Technical (Hospital) Services CAMPHOR-MENTHOL 0.5 %-0.5 % LOTION RX-23063 CDM 6370000100 HCPCS 250 RC 00316-0229-75 NDC outpatient 1 ML 5.66 5.66 UNITED HEALTHCARE (COMMERCIAL) [3081199] UNITED HEALTHCARE 87726 [308119901] 3.51 percent of total billed charges 3.51 5.38 Technical (Hospital) Services CAMPHOR-MENTHOL 0.5 %-0.5 % LOTION RX-23063 CDM 6370000100 HCPCS 250 RC 00316-0229-75 NDC outpatient 1 ML 5.66 5.66 MULTIPLAN INC 34080 [3081285] MULTIPLAN INC [308128501] 5.38 percent of total billed charges 3.51 5.38 Technical (Hospital) Services CAMPHOR-MENTHOL 0.5 %-0.5 % LOTION RX-23063 CDM 6370000100 HCPCS 250 RC 00316-0229-75 NDC outpatient 1 ML 5.66 5.66 CIGNA 62308 [3081051] CIGNA 62308 [308105105] 4.53 percent of total billed charges 3.51 5.38 Technical (Hospital) Services CAMPHOR-MENTHOL 0.5 %-0.5 % LOTION RX-23063 CDM 6370000100 HCPCS 250 RC 00316-0229-75 NDC outpatient 1 ML 5.66 5.66 CIGNA 62308 [3081051] CIGNA STATE OF WYOMING [308105107] 4.53 percent of total billed charges 3.51 5.38 Technical (Hospital) Services CAMPHOR-MENTHOL 0.5 %-0.5 % LOTION RX-23063 CDM 6370000100 HCPCS 250 RC 00316-0229-75 NDC outpatient 1 ML 5.66 5.66 MEDICA (COMMERCIAL) 94265 [3081118] MEDICA CLAIMS [308111801] 5.09 percent of total billed charges 3.51 5.38 Technical (Hospital) Services CAMPHOR-MENTHOL 0.5 %-0.5 % LOTION RX-23063 CDM 6370000100 HCPCS 250 RC 00316-0229-75 NDC outpatient 1 ML 5.66 5.66 BLUE CROSS BLUE SHIELD WELLMARK SB889 [3081026] BCBS WYOMING [308102603] 5.38 percent of total billed charges 3.51 5.38 Technical (Hospital) Services CAMPHOR-MENTHOL 0.5 %-0.5 % LOTION RX-23063 CDM 6370000100 HCPCS 250 RC 00316-0229-75 NDC outpatient 1 ML 5.66 5.66 HEALTHPARTNERS SX009 HEALTHPARTNERS 4.53 percent of total billed charges 3.51 5.38 Technical (Hospital) Services CAMPHOR-MENTHOL 0.5 %-0.5 % LOTION RX-23063 CDM 6370000100 HCPCS 250 RC 00316-0229-75 NDC outpatient 1 ML 5.66 5.66 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES PPO [308136801] 4.53 percent of total billed charges 3.51 5.38 Technical (Hospital) Services CAMPHOR-MENTHOL 0.5 %-0.5 % LOTION RX-23063 CDM 6370000100 HCPCS 250 RC 00316-0229-75 NDC outpatient 1 ML 5.66 5.66 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES HDHP [308136802] 4.53 percent of total billed charges 3.51 5.38 Technical (Hospital) Services CAMPHOR-MENTHOL 0.5 %-0.5 % LOTION RX-23063 CDM 6370000100 HCPCS 250 RC 00316-0229-75 NDC outpatient 1 ML 5.66 5.66 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES EPO [308136803] 4.53 percent of total billed charges 3.51 5.38 Technical (Hospital) Services SIMVASTATIN 80 MG TABLET RX-23449 CDM 6370000100 HCPCS 250 RC 16729-0007-15 NDC inpatient 1 UN 5.7 5.7 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES PPO [308136801] 4.51 percent of total billed charges 3.53 5.42 Technical (Hospital) Services SIMVASTATIN 80 MG TABLET RX-23449 CDM 6370000100 HCPCS 250 RC 16729-0007-15 NDC inpatient 1 UN 5.7 5.7 MULTIPLAN INC 34080 [3081285] MULTIPLAN INC [308128501] 5.42 percent of total billed charges 3.53 5.42 Technical (Hospital) Services SIMVASTATIN 80 MG TABLET RX-23449 CDM 6370000100 HCPCS 250 RC 16729-0007-15 NDC inpatient 1 UN 5.7 5.7 UNITED HEALTHCARE (COMMERCIAL) [3081199] UNITED HEALTHCARE 87726 [308119901] 3.53 percent of total billed charges 3.53 5.42 Technical (Hospital) Services SIMVASTATIN 80 MG TABLET RX-23449 CDM 6370000100 HCPCS 250 RC 16729-0007-15 NDC inpatient 1 UN 5.7 5.7 BLUE CROSS BLUE SHIELD WELLMARK SB889 [3081026] BCBS WYOMING [308102603] 5.42 percent of total billed charges 3.53 5.42 Technical (Hospital) Services SIMVASTATIN 80 MG TABLET RX-23449 CDM 6370000100 HCPCS 250 RC 16729-0007-15 NDC inpatient 1 UN 5.7 5.7 HEALTHPARTNERS SX009 HEALTHPARTNERS 4.51 percent of total billed charges 3.53 5.42 Technical (Hospital) Services SIMVASTATIN 80 MG TABLET RX-23449 CDM 6370000100 HCPCS 250 RC 16729-0007-15 NDC inpatient 1 UN 5.7 5.7 MEDICA (COMMERCIAL) 94265 [3081118] MEDICA CLAIMS [308111801] 5.13 percent of total billed charges 3.53 5.42 Technical (Hospital) Services SIMVASTATIN 80 MG TABLET RX-23449 CDM 6370000100 HCPCS 250 RC 16729-0007-15 NDC inpatient 1 UN 5.7 5.7 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES HDHP [308136802] 4.51 percent of total billed charges 3.53 5.42 Technical (Hospital) Services SIMVASTATIN 80 MG TABLET RX-23449 CDM 6370000100 HCPCS 250 RC 16729-0007-15 NDC inpatient 1 UN 5.7 5.7 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES EPO [308136803] 4.51 percent of total billed charges 3.53 5.42 Technical (Hospital) Services SIMVASTATIN 80 MG TABLET RX-23449 CDM 6370000100 HCPCS 250 RC 16729-0007-15 NDC inpatient 1 UN 5.7 5.7 CIGNA 62308 [3081051] CIGNA 62308 [308105105] 4.51 percent of total billed charges 3.53 5.42 Technical (Hospital) Services SIMVASTATIN 80 MG TABLET RX-23449 CDM 6370000100 HCPCS 250 RC 16729-0007-15 NDC inpatient 1 UN 5.7 5.7 CIGNA 62308 [3081051] CIGNA STATE OF WYOMING [308105107] 4.51 percent of total billed charges 3.53 5.42 Technical (Hospital) Services SIMVASTATIN 80 MG TABLET RX-23449 CDM 6370000100 HCPCS 250 RC 16729-0007-15 NDC outpatient 1 UN 5.7 5.7 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES EPO [308136803] 4.56 percent of total billed charges 3.53 5.42 Technical (Hospital) Services SIMVASTATIN 80 MG TABLET RX-23449 CDM 6370000100 HCPCS 250 RC 16729-0007-15 NDC outpatient 1 UN 5.7 5.7 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES PPO [308136801] 4.56 percent of total billed charges 3.53 5.42 Technical (Hospital) Services SIMVASTATIN 80 MG TABLET RX-23449 CDM 6370000100 HCPCS 250 RC 16729-0007-15 NDC outpatient 1 UN 5.7 5.7 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES HDHP [308136802] 4.56 percent of total billed charges 3.53 5.42 Technical (Hospital) Services SIMVASTATIN 80 MG TABLET RX-23449 CDM 6370000100 HCPCS 250 RC 16729-0007-15 NDC outpatient 1 UN 5.7 5.7 UNITED HEALTHCARE (COMMERCIAL) [3081199] UNITED HEALTHCARE 87726 [308119901] 3.53 percent of total billed charges 3.53 5.42 Technical (Hospital) Services SIMVASTATIN 80 MG TABLET RX-23449 CDM 6370000100 HCPCS 250 RC 16729-0007-15 NDC outpatient 1 UN 5.7 5.7 MULTIPLAN INC 34080 [3081285] MULTIPLAN INC [308128501] 5.42 percent of total billed charges 3.53 5.42 Technical (Hospital) Services SIMVASTATIN 80 MG TABLET RX-23449 CDM 6370000100 HCPCS 250 RC 16729-0007-15 NDC outpatient 1 UN 5.7 5.7 CIGNA 62308 [3081051] CIGNA 62308 [308105105] 4.56 percent of total billed charges 3.53 5.42 Technical (Hospital) Services SIMVASTATIN 80 MG TABLET RX-23449 CDM 6370000100 HCPCS 250 RC 16729-0007-15 NDC outpatient 1 UN 5.7 5.7 CIGNA 62308 [3081051] CIGNA STATE OF WYOMING [308105107] 4.56 percent of total billed charges 3.53 5.42 Technical (Hospital) Services SIMVASTATIN 80 MG TABLET RX-23449 CDM 6370000100 HCPCS 250 RC 16729-0007-15 NDC outpatient 1 UN 5.7 5.7 MEDICA (COMMERCIAL) 94265 [3081118] MEDICA CLAIMS [308111801] 5.13 percent of total billed charges 3.53 5.42 Technical (Hospital) Services SIMVASTATIN 80 MG TABLET RX-23449 CDM 6370000100 HCPCS 250 RC 16729-0007-15 NDC outpatient 1 UN 5.7 5.7 HEALTHPARTNERS SX009 HEALTHPARTNERS 4.56 percent of total billed charges 3.53 5.42 Technical (Hospital) Services SIMVASTATIN 80 MG TABLET RX-23449 CDM 6370000100 HCPCS 250 RC 16729-0007-15 NDC outpatient 1 UN 5.7 5.7 BLUE CROSS BLUE SHIELD WELLMARK SB889 [3081026] BCBS WYOMING [308102603] 5.42 percent of total billed charges 3.53 5.42 Technical (Hospital) Services LIDOCAINE 5 % TOPICAL CREAM RX-23460 CDM 6370000100 HCPCS 250 RC 00496-0892-30 NDC inpatient 1 GR 6.39 6.39 MULTIPLAN INC 34080 [3081285] MULTIPLAN INC [308128501] 6.07 percent of total billed charges 3.96 6.07 Technical (Hospital) Services LIDOCAINE 5 % TOPICAL CREAM RX-23460 CDM 6370000100 HCPCS 250 RC 00496-0892-30 NDC inpatient 1 GR 6.39 6.39 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES PPO [308136801] 5.06 percent of total billed charges 3.96 6.07 Technical (Hospital) Services LIDOCAINE 5 % TOPICAL CREAM RX-23460 CDM 6370000100 HCPCS 250 RC 00496-0892-30 NDC inpatient 1 GR 6.39 6.39 MEDICA (COMMERCIAL) 94265 [3081118] MEDICA CLAIMS [308111801] 5.75 percent of total billed charges 3.96 6.07 Technical (Hospital) Services LIDOCAINE 5 % TOPICAL CREAM RX-23460 CDM 6370000100 HCPCS 250 RC 00496-0892-30 NDC inpatient 1 GR 6.39 6.39 HEALTHPARTNERS SX009 HEALTHPARTNERS 5.06 percent of total billed charges 3.96 6.07 Technical (Hospital) Services LIDOCAINE 5 % TOPICAL CREAM RX-23460 CDM 6370000100 HCPCS 250 RC 00496-0892-30 NDC inpatient 1 GR 6.39 6.39 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES HDHP [308136802] 5.06 percent of total billed charges 3.96 6.07 Technical (Hospital) Services LIDOCAINE 5 % TOPICAL CREAM RX-23460 CDM 6370000100 HCPCS 250 RC 00496-0892-30 NDC inpatient 1 GR 6.39 6.39 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES EPO [308136803] 5.06 percent of total billed charges 3.96 6.07 Technical (Hospital) Services LIDOCAINE 5 % TOPICAL CREAM RX-23460 CDM 6370000100 HCPCS 250 RC 00496-0892-30 NDC inpatient 1 GR 6.39 6.39 CIGNA 62308 [3081051] CIGNA 62308 [308105105] 5.06 percent of total billed charges 3.96 6.07 Technical (Hospital) Services LIDOCAINE 5 % TOPICAL CREAM RX-23460 CDM 6370000100 HCPCS 250 RC 00496-0892-30 NDC inpatient 1 GR 6.39 6.39 CIGNA 62308 [3081051] CIGNA STATE OF WYOMING [308105107] 5.06 percent of total billed charges 3.96 6.07 Technical (Hospital) Services LIDOCAINE 5 % TOPICAL CREAM RX-23460 CDM 6370000100 HCPCS 250 RC 00496-0892-30 NDC inpatient 1 GR 6.39 6.39 BLUE CROSS BLUE SHIELD WELLMARK SB889 [3081026] BCBS WYOMING [308102603] 6.07 percent of total billed charges 3.96 6.07 Technical (Hospital) Services LIDOCAINE 5 % TOPICAL CREAM RX-23460 CDM 6370000100 HCPCS 250 RC 00496-0892-30 NDC inpatient 1 GR 6.39 6.39 UNITED HEALTHCARE (COMMERCIAL) [3081199] UNITED HEALTHCARE 87726 [308119901] 3.96 percent of total billed charges 3.96 6.07 Technical (Hospital) Services LIDOCAINE 5 % TOPICAL CREAM RX-23460 CDM 6370000100 HCPCS 250 RC 00496-0892-30 NDC outpatient 1 GR 6.39 6.39 CIGNA 62308 [3081051] CIGNA 62308 [308105105] 5.11 percent of total billed charges 3.96 6.07 Technical (Hospital) Services LIDOCAINE 5 % TOPICAL CREAM RX-23460 CDM 6370000100 HCPCS 250 RC 00496-0892-30 NDC outpatient 1 GR 6.39 6.39 CIGNA 62308 [3081051] CIGNA STATE OF WYOMING [308105107] 5.11 percent of total billed charges 3.96 6.07 Technical (Hospital) Services LIDOCAINE 5 % TOPICAL CREAM RX-23460 CDM 6370000100 HCPCS 250 RC 00496-0892-30 NDC outpatient 1 GR 6.39 6.39 MULTIPLAN INC 34080 [3081285] MULTIPLAN INC [308128501] 6.07 percent of total billed charges 3.96 6.07 Technical (Hospital) Services LIDOCAINE 5 % TOPICAL CREAM RX-23460 CDM 6370000100 HCPCS 250 RC 00496-0892-30 NDC outpatient 1 GR 6.39 6.39 MEDICA (COMMERCIAL) 94265 [3081118] MEDICA CLAIMS [308111801] 5.75 percent of total billed charges 3.96 6.07 Technical (Hospital) Services LIDOCAINE 5 % TOPICAL CREAM RX-23460 CDM 6370000100 HCPCS 250 RC 00496-0892-30 NDC outpatient 1 GR 6.39 6.39 HEALTHPARTNERS SX009 HEALTHPARTNERS 5.11 percent of total billed charges 3.96 6.07 Technical (Hospital) Services LIDOCAINE 5 % TOPICAL CREAM RX-23460 CDM 6370000100 HCPCS 250 RC 00496-0892-30 NDC outpatient 1 GR 6.39 6.39 UNITED HEALTHCARE (COMMERCIAL) [3081199] UNITED HEALTHCARE 87726 [308119901] 3.96 percent of total billed charges 3.96 6.07 Technical (Hospital) Services LIDOCAINE 5 % TOPICAL CREAM RX-23460 CDM 6370000100 HCPCS 250 RC 00496-0892-30 NDC outpatient 1 GR 6.39 6.39 BLUE CROSS BLUE SHIELD WELLMARK SB889 [3081026] BCBS WYOMING [308102603] 6.07 percent of total billed charges 3.96 6.07 Technical (Hospital) Services LIDOCAINE 5 % TOPICAL CREAM RX-23460 CDM 6370000100 HCPCS 250 RC 00496-0892-30 NDC outpatient 1 GR 6.39 6.39 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES EPO [308136803] 5.11 percent of total billed charges 3.96 6.07 Technical (Hospital) Services LIDOCAINE 5 % TOPICAL CREAM RX-23460 CDM 6370000100 HCPCS 250 RC 00496-0892-30 NDC outpatient 1 GR 6.39 6.39 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES HDHP [308136802] 5.11 percent of total billed charges 3.96 6.07 Technical (Hospital) Services LIDOCAINE 5 % TOPICAL CREAM RX-23460 CDM 6370000100 HCPCS 250 RC 00496-0892-30 NDC outpatient 1 GR 6.39 6.39 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES PPO [308136801] 5.11 percent of total billed charges 3.96 6.07 Technical (Hospital) Services CITALOPRAM 40 MG TABLET RX-23490 CDM 6370000100 HCPCS 250 RC 00378-6233-01 NDC inpatient 1 UN 5.72 5.72 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES PPO [308136801] 4.53 percent of total billed charges 3.55 5.43 Technical (Hospital) Services CITALOPRAM 40 MG TABLET RX-23490 CDM 6370000100 HCPCS 250 RC 00378-6233-01 NDC inpatient 1 UN 5.72 5.72 MULTIPLAN INC 34080 [3081285] MULTIPLAN INC [308128501] 5.43 percent of total billed charges 3.55 5.43 Technical (Hospital) Services CITALOPRAM 40 MG TABLET RX-23490 CDM 6370000100 HCPCS 250 RC 00378-6233-01 NDC inpatient 1 UN 5.72 5.72 BLUE CROSS BLUE SHIELD WELLMARK SB889 [3081026] BCBS WYOMING [308102603] 5.43 percent of total billed charges 3.55 5.43 Technical (Hospital) Services CITALOPRAM 40 MG TABLET RX-23490 CDM 6370000100 HCPCS 250 RC 00378-6233-01 NDC inpatient 1 UN 5.72 5.72 UNITED HEALTHCARE (COMMERCIAL) [3081199] UNITED HEALTHCARE 87726 [308119901] 3.55 percent of total billed charges 3.55 5.43 Technical (Hospital) Services CITALOPRAM 40 MG TABLET RX-23490 CDM 6370000100 HCPCS 250 RC 00378-6233-01 NDC inpatient 1 UN 5.72 5.72 HEALTHPARTNERS SX009 HEALTHPARTNERS 4.53 percent of total billed charges 3.55 5.43 Technical (Hospital) Services CITALOPRAM 40 MG TABLET RX-23490 CDM 6370000100 HCPCS 250 RC 00378-6233-01 NDC inpatient 1 UN 5.72 5.72 MEDICA (COMMERCIAL) 94265 [3081118] MEDICA CLAIMS [308111801] 5.15 percent of total billed charges 3.55 5.43 Technical (Hospital) Services CITALOPRAM 40 MG TABLET RX-23490 CDM 6370000100 HCPCS 250 RC 00378-6233-01 NDC inpatient 1 UN 5.72 5.72 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES HDHP [308136802] 4.53 percent of total billed charges 3.55 5.43 Technical (Hospital) Services CITALOPRAM 40 MG TABLET RX-23490 CDM 6370000100 HCPCS 250 RC 00378-6233-01 NDC inpatient 1 UN 5.72 5.72 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES EPO [308136803] 4.53 percent of total billed charges 3.55 5.43 Technical (Hospital) Services CITALOPRAM 40 MG TABLET RX-23490 CDM 6370000100 HCPCS 250 RC 00378-6233-01 NDC inpatient 1 UN 5.72 5.72 CIGNA 62308 [3081051] CIGNA 62308 [308105105] 4.53 percent of total billed charges 3.55 5.43 Technical (Hospital) Services CITALOPRAM 40 MG TABLET RX-23490 CDM 6370000100 HCPCS 250 RC 00378-6233-01 NDC inpatient 1 UN 5.72 5.72 CIGNA 62308 [3081051] CIGNA STATE OF WYOMING [308105107] 4.53 percent of total billed charges 3.55 5.43 Technical (Hospital) Services CITALOPRAM 40 MG TABLET RX-23490 CDM 6370000100 HCPCS 250 RC 00378-6233-01 NDC outpatient 1 UN 5.72 5.72 MEDICA (COMMERCIAL) 94265 [3081118] MEDICA CLAIMS [308111801] 5.15 percent of total billed charges 3.55 5.43 Technical (Hospital) Services CITALOPRAM 40 MG TABLET RX-23490 CDM 6370000100 HCPCS 250 RC 00378-6233-01 NDC outpatient 1 UN 5.72 5.72 MULTIPLAN INC 34080 [3081285] MULTIPLAN INC [308128501] 5.43 percent of total billed charges 3.55 5.43 Technical (Hospital) Services CITALOPRAM 40 MG TABLET RX-23490 CDM 6370000100 HCPCS 250 RC 00378-6233-01 NDC outpatient 1 UN 5.72 5.72 CIGNA 62308 [3081051] CIGNA 62308 [308105105] 4.58 percent of total billed charges 3.55 5.43 Technical (Hospital) Services CITALOPRAM 40 MG TABLET RX-23490 CDM 6370000100 HCPCS 250 RC 00378-6233-01 NDC outpatient 1 UN 5.72 5.72 CIGNA 62308 [3081051] CIGNA STATE OF WYOMING [308105107] 4.58 percent of total billed charges 3.55 5.43 Technical (Hospital) Services CITALOPRAM 40 MG TABLET RX-23490 CDM 6370000100 HCPCS 250 RC 00378-6233-01 NDC outpatient 1 UN 5.72 5.72 HEALTHPARTNERS SX009 HEALTHPARTNERS 4.58 percent of total billed charges 3.55 5.43 Technical (Hospital) Services CITALOPRAM 40 MG TABLET RX-23490 CDM 6370000100 HCPCS 250 RC 00378-6233-01 NDC outpatient 1 UN 5.72 5.72 UNITED HEALTHCARE (COMMERCIAL) [3081199] UNITED HEALTHCARE 87726 [308119901] 3.55 percent of total billed charges 3.55 5.43 Technical (Hospital) Services CITALOPRAM 40 MG TABLET RX-23490 CDM 6370000100 HCPCS 250 RC 00378-6233-01 NDC outpatient 1 UN 5.72 5.72 BLUE CROSS BLUE SHIELD WELLMARK SB889 [3081026] BCBS WYOMING [308102603] 5.43 percent of total billed charges 3.55 5.43 Technical (Hospital) Services CITALOPRAM 40 MG TABLET RX-23490 CDM 6370000100 HCPCS 250 RC 00378-6233-01 NDC outpatient 1 UN 5.72 5.72 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES HDHP [308136802] 4.58 percent of total billed charges 3.55 5.43 Technical (Hospital) Services CITALOPRAM 40 MG TABLET RX-23490 CDM 6370000100 HCPCS 250 RC 00378-6233-01 NDC outpatient 1 UN 5.72 5.72 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES PPO [308136801] 4.58 percent of total billed charges 3.55 5.43 Technical (Hospital) Services CITALOPRAM 40 MG TABLET RX-23490 CDM 6370000100 HCPCS 250 RC 00378-6233-01 NDC outpatient 1 UN 5.72 5.72 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES EPO [308136803] 4.58 percent of total billed charges 3.55 5.43 Technical (Hospital) Services CRANBERRY EXTRACT 425 MG CAPSULE RX-23496 CDM 6370000100 HCPCS 250 RC 43292-0558-12 NDC outpatient 1 UN 5.65 5.65 HEALTHPARTNERS SX009 HEALTHPARTNERS 4.52 percent of total billed charges 3.5 5.37 Technical (Hospital) Services CRANBERRY EXTRACT 425 MG CAPSULE RX-23496 CDM 6370000100 HCPCS 250 RC 43292-0558-12 NDC outpatient 1 UN 5.65 5.65 BLUE CROSS BLUE SHIELD WELLMARK SB889 [3081026] BCBS WYOMING [308102603] 5.37 percent of total billed charges 3.5 5.37 Technical (Hospital) Services CRANBERRY EXTRACT 425 MG CAPSULE RX-23496 CDM 6370000100 HCPCS 250 RC 43292-0558-12 NDC outpatient 1 UN 5.65 5.65 UNITED HEALTHCARE (COMMERCIAL) [3081199] UNITED HEALTHCARE 87726 [308119901] 3.5 percent of total billed charges 3.5 5.37 Technical (Hospital) Services CRANBERRY EXTRACT 425 MG CAPSULE RX-23496 CDM 6370000100 HCPCS 250 RC 43292-0558-12 NDC outpatient 1 UN 5.65 5.65 MULTIPLAN INC 34080 [3081285] MULTIPLAN INC [308128501] 5.37 percent of total billed charges 3.5 5.37 Technical (Hospital) Services CRANBERRY EXTRACT 425 MG CAPSULE RX-23496 CDM 6370000100 HCPCS 250 RC 43292-0558-12 NDC outpatient 1 UN 5.65 5.65 CIGNA 62308 [3081051] CIGNA 62308 [308105105] 4.52 percent of total billed charges 3.5 5.37 Technical (Hospital) Services CRANBERRY EXTRACT 425 MG CAPSULE RX-23496 CDM 6370000100 HCPCS 250 RC 43292-0558-12 NDC outpatient 1 UN 5.65 5.65 CIGNA 62308 [3081051] CIGNA STATE OF WYOMING [308105107] 4.52 percent of total billed charges 3.5 5.37 Technical (Hospital) Services CRANBERRY EXTRACT 425 MG CAPSULE RX-23496 CDM 6370000100 HCPCS 250 RC 43292-0558-12 NDC outpatient 1 UN 5.65 5.65 MEDICA (COMMERCIAL) 94265 [3081118] MEDICA CLAIMS [308111801] 5.09 percent of total billed charges 3.5 5.37 Technical (Hospital) Services CRANBERRY EXTRACT 425 MG CAPSULE RX-23496 CDM 6370000100 HCPCS 250 RC 43292-0558-12 NDC outpatient 1 UN 5.65 5.65 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES PPO [308136801] 4.52 percent of total billed charges 3.5 5.37 Technical (Hospital) Services CRANBERRY EXTRACT 425 MG CAPSULE RX-23496 CDM 6370000100 HCPCS 250 RC 43292-0558-12 NDC outpatient 1 UN 5.65 5.65 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES HDHP [308136802] 4.52 percent of total billed charges 3.5 5.37 Technical (Hospital) Services CRANBERRY EXTRACT 425 MG CAPSULE RX-23496 CDM 6370000100 HCPCS 250 RC 43292-0558-12 NDC outpatient 1 UN 5.65 5.65 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES EPO [308136803] 4.52 percent of total billed charges 3.5 5.37 Technical (Hospital) Services CRANBERRY EXTRACT 425 MG CAPSULE RX-23496 CDM 6370000100 HCPCS 250 RC 43292-0558-12 NDC inpatient 1 UN 5.65 5.65 MULTIPLAN INC 34080 [3081285] MULTIPLAN INC [308128501] 5.37 percent of total billed charges 3.5 5.37 Technical (Hospital) Services CRANBERRY EXTRACT 425 MG CAPSULE RX-23496 CDM 6370000100 HCPCS 250 RC 43292-0558-12 NDC inpatient 1 UN 5.65 5.65 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES PPO [308136801] 4.47 percent of total billed charges 3.5 5.37 Technical (Hospital) Services CRANBERRY EXTRACT 425 MG CAPSULE RX-23496 CDM 6370000100 HCPCS 250 RC 43292-0558-12 NDC inpatient 1 UN 5.65 5.65 HEALTHPARTNERS SX009 HEALTHPARTNERS 4.47 percent of total billed charges 3.5 5.37 Technical (Hospital) Services CRANBERRY EXTRACT 425 MG CAPSULE RX-23496 CDM 6370000100 HCPCS 250 RC 43292-0558-12 NDC inpatient 1 UN 5.65 5.65 MEDICA (COMMERCIAL) 94265 [3081118] MEDICA CLAIMS [308111801] 5.09 percent of total billed charges 3.5 5.37 Technical (Hospital) Services CRANBERRY EXTRACT 425 MG CAPSULE RX-23496 CDM 6370000100 HCPCS 250 RC 43292-0558-12 NDC inpatient 1 UN 5.65 5.65 UNITED HEALTHCARE (COMMERCIAL) [3081199] UNITED HEALTHCARE 87726 [308119901] 3.5 percent of total billed charges 3.5 5.37 Technical (Hospital) Services CRANBERRY EXTRACT 425 MG CAPSULE RX-23496 CDM 6370000100 HCPCS 250 RC 43292-0558-12 NDC inpatient 1 UN 5.65 5.65 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES HDHP [308136802] 4.47 percent of total billed charges 3.5 5.37 Technical (Hospital) Services CRANBERRY EXTRACT 425 MG CAPSULE RX-23496 CDM 6370000100 HCPCS 250 RC 43292-0558-12 NDC inpatient 1 UN 5.65 5.65 BLUE CROSS BLUE SHIELD WELLMARK SB889 [3081026] BCBS WYOMING [308102603] 5.37 percent of total billed charges 3.5 5.37 Technical (Hospital) Services CRANBERRY EXTRACT 425 MG CAPSULE RX-23496 CDM 6370000100 HCPCS 250 RC 43292-0558-12 NDC inpatient 1 UN 5.65 5.65 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES EPO [308136803] 4.47 percent of total billed charges 3.5 5.37 Technical (Hospital) Services CRANBERRY EXTRACT 425 MG CAPSULE RX-23496 CDM 6370000100 HCPCS 250 RC 43292-0558-12 NDC inpatient 1 UN 5.65 5.65 CIGNA 62308 [3081051] CIGNA 62308 [308105105] 4.47 percent of total billed charges 3.5 5.37 Technical (Hospital) Services CRANBERRY EXTRACT 425 MG CAPSULE RX-23496 CDM 6370000100 HCPCS 250 RC 43292-0558-12 NDC inpatient 1 UN 5.65 5.65 CIGNA 62308 [3081051] CIGNA STATE OF WYOMING [308105107] 4.47 percent of total billed charges 3.5 5.37 Technical (Hospital) Services DIAZEPAM 5 MG TABLET RX-2405 CDM 6370000100 HCPCS 250 RC 51079-0285-20 NDC inpatient 1 UN 5.69 5.69 UNITED HEALTHCARE (COMMERCIAL) [3081199] UNITED HEALTHCARE 87726 [308119901] 3.53 percent of total billed charges 3.53 5.41 Technical (Hospital) Services DIAZEPAM 5 MG TABLET RX-2405 CDM 6370000100 HCPCS 250 RC 51079-0285-20 NDC inpatient 1 UN 5.69 5.69 BLUE CROSS BLUE SHIELD WELLMARK SB889 [3081026] BCBS WYOMING [308102603] 5.41 percent of total billed charges 3.53 5.41 Technical (Hospital) Services DIAZEPAM 5 MG TABLET RX-2405 CDM 6370000100 HCPCS 250 RC 51079-0285-20 NDC inpatient 1 UN 5.69 5.69 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES EPO [308136803] 4.51 percent of total billed charges 3.53 5.41 Technical (Hospital) Services DIAZEPAM 5 MG TABLET RX-2405 CDM 6370000100 HCPCS 250 RC 51079-0285-20 NDC inpatient 1 UN 5.69 5.69 CIGNA 62308 [3081051] CIGNA 62308 [308105105] 4.51 percent of total billed charges 3.53 5.41 Technical (Hospital) Services DIAZEPAM 5 MG TABLET RX-2405 CDM 6370000100 HCPCS 250 RC 51079-0285-20 NDC inpatient 1 UN 5.69 5.69 CIGNA 62308 [3081051] CIGNA STATE OF WYOMING [308105107] 4.51 percent of total billed charges 3.53 5.41 Technical (Hospital) Services DIAZEPAM 5 MG TABLET RX-2405 CDM 6370000100 HCPCS 250 RC 51079-0285-20 NDC inpatient 1 UN 5.69 5.69 HEALTHPARTNERS SX009 HEALTHPARTNERS 4.51 percent of total billed charges 3.53 5.41 Technical (Hospital) Services DIAZEPAM 5 MG TABLET RX-2405 CDM 6370000100 HCPCS 250 RC 51079-0285-20 NDC inpatient 1 UN 5.69 5.69 MEDICA (COMMERCIAL) 94265 [3081118] MEDICA CLAIMS [308111801] 5.12 percent of total billed charges 3.53 5.41 Technical (Hospital) Services DIAZEPAM 5 MG TABLET RX-2405 CDM 6370000100 HCPCS 250 RC 51079-0285-20 NDC inpatient 1 UN 5.69 5.69 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES HDHP [308136802] 4.51 percent of total billed charges 3.53 5.41 Technical (Hospital) Services DIAZEPAM 5 MG TABLET RX-2405 CDM 6370000100 HCPCS 250 RC 51079-0285-20 NDC inpatient 1 UN 5.69 5.69 MULTIPLAN INC 34080 [3081285] MULTIPLAN INC [308128501] 5.41 percent of total billed charges 3.53 5.41 Technical (Hospital) Services DIAZEPAM 5 MG TABLET RX-2405 CDM 6370000100 HCPCS 250 RC 51079-0285-20 NDC inpatient 1 UN 5.69 5.69 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES PPO [308136801] 4.51 percent of total billed charges 3.53 5.41 Technical (Hospital) Services DIAZEPAM 5 MG TABLET RX-2405 CDM 6370000100 HCPCS 250 RC 51079-0285-20 NDC outpatient 1 UN 5.69 5.69 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES HDHP [308136802] 4.55 percent of total billed charges 3.53 5.41 Technical (Hospital) Services DIAZEPAM 5 MG TABLET RX-2405 CDM 6370000100 HCPCS 250 RC 51079-0285-20 NDC outpatient 1 UN 5.69 5.69 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES PPO [308136801] 4.55 percent of total billed charges 3.53 5.41 Technical (Hospital) Services DIAZEPAM 5 MG TABLET RX-2405 CDM 6370000100 HCPCS 250 RC 51079-0285-20 NDC outpatient 1 UN 5.69 5.69 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES EPO [308136803] 4.55 percent of total billed charges 3.53 5.41 Technical (Hospital) Services DIAZEPAM 5 MG TABLET RX-2405 CDM 6370000100 HCPCS 250 RC 51079-0285-20 NDC outpatient 1 UN 5.69 5.69 BLUE CROSS BLUE SHIELD WELLMARK SB889 [3081026] BCBS WYOMING [308102603] 5.41 percent of total billed charges 3.53 5.41 Technical (Hospital) Services DIAZEPAM 5 MG TABLET RX-2405 CDM 6370000100 HCPCS 250 RC 51079-0285-20 NDC outpatient 1 UN 5.69 5.69 CIGNA 62308 [3081051] CIGNA 62308 [308105105] 4.55 percent of total billed charges 3.53 5.41 Technical (Hospital) Services DIAZEPAM 5 MG TABLET RX-2405 CDM 6370000100 HCPCS 250 RC 51079-0285-20 NDC outpatient 1 UN 5.69 5.69 CIGNA 62308 [3081051] CIGNA STATE OF WYOMING [308105107] 4.55 percent of total billed charges 3.53 5.41 Technical (Hospital) Services DIAZEPAM 5 MG TABLET RX-2405 CDM 6370000100 HCPCS 250 RC 51079-0285-20 NDC outpatient 1 UN 5.69 5.69 MULTIPLAN INC 34080 [3081285] MULTIPLAN INC [308128501] 5.41 percent of total billed charges 3.53 5.41 Technical (Hospital) Services DIAZEPAM 5 MG TABLET RX-2405 CDM 6370000100 HCPCS 250 RC 51079-0285-20 NDC outpatient 1 UN 5.69 5.69 MEDICA (COMMERCIAL) 94265 [3081118] MEDICA CLAIMS [308111801] 5.12 percent of total billed charges 3.53 5.41 Technical (Hospital) Services DIAZEPAM 5 MG TABLET RX-2405 CDM 6370000100 HCPCS 250 RC 51079-0285-20 NDC outpatient 1 UN 5.69 5.69 UNITED HEALTHCARE (COMMERCIAL) [3081199] UNITED HEALTHCARE 87726 [308119901] 3.53 percent of total billed charges 3.53 5.41 Technical (Hospital) Services DIAZEPAM 5 MG TABLET RX-2405 CDM 6370000100 HCPCS 250 RC 51079-0285-20 NDC outpatient 1 UN 5.69 5.69 HEALTHPARTNERS SX009 HEALTHPARTNERS 4.55 percent of total billed charges 3.53 5.41 Technical (Hospital) Services DICLOXACILLIN 250 MG CAPSULE RX-2414 CDM 6370000100 HCPCS 250 RC 00093-3123-01 NDC inpatient 1 UN 6.25 6.25 MEDICA (COMMERCIAL) 94265 [3081118] MEDICA CLAIMS [308111801] 5.63 percent of total billed charges 3.88 5.94 Technical (Hospital) Services DICLOXACILLIN 250 MG CAPSULE RX-2414 CDM 6370000100 HCPCS 250 RC 00093-3123-01 NDC inpatient 1 UN 6.25 6.25 HEALTHPARTNERS SX009 HEALTHPARTNERS 4.95 percent of total billed charges 3.88 5.94 Technical (Hospital) Services DICLOXACILLIN 250 MG CAPSULE RX-2414 CDM 6370000100 HCPCS 250 RC 00093-3123-01 NDC inpatient 1 UN 6.25 6.25 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES PPO [308136801] 4.95 percent of total billed charges 3.88 5.94 Technical (Hospital) Services DICLOXACILLIN 250 MG CAPSULE RX-2414 CDM 6370000100 HCPCS 250 RC 00093-3123-01 NDC inpatient 1 UN 6.25 6.25 MULTIPLAN INC 34080 [3081285] MULTIPLAN INC [308128501] 5.94 percent of total billed charges 3.88 5.94 Technical (Hospital) Services DICLOXACILLIN 250 MG CAPSULE RX-2414 CDM 6370000100 HCPCS 250 RC 00093-3123-01 NDC inpatient 1 UN 6.25 6.25 BLUE CROSS BLUE SHIELD WELLMARK SB889 [3081026] BCBS WYOMING [308102603] 5.94 percent of total billed charges 3.88 5.94 Technical (Hospital) Services DICLOXACILLIN 250 MG CAPSULE RX-2414 CDM 6370000100 HCPCS 250 RC 00093-3123-01 NDC inpatient 1 UN 6.25 6.25 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES EPO [308136803] 4.95 percent of total billed charges 3.88 5.94 Technical (Hospital) Services DICLOXACILLIN 250 MG CAPSULE RX-2414 CDM 6370000100 HCPCS 250 RC 00093-3123-01 NDC inpatient 1 UN 6.25 6.25 CIGNA 62308 [3081051] CIGNA 62308 [308105105] 4.95 percent of total billed charges 3.88 5.94 Technical (Hospital) Services DICLOXACILLIN 250 MG CAPSULE RX-2414 CDM 6370000100 HCPCS 250 RC 00093-3123-01 NDC inpatient 1 UN 6.25 6.25 CIGNA 62308 [3081051] CIGNA STATE OF WYOMING [308105107] 4.95 percent of total billed charges 3.88 5.94 Technical (Hospital) Services DICLOXACILLIN 250 MG CAPSULE RX-2414 CDM 6370000100 HCPCS 250 RC 00093-3123-01 NDC inpatient 1 UN 6.25 6.25 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES HDHP [308136802] 4.95 percent of total billed charges 3.88 5.94 Technical (Hospital) Services DICLOXACILLIN 250 MG CAPSULE RX-2414 CDM 6370000100 HCPCS 250 RC 00093-3123-01 NDC inpatient 1 UN 6.25 6.25 UNITED HEALTHCARE (COMMERCIAL) [3081199] UNITED HEALTHCARE 87726 [308119901] 3.88 percent of total billed charges 3.88 5.94 Technical (Hospital) Services DICLOXACILLIN 250 MG CAPSULE RX-2414 CDM 6370000100 HCPCS 250 RC 00093-3123-01 NDC outpatient 1 UN 6.25 6.25 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES EPO [308136803] 5 percent of total billed charges 3.88 5.94 Technical (Hospital) Services DICLOXACILLIN 250 MG CAPSULE RX-2414 CDM 6370000100 HCPCS 250 RC 00093-3123-01 NDC outpatient 1 UN 6.25 6.25 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES HDHP [308136802] 5 percent of total billed charges 3.88 5.94 Technical (Hospital) Services DICLOXACILLIN 250 MG CAPSULE RX-2414 CDM 6370000100 HCPCS 250 RC 00093-3123-01 NDC outpatient 1 UN 6.25 6.25 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES PPO [308136801] 5 percent of total billed charges 3.88 5.94 Technical (Hospital) Services DICLOXACILLIN 250 MG CAPSULE RX-2414 CDM 6370000100 HCPCS 250 RC 00093-3123-01 NDC outpatient 1 UN 6.25 6.25 BLUE CROSS BLUE SHIELD WELLMARK SB889 [3081026] BCBS WYOMING [308102603] 5.94 percent of total billed charges 3.88 5.94 Technical (Hospital) Services DICLOXACILLIN 250 MG CAPSULE RX-2414 CDM 6370000100 HCPCS 250 RC 00093-3123-01 NDC outpatient 1 UN 6.25 6.25 HEALTHPARTNERS SX009 HEALTHPARTNERS 5 percent of total billed charges 3.88 5.94 Technical (Hospital) Services DICLOXACILLIN 250 MG CAPSULE RX-2414 CDM 6370000100 HCPCS 250 RC 00093-3123-01 NDC outpatient 1 UN 6.25 6.25 UNITED HEALTHCARE (COMMERCIAL) [3081199] UNITED HEALTHCARE 87726 [308119901] 3.88 percent of total billed charges 3.88 5.94 Technical (Hospital) Services DICLOXACILLIN 250 MG CAPSULE RX-2414 CDM 6370000100 HCPCS 250 RC 00093-3123-01 NDC outpatient 1 UN 6.25 6.25 MULTIPLAN INC 34080 [3081285] MULTIPLAN INC [308128501] 5.94 percent of total billed charges 3.88 5.94 Technical (Hospital) Services DICLOXACILLIN 250 MG CAPSULE RX-2414 CDM 6370000100 HCPCS 250 RC 00093-3123-01 NDC outpatient 1 UN 6.25 6.25 CIGNA 62308 [3081051] CIGNA 62308 [308105105] 5 percent of total billed charges 3.88 5.94 Technical (Hospital) Services DICLOXACILLIN 250 MG CAPSULE RX-2414 CDM 6370000100 HCPCS 250 RC 00093-3123-01 NDC outpatient 1 UN 6.25 6.25 CIGNA 62308 [3081051] CIGNA STATE OF WYOMING [308105107] 5 percent of total billed charges 3.88 5.94 Technical (Hospital) Services DICLOXACILLIN 250 MG CAPSULE RX-2414 CDM 6370000100 HCPCS 250 RC 00093-3123-01 NDC outpatient 1 UN 6.25 6.25 MEDICA (COMMERCIAL) 94265 [3081118] MEDICA CLAIMS [308111801] 5.63 percent of total billed charges 3.88 5.94 Technical (Hospital) Services DICLOXACILLIN 500 MG CAPSULE RX-2415 CDM 6370000100 HCPCS 250 RC 00093-3125-01 NDC inpatient 1 UN 6.87 6.87 CIGNA 62308 [3081051] CIGNA 62308 [308105105] 5.44 percent of total billed charges 4.26 6.53 Technical (Hospital) Services DICLOXACILLIN 500 MG CAPSULE RX-2415 CDM 6370000100 HCPCS 250 RC 00093-3125-01 NDC inpatient 1 UN 6.87 6.87 CIGNA 62308 [3081051] CIGNA STATE OF WYOMING [308105107] 5.44 percent of total billed charges 4.26 6.53 Technical (Hospital) Services DICLOXACILLIN 500 MG CAPSULE RX-2415 CDM 6370000100 HCPCS 250 RC 00093-3125-01 NDC inpatient 1 UN 6.87 6.87 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES EPO [308136803] 5.44 percent of total billed charges 4.26 6.53 Technical (Hospital) Services DICLOXACILLIN 500 MG CAPSULE RX-2415 CDM 6370000100 HCPCS 250 RC 00093-3125-01 NDC inpatient 1 UN 6.87 6.87 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES HDHP [308136802] 5.44 percent of total billed charges 4.26 6.53 Technical (Hospital) Services DICLOXACILLIN 500 MG CAPSULE RX-2415 CDM 6370000100 HCPCS 250 RC 00093-3125-01 NDC inpatient 1 UN 6.87 6.87 HEALTHPARTNERS SX009 HEALTHPARTNERS 5.44 percent of total billed charges 4.26 6.53 Technical (Hospital) Services DICLOXACILLIN 500 MG CAPSULE RX-2415 CDM 6370000100 HCPCS 250 RC 00093-3125-01 NDC inpatient 1 UN 6.87 6.87 MEDICA (COMMERCIAL) 94265 [3081118] MEDICA CLAIMS [308111801] 6.18 percent of total billed charges 4.26 6.53 Technical (Hospital) Services DICLOXACILLIN 500 MG CAPSULE RX-2415 CDM 6370000100 HCPCS 250 RC 00093-3125-01 NDC inpatient 1 UN 6.87 6.87 BLUE CROSS BLUE SHIELD WELLMARK SB889 [3081026] BCBS WYOMING [308102603] 6.53 percent of total billed charges 4.26 6.53 Technical (Hospital) Services DICLOXACILLIN 500 MG CAPSULE RX-2415 CDM 6370000100 HCPCS 250 RC 00093-3125-01 NDC inpatient 1 UN 6.87 6.87 UNITED HEALTHCARE (COMMERCIAL) [3081199] UNITED HEALTHCARE 87726 [308119901] 4.26 percent of total billed charges 4.26 6.53 Technical (Hospital) Services DICLOXACILLIN 500 MG CAPSULE RX-2415 CDM 6370000100 HCPCS 250 RC 00093-3125-01 NDC inpatient 1 UN 6.87 6.87 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES PPO [308136801] 5.44 percent of total billed charges 4.26 6.53 Technical (Hospital) Services DICLOXACILLIN 500 MG CAPSULE RX-2415 CDM 6370000100 HCPCS 250 RC 00093-3125-01 NDC inpatient 1 UN 6.87 6.87 MULTIPLAN INC 34080 [3081285] MULTIPLAN INC [308128501] 6.53 percent of total billed charges 4.26 6.53 Technical (Hospital) Services DICLOXACILLIN 500 MG CAPSULE RX-2415 CDM 6370000100 HCPCS 250 RC 00093-3125-01 NDC outpatient 1 UN 6.87 6.87 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES PPO [308136801] 5.5 percent of total billed charges 4.26 6.53 Technical (Hospital) Services DICLOXACILLIN 500 MG CAPSULE RX-2415 CDM 6370000100 HCPCS 250 RC 00093-3125-01 NDC outpatient 1 UN 6.87 6.87 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES EPO [308136803] 5.5 percent of total billed charges 4.26 6.53 Technical (Hospital) Services DICLOXACILLIN 500 MG CAPSULE RX-2415 CDM 6370000100 HCPCS 250 RC 00093-3125-01 NDC outpatient 1 UN 6.87 6.87 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES HDHP [308136802] 5.5 percent of total billed charges 4.26 6.53 Technical (Hospital) Services DICLOXACILLIN 500 MG CAPSULE RX-2415 CDM 6370000100 HCPCS 250 RC 00093-3125-01 NDC outpatient 1 UN 6.87 6.87 HEALTHPARTNERS SX009 HEALTHPARTNERS 5.5 percent of total billed charges 4.26 6.53 Technical (Hospital) Services DICLOXACILLIN 500 MG CAPSULE RX-2415 CDM 6370000100 HCPCS 250 RC 00093-3125-01 NDC outpatient 1 UN 6.87 6.87 BLUE CROSS BLUE SHIELD WELLMARK SB889 [3081026] BCBS WYOMING [308102603] 6.53 percent of total billed charges 4.26 6.53 Technical (Hospital) Services DICLOXACILLIN 500 MG CAPSULE RX-2415 CDM 6370000100 HCPCS 250 RC 00093-3125-01 NDC outpatient 1 UN 6.87 6.87 MEDICA (COMMERCIAL) 94265 [3081118] MEDICA CLAIMS [308111801] 6.18 percent of total billed charges 4.26 6.53 Technical (Hospital) Services DICLOXACILLIN 500 MG CAPSULE RX-2415 CDM 6370000100 HCPCS 250 RC 00093-3125-01 NDC outpatient 1 UN 6.87 6.87 CIGNA 62308 [3081051] CIGNA 62308 [308105105] 5.5 percent of total billed charges 4.26 6.53 Technical (Hospital) Services DICLOXACILLIN 500 MG CAPSULE RX-2415 CDM 6370000100 HCPCS 250 RC 00093-3125-01 NDC outpatient 1 UN 6.87 6.87 CIGNA 62308 [3081051] CIGNA STATE OF WYOMING [308105107] 5.5 percent of total billed charges 4.26 6.53 Technical (Hospital) Services DICLOXACILLIN 500 MG CAPSULE RX-2415 CDM 6370000100 HCPCS 250 RC 00093-3125-01 NDC outpatient 1 UN 6.87 6.87 UNITED HEALTHCARE (COMMERCIAL) [3081199] UNITED HEALTHCARE 87726 [308119901] 4.26 percent of total billed charges 4.26 6.53 Technical (Hospital) Services DICLOXACILLIN 500 MG CAPSULE RX-2415 CDM 6370000100 HCPCS 250 RC 00093-3125-01 NDC outpatient 1 UN 6.87 6.87 MULTIPLAN INC 34080 [3081285] MULTIPLAN INC [308128501] 6.53 percent of total billed charges 4.26 6.53 Technical (Hospital) Services TELMISARTAN 80 MG TABLET RX-24336 CDM 6370000100 HCPCS 250 RC 42571-0228-30 NDC outpatient 1 UN 6.46 6.46 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES PPO [308136801] 5.17 percent of total billed charges 4.01 6.14 Technical (Hospital) Services TELMISARTAN 80 MG TABLET RX-24336 CDM 6370000100 HCPCS 250 RC 42571-0228-30 NDC outpatient 1 UN 6.46 6.46 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES EPO [308136803] 5.17 percent of total billed charges 4.01 6.14 Technical (Hospital) Services TELMISARTAN 80 MG TABLET RX-24336 CDM 6370000100 HCPCS 250 RC 42571-0228-30 NDC outpatient 1 UN 6.46 6.46 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES HDHP [308136802] 5.17 percent of total billed charges 4.01 6.14 Technical (Hospital) Services TELMISARTAN 80 MG TABLET RX-24336 CDM 6370000100 HCPCS 250 RC 42571-0228-30 NDC outpatient 1 UN 6.46 6.46 BLUE CROSS BLUE SHIELD WELLMARK SB889 [3081026] BCBS WYOMING [308102603] 6.14 percent of total billed charges 4.01 6.14 Technical (Hospital) Services TELMISARTAN 80 MG TABLET RX-24336 CDM 6370000100 HCPCS 250 RC 42571-0228-30 NDC outpatient 1 UN 6.46 6.46 HEALTHPARTNERS SX009 HEALTHPARTNERS 5.17 percent of total billed charges 4.01 6.14 Technical (Hospital) Services TELMISARTAN 80 MG TABLET RX-24336 CDM 6370000100 HCPCS 250 RC 42571-0228-30 NDC outpatient 1 UN 6.46 6.46 MEDICA (COMMERCIAL) 94265 [3081118] MEDICA CLAIMS [308111801] 5.81 percent of total billed charges 4.01 6.14 Technical (Hospital) Services TELMISARTAN 80 MG TABLET RX-24336 CDM 6370000100 HCPCS 250 RC 42571-0228-30 NDC outpatient 1 UN 6.46 6.46 MULTIPLAN INC 34080 [3081285] MULTIPLAN INC [308128501] 6.14 percent of total billed charges 4.01 6.14 Technical (Hospital) Services TELMISARTAN 80 MG TABLET RX-24336 CDM 6370000100 HCPCS 250 RC 42571-0228-30 NDC outpatient 1 UN 6.46 6.46 CIGNA 62308 [3081051] CIGNA 62308 [308105105] 5.17 percent of total billed charges 4.01 6.14 Technical (Hospital) Services TELMISARTAN 80 MG TABLET RX-24336 CDM 6370000100 HCPCS 250 RC 42571-0228-30 NDC outpatient 1 UN 6.46 6.46 CIGNA 62308 [3081051] CIGNA STATE OF WYOMING [308105107] 5.17 percent of total billed charges 4.01 6.14 Technical (Hospital) Services TELMISARTAN 80 MG TABLET RX-24336 CDM 6370000100 HCPCS 250 RC 42571-0228-30 NDC outpatient 1 UN 6.46 6.46 UNITED HEALTHCARE (COMMERCIAL) [3081199] UNITED HEALTHCARE 87726 [308119901] 4.01 percent of total billed charges 4.01 6.14 Technical (Hospital) Services TELMISARTAN 80 MG TABLET RX-24336 CDM 6370000100 HCPCS 250 RC 42571-0228-30 NDC inpatient 1 UN 6.46 6.46 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES PPO [308136801] 5.12 percent of total billed charges 4.01 6.14 Technical (Hospital) Services TELMISARTAN 80 MG TABLET RX-24336 CDM 6370000100 HCPCS 250 RC 42571-0228-30 NDC inpatient 1 UN 6.46 6.46 MULTIPLAN INC 34080 [3081285] MULTIPLAN INC [308128501] 6.14 percent of total billed charges 4.01 6.14 Technical (Hospital) Services TELMISARTAN 80 MG TABLET RX-24336 CDM 6370000100 HCPCS 250 RC 42571-0228-30 NDC inpatient 1 UN 6.46 6.46 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES EPO [308136803] 5.12 percent of total billed charges 4.01 6.14 Technical (Hospital) Services TELMISARTAN 80 MG TABLET RX-24336 CDM 6370000100 HCPCS 250 RC 42571-0228-30 NDC inpatient 1 UN 6.46 6.46 CIGNA 62308 [3081051] CIGNA 62308 [308105105] 5.12 percent of total billed charges 4.01 6.14 Technical (Hospital) Services TELMISARTAN 80 MG TABLET RX-24336 CDM 6370000100 HCPCS 250 RC 42571-0228-30 NDC inpatient 1 UN 6.46 6.46 CIGNA 62308 [3081051] CIGNA STATE OF WYOMING [308105107] 5.12 percent of total billed charges 4.01 6.14 Technical (Hospital) Services TELMISARTAN 80 MG TABLET RX-24336 CDM 6370000100 HCPCS 250 RC 42571-0228-30 NDC inpatient 1 UN 6.46 6.46 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES HDHP [308136802] 5.12 percent of total billed charges 4.01 6.14 Technical (Hospital) Services TELMISARTAN 80 MG TABLET RX-24336 CDM 6370000100 HCPCS 250 RC 42571-0228-30 NDC inpatient 1 UN 6.46 6.46 HEALTHPARTNERS SX009 HEALTHPARTNERS 5.12 percent of total billed charges 4.01 6.14 Technical (Hospital) Services TELMISARTAN 80 MG TABLET RX-24336 CDM 6370000100 HCPCS 250 RC 42571-0228-30 NDC inpatient 1 UN 6.46 6.46 MEDICA (COMMERCIAL) 94265 [3081118] MEDICA CLAIMS [308111801] 5.81 percent of total billed charges 4.01 6.14 Technical (Hospital) Services TELMISARTAN 80 MG TABLET RX-24336 CDM 6370000100 HCPCS 250 RC 42571-0228-30 NDC inpatient 1 UN 6.46 6.46 BLUE CROSS BLUE SHIELD WELLMARK SB889 [3081026] BCBS WYOMING [308102603] 6.14 percent of total billed charges 4.01 6.14 Technical (Hospital) Services TELMISARTAN 80 MG TABLET RX-24336 CDM 6370000100 HCPCS 250 RC 42571-0228-30 NDC inpatient 1 UN 6.46 6.46 UNITED HEALTHCARE (COMMERCIAL) [3081199] UNITED HEALTHCARE 87726 [308119901] 4.01 percent of total billed charges 4.01 6.14 Technical (Hospital) Services DIGOXIN 125 MCG (0.125 MG) TABLET RX-2444 CDM 6370000100 HCPCS 250 RC 00904-5921-61 NDC inpatient 1 UN 6.97 6.97 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES PPO [308136801] 5.52 percent of total billed charges 4.32 6.62 Technical (Hospital) Services DIGOXIN 125 MCG (0.125 MG) TABLET RX-2444 CDM 6370000100 HCPCS 250 RC 00904-5921-61 NDC inpatient 1 UN 6.97 6.97 HEALTHPARTNERS SX009 HEALTHPARTNERS 5.52 percent of total billed charges 4.32 6.62 Technical (Hospital) Services DIGOXIN 125 MCG (0.125 MG) TABLET RX-2444 CDM 6370000100 HCPCS 250 RC 00904-5921-61 NDC inpatient 1 UN 6.97 6.97 MEDICA (COMMERCIAL) 94265 [3081118] MEDICA CLAIMS [308111801] 6.27 percent of total billed charges 4.32 6.62 Technical (Hospital) Services DIGOXIN 125 MCG (0.125 MG) TABLET RX-2444 CDM 6370000100 HCPCS 250 RC 00904-5921-61 NDC inpatient 1 UN 6.97 6.97 MULTIPLAN INC 34080 [3081285] MULTIPLAN INC [308128501] 6.62 percent of total billed charges 4.32 6.62 Technical (Hospital) Services DIGOXIN 125 MCG (0.125 MG) TABLET RX-2444 CDM 6370000100 HCPCS 250 RC 00904-5921-61 NDC inpatient 1 UN 6.97 6.97 UNITED HEALTHCARE (COMMERCIAL) [3081199] UNITED HEALTHCARE 87726 [308119901] 4.32 percent of total billed charges 4.32 6.62 Technical (Hospital) Services DIGOXIN 125 MCG (0.125 MG) TABLET RX-2444 CDM 6370000100 HCPCS 250 RC 00904-5921-61 NDC inpatient 1 UN 6.97 6.97 BLUE CROSS BLUE SHIELD WELLMARK SB889 [3081026] BCBS WYOMING [308102603] 6.62 percent of total billed charges 4.32 6.62 Technical (Hospital) Services DIGOXIN 125 MCG (0.125 MG) TABLET RX-2444 CDM 6370000100 HCPCS 250 RC 00904-5921-61 NDC inpatient 1 UN 6.97 6.97 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES EPO [308136803] 5.52 percent of total billed charges 4.32 6.62 Technical (Hospital) Services DIGOXIN 125 MCG (0.125 MG) TABLET RX-2444 CDM 6370000100 HCPCS 250 RC 00904-5921-61 NDC inpatient 1 UN 6.97 6.97 CIGNA 62308 [3081051] CIGNA 62308 [308105105] 5.52 percent of total billed charges 4.32 6.62 Technical (Hospital) Services DIGOXIN 125 MCG (0.125 MG) TABLET RX-2444 CDM 6370000100 HCPCS 250 RC 00904-5921-61 NDC inpatient 1 UN 6.97 6.97 CIGNA 62308 [3081051] CIGNA STATE OF WYOMING [308105107] 5.52 percent of total billed charges 4.32 6.62 Technical (Hospital) Services DIGOXIN 125 MCG (0.125 MG) TABLET RX-2444 CDM 6370000100 HCPCS 250 RC 00904-5921-61 NDC inpatient 1 UN 6.97 6.97 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES HDHP [308136802] 5.52 percent of total billed charges 4.32 6.62 Technical (Hospital) Services DIGOXIN 125 MCG (0.125 MG) TABLET RX-2444 CDM 6370000100 HCPCS 250 RC 00904-5921-61 NDC outpatient 1 UN 6.97 6.97 MULTIPLAN INC 34080 [3081285] MULTIPLAN INC [308128501] 6.62 percent of total billed charges 4.32 6.62 Technical (Hospital) Services DIGOXIN 125 MCG (0.125 MG) TABLET RX-2444 CDM 6370000100 HCPCS 250 RC 00904-5921-61 NDC outpatient 1 UN 6.97 6.97 CIGNA 62308 [3081051] CIGNA 62308 [308105105] 5.58 percent of total billed charges 4.32 6.62 Technical (Hospital) Services DIGOXIN 125 MCG (0.125 MG) TABLET RX-2444 CDM 6370000100 HCPCS 250 RC 00904-5921-61 NDC outpatient 1 UN 6.97 6.97 CIGNA 62308 [3081051] CIGNA STATE OF WYOMING [308105107] 5.58 percent of total billed charges 4.32 6.62 Technical (Hospital) Services DIGOXIN 125 MCG (0.125 MG) TABLET RX-2444 CDM 6370000100 HCPCS 250 RC 00904-5921-61 NDC outpatient 1 UN 6.97 6.97 MEDICA (COMMERCIAL) 94265 [3081118] MEDICA CLAIMS [308111801] 6.27 percent of total billed charges 4.32 6.62 Technical (Hospital) Services DIGOXIN 125 MCG (0.125 MG) TABLET RX-2444 CDM 6370000100 HCPCS 250 RC 00904-5921-61 NDC outpatient 1 UN 6.97 6.97 UNITED HEALTHCARE (COMMERCIAL) [3081199] UNITED HEALTHCARE 87726 [308119901] 4.32 percent of total billed charges 4.32 6.62 Technical (Hospital) Services DIGOXIN 125 MCG (0.125 MG) TABLET RX-2444 CDM 6370000100 HCPCS 250 RC 00904-5921-61 NDC outpatient 1 UN 6.97 6.97 HEALTHPARTNERS SX009 HEALTHPARTNERS 5.58 percent of total billed charges 4.32 6.62 Technical (Hospital) Services DIGOXIN 125 MCG (0.125 MG) TABLET RX-2444 CDM 6370000100 HCPCS 250 RC 00904-5921-61 NDC outpatient 1 UN 6.97 6.97 BLUE CROSS BLUE SHIELD WELLMARK SB889 [3081026] BCBS WYOMING [308102603] 6.62 percent of total billed charges 4.32 6.62 Technical (Hospital) Services DIGOXIN 125 MCG (0.125 MG) TABLET RX-2444 CDM 6370000100 HCPCS 250 RC 00904-5921-61 NDC outpatient 1 UN 6.97 6.97 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES EPO [308136803] 5.58 percent of total billed charges 4.32 6.62 Technical (Hospital) Services DIGOXIN 125 MCG (0.125 MG) TABLET RX-2444 CDM 6370000100 HCPCS 250 RC 00904-5921-61 NDC outpatient 1 UN 6.97 6.97 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES PPO [308136801] 5.58 percent of total billed charges 4.32 6.62 Technical (Hospital) Services DIGOXIN 125 MCG (0.125 MG) TABLET RX-2444 CDM 6370000100 HCPCS 250 RC 00904-5921-61 NDC outpatient 1 UN 6.97 6.97 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES HDHP [308136802] 5.58 percent of total billed charges 4.32 6.62 Technical (Hospital) Services "OXYBUTYNIN CHLORIDE ER 10 MG TABLET,EXTENDED RELEASE 24 HR" RX-24471 CDM 6370000100 HCPCS 250 RC 10135-0610-01 NDC inpatient 1 UN 6.42 6.42 BLUE CROSS BLUE SHIELD WELLMARK SB889 [3081026] BCBS WYOMING [308102603] 6.1 percent of total billed charges 3.98 6.1 Technical (Hospital) Services "OXYBUTYNIN CHLORIDE ER 10 MG TABLET,EXTENDED RELEASE 24 HR" RX-24471 CDM 6370000100 HCPCS 250 RC 10135-0610-01 NDC inpatient 1 UN 6.42 6.42 UNITED HEALTHCARE (COMMERCIAL) [3081199] UNITED HEALTHCARE 87726 [308119901] 3.98 percent of total billed charges 3.98 6.1 Technical (Hospital) Services "OXYBUTYNIN CHLORIDE ER 10 MG TABLET,EXTENDED RELEASE 24 HR" RX-24471 CDM 6370000100 HCPCS 250 RC 10135-0610-01 NDC inpatient 1 UN 6.42 6.42 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES EPO [308136803] 5.08 percent of total billed charges 3.98 6.1 Technical (Hospital) Services "OXYBUTYNIN CHLORIDE ER 10 MG TABLET,EXTENDED RELEASE 24 HR" RX-24471 CDM 6370000100 HCPCS 250 RC 10135-0610-01 NDC inpatient 1 UN 6.42 6.42 CIGNA 62308 [3081051] CIGNA 62308 [308105105] 5.08 percent of total billed charges 3.98 6.1 Technical (Hospital) Services "OXYBUTYNIN CHLORIDE ER 10 MG TABLET,EXTENDED RELEASE 24 HR" RX-24471 CDM 6370000100 HCPCS 250 RC 10135-0610-01 NDC inpatient 1 UN 6.42 6.42 CIGNA 62308 [3081051] CIGNA STATE OF WYOMING [308105107] 5.08 percent of total billed charges 3.98 6.1 Technical (Hospital) Services "OXYBUTYNIN CHLORIDE ER 10 MG TABLET,EXTENDED RELEASE 24 HR" RX-24471 CDM 6370000100 HCPCS 250 RC 10135-0610-01 NDC inpatient 1 UN 6.42 6.42 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES HDHP [308136802] 5.08 percent of total billed charges 3.98 6.1 Technical (Hospital) Services "OXYBUTYNIN CHLORIDE ER 10 MG TABLET,EXTENDED RELEASE 24 HR" RX-24471 CDM 6370000100 HCPCS 250 RC 10135-0610-01 NDC inpatient 1 UN 6.42 6.42 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES PPO [308136801] 5.08 percent of total billed charges 3.98 6.1 Technical (Hospital) Services "OXYBUTYNIN CHLORIDE ER 10 MG TABLET,EXTENDED RELEASE 24 HR" RX-24471 CDM 6370000100 HCPCS 250 RC 10135-0610-01 NDC inpatient 1 UN 6.42 6.42 MEDICA (COMMERCIAL) 94265 [3081118] MEDICA CLAIMS [308111801] 5.78 percent of total billed charges 3.98 6.1 Technical (Hospital) Services "OXYBUTYNIN CHLORIDE ER 10 MG TABLET,EXTENDED RELEASE 24 HR" RX-24471 CDM 6370000100 HCPCS 250 RC 10135-0610-01 NDC inpatient 1 UN 6.42 6.42 HEALTHPARTNERS SX009 HEALTHPARTNERS 5.08 percent of total billed charges 3.98 6.1 Technical (Hospital) Services "OXYBUTYNIN CHLORIDE ER 10 MG TABLET,EXTENDED RELEASE 24 HR" RX-24471 CDM 6370000100 HCPCS 250 RC 10135-0610-01 NDC inpatient 1 UN 6.42 6.42 MULTIPLAN INC 34080 [3081285] MULTIPLAN INC [308128501] 6.1 percent of total billed charges 3.98 6.1 Technical (Hospital) Services "OXYBUTYNIN CHLORIDE ER 10 MG TABLET,EXTENDED RELEASE 24 HR" RX-24471 CDM 6370000100 HCPCS 250 RC 10135-0610-01 NDC outpatient 1 UN 6.42 6.42 BLUE CROSS BLUE SHIELD WELLMARK SB889 [3081026] BCBS WYOMING [308102603] 6.1 percent of total billed charges 3.98 6.1 Technical (Hospital) Services "OXYBUTYNIN CHLORIDE ER 10 MG TABLET,EXTENDED RELEASE 24 HR" RX-24471 CDM 6370000100 HCPCS 250 RC 10135-0610-01 NDC outpatient 1 UN 6.42 6.42 UNITED HEALTHCARE (COMMERCIAL) [3081199] UNITED HEALTHCARE 87726 [308119901] 3.98 percent of total billed charges 3.98 6.1 Technical (Hospital) Services "OXYBUTYNIN CHLORIDE ER 10 MG TABLET,EXTENDED RELEASE 24 HR" RX-24471 CDM 6370000100 HCPCS 250 RC 10135-0610-01 NDC outpatient 1 UN 6.42 6.42 HEALTHPARTNERS SX009 HEALTHPARTNERS 5.14 percent of total billed charges 3.98 6.1 Technical (Hospital) Services "OXYBUTYNIN CHLORIDE ER 10 MG TABLET,EXTENDED RELEASE 24 HR" RX-24471 CDM 6370000100 HCPCS 250 RC 10135-0610-01 NDC outpatient 1 UN 6.42 6.42 MEDICA (COMMERCIAL) 94265 [3081118] MEDICA CLAIMS [308111801] 5.78 percent of total billed charges 3.98 6.1 Technical (Hospital) Services "OXYBUTYNIN CHLORIDE ER 10 MG TABLET,EXTENDED RELEASE 24 HR" RX-24471 CDM 6370000100 HCPCS 250 RC 10135-0610-01 NDC outpatient 1 UN 6.42 6.42 CIGNA 62308 [3081051] CIGNA 62308 [308105105] 5.14 percent of total billed charges 3.98 6.1 Technical (Hospital) Services "OXYBUTYNIN CHLORIDE ER 10 MG TABLET,EXTENDED RELEASE 24 HR" RX-24471 CDM 6370000100 HCPCS 250 RC 10135-0610-01 NDC outpatient 1 UN 6.42 6.42 CIGNA 62308 [3081051] CIGNA STATE OF WYOMING [308105107] 5.14 percent of total billed charges 3.98 6.1 Technical (Hospital) Services "OXYBUTYNIN CHLORIDE ER 10 MG TABLET,EXTENDED RELEASE 24 HR" RX-24471 CDM 6370000100 HCPCS 250 RC 10135-0610-01 NDC outpatient 1 UN 6.42 6.42 MULTIPLAN INC 34080 [3081285] MULTIPLAN INC [308128501] 6.1 percent of total billed charges 3.98 6.1 Technical (Hospital) Services "OXYBUTYNIN CHLORIDE ER 10 MG TABLET,EXTENDED RELEASE 24 HR" RX-24471 CDM 6370000100 HCPCS 250 RC 10135-0610-01 NDC outpatient 1 UN 6.42 6.42 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES PPO [308136801] 5.14 percent of total billed charges 3.98 6.1 Technical (Hospital) Services "OXYBUTYNIN CHLORIDE ER 10 MG TABLET,EXTENDED RELEASE 24 HR" RX-24471 CDM 6370000100 HCPCS 250 RC 10135-0610-01 NDC outpatient 1 UN 6.42 6.42 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES HDHP [308136802] 5.14 percent of total billed charges 3.98 6.1 Technical (Hospital) Services "OXYBUTYNIN CHLORIDE ER 10 MG TABLET,EXTENDED RELEASE 24 HR" RX-24471 CDM 6370000100 HCPCS 250 RC 10135-0610-01 NDC outpatient 1 UN 6.42 6.42 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES EPO [308136803] 5.14 percent of total billed charges 3.98 6.1 Technical (Hospital) Services CILOSTAZOL 50 MG TABLET RX-24473 CDM 6370000100 HCPCS 250 RC 60505-2521-01 NDC inpatient 1 UN 5.99 5.99 MULTIPLAN INC 34080 [3081285] MULTIPLAN INC [308128501] 5.69 percent of total billed charges 3.71 5.69 Technical (Hospital) Services CILOSTAZOL 50 MG TABLET RX-24473 CDM 6370000100 HCPCS 250 RC 60505-2521-01 NDC inpatient 1 UN 5.99 5.99 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES PPO [308136801] 4.74 percent of total billed charges 3.71 5.69 Technical (Hospital) Services CILOSTAZOL 50 MG TABLET RX-24473 CDM 6370000100 HCPCS 250 RC 60505-2521-01 NDC inpatient 1 UN 5.99 5.99 CIGNA 62308 [3081051] CIGNA 62308 [308105105] 4.74 percent of total billed charges 3.71 5.69 Technical (Hospital) Services CILOSTAZOL 50 MG TABLET RX-24473 CDM 6370000100 HCPCS 250 RC 60505-2521-01 NDC inpatient 1 UN 5.99 5.99 CIGNA 62308 [3081051] CIGNA STATE OF WYOMING [308105107] 4.74 percent of total billed charges 3.71 5.69 Technical (Hospital) Services CILOSTAZOL 50 MG TABLET RX-24473 CDM 6370000100 HCPCS 250 RC 60505-2521-01 NDC inpatient 1 UN 5.99 5.99 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES EPO [308136803] 4.74 percent of total billed charges 3.71 5.69 Technical (Hospital) Services CILOSTAZOL 50 MG TABLET RX-24473 CDM 6370000100 HCPCS 250 RC 60505-2521-01 NDC inpatient 1 UN 5.99 5.99 MEDICA (COMMERCIAL) 94265 [3081118] MEDICA CLAIMS [308111801] 5.39 percent of total billed charges 3.71 5.69 Technical (Hospital) Services CILOSTAZOL 50 MG TABLET RX-24473 CDM 6370000100 HCPCS 250 RC 60505-2521-01 NDC inpatient 1 UN 5.99 5.99 HEALTHPARTNERS SX009 HEALTHPARTNERS 4.74 percent of total billed charges 3.71 5.69 Technical (Hospital) Services CILOSTAZOL 50 MG TABLET RX-24473 CDM 6370000100 HCPCS 250 RC 60505-2521-01 NDC inpatient 1 UN 5.99 5.99 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES HDHP [308136802] 4.74 percent of total billed charges 3.71 5.69 Technical (Hospital) Services CILOSTAZOL 50 MG TABLET RX-24473 CDM 6370000100 HCPCS 250 RC 60505-2521-01 NDC inpatient 1 UN 5.99 5.99 BLUE CROSS BLUE SHIELD WELLMARK SB889 [3081026] BCBS WYOMING [308102603] 5.69 percent of total billed charges 3.71 5.69 Technical (Hospital) Services CILOSTAZOL 50 MG TABLET RX-24473 CDM 6370000100 HCPCS 250 RC 60505-2521-01 NDC inpatient 1 UN 5.99 5.99 UNITED HEALTHCARE (COMMERCIAL) [3081199] UNITED HEALTHCARE 87726 [308119901] 3.71 percent of total billed charges 3.71 5.69 Technical (Hospital) Services CILOSTAZOL 50 MG TABLET RX-24473 CDM 6370000100 HCPCS 250 RC 60505-2521-01 NDC outpatient 1 UN 5.99 5.99 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES EPO [308136803] 4.79 percent of total billed charges 3.71 5.69 Technical (Hospital) Services CILOSTAZOL 50 MG TABLET RX-24473 CDM 6370000100 HCPCS 250 RC 60505-2521-01 NDC outpatient 1 UN 5.99 5.99 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES HDHP [308136802] 4.79 percent of total billed charges 3.71 5.69 Technical (Hospital) Services CILOSTAZOL 50 MG TABLET RX-24473 CDM 6370000100 HCPCS 250 RC 60505-2521-01 NDC outpatient 1 UN 5.99 5.99 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES PPO [308136801] 4.79 percent of total billed charges 3.71 5.69 Technical (Hospital) Services CILOSTAZOL 50 MG TABLET RX-24473 CDM 6370000100 HCPCS 250 RC 60505-2521-01 NDC outpatient 1 UN 5.99 5.99 BLUE CROSS BLUE SHIELD WELLMARK SB889 [3081026] BCBS WYOMING [308102603] 5.69 percent of total billed charges 3.71 5.69 Technical (Hospital) Services CILOSTAZOL 50 MG TABLET RX-24473 CDM 6370000100 HCPCS 250 RC 60505-2521-01 NDC outpatient 1 UN 5.99 5.99 HEALTHPARTNERS SX009 HEALTHPARTNERS 4.79 percent of total billed charges 3.71 5.69 Technical (Hospital) Services CILOSTAZOL 50 MG TABLET RX-24473 CDM 6370000100 HCPCS 250 RC 60505-2521-01 NDC outpatient 1 UN 5.99 5.99 UNITED HEALTHCARE (COMMERCIAL) [3081199] UNITED HEALTHCARE 87726 [308119901] 3.71 percent of total billed charges 3.71 5.69 Technical (Hospital) Services CILOSTAZOL 50 MG TABLET RX-24473 CDM 6370000100 HCPCS 250 RC 60505-2521-01 NDC outpatient 1 UN 5.99 5.99 MEDICA (COMMERCIAL) 94265 [3081118] MEDICA CLAIMS [308111801] 5.39 percent of total billed charges 3.71 5.69 Technical (Hospital) Services CILOSTAZOL 50 MG TABLET RX-24473 CDM 6370000100 HCPCS 250 RC 60505-2521-01 NDC outpatient 1 UN 5.99 5.99 CIGNA 62308 [3081051] CIGNA 62308 [308105105] 4.79 percent of total billed charges 3.71 5.69 Technical (Hospital) Services CILOSTAZOL 50 MG TABLET RX-24473 CDM 6370000100 HCPCS 250 RC 60505-2521-01 NDC outpatient 1 UN 5.99 5.99 CIGNA 62308 [3081051] CIGNA STATE OF WYOMING [308105107] 4.79 percent of total billed charges 3.71 5.69 Technical (Hospital) Services CILOSTAZOL 50 MG TABLET RX-24473 CDM 6370000100 HCPCS 250 RC 60505-2521-01 NDC outpatient 1 UN 5.99 5.99 MULTIPLAN INC 34080 [3081285] MULTIPLAN INC [308128501] 5.69 percent of total billed charges 3.71 5.69 Technical (Hospital) Services CILOSTAZOL 100 MG TABLET RX-24474 CDM 6370000100 HCPCS 250 RC 00093-2064-06 NDC inpatient 1 UN 5.99 5.99 UNITED HEALTHCARE (COMMERCIAL) [3081199] UNITED HEALTHCARE 87726 [308119901] 3.71 percent of total billed charges 3.71 5.69 Technical (Hospital) Services CILOSTAZOL 100 MG TABLET RX-24474 CDM 6370000100 HCPCS 250 RC 00093-2064-06 NDC inpatient 1 UN 5.99 5.99 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES EPO [308136803] 4.74 percent of total billed charges 3.71 5.69 Technical (Hospital) Services CILOSTAZOL 100 MG TABLET RX-24474 CDM 6370000100 HCPCS 250 RC 00093-2064-06 NDC outpatient 1 UN 5.99 5.99 MULTIPLAN INC 34080 [3081285] MULTIPLAN INC [308128501] 5.69 percent of total billed charges 3.71 5.69 Technical (Hospital) Services CILOSTAZOL 100 MG TABLET RX-24474 CDM 6370000100 HCPCS 250 RC 00093-2064-06 NDC outpatient 1 UN 5.99 5.99 CIGNA 62308 [3081051] CIGNA 62308 [308105105] 4.79 percent of total billed charges 3.71 5.69 Technical (Hospital) Services CILOSTAZOL 100 MG TABLET RX-24474 CDM 6370000100 HCPCS 250 RC 00093-2064-06 NDC outpatient 1 UN 5.99 5.99 CIGNA 62308 [3081051] CIGNA STATE OF WYOMING [308105107] 4.79 percent of total billed charges 3.71 5.69 Technical (Hospital) Services CILOSTAZOL 100 MG TABLET RX-24474 CDM 6370000100 HCPCS 250 RC 00093-2064-06 NDC outpatient 1 UN 5.99 5.99 MEDICA (COMMERCIAL) 94265 [3081118] MEDICA CLAIMS [308111801] 5.39 percent of total billed charges 3.71 5.69 Technical (Hospital) Services CILOSTAZOL 100 MG TABLET RX-24474 CDM 6370000100 HCPCS 250 RC 00093-2064-06 NDC outpatient 1 UN 5.99 5.99 UNITED HEALTHCARE (COMMERCIAL) [3081199] UNITED HEALTHCARE 87726 [308119901] 3.71 percent of total billed charges 3.71 5.69 Technical (Hospital) Services CILOSTAZOL 100 MG TABLET RX-24474 CDM 6370000100 HCPCS 250 RC 00093-2064-06 NDC outpatient 1 UN 5.99 5.99 HEALTHPARTNERS SX009 HEALTHPARTNERS 4.79 percent of total billed charges 3.71 5.69 Technical (Hospital) Services CILOSTAZOL 100 MG TABLET RX-24474 CDM 6370000100 HCPCS 250 RC 00093-2064-06 NDC outpatient 1 UN 5.99 5.99 BLUE CROSS BLUE SHIELD WELLMARK SB889 [3081026] BCBS WYOMING [308102603] 5.69 percent of total billed charges 3.71 5.69 Technical (Hospital) Services CILOSTAZOL 100 MG TABLET RX-24474 CDM 6370000100 HCPCS 250 RC 00093-2064-06 NDC inpatient 1 UN 5.99 5.99 CIGNA 62308 [3081051] CIGNA 62308 [308105105] 4.74 percent of total billed charges 3.71 5.69 Technical (Hospital) Services CILOSTAZOL 100 MG TABLET RX-24474 CDM 6370000100 HCPCS 250 RC 00093-2064-06 NDC inpatient 1 UN 5.99 5.99 CIGNA 62308 [3081051] CIGNA STATE OF WYOMING [308105107] 4.74 percent of total billed charges 3.71 5.69 Technical (Hospital) Services CILOSTAZOL 100 MG TABLET RX-24474 CDM 6370000100 HCPCS 250 RC 00093-2064-06 NDC inpatient 1 UN 5.99 5.99 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES HDHP [308136802] 4.74 percent of total billed charges 3.71 5.69 Technical (Hospital) Services CILOSTAZOL 100 MG TABLET RX-24474 CDM 6370000100 HCPCS 250 RC 00093-2064-06 NDC inpatient 1 UN 5.99 5.99 BLUE CROSS BLUE SHIELD WELLMARK SB889 [3081026] BCBS WYOMING [308102603] 5.69 percent of total billed charges 3.71 5.69 Technical (Hospital) Services CILOSTAZOL 100 MG TABLET RX-24474 CDM 6370000100 HCPCS 250 RC 00093-2064-06 NDC inpatient 1 UN 5.99 5.99 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES PPO [308136801] 4.74 percent of total billed charges 3.71 5.69 Technical (Hospital) Services CILOSTAZOL 100 MG TABLET RX-24474 CDM 6370000100 HCPCS 250 RC 00093-2064-06 NDC inpatient 1 UN 5.99 5.99 HEALTHPARTNERS SX009 HEALTHPARTNERS 4.74 percent of total billed charges 3.71 5.69 Technical (Hospital) Services CILOSTAZOL 100 MG TABLET RX-24474 CDM 6370000100 HCPCS 250 RC 00093-2064-06 NDC inpatient 1 UN 5.99 5.99 MEDICA (COMMERCIAL) 94265 [3081118] MEDICA CLAIMS [308111801] 5.39 percent of total billed charges 3.71 5.69 Technical (Hospital) Services CILOSTAZOL 100 MG TABLET RX-24474 CDM 6370000100 HCPCS 250 RC 00093-2064-06 NDC inpatient 1 UN 5.99 5.99 MULTIPLAN INC 34080 [3081285] MULTIPLAN INC [308128501] 5.69 percent of total billed charges 3.71 5.69 Technical (Hospital) Services CILOSTAZOL 100 MG TABLET RX-24474 CDM 6370000100 HCPCS 250 RC 00093-2064-06 NDC outpatient 1 UN 5.99 5.99 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES PPO [308136801] 4.79 percent of total billed charges 3.71 5.69 Technical (Hospital) Services CILOSTAZOL 100 MG TABLET RX-24474 CDM 6370000100 HCPCS 250 RC 00093-2064-06 NDC outpatient 1 UN 5.99 5.99 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES HDHP [308136802] 4.79 percent of total billed charges 3.71 5.69 Technical (Hospital) Services CILOSTAZOL 100 MG TABLET RX-24474 CDM 6370000100 HCPCS 250 RC 00093-2064-06 NDC outpatient 1 UN 5.99 5.99 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES EPO [308136803] 4.79 percent of total billed charges 3.71 5.69 Technical (Hospital) Services CELECOXIB 100 MG CAPSULE RX-24500 CDM 6370000100 HCPCS 250 RC 59762-1516-01 NDC outpatient 1 UN 6.22 6.22 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES PPO [308136801] 4.98 percent of total billed charges 3.86 5.91 Technical (Hospital) Services CELECOXIB 100 MG CAPSULE RX-24500 CDM 6370000100 HCPCS 250 RC 59762-1516-01 NDC outpatient 1 UN 6.22 6.22 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES HDHP [308136802] 4.98 percent of total billed charges 3.86 5.91 Technical (Hospital) Services CELECOXIB 100 MG CAPSULE RX-24500 CDM 6370000100 HCPCS 250 RC 59762-1516-01 NDC outpatient 1 UN 6.22 6.22 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES EPO [308136803] 4.98 percent of total billed charges 3.86 5.91 Technical (Hospital) Services CELECOXIB 100 MG CAPSULE RX-24500 CDM 6370000100 HCPCS 250 RC 59762-1516-01 NDC outpatient 1 UN 6.22 6.22 BLUE CROSS BLUE SHIELD WELLMARK SB889 [3081026] BCBS WYOMING [308102603] 5.91 percent of total billed charges 3.86 5.91 Technical (Hospital) Services CELECOXIB 100 MG CAPSULE RX-24500 CDM 6370000100 HCPCS 250 RC 59762-1516-01 NDC outpatient 1 UN 6.22 6.22 HEALTHPARTNERS SX009 HEALTHPARTNERS 4.98 percent of total billed charges 3.86 5.91 Technical (Hospital) Services CELECOXIB 100 MG CAPSULE RX-24500 CDM 6370000100 HCPCS 250 RC 59762-1516-01 NDC outpatient 1 UN 6.22 6.22 UNITED HEALTHCARE (COMMERCIAL) [3081199] UNITED HEALTHCARE 87726 [308119901] 3.86 percent of total billed charges 3.86 5.91 Technical (Hospital) Services CELECOXIB 100 MG CAPSULE RX-24500 CDM 6370000100 HCPCS 250 RC 59762-1516-01 NDC outpatient 1 UN 6.22 6.22 MEDICA (COMMERCIAL) 94265 [3081118] MEDICA CLAIMS [308111801] 5.6 percent of total billed charges 3.86 5.91 Technical (Hospital) Services CELECOXIB 100 MG CAPSULE RX-24500 CDM 6370000100 HCPCS 250 RC 59762-1516-01 NDC outpatient 1 UN 6.22 6.22 MULTIPLAN INC 34080 [3081285] MULTIPLAN INC [308128501] 5.91 percent of total billed charges 3.86 5.91 Technical (Hospital) Services CELECOXIB 100 MG CAPSULE RX-24500 CDM 6370000100 HCPCS 250 RC 59762-1516-01 NDC outpatient 1 UN 6.22 6.22 CIGNA 62308 [3081051] CIGNA 62308 [308105105] 4.98 percent of total billed charges 3.86 5.91 Technical (Hospital) Services CELECOXIB 100 MG CAPSULE RX-24500 CDM 6370000100 HCPCS 250 RC 59762-1516-01 NDC outpatient 1 UN 6.22 6.22 CIGNA 62308 [3081051] CIGNA STATE OF WYOMING [308105107] 4.98 percent of total billed charges 3.86 5.91 Technical (Hospital) Services CELECOXIB 100 MG CAPSULE RX-24500 CDM 6370000100 HCPCS 250 RC 59762-1516-01 NDC inpatient 1 UN 6.22 6.22 UNITED HEALTHCARE (COMMERCIAL) [3081199] UNITED HEALTHCARE 87726 [308119901] 3.86 percent of total billed charges 3.86 5.91 Technical (Hospital) Services CELECOXIB 100 MG CAPSULE RX-24500 CDM 6370000100 HCPCS 250 RC 59762-1516-01 NDC inpatient 1 UN 6.22 6.22 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES HDHP [308136802] 4.92 percent of total billed charges 3.86 5.91 Technical (Hospital) Services CELECOXIB 100 MG CAPSULE RX-24500 CDM 6370000100 HCPCS 250 RC 59762-1516-01 NDC inpatient 1 UN 6.22 6.22 BLUE CROSS BLUE SHIELD WELLMARK SB889 [3081026] BCBS WYOMING [308102603] 5.91 percent of total billed charges 3.86 5.91 Technical (Hospital) Services CELECOXIB 100 MG CAPSULE RX-24500 CDM 6370000100 HCPCS 250 RC 59762-1516-01 NDC inpatient 1 UN 6.22 6.22 CIGNA 62308 [3081051] CIGNA 62308 [308105105] 4.92 percent of total billed charges 3.86 5.91 Technical (Hospital) Services CELECOXIB 100 MG CAPSULE RX-24500 CDM 6370000100 HCPCS 250 RC 59762-1516-01 NDC inpatient 1 UN 6.22 6.22 CIGNA 62308 [3081051] CIGNA STATE OF WYOMING [308105107] 4.92 percent of total billed charges 3.86 5.91 Technical (Hospital) Services CELECOXIB 100 MG CAPSULE RX-24500 CDM 6370000100 HCPCS 250 RC 59762-1516-01 NDC inpatient 1 UN 6.22 6.22 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES EPO [308136803] 4.92 percent of total billed charges 3.86 5.91 Technical (Hospital) Services CELECOXIB 100 MG CAPSULE RX-24500 CDM 6370000100 HCPCS 250 RC 59762-1516-01 NDC inpatient 1 UN 6.22 6.22 MEDICA (COMMERCIAL) 94265 [3081118] MEDICA CLAIMS [308111801] 5.6 percent of total billed charges 3.86 5.91 Technical (Hospital) Services CELECOXIB 100 MG CAPSULE RX-24500 CDM 6370000100 HCPCS 250 RC 59762-1516-01 NDC inpatient 1 UN 6.22 6.22 HEALTHPARTNERS SX009 HEALTHPARTNERS 4.92 percent of total billed charges 3.86 5.91 Technical (Hospital) Services CELECOXIB 100 MG CAPSULE RX-24500 CDM 6370000100 HCPCS 250 RC 59762-1516-01 NDC inpatient 1 UN 6.22 6.22 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES PPO [308136801] 4.92 percent of total billed charges 3.86 5.91 Technical (Hospital) Services CELECOXIB 100 MG CAPSULE RX-24500 CDM 6370000100 HCPCS 250 RC 59762-1516-01 NDC inpatient 1 UN 6.22 6.22 MULTIPLAN INC 34080 [3081285] MULTIPLAN INC [308128501] 5.91 percent of total billed charges 3.86 5.91 Technical (Hospital) Services CELECOXIB 200 MG CAPSULE RX-24501 CDM 6370000100 HCPCS 250 RC 69097-0421-07 NDC outpatient 1 UN 5.92 5.92 CIGNA 62308 [3081051] CIGNA 62308 [308105105] 4.74 percent of total billed charges 3.67 5.62 Technical (Hospital) Services CELECOXIB 200 MG CAPSULE RX-24501 CDM 6370000100 HCPCS 250 RC 69097-0421-07 NDC outpatient 1 UN 5.92 5.92 CIGNA 62308 [3081051] CIGNA STATE OF WYOMING [308105107] 4.74 percent of total billed charges 3.67 5.62 Technical (Hospital) Services CELECOXIB 200 MG CAPSULE RX-24501 CDM 6370000100 HCPCS 250 RC 69097-0421-07 NDC outpatient 1 UN 5.92 5.92 MULTIPLAN INC 34080 [3081285] MULTIPLAN INC [308128501] 5.62 percent of total billed charges 3.67 5.62 Technical (Hospital) Services CELECOXIB 200 MG CAPSULE RX-24501 CDM 6370000100 HCPCS 250 RC 69097-0421-07 NDC outpatient 1 UN 5.92 5.92 MEDICA (COMMERCIAL) 94265 [3081118] MEDICA CLAIMS [308111801] 5.33 percent of total billed charges 3.67 5.62 Technical (Hospital) Services CELECOXIB 200 MG CAPSULE RX-24501 CDM 6370000100 HCPCS 250 RC 69097-0421-07 NDC outpatient 1 UN 5.92 5.92 UNITED HEALTHCARE (COMMERCIAL) [3081199] UNITED HEALTHCARE 87726 [308119901] 3.67 percent of total billed charges 3.67 5.62 Technical (Hospital) Services CELECOXIB 200 MG CAPSULE RX-24501 CDM 6370000100 HCPCS 250 RC 69097-0421-07 NDC outpatient 1 UN 5.92 5.92 BLUE CROSS BLUE SHIELD WELLMARK SB889 [3081026] BCBS WYOMING [308102603] 5.62 percent of total billed charges 3.67 5.62 Technical (Hospital) Services CELECOXIB 200 MG CAPSULE RX-24501 CDM 6370000100 HCPCS 250 RC 69097-0421-07 NDC outpatient 1 UN 5.92 5.92 HEALTHPARTNERS SX009 HEALTHPARTNERS 4.74 percent of total billed charges 3.67 5.62 Technical (Hospital) Services CELECOXIB 200 MG CAPSULE RX-24501 CDM 6370000100 HCPCS 250 RC 69097-0421-07 NDC outpatient 1 UN 5.92 5.92 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES HDHP [308136802] 4.74 percent of total billed charges 3.67 5.62 Technical (Hospital) Services CELECOXIB 200 MG CAPSULE RX-24501 CDM 6370000100 HCPCS 250 RC 69097-0421-07 NDC outpatient 1 UN 5.92 5.92 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES PPO [308136801] 4.74 percent of total billed charges 3.67 5.62 Technical (Hospital) Services CELECOXIB 200 MG CAPSULE RX-24501 CDM 6370000100 HCPCS 250 RC 69097-0421-07 NDC outpatient 1 UN 5.92 5.92 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES EPO [308136803] 4.74 percent of total billed charges 3.67 5.62 Technical (Hospital) Services CELECOXIB 200 MG CAPSULE RX-24501 CDM 6370000100 HCPCS 250 RC 69097-0421-07 NDC inpatient 1 UN 5.92 5.92 MULTIPLAN INC 34080 [3081285] MULTIPLAN INC [308128501] 5.62 percent of total billed charges 3.67 5.62 Technical (Hospital) Services CELECOXIB 200 MG CAPSULE RX-24501 CDM 6370000100 HCPCS 250 RC 69097-0421-07 NDC inpatient 1 UN 5.92 5.92 MEDICA (COMMERCIAL) 94265 [3081118] MEDICA CLAIMS [308111801] 5.33 percent of total billed charges 3.67 5.62 Technical (Hospital) Services CELECOXIB 200 MG CAPSULE RX-24501 CDM 6370000100 HCPCS 250 RC 69097-0421-07 NDC inpatient 1 UN 5.92 5.92 HEALTHPARTNERS SX009 HEALTHPARTNERS 4.69 percent of total billed charges 3.67 5.62 Technical (Hospital) Services CELECOXIB 200 MG CAPSULE RX-24501 CDM 6370000100 HCPCS 250 RC 69097-0421-07 NDC inpatient 1 UN 5.92 5.92 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES PPO [308136801] 4.69 percent of total billed charges 3.67 5.62 Technical (Hospital) Services CELECOXIB 200 MG CAPSULE RX-24501 CDM 6370000100 HCPCS 250 RC 69097-0421-07 NDC inpatient 1 UN 5.92 5.92 UNITED HEALTHCARE (COMMERCIAL) [3081199] UNITED HEALTHCARE 87726 [308119901] 3.67 percent of total billed charges 3.67 5.62 Technical (Hospital) Services CELECOXIB 200 MG CAPSULE RX-24501 CDM 6370000100 HCPCS 250 RC 69097-0421-07 NDC inpatient 1 UN 5.92 5.92 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES HDHP [308136802] 4.69 percent of total billed charges 3.67 5.62 Technical (Hospital) Services CELECOXIB 200 MG CAPSULE RX-24501 CDM 6370000100 HCPCS 250 RC 69097-0421-07 NDC inpatient 1 UN 5.92 5.92 CIGNA 62308 [3081051] CIGNA 62308 [308105105] 4.69 percent of total billed charges 3.67 5.62 Technical (Hospital) Services CELECOXIB 200 MG CAPSULE RX-24501 CDM 6370000100 HCPCS 250 RC 69097-0421-07 NDC inpatient 1 UN 5.92 5.92 CIGNA 62308 [3081051] CIGNA STATE OF WYOMING [308105107] 4.69 percent of total billed charges 3.67 5.62 Technical (Hospital) Services CELECOXIB 200 MG CAPSULE RX-24501 CDM 6370000100 HCPCS 250 RC 69097-0421-07 NDC inpatient 1 UN 5.92 5.92 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES EPO [308136803] 4.69 percent of total billed charges 3.67 5.62 Technical (Hospital) Services CELECOXIB 200 MG CAPSULE RX-24501 CDM 6370000100 HCPCS 250 RC 69097-0421-07 NDC inpatient 1 UN 5.92 5.92 BLUE CROSS BLUE SHIELD WELLMARK SB889 [3081026] BCBS WYOMING [308102603] 5.62 percent of total billed charges 3.67 5.62 Technical (Hospital) Services MODAFINIL 200 MG TABLET RX-24703 CDM 6370000100 HCPCS 250 RC 60505-2527-03 NDC inpatient 1 UN 6.89 6.89 MULTIPLAN INC 34080 [3081285] MULTIPLAN INC [308128501] 6.55 percent of total billed charges 4.27 6.55 Technical (Hospital) Services MODAFINIL 200 MG TABLET RX-24703 CDM 6370000100 HCPCS 250 RC 60505-2527-03 NDC inpatient 1 UN 6.89 6.89 HEALTHPARTNERS SX009 HEALTHPARTNERS 5.46 percent of total billed charges 4.27 6.55 Technical (Hospital) Services MODAFINIL 200 MG TABLET RX-24703 CDM 6370000100 HCPCS 250 RC 60505-2527-03 NDC inpatient 1 UN 6.89 6.89 MEDICA (COMMERCIAL) 94265 [3081118] MEDICA CLAIMS [308111801] 6.2 percent of total billed charges 4.27 6.55 Technical (Hospital) Services MODAFINIL 200 MG TABLET RX-24703 CDM 6370000100 HCPCS 250 RC 60505-2527-03 NDC inpatient 1 UN 6.89 6.89 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES PPO [308136801] 5.46 percent of total billed charges 4.27 6.55 Technical (Hospital) Services MODAFINIL 200 MG TABLET RX-24703 CDM 6370000100 HCPCS 250 RC 60505-2527-03 NDC inpatient 1 UN 6.89 6.89 UNITED HEALTHCARE (COMMERCIAL) [3081199] UNITED HEALTHCARE 87726 [308119901] 4.27 percent of total billed charges 4.27 6.55 Technical (Hospital) Services MODAFINIL 200 MG TABLET RX-24703 CDM 6370000100 HCPCS 250 RC 60505-2527-03 NDC inpatient 1 UN 6.89 6.89 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES HDHP [308136802] 5.46 percent of total billed charges 4.27 6.55 Technical (Hospital) Services MODAFINIL 200 MG TABLET RX-24703 CDM 6370000100 HCPCS 250 RC 60505-2527-03 NDC inpatient 1 UN 6.89 6.89 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES EPO [308136803] 5.46 percent of total billed charges 4.27 6.55 Technical (Hospital) Services MODAFINIL 200 MG TABLET RX-24703 CDM 6370000100 HCPCS 250 RC 60505-2527-03 NDC inpatient 1 UN 6.89 6.89 CIGNA 62308 [3081051] CIGNA STATE OF WYOMING [308105107] 5.46 percent of total billed charges 4.27 6.55 Technical (Hospital) Services MODAFINIL 200 MG TABLET RX-24703 CDM 6370000100 HCPCS 250 RC 60505-2527-03 NDC inpatient 1 UN 6.89 6.89 CIGNA 62308 [3081051] CIGNA 62308 [308105105] 5.46 percent of total billed charges 4.27 6.55 Technical (Hospital) Services MODAFINIL 200 MG TABLET RX-24703 CDM 6370000100 HCPCS 250 RC 60505-2527-03 NDC inpatient 1 UN 6.89 6.89 BLUE CROSS BLUE SHIELD WELLMARK SB889 [3081026] BCBS WYOMING [308102603] 6.55 percent of total billed charges 4.27 6.55 Technical (Hospital) Services MODAFINIL 200 MG TABLET RX-24703 CDM 6370000100 HCPCS 250 RC 60505-2527-03 NDC outpatient 1 UN 6.89 6.89 UNITED HEALTHCARE (COMMERCIAL) [3081199] UNITED HEALTHCARE 87726 [308119901] 4.27 percent of total billed charges 4.27 6.55 Technical (Hospital) Services MODAFINIL 200 MG TABLET RX-24703 CDM 6370000100 HCPCS 250 RC 60505-2527-03 NDC outpatient 1 UN 6.89 6.89 CIGNA 62308 [3081051] CIGNA 62308 [308105105] 5.51 percent of total billed charges 4.27 6.55 Technical (Hospital) Services MODAFINIL 200 MG TABLET RX-24703 CDM 6370000100 HCPCS 250 RC 60505-2527-03 NDC outpatient 1 UN 6.89 6.89 CIGNA 62308 [3081051] CIGNA STATE OF WYOMING [308105107] 5.51 percent of total billed charges 4.27 6.55 Technical (Hospital) Services MODAFINIL 200 MG TABLET RX-24703 CDM 6370000100 HCPCS 250 RC 60505-2527-03 NDC outpatient 1 UN 6.89 6.89 MULTIPLAN INC 34080 [3081285] MULTIPLAN INC [308128501] 6.55 percent of total billed charges 4.27 6.55 Technical (Hospital) Services MODAFINIL 200 MG TABLET RX-24703 CDM 6370000100 HCPCS 250 RC 60505-2527-03 NDC outpatient 1 UN 6.89 6.89 MEDICA (COMMERCIAL) 94265 [3081118] MEDICA CLAIMS [308111801] 6.2 percent of total billed charges 4.27 6.55 Technical (Hospital) Services MODAFINIL 200 MG TABLET RX-24703 CDM 6370000100 HCPCS 250 RC 60505-2527-03 NDC outpatient 1 UN 6.89 6.89 HEALTHPARTNERS SX009 HEALTHPARTNERS 5.51 percent of total billed charges 4.27 6.55 Technical (Hospital) Services MODAFINIL 200 MG TABLET RX-24703 CDM 6370000100 HCPCS 250 RC 60505-2527-03 NDC outpatient 1 UN 6.89 6.89 BLUE CROSS BLUE SHIELD WELLMARK SB889 [3081026] BCBS WYOMING [308102603] 6.55 percent of total billed charges 4.27 6.55 Technical (Hospital) Services MODAFINIL 200 MG TABLET RX-24703 CDM 6370000100 HCPCS 250 RC 60505-2527-03 NDC outpatient 1 UN 6.89 6.89 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES EPO [308136803] 5.51 percent of total billed charges 4.27 6.55 Technical (Hospital) Services MODAFINIL 200 MG TABLET RX-24703 CDM 6370000100 HCPCS 250 RC 60505-2527-03 NDC outpatient 1 UN 6.89 6.89 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES HDHP [308136802] 5.51 percent of total billed charges 4.27 6.55 Technical (Hospital) Services MODAFINIL 200 MG TABLET RX-24703 CDM 6370000100 HCPCS 250 RC 60505-2527-03 NDC outpatient 1 UN 6.89 6.89 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES PPO [308136801] 5.51 percent of total billed charges 4.27 6.55 Technical (Hospital) Services LISINOPRIL 10 MG-HYDROCHLOROTHIAZIDE 12.5 MG TABLET RX-24711 CDM 6370000100 HCPCS 250 RC 68180-0518-01 NDC inpatient 1 UN 5.72 5.72 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES HDHP [308136802] 4.53 percent of total billed charges 3.55 5.43 Technical (Hospital) Services LISINOPRIL 10 MG-HYDROCHLOROTHIAZIDE 12.5 MG TABLET RX-24711 CDM 6370000100 HCPCS 250 RC 68180-0518-01 NDC inpatient 1 UN 5.72 5.72 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES EPO [308136803] 4.53 percent of total billed charges 3.55 5.43 Technical (Hospital) Services LISINOPRIL 10 MG-HYDROCHLOROTHIAZIDE 12.5 MG TABLET RX-24711 CDM 6370000100 HCPCS 250 RC 68180-0518-01 NDC inpatient 1 UN 5.72 5.72 CIGNA 62308 [3081051] CIGNA 62308 [308105105] 4.53 percent of total billed charges 3.55 5.43 Technical (Hospital) Services LISINOPRIL 10 MG-HYDROCHLOROTHIAZIDE 12.5 MG TABLET RX-24711 CDM 6370000100 HCPCS 250 RC 68180-0518-01 NDC inpatient 1 UN 5.72 5.72 CIGNA 62308 [3081051] CIGNA STATE OF WYOMING [308105107] 4.53 percent of total billed charges 3.55 5.43 Technical (Hospital) Services LISINOPRIL 10 MG-HYDROCHLOROTHIAZIDE 12.5 MG TABLET RX-24711 CDM 6370000100 HCPCS 250 RC 68180-0518-01 NDC inpatient 1 UN 5.72 5.72 BLUE CROSS BLUE SHIELD WELLMARK SB889 [3081026] BCBS WYOMING [308102603] 5.43 percent of total billed charges 3.55 5.43 Technical (Hospital) Services LISINOPRIL 10 MG-HYDROCHLOROTHIAZIDE 12.5 MG TABLET RX-24711 CDM 6370000100 HCPCS 250 RC 68180-0518-01 NDC inpatient 1 UN 5.72 5.72 UNITED HEALTHCARE (COMMERCIAL) [3081199] UNITED HEALTHCARE 87726 [308119901] 3.55 percent of total billed charges 3.55 5.43 Technical (Hospital) Services LISINOPRIL 10 MG-HYDROCHLOROTHIAZIDE 12.5 MG TABLET RX-24711 CDM 6370000100 HCPCS 250 RC 68180-0518-01 NDC inpatient 1 UN 5.72 5.72 MULTIPLAN INC 34080 [3081285] MULTIPLAN INC [308128501] 5.43 percent of total billed charges 3.55 5.43 Technical (Hospital) Services LISINOPRIL 10 MG-HYDROCHLOROTHIAZIDE 12.5 MG TABLET RX-24711 CDM 6370000100 HCPCS 250 RC 68180-0518-01 NDC inpatient 1 UN 5.72 5.72 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES PPO [308136801] 4.53 percent of total billed charges 3.55 5.43 Technical (Hospital) Services LISINOPRIL 10 MG-HYDROCHLOROTHIAZIDE 12.5 MG TABLET RX-24711 CDM 6370000100 HCPCS 250 RC 68180-0518-01 NDC inpatient 1 UN 5.72 5.72 MEDICA (COMMERCIAL) 94265 [3081118] MEDICA CLAIMS [308111801] 5.15 percent of total billed charges 3.55 5.43 Technical (Hospital) Services LISINOPRIL 10 MG-HYDROCHLOROTHIAZIDE 12.5 MG TABLET RX-24711 CDM 6370000100 HCPCS 250 RC 68180-0518-01 NDC inpatient 1 UN 5.72 5.72 HEALTHPARTNERS SX009 HEALTHPARTNERS 4.53 percent of total billed charges 3.55 5.43 Technical (Hospital) Services LISINOPRIL 10 MG-HYDROCHLOROTHIAZIDE 12.5 MG TABLET RX-24711 CDM 6370000100 HCPCS 250 RC 68180-0518-01 NDC outpatient 1 UN 5.72 5.72 UNITED HEALTHCARE (COMMERCIAL) [3081199] UNITED HEALTHCARE 87726 [308119901] 3.55 percent of total billed charges 3.55 5.43 Technical (Hospital) Services LISINOPRIL 10 MG-HYDROCHLOROTHIAZIDE 12.5 MG TABLET RX-24711 CDM 6370000100 HCPCS 250 RC 68180-0518-01 NDC outpatient 1 UN 5.72 5.72 MULTIPLAN INC 34080 [3081285] MULTIPLAN INC [308128501] 5.43 percent of total billed charges 3.55 5.43 Technical (Hospital) Services LISINOPRIL 10 MG-HYDROCHLOROTHIAZIDE 12.5 MG TABLET RX-24711 CDM 6370000100 HCPCS 250 RC 68180-0518-01 NDC outpatient 1 UN 5.72 5.72 CIGNA 62308 [3081051] CIGNA 62308 [308105105] 4.58 percent of total billed charges 3.55 5.43 Technical (Hospital) Services LISINOPRIL 10 MG-HYDROCHLOROTHIAZIDE 12.5 MG TABLET RX-24711 CDM 6370000100 HCPCS 250 RC 68180-0518-01 NDC outpatient 1 UN 5.72 5.72 CIGNA 62308 [3081051] CIGNA STATE OF WYOMING [308105107] 4.58 percent of total billed charges 3.55 5.43 Technical (Hospital) Services LISINOPRIL 10 MG-HYDROCHLOROTHIAZIDE 12.5 MG TABLET RX-24711 CDM 6370000100 HCPCS 250 RC 68180-0518-01 NDC outpatient 1 UN 5.72 5.72 MEDICA (COMMERCIAL) 94265 [3081118] MEDICA CLAIMS [308111801] 5.15 percent of total billed charges 3.55 5.43 Technical (Hospital) Services LISINOPRIL 10 MG-HYDROCHLOROTHIAZIDE 12.5 MG TABLET RX-24711 CDM 6370000100 HCPCS 250 RC 68180-0518-01 NDC outpatient 1 UN 5.72 5.72 BLUE CROSS BLUE SHIELD WELLMARK SB889 [3081026] BCBS WYOMING [308102603] 5.43 percent of total billed charges 3.55 5.43 Technical (Hospital) Services LISINOPRIL 10 MG-HYDROCHLOROTHIAZIDE 12.5 MG TABLET RX-24711 CDM 6370000100 HCPCS 250 RC 68180-0518-01 NDC outpatient 1 UN 5.72 5.72 HEALTHPARTNERS SX009 HEALTHPARTNERS 4.58 percent of total billed charges 3.55 5.43 Technical (Hospital) Services LISINOPRIL 10 MG-HYDROCHLOROTHIAZIDE 12.5 MG TABLET RX-24711 CDM 6370000100 HCPCS 250 RC 68180-0518-01 NDC outpatient 1 UN 5.72 5.72 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES EPO [308136803] 4.58 percent of total billed charges 3.55 5.43 Technical (Hospital) Services LISINOPRIL 10 MG-HYDROCHLOROTHIAZIDE 12.5 MG TABLET RX-24711 CDM 6370000100 HCPCS 250 RC 68180-0518-01 NDC outpatient 1 UN 5.72 5.72 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES HDHP [308136802] 4.58 percent of total billed charges 3.55 5.43 Technical (Hospital) Services LISINOPRIL 10 MG-HYDROCHLOROTHIAZIDE 12.5 MG TABLET RX-24711 CDM 6370000100 HCPCS 250 RC 68180-0518-01 NDC outpatient 1 UN 5.72 5.72 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES PPO [308136801] 4.58 percent of total billed charges 3.55 5.43 Technical (Hospital) Services DILTIAZEM 120 MG TABLET RX-2474 CDM 6370000100 HCPCS 250 RC 00093-0321-01 NDC inpatient 1 UN 6.05 6.05 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES PPO [308136801] 4.79 percent of total billed charges 3.75 5.75 Technical (Hospital) Services DILTIAZEM 120 MG TABLET RX-2474 CDM 6370000100 HCPCS 250 RC 00093-0321-01 NDC inpatient 1 UN 6.05 6.05 MEDICA (COMMERCIAL) 94265 [3081118] MEDICA CLAIMS [308111801] 5.45 percent of total billed charges 3.75 5.75 Technical (Hospital) Services DILTIAZEM 120 MG TABLET RX-2474 CDM 6370000100 HCPCS 250 RC 00093-0321-01 NDC inpatient 1 UN 6.05 6.05 HEALTHPARTNERS SX009 HEALTHPARTNERS 4.79 percent of total billed charges 3.75 5.75 Technical (Hospital) Services DILTIAZEM 120 MG TABLET RX-2474 CDM 6370000100 HCPCS 250 RC 00093-0321-01 NDC inpatient 1 UN 6.05 6.05 MULTIPLAN INC 34080 [3081285] MULTIPLAN INC [308128501] 5.75 percent of total billed charges 3.75 5.75 Technical (Hospital) Services DILTIAZEM 120 MG TABLET RX-2474 CDM 6370000100 HCPCS 250 RC 00093-0321-01 NDC inpatient 1 UN 6.05 6.05 UNITED HEALTHCARE (COMMERCIAL) [3081199] UNITED HEALTHCARE 87726 [308119901] 3.75 percent of total billed charges 3.75 5.75 Technical (Hospital) Services DILTIAZEM 120 MG TABLET RX-2474 CDM 6370000100 HCPCS 250 RC 00093-0321-01 NDC inpatient 1 UN 6.05 6.05 CIGNA 62308 [3081051] CIGNA 62308 [308105105] 4.79 percent of total billed charges 3.75 5.75 Technical (Hospital) Services DILTIAZEM 120 MG TABLET RX-2474 CDM 6370000100 HCPCS 250 RC 00093-0321-01 NDC inpatient 1 UN 6.05 6.05 CIGNA 62308 [3081051] CIGNA STATE OF WYOMING [308105107] 4.79 percent of total billed charges 3.75 5.75 Technical (Hospital) Services DILTIAZEM 120 MG TABLET RX-2474 CDM 6370000100 HCPCS 250 RC 00093-0321-01 NDC inpatient 1 UN 6.05 6.05 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES EPO [308136803] 4.79 percent of total billed charges 3.75 5.75 Technical (Hospital) Services DILTIAZEM 120 MG TABLET RX-2474 CDM 6370000100 HCPCS 250 RC 00093-0321-01 NDC inpatient 1 UN 6.05 6.05 BLUE CROSS BLUE SHIELD WELLMARK SB889 [3081026] BCBS WYOMING [308102603] 5.75 percent of total billed charges 3.75 5.75 Technical (Hospital) Services DILTIAZEM 120 MG TABLET RX-2474 CDM 6370000100 HCPCS 250 RC 00093-0321-01 NDC inpatient 1 UN 6.05 6.05 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES HDHP [308136802] 4.79 percent of total billed charges 3.75 5.75 Technical (Hospital) Services DILTIAZEM 120 MG TABLET RX-2474 CDM 6370000100 HCPCS 250 RC 00093-0321-01 NDC outpatient 1 UN 6.05 6.05 CIGNA 62308 [3081051] CIGNA 62308 [308105105] 4.84 percent of total billed charges 3.75 5.75 Technical (Hospital) Services DILTIAZEM 120 MG TABLET RX-2474 CDM 6370000100 HCPCS 250 RC 00093-0321-01 NDC outpatient 1 UN 6.05 6.05 CIGNA 62308 [3081051] CIGNA STATE OF WYOMING [308105107] 4.84 percent of total billed charges 3.75 5.75 Technical (Hospital) Services DILTIAZEM 120 MG TABLET RX-2474 CDM 6370000100 HCPCS 250 RC 00093-0321-01 NDC outpatient 1 UN 6.05 6.05 MULTIPLAN INC 34080 [3081285] MULTIPLAN INC [308128501] 5.75 percent of total billed charges 3.75 5.75 Technical (Hospital) Services DILTIAZEM 120 MG TABLET RX-2474 CDM 6370000100 HCPCS 250 RC 00093-0321-01 NDC outpatient 1 UN 6.05 6.05 MEDICA (COMMERCIAL) 94265 [3081118] MEDICA CLAIMS [308111801] 5.45 percent of total billed charges 3.75 5.75 Technical (Hospital) Services DILTIAZEM 120 MG TABLET RX-2474 CDM 6370000100 HCPCS 250 RC 00093-0321-01 NDC outpatient 1 UN 6.05 6.05 UNITED HEALTHCARE (COMMERCIAL) [3081199] UNITED HEALTHCARE 87726 [308119901] 3.75 percent of total billed charges 3.75 5.75 Technical (Hospital) Services DILTIAZEM 120 MG TABLET RX-2474 CDM 6370000100 HCPCS 250 RC 00093-0321-01 NDC outpatient 1 UN 6.05 6.05 BLUE CROSS BLUE SHIELD WELLMARK SB889 [3081026] BCBS WYOMING [308102603] 5.75 percent of total billed charges 3.75 5.75 Technical (Hospital) Services DILTIAZEM 120 MG TABLET RX-2474 CDM 6370000100 HCPCS 250 RC 00093-0321-01 NDC outpatient 1 UN 6.05 6.05 HEALTHPARTNERS SX009 HEALTHPARTNERS 4.84 percent of total billed charges 3.75 5.75 Technical (Hospital) Services DILTIAZEM 120 MG TABLET RX-2474 CDM 6370000100 HCPCS 250 RC 00093-0321-01 NDC outpatient 1 UN 6.05 6.05 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES EPO [308136803] 4.84 percent of total billed charges 3.75 5.75 Technical (Hospital) Services DILTIAZEM 120 MG TABLET RX-2474 CDM 6370000100 HCPCS 250 RC 00093-0321-01 NDC outpatient 1 UN 6.05 6.05 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES HDHP [308136802] 4.84 percent of total billed charges 3.75 5.75 Technical (Hospital) Services DILTIAZEM 120 MG TABLET RX-2474 CDM 6370000100 HCPCS 250 RC 00093-0321-01 NDC outpatient 1 UN 6.05 6.05 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES PPO [308136801] 4.84 percent of total billed charges 3.75 5.75 Technical (Hospital) Services DILTIAZEM 30 MG TABLET RX-2475 CDM 6370000100 HCPCS 250 RC 00093-0318-01 NDC outpatient 1 UN 5.77 5.77 BLUE CROSS BLUE SHIELD WELLMARK SB889 [3081026] BCBS WYOMING [308102603] 5.48 percent of total billed charges 3.58 5.48 Technical (Hospital) Services DILTIAZEM 30 MG TABLET RX-2475 CDM 6370000100 HCPCS 250 RC 00093-0318-01 NDC outpatient 1 UN 5.77 5.77 UNITED HEALTHCARE (COMMERCIAL) [3081199] UNITED HEALTHCARE 87726 [308119901] 3.58 percent of total billed charges 3.58 5.48 Technical (Hospital) Services DILTIAZEM 30 MG TABLET RX-2475 CDM 6370000100 HCPCS 250 RC 00093-0318-01 NDC outpatient 1 UN 5.77 5.77 HEALTHPARTNERS SX009 HEALTHPARTNERS 4.62 percent of total billed charges 3.58 5.48 Technical (Hospital) Services DILTIAZEM 30 MG TABLET RX-2475 CDM 6370000100 HCPCS 250 RC 00093-0318-01 NDC outpatient 1 UN 5.77 5.77 CIGNA 62308 [3081051] CIGNA 62308 [308105105] 4.62 percent of total billed charges 3.58 5.48 Technical (Hospital) Services DILTIAZEM 30 MG TABLET RX-2475 CDM 6370000100 HCPCS 250 RC 00093-0318-01 NDC outpatient 1 UN 5.77 5.77 CIGNA 62308 [3081051] CIGNA STATE OF WYOMING [308105107] 4.62 percent of total billed charges 3.58 5.48 Technical (Hospital) Services DILTIAZEM 30 MG TABLET RX-2475 CDM 6370000100 HCPCS 250 RC 00093-0318-01 NDC outpatient 1 UN 5.77 5.77 MULTIPLAN INC 34080 [3081285] MULTIPLAN INC [308128501] 5.48 percent of total billed charges 3.58 5.48 Technical (Hospital) Services DILTIAZEM 30 MG TABLET RX-2475 CDM 6370000100 HCPCS 250 RC 00093-0318-01 NDC outpatient 1 UN 5.77 5.77 MEDICA (COMMERCIAL) 94265 [3081118] MEDICA CLAIMS [308111801] 5.19 percent of total billed charges 3.58 5.48 Technical (Hospital) Services DILTIAZEM 30 MG TABLET RX-2475 CDM 6370000100 HCPCS 250 RC 00093-0318-01 NDC outpatient 1 UN 5.77 5.77 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES PPO [308136801] 4.62 percent of total billed charges 3.58 5.48 Technical (Hospital) Services DILTIAZEM 30 MG TABLET RX-2475 CDM 6370000100 HCPCS 250 RC 00093-0318-01 NDC outpatient 1 UN 5.77 5.77 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES HDHP [308136802] 4.62 percent of total billed charges 3.58 5.48 Technical (Hospital) Services DILTIAZEM 30 MG TABLET RX-2475 CDM 6370000100 HCPCS 250 RC 00093-0318-01 NDC outpatient 1 UN 5.77 5.77 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES EPO [308136803] 4.62 percent of total billed charges 3.58 5.48 Technical (Hospital) Services DILTIAZEM 30 MG TABLET RX-2475 CDM 6370000100 HCPCS 250 RC 00093-0318-01 NDC inpatient 1 UN 5.77 5.77 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES PPO [308136801] 4.57 percent of total billed charges 3.58 5.48 Technical (Hospital) Services DILTIAZEM 30 MG TABLET RX-2475 CDM 6370000100 HCPCS 250 RC 00093-0318-01 NDC inpatient 1 UN 5.77 5.77 MEDICA (COMMERCIAL) 94265 [3081118] MEDICA CLAIMS [308111801] 5.19 percent of total billed charges 3.58 5.48 Technical (Hospital) Services DILTIAZEM 30 MG TABLET RX-2475 CDM 6370000100 HCPCS 250 RC 00093-0318-01 NDC inpatient 1 UN 5.77 5.77 HEALTHPARTNERS SX009 HEALTHPARTNERS 4.57 percent of total billed charges 3.58 5.48 Technical (Hospital) Services DILTIAZEM 30 MG TABLET RX-2475 CDM 6370000100 HCPCS 250 RC 00093-0318-01 NDC inpatient 1 UN 5.77 5.77 MULTIPLAN INC 34080 [3081285] MULTIPLAN INC [308128501] 5.48 percent of total billed charges 3.58 5.48 Technical (Hospital) Services DILTIAZEM 30 MG TABLET RX-2475 CDM 6370000100 HCPCS 250 RC 00093-0318-01 NDC inpatient 1 UN 5.77 5.77 UNITED HEALTHCARE (COMMERCIAL) [3081199] UNITED HEALTHCARE 87726 [308119901] 3.58 percent of total billed charges 3.58 5.48 Technical (Hospital) Services DILTIAZEM 30 MG TABLET RX-2475 CDM 6370000100 HCPCS 250 RC 00093-0318-01 NDC inpatient 1 UN 5.77 5.77 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES HDHP [308136802] 4.57 percent of total billed charges 3.58 5.48 Technical (Hospital) Services DILTIAZEM 30 MG TABLET RX-2475 CDM 6370000100 HCPCS 250 RC 00093-0318-01 NDC inpatient 1 UN 5.77 5.77 BLUE CROSS BLUE SHIELD WELLMARK SB889 [3081026] BCBS WYOMING [308102603] 5.48 percent of total billed charges 3.58 5.48 Technical (Hospital) Services DILTIAZEM 30 MG TABLET RX-2475 CDM 6370000100 HCPCS 250 RC 00093-0318-01 NDC inpatient 1 UN 5.77 5.77 CIGNA 62308 [3081051] CIGNA 62308 [308105105] 4.57 percent of total billed charges 3.58 5.48 Technical (Hospital) Services DILTIAZEM 30 MG TABLET RX-2475 CDM 6370000100 HCPCS 250 RC 00093-0318-01 NDC inpatient 1 UN 5.77 5.77 CIGNA 62308 [3081051] CIGNA STATE OF WYOMING [308105107] 4.57 percent of total billed charges 3.58 5.48 Technical (Hospital) Services DILTIAZEM 30 MG TABLET RX-2475 CDM 6370000100 HCPCS 250 RC 00093-0318-01 NDC inpatient 1 UN 5.77 5.77 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES EPO [308136803] 4.57 percent of total billed charges 3.58 5.48 Technical (Hospital) Services DILTIAZEM 60 MG TABLET RX-2476 CDM 6370000100 HCPCS 250 RC 51079-0746-01 NDC inpatient 1 UN 5.89 5.89 UNITED HEALTHCARE (COMMERCIAL) [3081199] UNITED HEALTHCARE 87726 [308119901] 3.65 percent of total billed charges 3.65 5.6 Technical (Hospital) Services DILTIAZEM 60 MG TABLET RX-2476 CDM 6370000100 HCPCS 250 RC 51079-0746-01 NDC inpatient 1 UN 5.89 5.89 BLUE CROSS BLUE SHIELD WELLMARK SB889 [3081026] BCBS WYOMING [308102603] 5.6 percent of total billed charges 3.65 5.6 Technical (Hospital) Services DILTIAZEM 60 MG TABLET RX-2476 CDM 6370000100 HCPCS 250 RC 51079-0746-01 NDC inpatient 1 UN 5.89 5.89 CIGNA 62308 [3081051] CIGNA 62308 [308105105] 4.66 percent of total billed charges 3.65 5.6 Technical (Hospital) Services DILTIAZEM 60 MG TABLET RX-2476 CDM 6370000100 HCPCS 250 RC 51079-0746-01 NDC inpatient 1 UN 5.89 5.89 CIGNA 62308 [3081051] CIGNA STATE OF WYOMING [308105107] 4.66 percent of total billed charges 3.65 5.6 Technical (Hospital) Services DILTIAZEM 60 MG TABLET RX-2476 CDM 6370000100 HCPCS 250 RC 51079-0746-01 NDC inpatient 1 UN 5.89 5.89 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES EPO [308136803] 4.66 percent of total billed charges 3.65 5.6 Technical (Hospital) Services DILTIAZEM 60 MG TABLET RX-2476 CDM 6370000100 HCPCS 250 RC 51079-0746-01 NDC inpatient 1 UN 5.89 5.89 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES HDHP [308136802] 4.66 percent of total billed charges 3.65 5.6 Technical (Hospital) Services DILTIAZEM 60 MG TABLET RX-2476 CDM 6370000100 HCPCS 250 RC 51079-0746-01 NDC inpatient 1 UN 5.89 5.89 MEDICA (COMMERCIAL) 94265 [3081118] MEDICA CLAIMS [308111801] 5.3 percent of total billed charges 3.65 5.6 Technical (Hospital) Services DILTIAZEM 60 MG TABLET RX-2476 CDM 6370000100 HCPCS 250 RC 51079-0746-01 NDC inpatient 1 UN 5.89 5.89 HEALTHPARTNERS SX009 HEALTHPARTNERS 4.66 percent of total billed charges 3.65 5.6 Technical (Hospital) Services DILTIAZEM 60 MG TABLET RX-2476 CDM 6370000100 HCPCS 250 RC 51079-0746-01 NDC inpatient 1 UN 5.89 5.89 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES PPO [308136801] 4.66 percent of total billed charges 3.65 5.6 Technical (Hospital) Services DILTIAZEM 60 MG TABLET RX-2476 CDM 6370000100 HCPCS 250 RC 51079-0746-01 NDC inpatient 1 UN 5.89 5.89 MULTIPLAN INC 34080 [3081285] MULTIPLAN INC [308128501] 5.6 percent of total billed charges 3.65 5.6 Technical (Hospital) Services DILTIAZEM 60 MG TABLET RX-2476 CDM 6370000100 HCPCS 250 RC 51079-0746-01 NDC outpatient 1 UN 5.89 5.89 UNITED HEALTHCARE (COMMERCIAL) [3081199] UNITED HEALTHCARE 87726 [308119901] 3.65 percent of total billed charges 3.65 5.6 Technical (Hospital) Services DILTIAZEM 60 MG TABLET RX-2476 CDM 6370000100 HCPCS 250 RC 51079-0746-01 NDC outpatient 1 UN 5.89 5.89 HEALTHPARTNERS SX009 HEALTHPARTNERS 4.71 percent of total billed charges 3.65 5.6 Technical (Hospital) Services DILTIAZEM 60 MG TABLET RX-2476 CDM 6370000100 HCPCS 250 RC 51079-0746-01 NDC outpatient 1 UN 5.89 5.89 CIGNA 62308 [3081051] CIGNA 62308 [308105105] 4.71 percent of total billed charges 3.65 5.6 Technical (Hospital) Services DILTIAZEM 60 MG TABLET RX-2476 CDM 6370000100 HCPCS 250 RC 51079-0746-01 NDC outpatient 1 UN 5.89 5.89 CIGNA 62308 [3081051] CIGNA STATE OF WYOMING [308105107] 4.71 percent of total billed charges 3.65 5.6 Technical (Hospital) Services DILTIAZEM 60 MG TABLET RX-2476 CDM 6370000100 HCPCS 250 RC 51079-0746-01 NDC outpatient 1 UN 5.89 5.89 MULTIPLAN INC 34080 [3081285] MULTIPLAN INC [308128501] 5.6 percent of total billed charges 3.65 5.6 Technical (Hospital) Services DILTIAZEM 60 MG TABLET RX-2476 CDM 6370000100 HCPCS 250 RC 51079-0746-01 NDC outpatient 1 UN 5.89 5.89 MEDICA (COMMERCIAL) 94265 [3081118] MEDICA CLAIMS [308111801] 5.3 percent of total billed charges 3.65 5.6 Technical (Hospital) Services DILTIAZEM 60 MG TABLET RX-2476 CDM 6370000100 HCPCS 250 RC 51079-0746-01 NDC outpatient 1 UN 5.89 5.89 BLUE CROSS BLUE SHIELD WELLMARK SB889 [3081026] BCBS WYOMING [308102603] 5.6 percent of total billed charges 3.65 5.6 Technical (Hospital) Services DILTIAZEM 60 MG TABLET RX-2476 CDM 6370000100 HCPCS 250 RC 51079-0746-01 NDC outpatient 1 UN 5.89 5.89 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES EPO [308136803] 4.71 percent of total billed charges 3.65 5.6 Technical (Hospital) Services DILTIAZEM 60 MG TABLET RX-2476 CDM 6370000100 HCPCS 250 RC 51079-0746-01 NDC outpatient 1 UN 5.89 5.89 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES HDHP [308136802] 4.71 percent of total billed charges 3.65 5.6 Technical (Hospital) Services DILTIAZEM 60 MG TABLET RX-2476 CDM 6370000100 HCPCS 250 RC 51079-0746-01 NDC outpatient 1 UN 5.89 5.89 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES PPO [308136801] 4.71 percent of total billed charges 3.65 5.6 Technical (Hospital) Services DIMENHYDRINATE 50 MG TABLET RX-2485 CDM 6370000100 HCPCS 250 RC 00904-2051-59 NDC inpatient 1 UN 5.64 5.64 BLUE CROSS BLUE SHIELD WELLMARK SB889 [3081026] BCBS WYOMING [308102603] 5.36 percent of total billed charges 3.5 5.36 Technical (Hospital) Services DIMENHYDRINATE 50 MG TABLET RX-2485 CDM 6370000100 HCPCS 250 RC 00904-2051-59 NDC inpatient 1 UN 5.64 5.64 CIGNA 62308 [3081051] CIGNA 62308 [308105105] 4.47 percent of total billed charges 3.5 5.36 Technical (Hospital) Services DIMENHYDRINATE 50 MG TABLET RX-2485 CDM 6370000100 HCPCS 250 RC 00904-2051-59 NDC inpatient 1 UN 5.64 5.64 CIGNA 62308 [3081051] CIGNA STATE OF WYOMING [308105107] 4.47 percent of total billed charges 3.5 5.36 Technical (Hospital) Services DIMENHYDRINATE 50 MG TABLET RX-2485 CDM 6370000100 HCPCS 250 RC 00904-2051-59 NDC inpatient 1 UN 5.64 5.64 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES EPO [308136803] 4.47 percent of total billed charges 3.5 5.36 Technical (Hospital) Services DIMENHYDRINATE 50 MG TABLET RX-2485 CDM 6370000100 HCPCS 250 RC 00904-2051-59 NDC inpatient 1 UN 5.64 5.64 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES HDHP [308136802] 4.47 percent of total billed charges 3.5 5.36 Technical (Hospital) Services DIMENHYDRINATE 50 MG TABLET RX-2485 CDM 6370000100 HCPCS 250 RC 00904-2051-59 NDC inpatient 1 UN 5.64 5.64 UNITED HEALTHCARE (COMMERCIAL) [3081199] UNITED HEALTHCARE 87726 [308119901] 3.5 percent of total billed charges 3.5 5.36 Technical (Hospital) Services DIMENHYDRINATE 50 MG TABLET RX-2485 CDM 6370000100 HCPCS 250 RC 00904-2051-59 NDC inpatient 1 UN 5.64 5.64 MULTIPLAN INC 34080 [3081285] MULTIPLAN INC [308128501] 5.36 percent of total billed charges 3.5 5.36 Technical (Hospital) Services DIMENHYDRINATE 50 MG TABLET RX-2485 CDM 6370000100 HCPCS 250 RC 00904-2051-59 NDC inpatient 1 UN 5.64 5.64 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES PPO [308136801] 4.47 percent of total billed charges 3.5 5.36 Technical (Hospital) Services DIMENHYDRINATE 50 MG TABLET RX-2485 CDM 6370000100 HCPCS 250 RC 00904-2051-59 NDC inpatient 1 UN 5.64 5.64 HEALTHPARTNERS SX009 HEALTHPARTNERS 4.47 percent of total billed charges 3.5 5.36 Technical (Hospital) Services DIMENHYDRINATE 50 MG TABLET RX-2485 CDM 6370000100 HCPCS 250 RC 00904-2051-59 NDC inpatient 1 UN 5.64 5.64 MEDICA (COMMERCIAL) 94265 [3081118] MEDICA CLAIMS [308111801] 5.08 percent of total billed charges 3.5 5.36 Technical (Hospital) Services DIMENHYDRINATE 50 MG TABLET RX-2485 CDM 6370000100 HCPCS 250 RC 00904-2051-59 NDC outpatient 1 UN 5.64 5.64 MEDICA (COMMERCIAL) 94265 [3081118] MEDICA CLAIMS [308111801] 5.08 percent of total billed charges 3.5 5.36 Technical (Hospital) Services DIMENHYDRINATE 50 MG TABLET RX-2485 CDM 6370000100 HCPCS 250 RC 00904-2051-59 NDC outpatient 1 UN 5.64 5.64 CIGNA 62308 [3081051] CIGNA 62308 [308105105] 4.51 percent of total billed charges 3.5 5.36 Technical (Hospital) Services DIMENHYDRINATE 50 MG TABLET RX-2485 CDM 6370000100 HCPCS 250 RC 00904-2051-59 NDC outpatient 1 UN 5.64 5.64 CIGNA 62308 [3081051] CIGNA STATE OF WYOMING [308105107] 4.51 percent of total billed charges 3.5 5.36 Technical (Hospital) Services DIMENHYDRINATE 50 MG TABLET RX-2485 CDM 6370000100 HCPCS 250 RC 00904-2051-59 NDC outpatient 1 UN 5.64 5.64 MULTIPLAN INC 34080 [3081285] MULTIPLAN INC [308128501] 5.36 percent of total billed charges 3.5 5.36 Technical (Hospital) Services DIMENHYDRINATE 50 MG TABLET RX-2485 CDM 6370000100 HCPCS 250 RC 00904-2051-59 NDC outpatient 1 UN 5.64 5.64 UNITED HEALTHCARE (COMMERCIAL) [3081199] UNITED HEALTHCARE 87726 [308119901] 3.5 percent of total billed charges 3.5 5.36 Technical (Hospital) Services DIMENHYDRINATE 50 MG TABLET RX-2485 CDM 6370000100 HCPCS 250 RC 00904-2051-59 NDC outpatient 1 UN 5.64 5.64 HEALTHPARTNERS SX009 HEALTHPARTNERS 4.51 percent of total billed charges 3.5 5.36 Technical (Hospital) Services DIMENHYDRINATE 50 MG TABLET RX-2485 CDM 6370000100 HCPCS 250 RC 00904-2051-59 NDC outpatient 1 UN 5.64 5.64 BLUE CROSS BLUE SHIELD WELLMARK SB889 [3081026] BCBS WYOMING [308102603] 5.36 percent of total billed charges 3.5 5.36 Technical (Hospital) Services DIMENHYDRINATE 50 MG TABLET RX-2485 CDM 6370000100 HCPCS 250 RC 00904-2051-59 NDC outpatient 1 UN 5.64 5.64 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES PPO [308136801] 4.51 percent of total billed charges 3.5 5.36 Technical (Hospital) Services DIMENHYDRINATE 50 MG TABLET RX-2485 CDM 6370000100 HCPCS 250 RC 00904-2051-59 NDC outpatient 1 UN 5.64 5.64 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES HDHP [308136802] 4.51 percent of total billed charges 3.5 5.36 Technical (Hospital) Services DIMENHYDRINATE 50 MG TABLET RX-2485 CDM 6370000100 HCPCS 250 RC 00904-2051-59 NDC outpatient 1 UN 5.64 5.64 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES EPO [308136803] 4.51 percent of total billed charges 3.5 5.36 Technical (Hospital) Services CIPROFLOXACIN 500 MG TABLET RX-25119 CDM 6370000100 HCPCS 250 RC 00143-9928-01 NDC inpatient 1 UN 5.83 5.83 MULTIPLAN INC 34080 [3081285] MULTIPLAN INC [308128501] 5.54 percent of total billed charges 3.61 5.54 Technical (Hospital) Services CIPROFLOXACIN 500 MG TABLET RX-25119 CDM 6370000100 HCPCS 250 RC 00143-9928-01 NDC inpatient 1 UN 5.83 5.83 MEDICA (COMMERCIAL) 94265 [3081118] MEDICA CLAIMS [308111801] 5.25 percent of total billed charges 3.61 5.54 Technical (Hospital) Services CIPROFLOXACIN 500 MG TABLET RX-25119 CDM 6370000100 HCPCS 250 RC 00143-9928-01 NDC inpatient 1 UN 5.83 5.83 HEALTHPARTNERS SX009 HEALTHPARTNERS 4.62 percent of total billed charges 3.61 5.54 Technical (Hospital) Services CIPROFLOXACIN 500 MG TABLET RX-25119 CDM 6370000100 HCPCS 250 RC 00143-9928-01 NDC inpatient 1 UN 5.83 5.83 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES PPO [308136801] 4.62 percent of total billed charges 3.61 5.54 Technical (Hospital) Services CIPROFLOXACIN 500 MG TABLET RX-25119 CDM 6370000100 HCPCS 250 RC 00143-9928-01 NDC inpatient 1 UN 5.83 5.83 BLUE CROSS BLUE SHIELD WELLMARK SB889 [3081026] BCBS WYOMING [308102603] 5.54 percent of total billed charges 3.61 5.54 Technical (Hospital) Services CIPROFLOXACIN 500 MG TABLET RX-25119 CDM 6370000100 HCPCS 250 RC 00143-9928-01 NDC inpatient 1 UN 5.83 5.83 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES HDHP [308136802] 4.62 percent of total billed charges 3.61 5.54 Technical (Hospital) Services CIPROFLOXACIN 500 MG TABLET RX-25119 CDM 6370000100 HCPCS 250 RC 00143-9928-01 NDC inpatient 1 UN 5.83 5.83 CIGNA 62308 [3081051] CIGNA 62308 [308105105] 4.62 percent of total billed charges 3.61 5.54 Technical (Hospital) Services CIPROFLOXACIN 500 MG TABLET RX-25119 CDM 6370000100 HCPCS 250 RC 00143-9928-01 NDC inpatient 1 UN 5.83 5.83 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES EPO [308136803] 4.62 percent of total billed charges 3.61 5.54 Technical (Hospital) Services CIPROFLOXACIN 500 MG TABLET RX-25119 CDM 6370000100 HCPCS 250 RC 00143-9928-01 NDC inpatient 1 UN 5.83 5.83 CIGNA 62308 [3081051] CIGNA STATE OF WYOMING [308105107] 4.62 percent of total billed charges 3.61 5.54 Technical (Hospital) Services CIPROFLOXACIN 500 MG TABLET RX-25119 CDM 6370000100 HCPCS 250 RC 00143-9928-01 NDC inpatient 1 UN 5.83 5.83 UNITED HEALTHCARE (COMMERCIAL) [3081199] UNITED HEALTHCARE 87726 [308119901] 3.61 percent of total billed charges 3.61 5.54 Technical (Hospital) Services CIPROFLOXACIN 500 MG TABLET RX-25119 CDM 6370000100 HCPCS 250 RC 00143-9928-01 NDC outpatient 1 UN 5.83 5.83 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES EPO [308136803] 4.66 percent of total billed charges 3.61 5.54 Technical (Hospital) Services CIPROFLOXACIN 500 MG TABLET RX-25119 CDM 6370000100 HCPCS 250 RC 00143-9928-01 NDC outpatient 1 UN 5.83 5.83 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES PPO [308136801] 4.66 percent of total billed charges 3.61 5.54 Technical (Hospital) Services CIPROFLOXACIN 500 MG TABLET RX-25119 CDM 6370000100 HCPCS 250 RC 00143-9928-01 NDC outpatient 1 UN 5.83 5.83 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES HDHP [308136802] 4.66 percent of total billed charges 3.61 5.54 Technical (Hospital) Services CIPROFLOXACIN 500 MG TABLET RX-25119 CDM 6370000100 HCPCS 250 RC 00143-9928-01 NDC outpatient 1 UN 5.83 5.83 BLUE CROSS BLUE SHIELD WELLMARK SB889 [3081026] BCBS WYOMING [308102603] 5.54 percent of total billed charges 3.61 5.54 Technical (Hospital) Services CIPROFLOXACIN 500 MG TABLET RX-25119 CDM 6370000100 HCPCS 250 RC 00143-9928-01 NDC outpatient 1 UN 5.83 5.83 UNITED HEALTHCARE (COMMERCIAL) [3081199] UNITED HEALTHCARE 87726 [308119901] 3.61 percent of total billed charges 3.61 5.54 Technical (Hospital) Services CIPROFLOXACIN 500 MG TABLET RX-25119 CDM 6370000100 HCPCS 250 RC 00143-9928-01 NDC outpatient 1 UN 5.83 5.83 HEALTHPARTNERS SX009 HEALTHPARTNERS 4.66 percent of total billed charges 3.61 5.54 Technical (Hospital) Services CIPROFLOXACIN 500 MG TABLET RX-25119 CDM 6370000100 HCPCS 250 RC 00143-9928-01 NDC outpatient 1 UN 5.83 5.83 CIGNA 62308 [3081051] CIGNA STATE OF WYOMING [308105107] 4.66 percent of total billed charges 3.61 5.54 Technical (Hospital) Services CIPROFLOXACIN 500 MG TABLET RX-25119 CDM 6370000100 HCPCS 250 RC 00143-9928-01 NDC outpatient 1 UN 5.83 5.83 CIGNA 62308 [3081051] CIGNA 62308 [308105105] 4.66 percent of total billed charges 3.61 5.54 Technical (Hospital) Services CIPROFLOXACIN 500 MG TABLET RX-25119 CDM 6370000100 HCPCS 250 RC 00143-9928-01 NDC outpatient 1 UN 5.83 5.83 MULTIPLAN INC 34080 [3081285] MULTIPLAN INC [308128501] 5.54 percent of total billed charges 3.61 5.54 Technical (Hospital) Services CIPROFLOXACIN 500 MG TABLET RX-25119 CDM 6370000100 HCPCS 250 RC 00143-9928-01 NDC outpatient 1 UN 5.83 5.83 MEDICA (COMMERCIAL) 94265 [3081118] MEDICA CLAIMS [308111801] 5.25 percent of total billed charges 3.61 5.54 Technical (Hospital) Services AMOXICILLIN 400 MG/5 ML ORAL SUSPENSION RX-25246 CDM 6370000100 HCPCS 250 RC 00143-9887-01 NDC inpatient 100 ML 28.5 28.5 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES EPO [308136803] 22.57 percent of total billed charges 17.67 27.08 Technical (Hospital) Services AMOXICILLIN 400 MG/5 ML ORAL SUSPENSION RX-25246 CDM 6370000100 HCPCS 250 RC 00143-9887-01 NDC inpatient 100 ML 28.5 28.5 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES HDHP [308136802] 22.57 percent of total billed charges 17.67 27.08 Technical (Hospital) Services AMOXICILLIN 400 MG/5 ML ORAL SUSPENSION RX-25246 CDM 6370000100 HCPCS 250 RC 00143-9887-01 NDC inpatient 100 ML 28.5 28.5 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES PPO [308136801] 22.57 percent of total billed charges 17.67 27.08 Technical (Hospital) Services AMOXICILLIN 400 MG/5 ML ORAL SUSPENSION RX-25246 CDM 6370000100 HCPCS 250 RC 00143-9887-01 NDC inpatient 100 ML 28.5 28.5 CIGNA 62308 [3081051] CIGNA 62308 [308105105] 22.57 percent of total billed charges 17.67 27.08 Technical (Hospital) Services AMOXICILLIN 400 MG/5 ML ORAL SUSPENSION RX-25246 CDM 6370000100 HCPCS 250 RC 00143-9887-01 NDC inpatient 100 ML 28.5 28.5 CIGNA 62308 [3081051] CIGNA STATE OF WYOMING [308105107] 22.57 percent of total billed charges 17.67 27.08 Technical (Hospital) Services AMOXICILLIN 400 MG/5 ML ORAL SUSPENSION RX-25246 CDM 6370000100 HCPCS 250 RC 00143-9887-01 NDC inpatient 100 ML 28.5 28.5 MEDICA (COMMERCIAL) 94265 [3081118] MEDICA CLAIMS [308111801] 25.65 percent of total billed charges 17.67 27.08 Technical (Hospital) Services AMOXICILLIN 400 MG/5 ML ORAL SUSPENSION RX-25246 CDM 6370000100 HCPCS 250 RC 00143-9887-01 NDC inpatient 100 ML 28.5 28.5 MULTIPLAN INC 34080 [3081285] MULTIPLAN INC [308128501] 27.08 percent of total billed charges 17.67 27.08 Technical (Hospital) Services AMOXICILLIN 400 MG/5 ML ORAL SUSPENSION RX-25246 CDM 6370000100 HCPCS 250 RC 00143-9887-01 NDC inpatient 100 ML 28.5 28.5 HEALTHPARTNERS SX009 HEALTHPARTNERS 22.57 percent of total billed charges 17.67 27.08 Technical (Hospital) Services AMOXICILLIN 400 MG/5 ML ORAL SUSPENSION RX-25246 CDM 6370000100 HCPCS 250 RC 00143-9887-01 NDC inpatient 100 ML 28.5 28.5 UNITED HEALTHCARE (COMMERCIAL) [3081199] UNITED HEALTHCARE 87726 [308119901] 17.67 percent of total billed charges 17.67 27.08 Technical (Hospital) Services AMOXICILLIN 400 MG/5 ML ORAL SUSPENSION RX-25246 CDM 6370000100 HCPCS 250 RC 00143-9887-01 NDC outpatient 100 ML 28.5 28.5 CIGNA 62308 [3081051] CIGNA 62308 [308105105] 22.8 percent of total billed charges 17.67 27.08 Technical (Hospital) Services AMOXICILLIN 400 MG/5 ML ORAL SUSPENSION RX-25246 CDM 6370000100 HCPCS 250 RC 00143-9887-01 NDC outpatient 100 ML 28.5 28.5 CIGNA 62308 [3081051] CIGNA STATE OF WYOMING [308105107] 22.8 percent of total billed charges 17.67 27.08 Technical (Hospital) Services AMOXICILLIN 400 MG/5 ML ORAL SUSPENSION RX-25246 CDM 6370000100 HCPCS 250 RC 00143-9887-01 NDC outpatient 100 ML 28.5 28.5 MEDICA (COMMERCIAL) 94265 [3081118] MEDICA CLAIMS [308111801] 25.65 percent of total billed charges 17.67 27.08 Technical (Hospital) Services AMOXICILLIN 400 MG/5 ML ORAL SUSPENSION RX-25246 CDM 6370000100 HCPCS 250 RC 00143-9887-01 NDC outpatient 100 ML 28.5 28.5 MULTIPLAN INC 34080 [3081285] MULTIPLAN INC [308128501] 27.08 percent of total billed charges 17.67 27.08 Technical (Hospital) Services AMOXICILLIN 400 MG/5 ML ORAL SUSPENSION RX-25246 CDM 6370000100 HCPCS 250 RC 00143-9887-01 NDC outpatient 100 ML 28.5 28.5 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES EPO [308136803] 22.8 percent of total billed charges 17.67 27.08 Technical (Hospital) Services AMOXICILLIN 400 MG/5 ML ORAL SUSPENSION RX-25246 CDM 6370000100 HCPCS 250 RC 00143-9887-01 NDC outpatient 100 ML 28.5 28.5 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES HDHP [308136802] 22.8 percent of total billed charges 17.67 27.08 Technical (Hospital) Services AMOXICILLIN 400 MG/5 ML ORAL SUSPENSION RX-25246 CDM 6370000100 HCPCS 250 RC 00143-9887-01 NDC outpatient 100 ML 28.5 28.5 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES PPO [308136801] 22.8 percent of total billed charges 17.67 27.08 Technical (Hospital) Services AMOXICILLIN 400 MG/5 ML ORAL SUSPENSION RX-25246 CDM 6370000100 HCPCS 250 RC 00143-9887-01 NDC outpatient 100 ML 28.5 28.5 BLUE CROSS BLUE SHIELD WELLMARK SB889 [3081026] BCBS WYOMING [308102603] 27.08 percent of total billed charges 17.67 27.08 Technical (Hospital) Services AMOXICILLIN 400 MG/5 ML ORAL SUSPENSION RX-25246 CDM 6370000100 HCPCS 250 RC 00143-9887-01 NDC inpatient 100 ML 28.5 28.5 BLUE CROSS BLUE SHIELD WELLMARK SB889 [3081026] BCBS WYOMING [308102603] 27.08 percent of total billed charges 17.67 27.08 Technical (Hospital) Services AMOXICILLIN 400 MG/5 ML ORAL SUSPENSION RX-25246 CDM 6370000100 HCPCS 250 RC 00143-9887-01 NDC outpatient 100 ML 28.5 28.5 HEALTHPARTNERS SX009 HEALTHPARTNERS 22.8 percent of total billed charges 17.67 27.08 Technical (Hospital) Services AMOXICILLIN 400 MG/5 ML ORAL SUSPENSION RX-25246 CDM 6370000100 HCPCS 250 RC 00143-9887-01 NDC outpatient 100 ML 28.5 28.5 UNITED HEALTHCARE (COMMERCIAL) [3081199] UNITED HEALTHCARE 87726 [308119901] 17.67 percent of total billed charges 17.67 27.08 Technical (Hospital) Services GLUCOSAMINE-CHONDROITIN 500 MG-400 MG TABLET RX-25332 CDM 6370000100 HCPCS 250 RC 43292-0560-03 NDC outpatient 1 UN 5.73 5.73 HEALTHPARTNERS SX009 HEALTHPARTNERS 4.58 percent of total billed charges 3.55 5.44 Technical (Hospital) Services GLUCOSAMINE-CHONDROITIN 500 MG-400 MG TABLET RX-25332 CDM 6370000100 HCPCS 250 RC 43292-0560-03 NDC outpatient 1 UN 5.73 5.73 UNITED HEALTHCARE (COMMERCIAL) [3081199] UNITED HEALTHCARE 87726 [308119901] 3.55 percent of total billed charges 3.55 5.44 Technical (Hospital) Services GLUCOSAMINE-CHONDROITIN 500 MG-400 MG TABLET RX-25332 CDM 6370000100 HCPCS 250 RC 43292-0560-03 NDC outpatient 1 UN 5.73 5.73 MULTIPLAN INC 34080 [3081285] MULTIPLAN INC [308128501] 5.44 percent of total billed charges 3.55 5.44 Technical (Hospital) Services GLUCOSAMINE-CHONDROITIN 500 MG-400 MG TABLET RX-25332 CDM 6370000100 HCPCS 250 RC 43292-0560-03 NDC outpatient 1 UN 5.73 5.73 CIGNA 62308 [3081051] CIGNA 62308 [308105105] 4.58 percent of total billed charges 3.55 5.44 Technical (Hospital) Services GLUCOSAMINE-CHONDROITIN 500 MG-400 MG TABLET RX-25332 CDM 6370000100 HCPCS 250 RC 43292-0560-03 NDC outpatient 1 UN 5.73 5.73 CIGNA 62308 [3081051] CIGNA STATE OF WYOMING [308105107] 4.58 percent of total billed charges 3.55 5.44 Technical (Hospital) Services GLUCOSAMINE-CHONDROITIN 500 MG-400 MG TABLET RX-25332 CDM 6370000100 HCPCS 250 RC 43292-0560-03 NDC outpatient 1 UN 5.73 5.73 MEDICA (COMMERCIAL) 94265 [3081118] MEDICA CLAIMS [308111801] 5.16 percent of total billed charges 3.55 5.44 Technical (Hospital) Services GLUCOSAMINE-CHONDROITIN 500 MG-400 MG TABLET RX-25332 CDM 6370000100 HCPCS 250 RC 43292-0560-03 NDC outpatient 1 UN 5.73 5.73 BLUE CROSS BLUE SHIELD WELLMARK SB889 [3081026] BCBS WYOMING [308102603] 5.44 percent of total billed charges 3.55 5.44 Technical (Hospital) Services GLUCOSAMINE-CHONDROITIN 500 MG-400 MG TABLET RX-25332 CDM 6370000100 HCPCS 250 RC 43292-0560-03 NDC outpatient 1 UN 5.73 5.73 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES EPO [308136803] 4.58 percent of total billed charges 3.55 5.44 Technical (Hospital) Services GLUCOSAMINE-CHONDROITIN 500 MG-400 MG TABLET RX-25332 CDM 6370000100 HCPCS 250 RC 43292-0560-03 NDC outpatient 1 UN 5.73 5.73 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES HDHP [308136802] 4.58 percent of total billed charges 3.55 5.44 Technical (Hospital) Services GLUCOSAMINE-CHONDROITIN 500 MG-400 MG TABLET RX-25332 CDM 6370000100 HCPCS 250 RC 43292-0560-03 NDC outpatient 1 UN 5.73 5.73 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES PPO [308136801] 4.58 percent of total billed charges 3.55 5.44 Technical (Hospital) Services GLUCOSAMINE-CHONDROITIN 500 MG-400 MG TABLET RX-25332 CDM 6370000100 HCPCS 250 RC 43292-0560-03 NDC inpatient 1 UN 5.73 5.73 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES HDHP [308136802] 4.54 percent of total billed charges 3.55 5.44 Technical (Hospital) Services GLUCOSAMINE-CHONDROITIN 500 MG-400 MG TABLET RX-25332 CDM 6370000100 HCPCS 250 RC 43292-0560-03 NDC inpatient 1 UN 5.73 5.73 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES EPO [308136803] 4.54 percent of total billed charges 3.55 5.44 Technical (Hospital) Services GLUCOSAMINE-CHONDROITIN 500 MG-400 MG TABLET RX-25332 CDM 6370000100 HCPCS 250 RC 43292-0560-03 NDC inpatient 1 UN 5.73 5.73 CIGNA 62308 [3081051] CIGNA 62308 [308105105] 4.54 percent of total billed charges 3.55 5.44 Technical (Hospital) Services GLUCOSAMINE-CHONDROITIN 500 MG-400 MG TABLET RX-25332 CDM 6370000100 HCPCS 250 RC 43292-0560-03 NDC inpatient 1 UN 5.73 5.73 CIGNA 62308 [3081051] CIGNA STATE OF WYOMING [308105107] 4.54 percent of total billed charges 3.55 5.44 Technical (Hospital) Services GLUCOSAMINE-CHONDROITIN 500 MG-400 MG TABLET RX-25332 CDM 6370000100 HCPCS 250 RC 43292-0560-03 NDC inpatient 1 UN 5.73 5.73 UNITED HEALTHCARE (COMMERCIAL) [3081199] UNITED HEALTHCARE 87726 [308119901] 3.55 percent of total billed charges 3.55 5.44 Technical (Hospital) Services GLUCOSAMINE-CHONDROITIN 500 MG-400 MG TABLET RX-25332 CDM 6370000100 HCPCS 250 RC 43292-0560-03 NDC inpatient 1 UN 5.73 5.73 BLUE CROSS BLUE SHIELD WELLMARK SB889 [3081026] BCBS WYOMING [308102603] 5.44 percent of total billed charges 3.55 5.44 Technical (Hospital) Services GLUCOSAMINE-CHONDROITIN 500 MG-400 MG TABLET RX-25332 CDM 6370000100 HCPCS 250 RC 43292-0560-03 NDC inpatient 1 UN 5.73 5.73 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES PPO [308136801] 4.54 percent of total billed charges 3.55 5.44 Technical (Hospital) Services GLUCOSAMINE-CHONDROITIN 500 MG-400 MG TABLET RX-25332 CDM 6370000100 HCPCS 250 RC 43292-0560-03 NDC inpatient 1 UN 5.73 5.73 HEALTHPARTNERS SX009 HEALTHPARTNERS 4.54 percent of total billed charges 3.55 5.44 Technical (Hospital) Services GLUCOSAMINE-CHONDROITIN 500 MG-400 MG TABLET RX-25332 CDM 6370000100 HCPCS 250 RC 43292-0560-03 NDC inpatient 1 UN 5.73 5.73 MEDICA (COMMERCIAL) 94265 [3081118] MEDICA CLAIMS [308111801] 5.16 percent of total billed charges 3.55 5.44 Technical (Hospital) Services GLUCOSAMINE-CHONDROITIN 500 MG-400 MG TABLET RX-25332 CDM 6370000100 HCPCS 250 RC 43292-0560-03 NDC inpatient 1 UN 5.73 5.73 MULTIPLAN INC 34080 [3081285] MULTIPLAN INC [308128501] 5.44 percent of total billed charges 3.55 5.44 Technical (Hospital) Services RISPERIDONE 0.5 MG TABLET RX-25520 CDM 6370000100 HCPCS 250 RC 68382-0113-14 NDC inpatient 1 UN 5.74 5.74 MEDICA (COMMERCIAL) 94265 [3081118] MEDICA CLAIMS [308111801] 5.17 percent of total billed charges 3.56 5.45 Technical (Hospital) Services RISPERIDONE 0.5 MG TABLET RX-25520 CDM 6370000100 HCPCS 250 RC 68382-0113-14 NDC inpatient 1 UN 5.74 5.74 HEALTHPARTNERS SX009 HEALTHPARTNERS 4.54 percent of total billed charges 3.56 5.45 Technical (Hospital) Services RISPERIDONE 0.5 MG TABLET RX-25520 CDM 6370000100 HCPCS 250 RC 68382-0113-14 NDC inpatient 1 UN 5.74 5.74 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES PPO [308136801] 4.54 percent of total billed charges 3.56 5.45 Technical (Hospital) Services RISPERIDONE 0.5 MG TABLET RX-25520 CDM 6370000100 HCPCS 250 RC 68382-0113-14 NDC inpatient 1 UN 5.74 5.74 MULTIPLAN INC 34080 [3081285] MULTIPLAN INC [308128501] 5.45 percent of total billed charges 3.56 5.45 Technical (Hospital) Services RISPERIDONE 0.5 MG TABLET RX-25520 CDM 6370000100 HCPCS 250 RC 68382-0113-14 NDC inpatient 1 UN 5.74 5.74 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES HDHP [308136802] 4.54 percent of total billed charges 3.56 5.45 Technical (Hospital) Services RISPERIDONE 0.5 MG TABLET RX-25520 CDM 6370000100 HCPCS 250 RC 68382-0113-14 NDC inpatient 1 UN 5.74 5.74 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES EPO [308136803] 4.54 percent of total billed charges 3.56 5.45 Technical (Hospital) Services RISPERIDONE 0.5 MG TABLET RX-25520 CDM 6370000100 HCPCS 250 RC 68382-0113-14 NDC inpatient 1 UN 5.74 5.74 CIGNA 62308 [3081051] CIGNA 62308 [308105105] 4.54 percent of total billed charges 3.56 5.45 Technical (Hospital) Services RISPERIDONE 0.5 MG TABLET RX-25520 CDM 6370000100 HCPCS 250 RC 68382-0113-14 NDC inpatient 1 UN 5.74 5.74 CIGNA 62308 [3081051] CIGNA STATE OF WYOMING [308105107] 4.54 percent of total billed charges 3.56 5.45 Technical (Hospital) Services RISPERIDONE 0.5 MG TABLET RX-25520 CDM 6370000100 HCPCS 250 RC 68382-0113-14 NDC inpatient 1 UN 5.74 5.74 BLUE CROSS BLUE SHIELD WELLMARK SB889 [3081026] BCBS WYOMING [308102603] 5.45 percent of total billed charges 3.56 5.45 Technical (Hospital) Services RISPERIDONE 0.5 MG TABLET RX-25520 CDM 6370000100 HCPCS 250 RC 68382-0113-14 NDC inpatient 1 UN 5.74 5.74 UNITED HEALTHCARE (COMMERCIAL) [3081199] UNITED HEALTHCARE 87726 [308119901] 3.56 percent of total billed charges 3.56 5.45 Technical (Hospital) Services RISPERIDONE 0.5 MG TABLET RX-25520 CDM 6370000100 HCPCS 250 RC 68382-0113-14 NDC outpatient 1 UN 5.74 5.74 HEALTHPARTNERS SX009 HEALTHPARTNERS 4.59 percent of total billed charges 3.56 5.45 Technical (Hospital) Services RISPERIDONE 0.5 MG TABLET RX-25520 CDM 6370000100 HCPCS 250 RC 68382-0113-14 NDC outpatient 1 UN 5.74 5.74 BLUE CROSS BLUE SHIELD WELLMARK SB889 [3081026] BCBS WYOMING [308102603] 5.45 percent of total billed charges 3.56 5.45 Technical (Hospital) Services RISPERIDONE 0.5 MG TABLET RX-25520 CDM 6370000100 HCPCS 250 RC 68382-0113-14 NDC outpatient 1 UN 5.74 5.74 UNITED HEALTHCARE (COMMERCIAL) [3081199] UNITED HEALTHCARE 87726 [308119901] 3.56 percent of total billed charges 3.56 5.45 Technical (Hospital) Services RISPERIDONE 0.5 MG TABLET RX-25520 CDM 6370000100 HCPCS 250 RC 68382-0113-14 NDC outpatient 1 UN 5.74 5.74 CIGNA 62308 [3081051] CIGNA 62308 [308105105] 4.59 percent of total billed charges 3.56 5.45 Technical (Hospital) Services RISPERIDONE 0.5 MG TABLET RX-25520 CDM 6370000100 HCPCS 250 RC 68382-0113-14 NDC outpatient 1 UN 5.74 5.74 CIGNA 62308 [3081051] CIGNA STATE OF WYOMING [308105107] 4.59 percent of total billed charges 3.56 5.45 Technical (Hospital) Services RISPERIDONE 0.5 MG TABLET RX-25520 CDM 6370000100 HCPCS 250 RC 68382-0113-14 NDC outpatient 1 UN 5.74 5.74 MULTIPLAN INC 34080 [3081285] MULTIPLAN INC [308128501] 5.45 percent of total billed charges 3.56 5.45 Technical (Hospital) Services RISPERIDONE 0.5 MG TABLET RX-25520 CDM 6370000100 HCPCS 250 RC 68382-0113-14 NDC outpatient 1 UN 5.74 5.74 MEDICA (COMMERCIAL) 94265 [3081118] MEDICA CLAIMS [308111801] 5.17 percent of total billed charges 3.56 5.45 Technical (Hospital) Services RISPERIDONE 0.5 MG TABLET RX-25520 CDM 6370000100 HCPCS 250 RC 68382-0113-14 NDC outpatient 1 UN 5.74 5.74 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES EPO [308136803] 4.59 percent of total billed charges 3.56 5.45 Technical (Hospital) Services RISPERIDONE 0.5 MG TABLET RX-25520 CDM 6370000100 HCPCS 250 RC 68382-0113-14 NDC outpatient 1 UN 5.74 5.74 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES HDHP [308136802] 4.59 percent of total billed charges 3.56 5.45 Technical (Hospital) Services RISPERIDONE 0.5 MG TABLET RX-25520 CDM 6370000100 HCPCS 250 RC 68382-0113-14 NDC outpatient 1 UN 5.74 5.74 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES PPO [308136801] 4.59 percent of total billed charges 3.56 5.45 Technical (Hospital) Services PIOGLITAZONE 15 MG TABLET RX-25528 CDM 6370000100 HCPCS 250 RC 33342-0054-10 NDC outpatient 1 UN 5.75 5.75 MEDICA (COMMERCIAL) 94265 [3081118] MEDICA CLAIMS [308111801] 5.18 percent of total billed charges 3.57 5.46 Technical (Hospital) Services PIOGLITAZONE 15 MG TABLET RX-25528 CDM 6370000100 HCPCS 250 RC 33342-0054-10 NDC outpatient 1 UN 5.75 5.75 MULTIPLAN INC 34080 [3081285] MULTIPLAN INC [308128501] 5.46 percent of total billed charges 3.57 5.46 Technical (Hospital) Services PIOGLITAZONE 15 MG TABLET RX-25528 CDM 6370000100 HCPCS 250 RC 33342-0054-10 NDC outpatient 1 UN 5.75 5.75 CIGNA 62308 [3081051] CIGNA 62308 [308105105] 4.6 percent of total billed charges 3.57 5.46 Technical (Hospital) Services PIOGLITAZONE 15 MG TABLET RX-25528 CDM 6370000100 HCPCS 250 RC 33342-0054-10 NDC outpatient 1 UN 5.75 5.75 CIGNA 62308 [3081051] CIGNA STATE OF WYOMING [308105107] 4.6 percent of total billed charges 3.57 5.46 Technical (Hospital) Services PIOGLITAZONE 15 MG TABLET RX-25528 CDM 6370000100 HCPCS 250 RC 33342-0054-10 NDC outpatient 1 UN 5.75 5.75 UNITED HEALTHCARE (COMMERCIAL) [3081199] UNITED HEALTHCARE 87726 [308119901] 3.57 percent of total billed charges 3.57 5.46 Technical (Hospital) Services PIOGLITAZONE 15 MG TABLET RX-25528 CDM 6370000100 HCPCS 250 RC 33342-0054-10 NDC outpatient 1 UN 5.75 5.75 BLUE CROSS BLUE SHIELD WELLMARK SB889 [3081026] BCBS WYOMING [308102603] 5.46 percent of total billed charges 3.57 5.46 Technical (Hospital) Services PIOGLITAZONE 15 MG TABLET RX-25528 CDM 6370000100 HCPCS 250 RC 33342-0054-10 NDC outpatient 1 UN 5.75 5.75 HEALTHPARTNERS SX009 HEALTHPARTNERS 4.6 percent of total billed charges 3.57 5.46 Technical (Hospital) Services PIOGLITAZONE 15 MG TABLET RX-25528 CDM 6370000100 HCPCS 250 RC 33342-0054-10 NDC outpatient 1 UN 5.75 5.75 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES HDHP [308136802] 4.6 percent of total billed charges 3.57 5.46 Technical (Hospital) Services PIOGLITAZONE 15 MG TABLET RX-25528 CDM 6370000100 HCPCS 250 RC 33342-0054-10 NDC outpatient 1 UN 5.75 5.75 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES PPO [308136801] 4.6 percent of total billed charges 3.57 5.46 Technical (Hospital) Services PIOGLITAZONE 15 MG TABLET RX-25528 CDM 6370000100 HCPCS 250 RC 33342-0054-10 NDC outpatient 1 UN 5.75 5.75 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES EPO [308136803] 4.6 percent of total billed charges 3.57 5.46 Technical (Hospital) Services PIOGLITAZONE 15 MG TABLET RX-25528 CDM 6370000100 HCPCS 250 RC 33342-0054-10 NDC inpatient 1 UN 5.75 5.75 BLUE CROSS BLUE SHIELD WELLMARK SB889 [3081026] BCBS WYOMING [308102603] 5.46 percent of total billed charges 3.57 5.46 Technical (Hospital) Services PIOGLITAZONE 15 MG TABLET RX-25528 CDM 6370000100 HCPCS 250 RC 33342-0054-10 NDC inpatient 1 UN 5.75 5.75 UNITED HEALTHCARE (COMMERCIAL) [3081199] UNITED HEALTHCARE 87726 [308119901] 3.57 percent of total billed charges 3.57 5.46 Technical (Hospital) Services PIOGLITAZONE 15 MG TABLET RX-25528 CDM 6370000100 HCPCS 250 RC 33342-0054-10 NDC inpatient 1 UN 5.75 5.75 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES EPO [308136803] 4.55 percent of total billed charges 3.57 5.46 Technical (Hospital) Services PIOGLITAZONE 15 MG TABLET RX-25528 CDM 6370000100 HCPCS 250 RC 33342-0054-10 NDC inpatient 1 UN 5.75 5.75 CIGNA 62308 [3081051] CIGNA 62308 [308105105] 4.55 percent of total billed charges 3.57 5.46 Technical (Hospital) Services PIOGLITAZONE 15 MG TABLET RX-25528 CDM 6370000100 HCPCS 250 RC 33342-0054-10 NDC inpatient 1 UN 5.75 5.75 CIGNA 62308 [3081051] CIGNA STATE OF WYOMING [308105107] 4.55 percent of total billed charges 3.57 5.46 Technical (Hospital) Services PIOGLITAZONE 15 MG TABLET RX-25528 CDM 6370000100 HCPCS 250 RC 33342-0054-10 NDC inpatient 1 UN 5.75 5.75 MEDICA (COMMERCIAL) 94265 [3081118] MEDICA CLAIMS [308111801] 5.18 percent of total billed charges 3.57 5.46 Technical (Hospital) Services PIOGLITAZONE 15 MG TABLET RX-25528 CDM 6370000100 HCPCS 250 RC 33342-0054-10 NDC inpatient 1 UN 5.75 5.75 HEALTHPARTNERS SX009 HEALTHPARTNERS 4.55 percent of total billed charges 3.57 5.46 Technical (Hospital) Services PIOGLITAZONE 15 MG TABLET RX-25528 CDM 6370000100 HCPCS 250 RC 33342-0054-10 NDC inpatient 1 UN 5.75 5.75 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES HDHP [308136802] 4.55 percent of total billed charges 3.57 5.46 Technical (Hospital) Services PIOGLITAZONE 15 MG TABLET RX-25528 CDM 6370000100 HCPCS 250 RC 33342-0054-10 NDC inpatient 1 UN 5.75 5.75 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES PPO [308136801] 4.55 percent of total billed charges 3.57 5.46 Technical (Hospital) Services PIOGLITAZONE 15 MG TABLET RX-25528 CDM 6370000100 HCPCS 250 RC 33342-0054-10 NDC inpatient 1 UN 5.75 5.75 MULTIPLAN INC 34080 [3081285] MULTIPLAN INC [308128501] 5.46 percent of total billed charges 3.57 5.46 Technical (Hospital) Services PIOGLITAZONE 45 MG TABLET RX-25530 CDM 6370000100 HCPCS 250 RC 16729-0022-15 NDC outpatient 1 UN 5.81 5.81 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES EPO [308136803] 4.65 percent of total billed charges 3.6 5.52 Technical (Hospital) Services PIOGLITAZONE 45 MG TABLET RX-25530 CDM 6370000100 HCPCS 250 RC 16729-0022-15 NDC outpatient 1 UN 5.81 5.81 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES PPO [308136801] 4.65 percent of total billed charges 3.6 5.52 Technical (Hospital) Services PIOGLITAZONE 45 MG TABLET RX-25530 CDM 6370000100 HCPCS 250 RC 16729-0022-15 NDC outpatient 1 UN 5.81 5.81 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES HDHP [308136802] 4.65 percent of total billed charges 3.6 5.52 Technical (Hospital) Services PIOGLITAZONE 45 MG TABLET RX-25530 CDM 6370000100 HCPCS 250 RC 16729-0022-15 NDC outpatient 1 UN 5.81 5.81 HEALTHPARTNERS SX009 HEALTHPARTNERS 4.65 percent of total billed charges 3.6 5.52 Technical (Hospital) Services PIOGLITAZONE 45 MG TABLET RX-25530 CDM 6370000100 HCPCS 250 RC 16729-0022-15 NDC outpatient 1 UN 5.81 5.81 BLUE CROSS BLUE SHIELD WELLMARK SB889 [3081026] BCBS WYOMING [308102603] 5.52 percent of total billed charges 3.6 5.52 Technical (Hospital) Services PIOGLITAZONE 45 MG TABLET RX-25530 CDM 6370000100 HCPCS 250 RC 16729-0022-15 NDC outpatient 1 UN 5.81 5.81 UNITED HEALTHCARE (COMMERCIAL) [3081199] UNITED HEALTHCARE 87726 [308119901] 3.6 percent of total billed charges 3.6 5.52 Technical (Hospital) Services PIOGLITAZONE 45 MG TABLET RX-25530 CDM 6370000100 HCPCS 250 RC 16729-0022-15 NDC outpatient 1 UN 5.81 5.81 CIGNA 62308 [3081051] CIGNA 62308 [308105105] 4.65 percent of total billed charges 3.6 5.52 Technical (Hospital) Services PIOGLITAZONE 45 MG TABLET RX-25530 CDM 6370000100 HCPCS 250 RC 16729-0022-15 NDC outpatient 1 UN 5.81 5.81 CIGNA 62308 [3081051] CIGNA STATE OF WYOMING [308105107] 4.65 percent of total billed charges 3.6 5.52 Technical (Hospital) Services PIOGLITAZONE 45 MG TABLET RX-25530 CDM 6370000100 HCPCS 250 RC 16729-0022-15 NDC outpatient 1 UN 5.81 5.81 MULTIPLAN INC 34080 [3081285] MULTIPLAN INC [308128501] 5.52 percent of total billed charges 3.6 5.52 Technical (Hospital) Services PIOGLITAZONE 45 MG TABLET RX-25530 CDM 6370000100 HCPCS 250 RC 16729-0022-15 NDC outpatient 1 UN 5.81 5.81 MEDICA (COMMERCIAL) 94265 [3081118] MEDICA CLAIMS [308111801] 5.23 percent of total billed charges 3.6 5.52 Technical (Hospital) Services PIOGLITAZONE 45 MG TABLET RX-25530 CDM 6370000100 HCPCS 250 RC 16729-0022-15 NDC inpatient 1 UN 5.81 5.81 UNITED HEALTHCARE (COMMERCIAL) [3081199] UNITED HEALTHCARE 87726 [308119901] 3.6 percent of total billed charges 3.6 5.52 Technical (Hospital) Services PIOGLITAZONE 45 MG TABLET RX-25530 CDM 6370000100 HCPCS 250 RC 16729-0022-15 NDC inpatient 1 UN 5.81 5.81 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES HDHP [308136802] 4.6 percent of total billed charges 3.6 5.52 Technical (Hospital) Services PIOGLITAZONE 45 MG TABLET RX-25530 CDM 6370000100 HCPCS 250 RC 16729-0022-15 NDC inpatient 1 UN 5.81 5.81 BLUE CROSS BLUE SHIELD WELLMARK SB889 [3081026] BCBS WYOMING [308102603] 5.52 percent of total billed charges 3.6 5.52 Technical (Hospital) Services PIOGLITAZONE 45 MG TABLET RX-25530 CDM 6370000100 HCPCS 250 RC 16729-0022-15 NDC inpatient 1 UN 5.81 5.81 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES EPO [308136803] 4.6 percent of total billed charges 3.6 5.52 Technical (Hospital) Services PIOGLITAZONE 45 MG TABLET RX-25530 CDM 6370000100 HCPCS 250 RC 16729-0022-15 NDC inpatient 1 UN 5.81 5.81 CIGNA 62308 [3081051] CIGNA 62308 [308105105] 4.6 percent of total billed charges 3.6 5.52 Technical (Hospital) Services PIOGLITAZONE 45 MG TABLET RX-25530 CDM 6370000100 HCPCS 250 RC 16729-0022-15 NDC inpatient 1 UN 5.81 5.81 CIGNA 62308 [3081051] CIGNA STATE OF WYOMING [308105107] 4.6 percent of total billed charges 3.6 5.52 Technical (Hospital) Services PIOGLITAZONE 45 MG TABLET RX-25530 CDM 6370000100 HCPCS 250 RC 16729-0022-15 NDC inpatient 1 UN 5.81 5.81 MEDICA (COMMERCIAL) 94265 [3081118] MEDICA CLAIMS [308111801] 5.23 percent of total billed charges 3.6 5.52 Technical (Hospital) Services PIOGLITAZONE 45 MG TABLET RX-25530 CDM 6370000100 HCPCS 250 RC 16729-0022-15 NDC inpatient 1 UN 5.81 5.81 HEALTHPARTNERS SX009 HEALTHPARTNERS 4.6 percent of total billed charges 3.6 5.52 Technical (Hospital) Services PIOGLITAZONE 45 MG TABLET RX-25530 CDM 6370000100 HCPCS 250 RC 16729-0022-15 NDC inpatient 1 UN 5.81 5.81 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES PPO [308136801] 4.6 percent of total billed charges 3.6 5.52 Technical (Hospital) Services PIOGLITAZONE 45 MG TABLET RX-25530 CDM 6370000100 HCPCS 250 RC 16729-0022-15 NDC inpatient 1 UN 5.81 5.81 MULTIPLAN INC 34080 [3081285] MULTIPLAN INC [308128501] 5.52 percent of total billed charges 3.6 5.52 Technical (Hospital) Services DOCUSATE SODIUM 100 MG TABLET RX-2572 CDM 6370000100 HCPCS 250 RC 00904-6750-60 NDC inpatient 1 UN 5.66 5.66 MULTIPLAN INC 34080 [3081285] MULTIPLAN INC [308128501] 5.38 percent of total billed charges 3.51 5.38 Technical (Hospital) Services DOCUSATE SODIUM 100 MG TABLET RX-2572 CDM 6370000100 HCPCS 250 RC 00904-6750-60 NDC inpatient 1 UN 5.66 5.66 MEDICA (COMMERCIAL) 94265 [3081118] MEDICA CLAIMS [308111801] 5.09 percent of total billed charges 3.51 5.38 Technical (Hospital) Services DOCUSATE SODIUM 100 MG TABLET RX-2572 CDM 6370000100 HCPCS 250 RC 00904-6750-60 NDC inpatient 1 UN 5.66 5.66 HEALTHPARTNERS SX009 HEALTHPARTNERS 4.48 percent of total billed charges 3.51 5.38 Technical (Hospital) Services DOCUSATE SODIUM 100 MG TABLET RX-2572 CDM 6370000100 HCPCS 250 RC 00904-6750-60 NDC inpatient 1 UN 5.66 5.66 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES PPO [308136801] 4.48 percent of total billed charges 3.51 5.38 Technical (Hospital) Services DOCUSATE SODIUM 100 MG TABLET RX-2572 CDM 6370000100 HCPCS 250 RC 00904-6750-60 NDC inpatient 1 UN 5.66 5.66 UNITED HEALTHCARE (COMMERCIAL) [3081199] UNITED HEALTHCARE 87726 [308119901] 3.51 percent of total billed charges 3.51 5.38 Technical (Hospital) Services DOCUSATE SODIUM 100 MG TABLET RX-2572 CDM 6370000100 HCPCS 250 RC 00904-6750-60 NDC inpatient 1 UN 5.66 5.66 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES HDHP [308136802] 4.48 percent of total billed charges 3.51 5.38 Technical (Hospital) Services DOCUSATE SODIUM 100 MG TABLET RX-2572 CDM 6370000100 HCPCS 250 RC 00904-6750-60 NDC inpatient 1 UN 5.66 5.66 BLUE CROSS BLUE SHIELD WELLMARK SB889 [3081026] BCBS WYOMING [308102603] 5.38 percent of total billed charges 3.51 5.38 Technical (Hospital) Services DOCUSATE SODIUM 100 MG TABLET RX-2572 CDM 6370000100 HCPCS 250 RC 00904-6750-60 NDC inpatient 1 UN 5.66 5.66 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES EPO [308136803] 4.48 percent of total billed charges 3.51 5.38 Technical (Hospital) Services DOCUSATE SODIUM 100 MG TABLET RX-2572 CDM 6370000100 HCPCS 250 RC 00904-6750-60 NDC inpatient 1 UN 5.66 5.66 CIGNA 62308 [3081051] CIGNA 62308 [308105105] 4.48 percent of total billed charges 3.51 5.38 Technical (Hospital) Services DOCUSATE SODIUM 100 MG TABLET RX-2572 CDM 6370000100 HCPCS 250 RC 00904-6750-60 NDC inpatient 1 UN 5.66 5.66 CIGNA 62308 [3081051] CIGNA STATE OF WYOMING [308105107] 4.48 percent of total billed charges 3.51 5.38 Technical (Hospital) Services DOCUSATE SODIUM 100 MG TABLET RX-2572 CDM 6370000100 HCPCS 250 RC 00904-6750-60 NDC outpatient 1 UN 5.66 5.66 BLUE CROSS BLUE SHIELD WELLMARK SB889 [3081026] BCBS WYOMING [308102603] 5.38 percent of total billed charges 3.51 5.38 Technical (Hospital) Services DOCUSATE SODIUM 100 MG TABLET RX-2572 CDM 6370000100 HCPCS 250 RC 00904-6750-60 NDC outpatient 1 UN 5.66 5.66 MULTIPLAN INC 34080 [3081285] MULTIPLAN INC [308128501] 5.38 percent of total billed charges 3.51 5.38 Technical (Hospital) Services DOCUSATE SODIUM 100 MG TABLET RX-2572 CDM 6370000100 HCPCS 250 RC 00904-6750-60 NDC outpatient 1 UN 5.66 5.66 CIGNA 62308 [3081051] CIGNA 62308 [308105105] 4.53 percent of total billed charges 3.51 5.38 Technical (Hospital) Services DOCUSATE SODIUM 100 MG TABLET RX-2572 CDM 6370000100 HCPCS 250 RC 00904-6750-60 NDC outpatient 1 UN 5.66 5.66 CIGNA 62308 [3081051] CIGNA STATE OF WYOMING [308105107] 4.53 percent of total billed charges 3.51 5.38 Technical (Hospital) Services DOCUSATE SODIUM 100 MG TABLET RX-2572 CDM 6370000100 HCPCS 250 RC 00904-6750-60 NDC outpatient 1 UN 5.66 5.66 MEDICA (COMMERCIAL) 94265 [3081118] MEDICA CLAIMS [308111801] 5.09 percent of total billed charges 3.51 5.38 Technical (Hospital) Services DOCUSATE SODIUM 100 MG TABLET RX-2572 CDM 6370000100 HCPCS 250 RC 00904-6750-60 NDC outpatient 1 UN 5.66 5.66 HEALTHPARTNERS SX009 HEALTHPARTNERS 4.53 percent of total billed charges 3.51 5.38 Technical (Hospital) Services DOCUSATE SODIUM 100 MG TABLET RX-2572 CDM 6370000100 HCPCS 250 RC 00904-6750-60 NDC outpatient 1 UN 5.66 5.66 UNITED HEALTHCARE (COMMERCIAL) [3081199] UNITED HEALTHCARE 87726 [308119901] 3.51 percent of total billed charges 3.51 5.38 Technical (Hospital) Services DOCUSATE SODIUM 100 MG TABLET RX-2572 CDM 6370000100 HCPCS 250 RC 00904-6750-60 NDC outpatient 1 UN 5.66 5.66 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES EPO [308136803] 4.53 percent of total billed charges 3.51 5.38 Technical (Hospital) Services DOCUSATE SODIUM 100 MG TABLET RX-2572 CDM 6370000100 HCPCS 250 RC 00904-6750-60 NDC outpatient 1 UN 5.66 5.66 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES HDHP [308136802] 4.53 percent of total billed charges 3.51 5.38 Technical (Hospital) Services DOCUSATE SODIUM 100 MG TABLET RX-2572 CDM 6370000100 HCPCS 250 RC 00904-6750-60 NDC outpatient 1 UN 5.66 5.66 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES PPO [308136801] 4.53 percent of total billed charges 3.51 5.38 Technical (Hospital) Services GABAPENTIN 600 MG TABLET RX-25855 CDM 6370000100 HCPCS 250 RC 51224-0021-50 NDC inpatient 1 UN 5.78 5.78 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES EPO [308136803] 4.58 percent of total billed charges 3.58 5.49 Technical (Hospital) Services GABAPENTIN 600 MG TABLET RX-25855 CDM 6370000100 HCPCS 250 RC 51224-0021-50 NDC inpatient 1 UN 5.78 5.78 CIGNA 62308 [3081051] CIGNA 62308 [308105105] 4.58 percent of total billed charges 3.58 5.49 Technical (Hospital) Services GABAPENTIN 600 MG TABLET RX-25855 CDM 6370000100 HCPCS 250 RC 51224-0021-50 NDC inpatient 1 UN 5.78 5.78 CIGNA 62308 [3081051] CIGNA STATE OF WYOMING [308105107] 4.58 percent of total billed charges 3.58 5.49 Technical (Hospital) Services GABAPENTIN 600 MG TABLET RX-25855 CDM 6370000100 HCPCS 250 RC 51224-0021-50 NDC inpatient 1 UN 5.78 5.78 HEALTHPARTNERS SX009 HEALTHPARTNERS 4.58 percent of total billed charges 3.58 5.49 Technical (Hospital) Services GABAPENTIN 600 MG TABLET RX-25855 CDM 6370000100 HCPCS 250 RC 51224-0021-50 NDC inpatient 1 UN 5.78 5.78 MEDICA (COMMERCIAL) 94265 [3081118] MEDICA CLAIMS [308111801] 5.2 percent of total billed charges 3.58 5.49 Technical (Hospital) Services GABAPENTIN 600 MG TABLET RX-25855 CDM 6370000100 HCPCS 250 RC 51224-0021-50 NDC inpatient 1 UN 5.78 5.78 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES HDHP [308136802] 4.58 percent of total billed charges 3.58 5.49 Technical (Hospital) Services GABAPENTIN 600 MG TABLET RX-25855 CDM 6370000100 HCPCS 250 RC 51224-0021-50 NDC inpatient 1 UN 5.78 5.78 BLUE CROSS BLUE SHIELD WELLMARK SB889 [3081026] BCBS WYOMING [308102603] 5.49 percent of total billed charges 3.58 5.49 Technical (Hospital) Services GABAPENTIN 600 MG TABLET RX-25855 CDM 6370000100 HCPCS 250 RC 51224-0021-50 NDC inpatient 1 UN 5.78 5.78 UNITED HEALTHCARE (COMMERCIAL) [3081199] UNITED HEALTHCARE 87726 [308119901] 3.58 percent of total billed charges 3.58 5.49 Technical (Hospital) Services GABAPENTIN 600 MG TABLET RX-25855 CDM 6370000100 HCPCS 250 RC 51224-0021-50 NDC inpatient 1 UN 5.78 5.78 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES PPO [308136801] 4.58 percent of total billed charges 3.58 5.49 Technical (Hospital) Services GABAPENTIN 600 MG TABLET RX-25855 CDM 6370000100 HCPCS 250 RC 51224-0021-50 NDC inpatient 1 UN 5.78 5.78 MULTIPLAN INC 34080 [3081285] MULTIPLAN INC [308128501] 5.49 percent of total billed charges 3.58 5.49 Technical (Hospital) Services GABAPENTIN 600 MG TABLET RX-25855 CDM 6370000100 HCPCS 250 RC 51224-0021-50 NDC outpatient 1 UN 5.78 5.78 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES EPO [308136803] 4.62 percent of total billed charges 3.58 5.49 Technical (Hospital) Services GABAPENTIN 600 MG TABLET RX-25855 CDM 6370000100 HCPCS 250 RC 51224-0021-50 NDC outpatient 1 UN 5.78 5.78 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES PPO [308136801] 4.62 percent of total billed charges 3.58 5.49 Technical (Hospital) Services GABAPENTIN 600 MG TABLET RX-25855 CDM 6370000100 HCPCS 250 RC 51224-0021-50 NDC outpatient 1 UN 5.78 5.78 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES HDHP [308136802] 4.62 percent of total billed charges 3.58 5.49 Technical (Hospital) Services GABAPENTIN 600 MG TABLET RX-25855 CDM 6370000100 HCPCS 250 RC 51224-0021-50 NDC outpatient 1 UN 5.78 5.78 BLUE CROSS BLUE SHIELD WELLMARK SB889 [3081026] BCBS WYOMING [308102603] 5.49 percent of total billed charges 3.58 5.49 Technical (Hospital) Services GABAPENTIN 600 MG TABLET RX-25855 CDM 6370000100 HCPCS 250 RC 51224-0021-50 NDC outpatient 1 UN 5.78 5.78 UNITED HEALTHCARE (COMMERCIAL) [3081199] UNITED HEALTHCARE 87726 [308119901] 3.58 percent of total billed charges 3.58 5.49 Technical (Hospital) Services GABAPENTIN 600 MG TABLET RX-25855 CDM 6370000100 HCPCS 250 RC 51224-0021-50 NDC outpatient 1 UN 5.78 5.78 HEALTHPARTNERS SX009 HEALTHPARTNERS 4.62 percent of total billed charges 3.58 5.49 Technical (Hospital) Services GABAPENTIN 600 MG TABLET RX-25855 CDM 6370000100 HCPCS 250 RC 51224-0021-50 NDC outpatient 1 UN 5.78 5.78 CIGNA 62308 [3081051] CIGNA 62308 [308105105] 4.62 percent of total billed charges 3.58 5.49 Technical (Hospital) Services GABAPENTIN 600 MG TABLET RX-25855 CDM 6370000100 HCPCS 250 RC 51224-0021-50 NDC outpatient 1 UN 5.78 5.78 CIGNA 62308 [3081051] CIGNA STATE OF WYOMING [308105107] 4.62 percent of total billed charges 3.58 5.49 Technical (Hospital) Services GABAPENTIN 600 MG TABLET RX-25855 CDM 6370000100 HCPCS 250 RC 51224-0021-50 NDC outpatient 1 UN 5.78 5.78 MULTIPLAN INC 34080 [3081285] MULTIPLAN INC [308128501] 5.49 percent of total billed charges 3.58 5.49 Technical (Hospital) Services GABAPENTIN 600 MG TABLET RX-25855 CDM 6370000100 HCPCS 250 RC 51224-0021-50 NDC outpatient 1 UN 5.78 5.78 MEDICA (COMMERCIAL) 94265 [3081118] MEDICA CLAIMS [308111801] 5.2 percent of total billed charges 3.58 5.49 Technical (Hospital) Services DOXEPIN 10 MG CAPSULE RX-2608 CDM 6370000100 HCPCS 250 RC 00378-1049-01 NDC outpatient 1 UN 6.09 6.09 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES HDHP [308136802] 4.87 percent of total billed charges 3.78 5.79 Technical (Hospital) Services DOXEPIN 10 MG CAPSULE RX-2608 CDM 6370000100 HCPCS 250 RC 00378-1049-01 NDC outpatient 1 UN 6.09 6.09 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES EPO [308136803] 4.87 percent of total billed charges 3.78 5.79 Technical (Hospital) Services DOXEPIN 10 MG CAPSULE RX-2608 CDM 6370000100 HCPCS 250 RC 00378-1049-01 NDC outpatient 1 UN 6.09 6.09 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES PPO [308136801] 4.87 percent of total billed charges 3.78 5.79 Technical (Hospital) Services DOXEPIN 10 MG CAPSULE RX-2608 CDM 6370000100 HCPCS 250 RC 00378-1049-01 NDC outpatient 1 UN 6.09 6.09 MEDICA (COMMERCIAL) 94265 [3081118] MEDICA CLAIMS [308111801] 5.48 percent of total billed charges 3.78 5.79 Technical (Hospital) Services DOXEPIN 10 MG CAPSULE RX-2608 CDM 6370000100 HCPCS 250 RC 00378-1049-01 NDC outpatient 1 UN 6.09 6.09 CIGNA 62308 [3081051] CIGNA 62308 [308105105] 4.87 percent of total billed charges 3.78 5.79 Technical (Hospital) Services DOXEPIN 10 MG CAPSULE RX-2608 CDM 6370000100 HCPCS 250 RC 00378-1049-01 NDC outpatient 1 UN 6.09 6.09 CIGNA 62308 [3081051] CIGNA STATE OF WYOMING [308105107] 4.87 percent of total billed charges 3.78 5.79 Technical (Hospital) Services DOXEPIN 10 MG CAPSULE RX-2608 CDM 6370000100 HCPCS 250 RC 00378-1049-01 NDC outpatient 1 UN 6.09 6.09 MULTIPLAN INC 34080 [3081285] MULTIPLAN INC [308128501] 5.79 percent of total billed charges 3.78 5.79 Technical (Hospital) Services DOXEPIN 10 MG CAPSULE RX-2608 CDM 6370000100 HCPCS 250 RC 00378-1049-01 NDC outpatient 1 UN 6.09 6.09 UNITED HEALTHCARE (COMMERCIAL) [3081199] UNITED HEALTHCARE 87726 [308119901] 3.78 percent of total billed charges 3.78 5.79 Technical (Hospital) Services DOXEPIN 10 MG CAPSULE RX-2608 CDM 6370000100 HCPCS 250 RC 00378-1049-01 NDC outpatient 1 UN 6.09 6.09 BLUE CROSS BLUE SHIELD WELLMARK SB889 [3081026] BCBS WYOMING [308102603] 5.79 percent of total billed charges 3.78 5.79 Technical (Hospital) Services DOXEPIN 10 MG CAPSULE RX-2608 CDM 6370000100 HCPCS 250 RC 00378-1049-01 NDC outpatient 1 UN 6.09 6.09 HEALTHPARTNERS SX009 HEALTHPARTNERS 4.87 percent of total billed charges 3.78 5.79 Technical (Hospital) Services DOXEPIN 10 MG CAPSULE RX-2608 CDM 6370000100 HCPCS 250 RC 00378-1049-01 NDC inpatient 1 UN 6.09 6.09 UNITED HEALTHCARE (COMMERCIAL) [3081199] UNITED HEALTHCARE 87726 [308119901] 3.78 percent of total billed charges 3.78 5.79 Technical (Hospital) Services DOXEPIN 10 MG CAPSULE RX-2608 CDM 6370000100 HCPCS 250 RC 00378-1049-01 NDC inpatient 1 UN 6.09 6.09 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES EPO [308136803] 4.82 percent of total billed charges 3.78 5.79 Technical (Hospital) Services DOXEPIN 10 MG CAPSULE RX-2608 CDM 6370000100 HCPCS 250 RC 00378-1049-01 NDC inpatient 1 UN 6.09 6.09 CIGNA 62308 [3081051] CIGNA 62308 [308105105] 4.82 percent of total billed charges 3.78 5.79 Technical (Hospital) Services DOXEPIN 10 MG CAPSULE RX-2608 CDM 6370000100 HCPCS 250 RC 00378-1049-01 NDC inpatient 1 UN 6.09 6.09 CIGNA 62308 [3081051] CIGNA STATE OF WYOMING [308105107] 4.82 percent of total billed charges 3.78 5.79 Technical (Hospital) Services DOXEPIN 10 MG CAPSULE RX-2608 CDM 6370000100 HCPCS 250 RC 00378-1049-01 NDC inpatient 1 UN 6.09 6.09 BLUE CROSS BLUE SHIELD WELLMARK SB889 [3081026] BCBS WYOMING [308102603] 5.79 percent of total billed charges 3.78 5.79 Technical (Hospital) Services DOXEPIN 10 MG CAPSULE RX-2608 CDM 6370000100 HCPCS 250 RC 00378-1049-01 NDC inpatient 1 UN 6.09 6.09 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES HDHP [308136802] 4.82 percent of total billed charges 3.78 5.79 Technical (Hospital) Services DOXEPIN 10 MG CAPSULE RX-2608 CDM 6370000100 HCPCS 250 RC 00378-1049-01 NDC inpatient 1 UN 6.09 6.09 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES PPO [308136801] 4.82 percent of total billed charges 3.78 5.79 Technical (Hospital) Services DOXEPIN 10 MG CAPSULE RX-2608 CDM 6370000100 HCPCS 250 RC 00378-1049-01 NDC inpatient 1 UN 6.09 6.09 HEALTHPARTNERS SX009 HEALTHPARTNERS 4.82 percent of total billed charges 3.78 5.79 Technical (Hospital) Services DOXEPIN 10 MG CAPSULE RX-2608 CDM 6370000100 HCPCS 250 RC 00378-1049-01 NDC inpatient 1 UN 6.09 6.09 MEDICA (COMMERCIAL) 94265 [3081118] MEDICA CLAIMS [308111801] 5.48 percent of total billed charges 3.78 5.79 Technical (Hospital) Services DOXEPIN 10 MG CAPSULE RX-2608 CDM 6370000100 HCPCS 250 RC 00378-1049-01 NDC inpatient 1 UN 6.09 6.09 MULTIPLAN INC 34080 [3081285] MULTIPLAN INC [308128501] 5.79 percent of total billed charges 3.78 5.79 Technical (Hospital) Services "PANTOPRAZOLE 40 MG TABLET,DELAYED RELEASE" RX-26225 CDM 6370000100 HCPCS 250 RC 65862-0560-90 NDC outpatient 1 UN 5.76 5.76 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES EPO [308136803] 4.61 percent of total billed charges 3.57 5.47 Technical (Hospital) Services "PANTOPRAZOLE 40 MG TABLET,DELAYED RELEASE" RX-26225 CDM 6370000100 HCPCS 250 RC 65862-0560-90 NDC outpatient 1 UN 5.76 5.76 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES PPO [308136801] 4.61 percent of total billed charges 3.57 5.47 Technical (Hospital) Services "PANTOPRAZOLE 40 MG TABLET,DELAYED RELEASE" RX-26225 CDM 6370000100 HCPCS 250 RC 65862-0560-90 NDC outpatient 1 UN 5.76 5.76 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES HDHP [308136802] 4.61 percent of total billed charges 3.57 5.47 Technical (Hospital) Services "PANTOPRAZOLE 40 MG TABLET,DELAYED RELEASE" RX-26225 CDM 6370000100 HCPCS 250 RC 65862-0560-90 NDC outpatient 1 UN 5.76 5.76 HEALTHPARTNERS SX009 HEALTHPARTNERS 4.61 percent of total billed charges 3.57 5.47 Technical (Hospital) Services "PANTOPRAZOLE 40 MG TABLET,DELAYED RELEASE" RX-26225 CDM 6370000100 HCPCS 250 RC 65862-0560-90 NDC outpatient 1 UN 5.76 5.76 UNITED HEALTHCARE (COMMERCIAL) [3081199] UNITED HEALTHCARE 87726 [308119901] 3.57 percent of total billed charges 3.57 5.47 Technical (Hospital) Services "PANTOPRAZOLE 40 MG TABLET,DELAYED RELEASE" RX-26225 CDM 6370000100 HCPCS 250 RC 65862-0560-90 NDC outpatient 1 UN 5.76 5.76 MULTIPLAN INC 34080 [3081285] MULTIPLAN INC [308128501] 5.47 percent of total billed charges 3.57 5.47 Technical (Hospital) Services "PANTOPRAZOLE 40 MG TABLET,DELAYED RELEASE" RX-26225 CDM 6370000100 HCPCS 250 RC 65862-0560-90 NDC outpatient 1 UN 5.76 5.76 CIGNA 62308 [3081051] CIGNA 62308 [308105105] 4.61 percent of total billed charges 3.57 5.47 Technical (Hospital) Services "PANTOPRAZOLE 40 MG TABLET,DELAYED RELEASE" RX-26225 CDM 6370000100 HCPCS 250 RC 65862-0560-90 NDC outpatient 1 UN 5.76 5.76 CIGNA 62308 [3081051] CIGNA STATE OF WYOMING [308105107] 4.61 percent of total billed charges 3.57 5.47 Technical (Hospital) Services "PANTOPRAZOLE 40 MG TABLET,DELAYED RELEASE" RX-26225 CDM 6370000100 HCPCS 250 RC 65862-0560-90 NDC outpatient 1 UN 5.76 5.76 MEDICA (COMMERCIAL) 94265 [3081118] MEDICA CLAIMS [308111801] 5.18 percent of total billed charges 3.57 5.47 Technical (Hospital) Services "PANTOPRAZOLE 40 MG TABLET,DELAYED RELEASE" RX-26225 CDM 6370000100 HCPCS 250 RC 65862-0560-90 NDC outpatient 1 UN 5.76 5.76 BLUE CROSS BLUE SHIELD WELLMARK SB889 [3081026] BCBS WYOMING [308102603] 5.47 percent of total billed charges 3.57 5.47 Technical (Hospital) Services "PANTOPRAZOLE 40 MG TABLET,DELAYED RELEASE" RX-26225 CDM 6370000100 HCPCS 250 RC 65862-0560-90 NDC inpatient 1 UN 5.76 5.76 MULTIPLAN INC 34080 [3081285] MULTIPLAN INC [308128501] 5.47 percent of total billed charges 3.57 5.47 Technical (Hospital) Services "PANTOPRAZOLE 40 MG TABLET,DELAYED RELEASE" RX-26225 CDM 6370000100 HCPCS 250 RC 65862-0560-90 NDC inpatient 1 UN 5.76 5.76 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES PPO [308136801] 4.56 percent of total billed charges 3.57 5.47 Technical (Hospital) Services "PANTOPRAZOLE 40 MG TABLET,DELAYED RELEASE" RX-26225 CDM 6370000100 HCPCS 250 RC 65862-0560-90 NDC inpatient 1 UN 5.76 5.76 HEALTHPARTNERS SX009 HEALTHPARTNERS 4.56 percent of total billed charges 3.57 5.47 Technical (Hospital) Services "PANTOPRAZOLE 40 MG TABLET,DELAYED RELEASE" RX-26225 CDM 6370000100 HCPCS 250 RC 65862-0560-90 NDC inpatient 1 UN 5.76 5.76 MEDICA (COMMERCIAL) 94265 [3081118] MEDICA CLAIMS [308111801] 5.18 percent of total billed charges 3.57 5.47 Technical (Hospital) Services "PANTOPRAZOLE 40 MG TABLET,DELAYED RELEASE" RX-26225 CDM 6370000100 HCPCS 250 RC 65862-0560-90 NDC inpatient 1 UN 5.76 5.76 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES HDHP [308136802] 4.56 percent of total billed charges 3.57 5.47 Technical (Hospital) Services "PANTOPRAZOLE 40 MG TABLET,DELAYED RELEASE" RX-26225 CDM 6370000100 HCPCS 250 RC 65862-0560-90 NDC inpatient 1 UN 5.76 5.76 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES EPO [308136803] 4.56 percent of total billed charges 3.57 5.47 Technical (Hospital) Services "PANTOPRAZOLE 40 MG TABLET,DELAYED RELEASE" RX-26225 CDM 6370000100 HCPCS 250 RC 65862-0560-90 NDC inpatient 1 UN 5.76 5.76 CIGNA 62308 [3081051] CIGNA 62308 [308105105] 4.56 percent of total billed charges 3.57 5.47 Technical (Hospital) Services "PANTOPRAZOLE 40 MG TABLET,DELAYED RELEASE" RX-26225 CDM 6370000100 HCPCS 250 RC 65862-0560-90 NDC inpatient 1 UN 5.76 5.76 CIGNA 62308 [3081051] CIGNA STATE OF WYOMING [308105107] 4.56 percent of total billed charges 3.57 5.47 Technical (Hospital) Services "PANTOPRAZOLE 40 MG TABLET,DELAYED RELEASE" RX-26225 CDM 6370000100 HCPCS 250 RC 65862-0560-90 NDC inpatient 1 UN 5.76 5.76 UNITED HEALTHCARE (COMMERCIAL) [3081199] UNITED HEALTHCARE 87726 [308119901] 3.57 percent of total billed charges 3.57 5.47 Technical (Hospital) Services "PANTOPRAZOLE 40 MG TABLET,DELAYED RELEASE" RX-26225 CDM 6370000100 HCPCS 250 RC 65862-0560-90 NDC inpatient 1 UN 5.76 5.76 BLUE CROSS BLUE SHIELD WELLMARK SB889 [3081026] BCBS WYOMING [308102603] 5.47 percent of total billed charges 3.57 5.47 Technical (Hospital) Services DOXYCYCLINE HYCLATE 100 MG CAPSULE RX-2623 CDM 6370000100 HCPCS 250 RC 00143-3142-50 NDC outpatient 1 UN 6.82 6.82 MEDICA (COMMERCIAL) 94265 [3081118] MEDICA CLAIMS [308111801] 6.14 percent of total billed charges 4.23 6.48 Technical (Hospital) Services DOXYCYCLINE HYCLATE 100 MG CAPSULE RX-2623 CDM 6370000100 HCPCS 250 RC 00143-3142-50 NDC outpatient 1 UN 6.82 6.82 CIGNA 62308 [3081051] CIGNA 62308 [308105105] 5.46 percent of total billed charges 4.23 6.48 Technical (Hospital) Services DOXYCYCLINE HYCLATE 100 MG CAPSULE RX-2623 CDM 6370000100 HCPCS 250 RC 00143-3142-50 NDC outpatient 1 UN 6.82 6.82 CIGNA 62308 [3081051] CIGNA STATE OF WYOMING [308105107] 5.46 percent of total billed charges 4.23 6.48 Technical (Hospital) Services DOXYCYCLINE HYCLATE 100 MG CAPSULE RX-2623 CDM 6370000100 HCPCS 250 RC 00143-3142-50 NDC outpatient 1 UN 6.82 6.82 MULTIPLAN INC 34080 [3081285] MULTIPLAN INC [308128501] 6.48 percent of total billed charges 4.23 6.48 Technical (Hospital) Services DOXYCYCLINE HYCLATE 100 MG CAPSULE RX-2623 CDM 6370000100 HCPCS 250 RC 00143-3142-50 NDC outpatient 1 UN 6.82 6.82 UNITED HEALTHCARE (COMMERCIAL) [3081199] UNITED HEALTHCARE 87726 [308119901] 4.23 percent of total billed charges 4.23 6.48 Technical (Hospital) Services DOXYCYCLINE HYCLATE 100 MG CAPSULE RX-2623 CDM 6370000100 HCPCS 250 RC 00143-3142-50 NDC outpatient 1 UN 6.82 6.82 HEALTHPARTNERS SX009 HEALTHPARTNERS 5.46 percent of total billed charges 4.23 6.48 Technical (Hospital) Services DOXYCYCLINE HYCLATE 100 MG CAPSULE RX-2623 CDM 6370000100 HCPCS 250 RC 00143-3142-50 NDC outpatient 1 UN 6.82 6.82 BLUE CROSS BLUE SHIELD WELLMARK SB889 [3081026] BCBS WYOMING [308102603] 6.48 percent of total billed charges 4.23 6.48 Technical (Hospital) Services DOXYCYCLINE HYCLATE 100 MG CAPSULE RX-2623 CDM 6370000100 HCPCS 250 RC 00143-3142-50 NDC outpatient 1 UN 6.82 6.82 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES EPO [308136803] 5.46 percent of total billed charges 4.23 6.48 Technical (Hospital) Services DOXYCYCLINE HYCLATE 100 MG CAPSULE RX-2623 CDM 6370000100 HCPCS 250 RC 00143-3142-50 NDC outpatient 1 UN 6.82 6.82 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES HDHP [308136802] 5.46 percent of total billed charges 4.23 6.48 Technical (Hospital) Services DOXYCYCLINE HYCLATE 100 MG CAPSULE RX-2623 CDM 6370000100 HCPCS 250 RC 00143-3142-50 NDC outpatient 1 UN 6.82 6.82 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES PPO [308136801] 5.46 percent of total billed charges 4.23 6.48 Technical (Hospital) Services DOXYCYCLINE HYCLATE 100 MG CAPSULE RX-2623 CDM 6370000100 HCPCS 250 RC 00143-3142-50 NDC inpatient 1 UN 6.82 6.82 UNITED HEALTHCARE (COMMERCIAL) [3081199] UNITED HEALTHCARE 87726 [308119901] 4.23 percent of total billed charges 4.23 6.48 Technical (Hospital) Services DOXYCYCLINE HYCLATE 100 MG CAPSULE RX-2623 CDM 6370000100 HCPCS 250 RC 00143-3142-50 NDC inpatient 1 UN 6.82 6.82 BLUE CROSS BLUE SHIELD WELLMARK SB889 [3081026] BCBS WYOMING [308102603] 6.48 percent of total billed charges 4.23 6.48 Technical (Hospital) Services DOXYCYCLINE HYCLATE 100 MG CAPSULE RX-2623 CDM 6370000100 HCPCS 250 RC 00143-3142-50 NDC inpatient 1 UN 6.82 6.82 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES EPO [308136803] 5.4 percent of total billed charges 4.23 6.48 Technical (Hospital) Services DOXYCYCLINE HYCLATE 100 MG CAPSULE RX-2623 CDM 6370000100 HCPCS 250 RC 00143-3142-50 NDC inpatient 1 UN 6.82 6.82 CIGNA 62308 [3081051] CIGNA 62308 [308105105] 5.4 percent of total billed charges 4.23 6.48 Technical (Hospital) Services DOXYCYCLINE HYCLATE 100 MG CAPSULE RX-2623 CDM 6370000100 HCPCS 250 RC 00143-3142-50 NDC inpatient 1 UN 6.82 6.82 CIGNA 62308 [3081051] CIGNA STATE OF WYOMING [308105107] 5.4 percent of total billed charges 4.23 6.48 Technical (Hospital) Services DOXYCYCLINE HYCLATE 100 MG CAPSULE RX-2623 CDM 6370000100 HCPCS 250 RC 00143-3142-50 NDC inpatient 1 UN 6.82 6.82 HEALTHPARTNERS SX009 HEALTHPARTNERS 5.4 percent of total billed charges 4.23 6.48 Technical (Hospital) Services DOXYCYCLINE HYCLATE 100 MG CAPSULE RX-2623 CDM 6370000100 HCPCS 250 RC 00143-3142-50 NDC inpatient 1 UN 6.82 6.82 MEDICA (COMMERCIAL) 94265 [3081118] MEDICA CLAIMS [308111801] 6.14 percent of total billed charges 4.23 6.48 Technical (Hospital) Services DOXYCYCLINE HYCLATE 100 MG CAPSULE RX-2623 CDM 6370000100 HCPCS 250 RC 00143-3142-50 NDC inpatient 1 UN 6.82 6.82 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES HDHP [308136802] 5.4 percent of total billed charges 4.23 6.48 Technical (Hospital) Services DOXYCYCLINE HYCLATE 100 MG CAPSULE RX-2623 CDM 6370000100 HCPCS 250 RC 00143-3142-50 NDC inpatient 1 UN 6.82 6.82 MULTIPLAN INC 34080 [3081285] MULTIPLAN INC [308128501] 6.48 percent of total billed charges 4.23 6.48 Technical (Hospital) Services DOXYCYCLINE HYCLATE 100 MG CAPSULE RX-2623 CDM 6370000100 HCPCS 250 RC 00143-3142-50 NDC inpatient 1 UN 6.82 6.82 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES PPO [308136801] 5.4 percent of total billed charges 4.23 6.48 Technical (Hospital) Services OSELTAMIVIR 75 MG CAPSULE RX-26546 CDM 6370000100 HCPCS 250 RC 00004-0800-85 NDC inpatient 1 UN 54.19 54.19 BLUE CROSS BLUE SHIELD WELLMARK SB889 [3081026] BCBS WYOMING [308102603] 51.48 percent of total billed charges 33.6 51.48 Technical (Hospital) Services OSELTAMIVIR 75 MG CAPSULE RX-26546 CDM 6370000100 HCPCS 250 RC 00004-0800-85 NDC inpatient 1 UN 54.19 54.19 UNITED HEALTHCARE (COMMERCIAL) [3081199] UNITED HEALTHCARE 87726 [308119901] 33.6 percent of total billed charges 33.6 51.48 Technical (Hospital) Services OSELTAMIVIR 75 MG CAPSULE RX-26546 CDM 6370000100 HCPCS 250 RC 00004-0800-85 NDC inpatient 1 UN 54.19 54.19 HEALTHPARTNERS SX009 HEALTHPARTNERS 42.91 percent of total billed charges 33.6 51.48 Technical (Hospital) Services OSELTAMIVIR 75 MG CAPSULE RX-26546 CDM 6370000100 HCPCS 250 RC 00004-0800-85 NDC inpatient 1 UN 54.19 54.19 MEDICA (COMMERCIAL) 94265 [3081118] MEDICA CLAIMS [308111801] 48.77 percent of total billed charges 33.6 51.48 Technical (Hospital) Services OSELTAMIVIR 75 MG CAPSULE RX-26546 CDM 6370000100 HCPCS 250 RC 00004-0800-85 NDC inpatient 1 UN 54.19 54.19 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES HDHP [308136802] 42.91 percent of total billed charges 33.6 51.48 Technical (Hospital) Services OSELTAMIVIR 75 MG CAPSULE RX-26546 CDM 6370000100 HCPCS 250 RC 00004-0800-85 NDC inpatient 1 UN 54.19 54.19 CIGNA 62308 [3081051] CIGNA 62308 [308105105] 42.91 percent of total billed charges 33.6 51.48 Technical (Hospital) Services OSELTAMIVIR 75 MG CAPSULE RX-26546 CDM 6370000100 HCPCS 250 RC 00004-0800-85 NDC inpatient 1 UN 54.19 54.19 CIGNA 62308 [3081051] CIGNA STATE OF WYOMING [308105107] 42.91 percent of total billed charges 33.6 51.48 Technical (Hospital) Services OSELTAMIVIR 75 MG CAPSULE RX-26546 CDM 6370000100 HCPCS 250 RC 00004-0800-85 NDC inpatient 1 UN 54.19 54.19 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES EPO [308136803] 42.91 percent of total billed charges 33.6 51.48 Technical (Hospital) Services OSELTAMIVIR 75 MG CAPSULE RX-26546 CDM 6370000100 HCPCS 250 RC 00004-0800-85 NDC inpatient 1 UN 54.19 54.19 MULTIPLAN INC 34080 [3081285] MULTIPLAN INC [308128501] 51.48 percent of total billed charges 33.6 51.48 Technical (Hospital) Services OSELTAMIVIR 75 MG CAPSULE RX-26546 CDM 6370000100 HCPCS 250 RC 00004-0800-85 NDC inpatient 1 UN 54.19 54.19 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES PPO [308136801] 42.91 percent of total billed charges 33.6 51.48 Technical (Hospital) Services OSELTAMIVIR 75 MG CAPSULE RX-26546 CDM 6370000100 HCPCS 250 RC 00004-0800-85 NDC outpatient 1 UN 54.19 54.19 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES EPO [308136803] 43.35 percent of total billed charges 33.6 51.48 Technical (Hospital) Services OSELTAMIVIR 75 MG CAPSULE RX-26546 CDM 6370000100 HCPCS 250 RC 00004-0800-85 NDC outpatient 1 UN 54.19 54.19 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES HDHP [308136802] 43.35 percent of total billed charges 33.6 51.48 Technical (Hospital) Services OSELTAMIVIR 75 MG CAPSULE RX-26546 CDM 6370000100 HCPCS 250 RC 00004-0800-85 NDC outpatient 1 UN 54.19 54.19 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES PPO [308136801] 43.35 percent of total billed charges 33.6 51.48 Technical (Hospital) Services OSELTAMIVIR 75 MG CAPSULE RX-26546 CDM 6370000100 HCPCS 250 RC 00004-0800-85 NDC outpatient 1 UN 54.19 54.19 MULTIPLAN INC 34080 [3081285] MULTIPLAN INC [308128501] 51.48 percent of total billed charges 33.6 51.48 Technical (Hospital) Services OSELTAMIVIR 75 MG CAPSULE RX-26546 CDM 6370000100 HCPCS 250 RC 00004-0800-85 NDC outpatient 1 UN 54.19 54.19 CIGNA 62308 [3081051] CIGNA 62308 [308105105] 43.35 percent of total billed charges 33.6 51.48 Technical (Hospital) Services OSELTAMIVIR 75 MG CAPSULE RX-26546 CDM 6370000100 HCPCS 250 RC 00004-0800-85 NDC outpatient 1 UN 54.19 54.19 CIGNA 62308 [3081051] CIGNA STATE OF WYOMING [308105107] 43.35 percent of total billed charges 33.6 51.48 Technical (Hospital) Services OSELTAMIVIR 75 MG CAPSULE RX-26546 CDM 6370000100 HCPCS 250 RC 00004-0800-85 NDC outpatient 1 UN 54.19 54.19 UNITED HEALTHCARE (COMMERCIAL) [3081199] UNITED HEALTHCARE 87726 [308119901] 33.6 percent of total billed charges 33.6 51.48 Technical (Hospital) Services OSELTAMIVIR 75 MG CAPSULE RX-26546 CDM 6370000100 HCPCS 250 RC 00004-0800-85 NDC outpatient 1 UN 54.19 54.19 MEDICA (COMMERCIAL) 94265 [3081118] MEDICA CLAIMS [308111801] 48.77 percent of total billed charges 33.6 51.48 Technical (Hospital) Services OSELTAMIVIR 75 MG CAPSULE RX-26546 CDM 6370000100 HCPCS 250 RC 00004-0800-85 NDC outpatient 1 UN 54.19 54.19 BLUE CROSS BLUE SHIELD WELLMARK SB889 [3081026] BCBS WYOMING [308102603] 51.48 percent of total billed charges 33.6 51.48 Technical (Hospital) Services OSELTAMIVIR 75 MG CAPSULE RX-26546 CDM 6370000100 HCPCS 250 RC 00004-0800-85 NDC outpatient 1 UN 54.19 54.19 HEALTHPARTNERS SX009 HEALTHPARTNERS 43.35 percent of total billed charges 33.6 51.48 Technical (Hospital) Services LEVETIRACETAM 500 MG TABLET RX-26817 CDM 6370000100 HCPCS 250 RC 51079-0821-01 NDC outpatient 1 UN 6.2 6.2 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES PPO [308136801] 4.96 percent of total billed charges 3.84 5.89 Technical (Hospital) Services LEVETIRACETAM 500 MG TABLET RX-26817 CDM 6370000100 HCPCS 250 RC 51079-0821-01 NDC outpatient 1 UN 6.2 6.2 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES EPO [308136803] 4.96 percent of total billed charges 3.84 5.89 Technical (Hospital) Services LEVETIRACETAM 500 MG TABLET RX-26817 CDM 6370000100 HCPCS 250 RC 51079-0821-01 NDC outpatient 1 UN 6.2 6.2 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES HDHP [308136802] 4.96 percent of total billed charges 3.84 5.89 Technical (Hospital) Services LEVETIRACETAM 500 MG TABLET RX-26817 CDM 6370000100 HCPCS 250 RC 51079-0821-01 NDC outpatient 1 UN 6.2 6.2 MEDICA (COMMERCIAL) 94265 [3081118] MEDICA CLAIMS [308111801] 5.58 percent of total billed charges 3.84 5.89 Technical (Hospital) Services LEVETIRACETAM 500 MG TABLET RX-26817 CDM 6370000100 HCPCS 250 RC 51079-0821-01 NDC outpatient 1 UN 6.2 6.2 MULTIPLAN INC 34080 [3081285] MULTIPLAN INC [308128501] 5.89 percent of total billed charges 3.84 5.89 Technical (Hospital) Services LEVETIRACETAM 500 MG TABLET RX-26817 CDM 6370000100 HCPCS 250 RC 51079-0821-01 NDC outpatient 1 UN 6.2 6.2 CIGNA 62308 [3081051] CIGNA 62308 [308105105] 4.96 percent of total billed charges 3.84 5.89 Technical (Hospital) Services LEVETIRACETAM 500 MG TABLET RX-26817 CDM 6370000100 HCPCS 250 RC 51079-0821-01 NDC outpatient 1 UN 6.2 6.2 CIGNA 62308 [3081051] CIGNA STATE OF WYOMING [308105107] 4.96 percent of total billed charges 3.84 5.89 Technical (Hospital) Services LEVETIRACETAM 500 MG TABLET RX-26817 CDM 6370000100 HCPCS 250 RC 51079-0821-01 NDC outpatient 1 UN 6.2 6.2 UNITED HEALTHCARE (COMMERCIAL) [3081199] UNITED HEALTHCARE 87726 [308119901] 3.84 percent of total billed charges 3.84 5.89 Technical (Hospital) Services LEVETIRACETAM 500 MG TABLET RX-26817 CDM 6370000100 HCPCS 250 RC 51079-0821-01 NDC outpatient 1 UN 6.2 6.2 HEALTHPARTNERS SX009 HEALTHPARTNERS 4.96 percent of total billed charges 3.84 5.89 Technical (Hospital) Services LEVETIRACETAM 500 MG TABLET RX-26817 CDM 6370000100 HCPCS 250 RC 51079-0821-01 NDC outpatient 1 UN 6.2 6.2 BLUE CROSS BLUE SHIELD WELLMARK SB889 [3081026] BCBS WYOMING [308102603] 5.89 percent of total billed charges 3.84 5.89 Technical (Hospital) Services LEVETIRACETAM 500 MG TABLET RX-26817 CDM 6370000100 HCPCS 250 RC 51079-0821-01 NDC inpatient 1 UN 6.2 6.2 UNITED HEALTHCARE (COMMERCIAL) [3081199] UNITED HEALTHCARE 87726 [308119901] 3.84 percent of total billed charges 3.84 5.89 Technical (Hospital) Services LEVETIRACETAM 500 MG TABLET RX-26817 CDM 6370000100 HCPCS 250 RC 51079-0821-01 NDC inpatient 1 UN 6.2 6.2 BLUE CROSS BLUE SHIELD WELLMARK SB889 [3081026] BCBS WYOMING [308102603] 5.89 percent of total billed charges 3.84 5.89 Technical (Hospital) Services LEVETIRACETAM 500 MG TABLET RX-26817 CDM 6370000100 HCPCS 250 RC 51079-0821-01 NDC inpatient 1 UN 6.2 6.2 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES HDHP [308136802] 4.91 percent of total billed charges 3.84 5.89 Technical (Hospital) Services LEVETIRACETAM 500 MG TABLET RX-26817 CDM 6370000100 HCPCS 250 RC 51079-0821-01 NDC inpatient 1 UN 6.2 6.2 CIGNA 62308 [3081051] CIGNA 62308 [308105105] 4.91 percent of total billed charges 3.84 5.89 Technical (Hospital) Services LEVETIRACETAM 500 MG TABLET RX-26817 CDM 6370000100 HCPCS 250 RC 51079-0821-01 NDC inpatient 1 UN 6.2 6.2 CIGNA 62308 [3081051] CIGNA STATE OF WYOMING [308105107] 4.91 percent of total billed charges 3.84 5.89 Technical (Hospital) Services LEVETIRACETAM 500 MG TABLET RX-26817 CDM 6370000100 HCPCS 250 RC 51079-0821-01 NDC inpatient 1 UN 6.2 6.2 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES EPO [308136803] 4.91 percent of total billed charges 3.84 5.89 Technical (Hospital) Services LEVETIRACETAM 500 MG TABLET RX-26817 CDM 6370000100 HCPCS 250 RC 51079-0821-01 NDC inpatient 1 UN 6.2 6.2 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES PPO [308136801] 4.91 percent of total billed charges 3.84 5.89 Technical (Hospital) Services LEVETIRACETAM 500 MG TABLET RX-26817 CDM 6370000100 HCPCS 250 RC 51079-0821-01 NDC inpatient 1 UN 6.2 6.2 HEALTHPARTNERS SX009 HEALTHPARTNERS 4.91 percent of total billed charges 3.84 5.89 Technical (Hospital) Services LEVETIRACETAM 500 MG TABLET RX-26817 CDM 6370000100 HCPCS 250 RC 51079-0821-01 NDC inpatient 1 UN 6.2 6.2 MEDICA (COMMERCIAL) 94265 [3081118] MEDICA CLAIMS [308111801] 5.58 percent of total billed charges 3.84 5.89 Technical (Hospital) Services LEVETIRACETAM 500 MG TABLET RX-26817 CDM 6370000100 HCPCS 250 RC 51079-0821-01 NDC inpatient 1 UN 6.2 6.2 MULTIPLAN INC 34080 [3081285] MULTIPLAN INC [308128501] 5.89 percent of total billed charges 3.84 5.89 Technical (Hospital) Services DOFETILIDE 250 MCG CAPSULE RX-26966 CDM 6370000100 HCPCS 250 RC 47335-0062-86 NDC outpatient 1 UN 7.22 7.22 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES HDHP [308136802] 5.78 percent of total billed charges 4.48 6.86 Technical (Hospital) Services DOFETILIDE 250 MCG CAPSULE RX-26966 CDM 6370000100 HCPCS 250 RC 47335-0062-86 NDC outpatient 1 UN 7.22 7.22 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES EPO [308136803] 5.78 percent of total billed charges 4.48 6.86 Technical (Hospital) Services DOFETILIDE 250 MCG CAPSULE RX-26966 CDM 6370000100 HCPCS 250 RC 47335-0062-86 NDC outpatient 1 UN 7.22 7.22 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES PPO [308136801] 5.78 percent of total billed charges 4.48 6.86 Technical (Hospital) Services DOFETILIDE 250 MCG CAPSULE RX-26966 CDM 6370000100 HCPCS 250 RC 47335-0062-86 NDC outpatient 1 UN 7.22 7.22 BLUE CROSS BLUE SHIELD WELLMARK SB889 [3081026] BCBS WYOMING [308102603] 6.86 percent of total billed charges 4.48 6.86 Technical (Hospital) Services DOFETILIDE 250 MCG CAPSULE RX-26966 CDM 6370000100 HCPCS 250 RC 47335-0062-86 NDC outpatient 1 UN 7.22 7.22 HEALTHPARTNERS SX009 HEALTHPARTNERS 5.78 percent of total billed charges 4.48 6.86 Technical (Hospital) Services DOFETILIDE 250 MCG CAPSULE RX-26966 CDM 6370000100 HCPCS 250 RC 47335-0062-86 NDC outpatient 1 UN 7.22 7.22 CIGNA 62308 [3081051] CIGNA 62308 [308105105] 5.78 percent of total billed charges 4.48 6.86 Technical (Hospital) Services DOFETILIDE 250 MCG CAPSULE RX-26966 CDM 6370000100 HCPCS 250 RC 47335-0062-86 NDC outpatient 1 UN 7.22 7.22 CIGNA 62308 [3081051] CIGNA STATE OF WYOMING [308105107] 5.78 percent of total billed charges 4.48 6.86 Technical (Hospital) Services DOFETILIDE 250 MCG CAPSULE RX-26966 CDM 6370000100 HCPCS 250 RC 47335-0062-86 NDC outpatient 1 UN 7.22 7.22 MULTIPLAN INC 34080 [3081285] MULTIPLAN INC [308128501] 6.86 percent of total billed charges 4.48 6.86 Technical (Hospital) Services DOFETILIDE 250 MCG CAPSULE RX-26966 CDM 6370000100 HCPCS 250 RC 47335-0062-86 NDC outpatient 1 UN 7.22 7.22 UNITED HEALTHCARE (COMMERCIAL) [3081199] UNITED HEALTHCARE 87726 [308119901] 4.48 percent of total billed charges 4.48 6.86 Technical (Hospital) Services DOFETILIDE 250 MCG CAPSULE RX-26966 CDM 6370000100 HCPCS 250 RC 47335-0062-86 NDC outpatient 1 UN 7.22 7.22 MEDICA (COMMERCIAL) 94265 [3081118] MEDICA CLAIMS [308111801] 6.5 percent of total billed charges 4.48 6.86 Technical (Hospital) Services DOFETILIDE 250 MCG CAPSULE RX-26966 CDM 6370000100 HCPCS 250 RC 47335-0062-86 NDC inpatient 1 UN 7.22 7.22 CIGNA 62308 [3081051] CIGNA 62308 [308105105] 5.72 percent of total billed charges 4.48 6.86 Technical (Hospital) Services DOFETILIDE 250 MCG CAPSULE RX-26966 CDM 6370000100 HCPCS 250 RC 47335-0062-86 NDC inpatient 1 UN 7.22 7.22 CIGNA 62308 [3081051] CIGNA STATE OF WYOMING [308105107] 5.72 percent of total billed charges 4.48 6.86 Technical (Hospital) Services DOFETILIDE 250 MCG CAPSULE RX-26966 CDM 6370000100 HCPCS 250 RC 47335-0062-86 NDC inpatient 1 UN 7.22 7.22 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES EPO [308136803] 5.72 percent of total billed charges 4.48 6.86 Technical (Hospital) Services DOFETILIDE 250 MCG CAPSULE RX-26966 CDM 6370000100 HCPCS 250 RC 47335-0062-86 NDC inpatient 1 UN 7.22 7.22 BLUE CROSS BLUE SHIELD WELLMARK SB889 [3081026] BCBS WYOMING [308102603] 6.86 percent of total billed charges 4.48 6.86 Technical (Hospital) Services DOFETILIDE 250 MCG CAPSULE RX-26966 CDM 6370000100 HCPCS 250 RC 47335-0062-86 NDC inpatient 1 UN 7.22 7.22 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES HDHP [308136802] 5.72 percent of total billed charges 4.48 6.86 Technical (Hospital) Services DOFETILIDE 250 MCG CAPSULE RX-26966 CDM 6370000100 HCPCS 250 RC 47335-0062-86 NDC inpatient 1 UN 7.22 7.22 UNITED HEALTHCARE (COMMERCIAL) [3081199] UNITED HEALTHCARE 87726 [308119901] 4.48 percent of total billed charges 4.48 6.86 Technical (Hospital) Services DOFETILIDE 250 MCG CAPSULE RX-26966 CDM 6370000100 HCPCS 250 RC 47335-0062-86 NDC inpatient 1 UN 7.22 7.22 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES PPO [308136801] 5.72 percent of total billed charges 4.48 6.86 Technical (Hospital) Services DOFETILIDE 250 MCG CAPSULE RX-26966 CDM 6370000100 HCPCS 250 RC 47335-0062-86 NDC inpatient 1 UN 7.22 7.22 HEALTHPARTNERS SX009 HEALTHPARTNERS 5.72 percent of total billed charges 4.48 6.86 Technical (Hospital) Services DOFETILIDE 250 MCG CAPSULE RX-26966 CDM 6370000100 HCPCS 250 RC 47335-0062-86 NDC inpatient 1 UN 7.22 7.22 MEDICA (COMMERCIAL) 94265 [3081118] MEDICA CLAIMS [308111801] 6.5 percent of total billed charges 4.48 6.86 Technical (Hospital) Services DOFETILIDE 250 MCG CAPSULE RX-26966 CDM 6370000100 HCPCS 250 RC 47335-0062-86 NDC inpatient 1 UN 7.22 7.22 MULTIPLAN INC 34080 [3081285] MULTIPLAN INC [308128501] 6.86 percent of total billed charges 4.48 6.86 Technical (Hospital) Services CICLOPIROX 8 % TOPICAL SOLUTION RX-27158 CDM 6370000100 HCPCS 250 RC 51672-5302-00 NDC inpatient 6.6 ML 34 34 HEALTHPARTNERS SX009 HEALTHPARTNERS 26.92 percent of total billed charges 21.08 32.3 Technical (Hospital) Services CICLOPIROX 8 % TOPICAL SOLUTION RX-27158 CDM 6370000100 HCPCS 250 RC 51672-5302-00 NDC inpatient 6.6 ML 34 34 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES EPO [308136803] 26.92 percent of total billed charges 21.08 32.3 Technical (Hospital) Services CICLOPIROX 8 % TOPICAL SOLUTION RX-27158 CDM 6370000100 HCPCS 250 RC 51672-5302-00 NDC inpatient 6.6 ML 34 34 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES HDHP [308136802] 26.92 percent of total billed charges 21.08 32.3 Technical (Hospital) Services CICLOPIROX 8 % TOPICAL SOLUTION RX-27158 CDM 6370000100 HCPCS 250 RC 51672-5302-00 NDC inpatient 6.6 ML 34 34 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES PPO [308136801] 26.92 percent of total billed charges 21.08 32.3 Technical (Hospital) Services CICLOPIROX 8 % TOPICAL SOLUTION RX-27158 CDM 6370000100 HCPCS 250 RC 51672-5302-00 NDC inpatient 6.6 ML 34 34 MEDICA (COMMERCIAL) 94265 [3081118] MEDICA CLAIMS [308111801] 30.6 percent of total billed charges 21.08 32.3 Technical (Hospital) Services CICLOPIROX 8 % TOPICAL SOLUTION RX-27158 CDM 6370000100 HCPCS 250 RC 51672-5302-00 NDC inpatient 6.6 ML 34 34 MULTIPLAN INC 34080 [3081285] MULTIPLAN INC [308128501] 32.3 percent of total billed charges 21.08 32.3 Technical (Hospital) Services CICLOPIROX 8 % TOPICAL SOLUTION RX-27158 CDM 6370000100 HCPCS 250 RC 51672-5302-00 NDC inpatient 6.6 ML 34 34 CIGNA 62308 [3081051] CIGNA 62308 [308105105] 26.92 percent of total billed charges 21.08 32.3 Technical (Hospital) Services CICLOPIROX 8 % TOPICAL SOLUTION RX-27158 CDM 6370000100 HCPCS 250 RC 51672-5302-00 NDC inpatient 6.6 ML 34 34 CIGNA 62308 [3081051] CIGNA STATE OF WYOMING [308105107] 26.92 percent of total billed charges 21.08 32.3 Technical (Hospital) Services CICLOPIROX 8 % TOPICAL SOLUTION RX-27158 CDM 6370000100 HCPCS 250 RC 51672-5302-00 NDC inpatient 6.6 ML 34 34 BLUE CROSS BLUE SHIELD WELLMARK SB889 [3081026] BCBS WYOMING [308102603] 32.3 percent of total billed charges 21.08 32.3 Technical (Hospital) Services CICLOPIROX 8 % TOPICAL SOLUTION RX-27158 CDM 6370000100 HCPCS 250 RC 51672-5302-00 NDC inpatient 6.6 ML 34 34 UNITED HEALTHCARE (COMMERCIAL) [3081199] UNITED HEALTHCARE 87726 [308119901] 21.08 percent of total billed charges 21.08 32.3 Technical (Hospital) Services CICLOPIROX 8 % TOPICAL SOLUTION RX-27158 CDM 6370000100 HCPCS 250 RC 51672-5302-00 NDC outpatient 6.6 ML 34 34 MULTIPLAN INC 34080 [3081285] MULTIPLAN INC [308128501] 32.3 percent of total billed charges 21.08 32.3 Technical (Hospital) Services CICLOPIROX 8 % TOPICAL SOLUTION RX-27158 CDM 6370000100 HCPCS 250 RC 51672-5302-00 NDC outpatient 6.6 ML 34 34 MEDICA (COMMERCIAL) 94265 [3081118] MEDICA CLAIMS [308111801] 30.6 percent of total billed charges 21.08 32.3 Technical (Hospital) Services CICLOPIROX 8 % TOPICAL SOLUTION RX-27158 CDM 6370000100 HCPCS 250 RC 51672-5302-00 NDC outpatient 6.6 ML 34 34 CIGNA 62308 [3081051] CIGNA 62308 [308105105] 27.2 percent of total billed charges 21.08 32.3 Technical (Hospital) Services CICLOPIROX 8 % TOPICAL SOLUTION RX-27158 CDM 6370000100 HCPCS 250 RC 51672-5302-00 NDC outpatient 6.6 ML 34 34 CIGNA 62308 [3081051] CIGNA STATE OF WYOMING [308105107] 27.2 percent of total billed charges 21.08 32.3 Technical (Hospital) Services CICLOPIROX 8 % TOPICAL SOLUTION RX-27158 CDM 6370000100 HCPCS 250 RC 51672-5302-00 NDC outpatient 6.6 ML 34 34 HEALTHPARTNERS SX009 HEALTHPARTNERS 27.2 percent of total billed charges 21.08 32.3 Technical (Hospital) Services CICLOPIROX 8 % TOPICAL SOLUTION RX-27158 CDM 6370000100 HCPCS 250 RC 51672-5302-00 NDC outpatient 6.6 ML 34 34 BLUE CROSS BLUE SHIELD WELLMARK SB889 [3081026] BCBS WYOMING [308102603] 32.3 percent of total billed charges 21.08 32.3 Technical (Hospital) Services CICLOPIROX 8 % TOPICAL SOLUTION RX-27158 CDM 6370000100 HCPCS 250 RC 51672-5302-00 NDC outpatient 6.6 ML 34 34 UNITED HEALTHCARE (COMMERCIAL) [3081199] UNITED HEALTHCARE 87726 [308119901] 21.08 percent of total billed charges 21.08 32.3 Technical (Hospital) Services CICLOPIROX 8 % TOPICAL SOLUTION RX-27158 CDM 6370000100 HCPCS 250 RC 51672-5302-00 NDC outpatient 6.6 ML 34 34 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES EPO [308136803] 27.2 percent of total billed charges 21.08 32.3 Technical (Hospital) Services CICLOPIROX 8 % TOPICAL SOLUTION RX-27158 CDM 6370000100 HCPCS 250 RC 51672-5302-00 NDC outpatient 6.6 ML 34 34 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES HDHP [308136802] 27.2 percent of total billed charges 21.08 32.3 Technical (Hospital) Services CICLOPIROX 8 % TOPICAL SOLUTION RX-27158 CDM 6370000100 HCPCS 250 RC 51672-5302-00 NDC outpatient 6.6 ML 34 34 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES PPO [308136801] 27.2 percent of total billed charges 21.08 32.3 Technical (Hospital) Services MONTELUKAST 4 MG CHEWABLE TABLET RX-27234 CDM 6370000100 HCPCS 250 RC 33342-0110-10 NDC outpatient 1 UN 6.12 6.12 MEDICA (COMMERCIAL) 94265 [3081118] MEDICA CLAIMS [308111801] 5.51 percent of total billed charges 3.79 5.81 Technical (Hospital) Services MONTELUKAST 4 MG CHEWABLE TABLET RX-27234 CDM 6370000100 HCPCS 250 RC 33342-0110-10 NDC outpatient 1 UN 6.12 6.12 CIGNA 62308 [3081051] CIGNA 62308 [308105105] 4.9 percent of total billed charges 3.79 5.81 Technical (Hospital) Services MONTELUKAST 4 MG CHEWABLE TABLET RX-27234 CDM 6370000100 HCPCS 250 RC 33342-0110-10 NDC outpatient 1 UN 6.12 6.12 CIGNA 62308 [3081051] CIGNA STATE OF WYOMING [308105107] 4.9 percent of total billed charges 3.79 5.81 Technical (Hospital) Services MONTELUKAST 4 MG CHEWABLE TABLET RX-27234 CDM 6370000100 HCPCS 250 RC 33342-0110-10 NDC outpatient 1 UN 6.12 6.12 MULTIPLAN INC 34080 [3081285] MULTIPLAN INC [308128501] 5.81 percent of total billed charges 3.79 5.81 Technical (Hospital) Services MONTELUKAST 4 MG CHEWABLE TABLET RX-27234 CDM 6370000100 HCPCS 250 RC 33342-0110-10 NDC outpatient 1 UN 6.12 6.12 UNITED HEALTHCARE (COMMERCIAL) [3081199] UNITED HEALTHCARE 87726 [308119901] 3.79 percent of total billed charges 3.79 5.81 Technical (Hospital) Services MONTELUKAST 4 MG CHEWABLE TABLET RX-27234 CDM 6370000100 HCPCS 250 RC 33342-0110-10 NDC outpatient 1 UN 6.12 6.12 HEALTHPARTNERS SX009 HEALTHPARTNERS 4.9 percent of total billed charges 3.79 5.81 Technical (Hospital) Services MONTELUKAST 4 MG CHEWABLE TABLET RX-27234 CDM 6370000100 HCPCS 250 RC 33342-0110-10 NDC outpatient 1 UN 6.12 6.12 BLUE CROSS BLUE SHIELD WELLMARK SB889 [3081026] BCBS WYOMING [308102603] 5.81 percent of total billed charges 3.79 5.81 Technical (Hospital) Services MONTELUKAST 4 MG CHEWABLE TABLET RX-27234 CDM 6370000100 HCPCS 250 RC 33342-0110-10 NDC outpatient 1 UN 6.12 6.12 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES PPO [308136801] 4.9 percent of total billed charges 3.79 5.81 Technical (Hospital) Services MONTELUKAST 4 MG CHEWABLE TABLET RX-27234 CDM 6370000100 HCPCS 250 RC 33342-0110-10 NDC outpatient 1 UN 6.12 6.12 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES HDHP [308136802] 4.9 percent of total billed charges 3.79 5.81 Technical (Hospital) Services MONTELUKAST 4 MG CHEWABLE TABLET RX-27234 CDM 6370000100 HCPCS 250 RC 33342-0110-10 NDC outpatient 1 UN 6.12 6.12 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES EPO [308136803] 4.9 percent of total billed charges 3.79 5.81 Technical (Hospital) Services MONTELUKAST 4 MG CHEWABLE TABLET RX-27234 CDM 6370000100 HCPCS 250 RC 33342-0110-10 NDC inpatient 1 UN 6.12 6.12 HEALTHPARTNERS SX009 HEALTHPARTNERS 4.85 percent of total billed charges 3.79 5.81 Technical (Hospital) Services MONTELUKAST 4 MG CHEWABLE TABLET RX-27234 CDM 6370000100 HCPCS 250 RC 33342-0110-10 NDC inpatient 1 UN 6.12 6.12 MEDICA (COMMERCIAL) 94265 [3081118] MEDICA CLAIMS [308111801] 5.51 percent of total billed charges 3.79 5.81 Technical (Hospital) Services MONTELUKAST 4 MG CHEWABLE TABLET RX-27234 CDM 6370000100 HCPCS 250 RC 33342-0110-10 NDC inpatient 1 UN 6.12 6.12 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES PPO [308136801] 4.85 percent of total billed charges 3.79 5.81 Technical (Hospital) Services MONTELUKAST 4 MG CHEWABLE TABLET RX-27234 CDM 6370000100 HCPCS 250 RC 33342-0110-10 NDC inpatient 1 UN 6.12 6.12 MULTIPLAN INC 34080 [3081285] MULTIPLAN INC [308128501] 5.81 percent of total billed charges 3.79 5.81 Technical (Hospital) Services MONTELUKAST 4 MG CHEWABLE TABLET RX-27234 CDM 6370000100 HCPCS 250 RC 33342-0110-10 NDC inpatient 1 UN 6.12 6.12 UNITED HEALTHCARE (COMMERCIAL) [3081199] UNITED HEALTHCARE 87726 [308119901] 3.79 percent of total billed charges 3.79 5.81 Technical (Hospital) Services MONTELUKAST 4 MG CHEWABLE TABLET RX-27234 CDM 6370000100 HCPCS 250 RC 33342-0110-10 NDC inpatient 1 UN 6.12 6.12 BLUE CROSS BLUE SHIELD WELLMARK SB889 [3081026] BCBS WYOMING [308102603] 5.81 percent of total billed charges 3.79 5.81 Technical (Hospital) Services MONTELUKAST 4 MG CHEWABLE TABLET RX-27234 CDM 6370000100 HCPCS 250 RC 33342-0110-10 NDC inpatient 1 UN 6.12 6.12 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES EPO [308136803] 4.85 percent of total billed charges 3.79 5.81 Technical (Hospital) Services MONTELUKAST 4 MG CHEWABLE TABLET RX-27234 CDM 6370000100 HCPCS 250 RC 33342-0110-10 NDC inpatient 1 UN 6.12 6.12 CIGNA 62308 [3081051] CIGNA 62308 [308105105] 4.85 percent of total billed charges 3.79 5.81 Technical (Hospital) Services MONTELUKAST 4 MG CHEWABLE TABLET RX-27234 CDM 6370000100 HCPCS 250 RC 33342-0110-10 NDC inpatient 1 UN 6.12 6.12 CIGNA 62308 [3081051] CIGNA STATE OF WYOMING [308105107] 4.85 percent of total billed charges 3.79 5.81 Technical (Hospital) Services MONTELUKAST 4 MG CHEWABLE TABLET RX-27234 CDM 6370000100 HCPCS 250 RC 33342-0110-10 NDC inpatient 1 UN 6.12 6.12 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES HDHP [308136802] 4.85 percent of total billed charges 3.79 5.81 Technical (Hospital) Services "THEOPHYLLINE ER 200 MG CAPSULE,EXTENDED RELEASE 24 HR" RX-27419 CDM 6370000100 HCPCS 250 RC 52244-0200-10 NDC outpatient 1 UN 23.93 23.93 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES PPO [308136801] 19.14 percent of total billed charges 14.84 22.73 Technical (Hospital) Services "THEOPHYLLINE ER 200 MG CAPSULE,EXTENDED RELEASE 24 HR" RX-27419 CDM 6370000100 HCPCS 250 RC 52244-0200-10 NDC outpatient 1 UN 23.93 23.93 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES HDHP [308136802] 19.14 percent of total billed charges 14.84 22.73 Technical (Hospital) Services "THEOPHYLLINE ER 200 MG CAPSULE,EXTENDED RELEASE 24 HR" RX-27419 CDM 6370000100 HCPCS 250 RC 52244-0200-10 NDC outpatient 1 UN 23.93 23.93 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES EPO [308136803] 19.14 percent of total billed charges 14.84 22.73 Technical (Hospital) Services "THEOPHYLLINE ER 200 MG CAPSULE,EXTENDED RELEASE 24 HR" RX-27419 CDM 6370000100 HCPCS 250 RC 52244-0200-10 NDC outpatient 1 UN 23.93 23.93 MEDICA (COMMERCIAL) 94265 [3081118] MEDICA CLAIMS [308111801] 21.54 percent of total billed charges 14.84 22.73 Technical (Hospital) Services "THEOPHYLLINE ER 200 MG CAPSULE,EXTENDED RELEASE 24 HR" RX-27419 CDM 6370000100 HCPCS 250 RC 52244-0200-10 NDC outpatient 1 UN 23.93 23.93 CIGNA 62308 [3081051] CIGNA 62308 [308105105] 19.14 percent of total billed charges 14.84 22.73 Technical (Hospital) Services "THEOPHYLLINE ER 200 MG CAPSULE,EXTENDED RELEASE 24 HR" RX-27419 CDM 6370000100 HCPCS 250 RC 52244-0200-10 NDC outpatient 1 UN 23.93 23.93 CIGNA 62308 [3081051] CIGNA STATE OF WYOMING [308105107] 19.14 percent of total billed charges 14.84 22.73 Technical (Hospital) Services "THEOPHYLLINE ER 200 MG CAPSULE,EXTENDED RELEASE 24 HR" RX-27419 CDM 6370000100 HCPCS 250 RC 52244-0200-10 NDC outpatient 1 UN 23.93 23.93 MULTIPLAN INC 34080 [3081285] MULTIPLAN INC [308128501] 22.73 percent of total billed charges 14.84 22.73 Technical (Hospital) Services "THEOPHYLLINE ER 200 MG CAPSULE,EXTENDED RELEASE 24 HR" RX-27419 CDM 6370000100 HCPCS 250 RC 52244-0200-10 NDC outpatient 1 UN 23.93 23.93 UNITED HEALTHCARE (COMMERCIAL) [3081199] UNITED HEALTHCARE 87726 [308119901] 14.84 percent of total billed charges 14.84 22.73 Technical (Hospital) Services "THEOPHYLLINE ER 200 MG CAPSULE,EXTENDED RELEASE 24 HR" RX-27419 CDM 6370000100 HCPCS 250 RC 52244-0200-10 NDC outpatient 1 UN 23.93 23.93 BLUE CROSS BLUE SHIELD WELLMARK SB889 [3081026] BCBS WYOMING [308102603] 22.73 percent of total billed charges 14.84 22.73 Technical (Hospital) Services "THEOPHYLLINE ER 200 MG CAPSULE,EXTENDED RELEASE 24 HR" RX-27419 CDM 6370000100 HCPCS 250 RC 52244-0200-10 NDC outpatient 1 UN 23.93 23.93 HEALTHPARTNERS SX009 HEALTHPARTNERS 19.14 percent of total billed charges 14.84 22.73 Technical (Hospital) Services "THEOPHYLLINE ER 200 MG CAPSULE,EXTENDED RELEASE 24 HR" RX-27419 CDM 6370000100 HCPCS 250 RC 52244-0200-10 NDC inpatient 1 UN 23.93 23.93 UNITED HEALTHCARE (COMMERCIAL) [3081199] UNITED HEALTHCARE 87726 [308119901] 14.84 percent of total billed charges 14.84 22.73 Technical (Hospital) Services "THEOPHYLLINE ER 200 MG CAPSULE,EXTENDED RELEASE 24 HR" RX-27419 CDM 6370000100 HCPCS 250 RC 52244-0200-10 NDC inpatient 1 UN 23.93 23.93 BLUE CROSS BLUE SHIELD WELLMARK SB889 [3081026] BCBS WYOMING [308102603] 22.73 percent of total billed charges 14.84 22.73 Technical (Hospital) Services "THEOPHYLLINE ER 200 MG CAPSULE,EXTENDED RELEASE 24 HR" RX-27419 CDM 6370000100 HCPCS 250 RC 52244-0200-10 NDC inpatient 1 UN 23.93 23.93 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES HDHP [308136802] 18.95 percent of total billed charges 14.84 22.73 Technical (Hospital) Services "THEOPHYLLINE ER 200 MG CAPSULE,EXTENDED RELEASE 24 HR" RX-27419 CDM 6370000100 HCPCS 250 RC 52244-0200-10 NDC inpatient 1 UN 23.93 23.93 MEDICA (COMMERCIAL) 94265 [3081118] MEDICA CLAIMS [308111801] 21.54 percent of total billed charges 14.84 22.73 Technical (Hospital) Services "THEOPHYLLINE ER 200 MG CAPSULE,EXTENDED RELEASE 24 HR" RX-27419 CDM 6370000100 HCPCS 250 RC 52244-0200-10 NDC inpatient 1 UN 23.93 23.93 HEALTHPARTNERS SX009 HEALTHPARTNERS 18.95 percent of total billed charges 14.84 22.73 Technical (Hospital) Services "THEOPHYLLINE ER 200 MG CAPSULE,EXTENDED RELEASE 24 HR" RX-27419 CDM 6370000100 HCPCS 250 RC 52244-0200-10 NDC inpatient 1 UN 23.93 23.93 CIGNA 62308 [3081051] CIGNA 62308 [308105105] 18.95 percent of total billed charges 14.84 22.73 Technical (Hospital) Services "THEOPHYLLINE ER 200 MG CAPSULE,EXTENDED RELEASE 24 HR" RX-27419 CDM 6370000100 HCPCS 250 RC 52244-0200-10 NDC inpatient 1 UN 23.93 23.93 CIGNA 62308 [3081051] CIGNA STATE OF WYOMING [308105107] 18.95 percent of total billed charges 14.84 22.73 Technical (Hospital) Services "THEOPHYLLINE ER 200 MG CAPSULE,EXTENDED RELEASE 24 HR" RX-27419 CDM 6370000100 HCPCS 250 RC 52244-0200-10 NDC inpatient 1 UN 23.93 23.93 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES EPO [308136803] 18.95 percent of total billed charges 14.84 22.73 Technical (Hospital) Services "THEOPHYLLINE ER 200 MG CAPSULE,EXTENDED RELEASE 24 HR" RX-27419 CDM 6370000100 HCPCS 250 RC 52244-0200-10 NDC inpatient 1 UN 23.93 23.93 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES PPO [308136801] 18.95 percent of total billed charges 14.84 22.73 Technical (Hospital) Services "THEOPHYLLINE ER 200 MG CAPSULE,EXTENDED RELEASE 24 HR" RX-27419 CDM 6370000100 HCPCS 250 RC 52244-0200-10 NDC inpatient 1 UN 23.93 23.93 MULTIPLAN INC 34080 [3081285] MULTIPLAN INC [308128501] 22.73 percent of total billed charges 14.84 22.73 Technical (Hospital) Services NITROGLYCERIN 0.1 MG/HR TRANSDERMAL 24 HOUR PATCH RX-27471 CDM 6370000100 HCPCS 250 RC 00378-9102-16 NDC outpatient 1 UN 6.23 6.23 HEALTHPARTNERS SX009 HEALTHPARTNERS 4.98 percent of total billed charges 3.86 5.92 Technical (Hospital) Services NITROGLYCERIN 0.1 MG/HR TRANSDERMAL 24 HOUR PATCH RX-27471 CDM 6370000100 HCPCS 250 RC 00378-9102-16 NDC outpatient 1 UN 6.23 6.23 BLUE CROSS BLUE SHIELD WELLMARK SB889 [3081026] BCBS WYOMING [308102603] 5.92 percent of total billed charges 3.86 5.92 Technical (Hospital) Services NITROGLYCERIN 0.1 MG/HR TRANSDERMAL 24 HOUR PATCH RX-27471 CDM 6370000100 HCPCS 250 RC 00378-9102-16 NDC outpatient 1 UN 6.23 6.23 MEDICA (COMMERCIAL) 94265 [3081118] MEDICA CLAIMS [308111801] 5.61 percent of total billed charges 3.86 5.92 Technical (Hospital) Services NITROGLYCERIN 0.1 MG/HR TRANSDERMAL 24 HOUR PATCH RX-27471 CDM 6370000100 HCPCS 250 RC 00378-9102-16 NDC outpatient 1 UN 6.23 6.23 UNITED HEALTHCARE (COMMERCIAL) [3081199] UNITED HEALTHCARE 87726 [308119901] 3.86 percent of total billed charges 3.86 5.92 Technical (Hospital) Services NITROGLYCERIN 0.1 MG/HR TRANSDERMAL 24 HOUR PATCH RX-27471 CDM 6370000100 HCPCS 250 RC 00378-9102-16 NDC outpatient 1 UN 6.23 6.23 CIGNA 62308 [3081051] CIGNA 62308 [308105105] 4.98 percent of total billed charges 3.86 5.92 Technical (Hospital) Services NITROGLYCERIN 0.1 MG/HR TRANSDERMAL 24 HOUR PATCH RX-27471 CDM 6370000100 HCPCS 250 RC 00378-9102-16 NDC outpatient 1 UN 6.23 6.23 CIGNA 62308 [3081051] CIGNA STATE OF WYOMING [308105107] 4.98 percent of total billed charges 3.86 5.92 Technical (Hospital) Services NITROGLYCERIN 0.1 MG/HR TRANSDERMAL 24 HOUR PATCH RX-27471 CDM 6370000100 HCPCS 250 RC 00378-9102-16 NDC outpatient 1 UN 6.23 6.23 MULTIPLAN INC 34080 [3081285] MULTIPLAN INC [308128501] 5.92 percent of total billed charges 3.86 5.92 Technical (Hospital) Services NITROGLYCERIN 0.1 MG/HR TRANSDERMAL 24 HOUR PATCH RX-27471 CDM 6370000100 HCPCS 250 RC 00378-9102-16 NDC outpatient 1 UN 6.23 6.23 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES PPO [308136801] 4.98 percent of total billed charges 3.86 5.92 Technical (Hospital) Services NITROGLYCERIN 0.1 MG/HR TRANSDERMAL 24 HOUR PATCH RX-27471 CDM 6370000100 HCPCS 250 RC 00378-9102-16 NDC outpatient 1 UN 6.23 6.23 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES EPO [308136803] 4.98 percent of total billed charges 3.86 5.92 Technical (Hospital) Services NITROGLYCERIN 0.1 MG/HR TRANSDERMAL 24 HOUR PATCH RX-27471 CDM 6370000100 HCPCS 250 RC 00378-9102-16 NDC outpatient 1 UN 6.23 6.23 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES HDHP [308136802] 4.98 percent of total billed charges 3.86 5.92 Technical (Hospital) Services NITROGLYCERIN 0.1 MG/HR TRANSDERMAL 24 HOUR PATCH RX-27471 CDM 6370000100 HCPCS 250 RC 00378-9102-16 NDC inpatient 1 UN 6.23 6.23 HEALTHPARTNERS SX009 HEALTHPARTNERS 4.93 percent of total billed charges 3.86 5.92 Technical (Hospital) Services NITROGLYCERIN 0.1 MG/HR TRANSDERMAL 24 HOUR PATCH RX-27471 CDM 6370000100 HCPCS 250 RC 00378-9102-16 NDC inpatient 1 UN 6.23 6.23 MEDICA (COMMERCIAL) 94265 [3081118] MEDICA CLAIMS [308111801] 5.61 percent of total billed charges 3.86 5.92 Technical (Hospital) Services NITROGLYCERIN 0.1 MG/HR TRANSDERMAL 24 HOUR PATCH RX-27471 CDM 6370000100 HCPCS 250 RC 00378-9102-16 NDC inpatient 1 UN 6.23 6.23 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES PPO [308136801] 4.93 percent of total billed charges 3.86 5.92 Technical (Hospital) Services NITROGLYCERIN 0.1 MG/HR TRANSDERMAL 24 HOUR PATCH RX-27471 CDM 6370000100 HCPCS 250 RC 00378-9102-16 NDC inpatient 1 UN 6.23 6.23 MULTIPLAN INC 34080 [3081285] MULTIPLAN INC [308128501] 5.92 percent of total billed charges 3.86 5.92 Technical (Hospital) Services NITROGLYCERIN 0.1 MG/HR TRANSDERMAL 24 HOUR PATCH RX-27471 CDM 6370000100 HCPCS 250 RC 00378-9102-16 NDC inpatient 1 UN 6.23 6.23 BLUE CROSS BLUE SHIELD WELLMARK SB889 [3081026] BCBS WYOMING [308102603] 5.92 percent of total billed charges 3.86 5.92 Technical (Hospital) Services NITROGLYCERIN 0.1 MG/HR TRANSDERMAL 24 HOUR PATCH RX-27471 CDM 6370000100 HCPCS 250 RC 00378-9102-16 NDC inpatient 1 UN 6.23 6.23 UNITED HEALTHCARE (COMMERCIAL) [3081199] UNITED HEALTHCARE 87726 [308119901] 3.86 percent of total billed charges 3.86 5.92 Technical (Hospital) Services NITROGLYCERIN 0.1 MG/HR TRANSDERMAL 24 HOUR PATCH RX-27471 CDM 6370000100 HCPCS 250 RC 00378-9102-16 NDC inpatient 1 UN 6.23 6.23 CIGNA 62308 [3081051] CIGNA 62308 [308105105] 4.93 percent of total billed charges 3.86 5.92 Technical (Hospital) Services NITROGLYCERIN 0.1 MG/HR TRANSDERMAL 24 HOUR PATCH RX-27471 CDM 6370000100 HCPCS 250 RC 00378-9102-16 NDC inpatient 1 UN 6.23 6.23 CIGNA 62308 [3081051] CIGNA STATE OF WYOMING [308105107] 4.93 percent of total billed charges 3.86 5.92 Technical (Hospital) Services NITROGLYCERIN 0.1 MG/HR TRANSDERMAL 24 HOUR PATCH RX-27471 CDM 6370000100 HCPCS 250 RC 00378-9102-16 NDC inpatient 1 UN 6.23 6.23 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES EPO [308136803] 4.93 percent of total billed charges 3.86 5.92 Technical (Hospital) Services NITROGLYCERIN 0.1 MG/HR TRANSDERMAL 24 HOUR PATCH RX-27471 CDM 6370000100 HCPCS 250 RC 00378-9102-16 NDC inpatient 1 UN 6.23 6.23 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES HDHP [308136802] 4.93 percent of total billed charges 3.86 5.92 Technical (Hospital) Services NITROGLYCERIN 0.4 MG/HR TRANSDERMAL 24 HOUR PATCH RX-27474 CDM 6370000100 HCPCS 250 RC 00378-9112-93 NDC inpatient 1 UN 6.44 6.44 MULTIPLAN INC 34080 [3081285] MULTIPLAN INC [308128501] 6.12 percent of total billed charges 3.99 6.12 Technical (Hospital) Services NITROGLYCERIN 0.4 MG/HR TRANSDERMAL 24 HOUR PATCH RX-27474 CDM 6370000100 HCPCS 250 RC 00378-9112-93 NDC inpatient 1 UN 6.44 6.44 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES PPO [308136801] 5.1 percent of total billed charges 3.99 6.12 Technical (Hospital) Services NITROGLYCERIN 0.4 MG/HR TRANSDERMAL 24 HOUR PATCH RX-27474 CDM 6370000100 HCPCS 250 RC 00378-9112-93 NDC inpatient 1 UN 6.44 6.44 MEDICA (COMMERCIAL) 94265 [3081118] MEDICA CLAIMS [308111801] 5.8 percent of total billed charges 3.99 6.12 Technical (Hospital) Services NITROGLYCERIN 0.4 MG/HR TRANSDERMAL 24 HOUR PATCH RX-27474 CDM 6370000100 HCPCS 250 RC 00378-9112-93 NDC inpatient 1 UN 6.44 6.44 HEALTHPARTNERS SX009 HEALTHPARTNERS 5.1 percent of total billed charges 3.99 6.12 Technical (Hospital) Services NITROGLYCERIN 0.4 MG/HR TRANSDERMAL 24 HOUR PATCH RX-27474 CDM 6370000100 HCPCS 250 RC 00378-9112-93 NDC inpatient 1 UN 6.44 6.44 UNITED HEALTHCARE (COMMERCIAL) [3081199] UNITED HEALTHCARE 87726 [308119901] 3.99 percent of total billed charges 3.99 6.12 Technical (Hospital) Services NITROGLYCERIN 0.4 MG/HR TRANSDERMAL 24 HOUR PATCH RX-27474 CDM 6370000100 HCPCS 250 RC 00378-9112-93 NDC inpatient 1 UN 6.44 6.44 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES HDHP [308136802] 5.1 percent of total billed charges 3.99 6.12 Technical (Hospital) Services NITROGLYCERIN 0.4 MG/HR TRANSDERMAL 24 HOUR PATCH RX-27474 CDM 6370000100 HCPCS 250 RC 00378-9112-93 NDC inpatient 1 UN 6.44 6.44 BLUE CROSS BLUE SHIELD WELLMARK SB889 [3081026] BCBS WYOMING [308102603] 6.12 percent of total billed charges 3.99 6.12 Technical (Hospital) Services NITROGLYCERIN 0.4 MG/HR TRANSDERMAL 24 HOUR PATCH RX-27474 CDM 6370000100 HCPCS 250 RC 00378-9112-93 NDC inpatient 1 UN 6.44 6.44 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES EPO [308136803] 5.1 percent of total billed charges 3.99 6.12 Technical (Hospital) Services NITROGLYCERIN 0.4 MG/HR TRANSDERMAL 24 HOUR PATCH RX-27474 CDM 6370000100 HCPCS 250 RC 00378-9112-93 NDC inpatient 1 UN 6.44 6.44 CIGNA 62308 [3081051] CIGNA 62308 [308105105] 5.1 percent of total billed charges 3.99 6.12 Technical (Hospital) Services NITROGLYCERIN 0.4 MG/HR TRANSDERMAL 24 HOUR PATCH RX-27474 CDM 6370000100 HCPCS 250 RC 00378-9112-93 NDC inpatient 1 UN 6.44 6.44 CIGNA 62308 [3081051] CIGNA STATE OF WYOMING [308105107] 5.1 percent of total billed charges 3.99 6.12 Technical (Hospital) Services NITROGLYCERIN 0.4 MG/HR TRANSDERMAL 24 HOUR PATCH RX-27474 CDM 6370000100 HCPCS 250 RC 00378-9112-93 NDC outpatient 1 UN 6.44 6.44 BLUE CROSS BLUE SHIELD WELLMARK SB889 [3081026] BCBS WYOMING [308102603] 6.12 percent of total billed charges 3.99 6.12 Technical (Hospital) Services NITROGLYCERIN 0.4 MG/HR TRANSDERMAL 24 HOUR PATCH RX-27474 CDM 6370000100 HCPCS 250 RC 00378-9112-93 NDC outpatient 1 UN 6.44 6.44 CIGNA 62308 [3081051] CIGNA 62308 [308105105] 5.15 percent of total billed charges 3.99 6.12 Technical (Hospital) Services NITROGLYCERIN 0.4 MG/HR TRANSDERMAL 24 HOUR PATCH RX-27474 CDM 6370000100 HCPCS 250 RC 00378-9112-93 NDC outpatient 1 UN 6.44 6.44 CIGNA 62308 [3081051] CIGNA STATE OF WYOMING [308105107] 5.15 percent of total billed charges 3.99 6.12 Technical (Hospital) Services NITROGLYCERIN 0.4 MG/HR TRANSDERMAL 24 HOUR PATCH RX-27474 CDM 6370000100 HCPCS 250 RC 00378-9112-93 NDC outpatient 1 UN 6.44 6.44 MULTIPLAN INC 34080 [3081285] MULTIPLAN INC [308128501] 6.12 percent of total billed charges 3.99 6.12 Technical (Hospital) Services NITROGLYCERIN 0.4 MG/HR TRANSDERMAL 24 HOUR PATCH RX-27474 CDM 6370000100 HCPCS 250 RC 00378-9112-93 NDC outpatient 1 UN 6.44 6.44 MEDICA (COMMERCIAL) 94265 [3081118] MEDICA CLAIMS [308111801] 5.8 percent of total billed charges 3.99 6.12 Technical (Hospital) Services NITROGLYCERIN 0.4 MG/HR TRANSDERMAL 24 HOUR PATCH RX-27474 CDM 6370000100 HCPCS 250 RC 00378-9112-93 NDC outpatient 1 UN 6.44 6.44 UNITED HEALTHCARE (COMMERCIAL) [3081199] UNITED HEALTHCARE 87726 [308119901] 3.99 percent of total billed charges 3.99 6.12 Technical (Hospital) Services NITROGLYCERIN 0.4 MG/HR TRANSDERMAL 24 HOUR PATCH RX-27474 CDM 6370000100 HCPCS 250 RC 00378-9112-93 NDC outpatient 1 UN 6.44 6.44 HEALTHPARTNERS SX009 HEALTHPARTNERS 5.15 percent of total billed charges 3.99 6.12 Technical (Hospital) Services NITROGLYCERIN 0.4 MG/HR TRANSDERMAL 24 HOUR PATCH RX-27474 CDM 6370000100 HCPCS 250 RC 00378-9112-93 NDC outpatient 1 UN 6.44 6.44 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES HDHP [308136802] 5.15 percent of total billed charges 3.99 6.12 Technical (Hospital) Services NITROGLYCERIN 0.4 MG/HR TRANSDERMAL 24 HOUR PATCH RX-27474 CDM 6370000100 HCPCS 250 RC 00378-9112-93 NDC outpatient 1 UN 6.44 6.44 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES PPO [308136801] 5.15 percent of total billed charges 3.99 6.12 Technical (Hospital) Services NITROGLYCERIN 0.4 MG/HR TRANSDERMAL 24 HOUR PATCH RX-27474 CDM 6370000100 HCPCS 250 RC 00378-9112-93 NDC outpatient 1 UN 6.44 6.44 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES EPO [308136803] 5.15 percent of total billed charges 3.99 6.12 Technical (Hospital) Services "FELODIPINE ER 5 MG TABLET,EXTENDED RELEASE 24 HR" RX-27490 CDM 6370000100 HCPCS 250 RC 13668-0133-01 NDC outpatient 1 UN 6 6 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES PPO [308136801] 4.8 percent of total billed charges 3.72 5.7 Technical (Hospital) Services "FELODIPINE ER 5 MG TABLET,EXTENDED RELEASE 24 HR" RX-27490 CDM 6370000100 HCPCS 250 RC 13668-0133-01 NDC outpatient 1 UN 6 6 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES HDHP [308136802] 4.8 percent of total billed charges 3.72 5.7 Technical (Hospital) Services "FELODIPINE ER 5 MG TABLET,EXTENDED RELEASE 24 HR" RX-27490 CDM 6370000100 HCPCS 250 RC 13668-0133-01 NDC outpatient 1 UN 6 6 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES EPO [308136803] 4.8 percent of total billed charges 3.72 5.7 Technical (Hospital) Services "FELODIPINE ER 5 MG TABLET,EXTENDED RELEASE 24 HR" RX-27490 CDM 6370000100 HCPCS 250 RC 13668-0133-01 NDC outpatient 1 UN 6 6 UNITED HEALTHCARE (COMMERCIAL) [3081199] UNITED HEALTHCARE 87726 [308119901] 3.72 percent of total billed charges 3.72 5.7 Technical (Hospital) Services "FELODIPINE ER 5 MG TABLET,EXTENDED RELEASE 24 HR" RX-27490 CDM 6370000100 HCPCS 250 RC 13668-0133-01 NDC outpatient 1 UN 6 6 MULTIPLAN INC 34080 [3081285] MULTIPLAN INC [308128501] 5.7 percent of total billed charges 3.72 5.7 Technical (Hospital) Services "FELODIPINE ER 5 MG TABLET,EXTENDED RELEASE 24 HR" RX-27490 CDM 6370000100 HCPCS 250 RC 13668-0133-01 NDC outpatient 1 UN 6 6 MEDICA (COMMERCIAL) 94265 [3081118] MEDICA CLAIMS [308111801] 5.4 percent of total billed charges 3.72 5.7 Technical (Hospital) Services "FELODIPINE ER 5 MG TABLET,EXTENDED RELEASE 24 HR" RX-27490 CDM 6370000100 HCPCS 250 RC 13668-0133-01 NDC outpatient 1 UN 6 6 CIGNA 62308 [3081051] CIGNA 62308 [308105105] 4.8 percent of total billed charges 3.72 5.7 Technical (Hospital) Services "FELODIPINE ER 5 MG TABLET,EXTENDED RELEASE 24 HR" RX-27490 CDM 6370000100 HCPCS 250 RC 13668-0133-01 NDC outpatient 1 UN 6 6 CIGNA 62308 [3081051] CIGNA STATE OF WYOMING [308105107] 4.8 percent of total billed charges 3.72 5.7 Technical (Hospital) Services "FELODIPINE ER 5 MG TABLET,EXTENDED RELEASE 24 HR" RX-27490 CDM 6370000100 HCPCS 250 RC 13668-0133-01 NDC outpatient 1 UN 6 6 BLUE CROSS BLUE SHIELD WELLMARK SB889 [3081026] BCBS WYOMING [308102603] 5.7 percent of total billed charges 3.72 5.7 Technical (Hospital) Services "FELODIPINE ER 5 MG TABLET,EXTENDED RELEASE 24 HR" RX-27490 CDM 6370000100 HCPCS 250 RC 13668-0133-01 NDC outpatient 1 UN 6 6 HEALTHPARTNERS SX009 HEALTHPARTNERS 4.8 percent of total billed charges 3.72 5.7 Technical (Hospital) Services "FELODIPINE ER 5 MG TABLET,EXTENDED RELEASE 24 HR" RX-27490 CDM 6370000100 HCPCS 250 RC 13668-0133-01 NDC inpatient 1 UN 6 6 MEDICA (COMMERCIAL) 94265 [3081118] MEDICA CLAIMS [308111801] 5.4 percent of total billed charges 3.72 5.7 Technical (Hospital) Services "FELODIPINE ER 5 MG TABLET,EXTENDED RELEASE 24 HR" RX-27490 CDM 6370000100 HCPCS 250 RC 13668-0133-01 NDC inpatient 1 UN 6 6 HEALTHPARTNERS SX009 HEALTHPARTNERS 4.75 percent of total billed charges 3.72 5.7 Technical (Hospital) Services "FELODIPINE ER 5 MG TABLET,EXTENDED RELEASE 24 HR" RX-27490 CDM 6370000100 HCPCS 250 RC 13668-0133-01 NDC inpatient 1 UN 6 6 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES PPO [308136801] 4.75 percent of total billed charges 3.72 5.7 Technical (Hospital) Services "FELODIPINE ER 5 MG TABLET,EXTENDED RELEASE 24 HR" RX-27490 CDM 6370000100 HCPCS 250 RC 13668-0133-01 NDC inpatient 1 UN 6 6 MULTIPLAN INC 34080 [3081285] MULTIPLAN INC [308128501] 5.7 percent of total billed charges 3.72 5.7 Technical (Hospital) Services "FELODIPINE ER 5 MG TABLET,EXTENDED RELEASE 24 HR" RX-27490 CDM 6370000100 HCPCS 250 RC 13668-0133-01 NDC inpatient 1 UN 6 6 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES HDHP [308136802] 4.75 percent of total billed charges 3.72 5.7 Technical (Hospital) Services "FELODIPINE ER 5 MG TABLET,EXTENDED RELEASE 24 HR" RX-27490 CDM 6370000100 HCPCS 250 RC 13668-0133-01 NDC inpatient 1 UN 6 6 BLUE CROSS BLUE SHIELD WELLMARK SB889 [3081026] BCBS WYOMING [308102603] 5.7 percent of total billed charges 3.72 5.7 Technical (Hospital) Services "FELODIPINE ER 5 MG TABLET,EXTENDED RELEASE 24 HR" RX-27490 CDM 6370000100 HCPCS 250 RC 13668-0133-01 NDC inpatient 1 UN 6 6 CIGNA 62308 [3081051] CIGNA 62308 [308105105] 4.75 percent of total billed charges 3.72 5.7 Technical (Hospital) Services "FELODIPINE ER 5 MG TABLET,EXTENDED RELEASE 24 HR" RX-27490 CDM 6370000100 HCPCS 250 RC 13668-0133-01 NDC inpatient 1 UN 6 6 CIGNA 62308 [3081051] CIGNA STATE OF WYOMING [308105107] 4.75 percent of total billed charges 3.72 5.7 Technical (Hospital) Services "FELODIPINE ER 5 MG TABLET,EXTENDED RELEASE 24 HR" RX-27490 CDM 6370000100 HCPCS 250 RC 13668-0133-01 NDC inpatient 1 UN 6 6 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES EPO [308136803] 4.75 percent of total billed charges 3.72 5.7 Technical (Hospital) Services "FELODIPINE ER 5 MG TABLET,EXTENDED RELEASE 24 HR" RX-27490 CDM 6370000100 HCPCS 250 RC 13668-0133-01 NDC inpatient 1 UN 6 6 UNITED HEALTHCARE (COMMERCIAL) [3081199] UNITED HEALTHCARE 87726 [308119901] 3.72 percent of total billed charges 3.72 5.7 Technical (Hospital) Services "PSEUDOEPHEDRINE-GUAIFENESIN ER 60 MG-600 MG TABLET,EXTEND RELEASE 12HR" RX-27529 CDM 6370000100 HCPCS 250 RC 63824-0057-18 NDC inpatient 1 UN 6.33 6.33 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES PPO [308136801] 5.01 percent of total billed charges 3.92 6.01 Technical (Hospital) Services "PSEUDOEPHEDRINE-GUAIFENESIN ER 60 MG-600 MG TABLET,EXTEND RELEASE 12HR" RX-27529 CDM 6370000100 HCPCS 250 RC 63824-0057-18 NDC inpatient 1 UN 6.33 6.33 MEDICA (COMMERCIAL) 94265 [3081118] MEDICA CLAIMS [308111801] 5.7 percent of total billed charges 3.92 6.01 Technical (Hospital) Services "PSEUDOEPHEDRINE-GUAIFENESIN ER 60 MG-600 MG TABLET,EXTEND RELEASE 12HR" RX-27529 CDM 6370000100 HCPCS 250 RC 63824-0057-18 NDC inpatient 1 UN 6.33 6.33 HEALTHPARTNERS SX009 HEALTHPARTNERS 5.01 percent of total billed charges 3.92 6.01 Technical (Hospital) Services "PSEUDOEPHEDRINE-GUAIFENESIN ER 60 MG-600 MG TABLET,EXTEND RELEASE 12HR" RX-27529 CDM 6370000100 HCPCS 250 RC 63824-0057-18 NDC inpatient 1 UN 6.33 6.33 MULTIPLAN INC 34080 [3081285] MULTIPLAN INC [308128501] 6.01 percent of total billed charges 3.92 6.01 Technical (Hospital) Services "PSEUDOEPHEDRINE-GUAIFENESIN ER 60 MG-600 MG TABLET,EXTEND RELEASE 12HR" RX-27529 CDM 6370000100 HCPCS 250 RC 63824-0057-18 NDC inpatient 1 UN 6.33 6.33 UNITED HEALTHCARE (COMMERCIAL) [3081199] UNITED HEALTHCARE 87726 [308119901] 3.92 percent of total billed charges 3.92 6.01 Technical (Hospital) Services "PSEUDOEPHEDRINE-GUAIFENESIN ER 60 MG-600 MG TABLET,EXTEND RELEASE 12HR" RX-27529 CDM 6370000100 HCPCS 250 RC 63824-0057-18 NDC inpatient 1 UN 6.33 6.33 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES HDHP [308136802] 5.01 percent of total billed charges 3.92 6.01 Technical (Hospital) Services "PSEUDOEPHEDRINE-GUAIFENESIN ER 60 MG-600 MG TABLET,EXTEND RELEASE 12HR" RX-27529 CDM 6370000100 HCPCS 250 RC 63824-0057-18 NDC inpatient 1 UN 6.33 6.33 CIGNA 62308 [3081051] CIGNA 62308 [308105105] 5.01 percent of total billed charges 3.92 6.01 Technical (Hospital) Services "PSEUDOEPHEDRINE-GUAIFENESIN ER 60 MG-600 MG TABLET,EXTEND RELEASE 12HR" RX-27529 CDM 6370000100 HCPCS 250 RC 63824-0057-18 NDC inpatient 1 UN 6.33 6.33 CIGNA 62308 [3081051] CIGNA STATE OF WYOMING [308105107] 5.01 percent of total billed charges 3.92 6.01 Technical (Hospital) Services "PSEUDOEPHEDRINE-GUAIFENESIN ER 60 MG-600 MG TABLET,EXTEND RELEASE 12HR" RX-27529 CDM 6370000100 HCPCS 250 RC 63824-0057-18 NDC inpatient 1 UN 6.33 6.33 BLUE CROSS BLUE SHIELD WELLMARK SB889 [3081026] BCBS WYOMING [308102603] 6.01 percent of total billed charges 3.92 6.01 Technical (Hospital) Services "PSEUDOEPHEDRINE-GUAIFENESIN ER 60 MG-600 MG TABLET,EXTEND RELEASE 12HR" RX-27529 CDM 6370000100 HCPCS 250 RC 63824-0057-18 NDC inpatient 1 UN 6.33 6.33 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES EPO [308136803] 5.01 percent of total billed charges 3.92 6.01 Technical (Hospital) Services "PSEUDOEPHEDRINE-GUAIFENESIN ER 60 MG-600 MG TABLET,EXTEND RELEASE 12HR" RX-27529 CDM 6370000100 HCPCS 250 RC 63824-0057-18 NDC outpatient 1 UN 6.33 6.33 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES EPO [308136803] 5.06 percent of total billed charges 3.92 6.01 Technical (Hospital) Services "PSEUDOEPHEDRINE-GUAIFENESIN ER 60 MG-600 MG TABLET,EXTEND RELEASE 12HR" RX-27529 CDM 6370000100 HCPCS 250 RC 63824-0057-18 NDC outpatient 1 UN 6.33 6.33 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES PPO [308136801] 5.06 percent of total billed charges 3.92 6.01 Technical (Hospital) Services "PSEUDOEPHEDRINE-GUAIFENESIN ER 60 MG-600 MG TABLET,EXTEND RELEASE 12HR" RX-27529 CDM 6370000100 HCPCS 250 RC 63824-0057-18 NDC outpatient 1 UN 6.33 6.33 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES HDHP [308136802] 5.06 percent of total billed charges 3.92 6.01 Technical (Hospital) Services "PSEUDOEPHEDRINE-GUAIFENESIN ER 60 MG-600 MG TABLET,EXTEND RELEASE 12HR" RX-27529 CDM 6370000100 HCPCS 250 RC 63824-0057-18 NDC outpatient 1 UN 6.33 6.33 CIGNA 62308 [3081051] CIGNA 62308 [308105105] 5.06 percent of total billed charges 3.92 6.01 Technical (Hospital) Services "PSEUDOEPHEDRINE-GUAIFENESIN ER 60 MG-600 MG TABLET,EXTEND RELEASE 12HR" RX-27529 CDM 6370000100 HCPCS 250 RC 63824-0057-18 NDC outpatient 1 UN 6.33 6.33 CIGNA 62308 [3081051] CIGNA STATE OF WYOMING [308105107] 5.06 percent of total billed charges 3.92 6.01 Technical (Hospital) Services "PSEUDOEPHEDRINE-GUAIFENESIN ER 60 MG-600 MG TABLET,EXTEND RELEASE 12HR" RX-27529 CDM 6370000100 HCPCS 250 RC 63824-0057-18 NDC outpatient 1 UN 6.33 6.33 MULTIPLAN INC 34080 [3081285] MULTIPLAN INC [308128501] 6.01 percent of total billed charges 3.92 6.01 Technical (Hospital) Services "PSEUDOEPHEDRINE-GUAIFENESIN ER 60 MG-600 MG TABLET,EXTEND RELEASE 12HR" RX-27529 CDM 6370000100 HCPCS 250 RC 63824-0057-18 NDC outpatient 1 UN 6.33 6.33 MEDICA (COMMERCIAL) 94265 [3081118] MEDICA CLAIMS [308111801] 5.7 percent of total billed charges 3.92 6.01 Technical (Hospital) Services "PSEUDOEPHEDRINE-GUAIFENESIN ER 60 MG-600 MG TABLET,EXTEND RELEASE 12HR" RX-27529 CDM 6370000100 HCPCS 250 RC 63824-0057-18 NDC outpatient 1 UN 6.33 6.33 UNITED HEALTHCARE (COMMERCIAL) [3081199] UNITED HEALTHCARE 87726 [308119901] 3.92 percent of total billed charges 3.92 6.01 Technical (Hospital) Services "PSEUDOEPHEDRINE-GUAIFENESIN ER 60 MG-600 MG TABLET,EXTEND RELEASE 12HR" RX-27529 CDM 6370000100 HCPCS 250 RC 63824-0057-18 NDC outpatient 1 UN 6.33 6.33 BLUE CROSS BLUE SHIELD WELLMARK SB889 [3081026] BCBS WYOMING [308102603] 6.01 percent of total billed charges 3.92 6.01 Technical (Hospital) Services "PSEUDOEPHEDRINE-GUAIFENESIN ER 60 MG-600 MG TABLET,EXTEND RELEASE 12HR" RX-27529 CDM 6370000100 HCPCS 250 RC 63824-0057-18 NDC outpatient 1 UN 6.33 6.33 HEALTHPARTNERS SX009 HEALTHPARTNERS 5.06 percent of total billed charges 3.92 6.01 Technical (Hospital) Services "DIVALPROEX 125 MG CAPSULE,DELAYED RELEASE SPRINKLE" RX-27631 CDM 6370000100 HCPCS 250 RC 68382-0106-01 NDC inpatient 1 UN 6.18 6.18 MULTIPLAN INC 34080 [3081285] MULTIPLAN INC [308128501] 5.87 percent of total billed charges 3.83 5.87 Technical (Hospital) Services "DIVALPROEX 125 MG CAPSULE,DELAYED RELEASE SPRINKLE" RX-27631 CDM 6370000100 HCPCS 250 RC 68382-0106-01 NDC inpatient 1 UN 6.18 6.18 MEDICA (COMMERCIAL) 94265 [3081118] MEDICA CLAIMS [308111801] 5.56 percent of total billed charges 3.83 5.87 Technical (Hospital) Services "DIVALPROEX 125 MG CAPSULE,DELAYED RELEASE SPRINKLE" RX-27631 CDM 6370000100 HCPCS 250 RC 68382-0106-01 NDC inpatient 1 UN 6.18 6.18 HEALTHPARTNERS SX009 HEALTHPARTNERS 4.89 percent of total billed charges 3.83 5.87 Technical (Hospital) Services "DIVALPROEX 125 MG CAPSULE,DELAYED RELEASE SPRINKLE" RX-27631 CDM 6370000100 HCPCS 250 RC 68382-0106-01 NDC inpatient 1 UN 6.18 6.18 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES PPO [308136801] 4.89 percent of total billed charges 3.83 5.87 Technical (Hospital) Services "DIVALPROEX 125 MG CAPSULE,DELAYED RELEASE SPRINKLE" RX-27631 CDM 6370000100 HCPCS 250 RC 68382-0106-01 NDC inpatient 1 UN 6.18 6.18 BLUE CROSS BLUE SHIELD WELLMARK SB889 [3081026] BCBS WYOMING [308102603] 5.87 percent of total billed charges 3.83 5.87 Technical (Hospital) Services "DIVALPROEX 125 MG CAPSULE,DELAYED RELEASE SPRINKLE" RX-27631 CDM 6370000100 HCPCS 250 RC 68382-0106-01 NDC inpatient 1 UN 6.18 6.18 CIGNA 62308 [3081051] CIGNA 62308 [308105105] 4.89 percent of total billed charges 3.83 5.87 Technical (Hospital) Services "DIVALPROEX 125 MG CAPSULE,DELAYED RELEASE SPRINKLE" RX-27631 CDM 6370000100 HCPCS 250 RC 68382-0106-01 NDC inpatient 1 UN 6.18 6.18 CIGNA 62308 [3081051] CIGNA STATE OF WYOMING [308105107] 4.89 percent of total billed charges 3.83 5.87 Technical (Hospital) Services "DIVALPROEX 125 MG CAPSULE,DELAYED RELEASE SPRINKLE" RX-27631 CDM 6370000100 HCPCS 250 RC 68382-0106-01 NDC inpatient 1 UN 6.18 6.18 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES EPO [308136803] 4.89 percent of total billed charges 3.83 5.87 Technical (Hospital) Services "DIVALPROEX 125 MG CAPSULE,DELAYED RELEASE SPRINKLE" RX-27631 CDM 6370000100 HCPCS 250 RC 68382-0106-01 NDC outpatient 1 UN 6.18 6.18 HEALTHPARTNERS SX009 HEALTHPARTNERS 4.94 percent of total billed charges 3.83 5.87 Technical (Hospital) Services "DIVALPROEX 125 MG CAPSULE,DELAYED RELEASE SPRINKLE" RX-27631 CDM 6370000100 HCPCS 250 RC 68382-0106-01 NDC outpatient 1 UN 6.18 6.18 BLUE CROSS BLUE SHIELD WELLMARK SB889 [3081026] BCBS WYOMING [308102603] 5.87 percent of total billed charges 3.83 5.87 Technical (Hospital) Services "DIVALPROEX 125 MG CAPSULE,DELAYED RELEASE SPRINKLE" RX-27631 CDM 6370000100 HCPCS 250 RC 68382-0106-01 NDC outpatient 1 UN 6.18 6.18 MEDICA (COMMERCIAL) 94265 [3081118] MEDICA CLAIMS [308111801] 5.56 percent of total billed charges 3.83 5.87 Technical (Hospital) Services "DIVALPROEX 125 MG CAPSULE,DELAYED RELEASE SPRINKLE" RX-27631 CDM 6370000100 HCPCS 250 RC 68382-0106-01 NDC outpatient 1 UN 6.18 6.18 CIGNA 62308 [3081051] CIGNA 62308 [308105105] 4.94 percent of total billed charges 3.83 5.87 Technical (Hospital) Services "DIVALPROEX 125 MG CAPSULE,DELAYED RELEASE SPRINKLE" RX-27631 CDM 6370000100 HCPCS 250 RC 68382-0106-01 NDC outpatient 1 UN 6.18 6.18 CIGNA 62308 [3081051] CIGNA STATE OF WYOMING [308105107] 4.94 percent of total billed charges 3.83 5.87 Technical (Hospital) Services "DIVALPROEX 125 MG CAPSULE,DELAYED RELEASE SPRINKLE" RX-27631 CDM 6370000100 HCPCS 250 RC 68382-0106-01 NDC outpatient 1 UN 6.18 6.18 MULTIPLAN INC 34080 [3081285] MULTIPLAN INC [308128501] 5.87 percent of total billed charges 3.83 5.87 Technical (Hospital) Services "DIVALPROEX 125 MG CAPSULE,DELAYED RELEASE SPRINKLE" RX-27631 CDM 6370000100 HCPCS 250 RC 68382-0106-01 NDC outpatient 1 UN 6.18 6.18 UNITED HEALTHCARE (COMMERCIAL) [3081199] UNITED HEALTHCARE 87726 [308119901] 3.83 percent of total billed charges 3.83 5.87 Technical (Hospital) Services "DIVALPROEX 125 MG CAPSULE,DELAYED RELEASE SPRINKLE" RX-27631 CDM 6370000100 HCPCS 250 RC 68382-0106-01 NDC inpatient 1 UN 6.18 6.18 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES HDHP [308136802] 4.89 percent of total billed charges 3.83 5.87 Technical (Hospital) Services "DIVALPROEX 125 MG CAPSULE,DELAYED RELEASE SPRINKLE" RX-27631 CDM 6370000100 HCPCS 250 RC 68382-0106-01 NDC inpatient 1 UN 6.18 6.18 UNITED HEALTHCARE (COMMERCIAL) [3081199] UNITED HEALTHCARE 87726 [308119901] 3.83 percent of total billed charges 3.83 5.87 Technical (Hospital) Services "DIVALPROEX 125 MG CAPSULE,DELAYED RELEASE SPRINKLE" RX-27631 CDM 6370000100 HCPCS 250 RC 68382-0106-01 NDC outpatient 1 UN 6.18 6.18 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES PPO [308136801] 4.94 percent of total billed charges 3.83 5.87 Technical (Hospital) Services "DIVALPROEX 125 MG CAPSULE,DELAYED RELEASE SPRINKLE" RX-27631 CDM 6370000100 HCPCS 250 RC 68382-0106-01 NDC outpatient 1 UN 6.18 6.18 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES HDHP [308136802] 4.94 percent of total billed charges 3.83 5.87 Technical (Hospital) Services "DIVALPROEX 125 MG CAPSULE,DELAYED RELEASE SPRINKLE" RX-27631 CDM 6370000100 HCPCS 250 RC 68382-0106-01 NDC outpatient 1 UN 6.18 6.18 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES EPO [308136803] 4.94 percent of total billed charges 3.83 5.87 Technical (Hospital) Services "NIFEDIPINE ER 60 MG TABLET,EXTENDED RELEASE 24 HR" RX-27659 CDM 6370000100 HCPCS 250 RC 68682-0109-10 NDC outpatient 1 UN 7.47 7.47 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES EPO [308136803] 5.98 percent of total billed charges 4.63 7.1 Technical (Hospital) Services "NIFEDIPINE ER 60 MG TABLET,EXTENDED RELEASE 24 HR" RX-27659 CDM 6370000100 HCPCS 250 RC 68682-0109-10 NDC outpatient 1 UN 7.47 7.47 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES HDHP [308136802] 5.98 percent of total billed charges 4.63 7.1 Technical (Hospital) Services "NIFEDIPINE ER 60 MG TABLET,EXTENDED RELEASE 24 HR" RX-27659 CDM 6370000100 HCPCS 250 RC 68682-0109-10 NDC outpatient 1 UN 7.47 7.47 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES PPO [308136801] 5.98 percent of total billed charges 4.63 7.1 Technical (Hospital) Services "NIFEDIPINE ER 60 MG TABLET,EXTENDED RELEASE 24 HR" RX-27659 CDM 6370000100 HCPCS 250 RC 68682-0109-10 NDC outpatient 1 UN 7.47 7.47 BLUE CROSS BLUE SHIELD WELLMARK SB889 [3081026] BCBS WYOMING [308102603] 7.1 percent of total billed charges 4.63 7.1 Technical (Hospital) Services "NIFEDIPINE ER 60 MG TABLET,EXTENDED RELEASE 24 HR" RX-27659 CDM 6370000100 HCPCS 250 RC 68682-0109-10 NDC outpatient 1 UN 7.47 7.47 HEALTHPARTNERS SX009 HEALTHPARTNERS 5.98 percent of total billed charges 4.63 7.1 Technical (Hospital) Services "NIFEDIPINE ER 60 MG TABLET,EXTENDED RELEASE 24 HR" RX-27659 CDM 6370000100 HCPCS 250 RC 68682-0109-10 NDC outpatient 1 UN 7.47 7.47 UNITED HEALTHCARE (COMMERCIAL) [3081199] UNITED HEALTHCARE 87726 [308119901] 4.63 percent of total billed charges 4.63 7.1 Technical (Hospital) Services "NIFEDIPINE ER 60 MG TABLET,EXTENDED RELEASE 24 HR" RX-27659 CDM 6370000100 HCPCS 250 RC 68682-0109-10 NDC outpatient 1 UN 7.47 7.47 CIGNA 62308 [3081051] CIGNA 62308 [308105105] 5.98 percent of total billed charges 4.63 7.1 Technical (Hospital) Services "NIFEDIPINE ER 60 MG TABLET,EXTENDED RELEASE 24 HR" RX-27659 CDM 6370000100 HCPCS 250 RC 68682-0109-10 NDC outpatient 1 UN 7.47 7.47 CIGNA 62308 [3081051] CIGNA STATE OF WYOMING [308105107] 5.98 percent of total billed charges 4.63 7.1 Technical (Hospital) Services "NIFEDIPINE ER 60 MG TABLET,EXTENDED RELEASE 24 HR" RX-27659 CDM 6370000100 HCPCS 250 RC 68682-0109-10 NDC outpatient 1 UN 7.47 7.47 MULTIPLAN INC 34080 [3081285] MULTIPLAN INC [308128501] 7.1 percent of total billed charges 4.63 7.1 Technical (Hospital) Services "NIFEDIPINE ER 60 MG TABLET,EXTENDED RELEASE 24 HR" RX-27659 CDM 6370000100 HCPCS 250 RC 68682-0109-10 NDC outpatient 1 UN 7.47 7.47 MEDICA (COMMERCIAL) 94265 [3081118] MEDICA CLAIMS [308111801] 6.72 percent of total billed charges 4.63 7.1 Technical (Hospital) Services "NIFEDIPINE ER 60 MG TABLET,EXTENDED RELEASE 24 HR" RX-27659 CDM 6370000100 HCPCS 250 RC 68682-0109-10 NDC inpatient 1 UN 7.47 7.47 MULTIPLAN INC 34080 [3081285] MULTIPLAN INC [308128501] 7.1 percent of total billed charges 4.63 7.1 Technical (Hospital) Services "NIFEDIPINE ER 60 MG TABLET,EXTENDED RELEASE 24 HR" RX-27659 CDM 6370000100 HCPCS 250 RC 68682-0109-10 NDC inpatient 1 UN 7.47 7.47 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES PPO [308136801] 5.91 percent of total billed charges 4.63 7.1 Technical (Hospital) Services "NIFEDIPINE ER 60 MG TABLET,EXTENDED RELEASE 24 HR" RX-27659 CDM 6370000100 HCPCS 250 RC 68682-0109-10 NDC inpatient 1 UN 7.47 7.47 HEALTHPARTNERS SX009 HEALTHPARTNERS 5.91 percent of total billed charges 4.63 7.1 Technical (Hospital) Services "NIFEDIPINE ER 60 MG TABLET,EXTENDED RELEASE 24 HR" RX-27659 CDM 6370000100 HCPCS 250 RC 68682-0109-10 NDC inpatient 1 UN 7.47 7.47 MEDICA (COMMERCIAL) 94265 [3081118] MEDICA CLAIMS [308111801] 6.72 percent of total billed charges 4.63 7.1 Technical (Hospital) Services "NIFEDIPINE ER 60 MG TABLET,EXTENDED RELEASE 24 HR" RX-27659 CDM 6370000100 HCPCS 250 RC 68682-0109-10 NDC inpatient 1 UN 7.47 7.47 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES HDHP [308136802] 5.91 percent of total billed charges 4.63 7.1 Technical (Hospital) Services "NIFEDIPINE ER 60 MG TABLET,EXTENDED RELEASE 24 HR" RX-27659 CDM 6370000100 HCPCS 250 RC 68682-0109-10 NDC inpatient 1 UN 7.47 7.47 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES EPO [308136803] 5.91 percent of total billed charges 4.63 7.1 Technical (Hospital) Services "NIFEDIPINE ER 60 MG TABLET,EXTENDED RELEASE 24 HR" RX-27659 CDM 6370000100 HCPCS 250 RC 68682-0109-10 NDC inpatient 1 UN 7.47 7.47 CIGNA 62308 [3081051] CIGNA 62308 [308105105] 5.91 percent of total billed charges 4.63 7.1 Technical (Hospital) Services "NIFEDIPINE ER 60 MG TABLET,EXTENDED RELEASE 24 HR" RX-27659 CDM 6370000100 HCPCS 250 RC 68682-0109-10 NDC inpatient 1 UN 7.47 7.47 CIGNA 62308 [3081051] CIGNA STATE OF WYOMING [308105107] 5.91 percent of total billed charges 4.63 7.1 Technical (Hospital) Services "NIFEDIPINE ER 60 MG TABLET,EXTENDED RELEASE 24 HR" RX-27659 CDM 6370000100 HCPCS 250 RC 68682-0109-10 NDC inpatient 1 UN 7.47 7.47 BLUE CROSS BLUE SHIELD WELLMARK SB889 [3081026] BCBS WYOMING [308102603] 7.1 percent of total billed charges 4.63 7.1 Technical (Hospital) Services "NIFEDIPINE ER 60 MG TABLET,EXTENDED RELEASE 24 HR" RX-27659 CDM 6370000100 HCPCS 250 RC 68682-0109-10 NDC inpatient 1 UN 7.47 7.47 UNITED HEALTHCARE (COMMERCIAL) [3081199] UNITED HEALTHCARE 87726 [308119901] 4.63 percent of total billed charges 4.63 7.1 Technical (Hospital) Services "LANSOPRAZOLE 30 MG CAPSULE,DELAYED RELEASE" RX-27692 CDM 6370000100 HCPCS 250 RC 00378-8030-93 NDC outpatient 1 UN 6.62 6.62 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES EPO [308136803] 5.3 percent of total billed charges 4.1 6.29 Technical (Hospital) Services "LANSOPRAZOLE 30 MG CAPSULE,DELAYED RELEASE" RX-27692 CDM 6370000100 HCPCS 250 RC 00378-8030-93 NDC outpatient 1 UN 6.62 6.62 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES HDHP [308136802] 5.3 percent of total billed charges 4.1 6.29 Technical (Hospital) Services "LANSOPRAZOLE 30 MG CAPSULE,DELAYED RELEASE" RX-27692 CDM 6370000100 HCPCS 250 RC 00378-8030-93 NDC outpatient 1 UN 6.62 6.62 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES PPO [308136801] 5.3 percent of total billed charges 4.1 6.29 Technical (Hospital) Services "LANSOPRAZOLE 30 MG CAPSULE,DELAYED RELEASE" RX-27692 CDM 6370000100 HCPCS 250 RC 00378-8030-93 NDC outpatient 1 UN 6.62 6.62 BLUE CROSS BLUE SHIELD WELLMARK SB889 [3081026] BCBS WYOMING [308102603] 6.29 percent of total billed charges 4.1 6.29 Technical (Hospital) Services "LANSOPRAZOLE 30 MG CAPSULE,DELAYED RELEASE" RX-27692 CDM 6370000100 HCPCS 250 RC 00378-8030-93 NDC outpatient 1 UN 6.62 6.62 CIGNA 62308 [3081051] CIGNA 62308 [308105105] 5.3 percent of total billed charges 4.1 6.29 Technical (Hospital) Services "LANSOPRAZOLE 30 MG CAPSULE,DELAYED RELEASE" RX-27692 CDM 6370000100 HCPCS 250 RC 00378-8030-93 NDC outpatient 1 UN 6.62 6.62 CIGNA 62308 [3081051] CIGNA STATE OF WYOMING [308105107] 5.3 percent of total billed charges 4.1 6.29 Technical (Hospital) Services "LANSOPRAZOLE 30 MG CAPSULE,DELAYED RELEASE" RX-27692 CDM 6370000100 HCPCS 250 RC 00378-8030-93 NDC outpatient 1 UN 6.62 6.62 MULTIPLAN INC 34080 [3081285] MULTIPLAN INC [308128501] 6.29 percent of total billed charges 4.1 6.29 Technical (Hospital) Services "LANSOPRAZOLE 30 MG CAPSULE,DELAYED RELEASE" RX-27692 CDM 6370000100 HCPCS 250 RC 00378-8030-93 NDC outpatient 1 UN 6.62 6.62 MEDICA (COMMERCIAL) 94265 [3081118] MEDICA CLAIMS [308111801] 5.96 percent of total billed charges 4.1 6.29 Technical (Hospital) Services "LANSOPRAZOLE 30 MG CAPSULE,DELAYED RELEASE" RX-27692 CDM 6370000100 HCPCS 250 RC 00378-8030-93 NDC outpatient 1 UN 6.62 6.62 UNITED HEALTHCARE (COMMERCIAL) [3081199] UNITED HEALTHCARE 87726 [308119901] 4.1 percent of total billed charges 4.1 6.29 Technical (Hospital) Services "LANSOPRAZOLE 30 MG CAPSULE,DELAYED RELEASE" RX-27692 CDM 6370000100 HCPCS 250 RC 00378-8030-93 NDC outpatient 1 UN 6.62 6.62 HEALTHPARTNERS SX009 HEALTHPARTNERS 5.3 percent of total billed charges 4.1 6.29 Technical (Hospital) Services "LANSOPRAZOLE 30 MG CAPSULE,DELAYED RELEASE" RX-27692 CDM 6370000100 HCPCS 250 RC 00378-8030-93 NDC inpatient 1 UN 6.62 6.62 UNITED HEALTHCARE (COMMERCIAL) [3081199] UNITED HEALTHCARE 87726 [308119901] 4.1 percent of total billed charges 4.1 6.29 Technical (Hospital) Services "LANSOPRAZOLE 30 MG CAPSULE,DELAYED RELEASE" RX-27692 CDM 6370000100 HCPCS 250 RC 00378-8030-93 NDC inpatient 1 UN 6.62 6.62 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES EPO [308136803] 5.24 percent of total billed charges 4.1 6.29 Technical (Hospital) Services "LANSOPRAZOLE 30 MG CAPSULE,DELAYED RELEASE" RX-27692 CDM 6370000100 HCPCS 250 RC 00378-8030-93 NDC inpatient 1 UN 6.62 6.62 CIGNA 62308 [3081051] CIGNA 62308 [308105105] 5.24 percent of total billed charges 4.1 6.29 Technical (Hospital) Services "LANSOPRAZOLE 30 MG CAPSULE,DELAYED RELEASE" RX-27692 CDM 6370000100 HCPCS 250 RC 00378-8030-93 NDC inpatient 1 UN 6.62 6.62 CIGNA 62308 [3081051] CIGNA STATE OF WYOMING [308105107] 5.24 percent of total billed charges 4.1 6.29 Technical (Hospital) Services "LANSOPRAZOLE 30 MG CAPSULE,DELAYED RELEASE" RX-27692 CDM 6370000100 HCPCS 250 RC 00378-8030-93 NDC inpatient 1 UN 6.62 6.62 BLUE CROSS BLUE SHIELD WELLMARK SB889 [3081026] BCBS WYOMING [308102603] 6.29 percent of total billed charges 4.1 6.29 Technical (Hospital) Services "LANSOPRAZOLE 30 MG CAPSULE,DELAYED RELEASE" RX-27692 CDM 6370000100 HCPCS 250 RC 00378-8030-93 NDC inpatient 1 UN 6.62 6.62 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES HDHP [308136802] 5.24 percent of total billed charges 4.1 6.29 Technical (Hospital) Services "LANSOPRAZOLE 30 MG CAPSULE,DELAYED RELEASE" RX-27692 CDM 6370000100 HCPCS 250 RC 00378-8030-93 NDC inpatient 1 UN 6.62 6.62 MEDICA (COMMERCIAL) 94265 [3081118] MEDICA CLAIMS [308111801] 5.96 percent of total billed charges 4.1 6.29 Technical (Hospital) Services "LANSOPRAZOLE 30 MG CAPSULE,DELAYED RELEASE" RX-27692 CDM 6370000100 HCPCS 250 RC 00378-8030-93 NDC inpatient 1 UN 6.62 6.62 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES PPO [308136801] 5.24 percent of total billed charges 4.1 6.29 Technical (Hospital) Services "LANSOPRAZOLE 30 MG CAPSULE,DELAYED RELEASE" RX-27692 CDM 6370000100 HCPCS 250 RC 00378-8030-93 NDC inpatient 1 UN 6.62 6.62 HEALTHPARTNERS SX009 HEALTHPARTNERS 5.24 percent of total billed charges 4.1 6.29 Technical (Hospital) Services "LANSOPRAZOLE 30 MG CAPSULE,DELAYED RELEASE" RX-27692 CDM 6370000100 HCPCS 250 RC 00378-8030-93 NDC inpatient 1 UN 6.62 6.62 MULTIPLAN INC 34080 [3081285] MULTIPLAN INC [308128501] 6.29 percent of total billed charges 4.1 6.29 Technical (Hospital) Services "OMEPRAZOLE 20 MG CAPSULE,DELAYED RELEASE" RX-27694 CDM 6370000100 HCPCS 250 RC 68462-0396-10 NDC inpatient 1 UN 5.73 5.73 BLUE CROSS BLUE SHIELD WELLMARK SB889 [3081026] BCBS WYOMING [308102603] 5.44 percent of total billed charges 3.55 5.44 Technical (Hospital) Services "OMEPRAZOLE 20 MG CAPSULE,DELAYED RELEASE" RX-27694 CDM 6370000100 HCPCS 250 RC 68462-0396-10 NDC inpatient 1 UN 5.73 5.73 UNITED HEALTHCARE (COMMERCIAL) [3081199] UNITED HEALTHCARE 87726 [308119901] 3.55 percent of total billed charges 3.55 5.44 Technical (Hospital) Services "OMEPRAZOLE 20 MG CAPSULE,DELAYED RELEASE" RX-27694 CDM 6370000100 HCPCS 250 RC 68462-0396-10 NDC inpatient 1 UN 5.73 5.73 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES HDHP [308136802] 4.54 percent of total billed charges 3.55 5.44 Technical (Hospital) Services "OMEPRAZOLE 20 MG CAPSULE,DELAYED RELEASE" RX-27694 CDM 6370000100 HCPCS 250 RC 68462-0396-10 NDC inpatient 1 UN 5.73 5.73 MEDICA (COMMERCIAL) 94265 [3081118] MEDICA CLAIMS [308111801] 5.16 percent of total billed charges 3.55 5.44 Technical (Hospital) Services "OMEPRAZOLE 20 MG CAPSULE,DELAYED RELEASE" RX-27694 CDM 6370000100 HCPCS 250 RC 68462-0396-10 NDC inpatient 1 UN 5.73 5.73 HEALTHPARTNERS SX009 HEALTHPARTNERS 4.54 percent of total billed charges 3.55 5.44 Technical (Hospital) Services "OMEPRAZOLE 20 MG CAPSULE,DELAYED RELEASE" RX-27694 CDM 6370000100 HCPCS 250 RC 68462-0396-10 NDC inpatient 1 UN 5.73 5.73 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES EPO [308136803] 4.54 percent of total billed charges 3.55 5.44 Technical (Hospital) Services "OMEPRAZOLE 20 MG CAPSULE,DELAYED RELEASE" RX-27694 CDM 6370000100 HCPCS 250 RC 68462-0396-10 NDC inpatient 1 UN 5.73 5.73 CIGNA 62308 [3081051] CIGNA STATE OF WYOMING [308105107] 4.54 percent of total billed charges 3.55 5.44 Technical (Hospital) Services "OMEPRAZOLE 20 MG CAPSULE,DELAYED RELEASE" RX-27694 CDM 6370000100 HCPCS 250 RC 68462-0396-10 NDC inpatient 1 UN 5.73 5.73 CIGNA 62308 [3081051] CIGNA 62308 [308105105] 4.54 percent of total billed charges 3.55 5.44 Technical (Hospital) Services "OMEPRAZOLE 20 MG CAPSULE,DELAYED RELEASE" RX-27694 CDM 6370000100 HCPCS 250 RC 68462-0396-10 NDC inpatient 1 UN 5.73 5.73 MULTIPLAN INC 34080 [3081285] MULTIPLAN INC [308128501] 5.44 percent of total billed charges 3.55 5.44 Technical (Hospital) Services "OMEPRAZOLE 20 MG CAPSULE,DELAYED RELEASE" RX-27694 CDM 6370000100 HCPCS 250 RC 68462-0396-10 NDC inpatient 1 UN 5.73 5.73 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES PPO [308136801] 4.54 percent of total billed charges 3.55 5.44 Technical (Hospital) Services "OMEPRAZOLE 20 MG CAPSULE,DELAYED RELEASE" RX-27694 CDM 6370000100 HCPCS 250 RC 68462-0396-10 NDC outpatient 1 UN 5.73 5.73 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES PPO [308136801] 4.58 percent of total billed charges 3.55 5.44 Technical (Hospital) Services "OMEPRAZOLE 20 MG CAPSULE,DELAYED RELEASE" RX-27694 CDM 6370000100 HCPCS 250 RC 68462-0396-10 NDC outpatient 1 UN 5.73 5.73 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES EPO [308136803] 4.58 percent of total billed charges 3.55 5.44 Technical (Hospital) Services "OMEPRAZOLE 20 MG CAPSULE,DELAYED RELEASE" RX-27694 CDM 6370000100 HCPCS 250 RC 68462-0396-10 NDC outpatient 1 UN 5.73 5.73 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES HDHP [308136802] 4.58 percent of total billed charges 3.55 5.44 Technical (Hospital) Services "OMEPRAZOLE 20 MG CAPSULE,DELAYED RELEASE" RX-27694 CDM 6370000100 HCPCS 250 RC 68462-0396-10 NDC outpatient 1 UN 5.73 5.73 BLUE CROSS BLUE SHIELD WELLMARK SB889 [3081026] BCBS WYOMING [308102603] 5.44 percent of total billed charges 3.55 5.44 Technical (Hospital) Services "OMEPRAZOLE 20 MG CAPSULE,DELAYED RELEASE" RX-27694 CDM 6370000100 HCPCS 250 RC 68462-0396-10 NDC outpatient 1 UN 5.73 5.73 MEDICA (COMMERCIAL) 94265 [3081118] MEDICA CLAIMS [308111801] 5.16 percent of total billed charges 3.55 5.44 Technical (Hospital) Services "OMEPRAZOLE 20 MG CAPSULE,DELAYED RELEASE" RX-27694 CDM 6370000100 HCPCS 250 RC 68462-0396-10 NDC outpatient 1 UN 5.73 5.73 CIGNA 62308 [3081051] CIGNA 62308 [308105105] 4.58 percent of total billed charges 3.55 5.44 Technical (Hospital) Services "OMEPRAZOLE 20 MG CAPSULE,DELAYED RELEASE" RX-27694 CDM 6370000100 HCPCS 250 RC 68462-0396-10 NDC outpatient 1 UN 5.73 5.73 CIGNA 62308 [3081051] CIGNA STATE OF WYOMING [308105107] 4.58 percent of total billed charges 3.55 5.44 Technical (Hospital) Services "OMEPRAZOLE 20 MG CAPSULE,DELAYED RELEASE" RX-27694 CDM 6370000100 HCPCS 250 RC 68462-0396-10 NDC outpatient 1 UN 5.73 5.73 MULTIPLAN INC 34080 [3081285] MULTIPLAN INC [308128501] 5.44 percent of total billed charges 3.55 5.44 Technical (Hospital) Services "OMEPRAZOLE 20 MG CAPSULE,DELAYED RELEASE" RX-27694 CDM 6370000100 HCPCS 250 RC 68462-0396-10 NDC outpatient 1 UN 5.73 5.73 UNITED HEALTHCARE (COMMERCIAL) [3081199] UNITED HEALTHCARE 87726 [308119901] 3.55 percent of total billed charges 3.55 5.44 Technical (Hospital) Services "OMEPRAZOLE 20 MG CAPSULE,DELAYED RELEASE" RX-27694 CDM 6370000100 HCPCS 250 RC 68462-0396-10 NDC outpatient 1 UN 5.73 5.73 HEALTHPARTNERS SX009 HEALTHPARTNERS 4.58 percent of total billed charges 3.55 5.44 Technical (Hospital) Services "OMEPRAZOLE 40 MG CAPSULE,DELAYED RELEASE" RX-27695 CDM 6370000100 HCPCS 250 RC 00781-2234-01 NDC outpatient 1 UN 5.74 5.74 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES EPO [308136803] 4.59 percent of total billed charges 3.56 5.45 Technical (Hospital) Services "OMEPRAZOLE 40 MG CAPSULE,DELAYED RELEASE" RX-27695 CDM 6370000100 HCPCS 250 RC 00781-2234-01 NDC outpatient 1 UN 5.74 5.74 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES HDHP [308136802] 4.59 percent of total billed charges 3.56 5.45 Technical (Hospital) Services "OMEPRAZOLE 40 MG CAPSULE,DELAYED RELEASE" RX-27695 CDM 6370000100 HCPCS 250 RC 00781-2234-01 NDC outpatient 1 UN 5.74 5.74 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES PPO [308136801] 4.59 percent of total billed charges 3.56 5.45 Technical (Hospital) Services "OMEPRAZOLE 40 MG CAPSULE,DELAYED RELEASE" RX-27695 CDM 6370000100 HCPCS 250 RC 00781-2234-01 NDC outpatient 1 UN 5.74 5.74 UNITED HEALTHCARE (COMMERCIAL) [3081199] UNITED HEALTHCARE 87726 [308119901] 3.56 percent of total billed charges 3.56 5.45 Technical (Hospital) Services "OMEPRAZOLE 40 MG CAPSULE,DELAYED RELEASE" RX-27695 CDM 6370000100 HCPCS 250 RC 00781-2234-01 NDC outpatient 1 UN 5.74 5.74 CIGNA 62308 [3081051] CIGNA 62308 [308105105] 4.59 percent of total billed charges 3.56 5.45 Technical (Hospital) Services "OMEPRAZOLE 40 MG CAPSULE,DELAYED RELEASE" RX-27695 CDM 6370000100 HCPCS 250 RC 00781-2234-01 NDC outpatient 1 UN 5.74 5.74 CIGNA 62308 [3081051] CIGNA STATE OF WYOMING [308105107] 4.59 percent of total billed charges 3.56 5.45 Technical (Hospital) Services "OMEPRAZOLE 40 MG CAPSULE,DELAYED RELEASE" RX-27695 CDM 6370000100 HCPCS 250 RC 00781-2234-01 NDC outpatient 1 UN 5.74 5.74 MULTIPLAN INC 34080 [3081285] MULTIPLAN INC [308128501] 5.45 percent of total billed charges 3.56 5.45 Technical (Hospital) Services "OMEPRAZOLE 40 MG CAPSULE,DELAYED RELEASE" RX-27695 CDM 6370000100 HCPCS 250 RC 00781-2234-01 NDC outpatient 1 UN 5.74 5.74 MEDICA (COMMERCIAL) 94265 [3081118] MEDICA CLAIMS [308111801] 5.17 percent of total billed charges 3.56 5.45 Technical (Hospital) Services "OMEPRAZOLE 40 MG CAPSULE,DELAYED RELEASE" RX-27695 CDM 6370000100 HCPCS 250 RC 00781-2234-01 NDC outpatient 1 UN 5.74 5.74 HEALTHPARTNERS SX009 HEALTHPARTNERS 4.59 percent of total billed charges 3.56 5.45 Technical (Hospital) Services "OMEPRAZOLE 40 MG CAPSULE,DELAYED RELEASE" RX-27695 CDM 6370000100 HCPCS 250 RC 00781-2234-01 NDC outpatient 1 UN 5.74 5.74 BLUE CROSS BLUE SHIELD WELLMARK SB889 [3081026] BCBS WYOMING [308102603] 5.45 percent of total billed charges 3.56 5.45 Technical (Hospital) Services "OMEPRAZOLE 40 MG CAPSULE,DELAYED RELEASE" RX-27695 CDM 6370000100 HCPCS 250 RC 00781-2234-01 NDC inpatient 1 UN 5.74 5.74 MULTIPLAN INC 34080 [3081285] MULTIPLAN INC [308128501] 5.45 percent of total billed charges 3.56 5.45 Technical (Hospital) Services "OMEPRAZOLE 40 MG CAPSULE,DELAYED RELEASE" RX-27695 CDM 6370000100 HCPCS 250 RC 00781-2234-01 NDC inpatient 1 UN 5.74 5.74 HEALTHPARTNERS SX009 HEALTHPARTNERS 4.54 percent of total billed charges 3.56 5.45 Technical (Hospital) Services "OMEPRAZOLE 40 MG CAPSULE,DELAYED RELEASE" RX-27695 CDM 6370000100 HCPCS 250 RC 00781-2234-01 NDC inpatient 1 UN 5.74 5.74 MEDICA (COMMERCIAL) 94265 [3081118] MEDICA CLAIMS [308111801] 5.17 percent of total billed charges 3.56 5.45 Technical (Hospital) Services "OMEPRAZOLE 40 MG CAPSULE,DELAYED RELEASE" RX-27695 CDM 6370000100 HCPCS 250 RC 00781-2234-01 NDC inpatient 1 UN 5.74 5.74 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES PPO [308136801] 4.54 percent of total billed charges 3.56 5.45 Technical (Hospital) Services "OMEPRAZOLE 40 MG CAPSULE,DELAYED RELEASE" RX-27695 CDM 6370000100 HCPCS 250 RC 00781-2234-01 NDC inpatient 1 UN 5.74 5.74 UNITED HEALTHCARE (COMMERCIAL) [3081199] UNITED HEALTHCARE 87726 [308119901] 3.56 percent of total billed charges 3.56 5.45 Technical (Hospital) Services "OMEPRAZOLE 40 MG CAPSULE,DELAYED RELEASE" RX-27695 CDM 6370000100 HCPCS 250 RC 00781-2234-01 NDC inpatient 1 UN 5.74 5.74 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES HDHP [308136802] 4.54 percent of total billed charges 3.56 5.45 Technical (Hospital) Services "OMEPRAZOLE 40 MG CAPSULE,DELAYED RELEASE" RX-27695 CDM 6370000100 HCPCS 250 RC 00781-2234-01 NDC inpatient 1 UN 5.74 5.74 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES EPO [308136803] 4.54 percent of total billed charges 3.56 5.45 Technical (Hospital) Services "OMEPRAZOLE 40 MG CAPSULE,DELAYED RELEASE" RX-27695 CDM 6370000100 HCPCS 250 RC 00781-2234-01 NDC inpatient 1 UN 5.74 5.74 CIGNA 62308 [3081051] CIGNA STATE OF WYOMING [308105107] 4.54 percent of total billed charges 3.56 5.45 Technical (Hospital) Services "OMEPRAZOLE 40 MG CAPSULE,DELAYED RELEASE" RX-27695 CDM 6370000100 HCPCS 250 RC 00781-2234-01 NDC inpatient 1 UN 5.74 5.74 CIGNA 62308 [3081051] CIGNA 62308 [308105105] 4.54 percent of total billed charges 3.56 5.45 Technical (Hospital) Services "OMEPRAZOLE 40 MG CAPSULE,DELAYED RELEASE" RX-27695 CDM 6370000100 HCPCS 250 RC 00781-2234-01 NDC inpatient 1 UN 5.74 5.74 BLUE CROSS BLUE SHIELD WELLMARK SB889 [3081026] BCBS WYOMING [308102603] 5.45 percent of total billed charges 3.56 5.45 Technical (Hospital) Services ONDANSETRON 4 MG DISINTEGRATING TABLET RX-27697 CDM 6370000100 HCPCS 250 RC 68462-0157-40 NDC inpatient 1 UN 6.08 6.08 HEALTHPARTNERS SX009 HEALTHPARTNERS 4.81 percent of total billed charges 3.77 5.78 Technical (Hospital) Services ONDANSETRON 4 MG DISINTEGRATING TABLET RX-27697 CDM 6370000100 HCPCS 250 RC 68462-0157-40 NDC inpatient 1 UN 6.08 6.08 MEDICA (COMMERCIAL) 94265 [3081118] MEDICA CLAIMS [308111801] 5.47 percent of total billed charges 3.77 5.78 Technical (Hospital) Services ONDANSETRON 4 MG DISINTEGRATING TABLET RX-27697 CDM 6370000100 HCPCS 250 RC 68462-0157-40 NDC inpatient 1 UN 6.08 6.08 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES PPO [308136801] 4.81 percent of total billed charges 3.77 5.78 Technical (Hospital) Services ONDANSETRON 4 MG DISINTEGRATING TABLET RX-27697 CDM 6370000100 HCPCS 250 RC 68462-0157-40 NDC inpatient 1 UN 6.08 6.08 MULTIPLAN INC 34080 [3081285] MULTIPLAN INC [308128501] 5.78 percent of total billed charges 3.77 5.78 Technical (Hospital) Services ONDANSETRON 4 MG DISINTEGRATING TABLET RX-27697 CDM 6370000100 HCPCS 250 RC 68462-0157-40 NDC inpatient 1 UN 6.08 6.08 BLUE CROSS BLUE SHIELD WELLMARK SB889 [3081026] BCBS WYOMING [308102603] 5.78 percent of total billed charges 3.77 5.78 Technical (Hospital) Services ONDANSETRON 4 MG DISINTEGRATING TABLET RX-27697 CDM 6370000100 HCPCS 250 RC 68462-0157-40 NDC inpatient 1 UN 6.08 6.08 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES EPO [308136803] 4.81 percent of total billed charges 3.77 5.78 Technical (Hospital) Services ONDANSETRON 4 MG DISINTEGRATING TABLET RX-27697 CDM 6370000100 HCPCS 250 RC 68462-0157-40 NDC inpatient 1 UN 6.08 6.08 CIGNA 62308 [3081051] CIGNA 62308 [308105105] 4.81 percent of total billed charges 3.77 5.78 Technical (Hospital) Services ONDANSETRON 4 MG DISINTEGRATING TABLET RX-27697 CDM 6370000100 HCPCS 250 RC 68462-0157-40 NDC inpatient 1 UN 6.08 6.08 CIGNA 62308 [3081051] CIGNA STATE OF WYOMING [308105107] 4.81 percent of total billed charges 3.77 5.78 Technical (Hospital) Services ONDANSETRON 4 MG DISINTEGRATING TABLET RX-27697 CDM 6370000100 HCPCS 250 RC 68462-0157-40 NDC inpatient 1 UN 6.08 6.08 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES HDHP [308136802] 4.81 percent of total billed charges 3.77 5.78 Technical (Hospital) Services ONDANSETRON 4 MG DISINTEGRATING TABLET RX-27697 CDM 6370000100 HCPCS 250 RC 68462-0157-40 NDC inpatient 1 UN 6.08 6.08 UNITED HEALTHCARE (COMMERCIAL) [3081199] UNITED HEALTHCARE 87726 [308119901] 3.77 percent of total billed charges 3.77 5.78 Technical (Hospital) Services ONDANSETRON 4 MG DISINTEGRATING TABLET RX-27697 CDM 6370000100 HCPCS 250 RC 68462-0157-40 NDC outpatient 1 UN 6.08 6.08 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES EPO [308136803] 4.86 percent of total billed charges 3.77 5.78 Technical (Hospital) Services ONDANSETRON 4 MG DISINTEGRATING TABLET RX-27697 CDM 6370000100 HCPCS 250 RC 68462-0157-40 NDC outpatient 1 UN 6.08 6.08 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES HDHP [308136802] 4.86 percent of total billed charges 3.77 5.78 Technical (Hospital) Services ONDANSETRON 4 MG DISINTEGRATING TABLET RX-27697 CDM 6370000100 HCPCS 250 RC 68462-0157-40 NDC outpatient 1 UN 6.08 6.08 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES PPO [308136801] 4.86 percent of total billed charges 3.77 5.78 Technical (Hospital) Services ONDANSETRON 4 MG DISINTEGRATING TABLET RX-27697 CDM 6370000100 HCPCS 250 RC 68462-0157-40 NDC outpatient 1 UN 6.08 6.08 CIGNA 62308 [3081051] CIGNA 62308 [308105105] 4.86 percent of total billed charges 3.77 5.78 Technical (Hospital) Services ONDANSETRON 4 MG DISINTEGRATING TABLET RX-27697 CDM 6370000100 HCPCS 250 RC 68462-0157-40 NDC outpatient 1 UN 6.08 6.08 CIGNA 62308 [3081051] CIGNA STATE OF WYOMING [308105107] 4.86 percent of total billed charges 3.77 5.78 Technical (Hospital) Services ONDANSETRON 4 MG DISINTEGRATING TABLET RX-27697 CDM 6370000100 HCPCS 250 RC 68462-0157-40 NDC outpatient 1 UN 6.08 6.08 MULTIPLAN INC 34080 [3081285] MULTIPLAN INC [308128501] 5.78 percent of total billed charges 3.77 5.78 Technical (Hospital) Services ONDANSETRON 4 MG DISINTEGRATING TABLET RX-27697 CDM 6370000100 HCPCS 250 RC 68462-0157-40 NDC outpatient 1 UN 6.08 6.08 MEDICA (COMMERCIAL) 94265 [3081118] MEDICA CLAIMS [308111801] 5.47 percent of total billed charges 3.77 5.78 Technical (Hospital) Services ONDANSETRON 4 MG DISINTEGRATING TABLET RX-27697 CDM 6370000100 HCPCS 250 RC 68462-0157-40 NDC outpatient 1 UN 6.08 6.08 UNITED HEALTHCARE (COMMERCIAL) [3081199] UNITED HEALTHCARE 87726 [308119901] 3.77 percent of total billed charges 3.77 5.78 Technical (Hospital) Services ONDANSETRON 4 MG DISINTEGRATING TABLET RX-27697 CDM 6370000100 HCPCS 250 RC 68462-0157-40 NDC outpatient 1 UN 6.08 6.08 BLUE CROSS BLUE SHIELD WELLMARK SB889 [3081026] BCBS WYOMING [308102603] 5.78 percent of total billed charges 3.77 5.78 Technical (Hospital) Services ONDANSETRON 4 MG DISINTEGRATING TABLET RX-27697 CDM 6370000100 HCPCS 250 RC 68462-0157-40 NDC outpatient 1 UN 6.08 6.08 HEALTHPARTNERS SX009 HEALTHPARTNERS 4.86 percent of total billed charges 3.77 5.78 Technical (Hospital) Services "VENLAFAXINE ER 37.5 MG CAPSULE,EXTENDED RELEASE 24 HR" RX-27857 CDM 6370000100 HCPCS 250 RC 65862-0527-90 NDC outpatient 1 UN 5.81 5.81 MEDICA (COMMERCIAL) 94265 [3081118] MEDICA CLAIMS [308111801] 5.23 percent of total billed charges 3.6 5.52 Technical (Hospital) Services "VENLAFAXINE ER 37.5 MG CAPSULE,EXTENDED RELEASE 24 HR" RX-27857 CDM 6370000100 HCPCS 250 RC 65862-0527-90 NDC outpatient 1 UN 5.81 5.81 CIGNA 62308 [3081051] CIGNA 62308 [308105105] 4.65 percent of total billed charges 3.6 5.52 Technical (Hospital) Services "VENLAFAXINE ER 37.5 MG CAPSULE,EXTENDED RELEASE 24 HR" RX-27857 CDM 6370000100 HCPCS 250 RC 65862-0527-90 NDC outpatient 1 UN 5.81 5.81 CIGNA 62308 [3081051] CIGNA STATE OF WYOMING [308105107] 4.65 percent of total billed charges 3.6 5.52 Technical (Hospital) Services "VENLAFAXINE ER 37.5 MG CAPSULE,EXTENDED RELEASE 24 HR" RX-27857 CDM 6370000100 HCPCS 250 RC 65862-0527-90 NDC outpatient 1 UN 5.81 5.81 MULTIPLAN INC 34080 [3081285] MULTIPLAN INC [308128501] 5.52 percent of total billed charges 3.6 5.52 Technical (Hospital) Services "VENLAFAXINE ER 37.5 MG CAPSULE,EXTENDED RELEASE 24 HR" RX-27857 CDM 6370000100 HCPCS 250 RC 65862-0527-90 NDC outpatient 1 UN 5.81 5.81 HEALTHPARTNERS SX009 HEALTHPARTNERS 4.65 percent of total billed charges 3.6 5.52 Technical (Hospital) Services "VENLAFAXINE ER 37.5 MG CAPSULE,EXTENDED RELEASE 24 HR" RX-27857 CDM 6370000100 HCPCS 250 RC 65862-0527-90 NDC outpatient 1 UN 5.81 5.81 UNITED HEALTHCARE (COMMERCIAL) [3081199] UNITED HEALTHCARE 87726 [308119901] 3.6 percent of total billed charges 3.6 5.52 Technical (Hospital) Services "VENLAFAXINE ER 37.5 MG CAPSULE,EXTENDED RELEASE 24 HR" RX-27857 CDM 6370000100 HCPCS 250 RC 65862-0527-90 NDC outpatient 1 UN 5.81 5.81 BLUE CROSS BLUE SHIELD WELLMARK SB889 [3081026] BCBS WYOMING [308102603] 5.52 percent of total billed charges 3.6 5.52 Technical (Hospital) Services "VENLAFAXINE ER 37.5 MG CAPSULE,EXTENDED RELEASE 24 HR" RX-27857 CDM 6370000100 HCPCS 250 RC 65862-0527-90 NDC outpatient 1 UN 5.81 5.81 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES EPO [308136803] 4.65 percent of total billed charges 3.6 5.52 Technical (Hospital) Services "VENLAFAXINE ER 37.5 MG CAPSULE,EXTENDED RELEASE 24 HR" RX-27857 CDM 6370000100 HCPCS 250 RC 65862-0527-90 NDC outpatient 1 UN 5.81 5.81 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES HDHP [308136802] 4.65 percent of total billed charges 3.6 5.52 Technical (Hospital) Services "VENLAFAXINE ER 37.5 MG CAPSULE,EXTENDED RELEASE 24 HR" RX-27857 CDM 6370000100 HCPCS 250 RC 65862-0527-90 NDC outpatient 1 UN 5.81 5.81 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES PPO [308136801] 4.65 percent of total billed charges 3.6 5.52 Technical (Hospital) Services "VENLAFAXINE ER 37.5 MG CAPSULE,EXTENDED RELEASE 24 HR" RX-27857 CDM 6370000100 HCPCS 250 RC 65862-0527-90 NDC inpatient 1 UN 5.81 5.81 UNITED HEALTHCARE (COMMERCIAL) [3081199] UNITED HEALTHCARE 87726 [308119901] 3.6 percent of total billed charges 3.6 5.52 Technical (Hospital) Services "VENLAFAXINE ER 37.5 MG CAPSULE,EXTENDED RELEASE 24 HR" RX-27857 CDM 6370000100 HCPCS 250 RC 65862-0527-90 NDC inpatient 1 UN 5.81 5.81 BLUE CROSS BLUE SHIELD WELLMARK SB889 [3081026] BCBS WYOMING [308102603] 5.52 percent of total billed charges 3.6 5.52 Technical (Hospital) Services "VENLAFAXINE ER 37.5 MG CAPSULE,EXTENDED RELEASE 24 HR" RX-27857 CDM 6370000100 HCPCS 250 RC 65862-0527-90 NDC inpatient 1 UN 5.81 5.81 CIGNA 62308 [3081051] CIGNA STATE OF WYOMING [308105107] 4.6 percent of total billed charges 3.6 5.52 Technical (Hospital) Services "VENLAFAXINE ER 37.5 MG CAPSULE,EXTENDED RELEASE 24 HR" RX-27857 CDM 6370000100 HCPCS 250 RC 65862-0527-90 NDC inpatient 1 UN 5.81 5.81 CIGNA 62308 [3081051] CIGNA 62308 [308105105] 4.6 percent of total billed charges 3.6 5.52 Technical (Hospital) Services "VENLAFAXINE ER 37.5 MG CAPSULE,EXTENDED RELEASE 24 HR" RX-27857 CDM 6370000100 HCPCS 250 RC 65862-0527-90 NDC inpatient 1 UN 5.81 5.81 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES EPO [308136803] 4.6 percent of total billed charges 3.6 5.52 Technical (Hospital) Services "VENLAFAXINE ER 37.5 MG CAPSULE,EXTENDED RELEASE 24 HR" RX-27857 CDM 6370000100 HCPCS 250 RC 65862-0527-90 NDC inpatient 1 UN 5.81 5.81 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES HDHP [308136802] 4.6 percent of total billed charges 3.6 5.52 Technical (Hospital) Services "VENLAFAXINE ER 37.5 MG CAPSULE,EXTENDED RELEASE 24 HR" RX-27857 CDM 6370000100 HCPCS 250 RC 65862-0527-90 NDC inpatient 1 UN 5.81 5.81 MEDICA (COMMERCIAL) 94265 [3081118] MEDICA CLAIMS [308111801] 5.23 percent of total billed charges 3.6 5.52 Technical (Hospital) Services "VENLAFAXINE ER 37.5 MG CAPSULE,EXTENDED RELEASE 24 HR" RX-27857 CDM 6370000100 HCPCS 250 RC 65862-0527-90 NDC inpatient 1 UN 5.81 5.81 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES PPO [308136801] 4.6 percent of total billed charges 3.6 5.52 Technical (Hospital) Services "VENLAFAXINE ER 37.5 MG CAPSULE,EXTENDED RELEASE 24 HR" RX-27857 CDM 6370000100 HCPCS 250 RC 65862-0527-90 NDC inpatient 1 UN 5.81 5.81 HEALTHPARTNERS SX009 HEALTHPARTNERS 4.6 percent of total billed charges 3.6 5.52 Technical (Hospital) Services "VENLAFAXINE ER 37.5 MG CAPSULE,EXTENDED RELEASE 24 HR" RX-27857 CDM 6370000100 HCPCS 250 RC 65862-0527-90 NDC inpatient 1 UN 5.81 5.81 MULTIPLAN INC 34080 [3081285] MULTIPLAN INC [308128501] 5.52 percent of total billed charges 3.6 5.52 Technical (Hospital) Services "VENLAFAXINE ER 75 MG CAPSULE,EXTENDED RELEASE 24 HR" RX-27858 CDM 6370000100 HCPCS 250 RC 65862-0528-90 NDC outpatient 1 UN 5.85 5.85 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES PPO [308136801] 4.68 percent of total billed charges 3.63 5.56 Technical (Hospital) Services "VENLAFAXINE ER 75 MG CAPSULE,EXTENDED RELEASE 24 HR" RX-27858 CDM 6370000100 HCPCS 250 RC 65862-0528-90 NDC outpatient 1 UN 5.85 5.85 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES HDHP [308136802] 4.68 percent of total billed charges 3.63 5.56 Technical (Hospital) Services "VENLAFAXINE ER 75 MG CAPSULE,EXTENDED RELEASE 24 HR" RX-27858 CDM 6370000100 HCPCS 250 RC 65862-0528-90 NDC outpatient 1 UN 5.85 5.85 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES EPO [308136803] 4.68 percent of total billed charges 3.63 5.56 Technical (Hospital) Services "VENLAFAXINE ER 75 MG CAPSULE,EXTENDED RELEASE 24 HR" RX-27858 CDM 6370000100 HCPCS 250 RC 65862-0528-90 NDC outpatient 1 UN 5.85 5.85 BLUE CROSS BLUE SHIELD WELLMARK SB889 [3081026] BCBS WYOMING [308102603] 5.56 percent of total billed charges 3.63 5.56 Technical (Hospital) Services "VENLAFAXINE ER 75 MG CAPSULE,EXTENDED RELEASE 24 HR" RX-27858 CDM 6370000100 HCPCS 250 RC 65862-0528-90 NDC outpatient 1 UN 5.85 5.85 UNITED HEALTHCARE (COMMERCIAL) [3081199] UNITED HEALTHCARE 87726 [308119901] 3.63 percent of total billed charges 3.63 5.56 Technical (Hospital) Services "VENLAFAXINE ER 75 MG CAPSULE,EXTENDED RELEASE 24 HR" RX-27858 CDM 6370000100 HCPCS 250 RC 65862-0528-90 NDC outpatient 1 UN 5.85 5.85 HEALTHPARTNERS SX009 HEALTHPARTNERS 4.68 percent of total billed charges 3.63 5.56 Technical (Hospital) Services "VENLAFAXINE ER 75 MG CAPSULE,EXTENDED RELEASE 24 HR" RX-27858 CDM 6370000100 HCPCS 250 RC 65862-0528-90 NDC outpatient 1 UN 5.85 5.85 MULTIPLAN INC 34080 [3081285] MULTIPLAN INC [308128501] 5.56 percent of total billed charges 3.63 5.56 Technical (Hospital) Services "VENLAFAXINE ER 75 MG CAPSULE,EXTENDED RELEASE 24 HR" RX-27858 CDM 6370000100 HCPCS 250 RC 65862-0528-90 NDC outpatient 1 UN 5.85 5.85 CIGNA 62308 [3081051] CIGNA 62308 [308105105] 4.68 percent of total billed charges 3.63 5.56 Technical (Hospital) Services "VENLAFAXINE ER 75 MG CAPSULE,EXTENDED RELEASE 24 HR" RX-27858 CDM 6370000100 HCPCS 250 RC 65862-0528-90 NDC outpatient 1 UN 5.85 5.85 CIGNA 62308 [3081051] CIGNA STATE OF WYOMING [308105107] 4.68 percent of total billed charges 3.63 5.56 Technical (Hospital) Services "VENLAFAXINE ER 75 MG CAPSULE,EXTENDED RELEASE 24 HR" RX-27858 CDM 6370000100 HCPCS 250 RC 65862-0528-90 NDC outpatient 1 UN 5.85 5.85 MEDICA (COMMERCIAL) 94265 [3081118] MEDICA CLAIMS [308111801] 5.27 percent of total billed charges 3.63 5.56 Technical (Hospital) Services "VENLAFAXINE ER 75 MG CAPSULE,EXTENDED RELEASE 24 HR" RX-27858 CDM 6370000100 HCPCS 250 RC 65862-0528-90 NDC inpatient 1 UN 5.85 5.85 BLUE CROSS BLUE SHIELD WELLMARK SB889 [3081026] BCBS WYOMING [308102603] 5.56 percent of total billed charges 3.63 5.56 Technical (Hospital) Services "VENLAFAXINE ER 75 MG CAPSULE,EXTENDED RELEASE 24 HR" RX-27858 CDM 6370000100 HCPCS 250 RC 65862-0528-90 NDC inpatient 1 UN 5.85 5.85 UNITED HEALTHCARE (COMMERCIAL) [3081199] UNITED HEALTHCARE 87726 [308119901] 3.63 percent of total billed charges 3.63 5.56 Technical (Hospital) Services "VENLAFAXINE ER 75 MG CAPSULE,EXTENDED RELEASE 24 HR" RX-27858 CDM 6370000100 HCPCS 250 RC 65862-0528-90 NDC inpatient 1 UN 5.85 5.85 CIGNA 62308 [3081051] CIGNA 62308 [308105105] 4.63 percent of total billed charges 3.63 5.56 Technical (Hospital) Services "VENLAFAXINE ER 75 MG CAPSULE,EXTENDED RELEASE 24 HR" RX-27858 CDM 6370000100 HCPCS 250 RC 65862-0528-90 NDC inpatient 1 UN 5.85 5.85 CIGNA 62308 [3081051] CIGNA STATE OF WYOMING [308105107] 4.63 percent of total billed charges 3.63 5.56 Technical (Hospital) Services "VENLAFAXINE ER 75 MG CAPSULE,EXTENDED RELEASE 24 HR" RX-27858 CDM 6370000100 HCPCS 250 RC 65862-0528-90 NDC inpatient 1 UN 5.85 5.85 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES EPO [308136803] 4.63 percent of total billed charges 3.63 5.56 Technical (Hospital) Services "VENLAFAXINE ER 75 MG CAPSULE,EXTENDED RELEASE 24 HR" RX-27858 CDM 6370000100 HCPCS 250 RC 65862-0528-90 NDC inpatient 1 UN 5.85 5.85 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES HDHP [308136802] 4.63 percent of total billed charges 3.63 5.56 Technical (Hospital) Services "VENLAFAXINE ER 75 MG CAPSULE,EXTENDED RELEASE 24 HR" RX-27858 CDM 6370000100 HCPCS 250 RC 65862-0528-90 NDC inpatient 1 UN 5.85 5.85 MEDICA (COMMERCIAL) 94265 [3081118] MEDICA CLAIMS [308111801] 5.27 percent of total billed charges 3.63 5.56 Technical (Hospital) Services "VENLAFAXINE ER 75 MG CAPSULE,EXTENDED RELEASE 24 HR" RX-27858 CDM 6370000100 HCPCS 250 RC 65862-0528-90 NDC inpatient 1 UN 5.85 5.85 HEALTHPARTNERS SX009 HEALTHPARTNERS 4.63 percent of total billed charges 3.63 5.56 Technical (Hospital) Services "VENLAFAXINE ER 75 MG CAPSULE,EXTENDED RELEASE 24 HR" RX-27858 CDM 6370000100 HCPCS 250 RC 65862-0528-90 NDC inpatient 1 UN 5.85 5.85 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES PPO [308136801] 4.63 percent of total billed charges 3.63 5.56 Technical (Hospital) Services "VENLAFAXINE ER 75 MG CAPSULE,EXTENDED RELEASE 24 HR" RX-27858 CDM 6370000100 HCPCS 250 RC 65862-0528-90 NDC inpatient 1 UN 5.85 5.85 MULTIPLAN INC 34080 [3081285] MULTIPLAN INC [308128501] 5.56 percent of total billed charges 3.63 5.56 Technical (Hospital) Services FENTANYL 25 MCG/HR TRANSDERMAL PATCH RX-27905 CDM 6370000100 HCPCS 250 RC 00378-9121-98 NDC inpatient 1 UN 29.13 29.13 BLUE CROSS BLUE SHIELD WELLMARK SB889 [3081026] BCBS WYOMING [308102603] 27.67 percent of total billed charges 18.06 27.67 Technical (Hospital) Services FENTANYL 25 MCG/HR TRANSDERMAL PATCH RX-27905 CDM 6370000100 HCPCS 250 RC 00378-9121-98 NDC inpatient 1 UN 29.13 29.13 UNITED HEALTHCARE (COMMERCIAL) [3081199] UNITED HEALTHCARE 87726 [308119901] 18.06 percent of total billed charges 18.06 27.67 Technical (Hospital) Services FENTANYL 25 MCG/HR TRANSDERMAL PATCH RX-27905 CDM 6370000100 HCPCS 250 RC 00378-9121-98 NDC inpatient 1 UN 29.13 29.13 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES HDHP [308136802] 23.07 percent of total billed charges 18.06 27.67 Technical (Hospital) Services FENTANYL 25 MCG/HR TRANSDERMAL PATCH RX-27905 CDM 6370000100 HCPCS 250 RC 00378-9121-98 NDC inpatient 1 UN 29.13 29.13 MEDICA (COMMERCIAL) 94265 [3081118] MEDICA CLAIMS [308111801] 26.22 percent of total billed charges 18.06 27.67 Technical (Hospital) Services FENTANYL 25 MCG/HR TRANSDERMAL PATCH RX-27905 CDM 6370000100 HCPCS 250 RC 00378-9121-98 NDC inpatient 1 UN 29.13 29.13 HEALTHPARTNERS SX009 HEALTHPARTNERS 23.07 percent of total billed charges 18.06 27.67 Technical (Hospital) Services FENTANYL 25 MCG/HR TRANSDERMAL PATCH RX-27905 CDM 6370000100 HCPCS 250 RC 00378-9121-98 NDC inpatient 1 UN 29.13 29.13 CIGNA 62308 [3081051] CIGNA 62308 [308105105] 23.07 percent of total billed charges 18.06 27.67 Technical (Hospital) Services FENTANYL 25 MCG/HR TRANSDERMAL PATCH RX-27905 CDM 6370000100 HCPCS 250 RC 00378-9121-98 NDC inpatient 1 UN 29.13 29.13 CIGNA 62308 [3081051] CIGNA STATE OF WYOMING [308105107] 23.07 percent of total billed charges 18.06 27.67 Technical (Hospital) Services FENTANYL 25 MCG/HR TRANSDERMAL PATCH RX-27905 CDM 6370000100 HCPCS 250 RC 00378-9121-98 NDC inpatient 1 UN 29.13 29.13 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES EPO [308136803] 23.07 percent of total billed charges 18.06 27.67 Technical (Hospital) Services FENTANYL 25 MCG/HR TRANSDERMAL PATCH RX-27905 CDM 6370000100 HCPCS 250 RC 00378-9121-98 NDC inpatient 1 UN 29.13 29.13 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES PPO [308136801] 23.07 percent of total billed charges 18.06 27.67 Technical (Hospital) Services FENTANYL 25 MCG/HR TRANSDERMAL PATCH RX-27905 CDM 6370000100 HCPCS 250 RC 00378-9121-98 NDC inpatient 1 UN 29.13 29.13 MULTIPLAN INC 34080 [3081285] MULTIPLAN INC [308128501] 27.67 percent of total billed charges 18.06 27.67 Technical (Hospital) Services FENTANYL 25 MCG/HR TRANSDERMAL PATCH RX-27905 CDM 6370000100 HCPCS 250 RC 00378-9121-98 NDC outpatient 1 UN 29.13 29.13 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES PPO [308136801] 23.3 percent of total billed charges 18.06 27.67 Technical (Hospital) Services FENTANYL 25 MCG/HR TRANSDERMAL PATCH RX-27905 CDM 6370000100 HCPCS 250 RC 00378-9121-98 NDC outpatient 1 UN 29.13 29.13 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES HDHP [308136802] 23.3 percent of total billed charges 18.06 27.67 Technical (Hospital) Services FENTANYL 25 MCG/HR TRANSDERMAL PATCH RX-27905 CDM 6370000100 HCPCS 250 RC 00378-9121-98 NDC outpatient 1 UN 29.13 29.13 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES EPO [308136803] 23.3 percent of total billed charges 18.06 27.67 Technical (Hospital) Services FENTANYL 25 MCG/HR TRANSDERMAL PATCH RX-27905 CDM 6370000100 HCPCS 250 RC 00378-9121-98 NDC outpatient 1 UN 29.13 29.13 BLUE CROSS BLUE SHIELD WELLMARK SB889 [3081026] BCBS WYOMING [308102603] 27.67 percent of total billed charges 18.06 27.67 Technical (Hospital) Services FENTANYL 25 MCG/HR TRANSDERMAL PATCH RX-27905 CDM 6370000100 HCPCS 250 RC 00378-9121-98 NDC outpatient 1 UN 29.13 29.13 HEALTHPARTNERS SX009 HEALTHPARTNERS 23.3 percent of total billed charges 18.06 27.67 Technical (Hospital) Services FENTANYL 25 MCG/HR TRANSDERMAL PATCH RX-27905 CDM 6370000100 HCPCS 250 RC 00378-9121-98 NDC outpatient 1 UN 29.13 29.13 UNITED HEALTHCARE (COMMERCIAL) [3081199] UNITED HEALTHCARE 87726 [308119901] 18.06 percent of total billed charges 18.06 27.67 Technical (Hospital) Services FENTANYL 25 MCG/HR TRANSDERMAL PATCH RX-27905 CDM 6370000100 HCPCS 250 RC 00378-9121-98 NDC outpatient 1 UN 29.13 29.13 MEDICA (COMMERCIAL) 94265 [3081118] MEDICA CLAIMS [308111801] 26.22 percent of total billed charges 18.06 27.67 Technical (Hospital) Services FENTANYL 25 MCG/HR TRANSDERMAL PATCH RX-27905 CDM 6370000100 HCPCS 250 RC 00378-9121-98 NDC outpatient 1 UN 29.13 29.13 MULTIPLAN INC 34080 [3081285] MULTIPLAN INC [308128501] 27.67 percent of total billed charges 18.06 27.67 Technical (Hospital) Services FENTANYL 25 MCG/HR TRANSDERMAL PATCH RX-27905 CDM 6370000100 HCPCS 250 RC 00378-9121-98 NDC outpatient 1 UN 29.13 29.13 CIGNA 62308 [3081051] CIGNA 62308 [308105105] 23.3 percent of total billed charges 18.06 27.67 Technical (Hospital) Services FENTANYL 25 MCG/HR TRANSDERMAL PATCH RX-27905 CDM 6370000100 HCPCS 250 RC 00378-9121-98 NDC outpatient 1 UN 29.13 29.13 CIGNA 62308 [3081051] CIGNA STATE OF WYOMING [308105107] 23.3 percent of total billed charges 18.06 27.67 Technical (Hospital) Services FENTANYL 50 MCG/HR TRANSDERMAL PATCH RX-27906 CDM 6370000100 HCPCS 250 RC 47781-0426-47 NDC inpatient 1 UN 51.67 51.67 MULTIPLAN INC 34080 [3081285] MULTIPLAN INC [308128501] 49.09 percent of total billed charges 32.04 49.09 Technical (Hospital) Services FENTANYL 50 MCG/HR TRANSDERMAL PATCH RX-27906 CDM 6370000100 HCPCS 250 RC 47781-0426-47 NDC inpatient 1 UN 51.67 51.67 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES PPO [308136801] 40.91 percent of total billed charges 32.04 49.09 Technical (Hospital) Services FENTANYL 50 MCG/HR TRANSDERMAL PATCH RX-27906 CDM 6370000100 HCPCS 250 RC 47781-0426-47 NDC inpatient 1 UN 51.67 51.67 UNITED HEALTHCARE (COMMERCIAL) [3081199] UNITED HEALTHCARE 87726 [308119901] 32.04 percent of total billed charges 32.04 49.09 Technical (Hospital) Services FENTANYL 50 MCG/HR TRANSDERMAL PATCH RX-27906 CDM 6370000100 HCPCS 250 RC 47781-0426-47 NDC inpatient 1 UN 51.67 51.67 BLUE CROSS BLUE SHIELD WELLMARK SB889 [3081026] BCBS WYOMING [308102603] 49.09 percent of total billed charges 32.04 49.09 Technical (Hospital) Services FENTANYL 50 MCG/HR TRANSDERMAL PATCH RX-27906 CDM 6370000100 HCPCS 250 RC 47781-0426-47 NDC inpatient 1 UN 51.67 51.67 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES HDHP [308136802] 40.91 percent of total billed charges 32.04 49.09 Technical (Hospital) Services FENTANYL 50 MCG/HR TRANSDERMAL PATCH RX-27906 CDM 6370000100 HCPCS 250 RC 47781-0426-47 NDC inpatient 1 UN 51.67 51.67 MEDICA (COMMERCIAL) 94265 [3081118] MEDICA CLAIMS [308111801] 46.5 percent of total billed charges 32.04 49.09 Technical (Hospital) Services FENTANYL 50 MCG/HR TRANSDERMAL PATCH RX-27906 CDM 6370000100 HCPCS 250 RC 47781-0426-47 NDC inpatient 1 UN 51.67 51.67 HEALTHPARTNERS SX009 HEALTHPARTNERS 40.91 percent of total billed charges 32.04 49.09 Technical (Hospital) Services FENTANYL 50 MCG/HR TRANSDERMAL PATCH RX-27906 CDM 6370000100 HCPCS 250 RC 47781-0426-47 NDC inpatient 1 UN 51.67 51.67 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES EPO [308136803] 40.91 percent of total billed charges 32.04 49.09 Technical (Hospital) Services FENTANYL 50 MCG/HR TRANSDERMAL PATCH RX-27906 CDM 6370000100 HCPCS 250 RC 47781-0426-47 NDC inpatient 1 UN 51.67 51.67 CIGNA 62308 [3081051] CIGNA 62308 [308105105] 40.91 percent of total billed charges 32.04 49.09 Technical (Hospital) Services FENTANYL 50 MCG/HR TRANSDERMAL PATCH RX-27906 CDM 6370000100 HCPCS 250 RC 47781-0426-47 NDC inpatient 1 UN 51.67 51.67 CIGNA 62308 [3081051] CIGNA STATE OF WYOMING [308105107] 40.91 percent of total billed charges 32.04 49.09 Technical (Hospital) Services FENTANYL 50 MCG/HR TRANSDERMAL PATCH RX-27906 CDM 6370000100 HCPCS 250 RC 47781-0426-47 NDC outpatient 1 UN 51.67 51.67 UNITED HEALTHCARE (COMMERCIAL) [3081199] UNITED HEALTHCARE 87726 [308119901] 32.04 percent of total billed charges 32.04 49.09 Technical (Hospital) Services FENTANYL 50 MCG/HR TRANSDERMAL PATCH RX-27906 CDM 6370000100 HCPCS 250 RC 47781-0426-47 NDC outpatient 1 UN 51.67 51.67 MEDICA (COMMERCIAL) 94265 [3081118] MEDICA CLAIMS [308111801] 46.5 percent of total billed charges 32.04 49.09 Technical (Hospital) Services FENTANYL 50 MCG/HR TRANSDERMAL PATCH RX-27906 CDM 6370000100 HCPCS 250 RC 47781-0426-47 NDC outpatient 1 UN 51.67 51.67 CIGNA 62308 [3081051] CIGNA 62308 [308105105] 41.34 percent of total billed charges 32.04 49.09 Technical (Hospital) Services FENTANYL 50 MCG/HR TRANSDERMAL PATCH RX-27906 CDM 6370000100 HCPCS 250 RC 47781-0426-47 NDC outpatient 1 UN 51.67 51.67 CIGNA 62308 [3081051] CIGNA STATE OF WYOMING [308105107] 41.34 percent of total billed charges 32.04 49.09 Technical (Hospital) Services FENTANYL 50 MCG/HR TRANSDERMAL PATCH RX-27906 CDM 6370000100 HCPCS 250 RC 47781-0426-47 NDC outpatient 1 UN 51.67 51.67 MULTIPLAN INC 34080 [3081285] MULTIPLAN INC [308128501] 49.09 percent of total billed charges 32.04 49.09 Technical (Hospital) Services FENTANYL 50 MCG/HR TRANSDERMAL PATCH RX-27906 CDM 6370000100 HCPCS 250 RC 47781-0426-47 NDC outpatient 1 UN 51.67 51.67 HEALTHPARTNERS SX009 HEALTHPARTNERS 41.34 percent of total billed charges 32.04 49.09 Technical (Hospital) Services FENTANYL 50 MCG/HR TRANSDERMAL PATCH RX-27906 CDM 6370000100 HCPCS 250 RC 47781-0426-47 NDC outpatient 1 UN 51.67 51.67 BLUE CROSS BLUE SHIELD WELLMARK SB889 [3081026] BCBS WYOMING [308102603] 49.09 percent of total billed charges 32.04 49.09 Technical (Hospital) Services FENTANYL 50 MCG/HR TRANSDERMAL PATCH RX-27906 CDM 6370000100 HCPCS 250 RC 47781-0426-47 NDC outpatient 1 UN 51.67 51.67 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES EPO [308136803] 41.34 percent of total billed charges 32.04 49.09 Technical (Hospital) Services FENTANYL 50 MCG/HR TRANSDERMAL PATCH RX-27906 CDM 6370000100 HCPCS 250 RC 47781-0426-47 NDC outpatient 1 UN 51.67 51.67 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES HDHP [308136802] 41.34 percent of total billed charges 32.04 49.09 Technical (Hospital) Services FENTANYL 50 MCG/HR TRANSDERMAL PATCH RX-27906 CDM 6370000100 HCPCS 250 RC 47781-0426-47 NDC outpatient 1 UN 51.67 51.67 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES PPO [308136801] 41.34 percent of total billed charges 32.04 49.09 Technical (Hospital) Services CHLORHEXIDINE GLUCONATE 4 % TOPICAL LIQUID RX-28188 CDM 6370000100 HCPCS 250 RC 32551-0938-35 NDC outpatient 1 ML 5.65 5.65 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES EPO [308136803] 4.52 percent of total billed charges 3.5 5.37 Technical (Hospital) Services CHLORHEXIDINE GLUCONATE 4 % TOPICAL LIQUID RX-28188 CDM 6370000100 HCPCS 250 RC 32551-0938-35 NDC outpatient 1 ML 5.65 5.65 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES HDHP [308136802] 4.52 percent of total billed charges 3.5 5.37 Technical (Hospital) Services CHLORHEXIDINE GLUCONATE 4 % TOPICAL LIQUID RX-28188 CDM 6370000100 HCPCS 250 RC 32551-0938-35 NDC outpatient 1 ML 5.65 5.65 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES PPO [308136801] 4.52 percent of total billed charges 3.5 5.37 Technical (Hospital) Services CHLORHEXIDINE GLUCONATE 4 % TOPICAL LIQUID RX-28188 CDM 6370000100 HCPCS 250 RC 32551-0938-35 NDC outpatient 1 ML 5.65 5.65 BLUE CROSS BLUE SHIELD WELLMARK SB889 [3081026] BCBS WYOMING [308102603] 5.37 percent of total billed charges 3.5 5.37 Technical (Hospital) Services CHLORHEXIDINE GLUCONATE 4 % TOPICAL LIQUID RX-28188 CDM 6370000100 HCPCS 250 RC 32551-0938-35 NDC outpatient 1 ML 5.65 5.65 HEALTHPARTNERS SX009 HEALTHPARTNERS 4.52 percent of total billed charges 3.5 5.37 Technical (Hospital) Services CHLORHEXIDINE GLUCONATE 4 % TOPICAL LIQUID RX-28188 CDM 6370000100 HCPCS 250 RC 32551-0938-35 NDC outpatient 1 ML 5.65 5.65 UNITED HEALTHCARE (COMMERCIAL) [3081199] UNITED HEALTHCARE 87726 [308119901] 3.5 percent of total billed charges 3.5 5.37 Technical (Hospital) Services CHLORHEXIDINE GLUCONATE 4 % TOPICAL LIQUID RX-28188 CDM 6370000100 HCPCS 250 RC 32551-0938-35 NDC outpatient 1 ML 5.65 5.65 CIGNA 62308 [3081051] CIGNA 62308 [308105105] 4.52 percent of total billed charges 3.5 5.37 Technical (Hospital) Services CHLORHEXIDINE GLUCONATE 4 % TOPICAL LIQUID RX-28188 CDM 6370000100 HCPCS 250 RC 32551-0938-35 NDC outpatient 1 ML 5.65 5.65 CIGNA 62308 [3081051] CIGNA STATE OF WYOMING [308105107] 4.52 percent of total billed charges 3.5 5.37 Technical (Hospital) Services CHLORHEXIDINE GLUCONATE 4 % TOPICAL LIQUID RX-28188 CDM 6370000100 HCPCS 250 RC 32551-0938-35 NDC outpatient 1 ML 5.65 5.65 MULTIPLAN INC 34080 [3081285] MULTIPLAN INC [308128501] 5.37 percent of total billed charges 3.5 5.37 Technical (Hospital) Services CHLORHEXIDINE GLUCONATE 4 % TOPICAL LIQUID RX-28188 CDM 6370000100 HCPCS 250 RC 32551-0938-35 NDC outpatient 1 ML 5.65 5.65 MEDICA (COMMERCIAL) 94265 [3081118] MEDICA CLAIMS [308111801] 5.09 percent of total billed charges 3.5 5.37 Technical (Hospital) Services CHLORHEXIDINE GLUCONATE 4 % TOPICAL LIQUID RX-28188 CDM 6370000100 HCPCS 250 RC 32551-0938-35 NDC inpatient 1 ML 5.65 5.65 MEDICA (COMMERCIAL) 94265 [3081118] MEDICA CLAIMS [308111801] 5.09 percent of total billed charges 3.5 5.37 Technical (Hospital) Services CHLORHEXIDINE GLUCONATE 4 % TOPICAL LIQUID RX-28188 CDM 6370000100 HCPCS 250 RC 32551-0938-35 NDC inpatient 1 ML 5.65 5.65 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES PPO [308136801] 4.47 percent of total billed charges 3.5 5.37 Technical (Hospital) Services CHLORHEXIDINE GLUCONATE 4 % TOPICAL LIQUID RX-28188 CDM 6370000100 HCPCS 250 RC 32551-0938-35 NDC inpatient 1 ML 5.65 5.65 HEALTHPARTNERS SX009 HEALTHPARTNERS 4.47 percent of total billed charges 3.5 5.37 Technical (Hospital) Services CHLORHEXIDINE GLUCONATE 4 % TOPICAL LIQUID RX-28188 CDM 6370000100 HCPCS 250 RC 32551-0938-35 NDC inpatient 1 ML 5.65 5.65 MULTIPLAN INC 34080 [3081285] MULTIPLAN INC [308128501] 5.37 percent of total billed charges 3.5 5.37 Technical (Hospital) Services CHLORHEXIDINE GLUCONATE 4 % TOPICAL LIQUID RX-28188 CDM 6370000100 HCPCS 250 RC 32551-0938-35 NDC inpatient 1 ML 5.65 5.65 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES EPO [308136803] 4.47 percent of total billed charges 3.5 5.37 Technical (Hospital) Services CHLORHEXIDINE GLUCONATE 4 % TOPICAL LIQUID RX-28188 CDM 6370000100 HCPCS 250 RC 32551-0938-35 NDC inpatient 1 ML 5.65 5.65 CIGNA 62308 [3081051] CIGNA 62308 [308105105] 4.47 percent of total billed charges 3.5 5.37 Technical (Hospital) Services CHLORHEXIDINE GLUCONATE 4 % TOPICAL LIQUID RX-28188 CDM 6370000100 HCPCS 250 RC 32551-0938-35 NDC inpatient 1 ML 5.65 5.65 CIGNA 62308 [3081051] CIGNA STATE OF WYOMING [308105107] 4.47 percent of total billed charges 3.5 5.37 Technical (Hospital) Services CHLORHEXIDINE GLUCONATE 4 % TOPICAL LIQUID RX-28188 CDM 6370000100 HCPCS 250 RC 32551-0938-35 NDC inpatient 1 ML 5.65 5.65 BLUE CROSS BLUE SHIELD WELLMARK SB889 [3081026] BCBS WYOMING [308102603] 5.37 percent of total billed charges 3.5 5.37 Technical (Hospital) Services CHLORHEXIDINE GLUCONATE 4 % TOPICAL LIQUID RX-28188 CDM 6370000100 HCPCS 250 RC 32551-0938-35 NDC inpatient 1 ML 5.65 5.65 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES HDHP [308136802] 4.47 percent of total billed charges 3.5 5.37 Technical (Hospital) Services CHLORHEXIDINE GLUCONATE 4 % TOPICAL LIQUID RX-28188 CDM 6370000100 HCPCS 250 RC 32551-0938-35 NDC inpatient 1 ML 5.65 5.65 UNITED HEALTHCARE (COMMERCIAL) [3081199] UNITED HEALTHCARE 87726 [308119901] 3.5 percent of total billed charges 3.5 5.37 Technical (Hospital) Services LIDOCAINE 5 % TOPICAL PATCH RX-28203 CDM 6370000100 HCPCS 250 RC 00603-1880-10 NDC outpatient 1 UN 15 15 HEALTHPARTNERS SX009 HEALTHPARTNERS 12 percent of total billed charges 9.3 14.25 Technical (Hospital) Services LIDOCAINE 5 % TOPICAL PATCH RX-28203 CDM 6370000100 HCPCS 250 RC 00603-1880-10 NDC outpatient 1 UN 15 15 BLUE CROSS BLUE SHIELD WELLMARK SB889 [3081026] BCBS WYOMING [308102603] 14.25 percent of total billed charges 9.3 14.25 Technical (Hospital) Services LIDOCAINE 5 % TOPICAL PATCH RX-28203 CDM 6370000100 HCPCS 250 RC 00603-1880-10 NDC outpatient 1 UN 15 15 UNITED HEALTHCARE (COMMERCIAL) [3081199] UNITED HEALTHCARE 87726 [308119901] 9.3 percent of total billed charges 9.3 14.25 Technical (Hospital) Services LIDOCAINE 5 % TOPICAL PATCH RX-28203 CDM 6370000100 HCPCS 250 RC 00603-1880-10 NDC outpatient 1 UN 15 15 MULTIPLAN INC 34080 [3081285] MULTIPLAN INC [308128501] 14.25 percent of total billed charges 9.3 14.25 Technical (Hospital) Services LIDOCAINE 5 % TOPICAL PATCH RX-28203 CDM 6370000100 HCPCS 250 RC 00603-1880-10 NDC outpatient 1 UN 15 15 CIGNA 62308 [3081051] CIGNA 62308 [308105105] 12 percent of total billed charges 9.3 14.25 Technical (Hospital) Services LIDOCAINE 5 % TOPICAL PATCH RX-28203 CDM 6370000100 HCPCS 250 RC 00603-1880-10 NDC outpatient 1 UN 15 15 CIGNA 62308 [3081051] CIGNA STATE OF WYOMING [308105107] 12 percent of total billed charges 9.3 14.25 Technical (Hospital) Services LIDOCAINE 5 % TOPICAL PATCH RX-28203 CDM 6370000100 HCPCS 250 RC 00603-1880-10 NDC outpatient 1 UN 15 15 MEDICA (COMMERCIAL) 94265 [3081118] MEDICA CLAIMS [308111801] 13.5 percent of total billed charges 9.3 14.25 Technical (Hospital) Services LIDOCAINE 5 % TOPICAL PATCH RX-28203 CDM 6370000100 HCPCS 250 RC 00603-1880-10 NDC inpatient 1 UN 15 15 BLUE CROSS BLUE SHIELD WELLMARK SB889 [3081026] BCBS WYOMING [308102603] 14.25 percent of total billed charges 9.3 14.25 Technical (Hospital) Services LIDOCAINE 5 % TOPICAL PATCH RX-28203 CDM 6370000100 HCPCS 250 RC 00603-1880-10 NDC inpatient 1 UN 15 15 UNITED HEALTHCARE (COMMERCIAL) [3081199] UNITED HEALTHCARE 87726 [308119901] 9.3 percent of total billed charges 9.3 14.25 Technical (Hospital) Services LIDOCAINE 5 % TOPICAL PATCH RX-28203 CDM 6370000100 HCPCS 250 RC 00603-1880-10 NDC outpatient 1 UN 15 15 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES PPO [308136801] 12 percent of total billed charges 9.3 14.25 Technical (Hospital) Services LIDOCAINE 5 % TOPICAL PATCH RX-28203 CDM 6370000100 HCPCS 250 RC 00603-1880-10 NDC outpatient 1 UN 15 15 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES EPO [308136803] 12 percent of total billed charges 9.3 14.25 Technical (Hospital) Services LIDOCAINE 5 % TOPICAL PATCH RX-28203 CDM 6370000100 HCPCS 250 RC 00603-1880-10 NDC outpatient 1 UN 15 15 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES HDHP [308136802] 12 percent of total billed charges 9.3 14.25 Technical (Hospital) Services LIDOCAINE 5 % TOPICAL PATCH RX-28203 CDM 6370000100 HCPCS 250 RC 00603-1880-10 NDC inpatient 1 UN 15 15 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES HDHP [308136802] 11.88 percent of total billed charges 9.3 14.25 Technical (Hospital) Services LIDOCAINE 5 % TOPICAL PATCH RX-28203 CDM 6370000100 HCPCS 250 RC 00603-1880-10 NDC inpatient 1 UN 15 15 CIGNA 62308 [3081051] CIGNA 62308 [308105105] 11.88 percent of total billed charges 9.3 14.25 Technical (Hospital) Services LIDOCAINE 5 % TOPICAL PATCH RX-28203 CDM 6370000100 HCPCS 250 RC 00603-1880-10 NDC inpatient 1 UN 15 15 CIGNA 62308 [3081051] CIGNA STATE OF WYOMING [308105107] 11.88 percent of total billed charges 9.3 14.25 Technical (Hospital) Services LIDOCAINE 5 % TOPICAL PATCH RX-28203 CDM 6370000100 HCPCS 250 RC 00603-1880-10 NDC inpatient 1 UN 15 15 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES EPO [308136803] 11.88 percent of total billed charges 9.3 14.25 Technical (Hospital) Services LIDOCAINE 5 % TOPICAL PATCH RX-28203 CDM 6370000100 HCPCS 250 RC 00603-1880-10 NDC inpatient 1 UN 15 15 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES PPO [308136801] 11.88 percent of total billed charges 9.3 14.25 Technical (Hospital) Services LIDOCAINE 5 % TOPICAL PATCH RX-28203 CDM 6370000100 HCPCS 250 RC 00603-1880-10 NDC inpatient 1 UN 15 15 HEALTHPARTNERS SX009 HEALTHPARTNERS 11.88 percent of total billed charges 9.3 14.25 Technical (Hospital) Services LIDOCAINE 5 % TOPICAL PATCH RX-28203 CDM 6370000100 HCPCS 250 RC 00603-1880-10 NDC inpatient 1 UN 15 15 MEDICA (COMMERCIAL) 94265 [3081118] MEDICA CLAIMS [308111801] 13.5 percent of total billed charges 9.3 14.25 Technical (Hospital) Services LIDOCAINE 5 % TOPICAL PATCH RX-28203 CDM 6370000100 HCPCS 250 RC 00603-1880-10 NDC inpatient 1 UN 15 15 MULTIPLAN INC 34080 [3081285] MULTIPLAN INC [308128501] 14.25 percent of total billed charges 9.3 14.25 Technical (Hospital) Services LINEZOLID 600 MG TABLET RX-28224 CDM 6370000100 HCPCS 250 RC 59762-1307-01 NDC inpatient 1 UN 29.22 29.22 HEALTHPARTNERS SX009 HEALTHPARTNERS 23.14 percent of total billed charges 18.12 27.76 Technical (Hospital) Services LINEZOLID 600 MG TABLET RX-28224 CDM 6370000100 HCPCS 250 RC 59762-1307-01 NDC inpatient 1 UN 29.22 29.22 MEDICA (COMMERCIAL) 94265 [3081118] MEDICA CLAIMS [308111801] 26.3 percent of total billed charges 18.12 27.76 Technical (Hospital) Services LINEZOLID 600 MG TABLET RX-28224 CDM 6370000100 HCPCS 250 RC 59762-1307-01 NDC inpatient 1 UN 29.22 29.22 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES HDHP [308136802] 23.14 percent of total billed charges 18.12 27.76 Technical (Hospital) Services LINEZOLID 600 MG TABLET RX-28224 CDM 6370000100 HCPCS 250 RC 59762-1307-01 NDC inpatient 1 UN 29.22 29.22 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES EPO [308136803] 23.14 percent of total billed charges 18.12 27.76 Technical (Hospital) Services LINEZOLID 600 MG TABLET RX-28224 CDM 6370000100 HCPCS 250 RC 59762-1307-01 NDC inpatient 1 UN 29.22 29.22 CIGNA 62308 [3081051] CIGNA 62308 [308105105] 23.14 percent of total billed charges 18.12 27.76 Technical (Hospital) Services LINEZOLID 600 MG TABLET RX-28224 CDM 6370000100 HCPCS 250 RC 59762-1307-01 NDC inpatient 1 UN 29.22 29.22 CIGNA 62308 [3081051] CIGNA STATE OF WYOMING [308105107] 23.14 percent of total billed charges 18.12 27.76 Technical (Hospital) Services LINEZOLID 600 MG TABLET RX-28224 CDM 6370000100 HCPCS 250 RC 59762-1307-01 NDC inpatient 1 UN 29.22 29.22 BLUE CROSS BLUE SHIELD WELLMARK SB889 [3081026] BCBS WYOMING [308102603] 27.76 percent of total billed charges 18.12 27.76 Technical (Hospital) Services LINEZOLID 600 MG TABLET RX-28224 CDM 6370000100 HCPCS 250 RC 59762-1307-01 NDC inpatient 1 UN 29.22 29.22 UNITED HEALTHCARE (COMMERCIAL) [3081199] UNITED HEALTHCARE 87726 [308119901] 18.12 percent of total billed charges 18.12 27.76 Technical (Hospital) Services LINEZOLID 600 MG TABLET RX-28224 CDM 6370000100 HCPCS 250 RC 59762-1307-01 NDC inpatient 1 UN 29.22 29.22 MULTIPLAN INC 34080 [3081285] MULTIPLAN INC [308128501] 27.76 percent of total billed charges 18.12 27.76 Technical (Hospital) Services LINEZOLID 600 MG TABLET RX-28224 CDM 6370000100 HCPCS 250 RC 59762-1307-01 NDC inpatient 1 UN 29.22 29.22 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES PPO [308136801] 23.14 percent of total billed charges 18.12 27.76 Technical (Hospital) Services LINEZOLID 600 MG TABLET RX-28224 CDM 6370000100 HCPCS 250 RC 59762-1307-01 NDC outpatient 1 UN 29.22 29.22 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES PPO [308136801] 23.38 percent of total billed charges 18.12 27.76 Technical (Hospital) Services LINEZOLID 600 MG TABLET RX-28224 CDM 6370000100 HCPCS 250 RC 59762-1307-01 NDC outpatient 1 UN 29.22 29.22 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES HDHP [308136802] 23.38 percent of total billed charges 18.12 27.76 Technical (Hospital) Services LINEZOLID 600 MG TABLET RX-28224 CDM 6370000100 HCPCS 250 RC 59762-1307-01 NDC outpatient 1 UN 29.22 29.22 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES EPO [308136803] 23.38 percent of total billed charges 18.12 27.76 Technical (Hospital) Services LINEZOLID 600 MG TABLET RX-28224 CDM 6370000100 HCPCS 250 RC 59762-1307-01 NDC outpatient 1 UN 29.22 29.22 BLUE CROSS BLUE SHIELD WELLMARK SB889 [3081026] BCBS WYOMING [308102603] 27.76 percent of total billed charges 18.12 27.76 Technical (Hospital) Services LINEZOLID 600 MG TABLET RX-28224 CDM 6370000100 HCPCS 250 RC 59762-1307-01 NDC outpatient 1 UN 29.22 29.22 UNITED HEALTHCARE (COMMERCIAL) [3081199] UNITED HEALTHCARE 87726 [308119901] 18.12 percent of total billed charges 18.12 27.76 Technical (Hospital) Services LINEZOLID 600 MG TABLET RX-28224 CDM 6370000100 HCPCS 250 RC 59762-1307-01 NDC outpatient 1 UN 29.22 29.22 HEALTHPARTNERS SX009 HEALTHPARTNERS 23.38 percent of total billed charges 18.12 27.76 Technical (Hospital) Services LINEZOLID 600 MG TABLET RX-28224 CDM 6370000100 HCPCS 250 RC 59762-1307-01 NDC outpatient 1 UN 29.22 29.22 MEDICA (COMMERCIAL) 94265 [3081118] MEDICA CLAIMS [308111801] 26.3 percent of total billed charges 18.12 27.76 Technical (Hospital) Services LINEZOLID 600 MG TABLET RX-28224 CDM 6370000100 HCPCS 250 RC 59762-1307-01 NDC outpatient 1 UN 29.22 29.22 MULTIPLAN INC 34080 [3081285] MULTIPLAN INC [308128501] 27.76 percent of total billed charges 18.12 27.76 Technical (Hospital) Services LINEZOLID 600 MG TABLET RX-28224 CDM 6370000100 HCPCS 250 RC 59762-1307-01 NDC outpatient 1 UN 29.22 29.22 CIGNA 62308 [3081051] CIGNA 62308 [308105105] 23.38 percent of total billed charges 18.12 27.76 Technical (Hospital) Services LINEZOLID 600 MG TABLET RX-28224 CDM 6370000100 HCPCS 250 RC 59762-1307-01 NDC outpatient 1 UN 29.22 29.22 CIGNA 62308 [3081051] CIGNA STATE OF WYOMING [308105107] 23.38 percent of total billed charges 18.12 27.76 Technical (Hospital) Services INSULIN GLARGINE (U-100) 100 UNIT/ML SUBCUTANEOUS SOLUTION RX-28282 CDM 6370000100 HCPCS 250 RC 00088-2220-33 NDC inpatient 10 ML 256.26 256.26 CIGNA 62308 [3081051] CIGNA 62308 [308105105] 202.91 percent of total billed charges 158.88 243.45 Technical (Hospital) Services INSULIN GLARGINE (U-100) 100 UNIT/ML SUBCUTANEOUS SOLUTION RX-28282 CDM 6370000100 HCPCS 250 RC 00088-2220-33 NDC inpatient 10 ML 256.26 256.26 CIGNA 62308 [3081051] CIGNA STATE OF WYOMING [308105107] 202.91 percent of total billed charges 158.88 243.45 Technical (Hospital) Services INSULIN GLARGINE (U-100) 100 UNIT/ML SUBCUTANEOUS SOLUTION RX-28282 CDM 6370000100 HCPCS 250 RC 00088-2220-33 NDC inpatient 10 ML 256.26 256.26 BLUE CROSS BLUE SHIELD WELLMARK SB889 [3081026] BCBS WYOMING [308102603] 243.45 percent of total billed charges 158.88 243.45 Technical (Hospital) Services INSULIN GLARGINE (U-100) 100 UNIT/ML SUBCUTANEOUS SOLUTION RX-28282 CDM 6370000100 HCPCS 250 RC 00088-2220-33 NDC inpatient 10 ML 256.26 256.26 UNITED HEALTHCARE (COMMERCIAL) [3081199] UNITED HEALTHCARE 87726 [308119901] 158.88 percent of total billed charges 158.88 243.45 Technical (Hospital) Services INSULIN GLARGINE (U-100) 100 UNIT/ML SUBCUTANEOUS SOLUTION RX-28282 CDM 6370000100 HCPCS 250 RC 00088-2220-33 NDC inpatient 10 ML 256.26 256.26 MEDICA (COMMERCIAL) 94265 [3081118] MEDICA CLAIMS [308111801] 230.63 percent of total billed charges 158.88 243.45 Technical (Hospital) Services INSULIN GLARGINE (U-100) 100 UNIT/ML SUBCUTANEOUS SOLUTION RX-28282 CDM 6370000100 HCPCS 250 RC 00088-2220-33 NDC inpatient 10 ML 256.26 256.26 MULTIPLAN INC 34080 [3081285] MULTIPLAN INC [308128501] 243.45 percent of total billed charges 158.88 243.45 Technical (Hospital) Services INSULIN GLARGINE (U-100) 100 UNIT/ML SUBCUTANEOUS SOLUTION RX-28282 CDM 6370000100 HCPCS 250 RC 00088-2220-33 NDC inpatient 10 ML 256.26 256.26 HEALTHPARTNERS SX009 HEALTHPARTNERS 202.91 percent of total billed charges 158.88 243.45 Technical (Hospital) Services INSULIN GLARGINE (U-100) 100 UNIT/ML SUBCUTANEOUS SOLUTION RX-28282 CDM 6370000100 HCPCS 250 RC 00088-2220-33 NDC inpatient 10 ML 256.26 256.26 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES EPO [308136803] 202.91 percent of total billed charges 158.88 243.45 Technical (Hospital) Services INSULIN GLARGINE (U-100) 100 UNIT/ML SUBCUTANEOUS SOLUTION RX-28282 CDM 6370000100 HCPCS 250 RC 00088-2220-33 NDC inpatient 10 ML 256.26 256.26 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES PPO [308136801] 202.91 percent of total billed charges 158.88 243.45 Technical (Hospital) Services INSULIN GLARGINE (U-100) 100 UNIT/ML SUBCUTANEOUS SOLUTION RX-28282 CDM 6370000100 HCPCS 250 RC 00088-2220-33 NDC inpatient 10 ML 256.26 256.26 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES HDHP [308136802] 202.91 percent of total billed charges 158.88 243.45 Technical (Hospital) Services INSULIN GLARGINE (U-100) 100 UNIT/ML SUBCUTANEOUS SOLUTION RX-28282 CDM 6370000100 HCPCS 250 RC 00088-2220-33 NDC outpatient 10 ML 256.26 256.26 CIGNA 62308 [3081051] CIGNA 62308 [308105105] 205.01 percent of total billed charges 158.88 243.45 Technical (Hospital) Services INSULIN GLARGINE (U-100) 100 UNIT/ML SUBCUTANEOUS SOLUTION RX-28282 CDM 6370000100 HCPCS 250 RC 00088-2220-33 NDC outpatient 10 ML 256.26 256.26 CIGNA 62308 [3081051] CIGNA STATE OF WYOMING [308105107] 205.01 percent of total billed charges 158.88 243.45 Technical (Hospital) Services INSULIN GLARGINE (U-100) 100 UNIT/ML SUBCUTANEOUS SOLUTION RX-28282 CDM 6370000100 HCPCS 250 RC 00088-2220-33 NDC outpatient 10 ML 256.26 256.26 UNITED HEALTHCARE (COMMERCIAL) [3081199] UNITED HEALTHCARE 87726 [308119901] 158.88 percent of total billed charges 158.88 243.45 Technical (Hospital) Services INSULIN GLARGINE (U-100) 100 UNIT/ML SUBCUTANEOUS SOLUTION RX-28282 CDM 6370000100 HCPCS 250 RC 00088-2220-33 NDC outpatient 10 ML 256.26 256.26 HEALTHPARTNERS SX009 HEALTHPARTNERS 205.01 percent of total billed charges 158.88 243.45 Technical (Hospital) Services INSULIN GLARGINE (U-100) 100 UNIT/ML SUBCUTANEOUS SOLUTION RX-28282 CDM 6370000100 HCPCS 250 RC 00088-2220-33 NDC outpatient 10 ML 256.26 256.26 MEDICA (COMMERCIAL) 94265 [3081118] MEDICA CLAIMS [308111801] 230.63 percent of total billed charges 158.88 243.45 Technical (Hospital) Services INSULIN GLARGINE (U-100) 100 UNIT/ML SUBCUTANEOUS SOLUTION RX-28282 CDM 6370000100 HCPCS 250 RC 00088-2220-33 NDC outpatient 10 ML 256.26 256.26 MULTIPLAN INC 34080 [3081285] MULTIPLAN INC [308128501] 243.45 percent of total billed charges 158.88 243.45 Technical (Hospital) Services INSULIN GLARGINE (U-100) 100 UNIT/ML SUBCUTANEOUS SOLUTION RX-28282 CDM 6370000100 HCPCS 250 RC 00088-2220-33 NDC outpatient 10 ML 256.26 256.26 BLUE CROSS BLUE SHIELD WELLMARK SB889 [3081026] BCBS WYOMING [308102603] 243.45 percent of total billed charges 158.88 243.45 Technical (Hospital) Services INSULIN GLARGINE (U-100) 100 UNIT/ML SUBCUTANEOUS SOLUTION RX-28282 CDM 6370000100 HCPCS 250 RC 00088-2220-33 NDC outpatient 10 ML 256.26 256.26 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES EPO [308136803] 205.01 percent of total billed charges 158.88 243.45 Technical (Hospital) Services INSULIN GLARGINE (U-100) 100 UNIT/ML SUBCUTANEOUS SOLUTION RX-28282 CDM 6370000100 HCPCS 250 RC 00088-2220-33 NDC outpatient 10 ML 256.26 256.26 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES HDHP [308136802] 205.01 percent of total billed charges 158.88 243.45 Technical (Hospital) Services INSULIN GLARGINE (U-100) 100 UNIT/ML SUBCUTANEOUS SOLUTION RX-28282 CDM 6370000100 HCPCS 250 RC 00088-2220-33 NDC outpatient 10 ML 256.26 256.26 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES PPO [308136801] 205.01 percent of total billed charges 158.88 243.45 Technical (Hospital) Services HYDROCODONE 10 MG-ACETAMINOPHEN 325 MG TABLET RX-28384 CDM 6370000100 HCPCS 250 RC 60687-0418-01 NDC outpatient 1 UN 6.22 6.22 HEALTHPARTNERS SX009 HEALTHPARTNERS 4.98 percent of total billed charges 3.86 5.91 Technical (Hospital) Services HYDROCODONE 10 MG-ACETAMINOPHEN 325 MG TABLET RX-28384 CDM 6370000100 HCPCS 250 RC 60687-0418-01 NDC outpatient 1 UN 6.22 6.22 UNITED HEALTHCARE (COMMERCIAL) [3081199] UNITED HEALTHCARE 87726 [308119901] 3.86 percent of total billed charges 3.86 5.91 Technical (Hospital) Services HYDROCODONE 10 MG-ACETAMINOPHEN 325 MG TABLET RX-28384 CDM 6370000100 HCPCS 250 RC 60687-0418-01 NDC outpatient 1 UN 6.22 6.22 CIGNA 62308 [3081051] CIGNA 62308 [308105105] 4.98 percent of total billed charges 3.86 5.91 Technical (Hospital) Services HYDROCODONE 10 MG-ACETAMINOPHEN 325 MG TABLET RX-28384 CDM 6370000100 HCPCS 250 RC 60687-0418-01 NDC outpatient 1 UN 6.22 6.22 CIGNA 62308 [3081051] CIGNA STATE OF WYOMING [308105107] 4.98 percent of total billed charges 3.86 5.91 Technical (Hospital) Services HYDROCODONE 10 MG-ACETAMINOPHEN 325 MG TABLET RX-28384 CDM 6370000100 HCPCS 250 RC 60687-0418-01 NDC outpatient 1 UN 6.22 6.22 MULTIPLAN INC 34080 [3081285] MULTIPLAN INC [308128501] 5.91 percent of total billed charges 3.86 5.91 Technical (Hospital) Services HYDROCODONE 10 MG-ACETAMINOPHEN 325 MG TABLET RX-28384 CDM 6370000100 HCPCS 250 RC 60687-0418-01 NDC outpatient 1 UN 6.22 6.22 MEDICA (COMMERCIAL) 94265 [3081118] MEDICA CLAIMS [308111801] 5.6 percent of total billed charges 3.86 5.91 Technical (Hospital) Services HYDROCODONE 10 MG-ACETAMINOPHEN 325 MG TABLET RX-28384 CDM 6370000100 HCPCS 250 RC 60687-0418-01 NDC outpatient 1 UN 6.22 6.22 BLUE CROSS BLUE SHIELD WELLMARK SB889 [3081026] BCBS WYOMING [308102603] 5.91 percent of total billed charges 3.86 5.91 Technical (Hospital) Services HYDROCODONE 10 MG-ACETAMINOPHEN 325 MG TABLET RX-28384 CDM 6370000100 HCPCS 250 RC 60687-0418-01 NDC outpatient 1 UN 6.22 6.22 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES EPO [308136803] 4.98 percent of total billed charges 3.86 5.91 Technical (Hospital) Services HYDROCODONE 10 MG-ACETAMINOPHEN 325 MG TABLET RX-28384 CDM 6370000100 HCPCS 250 RC 60687-0418-01 NDC outpatient 1 UN 6.22 6.22 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES PPO [308136801] 4.98 percent of total billed charges 3.86 5.91 Technical (Hospital) Services HYDROCODONE 10 MG-ACETAMINOPHEN 325 MG TABLET RX-28384 CDM 6370000100 HCPCS 250 RC 60687-0418-01 NDC outpatient 1 UN 6.22 6.22 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES HDHP [308136802] 4.98 percent of total billed charges 3.86 5.91 Technical (Hospital) Services HYDROCODONE 10 MG-ACETAMINOPHEN 325 MG TABLET RX-28384 CDM 6370000100 HCPCS 250 RC 60687-0418-01 NDC inpatient 1 UN 6.22 6.22 CIGNA 62308 [3081051] CIGNA 62308 [308105105] 4.92 percent of total billed charges 3.86 5.91 Technical (Hospital) Services HYDROCODONE 10 MG-ACETAMINOPHEN 325 MG TABLET RX-28384 CDM 6370000100 HCPCS 250 RC 60687-0418-01 NDC inpatient 1 UN 6.22 6.22 CIGNA 62308 [3081051] CIGNA STATE OF WYOMING [308105107] 4.92 percent of total billed charges 3.86 5.91 Technical (Hospital) Services HYDROCODONE 10 MG-ACETAMINOPHEN 325 MG TABLET RX-28384 CDM 6370000100 HCPCS 250 RC 60687-0418-01 NDC inpatient 1 UN 6.22 6.22 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES EPO [308136803] 4.92 percent of total billed charges 3.86 5.91 Technical (Hospital) Services HYDROCODONE 10 MG-ACETAMINOPHEN 325 MG TABLET RX-28384 CDM 6370000100 HCPCS 250 RC 60687-0418-01 NDC inpatient 1 UN 6.22 6.22 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES HDHP [308136802] 4.92 percent of total billed charges 3.86 5.91 Technical (Hospital) Services HYDROCODONE 10 MG-ACETAMINOPHEN 325 MG TABLET RX-28384 CDM 6370000100 HCPCS 250 RC 60687-0418-01 NDC inpatient 1 UN 6.22 6.22 HEALTHPARTNERS SX009 HEALTHPARTNERS 4.92 percent of total billed charges 3.86 5.91 Technical (Hospital) Services HYDROCODONE 10 MG-ACETAMINOPHEN 325 MG TABLET RX-28384 CDM 6370000100 HCPCS 250 RC 60687-0418-01 NDC inpatient 1 UN 6.22 6.22 MEDICA (COMMERCIAL) 94265 [3081118] MEDICA CLAIMS [308111801] 5.6 percent of total billed charges 3.86 5.91 Technical (Hospital) Services HYDROCODONE 10 MG-ACETAMINOPHEN 325 MG TABLET RX-28384 CDM 6370000100 HCPCS 250 RC 60687-0418-01 NDC inpatient 1 UN 6.22 6.22 UNITED HEALTHCARE (COMMERCIAL) [3081199] UNITED HEALTHCARE 87726 [308119901] 3.86 percent of total billed charges 3.86 5.91 Technical (Hospital) Services HYDROCODONE 10 MG-ACETAMINOPHEN 325 MG TABLET RX-28384 CDM 6370000100 HCPCS 250 RC 60687-0418-01 NDC inpatient 1 UN 6.22 6.22 BLUE CROSS BLUE SHIELD WELLMARK SB889 [3081026] BCBS WYOMING [308102603] 5.91 percent of total billed charges 3.86 5.91 Technical (Hospital) Services HYDROCODONE 10 MG-ACETAMINOPHEN 325 MG TABLET RX-28384 CDM 6370000100 HCPCS 250 RC 60687-0418-01 NDC inpatient 1 UN 6.22 6.22 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES PPO [308136801] 4.92 percent of total billed charges 3.86 5.91 Technical (Hospital) Services HYDROCODONE 10 MG-ACETAMINOPHEN 325 MG TABLET RX-28384 CDM 6370000100 HCPCS 250 RC 60687-0418-01 NDC inpatient 1 UN 6.22 6.22 MULTIPLAN INC 34080 [3081285] MULTIPLAN INC [308128501] 5.91 percent of total billed charges 3.86 5.91 Technical (Hospital) Services INSULIN ASPART 100 UNIT/ML INJECTION SOLUTION RX-28534 CDM 6370000100 HCPCS 250 RC 00169-7501-11 NDC inpatient 10 ML 334.34 334.34 CIGNA 62308 [3081051] CIGNA 62308 [308105105] 264.73 percent of total billed charges 207.29 317.62 Technical (Hospital) Services INSULIN ASPART 100 UNIT/ML INJECTION SOLUTION RX-28534 CDM 6370000100 HCPCS 250 RC 00169-7501-11 NDC inpatient 10 ML 334.34 334.34 CIGNA 62308 [3081051] CIGNA STATE OF WYOMING [308105107] 264.73 percent of total billed charges 207.29 317.62 Technical (Hospital) Services INSULIN ASPART 100 UNIT/ML INJECTION SOLUTION RX-28534 CDM 6370000100 HCPCS 250 RC 00169-7501-11 NDC inpatient 10 ML 334.34 334.34 UNITED HEALTHCARE (COMMERCIAL) [3081199] UNITED HEALTHCARE 87726 [308119901] 207.29 percent of total billed charges 207.29 317.62 Technical (Hospital) Services INSULIN ASPART 100 UNIT/ML INJECTION SOLUTION RX-28534 CDM 6370000100 HCPCS 250 RC 00169-7501-11 NDC inpatient 10 ML 334.34 334.34 BLUE CROSS BLUE SHIELD WELLMARK SB889 [3081026] BCBS WYOMING [308102603] 317.62 percent of total billed charges 207.29 317.62 Technical (Hospital) Services INSULIN ASPART 100 UNIT/ML INJECTION SOLUTION RX-28534 CDM 6370000100 HCPCS 250 RC 00169-7501-11 NDC inpatient 10 ML 334.34 334.34 MULTIPLAN INC 34080 [3081285] MULTIPLAN INC [308128501] 317.62 percent of total billed charges 207.29 317.62 Technical (Hospital) Services INSULIN ASPART 100 UNIT/ML INJECTION SOLUTION RX-28534 CDM 6370000100 HCPCS 250 RC 00169-7501-11 NDC inpatient 10 ML 334.34 334.34 MEDICA (COMMERCIAL) 94265 [3081118] MEDICA CLAIMS [308111801] 300.91 percent of total billed charges 207.29 317.62 Technical (Hospital) Services INSULIN ASPART 100 UNIT/ML INJECTION SOLUTION RX-28534 CDM 6370000100 HCPCS 250 RC 00169-7501-11 NDC inpatient 10 ML 334.34 334.34 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES EPO [308136803] 264.73 percent of total billed charges 207.29 317.62 Technical (Hospital) Services INSULIN ASPART 100 UNIT/ML INJECTION SOLUTION RX-28534 CDM 6370000100 HCPCS 250 RC 00169-7501-11 NDC inpatient 10 ML 334.34 334.34 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES HDHP [308136802] 264.73 percent of total billed charges 207.29 317.62 Technical (Hospital) Services INSULIN ASPART 100 UNIT/ML INJECTION SOLUTION RX-28534 CDM 6370000100 HCPCS 250 RC 00169-7501-11 NDC inpatient 10 ML 334.34 334.34 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES PPO [308136801] 264.73 percent of total billed charges 207.29 317.62 Technical (Hospital) Services INSULIN ASPART 100 UNIT/ML INJECTION SOLUTION RX-28534 CDM 6370000100 HCPCS 250 RC 00169-7501-11 NDC inpatient 10 ML 334.34 334.34 HEALTHPARTNERS SX009 HEALTHPARTNERS 264.73 percent of total billed charges 207.29 317.62 Technical (Hospital) Services INSULIN ASPART 100 UNIT/ML INJECTION SOLUTION RX-28534 CDM 6370000100 HCPCS 250 RC 00169-7501-11 NDC outpatient 10 ML 334.34 334.34 CIGNA 62308 [3081051] CIGNA 62308 [308105105] 267.47 percent of total billed charges 207.29 317.62 Technical (Hospital) Services INSULIN ASPART 100 UNIT/ML INJECTION SOLUTION RX-28534 CDM 6370000100 HCPCS 250 RC 00169-7501-11 NDC outpatient 10 ML 334.34 334.34 CIGNA 62308 [3081051] CIGNA STATE OF WYOMING [308105107] 267.47 percent of total billed charges 207.29 317.62 Technical (Hospital) Services INSULIN ASPART 100 UNIT/ML INJECTION SOLUTION RX-28534 CDM 6370000100 HCPCS 250 RC 00169-7501-11 NDC outpatient 10 ML 334.34 334.34 MULTIPLAN INC 34080 [3081285] MULTIPLAN INC [308128501] 317.62 percent of total billed charges 207.29 317.62 Technical (Hospital) Services INSULIN ASPART 100 UNIT/ML INJECTION SOLUTION RX-28534 CDM 6370000100 HCPCS 250 RC 00169-7501-11 NDC outpatient 10 ML 334.34 334.34 MEDICA (COMMERCIAL) 94265 [3081118] MEDICA CLAIMS [308111801] 300.91 percent of total billed charges 207.29 317.62 Technical (Hospital) Services INSULIN ASPART 100 UNIT/ML INJECTION SOLUTION RX-28534 CDM 6370000100 HCPCS 250 RC 00169-7501-11 NDC outpatient 10 ML 334.34 334.34 UNITED HEALTHCARE (COMMERCIAL) [3081199] UNITED HEALTHCARE 87726 [308119901] 207.29 percent of total billed charges 207.29 317.62 Technical (Hospital) Services INSULIN ASPART 100 UNIT/ML INJECTION SOLUTION RX-28534 CDM 6370000100 HCPCS 250 RC 00169-7501-11 NDC outpatient 10 ML 334.34 334.34 HEALTHPARTNERS SX009 HEALTHPARTNERS 267.47 percent of total billed charges 207.29 317.62 Technical (Hospital) Services INSULIN ASPART 100 UNIT/ML INJECTION SOLUTION RX-28534 CDM 6370000100 HCPCS 250 RC 00169-7501-11 NDC outpatient 10 ML 334.34 334.34 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES EPO [308136803] 267.47 percent of total billed charges 207.29 317.62 Technical (Hospital) Services INSULIN ASPART 100 UNIT/ML INJECTION SOLUTION RX-28534 CDM 6370000100 HCPCS 250 RC 00169-7501-11 NDC outpatient 10 ML 334.34 334.34 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES HDHP [308136802] 267.47 percent of total billed charges 207.29 317.62 Technical (Hospital) Services INSULIN ASPART 100 UNIT/ML INJECTION SOLUTION RX-28534 CDM 6370000100 HCPCS 250 RC 00169-7501-11 NDC outpatient 10 ML 334.34 334.34 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES PPO [308136801] 267.47 percent of total billed charges 207.29 317.62 Technical (Hospital) Services INSULIN ASPART 100 UNIT/ML INJECTION SOLUTION RX-28534 CDM 6370000100 HCPCS 250 RC 00169-7501-11 NDC outpatient 10 ML 334.34 334.34 BLUE CROSS BLUE SHIELD WELLMARK SB889 [3081026] BCBS WYOMING [308102603] 317.62 percent of total billed charges 207.29 317.62 Technical (Hospital) Services CALCIUM CITRATE 315 MG-VITAMIN D3 5 MCG (200 UNIT) TABLET RX-28572 CDM 6370000100 HCPCS 250 RC 80681-0045-00 NDC inpatient 1 UN 5.69 5.69 MULTIPLAN INC 34080 [3081285] MULTIPLAN INC [308128501] 5.41 percent of total billed charges 3.53 5.41 Technical (Hospital) Services CALCIUM CITRATE 315 MG-VITAMIN D3 5 MCG (200 UNIT) TABLET RX-28572 CDM 6370000100 HCPCS 250 RC 80681-0045-00 NDC inpatient 1 UN 5.69 5.69 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES PPO [308136801] 4.51 percent of total billed charges 3.53 5.41 Technical (Hospital) Services CALCIUM CITRATE 315 MG-VITAMIN D3 5 MCG (200 UNIT) TABLET RX-28572 CDM 6370000100 HCPCS 250 RC 80681-0045-00 NDC inpatient 1 UN 5.69 5.69 BLUE CROSS BLUE SHIELD WELLMARK SB889 [3081026] BCBS WYOMING [308102603] 5.41 percent of total billed charges 3.53 5.41 Technical (Hospital) Services CALCIUM CITRATE 315 MG-VITAMIN D3 5 MCG (200 UNIT) TABLET RX-28572 CDM 6370000100 HCPCS 250 RC 80681-0045-00 NDC inpatient 1 UN 5.69 5.69 UNITED HEALTHCARE (COMMERCIAL) [3081199] UNITED HEALTHCARE 87726 [308119901] 3.53 percent of total billed charges 3.53 5.41 Technical (Hospital) Services CALCIUM CITRATE 315 MG-VITAMIN D3 5 MCG (200 UNIT) TABLET RX-28572 CDM 6370000100 HCPCS 250 RC 80681-0045-00 NDC inpatient 1 UN 5.69 5.69 HEALTHPARTNERS SX009 HEALTHPARTNERS 4.51 percent of total billed charges 3.53 5.41 Technical (Hospital) Services CALCIUM CITRATE 315 MG-VITAMIN D3 5 MCG (200 UNIT) TABLET RX-28572 CDM 6370000100 HCPCS 250 RC 80681-0045-00 NDC inpatient 1 UN 5.69 5.69 MEDICA (COMMERCIAL) 94265 [3081118] MEDICA CLAIMS [308111801] 5.12 percent of total billed charges 3.53 5.41 Technical (Hospital) Services CALCIUM CITRATE 315 MG-VITAMIN D3 5 MCG (200 UNIT) TABLET RX-28572 CDM 6370000100 HCPCS 250 RC 80681-0045-00 NDC inpatient 1 UN 5.69 5.69 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES HDHP [308136802] 4.51 percent of total billed charges 3.53 5.41 Technical (Hospital) Services CALCIUM CITRATE 315 MG-VITAMIN D3 5 MCG (200 UNIT) TABLET RX-28572 CDM 6370000100 HCPCS 250 RC 80681-0045-00 NDC inpatient 1 UN 5.69 5.69 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES EPO [308136803] 4.51 percent of total billed charges 3.53 5.41 Technical (Hospital) Services CALCIUM CITRATE 315 MG-VITAMIN D3 5 MCG (200 UNIT) TABLET RX-28572 CDM 6370000100 HCPCS 250 RC 80681-0045-00 NDC inpatient 1 UN 5.69 5.69 CIGNA 62308 [3081051] CIGNA 62308 [308105105] 4.51 percent of total billed charges 3.53 5.41 Technical (Hospital) Services CALCIUM CITRATE 315 MG-VITAMIN D3 5 MCG (200 UNIT) TABLET RX-28572 CDM 6370000100 HCPCS 250 RC 80681-0045-00 NDC inpatient 1 UN 5.69 5.69 CIGNA 62308 [3081051] CIGNA STATE OF WYOMING [308105107] 4.51 percent of total billed charges 3.53 5.41 Technical (Hospital) Services CALCIUM CITRATE 315 MG-VITAMIN D3 5 MCG (200 UNIT) TABLET RX-28572 CDM 6370000100 HCPCS 250 RC 80681-0045-00 NDC outpatient 1 UN 5.69 5.69 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES HDHP [308136802] 4.55 percent of total billed charges 3.53 5.41 Technical (Hospital) Services CALCIUM CITRATE 315 MG-VITAMIN D3 5 MCG (200 UNIT) TABLET RX-28572 CDM 6370000100 HCPCS 250 RC 80681-0045-00 NDC outpatient 1 UN 5.69 5.69 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES PPO [308136801] 4.55 percent of total billed charges 3.53 5.41 Technical (Hospital) Services CALCIUM CITRATE 315 MG-VITAMIN D3 5 MCG (200 UNIT) TABLET RX-28572 CDM 6370000100 HCPCS 250 RC 80681-0045-00 NDC outpatient 1 UN 5.69 5.69 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES EPO [308136803] 4.55 percent of total billed charges 3.53 5.41 Technical (Hospital) Services CALCIUM CITRATE 315 MG-VITAMIN D3 5 MCG (200 UNIT) TABLET RX-28572 CDM 6370000100 HCPCS 250 RC 80681-0045-00 NDC outpatient 1 UN 5.69 5.69 BLUE CROSS BLUE SHIELD WELLMARK SB889 [3081026] BCBS WYOMING [308102603] 5.41 percent of total billed charges 3.53 5.41 Technical (Hospital) Services CALCIUM CITRATE 315 MG-VITAMIN D3 5 MCG (200 UNIT) TABLET RX-28572 CDM 6370000100 HCPCS 250 RC 80681-0045-00 NDC outpatient 1 UN 5.69 5.69 MULTIPLAN INC 34080 [3081285] MULTIPLAN INC [308128501] 5.41 percent of total billed charges 3.53 5.41 Technical (Hospital) Services CALCIUM CITRATE 315 MG-VITAMIN D3 5 MCG (200 UNIT) TABLET RX-28572 CDM 6370000100 HCPCS 250 RC 80681-0045-00 NDC outpatient 1 UN 5.69 5.69 CIGNA 62308 [3081051] CIGNA 62308 [308105105] 4.55 percent of total billed charges 3.53 5.41 Technical (Hospital) Services CALCIUM CITRATE 315 MG-VITAMIN D3 5 MCG (200 UNIT) TABLET RX-28572 CDM 6370000100 HCPCS 250 RC 80681-0045-00 NDC outpatient 1 UN 5.69 5.69 CIGNA 62308 [3081051] CIGNA STATE OF WYOMING [308105107] 4.55 percent of total billed charges 3.53 5.41 Technical (Hospital) Services CALCIUM CITRATE 315 MG-VITAMIN D3 5 MCG (200 UNIT) TABLET RX-28572 CDM 6370000100 HCPCS 250 RC 80681-0045-00 NDC outpatient 1 UN 5.69 5.69 MEDICA (COMMERCIAL) 94265 [3081118] MEDICA CLAIMS [308111801] 5.12 percent of total billed charges 3.53 5.41 Technical (Hospital) Services CALCIUM CITRATE 315 MG-VITAMIN D3 5 MCG (200 UNIT) TABLET RX-28572 CDM 6370000100 HCPCS 250 RC 80681-0045-00 NDC outpatient 1 UN 5.69 5.69 HEALTHPARTNERS SX009 HEALTHPARTNERS 4.55 percent of total billed charges 3.53 5.41 Technical (Hospital) Services CALCIUM CITRATE 315 MG-VITAMIN D3 5 MCG (200 UNIT) TABLET RX-28572 CDM 6370000100 HCPCS 250 RC 80681-0045-00 NDC outpatient 1 UN 5.69 5.69 UNITED HEALTHCARE (COMMERCIAL) [3081199] UNITED HEALTHCARE 87726 [308119901] 3.53 percent of total billed charges 3.53 5.41 Technical (Hospital) Services "ERGOCALCIFEROL (VITAMIN D2) 1,250 MCG (50,000 UNIT) CAPSULE" RX-2863 CDM 6370000100 HCPCS 250 RC 64380-0737-06 NDC inpatient 1 UN 5.84 5.84 UNITED HEALTHCARE (COMMERCIAL) [3081199] UNITED HEALTHCARE 87726 [308119901] 3.62 percent of total billed charges 3.62 5.55 Technical (Hospital) Services "ERGOCALCIFEROL (VITAMIN D2) 1,250 MCG (50,000 UNIT) CAPSULE" RX-2863 CDM 6370000100 HCPCS 250 RC 64380-0737-06 NDC inpatient 1 UN 5.84 5.84 BLUE CROSS BLUE SHIELD WELLMARK SB889 [3081026] BCBS WYOMING [308102603] 5.55 percent of total billed charges 3.62 5.55 Technical (Hospital) Services "ERGOCALCIFEROL (VITAMIN D2) 1,250 MCG (50,000 UNIT) CAPSULE" RX-2863 CDM 6370000100 HCPCS 250 RC 64380-0737-06 NDC inpatient 1 UN 5.84 5.84 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES HDHP [308136802] 4.62 percent of total billed charges 3.62 5.55 Technical (Hospital) Services "ERGOCALCIFEROL (VITAMIN D2) 1,250 MCG (50,000 UNIT) CAPSULE" RX-2863 CDM 6370000100 HCPCS 250 RC 64380-0737-06 NDC inpatient 1 UN 5.84 5.84 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES EPO [308136803] 4.62 percent of total billed charges 3.62 5.55 Technical (Hospital) Services "ERGOCALCIFEROL (VITAMIN D2) 1,250 MCG (50,000 UNIT) CAPSULE" RX-2863 CDM 6370000100 HCPCS 250 RC 64380-0737-06 NDC inpatient 1 UN 5.84 5.84 CIGNA 62308 [3081051] CIGNA 62308 [308105105] 4.62 percent of total billed charges 3.62 5.55 Technical (Hospital) Services "ERGOCALCIFEROL (VITAMIN D2) 1,250 MCG (50,000 UNIT) CAPSULE" RX-2863 CDM 6370000100 HCPCS 250 RC 64380-0737-06 NDC inpatient 1 UN 5.84 5.84 CIGNA 62308 [3081051] CIGNA STATE OF WYOMING [308105107] 4.62 percent of total billed charges 3.62 5.55 Technical (Hospital) Services "ERGOCALCIFEROL (VITAMIN D2) 1,250 MCG (50,000 UNIT) CAPSULE" RX-2863 CDM 6370000100 HCPCS 250 RC 64380-0737-06 NDC inpatient 1 UN 5.84 5.84 MULTIPLAN INC 34080 [3081285] MULTIPLAN INC [308128501] 5.55 percent of total billed charges 3.62 5.55 Technical (Hospital) Services "ERGOCALCIFEROL (VITAMIN D2) 1,250 MCG (50,000 UNIT) CAPSULE" RX-2863 CDM 6370000100 HCPCS 250 RC 64380-0737-06 NDC inpatient 1 UN 5.84 5.84 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES PPO [308136801] 4.62 percent of total billed charges 3.62 5.55 Technical (Hospital) Services "ERGOCALCIFEROL (VITAMIN D2) 1,250 MCG (50,000 UNIT) CAPSULE" RX-2863 CDM 6370000100 HCPCS 250 RC 64380-0737-06 NDC inpatient 1 UN 5.84 5.84 HEALTHPARTNERS SX009 HEALTHPARTNERS 4.62 percent of total billed charges 3.62 5.55 Technical (Hospital) Services "ERGOCALCIFEROL (VITAMIN D2) 1,250 MCG (50,000 UNIT) CAPSULE" RX-2863 CDM 6370000100 HCPCS 250 RC 64380-0737-06 NDC inpatient 1 UN 5.84 5.84 MEDICA (COMMERCIAL) 94265 [3081118] MEDICA CLAIMS [308111801] 5.26 percent of total billed charges 3.62 5.55 Technical (Hospital) Services "ERGOCALCIFEROL (VITAMIN D2) 1,250 MCG (50,000 UNIT) CAPSULE" RX-2863 CDM 6370000100 HCPCS 250 RC 64380-0737-06 NDC outpatient 1 UN 5.84 5.84 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES PPO [308136801] 4.67 percent of total billed charges 3.62 5.55 Technical (Hospital) Services "ERGOCALCIFEROL (VITAMIN D2) 1,250 MCG (50,000 UNIT) CAPSULE" RX-2863 CDM 6370000100 HCPCS 250 RC 64380-0737-06 NDC outpatient 1 UN 5.84 5.84 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES EPO [308136803] 4.67 percent of total billed charges 3.62 5.55 Technical (Hospital) Services "ERGOCALCIFEROL (VITAMIN D2) 1,250 MCG (50,000 UNIT) CAPSULE" RX-2863 CDM 6370000100 HCPCS 250 RC 64380-0737-06 NDC outpatient 1 UN 5.84 5.84 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES HDHP [308136802] 4.67 percent of total billed charges 3.62 5.55 Technical (Hospital) Services "ERGOCALCIFEROL (VITAMIN D2) 1,250 MCG (50,000 UNIT) CAPSULE" RX-2863 CDM 6370000100 HCPCS 250 RC 64380-0737-06 NDC outpatient 1 UN 5.84 5.84 HEALTHPARTNERS SX009 HEALTHPARTNERS 4.67 percent of total billed charges 3.62 5.55 Technical (Hospital) Services "ERGOCALCIFEROL (VITAMIN D2) 1,250 MCG (50,000 UNIT) CAPSULE" RX-2863 CDM 6370000100 HCPCS 250 RC 64380-0737-06 NDC outpatient 1 UN 5.84 5.84 UNITED HEALTHCARE (COMMERCIAL) [3081199] UNITED HEALTHCARE 87726 [308119901] 3.62 percent of total billed charges 3.62 5.55 Technical (Hospital) Services "ERGOCALCIFEROL (VITAMIN D2) 1,250 MCG (50,000 UNIT) CAPSULE" RX-2863 CDM 6370000100 HCPCS 250 RC 64380-0737-06 NDC outpatient 1 UN 5.84 5.84 MULTIPLAN INC 34080 [3081285] MULTIPLAN INC [308128501] 5.55 percent of total billed charges 3.62 5.55 Technical (Hospital) Services "ERGOCALCIFEROL (VITAMIN D2) 1,250 MCG (50,000 UNIT) CAPSULE" RX-2863 CDM 6370000100 HCPCS 250 RC 64380-0737-06 NDC outpatient 1 UN 5.84 5.84 CIGNA 62308 [3081051] CIGNA 62308 [308105105] 4.67 percent of total billed charges 3.62 5.55 Technical (Hospital) Services "ERGOCALCIFEROL (VITAMIN D2) 1,250 MCG (50,000 UNIT) CAPSULE" RX-2863 CDM 6370000100 HCPCS 250 RC 64380-0737-06 NDC outpatient 1 UN 5.84 5.84 CIGNA 62308 [3081051] CIGNA STATE OF WYOMING [308105107] 4.67 percent of total billed charges 3.62 5.55 Technical (Hospital) Services "ERGOCALCIFEROL (VITAMIN D2) 1,250 MCG (50,000 UNIT) CAPSULE" RX-2863 CDM 6370000100 HCPCS 250 RC 64380-0737-06 NDC outpatient 1 UN 5.84 5.84 MEDICA (COMMERCIAL) 94265 [3081118] MEDICA CLAIMS [308111801] 5.26 percent of total billed charges 3.62 5.55 Technical (Hospital) Services "ERGOCALCIFEROL (VITAMIN D2) 1,250 MCG (50,000 UNIT) CAPSULE" RX-2863 CDM 6370000100 HCPCS 250 RC 64380-0737-06 NDC outpatient 1 UN 5.84 5.84 BLUE CROSS BLUE SHIELD WELLMARK SB889 [3081026] BCBS WYOMING [308102603] 5.55 percent of total billed charges 3.62 5.55 Technical (Hospital) Services "NIFEDIPINE ER 30 MG TABLET,EXTENDED RELEASE 24 HR" RX-28643 CDM 6370000100 HCPCS 250 RC 68682-0108-10 NDC outpatient 1 UN 6.69 6.69 BLUE CROSS BLUE SHIELD WELLMARK SB889 [3081026] BCBS WYOMING [308102603] 6.36 percent of total billed charges 4.15 6.36 Technical (Hospital) Services "NIFEDIPINE ER 30 MG TABLET,EXTENDED RELEASE 24 HR" RX-28643 CDM 6370000100 HCPCS 250 RC 68682-0108-10 NDC outpatient 1 UN 6.69 6.69 HEALTHPARTNERS SX009 HEALTHPARTNERS 5.35 percent of total billed charges 4.15 6.36 Technical (Hospital) Services "NIFEDIPINE ER 30 MG TABLET,EXTENDED RELEASE 24 HR" RX-28643 CDM 6370000100 HCPCS 250 RC 68682-0108-10 NDC outpatient 1 UN 6.69 6.69 MULTIPLAN INC 34080 [3081285] MULTIPLAN INC [308128501] 6.36 percent of total billed charges 4.15 6.36 Technical (Hospital) Services "NIFEDIPINE ER 30 MG TABLET,EXTENDED RELEASE 24 HR" RX-28643 CDM 6370000100 HCPCS 250 RC 68682-0108-10 NDC outpatient 1 UN 6.69 6.69 UNITED HEALTHCARE (COMMERCIAL) [3081199] UNITED HEALTHCARE 87726 [308119901] 4.15 percent of total billed charges 4.15 6.36 Technical (Hospital) Services "NIFEDIPINE ER 30 MG TABLET,EXTENDED RELEASE 24 HR" RX-28643 CDM 6370000100 HCPCS 250 RC 68682-0108-10 NDC outpatient 1 UN 6.69 6.69 CIGNA 62308 [3081051] CIGNA 62308 [308105105] 5.35 percent of total billed charges 4.15 6.36 Technical (Hospital) Services "NIFEDIPINE ER 30 MG TABLET,EXTENDED RELEASE 24 HR" RX-28643 CDM 6370000100 HCPCS 250 RC 68682-0108-10 NDC outpatient 1 UN 6.69 6.69 CIGNA 62308 [3081051] CIGNA STATE OF WYOMING [308105107] 5.35 percent of total billed charges 4.15 6.36 Technical (Hospital) Services "NIFEDIPINE ER 30 MG TABLET,EXTENDED RELEASE 24 HR" RX-28643 CDM 6370000100 HCPCS 250 RC 68682-0108-10 NDC outpatient 1 UN 6.69 6.69 MEDICA (COMMERCIAL) 94265 [3081118] MEDICA CLAIMS [308111801] 6.02 percent of total billed charges 4.15 6.36 Technical (Hospital) Services "NIFEDIPINE ER 30 MG TABLET,EXTENDED RELEASE 24 HR" RX-28643 CDM 6370000100 HCPCS 250 RC 68682-0108-10 NDC outpatient 1 UN 6.69 6.69 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES EPO [308136803] 5.35 percent of total billed charges 4.15 6.36 Technical (Hospital) Services "NIFEDIPINE ER 30 MG TABLET,EXTENDED RELEASE 24 HR" RX-28643 CDM 6370000100 HCPCS 250 RC 68682-0108-10 NDC outpatient 1 UN 6.69 6.69 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES HDHP [308136802] 5.35 percent of total billed charges 4.15 6.36 Technical (Hospital) Services "NIFEDIPINE ER 30 MG TABLET,EXTENDED RELEASE 24 HR" RX-28643 CDM 6370000100 HCPCS 250 RC 68682-0108-10 NDC outpatient 1 UN 6.69 6.69 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES PPO [308136801] 5.35 percent of total billed charges 4.15 6.36 Technical (Hospital) Services "NIFEDIPINE ER 30 MG TABLET,EXTENDED RELEASE 24 HR" RX-28643 CDM 6370000100 HCPCS 250 RC 68682-0108-10 NDC inpatient 1 UN 6.69 6.69 CIGNA 62308 [3081051] CIGNA 62308 [308105105] 5.3 percent of total billed charges 4.15 6.36 Technical (Hospital) Services "NIFEDIPINE ER 30 MG TABLET,EXTENDED RELEASE 24 HR" RX-28643 CDM 6370000100 HCPCS 250 RC 68682-0108-10 NDC inpatient 1 UN 6.69 6.69 CIGNA 62308 [3081051] CIGNA STATE OF WYOMING [308105107] 5.3 percent of total billed charges 4.15 6.36 Technical (Hospital) Services "NIFEDIPINE ER 30 MG TABLET,EXTENDED RELEASE 24 HR" RX-28643 CDM 6370000100 HCPCS 250 RC 68682-0108-10 NDC inpatient 1 UN 6.69 6.69 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES EPO [308136803] 5.3 percent of total billed charges 4.15 6.36 Technical (Hospital) Services "NIFEDIPINE ER 30 MG TABLET,EXTENDED RELEASE 24 HR" RX-28643 CDM 6370000100 HCPCS 250 RC 68682-0108-10 NDC inpatient 1 UN 6.69 6.69 BLUE CROSS BLUE SHIELD WELLMARK SB889 [3081026] BCBS WYOMING [308102603] 6.36 percent of total billed charges 4.15 6.36 Technical (Hospital) Services "NIFEDIPINE ER 30 MG TABLET,EXTENDED RELEASE 24 HR" RX-28643 CDM 6370000100 HCPCS 250 RC 68682-0108-10 NDC inpatient 1 UN 6.69 6.69 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES HDHP [308136802] 5.3 percent of total billed charges 4.15 6.36 Technical (Hospital) Services "NIFEDIPINE ER 30 MG TABLET,EXTENDED RELEASE 24 HR" RX-28643 CDM 6370000100 HCPCS 250 RC 68682-0108-10 NDC inpatient 1 UN 6.69 6.69 UNITED HEALTHCARE (COMMERCIAL) [3081199] UNITED HEALTHCARE 87726 [308119901] 4.15 percent of total billed charges 4.15 6.36 Technical (Hospital) Services "NIFEDIPINE ER 30 MG TABLET,EXTENDED RELEASE 24 HR" RX-28643 CDM 6370000100 HCPCS 250 RC 68682-0108-10 NDC inpatient 1 UN 6.69 6.69 HEALTHPARTNERS SX009 HEALTHPARTNERS 5.3 percent of total billed charges 4.15 6.36 Technical (Hospital) Services "NIFEDIPINE ER 30 MG TABLET,EXTENDED RELEASE 24 HR" RX-28643 CDM 6370000100 HCPCS 250 RC 68682-0108-10 NDC inpatient 1 UN 6.69 6.69 MEDICA (COMMERCIAL) 94265 [3081118] MEDICA CLAIMS [308111801] 6.02 percent of total billed charges 4.15 6.36 Technical (Hospital) Services "NIFEDIPINE ER 30 MG TABLET,EXTENDED RELEASE 24 HR" RX-28643 CDM 6370000100 HCPCS 250 RC 68682-0108-10 NDC inpatient 1 UN 6.69 6.69 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES PPO [308136801] 5.3 percent of total billed charges 4.15 6.36 Technical (Hospital) Services "NIFEDIPINE ER 30 MG TABLET,EXTENDED RELEASE 24 HR" RX-28643 CDM 6370000100 HCPCS 250 RC 68682-0108-10 NDC inpatient 1 UN 6.69 6.69 MULTIPLAN INC 34080 [3081285] MULTIPLAN INC [308128501] 6.36 percent of total billed charges 4.15 6.36 Technical (Hospital) Services ATORVASTATIN 80 MG TABLET RX-28645 CDM 6370000100 HCPCS 250 RC 00093-5057-98 NDC outpatient 1 UN 5.8 5.8 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES EPO [308136803] 4.64 percent of total billed charges 3.6 5.51 Technical (Hospital) Services ATORVASTATIN 80 MG TABLET RX-28645 CDM 6370000100 HCPCS 250 RC 00093-5057-98 NDC outpatient 1 UN 5.8 5.8 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES HDHP [308136802] 4.64 percent of total billed charges 3.6 5.51 Technical (Hospital) Services ATORVASTATIN 80 MG TABLET RX-28645 CDM 6370000100 HCPCS 250 RC 00093-5057-98 NDC outpatient 1 UN 5.8 5.8 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES PPO [308136801] 4.64 percent of total billed charges 3.6 5.51 Technical (Hospital) Services ATORVASTATIN 80 MG TABLET RX-28645 CDM 6370000100 HCPCS 250 RC 00093-5057-98 NDC outpatient 1 UN 5.8 5.8 HEALTHPARTNERS SX009 HEALTHPARTNERS 4.64 percent of total billed charges 3.6 5.51 Technical (Hospital) Services ATORVASTATIN 80 MG TABLET RX-28645 CDM 6370000100 HCPCS 250 RC 00093-5057-98 NDC outpatient 1 UN 5.8 5.8 BLUE CROSS BLUE SHIELD WELLMARK SB889 [3081026] BCBS WYOMING [308102603] 5.51 percent of total billed charges 3.6 5.51 Technical (Hospital) Services ATORVASTATIN 80 MG TABLET RX-28645 CDM 6370000100 HCPCS 250 RC 00093-5057-98 NDC outpatient 1 UN 5.8 5.8 UNITED HEALTHCARE (COMMERCIAL) [3081199] UNITED HEALTHCARE 87726 [308119901] 3.6 percent of total billed charges 3.6 5.51 Technical (Hospital) Services ATORVASTATIN 80 MG TABLET RX-28645 CDM 6370000100 HCPCS 250 RC 00093-5057-98 NDC outpatient 1 UN 5.8 5.8 MULTIPLAN INC 34080 [3081285] MULTIPLAN INC [308128501] 5.51 percent of total billed charges 3.6 5.51 Technical (Hospital) Services ATORVASTATIN 80 MG TABLET RX-28645 CDM 6370000100 HCPCS 250 RC 00093-5057-98 NDC outpatient 1 UN 5.8 5.8 MEDICA (COMMERCIAL) 94265 [3081118] MEDICA CLAIMS [308111801] 5.22 percent of total billed charges 3.6 5.51 Technical (Hospital) Services ATORVASTATIN 80 MG TABLET RX-28645 CDM 6370000100 HCPCS 250 RC 00093-5057-98 NDC outpatient 1 UN 5.8 5.8 CIGNA 62308 [3081051] CIGNA 62308 [308105105] 4.64 percent of total billed charges 3.6 5.51 Technical (Hospital) Services ATORVASTATIN 80 MG TABLET RX-28645 CDM 6370000100 HCPCS 250 RC 00093-5057-98 NDC outpatient 1 UN 5.8 5.8 CIGNA 62308 [3081051] CIGNA STATE OF WYOMING [308105107] 4.64 percent of total billed charges 3.6 5.51 Technical (Hospital) Services ATORVASTATIN 80 MG TABLET RX-28645 CDM 6370000100 HCPCS 250 RC 00093-5057-98 NDC inpatient 1 UN 5.8 5.8 BLUE CROSS BLUE SHIELD WELLMARK SB889 [3081026] BCBS WYOMING [308102603] 5.51 percent of total billed charges 3.6 5.51 Technical (Hospital) Services ATORVASTATIN 80 MG TABLET RX-28645 CDM 6370000100 HCPCS 250 RC 00093-5057-98 NDC inpatient 1 UN 5.8 5.8 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES EPO [308136803] 4.59 percent of total billed charges 3.6 5.51 Technical (Hospital) Services ATORVASTATIN 80 MG TABLET RX-28645 CDM 6370000100 HCPCS 250 RC 00093-5057-98 NDC inpatient 1 UN 5.8 5.8 CIGNA 62308 [3081051] CIGNA 62308 [308105105] 4.59 percent of total billed charges 3.6 5.51 Technical (Hospital) Services ATORVASTATIN 80 MG TABLET RX-28645 CDM 6370000100 HCPCS 250 RC 00093-5057-98 NDC inpatient 1 UN 5.8 5.8 CIGNA 62308 [3081051] CIGNA STATE OF WYOMING [308105107] 4.59 percent of total billed charges 3.6 5.51 Technical (Hospital) Services ATORVASTATIN 80 MG TABLET RX-28645 CDM 6370000100 HCPCS 250 RC 00093-5057-98 NDC inpatient 1 UN 5.8 5.8 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES HDHP [308136802] 4.59 percent of total billed charges 3.6 5.51 Technical (Hospital) Services ATORVASTATIN 80 MG TABLET RX-28645 CDM 6370000100 HCPCS 250 RC 00093-5057-98 NDC inpatient 1 UN 5.8 5.8 UNITED HEALTHCARE (COMMERCIAL) [3081199] UNITED HEALTHCARE 87726 [308119901] 3.6 percent of total billed charges 3.6 5.51 Technical (Hospital) Services ATORVASTATIN 80 MG TABLET RX-28645 CDM 6370000100 HCPCS 250 RC 00093-5057-98 NDC inpatient 1 UN 5.8 5.8 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES PPO [308136801] 4.59 percent of total billed charges 3.6 5.51 Technical (Hospital) Services ATORVASTATIN 80 MG TABLET RX-28645 CDM 6370000100 HCPCS 250 RC 00093-5057-98 NDC inpatient 1 UN 5.8 5.8 MEDICA (COMMERCIAL) 94265 [3081118] MEDICA CLAIMS [308111801] 5.22 percent of total billed charges 3.6 5.51 Technical (Hospital) Services ATORVASTATIN 80 MG TABLET RX-28645 CDM 6370000100 HCPCS 250 RC 00093-5057-98 NDC inpatient 1 UN 5.8 5.8 HEALTHPARTNERS SX009 HEALTHPARTNERS 4.59 percent of total billed charges 3.6 5.51 Technical (Hospital) Services ATORVASTATIN 80 MG TABLET RX-28645 CDM 6370000100 HCPCS 250 RC 00093-5057-98 NDC inpatient 1 UN 5.8 5.8 MULTIPLAN INC 34080 [3081285] MULTIPLAN INC [308128501] 5.51 percent of total billed charges 3.6 5.51 Technical (Hospital) Services GLYBURIDE 5 MG-METFORMIN 500 MG TABLET RX-28725 CDM 6370000100 HCPCS 250 RC 65862-0082-01 NDC inpatient 1 UN 5.71 5.71 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES EPO [308136803] 4.52 percent of total billed charges 3.54 5.42 Technical (Hospital) Services GLYBURIDE 5 MG-METFORMIN 500 MG TABLET RX-28725 CDM 6370000100 HCPCS 250 RC 65862-0082-01 NDC inpatient 1 UN 5.71 5.71 CIGNA 62308 [3081051] CIGNA 62308 [308105105] 4.52 percent of total billed charges 3.54 5.42 Technical (Hospital) Services GLYBURIDE 5 MG-METFORMIN 500 MG TABLET RX-28725 CDM 6370000100 HCPCS 250 RC 65862-0082-01 NDC inpatient 1 UN 5.71 5.71 CIGNA 62308 [3081051] CIGNA STATE OF WYOMING [308105107] 4.52 percent of total billed charges 3.54 5.42 Technical (Hospital) Services GLYBURIDE 5 MG-METFORMIN 500 MG TABLET RX-28725 CDM 6370000100 HCPCS 250 RC 65862-0082-01 NDC inpatient 1 UN 5.71 5.71 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES HDHP [308136802] 4.52 percent of total billed charges 3.54 5.42 Technical (Hospital) Services GLYBURIDE 5 MG-METFORMIN 500 MG TABLET RX-28725 CDM 6370000100 HCPCS 250 RC 65862-0082-01 NDC inpatient 1 UN 5.71 5.71 HEALTHPARTNERS SX009 HEALTHPARTNERS 4.52 percent of total billed charges 3.54 5.42 Technical (Hospital) Services GLYBURIDE 5 MG-METFORMIN 500 MG TABLET RX-28725 CDM 6370000100 HCPCS 250 RC 65862-0082-01 NDC inpatient 1 UN 5.71 5.71 UNITED HEALTHCARE (COMMERCIAL) [3081199] UNITED HEALTHCARE 87726 [308119901] 3.54 percent of total billed charges 3.54 5.42 Technical (Hospital) Services GLYBURIDE 5 MG-METFORMIN 500 MG TABLET RX-28725 CDM 6370000100 HCPCS 250 RC 65862-0082-01 NDC inpatient 1 UN 5.71 5.71 BLUE CROSS BLUE SHIELD WELLMARK SB889 [3081026] BCBS WYOMING [308102603] 5.42 percent of total billed charges 3.54 5.42 Technical (Hospital) Services GLYBURIDE 5 MG-METFORMIN 500 MG TABLET RX-28725 CDM 6370000100 HCPCS 250 RC 65862-0082-01 NDC inpatient 1 UN 5.71 5.71 MULTIPLAN INC 34080 [3081285] MULTIPLAN INC [308128501] 5.42 percent of total billed charges 3.54 5.42 Technical (Hospital) Services GLYBURIDE 5 MG-METFORMIN 500 MG TABLET RX-28725 CDM 6370000100 HCPCS 250 RC 65862-0082-01 NDC inpatient 1 UN 5.71 5.71 MEDICA (COMMERCIAL) 94265 [3081118] MEDICA CLAIMS [308111801] 5.14 percent of total billed charges 3.54 5.42 Technical (Hospital) Services GLYBURIDE 5 MG-METFORMIN 500 MG TABLET RX-28725 CDM 6370000100 HCPCS 250 RC 65862-0082-01 NDC inpatient 1 UN 5.71 5.71 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES PPO [308136801] 4.52 percent of total billed charges 3.54 5.42 Technical (Hospital) Services GLYBURIDE 5 MG-METFORMIN 500 MG TABLET RX-28725 CDM 6370000100 HCPCS 250 RC 65862-0082-01 NDC outpatient 1 UN 5.71 5.71 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES HDHP [308136802] 4.57 percent of total billed charges 3.54 5.42 Technical (Hospital) Services GLYBURIDE 5 MG-METFORMIN 500 MG TABLET RX-28725 CDM 6370000100 HCPCS 250 RC 65862-0082-01 NDC outpatient 1 UN 5.71 5.71 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES EPO [308136803] 4.57 percent of total billed charges 3.54 5.42 Technical (Hospital) Services GLYBURIDE 5 MG-METFORMIN 500 MG TABLET RX-28725 CDM 6370000100 HCPCS 250 RC 65862-0082-01 NDC outpatient 1 UN 5.71 5.71 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES PPO [308136801] 4.57 percent of total billed charges 3.54 5.42 Technical (Hospital) Services GLYBURIDE 5 MG-METFORMIN 500 MG TABLET RX-28725 CDM 6370000100 HCPCS 250 RC 65862-0082-01 NDC outpatient 1 UN 5.71 5.71 BLUE CROSS BLUE SHIELD WELLMARK SB889 [3081026] BCBS WYOMING [308102603] 5.42 percent of total billed charges 3.54 5.42 Technical (Hospital) Services GLYBURIDE 5 MG-METFORMIN 500 MG TABLET RX-28725 CDM 6370000100 HCPCS 250 RC 65862-0082-01 NDC outpatient 1 UN 5.71 5.71 MEDICA (COMMERCIAL) 94265 [3081118] MEDICA CLAIMS [308111801] 5.14 percent of total billed charges 3.54 5.42 Technical (Hospital) Services GLYBURIDE 5 MG-METFORMIN 500 MG TABLET RX-28725 CDM 6370000100 HCPCS 250 RC 65862-0082-01 NDC outpatient 1 UN 5.71 5.71 MULTIPLAN INC 34080 [3081285] MULTIPLAN INC [308128501] 5.42 percent of total billed charges 3.54 5.42 Technical (Hospital) Services GLYBURIDE 5 MG-METFORMIN 500 MG TABLET RX-28725 CDM 6370000100 HCPCS 250 RC 65862-0082-01 NDC outpatient 1 UN 5.71 5.71 CIGNA 62308 [3081051] CIGNA 62308 [308105105] 4.57 percent of total billed charges 3.54 5.42 Technical (Hospital) Services GLYBURIDE 5 MG-METFORMIN 500 MG TABLET RX-28725 CDM 6370000100 HCPCS 250 RC 65862-0082-01 NDC outpatient 1 UN 5.71 5.71 CIGNA 62308 [3081051] CIGNA STATE OF WYOMING [308105107] 4.57 percent of total billed charges 3.54 5.42 Technical (Hospital) Services GLYBURIDE 5 MG-METFORMIN 500 MG TABLET RX-28725 CDM 6370000100 HCPCS 250 RC 65862-0082-01 NDC outpatient 1 UN 5.71 5.71 HEALTHPARTNERS SX009 HEALTHPARTNERS 4.57 percent of total billed charges 3.54 5.42 Technical (Hospital) Services GLYBURIDE 5 MG-METFORMIN 500 MG TABLET RX-28725 CDM 6370000100 HCPCS 250 RC 65862-0082-01 NDC outpatient 1 UN 5.71 5.71 UNITED HEALTHCARE (COMMERCIAL) [3081199] UNITED HEALTHCARE 87726 [308119901] 3.54 percent of total billed charges 3.54 5.42 Technical (Hospital) Services HYDROCORTISONE 2.5 % TOPICAL CREAM WITH PERINEAL APPLICATOR RX-28824 CDM 6370000100 HCPCS 250 RC 64980-0324-30 NDC outpatient 1 GR 6.28 6.28 HEALTHPARTNERS SX009 HEALTHPARTNERS 5.02 percent of total billed charges 3.89 5.97 Technical (Hospital) Services HYDROCORTISONE 2.5 % TOPICAL CREAM WITH PERINEAL APPLICATOR RX-28824 CDM 6370000100 HCPCS 250 RC 64980-0324-30 NDC outpatient 1 GR 6.28 6.28 BLUE CROSS BLUE SHIELD WELLMARK SB889 [3081026] BCBS WYOMING [308102603] 5.97 percent of total billed charges 3.89 5.97 Technical (Hospital) Services HYDROCORTISONE 2.5 % TOPICAL CREAM WITH PERINEAL APPLICATOR RX-28824 CDM 6370000100 HCPCS 250 RC 64980-0324-30 NDC outpatient 1 GR 6.28 6.28 MULTIPLAN INC 34080 [3081285] MULTIPLAN INC [308128501] 5.97 percent of total billed charges 3.89 5.97 Technical (Hospital) Services HYDROCORTISONE 2.5 % TOPICAL CREAM WITH PERINEAL APPLICATOR RX-28824 CDM 6370000100 HCPCS 250 RC 64980-0324-30 NDC outpatient 1 GR 6.28 6.28 UNITED HEALTHCARE (COMMERCIAL) [3081199] UNITED HEALTHCARE 87726 [308119901] 3.89 percent of total billed charges 3.89 5.97 Technical (Hospital) Services HYDROCORTISONE 2.5 % TOPICAL CREAM WITH PERINEAL APPLICATOR RX-28824 CDM 6370000100 HCPCS 250 RC 64980-0324-30 NDC outpatient 1 GR 6.28 6.28 CIGNA 62308 [3081051] CIGNA 62308 [308105105] 5.02 percent of total billed charges 3.89 5.97 Technical (Hospital) Services HYDROCORTISONE 2.5 % TOPICAL CREAM WITH PERINEAL APPLICATOR RX-28824 CDM 6370000100 HCPCS 250 RC 64980-0324-30 NDC outpatient 1 GR 6.28 6.28 CIGNA 62308 [3081051] CIGNA STATE OF WYOMING [308105107] 5.02 percent of total billed charges 3.89 5.97 Technical (Hospital) Services HYDROCORTISONE 2.5 % TOPICAL CREAM WITH PERINEAL APPLICATOR RX-28824 CDM 6370000100 HCPCS 250 RC 64980-0324-30 NDC outpatient 1 GR 6.28 6.28 MEDICA (COMMERCIAL) 94265 [3081118] MEDICA CLAIMS [308111801] 5.65 percent of total billed charges 3.89 5.97 Technical (Hospital) Services HYDROCORTISONE 2.5 % TOPICAL CREAM WITH PERINEAL APPLICATOR RX-28824 CDM 6370000100 HCPCS 250 RC 64980-0324-30 NDC outpatient 1 GR 6.28 6.28 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES EPO [308136803] 5.02 percent of total billed charges 3.89 5.97 Technical (Hospital) Services HYDROCORTISONE 2.5 % TOPICAL CREAM WITH PERINEAL APPLICATOR RX-28824 CDM 6370000100 HCPCS 250 RC 64980-0324-30 NDC outpatient 1 GR 6.28 6.28 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES HDHP [308136802] 5.02 percent of total billed charges 3.89 5.97 Technical (Hospital) Services HYDROCORTISONE 2.5 % TOPICAL CREAM WITH PERINEAL APPLICATOR RX-28824 CDM 6370000100 HCPCS 250 RC 64980-0324-30 NDC outpatient 1 GR 6.28 6.28 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES PPO [308136801] 5.02 percent of total billed charges 3.89 5.97 Technical (Hospital) Services HYDROCORTISONE 2.5 % TOPICAL CREAM WITH PERINEAL APPLICATOR RX-28824 CDM 6370000100 HCPCS 250 RC 64980-0324-30 NDC inpatient 1 GR 6.28 6.28 MULTIPLAN INC 34080 [3081285] MULTIPLAN INC [308128501] 5.97 percent of total billed charges 3.89 5.97 Technical (Hospital) Services HYDROCORTISONE 2.5 % TOPICAL CREAM WITH PERINEAL APPLICATOR RX-28824 CDM 6370000100 HCPCS 250 RC 64980-0324-30 NDC inpatient 1 GR 6.28 6.28 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES PPO [308136801] 4.97 percent of total billed charges 3.89 5.97 Technical (Hospital) Services HYDROCORTISONE 2.5 % TOPICAL CREAM WITH PERINEAL APPLICATOR RX-28824 CDM 6370000100 HCPCS 250 RC 64980-0324-30 NDC inpatient 1 GR 6.28 6.28 BLUE CROSS BLUE SHIELD WELLMARK SB889 [3081026] BCBS WYOMING [308102603] 5.97 percent of total billed charges 3.89 5.97 Technical (Hospital) Services HYDROCORTISONE 2.5 % TOPICAL CREAM WITH PERINEAL APPLICATOR RX-28824 CDM 6370000100 HCPCS 250 RC 64980-0324-30 NDC inpatient 1 GR 6.28 6.28 UNITED HEALTHCARE (COMMERCIAL) [3081199] UNITED HEALTHCARE 87726 [308119901] 3.89 percent of total billed charges 3.89 5.97 Technical (Hospital) Services HYDROCORTISONE 2.5 % TOPICAL CREAM WITH PERINEAL APPLICATOR RX-28824 CDM 6370000100 HCPCS 250 RC 64980-0324-30 NDC inpatient 1 GR 6.28 6.28 MEDICA (COMMERCIAL) 94265 [3081118] MEDICA CLAIMS [308111801] 5.65 percent of total billed charges 3.89 5.97 Technical (Hospital) Services HYDROCORTISONE 2.5 % TOPICAL CREAM WITH PERINEAL APPLICATOR RX-28824 CDM 6370000100 HCPCS 250 RC 64980-0324-30 NDC inpatient 1 GR 6.28 6.28 HEALTHPARTNERS SX009 HEALTHPARTNERS 4.97 percent of total billed charges 3.89 5.97 Technical (Hospital) Services HYDROCORTISONE 2.5 % TOPICAL CREAM WITH PERINEAL APPLICATOR RX-28824 CDM 6370000100 HCPCS 250 RC 64980-0324-30 NDC inpatient 1 GR 6.28 6.28 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES HDHP [308136802] 4.97 percent of total billed charges 3.89 5.97 Technical (Hospital) Services HYDROCORTISONE 2.5 % TOPICAL CREAM WITH PERINEAL APPLICATOR RX-28824 CDM 6370000100 HCPCS 250 RC 64980-0324-30 NDC inpatient 1 GR 6.28 6.28 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES EPO [308136803] 4.97 percent of total billed charges 3.89 5.97 Technical (Hospital) Services HYDROCORTISONE 2.5 % TOPICAL CREAM WITH PERINEAL APPLICATOR RX-28824 CDM 6370000100 HCPCS 250 RC 64980-0324-30 NDC inpatient 1 GR 6.28 6.28 CIGNA 62308 [3081051] CIGNA 62308 [308105105] 4.97 percent of total billed charges 3.89 5.97 Technical (Hospital) Services HYDROCORTISONE 2.5 % TOPICAL CREAM WITH PERINEAL APPLICATOR RX-28824 CDM 6370000100 HCPCS 250 RC 64980-0324-30 NDC inpatient 1 GR 6.28 6.28 CIGNA 62308 [3081051] CIGNA STATE OF WYOMING [308105107] 4.97 percent of total billed charges 3.89 5.97 Technical (Hospital) Services ERYTHROMYCIN 5 MG/GRAM (0.5 %) EYE OINTMENT RX-2888 CDM 6370000100 HCPCS 250 RC 24208-0910-55 NDC inpatient 4 GR 112.9 112.9 MULTIPLAN INC 34080 [3081285] MULTIPLAN INC [308128501] 107.26 percent of total billed charges 70 107.26 Technical (Hospital) Services ERYTHROMYCIN 5 MG/GRAM (0.5 %) EYE OINTMENT RX-2888 CDM 6370000100 HCPCS 250 RC 24208-0910-55 NDC inpatient 4 GR 112.9 112.9 MEDICA (COMMERCIAL) 94265 [3081118] MEDICA CLAIMS [308111801] 101.61 percent of total billed charges 70 107.26 Technical (Hospital) Services ERYTHROMYCIN 5 MG/GRAM (0.5 %) EYE OINTMENT RX-2888 CDM 6370000100 HCPCS 250 RC 24208-0910-55 NDC inpatient 4 GR 112.9 112.9 CIGNA 62308 [3081051] CIGNA 62308 [308105105] 89.39 percent of total billed charges 70 107.26 Technical (Hospital) Services ERYTHROMYCIN 5 MG/GRAM (0.5 %) EYE OINTMENT RX-2888 CDM 6370000100 HCPCS 250 RC 24208-0910-55 NDC inpatient 4 GR 112.9 112.9 CIGNA 62308 [3081051] CIGNA STATE OF WYOMING [308105107] 89.39 percent of total billed charges 70 107.26 Technical (Hospital) Services ERYTHROMYCIN 5 MG/GRAM (0.5 %) EYE OINTMENT RX-2888 CDM 6370000100 HCPCS 250 RC 24208-0910-55 NDC inpatient 4 GR 112.9 112.9 UNITED HEALTHCARE (COMMERCIAL) [3081199] UNITED HEALTHCARE 87726 [308119901] 70 percent of total billed charges 70 107.26 Technical (Hospital) Services ERYTHROMYCIN 5 MG/GRAM (0.5 %) EYE OINTMENT RX-2888 CDM 6370000100 HCPCS 250 RC 24208-0910-55 NDC inpatient 4 GR 112.9 112.9 BLUE CROSS BLUE SHIELD WELLMARK SB889 [3081026] BCBS WYOMING [308102603] 107.26 percent of total billed charges 70 107.26 Technical (Hospital) Services ERYTHROMYCIN 5 MG/GRAM (0.5 %) EYE OINTMENT RX-2888 CDM 6370000100 HCPCS 250 RC 24208-0910-55 NDC inpatient 4 GR 112.9 112.9 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES PPO [308136801] 89.39 percent of total billed charges 70 107.26 Technical (Hospital) Services ERYTHROMYCIN 5 MG/GRAM (0.5 %) EYE OINTMENT RX-2888 CDM 6370000100 HCPCS 250 RC 24208-0910-55 NDC inpatient 4 GR 112.9 112.9 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES HDHP [308136802] 89.39 percent of total billed charges 70 107.26 Technical (Hospital) Services ERYTHROMYCIN 5 MG/GRAM (0.5 %) EYE OINTMENT RX-2888 CDM 6370000100 HCPCS 250 RC 24208-0910-55 NDC inpatient 4 GR 112.9 112.9 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES EPO [308136803] 89.39 percent of total billed charges 70 107.26 Technical (Hospital) Services ERYTHROMYCIN 5 MG/GRAM (0.5 %) EYE OINTMENT RX-2888 CDM 6370000100 HCPCS 250 RC 24208-0910-55 NDC inpatient 4 GR 112.9 112.9 HEALTHPARTNERS SX009 HEALTHPARTNERS 89.39 percent of total billed charges 70 107.26 Technical (Hospital) Services ERYTHROMYCIN 5 MG/GRAM (0.5 %) EYE OINTMENT RX-2888 CDM 6370000100 HCPCS 250 RC 24208-0910-55 NDC outpatient 4 GR 112.9 112.9 MEDICA (COMMERCIAL) 94265 [3081118] MEDICA CLAIMS [308111801] 101.61 percent of total billed charges 70 107.26 Technical (Hospital) Services ERYTHROMYCIN 5 MG/GRAM (0.5 %) EYE OINTMENT RX-2888 CDM 6370000100 HCPCS 250 RC 24208-0910-55 NDC outpatient 4 GR 112.9 112.9 MULTIPLAN INC 34080 [3081285] MULTIPLAN INC [308128501] 107.26 percent of total billed charges 70 107.26 Technical (Hospital) Services ERYTHROMYCIN 5 MG/GRAM (0.5 %) EYE OINTMENT RX-2888 CDM 6370000100 HCPCS 250 RC 24208-0910-55 NDC outpatient 4 GR 112.9 112.9 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES EPO [308136803] 90.32 percent of total billed charges 70 107.26 Technical (Hospital) Services ERYTHROMYCIN 5 MG/GRAM (0.5 %) EYE OINTMENT RX-2888 CDM 6370000100 HCPCS 250 RC 24208-0910-55 NDC outpatient 4 GR 112.9 112.9 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES HDHP [308136802] 90.32 percent of total billed charges 70 107.26 Technical (Hospital) Services ERYTHROMYCIN 5 MG/GRAM (0.5 %) EYE OINTMENT RX-2888 CDM 6370000100 HCPCS 250 RC 24208-0910-55 NDC outpatient 4 GR 112.9 112.9 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES PPO [308136801] 90.32 percent of total billed charges 70 107.26 Technical (Hospital) Services ERYTHROMYCIN 5 MG/GRAM (0.5 %) EYE OINTMENT RX-2888 CDM 6370000100 HCPCS 250 RC 24208-0910-55 NDC outpatient 4 GR 112.9 112.9 BLUE CROSS BLUE SHIELD WELLMARK SB889 [3081026] BCBS WYOMING [308102603] 107.26 percent of total billed charges 70 107.26 Technical (Hospital) Services ERYTHROMYCIN 5 MG/GRAM (0.5 %) EYE OINTMENT RX-2888 CDM 6370000100 HCPCS 250 RC 24208-0910-55 NDC outpatient 4 GR 112.9 112.9 CIGNA 62308 [3081051] CIGNA 62308 [308105105] 90.32 percent of total billed charges 70 107.26 Technical (Hospital) Services ERYTHROMYCIN 5 MG/GRAM (0.5 %) EYE OINTMENT RX-2888 CDM 6370000100 HCPCS 250 RC 24208-0910-55 NDC outpatient 4 GR 112.9 112.9 CIGNA 62308 [3081051] CIGNA STATE OF WYOMING [308105107] 90.32 percent of total billed charges 70 107.26 Technical (Hospital) Services ERYTHROMYCIN 5 MG/GRAM (0.5 %) EYE OINTMENT RX-2888 CDM 6370000100 HCPCS 250 RC 24208-0910-55 NDC outpatient 4 GR 112.9 112.9 HEALTHPARTNERS SX009 HEALTHPARTNERS 90.32 percent of total billed charges 70 107.26 Technical (Hospital) Services ERYTHROMYCIN 5 MG/GRAM (0.5 %) EYE OINTMENT RX-2888 CDM 6370000100 HCPCS 250 RC 24208-0910-55 NDC outpatient 4 GR 112.9 112.9 UNITED HEALTHCARE (COMMERCIAL) [3081199] UNITED HEALTHCARE 87726 [308119901] 70 percent of total billed charges 70 107.26 Technical (Hospital) Services "METFORMIN ER 500 MG TABLET,EXTENDED RELEASE 24 HR" RX-28995 CDM 6370000100 HCPCS 250 RC 62756-0142-01 NDC inpatient 1 UN 5.71 5.71 MULTIPLAN INC 34080 [3081285] MULTIPLAN INC [308128501] 5.42 percent of total billed charges 3.54 5.42 Technical (Hospital) Services "METFORMIN ER 500 MG TABLET,EXTENDED RELEASE 24 HR" RX-28995 CDM 6370000100 HCPCS 250 RC 62756-0142-01 NDC inpatient 1 UN 5.71 5.71 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES PPO [308136801] 4.52 percent of total billed charges 3.54 5.42 Technical (Hospital) Services "METFORMIN ER 500 MG TABLET,EXTENDED RELEASE 24 HR" RX-28995 CDM 6370000100 HCPCS 250 RC 62756-0142-01 NDC inpatient 1 UN 5.71 5.71 CIGNA 62308 [3081051] CIGNA 62308 [308105105] 4.52 percent of total billed charges 3.54 5.42 Technical (Hospital) Services "METFORMIN ER 500 MG TABLET,EXTENDED RELEASE 24 HR" RX-28995 CDM 6370000100 HCPCS 250 RC 62756-0142-01 NDC inpatient 1 UN 5.71 5.71 CIGNA 62308 [3081051] CIGNA STATE OF WYOMING [308105107] 4.52 percent of total billed charges 3.54 5.42 Technical (Hospital) Services "METFORMIN ER 500 MG TABLET,EXTENDED RELEASE 24 HR" RX-28995 CDM 6370000100 HCPCS 250 RC 62756-0142-01 NDC inpatient 1 UN 5.71 5.71 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES EPO [308136803] 4.52 percent of total billed charges 3.54 5.42 Technical (Hospital) Services "METFORMIN ER 500 MG TABLET,EXTENDED RELEASE 24 HR" RX-28995 CDM 6370000100 HCPCS 250 RC 62756-0142-01 NDC inpatient 1 UN 5.71 5.71 HEALTHPARTNERS SX009 HEALTHPARTNERS 4.52 percent of total billed charges 3.54 5.42 Technical (Hospital) Services "METFORMIN ER 500 MG TABLET,EXTENDED RELEASE 24 HR" RX-28995 CDM 6370000100 HCPCS 250 RC 62756-0142-01 NDC inpatient 1 UN 5.71 5.71 MEDICA (COMMERCIAL) 94265 [3081118] MEDICA CLAIMS [308111801] 5.14 percent of total billed charges 3.54 5.42 Technical (Hospital) Services "METFORMIN ER 500 MG TABLET,EXTENDED RELEASE 24 HR" RX-28995 CDM 6370000100 HCPCS 250 RC 62756-0142-01 NDC inpatient 1 UN 5.71 5.71 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES HDHP [308136802] 4.52 percent of total billed charges 3.54 5.42 Technical (Hospital) Services "METFORMIN ER 500 MG TABLET,EXTENDED RELEASE 24 HR" RX-28995 CDM 6370000100 HCPCS 250 RC 62756-0142-01 NDC inpatient 1 UN 5.71 5.71 BLUE CROSS BLUE SHIELD WELLMARK SB889 [3081026] BCBS WYOMING [308102603] 5.42 percent of total billed charges 3.54 5.42 Technical (Hospital) Services "METFORMIN ER 500 MG TABLET,EXTENDED RELEASE 24 HR" RX-28995 CDM 6370000100 HCPCS 250 RC 62756-0142-01 NDC inpatient 1 UN 5.71 5.71 UNITED HEALTHCARE (COMMERCIAL) [3081199] UNITED HEALTHCARE 87726 [308119901] 3.54 percent of total billed charges 3.54 5.42 Technical (Hospital) Services "METFORMIN ER 500 MG TABLET,EXTENDED RELEASE 24 HR" RX-28995 CDM 6370000100 HCPCS 250 RC 62756-0142-01 NDC outpatient 1 UN 5.71 5.71 HEALTHPARTNERS SX009 HEALTHPARTNERS 4.57 percent of total billed charges 3.54 5.42 Technical (Hospital) Services "METFORMIN ER 500 MG TABLET,EXTENDED RELEASE 24 HR" RX-28995 CDM 6370000100 HCPCS 250 RC 62756-0142-01 NDC outpatient 1 UN 5.71 5.71 BLUE CROSS BLUE SHIELD WELLMARK SB889 [3081026] BCBS WYOMING [308102603] 5.42 percent of total billed charges 3.54 5.42 Technical (Hospital) Services "METFORMIN ER 500 MG TABLET,EXTENDED RELEASE 24 HR" RX-28995 CDM 6370000100 HCPCS 250 RC 62756-0142-01 NDC outpatient 1 UN 5.71 5.71 MEDICA (COMMERCIAL) 94265 [3081118] MEDICA CLAIMS [308111801] 5.14 percent of total billed charges 3.54 5.42 Technical (Hospital) Services "METFORMIN ER 500 MG TABLET,EXTENDED RELEASE 24 HR" RX-28995 CDM 6370000100 HCPCS 250 RC 62756-0142-01 NDC outpatient 1 UN 5.71 5.71 UNITED HEALTHCARE (COMMERCIAL) [3081199] UNITED HEALTHCARE 87726 [308119901] 3.54 percent of total billed charges 3.54 5.42 Technical (Hospital) Services "METFORMIN ER 500 MG TABLET,EXTENDED RELEASE 24 HR" RX-28995 CDM 6370000100 HCPCS 250 RC 62756-0142-01 NDC outpatient 1 UN 5.71 5.71 MULTIPLAN INC 34080 [3081285] MULTIPLAN INC [308128501] 5.42 percent of total billed charges 3.54 5.42 Technical (Hospital) Services "METFORMIN ER 500 MG TABLET,EXTENDED RELEASE 24 HR" RX-28995 CDM 6370000100 HCPCS 250 RC 62756-0142-01 NDC outpatient 1 UN 5.71 5.71 CIGNA 62308 [3081051] CIGNA 62308 [308105105] 4.57 percent of total billed charges 3.54 5.42 Technical (Hospital) Services "METFORMIN ER 500 MG TABLET,EXTENDED RELEASE 24 HR" RX-28995 CDM 6370000100 HCPCS 250 RC 62756-0142-01 NDC outpatient 1 UN 5.71 5.71 CIGNA 62308 [3081051] CIGNA STATE OF WYOMING [308105107] 4.57 percent of total billed charges 3.54 5.42 Technical (Hospital) Services "METFORMIN ER 500 MG TABLET,EXTENDED RELEASE 24 HR" RX-28995 CDM 6370000100 HCPCS 250 RC 62756-0142-01 NDC outpatient 1 UN 5.71 5.71 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES EPO [308136803] 4.57 percent of total billed charges 3.54 5.42 Technical (Hospital) Services "METFORMIN ER 500 MG TABLET,EXTENDED RELEASE 24 HR" RX-28995 CDM 6370000100 HCPCS 250 RC 62756-0142-01 NDC outpatient 1 UN 5.71 5.71 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES HDHP [308136802] 4.57 percent of total billed charges 3.54 5.42 Technical (Hospital) Services "METFORMIN ER 500 MG TABLET,EXTENDED RELEASE 24 HR" RX-28995 CDM 6370000100 HCPCS 250 RC 62756-0142-01 NDC outpatient 1 UN 5.71 5.71 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES PPO [308136801] 4.57 percent of total billed charges 3.54 5.42 Technical (Hospital) Services ALENDRONATE 70 MG TABLET RX-29048 CDM 6370000100 HCPCS 250 RC 69097-0224-16 NDC inpatient 1 UN 6.5 6.5 MULTIPLAN INC 34080 [3081285] MULTIPLAN INC [308128501] 6.18 percent of total billed charges 4.03 6.18 Technical (Hospital) Services ALENDRONATE 70 MG TABLET RX-29048 CDM 6370000100 HCPCS 250 RC 69097-0224-16 NDC inpatient 1 UN 6.5 6.5 MEDICA (COMMERCIAL) 94265 [3081118] MEDICA CLAIMS [308111801] 5.85 percent of total billed charges 4.03 6.18 Technical (Hospital) Services ALENDRONATE 70 MG TABLET RX-29048 CDM 6370000100 HCPCS 250 RC 69097-0224-16 NDC inpatient 1 UN 6.5 6.5 HEALTHPARTNERS SX009 HEALTHPARTNERS 5.15 percent of total billed charges 4.03 6.18 Technical (Hospital) Services ALENDRONATE 70 MG TABLET RX-29048 CDM 6370000100 HCPCS 250 RC 69097-0224-16 NDC inpatient 1 UN 6.5 6.5 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES PPO [308136801] 5.15 percent of total billed charges 4.03 6.18 Technical (Hospital) Services ALENDRONATE 70 MG TABLET RX-29048 CDM 6370000100 HCPCS 250 RC 69097-0224-16 NDC inpatient 1 UN 6.5 6.5 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES EPO [308136803] 5.15 percent of total billed charges 4.03 6.18 Technical (Hospital) Services ALENDRONATE 70 MG TABLET RX-29048 CDM 6370000100 HCPCS 250 RC 69097-0224-16 NDC inpatient 1 UN 6.5 6.5 CIGNA 62308 [3081051] CIGNA 62308 [308105105] 5.15 percent of total billed charges 4.03 6.18 Technical (Hospital) Services ALENDRONATE 70 MG TABLET RX-29048 CDM 6370000100 HCPCS 250 RC 69097-0224-16 NDC inpatient 1 UN 6.5 6.5 CIGNA 62308 [3081051] CIGNA STATE OF WYOMING [308105107] 5.15 percent of total billed charges 4.03 6.18 Technical (Hospital) Services ALENDRONATE 70 MG TABLET RX-29048 CDM 6370000100 HCPCS 250 RC 69097-0224-16 NDC inpatient 1 UN 6.5 6.5 BLUE CROSS BLUE SHIELD WELLMARK SB889 [3081026] BCBS WYOMING [308102603] 6.18 percent of total billed charges 4.03 6.18 Technical (Hospital) Services ALENDRONATE 70 MG TABLET RX-29048 CDM 6370000100 HCPCS 250 RC 69097-0224-16 NDC inpatient 1 UN 6.5 6.5 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES HDHP [308136802] 5.15 percent of total billed charges 4.03 6.18 Technical (Hospital) Services ALENDRONATE 70 MG TABLET RX-29048 CDM 6370000100 HCPCS 250 RC 69097-0224-16 NDC inpatient 1 UN 6.5 6.5 UNITED HEALTHCARE (COMMERCIAL) [3081199] UNITED HEALTHCARE 87726 [308119901] 4.03 percent of total billed charges 4.03 6.18 Technical (Hospital) Services ALENDRONATE 70 MG TABLET RX-29048 CDM 6370000100 HCPCS 250 RC 69097-0224-16 NDC outpatient 1 UN 6.5 6.5 MEDICA (COMMERCIAL) 94265 [3081118] MEDICA CLAIMS [308111801] 5.85 percent of total billed charges 4.03 6.18 Technical (Hospital) Services ALENDRONATE 70 MG TABLET RX-29048 CDM 6370000100 HCPCS 250 RC 69097-0224-16 NDC outpatient 1 UN 6.5 6.5 MULTIPLAN INC 34080 [3081285] MULTIPLAN INC [308128501] 6.18 percent of total billed charges 4.03 6.18 Technical (Hospital) Services ALENDRONATE 70 MG TABLET RX-29048 CDM 6370000100 HCPCS 250 RC 69097-0224-16 NDC outpatient 1 UN 6.5 6.5 CIGNA 62308 [3081051] CIGNA 62308 [308105105] 5.2 percent of total billed charges 4.03 6.18 Technical (Hospital) Services ALENDRONATE 70 MG TABLET RX-29048 CDM 6370000100 HCPCS 250 RC 69097-0224-16 NDC outpatient 1 UN 6.5 6.5 CIGNA 62308 [3081051] CIGNA STATE OF WYOMING [308105107] 5.2 percent of total billed charges 4.03 6.18 Technical (Hospital) Services ALENDRONATE 70 MG TABLET RX-29048 CDM 6370000100 HCPCS 250 RC 69097-0224-16 NDC outpatient 1 UN 6.5 6.5 UNITED HEALTHCARE (COMMERCIAL) [3081199] UNITED HEALTHCARE 87726 [308119901] 4.03 percent of total billed charges 4.03 6.18 Technical (Hospital) Services ALENDRONATE 70 MG TABLET RX-29048 CDM 6370000100 HCPCS 250 RC 69097-0224-16 NDC outpatient 1 UN 6.5 6.5 HEALTHPARTNERS SX009 HEALTHPARTNERS 5.2 percent of total billed charges 4.03 6.18 Technical (Hospital) Services ALENDRONATE 70 MG TABLET RX-29048 CDM 6370000100 HCPCS 250 RC 69097-0224-16 NDC outpatient 1 UN 6.5 6.5 BLUE CROSS BLUE SHIELD WELLMARK SB889 [3081026] BCBS WYOMING [308102603] 6.18 percent of total billed charges 4.03 6.18 Technical (Hospital) Services ALENDRONATE 70 MG TABLET RX-29048 CDM 6370000100 HCPCS 250 RC 69097-0224-16 NDC outpatient 1 UN 6.5 6.5 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES PPO [308136801] 5.2 percent of total billed charges 4.03 6.18 Technical (Hospital) Services ALENDRONATE 70 MG TABLET RX-29048 CDM 6370000100 HCPCS 250 RC 69097-0224-16 NDC outpatient 1 UN 6.5 6.5 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES EPO [308136803] 5.2 percent of total billed charges 4.03 6.18 Technical (Hospital) Services ALENDRONATE 70 MG TABLET RX-29048 CDM 6370000100 HCPCS 250 RC 69097-0224-16 NDC outpatient 1 UN 6.5 6.5 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES HDHP [308136802] 5.2 percent of total billed charges 4.03 6.18 Technical (Hospital) Services QUETIAPINE 300 MG TABLET RX-29267 CDM 6370000100 HCPCS 250 RC 47335-0906-88 NDC inpatient 1 UN 6.41 6.41 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES PPO [308136801] 5.08 percent of total billed charges 3.97 6.09 Technical (Hospital) Services QUETIAPINE 300 MG TABLET RX-29267 CDM 6370000100 HCPCS 250 RC 47335-0906-88 NDC inpatient 1 UN 6.41 6.41 MULTIPLAN INC 34080 [3081285] MULTIPLAN INC [308128501] 6.09 percent of total billed charges 3.97 6.09 Technical (Hospital) Services QUETIAPINE 300 MG TABLET RX-29267 CDM 6370000100 HCPCS 250 RC 47335-0906-88 NDC inpatient 1 UN 6.41 6.41 UNITED HEALTHCARE (COMMERCIAL) [3081199] UNITED HEALTHCARE 87726 [308119901] 3.97 percent of total billed charges 3.97 6.09 Technical (Hospital) Services QUETIAPINE 300 MG TABLET RX-29267 CDM 6370000100 HCPCS 250 RC 47335-0906-88 NDC inpatient 1 UN 6.41 6.41 BLUE CROSS BLUE SHIELD WELLMARK SB889 [3081026] BCBS WYOMING [308102603] 6.09 percent of total billed charges 3.97 6.09 Technical (Hospital) Services QUETIAPINE 300 MG TABLET RX-29267 CDM 6370000100 HCPCS 250 RC 47335-0906-88 NDC inpatient 1 UN 6.41 6.41 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES EPO [308136803] 5.08 percent of total billed charges 3.97 6.09 Technical (Hospital) Services QUETIAPINE 300 MG TABLET RX-29267 CDM 6370000100 HCPCS 250 RC 47335-0906-88 NDC inpatient 1 UN 6.41 6.41 CIGNA 62308 [3081051] CIGNA 62308 [308105105] 5.08 percent of total billed charges 3.97 6.09 Technical (Hospital) Services QUETIAPINE 300 MG TABLET RX-29267 CDM 6370000100 HCPCS 250 RC 47335-0906-88 NDC inpatient 1 UN 6.41 6.41 CIGNA 62308 [3081051] CIGNA STATE OF WYOMING [308105107] 5.08 percent of total billed charges 3.97 6.09 Technical (Hospital) Services QUETIAPINE 300 MG TABLET RX-29267 CDM 6370000100 HCPCS 250 RC 47335-0906-88 NDC inpatient 1 UN 6.41 6.41 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES HDHP [308136802] 5.08 percent of total billed charges 3.97 6.09 Technical (Hospital) Services QUETIAPINE 300 MG TABLET RX-29267 CDM 6370000100 HCPCS 250 RC 47335-0906-88 NDC inpatient 1 UN 6.41 6.41 HEALTHPARTNERS SX009 HEALTHPARTNERS 5.08 percent of total billed charges 3.97 6.09 Technical (Hospital) Services QUETIAPINE 300 MG TABLET RX-29267 CDM 6370000100 HCPCS 250 RC 47335-0906-88 NDC inpatient 1 UN 6.41 6.41 MEDICA (COMMERCIAL) 94265 [3081118] MEDICA CLAIMS [308111801] 5.77 percent of total billed charges 3.97 6.09 Technical (Hospital) Services QUETIAPINE 300 MG TABLET RX-29267 CDM 6370000100 HCPCS 250 RC 47335-0906-88 NDC outpatient 1 UN 6.41 6.41 BLUE CROSS BLUE SHIELD WELLMARK SB889 [3081026] BCBS WYOMING [308102603] 6.09 percent of total billed charges 3.97 6.09 Technical (Hospital) Services QUETIAPINE 300 MG TABLET RX-29267 CDM 6370000100 HCPCS 250 RC 47335-0906-88 NDC outpatient 1 UN 6.41 6.41 MEDICA (COMMERCIAL) 94265 [3081118] MEDICA CLAIMS [308111801] 5.77 percent of total billed charges 3.97 6.09 Technical (Hospital) Services QUETIAPINE 300 MG TABLET RX-29267 CDM 6370000100 HCPCS 250 RC 47335-0906-88 NDC outpatient 1 UN 6.41 6.41 CIGNA 62308 [3081051] CIGNA STATE OF WYOMING [308105107] 5.13 percent of total billed charges 3.97 6.09 Technical (Hospital) Services QUETIAPINE 300 MG TABLET RX-29267 CDM 6370000100 HCPCS 250 RC 47335-0906-88 NDC outpatient 1 UN 6.41 6.41 MULTIPLAN INC 34080 [3081285] MULTIPLAN INC [308128501] 6.09 percent of total billed charges 3.97 6.09 Technical (Hospital) Services QUETIAPINE 300 MG TABLET RX-29267 CDM 6370000100 HCPCS 250 RC 47335-0906-88 NDC outpatient 1 UN 6.41 6.41 CIGNA 62308 [3081051] CIGNA 62308 [308105105] 5.13 percent of total billed charges 3.97 6.09 Technical (Hospital) Services QUETIAPINE 300 MG TABLET RX-29267 CDM 6370000100 HCPCS 250 RC 47335-0906-88 NDC outpatient 1 UN 6.41 6.41 UNITED HEALTHCARE (COMMERCIAL) [3081199] UNITED HEALTHCARE 87726 [308119901] 3.97 percent of total billed charges 3.97 6.09 Technical (Hospital) Services QUETIAPINE 300 MG TABLET RX-29267 CDM 6370000100 HCPCS 250 RC 47335-0906-88 NDC outpatient 1 UN 6.41 6.41 HEALTHPARTNERS SX009 HEALTHPARTNERS 5.13 percent of total billed charges 3.97 6.09 Technical (Hospital) Services QUETIAPINE 300 MG TABLET RX-29267 CDM 6370000100 HCPCS 250 RC 47335-0906-88 NDC outpatient 1 UN 6.41 6.41 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES EPO [308136803] 5.13 percent of total billed charges 3.97 6.09 Technical (Hospital) Services QUETIAPINE 300 MG TABLET RX-29267 CDM 6370000100 HCPCS 250 RC 47335-0906-88 NDC outpatient 1 UN 6.41 6.41 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES HDHP [308136802] 5.13 percent of total billed charges 3.97 6.09 Technical (Hospital) Services QUETIAPINE 300 MG TABLET RX-29267 CDM 6370000100 HCPCS 250 RC 47335-0906-88 NDC outpatient 1 UN 6.41 6.41 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES PPO [308136801] 5.13 percent of total billed charges 3.97 6.09 Technical (Hospital) Services "DILTIAZEM ER 120 MG CAPSULE,24 HR,EXTENDED RELEASE" RX-29269 CDM 6370000100 HCPCS 250 RC 68682-0367-90 NDC outpatient 1 UN 6.24 6.24 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES PPO [308136801] 4.99 percent of total billed charges 3.87 5.93 Technical (Hospital) Services "DILTIAZEM ER 120 MG CAPSULE,24 HR,EXTENDED RELEASE" RX-29269 CDM 6370000100 HCPCS 250 RC 68682-0367-90 NDC outpatient 1 UN 6.24 6.24 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES HDHP [308136802] 4.99 percent of total billed charges 3.87 5.93 Technical (Hospital) Services "DILTIAZEM ER 120 MG CAPSULE,24 HR,EXTENDED RELEASE" RX-29269 CDM 6370000100 HCPCS 250 RC 68682-0367-90 NDC outpatient 1 UN 6.24 6.24 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES EPO [308136803] 4.99 percent of total billed charges 3.87 5.93 Technical (Hospital) Services "DILTIAZEM ER 120 MG CAPSULE,24 HR,EXTENDED RELEASE" RX-29269 CDM 6370000100 HCPCS 250 RC 68682-0367-90 NDC outpatient 1 UN 6.24 6.24 BLUE CROSS BLUE SHIELD WELLMARK SB889 [3081026] BCBS WYOMING [308102603] 5.93 percent of total billed charges 3.87 5.93 Technical (Hospital) Services "DILTIAZEM ER 120 MG CAPSULE,24 HR,EXTENDED RELEASE" RX-29269 CDM 6370000100 HCPCS 250 RC 68682-0367-90 NDC outpatient 1 UN 6.24 6.24 HEALTHPARTNERS SX009 HEALTHPARTNERS 4.99 percent of total billed charges 3.87 5.93 Technical (Hospital) Services "DILTIAZEM ER 120 MG CAPSULE,24 HR,EXTENDED RELEASE" RX-29269 CDM 6370000100 HCPCS 250 RC 68682-0367-90 NDC outpatient 1 UN 6.24 6.24 UNITED HEALTHCARE (COMMERCIAL) [3081199] UNITED HEALTHCARE 87726 [308119901] 3.87 percent of total billed charges 3.87 5.93 Technical (Hospital) Services "DILTIAZEM ER 120 MG CAPSULE,24 HR,EXTENDED RELEASE" RX-29269 CDM 6370000100 HCPCS 250 RC 68682-0367-90 NDC outpatient 1 UN 6.24 6.24 CIGNA 62308 [3081051] CIGNA 62308 [308105105] 4.99 percent of total billed charges 3.87 5.93 Technical (Hospital) Services "DILTIAZEM ER 120 MG CAPSULE,24 HR,EXTENDED RELEASE" RX-29269 CDM 6370000100 HCPCS 250 RC 68682-0367-90 NDC outpatient 1 UN 6.24 6.24 CIGNA 62308 [3081051] CIGNA STATE OF WYOMING [308105107] 4.99 percent of total billed charges 3.87 5.93 Technical (Hospital) Services "DILTIAZEM ER 120 MG CAPSULE,24 HR,EXTENDED RELEASE" RX-29269 CDM 6370000100 HCPCS 250 RC 68682-0367-90 NDC outpatient 1 UN 6.24 6.24 MULTIPLAN INC 34080 [3081285] MULTIPLAN INC [308128501] 5.93 percent of total billed charges 3.87 5.93 Technical (Hospital) Services "DILTIAZEM ER 120 MG CAPSULE,24 HR,EXTENDED RELEASE" RX-29269 CDM 6370000100 HCPCS 250 RC 68682-0367-90 NDC outpatient 1 UN 6.24 6.24 MEDICA (COMMERCIAL) 94265 [3081118] MEDICA CLAIMS [308111801] 5.62 percent of total billed charges 3.87 5.93 Technical (Hospital) Services "DILTIAZEM ER 120 MG CAPSULE,24 HR,EXTENDED RELEASE" RX-29269 CDM 6370000100 HCPCS 250 RC 68682-0367-90 NDC inpatient 1 UN 6.24 6.24 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES PPO [308136801] 4.94 percent of total billed charges 3.87 5.93 Technical (Hospital) Services "DILTIAZEM ER 120 MG CAPSULE,24 HR,EXTENDED RELEASE" RX-29269 CDM 6370000100 HCPCS 250 RC 68682-0367-90 NDC inpatient 1 UN 6.24 6.24 HEALTHPARTNERS SX009 HEALTHPARTNERS 4.94 percent of total billed charges 3.87 5.93 Technical (Hospital) Services "DILTIAZEM ER 120 MG CAPSULE,24 HR,EXTENDED RELEASE" RX-29269 CDM 6370000100 HCPCS 250 RC 68682-0367-90 NDC inpatient 1 UN 6.24 6.24 MEDICA (COMMERCIAL) 94265 [3081118] MEDICA CLAIMS [308111801] 5.62 percent of total billed charges 3.87 5.93 Technical (Hospital) Services "DILTIAZEM ER 120 MG CAPSULE,24 HR,EXTENDED RELEASE" RX-29269 CDM 6370000100 HCPCS 250 RC 68682-0367-90 NDC inpatient 1 UN 6.24 6.24 MULTIPLAN INC 34080 [3081285] MULTIPLAN INC [308128501] 5.93 percent of total billed charges 3.87 5.93 Technical (Hospital) Services "DILTIAZEM ER 120 MG CAPSULE,24 HR,EXTENDED RELEASE" RX-29269 CDM 6370000100 HCPCS 250 RC 68682-0367-90 NDC inpatient 1 UN 6.24 6.24 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES HDHP [308136802] 4.94 percent of total billed charges 3.87 5.93 Technical (Hospital) Services "DILTIAZEM ER 120 MG CAPSULE,24 HR,EXTENDED RELEASE" RX-29269 CDM 6370000100 HCPCS 250 RC 68682-0367-90 NDC inpatient 1 UN 6.24 6.24 CIGNA 62308 [3081051] CIGNA 62308 [308105105] 4.94 percent of total billed charges 3.87 5.93 Technical (Hospital) Services "DILTIAZEM ER 120 MG CAPSULE,24 HR,EXTENDED RELEASE" RX-29269 CDM 6370000100 HCPCS 250 RC 68682-0367-90 NDC inpatient 1 UN 6.24 6.24 CIGNA 62308 [3081051] CIGNA STATE OF WYOMING [308105107] 4.94 percent of total billed charges 3.87 5.93 Technical (Hospital) Services "DILTIAZEM ER 120 MG CAPSULE,24 HR,EXTENDED RELEASE" RX-29269 CDM 6370000100 HCPCS 250 RC 68682-0367-90 NDC inpatient 1 UN 6.24 6.24 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES EPO [308136803] 4.94 percent of total billed charges 3.87 5.93 Technical (Hospital) Services "DILTIAZEM ER 120 MG CAPSULE,24 HR,EXTENDED RELEASE" RX-29269 CDM 6370000100 HCPCS 250 RC 68682-0367-90 NDC inpatient 1 UN 6.24 6.24 BLUE CROSS BLUE SHIELD WELLMARK SB889 [3081026] BCBS WYOMING [308102603] 5.93 percent of total billed charges 3.87 5.93 Technical (Hospital) Services "DILTIAZEM ER 120 MG CAPSULE,24 HR,EXTENDED RELEASE" RX-29269 CDM 6370000100 HCPCS 250 RC 68682-0367-90 NDC inpatient 1 UN 6.24 6.24 UNITED HEALTHCARE (COMMERCIAL) [3081199] UNITED HEALTHCARE 87726 [308119901] 3.87 percent of total billed charges 3.87 5.93 Technical (Hospital) Services CLOTRIMAZOLE-BETAMETHASONE 1 %-0.05 % TOPICAL CREAM RX-29424 CDM 6370000100 HCPCS 250 RC 00168-0258-15 NDC outpatient 1 GR 6.74 6.74 UNITED HEALTHCARE (COMMERCIAL) [3081199] UNITED HEALTHCARE 87726 [308119901] 4.18 percent of total billed charges 4.18 6.4 Technical (Hospital) Services CLOTRIMAZOLE-BETAMETHASONE 1 %-0.05 % TOPICAL CREAM RX-29424 CDM 6370000100 HCPCS 250 RC 00168-0258-15 NDC outpatient 1 GR 6.74 6.74 HEALTHPARTNERS SX009 HEALTHPARTNERS 5.39 percent of total billed charges 4.18 6.4 Technical (Hospital) Services CLOTRIMAZOLE-BETAMETHASONE 1 %-0.05 % TOPICAL CREAM RX-29424 CDM 6370000100 HCPCS 250 RC 00168-0258-15 NDC outpatient 1 GR 6.74 6.74 MULTIPLAN INC 34080 [3081285] MULTIPLAN INC [308128501] 6.4 percent of total billed charges 4.18 6.4 Technical (Hospital) Services CLOTRIMAZOLE-BETAMETHASONE 1 %-0.05 % TOPICAL CREAM RX-29424 CDM 6370000100 HCPCS 250 RC 00168-0258-15 NDC outpatient 1 GR 6.74 6.74 CIGNA 62308 [3081051] CIGNA 62308 [308105105] 5.39 percent of total billed charges 4.18 6.4 Technical (Hospital) Services CLOTRIMAZOLE-BETAMETHASONE 1 %-0.05 % TOPICAL CREAM RX-29424 CDM 6370000100 HCPCS 250 RC 00168-0258-15 NDC outpatient 1 GR 6.74 6.74 CIGNA 62308 [3081051] CIGNA STATE OF WYOMING [308105107] 5.39 percent of total billed charges 4.18 6.4 Technical (Hospital) Services CLOTRIMAZOLE-BETAMETHASONE 1 %-0.05 % TOPICAL CREAM RX-29424 CDM 6370000100 HCPCS 250 RC 00168-0258-15 NDC outpatient 1 GR 6.74 6.74 MEDICA (COMMERCIAL) 94265 [3081118] MEDICA CLAIMS [308111801] 6.07 percent of total billed charges 4.18 6.4 Technical (Hospital) Services CLOTRIMAZOLE-BETAMETHASONE 1 %-0.05 % TOPICAL CREAM RX-29424 CDM 6370000100 HCPCS 250 RC 00168-0258-15 NDC outpatient 1 GR 6.74 6.74 BLUE CROSS BLUE SHIELD WELLMARK SB889 [3081026] BCBS WYOMING [308102603] 6.4 percent of total billed charges 4.18 6.4 Technical (Hospital) Services CLOTRIMAZOLE-BETAMETHASONE 1 %-0.05 % TOPICAL CREAM RX-29424 CDM 6370000100 HCPCS 250 RC 00168-0258-15 NDC outpatient 1 GR 6.74 6.74 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES EPO [308136803] 5.39 percent of total billed charges 4.18 6.4 Technical (Hospital) Services CLOTRIMAZOLE-BETAMETHASONE 1 %-0.05 % TOPICAL CREAM RX-29424 CDM 6370000100 HCPCS 250 RC 00168-0258-15 NDC outpatient 1 GR 6.74 6.74 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES HDHP [308136802] 5.39 percent of total billed charges 4.18 6.4 Technical (Hospital) Services CLOTRIMAZOLE-BETAMETHASONE 1 %-0.05 % TOPICAL CREAM RX-29424 CDM 6370000100 HCPCS 250 RC 00168-0258-15 NDC outpatient 1 GR 6.74 6.74 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES PPO [308136801] 5.39 percent of total billed charges 4.18 6.4 Technical (Hospital) Services CLOTRIMAZOLE-BETAMETHASONE 1 %-0.05 % TOPICAL CREAM RX-29424 CDM 6370000100 HCPCS 250 RC 00168-0258-15 NDC inpatient 1 GR 6.74 6.74 MULTIPLAN INC 34080 [3081285] MULTIPLAN INC [308128501] 6.4 percent of total billed charges 4.18 6.4 Technical (Hospital) Services CLOTRIMAZOLE-BETAMETHASONE 1 %-0.05 % TOPICAL CREAM RX-29424 CDM 6370000100 HCPCS 250 RC 00168-0258-15 NDC inpatient 1 GR 6.74 6.74 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES PPO [308136801] 5.34 percent of total billed charges 4.18 6.4 Technical (Hospital) Services CLOTRIMAZOLE-BETAMETHASONE 1 %-0.05 % TOPICAL CREAM RX-29424 CDM 6370000100 HCPCS 250 RC 00168-0258-15 NDC inpatient 1 GR 6.74 6.74 MEDICA (COMMERCIAL) 94265 [3081118] MEDICA CLAIMS [308111801] 6.07 percent of total billed charges 4.18 6.4 Technical (Hospital) Services CLOTRIMAZOLE-BETAMETHASONE 1 %-0.05 % TOPICAL CREAM RX-29424 CDM 6370000100 HCPCS 250 RC 00168-0258-15 NDC inpatient 1 GR 6.74 6.74 BLUE CROSS BLUE SHIELD WELLMARK SB889 [3081026] BCBS WYOMING [308102603] 6.4 percent of total billed charges 4.18 6.4 Technical (Hospital) Services CLOTRIMAZOLE-BETAMETHASONE 1 %-0.05 % TOPICAL CREAM RX-29424 CDM 6370000100 HCPCS 250 RC 00168-0258-15 NDC inpatient 1 GR 6.74 6.74 UNITED HEALTHCARE (COMMERCIAL) [3081199] UNITED HEALTHCARE 87726 [308119901] 4.18 percent of total billed charges 4.18 6.4 Technical (Hospital) Services CLOTRIMAZOLE-BETAMETHASONE 1 %-0.05 % TOPICAL CREAM RX-29424 CDM 6370000100 HCPCS 250 RC 00168-0258-15 NDC inpatient 1 GR 6.74 6.74 HEALTHPARTNERS SX009 HEALTHPARTNERS 5.34 percent of total billed charges 4.18 6.4 Technical (Hospital) Services CLOTRIMAZOLE-BETAMETHASONE 1 %-0.05 % TOPICAL CREAM RX-29424 CDM 6370000100 HCPCS 250 RC 00168-0258-15 NDC inpatient 1 GR 6.74 6.74 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES HDHP [308136802] 5.34 percent of total billed charges 4.18 6.4 Technical (Hospital) Services CLOTRIMAZOLE-BETAMETHASONE 1 %-0.05 % TOPICAL CREAM RX-29424 CDM 6370000100 HCPCS 250 RC 00168-0258-15 NDC inpatient 1 GR 6.74 6.74 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES EPO [308136803] 5.34 percent of total billed charges 4.18 6.4 Technical (Hospital) Services CLOTRIMAZOLE-BETAMETHASONE 1 %-0.05 % TOPICAL CREAM RX-29424 CDM 6370000100 HCPCS 250 RC 00168-0258-15 NDC inpatient 1 GR 6.74 6.74 CIGNA 62308 [3081051] CIGNA 62308 [308105105] 5.34 percent of total billed charges 4.18 6.4 Technical (Hospital) Services CLOTRIMAZOLE-BETAMETHASONE 1 %-0.05 % TOPICAL CREAM RX-29424 CDM 6370000100 HCPCS 250 RC 00168-0258-15 NDC inpatient 1 GR 6.74 6.74 CIGNA 62308 [3081051] CIGNA STATE OF WYOMING [308105107] 5.34 percent of total billed charges 4.18 6.4 Technical (Hospital) Services "TOLTERODINE ER 2 MG CAPSULE,EXTENDED RELEASE 24 HR" RX-29434 CDM 6370000100 HCPCS 250 RC 00378-3402-93 NDC inpatient 1 UN 28.42 28.42 BLUE CROSS BLUE SHIELD WELLMARK SB889 [3081026] BCBS WYOMING [308102603] 27 percent of total billed charges 17.62 27 Technical (Hospital) Services "TOLTERODINE ER 2 MG CAPSULE,EXTENDED RELEASE 24 HR" RX-29434 CDM 6370000100 HCPCS 250 RC 00378-3402-93 NDC inpatient 1 UN 28.42 28.42 UNITED HEALTHCARE (COMMERCIAL) [3081199] UNITED HEALTHCARE 87726 [308119901] 17.62 percent of total billed charges 17.62 27 Technical (Hospital) Services "TOLTERODINE ER 2 MG CAPSULE,EXTENDED RELEASE 24 HR" RX-29434 CDM 6370000100 HCPCS 250 RC 00378-3402-93 NDC inpatient 1 UN 28.42 28.42 CIGNA 62308 [3081051] CIGNA 62308 [308105105] 22.5 percent of total billed charges 17.62 27 Technical (Hospital) Services "TOLTERODINE ER 2 MG CAPSULE,EXTENDED RELEASE 24 HR" RX-29434 CDM 6370000100 HCPCS 250 RC 00378-3402-93 NDC inpatient 1 UN 28.42 28.42 CIGNA 62308 [3081051] CIGNA STATE OF WYOMING [308105107] 22.5 percent of total billed charges 17.62 27 Technical (Hospital) Services "TOLTERODINE ER 2 MG CAPSULE,EXTENDED RELEASE 24 HR" RX-29434 CDM 6370000100 HCPCS 250 RC 00378-3402-93 NDC inpatient 1 UN 28.42 28.42 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES EPO [308136803] 22.5 percent of total billed charges 17.62 27 Technical (Hospital) Services "TOLTERODINE ER 2 MG CAPSULE,EXTENDED RELEASE 24 HR" RX-29434 CDM 6370000100 HCPCS 250 RC 00378-3402-93 NDC inpatient 1 UN 28.42 28.42 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES HDHP [308136802] 22.5 percent of total billed charges 17.62 27 Technical (Hospital) Services "TOLTERODINE ER 2 MG CAPSULE,EXTENDED RELEASE 24 HR" RX-29434 CDM 6370000100 HCPCS 250 RC 00378-3402-93 NDC inpatient 1 UN 28.42 28.42 HEALTHPARTNERS SX009 HEALTHPARTNERS 22.5 percent of total billed charges 17.62 27 Technical (Hospital) Services "TOLTERODINE ER 2 MG CAPSULE,EXTENDED RELEASE 24 HR" RX-29434 CDM 6370000100 HCPCS 250 RC 00378-3402-93 NDC inpatient 1 UN 28.42 28.42 MULTIPLAN INC 34080 [3081285] MULTIPLAN INC [308128501] 27 percent of total billed charges 17.62 27 Technical (Hospital) Services "TOLTERODINE ER 2 MG CAPSULE,EXTENDED RELEASE 24 HR" RX-29434 CDM 6370000100 HCPCS 250 RC 00378-3402-93 NDC inpatient 1 UN 28.42 28.42 MEDICA (COMMERCIAL) 94265 [3081118] MEDICA CLAIMS [308111801] 25.58 percent of total billed charges 17.62 27 Technical (Hospital) Services "TOLTERODINE ER 2 MG CAPSULE,EXTENDED RELEASE 24 HR" RX-29434 CDM 6370000100 HCPCS 250 RC 00378-3402-93 NDC inpatient 1 UN 28.42 28.42 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES PPO [308136801] 22.5 percent of total billed charges 17.62 27 Technical (Hospital) Services "TOLTERODINE ER 2 MG CAPSULE,EXTENDED RELEASE 24 HR" RX-29434 CDM 6370000100 HCPCS 250 RC 00378-3402-93 NDC outpatient 1 UN 28.42 28.42 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES EPO [308136803] 22.74 percent of total billed charges 17.62 27 Technical (Hospital) Services "TOLTERODINE ER 2 MG CAPSULE,EXTENDED RELEASE 24 HR" RX-29434 CDM 6370000100 HCPCS 250 RC 00378-3402-93 NDC outpatient 1 UN 28.42 28.42 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES HDHP [308136802] 22.74 percent of total billed charges 17.62 27 Technical (Hospital) Services "TOLTERODINE ER 2 MG CAPSULE,EXTENDED RELEASE 24 HR" RX-29434 CDM 6370000100 HCPCS 250 RC 00378-3402-93 NDC outpatient 1 UN 28.42 28.42 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES PPO [308136801] 22.74 percent of total billed charges 17.62 27 Technical (Hospital) Services "TOLTERODINE ER 2 MG CAPSULE,EXTENDED RELEASE 24 HR" RX-29434 CDM 6370000100 HCPCS 250 RC 00378-3402-93 NDC outpatient 1 UN 28.42 28.42 MEDICA (COMMERCIAL) 94265 [3081118] MEDICA CLAIMS [308111801] 25.58 percent of total billed charges 17.62 27 Technical (Hospital) Services "TOLTERODINE ER 2 MG CAPSULE,EXTENDED RELEASE 24 HR" RX-29434 CDM 6370000100 HCPCS 250 RC 00378-3402-93 NDC outpatient 1 UN 28.42 28.42 CIGNA 62308 [3081051] CIGNA 62308 [308105105] 22.74 percent of total billed charges 17.62 27 Technical (Hospital) Services "TOLTERODINE ER 2 MG CAPSULE,EXTENDED RELEASE 24 HR" RX-29434 CDM 6370000100 HCPCS 250 RC 00378-3402-93 NDC outpatient 1 UN 28.42 28.42 CIGNA 62308 [3081051] CIGNA STATE OF WYOMING [308105107] 22.74 percent of total billed charges 17.62 27 Technical (Hospital) Services "TOLTERODINE ER 2 MG CAPSULE,EXTENDED RELEASE 24 HR" RX-29434 CDM 6370000100 HCPCS 250 RC 00378-3402-93 NDC outpatient 1 UN 28.42 28.42 UNITED HEALTHCARE (COMMERCIAL) [3081199] UNITED HEALTHCARE 87726 [308119901] 17.62 percent of total billed charges 17.62 27 Technical (Hospital) Services "TOLTERODINE ER 2 MG CAPSULE,EXTENDED RELEASE 24 HR" RX-29434 CDM 6370000100 HCPCS 250 RC 00378-3402-93 NDC outpatient 1 UN 28.42 28.42 MULTIPLAN INC 34080 [3081285] MULTIPLAN INC [308128501] 27 percent of total billed charges 17.62 27 Technical (Hospital) Services "TOLTERODINE ER 2 MG CAPSULE,EXTENDED RELEASE 24 HR" RX-29434 CDM 6370000100 HCPCS 250 RC 00378-3402-93 NDC outpatient 1 UN 28.42 28.42 HEALTHPARTNERS SX009 HEALTHPARTNERS 22.74 percent of total billed charges 17.62 27 Technical (Hospital) Services "TOLTERODINE ER 2 MG CAPSULE,EXTENDED RELEASE 24 HR" RX-29434 CDM 6370000100 HCPCS 250 RC 00378-3402-93 NDC outpatient 1 UN 28.42 28.42 BLUE CROSS BLUE SHIELD WELLMARK SB889 [3081026] BCBS WYOMING [308102603] 27 percent of total billed charges 17.62 27 Technical (Hospital) Services "TOLTERODINE ER 4 MG CAPSULE,EXTENDED RELEASE 24 HR" RX-29435 CDM 6370000100 HCPCS 250 RC 70436-0161-04 NDC inpatient 1 UN 6.45 6.45 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES PPO [308136801] 5.11 percent of total billed charges 4 6.13 Technical (Hospital) Services "TOLTERODINE ER 4 MG CAPSULE,EXTENDED RELEASE 24 HR" RX-29435 CDM 6370000100 HCPCS 250 RC 70436-0161-04 NDC inpatient 1 UN 6.45 6.45 MEDICA (COMMERCIAL) 94265 [3081118] MEDICA CLAIMS [308111801] 5.81 percent of total billed charges 4 6.13 Technical (Hospital) Services "TOLTERODINE ER 4 MG CAPSULE,EXTENDED RELEASE 24 HR" RX-29435 CDM 6370000100 HCPCS 250 RC 70436-0161-04 NDC inpatient 1 UN 6.45 6.45 HEALTHPARTNERS SX009 HEALTHPARTNERS 5.11 percent of total billed charges 4 6.13 Technical (Hospital) Services "TOLTERODINE ER 4 MG CAPSULE,EXTENDED RELEASE 24 HR" RX-29435 CDM 6370000100 HCPCS 250 RC 70436-0161-04 NDC inpatient 1 UN 6.45 6.45 MULTIPLAN INC 34080 [3081285] MULTIPLAN INC [308128501] 6.13 percent of total billed charges 4 6.13 Technical (Hospital) Services "TOLTERODINE ER 4 MG CAPSULE,EXTENDED RELEASE 24 HR" RX-29435 CDM 6370000100 HCPCS 250 RC 70436-0161-04 NDC inpatient 1 UN 6.45 6.45 UNITED HEALTHCARE (COMMERCIAL) [3081199] UNITED HEALTHCARE 87726 [308119901] 4 percent of total billed charges 4 6.13 Technical (Hospital) Services "TOLTERODINE ER 4 MG CAPSULE,EXTENDED RELEASE 24 HR" RX-29435 CDM 6370000100 HCPCS 250 RC 70436-0161-04 NDC inpatient 1 UN 6.45 6.45 BLUE CROSS BLUE SHIELD WELLMARK SB889 [3081026] BCBS WYOMING [308102603] 6.13 percent of total billed charges 4 6.13 Technical (Hospital) Services "TOLTERODINE ER 4 MG CAPSULE,EXTENDED RELEASE 24 HR" RX-29435 CDM 6370000100 HCPCS 250 RC 70436-0161-04 NDC inpatient 1 UN 6.45 6.45 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES HDHP [308136802] 5.11 percent of total billed charges 4 6.13 Technical (Hospital) Services "TOLTERODINE ER 4 MG CAPSULE,EXTENDED RELEASE 24 HR" RX-29435 CDM 6370000100 HCPCS 250 RC 70436-0161-04 NDC inpatient 1 UN 6.45 6.45 CIGNA 62308 [3081051] CIGNA 62308 [308105105] 5.11 percent of total billed charges 4 6.13 Technical (Hospital) Services "TOLTERODINE ER 4 MG CAPSULE,EXTENDED RELEASE 24 HR" RX-29435 CDM 6370000100 HCPCS 250 RC 70436-0161-04 NDC inpatient 1 UN 6.45 6.45 CIGNA 62308 [3081051] CIGNA STATE OF WYOMING [308105107] 5.11 percent of total billed charges 4 6.13 Technical (Hospital) Services "TOLTERODINE ER 4 MG CAPSULE,EXTENDED RELEASE 24 HR" RX-29435 CDM 6370000100 HCPCS 250 RC 70436-0161-04 NDC inpatient 1 UN 6.45 6.45 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES EPO [308136803] 5.11 percent of total billed charges 4 6.13 Technical (Hospital) Services "TOLTERODINE ER 4 MG CAPSULE,EXTENDED RELEASE 24 HR" RX-29435 CDM 6370000100 HCPCS 250 RC 70436-0161-04 NDC outpatient 1 UN 6.45 6.45 CIGNA 62308 [3081051] CIGNA 62308 [308105105] 5.16 percent of total billed charges 4 6.13 Technical (Hospital) Services "TOLTERODINE ER 4 MG CAPSULE,EXTENDED RELEASE 24 HR" RX-29435 CDM 6370000100 HCPCS 250 RC 70436-0161-04 NDC outpatient 1 UN 6.45 6.45 CIGNA 62308 [3081051] CIGNA STATE OF WYOMING [308105107] 5.16 percent of total billed charges 4 6.13 Technical (Hospital) Services "TOLTERODINE ER 4 MG CAPSULE,EXTENDED RELEASE 24 HR" RX-29435 CDM 6370000100 HCPCS 250 RC 70436-0161-04 NDC outpatient 1 UN 6.45 6.45 MULTIPLAN INC 34080 [3081285] MULTIPLAN INC [308128501] 6.13 percent of total billed charges 4 6.13 Technical (Hospital) Services "TOLTERODINE ER 4 MG CAPSULE,EXTENDED RELEASE 24 HR" RX-29435 CDM 6370000100 HCPCS 250 RC 70436-0161-04 NDC outpatient 1 UN 6.45 6.45 MEDICA (COMMERCIAL) 94265 [3081118] MEDICA CLAIMS [308111801] 5.81 percent of total billed charges 4 6.13 Technical (Hospital) Services "TOLTERODINE ER 4 MG CAPSULE,EXTENDED RELEASE 24 HR" RX-29435 CDM 6370000100 HCPCS 250 RC 70436-0161-04 NDC outpatient 1 UN 6.45 6.45 HEALTHPARTNERS SX009 HEALTHPARTNERS 5.16 percent of total billed charges 4 6.13 Technical (Hospital) Services "TOLTERODINE ER 4 MG CAPSULE,EXTENDED RELEASE 24 HR" RX-29435 CDM 6370000100 HCPCS 250 RC 70436-0161-04 NDC outpatient 1 UN 6.45 6.45 UNITED HEALTHCARE (COMMERCIAL) [3081199] UNITED HEALTHCARE 87726 [308119901] 4 percent of total billed charges 4 6.13 Technical (Hospital) Services "TOLTERODINE ER 4 MG CAPSULE,EXTENDED RELEASE 24 HR" RX-29435 CDM 6370000100 HCPCS 250 RC 70436-0161-04 NDC outpatient 1 UN 6.45 6.45 BLUE CROSS BLUE SHIELD WELLMARK SB889 [3081026] BCBS WYOMING [308102603] 6.13 percent of total billed charges 4 6.13 Technical (Hospital) Services "TOLTERODINE ER 4 MG CAPSULE,EXTENDED RELEASE 24 HR" RX-29435 CDM 6370000100 HCPCS 250 RC 70436-0161-04 NDC outpatient 1 UN 6.45 6.45 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES PPO [308136801] 5.16 percent of total billed charges 4 6.13 Technical (Hospital) Services "TOLTERODINE ER 4 MG CAPSULE,EXTENDED RELEASE 24 HR" RX-29435 CDM 6370000100 HCPCS 250 RC 70436-0161-04 NDC outpatient 1 UN 6.45 6.45 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES EPO [308136803] 5.16 percent of total billed charges 4 6.13 Technical (Hospital) Services "TOLTERODINE ER 4 MG CAPSULE,EXTENDED RELEASE 24 HR" RX-29435 CDM 6370000100 HCPCS 250 RC 70436-0161-04 NDC outpatient 1 UN 6.45 6.45 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES HDHP [308136802] 5.16 percent of total billed charges 4 6.13 Technical (Hospital) Services SODIUM CHLORIDE 0.65 % NASAL SPRAY AEROSOL RX-29676 CDM 6370000100 HCPCS 250 RC 00904-3865-75 NDC inpatient 1 ML 5.64 5.64 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES PPO [308136801] 4.47 percent of total billed charges 3.5 5.36 Technical (Hospital) Services SODIUM CHLORIDE 0.65 % NASAL SPRAY AEROSOL RX-29676 CDM 6370000100 HCPCS 250 RC 00904-3865-75 NDC inpatient 1 ML 5.64 5.64 MEDICA (COMMERCIAL) 94265 [3081118] MEDICA CLAIMS [308111801] 5.08 percent of total billed charges 3.5 5.36 Technical (Hospital) Services SODIUM CHLORIDE 0.65 % NASAL SPRAY AEROSOL RX-29676 CDM 6370000100 HCPCS 250 RC 00904-3865-75 NDC inpatient 1 ML 5.64 5.64 HEALTHPARTNERS SX009 HEALTHPARTNERS 4.47 percent of total billed charges 3.5 5.36 Technical (Hospital) Services SODIUM CHLORIDE 0.65 % NASAL SPRAY AEROSOL RX-29676 CDM 6370000100 HCPCS 250 RC 00904-3865-75 NDC inpatient 1 ML 5.64 5.64 MULTIPLAN INC 34080 [3081285] MULTIPLAN INC [308128501] 5.36 percent of total billed charges 3.5 5.36 Technical (Hospital) Services SODIUM CHLORIDE 0.65 % NASAL SPRAY AEROSOL RX-29676 CDM 6370000100 HCPCS 250 RC 00904-3865-75 NDC inpatient 1 ML 5.64 5.64 BLUE CROSS BLUE SHIELD WELLMARK SB889 [3081026] BCBS WYOMING [308102603] 5.36 percent of total billed charges 3.5 5.36 Technical (Hospital) Services SODIUM CHLORIDE 0.65 % NASAL SPRAY AEROSOL RX-29676 CDM 6370000100 HCPCS 250 RC 00904-3865-75 NDC inpatient 1 ML 5.64 5.64 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES EPO [308136803] 4.47 percent of total billed charges 3.5 5.36 Technical (Hospital) Services SODIUM CHLORIDE 0.65 % NASAL SPRAY AEROSOL RX-29676 CDM 6370000100 HCPCS 250 RC 00904-3865-75 NDC inpatient 1 ML 5.64 5.64 CIGNA 62308 [3081051] CIGNA 62308 [308105105] 4.47 percent of total billed charges 3.5 5.36 Technical (Hospital) Services SODIUM CHLORIDE 0.65 % NASAL SPRAY AEROSOL RX-29676 CDM 6370000100 HCPCS 250 RC 00904-3865-75 NDC inpatient 1 ML 5.64 5.64 CIGNA 62308 [3081051] CIGNA STATE OF WYOMING [308105107] 4.47 percent of total billed charges 3.5 5.36 Technical (Hospital) Services SODIUM CHLORIDE 0.65 % NASAL SPRAY AEROSOL RX-29676 CDM 6370000100 HCPCS 250 RC 00904-3865-75 NDC inpatient 1 ML 5.64 5.64 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES HDHP [308136802] 4.47 percent of total billed charges 3.5 5.36 Technical (Hospital) Services SODIUM CHLORIDE 0.65 % NASAL SPRAY AEROSOL RX-29676 CDM 6370000100 HCPCS 250 RC 00904-3865-75 NDC inpatient 1 ML 5.64 5.64 UNITED HEALTHCARE (COMMERCIAL) [3081199] UNITED HEALTHCARE 87726 [308119901] 3.5 percent of total billed charges 3.5 5.36 Technical (Hospital) Services SODIUM CHLORIDE 0.65 % NASAL SPRAY AEROSOL RX-29676 CDM 6370000100 HCPCS 250 RC 00904-3865-75 NDC outpatient 1 ML 5.64 5.64 BLUE CROSS BLUE SHIELD WELLMARK SB889 [3081026] BCBS WYOMING [308102603] 5.36 percent of total billed charges 3.5 5.36 Technical (Hospital) Services SODIUM CHLORIDE 0.65 % NASAL SPRAY AEROSOL RX-29676 CDM 6370000100 HCPCS 250 RC 00904-3865-75 NDC outpatient 1 ML 5.64 5.64 CIGNA 62308 [3081051] CIGNA 62308 [308105105] 4.51 percent of total billed charges 3.5 5.36 Technical (Hospital) Services SODIUM CHLORIDE 0.65 % NASAL SPRAY AEROSOL RX-29676 CDM 6370000100 HCPCS 250 RC 00904-3865-75 NDC outpatient 1 ML 5.64 5.64 CIGNA 62308 [3081051] CIGNA STATE OF WYOMING [308105107] 4.51 percent of total billed charges 3.5 5.36 Technical (Hospital) Services SODIUM CHLORIDE 0.65 % NASAL SPRAY AEROSOL RX-29676 CDM 6370000100 HCPCS 250 RC 00904-3865-75 NDC outpatient 1 ML 5.64 5.64 MULTIPLAN INC 34080 [3081285] MULTIPLAN INC [308128501] 5.36 percent of total billed charges 3.5 5.36 Technical (Hospital) Services SODIUM CHLORIDE 0.65 % NASAL SPRAY AEROSOL RX-29676 CDM 6370000100 HCPCS 250 RC 00904-3865-75 NDC outpatient 1 ML 5.64 5.64 MEDICA (COMMERCIAL) 94265 [3081118] MEDICA CLAIMS [308111801] 5.08 percent of total billed charges 3.5 5.36 Technical (Hospital) Services SODIUM CHLORIDE 0.65 % NASAL SPRAY AEROSOL RX-29676 CDM 6370000100 HCPCS 250 RC 00904-3865-75 NDC outpatient 1 ML 5.64 5.64 UNITED HEALTHCARE (COMMERCIAL) [3081199] UNITED HEALTHCARE 87726 [308119901] 3.5 percent of total billed charges 3.5 5.36 Technical (Hospital) Services SODIUM CHLORIDE 0.65 % NASAL SPRAY AEROSOL RX-29676 CDM 6370000100 HCPCS 250 RC 00904-3865-75 NDC outpatient 1 ML 5.64 5.64 HEALTHPARTNERS SX009 HEALTHPARTNERS 4.51 percent of total billed charges 3.5 5.36 Technical (Hospital) Services SODIUM CHLORIDE 0.65 % NASAL SPRAY AEROSOL RX-29676 CDM 6370000100 HCPCS 250 RC 00904-3865-75 NDC outpatient 1 ML 5.64 5.64 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES EPO [308136803] 4.51 percent of total billed charges 3.5 5.36 Technical (Hospital) Services SODIUM CHLORIDE 0.65 % NASAL SPRAY AEROSOL RX-29676 CDM 6370000100 HCPCS 250 RC 00904-3865-75 NDC outpatient 1 ML 5.64 5.64 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES PPO [308136801] 4.51 percent of total billed charges 3.5 5.36 Technical (Hospital) Services SODIUM CHLORIDE 0.65 % NASAL SPRAY AEROSOL RX-29676 CDM 6370000100 HCPCS 250 RC 00904-3865-75 NDC outpatient 1 ML 5.64 5.64 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES HDHP [308136802] 4.51 percent of total billed charges 3.5 5.36 Technical (Hospital) Services "ESOMEPRAZOLE MAGNESIUM 20 MG CAPSULE,DELAYED RELEASE" RX-29745 CDM 6370000100 HCPCS 250 RC 00186-5020-54 NDC inpatient 1 UN 37.58 37.58 HEALTHPARTNERS SX009 HEALTHPARTNERS 29.76 percent of total billed charges 23.3 35.7 Technical (Hospital) Services "ESOMEPRAZOLE MAGNESIUM 20 MG CAPSULE,DELAYED RELEASE" RX-29745 CDM 6370000100 HCPCS 250 RC 00186-5020-54 NDC inpatient 1 UN 37.58 37.58 MEDICA (COMMERCIAL) 94265 [3081118] MEDICA CLAIMS [308111801] 33.82 percent of total billed charges 23.3 35.7 Technical (Hospital) Services "ESOMEPRAZOLE MAGNESIUM 20 MG CAPSULE,DELAYED RELEASE" RX-29745 CDM 6370000100 HCPCS 250 RC 00186-5020-54 NDC inpatient 1 UN 37.58 37.58 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES PPO [308136801] 29.76 percent of total billed charges 23.3 35.7 Technical (Hospital) Services "ESOMEPRAZOLE MAGNESIUM 20 MG CAPSULE,DELAYED RELEASE" RX-29745 CDM 6370000100 HCPCS 250 RC 00186-5020-54 NDC inpatient 1 UN 37.58 37.58 MULTIPLAN INC 34080 [3081285] MULTIPLAN INC [308128501] 35.7 percent of total billed charges 23.3 35.7 Technical (Hospital) Services "ESOMEPRAZOLE MAGNESIUM 20 MG CAPSULE,DELAYED RELEASE" RX-29745 CDM 6370000100 HCPCS 250 RC 00186-5020-54 NDC inpatient 1 UN 37.58 37.58 UNITED HEALTHCARE (COMMERCIAL) [3081199] UNITED HEALTHCARE 87726 [308119901] 23.3 percent of total billed charges 23.3 35.7 Technical (Hospital) Services "ESOMEPRAZOLE MAGNESIUM 20 MG CAPSULE,DELAYED RELEASE" RX-29745 CDM 6370000100 HCPCS 250 RC 00186-5020-54 NDC inpatient 1 UN 37.58 37.58 CIGNA 62308 [3081051] CIGNA STATE OF WYOMING [308105107] 29.76 percent of total billed charges 23.3 35.7 Technical (Hospital) Services "ESOMEPRAZOLE MAGNESIUM 20 MG CAPSULE,DELAYED RELEASE" RX-29745 CDM 6370000100 HCPCS 250 RC 00186-5020-54 NDC inpatient 1 UN 37.58 37.58 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES HDHP [308136802] 29.76 percent of total billed charges 23.3 35.7 Technical (Hospital) Services "ESOMEPRAZOLE MAGNESIUM 20 MG CAPSULE,DELAYED RELEASE" RX-29745 CDM 6370000100 HCPCS 250 RC 00186-5020-54 NDC inpatient 1 UN 37.58 37.58 CIGNA 62308 [3081051] CIGNA 62308 [308105105] 29.76 percent of total billed charges 23.3 35.7 Technical (Hospital) Services "ESOMEPRAZOLE MAGNESIUM 20 MG CAPSULE,DELAYED RELEASE" RX-29745 CDM 6370000100 HCPCS 250 RC 00186-5020-54 NDC inpatient 1 UN 37.58 37.58 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES EPO [308136803] 29.76 percent of total billed charges 23.3 35.7 Technical (Hospital) Services "ESOMEPRAZOLE MAGNESIUM 20 MG CAPSULE,DELAYED RELEASE" RX-29745 CDM 6370000100 HCPCS 250 RC 00186-5020-54 NDC inpatient 1 UN 37.58 37.58 BLUE CROSS BLUE SHIELD WELLMARK SB889 [3081026] BCBS WYOMING [308102603] 35.7 percent of total billed charges 23.3 35.7 Technical (Hospital) Services "ESOMEPRAZOLE MAGNESIUM 20 MG CAPSULE,DELAYED RELEASE" RX-29745 CDM 6370000100 HCPCS 250 RC 00186-5020-54 NDC outpatient 1 UN 37.58 37.58 HEALTHPARTNERS SX009 HEALTHPARTNERS 30.06 percent of total billed charges 23.3 35.7 Technical (Hospital) Services "ESOMEPRAZOLE MAGNESIUM 20 MG CAPSULE,DELAYED RELEASE" RX-29745 CDM 6370000100 HCPCS 250 RC 00186-5020-54 NDC outpatient 1 UN 37.58 37.58 UNITED HEALTHCARE (COMMERCIAL) [3081199] UNITED HEALTHCARE 87726 [308119901] 23.3 percent of total billed charges 23.3 35.7 Technical (Hospital) Services "ESOMEPRAZOLE MAGNESIUM 20 MG CAPSULE,DELAYED RELEASE" RX-29745 CDM 6370000100 HCPCS 250 RC 00186-5020-54 NDC outpatient 1 UN 37.58 37.58 MULTIPLAN INC 34080 [3081285] MULTIPLAN INC [308128501] 35.7 percent of total billed charges 23.3 35.7 Technical (Hospital) Services "ESOMEPRAZOLE MAGNESIUM 20 MG CAPSULE,DELAYED RELEASE" RX-29745 CDM 6370000100 HCPCS 250 RC 00186-5020-54 NDC outpatient 1 UN 37.58 37.58 CIGNA 62308 [3081051] CIGNA 62308 [308105105] 30.06 percent of total billed charges 23.3 35.7 Technical (Hospital) Services "ESOMEPRAZOLE MAGNESIUM 20 MG CAPSULE,DELAYED RELEASE" RX-29745 CDM 6370000100 HCPCS 250 RC 00186-5020-54 NDC outpatient 1 UN 37.58 37.58 CIGNA 62308 [3081051] CIGNA STATE OF WYOMING [308105107] 30.06 percent of total billed charges 23.3 35.7 Technical (Hospital) Services "ESOMEPRAZOLE MAGNESIUM 20 MG CAPSULE,DELAYED RELEASE" RX-29745 CDM 6370000100 HCPCS 250 RC 00186-5020-54 NDC outpatient 1 UN 37.58 37.58 MEDICA (COMMERCIAL) 94265 [3081118] MEDICA CLAIMS [308111801] 33.82 percent of total billed charges 23.3 35.7 Technical (Hospital) Services "ESOMEPRAZOLE MAGNESIUM 20 MG CAPSULE,DELAYED RELEASE" RX-29745 CDM 6370000100 HCPCS 250 RC 00186-5020-54 NDC outpatient 1 UN 37.58 37.58 BLUE CROSS BLUE SHIELD WELLMARK SB889 [3081026] BCBS WYOMING [308102603] 35.7 percent of total billed charges 23.3 35.7 Technical (Hospital) Services "ESOMEPRAZOLE MAGNESIUM 20 MG CAPSULE,DELAYED RELEASE" RX-29745 CDM 6370000100 HCPCS 250 RC 00186-5020-54 NDC outpatient 1 UN 37.58 37.58 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES EPO [308136803] 30.06 percent of total billed charges 23.3 35.7 Technical (Hospital) Services "ESOMEPRAZOLE MAGNESIUM 20 MG CAPSULE,DELAYED RELEASE" RX-29745 CDM 6370000100 HCPCS 250 RC 00186-5020-54 NDC outpatient 1 UN 37.58 37.58 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES PPO [308136801] 30.06 percent of total billed charges 23.3 35.7 Technical (Hospital) Services "ESOMEPRAZOLE MAGNESIUM 20 MG CAPSULE,DELAYED RELEASE" RX-29745 CDM 6370000100 HCPCS 250 RC 00186-5020-54 NDC outpatient 1 UN 37.58 37.58 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES HDHP [308136802] 30.06 percent of total billed charges 23.3 35.7 Technical (Hospital) Services "ESOMEPRAZOLE MAGNESIUM 40 MG CAPSULE,DELAYED RELEASE" RX-29746 CDM 6370000100 HCPCS 250 RC 00186-5040-54 NDC outpatient 1 UN 37.58 37.58 UNITED HEALTHCARE (COMMERCIAL) [3081199] UNITED HEALTHCARE 87726 [308119901] 23.3 percent of total billed charges 23.3 35.7 Technical (Hospital) Services "ESOMEPRAZOLE MAGNESIUM 40 MG CAPSULE,DELAYED RELEASE" RX-29746 CDM 6370000100 HCPCS 250 RC 00186-5040-54 NDC outpatient 1 UN 37.58 37.58 HEALTHPARTNERS SX009 HEALTHPARTNERS 30.06 percent of total billed charges 23.3 35.7 Technical (Hospital) Services "ESOMEPRAZOLE MAGNESIUM 40 MG CAPSULE,DELAYED RELEASE" RX-29746 CDM 6370000100 HCPCS 250 RC 00186-5040-54 NDC outpatient 1 UN 37.58 37.58 MEDICA (COMMERCIAL) 94265 [3081118] MEDICA CLAIMS [308111801] 33.82 percent of total billed charges 23.3 35.7 Technical (Hospital) Services "ESOMEPRAZOLE MAGNESIUM 40 MG CAPSULE,DELAYED RELEASE" RX-29746 CDM 6370000100 HCPCS 250 RC 00186-5040-54 NDC outpatient 1 UN 37.58 37.58 MULTIPLAN INC 34080 [3081285] MULTIPLAN INC [308128501] 35.7 percent of total billed charges 23.3 35.7 Technical (Hospital) Services "ESOMEPRAZOLE MAGNESIUM 40 MG CAPSULE,DELAYED RELEASE" RX-29746 CDM 6370000100 HCPCS 250 RC 00186-5040-54 NDC outpatient 1 UN 37.58 37.58 CIGNA 62308 [3081051] CIGNA 62308 [308105105] 30.06 percent of total billed charges 23.3 35.7 Technical (Hospital) Services "ESOMEPRAZOLE MAGNESIUM 40 MG CAPSULE,DELAYED RELEASE" RX-29746 CDM 6370000100 HCPCS 250 RC 00186-5040-54 NDC outpatient 1 UN 37.58 37.58 CIGNA 62308 [3081051] CIGNA STATE OF WYOMING [308105107] 30.06 percent of total billed charges 23.3 35.7 Technical (Hospital) Services "ESOMEPRAZOLE MAGNESIUM 40 MG CAPSULE,DELAYED RELEASE" RX-29746 CDM 6370000100 HCPCS 250 RC 00186-5040-54 NDC outpatient 1 UN 37.58 37.58 BLUE CROSS BLUE SHIELD WELLMARK SB889 [3081026] BCBS WYOMING [308102603] 35.7 percent of total billed charges 23.3 35.7 Technical (Hospital) Services "ESOMEPRAZOLE MAGNESIUM 40 MG CAPSULE,DELAYED RELEASE" RX-29746 CDM 6370000100 HCPCS 250 RC 00186-5040-54 NDC outpatient 1 UN 37.58 37.58 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES EPO [308136803] 30.06 percent of total billed charges 23.3 35.7 Technical (Hospital) Services "ESOMEPRAZOLE MAGNESIUM 40 MG CAPSULE,DELAYED RELEASE" RX-29746 CDM 6370000100 HCPCS 250 RC 00186-5040-54 NDC outpatient 1 UN 37.58 37.58 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES HDHP [308136802] 30.06 percent of total billed charges 23.3 35.7 Technical (Hospital) Services "ESOMEPRAZOLE MAGNESIUM 40 MG CAPSULE,DELAYED RELEASE" RX-29746 CDM 6370000100 HCPCS 250 RC 00186-5040-54 NDC outpatient 1 UN 37.58 37.58 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES PPO [308136801] 30.06 percent of total billed charges 23.3 35.7 Technical (Hospital) Services "ESOMEPRAZOLE MAGNESIUM 40 MG CAPSULE,DELAYED RELEASE" RX-29746 CDM 6370000100 HCPCS 250 RC 00186-5040-54 NDC inpatient 1 UN 37.58 37.58 BLUE CROSS BLUE SHIELD WELLMARK SB889 [3081026] BCBS WYOMING [308102603] 35.7 percent of total billed charges 23.3 35.7 Technical (Hospital) Services "ESOMEPRAZOLE MAGNESIUM 40 MG CAPSULE,DELAYED RELEASE" RX-29746 CDM 6370000100 HCPCS 250 RC 00186-5040-54 NDC inpatient 1 UN 37.58 37.58 UNITED HEALTHCARE (COMMERCIAL) [3081199] UNITED HEALTHCARE 87726 [308119901] 23.3 percent of total billed charges 23.3 35.7 Technical (Hospital) Services "ESOMEPRAZOLE MAGNESIUM 40 MG CAPSULE,DELAYED RELEASE" RX-29746 CDM 6370000100 HCPCS 250 RC 00186-5040-54 NDC inpatient 1 UN 37.58 37.58 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES HDHP [308136802] 29.76 percent of total billed charges 23.3 35.7 Technical (Hospital) Services "ESOMEPRAZOLE MAGNESIUM 40 MG CAPSULE,DELAYED RELEASE" RX-29746 CDM 6370000100 HCPCS 250 RC 00186-5040-54 NDC inpatient 1 UN 37.58 37.58 MEDICA (COMMERCIAL) 94265 [3081118] MEDICA CLAIMS [308111801] 33.82 percent of total billed charges 23.3 35.7 Technical (Hospital) Services "ESOMEPRAZOLE MAGNESIUM 40 MG CAPSULE,DELAYED RELEASE" RX-29746 CDM 6370000100 HCPCS 250 RC 00186-5040-54 NDC inpatient 1 UN 37.58 37.58 HEALTHPARTNERS SX009 HEALTHPARTNERS 29.76 percent of total billed charges 23.3 35.7 Technical (Hospital) Services "ESOMEPRAZOLE MAGNESIUM 40 MG CAPSULE,DELAYED RELEASE" RX-29746 CDM 6370000100 HCPCS 250 RC 00186-5040-54 NDC inpatient 1 UN 37.58 37.58 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES EPO [308136803] 29.76 percent of total billed charges 23.3 35.7 Technical (Hospital) Services "ESOMEPRAZOLE MAGNESIUM 40 MG CAPSULE,DELAYED RELEASE" RX-29746 CDM 6370000100 HCPCS 250 RC 00186-5040-54 NDC inpatient 1 UN 37.58 37.58 CIGNA 62308 [3081051] CIGNA 62308 [308105105] 29.76 percent of total billed charges 23.3 35.7 Technical (Hospital) Services "ESOMEPRAZOLE MAGNESIUM 40 MG CAPSULE,DELAYED RELEASE" RX-29746 CDM 6370000100 HCPCS 250 RC 00186-5040-54 NDC inpatient 1 UN 37.58 37.58 CIGNA 62308 [3081051] CIGNA STATE OF WYOMING [308105107] 29.76 percent of total billed charges 23.3 35.7 Technical (Hospital) Services "ESOMEPRAZOLE MAGNESIUM 40 MG CAPSULE,DELAYED RELEASE" RX-29746 CDM 6370000100 HCPCS 250 RC 00186-5040-54 NDC inpatient 1 UN 37.58 37.58 MULTIPLAN INC 34080 [3081285] MULTIPLAN INC [308128501] 35.7 percent of total billed charges 23.3 35.7 Technical (Hospital) Services "ESOMEPRAZOLE MAGNESIUM 40 MG CAPSULE,DELAYED RELEASE" RX-29746 CDM 6370000100 HCPCS 250 RC 00186-5040-54 NDC inpatient 1 UN 37.58 37.58 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES PPO [308136801] 29.76 percent of total billed charges 23.3 35.7 Technical (Hospital) Services "METOPROLOL SUCCINATE ER 25 MG TABLET,EXTENDED RELEASE 24 HR" RX-29858 CDM 6370000100 HCPCS 250 RC 00904-6322-06 NDC outpatient 1 UN 6.17 6.17 BLUE CROSS BLUE SHIELD WELLMARK SB889 [3081026] BCBS WYOMING [308102603] 5.86 percent of total billed charges 3.83 5.86 Technical (Hospital) Services "METOPROLOL SUCCINATE ER 25 MG TABLET,EXTENDED RELEASE 24 HR" RX-29858 CDM 6370000100 HCPCS 250 RC 00904-6322-06 NDC outpatient 1 UN 6.17 6.17 HEALTHPARTNERS SX009 HEALTHPARTNERS 4.94 percent of total billed charges 3.83 5.86 Technical (Hospital) Services "METOPROLOL SUCCINATE ER 25 MG TABLET,EXTENDED RELEASE 24 HR" RX-29858 CDM 6370000100 HCPCS 250 RC 00904-6322-06 NDC outpatient 1 UN 6.17 6.17 UNITED HEALTHCARE (COMMERCIAL) [3081199] UNITED HEALTHCARE 87726 [308119901] 3.83 percent of total billed charges 3.83 5.86 Technical (Hospital) Services "METOPROLOL SUCCINATE ER 25 MG TABLET,EXTENDED RELEASE 24 HR" RX-29858 CDM 6370000100 HCPCS 250 RC 00904-6322-06 NDC outpatient 1 UN 6.17 6.17 CIGNA 62308 [3081051] CIGNA 62308 [308105105] 4.94 percent of total billed charges 3.83 5.86 Technical (Hospital) Services "METOPROLOL SUCCINATE ER 25 MG TABLET,EXTENDED RELEASE 24 HR" RX-29858 CDM 6370000100 HCPCS 250 RC 00904-6322-06 NDC outpatient 1 UN 6.17 6.17 CIGNA 62308 [3081051] CIGNA STATE OF WYOMING [308105107] 4.94 percent of total billed charges 3.83 5.86 Technical (Hospital) Services "METOPROLOL SUCCINATE ER 25 MG TABLET,EXTENDED RELEASE 24 HR" RX-29858 CDM 6370000100 HCPCS 250 RC 00904-6322-06 NDC outpatient 1 UN 6.17 6.17 MULTIPLAN INC 34080 [3081285] MULTIPLAN INC [308128501] 5.86 percent of total billed charges 3.83 5.86 Technical (Hospital) Services "METOPROLOL SUCCINATE ER 25 MG TABLET,EXTENDED RELEASE 24 HR" RX-29858 CDM 6370000100 HCPCS 250 RC 00904-6322-06 NDC outpatient 1 UN 6.17 6.17 MEDICA (COMMERCIAL) 94265 [3081118] MEDICA CLAIMS [308111801] 5.55 percent of total billed charges 3.83 5.86 Technical (Hospital) Services "METOPROLOL SUCCINATE ER 25 MG TABLET,EXTENDED RELEASE 24 HR" RX-29858 CDM 6370000100 HCPCS 250 RC 00904-6322-06 NDC outpatient 1 UN 6.17 6.17 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES HDHP [308136802] 4.94 percent of total billed charges 3.83 5.86 Technical (Hospital) Services "METOPROLOL SUCCINATE ER 25 MG TABLET,EXTENDED RELEASE 24 HR" RX-29858 CDM 6370000100 HCPCS 250 RC 00904-6322-06 NDC outpatient 1 UN 6.17 6.17 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES EPO [308136803] 4.94 percent of total billed charges 3.83 5.86 Technical (Hospital) Services "METOPROLOL SUCCINATE ER 25 MG TABLET,EXTENDED RELEASE 24 HR" RX-29858 CDM 6370000100 HCPCS 250 RC 00904-6322-06 NDC outpatient 1 UN 6.17 6.17 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES PPO [308136801] 4.94 percent of total billed charges 3.83 5.86 Technical (Hospital) Services "METOPROLOL SUCCINATE ER 25 MG TABLET,EXTENDED RELEASE 24 HR" RX-29858 CDM 6370000100 HCPCS 250 RC 00904-6322-06 NDC inpatient 1 UN 6.17 6.17 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES HDHP [308136802] 4.89 percent of total billed charges 3.83 5.86 Technical (Hospital) Services "METOPROLOL SUCCINATE ER 25 MG TABLET,EXTENDED RELEASE 24 HR" RX-29858 CDM 6370000100 HCPCS 250 RC 00904-6322-06 NDC inpatient 1 UN 6.17 6.17 CIGNA 62308 [3081051] CIGNA 62308 [308105105] 4.89 percent of total billed charges 3.83 5.86 Technical (Hospital) Services "METOPROLOL SUCCINATE ER 25 MG TABLET,EXTENDED RELEASE 24 HR" RX-29858 CDM 6370000100 HCPCS 250 RC 00904-6322-06 NDC inpatient 1 UN 6.17 6.17 CIGNA 62308 [3081051] CIGNA STATE OF WYOMING [308105107] 4.89 percent of total billed charges 3.83 5.86 Technical (Hospital) Services "METOPROLOL SUCCINATE ER 25 MG TABLET,EXTENDED RELEASE 24 HR" RX-29858 CDM 6370000100 HCPCS 250 RC 00904-6322-06 NDC inpatient 1 UN 6.17 6.17 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES EPO [308136803] 4.89 percent of total billed charges 3.83 5.86 Technical (Hospital) Services "METOPROLOL SUCCINATE ER 25 MG TABLET,EXTENDED RELEASE 24 HR" RX-29858 CDM 6370000100 HCPCS 250 RC 00904-6322-06 NDC inpatient 1 UN 6.17 6.17 BLUE CROSS BLUE SHIELD WELLMARK SB889 [3081026] BCBS WYOMING [308102603] 5.86 percent of total billed charges 3.83 5.86 Technical (Hospital) Services "METOPROLOL SUCCINATE ER 25 MG TABLET,EXTENDED RELEASE 24 HR" RX-29858 CDM 6370000100 HCPCS 250 RC 00904-6322-06 NDC inpatient 1 UN 6.17 6.17 UNITED HEALTHCARE (COMMERCIAL) [3081199] UNITED HEALTHCARE 87726 [308119901] 3.83 percent of total billed charges 3.83 5.86 Technical (Hospital) Services "METOPROLOL SUCCINATE ER 25 MG TABLET,EXTENDED RELEASE 24 HR" RX-29858 CDM 6370000100 HCPCS 250 RC 00904-6322-06 NDC inpatient 1 UN 6.17 6.17 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES PPO [308136801] 4.89 percent of total billed charges 3.83 5.86 Technical (Hospital) Services "METOPROLOL SUCCINATE ER 25 MG TABLET,EXTENDED RELEASE 24 HR" RX-29858 CDM 6370000100 HCPCS 250 RC 00904-6322-06 NDC inpatient 1 UN 6.17 6.17 MEDICA (COMMERCIAL) 94265 [3081118] MEDICA CLAIMS [308111801] 5.55 percent of total billed charges 3.83 5.86 Technical (Hospital) Services "METOPROLOL SUCCINATE ER 25 MG TABLET,EXTENDED RELEASE 24 HR" RX-29858 CDM 6370000100 HCPCS 250 RC 00904-6322-06 NDC inpatient 1 UN 6.17 6.17 HEALTHPARTNERS SX009 HEALTHPARTNERS 4.89 percent of total billed charges 3.83 5.86 Technical (Hospital) Services "METOPROLOL SUCCINATE ER 25 MG TABLET,EXTENDED RELEASE 24 HR" RX-29858 CDM 6370000100 HCPCS 250 RC 00904-6322-06 NDC inpatient 1 UN 6.17 6.17 MULTIPLAN INC 34080 [3081285] MULTIPLAN INC [308128501] 5.86 percent of total billed charges 3.83 5.86 Technical (Hospital) Services "METOPROLOL SUCCINATE ER 50 MG TABLET,EXTENDED RELEASE 24 HR" RX-30070 CDM 6370000100 HCPCS 250 RC 70010-0781-01 NDC outpatient 1 UN 5.74 5.74 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES PPO [308136801] 4.59 percent of total billed charges 3.56 5.45 Technical (Hospital) Services "METOPROLOL SUCCINATE ER 50 MG TABLET,EXTENDED RELEASE 24 HR" RX-30070 CDM 6370000100 HCPCS 250 RC 70010-0781-01 NDC outpatient 1 UN 5.74 5.74 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES EPO [308136803] 4.59 percent of total billed charges 3.56 5.45 Technical (Hospital) Services "METOPROLOL SUCCINATE ER 50 MG TABLET,EXTENDED RELEASE 24 HR" RX-30070 CDM 6370000100 HCPCS 250 RC 70010-0781-01 NDC outpatient 1 UN 5.74 5.74 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES HDHP [308136802] 4.59 percent of total billed charges 3.56 5.45 Technical (Hospital) Services "METOPROLOL SUCCINATE ER 50 MG TABLET,EXTENDED RELEASE 24 HR" RX-30070 CDM 6370000100 HCPCS 250 RC 70010-0781-01 NDC outpatient 1 UN 5.74 5.74 CIGNA 62308 [3081051] CIGNA 62308 [308105105] 4.59 percent of total billed charges 3.56 5.45 Technical (Hospital) Services "METOPROLOL SUCCINATE ER 50 MG TABLET,EXTENDED RELEASE 24 HR" RX-30070 CDM 6370000100 HCPCS 250 RC 70010-0781-01 NDC outpatient 1 UN 5.74 5.74 CIGNA 62308 [3081051] CIGNA STATE OF WYOMING [308105107] 4.59 percent of total billed charges 3.56 5.45 Technical (Hospital) Services "METOPROLOL SUCCINATE ER 50 MG TABLET,EXTENDED RELEASE 24 HR" RX-30070 CDM 6370000100 HCPCS 250 RC 70010-0781-01 NDC outpatient 1 UN 5.74 5.74 MULTIPLAN INC 34080 [3081285] MULTIPLAN INC [308128501] 5.45 percent of total billed charges 3.56 5.45 Technical (Hospital) Services "METOPROLOL SUCCINATE ER 50 MG TABLET,EXTENDED RELEASE 24 HR" RX-30070 CDM 6370000100 HCPCS 250 RC 70010-0781-01 NDC outpatient 1 UN 5.74 5.74 UNITED HEALTHCARE (COMMERCIAL) [3081199] UNITED HEALTHCARE 87726 [308119901] 3.56 percent of total billed charges 3.56 5.45 Technical (Hospital) Services "METOPROLOL SUCCINATE ER 50 MG TABLET,EXTENDED RELEASE 24 HR" RX-30070 CDM 6370000100 HCPCS 250 RC 70010-0781-01 NDC outpatient 1 UN 5.74 5.74 MEDICA (COMMERCIAL) 94265 [3081118] MEDICA CLAIMS [308111801] 5.17 percent of total billed charges 3.56 5.45 Technical (Hospital) Services "METOPROLOL SUCCINATE ER 50 MG TABLET,EXTENDED RELEASE 24 HR" RX-30070 CDM 6370000100 HCPCS 250 RC 70010-0781-01 NDC outpatient 1 UN 5.74 5.74 HEALTHPARTNERS SX009 HEALTHPARTNERS 4.59 percent of total billed charges 3.56 5.45 Technical (Hospital) Services "METOPROLOL SUCCINATE ER 50 MG TABLET,EXTENDED RELEASE 24 HR" RX-30070 CDM 6370000100 HCPCS 250 RC 70010-0781-01 NDC outpatient 1 UN 5.74 5.74 BLUE CROSS BLUE SHIELD WELLMARK SB889 [3081026] BCBS WYOMING [308102603] 5.45 percent of total billed charges 3.56 5.45 Technical (Hospital) Services "METOPROLOL SUCCINATE ER 50 MG TABLET,EXTENDED RELEASE 24 HR" RX-30070 CDM 6370000100 HCPCS 250 RC 70010-0781-01 NDC inpatient 1 UN 5.74 5.74 MULTIPLAN INC 34080 [3081285] MULTIPLAN INC [308128501] 5.45 percent of total billed charges 3.56 5.45 Technical (Hospital) Services "METOPROLOL SUCCINATE ER 50 MG TABLET,EXTENDED RELEASE 24 HR" RX-30070 CDM 6370000100 HCPCS 250 RC 70010-0781-01 NDC inpatient 1 UN 5.74 5.74 HEALTHPARTNERS SX009 HEALTHPARTNERS 4.54 percent of total billed charges 3.56 5.45 Technical (Hospital) Services "METOPROLOL SUCCINATE ER 50 MG TABLET,EXTENDED RELEASE 24 HR" RX-30070 CDM 6370000100 HCPCS 250 RC 70010-0781-01 NDC inpatient 1 UN 5.74 5.74 MEDICA (COMMERCIAL) 94265 [3081118] MEDICA CLAIMS [308111801] 5.17 percent of total billed charges 3.56 5.45 Technical (Hospital) Services "METOPROLOL SUCCINATE ER 50 MG TABLET,EXTENDED RELEASE 24 HR" RX-30070 CDM 6370000100 HCPCS 250 RC 70010-0781-01 NDC inpatient 1 UN 5.74 5.74 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES PPO [308136801] 4.54 percent of total billed charges 3.56 5.45 Technical (Hospital) Services "METOPROLOL SUCCINATE ER 50 MG TABLET,EXTENDED RELEASE 24 HR" RX-30070 CDM 6370000100 HCPCS 250 RC 70010-0781-01 NDC inpatient 1 UN 5.74 5.74 UNITED HEALTHCARE (COMMERCIAL) [3081199] UNITED HEALTHCARE 87726 [308119901] 3.56 percent of total billed charges 3.56 5.45 Technical (Hospital) Services "METOPROLOL SUCCINATE ER 50 MG TABLET,EXTENDED RELEASE 24 HR" RX-30070 CDM 6370000100 HCPCS 250 RC 70010-0781-01 NDC inpatient 1 UN 5.74 5.74 BLUE CROSS BLUE SHIELD WELLMARK SB889 [3081026] BCBS WYOMING [308102603] 5.45 percent of total billed charges 3.56 5.45 Technical (Hospital) Services "METOPROLOL SUCCINATE ER 50 MG TABLET,EXTENDED RELEASE 24 HR" RX-30070 CDM 6370000100 HCPCS 250 RC 70010-0781-01 NDC inpatient 1 UN 5.74 5.74 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES EPO [308136803] 4.54 percent of total billed charges 3.56 5.45 Technical (Hospital) Services "METOPROLOL SUCCINATE ER 50 MG TABLET,EXTENDED RELEASE 24 HR" RX-30070 CDM 6370000100 HCPCS 250 RC 70010-0781-01 NDC inpatient 1 UN 5.74 5.74 CIGNA 62308 [3081051] CIGNA 62308 [308105105] 4.54 percent of total billed charges 3.56 5.45 Technical (Hospital) Services "METOPROLOL SUCCINATE ER 50 MG TABLET,EXTENDED RELEASE 24 HR" RX-30070 CDM 6370000100 HCPCS 250 RC 70010-0781-01 NDC inpatient 1 UN 5.74 5.74 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES HDHP [308136802] 4.54 percent of total billed charges 3.56 5.45 Technical (Hospital) Services "METOPROLOL SUCCINATE ER 50 MG TABLET,EXTENDED RELEASE 24 HR" RX-30070 CDM 6370000100 HCPCS 250 RC 70010-0781-01 NDC inpatient 1 UN 5.74 5.74 CIGNA 62308 [3081051] CIGNA STATE OF WYOMING [308105107] 4.54 percent of total billed charges 3.56 5.45 Technical (Hospital) Services "METOPROLOL SUCCINATE ER 100 MG TABLET,EXTENDED RELEASE 24 HR" RX-30071 CDM 6370000100 HCPCS 250 RC 68382-0566-01 NDC inpatient 1 UN 5.85 5.85 BLUE CROSS BLUE SHIELD WELLMARK SB889 [3081026] BCBS WYOMING [308102603] 5.56 percent of total billed charges 3.63 5.56 Technical (Hospital) Services "METOPROLOL SUCCINATE ER 100 MG TABLET,EXTENDED RELEASE 24 HR" RX-30071 CDM 6370000100 HCPCS 250 RC 68382-0566-01 NDC inpatient 1 UN 5.85 5.85 HEALTHPARTNERS SX009 HEALTHPARTNERS 4.63 percent of total billed charges 3.63 5.56 Technical (Hospital) Services "METOPROLOL SUCCINATE ER 100 MG TABLET,EXTENDED RELEASE 24 HR" RX-30071 CDM 6370000100 HCPCS 250 RC 68382-0566-01 NDC inpatient 1 UN 5.85 5.85 MEDICA (COMMERCIAL) 94265 [3081118] MEDICA CLAIMS [308111801] 5.27 percent of total billed charges 3.63 5.56 Technical (Hospital) Services "METOPROLOL SUCCINATE ER 100 MG TABLET,EXTENDED RELEASE 24 HR" RX-30071 CDM 6370000100 HCPCS 250 RC 68382-0566-01 NDC inpatient 1 UN 5.85 5.85 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES HDHP [308136802] 4.63 percent of total billed charges 3.63 5.56 Technical (Hospital) Services "METOPROLOL SUCCINATE ER 100 MG TABLET,EXTENDED RELEASE 24 HR" RX-30071 CDM 6370000100 HCPCS 250 RC 68382-0566-01 NDC inpatient 1 UN 5.85 5.85 UNITED HEALTHCARE (COMMERCIAL) [3081199] UNITED HEALTHCARE 87726 [308119901] 3.63 percent of total billed charges 3.63 5.56 Technical (Hospital) Services "METOPROLOL SUCCINATE ER 100 MG TABLET,EXTENDED RELEASE 24 HR" RX-30071 CDM 6370000100 HCPCS 250 RC 68382-0566-01 NDC inpatient 1 UN 5.85 5.85 CIGNA 62308 [3081051] CIGNA 62308 [308105105] 4.63 percent of total billed charges 3.63 5.56 Technical (Hospital) Services "METOPROLOL SUCCINATE ER 100 MG TABLET,EXTENDED RELEASE 24 HR" RX-30071 CDM 6370000100 HCPCS 250 RC 68382-0566-01 NDC inpatient 1 UN 5.85 5.85 CIGNA 62308 [3081051] CIGNA STATE OF WYOMING [308105107] 4.63 percent of total billed charges 3.63 5.56 Technical (Hospital) Services "METOPROLOL SUCCINATE ER 100 MG TABLET,EXTENDED RELEASE 24 HR" RX-30071 CDM 6370000100 HCPCS 250 RC 68382-0566-01 NDC inpatient 1 UN 5.85 5.85 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES EPO [308136803] 4.63 percent of total billed charges 3.63 5.56 Technical (Hospital) Services "METOPROLOL SUCCINATE ER 100 MG TABLET,EXTENDED RELEASE 24 HR" RX-30071 CDM 6370000100 HCPCS 250 RC 68382-0566-01 NDC inpatient 1 UN 5.85 5.85 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES PPO [308136801] 4.63 percent of total billed charges 3.63 5.56 Technical (Hospital) Services "METOPROLOL SUCCINATE ER 100 MG TABLET,EXTENDED RELEASE 24 HR" RX-30071 CDM 6370000100 HCPCS 250 RC 68382-0566-01 NDC inpatient 1 UN 5.85 5.85 MULTIPLAN INC 34080 [3081285] MULTIPLAN INC [308128501] 5.56 percent of total billed charges 3.63 5.56 Technical (Hospital) Services "METOPROLOL SUCCINATE ER 100 MG TABLET,EXTENDED RELEASE 24 HR" RX-30071 CDM 6370000100 HCPCS 250 RC 68382-0566-01 NDC outpatient 1 UN 5.85 5.85 MULTIPLAN INC 34080 [3081285] MULTIPLAN INC [308128501] 5.56 percent of total billed charges 3.63 5.56 Technical (Hospital) Services "METOPROLOL SUCCINATE ER 100 MG TABLET,EXTENDED RELEASE 24 HR" RX-30071 CDM 6370000100 HCPCS 250 RC 68382-0566-01 NDC outpatient 1 UN 5.85 5.85 CIGNA 62308 [3081051] CIGNA 62308 [308105105] 4.68 percent of total billed charges 3.63 5.56 Technical (Hospital) Services "METOPROLOL SUCCINATE ER 100 MG TABLET,EXTENDED RELEASE 24 HR" RX-30071 CDM 6370000100 HCPCS 250 RC 68382-0566-01 NDC outpatient 1 UN 5.85 5.85 CIGNA 62308 [3081051] CIGNA STATE OF WYOMING [308105107] 4.68 percent of total billed charges 3.63 5.56 Technical (Hospital) Services "METOPROLOL SUCCINATE ER 100 MG TABLET,EXTENDED RELEASE 24 HR" RX-30071 CDM 6370000100 HCPCS 250 RC 68382-0566-01 NDC outpatient 1 UN 5.85 5.85 MEDICA (COMMERCIAL) 94265 [3081118] MEDICA CLAIMS [308111801] 5.27 percent of total billed charges 3.63 5.56 Technical (Hospital) Services "METOPROLOL SUCCINATE ER 100 MG TABLET,EXTENDED RELEASE 24 HR" RX-30071 CDM 6370000100 HCPCS 250 RC 68382-0566-01 NDC outpatient 1 UN 5.85 5.85 HEALTHPARTNERS SX009 HEALTHPARTNERS 4.68 percent of total billed charges 3.63 5.56 Technical (Hospital) Services "METOPROLOL SUCCINATE ER 100 MG TABLET,EXTENDED RELEASE 24 HR" RX-30071 CDM 6370000100 HCPCS 250 RC 68382-0566-01 NDC outpatient 1 UN 5.85 5.85 UNITED HEALTHCARE (COMMERCIAL) [3081199] UNITED HEALTHCARE 87726 [308119901] 3.63 percent of total billed charges 3.63 5.56 Technical (Hospital) Services "METOPROLOL SUCCINATE ER 100 MG TABLET,EXTENDED RELEASE 24 HR" RX-30071 CDM 6370000100 HCPCS 250 RC 68382-0566-01 NDC outpatient 1 UN 5.85 5.85 BLUE CROSS BLUE SHIELD WELLMARK SB889 [3081026] BCBS WYOMING [308102603] 5.56 percent of total billed charges 3.63 5.56 Technical (Hospital) Services "METOPROLOL SUCCINATE ER 100 MG TABLET,EXTENDED RELEASE 24 HR" RX-30071 CDM 6370000100 HCPCS 250 RC 68382-0566-01 NDC outpatient 1 UN 5.85 5.85 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES EPO [308136803] 4.68 percent of total billed charges 3.63 5.56 Technical (Hospital) Services "METOPROLOL SUCCINATE ER 100 MG TABLET,EXTENDED RELEASE 24 HR" RX-30071 CDM 6370000100 HCPCS 250 RC 68382-0566-01 NDC outpatient 1 UN 5.85 5.85 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES PPO [308136801] 4.68 percent of total billed charges 3.63 5.56 Technical (Hospital) Services "METOPROLOL SUCCINATE ER 100 MG TABLET,EXTENDED RELEASE 24 HR" RX-30071 CDM 6370000100 HCPCS 250 RC 68382-0566-01 NDC outpatient 1 UN 5.85 5.85 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES HDHP [308136802] 4.68 percent of total billed charges 3.63 5.56 Technical (Hospital) Services VALGANCICLOVIR 450 MG TABLET RX-30148 CDM 6370000100 HCPCS 250 RC 00904-6796-04 NDC inpatient 1 UN 146.05 146.05 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES PPO [308136801] 115.64 percent of total billed charges 90.55 138.75 Technical (Hospital) Services VALGANCICLOVIR 450 MG TABLET RX-30148 CDM 6370000100 HCPCS 250 RC 00904-6796-04 NDC inpatient 1 UN 146.05 146.05 HEALTHPARTNERS SX009 HEALTHPARTNERS 115.64 percent of total billed charges 90.55 138.75 Technical (Hospital) Services VALGANCICLOVIR 450 MG TABLET RX-30148 CDM 6370000100 HCPCS 250 RC 00904-6796-04 NDC inpatient 1 UN 146.05 146.05 MEDICA (COMMERCIAL) 94265 [3081118] MEDICA CLAIMS [308111801] 131.45 percent of total billed charges 90.55 138.75 Technical (Hospital) Services VALGANCICLOVIR 450 MG TABLET RX-30148 CDM 6370000100 HCPCS 250 RC 00904-6796-04 NDC inpatient 1 UN 146.05 146.05 MULTIPLAN INC 34080 [3081285] MULTIPLAN INC [308128501] 138.75 percent of total billed charges 90.55 138.75 Technical (Hospital) Services VALGANCICLOVIR 450 MG TABLET RX-30148 CDM 6370000100 HCPCS 250 RC 00904-6796-04 NDC inpatient 1 UN 146.05 146.05 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES HDHP [308136802] 115.64 percent of total billed charges 90.55 138.75 Technical (Hospital) Services VALGANCICLOVIR 450 MG TABLET RX-30148 CDM 6370000100 HCPCS 250 RC 00904-6796-04 NDC inpatient 1 UN 146.05 146.05 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES EPO [308136803] 115.64 percent of total billed charges 90.55 138.75 Technical (Hospital) Services VALGANCICLOVIR 450 MG TABLET RX-30148 CDM 6370000100 HCPCS 250 RC 00904-6796-04 NDC inpatient 1 UN 146.05 146.05 CIGNA 62308 [3081051] CIGNA 62308 [308105105] 115.64 percent of total billed charges 90.55 138.75 Technical (Hospital) Services VALGANCICLOVIR 450 MG TABLET RX-30148 CDM 6370000100 HCPCS 250 RC 00904-6796-04 NDC inpatient 1 UN 146.05 146.05 CIGNA 62308 [3081051] CIGNA STATE OF WYOMING [308105107] 115.64 percent of total billed charges 90.55 138.75 Technical (Hospital) Services VALGANCICLOVIR 450 MG TABLET RX-30148 CDM 6370000100 HCPCS 250 RC 00904-6796-04 NDC inpatient 1 UN 146.05 146.05 UNITED HEALTHCARE (COMMERCIAL) [3081199] UNITED HEALTHCARE 87726 [308119901] 90.55 percent of total billed charges 90.55 138.75 Technical (Hospital) Services VALGANCICLOVIR 450 MG TABLET RX-30148 CDM 6370000100 HCPCS 250 RC 00904-6796-04 NDC inpatient 1 UN 146.05 146.05 BLUE CROSS BLUE SHIELD WELLMARK SB889 [3081026] BCBS WYOMING [308102603] 138.75 percent of total billed charges 90.55 138.75 Technical (Hospital) Services VALGANCICLOVIR 450 MG TABLET RX-30148 CDM 6370000100 HCPCS 250 RC 00904-6796-04 NDC outpatient 1 UN 146.05 146.05 HEALTHPARTNERS SX009 HEALTHPARTNERS 116.84 percent of total billed charges 90.55 138.75 Technical (Hospital) Services VALGANCICLOVIR 450 MG TABLET RX-30148 CDM 6370000100 HCPCS 250 RC 00904-6796-04 NDC outpatient 1 UN 146.05 146.05 BLUE CROSS BLUE SHIELD WELLMARK SB889 [3081026] BCBS WYOMING [308102603] 138.75 percent of total billed charges 90.55 138.75 Technical (Hospital) Services VALGANCICLOVIR 450 MG TABLET RX-30148 CDM 6370000100 HCPCS 250 RC 00904-6796-04 NDC outpatient 1 UN 146.05 146.05 UNITED HEALTHCARE (COMMERCIAL) [3081199] UNITED HEALTHCARE 87726 [308119901] 90.55 percent of total billed charges 90.55 138.75 Technical (Hospital) Services VALGANCICLOVIR 450 MG TABLET RX-30148 CDM 6370000100 HCPCS 250 RC 00904-6796-04 NDC outpatient 1 UN 146.05 146.05 CIGNA 62308 [3081051] CIGNA 62308 [308105105] 116.84 percent of total billed charges 90.55 138.75 Technical (Hospital) Services VALGANCICLOVIR 450 MG TABLET RX-30148 CDM 6370000100 HCPCS 250 RC 00904-6796-04 NDC outpatient 1 UN 146.05 146.05 CIGNA 62308 [3081051] CIGNA STATE OF WYOMING [308105107] 116.84 percent of total billed charges 90.55 138.75 Technical (Hospital) Services VALGANCICLOVIR 450 MG TABLET RX-30148 CDM 6370000100 HCPCS 250 RC 00904-6796-04 NDC outpatient 1 UN 146.05 146.05 MULTIPLAN INC 34080 [3081285] MULTIPLAN INC [308128501] 138.75 percent of total billed charges 90.55 138.75 Technical (Hospital) Services VALGANCICLOVIR 450 MG TABLET RX-30148 CDM 6370000100 HCPCS 250 RC 00904-6796-04 NDC outpatient 1 UN 146.05 146.05 MEDICA (COMMERCIAL) 94265 [3081118] MEDICA CLAIMS [308111801] 131.45 percent of total billed charges 90.55 138.75 Technical (Hospital) Services VALGANCICLOVIR 450 MG TABLET RX-30148 CDM 6370000100 HCPCS 250 RC 00904-6796-04 NDC outpatient 1 UN 146.05 146.05 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES EPO [308136803] 116.84 percent of total billed charges 90.55 138.75 Technical (Hospital) Services VALGANCICLOVIR 450 MG TABLET RX-30148 CDM 6370000100 HCPCS 250 RC 00904-6796-04 NDC outpatient 1 UN 146.05 146.05 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES PPO [308136801] 116.84 percent of total billed charges 90.55 138.75 Technical (Hospital) Services VALGANCICLOVIR 450 MG TABLET RX-30148 CDM 6370000100 HCPCS 250 RC 00904-6796-04 NDC outpatient 1 UN 146.05 146.05 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES HDHP [308136802] 116.84 percent of total billed charges 90.55 138.75 Technical (Hospital) Services CITALOPRAM 10 MG TABLET RX-30264 CDM 6370000100 HCPCS 250 RC 00378-6231-01 NDC inpatient 1 UN 5.69 5.69 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES EPO [308136803] 4.51 percent of total billed charges 3.53 5.41 Technical (Hospital) Services CITALOPRAM 10 MG TABLET RX-30264 CDM 6370000100 HCPCS 250 RC 00378-6231-01 NDC inpatient 1 UN 5.69 5.69 UNITED HEALTHCARE (COMMERCIAL) [3081199] UNITED HEALTHCARE 87726 [308119901] 3.53 percent of total billed charges 3.53 5.41 Technical (Hospital) Services CITALOPRAM 10 MG TABLET RX-30264 CDM 6370000100 HCPCS 250 RC 00378-6231-01 NDC inpatient 1 UN 5.69 5.69 CIGNA 62308 [3081051] CIGNA 62308 [308105105] 4.51 percent of total billed charges 3.53 5.41 Technical (Hospital) Services CITALOPRAM 10 MG TABLET RX-30264 CDM 6370000100 HCPCS 250 RC 00378-6231-01 NDC inpatient 1 UN 5.69 5.69 CIGNA 62308 [3081051] CIGNA STATE OF WYOMING [308105107] 4.51 percent of total billed charges 3.53 5.41 Technical (Hospital) Services CITALOPRAM 10 MG TABLET RX-30264 CDM 6370000100 HCPCS 250 RC 00378-6231-01 NDC inpatient 1 UN 5.69 5.69 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES HDHP [308136802] 4.51 percent of total billed charges 3.53 5.41 Technical (Hospital) Services CITALOPRAM 10 MG TABLET RX-30264 CDM 6370000100 HCPCS 250 RC 00378-6231-01 NDC inpatient 1 UN 5.69 5.69 HEALTHPARTNERS SX009 HEALTHPARTNERS 4.51 percent of total billed charges 3.53 5.41 Technical (Hospital) Services CITALOPRAM 10 MG TABLET RX-30264 CDM 6370000100 HCPCS 250 RC 00378-6231-01 NDC inpatient 1 UN 5.69 5.69 BLUE CROSS BLUE SHIELD WELLMARK SB889 [3081026] BCBS WYOMING [308102603] 5.41 percent of total billed charges 3.53 5.41 Technical (Hospital) Services CITALOPRAM 10 MG TABLET RX-30264 CDM 6370000100 HCPCS 250 RC 00378-6231-01 NDC inpatient 1 UN 5.69 5.69 MULTIPLAN INC 34080 [3081285] MULTIPLAN INC [308128501] 5.41 percent of total billed charges 3.53 5.41 Technical (Hospital) Services CITALOPRAM 10 MG TABLET RX-30264 CDM 6370000100 HCPCS 250 RC 00378-6231-01 NDC inpatient 1 UN 5.69 5.69 MEDICA (COMMERCIAL) 94265 [3081118] MEDICA CLAIMS [308111801] 5.12 percent of total billed charges 3.53 5.41 Technical (Hospital) Services CITALOPRAM 10 MG TABLET RX-30264 CDM 6370000100 HCPCS 250 RC 00378-6231-01 NDC inpatient 1 UN 5.69 5.69 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES PPO [308136801] 4.51 percent of total billed charges 3.53 5.41 Technical (Hospital) Services CITALOPRAM 10 MG TABLET RX-30264 CDM 6370000100 HCPCS 250 RC 00378-6231-01 NDC outpatient 1 UN 5.69 5.69 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES EPO [308136803] 4.55 percent of total billed charges 3.53 5.41 Technical (Hospital) Services CITALOPRAM 10 MG TABLET RX-30264 CDM 6370000100 HCPCS 250 RC 00378-6231-01 NDC outpatient 1 UN 5.69 5.69 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES HDHP [308136802] 4.55 percent of total billed charges 3.53 5.41 Technical (Hospital) Services CITALOPRAM 10 MG TABLET RX-30264 CDM 6370000100 HCPCS 250 RC 00378-6231-01 NDC outpatient 1 UN 5.69 5.69 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES PPO [308136801] 4.55 percent of total billed charges 3.53 5.41 Technical (Hospital) Services CITALOPRAM 10 MG TABLET RX-30264 CDM 6370000100 HCPCS 250 RC 00378-6231-01 NDC outpatient 1 UN 5.69 5.69 BLUE CROSS BLUE SHIELD WELLMARK SB889 [3081026] BCBS WYOMING [308102603] 5.41 percent of total billed charges 3.53 5.41 Technical (Hospital) Services CITALOPRAM 10 MG TABLET RX-30264 CDM 6370000100 HCPCS 250 RC 00378-6231-01 NDC outpatient 1 UN 5.69 5.69 HEALTHPARTNERS SX009 HEALTHPARTNERS 4.55 percent of total billed charges 3.53 5.41 Technical (Hospital) Services CITALOPRAM 10 MG TABLET RX-30264 CDM 6370000100 HCPCS 250 RC 00378-6231-01 NDC outpatient 1 UN 5.69 5.69 UNITED HEALTHCARE (COMMERCIAL) [3081199] UNITED HEALTHCARE 87726 [308119901] 3.53 percent of total billed charges 3.53 5.41 Technical (Hospital) Services CITALOPRAM 10 MG TABLET RX-30264 CDM 6370000100 HCPCS 250 RC 00378-6231-01 NDC outpatient 1 UN 5.69 5.69 MEDICA (COMMERCIAL) 94265 [3081118] MEDICA CLAIMS [308111801] 5.12 percent of total billed charges 3.53 5.41 Technical (Hospital) Services CITALOPRAM 10 MG TABLET RX-30264 CDM 6370000100 HCPCS 250 RC 00378-6231-01 NDC outpatient 1 UN 5.69 5.69 MULTIPLAN INC 34080 [3081285] MULTIPLAN INC [308128501] 5.41 percent of total billed charges 3.53 5.41 Technical (Hospital) Services CITALOPRAM 10 MG TABLET RX-30264 CDM 6370000100 HCPCS 250 RC 00378-6231-01 NDC outpatient 1 UN 5.69 5.69 CIGNA 62308 [3081051] CIGNA 62308 [308105105] 4.55 percent of total billed charges 3.53 5.41 Technical (Hospital) Services CITALOPRAM 10 MG TABLET RX-30264 CDM 6370000100 HCPCS 250 RC 00378-6231-01 NDC outpatient 1 UN 5.69 5.69 CIGNA 62308 [3081051] CIGNA STATE OF WYOMING [308105107] 4.55 percent of total billed charges 3.53 5.41 Technical (Hospital) Services FERROUS GLUCONATE 324 MG (38 MG IRON) TABLET RX-3066 CDM 6370000100 HCPCS 250 RC 00574-0508-01 NDC inpatient 1 UN 5.67 5.67 MULTIPLAN INC 34080 [3081285] MULTIPLAN INC [308128501] 5.39 percent of total billed charges 3.52 5.39 Technical (Hospital) Services FERROUS GLUCONATE 324 MG (38 MG IRON) TABLET RX-3066 CDM 6370000100 HCPCS 250 RC 00574-0508-01 NDC inpatient 1 UN 5.67 5.67 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES PPO [308136801] 4.49 percent of total billed charges 3.52 5.39 Technical (Hospital) Services FERROUS GLUCONATE 324 MG (38 MG IRON) TABLET RX-3066 CDM 6370000100 HCPCS 250 RC 00574-0508-01 NDC inpatient 1 UN 5.67 5.67 MEDICA (COMMERCIAL) 94265 [3081118] MEDICA CLAIMS [308111801] 5.1 percent of total billed charges 3.52 5.39 Technical (Hospital) Services FERROUS GLUCONATE 324 MG (38 MG IRON) TABLET RX-3066 CDM 6370000100 HCPCS 250 RC 00574-0508-01 NDC inpatient 1 UN 5.67 5.67 UNITED HEALTHCARE (COMMERCIAL) [3081199] UNITED HEALTHCARE 87726 [308119901] 3.52 percent of total billed charges 3.52 5.39 Technical (Hospital) Services FERROUS GLUCONATE 324 MG (38 MG IRON) TABLET RX-3066 CDM 6370000100 HCPCS 250 RC 00574-0508-01 NDC inpatient 1 UN 5.67 5.67 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES EPO [308136803] 4.49 percent of total billed charges 3.52 5.39 Technical (Hospital) Services FERROUS GLUCONATE 324 MG (38 MG IRON) TABLET RX-3066 CDM 6370000100 HCPCS 250 RC 00574-0508-01 NDC inpatient 1 UN 5.67 5.67 CIGNA 62308 [3081051] CIGNA 62308 [308105105] 4.49 percent of total billed charges 3.52 5.39 Technical (Hospital) Services FERROUS GLUCONATE 324 MG (38 MG IRON) TABLET RX-3066 CDM 6370000100 HCPCS 250 RC 00574-0508-01 NDC inpatient 1 UN 5.67 5.67 CIGNA 62308 [3081051] CIGNA STATE OF WYOMING [308105107] 4.49 percent of total billed charges 3.52 5.39 Technical (Hospital) Services FERROUS GLUCONATE 324 MG (38 MG IRON) TABLET RX-3066 CDM 6370000100 HCPCS 250 RC 00574-0508-01 NDC inpatient 1 UN 5.67 5.67 HEALTHPARTNERS SX009 HEALTHPARTNERS 4.49 percent of total billed charges 3.52 5.39 Technical (Hospital) Services FERROUS GLUCONATE 324 MG (38 MG IRON) TABLET RX-3066 CDM 6370000100 HCPCS 250 RC 00574-0508-01 NDC inpatient 1 UN 5.67 5.67 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES HDHP [308136802] 4.49 percent of total billed charges 3.52 5.39 Technical (Hospital) Services FERROUS GLUCONATE 324 MG (38 MG IRON) TABLET RX-3066 CDM 6370000100 HCPCS 250 RC 00574-0508-01 NDC inpatient 1 UN 5.67 5.67 BLUE CROSS BLUE SHIELD WELLMARK SB889 [3081026] BCBS WYOMING [308102603] 5.39 percent of total billed charges 3.52 5.39 Technical (Hospital) Services FERROUS GLUCONATE 324 MG (38 MG IRON) TABLET RX-3066 CDM 6370000100 HCPCS 250 RC 00574-0508-01 NDC outpatient 1 UN 5.67 5.67 BLUE CROSS BLUE SHIELD WELLMARK SB889 [3081026] BCBS WYOMING [308102603] 5.39 percent of total billed charges 3.52 5.39 Technical (Hospital) Services FERROUS GLUCONATE 324 MG (38 MG IRON) TABLET RX-3066 CDM 6370000100 HCPCS 250 RC 00574-0508-01 NDC outpatient 1 UN 5.67 5.67 HEALTHPARTNERS SX009 HEALTHPARTNERS 4.54 percent of total billed charges 3.52 5.39 Technical (Hospital) Services FERROUS GLUCONATE 324 MG (38 MG IRON) TABLET RX-3066 CDM 6370000100 HCPCS 250 RC 00574-0508-01 NDC outpatient 1 UN 5.67 5.67 UNITED HEALTHCARE (COMMERCIAL) [3081199] UNITED HEALTHCARE 87726 [308119901] 3.52 percent of total billed charges 3.52 5.39 Technical (Hospital) Services FERROUS GLUCONATE 324 MG (38 MG IRON) TABLET RX-3066 CDM 6370000100 HCPCS 250 RC 00574-0508-01 NDC outpatient 1 UN 5.67 5.67 CIGNA 62308 [3081051] CIGNA 62308 [308105105] 4.54 percent of total billed charges 3.52 5.39 Technical (Hospital) Services FERROUS GLUCONATE 324 MG (38 MG IRON) TABLET RX-3066 CDM 6370000100 HCPCS 250 RC 00574-0508-01 NDC outpatient 1 UN 5.67 5.67 CIGNA 62308 [3081051] CIGNA STATE OF WYOMING [308105107] 4.54 percent of total billed charges 3.52 5.39 Technical (Hospital) Services FERROUS GLUCONATE 324 MG (38 MG IRON) TABLET RX-3066 CDM 6370000100 HCPCS 250 RC 00574-0508-01 NDC outpatient 1 UN 5.67 5.67 MULTIPLAN INC 34080 [3081285] MULTIPLAN INC [308128501] 5.39 percent of total billed charges 3.52 5.39 Technical (Hospital) Services FERROUS GLUCONATE 324 MG (38 MG IRON) TABLET RX-3066 CDM 6370000100 HCPCS 250 RC 00574-0508-01 NDC outpatient 1 UN 5.67 5.67 MEDICA (COMMERCIAL) 94265 [3081118] MEDICA CLAIMS [308111801] 5.1 percent of total billed charges 3.52 5.39 Technical (Hospital) Services FERROUS GLUCONATE 324 MG (38 MG IRON) TABLET RX-3066 CDM 6370000100 HCPCS 250 RC 00574-0508-01 NDC outpatient 1 UN 5.67 5.67 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES EPO [308136803] 4.54 percent of total billed charges 3.52 5.39 Technical (Hospital) Services FERROUS GLUCONATE 324 MG (38 MG IRON) TABLET RX-3066 CDM 6370000100 HCPCS 250 RC 00574-0508-01 NDC outpatient 1 UN 5.67 5.67 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES PPO [308136801] 4.54 percent of total billed charges 3.52 5.39 Technical (Hospital) Services FERROUS GLUCONATE 324 MG (38 MG IRON) TABLET RX-3066 CDM 6370000100 HCPCS 250 RC 00574-0508-01 NDC outpatient 1 UN 5.67 5.67 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES HDHP [308136802] 4.54 percent of total billed charges 3.52 5.39 Technical (Hospital) Services FERROUS SULFATE 325 MG (65 MG IRON) TABLET RX-3074 CDM 6370000100 HCPCS 250 RC 00904-7591-80 NDC outpatient 1 UN 5.63 5.63 HEALTHPARTNERS SX009 HEALTHPARTNERS 4.5 percent of total billed charges 3.49 5.35 Technical (Hospital) Services FERROUS SULFATE 325 MG (65 MG IRON) TABLET RX-3074 CDM 6370000100 HCPCS 250 RC 00904-7591-80 NDC outpatient 1 UN 5.63 5.63 BLUE CROSS BLUE SHIELD WELLMARK SB889 [3081026] BCBS WYOMING [308102603] 5.35 percent of total billed charges 3.49 5.35 Technical (Hospital) Services FERROUS SULFATE 325 MG (65 MG IRON) TABLET RX-3074 CDM 6370000100 HCPCS 250 RC 00904-7591-80 NDC outpatient 1 UN 5.63 5.63 UNITED HEALTHCARE (COMMERCIAL) [3081199] UNITED HEALTHCARE 87726 [308119901] 3.49 percent of total billed charges 3.49 5.35 Technical (Hospital) Services FERROUS SULFATE 325 MG (65 MG IRON) TABLET RX-3074 CDM 6370000100 HCPCS 250 RC 00904-7591-80 NDC outpatient 1 UN 5.63 5.63 MULTIPLAN INC 34080 [3081285] MULTIPLAN INC [308128501] 5.35 percent of total billed charges 3.49 5.35 Technical (Hospital) Services FERROUS SULFATE 325 MG (65 MG IRON) TABLET RX-3074 CDM 6370000100 HCPCS 250 RC 00904-7591-80 NDC outpatient 1 UN 5.63 5.63 CIGNA 62308 [3081051] CIGNA 62308 [308105105] 4.5 percent of total billed charges 3.49 5.35 Technical (Hospital) Services FERROUS SULFATE 325 MG (65 MG IRON) TABLET RX-3074 CDM 6370000100 HCPCS 250 RC 00904-7591-80 NDC outpatient 1 UN 5.63 5.63 CIGNA 62308 [3081051] CIGNA STATE OF WYOMING [308105107] 4.5 percent of total billed charges 3.49 5.35 Technical (Hospital) Services FERROUS SULFATE 325 MG (65 MG IRON) TABLET RX-3074 CDM 6370000100 HCPCS 250 RC 00904-7591-80 NDC outpatient 1 UN 5.63 5.63 MEDICA (COMMERCIAL) 94265 [3081118] MEDICA CLAIMS [308111801] 5.07 percent of total billed charges 3.49 5.35 Technical (Hospital) Services FERROUS SULFATE 325 MG (65 MG IRON) TABLET RX-3074 CDM 6370000100 HCPCS 250 RC 00904-7591-80 NDC outpatient 1 UN 5.63 5.63 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES EPO [308136803] 4.5 percent of total billed charges 3.49 5.35 Technical (Hospital) Services FERROUS SULFATE 325 MG (65 MG IRON) TABLET RX-3074 CDM 6370000100 HCPCS 250 RC 00904-7591-80 NDC outpatient 1 UN 5.63 5.63 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES HDHP [308136802] 4.5 percent of total billed charges 3.49 5.35 Technical (Hospital) Services FERROUS SULFATE 325 MG (65 MG IRON) TABLET RX-3074 CDM 6370000100 HCPCS 250 RC 00904-7591-80 NDC outpatient 1 UN 5.63 5.63 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES PPO [308136801] 4.5 percent of total billed charges 3.49 5.35 Technical (Hospital) Services FERROUS SULFATE 325 MG (65 MG IRON) TABLET RX-3074 CDM 6370000100 HCPCS 250 RC 00904-7591-80 NDC inpatient 1 UN 5.63 5.63 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES HDHP [308136802] 4.46 percent of total billed charges 3.49 5.35 Technical (Hospital) Services FERROUS SULFATE 325 MG (65 MG IRON) TABLET RX-3074 CDM 6370000100 HCPCS 250 RC 00904-7591-80 NDC inpatient 1 UN 5.63 5.63 CIGNA 62308 [3081051] CIGNA 62308 [308105105] 4.46 percent of total billed charges 3.49 5.35 Technical (Hospital) Services FERROUS SULFATE 325 MG (65 MG IRON) TABLET RX-3074 CDM 6370000100 HCPCS 250 RC 00904-7591-80 NDC inpatient 1 UN 5.63 5.63 CIGNA 62308 [3081051] CIGNA STATE OF WYOMING [308105107] 4.46 percent of total billed charges 3.49 5.35 Technical (Hospital) Services FERROUS SULFATE 325 MG (65 MG IRON) TABLET RX-3074 CDM 6370000100 HCPCS 250 RC 00904-7591-80 NDC inpatient 1 UN 5.63 5.63 UNITED HEALTHCARE (COMMERCIAL) [3081199] UNITED HEALTHCARE 87726 [308119901] 3.49 percent of total billed charges 3.49 5.35 Technical (Hospital) Services FERROUS SULFATE 325 MG (65 MG IRON) TABLET RX-3074 CDM 6370000100 HCPCS 250 RC 00904-7591-80 NDC inpatient 1 UN 5.63 5.63 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES EPO [308136803] 4.46 percent of total billed charges 3.49 5.35 Technical (Hospital) Services FERROUS SULFATE 325 MG (65 MG IRON) TABLET RX-3074 CDM 6370000100 HCPCS 250 RC 00904-7591-80 NDC inpatient 1 UN 5.63 5.63 BLUE CROSS BLUE SHIELD WELLMARK SB889 [3081026] BCBS WYOMING [308102603] 5.35 percent of total billed charges 3.49 5.35 Technical (Hospital) Services FERROUS SULFATE 325 MG (65 MG IRON) TABLET RX-3074 CDM 6370000100 HCPCS 250 RC 00904-7591-80 NDC inpatient 1 UN 5.63 5.63 HEALTHPARTNERS SX009 HEALTHPARTNERS 4.46 percent of total billed charges 3.49 5.35 Technical (Hospital) Services FERROUS SULFATE 325 MG (65 MG IRON) TABLET RX-3074 CDM 6370000100 HCPCS 250 RC 00904-7591-80 NDC inpatient 1 UN 5.63 5.63 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES PPO [308136801] 4.46 percent of total billed charges 3.49 5.35 Technical (Hospital) Services FERROUS SULFATE 325 MG (65 MG IRON) TABLET RX-3074 CDM 6370000100 HCPCS 250 RC 00904-7591-80 NDC inpatient 1 UN 5.63 5.63 MEDICA (COMMERCIAL) 94265 [3081118] MEDICA CLAIMS [308111801] 5.07 percent of total billed charges 3.49 5.35 Technical (Hospital) Services FERROUS SULFATE 325 MG (65 MG IRON) TABLET RX-3074 CDM 6370000100 HCPCS 250 RC 00904-7591-80 NDC inpatient 1 UN 5.63 5.63 MULTIPLAN INC 34080 [3081285] MULTIPLAN INC [308128501] 5.35 percent of total billed charges 3.49 5.35 Technical (Hospital) Services ALLOPURINOL 100 MG TABLET RX-310 CDM 6370000100 HCPCS 250 RC 00378-0137-01 NDC inpatient 1 UN 5.9 5.9 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES HDHP [308136802] 4.67 percent of total billed charges 3.66 5.61 Technical (Hospital) Services ALLOPURINOL 100 MG TABLET RX-310 CDM 6370000100 HCPCS 250 RC 00378-0137-01 NDC inpatient 1 UN 5.9 5.9 HEALTHPARTNERS SX009 HEALTHPARTNERS 4.67 percent of total billed charges 3.66 5.61 Technical (Hospital) Services ALLOPURINOL 100 MG TABLET RX-310 CDM 6370000100 HCPCS 250 RC 00378-0137-01 NDC inpatient 1 UN 5.9 5.9 MEDICA (COMMERCIAL) 94265 [3081118] MEDICA CLAIMS [308111801] 5.31 percent of total billed charges 3.66 5.61 Technical (Hospital) Services ALLOPURINOL 100 MG TABLET RX-310 CDM 6370000100 HCPCS 250 RC 00378-0137-01 NDC inpatient 1 UN 5.9 5.9 UNITED HEALTHCARE (COMMERCIAL) [3081199] UNITED HEALTHCARE 87726 [308119901] 3.66 percent of total billed charges 3.66 5.61 Technical (Hospital) Services ALLOPURINOL 100 MG TABLET RX-310 CDM 6370000100 HCPCS 250 RC 00378-0137-01 NDC inpatient 1 UN 5.9 5.9 CIGNA 62308 [3081051] CIGNA 62308 [308105105] 4.67 percent of total billed charges 3.66 5.61 Technical (Hospital) Services ALLOPURINOL 100 MG TABLET RX-310 CDM 6370000100 HCPCS 250 RC 00378-0137-01 NDC inpatient 1 UN 5.9 5.9 CIGNA 62308 [3081051] CIGNA STATE OF WYOMING [308105107] 4.67 percent of total billed charges 3.66 5.61 Technical (Hospital) Services ALLOPURINOL 100 MG TABLET RX-310 CDM 6370000100 HCPCS 250 RC 00378-0137-01 NDC inpatient 1 UN 5.9 5.9 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES EPO [308136803] 4.67 percent of total billed charges 3.66 5.61 Technical (Hospital) Services ALLOPURINOL 100 MG TABLET RX-310 CDM 6370000100 HCPCS 250 RC 00378-0137-01 NDC inpatient 1 UN 5.9 5.9 BLUE CROSS BLUE SHIELD WELLMARK SB889 [3081026] BCBS WYOMING [308102603] 5.61 percent of total billed charges 3.66 5.61 Technical (Hospital) Services ALLOPURINOL 100 MG TABLET RX-310 CDM 6370000100 HCPCS 250 RC 00378-0137-01 NDC inpatient 1 UN 5.9 5.9 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES PPO [308136801] 4.67 percent of total billed charges 3.66 5.61 Technical (Hospital) Services ALLOPURINOL 100 MG TABLET RX-310 CDM 6370000100 HCPCS 250 RC 00378-0137-01 NDC inpatient 1 UN 5.9 5.9 MULTIPLAN INC 34080 [3081285] MULTIPLAN INC [308128501] 5.61 percent of total billed charges 3.66 5.61 Technical (Hospital) Services ALLOPURINOL 100 MG TABLET RX-310 CDM 6370000100 HCPCS 250 RC 00378-0137-01 NDC outpatient 1 UN 5.9 5.9 HEALTHPARTNERS SX009 HEALTHPARTNERS 4.72 percent of total billed charges 3.66 5.61 Technical (Hospital) Services ALLOPURINOL 100 MG TABLET RX-310 CDM 6370000100 HCPCS 250 RC 00378-0137-01 NDC outpatient 1 UN 5.9 5.9 BLUE CROSS BLUE SHIELD WELLMARK SB889 [3081026] BCBS WYOMING [308102603] 5.61 percent of total billed charges 3.66 5.61 Technical (Hospital) Services ALLOPURINOL 100 MG TABLET RX-310 CDM 6370000100 HCPCS 250 RC 00378-0137-01 NDC outpatient 1 UN 5.9 5.9 UNITED HEALTHCARE (COMMERCIAL) [3081199] UNITED HEALTHCARE 87726 [308119901] 3.66 percent of total billed charges 3.66 5.61 Technical (Hospital) Services ALLOPURINOL 100 MG TABLET RX-310 CDM 6370000100 HCPCS 250 RC 00378-0137-01 NDC outpatient 1 UN 5.9 5.9 MEDICA (COMMERCIAL) 94265 [3081118] MEDICA CLAIMS [308111801] 5.31 percent of total billed charges 3.66 5.61 Technical (Hospital) Services ALLOPURINOL 100 MG TABLET RX-310 CDM 6370000100 HCPCS 250 RC 00378-0137-01 NDC outpatient 1 UN 5.9 5.9 CIGNA 62308 [3081051] CIGNA 62308 [308105105] 4.72 percent of total billed charges 3.66 5.61 Technical (Hospital) Services ALLOPURINOL 100 MG TABLET RX-310 CDM 6370000100 HCPCS 250 RC 00378-0137-01 NDC outpatient 1 UN 5.9 5.9 CIGNA 62308 [3081051] CIGNA STATE OF WYOMING [308105107] 4.72 percent of total billed charges 3.66 5.61 Technical (Hospital) Services ALLOPURINOL 100 MG TABLET RX-310 CDM 6370000100 HCPCS 250 RC 00378-0137-01 NDC outpatient 1 UN 5.9 5.9 MULTIPLAN INC 34080 [3081285] MULTIPLAN INC [308128501] 5.61 percent of total billed charges 3.66 5.61 Technical (Hospital) Services ALLOPURINOL 100 MG TABLET RX-310 CDM 6370000100 HCPCS 250 RC 00378-0137-01 NDC outpatient 1 UN 5.9 5.9 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES HDHP [308136802] 4.72 percent of total billed charges 3.66 5.61 Technical (Hospital) Services ALLOPURINOL 100 MG TABLET RX-310 CDM 6370000100 HCPCS 250 RC 00378-0137-01 NDC outpatient 1 UN 5.9 5.9 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES PPO [308136801] 4.72 percent of total billed charges 3.66 5.61 Technical (Hospital) Services ALLOPURINOL 100 MG TABLET RX-310 CDM 6370000100 HCPCS 250 RC 00378-0137-01 NDC outpatient 1 UN 5.9 5.9 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES EPO [308136803] 4.72 percent of total billed charges 3.66 5.61 Technical (Hospital) Services ALLOPURINOL 300 MG TABLET RX-311 CDM 6370000100 HCPCS 250 RC 70710-1210-01 NDC outpatient 1 UN 5.83 5.83 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES PPO [308136801] 4.66 percent of total billed charges 3.61 5.54 Technical (Hospital) Services ALLOPURINOL 300 MG TABLET RX-311 CDM 6370000100 HCPCS 250 RC 70710-1210-01 NDC outpatient 1 UN 5.83 5.83 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES HDHP [308136802] 4.66 percent of total billed charges 3.61 5.54 Technical (Hospital) Services ALLOPURINOL 300 MG TABLET RX-311 CDM 6370000100 HCPCS 250 RC 70710-1210-01 NDC outpatient 1 UN 5.83 5.83 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES EPO [308136803] 4.66 percent of total billed charges 3.61 5.54 Technical (Hospital) Services ALLOPURINOL 300 MG TABLET RX-311 CDM 6370000100 HCPCS 250 RC 70710-1210-01 NDC outpatient 1 UN 5.83 5.83 HEALTHPARTNERS SX009 HEALTHPARTNERS 4.66 percent of total billed charges 3.61 5.54 Technical (Hospital) Services ALLOPURINOL 300 MG TABLET RX-311 CDM 6370000100 HCPCS 250 RC 70710-1210-01 NDC outpatient 1 UN 5.83 5.83 BLUE CROSS BLUE SHIELD WELLMARK SB889 [3081026] BCBS WYOMING [308102603] 5.54 percent of total billed charges 3.61 5.54 Technical (Hospital) Services ALLOPURINOL 300 MG TABLET RX-311 CDM 6370000100 HCPCS 250 RC 70710-1210-01 NDC outpatient 1 UN 5.83 5.83 UNITED HEALTHCARE (COMMERCIAL) [3081199] UNITED HEALTHCARE 87726 [308119901] 3.61 percent of total billed charges 3.61 5.54 Technical (Hospital) Services ALLOPURINOL 300 MG TABLET RX-311 CDM 6370000100 HCPCS 250 RC 70710-1210-01 NDC outpatient 1 UN 5.83 5.83 MEDICA (COMMERCIAL) 94265 [3081118] MEDICA CLAIMS [308111801] 5.25 percent of total billed charges 3.61 5.54 Technical (Hospital) Services ALLOPURINOL 300 MG TABLET RX-311 CDM 6370000100 HCPCS 250 RC 70710-1210-01 NDC outpatient 1 UN 5.83 5.83 MULTIPLAN INC 34080 [3081285] MULTIPLAN INC [308128501] 5.54 percent of total billed charges 3.61 5.54 Technical (Hospital) Services ALLOPURINOL 300 MG TABLET RX-311 CDM 6370000100 HCPCS 250 RC 70710-1210-01 NDC outpatient 1 UN 5.83 5.83 CIGNA 62308 [3081051] CIGNA 62308 [308105105] 4.66 percent of total billed charges 3.61 5.54 Technical (Hospital) Services ALLOPURINOL 300 MG TABLET RX-311 CDM 6370000100 HCPCS 250 RC 70710-1210-01 NDC outpatient 1 UN 5.83 5.83 CIGNA 62308 [3081051] CIGNA STATE OF WYOMING [308105107] 4.66 percent of total billed charges 3.61 5.54 Technical (Hospital) Services ALLOPURINOL 300 MG TABLET RX-311 CDM 6370000100 HCPCS 250 RC 70710-1210-01 NDC inpatient 1 UN 5.83 5.83 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES HDHP [308136802] 4.62 percent of total billed charges 3.61 5.54 Technical (Hospital) Services ALLOPURINOL 300 MG TABLET RX-311 CDM 6370000100 HCPCS 250 RC 70710-1210-01 NDC inpatient 1 UN 5.83 5.83 CIGNA 62308 [3081051] CIGNA 62308 [308105105] 4.62 percent of total billed charges 3.61 5.54 Technical (Hospital) Services ALLOPURINOL 300 MG TABLET RX-311 CDM 6370000100 HCPCS 250 RC 70710-1210-01 NDC inpatient 1 UN 5.83 5.83 CIGNA 62308 [3081051] CIGNA STATE OF WYOMING [308105107] 4.62 percent of total billed charges 3.61 5.54 Technical (Hospital) Services ALLOPURINOL 300 MG TABLET RX-311 CDM 6370000100 HCPCS 250 RC 70710-1210-01 NDC inpatient 1 UN 5.83 5.83 UNITED HEALTHCARE (COMMERCIAL) [3081199] UNITED HEALTHCARE 87726 [308119901] 3.61 percent of total billed charges 3.61 5.54 Technical (Hospital) Services ALLOPURINOL 300 MG TABLET RX-311 CDM 6370000100 HCPCS 250 RC 70710-1210-01 NDC inpatient 1 UN 5.83 5.83 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES EPO [308136803] 4.62 percent of total billed charges 3.61 5.54 Technical (Hospital) Services ALLOPURINOL 300 MG TABLET RX-311 CDM 6370000100 HCPCS 250 RC 70710-1210-01 NDC inpatient 1 UN 5.83 5.83 BLUE CROSS BLUE SHIELD WELLMARK SB889 [3081026] BCBS WYOMING [308102603] 5.54 percent of total billed charges 3.61 5.54 Technical (Hospital) Services ALLOPURINOL 300 MG TABLET RX-311 CDM 6370000100 HCPCS 250 RC 70710-1210-01 NDC inpatient 1 UN 5.83 5.83 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES PPO [308136801] 4.62 percent of total billed charges 3.61 5.54 Technical (Hospital) Services ALLOPURINOL 300 MG TABLET RX-311 CDM 6370000100 HCPCS 250 RC 70710-1210-01 NDC inpatient 1 UN 5.83 5.83 HEALTHPARTNERS SX009 HEALTHPARTNERS 4.62 percent of total billed charges 3.61 5.54 Technical (Hospital) Services ALLOPURINOL 300 MG TABLET RX-311 CDM 6370000100 HCPCS 250 RC 70710-1210-01 NDC inpatient 1 UN 5.83 5.83 MEDICA (COMMERCIAL) 94265 [3081118] MEDICA CLAIMS [308111801] 5.25 percent of total billed charges 3.61 5.54 Technical (Hospital) Services ALLOPURINOL 300 MG TABLET RX-311 CDM 6370000100 HCPCS 250 RC 70710-1210-01 NDC inpatient 1 UN 5.83 5.83 MULTIPLAN INC 34080 [3081285] MULTIPLAN INC [308128501] 5.54 percent of total billed charges 3.61 5.54 Technical (Hospital) Services VALSARTAN 80 MG TABLET RX-31209 CDM 6370000100 HCPCS 250 RC 51660-0141-90 NDC outpatient 1 UN 5.96 5.96 UNITED HEALTHCARE (COMMERCIAL) [3081199] UNITED HEALTHCARE 87726 [308119901] 3.7 percent of total billed charges 3.7 5.66 Technical (Hospital) Services VALSARTAN 80 MG TABLET RX-31209 CDM 6370000100 HCPCS 250 RC 51660-0141-90 NDC outpatient 1 UN 5.96 5.96 MEDICA (COMMERCIAL) 94265 [3081118] MEDICA CLAIMS [308111801] 5.36 percent of total billed charges 3.7 5.66 Technical (Hospital) Services VALSARTAN 80 MG TABLET RX-31209 CDM 6370000100 HCPCS 250 RC 51660-0141-90 NDC outpatient 1 UN 5.96 5.96 MULTIPLAN INC 34080 [3081285] MULTIPLAN INC [308128501] 5.66 percent of total billed charges 3.7 5.66 Technical (Hospital) Services VALSARTAN 80 MG TABLET RX-31209 CDM 6370000100 HCPCS 250 RC 51660-0141-90 NDC outpatient 1 UN 5.96 5.96 CIGNA 62308 [3081051] CIGNA 62308 [308105105] 4.77 percent of total billed charges 3.7 5.66 Technical (Hospital) Services VALSARTAN 80 MG TABLET RX-31209 CDM 6370000100 HCPCS 250 RC 51660-0141-90 NDC outpatient 1 UN 5.96 5.96 CIGNA 62308 [3081051] CIGNA STATE OF WYOMING [308105107] 4.77 percent of total billed charges 3.7 5.66 Technical (Hospital) Services VALSARTAN 80 MG TABLET RX-31209 CDM 6370000100 HCPCS 250 RC 51660-0141-90 NDC outpatient 1 UN 5.96 5.96 HEALTHPARTNERS SX009 HEALTHPARTNERS 4.77 percent of total billed charges 3.7 5.66 Technical (Hospital) Services VALSARTAN 80 MG TABLET RX-31209 CDM 6370000100 HCPCS 250 RC 51660-0141-90 NDC outpatient 1 UN 5.96 5.96 BLUE CROSS BLUE SHIELD WELLMARK SB889 [3081026] BCBS WYOMING [308102603] 5.66 percent of total billed charges 3.7 5.66 Technical (Hospital) Services VALSARTAN 80 MG TABLET RX-31209 CDM 6370000100 HCPCS 250 RC 51660-0141-90 NDC outpatient 1 UN 5.96 5.96 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES HDHP [308136802] 4.77 percent of total billed charges 3.7 5.66 Technical (Hospital) Services VALSARTAN 80 MG TABLET RX-31209 CDM 6370000100 HCPCS 250 RC 51660-0141-90 NDC outpatient 1 UN 5.96 5.96 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES EPO [308136803] 4.77 percent of total billed charges 3.7 5.66 Technical (Hospital) Services VALSARTAN 80 MG TABLET RX-31209 CDM 6370000100 HCPCS 250 RC 51660-0141-90 NDC outpatient 1 UN 5.96 5.96 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES PPO [308136801] 4.77 percent of total billed charges 3.7 5.66 Technical (Hospital) Services VALSARTAN 80 MG TABLET RX-31209 CDM 6370000100 HCPCS 250 RC 51660-0141-90 NDC inpatient 1 UN 5.96 5.96 BLUE CROSS BLUE SHIELD WELLMARK SB889 [3081026] BCBS WYOMING [308102603] 5.66 percent of total billed charges 3.7 5.66 Technical (Hospital) Services VALSARTAN 80 MG TABLET RX-31209 CDM 6370000100 HCPCS 250 RC 51660-0141-90 NDC inpatient 1 UN 5.96 5.96 UNITED HEALTHCARE (COMMERCIAL) [3081199] UNITED HEALTHCARE 87726 [308119901] 3.7 percent of total billed charges 3.7 5.66 Technical (Hospital) Services VALSARTAN 80 MG TABLET RX-31209 CDM 6370000100 HCPCS 250 RC 51660-0141-90 NDC inpatient 1 UN 5.96 5.96 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES EPO [308136803] 4.72 percent of total billed charges 3.7 5.66 Technical (Hospital) Services VALSARTAN 80 MG TABLET RX-31209 CDM 6370000100 HCPCS 250 RC 51660-0141-90 NDC inpatient 1 UN 5.96 5.96 CIGNA 62308 [3081051] CIGNA 62308 [308105105] 4.72 percent of total billed charges 3.7 5.66 Technical (Hospital) Services VALSARTAN 80 MG TABLET RX-31209 CDM 6370000100 HCPCS 250 RC 51660-0141-90 NDC inpatient 1 UN 5.96 5.96 CIGNA 62308 [3081051] CIGNA STATE OF WYOMING [308105107] 4.72 percent of total billed charges 3.7 5.66 Technical (Hospital) Services VALSARTAN 80 MG TABLET RX-31209 CDM 6370000100 HCPCS 250 RC 51660-0141-90 NDC inpatient 1 UN 5.96 5.96 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES HDHP [308136802] 4.72 percent of total billed charges 3.7 5.66 Technical (Hospital) Services VALSARTAN 80 MG TABLET RX-31209 CDM 6370000100 HCPCS 250 RC 51660-0141-90 NDC inpatient 1 UN 5.96 5.96 MEDICA (COMMERCIAL) 94265 [3081118] MEDICA CLAIMS [308111801] 5.36 percent of total billed charges 3.7 5.66 Technical (Hospital) Services VALSARTAN 80 MG TABLET RX-31209 CDM 6370000100 HCPCS 250 RC 51660-0141-90 NDC inpatient 1 UN 5.96 5.96 HEALTHPARTNERS SX009 HEALTHPARTNERS 4.72 percent of total billed charges 3.7 5.66 Technical (Hospital) Services VALSARTAN 80 MG TABLET RX-31209 CDM 6370000100 HCPCS 250 RC 51660-0141-90 NDC inpatient 1 UN 5.96 5.96 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES PPO [308136801] 4.72 percent of total billed charges 3.7 5.66 Technical (Hospital) Services VALSARTAN 80 MG TABLET RX-31209 CDM 6370000100 HCPCS 250 RC 51660-0141-90 NDC inpatient 1 UN 5.96 5.96 MULTIPLAN INC 34080 [3081285] MULTIPLAN INC [308128501] 5.66 percent of total billed charges 3.7 5.66 Technical (Hospital) Services OXYCODONE-ACETAMINOPHEN 10 MG-325 MG TABLET RX-31864 CDM 6370000100 HCPCS 250 RC 68308-0480-47 NDC outpatient 1 UN 7.42 7.42 BLUE CROSS BLUE SHIELD WELLMARK SB889 [3081026] BCBS WYOMING [308102603] 7.05 percent of total billed charges 4.6 7.05 Technical (Hospital) Services OXYCODONE-ACETAMINOPHEN 10 MG-325 MG TABLET RX-31864 CDM 6370000100 HCPCS 250 RC 68308-0480-47 NDC outpatient 1 UN 7.42 7.42 HEALTHPARTNERS SX009 HEALTHPARTNERS 5.94 percent of total billed charges 4.6 7.05 Technical (Hospital) Services OXYCODONE-ACETAMINOPHEN 10 MG-325 MG TABLET RX-31864 CDM 6370000100 HCPCS 250 RC 68308-0480-47 NDC outpatient 1 UN 7.42 7.42 UNITED HEALTHCARE (COMMERCIAL) [3081199] UNITED HEALTHCARE 87726 [308119901] 4.6 percent of total billed charges 4.6 7.05 Technical (Hospital) Services OXYCODONE-ACETAMINOPHEN 10 MG-325 MG TABLET RX-31864 CDM 6370000100 HCPCS 250 RC 68308-0480-47 NDC outpatient 1 UN 7.42 7.42 MULTIPLAN INC 34080 [3081285] MULTIPLAN INC [308128501] 7.05 percent of total billed charges 4.6 7.05 Technical (Hospital) Services OXYCODONE-ACETAMINOPHEN 10 MG-325 MG TABLET RX-31864 CDM 6370000100 HCPCS 250 RC 68308-0480-47 NDC outpatient 1 UN 7.42 7.42 CIGNA 62308 [3081051] CIGNA 62308 [308105105] 5.94 percent of total billed charges 4.6 7.05 Technical (Hospital) Services OXYCODONE-ACETAMINOPHEN 10 MG-325 MG TABLET RX-31864 CDM 6370000100 HCPCS 250 RC 68308-0480-47 NDC outpatient 1 UN 7.42 7.42 CIGNA 62308 [3081051] CIGNA STATE OF WYOMING [308105107] 5.94 percent of total billed charges 4.6 7.05 Technical (Hospital) Services OXYCODONE-ACETAMINOPHEN 10 MG-325 MG TABLET RX-31864 CDM 6370000100 HCPCS 250 RC 68308-0480-47 NDC outpatient 1 UN 7.42 7.42 MEDICA (COMMERCIAL) 94265 [3081118] MEDICA CLAIMS [308111801] 6.68 percent of total billed charges 4.6 7.05 Technical (Hospital) Services OXYCODONE-ACETAMINOPHEN 10 MG-325 MG TABLET RX-31864 CDM 6370000100 HCPCS 250 RC 68308-0480-47 NDC outpatient 1 UN 7.42 7.42 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES PPO [308136801] 5.94 percent of total billed charges 4.6 7.05 Technical (Hospital) Services OXYCODONE-ACETAMINOPHEN 10 MG-325 MG TABLET RX-31864 CDM 6370000100 HCPCS 250 RC 68308-0480-47 NDC outpatient 1 UN 7.42 7.42 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES HDHP [308136802] 5.94 percent of total billed charges 4.6 7.05 Technical (Hospital) Services OXYCODONE-ACETAMINOPHEN 10 MG-325 MG TABLET RX-31864 CDM 6370000100 HCPCS 250 RC 68308-0480-47 NDC outpatient 1 UN 7.42 7.42 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES EPO [308136803] 5.94 percent of total billed charges 4.6 7.05 Technical (Hospital) Services OXYCODONE-ACETAMINOPHEN 10 MG-325 MG TABLET RX-31864 CDM 6370000100 HCPCS 250 RC 68308-0480-47 NDC inpatient 1 UN 7.42 7.42 MEDICA (COMMERCIAL) 94265 [3081118] MEDICA CLAIMS [308111801] 6.68 percent of total billed charges 4.6 7.05 Technical (Hospital) Services OXYCODONE-ACETAMINOPHEN 10 MG-325 MG TABLET RX-31864 CDM 6370000100 HCPCS 250 RC 68308-0480-47 NDC inpatient 1 UN 7.42 7.42 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES PPO [308136801] 5.88 percent of total billed charges 4.6 7.05 Technical (Hospital) Services OXYCODONE-ACETAMINOPHEN 10 MG-325 MG TABLET RX-31864 CDM 6370000100 HCPCS 250 RC 68308-0480-47 NDC inpatient 1 UN 7.42 7.42 MULTIPLAN INC 34080 [3081285] MULTIPLAN INC [308128501] 7.05 percent of total billed charges 4.6 7.05 Technical (Hospital) Services OXYCODONE-ACETAMINOPHEN 10 MG-325 MG TABLET RX-31864 CDM 6370000100 HCPCS 250 RC 68308-0480-47 NDC inpatient 1 UN 7.42 7.42 UNITED HEALTHCARE (COMMERCIAL) [3081199] UNITED HEALTHCARE 87726 [308119901] 4.6 percent of total billed charges 4.6 7.05 Technical (Hospital) Services OXYCODONE-ACETAMINOPHEN 10 MG-325 MG TABLET RX-31864 CDM 6370000100 HCPCS 250 RC 68308-0480-47 NDC inpatient 1 UN 7.42 7.42 CIGNA 62308 [3081051] CIGNA 62308 [308105105] 5.88 percent of total billed charges 4.6 7.05 Technical (Hospital) Services OXYCODONE-ACETAMINOPHEN 10 MG-325 MG TABLET RX-31864 CDM 6370000100 HCPCS 250 RC 68308-0480-47 NDC inpatient 1 UN 7.42 7.42 CIGNA 62308 [3081051] CIGNA STATE OF WYOMING [308105107] 5.88 percent of total billed charges 4.6 7.05 Technical (Hospital) Services OXYCODONE-ACETAMINOPHEN 10 MG-325 MG TABLET RX-31864 CDM 6370000100 HCPCS 250 RC 68308-0480-47 NDC inpatient 1 UN 7.42 7.42 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES EPO [308136803] 5.88 percent of total billed charges 4.6 7.05 Technical (Hospital) Services OXYCODONE-ACETAMINOPHEN 10 MG-325 MG TABLET RX-31864 CDM 6370000100 HCPCS 250 RC 68308-0480-47 NDC inpatient 1 UN 7.42 7.42 HEALTHPARTNERS SX009 HEALTHPARTNERS 5.88 percent of total billed charges 4.6 7.05 Technical (Hospital) Services OXYCODONE-ACETAMINOPHEN 10 MG-325 MG TABLET RX-31864 CDM 6370000100 HCPCS 250 RC 68308-0480-47 NDC inpatient 1 UN 7.42 7.42 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES HDHP [308136802] 5.88 percent of total billed charges 4.6 7.05 Technical (Hospital) Services OXYCODONE-ACETAMINOPHEN 10 MG-325 MG TABLET RX-31864 CDM 6370000100 HCPCS 250 RC 68308-0480-47 NDC inpatient 1 UN 7.42 7.42 BLUE CROSS BLUE SHIELD WELLMARK SB889 [3081026] BCBS WYOMING [308102603] 7.05 percent of total billed charges 4.6 7.05 Technical (Hospital) Services "FLUOROMETHOLONE 0.1 % EYE DROPS,SUSPENSION" RX-3208 CDM 6370000100 HCPCS 250 RC 60758-0880-05 NDC inpatient 5 ML 308.94 308.94 MEDICA (COMMERCIAL) 94265 [3081118] MEDICA CLAIMS [308111801] 278.05 percent of total billed charges 191.54 293.49 Technical (Hospital) Services "FLUOROMETHOLONE 0.1 % EYE DROPS,SUSPENSION" RX-3208 CDM 6370000100 HCPCS 250 RC 60758-0880-05 NDC inpatient 5 ML 308.94 308.94 MULTIPLAN INC 34080 [3081285] MULTIPLAN INC [308128501] 293.49 percent of total billed charges 191.54 293.49 Technical (Hospital) Services "FLUOROMETHOLONE 0.1 % EYE DROPS,SUSPENSION" RX-3208 CDM 6370000100 HCPCS 250 RC 60758-0880-05 NDC inpatient 5 ML 308.94 308.94 BLUE CROSS BLUE SHIELD WELLMARK SB889 [3081026] BCBS WYOMING [308102603] 293.49 percent of total billed charges 191.54 293.49 Technical (Hospital) Services "FLUOROMETHOLONE 0.1 % EYE DROPS,SUSPENSION" RX-3208 CDM 6370000100 HCPCS 250 RC 60758-0880-05 NDC inpatient 5 ML 308.94 308.94 UNITED HEALTHCARE (COMMERCIAL) [3081199] UNITED HEALTHCARE 87726 [308119901] 191.54 percent of total billed charges 191.54 293.49 Technical (Hospital) Services "FLUOROMETHOLONE 0.1 % EYE DROPS,SUSPENSION" RX-3208 CDM 6370000100 HCPCS 250 RC 60758-0880-05 NDC inpatient 5 ML 308.94 308.94 CIGNA 62308 [3081051] CIGNA 62308 [308105105] 244.62 percent of total billed charges 191.54 293.49 Technical (Hospital) Services "FLUOROMETHOLONE 0.1 % EYE DROPS,SUSPENSION" RX-3208 CDM 6370000100 HCPCS 250 RC 60758-0880-05 NDC inpatient 5 ML 308.94 308.94 CIGNA 62308 [3081051] CIGNA STATE OF WYOMING [308105107] 244.62 percent of total billed charges 191.54 293.49 Technical (Hospital) Services "FLUOROMETHOLONE 0.1 % EYE DROPS,SUSPENSION" RX-3208 CDM 6370000100 HCPCS 250 RC 60758-0880-05 NDC inpatient 5 ML 308.94 308.94 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES PPO [308136801] 244.62 percent of total billed charges 191.54 293.49 Technical (Hospital) Services "FLUOROMETHOLONE 0.1 % EYE DROPS,SUSPENSION" RX-3208 CDM 6370000100 HCPCS 250 RC 60758-0880-05 NDC inpatient 5 ML 308.94 308.94 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES HDHP [308136802] 244.62 percent of total billed charges 191.54 293.49 Technical (Hospital) Services "FLUOROMETHOLONE 0.1 % EYE DROPS,SUSPENSION" RX-3208 CDM 6370000100 HCPCS 250 RC 60758-0880-05 NDC inpatient 5 ML 308.94 308.94 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES EPO [308136803] 244.62 percent of total billed charges 191.54 293.49 Technical (Hospital) Services "FLUOROMETHOLONE 0.1 % EYE DROPS,SUSPENSION" RX-3208 CDM 6370000100 HCPCS 250 RC 60758-0880-05 NDC inpatient 5 ML 308.94 308.94 HEALTHPARTNERS SX009 HEALTHPARTNERS 244.62 percent of total billed charges 191.54 293.49 Technical (Hospital) Services "FLUOROMETHOLONE 0.1 % EYE DROPS,SUSPENSION" RX-3208 CDM 6370000100 HCPCS 250 RC 60758-0880-05 NDC outpatient 5 ML 308.94 308.94 MEDICA (COMMERCIAL) 94265 [3081118] MEDICA CLAIMS [308111801] 278.05 percent of total billed charges 191.54 293.49 Technical (Hospital) Services "FLUOROMETHOLONE 0.1 % EYE DROPS,SUSPENSION" RX-3208 CDM 6370000100 HCPCS 250 RC 60758-0880-05 NDC outpatient 5 ML 308.94 308.94 MULTIPLAN INC 34080 [3081285] MULTIPLAN INC [308128501] 293.49 percent of total billed charges 191.54 293.49 Technical (Hospital) Services "FLUOROMETHOLONE 0.1 % EYE DROPS,SUSPENSION" RX-3208 CDM 6370000100 HCPCS 250 RC 60758-0880-05 NDC outpatient 5 ML 308.94 308.94 CIGNA 62308 [3081051] CIGNA 62308 [308105105] 247.15 percent of total billed charges 191.54 293.49 Technical (Hospital) Services "FLUOROMETHOLONE 0.1 % EYE DROPS,SUSPENSION" RX-3208 CDM 6370000100 HCPCS 250 RC 60758-0880-05 NDC outpatient 5 ML 308.94 308.94 CIGNA 62308 [3081051] CIGNA STATE OF WYOMING [308105107] 247.15 percent of total billed charges 191.54 293.49 Technical (Hospital) Services "FLUOROMETHOLONE 0.1 % EYE DROPS,SUSPENSION" RX-3208 CDM 6370000100 HCPCS 250 RC 60758-0880-05 NDC outpatient 5 ML 308.94 308.94 UNITED HEALTHCARE (COMMERCIAL) [3081199] UNITED HEALTHCARE 87726 [308119901] 191.54 percent of total billed charges 191.54 293.49 Technical (Hospital) Services "FLUOROMETHOLONE 0.1 % EYE DROPS,SUSPENSION" RX-3208 CDM 6370000100 HCPCS 250 RC 60758-0880-05 NDC outpatient 5 ML 308.94 308.94 HEALTHPARTNERS SX009 HEALTHPARTNERS 247.15 percent of total billed charges 191.54 293.49 Technical (Hospital) Services "FLUOROMETHOLONE 0.1 % EYE DROPS,SUSPENSION" RX-3208 CDM 6370000100 HCPCS 250 RC 60758-0880-05 NDC outpatient 5 ML 308.94 308.94 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES PPO [308136801] 247.15 percent of total billed charges 191.54 293.49 Technical (Hospital) Services "FLUOROMETHOLONE 0.1 % EYE DROPS,SUSPENSION" RX-3208 CDM 6370000100 HCPCS 250 RC 60758-0880-05 NDC outpatient 5 ML 308.94 308.94 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES HDHP [308136802] 247.15 percent of total billed charges 191.54 293.49 Technical (Hospital) Services "FLUOROMETHOLONE 0.1 % EYE DROPS,SUSPENSION" RX-3208 CDM 6370000100 HCPCS 250 RC 60758-0880-05 NDC outpatient 5 ML 308.94 308.94 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES EPO [308136803] 247.15 percent of total billed charges 191.54 293.49 Technical (Hospital) Services "FLUOROMETHOLONE 0.1 % EYE DROPS,SUSPENSION" RX-3208 CDM 6370000100 HCPCS 250 RC 60758-0880-05 NDC outpatient 5 ML 308.94 308.94 BLUE CROSS BLUE SHIELD WELLMARK SB889 [3081026] BCBS WYOMING [308102603] 293.49 percent of total billed charges 191.54 293.49 Technical (Hospital) Services FOLIC ACID 1 MG TABLET RX-3233 CDM 6370000100 HCPCS 250 RC 11534-0165-01 NDC inpatient 1 UN 5.68 5.68 UNITED HEALTHCARE (COMMERCIAL) [3081199] UNITED HEALTHCARE 87726 [308119901] 3.52 percent of total billed charges 3.52 5.4 Technical (Hospital) Services FOLIC ACID 1 MG TABLET RX-3233 CDM 6370000100 HCPCS 250 RC 11534-0165-01 NDC inpatient 1 UN 5.68 5.68 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES EPO [308136803] 4.5 percent of total billed charges 3.52 5.4 Technical (Hospital) Services FOLIC ACID 1 MG TABLET RX-3233 CDM 6370000100 HCPCS 250 RC 11534-0165-01 NDC inpatient 1 UN 5.68 5.68 CIGNA 62308 [3081051] CIGNA 62308 [308105105] 4.5 percent of total billed charges 3.52 5.4 Technical (Hospital) Services FOLIC ACID 1 MG TABLET RX-3233 CDM 6370000100 HCPCS 250 RC 11534-0165-01 NDC inpatient 1 UN 5.68 5.68 CIGNA 62308 [3081051] CIGNA STATE OF WYOMING [308105107] 4.5 percent of total billed charges 3.52 5.4 Technical (Hospital) Services FOLIC ACID 1 MG TABLET RX-3233 CDM 6370000100 HCPCS 250 RC 11534-0165-01 NDC inpatient 1 UN 5.68 5.68 BLUE CROSS BLUE SHIELD WELLMARK SB889 [3081026] BCBS WYOMING [308102603] 5.4 percent of total billed charges 3.52 5.4 Technical (Hospital) Services FOLIC ACID 1 MG TABLET RX-3233 CDM 6370000100 HCPCS 250 RC 11534-0165-01 NDC inpatient 1 UN 5.68 5.68 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES HDHP [308136802] 4.5 percent of total billed charges 3.52 5.4 Technical (Hospital) Services FOLIC ACID 1 MG TABLET RX-3233 CDM 6370000100 HCPCS 250 RC 11534-0165-01 NDC inpatient 1 UN 5.68 5.68 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES PPO [308136801] 4.5 percent of total billed charges 3.52 5.4 Technical (Hospital) Services FOLIC ACID 1 MG TABLET RX-3233 CDM 6370000100 HCPCS 250 RC 11534-0165-01 NDC inpatient 1 UN 5.68 5.68 HEALTHPARTNERS SX009 HEALTHPARTNERS 4.5 percent of total billed charges 3.52 5.4 Technical (Hospital) Services FOLIC ACID 1 MG TABLET RX-3233 CDM 6370000100 HCPCS 250 RC 11534-0165-01 NDC inpatient 1 UN 5.68 5.68 MEDICA (COMMERCIAL) 94265 [3081118] MEDICA CLAIMS [308111801] 5.11 percent of total billed charges 3.52 5.4 Technical (Hospital) Services FOLIC ACID 1 MG TABLET RX-3233 CDM 6370000100 HCPCS 250 RC 11534-0165-01 NDC inpatient 1 UN 5.68 5.68 MULTIPLAN INC 34080 [3081285] MULTIPLAN INC [308128501] 5.4 percent of total billed charges 3.52 5.4 Technical (Hospital) Services FOLIC ACID 1 MG TABLET RX-3233 CDM 6370000100 HCPCS 250 RC 11534-0165-01 NDC outpatient 1 UN 5.68 5.68 UNITED HEALTHCARE (COMMERCIAL) [3081199] UNITED HEALTHCARE 87726 [308119901] 3.52 percent of total billed charges 3.52 5.4 Technical (Hospital) Services FOLIC ACID 1 MG TABLET RX-3233 CDM 6370000100 HCPCS 250 RC 11534-0165-01 NDC outpatient 1 UN 5.68 5.68 HEALTHPARTNERS SX009 HEALTHPARTNERS 4.54 percent of total billed charges 3.52 5.4 Technical (Hospital) Services FOLIC ACID 1 MG TABLET RX-3233 CDM 6370000100 HCPCS 250 RC 11534-0165-01 NDC outpatient 1 UN 5.68 5.68 MEDICA (COMMERCIAL) 94265 [3081118] MEDICA CLAIMS [308111801] 5.11 percent of total billed charges 3.52 5.4 Technical (Hospital) Services FOLIC ACID 1 MG TABLET RX-3233 CDM 6370000100 HCPCS 250 RC 11534-0165-01 NDC outpatient 1 UN 5.68 5.68 MULTIPLAN INC 34080 [3081285] MULTIPLAN INC [308128501] 5.4 percent of total billed charges 3.52 5.4 Technical (Hospital) Services FOLIC ACID 1 MG TABLET RX-3233 CDM 6370000100 HCPCS 250 RC 11534-0165-01 NDC outpatient 1 UN 5.68 5.68 CIGNA 62308 [3081051] CIGNA 62308 [308105105] 4.54 percent of total billed charges 3.52 5.4 Technical (Hospital) Services FOLIC ACID 1 MG TABLET RX-3233 CDM 6370000100 HCPCS 250 RC 11534-0165-01 NDC outpatient 1 UN 5.68 5.68 CIGNA 62308 [3081051] CIGNA STATE OF WYOMING [308105107] 4.54 percent of total billed charges 3.52 5.4 Technical (Hospital) Services FOLIC ACID 1 MG TABLET RX-3233 CDM 6370000100 HCPCS 250 RC 11534-0165-01 NDC outpatient 1 UN 5.68 5.68 BLUE CROSS BLUE SHIELD WELLMARK SB889 [3081026] BCBS WYOMING [308102603] 5.4 percent of total billed charges 3.52 5.4 Technical (Hospital) Services FOLIC ACID 1 MG TABLET RX-3233 CDM 6370000100 HCPCS 250 RC 11534-0165-01 NDC outpatient 1 UN 5.68 5.68 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES EPO [308136803] 4.54 percent of total billed charges 3.52 5.4 Technical (Hospital) Services FOLIC ACID 1 MG TABLET RX-3233 CDM 6370000100 HCPCS 250 RC 11534-0165-01 NDC outpatient 1 UN 5.68 5.68 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES HDHP [308136802] 4.54 percent of total billed charges 3.52 5.4 Technical (Hospital) Services FOLIC ACID 1 MG TABLET RX-3233 CDM 6370000100 HCPCS 250 RC 11534-0165-01 NDC outpatient 1 UN 5.68 5.68 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES PPO [308136801] 4.54 percent of total billed charges 3.52 5.4 Technical (Hospital) Services ALPRAZOLAM 0.25 MG TABLET RX-324 CDM 6370000100 HCPCS 250 RC 51079-0788-01 NDC inpatient 1 UN 5.7 5.7 CIGNA 62308 [3081051] CIGNA 62308 [308105105] 4.51 percent of total billed charges 3.53 5.42 Technical (Hospital) Services ALPRAZOLAM 0.25 MG TABLET RX-324 CDM 6370000100 HCPCS 250 RC 51079-0788-01 NDC inpatient 1 UN 5.7 5.7 CIGNA 62308 [3081051] CIGNA STATE OF WYOMING [308105107] 4.51 percent of total billed charges 3.53 5.42 Technical (Hospital) Services ALPRAZOLAM 0.25 MG TABLET RX-324 CDM 6370000100 HCPCS 250 RC 51079-0788-01 NDC inpatient 1 UN 5.7 5.7 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES HDHP [308136802] 4.51 percent of total billed charges 3.53 5.42 Technical (Hospital) Services ALPRAZOLAM 0.25 MG TABLET RX-324 CDM 6370000100 HCPCS 250 RC 51079-0788-01 NDC inpatient 1 UN 5.7 5.7 BLUE CROSS BLUE SHIELD WELLMARK SB889 [3081026] BCBS WYOMING [308102603] 5.42 percent of total billed charges 3.53 5.42 Technical (Hospital) Services ALPRAZOLAM 0.25 MG TABLET RX-324 CDM 6370000100 HCPCS 250 RC 51079-0788-01 NDC inpatient 1 UN 5.7 5.7 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES EPO [308136803] 4.51 percent of total billed charges 3.53 5.42 Technical (Hospital) Services ALPRAZOLAM 0.25 MG TABLET RX-324 CDM 6370000100 HCPCS 250 RC 51079-0788-01 NDC inpatient 1 UN 5.7 5.7 UNITED HEALTHCARE (COMMERCIAL) [3081199] UNITED HEALTHCARE 87726 [308119901] 3.53 percent of total billed charges 3.53 5.42 Technical (Hospital) Services ALPRAZOLAM 0.25 MG TABLET RX-324 CDM 6370000100 HCPCS 250 RC 51079-0788-01 NDC inpatient 1 UN 5.7 5.7 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES PPO [308136801] 4.51 percent of total billed charges 3.53 5.42 Technical (Hospital) Services ALPRAZOLAM 0.25 MG TABLET RX-324 CDM 6370000100 HCPCS 250 RC 51079-0788-01 NDC inpatient 1 UN 5.7 5.7 MEDICA (COMMERCIAL) 94265 [3081118] MEDICA CLAIMS [308111801] 5.13 percent of total billed charges 3.53 5.42 Technical (Hospital) Services ALPRAZOLAM 0.25 MG TABLET RX-324 CDM 6370000100 HCPCS 250 RC 51079-0788-01 NDC inpatient 1 UN 5.7 5.7 HEALTHPARTNERS SX009 HEALTHPARTNERS 4.51 percent of total billed charges 3.53 5.42 Technical (Hospital) Services ALPRAZOLAM 0.25 MG TABLET RX-324 CDM 6370000100 HCPCS 250 RC 51079-0788-01 NDC inpatient 1 UN 5.7 5.7 MULTIPLAN INC 34080 [3081285] MULTIPLAN INC [308128501] 5.42 percent of total billed charges 3.53 5.42 Technical (Hospital) Services ALPRAZOLAM 0.25 MG TABLET RX-324 CDM 6370000100 HCPCS 250 RC 51079-0788-01 NDC outpatient 1 UN 5.7 5.7 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES PPO [308136801] 4.56 percent of total billed charges 3.53 5.42 Technical (Hospital) Services ALPRAZOLAM 0.25 MG TABLET RX-324 CDM 6370000100 HCPCS 250 RC 51079-0788-01 NDC outpatient 1 UN 5.7 5.7 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES EPO [308136803] 4.56 percent of total billed charges 3.53 5.42 Technical (Hospital) Services ALPRAZOLAM 0.25 MG TABLET RX-324 CDM 6370000100 HCPCS 250 RC 51079-0788-01 NDC outpatient 1 UN 5.7 5.7 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES HDHP [308136802] 4.56 percent of total billed charges 3.53 5.42 Technical (Hospital) Services ALPRAZOLAM 0.25 MG TABLET RX-324 CDM 6370000100 HCPCS 250 RC 51079-0788-01 NDC outpatient 1 UN 5.7 5.7 HEALTHPARTNERS SX009 HEALTHPARTNERS 4.56 percent of total billed charges 3.53 5.42 Technical (Hospital) Services ALPRAZOLAM 0.25 MG TABLET RX-324 CDM 6370000100 HCPCS 250 RC 51079-0788-01 NDC outpatient 1 UN 5.7 5.7 UNITED HEALTHCARE (COMMERCIAL) [3081199] UNITED HEALTHCARE 87726 [308119901] 3.53 percent of total billed charges 3.53 5.42 Technical (Hospital) Services ALPRAZOLAM 0.25 MG TABLET RX-324 CDM 6370000100 HCPCS 250 RC 51079-0788-01 NDC outpatient 1 UN 5.7 5.7 CIGNA 62308 [3081051] CIGNA 62308 [308105105] 4.56 percent of total billed charges 3.53 5.42 Technical (Hospital) Services ALPRAZOLAM 0.25 MG TABLET RX-324 CDM 6370000100 HCPCS 250 RC 51079-0788-01 NDC outpatient 1 UN 5.7 5.7 CIGNA 62308 [3081051] CIGNA STATE OF WYOMING [308105107] 4.56 percent of total billed charges 3.53 5.42 Technical (Hospital) Services ALPRAZOLAM 0.25 MG TABLET RX-324 CDM 6370000100 HCPCS 250 RC 51079-0788-01 NDC outpatient 1 UN 5.7 5.7 MULTIPLAN INC 34080 [3081285] MULTIPLAN INC [308128501] 5.42 percent of total billed charges 3.53 5.42 Technical (Hospital) Services ALPRAZOLAM 0.25 MG TABLET RX-324 CDM 6370000100 HCPCS 250 RC 51079-0788-01 NDC outpatient 1 UN 5.7 5.7 MEDICA (COMMERCIAL) 94265 [3081118] MEDICA CLAIMS [308111801] 5.13 percent of total billed charges 3.53 5.42 Technical (Hospital) Services ALPRAZOLAM 0.25 MG TABLET RX-324 CDM 6370000100 HCPCS 250 RC 51079-0788-01 NDC outpatient 1 UN 5.7 5.7 BLUE CROSS BLUE SHIELD WELLMARK SB889 [3081026] BCBS WYOMING [308102603] 5.42 percent of total billed charges 3.53 5.42 Technical (Hospital) Services ALPRAZOLAM 0.5 MG TABLET RX-325 CDM 6370000100 HCPCS 250 RC 65862-0677-01 NDC outpatient 1 UN 5.66 5.66 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES EPO [308136803] 4.53 percent of total billed charges 3.51 5.38 Technical (Hospital) Services ALPRAZOLAM 0.5 MG TABLET RX-325 CDM 6370000100 HCPCS 250 RC 65862-0677-01 NDC outpatient 1 UN 5.66 5.66 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES HDHP [308136802] 4.53 percent of total billed charges 3.51 5.38 Technical (Hospital) Services ALPRAZOLAM 0.5 MG TABLET RX-325 CDM 6370000100 HCPCS 250 RC 65862-0677-01 NDC outpatient 1 UN 5.66 5.66 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES PPO [308136801] 4.53 percent of total billed charges 3.51 5.38 Technical (Hospital) Services ALPRAZOLAM 0.5 MG TABLET RX-325 CDM 6370000100 HCPCS 250 RC 65862-0677-01 NDC outpatient 1 UN 5.66 5.66 BLUE CROSS BLUE SHIELD WELLMARK SB889 [3081026] BCBS WYOMING [308102603] 5.38 percent of total billed charges 3.51 5.38 Technical (Hospital) Services ALPRAZOLAM 0.5 MG TABLET RX-325 CDM 6370000100 HCPCS 250 RC 65862-0677-01 NDC outpatient 1 UN 5.66 5.66 UNITED HEALTHCARE (COMMERCIAL) [3081199] UNITED HEALTHCARE 87726 [308119901] 3.51 percent of total billed charges 3.51 5.38 Technical (Hospital) Services ALPRAZOLAM 0.5 MG TABLET RX-325 CDM 6370000100 HCPCS 250 RC 65862-0677-01 NDC outpatient 1 UN 5.66 5.66 HEALTHPARTNERS SX009 HEALTHPARTNERS 4.53 percent of total billed charges 3.51 5.38 Technical (Hospital) Services ALPRAZOLAM 0.5 MG TABLET RX-325 CDM 6370000100 HCPCS 250 RC 65862-0677-01 NDC outpatient 1 UN 5.66 5.66 MEDICA (COMMERCIAL) 94265 [3081118] MEDICA CLAIMS [308111801] 5.09 percent of total billed charges 3.51 5.38 Technical (Hospital) Services ALPRAZOLAM 0.5 MG TABLET RX-325 CDM 6370000100 HCPCS 250 RC 65862-0677-01 NDC outpatient 1 UN 5.66 5.66 CIGNA 62308 [3081051] CIGNA 62308 [308105105] 4.53 percent of total billed charges 3.51 5.38 Technical (Hospital) Services ALPRAZOLAM 0.5 MG TABLET RX-325 CDM 6370000100 HCPCS 250 RC 65862-0677-01 NDC outpatient 1 UN 5.66 5.66 CIGNA 62308 [3081051] CIGNA STATE OF WYOMING [308105107] 4.53 percent of total billed charges 3.51 5.38 Technical (Hospital) Services ALPRAZOLAM 0.5 MG TABLET RX-325 CDM 6370000100 HCPCS 250 RC 65862-0677-01 NDC outpatient 1 UN 5.66 5.66 MULTIPLAN INC 34080 [3081285] MULTIPLAN INC [308128501] 5.38 percent of total billed charges 3.51 5.38 Technical (Hospital) Services ALPRAZOLAM 0.5 MG TABLET RX-325 CDM 6370000100 HCPCS 250 RC 65862-0677-01 NDC inpatient 1 UN 5.66 5.66 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES PPO [308136801] 4.48 percent of total billed charges 3.51 5.38 Technical (Hospital) Services ALPRAZOLAM 0.5 MG TABLET RX-325 CDM 6370000100 HCPCS 250 RC 65862-0677-01 NDC inpatient 1 UN 5.66 5.66 MEDICA (COMMERCIAL) 94265 [3081118] MEDICA CLAIMS [308111801] 5.09 percent of total billed charges 3.51 5.38 Technical (Hospital) Services ALPRAZOLAM 0.5 MG TABLET RX-325 CDM 6370000100 HCPCS 250 RC 65862-0677-01 NDC inpatient 1 UN 5.66 5.66 HEALTHPARTNERS SX009 HEALTHPARTNERS 4.48 percent of total billed charges 3.51 5.38 Technical (Hospital) Services ALPRAZOLAM 0.5 MG TABLET RX-325 CDM 6370000100 HCPCS 250 RC 65862-0677-01 NDC inpatient 1 UN 5.66 5.66 MULTIPLAN INC 34080 [3081285] MULTIPLAN INC [308128501] 5.38 percent of total billed charges 3.51 5.38 Technical (Hospital) Services ALPRAZOLAM 0.5 MG TABLET RX-325 CDM 6370000100 HCPCS 250 RC 65862-0677-01 NDC inpatient 1 UN 5.66 5.66 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES HDHP [308136802] 4.48 percent of total billed charges 3.51 5.38 Technical (Hospital) Services ALPRAZOLAM 0.5 MG TABLET RX-325 CDM 6370000100 HCPCS 250 RC 65862-0677-01 NDC inpatient 1 UN 5.66 5.66 UNITED HEALTHCARE (COMMERCIAL) [3081199] UNITED HEALTHCARE 87726 [308119901] 3.51 percent of total billed charges 3.51 5.38 Technical (Hospital) Services ALPRAZOLAM 0.5 MG TABLET RX-325 CDM 6370000100 HCPCS 250 RC 65862-0677-01 NDC inpatient 1 UN 5.66 5.66 CIGNA 62308 [3081051] CIGNA 62308 [308105105] 4.48 percent of total billed charges 3.51 5.38 Technical (Hospital) Services ALPRAZOLAM 0.5 MG TABLET RX-325 CDM 6370000100 HCPCS 250 RC 65862-0677-01 NDC inpatient 1 UN 5.66 5.66 CIGNA 62308 [3081051] CIGNA STATE OF WYOMING [308105107] 4.48 percent of total billed charges 3.51 5.38 Technical (Hospital) Services ALPRAZOLAM 0.5 MG TABLET RX-325 CDM 6370000100 HCPCS 250 RC 65862-0677-01 NDC inpatient 1 UN 5.66 5.66 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES EPO [308136803] 4.48 percent of total billed charges 3.51 5.38 Technical (Hospital) Services ALPRAZOLAM 0.5 MG TABLET RX-325 CDM 6370000100 HCPCS 250 RC 65862-0677-01 NDC inpatient 1 UN 5.66 5.66 BLUE CROSS BLUE SHIELD WELLMARK SB889 [3081026] BCBS WYOMING [308102603] 5.38 percent of total billed charges 3.51 5.38 Technical (Hospital) Services RISEDRONATE 35 MG TABLET RX-32895 CDM 6370000100 HCPCS 250 RC 00430-0472-03 NDC outpatient 1 UN 316.75 316.75 HEALTHPARTNERS SX009 HEALTHPARTNERS 253.4 percent of total billed charges 196.39 300.91 Technical (Hospital) Services RISEDRONATE 35 MG TABLET RX-32895 CDM 6370000100 HCPCS 250 RC 00430-0472-03 NDC outpatient 1 UN 316.75 316.75 BLUE CROSS BLUE SHIELD WELLMARK SB889 [3081026] BCBS WYOMING [308102603] 300.91 percent of total billed charges 196.39 300.91 Technical (Hospital) Services RISEDRONATE 35 MG TABLET RX-32895 CDM 6370000100 HCPCS 250 RC 00430-0472-03 NDC outpatient 1 UN 316.75 316.75 UNITED HEALTHCARE (COMMERCIAL) [3081199] UNITED HEALTHCARE 87726 [308119901] 196.39 percent of total billed charges 196.39 300.91 Technical (Hospital) Services RISEDRONATE 35 MG TABLET RX-32895 CDM 6370000100 HCPCS 250 RC 00430-0472-03 NDC outpatient 1 UN 316.75 316.75 MEDICA (COMMERCIAL) 94265 [3081118] MEDICA CLAIMS [308111801] 285.08 percent of total billed charges 196.39 300.91 Technical (Hospital) Services RISEDRONATE 35 MG TABLET RX-32895 CDM 6370000100 HCPCS 250 RC 00430-0472-03 NDC outpatient 1 UN 316.75 316.75 CIGNA 62308 [3081051] CIGNA 62308 [308105105] 253.4 percent of total billed charges 196.39 300.91 Technical (Hospital) Services RISEDRONATE 35 MG TABLET RX-32895 CDM 6370000100 HCPCS 250 RC 00430-0472-03 NDC outpatient 1 UN 316.75 316.75 CIGNA 62308 [3081051] CIGNA STATE OF WYOMING [308105107] 253.4 percent of total billed charges 196.39 300.91 Technical (Hospital) Services RISEDRONATE 35 MG TABLET RX-32895 CDM 6370000100 HCPCS 250 RC 00430-0472-03 NDC outpatient 1 UN 316.75 316.75 MULTIPLAN INC 34080 [3081285] MULTIPLAN INC [308128501] 300.91 percent of total billed charges 196.39 300.91 Technical (Hospital) Services RISEDRONATE 35 MG TABLET RX-32895 CDM 6370000100 HCPCS 250 RC 00430-0472-03 NDC outpatient 1 UN 316.75 316.75 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES EPO [308136803] 253.4 percent of total billed charges 196.39 300.91 Technical (Hospital) Services RISEDRONATE 35 MG TABLET RX-32895 CDM 6370000100 HCPCS 250 RC 00430-0472-03 NDC outpatient 1 UN 316.75 316.75 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES PPO [308136801] 253.4 percent of total billed charges 196.39 300.91 Technical (Hospital) Services RISEDRONATE 35 MG TABLET RX-32895 CDM 6370000100 HCPCS 250 RC 00430-0472-03 NDC outpatient 1 UN 316.75 316.75 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES HDHP [308136802] 253.4 percent of total billed charges 196.39 300.91 Technical (Hospital) Services RISEDRONATE 35 MG TABLET RX-32895 CDM 6370000100 HCPCS 250 RC 00430-0472-03 NDC inpatient 1 UN 316.75 316.75 BLUE CROSS BLUE SHIELD WELLMARK SB889 [3081026] BCBS WYOMING [308102603] 300.91 percent of total billed charges 196.39 300.91 Technical (Hospital) Services RISEDRONATE 35 MG TABLET RX-32895 CDM 6370000100 HCPCS 250 RC 00430-0472-03 NDC inpatient 1 UN 316.75 316.75 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES HDHP [308136802] 250.8 percent of total billed charges 196.39 300.91 Technical (Hospital) Services RISEDRONATE 35 MG TABLET RX-32895 CDM 6370000100 HCPCS 250 RC 00430-0472-03 NDC inpatient 1 UN 316.75 316.75 CIGNA 62308 [3081051] CIGNA 62308 [308105105] 250.8 percent of total billed charges 196.39 300.91 Technical (Hospital) Services RISEDRONATE 35 MG TABLET RX-32895 CDM 6370000100 HCPCS 250 RC 00430-0472-03 NDC inpatient 1 UN 316.75 316.75 CIGNA 62308 [3081051] CIGNA STATE OF WYOMING [308105107] 250.8 percent of total billed charges 196.39 300.91 Technical (Hospital) Services RISEDRONATE 35 MG TABLET RX-32895 CDM 6370000100 HCPCS 250 RC 00430-0472-03 NDC inpatient 1 UN 316.75 316.75 UNITED HEALTHCARE (COMMERCIAL) [3081199] UNITED HEALTHCARE 87726 [308119901] 196.39 percent of total billed charges 196.39 300.91 Technical (Hospital) Services RISEDRONATE 35 MG TABLET RX-32895 CDM 6370000100 HCPCS 250 RC 00430-0472-03 NDC inpatient 1 UN 316.75 316.75 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES EPO [308136803] 250.8 percent of total billed charges 196.39 300.91 Technical (Hospital) Services RISEDRONATE 35 MG TABLET RX-32895 CDM 6370000100 HCPCS 250 RC 00430-0472-03 NDC inpatient 1 UN 316.75 316.75 HEALTHPARTNERS SX009 HEALTHPARTNERS 250.8 percent of total billed charges 196.39 300.91 Technical (Hospital) Services RISEDRONATE 35 MG TABLET RX-32895 CDM 6370000100 HCPCS 250 RC 00430-0472-03 NDC inpatient 1 UN 316.75 316.75 MEDICA (COMMERCIAL) 94265 [3081118] MEDICA CLAIMS [308111801] 285.08 percent of total billed charges 196.39 300.91 Technical (Hospital) Services RISEDRONATE 35 MG TABLET RX-32895 CDM 6370000100 HCPCS 250 RC 00430-0472-03 NDC inpatient 1 UN 316.75 316.75 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES PPO [308136801] 250.8 percent of total billed charges 196.39 300.91 Technical (Hospital) Services RISEDRONATE 35 MG TABLET RX-32895 CDM 6370000100 HCPCS 250 RC 00430-0472-03 NDC inpatient 1 UN 316.75 316.75 MULTIPLAN INC 34080 [3081285] MULTIPLAN INC [308128501] 300.91 percent of total billed charges 196.39 300.91 Technical (Hospital) Services FUROSEMIDE 10 MG/ML ORAL SOLUTION RX-3292 CDM 6370000100 HCPCS 250 RC 00054-3294-46 NDC outpatient 60 ML 28.72 28.72 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES EPO [308136803] 22.98 percent of total billed charges 17.81 27.28 Technical (Hospital) Services FUROSEMIDE 10 MG/ML ORAL SOLUTION RX-3292 CDM 6370000100 HCPCS 250 RC 00054-3294-46 NDC outpatient 60 ML 28.72 28.72 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES HDHP [308136802] 22.98 percent of total billed charges 17.81 27.28 Technical (Hospital) Services FUROSEMIDE 10 MG/ML ORAL SOLUTION RX-3292 CDM 6370000100 HCPCS 250 RC 00054-3294-46 NDC outpatient 60 ML 28.72 28.72 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES PPO [308136801] 22.98 percent of total billed charges 17.81 27.28 Technical (Hospital) Services FUROSEMIDE 10 MG/ML ORAL SOLUTION RX-3292 CDM 6370000100 HCPCS 250 RC 00054-3294-46 NDC outpatient 60 ML 28.72 28.72 MEDICA (COMMERCIAL) 94265 [3081118] MEDICA CLAIMS [308111801] 25.85 percent of total billed charges 17.81 27.28 Technical (Hospital) Services FUROSEMIDE 10 MG/ML ORAL SOLUTION RX-3292 CDM 6370000100 HCPCS 250 RC 00054-3294-46 NDC outpatient 60 ML 28.72 28.72 MULTIPLAN INC 34080 [3081285] MULTIPLAN INC [308128501] 27.28 percent of total billed charges 17.81 27.28 Technical (Hospital) Services FUROSEMIDE 10 MG/ML ORAL SOLUTION RX-3292 CDM 6370000100 HCPCS 250 RC 00054-3294-46 NDC outpatient 60 ML 28.72 28.72 UNITED HEALTHCARE (COMMERCIAL) [3081199] UNITED HEALTHCARE 87726 [308119901] 17.81 percent of total billed charges 17.81 27.28 Technical (Hospital) Services FUROSEMIDE 10 MG/ML ORAL SOLUTION RX-3292 CDM 6370000100 HCPCS 250 RC 00054-3294-46 NDC outpatient 60 ML 28.72 28.72 BLUE CROSS BLUE SHIELD WELLMARK SB889 [3081026] BCBS WYOMING [308102603] 27.28 percent of total billed charges 17.81 27.28 Technical (Hospital) Services FUROSEMIDE 10 MG/ML ORAL SOLUTION RX-3292 CDM 6370000100 HCPCS 250 RC 00054-3294-46 NDC outpatient 60 ML 28.72 28.72 HEALTHPARTNERS SX009 HEALTHPARTNERS 22.98 percent of total billed charges 17.81 27.28 Technical (Hospital) Services FUROSEMIDE 10 MG/ML ORAL SOLUTION RX-3292 CDM 6370000100 HCPCS 250 RC 00054-3294-46 NDC outpatient 60 ML 28.72 28.72 CIGNA 62308 [3081051] CIGNA 62308 [308105105] 22.98 percent of total billed charges 17.81 27.28 Technical (Hospital) Services FUROSEMIDE 10 MG/ML ORAL SOLUTION RX-3292 CDM 6370000100 HCPCS 250 RC 00054-3294-46 NDC outpatient 60 ML 28.72 28.72 CIGNA 62308 [3081051] CIGNA STATE OF WYOMING [308105107] 22.98 percent of total billed charges 17.81 27.28 Technical (Hospital) Services FUROSEMIDE 10 MG/ML ORAL SOLUTION RX-3292 CDM 6370000100 HCPCS 250 RC 00054-3294-46 NDC inpatient 60 ML 28.72 28.72 MULTIPLAN INC 34080 [3081285] MULTIPLAN INC [308128501] 27.28 percent of total billed charges 17.81 27.28 Technical (Hospital) Services FUROSEMIDE 10 MG/ML ORAL SOLUTION RX-3292 CDM 6370000100 HCPCS 250 RC 00054-3294-46 NDC inpatient 60 ML 28.72 28.72 MEDICA (COMMERCIAL) 94265 [3081118] MEDICA CLAIMS [308111801] 25.85 percent of total billed charges 17.81 27.28 Technical (Hospital) Services FUROSEMIDE 10 MG/ML ORAL SOLUTION RX-3292 CDM 6370000100 HCPCS 250 RC 00054-3294-46 NDC inpatient 60 ML 28.72 28.72 HEALTHPARTNERS SX009 HEALTHPARTNERS 22.74 percent of total billed charges 17.81 27.28 Technical (Hospital) Services FUROSEMIDE 10 MG/ML ORAL SOLUTION RX-3292 CDM 6370000100 HCPCS 250 RC 00054-3294-46 NDC inpatient 60 ML 28.72 28.72 BLUE CROSS BLUE SHIELD WELLMARK SB889 [3081026] BCBS WYOMING [308102603] 27.28 percent of total billed charges 17.81 27.28 Technical (Hospital) Services FUROSEMIDE 10 MG/ML ORAL SOLUTION RX-3292 CDM 6370000100 HCPCS 250 RC 00054-3294-46 NDC inpatient 60 ML 28.72 28.72 UNITED HEALTHCARE (COMMERCIAL) [3081199] UNITED HEALTHCARE 87726 [308119901] 17.81 percent of total billed charges 17.81 27.28 Technical (Hospital) Services FUROSEMIDE 10 MG/ML ORAL SOLUTION RX-3292 CDM 6370000100 HCPCS 250 RC 00054-3294-46 NDC inpatient 60 ML 28.72 28.72 CIGNA 62308 [3081051] CIGNA 62308 [308105105] 22.74 percent of total billed charges 17.81 27.28 Technical (Hospital) Services FUROSEMIDE 10 MG/ML ORAL SOLUTION RX-3292 CDM 6370000100 HCPCS 250 RC 00054-3294-46 NDC inpatient 60 ML 28.72 28.72 CIGNA 62308 [3081051] CIGNA STATE OF WYOMING [308105107] 22.74 percent of total billed charges 17.81 27.28 Technical (Hospital) Services FUROSEMIDE 10 MG/ML ORAL SOLUTION RX-3292 CDM 6370000100 HCPCS 250 RC 00054-3294-46 NDC inpatient 60 ML 28.72 28.72 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES EPO [308136803] 22.74 percent of total billed charges 17.81 27.28 Technical (Hospital) Services FUROSEMIDE 10 MG/ML ORAL SOLUTION RX-3292 CDM 6370000100 HCPCS 250 RC 00054-3294-46 NDC inpatient 60 ML 28.72 28.72 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES HDHP [308136802] 22.74 percent of total billed charges 17.81 27.28 Technical (Hospital) Services FUROSEMIDE 10 MG/ML ORAL SOLUTION RX-3292 CDM 6370000100 HCPCS 250 RC 00054-3294-46 NDC inpatient 60 ML 28.72 28.72 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES PPO [308136801] 22.74 percent of total billed charges 17.81 27.28 Technical (Hospital) Services FUROSEMIDE 20 MG TABLET RX-3294 CDM 6370000100 HCPCS 250 RC 00054-4297-31 NDC inpatient 1 UN 5.66 5.66 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES HDHP [308136802] 4.48 percent of total billed charges 3.51 5.38 Technical (Hospital) Services FUROSEMIDE 20 MG TABLET RX-3294 CDM 6370000100 HCPCS 250 RC 00054-4297-31 NDC inpatient 1 UN 5.66 5.66 BLUE CROSS BLUE SHIELD WELLMARK SB889 [3081026] BCBS WYOMING [308102603] 5.38 percent of total billed charges 3.51 5.38 Technical (Hospital) Services FUROSEMIDE 20 MG TABLET RX-3294 CDM 6370000100 HCPCS 250 RC 00054-4297-31 NDC inpatient 1 UN 5.66 5.66 UNITED HEALTHCARE (COMMERCIAL) [3081199] UNITED HEALTHCARE 87726 [308119901] 3.51 percent of total billed charges 3.51 5.38 Technical (Hospital) Services FUROSEMIDE 20 MG TABLET RX-3294 CDM 6370000100 HCPCS 250 RC 00054-4297-31 NDC inpatient 1 UN 5.66 5.66 CIGNA 62308 [3081051] CIGNA 62308 [308105105] 4.48 percent of total billed charges 3.51 5.38 Technical (Hospital) Services FUROSEMIDE 20 MG TABLET RX-3294 CDM 6370000100 HCPCS 250 RC 00054-4297-31 NDC inpatient 1 UN 5.66 5.66 CIGNA 62308 [3081051] CIGNA STATE OF WYOMING [308105107] 4.48 percent of total billed charges 3.51 5.38 Technical (Hospital) Services FUROSEMIDE 20 MG TABLET RX-3294 CDM 6370000100 HCPCS 250 RC 00054-4297-31 NDC inpatient 1 UN 5.66 5.66 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES EPO [308136803] 4.48 percent of total billed charges 3.51 5.38 Technical (Hospital) Services FUROSEMIDE 20 MG TABLET RX-3294 CDM 6370000100 HCPCS 250 RC 00054-4297-31 NDC inpatient 1 UN 5.66 5.66 MULTIPLAN INC 34080 [3081285] MULTIPLAN INC [308128501] 5.38 percent of total billed charges 3.51 5.38 Technical (Hospital) Services FUROSEMIDE 20 MG TABLET RX-3294 CDM 6370000100 HCPCS 250 RC 00054-4297-31 NDC inpatient 1 UN 5.66 5.66 MEDICA (COMMERCIAL) 94265 [3081118] MEDICA CLAIMS [308111801] 5.09 percent of total billed charges 3.51 5.38 Technical (Hospital) Services FUROSEMIDE 20 MG TABLET RX-3294 CDM 6370000100 HCPCS 250 RC 00054-4297-31 NDC inpatient 1 UN 5.66 5.66 HEALTHPARTNERS SX009 HEALTHPARTNERS 4.48 percent of total billed charges 3.51 5.38 Technical (Hospital) Services FUROSEMIDE 20 MG TABLET RX-3294 CDM 6370000100 HCPCS 250 RC 00054-4297-31 NDC inpatient 1 UN 5.66 5.66 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES PPO [308136801] 4.48 percent of total billed charges 3.51 5.38 Technical (Hospital) Services FUROSEMIDE 20 MG TABLET RX-3294 CDM 6370000100 HCPCS 250 RC 00054-4297-31 NDC outpatient 1 UN 5.66 5.66 UNITED HEALTHCARE (COMMERCIAL) [3081199] UNITED HEALTHCARE 87726 [308119901] 3.51 percent of total billed charges 3.51 5.38 Technical (Hospital) Services FUROSEMIDE 20 MG TABLET RX-3294 CDM 6370000100 HCPCS 250 RC 00054-4297-31 NDC outpatient 1 UN 5.66 5.66 HEALTHPARTNERS SX009 HEALTHPARTNERS 4.53 percent of total billed charges 3.51 5.38 Technical (Hospital) Services FUROSEMIDE 20 MG TABLET RX-3294 CDM 6370000100 HCPCS 250 RC 00054-4297-31 NDC outpatient 1 UN 5.66 5.66 CIGNA 62308 [3081051] CIGNA 62308 [308105105] 4.53 percent of total billed charges 3.51 5.38 Technical (Hospital) Services FUROSEMIDE 20 MG TABLET RX-3294 CDM 6370000100 HCPCS 250 RC 00054-4297-31 NDC outpatient 1 UN 5.66 5.66 CIGNA 62308 [3081051] CIGNA STATE OF WYOMING [308105107] 4.53 percent of total billed charges 3.51 5.38 Technical (Hospital) Services FUROSEMIDE 20 MG TABLET RX-3294 CDM 6370000100 HCPCS 250 RC 00054-4297-31 NDC outpatient 1 UN 5.66 5.66 MULTIPLAN INC 34080 [3081285] MULTIPLAN INC [308128501] 5.38 percent of total billed charges 3.51 5.38 Technical (Hospital) Services FUROSEMIDE 20 MG TABLET RX-3294 CDM 6370000100 HCPCS 250 RC 00054-4297-31 NDC outpatient 1 UN 5.66 5.66 MEDICA (COMMERCIAL) 94265 [3081118] MEDICA CLAIMS [308111801] 5.09 percent of total billed charges 3.51 5.38 Technical (Hospital) Services FUROSEMIDE 20 MG TABLET RX-3294 CDM 6370000100 HCPCS 250 RC 00054-4297-31 NDC outpatient 1 UN 5.66 5.66 BLUE CROSS BLUE SHIELD WELLMARK SB889 [3081026] BCBS WYOMING [308102603] 5.38 percent of total billed charges 3.51 5.38 Technical (Hospital) Services FUROSEMIDE 20 MG TABLET RX-3294 CDM 6370000100 HCPCS 250 RC 00054-4297-31 NDC outpatient 1 UN 5.66 5.66 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES HDHP [308136802] 4.53 percent of total billed charges 3.51 5.38 Technical (Hospital) Services FUROSEMIDE 20 MG TABLET RX-3294 CDM 6370000100 HCPCS 250 RC 00054-4297-31 NDC outpatient 1 UN 5.66 5.66 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES EPO [308136803] 4.53 percent of total billed charges 3.51 5.38 Technical (Hospital) Services FUROSEMIDE 20 MG TABLET RX-3294 CDM 6370000100 HCPCS 250 RC 00054-4297-31 NDC outpatient 1 UN 5.66 5.66 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES PPO [308136801] 4.53 percent of total billed charges 3.51 5.38 Technical (Hospital) Services FUROSEMIDE 40 MG TABLET RX-3295 CDM 6370000100 HCPCS 250 RC 00378-0216-10 NDC outpatient 1 UN 5.67 5.67 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES PPO [308136801] 4.54 percent of total billed charges 3.52 5.39 Technical (Hospital) Services FUROSEMIDE 40 MG TABLET RX-3295 CDM 6370000100 HCPCS 250 RC 00378-0216-10 NDC outpatient 1 UN 5.67 5.67 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES EPO [308136803] 4.54 percent of total billed charges 3.52 5.39 Technical (Hospital) Services FUROSEMIDE 40 MG TABLET RX-3295 CDM 6370000100 HCPCS 250 RC 00378-0216-10 NDC outpatient 1 UN 5.67 5.67 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES HDHP [308136802] 4.54 percent of total billed charges 3.52 5.39 Technical (Hospital) Services FUROSEMIDE 40 MG TABLET RX-3295 CDM 6370000100 HCPCS 250 RC 00378-0216-10 NDC outpatient 1 UN 5.67 5.67 BLUE CROSS BLUE SHIELD WELLMARK SB889 [3081026] BCBS WYOMING [308102603] 5.39 percent of total billed charges 3.52 5.39 Technical (Hospital) Services FUROSEMIDE 40 MG TABLET RX-3295 CDM 6370000100 HCPCS 250 RC 00378-0216-10 NDC outpatient 1 UN 5.67 5.67 MEDICA (COMMERCIAL) 94265 [3081118] MEDICA CLAIMS [308111801] 5.1 percent of total billed charges 3.52 5.39 Technical (Hospital) Services FUROSEMIDE 40 MG TABLET RX-3295 CDM 6370000100 HCPCS 250 RC 00378-0216-10 NDC outpatient 1 UN 5.67 5.67 MULTIPLAN INC 34080 [3081285] MULTIPLAN INC [308128501] 5.39 percent of total billed charges 3.52 5.39 Technical (Hospital) Services FUROSEMIDE 40 MG TABLET RX-3295 CDM 6370000100 HCPCS 250 RC 00378-0216-10 NDC outpatient 1 UN 5.67 5.67 CIGNA 62308 [3081051] CIGNA 62308 [308105105] 4.54 percent of total billed charges 3.52 5.39 Technical (Hospital) Services FUROSEMIDE 40 MG TABLET RX-3295 CDM 6370000100 HCPCS 250 RC 00378-0216-10 NDC outpatient 1 UN 5.67 5.67 CIGNA 62308 [3081051] CIGNA STATE OF WYOMING [308105107] 4.54 percent of total billed charges 3.52 5.39 Technical (Hospital) Services FUROSEMIDE 40 MG TABLET RX-3295 CDM 6370000100 HCPCS 250 RC 00378-0216-10 NDC outpatient 1 UN 5.67 5.67 HEALTHPARTNERS SX009 HEALTHPARTNERS 4.54 percent of total billed charges 3.52 5.39 Technical (Hospital) Services FUROSEMIDE 40 MG TABLET RX-3295 CDM 6370000100 HCPCS 250 RC 00378-0216-10 NDC outpatient 1 UN 5.67 5.67 UNITED HEALTHCARE (COMMERCIAL) [3081199] UNITED HEALTHCARE 87726 [308119901] 3.52 percent of total billed charges 3.52 5.39 Technical (Hospital) Services FUROSEMIDE 40 MG TABLET RX-3295 CDM 6370000100 HCPCS 250 RC 00378-0216-10 NDC inpatient 1 UN 5.67 5.67 HEALTHPARTNERS SX009 HEALTHPARTNERS 4.49 percent of total billed charges 3.52 5.39 Technical (Hospital) Services FUROSEMIDE 40 MG TABLET RX-3295 CDM 6370000100 HCPCS 250 RC 00378-0216-10 NDC inpatient 1 UN 5.67 5.67 MEDICA (COMMERCIAL) 94265 [3081118] MEDICA CLAIMS [308111801] 5.1 percent of total billed charges 3.52 5.39 Technical (Hospital) Services FUROSEMIDE 40 MG TABLET RX-3295 CDM 6370000100 HCPCS 250 RC 00378-0216-10 NDC inpatient 1 UN 5.67 5.67 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES PPO [308136801] 4.49 percent of total billed charges 3.52 5.39 Technical (Hospital) Services FUROSEMIDE 40 MG TABLET RX-3295 CDM 6370000100 HCPCS 250 RC 00378-0216-10 NDC inpatient 1 UN 5.67 5.67 MULTIPLAN INC 34080 [3081285] MULTIPLAN INC [308128501] 5.39 percent of total billed charges 3.52 5.39 Technical (Hospital) Services FUROSEMIDE 40 MG TABLET RX-3295 CDM 6370000100 HCPCS 250 RC 00378-0216-10 NDC inpatient 1 UN 5.67 5.67 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES HDHP [308136802] 4.49 percent of total billed charges 3.52 5.39 Technical (Hospital) Services FUROSEMIDE 40 MG TABLET RX-3295 CDM 6370000100 HCPCS 250 RC 00378-0216-10 NDC inpatient 1 UN 5.67 5.67 CIGNA 62308 [3081051] CIGNA 62308 [308105105] 4.49 percent of total billed charges 3.52 5.39 Technical (Hospital) Services FUROSEMIDE 40 MG TABLET RX-3295 CDM 6370000100 HCPCS 250 RC 00378-0216-10 NDC inpatient 1 UN 5.67 5.67 CIGNA 62308 [3081051] CIGNA STATE OF WYOMING [308105107] 4.49 percent of total billed charges 3.52 5.39 Technical (Hospital) Services FUROSEMIDE 40 MG TABLET RX-3295 CDM 6370000100 HCPCS 250 RC 00378-0216-10 NDC inpatient 1 UN 5.67 5.67 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES EPO [308136803] 4.49 percent of total billed charges 3.52 5.39 Technical (Hospital) Services FUROSEMIDE 40 MG TABLET RX-3295 CDM 6370000100 HCPCS 250 RC 00378-0216-10 NDC inpatient 1 UN 5.67 5.67 UNITED HEALTHCARE (COMMERCIAL) [3081199] UNITED HEALTHCARE 87726 [308119901] 3.52 percent of total billed charges 3.52 5.39 Technical (Hospital) Services FUROSEMIDE 40 MG TABLET RX-3295 CDM 6370000100 HCPCS 250 RC 00378-0216-10 NDC inpatient 1 UN 5.67 5.67 BLUE CROSS BLUE SHIELD WELLMARK SB889 [3081026] BCBS WYOMING [308102603] 5.39 percent of total billed charges 3.52 5.39 Technical (Hospital) Services FUROSEMIDE 80 MG TABLET RX-3296 CDM 6370000100 HCPCS 250 RC 00378-0232-01 NDC inpatient 1 UN 5.7 5.7 MULTIPLAN INC 34080 [3081285] MULTIPLAN INC [308128501] 5.42 percent of total billed charges 3.53 5.42 Technical (Hospital) Services FUROSEMIDE 80 MG TABLET RX-3296 CDM 6370000100 HCPCS 250 RC 00378-0232-01 NDC inpatient 1 UN 5.7 5.7 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES PPO [308136801] 4.51 percent of total billed charges 3.53 5.42 Technical (Hospital) Services FUROSEMIDE 80 MG TABLET RX-3296 CDM 6370000100 HCPCS 250 RC 00378-0232-01 NDC inpatient 1 UN 5.7 5.7 BLUE CROSS BLUE SHIELD WELLMARK SB889 [3081026] BCBS WYOMING [308102603] 5.42 percent of total billed charges 3.53 5.42 Technical (Hospital) Services FUROSEMIDE 80 MG TABLET RX-3296 CDM 6370000100 HCPCS 250 RC 00378-0232-01 NDC inpatient 1 UN 5.7 5.7 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES HDHP [308136802] 4.51 percent of total billed charges 3.53 5.42 Technical (Hospital) Services FUROSEMIDE 80 MG TABLET RX-3296 CDM 6370000100 HCPCS 250 RC 00378-0232-01 NDC inpatient 1 UN 5.7 5.7 HEALTHPARTNERS SX009 HEALTHPARTNERS 4.51 percent of total billed charges 3.53 5.42 Technical (Hospital) Services FUROSEMIDE 80 MG TABLET RX-3296 CDM 6370000100 HCPCS 250 RC 00378-0232-01 NDC inpatient 1 UN 5.7 5.7 MEDICA (COMMERCIAL) 94265 [3081118] MEDICA CLAIMS [308111801] 5.13 percent of total billed charges 3.53 5.42 Technical (Hospital) Services FUROSEMIDE 80 MG TABLET RX-3296 CDM 6370000100 HCPCS 250 RC 00378-0232-01 NDC inpatient 1 UN 5.7 5.7 CIGNA 62308 [3081051] CIGNA 62308 [308105105] 4.51 percent of total billed charges 3.53 5.42 Technical (Hospital) Services FUROSEMIDE 80 MG TABLET RX-3296 CDM 6370000100 HCPCS 250 RC 00378-0232-01 NDC inpatient 1 UN 5.7 5.7 CIGNA 62308 [3081051] CIGNA STATE OF WYOMING [308105107] 4.51 percent of total billed charges 3.53 5.42 Technical (Hospital) Services FUROSEMIDE 80 MG TABLET RX-3296 CDM 6370000100 HCPCS 250 RC 00378-0232-01 NDC inpatient 1 UN 5.7 5.7 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES EPO [308136803] 4.51 percent of total billed charges 3.53 5.42 Technical (Hospital) Services FUROSEMIDE 80 MG TABLET RX-3296 CDM 6370000100 HCPCS 250 RC 00378-0232-01 NDC inpatient 1 UN 5.7 5.7 UNITED HEALTHCARE (COMMERCIAL) [3081199] UNITED HEALTHCARE 87726 [308119901] 3.53 percent of total billed charges 3.53 5.42 Technical (Hospital) Services FUROSEMIDE 80 MG TABLET RX-3296 CDM 6370000100 HCPCS 250 RC 00378-0232-01 NDC outpatient 1 UN 5.7 5.7 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES HDHP [308136802] 4.56 percent of total billed charges 3.53 5.42 Technical (Hospital) Services FUROSEMIDE 80 MG TABLET RX-3296 CDM 6370000100 HCPCS 250 RC 00378-0232-01 NDC outpatient 1 UN 5.7 5.7 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES EPO [308136803] 4.56 percent of total billed charges 3.53 5.42 Technical (Hospital) Services FUROSEMIDE 80 MG TABLET RX-3296 CDM 6370000100 HCPCS 250 RC 00378-0232-01 NDC outpatient 1 UN 5.7 5.7 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES PPO [308136801] 4.56 percent of total billed charges 3.53 5.42 Technical (Hospital) Services FUROSEMIDE 80 MG TABLET RX-3296 CDM 6370000100 HCPCS 250 RC 00378-0232-01 NDC outpatient 1 UN 5.7 5.7 UNITED HEALTHCARE (COMMERCIAL) [3081199] UNITED HEALTHCARE 87726 [308119901] 3.53 percent of total billed charges 3.53 5.42 Technical (Hospital) Services FUROSEMIDE 80 MG TABLET RX-3296 CDM 6370000100 HCPCS 250 RC 00378-0232-01 NDC outpatient 1 UN 5.7 5.7 MEDICA (COMMERCIAL) 94265 [3081118] MEDICA CLAIMS [308111801] 5.13 percent of total billed charges 3.53 5.42 Technical (Hospital) Services FUROSEMIDE 80 MG TABLET RX-3296 CDM 6370000100 HCPCS 250 RC 00378-0232-01 NDC outpatient 1 UN 5.7 5.7 MULTIPLAN INC 34080 [3081285] MULTIPLAN INC [308128501] 5.42 percent of total billed charges 3.53 5.42 Technical (Hospital) Services FUROSEMIDE 80 MG TABLET RX-3296 CDM 6370000100 HCPCS 250 RC 00378-0232-01 NDC outpatient 1 UN 5.7 5.7 CIGNA 62308 [3081051] CIGNA 62308 [308105105] 4.56 percent of total billed charges 3.53 5.42 Technical (Hospital) Services FUROSEMIDE 80 MG TABLET RX-3296 CDM 6370000100 HCPCS 250 RC 00378-0232-01 NDC outpatient 1 UN 5.7 5.7 CIGNA 62308 [3081051] CIGNA STATE OF WYOMING [308105107] 4.56 percent of total billed charges 3.53 5.42 Technical (Hospital) Services FUROSEMIDE 80 MG TABLET RX-3296 CDM 6370000100 HCPCS 250 RC 00378-0232-01 NDC outpatient 1 UN 5.7 5.7 BLUE CROSS BLUE SHIELD WELLMARK SB889 [3081026] BCBS WYOMING [308102603] 5.42 percent of total billed charges 3.53 5.42 Technical (Hospital) Services FUROSEMIDE 80 MG TABLET RX-3296 CDM 6370000100 HCPCS 250 RC 00378-0232-01 NDC outpatient 1 UN 5.7 5.7 HEALTHPARTNERS SX009 HEALTHPARTNERS 4.56 percent of total billed charges 3.53 5.42 Technical (Hospital) Services AMOXICILLIN 875 MG-POTASSIUM CLAVULANATE 125 MG TABLET RX-33228 CDM 6370000100 HCPCS 250 RC 60687-0803-11 NDC outpatient 1 UN 28.37 28.37 CIGNA 62308 [3081051] CIGNA 62308 [308105105] 22.7 percent of total billed charges 17.59 26.95 Technical (Hospital) Services AMOXICILLIN 875 MG-POTASSIUM CLAVULANATE 125 MG TABLET RX-33228 CDM 6370000100 HCPCS 250 RC 60687-0803-11 NDC outpatient 1 UN 28.37 28.37 CIGNA 62308 [3081051] CIGNA STATE OF WYOMING [308105107] 22.7 percent of total billed charges 17.59 26.95 Technical (Hospital) Services AMOXICILLIN 875 MG-POTASSIUM CLAVULANATE 125 MG TABLET RX-33228 CDM 6370000100 HCPCS 250 RC 60687-0803-11 NDC outpatient 1 UN 28.37 28.37 MULTIPLAN INC 34080 [3081285] MULTIPLAN INC [308128501] 26.95 percent of total billed charges 17.59 26.95 Technical (Hospital) Services AMOXICILLIN 875 MG-POTASSIUM CLAVULANATE 125 MG TABLET RX-33228 CDM 6370000100 HCPCS 250 RC 60687-0803-11 NDC outpatient 1 UN 28.37 28.37 MEDICA (COMMERCIAL) 94265 [3081118] MEDICA CLAIMS [308111801] 25.53 percent of total billed charges 17.59 26.95 Technical (Hospital) Services AMOXICILLIN 875 MG-POTASSIUM CLAVULANATE 125 MG TABLET RX-33228 CDM 6370000100 HCPCS 250 RC 60687-0803-11 NDC outpatient 1 UN 28.37 28.37 HEALTHPARTNERS SX009 HEALTHPARTNERS 22.7 percent of total billed charges 17.59 26.95 Technical (Hospital) Services AMOXICILLIN 875 MG-POTASSIUM CLAVULANATE 125 MG TABLET RX-33228 CDM 6370000100 HCPCS 250 RC 60687-0803-11 NDC outpatient 1 UN 28.37 28.37 UNITED HEALTHCARE (COMMERCIAL) [3081199] UNITED HEALTHCARE 87726 [308119901] 17.59 percent of total billed charges 17.59 26.95 Technical (Hospital) Services AMOXICILLIN 875 MG-POTASSIUM CLAVULANATE 125 MG TABLET RX-33228 CDM 6370000100 HCPCS 250 RC 60687-0803-11 NDC outpatient 1 UN 28.37 28.37 BLUE CROSS BLUE SHIELD WELLMARK SB889 [3081026] BCBS WYOMING [308102603] 26.95 percent of total billed charges 17.59 26.95 Technical (Hospital) Services AMOXICILLIN 875 MG-POTASSIUM CLAVULANATE 125 MG TABLET RX-33228 CDM 6370000100 HCPCS 250 RC 60687-0803-11 NDC outpatient 1 UN 28.37 28.37 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES HDHP [308136802] 22.7 percent of total billed charges 17.59 26.95 Technical (Hospital) Services AMOXICILLIN 875 MG-POTASSIUM CLAVULANATE 125 MG TABLET RX-33228 CDM 6370000100 HCPCS 250 RC 60687-0803-11 NDC outpatient 1 UN 28.37 28.37 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES PPO [308136801] 22.7 percent of total billed charges 17.59 26.95 Technical (Hospital) Services AMOXICILLIN 875 MG-POTASSIUM CLAVULANATE 125 MG TABLET RX-33228 CDM 6370000100 HCPCS 250 RC 60687-0803-11 NDC outpatient 1 UN 28.37 28.37 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES EPO [308136803] 22.7 percent of total billed charges 17.59 26.95 Technical (Hospital) Services AMOXICILLIN 875 MG-POTASSIUM CLAVULANATE 125 MG TABLET RX-33228 CDM 6370000100 HCPCS 250 RC 60687-0803-11 NDC inpatient 1 UN 28.37 28.37 BLUE CROSS BLUE SHIELD WELLMARK SB889 [3081026] BCBS WYOMING [308102603] 26.95 percent of total billed charges 17.59 26.95 Technical (Hospital) Services AMOXICILLIN 875 MG-POTASSIUM CLAVULANATE 125 MG TABLET RX-33228 CDM 6370000100 HCPCS 250 RC 60687-0803-11 NDC inpatient 1 UN 28.37 28.37 UNITED HEALTHCARE (COMMERCIAL) [3081199] UNITED HEALTHCARE 87726 [308119901] 17.59 percent of total billed charges 17.59 26.95 Technical (Hospital) Services AMOXICILLIN 875 MG-POTASSIUM CLAVULANATE 125 MG TABLET RX-33228 CDM 6370000100 HCPCS 250 RC 60687-0803-11 NDC inpatient 1 UN 28.37 28.37 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES EPO [308136803] 22.46 percent of total billed charges 17.59 26.95 Technical (Hospital) Services AMOXICILLIN 875 MG-POTASSIUM CLAVULANATE 125 MG TABLET RX-33228 CDM 6370000100 HCPCS 250 RC 60687-0803-11 NDC inpatient 1 UN 28.37 28.37 CIGNA 62308 [3081051] CIGNA 62308 [308105105] 22.46 percent of total billed charges 17.59 26.95 Technical (Hospital) Services AMOXICILLIN 875 MG-POTASSIUM CLAVULANATE 125 MG TABLET RX-33228 CDM 6370000100 HCPCS 250 RC 60687-0803-11 NDC inpatient 1 UN 28.37 28.37 CIGNA 62308 [3081051] CIGNA STATE OF WYOMING [308105107] 22.46 percent of total billed charges 17.59 26.95 Technical (Hospital) Services AMOXICILLIN 875 MG-POTASSIUM CLAVULANATE 125 MG TABLET RX-33228 CDM 6370000100 HCPCS 250 RC 60687-0803-11 NDC inpatient 1 UN 28.37 28.37 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES HDHP [308136802] 22.46 percent of total billed charges 17.59 26.95 Technical (Hospital) Services AMOXICILLIN 875 MG-POTASSIUM CLAVULANATE 125 MG TABLET RX-33228 CDM 6370000100 HCPCS 250 RC 60687-0803-11 NDC inpatient 1 UN 28.37 28.37 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES PPO [308136801] 22.46 percent of total billed charges 17.59 26.95 Technical (Hospital) Services AMOXICILLIN 875 MG-POTASSIUM CLAVULANATE 125 MG TABLET RX-33228 CDM 6370000100 HCPCS 250 RC 60687-0803-11 NDC inpatient 1 UN 28.37 28.37 MEDICA (COMMERCIAL) 94265 [3081118] MEDICA CLAIMS [308111801] 25.53 percent of total billed charges 17.59 26.95 Technical (Hospital) Services AMOXICILLIN 875 MG-POTASSIUM CLAVULANATE 125 MG TABLET RX-33228 CDM 6370000100 HCPCS 250 RC 60687-0803-11 NDC inpatient 1 UN 28.37 28.37 HEALTHPARTNERS SX009 HEALTHPARTNERS 22.46 percent of total billed charges 17.59 26.95 Technical (Hospital) Services AMOXICILLIN 875 MG-POTASSIUM CLAVULANATE 125 MG TABLET RX-33228 CDM 6370000100 HCPCS 250 RC 60687-0803-11 NDC inpatient 1 UN 28.37 28.37 MULTIPLAN INC 34080 [3081285] MULTIPLAN INC [308128501] 26.95 percent of total billed charges 17.59 26.95 Technical (Hospital) Services AMOXICILLIN 400 MG-POTASSIUM CLAVULANATE 57 MG/5 ML ORAL SUSPENSION RX-33230 CDM 6370000100 HCPCS 250 RC 65862-0534-01 NDC inpatient 100 ML 53.6 53.6 CIGNA 62308 [3081051] CIGNA 62308 [308105105] 42.44 percent of total billed charges 33.23 50.92 Technical (Hospital) Services AMOXICILLIN 400 MG-POTASSIUM CLAVULANATE 57 MG/5 ML ORAL SUSPENSION RX-33230 CDM 6370000100 HCPCS 250 RC 65862-0534-01 NDC inpatient 100 ML 53.6 53.6 CIGNA 62308 [3081051] CIGNA STATE OF WYOMING [308105107] 42.44 percent of total billed charges 33.23 50.92 Technical (Hospital) Services AMOXICILLIN 400 MG-POTASSIUM CLAVULANATE 57 MG/5 ML ORAL SUSPENSION RX-33230 CDM 6370000100 HCPCS 250 RC 65862-0534-01 NDC inpatient 100 ML 53.6 53.6 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES EPO [308136803] 42.44 percent of total billed charges 33.23 50.92 Technical (Hospital) Services AMOXICILLIN 400 MG-POTASSIUM CLAVULANATE 57 MG/5 ML ORAL SUSPENSION RX-33230 CDM 6370000100 HCPCS 250 RC 65862-0534-01 NDC inpatient 100 ML 53.6 53.6 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES HDHP [308136802] 42.44 percent of total billed charges 33.23 50.92 Technical (Hospital) Services AMOXICILLIN 400 MG-POTASSIUM CLAVULANATE 57 MG/5 ML ORAL SUSPENSION RX-33230 CDM 6370000100 HCPCS 250 RC 65862-0534-01 NDC inpatient 100 ML 53.6 53.6 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES PPO [308136801] 42.44 percent of total billed charges 33.23 50.92 Technical (Hospital) Services AMOXICILLIN 400 MG-POTASSIUM CLAVULANATE 57 MG/5 ML ORAL SUSPENSION RX-33230 CDM 6370000100 HCPCS 250 RC 65862-0534-01 NDC inpatient 100 ML 53.6 53.6 HEALTHPARTNERS SX009 HEALTHPARTNERS 42.44 percent of total billed charges 33.23 50.92 Technical (Hospital) Services AMOXICILLIN 400 MG-POTASSIUM CLAVULANATE 57 MG/5 ML ORAL SUSPENSION RX-33230 CDM 6370000100 HCPCS 250 RC 65862-0534-01 NDC inpatient 100 ML 53.6 53.6 MEDICA (COMMERCIAL) 94265 [3081118] MEDICA CLAIMS [308111801] 48.24 percent of total billed charges 33.23 50.92 Technical (Hospital) Services AMOXICILLIN 400 MG-POTASSIUM CLAVULANATE 57 MG/5 ML ORAL SUSPENSION RX-33230 CDM 6370000100 HCPCS 250 RC 65862-0534-01 NDC inpatient 100 ML 53.6 53.6 MULTIPLAN INC 34080 [3081285] MULTIPLAN INC [308128501] 50.92 percent of total billed charges 33.23 50.92 Technical (Hospital) Services AMOXICILLIN 400 MG-POTASSIUM CLAVULANATE 57 MG/5 ML ORAL SUSPENSION RX-33230 CDM 6370000100 HCPCS 250 RC 65862-0534-01 NDC inpatient 100 ML 53.6 53.6 BLUE CROSS BLUE SHIELD WELLMARK SB889 [3081026] BCBS WYOMING [308102603] 50.92 percent of total billed charges 33.23 50.92 Technical (Hospital) Services AMOXICILLIN 400 MG-POTASSIUM CLAVULANATE 57 MG/5 ML ORAL SUSPENSION RX-33230 CDM 6370000100 HCPCS 250 RC 65862-0534-01 NDC inpatient 100 ML 53.6 53.6 UNITED HEALTHCARE (COMMERCIAL) [3081199] UNITED HEALTHCARE 87726 [308119901] 33.23 percent of total billed charges 33.23 50.92 Technical (Hospital) Services AMOXICILLIN 400 MG-POTASSIUM CLAVULANATE 57 MG/5 ML ORAL SUSPENSION RX-33230 CDM 6370000100 HCPCS 250 RC 65862-0534-01 NDC outpatient 100 ML 53.6 53.6 CIGNA 62308 [3081051] CIGNA STATE OF WYOMING [308105107] 42.88 percent of total billed charges 33.23 50.92 Technical (Hospital) Services AMOXICILLIN 400 MG-POTASSIUM CLAVULANATE 57 MG/5 ML ORAL SUSPENSION RX-33230 CDM 6370000100 HCPCS 250 RC 65862-0534-01 NDC outpatient 100 ML 53.6 53.6 CIGNA 62308 [3081051] CIGNA 62308 [308105105] 42.88 percent of total billed charges 33.23 50.92 Technical (Hospital) Services AMOXICILLIN 400 MG-POTASSIUM CLAVULANATE 57 MG/5 ML ORAL SUSPENSION RX-33230 CDM 6370000100 HCPCS 250 RC 65862-0534-01 NDC outpatient 100 ML 53.6 53.6 MEDICA (COMMERCIAL) 94265 [3081118] MEDICA CLAIMS [308111801] 48.24 percent of total billed charges 33.23 50.92 Technical (Hospital) Services AMOXICILLIN 400 MG-POTASSIUM CLAVULANATE 57 MG/5 ML ORAL SUSPENSION RX-33230 CDM 6370000100 HCPCS 250 RC 65862-0534-01 NDC outpatient 100 ML 53.6 53.6 MULTIPLAN INC 34080 [3081285] MULTIPLAN INC [308128501] 50.92 percent of total billed charges 33.23 50.92 Technical (Hospital) Services AMOXICILLIN 400 MG-POTASSIUM CLAVULANATE 57 MG/5 ML ORAL SUSPENSION RX-33230 CDM 6370000100 HCPCS 250 RC 65862-0534-01 NDC outpatient 100 ML 53.6 53.6 BLUE CROSS BLUE SHIELD WELLMARK SB889 [3081026] BCBS WYOMING [308102603] 50.92 percent of total billed charges 33.23 50.92 Technical (Hospital) Services AMOXICILLIN 400 MG-POTASSIUM CLAVULANATE 57 MG/5 ML ORAL SUSPENSION RX-33230 CDM 6370000100 HCPCS 250 RC 65862-0534-01 NDC outpatient 100 ML 53.6 53.6 HEALTHPARTNERS SX009 HEALTHPARTNERS 42.88 percent of total billed charges 33.23 50.92 Technical (Hospital) Services AMOXICILLIN 400 MG-POTASSIUM CLAVULANATE 57 MG/5 ML ORAL SUSPENSION RX-33230 CDM 6370000100 HCPCS 250 RC 65862-0534-01 NDC outpatient 100 ML 53.6 53.6 UNITED HEALTHCARE (COMMERCIAL) [3081199] UNITED HEALTHCARE 87726 [308119901] 33.23 percent of total billed charges 33.23 50.92 Technical (Hospital) Services AMOXICILLIN 400 MG-POTASSIUM CLAVULANATE 57 MG/5 ML ORAL SUSPENSION RX-33230 CDM 6370000100 HCPCS 250 RC 65862-0534-01 NDC outpatient 100 ML 53.6 53.6 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES HDHP [308136802] 42.88 percent of total billed charges 33.23 50.92 Technical (Hospital) Services AMOXICILLIN 400 MG-POTASSIUM CLAVULANATE 57 MG/5 ML ORAL SUSPENSION RX-33230 CDM 6370000100 HCPCS 250 RC 65862-0534-01 NDC outpatient 100 ML 53.6 53.6 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES PPO [308136801] 42.88 percent of total billed charges 33.23 50.92 Technical (Hospital) Services AMOXICILLIN 400 MG-POTASSIUM CLAVULANATE 57 MG/5 ML ORAL SUSPENSION RX-33230 CDM 6370000100 HCPCS 250 RC 65862-0534-01 NDC outpatient 100 ML 53.6 53.6 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES EPO [308136803] 42.88 percent of total billed charges 33.23 50.92 Technical (Hospital) Services ESCITALOPRAM 10 MG TABLET RX-33512 CDM 6370000100 HCPCS 250 RC 00904-6426-61 NDC outpatient 1 UN 5.77 5.77 HEALTHPARTNERS SX009 HEALTHPARTNERS 4.62 percent of total billed charges 3.58 5.48 Technical (Hospital) Services ESCITALOPRAM 10 MG TABLET RX-33512 CDM 6370000100 HCPCS 250 RC 00904-6426-61 NDC outpatient 1 UN 5.77 5.77 BLUE CROSS BLUE SHIELD WELLMARK SB889 [3081026] BCBS WYOMING [308102603] 5.48 percent of total billed charges 3.58 5.48 Technical (Hospital) Services ESCITALOPRAM 10 MG TABLET RX-33512 CDM 6370000100 HCPCS 250 RC 00904-6426-61 NDC outpatient 1 UN 5.77 5.77 MEDICA (COMMERCIAL) 94265 [3081118] MEDICA CLAIMS [308111801] 5.19 percent of total billed charges 3.58 5.48 Technical (Hospital) Services ESCITALOPRAM 10 MG TABLET RX-33512 CDM 6370000100 HCPCS 250 RC 00904-6426-61 NDC outpatient 1 UN 5.77 5.77 CIGNA 62308 [3081051] CIGNA 62308 [308105105] 4.62 percent of total billed charges 3.58 5.48 Technical (Hospital) Services ESCITALOPRAM 10 MG TABLET RX-33512 CDM 6370000100 HCPCS 250 RC 00904-6426-61 NDC outpatient 1 UN 5.77 5.77 CIGNA 62308 [3081051] CIGNA STATE OF WYOMING [308105107] 4.62 percent of total billed charges 3.58 5.48 Technical (Hospital) Services ESCITALOPRAM 10 MG TABLET RX-33512 CDM 6370000100 HCPCS 250 RC 00904-6426-61 NDC outpatient 1 UN 5.77 5.77 MULTIPLAN INC 34080 [3081285] MULTIPLAN INC [308128501] 5.48 percent of total billed charges 3.58 5.48 Technical (Hospital) Services ESCITALOPRAM 10 MG TABLET RX-33512 CDM 6370000100 HCPCS 250 RC 00904-6426-61 NDC outpatient 1 UN 5.77 5.77 UNITED HEALTHCARE (COMMERCIAL) [3081199] UNITED HEALTHCARE 87726 [308119901] 3.58 percent of total billed charges 3.58 5.48 Technical (Hospital) Services ESCITALOPRAM 10 MG TABLET RX-33512 CDM 6370000100 HCPCS 250 RC 00904-6426-61 NDC outpatient 1 UN 5.77 5.77 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES PPO [308136801] 4.62 percent of total billed charges 3.58 5.48 Technical (Hospital) Services ESCITALOPRAM 10 MG TABLET RX-33512 CDM 6370000100 HCPCS 250 RC 00904-6426-61 NDC outpatient 1 UN 5.77 5.77 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES HDHP [308136802] 4.62 percent of total billed charges 3.58 5.48 Technical (Hospital) Services ESCITALOPRAM 10 MG TABLET RX-33512 CDM 6370000100 HCPCS 250 RC 00904-6426-61 NDC outpatient 1 UN 5.77 5.77 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES EPO [308136803] 4.62 percent of total billed charges 3.58 5.48 Technical (Hospital) Services ESCITALOPRAM 10 MG TABLET RX-33512 CDM 6370000100 HCPCS 250 RC 00904-6426-61 NDC inpatient 1 UN 5.77 5.77 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES PPO [308136801] 4.57 percent of total billed charges 3.58 5.48 Technical (Hospital) Services ESCITALOPRAM 10 MG TABLET RX-33512 CDM 6370000100 HCPCS 250 RC 00904-6426-61 NDC inpatient 1 UN 5.77 5.77 MULTIPLAN INC 34080 [3081285] MULTIPLAN INC [308128501] 5.48 percent of total billed charges 3.58 5.48 Technical (Hospital) Services ESCITALOPRAM 10 MG TABLET RX-33512 CDM 6370000100 HCPCS 250 RC 00904-6426-61 NDC inpatient 1 UN 5.77 5.77 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES EPO [308136803] 4.57 percent of total billed charges 3.58 5.48 Technical (Hospital) Services ESCITALOPRAM 10 MG TABLET RX-33512 CDM 6370000100 HCPCS 250 RC 00904-6426-61 NDC inpatient 1 UN 5.77 5.77 CIGNA 62308 [3081051] CIGNA 62308 [308105105] 4.57 percent of total billed charges 3.58 5.48 Technical (Hospital) Services ESCITALOPRAM 10 MG TABLET RX-33512 CDM 6370000100 HCPCS 250 RC 00904-6426-61 NDC inpatient 1 UN 5.77 5.77 CIGNA 62308 [3081051] CIGNA STATE OF WYOMING [308105107] 4.57 percent of total billed charges 3.58 5.48 Technical (Hospital) Services ESCITALOPRAM 10 MG TABLET RX-33512 CDM 6370000100 HCPCS 250 RC 00904-6426-61 NDC inpatient 1 UN 5.77 5.77 UNITED HEALTHCARE (COMMERCIAL) [3081199] UNITED HEALTHCARE 87726 [308119901] 3.58 percent of total billed charges 3.58 5.48 Technical (Hospital) Services ESCITALOPRAM 10 MG TABLET RX-33512 CDM 6370000100 HCPCS 250 RC 00904-6426-61 NDC inpatient 1 UN 5.77 5.77 HEALTHPARTNERS SX009 HEALTHPARTNERS 4.57 percent of total billed charges 3.58 5.48 Technical (Hospital) Services ESCITALOPRAM 10 MG TABLET RX-33512 CDM 6370000100 HCPCS 250 RC 00904-6426-61 NDC inpatient 1 UN 5.77 5.77 MEDICA (COMMERCIAL) 94265 [3081118] MEDICA CLAIMS [308111801] 5.19 percent of total billed charges 3.58 5.48 Technical (Hospital) Services ESCITALOPRAM 10 MG TABLET RX-33512 CDM 6370000100 HCPCS 250 RC 00904-6426-61 NDC inpatient 1 UN 5.77 5.77 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES HDHP [308136802] 4.57 percent of total billed charges 3.58 5.48 Technical (Hospital) Services ESCITALOPRAM 10 MG TABLET RX-33512 CDM 6370000100 HCPCS 250 RC 00904-6426-61 NDC inpatient 1 UN 5.77 5.77 BLUE CROSS BLUE SHIELD WELLMARK SB889 [3081026] BCBS WYOMING [308102603] 5.48 percent of total billed charges 3.58 5.48 Technical (Hospital) Services VALSARTAN 40 MG TABLET RX-33541 CDM 6370000100 HCPCS 250 RC 42291-0856-30 NDC outpatient 1 UN 5.76 5.76 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES HDHP [308136802] 4.61 percent of total billed charges 3.57 5.47 Technical (Hospital) Services VALSARTAN 40 MG TABLET RX-33541 CDM 6370000100 HCPCS 250 RC 42291-0856-30 NDC outpatient 1 UN 5.76 5.76 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES PPO [308136801] 4.61 percent of total billed charges 3.57 5.47 Technical (Hospital) Services VALSARTAN 40 MG TABLET RX-33541 CDM 6370000100 HCPCS 250 RC 42291-0856-30 NDC outpatient 1 UN 5.76 5.76 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES EPO [308136803] 4.61 percent of total billed charges 3.57 5.47 Technical (Hospital) Services VALSARTAN 40 MG TABLET RX-33541 CDM 6370000100 HCPCS 250 RC 42291-0856-30 NDC outpatient 1 UN 5.76 5.76 MEDICA (COMMERCIAL) 94265 [3081118] MEDICA CLAIMS [308111801] 5.18 percent of total billed charges 3.57 5.47 Technical (Hospital) Services VALSARTAN 40 MG TABLET RX-33541 CDM 6370000100 HCPCS 250 RC 42291-0856-30 NDC outpatient 1 UN 5.76 5.76 MULTIPLAN INC 34080 [3081285] MULTIPLAN INC [308128501] 5.47 percent of total billed charges 3.57 5.47 Technical (Hospital) Services VALSARTAN 40 MG TABLET RX-33541 CDM 6370000100 HCPCS 250 RC 42291-0856-30 NDC outpatient 1 UN 5.76 5.76 CIGNA 62308 [3081051] CIGNA 62308 [308105105] 4.61 percent of total billed charges 3.57 5.47 Technical (Hospital) Services VALSARTAN 40 MG TABLET RX-33541 CDM 6370000100 HCPCS 250 RC 42291-0856-30 NDC outpatient 1 UN 5.76 5.76 CIGNA 62308 [3081051] CIGNA STATE OF WYOMING [308105107] 4.61 percent of total billed charges 3.57 5.47 Technical (Hospital) Services VALSARTAN 40 MG TABLET RX-33541 CDM 6370000100 HCPCS 250 RC 42291-0856-30 NDC outpatient 1 UN 5.76 5.76 UNITED HEALTHCARE (COMMERCIAL) [3081199] UNITED HEALTHCARE 87726 [308119901] 3.57 percent of total billed charges 3.57 5.47 Technical (Hospital) Services VALSARTAN 40 MG TABLET RX-33541 CDM 6370000100 HCPCS 250 RC 42291-0856-30 NDC outpatient 1 UN 5.76 5.76 HEALTHPARTNERS SX009 HEALTHPARTNERS 4.61 percent of total billed charges 3.57 5.47 Technical (Hospital) Services VALSARTAN 40 MG TABLET RX-33541 CDM 6370000100 HCPCS 250 RC 42291-0856-30 NDC outpatient 1 UN 5.76 5.76 BLUE CROSS BLUE SHIELD WELLMARK SB889 [3081026] BCBS WYOMING [308102603] 5.47 percent of total billed charges 3.57 5.47 Technical (Hospital) Services VALSARTAN 40 MG TABLET RX-33541 CDM 6370000100 HCPCS 250 RC 42291-0856-30 NDC inpatient 1 UN 5.76 5.76 CIGNA 62308 [3081051] CIGNA 62308 [308105105] 4.56 percent of total billed charges 3.57 5.47 Technical (Hospital) Services VALSARTAN 40 MG TABLET RX-33541 CDM 6370000100 HCPCS 250 RC 42291-0856-30 NDC inpatient 1 UN 5.76 5.76 CIGNA 62308 [3081051] CIGNA STATE OF WYOMING [308105107] 4.56 percent of total billed charges 3.57 5.47 Technical (Hospital) Services VALSARTAN 40 MG TABLET RX-33541 CDM 6370000100 HCPCS 250 RC 42291-0856-30 NDC inpatient 1 UN 5.76 5.76 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES HDHP [308136802] 4.56 percent of total billed charges 3.57 5.47 Technical (Hospital) Services VALSARTAN 40 MG TABLET RX-33541 CDM 6370000100 HCPCS 250 RC 42291-0856-30 NDC inpatient 1 UN 5.76 5.76 UNITED HEALTHCARE (COMMERCIAL) [3081199] UNITED HEALTHCARE 87726 [308119901] 3.57 percent of total billed charges 3.57 5.47 Technical (Hospital) Services VALSARTAN 40 MG TABLET RX-33541 CDM 6370000100 HCPCS 250 RC 42291-0856-30 NDC inpatient 1 UN 5.76 5.76 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES EPO [308136803] 4.56 percent of total billed charges 3.57 5.47 Technical (Hospital) Services VALSARTAN 40 MG TABLET RX-33541 CDM 6370000100 HCPCS 250 RC 42291-0856-30 NDC inpatient 1 UN 5.76 5.76 BLUE CROSS BLUE SHIELD WELLMARK SB889 [3081026] BCBS WYOMING [308102603] 5.47 percent of total billed charges 3.57 5.47 Technical (Hospital) Services VALSARTAN 40 MG TABLET RX-33541 CDM 6370000100 HCPCS 250 RC 42291-0856-30 NDC inpatient 1 UN 5.76 5.76 MULTIPLAN INC 34080 [3081285] MULTIPLAN INC [308128501] 5.47 percent of total billed charges 3.57 5.47 Technical (Hospital) Services VALSARTAN 40 MG TABLET RX-33541 CDM 6370000100 HCPCS 250 RC 42291-0856-30 NDC inpatient 1 UN 5.76 5.76 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES PPO [308136801] 4.56 percent of total billed charges 3.57 5.47 Technical (Hospital) Services VALSARTAN 40 MG TABLET RX-33541 CDM 6370000100 HCPCS 250 RC 42291-0856-30 NDC inpatient 1 UN 5.76 5.76 MEDICA (COMMERCIAL) 94265 [3081118] MEDICA CLAIMS [308111801] 5.18 percent of total billed charges 3.57 5.47 Technical (Hospital) Services VALSARTAN 40 MG TABLET RX-33541 CDM 6370000100 HCPCS 250 RC 42291-0856-30 NDC inpatient 1 UN 5.76 5.76 HEALTHPARTNERS SX009 HEALTHPARTNERS 4.56 percent of total billed charges 3.57 5.47 Technical (Hospital) Services GEMFIBROZIL 600 MG TABLET RX-3378 CDM 6370000100 HCPCS 250 RC 69097-0821-03 NDC inpatient 1 UN 5.79 5.79 BLUE CROSS BLUE SHIELD WELLMARK SB889 [3081026] BCBS WYOMING [308102603] 5.5 percent of total billed charges 3.59 5.5 Technical (Hospital) Services GEMFIBROZIL 600 MG TABLET RX-3378 CDM 6370000100 HCPCS 250 RC 69097-0821-03 NDC inpatient 1 UN 5.79 5.79 UNITED HEALTHCARE (COMMERCIAL) [3081199] UNITED HEALTHCARE 87726 [308119901] 3.59 percent of total billed charges 3.59 5.5 Technical (Hospital) Services GEMFIBROZIL 600 MG TABLET RX-3378 CDM 6370000100 HCPCS 250 RC 69097-0821-03 NDC inpatient 1 UN 5.79 5.79 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES EPO [308136803] 4.58 percent of total billed charges 3.59 5.5 Technical (Hospital) Services GEMFIBROZIL 600 MG TABLET RX-3378 CDM 6370000100 HCPCS 250 RC 69097-0821-03 NDC inpatient 1 UN 5.79 5.79 CIGNA 62308 [3081051] CIGNA 62308 [308105105] 4.58 percent of total billed charges 3.59 5.5 Technical (Hospital) Services GEMFIBROZIL 600 MG TABLET RX-3378 CDM 6370000100 HCPCS 250 RC 69097-0821-03 NDC inpatient 1 UN 5.79 5.79 CIGNA 62308 [3081051] CIGNA STATE OF WYOMING [308105107] 4.58 percent of total billed charges 3.59 5.5 Technical (Hospital) Services GEMFIBROZIL 600 MG TABLET RX-3378 CDM 6370000100 HCPCS 250 RC 69097-0821-03 NDC inpatient 1 UN 5.79 5.79 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES HDHP [308136802] 4.58 percent of total billed charges 3.59 5.5 Technical (Hospital) Services GEMFIBROZIL 600 MG TABLET RX-3378 CDM 6370000100 HCPCS 250 RC 69097-0821-03 NDC inpatient 1 UN 5.79 5.79 MULTIPLAN INC 34080 [3081285] MULTIPLAN INC [308128501] 5.5 percent of total billed charges 3.59 5.5 Technical (Hospital) Services GEMFIBROZIL 600 MG TABLET RX-3378 CDM 6370000100 HCPCS 250 RC 69097-0821-03 NDC inpatient 1 UN 5.79 5.79 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES PPO [308136801] 4.58 percent of total billed charges 3.59 5.5 Technical (Hospital) Services GEMFIBROZIL 600 MG TABLET RX-3378 CDM 6370000100 HCPCS 250 RC 69097-0821-03 NDC inpatient 1 UN 5.79 5.79 MEDICA (COMMERCIAL) 94265 [3081118] MEDICA CLAIMS [308111801] 5.21 percent of total billed charges 3.59 5.5 Technical (Hospital) Services GEMFIBROZIL 600 MG TABLET RX-3378 CDM 6370000100 HCPCS 250 RC 69097-0821-03 NDC inpatient 1 UN 5.79 5.79 HEALTHPARTNERS SX009 HEALTHPARTNERS 4.58 percent of total billed charges 3.59 5.5 Technical (Hospital) Services GEMFIBROZIL 600 MG TABLET RX-3378 CDM 6370000100 HCPCS 250 RC 69097-0821-03 NDC outpatient 1 UN 5.79 5.79 HEALTHPARTNERS SX009 HEALTHPARTNERS 4.63 percent of total billed charges 3.59 5.5 Technical (Hospital) Services GEMFIBROZIL 600 MG TABLET RX-3378 CDM 6370000100 HCPCS 250 RC 69097-0821-03 NDC outpatient 1 UN 5.79 5.79 BLUE CROSS BLUE SHIELD WELLMARK SB889 [3081026] BCBS WYOMING [308102603] 5.5 percent of total billed charges 3.59 5.5 Technical (Hospital) Services GEMFIBROZIL 600 MG TABLET RX-3378 CDM 6370000100 HCPCS 250 RC 69097-0821-03 NDC outpatient 1 UN 5.79 5.79 CIGNA 62308 [3081051] CIGNA 62308 [308105105] 4.63 percent of total billed charges 3.59 5.5 Technical (Hospital) Services GEMFIBROZIL 600 MG TABLET RX-3378 CDM 6370000100 HCPCS 250 RC 69097-0821-03 NDC outpatient 1 UN 5.79 5.79 CIGNA 62308 [3081051] CIGNA STATE OF WYOMING [308105107] 4.63 percent of total billed charges 3.59 5.5 Technical (Hospital) Services GEMFIBROZIL 600 MG TABLET RX-3378 CDM 6370000100 HCPCS 250 RC 69097-0821-03 NDC outpatient 1 UN 5.79 5.79 MULTIPLAN INC 34080 [3081285] MULTIPLAN INC [308128501] 5.5 percent of total billed charges 3.59 5.5 Technical (Hospital) Services GEMFIBROZIL 600 MG TABLET RX-3378 CDM 6370000100 HCPCS 250 RC 69097-0821-03 NDC outpatient 1 UN 5.79 5.79 MEDICA (COMMERCIAL) 94265 [3081118] MEDICA CLAIMS [308111801] 5.21 percent of total billed charges 3.59 5.5 Technical (Hospital) Services GEMFIBROZIL 600 MG TABLET RX-3378 CDM 6370000100 HCPCS 250 RC 69097-0821-03 NDC outpatient 1 UN 5.79 5.79 UNITED HEALTHCARE (COMMERCIAL) [3081199] UNITED HEALTHCARE 87726 [308119901] 3.59 percent of total billed charges 3.59 5.5 Technical (Hospital) Services GEMFIBROZIL 600 MG TABLET RX-3378 CDM 6370000100 HCPCS 250 RC 69097-0821-03 NDC outpatient 1 UN 5.79 5.79 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES PPO [308136801] 4.63 percent of total billed charges 3.59 5.5 Technical (Hospital) Services GEMFIBROZIL 600 MG TABLET RX-3378 CDM 6370000100 HCPCS 250 RC 69097-0821-03 NDC outpatient 1 UN 5.79 5.79 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES EPO [308136803] 4.63 percent of total billed charges 3.59 5.5 Technical (Hospital) Services GEMFIBROZIL 600 MG TABLET RX-3378 CDM 6370000100 HCPCS 250 RC 69097-0821-03 NDC outpatient 1 UN 5.79 5.79 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES HDHP [308136802] 4.63 percent of total billed charges 3.59 5.5 Technical (Hospital) Services EZETIMIBE 10 MG TABLET RX-34153 CDM 6370000100 HCPCS 250 RC 50228-0379-30 NDC outpatient 1 UN 5.9 5.9 BLUE CROSS BLUE SHIELD WELLMARK SB889 [3081026] BCBS WYOMING [308102603] 5.61 percent of total billed charges 3.66 5.61 Technical (Hospital) Services EZETIMIBE 10 MG TABLET RX-34153 CDM 6370000100 HCPCS 250 RC 50228-0379-30 NDC outpatient 1 UN 5.9 5.9 HEALTHPARTNERS SX009 HEALTHPARTNERS 4.72 percent of total billed charges 3.66 5.61 Technical (Hospital) Services EZETIMIBE 10 MG TABLET RX-34153 CDM 6370000100 HCPCS 250 RC 50228-0379-30 NDC outpatient 1 UN 5.9 5.9 UNITED HEALTHCARE (COMMERCIAL) [3081199] UNITED HEALTHCARE 87726 [308119901] 3.66 percent of total billed charges 3.66 5.61 Technical (Hospital) Services EZETIMIBE 10 MG TABLET RX-34153 CDM 6370000100 HCPCS 250 RC 50228-0379-30 NDC outpatient 1 UN 5.9 5.9 MULTIPLAN INC 34080 [3081285] MULTIPLAN INC [308128501] 5.61 percent of total billed charges 3.66 5.61 Technical (Hospital) Services EZETIMIBE 10 MG TABLET RX-34153 CDM 6370000100 HCPCS 250 RC 50228-0379-30 NDC outpatient 1 UN 5.9 5.9 CIGNA 62308 [3081051] CIGNA 62308 [308105105] 4.72 percent of total billed charges 3.66 5.61 Technical (Hospital) Services EZETIMIBE 10 MG TABLET RX-34153 CDM 6370000100 HCPCS 250 RC 50228-0379-30 NDC outpatient 1 UN 5.9 5.9 CIGNA 62308 [3081051] CIGNA STATE OF WYOMING [308105107] 4.72 percent of total billed charges 3.66 5.61 Technical (Hospital) Services EZETIMIBE 10 MG TABLET RX-34153 CDM 6370000100 HCPCS 250 RC 50228-0379-30 NDC outpatient 1 UN 5.9 5.9 MEDICA (COMMERCIAL) 94265 [3081118] MEDICA CLAIMS [308111801] 5.31 percent of total billed charges 3.66 5.61 Technical (Hospital) Services EZETIMIBE 10 MG TABLET RX-34153 CDM 6370000100 HCPCS 250 RC 50228-0379-30 NDC outpatient 1 UN 5.9 5.9 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES HDHP [308136802] 4.72 percent of total billed charges 3.66 5.61 Technical (Hospital) Services EZETIMIBE 10 MG TABLET RX-34153 CDM 6370000100 HCPCS 250 RC 50228-0379-30 NDC outpatient 1 UN 5.9 5.9 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES EPO [308136803] 4.72 percent of total billed charges 3.66 5.61 Technical (Hospital) Services EZETIMIBE 10 MG TABLET RX-34153 CDM 6370000100 HCPCS 250 RC 50228-0379-30 NDC outpatient 1 UN 5.9 5.9 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES PPO [308136801] 4.72 percent of total billed charges 3.66 5.61 Technical (Hospital) Services EZETIMIBE 10 MG TABLET RX-34153 CDM 6370000100 HCPCS 250 RC 50228-0379-30 NDC inpatient 1 UN 5.9 5.9 BLUE CROSS BLUE SHIELD WELLMARK SB889 [3081026] BCBS WYOMING [308102603] 5.61 percent of total billed charges 3.66 5.61 Technical (Hospital) Services EZETIMIBE 10 MG TABLET RX-34153 CDM 6370000100 HCPCS 250 RC 50228-0379-30 NDC inpatient 1 UN 5.9 5.9 UNITED HEALTHCARE (COMMERCIAL) [3081199] UNITED HEALTHCARE 87726 [308119901] 3.66 percent of total billed charges 3.66 5.61 Technical (Hospital) Services EZETIMIBE 10 MG TABLET RX-34153 CDM 6370000100 HCPCS 250 RC 50228-0379-30 NDC inpatient 1 UN 5.9 5.9 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES EPO [308136803] 4.67 percent of total billed charges 3.66 5.61 Technical (Hospital) Services EZETIMIBE 10 MG TABLET RX-34153 CDM 6370000100 HCPCS 250 RC 50228-0379-30 NDC inpatient 1 UN 5.9 5.9 CIGNA 62308 [3081051] CIGNA 62308 [308105105] 4.67 percent of total billed charges 3.66 5.61 Technical (Hospital) Services EZETIMIBE 10 MG TABLET RX-34153 CDM 6370000100 HCPCS 250 RC 50228-0379-30 NDC inpatient 1 UN 5.9 5.9 CIGNA 62308 [3081051] CIGNA STATE OF WYOMING [308105107] 4.67 percent of total billed charges 3.66 5.61 Technical (Hospital) Services EZETIMIBE 10 MG TABLET RX-34153 CDM 6370000100 HCPCS 250 RC 50228-0379-30 NDC inpatient 1 UN 5.9 5.9 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES HDHP [308136802] 4.67 percent of total billed charges 3.66 5.61 Technical (Hospital) Services EZETIMIBE 10 MG TABLET RX-34153 CDM 6370000100 HCPCS 250 RC 50228-0379-30 NDC inpatient 1 UN 5.9 5.9 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES PPO [308136801] 4.67 percent of total billed charges 3.66 5.61 Technical (Hospital) Services EZETIMIBE 10 MG TABLET RX-34153 CDM 6370000100 HCPCS 250 RC 50228-0379-30 NDC inpatient 1 UN 5.9 5.9 MEDICA (COMMERCIAL) 94265 [3081118] MEDICA CLAIMS [308111801] 5.31 percent of total billed charges 3.66 5.61 Technical (Hospital) Services EZETIMIBE 10 MG TABLET RX-34153 CDM 6370000100 HCPCS 250 RC 50228-0379-30 NDC inpatient 1 UN 5.9 5.9 HEALTHPARTNERS SX009 HEALTHPARTNERS 4.67 percent of total billed charges 3.66 5.61 Technical (Hospital) Services EZETIMIBE 10 MG TABLET RX-34153 CDM 6370000100 HCPCS 250 RC 50228-0379-30 NDC inpatient 1 UN 5.9 5.9 MULTIPLAN INC 34080 [3081285] MULTIPLAN INC [308128501] 5.61 percent of total billed charges 3.66 5.61 Technical (Hospital) Services GENTIAN VIOLET 1 % TOPICAL SOLUTION RX-3430 CDM 6370000100 HCPCS 250 RC 00395-1003-92 NDC outpatient 0.5 ML 5.68 5.68 HEALTHPARTNERS SX009 HEALTHPARTNERS 4.54 percent of total billed charges 3.52 5.4 Technical (Hospital) Services GENTIAN VIOLET 1 % TOPICAL SOLUTION RX-3430 CDM 6370000100 HCPCS 250 RC 00395-1003-92 NDC outpatient 0.5 ML 5.68 5.68 BLUE CROSS BLUE SHIELD WELLMARK SB889 [3081026] BCBS WYOMING [308102603] 5.4 percent of total billed charges 3.52 5.4 Technical (Hospital) Services GENTIAN VIOLET 1 % TOPICAL SOLUTION RX-3430 CDM 6370000100 HCPCS 250 RC 00395-1003-92 NDC outpatient 0.5 ML 5.68 5.68 MEDICA (COMMERCIAL) 94265 [3081118] MEDICA CLAIMS [308111801] 5.11 percent of total billed charges 3.52 5.4 Technical (Hospital) Services GENTIAN VIOLET 1 % TOPICAL SOLUTION RX-3430 CDM 6370000100 HCPCS 250 RC 00395-1003-92 NDC outpatient 0.5 ML 5.68 5.68 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES HDHP [308136802] 4.54 percent of total billed charges 3.52 5.4 Technical (Hospital) Services GENTIAN VIOLET 1 % TOPICAL SOLUTION RX-3430 CDM 6370000100 HCPCS 250 RC 00395-1003-92 NDC outpatient 0.5 ML 5.68 5.68 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES EPO [308136803] 4.54 percent of total billed charges 3.52 5.4 Technical (Hospital) Services GENTIAN VIOLET 1 % TOPICAL SOLUTION RX-3430 CDM 6370000100 HCPCS 250 RC 00395-1003-92 NDC outpatient 0.5 ML 5.68 5.68 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES PPO [308136801] 4.54 percent of total billed charges 3.52 5.4 Technical (Hospital) Services GENTIAN VIOLET 1 % TOPICAL SOLUTION RX-3430 CDM 6370000100 HCPCS 250 RC 00395-1003-92 NDC outpatient 0.5 ML 5.68 5.68 MULTIPLAN INC 34080 [3081285] MULTIPLAN INC [308128501] 5.4 percent of total billed charges 3.52 5.4 Technical (Hospital) Services GENTIAN VIOLET 1 % TOPICAL SOLUTION RX-3430 CDM 6370000100 HCPCS 250 RC 00395-1003-92 NDC outpatient 0.5 ML 5.68 5.68 CIGNA 62308 [3081051] CIGNA 62308 [308105105] 4.54 percent of total billed charges 3.52 5.4 Technical (Hospital) Services GENTIAN VIOLET 1 % TOPICAL SOLUTION RX-3430 CDM 6370000100 HCPCS 250 RC 00395-1003-92 NDC outpatient 0.5 ML 5.68 5.68 CIGNA 62308 [3081051] CIGNA STATE OF WYOMING [308105107] 4.54 percent of total billed charges 3.52 5.4 Technical (Hospital) Services GENTIAN VIOLET 1 % TOPICAL SOLUTION RX-3430 CDM 6370000100 HCPCS 250 RC 00395-1003-92 NDC outpatient 0.5 ML 5.68 5.68 UNITED HEALTHCARE (COMMERCIAL) [3081199] UNITED HEALTHCARE 87726 [308119901] 3.52 percent of total billed charges 3.52 5.4 Technical (Hospital) Services GENTIAN VIOLET 1 % TOPICAL SOLUTION RX-3430 CDM 6370000100 HCPCS 250 RC 00395-1003-92 NDC inpatient 0.5 ML 5.68 5.68 BLUE CROSS BLUE SHIELD WELLMARK SB889 [3081026] BCBS WYOMING [308102603] 5.4 percent of total billed charges 3.52 5.4 Technical (Hospital) Services GENTIAN VIOLET 1 % TOPICAL SOLUTION RX-3430 CDM 6370000100 HCPCS 250 RC 00395-1003-92 NDC inpatient 0.5 ML 5.68 5.68 UNITED HEALTHCARE (COMMERCIAL) [3081199] UNITED HEALTHCARE 87726 [308119901] 3.52 percent of total billed charges 3.52 5.4 Technical (Hospital) Services GENTIAN VIOLET 1 % TOPICAL SOLUTION RX-3430 CDM 6370000100 HCPCS 250 RC 00395-1003-92 NDC inpatient 0.5 ML 5.68 5.68 MEDICA (COMMERCIAL) 94265 [3081118] MEDICA CLAIMS [308111801] 5.11 percent of total billed charges 3.52 5.4 Technical (Hospital) Services GENTIAN VIOLET 1 % TOPICAL SOLUTION RX-3430 CDM 6370000100 HCPCS 250 RC 00395-1003-92 NDC inpatient 0.5 ML 5.68 5.68 HEALTHPARTNERS SX009 HEALTHPARTNERS 4.5 percent of total billed charges 3.52 5.4 Technical (Hospital) Services GENTIAN VIOLET 1 % TOPICAL SOLUTION RX-3430 CDM 6370000100 HCPCS 250 RC 00395-1003-92 NDC inpatient 0.5 ML 5.68 5.68 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES EPO [308136803] 4.5 percent of total billed charges 3.52 5.4 Technical (Hospital) Services GENTIAN VIOLET 1 % TOPICAL SOLUTION RX-3430 CDM 6370000100 HCPCS 250 RC 00395-1003-92 NDC inpatient 0.5 ML 5.68 5.68 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES PPO [308136801] 4.5 percent of total billed charges 3.52 5.4 Technical (Hospital) Services GENTIAN VIOLET 1 % TOPICAL SOLUTION RX-3430 CDM 6370000100 HCPCS 250 RC 00395-1003-92 NDC inpatient 0.5 ML 5.68 5.68 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES HDHP [308136802] 4.5 percent of total billed charges 3.52 5.4 Technical (Hospital) Services GENTIAN VIOLET 1 % TOPICAL SOLUTION RX-3430 CDM 6370000100 HCPCS 250 RC 00395-1003-92 NDC inpatient 0.5 ML 5.68 5.68 CIGNA 62308 [3081051] CIGNA 62308 [308105105] 4.5 percent of total billed charges 3.52 5.4 Technical (Hospital) Services GENTIAN VIOLET 1 % TOPICAL SOLUTION RX-3430 CDM 6370000100 HCPCS 250 RC 00395-1003-92 NDC inpatient 0.5 ML 5.68 5.68 CIGNA 62308 [3081051] CIGNA STATE OF WYOMING [308105107] 4.5 percent of total billed charges 3.52 5.4 Technical (Hospital) Services GENTIAN VIOLET 1 % TOPICAL SOLUTION RX-3430 CDM 6370000100 HCPCS 250 RC 00395-1003-92 NDC inpatient 0.5 ML 5.68 5.68 MULTIPLAN INC 34080 [3081285] MULTIPLAN INC [308128501] 5.4 percent of total billed charges 3.52 5.4 Technical (Hospital) Services GENTIAN VIOLET 2 % TOPICAL SOLUTION RX-3431 CDM 6370000100 HCPCS 250 RC 00395-1005-92 NDC outpatient 1 ML 5.85 5.85 MULTIPLAN INC 34080 [3081285] MULTIPLAN INC [308128501] 5.56 percent of total billed charges 3.63 5.56 Technical (Hospital) Services GENTIAN VIOLET 2 % TOPICAL SOLUTION RX-3431 CDM 6370000100 HCPCS 250 RC 00395-1005-92 NDC outpatient 1 ML 5.85 5.85 UNITED HEALTHCARE (COMMERCIAL) [3081199] UNITED HEALTHCARE 87726 [308119901] 3.63 percent of total billed charges 3.63 5.56 Technical (Hospital) Services GENTIAN VIOLET 2 % TOPICAL SOLUTION RX-3431 CDM 6370000100 HCPCS 250 RC 00395-1005-92 NDC outpatient 1 ML 5.85 5.85 MEDICA (COMMERCIAL) 94265 [3081118] MEDICA CLAIMS [308111801] 5.27 percent of total billed charges 3.63 5.56 Technical (Hospital) Services GENTIAN VIOLET 2 % TOPICAL SOLUTION RX-3431 CDM 6370000100 HCPCS 250 RC 00395-1005-92 NDC outpatient 1 ML 5.85 5.85 CIGNA 62308 [3081051] CIGNA 62308 [308105105] 4.68 percent of total billed charges 3.63 5.56 Technical (Hospital) Services GENTIAN VIOLET 2 % TOPICAL SOLUTION RX-3431 CDM 6370000100 HCPCS 250 RC 00395-1005-92 NDC outpatient 1 ML 5.85 5.85 CIGNA 62308 [3081051] CIGNA STATE OF WYOMING [308105107] 4.68 percent of total billed charges 3.63 5.56 Technical (Hospital) Services GENTIAN VIOLET 2 % TOPICAL SOLUTION RX-3431 CDM 6370000100 HCPCS 250 RC 00395-1005-92 NDC inpatient 1 ML 5.85 5.85 BLUE CROSS BLUE SHIELD WELLMARK SB889 [3081026] BCBS WYOMING [308102603] 5.56 percent of total billed charges 3.63 5.56 Technical (Hospital) Services GENTIAN VIOLET 2 % TOPICAL SOLUTION RX-3431 CDM 6370000100 HCPCS 250 RC 00395-1005-92 NDC outpatient 1 ML 5.85 5.85 BLUE CROSS BLUE SHIELD WELLMARK SB889 [3081026] BCBS WYOMING [308102603] 5.56 percent of total billed charges 3.63 5.56 Technical (Hospital) Services GENTIAN VIOLET 2 % TOPICAL SOLUTION RX-3431 CDM 6370000100 HCPCS 250 RC 00395-1005-92 NDC outpatient 1 ML 5.85 5.85 HEALTHPARTNERS SX009 HEALTHPARTNERS 4.68 percent of total billed charges 3.63 5.56 Technical (Hospital) Services GENTIAN VIOLET 2 % TOPICAL SOLUTION RX-3431 CDM 6370000100 HCPCS 250 RC 00395-1005-92 NDC outpatient 1 ML 5.85 5.85 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES PPO [308136801] 4.68 percent of total billed charges 3.63 5.56 Technical (Hospital) Services GENTIAN VIOLET 2 % TOPICAL SOLUTION RX-3431 CDM 6370000100 HCPCS 250 RC 00395-1005-92 NDC outpatient 1 ML 5.85 5.85 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES EPO [308136803] 4.68 percent of total billed charges 3.63 5.56 Technical (Hospital) Services GENTIAN VIOLET 2 % TOPICAL SOLUTION RX-3431 CDM 6370000100 HCPCS 250 RC 00395-1005-92 NDC outpatient 1 ML 5.85 5.85 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES HDHP [308136802] 4.68 percent of total billed charges 3.63 5.56 Technical (Hospital) Services GENTIAN VIOLET 2 % TOPICAL SOLUTION RX-3431 CDM 6370000100 HCPCS 250 RC 00395-1005-92 NDC inpatient 1 ML 5.85 5.85 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES HDHP [308136802] 4.63 percent of total billed charges 3.63 5.56 Technical (Hospital) Services GENTIAN VIOLET 2 % TOPICAL SOLUTION RX-3431 CDM 6370000100 HCPCS 250 RC 00395-1005-92 NDC inpatient 1 ML 5.85 5.85 HEALTHPARTNERS SX009 HEALTHPARTNERS 4.63 percent of total billed charges 3.63 5.56 Technical (Hospital) Services GENTIAN VIOLET 2 % TOPICAL SOLUTION RX-3431 CDM 6370000100 HCPCS 250 RC 00395-1005-92 NDC inpatient 1 ML 5.85 5.85 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES EPO [308136803] 4.63 percent of total billed charges 3.63 5.56 Technical (Hospital) Services GENTIAN VIOLET 2 % TOPICAL SOLUTION RX-3431 CDM 6370000100 HCPCS 250 RC 00395-1005-92 NDC inpatient 1 ML 5.85 5.85 CIGNA 62308 [3081051] CIGNA 62308 [308105105] 4.63 percent of total billed charges 3.63 5.56 Technical (Hospital) Services GENTIAN VIOLET 2 % TOPICAL SOLUTION RX-3431 CDM 6370000100 HCPCS 250 RC 00395-1005-92 NDC inpatient 1 ML 5.85 5.85 CIGNA 62308 [3081051] CIGNA STATE OF WYOMING [308105107] 4.63 percent of total billed charges 3.63 5.56 Technical (Hospital) Services GENTIAN VIOLET 2 % TOPICAL SOLUTION RX-3431 CDM 6370000100 HCPCS 250 RC 00395-1005-92 NDC inpatient 1 ML 5.85 5.85 UNITED HEALTHCARE (COMMERCIAL) [3081199] UNITED HEALTHCARE 87726 [308119901] 3.63 percent of total billed charges 3.63 5.56 Technical (Hospital) Services GENTIAN VIOLET 2 % TOPICAL SOLUTION RX-3431 CDM 6370000100 HCPCS 250 RC 00395-1005-92 NDC inpatient 1 ML 5.85 5.85 MULTIPLAN INC 34080 [3081285] MULTIPLAN INC [308128501] 5.56 percent of total billed charges 3.63 5.56 Technical (Hospital) Services GENTIAN VIOLET 2 % TOPICAL SOLUTION RX-3431 CDM 6370000100 HCPCS 250 RC 00395-1005-92 NDC inpatient 1 ML 5.85 5.85 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES PPO [308136801] 4.63 percent of total billed charges 3.63 5.56 Technical (Hospital) Services GENTIAN VIOLET 2 % TOPICAL SOLUTION RX-3431 CDM 6370000100 HCPCS 250 RC 00395-1005-92 NDC inpatient 1 ML 5.85 5.85 MEDICA (COMMERCIAL) 94265 [3081118] MEDICA CLAIMS [308111801] 5.27 percent of total billed charges 3.63 5.56 Technical (Hospital) Services ARIPIPRAZOLE 10 MG TABLET RX-34369 CDM 6370000100 HCPCS 250 RC 60505-2674-03 NDC inpatient 1 UN 7.11 7.11 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES EPO [308136803] 5.63 percent of total billed charges 4.41 6.75 Technical (Hospital) Services ARIPIPRAZOLE 10 MG TABLET RX-34369 CDM 6370000100 HCPCS 250 RC 60505-2674-03 NDC inpatient 1 UN 7.11 7.11 UNITED HEALTHCARE (COMMERCIAL) [3081199] UNITED HEALTHCARE 87726 [308119901] 4.41 percent of total billed charges 4.41 6.75 Technical (Hospital) Services ARIPIPRAZOLE 10 MG TABLET RX-34369 CDM 6370000100 HCPCS 250 RC 60505-2674-03 NDC inpatient 1 UN 7.11 7.11 CIGNA 62308 [3081051] CIGNA 62308 [308105105] 5.63 percent of total billed charges 4.41 6.75 Technical (Hospital) Services ARIPIPRAZOLE 10 MG TABLET RX-34369 CDM 6370000100 HCPCS 250 RC 60505-2674-03 NDC inpatient 1 UN 7.11 7.11 CIGNA 62308 [3081051] CIGNA STATE OF WYOMING [308105107] 5.63 percent of total billed charges 4.41 6.75 Technical (Hospital) Services ARIPIPRAZOLE 10 MG TABLET RX-34369 CDM 6370000100 HCPCS 250 RC 60505-2674-03 NDC inpatient 1 UN 7.11 7.11 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES HDHP [308136802] 5.63 percent of total billed charges 4.41 6.75 Technical (Hospital) Services ARIPIPRAZOLE 10 MG TABLET RX-34369 CDM 6370000100 HCPCS 250 RC 60505-2674-03 NDC inpatient 1 UN 7.11 7.11 BLUE CROSS BLUE SHIELD WELLMARK SB889 [3081026] BCBS WYOMING [308102603] 6.75 percent of total billed charges 4.41 6.75 Technical (Hospital) Services ARIPIPRAZOLE 10 MG TABLET RX-34369 CDM 6370000100 HCPCS 250 RC 60505-2674-03 NDC inpatient 1 UN 7.11 7.11 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES PPO [308136801] 5.63 percent of total billed charges 4.41 6.75 Technical (Hospital) Services ARIPIPRAZOLE 10 MG TABLET RX-34369 CDM 6370000100 HCPCS 250 RC 60505-2674-03 NDC inpatient 1 UN 7.11 7.11 HEALTHPARTNERS SX009 HEALTHPARTNERS 5.63 percent of total billed charges 4.41 6.75 Technical (Hospital) Services ARIPIPRAZOLE 10 MG TABLET RX-34369 CDM 6370000100 HCPCS 250 RC 60505-2674-03 NDC inpatient 1 UN 7.11 7.11 MEDICA (COMMERCIAL) 94265 [3081118] MEDICA CLAIMS [308111801] 6.4 percent of total billed charges 4.41 6.75 Technical (Hospital) Services ARIPIPRAZOLE 10 MG TABLET RX-34369 CDM 6370000100 HCPCS 250 RC 60505-2674-03 NDC inpatient 1 UN 7.11 7.11 MULTIPLAN INC 34080 [3081285] MULTIPLAN INC [308128501] 6.75 percent of total billed charges 4.41 6.75 Technical (Hospital) Services ARIPIPRAZOLE 10 MG TABLET RX-34369 CDM 6370000100 HCPCS 250 RC 60505-2674-03 NDC outpatient 1 UN 7.11 7.11 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES PPO [308136801] 5.69 percent of total billed charges 4.41 6.75 Technical (Hospital) Services ARIPIPRAZOLE 10 MG TABLET RX-34369 CDM 6370000100 HCPCS 250 RC 60505-2674-03 NDC outpatient 1 UN 7.11 7.11 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES EPO [308136803] 5.69 percent of total billed charges 4.41 6.75 Technical (Hospital) Services ARIPIPRAZOLE 10 MG TABLET RX-34369 CDM 6370000100 HCPCS 250 RC 60505-2674-03 NDC outpatient 1 UN 7.11 7.11 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES HDHP [308136802] 5.69 percent of total billed charges 4.41 6.75 Technical (Hospital) Services ARIPIPRAZOLE 10 MG TABLET RX-34369 CDM 6370000100 HCPCS 250 RC 60505-2674-03 NDC outpatient 1 UN 7.11 7.11 HEALTHPARTNERS SX009 HEALTHPARTNERS 5.69 percent of total billed charges 4.41 6.75 Technical (Hospital) Services ARIPIPRAZOLE 10 MG TABLET RX-34369 CDM 6370000100 HCPCS 250 RC 60505-2674-03 NDC outpatient 1 UN 7.11 7.11 UNITED HEALTHCARE (COMMERCIAL) [3081199] UNITED HEALTHCARE 87726 [308119901] 4.41 percent of total billed charges 4.41 6.75 Technical (Hospital) Services ARIPIPRAZOLE 10 MG TABLET RX-34369 CDM 6370000100 HCPCS 250 RC 60505-2674-03 NDC outpatient 1 UN 7.11 7.11 CIGNA 62308 [3081051] CIGNA STATE OF WYOMING [308105107] 5.69 percent of total billed charges 4.41 6.75 Technical (Hospital) Services ARIPIPRAZOLE 10 MG TABLET RX-34369 CDM 6370000100 HCPCS 250 RC 60505-2674-03 NDC outpatient 1 UN 7.11 7.11 MEDICA (COMMERCIAL) 94265 [3081118] MEDICA CLAIMS [308111801] 6.4 percent of total billed charges 4.41 6.75 Technical (Hospital) Services ARIPIPRAZOLE 10 MG TABLET RX-34369 CDM 6370000100 HCPCS 250 RC 60505-2674-03 NDC outpatient 1 UN 7.11 7.11 CIGNA 62308 [3081051] CIGNA 62308 [308105105] 5.69 percent of total billed charges 4.41 6.75 Technical (Hospital) Services ARIPIPRAZOLE 10 MG TABLET RX-34369 CDM 6370000100 HCPCS 250 RC 60505-2674-03 NDC outpatient 1 UN 7.11 7.11 MULTIPLAN INC 34080 [3081285] MULTIPLAN INC [308128501] 6.75 percent of total billed charges 4.41 6.75 Technical (Hospital) Services ARIPIPRAZOLE 10 MG TABLET RX-34369 CDM 6370000100 HCPCS 250 RC 60505-2674-03 NDC outpatient 1 UN 7.11 7.11 BLUE CROSS BLUE SHIELD WELLMARK SB889 [3081026] BCBS WYOMING [308102603] 6.75 percent of total billed charges 4.41 6.75 Technical (Hospital) Services HYDROCODONE 5 MG-ACETAMINOPHEN 325 MG TABLET RX-34505 CDM 6370000100 HCPCS 250 RC 53746-0109-05 NDC outpatient 1 UN 5.82 5.82 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES EPO [308136803] 4.66 percent of total billed charges 3.61 5.53 Technical (Hospital) Services HYDROCODONE 5 MG-ACETAMINOPHEN 325 MG TABLET RX-34505 CDM 6370000100 HCPCS 250 RC 53746-0109-05 NDC outpatient 1 UN 5.82 5.82 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES PPO [308136801] 4.66 percent of total billed charges 3.61 5.53 Technical (Hospital) Services HYDROCODONE 5 MG-ACETAMINOPHEN 325 MG TABLET RX-34505 CDM 6370000100 HCPCS 250 RC 53746-0109-05 NDC outpatient 1 UN 5.82 5.82 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES HDHP [308136802] 4.66 percent of total billed charges 3.61 5.53 Technical (Hospital) Services HYDROCODONE 5 MG-ACETAMINOPHEN 325 MG TABLET RX-34505 CDM 6370000100 HCPCS 250 RC 53746-0109-05 NDC outpatient 1 UN 5.82 5.82 BLUE CROSS BLUE SHIELD WELLMARK SB889 [3081026] BCBS WYOMING [308102603] 5.53 percent of total billed charges 3.61 5.53 Technical (Hospital) Services HYDROCODONE 5 MG-ACETAMINOPHEN 325 MG TABLET RX-34505 CDM 6370000100 HCPCS 250 RC 53746-0109-05 NDC outpatient 1 UN 5.82 5.82 UNITED HEALTHCARE (COMMERCIAL) [3081199] UNITED HEALTHCARE 87726 [308119901] 3.61 percent of total billed charges 3.61 5.53 Technical (Hospital) Services HYDROCODONE 5 MG-ACETAMINOPHEN 325 MG TABLET RX-34505 CDM 6370000100 HCPCS 250 RC 53746-0109-05 NDC outpatient 1 UN 5.82 5.82 HEALTHPARTNERS SX009 HEALTHPARTNERS 4.66 percent of total billed charges 3.61 5.53 Technical (Hospital) Services HYDROCODONE 5 MG-ACETAMINOPHEN 325 MG TABLET RX-34505 CDM 6370000100 HCPCS 250 RC 53746-0109-05 NDC outpatient 1 UN 5.82 5.82 MEDICA (COMMERCIAL) 94265 [3081118] MEDICA CLAIMS [308111801] 5.24 percent of total billed charges 3.61 5.53 Technical (Hospital) Services HYDROCODONE 5 MG-ACETAMINOPHEN 325 MG TABLET RX-34505 CDM 6370000100 HCPCS 250 RC 53746-0109-05 NDC outpatient 1 UN 5.82 5.82 CIGNA 62308 [3081051] CIGNA 62308 [308105105] 4.66 percent of total billed charges 3.61 5.53 Technical (Hospital) Services HYDROCODONE 5 MG-ACETAMINOPHEN 325 MG TABLET RX-34505 CDM 6370000100 HCPCS 250 RC 53746-0109-05 NDC outpatient 1 UN 5.82 5.82 CIGNA 62308 [3081051] CIGNA STATE OF WYOMING [308105107] 4.66 percent of total billed charges 3.61 5.53 Technical (Hospital) Services HYDROCODONE 5 MG-ACETAMINOPHEN 325 MG TABLET RX-34505 CDM 6370000100 HCPCS 250 RC 53746-0109-05 NDC outpatient 1 UN 5.82 5.82 MULTIPLAN INC 34080 [3081285] MULTIPLAN INC [308128501] 5.53 percent of total billed charges 3.61 5.53 Technical (Hospital) Services HYDROCODONE 5 MG-ACETAMINOPHEN 325 MG TABLET RX-34505 CDM 6370000100 HCPCS 250 RC 53746-0109-05 NDC inpatient 1 UN 5.82 5.82 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES PPO [308136801] 4.61 percent of total billed charges 3.61 5.53 Technical (Hospital) Services HYDROCODONE 5 MG-ACETAMINOPHEN 325 MG TABLET RX-34505 CDM 6370000100 HCPCS 250 RC 53746-0109-05 NDC inpatient 1 UN 5.82 5.82 MULTIPLAN INC 34080 [3081285] MULTIPLAN INC [308128501] 5.53 percent of total billed charges 3.61 5.53 Technical (Hospital) Services HYDROCODONE 5 MG-ACETAMINOPHEN 325 MG TABLET RX-34505 CDM 6370000100 HCPCS 250 RC 53746-0109-05 NDC inpatient 1 UN 5.82 5.82 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES HDHP [308136802] 4.61 percent of total billed charges 3.61 5.53 Technical (Hospital) Services HYDROCODONE 5 MG-ACETAMINOPHEN 325 MG TABLET RX-34505 CDM 6370000100 HCPCS 250 RC 53746-0109-05 NDC inpatient 1 UN 5.82 5.82 MEDICA (COMMERCIAL) 94265 [3081118] MEDICA CLAIMS [308111801] 5.24 percent of total billed charges 3.61 5.53 Technical (Hospital) Services HYDROCODONE 5 MG-ACETAMINOPHEN 325 MG TABLET RX-34505 CDM 6370000100 HCPCS 250 RC 53746-0109-05 NDC inpatient 1 UN 5.82 5.82 HEALTHPARTNERS SX009 HEALTHPARTNERS 4.61 percent of total billed charges 3.61 5.53 Technical (Hospital) Services HYDROCODONE 5 MG-ACETAMINOPHEN 325 MG TABLET RX-34505 CDM 6370000100 HCPCS 250 RC 53746-0109-05 NDC inpatient 1 UN 5.82 5.82 CIGNA 62308 [3081051] CIGNA 62308 [308105105] 4.61 percent of total billed charges 3.61 5.53 Technical (Hospital) Services HYDROCODONE 5 MG-ACETAMINOPHEN 325 MG TABLET RX-34505 CDM 6370000100 HCPCS 250 RC 53746-0109-05 NDC inpatient 1 UN 5.82 5.82 CIGNA 62308 [3081051] CIGNA STATE OF WYOMING [308105107] 4.61 percent of total billed charges 3.61 5.53 Technical (Hospital) Services HYDROCODONE 5 MG-ACETAMINOPHEN 325 MG TABLET RX-34505 CDM 6370000100 HCPCS 250 RC 53746-0109-05 NDC inpatient 1 UN 5.82 5.82 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES EPO [308136803] 4.61 percent of total billed charges 3.61 5.53 Technical (Hospital) Services HYDROCODONE 5 MG-ACETAMINOPHEN 325 MG TABLET RX-34505 CDM 6370000100 HCPCS 250 RC 53746-0109-05 NDC inpatient 1 UN 5.82 5.82 UNITED HEALTHCARE (COMMERCIAL) [3081199] UNITED HEALTHCARE 87726 [308119901] 3.61 percent of total billed charges 3.61 5.53 Technical (Hospital) Services HYDROCODONE 5 MG-ACETAMINOPHEN 325 MG TABLET RX-34505 CDM 6370000100 HCPCS 250 RC 53746-0109-05 NDC inpatient 1 UN 5.82 5.82 BLUE CROSS BLUE SHIELD WELLMARK SB889 [3081026] BCBS WYOMING [308102603] 5.53 percent of total billed charges 3.61 5.53 Technical (Hospital) Services HYDROCODONE 7.5 MG-ACETAMINOPHEN 325 MG TABLET RX-34544 CDM 6370000100 HCPCS 250 RC 13107-0020-05 NDC inpatient 1 UN 6.04 6.04 CIGNA 62308 [3081051] CIGNA 62308 [308105105] 4.78 percent of total billed charges 3.74 5.74 Technical (Hospital) Services HYDROCODONE 7.5 MG-ACETAMINOPHEN 325 MG TABLET RX-34544 CDM 6370000100 HCPCS 250 RC 13107-0020-05 NDC inpatient 1 UN 6.04 6.04 CIGNA 62308 [3081051] CIGNA STATE OF WYOMING [308105107] 4.78 percent of total billed charges 3.74 5.74 Technical (Hospital) Services HYDROCODONE 7.5 MG-ACETAMINOPHEN 325 MG TABLET RX-34544 CDM 6370000100 HCPCS 250 RC 13107-0020-05 NDC inpatient 1 UN 6.04 6.04 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES HDHP [308136802] 4.78 percent of total billed charges 3.74 5.74 Technical (Hospital) Services HYDROCODONE 7.5 MG-ACETAMINOPHEN 325 MG TABLET RX-34544 CDM 6370000100 HCPCS 250 RC 13107-0020-05 NDC inpatient 1 UN 6.04 6.04 BLUE CROSS BLUE SHIELD WELLMARK SB889 [3081026] BCBS WYOMING [308102603] 5.74 percent of total billed charges 3.74 5.74 Technical (Hospital) Services HYDROCODONE 7.5 MG-ACETAMINOPHEN 325 MG TABLET RX-34544 CDM 6370000100 HCPCS 250 RC 13107-0020-05 NDC inpatient 1 UN 6.04 6.04 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES EPO [308136803] 4.78 percent of total billed charges 3.74 5.74 Technical (Hospital) Services HYDROCODONE 7.5 MG-ACETAMINOPHEN 325 MG TABLET RX-34544 CDM 6370000100 HCPCS 250 RC 13107-0020-05 NDC inpatient 1 UN 6.04 6.04 UNITED HEALTHCARE (COMMERCIAL) [3081199] UNITED HEALTHCARE 87726 [308119901] 3.74 percent of total billed charges 3.74 5.74 Technical (Hospital) Services HYDROCODONE 7.5 MG-ACETAMINOPHEN 325 MG TABLET RX-34544 CDM 6370000100 HCPCS 250 RC 13107-0020-05 NDC inpatient 1 UN 6.04 6.04 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES PPO [308136801] 4.78 percent of total billed charges 3.74 5.74 Technical (Hospital) Services HYDROCODONE 7.5 MG-ACETAMINOPHEN 325 MG TABLET RX-34544 CDM 6370000100 HCPCS 250 RC 13107-0020-05 NDC inpatient 1 UN 6.04 6.04 HEALTHPARTNERS SX009 HEALTHPARTNERS 4.78 percent of total billed charges 3.74 5.74 Technical (Hospital) Services HYDROCODONE 7.5 MG-ACETAMINOPHEN 325 MG TABLET RX-34544 CDM 6370000100 HCPCS 250 RC 13107-0020-05 NDC inpatient 1 UN 6.04 6.04 MEDICA (COMMERCIAL) 94265 [3081118] MEDICA CLAIMS [308111801] 5.44 percent of total billed charges 3.74 5.74 Technical (Hospital) Services HYDROCODONE 7.5 MG-ACETAMINOPHEN 325 MG TABLET RX-34544 CDM 6370000100 HCPCS 250 RC 13107-0020-05 NDC inpatient 1 UN 6.04 6.04 MULTIPLAN INC 34080 [3081285] MULTIPLAN INC [308128501] 5.74 percent of total billed charges 3.74 5.74 Technical (Hospital) Services HYDROCODONE 7.5 MG-ACETAMINOPHEN 325 MG TABLET RX-34544 CDM 6370000100 HCPCS 250 RC 13107-0020-05 NDC outpatient 1 UN 6.04 6.04 BLUE CROSS BLUE SHIELD WELLMARK SB889 [3081026] BCBS WYOMING [308102603] 5.74 percent of total billed charges 3.74 5.74 Technical (Hospital) Services HYDROCODONE 7.5 MG-ACETAMINOPHEN 325 MG TABLET RX-34544 CDM 6370000100 HCPCS 250 RC 13107-0020-05 NDC outpatient 1 UN 6.04 6.04 HEALTHPARTNERS SX009 HEALTHPARTNERS 4.83 percent of total billed charges 3.74 5.74 Technical (Hospital) Services HYDROCODONE 7.5 MG-ACETAMINOPHEN 325 MG TABLET RX-34544 CDM 6370000100 HCPCS 250 RC 13107-0020-05 NDC outpatient 1 UN 6.04 6.04 MEDICA (COMMERCIAL) 94265 [3081118] MEDICA CLAIMS [308111801] 5.44 percent of total billed charges 3.74 5.74 Technical (Hospital) Services HYDROCODONE 7.5 MG-ACETAMINOPHEN 325 MG TABLET RX-34544 CDM 6370000100 HCPCS 250 RC 13107-0020-05 NDC outpatient 1 UN 6.04 6.04 CIGNA 62308 [3081051] CIGNA 62308 [308105105] 4.83 percent of total billed charges 3.74 5.74 Technical (Hospital) Services HYDROCODONE 7.5 MG-ACETAMINOPHEN 325 MG TABLET RX-34544 CDM 6370000100 HCPCS 250 RC 13107-0020-05 NDC outpatient 1 UN 6.04 6.04 CIGNA 62308 [3081051] CIGNA STATE OF WYOMING [308105107] 4.83 percent of total billed charges 3.74 5.74 Technical (Hospital) Services HYDROCODONE 7.5 MG-ACETAMINOPHEN 325 MG TABLET RX-34544 CDM 6370000100 HCPCS 250 RC 13107-0020-05 NDC outpatient 1 UN 6.04 6.04 MULTIPLAN INC 34080 [3081285] MULTIPLAN INC [308128501] 5.74 percent of total billed charges 3.74 5.74 Technical (Hospital) Services HYDROCODONE 7.5 MG-ACETAMINOPHEN 325 MG TABLET RX-34544 CDM 6370000100 HCPCS 250 RC 13107-0020-05 NDC outpatient 1 UN 6.04 6.04 UNITED HEALTHCARE (COMMERCIAL) [3081199] UNITED HEALTHCARE 87726 [308119901] 3.74 percent of total billed charges 3.74 5.74 Technical (Hospital) Services HYDROCODONE 7.5 MG-ACETAMINOPHEN 325 MG TABLET RX-34544 CDM 6370000100 HCPCS 250 RC 13107-0020-05 NDC outpatient 1 UN 6.04 6.04 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES EPO [308136803] 4.83 percent of total billed charges 3.74 5.74 Technical (Hospital) Services HYDROCODONE 7.5 MG-ACETAMINOPHEN 325 MG TABLET RX-34544 CDM 6370000100 HCPCS 250 RC 13107-0020-05 NDC outpatient 1 UN 6.04 6.04 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES HDHP [308136802] 4.83 percent of total billed charges 3.74 5.74 Technical (Hospital) Services HYDROCODONE 7.5 MG-ACETAMINOPHEN 325 MG TABLET RX-34544 CDM 6370000100 HCPCS 250 RC 13107-0020-05 NDC outpatient 1 UN 6.04 6.04 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES PPO [308136801] 4.83 percent of total billed charges 3.74 5.74 Technical (Hospital) Services GUAIFENESIN 400 MG TABLET RX-34574 CDM 6370000100 HCPCS 250 RC 57896-0794-01 NDC outpatient 1 UN 5.65 5.65 HEALTHPARTNERS SX009 HEALTHPARTNERS 4.52 percent of total billed charges 3.5 5.37 Technical (Hospital) Services GUAIFENESIN 400 MG TABLET RX-34574 CDM 6370000100 HCPCS 250 RC 57896-0794-01 NDC outpatient 1 UN 5.65 5.65 UNITED HEALTHCARE (COMMERCIAL) [3081199] UNITED HEALTHCARE 87726 [308119901] 3.5 percent of total billed charges 3.5 5.37 Technical (Hospital) Services GUAIFENESIN 400 MG TABLET RX-34574 CDM 6370000100 HCPCS 250 RC 57896-0794-01 NDC outpatient 1 UN 5.65 5.65 MEDICA (COMMERCIAL) 94265 [3081118] MEDICA CLAIMS [308111801] 5.09 percent of total billed charges 3.5 5.37 Technical (Hospital) Services GUAIFENESIN 400 MG TABLET RX-34574 CDM 6370000100 HCPCS 250 RC 57896-0794-01 NDC outpatient 1 UN 5.65 5.65 MULTIPLAN INC 34080 [3081285] MULTIPLAN INC [308128501] 5.37 percent of total billed charges 3.5 5.37 Technical (Hospital) Services GUAIFENESIN 400 MG TABLET RX-34574 CDM 6370000100 HCPCS 250 RC 57896-0794-01 NDC outpatient 1 UN 5.65 5.65 CIGNA 62308 [3081051] CIGNA 62308 [308105105] 4.52 percent of total billed charges 3.5 5.37 Technical (Hospital) Services GUAIFENESIN 400 MG TABLET RX-34574 CDM 6370000100 HCPCS 250 RC 57896-0794-01 NDC outpatient 1 UN 5.65 5.65 CIGNA 62308 [3081051] CIGNA STATE OF WYOMING [308105107] 4.52 percent of total billed charges 3.5 5.37 Technical (Hospital) Services GUAIFENESIN 400 MG TABLET RX-34574 CDM 6370000100 HCPCS 250 RC 57896-0794-01 NDC outpatient 1 UN 5.65 5.65 BLUE CROSS BLUE SHIELD WELLMARK SB889 [3081026] BCBS WYOMING [308102603] 5.37 percent of total billed charges 3.5 5.37 Technical (Hospital) Services GUAIFENESIN 400 MG TABLET RX-34574 CDM 6370000100 HCPCS 250 RC 57896-0794-01 NDC outpatient 1 UN 5.65 5.65 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES HDHP [308136802] 4.52 percent of total billed charges 3.5 5.37 Technical (Hospital) Services GUAIFENESIN 400 MG TABLET RX-34574 CDM 6370000100 HCPCS 250 RC 57896-0794-01 NDC outpatient 1 UN 5.65 5.65 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES PPO [308136801] 4.52 percent of total billed charges 3.5 5.37 Technical (Hospital) Services GUAIFENESIN 400 MG TABLET RX-34574 CDM 6370000100 HCPCS 250 RC 57896-0794-01 NDC outpatient 1 UN 5.65 5.65 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES EPO [308136803] 4.52 percent of total billed charges 3.5 5.37 Technical (Hospital) Services GUAIFENESIN 400 MG TABLET RX-34574 CDM 6370000100 HCPCS 250 RC 57896-0794-01 NDC inpatient 1 UN 5.65 5.65 MULTIPLAN INC 34080 [3081285] MULTIPLAN INC [308128501] 5.37 percent of total billed charges 3.5 5.37 Technical (Hospital) Services GUAIFENESIN 400 MG TABLET RX-34574 CDM 6370000100 HCPCS 250 RC 57896-0794-01 NDC inpatient 1 UN 5.65 5.65 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES PPO [308136801] 4.47 percent of total billed charges 3.5 5.37 Technical (Hospital) Services GUAIFENESIN 400 MG TABLET RX-34574 CDM 6370000100 HCPCS 250 RC 57896-0794-01 NDC inpatient 1 UN 5.65 5.65 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES HDHP [308136802] 4.47 percent of total billed charges 3.5 5.37 Technical (Hospital) Services GUAIFENESIN 400 MG TABLET RX-34574 CDM 6370000100 HCPCS 250 RC 57896-0794-01 NDC inpatient 1 UN 5.65 5.65 HEALTHPARTNERS SX009 HEALTHPARTNERS 4.47 percent of total billed charges 3.5 5.37 Technical (Hospital) Services GUAIFENESIN 400 MG TABLET RX-34574 CDM 6370000100 HCPCS 250 RC 57896-0794-01 NDC inpatient 1 UN 5.65 5.65 MEDICA (COMMERCIAL) 94265 [3081118] MEDICA CLAIMS [308111801] 5.09 percent of total billed charges 3.5 5.37 Technical (Hospital) Services GUAIFENESIN 400 MG TABLET RX-34574 CDM 6370000100 HCPCS 250 RC 57896-0794-01 NDC inpatient 1 UN 5.65 5.65 UNITED HEALTHCARE (COMMERCIAL) [3081199] UNITED HEALTHCARE 87726 [308119901] 3.5 percent of total billed charges 3.5 5.37 Technical (Hospital) Services GUAIFENESIN 400 MG TABLET RX-34574 CDM 6370000100 HCPCS 250 RC 57896-0794-01 NDC inpatient 1 UN 5.65 5.65 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES EPO [308136803] 4.47 percent of total billed charges 3.5 5.37 Technical (Hospital) Services GUAIFENESIN 400 MG TABLET RX-34574 CDM 6370000100 HCPCS 250 RC 57896-0794-01 NDC inpatient 1 UN 5.65 5.65 CIGNA 62308 [3081051] CIGNA 62308 [308105105] 4.47 percent of total billed charges 3.5 5.37 Technical (Hospital) Services GUAIFENESIN 400 MG TABLET RX-34574 CDM 6370000100 HCPCS 250 RC 57896-0794-01 NDC inpatient 1 UN 5.65 5.65 CIGNA 62308 [3081051] CIGNA STATE OF WYOMING [308105107] 4.47 percent of total billed charges 3.5 5.37 Technical (Hospital) Services GUAIFENESIN 400 MG TABLET RX-34574 CDM 6370000100 HCPCS 250 RC 57896-0794-01 NDC inpatient 1 UN 5.65 5.65 BLUE CROSS BLUE SHIELD WELLMARK SB889 [3081026] BCBS WYOMING [308102603] 5.37 percent of total billed charges 3.5 5.37 Technical (Hospital) Services "NEOMYCIN-POLYMYXIN-HYDROCORT 3.5 MG/ML-10,000 UNIT/ML-1 % EAR SOLUTION" RX-34814 CDM 6370000100 HCPCS 250 RC 61314-0646-10 NDC inpatient 10 ML 315.4 315.4 HEALTHPARTNERS SX009 HEALTHPARTNERS 249.73 percent of total billed charges 195.55 299.63 Technical (Hospital) Services "NEOMYCIN-POLYMYXIN-HYDROCORT 3.5 MG/ML-10,000 UNIT/ML-1 % EAR SOLUTION" RX-34814 CDM 6370000100 HCPCS 250 RC 61314-0646-10 NDC inpatient 10 ML 315.4 315.4 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES EPO [308136803] 249.73 percent of total billed charges 195.55 299.63 Technical (Hospital) Services "NEOMYCIN-POLYMYXIN-HYDROCORT 3.5 MG/ML-10,000 UNIT/ML-1 % EAR SOLUTION" RX-34814 CDM 6370000100 HCPCS 250 RC 61314-0646-10 NDC inpatient 10 ML 315.4 315.4 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES HDHP [308136802] 249.73 percent of total billed charges 195.55 299.63 Technical (Hospital) Services "NEOMYCIN-POLYMYXIN-HYDROCORT 3.5 MG/ML-10,000 UNIT/ML-1 % EAR SOLUTION" RX-34814 CDM 6370000100 HCPCS 250 RC 61314-0646-10 NDC inpatient 10 ML 315.4 315.4 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES PPO [308136801] 249.73 percent of total billed charges 195.55 299.63 Technical (Hospital) Services "NEOMYCIN-POLYMYXIN-HYDROCORT 3.5 MG/ML-10,000 UNIT/ML-1 % EAR SOLUTION" RX-34814 CDM 6370000100 HCPCS 250 RC 61314-0646-10 NDC inpatient 10 ML 315.4 315.4 BLUE CROSS BLUE SHIELD WELLMARK SB889 [3081026] BCBS WYOMING [308102603] 299.63 percent of total billed charges 195.55 299.63 Technical (Hospital) Services "NEOMYCIN-POLYMYXIN-HYDROCORT 3.5 MG/ML-10,000 UNIT/ML-1 % EAR SOLUTION" RX-34814 CDM 6370000100 HCPCS 250 RC 61314-0646-10 NDC inpatient 10 ML 315.4 315.4 UNITED HEALTHCARE (COMMERCIAL) [3081199] UNITED HEALTHCARE 87726 [308119901] 195.55 percent of total billed charges 195.55 299.63 Technical (Hospital) Services "NEOMYCIN-POLYMYXIN-HYDROCORT 3.5 MG/ML-10,000 UNIT/ML-1 % EAR SOLUTION" RX-34814 CDM 6370000100 HCPCS 250 RC 61314-0646-10 NDC inpatient 10 ML 315.4 315.4 CIGNA 62308 [3081051] CIGNA 62308 [308105105] 249.73 percent of total billed charges 195.55 299.63 Technical (Hospital) Services "NEOMYCIN-POLYMYXIN-HYDROCORT 3.5 MG/ML-10,000 UNIT/ML-1 % EAR SOLUTION" RX-34814 CDM 6370000100 HCPCS 250 RC 61314-0646-10 NDC inpatient 10 ML 315.4 315.4 CIGNA 62308 [3081051] CIGNA STATE OF WYOMING [308105107] 249.73 percent of total billed charges 195.55 299.63 Technical (Hospital) Services "NEOMYCIN-POLYMYXIN-HYDROCORT 3.5 MG/ML-10,000 UNIT/ML-1 % EAR SOLUTION" RX-34814 CDM 6370000100 HCPCS 250 RC 61314-0646-10 NDC inpatient 10 ML 315.4 315.4 MULTIPLAN INC 34080 [3081285] MULTIPLAN INC [308128501] 299.63 percent of total billed charges 195.55 299.63 Technical (Hospital) Services "NEOMYCIN-POLYMYXIN-HYDROCORT 3.5 MG/ML-10,000 UNIT/ML-1 % EAR SOLUTION" RX-34814 CDM 6370000100 HCPCS 250 RC 61314-0646-10 NDC inpatient 10 ML 315.4 315.4 MEDICA (COMMERCIAL) 94265 [3081118] MEDICA CLAIMS [308111801] 283.86 percent of total billed charges 195.55 299.63 Technical (Hospital) Services "NEOMYCIN-POLYMYXIN-HYDROCORT 3.5 MG/ML-10,000 UNIT/ML-1 % EAR SOLUTION" RX-34814 CDM 6370000100 HCPCS 250 RC 61314-0646-10 NDC outpatient 10 ML 315.4 315.4 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES PPO [308136801] 252.32 percent of total billed charges 195.55 299.63 Technical (Hospital) Services "NEOMYCIN-POLYMYXIN-HYDROCORT 3.5 MG/ML-10,000 UNIT/ML-1 % EAR SOLUTION" RX-34814 CDM 6370000100 HCPCS 250 RC 61314-0646-10 NDC outpatient 10 ML 315.4 315.4 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES HDHP [308136802] 252.32 percent of total billed charges 195.55 299.63 Technical (Hospital) Services "NEOMYCIN-POLYMYXIN-HYDROCORT 3.5 MG/ML-10,000 UNIT/ML-1 % EAR SOLUTION" RX-34814 CDM 6370000100 HCPCS 250 RC 61314-0646-10 NDC outpatient 10 ML 315.4 315.4 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES EPO [308136803] 252.32 percent of total billed charges 195.55 299.63 Technical (Hospital) Services "NEOMYCIN-POLYMYXIN-HYDROCORT 3.5 MG/ML-10,000 UNIT/ML-1 % EAR SOLUTION" RX-34814 CDM 6370000100 HCPCS 250 RC 61314-0646-10 NDC outpatient 10 ML 315.4 315.4 BLUE CROSS BLUE SHIELD WELLMARK SB889 [3081026] BCBS WYOMING [308102603] 299.63 percent of total billed charges 195.55 299.63 Technical (Hospital) Services "NEOMYCIN-POLYMYXIN-HYDROCORT 3.5 MG/ML-10,000 UNIT/ML-1 % EAR SOLUTION" RX-34814 CDM 6370000100 HCPCS 250 RC 61314-0646-10 NDC outpatient 10 ML 315.4 315.4 HEALTHPARTNERS SX009 HEALTHPARTNERS 252.32 percent of total billed charges 195.55 299.63 Technical (Hospital) Services "NEOMYCIN-POLYMYXIN-HYDROCORT 3.5 MG/ML-10,000 UNIT/ML-1 % EAR SOLUTION" RX-34814 CDM 6370000100 HCPCS 250 RC 61314-0646-10 NDC outpatient 10 ML 315.4 315.4 UNITED HEALTHCARE (COMMERCIAL) [3081199] UNITED HEALTHCARE 87726 [308119901] 195.55 percent of total billed charges 195.55 299.63 Technical (Hospital) Services "NEOMYCIN-POLYMYXIN-HYDROCORT 3.5 MG/ML-10,000 UNIT/ML-1 % EAR SOLUTION" RX-34814 CDM 6370000100 HCPCS 250 RC 61314-0646-10 NDC outpatient 10 ML 315.4 315.4 MULTIPLAN INC 34080 [3081285] MULTIPLAN INC [308128501] 299.63 percent of total billed charges 195.55 299.63 Technical (Hospital) Services "NEOMYCIN-POLYMYXIN-HYDROCORT 3.5 MG/ML-10,000 UNIT/ML-1 % EAR SOLUTION" RX-34814 CDM 6370000100 HCPCS 250 RC 61314-0646-10 NDC outpatient 10 ML 315.4 315.4 MEDICA (COMMERCIAL) 94265 [3081118] MEDICA CLAIMS [308111801] 283.86 percent of total billed charges 195.55 299.63 Technical (Hospital) Services "NEOMYCIN-POLYMYXIN-HYDROCORT 3.5 MG/ML-10,000 UNIT/ML-1 % EAR SOLUTION" RX-34814 CDM 6370000100 HCPCS 250 RC 61314-0646-10 NDC outpatient 10 ML 315.4 315.4 CIGNA 62308 [3081051] CIGNA 62308 [308105105] 252.32 percent of total billed charges 195.55 299.63 Technical (Hospital) Services "NEOMYCIN-POLYMYXIN-HYDROCORT 3.5 MG/ML-10,000 UNIT/ML-1 % EAR SOLUTION" RX-34814 CDM 6370000100 HCPCS 250 RC 61314-0646-10 NDC outpatient 10 ML 315.4 315.4 CIGNA 62308 [3081051] CIGNA STATE OF WYOMING [308105107] 252.32 percent of total billed charges 195.55 299.63 Technical (Hospital) Services GLYBURIDE 5 MG TABLET RX-3489 CDM 6370000100 HCPCS 250 RC 23155-0058-01 NDC inpatient 1 UN 5.94 5.94 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES HDHP [308136802] 4.7 percent of total billed charges 3.68 5.64 Technical (Hospital) Services GLYBURIDE 5 MG TABLET RX-3489 CDM 6370000100 HCPCS 250 RC 23155-0058-01 NDC inpatient 1 UN 5.94 5.94 CIGNA 62308 [3081051] CIGNA 62308 [308105105] 4.7 percent of total billed charges 3.68 5.64 Technical (Hospital) Services GLYBURIDE 5 MG TABLET RX-3489 CDM 6370000100 HCPCS 250 RC 23155-0058-01 NDC inpatient 1 UN 5.94 5.94 CIGNA 62308 [3081051] CIGNA STATE OF WYOMING [308105107] 4.7 percent of total billed charges 3.68 5.64 Technical (Hospital) Services GLYBURIDE 5 MG TABLET RX-3489 CDM 6370000100 HCPCS 250 RC 23155-0058-01 NDC inpatient 1 UN 5.94 5.94 BLUE CROSS BLUE SHIELD WELLMARK SB889 [3081026] BCBS WYOMING [308102603] 5.64 percent of total billed charges 3.68 5.64 Technical (Hospital) Services GLYBURIDE 5 MG TABLET RX-3489 CDM 6370000100 HCPCS 250 RC 23155-0058-01 NDC inpatient 1 UN 5.94 5.94 UNITED HEALTHCARE (COMMERCIAL) [3081199] UNITED HEALTHCARE 87726 [308119901] 3.68 percent of total billed charges 3.68 5.64 Technical (Hospital) Services GLYBURIDE 5 MG TABLET RX-3489 CDM 6370000100 HCPCS 250 RC 23155-0058-01 NDC inpatient 1 UN 5.94 5.94 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES EPO [308136803] 4.7 percent of total billed charges 3.68 5.64 Technical (Hospital) Services GLYBURIDE 5 MG TABLET RX-3489 CDM 6370000100 HCPCS 250 RC 23155-0058-01 NDC inpatient 1 UN 5.94 5.94 MULTIPLAN INC 34080 [3081285] MULTIPLAN INC [308128501] 5.64 percent of total billed charges 3.68 5.64 Technical (Hospital) Services GLYBURIDE 5 MG TABLET RX-3489 CDM 6370000100 HCPCS 250 RC 23155-0058-01 NDC inpatient 1 UN 5.94 5.94 MEDICA (COMMERCIAL) 94265 [3081118] MEDICA CLAIMS [308111801] 5.35 percent of total billed charges 3.68 5.64 Technical (Hospital) Services GLYBURIDE 5 MG TABLET RX-3489 CDM 6370000100 HCPCS 250 RC 23155-0058-01 NDC inpatient 1 UN 5.94 5.94 HEALTHPARTNERS SX009 HEALTHPARTNERS 4.7 percent of total billed charges 3.68 5.64 Technical (Hospital) Services GLYBURIDE 5 MG TABLET RX-3489 CDM 6370000100 HCPCS 250 RC 23155-0058-01 NDC inpatient 1 UN 5.94 5.94 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES PPO [308136801] 4.7 percent of total billed charges 3.68 5.64 Technical (Hospital) Services GLYBURIDE 5 MG TABLET RX-3489 CDM 6370000100 HCPCS 250 RC 23155-0058-01 NDC outpatient 1 UN 5.94 5.94 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES PPO [308136801] 4.75 percent of total billed charges 3.68 5.64 Technical (Hospital) Services GLYBURIDE 5 MG TABLET RX-3489 CDM 6370000100 HCPCS 250 RC 23155-0058-01 NDC outpatient 1 UN 5.94 5.94 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES HDHP [308136802] 4.75 percent of total billed charges 3.68 5.64 Technical (Hospital) Services GLYBURIDE 5 MG TABLET RX-3489 CDM 6370000100 HCPCS 250 RC 23155-0058-01 NDC outpatient 1 UN 5.94 5.94 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES EPO [308136803] 4.75 percent of total billed charges 3.68 5.64 Technical (Hospital) Services GLYBURIDE 5 MG TABLET RX-3489 CDM 6370000100 HCPCS 250 RC 23155-0058-01 NDC outpatient 1 UN 5.94 5.94 BLUE CROSS BLUE SHIELD WELLMARK SB889 [3081026] BCBS WYOMING [308102603] 5.64 percent of total billed charges 3.68 5.64 Technical (Hospital) Services GLYBURIDE 5 MG TABLET RX-3489 CDM 6370000100 HCPCS 250 RC 23155-0058-01 NDC outpatient 1 UN 5.94 5.94 HEALTHPARTNERS SX009 HEALTHPARTNERS 4.75 percent of total billed charges 3.68 5.64 Technical (Hospital) Services GLYBURIDE 5 MG TABLET RX-3489 CDM 6370000100 HCPCS 250 RC 23155-0058-01 NDC outpatient 1 UN 5.94 5.94 UNITED HEALTHCARE (COMMERCIAL) [3081199] UNITED HEALTHCARE 87726 [308119901] 3.68 percent of total billed charges 3.68 5.64 Technical (Hospital) Services GLYBURIDE 5 MG TABLET RX-3489 CDM 6370000100 HCPCS 250 RC 23155-0058-01 NDC outpatient 1 UN 5.94 5.94 MULTIPLAN INC 34080 [3081285] MULTIPLAN INC [308128501] 5.64 percent of total billed charges 3.68 5.64 Technical (Hospital) Services GLYBURIDE 5 MG TABLET RX-3489 CDM 6370000100 HCPCS 250 RC 23155-0058-01 NDC outpatient 1 UN 5.94 5.94 CIGNA 62308 [3081051] CIGNA 62308 [308105105] 4.75 percent of total billed charges 3.68 5.64 Technical (Hospital) Services GLYBURIDE 5 MG TABLET RX-3489 CDM 6370000100 HCPCS 250 RC 23155-0058-01 NDC outpatient 1 UN 5.94 5.94 CIGNA 62308 [3081051] CIGNA STATE OF WYOMING [308105107] 4.75 percent of total billed charges 3.68 5.64 Technical (Hospital) Services GLYBURIDE 5 MG TABLET RX-3489 CDM 6370000100 HCPCS 250 RC 23155-0058-01 NDC outpatient 1 UN 5.94 5.94 MEDICA (COMMERCIAL) 94265 [3081118] MEDICA CLAIMS [308111801] 5.35 percent of total billed charges 3.68 5.64 Technical (Hospital) Services ROSUVASTATIN 20 MG TABLET RX-35135 CDM 6370000100 HCPCS 250 RC 72205-0004-90 NDC inpatient 1 UN 5.69 5.69 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES HDHP [308136802] 4.51 percent of total billed charges 3.53 5.41 Technical (Hospital) Services ROSUVASTATIN 20 MG TABLET RX-35135 CDM 6370000100 HCPCS 250 RC 72205-0004-90 NDC inpatient 1 UN 5.69 5.69 UNITED HEALTHCARE (COMMERCIAL) [3081199] UNITED HEALTHCARE 87726 [308119901] 3.53 percent of total billed charges 3.53 5.41 Technical (Hospital) Services ROSUVASTATIN 20 MG TABLET RX-35135 CDM 6370000100 HCPCS 250 RC 72205-0004-90 NDC inpatient 1 UN 5.69 5.69 CIGNA 62308 [3081051] CIGNA 62308 [308105105] 4.51 percent of total billed charges 3.53 5.41 Technical (Hospital) Services ROSUVASTATIN 20 MG TABLET RX-35135 CDM 6370000100 HCPCS 250 RC 72205-0004-90 NDC inpatient 1 UN 5.69 5.69 CIGNA 62308 [3081051] CIGNA STATE OF WYOMING [308105107] 4.51 percent of total billed charges 3.53 5.41 Technical (Hospital) Services ROSUVASTATIN 20 MG TABLET RX-35135 CDM 6370000100 HCPCS 250 RC 72205-0004-90 NDC inpatient 1 UN 5.69 5.69 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES EPO [308136803] 4.51 percent of total billed charges 3.53 5.41 Technical (Hospital) Services ROSUVASTATIN 20 MG TABLET RX-35135 CDM 6370000100 HCPCS 250 RC 72205-0004-90 NDC inpatient 1 UN 5.69 5.69 BLUE CROSS BLUE SHIELD WELLMARK SB889 [3081026] BCBS WYOMING [308102603] 5.41 percent of total billed charges 3.53 5.41 Technical (Hospital) Services ROSUVASTATIN 20 MG TABLET RX-35135 CDM 6370000100 HCPCS 250 RC 72205-0004-90 NDC inpatient 1 UN 5.69 5.69 MULTIPLAN INC 34080 [3081285] MULTIPLAN INC [308128501] 5.41 percent of total billed charges 3.53 5.41 Technical (Hospital) Services ROSUVASTATIN 20 MG TABLET RX-35135 CDM 6370000100 HCPCS 250 RC 72205-0004-90 NDC inpatient 1 UN 5.69 5.69 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES PPO [308136801] 4.51 percent of total billed charges 3.53 5.41 Technical (Hospital) Services ROSUVASTATIN 20 MG TABLET RX-35135 CDM 6370000100 HCPCS 250 RC 72205-0004-90 NDC inpatient 1 UN 5.69 5.69 HEALTHPARTNERS SX009 HEALTHPARTNERS 4.51 percent of total billed charges 3.53 5.41 Technical (Hospital) Services ROSUVASTATIN 20 MG TABLET RX-35135 CDM 6370000100 HCPCS 250 RC 72205-0004-90 NDC inpatient 1 UN 5.69 5.69 MEDICA (COMMERCIAL) 94265 [3081118] MEDICA CLAIMS [308111801] 5.12 percent of total billed charges 3.53 5.41 Technical (Hospital) Services ROSUVASTATIN 20 MG TABLET RX-35135 CDM 6370000100 HCPCS 250 RC 72205-0004-90 NDC outpatient 1 UN 5.69 5.69 UNITED HEALTHCARE (COMMERCIAL) [3081199] UNITED HEALTHCARE 87726 [308119901] 3.53 percent of total billed charges 3.53 5.41 Technical (Hospital) Services ROSUVASTATIN 20 MG TABLET RX-35135 CDM 6370000100 HCPCS 250 RC 72205-0004-90 NDC outpatient 1 UN 5.69 5.69 MEDICA (COMMERCIAL) 94265 [3081118] MEDICA CLAIMS [308111801] 5.12 percent of total billed charges 3.53 5.41 Technical (Hospital) Services ROSUVASTATIN 20 MG TABLET RX-35135 CDM 6370000100 HCPCS 250 RC 72205-0004-90 NDC outpatient 1 UN 5.69 5.69 CIGNA 62308 [3081051] CIGNA 62308 [308105105] 4.55 percent of total billed charges 3.53 5.41 Technical (Hospital) Services ROSUVASTATIN 20 MG TABLET RX-35135 CDM 6370000100 HCPCS 250 RC 72205-0004-90 NDC outpatient 1 UN 5.69 5.69 CIGNA 62308 [3081051] CIGNA STATE OF WYOMING [308105107] 4.55 percent of total billed charges 3.53 5.41 Technical (Hospital) Services ROSUVASTATIN 20 MG TABLET RX-35135 CDM 6370000100 HCPCS 250 RC 72205-0004-90 NDC outpatient 1 UN 5.69 5.69 MULTIPLAN INC 34080 [3081285] MULTIPLAN INC [308128501] 5.41 percent of total billed charges 3.53 5.41 Technical (Hospital) Services ROSUVASTATIN 20 MG TABLET RX-35135 CDM 6370000100 HCPCS 250 RC 72205-0004-90 NDC outpatient 1 UN 5.69 5.69 HEALTHPARTNERS SX009 HEALTHPARTNERS 4.55 percent of total billed charges 3.53 5.41 Technical (Hospital) Services ROSUVASTATIN 20 MG TABLET RX-35135 CDM 6370000100 HCPCS 250 RC 72205-0004-90 NDC outpatient 1 UN 5.69 5.69 BLUE CROSS BLUE SHIELD WELLMARK SB889 [3081026] BCBS WYOMING [308102603] 5.41 percent of total billed charges 3.53 5.41 Technical (Hospital) Services ROSUVASTATIN 20 MG TABLET RX-35135 CDM 6370000100 HCPCS 250 RC 72205-0004-90 NDC outpatient 1 UN 5.69 5.69 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES HDHP [308136802] 4.55 percent of total billed charges 3.53 5.41 Technical (Hospital) Services ROSUVASTATIN 20 MG TABLET RX-35135 CDM 6370000100 HCPCS 250 RC 72205-0004-90 NDC outpatient 1 UN 5.69 5.69 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES EPO [308136803] 4.55 percent of total billed charges 3.53 5.41 Technical (Hospital) Services ROSUVASTATIN 20 MG TABLET RX-35135 CDM 6370000100 HCPCS 250 RC 72205-0004-90 NDC outpatient 1 UN 5.69 5.69 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES PPO [308136801] 4.55 percent of total billed charges 3.53 5.41 Technical (Hospital) Services ROSUVASTATIN 40 MG TABLET RX-35136 CDM 6370000100 HCPCS 250 RC 65862-0296-30 NDC outpatient 1 UN 5.7 5.7 BLUE CROSS BLUE SHIELD WELLMARK SB889 [3081026] BCBS WYOMING [308102603] 5.42 percent of total billed charges 3.53 5.42 Technical (Hospital) Services ROSUVASTATIN 40 MG TABLET RX-35136 CDM 6370000100 HCPCS 250 RC 65862-0296-30 NDC outpatient 1 UN 5.7 5.7 UNITED HEALTHCARE (COMMERCIAL) [3081199] UNITED HEALTHCARE 87726 [308119901] 3.53 percent of total billed charges 3.53 5.42 Technical (Hospital) Services ROSUVASTATIN 40 MG TABLET RX-35136 CDM 6370000100 HCPCS 250 RC 65862-0296-30 NDC outpatient 1 UN 5.7 5.7 HEALTHPARTNERS SX009 HEALTHPARTNERS 4.56 percent of total billed charges 3.53 5.42 Technical (Hospital) Services ROSUVASTATIN 40 MG TABLET RX-35136 CDM 6370000100 HCPCS 250 RC 65862-0296-30 NDC outpatient 1 UN 5.7 5.7 MULTIPLAN INC 34080 [3081285] MULTIPLAN INC [308128501] 5.42 percent of total billed charges 3.53 5.42 Technical (Hospital) Services ROSUVASTATIN 40 MG TABLET RX-35136 CDM 6370000100 HCPCS 250 RC 65862-0296-30 NDC outpatient 1 UN 5.7 5.7 CIGNA 62308 [3081051] CIGNA 62308 [308105105] 4.56 percent of total billed charges 3.53 5.42 Technical (Hospital) Services ROSUVASTATIN 40 MG TABLET RX-35136 CDM 6370000100 HCPCS 250 RC 65862-0296-30 NDC outpatient 1 UN 5.7 5.7 CIGNA 62308 [3081051] CIGNA STATE OF WYOMING [308105107] 4.56 percent of total billed charges 3.53 5.42 Technical (Hospital) Services ROSUVASTATIN 40 MG TABLET RX-35136 CDM 6370000100 HCPCS 250 RC 65862-0296-30 NDC outpatient 1 UN 5.7 5.7 MEDICA (COMMERCIAL) 94265 [3081118] MEDICA CLAIMS [308111801] 5.13 percent of total billed charges 3.53 5.42 Technical (Hospital) Services ROSUVASTATIN 40 MG TABLET RX-35136 CDM 6370000100 HCPCS 250 RC 65862-0296-30 NDC outpatient 1 UN 5.7 5.7 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES PPO [308136801] 4.56 percent of total billed charges 3.53 5.42 Technical (Hospital) Services ROSUVASTATIN 40 MG TABLET RX-35136 CDM 6370000100 HCPCS 250 RC 65862-0296-30 NDC outpatient 1 UN 5.7 5.7 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES HDHP [308136802] 4.56 percent of total billed charges 3.53 5.42 Technical (Hospital) Services ROSUVASTATIN 40 MG TABLET RX-35136 CDM 6370000100 HCPCS 250 RC 65862-0296-30 NDC outpatient 1 UN 5.7 5.7 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES EPO [308136803] 4.56 percent of total billed charges 3.53 5.42 Technical (Hospital) Services ROSUVASTATIN 40 MG TABLET RX-35136 CDM 6370000100 HCPCS 250 RC 65862-0296-30 NDC inpatient 1 UN 5.7 5.7 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES PPO [308136801] 4.51 percent of total billed charges 3.53 5.42 Technical (Hospital) Services ROSUVASTATIN 40 MG TABLET RX-35136 CDM 6370000100 HCPCS 250 RC 65862-0296-30 NDC inpatient 1 UN 5.7 5.7 MULTIPLAN INC 34080 [3081285] MULTIPLAN INC [308128501] 5.42 percent of total billed charges 3.53 5.42 Technical (Hospital) Services ROSUVASTATIN 40 MG TABLET RX-35136 CDM 6370000100 HCPCS 250 RC 65862-0296-30 NDC inpatient 1 UN 5.7 5.7 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES HDHP [308136802] 4.51 percent of total billed charges 3.53 5.42 Technical (Hospital) Services ROSUVASTATIN 40 MG TABLET RX-35136 CDM 6370000100 HCPCS 250 RC 65862-0296-30 NDC inpatient 1 UN 5.7 5.7 MEDICA (COMMERCIAL) 94265 [3081118] MEDICA CLAIMS [308111801] 5.13 percent of total billed charges 3.53 5.42 Technical (Hospital) Services ROSUVASTATIN 40 MG TABLET RX-35136 CDM 6370000100 HCPCS 250 RC 65862-0296-30 NDC inpatient 1 UN 5.7 5.7 HEALTHPARTNERS SX009 HEALTHPARTNERS 4.51 percent of total billed charges 3.53 5.42 Technical (Hospital) Services ROSUVASTATIN 40 MG TABLET RX-35136 CDM 6370000100 HCPCS 250 RC 65862-0296-30 NDC inpatient 1 UN 5.7 5.7 UNITED HEALTHCARE (COMMERCIAL) [3081199] UNITED HEALTHCARE 87726 [308119901] 3.53 percent of total billed charges 3.53 5.42 Technical (Hospital) Services ROSUVASTATIN 40 MG TABLET RX-35136 CDM 6370000100 HCPCS 250 RC 65862-0296-30 NDC inpatient 1 UN 5.7 5.7 CIGNA 62308 [3081051] CIGNA 62308 [308105105] 4.51 percent of total billed charges 3.53 5.42 Technical (Hospital) Services ROSUVASTATIN 40 MG TABLET RX-35136 CDM 6370000100 HCPCS 250 RC 65862-0296-30 NDC inpatient 1 UN 5.7 5.7 CIGNA 62308 [3081051] CIGNA STATE OF WYOMING [308105107] 4.51 percent of total billed charges 3.53 5.42 Technical (Hospital) Services ROSUVASTATIN 40 MG TABLET RX-35136 CDM 6370000100 HCPCS 250 RC 65862-0296-30 NDC inpatient 1 UN 5.7 5.7 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES EPO [308136803] 4.51 percent of total billed charges 3.53 5.42 Technical (Hospital) Services ROSUVASTATIN 40 MG TABLET RX-35136 CDM 6370000100 HCPCS 250 RC 65862-0296-30 NDC inpatient 1 UN 5.7 5.7 BLUE CROSS BLUE SHIELD WELLMARK SB889 [3081026] BCBS WYOMING [308102603] 5.42 percent of total billed charges 3.53 5.42 Technical (Hospital) Services COENZYME Q10 50 MG CAPSULE RX-35228 CDM 6370000100 HCPCS 250 RC 79854-0008-48 NDC outpatient 1 UN 5.83 5.83 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES HDHP [308136802] 4.66 percent of total billed charges 3.61 5.54 Technical (Hospital) Services COENZYME Q10 50 MG CAPSULE RX-35228 CDM 6370000100 HCPCS 250 RC 79854-0008-48 NDC outpatient 1 UN 5.83 5.83 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES PPO [308136801] 4.66 percent of total billed charges 3.61 5.54 Technical (Hospital) Services COENZYME Q10 50 MG CAPSULE RX-35228 CDM 6370000100 HCPCS 250 RC 79854-0008-48 NDC outpatient 1 UN 5.83 5.83 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES EPO [308136803] 4.66 percent of total billed charges 3.61 5.54 Technical (Hospital) Services COENZYME Q10 50 MG CAPSULE RX-35228 CDM 6370000100 HCPCS 250 RC 79854-0008-48 NDC outpatient 1 UN 5.83 5.83 BLUE CROSS BLUE SHIELD WELLMARK SB889 [3081026] BCBS WYOMING [308102603] 5.54 percent of total billed charges 3.61 5.54 Technical (Hospital) Services COENZYME Q10 50 MG CAPSULE RX-35228 CDM 6370000100 HCPCS 250 RC 79854-0008-48 NDC outpatient 1 UN 5.83 5.83 CIGNA 62308 [3081051] CIGNA 62308 [308105105] 4.66 percent of total billed charges 3.61 5.54 Technical (Hospital) Services COENZYME Q10 50 MG CAPSULE RX-35228 CDM 6370000100 HCPCS 250 RC 79854-0008-48 NDC outpatient 1 UN 5.83 5.83 CIGNA 62308 [3081051] CIGNA STATE OF WYOMING [308105107] 4.66 percent of total billed charges 3.61 5.54 Technical (Hospital) Services COENZYME Q10 50 MG CAPSULE RX-35228 CDM 6370000100 HCPCS 250 RC 79854-0008-48 NDC outpatient 1 UN 5.83 5.83 MULTIPLAN INC 34080 [3081285] MULTIPLAN INC [308128501] 5.54 percent of total billed charges 3.61 5.54 Technical (Hospital) Services COENZYME Q10 50 MG CAPSULE RX-35228 CDM 6370000100 HCPCS 250 RC 79854-0008-48 NDC outpatient 1 UN 5.83 5.83 MEDICA (COMMERCIAL) 94265 [3081118] MEDICA CLAIMS [308111801] 5.25 percent of total billed charges 3.61 5.54 Technical (Hospital) Services COENZYME Q10 50 MG CAPSULE RX-35228 CDM 6370000100 HCPCS 250 RC 79854-0008-48 NDC outpatient 1 UN 5.83 5.83 UNITED HEALTHCARE (COMMERCIAL) [3081199] UNITED HEALTHCARE 87726 [308119901] 3.61 percent of total billed charges 3.61 5.54 Technical (Hospital) Services COENZYME Q10 50 MG CAPSULE RX-35228 CDM 6370000100 HCPCS 250 RC 79854-0008-48 NDC outpatient 1 UN 5.83 5.83 HEALTHPARTNERS SX009 HEALTHPARTNERS 4.66 percent of total billed charges 3.61 5.54 Technical (Hospital) Services COENZYME Q10 50 MG CAPSULE RX-35228 CDM 6370000100 HCPCS 250 RC 79854-0008-48 NDC inpatient 1 UN 5.83 5.83 UNITED HEALTHCARE (COMMERCIAL) [3081199] UNITED HEALTHCARE 87726 [308119901] 3.61 percent of total billed charges 3.61 5.54 Technical (Hospital) Services COENZYME Q10 50 MG CAPSULE RX-35228 CDM 6370000100 HCPCS 250 RC 79854-0008-48 NDC inpatient 1 UN 5.83 5.83 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES EPO [308136803] 4.62 percent of total billed charges 3.61 5.54 Technical (Hospital) Services COENZYME Q10 50 MG CAPSULE RX-35228 CDM 6370000100 HCPCS 250 RC 79854-0008-48 NDC inpatient 1 UN 5.83 5.83 CIGNA 62308 [3081051] CIGNA 62308 [308105105] 4.62 percent of total billed charges 3.61 5.54 Technical (Hospital) Services COENZYME Q10 50 MG CAPSULE RX-35228 CDM 6370000100 HCPCS 250 RC 79854-0008-48 NDC inpatient 1 UN 5.83 5.83 CIGNA 62308 [3081051] CIGNA STATE OF WYOMING [308105107] 4.62 percent of total billed charges 3.61 5.54 Technical (Hospital) Services COENZYME Q10 50 MG CAPSULE RX-35228 CDM 6370000100 HCPCS 250 RC 79854-0008-48 NDC inpatient 1 UN 5.83 5.83 BLUE CROSS BLUE SHIELD WELLMARK SB889 [3081026] BCBS WYOMING [308102603] 5.54 percent of total billed charges 3.61 5.54 Technical (Hospital) Services COENZYME Q10 50 MG CAPSULE RX-35228 CDM 6370000100 HCPCS 250 RC 79854-0008-48 NDC inpatient 1 UN 5.83 5.83 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES HDHP [308136802] 4.62 percent of total billed charges 3.61 5.54 Technical (Hospital) Services COENZYME Q10 50 MG CAPSULE RX-35228 CDM 6370000100 HCPCS 250 RC 79854-0008-48 NDC inpatient 1 UN 5.83 5.83 MEDICA (COMMERCIAL) 94265 [3081118] MEDICA CLAIMS [308111801] 5.25 percent of total billed charges 3.61 5.54 Technical (Hospital) Services COENZYME Q10 50 MG CAPSULE RX-35228 CDM 6370000100 HCPCS 250 RC 79854-0008-48 NDC inpatient 1 UN 5.83 5.83 HEALTHPARTNERS SX009 HEALTHPARTNERS 4.62 percent of total billed charges 3.61 5.54 Technical (Hospital) Services COENZYME Q10 50 MG CAPSULE RX-35228 CDM 6370000100 HCPCS 250 RC 79854-0008-48 NDC inpatient 1 UN 5.83 5.83 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES PPO [308136801] 4.62 percent of total billed charges 3.61 5.54 Technical (Hospital) Services COENZYME Q10 50 MG CAPSULE RX-35228 CDM 6370000100 HCPCS 250 RC 79854-0008-48 NDC inpatient 1 UN 5.83 5.83 MULTIPLAN INC 34080 [3081285] MULTIPLAN INC [308128501] 5.54 percent of total billed charges 3.61 5.54 Technical (Hospital) Services "METFORMIN ER 750 MG TABLET,EXTENDED RELEASE 24 HR" RX-35771 CDM 6370000100 HCPCS 250 RC 70010-0492-01 NDC inpatient 1 UN 5.69 5.69 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES EPO [308136803] 4.51 percent of total billed charges 3.53 5.41 Technical (Hospital) Services "METFORMIN ER 750 MG TABLET,EXTENDED RELEASE 24 HR" RX-35771 CDM 6370000100 HCPCS 250 RC 70010-0492-01 NDC inpatient 1 UN 5.69 5.69 CIGNA 62308 [3081051] CIGNA 62308 [308105105] 4.51 percent of total billed charges 3.53 5.41 Technical (Hospital) Services "METFORMIN ER 750 MG TABLET,EXTENDED RELEASE 24 HR" RX-35771 CDM 6370000100 HCPCS 250 RC 70010-0492-01 NDC inpatient 1 UN 5.69 5.69 CIGNA 62308 [3081051] CIGNA STATE OF WYOMING [308105107] 4.51 percent of total billed charges 3.53 5.41 Technical (Hospital) Services "METFORMIN ER 750 MG TABLET,EXTENDED RELEASE 24 HR" RX-35771 CDM 6370000100 HCPCS 250 RC 70010-0492-01 NDC inpatient 1 UN 5.69 5.69 UNITED HEALTHCARE (COMMERCIAL) [3081199] UNITED HEALTHCARE 87726 [308119901] 3.53 percent of total billed charges 3.53 5.41 Technical (Hospital) Services "METFORMIN ER 750 MG TABLET,EXTENDED RELEASE 24 HR" RX-35771 CDM 6370000100 HCPCS 250 RC 70010-0492-01 NDC inpatient 1 UN 5.69 5.69 MEDICA (COMMERCIAL) 94265 [3081118] MEDICA CLAIMS [308111801] 5.12 percent of total billed charges 3.53 5.41 Technical (Hospital) Services "METFORMIN ER 750 MG TABLET,EXTENDED RELEASE 24 HR" RX-35771 CDM 6370000100 HCPCS 250 RC 70010-0492-01 NDC inpatient 1 UN 5.69 5.69 HEALTHPARTNERS SX009 HEALTHPARTNERS 4.51 percent of total billed charges 3.53 5.41 Technical (Hospital) Services "METFORMIN ER 750 MG TABLET,EXTENDED RELEASE 24 HR" RX-35771 CDM 6370000100 HCPCS 250 RC 70010-0492-01 NDC inpatient 1 UN 5.69 5.69 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES HDHP [308136802] 4.51 percent of total billed charges 3.53 5.41 Technical (Hospital) Services "METFORMIN ER 750 MG TABLET,EXTENDED RELEASE 24 HR" RX-35771 CDM 6370000100 HCPCS 250 RC 70010-0492-01 NDC inpatient 1 UN 5.69 5.69 BLUE CROSS BLUE SHIELD WELLMARK SB889 [3081026] BCBS WYOMING [308102603] 5.41 percent of total billed charges 3.53 5.41 Technical (Hospital) Services "METFORMIN ER 750 MG TABLET,EXTENDED RELEASE 24 HR" RX-35771 CDM 6370000100 HCPCS 250 RC 70010-0492-01 NDC inpatient 1 UN 5.69 5.69 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES PPO [308136801] 4.51 percent of total billed charges 3.53 5.41 Technical (Hospital) Services "METFORMIN ER 750 MG TABLET,EXTENDED RELEASE 24 HR" RX-35771 CDM 6370000100 HCPCS 250 RC 70010-0492-01 NDC inpatient 1 UN 5.69 5.69 MULTIPLAN INC 34080 [3081285] MULTIPLAN INC [308128501] 5.41 percent of total billed charges 3.53 5.41 Technical (Hospital) Services "METFORMIN ER 750 MG TABLET,EXTENDED RELEASE 24 HR" RX-35771 CDM 6370000100 HCPCS 250 RC 70010-0492-01 NDC outpatient 1 UN 5.69 5.69 MEDICA (COMMERCIAL) 94265 [3081118] MEDICA CLAIMS [308111801] 5.12 percent of total billed charges 3.53 5.41 Technical (Hospital) Services "METFORMIN ER 750 MG TABLET,EXTENDED RELEASE 24 HR" RX-35771 CDM 6370000100 HCPCS 250 RC 70010-0492-01 NDC outpatient 1 UN 5.69 5.69 MULTIPLAN INC 34080 [3081285] MULTIPLAN INC [308128501] 5.41 percent of total billed charges 3.53 5.41 Technical (Hospital) Services "METFORMIN ER 750 MG TABLET,EXTENDED RELEASE 24 HR" RX-35771 CDM 6370000100 HCPCS 250 RC 70010-0492-01 NDC outpatient 1 UN 5.69 5.69 CIGNA 62308 [3081051] CIGNA 62308 [308105105] 4.55 percent of total billed charges 3.53 5.41 Technical (Hospital) Services "METFORMIN ER 750 MG TABLET,EXTENDED RELEASE 24 HR" RX-35771 CDM 6370000100 HCPCS 250 RC 70010-0492-01 NDC outpatient 1 UN 5.69 5.69 CIGNA 62308 [3081051] CIGNA STATE OF WYOMING [308105107] 4.55 percent of total billed charges 3.53 5.41 Technical (Hospital) Services "METFORMIN ER 750 MG TABLET,EXTENDED RELEASE 24 HR" RX-35771 CDM 6370000100 HCPCS 250 RC 70010-0492-01 NDC outpatient 1 UN 5.69 5.69 UNITED HEALTHCARE (COMMERCIAL) [3081199] UNITED HEALTHCARE 87726 [308119901] 3.53 percent of total billed charges 3.53 5.41 Technical (Hospital) Services "METFORMIN ER 750 MG TABLET,EXTENDED RELEASE 24 HR" RX-35771 CDM 6370000100 HCPCS 250 RC 70010-0492-01 NDC outpatient 1 UN 5.69 5.69 HEALTHPARTNERS SX009 HEALTHPARTNERS 4.55 percent of total billed charges 3.53 5.41 Technical (Hospital) Services "METFORMIN ER 750 MG TABLET,EXTENDED RELEASE 24 HR" RX-35771 CDM 6370000100 HCPCS 250 RC 70010-0492-01 NDC outpatient 1 UN 5.69 5.69 BLUE CROSS BLUE SHIELD WELLMARK SB889 [3081026] BCBS WYOMING [308102603] 5.41 percent of total billed charges 3.53 5.41 Technical (Hospital) Services "METFORMIN ER 750 MG TABLET,EXTENDED RELEASE 24 HR" RX-35771 CDM 6370000100 HCPCS 250 RC 70010-0492-01 NDC outpatient 1 UN 5.69 5.69 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES HDHP [308136802] 4.55 percent of total billed charges 3.53 5.41 Technical (Hospital) Services "METFORMIN ER 750 MG TABLET,EXTENDED RELEASE 24 HR" RX-35771 CDM 6370000100 HCPCS 250 RC 70010-0492-01 NDC outpatient 1 UN 5.69 5.69 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES PPO [308136801] 4.55 percent of total billed charges 3.53 5.41 Technical (Hospital) Services "METFORMIN ER 750 MG TABLET,EXTENDED RELEASE 24 HR" RX-35771 CDM 6370000100 HCPCS 250 RC 70010-0492-01 NDC outpatient 1 UN 5.69 5.69 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES EPO [308136803] 4.55 percent of total billed charges 3.53 5.41 Technical (Hospital) Services HALOPERIDOL 1 MG TABLET RX-3579 CDM 6370000100 HCPCS 250 RC 00378-0257-01 NDC outpatient 1 UN 5.99 5.99 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES EPO [308136803] 4.79 percent of total billed charges 3.71 5.69 Technical (Hospital) Services HALOPERIDOL 1 MG TABLET RX-3579 CDM 6370000100 HCPCS 250 RC 00378-0257-01 NDC outpatient 1 UN 5.99 5.99 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES HDHP [308136802] 4.79 percent of total billed charges 3.71 5.69 Technical (Hospital) Services HALOPERIDOL 1 MG TABLET RX-3579 CDM 6370000100 HCPCS 250 RC 00378-0257-01 NDC outpatient 1 UN 5.99 5.99 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES PPO [308136801] 4.79 percent of total billed charges 3.71 5.69 Technical (Hospital) Services HALOPERIDOL 1 MG TABLET RX-3579 CDM 6370000100 HCPCS 250 RC 00378-0257-01 NDC outpatient 1 UN 5.99 5.99 BLUE CROSS BLUE SHIELD WELLMARK SB889 [3081026] BCBS WYOMING [308102603] 5.69 percent of total billed charges 3.71 5.69 Technical (Hospital) Services HALOPERIDOL 1 MG TABLET RX-3579 CDM 6370000100 HCPCS 250 RC 00378-0257-01 NDC outpatient 1 UN 5.99 5.99 HEALTHPARTNERS SX009 HEALTHPARTNERS 4.79 percent of total billed charges 3.71 5.69 Technical (Hospital) Services HALOPERIDOL 1 MG TABLET RX-3579 CDM 6370000100 HCPCS 250 RC 00378-0257-01 NDC outpatient 1 UN 5.99 5.99 MEDICA (COMMERCIAL) 94265 [3081118] MEDICA CLAIMS [308111801] 5.39 percent of total billed charges 3.71 5.69 Technical (Hospital) Services HALOPERIDOL 1 MG TABLET RX-3579 CDM 6370000100 HCPCS 250 RC 00378-0257-01 NDC outpatient 1 UN 5.99 5.99 CIGNA 62308 [3081051] CIGNA 62308 [308105105] 4.79 percent of total billed charges 3.71 5.69 Technical (Hospital) Services HALOPERIDOL 1 MG TABLET RX-3579 CDM 6370000100 HCPCS 250 RC 00378-0257-01 NDC outpatient 1 UN 5.99 5.99 CIGNA 62308 [3081051] CIGNA STATE OF WYOMING [308105107] 4.79 percent of total billed charges 3.71 5.69 Technical (Hospital) Services HALOPERIDOL 1 MG TABLET RX-3579 CDM 6370000100 HCPCS 250 RC 00378-0257-01 NDC outpatient 1 UN 5.99 5.99 MULTIPLAN INC 34080 [3081285] MULTIPLAN INC [308128501] 5.69 percent of total billed charges 3.71 5.69 Technical (Hospital) Services HALOPERIDOL 1 MG TABLET RX-3579 CDM 6370000100 HCPCS 250 RC 00378-0257-01 NDC outpatient 1 UN 5.99 5.99 UNITED HEALTHCARE (COMMERCIAL) [3081199] UNITED HEALTHCARE 87726 [308119901] 3.71 percent of total billed charges 3.71 5.69 Technical (Hospital) Services HALOPERIDOL 1 MG TABLET RX-3579 CDM 6370000100 HCPCS 250 RC 00378-0257-01 NDC inpatient 1 UN 5.99 5.99 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES HDHP [308136802] 4.74 percent of total billed charges 3.71 5.69 Technical (Hospital) Services HALOPERIDOL 1 MG TABLET RX-3579 CDM 6370000100 HCPCS 250 RC 00378-0257-01 NDC inpatient 1 UN 5.99 5.99 UNITED HEALTHCARE (COMMERCIAL) [3081199] UNITED HEALTHCARE 87726 [308119901] 3.71 percent of total billed charges 3.71 5.69 Technical (Hospital) Services HALOPERIDOL 1 MG TABLET RX-3579 CDM 6370000100 HCPCS 250 RC 00378-0257-01 NDC inpatient 1 UN 5.99 5.99 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES EPO [308136803] 4.74 percent of total billed charges 3.71 5.69 Technical (Hospital) Services HALOPERIDOL 1 MG TABLET RX-3579 CDM 6370000100 HCPCS 250 RC 00378-0257-01 NDC inpatient 1 UN 5.99 5.99 CIGNA 62308 [3081051] CIGNA 62308 [308105105] 4.74 percent of total billed charges 3.71 5.69 Technical (Hospital) Services HALOPERIDOL 1 MG TABLET RX-3579 CDM 6370000100 HCPCS 250 RC 00378-0257-01 NDC inpatient 1 UN 5.99 5.99 CIGNA 62308 [3081051] CIGNA STATE OF WYOMING [308105107] 4.74 percent of total billed charges 3.71 5.69 Technical (Hospital) Services HALOPERIDOL 1 MG TABLET RX-3579 CDM 6370000100 HCPCS 250 RC 00378-0257-01 NDC inpatient 1 UN 5.99 5.99 BLUE CROSS BLUE SHIELD WELLMARK SB889 [3081026] BCBS WYOMING [308102603] 5.69 percent of total billed charges 3.71 5.69 Technical (Hospital) Services HALOPERIDOL 1 MG TABLET RX-3579 CDM 6370000100 HCPCS 250 RC 00378-0257-01 NDC inpatient 1 UN 5.99 5.99 MULTIPLAN INC 34080 [3081285] MULTIPLAN INC [308128501] 5.69 percent of total billed charges 3.71 5.69 Technical (Hospital) Services HALOPERIDOL 1 MG TABLET RX-3579 CDM 6370000100 HCPCS 250 RC 00378-0257-01 NDC inpatient 1 UN 5.99 5.99 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES PPO [308136801] 4.74 percent of total billed charges 3.71 5.69 Technical (Hospital) Services HALOPERIDOL 1 MG TABLET RX-3579 CDM 6370000100 HCPCS 250 RC 00378-0257-01 NDC inpatient 1 UN 5.99 5.99 MEDICA (COMMERCIAL) 94265 [3081118] MEDICA CLAIMS [308111801] 5.39 percent of total billed charges 3.71 5.69 Technical (Hospital) Services HALOPERIDOL 1 MG TABLET RX-3579 CDM 6370000100 HCPCS 250 RC 00378-0257-01 NDC inpatient 1 UN 5.99 5.99 HEALTHPARTNERS SX009 HEALTHPARTNERS 4.74 percent of total billed charges 3.71 5.69 Technical (Hospital) Services MENTHOL 5 % TOPICAL PATCH RX-36121 CDM 6370000100 HCPCS 250 RC 41167-0008-43 NDC inpatient 1 UN 6.67 6.67 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES HDHP [308136802] 5.28 percent of total billed charges 4.14 6.34 Technical (Hospital) Services MENTHOL 5 % TOPICAL PATCH RX-36121 CDM 6370000100 HCPCS 250 RC 41167-0008-43 NDC inpatient 1 UN 6.67 6.67 CIGNA 62308 [3081051] CIGNA STATE OF WYOMING [308105107] 5.28 percent of total billed charges 4.14 6.34 Technical (Hospital) Services MENTHOL 5 % TOPICAL PATCH RX-36121 CDM 6370000100 HCPCS 250 RC 41167-0008-43 NDC inpatient 1 UN 6.67 6.67 CIGNA 62308 [3081051] CIGNA 62308 [308105105] 5.28 percent of total billed charges 4.14 6.34 Technical (Hospital) Services MENTHOL 5 % TOPICAL PATCH RX-36121 CDM 6370000100 HCPCS 250 RC 41167-0008-43 NDC inpatient 1 UN 6.67 6.67 BLUE CROSS BLUE SHIELD WELLMARK SB889 [3081026] BCBS WYOMING [308102603] 6.34 percent of total billed charges 4.14 6.34 Technical (Hospital) Services MENTHOL 5 % TOPICAL PATCH RX-36121 CDM 6370000100 HCPCS 250 RC 41167-0008-43 NDC inpatient 1 UN 6.67 6.67 UNITED HEALTHCARE (COMMERCIAL) [3081199] UNITED HEALTHCARE 87726 [308119901] 4.14 percent of total billed charges 4.14 6.34 Technical (Hospital) Services MENTHOL 5 % TOPICAL PATCH RX-36121 CDM 6370000100 HCPCS 250 RC 41167-0008-43 NDC inpatient 1 UN 6.67 6.67 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES EPO [308136803] 5.28 percent of total billed charges 4.14 6.34 Technical (Hospital) Services MENTHOL 5 % TOPICAL PATCH RX-36121 CDM 6370000100 HCPCS 250 RC 41167-0008-43 NDC inpatient 1 UN 6.67 6.67 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES PPO [308136801] 5.28 percent of total billed charges 4.14 6.34 Technical (Hospital) Services MENTHOL 5 % TOPICAL PATCH RX-36121 CDM 6370000100 HCPCS 250 RC 41167-0008-43 NDC inpatient 1 UN 6.67 6.67 HEALTHPARTNERS SX009 HEALTHPARTNERS 5.28 percent of total billed charges 4.14 6.34 Technical (Hospital) Services MENTHOL 5 % TOPICAL PATCH RX-36121 CDM 6370000100 HCPCS 250 RC 41167-0008-43 NDC inpatient 1 UN 6.67 6.67 MEDICA (COMMERCIAL) 94265 [3081118] MEDICA CLAIMS [308111801] 6 percent of total billed charges 4.14 6.34 Technical (Hospital) Services MENTHOL 5 % TOPICAL PATCH RX-36121 CDM 6370000100 HCPCS 250 RC 41167-0008-43 NDC inpatient 1 UN 6.67 6.67 MULTIPLAN INC 34080 [3081285] MULTIPLAN INC [308128501] 6.34 percent of total billed charges 4.14 6.34 Technical (Hospital) Services MENTHOL 5 % TOPICAL PATCH RX-36121 CDM 6370000100 HCPCS 250 RC 41167-0008-43 NDC outpatient 1 UN 6.67 6.67 MEDICA (COMMERCIAL) 94265 [3081118] MEDICA CLAIMS [308111801] 6 percent of total billed charges 4.14 6.34 Technical (Hospital) Services MENTHOL 5 % TOPICAL PATCH RX-36121 CDM 6370000100 HCPCS 250 RC 41167-0008-43 NDC outpatient 1 UN 6.67 6.67 CIGNA 62308 [3081051] CIGNA 62308 [308105105] 5.34 percent of total billed charges 4.14 6.34 Technical (Hospital) Services MENTHOL 5 % TOPICAL PATCH RX-36121 CDM 6370000100 HCPCS 250 RC 41167-0008-43 NDC outpatient 1 UN 6.67 6.67 CIGNA 62308 [3081051] CIGNA STATE OF WYOMING [308105107] 5.34 percent of total billed charges 4.14 6.34 Technical (Hospital) Services MENTHOL 5 % TOPICAL PATCH RX-36121 CDM 6370000100 HCPCS 250 RC 41167-0008-43 NDC outpatient 1 UN 6.67 6.67 MULTIPLAN INC 34080 [3081285] MULTIPLAN INC [308128501] 6.34 percent of total billed charges 4.14 6.34 Technical (Hospital) Services MENTHOL 5 % TOPICAL PATCH RX-36121 CDM 6370000100 HCPCS 250 RC 41167-0008-43 NDC outpatient 1 UN 6.67 6.67 UNITED HEALTHCARE (COMMERCIAL) [3081199] UNITED HEALTHCARE 87726 [308119901] 4.14 percent of total billed charges 4.14 6.34 Technical (Hospital) Services MENTHOL 5 % TOPICAL PATCH RX-36121 CDM 6370000100 HCPCS 250 RC 41167-0008-43 NDC outpatient 1 UN 6.67 6.67 HEALTHPARTNERS SX009 HEALTHPARTNERS 5.34 percent of total billed charges 4.14 6.34 Technical (Hospital) Services MENTHOL 5 % TOPICAL PATCH RX-36121 CDM 6370000100 HCPCS 250 RC 41167-0008-43 NDC outpatient 1 UN 6.67 6.67 BLUE CROSS BLUE SHIELD WELLMARK SB889 [3081026] BCBS WYOMING [308102603] 6.34 percent of total billed charges 4.14 6.34 Technical (Hospital) Services MENTHOL 5 % TOPICAL PATCH RX-36121 CDM 6370000100 HCPCS 250 RC 41167-0008-43 NDC outpatient 1 UN 6.67 6.67 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES EPO [308136803] 5.34 percent of total billed charges 4.14 6.34 Technical (Hospital) Services MENTHOL 5 % TOPICAL PATCH RX-36121 CDM 6370000100 HCPCS 250 RC 41167-0008-43 NDC outpatient 1 UN 6.67 6.67 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES PPO [308136801] 5.34 percent of total billed charges 4.14 6.34 Technical (Hospital) Services MENTHOL 5 % TOPICAL PATCH RX-36121 CDM 6370000100 HCPCS 250 RC 41167-0008-43 NDC outpatient 1 UN 6.67 6.67 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES HDHP [308136802] 5.34 percent of total billed charges 4.14 6.34 Technical (Hospital) Services AMANTADINE HCL 100 MG CAPSULE RX-364 CDM 6370000100 HCPCS 250 RC 42543-0493-01 NDC outpatient 1 UN 6.02 6.02 CIGNA 62308 [3081051] CIGNA 62308 [308105105] 4.82 percent of total billed charges 3.73 5.72 Technical (Hospital) Services AMANTADINE HCL 100 MG CAPSULE RX-364 CDM 6370000100 HCPCS 250 RC 42543-0493-01 NDC outpatient 1 UN 6.02 6.02 CIGNA 62308 [3081051] CIGNA STATE OF WYOMING [308105107] 4.82 percent of total billed charges 3.73 5.72 Technical (Hospital) Services AMANTADINE HCL 100 MG CAPSULE RX-364 CDM 6370000100 HCPCS 250 RC 42543-0493-01 NDC outpatient 1 UN 6.02 6.02 MULTIPLAN INC 34080 [3081285] MULTIPLAN INC [308128501] 5.72 percent of total billed charges 3.73 5.72 Technical (Hospital) Services AMANTADINE HCL 100 MG CAPSULE RX-364 CDM 6370000100 HCPCS 250 RC 42543-0493-01 NDC outpatient 1 UN 6.02 6.02 MEDICA (COMMERCIAL) 94265 [3081118] MEDICA CLAIMS [308111801] 5.42 percent of total billed charges 3.73 5.72 Technical (Hospital) Services AMANTADINE HCL 100 MG CAPSULE RX-364 CDM 6370000100 HCPCS 250 RC 42543-0493-01 NDC outpatient 1 UN 6.02 6.02 UNITED HEALTHCARE (COMMERCIAL) [3081199] UNITED HEALTHCARE 87726 [308119901] 3.73 percent of total billed charges 3.73 5.72 Technical (Hospital) Services AMANTADINE HCL 100 MG CAPSULE RX-364 CDM 6370000100 HCPCS 250 RC 42543-0493-01 NDC outpatient 1 UN 6.02 6.02 HEALTHPARTNERS SX009 HEALTHPARTNERS 4.82 percent of total billed charges 3.73 5.72 Technical (Hospital) Services AMANTADINE HCL 100 MG CAPSULE RX-364 CDM 6370000100 HCPCS 250 RC 42543-0493-01 NDC outpatient 1 UN 6.02 6.02 BLUE CROSS BLUE SHIELD WELLMARK SB889 [3081026] BCBS WYOMING [308102603] 5.72 percent of total billed charges 3.73 5.72 Technical (Hospital) Services AMANTADINE HCL 100 MG CAPSULE RX-364 CDM 6370000100 HCPCS 250 RC 42543-0493-01 NDC outpatient 1 UN 6.02 6.02 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES EPO [308136803] 4.82 percent of total billed charges 3.73 5.72 Technical (Hospital) Services AMANTADINE HCL 100 MG CAPSULE RX-364 CDM 6370000100 HCPCS 250 RC 42543-0493-01 NDC outpatient 1 UN 6.02 6.02 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES HDHP [308136802] 4.82 percent of total billed charges 3.73 5.72 Technical (Hospital) Services AMANTADINE HCL 100 MG CAPSULE RX-364 CDM 6370000100 HCPCS 250 RC 42543-0493-01 NDC outpatient 1 UN 6.02 6.02 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES PPO [308136801] 4.82 percent of total billed charges 3.73 5.72 Technical (Hospital) Services AMANTADINE HCL 100 MG CAPSULE RX-364 CDM 6370000100 HCPCS 250 RC 42543-0493-01 NDC inpatient 1 UN 6.02 6.02 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES PPO [308136801] 4.77 percent of total billed charges 3.73 5.72 Technical (Hospital) Services AMANTADINE HCL 100 MG CAPSULE RX-364 CDM 6370000100 HCPCS 250 RC 42543-0493-01 NDC inpatient 1 UN 6.02 6.02 HEALTHPARTNERS SX009 HEALTHPARTNERS 4.77 percent of total billed charges 3.73 5.72 Technical (Hospital) Services AMANTADINE HCL 100 MG CAPSULE RX-364 CDM 6370000100 HCPCS 250 RC 42543-0493-01 NDC inpatient 1 UN 6.02 6.02 MEDICA (COMMERCIAL) 94265 [3081118] MEDICA CLAIMS [308111801] 5.42 percent of total billed charges 3.73 5.72 Technical (Hospital) Services AMANTADINE HCL 100 MG CAPSULE RX-364 CDM 6370000100 HCPCS 250 RC 42543-0493-01 NDC inpatient 1 UN 6.02 6.02 MULTIPLAN INC 34080 [3081285] MULTIPLAN INC [308128501] 5.72 percent of total billed charges 3.73 5.72 Technical (Hospital) Services AMANTADINE HCL 100 MG CAPSULE RX-364 CDM 6370000100 HCPCS 250 RC 42543-0493-01 NDC inpatient 1 UN 6.02 6.02 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES HDHP [308136802] 4.77 percent of total billed charges 3.73 5.72 Technical (Hospital) Services AMANTADINE HCL 100 MG CAPSULE RX-364 CDM 6370000100 HCPCS 250 RC 42543-0493-01 NDC inpatient 1 UN 6.02 6.02 BLUE CROSS BLUE SHIELD WELLMARK SB889 [3081026] BCBS WYOMING [308102603] 5.72 percent of total billed charges 3.73 5.72 Technical (Hospital) Services AMANTADINE HCL 100 MG CAPSULE RX-364 CDM 6370000100 HCPCS 250 RC 42543-0493-01 NDC inpatient 1 UN 6.02 6.02 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES EPO [308136803] 4.77 percent of total billed charges 3.73 5.72 Technical (Hospital) Services AMANTADINE HCL 100 MG CAPSULE RX-364 CDM 6370000100 HCPCS 250 RC 42543-0493-01 NDC inpatient 1 UN 6.02 6.02 CIGNA 62308 [3081051] CIGNA 62308 [308105105] 4.77 percent of total billed charges 3.73 5.72 Technical (Hospital) Services AMANTADINE HCL 100 MG CAPSULE RX-364 CDM 6370000100 HCPCS 250 RC 42543-0493-01 NDC inpatient 1 UN 6.02 6.02 CIGNA 62308 [3081051] CIGNA STATE OF WYOMING [308105107] 4.77 percent of total billed charges 3.73 5.72 Technical (Hospital) Services AMANTADINE HCL 100 MG CAPSULE RX-364 CDM 6370000100 HCPCS 250 RC 42543-0493-01 NDC inpatient 1 UN 6.02 6.02 UNITED HEALTHCARE (COMMERCIAL) [3081199] UNITED HEALTHCARE 87726 [308119901] 3.73 percent of total billed charges 3.73 5.72 Technical (Hospital) Services ARIPIPRAZOLE 5 MG TABLET RX-36438 CDM 6370000100 HCPCS 250 RC 13668-0217-30 NDC inpatient 1 UN 5.85 5.85 HEALTHPARTNERS SX009 HEALTHPARTNERS 4.63 percent of total billed charges 3.63 5.56 Technical (Hospital) Services ARIPIPRAZOLE 5 MG TABLET RX-36438 CDM 6370000100 HCPCS 250 RC 13668-0217-30 NDC inpatient 1 UN 5.85 5.85 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES HDHP [308136802] 4.63 percent of total billed charges 3.63 5.56 Technical (Hospital) Services ARIPIPRAZOLE 5 MG TABLET RX-36438 CDM 6370000100 HCPCS 250 RC 13668-0217-30 NDC inpatient 1 UN 5.85 5.85 UNITED HEALTHCARE (COMMERCIAL) [3081199] UNITED HEALTHCARE 87726 [308119901] 3.63 percent of total billed charges 3.63 5.56 Technical (Hospital) Services ARIPIPRAZOLE 5 MG TABLET RX-36438 CDM 6370000100 HCPCS 250 RC 13668-0217-30 NDC inpatient 1 UN 5.85 5.85 CIGNA 62308 [3081051] CIGNA 62308 [308105105] 4.63 percent of total billed charges 3.63 5.56 Technical (Hospital) Services ARIPIPRAZOLE 5 MG TABLET RX-36438 CDM 6370000100 HCPCS 250 RC 13668-0217-30 NDC inpatient 1 UN 5.85 5.85 CIGNA 62308 [3081051] CIGNA STATE OF WYOMING [308105107] 4.63 percent of total billed charges 3.63 5.56 Technical (Hospital) Services ARIPIPRAZOLE 5 MG TABLET RX-36438 CDM 6370000100 HCPCS 250 RC 13668-0217-30 NDC inpatient 1 UN 5.85 5.85 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES EPO [308136803] 4.63 percent of total billed charges 3.63 5.56 Technical (Hospital) Services ARIPIPRAZOLE 5 MG TABLET RX-36438 CDM 6370000100 HCPCS 250 RC 13668-0217-30 NDC inpatient 1 UN 5.85 5.85 BLUE CROSS BLUE SHIELD WELLMARK SB889 [3081026] BCBS WYOMING [308102603] 5.56 percent of total billed charges 3.63 5.56 Technical (Hospital) Services ARIPIPRAZOLE 5 MG TABLET RX-36438 CDM 6370000100 HCPCS 250 RC 13668-0217-30 NDC inpatient 1 UN 5.85 5.85 MULTIPLAN INC 34080 [3081285] MULTIPLAN INC [308128501] 5.56 percent of total billed charges 3.63 5.56 Technical (Hospital) Services ARIPIPRAZOLE 5 MG TABLET RX-36438 CDM 6370000100 HCPCS 250 RC 13668-0217-30 NDC inpatient 1 UN 5.85 5.85 MEDICA (COMMERCIAL) 94265 [3081118] MEDICA CLAIMS [308111801] 5.27 percent of total billed charges 3.63 5.56 Technical (Hospital) Services ARIPIPRAZOLE 5 MG TABLET RX-36438 CDM 6370000100 HCPCS 250 RC 13668-0217-30 NDC inpatient 1 UN 5.85 5.85 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES PPO [308136801] 4.63 percent of total billed charges 3.63 5.56 Technical (Hospital) Services ARIPIPRAZOLE 5 MG TABLET RX-36438 CDM 6370000100 HCPCS 250 RC 13668-0217-30 NDC outpatient 1 UN 5.85 5.85 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES HDHP [308136802] 4.68 percent of total billed charges 3.63 5.56 Technical (Hospital) Services ARIPIPRAZOLE 5 MG TABLET RX-36438 CDM 6370000100 HCPCS 250 RC 13668-0217-30 NDC outpatient 1 UN 5.85 5.85 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES PPO [308136801] 4.68 percent of total billed charges 3.63 5.56 Technical (Hospital) Services ARIPIPRAZOLE 5 MG TABLET RX-36438 CDM 6370000100 HCPCS 250 RC 13668-0217-30 NDC outpatient 1 UN 5.85 5.85 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES EPO [308136803] 4.68 percent of total billed charges 3.63 5.56 Technical (Hospital) Services ARIPIPRAZOLE 5 MG TABLET RX-36438 CDM 6370000100 HCPCS 250 RC 13668-0217-30 NDC outpatient 1 UN 5.85 5.85 CIGNA 62308 [3081051] CIGNA 62308 [308105105] 4.68 percent of total billed charges 3.63 5.56 Technical (Hospital) Services ARIPIPRAZOLE 5 MG TABLET RX-36438 CDM 6370000100 HCPCS 250 RC 13668-0217-30 NDC outpatient 1 UN 5.85 5.85 CIGNA 62308 [3081051] CIGNA STATE OF WYOMING [308105107] 4.68 percent of total billed charges 3.63 5.56 Technical (Hospital) Services ARIPIPRAZOLE 5 MG TABLET RX-36438 CDM 6370000100 HCPCS 250 RC 13668-0217-30 NDC outpatient 1 UN 5.85 5.85 MULTIPLAN INC 34080 [3081285] MULTIPLAN INC [308128501] 5.56 percent of total billed charges 3.63 5.56 Technical (Hospital) Services ARIPIPRAZOLE 5 MG TABLET RX-36438 CDM 6370000100 HCPCS 250 RC 13668-0217-30 NDC outpatient 1 UN 5.85 5.85 MEDICA (COMMERCIAL) 94265 [3081118] MEDICA CLAIMS [308111801] 5.27 percent of total billed charges 3.63 5.56 Technical (Hospital) Services ARIPIPRAZOLE 5 MG TABLET RX-36438 CDM 6370000100 HCPCS 250 RC 13668-0217-30 NDC outpatient 1 UN 5.85 5.85 UNITED HEALTHCARE (COMMERCIAL) [3081199] UNITED HEALTHCARE 87726 [308119901] 3.63 percent of total billed charges 3.63 5.56 Technical (Hospital) Services ARIPIPRAZOLE 5 MG TABLET RX-36438 CDM 6370000100 HCPCS 250 RC 13668-0217-30 NDC outpatient 1 UN 5.85 5.85 HEALTHPARTNERS SX009 HEALTHPARTNERS 4.68 percent of total billed charges 3.63 5.56 Technical (Hospital) Services ARIPIPRAZOLE 5 MG TABLET RX-36438 CDM 6370000100 HCPCS 250 RC 13668-0217-30 NDC outpatient 1 UN 5.85 5.85 BLUE CROSS BLUE SHIELD WELLMARK SB889 [3081026] BCBS WYOMING [308102603] 5.56 percent of total billed charges 3.63 5.56 Technical (Hospital) Services "CIPROFLOXACIN 0.3 %-DEXAMETHASONE 0.1 % EAR DROPS,SUSPENSION" RX-36576 CDM 6370000100 HCPCS 250 RC 43598-0326-75 NDC outpatient 7.6 ML 985 985 HEALTHPARTNERS SX009 HEALTHPARTNERS 788 percent of total billed charges 610.7 935.75 Technical (Hospital) Services "CIPROFLOXACIN 0.3 %-DEXAMETHASONE 0.1 % EAR DROPS,SUSPENSION" RX-36576 CDM 6370000100 HCPCS 250 RC 43598-0326-75 NDC outpatient 7.6 ML 985 985 UNITED HEALTHCARE (COMMERCIAL) [3081199] UNITED HEALTHCARE 87726 [308119901] 610.7 percent of total billed charges 610.7 935.75 Technical (Hospital) Services "CIPROFLOXACIN 0.3 %-DEXAMETHASONE 0.1 % EAR DROPS,SUSPENSION" RX-36576 CDM 6370000100 HCPCS 250 RC 43598-0326-75 NDC outpatient 7.6 ML 985 985 BLUE CROSS BLUE SHIELD WELLMARK SB889 [3081026] BCBS WYOMING [308102603] 935.75 percent of total billed charges 610.7 935.75 Technical (Hospital) Services "CIPROFLOXACIN 0.3 %-DEXAMETHASONE 0.1 % EAR DROPS,SUSPENSION" RX-36576 CDM 6370000100 HCPCS 250 RC 43598-0326-75 NDC outpatient 7.6 ML 985 985 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES EPO [308136803] 788 percent of total billed charges 610.7 935.75 Technical (Hospital) Services "CIPROFLOXACIN 0.3 %-DEXAMETHASONE 0.1 % EAR DROPS,SUSPENSION" RX-36576 CDM 6370000100 HCPCS 250 RC 43598-0326-75 NDC outpatient 7.6 ML 985 985 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES HDHP [308136802] 788 percent of total billed charges 610.7 935.75 Technical (Hospital) Services "CIPROFLOXACIN 0.3 %-DEXAMETHASONE 0.1 % EAR DROPS,SUSPENSION" RX-36576 CDM 6370000100 HCPCS 250 RC 43598-0326-75 NDC outpatient 7.6 ML 985 985 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES PPO [308136801] 788 percent of total billed charges 610.7 935.75 Technical (Hospital) Services "CIPROFLOXACIN 0.3 %-DEXAMETHASONE 0.1 % EAR DROPS,SUSPENSION" RX-36576 CDM 6370000100 HCPCS 250 RC 43598-0326-75 NDC outpatient 7.6 ML 985 985 CIGNA 62308 [3081051] CIGNA 62308 [308105105] 788 percent of total billed charges 610.7 935.75 Technical (Hospital) Services "CIPROFLOXACIN 0.3 %-DEXAMETHASONE 0.1 % EAR DROPS,SUSPENSION" RX-36576 CDM 6370000100 HCPCS 250 RC 43598-0326-75 NDC outpatient 7.6 ML 985 985 CIGNA 62308 [3081051] CIGNA STATE OF WYOMING [308105107] 788 percent of total billed charges 610.7 935.75 Technical (Hospital) Services "CIPROFLOXACIN 0.3 %-DEXAMETHASONE 0.1 % EAR DROPS,SUSPENSION" RX-36576 CDM 6370000100 HCPCS 250 RC 43598-0326-75 NDC outpatient 7.6 ML 985 985 MULTIPLAN INC 34080 [3081285] MULTIPLAN INC [308128501] 935.75 percent of total billed charges 610.7 935.75 Technical (Hospital) Services "CIPROFLOXACIN 0.3 %-DEXAMETHASONE 0.1 % EAR DROPS,SUSPENSION" RX-36576 CDM 6370000100 HCPCS 250 RC 43598-0326-75 NDC outpatient 7.6 ML 985 985 MEDICA (COMMERCIAL) 94265 [3081118] MEDICA CLAIMS [308111801] 886.5 percent of total billed charges 610.7 935.75 Technical (Hospital) Services "CIPROFLOXACIN 0.3 %-DEXAMETHASONE 0.1 % EAR DROPS,SUSPENSION" RX-36576 CDM 6370000100 HCPCS 250 RC 43598-0326-75 NDC inpatient 7.6 ML 985 985 CIGNA 62308 [3081051] CIGNA 62308 [308105105] 779.92 percent of total billed charges 610.7 935.75 Technical (Hospital) Services "CIPROFLOXACIN 0.3 %-DEXAMETHASONE 0.1 % EAR DROPS,SUSPENSION" RX-36576 CDM 6370000100 HCPCS 250 RC 43598-0326-75 NDC inpatient 7.6 ML 985 985 CIGNA 62308 [3081051] CIGNA STATE OF WYOMING [308105107] 779.92 percent of total billed charges 610.7 935.75 Technical (Hospital) Services "CIPROFLOXACIN 0.3 %-DEXAMETHASONE 0.1 % EAR DROPS,SUSPENSION" RX-36576 CDM 6370000100 HCPCS 250 RC 43598-0326-75 NDC inpatient 7.6 ML 985 985 UNITED HEALTHCARE (COMMERCIAL) [3081199] UNITED HEALTHCARE 87726 [308119901] 610.7 percent of total billed charges 610.7 935.75 Technical (Hospital) Services "CIPROFLOXACIN 0.3 %-DEXAMETHASONE 0.1 % EAR DROPS,SUSPENSION" RX-36576 CDM 6370000100 HCPCS 250 RC 43598-0326-75 NDC inpatient 7.6 ML 985 985 BLUE CROSS BLUE SHIELD WELLMARK SB889 [3081026] BCBS WYOMING [308102603] 935.75 percent of total billed charges 610.7 935.75 Technical (Hospital) Services "CIPROFLOXACIN 0.3 %-DEXAMETHASONE 0.1 % EAR DROPS,SUSPENSION" RX-36576 CDM 6370000100 HCPCS 250 RC 43598-0326-75 NDC inpatient 7.6 ML 985 985 MULTIPLAN INC 34080 [3081285] MULTIPLAN INC [308128501] 935.75 percent of total billed charges 610.7 935.75 Technical (Hospital) Services "CIPROFLOXACIN 0.3 %-DEXAMETHASONE 0.1 % EAR DROPS,SUSPENSION" RX-36576 CDM 6370000100 HCPCS 250 RC 43598-0326-75 NDC inpatient 7.6 ML 985 985 MEDICA (COMMERCIAL) 94265 [3081118] MEDICA CLAIMS [308111801] 886.5 percent of total billed charges 610.7 935.75 Technical (Hospital) Services "CIPROFLOXACIN 0.3 %-DEXAMETHASONE 0.1 % EAR DROPS,SUSPENSION" RX-36576 CDM 6370000100 HCPCS 250 RC 43598-0326-75 NDC inpatient 7.6 ML 985 985 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES PPO [308136801] 779.92 percent of total billed charges 610.7 935.75 Technical (Hospital) Services "CIPROFLOXACIN 0.3 %-DEXAMETHASONE 0.1 % EAR DROPS,SUSPENSION" RX-36576 CDM 6370000100 HCPCS 250 RC 43598-0326-75 NDC inpatient 7.6 ML 985 985 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES EPO [308136803] 779.92 percent of total billed charges 610.7 935.75 Technical (Hospital) Services "CIPROFLOXACIN 0.3 %-DEXAMETHASONE 0.1 % EAR DROPS,SUSPENSION" RX-36576 CDM 6370000100 HCPCS 250 RC 43598-0326-75 NDC inpatient 7.6 ML 985 985 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES HDHP [308136802] 779.92 percent of total billed charges 610.7 935.75 Technical (Hospital) Services "CIPROFLOXACIN 0.3 %-DEXAMETHASONE 0.1 % EAR DROPS,SUSPENSION" RX-36576 CDM 6370000100 HCPCS 250 RC 43598-0326-75 NDC inpatient 7.6 ML 985 985 HEALTHPARTNERS SX009 HEALTHPARTNERS 779.92 percent of total billed charges 610.7 935.75 Technical (Hospital) Services LEVETIRACETAM 100 MG/ML ORAL SOLUTION RX-36590 CDM 6370000100 HCPCS 250 RC 16714-0358-01 NDC outpatient 473 ML 147.77 147.77 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES EPO [308136803] 118.22 percent of total billed charges 91.62 140.38 Technical (Hospital) Services LEVETIRACETAM 100 MG/ML ORAL SOLUTION RX-36590 CDM 6370000100 HCPCS 250 RC 16714-0358-01 NDC outpatient 473 ML 147.77 147.77 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES HDHP [308136802] 118.22 percent of total billed charges 91.62 140.38 Technical (Hospital) Services LEVETIRACETAM 100 MG/ML ORAL SOLUTION RX-36590 CDM 6370000100 HCPCS 250 RC 16714-0358-01 NDC outpatient 473 ML 147.77 147.77 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES PPO [308136801] 118.22 percent of total billed charges 91.62 140.38 Technical (Hospital) Services LEVETIRACETAM 100 MG/ML ORAL SOLUTION RX-36590 CDM 6370000100 HCPCS 250 RC 16714-0358-01 NDC outpatient 473 ML 147.77 147.77 BLUE CROSS BLUE SHIELD WELLMARK SB889 [3081026] BCBS WYOMING [308102603] 140.38 percent of total billed charges 91.62 140.38 Technical (Hospital) Services LEVETIRACETAM 100 MG/ML ORAL SOLUTION RX-36590 CDM 6370000100 HCPCS 250 RC 16714-0358-01 NDC outpatient 473 ML 147.77 147.77 HEALTHPARTNERS SX009 HEALTHPARTNERS 118.22 percent of total billed charges 91.62 140.38 Technical (Hospital) Services LEVETIRACETAM 100 MG/ML ORAL SOLUTION RX-36590 CDM 6370000100 HCPCS 250 RC 16714-0358-01 NDC outpatient 473 ML 147.77 147.77 UNITED HEALTHCARE (COMMERCIAL) [3081199] UNITED HEALTHCARE 87726 [308119901] 91.62 percent of total billed charges 91.62 140.38 Technical (Hospital) Services LEVETIRACETAM 100 MG/ML ORAL SOLUTION RX-36590 CDM 6370000100 HCPCS 250 RC 16714-0358-01 NDC outpatient 473 ML 147.77 147.77 MULTIPLAN INC 34080 [3081285] MULTIPLAN INC [308128501] 140.38 percent of total billed charges 91.62 140.38 Technical (Hospital) Services LEVETIRACETAM 100 MG/ML ORAL SOLUTION RX-36590 CDM 6370000100 HCPCS 250 RC 16714-0358-01 NDC outpatient 473 ML 147.77 147.77 MEDICA (COMMERCIAL) 94265 [3081118] MEDICA CLAIMS [308111801] 132.99 percent of total billed charges 91.62 140.38 Technical (Hospital) Services LEVETIRACETAM 100 MG/ML ORAL SOLUTION RX-36590 CDM 6370000100 HCPCS 250 RC 16714-0358-01 NDC outpatient 473 ML 147.77 147.77 CIGNA 62308 [3081051] CIGNA 62308 [308105105] 118.22 percent of total billed charges 91.62 140.38 Technical (Hospital) Services LEVETIRACETAM 100 MG/ML ORAL SOLUTION RX-36590 CDM 6370000100 HCPCS 250 RC 16714-0358-01 NDC outpatient 473 ML 147.77 147.77 CIGNA 62308 [3081051] CIGNA STATE OF WYOMING [308105107] 118.22 percent of total billed charges 91.62 140.38 Technical (Hospital) Services LEVETIRACETAM 100 MG/ML ORAL SOLUTION RX-36590 CDM 6370000100 HCPCS 250 RC 16714-0358-01 NDC inpatient 473 ML 147.77 147.77 CIGNA 62308 [3081051] CIGNA 62308 [308105105] 117 percent of total billed charges 91.62 140.38 Technical (Hospital) Services LEVETIRACETAM 100 MG/ML ORAL SOLUTION RX-36590 CDM 6370000100 HCPCS 250 RC 16714-0358-01 NDC inpatient 473 ML 147.77 147.77 CIGNA 62308 [3081051] CIGNA STATE OF WYOMING [308105107] 117 percent of total billed charges 91.62 140.38 Technical (Hospital) Services LEVETIRACETAM 100 MG/ML ORAL SOLUTION RX-36590 CDM 6370000100 HCPCS 250 RC 16714-0358-01 NDC inpatient 473 ML 147.77 147.77 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES EPO [308136803] 117 percent of total billed charges 91.62 140.38 Technical (Hospital) Services LEVETIRACETAM 100 MG/ML ORAL SOLUTION RX-36590 CDM 6370000100 HCPCS 250 RC 16714-0358-01 NDC inpatient 473 ML 147.77 147.77 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES HDHP [308136802] 117 percent of total billed charges 91.62 140.38 Technical (Hospital) Services LEVETIRACETAM 100 MG/ML ORAL SOLUTION RX-36590 CDM 6370000100 HCPCS 250 RC 16714-0358-01 NDC inpatient 473 ML 147.77 147.77 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES PPO [308136801] 117 percent of total billed charges 91.62 140.38 Technical (Hospital) Services LEVETIRACETAM 100 MG/ML ORAL SOLUTION RX-36590 CDM 6370000100 HCPCS 250 RC 16714-0358-01 NDC inpatient 473 ML 147.77 147.77 BLUE CROSS BLUE SHIELD WELLMARK SB889 [3081026] BCBS WYOMING [308102603] 140.38 percent of total billed charges 91.62 140.38 Technical (Hospital) Services LEVETIRACETAM 100 MG/ML ORAL SOLUTION RX-36590 CDM 6370000100 HCPCS 250 RC 16714-0358-01 NDC inpatient 473 ML 147.77 147.77 UNITED HEALTHCARE (COMMERCIAL) [3081199] UNITED HEALTHCARE 87726 [308119901] 91.62 percent of total billed charges 91.62 140.38 Technical (Hospital) Services LEVETIRACETAM 100 MG/ML ORAL SOLUTION RX-36590 CDM 6370000100 HCPCS 250 RC 16714-0358-01 NDC inpatient 473 ML 147.77 147.77 MEDICA (COMMERCIAL) 94265 [3081118] MEDICA CLAIMS [308111801] 132.99 percent of total billed charges 91.62 140.38 Technical (Hospital) Services LEVETIRACETAM 100 MG/ML ORAL SOLUTION RX-36590 CDM 6370000100 HCPCS 250 RC 16714-0358-01 NDC inpatient 473 ML 147.77 147.77 MULTIPLAN INC 34080 [3081285] MULTIPLAN INC [308128501] 140.38 percent of total billed charges 91.62 140.38 Technical (Hospital) Services LEVETIRACETAM 100 MG/ML ORAL SOLUTION RX-36590 CDM 6370000100 HCPCS 250 RC 16714-0358-01 NDC inpatient 473 ML 147.77 147.77 HEALTHPARTNERS SX009 HEALTHPARTNERS 117 percent of total billed charges 91.62 140.38 Technical (Hospital) Services ROSUVASTATIN 5 MG TABLET RX-36612 CDM 6370000100 HCPCS 250 RC 00904-6778-61 NDC outpatient 1 UN 6.62 6.62 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES PPO [308136801] 5.3 percent of total billed charges 4.1 6.29 Technical (Hospital) Services ROSUVASTATIN 5 MG TABLET RX-36612 CDM 6370000100 HCPCS 250 RC 00904-6778-61 NDC outpatient 1 UN 6.62 6.62 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES HDHP [308136802] 5.3 percent of total billed charges 4.1 6.29 Technical (Hospital) Services ROSUVASTATIN 5 MG TABLET RX-36612 CDM 6370000100 HCPCS 250 RC 00904-6778-61 NDC outpatient 1 UN 6.62 6.62 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES EPO [308136803] 5.3 percent of total billed charges 4.1 6.29 Technical (Hospital) Services ROSUVASTATIN 5 MG TABLET RX-36612 CDM 6370000100 HCPCS 250 RC 00904-6778-61 NDC outpatient 1 UN 6.62 6.62 MEDICA (COMMERCIAL) 94265 [3081118] MEDICA CLAIMS [308111801] 5.96 percent of total billed charges 4.1 6.29 Technical (Hospital) Services ROSUVASTATIN 5 MG TABLET RX-36612 CDM 6370000100 HCPCS 250 RC 00904-6778-61 NDC outpatient 1 UN 6.62 6.62 CIGNA 62308 [3081051] CIGNA 62308 [308105105] 5.3 percent of total billed charges 4.1 6.29 Technical (Hospital) Services ROSUVASTATIN 5 MG TABLET RX-36612 CDM 6370000100 HCPCS 250 RC 00904-6778-61 NDC outpatient 1 UN 6.62 6.62 CIGNA 62308 [3081051] CIGNA STATE OF WYOMING [308105107] 5.3 percent of total billed charges 4.1 6.29 Technical (Hospital) Services ROSUVASTATIN 5 MG TABLET RX-36612 CDM 6370000100 HCPCS 250 RC 00904-6778-61 NDC outpatient 1 UN 6.62 6.62 MULTIPLAN INC 34080 [3081285] MULTIPLAN INC [308128501] 6.29 percent of total billed charges 4.1 6.29 Technical (Hospital) Services ROSUVASTATIN 5 MG TABLET RX-36612 CDM 6370000100 HCPCS 250 RC 00904-6778-61 NDC outpatient 1 UN 6.62 6.62 UNITED HEALTHCARE (COMMERCIAL) [3081199] UNITED HEALTHCARE 87726 [308119901] 4.1 percent of total billed charges 4.1 6.29 Technical (Hospital) Services ROSUVASTATIN 5 MG TABLET RX-36612 CDM 6370000100 HCPCS 250 RC 00904-6778-61 NDC outpatient 1 UN 6.62 6.62 HEALTHPARTNERS SX009 HEALTHPARTNERS 5.3 percent of total billed charges 4.1 6.29 Technical (Hospital) Services ROSUVASTATIN 5 MG TABLET RX-36612 CDM 6370000100 HCPCS 250 RC 00904-6778-61 NDC outpatient 1 UN 6.62 6.62 BLUE CROSS BLUE SHIELD WELLMARK SB889 [3081026] BCBS WYOMING [308102603] 6.29 percent of total billed charges 4.1 6.29 Technical (Hospital) Services ROSUVASTATIN 5 MG TABLET RX-36612 CDM 6370000100 HCPCS 250 RC 00904-6778-61 NDC inpatient 1 UN 6.62 6.62 HEALTHPARTNERS SX009 HEALTHPARTNERS 5.24 percent of total billed charges 4.1 6.29 Technical (Hospital) Services ROSUVASTATIN 5 MG TABLET RX-36612 CDM 6370000100 HCPCS 250 RC 00904-6778-61 NDC inpatient 1 UN 6.62 6.62 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES PPO [308136801] 5.24 percent of total billed charges 4.1 6.29 Technical (Hospital) Services ROSUVASTATIN 5 MG TABLET RX-36612 CDM 6370000100 HCPCS 250 RC 00904-6778-61 NDC inpatient 1 UN 6.62 6.62 MEDICA (COMMERCIAL) 94265 [3081118] MEDICA CLAIMS [308111801] 5.96 percent of total billed charges 4.1 6.29 Technical (Hospital) Services ROSUVASTATIN 5 MG TABLET RX-36612 CDM 6370000100 HCPCS 250 RC 00904-6778-61 NDC inpatient 1 UN 6.62 6.62 MULTIPLAN INC 34080 [3081285] MULTIPLAN INC [308128501] 6.29 percent of total billed charges 4.1 6.29 Technical (Hospital) Services ROSUVASTATIN 5 MG TABLET RX-36612 CDM 6370000100 HCPCS 250 RC 00904-6778-61 NDC inpatient 1 UN 6.62 6.62 CIGNA 62308 [3081051] CIGNA 62308 [308105105] 5.24 percent of total billed charges 4.1 6.29 Technical (Hospital) Services ROSUVASTATIN 5 MG TABLET RX-36612 CDM 6370000100 HCPCS 250 RC 00904-6778-61 NDC inpatient 1 UN 6.62 6.62 CIGNA 62308 [3081051] CIGNA STATE OF WYOMING [308105107] 5.24 percent of total billed charges 4.1 6.29 Technical (Hospital) Services ROSUVASTATIN 5 MG TABLET RX-36612 CDM 6370000100 HCPCS 250 RC 00904-6778-61 NDC inpatient 1 UN 6.62 6.62 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES HDHP [308136802] 5.24 percent of total billed charges 4.1 6.29 Technical (Hospital) Services ROSUVASTATIN 5 MG TABLET RX-36612 CDM 6370000100 HCPCS 250 RC 00904-6778-61 NDC inpatient 1 UN 6.62 6.62 BLUE CROSS BLUE SHIELD WELLMARK SB889 [3081026] BCBS WYOMING [308102603] 6.29 percent of total billed charges 4.1 6.29 Technical (Hospital) Services ROSUVASTATIN 5 MG TABLET RX-36612 CDM 6370000100 HCPCS 250 RC 00904-6778-61 NDC inpatient 1 UN 6.62 6.62 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES EPO [308136803] 5.24 percent of total billed charges 4.1 6.29 Technical (Hospital) Services ROSUVASTATIN 5 MG TABLET RX-36612 CDM 6370000100 HCPCS 250 RC 00904-6778-61 NDC inpatient 1 UN 6.62 6.62 UNITED HEALTHCARE (COMMERCIAL) [3081199] UNITED HEALTHCARE 87726 [308119901] 4.1 percent of total billed charges 4.1 6.29 Technical (Hospital) Services "BUPROPION HCL XL 150 MG 24 HR TABLET, EXTENDED RELEASE" RX-36775 CDM 6370000100 HCPCS 250 RC 68180-0319-06 NDC outpatient 1 UN 5.8 5.8 BLUE CROSS BLUE SHIELD WELLMARK SB889 [3081026] BCBS WYOMING [308102603] 5.51 percent of total billed charges 3.6 5.51 Technical (Hospital) Services "BUPROPION HCL XL 150 MG 24 HR TABLET, EXTENDED RELEASE" RX-36775 CDM 6370000100 HCPCS 250 RC 68180-0319-06 NDC outpatient 1 UN 5.8 5.8 HEALTHPARTNERS SX009 HEALTHPARTNERS 4.64 percent of total billed charges 3.6 5.51 Technical (Hospital) Services "BUPROPION HCL XL 150 MG 24 HR TABLET, EXTENDED RELEASE" RX-36775 CDM 6370000100 HCPCS 250 RC 68180-0319-06 NDC outpatient 1 UN 5.8 5.8 UNITED HEALTHCARE (COMMERCIAL) [3081199] UNITED HEALTHCARE 87726 [308119901] 3.6 percent of total billed charges 3.6 5.51 Technical (Hospital) Services "BUPROPION HCL XL 150 MG 24 HR TABLET, EXTENDED RELEASE" RX-36775 CDM 6370000100 HCPCS 250 RC 68180-0319-06 NDC outpatient 1 UN 5.8 5.8 CIGNA 62308 [3081051] CIGNA 62308 [308105105] 4.64 percent of total billed charges 3.6 5.51 Technical (Hospital) Services "BUPROPION HCL XL 150 MG 24 HR TABLET, EXTENDED RELEASE" RX-36775 CDM 6370000100 HCPCS 250 RC 68180-0319-06 NDC outpatient 1 UN 5.8 5.8 CIGNA 62308 [3081051] CIGNA STATE OF WYOMING [308105107] 4.64 percent of total billed charges 3.6 5.51 Technical (Hospital) Services "BUPROPION HCL XL 150 MG 24 HR TABLET, EXTENDED RELEASE" RX-36775 CDM 6370000100 HCPCS 250 RC 68180-0319-06 NDC outpatient 1 UN 5.8 5.8 MULTIPLAN INC 34080 [3081285] MULTIPLAN INC [308128501] 5.51 percent of total billed charges 3.6 5.51 Technical (Hospital) Services "BUPROPION HCL XL 150 MG 24 HR TABLET, EXTENDED RELEASE" RX-36775 CDM 6370000100 HCPCS 250 RC 68180-0319-06 NDC outpatient 1 UN 5.8 5.8 MEDICA (COMMERCIAL) 94265 [3081118] MEDICA CLAIMS [308111801] 5.22 percent of total billed charges 3.6 5.51 Technical (Hospital) Services "BUPROPION HCL XL 150 MG 24 HR TABLET, EXTENDED RELEASE" RX-36775 CDM 6370000100 HCPCS 250 RC 68180-0319-06 NDC outpatient 1 UN 5.8 5.8 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES EPO [308136803] 4.64 percent of total billed charges 3.6 5.51 Technical (Hospital) Services "BUPROPION HCL XL 150 MG 24 HR TABLET, EXTENDED RELEASE" RX-36775 CDM 6370000100 HCPCS 250 RC 68180-0319-06 NDC outpatient 1 UN 5.8 5.8 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES HDHP [308136802] 4.64 percent of total billed charges 3.6 5.51 Technical (Hospital) Services "BUPROPION HCL XL 150 MG 24 HR TABLET, EXTENDED RELEASE" RX-36775 CDM 6370000100 HCPCS 250 RC 68180-0319-06 NDC outpatient 1 UN 5.8 5.8 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES PPO [308136801] 4.64 percent of total billed charges 3.6 5.51 Technical (Hospital) Services "BUPROPION HCL XL 150 MG 24 HR TABLET, EXTENDED RELEASE" RX-36775 CDM 6370000100 HCPCS 250 RC 68180-0319-06 NDC inpatient 1 UN 5.8 5.8 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES PPO [308136801] 4.59 percent of total billed charges 3.6 5.51 Technical (Hospital) Services "BUPROPION HCL XL 150 MG 24 HR TABLET, EXTENDED RELEASE" RX-36775 CDM 6370000100 HCPCS 250 RC 68180-0319-06 NDC inpatient 1 UN 5.8 5.8 MEDICA (COMMERCIAL) 94265 [3081118] MEDICA CLAIMS [308111801] 5.22 percent of total billed charges 3.6 5.51 Technical (Hospital) Services "BUPROPION HCL XL 150 MG 24 HR TABLET, EXTENDED RELEASE" RX-36775 CDM 6370000100 HCPCS 250 RC 68180-0319-06 NDC inpatient 1 UN 5.8 5.8 MULTIPLAN INC 34080 [3081285] MULTIPLAN INC [308128501] 5.51 percent of total billed charges 3.6 5.51 Technical (Hospital) Services "BUPROPION HCL XL 150 MG 24 HR TABLET, EXTENDED RELEASE" RX-36775 CDM 6370000100 HCPCS 250 RC 68180-0319-06 NDC inpatient 1 UN 5.8 5.8 HEALTHPARTNERS SX009 HEALTHPARTNERS 4.59 percent of total billed charges 3.6 5.51 Technical (Hospital) Services "BUPROPION HCL XL 150 MG 24 HR TABLET, EXTENDED RELEASE" RX-36775 CDM 6370000100 HCPCS 250 RC 68180-0319-06 NDC inpatient 1 UN 5.8 5.8 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES HDHP [308136802] 4.59 percent of total billed charges 3.6 5.51 Technical (Hospital) Services "BUPROPION HCL XL 150 MG 24 HR TABLET, EXTENDED RELEASE" RX-36775 CDM 6370000100 HCPCS 250 RC 68180-0319-06 NDC inpatient 1 UN 5.8 5.8 UNITED HEALTHCARE (COMMERCIAL) [3081199] UNITED HEALTHCARE 87726 [308119901] 3.6 percent of total billed charges 3.6 5.51 Technical (Hospital) Services "BUPROPION HCL XL 150 MG 24 HR TABLET, EXTENDED RELEASE" RX-36775 CDM 6370000100 HCPCS 250 RC 68180-0319-06 NDC inpatient 1 UN 5.8 5.8 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES EPO [308136803] 4.59 percent of total billed charges 3.6 5.51 Technical (Hospital) Services "BUPROPION HCL XL 150 MG 24 HR TABLET, EXTENDED RELEASE" RX-36775 CDM 6370000100 HCPCS 250 RC 68180-0319-06 NDC inpatient 1 UN 5.8 5.8 CIGNA 62308 [3081051] CIGNA 62308 [308105105] 4.59 percent of total billed charges 3.6 5.51 Technical (Hospital) Services "BUPROPION HCL XL 150 MG 24 HR TABLET, EXTENDED RELEASE" RX-36775 CDM 6370000100 HCPCS 250 RC 68180-0319-06 NDC inpatient 1 UN 5.8 5.8 CIGNA 62308 [3081051] CIGNA STATE OF WYOMING [308105107] 4.59 percent of total billed charges 3.6 5.51 Technical (Hospital) Services "BUPROPION HCL XL 150 MG 24 HR TABLET, EXTENDED RELEASE" RX-36775 CDM 6370000100 HCPCS 250 RC 68180-0319-06 NDC inpatient 1 UN 5.8 5.8 BLUE CROSS BLUE SHIELD WELLMARK SB889 [3081026] BCBS WYOMING [308102603] 5.51 percent of total billed charges 3.6 5.51 Technical (Hospital) Services PHENYLEPHRINE 0.125 % NASAL DROPS RX-36952 CDM 6370000100 HCPCS 250 RC 56184-0121-05 NDC outpatient 0.05 ML 5.63 5.63 CIGNA 62308 [3081051] CIGNA 62308 [308105105] 4.5 percent of total billed charges 3.49 5.35 Technical (Hospital) Services PHENYLEPHRINE 0.125 % NASAL DROPS RX-36952 CDM 6370000100 HCPCS 250 RC 56184-0121-05 NDC outpatient 0.05 ML 5.63 5.63 CIGNA 62308 [3081051] CIGNA STATE OF WYOMING [308105107] 4.5 percent of total billed charges 3.49 5.35 Technical (Hospital) Services PHENYLEPHRINE 0.125 % NASAL DROPS RX-36952 CDM 6370000100 HCPCS 250 RC 56184-0121-05 NDC outpatient 0.05 ML 5.63 5.63 MULTIPLAN INC 34080 [3081285] MULTIPLAN INC [308128501] 5.35 percent of total billed charges 3.49 5.35 Technical (Hospital) Services PHENYLEPHRINE 0.125 % NASAL DROPS RX-36952 CDM 6370000100 HCPCS 250 RC 56184-0121-05 NDC outpatient 0.05 ML 5.63 5.63 UNITED HEALTHCARE (COMMERCIAL) [3081199] UNITED HEALTHCARE 87726 [308119901] 3.49 percent of total billed charges 3.49 5.35 Technical (Hospital) Services PHENYLEPHRINE 0.125 % NASAL DROPS RX-36952 CDM 6370000100 HCPCS 250 RC 56184-0121-05 NDC outpatient 0.05 ML 5.63 5.63 MEDICA (COMMERCIAL) 94265 [3081118] MEDICA CLAIMS [308111801] 5.07 percent of total billed charges 3.49 5.35 Technical (Hospital) Services PHENYLEPHRINE 0.125 % NASAL DROPS RX-36952 CDM 6370000100 HCPCS 250 RC 56184-0121-05 NDC outpatient 0.05 ML 5.63 5.63 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES PPO [308136801] 4.5 percent of total billed charges 3.49 5.35 Technical (Hospital) Services PHENYLEPHRINE 0.125 % NASAL DROPS RX-36952 CDM 6370000100 HCPCS 250 RC 56184-0121-05 NDC outpatient 0.05 ML 5.63 5.63 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES HDHP [308136802] 4.5 percent of total billed charges 3.49 5.35 Technical (Hospital) Services PHENYLEPHRINE 0.125 % NASAL DROPS RX-36952 CDM 6370000100 HCPCS 250 RC 56184-0121-05 NDC outpatient 0.05 ML 5.63 5.63 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES EPO [308136803] 4.5 percent of total billed charges 3.49 5.35 Technical (Hospital) Services PHENYLEPHRINE 0.125 % NASAL DROPS RX-36952 CDM 6370000100 HCPCS 250 RC 56184-0121-05 NDC outpatient 0.05 ML 5.63 5.63 BLUE CROSS BLUE SHIELD WELLMARK SB889 [3081026] BCBS WYOMING [308102603] 5.35 percent of total billed charges 3.49 5.35 Technical (Hospital) Services PHENYLEPHRINE 0.125 % NASAL DROPS RX-36952 CDM 6370000100 HCPCS 250 RC 56184-0121-05 NDC outpatient 0.05 ML 5.63 5.63 HEALTHPARTNERS SX009 HEALTHPARTNERS 4.5 percent of total billed charges 3.49 5.35 Technical (Hospital) Services PHENYLEPHRINE 0.125 % NASAL DROPS RX-36952 CDM 6370000100 HCPCS 250 RC 56184-0121-05 NDC inpatient 0.05 ML 5.63 5.63 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES EPO [308136803] 4.46 percent of total billed charges 3.49 5.35 Technical (Hospital) Services PHENYLEPHRINE 0.125 % NASAL DROPS RX-36952 CDM 6370000100 HCPCS 250 RC 56184-0121-05 NDC inpatient 0.05 ML 5.63 5.63 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES HDHP [308136802] 4.46 percent of total billed charges 3.49 5.35 Technical (Hospital) Services PHENYLEPHRINE 0.125 % NASAL DROPS RX-36952 CDM 6370000100 HCPCS 250 RC 56184-0121-05 NDC inpatient 0.05 ML 5.63 5.63 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES PPO [308136801] 4.46 percent of total billed charges 3.49 5.35 Technical (Hospital) Services PHENYLEPHRINE 0.125 % NASAL DROPS RX-36952 CDM 6370000100 HCPCS 250 RC 56184-0121-05 NDC inpatient 0.05 ML 5.63 5.63 HEALTHPARTNERS SX009 HEALTHPARTNERS 4.46 percent of total billed charges 3.49 5.35 Technical (Hospital) Services PHENYLEPHRINE 0.125 % NASAL DROPS RX-36952 CDM 6370000100 HCPCS 250 RC 56184-0121-05 NDC inpatient 0.05 ML 5.63 5.63 MEDICA (COMMERCIAL) 94265 [3081118] MEDICA CLAIMS [308111801] 5.07 percent of total billed charges 3.49 5.35 Technical (Hospital) Services PHENYLEPHRINE 0.125 % NASAL DROPS RX-36952 CDM 6370000100 HCPCS 250 RC 56184-0121-05 NDC inpatient 0.05 ML 5.63 5.63 BLUE CROSS BLUE SHIELD WELLMARK SB889 [3081026] BCBS WYOMING [308102603] 5.35 percent of total billed charges 3.49 5.35 Technical (Hospital) Services PHENYLEPHRINE 0.125 % NASAL DROPS RX-36952 CDM 6370000100 HCPCS 250 RC 56184-0121-05 NDC inpatient 0.05 ML 5.63 5.63 UNITED HEALTHCARE (COMMERCIAL) [3081199] UNITED HEALTHCARE 87726 [308119901] 3.49 percent of total billed charges 3.49 5.35 Technical (Hospital) Services PHENYLEPHRINE 0.125 % NASAL DROPS RX-36952 CDM 6370000100 HCPCS 250 RC 56184-0121-05 NDC inpatient 0.05 ML 5.63 5.63 CIGNA 62308 [3081051] CIGNA 62308 [308105105] 4.46 percent of total billed charges 3.49 5.35 Technical (Hospital) Services PHENYLEPHRINE 0.125 % NASAL DROPS RX-36952 CDM 6370000100 HCPCS 250 RC 56184-0121-05 NDC inpatient 0.05 ML 5.63 5.63 CIGNA 62308 [3081051] CIGNA STATE OF WYOMING [308105107] 4.46 percent of total billed charges 3.49 5.35 Technical (Hospital) Services PHENYLEPHRINE 0.125 % NASAL DROPS RX-36952 CDM 6370000100 HCPCS 250 RC 56184-0121-05 NDC inpatient 0.05 ML 5.63 5.63 MULTIPLAN INC 34080 [3081285] MULTIPLAN INC [308128501] 5.35 percent of total billed charges 3.49 5.35 Technical (Hospital) Services AMIODARONE 100 MG TABLET RX-36959 CDM 6370000100 HCPCS 250 RC 51862-0240-30 NDC inpatient 1 UN 14.79 14.79 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES PPO [308136801] 11.71 percent of total billed charges 9.17 14.05 Technical (Hospital) Services AMIODARONE 100 MG TABLET RX-36959 CDM 6370000100 HCPCS 250 RC 51862-0240-30 NDC inpatient 1 UN 14.79 14.79 MEDICA (COMMERCIAL) 94265 [3081118] MEDICA CLAIMS [308111801] 13.31 percent of total billed charges 9.17 14.05 Technical (Hospital) Services AMIODARONE 100 MG TABLET RX-36959 CDM 6370000100 HCPCS 250 RC 51862-0240-30 NDC inpatient 1 UN 14.79 14.79 MULTIPLAN INC 34080 [3081285] MULTIPLAN INC [308128501] 14.05 percent of total billed charges 9.17 14.05 Technical (Hospital) Services AMIODARONE 100 MG TABLET RX-36959 CDM 6370000100 HCPCS 250 RC 51862-0240-30 NDC inpatient 1 UN 14.79 14.79 BLUE CROSS BLUE SHIELD WELLMARK SB889 [3081026] BCBS WYOMING [308102603] 14.05 percent of total billed charges 9.17 14.05 Technical (Hospital) Services AMIODARONE 100 MG TABLET RX-36959 CDM 6370000100 HCPCS 250 RC 51862-0240-30 NDC inpatient 1 UN 14.79 14.79 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES EPO [308136803] 11.71 percent of total billed charges 9.17 14.05 Technical (Hospital) Services AMIODARONE 100 MG TABLET RX-36959 CDM 6370000100 HCPCS 250 RC 51862-0240-30 NDC inpatient 1 UN 14.79 14.79 CIGNA 62308 [3081051] CIGNA 62308 [308105105] 11.71 percent of total billed charges 9.17 14.05 Technical (Hospital) Services AMIODARONE 100 MG TABLET RX-36959 CDM 6370000100 HCPCS 250 RC 51862-0240-30 NDC inpatient 1 UN 14.79 14.79 CIGNA 62308 [3081051] CIGNA STATE OF WYOMING [308105107] 11.71 percent of total billed charges 9.17 14.05 Technical (Hospital) Services AMIODARONE 100 MG TABLET RX-36959 CDM 6370000100 HCPCS 250 RC 51862-0240-30 NDC inpatient 1 UN 14.79 14.79 UNITED HEALTHCARE (COMMERCIAL) [3081199] UNITED HEALTHCARE 87726 [308119901] 9.17 percent of total billed charges 9.17 14.05 Technical (Hospital) Services AMIODARONE 100 MG TABLET RX-36959 CDM 6370000100 HCPCS 250 RC 51862-0240-30 NDC inpatient 1 UN 14.79 14.79 HEALTHPARTNERS SX009 HEALTHPARTNERS 11.71 percent of total billed charges 9.17 14.05 Technical (Hospital) Services AMIODARONE 100 MG TABLET RX-36959 CDM 6370000100 HCPCS 250 RC 51862-0240-30 NDC inpatient 1 UN 14.79 14.79 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES HDHP [308136802] 11.71 percent of total billed charges 9.17 14.05 Technical (Hospital) Services AMIODARONE 100 MG TABLET RX-36959 CDM 6370000100 HCPCS 250 RC 51862-0240-30 NDC outpatient 1 UN 14.79 14.79 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES PPO [308136801] 11.83 percent of total billed charges 9.17 14.05 Technical (Hospital) Services AMIODARONE 100 MG TABLET RX-36959 CDM 6370000100 HCPCS 250 RC 51862-0240-30 NDC outpatient 1 UN 14.79 14.79 MEDICA (COMMERCIAL) 94265 [3081118] MEDICA CLAIMS [308111801] 13.31 percent of total billed charges 9.17 14.05 Technical (Hospital) Services AMIODARONE 100 MG TABLET RX-36959 CDM 6370000100 HCPCS 250 RC 51862-0240-30 NDC outpatient 1 UN 14.79 14.79 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES HDHP [308136802] 11.83 percent of total billed charges 9.17 14.05 Technical (Hospital) Services AMIODARONE 100 MG TABLET RX-36959 CDM 6370000100 HCPCS 250 RC 51862-0240-30 NDC outpatient 1 UN 14.79 14.79 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES EPO [308136803] 11.83 percent of total billed charges 9.17 14.05 Technical (Hospital) Services AMIODARONE 100 MG TABLET RX-36959 CDM 6370000100 HCPCS 250 RC 51862-0240-30 NDC outpatient 1 UN 14.79 14.79 HEALTHPARTNERS SX009 HEALTHPARTNERS 11.83 percent of total billed charges 9.17 14.05 Technical (Hospital) Services AMIODARONE 100 MG TABLET RX-36959 CDM 6370000100 HCPCS 250 RC 51862-0240-30 NDC outpatient 1 UN 14.79 14.79 UNITED HEALTHCARE (COMMERCIAL) [3081199] UNITED HEALTHCARE 87726 [308119901] 9.17 percent of total billed charges 9.17 14.05 Technical (Hospital) Services AMIODARONE 100 MG TABLET RX-36959 CDM 6370000100 HCPCS 250 RC 51862-0240-30 NDC outpatient 1 UN 14.79 14.79 MULTIPLAN INC 34080 [3081285] MULTIPLAN INC [308128501] 14.05 percent of total billed charges 9.17 14.05 Technical (Hospital) Services AMIODARONE 100 MG TABLET RX-36959 CDM 6370000100 HCPCS 250 RC 51862-0240-30 NDC outpatient 1 UN 14.79 14.79 CIGNA 62308 [3081051] CIGNA 62308 [308105105] 11.83 percent of total billed charges 9.17 14.05 Technical (Hospital) Services AMIODARONE 100 MG TABLET RX-36959 CDM 6370000100 HCPCS 250 RC 51862-0240-30 NDC outpatient 1 UN 14.79 14.79 CIGNA 62308 [3081051] CIGNA STATE OF WYOMING [308105107] 11.83 percent of total billed charges 9.17 14.05 Technical (Hospital) Services AMIODARONE 100 MG TABLET RX-36959 CDM 6370000100 HCPCS 250 RC 51862-0240-30 NDC outpatient 1 UN 14.79 14.79 BLUE CROSS BLUE SHIELD WELLMARK SB889 [3081026] BCBS WYOMING [308102603] 14.05 percent of total billed charges 9.17 14.05 Technical (Hospital) Services MEMANTINE 10 MG TABLET RX-36966 CDM 6370000100 HCPCS 250 RC 29300-0172-16 NDC outpatient 1 UN 5.87 5.87 MEDICA (COMMERCIAL) 94265 [3081118] MEDICA CLAIMS [308111801] 5.28 percent of total billed charges 3.64 5.58 Technical (Hospital) Services MEMANTINE 10 MG TABLET RX-36966 CDM 6370000100 HCPCS 250 RC 29300-0172-16 NDC outpatient 1 UN 5.87 5.87 MULTIPLAN INC 34080 [3081285] MULTIPLAN INC [308128501] 5.58 percent of total billed charges 3.64 5.58 Technical (Hospital) Services MEMANTINE 10 MG TABLET RX-36966 CDM 6370000100 HCPCS 250 RC 29300-0172-16 NDC outpatient 1 UN 5.87 5.87 CIGNA 62308 [3081051] CIGNA 62308 [308105105] 4.7 percent of total billed charges 3.64 5.58 Technical (Hospital) Services MEMANTINE 10 MG TABLET RX-36966 CDM 6370000100 HCPCS 250 RC 29300-0172-16 NDC outpatient 1 UN 5.87 5.87 CIGNA 62308 [3081051] CIGNA STATE OF WYOMING [308105107] 4.7 percent of total billed charges 3.64 5.58 Technical (Hospital) Services MEMANTINE 10 MG TABLET RX-36966 CDM 6370000100 HCPCS 250 RC 29300-0172-16 NDC outpatient 1 UN 5.87 5.87 UNITED HEALTHCARE (COMMERCIAL) [3081199] UNITED HEALTHCARE 87726 [308119901] 3.64 percent of total billed charges 3.64 5.58 Technical (Hospital) Services MEMANTINE 10 MG TABLET RX-36966 CDM 6370000100 HCPCS 250 RC 29300-0172-16 NDC outpatient 1 UN 5.87 5.87 HEALTHPARTNERS SX009 HEALTHPARTNERS 4.7 percent of total billed charges 3.64 5.58 Technical (Hospital) Services MEMANTINE 10 MG TABLET RX-36966 CDM 6370000100 HCPCS 250 RC 29300-0172-16 NDC outpatient 1 UN 5.87 5.87 BLUE CROSS BLUE SHIELD WELLMARK SB889 [3081026] BCBS WYOMING [308102603] 5.58 percent of total billed charges 3.64 5.58 Technical (Hospital) Services MEMANTINE 10 MG TABLET RX-36966 CDM 6370000100 HCPCS 250 RC 29300-0172-16 NDC outpatient 1 UN 5.87 5.87 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES PPO [308136801] 4.7 percent of total billed charges 3.64 5.58 Technical (Hospital) Services MEMANTINE 10 MG TABLET RX-36966 CDM 6370000100 HCPCS 250 RC 29300-0172-16 NDC outpatient 1 UN 5.87 5.87 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES HDHP [308136802] 4.7 percent of total billed charges 3.64 5.58 Technical (Hospital) Services MEMANTINE 10 MG TABLET RX-36966 CDM 6370000100 HCPCS 250 RC 29300-0172-16 NDC outpatient 1 UN 5.87 5.87 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES EPO [308136803] 4.7 percent of total billed charges 3.64 5.58 Technical (Hospital) Services MEMANTINE 10 MG TABLET RX-36966 CDM 6370000100 HCPCS 250 RC 29300-0172-16 NDC inpatient 1 UN 5.87 5.87 BLUE CROSS BLUE SHIELD WELLMARK SB889 [3081026] BCBS WYOMING [308102603] 5.58 percent of total billed charges 3.64 5.58 Technical (Hospital) Services MEMANTINE 10 MG TABLET RX-36966 CDM 6370000100 HCPCS 250 RC 29300-0172-16 NDC inpatient 1 UN 5.87 5.87 UNITED HEALTHCARE (COMMERCIAL) [3081199] UNITED HEALTHCARE 87726 [308119901] 3.64 percent of total billed charges 3.64 5.58 Technical (Hospital) Services MEMANTINE 10 MG TABLET RX-36966 CDM 6370000100 HCPCS 250 RC 29300-0172-16 NDC inpatient 1 UN 5.87 5.87 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES EPO [308136803] 4.65 percent of total billed charges 3.64 5.58 Technical (Hospital) Services MEMANTINE 10 MG TABLET RX-36966 CDM 6370000100 HCPCS 250 RC 29300-0172-16 NDC inpatient 1 UN 5.87 5.87 CIGNA 62308 [3081051] CIGNA STATE OF WYOMING [308105107] 4.65 percent of total billed charges 3.64 5.58 Technical (Hospital) Services MEMANTINE 10 MG TABLET RX-36966 CDM 6370000100 HCPCS 250 RC 29300-0172-16 NDC inpatient 1 UN 5.87 5.87 CIGNA 62308 [3081051] CIGNA 62308 [308105105] 4.65 percent of total billed charges 3.64 5.58 Technical (Hospital) Services MEMANTINE 10 MG TABLET RX-36966 CDM 6370000100 HCPCS 250 RC 29300-0172-16 NDC inpatient 1 UN 5.87 5.87 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES HDHP [308136802] 4.65 percent of total billed charges 3.64 5.58 Technical (Hospital) Services MEMANTINE 10 MG TABLET RX-36966 CDM 6370000100 HCPCS 250 RC 29300-0172-16 NDC inpatient 1 UN 5.87 5.87 MEDICA (COMMERCIAL) 94265 [3081118] MEDICA CLAIMS [308111801] 5.28 percent of total billed charges 3.64 5.58 Technical (Hospital) Services MEMANTINE 10 MG TABLET RX-36966 CDM 6370000100 HCPCS 250 RC 29300-0172-16 NDC inpatient 1 UN 5.87 5.87 HEALTHPARTNERS SX009 HEALTHPARTNERS 4.65 percent of total billed charges 3.64 5.58 Technical (Hospital) Services MEMANTINE 10 MG TABLET RX-36966 CDM 6370000100 HCPCS 250 RC 29300-0172-16 NDC inpatient 1 UN 5.87 5.87 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES PPO [308136801] 4.65 percent of total billed charges 3.64 5.58 Technical (Hospital) Services MEMANTINE 10 MG TABLET RX-36966 CDM 6370000100 HCPCS 250 RC 29300-0172-16 NDC inpatient 1 UN 5.87 5.87 MULTIPLAN INC 34080 [3081285] MULTIPLAN INC [308128501] 5.58 percent of total billed charges 3.64 5.58 Technical (Hospital) Services "ALFUZOSIN ER 10 MG TABLET,EXTENDED RELEASE 24 HR" RX-36982 CDM 6370000100 HCPCS 250 RC 60505-2850-01 NDC inpatient 1 UN 5.97 5.97 CIGNA 62308 [3081051] CIGNA 62308 [308105105] 4.73 percent of total billed charges 3.7 5.67 Technical (Hospital) Services "ALFUZOSIN ER 10 MG TABLET,EXTENDED RELEASE 24 HR" RX-36982 CDM 6370000100 HCPCS 250 RC 60505-2850-01 NDC inpatient 1 UN 5.97 5.97 CIGNA 62308 [3081051] CIGNA STATE OF WYOMING [308105107] 4.73 percent of total billed charges 3.7 5.67 Technical (Hospital) Services "ALFUZOSIN ER 10 MG TABLET,EXTENDED RELEASE 24 HR" RX-36982 CDM 6370000100 HCPCS 250 RC 60505-2850-01 NDC inpatient 1 UN 5.97 5.97 UNITED HEALTHCARE (COMMERCIAL) [3081199] UNITED HEALTHCARE 87726 [308119901] 3.7 percent of total billed charges 3.7 5.67 Technical (Hospital) Services "ALFUZOSIN ER 10 MG TABLET,EXTENDED RELEASE 24 HR" RX-36982 CDM 6370000100 HCPCS 250 RC 60505-2850-01 NDC inpatient 1 UN 5.97 5.97 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES EPO [308136803] 4.73 percent of total billed charges 3.7 5.67 Technical (Hospital) Services "ALFUZOSIN ER 10 MG TABLET,EXTENDED RELEASE 24 HR" RX-36982 CDM 6370000100 HCPCS 250 RC 60505-2850-01 NDC inpatient 1 UN 5.97 5.97 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES HDHP [308136802] 4.73 percent of total billed charges 3.7 5.67 Technical (Hospital) Services "ALFUZOSIN ER 10 MG TABLET,EXTENDED RELEASE 24 HR" RX-36982 CDM 6370000100 HCPCS 250 RC 60505-2850-01 NDC inpatient 1 UN 5.97 5.97 BLUE CROSS BLUE SHIELD WELLMARK SB889 [3081026] BCBS WYOMING [308102603] 5.67 percent of total billed charges 3.7 5.67 Technical (Hospital) Services "ALFUZOSIN ER 10 MG TABLET,EXTENDED RELEASE 24 HR" RX-36982 CDM 6370000100 HCPCS 250 RC 60505-2850-01 NDC inpatient 1 UN 5.97 5.97 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES PPO [308136801] 4.73 percent of total billed charges 3.7 5.67 Technical (Hospital) Services "ALFUZOSIN ER 10 MG TABLET,EXTENDED RELEASE 24 HR" RX-36982 CDM 6370000100 HCPCS 250 RC 60505-2850-01 NDC inpatient 1 UN 5.97 5.97 MEDICA (COMMERCIAL) 94265 [3081118] MEDICA CLAIMS [308111801] 5.37 percent of total billed charges 3.7 5.67 Technical (Hospital) Services "ALFUZOSIN ER 10 MG TABLET,EXTENDED RELEASE 24 HR" RX-36982 CDM 6370000100 HCPCS 250 RC 60505-2850-01 NDC inpatient 1 UN 5.97 5.97 HEALTHPARTNERS SX009 HEALTHPARTNERS 4.73 percent of total billed charges 3.7 5.67 Technical (Hospital) Services "ALFUZOSIN ER 10 MG TABLET,EXTENDED RELEASE 24 HR" RX-36982 CDM 6370000100 HCPCS 250 RC 60505-2850-01 NDC inpatient 1 UN 5.97 5.97 MULTIPLAN INC 34080 [3081285] MULTIPLAN INC [308128501] 5.67 percent of total billed charges 3.7 5.67 Technical (Hospital) Services "ALFUZOSIN ER 10 MG TABLET,EXTENDED RELEASE 24 HR" RX-36982 CDM 6370000100 HCPCS 250 RC 60505-2850-01 NDC outpatient 1 UN 5.97 5.97 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES PPO [308136801] 4.78 percent of total billed charges 3.7 5.67 Technical (Hospital) Services "ALFUZOSIN ER 10 MG TABLET,EXTENDED RELEASE 24 HR" RX-36982 CDM 6370000100 HCPCS 250 RC 60505-2850-01 NDC outpatient 1 UN 5.97 5.97 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES EPO [308136803] 4.78 percent of total billed charges 3.7 5.67 Technical (Hospital) Services "ALFUZOSIN ER 10 MG TABLET,EXTENDED RELEASE 24 HR" RX-36982 CDM 6370000100 HCPCS 250 RC 60505-2850-01 NDC outpatient 1 UN 5.97 5.97 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES HDHP [308136802] 4.78 percent of total billed charges 3.7 5.67 Technical (Hospital) Services "ALFUZOSIN ER 10 MG TABLET,EXTENDED RELEASE 24 HR" RX-36982 CDM 6370000100 HCPCS 250 RC 60505-2850-01 NDC outpatient 1 UN 5.97 5.97 HEALTHPARTNERS SX009 HEALTHPARTNERS 4.78 percent of total billed charges 3.7 5.67 Technical (Hospital) Services "ALFUZOSIN ER 10 MG TABLET,EXTENDED RELEASE 24 HR" RX-36982 CDM 6370000100 HCPCS 250 RC 60505-2850-01 NDC outpatient 1 UN 5.97 5.97 UNITED HEALTHCARE (COMMERCIAL) [3081199] UNITED HEALTHCARE 87726 [308119901] 3.7 percent of total billed charges 3.7 5.67 Technical (Hospital) Services "ALFUZOSIN ER 10 MG TABLET,EXTENDED RELEASE 24 HR" RX-36982 CDM 6370000100 HCPCS 250 RC 60505-2850-01 NDC outpatient 1 UN 5.97 5.97 CIGNA 62308 [3081051] CIGNA 62308 [308105105] 4.78 percent of total billed charges 3.7 5.67 Technical (Hospital) Services "ALFUZOSIN ER 10 MG TABLET,EXTENDED RELEASE 24 HR" RX-36982 CDM 6370000100 HCPCS 250 RC 60505-2850-01 NDC outpatient 1 UN 5.97 5.97 CIGNA 62308 [3081051] CIGNA STATE OF WYOMING [308105107] 4.78 percent of total billed charges 3.7 5.67 Technical (Hospital) Services "ALFUZOSIN ER 10 MG TABLET,EXTENDED RELEASE 24 HR" RX-36982 CDM 6370000100 HCPCS 250 RC 60505-2850-01 NDC outpatient 1 UN 5.97 5.97 MEDICA (COMMERCIAL) 94265 [3081118] MEDICA CLAIMS [308111801] 5.37 percent of total billed charges 3.7 5.67 Technical (Hospital) Services "ALFUZOSIN ER 10 MG TABLET,EXTENDED RELEASE 24 HR" RX-36982 CDM 6370000100 HCPCS 250 RC 60505-2850-01 NDC outpatient 1 UN 5.97 5.97 MULTIPLAN INC 34080 [3081285] MULTIPLAN INC [308128501] 5.67 percent of total billed charges 3.7 5.67 Technical (Hospital) Services "ALFUZOSIN ER 10 MG TABLET,EXTENDED RELEASE 24 HR" RX-36982 CDM 6370000100 HCPCS 250 RC 60505-2850-01 NDC outpatient 1 UN 5.97 5.97 BLUE CROSS BLUE SHIELD WELLMARK SB889 [3081026] BCBS WYOMING [308102603] 5.67 percent of total billed charges 3.7 5.67 Technical (Hospital) Services HYDRALAZINE 25 MG TABLET RX-3700 CDM 6370000100 HCPCS 250 RC 23155-0002-01 NDC inpatient 1 UN 5.68 5.68 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES PPO [308136801] 4.5 percent of total billed charges 3.52 5.4 Technical (Hospital) Services HYDRALAZINE 25 MG TABLET RX-3700 CDM 6370000100 HCPCS 250 RC 23155-0002-01 NDC inpatient 1 UN 5.68 5.68 MEDICA (COMMERCIAL) 94265 [3081118] MEDICA CLAIMS [308111801] 5.11 percent of total billed charges 3.52 5.4 Technical (Hospital) Services HYDRALAZINE 25 MG TABLET RX-3700 CDM 6370000100 HCPCS 250 RC 23155-0002-01 NDC inpatient 1 UN 5.68 5.68 HEALTHPARTNERS SX009 HEALTHPARTNERS 4.5 percent of total billed charges 3.52 5.4 Technical (Hospital) Services HYDRALAZINE 25 MG TABLET RX-3700 CDM 6370000100 HCPCS 250 RC 23155-0002-01 NDC inpatient 1 UN 5.68 5.68 MULTIPLAN INC 34080 [3081285] MULTIPLAN INC [308128501] 5.4 percent of total billed charges 3.52 5.4 Technical (Hospital) Services HYDRALAZINE 25 MG TABLET RX-3700 CDM 6370000100 HCPCS 250 RC 23155-0002-01 NDC inpatient 1 UN 5.68 5.68 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES HDHP [308136802] 4.5 percent of total billed charges 3.52 5.4 Technical (Hospital) Services HYDRALAZINE 25 MG TABLET RX-3700 CDM 6370000100 HCPCS 250 RC 23155-0002-01 NDC inpatient 1 UN 5.68 5.68 CIGNA 62308 [3081051] CIGNA 62308 [308105105] 4.5 percent of total billed charges 3.52 5.4 Technical (Hospital) Services HYDRALAZINE 25 MG TABLET RX-3700 CDM 6370000100 HCPCS 250 RC 23155-0002-01 NDC inpatient 1 UN 5.68 5.68 CIGNA 62308 [3081051] CIGNA STATE OF WYOMING [308105107] 4.5 percent of total billed charges 3.52 5.4 Technical (Hospital) Services HYDRALAZINE 25 MG TABLET RX-3700 CDM 6370000100 HCPCS 250 RC 23155-0002-01 NDC inpatient 1 UN 5.68 5.68 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES EPO [308136803] 4.5 percent of total billed charges 3.52 5.4 Technical (Hospital) Services HYDRALAZINE 25 MG TABLET RX-3700 CDM 6370000100 HCPCS 250 RC 23155-0002-01 NDC inpatient 1 UN 5.68 5.68 UNITED HEALTHCARE (COMMERCIAL) [3081199] UNITED HEALTHCARE 87726 [308119901] 3.52 percent of total billed charges 3.52 5.4 Technical (Hospital) Services HYDRALAZINE 25 MG TABLET RX-3700 CDM 6370000100 HCPCS 250 RC 23155-0002-01 NDC inpatient 1 UN 5.68 5.68 BLUE CROSS BLUE SHIELD WELLMARK SB889 [3081026] BCBS WYOMING [308102603] 5.4 percent of total billed charges 3.52 5.4 Technical (Hospital) Services HYDRALAZINE 25 MG TABLET RX-3700 CDM 6370000100 HCPCS 250 RC 23155-0002-01 NDC outpatient 1 UN 5.68 5.68 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES PPO [308136801] 4.54 percent of total billed charges 3.52 5.4 Technical (Hospital) Services HYDRALAZINE 25 MG TABLET RX-3700 CDM 6370000100 HCPCS 250 RC 23155-0002-01 NDC outpatient 1 UN 5.68 5.68 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES EPO [308136803] 4.54 percent of total billed charges 3.52 5.4 Technical (Hospital) Services HYDRALAZINE 25 MG TABLET RX-3700 CDM 6370000100 HCPCS 250 RC 23155-0002-01 NDC outpatient 1 UN 5.68 5.68 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES HDHP [308136802] 4.54 percent of total billed charges 3.52 5.4 Technical (Hospital) Services HYDRALAZINE 25 MG TABLET RX-3700 CDM 6370000100 HCPCS 250 RC 23155-0002-01 NDC outpatient 1 UN 5.68 5.68 MEDICA (COMMERCIAL) 94265 [3081118] MEDICA CLAIMS [308111801] 5.11 percent of total billed charges 3.52 5.4 Technical (Hospital) Services HYDRALAZINE 25 MG TABLET RX-3700 CDM 6370000100 HCPCS 250 RC 23155-0002-01 NDC outpatient 1 UN 5.68 5.68 CIGNA 62308 [3081051] CIGNA 62308 [308105105] 4.54 percent of total billed charges 3.52 5.4 Technical (Hospital) Services HYDRALAZINE 25 MG TABLET RX-3700 CDM 6370000100 HCPCS 250 RC 23155-0002-01 NDC outpatient 1 UN 5.68 5.68 CIGNA 62308 [3081051] CIGNA STATE OF WYOMING [308105107] 4.54 percent of total billed charges 3.52 5.4 Technical (Hospital) Services HYDRALAZINE 25 MG TABLET RX-3700 CDM 6370000100 HCPCS 250 RC 23155-0002-01 NDC outpatient 1 UN 5.68 5.68 UNITED HEALTHCARE (COMMERCIAL) [3081199] UNITED HEALTHCARE 87726 [308119901] 3.52 percent of total billed charges 3.52 5.4 Technical (Hospital) Services HYDRALAZINE 25 MG TABLET RX-3700 CDM 6370000100 HCPCS 250 RC 23155-0002-01 NDC outpatient 1 UN 5.68 5.68 MULTIPLAN INC 34080 [3081285] MULTIPLAN INC [308128501] 5.4 percent of total billed charges 3.52 5.4 Technical (Hospital) Services HYDRALAZINE 25 MG TABLET RX-3700 CDM 6370000100 HCPCS 250 RC 23155-0002-01 NDC outpatient 1 UN 5.68 5.68 BLUE CROSS BLUE SHIELD WELLMARK SB889 [3081026] BCBS WYOMING [308102603] 5.4 percent of total billed charges 3.52 5.4 Technical (Hospital) Services HYDRALAZINE 25 MG TABLET RX-3700 CDM 6370000100 HCPCS 250 RC 23155-0002-01 NDC outpatient 1 UN 5.68 5.68 HEALTHPARTNERS SX009 HEALTHPARTNERS 4.54 percent of total billed charges 3.52 5.4 Technical (Hospital) Services HYDRALAZINE 50 MG TABLET RX-3701 CDM 6370000100 HCPCS 250 RC 23155-0003-01 NDC outpatient 1 UN 5.7 5.7 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES EPO [308136803] 4.56 percent of total billed charges 3.53 5.42 Technical (Hospital) Services HYDRALAZINE 50 MG TABLET RX-3701 CDM 6370000100 HCPCS 250 RC 23155-0003-01 NDC outpatient 1 UN 5.7 5.7 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES PPO [308136801] 4.56 percent of total billed charges 3.53 5.42 Technical (Hospital) Services HYDRALAZINE 50 MG TABLET RX-3701 CDM 6370000100 HCPCS 250 RC 23155-0003-01 NDC outpatient 1 UN 5.7 5.7 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES HDHP [308136802] 4.56 percent of total billed charges 3.53 5.42 Technical (Hospital) Services HYDRALAZINE 50 MG TABLET RX-3701 CDM 6370000100 HCPCS 250 RC 23155-0003-01 NDC outpatient 1 UN 5.7 5.7 BLUE CROSS BLUE SHIELD WELLMARK SB889 [3081026] BCBS WYOMING [308102603] 5.42 percent of total billed charges 3.53 5.42 Technical (Hospital) Services HYDRALAZINE 50 MG TABLET RX-3701 CDM 6370000100 HCPCS 250 RC 23155-0003-01 NDC outpatient 1 UN 5.7 5.7 UNITED HEALTHCARE (COMMERCIAL) [3081199] UNITED HEALTHCARE 87726 [308119901] 3.53 percent of total billed charges 3.53 5.42 Technical (Hospital) Services HYDRALAZINE 50 MG TABLET RX-3701 CDM 6370000100 HCPCS 250 RC 23155-0003-01 NDC outpatient 1 UN 5.7 5.7 HEALTHPARTNERS SX009 HEALTHPARTNERS 4.56 percent of total billed charges 3.53 5.42 Technical (Hospital) Services HYDRALAZINE 50 MG TABLET RX-3701 CDM 6370000100 HCPCS 250 RC 23155-0003-01 NDC outpatient 1 UN 5.7 5.7 MEDICA (COMMERCIAL) 94265 [3081118] MEDICA CLAIMS [308111801] 5.13 percent of total billed charges 3.53 5.42 Technical (Hospital) Services HYDRALAZINE 50 MG TABLET RX-3701 CDM 6370000100 HCPCS 250 RC 23155-0003-01 NDC outpatient 1 UN 5.7 5.7 CIGNA 62308 [3081051] CIGNA 62308 [308105105] 4.56 percent of total billed charges 3.53 5.42 Technical (Hospital) Services HYDRALAZINE 50 MG TABLET RX-3701 CDM 6370000100 HCPCS 250 RC 23155-0003-01 NDC outpatient 1 UN 5.7 5.7 CIGNA 62308 [3081051] CIGNA STATE OF WYOMING [308105107] 4.56 percent of total billed charges 3.53 5.42 Technical (Hospital) Services HYDRALAZINE 50 MG TABLET RX-3701 CDM 6370000100 HCPCS 250 RC 23155-0003-01 NDC outpatient 1 UN 5.7 5.7 MULTIPLAN INC 34080 [3081285] MULTIPLAN INC [308128501] 5.42 percent of total billed charges 3.53 5.42 Technical (Hospital) Services HYDRALAZINE 50 MG TABLET RX-3701 CDM 6370000100 HCPCS 250 RC 23155-0003-01 NDC inpatient 1 UN 5.7 5.7 MEDICA (COMMERCIAL) 94265 [3081118] MEDICA CLAIMS [308111801] 5.13 percent of total billed charges 3.53 5.42 Technical (Hospital) Services HYDRALAZINE 50 MG TABLET RX-3701 CDM 6370000100 HCPCS 250 RC 23155-0003-01 NDC inpatient 1 UN 5.7 5.7 HEALTHPARTNERS SX009 HEALTHPARTNERS 4.51 percent of total billed charges 3.53 5.42 Technical (Hospital) Services HYDRALAZINE 50 MG TABLET RX-3701 CDM 6370000100 HCPCS 250 RC 23155-0003-01 NDC inpatient 1 UN 5.7 5.7 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES PPO [308136801] 4.51 percent of total billed charges 3.53 5.42 Technical (Hospital) Services HYDRALAZINE 50 MG TABLET RX-3701 CDM 6370000100 HCPCS 250 RC 23155-0003-01 NDC inpatient 1 UN 5.7 5.7 MULTIPLAN INC 34080 [3081285] MULTIPLAN INC [308128501] 5.42 percent of total billed charges 3.53 5.42 Technical (Hospital) Services HYDRALAZINE 50 MG TABLET RX-3701 CDM 6370000100 HCPCS 250 RC 23155-0003-01 NDC inpatient 1 UN 5.7 5.7 UNITED HEALTHCARE (COMMERCIAL) [3081199] UNITED HEALTHCARE 87726 [308119901] 3.53 percent of total billed charges 3.53 5.42 Technical (Hospital) Services HYDRALAZINE 50 MG TABLET RX-3701 CDM 6370000100 HCPCS 250 RC 23155-0003-01 NDC inpatient 1 UN 5.7 5.7 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES EPO [308136803] 4.51 percent of total billed charges 3.53 5.42 Technical (Hospital) Services HYDRALAZINE 50 MG TABLET RX-3701 CDM 6370000100 HCPCS 250 RC 23155-0003-01 NDC inpatient 1 UN 5.7 5.7 CIGNA 62308 [3081051] CIGNA 62308 [308105105] 4.51 percent of total billed charges 3.53 5.42 Technical (Hospital) Services HYDRALAZINE 50 MG TABLET RX-3701 CDM 6370000100 HCPCS 250 RC 23155-0003-01 NDC inpatient 1 UN 5.7 5.7 CIGNA 62308 [3081051] CIGNA STATE OF WYOMING [308105107] 4.51 percent of total billed charges 3.53 5.42 Technical (Hospital) Services HYDRALAZINE 50 MG TABLET RX-3701 CDM 6370000100 HCPCS 250 RC 23155-0003-01 NDC inpatient 1 UN 5.7 5.7 BLUE CROSS BLUE SHIELD WELLMARK SB889 [3081026] BCBS WYOMING [308102603] 5.42 percent of total billed charges 3.53 5.42 Technical (Hospital) Services HYDRALAZINE 50 MG TABLET RX-3701 CDM 6370000100 HCPCS 250 RC 23155-0003-01 NDC inpatient 1 UN 5.7 5.7 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES HDHP [308136802] 4.51 percent of total billed charges 3.53 5.42 Technical (Hospital) Services HYDROCHLOROTHIAZIDE 25 MG TABLET RX-3720 CDM 6370000100 HCPCS 250 RC 16729-0183-01 NDC outpatient 1 UN 5.63 5.63 MULTIPLAN INC 34080 [3081285] MULTIPLAN INC [308128501] 5.35 percent of total billed charges 3.49 5.35 Technical (Hospital) Services HYDROCHLOROTHIAZIDE 25 MG TABLET RX-3720 CDM 6370000100 HCPCS 250 RC 16729-0183-01 NDC outpatient 1 UN 5.63 5.63 CIGNA 62308 [3081051] CIGNA 62308 [308105105] 4.5 percent of total billed charges 3.49 5.35 Technical (Hospital) Services HYDROCHLOROTHIAZIDE 25 MG TABLET RX-3720 CDM 6370000100 HCPCS 250 RC 16729-0183-01 NDC outpatient 1 UN 5.63 5.63 CIGNA 62308 [3081051] CIGNA STATE OF WYOMING [308105107] 4.5 percent of total billed charges 3.49 5.35 Technical (Hospital) Services HYDROCHLOROTHIAZIDE 25 MG TABLET RX-3720 CDM 6370000100 HCPCS 250 RC 16729-0183-01 NDC outpatient 1 UN 5.63 5.63 MEDICA (COMMERCIAL) 94265 [3081118] MEDICA CLAIMS [308111801] 5.07 percent of total billed charges 3.49 5.35 Technical (Hospital) Services HYDROCHLOROTHIAZIDE 25 MG TABLET RX-3720 CDM 6370000100 HCPCS 250 RC 16729-0183-01 NDC outpatient 1 UN 5.63 5.63 HEALTHPARTNERS SX009 HEALTHPARTNERS 4.5 percent of total billed charges 3.49 5.35 Technical (Hospital) Services HYDROCHLOROTHIAZIDE 25 MG TABLET RX-3720 CDM 6370000100 HCPCS 250 RC 16729-0183-01 NDC outpatient 1 UN 5.63 5.63 UNITED HEALTHCARE (COMMERCIAL) [3081199] UNITED HEALTHCARE 87726 [308119901] 3.49 percent of total billed charges 3.49 5.35 Technical (Hospital) Services HYDROCHLOROTHIAZIDE 25 MG TABLET RX-3720 CDM 6370000100 HCPCS 250 RC 16729-0183-01 NDC outpatient 1 UN 5.63 5.63 BLUE CROSS BLUE SHIELD WELLMARK SB889 [3081026] BCBS WYOMING [308102603] 5.35 percent of total billed charges 3.49 5.35 Technical (Hospital) Services HYDROCHLOROTHIAZIDE 25 MG TABLET RX-3720 CDM 6370000100 HCPCS 250 RC 16729-0183-01 NDC outpatient 1 UN 5.63 5.63 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES HDHP [308136802] 4.5 percent of total billed charges 3.49 5.35 Technical (Hospital) Services HYDROCHLOROTHIAZIDE 25 MG TABLET RX-3720 CDM 6370000100 HCPCS 250 RC 16729-0183-01 NDC outpatient 1 UN 5.63 5.63 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES PPO [308136801] 4.5 percent of total billed charges 3.49 5.35 Technical (Hospital) Services HYDROCHLOROTHIAZIDE 25 MG TABLET RX-3720 CDM 6370000100 HCPCS 250 RC 16729-0183-01 NDC outpatient 1 UN 5.63 5.63 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES EPO [308136803] 4.5 percent of total billed charges 3.49 5.35 Technical (Hospital) Services HYDROCHLOROTHIAZIDE 25 MG TABLET RX-3720 CDM 6370000100 HCPCS 250 RC 16729-0183-01 NDC inpatient 1 UN 5.63 5.63 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES HDHP [308136802] 4.46 percent of total billed charges 3.49 5.35 Technical (Hospital) Services HYDROCHLOROTHIAZIDE 25 MG TABLET RX-3720 CDM 6370000100 HCPCS 250 RC 16729-0183-01 NDC inpatient 1 UN 5.63 5.63 CIGNA 62308 [3081051] CIGNA 62308 [308105105] 4.46 percent of total billed charges 3.49 5.35 Technical (Hospital) Services HYDROCHLOROTHIAZIDE 25 MG TABLET RX-3720 CDM 6370000100 HCPCS 250 RC 16729-0183-01 NDC inpatient 1 UN 5.63 5.63 CIGNA 62308 [3081051] CIGNA STATE OF WYOMING [308105107] 4.46 percent of total billed charges 3.49 5.35 Technical (Hospital) Services HYDROCHLOROTHIAZIDE 25 MG TABLET RX-3720 CDM 6370000100 HCPCS 250 RC 16729-0183-01 NDC inpatient 1 UN 5.63 5.63 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES EPO [308136803] 4.46 percent of total billed charges 3.49 5.35 Technical (Hospital) Services HYDROCHLOROTHIAZIDE 25 MG TABLET RX-3720 CDM 6370000100 HCPCS 250 RC 16729-0183-01 NDC inpatient 1 UN 5.63 5.63 UNITED HEALTHCARE (COMMERCIAL) [3081199] UNITED HEALTHCARE 87726 [308119901] 3.49 percent of total billed charges 3.49 5.35 Technical (Hospital) Services HYDROCHLOROTHIAZIDE 25 MG TABLET RX-3720 CDM 6370000100 HCPCS 250 RC 16729-0183-01 NDC inpatient 1 UN 5.63 5.63 BLUE CROSS BLUE SHIELD WELLMARK SB889 [3081026] BCBS WYOMING [308102603] 5.35 percent of total billed charges 3.49 5.35 Technical (Hospital) Services HYDROCHLOROTHIAZIDE 25 MG TABLET RX-3720 CDM 6370000100 HCPCS 250 RC 16729-0183-01 NDC inpatient 1 UN 5.63 5.63 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES PPO [308136801] 4.46 percent of total billed charges 3.49 5.35 Technical (Hospital) Services HYDROCHLOROTHIAZIDE 25 MG TABLET RX-3720 CDM 6370000100 HCPCS 250 RC 16729-0183-01 NDC inpatient 1 UN 5.63 5.63 HEALTHPARTNERS SX009 HEALTHPARTNERS 4.46 percent of total billed charges 3.49 5.35 Technical (Hospital) Services HYDROCHLOROTHIAZIDE 25 MG TABLET RX-3720 CDM 6370000100 HCPCS 250 RC 16729-0183-01 NDC inpatient 1 UN 5.63 5.63 MEDICA (COMMERCIAL) 94265 [3081118] MEDICA CLAIMS [308111801] 5.07 percent of total billed charges 3.49 5.35 Technical (Hospital) Services HYDROCHLOROTHIAZIDE 25 MG TABLET RX-3720 CDM 6370000100 HCPCS 250 RC 16729-0183-01 NDC inpatient 1 UN 5.63 5.63 MULTIPLAN INC 34080 [3081285] MULTIPLAN INC [308128501] 5.35 percent of total billed charges 3.49 5.35 Technical (Hospital) Services HYDROCORTISONE 1 % TOPICAL CREAM RX-3726 CDM 6370000100 HCPCS 250 RC 45802-0438-03 NDC inpatient 28 GR 7.72 7.72 HEALTHPARTNERS SX009 HEALTHPARTNERS 6.11 percent of total billed charges 4.79 7.33 Technical (Hospital) Services HYDROCORTISONE 1 % TOPICAL CREAM RX-3726 CDM 6370000100 HCPCS 250 RC 45802-0438-03 NDC inpatient 28 GR 7.72 7.72 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES EPO [308136803] 6.11 percent of total billed charges 4.79 7.33 Technical (Hospital) Services HYDROCORTISONE 1 % TOPICAL CREAM RX-3726 CDM 6370000100 HCPCS 250 RC 45802-0438-03 NDC inpatient 28 GR 7.72 7.72 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES HDHP [308136802] 6.11 percent of total billed charges 4.79 7.33 Technical (Hospital) Services HYDROCORTISONE 1 % TOPICAL CREAM RX-3726 CDM 6370000100 HCPCS 250 RC 45802-0438-03 NDC inpatient 28 GR 7.72 7.72 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES PPO [308136801] 6.11 percent of total billed charges 4.79 7.33 Technical (Hospital) Services HYDROCORTISONE 1 % TOPICAL CREAM RX-3726 CDM 6370000100 HCPCS 250 RC 45802-0438-03 NDC inpatient 28 GR 7.72 7.72 CIGNA 62308 [3081051] CIGNA 62308 [308105105] 6.11 percent of total billed charges 4.79 7.33 Technical (Hospital) Services HYDROCORTISONE 1 % TOPICAL CREAM RX-3726 CDM 6370000100 HCPCS 250 RC 45802-0438-03 NDC inpatient 28 GR 7.72 7.72 CIGNA 62308 [3081051] CIGNA STATE OF WYOMING [308105107] 6.11 percent of total billed charges 4.79 7.33 Technical (Hospital) Services HYDROCORTISONE 1 % TOPICAL CREAM RX-3726 CDM 6370000100 HCPCS 250 RC 45802-0438-03 NDC inpatient 28 GR 7.72 7.72 UNITED HEALTHCARE (COMMERCIAL) [3081199] UNITED HEALTHCARE 87726 [308119901] 4.79 percent of total billed charges 4.79 7.33 Technical (Hospital) Services HYDROCORTISONE 1 % TOPICAL CREAM RX-3726 CDM 6370000100 HCPCS 250 RC 45802-0438-03 NDC inpatient 28 GR 7.72 7.72 BLUE CROSS BLUE SHIELD WELLMARK SB889 [3081026] BCBS WYOMING [308102603] 7.33 percent of total billed charges 4.79 7.33 Technical (Hospital) Services HYDROCORTISONE 1 % TOPICAL CREAM RX-3726 CDM 6370000100 HCPCS 250 RC 45802-0438-03 NDC inpatient 28 GR 7.72 7.72 MEDICA (COMMERCIAL) 94265 [3081118] MEDICA CLAIMS [308111801] 6.95 percent of total billed charges 4.79 7.33 Technical (Hospital) Services HYDROCORTISONE 1 % TOPICAL CREAM RX-3726 CDM 6370000100 HCPCS 250 RC 45802-0438-03 NDC inpatient 28 GR 7.72 7.72 MULTIPLAN INC 34080 [3081285] MULTIPLAN INC [308128501] 7.33 percent of total billed charges 4.79 7.33 Technical (Hospital) Services HYDROCORTISONE 1 % TOPICAL CREAM RX-3726 CDM 6370000100 HCPCS 250 RC 45802-0438-03 NDC outpatient 28 GR 7.72 7.72 UNITED HEALTHCARE (COMMERCIAL) [3081199] UNITED HEALTHCARE 87726 [308119901] 4.79 percent of total billed charges 4.79 7.33 Technical (Hospital) Services HYDROCORTISONE 1 % TOPICAL CREAM RX-3726 CDM 6370000100 HCPCS 250 RC 45802-0438-03 NDC outpatient 28 GR 7.72 7.72 HEALTHPARTNERS SX009 HEALTHPARTNERS 6.18 percent of total billed charges 4.79 7.33 Technical (Hospital) Services HYDROCORTISONE 1 % TOPICAL CREAM RX-3726 CDM 6370000100 HCPCS 250 RC 45802-0438-03 NDC outpatient 28 GR 7.72 7.72 BLUE CROSS BLUE SHIELD WELLMARK SB889 [3081026] BCBS WYOMING [308102603] 7.33 percent of total billed charges 4.79 7.33 Technical (Hospital) Services HYDROCORTISONE 1 % TOPICAL CREAM RX-3726 CDM 6370000100 HCPCS 250 RC 45802-0438-03 NDC outpatient 28 GR 7.72 7.72 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES EPO [308136803] 6.18 percent of total billed charges 4.79 7.33 Technical (Hospital) Services HYDROCORTISONE 1 % TOPICAL CREAM RX-3726 CDM 6370000100 HCPCS 250 RC 45802-0438-03 NDC outpatient 28 GR 7.72 7.72 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES HDHP [308136802] 6.18 percent of total billed charges 4.79 7.33 Technical (Hospital) Services HYDROCORTISONE 1 % TOPICAL CREAM RX-3726 CDM 6370000100 HCPCS 250 RC 45802-0438-03 NDC outpatient 28 GR 7.72 7.72 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES PPO [308136801] 6.18 percent of total billed charges 4.79 7.33 Technical (Hospital) Services HYDROCORTISONE 1 % TOPICAL CREAM RX-3726 CDM 6370000100 HCPCS 250 RC 45802-0438-03 NDC outpatient 28 GR 7.72 7.72 MULTIPLAN INC 34080 [3081285] MULTIPLAN INC [308128501] 7.33 percent of total billed charges 4.79 7.33 Technical (Hospital) Services HYDROCORTISONE 1 % TOPICAL CREAM RX-3726 CDM 6370000100 HCPCS 250 RC 45802-0438-03 NDC outpatient 28 GR 7.72 7.72 MEDICA (COMMERCIAL) 94265 [3081118] MEDICA CLAIMS [308111801] 6.95 percent of total billed charges 4.79 7.33 Technical (Hospital) Services HYDROCORTISONE 1 % TOPICAL CREAM RX-3726 CDM 6370000100 HCPCS 250 RC 45802-0438-03 NDC outpatient 28 GR 7.72 7.72 CIGNA 62308 [3081051] CIGNA 62308 [308105105] 6.18 percent of total billed charges 4.79 7.33 Technical (Hospital) Services HYDROCORTISONE 1 % TOPICAL CREAM RX-3726 CDM 6370000100 HCPCS 250 RC 45802-0438-03 NDC outpatient 28 GR 7.72 7.72 CIGNA 62308 [3081051] CIGNA STATE OF WYOMING [308105107] 6.18 percent of total billed charges 4.79 7.33 Technical (Hospital) Services HYDROCORTISONE 10 MG TABLET RX-3733 CDM 6370000100 HCPCS 250 RC 60687-0582-01 NDC outpatient 1 UN 7.29 7.29 UNITED HEALTHCARE (COMMERCIAL) [3081199] UNITED HEALTHCARE 87726 [308119901] 4.52 percent of total billed charges 4.52 6.93 Technical (Hospital) Services HYDROCORTISONE 10 MG TABLET RX-3733 CDM 6370000100 HCPCS 250 RC 60687-0582-01 NDC outpatient 1 UN 7.29 7.29 HEALTHPARTNERS SX009 HEALTHPARTNERS 5.83 percent of total billed charges 4.52 6.93 Technical (Hospital) Services HYDROCORTISONE 10 MG TABLET RX-3733 CDM 6370000100 HCPCS 250 RC 60687-0582-01 NDC outpatient 1 UN 7.29 7.29 MEDICA (COMMERCIAL) 94265 [3081118] MEDICA CLAIMS [308111801] 6.56 percent of total billed charges 4.52 6.93 Technical (Hospital) Services HYDROCORTISONE 10 MG TABLET RX-3733 CDM 6370000100 HCPCS 250 RC 60687-0582-01 NDC outpatient 1 UN 7.29 7.29 CIGNA 62308 [3081051] CIGNA 62308 [308105105] 5.83 percent of total billed charges 4.52 6.93 Technical (Hospital) Services HYDROCORTISONE 10 MG TABLET RX-3733 CDM 6370000100 HCPCS 250 RC 60687-0582-01 NDC outpatient 1 UN 7.29 7.29 CIGNA 62308 [3081051] CIGNA STATE OF WYOMING [308105107] 5.83 percent of total billed charges 4.52 6.93 Technical (Hospital) Services HYDROCORTISONE 10 MG TABLET RX-3733 CDM 6370000100 HCPCS 250 RC 60687-0582-01 NDC outpatient 1 UN 7.29 7.29 MULTIPLAN INC 34080 [3081285] MULTIPLAN INC [308128501] 6.93 percent of total billed charges 4.52 6.93 Technical (Hospital) Services HYDROCORTISONE 10 MG TABLET RX-3733 CDM 6370000100 HCPCS 250 RC 60687-0582-01 NDC outpatient 1 UN 7.29 7.29 BLUE CROSS BLUE SHIELD WELLMARK SB889 [3081026] BCBS WYOMING [308102603] 6.93 percent of total billed charges 4.52 6.93 Technical (Hospital) Services HYDROCORTISONE 10 MG TABLET RX-3733 CDM 6370000100 HCPCS 250 RC 60687-0582-01 NDC outpatient 1 UN 7.29 7.29 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES EPO [308136803] 5.83 percent of total billed charges 4.52 6.93 Technical (Hospital) Services HYDROCORTISONE 10 MG TABLET RX-3733 CDM 6370000100 HCPCS 250 RC 60687-0582-01 NDC outpatient 1 UN 7.29 7.29 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES HDHP [308136802] 5.83 percent of total billed charges 4.52 6.93 Technical (Hospital) Services HYDROCORTISONE 10 MG TABLET RX-3733 CDM 6370000100 HCPCS 250 RC 60687-0582-01 NDC outpatient 1 UN 7.29 7.29 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES PPO [308136801] 5.83 percent of total billed charges 4.52 6.93 Technical (Hospital) Services HYDROCORTISONE 10 MG TABLET RX-3733 CDM 6370000100 HCPCS 250 RC 60687-0582-01 NDC inpatient 1 UN 7.29 7.29 MULTIPLAN INC 34080 [3081285] MULTIPLAN INC [308128501] 6.93 percent of total billed charges 4.52 6.93 Technical (Hospital) Services HYDROCORTISONE 10 MG TABLET RX-3733 CDM 6370000100 HCPCS 250 RC 60687-0582-01 NDC inpatient 1 UN 7.29 7.29 MEDICA (COMMERCIAL) 94265 [3081118] MEDICA CLAIMS [308111801] 6.56 percent of total billed charges 4.52 6.93 Technical (Hospital) Services HYDROCORTISONE 10 MG TABLET RX-3733 CDM 6370000100 HCPCS 250 RC 60687-0582-01 NDC inpatient 1 UN 7.29 7.29 HEALTHPARTNERS SX009 HEALTHPARTNERS 5.77 percent of total billed charges 4.52 6.93 Technical (Hospital) Services HYDROCORTISONE 10 MG TABLET RX-3733 CDM 6370000100 HCPCS 250 RC 60687-0582-01 NDC inpatient 1 UN 7.29 7.29 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES PPO [308136801] 5.77 percent of total billed charges 4.52 6.93 Technical (Hospital) Services HYDROCORTISONE 10 MG TABLET RX-3733 CDM 6370000100 HCPCS 250 RC 60687-0582-01 NDC inpatient 1 UN 7.29 7.29 BLUE CROSS BLUE SHIELD WELLMARK SB889 [3081026] BCBS WYOMING [308102603] 6.93 percent of total billed charges 4.52 6.93 Technical (Hospital) Services HYDROCORTISONE 10 MG TABLET RX-3733 CDM 6370000100 HCPCS 250 RC 60687-0582-01 NDC inpatient 1 UN 7.29 7.29 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES EPO [308136803] 5.77 percent of total billed charges 4.52 6.93 Technical (Hospital) Services HYDROCORTISONE 10 MG TABLET RX-3733 CDM 6370000100 HCPCS 250 RC 60687-0582-01 NDC inpatient 1 UN 7.29 7.29 UNITED HEALTHCARE (COMMERCIAL) [3081199] UNITED HEALTHCARE 87726 [308119901] 4.52 percent of total billed charges 4.52 6.93 Technical (Hospital) Services HYDROCORTISONE 10 MG TABLET RX-3733 CDM 6370000100 HCPCS 250 RC 60687-0582-01 NDC inpatient 1 UN 7.29 7.29 CIGNA 62308 [3081051] CIGNA 62308 [308105105] 5.77 percent of total billed charges 4.52 6.93 Technical (Hospital) Services HYDROCORTISONE 10 MG TABLET RX-3733 CDM 6370000100 HCPCS 250 RC 60687-0582-01 NDC inpatient 1 UN 7.29 7.29 CIGNA 62308 [3081051] CIGNA STATE OF WYOMING [308105107] 5.77 percent of total billed charges 4.52 6.93 Technical (Hospital) Services HYDROCORTISONE 10 MG TABLET RX-3733 CDM 6370000100 HCPCS 250 RC 60687-0582-01 NDC inpatient 1 UN 7.29 7.29 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES HDHP [308136802] 5.77 percent of total billed charges 4.52 6.93 Technical (Hospital) Services HYDROCORTISONE 20 MG TABLET RX-3734 CDM 6370000100 HCPCS 250 RC 59762-0075-01 NDC outpatient 1 UN 6.13 6.13 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES HDHP [308136802] 4.9 percent of total billed charges 3.8 5.82 Technical (Hospital) Services HYDROCORTISONE 20 MG TABLET RX-3734 CDM 6370000100 HCPCS 250 RC 59762-0075-01 NDC outpatient 1 UN 6.13 6.13 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES PPO [308136801] 4.9 percent of total billed charges 3.8 5.82 Technical (Hospital) Services HYDROCORTISONE 20 MG TABLET RX-3734 CDM 6370000100 HCPCS 250 RC 59762-0075-01 NDC outpatient 1 UN 6.13 6.13 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES EPO [308136803] 4.9 percent of total billed charges 3.8 5.82 Technical (Hospital) Services HYDROCORTISONE 20 MG TABLET RX-3734 CDM 6370000100 HCPCS 250 RC 59762-0075-01 NDC outpatient 1 UN 6.13 6.13 BLUE CROSS BLUE SHIELD WELLMARK SB889 [3081026] BCBS WYOMING [308102603] 5.82 percent of total billed charges 3.8 5.82 Technical (Hospital) Services HYDROCORTISONE 20 MG TABLET RX-3734 CDM 6370000100 HCPCS 250 RC 59762-0075-01 NDC outpatient 1 UN 6.13 6.13 MEDICA (COMMERCIAL) 94265 [3081118] MEDICA CLAIMS [308111801] 5.52 percent of total billed charges 3.8 5.82 Technical (Hospital) Services HYDROCORTISONE 20 MG TABLET RX-3734 CDM 6370000100 HCPCS 250 RC 59762-0075-01 NDC outpatient 1 UN 6.13 6.13 MULTIPLAN INC 34080 [3081285] MULTIPLAN INC [308128501] 5.82 percent of total billed charges 3.8 5.82 Technical (Hospital) Services HYDROCORTISONE 20 MG TABLET RX-3734 CDM 6370000100 HCPCS 250 RC 59762-0075-01 NDC outpatient 1 UN 6.13 6.13 CIGNA 62308 [3081051] CIGNA 62308 [308105105] 4.9 percent of total billed charges 3.8 5.82 Technical (Hospital) Services HYDROCORTISONE 20 MG TABLET RX-3734 CDM 6370000100 HCPCS 250 RC 59762-0075-01 NDC outpatient 1 UN 6.13 6.13 CIGNA 62308 [3081051] CIGNA STATE OF WYOMING [308105107] 4.9 percent of total billed charges 3.8 5.82 Technical (Hospital) Services HYDROCORTISONE 20 MG TABLET RX-3734 CDM 6370000100 HCPCS 250 RC 59762-0075-01 NDC outpatient 1 UN 6.13 6.13 UNITED HEALTHCARE (COMMERCIAL) [3081199] UNITED HEALTHCARE 87726 [308119901] 3.8 percent of total billed charges 3.8 5.82 Technical (Hospital) Services HYDROCORTISONE 20 MG TABLET RX-3734 CDM 6370000100 HCPCS 250 RC 59762-0075-01 NDC outpatient 1 UN 6.13 6.13 HEALTHPARTNERS SX009 HEALTHPARTNERS 4.9 percent of total billed charges 3.8 5.82 Technical (Hospital) Services HYDROCORTISONE 20 MG TABLET RX-3734 CDM 6370000100 HCPCS 250 RC 59762-0075-01 NDC inpatient 1 UN 6.13 6.13 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES EPO [308136803] 4.85 percent of total billed charges 3.8 5.82 Technical (Hospital) Services HYDROCORTISONE 20 MG TABLET RX-3734 CDM 6370000100 HCPCS 250 RC 59762-0075-01 NDC inpatient 1 UN 6.13 6.13 CIGNA 62308 [3081051] CIGNA 62308 [308105105] 4.85 percent of total billed charges 3.8 5.82 Technical (Hospital) Services HYDROCORTISONE 20 MG TABLET RX-3734 CDM 6370000100 HCPCS 250 RC 59762-0075-01 NDC inpatient 1 UN 6.13 6.13 CIGNA 62308 [3081051] CIGNA STATE OF WYOMING [308105107] 4.85 percent of total billed charges 3.8 5.82 Technical (Hospital) Services HYDROCORTISONE 20 MG TABLET RX-3734 CDM 6370000100 HCPCS 250 RC 59762-0075-01 NDC inpatient 1 UN 6.13 6.13 UNITED HEALTHCARE (COMMERCIAL) [3081199] UNITED HEALTHCARE 87726 [308119901] 3.8 percent of total billed charges 3.8 5.82 Technical (Hospital) Services HYDROCORTISONE 20 MG TABLET RX-3734 CDM 6370000100 HCPCS 250 RC 59762-0075-01 NDC inpatient 1 UN 6.13 6.13 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES HDHP [308136802] 4.85 percent of total billed charges 3.8 5.82 Technical (Hospital) Services HYDROCORTISONE 20 MG TABLET RX-3734 CDM 6370000100 HCPCS 250 RC 59762-0075-01 NDC inpatient 1 UN 6.13 6.13 HEALTHPARTNERS SX009 HEALTHPARTNERS 4.85 percent of total billed charges 3.8 5.82 Technical (Hospital) Services HYDROCORTISONE 20 MG TABLET RX-3734 CDM 6370000100 HCPCS 250 RC 59762-0075-01 NDC inpatient 1 UN 6.13 6.13 BLUE CROSS BLUE SHIELD WELLMARK SB889 [3081026] BCBS WYOMING [308102603] 5.82 percent of total billed charges 3.8 5.82 Technical (Hospital) Services HYDROCORTISONE 20 MG TABLET RX-3734 CDM 6370000100 HCPCS 250 RC 59762-0075-01 NDC inpatient 1 UN 6.13 6.13 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES PPO [308136801] 4.85 percent of total billed charges 3.8 5.82 Technical (Hospital) Services HYDROCORTISONE 20 MG TABLET RX-3734 CDM 6370000100 HCPCS 250 RC 59762-0075-01 NDC inpatient 1 UN 6.13 6.13 MEDICA (COMMERCIAL) 94265 [3081118] MEDICA CLAIMS [308111801] 5.52 percent of total billed charges 3.8 5.82 Technical (Hospital) Services HYDROCORTISONE 20 MG TABLET RX-3734 CDM 6370000100 HCPCS 250 RC 59762-0075-01 NDC inpatient 1 UN 6.13 6.13 MULTIPLAN INC 34080 [3081285] MULTIPLAN INC [308128501] 5.82 percent of total billed charges 3.8 5.82 Technical (Hospital) Services HYDROCORTISONE ACETATE 25 MG RECTAL SUPPOSITORY RX-3738 CDM 6370000100 HCPCS 250 RC 00713-0503-12 NDC inpatient 1 UN 47.1 47.1 MULTIPLAN INC 34080 [3081285] MULTIPLAN INC [308128501] 44.75 percent of total billed charges 29.2 44.75 Technical (Hospital) Services HYDROCORTISONE ACETATE 25 MG RECTAL SUPPOSITORY RX-3738 CDM 6370000100 HCPCS 250 RC 00713-0503-12 NDC inpatient 1 UN 47.1 47.1 MEDICA (COMMERCIAL) 94265 [3081118] MEDICA CLAIMS [308111801] 42.39 percent of total billed charges 29.2 44.75 Technical (Hospital) Services HYDROCORTISONE ACETATE 25 MG RECTAL SUPPOSITORY RX-3738 CDM 6370000100 HCPCS 250 RC 00713-0503-12 NDC inpatient 1 UN 47.1 47.1 HEALTHPARTNERS SX009 HEALTHPARTNERS 37.29 percent of total billed charges 29.2 44.75 Technical (Hospital) Services HYDROCORTISONE ACETATE 25 MG RECTAL SUPPOSITORY RX-3738 CDM 6370000100 HCPCS 250 RC 00713-0503-12 NDC inpatient 1 UN 47.1 47.1 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES PPO [308136801] 37.29 percent of total billed charges 29.2 44.75 Technical (Hospital) Services HYDROCORTISONE ACETATE 25 MG RECTAL SUPPOSITORY RX-3738 CDM 6370000100 HCPCS 250 RC 00713-0503-12 NDC inpatient 1 UN 47.1 47.1 BLUE CROSS BLUE SHIELD WELLMARK SB889 [3081026] BCBS WYOMING [308102603] 44.75 percent of total billed charges 29.2 44.75 Technical (Hospital) Services HYDROCORTISONE ACETATE 25 MG RECTAL SUPPOSITORY RX-3738 CDM 6370000100 HCPCS 250 RC 00713-0503-12 NDC inpatient 1 UN 47.1 47.1 UNITED HEALTHCARE (COMMERCIAL) [3081199] UNITED HEALTHCARE 87726 [308119901] 29.2 percent of total billed charges 29.2 44.75 Technical (Hospital) Services HYDROCORTISONE ACETATE 25 MG RECTAL SUPPOSITORY RX-3738 CDM 6370000100 HCPCS 250 RC 00713-0503-12 NDC inpatient 1 UN 47.1 47.1 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES EPO [308136803] 37.29 percent of total billed charges 29.2 44.75 Technical (Hospital) Services HYDROCORTISONE ACETATE 25 MG RECTAL SUPPOSITORY RX-3738 CDM 6370000100 HCPCS 250 RC 00713-0503-12 NDC inpatient 1 UN 47.1 47.1 CIGNA 62308 [3081051] CIGNA 62308 [308105105] 37.29 percent of total billed charges 29.2 44.75 Technical (Hospital) Services HYDROCORTISONE ACETATE 25 MG RECTAL SUPPOSITORY RX-3738 CDM 6370000100 HCPCS 250 RC 00713-0503-12 NDC inpatient 1 UN 47.1 47.1 CIGNA 62308 [3081051] CIGNA STATE OF WYOMING [308105107] 37.29 percent of total billed charges 29.2 44.75 Technical (Hospital) Services HYDROCORTISONE ACETATE 25 MG RECTAL SUPPOSITORY RX-3738 CDM 6370000100 HCPCS 250 RC 00713-0503-12 NDC inpatient 1 UN 47.1 47.1 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES HDHP [308136802] 37.29 percent of total billed charges 29.2 44.75 Technical (Hospital) Services HYDROCORTISONE ACETATE 25 MG RECTAL SUPPOSITORY RX-3738 CDM 6370000100 HCPCS 250 RC 00713-0503-12 NDC outpatient 1 UN 47.1 47.1 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES PPO [308136801] 37.68 percent of total billed charges 29.2 44.75 Technical (Hospital) Services HYDROCORTISONE ACETATE 25 MG RECTAL SUPPOSITORY RX-3738 CDM 6370000100 HCPCS 250 RC 00713-0503-12 NDC outpatient 1 UN 47.1 47.1 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES EPO [308136803] 37.68 percent of total billed charges 29.2 44.75 Technical (Hospital) Services HYDROCORTISONE ACETATE 25 MG RECTAL SUPPOSITORY RX-3738 CDM 6370000100 HCPCS 250 RC 00713-0503-12 NDC outpatient 1 UN 47.1 47.1 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES HDHP [308136802] 37.68 percent of total billed charges 29.2 44.75 Technical (Hospital) Services HYDROCORTISONE ACETATE 25 MG RECTAL SUPPOSITORY RX-3738 CDM 6370000100 HCPCS 250 RC 00713-0503-12 NDC outpatient 1 UN 47.1 47.1 HEALTHPARTNERS SX009 HEALTHPARTNERS 37.68 percent of total billed charges 29.2 44.75 Technical (Hospital) Services HYDROCORTISONE ACETATE 25 MG RECTAL SUPPOSITORY RX-3738 CDM 6370000100 HCPCS 250 RC 00713-0503-12 NDC outpatient 1 UN 47.1 47.1 BLUE CROSS BLUE SHIELD WELLMARK SB889 [3081026] BCBS WYOMING [308102603] 44.75 percent of total billed charges 29.2 44.75 Technical (Hospital) Services HYDROCORTISONE ACETATE 25 MG RECTAL SUPPOSITORY RX-3738 CDM 6370000100 HCPCS 250 RC 00713-0503-12 NDC outpatient 1 UN 47.1 47.1 MEDICA (COMMERCIAL) 94265 [3081118] MEDICA CLAIMS [308111801] 42.39 percent of total billed charges 29.2 44.75 Technical (Hospital) Services HYDROCORTISONE ACETATE 25 MG RECTAL SUPPOSITORY RX-3738 CDM 6370000100 HCPCS 250 RC 00713-0503-12 NDC outpatient 1 UN 47.1 47.1 CIGNA 62308 [3081051] CIGNA 62308 [308105105] 37.68 percent of total billed charges 29.2 44.75 Technical (Hospital) Services HYDROCORTISONE ACETATE 25 MG RECTAL SUPPOSITORY RX-3738 CDM 6370000100 HCPCS 250 RC 00713-0503-12 NDC outpatient 1 UN 47.1 47.1 CIGNA 62308 [3081051] CIGNA STATE OF WYOMING [308105107] 37.68 percent of total billed charges 29.2 44.75 Technical (Hospital) Services HYDROCORTISONE ACETATE 25 MG RECTAL SUPPOSITORY RX-3738 CDM 6370000100 HCPCS 250 RC 00713-0503-12 NDC outpatient 1 UN 47.1 47.1 MULTIPLAN INC 34080 [3081285] MULTIPLAN INC [308128501] 44.75 percent of total billed charges 29.2 44.75 Technical (Hospital) Services HYDROCORTISONE ACETATE 25 MG RECTAL SUPPOSITORY RX-3738 CDM 6370000100 HCPCS 250 RC 00713-0503-12 NDC outpatient 1 UN 47.1 47.1 UNITED HEALTHCARE (COMMERCIAL) [3081199] UNITED HEALTHCARE 87726 [308119901] 29.2 percent of total billed charges 29.2 44.75 Technical (Hospital) Services HYDROMORPHONE 2 MG TABLET RX-3760 CDM 6370000100 HCPCS 250 RC 42858-0301-01 NDC inpatient 1 UN 5.86 5.86 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES HDHP [308136802] 4.64 percent of total billed charges 3.63 5.57 Technical (Hospital) Services HYDROMORPHONE 2 MG TABLET RX-3760 CDM 6370000100 HCPCS 250 RC 42858-0301-01 NDC inpatient 1 UN 5.86 5.86 CIGNA 62308 [3081051] CIGNA 62308 [308105105] 4.64 percent of total billed charges 3.63 5.57 Technical (Hospital) Services HYDROMORPHONE 2 MG TABLET RX-3760 CDM 6370000100 HCPCS 250 RC 42858-0301-01 NDC inpatient 1 UN 5.86 5.86 CIGNA 62308 [3081051] CIGNA STATE OF WYOMING [308105107] 4.64 percent of total billed charges 3.63 5.57 Technical (Hospital) Services HYDROMORPHONE 2 MG TABLET RX-3760 CDM 6370000100 HCPCS 250 RC 42858-0301-01 NDC inpatient 1 UN 5.86 5.86 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES EPO [308136803] 4.64 percent of total billed charges 3.63 5.57 Technical (Hospital) Services HYDROMORPHONE 2 MG TABLET RX-3760 CDM 6370000100 HCPCS 250 RC 42858-0301-01 NDC inpatient 1 UN 5.86 5.86 UNITED HEALTHCARE (COMMERCIAL) [3081199] UNITED HEALTHCARE 87726 [308119901] 3.63 percent of total billed charges 3.63 5.57 Technical (Hospital) Services HYDROMORPHONE 2 MG TABLET RX-3760 CDM 6370000100 HCPCS 250 RC 42858-0301-01 NDC inpatient 1 UN 5.86 5.86 BLUE CROSS BLUE SHIELD WELLMARK SB889 [3081026] BCBS WYOMING [308102603] 5.57 percent of total billed charges 3.63 5.57 Technical (Hospital) Services HYDROMORPHONE 2 MG TABLET RX-3760 CDM 6370000100 HCPCS 250 RC 42858-0301-01 NDC inpatient 1 UN 5.86 5.86 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES PPO [308136801] 4.64 percent of total billed charges 3.63 5.57 Technical (Hospital) Services HYDROMORPHONE 2 MG TABLET RX-3760 CDM 6370000100 HCPCS 250 RC 42858-0301-01 NDC inpatient 1 UN 5.86 5.86 HEALTHPARTNERS SX009 HEALTHPARTNERS 4.64 percent of total billed charges 3.63 5.57 Technical (Hospital) Services HYDROMORPHONE 2 MG TABLET RX-3760 CDM 6370000100 HCPCS 250 RC 42858-0301-01 NDC inpatient 1 UN 5.86 5.86 MEDICA (COMMERCIAL) 94265 [3081118] MEDICA CLAIMS [308111801] 5.27 percent of total billed charges 3.63 5.57 Technical (Hospital) Services HYDROMORPHONE 2 MG TABLET RX-3760 CDM 6370000100 HCPCS 250 RC 42858-0301-01 NDC inpatient 1 UN 5.86 5.86 MULTIPLAN INC 34080 [3081285] MULTIPLAN INC [308128501] 5.57 percent of total billed charges 3.63 5.57 Technical (Hospital) Services HYDROMORPHONE 2 MG TABLET RX-3760 CDM 6370000100 HCPCS 250 RC 42858-0301-01 NDC outpatient 1 UN 5.86 5.86 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES PPO [308136801] 4.69 percent of total billed charges 3.63 5.57 Technical (Hospital) Services HYDROMORPHONE 2 MG TABLET RX-3760 CDM 6370000100 HCPCS 250 RC 42858-0301-01 NDC outpatient 1 UN 5.86 5.86 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES HDHP [308136802] 4.69 percent of total billed charges 3.63 5.57 Technical (Hospital) Services HYDROMORPHONE 2 MG TABLET RX-3760 CDM 6370000100 HCPCS 250 RC 42858-0301-01 NDC outpatient 1 UN 5.86 5.86 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES EPO [308136803] 4.69 percent of total billed charges 3.63 5.57 Technical (Hospital) Services HYDROMORPHONE 2 MG TABLET RX-3760 CDM 6370000100 HCPCS 250 RC 42858-0301-01 NDC outpatient 1 UN 5.86 5.86 BLUE CROSS BLUE SHIELD WELLMARK SB889 [3081026] BCBS WYOMING [308102603] 5.57 percent of total billed charges 3.63 5.57 Technical (Hospital) Services HYDROMORPHONE 2 MG TABLET RX-3760 CDM 6370000100 HCPCS 250 RC 42858-0301-01 NDC outpatient 1 UN 5.86 5.86 MULTIPLAN INC 34080 [3081285] MULTIPLAN INC [308128501] 5.57 percent of total billed charges 3.63 5.57 Technical (Hospital) Services HYDROMORPHONE 2 MG TABLET RX-3760 CDM 6370000100 HCPCS 250 RC 42858-0301-01 NDC outpatient 1 UN 5.86 5.86 CIGNA 62308 [3081051] CIGNA 62308 [308105105] 4.69 percent of total billed charges 3.63 5.57 Technical (Hospital) Services HYDROMORPHONE 2 MG TABLET RX-3760 CDM 6370000100 HCPCS 250 RC 42858-0301-01 NDC outpatient 1 UN 5.86 5.86 CIGNA 62308 [3081051] CIGNA STATE OF WYOMING [308105107] 4.69 percent of total billed charges 3.63 5.57 Technical (Hospital) Services HYDROMORPHONE 2 MG TABLET RX-3760 CDM 6370000100 HCPCS 250 RC 42858-0301-01 NDC outpatient 1 UN 5.86 5.86 MEDICA (COMMERCIAL) 94265 [3081118] MEDICA CLAIMS [308111801] 5.27 percent of total billed charges 3.63 5.57 Technical (Hospital) Services HYDROMORPHONE 2 MG TABLET RX-3760 CDM 6370000100 HCPCS 250 RC 42858-0301-01 NDC outpatient 1 UN 5.86 5.86 HEALTHPARTNERS SX009 HEALTHPARTNERS 4.69 percent of total billed charges 3.63 5.57 Technical (Hospital) Services HYDROMORPHONE 2 MG TABLET RX-3760 CDM 6370000100 HCPCS 250 RC 42858-0301-01 NDC outpatient 1 UN 5.86 5.86 UNITED HEALTHCARE (COMMERCIAL) [3081199] UNITED HEALTHCARE 87726 [308119901] 3.63 percent of total billed charges 3.63 5.57 Technical (Hospital) Services METOPROLOL TARTRATE 25 MG TABLET RX-37637 CDM 6370000100 HCPCS 250 RC 00378-0018-05 NDC inpatient 1 UN 5.67 5.67 UNITED HEALTHCARE (COMMERCIAL) [3081199] UNITED HEALTHCARE 87726 [308119901] 3.52 percent of total billed charges 3.52 5.39 Technical (Hospital) Services METOPROLOL TARTRATE 25 MG TABLET RX-37637 CDM 6370000100 HCPCS 250 RC 00378-0018-05 NDC inpatient 1 UN 5.67 5.67 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES EPO [308136803] 4.49 percent of total billed charges 3.52 5.39 Technical (Hospital) Services METOPROLOL TARTRATE 25 MG TABLET RX-37637 CDM 6370000100 HCPCS 250 RC 00378-0018-05 NDC inpatient 1 UN 5.67 5.67 CIGNA 62308 [3081051] CIGNA 62308 [308105105] 4.49 percent of total billed charges 3.52 5.39 Technical (Hospital) Services METOPROLOL TARTRATE 25 MG TABLET RX-37637 CDM 6370000100 HCPCS 250 RC 00378-0018-05 NDC inpatient 1 UN 5.67 5.67 CIGNA 62308 [3081051] CIGNA STATE OF WYOMING [308105107] 4.49 percent of total billed charges 3.52 5.39 Technical (Hospital) Services METOPROLOL TARTRATE 25 MG TABLET RX-37637 CDM 6370000100 HCPCS 250 RC 00378-0018-05 NDC inpatient 1 UN 5.67 5.67 HEALTHPARTNERS SX009 HEALTHPARTNERS 4.49 percent of total billed charges 3.52 5.39 Technical (Hospital) Services METOPROLOL TARTRATE 25 MG TABLET RX-37637 CDM 6370000100 HCPCS 250 RC 00378-0018-05 NDC inpatient 1 UN 5.67 5.67 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES HDHP [308136802] 4.49 percent of total billed charges 3.52 5.39 Technical (Hospital) Services METOPROLOL TARTRATE 25 MG TABLET RX-37637 CDM 6370000100 HCPCS 250 RC 00378-0018-05 NDC inpatient 1 UN 5.67 5.67 BLUE CROSS BLUE SHIELD WELLMARK SB889 [3081026] BCBS WYOMING [308102603] 5.39 percent of total billed charges 3.52 5.39 Technical (Hospital) Services METOPROLOL TARTRATE 25 MG TABLET RX-37637 CDM 6370000100 HCPCS 250 RC 00378-0018-05 NDC inpatient 1 UN 5.67 5.67 MULTIPLAN INC 34080 [3081285] MULTIPLAN INC [308128501] 5.39 percent of total billed charges 3.52 5.39 Technical (Hospital) Services METOPROLOL TARTRATE 25 MG TABLET RX-37637 CDM 6370000100 HCPCS 250 RC 00378-0018-05 NDC inpatient 1 UN 5.67 5.67 MEDICA (COMMERCIAL) 94265 [3081118] MEDICA CLAIMS [308111801] 5.1 percent of total billed charges 3.52 5.39 Technical (Hospital) Services METOPROLOL TARTRATE 25 MG TABLET RX-37637 CDM 6370000100 HCPCS 250 RC 00378-0018-05 NDC inpatient 1 UN 5.67 5.67 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES PPO [308136801] 4.49 percent of total billed charges 3.52 5.39 Technical (Hospital) Services METOPROLOL TARTRATE 25 MG TABLET RX-37637 CDM 6370000100 HCPCS 250 RC 00378-0018-05 NDC outpatient 1 UN 5.67 5.67 MULTIPLAN INC 34080 [3081285] MULTIPLAN INC [308128501] 5.39 percent of total billed charges 3.52 5.39 Technical (Hospital) Services METOPROLOL TARTRATE 25 MG TABLET RX-37637 CDM 6370000100 HCPCS 250 RC 00378-0018-05 NDC outpatient 1 UN 5.67 5.67 CIGNA 62308 [3081051] CIGNA 62308 [308105105] 4.54 percent of total billed charges 3.52 5.39 Technical (Hospital) Services METOPROLOL TARTRATE 25 MG TABLET RX-37637 CDM 6370000100 HCPCS 250 RC 00378-0018-05 NDC outpatient 1 UN 5.67 5.67 CIGNA 62308 [3081051] CIGNA STATE OF WYOMING [308105107] 4.54 percent of total billed charges 3.52 5.39 Technical (Hospital) Services METOPROLOL TARTRATE 25 MG TABLET RX-37637 CDM 6370000100 HCPCS 250 RC 00378-0018-05 NDC outpatient 1 UN 5.67 5.67 MEDICA (COMMERCIAL) 94265 [3081118] MEDICA CLAIMS [308111801] 5.1 percent of total billed charges 3.52 5.39 Technical (Hospital) Services METOPROLOL TARTRATE 25 MG TABLET RX-37637 CDM 6370000100 HCPCS 250 RC 00378-0018-05 NDC outpatient 1 UN 5.67 5.67 UNITED HEALTHCARE (COMMERCIAL) [3081199] UNITED HEALTHCARE 87726 [308119901] 3.52 percent of total billed charges 3.52 5.39 Technical (Hospital) Services METOPROLOL TARTRATE 25 MG TABLET RX-37637 CDM 6370000100 HCPCS 250 RC 00378-0018-05 NDC outpatient 1 UN 5.67 5.67 HEALTHPARTNERS SX009 HEALTHPARTNERS 4.54 percent of total billed charges 3.52 5.39 Technical (Hospital) Services METOPROLOL TARTRATE 25 MG TABLET RX-37637 CDM 6370000100 HCPCS 250 RC 00378-0018-05 NDC outpatient 1 UN 5.67 5.67 BLUE CROSS BLUE SHIELD WELLMARK SB889 [3081026] BCBS WYOMING [308102603] 5.39 percent of total billed charges 3.52 5.39 Technical (Hospital) Services METOPROLOL TARTRATE 25 MG TABLET RX-37637 CDM 6370000100 HCPCS 250 RC 00378-0018-05 NDC outpatient 1 UN 5.67 5.67 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES EPO [308136803] 4.54 percent of total billed charges 3.52 5.39 Technical (Hospital) Services METOPROLOL TARTRATE 25 MG TABLET RX-37637 CDM 6370000100 HCPCS 250 RC 00378-0018-05 NDC outpatient 1 UN 5.67 5.67 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES PPO [308136801] 4.54 percent of total billed charges 3.52 5.39 Technical (Hospital) Services METOPROLOL TARTRATE 25 MG TABLET RX-37637 CDM 6370000100 HCPCS 250 RC 00378-0018-05 NDC outpatient 1 UN 5.67 5.67 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES HDHP [308136802] 4.54 percent of total billed charges 3.52 5.39 Technical (Hospital) Services "GLIPIZIDE ER 5 MG TABLET, EXTENDED RELEASE 24 HR" RX-37649 CDM 6370000100 HCPCS 250 RC 68084-0111-11 NDC inpatient 1 UN 6.22 6.22 MULTIPLAN INC 34080 [3081285] MULTIPLAN INC [308128501] 5.91 percent of total billed charges 3.86 5.91 Technical (Hospital) Services "GLIPIZIDE ER 5 MG TABLET, EXTENDED RELEASE 24 HR" RX-37649 CDM 6370000100 HCPCS 250 RC 68084-0111-11 NDC inpatient 1 UN 6.22 6.22 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES PPO [308136801] 4.92 percent of total billed charges 3.86 5.91 Technical (Hospital) Services "GLIPIZIDE ER 5 MG TABLET, EXTENDED RELEASE 24 HR" RX-37649 CDM 6370000100 HCPCS 250 RC 68084-0111-11 NDC inpatient 1 UN 6.22 6.22 HEALTHPARTNERS SX009 HEALTHPARTNERS 4.92 percent of total billed charges 3.86 5.91 Technical (Hospital) Services "GLIPIZIDE ER 5 MG TABLET, EXTENDED RELEASE 24 HR" RX-37649 CDM 6370000100 HCPCS 250 RC 68084-0111-11 NDC inpatient 1 UN 6.22 6.22 MEDICA (COMMERCIAL) 94265 [3081118] MEDICA CLAIMS [308111801] 5.6 percent of total billed charges 3.86 5.91 Technical (Hospital) Services "GLIPIZIDE ER 5 MG TABLET, EXTENDED RELEASE 24 HR" RX-37649 CDM 6370000100 HCPCS 250 RC 68084-0111-11 NDC inpatient 1 UN 6.22 6.22 BLUE CROSS BLUE SHIELD WELLMARK SB889 [3081026] BCBS WYOMING [308102603] 5.91 percent of total billed charges 3.86 5.91 Technical (Hospital) Services "GLIPIZIDE ER 5 MG TABLET, EXTENDED RELEASE 24 HR" RX-37649 CDM 6370000100 HCPCS 250 RC 68084-0111-11 NDC inpatient 1 UN 6.22 6.22 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES EPO [308136803] 4.92 percent of total billed charges 3.86 5.91 Technical (Hospital) Services "GLIPIZIDE ER 5 MG TABLET, EXTENDED RELEASE 24 HR" RX-37649 CDM 6370000100 HCPCS 250 RC 68084-0111-11 NDC inpatient 1 UN 6.22 6.22 CIGNA 62308 [3081051] CIGNA 62308 [308105105] 4.92 percent of total billed charges 3.86 5.91 Technical (Hospital) Services "GLIPIZIDE ER 5 MG TABLET, EXTENDED RELEASE 24 HR" RX-37649 CDM 6370000100 HCPCS 250 RC 68084-0111-11 NDC inpatient 1 UN 6.22 6.22 CIGNA 62308 [3081051] CIGNA STATE OF WYOMING [308105107] 4.92 percent of total billed charges 3.86 5.91 Technical (Hospital) Services "GLIPIZIDE ER 5 MG TABLET, EXTENDED RELEASE 24 HR" RX-37649 CDM 6370000100 HCPCS 250 RC 68084-0111-11 NDC inpatient 1 UN 6.22 6.22 UNITED HEALTHCARE (COMMERCIAL) [3081199] UNITED HEALTHCARE 87726 [308119901] 3.86 percent of total billed charges 3.86 5.91 Technical (Hospital) Services "GLIPIZIDE ER 5 MG TABLET, EXTENDED RELEASE 24 HR" RX-37649 CDM 6370000100 HCPCS 250 RC 68084-0111-11 NDC inpatient 1 UN 6.22 6.22 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES HDHP [308136802] 4.92 percent of total billed charges 3.86 5.91 Technical (Hospital) Services "GLIPIZIDE ER 5 MG TABLET, EXTENDED RELEASE 24 HR" RX-37649 CDM 6370000100 HCPCS 250 RC 68084-0111-11 NDC outpatient 1 UN 6.22 6.22 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES PPO [308136801] 4.98 percent of total billed charges 3.86 5.91 Technical (Hospital) Services "GLIPIZIDE ER 5 MG TABLET, EXTENDED RELEASE 24 HR" RX-37649 CDM 6370000100 HCPCS 250 RC 68084-0111-11 NDC outpatient 1 UN 6.22 6.22 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES EPO [308136803] 4.98 percent of total billed charges 3.86 5.91 Technical (Hospital) Services "GLIPIZIDE ER 5 MG TABLET, EXTENDED RELEASE 24 HR" RX-37649 CDM 6370000100 HCPCS 250 RC 68084-0111-11 NDC outpatient 1 UN 6.22 6.22 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES HDHP [308136802] 4.98 percent of total billed charges 3.86 5.91 Technical (Hospital) Services "GLIPIZIDE ER 5 MG TABLET, EXTENDED RELEASE 24 HR" RX-37649 CDM 6370000100 HCPCS 250 RC 68084-0111-11 NDC outpatient 1 UN 6.22 6.22 MULTIPLAN INC 34080 [3081285] MULTIPLAN INC [308128501] 5.91 percent of total billed charges 3.86 5.91 Technical (Hospital) Services "GLIPIZIDE ER 5 MG TABLET, EXTENDED RELEASE 24 HR" RX-37649 CDM 6370000100 HCPCS 250 RC 68084-0111-11 NDC outpatient 1 UN 6.22 6.22 CIGNA 62308 [3081051] CIGNA 62308 [308105105] 4.98 percent of total billed charges 3.86 5.91 Technical (Hospital) Services "GLIPIZIDE ER 5 MG TABLET, EXTENDED RELEASE 24 HR" RX-37649 CDM 6370000100 HCPCS 250 RC 68084-0111-11 NDC outpatient 1 UN 6.22 6.22 CIGNA 62308 [3081051] CIGNA STATE OF WYOMING [308105107] 4.98 percent of total billed charges 3.86 5.91 Technical (Hospital) Services "GLIPIZIDE ER 5 MG TABLET, EXTENDED RELEASE 24 HR" RX-37649 CDM 6370000100 HCPCS 250 RC 68084-0111-11 NDC outpatient 1 UN 6.22 6.22 MEDICA (COMMERCIAL) 94265 [3081118] MEDICA CLAIMS [308111801] 5.6 percent of total billed charges 3.86 5.91 Technical (Hospital) Services "GLIPIZIDE ER 5 MG TABLET, EXTENDED RELEASE 24 HR" RX-37649 CDM 6370000100 HCPCS 250 RC 68084-0111-11 NDC outpatient 1 UN 6.22 6.22 UNITED HEALTHCARE (COMMERCIAL) [3081199] UNITED HEALTHCARE 87726 [308119901] 3.86 percent of total billed charges 3.86 5.91 Technical (Hospital) Services "GLIPIZIDE ER 5 MG TABLET, EXTENDED RELEASE 24 HR" RX-37649 CDM 6370000100 HCPCS 250 RC 68084-0111-11 NDC outpatient 1 UN 6.22 6.22 HEALTHPARTNERS SX009 HEALTHPARTNERS 4.98 percent of total billed charges 3.86 5.91 Technical (Hospital) Services "GLIPIZIDE ER 5 MG TABLET, EXTENDED RELEASE 24 HR" RX-37649 CDM 6370000100 HCPCS 250 RC 68084-0111-11 NDC outpatient 1 UN 6.22 6.22 BLUE CROSS BLUE SHIELD WELLMARK SB889 [3081026] BCBS WYOMING [308102603] 5.91 percent of total billed charges 3.86 5.91 Technical (Hospital) Services "GLIPIZIDE ER 10 MG TABLET, EXTENDED RELEASE 24 HR" RX-37650 CDM 6370000100 HCPCS 250 RC 59762-0542-02 NDC inpatient 1 UN 5.93 5.93 MULTIPLAN INC 34080 [3081285] MULTIPLAN INC [308128501] 5.63 percent of total billed charges 3.68 5.63 Technical (Hospital) Services "GLIPIZIDE ER 10 MG TABLET, EXTENDED RELEASE 24 HR" RX-37650 CDM 6370000100 HCPCS 250 RC 59762-0542-02 NDC inpatient 1 UN 5.93 5.93 HEALTHPARTNERS SX009 HEALTHPARTNERS 4.7 percent of total billed charges 3.68 5.63 Technical (Hospital) Services "GLIPIZIDE ER 10 MG TABLET, EXTENDED RELEASE 24 HR" RX-37650 CDM 6370000100 HCPCS 250 RC 59762-0542-02 NDC inpatient 1 UN 5.93 5.93 MEDICA (COMMERCIAL) 94265 [3081118] MEDICA CLAIMS [308111801] 5.34 percent of total billed charges 3.68 5.63 Technical (Hospital) Services "GLIPIZIDE ER 10 MG TABLET, EXTENDED RELEASE 24 HR" RX-37650 CDM 6370000100 HCPCS 250 RC 59762-0542-02 NDC inpatient 1 UN 5.93 5.93 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES PPO [308136801] 4.7 percent of total billed charges 3.68 5.63 Technical (Hospital) Services "GLIPIZIDE ER 10 MG TABLET, EXTENDED RELEASE 24 HR" RX-37650 CDM 6370000100 HCPCS 250 RC 59762-0542-02 NDC inpatient 1 UN 5.93 5.93 CIGNA 62308 [3081051] CIGNA 62308 [308105105] 4.7 percent of total billed charges 3.68 5.63 Technical (Hospital) Services "GLIPIZIDE ER 10 MG TABLET, EXTENDED RELEASE 24 HR" RX-37650 CDM 6370000100 HCPCS 250 RC 59762-0542-02 NDC inpatient 1 UN 5.93 5.93 CIGNA 62308 [3081051] CIGNA STATE OF WYOMING [308105107] 4.7 percent of total billed charges 3.68 5.63 Technical (Hospital) Services "GLIPIZIDE ER 10 MG TABLET, EXTENDED RELEASE 24 HR" RX-37650 CDM 6370000100 HCPCS 250 RC 59762-0542-02 NDC inpatient 1 UN 5.93 5.93 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES HDHP [308136802] 4.7 percent of total billed charges 3.68 5.63 Technical (Hospital) Services "GLIPIZIDE ER 10 MG TABLET, EXTENDED RELEASE 24 HR" RX-37650 CDM 6370000100 HCPCS 250 RC 59762-0542-02 NDC inpatient 1 UN 5.93 5.93 UNITED HEALTHCARE (COMMERCIAL) [3081199] UNITED HEALTHCARE 87726 [308119901] 3.68 percent of total billed charges 3.68 5.63 Technical (Hospital) Services "GLIPIZIDE ER 10 MG TABLET, EXTENDED RELEASE 24 HR" RX-37650 CDM 6370000100 HCPCS 250 RC 59762-0542-02 NDC inpatient 1 UN 5.93 5.93 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES EPO [308136803] 4.7 percent of total billed charges 3.68 5.63 Technical (Hospital) Services "GLIPIZIDE ER 10 MG TABLET, EXTENDED RELEASE 24 HR" RX-37650 CDM 6370000100 HCPCS 250 RC 59762-0542-02 NDC inpatient 1 UN 5.93 5.93 BLUE CROSS BLUE SHIELD WELLMARK SB889 [3081026] BCBS WYOMING [308102603] 5.63 percent of total billed charges 3.68 5.63 Technical (Hospital) Services "GLIPIZIDE ER 10 MG TABLET, EXTENDED RELEASE 24 HR" RX-37650 CDM 6370000100 HCPCS 250 RC 59762-0542-02 NDC outpatient 1 UN 5.93 5.93 BLUE CROSS BLUE SHIELD WELLMARK SB889 [3081026] BCBS WYOMING [308102603] 5.63 percent of total billed charges 3.68 5.63 Technical (Hospital) Services "GLIPIZIDE ER 10 MG TABLET, EXTENDED RELEASE 24 HR" RX-37650 CDM 6370000100 HCPCS 250 RC 59762-0542-02 NDC outpatient 1 UN 5.93 5.93 UNITED HEALTHCARE (COMMERCIAL) [3081199] UNITED HEALTHCARE 87726 [308119901] 3.68 percent of total billed charges 3.68 5.63 Technical (Hospital) Services "GLIPIZIDE ER 10 MG TABLET, EXTENDED RELEASE 24 HR" RX-37650 CDM 6370000100 HCPCS 250 RC 59762-0542-02 NDC outpatient 1 UN 5.93 5.93 HEALTHPARTNERS SX009 HEALTHPARTNERS 4.74 percent of total billed charges 3.68 5.63 Technical (Hospital) Services "GLIPIZIDE ER 10 MG TABLET, EXTENDED RELEASE 24 HR" RX-37650 CDM 6370000100 HCPCS 250 RC 59762-0542-02 NDC outpatient 1 UN 5.93 5.93 MEDICA (COMMERCIAL) 94265 [3081118] MEDICA CLAIMS [308111801] 5.34 percent of total billed charges 3.68 5.63 Technical (Hospital) Services "GLIPIZIDE ER 10 MG TABLET, EXTENDED RELEASE 24 HR" RX-37650 CDM 6370000100 HCPCS 250 RC 59762-0542-02 NDC outpatient 1 UN 5.93 5.93 MULTIPLAN INC 34080 [3081285] MULTIPLAN INC [308128501] 5.63 percent of total billed charges 3.68 5.63 Technical (Hospital) Services "GLIPIZIDE ER 10 MG TABLET, EXTENDED RELEASE 24 HR" RX-37650 CDM 6370000100 HCPCS 250 RC 59762-0542-02 NDC outpatient 1 UN 5.93 5.93 CIGNA 62308 [3081051] CIGNA 62308 [308105105] 4.74 percent of total billed charges 3.68 5.63 Technical (Hospital) Services "GLIPIZIDE ER 10 MG TABLET, EXTENDED RELEASE 24 HR" RX-37650 CDM 6370000100 HCPCS 250 RC 59762-0542-02 NDC outpatient 1 UN 5.93 5.93 CIGNA 62308 [3081051] CIGNA STATE OF WYOMING [308105107] 4.74 percent of total billed charges 3.68 5.63 Technical (Hospital) Services "GLIPIZIDE ER 10 MG TABLET, EXTENDED RELEASE 24 HR" RX-37650 CDM 6370000100 HCPCS 250 RC 59762-0542-02 NDC outpatient 1 UN 5.93 5.93 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES HDHP [308136802] 4.74 percent of total billed charges 3.68 5.63 Technical (Hospital) Services "GLIPIZIDE ER 10 MG TABLET, EXTENDED RELEASE 24 HR" RX-37650 CDM 6370000100 HCPCS 250 RC 59762-0542-02 NDC outpatient 1 UN 5.93 5.93 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES PPO [308136801] 4.74 percent of total billed charges 3.68 5.63 Technical (Hospital) Services "GLIPIZIDE ER 10 MG TABLET, EXTENDED RELEASE 24 HR" RX-37650 CDM 6370000100 HCPCS 250 RC 59762-0542-02 NDC outpatient 1 UN 5.93 5.93 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES EPO [308136803] 4.74 percent of total billed charges 3.68 5.63 Technical (Hospital) Services "GUAIFENESIN ER 600 MG TABLET, EXTENDED RELEASE 12 HR" RX-37651 CDM 6370000100 HCPCS 250 RC 00904-6718-39 NDC outpatient 1 UN 6.51 6.51 BLUE CROSS BLUE SHIELD WELLMARK SB889 [3081026] BCBS WYOMING [308102603] 6.18 percent of total billed charges 4.04 6.18 Technical (Hospital) Services "GUAIFENESIN ER 600 MG TABLET, EXTENDED RELEASE 12 HR" RX-37651 CDM 6370000100 HCPCS 250 RC 00904-6718-39 NDC outpatient 1 UN 6.51 6.51 MEDICA (COMMERCIAL) 94265 [3081118] MEDICA CLAIMS [308111801] 5.86 percent of total billed charges 4.04 6.18 Technical (Hospital) Services "GUAIFENESIN ER 600 MG TABLET, EXTENDED RELEASE 12 HR" RX-37651 CDM 6370000100 HCPCS 250 RC 00904-6718-39 NDC outpatient 1 UN 6.51 6.51 MULTIPLAN INC 34080 [3081285] MULTIPLAN INC [308128501] 6.18 percent of total billed charges 4.04 6.18 Technical (Hospital) Services "GUAIFENESIN ER 600 MG TABLET, EXTENDED RELEASE 12 HR" RX-37651 CDM 6370000100 HCPCS 250 RC 00904-6718-39 NDC outpatient 1 UN 6.51 6.51 CIGNA 62308 [3081051] CIGNA 62308 [308105105] 5.21 percent of total billed charges 4.04 6.18 Technical (Hospital) Services "GUAIFENESIN ER 600 MG TABLET, EXTENDED RELEASE 12 HR" RX-37651 CDM 6370000100 HCPCS 250 RC 00904-6718-39 NDC outpatient 1 UN 6.51 6.51 CIGNA 62308 [3081051] CIGNA STATE OF WYOMING [308105107] 5.21 percent of total billed charges 4.04 6.18 Technical (Hospital) Services "GUAIFENESIN ER 600 MG TABLET, EXTENDED RELEASE 12 HR" RX-37651 CDM 6370000100 HCPCS 250 RC 00904-6718-39 NDC outpatient 1 UN 6.51 6.51 HEALTHPARTNERS SX009 HEALTHPARTNERS 5.21 percent of total billed charges 4.04 6.18 Technical (Hospital) Services "GUAIFENESIN ER 600 MG TABLET, EXTENDED RELEASE 12 HR" RX-37651 CDM 6370000100 HCPCS 250 RC 00904-6718-39 NDC outpatient 1 UN 6.51 6.51 UNITED HEALTHCARE (COMMERCIAL) [3081199] UNITED HEALTHCARE 87726 [308119901] 4.04 percent of total billed charges 4.04 6.18 Technical (Hospital) Services "GUAIFENESIN ER 600 MG TABLET, EXTENDED RELEASE 12 HR" RX-37651 CDM 6370000100 HCPCS 250 RC 00904-6718-39 NDC outpatient 1 UN 6.51 6.51 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES PPO [308136801] 5.21 percent of total billed charges 4.04 6.18 Technical (Hospital) Services "GUAIFENESIN ER 600 MG TABLET, EXTENDED RELEASE 12 HR" RX-37651 CDM 6370000100 HCPCS 250 RC 00904-6718-39 NDC outpatient 1 UN 6.51 6.51 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES HDHP [308136802] 5.21 percent of total billed charges 4.04 6.18 Technical (Hospital) Services "GUAIFENESIN ER 600 MG TABLET, EXTENDED RELEASE 12 HR" RX-37651 CDM 6370000100 HCPCS 250 RC 00904-6718-39 NDC outpatient 1 UN 6.51 6.51 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES EPO [308136803] 5.21 percent of total billed charges 4.04 6.18 Technical (Hospital) Services "GUAIFENESIN ER 600 MG TABLET, EXTENDED RELEASE 12 HR" RX-37651 CDM 6370000100 HCPCS 250 RC 00904-6718-39 NDC inpatient 1 UN 6.51 6.51 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES PPO [308136801] 5.15 percent of total billed charges 4.04 6.18 Technical (Hospital) Services "GUAIFENESIN ER 600 MG TABLET, EXTENDED RELEASE 12 HR" RX-37651 CDM 6370000100 HCPCS 250 RC 00904-6718-39 NDC inpatient 1 UN 6.51 6.51 MEDICA (COMMERCIAL) 94265 [3081118] MEDICA CLAIMS [308111801] 5.86 percent of total billed charges 4.04 6.18 Technical (Hospital) Services "GUAIFENESIN ER 600 MG TABLET, EXTENDED RELEASE 12 HR" RX-37651 CDM 6370000100 HCPCS 250 RC 00904-6718-39 NDC inpatient 1 UN 6.51 6.51 HEALTHPARTNERS SX009 HEALTHPARTNERS 5.15 percent of total billed charges 4.04 6.18 Technical (Hospital) Services "GUAIFENESIN ER 600 MG TABLET, EXTENDED RELEASE 12 HR" RX-37651 CDM 6370000100 HCPCS 250 RC 00904-6718-39 NDC inpatient 1 UN 6.51 6.51 MULTIPLAN INC 34080 [3081285] MULTIPLAN INC [308128501] 6.18 percent of total billed charges 4.04 6.18 Technical (Hospital) Services "GUAIFENESIN ER 600 MG TABLET, EXTENDED RELEASE 12 HR" RX-37651 CDM 6370000100 HCPCS 250 RC 00904-6718-39 NDC inpatient 1 UN 6.51 6.51 BLUE CROSS BLUE SHIELD WELLMARK SB889 [3081026] BCBS WYOMING [308102603] 6.18 percent of total billed charges 4.04 6.18 Technical (Hospital) Services "GUAIFENESIN ER 600 MG TABLET, EXTENDED RELEASE 12 HR" RX-37651 CDM 6370000100 HCPCS 250 RC 00904-6718-39 NDC inpatient 1 UN 6.51 6.51 CIGNA 62308 [3081051] CIGNA 62308 [308105105] 5.15 percent of total billed charges 4.04 6.18 Technical (Hospital) Services "GUAIFENESIN ER 600 MG TABLET, EXTENDED RELEASE 12 HR" RX-37651 CDM 6370000100 HCPCS 250 RC 00904-6718-39 NDC inpatient 1 UN 6.51 6.51 CIGNA 62308 [3081051] CIGNA STATE OF WYOMING [308105107] 5.15 percent of total billed charges 4.04 6.18 Technical (Hospital) Services "GUAIFENESIN ER 600 MG TABLET, EXTENDED RELEASE 12 HR" RX-37651 CDM 6370000100 HCPCS 250 RC 00904-6718-39 NDC inpatient 1 UN 6.51 6.51 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES EPO [308136803] 5.15 percent of total billed charges 4.04 6.18 Technical (Hospital) Services "GUAIFENESIN ER 600 MG TABLET, EXTENDED RELEASE 12 HR" RX-37651 CDM 6370000100 HCPCS 250 RC 00904-6718-39 NDC inpatient 1 UN 6.51 6.51 UNITED HEALTHCARE (COMMERCIAL) [3081199] UNITED HEALTHCARE 87726 [308119901] 4.04 percent of total billed charges 4.04 6.18 Technical (Hospital) Services "GUAIFENESIN ER 600 MG TABLET, EXTENDED RELEASE 12 HR" RX-37651 CDM 6370000100 HCPCS 250 RC 00904-6718-39 NDC inpatient 1 UN 6.51 6.51 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES HDHP [308136802] 5.15 percent of total billed charges 4.04 6.18 Technical (Hospital) Services HYDROXYZINE HCL 25 MG TABLET RX-3774 CDM 6370000100 HCPCS 250 RC 23155-0501-01 NDC inpatient 1 UN 5.68 5.68 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES PPO [308136801] 4.5 percent of total billed charges 3.52 5.4 Technical (Hospital) Services HYDROXYZINE HCL 25 MG TABLET RX-3774 CDM 6370000100 HCPCS 250 RC 23155-0501-01 NDC inpatient 1 UN 5.68 5.68 MEDICA (COMMERCIAL) 94265 [3081118] MEDICA CLAIMS [308111801] 5.11 percent of total billed charges 3.52 5.4 Technical (Hospital) Services HYDROXYZINE HCL 25 MG TABLET RX-3774 CDM 6370000100 HCPCS 250 RC 23155-0501-01 NDC inpatient 1 UN 5.68 5.68 HEALTHPARTNERS SX009 HEALTHPARTNERS 4.5 percent of total billed charges 3.52 5.4 Technical (Hospital) Services HYDROXYZINE HCL 25 MG TABLET RX-3774 CDM 6370000100 HCPCS 250 RC 23155-0501-01 NDC inpatient 1 UN 5.68 5.68 MULTIPLAN INC 34080 [3081285] MULTIPLAN INC [308128501] 5.4 percent of total billed charges 3.52 5.4 Technical (Hospital) Services HYDROXYZINE HCL 25 MG TABLET RX-3774 CDM 6370000100 HCPCS 250 RC 23155-0501-01 NDC inpatient 1 UN 5.68 5.68 BLUE CROSS BLUE SHIELD WELLMARK SB889 [3081026] BCBS WYOMING [308102603] 5.4 percent of total billed charges 3.52 5.4 Technical (Hospital) Services HYDROXYZINE HCL 25 MG TABLET RX-3774 CDM 6370000100 HCPCS 250 RC 23155-0501-01 NDC inpatient 1 UN 5.68 5.68 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES EPO [308136803] 4.5 percent of total billed charges 3.52 5.4 Technical (Hospital) Services HYDROXYZINE HCL 25 MG TABLET RX-3774 CDM 6370000100 HCPCS 250 RC 23155-0501-01 NDC inpatient 1 UN 5.68 5.68 UNITED HEALTHCARE (COMMERCIAL) [3081199] UNITED HEALTHCARE 87726 [308119901] 3.52 percent of total billed charges 3.52 5.4 Technical (Hospital) Services HYDROXYZINE HCL 25 MG TABLET RX-3774 CDM 6370000100 HCPCS 250 RC 23155-0501-01 NDC inpatient 1 UN 5.68 5.68 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES HDHP [308136802] 4.5 percent of total billed charges 3.52 5.4 Technical (Hospital) Services HYDROXYZINE HCL 25 MG TABLET RX-3774 CDM 6370000100 HCPCS 250 RC 23155-0501-01 NDC inpatient 1 UN 5.68 5.68 CIGNA 62308 [3081051] CIGNA 62308 [308105105] 4.5 percent of total billed charges 3.52 5.4 Technical (Hospital) Services HYDROXYZINE HCL 25 MG TABLET RX-3774 CDM 6370000100 HCPCS 250 RC 23155-0501-01 NDC inpatient 1 UN 5.68 5.68 CIGNA 62308 [3081051] CIGNA STATE OF WYOMING [308105107] 4.5 percent of total billed charges 3.52 5.4 Technical (Hospital) Services HYDROXYZINE HCL 25 MG TABLET RX-3774 CDM 6370000100 HCPCS 250 RC 23155-0501-01 NDC outpatient 1 UN 5.68 5.68 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES HDHP [308136802] 4.54 percent of total billed charges 3.52 5.4 Technical (Hospital) Services HYDROXYZINE HCL 25 MG TABLET RX-3774 CDM 6370000100 HCPCS 250 RC 23155-0501-01 NDC outpatient 1 UN 5.68 5.68 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES EPO [308136803] 4.54 percent of total billed charges 3.52 5.4 Technical (Hospital) Services HYDROXYZINE HCL 25 MG TABLET RX-3774 CDM 6370000100 HCPCS 250 RC 23155-0501-01 NDC outpatient 1 UN 5.68 5.68 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES PPO [308136801] 4.54 percent of total billed charges 3.52 5.4 Technical (Hospital) Services HYDROXYZINE HCL 25 MG TABLET RX-3774 CDM 6370000100 HCPCS 250 RC 23155-0501-01 NDC outpatient 1 UN 5.68 5.68 MULTIPLAN INC 34080 [3081285] MULTIPLAN INC [308128501] 5.4 percent of total billed charges 3.52 5.4 Technical (Hospital) Services HYDROXYZINE HCL 25 MG TABLET RX-3774 CDM 6370000100 HCPCS 250 RC 23155-0501-01 NDC outpatient 1 UN 5.68 5.68 UNITED HEALTHCARE (COMMERCIAL) [3081199] UNITED HEALTHCARE 87726 [308119901] 3.52 percent of total billed charges 3.52 5.4 Technical (Hospital) Services HYDROXYZINE HCL 25 MG TABLET RX-3774 CDM 6370000100 HCPCS 250 RC 23155-0501-01 NDC outpatient 1 UN 5.68 5.68 MEDICA (COMMERCIAL) 94265 [3081118] MEDICA CLAIMS [308111801] 5.11 percent of total billed charges 3.52 5.4 Technical (Hospital) Services HYDROXYZINE HCL 25 MG TABLET RX-3774 CDM 6370000100 HCPCS 250 RC 23155-0501-01 NDC outpatient 1 UN 5.68 5.68 CIGNA 62308 [3081051] CIGNA 62308 [308105105] 4.54 percent of total billed charges 3.52 5.4 Technical (Hospital) Services HYDROXYZINE HCL 25 MG TABLET RX-3774 CDM 6370000100 HCPCS 250 RC 23155-0501-01 NDC outpatient 1 UN 5.68 5.68 CIGNA 62308 [3081051] CIGNA STATE OF WYOMING [308105107] 4.54 percent of total billed charges 3.52 5.4 Technical (Hospital) Services HYDROXYZINE HCL 25 MG TABLET RX-3774 CDM 6370000100 HCPCS 250 RC 23155-0501-01 NDC outpatient 1 UN 5.68 5.68 HEALTHPARTNERS SX009 HEALTHPARTNERS 4.54 percent of total billed charges 3.52 5.4 Technical (Hospital) Services HYDROXYZINE HCL 25 MG TABLET RX-3774 CDM 6370000100 HCPCS 250 RC 23155-0501-01 NDC outpatient 1 UN 5.68 5.68 BLUE CROSS BLUE SHIELD WELLMARK SB889 [3081026] BCBS WYOMING [308102603] 5.4 percent of total billed charges 3.52 5.4 Technical (Hospital) Services "PROPRANOLOL ER 60 MG CAPSULE,24 HR,EXTENDED RELEASE" RX-38224 CDM 6370000100 HCPCS 250 RC 51991-0817-01 NDC outpatient 1 UN 6.17 6.17 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES EPO [308136803] 4.94 percent of total billed charges 3.83 5.86 Technical (Hospital) Services "PROPRANOLOL ER 60 MG CAPSULE,24 HR,EXTENDED RELEASE" RX-38224 CDM 6370000100 HCPCS 250 RC 51991-0817-01 NDC outpatient 1 UN 6.17 6.17 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES HDHP [308136802] 4.94 percent of total billed charges 3.83 5.86 Technical (Hospital) Services "PROPRANOLOL ER 60 MG CAPSULE,24 HR,EXTENDED RELEASE" RX-38224 CDM 6370000100 HCPCS 250 RC 51991-0817-01 NDC outpatient 1 UN 6.17 6.17 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES PPO [308136801] 4.94 percent of total billed charges 3.83 5.86 Technical (Hospital) Services "PROPRANOLOL ER 60 MG CAPSULE,24 HR,EXTENDED RELEASE" RX-38224 CDM 6370000100 HCPCS 250 RC 51991-0817-01 NDC outpatient 1 UN 6.17 6.17 MULTIPLAN INC 34080 [3081285] MULTIPLAN INC [308128501] 5.86 percent of total billed charges 3.83 5.86 Technical (Hospital) Services "PROPRANOLOL ER 60 MG CAPSULE,24 HR,EXTENDED RELEASE" RX-38224 CDM 6370000100 HCPCS 250 RC 51991-0817-01 NDC outpatient 1 UN 6.17 6.17 CIGNA 62308 [3081051] CIGNA 62308 [308105105] 4.94 percent of total billed charges 3.83 5.86 Technical (Hospital) Services "PROPRANOLOL ER 60 MG CAPSULE,24 HR,EXTENDED RELEASE" RX-38224 CDM 6370000100 HCPCS 250 RC 51991-0817-01 NDC outpatient 1 UN 6.17 6.17 CIGNA 62308 [3081051] CIGNA STATE OF WYOMING [308105107] 4.94 percent of total billed charges 3.83 5.86 Technical (Hospital) Services "PROPRANOLOL ER 60 MG CAPSULE,24 HR,EXTENDED RELEASE" RX-38224 CDM 6370000100 HCPCS 250 RC 51991-0817-01 NDC outpatient 1 UN 6.17 6.17 MEDICA (COMMERCIAL) 94265 [3081118] MEDICA CLAIMS [308111801] 5.55 percent of total billed charges 3.83 5.86 Technical (Hospital) Services "PROPRANOLOL ER 60 MG CAPSULE,24 HR,EXTENDED RELEASE" RX-38224 CDM 6370000100 HCPCS 250 RC 51991-0817-01 NDC outpatient 1 UN 6.17 6.17 UNITED HEALTHCARE (COMMERCIAL) [3081199] UNITED HEALTHCARE 87726 [308119901] 3.83 percent of total billed charges 3.83 5.86 Technical (Hospital) Services "PROPRANOLOL ER 60 MG CAPSULE,24 HR,EXTENDED RELEASE" RX-38224 CDM 6370000100 HCPCS 250 RC 51991-0817-01 NDC outpatient 1 UN 6.17 6.17 HEALTHPARTNERS SX009 HEALTHPARTNERS 4.94 percent of total billed charges 3.83 5.86 Technical (Hospital) Services "PROPRANOLOL ER 60 MG CAPSULE,24 HR,EXTENDED RELEASE" RX-38224 CDM 6370000100 HCPCS 250 RC 51991-0817-01 NDC outpatient 1 UN 6.17 6.17 BLUE CROSS BLUE SHIELD WELLMARK SB889 [3081026] BCBS WYOMING [308102603] 5.86 percent of total billed charges 3.83 5.86 Technical (Hospital) Services "PROPRANOLOL ER 60 MG CAPSULE,24 HR,EXTENDED RELEASE" RX-38224 CDM 6370000100 HCPCS 250 RC 51991-0817-01 NDC inpatient 1 UN 6.17 6.17 MULTIPLAN INC 34080 [3081285] MULTIPLAN INC [308128501] 5.86 percent of total billed charges 3.83 5.86 Technical (Hospital) Services "PROPRANOLOL ER 60 MG CAPSULE,24 HR,EXTENDED RELEASE" RX-38224 CDM 6370000100 HCPCS 250 RC 51991-0817-01 NDC inpatient 1 UN 6.17 6.17 MEDICA (COMMERCIAL) 94265 [3081118] MEDICA CLAIMS [308111801] 5.55 percent of total billed charges 3.83 5.86 Technical (Hospital) Services "PROPRANOLOL ER 60 MG CAPSULE,24 HR,EXTENDED RELEASE" RX-38224 CDM 6370000100 HCPCS 250 RC 51991-0817-01 NDC inpatient 1 UN 6.17 6.17 HEALTHPARTNERS SX009 HEALTHPARTNERS 4.89 percent of total billed charges 3.83 5.86 Technical (Hospital) Services "PROPRANOLOL ER 60 MG CAPSULE,24 HR,EXTENDED RELEASE" RX-38224 CDM 6370000100 HCPCS 250 RC 51991-0817-01 NDC inpatient 1 UN 6.17 6.17 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES PPO [308136801] 4.89 percent of total billed charges 3.83 5.86 Technical (Hospital) Services "PROPRANOLOL ER 60 MG CAPSULE,24 HR,EXTENDED RELEASE" RX-38224 CDM 6370000100 HCPCS 250 RC 51991-0817-01 NDC inpatient 1 UN 6.17 6.17 BLUE CROSS BLUE SHIELD WELLMARK SB889 [3081026] BCBS WYOMING [308102603] 5.86 percent of total billed charges 3.83 5.86 Technical (Hospital) Services "PROPRANOLOL ER 60 MG CAPSULE,24 HR,EXTENDED RELEASE" RX-38224 CDM 6370000100 HCPCS 250 RC 51991-0817-01 NDC inpatient 1 UN 6.17 6.17 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES EPO [308136803] 4.89 percent of total billed charges 3.83 5.86 Technical (Hospital) Services "PROPRANOLOL ER 60 MG CAPSULE,24 HR,EXTENDED RELEASE" RX-38224 CDM 6370000100 HCPCS 250 RC 51991-0817-01 NDC inpatient 1 UN 6.17 6.17 UNITED HEALTHCARE (COMMERCIAL) [3081199] UNITED HEALTHCARE 87726 [308119901] 3.83 percent of total billed charges 3.83 5.86 Technical (Hospital) Services "PROPRANOLOL ER 60 MG CAPSULE,24 HR,EXTENDED RELEASE" RX-38224 CDM 6370000100 HCPCS 250 RC 51991-0817-01 NDC inpatient 1 UN 6.17 6.17 CIGNA 62308 [3081051] CIGNA 62308 [308105105] 4.89 percent of total billed charges 3.83 5.86 Technical (Hospital) Services "PROPRANOLOL ER 60 MG CAPSULE,24 HR,EXTENDED RELEASE" RX-38224 CDM 6370000100 HCPCS 250 RC 51991-0817-01 NDC inpatient 1 UN 6.17 6.17 CIGNA 62308 [3081051] CIGNA STATE OF WYOMING [308105107] 4.89 percent of total billed charges 3.83 5.86 Technical (Hospital) Services "PROPRANOLOL ER 60 MG CAPSULE,24 HR,EXTENDED RELEASE" RX-38224 CDM 6370000100 HCPCS 250 RC 51991-0817-01 NDC inpatient 1 UN 6.17 6.17 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES HDHP [308136802] 4.89 percent of total billed charges 3.83 5.86 Technical (Hospital) Services TIOTROPIUM BROMIDE 18 MCG CAPSULE WITH INHALATION DEVICE RX-38315 CDM 6370000100 HCPCS 250 RC 00597-0075-75 NDC inpatient 1 UN 81.78 81.78 HEALTHPARTNERS SX009 HEALTHPARTNERS 64.75 percent of total billed charges 50.7 77.69 Technical (Hospital) Services TIOTROPIUM BROMIDE 18 MCG CAPSULE WITH INHALATION DEVICE RX-38315 CDM 6370000100 HCPCS 250 RC 00597-0075-75 NDC inpatient 1 UN 81.78 81.78 MEDICA (COMMERCIAL) 94265 [3081118] MEDICA CLAIMS [308111801] 73.6 percent of total billed charges 50.7 77.69 Technical (Hospital) Services TIOTROPIUM BROMIDE 18 MCG CAPSULE WITH INHALATION DEVICE RX-38315 CDM 6370000100 HCPCS 250 RC 00597-0075-75 NDC inpatient 1 UN 81.78 81.78 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES PPO [308136801] 64.75 percent of total billed charges 50.7 77.69 Technical (Hospital) Services TIOTROPIUM BROMIDE 18 MCG CAPSULE WITH INHALATION DEVICE RX-38315 CDM 6370000100 HCPCS 250 RC 00597-0075-75 NDC inpatient 1 UN 81.78 81.78 MULTIPLAN INC 34080 [3081285] MULTIPLAN INC [308128501] 77.69 percent of total billed charges 50.7 77.69 Technical (Hospital) Services TIOTROPIUM BROMIDE 18 MCG CAPSULE WITH INHALATION DEVICE RX-38315 CDM 6370000100 HCPCS 250 RC 00597-0075-75 NDC inpatient 1 UN 81.78 81.78 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES HDHP [308136802] 64.75 percent of total billed charges 50.7 77.69 Technical (Hospital) Services TIOTROPIUM BROMIDE 18 MCG CAPSULE WITH INHALATION DEVICE RX-38315 CDM 6370000100 HCPCS 250 RC 00597-0075-75 NDC inpatient 1 UN 81.78 81.78 UNITED HEALTHCARE (COMMERCIAL) [3081199] UNITED HEALTHCARE 87726 [308119901] 50.7 percent of total billed charges 50.7 77.69 Technical (Hospital) Services TIOTROPIUM BROMIDE 18 MCG CAPSULE WITH INHALATION DEVICE RX-38315 CDM 6370000100 HCPCS 250 RC 00597-0075-75 NDC inpatient 1 UN 81.78 81.78 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES EPO [308136803] 64.75 percent of total billed charges 50.7 77.69 Technical (Hospital) Services TIOTROPIUM BROMIDE 18 MCG CAPSULE WITH INHALATION DEVICE RX-38315 CDM 6370000100 HCPCS 250 RC 00597-0075-75 NDC inpatient 1 UN 81.78 81.78 CIGNA 62308 [3081051] CIGNA 62308 [308105105] 64.75 percent of total billed charges 50.7 77.69 Technical (Hospital) Services TIOTROPIUM BROMIDE 18 MCG CAPSULE WITH INHALATION DEVICE RX-38315 CDM 6370000100 HCPCS 250 RC 00597-0075-75 NDC inpatient 1 UN 81.78 81.78 CIGNA 62308 [3081051] CIGNA STATE OF WYOMING [308105107] 64.75 percent of total billed charges 50.7 77.69 Technical (Hospital) Services TIOTROPIUM BROMIDE 18 MCG CAPSULE WITH INHALATION DEVICE RX-38315 CDM 6370000100 HCPCS 250 RC 00597-0075-75 NDC inpatient 1 UN 81.78 81.78 BLUE CROSS BLUE SHIELD WELLMARK SB889 [3081026] BCBS WYOMING [308102603] 77.69 percent of total billed charges 50.7 77.69 Technical (Hospital) Services TIOTROPIUM BROMIDE 18 MCG CAPSULE WITH INHALATION DEVICE RX-38315 CDM 6370000100 HCPCS 250 RC 00597-0075-75 NDC outpatient 1 UN 81.78 81.78 BLUE CROSS BLUE SHIELD WELLMARK SB889 [3081026] BCBS WYOMING [308102603] 77.69 percent of total billed charges 50.7 77.69 Technical (Hospital) Services TIOTROPIUM BROMIDE 18 MCG CAPSULE WITH INHALATION DEVICE RX-38315 CDM 6370000100 HCPCS 250 RC 00597-0075-75 NDC outpatient 1 UN 81.78 81.78 HEALTHPARTNERS SX009 HEALTHPARTNERS 65.42 percent of total billed charges 50.7 77.69 Technical (Hospital) Services TIOTROPIUM BROMIDE 18 MCG CAPSULE WITH INHALATION DEVICE RX-38315 CDM 6370000100 HCPCS 250 RC 00597-0075-75 NDC outpatient 1 UN 81.78 81.78 UNITED HEALTHCARE (COMMERCIAL) [3081199] UNITED HEALTHCARE 87726 [308119901] 50.7 percent of total billed charges 50.7 77.69 Technical (Hospital) Services TIOTROPIUM BROMIDE 18 MCG CAPSULE WITH INHALATION DEVICE RX-38315 CDM 6370000100 HCPCS 250 RC 00597-0075-75 NDC outpatient 1 UN 81.78 81.78 CIGNA 62308 [3081051] CIGNA 62308 [308105105] 65.42 percent of total billed charges 50.7 77.69 Technical (Hospital) Services TIOTROPIUM BROMIDE 18 MCG CAPSULE WITH INHALATION DEVICE RX-38315 CDM 6370000100 HCPCS 250 RC 00597-0075-75 NDC outpatient 1 UN 81.78 81.78 CIGNA 62308 [3081051] CIGNA STATE OF WYOMING [308105107] 65.42 percent of total billed charges 50.7 77.69 Technical (Hospital) Services TIOTROPIUM BROMIDE 18 MCG CAPSULE WITH INHALATION DEVICE RX-38315 CDM 6370000100 HCPCS 250 RC 00597-0075-75 NDC outpatient 1 UN 81.78 81.78 MULTIPLAN INC 34080 [3081285] MULTIPLAN INC [308128501] 77.69 percent of total billed charges 50.7 77.69 Technical (Hospital) Services TIOTROPIUM BROMIDE 18 MCG CAPSULE WITH INHALATION DEVICE RX-38315 CDM 6370000100 HCPCS 250 RC 00597-0075-75 NDC outpatient 1 UN 81.78 81.78 MEDICA (COMMERCIAL) 94265 [3081118] MEDICA CLAIMS [308111801] 73.6 percent of total billed charges 50.7 77.69 Technical (Hospital) Services TIOTROPIUM BROMIDE 18 MCG CAPSULE WITH INHALATION DEVICE RX-38315 CDM 6370000100 HCPCS 250 RC 00597-0075-75 NDC outpatient 1 UN 81.78 81.78 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES HDHP [308136802] 65.42 percent of total billed charges 50.7 77.69 Technical (Hospital) Services TIOTROPIUM BROMIDE 18 MCG CAPSULE WITH INHALATION DEVICE RX-38315 CDM 6370000100 HCPCS 250 RC 00597-0075-75 NDC outpatient 1 UN 81.78 81.78 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES EPO [308136803] 65.42 percent of total billed charges 50.7 77.69 Technical (Hospital) Services TIOTROPIUM BROMIDE 18 MCG CAPSULE WITH INHALATION DEVICE RX-38315 CDM 6370000100 HCPCS 250 RC 00597-0075-75 NDC outpatient 1 UN 81.78 81.78 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES PPO [308136801] 65.42 percent of total billed charges 50.7 77.69 Technical (Hospital) Services IBUPROFEN 400 MG TABLET RX-3843 CDM 6370000100 HCPCS 250 RC 67877-0319-01 NDC inpatient 1 UN 5.69 5.69 UNITED HEALTHCARE (COMMERCIAL) [3081199] UNITED HEALTHCARE 87726 [308119901] 3.53 percent of total billed charges 3.53 5.41 Technical (Hospital) Services IBUPROFEN 400 MG TABLET RX-3843 CDM 6370000100 HCPCS 250 RC 67877-0319-01 NDC inpatient 1 UN 5.69 5.69 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES EPO [308136803] 4.51 percent of total billed charges 3.53 5.41 Technical (Hospital) Services IBUPROFEN 400 MG TABLET RX-3843 CDM 6370000100 HCPCS 250 RC 67877-0319-01 NDC inpatient 1 UN 5.69 5.69 CIGNA 62308 [3081051] CIGNA 62308 [308105105] 4.51 percent of total billed charges 3.53 5.41 Technical (Hospital) Services IBUPROFEN 400 MG TABLET RX-3843 CDM 6370000100 HCPCS 250 RC 67877-0319-01 NDC inpatient 1 UN 5.69 5.69 CIGNA 62308 [3081051] CIGNA STATE OF WYOMING [308105107] 4.51 percent of total billed charges 3.53 5.41 Technical (Hospital) Services IBUPROFEN 400 MG TABLET RX-3843 CDM 6370000100 HCPCS 250 RC 67877-0319-01 NDC inpatient 1 UN 5.69 5.69 HEALTHPARTNERS SX009 HEALTHPARTNERS 4.51 percent of total billed charges 3.53 5.41 Technical (Hospital) Services IBUPROFEN 400 MG TABLET RX-3843 CDM 6370000100 HCPCS 250 RC 67877-0319-01 NDC inpatient 1 UN 5.69 5.69 MEDICA (COMMERCIAL) 94265 [3081118] MEDICA CLAIMS [308111801] 5.12 percent of total billed charges 3.53 5.41 Technical (Hospital) Services IBUPROFEN 400 MG TABLET RX-3843 CDM 6370000100 HCPCS 250 RC 67877-0319-01 NDC inpatient 1 UN 5.69 5.69 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES HDHP [308136802] 4.51 percent of total billed charges 3.53 5.41 Technical (Hospital) Services IBUPROFEN 400 MG TABLET RX-3843 CDM 6370000100 HCPCS 250 RC 67877-0319-01 NDC inpatient 1 UN 5.69 5.69 BLUE CROSS BLUE SHIELD WELLMARK SB889 [3081026] BCBS WYOMING [308102603] 5.41 percent of total billed charges 3.53 5.41 Technical (Hospital) Services IBUPROFEN 400 MG TABLET RX-3843 CDM 6370000100 HCPCS 250 RC 67877-0319-01 NDC inpatient 1 UN 5.69 5.69 MULTIPLAN INC 34080 [3081285] MULTIPLAN INC [308128501] 5.41 percent of total billed charges 3.53 5.41 Technical (Hospital) Services IBUPROFEN 400 MG TABLET RX-3843 CDM 6370000100 HCPCS 250 RC 67877-0319-01 NDC inpatient 1 UN 5.69 5.69 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES PPO [308136801] 4.51 percent of total billed charges 3.53 5.41 Technical (Hospital) Services IBUPROFEN 400 MG TABLET RX-3843 CDM 6370000100 HCPCS 250 RC 67877-0319-01 NDC outpatient 1 UN 5.69 5.69 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES HDHP [308136802] 4.55 percent of total billed charges 3.53 5.41 Technical (Hospital) Services IBUPROFEN 400 MG TABLET RX-3843 CDM 6370000100 HCPCS 250 RC 67877-0319-01 NDC outpatient 1 UN 5.69 5.69 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES EPO [308136803] 4.55 percent of total billed charges 3.53 5.41 Technical (Hospital) Services IBUPROFEN 400 MG TABLET RX-3843 CDM 6370000100 HCPCS 250 RC 67877-0319-01 NDC outpatient 1 UN 5.69 5.69 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES PPO [308136801] 4.55 percent of total billed charges 3.53 5.41 Technical (Hospital) Services IBUPROFEN 400 MG TABLET RX-3843 CDM 6370000100 HCPCS 250 RC 67877-0319-01 NDC outpatient 1 UN 5.69 5.69 HEALTHPARTNERS SX009 HEALTHPARTNERS 4.55 percent of total billed charges 3.53 5.41 Technical (Hospital) Services IBUPROFEN 400 MG TABLET RX-3843 CDM 6370000100 HCPCS 250 RC 67877-0319-01 NDC outpatient 1 UN 5.69 5.69 BLUE CROSS BLUE SHIELD WELLMARK SB889 [3081026] BCBS WYOMING [308102603] 5.41 percent of total billed charges 3.53 5.41 Technical (Hospital) Services IBUPROFEN 400 MG TABLET RX-3843 CDM 6370000100 HCPCS 250 RC 67877-0319-01 NDC outpatient 1 UN 5.69 5.69 CIGNA 62308 [3081051] CIGNA 62308 [308105105] 4.55 percent of total billed charges 3.53 5.41 Technical (Hospital) Services IBUPROFEN 400 MG TABLET RX-3843 CDM 6370000100 HCPCS 250 RC 67877-0319-01 NDC outpatient 1 UN 5.69 5.69 CIGNA 62308 [3081051] CIGNA STATE OF WYOMING [308105107] 4.55 percent of total billed charges 3.53 5.41 Technical (Hospital) Services IBUPROFEN 400 MG TABLET RX-3843 CDM 6370000100 HCPCS 250 RC 67877-0319-01 NDC outpatient 1 UN 5.69 5.69 MULTIPLAN INC 34080 [3081285] MULTIPLAN INC [308128501] 5.41 percent of total billed charges 3.53 5.41 Technical (Hospital) Services IBUPROFEN 400 MG TABLET RX-3843 CDM 6370000100 HCPCS 250 RC 67877-0319-01 NDC outpatient 1 UN 5.69 5.69 MEDICA (COMMERCIAL) 94265 [3081118] MEDICA CLAIMS [308111801] 5.12 percent of total billed charges 3.53 5.41 Technical (Hospital) Services IBUPROFEN 400 MG TABLET RX-3843 CDM 6370000100 HCPCS 250 RC 67877-0319-01 NDC outpatient 1 UN 5.69 5.69 UNITED HEALTHCARE (COMMERCIAL) [3081199] UNITED HEALTHCARE 87726 [308119901] 3.53 percent of total billed charges 3.53 5.41 Technical (Hospital) Services IBUPROFEN 600 MG TABLET RX-3844 CDM 6370000100 HCPCS 250 RC 55111-0683-01 NDC inpatient 1 UN 5.73 5.73 BLUE CROSS BLUE SHIELD WELLMARK SB889 [3081026] BCBS WYOMING [308102603] 5.44 percent of total billed charges 3.55 5.44 Technical (Hospital) Services IBUPROFEN 600 MG TABLET RX-3844 CDM 6370000100 HCPCS 250 RC 55111-0683-01 NDC inpatient 1 UN 5.73 5.73 CIGNA 62308 [3081051] CIGNA 62308 [308105105] 4.54 percent of total billed charges 3.55 5.44 Technical (Hospital) Services IBUPROFEN 600 MG TABLET RX-3844 CDM 6370000100 HCPCS 250 RC 55111-0683-01 NDC inpatient 1 UN 5.73 5.73 CIGNA 62308 [3081051] CIGNA STATE OF WYOMING [308105107] 4.54 percent of total billed charges 3.55 5.44 Technical (Hospital) Services IBUPROFEN 600 MG TABLET RX-3844 CDM 6370000100 HCPCS 250 RC 55111-0683-01 NDC inpatient 1 UN 5.73 5.73 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES EPO [308136803] 4.54 percent of total billed charges 3.55 5.44 Technical (Hospital) Services IBUPROFEN 600 MG TABLET RX-3844 CDM 6370000100 HCPCS 250 RC 55111-0683-01 NDC inpatient 1 UN 5.73 5.73 UNITED HEALTHCARE (COMMERCIAL) [3081199] UNITED HEALTHCARE 87726 [308119901] 3.55 percent of total billed charges 3.55 5.44 Technical (Hospital) Services IBUPROFEN 600 MG TABLET RX-3844 CDM 6370000100 HCPCS 250 RC 55111-0683-01 NDC inpatient 1 UN 5.73 5.73 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES HDHP [308136802] 4.54 percent of total billed charges 3.55 5.44 Technical (Hospital) Services IBUPROFEN 600 MG TABLET RX-3844 CDM 6370000100 HCPCS 250 RC 55111-0683-01 NDC inpatient 1 UN 5.73 5.73 MULTIPLAN INC 34080 [3081285] MULTIPLAN INC [308128501] 5.44 percent of total billed charges 3.55 5.44 Technical (Hospital) Services IBUPROFEN 600 MG TABLET RX-3844 CDM 6370000100 HCPCS 250 RC 55111-0683-01 NDC inpatient 1 UN 5.73 5.73 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES PPO [308136801] 4.54 percent of total billed charges 3.55 5.44 Technical (Hospital) Services IBUPROFEN 600 MG TABLET RX-3844 CDM 6370000100 HCPCS 250 RC 55111-0683-01 NDC inpatient 1 UN 5.73 5.73 MEDICA (COMMERCIAL) 94265 [3081118] MEDICA CLAIMS [308111801] 5.16 percent of total billed charges 3.55 5.44 Technical (Hospital) Services IBUPROFEN 600 MG TABLET RX-3844 CDM 6370000100 HCPCS 250 RC 55111-0683-01 NDC inpatient 1 UN 5.73 5.73 HEALTHPARTNERS SX009 HEALTHPARTNERS 4.54 percent of total billed charges 3.55 5.44 Technical (Hospital) Services IBUPROFEN 600 MG TABLET RX-3844 CDM 6370000100 HCPCS 250 RC 55111-0683-01 NDC outpatient 1 UN 5.73 5.73 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES EPO [308136803] 4.58 percent of total billed charges 3.55 5.44 Technical (Hospital) Services IBUPROFEN 600 MG TABLET RX-3844 CDM 6370000100 HCPCS 250 RC 55111-0683-01 NDC outpatient 1 UN 5.73 5.73 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES HDHP [308136802] 4.58 percent of total billed charges 3.55 5.44 Technical (Hospital) Services IBUPROFEN 600 MG TABLET RX-3844 CDM 6370000100 HCPCS 250 RC 55111-0683-01 NDC outpatient 1 UN 5.73 5.73 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES PPO [308136801] 4.58 percent of total billed charges 3.55 5.44 Technical (Hospital) Services IBUPROFEN 600 MG TABLET RX-3844 CDM 6370000100 HCPCS 250 RC 55111-0683-01 NDC outpatient 1 UN 5.73 5.73 CIGNA 62308 [3081051] CIGNA 62308 [308105105] 4.58 percent of total billed charges 3.55 5.44 Technical (Hospital) Services IBUPROFEN 600 MG TABLET RX-3844 CDM 6370000100 HCPCS 250 RC 55111-0683-01 NDC outpatient 1 UN 5.73 5.73 CIGNA 62308 [3081051] CIGNA STATE OF WYOMING [308105107] 4.58 percent of total billed charges 3.55 5.44 Technical (Hospital) Services IBUPROFEN 600 MG TABLET RX-3844 CDM 6370000100 HCPCS 250 RC 55111-0683-01 NDC outpatient 1 UN 5.73 5.73 MEDICA (COMMERCIAL) 94265 [3081118] MEDICA CLAIMS [308111801] 5.16 percent of total billed charges 3.55 5.44 Technical (Hospital) Services IBUPROFEN 600 MG TABLET RX-3844 CDM 6370000100 HCPCS 250 RC 55111-0683-01 NDC outpatient 1 UN 5.73 5.73 MULTIPLAN INC 34080 [3081285] MULTIPLAN INC [308128501] 5.44 percent of total billed charges 3.55 5.44 Technical (Hospital) Services IBUPROFEN 600 MG TABLET RX-3844 CDM 6370000100 HCPCS 250 RC 55111-0683-01 NDC outpatient 1 UN 5.73 5.73 HEALTHPARTNERS SX009 HEALTHPARTNERS 4.58 percent of total billed charges 3.55 5.44 Technical (Hospital) Services IBUPROFEN 600 MG TABLET RX-3844 CDM 6370000100 HCPCS 250 RC 55111-0683-01 NDC outpatient 1 UN 5.73 5.73 UNITED HEALTHCARE (COMMERCIAL) [3081199] UNITED HEALTHCARE 87726 [308119901] 3.55 percent of total billed charges 3.55 5.44 Technical (Hospital) Services IBUPROFEN 600 MG TABLET RX-3844 CDM 6370000100 HCPCS 250 RC 55111-0683-01 NDC outpatient 1 UN 5.73 5.73 BLUE CROSS BLUE SHIELD WELLMARK SB889 [3081026] BCBS WYOMING [308102603] 5.44 percent of total billed charges 3.55 5.44 Technical (Hospital) Services IBUPROFEN 800 MG TABLET RX-3845 CDM 6370000100 HCPCS 250 RC 55111-0684-01 NDC outpatient 1 UN 5.77 5.77 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES EPO [308136803] 4.62 percent of total billed charges 3.58 5.48 Technical (Hospital) Services IBUPROFEN 800 MG TABLET RX-3845 CDM 6370000100 HCPCS 250 RC 55111-0684-01 NDC outpatient 1 UN 5.77 5.77 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES HDHP [308136802] 4.62 percent of total billed charges 3.58 5.48 Technical (Hospital) Services IBUPROFEN 800 MG TABLET RX-3845 CDM 6370000100 HCPCS 250 RC 55111-0684-01 NDC outpatient 1 UN 5.77 5.77 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES PPO [308136801] 4.62 percent of total billed charges 3.58 5.48 Technical (Hospital) Services IBUPROFEN 800 MG TABLET RX-3845 CDM 6370000100 HCPCS 250 RC 55111-0684-01 NDC outpatient 1 UN 5.77 5.77 BLUE CROSS BLUE SHIELD WELLMARK SB889 [3081026] BCBS WYOMING [308102603] 5.48 percent of total billed charges 3.58 5.48 Technical (Hospital) Services IBUPROFEN 800 MG TABLET RX-3845 CDM 6370000100 HCPCS 250 RC 55111-0684-01 NDC outpatient 1 UN 5.77 5.77 CIGNA 62308 [3081051] CIGNA 62308 [308105105] 4.62 percent of total billed charges 3.58 5.48 Technical (Hospital) Services IBUPROFEN 800 MG TABLET RX-3845 CDM 6370000100 HCPCS 250 RC 55111-0684-01 NDC outpatient 1 UN 5.77 5.77 CIGNA 62308 [3081051] CIGNA STATE OF WYOMING [308105107] 4.62 percent of total billed charges 3.58 5.48 Technical (Hospital) Services IBUPROFEN 800 MG TABLET RX-3845 CDM 6370000100 HCPCS 250 RC 55111-0684-01 NDC outpatient 1 UN 5.77 5.77 MULTIPLAN INC 34080 [3081285] MULTIPLAN INC [308128501] 5.48 percent of total billed charges 3.58 5.48 Technical (Hospital) Services IBUPROFEN 800 MG TABLET RX-3845 CDM 6370000100 HCPCS 250 RC 55111-0684-01 NDC outpatient 1 UN 5.77 5.77 MEDICA (COMMERCIAL) 94265 [3081118] MEDICA CLAIMS [308111801] 5.19 percent of total billed charges 3.58 5.48 Technical (Hospital) Services IBUPROFEN 800 MG TABLET RX-3845 CDM 6370000100 HCPCS 250 RC 55111-0684-01 NDC outpatient 1 UN 5.77 5.77 UNITED HEALTHCARE (COMMERCIAL) [3081199] UNITED HEALTHCARE 87726 [308119901] 3.58 percent of total billed charges 3.58 5.48 Technical (Hospital) Services IBUPROFEN 800 MG TABLET RX-3845 CDM 6370000100 HCPCS 250 RC 55111-0684-01 NDC outpatient 1 UN 5.77 5.77 HEALTHPARTNERS SX009 HEALTHPARTNERS 4.62 percent of total billed charges 3.58 5.48 Technical (Hospital) Services IBUPROFEN 800 MG TABLET RX-3845 CDM 6370000100 HCPCS 250 RC 55111-0684-01 NDC inpatient 1 UN 5.77 5.77 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES PPO [308136801] 4.57 percent of total billed charges 3.58 5.48 Technical (Hospital) Services IBUPROFEN 800 MG TABLET RX-3845 CDM 6370000100 HCPCS 250 RC 55111-0684-01 NDC inpatient 1 UN 5.77 5.77 MEDICA (COMMERCIAL) 94265 [3081118] MEDICA CLAIMS [308111801] 5.19 percent of total billed charges 3.58 5.48 Technical (Hospital) Services IBUPROFEN 800 MG TABLET RX-3845 CDM 6370000100 HCPCS 250 RC 55111-0684-01 NDC inpatient 1 UN 5.77 5.77 HEALTHPARTNERS SX009 HEALTHPARTNERS 4.57 percent of total billed charges 3.58 5.48 Technical (Hospital) Services IBUPROFEN 800 MG TABLET RX-3845 CDM 6370000100 HCPCS 250 RC 55111-0684-01 NDC inpatient 1 UN 5.77 5.77 MULTIPLAN INC 34080 [3081285] MULTIPLAN INC [308128501] 5.48 percent of total billed charges 3.58 5.48 Technical (Hospital) Services IBUPROFEN 800 MG TABLET RX-3845 CDM 6370000100 HCPCS 250 RC 55111-0684-01 NDC inpatient 1 UN 5.77 5.77 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES HDHP [308136802] 4.57 percent of total billed charges 3.58 5.48 Technical (Hospital) Services IBUPROFEN 800 MG TABLET RX-3845 CDM 6370000100 HCPCS 250 RC 55111-0684-01 NDC inpatient 1 UN 5.77 5.77 CIGNA 62308 [3081051] CIGNA 62308 [308105105] 4.57 percent of total billed charges 3.58 5.48 Technical (Hospital) Services IBUPROFEN 800 MG TABLET RX-3845 CDM 6370000100 HCPCS 250 RC 55111-0684-01 NDC inpatient 1 UN 5.77 5.77 CIGNA 62308 [3081051] CIGNA STATE OF WYOMING [308105107] 4.57 percent of total billed charges 3.58 5.48 Technical (Hospital) Services IBUPROFEN 800 MG TABLET RX-3845 CDM 6370000100 HCPCS 250 RC 55111-0684-01 NDC inpatient 1 UN 5.77 5.77 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES EPO [308136803] 4.57 percent of total billed charges 3.58 5.48 Technical (Hospital) Services IBUPROFEN 800 MG TABLET RX-3845 CDM 6370000100 HCPCS 250 RC 55111-0684-01 NDC inpatient 1 UN 5.77 5.77 UNITED HEALTHCARE (COMMERCIAL) [3081199] UNITED HEALTHCARE 87726 [308119901] 3.58 percent of total billed charges 3.58 5.48 Technical (Hospital) Services IBUPROFEN 800 MG TABLET RX-3845 CDM 6370000100 HCPCS 250 RC 55111-0684-01 NDC inpatient 1 UN 5.77 5.77 BLUE CROSS BLUE SHIELD WELLMARK SB889 [3081026] BCBS WYOMING [308102603] 5.48 percent of total billed charges 3.58 5.48 Technical (Hospital) Services INDOMETHACIN 25 MG CAPSULE RX-3897 CDM 6370000100 HCPCS 250 RC 68462-0406-01 NDC outpatient 1 UN 5.84 5.84 MULTIPLAN INC 34080 [3081285] MULTIPLAN INC [308128501] 5.55 percent of total billed charges 3.62 5.55 Technical (Hospital) Services INDOMETHACIN 25 MG CAPSULE RX-3897 CDM 6370000100 HCPCS 250 RC 68462-0406-01 NDC outpatient 1 UN 5.84 5.84 CIGNA 62308 [3081051] CIGNA 62308 [308105105] 4.67 percent of total billed charges 3.62 5.55 Technical (Hospital) Services INDOMETHACIN 25 MG CAPSULE RX-3897 CDM 6370000100 HCPCS 250 RC 68462-0406-01 NDC outpatient 1 UN 5.84 5.84 CIGNA 62308 [3081051] CIGNA STATE OF WYOMING [308105107] 4.67 percent of total billed charges 3.62 5.55 Technical (Hospital) Services INDOMETHACIN 25 MG CAPSULE RX-3897 CDM 6370000100 HCPCS 250 RC 68462-0406-01 NDC outpatient 1 UN 5.84 5.84 MEDICA (COMMERCIAL) 94265 [3081118] MEDICA CLAIMS [308111801] 5.26 percent of total billed charges 3.62 5.55 Technical (Hospital) Services INDOMETHACIN 25 MG CAPSULE RX-3897 CDM 6370000100 HCPCS 250 RC 68462-0406-01 NDC outpatient 1 UN 5.84 5.84 HEALTHPARTNERS SX009 HEALTHPARTNERS 4.67 percent of total billed charges 3.62 5.55 Technical (Hospital) Services INDOMETHACIN 25 MG CAPSULE RX-3897 CDM 6370000100 HCPCS 250 RC 68462-0406-01 NDC outpatient 1 UN 5.84 5.84 UNITED HEALTHCARE (COMMERCIAL) [3081199] UNITED HEALTHCARE 87726 [308119901] 3.62 percent of total billed charges 3.62 5.55 Technical (Hospital) Services INDOMETHACIN 25 MG CAPSULE RX-3897 CDM 6370000100 HCPCS 250 RC 68462-0406-01 NDC outpatient 1 UN 5.84 5.84 BLUE CROSS BLUE SHIELD WELLMARK SB889 [3081026] BCBS WYOMING [308102603] 5.55 percent of total billed charges 3.62 5.55 Technical (Hospital) Services INDOMETHACIN 25 MG CAPSULE RX-3897 CDM 6370000100 HCPCS 250 RC 68462-0406-01 NDC outpatient 1 UN 5.84 5.84 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES EPO [308136803] 4.67 percent of total billed charges 3.62 5.55 Technical (Hospital) Services INDOMETHACIN 25 MG CAPSULE RX-3897 CDM 6370000100 HCPCS 250 RC 68462-0406-01 NDC outpatient 1 UN 5.84 5.84 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES HDHP [308136802] 4.67 percent of total billed charges 3.62 5.55 Technical (Hospital) Services INDOMETHACIN 25 MG CAPSULE RX-3897 CDM 6370000100 HCPCS 250 RC 68462-0406-01 NDC outpatient 1 UN 5.84 5.84 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES PPO [308136801] 4.67 percent of total billed charges 3.62 5.55 Technical (Hospital) Services INDOMETHACIN 25 MG CAPSULE RX-3897 CDM 6370000100 HCPCS 250 RC 68462-0406-01 NDC inpatient 1 UN 5.84 5.84 HEALTHPARTNERS SX009 HEALTHPARTNERS 4.62 percent of total billed charges 3.62 5.55 Technical (Hospital) Services INDOMETHACIN 25 MG CAPSULE RX-3897 CDM 6370000100 HCPCS 250 RC 68462-0406-01 NDC inpatient 1 UN 5.84 5.84 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES HDHP [308136802] 4.62 percent of total billed charges 3.62 5.55 Technical (Hospital) Services INDOMETHACIN 25 MG CAPSULE RX-3897 CDM 6370000100 HCPCS 250 RC 68462-0406-01 NDC inpatient 1 UN 5.84 5.84 BLUE CROSS BLUE SHIELD WELLMARK SB889 [3081026] BCBS WYOMING [308102603] 5.55 percent of total billed charges 3.62 5.55 Technical (Hospital) Services INDOMETHACIN 25 MG CAPSULE RX-3897 CDM 6370000100 HCPCS 250 RC 68462-0406-01 NDC inpatient 1 UN 5.84 5.84 CIGNA 62308 [3081051] CIGNA 62308 [308105105] 4.62 percent of total billed charges 3.62 5.55 Technical (Hospital) Services INDOMETHACIN 25 MG CAPSULE RX-3897 CDM 6370000100 HCPCS 250 RC 68462-0406-01 NDC inpatient 1 UN 5.84 5.84 CIGNA 62308 [3081051] CIGNA STATE OF WYOMING [308105107] 4.62 percent of total billed charges 3.62 5.55 Technical (Hospital) Services INDOMETHACIN 25 MG CAPSULE RX-3897 CDM 6370000100 HCPCS 250 RC 68462-0406-01 NDC inpatient 1 UN 5.84 5.84 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES EPO [308136803] 4.62 percent of total billed charges 3.62 5.55 Technical (Hospital) Services INDOMETHACIN 25 MG CAPSULE RX-3897 CDM 6370000100 HCPCS 250 RC 68462-0406-01 NDC inpatient 1 UN 5.84 5.84 UNITED HEALTHCARE (COMMERCIAL) [3081199] UNITED HEALTHCARE 87726 [308119901] 3.62 percent of total billed charges 3.62 5.55 Technical (Hospital) Services INDOMETHACIN 25 MG CAPSULE RX-3897 CDM 6370000100 HCPCS 250 RC 68462-0406-01 NDC inpatient 1 UN 5.84 5.84 MULTIPLAN INC 34080 [3081285] MULTIPLAN INC [308128501] 5.55 percent of total billed charges 3.62 5.55 Technical (Hospital) Services INDOMETHACIN 25 MG CAPSULE RX-3897 CDM 6370000100 HCPCS 250 RC 68462-0406-01 NDC inpatient 1 UN 5.84 5.84 MEDICA (COMMERCIAL) 94265 [3081118] MEDICA CLAIMS [308111801] 5.26 percent of total billed charges 3.62 5.55 Technical (Hospital) Services INDOMETHACIN 25 MG CAPSULE RX-3897 CDM 6370000100 HCPCS 250 RC 68462-0406-01 NDC inpatient 1 UN 5.84 5.84 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES PPO [308136801] 4.62 percent of total billed charges 3.62 5.55 Technical (Hospital) Services AMILORIDE 5 MG TABLET RX-391 CDM 6370000100 HCPCS 250 RC 00574-0292-01 NDC outpatient 1 UN 5.84 5.84 BLUE CROSS BLUE SHIELD WELLMARK SB889 [3081026] BCBS WYOMING [308102603] 5.55 percent of total billed charges 3.62 5.55 Technical (Hospital) Services AMILORIDE 5 MG TABLET RX-391 CDM 6370000100 HCPCS 250 RC 00574-0292-01 NDC outpatient 1 UN 5.84 5.84 HEALTHPARTNERS SX009 HEALTHPARTNERS 4.67 percent of total billed charges 3.62 5.55 Technical (Hospital) Services AMILORIDE 5 MG TABLET RX-391 CDM 6370000100 HCPCS 250 RC 00574-0292-01 NDC outpatient 1 UN 5.84 5.84 UNITED HEALTHCARE (COMMERCIAL) [3081199] UNITED HEALTHCARE 87726 [308119901] 3.62 percent of total billed charges 3.62 5.55 Technical (Hospital) Services AMILORIDE 5 MG TABLET RX-391 CDM 6370000100 HCPCS 250 RC 00574-0292-01 NDC outpatient 1 UN 5.84 5.84 CIGNA 62308 [3081051] CIGNA 62308 [308105105] 4.67 percent of total billed charges 3.62 5.55 Technical (Hospital) Services AMILORIDE 5 MG TABLET RX-391 CDM 6370000100 HCPCS 250 RC 00574-0292-01 NDC outpatient 1 UN 5.84 5.84 CIGNA 62308 [3081051] CIGNA STATE OF WYOMING [308105107] 4.67 percent of total billed charges 3.62 5.55 Technical (Hospital) Services AMILORIDE 5 MG TABLET RX-391 CDM 6370000100 HCPCS 250 RC 00574-0292-01 NDC outpatient 1 UN 5.84 5.84 MULTIPLAN INC 34080 [3081285] MULTIPLAN INC [308128501] 5.55 percent of total billed charges 3.62 5.55 Technical (Hospital) Services AMILORIDE 5 MG TABLET RX-391 CDM 6370000100 HCPCS 250 RC 00574-0292-01 NDC outpatient 1 UN 5.84 5.84 MEDICA (COMMERCIAL) 94265 [3081118] MEDICA CLAIMS [308111801] 5.26 percent of total billed charges 3.62 5.55 Technical (Hospital) Services AMILORIDE 5 MG TABLET RX-391 CDM 6370000100 HCPCS 250 RC 00574-0292-01 NDC outpatient 1 UN 5.84 5.84 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES PPO [308136801] 4.67 percent of total billed charges 3.62 5.55 Technical (Hospital) Services AMILORIDE 5 MG TABLET RX-391 CDM 6370000100 HCPCS 250 RC 00574-0292-01 NDC outpatient 1 UN 5.84 5.84 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES HDHP [308136802] 4.67 percent of total billed charges 3.62 5.55 Technical (Hospital) Services AMILORIDE 5 MG TABLET RX-391 CDM 6370000100 HCPCS 250 RC 00574-0292-01 NDC outpatient 1 UN 5.84 5.84 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES EPO [308136803] 4.67 percent of total billed charges 3.62 5.55 Technical (Hospital) Services AMILORIDE 5 MG TABLET RX-391 CDM 6370000100 HCPCS 250 RC 00574-0292-01 NDC inpatient 1 UN 5.84 5.84 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES PPO [308136801] 4.62 percent of total billed charges 3.62 5.55 Technical (Hospital) Services AMILORIDE 5 MG TABLET RX-391 CDM 6370000100 HCPCS 250 RC 00574-0292-01 NDC inpatient 1 UN 5.84 5.84 MULTIPLAN INC 34080 [3081285] MULTIPLAN INC [308128501] 5.55 percent of total billed charges 3.62 5.55 Technical (Hospital) Services AMILORIDE 5 MG TABLET RX-391 CDM 6370000100 HCPCS 250 RC 00574-0292-01 NDC inpatient 1 UN 5.84 5.84 BLUE CROSS BLUE SHIELD WELLMARK SB889 [3081026] BCBS WYOMING [308102603] 5.55 percent of total billed charges 3.62 5.55 Technical (Hospital) Services AMILORIDE 5 MG TABLET RX-391 CDM 6370000100 HCPCS 250 RC 00574-0292-01 NDC inpatient 1 UN 5.84 5.84 UNITED HEALTHCARE (COMMERCIAL) [3081199] UNITED HEALTHCARE 87726 [308119901] 3.62 percent of total billed charges 3.62 5.55 Technical (Hospital) Services AMILORIDE 5 MG TABLET RX-391 CDM 6370000100 HCPCS 250 RC 00574-0292-01 NDC inpatient 1 UN 5.84 5.84 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES EPO [308136803] 4.62 percent of total billed charges 3.62 5.55 Technical (Hospital) Services AMILORIDE 5 MG TABLET RX-391 CDM 6370000100 HCPCS 250 RC 00574-0292-01 NDC inpatient 1 UN 5.84 5.84 CIGNA 62308 [3081051] CIGNA 62308 [308105105] 4.62 percent of total billed charges 3.62 5.55 Technical (Hospital) Services AMILORIDE 5 MG TABLET RX-391 CDM 6370000100 HCPCS 250 RC 00574-0292-01 NDC inpatient 1 UN 5.84 5.84 CIGNA 62308 [3081051] CIGNA STATE OF WYOMING [308105107] 4.62 percent of total billed charges 3.62 5.55 Technical (Hospital) Services AMILORIDE 5 MG TABLET RX-391 CDM 6370000100 HCPCS 250 RC 00574-0292-01 NDC inpatient 1 UN 5.84 5.84 MEDICA (COMMERCIAL) 94265 [3081118] MEDICA CLAIMS [308111801] 5.26 percent of total billed charges 3.62 5.55 Technical (Hospital) Services AMILORIDE 5 MG TABLET RX-391 CDM 6370000100 HCPCS 250 RC 00574-0292-01 NDC inpatient 1 UN 5.84 5.84 HEALTHPARTNERS SX009 HEALTHPARTNERS 4.62 percent of total billed charges 3.62 5.55 Technical (Hospital) Services AMILORIDE 5 MG TABLET RX-391 CDM 6370000100 HCPCS 250 RC 00574-0292-01 NDC inpatient 1 UN 5.84 5.84 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES HDHP [308136802] 4.62 percent of total billed charges 3.62 5.55 Technical (Hospital) Services "DULOXETINE 20 MG CAPSULE,DELAYED RELEASE" RX-39275 CDM 6370000100 HCPCS 250 RC 57237-0017-60 NDC inpatient 1 UN 5.92 5.92 MULTIPLAN INC 34080 [3081285] MULTIPLAN INC [308128501] 5.62 percent of total billed charges 3.67 5.62 Technical (Hospital) Services "DULOXETINE 20 MG CAPSULE,DELAYED RELEASE" RX-39275 CDM 6370000100 HCPCS 250 RC 57237-0017-60 NDC inpatient 1 UN 5.92 5.92 HEALTHPARTNERS SX009 HEALTHPARTNERS 4.69 percent of total billed charges 3.67 5.62 Technical (Hospital) Services "DULOXETINE 20 MG CAPSULE,DELAYED RELEASE" RX-39275 CDM 6370000100 HCPCS 250 RC 57237-0017-60 NDC inpatient 1 UN 5.92 5.92 MEDICA (COMMERCIAL) 94265 [3081118] MEDICA CLAIMS [308111801] 5.33 percent of total billed charges 3.67 5.62 Technical (Hospital) Services "DULOXETINE 20 MG CAPSULE,DELAYED RELEASE" RX-39275 CDM 6370000100 HCPCS 250 RC 57237-0017-60 NDC inpatient 1 UN 5.92 5.92 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES PPO [308136801] 4.69 percent of total billed charges 3.67 5.62 Technical (Hospital) Services "DULOXETINE 20 MG CAPSULE,DELAYED RELEASE" RX-39275 CDM 6370000100 HCPCS 250 RC 57237-0017-60 NDC inpatient 1 UN 5.92 5.92 BLUE CROSS BLUE SHIELD WELLMARK SB889 [3081026] BCBS WYOMING [308102603] 5.62 percent of total billed charges 3.67 5.62 Technical (Hospital) Services "DULOXETINE 20 MG CAPSULE,DELAYED RELEASE" RX-39275 CDM 6370000100 HCPCS 250 RC 57237-0017-60 NDC inpatient 1 UN 5.92 5.92 UNITED HEALTHCARE (COMMERCIAL) [3081199] UNITED HEALTHCARE 87726 [308119901] 3.67 percent of total billed charges 3.67 5.62 Technical (Hospital) Services "DULOXETINE 20 MG CAPSULE,DELAYED RELEASE" RX-39275 CDM 6370000100 HCPCS 250 RC 57237-0017-60 NDC inpatient 1 UN 5.92 5.92 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES EPO [308136803] 4.69 percent of total billed charges 3.67 5.62 Technical (Hospital) Services "DULOXETINE 20 MG CAPSULE,DELAYED RELEASE" RX-39275 CDM 6370000100 HCPCS 250 RC 57237-0017-60 NDC inpatient 1 UN 5.92 5.92 CIGNA 62308 [3081051] CIGNA 62308 [308105105] 4.69 percent of total billed charges 3.67 5.62 Technical (Hospital) Services "DULOXETINE 20 MG CAPSULE,DELAYED RELEASE" RX-39275 CDM 6370000100 HCPCS 250 RC 57237-0017-60 NDC inpatient 1 UN 5.92 5.92 CIGNA 62308 [3081051] CIGNA STATE OF WYOMING [308105107] 4.69 percent of total billed charges 3.67 5.62 Technical (Hospital) Services "DULOXETINE 20 MG CAPSULE,DELAYED RELEASE" RX-39275 CDM 6370000100 HCPCS 250 RC 57237-0017-60 NDC inpatient 1 UN 5.92 5.92 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES HDHP [308136802] 4.69 percent of total billed charges 3.67 5.62 Technical (Hospital) Services "DULOXETINE 20 MG CAPSULE,DELAYED RELEASE" RX-39275 CDM 6370000100 HCPCS 250 RC 57237-0017-60 NDC outpatient 1 UN 5.92 5.92 HEALTHPARTNERS SX009 HEALTHPARTNERS 4.74 percent of total billed charges 3.67 5.62 Technical (Hospital) Services "DULOXETINE 20 MG CAPSULE,DELAYED RELEASE" RX-39275 CDM 6370000100 HCPCS 250 RC 57237-0017-60 NDC outpatient 1 UN 5.92 5.92 BLUE CROSS BLUE SHIELD WELLMARK SB889 [3081026] BCBS WYOMING [308102603] 5.62 percent of total billed charges 3.67 5.62 Technical (Hospital) Services "DULOXETINE 20 MG CAPSULE,DELAYED RELEASE" RX-39275 CDM 6370000100 HCPCS 250 RC 57237-0017-60 NDC outpatient 1 UN 5.92 5.92 UNITED HEALTHCARE (COMMERCIAL) [3081199] UNITED HEALTHCARE 87726 [308119901] 3.67 percent of total billed charges 3.67 5.62 Technical (Hospital) Services "DULOXETINE 20 MG CAPSULE,DELAYED RELEASE" RX-39275 CDM 6370000100 HCPCS 250 RC 57237-0017-60 NDC outpatient 1 UN 5.92 5.92 MULTIPLAN INC 34080 [3081285] MULTIPLAN INC [308128501] 5.62 percent of total billed charges 3.67 5.62 Technical (Hospital) Services "DULOXETINE 20 MG CAPSULE,DELAYED RELEASE" RX-39275 CDM 6370000100 HCPCS 250 RC 57237-0017-60 NDC outpatient 1 UN 5.92 5.92 CIGNA 62308 [3081051] CIGNA 62308 [308105105] 4.74 percent of total billed charges 3.67 5.62 Technical (Hospital) Services "DULOXETINE 20 MG CAPSULE,DELAYED RELEASE" RX-39275 CDM 6370000100 HCPCS 250 RC 57237-0017-60 NDC outpatient 1 UN 5.92 5.92 CIGNA 62308 [3081051] CIGNA STATE OF WYOMING [308105107] 4.74 percent of total billed charges 3.67 5.62 Technical (Hospital) Services "DULOXETINE 20 MG CAPSULE,DELAYED RELEASE" RX-39275 CDM 6370000100 HCPCS 250 RC 57237-0017-60 NDC outpatient 1 UN 5.92 5.92 MEDICA (COMMERCIAL) 94265 [3081118] MEDICA CLAIMS [308111801] 5.33 percent of total billed charges 3.67 5.62 Technical (Hospital) Services "DULOXETINE 20 MG CAPSULE,DELAYED RELEASE" RX-39275 CDM 6370000100 HCPCS 250 RC 57237-0017-60 NDC outpatient 1 UN 5.92 5.92 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES HDHP [308136802] 4.74 percent of total billed charges 3.67 5.62 Technical (Hospital) Services "DULOXETINE 20 MG CAPSULE,DELAYED RELEASE" RX-39275 CDM 6370000100 HCPCS 250 RC 57237-0017-60 NDC outpatient 1 UN 5.92 5.92 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES EPO [308136803] 4.74 percent of total billed charges 3.67 5.62 Technical (Hospital) Services "DULOXETINE 20 MG CAPSULE,DELAYED RELEASE" RX-39275 CDM 6370000100 HCPCS 250 RC 57237-0017-60 NDC outpatient 1 UN 5.92 5.92 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES PPO [308136801] 4.74 percent of total billed charges 3.67 5.62 Technical (Hospital) Services "DULOXETINE 30 MG CAPSULE,DELAYED RELEASE" RX-39276 CDM 6370000100 HCPCS 250 RC 57237-0018-30 NDC outpatient 1 UN 5.95 5.95 UNITED HEALTHCARE (COMMERCIAL) [3081199] UNITED HEALTHCARE 87726 [308119901] 3.69 percent of total billed charges 3.69 5.65 Technical (Hospital) Services "DULOXETINE 30 MG CAPSULE,DELAYED RELEASE" RX-39276 CDM 6370000100 HCPCS 250 RC 57237-0018-30 NDC outpatient 1 UN 5.95 5.95 MULTIPLAN INC 34080 [3081285] MULTIPLAN INC [308128501] 5.65 percent of total billed charges 3.69 5.65 Technical (Hospital) Services "DULOXETINE 30 MG CAPSULE,DELAYED RELEASE" RX-39276 CDM 6370000100 HCPCS 250 RC 57237-0018-30 NDC outpatient 1 UN 5.95 5.95 CIGNA 62308 [3081051] CIGNA 62308 [308105105] 4.76 percent of total billed charges 3.69 5.65 Technical (Hospital) Services "DULOXETINE 30 MG CAPSULE,DELAYED RELEASE" RX-39276 CDM 6370000100 HCPCS 250 RC 57237-0018-30 NDC outpatient 1 UN 5.95 5.95 CIGNA 62308 [3081051] CIGNA STATE OF WYOMING [308105107] 4.76 percent of total billed charges 3.69 5.65 Technical (Hospital) Services "DULOXETINE 30 MG CAPSULE,DELAYED RELEASE" RX-39276 CDM 6370000100 HCPCS 250 RC 57237-0018-30 NDC outpatient 1 UN 5.95 5.95 MEDICA (COMMERCIAL) 94265 [3081118] MEDICA CLAIMS [308111801] 5.36 percent of total billed charges 3.69 5.65 Technical (Hospital) Services "DULOXETINE 30 MG CAPSULE,DELAYED RELEASE" RX-39276 CDM 6370000100 HCPCS 250 RC 57237-0018-30 NDC outpatient 1 UN 5.95 5.95 HEALTHPARTNERS SX009 HEALTHPARTNERS 4.76 percent of total billed charges 3.69 5.65 Technical (Hospital) Services "DULOXETINE 30 MG CAPSULE,DELAYED RELEASE" RX-39276 CDM 6370000100 HCPCS 250 RC 57237-0018-30 NDC outpatient 1 UN 5.95 5.95 BLUE CROSS BLUE SHIELD WELLMARK SB889 [3081026] BCBS WYOMING [308102603] 5.65 percent of total billed charges 3.69 5.65 Technical (Hospital) Services "DULOXETINE 30 MG CAPSULE,DELAYED RELEASE" RX-39276 CDM 6370000100 HCPCS 250 RC 57237-0018-30 NDC outpatient 1 UN 5.95 5.95 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES HDHP [308136802] 4.76 percent of total billed charges 3.69 5.65 Technical (Hospital) Services "DULOXETINE 30 MG CAPSULE,DELAYED RELEASE" RX-39276 CDM 6370000100 HCPCS 250 RC 57237-0018-30 NDC outpatient 1 UN 5.95 5.95 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES EPO [308136803] 4.76 percent of total billed charges 3.69 5.65 Technical (Hospital) Services "DULOXETINE 30 MG CAPSULE,DELAYED RELEASE" RX-39276 CDM 6370000100 HCPCS 250 RC 57237-0018-30 NDC outpatient 1 UN 5.95 5.95 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES PPO [308136801] 4.76 percent of total billed charges 3.69 5.65 Technical (Hospital) Services "DULOXETINE 30 MG CAPSULE,DELAYED RELEASE" RX-39276 CDM 6370000100 HCPCS 250 RC 57237-0018-30 NDC inpatient 1 UN 5.95 5.95 BLUE CROSS BLUE SHIELD WELLMARK SB889 [3081026] BCBS WYOMING [308102603] 5.65 percent of total billed charges 3.69 5.65 Technical (Hospital) Services "DULOXETINE 30 MG CAPSULE,DELAYED RELEASE" RX-39276 CDM 6370000100 HCPCS 250 RC 57237-0018-30 NDC inpatient 1 UN 5.95 5.95 UNITED HEALTHCARE (COMMERCIAL) [3081199] UNITED HEALTHCARE 87726 [308119901] 3.69 percent of total billed charges 3.69 5.65 Technical (Hospital) Services "DULOXETINE 30 MG CAPSULE,DELAYED RELEASE" RX-39276 CDM 6370000100 HCPCS 250 RC 57237-0018-30 NDC inpatient 1 UN 5.95 5.95 CIGNA 62308 [3081051] CIGNA 62308 [308105105] 4.71 percent of total billed charges 3.69 5.65 Technical (Hospital) Services "DULOXETINE 30 MG CAPSULE,DELAYED RELEASE" RX-39276 CDM 6370000100 HCPCS 250 RC 57237-0018-30 NDC inpatient 1 UN 5.95 5.95 CIGNA 62308 [3081051] CIGNA STATE OF WYOMING [308105107] 4.71 percent of total billed charges 3.69 5.65 Technical (Hospital) Services "DULOXETINE 30 MG CAPSULE,DELAYED RELEASE" RX-39276 CDM 6370000100 HCPCS 250 RC 57237-0018-30 NDC inpatient 1 UN 5.95 5.95 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES EPO [308136803] 4.71 percent of total billed charges 3.69 5.65 Technical (Hospital) Services "DULOXETINE 30 MG CAPSULE,DELAYED RELEASE" RX-39276 CDM 6370000100 HCPCS 250 RC 57237-0018-30 NDC inpatient 1 UN 5.95 5.95 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES HDHP [308136802] 4.71 percent of total billed charges 3.69 5.65 Technical (Hospital) Services "DULOXETINE 30 MG CAPSULE,DELAYED RELEASE" RX-39276 CDM 6370000100 HCPCS 250 RC 57237-0018-30 NDC inpatient 1 UN 5.95 5.95 HEALTHPARTNERS SX009 HEALTHPARTNERS 4.71 percent of total billed charges 3.69 5.65 Technical (Hospital) Services "DULOXETINE 30 MG CAPSULE,DELAYED RELEASE" RX-39276 CDM 6370000100 HCPCS 250 RC 57237-0018-30 NDC inpatient 1 UN 5.95 5.95 MEDICA (COMMERCIAL) 94265 [3081118] MEDICA CLAIMS [308111801] 5.36 percent of total billed charges 3.69 5.65 Technical (Hospital) Services "DULOXETINE 30 MG CAPSULE,DELAYED RELEASE" RX-39276 CDM 6370000100 HCPCS 250 RC 57237-0018-30 NDC inpatient 1 UN 5.95 5.95 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES PPO [308136801] 4.71 percent of total billed charges 3.69 5.65 Technical (Hospital) Services "DULOXETINE 30 MG CAPSULE,DELAYED RELEASE" RX-39276 CDM 6370000100 HCPCS 250 RC 57237-0018-30 NDC inpatient 1 UN 5.95 5.95 MULTIPLAN INC 34080 [3081285] MULTIPLAN INC [308128501] 5.65 percent of total billed charges 3.69 5.65 Technical (Hospital) Services "DULOXETINE 60 MG CAPSULE,DELAYED RELEASE" RX-39277 CDM 6370000100 HCPCS 250 RC 57237-0019-30 NDC inpatient 1 UN 5.95 5.95 MEDICA (COMMERCIAL) 94265 [3081118] MEDICA CLAIMS [308111801] 5.36 percent of total billed charges 3.69 5.65 Technical (Hospital) Services "DULOXETINE 60 MG CAPSULE,DELAYED RELEASE" RX-39277 CDM 6370000100 HCPCS 250 RC 57237-0019-30 NDC inpatient 1 UN 5.95 5.95 HEALTHPARTNERS SX009 HEALTHPARTNERS 4.71 percent of total billed charges 3.69 5.65 Technical (Hospital) Services "DULOXETINE 60 MG CAPSULE,DELAYED RELEASE" RX-39277 CDM 6370000100 HCPCS 250 RC 57237-0019-30 NDC inpatient 1 UN 5.95 5.95 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES PPO [308136801] 4.71 percent of total billed charges 3.69 5.65 Technical (Hospital) Services "DULOXETINE 60 MG CAPSULE,DELAYED RELEASE" RX-39277 CDM 6370000100 HCPCS 250 RC 57237-0019-30 NDC inpatient 1 UN 5.95 5.95 MULTIPLAN INC 34080 [3081285] MULTIPLAN INC [308128501] 5.65 percent of total billed charges 3.69 5.65 Technical (Hospital) Services "DULOXETINE 60 MG CAPSULE,DELAYED RELEASE" RX-39277 CDM 6370000100 HCPCS 250 RC 57237-0019-30 NDC inpatient 1 UN 5.95 5.95 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES HDHP [308136802] 4.71 percent of total billed charges 3.69 5.65 Technical (Hospital) Services "DULOXETINE 60 MG CAPSULE,DELAYED RELEASE" RX-39277 CDM 6370000100 HCPCS 250 RC 57237-0019-30 NDC inpatient 1 UN 5.95 5.95 CIGNA 62308 [3081051] CIGNA 62308 [308105105] 4.71 percent of total billed charges 3.69 5.65 Technical (Hospital) Services "DULOXETINE 60 MG CAPSULE,DELAYED RELEASE" RX-39277 CDM 6370000100 HCPCS 250 RC 57237-0019-30 NDC inpatient 1 UN 5.95 5.95 CIGNA 62308 [3081051] CIGNA STATE OF WYOMING [308105107] 4.71 percent of total billed charges 3.69 5.65 Technical (Hospital) Services "DULOXETINE 60 MG CAPSULE,DELAYED RELEASE" RX-39277 CDM 6370000100 HCPCS 250 RC 57237-0019-30 NDC inpatient 1 UN 5.95 5.95 UNITED HEALTHCARE (COMMERCIAL) [3081199] UNITED HEALTHCARE 87726 [308119901] 3.69 percent of total billed charges 3.69 5.65 Technical (Hospital) Services "DULOXETINE 60 MG CAPSULE,DELAYED RELEASE" RX-39277 CDM 6370000100 HCPCS 250 RC 57237-0019-30 NDC inpatient 1 UN 5.95 5.95 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES EPO [308136803] 4.71 percent of total billed charges 3.69 5.65 Technical (Hospital) Services "DULOXETINE 60 MG CAPSULE,DELAYED RELEASE" RX-39277 CDM 6370000100 HCPCS 250 RC 57237-0019-30 NDC inpatient 1 UN 5.95 5.95 BLUE CROSS BLUE SHIELD WELLMARK SB889 [3081026] BCBS WYOMING [308102603] 5.65 percent of total billed charges 3.69 5.65 Technical (Hospital) Services "DULOXETINE 60 MG CAPSULE,DELAYED RELEASE" RX-39277 CDM 6370000100 HCPCS 250 RC 57237-0019-30 NDC outpatient 1 UN 5.95 5.95 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES PPO [308136801] 4.76 percent of total billed charges 3.69 5.65 Technical (Hospital) Services "DULOXETINE 60 MG CAPSULE,DELAYED RELEASE" RX-39277 CDM 6370000100 HCPCS 250 RC 57237-0019-30 NDC outpatient 1 UN 5.95 5.95 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES EPO [308136803] 4.76 percent of total billed charges 3.69 5.65 Technical (Hospital) Services "DULOXETINE 60 MG CAPSULE,DELAYED RELEASE" RX-39277 CDM 6370000100 HCPCS 250 RC 57237-0019-30 NDC outpatient 1 UN 5.95 5.95 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES HDHP [308136802] 4.76 percent of total billed charges 3.69 5.65 Technical (Hospital) Services "DULOXETINE 60 MG CAPSULE,DELAYED RELEASE" RX-39277 CDM 6370000100 HCPCS 250 RC 57237-0019-30 NDC outpatient 1 UN 5.95 5.95 MEDICA (COMMERCIAL) 94265 [3081118] MEDICA CLAIMS [308111801] 5.36 percent of total billed charges 3.69 5.65 Technical (Hospital) Services "DULOXETINE 60 MG CAPSULE,DELAYED RELEASE" RX-39277 CDM 6370000100 HCPCS 250 RC 57237-0019-30 NDC outpatient 1 UN 5.95 5.95 CIGNA 62308 [3081051] CIGNA 62308 [308105105] 4.76 percent of total billed charges 3.69 5.65 Technical (Hospital) Services "DULOXETINE 60 MG CAPSULE,DELAYED RELEASE" RX-39277 CDM 6370000100 HCPCS 250 RC 57237-0019-30 NDC outpatient 1 UN 5.95 5.95 CIGNA 62308 [3081051] CIGNA STATE OF WYOMING [308105107] 4.76 percent of total billed charges 3.69 5.65 Technical (Hospital) Services "DULOXETINE 60 MG CAPSULE,DELAYED RELEASE" RX-39277 CDM 6370000100 HCPCS 250 RC 57237-0019-30 NDC outpatient 1 UN 5.95 5.95 MULTIPLAN INC 34080 [3081285] MULTIPLAN INC [308128501] 5.65 percent of total billed charges 3.69 5.65 Technical (Hospital) Services "DULOXETINE 60 MG CAPSULE,DELAYED RELEASE" RX-39277 CDM 6370000100 HCPCS 250 RC 57237-0019-30 NDC outpatient 1 UN 5.95 5.95 UNITED HEALTHCARE (COMMERCIAL) [3081199] UNITED HEALTHCARE 87726 [308119901] 3.69 percent of total billed charges 3.69 5.65 Technical (Hospital) Services "DULOXETINE 60 MG CAPSULE,DELAYED RELEASE" RX-39277 CDM 6370000100 HCPCS 250 RC 57237-0019-30 NDC outpatient 1 UN 5.95 5.95 BLUE CROSS BLUE SHIELD WELLMARK SB889 [3081026] BCBS WYOMING [308102603] 5.65 percent of total billed charges 3.69 5.65 Technical (Hospital) Services "DULOXETINE 60 MG CAPSULE,DELAYED RELEASE" RX-39277 CDM 6370000100 HCPCS 250 RC 57237-0019-30 NDC outpatient 1 UN 5.95 5.95 HEALTHPARTNERS SX009 HEALTHPARTNERS 4.76 percent of total billed charges 3.69 5.65 Technical (Hospital) Services URSODIOL 500 MG TABLET RX-39717 CDM 6370000100 HCPCS 250 RC 64380-0919-06 NDC inpatient 1 UN 6.62 6.62 MULTIPLAN INC 34080 [3081285] MULTIPLAN INC [308128501] 6.29 percent of total billed charges 4.1 6.29 Technical (Hospital) Services URSODIOL 500 MG TABLET RX-39717 CDM 6370000100 HCPCS 250 RC 64380-0919-06 NDC inpatient 1 UN 6.62 6.62 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES PPO [308136801] 5.24 percent of total billed charges 4.1 6.29 Technical (Hospital) Services URSODIOL 500 MG TABLET RX-39717 CDM 6370000100 HCPCS 250 RC 64380-0919-06 NDC inpatient 1 UN 6.62 6.62 MEDICA (COMMERCIAL) 94265 [3081118] MEDICA CLAIMS [308111801] 5.96 percent of total billed charges 4.1 6.29 Technical (Hospital) Services URSODIOL 500 MG TABLET RX-39717 CDM 6370000100 HCPCS 250 RC 64380-0919-06 NDC inpatient 1 UN 6.62 6.62 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES HDHP [308136802] 5.24 percent of total billed charges 4.1 6.29 Technical (Hospital) Services URSODIOL 500 MG TABLET RX-39717 CDM 6370000100 HCPCS 250 RC 64380-0919-06 NDC inpatient 1 UN 6.62 6.62 HEALTHPARTNERS SX009 HEALTHPARTNERS 5.24 percent of total billed charges 4.1 6.29 Technical (Hospital) Services URSODIOL 500 MG TABLET RX-39717 CDM 6370000100 HCPCS 250 RC 64380-0919-06 NDC inpatient 1 UN 6.62 6.62 UNITED HEALTHCARE (COMMERCIAL) [3081199] UNITED HEALTHCARE 87726 [308119901] 4.1 percent of total billed charges 4.1 6.29 Technical (Hospital) Services URSODIOL 500 MG TABLET RX-39717 CDM 6370000100 HCPCS 250 RC 64380-0919-06 NDC inpatient 1 UN 6.62 6.62 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES EPO [308136803] 5.24 percent of total billed charges 4.1 6.29 Technical (Hospital) Services URSODIOL 500 MG TABLET RX-39717 CDM 6370000100 HCPCS 250 RC 64380-0919-06 NDC inpatient 1 UN 6.62 6.62 CIGNA 62308 [3081051] CIGNA 62308 [308105105] 5.24 percent of total billed charges 4.1 6.29 Technical (Hospital) Services URSODIOL 500 MG TABLET RX-39717 CDM 6370000100 HCPCS 250 RC 64380-0919-06 NDC inpatient 1 UN 6.62 6.62 CIGNA 62308 [3081051] CIGNA STATE OF WYOMING [308105107] 5.24 percent of total billed charges 4.1 6.29 Technical (Hospital) Services URSODIOL 500 MG TABLET RX-39717 CDM 6370000100 HCPCS 250 RC 64380-0919-06 NDC inpatient 1 UN 6.62 6.62 BLUE CROSS BLUE SHIELD WELLMARK SB889 [3081026] BCBS WYOMING [308102603] 6.29 percent of total billed charges 4.1 6.29 Technical (Hospital) Services URSODIOL 500 MG TABLET RX-39717 CDM 6370000100 HCPCS 250 RC 64380-0919-06 NDC outpatient 1 UN 6.62 6.62 UNITED HEALTHCARE (COMMERCIAL) [3081199] UNITED HEALTHCARE 87726 [308119901] 4.1 percent of total billed charges 4.1 6.29 Technical (Hospital) Services URSODIOL 500 MG TABLET RX-39717 CDM 6370000100 HCPCS 250 RC 64380-0919-06 NDC outpatient 1 UN 6.62 6.62 MEDICA (COMMERCIAL) 94265 [3081118] MEDICA CLAIMS [308111801] 5.96 percent of total billed charges 4.1 6.29 Technical (Hospital) Services URSODIOL 500 MG TABLET RX-39717 CDM 6370000100 HCPCS 250 RC 64380-0919-06 NDC outpatient 1 UN 6.62 6.62 MULTIPLAN INC 34080 [3081285] MULTIPLAN INC [308128501] 6.29 percent of total billed charges 4.1 6.29 Technical (Hospital) Services URSODIOL 500 MG TABLET RX-39717 CDM 6370000100 HCPCS 250 RC 64380-0919-06 NDC outpatient 1 UN 6.62 6.62 CIGNA 62308 [3081051] CIGNA 62308 [308105105] 5.3 percent of total billed charges 4.1 6.29 Technical (Hospital) Services URSODIOL 500 MG TABLET RX-39717 CDM 6370000100 HCPCS 250 RC 64380-0919-06 NDC outpatient 1 UN 6.62 6.62 CIGNA 62308 [3081051] CIGNA STATE OF WYOMING [308105107] 5.3 percent of total billed charges 4.1 6.29 Technical (Hospital) Services URSODIOL 500 MG TABLET RX-39717 CDM 6370000100 HCPCS 250 RC 64380-0919-06 NDC outpatient 1 UN 6.62 6.62 HEALTHPARTNERS SX009 HEALTHPARTNERS 5.3 percent of total billed charges 4.1 6.29 Technical (Hospital) Services URSODIOL 500 MG TABLET RX-39717 CDM 6370000100 HCPCS 250 RC 64380-0919-06 NDC outpatient 1 UN 6.62 6.62 BLUE CROSS BLUE SHIELD WELLMARK SB889 [3081026] BCBS WYOMING [308102603] 6.29 percent of total billed charges 4.1 6.29 Technical (Hospital) Services URSODIOL 500 MG TABLET RX-39717 CDM 6370000100 HCPCS 250 RC 64380-0919-06 NDC outpatient 1 UN 6.62 6.62 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES EPO [308136803] 5.3 percent of total billed charges 4.1 6.29 Technical (Hospital) Services URSODIOL 500 MG TABLET RX-39717 CDM 6370000100 HCPCS 250 RC 64380-0919-06 NDC outpatient 1 UN 6.62 6.62 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES HDHP [308136802] 5.3 percent of total billed charges 4.1 6.29 Technical (Hospital) Services URSODIOL 500 MG TABLET RX-39717 CDM 6370000100 HCPCS 250 RC 64380-0919-06 NDC outpatient 1 UN 6.62 6.62 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES PPO [308136801] 5.3 percent of total billed charges 4.1 6.29 Technical (Hospital) Services FENOFIBRATE NANOCRYSTALLIZED 145 MG TABLET RX-40010 CDM 6370000100 HCPCS 250 RC 00378-3066-77 NDC inpatient 1 UN 6.27 6.27 MULTIPLAN INC 34080 [3081285] MULTIPLAN INC [308128501] 5.96 percent of total billed charges 3.89 5.96 Technical (Hospital) Services FENOFIBRATE NANOCRYSTALLIZED 145 MG TABLET RX-40010 CDM 6370000100 HCPCS 250 RC 00378-3066-77 NDC inpatient 1 UN 6.27 6.27 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES PPO [308136801] 4.96 percent of total billed charges 3.89 5.96 Technical (Hospital) Services FENOFIBRATE NANOCRYSTALLIZED 145 MG TABLET RX-40010 CDM 6370000100 HCPCS 250 RC 00378-3066-77 NDC inpatient 1 UN 6.27 6.27 MEDICA (COMMERCIAL) 94265 [3081118] MEDICA CLAIMS [308111801] 5.64 percent of total billed charges 3.89 5.96 Technical (Hospital) Services FENOFIBRATE NANOCRYSTALLIZED 145 MG TABLET RX-40010 CDM 6370000100 HCPCS 250 RC 00378-3066-77 NDC inpatient 1 UN 6.27 6.27 HEALTHPARTNERS SX009 HEALTHPARTNERS 4.96 percent of total billed charges 3.89 5.96 Technical (Hospital) Services FENOFIBRATE NANOCRYSTALLIZED 145 MG TABLET RX-40010 CDM 6370000100 HCPCS 250 RC 00378-3066-77 NDC inpatient 1 UN 6.27 6.27 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES HDHP [308136802] 4.96 percent of total billed charges 3.89 5.96 Technical (Hospital) Services FENOFIBRATE NANOCRYSTALLIZED 145 MG TABLET RX-40010 CDM 6370000100 HCPCS 250 RC 00378-3066-77 NDC inpatient 1 UN 6.27 6.27 CIGNA 62308 [3081051] CIGNA 62308 [308105105] 4.96 percent of total billed charges 3.89 5.96 Technical (Hospital) Services FENOFIBRATE NANOCRYSTALLIZED 145 MG TABLET RX-40010 CDM 6370000100 HCPCS 250 RC 00378-3066-77 NDC inpatient 1 UN 6.27 6.27 CIGNA 62308 [3081051] CIGNA STATE OF WYOMING [308105107] 4.96 percent of total billed charges 3.89 5.96 Technical (Hospital) Services FENOFIBRATE NANOCRYSTALLIZED 145 MG TABLET RX-40010 CDM 6370000100 HCPCS 250 RC 00378-3066-77 NDC inpatient 1 UN 6.27 6.27 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES EPO [308136803] 4.96 percent of total billed charges 3.89 5.96 Technical (Hospital) Services FENOFIBRATE NANOCRYSTALLIZED 145 MG TABLET RX-40010 CDM 6370000100 HCPCS 250 RC 00378-3066-77 NDC inpatient 1 UN 6.27 6.27 UNITED HEALTHCARE (COMMERCIAL) [3081199] UNITED HEALTHCARE 87726 [308119901] 3.89 percent of total billed charges 3.89 5.96 Technical (Hospital) Services FENOFIBRATE NANOCRYSTALLIZED 145 MG TABLET RX-40010 CDM 6370000100 HCPCS 250 RC 00378-3066-77 NDC inpatient 1 UN 6.27 6.27 BLUE CROSS BLUE SHIELD WELLMARK SB889 [3081026] BCBS WYOMING [308102603] 5.96 percent of total billed charges 3.89 5.96 Technical (Hospital) Services FENOFIBRATE NANOCRYSTALLIZED 145 MG TABLET RX-40010 CDM 6370000100 HCPCS 250 RC 00378-3066-77 NDC outpatient 1 UN 6.27 6.27 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES PPO [308136801] 5.02 percent of total billed charges 3.89 5.96 Technical (Hospital) Services FENOFIBRATE NANOCRYSTALLIZED 145 MG TABLET RX-40010 CDM 6370000100 HCPCS 250 RC 00378-3066-77 NDC outpatient 1 UN 6.27 6.27 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES HDHP [308136802] 5.02 percent of total billed charges 3.89 5.96 Technical (Hospital) Services FENOFIBRATE NANOCRYSTALLIZED 145 MG TABLET RX-40010 CDM 6370000100 HCPCS 250 RC 00378-3066-77 NDC outpatient 1 UN 6.27 6.27 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES EPO [308136803] 5.02 percent of total billed charges 3.89 5.96 Technical (Hospital) Services FENOFIBRATE NANOCRYSTALLIZED 145 MG TABLET RX-40010 CDM 6370000100 HCPCS 250 RC 00378-3066-77 NDC outpatient 1 UN 6.27 6.27 BLUE CROSS BLUE SHIELD WELLMARK SB889 [3081026] BCBS WYOMING [308102603] 5.96 percent of total billed charges 3.89 5.96 Technical (Hospital) Services FENOFIBRATE NANOCRYSTALLIZED 145 MG TABLET RX-40010 CDM 6370000100 HCPCS 250 RC 00378-3066-77 NDC outpatient 1 UN 6.27 6.27 HEALTHPARTNERS SX009 HEALTHPARTNERS 5.02 percent of total billed charges 3.89 5.96 Technical (Hospital) Services FENOFIBRATE NANOCRYSTALLIZED 145 MG TABLET RX-40010 CDM 6370000100 HCPCS 250 RC 00378-3066-77 NDC outpatient 1 UN 6.27 6.27 UNITED HEALTHCARE (COMMERCIAL) [3081199] UNITED HEALTHCARE 87726 [308119901] 3.89 percent of total billed charges 3.89 5.96 Technical (Hospital) Services FENOFIBRATE NANOCRYSTALLIZED 145 MG TABLET RX-40010 CDM 6370000100 HCPCS 250 RC 00378-3066-77 NDC outpatient 1 UN 6.27 6.27 CIGNA 62308 [3081051] CIGNA STATE OF WYOMING [308105107] 5.02 percent of total billed charges 3.89 5.96 Technical (Hospital) Services FENOFIBRATE NANOCRYSTALLIZED 145 MG TABLET RX-40010 CDM 6370000100 HCPCS 250 RC 00378-3066-77 NDC outpatient 1 UN 6.27 6.27 CIGNA 62308 [3081051] CIGNA 62308 [308105105] 5.02 percent of total billed charges 3.89 5.96 Technical (Hospital) Services FENOFIBRATE NANOCRYSTALLIZED 145 MG TABLET RX-40010 CDM 6370000100 HCPCS 250 RC 00378-3066-77 NDC outpatient 1 UN 6.27 6.27 MULTIPLAN INC 34080 [3081285] MULTIPLAN INC [308128501] 5.96 percent of total billed charges 3.89 5.96 Technical (Hospital) Services FENOFIBRATE NANOCRYSTALLIZED 145 MG TABLET RX-40010 CDM 6370000100 HCPCS 250 RC 00378-3066-77 NDC outpatient 1 UN 6.27 6.27 MEDICA (COMMERCIAL) 94265 [3081118] MEDICA CLAIMS [308111801] 5.64 percent of total billed charges 3.89 5.96 Technical (Hospital) Services "MESALAMINE 1,000 MG RECTAL SUPPOSITORY" RX-40369 CDM 6370000100 HCPCS 250 RC 64980-0282-03 NDC inpatient 1 UN 15.33 15.33 MULTIPLAN INC 34080 [3081285] MULTIPLAN INC [308128501] 14.56 percent of total billed charges 9.5 14.56 Technical (Hospital) Services "MESALAMINE 1,000 MG RECTAL SUPPOSITORY" RX-40369 CDM 6370000100 HCPCS 250 RC 64980-0282-03 NDC inpatient 1 UN 15.33 15.33 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES PPO [308136801] 12.14 percent of total billed charges 9.5 14.56 Technical (Hospital) Services "MESALAMINE 1,000 MG RECTAL SUPPOSITORY" RX-40369 CDM 6370000100 HCPCS 250 RC 64980-0282-03 NDC inpatient 1 UN 15.33 15.33 MEDICA (COMMERCIAL) 94265 [3081118] MEDICA CLAIMS [308111801] 13.8 percent of total billed charges 9.5 14.56 Technical (Hospital) Services "MESALAMINE 1,000 MG RECTAL SUPPOSITORY" RX-40369 CDM 6370000100 HCPCS 250 RC 64980-0282-03 NDC inpatient 1 UN 15.33 15.33 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES HDHP [308136802] 12.14 percent of total billed charges 9.5 14.56 Technical (Hospital) Services "MESALAMINE 1,000 MG RECTAL SUPPOSITORY" RX-40369 CDM 6370000100 HCPCS 250 RC 64980-0282-03 NDC inpatient 1 UN 15.33 15.33 HEALTHPARTNERS SX009 HEALTHPARTNERS 12.14 percent of total billed charges 9.5 14.56 Technical (Hospital) Services "MESALAMINE 1,000 MG RECTAL SUPPOSITORY" RX-40369 CDM 6370000100 HCPCS 250 RC 64980-0282-03 NDC inpatient 1 UN 15.33 15.33 BLUE CROSS BLUE SHIELD WELLMARK SB889 [3081026] BCBS WYOMING [308102603] 14.56 percent of total billed charges 9.5 14.56 Technical (Hospital) Services "MESALAMINE 1,000 MG RECTAL SUPPOSITORY" RX-40369 CDM 6370000100 HCPCS 250 RC 64980-0282-03 NDC inpatient 1 UN 15.33 15.33 CIGNA 62308 [3081051] CIGNA 62308 [308105105] 12.14 percent of total billed charges 9.5 14.56 Technical (Hospital) Services "MESALAMINE 1,000 MG RECTAL SUPPOSITORY" RX-40369 CDM 6370000100 HCPCS 250 RC 64980-0282-03 NDC inpatient 1 UN 15.33 15.33 CIGNA 62308 [3081051] CIGNA STATE OF WYOMING [308105107] 12.14 percent of total billed charges 9.5 14.56 Technical (Hospital) Services "MESALAMINE 1,000 MG RECTAL SUPPOSITORY" RX-40369 CDM 6370000100 HCPCS 250 RC 64980-0282-03 NDC inpatient 1 UN 15.33 15.33 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES EPO [308136803] 12.14 percent of total billed charges 9.5 14.56 Technical (Hospital) Services "MESALAMINE 1,000 MG RECTAL SUPPOSITORY" RX-40369 CDM 6370000100 HCPCS 250 RC 64980-0282-03 NDC inpatient 1 UN 15.33 15.33 UNITED HEALTHCARE (COMMERCIAL) [3081199] UNITED HEALTHCARE 87726 [308119901] 9.5 percent of total billed charges 9.5 14.56 Technical (Hospital) Services "MESALAMINE 1,000 MG RECTAL SUPPOSITORY" RX-40369 CDM 6370000100 HCPCS 250 RC 64980-0282-03 NDC outpatient 1 UN 15.33 15.33 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES EPO [308136803] 12.26 percent of total billed charges 9.5 14.56 Technical (Hospital) Services "MESALAMINE 1,000 MG RECTAL SUPPOSITORY" RX-40369 CDM 6370000100 HCPCS 250 RC 64980-0282-03 NDC outpatient 1 UN 15.33 15.33 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES PPO [308136801] 12.26 percent of total billed charges 9.5 14.56 Technical (Hospital) Services "MESALAMINE 1,000 MG RECTAL SUPPOSITORY" RX-40369 CDM 6370000100 HCPCS 250 RC 64980-0282-03 NDC outpatient 1 UN 15.33 15.33 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES HDHP [308136802] 12.26 percent of total billed charges 9.5 14.56 Technical (Hospital) Services "MESALAMINE 1,000 MG RECTAL SUPPOSITORY" RX-40369 CDM 6370000100 HCPCS 250 RC 64980-0282-03 NDC outpatient 1 UN 15.33 15.33 MEDICA (COMMERCIAL) 94265 [3081118] MEDICA CLAIMS [308111801] 13.8 percent of total billed charges 9.5 14.56 Technical (Hospital) Services "MESALAMINE 1,000 MG RECTAL SUPPOSITORY" RX-40369 CDM 6370000100 HCPCS 250 RC 64980-0282-03 NDC outpatient 1 UN 15.33 15.33 CIGNA 62308 [3081051] CIGNA 62308 [308105105] 12.26 percent of total billed charges 9.5 14.56 Technical (Hospital) Services "MESALAMINE 1,000 MG RECTAL SUPPOSITORY" RX-40369 CDM 6370000100 HCPCS 250 RC 64980-0282-03 NDC outpatient 1 UN 15.33 15.33 CIGNA 62308 [3081051] CIGNA STATE OF WYOMING [308105107] 12.26 percent of total billed charges 9.5 14.56 Technical (Hospital) Services "MESALAMINE 1,000 MG RECTAL SUPPOSITORY" RX-40369 CDM 6370000100 HCPCS 250 RC 64980-0282-03 NDC outpatient 1 UN 15.33 15.33 MULTIPLAN INC 34080 [3081285] MULTIPLAN INC [308128501] 14.56 percent of total billed charges 9.5 14.56 Technical (Hospital) Services "MESALAMINE 1,000 MG RECTAL SUPPOSITORY" RX-40369 CDM 6370000100 HCPCS 250 RC 64980-0282-03 NDC outpatient 1 UN 15.33 15.33 UNITED HEALTHCARE (COMMERCIAL) [3081199] UNITED HEALTHCARE 87726 [308119901] 9.5 percent of total billed charges 9.5 14.56 Technical (Hospital) Services "MESALAMINE 1,000 MG RECTAL SUPPOSITORY" RX-40369 CDM 6370000100 HCPCS 250 RC 64980-0282-03 NDC outpatient 1 UN 15.33 15.33 HEALTHPARTNERS SX009 HEALTHPARTNERS 12.26 percent of total billed charges 9.5 14.56 Technical (Hospital) Services "MESALAMINE 1,000 MG RECTAL SUPPOSITORY" RX-40369 CDM 6370000100 HCPCS 250 RC 64980-0282-03 NDC outpatient 1 UN 15.33 15.33 BLUE CROSS BLUE SHIELD WELLMARK SB889 [3081026] BCBS WYOMING [308102603] 14.56 percent of total billed charges 9.5 14.56 Technical (Hospital) Services "DARIFENACIN ER 7.5 MG TABLET,EXTENDED RELEASE 24 HR" RX-40402 CDM 6370000100 HCPCS 250 RC 69097-0431-02 NDC inpatient 1 UN 15.28 15.28 HEALTHPARTNERS SX009 HEALTHPARTNERS 12.1 percent of total billed charges 9.47 14.52 Technical (Hospital) Services "DARIFENACIN ER 7.5 MG TABLET,EXTENDED RELEASE 24 HR" RX-40402 CDM 6370000100 HCPCS 250 RC 69097-0431-02 NDC inpatient 1 UN 15.28 15.28 MEDICA (COMMERCIAL) 94265 [3081118] MEDICA CLAIMS [308111801] 13.75 percent of total billed charges 9.47 14.52 Technical (Hospital) Services "DARIFENACIN ER 7.5 MG TABLET,EXTENDED RELEASE 24 HR" RX-40402 CDM 6370000100 HCPCS 250 RC 69097-0431-02 NDC inpatient 1 UN 15.28 15.28 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES PPO [308136801] 12.1 percent of total billed charges 9.47 14.52 Technical (Hospital) Services "DARIFENACIN ER 7.5 MG TABLET,EXTENDED RELEASE 24 HR" RX-40402 CDM 6370000100 HCPCS 250 RC 69097-0431-02 NDC inpatient 1 UN 15.28 15.28 MULTIPLAN INC 34080 [3081285] MULTIPLAN INC [308128501] 14.52 percent of total billed charges 9.47 14.52 Technical (Hospital) Services "DARIFENACIN ER 7.5 MG TABLET,EXTENDED RELEASE 24 HR" RX-40402 CDM 6370000100 HCPCS 250 RC 69097-0431-02 NDC inpatient 1 UN 15.28 15.28 UNITED HEALTHCARE (COMMERCIAL) [3081199] UNITED HEALTHCARE 87726 [308119901] 9.47 percent of total billed charges 9.47 14.52 Technical (Hospital) Services "DARIFENACIN ER 7.5 MG TABLET,EXTENDED RELEASE 24 HR" RX-40402 CDM 6370000100 HCPCS 250 RC 69097-0431-02 NDC inpatient 1 UN 15.28 15.28 BLUE CROSS BLUE SHIELD WELLMARK SB889 [3081026] BCBS WYOMING [308102603] 14.52 percent of total billed charges 9.47 14.52 Technical (Hospital) Services "DARIFENACIN ER 7.5 MG TABLET,EXTENDED RELEASE 24 HR" RX-40402 CDM 6370000100 HCPCS 250 RC 69097-0431-02 NDC inpatient 1 UN 15.28 15.28 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES EPO [308136803] 12.1 percent of total billed charges 9.47 14.52 Technical (Hospital) Services "DARIFENACIN ER 7.5 MG TABLET,EXTENDED RELEASE 24 HR" RX-40402 CDM 6370000100 HCPCS 250 RC 69097-0431-02 NDC inpatient 1 UN 15.28 15.28 CIGNA 62308 [3081051] CIGNA 62308 [308105105] 12.1 percent of total billed charges 9.47 14.52 Technical (Hospital) Services "DARIFENACIN ER 7.5 MG TABLET,EXTENDED RELEASE 24 HR" RX-40402 CDM 6370000100 HCPCS 250 RC 69097-0431-02 NDC inpatient 1 UN 15.28 15.28 CIGNA 62308 [3081051] CIGNA STATE OF WYOMING [308105107] 12.1 percent of total billed charges 9.47 14.52 Technical (Hospital) Services "DARIFENACIN ER 7.5 MG TABLET,EXTENDED RELEASE 24 HR" RX-40402 CDM 6370000100 HCPCS 250 RC 69097-0431-02 NDC inpatient 1 UN 15.28 15.28 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES HDHP [308136802] 12.1 percent of total billed charges 9.47 14.52 Technical (Hospital) Services "DARIFENACIN ER 7.5 MG TABLET,EXTENDED RELEASE 24 HR" RX-40402 CDM 6370000100 HCPCS 250 RC 69097-0431-02 NDC outpatient 1 UN 15.28 15.28 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES PPO [308136801] 12.22 percent of total billed charges 9.47 14.52 Technical (Hospital) Services "DARIFENACIN ER 7.5 MG TABLET,EXTENDED RELEASE 24 HR" RX-40402 CDM 6370000100 HCPCS 250 RC 69097-0431-02 NDC outpatient 1 UN 15.28 15.28 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES EPO [308136803] 12.22 percent of total billed charges 9.47 14.52 Technical (Hospital) Services "DARIFENACIN ER 7.5 MG TABLET,EXTENDED RELEASE 24 HR" RX-40402 CDM 6370000100 HCPCS 250 RC 69097-0431-02 NDC outpatient 1 UN 15.28 15.28 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES HDHP [308136802] 12.22 percent of total billed charges 9.47 14.52 Technical (Hospital) Services "DARIFENACIN ER 7.5 MG TABLET,EXTENDED RELEASE 24 HR" RX-40402 CDM 6370000100 HCPCS 250 RC 69097-0431-02 NDC outpatient 1 UN 15.28 15.28 CIGNA 62308 [3081051] CIGNA 62308 [308105105] 12.22 percent of total billed charges 9.47 14.52 Technical (Hospital) Services "DARIFENACIN ER 7.5 MG TABLET,EXTENDED RELEASE 24 HR" RX-40402 CDM 6370000100 HCPCS 250 RC 69097-0431-02 NDC outpatient 1 UN 15.28 15.28 CIGNA 62308 [3081051] CIGNA STATE OF WYOMING [308105107] 12.22 percent of total billed charges 9.47 14.52 Technical (Hospital) Services "DARIFENACIN ER 7.5 MG TABLET,EXTENDED RELEASE 24 HR" RX-40402 CDM 6370000100 HCPCS 250 RC 69097-0431-02 NDC outpatient 1 UN 15.28 15.28 MULTIPLAN INC 34080 [3081285] MULTIPLAN INC [308128501] 14.52 percent of total billed charges 9.47 14.52 Technical (Hospital) Services "DARIFENACIN ER 7.5 MG TABLET,EXTENDED RELEASE 24 HR" RX-40402 CDM 6370000100 HCPCS 250 RC 69097-0431-02 NDC outpatient 1 UN 15.28 15.28 MEDICA (COMMERCIAL) 94265 [3081118] MEDICA CLAIMS [308111801] 13.75 percent of total billed charges 9.47 14.52 Technical (Hospital) Services "DARIFENACIN ER 7.5 MG TABLET,EXTENDED RELEASE 24 HR" RX-40402 CDM 6370000100 HCPCS 250 RC 69097-0431-02 NDC outpatient 1 UN 15.28 15.28 UNITED HEALTHCARE (COMMERCIAL) [3081199] UNITED HEALTHCARE 87726 [308119901] 9.47 percent of total billed charges 9.47 14.52 Technical (Hospital) Services "DARIFENACIN ER 7.5 MG TABLET,EXTENDED RELEASE 24 HR" RX-40402 CDM 6370000100 HCPCS 250 RC 69097-0431-02 NDC outpatient 1 UN 15.28 15.28 HEALTHPARTNERS SX009 HEALTHPARTNERS 12.22 percent of total billed charges 9.47 14.52 Technical (Hospital) Services "DARIFENACIN ER 7.5 MG TABLET,EXTENDED RELEASE 24 HR" RX-40402 CDM 6370000100 HCPCS 250 RC 69097-0431-02 NDC outpatient 1 UN 15.28 15.28 BLUE CROSS BLUE SHIELD WELLMARK SB889 [3081026] BCBS WYOMING [308102603] 14.52 percent of total billed charges 9.47 14.52 Technical (Hospital) Services ISOSORBIDE DINITRATE 10 MG TABLET RX-4064 CDM 6370000100 HCPCS 250 RC 00143-1771-01 NDC outpatient 1 UN 6.2 6.2 MEDICA (COMMERCIAL) 94265 [3081118] MEDICA CLAIMS [308111801] 5.58 percent of total billed charges 3.84 5.89 Technical (Hospital) Services ISOSORBIDE DINITRATE 10 MG TABLET RX-4064 CDM 6370000100 HCPCS 250 RC 00143-1771-01 NDC outpatient 1 UN 6.2 6.2 MULTIPLAN INC 34080 [3081285] MULTIPLAN INC [308128501] 5.89 percent of total billed charges 3.84 5.89 Technical (Hospital) Services ISOSORBIDE DINITRATE 10 MG TABLET RX-4064 CDM 6370000100 HCPCS 250 RC 00143-1771-01 NDC outpatient 1 UN 6.2 6.2 CIGNA 62308 [3081051] CIGNA 62308 [308105105] 4.96 percent of total billed charges 3.84 5.89 Technical (Hospital) Services ISOSORBIDE DINITRATE 10 MG TABLET RX-4064 CDM 6370000100 HCPCS 250 RC 00143-1771-01 NDC outpatient 1 UN 6.2 6.2 CIGNA 62308 [3081051] CIGNA STATE OF WYOMING [308105107] 4.96 percent of total billed charges 3.84 5.89 Technical (Hospital) Services ISOSORBIDE DINITRATE 10 MG TABLET RX-4064 CDM 6370000100 HCPCS 250 RC 00143-1771-01 NDC outpatient 1 UN 6.2 6.2 UNITED HEALTHCARE (COMMERCIAL) [3081199] UNITED HEALTHCARE 87726 [308119901] 3.84 percent of total billed charges 3.84 5.89 Technical (Hospital) Services ISOSORBIDE DINITRATE 10 MG TABLET RX-4064 CDM 6370000100 HCPCS 250 RC 00143-1771-01 NDC outpatient 1 UN 6.2 6.2 HEALTHPARTNERS SX009 HEALTHPARTNERS 4.96 percent of total billed charges 3.84 5.89 Technical (Hospital) Services ISOSORBIDE DINITRATE 10 MG TABLET RX-4064 CDM 6370000100 HCPCS 250 RC 00143-1771-01 NDC outpatient 1 UN 6.2 6.2 BLUE CROSS BLUE SHIELD WELLMARK SB889 [3081026] BCBS WYOMING [308102603] 5.89 percent of total billed charges 3.84 5.89 Technical (Hospital) Services ISOSORBIDE DINITRATE 10 MG TABLET RX-4064 CDM 6370000100 HCPCS 250 RC 00143-1771-01 NDC outpatient 1 UN 6.2 6.2 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES HDHP [308136802] 4.96 percent of total billed charges 3.84 5.89 Technical (Hospital) Services ISOSORBIDE DINITRATE 10 MG TABLET RX-4064 CDM 6370000100 HCPCS 250 RC 00143-1771-01 NDC outpatient 1 UN 6.2 6.2 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES PPO [308136801] 4.96 percent of total billed charges 3.84 5.89 Technical (Hospital) Services ISOSORBIDE DINITRATE 10 MG TABLET RX-4064 CDM 6370000100 HCPCS 250 RC 00143-1771-01 NDC outpatient 1 UN 6.2 6.2 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES EPO [308136803] 4.96 percent of total billed charges 3.84 5.89 Technical (Hospital) Services ISOSORBIDE DINITRATE 10 MG TABLET RX-4064 CDM 6370000100 HCPCS 250 RC 00143-1771-01 NDC inpatient 1 UN 6.2 6.2 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES HDHP [308136802] 4.91 percent of total billed charges 3.84 5.89 Technical (Hospital) Services ISOSORBIDE DINITRATE 10 MG TABLET RX-4064 CDM 6370000100 HCPCS 250 RC 00143-1771-01 NDC inpatient 1 UN 6.2 6.2 CIGNA 62308 [3081051] CIGNA 62308 [308105105] 4.91 percent of total billed charges 3.84 5.89 Technical (Hospital) Services ISOSORBIDE DINITRATE 10 MG TABLET RX-4064 CDM 6370000100 HCPCS 250 RC 00143-1771-01 NDC inpatient 1 UN 6.2 6.2 CIGNA 62308 [3081051] CIGNA STATE OF WYOMING [308105107] 4.91 percent of total billed charges 3.84 5.89 Technical (Hospital) Services ISOSORBIDE DINITRATE 10 MG TABLET RX-4064 CDM 6370000100 HCPCS 250 RC 00143-1771-01 NDC inpatient 1 UN 6.2 6.2 UNITED HEALTHCARE (COMMERCIAL) [3081199] UNITED HEALTHCARE 87726 [308119901] 3.84 percent of total billed charges 3.84 5.89 Technical (Hospital) Services ISOSORBIDE DINITRATE 10 MG TABLET RX-4064 CDM 6370000100 HCPCS 250 RC 00143-1771-01 NDC inpatient 1 UN 6.2 6.2 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES EPO [308136803] 4.91 percent of total billed charges 3.84 5.89 Technical (Hospital) Services ISOSORBIDE DINITRATE 10 MG TABLET RX-4064 CDM 6370000100 HCPCS 250 RC 00143-1771-01 NDC inpatient 1 UN 6.2 6.2 BLUE CROSS BLUE SHIELD WELLMARK SB889 [3081026] BCBS WYOMING [308102603] 5.89 percent of total billed charges 3.84 5.89 Technical (Hospital) Services ISOSORBIDE DINITRATE 10 MG TABLET RX-4064 CDM 6370000100 HCPCS 250 RC 00143-1771-01 NDC inpatient 1 UN 6.2 6.2 MULTIPLAN INC 34080 [3081285] MULTIPLAN INC [308128501] 5.89 percent of total billed charges 3.84 5.89 Technical (Hospital) Services ISOSORBIDE DINITRATE 10 MG TABLET RX-4064 CDM 6370000100 HCPCS 250 RC 00143-1771-01 NDC inpatient 1 UN 6.2 6.2 HEALTHPARTNERS SX009 HEALTHPARTNERS 4.91 percent of total billed charges 3.84 5.89 Technical (Hospital) Services ISOSORBIDE DINITRATE 10 MG TABLET RX-4064 CDM 6370000100 HCPCS 250 RC 00143-1771-01 NDC inpatient 1 UN 6.2 6.2 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES PPO [308136801] 4.91 percent of total billed charges 3.84 5.89 Technical (Hospital) Services ISOSORBIDE DINITRATE 10 MG TABLET RX-4064 CDM 6370000100 HCPCS 250 RC 00143-1771-01 NDC inpatient 1 UN 6.2 6.2 MEDICA (COMMERCIAL) 94265 [3081118] MEDICA CLAIMS [308111801] 5.58 percent of total billed charges 3.84 5.89 Technical (Hospital) Services "CHOLECALCIFEROL (VITAMIN D3) 1,000 (25 MCG) UNIT TAB/CAP" RX-4080010003 CDM 6370000100 HCPCS 250 RC 79854-0050-23 NDC outpatient 1 UN 5.65 5.65 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES EPO [308136803] 4.52 percent of total billed charges 3.5 5.37 Technical (Hospital) Services "CHOLECALCIFEROL (VITAMIN D3) 1,000 (25 MCG) UNIT TAB/CAP" RX-4080010003 CDM 6370000100 HCPCS 250 RC 79854-0050-23 NDC outpatient 1 UN 5.65 5.65 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES HDHP [308136802] 4.52 percent of total billed charges 3.5 5.37 Technical (Hospital) Services "CHOLECALCIFEROL (VITAMIN D3) 1,000 (25 MCG) UNIT TAB/CAP" RX-4080010003 CDM 6370000100 HCPCS 250 RC 79854-0050-23 NDC outpatient 1 UN 5.65 5.65 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES PPO [308136801] 4.52 percent of total billed charges 3.5 5.37 Technical (Hospital) Services "CHOLECALCIFEROL (VITAMIN D3) 1,000 (25 MCG) UNIT TAB/CAP" RX-4080010003 CDM 6370000100 HCPCS 250 RC 79854-0050-23 NDC outpatient 1 UN 5.65 5.65 BLUE CROSS BLUE SHIELD WELLMARK SB889 [3081026] BCBS WYOMING [308102603] 5.37 percent of total billed charges 3.5 5.37 Technical (Hospital) Services "CHOLECALCIFEROL (VITAMIN D3) 1,000 (25 MCG) UNIT TAB/CAP" RX-4080010003 CDM 6370000100 HCPCS 250 RC 79854-0050-23 NDC outpatient 1 UN 5.65 5.65 UNITED HEALTHCARE (COMMERCIAL) [3081199] UNITED HEALTHCARE 87726 [308119901] 3.5 percent of total billed charges 3.5 5.37 Technical (Hospital) Services "CHOLECALCIFEROL (VITAMIN D3) 1,000 (25 MCG) UNIT TAB/CAP" RX-4080010003 CDM 6370000100 HCPCS 250 RC 79854-0050-23 NDC outpatient 1 UN 5.65 5.65 HEALTHPARTNERS SX009 HEALTHPARTNERS 4.52 percent of total billed charges 3.5 5.37 Technical (Hospital) Services "CHOLECALCIFEROL (VITAMIN D3) 1,000 (25 MCG) UNIT TAB/CAP" RX-4080010003 CDM 6370000100 HCPCS 250 RC 79854-0050-23 NDC outpatient 1 UN 5.65 5.65 MULTIPLAN INC 34080 [3081285] MULTIPLAN INC [308128501] 5.37 percent of total billed charges 3.5 5.37 Technical (Hospital) Services "CHOLECALCIFEROL (VITAMIN D3) 1,000 (25 MCG) UNIT TAB/CAP" RX-4080010003 CDM 6370000100 HCPCS 250 RC 79854-0050-23 NDC outpatient 1 UN 5.65 5.65 CIGNA 62308 [3081051] CIGNA 62308 [308105105] 4.52 percent of total billed charges 3.5 5.37 Technical (Hospital) Services "CHOLECALCIFEROL (VITAMIN D3) 1,000 (25 MCG) UNIT TAB/CAP" RX-4080010003 CDM 6370000100 HCPCS 250 RC 79854-0050-23 NDC outpatient 1 UN 5.65 5.65 CIGNA 62308 [3081051] CIGNA STATE OF WYOMING [308105107] 4.52 percent of total billed charges 3.5 5.37 Technical (Hospital) Services "CHOLECALCIFEROL (VITAMIN D3) 1,000 (25 MCG) UNIT TAB/CAP" RX-4080010003 CDM 6370000100 HCPCS 250 RC 79854-0050-23 NDC outpatient 1 UN 5.65 5.65 MEDICA (COMMERCIAL) 94265 [3081118] MEDICA CLAIMS [308111801] 5.09 percent of total billed charges 3.5 5.37 Technical (Hospital) Services "CHOLECALCIFEROL (VITAMIN D3) 1,000 (25 MCG) UNIT TAB/CAP" RX-4080010003 CDM 6370000100 HCPCS 250 RC 79854-0050-23 NDC inpatient 1 UN 5.65 5.65 HEALTHPARTNERS SX009 HEALTHPARTNERS 4.47 percent of total billed charges 3.5 5.37 Technical (Hospital) Services "CHOLECALCIFEROL (VITAMIN D3) 1,000 (25 MCG) UNIT TAB/CAP" RX-4080010003 CDM 6370000100 HCPCS 250 RC 79854-0050-23 NDC inpatient 1 UN 5.65 5.65 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES PPO [308136801] 4.47 percent of total billed charges 3.5 5.37 Technical (Hospital) Services "CHOLECALCIFEROL (VITAMIN D3) 1,000 (25 MCG) UNIT TAB/CAP" RX-4080010003 CDM 6370000100 HCPCS 250 RC 79854-0050-23 NDC inpatient 1 UN 5.65 5.65 MEDICA (COMMERCIAL) 94265 [3081118] MEDICA CLAIMS [308111801] 5.09 percent of total billed charges 3.5 5.37 Technical (Hospital) Services "CHOLECALCIFEROL (VITAMIN D3) 1,000 (25 MCG) UNIT TAB/CAP" RX-4080010003 CDM 6370000100 HCPCS 250 RC 79854-0050-23 NDC inpatient 1 UN 5.65 5.65 MULTIPLAN INC 34080 [3081285] MULTIPLAN INC [308128501] 5.37 percent of total billed charges 3.5 5.37 Technical (Hospital) Services "CHOLECALCIFEROL (VITAMIN D3) 1,000 (25 MCG) UNIT TAB/CAP" RX-4080010003 CDM 6370000100 HCPCS 250 RC 79854-0050-23 NDC inpatient 1 UN 5.65 5.65 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES EPO [308136803] 4.47 percent of total billed charges 3.5 5.37 Technical (Hospital) Services "CHOLECALCIFEROL (VITAMIN D3) 1,000 (25 MCG) UNIT TAB/CAP" RX-4080010003 CDM 6370000100 HCPCS 250 RC 79854-0050-23 NDC inpatient 1 UN 5.65 5.65 UNITED HEALTHCARE (COMMERCIAL) [3081199] UNITED HEALTHCARE 87726 [308119901] 3.5 percent of total billed charges 3.5 5.37 Technical (Hospital) Services "CHOLECALCIFEROL (VITAMIN D3) 1,000 (25 MCG) UNIT TAB/CAP" RX-4080010003 CDM 6370000100 HCPCS 250 RC 79854-0050-23 NDC inpatient 1 UN 5.65 5.65 BLUE CROSS BLUE SHIELD WELLMARK SB889 [3081026] BCBS WYOMING [308102603] 5.37 percent of total billed charges 3.5 5.37 Technical (Hospital) Services "CHOLECALCIFEROL (VITAMIN D3) 1,000 (25 MCG) UNIT TAB/CAP" RX-4080010003 CDM 6370000100 HCPCS 250 RC 79854-0050-23 NDC inpatient 1 UN 5.65 5.65 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES HDHP [308136802] 4.47 percent of total billed charges 3.5 5.37 Technical (Hospital) Services "CHOLECALCIFEROL (VITAMIN D3) 1,000 (25 MCG) UNIT TAB/CAP" RX-4080010003 CDM 6370000100 HCPCS 250 RC 79854-0050-23 NDC inpatient 1 UN 5.65 5.65 CIGNA 62308 [3081051] CIGNA 62308 [308105105] 4.47 percent of total billed charges 3.5 5.37 Technical (Hospital) Services "CHOLECALCIFEROL (VITAMIN D3) 1,000 (25 MCG) UNIT TAB/CAP" RX-4080010003 CDM 6370000100 HCPCS 250 RC 79854-0050-23 NDC inpatient 1 UN 5.65 5.65 CIGNA 62308 [3081051] CIGNA STATE OF WYOMING [308105107] 4.47 percent of total billed charges 3.5 5.37 Technical (Hospital) Services CHOLECALCIFEROL (VITAMIN D3) 400 UNIT (10 MCG) TAB/CAP RX-4080010005 CDM 6370000100 HCPCS 250 RC 00904-5823-60 NDC outpatient 1 UN 5.63 5.63 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES EPO [308136803] 4.5 percent of total billed charges 3.49 5.35 Technical (Hospital) Services CHOLECALCIFEROL (VITAMIN D3) 400 UNIT (10 MCG) TAB/CAP RX-4080010005 CDM 6370000100 HCPCS 250 RC 00904-5823-60 NDC outpatient 1 UN 5.63 5.63 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES PPO [308136801] 4.5 percent of total billed charges 3.49 5.35 Technical (Hospital) Services CHOLECALCIFEROL (VITAMIN D3) 400 UNIT (10 MCG) TAB/CAP RX-4080010005 CDM 6370000100 HCPCS 250 RC 00904-5823-60 NDC outpatient 1 UN 5.63 5.63 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES HDHP [308136802] 4.5 percent of total billed charges 3.49 5.35 Technical (Hospital) Services CHOLECALCIFEROL (VITAMIN D3) 400 UNIT (10 MCG) TAB/CAP RX-4080010005 CDM 6370000100 HCPCS 250 RC 00904-5823-60 NDC outpatient 1 UN 5.63 5.63 BLUE CROSS BLUE SHIELD WELLMARK SB889 [3081026] BCBS WYOMING [308102603] 5.35 percent of total billed charges 3.49 5.35 Technical (Hospital) Services CHOLECALCIFEROL (VITAMIN D3) 400 UNIT (10 MCG) TAB/CAP RX-4080010005 CDM 6370000100 HCPCS 250 RC 00904-5823-60 NDC outpatient 1 UN 5.63 5.63 CIGNA 62308 [3081051] CIGNA 62308 [308105105] 4.5 percent of total billed charges 3.49 5.35 Technical (Hospital) Services CHOLECALCIFEROL (VITAMIN D3) 400 UNIT (10 MCG) TAB/CAP RX-4080010005 CDM 6370000100 HCPCS 250 RC 00904-5823-60 NDC outpatient 1 UN 5.63 5.63 CIGNA 62308 [3081051] CIGNA STATE OF WYOMING [308105107] 4.5 percent of total billed charges 3.49 5.35 Technical (Hospital) Services CHOLECALCIFEROL (VITAMIN D3) 400 UNIT (10 MCG) TAB/CAP RX-4080010005 CDM 6370000100 HCPCS 250 RC 00904-5823-60 NDC outpatient 1 UN 5.63 5.63 MULTIPLAN INC 34080 [3081285] MULTIPLAN INC [308128501] 5.35 percent of total billed charges 3.49 5.35 Technical (Hospital) Services CHOLECALCIFEROL (VITAMIN D3) 400 UNIT (10 MCG) TAB/CAP RX-4080010005 CDM 6370000100 HCPCS 250 RC 00904-5823-60 NDC outpatient 1 UN 5.63 5.63 MEDICA (COMMERCIAL) 94265 [3081118] MEDICA CLAIMS [308111801] 5.07 percent of total billed charges 3.49 5.35 Technical (Hospital) Services CHOLECALCIFEROL (VITAMIN D3) 400 UNIT (10 MCG) TAB/CAP RX-4080010005 CDM 6370000100 HCPCS 250 RC 00904-5823-60 NDC outpatient 1 UN 5.63 5.63 HEALTHPARTNERS SX009 HEALTHPARTNERS 4.5 percent of total billed charges 3.49 5.35 Technical (Hospital) Services CHOLECALCIFEROL (VITAMIN D3) 400 UNIT (10 MCG) TAB/CAP RX-4080010005 CDM 6370000100 HCPCS 250 RC 00904-5823-60 NDC outpatient 1 UN 5.63 5.63 UNITED HEALTHCARE (COMMERCIAL) [3081199] UNITED HEALTHCARE 87726 [308119901] 3.49 percent of total billed charges 3.49 5.35 Technical (Hospital) Services CHOLECALCIFEROL (VITAMIN D3) 400 UNIT (10 MCG) TAB/CAP RX-4080010005 CDM 6370000100 HCPCS 250 RC 00904-5823-60 NDC inpatient 1 UN 5.63 5.63 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES HDHP [308136802] 4.46 percent of total billed charges 3.49 5.35 Technical (Hospital) Services CHOLECALCIFEROL (VITAMIN D3) 400 UNIT (10 MCG) TAB/CAP RX-4080010005 CDM 6370000100 HCPCS 250 RC 00904-5823-60 NDC inpatient 1 UN 5.63 5.63 HEALTHPARTNERS SX009 HEALTHPARTNERS 4.46 percent of total billed charges 3.49 5.35 Technical (Hospital) Services CHOLECALCIFEROL (VITAMIN D3) 400 UNIT (10 MCG) TAB/CAP RX-4080010005 CDM 6370000100 HCPCS 250 RC 00904-5823-60 NDC inpatient 1 UN 5.63 5.63 CIGNA 62308 [3081051] CIGNA 62308 [308105105] 4.46 percent of total billed charges 3.49 5.35 Technical (Hospital) Services CHOLECALCIFEROL (VITAMIN D3) 400 UNIT (10 MCG) TAB/CAP RX-4080010005 CDM 6370000100 HCPCS 250 RC 00904-5823-60 NDC inpatient 1 UN 5.63 5.63 CIGNA 62308 [3081051] CIGNA STATE OF WYOMING [308105107] 4.46 percent of total billed charges 3.49 5.35 Technical (Hospital) Services CHOLECALCIFEROL (VITAMIN D3) 400 UNIT (10 MCG) TAB/CAP RX-4080010005 CDM 6370000100 HCPCS 250 RC 00904-5823-60 NDC inpatient 1 UN 5.63 5.63 UNITED HEALTHCARE (COMMERCIAL) [3081199] UNITED HEALTHCARE 87726 [308119901] 3.49 percent of total billed charges 3.49 5.35 Technical (Hospital) Services CHOLECALCIFEROL (VITAMIN D3) 400 UNIT (10 MCG) TAB/CAP RX-4080010005 CDM 6370000100 HCPCS 250 RC 00904-5823-60 NDC inpatient 1 UN 5.63 5.63 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES EPO [308136803] 4.46 percent of total billed charges 3.49 5.35 Technical (Hospital) Services CHOLECALCIFEROL (VITAMIN D3) 400 UNIT (10 MCG) TAB/CAP RX-4080010005 CDM 6370000100 HCPCS 250 RC 00904-5823-60 NDC inpatient 1 UN 5.63 5.63 BLUE CROSS BLUE SHIELD WELLMARK SB889 [3081026] BCBS WYOMING [308102603] 5.35 percent of total billed charges 3.49 5.35 Technical (Hospital) Services CHOLECALCIFEROL (VITAMIN D3) 400 UNIT (10 MCG) TAB/CAP RX-4080010005 CDM 6370000100 HCPCS 250 RC 00904-5823-60 NDC inpatient 1 UN 5.63 5.63 MEDICA (COMMERCIAL) 94265 [3081118] MEDICA CLAIMS [308111801] 5.07 percent of total billed charges 3.49 5.35 Technical (Hospital) Services CHOLECALCIFEROL (VITAMIN D3) 400 UNIT (10 MCG) TAB/CAP RX-4080010005 CDM 6370000100 HCPCS 250 RC 00904-5823-60 NDC inpatient 1 UN 5.63 5.63 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES PPO [308136801] 4.46 percent of total billed charges 3.49 5.35 Technical (Hospital) Services CHOLECALCIFEROL (VITAMIN D3) 400 UNIT (10 MCG) TAB/CAP RX-4080010005 CDM 6370000100 HCPCS 250 RC 00904-5823-60 NDC inpatient 1 UN 5.63 5.63 MULTIPLAN INC 34080 [3081285] MULTIPLAN INC [308128501] 5.35 percent of total billed charges 3.49 5.35 Technical (Hospital) Services LOPERAMIDE 2 MG TAB/CAP RX-4080010107 CDM 6370000100 HCPCS 250 RC 00378-2100-01 NDC outpatient 2 ME 5.99 5.99 MEDICA (COMMERCIAL) 94265 [3081118] MEDICA CLAIMS [308111801] 5.39 percent of total billed charges 3.71 5.69 Technical (Hospital) Services LOPERAMIDE 2 MG TAB/CAP RX-4080010107 CDM 6370000100 HCPCS 250 RC 00378-2100-01 NDC outpatient 2 ME 5.99 5.99 CIGNA 62308 [3081051] CIGNA 62308 [308105105] 4.79 percent of total billed charges 3.71 5.69 Technical (Hospital) Services LOPERAMIDE 2 MG TAB/CAP RX-4080010107 CDM 6370000100 HCPCS 250 RC 00378-2100-01 NDC outpatient 2 ME 5.99 5.99 CIGNA 62308 [3081051] CIGNA STATE OF WYOMING [308105107] 4.79 percent of total billed charges 3.71 5.69 Technical (Hospital) Services LOPERAMIDE 2 MG TAB/CAP RX-4080010107 CDM 6370000100 HCPCS 250 RC 00378-2100-01 NDC outpatient 2 ME 5.99 5.99 MULTIPLAN INC 34080 [3081285] MULTIPLAN INC [308128501] 5.69 percent of total billed charges 3.71 5.69 Technical (Hospital) Services LOPERAMIDE 2 MG TAB/CAP RX-4080010107 CDM 6370000100 HCPCS 250 RC 00378-2100-01 NDC outpatient 2 ME 5.99 5.99 UNITED HEALTHCARE (COMMERCIAL) [3081199] UNITED HEALTHCARE 87726 [308119901] 3.71 percent of total billed charges 3.71 5.69 Technical (Hospital) Services LOPERAMIDE 2 MG TAB/CAP RX-4080010107 CDM 6370000100 HCPCS 250 RC 00378-2100-01 NDC outpatient 2 ME 5.99 5.99 HEALTHPARTNERS SX009 HEALTHPARTNERS 4.79 percent of total billed charges 3.71 5.69 Technical (Hospital) Services LOPERAMIDE 2 MG TAB/CAP RX-4080010107 CDM 6370000100 HCPCS 250 RC 00378-2100-01 NDC outpatient 2 ME 5.99 5.99 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES PPO [308136801] 4.79 percent of total billed charges 3.71 5.69 Technical (Hospital) Services LOPERAMIDE 2 MG TAB/CAP RX-4080010107 CDM 6370000100 HCPCS 250 RC 00378-2100-01 NDC outpatient 2 ME 5.99 5.99 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES HDHP [308136802] 4.79 percent of total billed charges 3.71 5.69 Technical (Hospital) Services LOPERAMIDE 2 MG TAB/CAP RX-4080010107 CDM 6370000100 HCPCS 250 RC 00378-2100-01 NDC outpatient 2 ME 5.99 5.99 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES EPO [308136803] 4.79 percent of total billed charges 3.71 5.69 Technical (Hospital) Services LOPERAMIDE 2 MG TAB/CAP RX-4080010107 CDM 6370000100 HCPCS 250 RC 00378-2100-01 NDC outpatient 2 ME 5.99 5.99 BLUE CROSS BLUE SHIELD WELLMARK SB889 [3081026] BCBS WYOMING [308102603] 5.69 percent of total billed charges 3.71 5.69 Technical (Hospital) Services LOPERAMIDE 2 MG TAB/CAP RX-4080010107 CDM 6370000100 HCPCS 250 RC 00378-2100-01 NDC inpatient 2 ME 5.99 5.99 MEDICA (COMMERCIAL) 94265 [3081118] MEDICA CLAIMS [308111801] 5.39 percent of total billed charges 3.71 5.69 Technical (Hospital) Services LOPERAMIDE 2 MG TAB/CAP RX-4080010107 CDM 6370000100 HCPCS 250 RC 00378-2100-01 NDC inpatient 2 ME 5.99 5.99 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES PPO [308136801] 4.74 percent of total billed charges 3.71 5.69 Technical (Hospital) Services LOPERAMIDE 2 MG TAB/CAP RX-4080010107 CDM 6370000100 HCPCS 250 RC 00378-2100-01 NDC inpatient 2 ME 5.99 5.99 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES EPO [308136803] 4.74 percent of total billed charges 3.71 5.69 Technical (Hospital) Services LOPERAMIDE 2 MG TAB/CAP RX-4080010107 CDM 6370000100 HCPCS 250 RC 00378-2100-01 NDC inpatient 2 ME 5.99 5.99 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES HDHP [308136802] 4.74 percent of total billed charges 3.71 5.69 Technical (Hospital) Services LOPERAMIDE 2 MG TAB/CAP RX-4080010107 CDM 6370000100 HCPCS 250 RC 00378-2100-01 NDC inpatient 2 ME 5.99 5.99 HEALTHPARTNERS SX009 HEALTHPARTNERS 4.74 percent of total billed charges 3.71 5.69 Technical (Hospital) Services LOPERAMIDE 2 MG TAB/CAP RX-4080010107 CDM 6370000100 HCPCS 250 RC 00378-2100-01 NDC inpatient 2 ME 5.99 5.99 BLUE CROSS BLUE SHIELD WELLMARK SB889 [3081026] BCBS WYOMING [308102603] 5.69 percent of total billed charges 3.71 5.69 Technical (Hospital) Services LOPERAMIDE 2 MG TAB/CAP RX-4080010107 CDM 6370000100 HCPCS 250 RC 00378-2100-01 NDC inpatient 2 ME 5.99 5.99 UNITED HEALTHCARE (COMMERCIAL) [3081199] UNITED HEALTHCARE 87726 [308119901] 3.71 percent of total billed charges 3.71 5.69 Technical (Hospital) Services LOPERAMIDE 2 MG TAB/CAP RX-4080010107 CDM 6370000100 HCPCS 250 RC 00378-2100-01 NDC inpatient 2 ME 5.99 5.99 CIGNA 62308 [3081051] CIGNA 62308 [308105105] 4.74 percent of total billed charges 3.71 5.69 Technical (Hospital) Services LOPERAMIDE 2 MG TAB/CAP RX-4080010107 CDM 6370000100 HCPCS 250 RC 00378-2100-01 NDC inpatient 2 ME 5.99 5.99 CIGNA 62308 [3081051] CIGNA STATE OF WYOMING [308105107] 4.74 percent of total billed charges 3.71 5.69 Technical (Hospital) Services LOPERAMIDE 2 MG TAB/CAP RX-4080010107 CDM 6370000100 HCPCS 250 RC 00378-2100-01 NDC inpatient 2 ME 5.99 5.99 MULTIPLAN INC 34080 [3081285] MULTIPLAN INC [308128501] 5.69 percent of total billed charges 3.71 5.69 Technical (Hospital) Services LACTOBACILLUS CAPSULE WRAPPER RX-4080010179 CDM 6370000100 HCPCS 250 RC 49100-0381-64 NDC outpatient 1 UN 6.13 6.13 BLUE CROSS BLUE SHIELD WELLMARK SB889 [3081026] BCBS WYOMING [308102603] 5.82 percent of total billed charges 3.8 5.82 Technical (Hospital) Services LACTOBACILLUS CAPSULE WRAPPER RX-4080010179 CDM 6370000100 HCPCS 250 RC 49100-0381-64 NDC outpatient 1 UN 6.13 6.13 HEALTHPARTNERS SX009 HEALTHPARTNERS 4.9 percent of total billed charges 3.8 5.82 Technical (Hospital) Services LACTOBACILLUS CAPSULE WRAPPER RX-4080010179 CDM 6370000100 HCPCS 250 RC 49100-0381-64 NDC outpatient 1 UN 6.13 6.13 MEDICA (COMMERCIAL) 94265 [3081118] MEDICA CLAIMS [308111801] 5.52 percent of total billed charges 3.8 5.82 Technical (Hospital) Services LACTOBACILLUS CAPSULE WRAPPER RX-4080010179 CDM 6370000100 HCPCS 250 RC 49100-0381-64 NDC outpatient 1 UN 6.13 6.13 CIGNA 62308 [3081051] CIGNA 62308 [308105105] 4.9 percent of total billed charges 3.8 5.82 Technical (Hospital) Services LACTOBACILLUS CAPSULE WRAPPER RX-4080010179 CDM 6370000100 HCPCS 250 RC 49100-0381-64 NDC outpatient 1 UN 6.13 6.13 CIGNA 62308 [3081051] CIGNA STATE OF WYOMING [308105107] 4.9 percent of total billed charges 3.8 5.82 Technical (Hospital) Services LACTOBACILLUS CAPSULE WRAPPER RX-4080010179 CDM 6370000100 HCPCS 250 RC 49100-0381-64 NDC outpatient 1 UN 6.13 6.13 MULTIPLAN INC 34080 [3081285] MULTIPLAN INC [308128501] 5.82 percent of total billed charges 3.8 5.82 Technical (Hospital) Services LACTOBACILLUS CAPSULE WRAPPER RX-4080010179 CDM 6370000100 HCPCS 250 RC 49100-0381-64 NDC outpatient 1 UN 6.13 6.13 UNITED HEALTHCARE (COMMERCIAL) [3081199] UNITED HEALTHCARE 87726 [308119901] 3.8 percent of total billed charges 3.8 5.82 Technical (Hospital) Services LACTOBACILLUS CAPSULE WRAPPER RX-4080010179 CDM 6370000100 HCPCS 250 RC 49100-0381-64 NDC outpatient 1 UN 6.13 6.13 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES PPO [308136801] 4.9 percent of total billed charges 3.8 5.82 Technical (Hospital) Services LACTOBACILLUS CAPSULE WRAPPER RX-4080010179 CDM 6370000100 HCPCS 250 RC 49100-0381-64 NDC outpatient 1 UN 6.13 6.13 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES HDHP [308136802] 4.9 percent of total billed charges 3.8 5.82 Technical (Hospital) Services LACTOBACILLUS CAPSULE WRAPPER RX-4080010179 CDM 6370000100 HCPCS 250 RC 49100-0381-64 NDC outpatient 1 UN 6.13 6.13 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES EPO [308136803] 4.9 percent of total billed charges 3.8 5.82 Technical (Hospital) Services LACTOBACILLUS CAPSULE WRAPPER RX-4080010179 CDM 6370000100 HCPCS 250 RC 49100-0381-64 NDC inpatient 1 UN 6.13 6.13 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES EPO [308136803] 4.85 percent of total billed charges 3.8 5.82 Technical (Hospital) Services LACTOBACILLUS CAPSULE WRAPPER RX-4080010179 CDM 6370000100 HCPCS 250 RC 49100-0381-64 NDC inpatient 1 UN 6.13 6.13 UNITED HEALTHCARE (COMMERCIAL) [3081199] UNITED HEALTHCARE 87726 [308119901] 3.8 percent of total billed charges 3.8 5.82 Technical (Hospital) Services LACTOBACILLUS CAPSULE WRAPPER RX-4080010179 CDM 6370000100 HCPCS 250 RC 49100-0381-64 NDC inpatient 1 UN 6.13 6.13 BLUE CROSS BLUE SHIELD WELLMARK SB889 [3081026] BCBS WYOMING [308102603] 5.82 percent of total billed charges 3.8 5.82 Technical (Hospital) Services LACTOBACILLUS CAPSULE WRAPPER RX-4080010179 CDM 6370000100 HCPCS 250 RC 49100-0381-64 NDC inpatient 1 UN 6.13 6.13 CIGNA 62308 [3081051] CIGNA 62308 [308105105] 4.85 percent of total billed charges 3.8 5.82 Technical (Hospital) Services LACTOBACILLUS CAPSULE WRAPPER RX-4080010179 CDM 6370000100 HCPCS 250 RC 49100-0381-64 NDC inpatient 1 UN 6.13 6.13 CIGNA 62308 [3081051] CIGNA STATE OF WYOMING [308105107] 4.85 percent of total billed charges 3.8 5.82 Technical (Hospital) Services LACTOBACILLUS CAPSULE WRAPPER RX-4080010179 CDM 6370000100 HCPCS 250 RC 49100-0381-64 NDC inpatient 1 UN 6.13 6.13 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES HDHP [308136802] 4.85 percent of total billed charges 3.8 5.82 Technical (Hospital) Services LACTOBACILLUS CAPSULE WRAPPER RX-4080010179 CDM 6370000100 HCPCS 250 RC 49100-0381-64 NDC inpatient 1 UN 6.13 6.13 MULTIPLAN INC 34080 [3081285] MULTIPLAN INC [308128501] 5.82 percent of total billed charges 3.8 5.82 Technical (Hospital) Services LACTOBACILLUS CAPSULE WRAPPER RX-4080010179 CDM 6370000100 HCPCS 250 RC 49100-0381-64 NDC inpatient 1 UN 6.13 6.13 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES PPO [308136801] 4.85 percent of total billed charges 3.8 5.82 Technical (Hospital) Services LACTOBACILLUS CAPSULE WRAPPER RX-4080010179 CDM 6370000100 HCPCS 250 RC 49100-0381-64 NDC inpatient 1 UN 6.13 6.13 MEDICA (COMMERCIAL) 94265 [3081118] MEDICA CLAIMS [308111801] 5.52 percent of total billed charges 3.8 5.82 Technical (Hospital) Services LACTOBACILLUS CAPSULE WRAPPER RX-4080010179 CDM 6370000100 HCPCS 250 RC 49100-0381-64 NDC inpatient 1 UN 6.13 6.13 HEALTHPARTNERS SX009 HEALTHPARTNERS 4.85 percent of total billed charges 3.8 5.82 Technical (Hospital) Services WCH ED AMOXICILLIN 875 MG-POTASSIUM CLAVULANATE 125 MG TABLET #3 RX-4080030054 CDM 6370000100 HCPCS 250 RC 09999-3077-01 NDC inpatient 2625 ME 28.9 28.9 CIGNA 62308 [3081051] CIGNA 62308 [308105105] 22.88 percent of total billed charges 17.92 27.46 Technical (Hospital) Services WCH ED AMOXICILLIN 875 MG-POTASSIUM CLAVULANATE 125 MG TABLET #3 RX-4080030054 CDM 6370000100 HCPCS 250 RC 09999-3077-01 NDC inpatient 2625 ME 28.9 28.9 CIGNA 62308 [3081051] CIGNA STATE OF WYOMING [308105107] 22.88 percent of total billed charges 17.92 27.46 Technical (Hospital) Services WCH ED AMOXICILLIN 875 MG-POTASSIUM CLAVULANATE 125 MG TABLET #3 RX-4080030054 CDM 6370000100 HCPCS 250 RC 09999-3077-01 NDC inpatient 2625 ME 28.9 28.9 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES EPO [308136803] 22.88 percent of total billed charges 17.92 27.46 Technical (Hospital) Services WCH ED AMOXICILLIN 875 MG-POTASSIUM CLAVULANATE 125 MG TABLET #3 RX-4080030054 CDM 6370000100 HCPCS 250 RC 09999-3077-01 NDC inpatient 2625 ME 28.9 28.9 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES HDHP [308136802] 22.88 percent of total billed charges 17.92 27.46 Technical (Hospital) Services WCH ED AMOXICILLIN 875 MG-POTASSIUM CLAVULANATE 125 MG TABLET #3 RX-4080030054 CDM 6370000100 HCPCS 250 RC 09999-3077-01 NDC inpatient 2625 ME 28.9 28.9 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES PPO [308136801] 22.88 percent of total billed charges 17.92 27.46 Technical (Hospital) Services WCH ED AMOXICILLIN 875 MG-POTASSIUM CLAVULANATE 125 MG TABLET #3 RX-4080030054 CDM 6370000100 HCPCS 250 RC 09999-3077-01 NDC inpatient 2625 ME 28.9 28.9 BLUE CROSS BLUE SHIELD WELLMARK SB889 [3081026] BCBS WYOMING [308102603] 27.46 percent of total billed charges 17.92 27.46 Technical (Hospital) Services WCH ED AMOXICILLIN 875 MG-POTASSIUM CLAVULANATE 125 MG TABLET #3 RX-4080030054 CDM 6370000100 HCPCS 250 RC 09999-3077-01 NDC inpatient 2625 ME 28.9 28.9 UNITED HEALTHCARE (COMMERCIAL) [3081199] UNITED HEALTHCARE 87726 [308119901] 17.92 percent of total billed charges 17.92 27.46 Technical (Hospital) Services WCH ED AMOXICILLIN 875 MG-POTASSIUM CLAVULANATE 125 MG TABLET #3 RX-4080030054 CDM 6370000100 HCPCS 250 RC 09999-3077-01 NDC inpatient 2625 ME 28.9 28.9 MULTIPLAN INC 34080 [3081285] MULTIPLAN INC [308128501] 27.46 percent of total billed charges 17.92 27.46 Technical (Hospital) Services WCH ED AMOXICILLIN 875 MG-POTASSIUM CLAVULANATE 125 MG TABLET #3 RX-4080030054 CDM 6370000100 HCPCS 250 RC 09999-3077-01 NDC inpatient 2625 ME 28.9 28.9 MEDICA (COMMERCIAL) 94265 [3081118] MEDICA CLAIMS [308111801] 26.01 percent of total billed charges 17.92 27.46 Technical (Hospital) Services WCH ED AMOXICILLIN 875 MG-POTASSIUM CLAVULANATE 125 MG TABLET #3 RX-4080030054 CDM 6370000100 HCPCS 250 RC 09999-3077-01 NDC inpatient 2625 ME 28.9 28.9 HEALTHPARTNERS SX009 HEALTHPARTNERS 22.88 percent of total billed charges 17.92 27.46 Technical (Hospital) Services WCH ED AMOXICILLIN 875 MG-POTASSIUM CLAVULANATE 125 MG TABLET #3 RX-4080030054 CDM 6370000100 HCPCS 250 RC 09999-3077-01 NDC outpatient 2625 ME 28.9 28.9 UNITED HEALTHCARE (COMMERCIAL) [3081199] UNITED HEALTHCARE 87726 [308119901] 17.92 percent of total billed charges 17.92 27.46 Technical (Hospital) Services WCH ED AMOXICILLIN 875 MG-POTASSIUM CLAVULANATE 125 MG TABLET #3 RX-4080030054 CDM 6370000100 HCPCS 250 RC 09999-3077-01 NDC outpatient 2625 ME 28.9 28.9 BLUE CROSS BLUE SHIELD WELLMARK SB889 [3081026] BCBS WYOMING [308102603] 27.46 percent of total billed charges 17.92 27.46 Technical (Hospital) Services WCH ED AMOXICILLIN 875 MG-POTASSIUM CLAVULANATE 125 MG TABLET #3 RX-4080030054 CDM 6370000100 HCPCS 250 RC 09999-3077-01 NDC outpatient 2625 ME 28.9 28.9 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES EPO [308136803] 23.12 percent of total billed charges 17.92 27.46 Technical (Hospital) Services WCH ED AMOXICILLIN 875 MG-POTASSIUM CLAVULANATE 125 MG TABLET #3 RX-4080030054 CDM 6370000100 HCPCS 250 RC 09999-3077-01 NDC outpatient 2625 ME 28.9 28.9 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES HDHP [308136802] 23.12 percent of total billed charges 17.92 27.46 Technical (Hospital) Services WCH ED AMOXICILLIN 875 MG-POTASSIUM CLAVULANATE 125 MG TABLET #3 RX-4080030054 CDM 6370000100 HCPCS 250 RC 09999-3077-01 NDC outpatient 2625 ME 28.9 28.9 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES PPO [308136801] 23.12 percent of total billed charges 17.92 27.46 Technical (Hospital) Services WCH ED AMOXICILLIN 875 MG-POTASSIUM CLAVULANATE 125 MG TABLET #3 RX-4080030054 CDM 6370000100 HCPCS 250 RC 09999-3077-01 NDC outpatient 2625 ME 28.9 28.9 MEDICA (COMMERCIAL) 94265 [3081118] MEDICA CLAIMS [308111801] 26.01 percent of total billed charges 17.92 27.46 Technical (Hospital) Services WCH ED AMOXICILLIN 875 MG-POTASSIUM CLAVULANATE 125 MG TABLET #3 RX-4080030054 CDM 6370000100 HCPCS 250 RC 09999-3077-01 NDC outpatient 2625 ME 28.9 28.9 MULTIPLAN INC 34080 [3081285] MULTIPLAN INC [308128501] 27.46 percent of total billed charges 17.92 27.46 Technical (Hospital) Services WCH ED AMOXICILLIN 875 MG-POTASSIUM CLAVULANATE 125 MG TABLET #3 RX-4080030054 CDM 6370000100 HCPCS 250 RC 09999-3077-01 NDC outpatient 2625 ME 28.9 28.9 HEALTHPARTNERS SX009 HEALTHPARTNERS 23.12 percent of total billed charges 17.92 27.46 Technical (Hospital) Services WCH ED AMOXICILLIN 875 MG-POTASSIUM CLAVULANATE 125 MG TABLET #3 RX-4080030054 CDM 6370000100 HCPCS 250 RC 09999-3077-01 NDC outpatient 2625 ME 28.9 28.9 CIGNA 62308 [3081051] CIGNA 62308 [308105105] 23.12 percent of total billed charges 17.92 27.46 Technical (Hospital) Services WCH ED AMOXICILLIN 875 MG-POTASSIUM CLAVULANATE 125 MG TABLET #3 RX-4080030054 CDM 6370000100 HCPCS 250 RC 09999-3077-01 NDC outpatient 2625 ME 28.9 28.9 CIGNA 62308 [3081051] CIGNA STATE OF WYOMING [308105107] 23.12 percent of total billed charges 17.92 27.46 Technical (Hospital) Services WCH ED AMOXICILLIN 400 MG-POTASSIUM CLAVULANATE 57 MG/5 ML ORAL SUSP #100ML RX-4080030055 CDM 6370000100 HCPCS 250 RC 09999-3078-01 NDC inpatient 100 ML 28.35 28.35 CIGNA 62308 [3081051] CIGNA 62308 [308105105] 22.45 percent of total billed charges 17.58 26.93 Technical (Hospital) Services WCH ED AMOXICILLIN 400 MG-POTASSIUM CLAVULANATE 57 MG/5 ML ORAL SUSP #100ML RX-4080030055 CDM 6370000100 HCPCS 250 RC 09999-3078-01 NDC inpatient 100 ML 28.35 28.35 CIGNA 62308 [3081051] CIGNA STATE OF WYOMING [308105107] 22.45 percent of total billed charges 17.58 26.93 Technical (Hospital) Services WCH ED AMOXICILLIN 400 MG-POTASSIUM CLAVULANATE 57 MG/5 ML ORAL SUSP #100ML RX-4080030055 CDM 6370000100 HCPCS 250 RC 09999-3078-01 NDC inpatient 100 ML 28.35 28.35 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES EPO [308136803] 22.45 percent of total billed charges 17.58 26.93 Technical (Hospital) Services WCH ED AMOXICILLIN 400 MG-POTASSIUM CLAVULANATE 57 MG/5 ML ORAL SUSP #100ML RX-4080030055 CDM 6370000100 HCPCS 250 RC 09999-3078-01 NDC inpatient 100 ML 28.35 28.35 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES HDHP [308136802] 22.45 percent of total billed charges 17.58 26.93 Technical (Hospital) Services WCH ED AMOXICILLIN 400 MG-POTASSIUM CLAVULANATE 57 MG/5 ML ORAL SUSP #100ML RX-4080030055 CDM 6370000100 HCPCS 250 RC 09999-3078-01 NDC inpatient 100 ML 28.35 28.35 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES PPO [308136801] 22.45 percent of total billed charges 17.58 26.93 Technical (Hospital) Services WCH ED AMOXICILLIN 400 MG-POTASSIUM CLAVULANATE 57 MG/5 ML ORAL SUSP #100ML RX-4080030055 CDM 6370000100 HCPCS 250 RC 09999-3078-01 NDC inpatient 100 ML 28.35 28.35 HEALTHPARTNERS SX009 HEALTHPARTNERS 22.45 percent of total billed charges 17.58 26.93 Technical (Hospital) Services WCH ED AMOXICILLIN 400 MG-POTASSIUM CLAVULANATE 57 MG/5 ML ORAL SUSP #100ML RX-4080030055 CDM 6370000100 HCPCS 250 RC 09999-3078-01 NDC inpatient 100 ML 28.35 28.35 MULTIPLAN INC 34080 [3081285] MULTIPLAN INC [308128501] 26.93 percent of total billed charges 17.58 26.93 Technical (Hospital) Services WCH ED AMOXICILLIN 400 MG-POTASSIUM CLAVULANATE 57 MG/5 ML ORAL SUSP #100ML RX-4080030055 CDM 6370000100 HCPCS 250 RC 09999-3078-01 NDC inpatient 100 ML 28.35 28.35 MEDICA (COMMERCIAL) 94265 [3081118] MEDICA CLAIMS [308111801] 25.52 percent of total billed charges 17.58 26.93 Technical (Hospital) Services WCH ED AMOXICILLIN 400 MG-POTASSIUM CLAVULANATE 57 MG/5 ML ORAL SUSP #100ML RX-4080030055 CDM 6370000100 HCPCS 250 RC 09999-3078-01 NDC inpatient 100 ML 28.35 28.35 UNITED HEALTHCARE (COMMERCIAL) [3081199] UNITED HEALTHCARE 87726 [308119901] 17.58 percent of total billed charges 17.58 26.93 Technical (Hospital) Services WCH ED AMOXICILLIN 400 MG-POTASSIUM CLAVULANATE 57 MG/5 ML ORAL SUSP #100ML RX-4080030055 CDM 6370000100 HCPCS 250 RC 09999-3078-01 NDC inpatient 100 ML 28.35 28.35 BLUE CROSS BLUE SHIELD WELLMARK SB889 [3081026] BCBS WYOMING [308102603] 26.93 percent of total billed charges 17.58 26.93 Technical (Hospital) Services WCH ED AMOXICILLIN 400 MG-POTASSIUM CLAVULANATE 57 MG/5 ML ORAL SUSP #100ML RX-4080030055 CDM 6370000100 HCPCS 250 RC 09999-3078-01 NDC outpatient 100 ML 28.35 28.35 BLUE CROSS BLUE SHIELD WELLMARK SB889 [3081026] BCBS WYOMING [308102603] 26.93 percent of total billed charges 17.58 26.93 Technical (Hospital) Services WCH ED AMOXICILLIN 400 MG-POTASSIUM CLAVULANATE 57 MG/5 ML ORAL SUSP #100ML RX-4080030055 CDM 6370000100 HCPCS 250 RC 09999-3078-01 NDC outpatient 100 ML 28.35 28.35 HEALTHPARTNERS SX009 HEALTHPARTNERS 22.68 percent of total billed charges 17.58 26.93 Technical (Hospital) Services WCH ED AMOXICILLIN 400 MG-POTASSIUM CLAVULANATE 57 MG/5 ML ORAL SUSP #100ML RX-4080030055 CDM 6370000100 HCPCS 250 RC 09999-3078-01 NDC outpatient 100 ML 28.35 28.35 UNITED HEALTHCARE (COMMERCIAL) [3081199] UNITED HEALTHCARE 87726 [308119901] 17.58 percent of total billed charges 17.58 26.93 Technical (Hospital) Services WCH ED AMOXICILLIN 400 MG-POTASSIUM CLAVULANATE 57 MG/5 ML ORAL SUSP #100ML RX-4080030055 CDM 6370000100 HCPCS 250 RC 09999-3078-01 NDC outpatient 100 ML 28.35 28.35 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES PPO [308136801] 22.68 percent of total billed charges 17.58 26.93 Technical (Hospital) Services WCH ED AMOXICILLIN 400 MG-POTASSIUM CLAVULANATE 57 MG/5 ML ORAL SUSP #100ML RX-4080030055 CDM 6370000100 HCPCS 250 RC 09999-3078-01 NDC outpatient 100 ML 28.35 28.35 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES HDHP [308136802] 22.68 percent of total billed charges 17.58 26.93 Technical (Hospital) Services WCH ED AMOXICILLIN 400 MG-POTASSIUM CLAVULANATE 57 MG/5 ML ORAL SUSP #100ML RX-4080030055 CDM 6370000100 HCPCS 250 RC 09999-3078-01 NDC outpatient 100 ML 28.35 28.35 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES EPO [308136803] 22.68 percent of total billed charges 17.58 26.93 Technical (Hospital) Services WCH ED AMOXICILLIN 400 MG-POTASSIUM CLAVULANATE 57 MG/5 ML ORAL SUSP #100ML RX-4080030055 CDM 6370000100 HCPCS 250 RC 09999-3078-01 NDC outpatient 100 ML 28.35 28.35 MEDICA (COMMERCIAL) 94265 [3081118] MEDICA CLAIMS [308111801] 25.52 percent of total billed charges 17.58 26.93 Technical (Hospital) Services WCH ED AMOXICILLIN 400 MG-POTASSIUM CLAVULANATE 57 MG/5 ML ORAL SUSP #100ML RX-4080030055 CDM 6370000100 HCPCS 250 RC 09999-3078-01 NDC outpatient 100 ML 28.35 28.35 MULTIPLAN INC 34080 [3081285] MULTIPLAN INC [308128501] 26.93 percent of total billed charges 17.58 26.93 Technical (Hospital) Services WCH ED AMOXICILLIN 400 MG-POTASSIUM CLAVULANATE 57 MG/5 ML ORAL SUSP #100ML RX-4080030055 CDM 6370000100 HCPCS 250 RC 09999-3078-01 NDC outpatient 100 ML 28.35 28.35 CIGNA 62308 [3081051] CIGNA 62308 [308105105] 22.68 percent of total billed charges 17.58 26.93 Technical (Hospital) Services WCH ED AMOXICILLIN 400 MG-POTASSIUM CLAVULANATE 57 MG/5 ML ORAL SUSP #100ML RX-4080030055 CDM 6370000100 HCPCS 250 RC 09999-3078-01 NDC outpatient 100 ML 28.35 28.35 CIGNA 62308 [3081051] CIGNA STATE OF WYOMING [308105107] 22.68 percent of total billed charges 17.58 26.93 Technical (Hospital) Services WCH ED HYDROCODONE 7.5 MG-ACETAMINOPHEN 325 MG/15 ML ORAL SOLN #120ML RX-4080030056 CDM 6370000100 HCPCS 250 RC 09999-3079-01 NDC outpatient 120 ML 25.87 25.87 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES EPO [308136803] 20.7 percent of total billed charges 16.04 24.58 Technical (Hospital) Services WCH ED HYDROCODONE 7.5 MG-ACETAMINOPHEN 325 MG/15 ML ORAL SOLN #120ML RX-4080030056 CDM 6370000100 HCPCS 250 RC 09999-3079-01 NDC outpatient 120 ML 25.87 25.87 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES PPO [308136801] 20.7 percent of total billed charges 16.04 24.58 Technical (Hospital) Services WCH ED HYDROCODONE 7.5 MG-ACETAMINOPHEN 325 MG/15 ML ORAL SOLN #120ML RX-4080030056 CDM 6370000100 HCPCS 250 RC 09999-3079-01 NDC outpatient 120 ML 25.87 25.87 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES HDHP [308136802] 20.7 percent of total billed charges 16.04 24.58 Technical (Hospital) Services WCH ED HYDROCODONE 7.5 MG-ACETAMINOPHEN 325 MG/15 ML ORAL SOLN #120ML RX-4080030056 CDM 6370000100 HCPCS 250 RC 09999-3079-01 NDC outpatient 120 ML 25.87 25.87 BLUE CROSS BLUE SHIELD WELLMARK SB889 [3081026] BCBS WYOMING [308102603] 24.58 percent of total billed charges 16.04 24.58 Technical (Hospital) Services WCH ED HYDROCODONE 7.5 MG-ACETAMINOPHEN 325 MG/15 ML ORAL SOLN #120ML RX-4080030056 CDM 6370000100 HCPCS 250 RC 09999-3079-01 NDC outpatient 120 ML 25.87 25.87 UNITED HEALTHCARE (COMMERCIAL) [3081199] UNITED HEALTHCARE 87726 [308119901] 16.04 percent of total billed charges 16.04 24.58 Technical (Hospital) Services WCH ED HYDROCODONE 7.5 MG-ACETAMINOPHEN 325 MG/15 ML ORAL SOLN #120ML RX-4080030056 CDM 6370000100 HCPCS 250 RC 09999-3079-01 NDC outpatient 120 ML 25.87 25.87 HEALTHPARTNERS SX009 HEALTHPARTNERS 20.7 percent of total billed charges 16.04 24.58 Technical (Hospital) Services WCH ED HYDROCODONE 7.5 MG-ACETAMINOPHEN 325 MG/15 ML ORAL SOLN #120ML RX-4080030056 CDM 6370000100 HCPCS 250 RC 09999-3079-01 NDC outpatient 120 ML 25.87 25.87 MULTIPLAN INC 34080 [3081285] MULTIPLAN INC [308128501] 24.58 percent of total billed charges 16.04 24.58 Technical (Hospital) Services WCH ED HYDROCODONE 7.5 MG-ACETAMINOPHEN 325 MG/15 ML ORAL SOLN #120ML RX-4080030056 CDM 6370000100 HCPCS 250 RC 09999-3079-01 NDC outpatient 120 ML 25.87 25.87 MEDICA (COMMERCIAL) 94265 [3081118] MEDICA CLAIMS [308111801] 23.28 percent of total billed charges 16.04 24.58 Technical (Hospital) Services WCH ED HYDROCODONE 7.5 MG-ACETAMINOPHEN 325 MG/15 ML ORAL SOLN #120ML RX-4080030056 CDM 6370000100 HCPCS 250 RC 09999-3079-01 NDC outpatient 120 ML 25.87 25.87 CIGNA 62308 [3081051] CIGNA 62308 [308105105] 20.7 percent of total billed charges 16.04 24.58 Technical (Hospital) Services WCH ED HYDROCODONE 7.5 MG-ACETAMINOPHEN 325 MG/15 ML ORAL SOLN #120ML RX-4080030056 CDM 6370000100 HCPCS 250 RC 09999-3079-01 NDC outpatient 120 ML 25.87 25.87 CIGNA 62308 [3081051] CIGNA STATE OF WYOMING [308105107] 20.7 percent of total billed charges 16.04 24.58 Technical (Hospital) Services WCH ED HYDROCODONE 7.5 MG-ACETAMINOPHEN 325 MG/15 ML ORAL SOLN #120ML RX-4080030056 CDM 6370000100 HCPCS 250 RC 09999-3079-01 NDC inpatient 120 ML 25.87 25.87 CIGNA 62308 [3081051] CIGNA 62308 [308105105] 20.48 percent of total billed charges 16.04 24.58 Technical (Hospital) Services WCH ED HYDROCODONE 7.5 MG-ACETAMINOPHEN 325 MG/15 ML ORAL SOLN #120ML RX-4080030056 CDM 6370000100 HCPCS 250 RC 09999-3079-01 NDC inpatient 120 ML 25.87 25.87 CIGNA 62308 [3081051] CIGNA STATE OF WYOMING [308105107] 20.48 percent of total billed charges 16.04 24.58 Technical (Hospital) Services WCH ED HYDROCODONE 7.5 MG-ACETAMINOPHEN 325 MG/15 ML ORAL SOLN #120ML RX-4080030056 CDM 6370000100 HCPCS 250 RC 09999-3079-01 NDC inpatient 120 ML 25.87 25.87 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES EPO [308136803] 20.48 percent of total billed charges 16.04 24.58 Technical (Hospital) Services WCH ED HYDROCODONE 7.5 MG-ACETAMINOPHEN 325 MG/15 ML ORAL SOLN #120ML RX-4080030056 CDM 6370000100 HCPCS 250 RC 09999-3079-01 NDC inpatient 120 ML 25.87 25.87 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES HDHP [308136802] 20.48 percent of total billed charges 16.04 24.58 Technical (Hospital) Services WCH ED HYDROCODONE 7.5 MG-ACETAMINOPHEN 325 MG/15 ML ORAL SOLN #120ML RX-4080030056 CDM 6370000100 HCPCS 250 RC 09999-3079-01 NDC inpatient 120 ML 25.87 25.87 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES PPO [308136801] 20.48 percent of total billed charges 16.04 24.58 Technical (Hospital) Services WCH ED HYDROCODONE 7.5 MG-ACETAMINOPHEN 325 MG/15 ML ORAL SOLN #120ML RX-4080030056 CDM 6370000100 HCPCS 250 RC 09999-3079-01 NDC inpatient 120 ML 25.87 25.87 MEDICA (COMMERCIAL) 94265 [3081118] MEDICA CLAIMS [308111801] 23.28 percent of total billed charges 16.04 24.58 Technical (Hospital) Services WCH ED HYDROCODONE 7.5 MG-ACETAMINOPHEN 325 MG/15 ML ORAL SOLN #120ML RX-4080030056 CDM 6370000100 HCPCS 250 RC 09999-3079-01 NDC inpatient 120 ML 25.87 25.87 MULTIPLAN INC 34080 [3081285] MULTIPLAN INC [308128501] 24.58 percent of total billed charges 16.04 24.58 Technical (Hospital) Services WCH ED HYDROCODONE 7.5 MG-ACETAMINOPHEN 325 MG/15 ML ORAL SOLN #120ML RX-4080030056 CDM 6370000100 HCPCS 250 RC 09999-3079-01 NDC inpatient 120 ML 25.87 25.87 HEALTHPARTNERS SX009 HEALTHPARTNERS 20.48 percent of total billed charges 16.04 24.58 Technical (Hospital) Services WCH ED HYDROCODONE 7.5 MG-ACETAMINOPHEN 325 MG/15 ML ORAL SOLN #120ML RX-4080030056 CDM 6370000100 HCPCS 250 RC 09999-3079-01 NDC inpatient 120 ML 25.87 25.87 UNITED HEALTHCARE (COMMERCIAL) [3081199] UNITED HEALTHCARE 87726 [308119901] 16.04 percent of total billed charges 16.04 24.58 Technical (Hospital) Services WCH ED HYDROCODONE 7.5 MG-ACETAMINOPHEN 325 MG/15 ML ORAL SOLN #120ML RX-4080030056 CDM 6370000100 HCPCS 250 RC 09999-3079-01 NDC inpatient 120 ML 25.87 25.87 BLUE CROSS BLUE SHIELD WELLMARK SB889 [3081026] BCBS WYOMING [308102603] 24.58 percent of total billed charges 16.04 24.58 Technical (Hospital) Services WCH ED HYDROCODONE 10 MG-CHLORPHENIRAMINE 8 MG/5 ML ORAL SUSP #115ML RX-4080030057 CDM 6370000100 HCPCS 250 RC 09999-3080-01 NDC inpatient 115 ML 70.22 70.22 MEDICA (COMMERCIAL) 94265 [3081118] MEDICA CLAIMS [308111801] 63.2 percent of total billed charges 43.54 66.71 Technical (Hospital) Services WCH ED HYDROCODONE 10 MG-CHLORPHENIRAMINE 8 MG/5 ML ORAL SUSP #115ML RX-4080030057 CDM 6370000100 HCPCS 250 RC 09999-3080-01 NDC inpatient 115 ML 70.22 70.22 MULTIPLAN INC 34080 [3081285] MULTIPLAN INC [308128501] 66.71 percent of total billed charges 43.54 66.71 Technical (Hospital) Services WCH ED HYDROCODONE 10 MG-CHLORPHENIRAMINE 8 MG/5 ML ORAL SUSP #115ML RX-4080030057 CDM 6370000100 HCPCS 250 RC 09999-3080-01 NDC inpatient 115 ML 70.22 70.22 HEALTHPARTNERS SX009 HEALTHPARTNERS 55.6 percent of total billed charges 43.54 66.71 Technical (Hospital) Services WCH ED HYDROCODONE 10 MG-CHLORPHENIRAMINE 8 MG/5 ML ORAL SUSP #115ML RX-4080030057 CDM 6370000100 HCPCS 250 RC 09999-3080-01 NDC inpatient 115 ML 70.22 70.22 BLUE CROSS BLUE SHIELD WELLMARK SB889 [3081026] BCBS WYOMING [308102603] 66.71 percent of total billed charges 43.54 66.71 Technical (Hospital) Services WCH ED HYDROCODONE 10 MG-CHLORPHENIRAMINE 8 MG/5 ML ORAL SUSP #115ML RX-4080030057 CDM 6370000100 HCPCS 250 RC 09999-3080-01 NDC inpatient 115 ML 70.22 70.22 UNITED HEALTHCARE (COMMERCIAL) [3081199] UNITED HEALTHCARE 87726 [308119901] 43.54 percent of total billed charges 43.54 66.71 Technical (Hospital) Services WCH ED HYDROCODONE 10 MG-CHLORPHENIRAMINE 8 MG/5 ML ORAL SUSP #115ML RX-4080030057 CDM 6370000100 HCPCS 250 RC 09999-3080-01 NDC inpatient 115 ML 70.22 70.22 CIGNA 62308 [3081051] CIGNA 62308 [308105105] 55.6 percent of total billed charges 43.54 66.71 Technical (Hospital) Services WCH ED HYDROCODONE 10 MG-CHLORPHENIRAMINE 8 MG/5 ML ORAL SUSP #115ML RX-4080030057 CDM 6370000100 HCPCS 250 RC 09999-3080-01 NDC inpatient 115 ML 70.22 70.22 CIGNA 62308 [3081051] CIGNA STATE OF WYOMING [308105107] 55.6 percent of total billed charges 43.54 66.71 Technical (Hospital) Services WCH ED HYDROCODONE 10 MG-CHLORPHENIRAMINE 8 MG/5 ML ORAL SUSP #115ML RX-4080030057 CDM 6370000100 HCPCS 250 RC 09999-3080-01 NDC inpatient 115 ML 70.22 70.22 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES EPO [308136803] 55.6 percent of total billed charges 43.54 66.71 Technical (Hospital) Services WCH ED HYDROCODONE 10 MG-CHLORPHENIRAMINE 8 MG/5 ML ORAL SUSP #115ML RX-4080030057 CDM 6370000100 HCPCS 250 RC 09999-3080-01 NDC inpatient 115 ML 70.22 70.22 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES HDHP [308136802] 55.6 percent of total billed charges 43.54 66.71 Technical (Hospital) Services WCH ED HYDROCODONE 10 MG-CHLORPHENIRAMINE 8 MG/5 ML ORAL SUSP #115ML RX-4080030057 CDM 6370000100 HCPCS 250 RC 09999-3080-01 NDC inpatient 115 ML 70.22 70.22 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES PPO [308136801] 55.6 percent of total billed charges 43.54 66.71 Technical (Hospital) Services WCH ED HYDROCODONE 10 MG-CHLORPHENIRAMINE 8 MG/5 ML ORAL SUSP #115ML RX-4080030057 CDM 6370000100 HCPCS 250 RC 09999-3080-01 NDC outpatient 115 ML 70.22 70.22 CIGNA 62308 [3081051] CIGNA 62308 [308105105] 56.18 percent of total billed charges 43.54 66.71 Technical (Hospital) Services WCH ED HYDROCODONE 10 MG-CHLORPHENIRAMINE 8 MG/5 ML ORAL SUSP #115ML RX-4080030057 CDM 6370000100 HCPCS 250 RC 09999-3080-01 NDC outpatient 115 ML 70.22 70.22 CIGNA 62308 [3081051] CIGNA STATE OF WYOMING [308105107] 56.18 percent of total billed charges 43.54 66.71 Technical (Hospital) Services WCH ED HYDROCODONE 10 MG-CHLORPHENIRAMINE 8 MG/5 ML ORAL SUSP #115ML RX-4080030057 CDM 6370000100 HCPCS 250 RC 09999-3080-01 NDC outpatient 115 ML 70.22 70.22 MEDICA (COMMERCIAL) 94265 [3081118] MEDICA CLAIMS [308111801] 63.2 percent of total billed charges 43.54 66.71 Technical (Hospital) Services WCH ED HYDROCODONE 10 MG-CHLORPHENIRAMINE 8 MG/5 ML ORAL SUSP #115ML RX-4080030057 CDM 6370000100 HCPCS 250 RC 09999-3080-01 NDC outpatient 115 ML 70.22 70.22 MULTIPLAN INC 34080 [3081285] MULTIPLAN INC [308128501] 66.71 percent of total billed charges 43.54 66.71 Technical (Hospital) Services WCH ED HYDROCODONE 10 MG-CHLORPHENIRAMINE 8 MG/5 ML ORAL SUSP #115ML RX-4080030057 CDM 6370000100 HCPCS 250 RC 09999-3080-01 NDC outpatient 115 ML 70.22 70.22 HEALTHPARTNERS SX009 HEALTHPARTNERS 56.18 percent of total billed charges 43.54 66.71 Technical (Hospital) Services WCH ED HYDROCODONE 10 MG-CHLORPHENIRAMINE 8 MG/5 ML ORAL SUSP #115ML RX-4080030057 CDM 6370000100 HCPCS 250 RC 09999-3080-01 NDC outpatient 115 ML 70.22 70.22 BLUE CROSS BLUE SHIELD WELLMARK SB889 [3081026] BCBS WYOMING [308102603] 66.71 percent of total billed charges 43.54 66.71 Technical (Hospital) Services WCH ED HYDROCODONE 10 MG-CHLORPHENIRAMINE 8 MG/5 ML ORAL SUSP #115ML RX-4080030057 CDM 6370000100 HCPCS 250 RC 09999-3080-01 NDC outpatient 115 ML 70.22 70.22 UNITED HEALTHCARE (COMMERCIAL) [3081199] UNITED HEALTHCARE 87726 [308119901] 43.54 percent of total billed charges 43.54 66.71 Technical (Hospital) Services WCH ED HYDROCODONE 10 MG-CHLORPHENIRAMINE 8 MG/5 ML ORAL SUSP #115ML RX-4080030057 CDM 6370000100 HCPCS 250 RC 09999-3080-01 NDC outpatient 115 ML 70.22 70.22 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES EPO [308136803] 56.18 percent of total billed charges 43.54 66.71 Technical (Hospital) Services WCH ED HYDROCODONE 10 MG-CHLORPHENIRAMINE 8 MG/5 ML ORAL SUSP #115ML RX-4080030057 CDM 6370000100 HCPCS 250 RC 09999-3080-01 NDC outpatient 115 ML 70.22 70.22 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES HDHP [308136802] 56.18 percent of total billed charges 43.54 66.71 Technical (Hospital) Services WCH ED HYDROCODONE 10 MG-CHLORPHENIRAMINE 8 MG/5 ML ORAL SUSP #115ML RX-4080030057 CDM 6370000100 HCPCS 250 RC 09999-3080-01 NDC outpatient 115 ML 70.22 70.22 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES PPO [308136801] 56.18 percent of total billed charges 43.54 66.71 Technical (Hospital) Services WCH ED BUDESONIDE-FORMOTEROL HFA 160 MCG-4.5 MCG/ACTUATION #10.2GM RX-4080030099 CDM 6370000100 HCPCS 250 RC 09999-3130-01 NDC inpatient 10.2 GR 248.03 248.03 MEDICA (COMMERCIAL) 94265 [3081118] MEDICA CLAIMS [308111801] 223.23 percent of total billed charges 153.78 235.63 Technical (Hospital) Services WCH ED BUDESONIDE-FORMOTEROL HFA 160 MCG-4.5 MCG/ACTUATION #10.2GM RX-4080030099 CDM 6370000100 HCPCS 250 RC 09999-3130-01 NDC inpatient 10.2 GR 248.03 248.03 MULTIPLAN INC 34080 [3081285] MULTIPLAN INC [308128501] 235.63 percent of total billed charges 153.78 235.63 Technical (Hospital) Services WCH ED BUDESONIDE-FORMOTEROL HFA 160 MCG-4.5 MCG/ACTUATION #10.2GM RX-4080030099 CDM 6370000100 HCPCS 250 RC 09999-3130-01 NDC inpatient 10.2 GR 248.03 248.03 UNITED HEALTHCARE (COMMERCIAL) [3081199] UNITED HEALTHCARE 87726 [308119901] 153.78 percent of total billed charges 153.78 235.63 Technical (Hospital) Services WCH ED BUDESONIDE-FORMOTEROL HFA 160 MCG-4.5 MCG/ACTUATION #10.2GM RX-4080030099 CDM 6370000100 HCPCS 250 RC 09999-3130-01 NDC inpatient 10.2 GR 248.03 248.03 BLUE CROSS BLUE SHIELD WELLMARK SB889 [3081026] BCBS WYOMING [308102603] 235.63 percent of total billed charges 153.78 235.63 Technical (Hospital) Services WCH ED BUDESONIDE-FORMOTEROL HFA 160 MCG-4.5 MCG/ACTUATION #10.2GM RX-4080030099 CDM 6370000100 HCPCS 250 RC 09999-3130-01 NDC inpatient 10.2 GR 248.03 248.03 CIGNA 62308 [3081051] CIGNA 62308 [308105105] 196.39 percent of total billed charges 153.78 235.63 Technical (Hospital) Services WCH ED BUDESONIDE-FORMOTEROL HFA 160 MCG-4.5 MCG/ACTUATION #10.2GM RX-4080030099 CDM 6370000100 HCPCS 250 RC 09999-3130-01 NDC inpatient 10.2 GR 248.03 248.03 CIGNA 62308 [3081051] CIGNA STATE OF WYOMING [308105107] 196.39 percent of total billed charges 153.78 235.63 Technical (Hospital) Services WCH ED BUDESONIDE-FORMOTEROL HFA 160 MCG-4.5 MCG/ACTUATION #10.2GM RX-4080030099 CDM 6370000100 HCPCS 250 RC 09999-3130-01 NDC inpatient 10.2 GR 248.03 248.03 HEALTHPARTNERS SX009 HEALTHPARTNERS 196.39 percent of total billed charges 153.78 235.63 Technical (Hospital) Services WCH ED BUDESONIDE-FORMOTEROL HFA 160 MCG-4.5 MCG/ACTUATION #10.2GM RX-4080030099 CDM 6370000100 HCPCS 250 RC 09999-3130-01 NDC inpatient 10.2 GR 248.03 248.03 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES EPO [308136803] 196.39 percent of total billed charges 153.78 235.63 Technical (Hospital) Services WCH ED BUDESONIDE-FORMOTEROL HFA 160 MCG-4.5 MCG/ACTUATION #10.2GM RX-4080030099 CDM 6370000100 HCPCS 250 RC 09999-3130-01 NDC inpatient 10.2 GR 248.03 248.03 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES HDHP [308136802] 196.39 percent of total billed charges 153.78 235.63 Technical (Hospital) Services WCH ED BUDESONIDE-FORMOTEROL HFA 160 MCG-4.5 MCG/ACTUATION #10.2GM RX-4080030099 CDM 6370000100 HCPCS 250 RC 09999-3130-01 NDC inpatient 10.2 GR 248.03 248.03 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES PPO [308136801] 196.39 percent of total billed charges 153.78 235.63 Technical (Hospital) Services WCH ED BUDESONIDE-FORMOTEROL HFA 160 MCG-4.5 MCG/ACTUATION #10.2GM RX-4080030099 CDM 6370000100 HCPCS 250 RC 09999-3130-01 NDC outpatient 10.2 GR 248.03 248.03 BLUE CROSS BLUE SHIELD WELLMARK SB889 [3081026] BCBS WYOMING [308102603] 235.63 percent of total billed charges 153.78 235.63 Technical (Hospital) Services WCH ED BUDESONIDE-FORMOTEROL HFA 160 MCG-4.5 MCG/ACTUATION #10.2GM RX-4080030099 CDM 6370000100 HCPCS 250 RC 09999-3130-01 NDC outpatient 10.2 GR 248.03 248.03 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES EPO [308136803] 198.42 percent of total billed charges 153.78 235.63 Technical (Hospital) Services WCH ED BUDESONIDE-FORMOTEROL HFA 160 MCG-4.5 MCG/ACTUATION #10.2GM RX-4080030099 CDM 6370000100 HCPCS 250 RC 09999-3130-01 NDC outpatient 10.2 GR 248.03 248.03 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES HDHP [308136802] 198.42 percent of total billed charges 153.78 235.63 Technical (Hospital) Services WCH ED BUDESONIDE-FORMOTEROL HFA 160 MCG-4.5 MCG/ACTUATION #10.2GM RX-4080030099 CDM 6370000100 HCPCS 250 RC 09999-3130-01 NDC outpatient 10.2 GR 248.03 248.03 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES PPO [308136801] 198.42 percent of total billed charges 153.78 235.63 Technical (Hospital) Services WCH ED BUDESONIDE-FORMOTEROL HFA 160 MCG-4.5 MCG/ACTUATION #10.2GM RX-4080030099 CDM 6370000100 HCPCS 250 RC 09999-3130-01 NDC outpatient 10.2 GR 248.03 248.03 HEALTHPARTNERS SX009 HEALTHPARTNERS 198.42 percent of total billed charges 153.78 235.63 Technical (Hospital) Services WCH ED BUDESONIDE-FORMOTEROL HFA 160 MCG-4.5 MCG/ACTUATION #10.2GM RX-4080030099 CDM 6370000100 HCPCS 250 RC 09999-3130-01 NDC outpatient 10.2 GR 248.03 248.03 UNITED HEALTHCARE (COMMERCIAL) [3081199] UNITED HEALTHCARE 87726 [308119901] 153.78 percent of total billed charges 153.78 235.63 Technical (Hospital) Services WCH ED BUDESONIDE-FORMOTEROL HFA 160 MCG-4.5 MCG/ACTUATION #10.2GM RX-4080030099 CDM 6370000100 HCPCS 250 RC 09999-3130-01 NDC outpatient 10.2 GR 248.03 248.03 MULTIPLAN INC 34080 [3081285] MULTIPLAN INC [308128501] 235.63 percent of total billed charges 153.78 235.63 Technical (Hospital) Services WCH ED BUDESONIDE-FORMOTEROL HFA 160 MCG-4.5 MCG/ACTUATION #10.2GM RX-4080030099 CDM 6370000100 HCPCS 250 RC 09999-3130-01 NDC outpatient 10.2 GR 248.03 248.03 MEDICA (COMMERCIAL) 94265 [3081118] MEDICA CLAIMS [308111801] 223.23 percent of total billed charges 153.78 235.63 Technical (Hospital) Services WCH ED BUDESONIDE-FORMOTEROL HFA 160 MCG-4.5 MCG/ACTUATION #10.2GM RX-4080030099 CDM 6370000100 HCPCS 250 RC 09999-3130-01 NDC outpatient 10.2 GR 248.03 248.03 CIGNA 62308 [3081051] CIGNA 62308 [308105105] 198.42 percent of total billed charges 153.78 235.63 Technical (Hospital) Services WCH ED BUDESONIDE-FORMOTEROL HFA 160 MCG-4.5 MCG/ACTUATION #10.2GM RX-4080030099 CDM 6370000100 HCPCS 250 RC 09999-3130-01 NDC outpatient 10.2 GR 248.03 248.03 CIGNA 62308 [3081051] CIGNA STATE OF WYOMING [308105107] 198.42 percent of total billed charges 153.78 235.63 Technical (Hospital) Services WCH ED SULFAMETHOXAZOLE 200 MG-TRIMETHOPRIM 40 MG/5 ML ORAL SUSP #30ML RX-4080030107 CDM 6370000100 HCPCS 250 RC inpatient 30 ML 16.48 16.48 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES PPO [308136801] 13.05 percent of total billed charges 10.22 15.66 Technical (Hospital) Services WCH ED SULFAMETHOXAZOLE 200 MG-TRIMETHOPRIM 40 MG/5 ML ORAL SUSP #30ML RX-4080030107 CDM 6370000100 HCPCS 250 RC inpatient 30 ML 16.48 16.48 MULTIPLAN INC 34080 [3081285] MULTIPLAN INC [308128501] 15.66 percent of total billed charges 10.22 15.66 Technical (Hospital) Services WCH ED SULFAMETHOXAZOLE 200 MG-TRIMETHOPRIM 40 MG/5 ML ORAL SUSP #30ML RX-4080030107 CDM 6370000100 HCPCS 250 RC inpatient 30 ML 16.48 16.48 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES EPO [308136803] 13.05 percent of total billed charges 10.22 15.66 Technical (Hospital) Services WCH ED SULFAMETHOXAZOLE 200 MG-TRIMETHOPRIM 40 MG/5 ML ORAL SUSP #30ML RX-4080030107 CDM 6370000100 HCPCS 250 RC inpatient 30 ML 16.48 16.48 BLUE CROSS BLUE SHIELD WELLMARK SB889 [3081026] BCBS WYOMING [308102603] 15.66 percent of total billed charges 10.22 15.66 Technical (Hospital) Services WCH ED SULFAMETHOXAZOLE 200 MG-TRIMETHOPRIM 40 MG/5 ML ORAL SUSP #30ML RX-4080030107 CDM 6370000100 HCPCS 250 RC inpatient 30 ML 16.48 16.48 HEALTHPARTNERS SX009 HEALTHPARTNERS 13.05 percent of total billed charges 10.22 15.66 Technical (Hospital) Services WCH ED SULFAMETHOXAZOLE 200 MG-TRIMETHOPRIM 40 MG/5 ML ORAL SUSP #30ML RX-4080030107 CDM 6370000100 HCPCS 250 RC inpatient 30 ML 16.48 16.48 UNITED HEALTHCARE (COMMERCIAL) [3081199] UNITED HEALTHCARE 87726 [308119901] 10.22 percent of total billed charges 10.22 15.66 Technical (Hospital) Services WCH ED SULFAMETHOXAZOLE 200 MG-TRIMETHOPRIM 40 MG/5 ML ORAL SUSP #30ML RX-4080030107 CDM 6370000100 HCPCS 250 RC inpatient 30 ML 16.48 16.48 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES HDHP [308136802] 13.05 percent of total billed charges 10.22 15.66 Technical (Hospital) Services WCH ED SULFAMETHOXAZOLE 200 MG-TRIMETHOPRIM 40 MG/5 ML ORAL SUSP #30ML RX-4080030107 CDM 6370000100 HCPCS 250 RC inpatient 30 ML 16.48 16.48 CIGNA 62308 [3081051] CIGNA 62308 [308105105] 13.05 percent of total billed charges 10.22 15.66 Technical (Hospital) Services WCH ED SULFAMETHOXAZOLE 200 MG-TRIMETHOPRIM 40 MG/5 ML ORAL SUSP #30ML RX-4080030107 CDM 6370000100 HCPCS 250 RC inpatient 30 ML 16.48 16.48 CIGNA 62308 [3081051] CIGNA STATE OF WYOMING [308105107] 13.05 percent of total billed charges 10.22 15.66 Technical (Hospital) Services WCH ED SULFAMETHOXAZOLE 200 MG-TRIMETHOPRIM 40 MG/5 ML ORAL SUSP #30ML RX-4080030107 CDM 6370000100 HCPCS 250 RC inpatient 30 ML 16.48 16.48 MEDICA (COMMERCIAL) 94265 [3081118] MEDICA CLAIMS [308111801] 14.83 percent of total billed charges 10.22 15.66 Technical (Hospital) Services WCH ED SULFAMETHOXAZOLE 200 MG-TRIMETHOPRIM 40 MG/5 ML ORAL SUSP #30ML RX-4080030107 CDM 6370000100 HCPCS 250 RC outpatient 30 ML 16.48 16.48 CIGNA 62308 [3081051] CIGNA 62308 [308105105] 13.18 percent of total billed charges 10.22 15.66 Technical (Hospital) Services WCH ED SULFAMETHOXAZOLE 200 MG-TRIMETHOPRIM 40 MG/5 ML ORAL SUSP #30ML RX-4080030107 CDM 6370000100 HCPCS 250 RC outpatient 30 ML 16.48 16.48 CIGNA 62308 [3081051] CIGNA STATE OF WYOMING [308105107] 13.18 percent of total billed charges 10.22 15.66 Technical (Hospital) Services WCH ED SULFAMETHOXAZOLE 200 MG-TRIMETHOPRIM 40 MG/5 ML ORAL SUSP #30ML RX-4080030107 CDM 6370000100 HCPCS 250 RC outpatient 30 ML 16.48 16.48 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES HDHP [308136802] 13.18 percent of total billed charges 10.22 15.66 Technical (Hospital) Services WCH ED SULFAMETHOXAZOLE 200 MG-TRIMETHOPRIM 40 MG/5 ML ORAL SUSP #30ML RX-4080030107 CDM 6370000100 HCPCS 250 RC outpatient 30 ML 16.48 16.48 BLUE CROSS BLUE SHIELD WELLMARK SB889 [3081026] BCBS WYOMING [308102603] 15.66 percent of total billed charges 10.22 15.66 Technical (Hospital) Services WCH ED SULFAMETHOXAZOLE 200 MG-TRIMETHOPRIM 40 MG/5 ML ORAL SUSP #30ML RX-4080030107 CDM 6370000100 HCPCS 250 RC outpatient 30 ML 16.48 16.48 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES EPO [308136803] 13.18 percent of total billed charges 10.22 15.66 Technical (Hospital) Services WCH ED SULFAMETHOXAZOLE 200 MG-TRIMETHOPRIM 40 MG/5 ML ORAL SUSP #30ML RX-4080030107 CDM 6370000100 HCPCS 250 RC outpatient 30 ML 16.48 16.48 HEALTHPARTNERS SX009 HEALTHPARTNERS 13.18 percent of total billed charges 10.22 15.66 Technical (Hospital) Services WCH ED SULFAMETHOXAZOLE 200 MG-TRIMETHOPRIM 40 MG/5 ML ORAL SUSP #30ML RX-4080030107 CDM 6370000100 HCPCS 250 RC outpatient 30 ML 16.48 16.48 UNITED HEALTHCARE (COMMERCIAL) [3081199] UNITED HEALTHCARE 87726 [308119901] 10.22 percent of total billed charges 10.22 15.66 Technical (Hospital) Services WCH ED SULFAMETHOXAZOLE 200 MG-TRIMETHOPRIM 40 MG/5 ML ORAL SUSP #30ML RX-4080030107 CDM 6370000100 HCPCS 250 RC outpatient 30 ML 16.48 16.48 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES PPO [308136801] 13.18 percent of total billed charges 10.22 15.66 Technical (Hospital) Services WCH ED SULFAMETHOXAZOLE 200 MG-TRIMETHOPRIM 40 MG/5 ML ORAL SUSP #30ML RX-4080030107 CDM 6370000100 HCPCS 250 RC outpatient 30 ML 16.48 16.48 MULTIPLAN INC 34080 [3081285] MULTIPLAN INC [308128501] 15.66 percent of total billed charges 10.22 15.66 Technical (Hospital) Services WCH ED SULFAMETHOXAZOLE 200 MG-TRIMETHOPRIM 40 MG/5 ML ORAL SUSP #30ML RX-4080030107 CDM 6370000100 HCPCS 250 RC outpatient 30 ML 16.48 16.48 MEDICA (COMMERCIAL) 94265 [3081118] MEDICA CLAIMS [308111801] 14.83 percent of total billed charges 10.22 15.66 Technical (Hospital) Services WCH ED AZITHROMYCIN 200 MG/5 ML ORAL SUSPENSION #15ML RX-4080030108 CDM 6370000100 HCPCS 250 RC 09999-3137-01 NDC outpatient 600 ME 39.91 39.91 CIGNA 62308 [3081051] CIGNA 62308 [308105105] 31.93 percent of total billed charges 24.74 37.91 Technical (Hospital) Services WCH ED AZITHROMYCIN 200 MG/5 ML ORAL SUSPENSION #15ML RX-4080030108 CDM 6370000100 HCPCS 250 RC 09999-3137-01 NDC outpatient 600 ME 39.91 39.91 CIGNA 62308 [3081051] CIGNA STATE OF WYOMING [308105107] 31.93 percent of total billed charges 24.74 37.91 Technical (Hospital) Services WCH ED AZITHROMYCIN 200 MG/5 ML ORAL SUSPENSION #15ML RX-4080030108 CDM 6370000100 HCPCS 250 RC 09999-3137-01 NDC outpatient 600 ME 39.91 39.91 MULTIPLAN INC 34080 [3081285] MULTIPLAN INC [308128501] 37.91 percent of total billed charges 24.74 37.91 Technical (Hospital) Services WCH ED AZITHROMYCIN 200 MG/5 ML ORAL SUSPENSION #15ML RX-4080030108 CDM 6370000100 HCPCS 250 RC 09999-3137-01 NDC outpatient 600 ME 39.91 39.91 MEDICA (COMMERCIAL) 94265 [3081118] MEDICA CLAIMS [308111801] 35.92 percent of total billed charges 24.74 37.91 Technical (Hospital) Services WCH ED AZITHROMYCIN 200 MG/5 ML ORAL SUSPENSION #15ML RX-4080030108 CDM 6370000100 HCPCS 250 RC 09999-3137-01 NDC outpatient 600 ME 39.91 39.91 HEALTHPARTNERS SX009 HEALTHPARTNERS 31.93 percent of total billed charges 24.74 37.91 Technical (Hospital) Services WCH ED AZITHROMYCIN 200 MG/5 ML ORAL SUSPENSION #15ML RX-4080030108 CDM 6370000100 HCPCS 250 RC 09999-3137-01 NDC outpatient 600 ME 39.91 39.91 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES EPO [308136803] 31.93 percent of total billed charges 24.74 37.91 Technical (Hospital) Services WCH ED AZITHROMYCIN 200 MG/5 ML ORAL SUSPENSION #15ML RX-4080030108 CDM 6370000100 HCPCS 250 RC 09999-3137-01 NDC outpatient 600 ME 39.91 39.91 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES HDHP [308136802] 31.93 percent of total billed charges 24.74 37.91 Technical (Hospital) Services WCH ED AZITHROMYCIN 200 MG/5 ML ORAL SUSPENSION #15ML RX-4080030108 CDM 6370000100 HCPCS 250 RC 09999-3137-01 NDC outpatient 600 ME 39.91 39.91 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES PPO [308136801] 31.93 percent of total billed charges 24.74 37.91 Technical (Hospital) Services WCH ED AZITHROMYCIN 200 MG/5 ML ORAL SUSPENSION #15ML RX-4080030108 CDM 6370000100 HCPCS 250 RC 09999-3137-01 NDC outpatient 600 ME 39.91 39.91 BLUE CROSS BLUE SHIELD WELLMARK SB889 [3081026] BCBS WYOMING [308102603] 37.91 percent of total billed charges 24.74 37.91 Technical (Hospital) Services WCH ED AZITHROMYCIN 200 MG/5 ML ORAL SUSPENSION #15ML RX-4080030108 CDM 6370000100 HCPCS 250 RC 09999-3137-01 NDC outpatient 600 ME 39.91 39.91 UNITED HEALTHCARE (COMMERCIAL) [3081199] UNITED HEALTHCARE 87726 [308119901] 24.74 percent of total billed charges 24.74 37.91 Technical (Hospital) Services WCH ED AZITHROMYCIN 200 MG/5 ML ORAL SUSPENSION #15ML RX-4080030108 CDM 6370000100 HCPCS 250 RC 09999-3137-01 NDC inpatient 600 ME 39.91 39.91 CIGNA 62308 [3081051] CIGNA 62308 [308105105] 31.6 percent of total billed charges 24.74 37.91 Technical (Hospital) Services WCH ED AZITHROMYCIN 200 MG/5 ML ORAL SUSPENSION #15ML RX-4080030108 CDM 6370000100 HCPCS 250 RC 09999-3137-01 NDC inpatient 600 ME 39.91 39.91 CIGNA 62308 [3081051] CIGNA STATE OF WYOMING [308105107] 31.6 percent of total billed charges 24.74 37.91 Technical (Hospital) Services WCH ED AZITHROMYCIN 200 MG/5 ML ORAL SUSPENSION #15ML RX-4080030108 CDM 6370000100 HCPCS 250 RC 09999-3137-01 NDC inpatient 600 ME 39.91 39.91 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES EPO [308136803] 31.6 percent of total billed charges 24.74 37.91 Technical (Hospital) Services WCH ED AZITHROMYCIN 200 MG/5 ML ORAL SUSPENSION #15ML RX-4080030108 CDM 6370000100 HCPCS 250 RC 09999-3137-01 NDC inpatient 600 ME 39.91 39.91 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES HDHP [308136802] 31.6 percent of total billed charges 24.74 37.91 Technical (Hospital) Services WCH ED AZITHROMYCIN 200 MG/5 ML ORAL SUSPENSION #15ML RX-4080030108 CDM 6370000100 HCPCS 250 RC 09999-3137-01 NDC inpatient 600 ME 39.91 39.91 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES PPO [308136801] 31.6 percent of total billed charges 24.74 37.91 Technical (Hospital) Services WCH ED AZITHROMYCIN 200 MG/5 ML ORAL SUSPENSION #15ML RX-4080030108 CDM 6370000100 HCPCS 250 RC 09999-3137-01 NDC inpatient 600 ME 39.91 39.91 BLUE CROSS BLUE SHIELD WELLMARK SB889 [3081026] BCBS WYOMING [308102603] 37.91 percent of total billed charges 24.74 37.91 Technical (Hospital) Services WCH ED AZITHROMYCIN 200 MG/5 ML ORAL SUSPENSION #15ML RX-4080030108 CDM 6370000100 HCPCS 250 RC 09999-3137-01 NDC inpatient 600 ME 39.91 39.91 UNITED HEALTHCARE (COMMERCIAL) [3081199] UNITED HEALTHCARE 87726 [308119901] 24.74 percent of total billed charges 24.74 37.91 Technical (Hospital) Services WCH ED AZITHROMYCIN 200 MG/5 ML ORAL SUSPENSION #15ML RX-4080030108 CDM 6370000100 HCPCS 250 RC 09999-3137-01 NDC inpatient 600 ME 39.91 39.91 HEALTHPARTNERS SX009 HEALTHPARTNERS 31.6 percent of total billed charges 24.74 37.91 Technical (Hospital) Services WCH ED AZITHROMYCIN 200 MG/5 ML ORAL SUSPENSION #15ML RX-4080030108 CDM 6370000100 HCPCS 250 RC 09999-3137-01 NDC inpatient 600 ME 39.91 39.91 MULTIPLAN INC 34080 [3081285] MULTIPLAN INC [308128501] 37.91 percent of total billed charges 24.74 37.91 Technical (Hospital) Services WCH ED AZITHROMYCIN 200 MG/5 ML ORAL SUSPENSION #15ML RX-4080030108 CDM 6370000100 HCPCS 250 RC 09999-3137-01 NDC inpatient 600 ME 39.91 39.91 MEDICA (COMMERCIAL) 94265 [3081118] MEDICA CLAIMS [308111801] 35.92 percent of total billed charges 24.74 37.91 Technical (Hospital) Services DOXYCYCLINE 50 MG CAPSULE WRAPPER RX-4080050004 CDM 6370000100 HCPCS 250 RC 00143-9802-50 NDC inpatient 1 UN 5.9 5.9 UNITED HEALTHCARE (COMMERCIAL) [3081199] UNITED HEALTHCARE 87726 [308119901] 3.66 percent of total billed charges 3.66 5.61 Technical (Hospital) Services DOXYCYCLINE 50 MG CAPSULE WRAPPER RX-4080050004 CDM 6370000100 HCPCS 250 RC 00143-9802-50 NDC inpatient 1 UN 5.9 5.9 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES EPO [308136803] 4.67 percent of total billed charges 3.66 5.61 Technical (Hospital) Services DOXYCYCLINE 50 MG CAPSULE WRAPPER RX-4080050004 CDM 6370000100 HCPCS 250 RC 00143-9802-50 NDC inpatient 1 UN 5.9 5.9 CIGNA 62308 [3081051] CIGNA 62308 [308105105] 4.67 percent of total billed charges 3.66 5.61 Technical (Hospital) Services DOXYCYCLINE 50 MG CAPSULE WRAPPER RX-4080050004 CDM 6370000100 HCPCS 250 RC 00143-9802-50 NDC inpatient 1 UN 5.9 5.9 CIGNA 62308 [3081051] CIGNA STATE OF WYOMING [308105107] 4.67 percent of total billed charges 3.66 5.61 Technical (Hospital) Services DOXYCYCLINE 50 MG CAPSULE WRAPPER RX-4080050004 CDM 6370000100 HCPCS 250 RC 00143-9802-50 NDC inpatient 1 UN 5.9 5.9 BLUE CROSS BLUE SHIELD WELLMARK SB889 [3081026] BCBS WYOMING [308102603] 5.61 percent of total billed charges 3.66 5.61 Technical (Hospital) Services DOXYCYCLINE 50 MG CAPSULE WRAPPER RX-4080050004 CDM 6370000100 HCPCS 250 RC 00143-9802-50 NDC inpatient 1 UN 5.9 5.9 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES HDHP [308136802] 4.67 percent of total billed charges 3.66 5.61 Technical (Hospital) Services DOXYCYCLINE 50 MG CAPSULE WRAPPER RX-4080050004 CDM 6370000100 HCPCS 250 RC 00143-9802-50 NDC inpatient 1 UN 5.9 5.9 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES PPO [308136801] 4.67 percent of total billed charges 3.66 5.61 Technical (Hospital) Services DOXYCYCLINE 50 MG CAPSULE WRAPPER RX-4080050004 CDM 6370000100 HCPCS 250 RC 00143-9802-50 NDC inpatient 1 UN 5.9 5.9 MEDICA (COMMERCIAL) 94265 [3081118] MEDICA CLAIMS [308111801] 5.31 percent of total billed charges 3.66 5.61 Technical (Hospital) Services DOXYCYCLINE 50 MG CAPSULE WRAPPER RX-4080050004 CDM 6370000100 HCPCS 250 RC 00143-9802-50 NDC inpatient 1 UN 5.9 5.9 HEALTHPARTNERS SX009 HEALTHPARTNERS 4.67 percent of total billed charges 3.66 5.61 Technical (Hospital) Services DOXYCYCLINE 50 MG CAPSULE WRAPPER RX-4080050004 CDM 6370000100 HCPCS 250 RC 00143-9802-50 NDC inpatient 1 UN 5.9 5.9 MULTIPLAN INC 34080 [3081285] MULTIPLAN INC [308128501] 5.61 percent of total billed charges 3.66 5.61 Technical (Hospital) Services DOXYCYCLINE 50 MG CAPSULE WRAPPER RX-4080050004 CDM 6370000100 HCPCS 250 RC 00143-9802-50 NDC outpatient 1 UN 5.9 5.9 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES EPO [308136803] 4.72 percent of total billed charges 3.66 5.61 Technical (Hospital) Services DOXYCYCLINE 50 MG CAPSULE WRAPPER RX-4080050004 CDM 6370000100 HCPCS 250 RC 00143-9802-50 NDC outpatient 1 UN 5.9 5.9 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES HDHP [308136802] 4.72 percent of total billed charges 3.66 5.61 Technical (Hospital) Services DOXYCYCLINE 50 MG CAPSULE WRAPPER RX-4080050004 CDM 6370000100 HCPCS 250 RC 00143-9802-50 NDC outpatient 1 UN 5.9 5.9 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES PPO [308136801] 4.72 percent of total billed charges 3.66 5.61 Technical (Hospital) Services DOXYCYCLINE 50 MG CAPSULE WRAPPER RX-4080050004 CDM 6370000100 HCPCS 250 RC 00143-9802-50 NDC outpatient 1 UN 5.9 5.9 CIGNA 62308 [3081051] CIGNA 62308 [308105105] 4.72 percent of total billed charges 3.66 5.61 Technical (Hospital) Services DOXYCYCLINE 50 MG CAPSULE WRAPPER RX-4080050004 CDM 6370000100 HCPCS 250 RC 00143-9802-50 NDC outpatient 1 UN 5.9 5.9 CIGNA 62308 [3081051] CIGNA STATE OF WYOMING [308105107] 4.72 percent of total billed charges 3.66 5.61 Technical (Hospital) Services DOXYCYCLINE 50 MG CAPSULE WRAPPER RX-4080050004 CDM 6370000100 HCPCS 250 RC 00143-9802-50 NDC outpatient 1 UN 5.9 5.9 MULTIPLAN INC 34080 [3081285] MULTIPLAN INC [308128501] 5.61 percent of total billed charges 3.66 5.61 Technical (Hospital) Services DOXYCYCLINE 50 MG CAPSULE WRAPPER RX-4080050004 CDM 6370000100 HCPCS 250 RC 00143-9802-50 NDC outpatient 1 UN 5.9 5.9 MEDICA (COMMERCIAL) 94265 [3081118] MEDICA CLAIMS [308111801] 5.31 percent of total billed charges 3.66 5.61 Technical (Hospital) Services DOXYCYCLINE 50 MG CAPSULE WRAPPER RX-4080050004 CDM 6370000100 HCPCS 250 RC 00143-9802-50 NDC outpatient 1 UN 5.9 5.9 UNITED HEALTHCARE (COMMERCIAL) [3081199] UNITED HEALTHCARE 87726 [308119901] 3.66 percent of total billed charges 3.66 5.61 Technical (Hospital) Services DOXYCYCLINE 50 MG CAPSULE WRAPPER RX-4080050004 CDM 6370000100 HCPCS 250 RC 00143-9802-50 NDC outpatient 1 UN 5.9 5.9 HEALTHPARTNERS SX009 HEALTHPARTNERS 4.72 percent of total billed charges 3.66 5.61 Technical (Hospital) Services DOXYCYCLINE 50 MG CAPSULE WRAPPER RX-4080050004 CDM 6370000100 HCPCS 250 RC 00143-9802-50 NDC outpatient 1 UN 5.9 5.9 BLUE CROSS BLUE SHIELD WELLMARK SB889 [3081026] BCBS WYOMING [308102603] 5.61 percent of total billed charges 3.66 5.61 Technical (Hospital) Services MORPHINE CONCENTRATE 10 MG/0.5 ML ORAL SOLUTION WRAPPER RX-4080070007 CDM 6370000100 HCPCS 250 RC 00054-0517-44 NDC outpatient 0.5 ML 5.91 5.91 HEALTHPARTNERS SX009 HEALTHPARTNERS 4.73 percent of total billed charges 3.66 5.61 Technical (Hospital) Services MORPHINE CONCENTRATE 10 MG/0.5 ML ORAL SOLUTION WRAPPER RX-4080070007 CDM 6370000100 HCPCS 250 RC 00054-0517-44 NDC outpatient 0.5 ML 5.91 5.91 BLUE CROSS BLUE SHIELD WELLMARK SB889 [3081026] BCBS WYOMING [308102603] 5.61 percent of total billed charges 3.66 5.61 Technical (Hospital) Services MORPHINE CONCENTRATE 10 MG/0.5 ML ORAL SOLUTION WRAPPER RX-4080070007 CDM 6370000100 HCPCS 250 RC 00054-0517-44 NDC outpatient 0.5 ML 5.91 5.91 MEDICA (COMMERCIAL) 94265 [3081118] MEDICA CLAIMS [308111801] 5.32 percent of total billed charges 3.66 5.61 Technical (Hospital) Services MORPHINE CONCENTRATE 10 MG/0.5 ML ORAL SOLUTION WRAPPER RX-4080070007 CDM 6370000100 HCPCS 250 RC 00054-0517-44 NDC outpatient 0.5 ML 5.91 5.91 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES PPO [308136801] 4.73 percent of total billed charges 3.66 5.61 Technical (Hospital) Services MORPHINE CONCENTRATE 10 MG/0.5 ML ORAL SOLUTION WRAPPER RX-4080070007 CDM 6370000100 HCPCS 250 RC 00054-0517-44 NDC outpatient 0.5 ML 5.91 5.91 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES HDHP [308136802] 4.73 percent of total billed charges 3.66 5.61 Technical (Hospital) Services MORPHINE CONCENTRATE 10 MG/0.5 ML ORAL SOLUTION WRAPPER RX-4080070007 CDM 6370000100 HCPCS 250 RC 00054-0517-44 NDC outpatient 0.5 ML 5.91 5.91 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES EPO [308136803] 4.73 percent of total billed charges 3.66 5.61 Technical (Hospital) Services MORPHINE CONCENTRATE 10 MG/0.5 ML ORAL SOLUTION WRAPPER RX-4080070007 CDM 6370000100 HCPCS 250 RC 00054-0517-44 NDC outpatient 0.5 ML 5.91 5.91 UNITED HEALTHCARE (COMMERCIAL) [3081199] UNITED HEALTHCARE 87726 [308119901] 3.66 percent of total billed charges 3.66 5.61 Technical (Hospital) Services MORPHINE CONCENTRATE 10 MG/0.5 ML ORAL SOLUTION WRAPPER RX-4080070007 CDM 6370000100 HCPCS 250 RC 00054-0517-44 NDC outpatient 0.5 ML 5.91 5.91 CIGNA 62308 [3081051] CIGNA 62308 [308105105] 4.73 percent of total billed charges 3.66 5.61 Technical (Hospital) Services MORPHINE CONCENTRATE 10 MG/0.5 ML ORAL SOLUTION WRAPPER RX-4080070007 CDM 6370000100 HCPCS 250 RC 00054-0517-44 NDC outpatient 0.5 ML 5.91 5.91 CIGNA 62308 [3081051] CIGNA STATE OF WYOMING [308105107] 4.73 percent of total billed charges 3.66 5.61 Technical (Hospital) Services MORPHINE CONCENTRATE 10 MG/0.5 ML ORAL SOLUTION WRAPPER RX-4080070007 CDM 6370000100 HCPCS 250 RC 00054-0517-44 NDC outpatient 0.5 ML 5.91 5.91 MULTIPLAN INC 34080 [3081285] MULTIPLAN INC [308128501] 5.61 percent of total billed charges 3.66 5.61 Technical (Hospital) Services MORPHINE CONCENTRATE 10 MG/0.5 ML ORAL SOLUTION WRAPPER RX-4080070007 CDM 6370000100 HCPCS 250 RC 00054-0517-44 NDC inpatient 0.5 ML 5.91 5.91 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES EPO [308136803] 4.68 percent of total billed charges 3.66 5.61 Technical (Hospital) Services MORPHINE CONCENTRATE 10 MG/0.5 ML ORAL SOLUTION WRAPPER RX-4080070007 CDM 6370000100 HCPCS 250 RC 00054-0517-44 NDC inpatient 0.5 ML 5.91 5.91 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES HDHP [308136802] 4.68 percent of total billed charges 3.66 5.61 Technical (Hospital) Services MORPHINE CONCENTRATE 10 MG/0.5 ML ORAL SOLUTION WRAPPER RX-4080070007 CDM 6370000100 HCPCS 250 RC 00054-0517-44 NDC inpatient 0.5 ML 5.91 5.91 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES PPO [308136801] 4.68 percent of total billed charges 3.66 5.61 Technical (Hospital) Services MORPHINE CONCENTRATE 10 MG/0.5 ML ORAL SOLUTION WRAPPER RX-4080070007 CDM 6370000100 HCPCS 250 RC 00054-0517-44 NDC inpatient 0.5 ML 5.91 5.91 CIGNA 62308 [3081051] CIGNA 62308 [308105105] 4.68 percent of total billed charges 3.66 5.61 Technical (Hospital) Services MORPHINE CONCENTRATE 10 MG/0.5 ML ORAL SOLUTION WRAPPER RX-4080070007 CDM 6370000100 HCPCS 250 RC 00054-0517-44 NDC inpatient 0.5 ML 5.91 5.91 CIGNA 62308 [3081051] CIGNA STATE OF WYOMING [308105107] 4.68 percent of total billed charges 3.66 5.61 Technical (Hospital) Services MORPHINE CONCENTRATE 10 MG/0.5 ML ORAL SOLUTION WRAPPER RX-4080070007 CDM 6370000100 HCPCS 250 RC 00054-0517-44 NDC inpatient 0.5 ML 5.91 5.91 MEDICA (COMMERCIAL) 94265 [3081118] MEDICA CLAIMS [308111801] 5.32 percent of total billed charges 3.66 5.61 Technical (Hospital) Services MORPHINE CONCENTRATE 10 MG/0.5 ML ORAL SOLUTION WRAPPER RX-4080070007 CDM 6370000100 HCPCS 250 RC 00054-0517-44 NDC inpatient 0.5 ML 5.91 5.91 BLUE CROSS BLUE SHIELD WELLMARK SB889 [3081026] BCBS WYOMING [308102603] 5.61 percent of total billed charges 3.66 5.61 Technical (Hospital) Services MORPHINE CONCENTRATE 10 MG/0.5 ML ORAL SOLUTION WRAPPER RX-4080070007 CDM 6370000100 HCPCS 250 RC 00054-0517-44 NDC inpatient 0.5 ML 5.91 5.91 UNITED HEALTHCARE (COMMERCIAL) [3081199] UNITED HEALTHCARE 87726 [308119901] 3.66 percent of total billed charges 3.66 5.61 Technical (Hospital) Services MORPHINE CONCENTRATE 10 MG/0.5 ML ORAL SOLUTION WRAPPER RX-4080070007 CDM 6370000100 HCPCS 250 RC 00054-0517-44 NDC inpatient 0.5 ML 5.91 5.91 HEALTHPARTNERS SX009 HEALTHPARTNERS 4.68 percent of total billed charges 3.66 5.61 Technical (Hospital) Services MORPHINE CONCENTRATE 10 MG/0.5 ML ORAL SOLUTION WRAPPER RX-4080070007 CDM 6370000100 HCPCS 250 RC 00054-0517-44 NDC inpatient 0.5 ML 5.91 5.91 MULTIPLAN INC 34080 [3081285] MULTIPLAN INC [308128501] 5.61 percent of total billed charges 3.66 5.61 Technical (Hospital) Services "DILTIAZEM CD/XR/XT 180 MG CAP, EXT RELEASE 24 HR WRAPPER" RX-4080070022 CDM 6370000100 HCPCS 250 RC 60505-0015-06 NDC outpatient 1 UN 6.4 6.4 CIGNA 62308 [3081051] CIGNA 62308 [308105105] 5.12 percent of total billed charges 3.97 6.08 Technical (Hospital) Services "DILTIAZEM CD/XR/XT 180 MG CAP, EXT RELEASE 24 HR WRAPPER" RX-4080070022 CDM 6370000100 HCPCS 250 RC 60505-0015-06 NDC outpatient 1 UN 6.4 6.4 CIGNA 62308 [3081051] CIGNA STATE OF WYOMING [308105107] 5.12 percent of total billed charges 3.97 6.08 Technical (Hospital) Services "DILTIAZEM CD/XR/XT 180 MG CAP, EXT RELEASE 24 HR WRAPPER" RX-4080070022 CDM 6370000100 HCPCS 250 RC 60505-0015-06 NDC outpatient 1 UN 6.4 6.4 MULTIPLAN INC 34080 [3081285] MULTIPLAN INC [308128501] 6.08 percent of total billed charges 3.97 6.08 Technical (Hospital) Services "DILTIAZEM CD/XR/XT 180 MG CAP, EXT RELEASE 24 HR WRAPPER" RX-4080070022 CDM 6370000100 HCPCS 250 RC 60505-0015-06 NDC inpatient 1 UN 6.4 6.4 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES PPO [308136801] 5.07 percent of total billed charges 3.97 6.08 Technical (Hospital) Services "DILTIAZEM CD/XR/XT 180 MG CAP, EXT RELEASE 24 HR WRAPPER" RX-4080070022 CDM 6370000100 HCPCS 250 RC 60505-0015-06 NDC inpatient 1 UN 6.4 6.4 HEALTHPARTNERS SX009 HEALTHPARTNERS 5.07 percent of total billed charges 3.97 6.08 Technical (Hospital) Services "DILTIAZEM CD/XR/XT 180 MG CAP, EXT RELEASE 24 HR WRAPPER" RX-4080070022 CDM 6370000100 HCPCS 250 RC 60505-0015-06 NDC inpatient 1 UN 6.4 6.4 MEDICA (COMMERCIAL) 94265 [3081118] MEDICA CLAIMS [308111801] 5.76 percent of total billed charges 3.97 6.08 Technical (Hospital) Services "DILTIAZEM CD/XR/XT 180 MG CAP, EXT RELEASE 24 HR WRAPPER" RX-4080070022 CDM 6370000100 HCPCS 250 RC 60505-0015-06 NDC inpatient 1 UN 6.4 6.4 MULTIPLAN INC 34080 [3081285] MULTIPLAN INC [308128501] 6.08 percent of total billed charges 3.97 6.08 Technical (Hospital) Services "DILTIAZEM CD/XR/XT 180 MG CAP, EXT RELEASE 24 HR WRAPPER" RX-4080070022 CDM 6370000100 HCPCS 250 RC 60505-0015-06 NDC inpatient 1 UN 6.4 6.4 UNITED HEALTHCARE (COMMERCIAL) [3081199] UNITED HEALTHCARE 87726 [308119901] 3.97 percent of total billed charges 3.97 6.08 Technical (Hospital) Services "DILTIAZEM CD/XR/XT 180 MG CAP, EXT RELEASE 24 HR WRAPPER" RX-4080070022 CDM 6370000100 HCPCS 250 RC 60505-0015-06 NDC inpatient 1 UN 6.4 6.4 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES EPO [308136803] 5.07 percent of total billed charges 3.97 6.08 Technical (Hospital) Services "DILTIAZEM CD/XR/XT 180 MG CAP, EXT RELEASE 24 HR WRAPPER" RX-4080070022 CDM 6370000100 HCPCS 250 RC 60505-0015-06 NDC outpatient 1 UN 6.4 6.4 MEDICA (COMMERCIAL) 94265 [3081118] MEDICA CLAIMS [308111801] 5.76 percent of total billed charges 3.97 6.08 Technical (Hospital) Services "DILTIAZEM CD/XR/XT 180 MG CAP, EXT RELEASE 24 HR WRAPPER" RX-4080070022 CDM 6370000100 HCPCS 250 RC 60505-0015-06 NDC outpatient 1 UN 6.4 6.4 UNITED HEALTHCARE (COMMERCIAL) [3081199] UNITED HEALTHCARE 87726 [308119901] 3.97 percent of total billed charges 3.97 6.08 Technical (Hospital) Services "DILTIAZEM CD/XR/XT 180 MG CAP, EXT RELEASE 24 HR WRAPPER" RX-4080070022 CDM 6370000100 HCPCS 250 RC 60505-0015-06 NDC outpatient 1 UN 6.4 6.4 HEALTHPARTNERS SX009 HEALTHPARTNERS 5.12 percent of total billed charges 3.97 6.08 Technical (Hospital) Services "DILTIAZEM CD/XR/XT 180 MG CAP, EXT RELEASE 24 HR WRAPPER" RX-4080070022 CDM 6370000100 HCPCS 250 RC 60505-0015-06 NDC outpatient 1 UN 6.4 6.4 BLUE CROSS BLUE SHIELD WELLMARK SB889 [3081026] BCBS WYOMING [308102603] 6.08 percent of total billed charges 3.97 6.08 Technical (Hospital) Services "DILTIAZEM CD/XR/XT 180 MG CAP, EXT RELEASE 24 HR WRAPPER" RX-4080070022 CDM 6370000100 HCPCS 250 RC 60505-0015-06 NDC outpatient 1 UN 6.4 6.4 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES EPO [308136803] 5.12 percent of total billed charges 3.97 6.08 Technical (Hospital) Services "DILTIAZEM CD/XR/XT 180 MG CAP, EXT RELEASE 24 HR WRAPPER" RX-4080070022 CDM 6370000100 HCPCS 250 RC 60505-0015-06 NDC outpatient 1 UN 6.4 6.4 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES HDHP [308136802] 5.12 percent of total billed charges 3.97 6.08 Technical (Hospital) Services "DILTIAZEM CD/XR/XT 180 MG CAP, EXT RELEASE 24 HR WRAPPER" RX-4080070022 CDM 6370000100 HCPCS 250 RC 60505-0015-06 NDC outpatient 1 UN 6.4 6.4 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES PPO [308136801] 5.12 percent of total billed charges 3.97 6.08 Technical (Hospital) Services "DILTIAZEM CD/XR/XT 180 MG CAP, EXT RELEASE 24 HR WRAPPER" RX-4080070022 CDM 6370000100 HCPCS 250 RC 60505-0015-06 NDC inpatient 1 UN 6.4 6.4 BLUE CROSS BLUE SHIELD WELLMARK SB889 [3081026] BCBS WYOMING [308102603] 6.08 percent of total billed charges 3.97 6.08 Technical (Hospital) Services "DILTIAZEM CD/XR/XT 180 MG CAP, EXT RELEASE 24 HR WRAPPER" RX-4080070022 CDM 6370000100 HCPCS 250 RC 60505-0015-06 NDC inpatient 1 UN 6.4 6.4 CIGNA 62308 [3081051] CIGNA 62308 [308105105] 5.07 percent of total billed charges 3.97 6.08 Technical (Hospital) Services "DILTIAZEM CD/XR/XT 180 MG CAP, EXT RELEASE 24 HR WRAPPER" RX-4080070022 CDM 6370000100 HCPCS 250 RC 60505-0015-06 NDC inpatient 1 UN 6.4 6.4 CIGNA 62308 [3081051] CIGNA STATE OF WYOMING [308105107] 5.07 percent of total billed charges 3.97 6.08 Technical (Hospital) Services "DILTIAZEM CD/XR/XT 180 MG CAP, EXT RELEASE 24 HR WRAPPER" RX-4080070022 CDM 6370000100 HCPCS 250 RC 60505-0015-06 NDC inpatient 1 UN 6.4 6.4 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES HDHP [308136802] 5.07 percent of total billed charges 3.97 6.08 Technical (Hospital) Services "DILTIAZEM CD/XR/XT 240 MG CAP, EXT RELEASE 24 HR WRAPPER" RX-4080070024 CDM 6370000100 HCPCS 250 RC 10370-0831-09 NDC inpatient 1 UN 6.95 6.95 MULTIPLAN INC 34080 [3081285] MULTIPLAN INC [308128501] 6.6 percent of total billed charges 4.31 6.6 Technical (Hospital) Services "DILTIAZEM CD/XR/XT 240 MG CAP, EXT RELEASE 24 HR WRAPPER" RX-4080070024 CDM 6370000100 HCPCS 250 RC 10370-0831-09 NDC inpatient 1 UN 6.95 6.95 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES PPO [308136801] 5.5 percent of total billed charges 4.31 6.6 Technical (Hospital) Services "DILTIAZEM CD/XR/XT 240 MG CAP, EXT RELEASE 24 HR WRAPPER" RX-4080070024 CDM 6370000100 HCPCS 250 RC 10370-0831-09 NDC inpatient 1 UN 6.95 6.95 BLUE CROSS BLUE SHIELD WELLMARK SB889 [3081026] BCBS WYOMING [308102603] 6.6 percent of total billed charges 4.31 6.6 Technical (Hospital) Services "DILTIAZEM CD/XR/XT 240 MG CAP, EXT RELEASE 24 HR WRAPPER" RX-4080070024 CDM 6370000100 HCPCS 250 RC 10370-0831-09 NDC inpatient 1 UN 6.95 6.95 UNITED HEALTHCARE (COMMERCIAL) [3081199] UNITED HEALTHCARE 87726 [308119901] 4.31 percent of total billed charges 4.31 6.6 Technical (Hospital) Services "DILTIAZEM CD/XR/XT 240 MG CAP, EXT RELEASE 24 HR WRAPPER" RX-4080070024 CDM 6370000100 HCPCS 250 RC 10370-0831-09 NDC inpatient 1 UN 6.95 6.95 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES EPO [308136803] 5.5 percent of total billed charges 4.31 6.6 Technical (Hospital) Services "DILTIAZEM CD/XR/XT 240 MG CAP, EXT RELEASE 24 HR WRAPPER" RX-4080070024 CDM 6370000100 HCPCS 250 RC 10370-0831-09 NDC inpatient 1 UN 6.95 6.95 CIGNA 62308 [3081051] CIGNA 62308 [308105105] 5.5 percent of total billed charges 4.31 6.6 Technical (Hospital) Services "DILTIAZEM CD/XR/XT 240 MG CAP, EXT RELEASE 24 HR WRAPPER" RX-4080070024 CDM 6370000100 HCPCS 250 RC 10370-0831-09 NDC inpatient 1 UN 6.95 6.95 CIGNA 62308 [3081051] CIGNA STATE OF WYOMING [308105107] 5.5 percent of total billed charges 4.31 6.6 Technical (Hospital) Services "DILTIAZEM CD/XR/XT 240 MG CAP, EXT RELEASE 24 HR WRAPPER" RX-4080070024 CDM 6370000100 HCPCS 250 RC 10370-0831-09 NDC inpatient 1 UN 6.95 6.95 MEDICA (COMMERCIAL) 94265 [3081118] MEDICA CLAIMS [308111801] 6.26 percent of total billed charges 4.31 6.6 Technical (Hospital) Services "DILTIAZEM CD/XR/XT 240 MG CAP, EXT RELEASE 24 HR WRAPPER" RX-4080070024 CDM 6370000100 HCPCS 250 RC 10370-0831-09 NDC inpatient 1 UN 6.95 6.95 HEALTHPARTNERS SX009 HEALTHPARTNERS 5.5 percent of total billed charges 4.31 6.6 Technical (Hospital) Services "DILTIAZEM CD/XR/XT 240 MG CAP, EXT RELEASE 24 HR WRAPPER" RX-4080070024 CDM 6370000100 HCPCS 250 RC 10370-0831-09 NDC inpatient 1 UN 6.95 6.95 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES HDHP [308136802] 5.5 percent of total billed charges 4.31 6.6 Technical (Hospital) Services "DILTIAZEM CD/XR/XT 240 MG CAP, EXT RELEASE 24 HR WRAPPER" RX-4080070024 CDM 6370000100 HCPCS 250 RC 10370-0831-09 NDC outpatient 1 UN 6.95 6.95 CIGNA 62308 [3081051] CIGNA 62308 [308105105] 5.56 percent of total billed charges 4.31 6.6 Technical (Hospital) Services "DILTIAZEM CD/XR/XT 240 MG CAP, EXT RELEASE 24 HR WRAPPER" RX-4080070024 CDM 6370000100 HCPCS 250 RC 10370-0831-09 NDC outpatient 1 UN 6.95 6.95 CIGNA 62308 [3081051] CIGNA STATE OF WYOMING [308105107] 5.56 percent of total billed charges 4.31 6.6 Technical (Hospital) Services "DILTIAZEM CD/XR/XT 240 MG CAP, EXT RELEASE 24 HR WRAPPER" RX-4080070024 CDM 6370000100 HCPCS 250 RC 10370-0831-09 NDC outpatient 1 UN 6.95 6.95 MULTIPLAN INC 34080 [3081285] MULTIPLAN INC [308128501] 6.6 percent of total billed charges 4.31 6.6 Technical (Hospital) Services "DILTIAZEM CD/XR/XT 240 MG CAP, EXT RELEASE 24 HR WRAPPER" RX-4080070024 CDM 6370000100 HCPCS 250 RC 10370-0831-09 NDC outpatient 1 UN 6.95 6.95 MEDICA (COMMERCIAL) 94265 [3081118] MEDICA CLAIMS [308111801] 6.26 percent of total billed charges 4.31 6.6 Technical (Hospital) Services "DILTIAZEM CD/XR/XT 240 MG CAP, EXT RELEASE 24 HR WRAPPER" RX-4080070024 CDM 6370000100 HCPCS 250 RC 10370-0831-09 NDC outpatient 1 UN 6.95 6.95 UNITED HEALTHCARE (COMMERCIAL) [3081199] UNITED HEALTHCARE 87726 [308119901] 4.31 percent of total billed charges 4.31 6.6 Technical (Hospital) Services "DILTIAZEM CD/XR/XT 240 MG CAP, EXT RELEASE 24 HR WRAPPER" RX-4080070024 CDM 6370000100 HCPCS 250 RC 10370-0831-09 NDC outpatient 1 UN 6.95 6.95 HEALTHPARTNERS SX009 HEALTHPARTNERS 5.56 percent of total billed charges 4.31 6.6 Technical (Hospital) Services "DILTIAZEM CD/XR/XT 240 MG CAP, EXT RELEASE 24 HR WRAPPER" RX-4080070024 CDM 6370000100 HCPCS 250 RC 10370-0831-09 NDC outpatient 1 UN 6.95 6.95 BLUE CROSS BLUE SHIELD WELLMARK SB889 [3081026] BCBS WYOMING [308102603] 6.6 percent of total billed charges 4.31 6.6 Technical (Hospital) Services "DILTIAZEM CD/XR/XT 240 MG CAP, EXT RELEASE 24 HR WRAPPER" RX-4080070024 CDM 6370000100 HCPCS 250 RC 10370-0831-09 NDC outpatient 1 UN 6.95 6.95 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES EPO [308136803] 5.56 percent of total billed charges 4.31 6.6 Technical (Hospital) Services "DILTIAZEM CD/XR/XT 240 MG CAP, EXT RELEASE 24 HR WRAPPER" RX-4080070024 CDM 6370000100 HCPCS 250 RC 10370-0831-09 NDC outpatient 1 UN 6.95 6.95 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES HDHP [308136802] 5.56 percent of total billed charges 4.31 6.6 Technical (Hospital) Services "DILTIAZEM CD/XR/XT 240 MG CAP, EXT RELEASE 24 HR WRAPPER" RX-4080070024 CDM 6370000100 HCPCS 250 RC 10370-0831-09 NDC outpatient 1 UN 6.95 6.95 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES PPO [308136801] 5.56 percent of total billed charges 4.31 6.6 Technical (Hospital) Services LUBRICATING EYE OINTMENT WRAPPER RX-408007003 CDM 6370000100 HCPCS 250 RC 00065-0518-01 NDC inpatient 4 GR 53.3 53.3 HEALTHPARTNERS SX009 HEALTHPARTNERS 42.2 percent of total billed charges 33.05 50.64 Technical (Hospital) Services LUBRICATING EYE OINTMENT WRAPPER RX-408007003 CDM 6370000100 HCPCS 250 RC 00065-0518-01 NDC inpatient 4 GR 53.3 53.3 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES EPO [308136803] 42.2 percent of total billed charges 33.05 50.64 Technical (Hospital) Services LUBRICATING EYE OINTMENT WRAPPER RX-408007003 CDM 6370000100 HCPCS 250 RC 00065-0518-01 NDC inpatient 4 GR 53.3 53.3 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES PPO [308136801] 42.2 percent of total billed charges 33.05 50.64 Technical (Hospital) Services LUBRICATING EYE OINTMENT WRAPPER RX-408007003 CDM 6370000100 HCPCS 250 RC 00065-0518-01 NDC inpatient 4 GR 53.3 53.3 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES HDHP [308136802] 42.2 percent of total billed charges 33.05 50.64 Technical (Hospital) Services LUBRICATING EYE OINTMENT WRAPPER RX-408007003 CDM 6370000100 HCPCS 250 RC 00065-0518-01 NDC inpatient 4 GR 53.3 53.3 CIGNA 62308 [3081051] CIGNA 62308 [308105105] 42.2 percent of total billed charges 33.05 50.64 Technical (Hospital) Services LUBRICATING EYE OINTMENT WRAPPER RX-408007003 CDM 6370000100 HCPCS 250 RC 00065-0518-01 NDC inpatient 4 GR 53.3 53.3 CIGNA 62308 [3081051] CIGNA STATE OF WYOMING [308105107] 42.2 percent of total billed charges 33.05 50.64 Technical (Hospital) Services LUBRICATING EYE OINTMENT WRAPPER RX-408007003 CDM 6370000100 HCPCS 250 RC 00065-0518-01 NDC inpatient 4 GR 53.3 53.3 BLUE CROSS BLUE SHIELD WELLMARK SB889 [3081026] BCBS WYOMING [308102603] 50.64 percent of total billed charges 33.05 50.64 Technical (Hospital) Services LUBRICATING EYE OINTMENT WRAPPER RX-408007003 CDM 6370000100 HCPCS 250 RC 00065-0518-01 NDC inpatient 4 GR 53.3 53.3 UNITED HEALTHCARE (COMMERCIAL) [3081199] UNITED HEALTHCARE 87726 [308119901] 33.05 percent of total billed charges 33.05 50.64 Technical (Hospital) Services LUBRICATING EYE OINTMENT WRAPPER RX-408007003 CDM 6370000100 HCPCS 250 RC 00065-0518-01 NDC inpatient 4 GR 53.3 53.3 MEDICA (COMMERCIAL) 94265 [3081118] MEDICA CLAIMS [308111801] 47.97 percent of total billed charges 33.05 50.64 Technical (Hospital) Services LUBRICATING EYE OINTMENT WRAPPER RX-408007003 CDM 6370000100 HCPCS 250 RC 00065-0518-01 NDC inpatient 4 GR 53.3 53.3 MULTIPLAN INC 34080 [3081285] MULTIPLAN INC [308128501] 50.64 percent of total billed charges 33.05 50.64 Technical (Hospital) Services LUBRICATING EYE OINTMENT WRAPPER RX-408007003 CDM 6370000100 HCPCS 250 RC 00065-0518-01 NDC outpatient 4 GR 53.3 53.3 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES EPO [308136803] 42.64 percent of total billed charges 33.05 50.64 Technical (Hospital) Services LUBRICATING EYE OINTMENT WRAPPER RX-408007003 CDM 6370000100 HCPCS 250 RC 00065-0518-01 NDC outpatient 4 GR 53.3 53.3 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES HDHP [308136802] 42.64 percent of total billed charges 33.05 50.64 Technical (Hospital) Services LUBRICATING EYE OINTMENT WRAPPER RX-408007003 CDM 6370000100 HCPCS 250 RC 00065-0518-01 NDC outpatient 4 GR 53.3 53.3 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES PPO [308136801] 42.64 percent of total billed charges 33.05 50.64 Technical (Hospital) Services LUBRICATING EYE OINTMENT WRAPPER RX-408007003 CDM 6370000100 HCPCS 250 RC 00065-0518-01 NDC outpatient 4 GR 53.3 53.3 BLUE CROSS BLUE SHIELD WELLMARK SB889 [3081026] BCBS WYOMING [308102603] 50.64 percent of total billed charges 33.05 50.64 Technical (Hospital) Services LUBRICATING EYE OINTMENT WRAPPER RX-408007003 CDM 6370000100 HCPCS 250 RC 00065-0518-01 NDC outpatient 4 GR 53.3 53.3 UNITED HEALTHCARE (COMMERCIAL) [3081199] UNITED HEALTHCARE 87726 [308119901] 33.05 percent of total billed charges 33.05 50.64 Technical (Hospital) Services LUBRICATING EYE OINTMENT WRAPPER RX-408007003 CDM 6370000100 HCPCS 250 RC 00065-0518-01 NDC outpatient 4 GR 53.3 53.3 HEALTHPARTNERS SX009 HEALTHPARTNERS 42.64 percent of total billed charges 33.05 50.64 Technical (Hospital) Services LUBRICATING EYE OINTMENT WRAPPER RX-408007003 CDM 6370000100 HCPCS 250 RC 00065-0518-01 NDC outpatient 4 GR 53.3 53.3 CIGNA 62308 [3081051] CIGNA 62308 [308105105] 42.64 percent of total billed charges 33.05 50.64 Technical (Hospital) Services LUBRICATING EYE OINTMENT WRAPPER RX-408007003 CDM 6370000100 HCPCS 250 RC 00065-0518-01 NDC outpatient 4 GR 53.3 53.3 CIGNA 62308 [3081051] CIGNA STATE OF WYOMING [308105107] 42.64 percent of total billed charges 33.05 50.64 Technical (Hospital) Services LUBRICATING EYE OINTMENT WRAPPER RX-408007003 CDM 6370000100 HCPCS 250 RC 00065-0518-01 NDC outpatient 4 GR 53.3 53.3 MULTIPLAN INC 34080 [3081285] MULTIPLAN INC [308128501] 50.64 percent of total billed charges 33.05 50.64 Technical (Hospital) Services LUBRICATING EYE OINTMENT WRAPPER RX-408007003 CDM 6370000100 HCPCS 250 RC 00065-0518-01 NDC outpatient 4 GR 53.3 53.3 MEDICA (COMMERCIAL) 94265 [3081118] MEDICA CLAIMS [308111801] 47.97 percent of total billed charges 33.05 50.64 Technical (Hospital) Services WCH LET GEL KIT RX-4080070030 CDM 6370000100 HCPCS 250 RC 09999-7010-00 NDC inpatient 3 ML 14.82 14.82 MULTIPLAN INC 34080 [3081285] MULTIPLAN INC [308128501] 14.08 percent of total billed charges 9.19 14.08 Technical (Hospital) Services WCH LET GEL KIT RX-4080070030 CDM 6370000100 HCPCS 250 RC 09999-7010-00 NDC inpatient 3 ML 14.82 14.82 MEDICA (COMMERCIAL) 94265 [3081118] MEDICA CLAIMS [308111801] 13.34 percent of total billed charges 9.19 14.08 Technical (Hospital) Services WCH LET GEL KIT RX-4080070030 CDM 6370000100 HCPCS 250 RC 09999-7010-00 NDC inpatient 3 ML 14.82 14.82 CIGNA 62308 [3081051] CIGNA STATE OF WYOMING [308105107] 11.73 percent of total billed charges 9.19 14.08 Technical (Hospital) Services WCH LET GEL KIT RX-4080070030 CDM 6370000100 HCPCS 250 RC 09999-7010-00 NDC inpatient 3 ML 14.82 14.82 CIGNA 62308 [3081051] CIGNA 62308 [308105105] 11.73 percent of total billed charges 9.19 14.08 Technical (Hospital) Services WCH LET GEL KIT RX-4080070030 CDM 6370000100 HCPCS 250 RC 09999-7010-00 NDC inpatient 3 ML 14.82 14.82 UNITED HEALTHCARE (COMMERCIAL) [3081199] UNITED HEALTHCARE 87726 [308119901] 9.19 percent of total billed charges 9.19 14.08 Technical (Hospital) Services WCH LET GEL KIT RX-4080070030 CDM 6370000100 HCPCS 250 RC 09999-7010-00 NDC inpatient 3 ML 14.82 14.82 BLUE CROSS BLUE SHIELD WELLMARK SB889 [3081026] BCBS WYOMING [308102603] 14.08 percent of total billed charges 9.19 14.08 Technical (Hospital) Services WCH LET GEL KIT RX-4080070030 CDM 6370000100 HCPCS 250 RC 09999-7010-00 NDC inpatient 3 ML 14.82 14.82 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES HDHP [308136802] 11.73 percent of total billed charges 9.19 14.08 Technical (Hospital) Services WCH LET GEL KIT RX-4080070030 CDM 6370000100 HCPCS 250 RC 09999-7010-00 NDC inpatient 3 ML 14.82 14.82 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES EPO [308136803] 11.73 percent of total billed charges 9.19 14.08 Technical (Hospital) Services WCH LET GEL KIT RX-4080070030 CDM 6370000100 HCPCS 250 RC 09999-7010-00 NDC inpatient 3 ML 14.82 14.82 HEALTHPARTNERS SX009 HEALTHPARTNERS 11.73 percent of total billed charges 9.19 14.08 Technical (Hospital) Services WCH LET GEL KIT RX-4080070030 CDM 6370000100 HCPCS 250 RC 09999-7010-00 NDC inpatient 3 ML 14.82 14.82 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES PPO [308136801] 11.73 percent of total billed charges 9.19 14.08 Technical (Hospital) Services WCH LET GEL KIT RX-4080070030 CDM 6370000100 HCPCS 250 RC 09999-7010-00 NDC outpatient 3 ML 14.82 14.82 MEDICA (COMMERCIAL) 94265 [3081118] MEDICA CLAIMS [308111801] 13.34 percent of total billed charges 9.19 14.08 Technical (Hospital) Services WCH LET GEL KIT RX-4080070030 CDM 6370000100 HCPCS 250 RC 09999-7010-00 NDC outpatient 3 ML 14.82 14.82 MULTIPLAN INC 34080 [3081285] MULTIPLAN INC [308128501] 14.08 percent of total billed charges 9.19 14.08 Technical (Hospital) Services WCH LET GEL KIT RX-4080070030 CDM 6370000100 HCPCS 250 RC 09999-7010-00 NDC outpatient 3 ML 14.82 14.82 HEALTHPARTNERS SX009 HEALTHPARTNERS 11.86 percent of total billed charges 9.19 14.08 Technical (Hospital) Services WCH LET GEL KIT RX-4080070030 CDM 6370000100 HCPCS 250 RC 09999-7010-00 NDC outpatient 3 ML 14.82 14.82 UNITED HEALTHCARE (COMMERCIAL) [3081199] UNITED HEALTHCARE 87726 [308119901] 9.19 percent of total billed charges 9.19 14.08 Technical (Hospital) Services WCH LET GEL KIT RX-4080070030 CDM 6370000100 HCPCS 250 RC 09999-7010-00 NDC outpatient 3 ML 14.82 14.82 CIGNA 62308 [3081051] CIGNA 62308 [308105105] 11.86 percent of total billed charges 9.19 14.08 Technical (Hospital) Services WCH LET GEL KIT RX-4080070030 CDM 6370000100 HCPCS 250 RC 09999-7010-00 NDC outpatient 3 ML 14.82 14.82 CIGNA 62308 [3081051] CIGNA STATE OF WYOMING [308105107] 11.86 percent of total billed charges 9.19 14.08 Technical (Hospital) Services WCH LET GEL KIT RX-4080070030 CDM 6370000100 HCPCS 250 RC 09999-7010-00 NDC outpatient 3 ML 14.82 14.82 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES EPO [308136803] 11.86 percent of total billed charges 9.19 14.08 Technical (Hospital) Services WCH LET GEL KIT RX-4080070030 CDM 6370000100 HCPCS 250 RC 09999-7010-00 NDC outpatient 3 ML 14.82 14.82 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES HDHP [308136802] 11.86 percent of total billed charges 9.19 14.08 Technical (Hospital) Services WCH LET GEL KIT RX-4080070030 CDM 6370000100 HCPCS 250 RC 09999-7010-00 NDC outpatient 3 ML 14.82 14.82 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES PPO [308136801] 11.86 percent of total billed charges 9.19 14.08 Technical (Hospital) Services WCH LET GEL KIT RX-4080070030 CDM 6370000100 HCPCS 250 RC 09999-7010-00 NDC outpatient 3 ML 14.82 14.82 BLUE CROSS BLUE SHIELD WELLMARK SB889 [3081026] BCBS WYOMING [308102603] 14.08 percent of total billed charges 9.19 14.08 Technical (Hospital) Services POTASSIUM CHLORIDE ER 10 MEQ TABLET WRAPPER RX-408050005 CDM 6370000100 HCPCS 250 RC 00245-5316-15 NDC inpatient 1 UN 6.07 6.07 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES HDHP [308136802] 4.81 percent of total billed charges 3.76 5.77 Technical (Hospital) Services POTASSIUM CHLORIDE ER 10 MEQ TABLET WRAPPER RX-408050005 CDM 6370000100 HCPCS 250 RC 00245-5316-15 NDC inpatient 1 UN 6.07 6.07 CIGNA 62308 [3081051] CIGNA 62308 [308105105] 4.81 percent of total billed charges 3.76 5.77 Technical (Hospital) Services POTASSIUM CHLORIDE ER 10 MEQ TABLET WRAPPER RX-408050005 CDM 6370000100 HCPCS 250 RC 00245-5316-15 NDC inpatient 1 UN 6.07 6.07 CIGNA 62308 [3081051] CIGNA STATE OF WYOMING [308105107] 4.81 percent of total billed charges 3.76 5.77 Technical (Hospital) Services POTASSIUM CHLORIDE ER 10 MEQ TABLET WRAPPER RX-408050005 CDM 6370000100 HCPCS 250 RC 00245-5316-15 NDC inpatient 1 UN 6.07 6.07 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES EPO [308136803] 4.81 percent of total billed charges 3.76 5.77 Technical (Hospital) Services POTASSIUM CHLORIDE ER 10 MEQ TABLET WRAPPER RX-408050005 CDM 6370000100 HCPCS 250 RC 00245-5316-15 NDC inpatient 1 UN 6.07 6.07 UNITED HEALTHCARE (COMMERCIAL) [3081199] UNITED HEALTHCARE 87726 [308119901] 3.76 percent of total billed charges 3.76 5.77 Technical (Hospital) Services POTASSIUM CHLORIDE ER 10 MEQ TABLET WRAPPER RX-408050005 CDM 6370000100 HCPCS 250 RC 00245-5316-15 NDC inpatient 1 UN 6.07 6.07 BLUE CROSS BLUE SHIELD WELLMARK SB889 [3081026] BCBS WYOMING [308102603] 5.77 percent of total billed charges 3.76 5.77 Technical (Hospital) Services POTASSIUM CHLORIDE ER 10 MEQ TABLET WRAPPER RX-408050005 CDM 6370000100 HCPCS 250 RC 00245-5316-15 NDC inpatient 1 UN 6.07 6.07 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES PPO [308136801] 4.81 percent of total billed charges 3.76 5.77 Technical (Hospital) Services POTASSIUM CHLORIDE ER 10 MEQ TABLET WRAPPER RX-408050005 CDM 6370000100 HCPCS 250 RC 00245-5316-15 NDC inpatient 1 UN 6.07 6.07 HEALTHPARTNERS SX009 HEALTHPARTNERS 4.81 percent of total billed charges 3.76 5.77 Technical (Hospital) Services POTASSIUM CHLORIDE ER 10 MEQ TABLET WRAPPER RX-408050005 CDM 6370000100 HCPCS 250 RC 00245-5316-15 NDC inpatient 1 UN 6.07 6.07 MEDICA (COMMERCIAL) 94265 [3081118] MEDICA CLAIMS [308111801] 5.46 percent of total billed charges 3.76 5.77 Technical (Hospital) Services POTASSIUM CHLORIDE ER 10 MEQ TABLET WRAPPER RX-408050005 CDM 6370000100 HCPCS 250 RC 00245-5316-15 NDC inpatient 1 UN 6.07 6.07 MULTIPLAN INC 34080 [3081285] MULTIPLAN INC [308128501] 5.77 percent of total billed charges 3.76 5.77 Technical (Hospital) Services POTASSIUM CHLORIDE ER 10 MEQ TABLET WRAPPER RX-408050005 CDM 6370000100 HCPCS 250 RC 00245-5316-15 NDC outpatient 1 UN 6.07 6.07 BLUE CROSS BLUE SHIELD WELLMARK SB889 [3081026] BCBS WYOMING [308102603] 5.77 percent of total billed charges 3.76 5.77 Technical (Hospital) Services POTASSIUM CHLORIDE ER 10 MEQ TABLET WRAPPER RX-408050005 CDM 6370000100 HCPCS 250 RC 00245-5316-15 NDC outpatient 1 UN 6.07 6.07 HEALTHPARTNERS SX009 HEALTHPARTNERS 4.86 percent of total billed charges 3.76 5.77 Technical (Hospital) Services POTASSIUM CHLORIDE ER 10 MEQ TABLET WRAPPER RX-408050005 CDM 6370000100 HCPCS 250 RC 00245-5316-15 NDC outpatient 1 UN 6.07 6.07 UNITED HEALTHCARE (COMMERCIAL) [3081199] UNITED HEALTHCARE 87726 [308119901] 3.76 percent of total billed charges 3.76 5.77 Technical (Hospital) Services POTASSIUM CHLORIDE ER 10 MEQ TABLET WRAPPER RX-408050005 CDM 6370000100 HCPCS 250 RC 00245-5316-15 NDC outpatient 1 UN 6.07 6.07 MULTIPLAN INC 34080 [3081285] MULTIPLAN INC [308128501] 5.77 percent of total billed charges 3.76 5.77 Technical (Hospital) Services POTASSIUM CHLORIDE ER 10 MEQ TABLET WRAPPER RX-408050005 CDM 6370000100 HCPCS 250 RC 00245-5316-15 NDC outpatient 1 UN 6.07 6.07 CIGNA 62308 [3081051] CIGNA 62308 [308105105] 4.86 percent of total billed charges 3.76 5.77 Technical (Hospital) Services POTASSIUM CHLORIDE ER 10 MEQ TABLET WRAPPER RX-408050005 CDM 6370000100 HCPCS 250 RC 00245-5316-15 NDC outpatient 1 UN 6.07 6.07 CIGNA 62308 [3081051] CIGNA STATE OF WYOMING [308105107] 4.86 percent of total billed charges 3.76 5.77 Technical (Hospital) Services POTASSIUM CHLORIDE ER 10 MEQ TABLET WRAPPER RX-408050005 CDM 6370000100 HCPCS 250 RC 00245-5316-15 NDC outpatient 1 UN 6.07 6.07 MEDICA (COMMERCIAL) 94265 [3081118] MEDICA CLAIMS [308111801] 5.46 percent of total billed charges 3.76 5.77 Technical (Hospital) Services POTASSIUM CHLORIDE ER 10 MEQ TABLET WRAPPER RX-408050005 CDM 6370000100 HCPCS 250 RC 00245-5316-15 NDC outpatient 1 UN 6.07 6.07 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES EPO [308136803] 4.86 percent of total billed charges 3.76 5.77 Technical (Hospital) Services POTASSIUM CHLORIDE ER 10 MEQ TABLET WRAPPER RX-408050005 CDM 6370000100 HCPCS 250 RC 00245-5316-15 NDC outpatient 1 UN 6.07 6.07 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES HDHP [308136802] 4.86 percent of total billed charges 3.76 5.77 Technical (Hospital) Services POTASSIUM CHLORIDE ER 10 MEQ TABLET WRAPPER RX-408050005 CDM 6370000100 HCPCS 250 RC 00245-5316-15 NDC outpatient 1 UN 6.07 6.07 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES PPO [308136801] 4.86 percent of total billed charges 3.76 5.77 Technical (Hospital) Services WCH ED AMOXICILLIN 400 MG/5 ML #100 ML RX-408400102 CDM 6370000100 HCPCS 250 RC 09999-3084-01 NDC outpatient 8000 ME 20.25 20.25 CIGNA 62308 [3081051] CIGNA 62308 [308105105] 16.2 percent of total billed charges 12.56 19.24 Technical (Hospital) Services WCH ED AMOXICILLIN 400 MG/5 ML #100 ML RX-408400102 CDM 6370000100 HCPCS 250 RC 09999-3084-01 NDC outpatient 8000 ME 20.25 20.25 CIGNA 62308 [3081051] CIGNA STATE OF WYOMING [308105107] 16.2 percent of total billed charges 12.56 19.24 Technical (Hospital) Services WCH ED AMOXICILLIN 400 MG/5 ML #100 ML RX-408400102 CDM 6370000100 HCPCS 250 RC 09999-3084-01 NDC outpatient 8000 ME 20.25 20.25 MULTIPLAN INC 34080 [3081285] MULTIPLAN INC [308128501] 19.24 percent of total billed charges 12.56 19.24 Technical (Hospital) Services WCH ED AMOXICILLIN 400 MG/5 ML #100 ML RX-408400102 CDM 6370000100 HCPCS 250 RC 09999-3084-01 NDC outpatient 8000 ME 20.25 20.25 MEDICA (COMMERCIAL) 94265 [3081118] MEDICA CLAIMS [308111801] 18.23 percent of total billed charges 12.56 19.24 Technical (Hospital) Services WCH ED AMOXICILLIN 400 MG/5 ML #100 ML RX-408400102 CDM 6370000100 HCPCS 250 RC 09999-3084-01 NDC outpatient 8000 ME 20.25 20.25 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES EPO [308136803] 16.2 percent of total billed charges 12.56 19.24 Technical (Hospital) Services WCH ED AMOXICILLIN 400 MG/5 ML #100 ML RX-408400102 CDM 6370000100 HCPCS 250 RC 09999-3084-01 NDC outpatient 8000 ME 20.25 20.25 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES HDHP [308136802] 16.2 percent of total billed charges 12.56 19.24 Technical (Hospital) Services WCH ED AMOXICILLIN 400 MG/5 ML #100 ML RX-408400102 CDM 6370000100 HCPCS 250 RC 09999-3084-01 NDC outpatient 8000 ME 20.25 20.25 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES PPO [308136801] 16.2 percent of total billed charges 12.56 19.24 Technical (Hospital) Services WCH ED AMOXICILLIN 400 MG/5 ML #100 ML RX-408400102 CDM 6370000100 HCPCS 250 RC 09999-3084-01 NDC outpatient 8000 ME 20.25 20.25 BLUE CROSS BLUE SHIELD WELLMARK SB889 [3081026] BCBS WYOMING [308102603] 19.24 percent of total billed charges 12.56 19.24 Technical (Hospital) Services WCH ED AMOXICILLIN 400 MG/5 ML #100 ML RX-408400102 CDM 6370000100 HCPCS 250 RC 09999-3084-01 NDC outpatient 8000 ME 20.25 20.25 UNITED HEALTHCARE (COMMERCIAL) [3081199] UNITED HEALTHCARE 87726 [308119901] 12.56 percent of total billed charges 12.56 19.24 Technical (Hospital) Services WCH ED AMOXICILLIN 400 MG/5 ML #100 ML RX-408400102 CDM 6370000100 HCPCS 250 RC 09999-3084-01 NDC outpatient 8000 ME 20.25 20.25 HEALTHPARTNERS SX009 HEALTHPARTNERS 16.2 percent of total billed charges 12.56 19.24 Technical (Hospital) Services WCH ED AMOXICILLIN 400 MG/5 ML #100 ML RX-408400102 CDM 6370000100 HCPCS 250 RC 09999-3084-01 NDC inpatient 8000 ME 20.25 20.25 CIGNA 62308 [3081051] CIGNA 62308 [308105105] 16.03 percent of total billed charges 12.56 19.24 Technical (Hospital) Services WCH ED AMOXICILLIN 400 MG/5 ML #100 ML RX-408400102 CDM 6370000100 HCPCS 250 RC 09999-3084-01 NDC inpatient 8000 ME 20.25 20.25 CIGNA 62308 [3081051] CIGNA STATE OF WYOMING [308105107] 16.03 percent of total billed charges 12.56 19.24 Technical (Hospital) Services WCH ED AMOXICILLIN 400 MG/5 ML #100 ML RX-408400102 CDM 6370000100 HCPCS 250 RC 09999-3084-01 NDC inpatient 8000 ME 20.25 20.25 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES EPO [308136803] 16.03 percent of total billed charges 12.56 19.24 Technical (Hospital) Services WCH ED AMOXICILLIN 400 MG/5 ML #100 ML RX-408400102 CDM 6370000100 HCPCS 250 RC 09999-3084-01 NDC inpatient 8000 ME 20.25 20.25 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES HDHP [308136802] 16.03 percent of total billed charges 12.56 19.24 Technical (Hospital) Services WCH ED AMOXICILLIN 400 MG/5 ML #100 ML RX-408400102 CDM 6370000100 HCPCS 250 RC 09999-3084-01 NDC inpatient 8000 ME 20.25 20.25 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES PPO [308136801] 16.03 percent of total billed charges 12.56 19.24 Technical (Hospital) Services WCH ED AMOXICILLIN 400 MG/5 ML #100 ML RX-408400102 CDM 6370000100 HCPCS 250 RC 09999-3084-01 NDC inpatient 8000 ME 20.25 20.25 BLUE CROSS BLUE SHIELD WELLMARK SB889 [3081026] BCBS WYOMING [308102603] 19.24 percent of total billed charges 12.56 19.24 Technical (Hospital) Services WCH ED AMOXICILLIN 400 MG/5 ML #100 ML RX-408400102 CDM 6370000100 HCPCS 250 RC 09999-3084-01 NDC inpatient 8000 ME 20.25 20.25 UNITED HEALTHCARE (COMMERCIAL) [3081199] UNITED HEALTHCARE 87726 [308119901] 12.56 percent of total billed charges 12.56 19.24 Technical (Hospital) Services WCH ED AMOXICILLIN 400 MG/5 ML #100 ML RX-408400102 CDM 6370000100 HCPCS 250 RC 09999-3084-01 NDC inpatient 8000 ME 20.25 20.25 HEALTHPARTNERS SX009 HEALTHPARTNERS 16.03 percent of total billed charges 12.56 19.24 Technical (Hospital) Services WCH ED AMOXICILLIN 400 MG/5 ML #100 ML RX-408400102 CDM 6370000100 HCPCS 250 RC 09999-3084-01 NDC inpatient 8000 ME 20.25 20.25 MULTIPLAN INC 34080 [3081285] MULTIPLAN INC [308128501] 19.24 percent of total billed charges 12.56 19.24 Technical (Hospital) Services WCH ED AMOXICILLIN 400 MG/5 ML #100 ML RX-408400102 CDM 6370000100 HCPCS 250 RC 09999-3084-01 NDC inpatient 8000 ME 20.25 20.25 MEDICA (COMMERCIAL) 94265 [3081118] MEDICA CLAIMS [308111801] 18.23 percent of total billed charges 12.56 19.24 Technical (Hospital) Services WCH ED ACETAMINOPHEN 120 MG-CODEINE 12 MG/5 ML ORAL LIQUID #30ML RX-40880410000 CDM 6370000100 HCPCS 250 RC 09999-9990-00 NDC inpatient 30 ML 21.19 21.19 CIGNA 62308 [3081051] CIGNA 62308 [308105105] 16.78 percent of total billed charges 13.14 20.13 Technical (Hospital) Services WCH ED ACETAMINOPHEN 120 MG-CODEINE 12 MG/5 ML ORAL LIQUID #30ML RX-40880410000 CDM 6370000100 HCPCS 250 RC 09999-9990-00 NDC inpatient 30 ML 21.19 21.19 CIGNA 62308 [3081051] CIGNA STATE OF WYOMING [308105107] 16.78 percent of total billed charges 13.14 20.13 Technical (Hospital) Services WCH ED ACETAMINOPHEN 120 MG-CODEINE 12 MG/5 ML ORAL LIQUID #30ML RX-40880410000 CDM 6370000100 HCPCS 250 RC 09999-9990-00 NDC inpatient 30 ML 21.19 21.19 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES EPO [308136803] 16.78 percent of total billed charges 13.14 20.13 Technical (Hospital) Services WCH ED ACETAMINOPHEN 120 MG-CODEINE 12 MG/5 ML ORAL LIQUID #30ML RX-40880410000 CDM 6370000100 HCPCS 250 RC 09999-9990-00 NDC inpatient 30 ML 21.19 21.19 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES PPO [308136801] 16.78 percent of total billed charges 13.14 20.13 Technical (Hospital) Services WCH ED ACETAMINOPHEN 120 MG-CODEINE 12 MG/5 ML ORAL LIQUID #30ML RX-40880410000 CDM 6370000100 HCPCS 250 RC 09999-9990-00 NDC inpatient 30 ML 21.19 21.19 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES HDHP [308136802] 16.78 percent of total billed charges 13.14 20.13 Technical (Hospital) Services WCH ED ACETAMINOPHEN 120 MG-CODEINE 12 MG/5 ML ORAL LIQUID #30ML RX-40880410000 CDM 6370000100 HCPCS 250 RC 09999-9990-00 NDC inpatient 30 ML 21.19 21.19 BLUE CROSS BLUE SHIELD WELLMARK SB889 [3081026] BCBS WYOMING [308102603] 20.13 percent of total billed charges 13.14 20.13 Technical (Hospital) Services WCH ED ACETAMINOPHEN 120 MG-CODEINE 12 MG/5 ML ORAL LIQUID #30ML RX-40880410000 CDM 6370000100 HCPCS 250 RC 09999-9990-00 NDC inpatient 30 ML 21.19 21.19 UNITED HEALTHCARE (COMMERCIAL) [3081199] UNITED HEALTHCARE 87726 [308119901] 13.14 percent of total billed charges 13.14 20.13 Technical (Hospital) Services WCH ED ACETAMINOPHEN 120 MG-CODEINE 12 MG/5 ML ORAL LIQUID #30ML RX-40880410000 CDM 6370000100 HCPCS 250 RC 09999-9990-00 NDC inpatient 30 ML 21.19 21.19 HEALTHPARTNERS SX009 HEALTHPARTNERS 16.78 percent of total billed charges 13.14 20.13 Technical (Hospital) Services WCH ED ACETAMINOPHEN 120 MG-CODEINE 12 MG/5 ML ORAL LIQUID #30ML RX-40880410000 CDM 6370000100 HCPCS 250 RC 09999-9990-00 NDC inpatient 30 ML 21.19 21.19 MULTIPLAN INC 34080 [3081285] MULTIPLAN INC [308128501] 20.13 percent of total billed charges 13.14 20.13 Technical (Hospital) Services WCH ED ACETAMINOPHEN 120 MG-CODEINE 12 MG/5 ML ORAL LIQUID #30ML RX-40880410000 CDM 6370000100 HCPCS 250 RC 09999-9990-00 NDC inpatient 30 ML 21.19 21.19 MEDICA (COMMERCIAL) 94265 [3081118] MEDICA CLAIMS [308111801] 19.07 percent of total billed charges 13.14 20.13 Technical (Hospital) Services WCH ED ACETAMINOPHEN 120 MG-CODEINE 12 MG/5 ML ORAL LIQUID #30ML RX-40880410000 CDM 6370000100 HCPCS 250 RC 09999-9990-00 NDC outpatient 30 ML 21.19 21.19 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES EPO [308136803] 16.95 percent of total billed charges 13.14 20.13 Technical (Hospital) Services WCH ED ACETAMINOPHEN 120 MG-CODEINE 12 MG/5 ML ORAL LIQUID #30ML RX-40880410000 CDM 6370000100 HCPCS 250 RC 09999-9990-00 NDC outpatient 30 ML 21.19 21.19 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES HDHP [308136802] 16.95 percent of total billed charges 13.14 20.13 Technical (Hospital) Services WCH ED ACETAMINOPHEN 120 MG-CODEINE 12 MG/5 ML ORAL LIQUID #30ML RX-40880410000 CDM 6370000100 HCPCS 250 RC 09999-9990-00 NDC outpatient 30 ML 21.19 21.19 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES PPO [308136801] 16.95 percent of total billed charges 13.14 20.13 Technical (Hospital) Services WCH ED ACETAMINOPHEN 120 MG-CODEINE 12 MG/5 ML ORAL LIQUID #30ML RX-40880410000 CDM 6370000100 HCPCS 250 RC 09999-9990-00 NDC outpatient 30 ML 21.19 21.19 UNITED HEALTHCARE (COMMERCIAL) [3081199] UNITED HEALTHCARE 87726 [308119901] 13.14 percent of total billed charges 13.14 20.13 Technical (Hospital) Services WCH ED ACETAMINOPHEN 120 MG-CODEINE 12 MG/5 ML ORAL LIQUID #30ML RX-40880410000 CDM 6370000100 HCPCS 250 RC 09999-9990-00 NDC outpatient 30 ML 21.19 21.19 BLUE CROSS BLUE SHIELD WELLMARK SB889 [3081026] BCBS WYOMING [308102603] 20.13 percent of total billed charges 13.14 20.13 Technical (Hospital) Services WCH ED ACETAMINOPHEN 120 MG-CODEINE 12 MG/5 ML ORAL LIQUID #30ML RX-40880410000 CDM 6370000100 HCPCS 250 RC 09999-9990-00 NDC outpatient 30 ML 21.19 21.19 HEALTHPARTNERS SX009 HEALTHPARTNERS 16.95 percent of total billed charges 13.14 20.13 Technical (Hospital) Services WCH ED ACETAMINOPHEN 120 MG-CODEINE 12 MG/5 ML ORAL LIQUID #30ML RX-40880410000 CDM 6370000100 HCPCS 250 RC 09999-9990-00 NDC outpatient 30 ML 21.19 21.19 CIGNA 62308 [3081051] CIGNA 62308 [308105105] 16.95 percent of total billed charges 13.14 20.13 Technical (Hospital) Services WCH ED ACETAMINOPHEN 120 MG-CODEINE 12 MG/5 ML ORAL LIQUID #30ML RX-40880410000 CDM 6370000100 HCPCS 250 RC 09999-9990-00 NDC outpatient 30 ML 21.19 21.19 CIGNA 62308 [3081051] CIGNA STATE OF WYOMING [308105107] 16.95 percent of total billed charges 13.14 20.13 Technical (Hospital) Services WCH ED ACETAMINOPHEN 120 MG-CODEINE 12 MG/5 ML ORAL LIQUID #30ML RX-40880410000 CDM 6370000100 HCPCS 250 RC 09999-9990-00 NDC outpatient 30 ML 21.19 21.19 MULTIPLAN INC 34080 [3081285] MULTIPLAN INC [308128501] 20.13 percent of total billed charges 13.14 20.13 Technical (Hospital) Services WCH ED ACETAMINOPHEN 120 MG-CODEINE 12 MG/5 ML ORAL LIQUID #30ML RX-40880410000 CDM 6370000100 HCPCS 250 RC 09999-9990-00 NDC outpatient 30 ML 21.19 21.19 MEDICA (COMMERCIAL) 94265 [3081118] MEDICA CLAIMS [308111801] 19.07 percent of total billed charges 13.14 20.13 Technical (Hospital) Services WCH ED CEFPROZIL 250 MG/5 ML ORAL LIQUID #50ML RX-4088400012 CDM 6370000100 HCPCS 250 RC 09999-9990-07 NDC outpatient 2500 ME 43.05 43.05 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES EPO [308136803] 34.44 percent of total billed charges 26.69 40.9 Technical (Hospital) Services WCH ED CEFPROZIL 250 MG/5 ML ORAL LIQUID #50ML RX-4088400012 CDM 6370000100 HCPCS 250 RC 09999-9990-07 NDC outpatient 2500 ME 43.05 43.05 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES HDHP [308136802] 34.44 percent of total billed charges 26.69 40.9 Technical (Hospital) Services WCH ED CEFPROZIL 250 MG/5 ML ORAL LIQUID #50ML RX-4088400012 CDM 6370000100 HCPCS 250 RC 09999-9990-07 NDC outpatient 2500 ME 43.05 43.05 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES PPO [308136801] 34.44 percent of total billed charges 26.69 40.9 Technical (Hospital) Services WCH ED CEFPROZIL 250 MG/5 ML ORAL LIQUID #50ML RX-4088400012 CDM 6370000100 HCPCS 250 RC 09999-9990-07 NDC outpatient 2500 ME 43.05 43.05 BLUE CROSS BLUE SHIELD WELLMARK SB889 [3081026] BCBS WYOMING [308102603] 40.9 percent of total billed charges 26.69 40.9 Technical (Hospital) Services WCH ED CEFPROZIL 250 MG/5 ML ORAL LIQUID #50ML RX-4088400012 CDM 6370000100 HCPCS 250 RC 09999-9990-07 NDC outpatient 2500 ME 43.05 43.05 UNITED HEALTHCARE (COMMERCIAL) [3081199] UNITED HEALTHCARE 87726 [308119901] 26.69 percent of total billed charges 26.69 40.9 Technical (Hospital) Services WCH ED CEFPROZIL 250 MG/5 ML ORAL LIQUID #50ML RX-4088400012 CDM 6370000100 HCPCS 250 RC 09999-9990-07 NDC outpatient 2500 ME 43.05 43.05 MULTIPLAN INC 34080 [3081285] MULTIPLAN INC [308128501] 40.9 percent of total billed charges 26.69 40.9 Technical (Hospital) Services WCH ED CEFPROZIL 250 MG/5 ML ORAL LIQUID #50ML RX-4088400012 CDM 6370000100 HCPCS 250 RC 09999-9990-07 NDC outpatient 2500 ME 43.05 43.05 MEDICA (COMMERCIAL) 94265 [3081118] MEDICA CLAIMS [308111801] 38.75 percent of total billed charges 26.69 40.9 Technical (Hospital) Services WCH ED CEFPROZIL 250 MG/5 ML ORAL LIQUID #50ML RX-4088400012 CDM 6370000100 HCPCS 250 RC 09999-9990-07 NDC outpatient 2500 ME 43.05 43.05 HEALTHPARTNERS SX009 HEALTHPARTNERS 34.44 percent of total billed charges 26.69 40.9 Technical (Hospital) Services WCH ED CEFPROZIL 250 MG/5 ML ORAL LIQUID #50ML RX-4088400012 CDM 6370000100 HCPCS 250 RC 09999-9990-07 NDC outpatient 2500 ME 43.05 43.05 CIGNA 62308 [3081051] CIGNA 62308 [308105105] 34.44 percent of total billed charges 26.69 40.9 Technical (Hospital) Services WCH ED CEFPROZIL 250 MG/5 ML ORAL LIQUID #50ML RX-4088400012 CDM 6370000100 HCPCS 250 RC 09999-9990-07 NDC outpatient 2500 ME 43.05 43.05 CIGNA 62308 [3081051] CIGNA STATE OF WYOMING [308105107] 34.44 percent of total billed charges 26.69 40.9 Technical (Hospital) Services WCH ED CEFPROZIL 250 MG/5 ML ORAL LIQUID #50ML RX-4088400012 CDM 6370000100 HCPCS 250 RC 09999-9990-07 NDC inpatient 2500 ME 43.05 43.05 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES EPO [308136803] 34.09 percent of total billed charges 26.69 40.9 Technical (Hospital) Services WCH ED CEFPROZIL 250 MG/5 ML ORAL LIQUID #50ML RX-4088400012 CDM 6370000100 HCPCS 250 RC 09999-9990-07 NDC inpatient 2500 ME 43.05 43.05 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES HDHP [308136802] 34.09 percent of total billed charges 26.69 40.9 Technical (Hospital) Services WCH ED CEFPROZIL 250 MG/5 ML ORAL LIQUID #50ML RX-4088400012 CDM 6370000100 HCPCS 250 RC 09999-9990-07 NDC inpatient 2500 ME 43.05 43.05 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES PPO [308136801] 34.09 percent of total billed charges 26.69 40.9 Technical (Hospital) Services WCH ED CEFPROZIL 250 MG/5 ML ORAL LIQUID #50ML RX-4088400012 CDM 6370000100 HCPCS 250 RC 09999-9990-07 NDC inpatient 2500 ME 43.05 43.05 CIGNA 62308 [3081051] CIGNA 62308 [308105105] 34.09 percent of total billed charges 26.69 40.9 Technical (Hospital) Services WCH ED CEFPROZIL 250 MG/5 ML ORAL LIQUID #50ML RX-4088400012 CDM 6370000100 HCPCS 250 RC 09999-9990-07 NDC inpatient 2500 ME 43.05 43.05 CIGNA 62308 [3081051] CIGNA STATE OF WYOMING [308105107] 34.09 percent of total billed charges 26.69 40.9 Technical (Hospital) Services WCH ED CEFPROZIL 250 MG/5 ML ORAL LIQUID #50ML RX-4088400012 CDM 6370000100 HCPCS 250 RC 09999-9990-07 NDC inpatient 2500 ME 43.05 43.05 UNITED HEALTHCARE (COMMERCIAL) [3081199] UNITED HEALTHCARE 87726 [308119901] 26.69 percent of total billed charges 26.69 40.9 Technical (Hospital) Services WCH ED CEFPROZIL 250 MG/5 ML ORAL LIQUID #50ML RX-4088400012 CDM 6370000100 HCPCS 250 RC 09999-9990-07 NDC inpatient 2500 ME 43.05 43.05 BLUE CROSS BLUE SHIELD WELLMARK SB889 [3081026] BCBS WYOMING [308102603] 40.9 percent of total billed charges 26.69 40.9 Technical (Hospital) Services WCH ED CEFPROZIL 250 MG/5 ML ORAL LIQUID #50ML RX-4088400012 CDM 6370000100 HCPCS 250 RC 09999-9990-07 NDC inpatient 2500 ME 43.05 43.05 HEALTHPARTNERS SX009 HEALTHPARTNERS 34.09 percent of total billed charges 26.69 40.9 Technical (Hospital) Services WCH ED CEFPROZIL 250 MG/5 ML ORAL LIQUID #50ML RX-4088400012 CDM 6370000100 HCPCS 250 RC 09999-9990-07 NDC inpatient 2500 ME 43.05 43.05 MEDICA (COMMERCIAL) 94265 [3081118] MEDICA CLAIMS [308111801] 38.75 percent of total billed charges 26.69 40.9 Technical (Hospital) Services WCH ED CEFPROZIL 250 MG/5 ML ORAL LIQUID #50ML RX-4088400012 CDM 6370000100 HCPCS 250 RC 09999-9990-07 NDC inpatient 2500 ME 43.05 43.05 MULTIPLAN INC 34080 [3081285] MULTIPLAN INC [308128501] 40.9 percent of total billed charges 26.69 40.9 Technical (Hospital) Services WCH ED HYDROCODONE/ACETAMINOPHEN 5/325 MG TAB #10 RX-408840003 CDM 6370000100 HCPCS 250 RC inpatient 17.15 17.15 UNITED HEALTHCARE (COMMERCIAL) [3081199] UNITED HEALTHCARE 87726 [308119901] 10.63 percent of total billed charges 10.63 16.29 Technical (Hospital) Services WCH ED HYDROCODONE/ACETAMINOPHEN 5/325 MG TAB #10 RX-408840003 CDM 6370000100 HCPCS 250 RC inpatient 17.15 17.15 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES HDHP [308136802] 13.58 percent of total billed charges 10.63 16.29 Technical (Hospital) Services WCH ED HYDROCODONE/ACETAMINOPHEN 5/325 MG TAB #10 RX-408840003 CDM 6370000100 HCPCS 250 RC inpatient 17.15 17.15 CIGNA 62308 [3081051] CIGNA 62308 [308105105] 13.58 percent of total billed charges 10.63 16.29 Technical (Hospital) Services WCH ED HYDROCODONE/ACETAMINOPHEN 5/325 MG TAB #10 RX-408840003 CDM 6370000100 HCPCS 250 RC inpatient 17.15 17.15 CIGNA 62308 [3081051] CIGNA STATE OF WYOMING [308105107] 13.58 percent of total billed charges 10.63 16.29 Technical (Hospital) Services WCH ED HYDROCODONE/ACETAMINOPHEN 5/325 MG TAB #10 RX-408840003 CDM 6370000100 HCPCS 250 RC inpatient 17.15 17.15 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES PPO [308136801] 13.58 percent of total billed charges 10.63 16.29 Technical (Hospital) Services WCH ED HYDROCODONE/ACETAMINOPHEN 5/325 MG TAB #10 RX-408840003 CDM 6370000100 HCPCS 250 RC inpatient 17.15 17.15 MEDICA (COMMERCIAL) 94265 [3081118] MEDICA CLAIMS [308111801] 15.44 percent of total billed charges 10.63 16.29 Technical (Hospital) Services WCH ED HYDROCODONE/ACETAMINOPHEN 5/325 MG TAB #10 RX-408840003 CDM 6370000100 HCPCS 250 RC inpatient 17.15 17.15 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES EPO [308136803] 13.58 percent of total billed charges 10.63 16.29 Technical (Hospital) Services WCH ED HYDROCODONE/ACETAMINOPHEN 5/325 MG TAB #10 RX-408840003 CDM 6370000100 HCPCS 250 RC inpatient 17.15 17.15 MULTIPLAN INC 34080 [3081285] MULTIPLAN INC [308128501] 16.29 percent of total billed charges 10.63 16.29 Technical (Hospital) Services WCH ED HYDROCODONE/ACETAMINOPHEN 5/325 MG TAB #10 RX-408840003 CDM 6370000100 HCPCS 250 RC inpatient 17.15 17.15 BLUE CROSS BLUE SHIELD WELLMARK SB889 [3081026] BCBS WYOMING [308102603] 16.29 percent of total billed charges 10.63 16.29 Technical (Hospital) Services WCH ED HYDROCODONE/ACETAMINOPHEN 5/325 MG TAB #10 RX-408840003 CDM 6370000100 HCPCS 250 RC inpatient 17.15 17.15 HEALTHPARTNERS SX009 HEALTHPARTNERS 13.58 percent of total billed charges 10.63 16.29 Technical (Hospital) Services WCH ED HYDROCODONE/ACETAMINOPHEN 5/325 MG TAB #10 RX-408840003 CDM 6370000100 HCPCS 250 RC outpatient 17.15 17.15 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES HDHP [308136802] 13.72 percent of total billed charges 10.63 16.29 Technical (Hospital) Services WCH ED HYDROCODONE/ACETAMINOPHEN 5/325 MG TAB #10 RX-408840003 CDM 6370000100 HCPCS 250 RC outpatient 17.15 17.15 BLUE CROSS BLUE SHIELD WELLMARK SB889 [3081026] BCBS WYOMING [308102603] 16.29 percent of total billed charges 10.63 16.29 Technical (Hospital) Services WCH ED HYDROCODONE/ACETAMINOPHEN 5/325 MG TAB #10 RX-408840003 CDM 6370000100 HCPCS 250 RC outpatient 17.15 17.15 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES EPO [308136803] 13.72 percent of total billed charges 10.63 16.29 Technical (Hospital) Services WCH ED HYDROCODONE/ACETAMINOPHEN 5/325 MG TAB #10 RX-408840003 CDM 6370000100 HCPCS 250 RC outpatient 17.15 17.15 CIGNA 62308 [3081051] CIGNA 62308 [308105105] 13.72 percent of total billed charges 10.63 16.29 Technical (Hospital) Services WCH ED HYDROCODONE/ACETAMINOPHEN 5/325 MG TAB #10 RX-408840003 CDM 6370000100 HCPCS 250 RC outpatient 17.15 17.15 CIGNA 62308 [3081051] CIGNA STATE OF WYOMING [308105107] 13.72 percent of total billed charges 10.63 16.29 Technical (Hospital) Services WCH ED HYDROCODONE/ACETAMINOPHEN 5/325 MG TAB #10 RX-408840003 CDM 6370000100 HCPCS 250 RC outpatient 17.15 17.15 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES PPO [308136801] 13.72 percent of total billed charges 10.63 16.29 Technical (Hospital) Services WCH ED HYDROCODONE/ACETAMINOPHEN 5/325 MG TAB #10 RX-408840003 CDM 6370000100 HCPCS 250 RC outpatient 17.15 17.15 HEALTHPARTNERS SX009 HEALTHPARTNERS 13.72 percent of total billed charges 10.63 16.29 Technical (Hospital) Services WCH ED HYDROCODONE/ACETAMINOPHEN 5/325 MG TAB #10 RX-408840003 CDM 6370000100 HCPCS 250 RC outpatient 17.15 17.15 UNITED HEALTHCARE (COMMERCIAL) [3081199] UNITED HEALTHCARE 87726 [308119901] 10.63 percent of total billed charges 10.63 16.29 Technical (Hospital) Services WCH ED HYDROCODONE/ACETAMINOPHEN 5/325 MG TAB #10 RX-408840003 CDM 6370000100 HCPCS 250 RC outpatient 17.15 17.15 MEDICA (COMMERCIAL) 94265 [3081118] MEDICA CLAIMS [308111801] 15.44 percent of total billed charges 10.63 16.29 Technical (Hospital) Services WCH ED HYDROCODONE/ACETAMINOPHEN 5/325 MG TAB #10 RX-408840003 CDM 6370000100 HCPCS 250 RC outpatient 17.15 17.15 MULTIPLAN INC 34080 [3081285] MULTIPLAN INC [308128501] 16.29 percent of total billed charges 10.63 16.29 Technical (Hospital) Services WCH ED ALBUTEROL HFA INHALER #8GM RX-408840005 CDM 6370000100 HCPCS 250 RC 09999-9990-02 NDC inpatient 8 GR 35.17 35.17 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES EPO [308136803] 27.85 percent of total billed charges 21.81 33.41 Technical (Hospital) Services WCH ED ALBUTEROL HFA INHALER #8GM RX-408840005 CDM 6370000100 HCPCS 250 RC 09999-9990-02 NDC inpatient 8 GR 35.17 35.17 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES PPO [308136801] 27.85 percent of total billed charges 21.81 33.41 Technical (Hospital) Services WCH ED ALBUTEROL HFA INHALER #8GM RX-408840005 CDM 6370000100 HCPCS 250 RC 09999-9990-02 NDC inpatient 8 GR 35.17 35.17 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES HDHP [308136802] 27.85 percent of total billed charges 21.81 33.41 Technical (Hospital) Services WCH ED ALBUTEROL HFA INHALER #8GM RX-408840005 CDM 6370000100 HCPCS 250 RC 09999-9990-02 NDC inpatient 8 GR 35.17 35.17 HEALTHPARTNERS SX009 HEALTHPARTNERS 27.85 percent of total billed charges 21.81 33.41 Technical (Hospital) Services WCH ED ALBUTEROL HFA INHALER #8GM RX-408840005 CDM 6370000100 HCPCS 250 RC 09999-9990-02 NDC inpatient 8 GR 35.17 35.17 BLUE CROSS BLUE SHIELD WELLMARK SB889 [3081026] BCBS WYOMING [308102603] 33.41 percent of total billed charges 21.81 33.41 Technical (Hospital) Services WCH ED ALBUTEROL HFA INHALER #8GM RX-408840005 CDM 6370000100 HCPCS 250 RC 09999-9990-02 NDC inpatient 8 GR 35.17 35.17 UNITED HEALTHCARE (COMMERCIAL) [3081199] UNITED HEALTHCARE 87726 [308119901] 21.81 percent of total billed charges 21.81 33.41 Technical (Hospital) Services WCH ED ALBUTEROL HFA INHALER #8GM RX-408840005 CDM 6370000100 HCPCS 250 RC 09999-9990-02 NDC inpatient 8 GR 35.17 35.17 CIGNA 62308 [3081051] CIGNA 62308 [308105105] 27.85 percent of total billed charges 21.81 33.41 Technical (Hospital) Services WCH ED ALBUTEROL HFA INHALER #8GM RX-408840005 CDM 6370000100 HCPCS 250 RC 09999-9990-02 NDC inpatient 8 GR 35.17 35.17 CIGNA 62308 [3081051] CIGNA STATE OF WYOMING [308105107] 27.85 percent of total billed charges 21.81 33.41 Technical (Hospital) Services WCH ED ALBUTEROL HFA INHALER #8GM RX-408840005 CDM 6370000100 HCPCS 250 RC 09999-9990-02 NDC inpatient 8 GR 35.17 35.17 MEDICA (COMMERCIAL) 94265 [3081118] MEDICA CLAIMS [308111801] 31.65 percent of total billed charges 21.81 33.41 Technical (Hospital) Services WCH ED ALBUTEROL HFA INHALER #8GM RX-408840005 CDM 6370000100 HCPCS 250 RC 09999-9990-02 NDC inpatient 8 GR 35.17 35.17 MULTIPLAN INC 34080 [3081285] MULTIPLAN INC [308128501] 33.41 percent of total billed charges 21.81 33.41 Technical (Hospital) Services WCH ED ALBUTEROL HFA INHALER #8GM RX-408840005 CDM 6370000100 HCPCS 250 RC 09999-9990-02 NDC outpatient 8 GR 35.17 35.17 MULTIPLAN INC 34080 [3081285] MULTIPLAN INC [308128501] 33.41 percent of total billed charges 21.81 33.41 Technical (Hospital) Services WCH ED ALBUTEROL HFA INHALER #8GM RX-408840005 CDM 6370000100 HCPCS 250 RC 09999-9990-02 NDC outpatient 8 GR 35.17 35.17 MEDICA (COMMERCIAL) 94265 [3081118] MEDICA CLAIMS [308111801] 31.65 percent of total billed charges 21.81 33.41 Technical (Hospital) Services WCH ED ALBUTEROL HFA INHALER #8GM RX-408840005 CDM 6370000100 HCPCS 250 RC 09999-9990-02 NDC outpatient 8 GR 35.17 35.17 CIGNA 62308 [3081051] CIGNA 62308 [308105105] 28.14 percent of total billed charges 21.81 33.41 Technical (Hospital) Services WCH ED ALBUTEROL HFA INHALER #8GM RX-408840005 CDM 6370000100 HCPCS 250 RC 09999-9990-02 NDC outpatient 8 GR 35.17 35.17 CIGNA 62308 [3081051] CIGNA STATE OF WYOMING [308105107] 28.14 percent of total billed charges 21.81 33.41 Technical (Hospital) Services WCH ED ALBUTEROL HFA INHALER #8GM RX-408840005 CDM 6370000100 HCPCS 250 RC 09999-9990-02 NDC outpatient 8 GR 35.17 35.17 UNITED HEALTHCARE (COMMERCIAL) [3081199] UNITED HEALTHCARE 87726 [308119901] 21.81 percent of total billed charges 21.81 33.41 Technical (Hospital) Services WCH ED ALBUTEROL HFA INHALER #8GM RX-408840005 CDM 6370000100 HCPCS 250 RC 09999-9990-02 NDC outpatient 8 GR 35.17 35.17 HEALTHPARTNERS SX009 HEALTHPARTNERS 28.14 percent of total billed charges 21.81 33.41 Technical (Hospital) Services WCH ED ALBUTEROL HFA INHALER #8GM RX-408840005 CDM 6370000100 HCPCS 250 RC 09999-9990-02 NDC outpatient 8 GR 35.17 35.17 BLUE CROSS BLUE SHIELD WELLMARK SB889 [3081026] BCBS WYOMING [308102603] 33.41 percent of total billed charges 21.81 33.41 Technical (Hospital) Services WCH ED ALBUTEROL HFA INHALER #8GM RX-408840005 CDM 6370000100 HCPCS 250 RC 09999-9990-02 NDC outpatient 8 GR 35.17 35.17 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES EPO [308136803] 28.14 percent of total billed charges 21.81 33.41 Technical (Hospital) Services WCH ED ALBUTEROL HFA INHALER #8GM RX-408840005 CDM 6370000100 HCPCS 250 RC 09999-9990-02 NDC outpatient 8 GR 35.17 35.17 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES HDHP [308136802] 28.14 percent of total billed charges 21.81 33.41 Technical (Hospital) Services WCH ED ALBUTEROL HFA INHALER #8GM RX-408840005 CDM 6370000100 HCPCS 250 RC 09999-9990-02 NDC outpatient 8 GR 35.17 35.17 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES PPO [308136801] 28.14 percent of total billed charges 21.81 33.41 Technical (Hospital) Services WCH ED ALBUTEROL NEB SOLUTION 2.5 MG/3 ML #10 NEB RX-408840006 CDM 6370000100 HCPCS 250 RC outpatient 25 ME 15.34 15.34 CIGNA 62308 [3081051] CIGNA 62308 [308105105] 12.27 percent of total billed charges 9.51 14.57 Technical (Hospital) Services WCH ED ALBUTEROL NEB SOLUTION 2.5 MG/3 ML #10 NEB RX-408840006 CDM 6370000100 HCPCS 250 RC outpatient 25 ME 15.34 15.34 CIGNA 62308 [3081051] CIGNA STATE OF WYOMING [308105107] 12.27 percent of total billed charges 9.51 14.57 Technical (Hospital) Services WCH ED ALBUTEROL NEB SOLUTION 2.5 MG/3 ML #10 NEB RX-408840006 CDM 6370000100 HCPCS 250 RC outpatient 25 ME 15.34 15.34 HEALTHPARTNERS SX009 HEALTHPARTNERS 12.27 percent of total billed charges 9.51 14.57 Technical (Hospital) Services WCH ED ALBUTEROL NEB SOLUTION 2.5 MG/3 ML #10 NEB RX-408840006 CDM 6370000100 HCPCS 250 RC outpatient 25 ME 15.34 15.34 UNITED HEALTHCARE (COMMERCIAL) [3081199] UNITED HEALTHCARE 87726 [308119901] 9.51 percent of total billed charges 9.51 14.57 Technical (Hospital) Services WCH ED ALBUTEROL NEB SOLUTION 2.5 MG/3 ML #10 NEB RX-408840006 CDM 6370000100 HCPCS 250 RC outpatient 25 ME 15.34 15.34 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES HDHP [308136802] 12.27 percent of total billed charges 9.51 14.57 Technical (Hospital) Services WCH ED ALBUTEROL NEB SOLUTION 2.5 MG/3 ML #10 NEB RX-408840006 CDM 6370000100 HCPCS 250 RC outpatient 25 ME 15.34 15.34 BLUE CROSS BLUE SHIELD WELLMARK SB889 [3081026] BCBS WYOMING [308102603] 14.57 percent of total billed charges 9.51 14.57 Technical (Hospital) Services WCH ED ALBUTEROL NEB SOLUTION 2.5 MG/3 ML #10 NEB RX-408840006 CDM 6370000100 HCPCS 250 RC outpatient 25 ME 15.34 15.34 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES EPO [308136803] 12.27 percent of total billed charges 9.51 14.57 Technical (Hospital) Services WCH ED ALBUTEROL NEB SOLUTION 2.5 MG/3 ML #10 NEB RX-408840006 CDM 6370000100 HCPCS 250 RC outpatient 25 ME 15.34 15.34 MEDICA (COMMERCIAL) 94265 [3081118] MEDICA CLAIMS [308111801] 13.81 percent of total billed charges 9.51 14.57 Technical (Hospital) Services WCH ED ALBUTEROL NEB SOLUTION 2.5 MG/3 ML #10 NEB RX-408840006 CDM 6370000100 HCPCS 250 RC outpatient 25 ME 15.34 15.34 MULTIPLAN INC 34080 [3081285] MULTIPLAN INC [308128501] 14.57 percent of total billed charges 9.51 14.57 Technical (Hospital) Services WCH ED ALBUTEROL NEB SOLUTION 2.5 MG/3 ML #10 NEB RX-408840006 CDM 6370000100 HCPCS 250 RC outpatient 25 ME 15.34 15.34 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES PPO [308136801] 12.27 percent of total billed charges 9.51 14.57 Technical (Hospital) Services WCH ED ALBUTEROL NEB SOLUTION 2.5 MG/3 ML #10 NEB RX-408840006 CDM 6370000100 HCPCS 250 RC inpatient 25 ME 15.34 15.34 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES HDHP [308136802] 12.15 percent of total billed charges 9.51 14.57 Technical (Hospital) Services WCH ED ALBUTEROL NEB SOLUTION 2.5 MG/3 ML #10 NEB RX-408840006 CDM 6370000100 HCPCS 250 RC inpatient 25 ME 15.34 15.34 UNITED HEALTHCARE (COMMERCIAL) [3081199] UNITED HEALTHCARE 87726 [308119901] 9.51 percent of total billed charges 9.51 14.57 Technical (Hospital) Services WCH ED ALBUTEROL NEB SOLUTION 2.5 MG/3 ML #10 NEB RX-408840006 CDM 6370000100 HCPCS 250 RC inpatient 25 ME 15.34 15.34 CIGNA 62308 [3081051] CIGNA 62308 [308105105] 12.15 percent of total billed charges 9.51 14.57 Technical (Hospital) Services WCH ED ALBUTEROL NEB SOLUTION 2.5 MG/3 ML #10 NEB RX-408840006 CDM 6370000100 HCPCS 250 RC inpatient 25 ME 15.34 15.34 CIGNA 62308 [3081051] CIGNA STATE OF WYOMING [308105107] 12.15 percent of total billed charges 9.51 14.57 Technical (Hospital) Services WCH ED ALBUTEROL NEB SOLUTION 2.5 MG/3 ML #10 NEB RX-408840006 CDM 6370000100 HCPCS 250 RC inpatient 25 ME 15.34 15.34 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES PPO [308136801] 12.15 percent of total billed charges 9.51 14.57 Technical (Hospital) Services WCH ED ALBUTEROL NEB SOLUTION 2.5 MG/3 ML #10 NEB RX-408840006 CDM 6370000100 HCPCS 250 RC inpatient 25 ME 15.34 15.34 MEDICA (COMMERCIAL) 94265 [3081118] MEDICA CLAIMS [308111801] 13.81 percent of total billed charges 9.51 14.57 Technical (Hospital) Services WCH ED ALBUTEROL NEB SOLUTION 2.5 MG/3 ML #10 NEB RX-408840006 CDM 6370000100 HCPCS 250 RC inpatient 25 ME 15.34 15.34 MULTIPLAN INC 34080 [3081285] MULTIPLAN INC [308128501] 14.57 percent of total billed charges 9.51 14.57 Technical (Hospital) Services WCH ED ALBUTEROL NEB SOLUTION 2.5 MG/3 ML #10 NEB RX-408840006 CDM 6370000100 HCPCS 250 RC inpatient 25 ME 15.34 15.34 BLUE CROSS BLUE SHIELD WELLMARK SB889 [3081026] BCBS WYOMING [308102603] 14.57 percent of total billed charges 9.51 14.57 Technical (Hospital) Services WCH ED ALBUTEROL NEB SOLUTION 2.5 MG/3 ML #10 NEB RX-408840006 CDM 6370000100 HCPCS 250 RC inpatient 25 ME 15.34 15.34 HEALTHPARTNERS SX009 HEALTHPARTNERS 12.15 percent of total billed charges 9.51 14.57 Technical (Hospital) Services WCH ED ALBUTEROL NEB SOLUTION 2.5 MG/3 ML #10 NEB RX-408840006 CDM 6370000100 HCPCS 250 RC inpatient 25 ME 15.34 15.34 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES EPO [308136803] 12.15 percent of total billed charges 9.51 14.57 Technical (Hospital) Services WCH ED AMOXICILLIN 250 MG CAP #6 RX-408840007 CDM 6370000100 HCPCS 250 RC 09999-9990-04 NDC outpatient 1500 ME 14.44 14.44 BLUE CROSS BLUE SHIELD WELLMARK SB889 [3081026] BCBS WYOMING [308102603] 13.72 percent of total billed charges 8.95 13.72 Technical (Hospital) Services WCH ED AMOXICILLIN 250 MG CAP #6 RX-408840007 CDM 6370000100 HCPCS 250 RC 09999-9990-04 NDC outpatient 1500 ME 14.44 14.44 UNITED HEALTHCARE (COMMERCIAL) [3081199] UNITED HEALTHCARE 87726 [308119901] 8.95 percent of total billed charges 8.95 13.72 Technical (Hospital) Services WCH ED AMOXICILLIN 250 MG CAP #6 RX-408840007 CDM 6370000100 HCPCS 250 RC 09999-9990-04 NDC outpatient 1500 ME 14.44 14.44 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES EPO [308136803] 11.55 percent of total billed charges 8.95 13.72 Technical (Hospital) Services WCH ED AMOXICILLIN 250 MG CAP #6 RX-408840007 CDM 6370000100 HCPCS 250 RC 09999-9990-04 NDC outpatient 1500 ME 14.44 14.44 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES HDHP [308136802] 11.55 percent of total billed charges 8.95 13.72 Technical (Hospital) Services WCH ED AMOXICILLIN 250 MG CAP #6 RX-408840007 CDM 6370000100 HCPCS 250 RC 09999-9990-04 NDC outpatient 1500 ME 14.44 14.44 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES PPO [308136801] 11.55 percent of total billed charges 8.95 13.72 Technical (Hospital) Services WCH ED AMOXICILLIN 250 MG CAP #6 RX-408840007 CDM 6370000100 HCPCS 250 RC 09999-9990-04 NDC outpatient 1500 ME 14.44 14.44 MULTIPLAN INC 34080 [3081285] MULTIPLAN INC [308128501] 13.72 percent of total billed charges 8.95 13.72 Technical (Hospital) Services WCH ED AMOXICILLIN 250 MG CAP #6 RX-408840007 CDM 6370000100 HCPCS 250 RC 09999-9990-04 NDC outpatient 1500 ME 14.44 14.44 MEDICA (COMMERCIAL) 94265 [3081118] MEDICA CLAIMS [308111801] 13 percent of total billed charges 8.95 13.72 Technical (Hospital) Services WCH ED AMOXICILLIN 250 MG CAP #6 RX-408840007 CDM 6370000100 HCPCS 250 RC 09999-9990-04 NDC outpatient 1500 ME 14.44 14.44 HEALTHPARTNERS SX009 HEALTHPARTNERS 11.55 percent of total billed charges 8.95 13.72 Technical (Hospital) Services WCH ED AMOXICILLIN 250 MG CAP #6 RX-408840007 CDM 6370000100 HCPCS 250 RC 09999-9990-04 NDC outpatient 1500 ME 14.44 14.44 CIGNA 62308 [3081051] CIGNA 62308 [308105105] 11.55 percent of total billed charges 8.95 13.72 Technical (Hospital) Services WCH ED AMOXICILLIN 250 MG CAP #6 RX-408840007 CDM 6370000100 HCPCS 250 RC 09999-9990-04 NDC outpatient 1500 ME 14.44 14.44 CIGNA 62308 [3081051] CIGNA STATE OF WYOMING [308105107] 11.55 percent of total billed charges 8.95 13.72 Technical (Hospital) Services WCH ED AMOXICILLIN 250 MG CAP #6 RX-408840007 CDM 6370000100 HCPCS 250 RC 09999-9990-04 NDC inpatient 1500 ME 14.44 14.44 MEDICA (COMMERCIAL) 94265 [3081118] MEDICA CLAIMS [308111801] 13 percent of total billed charges 8.95 13.72 Technical (Hospital) Services WCH ED AMOXICILLIN 250 MG CAP #6 RX-408840007 CDM 6370000100 HCPCS 250 RC 09999-9990-04 NDC inpatient 1500 ME 14.44 14.44 MULTIPLAN INC 34080 [3081285] MULTIPLAN INC [308128501] 13.72 percent of total billed charges 8.95 13.72 Technical (Hospital) Services WCH ED AMOXICILLIN 250 MG CAP #6 RX-408840007 CDM 6370000100 HCPCS 250 RC 09999-9990-04 NDC inpatient 1500 ME 14.44 14.44 HEALTHPARTNERS SX009 HEALTHPARTNERS 11.43 percent of total billed charges 8.95 13.72 Technical (Hospital) Services WCH ED AMOXICILLIN 250 MG CAP #6 RX-408840007 CDM 6370000100 HCPCS 250 RC 09999-9990-04 NDC inpatient 1500 ME 14.44 14.44 UNITED HEALTHCARE (COMMERCIAL) [3081199] UNITED HEALTHCARE 87726 [308119901] 8.95 percent of total billed charges 8.95 13.72 Technical (Hospital) Services WCH ED AMOXICILLIN 250 MG CAP #6 RX-408840007 CDM 6370000100 HCPCS 250 RC 09999-9990-04 NDC inpatient 1500 ME 14.44 14.44 BLUE CROSS BLUE SHIELD WELLMARK SB889 [3081026] BCBS WYOMING [308102603] 13.72 percent of total billed charges 8.95 13.72 Technical (Hospital) Services WCH ED AMOXICILLIN 250 MG CAP #6 RX-408840007 CDM 6370000100 HCPCS 250 RC 09999-9990-04 NDC inpatient 1500 ME 14.44 14.44 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES EPO [308136803] 11.43 percent of total billed charges 8.95 13.72 Technical (Hospital) Services WCH ED AMOXICILLIN 250 MG CAP #6 RX-408840007 CDM 6370000100 HCPCS 250 RC 09999-9990-04 NDC inpatient 1500 ME 14.44 14.44 CIGNA 62308 [3081051] CIGNA 62308 [308105105] 11.43 percent of total billed charges 8.95 13.72 Technical (Hospital) Services WCH ED AMOXICILLIN 250 MG CAP #6 RX-408840007 CDM 6370000100 HCPCS 250 RC 09999-9990-04 NDC inpatient 1500 ME 14.44 14.44 CIGNA 62308 [3081051] CIGNA STATE OF WYOMING [308105107] 11.43 percent of total billed charges 8.95 13.72 Technical (Hospital) Services WCH ED AMOXICILLIN 250 MG CAP #6 RX-408840007 CDM 6370000100 HCPCS 250 RC 09999-9990-04 NDC inpatient 1500 ME 14.44 14.44 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES HDHP [308136802] 11.43 percent of total billed charges 8.95 13.72 Technical (Hospital) Services WCH ED AMOXICILLIN 250 MG CAP #6 RX-408840007 CDM 6370000100 HCPCS 250 RC 09999-9990-04 NDC inpatient 1500 ME 14.44 14.44 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES PPO [308136801] 11.43 percent of total billed charges 8.95 13.72 Technical (Hospital) Services WCH ED AMOXICILLIN 250 MG CHEWABLE TAB #4 RX-408840008 CDM 6370000100 HCPCS 250 RC 09999-9990-05 NDC inpatient 1000 ME 14.95 14.95 HEALTHPARTNERS SX009 HEALTHPARTNERS 11.84 percent of total billed charges 9.27 14.2 Technical (Hospital) Services WCH ED AMOXICILLIN 250 MG CHEWABLE TAB #4 RX-408840008 CDM 6370000100 HCPCS 250 RC 09999-9990-05 NDC inpatient 1000 ME 14.95 14.95 MULTIPLAN INC 34080 [3081285] MULTIPLAN INC [308128501] 14.2 percent of total billed charges 9.27 14.2 Technical (Hospital) Services WCH ED AMOXICILLIN 250 MG CHEWABLE TAB #4 RX-408840008 CDM 6370000100 HCPCS 250 RC 09999-9990-05 NDC inpatient 1000 ME 14.95 14.95 MEDICA (COMMERCIAL) 94265 [3081118] MEDICA CLAIMS [308111801] 13.46 percent of total billed charges 9.27 14.2 Technical (Hospital) Services WCH ED AMOXICILLIN 250 MG CHEWABLE TAB #4 RX-408840008 CDM 6370000100 HCPCS 250 RC 09999-9990-05 NDC inpatient 1000 ME 14.95 14.95 BLUE CROSS BLUE SHIELD WELLMARK SB889 [3081026] BCBS WYOMING [308102603] 14.2 percent of total billed charges 9.27 14.2 Technical (Hospital) Services WCH ED AMOXICILLIN 250 MG CHEWABLE TAB #4 RX-408840008 CDM 6370000100 HCPCS 250 RC 09999-9990-05 NDC inpatient 1000 ME 14.95 14.95 UNITED HEALTHCARE (COMMERCIAL) [3081199] UNITED HEALTHCARE 87726 [308119901] 9.27 percent of total billed charges 9.27 14.2 Technical (Hospital) Services WCH ED AMOXICILLIN 250 MG CHEWABLE TAB #4 RX-408840008 CDM 6370000100 HCPCS 250 RC 09999-9990-05 NDC inpatient 1000 ME 14.95 14.95 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES HDHP [308136802] 11.84 percent of total billed charges 9.27 14.2 Technical (Hospital) Services WCH ED AMOXICILLIN 250 MG CHEWABLE TAB #4 RX-408840008 CDM 6370000100 HCPCS 250 RC 09999-9990-05 NDC inpatient 1000 ME 14.95 14.95 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES PPO [308136801] 11.84 percent of total billed charges 9.27 14.2 Technical (Hospital) Services WCH ED AMOXICILLIN 250 MG CHEWABLE TAB #4 RX-408840008 CDM 6370000100 HCPCS 250 RC 09999-9990-05 NDC inpatient 1000 ME 14.95 14.95 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES EPO [308136803] 11.84 percent of total billed charges 9.27 14.2 Technical (Hospital) Services WCH ED AMOXICILLIN 250 MG CHEWABLE TAB #4 RX-408840008 CDM 6370000100 HCPCS 250 RC 09999-9990-05 NDC inpatient 1000 ME 14.95 14.95 CIGNA 62308 [3081051] CIGNA 62308 [308105105] 11.84 percent of total billed charges 9.27 14.2 Technical (Hospital) Services WCH ED AMOXICILLIN 250 MG CHEWABLE TAB #4 RX-408840008 CDM 6370000100 HCPCS 250 RC 09999-9990-05 NDC inpatient 1000 ME 14.95 14.95 CIGNA 62308 [3081051] CIGNA STATE OF WYOMING [308105107] 11.84 percent of total billed charges 9.27 14.2 Technical (Hospital) Services WCH ED AMOXICILLIN 250 MG CHEWABLE TAB #4 RX-408840008 CDM 6370000100 HCPCS 250 RC 09999-9990-05 NDC outpatient 1000 ME 14.95 14.95 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES HDHP [308136802] 11.96 percent of total billed charges 9.27 14.2 Technical (Hospital) Services WCH ED AMOXICILLIN 250 MG CHEWABLE TAB #4 RX-408840008 CDM 6370000100 HCPCS 250 RC 09999-9990-05 NDC outpatient 1000 ME 14.95 14.95 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES EPO [308136803] 11.96 percent of total billed charges 9.27 14.2 Technical (Hospital) Services WCH ED AMOXICILLIN 250 MG CHEWABLE TAB #4 RX-408840008 CDM 6370000100 HCPCS 250 RC 09999-9990-05 NDC outpatient 1000 ME 14.95 14.95 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES PPO [308136801] 11.96 percent of total billed charges 9.27 14.2 Technical (Hospital) Services WCH ED AMOXICILLIN 250 MG CHEWABLE TAB #4 RX-408840008 CDM 6370000100 HCPCS 250 RC 09999-9990-05 NDC outpatient 1000 ME 14.95 14.95 BLUE CROSS BLUE SHIELD WELLMARK SB889 [3081026] BCBS WYOMING [308102603] 14.2 percent of total billed charges 9.27 14.2 Technical (Hospital) Services WCH ED AMOXICILLIN 250 MG CHEWABLE TAB #4 RX-408840008 CDM 6370000100 HCPCS 250 RC 09999-9990-05 NDC outpatient 1000 ME 14.95 14.95 UNITED HEALTHCARE (COMMERCIAL) [3081199] UNITED HEALTHCARE 87726 [308119901] 9.27 percent of total billed charges 9.27 14.2 Technical (Hospital) Services WCH ED AMOXICILLIN 250 MG CHEWABLE TAB #4 RX-408840008 CDM 6370000100 HCPCS 250 RC 09999-9990-05 NDC outpatient 1000 ME 14.95 14.95 HEALTHPARTNERS SX009 HEALTHPARTNERS 11.96 percent of total billed charges 9.27 14.2 Technical (Hospital) Services WCH ED AMOXICILLIN 250 MG CHEWABLE TAB #4 RX-408840008 CDM 6370000100 HCPCS 250 RC 09999-9990-05 NDC outpatient 1000 ME 14.95 14.95 CIGNA 62308 [3081051] CIGNA 62308 [308105105] 11.96 percent of total billed charges 9.27 14.2 Technical (Hospital) Services WCH ED AMOXICILLIN 250 MG CHEWABLE TAB #4 RX-408840008 CDM 6370000100 HCPCS 250 RC 09999-9990-05 NDC outpatient 1000 ME 14.95 14.95 CIGNA 62308 [3081051] CIGNA STATE OF WYOMING [308105107] 11.96 percent of total billed charges 9.27 14.2 Technical (Hospital) Services WCH ED AMOXICILLIN 250 MG CHEWABLE TAB #4 RX-408840008 CDM 6370000100 HCPCS 250 RC 09999-9990-05 NDC outpatient 1000 ME 14.95 14.95 MULTIPLAN INC 34080 [3081285] MULTIPLAN INC [308128501] 14.2 percent of total billed charges 9.27 14.2 Technical (Hospital) Services WCH ED AMOXICILLIN 250 MG CHEWABLE TAB #4 RX-408840008 CDM 6370000100 HCPCS 250 RC 09999-9990-05 NDC outpatient 1000 ME 14.95 14.95 MEDICA (COMMERCIAL) 94265 [3081118] MEDICA CLAIMS [308111801] 13.46 percent of total billed charges 9.27 14.2 Technical (Hospital) Services WCH ED CLINDAMYCIN 150 MG CAP #24 RX-408840010005 CDM 6370000100 HCPCS 250 RC 09999-3083-01 NDC inpatient 3600 ME 17.21 17.21 HEALTHPARTNERS SX009 HEALTHPARTNERS 13.63 percent of total billed charges 10.67 16.35 Technical (Hospital) Services WCH ED CLINDAMYCIN 150 MG CAP #24 RX-408840010005 CDM 6370000100 HCPCS 250 RC 09999-3083-01 NDC inpatient 3600 ME 17.21 17.21 MULTIPLAN INC 34080 [3081285] MULTIPLAN INC [308128501] 16.35 percent of total billed charges 10.67 16.35 Technical (Hospital) Services WCH ED CLINDAMYCIN 150 MG CAP #24 RX-408840010005 CDM 6370000100 HCPCS 250 RC 09999-3083-01 NDC inpatient 3600 ME 17.21 17.21 MEDICA (COMMERCIAL) 94265 [3081118] MEDICA CLAIMS [308111801] 15.49 percent of total billed charges 10.67 16.35 Technical (Hospital) Services WCH ED CLINDAMYCIN 150 MG CAP #24 RX-408840010005 CDM 6370000100 HCPCS 250 RC 09999-3083-01 NDC inpatient 3600 ME 17.21 17.21 UNITED HEALTHCARE (COMMERCIAL) [3081199] UNITED HEALTHCARE 87726 [308119901] 10.67 percent of total billed charges 10.67 16.35 Technical (Hospital) Services WCH ED CLINDAMYCIN 150 MG CAP #24 RX-408840010005 CDM 6370000100 HCPCS 250 RC 09999-3083-01 NDC inpatient 3600 ME 17.21 17.21 BLUE CROSS BLUE SHIELD WELLMARK SB889 [3081026] BCBS WYOMING [308102603] 16.35 percent of total billed charges 10.67 16.35 Technical (Hospital) Services WCH ED CLINDAMYCIN 150 MG CAP #24 RX-408840010005 CDM 6370000100 HCPCS 250 RC 09999-3083-01 NDC inpatient 3600 ME 17.21 17.21 CIGNA 62308 [3081051] CIGNA 62308 [308105105] 13.63 percent of total billed charges 10.67 16.35 Technical (Hospital) Services WCH ED CLINDAMYCIN 150 MG CAP #24 RX-408840010005 CDM 6370000100 HCPCS 250 RC 09999-3083-01 NDC inpatient 3600 ME 17.21 17.21 CIGNA 62308 [3081051] CIGNA STATE OF WYOMING [308105107] 13.63 percent of total billed charges 10.67 16.35 Technical (Hospital) Services WCH ED CLINDAMYCIN 150 MG CAP #24 RX-408840010005 CDM 6370000100 HCPCS 250 RC 09999-3083-01 NDC inpatient 3600 ME 17.21 17.21 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES EPO [308136803] 13.63 percent of total billed charges 10.67 16.35 Technical (Hospital) Services WCH ED CLINDAMYCIN 150 MG CAP #24 RX-408840010005 CDM 6370000100 HCPCS 250 RC 09999-3083-01 NDC inpatient 3600 ME 17.21 17.21 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES HDHP [308136802] 13.63 percent of total billed charges 10.67 16.35 Technical (Hospital) Services WCH ED CLINDAMYCIN 150 MG CAP #24 RX-408840010005 CDM 6370000100 HCPCS 250 RC 09999-3083-01 NDC inpatient 3600 ME 17.21 17.21 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES PPO [308136801] 13.63 percent of total billed charges 10.67 16.35 Technical (Hospital) Services WCH ED CLINDAMYCIN 150 MG CAP #24 RX-408840010005 CDM 6370000100 HCPCS 250 RC 09999-3083-01 NDC outpatient 3600 ME 17.21 17.21 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES EPO [308136803] 13.77 percent of total billed charges 10.67 16.35 Technical (Hospital) Services WCH ED CLINDAMYCIN 150 MG CAP #24 RX-408840010005 CDM 6370000100 HCPCS 250 RC 09999-3083-01 NDC outpatient 3600 ME 17.21 17.21 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES HDHP [308136802] 13.77 percent of total billed charges 10.67 16.35 Technical (Hospital) Services WCH ED CLINDAMYCIN 150 MG CAP #24 RX-408840010005 CDM 6370000100 HCPCS 250 RC 09999-3083-01 NDC outpatient 3600 ME 17.21 17.21 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES PPO [308136801] 13.77 percent of total billed charges 10.67 16.35 Technical (Hospital) Services WCH ED CLINDAMYCIN 150 MG CAP #24 RX-408840010005 CDM 6370000100 HCPCS 250 RC 09999-3083-01 NDC outpatient 3600 ME 17.21 17.21 BLUE CROSS BLUE SHIELD WELLMARK SB889 [3081026] BCBS WYOMING [308102603] 16.35 percent of total billed charges 10.67 16.35 Technical (Hospital) Services WCH ED CLINDAMYCIN 150 MG CAP #24 RX-408840010005 CDM 6370000100 HCPCS 250 RC 09999-3083-01 NDC outpatient 3600 ME 17.21 17.21 UNITED HEALTHCARE (COMMERCIAL) [3081199] UNITED HEALTHCARE 87726 [308119901] 10.67 percent of total billed charges 10.67 16.35 Technical (Hospital) Services WCH ED CLINDAMYCIN 150 MG CAP #24 RX-408840010005 CDM 6370000100 HCPCS 250 RC 09999-3083-01 NDC outpatient 3600 ME 17.21 17.21 HEALTHPARTNERS SX009 HEALTHPARTNERS 13.77 percent of total billed charges 10.67 16.35 Technical (Hospital) Services WCH ED CLINDAMYCIN 150 MG CAP #24 RX-408840010005 CDM 6370000100 HCPCS 250 RC 09999-3083-01 NDC outpatient 3600 ME 17.21 17.21 CIGNA 62308 [3081051] CIGNA 62308 [308105105] 13.77 percent of total billed charges 10.67 16.35 Technical (Hospital) Services WCH ED CLINDAMYCIN 150 MG CAP #24 RX-408840010005 CDM 6370000100 HCPCS 250 RC 09999-3083-01 NDC outpatient 3600 ME 17.21 17.21 CIGNA 62308 [3081051] CIGNA STATE OF WYOMING [308105107] 13.77 percent of total billed charges 10.67 16.35 Technical (Hospital) Services WCH ED CLINDAMYCIN 150 MG CAP #24 RX-408840010005 CDM 6370000100 HCPCS 250 RC 09999-3083-01 NDC outpatient 3600 ME 17.21 17.21 MEDICA (COMMERCIAL) 94265 [3081118] MEDICA CLAIMS [308111801] 15.49 percent of total billed charges 10.67 16.35 Technical (Hospital) Services WCH ED CLINDAMYCIN 150 MG CAP #24 RX-408840010005 CDM 6370000100 HCPCS 250 RC 09999-3083-01 NDC outpatient 3600 ME 17.21 17.21 MULTIPLAN INC 34080 [3081285] MULTIPLAN INC [308128501] 16.35 percent of total billed charges 10.67 16.35 Technical (Hospital) Services WCH ED IBUPROFEN 600 MG TAB #5 RX-40884001007 CDM 6370000100 HCPCS 250 RC 09999-3081-01 NDC outpatient 3000 ME 14.31 14.31 HEALTHPARTNERS SX009 HEALTHPARTNERS 11.45 percent of total billed charges 8.87 13.59 Technical (Hospital) Services WCH ED IBUPROFEN 600 MG TAB #5 RX-40884001007 CDM 6370000100 HCPCS 250 RC 09999-3081-01 NDC outpatient 3000 ME 14.31 14.31 BLUE CROSS BLUE SHIELD WELLMARK SB889 [3081026] BCBS WYOMING [308102603] 13.59 percent of total billed charges 8.87 13.59 Technical (Hospital) Services WCH ED IBUPROFEN 600 MG TAB #5 RX-40884001007 CDM 6370000100 HCPCS 250 RC 09999-3081-01 NDC outpatient 3000 ME 14.31 14.31 UNITED HEALTHCARE (COMMERCIAL) [3081199] UNITED HEALTHCARE 87726 [308119901] 8.87 percent of total billed charges 8.87 13.59 Technical (Hospital) Services WCH ED IBUPROFEN 600 MG TAB #5 RX-40884001007 CDM 6370000100 HCPCS 250 RC 09999-3081-01 NDC outpatient 3000 ME 14.31 14.31 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES EPO [308136803] 11.45 percent of total billed charges 8.87 13.59 Technical (Hospital) Services WCH ED IBUPROFEN 600 MG TAB #5 RX-40884001007 CDM 6370000100 HCPCS 250 RC 09999-3081-01 NDC outpatient 3000 ME 14.31 14.31 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES HDHP [308136802] 11.45 percent of total billed charges 8.87 13.59 Technical (Hospital) Services WCH ED IBUPROFEN 600 MG TAB #5 RX-40884001007 CDM 6370000100 HCPCS 250 RC 09999-3081-01 NDC outpatient 3000 ME 14.31 14.31 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES PPO [308136801] 11.45 percent of total billed charges 8.87 13.59 Technical (Hospital) Services WCH ED IBUPROFEN 600 MG TAB #5 RX-40884001007 CDM 6370000100 HCPCS 250 RC 09999-3081-01 NDC outpatient 3000 ME 14.31 14.31 CIGNA 62308 [3081051] CIGNA 62308 [308105105] 11.45 percent of total billed charges 8.87 13.59 Technical (Hospital) Services WCH ED IBUPROFEN 600 MG TAB #5 RX-40884001007 CDM 6370000100 HCPCS 250 RC 09999-3081-01 NDC outpatient 3000 ME 14.31 14.31 CIGNA 62308 [3081051] CIGNA STATE OF WYOMING [308105107] 11.45 percent of total billed charges 8.87 13.59 Technical (Hospital) Services WCH ED IBUPROFEN 600 MG TAB #5 RX-40884001007 CDM 6370000100 HCPCS 250 RC 09999-3081-01 NDC outpatient 3000 ME 14.31 14.31 MEDICA (COMMERCIAL) 94265 [3081118] MEDICA CLAIMS [308111801] 12.88 percent of total billed charges 8.87 13.59 Technical (Hospital) Services WCH ED IBUPROFEN 600 MG TAB #5 RX-40884001007 CDM 6370000100 HCPCS 250 RC 09999-3081-01 NDC outpatient 3000 ME 14.31 14.31 MULTIPLAN INC 34080 [3081285] MULTIPLAN INC [308128501] 13.59 percent of total billed charges 8.87 13.59 Technical (Hospital) Services WCH ED IBUPROFEN 600 MG TAB #5 RX-40884001007 CDM 6370000100 HCPCS 250 RC 09999-3081-01 NDC inpatient 3000 ME 14.31 14.31 MULTIPLAN INC 34080 [3081285] MULTIPLAN INC [308128501] 13.59 percent of total billed charges 8.87 13.59 Technical (Hospital) Services WCH ED IBUPROFEN 600 MG TAB #5 RX-40884001007 CDM 6370000100 HCPCS 250 RC 09999-3081-01 NDC inpatient 3000 ME 14.31 14.31 MEDICA (COMMERCIAL) 94265 [3081118] MEDICA CLAIMS [308111801] 12.88 percent of total billed charges 8.87 13.59 Technical (Hospital) Services WCH ED IBUPROFEN 600 MG TAB #5 RX-40884001007 CDM 6370000100 HCPCS 250 RC 09999-3081-01 NDC inpatient 3000 ME 14.31 14.31 HEALTHPARTNERS SX009 HEALTHPARTNERS 11.33 percent of total billed charges 8.87 13.59 Technical (Hospital) Services WCH ED IBUPROFEN 600 MG TAB #5 RX-40884001007 CDM 6370000100 HCPCS 250 RC 09999-3081-01 NDC inpatient 3000 ME 14.31 14.31 UNITED HEALTHCARE (COMMERCIAL) [3081199] UNITED HEALTHCARE 87726 [308119901] 8.87 percent of total billed charges 8.87 13.59 Technical (Hospital) Services WCH ED IBUPROFEN 600 MG TAB #5 RX-40884001007 CDM 6370000100 HCPCS 250 RC 09999-3081-01 NDC inpatient 3000 ME 14.31 14.31 BLUE CROSS BLUE SHIELD WELLMARK SB889 [3081026] BCBS WYOMING [308102603] 13.59 percent of total billed charges 8.87 13.59 Technical (Hospital) Services WCH ED IBUPROFEN 600 MG TAB #5 RX-40884001007 CDM 6370000100 HCPCS 250 RC 09999-3081-01 NDC inpatient 3000 ME 14.31 14.31 CIGNA 62308 [3081051] CIGNA 62308 [308105105] 11.33 percent of total billed charges 8.87 13.59 Technical (Hospital) Services WCH ED IBUPROFEN 600 MG TAB #5 RX-40884001007 CDM 6370000100 HCPCS 250 RC 09999-3081-01 NDC inpatient 3000 ME 14.31 14.31 CIGNA 62308 [3081051] CIGNA STATE OF WYOMING [308105107] 11.33 percent of total billed charges 8.87 13.59 Technical (Hospital) Services WCH ED IBUPROFEN 600 MG TAB #5 RX-40884001007 CDM 6370000100 HCPCS 250 RC 09999-3081-01 NDC inpatient 3000 ME 14.31 14.31 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES EPO [308136803] 11.33 percent of total billed charges 8.87 13.59 Technical (Hospital) Services WCH ED IBUPROFEN 600 MG TAB #5 RX-40884001007 CDM 6370000100 HCPCS 250 RC 09999-3081-01 NDC inpatient 3000 ME 14.31 14.31 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES HDHP [308136802] 11.33 percent of total billed charges 8.87 13.59 Technical (Hospital) Services WCH ED IBUPROFEN 600 MG TAB #5 RX-40884001007 CDM 6370000100 HCPCS 250 RC 09999-3081-01 NDC inpatient 3000 ME 14.31 14.31 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES PPO [308136801] 11.33 percent of total billed charges 8.87 13.59 Technical (Hospital) Services WCH ED CEFPROZIL 250 MG TAB #4 RX-408840013 CDM 6370000100 HCPCS 250 RC 09999-9990-06 NDC inpatient 1000 ME 20.13 20.13 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES PPO [308136801] 15.94 percent of total billed charges 12.48 19.12 Technical (Hospital) Services WCH ED CEFPROZIL 250 MG TAB #4 RX-408840013 CDM 6370000100 HCPCS 250 RC 09999-9990-06 NDC inpatient 1000 ME 20.13 20.13 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES HDHP [308136802] 15.94 percent of total billed charges 12.48 19.12 Technical (Hospital) Services WCH ED CEFPROZIL 250 MG TAB #4 RX-408840013 CDM 6370000100 HCPCS 250 RC 09999-9990-06 NDC inpatient 1000 ME 20.13 20.13 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES EPO [308136803] 15.94 percent of total billed charges 12.48 19.12 Technical (Hospital) Services WCH ED CEFPROZIL 250 MG TAB #4 RX-408840013 CDM 6370000100 HCPCS 250 RC 09999-9990-06 NDC inpatient 1000 ME 20.13 20.13 CIGNA 62308 [3081051] CIGNA STATE OF WYOMING [308105107] 15.94 percent of total billed charges 12.48 19.12 Technical (Hospital) Services WCH ED CEFPROZIL 250 MG TAB #4 RX-408840013 CDM 6370000100 HCPCS 250 RC 09999-9990-06 NDC inpatient 1000 ME 20.13 20.13 CIGNA 62308 [3081051] CIGNA 62308 [308105105] 15.94 percent of total billed charges 12.48 19.12 Technical (Hospital) Services WCH ED CEFPROZIL 250 MG TAB #4 RX-408840013 CDM 6370000100 HCPCS 250 RC 09999-9990-06 NDC inpatient 1000 ME 20.13 20.13 BLUE CROSS BLUE SHIELD WELLMARK SB889 [3081026] BCBS WYOMING [308102603] 19.12 percent of total billed charges 12.48 19.12 Technical (Hospital) Services WCH ED CEFPROZIL 250 MG TAB #4 RX-408840013 CDM 6370000100 HCPCS 250 RC 09999-9990-06 NDC inpatient 1000 ME 20.13 20.13 UNITED HEALTHCARE (COMMERCIAL) [3081199] UNITED HEALTHCARE 87726 [308119901] 12.48 percent of total billed charges 12.48 19.12 Technical (Hospital) Services WCH ED CEFPROZIL 250 MG TAB #4 RX-408840013 CDM 6370000100 HCPCS 250 RC 09999-9990-06 NDC inpatient 1000 ME 20.13 20.13 MEDICA (COMMERCIAL) 94265 [3081118] MEDICA CLAIMS [308111801] 18.12 percent of total billed charges 12.48 19.12 Technical (Hospital) Services WCH ED CEFPROZIL 250 MG TAB #4 RX-408840013 CDM 6370000100 HCPCS 250 RC 09999-9990-06 NDC inpatient 1000 ME 20.13 20.13 MULTIPLAN INC 34080 [3081285] MULTIPLAN INC [308128501] 19.12 percent of total billed charges 12.48 19.12 Technical (Hospital) Services WCH ED CEFPROZIL 250 MG TAB #4 RX-408840013 CDM 6370000100 HCPCS 250 RC 09999-9990-06 NDC inpatient 1000 ME 20.13 20.13 HEALTHPARTNERS SX009 HEALTHPARTNERS 15.94 percent of total billed charges 12.48 19.12 Technical (Hospital) Services WCH ED CEFPROZIL 250 MG TAB #4 RX-408840013 CDM 6370000100 HCPCS 250 RC 09999-9990-06 NDC outpatient 1000 ME 20.13 20.13 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES EPO [308136803] 16.1 percent of total billed charges 12.48 19.12 Technical (Hospital) Services WCH ED CEFPROZIL 250 MG TAB #4 RX-408840013 CDM 6370000100 HCPCS 250 RC 09999-9990-06 NDC outpatient 1000 ME 20.13 20.13 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES HDHP [308136802] 16.1 percent of total billed charges 12.48 19.12 Technical (Hospital) Services WCH ED CEFPROZIL 250 MG TAB #4 RX-408840013 CDM 6370000100 HCPCS 250 RC 09999-9990-06 NDC outpatient 1000 ME 20.13 20.13 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES PPO [308136801] 16.1 percent of total billed charges 12.48 19.12 Technical (Hospital) Services WCH ED CEFPROZIL 250 MG TAB #4 RX-408840013 CDM 6370000100 HCPCS 250 RC 09999-9990-06 NDC outpatient 1000 ME 20.13 20.13 BLUE CROSS BLUE SHIELD WELLMARK SB889 [3081026] BCBS WYOMING [308102603] 19.12 percent of total billed charges 12.48 19.12 Technical (Hospital) Services WCH ED CEFPROZIL 250 MG TAB #4 RX-408840013 CDM 6370000100 HCPCS 250 RC 09999-9990-06 NDC outpatient 1000 ME 20.13 20.13 UNITED HEALTHCARE (COMMERCIAL) [3081199] UNITED HEALTHCARE 87726 [308119901] 12.48 percent of total billed charges 12.48 19.12 Technical (Hospital) Services WCH ED CEFPROZIL 250 MG TAB #4 RX-408840013 CDM 6370000100 HCPCS 250 RC 09999-9990-06 NDC outpatient 1000 ME 20.13 20.13 HEALTHPARTNERS SX009 HEALTHPARTNERS 16.1 percent of total billed charges 12.48 19.12 Technical (Hospital) Services WCH ED CEFPROZIL 250 MG TAB #4 RX-408840013 CDM 6370000100 HCPCS 250 RC 09999-9990-06 NDC outpatient 1000 ME 20.13 20.13 MEDICA (COMMERCIAL) 94265 [3081118] MEDICA CLAIMS [308111801] 18.12 percent of total billed charges 12.48 19.12 Technical (Hospital) Services WCH ED CEFPROZIL 250 MG TAB #4 RX-408840013 CDM 6370000100 HCPCS 250 RC 09999-9990-06 NDC outpatient 1000 ME 20.13 20.13 MULTIPLAN INC 34080 [3081285] MULTIPLAN INC [308128501] 19.12 percent of total billed charges 12.48 19.12 Technical (Hospital) Services WCH ED CEFPROZIL 250 MG TAB #4 RX-408840013 CDM 6370000100 HCPCS 250 RC 09999-9990-06 NDC outpatient 1000 ME 20.13 20.13 CIGNA 62308 [3081051] CIGNA 62308 [308105105] 16.1 percent of total billed charges 12.48 19.12 Technical (Hospital) Services WCH ED CEFPROZIL 250 MG TAB #4 RX-408840013 CDM 6370000100 HCPCS 250 RC 09999-9990-06 NDC outpatient 1000 ME 20.13 20.13 CIGNA 62308 [3081051] CIGNA STATE OF WYOMING [308105107] 16.1 percent of total billed charges 12.48 19.12 Technical (Hospital) Services WCH ED CEPHALEXIN 250 MG /5 ML #100ML RX-408840014 CDM 6370000100 HCPCS 250 RC 09999-9990-08 NDC outpatient 5000 ME 36.75 36.75 CIGNA 62308 [3081051] CIGNA 62308 [308105105] 29.4 percent of total billed charges 22.79 34.91 Technical (Hospital) Services WCH ED CEPHALEXIN 250 MG /5 ML #100ML RX-408840014 CDM 6370000100 HCPCS 250 RC 09999-9990-08 NDC outpatient 5000 ME 36.75 36.75 CIGNA 62308 [3081051] CIGNA STATE OF WYOMING [308105107] 29.4 percent of total billed charges 22.79 34.91 Technical (Hospital) Services WCH ED CEPHALEXIN 250 MG /5 ML #100ML RX-408840014 CDM 6370000100 HCPCS 250 RC 09999-9990-08 NDC outpatient 5000 ME 36.75 36.75 MEDICA (COMMERCIAL) 94265 [3081118] MEDICA CLAIMS [308111801] 33.08 percent of total billed charges 22.79 34.91 Technical (Hospital) Services WCH ED CEPHALEXIN 250 MG /5 ML #100ML RX-408840014 CDM 6370000100 HCPCS 250 RC 09999-9990-08 NDC outpatient 5000 ME 36.75 36.75 MULTIPLAN INC 34080 [3081285] MULTIPLAN INC [308128501] 34.91 percent of total billed charges 22.79 34.91 Technical (Hospital) Services WCH ED CEPHALEXIN 250 MG /5 ML #100ML RX-408840014 CDM 6370000100 HCPCS 250 RC 09999-9990-08 NDC outpatient 5000 ME 36.75 36.75 HEALTHPARTNERS SX009 HEALTHPARTNERS 29.4 percent of total billed charges 22.79 34.91 Technical (Hospital) Services WCH ED CEPHALEXIN 250 MG /5 ML #100ML RX-408840014 CDM 6370000100 HCPCS 250 RC 09999-9990-08 NDC outpatient 5000 ME 36.75 36.75 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES EPO [308136803] 29.4 percent of total billed charges 22.79 34.91 Technical (Hospital) Services WCH ED CEPHALEXIN 250 MG /5 ML #100ML RX-408840014 CDM 6370000100 HCPCS 250 RC 09999-9990-08 NDC outpatient 5000 ME 36.75 36.75 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES HDHP [308136802] 29.4 percent of total billed charges 22.79 34.91 Technical (Hospital) Services WCH ED CEPHALEXIN 250 MG /5 ML #100ML RX-408840014 CDM 6370000100 HCPCS 250 RC 09999-9990-08 NDC outpatient 5000 ME 36.75 36.75 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES PPO [308136801] 29.4 percent of total billed charges 22.79 34.91 Technical (Hospital) Services WCH ED CEPHALEXIN 250 MG /5 ML #100ML RX-408840014 CDM 6370000100 HCPCS 250 RC 09999-9990-08 NDC outpatient 5000 ME 36.75 36.75 UNITED HEALTHCARE (COMMERCIAL) [3081199] UNITED HEALTHCARE 87726 [308119901] 22.79 percent of total billed charges 22.79 34.91 Technical (Hospital) Services WCH ED CEPHALEXIN 250 MG /5 ML #100ML RX-408840014 CDM 6370000100 HCPCS 250 RC 09999-9990-08 NDC outpatient 5000 ME 36.75 36.75 BLUE CROSS BLUE SHIELD WELLMARK SB889 [3081026] BCBS WYOMING [308102603] 34.91 percent of total billed charges 22.79 34.91 Technical (Hospital) Services WCH ED CEPHALEXIN 250 MG /5 ML #100ML RX-408840014 CDM 6370000100 HCPCS 250 RC 09999-9990-08 NDC inpatient 5000 ME 36.75 36.75 CIGNA 62308 [3081051] CIGNA 62308 [308105105] 29.1 percent of total billed charges 22.79 34.91 Technical (Hospital) Services WCH ED CEPHALEXIN 250 MG /5 ML #100ML RX-408840014 CDM 6370000100 HCPCS 250 RC 09999-9990-08 NDC inpatient 5000 ME 36.75 36.75 CIGNA 62308 [3081051] CIGNA STATE OF WYOMING [308105107] 29.1 percent of total billed charges 22.79 34.91 Technical (Hospital) Services WCH ED CEPHALEXIN 250 MG /5 ML #100ML RX-408840014 CDM 6370000100 HCPCS 250 RC 09999-9990-08 NDC inpatient 5000 ME 36.75 36.75 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES EPO [308136803] 29.1 percent of total billed charges 22.79 34.91 Technical (Hospital) Services WCH ED CEPHALEXIN 250 MG /5 ML #100ML RX-408840014 CDM 6370000100 HCPCS 250 RC 09999-9990-08 NDC inpatient 5000 ME 36.75 36.75 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES HDHP [308136802] 29.1 percent of total billed charges 22.79 34.91 Technical (Hospital) Services WCH ED CEPHALEXIN 250 MG /5 ML #100ML RX-408840014 CDM 6370000100 HCPCS 250 RC 09999-9990-08 NDC inpatient 5000 ME 36.75 36.75 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES PPO [308136801] 29.1 percent of total billed charges 22.79 34.91 Technical (Hospital) Services WCH ED CEPHALEXIN 250 MG /5 ML #100ML RX-408840014 CDM 6370000100 HCPCS 250 RC 09999-9990-08 NDC inpatient 5000 ME 36.75 36.75 BLUE CROSS BLUE SHIELD WELLMARK SB889 [3081026] BCBS WYOMING [308102603] 34.91 percent of total billed charges 22.79 34.91 Technical (Hospital) Services WCH ED CEPHALEXIN 250 MG /5 ML #100ML RX-408840014 CDM 6370000100 HCPCS 250 RC 09999-9990-08 NDC inpatient 5000 ME 36.75 36.75 UNITED HEALTHCARE (COMMERCIAL) [3081199] UNITED HEALTHCARE 87726 [308119901] 22.79 percent of total billed charges 22.79 34.91 Technical (Hospital) Services WCH ED CEPHALEXIN 250 MG /5 ML #100ML RX-408840014 CDM 6370000100 HCPCS 250 RC 09999-9990-08 NDC inpatient 5000 ME 36.75 36.75 HEALTHPARTNERS SX009 HEALTHPARTNERS 29.1 percent of total billed charges 22.79 34.91 Technical (Hospital) Services WCH ED CEPHALEXIN 250 MG /5 ML #100ML RX-408840014 CDM 6370000100 HCPCS 250 RC 09999-9990-08 NDC inpatient 5000 ME 36.75 36.75 MULTIPLAN INC 34080 [3081285] MULTIPLAN INC [308128501] 34.91 percent of total billed charges 22.79 34.91 Technical (Hospital) Services WCH ED CEPHALEXIN 250 MG /5 ML #100ML RX-408840014 CDM 6370000100 HCPCS 250 RC 09999-9990-08 NDC inpatient 5000 ME 36.75 36.75 MEDICA (COMMERCIAL) 94265 [3081118] MEDICA CLAIMS [308111801] 33.08 percent of total billed charges 22.79 34.91 Technical (Hospital) Services WCH ED CEPHALEXIN 250 MG CAP #6 RX-408840015 CDM 6370000100 HCPCS 250 RC 09999-9990-09 NDC inpatient 1500 ME 14.54 14.54 CIGNA 62308 [3081051] CIGNA 62308 [308105105] 11.51 percent of total billed charges 9.01 13.81 Technical (Hospital) Services WCH ED CEPHALEXIN 250 MG CAP #6 RX-408840015 CDM 6370000100 HCPCS 250 RC 09999-9990-09 NDC inpatient 1500 ME 14.54 14.54 CIGNA 62308 [3081051] CIGNA STATE OF WYOMING [308105107] 11.51 percent of total billed charges 9.01 13.81 Technical (Hospital) Services WCH ED CEPHALEXIN 250 MG CAP #6 RX-408840015 CDM 6370000100 HCPCS 250 RC 09999-9990-09 NDC inpatient 1500 ME 14.54 14.54 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES PPO [308136801] 11.51 percent of total billed charges 9.01 13.81 Technical (Hospital) Services WCH ED CEPHALEXIN 250 MG CAP #6 RX-408840015 CDM 6370000100 HCPCS 250 RC 09999-9990-09 NDC inpatient 1500 ME 14.54 14.54 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES EPO [308136803] 11.51 percent of total billed charges 9.01 13.81 Technical (Hospital) Services WCH ED CEPHALEXIN 250 MG CAP #6 RX-408840015 CDM 6370000100 HCPCS 250 RC 09999-9990-09 NDC inpatient 1500 ME 14.54 14.54 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES HDHP [308136802] 11.51 percent of total billed charges 9.01 13.81 Technical (Hospital) Services WCH ED CEPHALEXIN 250 MG CAP #6 RX-408840015 CDM 6370000100 HCPCS 250 RC 09999-9990-09 NDC inpatient 1500 ME 14.54 14.54 BLUE CROSS BLUE SHIELD WELLMARK SB889 [3081026] BCBS WYOMING [308102603] 13.81 percent of total billed charges 9.01 13.81 Technical (Hospital) Services WCH ED CEPHALEXIN 250 MG CAP #6 RX-408840015 CDM 6370000100 HCPCS 250 RC 09999-9990-09 NDC inpatient 1500 ME 14.54 14.54 UNITED HEALTHCARE (COMMERCIAL) [3081199] UNITED HEALTHCARE 87726 [308119901] 9.01 percent of total billed charges 9.01 13.81 Technical (Hospital) Services WCH ED CEPHALEXIN 250 MG CAP #6 RX-408840015 CDM 6370000100 HCPCS 250 RC 09999-9990-09 NDC inpatient 1500 ME 14.54 14.54 HEALTHPARTNERS SX009 HEALTHPARTNERS 11.51 percent of total billed charges 9.01 13.81 Technical (Hospital) Services WCH ED CEPHALEXIN 250 MG CAP #6 RX-408840015 CDM 6370000100 HCPCS 250 RC 09999-9990-09 NDC inpatient 1500 ME 14.54 14.54 MEDICA (COMMERCIAL) 94265 [3081118] MEDICA CLAIMS [308111801] 13.09 percent of total billed charges 9.01 13.81 Technical (Hospital) Services WCH ED CEPHALEXIN 250 MG CAP #6 RX-408840015 CDM 6370000100 HCPCS 250 RC 09999-9990-09 NDC inpatient 1500 ME 14.54 14.54 MULTIPLAN INC 34080 [3081285] MULTIPLAN INC [308128501] 13.81 percent of total billed charges 9.01 13.81 Technical (Hospital) Services WCH ED CEPHALEXIN 250 MG CAP #6 RX-408840015 CDM 6370000100 HCPCS 250 RC 09999-9990-09 NDC outpatient 1500 ME 14.54 14.54 MULTIPLAN INC 34080 [3081285] MULTIPLAN INC [308128501] 13.81 percent of total billed charges 9.01 13.81 Technical (Hospital) Services WCH ED CEPHALEXIN 250 MG CAP #6 RX-408840015 CDM 6370000100 HCPCS 250 RC 09999-9990-09 NDC outpatient 1500 ME 14.54 14.54 MEDICA (COMMERCIAL) 94265 [3081118] MEDICA CLAIMS [308111801] 13.09 percent of total billed charges 9.01 13.81 Technical (Hospital) Services WCH ED CEPHALEXIN 250 MG CAP #6 RX-408840015 CDM 6370000100 HCPCS 250 RC 09999-9990-09 NDC outpatient 1500 ME 14.54 14.54 CIGNA 62308 [3081051] CIGNA 62308 [308105105] 11.63 percent of total billed charges 9.01 13.81 Technical (Hospital) Services WCH ED CEPHALEXIN 250 MG CAP #6 RX-408840015 CDM 6370000100 HCPCS 250 RC 09999-9990-09 NDC outpatient 1500 ME 14.54 14.54 CIGNA 62308 [3081051] CIGNA STATE OF WYOMING [308105107] 11.63 percent of total billed charges 9.01 13.81 Technical (Hospital) Services WCH ED CEPHALEXIN 250 MG CAP #6 RX-408840015 CDM 6370000100 HCPCS 250 RC 09999-9990-09 NDC outpatient 1500 ME 14.54 14.54 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES EPO [308136803] 11.63 percent of total billed charges 9.01 13.81 Technical (Hospital) Services WCH ED CEPHALEXIN 250 MG CAP #6 RX-408840015 CDM 6370000100 HCPCS 250 RC 09999-9990-09 NDC outpatient 1500 ME 14.54 14.54 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES HDHP [308136802] 11.63 percent of total billed charges 9.01 13.81 Technical (Hospital) Services WCH ED CEPHALEXIN 250 MG CAP #6 RX-408840015 CDM 6370000100 HCPCS 250 RC 09999-9990-09 NDC outpatient 1500 ME 14.54 14.54 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES PPO [308136801] 11.63 percent of total billed charges 9.01 13.81 Technical (Hospital) Services WCH ED CEPHALEXIN 250 MG CAP #6 RX-408840015 CDM 6370000100 HCPCS 250 RC 09999-9990-09 NDC outpatient 1500 ME 14.54 14.54 UNITED HEALTHCARE (COMMERCIAL) [3081199] UNITED HEALTHCARE 87726 [308119901] 9.01 percent of total billed charges 9.01 13.81 Technical (Hospital) Services WCH ED CEPHALEXIN 250 MG CAP #6 RX-408840015 CDM 6370000100 HCPCS 250 RC 09999-9990-09 NDC outpatient 1500 ME 14.54 14.54 BLUE CROSS BLUE SHIELD WELLMARK SB889 [3081026] BCBS WYOMING [308102603] 13.81 percent of total billed charges 9.01 13.81 Technical (Hospital) Services WCH ED CEPHALEXIN 250 MG CAP #6 RX-408840015 CDM 6370000100 HCPCS 250 RC 09999-9990-09 NDC outpatient 1500 ME 14.54 14.54 HEALTHPARTNERS SX009 HEALTHPARTNERS 11.63 percent of total billed charges 9.01 13.81 Technical (Hospital) Services WCH ED CIPROFLOXACIN 500 MG TAB #4 RX-408840016 CDM 6370000100 HCPCS 250 RC 09999-9990-10 NDC inpatient 2000 ME 14.59 14.59 CIGNA 62308 [3081051] CIGNA 62308 [308105105] 11.55 percent of total billed charges 9.05 13.86 Technical (Hospital) Services WCH ED CIPROFLOXACIN 500 MG TAB #4 RX-408840016 CDM 6370000100 HCPCS 250 RC 09999-9990-10 NDC inpatient 2000 ME 14.59 14.59 CIGNA 62308 [3081051] CIGNA STATE OF WYOMING [308105107] 11.55 percent of total billed charges 9.05 13.86 Technical (Hospital) Services WCH ED CIPROFLOXACIN 500 MG TAB #4 RX-408840016 CDM 6370000100 HCPCS 250 RC 09999-9990-10 NDC inpatient 2000 ME 14.59 14.59 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES EPO [308136803] 11.55 percent of total billed charges 9.05 13.86 Technical (Hospital) Services WCH ED CIPROFLOXACIN 500 MG TAB #4 RX-408840016 CDM 6370000100 HCPCS 250 RC 09999-9990-10 NDC inpatient 2000 ME 14.59 14.59 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES HDHP [308136802] 11.55 percent of total billed charges 9.05 13.86 Technical (Hospital) Services WCH ED CIPROFLOXACIN 500 MG TAB #4 RX-408840016 CDM 6370000100 HCPCS 250 RC 09999-9990-10 NDC inpatient 2000 ME 14.59 14.59 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES PPO [308136801] 11.55 percent of total billed charges 9.05 13.86 Technical (Hospital) Services WCH ED CIPROFLOXACIN 500 MG TAB #4 RX-408840016 CDM 6370000100 HCPCS 250 RC 09999-9990-10 NDC inpatient 2000 ME 14.59 14.59 HEALTHPARTNERS SX009 HEALTHPARTNERS 11.55 percent of total billed charges 9.05 13.86 Technical (Hospital) Services WCH ED CIPROFLOXACIN 500 MG TAB #4 RX-408840016 CDM 6370000100 HCPCS 250 RC 09999-9990-10 NDC inpatient 2000 ME 14.59 14.59 MULTIPLAN INC 34080 [3081285] MULTIPLAN INC [308128501] 13.86 percent of total billed charges 9.05 13.86 Technical (Hospital) Services WCH ED CIPROFLOXACIN 500 MG TAB #4 RX-408840016 CDM 6370000100 HCPCS 250 RC 09999-9990-10 NDC inpatient 2000 ME 14.59 14.59 MEDICA (COMMERCIAL) 94265 [3081118] MEDICA CLAIMS [308111801] 13.13 percent of total billed charges 9.05 13.86 Technical (Hospital) Services WCH ED CIPROFLOXACIN 500 MG TAB #4 RX-408840016 CDM 6370000100 HCPCS 250 RC 09999-9990-10 NDC inpatient 2000 ME 14.59 14.59 UNITED HEALTHCARE (COMMERCIAL) [3081199] UNITED HEALTHCARE 87726 [308119901] 9.05 percent of total billed charges 9.05 13.86 Technical (Hospital) Services WCH ED CIPROFLOXACIN 500 MG TAB #4 RX-408840016 CDM 6370000100 HCPCS 250 RC 09999-9990-10 NDC inpatient 2000 ME 14.59 14.59 BLUE CROSS BLUE SHIELD WELLMARK SB889 [3081026] BCBS WYOMING [308102603] 13.86 percent of total billed charges 9.05 13.86 Technical (Hospital) Services WCH ED CIPROFLOXACIN 500 MG TAB #4 RX-408840016 CDM 6370000100 HCPCS 250 RC 09999-9990-10 NDC outpatient 2000 ME 14.59 14.59 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES EPO [308136803] 11.67 percent of total billed charges 9.05 13.86 Technical (Hospital) Services WCH ED CIPROFLOXACIN 500 MG TAB #4 RX-408840016 CDM 6370000100 HCPCS 250 RC 09999-9990-10 NDC outpatient 2000 ME 14.59 14.59 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES HDHP [308136802] 11.67 percent of total billed charges 9.05 13.86 Technical (Hospital) Services WCH ED CIPROFLOXACIN 500 MG TAB #4 RX-408840016 CDM 6370000100 HCPCS 250 RC 09999-9990-10 NDC outpatient 2000 ME 14.59 14.59 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES PPO [308136801] 11.67 percent of total billed charges 9.05 13.86 Technical (Hospital) Services WCH ED CIPROFLOXACIN 500 MG TAB #4 RX-408840016 CDM 6370000100 HCPCS 250 RC 09999-9990-10 NDC outpatient 2000 ME 14.59 14.59 UNITED HEALTHCARE (COMMERCIAL) [3081199] UNITED HEALTHCARE 87726 [308119901] 9.05 percent of total billed charges 9.05 13.86 Technical (Hospital) Services WCH ED CIPROFLOXACIN 500 MG TAB #4 RX-408840016 CDM 6370000100 HCPCS 250 RC 09999-9990-10 NDC outpatient 2000 ME 14.59 14.59 BLUE CROSS BLUE SHIELD WELLMARK SB889 [3081026] BCBS WYOMING [308102603] 13.86 percent of total billed charges 9.05 13.86 Technical (Hospital) Services WCH ED CIPROFLOXACIN 500 MG TAB #4 RX-408840016 CDM 6370000100 HCPCS 250 RC 09999-9990-10 NDC outpatient 2000 ME 14.59 14.59 HEALTHPARTNERS SX009 HEALTHPARTNERS 11.67 percent of total billed charges 9.05 13.86 Technical (Hospital) Services WCH ED CIPROFLOXACIN 500 MG TAB #4 RX-408840016 CDM 6370000100 HCPCS 250 RC 09999-9990-10 NDC outpatient 2000 ME 14.59 14.59 MULTIPLAN INC 34080 [3081285] MULTIPLAN INC [308128501] 13.86 percent of total billed charges 9.05 13.86 Technical (Hospital) Services WCH ED CIPROFLOXACIN 500 MG TAB #4 RX-408840016 CDM 6370000100 HCPCS 250 RC 09999-9990-10 NDC outpatient 2000 ME 14.59 14.59 MEDICA (COMMERCIAL) 94265 [3081118] MEDICA CLAIMS [308111801] 13.13 percent of total billed charges 9.05 13.86 Technical (Hospital) Services WCH ED CIPROFLOXACIN 500 MG TAB #4 RX-408840016 CDM 6370000100 HCPCS 250 RC 09999-9990-10 NDC outpatient 2000 ME 14.59 14.59 CIGNA 62308 [3081051] CIGNA 62308 [308105105] 11.67 percent of total billed charges 9.05 13.86 Technical (Hospital) Services WCH ED CIPROFLOXACIN 500 MG TAB #4 RX-408840016 CDM 6370000100 HCPCS 250 RC 09999-9990-10 NDC outpatient 2000 ME 14.59 14.59 CIGNA 62308 [3081051] CIGNA STATE OF WYOMING [308105107] 11.67 percent of total billed charges 9.05 13.86 Technical (Hospital) Services WCH ED GUAIFENESIN/CODEINE 100 MG-10 MG 5 ML ORAL SYRUP #60ML RX-408840017 CDM 6370000100 HCPCS 250 RC 09999-9990-13 NDC inpatient 60 ML 19.21 19.21 HEALTHPARTNERS SX009 HEALTHPARTNERS 15.21 percent of total billed charges 11.91 18.25 Technical (Hospital) Services WCH ED GUAIFENESIN/CODEINE 100 MG-10 MG 5 ML ORAL SYRUP #60ML RX-408840017 CDM 6370000100 HCPCS 250 RC 09999-9990-13 NDC inpatient 60 ML 19.21 19.21 MULTIPLAN INC 34080 [3081285] MULTIPLAN INC [308128501] 18.25 percent of total billed charges 11.91 18.25 Technical (Hospital) Services WCH ED GUAIFENESIN/CODEINE 100 MG-10 MG 5 ML ORAL SYRUP #60ML RX-408840017 CDM 6370000100 HCPCS 250 RC 09999-9990-13 NDC inpatient 60 ML 19.21 19.21 MEDICA (COMMERCIAL) 94265 [3081118] MEDICA CLAIMS [308111801] 17.29 percent of total billed charges 11.91 18.25 Technical (Hospital) Services WCH ED GUAIFENESIN/CODEINE 100 MG-10 MG 5 ML ORAL SYRUP #60ML RX-408840017 CDM 6370000100 HCPCS 250 RC 09999-9990-13 NDC inpatient 60 ML 19.21 19.21 BLUE CROSS BLUE SHIELD WELLMARK SB889 [3081026] BCBS WYOMING [308102603] 18.25 percent of total billed charges 11.91 18.25 Technical (Hospital) Services WCH ED GUAIFENESIN/CODEINE 100 MG-10 MG 5 ML ORAL SYRUP #60ML RX-408840017 CDM 6370000100 HCPCS 250 RC 09999-9990-13 NDC inpatient 60 ML 19.21 19.21 UNITED HEALTHCARE (COMMERCIAL) [3081199] UNITED HEALTHCARE 87726 [308119901] 11.91 percent of total billed charges 11.91 18.25 Technical (Hospital) Services WCH ED GUAIFENESIN/CODEINE 100 MG-10 MG 5 ML ORAL SYRUP #60ML RX-408840017 CDM 6370000100 HCPCS 250 RC 09999-9990-13 NDC inpatient 60 ML 19.21 19.21 CIGNA 62308 [3081051] CIGNA 62308 [308105105] 15.21 percent of total billed charges 11.91 18.25 Technical (Hospital) Services WCH ED GUAIFENESIN/CODEINE 100 MG-10 MG 5 ML ORAL SYRUP #60ML RX-408840017 CDM 6370000100 HCPCS 250 RC 09999-9990-13 NDC inpatient 60 ML 19.21 19.21 CIGNA 62308 [3081051] CIGNA STATE OF WYOMING [308105107] 15.21 percent of total billed charges 11.91 18.25 Technical (Hospital) Services WCH ED GUAIFENESIN/CODEINE 100 MG-10 MG 5 ML ORAL SYRUP #60ML RX-408840017 CDM 6370000100 HCPCS 250 RC 09999-9990-13 NDC inpatient 60 ML 19.21 19.21 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES EPO [308136803] 15.21 percent of total billed charges 11.91 18.25 Technical (Hospital) Services WCH ED GUAIFENESIN/CODEINE 100 MG-10 MG 5 ML ORAL SYRUP #60ML RX-408840017 CDM 6370000100 HCPCS 250 RC 09999-9990-13 NDC inpatient 60 ML 19.21 19.21 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES HDHP [308136802] 15.21 percent of total billed charges 11.91 18.25 Technical (Hospital) Services WCH ED GUAIFENESIN/CODEINE 100 MG-10 MG 5 ML ORAL SYRUP #60ML RX-408840017 CDM 6370000100 HCPCS 250 RC 09999-9990-13 NDC inpatient 60 ML 19.21 19.21 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES PPO [308136801] 15.21 percent of total billed charges 11.91 18.25 Technical (Hospital) Services WCH ED GUAIFENESIN/CODEINE 100 MG-10 MG 5 ML ORAL SYRUP #60ML RX-408840017 CDM 6370000100 HCPCS 250 RC 09999-9990-13 NDC outpatient 60 ML 19.21 19.21 CIGNA 62308 [3081051] CIGNA 62308 [308105105] 15.37 percent of total billed charges 11.91 18.25 Technical (Hospital) Services WCH ED GUAIFENESIN/CODEINE 100 MG-10 MG 5 ML ORAL SYRUP #60ML RX-408840017 CDM 6370000100 HCPCS 250 RC 09999-9990-13 NDC outpatient 60 ML 19.21 19.21 CIGNA 62308 [3081051] CIGNA STATE OF WYOMING [308105107] 15.37 percent of total billed charges 11.91 18.25 Technical (Hospital) Services WCH ED GUAIFENESIN/CODEINE 100 MG-10 MG 5 ML ORAL SYRUP #60ML RX-408840017 CDM 6370000100 HCPCS 250 RC 09999-9990-13 NDC outpatient 60 ML 19.21 19.21 MULTIPLAN INC 34080 [3081285] MULTIPLAN INC [308128501] 18.25 percent of total billed charges 11.91 18.25 Technical (Hospital) Services WCH ED GUAIFENESIN/CODEINE 100 MG-10 MG 5 ML ORAL SYRUP #60ML RX-408840017 CDM 6370000100 HCPCS 250 RC 09999-9990-13 NDC outpatient 60 ML 19.21 19.21 MEDICA (COMMERCIAL) 94265 [3081118] MEDICA CLAIMS [308111801] 17.29 percent of total billed charges 11.91 18.25 Technical (Hospital) Services WCH ED GUAIFENESIN/CODEINE 100 MG-10 MG 5 ML ORAL SYRUP #60ML RX-408840017 CDM 6370000100 HCPCS 250 RC 09999-9990-13 NDC outpatient 60 ML 19.21 19.21 UNITED HEALTHCARE (COMMERCIAL) [3081199] UNITED HEALTHCARE 87726 [308119901] 11.91 percent of total billed charges 11.91 18.25 Technical (Hospital) Services WCH ED GUAIFENESIN/CODEINE 100 MG-10 MG 5 ML ORAL SYRUP #60ML RX-408840017 CDM 6370000100 HCPCS 250 RC 09999-9990-13 NDC outpatient 60 ML 19.21 19.21 HEALTHPARTNERS SX009 HEALTHPARTNERS 15.37 percent of total billed charges 11.91 18.25 Technical (Hospital) Services WCH ED GUAIFENESIN/CODEINE 100 MG-10 MG 5 ML ORAL SYRUP #60ML RX-408840017 CDM 6370000100 HCPCS 250 RC 09999-9990-13 NDC outpatient 60 ML 19.21 19.21 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES EPO [308136803] 15.37 percent of total billed charges 11.91 18.25 Technical (Hospital) Services WCH ED GUAIFENESIN/CODEINE 100 MG-10 MG 5 ML ORAL SYRUP #60ML RX-408840017 CDM 6370000100 HCPCS 250 RC 09999-9990-13 NDC outpatient 60 ML 19.21 19.21 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES HDHP [308136802] 15.37 percent of total billed charges 11.91 18.25 Technical (Hospital) Services WCH ED GUAIFENESIN/CODEINE 100 MG-10 MG 5 ML ORAL SYRUP #60ML RX-408840017 CDM 6370000100 HCPCS 250 RC 09999-9990-13 NDC outpatient 60 ML 19.21 19.21 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES PPO [308136801] 15.37 percent of total billed charges 11.91 18.25 Technical (Hospital) Services WCH ED GUAIFENESIN/CODEINE 100 MG-10 MG 5 ML ORAL SYRUP #60ML RX-408840017 CDM 6370000100 HCPCS 250 RC 09999-9990-13 NDC outpatient 60 ML 19.21 19.21 BLUE CROSS BLUE SHIELD WELLMARK SB889 [3081026] BCBS WYOMING [308102603] 18.25 percent of total billed charges 11.91 18.25 Technical (Hospital) Services WCH ED CYCLOBENZAPRINE 10 MG ORAL TABLET #10 RX-408840018 CDM 6370000100 HCPCS 250 RC 09999-9990-11 NDC outpatient 100 ME 14.29 14.29 BLUE CROSS BLUE SHIELD WELLMARK SB889 [3081026] BCBS WYOMING [308102603] 13.58 percent of total billed charges 8.86 13.58 Technical (Hospital) Services WCH ED CYCLOBENZAPRINE 10 MG ORAL TABLET #10 RX-408840018 CDM 6370000100 HCPCS 250 RC 09999-9990-11 NDC outpatient 100 ME 14.29 14.29 HEALTHPARTNERS SX009 HEALTHPARTNERS 11.43 percent of total billed charges 8.86 13.58 Technical (Hospital) Services WCH ED CYCLOBENZAPRINE 10 MG ORAL TABLET #10 RX-408840018 CDM 6370000100 HCPCS 250 RC 09999-9990-11 NDC outpatient 100 ME 14.29 14.29 UNITED HEALTHCARE (COMMERCIAL) [3081199] UNITED HEALTHCARE 87726 [308119901] 8.86 percent of total billed charges 8.86 13.58 Technical (Hospital) Services WCH ED CYCLOBENZAPRINE 10 MG ORAL TABLET #10 RX-408840018 CDM 6370000100 HCPCS 250 RC 09999-9990-11 NDC outpatient 100 ME 14.29 14.29 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES EPO [308136803] 11.43 percent of total billed charges 8.86 13.58 Technical (Hospital) Services WCH ED CYCLOBENZAPRINE 10 MG ORAL TABLET #10 RX-408840018 CDM 6370000100 HCPCS 250 RC 09999-9990-11 NDC outpatient 100 ME 14.29 14.29 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES PPO [308136801] 11.43 percent of total billed charges 8.86 13.58 Technical (Hospital) Services WCH ED CYCLOBENZAPRINE 10 MG ORAL TABLET #10 RX-408840018 CDM 6370000100 HCPCS 250 RC 09999-9990-11 NDC outpatient 100 ME 14.29 14.29 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES HDHP [308136802] 11.43 percent of total billed charges 8.86 13.58 Technical (Hospital) Services WCH ED CYCLOBENZAPRINE 10 MG ORAL TABLET #10 RX-408840018 CDM 6370000100 HCPCS 250 RC 09999-9990-11 NDC outpatient 100 ME 14.29 14.29 CIGNA 62308 [3081051] CIGNA 62308 [308105105] 11.43 percent of total billed charges 8.86 13.58 Technical (Hospital) Services WCH ED CYCLOBENZAPRINE 10 MG ORAL TABLET #10 RX-408840018 CDM 6370000100 HCPCS 250 RC 09999-9990-11 NDC outpatient 100 ME 14.29 14.29 CIGNA 62308 [3081051] CIGNA STATE OF WYOMING [308105107] 11.43 percent of total billed charges 8.86 13.58 Technical (Hospital) Services WCH ED CYCLOBENZAPRINE 10 MG ORAL TABLET #10 RX-408840018 CDM 6370000100 HCPCS 250 RC 09999-9990-11 NDC outpatient 100 ME 14.29 14.29 MEDICA (COMMERCIAL) 94265 [3081118] MEDICA CLAIMS [308111801] 12.86 percent of total billed charges 8.86 13.58 Technical (Hospital) Services WCH ED CYCLOBENZAPRINE 10 MG ORAL TABLET #10 RX-408840018 CDM 6370000100 HCPCS 250 RC 09999-9990-11 NDC outpatient 100 ME 14.29 14.29 MULTIPLAN INC 34080 [3081285] MULTIPLAN INC [308128501] 13.58 percent of total billed charges 8.86 13.58 Technical (Hospital) Services WCH ED CYCLOBENZAPRINE 10 MG ORAL TABLET #10 RX-408840018 CDM 6370000100 HCPCS 250 RC 09999-9990-11 NDC inpatient 100 ME 14.29 14.29 CIGNA 62308 [3081051] CIGNA 62308 [308105105] 11.31 percent of total billed charges 8.86 13.58 Technical (Hospital) Services WCH ED CYCLOBENZAPRINE 10 MG ORAL TABLET #10 RX-408840018 CDM 6370000100 HCPCS 250 RC 09999-9990-11 NDC inpatient 100 ME 14.29 14.29 CIGNA 62308 [3081051] CIGNA STATE OF WYOMING [308105107] 11.31 percent of total billed charges 8.86 13.58 Technical (Hospital) Services WCH ED CYCLOBENZAPRINE 10 MG ORAL TABLET #10 RX-408840018 CDM 6370000100 HCPCS 250 RC 09999-9990-11 NDC inpatient 100 ME 14.29 14.29 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES EPO [308136803] 11.31 percent of total billed charges 8.86 13.58 Technical (Hospital) Services WCH ED CYCLOBENZAPRINE 10 MG ORAL TABLET #10 RX-408840018 CDM 6370000100 HCPCS 250 RC 09999-9990-11 NDC inpatient 100 ME 14.29 14.29 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES HDHP [308136802] 11.31 percent of total billed charges 8.86 13.58 Technical (Hospital) Services WCH ED CYCLOBENZAPRINE 10 MG ORAL TABLET #10 RX-408840018 CDM 6370000100 HCPCS 250 RC 09999-9990-11 NDC inpatient 100 ME 14.29 14.29 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES PPO [308136801] 11.31 percent of total billed charges 8.86 13.58 Technical (Hospital) Services WCH ED CYCLOBENZAPRINE 10 MG ORAL TABLET #10 RX-408840018 CDM 6370000100 HCPCS 250 RC 09999-9990-11 NDC inpatient 100 ME 14.29 14.29 BLUE CROSS BLUE SHIELD WELLMARK SB889 [3081026] BCBS WYOMING [308102603] 13.58 percent of total billed charges 8.86 13.58 Technical (Hospital) Services WCH ED CYCLOBENZAPRINE 10 MG ORAL TABLET #10 RX-408840018 CDM 6370000100 HCPCS 250 RC 09999-9990-11 NDC inpatient 100 ME 14.29 14.29 UNITED HEALTHCARE (COMMERCIAL) [3081199] UNITED HEALTHCARE 87726 [308119901] 8.86 percent of total billed charges 8.86 13.58 Technical (Hospital) Services WCH ED CYCLOBENZAPRINE 10 MG ORAL TABLET #10 RX-408840018 CDM 6370000100 HCPCS 250 RC 09999-9990-11 NDC inpatient 100 ME 14.29 14.29 HEALTHPARTNERS SX009 HEALTHPARTNERS 11.31 percent of total billed charges 8.86 13.58 Technical (Hospital) Services WCH ED CYCLOBENZAPRINE 10 MG ORAL TABLET #10 RX-408840018 CDM 6370000100 HCPCS 250 RC 09999-9990-11 NDC inpatient 100 ME 14.29 14.29 MEDICA (COMMERCIAL) 94265 [3081118] MEDICA CLAIMS [308111801] 12.86 percent of total billed charges 8.86 13.58 Technical (Hospital) Services WCH ED CYCLOBENZAPRINE 10 MG ORAL TABLET #10 RX-408840018 CDM 6370000100 HCPCS 250 RC 09999-9990-11 NDC inpatient 100 ME 14.29 14.29 MULTIPLAN INC 34080 [3081285] MULTIPLAN INC [308128501] 13.58 percent of total billed charges 8.86 13.58 Technical (Hospital) Services WCH ED LORAZEPAM 1 MG ORAL TABLET #3 RX-408840020 CDM 6370000100 HCPCS 250 RC 09999-9990-15 NDC outpatient 3 ME 14.01 14.01 BLUE CROSS BLUE SHIELD WELLMARK SB889 [3081026] BCBS WYOMING [308102603] 13.31 percent of total billed charges 8.69 13.31 Technical (Hospital) Services WCH ED LORAZEPAM 1 MG ORAL TABLET #3 RX-408840020 CDM 6370000100 HCPCS 250 RC 09999-9990-15 NDC outpatient 3 ME 14.01 14.01 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES PPO [308136801] 11.21 percent of total billed charges 8.69 13.31 Technical (Hospital) Services WCH ED LORAZEPAM 1 MG ORAL TABLET #3 RX-408840020 CDM 6370000100 HCPCS 250 RC 09999-9990-15 NDC outpatient 3 ME 14.01 14.01 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES HDHP [308136802] 11.21 percent of total billed charges 8.69 13.31 Technical (Hospital) Services WCH ED LORAZEPAM 1 MG ORAL TABLET #3 RX-408840020 CDM 6370000100 HCPCS 250 RC 09999-9990-15 NDC outpatient 3 ME 14.01 14.01 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES EPO [308136803] 11.21 percent of total billed charges 8.69 13.31 Technical (Hospital) Services WCH ED LORAZEPAM 1 MG ORAL TABLET #3 RX-408840020 CDM 6370000100 HCPCS 250 RC 09999-9990-15 NDC outpatient 3 ME 14.01 14.01 CIGNA 62308 [3081051] CIGNA 62308 [308105105] 11.21 percent of total billed charges 8.69 13.31 Technical (Hospital) Services WCH ED LORAZEPAM 1 MG ORAL TABLET #3 RX-408840020 CDM 6370000100 HCPCS 250 RC 09999-9990-15 NDC outpatient 3 ME 14.01 14.01 CIGNA 62308 [3081051] CIGNA STATE OF WYOMING [308105107] 11.21 percent of total billed charges 8.69 13.31 Technical (Hospital) Services WCH ED LORAZEPAM 1 MG ORAL TABLET #3 RX-408840020 CDM 6370000100 HCPCS 250 RC 09999-9990-15 NDC outpatient 3 ME 14.01 14.01 UNITED HEALTHCARE (COMMERCIAL) [3081199] UNITED HEALTHCARE 87726 [308119901] 8.69 percent of total billed charges 8.69 13.31 Technical (Hospital) Services WCH ED LORAZEPAM 1 MG ORAL TABLET #3 RX-408840020 CDM 6370000100 HCPCS 250 RC 09999-9990-15 NDC outpatient 3 ME 14.01 14.01 HEALTHPARTNERS SX009 HEALTHPARTNERS 11.21 percent of total billed charges 8.69 13.31 Technical (Hospital) Services WCH ED LORAZEPAM 1 MG ORAL TABLET #3 RX-408840020 CDM 6370000100 HCPCS 250 RC 09999-9990-15 NDC outpatient 3 ME 14.01 14.01 MULTIPLAN INC 34080 [3081285] MULTIPLAN INC [308128501] 13.31 percent of total billed charges 8.69 13.31 Technical (Hospital) Services WCH ED LORAZEPAM 1 MG ORAL TABLET #3 RX-408840020 CDM 6370000100 HCPCS 250 RC 09999-9990-15 NDC outpatient 3 ME 14.01 14.01 MEDICA (COMMERCIAL) 94265 [3081118] MEDICA CLAIMS [308111801] 12.61 percent of total billed charges 8.69 13.31 Technical (Hospital) Services WCH ED LORAZEPAM 1 MG ORAL TABLET #3 RX-408840020 CDM 6370000100 HCPCS 250 RC 09999-9990-15 NDC inpatient 3 ME 14.01 14.01 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES PPO [308136801] 11.09 percent of total billed charges 8.69 13.31 Technical (Hospital) Services WCH ED LORAZEPAM 1 MG ORAL TABLET #3 RX-408840020 CDM 6370000100 HCPCS 250 RC 09999-9990-15 NDC inpatient 3 ME 14.01 14.01 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES EPO [308136803] 11.09 percent of total billed charges 8.69 13.31 Technical (Hospital) Services WCH ED LORAZEPAM 1 MG ORAL TABLET #3 RX-408840020 CDM 6370000100 HCPCS 250 RC 09999-9990-15 NDC inpatient 3 ME 14.01 14.01 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES HDHP [308136802] 11.09 percent of total billed charges 8.69 13.31 Technical (Hospital) Services WCH ED LORAZEPAM 1 MG ORAL TABLET #3 RX-408840020 CDM 6370000100 HCPCS 250 RC 09999-9990-15 NDC inpatient 3 ME 14.01 14.01 HEALTHPARTNERS SX009 HEALTHPARTNERS 11.09 percent of total billed charges 8.69 13.31 Technical (Hospital) Services WCH ED LORAZEPAM 1 MG ORAL TABLET #3 RX-408840020 CDM 6370000100 HCPCS 250 RC 09999-9990-15 NDC inpatient 3 ME 14.01 14.01 MULTIPLAN INC 34080 [3081285] MULTIPLAN INC [308128501] 13.31 percent of total billed charges 8.69 13.31 Technical (Hospital) Services WCH ED LORAZEPAM 1 MG ORAL TABLET #3 RX-408840020 CDM 6370000100 HCPCS 250 RC 09999-9990-15 NDC inpatient 3 ME 14.01 14.01 MEDICA (COMMERCIAL) 94265 [3081118] MEDICA CLAIMS [308111801] 12.61 percent of total billed charges 8.69 13.31 Technical (Hospital) Services WCH ED LORAZEPAM 1 MG ORAL TABLET #3 RX-408840020 CDM 6370000100 HCPCS 250 RC 09999-9990-15 NDC inpatient 3 ME 14.01 14.01 BLUE CROSS BLUE SHIELD WELLMARK SB889 [3081026] BCBS WYOMING [308102603] 13.31 percent of total billed charges 8.69 13.31 Technical (Hospital) Services WCH ED LORAZEPAM 1 MG ORAL TABLET #3 RX-408840020 CDM 6370000100 HCPCS 250 RC 09999-9990-15 NDC inpatient 3 ME 14.01 14.01 CIGNA 62308 [3081051] CIGNA 62308 [308105105] 11.09 percent of total billed charges 8.69 13.31 Technical (Hospital) Services WCH ED LORAZEPAM 1 MG ORAL TABLET #3 RX-408840020 CDM 6370000100 HCPCS 250 RC 09999-9990-15 NDC inpatient 3 ME 14.01 14.01 CIGNA 62308 [3081051] CIGNA STATE OF WYOMING [308105107] 11.09 percent of total billed charges 8.69 13.31 Technical (Hospital) Services WCH ED LORAZEPAM 1 MG ORAL TABLET #3 RX-408840020 CDM 6370000100 HCPCS 250 RC 09999-9990-15 NDC inpatient 3 ME 14.01 14.01 UNITED HEALTHCARE (COMMERCIAL) [3081199] UNITED HEALTHCARE 87726 [308119901] 8.69 percent of total billed charges 8.69 13.31 Technical (Hospital) Services WCH ED METOCLOPRAMIDE 10 MG TAB #6 RX-408840021 CDM 6370000100 HCPCS 250 RC 09999-9990-16 NDC inpatient 60 ME 14.19 14.19 UNITED HEALTHCARE (COMMERCIAL) [3081199] UNITED HEALTHCARE 87726 [308119901] 8.8 percent of total billed charges 8.8 13.48 Technical (Hospital) Services WCH ED METOCLOPRAMIDE 10 MG TAB #6 RX-408840021 CDM 6370000100 HCPCS 250 RC 09999-9990-16 NDC inpatient 60 ME 14.19 14.19 BLUE CROSS BLUE SHIELD WELLMARK SB889 [3081026] BCBS WYOMING [308102603] 13.48 percent of total billed charges 8.8 13.48 Technical (Hospital) Services WCH ED METOCLOPRAMIDE 10 MG TAB #6 RX-408840021 CDM 6370000100 HCPCS 250 RC 09999-9990-16 NDC inpatient 60 ME 14.19 14.19 MEDICA (COMMERCIAL) 94265 [3081118] MEDICA CLAIMS [308111801] 12.77 percent of total billed charges 8.8 13.48 Technical (Hospital) Services WCH ED METOCLOPRAMIDE 10 MG TAB #6 RX-408840021 CDM 6370000100 HCPCS 250 RC 09999-9990-16 NDC inpatient 60 ME 14.19 14.19 MULTIPLAN INC 34080 [3081285] MULTIPLAN INC [308128501] 13.48 percent of total billed charges 8.8 13.48 Technical (Hospital) Services WCH ED METOCLOPRAMIDE 10 MG TAB #6 RX-408840021 CDM 6370000100 HCPCS 250 RC 09999-9990-16 NDC inpatient 60 ME 14.19 14.19 HEALTHPARTNERS SX009 HEALTHPARTNERS 11.24 percent of total billed charges 8.8 13.48 Technical (Hospital) Services WCH ED METOCLOPRAMIDE 10 MG TAB #6 RX-408840021 CDM 6370000100 HCPCS 250 RC 09999-9990-16 NDC inpatient 60 ME 14.19 14.19 CIGNA 62308 [3081051] CIGNA 62308 [308105105] 11.24 percent of total billed charges 8.8 13.48 Technical (Hospital) Services WCH ED METOCLOPRAMIDE 10 MG TAB #6 RX-408840021 CDM 6370000100 HCPCS 250 RC 09999-9990-16 NDC inpatient 60 ME 14.19 14.19 CIGNA 62308 [3081051] CIGNA STATE OF WYOMING [308105107] 11.24 percent of total billed charges 8.8 13.48 Technical (Hospital) Services WCH ED METOCLOPRAMIDE 10 MG TAB #6 RX-408840021 CDM 6370000100 HCPCS 250 RC 09999-9990-16 NDC inpatient 60 ME 14.19 14.19 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES EPO [308136803] 11.24 percent of total billed charges 8.8 13.48 Technical (Hospital) Services WCH ED METOCLOPRAMIDE 10 MG TAB #6 RX-408840021 CDM 6370000100 HCPCS 250 RC 09999-9990-16 NDC inpatient 60 ME 14.19 14.19 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES HDHP [308136802] 11.24 percent of total billed charges 8.8 13.48 Technical (Hospital) Services WCH ED METOCLOPRAMIDE 10 MG TAB #6 RX-408840021 CDM 6370000100 HCPCS 250 RC 09999-9990-16 NDC inpatient 60 ME 14.19 14.19 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES PPO [308136801] 11.24 percent of total billed charges 8.8 13.48 Technical (Hospital) Services WCH ED METOCLOPRAMIDE 10 MG TAB #6 RX-408840021 CDM 6370000100 HCPCS 250 RC 09999-9990-16 NDC outpatient 60 ME 14.19 14.19 CIGNA 62308 [3081051] CIGNA 62308 [308105105] 11.35 percent of total billed charges 8.8 13.48 Technical (Hospital) Services WCH ED METOCLOPRAMIDE 10 MG TAB #6 RX-408840021 CDM 6370000100 HCPCS 250 RC 09999-9990-16 NDC outpatient 60 ME 14.19 14.19 CIGNA 62308 [3081051] CIGNA STATE OF WYOMING [308105107] 11.35 percent of total billed charges 8.8 13.48 Technical (Hospital) Services WCH ED METOCLOPRAMIDE 10 MG TAB #6 RX-408840021 CDM 6370000100 HCPCS 250 RC 09999-9990-16 NDC outpatient 60 ME 14.19 14.19 MULTIPLAN INC 34080 [3081285] MULTIPLAN INC [308128501] 13.48 percent of total billed charges 8.8 13.48 Technical (Hospital) Services WCH ED METOCLOPRAMIDE 10 MG TAB #6 RX-408840021 CDM 6370000100 HCPCS 250 RC 09999-9990-16 NDC outpatient 60 ME 14.19 14.19 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES EPO [308136803] 11.35 percent of total billed charges 8.8 13.48 Technical (Hospital) Services WCH ED METOCLOPRAMIDE 10 MG TAB #6 RX-408840021 CDM 6370000100 HCPCS 250 RC 09999-9990-16 NDC outpatient 60 ME 14.19 14.19 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES HDHP [308136802] 11.35 percent of total billed charges 8.8 13.48 Technical (Hospital) Services WCH ED METOCLOPRAMIDE 10 MG TAB #6 RX-408840021 CDM 6370000100 HCPCS 250 RC 09999-9990-16 NDC outpatient 60 ME 14.19 14.19 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES PPO [308136801] 11.35 percent of total billed charges 8.8 13.48 Technical (Hospital) Services WCH ED METOCLOPRAMIDE 10 MG TAB #6 RX-408840021 CDM 6370000100 HCPCS 250 RC 09999-9990-16 NDC outpatient 60 ME 14.19 14.19 BLUE CROSS BLUE SHIELD WELLMARK SB889 [3081026] BCBS WYOMING [308102603] 13.48 percent of total billed charges 8.8 13.48 Technical (Hospital) Services WCH ED METOCLOPRAMIDE 10 MG TAB #6 RX-408840021 CDM 6370000100 HCPCS 250 RC 09999-9990-16 NDC outpatient 60 ME 14.19 14.19 HEALTHPARTNERS SX009 HEALTHPARTNERS 11.35 percent of total billed charges 8.8 13.48 Technical (Hospital) Services WCH ED METOCLOPRAMIDE 10 MG TAB #6 RX-408840021 CDM 6370000100 HCPCS 250 RC 09999-9990-16 NDC outpatient 60 ME 14.19 14.19 UNITED HEALTHCARE (COMMERCIAL) [3081199] UNITED HEALTHCARE 87726 [308119901] 8.8 percent of total billed charges 8.8 13.48 Technical (Hospital) Services WCH ED METOCLOPRAMIDE 10 MG TAB #6 RX-408840021 CDM 6370000100 HCPCS 250 RC 09999-9990-16 NDC outpatient 60 ME 14.19 14.19 MEDICA (COMMERCIAL) 94265 [3081118] MEDICA CLAIMS [308111801] 12.77 percent of total billed charges 8.8 13.48 Technical (Hospital) Services WCH ED NITROFURANTOIN MONOHYDRATE/MACROCRYSTALS 100 MG CAPS #6 RX-408840022 CDM 6370000100 HCPCS 250 RC 09999-9990-19 NDC inpatient 600 ME 29.13 29.13 MEDICA (COMMERCIAL) 94265 [3081118] MEDICA CLAIMS [308111801] 26.22 percent of total billed charges 18.06 27.67 Technical (Hospital) Services WCH ED NITROFURANTOIN MONOHYDRATE/MACROCRYSTALS 100 MG CAPS #6 RX-408840022 CDM 6370000100 HCPCS 250 RC 09999-9990-19 NDC inpatient 600 ME 29.13 29.13 MULTIPLAN INC 34080 [3081285] MULTIPLAN INC [308128501] 27.67 percent of total billed charges 18.06 27.67 Technical (Hospital) Services WCH ED NITROFURANTOIN MONOHYDRATE/MACROCRYSTALS 100 MG CAPS #6 RX-408840022 CDM 6370000100 HCPCS 250 RC 09999-9990-19 NDC inpatient 600 ME 29.13 29.13 HEALTHPARTNERS SX009 HEALTHPARTNERS 23.07 percent of total billed charges 18.06 27.67 Technical (Hospital) Services WCH ED NITROFURANTOIN MONOHYDRATE/MACROCRYSTALS 100 MG CAPS #6 RX-408840022 CDM 6370000100 HCPCS 250 RC 09999-9990-19 NDC inpatient 600 ME 29.13 29.13 BLUE CROSS BLUE SHIELD WELLMARK SB889 [3081026] BCBS WYOMING [308102603] 27.67 percent of total billed charges 18.06 27.67 Technical (Hospital) Services WCH ED NITROFURANTOIN MONOHYDRATE/MACROCRYSTALS 100 MG CAPS #6 RX-408840022 CDM 6370000100 HCPCS 250 RC 09999-9990-19 NDC inpatient 600 ME 29.13 29.13 UNITED HEALTHCARE (COMMERCIAL) [3081199] UNITED HEALTHCARE 87726 [308119901] 18.06 percent of total billed charges 18.06 27.67 Technical (Hospital) Services WCH ED NITROFURANTOIN MONOHYDRATE/MACROCRYSTALS 100 MG CAPS #6 RX-408840022 CDM 6370000100 HCPCS 250 RC 09999-9990-19 NDC inpatient 600 ME 29.13 29.13 CIGNA 62308 [3081051] CIGNA 62308 [308105105] 23.07 percent of total billed charges 18.06 27.67 Technical (Hospital) Services WCH ED NITROFURANTOIN MONOHYDRATE/MACROCRYSTALS 100 MG CAPS #6 RX-408840022 CDM 6370000100 HCPCS 250 RC 09999-9990-19 NDC inpatient 600 ME 29.13 29.13 CIGNA 62308 [3081051] CIGNA STATE OF WYOMING [308105107] 23.07 percent of total billed charges 18.06 27.67 Technical (Hospital) Services WCH ED NITROFURANTOIN MONOHYDRATE/MACROCRYSTALS 100 MG CAPS #6 RX-408840022 CDM 6370000100 HCPCS 250 RC 09999-9990-19 NDC inpatient 600 ME 29.13 29.13 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES EPO [308136803] 23.07 percent of total billed charges 18.06 27.67 Technical (Hospital) Services WCH ED NITROFURANTOIN MONOHYDRATE/MACROCRYSTALS 100 MG CAPS #6 RX-408840022 CDM 6370000100 HCPCS 250 RC 09999-9990-19 NDC inpatient 600 ME 29.13 29.13 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES HDHP [308136802] 23.07 percent of total billed charges 18.06 27.67 Technical (Hospital) Services WCH ED NITROFURANTOIN MONOHYDRATE/MACROCRYSTALS 100 MG CAPS #6 RX-408840022 CDM 6370000100 HCPCS 250 RC 09999-9990-19 NDC inpatient 600 ME 29.13 29.13 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES PPO [308136801] 23.07 percent of total billed charges 18.06 27.67 Technical (Hospital) Services WCH ED NITROFURANTOIN MONOHYDRATE/MACROCRYSTALS 100 MG CAPS #6 RX-408840022 CDM 6370000100 HCPCS 250 RC 09999-9990-19 NDC outpatient 600 ME 29.13 29.13 CIGNA 62308 [3081051] CIGNA 62308 [308105105] 23.3 percent of total billed charges 18.06 27.67 Technical (Hospital) Services WCH ED NITROFURANTOIN MONOHYDRATE/MACROCRYSTALS 100 MG CAPS #6 RX-408840022 CDM 6370000100 HCPCS 250 RC 09999-9990-19 NDC outpatient 600 ME 29.13 29.13 CIGNA 62308 [3081051] CIGNA STATE OF WYOMING [308105107] 23.3 percent of total billed charges 18.06 27.67 Technical (Hospital) Services WCH ED NITROFURANTOIN MONOHYDRATE/MACROCRYSTALS 100 MG CAPS #6 RX-408840022 CDM 6370000100 HCPCS 250 RC 09999-9990-19 NDC outpatient 600 ME 29.13 29.13 MULTIPLAN INC 34080 [3081285] MULTIPLAN INC [308128501] 27.67 percent of total billed charges 18.06 27.67 Technical (Hospital) Services WCH ED NITROFURANTOIN MONOHYDRATE/MACROCRYSTALS 100 MG CAPS #6 RX-408840022 CDM 6370000100 HCPCS 250 RC 09999-9990-19 NDC outpatient 600 ME 29.13 29.13 MEDICA (COMMERCIAL) 94265 [3081118] MEDICA CLAIMS [308111801] 26.22 percent of total billed charges 18.06 27.67 Technical (Hospital) Services WCH ED NITROFURANTOIN MONOHYDRATE/MACROCRYSTALS 100 MG CAPS #6 RX-408840022 CDM 6370000100 HCPCS 250 RC 09999-9990-19 NDC outpatient 600 ME 29.13 29.13 HEALTHPARTNERS SX009 HEALTHPARTNERS 23.3 percent of total billed charges 18.06 27.67 Technical (Hospital) Services WCH ED NITROFURANTOIN MONOHYDRATE/MACROCRYSTALS 100 MG CAPS #6 RX-408840022 CDM 6370000100 HCPCS 250 RC 09999-9990-19 NDC outpatient 600 ME 29.13 29.13 BLUE CROSS BLUE SHIELD WELLMARK SB889 [3081026] BCBS WYOMING [308102603] 27.67 percent of total billed charges 18.06 27.67 Technical (Hospital) Services WCH ED NITROFURANTOIN MONOHYDRATE/MACROCRYSTALS 100 MG CAPS #6 RX-408840022 CDM 6370000100 HCPCS 250 RC 09999-9990-19 NDC outpatient 600 ME 29.13 29.13 UNITED HEALTHCARE (COMMERCIAL) [3081199] UNITED HEALTHCARE 87726 [308119901] 18.06 percent of total billed charges 18.06 27.67 Technical (Hospital) Services WCH ED NITROFURANTOIN MONOHYDRATE/MACROCRYSTALS 100 MG CAPS #6 RX-408840022 CDM 6370000100 HCPCS 250 RC 09999-9990-19 NDC outpatient 600 ME 29.13 29.13 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES EPO [308136803] 23.3 percent of total billed charges 18.06 27.67 Technical (Hospital) Services WCH ED NITROFURANTOIN MONOHYDRATE/MACROCRYSTALS 100 MG CAPS #6 RX-408840022 CDM 6370000100 HCPCS 250 RC 09999-9990-19 NDC outpatient 600 ME 29.13 29.13 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES HDHP [308136802] 23.3 percent of total billed charges 18.06 27.67 Technical (Hospital) Services WCH ED NITROFURANTOIN MONOHYDRATE/MACROCRYSTALS 100 MG CAPS #6 RX-408840022 CDM 6370000100 HCPCS 250 RC 09999-9990-19 NDC outpatient 600 ME 29.13 29.13 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES PPO [308136801] 23.3 percent of total billed charges 18.06 27.67 Technical (Hospital) Services WCH ED OFLOXACIN 0.3 % OPHTHALMIC SOLUTION #5ML RX-408840023 CDM 6370000100 HCPCS 250 RC 09999-9990-20 NDC outpatient 5 ML 26.8 26.8 BLUE CROSS BLUE SHIELD WELLMARK SB889 [3081026] BCBS WYOMING [308102603] 25.46 percent of total billed charges 16.62 25.46 Technical (Hospital) Services WCH ED OFLOXACIN 0.3 % OPHTHALMIC SOLUTION #5ML RX-408840023 CDM 6370000100 HCPCS 250 RC 09999-9990-20 NDC outpatient 5 ML 26.8 26.8 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES EPO [308136803] 21.44 percent of total billed charges 16.62 25.46 Technical (Hospital) Services WCH ED OFLOXACIN 0.3 % OPHTHALMIC SOLUTION #5ML RX-408840023 CDM 6370000100 HCPCS 250 RC 09999-9990-20 NDC outpatient 5 ML 26.8 26.8 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES HDHP [308136802] 21.44 percent of total billed charges 16.62 25.46 Technical (Hospital) Services WCH ED OFLOXACIN 0.3 % OPHTHALMIC SOLUTION #5ML RX-408840023 CDM 6370000100 HCPCS 250 RC 09999-9990-20 NDC outpatient 5 ML 26.8 26.8 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES PPO [308136801] 21.44 percent of total billed charges 16.62 25.46 Technical (Hospital) Services WCH ED OFLOXACIN 0.3 % OPHTHALMIC SOLUTION #5ML RX-408840023 CDM 6370000100 HCPCS 250 RC 09999-9990-20 NDC outpatient 5 ML 26.8 26.8 UNITED HEALTHCARE (COMMERCIAL) [3081199] UNITED HEALTHCARE 87726 [308119901] 16.62 percent of total billed charges 16.62 25.46 Technical (Hospital) Services WCH ED OFLOXACIN 0.3 % OPHTHALMIC SOLUTION #5ML RX-408840023 CDM 6370000100 HCPCS 250 RC 09999-9990-20 NDC outpatient 5 ML 26.8 26.8 HEALTHPARTNERS SX009 HEALTHPARTNERS 21.44 percent of total billed charges 16.62 25.46 Technical (Hospital) Services WCH ED OFLOXACIN 0.3 % OPHTHALMIC SOLUTION #5ML RX-408840023 CDM 6370000100 HCPCS 250 RC 09999-9990-20 NDC outpatient 5 ML 26.8 26.8 MEDICA (COMMERCIAL) 94265 [3081118] MEDICA CLAIMS [308111801] 24.12 percent of total billed charges 16.62 25.46 Technical (Hospital) Services WCH ED OFLOXACIN 0.3 % OPHTHALMIC SOLUTION #5ML RX-408840023 CDM 6370000100 HCPCS 250 RC 09999-9990-20 NDC outpatient 5 ML 26.8 26.8 MULTIPLAN INC 34080 [3081285] MULTIPLAN INC [308128501] 25.46 percent of total billed charges 16.62 25.46 Technical (Hospital) Services WCH ED OFLOXACIN 0.3 % OPHTHALMIC SOLUTION #5ML RX-408840023 CDM 6370000100 HCPCS 250 RC 09999-9990-20 NDC outpatient 5 ML 26.8 26.8 CIGNA 62308 [3081051] CIGNA 62308 [308105105] 21.44 percent of total billed charges 16.62 25.46 Technical (Hospital) Services WCH ED OFLOXACIN 0.3 % OPHTHALMIC SOLUTION #5ML RX-408840023 CDM 6370000100 HCPCS 250 RC 09999-9990-20 NDC outpatient 5 ML 26.8 26.8 CIGNA 62308 [3081051] CIGNA STATE OF WYOMING [308105107] 21.44 percent of total billed charges 16.62 25.46 Technical (Hospital) Services WCH ED OFLOXACIN 0.3 % OPHTHALMIC SOLUTION #5ML RX-408840023 CDM 6370000100 HCPCS 250 RC 09999-9990-20 NDC inpatient 5 ML 26.8 26.8 HEALTHPARTNERS SX009 HEALTHPARTNERS 21.22 percent of total billed charges 16.62 25.46 Technical (Hospital) Services WCH ED OFLOXACIN 0.3 % OPHTHALMIC SOLUTION #5ML RX-408840023 CDM 6370000100 HCPCS 250 RC 09999-9990-20 NDC inpatient 5 ML 26.8 26.8 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES EPO [308136803] 21.22 percent of total billed charges 16.62 25.46 Technical (Hospital) Services WCH ED OFLOXACIN 0.3 % OPHTHALMIC SOLUTION #5ML RX-408840023 CDM 6370000100 HCPCS 250 RC 09999-9990-20 NDC inpatient 5 ML 26.8 26.8 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES HDHP [308136802] 21.22 percent of total billed charges 16.62 25.46 Technical (Hospital) Services WCH ED OFLOXACIN 0.3 % OPHTHALMIC SOLUTION #5ML RX-408840023 CDM 6370000100 HCPCS 250 RC 09999-9990-20 NDC inpatient 5 ML 26.8 26.8 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES PPO [308136801] 21.22 percent of total billed charges 16.62 25.46 Technical (Hospital) Services WCH ED OFLOXACIN 0.3 % OPHTHALMIC SOLUTION #5ML RX-408840023 CDM 6370000100 HCPCS 250 RC 09999-9990-20 NDC inpatient 5 ML 26.8 26.8 CIGNA 62308 [3081051] CIGNA 62308 [308105105] 21.22 percent of total billed charges 16.62 25.46 Technical (Hospital) Services WCH ED OFLOXACIN 0.3 % OPHTHALMIC SOLUTION #5ML RX-408840023 CDM 6370000100 HCPCS 250 RC 09999-9990-20 NDC inpatient 5 ML 26.8 26.8 CIGNA 62308 [3081051] CIGNA STATE OF WYOMING [308105107] 21.22 percent of total billed charges 16.62 25.46 Technical (Hospital) Services WCH ED OFLOXACIN 0.3 % OPHTHALMIC SOLUTION #5ML RX-408840023 CDM 6370000100 HCPCS 250 RC 09999-9990-20 NDC inpatient 5 ML 26.8 26.8 BLUE CROSS BLUE SHIELD WELLMARK SB889 [3081026] BCBS WYOMING [308102603] 25.46 percent of total billed charges 16.62 25.46 Technical (Hospital) Services WCH ED OFLOXACIN 0.3 % OPHTHALMIC SOLUTION #5ML RX-408840023 CDM 6370000100 HCPCS 250 RC 09999-9990-20 NDC inpatient 5 ML 26.8 26.8 UNITED HEALTHCARE (COMMERCIAL) [3081199] UNITED HEALTHCARE 87726 [308119901] 16.62 percent of total billed charges 16.62 25.46 Technical (Hospital) Services WCH ED OFLOXACIN 0.3 % OPHTHALMIC SOLUTION #5ML RX-408840023 CDM 6370000100 HCPCS 250 RC 09999-9990-20 NDC inpatient 5 ML 26.8 26.8 MEDICA (COMMERCIAL) 94265 [3081118] MEDICA CLAIMS [308111801] 24.12 percent of total billed charges 16.62 25.46 Technical (Hospital) Services WCH ED OFLOXACIN 0.3 % OPHTHALMIC SOLUTION #5ML RX-408840023 CDM 6370000100 HCPCS 250 RC 09999-9990-20 NDC inpatient 5 ML 26.8 26.8 MULTIPLAN INC 34080 [3081285] MULTIPLAN INC [308128501] 25.46 percent of total billed charges 16.62 25.46 Technical (Hospital) Services WCH ED OSELTAMIVIR 75 MG CAP #3 RX-408840025 CDM 6370000100 HCPCS 250 RC 09999-9990-22 NDC inpatient 225 ME 59.31 59.31 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES EPO [308136803] 46.96 percent of total billed charges 36.77 56.34 Technical (Hospital) Services WCH ED OSELTAMIVIR 75 MG CAP #3 RX-408840025 CDM 6370000100 HCPCS 250 RC 09999-9990-22 NDC inpatient 225 ME 59.31 59.31 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES HDHP [308136802] 46.96 percent of total billed charges 36.77 56.34 Technical (Hospital) Services WCH ED OSELTAMIVIR 75 MG CAP #3 RX-408840025 CDM 6370000100 HCPCS 250 RC 09999-9990-22 NDC inpatient 225 ME 59.31 59.31 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES PPO [308136801] 46.96 percent of total billed charges 36.77 56.34 Technical (Hospital) Services WCH ED OSELTAMIVIR 75 MG CAP #3 RX-408840025 CDM 6370000100 HCPCS 250 RC 09999-9990-22 NDC inpatient 225 ME 59.31 59.31 CIGNA 62308 [3081051] CIGNA 62308 [308105105] 46.96 percent of total billed charges 36.77 56.34 Technical (Hospital) Services WCH ED OSELTAMIVIR 75 MG CAP #3 RX-408840025 CDM 6370000100 HCPCS 250 RC 09999-9990-22 NDC inpatient 225 ME 59.31 59.31 CIGNA 62308 [3081051] CIGNA STATE OF WYOMING [308105107] 46.96 percent of total billed charges 36.77 56.34 Technical (Hospital) Services WCH ED OSELTAMIVIR 75 MG CAP #3 RX-408840025 CDM 6370000100 HCPCS 250 RC 09999-9990-22 NDC inpatient 225 ME 59.31 59.31 BLUE CROSS BLUE SHIELD WELLMARK SB889 [3081026] BCBS WYOMING [308102603] 56.34 percent of total billed charges 36.77 56.34 Technical (Hospital) Services WCH ED OSELTAMIVIR 75 MG CAP #3 RX-408840025 CDM 6370000100 HCPCS 250 RC 09999-9990-22 NDC inpatient 225 ME 59.31 59.31 UNITED HEALTHCARE (COMMERCIAL) [3081199] UNITED HEALTHCARE 87726 [308119901] 36.77 percent of total billed charges 36.77 56.34 Technical (Hospital) Services WCH ED OSELTAMIVIR 75 MG CAP #3 RX-408840025 CDM 6370000100 HCPCS 250 RC 09999-9990-22 NDC inpatient 225 ME 59.31 59.31 HEALTHPARTNERS SX009 HEALTHPARTNERS 46.96 percent of total billed charges 36.77 56.34 Technical (Hospital) Services WCH ED OSELTAMIVIR 75 MG CAP #3 RX-408840025 CDM 6370000100 HCPCS 250 RC 09999-9990-22 NDC inpatient 225 ME 59.31 59.31 MEDICA (COMMERCIAL) 94265 [3081118] MEDICA CLAIMS [308111801] 53.38 percent of total billed charges 36.77 56.34 Technical (Hospital) Services WCH ED OSELTAMIVIR 75 MG CAP #3 RX-408840025 CDM 6370000100 HCPCS 250 RC 09999-9990-22 NDC inpatient 225 ME 59.31 59.31 MULTIPLAN INC 34080 [3081285] MULTIPLAN INC [308128501] 56.34 percent of total billed charges 36.77 56.34 Technical (Hospital) Services WCH ED OSELTAMIVIR 75 MG CAP #3 RX-408840025 CDM 6370000100 HCPCS 250 RC 09999-9990-22 NDC outpatient 225 ME 59.31 59.31 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES HDHP [308136802] 47.45 percent of total billed charges 36.77 56.34 Technical (Hospital) Services WCH ED OSELTAMIVIR 75 MG CAP #3 RX-408840025 CDM 6370000100 HCPCS 250 RC 09999-9990-22 NDC outpatient 225 ME 59.31 59.31 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES PPO [308136801] 47.45 percent of total billed charges 36.77 56.34 Technical (Hospital) Services WCH ED OSELTAMIVIR 75 MG CAP #3 RX-408840025 CDM 6370000100 HCPCS 250 RC 09999-9990-22 NDC outpatient 225 ME 59.31 59.31 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES EPO [308136803] 47.45 percent of total billed charges 36.77 56.34 Technical (Hospital) Services WCH ED OSELTAMIVIR 75 MG CAP #3 RX-408840025 CDM 6370000100 HCPCS 250 RC 09999-9990-22 NDC outpatient 225 ME 59.31 59.31 BLUE CROSS BLUE SHIELD WELLMARK SB889 [3081026] BCBS WYOMING [308102603] 56.34 percent of total billed charges 36.77 56.34 Technical (Hospital) Services WCH ED OSELTAMIVIR 75 MG CAP #3 RX-408840025 CDM 6370000100 HCPCS 250 RC 09999-9990-22 NDC outpatient 225 ME 59.31 59.31 UNITED HEALTHCARE (COMMERCIAL) [3081199] UNITED HEALTHCARE 87726 [308119901] 36.77 percent of total billed charges 36.77 56.34 Technical (Hospital) Services WCH ED OSELTAMIVIR 75 MG CAP #3 RX-408840025 CDM 6370000100 HCPCS 250 RC 09999-9990-22 NDC outpatient 225 ME 59.31 59.31 HEALTHPARTNERS SX009 HEALTHPARTNERS 47.45 percent of total billed charges 36.77 56.34 Technical (Hospital) Services WCH ED OSELTAMIVIR 75 MG CAP #3 RX-408840025 CDM 6370000100 HCPCS 250 RC 09999-9990-22 NDC outpatient 225 ME 59.31 59.31 MEDICA (COMMERCIAL) 94265 [3081118] MEDICA CLAIMS [308111801] 53.38 percent of total billed charges 36.77 56.34 Technical (Hospital) Services WCH ED OSELTAMIVIR 75 MG CAP #3 RX-408840025 CDM 6370000100 HCPCS 250 RC 09999-9990-22 NDC outpatient 225 ME 59.31 59.31 MULTIPLAN INC 34080 [3081285] MULTIPLAN INC [308128501] 56.34 percent of total billed charges 36.77 56.34 Technical (Hospital) Services WCH ED OSELTAMIVIR 75 MG CAP #3 RX-408840025 CDM 6370000100 HCPCS 250 RC 09999-9990-22 NDC outpatient 225 ME 59.31 59.31 CIGNA 62308 [3081051] CIGNA 62308 [308105105] 47.45 percent of total billed charges 36.77 56.34 Technical (Hospital) Services WCH ED OSELTAMIVIR 75 MG CAP #3 RX-408840025 CDM 6370000100 HCPCS 250 RC 09999-9990-22 NDC outpatient 225 ME 59.31 59.31 CIGNA 62308 [3081051] CIGNA STATE OF WYOMING [308105107] 47.45 percent of total billed charges 36.77 56.34 Technical (Hospital) Services WCH ED PENICILLIN VK 250 MG TABLET #6 RX-408840026 CDM 6370000100 HCPCS 250 RC 09999-9990-24 NDC inpatient 1500 ME 14.96 14.96 CIGNA 62308 [3081051] CIGNA 62308 [308105105] 11.85 percent of total billed charges 9.28 14.21 Technical (Hospital) Services WCH ED PENICILLIN VK 250 MG TABLET #6 RX-408840026 CDM 6370000100 HCPCS 250 RC 09999-9990-24 NDC inpatient 1500 ME 14.96 14.96 CIGNA 62308 [3081051] CIGNA STATE OF WYOMING [308105107] 11.85 percent of total billed charges 9.28 14.21 Technical (Hospital) Services WCH ED PENICILLIN VK 250 MG TABLET #6 RX-408840026 CDM 6370000100 HCPCS 250 RC 09999-9990-24 NDC inpatient 1500 ME 14.96 14.96 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES HDHP [308136802] 11.85 percent of total billed charges 9.28 14.21 Technical (Hospital) Services WCH ED PENICILLIN VK 250 MG TABLET #6 RX-408840026 CDM 6370000100 HCPCS 250 RC 09999-9990-24 NDC inpatient 1500 ME 14.96 14.96 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES EPO [308136803] 11.85 percent of total billed charges 9.28 14.21 Technical (Hospital) Services WCH ED PENICILLIN VK 250 MG TABLET #6 RX-408840026 CDM 6370000100 HCPCS 250 RC 09999-9990-24 NDC inpatient 1500 ME 14.96 14.96 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES PPO [308136801] 11.85 percent of total billed charges 9.28 14.21 Technical (Hospital) Services WCH ED PENICILLIN VK 250 MG TABLET #6 RX-408840026 CDM 6370000100 HCPCS 250 RC 09999-9990-24 NDC inpatient 1500 ME 14.96 14.96 BLUE CROSS BLUE SHIELD WELLMARK SB889 [3081026] BCBS WYOMING [308102603] 14.21 percent of total billed charges 9.28 14.21 Technical (Hospital) Services WCH ED PENICILLIN VK 250 MG TABLET #6 RX-408840026 CDM 6370000100 HCPCS 250 RC 09999-9990-24 NDC inpatient 1500 ME 14.96 14.96 UNITED HEALTHCARE (COMMERCIAL) [3081199] UNITED HEALTHCARE 87726 [308119901] 9.28 percent of total billed charges 9.28 14.21 Technical (Hospital) Services WCH ED PENICILLIN VK 250 MG TABLET #6 RX-408840026 CDM 6370000100 HCPCS 250 RC 09999-9990-24 NDC inpatient 1500 ME 14.96 14.96 HEALTHPARTNERS SX009 HEALTHPARTNERS 11.85 percent of total billed charges 9.28 14.21 Technical (Hospital) Services WCH ED PENICILLIN VK 250 MG TABLET #6 RX-408840026 CDM 6370000100 HCPCS 250 RC 09999-9990-24 NDC inpatient 1500 ME 14.96 14.96 MULTIPLAN INC 34080 [3081285] MULTIPLAN INC [308128501] 14.21 percent of total billed charges 9.28 14.21 Technical (Hospital) Services WCH ED PENICILLIN VK 250 MG TABLET #6 RX-408840026 CDM 6370000100 HCPCS 250 RC 09999-9990-24 NDC inpatient 1500 ME 14.96 14.96 MEDICA (COMMERCIAL) 94265 [3081118] MEDICA CLAIMS [308111801] 13.46 percent of total billed charges 9.28 14.21 Technical (Hospital) Services WCH ED PENICILLIN VK 250 MG TABLET #6 RX-408840026 CDM 6370000100 HCPCS 250 RC 09999-9990-24 NDC outpatient 1500 ME 14.96 14.96 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES HDHP [308136802] 11.97 percent of total billed charges 9.28 14.21 Technical (Hospital) Services WCH ED PENICILLIN VK 250 MG TABLET #6 RX-408840026 CDM 6370000100 HCPCS 250 RC 09999-9990-24 NDC outpatient 1500 ME 14.96 14.96 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES PPO [308136801] 11.97 percent of total billed charges 9.28 14.21 Technical (Hospital) Services WCH ED PENICILLIN VK 250 MG TABLET #6 RX-408840026 CDM 6370000100 HCPCS 250 RC 09999-9990-24 NDC outpatient 1500 ME 14.96 14.96 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES EPO [308136803] 11.97 percent of total billed charges 9.28 14.21 Technical (Hospital) Services WCH ED PENICILLIN VK 250 MG TABLET #6 RX-408840026 CDM 6370000100 HCPCS 250 RC 09999-9990-24 NDC outpatient 1500 ME 14.96 14.96 UNITED HEALTHCARE (COMMERCIAL) [3081199] UNITED HEALTHCARE 87726 [308119901] 9.28 percent of total billed charges 9.28 14.21 Technical (Hospital) Services WCH ED PENICILLIN VK 250 MG TABLET #6 RX-408840026 CDM 6370000100 HCPCS 250 RC 09999-9990-24 NDC outpatient 1500 ME 14.96 14.96 BLUE CROSS BLUE SHIELD WELLMARK SB889 [3081026] BCBS WYOMING [308102603] 14.21 percent of total billed charges 9.28 14.21 Technical (Hospital) Services WCH ED PENICILLIN VK 250 MG TABLET #6 RX-408840026 CDM 6370000100 HCPCS 250 RC 09999-9990-24 NDC outpatient 1500 ME 14.96 14.96 HEALTHPARTNERS SX009 HEALTHPARTNERS 11.97 percent of total billed charges 9.28 14.21 Technical (Hospital) Services WCH ED PENICILLIN VK 250 MG TABLET #6 RX-408840026 CDM 6370000100 HCPCS 250 RC 09999-9990-24 NDC outpatient 1500 ME 14.96 14.96 MEDICA (COMMERCIAL) 94265 [3081118] MEDICA CLAIMS [308111801] 13.46 percent of total billed charges 9.28 14.21 Technical (Hospital) Services WCH ED PENICILLIN VK 250 MG TABLET #6 RX-408840026 CDM 6370000100 HCPCS 250 RC 09999-9990-24 NDC outpatient 1500 ME 14.96 14.96 MULTIPLAN INC 34080 [3081285] MULTIPLAN INC [308128501] 14.21 percent of total billed charges 9.28 14.21 Technical (Hospital) Services WCH ED PENICILLIN VK 250 MG TABLET #6 RX-408840026 CDM 6370000100 HCPCS 250 RC 09999-9990-24 NDC outpatient 1500 ME 14.96 14.96 CIGNA 62308 [3081051] CIGNA 62308 [308105105] 11.97 percent of total billed charges 9.28 14.21 Technical (Hospital) Services WCH ED PENICILLIN VK 250 MG TABLET #6 RX-408840026 CDM 6370000100 HCPCS 250 RC 09999-9990-24 NDC outpatient 1500 ME 14.96 14.96 CIGNA 62308 [3081051] CIGNA STATE OF WYOMING [308105107] 11.97 percent of total billed charges 9.28 14.21 Technical (Hospital) Services WCH ED PHENAZOPYRIDINE 200 MG TAB #4 RX-408840027 CDM 6370000100 HCPCS 250 RC inpatient 800 ME 19.99 19.99 BLUE CROSS BLUE SHIELD WELLMARK SB889 [3081026] BCBS WYOMING [308102603] 18.99 percent of total billed charges 12.39 18.99 Technical (Hospital) Services WCH ED PHENAZOPYRIDINE 200 MG TAB #4 RX-408840027 CDM 6370000100 HCPCS 250 RC inpatient 800 ME 19.99 19.99 MULTIPLAN INC 34080 [3081285] MULTIPLAN INC [308128501] 18.99 percent of total billed charges 12.39 18.99 Technical (Hospital) Services WCH ED PHENAZOPYRIDINE 200 MG TAB #4 RX-408840027 CDM 6370000100 HCPCS 250 RC inpatient 800 ME 19.99 19.99 HEALTHPARTNERS SX009 HEALTHPARTNERS 15.83 percent of total billed charges 12.39 18.99 Technical (Hospital) Services WCH ED PHENAZOPYRIDINE 200 MG TAB #4 RX-408840027 CDM 6370000100 HCPCS 250 RC inpatient 800 ME 19.99 19.99 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES EPO [308136803] 15.83 percent of total billed charges 12.39 18.99 Technical (Hospital) Services WCH ED PHENAZOPYRIDINE 200 MG TAB #4 RX-408840027 CDM 6370000100 HCPCS 250 RC inpatient 800 ME 19.99 19.99 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES HDHP [308136802] 15.83 percent of total billed charges 12.39 18.99 Technical (Hospital) Services WCH ED PHENAZOPYRIDINE 200 MG TAB #4 RX-408840027 CDM 6370000100 HCPCS 250 RC inpatient 800 ME 19.99 19.99 UNITED HEALTHCARE (COMMERCIAL) [3081199] UNITED HEALTHCARE 87726 [308119901] 12.39 percent of total billed charges 12.39 18.99 Technical (Hospital) Services WCH ED PHENAZOPYRIDINE 200 MG TAB #4 RX-408840027 CDM 6370000100 HCPCS 250 RC inpatient 800 ME 19.99 19.99 CIGNA 62308 [3081051] CIGNA 62308 [308105105] 15.83 percent of total billed charges 12.39 18.99 Technical (Hospital) Services WCH ED PHENAZOPYRIDINE 200 MG TAB #4 RX-408840027 CDM 6370000100 HCPCS 250 RC inpatient 800 ME 19.99 19.99 CIGNA 62308 [3081051] CIGNA STATE OF WYOMING [308105107] 15.83 percent of total billed charges 12.39 18.99 Technical (Hospital) Services WCH ED PHENAZOPYRIDINE 200 MG TAB #4 RX-408840027 CDM 6370000100 HCPCS 250 RC inpatient 800 ME 19.99 19.99 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES PPO [308136801] 15.83 percent of total billed charges 12.39 18.99 Technical (Hospital) Services WCH ED PHENAZOPYRIDINE 200 MG TAB #4 RX-408840027 CDM 6370000100 HCPCS 250 RC inpatient 800 ME 19.99 19.99 MEDICA (COMMERCIAL) 94265 [3081118] MEDICA CLAIMS [308111801] 17.99 percent of total billed charges 12.39 18.99 Technical (Hospital) Services WCH ED PHENAZOPYRIDINE 200 MG TAB #4 RX-408840027 CDM 6370000100 HCPCS 250 RC outpatient 800 ME 19.99 19.99 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES PPO [308136801] 15.99 percent of total billed charges 12.39 18.99 Technical (Hospital) Services WCH ED PHENAZOPYRIDINE 200 MG TAB #4 RX-408840027 CDM 6370000100 HCPCS 250 RC outpatient 800 ME 19.99 19.99 HEALTHPARTNERS SX009 HEALTHPARTNERS 15.99 percent of total billed charges 12.39 18.99 Technical (Hospital) Services WCH ED PHENAZOPYRIDINE 200 MG TAB #4 RX-408840027 CDM 6370000100 HCPCS 250 RC outpatient 800 ME 19.99 19.99 MULTIPLAN INC 34080 [3081285] MULTIPLAN INC [308128501] 18.99 percent of total billed charges 12.39 18.99 Technical (Hospital) Services WCH ED PHENAZOPYRIDINE 200 MG TAB #4 RX-408840027 CDM 6370000100 HCPCS 250 RC outpatient 800 ME 19.99 19.99 MEDICA (COMMERCIAL) 94265 [3081118] MEDICA CLAIMS [308111801] 17.99 percent of total billed charges 12.39 18.99 Technical (Hospital) Services WCH ED PHENAZOPYRIDINE 200 MG TAB #4 RX-408840027 CDM 6370000100 HCPCS 250 RC outpatient 800 ME 19.99 19.99 CIGNA 62308 [3081051] CIGNA 62308 [308105105] 15.99 percent of total billed charges 12.39 18.99 Technical (Hospital) Services WCH ED PHENAZOPYRIDINE 200 MG TAB #4 RX-408840027 CDM 6370000100 HCPCS 250 RC outpatient 800 ME 19.99 19.99 CIGNA 62308 [3081051] CIGNA STATE OF WYOMING [308105107] 15.99 percent of total billed charges 12.39 18.99 Technical (Hospital) Services WCH ED PHENAZOPYRIDINE 200 MG TAB #4 RX-408840027 CDM 6370000100 HCPCS 250 RC outpatient 800 ME 19.99 19.99 UNITED HEALTHCARE (COMMERCIAL) [3081199] UNITED HEALTHCARE 87726 [308119901] 12.39 percent of total billed charges 12.39 18.99 Technical (Hospital) Services WCH ED PHENAZOPYRIDINE 200 MG TAB #4 RX-408840027 CDM 6370000100 HCPCS 250 RC outpatient 800 ME 19.99 19.99 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES EPO [308136803] 15.99 percent of total billed charges 12.39 18.99 Technical (Hospital) Services WCH ED PHENAZOPYRIDINE 200 MG TAB #4 RX-408840027 CDM 6370000100 HCPCS 250 RC outpatient 800 ME 19.99 19.99 BLUE CROSS BLUE SHIELD WELLMARK SB889 [3081026] BCBS WYOMING [308102603] 18.99 percent of total billed charges 12.39 18.99 Technical (Hospital) Services WCH ED PHENAZOPYRIDINE 200 MG TAB #4 RX-408840027 CDM 6370000100 HCPCS 250 RC outpatient 800 ME 19.99 19.99 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES HDHP [308136802] 15.99 percent of total billed charges 12.39 18.99 Technical (Hospital) Services WCH ED SULFA/TMP 800/160 MG TAB #4 RX-408840032 CDM 6370000100 HCPCS 250 RC outpatient 14.55 14.55 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES EPO [308136803] 11.64 percent of total billed charges 9.02 13.82 Technical (Hospital) Services WCH ED SULFA/TMP 800/160 MG TAB #4 RX-408840032 CDM 6370000100 HCPCS 250 RC outpatient 14.55 14.55 BLUE CROSS BLUE SHIELD WELLMARK SB889 [3081026] BCBS WYOMING [308102603] 13.82 percent of total billed charges 9.02 13.82 Technical (Hospital) Services WCH ED SULFA/TMP 800/160 MG TAB #4 RX-408840032 CDM 6370000100 HCPCS 250 RC outpatient 14.55 14.55 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES HDHP [308136802] 11.64 percent of total billed charges 9.02 13.82 Technical (Hospital) Services WCH ED SULFA/TMP 800/160 MG TAB #4 RX-408840032 CDM 6370000100 HCPCS 250 RC outpatient 14.55 14.55 UNITED HEALTHCARE (COMMERCIAL) [3081199] UNITED HEALTHCARE 87726 [308119901] 9.02 percent of total billed charges 9.02 13.82 Technical (Hospital) Services WCH ED SULFA/TMP 800/160 MG TAB #4 RX-408840032 CDM 6370000100 HCPCS 250 RC outpatient 14.55 14.55 HEALTHPARTNERS SX009 HEALTHPARTNERS 11.64 percent of total billed charges 9.02 13.82 Technical (Hospital) Services WCH ED SULFA/TMP 800/160 MG TAB #4 RX-408840032 CDM 6370000100 HCPCS 250 RC outpatient 14.55 14.55 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES PPO [308136801] 11.64 percent of total billed charges 9.02 13.82 Technical (Hospital) Services WCH ED SULFA/TMP 800/160 MG TAB #4 RX-408840032 CDM 6370000100 HCPCS 250 RC outpatient 14.55 14.55 CIGNA 62308 [3081051] CIGNA 62308 [308105105] 11.64 percent of total billed charges 9.02 13.82 Technical (Hospital) Services WCH ED SULFA/TMP 800/160 MG TAB #4 RX-408840032 CDM 6370000100 HCPCS 250 RC outpatient 14.55 14.55 CIGNA 62308 [3081051] CIGNA STATE OF WYOMING [308105107] 11.64 percent of total billed charges 9.02 13.82 Technical (Hospital) Services WCH ED SULFA/TMP 800/160 MG TAB #4 RX-408840032 CDM 6370000100 HCPCS 250 RC outpatient 14.55 14.55 MEDICA (COMMERCIAL) 94265 [3081118] MEDICA CLAIMS [308111801] 13.1 percent of total billed charges 9.02 13.82 Technical (Hospital) Services WCH ED SULFA/TMP 800/160 MG TAB #4 RX-408840032 CDM 6370000100 HCPCS 250 RC outpatient 14.55 14.55 MULTIPLAN INC 34080 [3081285] MULTIPLAN INC [308128501] 13.82 percent of total billed charges 9.02 13.82 Technical (Hospital) Services WCH ED SULFA/TMP 800/160 MG TAB #4 RX-408840032 CDM 6370000100 HCPCS 250 RC inpatient 14.55 14.55 UNITED HEALTHCARE (COMMERCIAL) [3081199] UNITED HEALTHCARE 87726 [308119901] 9.02 percent of total billed charges 9.02 13.82 Technical (Hospital) Services WCH ED SULFA/TMP 800/160 MG TAB #4 RX-408840032 CDM 6370000100 HCPCS 250 RC inpatient 14.55 14.55 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES HDHP [308136802] 11.52 percent of total billed charges 9.02 13.82 Technical (Hospital) Services WCH ED SULFA/TMP 800/160 MG TAB #4 RX-408840032 CDM 6370000100 HCPCS 250 RC inpatient 14.55 14.55 CIGNA 62308 [3081051] CIGNA 62308 [308105105] 11.52 percent of total billed charges 9.02 13.82 Technical (Hospital) Services WCH ED SULFA/TMP 800/160 MG TAB #4 RX-408840032 CDM 6370000100 HCPCS 250 RC inpatient 14.55 14.55 CIGNA 62308 [3081051] CIGNA STATE OF WYOMING [308105107] 11.52 percent of total billed charges 9.02 13.82 Technical (Hospital) Services WCH ED SULFA/TMP 800/160 MG TAB #4 RX-408840032 CDM 6370000100 HCPCS 250 RC inpatient 14.55 14.55 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES PPO [308136801] 11.52 percent of total billed charges 9.02 13.82 Technical (Hospital) Services WCH ED SULFA/TMP 800/160 MG TAB #4 RX-408840032 CDM 6370000100 HCPCS 250 RC inpatient 14.55 14.55 MEDICA (COMMERCIAL) 94265 [3081118] MEDICA CLAIMS [308111801] 13.1 percent of total billed charges 9.02 13.82 Technical (Hospital) Services WCH ED SULFA/TMP 800/160 MG TAB #4 RX-408840032 CDM 6370000100 HCPCS 250 RC inpatient 14.55 14.55 HEALTHPARTNERS SX009 HEALTHPARTNERS 11.52 percent of total billed charges 9.02 13.82 Technical (Hospital) Services WCH ED SULFA/TMP 800/160 MG TAB #4 RX-408840032 CDM 6370000100 HCPCS 250 RC inpatient 14.55 14.55 MULTIPLAN INC 34080 [3081285] MULTIPLAN INC [308128501] 13.82 percent of total billed charges 9.02 13.82 Technical (Hospital) Services WCH ED SULFA/TMP 800/160 MG TAB #4 RX-408840032 CDM 6370000100 HCPCS 250 RC inpatient 14.55 14.55 BLUE CROSS BLUE SHIELD WELLMARK SB889 [3081026] BCBS WYOMING [308102603] 13.82 percent of total billed charges 9.02 13.82 Technical (Hospital) Services WCH ED SULFA/TMP 800/160 MG TAB #4 RX-408840032 CDM 6370000100 HCPCS 250 RC inpatient 14.55 14.55 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES EPO [308136803] 11.52 percent of total billed charges 9.02 13.82 Technical (Hospital) Services WCH ED RX TRAMADOL 50 MG TAB #10 RX-408840033 CDM 6370000100 HCPCS 250 RC 09999-9990-30 NDC outpatient 500 ME 14.2 14.2 CIGNA 62308 [3081051] CIGNA 62308 [308105105] 11.36 percent of total billed charges 8.8 13.49 Technical (Hospital) Services WCH ED RX TRAMADOL 50 MG TAB #10 RX-408840033 CDM 6370000100 HCPCS 250 RC 09999-9990-30 NDC outpatient 500 ME 14.2 14.2 CIGNA 62308 [3081051] CIGNA STATE OF WYOMING [308105107] 11.36 percent of total billed charges 8.8 13.49 Technical (Hospital) Services WCH ED RX TRAMADOL 50 MG TAB #10 RX-408840033 CDM 6370000100 HCPCS 250 RC 09999-9990-30 NDC outpatient 500 ME 14.2 14.2 MEDICA (COMMERCIAL) 94265 [3081118] MEDICA CLAIMS [308111801] 12.78 percent of total billed charges 8.8 13.49 Technical (Hospital) Services WCH ED RX TRAMADOL 50 MG TAB #10 RX-408840033 CDM 6370000100 HCPCS 250 RC 09999-9990-30 NDC outpatient 500 ME 14.2 14.2 MULTIPLAN INC 34080 [3081285] MULTIPLAN INC [308128501] 13.49 percent of total billed charges 8.8 13.49 Technical (Hospital) Services WCH ED RX TRAMADOL 50 MG TAB #10 RX-408840033 CDM 6370000100 HCPCS 250 RC 09999-9990-30 NDC outpatient 500 ME 14.2 14.2 HEALTHPARTNERS SX009 HEALTHPARTNERS 11.36 percent of total billed charges 8.8 13.49 Technical (Hospital) Services WCH ED RX TRAMADOL 50 MG TAB #10 RX-408840033 CDM 6370000100 HCPCS 250 RC 09999-9990-30 NDC outpatient 500 ME 14.2 14.2 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES EPO [308136803] 11.36 percent of total billed charges 8.8 13.49 Technical (Hospital) Services WCH ED RX TRAMADOL 50 MG TAB #10 RX-408840033 CDM 6370000100 HCPCS 250 RC 09999-9990-30 NDC outpatient 500 ME 14.2 14.2 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES HDHP [308136802] 11.36 percent of total billed charges 8.8 13.49 Technical (Hospital) Services WCH ED RX TRAMADOL 50 MG TAB #10 RX-408840033 CDM 6370000100 HCPCS 250 RC 09999-9990-30 NDC outpatient 500 ME 14.2 14.2 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES PPO [308136801] 11.36 percent of total billed charges 8.8 13.49 Technical (Hospital) Services WCH ED RX TRAMADOL 50 MG TAB #10 RX-408840033 CDM 6370000100 HCPCS 250 RC 09999-9990-30 NDC outpatient 500 ME 14.2 14.2 BLUE CROSS BLUE SHIELD WELLMARK SB889 [3081026] BCBS WYOMING [308102603] 13.49 percent of total billed charges 8.8 13.49 Technical (Hospital) Services WCH ED RX TRAMADOL 50 MG TAB #10 RX-408840033 CDM 6370000100 HCPCS 250 RC 09999-9990-30 NDC outpatient 500 ME 14.2 14.2 UNITED HEALTHCARE (COMMERCIAL) [3081199] UNITED HEALTHCARE 87726 [308119901] 8.8 percent of total billed charges 8.8 13.49 Technical (Hospital) Services WCH ED RX TRAMADOL 50 MG TAB #10 RX-408840033 CDM 6370000100 HCPCS 250 RC 09999-9990-30 NDC inpatient 500 ME 14.2 14.2 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES EPO [308136803] 11.24 percent of total billed charges 8.8 13.49 Technical (Hospital) Services WCH ED RX TRAMADOL 50 MG TAB #10 RX-408840033 CDM 6370000100 HCPCS 250 RC 09999-9990-30 NDC inpatient 500 ME 14.2 14.2 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES HDHP [308136802] 11.24 percent of total billed charges 8.8 13.49 Technical (Hospital) Services WCH ED RX TRAMADOL 50 MG TAB #10 RX-408840033 CDM 6370000100 HCPCS 250 RC 09999-9990-30 NDC inpatient 500 ME 14.2 14.2 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES PPO [308136801] 11.24 percent of total billed charges 8.8 13.49 Technical (Hospital) Services WCH ED RX TRAMADOL 50 MG TAB #10 RX-408840033 CDM 6370000100 HCPCS 250 RC 09999-9990-30 NDC inpatient 500 ME 14.2 14.2 CIGNA 62308 [3081051] CIGNA 62308 [308105105] 11.24 percent of total billed charges 8.8 13.49 Technical (Hospital) Services WCH ED RX TRAMADOL 50 MG TAB #10 RX-408840033 CDM 6370000100 HCPCS 250 RC 09999-9990-30 NDC inpatient 500 ME 14.2 14.2 CIGNA 62308 [3081051] CIGNA STATE OF WYOMING [308105107] 11.24 percent of total billed charges 8.8 13.49 Technical (Hospital) Services WCH ED RX TRAMADOL 50 MG TAB #10 RX-408840033 CDM 6370000100 HCPCS 250 RC 09999-9990-30 NDC inpatient 500 ME 14.2 14.2 MULTIPLAN INC 34080 [3081285] MULTIPLAN INC [308128501] 13.49 percent of total billed charges 8.8 13.49 Technical (Hospital) Services WCH ED RX TRAMADOL 50 MG TAB #10 RX-408840033 CDM 6370000100 HCPCS 250 RC 09999-9990-30 NDC inpatient 500 ME 14.2 14.2 MEDICA (COMMERCIAL) 94265 [3081118] MEDICA CLAIMS [308111801] 12.78 percent of total billed charges 8.8 13.49 Technical (Hospital) Services WCH ED RX TRAMADOL 50 MG TAB #10 RX-408840033 CDM 6370000100 HCPCS 250 RC 09999-9990-30 NDC inpatient 500 ME 14.2 14.2 HEALTHPARTNERS SX009 HEALTHPARTNERS 11.24 percent of total billed charges 8.8 13.49 Technical (Hospital) Services WCH ED RX TRAMADOL 50 MG TAB #10 RX-408840033 CDM 6370000100 HCPCS 250 RC 09999-9990-30 NDC inpatient 500 ME 14.2 14.2 UNITED HEALTHCARE (COMMERCIAL) [3081199] UNITED HEALTHCARE 87726 [308119901] 8.8 percent of total billed charges 8.8 13.49 Technical (Hospital) Services WCH ED RX TRAMADOL 50 MG TAB #10 RX-408840033 CDM 6370000100 HCPCS 250 RC 09999-9990-30 NDC inpatient 500 ME 14.2 14.2 BLUE CROSS BLUE SHIELD WELLMARK SB889 [3081026] BCBS WYOMING [308102603] 13.49 percent of total billed charges 8.8 13.49 Technical (Hospital) Services WCH ED ERYTHROMYCIN 0.5 % OPTHALMIC OINTMENT #3.5GM RX-408840034 CDM 6370000100 HCPCS 250 RC 09999-9990-12 NDC inpatient 3.5 GR 28.95 28.95 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES EPO [308136803] 22.92 percent of total billed charges 17.95 27.5 Technical (Hospital) Services WCH ED ERYTHROMYCIN 0.5 % OPTHALMIC OINTMENT #3.5GM RX-408840034 CDM 6370000100 HCPCS 250 RC 09999-9990-12 NDC inpatient 3.5 GR 28.95 28.95 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES HDHP [308136802] 22.92 percent of total billed charges 17.95 27.5 Technical (Hospital) Services WCH ED ERYTHROMYCIN 0.5 % OPTHALMIC OINTMENT #3.5GM RX-408840034 CDM 6370000100 HCPCS 250 RC 09999-9990-12 NDC inpatient 3.5 GR 28.95 28.95 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES PPO [308136801] 22.92 percent of total billed charges 17.95 27.5 Technical (Hospital) Services WCH ED ERYTHROMYCIN 0.5 % OPTHALMIC OINTMENT #3.5GM RX-408840034 CDM 6370000100 HCPCS 250 RC 09999-9990-12 NDC inpatient 3.5 GR 28.95 28.95 HEALTHPARTNERS SX009 HEALTHPARTNERS 22.92 percent of total billed charges 17.95 27.5 Technical (Hospital) Services WCH ED ERYTHROMYCIN 0.5 % OPTHALMIC OINTMENT #3.5GM RX-408840034 CDM 6370000100 HCPCS 250 RC 09999-9990-12 NDC inpatient 3.5 GR 28.95 28.95 CIGNA 62308 [3081051] CIGNA 62308 [308105105] 22.92 percent of total billed charges 17.95 27.5 Technical (Hospital) Services WCH ED ERYTHROMYCIN 0.5 % OPTHALMIC OINTMENT #3.5GM RX-408840034 CDM 6370000100 HCPCS 250 RC 09999-9990-12 NDC inpatient 3.5 GR 28.95 28.95 CIGNA 62308 [3081051] CIGNA STATE OF WYOMING [308105107] 22.92 percent of total billed charges 17.95 27.5 Technical (Hospital) Services WCH ED ERYTHROMYCIN 0.5 % OPTHALMIC OINTMENT #3.5GM RX-408840034 CDM 6370000100 HCPCS 250 RC 09999-9990-12 NDC inpatient 3.5 GR 28.95 28.95 UNITED HEALTHCARE (COMMERCIAL) [3081199] UNITED HEALTHCARE 87726 [308119901] 17.95 percent of total billed charges 17.95 27.5 Technical (Hospital) Services WCH ED ERYTHROMYCIN 0.5 % OPTHALMIC OINTMENT #3.5GM RX-408840034 CDM 6370000100 HCPCS 250 RC 09999-9990-12 NDC inpatient 3.5 GR 28.95 28.95 BLUE CROSS BLUE SHIELD WELLMARK SB889 [3081026] BCBS WYOMING [308102603] 27.5 percent of total billed charges 17.95 27.5 Technical (Hospital) Services WCH ED ERYTHROMYCIN 0.5 % OPTHALMIC OINTMENT #3.5GM RX-408840034 CDM 6370000100 HCPCS 250 RC 09999-9990-12 NDC inpatient 3.5 GR 28.95 28.95 MULTIPLAN INC 34080 [3081285] MULTIPLAN INC [308128501] 27.5 percent of total billed charges 17.95 27.5 Technical (Hospital) Services WCH ED ERYTHROMYCIN 0.5 % OPTHALMIC OINTMENT #3.5GM RX-408840034 CDM 6370000100 HCPCS 250 RC 09999-9990-12 NDC inpatient 3.5 GR 28.95 28.95 MEDICA (COMMERCIAL) 94265 [3081118] MEDICA CLAIMS [308111801] 26.06 percent of total billed charges 17.95 27.5 Technical (Hospital) Services WCH ED ERYTHROMYCIN 0.5 % OPTHALMIC OINTMENT #3.5GM RX-408840034 CDM 6370000100 HCPCS 250 RC 09999-9990-12 NDC outpatient 3.5 GR 28.95 28.95 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES PPO [308136801] 23.16 percent of total billed charges 17.95 27.5 Technical (Hospital) Services WCH ED ERYTHROMYCIN 0.5 % OPTHALMIC OINTMENT #3.5GM RX-408840034 CDM 6370000100 HCPCS 250 RC 09999-9990-12 NDC outpatient 3.5 GR 28.95 28.95 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES HDHP [308136802] 23.16 percent of total billed charges 17.95 27.5 Technical (Hospital) Services WCH ED ERYTHROMYCIN 0.5 % OPTHALMIC OINTMENT #3.5GM RX-408840034 CDM 6370000100 HCPCS 250 RC 09999-9990-12 NDC outpatient 3.5 GR 28.95 28.95 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES EPO [308136803] 23.16 percent of total billed charges 17.95 27.5 Technical (Hospital) Services WCH ED ERYTHROMYCIN 0.5 % OPTHALMIC OINTMENT #3.5GM RX-408840034 CDM 6370000100 HCPCS 250 RC 09999-9990-12 NDC outpatient 3.5 GR 28.95 28.95 BLUE CROSS BLUE SHIELD WELLMARK SB889 [3081026] BCBS WYOMING [308102603] 27.5 percent of total billed charges 17.95 27.5 Technical (Hospital) Services WCH ED ERYTHROMYCIN 0.5 % OPTHALMIC OINTMENT #3.5GM RX-408840034 CDM 6370000100 HCPCS 250 RC 09999-9990-12 NDC outpatient 3.5 GR 28.95 28.95 HEALTHPARTNERS SX009 HEALTHPARTNERS 23.16 percent of total billed charges 17.95 27.5 Technical (Hospital) Services WCH ED ERYTHROMYCIN 0.5 % OPTHALMIC OINTMENT #3.5GM RX-408840034 CDM 6370000100 HCPCS 250 RC 09999-9990-12 NDC outpatient 3.5 GR 28.95 28.95 UNITED HEALTHCARE (COMMERCIAL) [3081199] UNITED HEALTHCARE 87726 [308119901] 17.95 percent of total billed charges 17.95 27.5 Technical (Hospital) Services WCH ED ERYTHROMYCIN 0.5 % OPTHALMIC OINTMENT #3.5GM RX-408840034 CDM 6370000100 HCPCS 250 RC 09999-9990-12 NDC outpatient 3.5 GR 28.95 28.95 MEDICA (COMMERCIAL) 94265 [3081118] MEDICA CLAIMS [308111801] 26.06 percent of total billed charges 17.95 27.5 Technical (Hospital) Services WCH ED ERYTHROMYCIN 0.5 % OPTHALMIC OINTMENT #3.5GM RX-408840034 CDM 6370000100 HCPCS 250 RC 09999-9990-12 NDC outpatient 3.5 GR 28.95 28.95 MULTIPLAN INC 34080 [3081285] MULTIPLAN INC [308128501] 27.5 percent of total billed charges 17.95 27.5 Technical (Hospital) Services WCH ED ERYTHROMYCIN 0.5 % OPTHALMIC OINTMENT #3.5GM RX-408840034 CDM 6370000100 HCPCS 250 RC 09999-9990-12 NDC outpatient 3.5 GR 28.95 28.95 CIGNA 62308 [3081051] CIGNA 62308 [308105105] 23.16 percent of total billed charges 17.95 27.5 Technical (Hospital) Services WCH ED ERYTHROMYCIN 0.5 % OPTHALMIC OINTMENT #3.5GM RX-408840034 CDM 6370000100 HCPCS 250 RC 09999-9990-12 NDC outpatient 3.5 GR 28.95 28.95 CIGNA 62308 [3081051] CIGNA STATE OF WYOMING [308105107] 23.16 percent of total billed charges 17.95 27.5 Technical (Hospital) Services WCH ED NEOMYCIN/POLYMIXIN B SULFATES/DEXAMETHASONE OPTH OINNT #3.5GM RX-408840035 CDM 6370000100 HCPCS 250 RC 09999-9990-17 NDC outpatient 3.5 GR 30.4 30.4 MEDICA (COMMERCIAL) 94265 [3081118] MEDICA CLAIMS [308111801] 27.36 percent of total billed charges 18.85 28.88 Technical (Hospital) Services WCH ED NEOMYCIN/POLYMIXIN B SULFATES/DEXAMETHASONE OPTH OINNT #3.5GM RX-408840035 CDM 6370000100 HCPCS 250 RC 09999-9990-17 NDC outpatient 3.5 GR 30.4 30.4 MULTIPLAN INC 34080 [3081285] MULTIPLAN INC [308128501] 28.88 percent of total billed charges 18.85 28.88 Technical (Hospital) Services WCH ED NEOMYCIN/POLYMIXIN B SULFATES/DEXAMETHASONE OPTH OINNT #3.5GM RX-408840035 CDM 6370000100 HCPCS 250 RC 09999-9990-17 NDC outpatient 3.5 GR 30.4 30.4 CIGNA 62308 [3081051] CIGNA 62308 [308105105] 24.32 percent of total billed charges 18.85 28.88 Technical (Hospital) Services WCH ED NEOMYCIN/POLYMIXIN B SULFATES/DEXAMETHASONE OPTH OINNT #3.5GM RX-408840035 CDM 6370000100 HCPCS 250 RC 09999-9990-17 NDC outpatient 3.5 GR 30.4 30.4 CIGNA 62308 [3081051] CIGNA STATE OF WYOMING [308105107] 24.32 percent of total billed charges 18.85 28.88 Technical (Hospital) Services WCH ED NEOMYCIN/POLYMIXIN B SULFATES/DEXAMETHASONE OPTH OINNT #3.5GM RX-408840035 CDM 6370000100 HCPCS 250 RC 09999-9990-17 NDC outpatient 3.5 GR 30.4 30.4 UNITED HEALTHCARE (COMMERCIAL) [3081199] UNITED HEALTHCARE 87726 [308119901] 18.85 percent of total billed charges 18.85 28.88 Technical (Hospital) Services WCH ED NEOMYCIN/POLYMIXIN B SULFATES/DEXAMETHASONE OPTH OINNT #3.5GM RX-408840035 CDM 6370000100 HCPCS 250 RC 09999-9990-17 NDC outpatient 3.5 GR 30.4 30.4 HEALTHPARTNERS SX009 HEALTHPARTNERS 24.32 percent of total billed charges 18.85 28.88 Technical (Hospital) Services WCH ED NEOMYCIN/POLYMIXIN B SULFATES/DEXAMETHASONE OPTH OINNT #3.5GM RX-408840035 CDM 6370000100 HCPCS 250 RC 09999-9990-17 NDC outpatient 3.5 GR 30.4 30.4 BLUE CROSS BLUE SHIELD WELLMARK SB889 [3081026] BCBS WYOMING [308102603] 28.88 percent of total billed charges 18.85 28.88 Technical (Hospital) Services WCH ED NEOMYCIN/POLYMIXIN B SULFATES/DEXAMETHASONE OPTH OINNT #3.5GM RX-408840035 CDM 6370000100 HCPCS 250 RC 09999-9990-17 NDC outpatient 3.5 GR 30.4 30.4 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES EPO [308136803] 24.32 percent of total billed charges 18.85 28.88 Technical (Hospital) Services WCH ED NEOMYCIN/POLYMIXIN B SULFATES/DEXAMETHASONE OPTH OINNT #3.5GM RX-408840035 CDM 6370000100 HCPCS 250 RC 09999-9990-17 NDC outpatient 3.5 GR 30.4 30.4 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES PPO [308136801] 24.32 percent of total billed charges 18.85 28.88 Technical (Hospital) Services WCH ED NEOMYCIN/POLYMIXIN B SULFATES/DEXAMETHASONE OPTH OINNT #3.5GM RX-408840035 CDM 6370000100 HCPCS 250 RC 09999-9990-17 NDC outpatient 3.5 GR 30.4 30.4 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES HDHP [308136802] 24.32 percent of total billed charges 18.85 28.88 Technical (Hospital) Services WCH ED NEOMYCIN/POLYMIXIN B SULFATES/DEXAMETHASONE OPTH OINNT #3.5GM RX-408840035 CDM 6370000100 HCPCS 250 RC 09999-9990-17 NDC inpatient 3.5 GR 30.4 30.4 UNITED HEALTHCARE (COMMERCIAL) [3081199] UNITED HEALTHCARE 87726 [308119901] 18.85 percent of total billed charges 18.85 28.88 Technical (Hospital) Services WCH ED NEOMYCIN/POLYMIXIN B SULFATES/DEXAMETHASONE OPTH OINNT #3.5GM RX-408840035 CDM 6370000100 HCPCS 250 RC 09999-9990-17 NDC inpatient 3.5 GR 30.4 30.4 CIGNA 62308 [3081051] CIGNA 62308 [308105105] 24.07 percent of total billed charges 18.85 28.88 Technical (Hospital) Services WCH ED NEOMYCIN/POLYMIXIN B SULFATES/DEXAMETHASONE OPTH OINNT #3.5GM RX-408840035 CDM 6370000100 HCPCS 250 RC 09999-9990-17 NDC inpatient 3.5 GR 30.4 30.4 CIGNA 62308 [3081051] CIGNA STATE OF WYOMING [308105107] 24.07 percent of total billed charges 18.85 28.88 Technical (Hospital) Services WCH ED NEOMYCIN/POLYMIXIN B SULFATES/DEXAMETHASONE OPTH OINNT #3.5GM RX-408840035 CDM 6370000100 HCPCS 250 RC 09999-9990-17 NDC inpatient 3.5 GR 30.4 30.4 BLUE CROSS BLUE SHIELD WELLMARK SB889 [3081026] BCBS WYOMING [308102603] 28.88 percent of total billed charges 18.85 28.88 Technical (Hospital) Services WCH ED NEOMYCIN/POLYMIXIN B SULFATES/DEXAMETHASONE OPTH OINNT #3.5GM RX-408840035 CDM 6370000100 HCPCS 250 RC 09999-9990-17 NDC inpatient 3.5 GR 30.4 30.4 MEDICA (COMMERCIAL) 94265 [3081118] MEDICA CLAIMS [308111801] 27.36 percent of total billed charges 18.85 28.88 Technical (Hospital) Services WCH ED NEOMYCIN/POLYMIXIN B SULFATES/DEXAMETHASONE OPTH OINNT #3.5GM RX-408840035 CDM 6370000100 HCPCS 250 RC 09999-9990-17 NDC inpatient 3.5 GR 30.4 30.4 MULTIPLAN INC 34080 [3081285] MULTIPLAN INC [308128501] 28.88 percent of total billed charges 18.85 28.88 Technical (Hospital) Services WCH ED NEOMYCIN/POLYMIXIN B SULFATES/DEXAMETHASONE OPTH OINNT #3.5GM RX-408840035 CDM 6370000100 HCPCS 250 RC 09999-9990-17 NDC inpatient 3.5 GR 30.4 30.4 HEALTHPARTNERS SX009 HEALTHPARTNERS 24.07 percent of total billed charges 18.85 28.88 Technical (Hospital) Services WCH ED NEOMYCIN/POLYMIXIN B SULFATES/DEXAMETHASONE OPTH OINNT #3.5GM RX-408840035 CDM 6370000100 HCPCS 250 RC 09999-9990-17 NDC inpatient 3.5 GR 30.4 30.4 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES EPO [308136803] 24.07 percent of total billed charges 18.85 28.88 Technical (Hospital) Services WCH ED NEOMYCIN/POLYMIXIN B SULFATES/DEXAMETHASONE OPTH OINNT #3.5GM RX-408840035 CDM 6370000100 HCPCS 250 RC 09999-9990-17 NDC inpatient 3.5 GR 30.4 30.4 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES HDHP [308136802] 24.07 percent of total billed charges 18.85 28.88 Technical (Hospital) Services WCH ED NEOMYCIN/POLYMIXIN B SULFATES/DEXAMETHASONE OPTH OINNT #3.5GM RX-408840035 CDM 6370000100 HCPCS 250 RC 09999-9990-17 NDC inpatient 3.5 GR 30.4 30.4 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES PPO [308136801] 24.07 percent of total billed charges 18.85 28.88 Technical (Hospital) Services WCH ED NEOMYCIN-POLYMIXIN-HYDROCORT OTIC SOL #30ML RX-408840038 CDM 6370000100 HCPCS 250 RC inpatient 30 ML 265.45 265.45 CIGNA 62308 [3081051] CIGNA 62308 [308105105] 210.18 percent of total billed charges 164.58 252.18 Technical (Hospital) Services WCH ED NEOMYCIN-POLYMIXIN-HYDROCORT OTIC SOL #30ML RX-408840038 CDM 6370000100 HCPCS 250 RC inpatient 30 ML 265.45 265.45 CIGNA 62308 [3081051] CIGNA STATE OF WYOMING [308105107] 210.18 percent of total billed charges 164.58 252.18 Technical (Hospital) Services WCH ED NEOMYCIN-POLYMIXIN-HYDROCORT OTIC SOL #30ML RX-408840038 CDM 6370000100 HCPCS 250 RC inpatient 30 ML 265.45 265.45 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES HDHP [308136802] 210.18 percent of total billed charges 164.58 252.18 Technical (Hospital) Services WCH ED NEOMYCIN-POLYMIXIN-HYDROCORT OTIC SOL #30ML RX-408840038 CDM 6370000100 HCPCS 250 RC inpatient 30 ML 265.45 265.45 UNITED HEALTHCARE (COMMERCIAL) [3081199] UNITED HEALTHCARE 87726 [308119901] 164.58 percent of total billed charges 164.58 252.18 Technical (Hospital) Services WCH ED NEOMYCIN-POLYMIXIN-HYDROCORT OTIC SOL #30ML RX-408840038 CDM 6370000100 HCPCS 250 RC inpatient 30 ML 265.45 265.45 MEDICA (COMMERCIAL) 94265 [3081118] MEDICA CLAIMS [308111801] 238.91 percent of total billed charges 164.58 252.18 Technical (Hospital) Services WCH ED NEOMYCIN-POLYMIXIN-HYDROCORT OTIC SOL #30ML RX-408840038 CDM 6370000100 HCPCS 250 RC inpatient 30 ML 265.45 265.45 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES PPO [308136801] 210.18 percent of total billed charges 164.58 252.18 Technical (Hospital) Services WCH ED NEOMYCIN-POLYMIXIN-HYDROCORT OTIC SOL #30ML RX-408840038 CDM 6370000100 HCPCS 250 RC inpatient 30 ML 265.45 265.45 BLUE CROSS BLUE SHIELD WELLMARK SB889 [3081026] BCBS WYOMING [308102603] 252.18 percent of total billed charges 164.58 252.18 Technical (Hospital) Services WCH ED NEOMYCIN-POLYMIXIN-HYDROCORT OTIC SOL #30ML RX-408840038 CDM 6370000100 HCPCS 250 RC inpatient 30 ML 265.45 265.45 MULTIPLAN INC 34080 [3081285] MULTIPLAN INC [308128501] 252.18 percent of total billed charges 164.58 252.18 Technical (Hospital) Services WCH ED NEOMYCIN-POLYMIXIN-HYDROCORT OTIC SOL #30ML RX-408840038 CDM 6370000100 HCPCS 250 RC inpatient 30 ML 265.45 265.45 HEALTHPARTNERS SX009 HEALTHPARTNERS 210.18 percent of total billed charges 164.58 252.18 Technical (Hospital) Services WCH ED NEOMYCIN-POLYMIXIN-HYDROCORT OTIC SOL #30ML RX-408840038 CDM 6370000100 HCPCS 250 RC inpatient 30 ML 265.45 265.45 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES EPO [308136803] 210.18 percent of total billed charges 164.58 252.18 Technical (Hospital) Services WCH ED NEOMYCIN-POLYMIXIN-HYDROCORT OTIC SOL #30ML RX-408840038 CDM 6370000100 HCPCS 250 RC outpatient 30 ML 265.45 265.45 MULTIPLAN INC 34080 [3081285] MULTIPLAN INC [308128501] 252.18 percent of total billed charges 164.58 252.18 Technical (Hospital) Services WCH ED NEOMYCIN-POLYMIXIN-HYDROCORT OTIC SOL #30ML RX-408840038 CDM 6370000100 HCPCS 250 RC outpatient 30 ML 265.45 265.45 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES PPO [308136801] 212.36 percent of total billed charges 164.58 252.18 Technical (Hospital) Services WCH ED NEOMYCIN-POLYMIXIN-HYDROCORT OTIC SOL #30ML RX-408840038 CDM 6370000100 HCPCS 250 RC outpatient 30 ML 265.45 265.45 MEDICA (COMMERCIAL) 94265 [3081118] MEDICA CLAIMS [308111801] 238.91 percent of total billed charges 164.58 252.18 Technical (Hospital) Services WCH ED NEOMYCIN-POLYMIXIN-HYDROCORT OTIC SOL #30ML RX-408840038 CDM 6370000100 HCPCS 250 RC outpatient 30 ML 265.45 265.45 UNITED HEALTHCARE (COMMERCIAL) [3081199] UNITED HEALTHCARE 87726 [308119901] 164.58 percent of total billed charges 164.58 252.18 Technical (Hospital) Services WCH ED NEOMYCIN-POLYMIXIN-HYDROCORT OTIC SOL #30ML RX-408840038 CDM 6370000100 HCPCS 250 RC outpatient 30 ML 265.45 265.45 HEALTHPARTNERS SX009 HEALTHPARTNERS 212.36 percent of total billed charges 164.58 252.18 Technical (Hospital) Services WCH ED NEOMYCIN-POLYMIXIN-HYDROCORT OTIC SOL #30ML RX-408840038 CDM 6370000100 HCPCS 250 RC outpatient 30 ML 265.45 265.45 CIGNA 62308 [3081051] CIGNA 62308 [308105105] 212.36 percent of total billed charges 164.58 252.18 Technical (Hospital) Services WCH ED NEOMYCIN-POLYMIXIN-HYDROCORT OTIC SOL #30ML RX-408840038 CDM 6370000100 HCPCS 250 RC outpatient 30 ML 265.45 265.45 CIGNA 62308 [3081051] CIGNA STATE OF WYOMING [308105107] 212.36 percent of total billed charges 164.58 252.18 Technical (Hospital) Services WCH ED NEOMYCIN-POLYMIXIN-HYDROCORT OTIC SOL #30ML RX-408840038 CDM 6370000100 HCPCS 250 RC outpatient 30 ML 265.45 265.45 BLUE CROSS BLUE SHIELD WELLMARK SB889 [3081026] BCBS WYOMING [308102603] 252.18 percent of total billed charges 164.58 252.18 Technical (Hospital) Services WCH ED NEOMYCIN-POLYMIXIN-HYDROCORT OTIC SOL #30ML RX-408840038 CDM 6370000100 HCPCS 250 RC outpatient 30 ML 265.45 265.45 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES EPO [308136803] 212.36 percent of total billed charges 164.58 252.18 Technical (Hospital) Services WCH ED NEOMYCIN-POLYMIXIN-HYDROCORT OTIC SOL #30ML RX-408840038 CDM 6370000100 HCPCS 250 RC outpatient 30 ML 265.45 265.45 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES HDHP [308136802] 212.36 percent of total billed charges 164.58 252.18 Technical (Hospital) Services WCH ED AZITHROMYCIN 250 MG TAB #6 RX-4088401000 CDM 6370000100 HCPCS 250 RC inpatient 1500 ME 28.75 28.75 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES HDHP [308136802] 22.76 percent of total billed charges 17.83 27.31 Technical (Hospital) Services WCH ED AZITHROMYCIN 250 MG TAB #6 RX-4088401000 CDM 6370000100 HCPCS 250 RC inpatient 1500 ME 28.75 28.75 UNITED HEALTHCARE (COMMERCIAL) [3081199] UNITED HEALTHCARE 87726 [308119901] 17.83 percent of total billed charges 17.83 27.31 Technical (Hospital) Services WCH ED AZITHROMYCIN 250 MG TAB #6 RX-4088401000 CDM 6370000100 HCPCS 250 RC inpatient 1500 ME 28.75 28.75 CIGNA 62308 [3081051] CIGNA 62308 [308105105] 22.76 percent of total billed charges 17.83 27.31 Technical (Hospital) Services WCH ED AZITHROMYCIN 250 MG TAB #6 RX-4088401000 CDM 6370000100 HCPCS 250 RC inpatient 1500 ME 28.75 28.75 CIGNA 62308 [3081051] CIGNA STATE OF WYOMING [308105107] 22.76 percent of total billed charges 17.83 27.31 Technical (Hospital) Services WCH ED AZITHROMYCIN 250 MG TAB #6 RX-4088401000 CDM 6370000100 HCPCS 250 RC inpatient 1500 ME 28.75 28.75 MEDICA (COMMERCIAL) 94265 [3081118] MEDICA CLAIMS [308111801] 25.88 percent of total billed charges 17.83 27.31 Technical (Hospital) Services WCH ED AZITHROMYCIN 250 MG TAB #6 RX-4088401000 CDM 6370000100 HCPCS 250 RC inpatient 1500 ME 28.75 28.75 HEALTHPARTNERS SX009 HEALTHPARTNERS 22.76 percent of total billed charges 17.83 27.31 Technical (Hospital) Services WCH ED AZITHROMYCIN 250 MG TAB #6 RX-4088401000 CDM 6370000100 HCPCS 250 RC inpatient 1500 ME 28.75 28.75 BLUE CROSS BLUE SHIELD WELLMARK SB889 [3081026] BCBS WYOMING [308102603] 27.31 percent of total billed charges 17.83 27.31 Technical (Hospital) Services WCH ED AZITHROMYCIN 250 MG TAB #6 RX-4088401000 CDM 6370000100 HCPCS 250 RC inpatient 1500 ME 28.75 28.75 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES EPO [308136803] 22.76 percent of total billed charges 17.83 27.31 Technical (Hospital) Services WCH ED AZITHROMYCIN 250 MG TAB #6 RX-4088401000 CDM 6370000100 HCPCS 250 RC inpatient 1500 ME 28.75 28.75 MULTIPLAN INC 34080 [3081285] MULTIPLAN INC [308128501] 27.31 percent of total billed charges 17.83 27.31 Technical (Hospital) Services WCH ED AZITHROMYCIN 250 MG TAB #6 RX-4088401000 CDM 6370000100 HCPCS 250 RC inpatient 1500 ME 28.75 28.75 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES PPO [308136801] 22.76 percent of total billed charges 17.83 27.31 Technical (Hospital) Services WCH ED AZITHROMYCIN 250 MG TAB #6 RX-4088401000 CDM 6370000100 HCPCS 250 RC outpatient 1500 ME 28.75 28.75 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES HDHP [308136802] 23 percent of total billed charges 17.83 27.31 Technical (Hospital) Services WCH ED AZITHROMYCIN 250 MG TAB #6 RX-4088401000 CDM 6370000100 HCPCS 250 RC outpatient 1500 ME 28.75 28.75 BLUE CROSS BLUE SHIELD WELLMARK SB889 [3081026] BCBS WYOMING [308102603] 27.31 percent of total billed charges 17.83 27.31 Technical (Hospital) Services WCH ED AZITHROMYCIN 250 MG TAB #6 RX-4088401000 CDM 6370000100 HCPCS 250 RC outpatient 1500 ME 28.75 28.75 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES EPO [308136803] 23 percent of total billed charges 17.83 27.31 Technical (Hospital) Services WCH ED AZITHROMYCIN 250 MG TAB #6 RX-4088401000 CDM 6370000100 HCPCS 250 RC outpatient 1500 ME 28.75 28.75 UNITED HEALTHCARE (COMMERCIAL) [3081199] UNITED HEALTHCARE 87726 [308119901] 17.83 percent of total billed charges 17.83 27.31 Technical (Hospital) Services WCH ED AZITHROMYCIN 250 MG TAB #6 RX-4088401000 CDM 6370000100 HCPCS 250 RC outpatient 1500 ME 28.75 28.75 CIGNA 62308 [3081051] CIGNA 62308 [308105105] 23 percent of total billed charges 17.83 27.31 Technical (Hospital) Services WCH ED AZITHROMYCIN 250 MG TAB #6 RX-4088401000 CDM 6370000100 HCPCS 250 RC outpatient 1500 ME 28.75 28.75 CIGNA 62308 [3081051] CIGNA STATE OF WYOMING [308105107] 23 percent of total billed charges 17.83 27.31 Technical (Hospital) Services WCH ED AZITHROMYCIN 250 MG TAB #6 RX-4088401000 CDM 6370000100 HCPCS 250 RC outpatient 1500 ME 28.75 28.75 MEDICA (COMMERCIAL) 94265 [3081118] MEDICA CLAIMS [308111801] 25.88 percent of total billed charges 17.83 27.31 Technical (Hospital) Services WCH ED AZITHROMYCIN 250 MG TAB #6 RX-4088401000 CDM 6370000100 HCPCS 250 RC outpatient 1500 ME 28.75 28.75 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES PPO [308136801] 23 percent of total billed charges 17.83 27.31 Technical (Hospital) Services WCH ED AZITHROMYCIN 250 MG TAB #6 RX-4088401000 CDM 6370000100 HCPCS 250 RC outpatient 1500 ME 28.75 28.75 HEALTHPARTNERS SX009 HEALTHPARTNERS 23 percent of total billed charges 17.83 27.31 Technical (Hospital) Services WCH ED AZITHROMYCIN 250 MG TAB #6 RX-4088401000 CDM 6370000100 HCPCS 250 RC outpatient 1500 ME 28.75 28.75 MULTIPLAN INC 34080 [3081285] MULTIPLAN INC [308128501] 27.31 percent of total billed charges 17.83 27.31 Technical (Hospital) Services GLYCERIN (ADULT) RECTAL SUPPOSITORY RX-41003 CDM 6370000100 HCPCS 250 RC 00132-0079-12 NDC inpatient 1 UN 5.72 5.72 MEDICA (COMMERCIAL) 94265 [3081118] MEDICA CLAIMS [308111801] 5.15 percent of total billed charges 3.55 5.43 Technical (Hospital) Services GLYCERIN (ADULT) RECTAL SUPPOSITORY RX-41003 CDM 6370000100 HCPCS 250 RC 00132-0079-12 NDC inpatient 1 UN 5.72 5.72 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES PPO [308136801] 4.53 percent of total billed charges 3.55 5.43 Technical (Hospital) Services GLYCERIN (ADULT) RECTAL SUPPOSITORY RX-41003 CDM 6370000100 HCPCS 250 RC 00132-0079-12 NDC inpatient 1 UN 5.72 5.72 HEALTHPARTNERS SX009 HEALTHPARTNERS 4.53 percent of total billed charges 3.55 5.43 Technical (Hospital) Services GLYCERIN (ADULT) RECTAL SUPPOSITORY RX-41003 CDM 6370000100 HCPCS 250 RC 00132-0079-12 NDC inpatient 1 UN 5.72 5.72 MULTIPLAN INC 34080 [3081285] MULTIPLAN INC [308128501] 5.43 percent of total billed charges 3.55 5.43 Technical (Hospital) Services GLYCERIN (ADULT) RECTAL SUPPOSITORY RX-41003 CDM 6370000100 HCPCS 250 RC 00132-0079-12 NDC inpatient 1 UN 5.72 5.72 CIGNA 62308 [3081051] CIGNA 62308 [308105105] 4.53 percent of total billed charges 3.55 5.43 Technical (Hospital) Services GLYCERIN (ADULT) RECTAL SUPPOSITORY RX-41003 CDM 6370000100 HCPCS 250 RC 00132-0079-12 NDC inpatient 1 UN 5.72 5.72 CIGNA 62308 [3081051] CIGNA STATE OF WYOMING [308105107] 4.53 percent of total billed charges 3.55 5.43 Technical (Hospital) Services GLYCERIN (ADULT) RECTAL SUPPOSITORY RX-41003 CDM 6370000100 HCPCS 250 RC 00132-0079-12 NDC inpatient 1 UN 5.72 5.72 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES HDHP [308136802] 4.53 percent of total billed charges 3.55 5.43 Technical (Hospital) Services GLYCERIN (ADULT) RECTAL SUPPOSITORY RX-41003 CDM 6370000100 HCPCS 250 RC 00132-0079-12 NDC inpatient 1 UN 5.72 5.72 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES EPO [308136803] 4.53 percent of total billed charges 3.55 5.43 Technical (Hospital) Services GLYCERIN (ADULT) RECTAL SUPPOSITORY RX-41003 CDM 6370000100 HCPCS 250 RC 00132-0079-12 NDC inpatient 1 UN 5.72 5.72 UNITED HEALTHCARE (COMMERCIAL) [3081199] UNITED HEALTHCARE 87726 [308119901] 3.55 percent of total billed charges 3.55 5.43 Technical (Hospital) Services GLYCERIN (ADULT) RECTAL SUPPOSITORY RX-41003 CDM 6370000100 HCPCS 250 RC 00132-0079-12 NDC inpatient 1 UN 5.72 5.72 BLUE CROSS BLUE SHIELD WELLMARK SB889 [3081026] BCBS WYOMING [308102603] 5.43 percent of total billed charges 3.55 5.43 Technical (Hospital) Services GLYCERIN (ADULT) RECTAL SUPPOSITORY RX-41003 CDM 6370000100 HCPCS 250 RC 00132-0079-12 NDC outpatient 1 UN 5.72 5.72 HEALTHPARTNERS SX009 HEALTHPARTNERS 4.58 percent of total billed charges 3.55 5.43 Technical (Hospital) Services GLYCERIN (ADULT) RECTAL SUPPOSITORY RX-41003 CDM 6370000100 HCPCS 250 RC 00132-0079-12 NDC outpatient 1 UN 5.72 5.72 UNITED HEALTHCARE (COMMERCIAL) [3081199] UNITED HEALTHCARE 87726 [308119901] 3.55 percent of total billed charges 3.55 5.43 Technical (Hospital) Services GLYCERIN (ADULT) RECTAL SUPPOSITORY RX-41003 CDM 6370000100 HCPCS 250 RC 00132-0079-12 NDC outpatient 1 UN 5.72 5.72 CIGNA 62308 [3081051] CIGNA 62308 [308105105] 4.58 percent of total billed charges 3.55 5.43 Technical (Hospital) Services GLYCERIN (ADULT) RECTAL SUPPOSITORY RX-41003 CDM 6370000100 HCPCS 250 RC 00132-0079-12 NDC outpatient 1 UN 5.72 5.72 CIGNA 62308 [3081051] CIGNA STATE OF WYOMING [308105107] 4.58 percent of total billed charges 3.55 5.43 Technical (Hospital) Services GLYCERIN (ADULT) RECTAL SUPPOSITORY RX-41003 CDM 6370000100 HCPCS 250 RC 00132-0079-12 NDC outpatient 1 UN 5.72 5.72 MULTIPLAN INC 34080 [3081285] MULTIPLAN INC [308128501] 5.43 percent of total billed charges 3.55 5.43 Technical (Hospital) Services GLYCERIN (ADULT) RECTAL SUPPOSITORY RX-41003 CDM 6370000100 HCPCS 250 RC 00132-0079-12 NDC outpatient 1 UN 5.72 5.72 MEDICA (COMMERCIAL) 94265 [3081118] MEDICA CLAIMS [308111801] 5.15 percent of total billed charges 3.55 5.43 Technical (Hospital) Services GLYCERIN (ADULT) RECTAL SUPPOSITORY RX-41003 CDM 6370000100 HCPCS 250 RC 00132-0079-12 NDC outpatient 1 UN 5.72 5.72 BLUE CROSS BLUE SHIELD WELLMARK SB889 [3081026] BCBS WYOMING [308102603] 5.43 percent of total billed charges 3.55 5.43 Technical (Hospital) Services GLYCERIN (ADULT) RECTAL SUPPOSITORY RX-41003 CDM 6370000100 HCPCS 250 RC 00132-0079-12 NDC outpatient 1 UN 5.72 5.72 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES EPO [308136803] 4.58 percent of total billed charges 3.55 5.43 Technical (Hospital) Services GLYCERIN (ADULT) RECTAL SUPPOSITORY RX-41003 CDM 6370000100 HCPCS 250 RC 00132-0079-12 NDC outpatient 1 UN 5.72 5.72 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES HDHP [308136802] 4.58 percent of total billed charges 3.55 5.43 Technical (Hospital) Services GLYCERIN (ADULT) RECTAL SUPPOSITORY RX-41003 CDM 6370000100 HCPCS 250 RC 00132-0079-12 NDC outpatient 1 UN 5.72 5.72 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES PPO [308136801] 4.58 percent of total billed charges 3.55 5.43 Technical (Hospital) Services ENTECAVIR 0.5 MG TABLET RX-41147 CDM 6370000100 HCPCS 250 RC 31722-0833-30 NDC inpatient 1 UN 6.95 6.95 CIGNA 62308 [3081051] CIGNA 62308 [308105105] 5.5 percent of total billed charges 4.31 6.6 Technical (Hospital) Services ENTECAVIR 0.5 MG TABLET RX-41147 CDM 6370000100 HCPCS 250 RC 31722-0833-30 NDC inpatient 1 UN 6.95 6.95 CIGNA 62308 [3081051] CIGNA STATE OF WYOMING [308105107] 5.5 percent of total billed charges 4.31 6.6 Technical (Hospital) Services ENTECAVIR 0.5 MG TABLET RX-41147 CDM 6370000100 HCPCS 250 RC 31722-0833-30 NDC inpatient 1 UN 6.95 6.95 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES HDHP [308136802] 5.5 percent of total billed charges 4.31 6.6 Technical (Hospital) Services ENTECAVIR 0.5 MG TABLET RX-41147 CDM 6370000100 HCPCS 250 RC 31722-0833-30 NDC inpatient 1 UN 6.95 6.95 UNITED HEALTHCARE (COMMERCIAL) [3081199] UNITED HEALTHCARE 87726 [308119901] 4.31 percent of total billed charges 4.31 6.6 Technical (Hospital) Services ENTECAVIR 0.5 MG TABLET RX-41147 CDM 6370000100 HCPCS 250 RC 31722-0833-30 NDC inpatient 1 UN 6.95 6.95 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES EPO [308136803] 5.5 percent of total billed charges 4.31 6.6 Technical (Hospital) Services ENTECAVIR 0.5 MG TABLET RX-41147 CDM 6370000100 HCPCS 250 RC 31722-0833-30 NDC inpatient 1 UN 6.95 6.95 BLUE CROSS BLUE SHIELD WELLMARK SB889 [3081026] BCBS WYOMING [308102603] 6.6 percent of total billed charges 4.31 6.6 Technical (Hospital) Services ENTECAVIR 0.5 MG TABLET RX-41147 CDM 6370000100 HCPCS 250 RC 31722-0833-30 NDC inpatient 1 UN 6.95 6.95 MULTIPLAN INC 34080 [3081285] MULTIPLAN INC [308128501] 6.6 percent of total billed charges 4.31 6.6 Technical (Hospital) Services ENTECAVIR 0.5 MG TABLET RX-41147 CDM 6370000100 HCPCS 250 RC 31722-0833-30 NDC inpatient 1 UN 6.95 6.95 HEALTHPARTNERS SX009 HEALTHPARTNERS 5.5 percent of total billed charges 4.31 6.6 Technical (Hospital) Services ENTECAVIR 0.5 MG TABLET RX-41147 CDM 6370000100 HCPCS 250 RC 31722-0833-30 NDC inpatient 1 UN 6.95 6.95 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES PPO [308136801] 5.5 percent of total billed charges 4.31 6.6 Technical (Hospital) Services ENTECAVIR 0.5 MG TABLET RX-41147 CDM 6370000100 HCPCS 250 RC 31722-0833-30 NDC inpatient 1 UN 6.95 6.95 MEDICA (COMMERCIAL) 94265 [3081118] MEDICA CLAIMS [308111801] 6.26 percent of total billed charges 4.31 6.6 Technical (Hospital) Services ENTECAVIR 0.5 MG TABLET RX-41147 CDM 6370000100 HCPCS 250 RC 31722-0833-30 NDC outpatient 1 UN 6.95 6.95 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES EPO [308136803] 5.56 percent of total billed charges 4.31 6.6 Technical (Hospital) Services ENTECAVIR 0.5 MG TABLET RX-41147 CDM 6370000100 HCPCS 250 RC 31722-0833-30 NDC outpatient 1 UN 6.95 6.95 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES PPO [308136801] 5.56 percent of total billed charges 4.31 6.6 Technical (Hospital) Services ENTECAVIR 0.5 MG TABLET RX-41147 CDM 6370000100 HCPCS 250 RC 31722-0833-30 NDC outpatient 1 UN 6.95 6.95 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES HDHP [308136802] 5.56 percent of total billed charges 4.31 6.6 Technical (Hospital) Services ENTECAVIR 0.5 MG TABLET RX-41147 CDM 6370000100 HCPCS 250 RC 31722-0833-30 NDC outpatient 1 UN 6.95 6.95 HEALTHPARTNERS SX009 HEALTHPARTNERS 5.56 percent of total billed charges 4.31 6.6 Technical (Hospital) Services ENTECAVIR 0.5 MG TABLET RX-41147 CDM 6370000100 HCPCS 250 RC 31722-0833-30 NDC outpatient 1 UN 6.95 6.95 UNITED HEALTHCARE (COMMERCIAL) [3081199] UNITED HEALTHCARE 87726 [308119901] 4.31 percent of total billed charges 4.31 6.6 Technical (Hospital) Services ENTECAVIR 0.5 MG TABLET RX-41147 CDM 6370000100 HCPCS 250 RC 31722-0833-30 NDC outpatient 1 UN 6.95 6.95 CIGNA 62308 [3081051] CIGNA 62308 [308105105] 5.56 percent of total billed charges 4.31 6.6 Technical (Hospital) Services ENTECAVIR 0.5 MG TABLET RX-41147 CDM 6370000100 HCPCS 250 RC 31722-0833-30 NDC outpatient 1 UN 6.95 6.95 CIGNA 62308 [3081051] CIGNA STATE OF WYOMING [308105107] 5.56 percent of total billed charges 4.31 6.6 Technical (Hospital) Services ENTECAVIR 0.5 MG TABLET RX-41147 CDM 6370000100 HCPCS 250 RC 31722-0833-30 NDC outpatient 1 UN 6.95 6.95 MULTIPLAN INC 34080 [3081285] MULTIPLAN INC [308128501] 6.6 percent of total billed charges 4.31 6.6 Technical (Hospital) Services ENTECAVIR 0.5 MG TABLET RX-41147 CDM 6370000100 HCPCS 250 RC 31722-0833-30 NDC outpatient 1 UN 6.95 6.95 MEDICA (COMMERCIAL) 94265 [3081118] MEDICA CLAIMS [308111801] 6.26 percent of total billed charges 4.31 6.6 Technical (Hospital) Services ENTECAVIR 0.5 MG TABLET RX-41147 CDM 6370000100 HCPCS 250 RC 31722-0833-30 NDC outpatient 1 UN 6.95 6.95 BLUE CROSS BLUE SHIELD WELLMARK SB889 [3081026] BCBS WYOMING [308102603] 6.6 percent of total billed charges 4.31 6.6 Technical (Hospital) Services SILDENAFIL (PULMONARY HYPERTENSION) 20 MG TABLET RX-41832 CDM 6370000100 HCPCS 250 RC 59762-0033-01 NDC outpatient 1 UN 107 107 HEALTHPARTNERS SX009 HEALTHPARTNERS 85.6 percent of total billed charges 66.34 101.65 Technical (Hospital) Services SILDENAFIL (PULMONARY HYPERTENSION) 20 MG TABLET RX-41832 CDM 6370000100 HCPCS 250 RC 59762-0033-01 NDC outpatient 1 UN 107 107 BLUE CROSS BLUE SHIELD WELLMARK SB889 [3081026] BCBS WYOMING [308102603] 101.65 percent of total billed charges 66.34 101.65 Technical (Hospital) Services SILDENAFIL (PULMONARY HYPERTENSION) 20 MG TABLET RX-41832 CDM 6370000100 HCPCS 250 RC 59762-0033-01 NDC outpatient 1 UN 107 107 MEDICA (COMMERCIAL) 94265 [3081118] MEDICA CLAIMS [308111801] 96.3 percent of total billed charges 66.34 101.65 Technical (Hospital) Services SILDENAFIL (PULMONARY HYPERTENSION) 20 MG TABLET RX-41832 CDM 6370000100 HCPCS 250 RC 59762-0033-01 NDC outpatient 1 UN 107 107 MULTIPLAN INC 34080 [3081285] MULTIPLAN INC [308128501] 101.65 percent of total billed charges 66.34 101.65 Technical (Hospital) Services SILDENAFIL (PULMONARY HYPERTENSION) 20 MG TABLET RX-41832 CDM 6370000100 HCPCS 250 RC 59762-0033-01 NDC outpatient 1 UN 107 107 CIGNA 62308 [3081051] CIGNA 62308 [308105105] 85.6 percent of total billed charges 66.34 101.65 Technical (Hospital) Services SILDENAFIL (PULMONARY HYPERTENSION) 20 MG TABLET RX-41832 CDM 6370000100 HCPCS 250 RC 59762-0033-01 NDC outpatient 1 UN 107 107 CIGNA 62308 [3081051] CIGNA STATE OF WYOMING [308105107] 85.6 percent of total billed charges 66.34 101.65 Technical (Hospital) Services SILDENAFIL (PULMONARY HYPERTENSION) 20 MG TABLET RX-41832 CDM 6370000100 HCPCS 250 RC 59762-0033-01 NDC outpatient 1 UN 107 107 UNITED HEALTHCARE (COMMERCIAL) [3081199] UNITED HEALTHCARE 87726 [308119901] 66.34 percent of total billed charges 66.34 101.65 Technical (Hospital) Services SILDENAFIL (PULMONARY HYPERTENSION) 20 MG TABLET RX-41832 CDM 6370000100 HCPCS 250 RC 59762-0033-01 NDC outpatient 1 UN 107 107 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES EPO [308136803] 85.6 percent of total billed charges 66.34 101.65 Technical (Hospital) Services SILDENAFIL (PULMONARY HYPERTENSION) 20 MG TABLET RX-41832 CDM 6370000100 HCPCS 250 RC 59762-0033-01 NDC outpatient 1 UN 107 107 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES PPO [308136801] 85.6 percent of total billed charges 66.34 101.65 Technical (Hospital) Services SILDENAFIL (PULMONARY HYPERTENSION) 20 MG TABLET RX-41832 CDM 6370000100 HCPCS 250 RC 59762-0033-01 NDC outpatient 1 UN 107 107 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES HDHP [308136802] 85.6 percent of total billed charges 66.34 101.65 Technical (Hospital) Services SILDENAFIL (PULMONARY HYPERTENSION) 20 MG TABLET RX-41832 CDM 6370000100 HCPCS 250 RC 59762-0033-01 NDC inpatient 1 UN 107 107 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES HDHP [308136802] 84.72 percent of total billed charges 66.34 101.65 Technical (Hospital) Services SILDENAFIL (PULMONARY HYPERTENSION) 20 MG TABLET RX-41832 CDM 6370000100 HCPCS 250 RC 59762-0033-01 NDC inpatient 1 UN 107 107 CIGNA 62308 [3081051] CIGNA 62308 [308105105] 84.72 percent of total billed charges 66.34 101.65 Technical (Hospital) Services SILDENAFIL (PULMONARY HYPERTENSION) 20 MG TABLET RX-41832 CDM 6370000100 HCPCS 250 RC 59762-0033-01 NDC inpatient 1 UN 107 107 CIGNA 62308 [3081051] CIGNA STATE OF WYOMING [308105107] 84.72 percent of total billed charges 66.34 101.65 Technical (Hospital) Services SILDENAFIL (PULMONARY HYPERTENSION) 20 MG TABLET RX-41832 CDM 6370000100 HCPCS 250 RC 59762-0033-01 NDC inpatient 1 UN 107 107 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES EPO [308136803] 84.72 percent of total billed charges 66.34 101.65 Technical (Hospital) Services SILDENAFIL (PULMONARY HYPERTENSION) 20 MG TABLET RX-41832 CDM 6370000100 HCPCS 250 RC 59762-0033-01 NDC inpatient 1 UN 107 107 UNITED HEALTHCARE (COMMERCIAL) [3081199] UNITED HEALTHCARE 87726 [308119901] 66.34 percent of total billed charges 66.34 101.65 Technical (Hospital) Services SILDENAFIL (PULMONARY HYPERTENSION) 20 MG TABLET RX-41832 CDM 6370000100 HCPCS 250 RC 59762-0033-01 NDC inpatient 1 UN 107 107 BLUE CROSS BLUE SHIELD WELLMARK SB889 [3081026] BCBS WYOMING [308102603] 101.65 percent of total billed charges 66.34 101.65 Technical (Hospital) Services SILDENAFIL (PULMONARY HYPERTENSION) 20 MG TABLET RX-41832 CDM 6370000100 HCPCS 250 RC 59762-0033-01 NDC inpatient 1 UN 107 107 HEALTHPARTNERS SX009 HEALTHPARTNERS 84.72 percent of total billed charges 66.34 101.65 Technical (Hospital) Services SILDENAFIL (PULMONARY HYPERTENSION) 20 MG TABLET RX-41832 CDM 6370000100 HCPCS 250 RC 59762-0033-01 NDC inpatient 1 UN 107 107 MEDICA (COMMERCIAL) 94265 [3081118] MEDICA CLAIMS [308111801] 96.3 percent of total billed charges 66.34 101.65 Technical (Hospital) Services SILDENAFIL (PULMONARY HYPERTENSION) 20 MG TABLET RX-41832 CDM 6370000100 HCPCS 250 RC 59762-0033-01 NDC inpatient 1 UN 107 107 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES PPO [308136801] 84.72 percent of total billed charges 66.34 101.65 Technical (Hospital) Services SILDENAFIL (PULMONARY HYPERTENSION) 20 MG TABLET RX-41832 CDM 6370000100 HCPCS 250 RC 59762-0033-01 NDC inpatient 1 UN 107 107 MULTIPLAN INC 34080 [3081285] MULTIPLAN INC [308128501] 101.65 percent of total billed charges 66.34 101.65 Technical (Hospital) Services PREGABALIN 25 MG CAPSULE RX-42162 CDM 6370000100 HCPCS 250 RC 00071-1012-68 NDC outpatient 1 UN 38.52 38.52 BLUE CROSS BLUE SHIELD WELLMARK SB889 [3081026] BCBS WYOMING [308102603] 36.59 percent of total billed charges 23.88 36.59 Technical (Hospital) Services PREGABALIN 25 MG CAPSULE RX-42162 CDM 6370000100 HCPCS 250 RC 00071-1012-68 NDC outpatient 1 UN 38.52 38.52 HEALTHPARTNERS SX009 HEALTHPARTNERS 30.82 percent of total billed charges 23.88 36.59 Technical (Hospital) Services PREGABALIN 25 MG CAPSULE RX-42162 CDM 6370000100 HCPCS 250 RC 00071-1012-68 NDC outpatient 1 UN 38.52 38.52 MEDICA (COMMERCIAL) 94265 [3081118] MEDICA CLAIMS [308111801] 34.67 percent of total billed charges 23.88 36.59 Technical (Hospital) Services PREGABALIN 25 MG CAPSULE RX-42162 CDM 6370000100 HCPCS 250 RC 00071-1012-68 NDC outpatient 1 UN 38.52 38.52 CIGNA 62308 [3081051] CIGNA 62308 [308105105] 30.82 percent of total billed charges 23.88 36.59 Technical (Hospital) Services PREGABALIN 25 MG CAPSULE RX-42162 CDM 6370000100 HCPCS 250 RC 00071-1012-68 NDC outpatient 1 UN 38.52 38.52 CIGNA 62308 [3081051] CIGNA STATE OF WYOMING [308105107] 30.82 percent of total billed charges 23.88 36.59 Technical (Hospital) Services PREGABALIN 25 MG CAPSULE RX-42162 CDM 6370000100 HCPCS 250 RC 00071-1012-68 NDC outpatient 1 UN 38.52 38.52 MULTIPLAN INC 34080 [3081285] MULTIPLAN INC [308128501] 36.59 percent of total billed charges 23.88 36.59 Technical (Hospital) Services PREGABALIN 25 MG CAPSULE RX-42162 CDM 6370000100 HCPCS 250 RC 00071-1012-68 NDC outpatient 1 UN 38.52 38.52 UNITED HEALTHCARE (COMMERCIAL) [3081199] UNITED HEALTHCARE 87726 [308119901] 23.88 percent of total billed charges 23.88 36.59 Technical (Hospital) Services PREGABALIN 25 MG CAPSULE RX-42162 CDM 6370000100 HCPCS 250 RC 00071-1012-68 NDC outpatient 1 UN 38.52 38.52 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES PPO [308136801] 30.82 percent of total billed charges 23.88 36.59 Technical (Hospital) Services PREGABALIN 25 MG CAPSULE RX-42162 CDM 6370000100 HCPCS 250 RC 00071-1012-68 NDC outpatient 1 UN 38.52 38.52 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES HDHP [308136802] 30.82 percent of total billed charges 23.88 36.59 Technical (Hospital) Services PREGABALIN 25 MG CAPSULE RX-42162 CDM 6370000100 HCPCS 250 RC 00071-1012-68 NDC outpatient 1 UN 38.52 38.52 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES EPO [308136803] 30.82 percent of total billed charges 23.88 36.59 Technical (Hospital) Services PREGABALIN 25 MG CAPSULE RX-42162 CDM 6370000100 HCPCS 250 RC 00071-1012-68 NDC inpatient 1 UN 38.52 38.52 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES PPO [308136801] 30.5 percent of total billed charges 23.88 36.59 Technical (Hospital) Services PREGABALIN 25 MG CAPSULE RX-42162 CDM 6370000100 HCPCS 250 RC 00071-1012-68 NDC inpatient 1 UN 38.52 38.52 MEDICA (COMMERCIAL) 94265 [3081118] MEDICA CLAIMS [308111801] 34.67 percent of total billed charges 23.88 36.59 Technical (Hospital) Services PREGABALIN 25 MG CAPSULE RX-42162 CDM 6370000100 HCPCS 250 RC 00071-1012-68 NDC inpatient 1 UN 38.52 38.52 HEALTHPARTNERS SX009 HEALTHPARTNERS 30.5 percent of total billed charges 23.88 36.59 Technical (Hospital) Services PREGABALIN 25 MG CAPSULE RX-42162 CDM 6370000100 HCPCS 250 RC 00071-1012-68 NDC inpatient 1 UN 38.52 38.52 MULTIPLAN INC 34080 [3081285] MULTIPLAN INC [308128501] 36.59 percent of total billed charges 23.88 36.59 Technical (Hospital) Services PREGABALIN 25 MG CAPSULE RX-42162 CDM 6370000100 HCPCS 250 RC 00071-1012-68 NDC inpatient 1 UN 38.52 38.52 BLUE CROSS BLUE SHIELD WELLMARK SB889 [3081026] BCBS WYOMING [308102603] 36.59 percent of total billed charges 23.88 36.59 Technical (Hospital) Services PREGABALIN 25 MG CAPSULE RX-42162 CDM 6370000100 HCPCS 250 RC 00071-1012-68 NDC inpatient 1 UN 38.52 38.52 UNITED HEALTHCARE (COMMERCIAL) [3081199] UNITED HEALTHCARE 87726 [308119901] 23.88 percent of total billed charges 23.88 36.59 Technical (Hospital) Services PREGABALIN 25 MG CAPSULE RX-42162 CDM 6370000100 HCPCS 250 RC 00071-1012-68 NDC inpatient 1 UN 38.52 38.52 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES EPO [308136803] 30.5 percent of total billed charges 23.88 36.59 Technical (Hospital) Services PREGABALIN 25 MG CAPSULE RX-42162 CDM 6370000100 HCPCS 250 RC 00071-1012-68 NDC inpatient 1 UN 38.52 38.52 CIGNA 62308 [3081051] CIGNA 62308 [308105105] 30.5 percent of total billed charges 23.88 36.59 Technical (Hospital) Services PREGABALIN 25 MG CAPSULE RX-42162 CDM 6370000100 HCPCS 250 RC 00071-1012-68 NDC inpatient 1 UN 38.52 38.52 CIGNA 62308 [3081051] CIGNA STATE OF WYOMING [308105107] 30.5 percent of total billed charges 23.88 36.59 Technical (Hospital) Services PREGABALIN 25 MG CAPSULE RX-42162 CDM 6370000100 HCPCS 250 RC 00071-1012-68 NDC inpatient 1 UN 38.52 38.52 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES HDHP [308136802] 30.5 percent of total billed charges 23.88 36.59 Technical (Hospital) Services PREGABALIN 50 MG CAPSULE RX-42163 CDM 6370000100 HCPCS 250 RC 00071-1013-68 NDC inpatient 1 UN 38.52 38.52 HEALTHPARTNERS SX009 HEALTHPARTNERS 30.5 percent of total billed charges 23.88 36.59 Technical (Hospital) Services PREGABALIN 50 MG CAPSULE RX-42163 CDM 6370000100 HCPCS 250 RC 00071-1013-68 NDC inpatient 1 UN 38.52 38.52 MEDICA (COMMERCIAL) 94265 [3081118] MEDICA CLAIMS [308111801] 34.67 percent of total billed charges 23.88 36.59 Technical (Hospital) Services PREGABALIN 50 MG CAPSULE RX-42163 CDM 6370000100 HCPCS 250 RC 00071-1013-68 NDC inpatient 1 UN 38.52 38.52 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES PPO [308136801] 30.5 percent of total billed charges 23.88 36.59 Technical (Hospital) Services PREGABALIN 50 MG CAPSULE RX-42163 CDM 6370000100 HCPCS 250 RC 00071-1013-68 NDC inpatient 1 UN 38.52 38.52 MULTIPLAN INC 34080 [3081285] MULTIPLAN INC [308128501] 36.59 percent of total billed charges 23.88 36.59 Technical (Hospital) Services PREGABALIN 50 MG CAPSULE RX-42163 CDM 6370000100 HCPCS 250 RC 00071-1013-68 NDC inpatient 1 UN 38.52 38.52 BLUE CROSS BLUE SHIELD WELLMARK SB889 [3081026] BCBS WYOMING [308102603] 36.59 percent of total billed charges 23.88 36.59 Technical (Hospital) Services PREGABALIN 50 MG CAPSULE RX-42163 CDM 6370000100 HCPCS 250 RC 00071-1013-68 NDC inpatient 1 UN 38.52 38.52 UNITED HEALTHCARE (COMMERCIAL) [3081199] UNITED HEALTHCARE 87726 [308119901] 23.88 percent of total billed charges 23.88 36.59 Technical (Hospital) Services PREGABALIN 50 MG CAPSULE RX-42163 CDM 6370000100 HCPCS 250 RC 00071-1013-68 NDC inpatient 1 UN 38.52 38.52 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES EPO [308136803] 30.5 percent of total billed charges 23.88 36.59 Technical (Hospital) Services PREGABALIN 50 MG CAPSULE RX-42163 CDM 6370000100 HCPCS 250 RC 00071-1013-68 NDC inpatient 1 UN 38.52 38.52 CIGNA 62308 [3081051] CIGNA 62308 [308105105] 30.5 percent of total billed charges 23.88 36.59 Technical (Hospital) Services PREGABALIN 50 MG CAPSULE RX-42163 CDM 6370000100 HCPCS 250 RC 00071-1013-68 NDC inpatient 1 UN 38.52 38.52 CIGNA 62308 [3081051] CIGNA STATE OF WYOMING [308105107] 30.5 percent of total billed charges 23.88 36.59 Technical (Hospital) Services PREGABALIN 50 MG CAPSULE RX-42163 CDM 6370000100 HCPCS 250 RC 00071-1013-68 NDC inpatient 1 UN 38.52 38.52 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES HDHP [308136802] 30.5 percent of total billed charges 23.88 36.59 Technical (Hospital) Services PREGABALIN 50 MG CAPSULE RX-42163 CDM 6370000100 HCPCS 250 RC 00071-1013-68 NDC outpatient 1 UN 38.52 38.52 CIGNA 62308 [3081051] CIGNA 62308 [308105105] 30.82 percent of total billed charges 23.88 36.59 Technical (Hospital) Services PREGABALIN 50 MG CAPSULE RX-42163 CDM 6370000100 HCPCS 250 RC 00071-1013-68 NDC outpatient 1 UN 38.52 38.52 CIGNA 62308 [3081051] CIGNA STATE OF WYOMING [308105107] 30.82 percent of total billed charges 23.88 36.59 Technical (Hospital) Services PREGABALIN 50 MG CAPSULE RX-42163 CDM 6370000100 HCPCS 250 RC 00071-1013-68 NDC outpatient 1 UN 38.52 38.52 MEDICA (COMMERCIAL) 94265 [3081118] MEDICA CLAIMS [308111801] 34.67 percent of total billed charges 23.88 36.59 Technical (Hospital) Services PREGABALIN 50 MG CAPSULE RX-42163 CDM 6370000100 HCPCS 250 RC 00071-1013-68 NDC outpatient 1 UN 38.52 38.52 MULTIPLAN INC 34080 [3081285] MULTIPLAN INC [308128501] 36.59 percent of total billed charges 23.88 36.59 Technical (Hospital) Services PREGABALIN 50 MG CAPSULE RX-42163 CDM 6370000100 HCPCS 250 RC 00071-1013-68 NDC outpatient 1 UN 38.52 38.52 HEALTHPARTNERS SX009 HEALTHPARTNERS 30.82 percent of total billed charges 23.88 36.59 Technical (Hospital) Services PREGABALIN 50 MG CAPSULE RX-42163 CDM 6370000100 HCPCS 250 RC 00071-1013-68 NDC outpatient 1 UN 38.52 38.52 UNITED HEALTHCARE (COMMERCIAL) [3081199] UNITED HEALTHCARE 87726 [308119901] 23.88 percent of total billed charges 23.88 36.59 Technical (Hospital) Services PREGABALIN 50 MG CAPSULE RX-42163 CDM 6370000100 HCPCS 250 RC 00071-1013-68 NDC outpatient 1 UN 38.52 38.52 BLUE CROSS BLUE SHIELD WELLMARK SB889 [3081026] BCBS WYOMING [308102603] 36.59 percent of total billed charges 23.88 36.59 Technical (Hospital) Services PREGABALIN 50 MG CAPSULE RX-42163 CDM 6370000100 HCPCS 250 RC 00071-1013-68 NDC outpatient 1 UN 38.52 38.52 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES PPO [308136801] 30.82 percent of total billed charges 23.88 36.59 Technical (Hospital) Services PREGABALIN 50 MG CAPSULE RX-42163 CDM 6370000100 HCPCS 250 RC 00071-1013-68 NDC outpatient 1 UN 38.52 38.52 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES EPO [308136803] 30.82 percent of total billed charges 23.88 36.59 Technical (Hospital) Services PREGABALIN 50 MG CAPSULE RX-42163 CDM 6370000100 HCPCS 250 RC 00071-1013-68 NDC outpatient 1 UN 38.52 38.52 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES HDHP [308136802] 30.82 percent of total billed charges 23.88 36.59 Technical (Hospital) Services PREGABALIN 75 MG CAPSULE RX-42164 CDM 6370000100 HCPCS 250 RC 00071-1014-68 NDC outpatient 1 UN 38.52 38.52 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES EPO [308136803] 30.82 percent of total billed charges 23.88 36.59 Technical (Hospital) Services PREGABALIN 75 MG CAPSULE RX-42164 CDM 6370000100 HCPCS 250 RC 00071-1014-68 NDC outpatient 1 UN 38.52 38.52 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES HDHP [308136802] 30.82 percent of total billed charges 23.88 36.59 Technical (Hospital) Services PREGABALIN 75 MG CAPSULE RX-42164 CDM 6370000100 HCPCS 250 RC 00071-1014-68 NDC outpatient 1 UN 38.52 38.52 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES PPO [308136801] 30.82 percent of total billed charges 23.88 36.59 Technical (Hospital) Services PREGABALIN 75 MG CAPSULE RX-42164 CDM 6370000100 HCPCS 250 RC 00071-1014-68 NDC outpatient 1 UN 38.52 38.52 UNITED HEALTHCARE (COMMERCIAL) [3081199] UNITED HEALTHCARE 87726 [308119901] 23.88 percent of total billed charges 23.88 36.59 Technical (Hospital) Services PREGABALIN 75 MG CAPSULE RX-42164 CDM 6370000100 HCPCS 250 RC 00071-1014-68 NDC outpatient 1 UN 38.52 38.52 HEALTHPARTNERS SX009 HEALTHPARTNERS 30.82 percent of total billed charges 23.88 36.59 Technical (Hospital) Services PREGABALIN 75 MG CAPSULE RX-42164 CDM 6370000100 HCPCS 250 RC 00071-1014-68 NDC outpatient 1 UN 38.52 38.52 CIGNA 62308 [3081051] CIGNA 62308 [308105105] 30.82 percent of total billed charges 23.88 36.59 Technical (Hospital) Services PREGABALIN 75 MG CAPSULE RX-42164 CDM 6370000100 HCPCS 250 RC 00071-1014-68 NDC outpatient 1 UN 38.52 38.52 CIGNA 62308 [3081051] CIGNA STATE OF WYOMING [308105107] 30.82 percent of total billed charges 23.88 36.59 Technical (Hospital) Services PREGABALIN 75 MG CAPSULE RX-42164 CDM 6370000100 HCPCS 250 RC 00071-1014-68 NDC outpatient 1 UN 38.52 38.52 MULTIPLAN INC 34080 [3081285] MULTIPLAN INC [308128501] 36.59 percent of total billed charges 23.88 36.59 Technical (Hospital) Services PREGABALIN 75 MG CAPSULE RX-42164 CDM 6370000100 HCPCS 250 RC 00071-1014-68 NDC outpatient 1 UN 38.52 38.52 MEDICA (COMMERCIAL) 94265 [3081118] MEDICA CLAIMS [308111801] 34.67 percent of total billed charges 23.88 36.59 Technical (Hospital) Services PREGABALIN 75 MG CAPSULE RX-42164 CDM 6370000100 HCPCS 250 RC 00071-1014-68 NDC outpatient 1 UN 38.52 38.52 BLUE CROSS BLUE SHIELD WELLMARK SB889 [3081026] BCBS WYOMING [308102603] 36.59 percent of total billed charges 23.88 36.59 Technical (Hospital) Services PREGABALIN 75 MG CAPSULE RX-42164 CDM 6370000100 HCPCS 250 RC 00071-1014-68 NDC inpatient 1 UN 38.52 38.52 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES PPO [308136801] 30.5 percent of total billed charges 23.88 36.59 Technical (Hospital) Services PREGABALIN 75 MG CAPSULE RX-42164 CDM 6370000100 HCPCS 250 RC 00071-1014-68 NDC inpatient 1 UN 38.52 38.52 MEDICA (COMMERCIAL) 94265 [3081118] MEDICA CLAIMS [308111801] 34.67 percent of total billed charges 23.88 36.59 Technical (Hospital) Services PREGABALIN 75 MG CAPSULE RX-42164 CDM 6370000100 HCPCS 250 RC 00071-1014-68 NDC inpatient 1 UN 38.52 38.52 HEALTHPARTNERS SX009 HEALTHPARTNERS 30.5 percent of total billed charges 23.88 36.59 Technical (Hospital) Services PREGABALIN 75 MG CAPSULE RX-42164 CDM 6370000100 HCPCS 250 RC 00071-1014-68 NDC inpatient 1 UN 38.52 38.52 MULTIPLAN INC 34080 [3081285] MULTIPLAN INC [308128501] 36.59 percent of total billed charges 23.88 36.59 Technical (Hospital) Services PREGABALIN 75 MG CAPSULE RX-42164 CDM 6370000100 HCPCS 250 RC 00071-1014-68 NDC inpatient 1 UN 38.52 38.52 BLUE CROSS BLUE SHIELD WELLMARK SB889 [3081026] BCBS WYOMING [308102603] 36.59 percent of total billed charges 23.88 36.59 Technical (Hospital) Services PREGABALIN 75 MG CAPSULE RX-42164 CDM 6370000100 HCPCS 250 RC 00071-1014-68 NDC inpatient 1 UN 38.52 38.52 CIGNA 62308 [3081051] CIGNA 62308 [308105105] 30.5 percent of total billed charges 23.88 36.59 Technical (Hospital) Services PREGABALIN 75 MG CAPSULE RX-42164 CDM 6370000100 HCPCS 250 RC 00071-1014-68 NDC inpatient 1 UN 38.52 38.52 CIGNA 62308 [3081051] CIGNA STATE OF WYOMING [308105107] 30.5 percent of total billed charges 23.88 36.59 Technical (Hospital) Services PREGABALIN 75 MG CAPSULE RX-42164 CDM 6370000100 HCPCS 250 RC 00071-1014-68 NDC inpatient 1 UN 38.52 38.52 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES EPO [308136803] 30.5 percent of total billed charges 23.88 36.59 Technical (Hospital) Services PREGABALIN 75 MG CAPSULE RX-42164 CDM 6370000100 HCPCS 250 RC 00071-1014-68 NDC inpatient 1 UN 38.52 38.52 UNITED HEALTHCARE (COMMERCIAL) [3081199] UNITED HEALTHCARE 87726 [308119901] 23.88 percent of total billed charges 23.88 36.59 Technical (Hospital) Services PREGABALIN 75 MG CAPSULE RX-42164 CDM 6370000100 HCPCS 250 RC 00071-1014-68 NDC inpatient 1 UN 38.52 38.52 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES HDHP [308136802] 30.5 percent of total billed charges 23.88 36.59 Technical (Hospital) Services PREGABALIN 100 MG CAPSULE RX-42165 CDM 6370000100 HCPCS 250 RC 00071-1015-68 NDC outpatient 1 UN 38.52 38.52 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES EPO [308136803] 30.82 percent of total billed charges 23.88 36.59 Technical (Hospital) Services PREGABALIN 100 MG CAPSULE RX-42165 CDM 6370000100 HCPCS 250 RC 00071-1015-68 NDC outpatient 1 UN 38.52 38.52 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES HDHP [308136802] 30.82 percent of total billed charges 23.88 36.59 Technical (Hospital) Services PREGABALIN 100 MG CAPSULE RX-42165 CDM 6370000100 HCPCS 250 RC 00071-1015-68 NDC outpatient 1 UN 38.52 38.52 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES PPO [308136801] 30.82 percent of total billed charges 23.88 36.59 Technical (Hospital) Services PREGABALIN 100 MG CAPSULE RX-42165 CDM 6370000100 HCPCS 250 RC 00071-1015-68 NDC outpatient 1 UN 38.52 38.52 UNITED HEALTHCARE (COMMERCIAL) [3081199] UNITED HEALTHCARE 87726 [308119901] 23.88 percent of total billed charges 23.88 36.59 Technical (Hospital) Services PREGABALIN 100 MG CAPSULE RX-42165 CDM 6370000100 HCPCS 250 RC 00071-1015-68 NDC outpatient 1 UN 38.52 38.52 MULTIPLAN INC 34080 [3081285] MULTIPLAN INC [308128501] 36.59 percent of total billed charges 23.88 36.59 Technical (Hospital) Services PREGABALIN 100 MG CAPSULE RX-42165 CDM 6370000100 HCPCS 250 RC 00071-1015-68 NDC outpatient 1 UN 38.52 38.52 CIGNA 62308 [3081051] CIGNA 62308 [308105105] 30.82 percent of total billed charges 23.88 36.59 Technical (Hospital) Services PREGABALIN 100 MG CAPSULE RX-42165 CDM 6370000100 HCPCS 250 RC 00071-1015-68 NDC outpatient 1 UN 38.52 38.52 CIGNA 62308 [3081051] CIGNA STATE OF WYOMING [308105107] 30.82 percent of total billed charges 23.88 36.59 Technical (Hospital) Services PREGABALIN 100 MG CAPSULE RX-42165 CDM 6370000100 HCPCS 250 RC 00071-1015-68 NDC inpatient 1 UN 38.52 38.52 CIGNA 62308 [3081051] CIGNA 62308 [308105105] 30.5 percent of total billed charges 23.88 36.59 Technical (Hospital) Services PREGABALIN 100 MG CAPSULE RX-42165 CDM 6370000100 HCPCS 250 RC 00071-1015-68 NDC inpatient 1 UN 38.52 38.52 CIGNA 62308 [3081051] CIGNA STATE OF WYOMING [308105107] 30.5 percent of total billed charges 23.88 36.59 Technical (Hospital) Services PREGABALIN 100 MG CAPSULE RX-42165 CDM 6370000100 HCPCS 250 RC 00071-1015-68 NDC inpatient 1 UN 38.52 38.52 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES EPO [308136803] 30.5 percent of total billed charges 23.88 36.59 Technical (Hospital) Services PREGABALIN 100 MG CAPSULE RX-42165 CDM 6370000100 HCPCS 250 RC 00071-1015-68 NDC inpatient 1 UN 38.52 38.52 UNITED HEALTHCARE (COMMERCIAL) [3081199] UNITED HEALTHCARE 87726 [308119901] 23.88 percent of total billed charges 23.88 36.59 Technical (Hospital) Services PREGABALIN 100 MG CAPSULE RX-42165 CDM 6370000100 HCPCS 250 RC 00071-1015-68 NDC inpatient 1 UN 38.52 38.52 HEALTHPARTNERS SX009 HEALTHPARTNERS 30.5 percent of total billed charges 23.88 36.59 Technical (Hospital) Services PREGABALIN 100 MG CAPSULE RX-42165 CDM 6370000100 HCPCS 250 RC 00071-1015-68 NDC inpatient 1 UN 38.52 38.52 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES HDHP [308136802] 30.5 percent of total billed charges 23.88 36.59 Technical (Hospital) Services PREGABALIN 100 MG CAPSULE RX-42165 CDM 6370000100 HCPCS 250 RC 00071-1015-68 NDC outpatient 1 UN 38.52 38.52 MEDICA (COMMERCIAL) 94265 [3081118] MEDICA CLAIMS [308111801] 34.67 percent of total billed charges 23.88 36.59 Technical (Hospital) Services PREGABALIN 100 MG CAPSULE RX-42165 CDM 6370000100 HCPCS 250 RC 00071-1015-68 NDC outpatient 1 UN 38.52 38.52 HEALTHPARTNERS SX009 HEALTHPARTNERS 30.82 percent of total billed charges 23.88 36.59 Technical (Hospital) Services PREGABALIN 100 MG CAPSULE RX-42165 CDM 6370000100 HCPCS 250 RC 00071-1015-68 NDC outpatient 1 UN 38.52 38.52 BLUE CROSS BLUE SHIELD WELLMARK SB889 [3081026] BCBS WYOMING [308102603] 36.59 percent of total billed charges 23.88 36.59 Technical (Hospital) Services PREGABALIN 100 MG CAPSULE RX-42165 CDM 6370000100 HCPCS 250 RC 00071-1015-68 NDC inpatient 1 UN 38.52 38.52 BLUE CROSS BLUE SHIELD WELLMARK SB889 [3081026] BCBS WYOMING [308102603] 36.59 percent of total billed charges 23.88 36.59 Technical (Hospital) Services PREGABALIN 100 MG CAPSULE RX-42165 CDM 6370000100 HCPCS 250 RC 00071-1015-68 NDC inpatient 1 UN 38.52 38.52 MEDICA (COMMERCIAL) 94265 [3081118] MEDICA CLAIMS [308111801] 34.67 percent of total billed charges 23.88 36.59 Technical (Hospital) Services PREGABALIN 100 MG CAPSULE RX-42165 CDM 6370000100 HCPCS 250 RC 00071-1015-68 NDC inpatient 1 UN 38.52 38.52 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES PPO [308136801] 30.5 percent of total billed charges 23.88 36.59 Technical (Hospital) Services PREGABALIN 100 MG CAPSULE RX-42165 CDM 6370000100 HCPCS 250 RC 00071-1015-68 NDC inpatient 1 UN 38.52 38.52 MULTIPLAN INC 34080 [3081285] MULTIPLAN INC [308128501] 36.59 percent of total billed charges 23.88 36.59 Technical (Hospital) Services PREGABALIN 300 MG CAPSULE RX-42169 CDM 6370000100 HCPCS 250 RC 67877-0469-90 NDC outpatient 1 UN 5.79 5.79 CIGNA 62308 [3081051] CIGNA 62308 [308105105] 4.63 percent of total billed charges 3.59 5.5 Technical (Hospital) Services PREGABALIN 300 MG CAPSULE RX-42169 CDM 6370000100 HCPCS 250 RC 67877-0469-90 NDC outpatient 1 UN 5.79 5.79 CIGNA 62308 [3081051] CIGNA STATE OF WYOMING [308105107] 4.63 percent of total billed charges 3.59 5.5 Technical (Hospital) Services PREGABALIN 300 MG CAPSULE RX-42169 CDM 6370000100 HCPCS 250 RC 67877-0469-90 NDC outpatient 1 UN 5.79 5.79 MULTIPLAN INC 34080 [3081285] MULTIPLAN INC [308128501] 5.5 percent of total billed charges 3.59 5.5 Technical (Hospital) Services PREGABALIN 300 MG CAPSULE RX-42169 CDM 6370000100 HCPCS 250 RC 67877-0469-90 NDC outpatient 1 UN 5.79 5.79 MEDICA (COMMERCIAL) 94265 [3081118] MEDICA CLAIMS [308111801] 5.21 percent of total billed charges 3.59 5.5 Technical (Hospital) Services PREGABALIN 300 MG CAPSULE RX-42169 CDM 6370000100 HCPCS 250 RC 67877-0469-90 NDC outpatient 1 UN 5.79 5.79 UNITED HEALTHCARE (COMMERCIAL) [3081199] UNITED HEALTHCARE 87726 [308119901] 3.59 percent of total billed charges 3.59 5.5 Technical (Hospital) Services PREGABALIN 300 MG CAPSULE RX-42169 CDM 6370000100 HCPCS 250 RC 67877-0469-90 NDC outpatient 1 UN 5.79 5.79 BLUE CROSS BLUE SHIELD WELLMARK SB889 [3081026] BCBS WYOMING [308102603] 5.5 percent of total billed charges 3.59 5.5 Technical (Hospital) Services PREGABALIN 300 MG CAPSULE RX-42169 CDM 6370000100 HCPCS 250 RC 67877-0469-90 NDC outpatient 1 UN 5.79 5.79 HEALTHPARTNERS SX009 HEALTHPARTNERS 4.63 percent of total billed charges 3.59 5.5 Technical (Hospital) Services PREGABALIN 300 MG CAPSULE RX-42169 CDM 6370000100 HCPCS 250 RC 67877-0469-90 NDC outpatient 1 UN 5.79 5.79 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES EPO [308136803] 4.63 percent of total billed charges 3.59 5.5 Technical (Hospital) Services PREGABALIN 300 MG CAPSULE RX-42169 CDM 6370000100 HCPCS 250 RC 67877-0469-90 NDC outpatient 1 UN 5.79 5.79 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES HDHP [308136802] 4.63 percent of total billed charges 3.59 5.5 Technical (Hospital) Services PREGABALIN 300 MG CAPSULE RX-42169 CDM 6370000100 HCPCS 250 RC 67877-0469-90 NDC outpatient 1 UN 5.79 5.79 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES PPO [308136801] 4.63 percent of total billed charges 3.59 5.5 Technical (Hospital) Services PREGABALIN 300 MG CAPSULE RX-42169 CDM 6370000100 HCPCS 250 RC 67877-0469-90 NDC inpatient 1 UN 5.79 5.79 MEDICA (COMMERCIAL) 94265 [3081118] MEDICA CLAIMS [308111801] 5.21 percent of total billed charges 3.59 5.5 Technical (Hospital) Services PREGABALIN 300 MG CAPSULE RX-42169 CDM 6370000100 HCPCS 250 RC 67877-0469-90 NDC inpatient 1 UN 5.79 5.79 HEALTHPARTNERS SX009 HEALTHPARTNERS 4.58 percent of total billed charges 3.59 5.5 Technical (Hospital) Services PREGABALIN 300 MG CAPSULE RX-42169 CDM 6370000100 HCPCS 250 RC 67877-0469-90 NDC inpatient 1 UN 5.79 5.79 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES PPO [308136801] 4.58 percent of total billed charges 3.59 5.5 Technical (Hospital) Services PREGABALIN 300 MG CAPSULE RX-42169 CDM 6370000100 HCPCS 250 RC 67877-0469-90 NDC inpatient 1 UN 5.79 5.79 MULTIPLAN INC 34080 [3081285] MULTIPLAN INC [308128501] 5.5 percent of total billed charges 3.59 5.5 Technical (Hospital) Services PREGABALIN 300 MG CAPSULE RX-42169 CDM 6370000100 HCPCS 250 RC 67877-0469-90 NDC inpatient 1 UN 5.79 5.79 BLUE CROSS BLUE SHIELD WELLMARK SB889 [3081026] BCBS WYOMING [308102603] 5.5 percent of total billed charges 3.59 5.5 Technical (Hospital) Services PREGABALIN 300 MG CAPSULE RX-42169 CDM 6370000100 HCPCS 250 RC 67877-0469-90 NDC inpatient 1 UN 5.79 5.79 UNITED HEALTHCARE (COMMERCIAL) [3081199] UNITED HEALTHCARE 87726 [308119901] 3.59 percent of total billed charges 3.59 5.5 Technical (Hospital) Services PREGABALIN 300 MG CAPSULE RX-42169 CDM 6370000100 HCPCS 250 RC 67877-0469-90 NDC inpatient 1 UN 5.79 5.79 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES HDHP [308136802] 4.58 percent of total billed charges 3.59 5.5 Technical (Hospital) Services PREGABALIN 300 MG CAPSULE RX-42169 CDM 6370000100 HCPCS 250 RC 67877-0469-90 NDC inpatient 1 UN 5.79 5.79 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES EPO [308136803] 4.58 percent of total billed charges 3.59 5.5 Technical (Hospital) Services PREGABALIN 300 MG CAPSULE RX-42169 CDM 6370000100 HCPCS 250 RC 67877-0469-90 NDC inpatient 1 UN 5.79 5.79 CIGNA 62308 [3081051] CIGNA 62308 [308105105] 4.58 percent of total billed charges 3.59 5.5 Technical (Hospital) Services PREGABALIN 300 MG CAPSULE RX-42169 CDM 6370000100 HCPCS 250 RC 67877-0469-90 NDC inpatient 1 UN 5.79 5.79 CIGNA 62308 [3081051] CIGNA STATE OF WYOMING [308105107] 4.58 percent of total billed charges 3.59 5.5 Technical (Hospital) Services LOSARTAN 100 MG-HYDROCHLOROTHIAZIDE 12.5 MG TABLET RX-43230 CDM 6370000100 HCPCS 250 RC 13668-0117-90 NDC outpatient 1 UN 5.91 5.91 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES PPO [308136801] 4.73 percent of total billed charges 3.66 5.61 Technical (Hospital) Services LOSARTAN 100 MG-HYDROCHLOROTHIAZIDE 12.5 MG TABLET RX-43230 CDM 6370000100 HCPCS 250 RC 13668-0117-90 NDC outpatient 1 UN 5.91 5.91 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES HDHP [308136802] 4.73 percent of total billed charges 3.66 5.61 Technical (Hospital) Services LOSARTAN 100 MG-HYDROCHLOROTHIAZIDE 12.5 MG TABLET RX-43230 CDM 6370000100 HCPCS 250 RC 13668-0117-90 NDC outpatient 1 UN 5.91 5.91 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES EPO [308136803] 4.73 percent of total billed charges 3.66 5.61 Technical (Hospital) Services LOSARTAN 100 MG-HYDROCHLOROTHIAZIDE 12.5 MG TABLET RX-43230 CDM 6370000100 HCPCS 250 RC 13668-0117-90 NDC outpatient 1 UN 5.91 5.91 BLUE CROSS BLUE SHIELD WELLMARK SB889 [3081026] BCBS WYOMING [308102603] 5.61 percent of total billed charges 3.66 5.61 Technical (Hospital) Services LOSARTAN 100 MG-HYDROCHLOROTHIAZIDE 12.5 MG TABLET RX-43230 CDM 6370000100 HCPCS 250 RC 13668-0117-90 NDC outpatient 1 UN 5.91 5.91 HEALTHPARTNERS SX009 HEALTHPARTNERS 4.73 percent of total billed charges 3.66 5.61 Technical (Hospital) Services LOSARTAN 100 MG-HYDROCHLOROTHIAZIDE 12.5 MG TABLET RX-43230 CDM 6370000100 HCPCS 250 RC 13668-0117-90 NDC outpatient 1 UN 5.91 5.91 MEDICA (COMMERCIAL) 94265 [3081118] MEDICA CLAIMS [308111801] 5.32 percent of total billed charges 3.66 5.61 Technical (Hospital) Services LOSARTAN 100 MG-HYDROCHLOROTHIAZIDE 12.5 MG TABLET RX-43230 CDM 6370000100 HCPCS 250 RC 13668-0117-90 NDC outpatient 1 UN 5.91 5.91 CIGNA 62308 [3081051] CIGNA 62308 [308105105] 4.73 percent of total billed charges 3.66 5.61 Technical (Hospital) Services LOSARTAN 100 MG-HYDROCHLOROTHIAZIDE 12.5 MG TABLET RX-43230 CDM 6370000100 HCPCS 250 RC 13668-0117-90 NDC outpatient 1 UN 5.91 5.91 CIGNA 62308 [3081051] CIGNA STATE OF WYOMING [308105107] 4.73 percent of total billed charges 3.66 5.61 Technical (Hospital) Services LOSARTAN 100 MG-HYDROCHLOROTHIAZIDE 12.5 MG TABLET RX-43230 CDM 6370000100 HCPCS 250 RC 13668-0117-90 NDC outpatient 1 UN 5.91 5.91 MULTIPLAN INC 34080 [3081285] MULTIPLAN INC [308128501] 5.61 percent of total billed charges 3.66 5.61 Technical (Hospital) Services LOSARTAN 100 MG-HYDROCHLOROTHIAZIDE 12.5 MG TABLET RX-43230 CDM 6370000100 HCPCS 250 RC 13668-0117-90 NDC outpatient 1 UN 5.91 5.91 UNITED HEALTHCARE (COMMERCIAL) [3081199] UNITED HEALTHCARE 87726 [308119901] 3.66 percent of total billed charges 3.66 5.61 Technical (Hospital) Services LOSARTAN 100 MG-HYDROCHLOROTHIAZIDE 12.5 MG TABLET RX-43230 CDM 6370000100 HCPCS 250 RC 13668-0117-90 NDC inpatient 1 UN 5.91 5.91 BLUE CROSS BLUE SHIELD WELLMARK SB889 [3081026] BCBS WYOMING [308102603] 5.61 percent of total billed charges 3.66 5.61 Technical (Hospital) Services LOSARTAN 100 MG-HYDROCHLOROTHIAZIDE 12.5 MG TABLET RX-43230 CDM 6370000100 HCPCS 250 RC 13668-0117-90 NDC inpatient 1 UN 5.91 5.91 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES HDHP [308136802] 4.68 percent of total billed charges 3.66 5.61 Technical (Hospital) Services LOSARTAN 100 MG-HYDROCHLOROTHIAZIDE 12.5 MG TABLET RX-43230 CDM 6370000100 HCPCS 250 RC 13668-0117-90 NDC inpatient 1 UN 5.91 5.91 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES EPO [308136803] 4.68 percent of total billed charges 3.66 5.61 Technical (Hospital) Services LOSARTAN 100 MG-HYDROCHLOROTHIAZIDE 12.5 MG TABLET RX-43230 CDM 6370000100 HCPCS 250 RC 13668-0117-90 NDC inpatient 1 UN 5.91 5.91 CIGNA 62308 [3081051] CIGNA 62308 [308105105] 4.68 percent of total billed charges 3.66 5.61 Technical (Hospital) Services LOSARTAN 100 MG-HYDROCHLOROTHIAZIDE 12.5 MG TABLET RX-43230 CDM 6370000100 HCPCS 250 RC 13668-0117-90 NDC inpatient 1 UN 5.91 5.91 CIGNA 62308 [3081051] CIGNA STATE OF WYOMING [308105107] 4.68 percent of total billed charges 3.66 5.61 Technical (Hospital) Services LOSARTAN 100 MG-HYDROCHLOROTHIAZIDE 12.5 MG TABLET RX-43230 CDM 6370000100 HCPCS 250 RC 13668-0117-90 NDC inpatient 1 UN 5.91 5.91 UNITED HEALTHCARE (COMMERCIAL) [3081199] UNITED HEALTHCARE 87726 [308119901] 3.66 percent of total billed charges 3.66 5.61 Technical (Hospital) Services LOSARTAN 100 MG-HYDROCHLOROTHIAZIDE 12.5 MG TABLET RX-43230 CDM 6370000100 HCPCS 250 RC 13668-0117-90 NDC inpatient 1 UN 5.91 5.91 HEALTHPARTNERS SX009 HEALTHPARTNERS 4.68 percent of total billed charges 3.66 5.61 Technical (Hospital) Services LOSARTAN 100 MG-HYDROCHLOROTHIAZIDE 12.5 MG TABLET RX-43230 CDM 6370000100 HCPCS 250 RC 13668-0117-90 NDC inpatient 1 UN 5.91 5.91 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES PPO [308136801] 4.68 percent of total billed charges 3.66 5.61 Technical (Hospital) Services LOSARTAN 100 MG-HYDROCHLOROTHIAZIDE 12.5 MG TABLET RX-43230 CDM 6370000100 HCPCS 250 RC 13668-0117-90 NDC inpatient 1 UN 5.91 5.91 MEDICA (COMMERCIAL) 94265 [3081118] MEDICA CLAIMS [308111801] 5.32 percent of total billed charges 3.66 5.61 Technical (Hospital) Services LOSARTAN 100 MG-HYDROCHLOROTHIAZIDE 12.5 MG TABLET RX-43230 CDM 6370000100 HCPCS 250 RC 13668-0117-90 NDC inpatient 1 UN 5.91 5.91 MULTIPLAN INC 34080 [3081285] MULTIPLAN INC [308128501] 5.61 percent of total billed charges 3.66 5.61 Technical (Hospital) Services LEUCOVORIN CALCIUM 5 MG TABLET RX-4398 CDM 6370000100 HCPCS 250 RC 00054-4496-13 NDC inpatient 1 UN 6.74 6.74 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES EPO [308136803] 5.34 percent of total billed charges 4.18 6.4 Technical (Hospital) Services LEUCOVORIN CALCIUM 5 MG TABLET RX-4398 CDM 6370000100 HCPCS 250 RC 00054-4496-13 NDC inpatient 1 UN 6.74 6.74 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES HDHP [308136802] 5.34 percent of total billed charges 4.18 6.4 Technical (Hospital) Services LEUCOVORIN CALCIUM 5 MG TABLET RX-4398 CDM 6370000100 HCPCS 250 RC 00054-4496-13 NDC inpatient 1 UN 6.74 6.74 BLUE CROSS BLUE SHIELD WELLMARK SB889 [3081026] BCBS WYOMING [308102603] 6.4 percent of total billed charges 4.18 6.4 Technical (Hospital) Services LEUCOVORIN CALCIUM 5 MG TABLET RX-4398 CDM 6370000100 HCPCS 250 RC 00054-4496-13 NDC inpatient 1 UN 6.74 6.74 CIGNA 62308 [3081051] CIGNA 62308 [308105105] 5.34 percent of total billed charges 4.18 6.4 Technical (Hospital) Services LEUCOVORIN CALCIUM 5 MG TABLET RX-4398 CDM 6370000100 HCPCS 250 RC 00054-4496-13 NDC inpatient 1 UN 6.74 6.74 CIGNA 62308 [3081051] CIGNA STATE OF WYOMING [308105107] 5.34 percent of total billed charges 4.18 6.4 Technical (Hospital) Services LEUCOVORIN CALCIUM 5 MG TABLET RX-4398 CDM 6370000100 HCPCS 250 RC 00054-4496-13 NDC inpatient 1 UN 6.74 6.74 UNITED HEALTHCARE (COMMERCIAL) [3081199] UNITED HEALTHCARE 87726 [308119901] 4.18 percent of total billed charges 4.18 6.4 Technical (Hospital) Services LEUCOVORIN CALCIUM 5 MG TABLET RX-4398 CDM 6370000100 HCPCS 250 RC 00054-4496-13 NDC inpatient 1 UN 6.74 6.74 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES PPO [308136801] 5.34 percent of total billed charges 4.18 6.4 Technical (Hospital) Services LEUCOVORIN CALCIUM 5 MG TABLET RX-4398 CDM 6370000100 HCPCS 250 RC 00054-4496-13 NDC inpatient 1 UN 6.74 6.74 MEDICA (COMMERCIAL) 94265 [3081118] MEDICA CLAIMS [308111801] 6.07 percent of total billed charges 4.18 6.4 Technical (Hospital) Services LEUCOVORIN CALCIUM 5 MG TABLET RX-4398 CDM 6370000100 HCPCS 250 RC 00054-4496-13 NDC inpatient 1 UN 6.74 6.74 HEALTHPARTNERS SX009 HEALTHPARTNERS 5.34 percent of total billed charges 4.18 6.4 Technical (Hospital) Services LEUCOVORIN CALCIUM 5 MG TABLET RX-4398 CDM 6370000100 HCPCS 250 RC 00054-4496-13 NDC inpatient 1 UN 6.74 6.74 MULTIPLAN INC 34080 [3081285] MULTIPLAN INC [308128501] 6.4 percent of total billed charges 4.18 6.4 Technical (Hospital) Services LEUCOVORIN CALCIUM 5 MG TABLET RX-4398 CDM 6370000100 HCPCS 250 RC 00054-4496-13 NDC outpatient 1 UN 6.74 6.74 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES HDHP [308136802] 5.39 percent of total billed charges 4.18 6.4 Technical (Hospital) Services LEUCOVORIN CALCIUM 5 MG TABLET RX-4398 CDM 6370000100 HCPCS 250 RC 00054-4496-13 NDC outpatient 1 UN 6.74 6.74 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES EPO [308136803] 5.39 percent of total billed charges 4.18 6.4 Technical (Hospital) Services LEUCOVORIN CALCIUM 5 MG TABLET RX-4398 CDM 6370000100 HCPCS 250 RC 00054-4496-13 NDC outpatient 1 UN 6.74 6.74 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES PPO [308136801] 5.39 percent of total billed charges 4.18 6.4 Technical (Hospital) Services LEUCOVORIN CALCIUM 5 MG TABLET RX-4398 CDM 6370000100 HCPCS 250 RC 00054-4496-13 NDC outpatient 1 UN 6.74 6.74 MULTIPLAN INC 34080 [3081285] MULTIPLAN INC [308128501] 6.4 percent of total billed charges 4.18 6.4 Technical (Hospital) Services LEUCOVORIN CALCIUM 5 MG TABLET RX-4398 CDM 6370000100 HCPCS 250 RC 00054-4496-13 NDC outpatient 1 UN 6.74 6.74 MEDICA (COMMERCIAL) 94265 [3081118] MEDICA CLAIMS [308111801] 6.07 percent of total billed charges 4.18 6.4 Technical (Hospital) Services LEUCOVORIN CALCIUM 5 MG TABLET RX-4398 CDM 6370000100 HCPCS 250 RC 00054-4496-13 NDC outpatient 1 UN 6.74 6.74 CIGNA 62308 [3081051] CIGNA 62308 [308105105] 5.39 percent of total billed charges 4.18 6.4 Technical (Hospital) Services LEUCOVORIN CALCIUM 5 MG TABLET RX-4398 CDM 6370000100 HCPCS 250 RC 00054-4496-13 NDC outpatient 1 UN 6.74 6.74 CIGNA 62308 [3081051] CIGNA STATE OF WYOMING [308105107] 5.39 percent of total billed charges 4.18 6.4 Technical (Hospital) Services LEUCOVORIN CALCIUM 5 MG TABLET RX-4398 CDM 6370000100 HCPCS 250 RC 00054-4496-13 NDC outpatient 1 UN 6.74 6.74 HEALTHPARTNERS SX009 HEALTHPARTNERS 5.39 percent of total billed charges 4.18 6.4 Technical (Hospital) Services LEUCOVORIN CALCIUM 5 MG TABLET RX-4398 CDM 6370000100 HCPCS 250 RC 00054-4496-13 NDC outpatient 1 UN 6.74 6.74 UNITED HEALTHCARE (COMMERCIAL) [3081199] UNITED HEALTHCARE 87726 [308119901] 4.18 percent of total billed charges 4.18 6.4 Technical (Hospital) Services LEUCOVORIN CALCIUM 5 MG TABLET RX-4398 CDM 6370000100 HCPCS 250 RC 00054-4496-13 NDC outpatient 1 UN 6.74 6.74 BLUE CROSS BLUE SHIELD WELLMARK SB889 [3081026] BCBS WYOMING [308102603] 6.4 percent of total billed charges 4.18 6.4 Technical (Hospital) Services LEVOTHYROXINE 50 MCG TABLET RX-4421 CDM 6370000100 HCPCS 250 RC 00378-1803-77 NDC inpatient 1 UN 5.99 5.99 MULTIPLAN INC 34080 [3081285] MULTIPLAN INC [308128501] 5.69 percent of total billed charges 3.71 5.69 Technical (Hospital) Services LEVOTHYROXINE 50 MCG TABLET RX-4421 CDM 6370000100 HCPCS 250 RC 00378-1803-77 NDC inpatient 1 UN 5.99 5.99 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES PPO [308136801] 4.74 percent of total billed charges 3.71 5.69 Technical (Hospital) Services LEVOTHYROXINE 50 MCG TABLET RX-4421 CDM 6370000100 HCPCS 250 RC 00378-1803-77 NDC inpatient 1 UN 5.99 5.99 MEDICA (COMMERCIAL) 94265 [3081118] MEDICA CLAIMS [308111801] 5.39 percent of total billed charges 3.71 5.69 Technical (Hospital) Services LEVOTHYROXINE 50 MCG TABLET RX-4421 CDM 6370000100 HCPCS 250 RC 00378-1803-77 NDC inpatient 1 UN 5.99 5.99 HEALTHPARTNERS SX009 HEALTHPARTNERS 4.74 percent of total billed charges 3.71 5.69 Technical (Hospital) Services LEVOTHYROXINE 50 MCG TABLET RX-4421 CDM 6370000100 HCPCS 250 RC 00378-1803-77 NDC inpatient 1 UN 5.99 5.99 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES HDHP [308136802] 4.74 percent of total billed charges 3.71 5.69 Technical (Hospital) Services LEVOTHYROXINE 50 MCG TABLET RX-4421 CDM 6370000100 HCPCS 250 RC 00378-1803-77 NDC inpatient 1 UN 5.99 5.99 CIGNA 62308 [3081051] CIGNA 62308 [308105105] 4.74 percent of total billed charges 3.71 5.69 Technical (Hospital) Services LEVOTHYROXINE 50 MCG TABLET RX-4421 CDM 6370000100 HCPCS 250 RC 00378-1803-77 NDC inpatient 1 UN 5.99 5.99 CIGNA 62308 [3081051] CIGNA STATE OF WYOMING [308105107] 4.74 percent of total billed charges 3.71 5.69 Technical (Hospital) Services LEVOTHYROXINE 50 MCG TABLET RX-4421 CDM 6370000100 HCPCS 250 RC 00378-1803-77 NDC inpatient 1 UN 5.99 5.99 UNITED HEALTHCARE (COMMERCIAL) [3081199] UNITED HEALTHCARE 87726 [308119901] 3.71 percent of total billed charges 3.71 5.69 Technical (Hospital) Services LEVOTHYROXINE 50 MCG TABLET RX-4421 CDM 6370000100 HCPCS 250 RC 00378-1803-77 NDC inpatient 1 UN 5.99 5.99 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES EPO [308136803] 4.74 percent of total billed charges 3.71 5.69 Technical (Hospital) Services LEVOTHYROXINE 50 MCG TABLET RX-4421 CDM 6370000100 HCPCS 250 RC 00378-1803-77 NDC inpatient 1 UN 5.99 5.99 BLUE CROSS BLUE SHIELD WELLMARK SB889 [3081026] BCBS WYOMING [308102603] 5.69 percent of total billed charges 3.71 5.69 Technical (Hospital) Services LEVOTHYROXINE 50 MCG TABLET RX-4421 CDM 6370000100 HCPCS 250 RC 00378-1803-77 NDC outpatient 1 UN 5.99 5.99 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES EPO [308136803] 4.79 percent of total billed charges 3.71 5.69 Technical (Hospital) Services LEVOTHYROXINE 50 MCG TABLET RX-4421 CDM 6370000100 HCPCS 250 RC 00378-1803-77 NDC outpatient 1 UN 5.99 5.99 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES HDHP [308136802] 4.79 percent of total billed charges 3.71 5.69 Technical (Hospital) Services LEVOTHYROXINE 50 MCG TABLET RX-4421 CDM 6370000100 HCPCS 250 RC 00378-1803-77 NDC outpatient 1 UN 5.99 5.99 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES PPO [308136801] 4.79 percent of total billed charges 3.71 5.69 Technical (Hospital) Services LEVOTHYROXINE 50 MCG TABLET RX-4421 CDM 6370000100 HCPCS 250 RC 00378-1803-77 NDC outpatient 1 UN 5.99 5.99 BLUE CROSS BLUE SHIELD WELLMARK SB889 [3081026] BCBS WYOMING [308102603] 5.69 percent of total billed charges 3.71 5.69 Technical (Hospital) Services LEVOTHYROXINE 50 MCG TABLET RX-4421 CDM 6370000100 HCPCS 250 RC 00378-1803-77 NDC outpatient 1 UN 5.99 5.99 UNITED HEALTHCARE (COMMERCIAL) [3081199] UNITED HEALTHCARE 87726 [308119901] 3.71 percent of total billed charges 3.71 5.69 Technical (Hospital) Services LEVOTHYROXINE 50 MCG TABLET RX-4421 CDM 6370000100 HCPCS 250 RC 00378-1803-77 NDC outpatient 1 UN 5.99 5.99 HEALTHPARTNERS SX009 HEALTHPARTNERS 4.79 percent of total billed charges 3.71 5.69 Technical (Hospital) Services LEVOTHYROXINE 50 MCG TABLET RX-4421 CDM 6370000100 HCPCS 250 RC 00378-1803-77 NDC outpatient 1 UN 5.99 5.99 MEDICA (COMMERCIAL) 94265 [3081118] MEDICA CLAIMS [308111801] 5.39 percent of total billed charges 3.71 5.69 Technical (Hospital) Services LEVOTHYROXINE 50 MCG TABLET RX-4421 CDM 6370000100 HCPCS 250 RC 00378-1803-77 NDC outpatient 1 UN 5.99 5.99 CIGNA 62308 [3081051] CIGNA 62308 [308105105] 4.79 percent of total billed charges 3.71 5.69 Technical (Hospital) Services LEVOTHYROXINE 50 MCG TABLET RX-4421 CDM 6370000100 HCPCS 250 RC 00378-1803-77 NDC outpatient 1 UN 5.99 5.99 CIGNA 62308 [3081051] CIGNA STATE OF WYOMING [308105107] 4.79 percent of total billed charges 3.71 5.69 Technical (Hospital) Services LEVOTHYROXINE 50 MCG TABLET RX-4421 CDM 6370000100 HCPCS 250 RC 00378-1803-77 NDC outpatient 1 UN 5.99 5.99 MULTIPLAN INC 34080 [3081285] MULTIPLAN INC [308128501] 5.69 percent of total billed charges 3.71 5.69 Technical (Hospital) Services LEVOTHYROXINE 75 MCG TABLET RX-4422 CDM 6370000100 HCPCS 250 RC 00904-6951-61 NDC outpatient 1 UN 6.19 6.19 BLUE CROSS BLUE SHIELD WELLMARK SB889 [3081026] BCBS WYOMING [308102603] 5.88 percent of total billed charges 3.84 5.88 Technical (Hospital) Services LEVOTHYROXINE 75 MCG TABLET RX-4422 CDM 6370000100 HCPCS 250 RC 00904-6951-61 NDC outpatient 1 UN 6.19 6.19 HEALTHPARTNERS SX009 HEALTHPARTNERS 4.95 percent of total billed charges 3.84 5.88 Technical (Hospital) Services LEVOTHYROXINE 75 MCG TABLET RX-4422 CDM 6370000100 HCPCS 250 RC 00904-6951-61 NDC outpatient 1 UN 6.19 6.19 UNITED HEALTHCARE (COMMERCIAL) [3081199] UNITED HEALTHCARE 87726 [308119901] 3.84 percent of total billed charges 3.84 5.88 Technical (Hospital) Services LEVOTHYROXINE 75 MCG TABLET RX-4422 CDM 6370000100 HCPCS 250 RC 00904-6951-61 NDC outpatient 1 UN 6.19 6.19 MEDICA (COMMERCIAL) 94265 [3081118] MEDICA CLAIMS [308111801] 5.57 percent of total billed charges 3.84 5.88 Technical (Hospital) Services LEVOTHYROXINE 75 MCG TABLET RX-4422 CDM 6370000100 HCPCS 250 RC 00904-6951-61 NDC outpatient 1 UN 6.19 6.19 MULTIPLAN INC 34080 [3081285] MULTIPLAN INC [308128501] 5.88 percent of total billed charges 3.84 5.88 Technical (Hospital) Services LEVOTHYROXINE 75 MCG TABLET RX-4422 CDM 6370000100 HCPCS 250 RC 00904-6951-61 NDC outpatient 1 UN 6.19 6.19 CIGNA 62308 [3081051] CIGNA 62308 [308105105] 4.95 percent of total billed charges 3.84 5.88 Technical (Hospital) Services LEVOTHYROXINE 75 MCG TABLET RX-4422 CDM 6370000100 HCPCS 250 RC 00904-6951-61 NDC outpatient 1 UN 6.19 6.19 CIGNA 62308 [3081051] CIGNA STATE OF WYOMING [308105107] 4.95 percent of total billed charges 3.84 5.88 Technical (Hospital) Services LEVOTHYROXINE 75 MCG TABLET RX-4422 CDM 6370000100 HCPCS 250 RC 00904-6951-61 NDC inpatient 1 UN 6.19 6.19 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES PPO [308136801] 4.9 percent of total billed charges 3.84 5.88 Technical (Hospital) Services LEVOTHYROXINE 75 MCG TABLET RX-4422 CDM 6370000100 HCPCS 250 RC 00904-6951-61 NDC inpatient 1 UN 6.19 6.19 HEALTHPARTNERS SX009 HEALTHPARTNERS 4.9 percent of total billed charges 3.84 5.88 Technical (Hospital) Services LEVOTHYROXINE 75 MCG TABLET RX-4422 CDM 6370000100 HCPCS 250 RC 00904-6951-61 NDC inpatient 1 UN 6.19 6.19 MEDICA (COMMERCIAL) 94265 [3081118] MEDICA CLAIMS [308111801] 5.57 percent of total billed charges 3.84 5.88 Technical (Hospital) Services LEVOTHYROXINE 75 MCG TABLET RX-4422 CDM 6370000100 HCPCS 250 RC 00904-6951-61 NDC inpatient 1 UN 6.19 6.19 MULTIPLAN INC 34080 [3081285] MULTIPLAN INC [308128501] 5.88 percent of total billed charges 3.84 5.88 Technical (Hospital) Services LEVOTHYROXINE 75 MCG TABLET RX-4422 CDM 6370000100 HCPCS 250 RC 00904-6951-61 NDC inpatient 1 UN 6.19 6.19 BLUE CROSS BLUE SHIELD WELLMARK SB889 [3081026] BCBS WYOMING [308102603] 5.88 percent of total billed charges 3.84 5.88 Technical (Hospital) Services LEVOTHYROXINE 75 MCG TABLET RX-4422 CDM 6370000100 HCPCS 250 RC 00904-6951-61 NDC inpatient 1 UN 6.19 6.19 UNITED HEALTHCARE (COMMERCIAL) [3081199] UNITED HEALTHCARE 87726 [308119901] 3.84 percent of total billed charges 3.84 5.88 Technical (Hospital) Services LEVOTHYROXINE 75 MCG TABLET RX-4422 CDM 6370000100 HCPCS 250 RC 00904-6951-61 NDC inpatient 1 UN 6.19 6.19 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES HDHP [308136802] 4.9 percent of total billed charges 3.84 5.88 Technical (Hospital) Services LEVOTHYROXINE 75 MCG TABLET RX-4422 CDM 6370000100 HCPCS 250 RC 00904-6951-61 NDC outpatient 1 UN 6.19 6.19 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES PPO [308136801] 4.95 percent of total billed charges 3.84 5.88 Technical (Hospital) Services LEVOTHYROXINE 75 MCG TABLET RX-4422 CDM 6370000100 HCPCS 250 RC 00904-6951-61 NDC outpatient 1 UN 6.19 6.19 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES EPO [308136803] 4.95 percent of total billed charges 3.84 5.88 Technical (Hospital) Services LEVOTHYROXINE 75 MCG TABLET RX-4422 CDM 6370000100 HCPCS 250 RC 00904-6951-61 NDC outpatient 1 UN 6.19 6.19 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES HDHP [308136802] 4.95 percent of total billed charges 3.84 5.88 Technical (Hospital) Services LEVOTHYROXINE 75 MCG TABLET RX-4422 CDM 6370000100 HCPCS 250 RC 00904-6951-61 NDC inpatient 1 UN 6.19 6.19 CIGNA 62308 [3081051] CIGNA 62308 [308105105] 4.9 percent of total billed charges 3.84 5.88 Technical (Hospital) Services LEVOTHYROXINE 75 MCG TABLET RX-4422 CDM 6370000100 HCPCS 250 RC 00904-6951-61 NDC inpatient 1 UN 6.19 6.19 CIGNA 62308 [3081051] CIGNA STATE OF WYOMING [308105107] 4.9 percent of total billed charges 3.84 5.88 Technical (Hospital) Services LEVOTHYROXINE 75 MCG TABLET RX-4422 CDM 6370000100 HCPCS 250 RC 00904-6951-61 NDC inpatient 1 UN 6.19 6.19 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES EPO [308136803] 4.9 percent of total billed charges 3.84 5.88 Technical (Hospital) Services LEVOTHYROXINE 100 MCG TABLET RX-4423 CDM 6370000100 HCPCS 250 RC 00378-1809-77 NDC outpatient 1 UN 6.04 6.04 BLUE CROSS BLUE SHIELD WELLMARK SB889 [3081026] BCBS WYOMING [308102603] 5.74 percent of total billed charges 3.74 5.74 Technical (Hospital) Services LEVOTHYROXINE 100 MCG TABLET RX-4423 CDM 6370000100 HCPCS 250 RC 00378-1809-77 NDC outpatient 1 UN 6.04 6.04 HEALTHPARTNERS SX009 HEALTHPARTNERS 4.83 percent of total billed charges 3.74 5.74 Technical (Hospital) Services LEVOTHYROXINE 100 MCG TABLET RX-4423 CDM 6370000100 HCPCS 250 RC 00378-1809-77 NDC outpatient 1 UN 6.04 6.04 UNITED HEALTHCARE (COMMERCIAL) [3081199] UNITED HEALTHCARE 87726 [308119901] 3.74 percent of total billed charges 3.74 5.74 Technical (Hospital) Services LEVOTHYROXINE 100 MCG TABLET RX-4423 CDM 6370000100 HCPCS 250 RC 00378-1809-77 NDC outpatient 1 UN 6.04 6.04 CIGNA 62308 [3081051] CIGNA 62308 [308105105] 4.83 percent of total billed charges 3.74 5.74 Technical (Hospital) Services LEVOTHYROXINE 100 MCG TABLET RX-4423 CDM 6370000100 HCPCS 250 RC 00378-1809-77 NDC outpatient 1 UN 6.04 6.04 CIGNA 62308 [3081051] CIGNA STATE OF WYOMING [308105107] 4.83 percent of total billed charges 3.74 5.74 Technical (Hospital) Services LEVOTHYROXINE 100 MCG TABLET RX-4423 CDM 6370000100 HCPCS 250 RC 00378-1809-77 NDC outpatient 1 UN 6.04 6.04 MULTIPLAN INC 34080 [3081285] MULTIPLAN INC [308128501] 5.74 percent of total billed charges 3.74 5.74 Technical (Hospital) Services LEVOTHYROXINE 100 MCG TABLET RX-4423 CDM 6370000100 HCPCS 250 RC 00378-1809-77 NDC outpatient 1 UN 6.04 6.04 MEDICA (COMMERCIAL) 94265 [3081118] MEDICA CLAIMS [308111801] 5.44 percent of total billed charges 3.74 5.74 Technical (Hospital) Services LEVOTHYROXINE 100 MCG TABLET RX-4423 CDM 6370000100 HCPCS 250 RC 00378-1809-77 NDC outpatient 1 UN 6.04 6.04 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES HDHP [308136802] 4.83 percent of total billed charges 3.74 5.74 Technical (Hospital) Services LEVOTHYROXINE 100 MCG TABLET RX-4423 CDM 6370000100 HCPCS 250 RC 00378-1809-77 NDC outpatient 1 UN 6.04 6.04 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES EPO [308136803] 4.83 percent of total billed charges 3.74 5.74 Technical (Hospital) Services LEVOTHYROXINE 100 MCG TABLET RX-4423 CDM 6370000100 HCPCS 250 RC 00378-1809-77 NDC outpatient 1 UN 6.04 6.04 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES PPO [308136801] 4.83 percent of total billed charges 3.74 5.74 Technical (Hospital) Services LEVOTHYROXINE 100 MCG TABLET RX-4423 CDM 6370000100 HCPCS 250 RC 00378-1809-77 NDC inpatient 1 UN 6.04 6.04 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES PPO [308136801] 4.78 percent of total billed charges 3.74 5.74 Technical (Hospital) Services LEVOTHYROXINE 100 MCG TABLET RX-4423 CDM 6370000100 HCPCS 250 RC 00378-1809-77 NDC inpatient 1 UN 6.04 6.04 MEDICA (COMMERCIAL) 94265 [3081118] MEDICA CLAIMS [308111801] 5.44 percent of total billed charges 3.74 5.74 Technical (Hospital) Services LEVOTHYROXINE 100 MCG TABLET RX-4423 CDM 6370000100 HCPCS 250 RC 00378-1809-77 NDC inpatient 1 UN 6.04 6.04 HEALTHPARTNERS SX009 HEALTHPARTNERS 4.78 percent of total billed charges 3.74 5.74 Technical (Hospital) Services LEVOTHYROXINE 100 MCG TABLET RX-4423 CDM 6370000100 HCPCS 250 RC 00378-1809-77 NDC inpatient 1 UN 6.04 6.04 MULTIPLAN INC 34080 [3081285] MULTIPLAN INC [308128501] 5.74 percent of total billed charges 3.74 5.74 Technical (Hospital) Services LEVOTHYROXINE 100 MCG TABLET RX-4423 CDM 6370000100 HCPCS 250 RC 00378-1809-77 NDC inpatient 1 UN 6.04 6.04 BLUE CROSS BLUE SHIELD WELLMARK SB889 [3081026] BCBS WYOMING [308102603] 5.74 percent of total billed charges 3.74 5.74 Technical (Hospital) Services LEVOTHYROXINE 100 MCG TABLET RX-4423 CDM 6370000100 HCPCS 250 RC 00378-1809-77 NDC inpatient 1 UN 6.04 6.04 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES HDHP [308136802] 4.78 percent of total billed charges 3.74 5.74 Technical (Hospital) Services LEVOTHYROXINE 100 MCG TABLET RX-4423 CDM 6370000100 HCPCS 250 RC 00378-1809-77 NDC inpatient 1 UN 6.04 6.04 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES EPO [308136803] 4.78 percent of total billed charges 3.74 5.74 Technical (Hospital) Services LEVOTHYROXINE 100 MCG TABLET RX-4423 CDM 6370000100 HCPCS 250 RC 00378-1809-77 NDC inpatient 1 UN 6.04 6.04 CIGNA 62308 [3081051] CIGNA 62308 [308105105] 4.78 percent of total billed charges 3.74 5.74 Technical (Hospital) Services LEVOTHYROXINE 100 MCG TABLET RX-4423 CDM 6370000100 HCPCS 250 RC 00378-1809-77 NDC inpatient 1 UN 6.04 6.04 CIGNA 62308 [3081051] CIGNA STATE OF WYOMING [308105107] 4.78 percent of total billed charges 3.74 5.74 Technical (Hospital) Services LEVOTHYROXINE 100 MCG TABLET RX-4423 CDM 6370000100 HCPCS 250 RC 00378-1809-77 NDC inpatient 1 UN 6.04 6.04 UNITED HEALTHCARE (COMMERCIAL) [3081199] UNITED HEALTHCARE 87726 [308119901] 3.74 percent of total billed charges 3.74 5.74 Technical (Hospital) Services LEVOTHYROXINE 125 MCG TABLET RX-4424 CDM 6370000100 HCPCS 250 RC 00378-1813-77 NDC inpatient 1 UN 6.12 6.12 MEDICA (COMMERCIAL) 94265 [3081118] MEDICA CLAIMS [308111801] 5.51 percent of total billed charges 3.79 5.81 Technical (Hospital) Services LEVOTHYROXINE 125 MCG TABLET RX-4424 CDM 6370000100 HCPCS 250 RC 00378-1813-77 NDC inpatient 1 UN 6.12 6.12 HEALTHPARTNERS SX009 HEALTHPARTNERS 4.85 percent of total billed charges 3.79 5.81 Technical (Hospital) Services LEVOTHYROXINE 125 MCG TABLET RX-4424 CDM 6370000100 HCPCS 250 RC 00378-1813-77 NDC inpatient 1 UN 6.12 6.12 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES PPO [308136801] 4.85 percent of total billed charges 3.79 5.81 Technical (Hospital) Services LEVOTHYROXINE 125 MCG TABLET RX-4424 CDM 6370000100 HCPCS 250 RC 00378-1813-77 NDC inpatient 1 UN 6.12 6.12 MULTIPLAN INC 34080 [3081285] MULTIPLAN INC [308128501] 5.81 percent of total billed charges 3.79 5.81 Technical (Hospital) Services LEVOTHYROXINE 125 MCG TABLET RX-4424 CDM 6370000100 HCPCS 250 RC 00378-1813-77 NDC inpatient 1 UN 6.12 6.12 BLUE CROSS BLUE SHIELD WELLMARK SB889 [3081026] BCBS WYOMING [308102603] 5.81 percent of total billed charges 3.79 5.81 Technical (Hospital) Services LEVOTHYROXINE 125 MCG TABLET RX-4424 CDM 6370000100 HCPCS 250 RC 00378-1813-77 NDC inpatient 1 UN 6.12 6.12 UNITED HEALTHCARE (COMMERCIAL) [3081199] UNITED HEALTHCARE 87726 [308119901] 3.79 percent of total billed charges 3.79 5.81 Technical (Hospital) Services LEVOTHYROXINE 125 MCG TABLET RX-4424 CDM 6370000100 HCPCS 250 RC 00378-1813-77 NDC inpatient 1 UN 6.12 6.12 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES HDHP [308136802] 4.85 percent of total billed charges 3.79 5.81 Technical (Hospital) Services LEVOTHYROXINE 125 MCG TABLET RX-4424 CDM 6370000100 HCPCS 250 RC 00378-1813-77 NDC inpatient 1 UN 6.12 6.12 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES EPO [308136803] 4.85 percent of total billed charges 3.79 5.81 Technical (Hospital) Services LEVOTHYROXINE 125 MCG TABLET RX-4424 CDM 6370000100 HCPCS 250 RC 00378-1813-77 NDC inpatient 1 UN 6.12 6.12 CIGNA 62308 [3081051] CIGNA 62308 [308105105] 4.85 percent of total billed charges 3.79 5.81 Technical (Hospital) Services LEVOTHYROXINE 125 MCG TABLET RX-4424 CDM 6370000100 HCPCS 250 RC 00378-1813-77 NDC inpatient 1 UN 6.12 6.12 CIGNA 62308 [3081051] CIGNA STATE OF WYOMING [308105107] 4.85 percent of total billed charges 3.79 5.81 Technical (Hospital) Services LEVOTHYROXINE 125 MCG TABLET RX-4424 CDM 6370000100 HCPCS 250 RC 00378-1813-77 NDC outpatient 1 UN 6.12 6.12 HEALTHPARTNERS SX009 HEALTHPARTNERS 4.9 percent of total billed charges 3.79 5.81 Technical (Hospital) Services LEVOTHYROXINE 125 MCG TABLET RX-4424 CDM 6370000100 HCPCS 250 RC 00378-1813-77 NDC outpatient 1 UN 6.12 6.12 BLUE CROSS BLUE SHIELD WELLMARK SB889 [3081026] BCBS WYOMING [308102603] 5.81 percent of total billed charges 3.79 5.81 Technical (Hospital) Services LEVOTHYROXINE 125 MCG TABLET RX-4424 CDM 6370000100 HCPCS 250 RC 00378-1813-77 NDC outpatient 1 UN 6.12 6.12 MULTIPLAN INC 34080 [3081285] MULTIPLAN INC [308128501] 5.81 percent of total billed charges 3.79 5.81 Technical (Hospital) Services LEVOTHYROXINE 125 MCG TABLET RX-4424 CDM 6370000100 HCPCS 250 RC 00378-1813-77 NDC outpatient 1 UN 6.12 6.12 CIGNA 62308 [3081051] CIGNA 62308 [308105105] 4.9 percent of total billed charges 3.79 5.81 Technical (Hospital) Services LEVOTHYROXINE 125 MCG TABLET RX-4424 CDM 6370000100 HCPCS 250 RC 00378-1813-77 NDC outpatient 1 UN 6.12 6.12 CIGNA 62308 [3081051] CIGNA STATE OF WYOMING [308105107] 4.9 percent of total billed charges 3.79 5.81 Technical (Hospital) Services LEVOTHYROXINE 125 MCG TABLET RX-4424 CDM 6370000100 HCPCS 250 RC 00378-1813-77 NDC outpatient 1 UN 6.12 6.12 MEDICA (COMMERCIAL) 94265 [3081118] MEDICA CLAIMS [308111801] 5.51 percent of total billed charges 3.79 5.81 Technical (Hospital) Services LEVOTHYROXINE 125 MCG TABLET RX-4424 CDM 6370000100 HCPCS 250 RC 00378-1813-77 NDC outpatient 1 UN 6.12 6.12 UNITED HEALTHCARE (COMMERCIAL) [3081199] UNITED HEALTHCARE 87726 [308119901] 3.79 percent of total billed charges 3.79 5.81 Technical (Hospital) Services LEVOTHYROXINE 125 MCG TABLET RX-4424 CDM 6370000100 HCPCS 250 RC 00378-1813-77 NDC outpatient 1 UN 6.12 6.12 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES EPO [308136803] 4.9 percent of total billed charges 3.79 5.81 Technical (Hospital) Services LEVOTHYROXINE 125 MCG TABLET RX-4424 CDM 6370000100 HCPCS 250 RC 00378-1813-77 NDC outpatient 1 UN 6.12 6.12 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES HDHP [308136802] 4.9 percent of total billed charges 3.79 5.81 Technical (Hospital) Services LEVOTHYROXINE 125 MCG TABLET RX-4424 CDM 6370000100 HCPCS 250 RC 00378-1813-77 NDC outpatient 1 UN 6.12 6.12 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES PPO [308136801] 4.9 percent of total billed charges 3.79 5.81 Technical (Hospital) Services LEVOTHYROXINE 150 MCG TABLET RX-4425 CDM 6370000100 HCPCS 250 RC 00378-1815-77 NDC inpatient 1 UN 6.13 6.13 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES PPO [308136801] 4.85 percent of total billed charges 3.8 5.82 Technical (Hospital) Services LEVOTHYROXINE 150 MCG TABLET RX-4425 CDM 6370000100 HCPCS 250 RC 00378-1815-77 NDC inpatient 1 UN 6.13 6.13 MEDICA (COMMERCIAL) 94265 [3081118] MEDICA CLAIMS [308111801] 5.52 percent of total billed charges 3.8 5.82 Technical (Hospital) Services LEVOTHYROXINE 150 MCG TABLET RX-4425 CDM 6370000100 HCPCS 250 RC 00378-1815-77 NDC inpatient 1 UN 6.13 6.13 MULTIPLAN INC 34080 [3081285] MULTIPLAN INC [308128501] 5.82 percent of total billed charges 3.8 5.82 Technical (Hospital) Services LEVOTHYROXINE 150 MCG TABLET RX-4425 CDM 6370000100 HCPCS 250 RC 00378-1815-77 NDC inpatient 1 UN 6.13 6.13 BLUE CROSS BLUE SHIELD WELLMARK SB889 [3081026] BCBS WYOMING [308102603] 5.82 percent of total billed charges 3.8 5.82 Technical (Hospital) Services LEVOTHYROXINE 150 MCG TABLET RX-4425 CDM 6370000100 HCPCS 250 RC 00378-1815-77 NDC inpatient 1 UN 6.13 6.13 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES EPO [308136803] 4.85 percent of total billed charges 3.8 5.82 Technical (Hospital) Services LEVOTHYROXINE 150 MCG TABLET RX-4425 CDM 6370000100 HCPCS 250 RC 00378-1815-77 NDC inpatient 1 UN 6.13 6.13 CIGNA 62308 [3081051] CIGNA 62308 [308105105] 4.85 percent of total billed charges 3.8 5.82 Technical (Hospital) Services LEVOTHYROXINE 150 MCG TABLET RX-4425 CDM 6370000100 HCPCS 250 RC 00378-1815-77 NDC inpatient 1 UN 6.13 6.13 CIGNA 62308 [3081051] CIGNA STATE OF WYOMING [308105107] 4.85 percent of total billed charges 3.8 5.82 Technical (Hospital) Services LEVOTHYROXINE 150 MCG TABLET RX-4425 CDM 6370000100 HCPCS 250 RC 00378-1815-77 NDC inpatient 1 UN 6.13 6.13 UNITED HEALTHCARE (COMMERCIAL) [3081199] UNITED HEALTHCARE 87726 [308119901] 3.8 percent of total billed charges 3.8 5.82 Technical (Hospital) Services LEVOTHYROXINE 150 MCG TABLET RX-4425 CDM 6370000100 HCPCS 250 RC 00378-1815-77 NDC inpatient 1 UN 6.13 6.13 HEALTHPARTNERS SX009 HEALTHPARTNERS 4.85 percent of total billed charges 3.8 5.82 Technical (Hospital) Services LEVOTHYROXINE 150 MCG TABLET RX-4425 CDM 6370000100 HCPCS 250 RC 00378-1815-77 NDC inpatient 1 UN 6.13 6.13 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES HDHP [308136802] 4.85 percent of total billed charges 3.8 5.82 Technical (Hospital) Services LEVOTHYROXINE 150 MCG TABLET RX-4425 CDM 6370000100 HCPCS 250 RC 00378-1815-77 NDC outpatient 1 UN 6.13 6.13 MULTIPLAN INC 34080 [3081285] MULTIPLAN INC [308128501] 5.82 percent of total billed charges 3.8 5.82 Technical (Hospital) Services LEVOTHYROXINE 150 MCG TABLET RX-4425 CDM 6370000100 HCPCS 250 RC 00378-1815-77 NDC outpatient 1 UN 6.13 6.13 CIGNA 62308 [3081051] CIGNA 62308 [308105105] 4.9 percent of total billed charges 3.8 5.82 Technical (Hospital) Services LEVOTHYROXINE 150 MCG TABLET RX-4425 CDM 6370000100 HCPCS 250 RC 00378-1815-77 NDC outpatient 1 UN 6.13 6.13 CIGNA 62308 [3081051] CIGNA STATE OF WYOMING [308105107] 4.9 percent of total billed charges 3.8 5.82 Technical (Hospital) Services LEVOTHYROXINE 150 MCG TABLET RX-4425 CDM 6370000100 HCPCS 250 RC 00378-1815-77 NDC outpatient 1 UN 6.13 6.13 MEDICA (COMMERCIAL) 94265 [3081118] MEDICA CLAIMS [308111801] 5.52 percent of total billed charges 3.8 5.82 Technical (Hospital) Services LEVOTHYROXINE 150 MCG TABLET RX-4425 CDM 6370000100 HCPCS 250 RC 00378-1815-77 NDC outpatient 1 UN 6.13 6.13 UNITED HEALTHCARE (COMMERCIAL) [3081199] UNITED HEALTHCARE 87726 [308119901] 3.8 percent of total billed charges 3.8 5.82 Technical (Hospital) Services LEVOTHYROXINE 150 MCG TABLET RX-4425 CDM 6370000100 HCPCS 250 RC 00378-1815-77 NDC outpatient 1 UN 6.13 6.13 HEALTHPARTNERS SX009 HEALTHPARTNERS 4.9 percent of total billed charges 3.8 5.82 Technical (Hospital) Services LEVOTHYROXINE 150 MCG TABLET RX-4425 CDM 6370000100 HCPCS 250 RC 00378-1815-77 NDC outpatient 1 UN 6.13 6.13 BLUE CROSS BLUE SHIELD WELLMARK SB889 [3081026] BCBS WYOMING [308102603] 5.82 percent of total billed charges 3.8 5.82 Technical (Hospital) Services LEVOTHYROXINE 150 MCG TABLET RX-4425 CDM 6370000100 HCPCS 250 RC 00378-1815-77 NDC outpatient 1 UN 6.13 6.13 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES EPO [308136803] 4.9 percent of total billed charges 3.8 5.82 Technical (Hospital) Services LEVOTHYROXINE 150 MCG TABLET RX-4425 CDM 6370000100 HCPCS 250 RC 00378-1815-77 NDC outpatient 1 UN 6.13 6.13 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES HDHP [308136802] 4.9 percent of total billed charges 3.8 5.82 Technical (Hospital) Services LEVOTHYROXINE 150 MCG TABLET RX-4425 CDM 6370000100 HCPCS 250 RC 00378-1815-77 NDC outpatient 1 UN 6.13 6.13 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES PPO [308136801] 4.9 percent of total billed charges 3.8 5.82 Technical (Hospital) Services AMOXICILLIN 250 MG CAPSULE RX-450 CDM 6370000100 HCPCS 250 RC 00781-2020-01 NDC outpatient 1 UN 5.74 5.74 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES EPO [308136803] 4.59 percent of total billed charges 3.56 5.45 Technical (Hospital) Services AMOXICILLIN 250 MG CAPSULE RX-450 CDM 6370000100 HCPCS 250 RC 00781-2020-01 NDC outpatient 1 UN 5.74 5.74 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES HDHP [308136802] 4.59 percent of total billed charges 3.56 5.45 Technical (Hospital) Services AMOXICILLIN 250 MG CAPSULE RX-450 CDM 6370000100 HCPCS 250 RC 00781-2020-01 NDC outpatient 1 UN 5.74 5.74 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES PPO [308136801] 4.59 percent of total billed charges 3.56 5.45 Technical (Hospital) Services AMOXICILLIN 250 MG CAPSULE RX-450 CDM 6370000100 HCPCS 250 RC 00781-2020-01 NDC outpatient 1 UN 5.74 5.74 BLUE CROSS BLUE SHIELD WELLMARK SB889 [3081026] BCBS WYOMING [308102603] 5.45 percent of total billed charges 3.56 5.45 Technical (Hospital) Services AMOXICILLIN 250 MG CAPSULE RX-450 CDM 6370000100 HCPCS 250 RC 00781-2020-01 NDC outpatient 1 UN 5.74 5.74 HEALTHPARTNERS SX009 HEALTHPARTNERS 4.59 percent of total billed charges 3.56 5.45 Technical (Hospital) Services AMOXICILLIN 250 MG CAPSULE RX-450 CDM 6370000100 HCPCS 250 RC 00781-2020-01 NDC outpatient 1 UN 5.74 5.74 UNITED HEALTHCARE (COMMERCIAL) [3081199] UNITED HEALTHCARE 87726 [308119901] 3.56 percent of total billed charges 3.56 5.45 Technical (Hospital) Services AMOXICILLIN 250 MG CAPSULE RX-450 CDM 6370000100 HCPCS 250 RC 00781-2020-01 NDC outpatient 1 UN 5.74 5.74 MULTIPLAN INC 34080 [3081285] MULTIPLAN INC [308128501] 5.45 percent of total billed charges 3.56 5.45 Technical (Hospital) Services AMOXICILLIN 250 MG CAPSULE RX-450 CDM 6370000100 HCPCS 250 RC 00781-2020-01 NDC outpatient 1 UN 5.74 5.74 CIGNA 62308 [3081051] CIGNA 62308 [308105105] 4.59 percent of total billed charges 3.56 5.45 Technical (Hospital) Services AMOXICILLIN 250 MG CAPSULE RX-450 CDM 6370000100 HCPCS 250 RC 00781-2020-01 NDC outpatient 1 UN 5.74 5.74 CIGNA 62308 [3081051] CIGNA STATE OF WYOMING [308105107] 4.59 percent of total billed charges 3.56 5.45 Technical (Hospital) Services AMOXICILLIN 250 MG CAPSULE RX-450 CDM 6370000100 HCPCS 250 RC 00781-2020-01 NDC outpatient 1 UN 5.74 5.74 MEDICA (COMMERCIAL) 94265 [3081118] MEDICA CLAIMS [308111801] 5.17 percent of total billed charges 3.56 5.45 Technical (Hospital) Services AMOXICILLIN 250 MG CAPSULE RX-450 CDM 6370000100 HCPCS 250 RC 00781-2020-01 NDC inpatient 1 UN 5.74 5.74 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES PPO [308136801] 4.54 percent of total billed charges 3.56 5.45 Technical (Hospital) Services AMOXICILLIN 250 MG CAPSULE RX-450 CDM 6370000100 HCPCS 250 RC 00781-2020-01 NDC inpatient 1 UN 5.74 5.74 MEDICA (COMMERCIAL) 94265 [3081118] MEDICA CLAIMS [308111801] 5.17 percent of total billed charges 3.56 5.45 Technical (Hospital) Services AMOXICILLIN 250 MG CAPSULE RX-450 CDM 6370000100 HCPCS 250 RC 00781-2020-01 NDC inpatient 1 UN 5.74 5.74 MULTIPLAN INC 34080 [3081285] MULTIPLAN INC [308128501] 5.45 percent of total billed charges 3.56 5.45 Technical (Hospital) Services AMOXICILLIN 250 MG CAPSULE RX-450 CDM 6370000100 HCPCS 250 RC 00781-2020-01 NDC inpatient 1 UN 5.74 5.74 BLUE CROSS BLUE SHIELD WELLMARK SB889 [3081026] BCBS WYOMING [308102603] 5.45 percent of total billed charges 3.56 5.45 Technical (Hospital) Services AMOXICILLIN 250 MG CAPSULE RX-450 CDM 6370000100 HCPCS 250 RC 00781-2020-01 NDC inpatient 1 UN 5.74 5.74 UNITED HEALTHCARE (COMMERCIAL) [3081199] UNITED HEALTHCARE 87726 [308119901] 3.56 percent of total billed charges 3.56 5.45 Technical (Hospital) Services AMOXICILLIN 250 MG CAPSULE RX-450 CDM 6370000100 HCPCS 250 RC 00781-2020-01 NDC inpatient 1 UN 5.74 5.74 CIGNA 62308 [3081051] CIGNA 62308 [308105105] 4.54 percent of total billed charges 3.56 5.45 Technical (Hospital) Services AMOXICILLIN 250 MG CAPSULE RX-450 CDM 6370000100 HCPCS 250 RC 00781-2020-01 NDC inpatient 1 UN 5.74 5.74 CIGNA 62308 [3081051] CIGNA STATE OF WYOMING [308105107] 4.54 percent of total billed charges 3.56 5.45 Technical (Hospital) Services AMOXICILLIN 250 MG CAPSULE RX-450 CDM 6370000100 HCPCS 250 RC 00781-2020-01 NDC inpatient 1 UN 5.74 5.74 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES EPO [308136803] 4.54 percent of total billed charges 3.56 5.45 Technical (Hospital) Services AMOXICILLIN 250 MG CAPSULE RX-450 CDM 6370000100 HCPCS 250 RC 00781-2020-01 NDC inpatient 1 UN 5.74 5.74 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES HDHP [308136802] 4.54 percent of total billed charges 3.56 5.45 Technical (Hospital) Services AMOXICILLIN 250 MG CAPSULE RX-450 CDM 6370000100 HCPCS 250 RC 00781-2020-01 NDC inpatient 1 UN 5.74 5.74 HEALTHPARTNERS SX009 HEALTHPARTNERS 4.54 percent of total billed charges 3.56 5.45 Technical (Hospital) Services LIOTHYRONINE 25 MCG TABLET RX-4504 CDM 6370000100 HCPCS 250 RC 42794-0019-02 NDC inpatient 1 UN 6.45 6.45 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES PPO [308136801] 5.11 percent of total billed charges 4 6.13 Technical (Hospital) Services LIOTHYRONINE 25 MCG TABLET RX-4504 CDM 6370000100 HCPCS 250 RC 42794-0019-02 NDC inpatient 1 UN 6.45 6.45 HEALTHPARTNERS SX009 HEALTHPARTNERS 5.11 percent of total billed charges 4 6.13 Technical (Hospital) Services LIOTHYRONINE 25 MCG TABLET RX-4504 CDM 6370000100 HCPCS 250 RC 42794-0019-02 NDC inpatient 1 UN 6.45 6.45 MEDICA (COMMERCIAL) 94265 [3081118] MEDICA CLAIMS [308111801] 5.81 percent of total billed charges 4 6.13 Technical (Hospital) Services LIOTHYRONINE 25 MCG TABLET RX-4504 CDM 6370000100 HCPCS 250 RC 42794-0019-02 NDC inpatient 1 UN 6.45 6.45 MULTIPLAN INC 34080 [3081285] MULTIPLAN INC [308128501] 6.13 percent of total billed charges 4 6.13 Technical (Hospital) Services LIOTHYRONINE 25 MCG TABLET RX-4504 CDM 6370000100 HCPCS 250 RC 42794-0019-02 NDC inpatient 1 UN 6.45 6.45 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES HDHP [308136802] 5.11 percent of total billed charges 4 6.13 Technical (Hospital) Services LIOTHYRONINE 25 MCG TABLET RX-4504 CDM 6370000100 HCPCS 250 RC 42794-0019-02 NDC inpatient 1 UN 6.45 6.45 CIGNA 62308 [3081051] CIGNA 62308 [308105105] 5.11 percent of total billed charges 4 6.13 Technical (Hospital) Services LIOTHYRONINE 25 MCG TABLET RX-4504 CDM 6370000100 HCPCS 250 RC 42794-0019-02 NDC inpatient 1 UN 6.45 6.45 CIGNA 62308 [3081051] CIGNA STATE OF WYOMING [308105107] 5.11 percent of total billed charges 4 6.13 Technical (Hospital) Services LIOTHYRONINE 25 MCG TABLET RX-4504 CDM 6370000100 HCPCS 250 RC 42794-0019-02 NDC inpatient 1 UN 6.45 6.45 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES EPO [308136803] 5.11 percent of total billed charges 4 6.13 Technical (Hospital) Services LIOTHYRONINE 25 MCG TABLET RX-4504 CDM 6370000100 HCPCS 250 RC 42794-0019-02 NDC inpatient 1 UN 6.45 6.45 UNITED HEALTHCARE (COMMERCIAL) [3081199] UNITED HEALTHCARE 87726 [308119901] 4 percent of total billed charges 4 6.13 Technical (Hospital) Services LIOTHYRONINE 25 MCG TABLET RX-4504 CDM 6370000100 HCPCS 250 RC 42794-0019-02 NDC inpatient 1 UN 6.45 6.45 BLUE CROSS BLUE SHIELD WELLMARK SB889 [3081026] BCBS WYOMING [308102603] 6.13 percent of total billed charges 4 6.13 Technical (Hospital) Services LIOTHYRONINE 25 MCG TABLET RX-4504 CDM 6370000100 HCPCS 250 RC 42794-0019-02 NDC outpatient 1 UN 6.45 6.45 BLUE CROSS BLUE SHIELD WELLMARK SB889 [3081026] BCBS WYOMING [308102603] 6.13 percent of total billed charges 4 6.13 Technical (Hospital) Services LIOTHYRONINE 25 MCG TABLET RX-4504 CDM 6370000100 HCPCS 250 RC 42794-0019-02 NDC outpatient 1 UN 6.45 6.45 UNITED HEALTHCARE (COMMERCIAL) [3081199] UNITED HEALTHCARE 87726 [308119901] 4 percent of total billed charges 4 6.13 Technical (Hospital) Services LIOTHYRONINE 25 MCG TABLET RX-4504 CDM 6370000100 HCPCS 250 RC 42794-0019-02 NDC outpatient 1 UN 6.45 6.45 HEALTHPARTNERS SX009 HEALTHPARTNERS 5.16 percent of total billed charges 4 6.13 Technical (Hospital) Services LIOTHYRONINE 25 MCG TABLET RX-4504 CDM 6370000100 HCPCS 250 RC 42794-0019-02 NDC outpatient 1 UN 6.45 6.45 MULTIPLAN INC 34080 [3081285] MULTIPLAN INC [308128501] 6.13 percent of total billed charges 4 6.13 Technical (Hospital) Services LIOTHYRONINE 25 MCG TABLET RX-4504 CDM 6370000100 HCPCS 250 RC 42794-0019-02 NDC outpatient 1 UN 6.45 6.45 CIGNA 62308 [3081051] CIGNA 62308 [308105105] 5.16 percent of total billed charges 4 6.13 Technical (Hospital) Services LIOTHYRONINE 25 MCG TABLET RX-4504 CDM 6370000100 HCPCS 250 RC 42794-0019-02 NDC outpatient 1 UN 6.45 6.45 CIGNA 62308 [3081051] CIGNA STATE OF WYOMING [308105107] 5.16 percent of total billed charges 4 6.13 Technical (Hospital) Services LIOTHYRONINE 25 MCG TABLET RX-4504 CDM 6370000100 HCPCS 250 RC 42794-0019-02 NDC outpatient 1 UN 6.45 6.45 MEDICA (COMMERCIAL) 94265 [3081118] MEDICA CLAIMS [308111801] 5.81 percent of total billed charges 4 6.13 Technical (Hospital) Services LIOTHYRONINE 25 MCG TABLET RX-4504 CDM 6370000100 HCPCS 250 RC 42794-0019-02 NDC outpatient 1 UN 6.45 6.45 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES EPO [308136803] 5.16 percent of total billed charges 4 6.13 Technical (Hospital) Services LIOTHYRONINE 25 MCG TABLET RX-4504 CDM 6370000100 HCPCS 250 RC 42794-0019-02 NDC outpatient 1 UN 6.45 6.45 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES HDHP [308136802] 5.16 percent of total billed charges 4 6.13 Technical (Hospital) Services LIOTHYRONINE 25 MCG TABLET RX-4504 CDM 6370000100 HCPCS 250 RC 42794-0019-02 NDC outpatient 1 UN 6.45 6.45 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES PPO [308136801] 5.16 percent of total billed charges 4 6.13 Technical (Hospital) Services AMOXICILLIN 500 MG CAPSULE RX-451 CDM 6370000100 HCPCS 250 RC 00781-2613-01 NDC inpatient 1 UN 5.8 5.8 MULTIPLAN INC 34080 [3081285] MULTIPLAN INC [308128501] 5.51 percent of total billed charges 3.6 5.51 Technical (Hospital) Services AMOXICILLIN 500 MG CAPSULE RX-451 CDM 6370000100 HCPCS 250 RC 00781-2613-01 NDC inpatient 1 UN 5.8 5.8 MEDICA (COMMERCIAL) 94265 [3081118] MEDICA CLAIMS [308111801] 5.22 percent of total billed charges 3.6 5.51 Technical (Hospital) Services AMOXICILLIN 500 MG CAPSULE RX-451 CDM 6370000100 HCPCS 250 RC 00781-2613-01 NDC inpatient 1 UN 5.8 5.8 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES PPO [308136801] 4.59 percent of total billed charges 3.6 5.51 Technical (Hospital) Services AMOXICILLIN 500 MG CAPSULE RX-451 CDM 6370000100 HCPCS 250 RC 00781-2613-01 NDC inpatient 1 UN 5.8 5.8 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES EPO [308136803] 4.59 percent of total billed charges 3.6 5.51 Technical (Hospital) Services AMOXICILLIN 500 MG CAPSULE RX-451 CDM 6370000100 HCPCS 250 RC 00781-2613-01 NDC inpatient 1 UN 5.8 5.8 UNITED HEALTHCARE (COMMERCIAL) [3081199] UNITED HEALTHCARE 87726 [308119901] 3.6 percent of total billed charges 3.6 5.51 Technical (Hospital) Services AMOXICILLIN 500 MG CAPSULE RX-451 CDM 6370000100 HCPCS 250 RC 00781-2613-01 NDC inpatient 1 UN 5.8 5.8 CIGNA 62308 [3081051] CIGNA 62308 [308105105] 4.59 percent of total billed charges 3.6 5.51 Technical (Hospital) Services AMOXICILLIN 500 MG CAPSULE RX-451 CDM 6370000100 HCPCS 250 RC 00781-2613-01 NDC inpatient 1 UN 5.8 5.8 CIGNA 62308 [3081051] CIGNA STATE OF WYOMING [308105107] 4.59 percent of total billed charges 3.6 5.51 Technical (Hospital) Services AMOXICILLIN 500 MG CAPSULE RX-451 CDM 6370000100 HCPCS 250 RC 00781-2613-01 NDC inpatient 1 UN 5.8 5.8 BLUE CROSS BLUE SHIELD WELLMARK SB889 [3081026] BCBS WYOMING [308102603] 5.51 percent of total billed charges 3.6 5.51 Technical (Hospital) Services AMOXICILLIN 500 MG CAPSULE RX-451 CDM 6370000100 HCPCS 250 RC 00781-2613-01 NDC inpatient 1 UN 5.8 5.8 HEALTHPARTNERS SX009 HEALTHPARTNERS 4.59 percent of total billed charges 3.6 5.51 Technical (Hospital) Services AMOXICILLIN 500 MG CAPSULE RX-451 CDM 6370000100 HCPCS 250 RC 00781-2613-01 NDC inpatient 1 UN 5.8 5.8 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES HDHP [308136802] 4.59 percent of total billed charges 3.6 5.51 Technical (Hospital) Services AMOXICILLIN 500 MG CAPSULE RX-451 CDM 6370000100 HCPCS 250 RC 00781-2613-01 NDC outpatient 1 UN 5.8 5.8 UNITED HEALTHCARE (COMMERCIAL) [3081199] UNITED HEALTHCARE 87726 [308119901] 3.6 percent of total billed charges 3.6 5.51 Technical (Hospital) Services AMOXICILLIN 500 MG CAPSULE RX-451 CDM 6370000100 HCPCS 250 RC 00781-2613-01 NDC outpatient 1 UN 5.8 5.8 MEDICA (COMMERCIAL) 94265 [3081118] MEDICA CLAIMS [308111801] 5.22 percent of total billed charges 3.6 5.51 Technical (Hospital) Services AMOXICILLIN 500 MG CAPSULE RX-451 CDM 6370000100 HCPCS 250 RC 00781-2613-01 NDC outpatient 1 UN 5.8 5.8 CIGNA 62308 [3081051] CIGNA 62308 [308105105] 4.64 percent of total billed charges 3.6 5.51 Technical (Hospital) Services AMOXICILLIN 500 MG CAPSULE RX-451 CDM 6370000100 HCPCS 250 RC 00781-2613-01 NDC outpatient 1 UN 5.8 5.8 CIGNA 62308 [3081051] CIGNA STATE OF WYOMING [308105107] 4.64 percent of total billed charges 3.6 5.51 Technical (Hospital) Services AMOXICILLIN 500 MG CAPSULE RX-451 CDM 6370000100 HCPCS 250 RC 00781-2613-01 NDC outpatient 1 UN 5.8 5.8 MULTIPLAN INC 34080 [3081285] MULTIPLAN INC [308128501] 5.51 percent of total billed charges 3.6 5.51 Technical (Hospital) Services AMOXICILLIN 500 MG CAPSULE RX-451 CDM 6370000100 HCPCS 250 RC 00781-2613-01 NDC outpatient 1 UN 5.8 5.8 BLUE CROSS BLUE SHIELD WELLMARK SB889 [3081026] BCBS WYOMING [308102603] 5.51 percent of total billed charges 3.6 5.51 Technical (Hospital) Services AMOXICILLIN 500 MG CAPSULE RX-451 CDM 6370000100 HCPCS 250 RC 00781-2613-01 NDC outpatient 1 UN 5.8 5.8 HEALTHPARTNERS SX009 HEALTHPARTNERS 4.64 percent of total billed charges 3.6 5.51 Technical (Hospital) Services AMOXICILLIN 500 MG CAPSULE RX-451 CDM 6370000100 HCPCS 250 RC 00781-2613-01 NDC outpatient 1 UN 5.8 5.8 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES EPO [308136803] 4.64 percent of total billed charges 3.6 5.51 Technical (Hospital) Services AMOXICILLIN 500 MG CAPSULE RX-451 CDM 6370000100 HCPCS 250 RC 00781-2613-01 NDC outpatient 1 UN 5.8 5.8 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES PPO [308136801] 4.64 percent of total billed charges 3.6 5.51 Technical (Hospital) Services AMOXICILLIN 500 MG CAPSULE RX-451 CDM 6370000100 HCPCS 250 RC 00781-2613-01 NDC outpatient 1 UN 5.8 5.8 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES HDHP [308136802] 4.64 percent of total billed charges 3.6 5.51 Technical (Hospital) Services AMOXICILLIN 250 MG CHEWABLE TABLET RX-452 CDM 6370000100 HCPCS 250 RC 00093-2268-01 NDC inpatient 1 UN 5.92 5.92 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES HDHP [308136802] 4.69 percent of total billed charges 3.67 5.62 Technical (Hospital) Services AMOXICILLIN 250 MG CHEWABLE TABLET RX-452 CDM 6370000100 HCPCS 250 RC 00093-2268-01 NDC inpatient 1 UN 5.92 5.92 HEALTHPARTNERS SX009 HEALTHPARTNERS 4.69 percent of total billed charges 3.67 5.62 Technical (Hospital) Services AMOXICILLIN 250 MG CHEWABLE TABLET RX-452 CDM 6370000100 HCPCS 250 RC 00093-2268-01 NDC inpatient 1 UN 5.92 5.92 BLUE CROSS BLUE SHIELD WELLMARK SB889 [3081026] BCBS WYOMING [308102603] 5.62 percent of total billed charges 3.67 5.62 Technical (Hospital) Services AMOXICILLIN 250 MG CHEWABLE TABLET RX-452 CDM 6370000100 HCPCS 250 RC 00093-2268-01 NDC inpatient 1 UN 5.92 5.92 CIGNA 62308 [3081051] CIGNA 62308 [308105105] 4.69 percent of total billed charges 3.67 5.62 Technical (Hospital) Services AMOXICILLIN 250 MG CHEWABLE TABLET RX-452 CDM 6370000100 HCPCS 250 RC 00093-2268-01 NDC inpatient 1 UN 5.92 5.92 CIGNA 62308 [3081051] CIGNA STATE OF WYOMING [308105107] 4.69 percent of total billed charges 3.67 5.62 Technical (Hospital) Services AMOXICILLIN 250 MG CHEWABLE TABLET RX-452 CDM 6370000100 HCPCS 250 RC 00093-2268-01 NDC inpatient 1 UN 5.92 5.92 UNITED HEALTHCARE (COMMERCIAL) [3081199] UNITED HEALTHCARE 87726 [308119901] 3.67 percent of total billed charges 3.67 5.62 Technical (Hospital) Services AMOXICILLIN 250 MG CHEWABLE TABLET RX-452 CDM 6370000100 HCPCS 250 RC 00093-2268-01 NDC inpatient 1 UN 5.92 5.92 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES EPO [308136803] 4.69 percent of total billed charges 3.67 5.62 Technical (Hospital) Services AMOXICILLIN 250 MG CHEWABLE TABLET RX-452 CDM 6370000100 HCPCS 250 RC 00093-2268-01 NDC inpatient 1 UN 5.92 5.92 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES PPO [308136801] 4.69 percent of total billed charges 3.67 5.62 Technical (Hospital) Services AMOXICILLIN 250 MG CHEWABLE TABLET RX-452 CDM 6370000100 HCPCS 250 RC 00093-2268-01 NDC inpatient 1 UN 5.92 5.92 MEDICA (COMMERCIAL) 94265 [3081118] MEDICA CLAIMS [308111801] 5.33 percent of total billed charges 3.67 5.62 Technical (Hospital) Services AMOXICILLIN 250 MG CHEWABLE TABLET RX-452 CDM 6370000100 HCPCS 250 RC 00093-2268-01 NDC inpatient 1 UN 5.92 5.92 MULTIPLAN INC 34080 [3081285] MULTIPLAN INC [308128501] 5.62 percent of total billed charges 3.67 5.62 Technical (Hospital) Services AMOXICILLIN 250 MG CHEWABLE TABLET RX-452 CDM 6370000100 HCPCS 250 RC 00093-2268-01 NDC outpatient 1 UN 5.92 5.92 BLUE CROSS BLUE SHIELD WELLMARK SB889 [3081026] BCBS WYOMING [308102603] 5.62 percent of total billed charges 3.67 5.62 Technical (Hospital) Services AMOXICILLIN 250 MG CHEWABLE TABLET RX-452 CDM 6370000100 HCPCS 250 RC 00093-2268-01 NDC outpatient 1 UN 5.92 5.92 CIGNA 62308 [3081051] CIGNA 62308 [308105105] 4.74 percent of total billed charges 3.67 5.62 Technical (Hospital) Services AMOXICILLIN 250 MG CHEWABLE TABLET RX-452 CDM 6370000100 HCPCS 250 RC 00093-2268-01 NDC outpatient 1 UN 5.92 5.92 CIGNA 62308 [3081051] CIGNA STATE OF WYOMING [308105107] 4.74 percent of total billed charges 3.67 5.62 Technical (Hospital) Services AMOXICILLIN 250 MG CHEWABLE TABLET RX-452 CDM 6370000100 HCPCS 250 RC 00093-2268-01 NDC outpatient 1 UN 5.92 5.92 MULTIPLAN INC 34080 [3081285] MULTIPLAN INC [308128501] 5.62 percent of total billed charges 3.67 5.62 Technical (Hospital) Services AMOXICILLIN 250 MG CHEWABLE TABLET RX-452 CDM 6370000100 HCPCS 250 RC 00093-2268-01 NDC outpatient 1 UN 5.92 5.92 UNITED HEALTHCARE (COMMERCIAL) [3081199] UNITED HEALTHCARE 87726 [308119901] 3.67 percent of total billed charges 3.67 5.62 Technical (Hospital) Services AMOXICILLIN 250 MG CHEWABLE TABLET RX-452 CDM 6370000100 HCPCS 250 RC 00093-2268-01 NDC outpatient 1 UN 5.92 5.92 HEALTHPARTNERS SX009 HEALTHPARTNERS 4.74 percent of total billed charges 3.67 5.62 Technical (Hospital) Services AMOXICILLIN 250 MG CHEWABLE TABLET RX-452 CDM 6370000100 HCPCS 250 RC 00093-2268-01 NDC outpatient 1 UN 5.92 5.92 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES HDHP [308136802] 4.74 percent of total billed charges 3.67 5.62 Technical (Hospital) Services AMOXICILLIN 250 MG CHEWABLE TABLET RX-452 CDM 6370000100 HCPCS 250 RC 00093-2268-01 NDC outpatient 1 UN 5.92 5.92 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES EPO [308136803] 4.74 percent of total billed charges 3.67 5.62 Technical (Hospital) Services AMOXICILLIN 250 MG CHEWABLE TABLET RX-452 CDM 6370000100 HCPCS 250 RC 00093-2268-01 NDC outpatient 1 UN 5.92 5.92 MEDICA (COMMERCIAL) 94265 [3081118] MEDICA CLAIMS [308111801] 5.33 percent of total billed charges 3.67 5.62 Technical (Hospital) Services AMOXICILLIN 250 MG CHEWABLE TABLET RX-452 CDM 6370000100 HCPCS 250 RC 00093-2268-01 NDC outpatient 1 UN 5.92 5.92 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES PPO [308136801] 4.74 percent of total billed charges 3.67 5.62 Technical (Hospital) Services LISINOPRIL 20 MG TABLET RX-4526 CDM 6370000100 HCPCS 250 RC 68180-0981-03 NDC outpatient 1 UN 5.68 5.68 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES EPO [308136803] 4.54 percent of total billed charges 3.52 5.4 Technical (Hospital) Services LISINOPRIL 20 MG TABLET RX-4526 CDM 6370000100 HCPCS 250 RC 68180-0981-03 NDC outpatient 1 UN 5.68 5.68 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES HDHP [308136802] 4.54 percent of total billed charges 3.52 5.4 Technical (Hospital) Services LISINOPRIL 20 MG TABLET RX-4526 CDM 6370000100 HCPCS 250 RC 68180-0981-03 NDC outpatient 1 UN 5.68 5.68 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES PPO [308136801] 4.54 percent of total billed charges 3.52 5.4 Technical (Hospital) Services LISINOPRIL 20 MG TABLET RX-4526 CDM 6370000100 HCPCS 250 RC 68180-0981-03 NDC outpatient 1 UN 5.68 5.68 UNITED HEALTHCARE (COMMERCIAL) [3081199] UNITED HEALTHCARE 87726 [308119901] 3.52 percent of total billed charges 3.52 5.4 Technical (Hospital) Services LISINOPRIL 20 MG TABLET RX-4526 CDM 6370000100 HCPCS 250 RC 68180-0981-03 NDC outpatient 1 UN 5.68 5.68 HEALTHPARTNERS SX009 HEALTHPARTNERS 4.54 percent of total billed charges 3.52 5.4 Technical (Hospital) Services LISINOPRIL 20 MG TABLET RX-4526 CDM 6370000100 HCPCS 250 RC 68180-0981-03 NDC outpatient 1 UN 5.68 5.68 MULTIPLAN INC 34080 [3081285] MULTIPLAN INC [308128501] 5.4 percent of total billed charges 3.52 5.4 Technical (Hospital) Services LISINOPRIL 20 MG TABLET RX-4526 CDM 6370000100 HCPCS 250 RC 68180-0981-03 NDC outpatient 1 UN 5.68 5.68 CIGNA 62308 [3081051] CIGNA 62308 [308105105] 4.54 percent of total billed charges 3.52 5.4 Technical (Hospital) Services LISINOPRIL 20 MG TABLET RX-4526 CDM 6370000100 HCPCS 250 RC 68180-0981-03 NDC outpatient 1 UN 5.68 5.68 CIGNA 62308 [3081051] CIGNA STATE OF WYOMING [308105107] 4.54 percent of total billed charges 3.52 5.4 Technical (Hospital) Services LISINOPRIL 20 MG TABLET RX-4526 CDM 6370000100 HCPCS 250 RC 68180-0981-03 NDC outpatient 1 UN 5.68 5.68 MEDICA (COMMERCIAL) 94265 [3081118] MEDICA CLAIMS [308111801] 5.11 percent of total billed charges 3.52 5.4 Technical (Hospital) Services LISINOPRIL 20 MG TABLET RX-4526 CDM 6370000100 HCPCS 250 RC 68180-0981-03 NDC outpatient 1 UN 5.68 5.68 BLUE CROSS BLUE SHIELD WELLMARK SB889 [3081026] BCBS WYOMING [308102603] 5.4 percent of total billed charges 3.52 5.4 Technical (Hospital) Services LISINOPRIL 20 MG TABLET RX-4526 CDM 6370000100 HCPCS 250 RC 68180-0981-03 NDC inpatient 1 UN 5.68 5.68 MEDICA (COMMERCIAL) 94265 [3081118] MEDICA CLAIMS [308111801] 5.11 percent of total billed charges 3.52 5.4 Technical (Hospital) Services LISINOPRIL 20 MG TABLET RX-4526 CDM 6370000100 HCPCS 250 RC 68180-0981-03 NDC inpatient 1 UN 5.68 5.68 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES PPO [308136801] 4.5 percent of total billed charges 3.52 5.4 Technical (Hospital) Services LISINOPRIL 20 MG TABLET RX-4526 CDM 6370000100 HCPCS 250 RC 68180-0981-03 NDC inpatient 1 UN 5.68 5.68 MULTIPLAN INC 34080 [3081285] MULTIPLAN INC [308128501] 5.4 percent of total billed charges 3.52 5.4 Technical (Hospital) Services LISINOPRIL 20 MG TABLET RX-4526 CDM 6370000100 HCPCS 250 RC 68180-0981-03 NDC inpatient 1 UN 5.68 5.68 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES HDHP [308136802] 4.5 percent of total billed charges 3.52 5.4 Technical (Hospital) Services LISINOPRIL 20 MG TABLET RX-4526 CDM 6370000100 HCPCS 250 RC 68180-0981-03 NDC inpatient 1 UN 5.68 5.68 HEALTHPARTNERS SX009 HEALTHPARTNERS 4.5 percent of total billed charges 3.52 5.4 Technical (Hospital) Services LISINOPRIL 20 MG TABLET RX-4526 CDM 6370000100 HCPCS 250 RC 68180-0981-03 NDC inpatient 1 UN 5.68 5.68 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES EPO [308136803] 4.5 percent of total billed charges 3.52 5.4 Technical (Hospital) Services LISINOPRIL 20 MG TABLET RX-4526 CDM 6370000100 HCPCS 250 RC 68180-0981-03 NDC inpatient 1 UN 5.68 5.68 UNITED HEALTHCARE (COMMERCIAL) [3081199] UNITED HEALTHCARE 87726 [308119901] 3.52 percent of total billed charges 3.52 5.4 Technical (Hospital) Services LISINOPRIL 20 MG TABLET RX-4526 CDM 6370000100 HCPCS 250 RC 68180-0981-03 NDC inpatient 1 UN 5.68 5.68 CIGNA 62308 [3081051] CIGNA 62308 [308105105] 4.5 percent of total billed charges 3.52 5.4 Technical (Hospital) Services LISINOPRIL 20 MG TABLET RX-4526 CDM 6370000100 HCPCS 250 RC 68180-0981-03 NDC inpatient 1 UN 5.68 5.68 CIGNA 62308 [3081051] CIGNA STATE OF WYOMING [308105107] 4.5 percent of total billed charges 3.52 5.4 Technical (Hospital) Services LISINOPRIL 20 MG TABLET RX-4526 CDM 6370000100 HCPCS 250 RC 68180-0981-03 NDC inpatient 1 UN 5.68 5.68 BLUE CROSS BLUE SHIELD WELLMARK SB889 [3081026] BCBS WYOMING [308102603] 5.4 percent of total billed charges 3.52 5.4 Technical (Hospital) Services AMOXICILLIN 250 MG/5 ML ORAL SUSPENSION RX-454 CDM 6370000100 HCPCS 250 RC 00143-9889-15 NDC inpatient 150 ML 23.35 23.35 UNITED HEALTHCARE (COMMERCIAL) [3081199] UNITED HEALTHCARE 87726 [308119901] 14.48 percent of total billed charges 14.48 22.18 Technical (Hospital) Services AMOXICILLIN 250 MG/5 ML ORAL SUSPENSION RX-454 CDM 6370000100 HCPCS 250 RC 00143-9889-15 NDC inpatient 150 ML 23.35 23.35 BLUE CROSS BLUE SHIELD WELLMARK SB889 [3081026] BCBS WYOMING [308102603] 22.18 percent of total billed charges 14.48 22.18 Technical (Hospital) Services AMOXICILLIN 250 MG/5 ML ORAL SUSPENSION RX-454 CDM 6370000100 HCPCS 250 RC 00143-9889-15 NDC inpatient 150 ML 23.35 23.35 MEDICA (COMMERCIAL) 94265 [3081118] MEDICA CLAIMS [308111801] 21.02 percent of total billed charges 14.48 22.18 Technical (Hospital) Services AMOXICILLIN 250 MG/5 ML ORAL SUSPENSION RX-454 CDM 6370000100 HCPCS 250 RC 00143-9889-15 NDC inpatient 150 ML 23.35 23.35 MULTIPLAN INC 34080 [3081285] MULTIPLAN INC [308128501] 22.18 percent of total billed charges 14.48 22.18 Technical (Hospital) Services AMOXICILLIN 250 MG/5 ML ORAL SUSPENSION RX-454 CDM 6370000100 HCPCS 250 RC 00143-9889-15 NDC inpatient 150 ML 23.35 23.35 HEALTHPARTNERS SX009 HEALTHPARTNERS 18.49 percent of total billed charges 14.48 22.18 Technical (Hospital) Services AMOXICILLIN 250 MG/5 ML ORAL SUSPENSION RX-454 CDM 6370000100 HCPCS 250 RC 00143-9889-15 NDC inpatient 150 ML 23.35 23.35 CIGNA 62308 [3081051] CIGNA 62308 [308105105] 18.49 percent of total billed charges 14.48 22.18 Technical (Hospital) Services AMOXICILLIN 250 MG/5 ML ORAL SUSPENSION RX-454 CDM 6370000100 HCPCS 250 RC 00143-9889-15 NDC inpatient 150 ML 23.35 23.35 CIGNA 62308 [3081051] CIGNA STATE OF WYOMING [308105107] 18.49 percent of total billed charges 14.48 22.18 Technical (Hospital) Services AMOXICILLIN 250 MG/5 ML ORAL SUSPENSION RX-454 CDM 6370000100 HCPCS 250 RC 00143-9889-15 NDC inpatient 150 ML 23.35 23.35 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES EPO [308136803] 18.49 percent of total billed charges 14.48 22.18 Technical (Hospital) Services AMOXICILLIN 250 MG/5 ML ORAL SUSPENSION RX-454 CDM 6370000100 HCPCS 250 RC 00143-9889-15 NDC inpatient 150 ML 23.35 23.35 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES HDHP [308136802] 18.49 percent of total billed charges 14.48 22.18 Technical (Hospital) Services AMOXICILLIN 250 MG/5 ML ORAL SUSPENSION RX-454 CDM 6370000100 HCPCS 250 RC 00143-9889-15 NDC inpatient 150 ML 23.35 23.35 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES PPO [308136801] 18.49 percent of total billed charges 14.48 22.18 Technical (Hospital) Services AMOXICILLIN 250 MG/5 ML ORAL SUSPENSION RX-454 CDM 6370000100 HCPCS 250 RC 00143-9889-15 NDC outpatient 150 ML 23.35 23.35 CIGNA 62308 [3081051] CIGNA 62308 [308105105] 18.68 percent of total billed charges 14.48 22.18 Technical (Hospital) Services AMOXICILLIN 250 MG/5 ML ORAL SUSPENSION RX-454 CDM 6370000100 HCPCS 250 RC 00143-9889-15 NDC outpatient 150 ML 23.35 23.35 CIGNA 62308 [3081051] CIGNA STATE OF WYOMING [308105107] 18.68 percent of total billed charges 14.48 22.18 Technical (Hospital) Services AMOXICILLIN 250 MG/5 ML ORAL SUSPENSION RX-454 CDM 6370000100 HCPCS 250 RC 00143-9889-15 NDC outpatient 150 ML 23.35 23.35 MULTIPLAN INC 34080 [3081285] MULTIPLAN INC [308128501] 22.18 percent of total billed charges 14.48 22.18 Technical (Hospital) Services AMOXICILLIN 250 MG/5 ML ORAL SUSPENSION RX-454 CDM 6370000100 HCPCS 250 RC 00143-9889-15 NDC outpatient 150 ML 23.35 23.35 MEDICA (COMMERCIAL) 94265 [3081118] MEDICA CLAIMS [308111801] 21.02 percent of total billed charges 14.48 22.18 Technical (Hospital) Services AMOXICILLIN 250 MG/5 ML ORAL SUSPENSION RX-454 CDM 6370000100 HCPCS 250 RC 00143-9889-15 NDC outpatient 150 ML 23.35 23.35 BLUE CROSS BLUE SHIELD WELLMARK SB889 [3081026] BCBS WYOMING [308102603] 22.18 percent of total billed charges 14.48 22.18 Technical (Hospital) Services AMOXICILLIN 250 MG/5 ML ORAL SUSPENSION RX-454 CDM 6370000100 HCPCS 250 RC 00143-9889-15 NDC outpatient 150 ML 23.35 23.35 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES EPO [308136803] 18.68 percent of total billed charges 14.48 22.18 Technical (Hospital) Services AMOXICILLIN 250 MG/5 ML ORAL SUSPENSION RX-454 CDM 6370000100 HCPCS 250 RC 00143-9889-15 NDC outpatient 150 ML 23.35 23.35 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES HDHP [308136802] 18.68 percent of total billed charges 14.48 22.18 Technical (Hospital) Services AMOXICILLIN 250 MG/5 ML ORAL SUSPENSION RX-454 CDM 6370000100 HCPCS 250 RC 00143-9889-15 NDC outpatient 150 ML 23.35 23.35 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES PPO [308136801] 18.68 percent of total billed charges 14.48 22.18 Technical (Hospital) Services AMOXICILLIN 250 MG/5 ML ORAL SUSPENSION RX-454 CDM 6370000100 HCPCS 250 RC 00143-9889-15 NDC outpatient 150 ML 23.35 23.35 HEALTHPARTNERS SX009 HEALTHPARTNERS 18.68 percent of total billed charges 14.48 22.18 Technical (Hospital) Services AMOXICILLIN 250 MG/5 ML ORAL SUSPENSION RX-454 CDM 6370000100 HCPCS 250 RC 00143-9889-15 NDC outpatient 150 ML 23.35 23.35 UNITED HEALTHCARE (COMMERCIAL) [3081199] UNITED HEALTHCARE 87726 [308119901] 14.48 percent of total billed charges 14.48 22.18 Technical (Hospital) Services LOPERAMIDE 2 MG CAPSULE RX-4560 CDM 6370000100 HCPCS 250 RC 00378-2100-01 NDC inpatient 1 UN 5.99 5.99 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES HDHP [308136802] 4.74 percent of total billed charges 3.71 5.69 Technical (Hospital) Services LOPERAMIDE 2 MG CAPSULE RX-4560 CDM 6370000100 HCPCS 250 RC 00378-2100-01 NDC inpatient 1 UN 5.99 5.99 HEALTHPARTNERS SX009 HEALTHPARTNERS 4.74 percent of total billed charges 3.71 5.69 Technical (Hospital) Services LOPERAMIDE 2 MG CAPSULE RX-4560 CDM 6370000100 HCPCS 250 RC 00378-2100-01 NDC inpatient 1 UN 5.99 5.99 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES EPO [308136803] 4.74 percent of total billed charges 3.71 5.69 Technical (Hospital) Services LOPERAMIDE 2 MG CAPSULE RX-4560 CDM 6370000100 HCPCS 250 RC 00378-2100-01 NDC inpatient 1 UN 5.99 5.99 CIGNA 62308 [3081051] CIGNA 62308 [308105105] 4.74 percent of total billed charges 3.71 5.69 Technical (Hospital) Services LOPERAMIDE 2 MG CAPSULE RX-4560 CDM 6370000100 HCPCS 250 RC 00378-2100-01 NDC inpatient 1 UN 5.99 5.99 CIGNA 62308 [3081051] CIGNA STATE OF WYOMING [308105107] 4.74 percent of total billed charges 3.71 5.69 Technical (Hospital) Services LOPERAMIDE 2 MG CAPSULE RX-4560 CDM 6370000100 HCPCS 250 RC 00378-2100-01 NDC inpatient 1 UN 5.99 5.99 UNITED HEALTHCARE (COMMERCIAL) [3081199] UNITED HEALTHCARE 87726 [308119901] 3.71 percent of total billed charges 3.71 5.69 Technical (Hospital) Services LOPERAMIDE 2 MG CAPSULE RX-4560 CDM 6370000100 HCPCS 250 RC 00378-2100-01 NDC inpatient 1 UN 5.99 5.99 BLUE CROSS BLUE SHIELD WELLMARK SB889 [3081026] BCBS WYOMING [308102603] 5.69 percent of total billed charges 3.71 5.69 Technical (Hospital) Services LOPERAMIDE 2 MG CAPSULE RX-4560 CDM 6370000100 HCPCS 250 RC 00378-2100-01 NDC inpatient 1 UN 5.99 5.99 MULTIPLAN INC 34080 [3081285] MULTIPLAN INC [308128501] 5.69 percent of total billed charges 3.71 5.69 Technical (Hospital) Services LOPERAMIDE 2 MG CAPSULE RX-4560 CDM 6370000100 HCPCS 250 RC 00378-2100-01 NDC inpatient 1 UN 5.99 5.99 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES PPO [308136801] 4.74 percent of total billed charges 3.71 5.69 Technical (Hospital) Services LOPERAMIDE 2 MG CAPSULE RX-4560 CDM 6370000100 HCPCS 250 RC 00378-2100-01 NDC inpatient 1 UN 5.99 5.99 MEDICA (COMMERCIAL) 94265 [3081118] MEDICA CLAIMS [308111801] 5.39 percent of total billed charges 3.71 5.69 Technical (Hospital) Services LOPERAMIDE 2 MG CAPSULE RX-4560 CDM 6370000100 HCPCS 250 RC 00378-2100-01 NDC outpatient 1 UN 5.99 5.99 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES PPO [308136801] 4.79 percent of total billed charges 3.71 5.69 Technical (Hospital) Services LOPERAMIDE 2 MG CAPSULE RX-4560 CDM 6370000100 HCPCS 250 RC 00378-2100-01 NDC outpatient 1 UN 5.99 5.99 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES HDHP [308136802] 4.79 percent of total billed charges 3.71 5.69 Technical (Hospital) Services LOPERAMIDE 2 MG CAPSULE RX-4560 CDM 6370000100 HCPCS 250 RC 00378-2100-01 NDC outpatient 1 UN 5.99 5.99 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES EPO [308136803] 4.79 percent of total billed charges 3.71 5.69 Technical (Hospital) Services LOPERAMIDE 2 MG CAPSULE RX-4560 CDM 6370000100 HCPCS 250 RC 00378-2100-01 NDC outpatient 1 UN 5.99 5.99 HEALTHPARTNERS SX009 HEALTHPARTNERS 4.79 percent of total billed charges 3.71 5.69 Technical (Hospital) Services LOPERAMIDE 2 MG CAPSULE RX-4560 CDM 6370000100 HCPCS 250 RC 00378-2100-01 NDC outpatient 1 UN 5.99 5.99 BLUE CROSS BLUE SHIELD WELLMARK SB889 [3081026] BCBS WYOMING [308102603] 5.69 percent of total billed charges 3.71 5.69 Technical (Hospital) Services LOPERAMIDE 2 MG CAPSULE RX-4560 CDM 6370000100 HCPCS 250 RC 00378-2100-01 NDC outpatient 1 UN 5.99 5.99 MEDICA (COMMERCIAL) 94265 [3081118] MEDICA CLAIMS [308111801] 5.39 percent of total billed charges 3.71 5.69 Technical (Hospital) Services LOPERAMIDE 2 MG CAPSULE RX-4560 CDM 6370000100 HCPCS 250 RC 00378-2100-01 NDC outpatient 1 UN 5.99 5.99 CIGNA 62308 [3081051] CIGNA 62308 [308105105] 4.79 percent of total billed charges 3.71 5.69 Technical (Hospital) Services LOPERAMIDE 2 MG CAPSULE RX-4560 CDM 6370000100 HCPCS 250 RC 00378-2100-01 NDC outpatient 1 UN 5.99 5.99 CIGNA 62308 [3081051] CIGNA STATE OF WYOMING [308105107] 4.79 percent of total billed charges 3.71 5.69 Technical (Hospital) Services LOPERAMIDE 2 MG CAPSULE RX-4560 CDM 6370000100 HCPCS 250 RC 00378-2100-01 NDC outpatient 1 UN 5.99 5.99 MULTIPLAN INC 34080 [3081285] MULTIPLAN INC [308128501] 5.69 percent of total billed charges 3.71 5.69 Technical (Hospital) Services LOPERAMIDE 2 MG CAPSULE RX-4560 CDM 6370000100 HCPCS 250 RC 00378-2100-01 NDC outpatient 1 UN 5.99 5.99 UNITED HEALTHCARE (COMMERCIAL) [3081199] UNITED HEALTHCARE 87726 [308119901] 3.71 percent of total billed charges 3.71 5.69 Technical (Hospital) Services LORAZEPAM 2 MG/ML ORAL CONCENTRATE RX-4571 CDM 6370000100 HCPCS 250 RC 00054-3532-44 NDC inpatient 30 ML 114.06 114.06 BLUE CROSS BLUE SHIELD WELLMARK SB889 [3081026] BCBS WYOMING [308102603] 108.36 percent of total billed charges 70.72 108.36 Technical (Hospital) Services LORAZEPAM 2 MG/ML ORAL CONCENTRATE RX-4571 CDM 6370000100 HCPCS 250 RC 00054-3532-44 NDC inpatient 30 ML 114.06 114.06 UNITED HEALTHCARE (COMMERCIAL) [3081199] UNITED HEALTHCARE 87726 [308119901] 70.72 percent of total billed charges 70.72 108.36 Technical (Hospital) Services LORAZEPAM 2 MG/ML ORAL CONCENTRATE RX-4571 CDM 6370000100 HCPCS 250 RC 00054-3532-44 NDC inpatient 30 ML 114.06 114.06 MEDICA (COMMERCIAL) 94265 [3081118] MEDICA CLAIMS [308111801] 102.65 percent of total billed charges 70.72 108.36 Technical (Hospital) Services LORAZEPAM 2 MG/ML ORAL CONCENTRATE RX-4571 CDM 6370000100 HCPCS 250 RC 00054-3532-44 NDC inpatient 30 ML 114.06 114.06 MULTIPLAN INC 34080 [3081285] MULTIPLAN INC [308128501] 108.36 percent of total billed charges 70.72 108.36 Technical (Hospital) Services LORAZEPAM 2 MG/ML ORAL CONCENTRATE RX-4571 CDM 6370000100 HCPCS 250 RC 00054-3532-44 NDC inpatient 30 ML 114.06 114.06 HEALTHPARTNERS SX009 HEALTHPARTNERS 90.31 percent of total billed charges 70.72 108.36 Technical (Hospital) Services LORAZEPAM 2 MG/ML ORAL CONCENTRATE RX-4571 CDM 6370000100 HCPCS 250 RC 00054-3532-44 NDC inpatient 30 ML 114.06 114.06 CIGNA 62308 [3081051] CIGNA 62308 [308105105] 90.31 percent of total billed charges 70.72 108.36 Technical (Hospital) Services LORAZEPAM 2 MG/ML ORAL CONCENTRATE RX-4571 CDM 6370000100 HCPCS 250 RC 00054-3532-44 NDC inpatient 30 ML 114.06 114.06 CIGNA 62308 [3081051] CIGNA STATE OF WYOMING [308105107] 90.31 percent of total billed charges 70.72 108.36 Technical (Hospital) Services LORAZEPAM 2 MG/ML ORAL CONCENTRATE RX-4571 CDM 6370000100 HCPCS 250 RC 00054-3532-44 NDC inpatient 30 ML 114.06 114.06 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES PPO [308136801] 90.31 percent of total billed charges 70.72 108.36 Technical (Hospital) Services LORAZEPAM 2 MG/ML ORAL CONCENTRATE RX-4571 CDM 6370000100 HCPCS 250 RC 00054-3532-44 NDC inpatient 30 ML 114.06 114.06 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES EPO [308136803] 90.31 percent of total billed charges 70.72 108.36 Technical (Hospital) Services LORAZEPAM 2 MG/ML ORAL CONCENTRATE RX-4571 CDM 6370000100 HCPCS 250 RC 00054-3532-44 NDC inpatient 30 ML 114.06 114.06 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES HDHP [308136802] 90.31 percent of total billed charges 70.72 108.36 Technical (Hospital) Services LORAZEPAM 2 MG/ML ORAL CONCENTRATE RX-4571 CDM 6370000100 HCPCS 250 RC 00054-3532-44 NDC outpatient 30 ML 114.06 114.06 MEDICA (COMMERCIAL) 94265 [3081118] MEDICA CLAIMS [308111801] 102.65 percent of total billed charges 70.72 108.36 Technical (Hospital) Services LORAZEPAM 2 MG/ML ORAL CONCENTRATE RX-4571 CDM 6370000100 HCPCS 250 RC 00054-3532-44 NDC outpatient 30 ML 114.06 114.06 MULTIPLAN INC 34080 [3081285] MULTIPLAN INC [308128501] 108.36 percent of total billed charges 70.72 108.36 Technical (Hospital) Services LORAZEPAM 2 MG/ML ORAL CONCENTRATE RX-4571 CDM 6370000100 HCPCS 250 RC 00054-3532-44 NDC outpatient 30 ML 114.06 114.06 CIGNA 62308 [3081051] CIGNA 62308 [308105105] 91.25 percent of total billed charges 70.72 108.36 Technical (Hospital) Services LORAZEPAM 2 MG/ML ORAL CONCENTRATE RX-4571 CDM 6370000100 HCPCS 250 RC 00054-3532-44 NDC outpatient 30 ML 114.06 114.06 CIGNA 62308 [3081051] CIGNA STATE OF WYOMING [308105107] 91.25 percent of total billed charges 70.72 108.36 Technical (Hospital) Services LORAZEPAM 2 MG/ML ORAL CONCENTRATE RX-4571 CDM 6370000100 HCPCS 250 RC 00054-3532-44 NDC outpatient 30 ML 114.06 114.06 HEALTHPARTNERS SX009 HEALTHPARTNERS 91.25 percent of total billed charges 70.72 108.36 Technical (Hospital) Services LORAZEPAM 2 MG/ML ORAL CONCENTRATE RX-4571 CDM 6370000100 HCPCS 250 RC 00054-3532-44 NDC outpatient 30 ML 114.06 114.06 BLUE CROSS BLUE SHIELD WELLMARK SB889 [3081026] BCBS WYOMING [308102603] 108.36 percent of total billed charges 70.72 108.36 Technical (Hospital) Services LORAZEPAM 2 MG/ML ORAL CONCENTRATE RX-4571 CDM 6370000100 HCPCS 250 RC 00054-3532-44 NDC outpatient 30 ML 114.06 114.06 UNITED HEALTHCARE (COMMERCIAL) [3081199] UNITED HEALTHCARE 87726 [308119901] 70.72 percent of total billed charges 70.72 108.36 Technical (Hospital) Services LORAZEPAM 2 MG/ML ORAL CONCENTRATE RX-4571 CDM 6370000100 HCPCS 250 RC 00054-3532-44 NDC outpatient 30 ML 114.06 114.06 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES EPO [308136803] 91.25 percent of total billed charges 70.72 108.36 Technical (Hospital) Services LORAZEPAM 2 MG/ML ORAL CONCENTRATE RX-4571 CDM 6370000100 HCPCS 250 RC 00054-3532-44 NDC outpatient 30 ML 114.06 114.06 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES HDHP [308136802] 91.25 percent of total billed charges 70.72 108.36 Technical (Hospital) Services LORAZEPAM 2 MG/ML ORAL CONCENTRATE RX-4571 CDM 6370000100 HCPCS 250 RC 00054-3532-44 NDC outpatient 30 ML 114.06 114.06 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES PPO [308136801] 91.25 percent of total billed charges 70.72 108.36 Technical (Hospital) Services LORAZEPAM 0.5 MG TABLET RX-4572 CDM 6370000100 HCPCS 250 RC 00904-6007-61 NDC inpatient 1 UN 5.7 5.7 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES PPO [308136801] 4.51 percent of total billed charges 3.53 5.42 Technical (Hospital) Services LORAZEPAM 0.5 MG TABLET RX-4572 CDM 6370000100 HCPCS 250 RC 00904-6007-61 NDC inpatient 1 UN 5.7 5.7 MEDICA (COMMERCIAL) 94265 [3081118] MEDICA CLAIMS [308111801] 5.13 percent of total billed charges 3.53 5.42 Technical (Hospital) Services LORAZEPAM 0.5 MG TABLET RX-4572 CDM 6370000100 HCPCS 250 RC 00904-6007-61 NDC inpatient 1 UN 5.7 5.7 HEALTHPARTNERS SX009 HEALTHPARTNERS 4.51 percent of total billed charges 3.53 5.42 Technical (Hospital) Services LORAZEPAM 0.5 MG TABLET RX-4572 CDM 6370000100 HCPCS 250 RC 00904-6007-61 NDC inpatient 1 UN 5.7 5.7 MULTIPLAN INC 34080 [3081285] MULTIPLAN INC [308128501] 5.42 percent of total billed charges 3.53 5.42 Technical (Hospital) Services LORAZEPAM 0.5 MG TABLET RX-4572 CDM 6370000100 HCPCS 250 RC 00904-6007-61 NDC inpatient 1 UN 5.7 5.7 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES HDHP [308136802] 4.51 percent of total billed charges 3.53 5.42 Technical (Hospital) Services LORAZEPAM 0.5 MG TABLET RX-4572 CDM 6370000100 HCPCS 250 RC 00904-6007-61 NDC inpatient 1 UN 5.7 5.7 BLUE CROSS BLUE SHIELD WELLMARK SB889 [3081026] BCBS WYOMING [308102603] 5.42 percent of total billed charges 3.53 5.42 Technical (Hospital) Services LORAZEPAM 0.5 MG TABLET RX-4572 CDM 6370000100 HCPCS 250 RC 00904-6007-61 NDC inpatient 1 UN 5.7 5.7 CIGNA 62308 [3081051] CIGNA 62308 [308105105] 4.51 percent of total billed charges 3.53 5.42 Technical (Hospital) Services LORAZEPAM 0.5 MG TABLET RX-4572 CDM 6370000100 HCPCS 250 RC 00904-6007-61 NDC inpatient 1 UN 5.7 5.7 CIGNA 62308 [3081051] CIGNA STATE OF WYOMING [308105107] 4.51 percent of total billed charges 3.53 5.42 Technical (Hospital) Services LORAZEPAM 0.5 MG TABLET RX-4572 CDM 6370000100 HCPCS 250 RC 00904-6007-61 NDC inpatient 1 UN 5.7 5.7 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES EPO [308136803] 4.51 percent of total billed charges 3.53 5.42 Technical (Hospital) Services LORAZEPAM 0.5 MG TABLET RX-4572 CDM 6370000100 HCPCS 250 RC 00904-6007-61 NDC inpatient 1 UN 5.7 5.7 UNITED HEALTHCARE (COMMERCIAL) [3081199] UNITED HEALTHCARE 87726 [308119901] 3.53 percent of total billed charges 3.53 5.42 Technical (Hospital) Services LORAZEPAM 0.5 MG TABLET RX-4572 CDM 6370000100 HCPCS 250 RC 00904-6007-61 NDC outpatient 1 UN 5.7 5.7 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES PPO [308136801] 4.56 percent of total billed charges 3.53 5.42 Technical (Hospital) Services LORAZEPAM 0.5 MG TABLET RX-4572 CDM 6370000100 HCPCS 250 RC 00904-6007-61 NDC outpatient 1 UN 5.7 5.7 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES EPO [308136803] 4.56 percent of total billed charges 3.53 5.42 Technical (Hospital) Services LORAZEPAM 0.5 MG TABLET RX-4572 CDM 6370000100 HCPCS 250 RC 00904-6007-61 NDC outpatient 1 UN 5.7 5.7 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES HDHP [308136802] 4.56 percent of total billed charges 3.53 5.42 Technical (Hospital) Services LORAZEPAM 0.5 MG TABLET RX-4572 CDM 6370000100 HCPCS 250 RC 00904-6007-61 NDC outpatient 1 UN 5.7 5.7 MEDICA (COMMERCIAL) 94265 [3081118] MEDICA CLAIMS [308111801] 5.13 percent of total billed charges 3.53 5.42 Technical (Hospital) Services LORAZEPAM 0.5 MG TABLET RX-4572 CDM 6370000100 HCPCS 250 RC 00904-6007-61 NDC outpatient 1 UN 5.7 5.7 BLUE CROSS BLUE SHIELD WELLMARK SB889 [3081026] BCBS WYOMING [308102603] 5.42 percent of total billed charges 3.53 5.42 Technical (Hospital) Services LORAZEPAM 0.5 MG TABLET RX-4572 CDM 6370000100 HCPCS 250 RC 00904-6007-61 NDC outpatient 1 UN 5.7 5.7 MULTIPLAN INC 34080 [3081285] MULTIPLAN INC [308128501] 5.42 percent of total billed charges 3.53 5.42 Technical (Hospital) Services LORAZEPAM 0.5 MG TABLET RX-4572 CDM 6370000100 HCPCS 250 RC 00904-6007-61 NDC outpatient 1 UN 5.7 5.7 CIGNA 62308 [3081051] CIGNA 62308 [308105105] 4.56 percent of total billed charges 3.53 5.42 Technical (Hospital) Services LORAZEPAM 0.5 MG TABLET RX-4572 CDM 6370000100 HCPCS 250 RC 00904-6007-61 NDC outpatient 1 UN 5.7 5.7 CIGNA 62308 [3081051] CIGNA STATE OF WYOMING [308105107] 4.56 percent of total billed charges 3.53 5.42 Technical (Hospital) Services LORAZEPAM 0.5 MG TABLET RX-4572 CDM 6370000100 HCPCS 250 RC 00904-6007-61 NDC outpatient 1 UN 5.7 5.7 UNITED HEALTHCARE (COMMERCIAL) [3081199] UNITED HEALTHCARE 87726 [308119901] 3.53 percent of total billed charges 3.53 5.42 Technical (Hospital) Services LORAZEPAM 0.5 MG TABLET RX-4572 CDM 6370000100 HCPCS 250 RC 00904-6007-61 NDC outpatient 1 UN 5.7 5.7 HEALTHPARTNERS SX009 HEALTHPARTNERS 4.56 percent of total billed charges 3.53 5.42 Technical (Hospital) Services LORAZEPAM 1 MG TABLET RX-4573 CDM 6370000100 HCPCS 250 RC 69315-0905-01 NDC inpatient 1 UN 5.7 5.7 CIGNA 62308 [3081051] CIGNA 62308 [308105105] 4.51 percent of total billed charges 3.53 5.42 Technical (Hospital) Services LORAZEPAM 1 MG TABLET RX-4573 CDM 6370000100 HCPCS 250 RC 69315-0905-01 NDC inpatient 1 UN 5.7 5.7 CIGNA 62308 [3081051] CIGNA STATE OF WYOMING [308105107] 4.51 percent of total billed charges 3.53 5.42 Technical (Hospital) Services LORAZEPAM 1 MG TABLET RX-4573 CDM 6370000100 HCPCS 250 RC 69315-0905-01 NDC inpatient 1 UN 5.7 5.7 UNITED HEALTHCARE (COMMERCIAL) [3081199] UNITED HEALTHCARE 87726 [308119901] 3.53 percent of total billed charges 3.53 5.42 Technical (Hospital) Services LORAZEPAM 1 MG TABLET RX-4573 CDM 6370000100 HCPCS 250 RC 69315-0905-01 NDC inpatient 1 UN 5.7 5.7 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES EPO [308136803] 4.51 percent of total billed charges 3.53 5.42 Technical (Hospital) Services LORAZEPAM 1 MG TABLET RX-4573 CDM 6370000100 HCPCS 250 RC 69315-0905-01 NDC inpatient 1 UN 5.7 5.7 BLUE CROSS BLUE SHIELD WELLMARK SB889 [3081026] BCBS WYOMING [308102603] 5.42 percent of total billed charges 3.53 5.42 Technical (Hospital) Services LORAZEPAM 1 MG TABLET RX-4573 CDM 6370000100 HCPCS 250 RC 69315-0905-01 NDC inpatient 1 UN 5.7 5.7 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES HDHP [308136802] 4.51 percent of total billed charges 3.53 5.42 Technical (Hospital) Services LORAZEPAM 1 MG TABLET RX-4573 CDM 6370000100 HCPCS 250 RC 69315-0905-01 NDC inpatient 1 UN 5.7 5.7 HEALTHPARTNERS SX009 HEALTHPARTNERS 4.51 percent of total billed charges 3.53 5.42 Technical (Hospital) Services LORAZEPAM 1 MG TABLET RX-4573 CDM 6370000100 HCPCS 250 RC 69315-0905-01 NDC inpatient 1 UN 5.7 5.7 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES PPO [308136801] 4.51 percent of total billed charges 3.53 5.42 Technical (Hospital) Services LORAZEPAM 1 MG TABLET RX-4573 CDM 6370000100 HCPCS 250 RC 69315-0905-01 NDC inpatient 1 UN 5.7 5.7 MEDICA (COMMERCIAL) 94265 [3081118] MEDICA CLAIMS [308111801] 5.13 percent of total billed charges 3.53 5.42 Technical (Hospital) Services LORAZEPAM 1 MG TABLET RX-4573 CDM 6370000100 HCPCS 250 RC 69315-0905-01 NDC inpatient 1 UN 5.7 5.7 MULTIPLAN INC 34080 [3081285] MULTIPLAN INC [308128501] 5.42 percent of total billed charges 3.53 5.42 Technical (Hospital) Services LORAZEPAM 1 MG TABLET RX-4573 CDM 6370000100 HCPCS 250 RC 69315-0905-01 NDC outpatient 1 UN 5.7 5.7 UNITED HEALTHCARE (COMMERCIAL) [3081199] UNITED HEALTHCARE 87726 [308119901] 3.53 percent of total billed charges 3.53 5.42 Technical (Hospital) Services LORAZEPAM 1 MG TABLET RX-4573 CDM 6370000100 HCPCS 250 RC 69315-0905-01 NDC outpatient 1 UN 5.7 5.7 MULTIPLAN INC 34080 [3081285] MULTIPLAN INC [308128501] 5.42 percent of total billed charges 3.53 5.42 Technical (Hospital) Services LORAZEPAM 1 MG TABLET RX-4573 CDM 6370000100 HCPCS 250 RC 69315-0905-01 NDC outpatient 1 UN 5.7 5.7 CIGNA 62308 [3081051] CIGNA 62308 [308105105] 4.56 percent of total billed charges 3.53 5.42 Technical (Hospital) Services LORAZEPAM 1 MG TABLET RX-4573 CDM 6370000100 HCPCS 250 RC 69315-0905-01 NDC outpatient 1 UN 5.7 5.7 CIGNA 62308 [3081051] CIGNA STATE OF WYOMING [308105107] 4.56 percent of total billed charges 3.53 5.42 Technical (Hospital) Services LORAZEPAM 1 MG TABLET RX-4573 CDM 6370000100 HCPCS 250 RC 69315-0905-01 NDC outpatient 1 UN 5.7 5.7 MEDICA (COMMERCIAL) 94265 [3081118] MEDICA CLAIMS [308111801] 5.13 percent of total billed charges 3.53 5.42 Technical (Hospital) Services LORAZEPAM 1 MG TABLET RX-4573 CDM 6370000100 HCPCS 250 RC 69315-0905-01 NDC outpatient 1 UN 5.7 5.7 HEALTHPARTNERS SX009 HEALTHPARTNERS 4.56 percent of total billed charges 3.53 5.42 Technical (Hospital) Services LORAZEPAM 1 MG TABLET RX-4573 CDM 6370000100 HCPCS 250 RC 69315-0905-01 NDC outpatient 1 UN 5.7 5.7 BLUE CROSS BLUE SHIELD WELLMARK SB889 [3081026] BCBS WYOMING [308102603] 5.42 percent of total billed charges 3.53 5.42 Technical (Hospital) Services LORAZEPAM 1 MG TABLET RX-4573 CDM 6370000100 HCPCS 250 RC 69315-0905-01 NDC outpatient 1 UN 5.7 5.7 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES EPO [308136803] 4.56 percent of total billed charges 3.53 5.42 Technical (Hospital) Services LORAZEPAM 1 MG TABLET RX-4573 CDM 6370000100 HCPCS 250 RC 69315-0905-01 NDC outpatient 1 UN 5.7 5.7 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES HDHP [308136802] 4.56 percent of total billed charges 3.53 5.42 Technical (Hospital) Services LORAZEPAM 1 MG TABLET RX-4573 CDM 6370000100 HCPCS 250 RC 69315-0905-01 NDC outpatient 1 UN 5.7 5.7 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES PPO [308136801] 4.56 percent of total billed charges 3.53 5.42 Technical (Hospital) Services MAGNESIUM CITRATE ORAL SOLUTION RX-4712 CDM 6370000100 HCPCS 250 RC 71399-0051-01 NDC outpatient 296 ML 14.96 14.96 CIGNA 62308 [3081051] CIGNA 62308 [308105105] 11.97 percent of total billed charges 9.28 14.21 Technical (Hospital) Services MAGNESIUM CITRATE ORAL SOLUTION RX-4712 CDM 6370000100 HCPCS 250 RC 71399-0051-01 NDC outpatient 296 ML 14.96 14.96 CIGNA 62308 [3081051] CIGNA STATE OF WYOMING [308105107] 11.97 percent of total billed charges 9.28 14.21 Technical (Hospital) Services MAGNESIUM CITRATE ORAL SOLUTION RX-4712 CDM 6370000100 HCPCS 250 RC 71399-0051-01 NDC outpatient 296 ML 14.96 14.96 MULTIPLAN INC 34080 [3081285] MULTIPLAN INC [308128501] 14.21 percent of total billed charges 9.28 14.21 Technical (Hospital) Services MAGNESIUM CITRATE ORAL SOLUTION RX-4712 CDM 6370000100 HCPCS 250 RC 71399-0051-01 NDC outpatient 296 ML 14.96 14.96 MEDICA (COMMERCIAL) 94265 [3081118] MEDICA CLAIMS [308111801] 13.46 percent of total billed charges 9.28 14.21 Technical (Hospital) Services MAGNESIUM CITRATE ORAL SOLUTION RX-4712 CDM 6370000100 HCPCS 250 RC 71399-0051-01 NDC outpatient 296 ML 14.96 14.96 HEALTHPARTNERS SX009 HEALTHPARTNERS 11.97 percent of total billed charges 9.28 14.21 Technical (Hospital) Services MAGNESIUM CITRATE ORAL SOLUTION RX-4712 CDM 6370000100 HCPCS 250 RC 71399-0051-01 NDC outpatient 296 ML 14.96 14.96 UNITED HEALTHCARE (COMMERCIAL) [3081199] UNITED HEALTHCARE 87726 [308119901] 9.28 percent of total billed charges 9.28 14.21 Technical (Hospital) Services MAGNESIUM CITRATE ORAL SOLUTION RX-4712 CDM 6370000100 HCPCS 250 RC 71399-0051-01 NDC outpatient 296 ML 14.96 14.96 BLUE CROSS BLUE SHIELD WELLMARK SB889 [3081026] BCBS WYOMING [308102603] 14.21 percent of total billed charges 9.28 14.21 Technical (Hospital) Services MAGNESIUM CITRATE ORAL SOLUTION RX-4712 CDM 6370000100 HCPCS 250 RC 71399-0051-01 NDC outpatient 296 ML 14.96 14.96 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES EPO [308136803] 11.97 percent of total billed charges 9.28 14.21 Technical (Hospital) Services MAGNESIUM CITRATE ORAL SOLUTION RX-4712 CDM 6370000100 HCPCS 250 RC 71399-0051-01 NDC outpatient 296 ML 14.96 14.96 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES HDHP [308136802] 11.97 percent of total billed charges 9.28 14.21 Technical (Hospital) Services MAGNESIUM CITRATE ORAL SOLUTION RX-4712 CDM 6370000100 HCPCS 250 RC 71399-0051-01 NDC outpatient 296 ML 14.96 14.96 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES PPO [308136801] 11.97 percent of total billed charges 9.28 14.21 Technical (Hospital) Services MAGNESIUM CITRATE ORAL SOLUTION RX-4712 CDM 6370000100 HCPCS 250 RC 71399-0051-01 NDC inpatient 296 ML 14.96 14.96 CIGNA 62308 [3081051] CIGNA 62308 [308105105] 11.85 percent of total billed charges 9.28 14.21 Technical (Hospital) Services MAGNESIUM CITRATE ORAL SOLUTION RX-4712 CDM 6370000100 HCPCS 250 RC 71399-0051-01 NDC inpatient 296 ML 14.96 14.96 CIGNA 62308 [3081051] CIGNA STATE OF WYOMING [308105107] 11.85 percent of total billed charges 9.28 14.21 Technical (Hospital) Services MAGNESIUM CITRATE ORAL SOLUTION RX-4712 CDM 6370000100 HCPCS 250 RC 71399-0051-01 NDC inpatient 296 ML 14.96 14.96 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES HDHP [308136802] 11.85 percent of total billed charges 9.28 14.21 Technical (Hospital) Services MAGNESIUM CITRATE ORAL SOLUTION RX-4712 CDM 6370000100 HCPCS 250 RC 71399-0051-01 NDC inpatient 296 ML 14.96 14.96 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES PPO [308136801] 11.85 percent of total billed charges 9.28 14.21 Technical (Hospital) Services MAGNESIUM CITRATE ORAL SOLUTION RX-4712 CDM 6370000100 HCPCS 250 RC 71399-0051-01 NDC inpatient 296 ML 14.96 14.96 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES EPO [308136803] 11.85 percent of total billed charges 9.28 14.21 Technical (Hospital) Services MAGNESIUM CITRATE ORAL SOLUTION RX-4712 CDM 6370000100 HCPCS 250 RC 71399-0051-01 NDC inpatient 296 ML 14.96 14.96 HEALTHPARTNERS SX009 HEALTHPARTNERS 11.85 percent of total billed charges 9.28 14.21 Technical (Hospital) Services MAGNESIUM CITRATE ORAL SOLUTION RX-4712 CDM 6370000100 HCPCS 250 RC 71399-0051-01 NDC inpatient 296 ML 14.96 14.96 MEDICA (COMMERCIAL) 94265 [3081118] MEDICA CLAIMS [308111801] 13.46 percent of total billed charges 9.28 14.21 Technical (Hospital) Services MAGNESIUM CITRATE ORAL SOLUTION RX-4712 CDM 6370000100 HCPCS 250 RC 71399-0051-01 NDC inpatient 296 ML 14.96 14.96 MULTIPLAN INC 34080 [3081285] MULTIPLAN INC [308128501] 14.21 percent of total billed charges 9.28 14.21 Technical (Hospital) Services MAGNESIUM CITRATE ORAL SOLUTION RX-4712 CDM 6370000100 HCPCS 250 RC 71399-0051-01 NDC inpatient 296 ML 14.96 14.96 UNITED HEALTHCARE (COMMERCIAL) [3081199] UNITED HEALTHCARE 87726 [308119901] 9.28 percent of total billed charges 9.28 14.21 Technical (Hospital) Services MAGNESIUM CITRATE ORAL SOLUTION RX-4712 CDM 6370000100 HCPCS 250 RC 71399-0051-01 NDC inpatient 296 ML 14.96 14.96 BLUE CROSS BLUE SHIELD WELLMARK SB889 [3081026] BCBS WYOMING [308102603] 14.21 percent of total billed charges 9.28 14.21 Technical (Hospital) Services MAGNESIUM 500 MG (AS MAGNESIUM OXIDE) TABLET RX-4717 CDM 6370000100 HCPCS 250 RC 00904-4239-60 NDC inpatient 1 UN 5.65 5.65 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES PPO [308136801] 4.47 percent of total billed charges 3.5 5.37 Technical (Hospital) Services MAGNESIUM 500 MG (AS MAGNESIUM OXIDE) TABLET RX-4717 CDM 6370000100 HCPCS 250 RC 00904-4239-60 NDC inpatient 1 UN 5.65 5.65 MEDICA (COMMERCIAL) 94265 [3081118] MEDICA CLAIMS [308111801] 5.09 percent of total billed charges 3.5 5.37 Technical (Hospital) Services MAGNESIUM 500 MG (AS MAGNESIUM OXIDE) TABLET RX-4717 CDM 6370000100 HCPCS 250 RC 00904-4239-60 NDC inpatient 1 UN 5.65 5.65 HEALTHPARTNERS SX009 HEALTHPARTNERS 4.47 percent of total billed charges 3.5 5.37 Technical (Hospital) Services MAGNESIUM 500 MG (AS MAGNESIUM OXIDE) TABLET RX-4717 CDM 6370000100 HCPCS 250 RC 00904-4239-60 NDC inpatient 1 UN 5.65 5.65 MULTIPLAN INC 34080 [3081285] MULTIPLAN INC [308128501] 5.37 percent of total billed charges 3.5 5.37 Technical (Hospital) Services MAGNESIUM 500 MG (AS MAGNESIUM OXIDE) TABLET RX-4717 CDM 6370000100 HCPCS 250 RC 00904-4239-60 NDC inpatient 1 UN 5.65 5.65 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES EPO [308136803] 4.47 percent of total billed charges 3.5 5.37 Technical (Hospital) Services MAGNESIUM 500 MG (AS MAGNESIUM OXIDE) TABLET RX-4717 CDM 6370000100 HCPCS 250 RC 00904-4239-60 NDC inpatient 1 UN 5.65 5.65 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES HDHP [308136802] 4.47 percent of total billed charges 3.5 5.37 Technical (Hospital) Services MAGNESIUM 500 MG (AS MAGNESIUM OXIDE) TABLET RX-4717 CDM 6370000100 HCPCS 250 RC 00904-4239-60 NDC inpatient 1 UN 5.65 5.65 CIGNA 62308 [3081051] CIGNA 62308 [308105105] 4.47 percent of total billed charges 3.5 5.37 Technical (Hospital) Services MAGNESIUM 500 MG (AS MAGNESIUM OXIDE) TABLET RX-4717 CDM 6370000100 HCPCS 250 RC 00904-4239-60 NDC inpatient 1 UN 5.65 5.65 CIGNA 62308 [3081051] CIGNA STATE OF WYOMING [308105107] 4.47 percent of total billed charges 3.5 5.37 Technical (Hospital) Services MAGNESIUM 500 MG (AS MAGNESIUM OXIDE) TABLET RX-4717 CDM 6370000100 HCPCS 250 RC 00904-4239-60 NDC inpatient 1 UN 5.65 5.65 UNITED HEALTHCARE (COMMERCIAL) [3081199] UNITED HEALTHCARE 87726 [308119901] 3.5 percent of total billed charges 3.5 5.37 Technical (Hospital) Services MAGNESIUM 500 MG (AS MAGNESIUM OXIDE) TABLET RX-4717 CDM 6370000100 HCPCS 250 RC 00904-4239-60 NDC inpatient 1 UN 5.65 5.65 BLUE CROSS BLUE SHIELD WELLMARK SB889 [3081026] BCBS WYOMING [308102603] 5.37 percent of total billed charges 3.5 5.37 Technical (Hospital) Services MAGNESIUM 500 MG (AS MAGNESIUM OXIDE) TABLET RX-4717 CDM 6370000100 HCPCS 250 RC 00904-4239-60 NDC outpatient 1 UN 5.65 5.65 BLUE CROSS BLUE SHIELD WELLMARK SB889 [3081026] BCBS WYOMING [308102603] 5.37 percent of total billed charges 3.5 5.37 Technical (Hospital) Services MAGNESIUM 500 MG (AS MAGNESIUM OXIDE) TABLET RX-4717 CDM 6370000100 HCPCS 250 RC 00904-4239-60 NDC outpatient 1 UN 5.65 5.65 UNITED HEALTHCARE (COMMERCIAL) [3081199] UNITED HEALTHCARE 87726 [308119901] 3.5 percent of total billed charges 3.5 5.37 Technical (Hospital) Services MAGNESIUM 500 MG (AS MAGNESIUM OXIDE) TABLET RX-4717 CDM 6370000100 HCPCS 250 RC 00904-4239-60 NDC outpatient 1 UN 5.65 5.65 HEALTHPARTNERS SX009 HEALTHPARTNERS 4.52 percent of total billed charges 3.5 5.37 Technical (Hospital) Services MAGNESIUM 500 MG (AS MAGNESIUM OXIDE) TABLET RX-4717 CDM 6370000100 HCPCS 250 RC 00904-4239-60 NDC outpatient 1 UN 5.65 5.65 MULTIPLAN INC 34080 [3081285] MULTIPLAN INC [308128501] 5.37 percent of total billed charges 3.5 5.37 Technical (Hospital) Services MAGNESIUM 500 MG (AS MAGNESIUM OXIDE) TABLET RX-4717 CDM 6370000100 HCPCS 250 RC 00904-4239-60 NDC outpatient 1 UN 5.65 5.65 CIGNA 62308 [3081051] CIGNA 62308 [308105105] 4.52 percent of total billed charges 3.5 5.37 Technical (Hospital) Services MAGNESIUM 500 MG (AS MAGNESIUM OXIDE) TABLET RX-4717 CDM 6370000100 HCPCS 250 RC 00904-4239-60 NDC outpatient 1 UN 5.65 5.65 CIGNA 62308 [3081051] CIGNA STATE OF WYOMING [308105107] 4.52 percent of total billed charges 3.5 5.37 Technical (Hospital) Services MAGNESIUM 500 MG (AS MAGNESIUM OXIDE) TABLET RX-4717 CDM 6370000100 HCPCS 250 RC 00904-4239-60 NDC outpatient 1 UN 5.65 5.65 MEDICA (COMMERCIAL) 94265 [3081118] MEDICA CLAIMS [308111801] 5.09 percent of total billed charges 3.5 5.37 Technical (Hospital) Services MAGNESIUM 500 MG (AS MAGNESIUM OXIDE) TABLET RX-4717 CDM 6370000100 HCPCS 250 RC 00904-4239-60 NDC outpatient 1 UN 5.65 5.65 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES EPO [308136803] 4.52 percent of total billed charges 3.5 5.37 Technical (Hospital) Services MAGNESIUM 500 MG (AS MAGNESIUM OXIDE) TABLET RX-4717 CDM 6370000100 HCPCS 250 RC 00904-4239-60 NDC outpatient 1 UN 5.65 5.65 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES HDHP [308136802] 4.52 percent of total billed charges 3.5 5.37 Technical (Hospital) Services MAGNESIUM 500 MG (AS MAGNESIUM OXIDE) TABLET RX-4717 CDM 6370000100 HCPCS 250 RC 00904-4239-60 NDC outpatient 1 UN 5.65 5.65 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES PPO [308136801] 4.52 percent of total billed charges 3.5 5.37 Technical (Hospital) Services MEDROXYPROGESTERONE 2.5 MG TABLET RX-4855 CDM 6370000100 HCPCS 250 RC 00555-0872-02 NDC inpatient 1 UN 5.76 5.76 HEALTHPARTNERS SX009 HEALTHPARTNERS 4.56 percent of total billed charges 3.57 5.47 Technical (Hospital) Services MEDROXYPROGESTERONE 2.5 MG TABLET RX-4855 CDM 6370000100 HCPCS 250 RC 00555-0872-02 NDC inpatient 1 UN 5.76 5.76 MEDICA (COMMERCIAL) 94265 [3081118] MEDICA CLAIMS [308111801] 5.18 percent of total billed charges 3.57 5.47 Technical (Hospital) Services MEDROXYPROGESTERONE 2.5 MG TABLET RX-4855 CDM 6370000100 HCPCS 250 RC 00555-0872-02 NDC inpatient 1 UN 5.76 5.76 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES PPO [308136801] 4.56 percent of total billed charges 3.57 5.47 Technical (Hospital) Services MEDROXYPROGESTERONE 2.5 MG TABLET RX-4855 CDM 6370000100 HCPCS 250 RC 00555-0872-02 NDC inpatient 1 UN 5.76 5.76 MULTIPLAN INC 34080 [3081285] MULTIPLAN INC [308128501] 5.47 percent of total billed charges 3.57 5.47 Technical (Hospital) Services MEDROXYPROGESTERONE 2.5 MG TABLET RX-4855 CDM 6370000100 HCPCS 250 RC 00555-0872-02 NDC inpatient 1 UN 5.76 5.76 CIGNA 62308 [3081051] CIGNA 62308 [308105105] 4.56 percent of total billed charges 3.57 5.47 Technical (Hospital) Services MEDROXYPROGESTERONE 2.5 MG TABLET RX-4855 CDM 6370000100 HCPCS 250 RC 00555-0872-02 NDC inpatient 1 UN 5.76 5.76 CIGNA 62308 [3081051] CIGNA STATE OF WYOMING [308105107] 4.56 percent of total billed charges 3.57 5.47 Technical (Hospital) Services MEDROXYPROGESTERONE 2.5 MG TABLET RX-4855 CDM 6370000100 HCPCS 250 RC 00555-0872-02 NDC inpatient 1 UN 5.76 5.76 UNITED HEALTHCARE (COMMERCIAL) [3081199] UNITED HEALTHCARE 87726 [308119901] 3.57 percent of total billed charges 3.57 5.47 Technical (Hospital) Services MEDROXYPROGESTERONE 2.5 MG TABLET RX-4855 CDM 6370000100 HCPCS 250 RC 00555-0872-02 NDC inpatient 1 UN 5.76 5.76 BLUE CROSS BLUE SHIELD WELLMARK SB889 [3081026] BCBS WYOMING [308102603] 5.47 percent of total billed charges 3.57 5.47 Technical (Hospital) Services MEDROXYPROGESTERONE 2.5 MG TABLET RX-4855 CDM 6370000100 HCPCS 250 RC 00555-0872-02 NDC inpatient 1 UN 5.76 5.76 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES HDHP [308136802] 4.56 percent of total billed charges 3.57 5.47 Technical (Hospital) Services MEDROXYPROGESTERONE 2.5 MG TABLET RX-4855 CDM 6370000100 HCPCS 250 RC 00555-0872-02 NDC inpatient 1 UN 5.76 5.76 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES EPO [308136803] 4.56 percent of total billed charges 3.57 5.47 Technical (Hospital) Services MEDROXYPROGESTERONE 2.5 MG TABLET RX-4855 CDM 6370000100 HCPCS 250 RC 00555-0872-02 NDC outpatient 1 UN 5.76 5.76 MEDICA (COMMERCIAL) 94265 [3081118] MEDICA CLAIMS [308111801] 5.18 percent of total billed charges 3.57 5.47 Technical (Hospital) Services MEDROXYPROGESTERONE 2.5 MG TABLET RX-4855 CDM 6370000100 HCPCS 250 RC 00555-0872-02 NDC outpatient 1 UN 5.76 5.76 CIGNA 62308 [3081051] CIGNA 62308 [308105105] 4.61 percent of total billed charges 3.57 5.47 Technical (Hospital) Services MEDROXYPROGESTERONE 2.5 MG TABLET RX-4855 CDM 6370000100 HCPCS 250 RC 00555-0872-02 NDC outpatient 1 UN 5.76 5.76 CIGNA 62308 [3081051] CIGNA STATE OF WYOMING [308105107] 4.61 percent of total billed charges 3.57 5.47 Technical (Hospital) Services MEDROXYPROGESTERONE 2.5 MG TABLET RX-4855 CDM 6370000100 HCPCS 250 RC 00555-0872-02 NDC outpatient 1 UN 5.76 5.76 MULTIPLAN INC 34080 [3081285] MULTIPLAN INC [308128501] 5.47 percent of total billed charges 3.57 5.47 Technical (Hospital) Services MEDROXYPROGESTERONE 2.5 MG TABLET RX-4855 CDM 6370000100 HCPCS 250 RC 00555-0872-02 NDC outpatient 1 UN 5.76 5.76 UNITED HEALTHCARE (COMMERCIAL) [3081199] UNITED HEALTHCARE 87726 [308119901] 3.57 percent of total billed charges 3.57 5.47 Technical (Hospital) Services MEDROXYPROGESTERONE 2.5 MG TABLET RX-4855 CDM 6370000100 HCPCS 250 RC 00555-0872-02 NDC outpatient 1 UN 5.76 5.76 HEALTHPARTNERS SX009 HEALTHPARTNERS 4.61 percent of total billed charges 3.57 5.47 Technical (Hospital) Services MEDROXYPROGESTERONE 2.5 MG TABLET RX-4855 CDM 6370000100 HCPCS 250 RC 00555-0872-02 NDC outpatient 1 UN 5.76 5.76 BLUE CROSS BLUE SHIELD WELLMARK SB889 [3081026] BCBS WYOMING [308102603] 5.47 percent of total billed charges 3.57 5.47 Technical (Hospital) Services MEDROXYPROGESTERONE 2.5 MG TABLET RX-4855 CDM 6370000100 HCPCS 250 RC 00555-0872-02 NDC outpatient 1 UN 5.76 5.76 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES EPO [308136803] 4.61 percent of total billed charges 3.57 5.47 Technical (Hospital) Services MEDROXYPROGESTERONE 2.5 MG TABLET RX-4855 CDM 6370000100 HCPCS 250 RC 00555-0872-02 NDC outpatient 1 UN 5.76 5.76 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES PPO [308136801] 4.61 percent of total billed charges 3.57 5.47 Technical (Hospital) Services MEDROXYPROGESTERONE 2.5 MG TABLET RX-4855 CDM 6370000100 HCPCS 250 RC 00555-0872-02 NDC outpatient 1 UN 5.76 5.76 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES HDHP [308136802] 4.61 percent of total billed charges 3.57 5.47 Technical (Hospital) Services WCH ED PROMETHAZINE 25 MG RECTAL SUPPOSITORY #3 SUPP RX-48840030 CDM 6370000100 HCPCS 250 RC 09999-9990-28 NDC inpatient 75 ME 42.99 42.99 UNITED HEALTHCARE (COMMERCIAL) [3081199] UNITED HEALTHCARE 87726 [308119901] 26.65 percent of total billed charges 26.65 40.84 Technical (Hospital) Services WCH ED PROMETHAZINE 25 MG RECTAL SUPPOSITORY #3 SUPP RX-48840030 CDM 6370000100 HCPCS 250 RC 09999-9990-28 NDC inpatient 75 ME 42.99 42.99 BLUE CROSS BLUE SHIELD WELLMARK SB889 [3081026] BCBS WYOMING [308102603] 40.84 percent of total billed charges 26.65 40.84 Technical (Hospital) Services WCH ED PROMETHAZINE 25 MG RECTAL SUPPOSITORY #3 SUPP RX-48840030 CDM 6370000100 HCPCS 250 RC 09999-9990-28 NDC inpatient 75 ME 42.99 42.99 HEALTHPARTNERS SX009 HEALTHPARTNERS 34.04 percent of total billed charges 26.65 40.84 Technical (Hospital) Services WCH ED PROMETHAZINE 25 MG RECTAL SUPPOSITORY #3 SUPP RX-48840030 CDM 6370000100 HCPCS 250 RC 09999-9990-28 NDC inpatient 75 ME 42.99 42.99 MEDICA (COMMERCIAL) 94265 [3081118] MEDICA CLAIMS [308111801] 38.69 percent of total billed charges 26.65 40.84 Technical (Hospital) Services WCH ED PROMETHAZINE 25 MG RECTAL SUPPOSITORY #3 SUPP RX-48840030 CDM 6370000100 HCPCS 250 RC 09999-9990-28 NDC inpatient 75 ME 42.99 42.99 MULTIPLAN INC 34080 [3081285] MULTIPLAN INC [308128501] 40.84 percent of total billed charges 26.65 40.84 Technical (Hospital) Services WCH ED PROMETHAZINE 25 MG RECTAL SUPPOSITORY #3 SUPP RX-48840030 CDM 6370000100 HCPCS 250 RC 09999-9990-28 NDC inpatient 75 ME 42.99 42.99 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES HDHP [308136802] 34.04 percent of total billed charges 26.65 40.84 Technical (Hospital) Services WCH ED PROMETHAZINE 25 MG RECTAL SUPPOSITORY #3 SUPP RX-48840030 CDM 6370000100 HCPCS 250 RC 09999-9990-28 NDC inpatient 75 ME 42.99 42.99 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES PPO [308136801] 34.04 percent of total billed charges 26.65 40.84 Technical (Hospital) Services WCH ED PROMETHAZINE 25 MG RECTAL SUPPOSITORY #3 SUPP RX-48840030 CDM 6370000100 HCPCS 250 RC 09999-9990-28 NDC inpatient 75 ME 42.99 42.99 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES EPO [308136803] 34.04 percent of total billed charges 26.65 40.84 Technical (Hospital) Services WCH ED PROMETHAZINE 25 MG RECTAL SUPPOSITORY #3 SUPP RX-48840030 CDM 6370000100 HCPCS 250 RC 09999-9990-28 NDC inpatient 75 ME 42.99 42.99 CIGNA 62308 [3081051] CIGNA 62308 [308105105] 34.04 percent of total billed charges 26.65 40.84 Technical (Hospital) Services WCH ED PROMETHAZINE 25 MG RECTAL SUPPOSITORY #3 SUPP RX-48840030 CDM 6370000100 HCPCS 250 RC 09999-9990-28 NDC inpatient 75 ME 42.99 42.99 CIGNA 62308 [3081051] CIGNA STATE OF WYOMING [308105107] 34.04 percent of total billed charges 26.65 40.84 Technical (Hospital) Services WCH ED PROMETHAZINE 25 MG RECTAL SUPPOSITORY #3 SUPP RX-48840030 CDM 6370000100 HCPCS 250 RC 09999-9990-28 NDC outpatient 75 ME 42.99 42.99 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES EPO [308136803] 34.39 percent of total billed charges 26.65 40.84 Technical (Hospital) Services WCH ED PROMETHAZINE 25 MG RECTAL SUPPOSITORY #3 SUPP RX-48840030 CDM 6370000100 HCPCS 250 RC 09999-9990-28 NDC outpatient 75 ME 42.99 42.99 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES HDHP [308136802] 34.39 percent of total billed charges 26.65 40.84 Technical (Hospital) Services WCH ED PROMETHAZINE 25 MG RECTAL SUPPOSITORY #3 SUPP RX-48840030 CDM 6370000100 HCPCS 250 RC 09999-9990-28 NDC outpatient 75 ME 42.99 42.99 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES PPO [308136801] 34.39 percent of total billed charges 26.65 40.84 Technical (Hospital) Services WCH ED PROMETHAZINE 25 MG RECTAL SUPPOSITORY #3 SUPP RX-48840030 CDM 6370000100 HCPCS 250 RC 09999-9990-28 NDC outpatient 75 ME 42.99 42.99 UNITED HEALTHCARE (COMMERCIAL) [3081199] UNITED HEALTHCARE 87726 [308119901] 26.65 percent of total billed charges 26.65 40.84 Technical (Hospital) Services WCH ED PROMETHAZINE 25 MG RECTAL SUPPOSITORY #3 SUPP RX-48840030 CDM 6370000100 HCPCS 250 RC 09999-9990-28 NDC outpatient 75 ME 42.99 42.99 BLUE CROSS BLUE SHIELD WELLMARK SB889 [3081026] BCBS WYOMING [308102603] 40.84 percent of total billed charges 26.65 40.84 Technical (Hospital) Services WCH ED PROMETHAZINE 25 MG RECTAL SUPPOSITORY #3 SUPP RX-48840030 CDM 6370000100 HCPCS 250 RC 09999-9990-28 NDC outpatient 75 ME 42.99 42.99 HEALTHPARTNERS SX009 HEALTHPARTNERS 34.39 percent of total billed charges 26.65 40.84 Technical (Hospital) Services WCH ED PROMETHAZINE 25 MG RECTAL SUPPOSITORY #3 SUPP RX-48840030 CDM 6370000100 HCPCS 250 RC 09999-9990-28 NDC outpatient 75 ME 42.99 42.99 CIGNA 62308 [3081051] CIGNA 62308 [308105105] 34.39 percent of total billed charges 26.65 40.84 Technical (Hospital) Services WCH ED PROMETHAZINE 25 MG RECTAL SUPPOSITORY #3 SUPP RX-48840030 CDM 6370000100 HCPCS 250 RC 09999-9990-28 NDC outpatient 75 ME 42.99 42.99 CIGNA 62308 [3081051] CIGNA STATE OF WYOMING [308105107] 34.39 percent of total billed charges 26.65 40.84 Technical (Hospital) Services WCH ED PROMETHAZINE 25 MG RECTAL SUPPOSITORY #3 SUPP RX-48840030 CDM 6370000100 HCPCS 250 RC 09999-9990-28 NDC outpatient 75 ME 42.99 42.99 MEDICA (COMMERCIAL) 94265 [3081118] MEDICA CLAIMS [308111801] 38.69 percent of total billed charges 26.65 40.84 Technical (Hospital) Services WCH ED PROMETHAZINE 25 MG RECTAL SUPPOSITORY #3 SUPP RX-48840030 CDM 6370000100 HCPCS 250 RC 09999-9990-28 NDC outpatient 75 ME 42.99 42.99 MULTIPLAN INC 34080 [3081285] MULTIPLAN INC [308128501] 40.84 percent of total billed charges 26.65 40.84 Technical (Hospital) Services MEPERIDINE 50 MG TABLET RX-4908 CDM 6370000100 HCPCS 250 RC 42806-0050-30 NDC inpatient 1 UN 137.29 137.29 MULTIPLAN INC 34080 [3081285] MULTIPLAN INC [308128501] 130.43 percent of total billed charges 85.12 130.43 Technical (Hospital) Services MEPERIDINE 50 MG TABLET RX-4908 CDM 6370000100 HCPCS 250 RC 42806-0050-30 NDC inpatient 1 UN 137.29 137.29 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES PPO [308136801] 108.71 percent of total billed charges 85.12 130.43 Technical (Hospital) Services MEPERIDINE 50 MG TABLET RX-4908 CDM 6370000100 HCPCS 250 RC 42806-0050-30 NDC inpatient 1 UN 137.29 137.29 MEDICA (COMMERCIAL) 94265 [3081118] MEDICA CLAIMS [308111801] 123.56 percent of total billed charges 85.12 130.43 Technical (Hospital) Services MEPERIDINE 50 MG TABLET RX-4908 CDM 6370000100 HCPCS 250 RC 42806-0050-30 NDC inpatient 1 UN 137.29 137.29 CIGNA 62308 [3081051] CIGNA STATE OF WYOMING [308105107] 108.71 percent of total billed charges 85.12 130.43 Technical (Hospital) Services MEPERIDINE 50 MG TABLET RX-4908 CDM 6370000100 HCPCS 250 RC 42806-0050-30 NDC inpatient 1 UN 137.29 137.29 CIGNA 62308 [3081051] CIGNA 62308 [308105105] 108.71 percent of total billed charges 85.12 130.43 Technical (Hospital) Services MEPERIDINE 50 MG TABLET RX-4908 CDM 6370000100 HCPCS 250 RC 42806-0050-30 NDC inpatient 1 UN 137.29 137.29 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES EPO [308136803] 108.71 percent of total billed charges 85.12 130.43 Technical (Hospital) Services MEPERIDINE 50 MG TABLET RX-4908 CDM 6370000100 HCPCS 250 RC 42806-0050-30 NDC inpatient 1 UN 137.29 137.29 UNITED HEALTHCARE (COMMERCIAL) [3081199] UNITED HEALTHCARE 87726 [308119901] 85.12 percent of total billed charges 85.12 130.43 Technical (Hospital) Services MEPERIDINE 50 MG TABLET RX-4908 CDM 6370000100 HCPCS 250 RC 42806-0050-30 NDC inpatient 1 UN 137.29 137.29 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES HDHP [308136802] 108.71 percent of total billed charges 85.12 130.43 Technical (Hospital) Services MEPERIDINE 50 MG TABLET RX-4908 CDM 6370000100 HCPCS 250 RC 42806-0050-30 NDC inpatient 1 UN 137.29 137.29 HEALTHPARTNERS SX009 HEALTHPARTNERS 108.71 percent of total billed charges 85.12 130.43 Technical (Hospital) Services MEPERIDINE 50 MG TABLET RX-4908 CDM 6370000100 HCPCS 250 RC 42806-0050-30 NDC inpatient 1 UN 137.29 137.29 BLUE CROSS BLUE SHIELD WELLMARK SB889 [3081026] BCBS WYOMING [308102603] 130.43 percent of total billed charges 85.12 130.43 Technical (Hospital) Services MEPERIDINE 50 MG TABLET RX-4908 CDM 6370000100 HCPCS 250 RC 42806-0050-30 NDC outpatient 1 UN 137.29 137.29 BLUE CROSS BLUE SHIELD WELLMARK SB889 [3081026] BCBS WYOMING [308102603] 130.43 percent of total billed charges 85.12 130.43 Technical (Hospital) Services MEPERIDINE 50 MG TABLET RX-4908 CDM 6370000100 HCPCS 250 RC 42806-0050-30 NDC outpatient 1 UN 137.29 137.29 HEALTHPARTNERS SX009 HEALTHPARTNERS 109.83 percent of total billed charges 85.12 130.43 Technical (Hospital) Services MEPERIDINE 50 MG TABLET RX-4908 CDM 6370000100 HCPCS 250 RC 42806-0050-30 NDC outpatient 1 UN 137.29 137.29 UNITED HEALTHCARE (COMMERCIAL) [3081199] UNITED HEALTHCARE 87726 [308119901] 85.12 percent of total billed charges 85.12 130.43 Technical (Hospital) Services MEPERIDINE 50 MG TABLET RX-4908 CDM 6370000100 HCPCS 250 RC 42806-0050-30 NDC outpatient 1 UN 137.29 137.29 MULTIPLAN INC 34080 [3081285] MULTIPLAN INC [308128501] 130.43 percent of total billed charges 85.12 130.43 Technical (Hospital) Services MEPERIDINE 50 MG TABLET RX-4908 CDM 6370000100 HCPCS 250 RC 42806-0050-30 NDC outpatient 1 UN 137.29 137.29 CIGNA 62308 [3081051] CIGNA 62308 [308105105] 109.83 percent of total billed charges 85.12 130.43 Technical (Hospital) Services MEPERIDINE 50 MG TABLET RX-4908 CDM 6370000100 HCPCS 250 RC 42806-0050-30 NDC outpatient 1 UN 137.29 137.29 CIGNA 62308 [3081051] CIGNA STATE OF WYOMING [308105107] 109.83 percent of total billed charges 85.12 130.43 Technical (Hospital) Services MEPERIDINE 50 MG TABLET RX-4908 CDM 6370000100 HCPCS 250 RC 42806-0050-30 NDC outpatient 1 UN 137.29 137.29 MEDICA (COMMERCIAL) 94265 [3081118] MEDICA CLAIMS [308111801] 123.56 percent of total billed charges 85.12 130.43 Technical (Hospital) Services MEPERIDINE 50 MG TABLET RX-4908 CDM 6370000100 HCPCS 250 RC 42806-0050-30 NDC outpatient 1 UN 137.29 137.29 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES HDHP [308136802] 109.83 percent of total billed charges 85.12 130.43 Technical (Hospital) Services MEPERIDINE 50 MG TABLET RX-4908 CDM 6370000100 HCPCS 250 RC 42806-0050-30 NDC outpatient 1 UN 137.29 137.29 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES PPO [308136801] 109.83 percent of total billed charges 85.12 130.43 Technical (Hospital) Services MEPERIDINE 50 MG TABLET RX-4908 CDM 6370000100 HCPCS 250 RC 42806-0050-30 NDC outpatient 1 UN 137.29 137.29 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES EPO [308136803] 109.83 percent of total billed charges 85.12 130.43 Technical (Hospital) Services METHOCARBAMOL 500 MG TABLET RX-4971 CDM 6370000100 HCPCS 250 RC 76385-0123-01 NDC outpatient 1 UN 5.7 5.7 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES HDHP [308136802] 4.56 percent of total billed charges 3.53 5.42 Technical (Hospital) Services METHOCARBAMOL 500 MG TABLET RX-4971 CDM 6370000100 HCPCS 250 RC 76385-0123-01 NDC outpatient 1 UN 5.7 5.7 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES EPO [308136803] 4.56 percent of total billed charges 3.53 5.42 Technical (Hospital) Services METHOCARBAMOL 500 MG TABLET RX-4971 CDM 6370000100 HCPCS 250 RC 76385-0123-01 NDC outpatient 1 UN 5.7 5.7 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES PPO [308136801] 4.56 percent of total billed charges 3.53 5.42 Technical (Hospital) Services METHOCARBAMOL 500 MG TABLET RX-4971 CDM 6370000100 HCPCS 250 RC 76385-0123-01 NDC outpatient 1 UN 5.7 5.7 HEALTHPARTNERS SX009 HEALTHPARTNERS 4.56 percent of total billed charges 3.53 5.42 Technical (Hospital) Services METHOCARBAMOL 500 MG TABLET RX-4971 CDM 6370000100 HCPCS 250 RC 76385-0123-01 NDC outpatient 1 UN 5.7 5.7 BLUE CROSS BLUE SHIELD WELLMARK SB889 [3081026] BCBS WYOMING [308102603] 5.42 percent of total billed charges 3.53 5.42 Technical (Hospital) Services METHOCARBAMOL 500 MG TABLET RX-4971 CDM 6370000100 HCPCS 250 RC 76385-0123-01 NDC outpatient 1 UN 5.7 5.7 MEDICA (COMMERCIAL) 94265 [3081118] MEDICA CLAIMS [308111801] 5.13 percent of total billed charges 3.53 5.42 Technical (Hospital) Services METHOCARBAMOL 500 MG TABLET RX-4971 CDM 6370000100 HCPCS 250 RC 76385-0123-01 NDC outpatient 1 UN 5.7 5.7 MULTIPLAN INC 34080 [3081285] MULTIPLAN INC [308128501] 5.42 percent of total billed charges 3.53 5.42 Technical (Hospital) Services METHOCARBAMOL 500 MG TABLET RX-4971 CDM 6370000100 HCPCS 250 RC 76385-0123-01 NDC outpatient 1 UN 5.7 5.7 CIGNA 62308 [3081051] CIGNA 62308 [308105105] 4.56 percent of total billed charges 3.53 5.42 Technical (Hospital) Services METHOCARBAMOL 500 MG TABLET RX-4971 CDM 6370000100 HCPCS 250 RC 76385-0123-01 NDC outpatient 1 UN 5.7 5.7 CIGNA 62308 [3081051] CIGNA STATE OF WYOMING [308105107] 4.56 percent of total billed charges 3.53 5.42 Technical (Hospital) Services METHOCARBAMOL 500 MG TABLET RX-4971 CDM 6370000100 HCPCS 250 RC 76385-0123-01 NDC outpatient 1 UN 5.7 5.7 UNITED HEALTHCARE (COMMERCIAL) [3081199] UNITED HEALTHCARE 87726 [308119901] 3.53 percent of total billed charges 3.53 5.42 Technical (Hospital) Services METHOCARBAMOL 500 MG TABLET RX-4971 CDM 6370000100 HCPCS 250 RC 76385-0123-01 NDC inpatient 1 UN 5.7 5.7 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES PPO [308136801] 4.51 percent of total billed charges 3.53 5.42 Technical (Hospital) Services METHOCARBAMOL 500 MG TABLET RX-4971 CDM 6370000100 HCPCS 250 RC 76385-0123-01 NDC inpatient 1 UN 5.7 5.7 MEDICA (COMMERCIAL) 94265 [3081118] MEDICA CLAIMS [308111801] 5.13 percent of total billed charges 3.53 5.42 Technical (Hospital) Services METHOCARBAMOL 500 MG TABLET RX-4971 CDM 6370000100 HCPCS 250 RC 76385-0123-01 NDC inpatient 1 UN 5.7 5.7 HEALTHPARTNERS SX009 HEALTHPARTNERS 4.51 percent of total billed charges 3.53 5.42 Technical (Hospital) Services METHOCARBAMOL 500 MG TABLET RX-4971 CDM 6370000100 HCPCS 250 RC 76385-0123-01 NDC inpatient 1 UN 5.7 5.7 MULTIPLAN INC 34080 [3081285] MULTIPLAN INC [308128501] 5.42 percent of total billed charges 3.53 5.42 Technical (Hospital) Services METHOCARBAMOL 500 MG TABLET RX-4971 CDM 6370000100 HCPCS 250 RC 76385-0123-01 NDC inpatient 1 UN 5.7 5.7 UNITED HEALTHCARE (COMMERCIAL) [3081199] UNITED HEALTHCARE 87726 [308119901] 3.53 percent of total billed charges 3.53 5.42 Technical (Hospital) Services METHOCARBAMOL 500 MG TABLET RX-4971 CDM 6370000100 HCPCS 250 RC 76385-0123-01 NDC inpatient 1 UN 5.7 5.7 CIGNA 62308 [3081051] CIGNA 62308 [308105105] 4.51 percent of total billed charges 3.53 5.42 Technical (Hospital) Services METHOCARBAMOL 500 MG TABLET RX-4971 CDM 6370000100 HCPCS 250 RC 76385-0123-01 NDC inpatient 1 UN 5.7 5.7 CIGNA 62308 [3081051] CIGNA STATE OF WYOMING [308105107] 4.51 percent of total billed charges 3.53 5.42 Technical (Hospital) Services METHOCARBAMOL 500 MG TABLET RX-4971 CDM 6370000100 HCPCS 250 RC 76385-0123-01 NDC inpatient 1 UN 5.7 5.7 BLUE CROSS BLUE SHIELD WELLMARK SB889 [3081026] BCBS WYOMING [308102603] 5.42 percent of total billed charges 3.53 5.42 Technical (Hospital) Services METHOCARBAMOL 500 MG TABLET RX-4971 CDM 6370000100 HCPCS 250 RC 76385-0123-01 NDC inpatient 1 UN 5.7 5.7 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES EPO [308136803] 4.51 percent of total billed charges 3.53 5.42 Technical (Hospital) Services METHOCARBAMOL 500 MG TABLET RX-4971 CDM 6370000100 HCPCS 250 RC 76385-0123-01 NDC inpatient 1 UN 5.7 5.7 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES HDHP [308136802] 4.51 percent of total billed charges 3.53 5.42 Technical (Hospital) Services METHOCARBAMOL 750 MG TABLET RX-4972 CDM 6370000100 HCPCS 250 RC 31722-0534-01 NDC inpatient 1 UN 5.68 5.68 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES PPO [308136801] 4.5 percent of total billed charges 3.52 5.4 Technical (Hospital) Services METHOCARBAMOL 750 MG TABLET RX-4972 CDM 6370000100 HCPCS 250 RC 31722-0534-01 NDC inpatient 1 UN 5.68 5.68 MEDICA (COMMERCIAL) 94265 [3081118] MEDICA CLAIMS [308111801] 5.11 percent of total billed charges 3.52 5.4 Technical (Hospital) Services METHOCARBAMOL 750 MG TABLET RX-4972 CDM 6370000100 HCPCS 250 RC 31722-0534-01 NDC inpatient 1 UN 5.68 5.68 HEALTHPARTNERS SX009 HEALTHPARTNERS 4.5 percent of total billed charges 3.52 5.4 Technical (Hospital) Services METHOCARBAMOL 750 MG TABLET RX-4972 CDM 6370000100 HCPCS 250 RC 31722-0534-01 NDC inpatient 1 UN 5.68 5.68 MULTIPLAN INC 34080 [3081285] MULTIPLAN INC [308128501] 5.4 percent of total billed charges 3.52 5.4 Technical (Hospital) Services METHOCARBAMOL 750 MG TABLET RX-4972 CDM 6370000100 HCPCS 250 RC 31722-0534-01 NDC inpatient 1 UN 5.68 5.68 BLUE CROSS BLUE SHIELD WELLMARK SB889 [3081026] BCBS WYOMING [308102603] 5.4 percent of total billed charges 3.52 5.4 Technical (Hospital) Services METHOCARBAMOL 750 MG TABLET RX-4972 CDM 6370000100 HCPCS 250 RC 31722-0534-01 NDC inpatient 1 UN 5.68 5.68 UNITED HEALTHCARE (COMMERCIAL) [3081199] UNITED HEALTHCARE 87726 [308119901] 3.52 percent of total billed charges 3.52 5.4 Technical (Hospital) Services METHOCARBAMOL 750 MG TABLET RX-4972 CDM 6370000100 HCPCS 250 RC 31722-0534-01 NDC inpatient 1 UN 5.68 5.68 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES EPO [308136803] 4.5 percent of total billed charges 3.52 5.4 Technical (Hospital) Services METHOCARBAMOL 750 MG TABLET RX-4972 CDM 6370000100 HCPCS 250 RC 31722-0534-01 NDC inpatient 1 UN 5.68 5.68 CIGNA 62308 [3081051] CIGNA 62308 [308105105] 4.5 percent of total billed charges 3.52 5.4 Technical (Hospital) Services METHOCARBAMOL 750 MG TABLET RX-4972 CDM 6370000100 HCPCS 250 RC 31722-0534-01 NDC inpatient 1 UN 5.68 5.68 CIGNA 62308 [3081051] CIGNA STATE OF WYOMING [308105107] 4.5 percent of total billed charges 3.52 5.4 Technical (Hospital) Services METHOCARBAMOL 750 MG TABLET RX-4972 CDM 6370000100 HCPCS 250 RC 31722-0534-01 NDC inpatient 1 UN 5.68 5.68 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES HDHP [308136802] 4.5 percent of total billed charges 3.52 5.4 Technical (Hospital) Services METHOCARBAMOL 750 MG TABLET RX-4972 CDM 6370000100 HCPCS 250 RC 31722-0534-01 NDC outpatient 1 UN 5.68 5.68 MEDICA (COMMERCIAL) 94265 [3081118] MEDICA CLAIMS [308111801] 5.11 percent of total billed charges 3.52 5.4 Technical (Hospital) Services METHOCARBAMOL 750 MG TABLET RX-4972 CDM 6370000100 HCPCS 250 RC 31722-0534-01 NDC outpatient 1 UN 5.68 5.68 MULTIPLAN INC 34080 [3081285] MULTIPLAN INC [308128501] 5.4 percent of total billed charges 3.52 5.4 Technical (Hospital) Services METHOCARBAMOL 750 MG TABLET RX-4972 CDM 6370000100 HCPCS 250 RC 31722-0534-01 NDC outpatient 1 UN 5.68 5.68 CIGNA 62308 [3081051] CIGNA 62308 [308105105] 4.54 percent of total billed charges 3.52 5.4 Technical (Hospital) Services METHOCARBAMOL 750 MG TABLET RX-4972 CDM 6370000100 HCPCS 250 RC 31722-0534-01 NDC outpatient 1 UN 5.68 5.68 CIGNA 62308 [3081051] CIGNA STATE OF WYOMING [308105107] 4.54 percent of total billed charges 3.52 5.4 Technical (Hospital) Services METHOCARBAMOL 750 MG TABLET RX-4972 CDM 6370000100 HCPCS 250 RC 31722-0534-01 NDC outpatient 1 UN 5.68 5.68 UNITED HEALTHCARE (COMMERCIAL) [3081199] UNITED HEALTHCARE 87726 [308119901] 3.52 percent of total billed charges 3.52 5.4 Technical (Hospital) Services METHOCARBAMOL 750 MG TABLET RX-4972 CDM 6370000100 HCPCS 250 RC 31722-0534-01 NDC outpatient 1 UN 5.68 5.68 HEALTHPARTNERS SX009 HEALTHPARTNERS 4.54 percent of total billed charges 3.52 5.4 Technical (Hospital) Services METHOCARBAMOL 750 MG TABLET RX-4972 CDM 6370000100 HCPCS 250 RC 31722-0534-01 NDC outpatient 1 UN 5.68 5.68 BLUE CROSS BLUE SHIELD WELLMARK SB889 [3081026] BCBS WYOMING [308102603] 5.4 percent of total billed charges 3.52 5.4 Technical (Hospital) Services METHOCARBAMOL 750 MG TABLET RX-4972 CDM 6370000100 HCPCS 250 RC 31722-0534-01 NDC outpatient 1 UN 5.68 5.68 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES EPO [308136803] 4.54 percent of total billed charges 3.52 5.4 Technical (Hospital) Services METHOCARBAMOL 750 MG TABLET RX-4972 CDM 6370000100 HCPCS 250 RC 31722-0534-01 NDC outpatient 1 UN 5.68 5.68 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES PPO [308136801] 4.54 percent of total billed charges 3.52 5.4 Technical (Hospital) Services METHOCARBAMOL 750 MG TABLET RX-4972 CDM 6370000100 HCPCS 250 RC 31722-0534-01 NDC outpatient 1 UN 5.68 5.68 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES HDHP [308136802] 4.54 percent of total billed charges 3.52 5.4 Technical (Hospital) Services METHYLPHENIDATE 10 MG TABLET RX-4986 CDM 6370000100 HCPCS 250 RC 31722-0174-01 NDC inpatient 1 UN 5.9 5.9 CIGNA 62308 [3081051] CIGNA 62308 [308105105] 4.67 percent of total billed charges 3.66 5.61 Technical (Hospital) Services METHYLPHENIDATE 10 MG TABLET RX-4986 CDM 6370000100 HCPCS 250 RC 31722-0174-01 NDC inpatient 1 UN 5.9 5.9 CIGNA 62308 [3081051] CIGNA STATE OF WYOMING [308105107] 4.67 percent of total billed charges 3.66 5.61 Technical (Hospital) Services METHYLPHENIDATE 10 MG TABLET RX-4986 CDM 6370000100 HCPCS 250 RC 31722-0174-01 NDC inpatient 1 UN 5.9 5.9 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES EPO [308136803] 4.67 percent of total billed charges 3.66 5.61 Technical (Hospital) Services METHYLPHENIDATE 10 MG TABLET RX-4986 CDM 6370000100 HCPCS 250 RC 31722-0174-01 NDC inpatient 1 UN 5.9 5.9 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES HDHP [308136802] 4.67 percent of total billed charges 3.66 5.61 Technical (Hospital) Services METHYLPHENIDATE 10 MG TABLET RX-4986 CDM 6370000100 HCPCS 250 RC 31722-0174-01 NDC inpatient 1 UN 5.9 5.9 BLUE CROSS BLUE SHIELD WELLMARK SB889 [3081026] BCBS WYOMING [308102603] 5.61 percent of total billed charges 3.66 5.61 Technical (Hospital) Services METHYLPHENIDATE 10 MG TABLET RX-4986 CDM 6370000100 HCPCS 250 RC 31722-0174-01 NDC inpatient 1 UN 5.9 5.9 UNITED HEALTHCARE (COMMERCIAL) [3081199] UNITED HEALTHCARE 87726 [308119901] 3.66 percent of total billed charges 3.66 5.61 Technical (Hospital) Services METHYLPHENIDATE 10 MG TABLET RX-4986 CDM 6370000100 HCPCS 250 RC 31722-0174-01 NDC inpatient 1 UN 5.9 5.9 MULTIPLAN INC 34080 [3081285] MULTIPLAN INC [308128501] 5.61 percent of total billed charges 3.66 5.61 Technical (Hospital) Services METHYLPHENIDATE 10 MG TABLET RX-4986 CDM 6370000100 HCPCS 250 RC 31722-0174-01 NDC inpatient 1 UN 5.9 5.9 HEALTHPARTNERS SX009 HEALTHPARTNERS 4.67 percent of total billed charges 3.66 5.61 Technical (Hospital) Services METHYLPHENIDATE 10 MG TABLET RX-4986 CDM 6370000100 HCPCS 250 RC 31722-0174-01 NDC inpatient 1 UN 5.9 5.9 MEDICA (COMMERCIAL) 94265 [3081118] MEDICA CLAIMS [308111801] 5.31 percent of total billed charges 3.66 5.61 Technical (Hospital) Services METHYLPHENIDATE 10 MG TABLET RX-4986 CDM 6370000100 HCPCS 250 RC 31722-0174-01 NDC inpatient 1 UN 5.9 5.9 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES PPO [308136801] 4.67 percent of total billed charges 3.66 5.61 Technical (Hospital) Services METHYLPHENIDATE 10 MG TABLET RX-4986 CDM 6370000100 HCPCS 250 RC 31722-0174-01 NDC outpatient 1 UN 5.9 5.9 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES HDHP [308136802] 4.72 percent of total billed charges 3.66 5.61 Technical (Hospital) Services METHYLPHENIDATE 10 MG TABLET RX-4986 CDM 6370000100 HCPCS 250 RC 31722-0174-01 NDC outpatient 1 UN 5.9 5.9 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES EPO [308136803] 4.72 percent of total billed charges 3.66 5.61 Technical (Hospital) Services METHYLPHENIDATE 10 MG TABLET RX-4986 CDM 6370000100 HCPCS 250 RC 31722-0174-01 NDC outpatient 1 UN 5.9 5.9 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES PPO [308136801] 4.72 percent of total billed charges 3.66 5.61 Technical (Hospital) Services METHYLPHENIDATE 10 MG TABLET RX-4986 CDM 6370000100 HCPCS 250 RC 31722-0174-01 NDC outpatient 1 UN 5.9 5.9 MULTIPLAN INC 34080 [3081285] MULTIPLAN INC [308128501] 5.61 percent of total billed charges 3.66 5.61 Technical (Hospital) Services METHYLPHENIDATE 10 MG TABLET RX-4986 CDM 6370000100 HCPCS 250 RC 31722-0174-01 NDC outpatient 1 UN 5.9 5.9 CIGNA 62308 [3081051] CIGNA 62308 [308105105] 4.72 percent of total billed charges 3.66 5.61 Technical (Hospital) Services METHYLPHENIDATE 10 MG TABLET RX-4986 CDM 6370000100 HCPCS 250 RC 31722-0174-01 NDC outpatient 1 UN 5.9 5.9 CIGNA 62308 [3081051] CIGNA STATE OF WYOMING [308105107] 4.72 percent of total billed charges 3.66 5.61 Technical (Hospital) Services METHYLPHENIDATE 10 MG TABLET RX-4986 CDM 6370000100 HCPCS 250 RC 31722-0174-01 NDC outpatient 1 UN 5.9 5.9 MEDICA (COMMERCIAL) 94265 [3081118] MEDICA CLAIMS [308111801] 5.31 percent of total billed charges 3.66 5.61 Technical (Hospital) Services METHYLPHENIDATE 10 MG TABLET RX-4986 CDM 6370000100 HCPCS 250 RC 31722-0174-01 NDC outpatient 1 UN 5.9 5.9 UNITED HEALTHCARE (COMMERCIAL) [3081199] UNITED HEALTHCARE 87726 [308119901] 3.66 percent of total billed charges 3.66 5.61 Technical (Hospital) Services METHYLPHENIDATE 10 MG TABLET RX-4986 CDM 6370000100 HCPCS 250 RC 31722-0174-01 NDC outpatient 1 UN 5.9 5.9 BLUE CROSS BLUE SHIELD WELLMARK SB889 [3081026] BCBS WYOMING [308102603] 5.61 percent of total billed charges 3.66 5.61 Technical (Hospital) Services METHYLPHENIDATE 10 MG TABLET RX-4986 CDM 6370000100 HCPCS 250 RC 31722-0174-01 NDC outpatient 1 UN 5.9 5.9 HEALTHPARTNERS SX009 HEALTHPARTNERS 4.72 percent of total billed charges 3.66 5.61 Technical (Hospital) Services METHYLPHENIDATE 5 MG TABLET RX-4988 CDM 6370000100 HCPCS 250 RC 16729-0478-01 NDC outpatient 1 UN 5.82 5.82 BLUE CROSS BLUE SHIELD WELLMARK SB889 [3081026] BCBS WYOMING [308102603] 5.53 percent of total billed charges 3.61 5.53 Technical (Hospital) Services METHYLPHENIDATE 5 MG TABLET RX-4988 CDM 6370000100 HCPCS 250 RC 16729-0478-01 NDC outpatient 1 UN 5.82 5.82 HEALTHPARTNERS SX009 HEALTHPARTNERS 4.66 percent of total billed charges 3.61 5.53 Technical (Hospital) Services METHYLPHENIDATE 5 MG TABLET RX-4988 CDM 6370000100 HCPCS 250 RC 16729-0478-01 NDC outpatient 1 UN 5.82 5.82 MEDICA (COMMERCIAL) 94265 [3081118] MEDICA CLAIMS [308111801] 5.24 percent of total billed charges 3.61 5.53 Technical (Hospital) Services METHYLPHENIDATE 5 MG TABLET RX-4988 CDM 6370000100 HCPCS 250 RC 16729-0478-01 NDC outpatient 1 UN 5.82 5.82 MULTIPLAN INC 34080 [3081285] MULTIPLAN INC [308128501] 5.53 percent of total billed charges 3.61 5.53 Technical (Hospital) Services METHYLPHENIDATE 5 MG TABLET RX-4988 CDM 6370000100 HCPCS 250 RC 16729-0478-01 NDC outpatient 1 UN 5.82 5.82 CIGNA 62308 [3081051] CIGNA 62308 [308105105] 4.66 percent of total billed charges 3.61 5.53 Technical (Hospital) Services METHYLPHENIDATE 5 MG TABLET RX-4988 CDM 6370000100 HCPCS 250 RC 16729-0478-01 NDC outpatient 1 UN 5.82 5.82 CIGNA 62308 [3081051] CIGNA STATE OF WYOMING [308105107] 4.66 percent of total billed charges 3.61 5.53 Technical (Hospital) Services METHYLPHENIDATE 5 MG TABLET RX-4988 CDM 6370000100 HCPCS 250 RC 16729-0478-01 NDC outpatient 1 UN 5.82 5.82 UNITED HEALTHCARE (COMMERCIAL) [3081199] UNITED HEALTHCARE 87726 [308119901] 3.61 percent of total billed charges 3.61 5.53 Technical (Hospital) Services METHYLPHENIDATE 5 MG TABLET RX-4988 CDM 6370000100 HCPCS 250 RC 16729-0478-01 NDC outpatient 1 UN 5.82 5.82 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES PPO [308136801] 4.66 percent of total billed charges 3.61 5.53 Technical (Hospital) Services METHYLPHENIDATE 5 MG TABLET RX-4988 CDM 6370000100 HCPCS 250 RC 16729-0478-01 NDC outpatient 1 UN 5.82 5.82 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES EPO [308136803] 4.66 percent of total billed charges 3.61 5.53 Technical (Hospital) Services METHYLPHENIDATE 5 MG TABLET RX-4988 CDM 6370000100 HCPCS 250 RC 16729-0478-01 NDC outpatient 1 UN 5.82 5.82 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES HDHP [308136802] 4.66 percent of total billed charges 3.61 5.53 Technical (Hospital) Services METHYLPHENIDATE 5 MG TABLET RX-4988 CDM 6370000100 HCPCS 250 RC 16729-0478-01 NDC inpatient 1 UN 5.82 5.82 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES PPO [308136801] 4.61 percent of total billed charges 3.61 5.53 Technical (Hospital) Services METHYLPHENIDATE 5 MG TABLET RX-4988 CDM 6370000100 HCPCS 250 RC 16729-0478-01 NDC inpatient 1 UN 5.82 5.82 MEDICA (COMMERCIAL) 94265 [3081118] MEDICA CLAIMS [308111801] 5.24 percent of total billed charges 3.61 5.53 Technical (Hospital) Services METHYLPHENIDATE 5 MG TABLET RX-4988 CDM 6370000100 HCPCS 250 RC 16729-0478-01 NDC inpatient 1 UN 5.82 5.82 HEALTHPARTNERS SX009 HEALTHPARTNERS 4.61 percent of total billed charges 3.61 5.53 Technical (Hospital) Services METHYLPHENIDATE 5 MG TABLET RX-4988 CDM 6370000100 HCPCS 250 RC 16729-0478-01 NDC inpatient 1 UN 5.82 5.82 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES HDHP [308136802] 4.61 percent of total billed charges 3.61 5.53 Technical (Hospital) Services METHYLPHENIDATE 5 MG TABLET RX-4988 CDM 6370000100 HCPCS 250 RC 16729-0478-01 NDC inpatient 1 UN 5.82 5.82 UNITED HEALTHCARE (COMMERCIAL) [3081199] UNITED HEALTHCARE 87726 [308119901] 3.61 percent of total billed charges 3.61 5.53 Technical (Hospital) Services METHYLPHENIDATE 5 MG TABLET RX-4988 CDM 6370000100 HCPCS 250 RC 16729-0478-01 NDC inpatient 1 UN 5.82 5.82 CIGNA 62308 [3081051] CIGNA 62308 [308105105] 4.61 percent of total billed charges 3.61 5.53 Technical (Hospital) Services METHYLPHENIDATE 5 MG TABLET RX-4988 CDM 6370000100 HCPCS 250 RC 16729-0478-01 NDC inpatient 1 UN 5.82 5.82 CIGNA 62308 [3081051] CIGNA STATE OF WYOMING [308105107] 4.61 percent of total billed charges 3.61 5.53 Technical (Hospital) Services METHYLPHENIDATE 5 MG TABLET RX-4988 CDM 6370000100 HCPCS 250 RC 16729-0478-01 NDC inpatient 1 UN 5.82 5.82 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES EPO [308136803] 4.61 percent of total billed charges 3.61 5.53 Technical (Hospital) Services METHYLPHENIDATE 5 MG TABLET RX-4988 CDM 6370000100 HCPCS 250 RC 16729-0478-01 NDC inpatient 1 UN 5.82 5.82 BLUE CROSS BLUE SHIELD WELLMARK SB889 [3081026] BCBS WYOMING [308102603] 5.53 percent of total billed charges 3.61 5.53 Technical (Hospital) Services METHYLPHENIDATE 5 MG TABLET RX-4988 CDM 6370000100 HCPCS 250 RC 16729-0478-01 NDC inpatient 1 UN 5.82 5.82 MULTIPLAN INC 34080 [3081285] MULTIPLAN INC [308128501] 5.53 percent of total billed charges 3.61 5.53 Technical (Hospital) Services METOCLOPRAMIDE 10 MG TABLET RX-5005 CDM 6370000100 HCPCS 250 RC 00093-2203-01 NDC outpatient 1 UN 5.69 5.69 CIGNA 62308 [3081051] CIGNA 62308 [308105105] 4.55 percent of total billed charges 3.53 5.41 Technical (Hospital) Services METOCLOPRAMIDE 10 MG TABLET RX-5005 CDM 6370000100 HCPCS 250 RC 00093-2203-01 NDC outpatient 1 UN 5.69 5.69 CIGNA 62308 [3081051] CIGNA STATE OF WYOMING [308105107] 4.55 percent of total billed charges 3.53 5.41 Technical (Hospital) Services METOCLOPRAMIDE 10 MG TABLET RX-5005 CDM 6370000100 HCPCS 250 RC 00093-2203-01 NDC outpatient 1 UN 5.69 5.69 MULTIPLAN INC 34080 [3081285] MULTIPLAN INC [308128501] 5.41 percent of total billed charges 3.53 5.41 Technical (Hospital) Services METOCLOPRAMIDE 10 MG TABLET RX-5005 CDM 6370000100 HCPCS 250 RC 00093-2203-01 NDC outpatient 1 UN 5.69 5.69 MEDICA (COMMERCIAL) 94265 [3081118] MEDICA CLAIMS [308111801] 5.12 percent of total billed charges 3.53 5.41 Technical (Hospital) Services METOCLOPRAMIDE 10 MG TABLET RX-5005 CDM 6370000100 HCPCS 250 RC 00093-2203-01 NDC outpatient 1 UN 5.69 5.69 HEALTHPARTNERS SX009 HEALTHPARTNERS 4.55 percent of total billed charges 3.53 5.41 Technical (Hospital) Services METOCLOPRAMIDE 10 MG TABLET RX-5005 CDM 6370000100 HCPCS 250 RC 00093-2203-01 NDC outpatient 1 UN 5.69 5.69 UNITED HEALTHCARE (COMMERCIAL) [3081199] UNITED HEALTHCARE 87726 [308119901] 3.53 percent of total billed charges 3.53 5.41 Technical (Hospital) Services METOCLOPRAMIDE 10 MG TABLET RX-5005 CDM 6370000100 HCPCS 250 RC 00093-2203-01 NDC outpatient 1 UN 5.69 5.69 BLUE CROSS BLUE SHIELD WELLMARK SB889 [3081026] BCBS WYOMING [308102603] 5.41 percent of total billed charges 3.53 5.41 Technical (Hospital) Services METOCLOPRAMIDE 10 MG TABLET RX-5005 CDM 6370000100 HCPCS 250 RC 00093-2203-01 NDC outpatient 1 UN 5.69 5.69 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES EPO [308136803] 4.55 percent of total billed charges 3.53 5.41 Technical (Hospital) Services METOCLOPRAMIDE 10 MG TABLET RX-5005 CDM 6370000100 HCPCS 250 RC 00093-2203-01 NDC outpatient 1 UN 5.69 5.69 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES HDHP [308136802] 4.55 percent of total billed charges 3.53 5.41 Technical (Hospital) Services METOCLOPRAMIDE 10 MG TABLET RX-5005 CDM 6370000100 HCPCS 250 RC 00093-2203-01 NDC outpatient 1 UN 5.69 5.69 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES PPO [308136801] 4.55 percent of total billed charges 3.53 5.41 Technical (Hospital) Services METOCLOPRAMIDE 10 MG TABLET RX-5005 CDM 6370000100 HCPCS 250 RC 00093-2203-01 NDC inpatient 1 UN 5.69 5.69 MEDICA (COMMERCIAL) 94265 [3081118] MEDICA CLAIMS [308111801] 5.12 percent of total billed charges 3.53 5.41 Technical (Hospital) Services METOCLOPRAMIDE 10 MG TABLET RX-5005 CDM 6370000100 HCPCS 250 RC 00093-2203-01 NDC inpatient 1 UN 5.69 5.69 HEALTHPARTNERS SX009 HEALTHPARTNERS 4.51 percent of total billed charges 3.53 5.41 Technical (Hospital) Services METOCLOPRAMIDE 10 MG TABLET RX-5005 CDM 6370000100 HCPCS 250 RC 00093-2203-01 NDC inpatient 1 UN 5.69 5.69 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES PPO [308136801] 4.51 percent of total billed charges 3.53 5.41 Technical (Hospital) Services METOCLOPRAMIDE 10 MG TABLET RX-5005 CDM 6370000100 HCPCS 250 RC 00093-2203-01 NDC inpatient 1 UN 5.69 5.69 MULTIPLAN INC 34080 [3081285] MULTIPLAN INC [308128501] 5.41 percent of total billed charges 3.53 5.41 Technical (Hospital) Services METOCLOPRAMIDE 10 MG TABLET RX-5005 CDM 6370000100 HCPCS 250 RC 00093-2203-01 NDC inpatient 1 UN 5.69 5.69 BLUE CROSS BLUE SHIELD WELLMARK SB889 [3081026] BCBS WYOMING [308102603] 5.41 percent of total billed charges 3.53 5.41 Technical (Hospital) Services METOCLOPRAMIDE 10 MG TABLET RX-5005 CDM 6370000100 HCPCS 250 RC 00093-2203-01 NDC inpatient 1 UN 5.69 5.69 UNITED HEALTHCARE (COMMERCIAL) [3081199] UNITED HEALTHCARE 87726 [308119901] 3.53 percent of total billed charges 3.53 5.41 Technical (Hospital) Services METOCLOPRAMIDE 10 MG TABLET RX-5005 CDM 6370000100 HCPCS 250 RC 00093-2203-01 NDC inpatient 1 UN 5.69 5.69 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES HDHP [308136802] 4.51 percent of total billed charges 3.53 5.41 Technical (Hospital) Services METOCLOPRAMIDE 10 MG TABLET RX-5005 CDM 6370000100 HCPCS 250 RC 00093-2203-01 NDC inpatient 1 UN 5.69 5.69 CIGNA 62308 [3081051] CIGNA 62308 [308105105] 4.51 percent of total billed charges 3.53 5.41 Technical (Hospital) Services METOCLOPRAMIDE 10 MG TABLET RX-5005 CDM 6370000100 HCPCS 250 RC 00093-2203-01 NDC inpatient 1 UN 5.69 5.69 CIGNA 62308 [3081051] CIGNA STATE OF WYOMING [308105107] 4.51 percent of total billed charges 3.53 5.41 Technical (Hospital) Services METOCLOPRAMIDE 10 MG TABLET RX-5005 CDM 6370000100 HCPCS 250 RC 00093-2203-01 NDC inpatient 1 UN 5.69 5.69 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES EPO [308136803] 4.51 percent of total billed charges 3.53 5.41 Technical (Hospital) Services METOCLOPRAMIDE 5 MG TABLET RX-5006 CDM 6370000100 HCPCS 250 RC 00093-2204-01 NDC inpatient 1 UN 5.69 5.69 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES PPO [308136801] 4.51 percent of total billed charges 3.53 5.41 Technical (Hospital) Services METOCLOPRAMIDE 5 MG TABLET RX-5006 CDM 6370000100 HCPCS 250 RC 00093-2204-01 NDC inpatient 1 UN 5.69 5.69 MEDICA (COMMERCIAL) 94265 [3081118] MEDICA CLAIMS [308111801] 5.12 percent of total billed charges 3.53 5.41 Technical (Hospital) Services METOCLOPRAMIDE 5 MG TABLET RX-5006 CDM 6370000100 HCPCS 250 RC 00093-2204-01 NDC inpatient 1 UN 5.69 5.69 HEALTHPARTNERS SX009 HEALTHPARTNERS 4.51 percent of total billed charges 3.53 5.41 Technical (Hospital) Services METOCLOPRAMIDE 5 MG TABLET RX-5006 CDM 6370000100 HCPCS 250 RC 00093-2204-01 NDC inpatient 1 UN 5.69 5.69 MULTIPLAN INC 34080 [3081285] MULTIPLAN INC [308128501] 5.41 percent of total billed charges 3.53 5.41 Technical (Hospital) Services METOCLOPRAMIDE 5 MG TABLET RX-5006 CDM 6370000100 HCPCS 250 RC 00093-2204-01 NDC inpatient 1 UN 5.69 5.69 UNITED HEALTHCARE (COMMERCIAL) [3081199] UNITED HEALTHCARE 87726 [308119901] 3.53 percent of total billed charges 3.53 5.41 Technical (Hospital) Services METOCLOPRAMIDE 5 MG TABLET RX-5006 CDM 6370000100 HCPCS 250 RC 00093-2204-01 NDC inpatient 1 UN 5.69 5.69 BLUE CROSS BLUE SHIELD WELLMARK SB889 [3081026] BCBS WYOMING [308102603] 5.41 percent of total billed charges 3.53 5.41 Technical (Hospital) Services METOCLOPRAMIDE 5 MG TABLET RX-5006 CDM 6370000100 HCPCS 250 RC 00093-2204-01 NDC inpatient 1 UN 5.69 5.69 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES EPO [308136803] 4.51 percent of total billed charges 3.53 5.41 Technical (Hospital) Services METOCLOPRAMIDE 5 MG TABLET RX-5006 CDM 6370000100 HCPCS 250 RC 00093-2204-01 NDC inpatient 1 UN 5.69 5.69 CIGNA 62308 [3081051] CIGNA 62308 [308105105] 4.51 percent of total billed charges 3.53 5.41 Technical (Hospital) Services METOCLOPRAMIDE 5 MG TABLET RX-5006 CDM 6370000100 HCPCS 250 RC 00093-2204-01 NDC inpatient 1 UN 5.69 5.69 CIGNA 62308 [3081051] CIGNA STATE OF WYOMING [308105107] 4.51 percent of total billed charges 3.53 5.41 Technical (Hospital) Services METOCLOPRAMIDE 5 MG TABLET RX-5006 CDM 6370000100 HCPCS 250 RC 00093-2204-01 NDC inpatient 1 UN 5.69 5.69 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES HDHP [308136802] 4.51 percent of total billed charges 3.53 5.41 Technical (Hospital) Services METOCLOPRAMIDE 5 MG TABLET RX-5006 CDM 6370000100 HCPCS 250 RC 00093-2204-01 NDC outpatient 1 UN 5.69 5.69 BLUE CROSS BLUE SHIELD WELLMARK SB889 [3081026] BCBS WYOMING [308102603] 5.41 percent of total billed charges 3.53 5.41 Technical (Hospital) Services METOCLOPRAMIDE 5 MG TABLET RX-5006 CDM 6370000100 HCPCS 250 RC 00093-2204-01 NDC outpatient 1 UN 5.69 5.69 UNITED HEALTHCARE (COMMERCIAL) [3081199] UNITED HEALTHCARE 87726 [308119901] 3.53 percent of total billed charges 3.53 5.41 Technical (Hospital) Services METOCLOPRAMIDE 5 MG TABLET RX-5006 CDM 6370000100 HCPCS 250 RC 00093-2204-01 NDC outpatient 1 UN 5.69 5.69 HEALTHPARTNERS SX009 HEALTHPARTNERS 4.55 percent of total billed charges 3.53 5.41 Technical (Hospital) Services METOCLOPRAMIDE 5 MG TABLET RX-5006 CDM 6370000100 HCPCS 250 RC 00093-2204-01 NDC outpatient 1 UN 5.69 5.69 MULTIPLAN INC 34080 [3081285] MULTIPLAN INC [308128501] 5.41 percent of total billed charges 3.53 5.41 Technical (Hospital) Services METOCLOPRAMIDE 5 MG TABLET RX-5006 CDM 6370000100 HCPCS 250 RC 00093-2204-01 NDC outpatient 1 UN 5.69 5.69 CIGNA 62308 [3081051] CIGNA 62308 [308105105] 4.55 percent of total billed charges 3.53 5.41 Technical (Hospital) Services METOCLOPRAMIDE 5 MG TABLET RX-5006 CDM 6370000100 HCPCS 250 RC 00093-2204-01 NDC outpatient 1 UN 5.69 5.69 CIGNA 62308 [3081051] CIGNA STATE OF WYOMING [308105107] 4.55 percent of total billed charges 3.53 5.41 Technical (Hospital) Services METOCLOPRAMIDE 5 MG TABLET RX-5006 CDM 6370000100 HCPCS 250 RC 00093-2204-01 NDC outpatient 1 UN 5.69 5.69 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES PPO [308136801] 4.55 percent of total billed charges 3.53 5.41 Technical (Hospital) Services METOCLOPRAMIDE 5 MG TABLET RX-5006 CDM 6370000100 HCPCS 250 RC 00093-2204-01 NDC outpatient 1 UN 5.69 5.69 MEDICA (COMMERCIAL) 94265 [3081118] MEDICA CLAIMS [308111801] 5.12 percent of total billed charges 3.53 5.41 Technical (Hospital) Services METOCLOPRAMIDE 5 MG TABLET RX-5006 CDM 6370000100 HCPCS 250 RC 00093-2204-01 NDC outpatient 1 UN 5.69 5.69 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES HDHP [308136802] 4.55 percent of total billed charges 3.53 5.41 Technical (Hospital) Services METOCLOPRAMIDE 5 MG TABLET RX-5006 CDM 6370000100 HCPCS 250 RC 00093-2204-01 NDC outpatient 1 UN 5.69 5.69 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES EPO [308136803] 4.55 percent of total billed charges 3.53 5.41 Technical (Hospital) Services METOPROLOL TARTRATE 50 MG TABLET RX-5009 CDM 6370000100 HCPCS 250 RC 00378-0032-01 NDC inpatient 1 UN 5.67 5.67 MULTIPLAN INC 34080 [3081285] MULTIPLAN INC [308128501] 5.39 percent of total billed charges 3.52 5.39 Technical (Hospital) Services METOPROLOL TARTRATE 50 MG TABLET RX-5009 CDM 6370000100 HCPCS 250 RC 00378-0032-01 NDC inpatient 1 UN 5.67 5.67 BLUE CROSS BLUE SHIELD WELLMARK SB889 [3081026] BCBS WYOMING [308102603] 5.39 percent of total billed charges 3.52 5.39 Technical (Hospital) Services METOPROLOL TARTRATE 50 MG TABLET RX-5009 CDM 6370000100 HCPCS 250 RC 00378-0032-01 NDC inpatient 1 UN 5.67 5.67 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES EPO [308136803] 4.49 percent of total billed charges 3.52 5.39 Technical (Hospital) Services METOPROLOL TARTRATE 50 MG TABLET RX-5009 CDM 6370000100 HCPCS 250 RC 00378-0032-01 NDC inpatient 1 UN 5.67 5.67 CIGNA 62308 [3081051] CIGNA 62308 [308105105] 4.49 percent of total billed charges 3.52 5.39 Technical (Hospital) Services METOPROLOL TARTRATE 50 MG TABLET RX-5009 CDM 6370000100 HCPCS 250 RC 00378-0032-01 NDC inpatient 1 UN 5.67 5.67 CIGNA 62308 [3081051] CIGNA STATE OF WYOMING [308105107] 4.49 percent of total billed charges 3.52 5.39 Technical (Hospital) Services METOPROLOL TARTRATE 50 MG TABLET RX-5009 CDM 6370000100 HCPCS 250 RC 00378-0032-01 NDC inpatient 1 UN 5.67 5.67 UNITED HEALTHCARE (COMMERCIAL) [3081199] UNITED HEALTHCARE 87726 [308119901] 3.52 percent of total billed charges 3.52 5.39 Technical (Hospital) Services METOPROLOL TARTRATE 50 MG TABLET RX-5009 CDM 6370000100 HCPCS 250 RC 00378-0032-01 NDC inpatient 1 UN 5.67 5.67 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES HDHP [308136802] 4.49 percent of total billed charges 3.52 5.39 Technical (Hospital) Services METOPROLOL TARTRATE 50 MG TABLET RX-5009 CDM 6370000100 HCPCS 250 RC 00378-0032-01 NDC inpatient 1 UN 5.67 5.67 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES PPO [308136801] 4.49 percent of total billed charges 3.52 5.39 Technical (Hospital) Services METOPROLOL TARTRATE 50 MG TABLET RX-5009 CDM 6370000100 HCPCS 250 RC 00378-0032-01 NDC inpatient 1 UN 5.67 5.67 HEALTHPARTNERS SX009 HEALTHPARTNERS 4.49 percent of total billed charges 3.52 5.39 Technical (Hospital) Services METOPROLOL TARTRATE 50 MG TABLET RX-5009 CDM 6370000100 HCPCS 250 RC 00378-0032-01 NDC inpatient 1 UN 5.67 5.67 MEDICA (COMMERCIAL) 94265 [3081118] MEDICA CLAIMS [308111801] 5.1 percent of total billed charges 3.52 5.39 Technical (Hospital) Services METOPROLOL TARTRATE 50 MG TABLET RX-5009 CDM 6370000100 HCPCS 250 RC 00378-0032-01 NDC outpatient 1 UN 5.67 5.67 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES EPO [308136803] 4.54 percent of total billed charges 3.52 5.39 Technical (Hospital) Services METOPROLOL TARTRATE 50 MG TABLET RX-5009 CDM 6370000100 HCPCS 250 RC 00378-0032-01 NDC outpatient 1 UN 5.67 5.67 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES HDHP [308136802] 4.54 percent of total billed charges 3.52 5.39 Technical (Hospital) Services METOPROLOL TARTRATE 50 MG TABLET RX-5009 CDM 6370000100 HCPCS 250 RC 00378-0032-01 NDC outpatient 1 UN 5.67 5.67 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES PPO [308136801] 4.54 percent of total billed charges 3.52 5.39 Technical (Hospital) Services METOPROLOL TARTRATE 50 MG TABLET RX-5009 CDM 6370000100 HCPCS 250 RC 00378-0032-01 NDC outpatient 1 UN 5.67 5.67 MULTIPLAN INC 34080 [3081285] MULTIPLAN INC [308128501] 5.39 percent of total billed charges 3.52 5.39 Technical (Hospital) Services METOPROLOL TARTRATE 50 MG TABLET RX-5009 CDM 6370000100 HCPCS 250 RC 00378-0032-01 NDC outpatient 1 UN 5.67 5.67 CIGNA 62308 [3081051] CIGNA 62308 [308105105] 4.54 percent of total billed charges 3.52 5.39 Technical (Hospital) Services METOPROLOL TARTRATE 50 MG TABLET RX-5009 CDM 6370000100 HCPCS 250 RC 00378-0032-01 NDC outpatient 1 UN 5.67 5.67 CIGNA 62308 [3081051] CIGNA STATE OF WYOMING [308105107] 4.54 percent of total billed charges 3.52 5.39 Technical (Hospital) Services METOPROLOL TARTRATE 50 MG TABLET RX-5009 CDM 6370000100 HCPCS 250 RC 00378-0032-01 NDC outpatient 1 UN 5.67 5.67 MEDICA (COMMERCIAL) 94265 [3081118] MEDICA CLAIMS [308111801] 5.1 percent of total billed charges 3.52 5.39 Technical (Hospital) Services METOPROLOL TARTRATE 50 MG TABLET RX-5009 CDM 6370000100 HCPCS 250 RC 00378-0032-01 NDC outpatient 1 UN 5.67 5.67 UNITED HEALTHCARE (COMMERCIAL) [3081199] UNITED HEALTHCARE 87726 [308119901] 3.52 percent of total billed charges 3.52 5.39 Technical (Hospital) Services METOPROLOL TARTRATE 50 MG TABLET RX-5009 CDM 6370000100 HCPCS 250 RC 00378-0032-01 NDC outpatient 1 UN 5.67 5.67 HEALTHPARTNERS SX009 HEALTHPARTNERS 4.54 percent of total billed charges 3.52 5.39 Technical (Hospital) Services METOPROLOL TARTRATE 50 MG TABLET RX-5009 CDM 6370000100 HCPCS 250 RC 00378-0032-01 NDC outpatient 1 UN 5.67 5.67 BLUE CROSS BLUE SHIELD WELLMARK SB889 [3081026] BCBS WYOMING [308102603] 5.39 percent of total billed charges 3.52 5.39 Technical (Hospital) Services METRONIDAZOLE 500 MG TABLET RX-5016 CDM 6370000100 HCPCS 250 RC 29300-0227-01 NDC inpatient 1 UN 6.13 6.13 HEALTHPARTNERS SX009 HEALTHPARTNERS 4.85 percent of total billed charges 3.8 5.82 Technical (Hospital) Services METRONIDAZOLE 500 MG TABLET RX-5016 CDM 6370000100 HCPCS 250 RC 29300-0227-01 NDC inpatient 1 UN 6.13 6.13 MEDICA (COMMERCIAL) 94265 [3081118] MEDICA CLAIMS [308111801] 5.52 percent of total billed charges 3.8 5.82 Technical (Hospital) Services METRONIDAZOLE 500 MG TABLET RX-5016 CDM 6370000100 HCPCS 250 RC 29300-0227-01 NDC inpatient 1 UN 6.13 6.13 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES PPO [308136801] 4.85 percent of total billed charges 3.8 5.82 Technical (Hospital) Services METRONIDAZOLE 500 MG TABLET RX-5016 CDM 6370000100 HCPCS 250 RC 29300-0227-01 NDC inpatient 1 UN 6.13 6.13 MULTIPLAN INC 34080 [3081285] MULTIPLAN INC [308128501] 5.82 percent of total billed charges 3.8 5.82 Technical (Hospital) Services METRONIDAZOLE 500 MG TABLET RX-5016 CDM 6370000100 HCPCS 250 RC 29300-0227-01 NDC inpatient 1 UN 6.13 6.13 UNITED HEALTHCARE (COMMERCIAL) [3081199] UNITED HEALTHCARE 87726 [308119901] 3.8 percent of total billed charges 3.8 5.82 Technical (Hospital) Services METRONIDAZOLE 500 MG TABLET RX-5016 CDM 6370000100 HCPCS 250 RC 29300-0227-01 NDC inpatient 1 UN 6.13 6.13 BLUE CROSS BLUE SHIELD WELLMARK SB889 [3081026] BCBS WYOMING [308102603] 5.82 percent of total billed charges 3.8 5.82 Technical (Hospital) Services METRONIDAZOLE 500 MG TABLET RX-5016 CDM 6370000100 HCPCS 250 RC 29300-0227-01 NDC inpatient 1 UN 6.13 6.13 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES HDHP [308136802] 4.85 percent of total billed charges 3.8 5.82 Technical (Hospital) Services METRONIDAZOLE 500 MG TABLET RX-5016 CDM 6370000100 HCPCS 250 RC 29300-0227-01 NDC inpatient 1 UN 6.13 6.13 CIGNA 62308 [3081051] CIGNA 62308 [308105105] 4.85 percent of total billed charges 3.8 5.82 Technical (Hospital) Services METRONIDAZOLE 500 MG TABLET RX-5016 CDM 6370000100 HCPCS 250 RC 29300-0227-01 NDC inpatient 1 UN 6.13 6.13 CIGNA 62308 [3081051] CIGNA STATE OF WYOMING [308105107] 4.85 percent of total billed charges 3.8 5.82 Technical (Hospital) Services METRONIDAZOLE 500 MG TABLET RX-5016 CDM 6370000100 HCPCS 250 RC 29300-0227-01 NDC inpatient 1 UN 6.13 6.13 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES EPO [308136803] 4.85 percent of total billed charges 3.8 5.82 Technical (Hospital) Services METRONIDAZOLE 500 MG TABLET RX-5016 CDM 6370000100 HCPCS 250 RC 29300-0227-01 NDC outpatient 1 UN 6.13 6.13 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES HDHP [308136802] 4.9 percent of total billed charges 3.8 5.82 Technical (Hospital) Services METRONIDAZOLE 500 MG TABLET RX-5016 CDM 6370000100 HCPCS 250 RC 29300-0227-01 NDC outpatient 1 UN 6.13 6.13 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES PPO [308136801] 4.9 percent of total billed charges 3.8 5.82 Technical (Hospital) Services METRONIDAZOLE 500 MG TABLET RX-5016 CDM 6370000100 HCPCS 250 RC 29300-0227-01 NDC outpatient 1 UN 6.13 6.13 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES EPO [308136803] 4.9 percent of total billed charges 3.8 5.82 Technical (Hospital) Services METRONIDAZOLE 500 MG TABLET RX-5016 CDM 6370000100 HCPCS 250 RC 29300-0227-01 NDC outpatient 1 UN 6.13 6.13 BLUE CROSS BLUE SHIELD WELLMARK SB889 [3081026] BCBS WYOMING [308102603] 5.82 percent of total billed charges 3.8 5.82 Technical (Hospital) Services METRONIDAZOLE 500 MG TABLET RX-5016 CDM 6370000100 HCPCS 250 RC 29300-0227-01 NDC outpatient 1 UN 6.13 6.13 HEALTHPARTNERS SX009 HEALTHPARTNERS 4.9 percent of total billed charges 3.8 5.82 Technical (Hospital) Services METRONIDAZOLE 500 MG TABLET RX-5016 CDM 6370000100 HCPCS 250 RC 29300-0227-01 NDC outpatient 1 UN 6.13 6.13 UNITED HEALTHCARE (COMMERCIAL) [3081199] UNITED HEALTHCARE 87726 [308119901] 3.8 percent of total billed charges 3.8 5.82 Technical (Hospital) Services METRONIDAZOLE 500 MG TABLET RX-5016 CDM 6370000100 HCPCS 250 RC 29300-0227-01 NDC outpatient 1 UN 6.13 6.13 MEDICA (COMMERCIAL) 94265 [3081118] MEDICA CLAIMS [308111801] 5.52 percent of total billed charges 3.8 5.82 Technical (Hospital) Services METRONIDAZOLE 500 MG TABLET RX-5016 CDM 6370000100 HCPCS 250 RC 29300-0227-01 NDC outpatient 1 UN 6.13 6.13 CIGNA 62308 [3081051] CIGNA 62308 [308105105] 4.9 percent of total billed charges 3.8 5.82 Technical (Hospital) Services METRONIDAZOLE 500 MG TABLET RX-5016 CDM 6370000100 HCPCS 250 RC 29300-0227-01 NDC outpatient 1 UN 6.13 6.13 CIGNA 62308 [3081051] CIGNA STATE OF WYOMING [308105107] 4.9 percent of total billed charges 3.8 5.82 Technical (Hospital) Services METRONIDAZOLE 500 MG TABLET RX-5016 CDM 6370000100 HCPCS 250 RC 29300-0227-01 NDC outpatient 1 UN 6.13 6.13 MULTIPLAN INC 34080 [3081285] MULTIPLAN INC [308128501] 5.82 percent of total billed charges 3.8 5.82 Technical (Hospital) Services MORPHINE 15 MG IMMEDIATE RELEASE TABLET RX-5178 CDM 6370000100 HCPCS 250 RC 00054-0235-25 NDC outpatient 1 UN 6.05 6.05 CIGNA 62308 [3081051] CIGNA 62308 [308105105] 4.84 percent of total billed charges 3.75 5.75 Technical (Hospital) Services MORPHINE 15 MG IMMEDIATE RELEASE TABLET RX-5178 CDM 6370000100 HCPCS 250 RC 00054-0235-25 NDC outpatient 1 UN 6.05 6.05 CIGNA 62308 [3081051] CIGNA STATE OF WYOMING [308105107] 4.84 percent of total billed charges 3.75 5.75 Technical (Hospital) Services MORPHINE 15 MG IMMEDIATE RELEASE TABLET RX-5178 CDM 6370000100 HCPCS 250 RC 00054-0235-25 NDC outpatient 1 UN 6.05 6.05 MULTIPLAN INC 34080 [3081285] MULTIPLAN INC [308128501] 5.75 percent of total billed charges 3.75 5.75 Technical (Hospital) Services MORPHINE 15 MG IMMEDIATE RELEASE TABLET RX-5178 CDM 6370000100 HCPCS 250 RC 00054-0235-25 NDC outpatient 1 UN 6.05 6.05 MEDICA (COMMERCIAL) 94265 [3081118] MEDICA CLAIMS [308111801] 5.45 percent of total billed charges 3.75 5.75 Technical (Hospital) Services MORPHINE 15 MG IMMEDIATE RELEASE TABLET RX-5178 CDM 6370000100 HCPCS 250 RC 00054-0235-25 NDC outpatient 1 UN 6.05 6.05 UNITED HEALTHCARE (COMMERCIAL) [3081199] UNITED HEALTHCARE 87726 [308119901] 3.75 percent of total billed charges 3.75 5.75 Technical (Hospital) Services MORPHINE 15 MG IMMEDIATE RELEASE TABLET RX-5178 CDM 6370000100 HCPCS 250 RC 00054-0235-25 NDC outpatient 1 UN 6.05 6.05 HEALTHPARTNERS SX009 HEALTHPARTNERS 4.84 percent of total billed charges 3.75 5.75 Technical (Hospital) Services MORPHINE 15 MG IMMEDIATE RELEASE TABLET RX-5178 CDM 6370000100 HCPCS 250 RC 00054-0235-25 NDC outpatient 1 UN 6.05 6.05 BLUE CROSS BLUE SHIELD WELLMARK SB889 [3081026] BCBS WYOMING [308102603] 5.75 percent of total billed charges 3.75 5.75 Technical (Hospital) Services MORPHINE 15 MG IMMEDIATE RELEASE TABLET RX-5178 CDM 6370000100 HCPCS 250 RC 00054-0235-25 NDC outpatient 1 UN 6.05 6.05 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES EPO [308136803] 4.84 percent of total billed charges 3.75 5.75 Technical (Hospital) Services MORPHINE 15 MG IMMEDIATE RELEASE TABLET RX-5178 CDM 6370000100 HCPCS 250 RC 00054-0235-25 NDC outpatient 1 UN 6.05 6.05 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES PPO [308136801] 4.84 percent of total billed charges 3.75 5.75 Technical (Hospital) Services MORPHINE 15 MG IMMEDIATE RELEASE TABLET RX-5178 CDM 6370000100 HCPCS 250 RC 00054-0235-25 NDC outpatient 1 UN 6.05 6.05 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES HDHP [308136802] 4.84 percent of total billed charges 3.75 5.75 Technical (Hospital) Services MORPHINE 15 MG IMMEDIATE RELEASE TABLET RX-5178 CDM 6370000100 HCPCS 250 RC 00054-0235-25 NDC inpatient 1 UN 6.05 6.05 BLUE CROSS BLUE SHIELD WELLMARK SB889 [3081026] BCBS WYOMING [308102603] 5.75 percent of total billed charges 3.75 5.75 Technical (Hospital) Services MORPHINE 15 MG IMMEDIATE RELEASE TABLET RX-5178 CDM 6370000100 HCPCS 250 RC 00054-0235-25 NDC inpatient 1 UN 6.05 6.05 UNITED HEALTHCARE (COMMERCIAL) [3081199] UNITED HEALTHCARE 87726 [308119901] 3.75 percent of total billed charges 3.75 5.75 Technical (Hospital) Services MORPHINE 15 MG IMMEDIATE RELEASE TABLET RX-5178 CDM 6370000100 HCPCS 250 RC 00054-0235-25 NDC inpatient 1 UN 6.05 6.05 CIGNA 62308 [3081051] CIGNA STATE OF WYOMING [308105107] 4.79 percent of total billed charges 3.75 5.75 Technical (Hospital) Services MORPHINE 15 MG IMMEDIATE RELEASE TABLET RX-5178 CDM 6370000100 HCPCS 250 RC 00054-0235-25 NDC inpatient 1 UN 6.05 6.05 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES EPO [308136803] 4.79 percent of total billed charges 3.75 5.75 Technical (Hospital) Services MORPHINE 15 MG IMMEDIATE RELEASE TABLET RX-5178 CDM 6370000100 HCPCS 250 RC 00054-0235-25 NDC inpatient 1 UN 6.05 6.05 CIGNA 62308 [3081051] CIGNA 62308 [308105105] 4.79 percent of total billed charges 3.75 5.75 Technical (Hospital) Services MORPHINE 15 MG IMMEDIATE RELEASE TABLET RX-5178 CDM 6370000100 HCPCS 250 RC 00054-0235-25 NDC inpatient 1 UN 6.05 6.05 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES HDHP [308136802] 4.79 percent of total billed charges 3.75 5.75 Technical (Hospital) Services MORPHINE 15 MG IMMEDIATE RELEASE TABLET RX-5178 CDM 6370000100 HCPCS 250 RC 00054-0235-25 NDC inpatient 1 UN 6.05 6.05 MULTIPLAN INC 34080 [3081285] MULTIPLAN INC [308128501] 5.75 percent of total billed charges 3.75 5.75 Technical (Hospital) Services MORPHINE 15 MG IMMEDIATE RELEASE TABLET RX-5178 CDM 6370000100 HCPCS 250 RC 00054-0235-25 NDC inpatient 1 UN 6.05 6.05 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES PPO [308136801] 4.79 percent of total billed charges 3.75 5.75 Technical (Hospital) Services MORPHINE 15 MG IMMEDIATE RELEASE TABLET RX-5178 CDM 6370000100 HCPCS 250 RC 00054-0235-25 NDC inpatient 1 UN 6.05 6.05 MEDICA (COMMERCIAL) 94265 [3081118] MEDICA CLAIMS [308111801] 5.45 percent of total billed charges 3.75 5.75 Technical (Hospital) Services MORPHINE 15 MG IMMEDIATE RELEASE TABLET RX-5178 CDM 6370000100 HCPCS 250 RC 00054-0235-25 NDC inpatient 1 UN 6.05 6.05 HEALTHPARTNERS SX009 HEALTHPARTNERS 4.79 percent of total billed charges 3.75 5.75 Technical (Hospital) Services NAPROXEN 250 MG TABLET RX-5391 CDM 6370000100 HCPCS 250 RC 68462-0188-01 NDC outpatient 1 UN 5.71 5.71 HEALTHPARTNERS SX009 HEALTHPARTNERS 4.57 percent of total billed charges 3.54 5.42 Technical (Hospital) Services NAPROXEN 250 MG TABLET RX-5391 CDM 6370000100 HCPCS 250 RC 68462-0188-01 NDC outpatient 1 UN 5.71 5.71 BLUE CROSS BLUE SHIELD WELLMARK SB889 [3081026] BCBS WYOMING [308102603] 5.42 percent of total billed charges 3.54 5.42 Technical (Hospital) Services NAPROXEN 250 MG TABLET RX-5391 CDM 6370000100 HCPCS 250 RC 68462-0188-01 NDC outpatient 1 UN 5.71 5.71 UNITED HEALTHCARE (COMMERCIAL) [3081199] UNITED HEALTHCARE 87726 [308119901] 3.54 percent of total billed charges 3.54 5.42 Technical (Hospital) Services NAPROXEN 250 MG TABLET RX-5391 CDM 6370000100 HCPCS 250 RC 68462-0188-01 NDC outpatient 1 UN 5.71 5.71 MULTIPLAN INC 34080 [3081285] MULTIPLAN INC [308128501] 5.42 percent of total billed charges 3.54 5.42 Technical (Hospital) Services NAPROXEN 250 MG TABLET RX-5391 CDM 6370000100 HCPCS 250 RC 68462-0188-01 NDC outpatient 1 UN 5.71 5.71 CIGNA 62308 [3081051] CIGNA 62308 [308105105] 4.57 percent of total billed charges 3.54 5.42 Technical (Hospital) Services NAPROXEN 250 MG TABLET RX-5391 CDM 6370000100 HCPCS 250 RC 68462-0188-01 NDC outpatient 1 UN 5.71 5.71 CIGNA 62308 [3081051] CIGNA STATE OF WYOMING [308105107] 4.57 percent of total billed charges 3.54 5.42 Technical (Hospital) Services NAPROXEN 250 MG TABLET RX-5391 CDM 6370000100 HCPCS 250 RC 68462-0188-01 NDC outpatient 1 UN 5.71 5.71 MEDICA (COMMERCIAL) 94265 [3081118] MEDICA CLAIMS [308111801] 5.14 percent of total billed charges 3.54 5.42 Technical (Hospital) Services NAPROXEN 250 MG TABLET RX-5391 CDM 6370000100 HCPCS 250 RC 68462-0188-01 NDC outpatient 1 UN 5.71 5.71 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES PPO [308136801] 4.57 percent of total billed charges 3.54 5.42 Technical (Hospital) Services NAPROXEN 250 MG TABLET RX-5391 CDM 6370000100 HCPCS 250 RC 68462-0188-01 NDC outpatient 1 UN 5.71 5.71 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES EPO [308136803] 4.57 percent of total billed charges 3.54 5.42 Technical (Hospital) Services NAPROXEN 250 MG TABLET RX-5391 CDM 6370000100 HCPCS 250 RC 68462-0188-01 NDC outpatient 1 UN 5.71 5.71 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES HDHP [308136802] 4.57 percent of total billed charges 3.54 5.42 Technical (Hospital) Services NAPROXEN 250 MG TABLET RX-5391 CDM 6370000100 HCPCS 250 RC 68462-0188-01 NDC inpatient 1 UN 5.71 5.71 UNITED HEALTHCARE (COMMERCIAL) [3081199] UNITED HEALTHCARE 87726 [308119901] 3.54 percent of total billed charges 3.54 5.42 Technical (Hospital) Services NAPROXEN 250 MG TABLET RX-5391 CDM 6370000100 HCPCS 250 RC 68462-0188-01 NDC inpatient 1 UN 5.71 5.71 BLUE CROSS BLUE SHIELD WELLMARK SB889 [3081026] BCBS WYOMING [308102603] 5.42 percent of total billed charges 3.54 5.42 Technical (Hospital) Services NAPROXEN 250 MG TABLET RX-5391 CDM 6370000100 HCPCS 250 RC 68462-0188-01 NDC inpatient 1 UN 5.71 5.71 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES HDHP [308136802] 4.52 percent of total billed charges 3.54 5.42 Technical (Hospital) Services NAPROXEN 250 MG TABLET RX-5391 CDM 6370000100 HCPCS 250 RC 68462-0188-01 NDC inpatient 1 UN 5.71 5.71 CIGNA 62308 [3081051] CIGNA 62308 [308105105] 4.52 percent of total billed charges 3.54 5.42 Technical (Hospital) Services NAPROXEN 250 MG TABLET RX-5391 CDM 6370000100 HCPCS 250 RC 68462-0188-01 NDC inpatient 1 UN 5.71 5.71 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES EPO [308136803] 4.52 percent of total billed charges 3.54 5.42 Technical (Hospital) Services NAPROXEN 250 MG TABLET RX-5391 CDM 6370000100 HCPCS 250 RC 68462-0188-01 NDC inpatient 1 UN 5.71 5.71 CIGNA 62308 [3081051] CIGNA STATE OF WYOMING [308105107] 4.52 percent of total billed charges 3.54 5.42 Technical (Hospital) Services NAPROXEN 250 MG TABLET RX-5391 CDM 6370000100 HCPCS 250 RC 68462-0188-01 NDC inpatient 1 UN 5.71 5.71 MULTIPLAN INC 34080 [3081285] MULTIPLAN INC [308128501] 5.42 percent of total billed charges 3.54 5.42 Technical (Hospital) Services NAPROXEN 250 MG TABLET RX-5391 CDM 6370000100 HCPCS 250 RC 68462-0188-01 NDC inpatient 1 UN 5.71 5.71 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES PPO [308136801] 4.52 percent of total billed charges 3.54 5.42 Technical (Hospital) Services NAPROXEN 250 MG TABLET RX-5391 CDM 6370000100 HCPCS 250 RC 68462-0188-01 NDC inpatient 1 UN 5.71 5.71 MEDICA (COMMERCIAL) 94265 [3081118] MEDICA CLAIMS [308111801] 5.14 percent of total billed charges 3.54 5.42 Technical (Hospital) Services NAPROXEN 250 MG TABLET RX-5391 CDM 6370000100 HCPCS 250 RC 68462-0188-01 NDC inpatient 1 UN 5.71 5.71 HEALTHPARTNERS SX009 HEALTHPARTNERS 4.52 percent of total billed charges 3.54 5.42 Technical (Hospital) Services NAPROXEN 500 MG TABLET RX-5393 CDM 6370000100 HCPCS 250 RC 49483-0618-01 NDC inpatient 1 UN 5.7 5.7 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES PPO [308136801] 4.51 percent of total billed charges 3.53 5.42 Technical (Hospital) Services NAPROXEN 500 MG TABLET RX-5393 CDM 6370000100 HCPCS 250 RC 49483-0618-01 NDC inpatient 1 UN 5.7 5.7 MEDICA (COMMERCIAL) 94265 [3081118] MEDICA CLAIMS [308111801] 5.13 percent of total billed charges 3.53 5.42 Technical (Hospital) Services NAPROXEN 500 MG TABLET RX-5393 CDM 6370000100 HCPCS 250 RC 49483-0618-01 NDC inpatient 1 UN 5.7 5.7 HEALTHPARTNERS SX009 HEALTHPARTNERS 4.51 percent of total billed charges 3.53 5.42 Technical (Hospital) Services NAPROXEN 500 MG TABLET RX-5393 CDM 6370000100 HCPCS 250 RC 49483-0618-01 NDC inpatient 1 UN 5.7 5.7 MULTIPLAN INC 34080 [3081285] MULTIPLAN INC [308128501] 5.42 percent of total billed charges 3.53 5.42 Technical (Hospital) Services NAPROXEN 500 MG TABLET RX-5393 CDM 6370000100 HCPCS 250 RC 49483-0618-01 NDC inpatient 1 UN 5.7 5.7 UNITED HEALTHCARE (COMMERCIAL) [3081199] UNITED HEALTHCARE 87726 [308119901] 3.53 percent of total billed charges 3.53 5.42 Technical (Hospital) Services NAPROXEN 500 MG TABLET RX-5393 CDM 6370000100 HCPCS 250 RC 49483-0618-01 NDC inpatient 1 UN 5.7 5.7 CIGNA 62308 [3081051] CIGNA 62308 [308105105] 4.51 percent of total billed charges 3.53 5.42 Technical (Hospital) Services NAPROXEN 500 MG TABLET RX-5393 CDM 6370000100 HCPCS 250 RC 49483-0618-01 NDC inpatient 1 UN 5.7 5.7 CIGNA 62308 [3081051] CIGNA STATE OF WYOMING [308105107] 4.51 percent of total billed charges 3.53 5.42 Technical (Hospital) Services NAPROXEN 500 MG TABLET RX-5393 CDM 6370000100 HCPCS 250 RC 49483-0618-01 NDC inpatient 1 UN 5.7 5.7 BLUE CROSS BLUE SHIELD WELLMARK SB889 [3081026] BCBS WYOMING [308102603] 5.42 percent of total billed charges 3.53 5.42 Technical (Hospital) Services NAPROXEN 500 MG TABLET RX-5393 CDM 6370000100 HCPCS 250 RC 49483-0618-01 NDC inpatient 1 UN 5.7 5.7 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES HDHP [308136802] 4.51 percent of total billed charges 3.53 5.42 Technical (Hospital) Services NAPROXEN 500 MG TABLET RX-5393 CDM 6370000100 HCPCS 250 RC 49483-0618-01 NDC inpatient 1 UN 5.7 5.7 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES EPO [308136803] 4.51 percent of total billed charges 3.53 5.42 Technical (Hospital) Services NAPROXEN 500 MG TABLET RX-5393 CDM 6370000100 HCPCS 250 RC 49483-0618-01 NDC outpatient 1 UN 5.7 5.7 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES PPO [308136801] 4.56 percent of total billed charges 3.53 5.42 Technical (Hospital) Services NAPROXEN 500 MG TABLET RX-5393 CDM 6370000100 HCPCS 250 RC 49483-0618-01 NDC outpatient 1 UN 5.7 5.7 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES HDHP [308136802] 4.56 percent of total billed charges 3.53 5.42 Technical (Hospital) Services NAPROXEN 500 MG TABLET RX-5393 CDM 6370000100 HCPCS 250 RC 49483-0618-01 NDC outpatient 1 UN 5.7 5.7 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES EPO [308136803] 4.56 percent of total billed charges 3.53 5.42 Technical (Hospital) Services NAPROXEN 500 MG TABLET RX-5393 CDM 6370000100 HCPCS 250 RC 49483-0618-01 NDC outpatient 1 UN 5.7 5.7 HEALTHPARTNERS SX009 HEALTHPARTNERS 4.56 percent of total billed charges 3.53 5.42 Technical (Hospital) Services NAPROXEN 500 MG TABLET RX-5393 CDM 6370000100 HCPCS 250 RC 49483-0618-01 NDC outpatient 1 UN 5.7 5.7 UNITED HEALTHCARE (COMMERCIAL) [3081199] UNITED HEALTHCARE 87726 [308119901] 3.53 percent of total billed charges 3.53 5.42 Technical (Hospital) Services NAPROXEN 500 MG TABLET RX-5393 CDM 6370000100 HCPCS 250 RC 49483-0618-01 NDC outpatient 1 UN 5.7 5.7 MULTIPLAN INC 34080 [3081285] MULTIPLAN INC [308128501] 5.42 percent of total billed charges 3.53 5.42 Technical (Hospital) Services NAPROXEN 500 MG TABLET RX-5393 CDM 6370000100 HCPCS 250 RC 49483-0618-01 NDC outpatient 1 UN 5.7 5.7 CIGNA 62308 [3081051] CIGNA 62308 [308105105] 4.56 percent of total billed charges 3.53 5.42 Technical (Hospital) Services NAPROXEN 500 MG TABLET RX-5393 CDM 6370000100 HCPCS 250 RC 49483-0618-01 NDC outpatient 1 UN 5.7 5.7 CIGNA 62308 [3081051] CIGNA STATE OF WYOMING [308105107] 4.56 percent of total billed charges 3.53 5.42 Technical (Hospital) Services NAPROXEN 500 MG TABLET RX-5393 CDM 6370000100 HCPCS 250 RC 49483-0618-01 NDC outpatient 1 UN 5.7 5.7 MEDICA (COMMERCIAL) 94265 [3081118] MEDICA CLAIMS [308111801] 5.13 percent of total billed charges 3.53 5.42 Technical (Hospital) Services NAPROXEN 500 MG TABLET RX-5393 CDM 6370000100 HCPCS 250 RC 49483-0618-01 NDC outpatient 1 UN 5.7 5.7 BLUE CROSS BLUE SHIELD WELLMARK SB889 [3081026] BCBS WYOMING [308102603] 5.42 percent of total billed charges 3.53 5.42 Technical (Hospital) Services NIACIN 100 MG TABLET RX-5539 CDM 6370000100 HCPCS 250 RC 79854-0201-30 NDC inpatient 1 UN 5.65 5.65 MULTIPLAN INC 34080 [3081285] MULTIPLAN INC [308128501] 5.37 percent of total billed charges 3.5 5.37 Technical (Hospital) Services NIACIN 100 MG TABLET RX-5539 CDM 6370000100 HCPCS 250 RC 79854-0201-30 NDC inpatient 1 UN 5.65 5.65 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES HDHP [308136802] 4.47 percent of total billed charges 3.5 5.37 Technical (Hospital) Services NIACIN 100 MG TABLET RX-5539 CDM 6370000100 HCPCS 250 RC 79854-0201-30 NDC inpatient 1 UN 5.65 5.65 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES EPO [308136803] 4.47 percent of total billed charges 3.5 5.37 Technical (Hospital) Services NIACIN 100 MG TABLET RX-5539 CDM 6370000100 HCPCS 250 RC 79854-0201-30 NDC inpatient 1 UN 5.65 5.65 CIGNA 62308 [3081051] CIGNA 62308 [308105105] 4.47 percent of total billed charges 3.5 5.37 Technical (Hospital) Services NIACIN 100 MG TABLET RX-5539 CDM 6370000100 HCPCS 250 RC 79854-0201-30 NDC inpatient 1 UN 5.65 5.65 CIGNA 62308 [3081051] CIGNA STATE OF WYOMING [308105107] 4.47 percent of total billed charges 3.5 5.37 Technical (Hospital) Services NIACIN 100 MG TABLET RX-5539 CDM 6370000100 HCPCS 250 RC 79854-0201-30 NDC inpatient 1 UN 5.65 5.65 UNITED HEALTHCARE (COMMERCIAL) [3081199] UNITED HEALTHCARE 87726 [308119901] 3.5 percent of total billed charges 3.5 5.37 Technical (Hospital) Services NIACIN 100 MG TABLET RX-5539 CDM 6370000100 HCPCS 250 RC 79854-0201-30 NDC inpatient 1 UN 5.65 5.65 BLUE CROSS BLUE SHIELD WELLMARK SB889 [3081026] BCBS WYOMING [308102603] 5.37 percent of total billed charges 3.5 5.37 Technical (Hospital) Services NIACIN 100 MG TABLET RX-5539 CDM 6370000100 HCPCS 250 RC 79854-0201-30 NDC inpatient 1 UN 5.65 5.65 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES PPO [308136801] 4.47 percent of total billed charges 3.5 5.37 Technical (Hospital) Services NIACIN 100 MG TABLET RX-5539 CDM 6370000100 HCPCS 250 RC 79854-0201-30 NDC inpatient 1 UN 5.65 5.65 MEDICA (COMMERCIAL) 94265 [3081118] MEDICA CLAIMS [308111801] 5.09 percent of total billed charges 3.5 5.37 Technical (Hospital) Services NIACIN 100 MG TABLET RX-5539 CDM 6370000100 HCPCS 250 RC 79854-0201-30 NDC inpatient 1 UN 5.65 5.65 HEALTHPARTNERS SX009 HEALTHPARTNERS 4.47 percent of total billed charges 3.5 5.37 Technical (Hospital) Services NIACIN 100 MG TABLET RX-5539 CDM 6370000100 HCPCS 250 RC 79854-0201-30 NDC outpatient 1 UN 5.65 5.65 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES EPO [308136803] 4.52 percent of total billed charges 3.5 5.37 Technical (Hospital) Services NIACIN 100 MG TABLET RX-5539 CDM 6370000100 HCPCS 250 RC 79854-0201-30 NDC outpatient 1 UN 5.65 5.65 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES HDHP [308136802] 4.52 percent of total billed charges 3.5 5.37 Technical (Hospital) Services NIACIN 100 MG TABLET RX-5539 CDM 6370000100 HCPCS 250 RC 79854-0201-30 NDC outpatient 1 UN 5.65 5.65 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES PPO [308136801] 4.52 percent of total billed charges 3.5 5.37 Technical (Hospital) Services NIACIN 100 MG TABLET RX-5539 CDM 6370000100 HCPCS 250 RC 79854-0201-30 NDC outpatient 1 UN 5.65 5.65 HEALTHPARTNERS SX009 HEALTHPARTNERS 4.52 percent of total billed charges 3.5 5.37 Technical (Hospital) Services NIACIN 100 MG TABLET RX-5539 CDM 6370000100 HCPCS 250 RC 79854-0201-30 NDC outpatient 1 UN 5.65 5.65 UNITED HEALTHCARE (COMMERCIAL) [3081199] UNITED HEALTHCARE 87726 [308119901] 3.5 percent of total billed charges 3.5 5.37 Technical (Hospital) Services NIACIN 100 MG TABLET RX-5539 CDM 6370000100 HCPCS 250 RC 79854-0201-30 NDC outpatient 1 UN 5.65 5.65 MULTIPLAN INC 34080 [3081285] MULTIPLAN INC [308128501] 5.37 percent of total billed charges 3.5 5.37 Technical (Hospital) Services NIACIN 100 MG TABLET RX-5539 CDM 6370000100 HCPCS 250 RC 79854-0201-30 NDC outpatient 1 UN 5.65 5.65 CIGNA 62308 [3081051] CIGNA 62308 [308105105] 4.52 percent of total billed charges 3.5 5.37 Technical (Hospital) Services NIACIN 100 MG TABLET RX-5539 CDM 6370000100 HCPCS 250 RC 79854-0201-30 NDC outpatient 1 UN 5.65 5.65 CIGNA 62308 [3081051] CIGNA STATE OF WYOMING [308105107] 4.52 percent of total billed charges 3.5 5.37 Technical (Hospital) Services NIACIN 100 MG TABLET RX-5539 CDM 6370000100 HCPCS 250 RC 79854-0201-30 NDC outpatient 1 UN 5.65 5.65 MEDICA (COMMERCIAL) 94265 [3081118] MEDICA CLAIMS [308111801] 5.09 percent of total billed charges 3.5 5.37 Technical (Hospital) Services NIACIN 100 MG TABLET RX-5539 CDM 6370000100 HCPCS 250 RC 79854-0201-30 NDC outpatient 1 UN 5.65 5.65 BLUE CROSS BLUE SHIELD WELLMARK SB889 [3081026] BCBS WYOMING [308102603] 5.37 percent of total billed charges 3.5 5.37 Technical (Hospital) Services NIACIN 500 MG TABLET RX-5542 CDM 6370000100 HCPCS 250 RC 00904-2272-60 NDC outpatient 1 UN 5.65 5.65 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES HDHP [308136802] 4.52 percent of total billed charges 3.5 5.37 Technical (Hospital) Services NIACIN 500 MG TABLET RX-5542 CDM 6370000100 HCPCS 250 RC 00904-2272-60 NDC outpatient 1 UN 5.65 5.65 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES EPO [308136803] 4.52 percent of total billed charges 3.5 5.37 Technical (Hospital) Services NIACIN 500 MG TABLET RX-5542 CDM 6370000100 HCPCS 250 RC 00904-2272-60 NDC outpatient 1 UN 5.65 5.65 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES PPO [308136801] 4.52 percent of total billed charges 3.5 5.37 Technical (Hospital) Services NIACIN 500 MG TABLET RX-5542 CDM 6370000100 HCPCS 250 RC 00904-2272-60 NDC outpatient 1 UN 5.65 5.65 UNITED HEALTHCARE (COMMERCIAL) [3081199] UNITED HEALTHCARE 87726 [308119901] 3.5 percent of total billed charges 3.5 5.37 Technical (Hospital) Services NIACIN 500 MG TABLET RX-5542 CDM 6370000100 HCPCS 250 RC 00904-2272-60 NDC outpatient 1 UN 5.65 5.65 MULTIPLAN INC 34080 [3081285] MULTIPLAN INC [308128501] 5.37 percent of total billed charges 3.5 5.37 Technical (Hospital) Services NIACIN 500 MG TABLET RX-5542 CDM 6370000100 HCPCS 250 RC 00904-2272-60 NDC outpatient 1 UN 5.65 5.65 CIGNA 62308 [3081051] CIGNA 62308 [308105105] 4.52 percent of total billed charges 3.5 5.37 Technical (Hospital) Services NIACIN 500 MG TABLET RX-5542 CDM 6370000100 HCPCS 250 RC 00904-2272-60 NDC outpatient 1 UN 5.65 5.65 CIGNA 62308 [3081051] CIGNA STATE OF WYOMING [308105107] 4.52 percent of total billed charges 3.5 5.37 Technical (Hospital) Services NIACIN 500 MG TABLET RX-5542 CDM 6370000100 HCPCS 250 RC 00904-2272-60 NDC outpatient 1 UN 5.65 5.65 MEDICA (COMMERCIAL) 94265 [3081118] MEDICA CLAIMS [308111801] 5.09 percent of total billed charges 3.5 5.37 Technical (Hospital) Services NIACIN 500 MG TABLET RX-5542 CDM 6370000100 HCPCS 250 RC 00904-2272-60 NDC outpatient 1 UN 5.65 5.65 BLUE CROSS BLUE SHIELD WELLMARK SB889 [3081026] BCBS WYOMING [308102603] 5.37 percent of total billed charges 3.5 5.37 Technical (Hospital) Services NIACIN 500 MG TABLET RX-5542 CDM 6370000100 HCPCS 250 RC 00904-2272-60 NDC outpatient 1 UN 5.65 5.65 HEALTHPARTNERS SX009 HEALTHPARTNERS 4.52 percent of total billed charges 3.5 5.37 Technical (Hospital) Services NIACIN 500 MG TABLET RX-5542 CDM 6370000100 HCPCS 250 RC 00904-2272-60 NDC inpatient 1 UN 5.65 5.65 MEDICA (COMMERCIAL) 94265 [3081118] MEDICA CLAIMS [308111801] 5.09 percent of total billed charges 3.5 5.37 Technical (Hospital) Services NIACIN 500 MG TABLET RX-5542 CDM 6370000100 HCPCS 250 RC 00904-2272-60 NDC inpatient 1 UN 5.65 5.65 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES PPO [308136801] 4.47 percent of total billed charges 3.5 5.37 Technical (Hospital) Services NIACIN 500 MG TABLET RX-5542 CDM 6370000100 HCPCS 250 RC 00904-2272-60 NDC inpatient 1 UN 5.65 5.65 HEALTHPARTNERS SX009 HEALTHPARTNERS 4.47 percent of total billed charges 3.5 5.37 Technical (Hospital) Services NIACIN 500 MG TABLET RX-5542 CDM 6370000100 HCPCS 250 RC 00904-2272-60 NDC inpatient 1 UN 5.65 5.65 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES HDHP [308136802] 4.47 percent of total billed charges 3.5 5.37 Technical (Hospital) Services NIACIN 500 MG TABLET RX-5542 CDM 6370000100 HCPCS 250 RC 00904-2272-60 NDC inpatient 1 UN 5.65 5.65 UNITED HEALTHCARE (COMMERCIAL) [3081199] UNITED HEALTHCARE 87726 [308119901] 3.5 percent of total billed charges 3.5 5.37 Technical (Hospital) Services NIACIN 500 MG TABLET RX-5542 CDM 6370000100 HCPCS 250 RC 00904-2272-60 NDC inpatient 1 UN 5.65 5.65 CIGNA 62308 [3081051] CIGNA 62308 [308105105] 4.47 percent of total billed charges 3.5 5.37 Technical (Hospital) Services NIACIN 500 MG TABLET RX-5542 CDM 6370000100 HCPCS 250 RC 00904-2272-60 NDC inpatient 1 UN 5.65 5.65 CIGNA 62308 [3081051] CIGNA STATE OF WYOMING [308105107] 4.47 percent of total billed charges 3.5 5.37 Technical (Hospital) Services NIACIN 500 MG TABLET RX-5542 CDM 6370000100 HCPCS 250 RC 00904-2272-60 NDC inpatient 1 UN 5.65 5.65 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES EPO [308136803] 4.47 percent of total billed charges 3.5 5.37 Technical (Hospital) Services NIACIN 500 MG TABLET RX-5542 CDM 6370000100 HCPCS 250 RC 00904-2272-60 NDC inpatient 1 UN 5.65 5.65 BLUE CROSS BLUE SHIELD WELLMARK SB889 [3081026] BCBS WYOMING [308102603] 5.37 percent of total billed charges 3.5 5.37 Technical (Hospital) Services NIACIN 500 MG TABLET RX-5542 CDM 6370000100 HCPCS 250 RC 00904-2272-60 NDC inpatient 1 UN 5.65 5.65 MULTIPLAN INC 34080 [3081285] MULTIPLAN INC [308128501] 5.37 percent of total billed charges 3.5 5.37 Technical (Hospital) Services "NITROGLYCERIN ER 2.5 MG CAPSULE,EXTENDED RELEASE" RX-5600 CDM 6370000100 HCPCS 250 RC 49483-0221-10 NDC outpatient 1 UN 6.12 6.12 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES PPO [308136801] 4.9 percent of total billed charges 3.79 5.81 Technical (Hospital) Services "NITROGLYCERIN ER 2.5 MG CAPSULE,EXTENDED RELEASE" RX-5600 CDM 6370000100 HCPCS 250 RC 49483-0221-10 NDC outpatient 1 UN 6.12 6.12 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES HDHP [308136802] 4.9 percent of total billed charges 3.79 5.81 Technical (Hospital) Services "NITROGLYCERIN ER 2.5 MG CAPSULE,EXTENDED RELEASE" RX-5600 CDM 6370000100 HCPCS 250 RC 49483-0221-10 NDC outpatient 1 UN 6.12 6.12 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES EPO [308136803] 4.9 percent of total billed charges 3.79 5.81 Technical (Hospital) Services "NITROGLYCERIN ER 2.5 MG CAPSULE,EXTENDED RELEASE" RX-5600 CDM 6370000100 HCPCS 250 RC 49483-0221-10 NDC outpatient 1 UN 6.12 6.12 BLUE CROSS BLUE SHIELD WELLMARK SB889 [3081026] BCBS WYOMING [308102603] 5.81 percent of total billed charges 3.79 5.81 Technical (Hospital) Services "NITROGLYCERIN ER 2.5 MG CAPSULE,EXTENDED RELEASE" RX-5600 CDM 6370000100 HCPCS 250 RC 49483-0221-10 NDC outpatient 1 UN 6.12 6.12 HEALTHPARTNERS SX009 HEALTHPARTNERS 4.9 percent of total billed charges 3.79 5.81 Technical (Hospital) Services "NITROGLYCERIN ER 2.5 MG CAPSULE,EXTENDED RELEASE" RX-5600 CDM 6370000100 HCPCS 250 RC 49483-0221-10 NDC outpatient 1 UN 6.12 6.12 UNITED HEALTHCARE (COMMERCIAL) [3081199] UNITED HEALTHCARE 87726 [308119901] 3.79 percent of total billed charges 3.79 5.81 Technical (Hospital) Services "NITROGLYCERIN ER 2.5 MG CAPSULE,EXTENDED RELEASE" RX-5600 CDM 6370000100 HCPCS 250 RC 49483-0221-10 NDC outpatient 1 UN 6.12 6.12 MULTIPLAN INC 34080 [3081285] MULTIPLAN INC [308128501] 5.81 percent of total billed charges 3.79 5.81 Technical (Hospital) Services "NITROGLYCERIN ER 2.5 MG CAPSULE,EXTENDED RELEASE" RX-5600 CDM 6370000100 HCPCS 250 RC 49483-0221-10 NDC outpatient 1 UN 6.12 6.12 CIGNA 62308 [3081051] CIGNA 62308 [308105105] 4.9 percent of total billed charges 3.79 5.81 Technical (Hospital) Services "NITROGLYCERIN ER 2.5 MG CAPSULE,EXTENDED RELEASE" RX-5600 CDM 6370000100 HCPCS 250 RC 49483-0221-10 NDC outpatient 1 UN 6.12 6.12 CIGNA 62308 [3081051] CIGNA STATE OF WYOMING [308105107] 4.9 percent of total billed charges 3.79 5.81 Technical (Hospital) Services "NITROGLYCERIN ER 2.5 MG CAPSULE,EXTENDED RELEASE" RX-5600 CDM 6370000100 HCPCS 250 RC 49483-0221-10 NDC outpatient 1 UN 6.12 6.12 MEDICA (COMMERCIAL) 94265 [3081118] MEDICA CLAIMS [308111801] 5.51 percent of total billed charges 3.79 5.81 Technical (Hospital) Services "NITROGLYCERIN ER 2.5 MG CAPSULE,EXTENDED RELEASE" RX-5600 CDM 6370000100 HCPCS 250 RC 49483-0221-10 NDC inpatient 1 UN 6.12 6.12 BLUE CROSS BLUE SHIELD WELLMARK SB889 [3081026] BCBS WYOMING [308102603] 5.81 percent of total billed charges 3.79 5.81 Technical (Hospital) Services "NITROGLYCERIN ER 2.5 MG CAPSULE,EXTENDED RELEASE" RX-5600 CDM 6370000100 HCPCS 250 RC 49483-0221-10 NDC inpatient 1 UN 6.12 6.12 CIGNA 62308 [3081051] CIGNA 62308 [308105105] 4.85 percent of total billed charges 3.79 5.81 Technical (Hospital) Services "NITROGLYCERIN ER 2.5 MG CAPSULE,EXTENDED RELEASE" RX-5600 CDM 6370000100 HCPCS 250 RC 49483-0221-10 NDC inpatient 1 UN 6.12 6.12 CIGNA 62308 [3081051] CIGNA STATE OF WYOMING [308105107] 4.85 percent of total billed charges 3.79 5.81 Technical (Hospital) Services "NITROGLYCERIN ER 2.5 MG CAPSULE,EXTENDED RELEASE" RX-5600 CDM 6370000100 HCPCS 250 RC 49483-0221-10 NDC inpatient 1 UN 6.12 6.12 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES EPO [308136803] 4.85 percent of total billed charges 3.79 5.81 Technical (Hospital) Services "NITROGLYCERIN ER 2.5 MG CAPSULE,EXTENDED RELEASE" RX-5600 CDM 6370000100 HCPCS 250 RC 49483-0221-10 NDC inpatient 1 UN 6.12 6.12 UNITED HEALTHCARE (COMMERCIAL) [3081199] UNITED HEALTHCARE 87726 [308119901] 3.79 percent of total billed charges 3.79 5.81 Technical (Hospital) Services "NITROGLYCERIN ER 2.5 MG CAPSULE,EXTENDED RELEASE" RX-5600 CDM 6370000100 HCPCS 250 RC 49483-0221-10 NDC inpatient 1 UN 6.12 6.12 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES HDHP [308136802] 4.85 percent of total billed charges 3.79 5.81 Technical (Hospital) Services "NITROGLYCERIN ER 2.5 MG CAPSULE,EXTENDED RELEASE" RX-5600 CDM 6370000100 HCPCS 250 RC 49483-0221-10 NDC inpatient 1 UN 6.12 6.12 MULTIPLAN INC 34080 [3081285] MULTIPLAN INC [308128501] 5.81 percent of total billed charges 3.79 5.81 Technical (Hospital) Services "NITROGLYCERIN ER 2.5 MG CAPSULE,EXTENDED RELEASE" RX-5600 CDM 6370000100 HCPCS 250 RC 49483-0221-10 NDC inpatient 1 UN 6.12 6.12 HEALTHPARTNERS SX009 HEALTHPARTNERS 4.85 percent of total billed charges 3.79 5.81 Technical (Hospital) Services "NITROGLYCERIN ER 2.5 MG CAPSULE,EXTENDED RELEASE" RX-5600 CDM 6370000100 HCPCS 250 RC 49483-0221-10 NDC inpatient 1 UN 6.12 6.12 MEDICA (COMMERCIAL) 94265 [3081118] MEDICA CLAIMS [308111801] 5.51 percent of total billed charges 3.79 5.81 Technical (Hospital) Services "NITROGLYCERIN ER 2.5 MG CAPSULE,EXTENDED RELEASE" RX-5600 CDM 6370000100 HCPCS 250 RC 49483-0221-10 NDC inpatient 1 UN 6.12 6.12 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES PPO [308136801] 4.85 percent of total billed charges 3.79 5.81 Technical (Hospital) Services "NITROGLYCERIN ER 6.5 MG CAPSULE,EXTENDED RELEASE" RX-5601 CDM 6370000100 HCPCS 250 RC 43063-0918-60 NDC outpatient 1 UN 6.25 6.25 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES EPO [308136803] 5 percent of total billed charges 3.88 5.94 Technical (Hospital) Services "NITROGLYCERIN ER 6.5 MG CAPSULE,EXTENDED RELEASE" RX-5601 CDM 6370000100 HCPCS 250 RC 43063-0918-60 NDC outpatient 1 UN 6.25 6.25 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES PPO [308136801] 5 percent of total billed charges 3.88 5.94 Technical (Hospital) Services "NITROGLYCERIN ER 6.5 MG CAPSULE,EXTENDED RELEASE" RX-5601 CDM 6370000100 HCPCS 250 RC 43063-0918-60 NDC outpatient 1 UN 6.25 6.25 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES HDHP [308136802] 5 percent of total billed charges 3.88 5.94 Technical (Hospital) Services "NITROGLYCERIN ER 6.5 MG CAPSULE,EXTENDED RELEASE" RX-5601 CDM 6370000100 HCPCS 250 RC 43063-0918-60 NDC outpatient 1 UN 6.25 6.25 UNITED HEALTHCARE (COMMERCIAL) [3081199] UNITED HEALTHCARE 87726 [308119901] 3.88 percent of total billed charges 3.88 5.94 Technical (Hospital) Services "NITROGLYCERIN ER 6.5 MG CAPSULE,EXTENDED RELEASE" RX-5601 CDM 6370000100 HCPCS 250 RC 43063-0918-60 NDC outpatient 1 UN 6.25 6.25 HEALTHPARTNERS SX009 HEALTHPARTNERS 5 percent of total billed charges 3.88 5.94 Technical (Hospital) Services "NITROGLYCERIN ER 6.5 MG CAPSULE,EXTENDED RELEASE" RX-5601 CDM 6370000100 HCPCS 250 RC 43063-0918-60 NDC outpatient 1 UN 6.25 6.25 CIGNA 62308 [3081051] CIGNA 62308 [308105105] 5 percent of total billed charges 3.88 5.94 Technical (Hospital) Services "NITROGLYCERIN ER 6.5 MG CAPSULE,EXTENDED RELEASE" RX-5601 CDM 6370000100 HCPCS 250 RC 43063-0918-60 NDC outpatient 1 UN 6.25 6.25 CIGNA 62308 [3081051] CIGNA STATE OF WYOMING [308105107] 5 percent of total billed charges 3.88 5.94 Technical (Hospital) Services "NITROGLYCERIN ER 6.5 MG CAPSULE,EXTENDED RELEASE" RX-5601 CDM 6370000100 HCPCS 250 RC 43063-0918-60 NDC outpatient 1 UN 6.25 6.25 MULTIPLAN INC 34080 [3081285] MULTIPLAN INC [308128501] 5.94 percent of total billed charges 3.88 5.94 Technical (Hospital) Services "NITROGLYCERIN ER 6.5 MG CAPSULE,EXTENDED RELEASE" RX-5601 CDM 6370000100 HCPCS 250 RC 43063-0918-60 NDC outpatient 1 UN 6.25 6.25 MEDICA (COMMERCIAL) 94265 [3081118] MEDICA CLAIMS [308111801] 5.63 percent of total billed charges 3.88 5.94 Technical (Hospital) Services "NITROGLYCERIN ER 6.5 MG CAPSULE,EXTENDED RELEASE" RX-5601 CDM 6370000100 HCPCS 250 RC 43063-0918-60 NDC outpatient 1 UN 6.25 6.25 BLUE CROSS BLUE SHIELD WELLMARK SB889 [3081026] BCBS WYOMING [308102603] 5.94 percent of total billed charges 3.88 5.94 Technical (Hospital) Services "NITROGLYCERIN ER 6.5 MG CAPSULE,EXTENDED RELEASE" RX-5601 CDM 6370000100 HCPCS 250 RC 43063-0918-60 NDC inpatient 1 UN 6.25 6.25 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES PPO [308136801] 4.95 percent of total billed charges 3.88 5.94 Technical (Hospital) Services "NITROGLYCERIN ER 6.5 MG CAPSULE,EXTENDED RELEASE" RX-5601 CDM 6370000100 HCPCS 250 RC 43063-0918-60 NDC inpatient 1 UN 6.25 6.25 MEDICA (COMMERCIAL) 94265 [3081118] MEDICA CLAIMS [308111801] 5.63 percent of total billed charges 3.88 5.94 Technical (Hospital) Services "NITROGLYCERIN ER 6.5 MG CAPSULE,EXTENDED RELEASE" RX-5601 CDM 6370000100 HCPCS 250 RC 43063-0918-60 NDC inpatient 1 UN 6.25 6.25 HEALTHPARTNERS SX009 HEALTHPARTNERS 4.95 percent of total billed charges 3.88 5.94 Technical (Hospital) Services "NITROGLYCERIN ER 6.5 MG CAPSULE,EXTENDED RELEASE" RX-5601 CDM 6370000100 HCPCS 250 RC 43063-0918-60 NDC inpatient 1 UN 6.25 6.25 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES HDHP [308136802] 4.95 percent of total billed charges 3.88 5.94 Technical (Hospital) Services "NITROGLYCERIN ER 6.5 MG CAPSULE,EXTENDED RELEASE" RX-5601 CDM 6370000100 HCPCS 250 RC 43063-0918-60 NDC inpatient 1 UN 6.25 6.25 UNITED HEALTHCARE (COMMERCIAL) [3081199] UNITED HEALTHCARE 87726 [308119901] 3.88 percent of total billed charges 3.88 5.94 Technical (Hospital) Services "NITROGLYCERIN ER 6.5 MG CAPSULE,EXTENDED RELEASE" RX-5601 CDM 6370000100 HCPCS 250 RC 43063-0918-60 NDC inpatient 1 UN 6.25 6.25 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES EPO [308136803] 4.95 percent of total billed charges 3.88 5.94 Technical (Hospital) Services "NITROGLYCERIN ER 6.5 MG CAPSULE,EXTENDED RELEASE" RX-5601 CDM 6370000100 HCPCS 250 RC 43063-0918-60 NDC inpatient 1 UN 6.25 6.25 CIGNA 62308 [3081051] CIGNA 62308 [308105105] 4.95 percent of total billed charges 3.88 5.94 Technical (Hospital) Services "NITROGLYCERIN ER 6.5 MG CAPSULE,EXTENDED RELEASE" RX-5601 CDM 6370000100 HCPCS 250 RC 43063-0918-60 NDC inpatient 1 UN 6.25 6.25 CIGNA 62308 [3081051] CIGNA STATE OF WYOMING [308105107] 4.95 percent of total billed charges 3.88 5.94 Technical (Hospital) Services "NITROGLYCERIN ER 6.5 MG CAPSULE,EXTENDED RELEASE" RX-5601 CDM 6370000100 HCPCS 250 RC 43063-0918-60 NDC inpatient 1 UN 6.25 6.25 BLUE CROSS BLUE SHIELD WELLMARK SB889 [3081026] BCBS WYOMING [308102603] 5.94 percent of total billed charges 3.88 5.94 Technical (Hospital) Services "NITROGLYCERIN ER 6.5 MG CAPSULE,EXTENDED RELEASE" RX-5601 CDM 6370000100 HCPCS 250 RC 43063-0918-60 NDC inpatient 1 UN 6.25 6.25 MULTIPLAN INC 34080 [3081285] MULTIPLAN INC [308128501] 5.94 percent of total billed charges 3.88 5.94 Technical (Hospital) Services NITROGLYCERIN 0.4 MG SUBLINGUAL TABLET RX-5604 CDM 6370000100 HCPCS 250 RC 00071-0418-13 NDC outpatient 1 UN 7.24 7.24 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES HDHP [308136802] 5.79 percent of total billed charges 4.49 6.88 Technical (Hospital) Services NITROGLYCERIN 0.4 MG SUBLINGUAL TABLET RX-5604 CDM 6370000100 HCPCS 250 RC 00071-0418-13 NDC outpatient 1 UN 7.24 7.24 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES EPO [308136803] 5.79 percent of total billed charges 4.49 6.88 Technical (Hospital) Services NITROGLYCERIN 0.4 MG SUBLINGUAL TABLET RX-5604 CDM 6370000100 HCPCS 250 RC 00071-0418-13 NDC outpatient 1 UN 7.24 7.24 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES PPO [308136801] 5.79 percent of total billed charges 4.49 6.88 Technical (Hospital) Services NITROGLYCERIN 0.4 MG SUBLINGUAL TABLET RX-5604 CDM 6370000100 HCPCS 250 RC 00071-0418-13 NDC outpatient 1 UN 7.24 7.24 UNITED HEALTHCARE (COMMERCIAL) [3081199] UNITED HEALTHCARE 87726 [308119901] 4.49 percent of total billed charges 4.49 6.88 Technical (Hospital) Services NITROGLYCERIN 0.4 MG SUBLINGUAL TABLET RX-5604 CDM 6370000100 HCPCS 250 RC 00071-0418-13 NDC outpatient 1 UN 7.24 7.24 MEDICA (COMMERCIAL) 94265 [3081118] MEDICA CLAIMS [308111801] 6.52 percent of total billed charges 4.49 6.88 Technical (Hospital) Services NITROGLYCERIN 0.4 MG SUBLINGUAL TABLET RX-5604 CDM 6370000100 HCPCS 250 RC 00071-0418-13 NDC outpatient 1 UN 7.24 7.24 MULTIPLAN INC 34080 [3081285] MULTIPLAN INC [308128501] 6.88 percent of total billed charges 4.49 6.88 Technical (Hospital) Services NITROGLYCERIN 0.4 MG SUBLINGUAL TABLET RX-5604 CDM 6370000100 HCPCS 250 RC 00071-0418-13 NDC outpatient 1 UN 7.24 7.24 CIGNA 62308 [3081051] CIGNA 62308 [308105105] 5.79 percent of total billed charges 4.49 6.88 Technical (Hospital) Services NITROGLYCERIN 0.4 MG SUBLINGUAL TABLET RX-5604 CDM 6370000100 HCPCS 250 RC 00071-0418-13 NDC outpatient 1 UN 7.24 7.24 CIGNA 62308 [3081051] CIGNA STATE OF WYOMING [308105107] 5.79 percent of total billed charges 4.49 6.88 Technical (Hospital) Services NITROGLYCERIN 0.4 MG SUBLINGUAL TABLET RX-5604 CDM 6370000100 HCPCS 250 RC 00071-0418-13 NDC outpatient 1 UN 7.24 7.24 HEALTHPARTNERS SX009 HEALTHPARTNERS 5.79 percent of total billed charges 4.49 6.88 Technical (Hospital) Services NITROGLYCERIN 0.4 MG SUBLINGUAL TABLET RX-5604 CDM 6370000100 HCPCS 250 RC 00071-0418-13 NDC outpatient 1 UN 7.24 7.24 BLUE CROSS BLUE SHIELD WELLMARK SB889 [3081026] BCBS WYOMING [308102603] 6.88 percent of total billed charges 4.49 6.88 Technical (Hospital) Services NITROGLYCERIN 0.4 MG SUBLINGUAL TABLET RX-5604 CDM 6370000100 HCPCS 250 RC 00071-0418-13 NDC inpatient 1 UN 7.24 7.24 MULTIPLAN INC 34080 [3081285] MULTIPLAN INC [308128501] 6.88 percent of total billed charges 4.49 6.88 Technical (Hospital) Services NITROGLYCERIN 0.4 MG SUBLINGUAL TABLET RX-5604 CDM 6370000100 HCPCS 250 RC 00071-0418-13 NDC inpatient 1 UN 7.24 7.24 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES EPO [308136803] 5.73 percent of total billed charges 4.49 6.88 Technical (Hospital) Services NITROGLYCERIN 0.4 MG SUBLINGUAL TABLET RX-5604 CDM 6370000100 HCPCS 250 RC 00071-0418-13 NDC inpatient 1 UN 7.24 7.24 CIGNA 62308 [3081051] CIGNA 62308 [308105105] 5.73 percent of total billed charges 4.49 6.88 Technical (Hospital) Services NITROGLYCERIN 0.4 MG SUBLINGUAL TABLET RX-5604 CDM 6370000100 HCPCS 250 RC 00071-0418-13 NDC inpatient 1 UN 7.24 7.24 CIGNA 62308 [3081051] CIGNA STATE OF WYOMING [308105107] 5.73 percent of total billed charges 4.49 6.88 Technical (Hospital) Services NITROGLYCERIN 0.4 MG SUBLINGUAL TABLET RX-5604 CDM 6370000100 HCPCS 250 RC 00071-0418-13 NDC inpatient 1 UN 7.24 7.24 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES HDHP [308136802] 5.73 percent of total billed charges 4.49 6.88 Technical (Hospital) Services NITROGLYCERIN 0.4 MG SUBLINGUAL TABLET RX-5604 CDM 6370000100 HCPCS 250 RC 00071-0418-13 NDC inpatient 1 UN 7.24 7.24 BLUE CROSS BLUE SHIELD WELLMARK SB889 [3081026] BCBS WYOMING [308102603] 6.88 percent of total billed charges 4.49 6.88 Technical (Hospital) Services NITROGLYCERIN 0.4 MG SUBLINGUAL TABLET RX-5604 CDM 6370000100 HCPCS 250 RC 00071-0418-13 NDC inpatient 1 UN 7.24 7.24 UNITED HEALTHCARE (COMMERCIAL) [3081199] UNITED HEALTHCARE 87726 [308119901] 4.49 percent of total billed charges 4.49 6.88 Technical (Hospital) Services NITROGLYCERIN 0.4 MG SUBLINGUAL TABLET RX-5604 CDM 6370000100 HCPCS 250 RC 00071-0418-13 NDC inpatient 1 UN 7.24 7.24 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES PPO [308136801] 5.73 percent of total billed charges 4.49 6.88 Technical (Hospital) Services NITROGLYCERIN 0.4 MG SUBLINGUAL TABLET RX-5604 CDM 6370000100 HCPCS 250 RC 00071-0418-13 NDC inpatient 1 UN 7.24 7.24 MEDICA (COMMERCIAL) 94265 [3081118] MEDICA CLAIMS [308111801] 6.52 percent of total billed charges 4.49 6.88 Technical (Hospital) Services NITROGLYCERIN 0.4 MG SUBLINGUAL TABLET RX-5604 CDM 6370000100 HCPCS 250 RC 00071-0418-13 NDC inpatient 1 UN 7.24 7.24 HEALTHPARTNERS SX009 HEALTHPARTNERS 5.73 percent of total billed charges 4.49 6.88 Technical (Hospital) Services NITROGLYCERIN 2 % TRANSDERMAL OINTMENT RX-5606 CDM 6370000100 HCPCS 250 RC 00281-0326-08 NDC inpatient 1 GR 8.04 8.04 MEDICA (COMMERCIAL) 94265 [3081118] MEDICA CLAIMS [308111801] 7.24 percent of total billed charges 4.98 7.64 Technical (Hospital) Services NITROGLYCERIN 2 % TRANSDERMAL OINTMENT RX-5606 CDM 6370000100 HCPCS 250 RC 00281-0326-08 NDC inpatient 1 GR 8.04 8.04 HEALTHPARTNERS SX009 HEALTHPARTNERS 6.37 percent of total billed charges 4.98 7.64 Technical (Hospital) Services NITROGLYCERIN 2 % TRANSDERMAL OINTMENT RX-5606 CDM 6370000100 HCPCS 250 RC 00281-0326-08 NDC inpatient 1 GR 8.04 8.04 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES PPO [308136801] 6.37 percent of total billed charges 4.98 7.64 Technical (Hospital) Services NITROGLYCERIN 2 % TRANSDERMAL OINTMENT RX-5606 CDM 6370000100 HCPCS 250 RC 00281-0326-08 NDC inpatient 1 GR 8.04 8.04 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES HDHP [308136802] 6.37 percent of total billed charges 4.98 7.64 Technical (Hospital) Services NITROGLYCERIN 2 % TRANSDERMAL OINTMENT RX-5606 CDM 6370000100 HCPCS 250 RC 00281-0326-08 NDC inpatient 1 GR 8.04 8.04 BLUE CROSS BLUE SHIELD WELLMARK SB889 [3081026] BCBS WYOMING [308102603] 7.64 percent of total billed charges 4.98 7.64 Technical (Hospital) Services NITROGLYCERIN 2 % TRANSDERMAL OINTMENT RX-5606 CDM 6370000100 HCPCS 250 RC 00281-0326-08 NDC inpatient 1 GR 8.04 8.04 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES EPO [308136803] 6.37 percent of total billed charges 4.98 7.64 Technical (Hospital) Services NITROGLYCERIN 2 % TRANSDERMAL OINTMENT RX-5606 CDM 6370000100 HCPCS 250 RC 00281-0326-08 NDC inpatient 1 GR 8.04 8.04 CIGNA 62308 [3081051] CIGNA 62308 [308105105] 6.37 percent of total billed charges 4.98 7.64 Technical (Hospital) Services NITROGLYCERIN 2 % TRANSDERMAL OINTMENT RX-5606 CDM 6370000100 HCPCS 250 RC 00281-0326-08 NDC inpatient 1 GR 8.04 8.04 CIGNA 62308 [3081051] CIGNA STATE OF WYOMING [308105107] 6.37 percent of total billed charges 4.98 7.64 Technical (Hospital) Services NITROGLYCERIN 2 % TRANSDERMAL OINTMENT RX-5606 CDM 6370000100 HCPCS 250 RC 00281-0326-08 NDC inpatient 1 GR 8.04 8.04 UNITED HEALTHCARE (COMMERCIAL) [3081199] UNITED HEALTHCARE 87726 [308119901] 4.98 percent of total billed charges 4.98 7.64 Technical (Hospital) Services NITROGLYCERIN 2 % TRANSDERMAL OINTMENT RX-5606 CDM 6370000100 HCPCS 250 RC 00281-0326-08 NDC inpatient 1 GR 8.04 8.04 MULTIPLAN INC 34080 [3081285] MULTIPLAN INC [308128501] 7.64 percent of total billed charges 4.98 7.64 Technical (Hospital) Services NITROGLYCERIN 2 % TRANSDERMAL OINTMENT RX-5606 CDM 6370000100 HCPCS 250 RC 00281-0326-08 NDC outpatient 1 GR 8.04 8.04 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES EPO [308136803] 6.43 percent of total billed charges 4.98 7.64 Technical (Hospital) Services NITROGLYCERIN 2 % TRANSDERMAL OINTMENT RX-5606 CDM 6370000100 HCPCS 250 RC 00281-0326-08 NDC outpatient 1 GR 8.04 8.04 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES PPO [308136801] 6.43 percent of total billed charges 4.98 7.64 Technical (Hospital) Services NITROGLYCERIN 2 % TRANSDERMAL OINTMENT RX-5606 CDM 6370000100 HCPCS 250 RC 00281-0326-08 NDC outpatient 1 GR 8.04 8.04 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES HDHP [308136802] 6.43 percent of total billed charges 4.98 7.64 Technical (Hospital) Services NITROGLYCERIN 2 % TRANSDERMAL OINTMENT RX-5606 CDM 6370000100 HCPCS 250 RC 00281-0326-08 NDC outpatient 1 GR 8.04 8.04 HEALTHPARTNERS SX009 HEALTHPARTNERS 6.43 percent of total billed charges 4.98 7.64 Technical (Hospital) Services NITROGLYCERIN 2 % TRANSDERMAL OINTMENT RX-5606 CDM 6370000100 HCPCS 250 RC 00281-0326-08 NDC outpatient 1 GR 8.04 8.04 UNITED HEALTHCARE (COMMERCIAL) [3081199] UNITED HEALTHCARE 87726 [308119901] 4.98 percent of total billed charges 4.98 7.64 Technical (Hospital) Services NITROGLYCERIN 2 % TRANSDERMAL OINTMENT RX-5606 CDM 6370000100 HCPCS 250 RC 00281-0326-08 NDC outpatient 1 GR 8.04 8.04 MEDICA (COMMERCIAL) 94265 [3081118] MEDICA CLAIMS [308111801] 7.24 percent of total billed charges 4.98 7.64 Technical (Hospital) Services NITROGLYCERIN 2 % TRANSDERMAL OINTMENT RX-5606 CDM 6370000100 HCPCS 250 RC 00281-0326-08 NDC outpatient 1 GR 8.04 8.04 MULTIPLAN INC 34080 [3081285] MULTIPLAN INC [308128501] 7.64 percent of total billed charges 4.98 7.64 Technical (Hospital) Services NITROGLYCERIN 2 % TRANSDERMAL OINTMENT RX-5606 CDM 6370000100 HCPCS 250 RC 00281-0326-08 NDC outpatient 1 GR 8.04 8.04 CIGNA 62308 [3081051] CIGNA 62308 [308105105] 6.43 percent of total billed charges 4.98 7.64 Technical (Hospital) Services NITROGLYCERIN 2 % TRANSDERMAL OINTMENT RX-5606 CDM 6370000100 HCPCS 250 RC 00281-0326-08 NDC outpatient 1 GR 8.04 8.04 CIGNA 62308 [3081051] CIGNA STATE OF WYOMING [308105107] 6.43 percent of total billed charges 4.98 7.64 Technical (Hospital) Services NITROGLYCERIN 2 % TRANSDERMAL OINTMENT RX-5606 CDM 6370000100 HCPCS 250 RC 00281-0326-08 NDC outpatient 1 GR 8.04 8.04 BLUE CROSS BLUE SHIELD WELLMARK SB889 [3081026] BCBS WYOMING [308102603] 7.64 percent of total billed charges 4.98 7.64 Technical (Hospital) Services NORTRIPTYLINE 10 MG CAPSULE RX-5674 CDM 6370000100 HCPCS 250 RC 00093-0810-01 NDC outpatient 1 UN 5.82 5.82 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES PPO [308136801] 4.66 percent of total billed charges 3.61 5.53 Technical (Hospital) Services NORTRIPTYLINE 10 MG CAPSULE RX-5674 CDM 6370000100 HCPCS 250 RC 00093-0810-01 NDC outpatient 1 UN 5.82 5.82 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES HDHP [308136802] 4.66 percent of total billed charges 3.61 5.53 Technical (Hospital) Services NORTRIPTYLINE 10 MG CAPSULE RX-5674 CDM 6370000100 HCPCS 250 RC 00093-0810-01 NDC outpatient 1 UN 5.82 5.82 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES EPO [308136803] 4.66 percent of total billed charges 3.61 5.53 Technical (Hospital) Services NORTRIPTYLINE 10 MG CAPSULE RX-5674 CDM 6370000100 HCPCS 250 RC 00093-0810-01 NDC outpatient 1 UN 5.82 5.82 UNITED HEALTHCARE (COMMERCIAL) [3081199] UNITED HEALTHCARE 87726 [308119901] 3.61 percent of total billed charges 3.61 5.53 Technical (Hospital) Services NORTRIPTYLINE 10 MG CAPSULE RX-5674 CDM 6370000100 HCPCS 250 RC 00093-0810-01 NDC outpatient 1 UN 5.82 5.82 MEDICA (COMMERCIAL) 94265 [3081118] MEDICA CLAIMS [308111801] 5.24 percent of total billed charges 3.61 5.53 Technical (Hospital) Services NORTRIPTYLINE 10 MG CAPSULE RX-5674 CDM 6370000100 HCPCS 250 RC 00093-0810-01 NDC outpatient 1 UN 5.82 5.82 MULTIPLAN INC 34080 [3081285] MULTIPLAN INC [308128501] 5.53 percent of total billed charges 3.61 5.53 Technical (Hospital) Services NORTRIPTYLINE 10 MG CAPSULE RX-5674 CDM 6370000100 HCPCS 250 RC 00093-0810-01 NDC outpatient 1 UN 5.82 5.82 CIGNA 62308 [3081051] CIGNA 62308 [308105105] 4.66 percent of total billed charges 3.61 5.53 Technical (Hospital) Services NORTRIPTYLINE 10 MG CAPSULE RX-5674 CDM 6370000100 HCPCS 250 RC 00093-0810-01 NDC outpatient 1 UN 5.82 5.82 CIGNA 62308 [3081051] CIGNA STATE OF WYOMING [308105107] 4.66 percent of total billed charges 3.61 5.53 Technical (Hospital) Services NORTRIPTYLINE 10 MG CAPSULE RX-5674 CDM 6370000100 HCPCS 250 RC 00093-0810-01 NDC outpatient 1 UN 5.82 5.82 HEALTHPARTNERS SX009 HEALTHPARTNERS 4.66 percent of total billed charges 3.61 5.53 Technical (Hospital) Services NORTRIPTYLINE 10 MG CAPSULE RX-5674 CDM 6370000100 HCPCS 250 RC 00093-0810-01 NDC outpatient 1 UN 5.82 5.82 BLUE CROSS BLUE SHIELD WELLMARK SB889 [3081026] BCBS WYOMING [308102603] 5.53 percent of total billed charges 3.61 5.53 Technical (Hospital) Services NORTRIPTYLINE 10 MG CAPSULE RX-5674 CDM 6370000100 HCPCS 250 RC 00093-0810-01 NDC inpatient 1 UN 5.82 5.82 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES HDHP [308136802] 4.61 percent of total billed charges 3.61 5.53 Technical (Hospital) Services NORTRIPTYLINE 10 MG CAPSULE RX-5674 CDM 6370000100 HCPCS 250 RC 00093-0810-01 NDC inpatient 1 UN 5.82 5.82 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES EPO [308136803] 4.61 percent of total billed charges 3.61 5.53 Technical (Hospital) Services NORTRIPTYLINE 10 MG CAPSULE RX-5674 CDM 6370000100 HCPCS 250 RC 00093-0810-01 NDC inpatient 1 UN 5.82 5.82 CIGNA 62308 [3081051] CIGNA 62308 [308105105] 4.61 percent of total billed charges 3.61 5.53 Technical (Hospital) Services NORTRIPTYLINE 10 MG CAPSULE RX-5674 CDM 6370000100 HCPCS 250 RC 00093-0810-01 NDC inpatient 1 UN 5.82 5.82 CIGNA 62308 [3081051] CIGNA STATE OF WYOMING [308105107] 4.61 percent of total billed charges 3.61 5.53 Technical (Hospital) Services NORTRIPTYLINE 10 MG CAPSULE RX-5674 CDM 6370000100 HCPCS 250 RC 00093-0810-01 NDC inpatient 1 UN 5.82 5.82 UNITED HEALTHCARE (COMMERCIAL) [3081199] UNITED HEALTHCARE 87726 [308119901] 3.61 percent of total billed charges 3.61 5.53 Technical (Hospital) Services NORTRIPTYLINE 10 MG CAPSULE RX-5674 CDM 6370000100 HCPCS 250 RC 00093-0810-01 NDC inpatient 1 UN 5.82 5.82 BLUE CROSS BLUE SHIELD WELLMARK SB889 [3081026] BCBS WYOMING [308102603] 5.53 percent of total billed charges 3.61 5.53 Technical (Hospital) Services NORTRIPTYLINE 10 MG CAPSULE RX-5674 CDM 6370000100 HCPCS 250 RC 00093-0810-01 NDC inpatient 1 UN 5.82 5.82 MULTIPLAN INC 34080 [3081285] MULTIPLAN INC [308128501] 5.53 percent of total billed charges 3.61 5.53 Technical (Hospital) Services NORTRIPTYLINE 10 MG CAPSULE RX-5674 CDM 6370000100 HCPCS 250 RC 00093-0810-01 NDC inpatient 1 UN 5.82 5.82 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES PPO [308136801] 4.61 percent of total billed charges 3.61 5.53 Technical (Hospital) Services NORTRIPTYLINE 10 MG CAPSULE RX-5674 CDM 6370000100 HCPCS 250 RC 00093-0810-01 NDC inpatient 1 UN 5.82 5.82 MEDICA (COMMERCIAL) 94265 [3081118] MEDICA CLAIMS [308111801] 5.24 percent of total billed charges 3.61 5.53 Technical (Hospital) Services NORTRIPTYLINE 10 MG CAPSULE RX-5674 CDM 6370000100 HCPCS 250 RC 00093-0810-01 NDC inpatient 1 UN 5.82 5.82 HEALTHPARTNERS SX009 HEALTHPARTNERS 4.61 percent of total billed charges 3.61 5.53 Technical (Hospital) Services NORTRIPTYLINE 25 MG CAPSULE RX-5675 CDM 6370000100 HCPCS 250 RC 51672-4002-05 NDC outpatient 1 UN 5.76 5.76 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES HDHP [308136802] 4.61 percent of total billed charges 3.57 5.47 Technical (Hospital) Services NORTRIPTYLINE 25 MG CAPSULE RX-5675 CDM 6370000100 HCPCS 250 RC 51672-4002-05 NDC outpatient 1 UN 5.76 5.76 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES PPO [308136801] 4.61 percent of total billed charges 3.57 5.47 Technical (Hospital) Services NORTRIPTYLINE 25 MG CAPSULE RX-5675 CDM 6370000100 HCPCS 250 RC 51672-4002-05 NDC outpatient 1 UN 5.76 5.76 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES EPO [308136803] 4.61 percent of total billed charges 3.57 5.47 Technical (Hospital) Services NORTRIPTYLINE 25 MG CAPSULE RX-5675 CDM 6370000100 HCPCS 250 RC 51672-4002-05 NDC outpatient 1 UN 5.76 5.76 UNITED HEALTHCARE (COMMERCIAL) [3081199] UNITED HEALTHCARE 87726 [308119901] 3.57 percent of total billed charges 3.57 5.47 Technical (Hospital) Services NORTRIPTYLINE 25 MG CAPSULE RX-5675 CDM 6370000100 HCPCS 250 RC 51672-4002-05 NDC outpatient 1 UN 5.76 5.76 HEALTHPARTNERS SX009 HEALTHPARTNERS 4.61 percent of total billed charges 3.57 5.47 Technical (Hospital) Services NORTRIPTYLINE 25 MG CAPSULE RX-5675 CDM 6370000100 HCPCS 250 RC 51672-4002-05 NDC outpatient 1 UN 5.76 5.76 CIGNA 62308 [3081051] CIGNA 62308 [308105105] 4.61 percent of total billed charges 3.57 5.47 Technical (Hospital) Services NORTRIPTYLINE 25 MG CAPSULE RX-5675 CDM 6370000100 HCPCS 250 RC 51672-4002-05 NDC outpatient 1 UN 5.76 5.76 CIGNA 62308 [3081051] CIGNA STATE OF WYOMING [308105107] 4.61 percent of total billed charges 3.57 5.47 Technical (Hospital) Services NORTRIPTYLINE 25 MG CAPSULE RX-5675 CDM 6370000100 HCPCS 250 RC 51672-4002-05 NDC outpatient 1 UN 5.76 5.76 MULTIPLAN INC 34080 [3081285] MULTIPLAN INC [308128501] 5.47 percent of total billed charges 3.57 5.47 Technical (Hospital) Services NORTRIPTYLINE 25 MG CAPSULE RX-5675 CDM 6370000100 HCPCS 250 RC 51672-4002-05 NDC outpatient 1 UN 5.76 5.76 MEDICA (COMMERCIAL) 94265 [3081118] MEDICA CLAIMS [308111801] 5.18 percent of total billed charges 3.57 5.47 Technical (Hospital) Services NORTRIPTYLINE 25 MG CAPSULE RX-5675 CDM 6370000100 HCPCS 250 RC 51672-4002-05 NDC outpatient 1 UN 5.76 5.76 BLUE CROSS BLUE SHIELD WELLMARK SB889 [3081026] BCBS WYOMING [308102603] 5.47 percent of total billed charges 3.57 5.47 Technical (Hospital) Services NORTRIPTYLINE 25 MG CAPSULE RX-5675 CDM 6370000100 HCPCS 250 RC 51672-4002-05 NDC inpatient 1 UN 5.76 5.76 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES PPO [308136801] 4.56 percent of total billed charges 3.57 5.47 Technical (Hospital) Services NORTRIPTYLINE 25 MG CAPSULE RX-5675 CDM 6370000100 HCPCS 250 RC 51672-4002-05 NDC inpatient 1 UN 5.76 5.76 HEALTHPARTNERS SX009 HEALTHPARTNERS 4.56 percent of total billed charges 3.57 5.47 Technical (Hospital) Services NORTRIPTYLINE 25 MG CAPSULE RX-5675 CDM 6370000100 HCPCS 250 RC 51672-4002-05 NDC inpatient 1 UN 5.76 5.76 MEDICA (COMMERCIAL) 94265 [3081118] MEDICA CLAIMS [308111801] 5.18 percent of total billed charges 3.57 5.47 Technical (Hospital) Services NORTRIPTYLINE 25 MG CAPSULE RX-5675 CDM 6370000100 HCPCS 250 RC 51672-4002-05 NDC inpatient 1 UN 5.76 5.76 BLUE CROSS BLUE SHIELD WELLMARK SB889 [3081026] BCBS WYOMING [308102603] 5.47 percent of total billed charges 3.57 5.47 Technical (Hospital) Services NORTRIPTYLINE 25 MG CAPSULE RX-5675 CDM 6370000100 HCPCS 250 RC 51672-4002-05 NDC inpatient 1 UN 5.76 5.76 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES EPO [308136803] 4.56 percent of total billed charges 3.57 5.47 Technical (Hospital) Services NORTRIPTYLINE 25 MG CAPSULE RX-5675 CDM 6370000100 HCPCS 250 RC 51672-4002-05 NDC inpatient 1 UN 5.76 5.76 CIGNA 62308 [3081051] CIGNA 62308 [308105105] 4.56 percent of total billed charges 3.57 5.47 Technical (Hospital) Services NORTRIPTYLINE 25 MG CAPSULE RX-5675 CDM 6370000100 HCPCS 250 RC 51672-4002-05 NDC inpatient 1 UN 5.76 5.76 CIGNA 62308 [3081051] CIGNA STATE OF WYOMING [308105107] 4.56 percent of total billed charges 3.57 5.47 Technical (Hospital) Services NORTRIPTYLINE 25 MG CAPSULE RX-5675 CDM 6370000100 HCPCS 250 RC 51672-4002-05 NDC inpatient 1 UN 5.76 5.76 UNITED HEALTHCARE (COMMERCIAL) [3081199] UNITED HEALTHCARE 87726 [308119901] 3.57 percent of total billed charges 3.57 5.47 Technical (Hospital) Services NORTRIPTYLINE 25 MG CAPSULE RX-5675 CDM 6370000100 HCPCS 250 RC 51672-4002-05 NDC inpatient 1 UN 5.76 5.76 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES HDHP [308136802] 4.56 percent of total billed charges 3.57 5.47 Technical (Hospital) Services NORTRIPTYLINE 25 MG CAPSULE RX-5675 CDM 6370000100 HCPCS 250 RC 51672-4002-05 NDC inpatient 1 UN 5.76 5.76 MULTIPLAN INC 34080 [3081285] MULTIPLAN INC [308128501] 5.47 percent of total billed charges 3.57 5.47 Technical (Hospital) Services "NYSTATIN 100,000 UNIT/GRAM TOPICAL CREAM" RX-5749 CDM 6370000100 HCPCS 250 RC 45802-0059-11 NDC inpatient 1 GR 6.5 6.5 BLUE CROSS BLUE SHIELD WELLMARK SB889 [3081026] BCBS WYOMING [308102603] 6.18 percent of total billed charges 4.03 6.18 Technical (Hospital) Services "NYSTATIN 100,000 UNIT/GRAM TOPICAL CREAM" RX-5749 CDM 6370000100 HCPCS 250 RC 45802-0059-11 NDC inpatient 1 GR 6.5 6.5 MULTIPLAN INC 34080 [3081285] MULTIPLAN INC [308128501] 6.18 percent of total billed charges 4.03 6.18 Technical (Hospital) Services "NYSTATIN 100,000 UNIT/GRAM TOPICAL CREAM" RX-5749 CDM 6370000100 HCPCS 250 RC 45802-0059-11 NDC inpatient 1 GR 6.5 6.5 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES HDHP [308136802] 5.15 percent of total billed charges 4.03 6.18 Technical (Hospital) Services "NYSTATIN 100,000 UNIT/GRAM TOPICAL CREAM" RX-5749 CDM 6370000100 HCPCS 250 RC 45802-0059-11 NDC inpatient 1 GR 6.5 6.5 HEALTHPARTNERS SX009 HEALTHPARTNERS 5.15 percent of total billed charges 4.03 6.18 Technical (Hospital) Services "NYSTATIN 100,000 UNIT/GRAM TOPICAL CREAM" RX-5749 CDM 6370000100 HCPCS 250 RC 45802-0059-11 NDC inpatient 1 GR 6.5 6.5 UNITED HEALTHCARE (COMMERCIAL) [3081199] UNITED HEALTHCARE 87726 [308119901] 4.03 percent of total billed charges 4.03 6.18 Technical (Hospital) Services "NYSTATIN 100,000 UNIT/GRAM TOPICAL CREAM" RX-5749 CDM 6370000100 HCPCS 250 RC 45802-0059-11 NDC inpatient 1 GR 6.5 6.5 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES EPO [308136803] 5.15 percent of total billed charges 4.03 6.18 Technical (Hospital) Services "NYSTATIN 100,000 UNIT/GRAM TOPICAL CREAM" RX-5749 CDM 6370000100 HCPCS 250 RC 45802-0059-11 NDC inpatient 1 GR 6.5 6.5 CIGNA 62308 [3081051] CIGNA 62308 [308105105] 5.15 percent of total billed charges 4.03 6.18 Technical (Hospital) Services "NYSTATIN 100,000 UNIT/GRAM TOPICAL CREAM" RX-5749 CDM 6370000100 HCPCS 250 RC 45802-0059-11 NDC inpatient 1 GR 6.5 6.5 CIGNA 62308 [3081051] CIGNA STATE OF WYOMING [308105107] 5.15 percent of total billed charges 4.03 6.18 Technical (Hospital) Services "NYSTATIN 100,000 UNIT/GRAM TOPICAL CREAM" RX-5749 CDM 6370000100 HCPCS 250 RC 45802-0059-11 NDC inpatient 1 GR 6.5 6.5 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES PPO [308136801] 5.15 percent of total billed charges 4.03 6.18 Technical (Hospital) Services "NYSTATIN 100,000 UNIT/GRAM TOPICAL CREAM" RX-5749 CDM 6370000100 HCPCS 250 RC 45802-0059-11 NDC inpatient 1 GR 6.5 6.5 MEDICA (COMMERCIAL) 94265 [3081118] MEDICA CLAIMS [308111801] 5.85 percent of total billed charges 4.03 6.18 Technical (Hospital) Services "NYSTATIN 100,000 UNIT/GRAM TOPICAL CREAM" RX-5749 CDM 6370000100 HCPCS 250 RC 45802-0059-11 NDC outpatient 1 GR 6.5 6.5 HEALTHPARTNERS SX009 HEALTHPARTNERS 5.2 percent of total billed charges 4.03 6.18 Technical (Hospital) Services "NYSTATIN 100,000 UNIT/GRAM TOPICAL CREAM" RX-5749 CDM 6370000100 HCPCS 250 RC 45802-0059-11 NDC outpatient 1 GR 6.5 6.5 BLUE CROSS BLUE SHIELD WELLMARK SB889 [3081026] BCBS WYOMING [308102603] 6.18 percent of total billed charges 4.03 6.18 Technical (Hospital) Services "NYSTATIN 100,000 UNIT/GRAM TOPICAL CREAM" RX-5749 CDM 6370000100 HCPCS 250 RC 45802-0059-11 NDC outpatient 1 GR 6.5 6.5 UNITED HEALTHCARE (COMMERCIAL) [3081199] UNITED HEALTHCARE 87726 [308119901] 4.03 percent of total billed charges 4.03 6.18 Technical (Hospital) Services "NYSTATIN 100,000 UNIT/GRAM TOPICAL CREAM" RX-5749 CDM 6370000100 HCPCS 250 RC 45802-0059-11 NDC outpatient 1 GR 6.5 6.5 MULTIPLAN INC 34080 [3081285] MULTIPLAN INC [308128501] 6.18 percent of total billed charges 4.03 6.18 Technical (Hospital) Services "NYSTATIN 100,000 UNIT/GRAM TOPICAL CREAM" RX-5749 CDM 6370000100 HCPCS 250 RC 45802-0059-11 NDC outpatient 1 GR 6.5 6.5 CIGNA 62308 [3081051] CIGNA 62308 [308105105] 5.2 percent of total billed charges 4.03 6.18 Technical (Hospital) Services "NYSTATIN 100,000 UNIT/GRAM TOPICAL CREAM" RX-5749 CDM 6370000100 HCPCS 250 RC 45802-0059-11 NDC outpatient 1 GR 6.5 6.5 CIGNA 62308 [3081051] CIGNA STATE OF WYOMING [308105107] 5.2 percent of total billed charges 4.03 6.18 Technical (Hospital) Services "NYSTATIN 100,000 UNIT/GRAM TOPICAL CREAM" RX-5749 CDM 6370000100 HCPCS 250 RC 45802-0059-11 NDC outpatient 1 GR 6.5 6.5 MEDICA (COMMERCIAL) 94265 [3081118] MEDICA CLAIMS [308111801] 5.85 percent of total billed charges 4.03 6.18 Technical (Hospital) Services "NYSTATIN 100,000 UNIT/GRAM TOPICAL CREAM" RX-5749 CDM 6370000100 HCPCS 250 RC 45802-0059-11 NDC outpatient 1 GR 6.5 6.5 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES PPO [308136801] 5.2 percent of total billed charges 4.03 6.18 Technical (Hospital) Services "NYSTATIN 100,000 UNIT/GRAM TOPICAL CREAM" RX-5749 CDM 6370000100 HCPCS 250 RC 45802-0059-11 NDC outpatient 1 GR 6.5 6.5 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES EPO [308136803] 5.2 percent of total billed charges 4.03 6.18 Technical (Hospital) Services "NYSTATIN 100,000 UNIT/GRAM TOPICAL CREAM" RX-5749 CDM 6370000100 HCPCS 250 RC 45802-0059-11 NDC outpatient 1 GR 6.5 6.5 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES HDHP [308136802] 5.2 percent of total billed charges 4.03 6.18 Technical (Hospital) Services OXYBUTYNIN CHLORIDE 5 MG TABLET RX-5938 CDM 6370000100 HCPCS 250 RC 00832-0038-00 NDC inpatient 1 UN 5.74 5.74 MULTIPLAN INC 34080 [3081285] MULTIPLAN INC [308128501] 5.45 percent of total billed charges 3.56 5.45 Technical (Hospital) Services OXYBUTYNIN CHLORIDE 5 MG TABLET RX-5938 CDM 6370000100 HCPCS 250 RC 00832-0038-00 NDC inpatient 1 UN 5.74 5.74 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES HDHP [308136802] 4.54 percent of total billed charges 3.56 5.45 Technical (Hospital) Services OXYBUTYNIN CHLORIDE 5 MG TABLET RX-5938 CDM 6370000100 HCPCS 250 RC 00832-0038-00 NDC inpatient 1 UN 5.74 5.74 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES EPO [308136803] 4.54 percent of total billed charges 3.56 5.45 Technical (Hospital) Services OXYBUTYNIN CHLORIDE 5 MG TABLET RX-5938 CDM 6370000100 HCPCS 250 RC 00832-0038-00 NDC inpatient 1 UN 5.74 5.74 CIGNA 62308 [3081051] CIGNA 62308 [308105105] 4.54 percent of total billed charges 3.56 5.45 Technical (Hospital) Services OXYBUTYNIN CHLORIDE 5 MG TABLET RX-5938 CDM 6370000100 HCPCS 250 RC 00832-0038-00 NDC inpatient 1 UN 5.74 5.74 CIGNA 62308 [3081051] CIGNA STATE OF WYOMING [308105107] 4.54 percent of total billed charges 3.56 5.45 Technical (Hospital) Services OXYBUTYNIN CHLORIDE 5 MG TABLET RX-5938 CDM 6370000100 HCPCS 250 RC 00832-0038-00 NDC inpatient 1 UN 5.74 5.74 UNITED HEALTHCARE (COMMERCIAL) [3081199] UNITED HEALTHCARE 87726 [308119901] 3.56 percent of total billed charges 3.56 5.45 Technical (Hospital) Services OXYBUTYNIN CHLORIDE 5 MG TABLET RX-5938 CDM 6370000100 HCPCS 250 RC 00832-0038-00 NDC inpatient 1 UN 5.74 5.74 BLUE CROSS BLUE SHIELD WELLMARK SB889 [3081026] BCBS WYOMING [308102603] 5.45 percent of total billed charges 3.56 5.45 Technical (Hospital) Services OXYBUTYNIN CHLORIDE 5 MG TABLET RX-5938 CDM 6370000100 HCPCS 250 RC 00832-0038-00 NDC inpatient 1 UN 5.74 5.74 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES PPO [308136801] 4.54 percent of total billed charges 3.56 5.45 Technical (Hospital) Services OXYBUTYNIN CHLORIDE 5 MG TABLET RX-5938 CDM 6370000100 HCPCS 250 RC 00832-0038-00 NDC inpatient 1 UN 5.74 5.74 MEDICA (COMMERCIAL) 94265 [3081118] MEDICA CLAIMS [308111801] 5.17 percent of total billed charges 3.56 5.45 Technical (Hospital) Services OXYBUTYNIN CHLORIDE 5 MG TABLET RX-5938 CDM 6370000100 HCPCS 250 RC 00832-0038-00 NDC inpatient 1 UN 5.74 5.74 HEALTHPARTNERS SX009 HEALTHPARTNERS 4.54 percent of total billed charges 3.56 5.45 Technical (Hospital) Services OXYBUTYNIN CHLORIDE 5 MG TABLET RX-5938 CDM 6370000100 HCPCS 250 RC 00832-0038-00 NDC outpatient 1 UN 5.74 5.74 UNITED HEALTHCARE (COMMERCIAL) [3081199] UNITED HEALTHCARE 87726 [308119901] 3.56 percent of total billed charges 3.56 5.45 Technical (Hospital) Services OXYBUTYNIN CHLORIDE 5 MG TABLET RX-5938 CDM 6370000100 HCPCS 250 RC 00832-0038-00 NDC outpatient 1 UN 5.74 5.74 CIGNA 62308 [3081051] CIGNA 62308 [308105105] 4.59 percent of total billed charges 3.56 5.45 Technical (Hospital) Services OXYBUTYNIN CHLORIDE 5 MG TABLET RX-5938 CDM 6370000100 HCPCS 250 RC 00832-0038-00 NDC outpatient 1 UN 5.74 5.74 CIGNA 62308 [3081051] CIGNA STATE OF WYOMING [308105107] 4.59 percent of total billed charges 3.56 5.45 Technical (Hospital) Services OXYBUTYNIN CHLORIDE 5 MG TABLET RX-5938 CDM 6370000100 HCPCS 250 RC 00832-0038-00 NDC outpatient 1 UN 5.74 5.74 MULTIPLAN INC 34080 [3081285] MULTIPLAN INC [308128501] 5.45 percent of total billed charges 3.56 5.45 Technical (Hospital) Services OXYBUTYNIN CHLORIDE 5 MG TABLET RX-5938 CDM 6370000100 HCPCS 250 RC 00832-0038-00 NDC outpatient 1 UN 5.74 5.74 MEDICA (COMMERCIAL) 94265 [3081118] MEDICA CLAIMS [308111801] 5.17 percent of total billed charges 3.56 5.45 Technical (Hospital) Services OXYBUTYNIN CHLORIDE 5 MG TABLET RX-5938 CDM 6370000100 HCPCS 250 RC 00832-0038-00 NDC outpatient 1 UN 5.74 5.74 BLUE CROSS BLUE SHIELD WELLMARK SB889 [3081026] BCBS WYOMING [308102603] 5.45 percent of total billed charges 3.56 5.45 Technical (Hospital) Services OXYBUTYNIN CHLORIDE 5 MG TABLET RX-5938 CDM 6370000100 HCPCS 250 RC 00832-0038-00 NDC outpatient 1 UN 5.74 5.74 HEALTHPARTNERS SX009 HEALTHPARTNERS 4.59 percent of total billed charges 3.56 5.45 Technical (Hospital) Services OXYBUTYNIN CHLORIDE 5 MG TABLET RX-5938 CDM 6370000100 HCPCS 250 RC 00832-0038-00 NDC outpatient 1 UN 5.74 5.74 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES PPO [308136801] 4.59 percent of total billed charges 3.56 5.45 Technical (Hospital) Services OXYBUTYNIN CHLORIDE 5 MG TABLET RX-5938 CDM 6370000100 HCPCS 250 RC 00832-0038-00 NDC outpatient 1 UN 5.74 5.74 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES EPO [308136803] 4.59 percent of total billed charges 3.56 5.45 Technical (Hospital) Services OXYBUTYNIN CHLORIDE 5 MG TABLET RX-5938 CDM 6370000100 HCPCS 250 RC 00832-0038-00 NDC outpatient 1 UN 5.74 5.74 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES HDHP [308136802] 4.59 percent of total billed charges 3.56 5.45 Technical (Hospital) Services OXYCODONE-ACETAMINOPHEN 5 MG-325 MG TABLET RX-5940 CDM 6370000100 HCPCS 250 RC 53746-0203-05 NDC inpatient 1 UN 5.8 5.8 MULTIPLAN INC 34080 [3081285] MULTIPLAN INC [308128501] 5.51 percent of total billed charges 3.6 5.51 Technical (Hospital) Services OXYCODONE-ACETAMINOPHEN 5 MG-325 MG TABLET RX-5940 CDM 6370000100 HCPCS 250 RC 53746-0203-05 NDC inpatient 1 UN 5.8 5.8 BLUE CROSS BLUE SHIELD WELLMARK SB889 [3081026] BCBS WYOMING [308102603] 5.51 percent of total billed charges 3.6 5.51 Technical (Hospital) Services OXYCODONE-ACETAMINOPHEN 5 MG-325 MG TABLET RX-5940 CDM 6370000100 HCPCS 250 RC 53746-0203-05 NDC inpatient 1 UN 5.8 5.8 CIGNA 62308 [3081051] CIGNA 62308 [308105105] 4.59 percent of total billed charges 3.6 5.51 Technical (Hospital) Services OXYCODONE-ACETAMINOPHEN 5 MG-325 MG TABLET RX-5940 CDM 6370000100 HCPCS 250 RC 53746-0203-05 NDC inpatient 1 UN 5.8 5.8 CIGNA 62308 [3081051] CIGNA STATE OF WYOMING [308105107] 4.59 percent of total billed charges 3.6 5.51 Technical (Hospital) Services OXYCODONE-ACETAMINOPHEN 5 MG-325 MG TABLET RX-5940 CDM 6370000100 HCPCS 250 RC 53746-0203-05 NDC inpatient 1 UN 5.8 5.8 UNITED HEALTHCARE (COMMERCIAL) [3081199] UNITED HEALTHCARE 87726 [308119901] 3.6 percent of total billed charges 3.6 5.51 Technical (Hospital) Services OXYCODONE-ACETAMINOPHEN 5 MG-325 MG TABLET RX-5940 CDM 6370000100 HCPCS 250 RC 53746-0203-05 NDC inpatient 1 UN 5.8 5.8 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES EPO [308136803] 4.59 percent of total billed charges 3.6 5.51 Technical (Hospital) Services OXYCODONE-ACETAMINOPHEN 5 MG-325 MG TABLET RX-5940 CDM 6370000100 HCPCS 250 RC 53746-0203-05 NDC inpatient 1 UN 5.8 5.8 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES HDHP [308136802] 4.59 percent of total billed charges 3.6 5.51 Technical (Hospital) Services OXYCODONE-ACETAMINOPHEN 5 MG-325 MG TABLET RX-5940 CDM 6370000100 HCPCS 250 RC 53746-0203-05 NDC inpatient 1 UN 5.8 5.8 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES PPO [308136801] 4.59 percent of total billed charges 3.6 5.51 Technical (Hospital) Services OXYCODONE-ACETAMINOPHEN 5 MG-325 MG TABLET RX-5940 CDM 6370000100 HCPCS 250 RC 53746-0203-05 NDC inpatient 1 UN 5.8 5.8 MEDICA (COMMERCIAL) 94265 [3081118] MEDICA CLAIMS [308111801] 5.22 percent of total billed charges 3.6 5.51 Technical (Hospital) Services OXYCODONE-ACETAMINOPHEN 5 MG-325 MG TABLET RX-5940 CDM 6370000100 HCPCS 250 RC 53746-0203-05 NDC inpatient 1 UN 5.8 5.8 HEALTHPARTNERS SX009 HEALTHPARTNERS 4.59 percent of total billed charges 3.6 5.51 Technical (Hospital) Services OXYCODONE-ACETAMINOPHEN 5 MG-325 MG TABLET RX-5940 CDM 6370000100 HCPCS 250 RC 53746-0203-05 NDC outpatient 1 UN 5.8 5.8 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES EPO [308136803] 4.64 percent of total billed charges 3.6 5.51 Technical (Hospital) Services OXYCODONE-ACETAMINOPHEN 5 MG-325 MG TABLET RX-5940 CDM 6370000100 HCPCS 250 RC 53746-0203-05 NDC outpatient 1 UN 5.8 5.8 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES HDHP [308136802] 4.64 percent of total billed charges 3.6 5.51 Technical (Hospital) Services OXYCODONE-ACETAMINOPHEN 5 MG-325 MG TABLET RX-5940 CDM 6370000100 HCPCS 250 RC 53746-0203-05 NDC outpatient 1 UN 5.8 5.8 MEDICA (COMMERCIAL) 94265 [3081118] MEDICA CLAIMS [308111801] 5.22 percent of total billed charges 3.6 5.51 Technical (Hospital) Services OXYCODONE-ACETAMINOPHEN 5 MG-325 MG TABLET RX-5940 CDM 6370000100 HCPCS 250 RC 53746-0203-05 NDC outpatient 1 UN 5.8 5.8 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES PPO [308136801] 4.64 percent of total billed charges 3.6 5.51 Technical (Hospital) Services OXYCODONE-ACETAMINOPHEN 5 MG-325 MG TABLET RX-5940 CDM 6370000100 HCPCS 250 RC 53746-0203-05 NDC outpatient 1 UN 5.8 5.8 BLUE CROSS BLUE SHIELD WELLMARK SB889 [3081026] BCBS WYOMING [308102603] 5.51 percent of total billed charges 3.6 5.51 Technical (Hospital) Services OXYCODONE-ACETAMINOPHEN 5 MG-325 MG TABLET RX-5940 CDM 6370000100 HCPCS 250 RC 53746-0203-05 NDC outpatient 1 UN 5.8 5.8 HEALTHPARTNERS SX009 HEALTHPARTNERS 4.64 percent of total billed charges 3.6 5.51 Technical (Hospital) Services OXYCODONE-ACETAMINOPHEN 5 MG-325 MG TABLET RX-5940 CDM 6370000100 HCPCS 250 RC 53746-0203-05 NDC outpatient 1 UN 5.8 5.8 UNITED HEALTHCARE (COMMERCIAL) [3081199] UNITED HEALTHCARE 87726 [308119901] 3.6 percent of total billed charges 3.6 5.51 Technical (Hospital) Services OXYCODONE-ACETAMINOPHEN 5 MG-325 MG TABLET RX-5940 CDM 6370000100 HCPCS 250 RC 53746-0203-05 NDC outpatient 1 UN 5.8 5.8 CIGNA 62308 [3081051] CIGNA 62308 [308105105] 4.64 percent of total billed charges 3.6 5.51 Technical (Hospital) Services OXYCODONE-ACETAMINOPHEN 5 MG-325 MG TABLET RX-5940 CDM 6370000100 HCPCS 250 RC 53746-0203-05 NDC outpatient 1 UN 5.8 5.8 CIGNA 62308 [3081051] CIGNA STATE OF WYOMING [308105107] 4.64 percent of total billed charges 3.6 5.51 Technical (Hospital) Services OXYCODONE-ACETAMINOPHEN 5 MG-325 MG TABLET RX-5940 CDM 6370000100 HCPCS 250 RC 53746-0203-05 NDC outpatient 1 UN 5.8 5.8 MULTIPLAN INC 34080 [3081285] MULTIPLAN INC [308128501] 5.51 percent of total billed charges 3.6 5.51 Technical (Hospital) Services OXYMETAZOLINE 0.05 % NASAL SPRAY RX-5943 CDM 6370000100 HCPCS 250 RC 00904-7006-35 NDC outpatient 0.1 ML 5.63 5.63 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES EPO [308136803] 4.5 percent of total billed charges 3.49 5.35 Technical (Hospital) Services OXYMETAZOLINE 0.05 % NASAL SPRAY RX-5943 CDM 6370000100 HCPCS 250 RC 00904-7006-35 NDC outpatient 0.1 ML 5.63 5.63 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES HDHP [308136802] 4.5 percent of total billed charges 3.49 5.35 Technical (Hospital) Services OXYMETAZOLINE 0.05 % NASAL SPRAY RX-5943 CDM 6370000100 HCPCS 250 RC 00904-7006-35 NDC outpatient 0.1 ML 5.63 5.63 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES PPO [308136801] 4.5 percent of total billed charges 3.49 5.35 Technical (Hospital) Services OXYMETAZOLINE 0.05 % NASAL SPRAY RX-5943 CDM 6370000100 HCPCS 250 RC 00904-7006-35 NDC outpatient 0.1 ML 5.63 5.63 MEDICA (COMMERCIAL) 94265 [3081118] MEDICA CLAIMS [308111801] 5.07 percent of total billed charges 3.49 5.35 Technical (Hospital) Services OXYMETAZOLINE 0.05 % NASAL SPRAY RX-5943 CDM 6370000100 HCPCS 250 RC 00904-7006-35 NDC outpatient 0.1 ML 5.63 5.63 MULTIPLAN INC 34080 [3081285] MULTIPLAN INC [308128501] 5.35 percent of total billed charges 3.49 5.35 Technical (Hospital) Services OXYMETAZOLINE 0.05 % NASAL SPRAY RX-5943 CDM 6370000100 HCPCS 250 RC 00904-7006-35 NDC outpatient 0.1 ML 5.63 5.63 CIGNA 62308 [3081051] CIGNA 62308 [308105105] 4.5 percent of total billed charges 3.49 5.35 Technical (Hospital) Services OXYMETAZOLINE 0.05 % NASAL SPRAY RX-5943 CDM 6370000100 HCPCS 250 RC 00904-7006-35 NDC outpatient 0.1 ML 5.63 5.63 CIGNA 62308 [3081051] CIGNA STATE OF WYOMING [308105107] 4.5 percent of total billed charges 3.49 5.35 Technical (Hospital) Services OXYMETAZOLINE 0.05 % NASAL SPRAY RX-5943 CDM 6370000100 HCPCS 250 RC 00904-7006-35 NDC outpatient 0.1 ML 5.63 5.63 UNITED HEALTHCARE (COMMERCIAL) [3081199] UNITED HEALTHCARE 87726 [308119901] 3.49 percent of total billed charges 3.49 5.35 Technical (Hospital) Services OXYMETAZOLINE 0.05 % NASAL SPRAY RX-5943 CDM 6370000100 HCPCS 250 RC 00904-7006-35 NDC outpatient 0.1 ML 5.63 5.63 BLUE CROSS BLUE SHIELD WELLMARK SB889 [3081026] BCBS WYOMING [308102603] 5.35 percent of total billed charges 3.49 5.35 Technical (Hospital) Services OXYMETAZOLINE 0.05 % NASAL SPRAY RX-5943 CDM 6370000100 HCPCS 250 RC 00904-7006-35 NDC outpatient 0.1 ML 5.63 5.63 HEALTHPARTNERS SX009 HEALTHPARTNERS 4.5 percent of total billed charges 3.49 5.35 Technical (Hospital) Services OXYMETAZOLINE 0.05 % NASAL SPRAY RX-5943 CDM 6370000100 HCPCS 250 RC 00904-7006-35 NDC inpatient 0.1 ML 5.63 5.63 HEALTHPARTNERS SX009 HEALTHPARTNERS 4.46 percent of total billed charges 3.49 5.35 Technical (Hospital) Services OXYMETAZOLINE 0.05 % NASAL SPRAY RX-5943 CDM 6370000100 HCPCS 250 RC 00904-7006-35 NDC inpatient 0.1 ML 5.63 5.63 MULTIPLAN INC 34080 [3081285] MULTIPLAN INC [308128501] 5.35 percent of total billed charges 3.49 5.35 Technical (Hospital) Services OXYMETAZOLINE 0.05 % NASAL SPRAY RX-5943 CDM 6370000100 HCPCS 250 RC 00904-7006-35 NDC inpatient 0.1 ML 5.63 5.63 CIGNA 62308 [3081051] CIGNA 62308 [308105105] 4.46 percent of total billed charges 3.49 5.35 Technical (Hospital) Services OXYMETAZOLINE 0.05 % NASAL SPRAY RX-5943 CDM 6370000100 HCPCS 250 RC 00904-7006-35 NDC inpatient 0.1 ML 5.63 5.63 CIGNA 62308 [3081051] CIGNA STATE OF WYOMING [308105107] 4.46 percent of total billed charges 3.49 5.35 Technical (Hospital) Services OXYMETAZOLINE 0.05 % NASAL SPRAY RX-5943 CDM 6370000100 HCPCS 250 RC 00904-7006-35 NDC inpatient 0.1 ML 5.63 5.63 BLUE CROSS BLUE SHIELD WELLMARK SB889 [3081026] BCBS WYOMING [308102603] 5.35 percent of total billed charges 3.49 5.35 Technical (Hospital) Services OXYMETAZOLINE 0.05 % NASAL SPRAY RX-5943 CDM 6370000100 HCPCS 250 RC 00904-7006-35 NDC inpatient 0.1 ML 5.63 5.63 UNITED HEALTHCARE (COMMERCIAL) [3081199] UNITED HEALTHCARE 87726 [308119901] 3.49 percent of total billed charges 3.49 5.35 Technical (Hospital) Services OXYMETAZOLINE 0.05 % NASAL SPRAY RX-5943 CDM 6370000100 HCPCS 250 RC 00904-7006-35 NDC inpatient 0.1 ML 5.63 5.63 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES PPO [308136801] 4.46 percent of total billed charges 3.49 5.35 Technical (Hospital) Services OXYMETAZOLINE 0.05 % NASAL SPRAY RX-5943 CDM 6370000100 HCPCS 250 RC 00904-7006-35 NDC inpatient 0.1 ML 5.63 5.63 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES EPO [308136803] 4.46 percent of total billed charges 3.49 5.35 Technical (Hospital) Services OXYMETAZOLINE 0.05 % NASAL SPRAY RX-5943 CDM 6370000100 HCPCS 250 RC 00904-7006-35 NDC inpatient 0.1 ML 5.63 5.63 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES HDHP [308136802] 4.46 percent of total billed charges 3.49 5.35 Technical (Hospital) Services OXYMETAZOLINE 0.05 % NASAL SPRAY RX-5943 CDM 6370000100 HCPCS 250 RC 00904-7006-35 NDC inpatient 0.1 ML 5.63 5.63 MEDICA (COMMERCIAL) 94265 [3081118] MEDICA CLAIMS [308111801] 5.07 percent of total billed charges 3.49 5.35 Technical (Hospital) Services PENICILLIN V POTASSIUM 250 MG/5 ML ORAL SOLUTION RX-6091 CDM 6370000100 HCPCS 250 RC 00093-4127-73 NDC outpatient 100 ML 33.7 33.7 MULTIPLAN INC 34080 [3081285] MULTIPLAN INC [308128501] 32.02 percent of total billed charges 20.89 32.02 Technical (Hospital) Services PENICILLIN V POTASSIUM 250 MG/5 ML ORAL SOLUTION RX-6091 CDM 6370000100 HCPCS 250 RC 00093-4127-73 NDC outpatient 100 ML 33.7 33.7 MEDICA (COMMERCIAL) 94265 [3081118] MEDICA CLAIMS [308111801] 30.33 percent of total billed charges 20.89 32.02 Technical (Hospital) Services PENICILLIN V POTASSIUM 250 MG/5 ML ORAL SOLUTION RX-6091 CDM 6370000100 HCPCS 250 RC 00093-4127-73 NDC outpatient 100 ML 33.7 33.7 CIGNA 62308 [3081051] CIGNA 62308 [308105105] 26.96 percent of total billed charges 20.89 32.02 Technical (Hospital) Services PENICILLIN V POTASSIUM 250 MG/5 ML ORAL SOLUTION RX-6091 CDM 6370000100 HCPCS 250 RC 00093-4127-73 NDC outpatient 100 ML 33.7 33.7 CIGNA 62308 [3081051] CIGNA STATE OF WYOMING [308105107] 26.96 percent of total billed charges 20.89 32.02 Technical (Hospital) Services PENICILLIN V POTASSIUM 250 MG/5 ML ORAL SOLUTION RX-6091 CDM 6370000100 HCPCS 250 RC 00093-4127-73 NDC outpatient 100 ML 33.7 33.7 UNITED HEALTHCARE (COMMERCIAL) [3081199] UNITED HEALTHCARE 87726 [308119901] 20.89 percent of total billed charges 20.89 32.02 Technical (Hospital) Services PENICILLIN V POTASSIUM 250 MG/5 ML ORAL SOLUTION RX-6091 CDM 6370000100 HCPCS 250 RC 00093-4127-73 NDC outpatient 100 ML 33.7 33.7 HEALTHPARTNERS SX009 HEALTHPARTNERS 26.96 percent of total billed charges 20.89 32.02 Technical (Hospital) Services PENICILLIN V POTASSIUM 250 MG/5 ML ORAL SOLUTION RX-6091 CDM 6370000100 HCPCS 250 RC 00093-4127-73 NDC outpatient 100 ML 33.7 33.7 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES PPO [308136801] 26.96 percent of total billed charges 20.89 32.02 Technical (Hospital) Services PENICILLIN V POTASSIUM 250 MG/5 ML ORAL SOLUTION RX-6091 CDM 6370000100 HCPCS 250 RC 00093-4127-73 NDC outpatient 100 ML 33.7 33.7 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES EPO [308136803] 26.96 percent of total billed charges 20.89 32.02 Technical (Hospital) Services PENICILLIN V POTASSIUM 250 MG/5 ML ORAL SOLUTION RX-6091 CDM 6370000100 HCPCS 250 RC 00093-4127-73 NDC outpatient 100 ML 33.7 33.7 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES HDHP [308136802] 26.96 percent of total billed charges 20.89 32.02 Technical (Hospital) Services PENICILLIN V POTASSIUM 250 MG/5 ML ORAL SOLUTION RX-6091 CDM 6370000100 HCPCS 250 RC 00093-4127-73 NDC outpatient 100 ML 33.7 33.7 BLUE CROSS BLUE SHIELD WELLMARK SB889 [3081026] BCBS WYOMING [308102603] 32.02 percent of total billed charges 20.89 32.02 Technical (Hospital) Services PENICILLIN V POTASSIUM 250 MG/5 ML ORAL SOLUTION RX-6091 CDM 6370000100 HCPCS 250 RC 00093-4127-73 NDC inpatient 100 ML 33.7 33.7 CIGNA 62308 [3081051] CIGNA 62308 [308105105] 26.68 percent of total billed charges 20.89 32.02 Technical (Hospital) Services PENICILLIN V POTASSIUM 250 MG/5 ML ORAL SOLUTION RX-6091 CDM 6370000100 HCPCS 250 RC 00093-4127-73 NDC inpatient 100 ML 33.7 33.7 CIGNA 62308 [3081051] CIGNA STATE OF WYOMING [308105107] 26.68 percent of total billed charges 20.89 32.02 Technical (Hospital) Services PENICILLIN V POTASSIUM 250 MG/5 ML ORAL SOLUTION RX-6091 CDM 6370000100 HCPCS 250 RC 00093-4127-73 NDC inpatient 100 ML 33.7 33.7 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES PPO [308136801] 26.68 percent of total billed charges 20.89 32.02 Technical (Hospital) Services PENICILLIN V POTASSIUM 250 MG/5 ML ORAL SOLUTION RX-6091 CDM 6370000100 HCPCS 250 RC 00093-4127-73 NDC inpatient 100 ML 33.7 33.7 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES EPO [308136803] 26.68 percent of total billed charges 20.89 32.02 Technical (Hospital) Services PENICILLIN V POTASSIUM 250 MG/5 ML ORAL SOLUTION RX-6091 CDM 6370000100 HCPCS 250 RC 00093-4127-73 NDC inpatient 100 ML 33.7 33.7 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES HDHP [308136802] 26.68 percent of total billed charges 20.89 32.02 Technical (Hospital) Services PENICILLIN V POTASSIUM 250 MG/5 ML ORAL SOLUTION RX-6091 CDM 6370000100 HCPCS 250 RC 00093-4127-73 NDC inpatient 100 ML 33.7 33.7 BLUE CROSS BLUE SHIELD WELLMARK SB889 [3081026] BCBS WYOMING [308102603] 32.02 percent of total billed charges 20.89 32.02 Technical (Hospital) Services PENICILLIN V POTASSIUM 250 MG/5 ML ORAL SOLUTION RX-6091 CDM 6370000100 HCPCS 250 RC 00093-4127-73 NDC inpatient 100 ML 33.7 33.7 UNITED HEALTHCARE (COMMERCIAL) [3081199] UNITED HEALTHCARE 87726 [308119901] 20.89 percent of total billed charges 20.89 32.02 Technical (Hospital) Services PENICILLIN V POTASSIUM 250 MG/5 ML ORAL SOLUTION RX-6091 CDM 6370000100 HCPCS 250 RC 00093-4127-73 NDC inpatient 100 ML 33.7 33.7 HEALTHPARTNERS SX009 HEALTHPARTNERS 26.68 percent of total billed charges 20.89 32.02 Technical (Hospital) Services PENICILLIN V POTASSIUM 250 MG/5 ML ORAL SOLUTION RX-6091 CDM 6370000100 HCPCS 250 RC 00093-4127-73 NDC inpatient 100 ML 33.7 33.7 MEDICA (COMMERCIAL) 94265 [3081118] MEDICA CLAIMS [308111801] 30.33 percent of total billed charges 20.89 32.02 Technical (Hospital) Services PENICILLIN V POTASSIUM 250 MG/5 ML ORAL SOLUTION RX-6091 CDM 6370000100 HCPCS 250 RC 00093-4127-73 NDC inpatient 100 ML 33.7 33.7 MULTIPLAN INC 34080 [3081285] MULTIPLAN INC [308128501] 32.02 percent of total billed charges 20.89 32.02 Technical (Hospital) Services PENICILLIN V POTASSIUM 250 MG TABLET RX-6092 CDM 6370000100 HCPCS 250 RC 16714-0234-01 NDC inpatient 1 UN 5.82 5.82 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES PPO [308136801] 4.61 percent of total billed charges 3.61 5.53 Technical (Hospital) Services PENICILLIN V POTASSIUM 250 MG TABLET RX-6092 CDM 6370000100 HCPCS 250 RC 16714-0234-01 NDC inpatient 1 UN 5.82 5.82 MEDICA (COMMERCIAL) 94265 [3081118] MEDICA CLAIMS [308111801] 5.24 percent of total billed charges 3.61 5.53 Technical (Hospital) Services PENICILLIN V POTASSIUM 250 MG TABLET RX-6092 CDM 6370000100 HCPCS 250 RC 16714-0234-01 NDC inpatient 1 UN 5.82 5.82 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES HDHP [308136802] 4.61 percent of total billed charges 3.61 5.53 Technical (Hospital) Services PENICILLIN V POTASSIUM 250 MG TABLET RX-6092 CDM 6370000100 HCPCS 250 RC 16714-0234-01 NDC inpatient 1 UN 5.82 5.82 HEALTHPARTNERS SX009 HEALTHPARTNERS 4.61 percent of total billed charges 3.61 5.53 Technical (Hospital) Services PENICILLIN V POTASSIUM 250 MG TABLET RX-6092 CDM 6370000100 HCPCS 250 RC 16714-0234-01 NDC inpatient 1 UN 5.82 5.82 CIGNA 62308 [3081051] CIGNA 62308 [308105105] 4.61 percent of total billed charges 3.61 5.53 Technical (Hospital) Services PENICILLIN V POTASSIUM 250 MG TABLET RX-6092 CDM 6370000100 HCPCS 250 RC 16714-0234-01 NDC inpatient 1 UN 5.82 5.82 CIGNA 62308 [3081051] CIGNA STATE OF WYOMING [308105107] 4.61 percent of total billed charges 3.61 5.53 Technical (Hospital) Services PENICILLIN V POTASSIUM 250 MG TABLET RX-6092 CDM 6370000100 HCPCS 250 RC 16714-0234-01 NDC inpatient 1 UN 5.82 5.82 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES EPO [308136803] 4.61 percent of total billed charges 3.61 5.53 Technical (Hospital) Services PENICILLIN V POTASSIUM 250 MG TABLET RX-6092 CDM 6370000100 HCPCS 250 RC 16714-0234-01 NDC inpatient 1 UN 5.82 5.82 UNITED HEALTHCARE (COMMERCIAL) [3081199] UNITED HEALTHCARE 87726 [308119901] 3.61 percent of total billed charges 3.61 5.53 Technical (Hospital) Services PENICILLIN V POTASSIUM 250 MG TABLET RX-6092 CDM 6370000100 HCPCS 250 RC 16714-0234-01 NDC inpatient 1 UN 5.82 5.82 MULTIPLAN INC 34080 [3081285] MULTIPLAN INC [308128501] 5.53 percent of total billed charges 3.61 5.53 Technical (Hospital) Services PENICILLIN V POTASSIUM 250 MG TABLET RX-6092 CDM 6370000100 HCPCS 250 RC 16714-0234-01 NDC inpatient 1 UN 5.82 5.82 BLUE CROSS BLUE SHIELD WELLMARK SB889 [3081026] BCBS WYOMING [308102603] 5.53 percent of total billed charges 3.61 5.53 Technical (Hospital) Services PENICILLIN V POTASSIUM 250 MG TABLET RX-6092 CDM 6370000100 HCPCS 250 RC 16714-0234-01 NDC outpatient 1 UN 5.82 5.82 HEALTHPARTNERS SX009 HEALTHPARTNERS 4.66 percent of total billed charges 3.61 5.53 Technical (Hospital) Services PENICILLIN V POTASSIUM 250 MG TABLET RX-6092 CDM 6370000100 HCPCS 250 RC 16714-0234-01 NDC outpatient 1 UN 5.82 5.82 BLUE CROSS BLUE SHIELD WELLMARK SB889 [3081026] BCBS WYOMING [308102603] 5.53 percent of total billed charges 3.61 5.53 Technical (Hospital) Services PENICILLIN V POTASSIUM 250 MG TABLET RX-6092 CDM 6370000100 HCPCS 250 RC 16714-0234-01 NDC outpatient 1 UN 5.82 5.82 UNITED HEALTHCARE (COMMERCIAL) [3081199] UNITED HEALTHCARE 87726 [308119901] 3.61 percent of total billed charges 3.61 5.53 Technical (Hospital) Services PENICILLIN V POTASSIUM 250 MG TABLET RX-6092 CDM 6370000100 HCPCS 250 RC 16714-0234-01 NDC outpatient 1 UN 5.82 5.82 MEDICA (COMMERCIAL) 94265 [3081118] MEDICA CLAIMS [308111801] 5.24 percent of total billed charges 3.61 5.53 Technical (Hospital) Services PENICILLIN V POTASSIUM 250 MG TABLET RX-6092 CDM 6370000100 HCPCS 250 RC 16714-0234-01 NDC outpatient 1 UN 5.82 5.82 MULTIPLAN INC 34080 [3081285] MULTIPLAN INC [308128501] 5.53 percent of total billed charges 3.61 5.53 Technical (Hospital) Services PENICILLIN V POTASSIUM 250 MG TABLET RX-6092 CDM 6370000100 HCPCS 250 RC 16714-0234-01 NDC outpatient 1 UN 5.82 5.82 CIGNA 62308 [3081051] CIGNA 62308 [308105105] 4.66 percent of total billed charges 3.61 5.53 Technical (Hospital) Services PENICILLIN V POTASSIUM 250 MG TABLET RX-6092 CDM 6370000100 HCPCS 250 RC 16714-0234-01 NDC outpatient 1 UN 5.82 5.82 CIGNA 62308 [3081051] CIGNA STATE OF WYOMING [308105107] 4.66 percent of total billed charges 3.61 5.53 Technical (Hospital) Services PENICILLIN V POTASSIUM 250 MG TABLET RX-6092 CDM 6370000100 HCPCS 250 RC 16714-0234-01 NDC outpatient 1 UN 5.82 5.82 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES EPO [308136803] 4.66 percent of total billed charges 3.61 5.53 Technical (Hospital) Services PENICILLIN V POTASSIUM 250 MG TABLET RX-6092 CDM 6370000100 HCPCS 250 RC 16714-0234-01 NDC outpatient 1 UN 5.82 5.82 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES HDHP [308136802] 4.66 percent of total billed charges 3.61 5.53 Technical (Hospital) Services PENICILLIN V POTASSIUM 250 MG TABLET RX-6092 CDM 6370000100 HCPCS 250 RC 16714-0234-01 NDC outpatient 1 UN 5.82 5.82 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES PPO [308136801] 4.66 percent of total billed charges 3.61 5.53 Technical (Hospital) Services PHENAZOPYRIDINE 200 MG TABLET RX-6194 CDM 6370000100 HCPCS 250 RC 75826-0115-10 NDC inpatient 1 UN 5.99 5.99 MULTIPLAN INC 34080 [3081285] MULTIPLAN INC [308128501] 5.69 percent of total billed charges 3.71 5.69 Technical (Hospital) Services PHENAZOPYRIDINE 200 MG TABLET RX-6194 CDM 6370000100 HCPCS 250 RC 75826-0115-10 NDC inpatient 1 UN 5.99 5.99 BLUE CROSS BLUE SHIELD WELLMARK SB889 [3081026] BCBS WYOMING [308102603] 5.69 percent of total billed charges 3.71 5.69 Technical (Hospital) Services PHENAZOPYRIDINE 200 MG TABLET RX-6194 CDM 6370000100 HCPCS 250 RC 75826-0115-10 NDC inpatient 1 UN 5.99 5.99 UNITED HEALTHCARE (COMMERCIAL) [3081199] UNITED HEALTHCARE 87726 [308119901] 3.71 percent of total billed charges 3.71 5.69 Technical (Hospital) Services PHENAZOPYRIDINE 200 MG TABLET RX-6194 CDM 6370000100 HCPCS 250 RC 75826-0115-10 NDC inpatient 1 UN 5.99 5.99 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES EPO [308136803] 4.74 percent of total billed charges 3.71 5.69 Technical (Hospital) Services PHENAZOPYRIDINE 200 MG TABLET RX-6194 CDM 6370000100 HCPCS 250 RC 75826-0115-10 NDC inpatient 1 UN 5.99 5.99 CIGNA 62308 [3081051] CIGNA 62308 [308105105] 4.74 percent of total billed charges 3.71 5.69 Technical (Hospital) Services PHENAZOPYRIDINE 200 MG TABLET RX-6194 CDM 6370000100 HCPCS 250 RC 75826-0115-10 NDC inpatient 1 UN 5.99 5.99 CIGNA 62308 [3081051] CIGNA STATE OF WYOMING [308105107] 4.74 percent of total billed charges 3.71 5.69 Technical (Hospital) Services PHENAZOPYRIDINE 200 MG TABLET RX-6194 CDM 6370000100 HCPCS 250 RC 75826-0115-10 NDC inpatient 1 UN 5.99 5.99 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES HDHP [308136802] 4.74 percent of total billed charges 3.71 5.69 Technical (Hospital) Services PHENAZOPYRIDINE 200 MG TABLET RX-6194 CDM 6370000100 HCPCS 250 RC 75826-0115-10 NDC inpatient 1 UN 5.99 5.99 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES PPO [308136801] 4.74 percent of total billed charges 3.71 5.69 Technical (Hospital) Services PHENAZOPYRIDINE 200 MG TABLET RX-6194 CDM 6370000100 HCPCS 250 RC 75826-0115-10 NDC inpatient 1 UN 5.99 5.99 MEDICA (COMMERCIAL) 94265 [3081118] MEDICA CLAIMS [308111801] 5.39 percent of total billed charges 3.71 5.69 Technical (Hospital) Services PHENAZOPYRIDINE 200 MG TABLET RX-6194 CDM 6370000100 HCPCS 250 RC 75826-0115-10 NDC inpatient 1 UN 5.99 5.99 HEALTHPARTNERS SX009 HEALTHPARTNERS 4.74 percent of total billed charges 3.71 5.69 Technical (Hospital) Services PHENAZOPYRIDINE 200 MG TABLET RX-6194 CDM 6370000100 HCPCS 250 RC 75826-0115-10 NDC outpatient 1 UN 5.99 5.99 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES EPO [308136803] 4.79 percent of total billed charges 3.71 5.69 Technical (Hospital) Services PHENAZOPYRIDINE 200 MG TABLET RX-6194 CDM 6370000100 HCPCS 250 RC 75826-0115-10 NDC outpatient 1 UN 5.99 5.99 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES PPO [308136801] 4.79 percent of total billed charges 3.71 5.69 Technical (Hospital) Services PHENAZOPYRIDINE 200 MG TABLET RX-6194 CDM 6370000100 HCPCS 250 RC 75826-0115-10 NDC outpatient 1 UN 5.99 5.99 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES HDHP [308136802] 4.79 percent of total billed charges 3.71 5.69 Technical (Hospital) Services PHENAZOPYRIDINE 200 MG TABLET RX-6194 CDM 6370000100 HCPCS 250 RC 75826-0115-10 NDC outpatient 1 UN 5.99 5.99 MULTIPLAN INC 34080 [3081285] MULTIPLAN INC [308128501] 5.69 percent of total billed charges 3.71 5.69 Technical (Hospital) Services PHENAZOPYRIDINE 200 MG TABLET RX-6194 CDM 6370000100 HCPCS 250 RC 75826-0115-10 NDC outpatient 1 UN 5.99 5.99 CIGNA 62308 [3081051] CIGNA 62308 [308105105] 4.79 percent of total billed charges 3.71 5.69 Technical (Hospital) Services PHENAZOPYRIDINE 200 MG TABLET RX-6194 CDM 6370000100 HCPCS 250 RC 75826-0115-10 NDC outpatient 1 UN 5.99 5.99 CIGNA 62308 [3081051] CIGNA STATE OF WYOMING [308105107] 4.79 percent of total billed charges 3.71 5.69 Technical (Hospital) Services PHENAZOPYRIDINE 200 MG TABLET RX-6194 CDM 6370000100 HCPCS 250 RC 75826-0115-10 NDC outpatient 1 UN 5.99 5.99 MEDICA (COMMERCIAL) 94265 [3081118] MEDICA CLAIMS [308111801] 5.39 percent of total billed charges 3.71 5.69 Technical (Hospital) Services PHENAZOPYRIDINE 200 MG TABLET RX-6194 CDM 6370000100 HCPCS 250 RC 75826-0115-10 NDC outpatient 1 UN 5.99 5.99 UNITED HEALTHCARE (COMMERCIAL) [3081199] UNITED HEALTHCARE 87726 [308119901] 3.71 percent of total billed charges 3.71 5.69 Technical (Hospital) Services PHENAZOPYRIDINE 200 MG TABLET RX-6194 CDM 6370000100 HCPCS 250 RC 75826-0115-10 NDC outpatient 1 UN 5.99 5.99 HEALTHPARTNERS SX009 HEALTHPARTNERS 4.79 percent of total billed charges 3.71 5.69 Technical (Hospital) Services PHENAZOPYRIDINE 200 MG TABLET RX-6194 CDM 6370000100 HCPCS 250 RC 75826-0115-10 NDC outpatient 1 UN 5.99 5.99 BLUE CROSS BLUE SHIELD WELLMARK SB889 [3081026] BCBS WYOMING [308102603] 5.69 percent of total billed charges 3.71 5.69 Technical (Hospital) Services PHENOBARB-HYOSCY-ATROPINE-SCOP 16.2 MG-0.1037 MG-0.0194 MG/5 ML ELIXIR RX-6225 CDM 6370000100 HCPCS 250 RC 75826-0128-04 NDC outpatient 120 ML 318.5 318.5 BLUE CROSS BLUE SHIELD WELLMARK SB889 [3081026] BCBS WYOMING [308102603] 302.58 percent of total billed charges 197.47 302.58 Technical (Hospital) Services PHENOBARB-HYOSCY-ATROPINE-SCOP 16.2 MG-0.1037 MG-0.0194 MG/5 ML ELIXIR RX-6225 CDM 6370000100 HCPCS 250 RC 75826-0128-04 NDC outpatient 120 ML 318.5 318.5 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES HDHP [308136802] 254.8 percent of total billed charges 197.47 302.58 Technical (Hospital) Services PHENOBARB-HYOSCY-ATROPINE-SCOP 16.2 MG-0.1037 MG-0.0194 MG/5 ML ELIXIR RX-6225 CDM 6370000100 HCPCS 250 RC 75826-0128-04 NDC outpatient 120 ML 318.5 318.5 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES PPO [308136801] 254.8 percent of total billed charges 197.47 302.58 Technical (Hospital) Services PHENOBARB-HYOSCY-ATROPINE-SCOP 16.2 MG-0.1037 MG-0.0194 MG/5 ML ELIXIR RX-6225 CDM 6370000100 HCPCS 250 RC 75826-0128-04 NDC outpatient 120 ML 318.5 318.5 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES EPO [308136803] 254.8 percent of total billed charges 197.47 302.58 Technical (Hospital) Services PHENOBARB-HYOSCY-ATROPINE-SCOP 16.2 MG-0.1037 MG-0.0194 MG/5 ML ELIXIR RX-6225 CDM 6370000100 HCPCS 250 RC 75826-0128-04 NDC outpatient 120 ML 318.5 318.5 HEALTHPARTNERS SX009 HEALTHPARTNERS 254.8 percent of total billed charges 197.47 302.58 Technical (Hospital) Services PHENOBARB-HYOSCY-ATROPINE-SCOP 16.2 MG-0.1037 MG-0.0194 MG/5 ML ELIXIR RX-6225 CDM 6370000100 HCPCS 250 RC 75826-0128-04 NDC outpatient 120 ML 318.5 318.5 UNITED HEALTHCARE (COMMERCIAL) [3081199] UNITED HEALTHCARE 87726 [308119901] 197.47 percent of total billed charges 197.47 302.58 Technical (Hospital) Services PHENOBARB-HYOSCY-ATROPINE-SCOP 16.2 MG-0.1037 MG-0.0194 MG/5 ML ELIXIR RX-6225 CDM 6370000100 HCPCS 250 RC 75826-0128-04 NDC outpatient 120 ML 318.5 318.5 MULTIPLAN INC 34080 [3081285] MULTIPLAN INC [308128501] 302.58 percent of total billed charges 197.47 302.58 Technical (Hospital) Services PHENOBARB-HYOSCY-ATROPINE-SCOP 16.2 MG-0.1037 MG-0.0194 MG/5 ML ELIXIR RX-6225 CDM 6370000100 HCPCS 250 RC 75826-0128-04 NDC outpatient 120 ML 318.5 318.5 MEDICA (COMMERCIAL) 94265 [3081118] MEDICA CLAIMS [308111801] 286.65 percent of total billed charges 197.47 302.58 Technical (Hospital) Services PHENOBARB-HYOSCY-ATROPINE-SCOP 16.2 MG-0.1037 MG-0.0194 MG/5 ML ELIXIR RX-6225 CDM 6370000100 HCPCS 250 RC 75826-0128-04 NDC outpatient 120 ML 318.5 318.5 CIGNA 62308 [3081051] CIGNA 62308 [308105105] 254.8 percent of total billed charges 197.47 302.58 Technical (Hospital) Services PHENOBARB-HYOSCY-ATROPINE-SCOP 16.2 MG-0.1037 MG-0.0194 MG/5 ML ELIXIR RX-6225 CDM 6370000100 HCPCS 250 RC 75826-0128-04 NDC outpatient 120 ML 318.5 318.5 CIGNA 62308 [3081051] CIGNA STATE OF WYOMING [308105107] 254.8 percent of total billed charges 197.47 302.58 Technical (Hospital) Services PHENOBARB-HYOSCY-ATROPINE-SCOP 16.2 MG-0.1037 MG-0.0194 MG/5 ML ELIXIR RX-6225 CDM 6370000100 HCPCS 250 RC 75826-0128-04 NDC inpatient 120 ML 318.5 318.5 CIGNA 62308 [3081051] CIGNA 62308 [308105105] 252.19 percent of total billed charges 197.47 302.58 Technical (Hospital) Services PHENOBARB-HYOSCY-ATROPINE-SCOP 16.2 MG-0.1037 MG-0.0194 MG/5 ML ELIXIR RX-6225 CDM 6370000100 HCPCS 250 RC 75826-0128-04 NDC inpatient 120 ML 318.5 318.5 CIGNA 62308 [3081051] CIGNA STATE OF WYOMING [308105107] 252.19 percent of total billed charges 197.47 302.58 Technical (Hospital) Services PHENOBARB-HYOSCY-ATROPINE-SCOP 16.2 MG-0.1037 MG-0.0194 MG/5 ML ELIXIR RX-6225 CDM 6370000100 HCPCS 250 RC 75826-0128-04 NDC inpatient 120 ML 318.5 318.5 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES EPO [308136803] 252.19 percent of total billed charges 197.47 302.58 Technical (Hospital) Services PHENOBARB-HYOSCY-ATROPINE-SCOP 16.2 MG-0.1037 MG-0.0194 MG/5 ML ELIXIR RX-6225 CDM 6370000100 HCPCS 250 RC 75826-0128-04 NDC inpatient 120 ML 318.5 318.5 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES HDHP [308136802] 252.19 percent of total billed charges 197.47 302.58 Technical (Hospital) Services PHENOBARB-HYOSCY-ATROPINE-SCOP 16.2 MG-0.1037 MG-0.0194 MG/5 ML ELIXIR RX-6225 CDM 6370000100 HCPCS 250 RC 75826-0128-04 NDC inpatient 120 ML 318.5 318.5 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES PPO [308136801] 252.19 percent of total billed charges 197.47 302.58 Technical (Hospital) Services PHENOBARB-HYOSCY-ATROPINE-SCOP 16.2 MG-0.1037 MG-0.0194 MG/5 ML ELIXIR RX-6225 CDM 6370000100 HCPCS 250 RC 75826-0128-04 NDC inpatient 120 ML 318.5 318.5 HEALTHPARTNERS SX009 HEALTHPARTNERS 252.19 percent of total billed charges 197.47 302.58 Technical (Hospital) Services PHENOBARB-HYOSCY-ATROPINE-SCOP 16.2 MG-0.1037 MG-0.0194 MG/5 ML ELIXIR RX-6225 CDM 6370000100 HCPCS 250 RC 75826-0128-04 NDC inpatient 120 ML 318.5 318.5 MEDICA (COMMERCIAL) 94265 [3081118] MEDICA CLAIMS [308111801] 286.65 percent of total billed charges 197.47 302.58 Technical (Hospital) Services PHENOBARB-HYOSCY-ATROPINE-SCOP 16.2 MG-0.1037 MG-0.0194 MG/5 ML ELIXIR RX-6225 CDM 6370000100 HCPCS 250 RC 75826-0128-04 NDC inpatient 120 ML 318.5 318.5 MULTIPLAN INC 34080 [3081285] MULTIPLAN INC [308128501] 302.58 percent of total billed charges 197.47 302.58 Technical (Hospital) Services PHENOBARB-HYOSCY-ATROPINE-SCOP 16.2 MG-0.1037 MG-0.0194 MG/5 ML ELIXIR RX-6225 CDM 6370000100 HCPCS 250 RC 75826-0128-04 NDC inpatient 120 ML 318.5 318.5 UNITED HEALTHCARE (COMMERCIAL) [3081199] UNITED HEALTHCARE 87726 [308119901] 197.47 percent of total billed charges 197.47 302.58 Technical (Hospital) Services PHENOBARB-HYOSCY-ATROPINE-SCOP 16.2 MG-0.1037 MG-0.0194 MG/5 ML ELIXIR RX-6225 CDM 6370000100 HCPCS 250 RC 75826-0128-04 NDC inpatient 120 ML 318.5 318.5 BLUE CROSS BLUE SHIELD WELLMARK SB889 [3081026] BCBS WYOMING [308102603] 302.58 percent of total billed charges 197.47 302.58 Technical (Hospital) Services PILOCARPINE 1 % EYE DROPS RX-6279 CDM 6370000100 HCPCS 250 RC 61314-0203-15 NDC inpatient 15 ML 310.36 310.36 BLUE CROSS BLUE SHIELD WELLMARK SB889 [3081026] BCBS WYOMING [308102603] 294.84 percent of total billed charges 192.42 294.84 Technical (Hospital) Services PILOCARPINE 1 % EYE DROPS RX-6279 CDM 6370000100 HCPCS 250 RC 61314-0203-15 NDC inpatient 15 ML 310.36 310.36 UNITED HEALTHCARE (COMMERCIAL) [3081199] UNITED HEALTHCARE 87726 [308119901] 192.42 percent of total billed charges 192.42 294.84 Technical (Hospital) Services PILOCARPINE 1 % EYE DROPS RX-6279 CDM 6370000100 HCPCS 250 RC 61314-0203-15 NDC inpatient 15 ML 310.36 310.36 MULTIPLAN INC 34080 [3081285] MULTIPLAN INC [308128501] 294.84 percent of total billed charges 192.42 294.84 Technical (Hospital) Services PILOCARPINE 1 % EYE DROPS RX-6279 CDM 6370000100 HCPCS 250 RC 61314-0203-15 NDC inpatient 15 ML 310.36 310.36 MEDICA (COMMERCIAL) 94265 [3081118] MEDICA CLAIMS [308111801] 279.32 percent of total billed charges 192.42 294.84 Technical (Hospital) Services PILOCARPINE 1 % EYE DROPS RX-6279 CDM 6370000100 HCPCS 250 RC 61314-0203-15 NDC inpatient 15 ML 310.36 310.36 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES EPO [308136803] 245.74 percent of total billed charges 192.42 294.84 Technical (Hospital) Services PILOCARPINE 1 % EYE DROPS RX-6279 CDM 6370000100 HCPCS 250 RC 61314-0203-15 NDC inpatient 15 ML 310.36 310.36 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES HDHP [308136802] 245.74 percent of total billed charges 192.42 294.84 Technical (Hospital) Services PILOCARPINE 1 % EYE DROPS RX-6279 CDM 6370000100 HCPCS 250 RC 61314-0203-15 NDC inpatient 15 ML 310.36 310.36 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES PPO [308136801] 245.74 percent of total billed charges 192.42 294.84 Technical (Hospital) Services PILOCARPINE 1 % EYE DROPS RX-6279 CDM 6370000100 HCPCS 250 RC 61314-0203-15 NDC inpatient 15 ML 310.36 310.36 CIGNA 62308 [3081051] CIGNA 62308 [308105105] 245.74 percent of total billed charges 192.42 294.84 Technical (Hospital) Services PILOCARPINE 1 % EYE DROPS RX-6279 CDM 6370000100 HCPCS 250 RC 61314-0203-15 NDC inpatient 15 ML 310.36 310.36 CIGNA 62308 [3081051] CIGNA STATE OF WYOMING [308105107] 245.74 percent of total billed charges 192.42 294.84 Technical (Hospital) Services PILOCARPINE 1 % EYE DROPS RX-6279 CDM 6370000100 HCPCS 250 RC 61314-0203-15 NDC inpatient 15 ML 310.36 310.36 HEALTHPARTNERS SX009 HEALTHPARTNERS 245.74 percent of total billed charges 192.42 294.84 Technical (Hospital) Services PILOCARPINE 1 % EYE DROPS RX-6279 CDM 6370000100 HCPCS 250 RC 61314-0203-15 NDC outpatient 15 ML 310.36 310.36 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES HDHP [308136802] 248.29 percent of total billed charges 192.42 294.84 Technical (Hospital) Services PILOCARPINE 1 % EYE DROPS RX-6279 CDM 6370000100 HCPCS 250 RC 61314-0203-15 NDC outpatient 15 ML 310.36 310.36 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES EPO [308136803] 248.29 percent of total billed charges 192.42 294.84 Technical (Hospital) Services PILOCARPINE 1 % EYE DROPS RX-6279 CDM 6370000100 HCPCS 250 RC 61314-0203-15 NDC outpatient 15 ML 310.36 310.36 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES PPO [308136801] 248.29 percent of total billed charges 192.42 294.84 Technical (Hospital) Services PILOCARPINE 1 % EYE DROPS RX-6279 CDM 6370000100 HCPCS 250 RC 61314-0203-15 NDC outpatient 15 ML 310.36 310.36 BLUE CROSS BLUE SHIELD WELLMARK SB889 [3081026] BCBS WYOMING [308102603] 294.84 percent of total billed charges 192.42 294.84 Technical (Hospital) Services PILOCARPINE 1 % EYE DROPS RX-6279 CDM 6370000100 HCPCS 250 RC 61314-0203-15 NDC outpatient 15 ML 310.36 310.36 HEALTHPARTNERS SX009 HEALTHPARTNERS 248.29 percent of total billed charges 192.42 294.84 Technical (Hospital) Services PILOCARPINE 1 % EYE DROPS RX-6279 CDM 6370000100 HCPCS 250 RC 61314-0203-15 NDC outpatient 15 ML 310.36 310.36 UNITED HEALTHCARE (COMMERCIAL) [3081199] UNITED HEALTHCARE 87726 [308119901] 192.42 percent of total billed charges 192.42 294.84 Technical (Hospital) Services PILOCARPINE 1 % EYE DROPS RX-6279 CDM 6370000100 HCPCS 250 RC 61314-0203-15 NDC outpatient 15 ML 310.36 310.36 MEDICA (COMMERCIAL) 94265 [3081118] MEDICA CLAIMS [308111801] 279.32 percent of total billed charges 192.42 294.84 Technical (Hospital) Services PILOCARPINE 1 % EYE DROPS RX-6279 CDM 6370000100 HCPCS 250 RC 61314-0203-15 NDC outpatient 15 ML 310.36 310.36 MULTIPLAN INC 34080 [3081285] MULTIPLAN INC [308128501] 294.84 percent of total billed charges 192.42 294.84 Technical (Hospital) Services PILOCARPINE 1 % EYE DROPS RX-6279 CDM 6370000100 HCPCS 250 RC 61314-0203-15 NDC outpatient 15 ML 310.36 310.36 CIGNA 62308 [3081051] CIGNA 62308 [308105105] 248.29 percent of total billed charges 192.42 294.84 Technical (Hospital) Services PILOCARPINE 1 % EYE DROPS RX-6279 CDM 6370000100 HCPCS 250 RC 61314-0203-15 NDC outpatient 15 ML 310.36 310.36 CIGNA 62308 [3081051] CIGNA STATE OF WYOMING [308105107] 248.29 percent of total billed charges 192.42 294.84 Technical (Hospital) Services POTASSIUM CHLORIDE 20 MEQ ORAL PACKET RX-6434 CDM 6370000100 HCPCS 250 RC 69238-1617-01 NDC inpatient 1 UN 7.14 7.14 MULTIPLAN INC 34080 [3081285] MULTIPLAN INC [308128501] 6.78 percent of total billed charges 4.43 6.78 Technical (Hospital) Services POTASSIUM CHLORIDE 20 MEQ ORAL PACKET RX-6434 CDM 6370000100 HCPCS 250 RC 69238-1617-01 NDC inpatient 1 UN 7.14 7.14 UNITED HEALTHCARE (COMMERCIAL) [3081199] UNITED HEALTHCARE 87726 [308119901] 4.43 percent of total billed charges 4.43 6.78 Technical (Hospital) Services POTASSIUM CHLORIDE 20 MEQ ORAL PACKET RX-6434 CDM 6370000100 HCPCS 250 RC 69238-1617-01 NDC inpatient 1 UN 7.14 7.14 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES EPO [308136803] 5.65 percent of total billed charges 4.43 6.78 Technical (Hospital) Services POTASSIUM CHLORIDE 20 MEQ ORAL PACKET RX-6434 CDM 6370000100 HCPCS 250 RC 69238-1617-01 NDC inpatient 1 UN 7.14 7.14 CIGNA 62308 [3081051] CIGNA 62308 [308105105] 5.65 percent of total billed charges 4.43 6.78 Technical (Hospital) Services POTASSIUM CHLORIDE 20 MEQ ORAL PACKET RX-6434 CDM 6370000100 HCPCS 250 RC 69238-1617-01 NDC inpatient 1 UN 7.14 7.14 CIGNA 62308 [3081051] CIGNA STATE OF WYOMING [308105107] 5.65 percent of total billed charges 4.43 6.78 Technical (Hospital) Services POTASSIUM CHLORIDE 20 MEQ ORAL PACKET RX-6434 CDM 6370000100 HCPCS 250 RC 69238-1617-01 NDC inpatient 1 UN 7.14 7.14 BLUE CROSS BLUE SHIELD WELLMARK SB889 [3081026] BCBS WYOMING [308102603] 6.78 percent of total billed charges 4.43 6.78 Technical (Hospital) Services POTASSIUM CHLORIDE 20 MEQ ORAL PACKET RX-6434 CDM 6370000100 HCPCS 250 RC 69238-1617-01 NDC inpatient 1 UN 7.14 7.14 HEALTHPARTNERS SX009 HEALTHPARTNERS 5.65 percent of total billed charges 4.43 6.78 Technical (Hospital) Services POTASSIUM CHLORIDE 20 MEQ ORAL PACKET RX-6434 CDM 6370000100 HCPCS 250 RC 69238-1617-01 NDC inpatient 1 UN 7.14 7.14 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES HDHP [308136802] 5.65 percent of total billed charges 4.43 6.78 Technical (Hospital) Services POTASSIUM CHLORIDE 20 MEQ ORAL PACKET RX-6434 CDM 6370000100 HCPCS 250 RC 69238-1617-01 NDC inpatient 1 UN 7.14 7.14 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES PPO [308136801] 5.65 percent of total billed charges 4.43 6.78 Technical (Hospital) Services POTASSIUM CHLORIDE 20 MEQ ORAL PACKET RX-6434 CDM 6370000100 HCPCS 250 RC 69238-1617-01 NDC inpatient 1 UN 7.14 7.14 MEDICA (COMMERCIAL) 94265 [3081118] MEDICA CLAIMS [308111801] 6.43 percent of total billed charges 4.43 6.78 Technical (Hospital) Services POTASSIUM CHLORIDE 20 MEQ ORAL PACKET RX-6434 CDM 6370000100 HCPCS 250 RC 69238-1617-01 NDC outpatient 1 UN 7.14 7.14 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES EPO [308136803] 5.71 percent of total billed charges 4.43 6.78 Technical (Hospital) Services POTASSIUM CHLORIDE 20 MEQ ORAL PACKET RX-6434 CDM 6370000100 HCPCS 250 RC 69238-1617-01 NDC outpatient 1 UN 7.14 7.14 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES PPO [308136801] 5.71 percent of total billed charges 4.43 6.78 Technical (Hospital) Services POTASSIUM CHLORIDE 20 MEQ ORAL PACKET RX-6434 CDM 6370000100 HCPCS 250 RC 69238-1617-01 NDC outpatient 1 UN 7.14 7.14 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES HDHP [308136802] 5.71 percent of total billed charges 4.43 6.78 Technical (Hospital) Services POTASSIUM CHLORIDE 20 MEQ ORAL PACKET RX-6434 CDM 6370000100 HCPCS 250 RC 69238-1617-01 NDC outpatient 1 UN 7.14 7.14 MULTIPLAN INC 34080 [3081285] MULTIPLAN INC [308128501] 6.78 percent of total billed charges 4.43 6.78 Technical (Hospital) Services POTASSIUM CHLORIDE 20 MEQ ORAL PACKET RX-6434 CDM 6370000100 HCPCS 250 RC 69238-1617-01 NDC outpatient 1 UN 7.14 7.14 CIGNA 62308 [3081051] CIGNA 62308 [308105105] 5.71 percent of total billed charges 4.43 6.78 Technical (Hospital) Services POTASSIUM CHLORIDE 20 MEQ ORAL PACKET RX-6434 CDM 6370000100 HCPCS 250 RC 69238-1617-01 NDC outpatient 1 UN 7.14 7.14 CIGNA 62308 [3081051] CIGNA STATE OF WYOMING [308105107] 5.71 percent of total billed charges 4.43 6.78 Technical (Hospital) Services POTASSIUM CHLORIDE 20 MEQ ORAL PACKET RX-6434 CDM 6370000100 HCPCS 250 RC 69238-1617-01 NDC outpatient 1 UN 7.14 7.14 MEDICA (COMMERCIAL) 94265 [3081118] MEDICA CLAIMS [308111801] 6.43 percent of total billed charges 4.43 6.78 Technical (Hospital) Services POTASSIUM CHLORIDE 20 MEQ ORAL PACKET RX-6434 CDM 6370000100 HCPCS 250 RC 69238-1617-01 NDC outpatient 1 UN 7.14 7.14 UNITED HEALTHCARE (COMMERCIAL) [3081199] UNITED HEALTHCARE 87726 [308119901] 4.43 percent of total billed charges 4.43 6.78 Technical (Hospital) Services POTASSIUM CHLORIDE 20 MEQ ORAL PACKET RX-6434 CDM 6370000100 HCPCS 250 RC 69238-1617-01 NDC outpatient 1 UN 7.14 7.14 HEALTHPARTNERS SX009 HEALTHPARTNERS 5.71 percent of total billed charges 4.43 6.78 Technical (Hospital) Services POTASSIUM CHLORIDE 20 MEQ ORAL PACKET RX-6434 CDM 6370000100 HCPCS 250 RC 69238-1617-01 NDC outpatient 1 UN 7.14 7.14 BLUE CROSS BLUE SHIELD WELLMARK SB889 [3081026] BCBS WYOMING [308102603] 6.78 percent of total billed charges 4.43 6.78 Technical (Hospital) Services "PREDNISOLONE ACETATE 1 % EYE DROPS,SUSPENSION" RX-6487 CDM 6370000100 HCPCS 250 RC 61314-0637-05 NDC inpatient 5 ML 144.25 144.25 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES PPO [308136801] 114.22 percent of total billed charges 89.44 137.04 Technical (Hospital) Services "PREDNISOLONE ACETATE 1 % EYE DROPS,SUSPENSION" RX-6487 CDM 6370000100 HCPCS 250 RC 61314-0637-05 NDC inpatient 5 ML 144.25 144.25 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES HDHP [308136802] 114.22 percent of total billed charges 89.44 137.04 Technical (Hospital) Services "PREDNISOLONE ACETATE 1 % EYE DROPS,SUSPENSION" RX-6487 CDM 6370000100 HCPCS 250 RC 61314-0637-05 NDC inpatient 5 ML 144.25 144.25 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES EPO [308136803] 114.22 percent of total billed charges 89.44 137.04 Technical (Hospital) Services "PREDNISOLONE ACETATE 1 % EYE DROPS,SUSPENSION" RX-6487 CDM 6370000100 HCPCS 250 RC 61314-0637-05 NDC inpatient 5 ML 144.25 144.25 HEALTHPARTNERS SX009 HEALTHPARTNERS 114.22 percent of total billed charges 89.44 137.04 Technical (Hospital) Services "PREDNISOLONE ACETATE 1 % EYE DROPS,SUSPENSION" RX-6487 CDM 6370000100 HCPCS 250 RC 61314-0637-05 NDC inpatient 5 ML 144.25 144.25 BLUE CROSS BLUE SHIELD WELLMARK SB889 [3081026] BCBS WYOMING [308102603] 137.04 percent of total billed charges 89.44 137.04 Technical (Hospital) Services "PREDNISOLONE ACETATE 1 % EYE DROPS,SUSPENSION" RX-6487 CDM 6370000100 HCPCS 250 RC 61314-0637-05 NDC inpatient 5 ML 144.25 144.25 UNITED HEALTHCARE (COMMERCIAL) [3081199] UNITED HEALTHCARE 87726 [308119901] 89.44 percent of total billed charges 89.44 137.04 Technical (Hospital) Services "PREDNISOLONE ACETATE 1 % EYE DROPS,SUSPENSION" RX-6487 CDM 6370000100 HCPCS 250 RC 61314-0637-05 NDC inpatient 5 ML 144.25 144.25 CIGNA 62308 [3081051] CIGNA 62308 [308105105] 114.22 percent of total billed charges 89.44 137.04 Technical (Hospital) Services "PREDNISOLONE ACETATE 1 % EYE DROPS,SUSPENSION" RX-6487 CDM 6370000100 HCPCS 250 RC 61314-0637-05 NDC inpatient 5 ML 144.25 144.25 CIGNA 62308 [3081051] CIGNA STATE OF WYOMING [308105107] 114.22 percent of total billed charges 89.44 137.04 Technical (Hospital) Services "PREDNISOLONE ACETATE 1 % EYE DROPS,SUSPENSION" RX-6487 CDM 6370000100 HCPCS 250 RC 61314-0637-05 NDC inpatient 5 ML 144.25 144.25 MULTIPLAN INC 34080 [3081285] MULTIPLAN INC [308128501] 137.04 percent of total billed charges 89.44 137.04 Technical (Hospital) Services "PREDNISOLONE ACETATE 1 % EYE DROPS,SUSPENSION" RX-6487 CDM 6370000100 HCPCS 250 RC 61314-0637-05 NDC inpatient 5 ML 144.25 144.25 MEDICA (COMMERCIAL) 94265 [3081118] MEDICA CLAIMS [308111801] 129.83 percent of total billed charges 89.44 137.04 Technical (Hospital) Services "PREDNISOLONE ACETATE 1 % EYE DROPS,SUSPENSION" RX-6487 CDM 6370000100 HCPCS 250 RC 61314-0637-05 NDC outpatient 5 ML 144.25 144.25 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES PPO [308136801] 115.4 percent of total billed charges 89.44 137.04 Technical (Hospital) Services "PREDNISOLONE ACETATE 1 % EYE DROPS,SUSPENSION" RX-6487 CDM 6370000100 HCPCS 250 RC 61314-0637-05 NDC outpatient 5 ML 144.25 144.25 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES HDHP [308136802] 115.4 percent of total billed charges 89.44 137.04 Technical (Hospital) Services "PREDNISOLONE ACETATE 1 % EYE DROPS,SUSPENSION" RX-6487 CDM 6370000100 HCPCS 250 RC 61314-0637-05 NDC outpatient 5 ML 144.25 144.25 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES EPO [308136803] 115.4 percent of total billed charges 89.44 137.04 Technical (Hospital) Services "PREDNISOLONE ACETATE 1 % EYE DROPS,SUSPENSION" RX-6487 CDM 6370000100 HCPCS 250 RC 61314-0637-05 NDC outpatient 5 ML 144.25 144.25 CIGNA 62308 [3081051] CIGNA 62308 [308105105] 115.4 percent of total billed charges 89.44 137.04 Technical (Hospital) Services "PREDNISOLONE ACETATE 1 % EYE DROPS,SUSPENSION" RX-6487 CDM 6370000100 HCPCS 250 RC 61314-0637-05 NDC outpatient 5 ML 144.25 144.25 CIGNA 62308 [3081051] CIGNA STATE OF WYOMING [308105107] 115.4 percent of total billed charges 89.44 137.04 Technical (Hospital) Services "PREDNISOLONE ACETATE 1 % EYE DROPS,SUSPENSION" RX-6487 CDM 6370000100 HCPCS 250 RC 61314-0637-05 NDC outpatient 5 ML 144.25 144.25 UNITED HEALTHCARE (COMMERCIAL) [3081199] UNITED HEALTHCARE 87726 [308119901] 89.44 percent of total billed charges 89.44 137.04 Technical (Hospital) Services "PREDNISOLONE ACETATE 1 % EYE DROPS,SUSPENSION" RX-6487 CDM 6370000100 HCPCS 250 RC 61314-0637-05 NDC outpatient 5 ML 144.25 144.25 HEALTHPARTNERS SX009 HEALTHPARTNERS 115.4 percent of total billed charges 89.44 137.04 Technical (Hospital) Services "PREDNISOLONE ACETATE 1 % EYE DROPS,SUSPENSION" RX-6487 CDM 6370000100 HCPCS 250 RC 61314-0637-05 NDC outpatient 5 ML 144.25 144.25 BLUE CROSS BLUE SHIELD WELLMARK SB889 [3081026] BCBS WYOMING [308102603] 137.04 percent of total billed charges 89.44 137.04 Technical (Hospital) Services "PREDNISOLONE ACETATE 1 % EYE DROPS,SUSPENSION" RX-6487 CDM 6370000100 HCPCS 250 RC 61314-0637-05 NDC outpatient 5 ML 144.25 144.25 MULTIPLAN INC 34080 [3081285] MULTIPLAN INC [308128501] 137.04 percent of total billed charges 89.44 137.04 Technical (Hospital) Services "PREDNISOLONE ACETATE 1 % EYE DROPS,SUSPENSION" RX-6487 CDM 6370000100 HCPCS 250 RC 61314-0637-05 NDC outpatient 5 ML 144.25 144.25 MEDICA (COMMERCIAL) 94265 [3081118] MEDICA CLAIMS [308111801] 129.83 percent of total billed charges 89.44 137.04 Technical (Hospital) Services ASCORBIC ACID (VITAMIN C) 250 MG TABLET RX-663 CDM 6370000100 HCPCS 250 RC 96295-0128-43 NDC outpatient 1 UN 5.66 5.66 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES EPO [308136803] 4.53 percent of total billed charges 3.51 5.38 Technical (Hospital) Services ASCORBIC ACID (VITAMIN C) 250 MG TABLET RX-663 CDM 6370000100 HCPCS 250 RC 96295-0128-43 NDC outpatient 1 UN 5.66 5.66 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES HDHP [308136802] 4.53 percent of total billed charges 3.51 5.38 Technical (Hospital) Services ASCORBIC ACID (VITAMIN C) 250 MG TABLET RX-663 CDM 6370000100 HCPCS 250 RC 96295-0128-43 NDC outpatient 1 UN 5.66 5.66 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES PPO [308136801] 4.53 percent of total billed charges 3.51 5.38 Technical (Hospital) Services ASCORBIC ACID (VITAMIN C) 250 MG TABLET RX-663 CDM 6370000100 HCPCS 250 RC 96295-0128-43 NDC outpatient 1 UN 5.66 5.66 BLUE CROSS BLUE SHIELD WELLMARK SB889 [3081026] BCBS WYOMING [308102603] 5.38 percent of total billed charges 3.51 5.38 Technical (Hospital) Services ASCORBIC ACID (VITAMIN C) 250 MG TABLET RX-663 CDM 6370000100 HCPCS 250 RC 96295-0128-43 NDC outpatient 1 UN 5.66 5.66 UNITED HEALTHCARE (COMMERCIAL) [3081199] UNITED HEALTHCARE 87726 [308119901] 3.51 percent of total billed charges 3.51 5.38 Technical (Hospital) Services ASCORBIC ACID (VITAMIN C) 250 MG TABLET RX-663 CDM 6370000100 HCPCS 250 RC 96295-0128-43 NDC outpatient 1 UN 5.66 5.66 HEALTHPARTNERS SX009 HEALTHPARTNERS 4.53 percent of total billed charges 3.51 5.38 Technical (Hospital) Services ASCORBIC ACID (VITAMIN C) 250 MG TABLET RX-663 CDM 6370000100 HCPCS 250 RC 96295-0128-43 NDC outpatient 1 UN 5.66 5.66 CIGNA 62308 [3081051] CIGNA 62308 [308105105] 4.53 percent of total billed charges 3.51 5.38 Technical (Hospital) Services ASCORBIC ACID (VITAMIN C) 250 MG TABLET RX-663 CDM 6370000100 HCPCS 250 RC 96295-0128-43 NDC outpatient 1 UN 5.66 5.66 CIGNA 62308 [3081051] CIGNA STATE OF WYOMING [308105107] 4.53 percent of total billed charges 3.51 5.38 Technical (Hospital) Services ASCORBIC ACID (VITAMIN C) 250 MG TABLET RX-663 CDM 6370000100 HCPCS 250 RC 96295-0128-43 NDC outpatient 1 UN 5.66 5.66 MULTIPLAN INC 34080 [3081285] MULTIPLAN INC [308128501] 5.38 percent of total billed charges 3.51 5.38 Technical (Hospital) Services ASCORBIC ACID (VITAMIN C) 250 MG TABLET RX-663 CDM 6370000100 HCPCS 250 RC 96295-0128-43 NDC outpatient 1 UN 5.66 5.66 MEDICA (COMMERCIAL) 94265 [3081118] MEDICA CLAIMS [308111801] 5.09 percent of total billed charges 3.51 5.38 Technical (Hospital) Services ASCORBIC ACID (VITAMIN C) 250 MG TABLET RX-663 CDM 6370000100 HCPCS 250 RC 96295-0128-43 NDC inpatient 1 UN 5.66 5.66 MEDICA (COMMERCIAL) 94265 [3081118] MEDICA CLAIMS [308111801] 5.09 percent of total billed charges 3.51 5.38 Technical (Hospital) Services ASCORBIC ACID (VITAMIN C) 250 MG TABLET RX-663 CDM 6370000100 HCPCS 250 RC 96295-0128-43 NDC inpatient 1 UN 5.66 5.66 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES PPO [308136801] 4.48 percent of total billed charges 3.51 5.38 Technical (Hospital) Services ASCORBIC ACID (VITAMIN C) 250 MG TABLET RX-663 CDM 6370000100 HCPCS 250 RC 96295-0128-43 NDC inpatient 1 UN 5.66 5.66 MULTIPLAN INC 34080 [3081285] MULTIPLAN INC [308128501] 5.38 percent of total billed charges 3.51 5.38 Technical (Hospital) Services ASCORBIC ACID (VITAMIN C) 250 MG TABLET RX-663 CDM 6370000100 HCPCS 250 RC 96295-0128-43 NDC inpatient 1 UN 5.66 5.66 HEALTHPARTNERS SX009 HEALTHPARTNERS 4.48 percent of total billed charges 3.51 5.38 Technical (Hospital) Services ASCORBIC ACID (VITAMIN C) 250 MG TABLET RX-663 CDM 6370000100 HCPCS 250 RC 96295-0128-43 NDC inpatient 1 UN 5.66 5.66 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES HDHP [308136802] 4.48 percent of total billed charges 3.51 5.38 Technical (Hospital) Services ASCORBIC ACID (VITAMIN C) 250 MG TABLET RX-663 CDM 6370000100 HCPCS 250 RC 96295-0128-43 NDC inpatient 1 UN 5.66 5.66 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES EPO [308136803] 4.48 percent of total billed charges 3.51 5.38 Technical (Hospital) Services ASCORBIC ACID (VITAMIN C) 250 MG TABLET RX-663 CDM 6370000100 HCPCS 250 RC 96295-0128-43 NDC inpatient 1 UN 5.66 5.66 CIGNA 62308 [3081051] CIGNA 62308 [308105105] 4.48 percent of total billed charges 3.51 5.38 Technical (Hospital) Services ASCORBIC ACID (VITAMIN C) 250 MG TABLET RX-663 CDM 6370000100 HCPCS 250 RC 96295-0128-43 NDC inpatient 1 UN 5.66 5.66 CIGNA 62308 [3081051] CIGNA STATE OF WYOMING [308105107] 4.48 percent of total billed charges 3.51 5.38 Technical (Hospital) Services ASCORBIC ACID (VITAMIN C) 250 MG TABLET RX-663 CDM 6370000100 HCPCS 250 RC 96295-0128-43 NDC inpatient 1 UN 5.66 5.66 UNITED HEALTHCARE (COMMERCIAL) [3081199] UNITED HEALTHCARE 87726 [308119901] 3.51 percent of total billed charges 3.51 5.38 Technical (Hospital) Services ASCORBIC ACID (VITAMIN C) 250 MG TABLET RX-663 CDM 6370000100 HCPCS 250 RC 96295-0128-43 NDC inpatient 1 UN 5.66 5.66 BLUE CROSS BLUE SHIELD WELLMARK SB889 [3081026] BCBS WYOMING [308102603] 5.38 percent of total billed charges 3.51 5.38 Technical (Hospital) Services ASCORBIC ACID (VITAMIN C) 500 MG TABLET RX-664 CDM 6370000100 HCPCS 250 RC 00904-0523-60 NDC inpatient 1 UN 5.64 5.64 HEALTHPARTNERS SX009 HEALTHPARTNERS 4.47 percent of total billed charges 3.5 5.36 Technical (Hospital) Services ASCORBIC ACID (VITAMIN C) 500 MG TABLET RX-664 CDM 6370000100 HCPCS 250 RC 00904-0523-60 NDC inpatient 1 UN 5.64 5.64 MEDICA (COMMERCIAL) 94265 [3081118] MEDICA CLAIMS [308111801] 5.08 percent of total billed charges 3.5 5.36 Technical (Hospital) Services ASCORBIC ACID (VITAMIN C) 500 MG TABLET RX-664 CDM 6370000100 HCPCS 250 RC 00904-0523-60 NDC inpatient 1 UN 5.64 5.64 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES PPO [308136801] 4.47 percent of total billed charges 3.5 5.36 Technical (Hospital) Services ASCORBIC ACID (VITAMIN C) 500 MG TABLET RX-664 CDM 6370000100 HCPCS 250 RC 00904-0523-60 NDC inpatient 1 UN 5.64 5.64 MULTIPLAN INC 34080 [3081285] MULTIPLAN INC [308128501] 5.36 percent of total billed charges 3.5 5.36 Technical (Hospital) Services ASCORBIC ACID (VITAMIN C) 500 MG TABLET RX-664 CDM 6370000100 HCPCS 250 RC 00904-0523-60 NDC inpatient 1 UN 5.64 5.64 BLUE CROSS BLUE SHIELD WELLMARK SB889 [3081026] BCBS WYOMING [308102603] 5.36 percent of total billed charges 3.5 5.36 Technical (Hospital) Services ASCORBIC ACID (VITAMIN C) 500 MG TABLET RX-664 CDM 6370000100 HCPCS 250 RC 00904-0523-60 NDC inpatient 1 UN 5.64 5.64 UNITED HEALTHCARE (COMMERCIAL) [3081199] UNITED HEALTHCARE 87726 [308119901] 3.5 percent of total billed charges 3.5 5.36 Technical (Hospital) Services ASCORBIC ACID (VITAMIN C) 500 MG TABLET RX-664 CDM 6370000100 HCPCS 250 RC 00904-0523-60 NDC inpatient 1 UN 5.64 5.64 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES EPO [308136803] 4.47 percent of total billed charges 3.5 5.36 Technical (Hospital) Services ASCORBIC ACID (VITAMIN C) 500 MG TABLET RX-664 CDM 6370000100 HCPCS 250 RC 00904-0523-60 NDC inpatient 1 UN 5.64 5.64 CIGNA 62308 [3081051] CIGNA 62308 [308105105] 4.47 percent of total billed charges 3.5 5.36 Technical (Hospital) Services ASCORBIC ACID (VITAMIN C) 500 MG TABLET RX-664 CDM 6370000100 HCPCS 250 RC 00904-0523-60 NDC inpatient 1 UN 5.64 5.64 CIGNA 62308 [3081051] CIGNA STATE OF WYOMING [308105107] 4.47 percent of total billed charges 3.5 5.36 Technical (Hospital) Services ASCORBIC ACID (VITAMIN C) 500 MG TABLET RX-664 CDM 6370000100 HCPCS 250 RC 00904-0523-60 NDC inpatient 1 UN 5.64 5.64 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES HDHP [308136802] 4.47 percent of total billed charges 3.5 5.36 Technical (Hospital) Services ASCORBIC ACID (VITAMIN C) 500 MG TABLET RX-664 CDM 6370000100 HCPCS 250 RC 00904-0523-60 NDC outpatient 1 UN 5.64 5.64 BLUE CROSS BLUE SHIELD WELLMARK SB889 [3081026] BCBS WYOMING [308102603] 5.36 percent of total billed charges 3.5 5.36 Technical (Hospital) Services ASCORBIC ACID (VITAMIN C) 500 MG TABLET RX-664 CDM 6370000100 HCPCS 250 RC 00904-0523-60 NDC outpatient 1 UN 5.64 5.64 MULTIPLAN INC 34080 [3081285] MULTIPLAN INC [308128501] 5.36 percent of total billed charges 3.5 5.36 Technical (Hospital) Services ASCORBIC ACID (VITAMIN C) 500 MG TABLET RX-664 CDM 6370000100 HCPCS 250 RC 00904-0523-60 NDC outpatient 1 UN 5.64 5.64 CIGNA 62308 [3081051] CIGNA 62308 [308105105] 4.51 percent of total billed charges 3.5 5.36 Technical (Hospital) Services ASCORBIC ACID (VITAMIN C) 500 MG TABLET RX-664 CDM 6370000100 HCPCS 250 RC 00904-0523-60 NDC outpatient 1 UN 5.64 5.64 CIGNA 62308 [3081051] CIGNA STATE OF WYOMING [308105107] 4.51 percent of total billed charges 3.5 5.36 Technical (Hospital) Services ASCORBIC ACID (VITAMIN C) 500 MG TABLET RX-664 CDM 6370000100 HCPCS 250 RC 00904-0523-60 NDC outpatient 1 UN 5.64 5.64 MEDICA (COMMERCIAL) 94265 [3081118] MEDICA CLAIMS [308111801] 5.08 percent of total billed charges 3.5 5.36 Technical (Hospital) Services ASCORBIC ACID (VITAMIN C) 500 MG TABLET RX-664 CDM 6370000100 HCPCS 250 RC 00904-0523-60 NDC outpatient 1 UN 5.64 5.64 HEALTHPARTNERS SX009 HEALTHPARTNERS 4.51 percent of total billed charges 3.5 5.36 Technical (Hospital) Services ASCORBIC ACID (VITAMIN C) 500 MG TABLET RX-664 CDM 6370000100 HCPCS 250 RC 00904-0523-60 NDC outpatient 1 UN 5.64 5.64 UNITED HEALTHCARE (COMMERCIAL) [3081199] UNITED HEALTHCARE 87726 [308119901] 3.5 percent of total billed charges 3.5 5.36 Technical (Hospital) Services ASCORBIC ACID (VITAMIN C) 500 MG TABLET RX-664 CDM 6370000100 HCPCS 250 RC 00904-0523-60 NDC outpatient 1 UN 5.64 5.64 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES HDHP [308136802] 4.51 percent of total billed charges 3.5 5.36 Technical (Hospital) Services ASCORBIC ACID (VITAMIN C) 500 MG TABLET RX-664 CDM 6370000100 HCPCS 250 RC 00904-0523-60 NDC outpatient 1 UN 5.64 5.64 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES PPO [308136801] 4.51 percent of total billed charges 3.5 5.36 Technical (Hospital) Services ASCORBIC ACID (VITAMIN C) 500 MG TABLET RX-664 CDM 6370000100 HCPCS 250 RC 00904-0523-60 NDC outpatient 1 UN 5.64 5.64 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES EPO [308136803] 4.51 percent of total billed charges 3.5 5.36 Technical (Hospital) Services PROPRANOLOL 10 MG TABLET RX-6656 CDM 6370000100 HCPCS 250 RC 00115-1659-01 NDC inpatient 1 UN 5.78 5.78 HEALTHPARTNERS SX009 HEALTHPARTNERS 4.58 percent of total billed charges 3.58 5.49 Technical (Hospital) Services PROPRANOLOL 10 MG TABLET RX-6656 CDM 6370000100 HCPCS 250 RC 00115-1659-01 NDC inpatient 1 UN 5.78 5.78 MEDICA (COMMERCIAL) 94265 [3081118] MEDICA CLAIMS [308111801] 5.2 percent of total billed charges 3.58 5.49 Technical (Hospital) Services PROPRANOLOL 10 MG TABLET RX-6656 CDM 6370000100 HCPCS 250 RC 00115-1659-01 NDC inpatient 1 UN 5.78 5.78 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES PPO [308136801] 4.58 percent of total billed charges 3.58 5.49 Technical (Hospital) Services PROPRANOLOL 10 MG TABLET RX-6656 CDM 6370000100 HCPCS 250 RC 00115-1659-01 NDC inpatient 1 UN 5.78 5.78 MULTIPLAN INC 34080 [3081285] MULTIPLAN INC [308128501] 5.49 percent of total billed charges 3.58 5.49 Technical (Hospital) Services PROPRANOLOL 10 MG TABLET RX-6656 CDM 6370000100 HCPCS 250 RC 00115-1659-01 NDC inpatient 1 UN 5.78 5.78 UNITED HEALTHCARE (COMMERCIAL) [3081199] UNITED HEALTHCARE 87726 [308119901] 3.58 percent of total billed charges 3.58 5.49 Technical (Hospital) Services PROPRANOLOL 10 MG TABLET RX-6656 CDM 6370000100 HCPCS 250 RC 00115-1659-01 NDC inpatient 1 UN 5.78 5.78 BLUE CROSS BLUE SHIELD WELLMARK SB889 [3081026] BCBS WYOMING [308102603] 5.49 percent of total billed charges 3.58 5.49 Technical (Hospital) Services PROPRANOLOL 10 MG TABLET RX-6656 CDM 6370000100 HCPCS 250 RC 00115-1659-01 NDC inpatient 1 UN 5.78 5.78 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES EPO [308136803] 4.58 percent of total billed charges 3.58 5.49 Technical (Hospital) Services PROPRANOLOL 10 MG TABLET RX-6656 CDM 6370000100 HCPCS 250 RC 00115-1659-01 NDC inpatient 1 UN 5.78 5.78 CIGNA 62308 [3081051] CIGNA 62308 [308105105] 4.58 percent of total billed charges 3.58 5.49 Technical (Hospital) Services PROPRANOLOL 10 MG TABLET RX-6656 CDM 6370000100 HCPCS 250 RC 00115-1659-01 NDC inpatient 1 UN 5.78 5.78 CIGNA 62308 [3081051] CIGNA STATE OF WYOMING [308105107] 4.58 percent of total billed charges 3.58 5.49 Technical (Hospital) Services PROPRANOLOL 10 MG TABLET RX-6656 CDM 6370000100 HCPCS 250 RC 00115-1659-01 NDC inpatient 1 UN 5.78 5.78 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES HDHP [308136802] 4.58 percent of total billed charges 3.58 5.49 Technical (Hospital) Services PROPRANOLOL 10 MG TABLET RX-6656 CDM 6370000100 HCPCS 250 RC 00115-1659-01 NDC outpatient 1 UN 5.78 5.78 MULTIPLAN INC 34080 [3081285] MULTIPLAN INC [308128501] 5.49 percent of total billed charges 3.58 5.49 Technical (Hospital) Services PROPRANOLOL 10 MG TABLET RX-6656 CDM 6370000100 HCPCS 250 RC 00115-1659-01 NDC outpatient 1 UN 5.78 5.78 CIGNA 62308 [3081051] CIGNA 62308 [308105105] 4.62 percent of total billed charges 3.58 5.49 Technical (Hospital) Services PROPRANOLOL 10 MG TABLET RX-6656 CDM 6370000100 HCPCS 250 RC 00115-1659-01 NDC outpatient 1 UN 5.78 5.78 CIGNA 62308 [3081051] CIGNA STATE OF WYOMING [308105107] 4.62 percent of total billed charges 3.58 5.49 Technical (Hospital) Services PROPRANOLOL 10 MG TABLET RX-6656 CDM 6370000100 HCPCS 250 RC 00115-1659-01 NDC outpatient 1 UN 5.78 5.78 MEDICA (COMMERCIAL) 94265 [3081118] MEDICA CLAIMS [308111801] 5.2 percent of total billed charges 3.58 5.49 Technical (Hospital) Services PROPRANOLOL 10 MG TABLET RX-6656 CDM 6370000100 HCPCS 250 RC 00115-1659-01 NDC outpatient 1 UN 5.78 5.78 UNITED HEALTHCARE (COMMERCIAL) [3081199] UNITED HEALTHCARE 87726 [308119901] 3.58 percent of total billed charges 3.58 5.49 Technical (Hospital) Services PROPRANOLOL 10 MG TABLET RX-6656 CDM 6370000100 HCPCS 250 RC 00115-1659-01 NDC outpatient 1 UN 5.78 5.78 HEALTHPARTNERS SX009 HEALTHPARTNERS 4.62 percent of total billed charges 3.58 5.49 Technical (Hospital) Services PROPRANOLOL 10 MG TABLET RX-6656 CDM 6370000100 HCPCS 250 RC 00115-1659-01 NDC outpatient 1 UN 5.78 5.78 BLUE CROSS BLUE SHIELD WELLMARK SB889 [3081026] BCBS WYOMING [308102603] 5.49 percent of total billed charges 3.58 5.49 Technical (Hospital) Services PROPRANOLOL 10 MG TABLET RX-6656 CDM 6370000100 HCPCS 250 RC 00115-1659-01 NDC outpatient 1 UN 5.78 5.78 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES EPO [308136803] 4.62 percent of total billed charges 3.58 5.49 Technical (Hospital) Services PROPRANOLOL 10 MG TABLET RX-6656 CDM 6370000100 HCPCS 250 RC 00115-1659-01 NDC outpatient 1 UN 5.78 5.78 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES PPO [308136801] 4.62 percent of total billed charges 3.58 5.49 Technical (Hospital) Services PROPRANOLOL 10 MG TABLET RX-6656 CDM 6370000100 HCPCS 250 RC 00115-1659-01 NDC outpatient 1 UN 5.78 5.78 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES HDHP [308136802] 4.62 percent of total billed charges 3.58 5.49 Technical (Hospital) Services PROPRANOLOL 40 MG TABLET RX-6658 CDM 6370000100 HCPCS 250 RC 00115-1661-01 NDC inpatient 1 UN 5.87 5.87 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES HDHP [308136802] 4.65 percent of total billed charges 3.64 5.58 Technical (Hospital) Services PROPRANOLOL 40 MG TABLET RX-6658 CDM 6370000100 HCPCS 250 RC 00115-1661-01 NDC inpatient 1 UN 5.87 5.87 CIGNA 62308 [3081051] CIGNA 62308 [308105105] 4.65 percent of total billed charges 3.64 5.58 Technical (Hospital) Services PROPRANOLOL 40 MG TABLET RX-6658 CDM 6370000100 HCPCS 250 RC 00115-1661-01 NDC inpatient 1 UN 5.87 5.87 CIGNA 62308 [3081051] CIGNA STATE OF WYOMING [308105107] 4.65 percent of total billed charges 3.64 5.58 Technical (Hospital) Services PROPRANOLOL 40 MG TABLET RX-6658 CDM 6370000100 HCPCS 250 RC 00115-1661-01 NDC inpatient 1 UN 5.87 5.87 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES EPO [308136803] 4.65 percent of total billed charges 3.64 5.58 Technical (Hospital) Services PROPRANOLOL 40 MG TABLET RX-6658 CDM 6370000100 HCPCS 250 RC 00115-1661-01 NDC inpatient 1 UN 5.87 5.87 BLUE CROSS BLUE SHIELD WELLMARK SB889 [3081026] BCBS WYOMING [308102603] 5.58 percent of total billed charges 3.64 5.58 Technical (Hospital) Services PROPRANOLOL 40 MG TABLET RX-6658 CDM 6370000100 HCPCS 250 RC 00115-1661-01 NDC inpatient 1 UN 5.87 5.87 UNITED HEALTHCARE (COMMERCIAL) [3081199] UNITED HEALTHCARE 87726 [308119901] 3.64 percent of total billed charges 3.64 5.58 Technical (Hospital) Services PROPRANOLOL 40 MG TABLET RX-6658 CDM 6370000100 HCPCS 250 RC 00115-1661-01 NDC inpatient 1 UN 5.87 5.87 MULTIPLAN INC 34080 [3081285] MULTIPLAN INC [308128501] 5.58 percent of total billed charges 3.64 5.58 Technical (Hospital) Services PROPRANOLOL 40 MG TABLET RX-6658 CDM 6370000100 HCPCS 250 RC 00115-1661-01 NDC inpatient 1 UN 5.87 5.87 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES PPO [308136801] 4.65 percent of total billed charges 3.64 5.58 Technical (Hospital) Services PROPRANOLOL 40 MG TABLET RX-6658 CDM 6370000100 HCPCS 250 RC 00115-1661-01 NDC inpatient 1 UN 5.87 5.87 MEDICA (COMMERCIAL) 94265 [3081118] MEDICA CLAIMS [308111801] 5.28 percent of total billed charges 3.64 5.58 Technical (Hospital) Services PROPRANOLOL 40 MG TABLET RX-6658 CDM 6370000100 HCPCS 250 RC 00115-1661-01 NDC inpatient 1 UN 5.87 5.87 HEALTHPARTNERS SX009 HEALTHPARTNERS 4.65 percent of total billed charges 3.64 5.58 Technical (Hospital) Services PROPRANOLOL 40 MG TABLET RX-6658 CDM 6370000100 HCPCS 250 RC 00115-1661-01 NDC outpatient 1 UN 5.87 5.87 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES EPO [308136803] 4.7 percent of total billed charges 3.64 5.58 Technical (Hospital) Services PROPRANOLOL 40 MG TABLET RX-6658 CDM 6370000100 HCPCS 250 RC 00115-1661-01 NDC outpatient 1 UN 5.87 5.87 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES HDHP [308136802] 4.7 percent of total billed charges 3.64 5.58 Technical (Hospital) Services PROPRANOLOL 40 MG TABLET RX-6658 CDM 6370000100 HCPCS 250 RC 00115-1661-01 NDC outpatient 1 UN 5.87 5.87 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES PPO [308136801] 4.7 percent of total billed charges 3.64 5.58 Technical (Hospital) Services PROPRANOLOL 40 MG TABLET RX-6658 CDM 6370000100 HCPCS 250 RC 00115-1661-01 NDC outpatient 1 UN 5.87 5.87 BLUE CROSS BLUE SHIELD WELLMARK SB889 [3081026] BCBS WYOMING [308102603] 5.58 percent of total billed charges 3.64 5.58 Technical (Hospital) Services PROPRANOLOL 40 MG TABLET RX-6658 CDM 6370000100 HCPCS 250 RC 00115-1661-01 NDC outpatient 1 UN 5.87 5.87 HEALTHPARTNERS SX009 HEALTHPARTNERS 4.7 percent of total billed charges 3.64 5.58 Technical (Hospital) Services PROPRANOLOL 40 MG TABLET RX-6658 CDM 6370000100 HCPCS 250 RC 00115-1661-01 NDC outpatient 1 UN 5.87 5.87 UNITED HEALTHCARE (COMMERCIAL) [3081199] UNITED HEALTHCARE 87726 [308119901] 3.64 percent of total billed charges 3.64 5.58 Technical (Hospital) Services PROPRANOLOL 40 MG TABLET RX-6658 CDM 6370000100 HCPCS 250 RC 00115-1661-01 NDC outpatient 1 UN 5.87 5.87 MEDICA (COMMERCIAL) 94265 [3081118] MEDICA CLAIMS [308111801] 5.28 percent of total billed charges 3.64 5.58 Technical (Hospital) Services PROPRANOLOL 40 MG TABLET RX-6658 CDM 6370000100 HCPCS 250 RC 00115-1661-01 NDC outpatient 1 UN 5.87 5.87 MULTIPLAN INC 34080 [3081285] MULTIPLAN INC [308128501] 5.58 percent of total billed charges 3.64 5.58 Technical (Hospital) Services PROPRANOLOL 40 MG TABLET RX-6658 CDM 6370000100 HCPCS 250 RC 00115-1661-01 NDC outpatient 1 UN 5.87 5.87 CIGNA 62308 [3081051] CIGNA 62308 [308105105] 4.7 percent of total billed charges 3.64 5.58 Technical (Hospital) Services PROPRANOLOL 40 MG TABLET RX-6658 CDM 6370000100 HCPCS 250 RC 00115-1661-01 NDC outpatient 1 UN 5.87 5.87 CIGNA 62308 [3081051] CIGNA STATE OF WYOMING [308105107] 4.7 percent of total billed charges 3.64 5.58 Technical (Hospital) Services PSEUDOEPHEDRINE 30 MG TABLET RX-6714 CDM 6370000100 HCPCS 250 RC 00904-6337-24 NDC inpatient 1 UN 5.66 5.66 UNITED HEALTHCARE (COMMERCIAL) [3081199] UNITED HEALTHCARE 87726 [308119901] 3.51 percent of total billed charges 3.51 5.38 Technical (Hospital) Services PSEUDOEPHEDRINE 30 MG TABLET RX-6714 CDM 6370000100 HCPCS 250 RC 00904-6337-24 NDC inpatient 1 UN 5.66 5.66 BLUE CROSS BLUE SHIELD WELLMARK SB889 [3081026] BCBS WYOMING [308102603] 5.38 percent of total billed charges 3.51 5.38 Technical (Hospital) Services PSEUDOEPHEDRINE 30 MG TABLET RX-6714 CDM 6370000100 HCPCS 250 RC 00904-6337-24 NDC inpatient 1 UN 5.66 5.66 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES EPO [308136803] 4.48 percent of total billed charges 3.51 5.38 Technical (Hospital) Services PSEUDOEPHEDRINE 30 MG TABLET RX-6714 CDM 6370000100 HCPCS 250 RC 00904-6337-24 NDC inpatient 1 UN 5.66 5.66 CIGNA 62308 [3081051] CIGNA 62308 [308105105] 4.48 percent of total billed charges 3.51 5.38 Technical (Hospital) Services PSEUDOEPHEDRINE 30 MG TABLET RX-6714 CDM 6370000100 HCPCS 250 RC 00904-6337-24 NDC inpatient 1 UN 5.66 5.66 CIGNA 62308 [3081051] CIGNA STATE OF WYOMING [308105107] 4.48 percent of total billed charges 3.51 5.38 Technical (Hospital) Services PSEUDOEPHEDRINE 30 MG TABLET RX-6714 CDM 6370000100 HCPCS 250 RC 00904-6337-24 NDC inpatient 1 UN 5.66 5.66 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES HDHP [308136802] 4.48 percent of total billed charges 3.51 5.38 Technical (Hospital) Services PSEUDOEPHEDRINE 30 MG TABLET RX-6714 CDM 6370000100 HCPCS 250 RC 00904-6337-24 NDC inpatient 1 UN 5.66 5.66 MULTIPLAN INC 34080 [3081285] MULTIPLAN INC [308128501] 5.38 percent of total billed charges 3.51 5.38 Technical (Hospital) Services PSEUDOEPHEDRINE 30 MG TABLET RX-6714 CDM 6370000100 HCPCS 250 RC 00904-6337-24 NDC inpatient 1 UN 5.66 5.66 HEALTHPARTNERS SX009 HEALTHPARTNERS 4.48 percent of total billed charges 3.51 5.38 Technical (Hospital) Services PSEUDOEPHEDRINE 30 MG TABLET RX-6714 CDM 6370000100 HCPCS 250 RC 00904-6337-24 NDC inpatient 1 UN 5.66 5.66 MEDICA (COMMERCIAL) 94265 [3081118] MEDICA CLAIMS [308111801] 5.09 percent of total billed charges 3.51 5.38 Technical (Hospital) Services PSEUDOEPHEDRINE 30 MG TABLET RX-6714 CDM 6370000100 HCPCS 250 RC 00904-6337-24 NDC inpatient 1 UN 5.66 5.66 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES PPO [308136801] 4.48 percent of total billed charges 3.51 5.38 Technical (Hospital) Services PSEUDOEPHEDRINE 30 MG TABLET RX-6714 CDM 6370000100 HCPCS 250 RC 00904-6337-24 NDC outpatient 1 UN 5.66 5.66 BLUE CROSS BLUE SHIELD WELLMARK SB889 [3081026] BCBS WYOMING [308102603] 5.38 percent of total billed charges 3.51 5.38 Technical (Hospital) Services PSEUDOEPHEDRINE 30 MG TABLET RX-6714 CDM 6370000100 HCPCS 250 RC 00904-6337-24 NDC outpatient 1 UN 5.66 5.66 HEALTHPARTNERS SX009 HEALTHPARTNERS 4.53 percent of total billed charges 3.51 5.38 Technical (Hospital) Services PSEUDOEPHEDRINE 30 MG TABLET RX-6714 CDM 6370000100 HCPCS 250 RC 00904-6337-24 NDC outpatient 1 UN 5.66 5.66 UNITED HEALTHCARE (COMMERCIAL) [3081199] UNITED HEALTHCARE 87726 [308119901] 3.51 percent of total billed charges 3.51 5.38 Technical (Hospital) Services PSEUDOEPHEDRINE 30 MG TABLET RX-6714 CDM 6370000100 HCPCS 250 RC 00904-6337-24 NDC outpatient 1 UN 5.66 5.66 MULTIPLAN INC 34080 [3081285] MULTIPLAN INC [308128501] 5.38 percent of total billed charges 3.51 5.38 Technical (Hospital) Services PSEUDOEPHEDRINE 30 MG TABLET RX-6714 CDM 6370000100 HCPCS 250 RC 00904-6337-24 NDC outpatient 1 UN 5.66 5.66 CIGNA 62308 [3081051] CIGNA 62308 [308105105] 4.53 percent of total billed charges 3.51 5.38 Technical (Hospital) Services PSEUDOEPHEDRINE 30 MG TABLET RX-6714 CDM 6370000100 HCPCS 250 RC 00904-6337-24 NDC outpatient 1 UN 5.66 5.66 CIGNA 62308 [3081051] CIGNA STATE OF WYOMING [308105107] 4.53 percent of total billed charges 3.51 5.38 Technical (Hospital) Services PSEUDOEPHEDRINE 30 MG TABLET RX-6714 CDM 6370000100 HCPCS 250 RC 00904-6337-24 NDC outpatient 1 UN 5.66 5.66 MEDICA (COMMERCIAL) 94265 [3081118] MEDICA CLAIMS [308111801] 5.09 percent of total billed charges 3.51 5.38 Technical (Hospital) Services PSEUDOEPHEDRINE 30 MG TABLET RX-6714 CDM 6370000100 HCPCS 250 RC 00904-6337-24 NDC outpatient 1 UN 5.66 5.66 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES PPO [308136801] 4.53 percent of total billed charges 3.51 5.38 Technical (Hospital) Services PSEUDOEPHEDRINE 30 MG TABLET RX-6714 CDM 6370000100 HCPCS 250 RC 00904-6337-24 NDC outpatient 1 UN 5.66 5.66 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES HDHP [308136802] 4.53 percent of total billed charges 3.51 5.38 Technical (Hospital) Services PSEUDOEPHEDRINE 30 MG TABLET RX-6714 CDM 6370000100 HCPCS 250 RC 00904-6337-24 NDC outpatient 1 UN 5.66 5.66 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES EPO [308136803] 4.53 percent of total billed charges 3.51 5.38 Technical (Hospital) Services PYRIDOXINE (VITAMIN B6) 50 MG TABLET RX-6748 CDM 6370000100 HCPCS 250 RC 37864-0909-01 NDC outpatient 1 UN 5.64 5.64 BLUE CROSS BLUE SHIELD WELLMARK SB889 [3081026] BCBS WYOMING [308102603] 5.36 percent of total billed charges 3.5 5.36 Technical (Hospital) Services PYRIDOXINE (VITAMIN B6) 50 MG TABLET RX-6748 CDM 6370000100 HCPCS 250 RC 37864-0909-01 NDC outpatient 1 UN 5.64 5.64 HEALTHPARTNERS SX009 HEALTHPARTNERS 4.51 percent of total billed charges 3.5 5.36 Technical (Hospital) Services PYRIDOXINE (VITAMIN B6) 50 MG TABLET RX-6748 CDM 6370000100 HCPCS 250 RC 37864-0909-01 NDC outpatient 1 UN 5.64 5.64 UNITED HEALTHCARE (COMMERCIAL) [3081199] UNITED HEALTHCARE 87726 [308119901] 3.5 percent of total billed charges 3.5 5.36 Technical (Hospital) Services PYRIDOXINE (VITAMIN B6) 50 MG TABLET RX-6748 CDM 6370000100 HCPCS 250 RC 37864-0909-01 NDC outpatient 1 UN 5.64 5.64 CIGNA 62308 [3081051] CIGNA 62308 [308105105] 4.51 percent of total billed charges 3.5 5.36 Technical (Hospital) Services PYRIDOXINE (VITAMIN B6) 50 MG TABLET RX-6748 CDM 6370000100 HCPCS 250 RC 37864-0909-01 NDC outpatient 1 UN 5.64 5.64 CIGNA 62308 [3081051] CIGNA STATE OF WYOMING [308105107] 4.51 percent of total billed charges 3.5 5.36 Technical (Hospital) Services PYRIDOXINE (VITAMIN B6) 50 MG TABLET RX-6748 CDM 6370000100 HCPCS 250 RC 37864-0909-01 NDC outpatient 1 UN 5.64 5.64 MULTIPLAN INC 34080 [3081285] MULTIPLAN INC [308128501] 5.36 percent of total billed charges 3.5 5.36 Technical (Hospital) Services PYRIDOXINE (VITAMIN B6) 50 MG TABLET RX-6748 CDM 6370000100 HCPCS 250 RC 37864-0909-01 NDC outpatient 1 UN 5.64 5.64 MEDICA (COMMERCIAL) 94265 [3081118] MEDICA CLAIMS [308111801] 5.08 percent of total billed charges 3.5 5.36 Technical (Hospital) Services PYRIDOXINE (VITAMIN B6) 50 MG TABLET RX-6748 CDM 6370000100 HCPCS 250 RC 37864-0909-01 NDC outpatient 1 UN 5.64 5.64 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES HDHP [308136802] 4.51 percent of total billed charges 3.5 5.36 Technical (Hospital) Services PYRIDOXINE (VITAMIN B6) 50 MG TABLET RX-6748 CDM 6370000100 HCPCS 250 RC 37864-0909-01 NDC outpatient 1 UN 5.64 5.64 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES PPO [308136801] 4.51 percent of total billed charges 3.5 5.36 Technical (Hospital) Services PYRIDOXINE (VITAMIN B6) 50 MG TABLET RX-6748 CDM 6370000100 HCPCS 250 RC 37864-0909-01 NDC outpatient 1 UN 5.64 5.64 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES EPO [308136803] 4.51 percent of total billed charges 3.5 5.36 Technical (Hospital) Services PYRIDOXINE (VITAMIN B6) 50 MG TABLET RX-6748 CDM 6370000100 HCPCS 250 RC 37864-0909-01 NDC inpatient 1 UN 5.64 5.64 HEALTHPARTNERS SX009 HEALTHPARTNERS 4.47 percent of total billed charges 3.5 5.36 Technical (Hospital) Services PYRIDOXINE (VITAMIN B6) 50 MG TABLET RX-6748 CDM 6370000100 HCPCS 250 RC 37864-0909-01 NDC inpatient 1 UN 5.64 5.64 MEDICA (COMMERCIAL) 94265 [3081118] MEDICA CLAIMS [308111801] 5.08 percent of total billed charges 3.5 5.36 Technical (Hospital) Services PYRIDOXINE (VITAMIN B6) 50 MG TABLET RX-6748 CDM 6370000100 HCPCS 250 RC 37864-0909-01 NDC inpatient 1 UN 5.64 5.64 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES PPO [308136801] 4.47 percent of total billed charges 3.5 5.36 Technical (Hospital) Services PYRIDOXINE (VITAMIN B6) 50 MG TABLET RX-6748 CDM 6370000100 HCPCS 250 RC 37864-0909-01 NDC inpatient 1 UN 5.64 5.64 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES EPO [308136803] 4.47 percent of total billed charges 3.5 5.36 Technical (Hospital) Services PYRIDOXINE (VITAMIN B6) 50 MG TABLET RX-6748 CDM 6370000100 HCPCS 250 RC 37864-0909-01 NDC inpatient 1 UN 5.64 5.64 CIGNA 62308 [3081051] CIGNA 62308 [308105105] 4.47 percent of total billed charges 3.5 5.36 Technical (Hospital) Services PYRIDOXINE (VITAMIN B6) 50 MG TABLET RX-6748 CDM 6370000100 HCPCS 250 RC 37864-0909-01 NDC inpatient 1 UN 5.64 5.64 CIGNA 62308 [3081051] CIGNA STATE OF WYOMING [308105107] 4.47 percent of total billed charges 3.5 5.36 Technical (Hospital) Services PYRIDOXINE (VITAMIN B6) 50 MG TABLET RX-6748 CDM 6370000100 HCPCS 250 RC 37864-0909-01 NDC inpatient 1 UN 5.64 5.64 UNITED HEALTHCARE (COMMERCIAL) [3081199] UNITED HEALTHCARE 87726 [308119901] 3.5 percent of total billed charges 3.5 5.36 Technical (Hospital) Services PYRIDOXINE (VITAMIN B6) 50 MG TABLET RX-6748 CDM 6370000100 HCPCS 250 RC 37864-0909-01 NDC inpatient 1 UN 5.64 5.64 BLUE CROSS BLUE SHIELD WELLMARK SB889 [3081026] BCBS WYOMING [308102603] 5.36 percent of total billed charges 3.5 5.36 Technical (Hospital) Services PYRIDOXINE (VITAMIN B6) 50 MG TABLET RX-6748 CDM 6370000100 HCPCS 250 RC 37864-0909-01 NDC inpatient 1 UN 5.64 5.64 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES HDHP [308136802] 4.47 percent of total billed charges 3.5 5.36 Technical (Hospital) Services PYRIDOXINE (VITAMIN B6) 50 MG TABLET RX-6748 CDM 6370000100 HCPCS 250 RC 37864-0909-01 NDC inpatient 1 UN 5.64 5.64 MULTIPLAN INC 34080 [3081285] MULTIPLAN INC [308128501] 5.36 percent of total billed charges 3.5 5.36 Technical (Hospital) Services ARIPIPRAZOLE 2 MG TABLET RX-70306 CDM 6370000100 HCPCS 250 RC 67877-0430-03 NDC outpatient 1 UN 5.85 5.85 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES HDHP [308136802] 4.68 percent of total billed charges 3.63 5.56 Technical (Hospital) Services ARIPIPRAZOLE 2 MG TABLET RX-70306 CDM 6370000100 HCPCS 250 RC 67877-0430-03 NDC outpatient 1 UN 5.85 5.85 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES EPO [308136803] 4.68 percent of total billed charges 3.63 5.56 Technical (Hospital) Services ARIPIPRAZOLE 2 MG TABLET RX-70306 CDM 6370000100 HCPCS 250 RC 67877-0430-03 NDC outpatient 1 UN 5.85 5.85 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES PPO [308136801] 4.68 percent of total billed charges 3.63 5.56 Technical (Hospital) Services ARIPIPRAZOLE 2 MG TABLET RX-70306 CDM 6370000100 HCPCS 250 RC 67877-0430-03 NDC outpatient 1 UN 5.85 5.85 HEALTHPARTNERS SX009 HEALTHPARTNERS 4.68 percent of total billed charges 3.63 5.56 Technical (Hospital) Services ARIPIPRAZOLE 2 MG TABLET RX-70306 CDM 6370000100 HCPCS 250 RC 67877-0430-03 NDC outpatient 1 UN 5.85 5.85 BLUE CROSS BLUE SHIELD WELLMARK SB889 [3081026] BCBS WYOMING [308102603] 5.56 percent of total billed charges 3.63 5.56 Technical (Hospital) Services ARIPIPRAZOLE 2 MG TABLET RX-70306 CDM 6370000100 HCPCS 250 RC 67877-0430-03 NDC outpatient 1 UN 5.85 5.85 UNITED HEALTHCARE (COMMERCIAL) [3081199] UNITED HEALTHCARE 87726 [308119901] 3.63 percent of total billed charges 3.63 5.56 Technical (Hospital) Services ARIPIPRAZOLE 2 MG TABLET RX-70306 CDM 6370000100 HCPCS 250 RC 67877-0430-03 NDC outpatient 1 UN 5.85 5.85 CIGNA 62308 [3081051] CIGNA 62308 [308105105] 4.68 percent of total billed charges 3.63 5.56 Technical (Hospital) Services ARIPIPRAZOLE 2 MG TABLET RX-70306 CDM 6370000100 HCPCS 250 RC 67877-0430-03 NDC outpatient 1 UN 5.85 5.85 CIGNA 62308 [3081051] CIGNA STATE OF WYOMING [308105107] 4.68 percent of total billed charges 3.63 5.56 Technical (Hospital) Services ARIPIPRAZOLE 2 MG TABLET RX-70306 CDM 6370000100 HCPCS 250 RC 67877-0430-03 NDC outpatient 1 UN 5.85 5.85 MULTIPLAN INC 34080 [3081285] MULTIPLAN INC [308128501] 5.56 percent of total billed charges 3.63 5.56 Technical (Hospital) Services ARIPIPRAZOLE 2 MG TABLET RX-70306 CDM 6370000100 HCPCS 250 RC 67877-0430-03 NDC outpatient 1 UN 5.85 5.85 MEDICA (COMMERCIAL) 94265 [3081118] MEDICA CLAIMS [308111801] 5.27 percent of total billed charges 3.63 5.56 Technical (Hospital) Services ARIPIPRAZOLE 2 MG TABLET RX-70306 CDM 6370000100 HCPCS 250 RC 67877-0430-03 NDC inpatient 1 UN 5.85 5.85 MULTIPLAN INC 34080 [3081285] MULTIPLAN INC [308128501] 5.56 percent of total billed charges 3.63 5.56 Technical (Hospital) Services ARIPIPRAZOLE 2 MG TABLET RX-70306 CDM 6370000100 HCPCS 250 RC 67877-0430-03 NDC inpatient 1 UN 5.85 5.85 CIGNA 62308 [3081051] CIGNA 62308 [308105105] 4.63 percent of total billed charges 3.63 5.56 Technical (Hospital) Services ARIPIPRAZOLE 2 MG TABLET RX-70306 CDM 6370000100 HCPCS 250 RC 67877-0430-03 NDC inpatient 1 UN 5.85 5.85 CIGNA 62308 [3081051] CIGNA STATE OF WYOMING [308105107] 4.63 percent of total billed charges 3.63 5.56 Technical (Hospital) Services ARIPIPRAZOLE 2 MG TABLET RX-70306 CDM 6370000100 HCPCS 250 RC 67877-0430-03 NDC inpatient 1 UN 5.85 5.85 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES EPO [308136803] 4.63 percent of total billed charges 3.63 5.56 Technical (Hospital) Services ARIPIPRAZOLE 2 MG TABLET RX-70306 CDM 6370000100 HCPCS 250 RC 67877-0430-03 NDC inpatient 1 UN 5.85 5.85 UNITED HEALTHCARE (COMMERCIAL) [3081199] UNITED HEALTHCARE 87726 [308119901] 3.63 percent of total billed charges 3.63 5.56 Technical (Hospital) Services ARIPIPRAZOLE 2 MG TABLET RX-70306 CDM 6370000100 HCPCS 250 RC 67877-0430-03 NDC inpatient 1 UN 5.85 5.85 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES HDHP [308136802] 4.63 percent of total billed charges 3.63 5.56 Technical (Hospital) Services ARIPIPRAZOLE 2 MG TABLET RX-70306 CDM 6370000100 HCPCS 250 RC 67877-0430-03 NDC inpatient 1 UN 5.85 5.85 BLUE CROSS BLUE SHIELD WELLMARK SB889 [3081026] BCBS WYOMING [308102603] 5.56 percent of total billed charges 3.63 5.56 Technical (Hospital) Services ARIPIPRAZOLE 2 MG TABLET RX-70306 CDM 6370000100 HCPCS 250 RC 67877-0430-03 NDC inpatient 1 UN 5.85 5.85 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES PPO [308136801] 4.63 percent of total billed charges 3.63 5.56 Technical (Hospital) Services ARIPIPRAZOLE 2 MG TABLET RX-70306 CDM 6370000100 HCPCS 250 RC 67877-0430-03 NDC inpatient 1 UN 5.85 5.85 MEDICA (COMMERCIAL) 94265 [3081118] MEDICA CLAIMS [308111801] 5.27 percent of total billed charges 3.63 5.56 Technical (Hospital) Services ARIPIPRAZOLE 2 MG TABLET RX-70306 CDM 6370000100 HCPCS 250 RC 67877-0430-03 NDC inpatient 1 UN 5.85 5.85 HEALTHPARTNERS SX009 HEALTHPARTNERS 4.63 percent of total billed charges 3.63 5.56 Technical (Hospital) Services QUETIAPINE 50 MG TABLET RX-70397 CDM 6370000100 HCPCS 250 RC 67877-0249-01 NDC outpatient 1 UN 5.68 5.68 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES PPO [308136801] 4.54 percent of total billed charges 3.52 5.4 Technical (Hospital) Services QUETIAPINE 50 MG TABLET RX-70397 CDM 6370000100 HCPCS 250 RC 67877-0249-01 NDC outpatient 1 UN 5.68 5.68 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES HDHP [308136802] 4.54 percent of total billed charges 3.52 5.4 Technical (Hospital) Services QUETIAPINE 50 MG TABLET RX-70397 CDM 6370000100 HCPCS 250 RC 67877-0249-01 NDC outpatient 1 UN 5.68 5.68 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES EPO [308136803] 4.54 percent of total billed charges 3.52 5.4 Technical (Hospital) Services QUETIAPINE 50 MG TABLET RX-70397 CDM 6370000100 HCPCS 250 RC 67877-0249-01 NDC outpatient 1 UN 5.68 5.68 HEALTHPARTNERS SX009 HEALTHPARTNERS 4.54 percent of total billed charges 3.52 5.4 Technical (Hospital) Services QUETIAPINE 50 MG TABLET RX-70397 CDM 6370000100 HCPCS 250 RC 67877-0249-01 NDC outpatient 1 UN 5.68 5.68 UNITED HEALTHCARE (COMMERCIAL) [3081199] UNITED HEALTHCARE 87726 [308119901] 3.52 percent of total billed charges 3.52 5.4 Technical (Hospital) Services QUETIAPINE 50 MG TABLET RX-70397 CDM 6370000100 HCPCS 250 RC 67877-0249-01 NDC outpatient 1 UN 5.68 5.68 MULTIPLAN INC 34080 [3081285] MULTIPLAN INC [308128501] 5.4 percent of total billed charges 3.52 5.4 Technical (Hospital) Services QUETIAPINE 50 MG TABLET RX-70397 CDM 6370000100 HCPCS 250 RC 67877-0249-01 NDC outpatient 1 UN 5.68 5.68 CIGNA 62308 [3081051] CIGNA STATE OF WYOMING [308105107] 4.54 percent of total billed charges 3.52 5.4 Technical (Hospital) Services QUETIAPINE 50 MG TABLET RX-70397 CDM 6370000100 HCPCS 250 RC 67877-0249-01 NDC outpatient 1 UN 5.68 5.68 CIGNA 62308 [3081051] CIGNA 62308 [308105105] 4.54 percent of total billed charges 3.52 5.4 Technical (Hospital) Services QUETIAPINE 50 MG TABLET RX-70397 CDM 6370000100 HCPCS 250 RC 67877-0249-01 NDC outpatient 1 UN 5.68 5.68 MEDICA (COMMERCIAL) 94265 [3081118] MEDICA CLAIMS [308111801] 5.11 percent of total billed charges 3.52 5.4 Technical (Hospital) Services QUETIAPINE 50 MG TABLET RX-70397 CDM 6370000100 HCPCS 250 RC 67877-0249-01 NDC outpatient 1 UN 5.68 5.68 BLUE CROSS BLUE SHIELD WELLMARK SB889 [3081026] BCBS WYOMING [308102603] 5.4 percent of total billed charges 3.52 5.4 Technical (Hospital) Services QUETIAPINE 50 MG TABLET RX-70397 CDM 6370000100 HCPCS 250 RC 67877-0249-01 NDC inpatient 1 UN 5.68 5.68 MEDICA (COMMERCIAL) 94265 [3081118] MEDICA CLAIMS [308111801] 5.11 percent of total billed charges 3.52 5.4 Technical (Hospital) Services QUETIAPINE 50 MG TABLET RX-70397 CDM 6370000100 HCPCS 250 RC 67877-0249-01 NDC inpatient 1 UN 5.68 5.68 HEALTHPARTNERS SX009 HEALTHPARTNERS 4.5 percent of total billed charges 3.52 5.4 Technical (Hospital) Services QUETIAPINE 50 MG TABLET RX-70397 CDM 6370000100 HCPCS 250 RC 67877-0249-01 NDC inpatient 1 UN 5.68 5.68 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES PPO [308136801] 4.5 percent of total billed charges 3.52 5.4 Technical (Hospital) Services QUETIAPINE 50 MG TABLET RX-70397 CDM 6370000100 HCPCS 250 RC 67877-0249-01 NDC inpatient 1 UN 5.68 5.68 CIGNA 62308 [3081051] CIGNA 62308 [308105105] 4.5 percent of total billed charges 3.52 5.4 Technical (Hospital) Services QUETIAPINE 50 MG TABLET RX-70397 CDM 6370000100 HCPCS 250 RC 67877-0249-01 NDC inpatient 1 UN 5.68 5.68 CIGNA 62308 [3081051] CIGNA STATE OF WYOMING [308105107] 4.5 percent of total billed charges 3.52 5.4 Technical (Hospital) Services QUETIAPINE 50 MG TABLET RX-70397 CDM 6370000100 HCPCS 250 RC 67877-0249-01 NDC inpatient 1 UN 5.68 5.68 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES EPO [308136803] 4.5 percent of total billed charges 3.52 5.4 Technical (Hospital) Services QUETIAPINE 50 MG TABLET RX-70397 CDM 6370000100 HCPCS 250 RC 67877-0249-01 NDC inpatient 1 UN 5.68 5.68 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES HDHP [308136802] 4.5 percent of total billed charges 3.52 5.4 Technical (Hospital) Services QUETIAPINE 50 MG TABLET RX-70397 CDM 6370000100 HCPCS 250 RC 67877-0249-01 NDC inpatient 1 UN 5.68 5.68 UNITED HEALTHCARE (COMMERCIAL) [3081199] UNITED HEALTHCARE 87726 [308119901] 3.52 percent of total billed charges 3.52 5.4 Technical (Hospital) Services QUETIAPINE 50 MG TABLET RX-70397 CDM 6370000100 HCPCS 250 RC 67877-0249-01 NDC inpatient 1 UN 5.68 5.68 BLUE CROSS BLUE SHIELD WELLMARK SB889 [3081026] BCBS WYOMING [308102603] 5.4 percent of total billed charges 3.52 5.4 Technical (Hospital) Services QUETIAPINE 50 MG TABLET RX-70397 CDM 6370000100 HCPCS 250 RC 67877-0249-01 NDC inpatient 1 UN 5.68 5.68 MULTIPLAN INC 34080 [3081285] MULTIPLAN INC [308128501] 5.4 percent of total billed charges 3.52 5.4 Technical (Hospital) Services "RANOLAZINE ER 500 MG TABLET,EXTENDED RELEASE,12 HR" RX-70434 CDM 6370000100 HCPCS 250 RC 68462-0319-60 NDC inpatient 1 UN 6.29 6.29 CIGNA 62308 [3081051] CIGNA 62308 [308105105] 4.98 percent of total billed charges 3.9 5.98 Technical (Hospital) Services "RANOLAZINE ER 500 MG TABLET,EXTENDED RELEASE,12 HR" RX-70434 CDM 6370000100 HCPCS 250 RC 68462-0319-60 NDC inpatient 1 UN 6.29 6.29 CIGNA 62308 [3081051] CIGNA STATE OF WYOMING [308105107] 4.98 percent of total billed charges 3.9 5.98 Technical (Hospital) Services "RANOLAZINE ER 500 MG TABLET,EXTENDED RELEASE,12 HR" RX-70434 CDM 6370000100 HCPCS 250 RC 68462-0319-60 NDC inpatient 1 UN 6.29 6.29 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES EPO [308136803] 4.98 percent of total billed charges 3.9 5.98 Technical (Hospital) Services "RANOLAZINE ER 500 MG TABLET,EXTENDED RELEASE,12 HR" RX-70434 CDM 6370000100 HCPCS 250 RC 68462-0319-60 NDC inpatient 1 UN 6.29 6.29 UNITED HEALTHCARE (COMMERCIAL) [3081199] UNITED HEALTHCARE 87726 [308119901] 3.9 percent of total billed charges 3.9 5.98 Technical (Hospital) Services "RANOLAZINE ER 500 MG TABLET,EXTENDED RELEASE,12 HR" RX-70434 CDM 6370000100 HCPCS 250 RC 68462-0319-60 NDC inpatient 1 UN 6.29 6.29 BLUE CROSS BLUE SHIELD WELLMARK SB889 [3081026] BCBS WYOMING [308102603] 5.98 percent of total billed charges 3.9 5.98 Technical (Hospital) Services "RANOLAZINE ER 500 MG TABLET,EXTENDED RELEASE,12 HR" RX-70434 CDM 6370000100 HCPCS 250 RC 68462-0319-60 NDC inpatient 1 UN 6.29 6.29 HEALTHPARTNERS SX009 HEALTHPARTNERS 4.98 percent of total billed charges 3.9 5.98 Technical (Hospital) Services "RANOLAZINE ER 500 MG TABLET,EXTENDED RELEASE,12 HR" RX-70434 CDM 6370000100 HCPCS 250 RC 68462-0319-60 NDC inpatient 1 UN 6.29 6.29 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES HDHP [308136802] 4.98 percent of total billed charges 3.9 5.98 Technical (Hospital) Services "RANOLAZINE ER 500 MG TABLET,EXTENDED RELEASE,12 HR" RX-70434 CDM 6370000100 HCPCS 250 RC 68462-0319-60 NDC inpatient 1 UN 6.29 6.29 MULTIPLAN INC 34080 [3081285] MULTIPLAN INC [308128501] 5.98 percent of total billed charges 3.9 5.98 Technical (Hospital) Services "RANOLAZINE ER 500 MG TABLET,EXTENDED RELEASE,12 HR" RX-70434 CDM 6370000100 HCPCS 250 RC 68462-0319-60 NDC inpatient 1 UN 6.29 6.29 MEDICA (COMMERCIAL) 94265 [3081118] MEDICA CLAIMS [308111801] 5.66 percent of total billed charges 3.9 5.98 Technical (Hospital) Services "RANOLAZINE ER 500 MG TABLET,EXTENDED RELEASE,12 HR" RX-70434 CDM 6370000100 HCPCS 250 RC 68462-0319-60 NDC inpatient 1 UN 6.29 6.29 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES PPO [308136801] 4.98 percent of total billed charges 3.9 5.98 Technical (Hospital) Services "RANOLAZINE ER 500 MG TABLET,EXTENDED RELEASE,12 HR" RX-70434 CDM 6370000100 HCPCS 250 RC 68462-0319-60 NDC outpatient 1 UN 6.29 6.29 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES HDHP [308136802] 5.03 percent of total billed charges 3.9 5.98 Technical (Hospital) Services "RANOLAZINE ER 500 MG TABLET,EXTENDED RELEASE,12 HR" RX-70434 CDM 6370000100 HCPCS 250 RC 68462-0319-60 NDC outpatient 1 UN 6.29 6.29 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES PPO [308136801] 5.03 percent of total billed charges 3.9 5.98 Technical (Hospital) Services "RANOLAZINE ER 500 MG TABLET,EXTENDED RELEASE,12 HR" RX-70434 CDM 6370000100 HCPCS 250 RC 68462-0319-60 NDC outpatient 1 UN 6.29 6.29 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES EPO [308136803] 5.03 percent of total billed charges 3.9 5.98 Technical (Hospital) Services "RANOLAZINE ER 500 MG TABLET,EXTENDED RELEASE,12 HR" RX-70434 CDM 6370000100 HCPCS 250 RC 68462-0319-60 NDC outpatient 1 UN 6.29 6.29 MULTIPLAN INC 34080 [3081285] MULTIPLAN INC [308128501] 5.98 percent of total billed charges 3.9 5.98 Technical (Hospital) Services "RANOLAZINE ER 500 MG TABLET,EXTENDED RELEASE,12 HR" RX-70434 CDM 6370000100 HCPCS 250 RC 68462-0319-60 NDC outpatient 1 UN 6.29 6.29 CIGNA 62308 [3081051] CIGNA 62308 [308105105] 5.03 percent of total billed charges 3.9 5.98 Technical (Hospital) Services "RANOLAZINE ER 500 MG TABLET,EXTENDED RELEASE,12 HR" RX-70434 CDM 6370000100 HCPCS 250 RC 68462-0319-60 NDC outpatient 1 UN 6.29 6.29 CIGNA 62308 [3081051] CIGNA STATE OF WYOMING [308105107] 5.03 percent of total billed charges 3.9 5.98 Technical (Hospital) Services "RANOLAZINE ER 500 MG TABLET,EXTENDED RELEASE,12 HR" RX-70434 CDM 6370000100 HCPCS 250 RC 68462-0319-60 NDC outpatient 1 UN 6.29 6.29 MEDICA (COMMERCIAL) 94265 [3081118] MEDICA CLAIMS [308111801] 5.66 percent of total billed charges 3.9 5.98 Technical (Hospital) Services "RANOLAZINE ER 500 MG TABLET,EXTENDED RELEASE,12 HR" RX-70434 CDM 6370000100 HCPCS 250 RC 68462-0319-60 NDC outpatient 1 UN 6.29 6.29 HEALTHPARTNERS SX009 HEALTHPARTNERS 5.03 percent of total billed charges 3.9 5.98 Technical (Hospital) Services "RANOLAZINE ER 500 MG TABLET,EXTENDED RELEASE,12 HR" RX-70434 CDM 6370000100 HCPCS 250 RC 68462-0319-60 NDC outpatient 1 UN 6.29 6.29 UNITED HEALTHCARE (COMMERCIAL) [3081199] UNITED HEALTHCARE 87726 [308119901] 3.9 percent of total billed charges 3.9 5.98 Technical (Hospital) Services "RANOLAZINE ER 500 MG TABLET,EXTENDED RELEASE,12 HR" RX-70434 CDM 6370000100 HCPCS 250 RC 68462-0319-60 NDC outpatient 1 UN 6.29 6.29 BLUE CROSS BLUE SHIELD WELLMARK SB889 [3081026] BCBS WYOMING [308102603] 5.98 percent of total billed charges 3.9 5.98 Technical (Hospital) Services "FLUTICASONE PROPIONATE 50 MCG/ACTUATION NASAL SPRAY,SUSPENSION" RX-70536 CDM 6370000100 HCPCS 250 RC 60505-0829-01 NDC inpatient 16 GR 66 66 HEALTHPARTNERS SX009 HEALTHPARTNERS 52.26 percent of total billed charges 40.92 62.7 Technical (Hospital) Services "FLUTICASONE PROPIONATE 50 MCG/ACTUATION NASAL SPRAY,SUSPENSION" RX-70536 CDM 6370000100 HCPCS 250 RC 60505-0829-01 NDC inpatient 16 GR 66 66 CIGNA 62308 [3081051] CIGNA 62308 [308105105] 52.26 percent of total billed charges 40.92 62.7 Technical (Hospital) Services "FLUTICASONE PROPIONATE 50 MCG/ACTUATION NASAL SPRAY,SUSPENSION" RX-70536 CDM 6370000100 HCPCS 250 RC 60505-0829-01 NDC inpatient 16 GR 66 66 CIGNA 62308 [3081051] CIGNA STATE OF WYOMING [308105107] 52.26 percent of total billed charges 40.92 62.7 Technical (Hospital) Services "FLUTICASONE PROPIONATE 50 MCG/ACTUATION NASAL SPRAY,SUSPENSION" RX-70536 CDM 6370000100 HCPCS 250 RC 60505-0829-01 NDC inpatient 16 GR 66 66 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES HDHP [308136802] 52.26 percent of total billed charges 40.92 62.7 Technical (Hospital) Services "FLUTICASONE PROPIONATE 50 MCG/ACTUATION NASAL SPRAY,SUSPENSION" RX-70536 CDM 6370000100 HCPCS 250 RC 60505-0829-01 NDC inpatient 16 GR 66 66 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES PPO [308136801] 52.26 percent of total billed charges 40.92 62.7 Technical (Hospital) Services "FLUTICASONE PROPIONATE 50 MCG/ACTUATION NASAL SPRAY,SUSPENSION" RX-70536 CDM 6370000100 HCPCS 250 RC 60505-0829-01 NDC inpatient 16 GR 66 66 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES EPO [308136803] 52.26 percent of total billed charges 40.92 62.7 Technical (Hospital) Services "FLUTICASONE PROPIONATE 50 MCG/ACTUATION NASAL SPRAY,SUSPENSION" RX-70536 CDM 6370000100 HCPCS 250 RC 60505-0829-01 NDC inpatient 16 GR 66 66 MULTIPLAN INC 34080 [3081285] MULTIPLAN INC [308128501] 62.7 percent of total billed charges 40.92 62.7 Technical (Hospital) Services "FLUTICASONE PROPIONATE 50 MCG/ACTUATION NASAL SPRAY,SUSPENSION" RX-70536 CDM 6370000100 HCPCS 250 RC 60505-0829-01 NDC inpatient 16 GR 66 66 MEDICA (COMMERCIAL) 94265 [3081118] MEDICA CLAIMS [308111801] 59.4 percent of total billed charges 40.92 62.7 Technical (Hospital) Services "FLUTICASONE PROPIONATE 50 MCG/ACTUATION NASAL SPRAY,SUSPENSION" RX-70536 CDM 6370000100 HCPCS 250 RC 60505-0829-01 NDC inpatient 16 GR 66 66 BLUE CROSS BLUE SHIELD WELLMARK SB889 [3081026] BCBS WYOMING [308102603] 62.7 percent of total billed charges 40.92 62.7 Technical (Hospital) Services "FLUTICASONE PROPIONATE 50 MCG/ACTUATION NASAL SPRAY,SUSPENSION" RX-70536 CDM 6370000100 HCPCS 250 RC 60505-0829-01 NDC inpatient 16 GR 66 66 UNITED HEALTHCARE (COMMERCIAL) [3081199] UNITED HEALTHCARE 87726 [308119901] 40.92 percent of total billed charges 40.92 62.7 Technical (Hospital) Services "FLUTICASONE PROPIONATE 50 MCG/ACTUATION NASAL SPRAY,SUSPENSION" RX-70536 CDM 6370000100 HCPCS 250 RC 60505-0829-01 NDC outpatient 16 GR 66 66 UNITED HEALTHCARE (COMMERCIAL) [3081199] UNITED HEALTHCARE 87726 [308119901] 40.92 percent of total billed charges 40.92 62.7 Technical (Hospital) Services "FLUTICASONE PROPIONATE 50 MCG/ACTUATION NASAL SPRAY,SUSPENSION" RX-70536 CDM 6370000100 HCPCS 250 RC 60505-0829-01 NDC outpatient 16 GR 66 66 BLUE CROSS BLUE SHIELD WELLMARK SB889 [3081026] BCBS WYOMING [308102603] 62.7 percent of total billed charges 40.92 62.7 Technical (Hospital) Services "FLUTICASONE PROPIONATE 50 MCG/ACTUATION NASAL SPRAY,SUSPENSION" RX-70536 CDM 6370000100 HCPCS 250 RC 60505-0829-01 NDC outpatient 16 GR 66 66 HEALTHPARTNERS SX009 HEALTHPARTNERS 52.8 percent of total billed charges 40.92 62.7 Technical (Hospital) Services "FLUTICASONE PROPIONATE 50 MCG/ACTUATION NASAL SPRAY,SUSPENSION" RX-70536 CDM 6370000100 HCPCS 250 RC 60505-0829-01 NDC outpatient 16 GR 66 66 MEDICA (COMMERCIAL) 94265 [3081118] MEDICA CLAIMS [308111801] 59.4 percent of total billed charges 40.92 62.7 Technical (Hospital) Services "FLUTICASONE PROPIONATE 50 MCG/ACTUATION NASAL SPRAY,SUSPENSION" RX-70536 CDM 6370000100 HCPCS 250 RC 60505-0829-01 NDC outpatient 16 GR 66 66 MULTIPLAN INC 34080 [3081285] MULTIPLAN INC [308128501] 62.7 percent of total billed charges 40.92 62.7 Technical (Hospital) Services "FLUTICASONE PROPIONATE 50 MCG/ACTUATION NASAL SPRAY,SUSPENSION" RX-70536 CDM 6370000100 HCPCS 250 RC 60505-0829-01 NDC outpatient 16 GR 66 66 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES EPO [308136803] 52.8 percent of total billed charges 40.92 62.7 Technical (Hospital) Services "FLUTICASONE PROPIONATE 50 MCG/ACTUATION NASAL SPRAY,SUSPENSION" RX-70536 CDM 6370000100 HCPCS 250 RC 60505-0829-01 NDC outpatient 16 GR 66 66 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES HDHP [308136802] 52.8 percent of total billed charges 40.92 62.7 Technical (Hospital) Services "FLUTICASONE PROPIONATE 50 MCG/ACTUATION NASAL SPRAY,SUSPENSION" RX-70536 CDM 6370000100 HCPCS 250 RC 60505-0829-01 NDC outpatient 16 GR 66 66 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES PPO [308136801] 52.8 percent of total billed charges 40.92 62.7 Technical (Hospital) Services "FLUTICASONE PROPIONATE 50 MCG/ACTUATION NASAL SPRAY,SUSPENSION" RX-70536 CDM 6370000100 HCPCS 250 RC 60505-0829-01 NDC outpatient 16 GR 66 66 CIGNA 62308 [3081051] CIGNA 62308 [308105105] 52.8 percent of total billed charges 40.92 62.7 Technical (Hospital) Services "FLUTICASONE PROPIONATE 50 MCG/ACTUATION NASAL SPRAY,SUSPENSION" RX-70536 CDM 6370000100 HCPCS 250 RC 60505-0829-01 NDC outpatient 16 GR 66 66 CIGNA 62308 [3081051] CIGNA STATE OF WYOMING [308105107] 52.8 percent of total billed charges 40.92 62.7 Technical (Hospital) Services ATENOLOL 100 MG TABLET RX-716 CDM 6370000100 HCPCS 250 RC 00093-0753-01 NDC inpatient 1 UN 5.68 5.68 HEALTHPARTNERS SX009 HEALTHPARTNERS 4.5 percent of total billed charges 3.52 5.4 Technical (Hospital) Services ATENOLOL 100 MG TABLET RX-716 CDM 6370000100 HCPCS 250 RC 00093-0753-01 NDC inpatient 1 UN 5.68 5.68 MEDICA (COMMERCIAL) 94265 [3081118] MEDICA CLAIMS [308111801] 5.11 percent of total billed charges 3.52 5.4 Technical (Hospital) Services ATENOLOL 100 MG TABLET RX-716 CDM 6370000100 HCPCS 250 RC 00093-0753-01 NDC inpatient 1 UN 5.68 5.68 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES PPO [308136801] 4.5 percent of total billed charges 3.52 5.4 Technical (Hospital) Services ATENOLOL 100 MG TABLET RX-716 CDM 6370000100 HCPCS 250 RC 00093-0753-01 NDC inpatient 1 UN 5.68 5.68 MULTIPLAN INC 34080 [3081285] MULTIPLAN INC [308128501] 5.4 percent of total billed charges 3.52 5.4 Technical (Hospital) Services ATENOLOL 100 MG TABLET RX-716 CDM 6370000100 HCPCS 250 RC 00093-0753-01 NDC inpatient 1 UN 5.68 5.68 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES HDHP [308136802] 4.5 percent of total billed charges 3.52 5.4 Technical (Hospital) Services ATENOLOL 100 MG TABLET RX-716 CDM 6370000100 HCPCS 250 RC 00093-0753-01 NDC inpatient 1 UN 5.68 5.68 UNITED HEALTHCARE (COMMERCIAL) [3081199] UNITED HEALTHCARE 87726 [308119901] 3.52 percent of total billed charges 3.52 5.4 Technical (Hospital) Services ATENOLOL 100 MG TABLET RX-716 CDM 6370000100 HCPCS 250 RC 00093-0753-01 NDC inpatient 1 UN 5.68 5.68 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES EPO [308136803] 4.5 percent of total billed charges 3.52 5.4 Technical (Hospital) Services ATENOLOL 100 MG TABLET RX-716 CDM 6370000100 HCPCS 250 RC 00093-0753-01 NDC inpatient 1 UN 5.68 5.68 CIGNA 62308 [3081051] CIGNA 62308 [308105105] 4.5 percent of total billed charges 3.52 5.4 Technical (Hospital) Services ATENOLOL 100 MG TABLET RX-716 CDM 6370000100 HCPCS 250 RC 00093-0753-01 NDC inpatient 1 UN 5.68 5.68 CIGNA 62308 [3081051] CIGNA STATE OF WYOMING [308105107] 4.5 percent of total billed charges 3.52 5.4 Technical (Hospital) Services ATENOLOL 100 MG TABLET RX-716 CDM 6370000100 HCPCS 250 RC 00093-0753-01 NDC inpatient 1 UN 5.68 5.68 BLUE CROSS BLUE SHIELD WELLMARK SB889 [3081026] BCBS WYOMING [308102603] 5.4 percent of total billed charges 3.52 5.4 Technical (Hospital) Services ATENOLOL 100 MG TABLET RX-716 CDM 6370000100 HCPCS 250 RC 00093-0753-01 NDC outpatient 1 UN 5.68 5.68 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES PPO [308136801] 4.54 percent of total billed charges 3.52 5.4 Technical (Hospital) Services ATENOLOL 100 MG TABLET RX-716 CDM 6370000100 HCPCS 250 RC 00093-0753-01 NDC outpatient 1 UN 5.68 5.68 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES HDHP [308136802] 4.54 percent of total billed charges 3.52 5.4 Technical (Hospital) Services ATENOLOL 100 MG TABLET RX-716 CDM 6370000100 HCPCS 250 RC 00093-0753-01 NDC outpatient 1 UN 5.68 5.68 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES EPO [308136803] 4.54 percent of total billed charges 3.52 5.4 Technical (Hospital) Services ATENOLOL 100 MG TABLET RX-716 CDM 6370000100 HCPCS 250 RC 00093-0753-01 NDC outpatient 1 UN 5.68 5.68 BLUE CROSS BLUE SHIELD WELLMARK SB889 [3081026] BCBS WYOMING [308102603] 5.4 percent of total billed charges 3.52 5.4 Technical (Hospital) Services ATENOLOL 100 MG TABLET RX-716 CDM 6370000100 HCPCS 250 RC 00093-0753-01 NDC outpatient 1 UN 5.68 5.68 HEALTHPARTNERS SX009 HEALTHPARTNERS 4.54 percent of total billed charges 3.52 5.4 Technical (Hospital) Services ATENOLOL 100 MG TABLET RX-716 CDM 6370000100 HCPCS 250 RC 00093-0753-01 NDC outpatient 1 UN 5.68 5.68 UNITED HEALTHCARE (COMMERCIAL) [3081199] UNITED HEALTHCARE 87726 [308119901] 3.52 percent of total billed charges 3.52 5.4 Technical (Hospital) Services ATENOLOL 100 MG TABLET RX-716 CDM 6370000100 HCPCS 250 RC 00093-0753-01 NDC outpatient 1 UN 5.68 5.68 MEDICA (COMMERCIAL) 94265 [3081118] MEDICA CLAIMS [308111801] 5.11 percent of total billed charges 3.52 5.4 Technical (Hospital) Services ATENOLOL 100 MG TABLET RX-716 CDM 6370000100 HCPCS 250 RC 00093-0753-01 NDC outpatient 1 UN 5.68 5.68 MULTIPLAN INC 34080 [3081285] MULTIPLAN INC [308128501] 5.4 percent of total billed charges 3.52 5.4 Technical (Hospital) Services ATENOLOL 100 MG TABLET RX-716 CDM 6370000100 HCPCS 250 RC 00093-0753-01 NDC outpatient 1 UN 5.68 5.68 CIGNA 62308 [3081051] CIGNA 62308 [308105105] 4.54 percent of total billed charges 3.52 5.4 Technical (Hospital) Services ATENOLOL 100 MG TABLET RX-716 CDM 6370000100 HCPCS 250 RC 00093-0753-01 NDC outpatient 1 UN 5.68 5.68 CIGNA 62308 [3081051] CIGNA STATE OF WYOMING [308105107] 4.54 percent of total billed charges 3.52 5.4 Technical (Hospital) Services ATENOLOL 25 MG TABLET RX-717 CDM 6370000100 HCPCS 250 RC 00093-0787-01 NDC inpatient 1 UN 5.65 5.65 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES HDHP [308136802] 4.47 percent of total billed charges 3.5 5.37 Technical (Hospital) Services ATENOLOL 25 MG TABLET RX-717 CDM 6370000100 HCPCS 250 RC 00093-0787-01 NDC inpatient 1 UN 5.65 5.65 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES EPO [308136803] 4.47 percent of total billed charges 3.5 5.37 Technical (Hospital) Services ATENOLOL 25 MG TABLET RX-717 CDM 6370000100 HCPCS 250 RC 00093-0787-01 NDC inpatient 1 UN 5.65 5.65 CIGNA 62308 [3081051] CIGNA 62308 [308105105] 4.47 percent of total billed charges 3.5 5.37 Technical (Hospital) Services ATENOLOL 25 MG TABLET RX-717 CDM 6370000100 HCPCS 250 RC 00093-0787-01 NDC inpatient 1 UN 5.65 5.65 CIGNA 62308 [3081051] CIGNA STATE OF WYOMING [308105107] 4.47 percent of total billed charges 3.5 5.37 Technical (Hospital) Services ATENOLOL 25 MG TABLET RX-717 CDM 6370000100 HCPCS 250 RC 00093-0787-01 NDC inpatient 1 UN 5.65 5.65 BLUE CROSS BLUE SHIELD WELLMARK SB889 [3081026] BCBS WYOMING [308102603] 5.37 percent of total billed charges 3.5 5.37 Technical (Hospital) Services ATENOLOL 25 MG TABLET RX-717 CDM 6370000100 HCPCS 250 RC 00093-0787-01 NDC inpatient 1 UN 5.65 5.65 UNITED HEALTHCARE (COMMERCIAL) [3081199] UNITED HEALTHCARE 87726 [308119901] 3.5 percent of total billed charges 3.5 5.37 Technical (Hospital) Services ATENOLOL 25 MG TABLET RX-717 CDM 6370000100 HCPCS 250 RC 00093-0787-01 NDC inpatient 1 UN 5.65 5.65 MULTIPLAN INC 34080 [3081285] MULTIPLAN INC [308128501] 5.37 percent of total billed charges 3.5 5.37 Technical (Hospital) Services ATENOLOL 25 MG TABLET RX-717 CDM 6370000100 HCPCS 250 RC 00093-0787-01 NDC inpatient 1 UN 5.65 5.65 HEALTHPARTNERS SX009 HEALTHPARTNERS 4.47 percent of total billed charges 3.5 5.37 Technical (Hospital) Services ATENOLOL 25 MG TABLET RX-717 CDM 6370000100 HCPCS 250 RC 00093-0787-01 NDC inpatient 1 UN 5.65 5.65 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES PPO [308136801] 4.47 percent of total billed charges 3.5 5.37 Technical (Hospital) Services ATENOLOL 25 MG TABLET RX-717 CDM 6370000100 HCPCS 250 RC 00093-0787-01 NDC inpatient 1 UN 5.65 5.65 MEDICA (COMMERCIAL) 94265 [3081118] MEDICA CLAIMS [308111801] 5.09 percent of total billed charges 3.5 5.37 Technical (Hospital) Services ATENOLOL 25 MG TABLET RX-717 CDM 6370000100 HCPCS 250 RC 00093-0787-01 NDC outpatient 1 UN 5.65 5.65 MULTIPLAN INC 34080 [3081285] MULTIPLAN INC [308128501] 5.37 percent of total billed charges 3.5 5.37 Technical (Hospital) Services ATENOLOL 25 MG TABLET RX-717 CDM 6370000100 HCPCS 250 RC 00093-0787-01 NDC outpatient 1 UN 5.65 5.65 CIGNA 62308 [3081051] CIGNA 62308 [308105105] 4.52 percent of total billed charges 3.5 5.37 Technical (Hospital) Services ATENOLOL 25 MG TABLET RX-717 CDM 6370000100 HCPCS 250 RC 00093-0787-01 NDC outpatient 1 UN 5.65 5.65 CIGNA 62308 [3081051] CIGNA STATE OF WYOMING [308105107] 4.52 percent of total billed charges 3.5 5.37 Technical (Hospital) Services ATENOLOL 25 MG TABLET RX-717 CDM 6370000100 HCPCS 250 RC 00093-0787-01 NDC outpatient 1 UN 5.65 5.65 MEDICA (COMMERCIAL) 94265 [3081118] MEDICA CLAIMS [308111801] 5.09 percent of total billed charges 3.5 5.37 Technical (Hospital) Services ATENOLOL 25 MG TABLET RX-717 CDM 6370000100 HCPCS 250 RC 00093-0787-01 NDC outpatient 1 UN 5.65 5.65 UNITED HEALTHCARE (COMMERCIAL) [3081199] UNITED HEALTHCARE 87726 [308119901] 3.5 percent of total billed charges 3.5 5.37 Technical (Hospital) Services ATENOLOL 25 MG TABLET RX-717 CDM 6370000100 HCPCS 250 RC 00093-0787-01 NDC outpatient 1 UN 5.65 5.65 BLUE CROSS BLUE SHIELD WELLMARK SB889 [3081026] BCBS WYOMING [308102603] 5.37 percent of total billed charges 3.5 5.37 Technical (Hospital) Services ATENOLOL 25 MG TABLET RX-717 CDM 6370000100 HCPCS 250 RC 00093-0787-01 NDC outpatient 1 UN 5.65 5.65 HEALTHPARTNERS SX009 HEALTHPARTNERS 4.52 percent of total billed charges 3.5 5.37 Technical (Hospital) Services ATENOLOL 25 MG TABLET RX-717 CDM 6370000100 HCPCS 250 RC 00093-0787-01 NDC outpatient 1 UN 5.65 5.65 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES PPO [308136801] 4.52 percent of total billed charges 3.5 5.37 Technical (Hospital) Services ATENOLOL 25 MG TABLET RX-717 CDM 6370000100 HCPCS 250 RC 00093-0787-01 NDC outpatient 1 UN 5.65 5.65 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES HDHP [308136802] 4.52 percent of total billed charges 3.5 5.37 Technical (Hospital) Services ATENOLOL 25 MG TABLET RX-717 CDM 6370000100 HCPCS 250 RC 00093-0787-01 NDC outpatient 1 UN 5.65 5.65 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES EPO [308136803] 4.52 percent of total billed charges 3.5 5.37 Technical (Hospital) Services ATENOLOL 50 MG TABLET RX-718 CDM 6370000100 HCPCS 250 RC 00093-0752-01 NDC outpatient 1 UN 5.66 5.66 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES HDHP [308136802] 4.53 percent of total billed charges 3.51 5.38 Technical (Hospital) Services ATENOLOL 50 MG TABLET RX-718 CDM 6370000100 HCPCS 250 RC 00093-0752-01 NDC outpatient 1 UN 5.66 5.66 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES PPO [308136801] 4.53 percent of total billed charges 3.51 5.38 Technical (Hospital) Services ATENOLOL 50 MG TABLET RX-718 CDM 6370000100 HCPCS 250 RC 00093-0752-01 NDC outpatient 1 UN 5.66 5.66 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES EPO [308136803] 4.53 percent of total billed charges 3.51 5.38 Technical (Hospital) Services ATENOLOL 50 MG TABLET RX-718 CDM 6370000100 HCPCS 250 RC 00093-0752-01 NDC outpatient 1 UN 5.66 5.66 UNITED HEALTHCARE (COMMERCIAL) [3081199] UNITED HEALTHCARE 87726 [308119901] 3.51 percent of total billed charges 3.51 5.38 Technical (Hospital) Services ATENOLOL 50 MG TABLET RX-718 CDM 6370000100 HCPCS 250 RC 00093-0752-01 NDC outpatient 1 UN 5.66 5.66 HEALTHPARTNERS SX009 HEALTHPARTNERS 4.53 percent of total billed charges 3.51 5.38 Technical (Hospital) Services ATENOLOL 50 MG TABLET RX-718 CDM 6370000100 HCPCS 250 RC 00093-0752-01 NDC outpatient 1 UN 5.66 5.66 CIGNA 62308 [3081051] CIGNA 62308 [308105105] 4.53 percent of total billed charges 3.51 5.38 Technical (Hospital) Services ATENOLOL 50 MG TABLET RX-718 CDM 6370000100 HCPCS 250 RC 00093-0752-01 NDC outpatient 1 UN 5.66 5.66 CIGNA 62308 [3081051] CIGNA STATE OF WYOMING [308105107] 4.53 percent of total billed charges 3.51 5.38 Technical (Hospital) Services ATENOLOL 50 MG TABLET RX-718 CDM 6370000100 HCPCS 250 RC 00093-0752-01 NDC outpatient 1 UN 5.66 5.66 MULTIPLAN INC 34080 [3081285] MULTIPLAN INC [308128501] 5.38 percent of total billed charges 3.51 5.38 Technical (Hospital) Services ATENOLOL 50 MG TABLET RX-718 CDM 6370000100 HCPCS 250 RC 00093-0752-01 NDC outpatient 1 UN 5.66 5.66 MEDICA (COMMERCIAL) 94265 [3081118] MEDICA CLAIMS [308111801] 5.09 percent of total billed charges 3.51 5.38 Technical (Hospital) Services ATENOLOL 50 MG TABLET RX-718 CDM 6370000100 HCPCS 250 RC 00093-0752-01 NDC outpatient 1 UN 5.66 5.66 BLUE CROSS BLUE SHIELD WELLMARK SB889 [3081026] BCBS WYOMING [308102603] 5.38 percent of total billed charges 3.51 5.38 Technical (Hospital) Services ATENOLOL 50 MG TABLET RX-718 CDM 6370000100 HCPCS 250 RC 00093-0752-01 NDC inpatient 1 UN 5.66 5.66 BLUE CROSS BLUE SHIELD WELLMARK SB889 [3081026] BCBS WYOMING [308102603] 5.38 percent of total billed charges 3.51 5.38 Technical (Hospital) Services ATENOLOL 50 MG TABLET RX-718 CDM 6370000100 HCPCS 250 RC 00093-0752-01 NDC inpatient 1 UN 5.66 5.66 CIGNA 62308 [3081051] CIGNA 62308 [308105105] 4.48 percent of total billed charges 3.51 5.38 Technical (Hospital) Services ATENOLOL 50 MG TABLET RX-718 CDM 6370000100 HCPCS 250 RC 00093-0752-01 NDC inpatient 1 UN 5.66 5.66 CIGNA 62308 [3081051] CIGNA STATE OF WYOMING [308105107] 4.48 percent of total billed charges 3.51 5.38 Technical (Hospital) Services ATENOLOL 50 MG TABLET RX-718 CDM 6370000100 HCPCS 250 RC 00093-0752-01 NDC inpatient 1 UN 5.66 5.66 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES EPO [308136803] 4.48 percent of total billed charges 3.51 5.38 Technical (Hospital) Services ATENOLOL 50 MG TABLET RX-718 CDM 6370000100 HCPCS 250 RC 00093-0752-01 NDC inpatient 1 UN 5.66 5.66 UNITED HEALTHCARE (COMMERCIAL) [3081199] UNITED HEALTHCARE 87726 [308119901] 3.51 percent of total billed charges 3.51 5.38 Technical (Hospital) Services ATENOLOL 50 MG TABLET RX-718 CDM 6370000100 HCPCS 250 RC 00093-0752-01 NDC inpatient 1 UN 5.66 5.66 HEALTHPARTNERS SX009 HEALTHPARTNERS 4.48 percent of total billed charges 3.51 5.38 Technical (Hospital) Services ATENOLOL 50 MG TABLET RX-718 CDM 6370000100 HCPCS 250 RC 00093-0752-01 NDC inpatient 1 UN 5.66 5.66 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES HDHP [308136802] 4.48 percent of total billed charges 3.51 5.38 Technical (Hospital) Services ATENOLOL 50 MG TABLET RX-718 CDM 6370000100 HCPCS 250 RC 00093-0752-01 NDC inpatient 1 UN 5.66 5.66 MULTIPLAN INC 34080 [3081285] MULTIPLAN INC [308128501] 5.38 percent of total billed charges 3.51 5.38 Technical (Hospital) Services ATENOLOL 50 MG TABLET RX-718 CDM 6370000100 HCPCS 250 RC 00093-0752-01 NDC inpatient 1 UN 5.66 5.66 MEDICA (COMMERCIAL) 94265 [3081118] MEDICA CLAIMS [308111801] 5.09 percent of total billed charges 3.51 5.38 Technical (Hospital) Services ATENOLOL 50 MG TABLET RX-718 CDM 6370000100 HCPCS 250 RC 00093-0752-01 NDC inpatient 1 UN 5.66 5.66 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES PPO [308136801] 4.48 percent of total billed charges 3.51 5.38 Technical (Hospital) Services SILVER SULFADIAZINE 1 % TOPICAL CREAM RX-7224 CDM 6370000100 HCPCS 250 RC 61570-0131-40 NDC inpatient 1 GR 5.74 5.74 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES PPO [308136801] 4.54 percent of total billed charges 3.56 5.45 Technical (Hospital) Services SILVER SULFADIAZINE 1 % TOPICAL CREAM RX-7224 CDM 6370000100 HCPCS 250 RC 61570-0131-40 NDC inpatient 1 GR 5.74 5.74 MEDICA (COMMERCIAL) 94265 [3081118] MEDICA CLAIMS [308111801] 5.17 percent of total billed charges 3.56 5.45 Technical (Hospital) Services SILVER SULFADIAZINE 1 % TOPICAL CREAM RX-7224 CDM 6370000100 HCPCS 250 RC 61570-0131-40 NDC inpatient 1 GR 5.74 5.74 HEALTHPARTNERS SX009 HEALTHPARTNERS 4.54 percent of total billed charges 3.56 5.45 Technical (Hospital) Services SILVER SULFADIAZINE 1 % TOPICAL CREAM RX-7224 CDM 6370000100 HCPCS 250 RC 61570-0131-40 NDC inpatient 1 GR 5.74 5.74 UNITED HEALTHCARE (COMMERCIAL) [3081199] UNITED HEALTHCARE 87726 [308119901] 3.56 percent of total billed charges 3.56 5.45 Technical (Hospital) Services SILVER SULFADIAZINE 1 % TOPICAL CREAM RX-7224 CDM 6370000100 HCPCS 250 RC 61570-0131-40 NDC inpatient 1 GR 5.74 5.74 BLUE CROSS BLUE SHIELD WELLMARK SB889 [3081026] BCBS WYOMING [308102603] 5.45 percent of total billed charges 3.56 5.45 Technical (Hospital) Services SILVER SULFADIAZINE 1 % TOPICAL CREAM RX-7224 CDM 6370000100 HCPCS 250 RC 61570-0131-40 NDC inpatient 1 GR 5.74 5.74 CIGNA 62308 [3081051] CIGNA 62308 [308105105] 4.54 percent of total billed charges 3.56 5.45 Technical (Hospital) Services SILVER SULFADIAZINE 1 % TOPICAL CREAM RX-7224 CDM 6370000100 HCPCS 250 RC 61570-0131-40 NDC inpatient 1 GR 5.74 5.74 CIGNA 62308 [3081051] CIGNA STATE OF WYOMING [308105107] 4.54 percent of total billed charges 3.56 5.45 Technical (Hospital) Services SILVER SULFADIAZINE 1 % TOPICAL CREAM RX-7224 CDM 6370000100 HCPCS 250 RC 61570-0131-40 NDC inpatient 1 GR 5.74 5.74 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES EPO [308136803] 4.54 percent of total billed charges 3.56 5.45 Technical (Hospital) Services SILVER SULFADIAZINE 1 % TOPICAL CREAM RX-7224 CDM 6370000100 HCPCS 250 RC 61570-0131-40 NDC inpatient 1 GR 5.74 5.74 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES HDHP [308136802] 4.54 percent of total billed charges 3.56 5.45 Technical (Hospital) Services SILVER SULFADIAZINE 1 % TOPICAL CREAM RX-7224 CDM 6370000100 HCPCS 250 RC 61570-0131-40 NDC inpatient 1 GR 5.74 5.74 MULTIPLAN INC 34080 [3081285] MULTIPLAN INC [308128501] 5.45 percent of total billed charges 3.56 5.45 Technical (Hospital) Services SILVER SULFADIAZINE 1 % TOPICAL CREAM RX-7224 CDM 6370000100 HCPCS 250 RC 61570-0131-40 NDC outpatient 1 GR 5.74 5.74 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES EPO [308136803] 4.59 percent of total billed charges 3.56 5.45 Technical (Hospital) Services SILVER SULFADIAZINE 1 % TOPICAL CREAM RX-7224 CDM 6370000100 HCPCS 250 RC 61570-0131-40 NDC outpatient 1 GR 5.74 5.74 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES HDHP [308136802] 4.59 percent of total billed charges 3.56 5.45 Technical (Hospital) Services SILVER SULFADIAZINE 1 % TOPICAL CREAM RX-7224 CDM 6370000100 HCPCS 250 RC 61570-0131-40 NDC outpatient 1 GR 5.74 5.74 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES PPO [308136801] 4.59 percent of total billed charges 3.56 5.45 Technical (Hospital) Services SILVER SULFADIAZINE 1 % TOPICAL CREAM RX-7224 CDM 6370000100 HCPCS 250 RC 61570-0131-40 NDC outpatient 1 GR 5.74 5.74 HEALTHPARTNERS SX009 HEALTHPARTNERS 4.59 percent of total billed charges 3.56 5.45 Technical (Hospital) Services SILVER SULFADIAZINE 1 % TOPICAL CREAM RX-7224 CDM 6370000100 HCPCS 250 RC 61570-0131-40 NDC outpatient 1 GR 5.74 5.74 UNITED HEALTHCARE (COMMERCIAL) [3081199] UNITED HEALTHCARE 87726 [308119901] 3.56 percent of total billed charges 3.56 5.45 Technical (Hospital) Services SILVER SULFADIAZINE 1 % TOPICAL CREAM RX-7224 CDM 6370000100 HCPCS 250 RC 61570-0131-40 NDC outpatient 1 GR 5.74 5.74 MULTIPLAN INC 34080 [3081285] MULTIPLAN INC [308128501] 5.45 percent of total billed charges 3.56 5.45 Technical (Hospital) Services SILVER SULFADIAZINE 1 % TOPICAL CREAM RX-7224 CDM 6370000100 HCPCS 250 RC 61570-0131-40 NDC outpatient 1 GR 5.74 5.74 CIGNA 62308 [3081051] CIGNA 62308 [308105105] 4.59 percent of total billed charges 3.56 5.45 Technical (Hospital) Services SILVER SULFADIAZINE 1 % TOPICAL CREAM RX-7224 CDM 6370000100 HCPCS 250 RC 61570-0131-40 NDC outpatient 1 GR 5.74 5.74 CIGNA 62308 [3081051] CIGNA STATE OF WYOMING [308105107] 4.59 percent of total billed charges 3.56 5.45 Technical (Hospital) Services SILVER SULFADIAZINE 1 % TOPICAL CREAM RX-7224 CDM 6370000100 HCPCS 250 RC 61570-0131-40 NDC outpatient 1 GR 5.74 5.74 MEDICA (COMMERCIAL) 94265 [3081118] MEDICA CLAIMS [308111801] 5.17 percent of total billed charges 3.56 5.45 Technical (Hospital) Services SILVER SULFADIAZINE 1 % TOPICAL CREAM RX-7224 CDM 6370000100 HCPCS 250 RC 61570-0131-40 NDC outpatient 1 GR 5.74 5.74 BLUE CROSS BLUE SHIELD WELLMARK SB889 [3081026] BCBS WYOMING [308102603] 5.45 percent of total billed charges 3.56 5.45 Technical (Hospital) Services SODIUM BICARBONATE 650 MG TABLET RX-7313 CDM 6370000100 HCPCS 250 RC 00223-1721-01 NDC outpatient 1 UN 5.68 5.68 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES EPO [308136803] 4.54 percent of total billed charges 3.52 5.4 Technical (Hospital) Services SODIUM BICARBONATE 650 MG TABLET RX-7313 CDM 6370000100 HCPCS 250 RC 00223-1721-01 NDC outpatient 1 UN 5.68 5.68 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES HDHP [308136802] 4.54 percent of total billed charges 3.52 5.4 Technical (Hospital) Services SODIUM BICARBONATE 650 MG TABLET RX-7313 CDM 6370000100 HCPCS 250 RC 00223-1721-01 NDC outpatient 1 UN 5.68 5.68 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES PPO [308136801] 4.54 percent of total billed charges 3.52 5.4 Technical (Hospital) Services SODIUM BICARBONATE 650 MG TABLET RX-7313 CDM 6370000100 HCPCS 250 RC 00223-1721-01 NDC outpatient 1 UN 5.68 5.68 MULTIPLAN INC 34080 [3081285] MULTIPLAN INC [308128501] 5.4 percent of total billed charges 3.52 5.4 Technical (Hospital) Services SODIUM BICARBONATE 650 MG TABLET RX-7313 CDM 6370000100 HCPCS 250 RC 00223-1721-01 NDC outpatient 1 UN 5.68 5.68 CIGNA 62308 [3081051] CIGNA 62308 [308105105] 4.54 percent of total billed charges 3.52 5.4 Technical (Hospital) Services SODIUM BICARBONATE 650 MG TABLET RX-7313 CDM 6370000100 HCPCS 250 RC 00223-1721-01 NDC outpatient 1 UN 5.68 5.68 CIGNA 62308 [3081051] CIGNA STATE OF WYOMING [308105107] 4.54 percent of total billed charges 3.52 5.4 Technical (Hospital) Services SODIUM BICARBONATE 650 MG TABLET RX-7313 CDM 6370000100 HCPCS 250 RC 00223-1721-01 NDC outpatient 1 UN 5.68 5.68 MEDICA (COMMERCIAL) 94265 [3081118] MEDICA CLAIMS [308111801] 5.11 percent of total billed charges 3.52 5.4 Technical (Hospital) Services SODIUM BICARBONATE 650 MG TABLET RX-7313 CDM 6370000100 HCPCS 250 RC 00223-1721-01 NDC outpatient 1 UN 5.68 5.68 HEALTHPARTNERS SX009 HEALTHPARTNERS 4.54 percent of total billed charges 3.52 5.4 Technical (Hospital) Services SODIUM BICARBONATE 650 MG TABLET RX-7313 CDM 6370000100 HCPCS 250 RC 00223-1721-01 NDC outpatient 1 UN 5.68 5.68 UNITED HEALTHCARE (COMMERCIAL) [3081199] UNITED HEALTHCARE 87726 [308119901] 3.52 percent of total billed charges 3.52 5.4 Technical (Hospital) Services SODIUM BICARBONATE 650 MG TABLET RX-7313 CDM 6370000100 HCPCS 250 RC 00223-1721-01 NDC outpatient 1 UN 5.68 5.68 BLUE CROSS BLUE SHIELD WELLMARK SB889 [3081026] BCBS WYOMING [308102603] 5.4 percent of total billed charges 3.52 5.4 Technical (Hospital) Services SODIUM BICARBONATE 650 MG TABLET RX-7313 CDM 6370000100 HCPCS 250 RC 00223-1721-01 NDC inpatient 1 UN 5.68 5.68 MULTIPLAN INC 34080 [3081285] MULTIPLAN INC [308128501] 5.4 percent of total billed charges 3.52 5.4 Technical (Hospital) Services SODIUM BICARBONATE 650 MG TABLET RX-7313 CDM 6370000100 HCPCS 250 RC 00223-1721-01 NDC inpatient 1 UN 5.68 5.68 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES HDHP [308136802] 4.5 percent of total billed charges 3.52 5.4 Technical (Hospital) Services SODIUM BICARBONATE 650 MG TABLET RX-7313 CDM 6370000100 HCPCS 250 RC 00223-1721-01 NDC inpatient 1 UN 5.68 5.68 BLUE CROSS BLUE SHIELD WELLMARK SB889 [3081026] BCBS WYOMING [308102603] 5.4 percent of total billed charges 3.52 5.4 Technical (Hospital) Services SODIUM BICARBONATE 650 MG TABLET RX-7313 CDM 6370000100 HCPCS 250 RC 00223-1721-01 NDC inpatient 1 UN 5.68 5.68 UNITED HEALTHCARE (COMMERCIAL) [3081199] UNITED HEALTHCARE 87726 [308119901] 3.52 percent of total billed charges 3.52 5.4 Technical (Hospital) Services SODIUM BICARBONATE 650 MG TABLET RX-7313 CDM 6370000100 HCPCS 250 RC 00223-1721-01 NDC inpatient 1 UN 5.68 5.68 CIGNA 62308 [3081051] CIGNA 62308 [308105105] 4.5 percent of total billed charges 3.52 5.4 Technical (Hospital) Services SODIUM BICARBONATE 650 MG TABLET RX-7313 CDM 6370000100 HCPCS 250 RC 00223-1721-01 NDC inpatient 1 UN 5.68 5.68 CIGNA 62308 [3081051] CIGNA STATE OF WYOMING [308105107] 4.5 percent of total billed charges 3.52 5.4 Technical (Hospital) Services SODIUM BICARBONATE 650 MG TABLET RX-7313 CDM 6370000100 HCPCS 250 RC 00223-1721-01 NDC inpatient 1 UN 5.68 5.68 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES EPO [308136803] 4.5 percent of total billed charges 3.52 5.4 Technical (Hospital) Services SODIUM BICARBONATE 650 MG TABLET RX-7313 CDM 6370000100 HCPCS 250 RC 00223-1721-01 NDC inpatient 1 UN 5.68 5.68 HEALTHPARTNERS SX009 HEALTHPARTNERS 4.5 percent of total billed charges 3.52 5.4 Technical (Hospital) Services SODIUM BICARBONATE 650 MG TABLET RX-7313 CDM 6370000100 HCPCS 250 RC 00223-1721-01 NDC inpatient 1 UN 5.68 5.68 MEDICA (COMMERCIAL) 94265 [3081118] MEDICA CLAIMS [308111801] 5.11 percent of total billed charges 3.52 5.4 Technical (Hospital) Services SODIUM BICARBONATE 650 MG TABLET RX-7313 CDM 6370000100 HCPCS 250 RC 00223-1721-01 NDC inpatient 1 UN 5.68 5.68 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES PPO [308136801] 4.5 percent of total billed charges 3.52 5.4 Technical (Hospital) Services SPIRONOLACTONE 25 MG TABLET RX-7437 CDM 6370000100 HCPCS 250 RC 63739-0544-10 NDC inpatient 1 UN 5.85 5.85 MEDICA (COMMERCIAL) 94265 [3081118] MEDICA CLAIMS [308111801] 5.27 percent of total billed charges 3.63 5.56 Technical (Hospital) Services SPIRONOLACTONE 25 MG TABLET RX-7437 CDM 6370000100 HCPCS 250 RC 63739-0544-10 NDC inpatient 1 UN 5.85 5.85 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES PPO [308136801] 4.63 percent of total billed charges 3.63 5.56 Technical (Hospital) Services SPIRONOLACTONE 25 MG TABLET RX-7437 CDM 6370000100 HCPCS 250 RC 63739-0544-10 NDC inpatient 1 UN 5.85 5.85 MULTIPLAN INC 34080 [3081285] MULTIPLAN INC [308128501] 5.56 percent of total billed charges 3.63 5.56 Technical (Hospital) Services SPIRONOLACTONE 25 MG TABLET RX-7437 CDM 6370000100 HCPCS 250 RC 63739-0544-10 NDC inpatient 1 UN 5.85 5.85 BLUE CROSS BLUE SHIELD WELLMARK SB889 [3081026] BCBS WYOMING [308102603] 5.56 percent of total billed charges 3.63 5.56 Technical (Hospital) Services SPIRONOLACTONE 25 MG TABLET RX-7437 CDM 6370000100 HCPCS 250 RC 63739-0544-10 NDC inpatient 1 UN 5.85 5.85 HEALTHPARTNERS SX009 HEALTHPARTNERS 4.63 percent of total billed charges 3.63 5.56 Technical (Hospital) Services SPIRONOLACTONE 25 MG TABLET RX-7437 CDM 6370000100 HCPCS 250 RC 63739-0544-10 NDC inpatient 1 UN 5.85 5.85 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES HDHP [308136802] 4.63 percent of total billed charges 3.63 5.56 Technical (Hospital) Services SPIRONOLACTONE 25 MG TABLET RX-7437 CDM 6370000100 HCPCS 250 RC 63739-0544-10 NDC inpatient 1 UN 5.85 5.85 UNITED HEALTHCARE (COMMERCIAL) [3081199] UNITED HEALTHCARE 87726 [308119901] 3.63 percent of total billed charges 3.63 5.56 Technical (Hospital) Services SPIRONOLACTONE 25 MG TABLET RX-7437 CDM 6370000100 HCPCS 250 RC 63739-0544-10 NDC inpatient 1 UN 5.85 5.85 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES EPO [308136803] 4.63 percent of total billed charges 3.63 5.56 Technical (Hospital) Services SPIRONOLACTONE 25 MG TABLET RX-7437 CDM 6370000100 HCPCS 250 RC 63739-0544-10 NDC inpatient 1 UN 5.85 5.85 CIGNA 62308 [3081051] CIGNA 62308 [308105105] 4.63 percent of total billed charges 3.63 5.56 Technical (Hospital) Services SPIRONOLACTONE 25 MG TABLET RX-7437 CDM 6370000100 HCPCS 250 RC 63739-0544-10 NDC inpatient 1 UN 5.85 5.85 CIGNA 62308 [3081051] CIGNA STATE OF WYOMING [308105107] 4.63 percent of total billed charges 3.63 5.56 Technical (Hospital) Services SPIRONOLACTONE 25 MG TABLET RX-7437 CDM 6370000100 HCPCS 250 RC 63739-0544-10 NDC outpatient 1 UN 5.85 5.85 UNITED HEALTHCARE (COMMERCIAL) [3081199] UNITED HEALTHCARE 87726 [308119901] 3.63 percent of total billed charges 3.63 5.56 Technical (Hospital) Services SPIRONOLACTONE 25 MG TABLET RX-7437 CDM 6370000100 HCPCS 250 RC 63739-0544-10 NDC outpatient 1 UN 5.85 5.85 MULTIPLAN INC 34080 [3081285] MULTIPLAN INC [308128501] 5.56 percent of total billed charges 3.63 5.56 Technical (Hospital) Services SPIRONOLACTONE 25 MG TABLET RX-7437 CDM 6370000100 HCPCS 250 RC 63739-0544-10 NDC outpatient 1 UN 5.85 5.85 CIGNA 62308 [3081051] CIGNA 62308 [308105105] 4.68 percent of total billed charges 3.63 5.56 Technical (Hospital) Services SPIRONOLACTONE 25 MG TABLET RX-7437 CDM 6370000100 HCPCS 250 RC 63739-0544-10 NDC outpatient 1 UN 5.85 5.85 CIGNA 62308 [3081051] CIGNA STATE OF WYOMING [308105107] 4.68 percent of total billed charges 3.63 5.56 Technical (Hospital) Services SPIRONOLACTONE 25 MG TABLET RX-7437 CDM 6370000100 HCPCS 250 RC 63739-0544-10 NDC outpatient 1 UN 5.85 5.85 MEDICA (COMMERCIAL) 94265 [3081118] MEDICA CLAIMS [308111801] 5.27 percent of total billed charges 3.63 5.56 Technical (Hospital) Services SPIRONOLACTONE 25 MG TABLET RX-7437 CDM 6370000100 HCPCS 250 RC 63739-0544-10 NDC outpatient 1 UN 5.85 5.85 HEALTHPARTNERS SX009 HEALTHPARTNERS 4.68 percent of total billed charges 3.63 5.56 Technical (Hospital) Services SPIRONOLACTONE 25 MG TABLET RX-7437 CDM 6370000100 HCPCS 250 RC 63739-0544-10 NDC outpatient 1 UN 5.85 5.85 BLUE CROSS BLUE SHIELD WELLMARK SB889 [3081026] BCBS WYOMING [308102603] 5.56 percent of total billed charges 3.63 5.56 Technical (Hospital) Services SPIRONOLACTONE 25 MG TABLET RX-7437 CDM 6370000100 HCPCS 250 RC 63739-0544-10 NDC outpatient 1 UN 5.85 5.85 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES EPO [308136803] 4.68 percent of total billed charges 3.63 5.56 Technical (Hospital) Services SPIRONOLACTONE 25 MG TABLET RX-7437 CDM 6370000100 HCPCS 250 RC 63739-0544-10 NDC outpatient 1 UN 5.85 5.85 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES HDHP [308136802] 4.68 percent of total billed charges 3.63 5.56 Technical (Hospital) Services SPIRONOLACTONE 25 MG TABLET RX-7437 CDM 6370000100 HCPCS 250 RC 63739-0544-10 NDC outpatient 1 UN 5.85 5.85 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES PPO [308136801] 4.68 percent of total billed charges 3.63 5.56 Technical (Hospital) Services SULFAMETHOXAZOLE 400 MG-TRIMETHOPRIM 80 MG TABLET RX-7557 CDM 6370000100 HCPCS 250 RC 53746-0271-01 NDC inpatient 1 UN 5.81 5.81 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES PPO [308136801] 4.6 percent of total billed charges 3.6 5.52 Technical (Hospital) Services SULFAMETHOXAZOLE 400 MG-TRIMETHOPRIM 80 MG TABLET RX-7557 CDM 6370000100 HCPCS 250 RC 53746-0271-01 NDC inpatient 1 UN 5.81 5.81 MEDICA (COMMERCIAL) 94265 [3081118] MEDICA CLAIMS [308111801] 5.23 percent of total billed charges 3.6 5.52 Technical (Hospital) Services SULFAMETHOXAZOLE 400 MG-TRIMETHOPRIM 80 MG TABLET RX-7557 CDM 6370000100 HCPCS 250 RC 53746-0271-01 NDC inpatient 1 UN 5.81 5.81 BLUE CROSS BLUE SHIELD WELLMARK SB889 [3081026] BCBS WYOMING [308102603] 5.52 percent of total billed charges 3.6 5.52 Technical (Hospital) Services SULFAMETHOXAZOLE 400 MG-TRIMETHOPRIM 80 MG TABLET RX-7557 CDM 6370000100 HCPCS 250 RC 53746-0271-01 NDC inpatient 1 UN 5.81 5.81 MULTIPLAN INC 34080 [3081285] MULTIPLAN INC [308128501] 5.52 percent of total billed charges 3.6 5.52 Technical (Hospital) Services SULFAMETHOXAZOLE 400 MG-TRIMETHOPRIM 80 MG TABLET RX-7557 CDM 6370000100 HCPCS 250 RC 53746-0271-01 NDC inpatient 1 UN 5.81 5.81 CIGNA 62308 [3081051] CIGNA 62308 [308105105] 4.6 percent of total billed charges 3.6 5.52 Technical (Hospital) Services SULFAMETHOXAZOLE 400 MG-TRIMETHOPRIM 80 MG TABLET RX-7557 CDM 6370000100 HCPCS 250 RC 53746-0271-01 NDC inpatient 1 UN 5.81 5.81 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES EPO [308136803] 4.6 percent of total billed charges 3.6 5.52 Technical (Hospital) Services SULFAMETHOXAZOLE 400 MG-TRIMETHOPRIM 80 MG TABLET RX-7557 CDM 6370000100 HCPCS 250 RC 53746-0271-01 NDC inpatient 1 UN 5.81 5.81 CIGNA 62308 [3081051] CIGNA STATE OF WYOMING [308105107] 4.6 percent of total billed charges 3.6 5.52 Technical (Hospital) Services SULFAMETHOXAZOLE 400 MG-TRIMETHOPRIM 80 MG TABLET RX-7557 CDM 6370000100 HCPCS 250 RC 53746-0271-01 NDC inpatient 1 UN 5.81 5.81 UNITED HEALTHCARE (COMMERCIAL) [3081199] UNITED HEALTHCARE 87726 [308119901] 3.6 percent of total billed charges 3.6 5.52 Technical (Hospital) Services SULFAMETHOXAZOLE 400 MG-TRIMETHOPRIM 80 MG TABLET RX-7557 CDM 6370000100 HCPCS 250 RC 53746-0271-01 NDC inpatient 1 UN 5.81 5.81 HEALTHPARTNERS SX009 HEALTHPARTNERS 4.6 percent of total billed charges 3.6 5.52 Technical (Hospital) Services SULFAMETHOXAZOLE 400 MG-TRIMETHOPRIM 80 MG TABLET RX-7557 CDM 6370000100 HCPCS 250 RC 53746-0271-01 NDC inpatient 1 UN 5.81 5.81 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES HDHP [308136802] 4.6 percent of total billed charges 3.6 5.52 Technical (Hospital) Services SULFAMETHOXAZOLE 400 MG-TRIMETHOPRIM 80 MG TABLET RX-7557 CDM 6370000100 HCPCS 250 RC 53746-0271-01 NDC outpatient 1 UN 5.81 5.81 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES HDHP [308136802] 4.65 percent of total billed charges 3.6 5.52 Technical (Hospital) Services SULFAMETHOXAZOLE 400 MG-TRIMETHOPRIM 80 MG TABLET RX-7557 CDM 6370000100 HCPCS 250 RC 53746-0271-01 NDC outpatient 1 UN 5.81 5.81 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES EPO [308136803] 4.65 percent of total billed charges 3.6 5.52 Technical (Hospital) Services SULFAMETHOXAZOLE 400 MG-TRIMETHOPRIM 80 MG TABLET RX-7557 CDM 6370000100 HCPCS 250 RC 53746-0271-01 NDC outpatient 1 UN 5.81 5.81 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES PPO [308136801] 4.65 percent of total billed charges 3.6 5.52 Technical (Hospital) Services SULFAMETHOXAZOLE 400 MG-TRIMETHOPRIM 80 MG TABLET RX-7557 CDM 6370000100 HCPCS 250 RC 53746-0271-01 NDC outpatient 1 UN 5.81 5.81 UNITED HEALTHCARE (COMMERCIAL) [3081199] UNITED HEALTHCARE 87726 [308119901] 3.6 percent of total billed charges 3.6 5.52 Technical (Hospital) Services SULFAMETHOXAZOLE 400 MG-TRIMETHOPRIM 80 MG TABLET RX-7557 CDM 6370000100 HCPCS 250 RC 53746-0271-01 NDC outpatient 1 UN 5.81 5.81 CIGNA 62308 [3081051] CIGNA 62308 [308105105] 4.65 percent of total billed charges 3.6 5.52 Technical (Hospital) Services SULFAMETHOXAZOLE 400 MG-TRIMETHOPRIM 80 MG TABLET RX-7557 CDM 6370000100 HCPCS 250 RC 53746-0271-01 NDC outpatient 1 UN 5.81 5.81 CIGNA 62308 [3081051] CIGNA STATE OF WYOMING [308105107] 4.65 percent of total billed charges 3.6 5.52 Technical (Hospital) Services SULFAMETHOXAZOLE 400 MG-TRIMETHOPRIM 80 MG TABLET RX-7557 CDM 6370000100 HCPCS 250 RC 53746-0271-01 NDC outpatient 1 UN 5.81 5.81 MULTIPLAN INC 34080 [3081285] MULTIPLAN INC [308128501] 5.52 percent of total billed charges 3.6 5.52 Technical (Hospital) Services SULFAMETHOXAZOLE 400 MG-TRIMETHOPRIM 80 MG TABLET RX-7557 CDM 6370000100 HCPCS 250 RC 53746-0271-01 NDC outpatient 1 UN 5.81 5.81 MEDICA (COMMERCIAL) 94265 [3081118] MEDICA CLAIMS [308111801] 5.23 percent of total billed charges 3.6 5.52 Technical (Hospital) Services SULFAMETHOXAZOLE 400 MG-TRIMETHOPRIM 80 MG TABLET RX-7557 CDM 6370000100 HCPCS 250 RC 53746-0271-01 NDC outpatient 1 UN 5.81 5.81 HEALTHPARTNERS SX009 HEALTHPARTNERS 4.65 percent of total billed charges 3.6 5.52 Technical (Hospital) Services SULFAMETHOXAZOLE 400 MG-TRIMETHOPRIM 80 MG TABLET RX-7557 CDM 6370000100 HCPCS 250 RC 53746-0271-01 NDC outpatient 1 UN 5.81 5.81 BLUE CROSS BLUE SHIELD WELLMARK SB889 [3081026] BCBS WYOMING [308102603] 5.52 percent of total billed charges 3.6 5.52 Technical (Hospital) Services POTASSIUM CHLORIDE 20 MEQ/15 ML ORAL LIQUID RX-76913 CDM 6370000100 HCPCS 250 RC 00603-1542-58 NDC inpatient 473 ML 624.94 624.94 CIGNA 62308 [3081051] CIGNA 62308 [308105105] 494.83 percent of total billed charges 387.46 593.69 Technical (Hospital) Services POTASSIUM CHLORIDE 20 MEQ/15 ML ORAL LIQUID RX-76913 CDM 6370000100 HCPCS 250 RC 00603-1542-58 NDC inpatient 473 ML 624.94 624.94 CIGNA 62308 [3081051] CIGNA STATE OF WYOMING [308105107] 494.83 percent of total billed charges 387.46 593.69 Technical (Hospital) Services POTASSIUM CHLORIDE 20 MEQ/15 ML ORAL LIQUID RX-76913 CDM 6370000100 HCPCS 250 RC 00603-1542-58 NDC inpatient 473 ML 624.94 624.94 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES EPO [308136803] 494.83 percent of total billed charges 387.46 593.69 Technical (Hospital) Services POTASSIUM CHLORIDE 20 MEQ/15 ML ORAL LIQUID RX-76913 CDM 6370000100 HCPCS 250 RC 00603-1542-58 NDC inpatient 473 ML 624.94 624.94 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES HDHP [308136802] 494.83 percent of total billed charges 387.46 593.69 Technical (Hospital) Services POTASSIUM CHLORIDE 20 MEQ/15 ML ORAL LIQUID RX-76913 CDM 6370000100 HCPCS 250 RC 00603-1542-58 NDC inpatient 473 ML 624.94 624.94 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES PPO [308136801] 494.83 percent of total billed charges 387.46 593.69 Technical (Hospital) Services POTASSIUM CHLORIDE 20 MEQ/15 ML ORAL LIQUID RX-76913 CDM 6370000100 HCPCS 250 RC 00603-1542-58 NDC inpatient 473 ML 624.94 624.94 UNITED HEALTHCARE (COMMERCIAL) [3081199] UNITED HEALTHCARE 87726 [308119901] 387.46 percent of total billed charges 387.46 593.69 Technical (Hospital) Services POTASSIUM CHLORIDE 20 MEQ/15 ML ORAL LIQUID RX-76913 CDM 6370000100 HCPCS 250 RC 00603-1542-58 NDC inpatient 473 ML 624.94 624.94 BLUE CROSS BLUE SHIELD WELLMARK SB889 [3081026] BCBS WYOMING [308102603] 593.69 percent of total billed charges 387.46 593.69 Technical (Hospital) Services POTASSIUM CHLORIDE 20 MEQ/15 ML ORAL LIQUID RX-76913 CDM 6370000100 HCPCS 250 RC 00603-1542-58 NDC inpatient 473 ML 624.94 624.94 MEDICA (COMMERCIAL) 94265 [3081118] MEDICA CLAIMS [308111801] 562.45 percent of total billed charges 387.46 593.69 Technical (Hospital) Services POTASSIUM CHLORIDE 20 MEQ/15 ML ORAL LIQUID RX-76913 CDM 6370000100 HCPCS 250 RC 00603-1542-58 NDC inpatient 473 ML 624.94 624.94 MULTIPLAN INC 34080 [3081285] MULTIPLAN INC [308128501] 593.69 percent of total billed charges 387.46 593.69 Technical (Hospital) Services POTASSIUM CHLORIDE 20 MEQ/15 ML ORAL LIQUID RX-76913 CDM 6370000100 HCPCS 250 RC 00603-1542-58 NDC inpatient 473 ML 624.94 624.94 HEALTHPARTNERS SX009 HEALTHPARTNERS 494.83 percent of total billed charges 387.46 593.69 Technical (Hospital) Services POTASSIUM CHLORIDE 20 MEQ/15 ML ORAL LIQUID RX-76913 CDM 6370000100 HCPCS 250 RC 00603-1542-58 NDC outpatient 473 ML 624.94 624.94 CIGNA 62308 [3081051] CIGNA 62308 [308105105] 499.95 percent of total billed charges 387.46 593.69 Technical (Hospital) Services POTASSIUM CHLORIDE 20 MEQ/15 ML ORAL LIQUID RX-76913 CDM 6370000100 HCPCS 250 RC 00603-1542-58 NDC outpatient 473 ML 624.94 624.94 CIGNA 62308 [3081051] CIGNA STATE OF WYOMING [308105107] 499.95 percent of total billed charges 387.46 593.69 Technical (Hospital) Services POTASSIUM CHLORIDE 20 MEQ/15 ML ORAL LIQUID RX-76913 CDM 6370000100 HCPCS 250 RC 00603-1542-58 NDC outpatient 473 ML 624.94 624.94 MULTIPLAN INC 34080 [3081285] MULTIPLAN INC [308128501] 593.69 percent of total billed charges 387.46 593.69 Technical (Hospital) Services POTASSIUM CHLORIDE 20 MEQ/15 ML ORAL LIQUID RX-76913 CDM 6370000100 HCPCS 250 RC 00603-1542-58 NDC outpatient 473 ML 624.94 624.94 MEDICA (COMMERCIAL) 94265 [3081118] MEDICA CLAIMS [308111801] 562.45 percent of total billed charges 387.46 593.69 Technical (Hospital) Services POTASSIUM CHLORIDE 20 MEQ/15 ML ORAL LIQUID RX-76913 CDM 6370000100 HCPCS 250 RC 00603-1542-58 NDC outpatient 473 ML 624.94 624.94 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES EPO [308136803] 499.95 percent of total billed charges 387.46 593.69 Technical (Hospital) Services POTASSIUM CHLORIDE 20 MEQ/15 ML ORAL LIQUID RX-76913 CDM 6370000100 HCPCS 250 RC 00603-1542-58 NDC outpatient 473 ML 624.94 624.94 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES HDHP [308136802] 499.95 percent of total billed charges 387.46 593.69 Technical (Hospital) Services POTASSIUM CHLORIDE 20 MEQ/15 ML ORAL LIQUID RX-76913 CDM 6370000100 HCPCS 250 RC 00603-1542-58 NDC outpatient 473 ML 624.94 624.94 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES PPO [308136801] 499.95 percent of total billed charges 387.46 593.69 Technical (Hospital) Services POTASSIUM CHLORIDE 20 MEQ/15 ML ORAL LIQUID RX-76913 CDM 6370000100 HCPCS 250 RC 00603-1542-58 NDC outpatient 473 ML 624.94 624.94 UNITED HEALTHCARE (COMMERCIAL) [3081199] UNITED HEALTHCARE 87726 [308119901] 387.46 percent of total billed charges 387.46 593.69 Technical (Hospital) Services POTASSIUM CHLORIDE 20 MEQ/15 ML ORAL LIQUID RX-76913 CDM 6370000100 HCPCS 250 RC 00603-1542-58 NDC outpatient 473 ML 624.94 624.94 BLUE CROSS BLUE SHIELD WELLMARK SB889 [3081026] BCBS WYOMING [308102603] 593.69 percent of total billed charges 387.46 593.69 Technical (Hospital) Services POTASSIUM CHLORIDE 20 MEQ/15 ML ORAL LIQUID RX-76913 CDM 6370000100 HCPCS 250 RC 00603-1542-58 NDC outpatient 473 ML 624.94 624.94 HEALTHPARTNERS SX009 HEALTHPARTNERS 499.95 percent of total billed charges 387.46 593.69 Technical (Hospital) Services TEMAZEPAM 15 MG CAPSULE RX-7753 CDM 6370000100 HCPCS 250 RC 00378-4010-01 NDC inpatient 1 UN 5.71 5.71 BLUE CROSS BLUE SHIELD WELLMARK SB889 [3081026] BCBS WYOMING [308102603] 5.42 percent of total billed charges 3.54 5.42 Technical (Hospital) Services TEMAZEPAM 15 MG CAPSULE RX-7753 CDM 6370000100 HCPCS 250 RC 00378-4010-01 NDC inpatient 1 UN 5.71 5.71 UNITED HEALTHCARE (COMMERCIAL) [3081199] UNITED HEALTHCARE 87726 [308119901] 3.54 percent of total billed charges 3.54 5.42 Technical (Hospital) Services TEMAZEPAM 15 MG CAPSULE RX-7753 CDM 6370000100 HCPCS 250 RC 00378-4010-01 NDC inpatient 1 UN 5.71 5.71 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES HDHP [308136802] 4.52 percent of total billed charges 3.54 5.42 Technical (Hospital) Services TEMAZEPAM 15 MG CAPSULE RX-7753 CDM 6370000100 HCPCS 250 RC 00378-4010-01 NDC inpatient 1 UN 5.71 5.71 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES EPO [308136803] 4.52 percent of total billed charges 3.54 5.42 Technical (Hospital) Services TEMAZEPAM 15 MG CAPSULE RX-7753 CDM 6370000100 HCPCS 250 RC 00378-4010-01 NDC inpatient 1 UN 5.71 5.71 CIGNA 62308 [3081051] CIGNA 62308 [308105105] 4.52 percent of total billed charges 3.54 5.42 Technical (Hospital) Services TEMAZEPAM 15 MG CAPSULE RX-7753 CDM 6370000100 HCPCS 250 RC 00378-4010-01 NDC inpatient 1 UN 5.71 5.71 CIGNA 62308 [3081051] CIGNA STATE OF WYOMING [308105107] 4.52 percent of total billed charges 3.54 5.42 Technical (Hospital) Services TEMAZEPAM 15 MG CAPSULE RX-7753 CDM 6370000100 HCPCS 250 RC 00378-4010-01 NDC inpatient 1 UN 5.71 5.71 MULTIPLAN INC 34080 [3081285] MULTIPLAN INC [308128501] 5.42 percent of total billed charges 3.54 5.42 Technical (Hospital) Services TEMAZEPAM 15 MG CAPSULE RX-7753 CDM 6370000100 HCPCS 250 RC 00378-4010-01 NDC inpatient 1 UN 5.71 5.71 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES PPO [308136801] 4.52 percent of total billed charges 3.54 5.42 Technical (Hospital) Services TEMAZEPAM 15 MG CAPSULE RX-7753 CDM 6370000100 HCPCS 250 RC 00378-4010-01 NDC inpatient 1 UN 5.71 5.71 MEDICA (COMMERCIAL) 94265 [3081118] MEDICA CLAIMS [308111801] 5.14 percent of total billed charges 3.54 5.42 Technical (Hospital) Services TEMAZEPAM 15 MG CAPSULE RX-7753 CDM 6370000100 HCPCS 250 RC 00378-4010-01 NDC inpatient 1 UN 5.71 5.71 HEALTHPARTNERS SX009 HEALTHPARTNERS 4.52 percent of total billed charges 3.54 5.42 Technical (Hospital) Services TEMAZEPAM 15 MG CAPSULE RX-7753 CDM 6370000100 HCPCS 250 RC 00378-4010-01 NDC outpatient 1 UN 5.71 5.71 HEALTHPARTNERS SX009 HEALTHPARTNERS 4.57 percent of total billed charges 3.54 5.42 Technical (Hospital) Services TEMAZEPAM 15 MG CAPSULE RX-7753 CDM 6370000100 HCPCS 250 RC 00378-4010-01 NDC outpatient 1 UN 5.71 5.71 BLUE CROSS BLUE SHIELD WELLMARK SB889 [3081026] BCBS WYOMING [308102603] 5.42 percent of total billed charges 3.54 5.42 Technical (Hospital) Services TEMAZEPAM 15 MG CAPSULE RX-7753 CDM 6370000100 HCPCS 250 RC 00378-4010-01 NDC outpatient 1 UN 5.71 5.71 MEDICA (COMMERCIAL) 94265 [3081118] MEDICA CLAIMS [308111801] 5.14 percent of total billed charges 3.54 5.42 Technical (Hospital) Services TEMAZEPAM 15 MG CAPSULE RX-7753 CDM 6370000100 HCPCS 250 RC 00378-4010-01 NDC outpatient 1 UN 5.71 5.71 MULTIPLAN INC 34080 [3081285] MULTIPLAN INC [308128501] 5.42 percent of total billed charges 3.54 5.42 Technical (Hospital) Services TEMAZEPAM 15 MG CAPSULE RX-7753 CDM 6370000100 HCPCS 250 RC 00378-4010-01 NDC outpatient 1 UN 5.71 5.71 CIGNA 62308 [3081051] CIGNA 62308 [308105105] 4.57 percent of total billed charges 3.54 5.42 Technical (Hospital) Services TEMAZEPAM 15 MG CAPSULE RX-7753 CDM 6370000100 HCPCS 250 RC 00378-4010-01 NDC outpatient 1 UN 5.71 5.71 CIGNA 62308 [3081051] CIGNA STATE OF WYOMING [308105107] 4.57 percent of total billed charges 3.54 5.42 Technical (Hospital) Services TEMAZEPAM 15 MG CAPSULE RX-7753 CDM 6370000100 HCPCS 250 RC 00378-4010-01 NDC outpatient 1 UN 5.71 5.71 UNITED HEALTHCARE (COMMERCIAL) [3081199] UNITED HEALTHCARE 87726 [308119901] 3.54 percent of total billed charges 3.54 5.42 Technical (Hospital) Services TEMAZEPAM 15 MG CAPSULE RX-7753 CDM 6370000100 HCPCS 250 RC 00378-4010-01 NDC outpatient 1 UN 5.71 5.71 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES PPO [308136801] 4.57 percent of total billed charges 3.54 5.42 Technical (Hospital) Services TEMAZEPAM 15 MG CAPSULE RX-7753 CDM 6370000100 HCPCS 250 RC 00378-4010-01 NDC outpatient 1 UN 5.71 5.71 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES EPO [308136803] 4.57 percent of total billed charges 3.54 5.42 Technical (Hospital) Services TEMAZEPAM 15 MG CAPSULE RX-7753 CDM 6370000100 HCPCS 250 RC 00378-4010-01 NDC outpatient 1 UN 5.71 5.71 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES HDHP [308136802] 4.57 percent of total billed charges 3.54 5.42 Technical (Hospital) Services SITAGLIPTIN PHOSPHATE 100 MG TABLET RX-77617 CDM 6370000100 HCPCS 250 RC 00006-0277-31 NDC outpatient 1 UN 67.1 67.1 BLUE CROSS BLUE SHIELD WELLMARK SB889 [3081026] BCBS WYOMING [308102603] 63.75 percent of total billed charges 41.6 63.75 Technical (Hospital) Services SITAGLIPTIN PHOSPHATE 100 MG TABLET RX-77617 CDM 6370000100 HCPCS 250 RC 00006-0277-31 NDC outpatient 1 UN 67.1 67.1 MEDICA (COMMERCIAL) 94265 [3081118] MEDICA CLAIMS [308111801] 60.39 percent of total billed charges 41.6 63.75 Technical (Hospital) Services SITAGLIPTIN PHOSPHATE 100 MG TABLET RX-77617 CDM 6370000100 HCPCS 250 RC 00006-0277-31 NDC outpatient 1 UN 67.1 67.1 MULTIPLAN INC 34080 [3081285] MULTIPLAN INC [308128501] 63.75 percent of total billed charges 41.6 63.75 Technical (Hospital) Services SITAGLIPTIN PHOSPHATE 100 MG TABLET RX-77617 CDM 6370000100 HCPCS 250 RC 00006-0277-31 NDC outpatient 1 UN 67.1 67.1 CIGNA 62308 [3081051] CIGNA 62308 [308105105] 53.68 percent of total billed charges 41.6 63.75 Technical (Hospital) Services SITAGLIPTIN PHOSPHATE 100 MG TABLET RX-77617 CDM 6370000100 HCPCS 250 RC 00006-0277-31 NDC outpatient 1 UN 67.1 67.1 CIGNA 62308 [3081051] CIGNA STATE OF WYOMING [308105107] 53.68 percent of total billed charges 41.6 63.75 Technical (Hospital) Services SITAGLIPTIN PHOSPHATE 100 MG TABLET RX-77617 CDM 6370000100 HCPCS 250 RC 00006-0277-31 NDC outpatient 1 UN 67.1 67.1 UNITED HEALTHCARE (COMMERCIAL) [3081199] UNITED HEALTHCARE 87726 [308119901] 41.6 percent of total billed charges 41.6 63.75 Technical (Hospital) Services SITAGLIPTIN PHOSPHATE 100 MG TABLET RX-77617 CDM 6370000100 HCPCS 250 RC 00006-0277-31 NDC outpatient 1 UN 67.1 67.1 HEALTHPARTNERS SX009 HEALTHPARTNERS 53.68 percent of total billed charges 41.6 63.75 Technical (Hospital) Services SITAGLIPTIN PHOSPHATE 100 MG TABLET RX-77617 CDM 6370000100 HCPCS 250 RC 00006-0277-31 NDC outpatient 1 UN 67.1 67.1 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES HDHP [308136802] 53.68 percent of total billed charges 41.6 63.75 Technical (Hospital) Services SITAGLIPTIN PHOSPHATE 100 MG TABLET RX-77617 CDM 6370000100 HCPCS 250 RC 00006-0277-31 NDC outpatient 1 UN 67.1 67.1 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES PPO [308136801] 53.68 percent of total billed charges 41.6 63.75 Technical (Hospital) Services SITAGLIPTIN PHOSPHATE 100 MG TABLET RX-77617 CDM 6370000100 HCPCS 250 RC 00006-0277-31 NDC outpatient 1 UN 67.1 67.1 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES EPO [308136803] 53.68 percent of total billed charges 41.6 63.75 Technical (Hospital) Services SITAGLIPTIN PHOSPHATE 100 MG TABLET RX-77617 CDM 6370000100 HCPCS 250 RC 00006-0277-31 NDC inpatient 1 UN 67.1 67.1 MULTIPLAN INC 34080 [3081285] MULTIPLAN INC [308128501] 63.75 percent of total billed charges 41.6 63.75 Technical (Hospital) Services SITAGLIPTIN PHOSPHATE 100 MG TABLET RX-77617 CDM 6370000100 HCPCS 250 RC 00006-0277-31 NDC inpatient 1 UN 67.1 67.1 UNITED HEALTHCARE (COMMERCIAL) [3081199] UNITED HEALTHCARE 87726 [308119901] 41.6 percent of total billed charges 41.6 63.75 Technical (Hospital) Services SITAGLIPTIN PHOSPHATE 100 MG TABLET RX-77617 CDM 6370000100 HCPCS 250 RC 00006-0277-31 NDC inpatient 1 UN 67.1 67.1 BLUE CROSS BLUE SHIELD WELLMARK SB889 [3081026] BCBS WYOMING [308102603] 63.75 percent of total billed charges 41.6 63.75 Technical (Hospital) Services SITAGLIPTIN PHOSPHATE 100 MG TABLET RX-77617 CDM 6370000100 HCPCS 250 RC 00006-0277-31 NDC inpatient 1 UN 67.1 67.1 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES HDHP [308136802] 53.13 percent of total billed charges 41.6 63.75 Technical (Hospital) Services SITAGLIPTIN PHOSPHATE 100 MG TABLET RX-77617 CDM 6370000100 HCPCS 250 RC 00006-0277-31 NDC inpatient 1 UN 67.1 67.1 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES EPO [308136803] 53.13 percent of total billed charges 41.6 63.75 Technical (Hospital) Services SITAGLIPTIN PHOSPHATE 100 MG TABLET RX-77617 CDM 6370000100 HCPCS 250 RC 00006-0277-31 NDC inpatient 1 UN 67.1 67.1 CIGNA 62308 [3081051] CIGNA 62308 [308105105] 53.13 percent of total billed charges 41.6 63.75 Technical (Hospital) Services SITAGLIPTIN PHOSPHATE 100 MG TABLET RX-77617 CDM 6370000100 HCPCS 250 RC 00006-0277-31 NDC inpatient 1 UN 67.1 67.1 CIGNA 62308 [3081051] CIGNA STATE OF WYOMING [308105107] 53.13 percent of total billed charges 41.6 63.75 Technical (Hospital) Services SITAGLIPTIN PHOSPHATE 100 MG TABLET RX-77617 CDM 6370000100 HCPCS 250 RC 00006-0277-31 NDC inpatient 1 UN 67.1 67.1 MEDICA (COMMERCIAL) 94265 [3081118] MEDICA CLAIMS [308111801] 60.39 percent of total billed charges 41.6 63.75 Technical (Hospital) Services SITAGLIPTIN PHOSPHATE 100 MG TABLET RX-77617 CDM 6370000100 HCPCS 250 RC 00006-0277-31 NDC inpatient 1 UN 67.1 67.1 HEALTHPARTNERS SX009 HEALTHPARTNERS 53.13 percent of total billed charges 41.6 63.75 Technical (Hospital) Services SITAGLIPTIN PHOSPHATE 100 MG TABLET RX-77617 CDM 6370000100 HCPCS 250 RC 00006-0277-31 NDC inpatient 1 UN 67.1 67.1 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES PPO [308136801] 53.13 percent of total billed charges 41.6 63.75 Technical (Hospital) Services CODEINE 10 MG-GUAIFENESIN 100 MG/5 ML ORAL LIQUID RX-78003 CDM 6370000100 HCPCS 250 RC 00121-0775-04 NDC inpatient 118 ML 28.49 28.49 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES EPO [308136803] 22.56 percent of total billed charges 17.66 27.07 Technical (Hospital) Services CODEINE 10 MG-GUAIFENESIN 100 MG/5 ML ORAL LIQUID RX-78003 CDM 6370000100 HCPCS 250 RC 00121-0775-04 NDC inpatient 118 ML 28.49 28.49 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES HDHP [308136802] 22.56 percent of total billed charges 17.66 27.07 Technical (Hospital) Services CODEINE 10 MG-GUAIFENESIN 100 MG/5 ML ORAL LIQUID RX-78003 CDM 6370000100 HCPCS 250 RC 00121-0775-04 NDC inpatient 118 ML 28.49 28.49 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES PPO [308136801] 22.56 percent of total billed charges 17.66 27.07 Technical (Hospital) Services CODEINE 10 MG-GUAIFENESIN 100 MG/5 ML ORAL LIQUID RX-78003 CDM 6370000100 HCPCS 250 RC 00121-0775-04 NDC inpatient 118 ML 28.49 28.49 CIGNA 62308 [3081051] CIGNA 62308 [308105105] 22.56 percent of total billed charges 17.66 27.07 Technical (Hospital) Services CODEINE 10 MG-GUAIFENESIN 100 MG/5 ML ORAL LIQUID RX-78003 CDM 6370000100 HCPCS 250 RC 00121-0775-04 NDC inpatient 118 ML 28.49 28.49 CIGNA 62308 [3081051] CIGNA STATE OF WYOMING [308105107] 22.56 percent of total billed charges 17.66 27.07 Technical (Hospital) Services CODEINE 10 MG-GUAIFENESIN 100 MG/5 ML ORAL LIQUID RX-78003 CDM 6370000100 HCPCS 250 RC 00121-0775-04 NDC inpatient 118 ML 28.49 28.49 UNITED HEALTHCARE (COMMERCIAL) [3081199] UNITED HEALTHCARE 87726 [308119901] 17.66 percent of total billed charges 17.66 27.07 Technical (Hospital) Services CODEINE 10 MG-GUAIFENESIN 100 MG/5 ML ORAL LIQUID RX-78003 CDM 6370000100 HCPCS 250 RC 00121-0775-04 NDC inpatient 118 ML 28.49 28.49 BLUE CROSS BLUE SHIELD WELLMARK SB889 [3081026] BCBS WYOMING [308102603] 27.07 percent of total billed charges 17.66 27.07 Technical (Hospital) Services CODEINE 10 MG-GUAIFENESIN 100 MG/5 ML ORAL LIQUID RX-78003 CDM 6370000100 HCPCS 250 RC 00121-0775-04 NDC inpatient 118 ML 28.49 28.49 HEALTHPARTNERS SX009 HEALTHPARTNERS 22.56 percent of total billed charges 17.66 27.07 Technical (Hospital) Services CODEINE 10 MG-GUAIFENESIN 100 MG/5 ML ORAL LIQUID RX-78003 CDM 6370000100 HCPCS 250 RC 00121-0775-04 NDC inpatient 118 ML 28.49 28.49 MEDICA (COMMERCIAL) 94265 [3081118] MEDICA CLAIMS [308111801] 25.64 percent of total billed charges 17.66 27.07 Technical (Hospital) Services CODEINE 10 MG-GUAIFENESIN 100 MG/5 ML ORAL LIQUID RX-78003 CDM 6370000100 HCPCS 250 RC 00121-0775-04 NDC inpatient 118 ML 28.49 28.49 MULTIPLAN INC 34080 [3081285] MULTIPLAN INC [308128501] 27.07 percent of total billed charges 17.66 27.07 Technical (Hospital) Services CODEINE 10 MG-GUAIFENESIN 100 MG/5 ML ORAL LIQUID RX-78003 CDM 6370000100 HCPCS 250 RC 00121-0775-04 NDC outpatient 118 ML 28.49 28.49 CIGNA 62308 [3081051] CIGNA 62308 [308105105] 22.79 percent of total billed charges 17.66 27.07 Technical (Hospital) Services CODEINE 10 MG-GUAIFENESIN 100 MG/5 ML ORAL LIQUID RX-78003 CDM 6370000100 HCPCS 250 RC 00121-0775-04 NDC outpatient 118 ML 28.49 28.49 CIGNA 62308 [3081051] CIGNA STATE OF WYOMING [308105107] 22.79 percent of total billed charges 17.66 27.07 Technical (Hospital) Services CODEINE 10 MG-GUAIFENESIN 100 MG/5 ML ORAL LIQUID RX-78003 CDM 6370000100 HCPCS 250 RC 00121-0775-04 NDC outpatient 118 ML 28.49 28.49 BLUE CROSS BLUE SHIELD WELLMARK SB889 [3081026] BCBS WYOMING [308102603] 27.07 percent of total billed charges 17.66 27.07 Technical (Hospital) Services CODEINE 10 MG-GUAIFENESIN 100 MG/5 ML ORAL LIQUID RX-78003 CDM 6370000100 HCPCS 250 RC 00121-0775-04 NDC outpatient 118 ML 28.49 28.49 HEALTHPARTNERS SX009 HEALTHPARTNERS 22.79 percent of total billed charges 17.66 27.07 Technical (Hospital) Services CODEINE 10 MG-GUAIFENESIN 100 MG/5 ML ORAL LIQUID RX-78003 CDM 6370000100 HCPCS 250 RC 00121-0775-04 NDC outpatient 118 ML 28.49 28.49 UNITED HEALTHCARE (COMMERCIAL) [3081199] UNITED HEALTHCARE 87726 [308119901] 17.66 percent of total billed charges 17.66 27.07 Technical (Hospital) Services CODEINE 10 MG-GUAIFENESIN 100 MG/5 ML ORAL LIQUID RX-78003 CDM 6370000100 HCPCS 250 RC 00121-0775-04 NDC outpatient 118 ML 28.49 28.49 MULTIPLAN INC 34080 [3081285] MULTIPLAN INC [308128501] 27.07 percent of total billed charges 17.66 27.07 Technical (Hospital) Services CODEINE 10 MG-GUAIFENESIN 100 MG/5 ML ORAL LIQUID RX-78003 CDM 6370000100 HCPCS 250 RC 00121-0775-04 NDC outpatient 118 ML 28.49 28.49 MEDICA (COMMERCIAL) 94265 [3081118] MEDICA CLAIMS [308111801] 25.64 percent of total billed charges 17.66 27.07 Technical (Hospital) Services CODEINE 10 MG-GUAIFENESIN 100 MG/5 ML ORAL LIQUID RX-78003 CDM 6370000100 HCPCS 250 RC 00121-0775-04 NDC outpatient 118 ML 28.49 28.49 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES EPO [308136803] 22.79 percent of total billed charges 17.66 27.07 Technical (Hospital) Services CODEINE 10 MG-GUAIFENESIN 100 MG/5 ML ORAL LIQUID RX-78003 CDM 6370000100 HCPCS 250 RC 00121-0775-04 NDC outpatient 118 ML 28.49 28.49 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES HDHP [308136802] 22.79 percent of total billed charges 17.66 27.07 Technical (Hospital) Services CODEINE 10 MG-GUAIFENESIN 100 MG/5 ML ORAL LIQUID RX-78003 CDM 6370000100 HCPCS 250 RC 00121-0775-04 NDC outpatient 118 ML 28.49 28.49 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES PPO [308136801] 22.79 percent of total billed charges 17.66 27.07 Technical (Hospital) Services THIORIDAZINE 25 MG TABLET RX-7899 CDM 6370000100 HCPCS 250 RC 00378-0614-01 NDC inpatient 1 UN 6.29 6.29 HEALTHPARTNERS SX009 HEALTHPARTNERS 4.98 percent of total billed charges 3.9 5.98 Technical (Hospital) Services THIORIDAZINE 25 MG TABLET RX-7899 CDM 6370000100 HCPCS 250 RC 00378-0614-01 NDC inpatient 1 UN 6.29 6.29 MEDICA (COMMERCIAL) 94265 [3081118] MEDICA CLAIMS [308111801] 5.66 percent of total billed charges 3.9 5.98 Technical (Hospital) Services THIORIDAZINE 25 MG TABLET RX-7899 CDM 6370000100 HCPCS 250 RC 00378-0614-01 NDC inpatient 1 UN 6.29 6.29 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES PPO [308136801] 4.98 percent of total billed charges 3.9 5.98 Technical (Hospital) Services THIORIDAZINE 25 MG TABLET RX-7899 CDM 6370000100 HCPCS 250 RC 00378-0614-01 NDC inpatient 1 UN 6.29 6.29 MULTIPLAN INC 34080 [3081285] MULTIPLAN INC [308128501] 5.98 percent of total billed charges 3.9 5.98 Technical (Hospital) Services THIORIDAZINE 25 MG TABLET RX-7899 CDM 6370000100 HCPCS 250 RC 00378-0614-01 NDC inpatient 1 UN 6.29 6.29 UNITED HEALTHCARE (COMMERCIAL) [3081199] UNITED HEALTHCARE 87726 [308119901] 3.9 percent of total billed charges 3.9 5.98 Technical (Hospital) Services THIORIDAZINE 25 MG TABLET RX-7899 CDM 6370000100 HCPCS 250 RC 00378-0614-01 NDC inpatient 1 UN 6.29 6.29 BLUE CROSS BLUE SHIELD WELLMARK SB889 [3081026] BCBS WYOMING [308102603] 5.98 percent of total billed charges 3.9 5.98 Technical (Hospital) Services THIORIDAZINE 25 MG TABLET RX-7899 CDM 6370000100 HCPCS 250 RC 00378-0614-01 NDC inpatient 1 UN 6.29 6.29 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES HDHP [308136802] 4.98 percent of total billed charges 3.9 5.98 Technical (Hospital) Services THIORIDAZINE 25 MG TABLET RX-7899 CDM 6370000100 HCPCS 250 RC 00378-0614-01 NDC inpatient 1 UN 6.29 6.29 CIGNA 62308 [3081051] CIGNA 62308 [308105105] 4.98 percent of total billed charges 3.9 5.98 Technical (Hospital) Services THIORIDAZINE 25 MG TABLET RX-7899 CDM 6370000100 HCPCS 250 RC 00378-0614-01 NDC inpatient 1 UN 6.29 6.29 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES EPO [308136803] 4.98 percent of total billed charges 3.9 5.98 Technical (Hospital) Services THIORIDAZINE 25 MG TABLET RX-7899 CDM 6370000100 HCPCS 250 RC 00378-0614-01 NDC inpatient 1 UN 6.29 6.29 CIGNA 62308 [3081051] CIGNA STATE OF WYOMING [308105107] 4.98 percent of total billed charges 3.9 5.98 Technical (Hospital) Services THIORIDAZINE 25 MG TABLET RX-7899 CDM 6370000100 HCPCS 250 RC 00378-0614-01 NDC outpatient 1 UN 6.29 6.29 MULTIPLAN INC 34080 [3081285] MULTIPLAN INC [308128501] 5.98 percent of total billed charges 3.9 5.98 Technical (Hospital) Services THIORIDAZINE 25 MG TABLET RX-7899 CDM 6370000100 HCPCS 250 RC 00378-0614-01 NDC outpatient 1 UN 6.29 6.29 CIGNA 62308 [3081051] CIGNA 62308 [308105105] 5.03 percent of total billed charges 3.9 5.98 Technical (Hospital) Services THIORIDAZINE 25 MG TABLET RX-7899 CDM 6370000100 HCPCS 250 RC 00378-0614-01 NDC outpatient 1 UN 6.29 6.29 CIGNA 62308 [3081051] CIGNA STATE OF WYOMING [308105107] 5.03 percent of total billed charges 3.9 5.98 Technical (Hospital) Services THIORIDAZINE 25 MG TABLET RX-7899 CDM 6370000100 HCPCS 250 RC 00378-0614-01 NDC outpatient 1 UN 6.29 6.29 MEDICA (COMMERCIAL) 94265 [3081118] MEDICA CLAIMS [308111801] 5.66 percent of total billed charges 3.9 5.98 Technical (Hospital) Services THIORIDAZINE 25 MG TABLET RX-7899 CDM 6370000100 HCPCS 250 RC 00378-0614-01 NDC outpatient 1 UN 6.29 6.29 HEALTHPARTNERS SX009 HEALTHPARTNERS 5.03 percent of total billed charges 3.9 5.98 Technical (Hospital) Services THIORIDAZINE 25 MG TABLET RX-7899 CDM 6370000100 HCPCS 250 RC 00378-0614-01 NDC outpatient 1 UN 6.29 6.29 UNITED HEALTHCARE (COMMERCIAL) [3081199] UNITED HEALTHCARE 87726 [308119901] 3.9 percent of total billed charges 3.9 5.98 Technical (Hospital) Services THIORIDAZINE 25 MG TABLET RX-7899 CDM 6370000100 HCPCS 250 RC 00378-0614-01 NDC outpatient 1 UN 6.29 6.29 BLUE CROSS BLUE SHIELD WELLMARK SB889 [3081026] BCBS WYOMING [308102603] 5.98 percent of total billed charges 3.9 5.98 Technical (Hospital) Services THIORIDAZINE 25 MG TABLET RX-7899 CDM 6370000100 HCPCS 250 RC 00378-0614-01 NDC outpatient 1 UN 6.29 6.29 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES EPO [308136803] 5.03 percent of total billed charges 3.9 5.98 Technical (Hospital) Services THIORIDAZINE 25 MG TABLET RX-7899 CDM 6370000100 HCPCS 250 RC 00378-0614-01 NDC outpatient 1 UN 6.29 6.29 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES HDHP [308136802] 5.03 percent of total billed charges 3.9 5.98 Technical (Hospital) Services THIORIDAZINE 25 MG TABLET RX-7899 CDM 6370000100 HCPCS 250 RC 00378-0614-01 NDC outpatient 1 UN 6.29 6.29 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES PPO [308136801] 5.03 percent of total billed charges 3.9 5.98 Technical (Hospital) Services THIORIDAZINE 50 MG TABLET RX-7900 CDM 6370000100 HCPCS 250 RC 00378-0616-01 NDC inpatient 1 UN 6.46 6.46 MULTIPLAN INC 34080 [3081285] MULTIPLAN INC [308128501] 6.14 percent of total billed charges 4.01 6.14 Technical (Hospital) Services THIORIDAZINE 50 MG TABLET RX-7900 CDM 6370000100 HCPCS 250 RC 00378-0616-01 NDC inpatient 1 UN 6.46 6.46 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES HDHP [308136802] 5.12 percent of total billed charges 4.01 6.14 Technical (Hospital) Services THIORIDAZINE 50 MG TABLET RX-7900 CDM 6370000100 HCPCS 250 RC 00378-0616-01 NDC inpatient 1 UN 6.46 6.46 HEALTHPARTNERS SX009 HEALTHPARTNERS 5.12 percent of total billed charges 4.01 6.14 Technical (Hospital) Services THIORIDAZINE 50 MG TABLET RX-7900 CDM 6370000100 HCPCS 250 RC 00378-0616-01 NDC inpatient 1 UN 6.46 6.46 UNITED HEALTHCARE (COMMERCIAL) [3081199] UNITED HEALTHCARE 87726 [308119901] 4.01 percent of total billed charges 4.01 6.14 Technical (Hospital) Services THIORIDAZINE 50 MG TABLET RX-7900 CDM 6370000100 HCPCS 250 RC 00378-0616-01 NDC inpatient 1 UN 6.46 6.46 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES EPO [308136803] 5.12 percent of total billed charges 4.01 6.14 Technical (Hospital) Services THIORIDAZINE 50 MG TABLET RX-7900 CDM 6370000100 HCPCS 250 RC 00378-0616-01 NDC inpatient 1 UN 6.46 6.46 CIGNA 62308 [3081051] CIGNA 62308 [308105105] 5.12 percent of total billed charges 4.01 6.14 Technical (Hospital) Services THIORIDAZINE 50 MG TABLET RX-7900 CDM 6370000100 HCPCS 250 RC 00378-0616-01 NDC inpatient 1 UN 6.46 6.46 CIGNA 62308 [3081051] CIGNA STATE OF WYOMING [308105107] 5.12 percent of total billed charges 4.01 6.14 Technical (Hospital) Services THIORIDAZINE 50 MG TABLET RX-7900 CDM 6370000100 HCPCS 250 RC 00378-0616-01 NDC inpatient 1 UN 6.46 6.46 BLUE CROSS BLUE SHIELD WELLMARK SB889 [3081026] BCBS WYOMING [308102603] 6.14 percent of total billed charges 4.01 6.14 Technical (Hospital) Services THIORIDAZINE 50 MG TABLET RX-7900 CDM 6370000100 HCPCS 250 RC 00378-0616-01 NDC inpatient 1 UN 6.46 6.46 MEDICA (COMMERCIAL) 94265 [3081118] MEDICA CLAIMS [308111801] 5.81 percent of total billed charges 4.01 6.14 Technical (Hospital) Services THIORIDAZINE 50 MG TABLET RX-7900 CDM 6370000100 HCPCS 250 RC 00378-0616-01 NDC inpatient 1 UN 6.46 6.46 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES PPO [308136801] 5.12 percent of total billed charges 4.01 6.14 Technical (Hospital) Services THIORIDAZINE 50 MG TABLET RX-7900 CDM 6370000100 HCPCS 250 RC 00378-0616-01 NDC outpatient 1 UN 6.46 6.46 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES EPO [308136803] 5.17 percent of total billed charges 4.01 6.14 Technical (Hospital) Services THIORIDAZINE 50 MG TABLET RX-7900 CDM 6370000100 HCPCS 250 RC 00378-0616-01 NDC outpatient 1 UN 6.46 6.46 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES HDHP [308136802] 5.17 percent of total billed charges 4.01 6.14 Technical (Hospital) Services THIORIDAZINE 50 MG TABLET RX-7900 CDM 6370000100 HCPCS 250 RC 00378-0616-01 NDC outpatient 1 UN 6.46 6.46 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES PPO [308136801] 5.17 percent of total billed charges 4.01 6.14 Technical (Hospital) Services THIORIDAZINE 50 MG TABLET RX-7900 CDM 6370000100 HCPCS 250 RC 00378-0616-01 NDC outpatient 1 UN 6.46 6.46 HEALTHPARTNERS SX009 HEALTHPARTNERS 5.17 percent of total billed charges 4.01 6.14 Technical (Hospital) Services THIORIDAZINE 50 MG TABLET RX-7900 CDM 6370000100 HCPCS 250 RC 00378-0616-01 NDC outpatient 1 UN 6.46 6.46 UNITED HEALTHCARE (COMMERCIAL) [3081199] UNITED HEALTHCARE 87726 [308119901] 4.01 percent of total billed charges 4.01 6.14 Technical (Hospital) Services THIORIDAZINE 50 MG TABLET RX-7900 CDM 6370000100 HCPCS 250 RC 00378-0616-01 NDC outpatient 1 UN 6.46 6.46 MEDICA (COMMERCIAL) 94265 [3081118] MEDICA CLAIMS [308111801] 5.81 percent of total billed charges 4.01 6.14 Technical (Hospital) Services THIORIDAZINE 50 MG TABLET RX-7900 CDM 6370000100 HCPCS 250 RC 00378-0616-01 NDC outpatient 1 UN 6.46 6.46 MULTIPLAN INC 34080 [3081285] MULTIPLAN INC [308128501] 6.14 percent of total billed charges 4.01 6.14 Technical (Hospital) Services THIORIDAZINE 50 MG TABLET RX-7900 CDM 6370000100 HCPCS 250 RC 00378-0616-01 NDC outpatient 1 UN 6.46 6.46 CIGNA 62308 [3081051] CIGNA 62308 [308105105] 5.17 percent of total billed charges 4.01 6.14 Technical (Hospital) Services THIORIDAZINE 50 MG TABLET RX-7900 CDM 6370000100 HCPCS 250 RC 00378-0616-01 NDC outpatient 1 UN 6.46 6.46 CIGNA 62308 [3081051] CIGNA STATE OF WYOMING [308105107] 5.17 percent of total billed charges 4.01 6.14 Technical (Hospital) Services THIORIDAZINE 50 MG TABLET RX-7900 CDM 6370000100 HCPCS 250 RC 00378-0616-01 NDC outpatient 1 UN 6.46 6.46 BLUE CROSS BLUE SHIELD WELLMARK SB889 [3081026] BCBS WYOMING [308102603] 6.14 percent of total billed charges 4.01 6.14 Technical (Hospital) Services TRAZODONE 100 MG TABLET RX-8083 CDM 6370000100 HCPCS 250 RC 50111-0561-01 NDC outpatient 1 UN 5.74 5.74 HEALTHPARTNERS SX009 HEALTHPARTNERS 4.59 percent of total billed charges 3.56 5.45 Technical (Hospital) Services TRAZODONE 100 MG TABLET RX-8083 CDM 6370000100 HCPCS 250 RC 50111-0561-01 NDC outpatient 1 UN 5.74 5.74 UNITED HEALTHCARE (COMMERCIAL) [3081199] UNITED HEALTHCARE 87726 [308119901] 3.56 percent of total billed charges 3.56 5.45 Technical (Hospital) Services TRAZODONE 100 MG TABLET RX-8083 CDM 6370000100 HCPCS 250 RC 50111-0561-01 NDC outpatient 1 UN 5.74 5.74 CIGNA 62308 [3081051] CIGNA 62308 [308105105] 4.59 percent of total billed charges 3.56 5.45 Technical (Hospital) Services TRAZODONE 100 MG TABLET RX-8083 CDM 6370000100 HCPCS 250 RC 50111-0561-01 NDC outpatient 1 UN 5.74 5.74 CIGNA 62308 [3081051] CIGNA STATE OF WYOMING [308105107] 4.59 percent of total billed charges 3.56 5.45 Technical (Hospital) Services TRAZODONE 100 MG TABLET RX-8083 CDM 6370000100 HCPCS 250 RC 50111-0561-01 NDC outpatient 1 UN 5.74 5.74 MULTIPLAN INC 34080 [3081285] MULTIPLAN INC [308128501] 5.45 percent of total billed charges 3.56 5.45 Technical (Hospital) Services TRAZODONE 100 MG TABLET RX-8083 CDM 6370000100 HCPCS 250 RC 50111-0561-01 NDC outpatient 1 UN 5.74 5.74 MEDICA (COMMERCIAL) 94265 [3081118] MEDICA CLAIMS [308111801] 5.17 percent of total billed charges 3.56 5.45 Technical (Hospital) Services TRAZODONE 100 MG TABLET RX-8083 CDM 6370000100 HCPCS 250 RC 50111-0561-01 NDC outpatient 1 UN 5.74 5.74 BLUE CROSS BLUE SHIELD WELLMARK SB889 [3081026] BCBS WYOMING [308102603] 5.45 percent of total billed charges 3.56 5.45 Technical (Hospital) Services TRAZODONE 100 MG TABLET RX-8083 CDM 6370000100 HCPCS 250 RC 50111-0561-01 NDC outpatient 1 UN 5.74 5.74 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES EPO [308136803] 4.59 percent of total billed charges 3.56 5.45 Technical (Hospital) Services TRAZODONE 100 MG TABLET RX-8083 CDM 6370000100 HCPCS 250 RC 50111-0561-01 NDC outpatient 1 UN 5.74 5.74 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES HDHP [308136802] 4.59 percent of total billed charges 3.56 5.45 Technical (Hospital) Services TRAZODONE 100 MG TABLET RX-8083 CDM 6370000100 HCPCS 250 RC 50111-0561-01 NDC outpatient 1 UN 5.74 5.74 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES PPO [308136801] 4.59 percent of total billed charges 3.56 5.45 Technical (Hospital) Services TRAZODONE 100 MG TABLET RX-8083 CDM 6370000100 HCPCS 250 RC 50111-0561-01 NDC inpatient 1 UN 5.74 5.74 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES PPO [308136801] 4.54 percent of total billed charges 3.56 5.45 Technical (Hospital) Services TRAZODONE 100 MG TABLET RX-8083 CDM 6370000100 HCPCS 250 RC 50111-0561-01 NDC inpatient 1 UN 5.74 5.74 MEDICA (COMMERCIAL) 94265 [3081118] MEDICA CLAIMS [308111801] 5.17 percent of total billed charges 3.56 5.45 Technical (Hospital) Services TRAZODONE 100 MG TABLET RX-8083 CDM 6370000100 HCPCS 250 RC 50111-0561-01 NDC inpatient 1 UN 5.74 5.74 HEALTHPARTNERS SX009 HEALTHPARTNERS 4.54 percent of total billed charges 3.56 5.45 Technical (Hospital) Services TRAZODONE 100 MG TABLET RX-8083 CDM 6370000100 HCPCS 250 RC 50111-0561-01 NDC inpatient 1 UN 5.74 5.74 MULTIPLAN INC 34080 [3081285] MULTIPLAN INC [308128501] 5.45 percent of total billed charges 3.56 5.45 Technical (Hospital) Services TRAZODONE 100 MG TABLET RX-8083 CDM 6370000100 HCPCS 250 RC 50111-0561-01 NDC inpatient 1 UN 5.74 5.74 UNITED HEALTHCARE (COMMERCIAL) [3081199] UNITED HEALTHCARE 87726 [308119901] 3.56 percent of total billed charges 3.56 5.45 Technical (Hospital) Services TRAZODONE 100 MG TABLET RX-8083 CDM 6370000100 HCPCS 250 RC 50111-0561-01 NDC inpatient 1 UN 5.74 5.74 BLUE CROSS BLUE SHIELD WELLMARK SB889 [3081026] BCBS WYOMING [308102603] 5.45 percent of total billed charges 3.56 5.45 Technical (Hospital) Services TRAZODONE 100 MG TABLET RX-8083 CDM 6370000100 HCPCS 250 RC 50111-0561-01 NDC inpatient 1 UN 5.74 5.74 CIGNA 62308 [3081051] CIGNA 62308 [308105105] 4.54 percent of total billed charges 3.56 5.45 Technical (Hospital) Services TRAZODONE 100 MG TABLET RX-8083 CDM 6370000100 HCPCS 250 RC 50111-0561-01 NDC inpatient 1 UN 5.74 5.74 CIGNA 62308 [3081051] CIGNA STATE OF WYOMING [308105107] 4.54 percent of total billed charges 3.56 5.45 Technical (Hospital) Services TRAZODONE 100 MG TABLET RX-8083 CDM 6370000100 HCPCS 250 RC 50111-0561-01 NDC inpatient 1 UN 5.74 5.74 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES EPO [308136803] 4.54 percent of total billed charges 3.56 5.45 Technical (Hospital) Services TRAZODONE 100 MG TABLET RX-8083 CDM 6370000100 HCPCS 250 RC 50111-0561-01 NDC inpatient 1 UN 5.74 5.74 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES HDHP [308136802] 4.54 percent of total billed charges 3.56 5.45 Technical (Hospital) Services TRAZODONE 50 MG TABLET RX-8085 CDM 6370000100 HCPCS 250 RC 60687-0443-11 NDC inpatient 1 UN 5.75 5.75 MULTIPLAN INC 34080 [3081285] MULTIPLAN INC [308128501] 5.46 percent of total billed charges 3.57 5.46 Technical (Hospital) Services TRAZODONE 50 MG TABLET RX-8085 CDM 6370000100 HCPCS 250 RC 60687-0443-11 NDC inpatient 1 UN 5.75 5.75 BLUE CROSS BLUE SHIELD WELLMARK SB889 [3081026] BCBS WYOMING [308102603] 5.46 percent of total billed charges 3.57 5.46 Technical (Hospital) Services TRAZODONE 50 MG TABLET RX-8085 CDM 6370000100 HCPCS 250 RC 60687-0443-11 NDC inpatient 1 UN 5.75 5.75 UNITED HEALTHCARE (COMMERCIAL) [3081199] UNITED HEALTHCARE 87726 [308119901] 3.57 percent of total billed charges 3.57 5.46 Technical (Hospital) Services TRAZODONE 50 MG TABLET RX-8085 CDM 6370000100 HCPCS 250 RC 60687-0443-11 NDC inpatient 1 UN 5.75 5.75 CIGNA 62308 [3081051] CIGNA 62308 [308105105] 4.55 percent of total billed charges 3.57 5.46 Technical (Hospital) Services TRAZODONE 50 MG TABLET RX-8085 CDM 6370000100 HCPCS 250 RC 60687-0443-11 NDC inpatient 1 UN 5.75 5.75 CIGNA 62308 [3081051] CIGNA STATE OF WYOMING [308105107] 4.55 percent of total billed charges 3.57 5.46 Technical (Hospital) Services TRAZODONE 50 MG TABLET RX-8085 CDM 6370000100 HCPCS 250 RC 60687-0443-11 NDC inpatient 1 UN 5.75 5.75 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES EPO [308136803] 4.55 percent of total billed charges 3.57 5.46 Technical (Hospital) Services TRAZODONE 50 MG TABLET RX-8085 CDM 6370000100 HCPCS 250 RC 60687-0443-11 NDC inpatient 1 UN 5.75 5.75 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES HDHP [308136802] 4.55 percent of total billed charges 3.57 5.46 Technical (Hospital) Services TRAZODONE 50 MG TABLET RX-8085 CDM 6370000100 HCPCS 250 RC 60687-0443-11 NDC inpatient 1 UN 5.75 5.75 HEALTHPARTNERS SX009 HEALTHPARTNERS 4.55 percent of total billed charges 3.57 5.46 Technical (Hospital) Services TRAZODONE 50 MG TABLET RX-8085 CDM 6370000100 HCPCS 250 RC 60687-0443-11 NDC inpatient 1 UN 5.75 5.75 MEDICA (COMMERCIAL) 94265 [3081118] MEDICA CLAIMS [308111801] 5.18 percent of total billed charges 3.57 5.46 Technical (Hospital) Services TRAZODONE 50 MG TABLET RX-8085 CDM 6370000100 HCPCS 250 RC 60687-0443-11 NDC inpatient 1 UN 5.75 5.75 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES PPO [308136801] 4.55 percent of total billed charges 3.57 5.46 Technical (Hospital) Services TRAZODONE 50 MG TABLET RX-8085 CDM 6370000100 HCPCS 250 RC 60687-0443-11 NDC outpatient 1 UN 5.75 5.75 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES EPO [308136803] 4.6 percent of total billed charges 3.57 5.46 Technical (Hospital) Services TRAZODONE 50 MG TABLET RX-8085 CDM 6370000100 HCPCS 250 RC 60687-0443-11 NDC outpatient 1 UN 5.75 5.75 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES HDHP [308136802] 4.6 percent of total billed charges 3.57 5.46 Technical (Hospital) Services TRAZODONE 50 MG TABLET RX-8085 CDM 6370000100 HCPCS 250 RC 60687-0443-11 NDC outpatient 1 UN 5.75 5.75 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES PPO [308136801] 4.6 percent of total billed charges 3.57 5.46 Technical (Hospital) Services TRAZODONE 50 MG TABLET RX-8085 CDM 6370000100 HCPCS 250 RC 60687-0443-11 NDC outpatient 1 UN 5.75 5.75 MEDICA (COMMERCIAL) 94265 [3081118] MEDICA CLAIMS [308111801] 5.18 percent of total billed charges 3.57 5.46 Technical (Hospital) Services TRAZODONE 50 MG TABLET RX-8085 CDM 6370000100 HCPCS 250 RC 60687-0443-11 NDC outpatient 1 UN 5.75 5.75 MULTIPLAN INC 34080 [3081285] MULTIPLAN INC [308128501] 5.46 percent of total billed charges 3.57 5.46 Technical (Hospital) Services TRAZODONE 50 MG TABLET RX-8085 CDM 6370000100 HCPCS 250 RC 60687-0443-11 NDC outpatient 1 UN 5.75 5.75 CIGNA 62308 [3081051] CIGNA 62308 [308105105] 4.6 percent of total billed charges 3.57 5.46 Technical (Hospital) Services TRAZODONE 50 MG TABLET RX-8085 CDM 6370000100 HCPCS 250 RC 60687-0443-11 NDC outpatient 1 UN 5.75 5.75 CIGNA 62308 [3081051] CIGNA STATE OF WYOMING [308105107] 4.6 percent of total billed charges 3.57 5.46 Technical (Hospital) Services TRAZODONE 50 MG TABLET RX-8085 CDM 6370000100 HCPCS 250 RC 60687-0443-11 NDC outpatient 1 UN 5.75 5.75 UNITED HEALTHCARE (COMMERCIAL) [3081199] UNITED HEALTHCARE 87726 [308119901] 3.57 percent of total billed charges 3.57 5.46 Technical (Hospital) Services TRAZODONE 50 MG TABLET RX-8085 CDM 6370000100 HCPCS 250 RC 60687-0443-11 NDC outpatient 1 UN 5.75 5.75 HEALTHPARTNERS SX009 HEALTHPARTNERS 4.6 percent of total billed charges 3.57 5.46 Technical (Hospital) Services TRAZODONE 50 MG TABLET RX-8085 CDM 6370000100 HCPCS 250 RC 60687-0443-11 NDC outpatient 1 UN 5.75 5.75 BLUE CROSS BLUE SHIELD WELLMARK SB889 [3081026] BCBS WYOMING [308102603] 5.46 percent of total billed charges 3.57 5.46 Technical (Hospital) Services TRIAMCINOLONE ACETONIDE 0.025 % TOPICAL CREAM RX-8112 CDM 6370000100 HCPCS 250 RC 00168-0003-15 NDC outpatient 15 GR 34 34 UNITED HEALTHCARE (COMMERCIAL) [3081199] UNITED HEALTHCARE 87726 [308119901] 21.08 percent of total billed charges 21.08 32.3 Technical (Hospital) Services TRIAMCINOLONE ACETONIDE 0.025 % TOPICAL CREAM RX-8112 CDM 6370000100 HCPCS 250 RC 00168-0003-15 NDC outpatient 15 GR 34 34 HEALTHPARTNERS SX009 HEALTHPARTNERS 27.2 percent of total billed charges 21.08 32.3 Technical (Hospital) Services TRIAMCINOLONE ACETONIDE 0.025 % TOPICAL CREAM RX-8112 CDM 6370000100 HCPCS 250 RC 00168-0003-15 NDC outpatient 15 GR 34 34 BLUE CROSS BLUE SHIELD WELLMARK SB889 [3081026] BCBS WYOMING [308102603] 32.3 percent of total billed charges 21.08 32.3 Technical (Hospital) Services TRIAMCINOLONE ACETONIDE 0.025 % TOPICAL CREAM RX-8112 CDM 6370000100 HCPCS 250 RC 00168-0003-15 NDC outpatient 15 GR 34 34 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES HDHP [308136802] 27.2 percent of total billed charges 21.08 32.3 Technical (Hospital) Services TRIAMCINOLONE ACETONIDE 0.025 % TOPICAL CREAM RX-8112 CDM 6370000100 HCPCS 250 RC 00168-0003-15 NDC outpatient 15 GR 34 34 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES PPO [308136801] 27.2 percent of total billed charges 21.08 32.3 Technical (Hospital) Services TRIAMCINOLONE ACETONIDE 0.025 % TOPICAL CREAM RX-8112 CDM 6370000100 HCPCS 250 RC 00168-0003-15 NDC outpatient 15 GR 34 34 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES EPO [308136803] 27.2 percent of total billed charges 21.08 32.3 Technical (Hospital) Services TRIAMCINOLONE ACETONIDE 0.025 % TOPICAL CREAM RX-8112 CDM 6370000100 HCPCS 250 RC 00168-0003-15 NDC outpatient 15 GR 34 34 CIGNA 62308 [3081051] CIGNA 62308 [308105105] 27.2 percent of total billed charges 21.08 32.3 Technical (Hospital) Services TRIAMCINOLONE ACETONIDE 0.025 % TOPICAL CREAM RX-8112 CDM 6370000100 HCPCS 250 RC 00168-0003-15 NDC outpatient 15 GR 34 34 CIGNA 62308 [3081051] CIGNA STATE OF WYOMING [308105107] 27.2 percent of total billed charges 21.08 32.3 Technical (Hospital) Services TRIAMCINOLONE ACETONIDE 0.025 % TOPICAL CREAM RX-8112 CDM 6370000100 HCPCS 250 RC 00168-0003-15 NDC outpatient 15 GR 34 34 MULTIPLAN INC 34080 [3081285] MULTIPLAN INC [308128501] 32.3 percent of total billed charges 21.08 32.3 Technical (Hospital) Services TRIAMCINOLONE ACETONIDE 0.025 % TOPICAL CREAM RX-8112 CDM 6370000100 HCPCS 250 RC 00168-0003-15 NDC outpatient 15 GR 34 34 MEDICA (COMMERCIAL) 94265 [3081118] MEDICA CLAIMS [308111801] 30.6 percent of total billed charges 21.08 32.3 Technical (Hospital) Services TRIAMCINOLONE ACETONIDE 0.025 % TOPICAL CREAM RX-8112 CDM 6370000100 HCPCS 250 RC 00168-0003-15 NDC inpatient 15 GR 34 34 MULTIPLAN INC 34080 [3081285] MULTIPLAN INC [308128501] 32.3 percent of total billed charges 21.08 32.3 Technical (Hospital) Services TRIAMCINOLONE ACETONIDE 0.025 % TOPICAL CREAM RX-8112 CDM 6370000100 HCPCS 250 RC 00168-0003-15 NDC inpatient 15 GR 34 34 MEDICA (COMMERCIAL) 94265 [3081118] MEDICA CLAIMS [308111801] 30.6 percent of total billed charges 21.08 32.3 Technical (Hospital) Services TRIAMCINOLONE ACETONIDE 0.025 % TOPICAL CREAM RX-8112 CDM 6370000100 HCPCS 250 RC 00168-0003-15 NDC inpatient 15 GR 34 34 UNITED HEALTHCARE (COMMERCIAL) [3081199] UNITED HEALTHCARE 87726 [308119901] 21.08 percent of total billed charges 21.08 32.3 Technical (Hospital) Services TRIAMCINOLONE ACETONIDE 0.025 % TOPICAL CREAM RX-8112 CDM 6370000100 HCPCS 250 RC 00168-0003-15 NDC inpatient 15 GR 34 34 BLUE CROSS BLUE SHIELD WELLMARK SB889 [3081026] BCBS WYOMING [308102603] 32.3 percent of total billed charges 21.08 32.3 Technical (Hospital) Services TRIAMCINOLONE ACETONIDE 0.025 % TOPICAL CREAM RX-8112 CDM 6370000100 HCPCS 250 RC 00168-0003-15 NDC inpatient 15 GR 34 34 HEALTHPARTNERS SX009 HEALTHPARTNERS 26.92 percent of total billed charges 21.08 32.3 Technical (Hospital) Services TRIAMCINOLONE ACETONIDE 0.025 % TOPICAL CREAM RX-8112 CDM 6370000100 HCPCS 250 RC 00168-0003-15 NDC inpatient 15 GR 34 34 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES EPO [308136803] 26.92 percent of total billed charges 21.08 32.3 Technical (Hospital) Services TRIAMCINOLONE ACETONIDE 0.025 % TOPICAL CREAM RX-8112 CDM 6370000100 HCPCS 250 RC 00168-0003-15 NDC inpatient 15 GR 34 34 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES HDHP [308136802] 26.92 percent of total billed charges 21.08 32.3 Technical (Hospital) Services TRIAMCINOLONE ACETONIDE 0.025 % TOPICAL CREAM RX-8112 CDM 6370000100 HCPCS 250 RC 00168-0003-15 NDC inpatient 15 GR 34 34 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES PPO [308136801] 26.92 percent of total billed charges 21.08 32.3 Technical (Hospital) Services TRIAMCINOLONE ACETONIDE 0.025 % TOPICAL CREAM RX-8112 CDM 6370000100 HCPCS 250 RC 00168-0003-15 NDC inpatient 15 GR 34 34 CIGNA 62308 [3081051] CIGNA STATE OF WYOMING [308105107] 26.92 percent of total billed charges 21.08 32.3 Technical (Hospital) Services TRIAMCINOLONE ACETONIDE 0.025 % TOPICAL CREAM RX-8112 CDM 6370000100 HCPCS 250 RC 00168-0003-15 NDC inpatient 15 GR 34 34 CIGNA 62308 [3081051] CIGNA 62308 [308105105] 26.92 percent of total billed charges 21.08 32.3 Technical (Hospital) Services TRIAMCINOLONE ACETONIDE 0.1 % TOPICAL CREAM RX-8113 CDM 6370000100 HCPCS 250 RC 00168-0004-80 NDC inpatient 1 GR 5.71 5.71 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES PPO [308136801] 4.52 percent of total billed charges 3.54 5.42 Technical (Hospital) Services TRIAMCINOLONE ACETONIDE 0.1 % TOPICAL CREAM RX-8113 CDM 6370000100 HCPCS 250 RC 00168-0004-80 NDC inpatient 1 GR 5.71 5.71 MEDICA (COMMERCIAL) 94265 [3081118] MEDICA CLAIMS [308111801] 5.14 percent of total billed charges 3.54 5.42 Technical (Hospital) Services TRIAMCINOLONE ACETONIDE 0.1 % TOPICAL CREAM RX-8113 CDM 6370000100 HCPCS 250 RC 00168-0004-80 NDC inpatient 1 GR 5.71 5.71 MULTIPLAN INC 34080 [3081285] MULTIPLAN INC [308128501] 5.42 percent of total billed charges 3.54 5.42 Technical (Hospital) Services TRIAMCINOLONE ACETONIDE 0.1 % TOPICAL CREAM RX-8113 CDM 6370000100 HCPCS 250 RC 00168-0004-80 NDC inpatient 1 GR 5.71 5.71 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES HDHP [308136802] 4.52 percent of total billed charges 3.54 5.42 Technical (Hospital) Services TRIAMCINOLONE ACETONIDE 0.1 % TOPICAL CREAM RX-8113 CDM 6370000100 HCPCS 250 RC 00168-0004-80 NDC inpatient 1 GR 5.71 5.71 HEALTHPARTNERS SX009 HEALTHPARTNERS 4.52 percent of total billed charges 3.54 5.42 Technical (Hospital) Services TRIAMCINOLONE ACETONIDE 0.1 % TOPICAL CREAM RX-8113 CDM 6370000100 HCPCS 250 RC 00168-0004-80 NDC inpatient 1 GR 5.71 5.71 CIGNA 62308 [3081051] CIGNA 62308 [308105105] 4.52 percent of total billed charges 3.54 5.42 Technical (Hospital) Services TRIAMCINOLONE ACETONIDE 0.1 % TOPICAL CREAM RX-8113 CDM 6370000100 HCPCS 250 RC 00168-0004-80 NDC inpatient 1 GR 5.71 5.71 CIGNA 62308 [3081051] CIGNA STATE OF WYOMING [308105107] 4.52 percent of total billed charges 3.54 5.42 Technical (Hospital) Services TRIAMCINOLONE ACETONIDE 0.1 % TOPICAL CREAM RX-8113 CDM 6370000100 HCPCS 250 RC 00168-0004-80 NDC inpatient 1 GR 5.71 5.71 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES EPO [308136803] 4.52 percent of total billed charges 3.54 5.42 Technical (Hospital) Services TRIAMCINOLONE ACETONIDE 0.1 % TOPICAL CREAM RX-8113 CDM 6370000100 HCPCS 250 RC 00168-0004-80 NDC inpatient 1 GR 5.71 5.71 UNITED HEALTHCARE (COMMERCIAL) [3081199] UNITED HEALTHCARE 87726 [308119901] 3.54 percent of total billed charges 3.54 5.42 Technical (Hospital) Services TRIAMCINOLONE ACETONIDE 0.1 % TOPICAL CREAM RX-8113 CDM 6370000100 HCPCS 250 RC 00168-0004-80 NDC inpatient 1 GR 5.71 5.71 BLUE CROSS BLUE SHIELD WELLMARK SB889 [3081026] BCBS WYOMING [308102603] 5.42 percent of total billed charges 3.54 5.42 Technical (Hospital) Services TRIAMCINOLONE ACETONIDE 0.1 % TOPICAL CREAM RX-8113 CDM 6370000100 HCPCS 250 RC 00168-0004-80 NDC outpatient 1 GR 5.71 5.71 MEDICA (COMMERCIAL) 94265 [3081118] MEDICA CLAIMS [308111801] 5.14 percent of total billed charges 3.54 5.42 Technical (Hospital) Services TRIAMCINOLONE ACETONIDE 0.1 % TOPICAL CREAM RX-8113 CDM 6370000100 HCPCS 250 RC 00168-0004-80 NDC outpatient 1 GR 5.71 5.71 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES HDHP [308136802] 4.57 percent of total billed charges 3.54 5.42 Technical (Hospital) Services TRIAMCINOLONE ACETONIDE 0.1 % TOPICAL CREAM RX-8113 CDM 6370000100 HCPCS 250 RC 00168-0004-80 NDC outpatient 1 GR 5.71 5.71 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES EPO [308136803] 4.57 percent of total billed charges 3.54 5.42 Technical (Hospital) Services TRIAMCINOLONE ACETONIDE 0.1 % TOPICAL CREAM RX-8113 CDM 6370000100 HCPCS 250 RC 00168-0004-80 NDC outpatient 1 GR 5.71 5.71 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES PPO [308136801] 4.57 percent of total billed charges 3.54 5.42 Technical (Hospital) Services TRIAMCINOLONE ACETONIDE 0.1 % TOPICAL CREAM RX-8113 CDM 6370000100 HCPCS 250 RC 00168-0004-80 NDC outpatient 1 GR 5.71 5.71 BLUE CROSS BLUE SHIELD WELLMARK SB889 [3081026] BCBS WYOMING [308102603] 5.42 percent of total billed charges 3.54 5.42 Technical (Hospital) Services TRIAMCINOLONE ACETONIDE 0.1 % TOPICAL CREAM RX-8113 CDM 6370000100 HCPCS 250 RC 00168-0004-80 NDC outpatient 1 GR 5.71 5.71 HEALTHPARTNERS SX009 HEALTHPARTNERS 4.57 percent of total billed charges 3.54 5.42 Technical (Hospital) Services TRIAMCINOLONE ACETONIDE 0.1 % TOPICAL CREAM RX-8113 CDM 6370000100 HCPCS 250 RC 00168-0004-80 NDC outpatient 1 GR 5.71 5.71 UNITED HEALTHCARE (COMMERCIAL) [3081199] UNITED HEALTHCARE 87726 [308119901] 3.54 percent of total billed charges 3.54 5.42 Technical (Hospital) Services TRIAMCINOLONE ACETONIDE 0.1 % TOPICAL CREAM RX-8113 CDM 6370000100 HCPCS 250 RC 00168-0004-80 NDC outpatient 1 GR 5.71 5.71 MULTIPLAN INC 34080 [3081285] MULTIPLAN INC [308128501] 5.42 percent of total billed charges 3.54 5.42 Technical (Hospital) Services TRIAMCINOLONE ACETONIDE 0.1 % TOPICAL CREAM RX-8113 CDM 6370000100 HCPCS 250 RC 00168-0004-80 NDC outpatient 1 GR 5.71 5.71 CIGNA 62308 [3081051] CIGNA 62308 [308105105] 4.57 percent of total billed charges 3.54 5.42 Technical (Hospital) Services TRIAMCINOLONE ACETONIDE 0.1 % TOPICAL CREAM RX-8113 CDM 6370000100 HCPCS 250 RC 00168-0004-80 NDC outpatient 1 GR 5.71 5.71 CIGNA 62308 [3081051] CIGNA STATE OF WYOMING [308105107] 4.57 percent of total billed charges 3.54 5.42 Technical (Hospital) Services TRIAMCINOLONE ACETONIDE 0.025 % TOPICAL OINTMENT RX-8117 CDM 6370000100 HCPCS 250 RC 45802-0054-35 NDC inpatient 15 GR 34 34 HEALTHPARTNERS SX009 HEALTHPARTNERS 26.92 percent of total billed charges 21.08 32.3 Technical (Hospital) Services TRIAMCINOLONE ACETONIDE 0.025 % TOPICAL OINTMENT RX-8117 CDM 6370000100 HCPCS 250 RC 45802-0054-35 NDC inpatient 15 GR 34 34 CIGNA 62308 [3081051] CIGNA 62308 [308105105] 26.92 percent of total billed charges 21.08 32.3 Technical (Hospital) Services TRIAMCINOLONE ACETONIDE 0.025 % TOPICAL OINTMENT RX-8117 CDM 6370000100 HCPCS 250 RC 45802-0054-35 NDC inpatient 15 GR 34 34 CIGNA 62308 [3081051] CIGNA STATE OF WYOMING [308105107] 26.92 percent of total billed charges 21.08 32.3 Technical (Hospital) Services TRIAMCINOLONE ACETONIDE 0.025 % TOPICAL OINTMENT RX-8117 CDM 6370000100 HCPCS 250 RC 45802-0054-35 NDC inpatient 15 GR 34 34 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES PPO [308136801] 26.92 percent of total billed charges 21.08 32.3 Technical (Hospital) Services TRIAMCINOLONE ACETONIDE 0.025 % TOPICAL OINTMENT RX-8117 CDM 6370000100 HCPCS 250 RC 45802-0054-35 NDC inpatient 15 GR 34 34 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES HDHP [308136802] 26.92 percent of total billed charges 21.08 32.3 Technical (Hospital) Services TRIAMCINOLONE ACETONIDE 0.025 % TOPICAL OINTMENT RX-8117 CDM 6370000100 HCPCS 250 RC 45802-0054-35 NDC inpatient 15 GR 34 34 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES EPO [308136803] 26.92 percent of total billed charges 21.08 32.3 Technical (Hospital) Services TRIAMCINOLONE ACETONIDE 0.025 % TOPICAL OINTMENT RX-8117 CDM 6370000100 HCPCS 250 RC 45802-0054-35 NDC inpatient 15 GR 34 34 MEDICA (COMMERCIAL) 94265 [3081118] MEDICA CLAIMS [308111801] 30.6 percent of total billed charges 21.08 32.3 Technical (Hospital) Services TRIAMCINOLONE ACETONIDE 0.025 % TOPICAL OINTMENT RX-8117 CDM 6370000100 HCPCS 250 RC 45802-0054-35 NDC inpatient 15 GR 34 34 MULTIPLAN INC 34080 [3081285] MULTIPLAN INC [308128501] 32.3 percent of total billed charges 21.08 32.3 Technical (Hospital) Services TRIAMCINOLONE ACETONIDE 0.025 % TOPICAL OINTMENT RX-8117 CDM 6370000100 HCPCS 250 RC 45802-0054-35 NDC inpatient 15 GR 34 34 BLUE CROSS BLUE SHIELD WELLMARK SB889 [3081026] BCBS WYOMING [308102603] 32.3 percent of total billed charges 21.08 32.3 Technical (Hospital) Services TRIAMCINOLONE ACETONIDE 0.025 % TOPICAL OINTMENT RX-8117 CDM 6370000100 HCPCS 250 RC 45802-0054-35 NDC inpatient 15 GR 34 34 UNITED HEALTHCARE (COMMERCIAL) [3081199] UNITED HEALTHCARE 87726 [308119901] 21.08 percent of total billed charges 21.08 32.3 Technical (Hospital) Services TRIAMCINOLONE ACETONIDE 0.025 % TOPICAL OINTMENT RX-8117 CDM 6370000100 HCPCS 250 RC 45802-0054-35 NDC outpatient 15 GR 34 34 CIGNA 62308 [3081051] CIGNA 62308 [308105105] 27.2 percent of total billed charges 21.08 32.3 Technical (Hospital) Services TRIAMCINOLONE ACETONIDE 0.025 % TOPICAL OINTMENT RX-8117 CDM 6370000100 HCPCS 250 RC 45802-0054-35 NDC outpatient 15 GR 34 34 CIGNA 62308 [3081051] CIGNA STATE OF WYOMING [308105107] 27.2 percent of total billed charges 21.08 32.3 Technical (Hospital) Services TRIAMCINOLONE ACETONIDE 0.025 % TOPICAL OINTMENT RX-8117 CDM 6370000100 HCPCS 250 RC 45802-0054-35 NDC outpatient 15 GR 34 34 HEALTHPARTNERS SX009 HEALTHPARTNERS 27.2 percent of total billed charges 21.08 32.3 Technical (Hospital) Services TRIAMCINOLONE ACETONIDE 0.025 % TOPICAL OINTMENT RX-8117 CDM 6370000100 HCPCS 250 RC 45802-0054-35 NDC outpatient 15 GR 34 34 UNITED HEALTHCARE (COMMERCIAL) [3081199] UNITED HEALTHCARE 87726 [308119901] 21.08 percent of total billed charges 21.08 32.3 Technical (Hospital) Services TRIAMCINOLONE ACETONIDE 0.025 % TOPICAL OINTMENT RX-8117 CDM 6370000100 HCPCS 250 RC 45802-0054-35 NDC outpatient 15 GR 34 34 MULTIPLAN INC 34080 [3081285] MULTIPLAN INC [308128501] 32.3 percent of total billed charges 21.08 32.3 Technical (Hospital) Services TRIAMCINOLONE ACETONIDE 0.025 % TOPICAL OINTMENT RX-8117 CDM 6370000100 HCPCS 250 RC 45802-0054-35 NDC outpatient 15 GR 34 34 MEDICA (COMMERCIAL) 94265 [3081118] MEDICA CLAIMS [308111801] 30.6 percent of total billed charges 21.08 32.3 Technical (Hospital) Services TRIAMCINOLONE ACETONIDE 0.025 % TOPICAL OINTMENT RX-8117 CDM 6370000100 HCPCS 250 RC 45802-0054-35 NDC outpatient 15 GR 34 34 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES EPO [308136803] 27.2 percent of total billed charges 21.08 32.3 Technical (Hospital) Services TRIAMCINOLONE ACETONIDE 0.025 % TOPICAL OINTMENT RX-8117 CDM 6370000100 HCPCS 250 RC 45802-0054-35 NDC outpatient 15 GR 34 34 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES HDHP [308136802] 27.2 percent of total billed charges 21.08 32.3 Technical (Hospital) Services TRIAMCINOLONE ACETONIDE 0.025 % TOPICAL OINTMENT RX-8117 CDM 6370000100 HCPCS 250 RC 45802-0054-35 NDC outpatient 15 GR 34 34 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES PPO [308136801] 27.2 percent of total billed charges 21.08 32.3 Technical (Hospital) Services TRIAMCINOLONE ACETONIDE 0.025 % TOPICAL OINTMENT RX-8117 CDM 6370000100 HCPCS 250 RC 45802-0054-35 NDC outpatient 15 GR 34 34 BLUE CROSS BLUE SHIELD WELLMARK SB889 [3081026] BCBS WYOMING [308102603] 32.3 percent of total billed charges 21.08 32.3 Technical (Hospital) Services TRIAMCINOLONE ACETONIDE 0.1 % TOPICAL OINTMENT RX-8118 CDM 6370000100 HCPCS 250 RC 00168-0006-15 NDC outpatient 1 GR 5.93 5.93 MULTIPLAN INC 34080 [3081285] MULTIPLAN INC [308128501] 5.63 percent of total billed charges 3.68 5.63 Technical (Hospital) Services TRIAMCINOLONE ACETONIDE 0.1 % TOPICAL OINTMENT RX-8118 CDM 6370000100 HCPCS 250 RC 00168-0006-15 NDC outpatient 1 GR 5.93 5.93 CIGNA 62308 [3081051] CIGNA 62308 [308105105] 4.74 percent of total billed charges 3.68 5.63 Technical (Hospital) Services TRIAMCINOLONE ACETONIDE 0.1 % TOPICAL OINTMENT RX-8118 CDM 6370000100 HCPCS 250 RC 00168-0006-15 NDC outpatient 1 GR 5.93 5.93 CIGNA 62308 [3081051] CIGNA STATE OF WYOMING [308105107] 4.74 percent of total billed charges 3.68 5.63 Technical (Hospital) Services TRIAMCINOLONE ACETONIDE 0.1 % TOPICAL OINTMENT RX-8118 CDM 6370000100 HCPCS 250 RC 00168-0006-15 NDC outpatient 1 GR 5.93 5.93 MEDICA (COMMERCIAL) 94265 [3081118] MEDICA CLAIMS [308111801] 5.34 percent of total billed charges 3.68 5.63 Technical (Hospital) Services TRIAMCINOLONE ACETONIDE 0.1 % TOPICAL OINTMENT RX-8118 CDM 6370000100 HCPCS 250 RC 00168-0006-15 NDC outpatient 1 GR 5.93 5.93 HEALTHPARTNERS SX009 HEALTHPARTNERS 4.74 percent of total billed charges 3.68 5.63 Technical (Hospital) Services TRIAMCINOLONE ACETONIDE 0.1 % TOPICAL OINTMENT RX-8118 CDM 6370000100 HCPCS 250 RC 00168-0006-15 NDC outpatient 1 GR 5.93 5.93 UNITED HEALTHCARE (COMMERCIAL) [3081199] UNITED HEALTHCARE 87726 [308119901] 3.68 percent of total billed charges 3.68 5.63 Technical (Hospital) Services TRIAMCINOLONE ACETONIDE 0.1 % TOPICAL OINTMENT RX-8118 CDM 6370000100 HCPCS 250 RC 00168-0006-15 NDC outpatient 1 GR 5.93 5.93 BLUE CROSS BLUE SHIELD WELLMARK SB889 [3081026] BCBS WYOMING [308102603] 5.63 percent of total billed charges 3.68 5.63 Technical (Hospital) Services TRIAMCINOLONE ACETONIDE 0.1 % TOPICAL OINTMENT RX-8118 CDM 6370000100 HCPCS 250 RC 00168-0006-15 NDC outpatient 1 GR 5.93 5.93 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES EPO [308136803] 4.74 percent of total billed charges 3.68 5.63 Technical (Hospital) Services TRIAMCINOLONE ACETONIDE 0.1 % TOPICAL OINTMENT RX-8118 CDM 6370000100 HCPCS 250 RC 00168-0006-15 NDC outpatient 1 GR 5.93 5.93 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES PPO [308136801] 4.74 percent of total billed charges 3.68 5.63 Technical (Hospital) Services TRIAMCINOLONE ACETONIDE 0.1 % TOPICAL OINTMENT RX-8118 CDM 6370000100 HCPCS 250 RC 00168-0006-15 NDC outpatient 1 GR 5.93 5.93 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES HDHP [308136802] 4.74 percent of total billed charges 3.68 5.63 Technical (Hospital) Services TRIAMCINOLONE ACETONIDE 0.1 % TOPICAL OINTMENT RX-8118 CDM 6370000100 HCPCS 250 RC 00168-0006-15 NDC inpatient 1 GR 5.93 5.93 MULTIPLAN INC 34080 [3081285] MULTIPLAN INC [308128501] 5.63 percent of total billed charges 3.68 5.63 Technical (Hospital) Services TRIAMCINOLONE ACETONIDE 0.1 % TOPICAL OINTMENT RX-8118 CDM 6370000100 HCPCS 250 RC 00168-0006-15 NDC inpatient 1 GR 5.93 5.93 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES HDHP [308136802] 4.7 percent of total billed charges 3.68 5.63 Technical (Hospital) Services TRIAMCINOLONE ACETONIDE 0.1 % TOPICAL OINTMENT RX-8118 CDM 6370000100 HCPCS 250 RC 00168-0006-15 NDC inpatient 1 GR 5.93 5.93 UNITED HEALTHCARE (COMMERCIAL) [3081199] UNITED HEALTHCARE 87726 [308119901] 3.68 percent of total billed charges 3.68 5.63 Technical (Hospital) Services TRIAMCINOLONE ACETONIDE 0.1 % TOPICAL OINTMENT RX-8118 CDM 6370000100 HCPCS 250 RC 00168-0006-15 NDC inpatient 1 GR 5.93 5.93 CIGNA 62308 [3081051] CIGNA 62308 [308105105] 4.7 percent of total billed charges 3.68 5.63 Technical (Hospital) Services TRIAMCINOLONE ACETONIDE 0.1 % TOPICAL OINTMENT RX-8118 CDM 6370000100 HCPCS 250 RC 00168-0006-15 NDC inpatient 1 GR 5.93 5.93 CIGNA 62308 [3081051] CIGNA STATE OF WYOMING [308105107] 4.7 percent of total billed charges 3.68 5.63 Technical (Hospital) Services TRIAMCINOLONE ACETONIDE 0.1 % TOPICAL OINTMENT RX-8118 CDM 6370000100 HCPCS 250 RC 00168-0006-15 NDC inpatient 1 GR 5.93 5.93 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES EPO [308136803] 4.7 percent of total billed charges 3.68 5.63 Technical (Hospital) Services TRIAMCINOLONE ACETONIDE 0.1 % TOPICAL OINTMENT RX-8118 CDM 6370000100 HCPCS 250 RC 00168-0006-15 NDC inpatient 1 GR 5.93 5.93 BLUE CROSS BLUE SHIELD WELLMARK SB889 [3081026] BCBS WYOMING [308102603] 5.63 percent of total billed charges 3.68 5.63 Technical (Hospital) Services TRIAMCINOLONE ACETONIDE 0.1 % TOPICAL OINTMENT RX-8118 CDM 6370000100 HCPCS 250 RC 00168-0006-15 NDC inpatient 1 GR 5.93 5.93 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES PPO [308136801] 4.7 percent of total billed charges 3.68 5.63 Technical (Hospital) Services TRIAMCINOLONE ACETONIDE 0.1 % TOPICAL OINTMENT RX-8118 CDM 6370000100 HCPCS 250 RC 00168-0006-15 NDC inpatient 1 GR 5.93 5.93 HEALTHPARTNERS SX009 HEALTHPARTNERS 4.7 percent of total billed charges 3.68 5.63 Technical (Hospital) Services TRIAMCINOLONE ACETONIDE 0.1 % TOPICAL OINTMENT RX-8118 CDM 6370000100 HCPCS 250 RC 00168-0006-15 NDC inpatient 1 GR 5.93 5.93 MEDICA (COMMERCIAL) 94265 [3081118] MEDICA CLAIMS [308111801] 5.34 percent of total billed charges 3.68 5.63 Technical (Hospital) Services BUDESONIDE-FORMOTEROL HFA 80 MCG-4.5 MCG/ACTUATION AEROSOL INHALER RX-81453 CDM 6370000100 HCPCS 250 RC 00186-0372-20 NDC inpatient 11 GR 1044.94 1044.94 BLUE CROSS BLUE SHIELD WELLMARK SB889 [3081026] BCBS WYOMING [308102603] 992.69 percent of total billed charges 647.86 992.69 Technical (Hospital) Services BUDESONIDE-FORMOTEROL HFA 80 MCG-4.5 MCG/ACTUATION AEROSOL INHALER RX-81453 CDM 6370000100 HCPCS 250 RC 00186-0372-20 NDC inpatient 11 GR 1044.94 1044.94 UNITED HEALTHCARE (COMMERCIAL) [3081199] UNITED HEALTHCARE 87726 [308119901] 647.86 percent of total billed charges 647.86 992.69 Technical (Hospital) Services BUDESONIDE-FORMOTEROL HFA 80 MCG-4.5 MCG/ACTUATION AEROSOL INHALER RX-81453 CDM 6370000100 HCPCS 250 RC 00186-0372-20 NDC inpatient 11 GR 1044.94 1044.94 MULTIPLAN INC 34080 [3081285] MULTIPLAN INC [308128501] 992.69 percent of total billed charges 647.86 992.69 Technical (Hospital) Services BUDESONIDE-FORMOTEROL HFA 80 MCG-4.5 MCG/ACTUATION AEROSOL INHALER RX-81453 CDM 6370000100 HCPCS 250 RC 00186-0372-20 NDC inpatient 11 GR 1044.94 1044.94 MEDICA (COMMERCIAL) 94265 [3081118] MEDICA CLAIMS [308111801] 940.45 percent of total billed charges 647.86 992.69 Technical (Hospital) Services BUDESONIDE-FORMOTEROL HFA 80 MCG-4.5 MCG/ACTUATION AEROSOL INHALER RX-81453 CDM 6370000100 HCPCS 250 RC 00186-0372-20 NDC inpatient 11 GR 1044.94 1044.94 HEALTHPARTNERS SX009 HEALTHPARTNERS 827.38 percent of total billed charges 647.86 992.69 Technical (Hospital) Services BUDESONIDE-FORMOTEROL HFA 80 MCG-4.5 MCG/ACTUATION AEROSOL INHALER RX-81453 CDM 6370000100 HCPCS 250 RC 00186-0372-20 NDC inpatient 11 GR 1044.94 1044.94 CIGNA 62308 [3081051] CIGNA 62308 [308105105] 827.38 percent of total billed charges 647.86 992.69 Technical (Hospital) Services BUDESONIDE-FORMOTEROL HFA 80 MCG-4.5 MCG/ACTUATION AEROSOL INHALER RX-81453 CDM 6370000100 HCPCS 250 RC 00186-0372-20 NDC inpatient 11 GR 1044.94 1044.94 CIGNA 62308 [3081051] CIGNA STATE OF WYOMING [308105107] 827.38 percent of total billed charges 647.86 992.69 Technical (Hospital) Services BUDESONIDE-FORMOTEROL HFA 80 MCG-4.5 MCG/ACTUATION AEROSOL INHALER RX-81453 CDM 6370000100 HCPCS 250 RC 00186-0372-20 NDC inpatient 11 GR 1044.94 1044.94 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES EPO [308136803] 827.38 percent of total billed charges 647.86 992.69 Technical (Hospital) Services BUDESONIDE-FORMOTEROL HFA 80 MCG-4.5 MCG/ACTUATION AEROSOL INHALER RX-81453 CDM 6370000100 HCPCS 250 RC 00186-0372-20 NDC inpatient 11 GR 1044.94 1044.94 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES HDHP [308136802] 827.38 percent of total billed charges 647.86 992.69 Technical (Hospital) Services BUDESONIDE-FORMOTEROL HFA 80 MCG-4.5 MCG/ACTUATION AEROSOL INHALER RX-81453 CDM 6370000100 HCPCS 250 RC 00186-0372-20 NDC inpatient 11 GR 1044.94 1044.94 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES PPO [308136801] 827.38 percent of total billed charges 647.86 992.69 Technical (Hospital) Services BUDESONIDE-FORMOTEROL HFA 80 MCG-4.5 MCG/ACTUATION AEROSOL INHALER RX-81453 CDM 6370000100 HCPCS 250 RC 00186-0372-20 NDC outpatient 11 GR 1044.94 1044.94 BLUE CROSS BLUE SHIELD WELLMARK SB889 [3081026] BCBS WYOMING [308102603] 992.69 percent of total billed charges 647.86 992.69 Technical (Hospital) Services BUDESONIDE-FORMOTEROL HFA 80 MCG-4.5 MCG/ACTUATION AEROSOL INHALER RX-81453 CDM 6370000100 HCPCS 250 RC 00186-0372-20 NDC outpatient 11 GR 1044.94 1044.94 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES EPO [308136803] 835.95 percent of total billed charges 647.86 992.69 Technical (Hospital) Services BUDESONIDE-FORMOTEROL HFA 80 MCG-4.5 MCG/ACTUATION AEROSOL INHALER RX-81453 CDM 6370000100 HCPCS 250 RC 00186-0372-20 NDC outpatient 11 GR 1044.94 1044.94 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES HDHP [308136802] 835.95 percent of total billed charges 647.86 992.69 Technical (Hospital) Services BUDESONIDE-FORMOTEROL HFA 80 MCG-4.5 MCG/ACTUATION AEROSOL INHALER RX-81453 CDM 6370000100 HCPCS 250 RC 00186-0372-20 NDC outpatient 11 GR 1044.94 1044.94 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES PPO [308136801] 835.95 percent of total billed charges 647.86 992.69 Technical (Hospital) Services BUDESONIDE-FORMOTEROL HFA 80 MCG-4.5 MCG/ACTUATION AEROSOL INHALER RX-81453 CDM 6370000100 HCPCS 250 RC 00186-0372-20 NDC outpatient 11 GR 1044.94 1044.94 UNITED HEALTHCARE (COMMERCIAL) [3081199] UNITED HEALTHCARE 87726 [308119901] 647.86 percent of total billed charges 647.86 992.69 Technical (Hospital) Services BUDESONIDE-FORMOTEROL HFA 80 MCG-4.5 MCG/ACTUATION AEROSOL INHALER RX-81453 CDM 6370000100 HCPCS 250 RC 00186-0372-20 NDC outpatient 11 GR 1044.94 1044.94 HEALTHPARTNERS SX009 HEALTHPARTNERS 835.95 percent of total billed charges 647.86 992.69 Technical (Hospital) Services BUDESONIDE-FORMOTEROL HFA 80 MCG-4.5 MCG/ACTUATION AEROSOL INHALER RX-81453 CDM 6370000100 HCPCS 250 RC 00186-0372-20 NDC outpatient 11 GR 1044.94 1044.94 MULTIPLAN INC 34080 [3081285] MULTIPLAN INC [308128501] 992.69 percent of total billed charges 647.86 992.69 Technical (Hospital) Services BUDESONIDE-FORMOTEROL HFA 80 MCG-4.5 MCG/ACTUATION AEROSOL INHALER RX-81453 CDM 6370000100 HCPCS 250 RC 00186-0372-20 NDC outpatient 11 GR 1044.94 1044.94 MEDICA (COMMERCIAL) 94265 [3081118] MEDICA CLAIMS [308111801] 940.45 percent of total billed charges 647.86 992.69 Technical (Hospital) Services BUDESONIDE-FORMOTEROL HFA 80 MCG-4.5 MCG/ACTUATION AEROSOL INHALER RX-81453 CDM 6370000100 HCPCS 250 RC 00186-0372-20 NDC outpatient 11 GR 1044.94 1044.94 CIGNA 62308 [3081051] CIGNA 62308 [308105105] 835.95 percent of total billed charges 647.86 992.69 Technical (Hospital) Services BUDESONIDE-FORMOTEROL HFA 80 MCG-4.5 MCG/ACTUATION AEROSOL INHALER RX-81453 CDM 6370000100 HCPCS 250 RC 00186-0372-20 NDC outpatient 11 GR 1044.94 1044.94 CIGNA 62308 [3081051] CIGNA STATE OF WYOMING [308105107] 835.95 percent of total billed charges 647.86 992.69 Technical (Hospital) Services BUDESONIDE-FORMOTEROL HFA 160 MCG-4.5 MCG/ACTUATION AEROSOL INHALER RX-81454 CDM 6370000100 HCPCS 250 RC 00186-0370-20 NDC outpatient 11 GR 1103.57 1103.57 HEALTHPARTNERS SX009 HEALTHPARTNERS 882.86 percent of total billed charges 684.21 1048.39 Technical (Hospital) Services BUDESONIDE-FORMOTEROL HFA 160 MCG-4.5 MCG/ACTUATION AEROSOL INHALER RX-81454 CDM 6370000100 HCPCS 250 RC 00186-0370-20 NDC outpatient 11 GR 1103.57 1103.57 UNITED HEALTHCARE (COMMERCIAL) [3081199] UNITED HEALTHCARE 87726 [308119901] 684.21 percent of total billed charges 684.21 1048.39 Technical (Hospital) Services BUDESONIDE-FORMOTEROL HFA 160 MCG-4.5 MCG/ACTUATION AEROSOL INHALER RX-81454 CDM 6370000100 HCPCS 250 RC 00186-0370-20 NDC outpatient 11 GR 1103.57 1103.57 BLUE CROSS BLUE SHIELD WELLMARK SB889 [3081026] BCBS WYOMING [308102603] 1048.39 percent of total billed charges 684.21 1048.39 Technical (Hospital) Services BUDESONIDE-FORMOTEROL HFA 160 MCG-4.5 MCG/ACTUATION AEROSOL INHALER RX-81454 CDM 6370000100 HCPCS 250 RC 00186-0370-20 NDC outpatient 11 GR 1103.57 1103.57 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES EPO [308136803] 882.86 percent of total billed charges 684.21 1048.39 Technical (Hospital) Services BUDESONIDE-FORMOTEROL HFA 160 MCG-4.5 MCG/ACTUATION AEROSOL INHALER RX-81454 CDM 6370000100 HCPCS 250 RC 00186-0370-20 NDC inpatient 11 GR 1103.57 1103.57 CIGNA 62308 [3081051] CIGNA 62308 [308105105] 873.81 percent of total billed charges 684.21 1048.39 Technical (Hospital) Services BUDESONIDE-FORMOTEROL HFA 160 MCG-4.5 MCG/ACTUATION AEROSOL INHALER RX-81454 CDM 6370000100 HCPCS 250 RC 00186-0370-20 NDC inpatient 11 GR 1103.57 1103.57 CIGNA 62308 [3081051] CIGNA STATE OF WYOMING [308105107] 873.81 percent of total billed charges 684.21 1048.39 Technical (Hospital) Services BUDESONIDE-FORMOTEROL HFA 160 MCG-4.5 MCG/ACTUATION AEROSOL INHALER RX-81454 CDM 6370000100 HCPCS 250 RC 00186-0370-20 NDC outpatient 11 GR 1103.57 1103.57 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES HDHP [308136802] 882.86 percent of total billed charges 684.21 1048.39 Technical (Hospital) Services BUDESONIDE-FORMOTEROL HFA 160 MCG-4.5 MCG/ACTUATION AEROSOL INHALER RX-81454 CDM 6370000100 HCPCS 250 RC 00186-0370-20 NDC outpatient 11 GR 1103.57 1103.57 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES PPO [308136801] 882.86 percent of total billed charges 684.21 1048.39 Technical (Hospital) Services BUDESONIDE-FORMOTEROL HFA 160 MCG-4.5 MCG/ACTUATION AEROSOL INHALER RX-81454 CDM 6370000100 HCPCS 250 RC 00186-0370-20 NDC outpatient 11 GR 1103.57 1103.57 CIGNA 62308 [3081051] CIGNA 62308 [308105105] 882.86 percent of total billed charges 684.21 1048.39 Technical (Hospital) Services BUDESONIDE-FORMOTEROL HFA 160 MCG-4.5 MCG/ACTUATION AEROSOL INHALER RX-81454 CDM 6370000100 HCPCS 250 RC 00186-0370-20 NDC outpatient 11 GR 1103.57 1103.57 CIGNA 62308 [3081051] CIGNA STATE OF WYOMING [308105107] 882.86 percent of total billed charges 684.21 1048.39 Technical (Hospital) Services BUDESONIDE-FORMOTEROL HFA 160 MCG-4.5 MCG/ACTUATION AEROSOL INHALER RX-81454 CDM 6370000100 HCPCS 250 RC 00186-0370-20 NDC outpatient 11 GR 1103.57 1103.57 MEDICA (COMMERCIAL) 94265 [3081118] MEDICA CLAIMS [308111801] 993.21 percent of total billed charges 684.21 1048.39 Technical (Hospital) Services BUDESONIDE-FORMOTEROL HFA 160 MCG-4.5 MCG/ACTUATION AEROSOL INHALER RX-81454 CDM 6370000100 HCPCS 250 RC 00186-0370-20 NDC outpatient 11 GR 1103.57 1103.57 MULTIPLAN INC 34080 [3081285] MULTIPLAN INC [308128501] 1048.39 percent of total billed charges 684.21 1048.39 Technical (Hospital) Services BUDESONIDE-FORMOTEROL HFA 160 MCG-4.5 MCG/ACTUATION AEROSOL INHALER RX-81454 CDM 6370000100 HCPCS 250 RC 00186-0370-20 NDC inpatient 11 GR 1103.57 1103.57 HEALTHPARTNERS SX009 HEALTHPARTNERS 873.81 percent of total billed charges 684.21 1048.39 Technical (Hospital) Services BUDESONIDE-FORMOTEROL HFA 160 MCG-4.5 MCG/ACTUATION AEROSOL INHALER RX-81454 CDM 6370000100 HCPCS 250 RC 00186-0370-20 NDC inpatient 11 GR 1103.57 1103.57 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES EPO [308136803] 873.81 percent of total billed charges 684.21 1048.39 Technical (Hospital) Services BUDESONIDE-FORMOTEROL HFA 160 MCG-4.5 MCG/ACTUATION AEROSOL INHALER RX-81454 CDM 6370000100 HCPCS 250 RC 00186-0370-20 NDC inpatient 11 GR 1103.57 1103.57 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES HDHP [308136802] 873.81 percent of total billed charges 684.21 1048.39 Technical (Hospital) Services BUDESONIDE-FORMOTEROL HFA 160 MCG-4.5 MCG/ACTUATION AEROSOL INHALER RX-81454 CDM 6370000100 HCPCS 250 RC 00186-0370-20 NDC inpatient 11 GR 1103.57 1103.57 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES PPO [308136801] 873.81 percent of total billed charges 684.21 1048.39 Technical (Hospital) Services BUDESONIDE-FORMOTEROL HFA 160 MCG-4.5 MCG/ACTUATION AEROSOL INHALER RX-81454 CDM 6370000100 HCPCS 250 RC 00186-0370-20 NDC inpatient 11 GR 1103.57 1103.57 UNITED HEALTHCARE (COMMERCIAL) [3081199] UNITED HEALTHCARE 87726 [308119901] 684.21 percent of total billed charges 684.21 1048.39 Technical (Hospital) Services BUDESONIDE-FORMOTEROL HFA 160 MCG-4.5 MCG/ACTUATION AEROSOL INHALER RX-81454 CDM 6370000100 HCPCS 250 RC 00186-0370-20 NDC inpatient 11 GR 1103.57 1103.57 BLUE CROSS BLUE SHIELD WELLMARK SB889 [3081026] BCBS WYOMING [308102603] 1048.39 percent of total billed charges 684.21 1048.39 Technical (Hospital) Services BUDESONIDE-FORMOTEROL HFA 160 MCG-4.5 MCG/ACTUATION AEROSOL INHALER RX-81454 CDM 6370000100 HCPCS 250 RC 00186-0370-20 NDC inpatient 11 GR 1103.57 1103.57 MULTIPLAN INC 34080 [3081285] MULTIPLAN INC [308128501] 1048.39 percent of total billed charges 684.21 1048.39 Technical (Hospital) Services BUDESONIDE-FORMOTEROL HFA 160 MCG-4.5 MCG/ACTUATION AEROSOL INHALER RX-81454 CDM 6370000100 HCPCS 250 RC 00186-0370-20 NDC inpatient 11 GR 1103.57 1103.57 MEDICA (COMMERCIAL) 94265 [3081118] MEDICA CLAIMS [308111801] 993.21 percent of total billed charges 684.21 1048.39 Technical (Hospital) Services "QUETIAPINE ER 200 MG TABLET,EXTENDED RELEASE 24 HR" RX-82089 CDM 6370000100 HCPCS 250 RC 00310-0282-60 NDC inpatient 1 UN 64.23 64.23 MULTIPLAN INC 34080 [3081285] MULTIPLAN INC [308128501] 61.02 percent of total billed charges 39.82 61.02 Technical (Hospital) Services "QUETIAPINE ER 200 MG TABLET,EXTENDED RELEASE 24 HR" RX-82089 CDM 6370000100 HCPCS 250 RC 00310-0282-60 NDC inpatient 1 UN 64.23 64.23 BLUE CROSS BLUE SHIELD WELLMARK SB889 [3081026] BCBS WYOMING [308102603] 61.02 percent of total billed charges 39.82 61.02 Technical (Hospital) Services "QUETIAPINE ER 200 MG TABLET,EXTENDED RELEASE 24 HR" RX-82089 CDM 6370000100 HCPCS 250 RC 00310-0282-60 NDC inpatient 1 UN 64.23 64.23 UNITED HEALTHCARE (COMMERCIAL) [3081199] UNITED HEALTHCARE 87726 [308119901] 39.82 percent of total billed charges 39.82 61.02 Technical (Hospital) Services "QUETIAPINE ER 200 MG TABLET,EXTENDED RELEASE 24 HR" RX-82089 CDM 6370000100 HCPCS 250 RC 00310-0282-60 NDC inpatient 1 UN 64.23 64.23 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES HDHP [308136802] 50.86 percent of total billed charges 39.82 61.02 Technical (Hospital) Services "QUETIAPINE ER 200 MG TABLET,EXTENDED RELEASE 24 HR" RX-82089 CDM 6370000100 HCPCS 250 RC 00310-0282-60 NDC inpatient 1 UN 64.23 64.23 CIGNA 62308 [3081051] CIGNA 62308 [308105105] 50.86 percent of total billed charges 39.82 61.02 Technical (Hospital) Services "QUETIAPINE ER 200 MG TABLET,EXTENDED RELEASE 24 HR" RX-82089 CDM 6370000100 HCPCS 250 RC 00310-0282-60 NDC inpatient 1 UN 64.23 64.23 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES EPO [308136803] 50.86 percent of total billed charges 39.82 61.02 Technical (Hospital) Services "QUETIAPINE ER 200 MG TABLET,EXTENDED RELEASE 24 HR" RX-82089 CDM 6370000100 HCPCS 250 RC 00310-0282-60 NDC inpatient 1 UN 64.23 64.23 CIGNA 62308 [3081051] CIGNA STATE OF WYOMING [308105107] 50.86 percent of total billed charges 39.82 61.02 Technical (Hospital) Services "QUETIAPINE ER 200 MG TABLET,EXTENDED RELEASE 24 HR" RX-82089 CDM 6370000100 HCPCS 250 RC 00310-0282-60 NDC inpatient 1 UN 64.23 64.23 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES PPO [308136801] 50.86 percent of total billed charges 39.82 61.02 Technical (Hospital) Services "QUETIAPINE ER 200 MG TABLET,EXTENDED RELEASE 24 HR" RX-82089 CDM 6370000100 HCPCS 250 RC 00310-0282-60 NDC inpatient 1 UN 64.23 64.23 MEDICA (COMMERCIAL) 94265 [3081118] MEDICA CLAIMS [308111801] 57.81 percent of total billed charges 39.82 61.02 Technical (Hospital) Services "QUETIAPINE ER 200 MG TABLET,EXTENDED RELEASE 24 HR" RX-82089 CDM 6370000100 HCPCS 250 RC 00310-0282-60 NDC inpatient 1 UN 64.23 64.23 HEALTHPARTNERS SX009 HEALTHPARTNERS 50.86 percent of total billed charges 39.82 61.02 Technical (Hospital) Services "QUETIAPINE ER 200 MG TABLET,EXTENDED RELEASE 24 HR" RX-82089 CDM 6370000100 HCPCS 250 RC 00310-0282-60 NDC outpatient 1 UN 64.23 64.23 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES EPO [308136803] 51.38 percent of total billed charges 39.82 61.02 Technical (Hospital) Services "QUETIAPINE ER 200 MG TABLET,EXTENDED RELEASE 24 HR" RX-82089 CDM 6370000100 HCPCS 250 RC 00310-0282-60 NDC outpatient 1 UN 64.23 64.23 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES HDHP [308136802] 51.38 percent of total billed charges 39.82 61.02 Technical (Hospital) Services "QUETIAPINE ER 200 MG TABLET,EXTENDED RELEASE 24 HR" RX-82089 CDM 6370000100 HCPCS 250 RC 00310-0282-60 NDC outpatient 1 UN 64.23 64.23 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES PPO [308136801] 51.38 percent of total billed charges 39.82 61.02 Technical (Hospital) Services "QUETIAPINE ER 200 MG TABLET,EXTENDED RELEASE 24 HR" RX-82089 CDM 6370000100 HCPCS 250 RC 00310-0282-60 NDC outpatient 1 UN 64.23 64.23 MULTIPLAN INC 34080 [3081285] MULTIPLAN INC [308128501] 61.02 percent of total billed charges 39.82 61.02 Technical (Hospital) Services "QUETIAPINE ER 200 MG TABLET,EXTENDED RELEASE 24 HR" RX-82089 CDM 6370000100 HCPCS 250 RC 00310-0282-60 NDC outpatient 1 UN 64.23 64.23 CIGNA 62308 [3081051] CIGNA 62308 [308105105] 51.38 percent of total billed charges 39.82 61.02 Technical (Hospital) Services "QUETIAPINE ER 200 MG TABLET,EXTENDED RELEASE 24 HR" RX-82089 CDM 6370000100 HCPCS 250 RC 00310-0282-60 NDC outpatient 1 UN 64.23 64.23 CIGNA 62308 [3081051] CIGNA STATE OF WYOMING [308105107] 51.38 percent of total billed charges 39.82 61.02 Technical (Hospital) Services "QUETIAPINE ER 200 MG TABLET,EXTENDED RELEASE 24 HR" RX-82089 CDM 6370000100 HCPCS 250 RC 00310-0282-60 NDC outpatient 1 UN 64.23 64.23 MEDICA (COMMERCIAL) 94265 [3081118] MEDICA CLAIMS [308111801] 57.81 percent of total billed charges 39.82 61.02 Technical (Hospital) Services "QUETIAPINE ER 200 MG TABLET,EXTENDED RELEASE 24 HR" RX-82089 CDM 6370000100 HCPCS 250 RC 00310-0282-60 NDC outpatient 1 UN 64.23 64.23 UNITED HEALTHCARE (COMMERCIAL) [3081199] UNITED HEALTHCARE 87726 [308119901] 39.82 percent of total billed charges 39.82 61.02 Technical (Hospital) Services "QUETIAPINE ER 200 MG TABLET,EXTENDED RELEASE 24 HR" RX-82089 CDM 6370000100 HCPCS 250 RC 00310-0282-60 NDC outpatient 1 UN 64.23 64.23 HEALTHPARTNERS SX009 HEALTHPARTNERS 51.38 percent of total billed charges 39.82 61.02 Technical (Hospital) Services "QUETIAPINE ER 200 MG TABLET,EXTENDED RELEASE 24 HR" RX-82089 CDM 6370000100 HCPCS 250 RC 00310-0282-60 NDC outpatient 1 UN 64.23 64.23 BLUE CROSS BLUE SHIELD WELLMARK SB889 [3081026] BCBS WYOMING [308102603] 61.02 percent of total billed charges 39.82 61.02 Technical (Hospital) Services SODIUM CHLORIDE 7 % FOR NEBULIZATION RX-82134 CDM 6370000100 HCPCS 250 RC 83490-0307-60 NDC inpatient 4 ML 5.87 5.87 MEDICA (COMMERCIAL) 94265 [3081118] MEDICA CLAIMS [308111801] 5.28 percent of total billed charges 3.64 5.58 Technical (Hospital) Services SODIUM CHLORIDE 7 % FOR NEBULIZATION RX-82134 CDM 6370000100 HCPCS 250 RC 83490-0307-60 NDC inpatient 4 ML 5.87 5.87 MULTIPLAN INC 34080 [3081285] MULTIPLAN INC [308128501] 5.58 percent of total billed charges 3.64 5.58 Technical (Hospital) Services SODIUM CHLORIDE 7 % FOR NEBULIZATION RX-82134 CDM 6370000100 HCPCS 250 RC 83490-0307-60 NDC inpatient 4 ML 5.87 5.87 BLUE CROSS BLUE SHIELD WELLMARK SB889 [3081026] BCBS WYOMING [308102603] 5.58 percent of total billed charges 3.64 5.58 Technical (Hospital) Services SODIUM CHLORIDE 7 % FOR NEBULIZATION RX-82134 CDM 6370000100 HCPCS 250 RC 83490-0307-60 NDC inpatient 4 ML 5.87 5.87 UNITED HEALTHCARE (COMMERCIAL) [3081199] UNITED HEALTHCARE 87726 [308119901] 3.64 percent of total billed charges 3.64 5.58 Technical (Hospital) Services SODIUM CHLORIDE 7 % FOR NEBULIZATION RX-82134 CDM 6370000100 HCPCS 250 RC 83490-0307-60 NDC inpatient 4 ML 5.87 5.87 CIGNA 62308 [3081051] CIGNA 62308 [308105105] 4.65 percent of total billed charges 3.64 5.58 Technical (Hospital) Services SODIUM CHLORIDE 7 % FOR NEBULIZATION RX-82134 CDM 6370000100 HCPCS 250 RC 83490-0307-60 NDC inpatient 4 ML 5.87 5.87 CIGNA 62308 [3081051] CIGNA STATE OF WYOMING [308105107] 4.65 percent of total billed charges 3.64 5.58 Technical (Hospital) Services SODIUM CHLORIDE 7 % FOR NEBULIZATION RX-82134 CDM 6370000100 HCPCS 250 RC 83490-0307-60 NDC inpatient 4 ML 5.87 5.87 HEALTHPARTNERS SX009 HEALTHPARTNERS 4.65 percent of total billed charges 3.64 5.58 Technical (Hospital) Services SODIUM CHLORIDE 7 % FOR NEBULIZATION RX-82134 CDM 6370000100 HCPCS 250 RC 83490-0307-60 NDC inpatient 4 ML 5.87 5.87 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES EPO [308136803] 4.65 percent of total billed charges 3.64 5.58 Technical (Hospital) Services SODIUM CHLORIDE 7 % FOR NEBULIZATION RX-82134 CDM 6370000100 HCPCS 250 RC 83490-0307-60 NDC inpatient 4 ML 5.87 5.87 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES PPO [308136801] 4.65 percent of total billed charges 3.64 5.58 Technical (Hospital) Services SODIUM CHLORIDE 7 % FOR NEBULIZATION RX-82134 CDM 6370000100 HCPCS 250 RC 83490-0307-60 NDC inpatient 4 ML 5.87 5.87 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES HDHP [308136802] 4.65 percent of total billed charges 3.64 5.58 Technical (Hospital) Services SODIUM CHLORIDE 7 % FOR NEBULIZATION RX-82134 CDM 6370000100 HCPCS 250 RC 83490-0307-60 NDC outpatient 4 ML 5.87 5.87 MEDICA (COMMERCIAL) 94265 [3081118] MEDICA CLAIMS [308111801] 5.28 percent of total billed charges 3.64 5.58 Technical (Hospital) Services SODIUM CHLORIDE 7 % FOR NEBULIZATION RX-82134 CDM 6370000100 HCPCS 250 RC 83490-0307-60 NDC outpatient 4 ML 5.87 5.87 MULTIPLAN INC 34080 [3081285] MULTIPLAN INC [308128501] 5.58 percent of total billed charges 3.64 5.58 Technical (Hospital) Services SODIUM CHLORIDE 7 % FOR NEBULIZATION RX-82134 CDM 6370000100 HCPCS 250 RC 83490-0307-60 NDC outpatient 4 ML 5.87 5.87 UNITED HEALTHCARE (COMMERCIAL) [3081199] UNITED HEALTHCARE 87726 [308119901] 3.64 percent of total billed charges 3.64 5.58 Technical (Hospital) Services SODIUM CHLORIDE 7 % FOR NEBULIZATION RX-82134 CDM 6370000100 HCPCS 250 RC 83490-0307-60 NDC outpatient 4 ML 5.87 5.87 HEALTHPARTNERS SX009 HEALTHPARTNERS 4.7 percent of total billed charges 3.64 5.58 Technical (Hospital) Services SODIUM CHLORIDE 7 % FOR NEBULIZATION RX-82134 CDM 6370000100 HCPCS 250 RC 83490-0307-60 NDC outpatient 4 ML 5.87 5.87 CIGNA 62308 [3081051] CIGNA 62308 [308105105] 4.7 percent of total billed charges 3.64 5.58 Technical (Hospital) Services SODIUM CHLORIDE 7 % FOR NEBULIZATION RX-82134 CDM 6370000100 HCPCS 250 RC 83490-0307-60 NDC outpatient 4 ML 5.87 5.87 CIGNA 62308 [3081051] CIGNA STATE OF WYOMING [308105107] 4.7 percent of total billed charges 3.64 5.58 Technical (Hospital) Services SODIUM CHLORIDE 7 % FOR NEBULIZATION RX-82134 CDM 6370000100 HCPCS 250 RC 83490-0307-60 NDC outpatient 4 ML 5.87 5.87 BLUE CROSS BLUE SHIELD WELLMARK SB889 [3081026] BCBS WYOMING [308102603] 5.58 percent of total billed charges 3.64 5.58 Technical (Hospital) Services SODIUM CHLORIDE 7 % FOR NEBULIZATION RX-82134 CDM 6370000100 HCPCS 250 RC 83490-0307-60 NDC outpatient 4 ML 5.87 5.87 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES EPO [308136803] 4.7 percent of total billed charges 3.64 5.58 Technical (Hospital) Services SODIUM CHLORIDE 7 % FOR NEBULIZATION RX-82134 CDM 6370000100 HCPCS 250 RC 83490-0307-60 NDC outpatient 4 ML 5.87 5.87 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES HDHP [308136802] 4.7 percent of total billed charges 3.64 5.58 Technical (Hospital) Services SODIUM CHLORIDE 7 % FOR NEBULIZATION RX-82134 CDM 6370000100 HCPCS 250 RC 83490-0307-60 NDC outpatient 4 ML 5.87 5.87 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES PPO [308136801] 4.7 percent of total billed charges 3.64 5.58 Technical (Hospital) Services MELATONIN 1 MG TABLET RX-82464 CDM 6370000100 HCPCS 250 RC 80681-0041-00 NDC inpatient 1 UN 5.64 5.64 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES EPO [308136803] 4.47 percent of total billed charges 3.5 5.36 Technical (Hospital) Services MELATONIN 1 MG TABLET RX-82464 CDM 6370000100 HCPCS 250 RC 80681-0041-00 NDC inpatient 1 UN 5.64 5.64 CIGNA 62308 [3081051] CIGNA 62308 [308105105] 4.47 percent of total billed charges 3.5 5.36 Technical (Hospital) Services MELATONIN 1 MG TABLET RX-82464 CDM 6370000100 HCPCS 250 RC 80681-0041-00 NDC inpatient 1 UN 5.64 5.64 CIGNA 62308 [3081051] CIGNA STATE OF WYOMING [308105107] 4.47 percent of total billed charges 3.5 5.36 Technical (Hospital) Services MELATONIN 1 MG TABLET RX-82464 CDM 6370000100 HCPCS 250 RC 80681-0041-00 NDC inpatient 1 UN 5.64 5.64 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES HDHP [308136802] 4.47 percent of total billed charges 3.5 5.36 Technical (Hospital) Services MELATONIN 1 MG TABLET RX-82464 CDM 6370000100 HCPCS 250 RC 80681-0041-00 NDC inpatient 1 UN 5.64 5.64 BLUE CROSS BLUE SHIELD WELLMARK SB889 [3081026] BCBS WYOMING [308102603] 5.36 percent of total billed charges 3.5 5.36 Technical (Hospital) Services MELATONIN 1 MG TABLET RX-82464 CDM 6370000100 HCPCS 250 RC 80681-0041-00 NDC inpatient 1 UN 5.64 5.64 UNITED HEALTHCARE (COMMERCIAL) [3081199] UNITED HEALTHCARE 87726 [308119901] 3.5 percent of total billed charges 3.5 5.36 Technical (Hospital) Services MELATONIN 1 MG TABLET RX-82464 CDM 6370000100 HCPCS 250 RC 80681-0041-00 NDC inpatient 1 UN 5.64 5.64 MULTIPLAN INC 34080 [3081285] MULTIPLAN INC [308128501] 5.36 percent of total billed charges 3.5 5.36 Technical (Hospital) Services MELATONIN 1 MG TABLET RX-82464 CDM 6370000100 HCPCS 250 RC 80681-0041-00 NDC inpatient 1 UN 5.64 5.64 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES PPO [308136801] 4.47 percent of total billed charges 3.5 5.36 Technical (Hospital) Services MELATONIN 1 MG TABLET RX-82464 CDM 6370000100 HCPCS 250 RC 80681-0041-00 NDC inpatient 1 UN 5.64 5.64 MEDICA (COMMERCIAL) 94265 [3081118] MEDICA CLAIMS [308111801] 5.08 percent of total billed charges 3.5 5.36 Technical (Hospital) Services MELATONIN 1 MG TABLET RX-82464 CDM 6370000100 HCPCS 250 RC 80681-0041-00 NDC inpatient 1 UN 5.64 5.64 HEALTHPARTNERS SX009 HEALTHPARTNERS 4.47 percent of total billed charges 3.5 5.36 Technical (Hospital) Services MELATONIN 1 MG TABLET RX-82464 CDM 6370000100 HCPCS 250 RC 80681-0041-00 NDC outpatient 1 UN 5.64 5.64 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES HDHP [308136802] 4.51 percent of total billed charges 3.5 5.36 Technical (Hospital) Services MELATONIN 1 MG TABLET RX-82464 CDM 6370000100 HCPCS 250 RC 80681-0041-00 NDC outpatient 1 UN 5.64 5.64 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES PPO [308136801] 4.51 percent of total billed charges 3.5 5.36 Technical (Hospital) Services MELATONIN 1 MG TABLET RX-82464 CDM 6370000100 HCPCS 250 RC 80681-0041-00 NDC outpatient 1 UN 5.64 5.64 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES EPO [308136803] 4.51 percent of total billed charges 3.5 5.36 Technical (Hospital) Services MELATONIN 1 MG TABLET RX-82464 CDM 6370000100 HCPCS 250 RC 80681-0041-00 NDC outpatient 1 UN 5.64 5.64 BLUE CROSS BLUE SHIELD WELLMARK SB889 [3081026] BCBS WYOMING [308102603] 5.36 percent of total billed charges 3.5 5.36 Technical (Hospital) Services MELATONIN 1 MG TABLET RX-82464 CDM 6370000100 HCPCS 250 RC 80681-0041-00 NDC outpatient 1 UN 5.64 5.64 HEALTHPARTNERS SX009 HEALTHPARTNERS 4.51 percent of total billed charges 3.5 5.36 Technical (Hospital) Services MELATONIN 1 MG TABLET RX-82464 CDM 6370000100 HCPCS 250 RC 80681-0041-00 NDC outpatient 1 UN 5.64 5.64 UNITED HEALTHCARE (COMMERCIAL) [3081199] UNITED HEALTHCARE 87726 [308119901] 3.5 percent of total billed charges 3.5 5.36 Technical (Hospital) Services MELATONIN 1 MG TABLET RX-82464 CDM 6370000100 HCPCS 250 RC 80681-0041-00 NDC outpatient 1 UN 5.64 5.64 MULTIPLAN INC 34080 [3081285] MULTIPLAN INC [308128501] 5.36 percent of total billed charges 3.5 5.36 Technical (Hospital) Services MELATONIN 1 MG TABLET RX-82464 CDM 6370000100 HCPCS 250 RC 80681-0041-00 NDC outpatient 1 UN 5.64 5.64 CIGNA 62308 [3081051] CIGNA 62308 [308105105] 4.51 percent of total billed charges 3.5 5.36 Technical (Hospital) Services MELATONIN 1 MG TABLET RX-82464 CDM 6370000100 HCPCS 250 RC 80681-0041-00 NDC outpatient 1 UN 5.64 5.64 CIGNA 62308 [3081051] CIGNA STATE OF WYOMING [308105107] 4.51 percent of total billed charges 3.5 5.36 Technical (Hospital) Services MELATONIN 1 MG TABLET RX-82464 CDM 6370000100 HCPCS 250 RC 80681-0041-00 NDC outpatient 1 UN 5.64 5.64 MEDICA (COMMERCIAL) 94265 [3081118] MEDICA CLAIMS [308111801] 5.08 percent of total billed charges 3.5 5.36 Technical (Hospital) Services VERAPAMIL 40 MG TABLET RX-8529 CDM 6370000100 HCPCS 250 RC 23155-0059-01 NDC inpatient 1 UN 5.78 5.78 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES PPO [308136801] 4.58 percent of total billed charges 3.58 5.49 Technical (Hospital) Services VERAPAMIL 40 MG TABLET RX-8529 CDM 6370000100 HCPCS 250 RC 23155-0059-01 NDC inpatient 1 UN 5.78 5.78 MEDICA (COMMERCIAL) 94265 [3081118] MEDICA CLAIMS [308111801] 5.2 percent of total billed charges 3.58 5.49 Technical (Hospital) Services VERAPAMIL 40 MG TABLET RX-8529 CDM 6370000100 HCPCS 250 RC 23155-0059-01 NDC inpatient 1 UN 5.78 5.78 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES EPO [308136803] 4.58 percent of total billed charges 3.58 5.49 Technical (Hospital) Services VERAPAMIL 40 MG TABLET RX-8529 CDM 6370000100 HCPCS 250 RC 23155-0059-01 NDC inpatient 1 UN 5.78 5.78 CIGNA 62308 [3081051] CIGNA 62308 [308105105] 4.58 percent of total billed charges 3.58 5.49 Technical (Hospital) Services VERAPAMIL 40 MG TABLET RX-8529 CDM 6370000100 HCPCS 250 RC 23155-0059-01 NDC inpatient 1 UN 5.78 5.78 CIGNA 62308 [3081051] CIGNA STATE OF WYOMING [308105107] 4.58 percent of total billed charges 3.58 5.49 Technical (Hospital) Services VERAPAMIL 40 MG TABLET RX-8529 CDM 6370000100 HCPCS 250 RC 23155-0059-01 NDC inpatient 1 UN 5.78 5.78 UNITED HEALTHCARE (COMMERCIAL) [3081199] UNITED HEALTHCARE 87726 [308119901] 3.58 percent of total billed charges 3.58 5.49 Technical (Hospital) Services VERAPAMIL 40 MG TABLET RX-8529 CDM 6370000100 HCPCS 250 RC 23155-0059-01 NDC inpatient 1 UN 5.78 5.78 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES HDHP [308136802] 4.58 percent of total billed charges 3.58 5.49 Technical (Hospital) Services VERAPAMIL 40 MG TABLET RX-8529 CDM 6370000100 HCPCS 250 RC 23155-0059-01 NDC inpatient 1 UN 5.78 5.78 HEALTHPARTNERS SX009 HEALTHPARTNERS 4.58 percent of total billed charges 3.58 5.49 Technical (Hospital) Services VERAPAMIL 40 MG TABLET RX-8529 CDM 6370000100 HCPCS 250 RC 23155-0059-01 NDC inpatient 1 UN 5.78 5.78 MULTIPLAN INC 34080 [3081285] MULTIPLAN INC [308128501] 5.49 percent of total billed charges 3.58 5.49 Technical (Hospital) Services VERAPAMIL 40 MG TABLET RX-8529 CDM 6370000100 HCPCS 250 RC 23155-0059-01 NDC inpatient 1 UN 5.78 5.78 BLUE CROSS BLUE SHIELD WELLMARK SB889 [3081026] BCBS WYOMING [308102603] 5.49 percent of total billed charges 3.58 5.49 Technical (Hospital) Services VERAPAMIL 40 MG TABLET RX-8529 CDM 6370000100 HCPCS 250 RC 23155-0059-01 NDC outpatient 1 UN 5.78 5.78 MEDICA (COMMERCIAL) 94265 [3081118] MEDICA CLAIMS [308111801] 5.2 percent of total billed charges 3.58 5.49 Technical (Hospital) Services VERAPAMIL 40 MG TABLET RX-8529 CDM 6370000100 HCPCS 250 RC 23155-0059-01 NDC outpatient 1 UN 5.78 5.78 CIGNA 62308 [3081051] CIGNA 62308 [308105105] 4.62 percent of total billed charges 3.58 5.49 Technical (Hospital) Services VERAPAMIL 40 MG TABLET RX-8529 CDM 6370000100 HCPCS 250 RC 23155-0059-01 NDC outpatient 1 UN 5.78 5.78 CIGNA 62308 [3081051] CIGNA STATE OF WYOMING [308105107] 4.62 percent of total billed charges 3.58 5.49 Technical (Hospital) Services VERAPAMIL 40 MG TABLET RX-8529 CDM 6370000100 HCPCS 250 RC 23155-0059-01 NDC outpatient 1 UN 5.78 5.78 MULTIPLAN INC 34080 [3081285] MULTIPLAN INC [308128501] 5.49 percent of total billed charges 3.58 5.49 Technical (Hospital) Services VERAPAMIL 40 MG TABLET RX-8529 CDM 6370000100 HCPCS 250 RC 23155-0059-01 NDC outpatient 1 UN 5.78 5.78 UNITED HEALTHCARE (COMMERCIAL) [3081199] UNITED HEALTHCARE 87726 [308119901] 3.58 percent of total billed charges 3.58 5.49 Technical (Hospital) Services VERAPAMIL 40 MG TABLET RX-8529 CDM 6370000100 HCPCS 250 RC 23155-0059-01 NDC outpatient 1 UN 5.78 5.78 HEALTHPARTNERS SX009 HEALTHPARTNERS 4.62 percent of total billed charges 3.58 5.49 Technical (Hospital) Services VERAPAMIL 40 MG TABLET RX-8529 CDM 6370000100 HCPCS 250 RC 23155-0059-01 NDC outpatient 1 UN 5.78 5.78 BLUE CROSS BLUE SHIELD WELLMARK SB889 [3081026] BCBS WYOMING [308102603] 5.49 percent of total billed charges 3.58 5.49 Technical (Hospital) Services VERAPAMIL 40 MG TABLET RX-8529 CDM 6370000100 HCPCS 250 RC 23155-0059-01 NDC outpatient 1 UN 5.78 5.78 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES HDHP [308136802] 4.62 percent of total billed charges 3.58 5.49 Technical (Hospital) Services VERAPAMIL 40 MG TABLET RX-8529 CDM 6370000100 HCPCS 250 RC 23155-0059-01 NDC outpatient 1 UN 5.78 5.78 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES PPO [308136801] 4.62 percent of total billed charges 3.58 5.49 Technical (Hospital) Services VERAPAMIL 40 MG TABLET RX-8529 CDM 6370000100 HCPCS 250 RC 23155-0059-01 NDC outpatient 1 UN 5.78 5.78 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES EPO [308136803] 4.62 percent of total billed charges 3.58 5.49 Technical (Hospital) Services BACLOFEN 10 MG TABLET RX-860 CDM 6370000100 HCPCS 250 RC 00172-4096-80 NDC inpatient 1 UN 5.84 5.84 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES PPO [308136801] 4.62 percent of total billed charges 3.62 5.55 Technical (Hospital) Services BACLOFEN 10 MG TABLET RX-860 CDM 6370000100 HCPCS 250 RC 00172-4096-80 NDC inpatient 1 UN 5.84 5.84 MEDICA (COMMERCIAL) 94265 [3081118] MEDICA CLAIMS [308111801] 5.26 percent of total billed charges 3.62 5.55 Technical (Hospital) Services BACLOFEN 10 MG TABLET RX-860 CDM 6370000100 HCPCS 250 RC 00172-4096-80 NDC inpatient 1 UN 5.84 5.84 BLUE CROSS BLUE SHIELD WELLMARK SB889 [3081026] BCBS WYOMING [308102603] 5.55 percent of total billed charges 3.62 5.55 Technical (Hospital) Services BACLOFEN 10 MG TABLET RX-860 CDM 6370000100 HCPCS 250 RC 00172-4096-80 NDC inpatient 1 UN 5.84 5.84 MULTIPLAN INC 34080 [3081285] MULTIPLAN INC [308128501] 5.55 percent of total billed charges 3.62 5.55 Technical (Hospital) Services BACLOFEN 10 MG TABLET RX-860 CDM 6370000100 HCPCS 250 RC 00172-4096-80 NDC inpatient 1 UN 5.84 5.84 UNITED HEALTHCARE (COMMERCIAL) [3081199] UNITED HEALTHCARE 87726 [308119901] 3.62 percent of total billed charges 3.62 5.55 Technical (Hospital) Services BACLOFEN 10 MG TABLET RX-860 CDM 6370000100 HCPCS 250 RC 00172-4096-80 NDC inpatient 1 UN 5.84 5.84 CIGNA 62308 [3081051] CIGNA 62308 [308105105] 4.62 percent of total billed charges 3.62 5.55 Technical (Hospital) Services BACLOFEN 10 MG TABLET RX-860 CDM 6370000100 HCPCS 250 RC 00172-4096-80 NDC inpatient 1 UN 5.84 5.84 CIGNA 62308 [3081051] CIGNA STATE OF WYOMING [308105107] 4.62 percent of total billed charges 3.62 5.55 Technical (Hospital) Services BACLOFEN 10 MG TABLET RX-860 CDM 6370000100 HCPCS 250 RC 00172-4096-80 NDC inpatient 1 UN 5.84 5.84 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES EPO [308136803] 4.62 percent of total billed charges 3.62 5.55 Technical (Hospital) Services BACLOFEN 10 MG TABLET RX-860 CDM 6370000100 HCPCS 250 RC 00172-4096-80 NDC inpatient 1 UN 5.84 5.84 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES HDHP [308136802] 4.62 percent of total billed charges 3.62 5.55 Technical (Hospital) Services BACLOFEN 10 MG TABLET RX-860 CDM 6370000100 HCPCS 250 RC 00172-4096-80 NDC inpatient 1 UN 5.84 5.84 HEALTHPARTNERS SX009 HEALTHPARTNERS 4.62 percent of total billed charges 3.62 5.55 Technical (Hospital) Services BACLOFEN 10 MG TABLET RX-860 CDM 6370000100 HCPCS 250 RC 00172-4096-80 NDC outpatient 1 UN 5.84 5.84 BLUE CROSS BLUE SHIELD WELLMARK SB889 [3081026] BCBS WYOMING [308102603] 5.55 percent of total billed charges 3.62 5.55 Technical (Hospital) Services BACLOFEN 10 MG TABLET RX-860 CDM 6370000100 HCPCS 250 RC 00172-4096-80 NDC outpatient 1 UN 5.84 5.84 HEALTHPARTNERS SX009 HEALTHPARTNERS 4.67 percent of total billed charges 3.62 5.55 Technical (Hospital) Services BACLOFEN 10 MG TABLET RX-860 CDM 6370000100 HCPCS 250 RC 00172-4096-80 NDC outpatient 1 UN 5.84 5.84 UNITED HEALTHCARE (COMMERCIAL) [3081199] UNITED HEALTHCARE 87726 [308119901] 3.62 percent of total billed charges 3.62 5.55 Technical (Hospital) Services BACLOFEN 10 MG TABLET RX-860 CDM 6370000100 HCPCS 250 RC 00172-4096-80 NDC outpatient 1 UN 5.84 5.84 MEDICA (COMMERCIAL) 94265 [3081118] MEDICA CLAIMS [308111801] 5.26 percent of total billed charges 3.62 5.55 Technical (Hospital) Services BACLOFEN 10 MG TABLET RX-860 CDM 6370000100 HCPCS 250 RC 00172-4096-80 NDC outpatient 1 UN 5.84 5.84 CIGNA 62308 [3081051] CIGNA 62308 [308105105] 4.67 percent of total billed charges 3.62 5.55 Technical (Hospital) Services BACLOFEN 10 MG TABLET RX-860 CDM 6370000100 HCPCS 250 RC 00172-4096-80 NDC outpatient 1 UN 5.84 5.84 CIGNA 62308 [3081051] CIGNA STATE OF WYOMING [308105107] 4.67 percent of total billed charges 3.62 5.55 Technical (Hospital) Services BACLOFEN 10 MG TABLET RX-860 CDM 6370000100 HCPCS 250 RC 00172-4096-80 NDC outpatient 1 UN 5.84 5.84 MULTIPLAN INC 34080 [3081285] MULTIPLAN INC [308128501] 5.55 percent of total billed charges 3.62 5.55 Technical (Hospital) Services BACLOFEN 10 MG TABLET RX-860 CDM 6370000100 HCPCS 250 RC 00172-4096-80 NDC outpatient 1 UN 5.84 5.84 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES EPO [308136803] 4.67 percent of total billed charges 3.62 5.55 Technical (Hospital) Services BACLOFEN 10 MG TABLET RX-860 CDM 6370000100 HCPCS 250 RC 00172-4096-80 NDC outpatient 1 UN 5.84 5.84 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES PPO [308136801] 4.67 percent of total billed charges 3.62 5.55 Technical (Hospital) Services BACLOFEN 10 MG TABLET RX-860 CDM 6370000100 HCPCS 250 RC 00172-4096-80 NDC outpatient 1 UN 5.84 5.84 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES HDHP [308136802] 4.67 percent of total billed charges 3.62 5.55 Technical (Hospital) Services WARFARIN 2 MG TABLET RX-8749 CDM 6370000100 HCPCS 250 RC 00093-1713-01 NDC inpatient 1 UN 5.85 5.85 MULTIPLAN INC 34080 [3081285] MULTIPLAN INC [308128501] 5.56 percent of total billed charges 3.63 5.56 Technical (Hospital) Services WARFARIN 2 MG TABLET RX-8749 CDM 6370000100 HCPCS 250 RC 00093-1713-01 NDC inpatient 1 UN 5.85 5.85 BLUE CROSS BLUE SHIELD WELLMARK SB889 [3081026] BCBS WYOMING [308102603] 5.56 percent of total billed charges 3.63 5.56 Technical (Hospital) Services WARFARIN 2 MG TABLET RX-8749 CDM 6370000100 HCPCS 250 RC 00093-1713-01 NDC inpatient 1 UN 5.85 5.85 UNITED HEALTHCARE (COMMERCIAL) [3081199] UNITED HEALTHCARE 87726 [308119901] 3.63 percent of total billed charges 3.63 5.56 Technical (Hospital) Services WARFARIN 2 MG TABLET RX-8749 CDM 6370000100 HCPCS 250 RC 00093-1713-01 NDC inpatient 1 UN 5.85 5.85 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES HDHP [308136802] 4.63 percent of total billed charges 3.63 5.56 Technical (Hospital) Services WARFARIN 2 MG TABLET RX-8749 CDM 6370000100 HCPCS 250 RC 00093-1713-01 NDC inpatient 1 UN 5.85 5.85 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES EPO [308136803] 4.63 percent of total billed charges 3.63 5.56 Technical (Hospital) Services WARFARIN 2 MG TABLET RX-8749 CDM 6370000100 HCPCS 250 RC 00093-1713-01 NDC inpatient 1 UN 5.85 5.85 CIGNA 62308 [3081051] CIGNA 62308 [308105105] 4.63 percent of total billed charges 3.63 5.56 Technical (Hospital) Services WARFARIN 2 MG TABLET RX-8749 CDM 6370000100 HCPCS 250 RC 00093-1713-01 NDC inpatient 1 UN 5.85 5.85 CIGNA 62308 [3081051] CIGNA STATE OF WYOMING [308105107] 4.63 percent of total billed charges 3.63 5.56 Technical (Hospital) Services WARFARIN 2 MG TABLET RX-8749 CDM 6370000100 HCPCS 250 RC 00093-1713-01 NDC inpatient 1 UN 5.85 5.85 MEDICA (COMMERCIAL) 94265 [3081118] MEDICA CLAIMS [308111801] 5.27 percent of total billed charges 3.63 5.56 Technical (Hospital) Services WARFARIN 2 MG TABLET RX-8749 CDM 6370000100 HCPCS 250 RC 00093-1713-01 NDC inpatient 1 UN 5.85 5.85 HEALTHPARTNERS SX009 HEALTHPARTNERS 4.63 percent of total billed charges 3.63 5.56 Technical (Hospital) Services WARFARIN 2 MG TABLET RX-8749 CDM 6370000100 HCPCS 250 RC 00093-1713-01 NDC inpatient 1 UN 5.85 5.85 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES PPO [308136801] 4.63 percent of total billed charges 3.63 5.56 Technical (Hospital) Services WARFARIN 2 MG TABLET RX-8749 CDM 6370000100 HCPCS 250 RC 00093-1713-01 NDC outpatient 1 UN 5.85 5.85 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES EPO [308136803] 4.68 percent of total billed charges 3.63 5.56 Technical (Hospital) Services WARFARIN 2 MG TABLET RX-8749 CDM 6370000100 HCPCS 250 RC 00093-1713-01 NDC outpatient 1 UN 5.85 5.85 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES HDHP [308136802] 4.68 percent of total billed charges 3.63 5.56 Technical (Hospital) Services WARFARIN 2 MG TABLET RX-8749 CDM 6370000100 HCPCS 250 RC 00093-1713-01 NDC outpatient 1 UN 5.85 5.85 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES PPO [308136801] 4.68 percent of total billed charges 3.63 5.56 Technical (Hospital) Services WARFARIN 2 MG TABLET RX-8749 CDM 6370000100 HCPCS 250 RC 00093-1713-01 NDC outpatient 1 UN 5.85 5.85 MULTIPLAN INC 34080 [3081285] MULTIPLAN INC [308128501] 5.56 percent of total billed charges 3.63 5.56 Technical (Hospital) Services WARFARIN 2 MG TABLET RX-8749 CDM 6370000100 HCPCS 250 RC 00093-1713-01 NDC outpatient 1 UN 5.85 5.85 CIGNA 62308 [3081051] CIGNA 62308 [308105105] 4.68 percent of total billed charges 3.63 5.56 Technical (Hospital) Services WARFARIN 2 MG TABLET RX-8749 CDM 6370000100 HCPCS 250 RC 00093-1713-01 NDC outpatient 1 UN 5.85 5.85 CIGNA 62308 [3081051] CIGNA STATE OF WYOMING [308105107] 4.68 percent of total billed charges 3.63 5.56 Technical (Hospital) Services WARFARIN 2 MG TABLET RX-8749 CDM 6370000100 HCPCS 250 RC 00093-1713-01 NDC outpatient 1 UN 5.85 5.85 MEDICA (COMMERCIAL) 94265 [3081118] MEDICA CLAIMS [308111801] 5.27 percent of total billed charges 3.63 5.56 Technical (Hospital) Services WARFARIN 2 MG TABLET RX-8749 CDM 6370000100 HCPCS 250 RC 00093-1713-01 NDC outpatient 1 UN 5.85 5.85 UNITED HEALTHCARE (COMMERCIAL) [3081199] UNITED HEALTHCARE 87726 [308119901] 3.63 percent of total billed charges 3.63 5.56 Technical (Hospital) Services WARFARIN 2 MG TABLET RX-8749 CDM 6370000100 HCPCS 250 RC 00093-1713-01 NDC outpatient 1 UN 5.85 5.85 HEALTHPARTNERS SX009 HEALTHPARTNERS 4.68 percent of total billed charges 3.63 5.56 Technical (Hospital) Services WARFARIN 2 MG TABLET RX-8749 CDM 6370000100 HCPCS 250 RC 00093-1713-01 NDC outpatient 1 UN 5.85 5.85 BLUE CROSS BLUE SHIELD WELLMARK SB889 [3081026] BCBS WYOMING [308102603] 5.56 percent of total billed charges 3.63 5.56 Technical (Hospital) Services WARFARIN 2.5 MG TABLET RX-8750 CDM 6370000100 HCPCS 250 RC 00093-1714-01 NDC inpatient 1 UN 5.86 5.86 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES PPO [308136801] 4.64 percent of total billed charges 3.63 5.57 Technical (Hospital) Services WARFARIN 2.5 MG TABLET RX-8750 CDM 6370000100 HCPCS 250 RC 00093-1714-01 NDC inpatient 1 UN 5.86 5.86 MEDICA (COMMERCIAL) 94265 [3081118] MEDICA CLAIMS [308111801] 5.27 percent of total billed charges 3.63 5.57 Technical (Hospital) Services WARFARIN 2.5 MG TABLET RX-8750 CDM 6370000100 HCPCS 250 RC 00093-1714-01 NDC inpatient 1 UN 5.86 5.86 HEALTHPARTNERS SX009 HEALTHPARTNERS 4.64 percent of total billed charges 3.63 5.57 Technical (Hospital) Services WARFARIN 2.5 MG TABLET RX-8750 CDM 6370000100 HCPCS 250 RC 00093-1714-01 NDC inpatient 1 UN 5.86 5.86 MULTIPLAN INC 34080 [3081285] MULTIPLAN INC [308128501] 5.57 percent of total billed charges 3.63 5.57 Technical (Hospital) Services WARFARIN 2.5 MG TABLET RX-8750 CDM 6370000100 HCPCS 250 RC 00093-1714-01 NDC inpatient 1 UN 5.86 5.86 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES HDHP [308136802] 4.64 percent of total billed charges 3.63 5.57 Technical (Hospital) Services WARFARIN 2.5 MG TABLET RX-8750 CDM 6370000100 HCPCS 250 RC 00093-1714-01 NDC inpatient 1 UN 5.86 5.86 CIGNA 62308 [3081051] CIGNA 62308 [308105105] 4.64 percent of total billed charges 3.63 5.57 Technical (Hospital) Services WARFARIN 2.5 MG TABLET RX-8750 CDM 6370000100 HCPCS 250 RC 00093-1714-01 NDC inpatient 1 UN 5.86 5.86 CIGNA 62308 [3081051] CIGNA STATE OF WYOMING [308105107] 4.64 percent of total billed charges 3.63 5.57 Technical (Hospital) Services WARFARIN 2.5 MG TABLET RX-8750 CDM 6370000100 HCPCS 250 RC 00093-1714-01 NDC inpatient 1 UN 5.86 5.86 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES EPO [308136803] 4.64 percent of total billed charges 3.63 5.57 Technical (Hospital) Services WARFARIN 2.5 MG TABLET RX-8750 CDM 6370000100 HCPCS 250 RC 00093-1714-01 NDC inpatient 1 UN 5.86 5.86 BLUE CROSS BLUE SHIELD WELLMARK SB889 [3081026] BCBS WYOMING [308102603] 5.57 percent of total billed charges 3.63 5.57 Technical (Hospital) Services WARFARIN 2.5 MG TABLET RX-8750 CDM 6370000100 HCPCS 250 RC 00093-1714-01 NDC inpatient 1 UN 5.86 5.86 UNITED HEALTHCARE (COMMERCIAL) [3081199] UNITED HEALTHCARE 87726 [308119901] 3.63 percent of total billed charges 3.63 5.57 Technical (Hospital) Services WARFARIN 2.5 MG TABLET RX-8750 CDM 6370000100 HCPCS 250 RC 00093-1714-01 NDC outpatient 1 UN 5.86 5.86 BLUE CROSS BLUE SHIELD WELLMARK SB889 [3081026] BCBS WYOMING [308102603] 5.57 percent of total billed charges 3.63 5.57 Technical (Hospital) Services WARFARIN 2.5 MG TABLET RX-8750 CDM 6370000100 HCPCS 250 RC 00093-1714-01 NDC outpatient 1 UN 5.86 5.86 HEALTHPARTNERS SX009 HEALTHPARTNERS 4.69 percent of total billed charges 3.63 5.57 Technical (Hospital) Services WARFARIN 2.5 MG TABLET RX-8750 CDM 6370000100 HCPCS 250 RC 00093-1714-01 NDC outpatient 1 UN 5.86 5.86 UNITED HEALTHCARE (COMMERCIAL) [3081199] UNITED HEALTHCARE 87726 [308119901] 3.63 percent of total billed charges 3.63 5.57 Technical (Hospital) Services WARFARIN 2.5 MG TABLET RX-8750 CDM 6370000100 HCPCS 250 RC 00093-1714-01 NDC outpatient 1 UN 5.86 5.86 MEDICA (COMMERCIAL) 94265 [3081118] MEDICA CLAIMS [308111801] 5.27 percent of total billed charges 3.63 5.57 Technical (Hospital) Services WARFARIN 2.5 MG TABLET RX-8750 CDM 6370000100 HCPCS 250 RC 00093-1714-01 NDC outpatient 1 UN 5.86 5.86 CIGNA 62308 [3081051] CIGNA 62308 [308105105] 4.69 percent of total billed charges 3.63 5.57 Technical (Hospital) Services WARFARIN 2.5 MG TABLET RX-8750 CDM 6370000100 HCPCS 250 RC 00093-1714-01 NDC outpatient 1 UN 5.86 5.86 CIGNA 62308 [3081051] CIGNA STATE OF WYOMING [308105107] 4.69 percent of total billed charges 3.63 5.57 Technical (Hospital) Services WARFARIN 2.5 MG TABLET RX-8750 CDM 6370000100 HCPCS 250 RC 00093-1714-01 NDC outpatient 1 UN 5.86 5.86 MULTIPLAN INC 34080 [3081285] MULTIPLAN INC [308128501] 5.57 percent of total billed charges 3.63 5.57 Technical (Hospital) Services WARFARIN 2.5 MG TABLET RX-8750 CDM 6370000100 HCPCS 250 RC 00093-1714-01 NDC outpatient 1 UN 5.86 5.86 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES PPO [308136801] 4.69 percent of total billed charges 3.63 5.57 Technical (Hospital) Services WARFARIN 2.5 MG TABLET RX-8750 CDM 6370000100 HCPCS 250 RC 00093-1714-01 NDC outpatient 1 UN 5.86 5.86 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES HDHP [308136802] 4.69 percent of total billed charges 3.63 5.57 Technical (Hospital) Services WARFARIN 2.5 MG TABLET RX-8750 CDM 6370000100 HCPCS 250 RC 00093-1714-01 NDC outpatient 1 UN 5.86 5.86 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES EPO [308136803] 4.69 percent of total billed charges 3.63 5.57 Technical (Hospital) Services WARFARIN 5 MG TABLET RX-8751 CDM 6370000100 HCPCS 250 RC 00093-1721-01 NDC inpatient 1 UN 5.86 5.86 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES PPO [308136801] 4.64 percent of total billed charges 3.63 5.57 Technical (Hospital) Services WARFARIN 5 MG TABLET RX-8751 CDM 6370000100 HCPCS 250 RC 00093-1721-01 NDC inpatient 1 UN 5.86 5.86 MEDICA (COMMERCIAL) 94265 [3081118] MEDICA CLAIMS [308111801] 5.27 percent of total billed charges 3.63 5.57 Technical (Hospital) Services WARFARIN 5 MG TABLET RX-8751 CDM 6370000100 HCPCS 250 RC 00093-1721-01 NDC inpatient 1 UN 5.86 5.86 MULTIPLAN INC 34080 [3081285] MULTIPLAN INC [308128501] 5.57 percent of total billed charges 3.63 5.57 Technical (Hospital) Services WARFARIN 5 MG TABLET RX-8751 CDM 6370000100 HCPCS 250 RC 00093-1721-01 NDC inpatient 1 UN 5.86 5.86 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES HDHP [308136802] 4.64 percent of total billed charges 3.63 5.57 Technical (Hospital) Services WARFARIN 5 MG TABLET RX-8751 CDM 6370000100 HCPCS 250 RC 00093-1721-01 NDC inpatient 1 UN 5.86 5.86 HEALTHPARTNERS SX009 HEALTHPARTNERS 4.64 percent of total billed charges 3.63 5.57 Technical (Hospital) Services WARFARIN 5 MG TABLET RX-8751 CDM 6370000100 HCPCS 250 RC 00093-1721-01 NDC inpatient 1 UN 5.86 5.86 UNITED HEALTHCARE (COMMERCIAL) [3081199] UNITED HEALTHCARE 87726 [308119901] 3.63 percent of total billed charges 3.63 5.57 Technical (Hospital) Services WARFARIN 5 MG TABLET RX-8751 CDM 6370000100 HCPCS 250 RC 00093-1721-01 NDC inpatient 1 UN 5.86 5.86 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES EPO [308136803] 4.64 percent of total billed charges 3.63 5.57 Technical (Hospital) Services WARFARIN 5 MG TABLET RX-8751 CDM 6370000100 HCPCS 250 RC 00093-1721-01 NDC inpatient 1 UN 5.86 5.86 CIGNA 62308 [3081051] CIGNA 62308 [308105105] 4.64 percent of total billed charges 3.63 5.57 Technical (Hospital) Services WARFARIN 5 MG TABLET RX-8751 CDM 6370000100 HCPCS 250 RC 00093-1721-01 NDC inpatient 1 UN 5.86 5.86 CIGNA 62308 [3081051] CIGNA STATE OF WYOMING [308105107] 4.64 percent of total billed charges 3.63 5.57 Technical (Hospital) Services WARFARIN 5 MG TABLET RX-8751 CDM 6370000100 HCPCS 250 RC 00093-1721-01 NDC inpatient 1 UN 5.86 5.86 BLUE CROSS BLUE SHIELD WELLMARK SB889 [3081026] BCBS WYOMING [308102603] 5.57 percent of total billed charges 3.63 5.57 Technical (Hospital) Services WARFARIN 5 MG TABLET RX-8751 CDM 6370000100 HCPCS 250 RC 00093-1721-01 NDC outpatient 1 UN 5.86 5.86 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES PPO [308136801] 4.69 percent of total billed charges 3.63 5.57 Technical (Hospital) Services WARFARIN 5 MG TABLET RX-8751 CDM 6370000100 HCPCS 250 RC 00093-1721-01 NDC outpatient 1 UN 5.86 5.86 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES HDHP [308136802] 4.69 percent of total billed charges 3.63 5.57 Technical (Hospital) Services WARFARIN 5 MG TABLET RX-8751 CDM 6370000100 HCPCS 250 RC 00093-1721-01 NDC outpatient 1 UN 5.86 5.86 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES EPO [308136803] 4.69 percent of total billed charges 3.63 5.57 Technical (Hospital) Services WARFARIN 5 MG TABLET RX-8751 CDM 6370000100 HCPCS 250 RC 00093-1721-01 NDC outpatient 1 UN 5.86 5.86 UNITED HEALTHCARE (COMMERCIAL) [3081199] UNITED HEALTHCARE 87726 [308119901] 3.63 percent of total billed charges 3.63 5.57 Technical (Hospital) Services WARFARIN 5 MG TABLET RX-8751 CDM 6370000100 HCPCS 250 RC 00093-1721-01 NDC outpatient 1 UN 5.86 5.86 MULTIPLAN INC 34080 [3081285] MULTIPLAN INC [308128501] 5.57 percent of total billed charges 3.63 5.57 Technical (Hospital) Services WARFARIN 5 MG TABLET RX-8751 CDM 6370000100 HCPCS 250 RC 00093-1721-01 NDC outpatient 1 UN 5.86 5.86 CIGNA 62308 [3081051] CIGNA 62308 [308105105] 4.69 percent of total billed charges 3.63 5.57 Technical (Hospital) Services WARFARIN 5 MG TABLET RX-8751 CDM 6370000100 HCPCS 250 RC 00093-1721-01 NDC outpatient 1 UN 5.86 5.86 CIGNA 62308 [3081051] CIGNA STATE OF WYOMING [308105107] 4.69 percent of total billed charges 3.63 5.57 Technical (Hospital) Services WARFARIN 5 MG TABLET RX-8751 CDM 6370000100 HCPCS 250 RC 00093-1721-01 NDC outpatient 1 UN 5.86 5.86 MEDICA (COMMERCIAL) 94265 [3081118] MEDICA CLAIMS [308111801] 5.27 percent of total billed charges 3.63 5.57 Technical (Hospital) Services WARFARIN 5 MG TABLET RX-8751 CDM 6370000100 HCPCS 250 RC 00093-1721-01 NDC outpatient 1 UN 5.86 5.86 HEALTHPARTNERS SX009 HEALTHPARTNERS 4.69 percent of total billed charges 3.63 5.57 Technical (Hospital) Services WARFARIN 5 MG TABLET RX-8751 CDM 6370000100 HCPCS 250 RC 00093-1721-01 NDC outpatient 1 UN 5.86 5.86 BLUE CROSS BLUE SHIELD WELLMARK SB889 [3081026] BCBS WYOMING [308102603] 5.57 percent of total billed charges 3.63 5.57 Technical (Hospital) Services OXYCODONE 10 MG TABLET RX-87795 CDM 6370000100 HCPCS 250 RC 00406-8510-62 NDC inpatient 1 UN 6.34 6.34 HEALTHPARTNERS SX009 HEALTHPARTNERS 5.02 percent of total billed charges 3.93 6.02 Technical (Hospital) Services OXYCODONE 10 MG TABLET RX-87795 CDM 6370000100 HCPCS 250 RC 00406-8510-62 NDC inpatient 1 UN 6.34 6.34 MEDICA (COMMERCIAL) 94265 [3081118] MEDICA CLAIMS [308111801] 5.71 percent of total billed charges 3.93 6.02 Technical (Hospital) Services OXYCODONE 10 MG TABLET RX-87795 CDM 6370000100 HCPCS 250 RC 00406-8510-62 NDC inpatient 1 UN 6.34 6.34 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES PPO [308136801] 5.02 percent of total billed charges 3.93 6.02 Technical (Hospital) Services OXYCODONE 10 MG TABLET RX-87795 CDM 6370000100 HCPCS 250 RC 00406-8510-62 NDC inpatient 1 UN 6.34 6.34 MULTIPLAN INC 34080 [3081285] MULTIPLAN INC [308128501] 6.02 percent of total billed charges 3.93 6.02 Technical (Hospital) Services OXYCODONE 10 MG TABLET RX-87795 CDM 6370000100 HCPCS 250 RC 00406-8510-62 NDC inpatient 1 UN 6.34 6.34 UNITED HEALTHCARE (COMMERCIAL) [3081199] UNITED HEALTHCARE 87726 [308119901] 3.93 percent of total billed charges 3.93 6.02 Technical (Hospital) Services OXYCODONE 10 MG TABLET RX-87795 CDM 6370000100 HCPCS 250 RC 00406-8510-62 NDC inpatient 1 UN 6.34 6.34 BLUE CROSS BLUE SHIELD WELLMARK SB889 [3081026] BCBS WYOMING [308102603] 6.02 percent of total billed charges 3.93 6.02 Technical (Hospital) Services OXYCODONE 10 MG TABLET RX-87795 CDM 6370000100 HCPCS 250 RC 00406-8510-62 NDC inpatient 1 UN 6.34 6.34 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES HDHP [308136802] 5.02 percent of total billed charges 3.93 6.02 Technical (Hospital) Services OXYCODONE 10 MG TABLET RX-87795 CDM 6370000100 HCPCS 250 RC 00406-8510-62 NDC inpatient 1 UN 6.34 6.34 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES EPO [308136803] 5.02 percent of total billed charges 3.93 6.02 Technical (Hospital) Services OXYCODONE 10 MG TABLET RX-87795 CDM 6370000100 HCPCS 250 RC 00406-8510-62 NDC inpatient 1 UN 6.34 6.34 CIGNA 62308 [3081051] CIGNA 62308 [308105105] 5.02 percent of total billed charges 3.93 6.02 Technical (Hospital) Services OXYCODONE 10 MG TABLET RX-87795 CDM 6370000100 HCPCS 250 RC 00406-8510-62 NDC inpatient 1 UN 6.34 6.34 CIGNA 62308 [3081051] CIGNA STATE OF WYOMING [308105107] 5.02 percent of total billed charges 3.93 6.02 Technical (Hospital) Services OXYCODONE 10 MG TABLET RX-87795 CDM 6370000100 HCPCS 250 RC 00406-8510-62 NDC outpatient 1 UN 6.34 6.34 MULTIPLAN INC 34080 [3081285] MULTIPLAN INC [308128501] 6.02 percent of total billed charges 3.93 6.02 Technical (Hospital) Services OXYCODONE 10 MG TABLET RX-87795 CDM 6370000100 HCPCS 250 RC 00406-8510-62 NDC outpatient 1 UN 6.34 6.34 CIGNA 62308 [3081051] CIGNA 62308 [308105105] 5.07 percent of total billed charges 3.93 6.02 Technical (Hospital) Services OXYCODONE 10 MG TABLET RX-87795 CDM 6370000100 HCPCS 250 RC 00406-8510-62 NDC outpatient 1 UN 6.34 6.34 CIGNA 62308 [3081051] CIGNA STATE OF WYOMING [308105107] 5.07 percent of total billed charges 3.93 6.02 Technical (Hospital) Services OXYCODONE 10 MG TABLET RX-87795 CDM 6370000100 HCPCS 250 RC 00406-8510-62 NDC outpatient 1 UN 6.34 6.34 MEDICA (COMMERCIAL) 94265 [3081118] MEDICA CLAIMS [308111801] 5.71 percent of total billed charges 3.93 6.02 Technical (Hospital) Services OXYCODONE 10 MG TABLET RX-87795 CDM 6370000100 HCPCS 250 RC 00406-8510-62 NDC outpatient 1 UN 6.34 6.34 HEALTHPARTNERS SX009 HEALTHPARTNERS 5.07 percent of total billed charges 3.93 6.02 Technical (Hospital) Services OXYCODONE 10 MG TABLET RX-87795 CDM 6370000100 HCPCS 250 RC 00406-8510-62 NDC outpatient 1 UN 6.34 6.34 UNITED HEALTHCARE (COMMERCIAL) [3081199] UNITED HEALTHCARE 87726 [308119901] 3.93 percent of total billed charges 3.93 6.02 Technical (Hospital) Services OXYCODONE 10 MG TABLET RX-87795 CDM 6370000100 HCPCS 250 RC 00406-8510-62 NDC outpatient 1 UN 6.34 6.34 BLUE CROSS BLUE SHIELD WELLMARK SB889 [3081026] BCBS WYOMING [308102603] 6.02 percent of total billed charges 3.93 6.02 Technical (Hospital) Services OXYCODONE 10 MG TABLET RX-87795 CDM 6370000100 HCPCS 250 RC 00406-8510-62 NDC outpatient 1 UN 6.34 6.34 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES EPO [308136803] 5.07 percent of total billed charges 3.93 6.02 Technical (Hospital) Services OXYCODONE 10 MG TABLET RX-87795 CDM 6370000100 HCPCS 250 RC 00406-8510-62 NDC outpatient 1 UN 6.34 6.34 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES HDHP [308136802] 5.07 percent of total billed charges 3.93 6.02 Technical (Hospital) Services OXYCODONE 10 MG TABLET RX-87795 CDM 6370000100 HCPCS 250 RC 00406-8510-62 NDC outpatient 1 UN 6.34 6.34 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES PPO [308136801] 5.07 percent of total billed charges 3.93 6.02 Technical (Hospital) Services POTASSIUM BICARBONATE-CITRIC ACID 10 MEQ EFFERVESCENT TABLET RX-87911 CDM 6370000100 HCPCS 250 RC 51801-0013-30 NDC outpatient 1 UN 6.1 6.1 UNITED HEALTHCARE (COMMERCIAL) [3081199] UNITED HEALTHCARE 87726 [308119901] 3.78 percent of total billed charges 3.78 5.8 Technical (Hospital) Services POTASSIUM BICARBONATE-CITRIC ACID 10 MEQ EFFERVESCENT TABLET RX-87911 CDM 6370000100 HCPCS 250 RC 51801-0013-30 NDC outpatient 1 UN 6.1 6.1 HEALTHPARTNERS SX009 HEALTHPARTNERS 4.88 percent of total billed charges 3.78 5.8 Technical (Hospital) Services POTASSIUM BICARBONATE-CITRIC ACID 10 MEQ EFFERVESCENT TABLET RX-87911 CDM 6370000100 HCPCS 250 RC 51801-0013-30 NDC outpatient 1 UN 6.1 6.1 MEDICA (COMMERCIAL) 94265 [3081118] MEDICA CLAIMS [308111801] 5.49 percent of total billed charges 3.78 5.8 Technical (Hospital) Services POTASSIUM BICARBONATE-CITRIC ACID 10 MEQ EFFERVESCENT TABLET RX-87911 CDM 6370000100 HCPCS 250 RC 51801-0013-30 NDC outpatient 1 UN 6.1 6.1 MULTIPLAN INC 34080 [3081285] MULTIPLAN INC [308128501] 5.8 percent of total billed charges 3.78 5.8 Technical (Hospital) Services POTASSIUM BICARBONATE-CITRIC ACID 10 MEQ EFFERVESCENT TABLET RX-87911 CDM 6370000100 HCPCS 250 RC 51801-0013-30 NDC outpatient 1 UN 6.1 6.1 CIGNA 62308 [3081051] CIGNA 62308 [308105105] 4.88 percent of total billed charges 3.78 5.8 Technical (Hospital) Services POTASSIUM BICARBONATE-CITRIC ACID 10 MEQ EFFERVESCENT TABLET RX-87911 CDM 6370000100 HCPCS 250 RC 51801-0013-30 NDC outpatient 1 UN 6.1 6.1 CIGNA 62308 [3081051] CIGNA STATE OF WYOMING [308105107] 4.88 percent of total billed charges 3.78 5.8 Technical (Hospital) Services POTASSIUM BICARBONATE-CITRIC ACID 10 MEQ EFFERVESCENT TABLET RX-87911 CDM 6370000100 HCPCS 250 RC 51801-0013-30 NDC outpatient 1 UN 6.1 6.1 BLUE CROSS BLUE SHIELD WELLMARK SB889 [3081026] BCBS WYOMING [308102603] 5.8 percent of total billed charges 3.78 5.8 Technical (Hospital) Services POTASSIUM BICARBONATE-CITRIC ACID 10 MEQ EFFERVESCENT TABLET RX-87911 CDM 6370000100 HCPCS 250 RC 51801-0013-30 NDC outpatient 1 UN 6.1 6.1 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES HDHP [308136802] 4.88 percent of total billed charges 3.78 5.8 Technical (Hospital) Services POTASSIUM BICARBONATE-CITRIC ACID 10 MEQ EFFERVESCENT TABLET RX-87911 CDM 6370000100 HCPCS 250 RC 51801-0013-30 NDC outpatient 1 UN 6.1 6.1 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES PPO [308136801] 4.88 percent of total billed charges 3.78 5.8 Technical (Hospital) Services POTASSIUM BICARBONATE-CITRIC ACID 10 MEQ EFFERVESCENT TABLET RX-87911 CDM 6370000100 HCPCS 250 RC 51801-0013-30 NDC outpatient 1 UN 6.1 6.1 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES EPO [308136803] 4.88 percent of total billed charges 3.78 5.8 Technical (Hospital) Services POTASSIUM BICARBONATE-CITRIC ACID 10 MEQ EFFERVESCENT TABLET RX-87911 CDM 6370000100 HCPCS 250 RC 51801-0013-30 NDC inpatient 1 UN 6.1 6.1 HEALTHPARTNERS SX009 HEALTHPARTNERS 4.83 percent of total billed charges 3.78 5.8 Technical (Hospital) Services POTASSIUM BICARBONATE-CITRIC ACID 10 MEQ EFFERVESCENT TABLET RX-87911 CDM 6370000100 HCPCS 250 RC 51801-0013-30 NDC inpatient 1 UN 6.1 6.1 MEDICA (COMMERCIAL) 94265 [3081118] MEDICA CLAIMS [308111801] 5.49 percent of total billed charges 3.78 5.8 Technical (Hospital) Services POTASSIUM BICARBONATE-CITRIC ACID 10 MEQ EFFERVESCENT TABLET RX-87911 CDM 6370000100 HCPCS 250 RC 51801-0013-30 NDC inpatient 1 UN 6.1 6.1 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES PPO [308136801] 4.83 percent of total billed charges 3.78 5.8 Technical (Hospital) Services POTASSIUM BICARBONATE-CITRIC ACID 10 MEQ EFFERVESCENT TABLET RX-87911 CDM 6370000100 HCPCS 250 RC 51801-0013-30 NDC inpatient 1 UN 6.1 6.1 MULTIPLAN INC 34080 [3081285] MULTIPLAN INC [308128501] 5.8 percent of total billed charges 3.78 5.8 Technical (Hospital) Services POTASSIUM BICARBONATE-CITRIC ACID 10 MEQ EFFERVESCENT TABLET RX-87911 CDM 6370000100 HCPCS 250 RC 51801-0013-30 NDC inpatient 1 UN 6.1 6.1 UNITED HEALTHCARE (COMMERCIAL) [3081199] UNITED HEALTHCARE 87726 [308119901] 3.78 percent of total billed charges 3.78 5.8 Technical (Hospital) Services POTASSIUM BICARBONATE-CITRIC ACID 10 MEQ EFFERVESCENT TABLET RX-87911 CDM 6370000100 HCPCS 250 RC 51801-0013-30 NDC inpatient 1 UN 6.1 6.1 BLUE CROSS BLUE SHIELD WELLMARK SB889 [3081026] BCBS WYOMING [308102603] 5.8 percent of total billed charges 3.78 5.8 Technical (Hospital) Services POTASSIUM BICARBONATE-CITRIC ACID 10 MEQ EFFERVESCENT TABLET RX-87911 CDM 6370000100 HCPCS 250 RC 51801-0013-30 NDC inpatient 1 UN 6.1 6.1 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES EPO [308136803] 4.83 percent of total billed charges 3.78 5.8 Technical (Hospital) Services POTASSIUM BICARBONATE-CITRIC ACID 10 MEQ EFFERVESCENT TABLET RX-87911 CDM 6370000100 HCPCS 250 RC 51801-0013-30 NDC inpatient 1 UN 6.1 6.1 CIGNA 62308 [3081051] CIGNA 62308 [308105105] 4.83 percent of total billed charges 3.78 5.8 Technical (Hospital) Services POTASSIUM BICARBONATE-CITRIC ACID 10 MEQ EFFERVESCENT TABLET RX-87911 CDM 6370000100 HCPCS 250 RC 51801-0013-30 NDC inpatient 1 UN 6.1 6.1 CIGNA 62308 [3081051] CIGNA STATE OF WYOMING [308105107] 4.83 percent of total billed charges 3.78 5.8 Technical (Hospital) Services POTASSIUM BICARBONATE-CITRIC ACID 10 MEQ EFFERVESCENT TABLET RX-87911 CDM 6370000100 HCPCS 250 RC 51801-0013-30 NDC inpatient 1 UN 6.1 6.1 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES HDHP [308136802] 4.83 percent of total billed charges 3.78 5.8 Technical (Hospital) Services POTASSIUM BICARBONATE-CITRIC ACID 20 MEQ EFFERVESCENT TABLET RX-87912 CDM 6370000100 HCPCS 250 RC 51801-0012-30 NDC outpatient 1 UN 6.17 6.17 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES PPO [308136801] 4.94 percent of total billed charges 3.83 5.86 Technical (Hospital) Services POTASSIUM BICARBONATE-CITRIC ACID 20 MEQ EFFERVESCENT TABLET RX-87912 CDM 6370000100 HCPCS 250 RC 51801-0012-30 NDC outpatient 1 UN 6.17 6.17 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES HDHP [308136802] 4.94 percent of total billed charges 3.83 5.86 Technical (Hospital) Services POTASSIUM BICARBONATE-CITRIC ACID 20 MEQ EFFERVESCENT TABLET RX-87912 CDM 6370000100 HCPCS 250 RC 51801-0012-30 NDC outpatient 1 UN 6.17 6.17 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES EPO [308136803] 4.94 percent of total billed charges 3.83 5.86 Technical (Hospital) Services POTASSIUM BICARBONATE-CITRIC ACID 20 MEQ EFFERVESCENT TABLET RX-87912 CDM 6370000100 HCPCS 250 RC 51801-0012-30 NDC outpatient 1 UN 6.17 6.17 CIGNA 62308 [3081051] CIGNA 62308 [308105105] 4.94 percent of total billed charges 3.83 5.86 Technical (Hospital) Services POTASSIUM BICARBONATE-CITRIC ACID 20 MEQ EFFERVESCENT TABLET RX-87912 CDM 6370000100 HCPCS 250 RC 51801-0012-30 NDC outpatient 1 UN 6.17 6.17 CIGNA 62308 [3081051] CIGNA STATE OF WYOMING [308105107] 4.94 percent of total billed charges 3.83 5.86 Technical (Hospital) Services POTASSIUM BICARBONATE-CITRIC ACID 20 MEQ EFFERVESCENT TABLET RX-87912 CDM 6370000100 HCPCS 250 RC 51801-0012-30 NDC outpatient 1 UN 6.17 6.17 MULTIPLAN INC 34080 [3081285] MULTIPLAN INC [308128501] 5.86 percent of total billed charges 3.83 5.86 Technical (Hospital) Services POTASSIUM BICARBONATE-CITRIC ACID 20 MEQ EFFERVESCENT TABLET RX-87912 CDM 6370000100 HCPCS 250 RC 51801-0012-30 NDC outpatient 1 UN 6.17 6.17 MEDICA (COMMERCIAL) 94265 [3081118] MEDICA CLAIMS [308111801] 5.55 percent of total billed charges 3.83 5.86 Technical (Hospital) Services POTASSIUM BICARBONATE-CITRIC ACID 20 MEQ EFFERVESCENT TABLET RX-87912 CDM 6370000100 HCPCS 250 RC 51801-0012-30 NDC outpatient 1 UN 6.17 6.17 HEALTHPARTNERS SX009 HEALTHPARTNERS 4.94 percent of total billed charges 3.83 5.86 Technical (Hospital) Services POTASSIUM BICARBONATE-CITRIC ACID 20 MEQ EFFERVESCENT TABLET RX-87912 CDM 6370000100 HCPCS 250 RC 51801-0012-30 NDC outpatient 1 UN 6.17 6.17 UNITED HEALTHCARE (COMMERCIAL) [3081199] UNITED HEALTHCARE 87726 [308119901] 3.83 percent of total billed charges 3.83 5.86 Technical (Hospital) Services POTASSIUM BICARBONATE-CITRIC ACID 20 MEQ EFFERVESCENT TABLET RX-87912 CDM 6370000100 HCPCS 250 RC 51801-0012-30 NDC outpatient 1 UN 6.17 6.17 BLUE CROSS BLUE SHIELD WELLMARK SB889 [3081026] BCBS WYOMING [308102603] 5.86 percent of total billed charges 3.83 5.86 Technical (Hospital) Services POTASSIUM BICARBONATE-CITRIC ACID 20 MEQ EFFERVESCENT TABLET RX-87912 CDM 6370000100 HCPCS 250 RC 51801-0012-30 NDC inpatient 1 UN 6.17 6.17 MEDICA (COMMERCIAL) 94265 [3081118] MEDICA CLAIMS [308111801] 5.55 percent of total billed charges 3.83 5.86 Technical (Hospital) Services POTASSIUM BICARBONATE-CITRIC ACID 20 MEQ EFFERVESCENT TABLET RX-87912 CDM 6370000100 HCPCS 250 RC 51801-0012-30 NDC inpatient 1 UN 6.17 6.17 HEALTHPARTNERS SX009 HEALTHPARTNERS 4.89 percent of total billed charges 3.83 5.86 Technical (Hospital) Services POTASSIUM BICARBONATE-CITRIC ACID 20 MEQ EFFERVESCENT TABLET RX-87912 CDM 6370000100 HCPCS 250 RC 51801-0012-30 NDC inpatient 1 UN 6.17 6.17 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES PPO [308136801] 4.89 percent of total billed charges 3.83 5.86 Technical (Hospital) Services POTASSIUM BICARBONATE-CITRIC ACID 20 MEQ EFFERVESCENT TABLET RX-87912 CDM 6370000100 HCPCS 250 RC 51801-0012-30 NDC inpatient 1 UN 6.17 6.17 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES HDHP [308136802] 4.89 percent of total billed charges 3.83 5.86 Technical (Hospital) Services POTASSIUM BICARBONATE-CITRIC ACID 20 MEQ EFFERVESCENT TABLET RX-87912 CDM 6370000100 HCPCS 250 RC 51801-0012-30 NDC inpatient 1 UN 6.17 6.17 UNITED HEALTHCARE (COMMERCIAL) [3081199] UNITED HEALTHCARE 87726 [308119901] 3.83 percent of total billed charges 3.83 5.86 Technical (Hospital) Services POTASSIUM BICARBONATE-CITRIC ACID 20 MEQ EFFERVESCENT TABLET RX-87912 CDM 6370000100 HCPCS 250 RC 51801-0012-30 NDC inpatient 1 UN 6.17 6.17 CIGNA 62308 [3081051] CIGNA 62308 [308105105] 4.89 percent of total billed charges 3.83 5.86 Technical (Hospital) Services POTASSIUM BICARBONATE-CITRIC ACID 20 MEQ EFFERVESCENT TABLET RX-87912 CDM 6370000100 HCPCS 250 RC 51801-0012-30 NDC inpatient 1 UN 6.17 6.17 CIGNA 62308 [3081051] CIGNA STATE OF WYOMING [308105107] 4.89 percent of total billed charges 3.83 5.86 Technical (Hospital) Services POTASSIUM BICARBONATE-CITRIC ACID 20 MEQ EFFERVESCENT TABLET RX-87912 CDM 6370000100 HCPCS 250 RC 51801-0012-30 NDC inpatient 1 UN 6.17 6.17 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES EPO [308136803] 4.89 percent of total billed charges 3.83 5.86 Technical (Hospital) Services POTASSIUM BICARBONATE-CITRIC ACID 20 MEQ EFFERVESCENT TABLET RX-87912 CDM 6370000100 HCPCS 250 RC 51801-0012-30 NDC inpatient 1 UN 6.17 6.17 BLUE CROSS BLUE SHIELD WELLMARK SB889 [3081026] BCBS WYOMING [308102603] 5.86 percent of total billed charges 3.83 5.86 Technical (Hospital) Services POTASSIUM BICARBONATE-CITRIC ACID 20 MEQ EFFERVESCENT TABLET RX-87912 CDM 6370000100 HCPCS 250 RC 51801-0012-30 NDC inpatient 1 UN 6.17 6.17 MULTIPLAN INC 34080 [3081285] MULTIPLAN INC [308128501] 5.86 percent of total billed charges 3.83 5.86 Technical (Hospital) Services FORMOTEROL FUMARATE 20 MCG/2 ML SOLUTION FOR NEBULIZATION RX-88225 CDM 6370000100 HCPCS 250 RC 49502-0605-95 NDC outpatient 2 ML 67.52 67.52 MULTIPLAN INC 34080 [3081285] MULTIPLAN INC [308128501] 64.14 percent of total billed charges 41.86 64.14 Technical (Hospital) Services FORMOTEROL FUMARATE 20 MCG/2 ML SOLUTION FOR NEBULIZATION RX-88225 CDM 6370000100 HCPCS 250 RC 49502-0605-95 NDC outpatient 2 ML 67.52 67.52 BLUE CROSS BLUE SHIELD WELLMARK SB889 [3081026] BCBS WYOMING [308102603] 64.14 percent of total billed charges 41.86 64.14 Technical (Hospital) Services FORMOTEROL FUMARATE 20 MCG/2 ML SOLUTION FOR NEBULIZATION RX-88225 CDM 6370000100 HCPCS 250 RC 49502-0605-95 NDC outpatient 2 ML 67.52 67.52 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES HDHP [308136802] 54.02 percent of total billed charges 41.86 64.14 Technical (Hospital) Services FORMOTEROL FUMARATE 20 MCG/2 ML SOLUTION FOR NEBULIZATION RX-88225 CDM 6370000100 HCPCS 250 RC 49502-0605-95 NDC outpatient 2 ML 67.52 67.52 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES PPO [308136801] 54.02 percent of total billed charges 41.86 64.14 Technical (Hospital) Services FORMOTEROL FUMARATE 20 MCG/2 ML SOLUTION FOR NEBULIZATION RX-88225 CDM 6370000100 HCPCS 250 RC 49502-0605-95 NDC outpatient 2 ML 67.52 67.52 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES EPO [308136803] 54.02 percent of total billed charges 41.86 64.14 Technical (Hospital) Services FORMOTEROL FUMARATE 20 MCG/2 ML SOLUTION FOR NEBULIZATION RX-88225 CDM 6370000100 HCPCS 250 RC 49502-0605-95 NDC outpatient 2 ML 67.52 67.52 CIGNA 62308 [3081051] CIGNA 62308 [308105105] 54.02 percent of total billed charges 41.86 64.14 Technical (Hospital) Services FORMOTEROL FUMARATE 20 MCG/2 ML SOLUTION FOR NEBULIZATION RX-88225 CDM 6370000100 HCPCS 250 RC 49502-0605-95 NDC outpatient 2 ML 67.52 67.52 CIGNA 62308 [3081051] CIGNA STATE OF WYOMING [308105107] 54.02 percent of total billed charges 41.86 64.14 Technical (Hospital) Services FORMOTEROL FUMARATE 20 MCG/2 ML SOLUTION FOR NEBULIZATION RX-88225 CDM 6370000100 HCPCS 250 RC 49502-0605-95 NDC outpatient 2 ML 67.52 67.52 MEDICA (COMMERCIAL) 94265 [3081118] MEDICA CLAIMS [308111801] 60.77 percent of total billed charges 41.86 64.14 Technical (Hospital) Services FORMOTEROL FUMARATE 20 MCG/2 ML SOLUTION FOR NEBULIZATION RX-88225 CDM 6370000100 HCPCS 250 RC 49502-0605-95 NDC outpatient 2 ML 67.52 67.52 UNITED HEALTHCARE (COMMERCIAL) [3081199] UNITED HEALTHCARE 87726 [308119901] 41.86 percent of total billed charges 41.86 64.14 Technical (Hospital) Services FORMOTEROL FUMARATE 20 MCG/2 ML SOLUTION FOR NEBULIZATION RX-88225 CDM 6370000100 HCPCS 250 RC 49502-0605-95 NDC outpatient 2 ML 67.52 67.52 HEALTHPARTNERS SX009 HEALTHPARTNERS 54.02 percent of total billed charges 41.86 64.14 Technical (Hospital) Services FORMOTEROL FUMARATE 20 MCG/2 ML SOLUTION FOR NEBULIZATION RX-88225 CDM 6370000100 HCPCS 250 RC 49502-0605-95 NDC inpatient 2 ML 67.52 67.52 BLUE CROSS BLUE SHIELD WELLMARK SB889 [3081026] BCBS WYOMING [308102603] 64.14 percent of total billed charges 41.86 64.14 Technical (Hospital) Services FORMOTEROL FUMARATE 20 MCG/2 ML SOLUTION FOR NEBULIZATION RX-88225 CDM 6370000100 HCPCS 250 RC 49502-0605-95 NDC inpatient 2 ML 67.52 67.52 UNITED HEALTHCARE (COMMERCIAL) [3081199] UNITED HEALTHCARE 87726 [308119901] 41.86 percent of total billed charges 41.86 64.14 Technical (Hospital) Services FORMOTEROL FUMARATE 20 MCG/2 ML SOLUTION FOR NEBULIZATION RX-88225 CDM 6370000100 HCPCS 250 RC 49502-0605-95 NDC inpatient 2 ML 67.52 67.52 CIGNA 62308 [3081051] CIGNA 62308 [308105105] 53.46 percent of total billed charges 41.86 64.14 Technical (Hospital) Services FORMOTEROL FUMARATE 20 MCG/2 ML SOLUTION FOR NEBULIZATION RX-88225 CDM 6370000100 HCPCS 250 RC 49502-0605-95 NDC inpatient 2 ML 67.52 67.52 CIGNA 62308 [3081051] CIGNA STATE OF WYOMING [308105107] 53.46 percent of total billed charges 41.86 64.14 Technical (Hospital) Services FORMOTEROL FUMARATE 20 MCG/2 ML SOLUTION FOR NEBULIZATION RX-88225 CDM 6370000100 HCPCS 250 RC 49502-0605-95 NDC inpatient 2 ML 67.52 67.52 MULTIPLAN INC 34080 [3081285] MULTIPLAN INC [308128501] 64.14 percent of total billed charges 41.86 64.14 Technical (Hospital) Services FORMOTEROL FUMARATE 20 MCG/2 ML SOLUTION FOR NEBULIZATION RX-88225 CDM 6370000100 HCPCS 250 RC 49502-0605-95 NDC inpatient 2 ML 67.52 67.52 MEDICA (COMMERCIAL) 94265 [3081118] MEDICA CLAIMS [308111801] 60.77 percent of total billed charges 41.86 64.14 Technical (Hospital) Services FORMOTEROL FUMARATE 20 MCG/2 ML SOLUTION FOR NEBULIZATION RX-88225 CDM 6370000100 HCPCS 250 RC 49502-0605-95 NDC inpatient 2 ML 67.52 67.52 HEALTHPARTNERS SX009 HEALTHPARTNERS 53.46 percent of total billed charges 41.86 64.14 Technical (Hospital) Services FORMOTEROL FUMARATE 20 MCG/2 ML SOLUTION FOR NEBULIZATION RX-88225 CDM 6370000100 HCPCS 250 RC 49502-0605-95 NDC inpatient 2 ML 67.52 67.52 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES PPO [308136801] 53.46 percent of total billed charges 41.86 64.14 Technical (Hospital) Services FORMOTEROL FUMARATE 20 MCG/2 ML SOLUTION FOR NEBULIZATION RX-88225 CDM 6370000100 HCPCS 250 RC 49502-0605-95 NDC inpatient 2 ML 67.52 67.52 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES EPO [308136803] 53.46 percent of total billed charges 41.86 64.14 Technical (Hospital) Services FORMOTEROL FUMARATE 20 MCG/2 ML SOLUTION FOR NEBULIZATION RX-88225 CDM 6370000100 HCPCS 250 RC 49502-0605-95 NDC inpatient 2 ML 67.52 67.52 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES HDHP [308136802] 53.46 percent of total billed charges 41.86 64.14 Technical (Hospital) Services OSELTAMIVIR 30 MG CAPSULE RX-88704 CDM 6370000100 HCPCS 250 RC 47781-0468-13 NDC inpatient 1 UN 37.76 37.76 MULTIPLAN INC 34080 [3081285] MULTIPLAN INC [308128501] 35.87 percent of total billed charges 23.41 35.87 Technical (Hospital) Services OSELTAMIVIR 30 MG CAPSULE RX-88704 CDM 6370000100 HCPCS 250 RC 47781-0468-13 NDC inpatient 1 UN 37.76 37.76 BLUE CROSS BLUE SHIELD WELLMARK SB889 [3081026] BCBS WYOMING [308102603] 35.87 percent of total billed charges 23.41 35.87 Technical (Hospital) Services OSELTAMIVIR 30 MG CAPSULE RX-88704 CDM 6370000100 HCPCS 250 RC 47781-0468-13 NDC inpatient 1 UN 37.76 37.76 UNITED HEALTHCARE (COMMERCIAL) [3081199] UNITED HEALTHCARE 87726 [308119901] 23.41 percent of total billed charges 23.41 35.87 Technical (Hospital) Services OSELTAMIVIR 30 MG CAPSULE RX-88704 CDM 6370000100 HCPCS 250 RC 47781-0468-13 NDC inpatient 1 UN 37.76 37.76 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES HDHP [308136802] 29.9 percent of total billed charges 23.41 35.87 Technical (Hospital) Services OSELTAMIVIR 30 MG CAPSULE RX-88704 CDM 6370000100 HCPCS 250 RC 47781-0468-13 NDC inpatient 1 UN 37.76 37.76 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES EPO [308136803] 29.9 percent of total billed charges 23.41 35.87 Technical (Hospital) Services OSELTAMIVIR 30 MG CAPSULE RX-88704 CDM 6370000100 HCPCS 250 RC 47781-0468-13 NDC inpatient 1 UN 37.76 37.76 CIGNA 62308 [3081051] CIGNA 62308 [308105105] 29.9 percent of total billed charges 23.41 35.87 Technical (Hospital) Services OSELTAMIVIR 30 MG CAPSULE RX-88704 CDM 6370000100 HCPCS 250 RC 47781-0468-13 NDC inpatient 1 UN 37.76 37.76 CIGNA 62308 [3081051] CIGNA STATE OF WYOMING [308105107] 29.9 percent of total billed charges 23.41 35.87 Technical (Hospital) Services OSELTAMIVIR 30 MG CAPSULE RX-88704 CDM 6370000100 HCPCS 250 RC 47781-0468-13 NDC inpatient 1 UN 37.76 37.76 MEDICA (COMMERCIAL) 94265 [3081118] MEDICA CLAIMS [308111801] 33.98 percent of total billed charges 23.41 35.87 Technical (Hospital) Services OSELTAMIVIR 30 MG CAPSULE RX-88704 CDM 6370000100 HCPCS 250 RC 47781-0468-13 NDC inpatient 1 UN 37.76 37.76 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES PPO [308136801] 29.9 percent of total billed charges 23.41 35.87 Technical (Hospital) Services OSELTAMIVIR 30 MG CAPSULE RX-88704 CDM 6370000100 HCPCS 250 RC 47781-0468-13 NDC inpatient 1 UN 37.76 37.76 HEALTHPARTNERS SX009 HEALTHPARTNERS 29.9 percent of total billed charges 23.41 35.87 Technical (Hospital) Services OSELTAMIVIR 30 MG CAPSULE RX-88704 CDM 6370000100 HCPCS 250 RC 47781-0468-13 NDC outpatient 1 UN 37.76 37.76 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES PPO [308136801] 30.21 percent of total billed charges 23.41 35.87 Technical (Hospital) Services OSELTAMIVIR 30 MG CAPSULE RX-88704 CDM 6370000100 HCPCS 250 RC 47781-0468-13 NDC outpatient 1 UN 37.76 37.76 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES HDHP [308136802] 30.21 percent of total billed charges 23.41 35.87 Technical (Hospital) Services OSELTAMIVIR 30 MG CAPSULE RX-88704 CDM 6370000100 HCPCS 250 RC 47781-0468-13 NDC outpatient 1 UN 37.76 37.76 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES EPO [308136803] 30.21 percent of total billed charges 23.41 35.87 Technical (Hospital) Services OSELTAMIVIR 30 MG CAPSULE RX-88704 CDM 6370000100 HCPCS 250 RC 47781-0468-13 NDC outpatient 1 UN 37.76 37.76 MEDICA (COMMERCIAL) 94265 [3081118] MEDICA CLAIMS [308111801] 33.98 percent of total billed charges 23.41 35.87 Technical (Hospital) Services OSELTAMIVIR 30 MG CAPSULE RX-88704 CDM 6370000100 HCPCS 250 RC 47781-0468-13 NDC outpatient 1 UN 37.76 37.76 BLUE CROSS BLUE SHIELD WELLMARK SB889 [3081026] BCBS WYOMING [308102603] 35.87 percent of total billed charges 23.41 35.87 Technical (Hospital) Services OSELTAMIVIR 30 MG CAPSULE RX-88704 CDM 6370000100 HCPCS 250 RC 47781-0468-13 NDC outpatient 1 UN 37.76 37.76 CIGNA 62308 [3081051] CIGNA 62308 [308105105] 30.21 percent of total billed charges 23.41 35.87 Technical (Hospital) Services OSELTAMIVIR 30 MG CAPSULE RX-88704 CDM 6370000100 HCPCS 250 RC 47781-0468-13 NDC outpatient 1 UN 37.76 37.76 CIGNA 62308 [3081051] CIGNA STATE OF WYOMING [308105107] 30.21 percent of total billed charges 23.41 35.87 Technical (Hospital) Services OSELTAMIVIR 30 MG CAPSULE RX-88704 CDM 6370000100 HCPCS 250 RC 47781-0468-13 NDC outpatient 1 UN 37.76 37.76 MULTIPLAN INC 34080 [3081285] MULTIPLAN INC [308128501] 35.87 percent of total billed charges 23.41 35.87 Technical (Hospital) Services OSELTAMIVIR 30 MG CAPSULE RX-88704 CDM 6370000100 HCPCS 250 RC 47781-0468-13 NDC outpatient 1 UN 37.76 37.76 UNITED HEALTHCARE (COMMERCIAL) [3081199] UNITED HEALTHCARE 87726 [308119901] 23.41 percent of total billed charges 23.41 35.87 Technical (Hospital) Services OSELTAMIVIR 30 MG CAPSULE RX-88704 CDM 6370000100 HCPCS 250 RC 47781-0468-13 NDC outpatient 1 UN 37.76 37.76 HEALTHPARTNERS SX009 HEALTHPARTNERS 30.21 percent of total billed charges 23.41 35.87 Technical (Hospital) Services "CHOLECALCIFEROL (VITAMIN D3) 1,250 MCG (50,000 UNIT) CAPSULE" RX-88945 CDM 6370000100 HCPCS 250 RC 75834-0020-01 NDC inpatient 1 UN 5.77 5.77 BLUE CROSS BLUE SHIELD WELLMARK SB889 [3081026] BCBS WYOMING [308102603] 5.48 percent of total billed charges 3.58 5.48 Technical (Hospital) Services "CHOLECALCIFEROL (VITAMIN D3) 1,250 MCG (50,000 UNIT) CAPSULE" RX-88945 CDM 6370000100 HCPCS 250 RC 75834-0020-01 NDC inpatient 1 UN 5.77 5.77 MULTIPLAN INC 34080 [3081285] MULTIPLAN INC [308128501] 5.48 percent of total billed charges 3.58 5.48 Technical (Hospital) Services "CHOLECALCIFEROL (VITAMIN D3) 1,250 MCG (50,000 UNIT) CAPSULE" RX-88945 CDM 6370000100 HCPCS 250 RC 75834-0020-01 NDC inpatient 1 UN 5.77 5.77 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES HDHP [308136802] 4.57 percent of total billed charges 3.58 5.48 Technical (Hospital) Services "CHOLECALCIFEROL (VITAMIN D3) 1,250 MCG (50,000 UNIT) CAPSULE" RX-88945 CDM 6370000100 HCPCS 250 RC 75834-0020-01 NDC inpatient 1 UN 5.77 5.77 HEALTHPARTNERS SX009 HEALTHPARTNERS 4.57 percent of total billed charges 3.58 5.48 Technical (Hospital) Services "CHOLECALCIFEROL (VITAMIN D3) 1,250 MCG (50,000 UNIT) CAPSULE" RX-88945 CDM 6370000100 HCPCS 250 RC 75834-0020-01 NDC inpatient 1 UN 5.77 5.77 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES EPO [308136803] 4.57 percent of total billed charges 3.58 5.48 Technical (Hospital) Services "CHOLECALCIFEROL (VITAMIN D3) 1,250 MCG (50,000 UNIT) CAPSULE" RX-88945 CDM 6370000100 HCPCS 250 RC 75834-0020-01 NDC inpatient 1 UN 5.77 5.77 CIGNA 62308 [3081051] CIGNA 62308 [308105105] 4.57 percent of total billed charges 3.58 5.48 Technical (Hospital) Services "CHOLECALCIFEROL (VITAMIN D3) 1,250 MCG (50,000 UNIT) CAPSULE" RX-88945 CDM 6370000100 HCPCS 250 RC 75834-0020-01 NDC inpatient 1 UN 5.77 5.77 CIGNA 62308 [3081051] CIGNA STATE OF WYOMING [308105107] 4.57 percent of total billed charges 3.58 5.48 Technical (Hospital) Services "CHOLECALCIFEROL (VITAMIN D3) 1,250 MCG (50,000 UNIT) CAPSULE" RX-88945 CDM 6370000100 HCPCS 250 RC 75834-0020-01 NDC inpatient 1 UN 5.77 5.77 UNITED HEALTHCARE (COMMERCIAL) [3081199] UNITED HEALTHCARE 87726 [308119901] 3.58 percent of total billed charges 3.58 5.48 Technical (Hospital) Services "CHOLECALCIFEROL (VITAMIN D3) 1,250 MCG (50,000 UNIT) CAPSULE" RX-88945 CDM 6370000100 HCPCS 250 RC 75834-0020-01 NDC inpatient 1 UN 5.77 5.77 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES PPO [308136801] 4.57 percent of total billed charges 3.58 5.48 Technical (Hospital) Services "CHOLECALCIFEROL (VITAMIN D3) 1,250 MCG (50,000 UNIT) CAPSULE" RX-88945 CDM 6370000100 HCPCS 250 RC 75834-0020-01 NDC inpatient 1 UN 5.77 5.77 MEDICA (COMMERCIAL) 94265 [3081118] MEDICA CLAIMS [308111801] 5.19 percent of total billed charges 3.58 5.48 Technical (Hospital) Services "CHOLECALCIFEROL (VITAMIN D3) 1,250 MCG (50,000 UNIT) CAPSULE" RX-88945 CDM 6370000100 HCPCS 250 RC 75834-0020-01 NDC outpatient 1 UN 5.77 5.77 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES HDHP [308136802] 4.62 percent of total billed charges 3.58 5.48 Technical (Hospital) Services "CHOLECALCIFEROL (VITAMIN D3) 1,250 MCG (50,000 UNIT) CAPSULE" RX-88945 CDM 6370000100 HCPCS 250 RC 75834-0020-01 NDC outpatient 1 UN 5.77 5.77 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES EPO [308136803] 4.62 percent of total billed charges 3.58 5.48 Technical (Hospital) Services "CHOLECALCIFEROL (VITAMIN D3) 1,250 MCG (50,000 UNIT) CAPSULE" RX-88945 CDM 6370000100 HCPCS 250 RC 75834-0020-01 NDC outpatient 1 UN 5.77 5.77 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES PPO [308136801] 4.62 percent of total billed charges 3.58 5.48 Technical (Hospital) Services "CHOLECALCIFEROL (VITAMIN D3) 1,250 MCG (50,000 UNIT) CAPSULE" RX-88945 CDM 6370000100 HCPCS 250 RC 75834-0020-01 NDC outpatient 1 UN 5.77 5.77 UNITED HEALTHCARE (COMMERCIAL) [3081199] UNITED HEALTHCARE 87726 [308119901] 3.58 percent of total billed charges 3.58 5.48 Technical (Hospital) Services "CHOLECALCIFEROL (VITAMIN D3) 1,250 MCG (50,000 UNIT) CAPSULE" RX-88945 CDM 6370000100 HCPCS 250 RC 75834-0020-01 NDC outpatient 1 UN 5.77 5.77 MEDICA (COMMERCIAL) 94265 [3081118] MEDICA CLAIMS [308111801] 5.19 percent of total billed charges 3.58 5.48 Technical (Hospital) Services "CHOLECALCIFEROL (VITAMIN D3) 1,250 MCG (50,000 UNIT) CAPSULE" RX-88945 CDM 6370000100 HCPCS 250 RC 75834-0020-01 NDC outpatient 1 UN 5.77 5.77 CIGNA 62308 [3081051] CIGNA 62308 [308105105] 4.62 percent of total billed charges 3.58 5.48 Technical (Hospital) Services "CHOLECALCIFEROL (VITAMIN D3) 1,250 MCG (50,000 UNIT) CAPSULE" RX-88945 CDM 6370000100 HCPCS 250 RC 75834-0020-01 NDC outpatient 1 UN 5.77 5.77 CIGNA 62308 [3081051] CIGNA STATE OF WYOMING [308105107] 4.62 percent of total billed charges 3.58 5.48 Technical (Hospital) Services "CHOLECALCIFEROL (VITAMIN D3) 1,250 MCG (50,000 UNIT) CAPSULE" RX-88945 CDM 6370000100 HCPCS 250 RC 75834-0020-01 NDC outpatient 1 UN 5.77 5.77 MULTIPLAN INC 34080 [3081285] MULTIPLAN INC [308128501] 5.48 percent of total billed charges 3.58 5.48 Technical (Hospital) Services "CHOLECALCIFEROL (VITAMIN D3) 1,250 MCG (50,000 UNIT) CAPSULE" RX-88945 CDM 6370000100 HCPCS 250 RC 75834-0020-01 NDC outpatient 1 UN 5.77 5.77 HEALTHPARTNERS SX009 HEALTHPARTNERS 4.62 percent of total billed charges 3.58 5.48 Technical (Hospital) Services "CHOLECALCIFEROL (VITAMIN D3) 1,250 MCG (50,000 UNIT) CAPSULE" RX-88945 CDM 6370000100 HCPCS 250 RC 75834-0020-01 NDC outpatient 1 UN 5.77 5.77 BLUE CROSS BLUE SHIELD WELLMARK SB889 [3081026] BCBS WYOMING [308102603] 5.48 percent of total billed charges 3.58 5.48 Technical (Hospital) Services "ACETAZOLAMIDE ER 500 MG CAPSULE,EXTENDED RELEASE" RX-8962 CDM 6370000100 HCPCS 250 RC 50742-0233-01 NDC outpatient 1 UN 6.12 6.12 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES PPO [308136801] 4.9 percent of total billed charges 3.79 5.81 Technical (Hospital) Services "ACETAZOLAMIDE ER 500 MG CAPSULE,EXTENDED RELEASE" RX-8962 CDM 6370000100 HCPCS 250 RC 50742-0233-01 NDC outpatient 1 UN 6.12 6.12 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES HDHP [308136802] 4.9 percent of total billed charges 3.79 5.81 Technical (Hospital) Services "ACETAZOLAMIDE ER 500 MG CAPSULE,EXTENDED RELEASE" RX-8962 CDM 6370000100 HCPCS 250 RC 50742-0233-01 NDC outpatient 1 UN 6.12 6.12 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES EPO [308136803] 4.9 percent of total billed charges 3.79 5.81 Technical (Hospital) Services "ACETAZOLAMIDE ER 500 MG CAPSULE,EXTENDED RELEASE" RX-8962 CDM 6370000100 HCPCS 250 RC 50742-0233-01 NDC outpatient 1 UN 6.12 6.12 UNITED HEALTHCARE (COMMERCIAL) [3081199] UNITED HEALTHCARE 87726 [308119901] 3.79 percent of total billed charges 3.79 5.81 Technical (Hospital) Services "ACETAZOLAMIDE ER 500 MG CAPSULE,EXTENDED RELEASE" RX-8962 CDM 6370000100 HCPCS 250 RC 50742-0233-01 NDC outpatient 1 UN 6.12 6.12 HEALTHPARTNERS SX009 HEALTHPARTNERS 4.9 percent of total billed charges 3.79 5.81 Technical (Hospital) Services "ACETAZOLAMIDE ER 500 MG CAPSULE,EXTENDED RELEASE" RX-8962 CDM 6370000100 HCPCS 250 RC 50742-0233-01 NDC outpatient 1 UN 6.12 6.12 MEDICA (COMMERCIAL) 94265 [3081118] MEDICA CLAIMS [308111801] 5.51 percent of total billed charges 3.79 5.81 Technical (Hospital) Services "ACETAZOLAMIDE ER 500 MG CAPSULE,EXTENDED RELEASE" RX-8962 CDM 6370000100 HCPCS 250 RC 50742-0233-01 NDC outpatient 1 UN 6.12 6.12 MULTIPLAN INC 34080 [3081285] MULTIPLAN INC [308128501] 5.81 percent of total billed charges 3.79 5.81 Technical (Hospital) Services "ACETAZOLAMIDE ER 500 MG CAPSULE,EXTENDED RELEASE" RX-8962 CDM 6370000100 HCPCS 250 RC 50742-0233-01 NDC outpatient 1 UN 6.12 6.12 CIGNA 62308 [3081051] CIGNA 62308 [308105105] 4.9 percent of total billed charges 3.79 5.81 Technical (Hospital) Services "ACETAZOLAMIDE ER 500 MG CAPSULE,EXTENDED RELEASE" RX-8962 CDM 6370000100 HCPCS 250 RC 50742-0233-01 NDC outpatient 1 UN 6.12 6.12 CIGNA 62308 [3081051] CIGNA STATE OF WYOMING [308105107] 4.9 percent of total billed charges 3.79 5.81 Technical (Hospital) Services "ACETAZOLAMIDE ER 500 MG CAPSULE,EXTENDED RELEASE" RX-8962 CDM 6370000100 HCPCS 250 RC 50742-0233-01 NDC outpatient 1 UN 6.12 6.12 BLUE CROSS BLUE SHIELD WELLMARK SB889 [3081026] BCBS WYOMING [308102603] 5.81 percent of total billed charges 3.79 5.81 Technical (Hospital) Services "ACETAZOLAMIDE ER 500 MG CAPSULE,EXTENDED RELEASE" RX-8962 CDM 6370000100 HCPCS 250 RC 50742-0233-01 NDC inpatient 1 UN 6.12 6.12 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES PPO [308136801] 4.85 percent of total billed charges 3.79 5.81 Technical (Hospital) Services "ACETAZOLAMIDE ER 500 MG CAPSULE,EXTENDED RELEASE" RX-8962 CDM 6370000100 HCPCS 250 RC 50742-0233-01 NDC inpatient 1 UN 6.12 6.12 MEDICA (COMMERCIAL) 94265 [3081118] MEDICA CLAIMS [308111801] 5.51 percent of total billed charges 3.79 5.81 Technical (Hospital) Services "ACETAZOLAMIDE ER 500 MG CAPSULE,EXTENDED RELEASE" RX-8962 CDM 6370000100 HCPCS 250 RC 50742-0233-01 NDC inpatient 1 UN 6.12 6.12 HEALTHPARTNERS SX009 HEALTHPARTNERS 4.85 percent of total billed charges 3.79 5.81 Technical (Hospital) Services "ACETAZOLAMIDE ER 500 MG CAPSULE,EXTENDED RELEASE" RX-8962 CDM 6370000100 HCPCS 250 RC 50742-0233-01 NDC inpatient 1 UN 6.12 6.12 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES HDHP [308136802] 4.85 percent of total billed charges 3.79 5.81 Technical (Hospital) Services "ACETAZOLAMIDE ER 500 MG CAPSULE,EXTENDED RELEASE" RX-8962 CDM 6370000100 HCPCS 250 RC 50742-0233-01 NDC inpatient 1 UN 6.12 6.12 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES EPO [308136803] 4.85 percent of total billed charges 3.79 5.81 Technical (Hospital) Services "ACETAZOLAMIDE ER 500 MG CAPSULE,EXTENDED RELEASE" RX-8962 CDM 6370000100 HCPCS 250 RC 50742-0233-01 NDC inpatient 1 UN 6.12 6.12 CIGNA 62308 [3081051] CIGNA 62308 [308105105] 4.85 percent of total billed charges 3.79 5.81 Technical (Hospital) Services "ACETAZOLAMIDE ER 500 MG CAPSULE,EXTENDED RELEASE" RX-8962 CDM 6370000100 HCPCS 250 RC 50742-0233-01 NDC inpatient 1 UN 6.12 6.12 CIGNA 62308 [3081051] CIGNA STATE OF WYOMING [308105107] 4.85 percent of total billed charges 3.79 5.81 Technical (Hospital) Services "ACETAZOLAMIDE ER 500 MG CAPSULE,EXTENDED RELEASE" RX-8962 CDM 6370000100 HCPCS 250 RC 50742-0233-01 NDC inpatient 1 UN 6.12 6.12 UNITED HEALTHCARE (COMMERCIAL) [3081199] UNITED HEALTHCARE 87726 [308119901] 3.79 percent of total billed charges 3.79 5.81 Technical (Hospital) Services "ACETAZOLAMIDE ER 500 MG CAPSULE,EXTENDED RELEASE" RX-8962 CDM 6370000100 HCPCS 250 RC 50742-0233-01 NDC inpatient 1 UN 6.12 6.12 BLUE CROSS BLUE SHIELD WELLMARK SB889 [3081026] BCBS WYOMING [308102603] 5.81 percent of total billed charges 3.79 5.81 Technical (Hospital) Services "ACETAZOLAMIDE ER 500 MG CAPSULE,EXTENDED RELEASE" RX-8962 CDM 6370000100 HCPCS 250 RC 50742-0233-01 NDC inpatient 1 UN 6.12 6.12 MULTIPLAN INC 34080 [3081285] MULTIPLAN INC [308128501] 5.81 percent of total billed charges 3.79 5.81 Technical (Hospital) Services ACYCLOVIR 800 MG TABLET RX-8972 CDM 6370000100 HCPCS 250 RC 60505-5307-01 NDC inpatient 1 UN 5.92 5.92 MEDICA (COMMERCIAL) 94265 [3081118] MEDICA CLAIMS [308111801] 5.33 percent of total billed charges 3.67 5.62 Technical (Hospital) Services ACYCLOVIR 800 MG TABLET RX-8972 CDM 6370000100 HCPCS 250 RC 60505-5307-01 NDC inpatient 1 UN 5.92 5.92 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES PPO [308136801] 4.69 percent of total billed charges 3.67 5.62 Technical (Hospital) Services ACYCLOVIR 800 MG TABLET RX-8972 CDM 6370000100 HCPCS 250 RC 60505-5307-01 NDC inpatient 1 UN 5.92 5.92 HEALTHPARTNERS SX009 HEALTHPARTNERS 4.69 percent of total billed charges 3.67 5.62 Technical (Hospital) Services ACYCLOVIR 800 MG TABLET RX-8972 CDM 6370000100 HCPCS 250 RC 60505-5307-01 NDC inpatient 1 UN 5.92 5.92 MULTIPLAN INC 34080 [3081285] MULTIPLAN INC [308128501] 5.62 percent of total billed charges 3.67 5.62 Technical (Hospital) Services ACYCLOVIR 800 MG TABLET RX-8972 CDM 6370000100 HCPCS 250 RC 60505-5307-01 NDC inpatient 1 UN 5.92 5.92 UNITED HEALTHCARE (COMMERCIAL) [3081199] UNITED HEALTHCARE 87726 [308119901] 3.67 percent of total billed charges 3.67 5.62 Technical (Hospital) Services ACYCLOVIR 800 MG TABLET RX-8972 CDM 6370000100 HCPCS 250 RC 60505-5307-01 NDC inpatient 1 UN 5.92 5.92 BLUE CROSS BLUE SHIELD WELLMARK SB889 [3081026] BCBS WYOMING [308102603] 5.62 percent of total billed charges 3.67 5.62 Technical (Hospital) Services ACYCLOVIR 800 MG TABLET RX-8972 CDM 6370000100 HCPCS 250 RC 60505-5307-01 NDC inpatient 1 UN 5.92 5.92 CIGNA 62308 [3081051] CIGNA 62308 [308105105] 4.69 percent of total billed charges 3.67 5.62 Technical (Hospital) Services ACYCLOVIR 800 MG TABLET RX-8972 CDM 6370000100 HCPCS 250 RC 60505-5307-01 NDC inpatient 1 UN 5.92 5.92 CIGNA 62308 [3081051] CIGNA STATE OF WYOMING [308105107] 4.69 percent of total billed charges 3.67 5.62 Technical (Hospital) Services ACYCLOVIR 800 MG TABLET RX-8972 CDM 6370000100 HCPCS 250 RC 60505-5307-01 NDC inpatient 1 UN 5.92 5.92 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES EPO [308136803] 4.69 percent of total billed charges 3.67 5.62 Technical (Hospital) Services ACYCLOVIR 800 MG TABLET RX-8972 CDM 6370000100 HCPCS 250 RC 60505-5307-01 NDC inpatient 1 UN 5.92 5.92 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES HDHP [308136802] 4.69 percent of total billed charges 3.67 5.62 Technical (Hospital) Services ACYCLOVIR 800 MG TABLET RX-8972 CDM 6370000100 HCPCS 250 RC 60505-5307-01 NDC outpatient 1 UN 5.92 5.92 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES EPO [308136803] 4.74 percent of total billed charges 3.67 5.62 Technical (Hospital) Services ACYCLOVIR 800 MG TABLET RX-8972 CDM 6370000100 HCPCS 250 RC 60505-5307-01 NDC outpatient 1 UN 5.92 5.92 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES PPO [308136801] 4.74 percent of total billed charges 3.67 5.62 Technical (Hospital) Services ACYCLOVIR 800 MG TABLET RX-8972 CDM 6370000100 HCPCS 250 RC 60505-5307-01 NDC outpatient 1 UN 5.92 5.92 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES HDHP [308136802] 4.74 percent of total billed charges 3.67 5.62 Technical (Hospital) Services ACYCLOVIR 800 MG TABLET RX-8972 CDM 6370000100 HCPCS 250 RC 60505-5307-01 NDC outpatient 1 UN 5.92 5.92 MULTIPLAN INC 34080 [3081285] MULTIPLAN INC [308128501] 5.62 percent of total billed charges 3.67 5.62 Technical (Hospital) Services ACYCLOVIR 800 MG TABLET RX-8972 CDM 6370000100 HCPCS 250 RC 60505-5307-01 NDC outpatient 1 UN 5.92 5.92 CIGNA 62308 [3081051] CIGNA 62308 [308105105] 4.74 percent of total billed charges 3.67 5.62 Technical (Hospital) Services ACYCLOVIR 800 MG TABLET RX-8972 CDM 6370000100 HCPCS 250 RC 60505-5307-01 NDC outpatient 1 UN 5.92 5.92 CIGNA 62308 [3081051] CIGNA STATE OF WYOMING [308105107] 4.74 percent of total billed charges 3.67 5.62 Technical (Hospital) Services ACYCLOVIR 800 MG TABLET RX-8972 CDM 6370000100 HCPCS 250 RC 60505-5307-01 NDC outpatient 1 UN 5.92 5.92 MEDICA (COMMERCIAL) 94265 [3081118] MEDICA CLAIMS [308111801] 5.33 percent of total billed charges 3.67 5.62 Technical (Hospital) Services ACYCLOVIR 800 MG TABLET RX-8972 CDM 6370000100 HCPCS 250 RC 60505-5307-01 NDC outpatient 1 UN 5.92 5.92 UNITED HEALTHCARE (COMMERCIAL) [3081199] UNITED HEALTHCARE 87726 [308119901] 3.67 percent of total billed charges 3.67 5.62 Technical (Hospital) Services ACYCLOVIR 800 MG TABLET RX-8972 CDM 6370000100 HCPCS 250 RC 60505-5307-01 NDC outpatient 1 UN 5.92 5.92 HEALTHPARTNERS SX009 HEALTHPARTNERS 4.74 percent of total billed charges 3.67 5.62 Technical (Hospital) Services ACYCLOVIR 800 MG TABLET RX-8972 CDM 6370000100 HCPCS 250 RC 60505-5307-01 NDC outpatient 1 UN 5.92 5.92 BLUE CROSS BLUE SHIELD WELLMARK SB889 [3081026] BCBS WYOMING [308102603] 5.62 percent of total billed charges 3.67 5.62 Technical (Hospital) Services AMIODARONE 200 MG TABLET RX-9066 CDM 6370000100 HCPCS 250 RC 51672-4025-04 NDC inpatient 1 UN 5.89 5.89 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES PPO [308136801] 4.66 percent of total billed charges 3.65 5.6 Technical (Hospital) Services AMIODARONE 200 MG TABLET RX-9066 CDM 6370000100 HCPCS 250 RC 51672-4025-04 NDC inpatient 1 UN 5.89 5.89 HEALTHPARTNERS SX009 HEALTHPARTNERS 4.66 percent of total billed charges 3.65 5.6 Technical (Hospital) Services AMIODARONE 200 MG TABLET RX-9066 CDM 6370000100 HCPCS 250 RC 51672-4025-04 NDC inpatient 1 UN 5.89 5.89 MEDICA (COMMERCIAL) 94265 [3081118] MEDICA CLAIMS [308111801] 5.3 percent of total billed charges 3.65 5.6 Technical (Hospital) Services AMIODARONE 200 MG TABLET RX-9066 CDM 6370000100 HCPCS 250 RC 51672-4025-04 NDC inpatient 1 UN 5.89 5.89 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES EPO [308136803] 4.66 percent of total billed charges 3.65 5.6 Technical (Hospital) Services AMIODARONE 200 MG TABLET RX-9066 CDM 6370000100 HCPCS 250 RC 51672-4025-04 NDC inpatient 1 UN 5.89 5.89 CIGNA 62308 [3081051] CIGNA 62308 [308105105] 4.66 percent of total billed charges 3.65 5.6 Technical (Hospital) Services AMIODARONE 200 MG TABLET RX-9066 CDM 6370000100 HCPCS 250 RC 51672-4025-04 NDC inpatient 1 UN 5.89 5.89 CIGNA 62308 [3081051] CIGNA STATE OF WYOMING [308105107] 4.66 percent of total billed charges 3.65 5.6 Technical (Hospital) Services AMIODARONE 200 MG TABLET RX-9066 CDM 6370000100 HCPCS 250 RC 51672-4025-04 NDC inpatient 1 UN 5.89 5.89 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES HDHP [308136802] 4.66 percent of total billed charges 3.65 5.6 Technical (Hospital) Services AMIODARONE 200 MG TABLET RX-9066 CDM 6370000100 HCPCS 250 RC 51672-4025-04 NDC inpatient 1 UN 5.89 5.89 UNITED HEALTHCARE (COMMERCIAL) [3081199] UNITED HEALTHCARE 87726 [308119901] 3.65 percent of total billed charges 3.65 5.6 Technical (Hospital) Services AMIODARONE 200 MG TABLET RX-9066 CDM 6370000100 HCPCS 250 RC 51672-4025-04 NDC inpatient 1 UN 5.89 5.89 BLUE CROSS BLUE SHIELD WELLMARK SB889 [3081026] BCBS WYOMING [308102603] 5.6 percent of total billed charges 3.65 5.6 Technical (Hospital) Services AMIODARONE 200 MG TABLET RX-9066 CDM 6370000100 HCPCS 250 RC 51672-4025-04 NDC inpatient 1 UN 5.89 5.89 MULTIPLAN INC 34080 [3081285] MULTIPLAN INC [308128501] 5.6 percent of total billed charges 3.65 5.6 Technical (Hospital) Services AMIODARONE 200 MG TABLET RX-9066 CDM 6370000100 HCPCS 250 RC 51672-4025-04 NDC outpatient 1 UN 5.89 5.89 CIGNA 62308 [3081051] CIGNA 62308 [308105105] 4.71 percent of total billed charges 3.65 5.6 Technical (Hospital) Services AMIODARONE 200 MG TABLET RX-9066 CDM 6370000100 HCPCS 250 RC 51672-4025-04 NDC outpatient 1 UN 5.89 5.89 CIGNA 62308 [3081051] CIGNA STATE OF WYOMING [308105107] 4.71 percent of total billed charges 3.65 5.6 Technical (Hospital) Services AMIODARONE 200 MG TABLET RX-9066 CDM 6370000100 HCPCS 250 RC 51672-4025-04 NDC outpatient 1 UN 5.89 5.89 MULTIPLAN INC 34080 [3081285] MULTIPLAN INC [308128501] 5.6 percent of total billed charges 3.65 5.6 Technical (Hospital) Services AMIODARONE 200 MG TABLET RX-9066 CDM 6370000100 HCPCS 250 RC 51672-4025-04 NDC outpatient 1 UN 5.89 5.89 MEDICA (COMMERCIAL) 94265 [3081118] MEDICA CLAIMS [308111801] 5.3 percent of total billed charges 3.65 5.6 Technical (Hospital) Services AMIODARONE 200 MG TABLET RX-9066 CDM 6370000100 HCPCS 250 RC 51672-4025-04 NDC outpatient 1 UN 5.89 5.89 UNITED HEALTHCARE (COMMERCIAL) [3081199] UNITED HEALTHCARE 87726 [308119901] 3.65 percent of total billed charges 3.65 5.6 Technical (Hospital) Services AMIODARONE 200 MG TABLET RX-9066 CDM 6370000100 HCPCS 250 RC 51672-4025-04 NDC outpatient 1 UN 5.89 5.89 HEALTHPARTNERS SX009 HEALTHPARTNERS 4.71 percent of total billed charges 3.65 5.6 Technical (Hospital) Services AMIODARONE 200 MG TABLET RX-9066 CDM 6370000100 HCPCS 250 RC 51672-4025-04 NDC outpatient 1 UN 5.89 5.89 BLUE CROSS BLUE SHIELD WELLMARK SB889 [3081026] BCBS WYOMING [308102603] 5.6 percent of total billed charges 3.65 5.6 Technical (Hospital) Services AMIODARONE 200 MG TABLET RX-9066 CDM 6370000100 HCPCS 250 RC 51672-4025-04 NDC outpatient 1 UN 5.89 5.89 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES PPO [308136801] 4.71 percent of total billed charges 3.65 5.6 Technical (Hospital) Services AMIODARONE 200 MG TABLET RX-9066 CDM 6370000100 HCPCS 250 RC 51672-4025-04 NDC outpatient 1 UN 5.89 5.89 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES EPO [308136803] 4.71 percent of total billed charges 3.65 5.6 Technical (Hospital) Services AMIODARONE 200 MG TABLET RX-9066 CDM 6370000100 HCPCS 250 RC 51672-4025-04 NDC outpatient 1 UN 5.89 5.89 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES HDHP [308136802] 4.71 percent of total billed charges 3.65 5.6 Technical (Hospital) Services AMLODIPINE 10 MG TABLET RX-9069 CDM 6370000100 HCPCS 250 RC 67877-0199-90 NDC inpatient 1 UN 5.66 5.66 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES HDHP [308136802] 4.48 percent of total billed charges 3.51 5.38 Technical (Hospital) Services AMLODIPINE 10 MG TABLET RX-9069 CDM 6370000100 HCPCS 250 RC 67877-0199-90 NDC inpatient 1 UN 5.66 5.66 CIGNA 62308 [3081051] CIGNA 62308 [308105105] 4.48 percent of total billed charges 3.51 5.38 Technical (Hospital) Services AMLODIPINE 10 MG TABLET RX-9069 CDM 6370000100 HCPCS 250 RC 67877-0199-90 NDC inpatient 1 UN 5.66 5.66 CIGNA 62308 [3081051] CIGNA STATE OF WYOMING [308105107] 4.48 percent of total billed charges 3.51 5.38 Technical (Hospital) Services AMLODIPINE 10 MG TABLET RX-9069 CDM 6370000100 HCPCS 250 RC 67877-0199-90 NDC inpatient 1 UN 5.66 5.66 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES EPO [308136803] 4.48 percent of total billed charges 3.51 5.38 Technical (Hospital) Services AMLODIPINE 10 MG TABLET RX-9069 CDM 6370000100 HCPCS 250 RC 67877-0199-90 NDC inpatient 1 UN 5.66 5.66 UNITED HEALTHCARE (COMMERCIAL) [3081199] UNITED HEALTHCARE 87726 [308119901] 3.51 percent of total billed charges 3.51 5.38 Technical (Hospital) Services AMLODIPINE 10 MG TABLET RX-9069 CDM 6370000100 HCPCS 250 RC 67877-0199-90 NDC inpatient 1 UN 5.66 5.66 BLUE CROSS BLUE SHIELD WELLMARK SB889 [3081026] BCBS WYOMING [308102603] 5.38 percent of total billed charges 3.51 5.38 Technical (Hospital) Services AMLODIPINE 10 MG TABLET RX-9069 CDM 6370000100 HCPCS 250 RC 67877-0199-90 NDC inpatient 1 UN 5.66 5.66 MULTIPLAN INC 34080 [3081285] MULTIPLAN INC [308128501] 5.38 percent of total billed charges 3.51 5.38 Technical (Hospital) Services AMLODIPINE 10 MG TABLET RX-9069 CDM 6370000100 HCPCS 250 RC 67877-0199-90 NDC inpatient 1 UN 5.66 5.66 MEDICA (COMMERCIAL) 94265 [3081118] MEDICA CLAIMS [308111801] 5.09 percent of total billed charges 3.51 5.38 Technical (Hospital) Services AMLODIPINE 10 MG TABLET RX-9069 CDM 6370000100 HCPCS 250 RC 67877-0199-90 NDC inpatient 1 UN 5.66 5.66 HEALTHPARTNERS SX009 HEALTHPARTNERS 4.48 percent of total billed charges 3.51 5.38 Technical (Hospital) Services AMLODIPINE 10 MG TABLET RX-9069 CDM 6370000100 HCPCS 250 RC 67877-0199-90 NDC inpatient 1 UN 5.66 5.66 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES PPO [308136801] 4.48 percent of total billed charges 3.51 5.38 Technical (Hospital) Services AMLODIPINE 10 MG TABLET RX-9069 CDM 6370000100 HCPCS 250 RC 67877-0199-90 NDC outpatient 1 UN 5.66 5.66 UNITED HEALTHCARE (COMMERCIAL) [3081199] UNITED HEALTHCARE 87726 [308119901] 3.51 percent of total billed charges 3.51 5.38 Technical (Hospital) Services AMLODIPINE 10 MG TABLET RX-9069 CDM 6370000100 HCPCS 250 RC 67877-0199-90 NDC outpatient 1 UN 5.66 5.66 HEALTHPARTNERS SX009 HEALTHPARTNERS 4.53 percent of total billed charges 3.51 5.38 Technical (Hospital) Services AMLODIPINE 10 MG TABLET RX-9069 CDM 6370000100 HCPCS 250 RC 67877-0199-90 NDC outpatient 1 UN 5.66 5.66 CIGNA 62308 [3081051] CIGNA 62308 [308105105] 4.53 percent of total billed charges 3.51 5.38 Technical (Hospital) Services AMLODIPINE 10 MG TABLET RX-9069 CDM 6370000100 HCPCS 250 RC 67877-0199-90 NDC outpatient 1 UN 5.66 5.66 CIGNA 62308 [3081051] CIGNA STATE OF WYOMING [308105107] 4.53 percent of total billed charges 3.51 5.38 Technical (Hospital) Services AMLODIPINE 10 MG TABLET RX-9069 CDM 6370000100 HCPCS 250 RC 67877-0199-90 NDC outpatient 1 UN 5.66 5.66 MULTIPLAN INC 34080 [3081285] MULTIPLAN INC [308128501] 5.38 percent of total billed charges 3.51 5.38 Technical (Hospital) Services AMLODIPINE 10 MG TABLET RX-9069 CDM 6370000100 HCPCS 250 RC 67877-0199-90 NDC outpatient 1 UN 5.66 5.66 MEDICA (COMMERCIAL) 94265 [3081118] MEDICA CLAIMS [308111801] 5.09 percent of total billed charges 3.51 5.38 Technical (Hospital) Services AMLODIPINE 10 MG TABLET RX-9069 CDM 6370000100 HCPCS 250 RC 67877-0199-90 NDC outpatient 1 UN 5.66 5.66 BLUE CROSS BLUE SHIELD WELLMARK SB889 [3081026] BCBS WYOMING [308102603] 5.38 percent of total billed charges 3.51 5.38 Technical (Hospital) Services AMLODIPINE 10 MG TABLET RX-9069 CDM 6370000100 HCPCS 250 RC 67877-0199-90 NDC outpatient 1 UN 5.66 5.66 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES HDHP [308136802] 4.53 percent of total billed charges 3.51 5.38 Technical (Hospital) Services AMLODIPINE 10 MG TABLET RX-9069 CDM 6370000100 HCPCS 250 RC 67877-0199-90 NDC outpatient 1 UN 5.66 5.66 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES PPO [308136801] 4.53 percent of total billed charges 3.51 5.38 Technical (Hospital) Services AMLODIPINE 10 MG TABLET RX-9069 CDM 6370000100 HCPCS 250 RC 67877-0199-90 NDC outpatient 1 UN 5.66 5.66 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES EPO [308136803] 4.53 percent of total billed charges 3.51 5.38 Technical (Hospital) Services AMLODIPINE 5 MG TABLET RX-9071 CDM 6370000100 HCPCS 250 RC 69097-0127-05 NDC inpatient 1 UN 5.66 5.66 MEDICA (COMMERCIAL) 94265 [3081118] MEDICA CLAIMS [308111801] 5.09 percent of total billed charges 3.51 5.38 Technical (Hospital) Services AMLODIPINE 5 MG TABLET RX-9071 CDM 6370000100 HCPCS 250 RC 69097-0127-05 NDC inpatient 1 UN 5.66 5.66 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES PPO [308136801] 4.48 percent of total billed charges 3.51 5.38 Technical (Hospital) Services AMLODIPINE 5 MG TABLET RX-9071 CDM 6370000100 HCPCS 250 RC 69097-0127-05 NDC inpatient 1 UN 5.66 5.66 MULTIPLAN INC 34080 [3081285] MULTIPLAN INC [308128501] 5.38 percent of total billed charges 3.51 5.38 Technical (Hospital) Services AMLODIPINE 5 MG TABLET RX-9071 CDM 6370000100 HCPCS 250 RC 69097-0127-05 NDC inpatient 1 UN 5.66 5.66 UNITED HEALTHCARE (COMMERCIAL) [3081199] UNITED HEALTHCARE 87726 [308119901] 3.51 percent of total billed charges 3.51 5.38 Technical (Hospital) Services AMLODIPINE 5 MG TABLET RX-9071 CDM 6370000100 HCPCS 250 RC 69097-0127-05 NDC inpatient 1 UN 5.66 5.66 CIGNA 62308 [3081051] CIGNA 62308 [308105105] 4.48 percent of total billed charges 3.51 5.38 Technical (Hospital) Services AMLODIPINE 5 MG TABLET RX-9071 CDM 6370000100 HCPCS 250 RC 69097-0127-05 NDC inpatient 1 UN 5.66 5.66 CIGNA 62308 [3081051] CIGNA STATE OF WYOMING [308105107] 4.48 percent of total billed charges 3.51 5.38 Technical (Hospital) Services AMLODIPINE 5 MG TABLET RX-9071 CDM 6370000100 HCPCS 250 RC 69097-0127-05 NDC inpatient 1 UN 5.66 5.66 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES EPO [308136803] 4.48 percent of total billed charges 3.51 5.38 Technical (Hospital) Services AMLODIPINE 5 MG TABLET RX-9071 CDM 6370000100 HCPCS 250 RC 69097-0127-05 NDC inpatient 1 UN 5.66 5.66 BLUE CROSS BLUE SHIELD WELLMARK SB889 [3081026] BCBS WYOMING [308102603] 5.38 percent of total billed charges 3.51 5.38 Technical (Hospital) Services AMLODIPINE 5 MG TABLET RX-9071 CDM 6370000100 HCPCS 250 RC 69097-0127-05 NDC inpatient 1 UN 5.66 5.66 HEALTHPARTNERS SX009 HEALTHPARTNERS 4.48 percent of total billed charges 3.51 5.38 Technical (Hospital) Services AMLODIPINE 5 MG TABLET RX-9071 CDM 6370000100 HCPCS 250 RC 69097-0127-05 NDC inpatient 1 UN 5.66 5.66 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES HDHP [308136802] 4.48 percent of total billed charges 3.51 5.38 Technical (Hospital) Services AMLODIPINE 5 MG TABLET RX-9071 CDM 6370000100 HCPCS 250 RC 69097-0127-05 NDC outpatient 1 UN 5.66 5.66 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES PPO [308136801] 4.53 percent of total billed charges 3.51 5.38 Technical (Hospital) Services AMLODIPINE 5 MG TABLET RX-9071 CDM 6370000100 HCPCS 250 RC 69097-0127-05 NDC outpatient 1 UN 5.66 5.66 MEDICA (COMMERCIAL) 94265 [3081118] MEDICA CLAIMS [308111801] 5.09 percent of total billed charges 3.51 5.38 Technical (Hospital) Services AMLODIPINE 5 MG TABLET RX-9071 CDM 6370000100 HCPCS 250 RC 69097-0127-05 NDC outpatient 1 UN 5.66 5.66 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES EPO [308136803] 4.53 percent of total billed charges 3.51 5.38 Technical (Hospital) Services AMLODIPINE 5 MG TABLET RX-9071 CDM 6370000100 HCPCS 250 RC 69097-0127-05 NDC outpatient 1 UN 5.66 5.66 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES HDHP [308136802] 4.53 percent of total billed charges 3.51 5.38 Technical (Hospital) Services AMLODIPINE 5 MG TABLET RX-9071 CDM 6370000100 HCPCS 250 RC 69097-0127-05 NDC outpatient 1 UN 5.66 5.66 HEALTHPARTNERS SX009 HEALTHPARTNERS 4.53 percent of total billed charges 3.51 5.38 Technical (Hospital) Services AMLODIPINE 5 MG TABLET RX-9071 CDM 6370000100 HCPCS 250 RC 69097-0127-05 NDC outpatient 1 UN 5.66 5.66 UNITED HEALTHCARE (COMMERCIAL) [3081199] UNITED HEALTHCARE 87726 [308119901] 3.51 percent of total billed charges 3.51 5.38 Technical (Hospital) Services AMLODIPINE 5 MG TABLET RX-9071 CDM 6370000100 HCPCS 250 RC 69097-0127-05 NDC outpatient 1 UN 5.66 5.66 MULTIPLAN INC 34080 [3081285] MULTIPLAN INC [308128501] 5.38 percent of total billed charges 3.51 5.38 Technical (Hospital) Services AMLODIPINE 5 MG TABLET RX-9071 CDM 6370000100 HCPCS 250 RC 69097-0127-05 NDC outpatient 1 UN 5.66 5.66 CIGNA 62308 [3081051] CIGNA 62308 [308105105] 4.53 percent of total billed charges 3.51 5.38 Technical (Hospital) Services AMLODIPINE 5 MG TABLET RX-9071 CDM 6370000100 HCPCS 250 RC 69097-0127-05 NDC outpatient 1 UN 5.66 5.66 CIGNA 62308 [3081051] CIGNA STATE OF WYOMING [308105107] 4.53 percent of total billed charges 3.51 5.38 Technical (Hospital) Services AMLODIPINE 5 MG TABLET RX-9071 CDM 6370000100 HCPCS 250 RC 69097-0127-05 NDC outpatient 1 UN 5.66 5.66 BLUE CROSS BLUE SHIELD WELLMARK SB889 [3081026] BCBS WYOMING [308102603] 5.38 percent of total billed charges 3.51 5.38 Technical (Hospital) Services AMOXICILLIN 250 MG- CLAVULANATE 62.5 MG/5 ML ORAL SUSPENSION RX-9080 CDM 6370000100 HCPCS 250 RC 43598-0204-53 NDC inpatient 150 ML 617.75 617.75 UNITED HEALTHCARE (COMMERCIAL) [3081199] UNITED HEALTHCARE 87726 [308119901] 383.01 percent of total billed charges 383.01 586.86 Technical (Hospital) Services AMOXICILLIN 250 MG- CLAVULANATE 62.5 MG/5 ML ORAL SUSPENSION RX-9080 CDM 6370000100 HCPCS 250 RC 43598-0204-53 NDC inpatient 150 ML 617.75 617.75 BLUE CROSS BLUE SHIELD WELLMARK SB889 [3081026] BCBS WYOMING [308102603] 586.86 percent of total billed charges 383.01 586.86 Technical (Hospital) Services AMOXICILLIN 250 MG- CLAVULANATE 62.5 MG/5 ML ORAL SUSPENSION RX-9080 CDM 6370000100 HCPCS 250 RC 43598-0204-53 NDC inpatient 150 ML 617.75 617.75 MULTIPLAN INC 34080 [3081285] MULTIPLAN INC [308128501] 586.86 percent of total billed charges 383.01 586.86 Technical (Hospital) Services AMOXICILLIN 250 MG- CLAVULANATE 62.5 MG/5 ML ORAL SUSPENSION RX-9080 CDM 6370000100 HCPCS 250 RC 43598-0204-53 NDC inpatient 150 ML 617.75 617.75 MEDICA (COMMERCIAL) 94265 [3081118] MEDICA CLAIMS [308111801] 555.98 percent of total billed charges 383.01 586.86 Technical (Hospital) Services AMOXICILLIN 250 MG- CLAVULANATE 62.5 MG/5 ML ORAL SUSPENSION RX-9080 CDM 6370000100 HCPCS 250 RC 43598-0204-53 NDC inpatient 150 ML 617.75 617.75 HEALTHPARTNERS SX009 HEALTHPARTNERS 489.13 percent of total billed charges 383.01 586.86 Technical (Hospital) Services AMOXICILLIN 250 MG- CLAVULANATE 62.5 MG/5 ML ORAL SUSPENSION RX-9080 CDM 6370000100 HCPCS 250 RC 43598-0204-53 NDC inpatient 150 ML 617.75 617.75 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES EPO [308136803] 489.13 percent of total billed charges 383.01 586.86 Technical (Hospital) Services AMOXICILLIN 250 MG- CLAVULANATE 62.5 MG/5 ML ORAL SUSPENSION RX-9080 CDM 6370000100 HCPCS 250 RC 43598-0204-53 NDC inpatient 150 ML 617.75 617.75 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES HDHP [308136802] 489.13 percent of total billed charges 383.01 586.86 Technical (Hospital) Services AMOXICILLIN 250 MG- CLAVULANATE 62.5 MG/5 ML ORAL SUSPENSION RX-9080 CDM 6370000100 HCPCS 250 RC 43598-0204-53 NDC inpatient 150 ML 617.75 617.75 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES PPO [308136801] 489.13 percent of total billed charges 383.01 586.86 Technical (Hospital) Services AMOXICILLIN 250 MG- CLAVULANATE 62.5 MG/5 ML ORAL SUSPENSION RX-9080 CDM 6370000100 HCPCS 250 RC 43598-0204-53 NDC inpatient 150 ML 617.75 617.75 CIGNA 62308 [3081051] CIGNA 62308 [308105105] 489.13 percent of total billed charges 383.01 586.86 Technical (Hospital) Services AMOXICILLIN 250 MG- CLAVULANATE 62.5 MG/5 ML ORAL SUSPENSION RX-9080 CDM 6370000100 HCPCS 250 RC 43598-0204-53 NDC inpatient 150 ML 617.75 617.75 CIGNA 62308 [3081051] CIGNA STATE OF WYOMING [308105107] 489.13 percent of total billed charges 383.01 586.86 Technical (Hospital) Services AMOXICILLIN 250 MG- CLAVULANATE 62.5 MG/5 ML ORAL SUSPENSION RX-9080 CDM 6370000100 HCPCS 250 RC 43598-0204-53 NDC outpatient 150 ML 617.75 617.75 UNITED HEALTHCARE (COMMERCIAL) [3081199] UNITED HEALTHCARE 87726 [308119901] 383.01 percent of total billed charges 383.01 586.86 Technical (Hospital) Services AMOXICILLIN 250 MG- CLAVULANATE 62.5 MG/5 ML ORAL SUSPENSION RX-9080 CDM 6370000100 HCPCS 250 RC 43598-0204-53 NDC outpatient 150 ML 617.75 617.75 HEALTHPARTNERS SX009 HEALTHPARTNERS 494.2 percent of total billed charges 383.01 586.86 Technical (Hospital) Services AMOXICILLIN 250 MG- CLAVULANATE 62.5 MG/5 ML ORAL SUSPENSION RX-9080 CDM 6370000100 HCPCS 250 RC 43598-0204-53 NDC outpatient 150 ML 617.75 617.75 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES EPO [308136803] 494.2 percent of total billed charges 383.01 586.86 Technical (Hospital) Services AMOXICILLIN 250 MG- CLAVULANATE 62.5 MG/5 ML ORAL SUSPENSION RX-9080 CDM 6370000100 HCPCS 250 RC 43598-0204-53 NDC outpatient 150 ML 617.75 617.75 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES HDHP [308136802] 494.2 percent of total billed charges 383.01 586.86 Technical (Hospital) Services AMOXICILLIN 250 MG- CLAVULANATE 62.5 MG/5 ML ORAL SUSPENSION RX-9080 CDM 6370000100 HCPCS 250 RC 43598-0204-53 NDC outpatient 150 ML 617.75 617.75 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES PPO [308136801] 494.2 percent of total billed charges 383.01 586.86 Technical (Hospital) Services AMOXICILLIN 250 MG- CLAVULANATE 62.5 MG/5 ML ORAL SUSPENSION RX-9080 CDM 6370000100 HCPCS 250 RC 43598-0204-53 NDC outpatient 150 ML 617.75 617.75 BLUE CROSS BLUE SHIELD WELLMARK SB889 [3081026] BCBS WYOMING [308102603] 586.86 percent of total billed charges 383.01 586.86 Technical (Hospital) Services AMOXICILLIN 250 MG- CLAVULANATE 62.5 MG/5 ML ORAL SUSPENSION RX-9080 CDM 6370000100 HCPCS 250 RC 43598-0204-53 NDC outpatient 150 ML 617.75 617.75 CIGNA 62308 [3081051] CIGNA 62308 [308105105] 494.2 percent of total billed charges 383.01 586.86 Technical (Hospital) Services AMOXICILLIN 250 MG- CLAVULANATE 62.5 MG/5 ML ORAL SUSPENSION RX-9080 CDM 6370000100 HCPCS 250 RC 43598-0204-53 NDC outpatient 150 ML 617.75 617.75 CIGNA 62308 [3081051] CIGNA STATE OF WYOMING [308105107] 494.2 percent of total billed charges 383.01 586.86 Technical (Hospital) Services AMOXICILLIN 250 MG- CLAVULANATE 62.5 MG/5 ML ORAL SUSPENSION RX-9080 CDM 6370000100 HCPCS 250 RC 43598-0204-53 NDC outpatient 150 ML 617.75 617.75 MULTIPLAN INC 34080 [3081285] MULTIPLAN INC [308128501] 586.86 percent of total billed charges 383.01 586.86 Technical (Hospital) Services AMOXICILLIN 250 MG- CLAVULANATE 62.5 MG/5 ML ORAL SUSPENSION RX-9080 CDM 6370000100 HCPCS 250 RC 43598-0204-53 NDC outpatient 150 ML 617.75 617.75 MEDICA (COMMERCIAL) 94265 [3081118] MEDICA CLAIMS [308111801] 555.98 percent of total billed charges 383.01 586.86 Technical (Hospital) Services OCTREOTIDE ACETATE 100 MCG/ML INJECTION SOLUTION RX-91279 CDM 6370000100 HCPCS 250 RC 63323-0376-04 NDC outpatient 0.75 ML 60.85 60.85 UNITED HEALTHCARE (COMMERCIAL) [3081199] UNITED HEALTHCARE 87726 [308119901] 37.73 percent of total billed charges 37.73 57.81 Technical (Hospital) Services OCTREOTIDE ACETATE 100 MCG/ML INJECTION SOLUTION RX-91279 CDM 6370000100 HCPCS 250 RC 63323-0376-04 NDC outpatient 0.75 ML 60.85 60.85 MULTIPLAN INC 34080 [3081285] MULTIPLAN INC [308128501] 57.81 percent of total billed charges 37.73 57.81 Technical (Hospital) Services OCTREOTIDE ACETATE 100 MCG/ML INJECTION SOLUTION RX-91279 CDM 6370000100 HCPCS 250 RC 63323-0376-04 NDC outpatient 0.75 ML 60.85 60.85 CIGNA 62308 [3081051] CIGNA 62308 [308105105] 48.68 percent of total billed charges 37.73 57.81 Technical (Hospital) Services OCTREOTIDE ACETATE 100 MCG/ML INJECTION SOLUTION RX-91279 CDM 6370000100 HCPCS 250 RC 63323-0376-04 NDC outpatient 0.75 ML 60.85 60.85 CIGNA 62308 [3081051] CIGNA STATE OF WYOMING [308105107] 48.68 percent of total billed charges 37.73 57.81 Technical (Hospital) Services OCTREOTIDE ACETATE 100 MCG/ML INJECTION SOLUTION RX-91279 CDM 6370000100 HCPCS 250 RC 63323-0376-04 NDC outpatient 0.75 ML 60.85 60.85 MEDICA (COMMERCIAL) 94265 [3081118] MEDICA CLAIMS [308111801] 54.77 percent of total billed charges 37.73 57.81 Technical (Hospital) Services OCTREOTIDE ACETATE 100 MCG/ML INJECTION SOLUTION RX-91279 CDM 6370000100 HCPCS 250 RC 63323-0376-04 NDC outpatient 0.75 ML 60.85 60.85 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES EPO [308136803] 48.68 percent of total billed charges 37.73 57.81 Technical (Hospital) Services OCTREOTIDE ACETATE 100 MCG/ML INJECTION SOLUTION RX-91279 CDM 6370000100 HCPCS 250 RC 63323-0376-04 NDC outpatient 0.75 ML 60.85 60.85 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES HDHP [308136802] 48.68 percent of total billed charges 37.73 57.81 Technical (Hospital) Services OCTREOTIDE ACETATE 100 MCG/ML INJECTION SOLUTION RX-91279 CDM 6370000100 HCPCS 250 RC 63323-0376-04 NDC outpatient 0.75 ML 60.85 60.85 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES PPO [308136801] 48.68 percent of total billed charges 37.73 57.81 Technical (Hospital) Services OCTREOTIDE ACETATE 100 MCG/ML INJECTION SOLUTION RX-91279 CDM 6370000100 HCPCS 250 RC 63323-0376-04 NDC outpatient 0.75 ML 60.85 60.85 HEALTHPARTNERS SX009 HEALTHPARTNERS 48.68 percent of total billed charges 37.73 57.81 Technical (Hospital) Services OCTREOTIDE ACETATE 100 MCG/ML INJECTION SOLUTION RX-91279 CDM 6370000100 HCPCS 250 RC 63323-0376-04 NDC outpatient 0.75 ML 60.85 60.85 BLUE CROSS BLUE SHIELD WELLMARK SB889 [3081026] BCBS WYOMING [308102603] 57.81 percent of total billed charges 37.73 57.81 Technical (Hospital) Services OCTREOTIDE ACETATE 100 MCG/ML INJECTION SOLUTION RX-91279 CDM 6370000100 HCPCS 250 RC 63323-0376-04 NDC inpatient 0.75 ML 60.85 60.85 MULTIPLAN INC 34080 [3081285] MULTIPLAN INC [308128501] 57.81 percent of total billed charges 37.73 57.81 Technical (Hospital) Services OCTREOTIDE ACETATE 100 MCG/ML INJECTION SOLUTION RX-91279 CDM 6370000100 HCPCS 250 RC 63323-0376-04 NDC inpatient 0.75 ML 60.85 60.85 CIGNA 62308 [3081051] CIGNA 62308 [308105105] 48.18 percent of total billed charges 37.73 57.81 Technical (Hospital) Services OCTREOTIDE ACETATE 100 MCG/ML INJECTION SOLUTION RX-91279 CDM 6370000100 HCPCS 250 RC 63323-0376-04 NDC inpatient 0.75 ML 60.85 60.85 CIGNA 62308 [3081051] CIGNA STATE OF WYOMING [308105107] 48.18 percent of total billed charges 37.73 57.81 Technical (Hospital) Services OCTREOTIDE ACETATE 100 MCG/ML INJECTION SOLUTION RX-91279 CDM 6370000100 HCPCS 250 RC 63323-0376-04 NDC inpatient 0.75 ML 60.85 60.85 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES EPO [308136803] 48.18 percent of total billed charges 37.73 57.81 Technical (Hospital) Services OCTREOTIDE ACETATE 100 MCG/ML INJECTION SOLUTION RX-91279 CDM 6370000100 HCPCS 250 RC 63323-0376-04 NDC inpatient 0.75 ML 60.85 60.85 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES HDHP [308136802] 48.18 percent of total billed charges 37.73 57.81 Technical (Hospital) Services OCTREOTIDE ACETATE 100 MCG/ML INJECTION SOLUTION RX-91279 CDM 6370000100 HCPCS 250 RC 63323-0376-04 NDC inpatient 0.75 ML 60.85 60.85 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES PPO [308136801] 48.18 percent of total billed charges 37.73 57.81 Technical (Hospital) Services OCTREOTIDE ACETATE 100 MCG/ML INJECTION SOLUTION RX-91279 CDM 6370000100 HCPCS 250 RC 63323-0376-04 NDC inpatient 0.75 ML 60.85 60.85 MEDICA (COMMERCIAL) 94265 [3081118] MEDICA CLAIMS [308111801] 54.77 percent of total billed charges 37.73 57.81 Technical (Hospital) Services OCTREOTIDE ACETATE 100 MCG/ML INJECTION SOLUTION RX-91279 CDM 6370000100 HCPCS 250 RC 63323-0376-04 NDC inpatient 0.75 ML 60.85 60.85 HEALTHPARTNERS SX009 HEALTHPARTNERS 48.18 percent of total billed charges 37.73 57.81 Technical (Hospital) Services OCTREOTIDE ACETATE 100 MCG/ML INJECTION SOLUTION RX-91279 CDM 6370000100 HCPCS 250 RC 63323-0376-04 NDC inpatient 0.75 ML 60.85 60.85 UNITED HEALTHCARE (COMMERCIAL) [3081199] UNITED HEALTHCARE 87726 [308119901] 37.73 percent of total billed charges 37.73 57.81 Technical (Hospital) Services OCTREOTIDE ACETATE 100 MCG/ML INJECTION SOLUTION RX-91279 CDM 6370000100 HCPCS 250 RC 63323-0376-04 NDC inpatient 0.75 ML 60.85 60.85 BLUE CROSS BLUE SHIELD WELLMARK SB889 [3081026] BCBS WYOMING [308102603] 57.81 percent of total billed charges 37.73 57.81 Technical (Hospital) Services BUMETANIDE 1 MG TABLET RX-9310 CDM 6370000100 HCPCS 250 RC 00185-0129-01 NDC outpatient 1 UN 6.07 6.07 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES EPO [308136803] 4.86 percent of total billed charges 3.76 5.77 Technical (Hospital) Services BUMETANIDE 1 MG TABLET RX-9310 CDM 6370000100 HCPCS 250 RC 00185-0129-01 NDC outpatient 1 UN 6.07 6.07 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES PPO [308136801] 4.86 percent of total billed charges 3.76 5.77 Technical (Hospital) Services BUMETANIDE 1 MG TABLET RX-9310 CDM 6370000100 HCPCS 250 RC 00185-0129-01 NDC outpatient 1 UN 6.07 6.07 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES HDHP [308136802] 4.86 percent of total billed charges 3.76 5.77 Technical (Hospital) Services BUMETANIDE 1 MG TABLET RX-9310 CDM 6370000100 HCPCS 250 RC 00185-0129-01 NDC outpatient 1 UN 6.07 6.07 CIGNA 62308 [3081051] CIGNA 62308 [308105105] 4.86 percent of total billed charges 3.76 5.77 Technical (Hospital) Services BUMETANIDE 1 MG TABLET RX-9310 CDM 6370000100 HCPCS 250 RC 00185-0129-01 NDC outpatient 1 UN 6.07 6.07 CIGNA 62308 [3081051] CIGNA STATE OF WYOMING [308105107] 4.86 percent of total billed charges 3.76 5.77 Technical (Hospital) Services BUMETANIDE 1 MG TABLET RX-9310 CDM 6370000100 HCPCS 250 RC 00185-0129-01 NDC outpatient 1 UN 6.07 6.07 MULTIPLAN INC 34080 [3081285] MULTIPLAN INC [308128501] 5.77 percent of total billed charges 3.76 5.77 Technical (Hospital) Services BUMETANIDE 1 MG TABLET RX-9310 CDM 6370000100 HCPCS 250 RC 00185-0129-01 NDC outpatient 1 UN 6.07 6.07 MEDICA (COMMERCIAL) 94265 [3081118] MEDICA CLAIMS [308111801] 5.46 percent of total billed charges 3.76 5.77 Technical (Hospital) Services BUMETANIDE 1 MG TABLET RX-9310 CDM 6370000100 HCPCS 250 RC 00185-0129-01 NDC outpatient 1 UN 6.07 6.07 UNITED HEALTHCARE (COMMERCIAL) [3081199] UNITED HEALTHCARE 87726 [308119901] 3.76 percent of total billed charges 3.76 5.77 Technical (Hospital) Services BUMETANIDE 1 MG TABLET RX-9310 CDM 6370000100 HCPCS 250 RC 00185-0129-01 NDC outpatient 1 UN 6.07 6.07 BLUE CROSS BLUE SHIELD WELLMARK SB889 [3081026] BCBS WYOMING [308102603] 5.77 percent of total billed charges 3.76 5.77 Technical (Hospital) Services BUMETANIDE 1 MG TABLET RX-9310 CDM 6370000100 HCPCS 250 RC 00185-0129-01 NDC outpatient 1 UN 6.07 6.07 HEALTHPARTNERS SX009 HEALTHPARTNERS 4.86 percent of total billed charges 3.76 5.77 Technical (Hospital) Services BUMETANIDE 1 MG TABLET RX-9310 CDM 6370000100 HCPCS 250 RC 00185-0129-01 NDC inpatient 1 UN 6.07 6.07 MEDICA (COMMERCIAL) 94265 [3081118] MEDICA CLAIMS [308111801] 5.46 percent of total billed charges 3.76 5.77 Technical (Hospital) Services BUMETANIDE 1 MG TABLET RX-9310 CDM 6370000100 HCPCS 250 RC 00185-0129-01 NDC inpatient 1 UN 6.07 6.07 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES PPO [308136801] 4.81 percent of total billed charges 3.76 5.77 Technical (Hospital) Services BUMETANIDE 1 MG TABLET RX-9310 CDM 6370000100 HCPCS 250 RC 00185-0129-01 NDC inpatient 1 UN 6.07 6.07 HEALTHPARTNERS SX009 HEALTHPARTNERS 4.81 percent of total billed charges 3.76 5.77 Technical (Hospital) Services BUMETANIDE 1 MG TABLET RX-9310 CDM 6370000100 HCPCS 250 RC 00185-0129-01 NDC inpatient 1 UN 6.07 6.07 MULTIPLAN INC 34080 [3081285] MULTIPLAN INC [308128501] 5.77 percent of total billed charges 3.76 5.77 Technical (Hospital) Services BUMETANIDE 1 MG TABLET RX-9310 CDM 6370000100 HCPCS 250 RC 00185-0129-01 NDC inpatient 1 UN 6.07 6.07 BLUE CROSS BLUE SHIELD WELLMARK SB889 [3081026] BCBS WYOMING [308102603] 5.77 percent of total billed charges 3.76 5.77 Technical (Hospital) Services BUMETANIDE 1 MG TABLET RX-9310 CDM 6370000100 HCPCS 250 RC 00185-0129-01 NDC inpatient 1 UN 6.07 6.07 UNITED HEALTHCARE (COMMERCIAL) [3081199] UNITED HEALTHCARE 87726 [308119901] 3.76 percent of total billed charges 3.76 5.77 Technical (Hospital) Services BUMETANIDE 1 MG TABLET RX-9310 CDM 6370000100 HCPCS 250 RC 00185-0129-01 NDC inpatient 1 UN 6.07 6.07 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES EPO [308136803] 4.81 percent of total billed charges 3.76 5.77 Technical (Hospital) Services BUMETANIDE 1 MG TABLET RX-9310 CDM 6370000100 HCPCS 250 RC 00185-0129-01 NDC inpatient 1 UN 6.07 6.07 CIGNA 62308 [3081051] CIGNA STATE OF WYOMING [308105107] 4.81 percent of total billed charges 3.76 5.77 Technical (Hospital) Services BUMETANIDE 1 MG TABLET RX-9310 CDM 6370000100 HCPCS 250 RC 00185-0129-01 NDC inpatient 1 UN 6.07 6.07 CIGNA 62308 [3081051] CIGNA 62308 [308105105] 4.81 percent of total billed charges 3.76 5.77 Technical (Hospital) Services BUMETANIDE 1 MG TABLET RX-9310 CDM 6370000100 HCPCS 250 RC 00185-0129-01 NDC inpatient 1 UN 6.07 6.07 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES HDHP [308136802] 4.81 percent of total billed charges 3.76 5.77 Technical (Hospital) Services BUMETANIDE 2 MG TABLET RX-9311 CDM 6370000100 HCPCS 250 RC 00185-0130-01 NDC outpatient 1 UN 6.46 6.46 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES EPO [308136803] 5.17 percent of total billed charges 4.01 6.14 Technical (Hospital) Services BUMETANIDE 2 MG TABLET RX-9311 CDM 6370000100 HCPCS 250 RC 00185-0130-01 NDC outpatient 1 UN 6.46 6.46 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES HDHP [308136802] 5.17 percent of total billed charges 4.01 6.14 Technical (Hospital) Services BUMETANIDE 2 MG TABLET RX-9311 CDM 6370000100 HCPCS 250 RC 00185-0130-01 NDC outpatient 1 UN 6.46 6.46 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES PPO [308136801] 5.17 percent of total billed charges 4.01 6.14 Technical (Hospital) Services BUMETANIDE 2 MG TABLET RX-9311 CDM 6370000100 HCPCS 250 RC 00185-0130-01 NDC outpatient 1 UN 6.46 6.46 BLUE CROSS BLUE SHIELD WELLMARK SB889 [3081026] BCBS WYOMING [308102603] 6.14 percent of total billed charges 4.01 6.14 Technical (Hospital) Services BUMETANIDE 2 MG TABLET RX-9311 CDM 6370000100 HCPCS 250 RC 00185-0130-01 NDC outpatient 1 UN 6.46 6.46 UNITED HEALTHCARE (COMMERCIAL) [3081199] UNITED HEALTHCARE 87726 [308119901] 4.01 percent of total billed charges 4.01 6.14 Technical (Hospital) Services BUMETANIDE 2 MG TABLET RX-9311 CDM 6370000100 HCPCS 250 RC 00185-0130-01 NDC outpatient 1 UN 6.46 6.46 HEALTHPARTNERS SX009 HEALTHPARTNERS 5.17 percent of total billed charges 4.01 6.14 Technical (Hospital) Services BUMETANIDE 2 MG TABLET RX-9311 CDM 6370000100 HCPCS 250 RC 00185-0130-01 NDC outpatient 1 UN 6.46 6.46 CIGNA 62308 [3081051] CIGNA 62308 [308105105] 5.17 percent of total billed charges 4.01 6.14 Technical (Hospital) Services BUMETANIDE 2 MG TABLET RX-9311 CDM 6370000100 HCPCS 250 RC 00185-0130-01 NDC outpatient 1 UN 6.46 6.46 CIGNA 62308 [3081051] CIGNA STATE OF WYOMING [308105107] 5.17 percent of total billed charges 4.01 6.14 Technical (Hospital) Services BUMETANIDE 2 MG TABLET RX-9311 CDM 6370000100 HCPCS 250 RC 00185-0130-01 NDC outpatient 1 UN 6.46 6.46 MULTIPLAN INC 34080 [3081285] MULTIPLAN INC [308128501] 6.14 percent of total billed charges 4.01 6.14 Technical (Hospital) Services BUMETANIDE 2 MG TABLET RX-9311 CDM 6370000100 HCPCS 250 RC 00185-0130-01 NDC outpatient 1 UN 6.46 6.46 MEDICA (COMMERCIAL) 94265 [3081118] MEDICA CLAIMS [308111801] 5.81 percent of total billed charges 4.01 6.14 Technical (Hospital) Services BUMETANIDE 2 MG TABLET RX-9311 CDM 6370000100 HCPCS 250 RC 00185-0130-01 NDC inpatient 1 UN 6.46 6.46 HEALTHPARTNERS SX009 HEALTHPARTNERS 5.12 percent of total billed charges 4.01 6.14 Technical (Hospital) Services BUMETANIDE 2 MG TABLET RX-9311 CDM 6370000100 HCPCS 250 RC 00185-0130-01 NDC inpatient 1 UN 6.46 6.46 MEDICA (COMMERCIAL) 94265 [3081118] MEDICA CLAIMS [308111801] 5.81 percent of total billed charges 4.01 6.14 Technical (Hospital) Services BUMETANIDE 2 MG TABLET RX-9311 CDM 6370000100 HCPCS 250 RC 00185-0130-01 NDC inpatient 1 UN 6.46 6.46 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES PPO [308136801] 5.12 percent of total billed charges 4.01 6.14 Technical (Hospital) Services BUMETANIDE 2 MG TABLET RX-9311 CDM 6370000100 HCPCS 250 RC 00185-0130-01 NDC inpatient 1 UN 6.46 6.46 MULTIPLAN INC 34080 [3081285] MULTIPLAN INC [308128501] 6.14 percent of total billed charges 4.01 6.14 Technical (Hospital) Services BUMETANIDE 2 MG TABLET RX-9311 CDM 6370000100 HCPCS 250 RC 00185-0130-01 NDC inpatient 1 UN 6.46 6.46 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES HDHP [308136802] 5.12 percent of total billed charges 4.01 6.14 Technical (Hospital) Services BUMETANIDE 2 MG TABLET RX-9311 CDM 6370000100 HCPCS 250 RC 00185-0130-01 NDC inpatient 1 UN 6.46 6.46 UNITED HEALTHCARE (COMMERCIAL) [3081199] UNITED HEALTHCARE 87726 [308119901] 4.01 percent of total billed charges 4.01 6.14 Technical (Hospital) Services BUMETANIDE 2 MG TABLET RX-9311 CDM 6370000100 HCPCS 250 RC 00185-0130-01 NDC inpatient 1 UN 6.46 6.46 CIGNA 62308 [3081051] CIGNA 62308 [308105105] 5.12 percent of total billed charges 4.01 6.14 Technical (Hospital) Services BUMETANIDE 2 MG TABLET RX-9311 CDM 6370000100 HCPCS 250 RC 00185-0130-01 NDC inpatient 1 UN 6.46 6.46 CIGNA 62308 [3081051] CIGNA STATE OF WYOMING [308105107] 5.12 percent of total billed charges 4.01 6.14 Technical (Hospital) Services BUMETANIDE 2 MG TABLET RX-9311 CDM 6370000100 HCPCS 250 RC 00185-0130-01 NDC inpatient 1 UN 6.46 6.46 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES EPO [308136803] 5.12 percent of total billed charges 4.01 6.14 Technical (Hospital) Services BUMETANIDE 2 MG TABLET RX-9311 CDM 6370000100 HCPCS 250 RC 00185-0130-01 NDC inpatient 1 UN 6.46 6.46 BLUE CROSS BLUE SHIELD WELLMARK SB889 [3081026] BCBS WYOMING [308102603] 6.14 percent of total billed charges 4.01 6.14 Technical (Hospital) Services BUPROPION HCL 75 MG TABLET RX-9322 CDM 6370000100 HCPCS 250 RC 60505-0158-01 NDC inpatient 1 UN 6.16 6.16 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES PPO [308136801] 4.88 percent of total billed charges 3.82 5.85 Technical (Hospital) Services BUPROPION HCL 75 MG TABLET RX-9322 CDM 6370000100 HCPCS 250 RC 60505-0158-01 NDC inpatient 1 UN 6.16 6.16 HEALTHPARTNERS SX009 HEALTHPARTNERS 4.88 percent of total billed charges 3.82 5.85 Technical (Hospital) Services BUPROPION HCL 75 MG TABLET RX-9322 CDM 6370000100 HCPCS 250 RC 60505-0158-01 NDC inpatient 1 UN 6.16 6.16 MEDICA (COMMERCIAL) 94265 [3081118] MEDICA CLAIMS [308111801] 5.54 percent of total billed charges 3.82 5.85 Technical (Hospital) Services BUPROPION HCL 75 MG TABLET RX-9322 CDM 6370000100 HCPCS 250 RC 60505-0158-01 NDC inpatient 1 UN 6.16 6.16 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES HDHP [308136802] 4.88 percent of total billed charges 3.82 5.85 Technical (Hospital) Services BUPROPION HCL 75 MG TABLET RX-9322 CDM 6370000100 HCPCS 250 RC 60505-0158-01 NDC inpatient 1 UN 6.16 6.16 CIGNA 62308 [3081051] CIGNA 62308 [308105105] 4.88 percent of total billed charges 3.82 5.85 Technical (Hospital) Services BUPROPION HCL 75 MG TABLET RX-9322 CDM 6370000100 HCPCS 250 RC 60505-0158-01 NDC inpatient 1 UN 6.16 6.16 CIGNA 62308 [3081051] CIGNA STATE OF WYOMING [308105107] 4.88 percent of total billed charges 3.82 5.85 Technical (Hospital) Services BUPROPION HCL 75 MG TABLET RX-9322 CDM 6370000100 HCPCS 250 RC 60505-0158-01 NDC inpatient 1 UN 6.16 6.16 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES EPO [308136803] 4.88 percent of total billed charges 3.82 5.85 Technical (Hospital) Services BUPROPION HCL 75 MG TABLET RX-9322 CDM 6370000100 HCPCS 250 RC 60505-0158-01 NDC inpatient 1 UN 6.16 6.16 UNITED HEALTHCARE (COMMERCIAL) [3081199] UNITED HEALTHCARE 87726 [308119901] 3.82 percent of total billed charges 3.82 5.85 Technical (Hospital) Services BUPROPION HCL 75 MG TABLET RX-9322 CDM 6370000100 HCPCS 250 RC 60505-0158-01 NDC inpatient 1 UN 6.16 6.16 BLUE CROSS BLUE SHIELD WELLMARK SB889 [3081026] BCBS WYOMING [308102603] 5.85 percent of total billed charges 3.82 5.85 Technical (Hospital) Services BUPROPION HCL 75 MG TABLET RX-9322 CDM 6370000100 HCPCS 250 RC 60505-0158-01 NDC inpatient 1 UN 6.16 6.16 MULTIPLAN INC 34080 [3081285] MULTIPLAN INC [308128501] 5.85 percent of total billed charges 3.82 5.85 Technical (Hospital) Services BUPROPION HCL 75 MG TABLET RX-9322 CDM 6370000100 HCPCS 250 RC 60505-0158-01 NDC outpatient 1 UN 6.16 6.16 HEALTHPARTNERS SX009 HEALTHPARTNERS 4.93 percent of total billed charges 3.82 5.85 Technical (Hospital) Services BUPROPION HCL 75 MG TABLET RX-9322 CDM 6370000100 HCPCS 250 RC 60505-0158-01 NDC outpatient 1 UN 6.16 6.16 BLUE CROSS BLUE SHIELD WELLMARK SB889 [3081026] BCBS WYOMING [308102603] 5.85 percent of total billed charges 3.82 5.85 Technical (Hospital) Services BUPROPION HCL 75 MG TABLET RX-9322 CDM 6370000100 HCPCS 250 RC 60505-0158-01 NDC outpatient 1 UN 6.16 6.16 UNITED HEALTHCARE (COMMERCIAL) [3081199] UNITED HEALTHCARE 87726 [308119901] 3.82 percent of total billed charges 3.82 5.85 Technical (Hospital) Services BUPROPION HCL 75 MG TABLET RX-9322 CDM 6370000100 HCPCS 250 RC 60505-0158-01 NDC outpatient 1 UN 6.16 6.16 CIGNA 62308 [3081051] CIGNA 62308 [308105105] 4.93 percent of total billed charges 3.82 5.85 Technical (Hospital) Services BUPROPION HCL 75 MG TABLET RX-9322 CDM 6370000100 HCPCS 250 RC 60505-0158-01 NDC outpatient 1 UN 6.16 6.16 CIGNA 62308 [3081051] CIGNA STATE OF WYOMING [308105107] 4.93 percent of total billed charges 3.82 5.85 Technical (Hospital) Services BUPROPION HCL 75 MG TABLET RX-9322 CDM 6370000100 HCPCS 250 RC 60505-0158-01 NDC outpatient 1 UN 6.16 6.16 MULTIPLAN INC 34080 [3081285] MULTIPLAN INC [308128501] 5.85 percent of total billed charges 3.82 5.85 Technical (Hospital) Services BUPROPION HCL 75 MG TABLET RX-9322 CDM 6370000100 HCPCS 250 RC 60505-0158-01 NDC outpatient 1 UN 6.16 6.16 MEDICA (COMMERCIAL) 94265 [3081118] MEDICA CLAIMS [308111801] 5.54 percent of total billed charges 3.82 5.85 Technical (Hospital) Services BUPROPION HCL 75 MG TABLET RX-9322 CDM 6370000100 HCPCS 250 RC 60505-0158-01 NDC outpatient 1 UN 6.16 6.16 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES PPO [308136801] 4.93 percent of total billed charges 3.82 5.85 Technical (Hospital) Services BUPROPION HCL 75 MG TABLET RX-9322 CDM 6370000100 HCPCS 250 RC 60505-0158-01 NDC outpatient 1 UN 6.16 6.16 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES HDHP [308136802] 4.93 percent of total billed charges 3.82 5.85 Technical (Hospital) Services BUPROPION HCL 75 MG TABLET RX-9322 CDM 6370000100 HCPCS 250 RC 60505-0158-01 NDC outpatient 1 UN 6.16 6.16 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES EPO [308136803] 4.93 percent of total billed charges 3.82 5.85 Technical (Hospital) Services BUSPIRONE 10 MG TABLET RX-9323 CDM 6370000100 HCPCS 250 RC 23155-0024-01 NDC inpatient 1 UN 5.7 5.7 HEALTHPARTNERS SX009 HEALTHPARTNERS 4.51 percent of total billed charges 3.53 5.42 Technical (Hospital) Services BUSPIRONE 10 MG TABLET RX-9323 CDM 6370000100 HCPCS 250 RC 23155-0024-01 NDC inpatient 1 UN 5.7 5.7 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES PPO [308136801] 4.51 percent of total billed charges 3.53 5.42 Technical (Hospital) Services BUSPIRONE 10 MG TABLET RX-9323 CDM 6370000100 HCPCS 250 RC 23155-0024-01 NDC inpatient 1 UN 5.7 5.7 MEDICA (COMMERCIAL) 94265 [3081118] MEDICA CLAIMS [308111801] 5.13 percent of total billed charges 3.53 5.42 Technical (Hospital) Services BUSPIRONE 10 MG TABLET RX-9323 CDM 6370000100 HCPCS 250 RC 23155-0024-01 NDC inpatient 1 UN 5.7 5.7 UNITED HEALTHCARE (COMMERCIAL) [3081199] UNITED HEALTHCARE 87726 [308119901] 3.53 percent of total billed charges 3.53 5.42 Technical (Hospital) Services BUSPIRONE 10 MG TABLET RX-9323 CDM 6370000100 HCPCS 250 RC 23155-0024-01 NDC inpatient 1 UN 5.7 5.7 BLUE CROSS BLUE SHIELD WELLMARK SB889 [3081026] BCBS WYOMING [308102603] 5.42 percent of total billed charges 3.53 5.42 Technical (Hospital) Services BUSPIRONE 10 MG TABLET RX-9323 CDM 6370000100 HCPCS 250 RC 23155-0024-01 NDC inpatient 1 UN 5.7 5.7 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES HDHP [308136802] 4.51 percent of total billed charges 3.53 5.42 Technical (Hospital) Services BUSPIRONE 10 MG TABLET RX-9323 CDM 6370000100 HCPCS 250 RC 23155-0024-01 NDC inpatient 1 UN 5.7 5.7 CIGNA 62308 [3081051] CIGNA STATE OF WYOMING [308105107] 4.51 percent of total billed charges 3.53 5.42 Technical (Hospital) Services BUSPIRONE 10 MG TABLET RX-9323 CDM 6370000100 HCPCS 250 RC 23155-0024-01 NDC inpatient 1 UN 5.7 5.7 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES EPO [308136803] 4.51 percent of total billed charges 3.53 5.42 Technical (Hospital) Services BUSPIRONE 10 MG TABLET RX-9323 CDM 6370000100 HCPCS 250 RC 23155-0024-01 NDC inpatient 1 UN 5.7 5.7 CIGNA 62308 [3081051] CIGNA 62308 [308105105] 4.51 percent of total billed charges 3.53 5.42 Technical (Hospital) Services BUSPIRONE 10 MG TABLET RX-9323 CDM 6370000100 HCPCS 250 RC 23155-0024-01 NDC inpatient 1 UN 5.7 5.7 MULTIPLAN INC 34080 [3081285] MULTIPLAN INC [308128501] 5.42 percent of total billed charges 3.53 5.42 Technical (Hospital) Services BUSPIRONE 10 MG TABLET RX-9323 CDM 6370000100 HCPCS 250 RC 23155-0024-01 NDC outpatient 1 UN 5.7 5.7 BLUE CROSS BLUE SHIELD WELLMARK SB889 [3081026] BCBS WYOMING [308102603] 5.42 percent of total billed charges 3.53 5.42 Technical (Hospital) Services BUSPIRONE 10 MG TABLET RX-9323 CDM 6370000100 HCPCS 250 RC 23155-0024-01 NDC outpatient 1 UN 5.7 5.7 MULTIPLAN INC 34080 [3081285] MULTIPLAN INC [308128501] 5.42 percent of total billed charges 3.53 5.42 Technical (Hospital) Services BUSPIRONE 10 MG TABLET RX-9323 CDM 6370000100 HCPCS 250 RC 23155-0024-01 NDC outpatient 1 UN 5.7 5.7 CIGNA 62308 [3081051] CIGNA 62308 [308105105] 4.56 percent of total billed charges 3.53 5.42 Technical (Hospital) Services BUSPIRONE 10 MG TABLET RX-9323 CDM 6370000100 HCPCS 250 RC 23155-0024-01 NDC outpatient 1 UN 5.7 5.7 CIGNA 62308 [3081051] CIGNA STATE OF WYOMING [308105107] 4.56 percent of total billed charges 3.53 5.42 Technical (Hospital) Services BUSPIRONE 10 MG TABLET RX-9323 CDM 6370000100 HCPCS 250 RC 23155-0024-01 NDC outpatient 1 UN 5.7 5.7 MEDICA (COMMERCIAL) 94265 [3081118] MEDICA CLAIMS [308111801] 5.13 percent of total billed charges 3.53 5.42 Technical (Hospital) Services BUSPIRONE 10 MG TABLET RX-9323 CDM 6370000100 HCPCS 250 RC 23155-0024-01 NDC outpatient 1 UN 5.7 5.7 HEALTHPARTNERS SX009 HEALTHPARTNERS 4.56 percent of total billed charges 3.53 5.42 Technical (Hospital) Services BUSPIRONE 10 MG TABLET RX-9323 CDM 6370000100 HCPCS 250 RC 23155-0024-01 NDC outpatient 1 UN 5.7 5.7 UNITED HEALTHCARE (COMMERCIAL) [3081199] UNITED HEALTHCARE 87726 [308119901] 3.53 percent of total billed charges 3.53 5.42 Technical (Hospital) Services BUSPIRONE 10 MG TABLET RX-9323 CDM 6370000100 HCPCS 250 RC 23155-0024-01 NDC outpatient 1 UN 5.7 5.7 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES HDHP [308136802] 4.56 percent of total billed charges 3.53 5.42 Technical (Hospital) Services BUSPIRONE 10 MG TABLET RX-9323 CDM 6370000100 HCPCS 250 RC 23155-0024-01 NDC outpatient 1 UN 5.7 5.7 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES PPO [308136801] 4.56 percent of total billed charges 3.53 5.42 Technical (Hospital) Services BUSPIRONE 10 MG TABLET RX-9323 CDM 6370000100 HCPCS 250 RC 23155-0024-01 NDC outpatient 1 UN 5.7 5.7 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES EPO [308136803] 4.56 percent of total billed charges 3.53 5.42 Technical (Hospital) Services BUSPIRONE 5 MG TABLET RX-9324 CDM 6370000100 HCPCS 250 RC 00904-7122-61 NDC outpatient 1 UN 5.75 5.75 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES EPO [308136803] 4.6 percent of total billed charges 3.57 5.46 Technical (Hospital) Services BUSPIRONE 5 MG TABLET RX-9324 CDM 6370000100 HCPCS 250 RC 00904-7122-61 NDC outpatient 1 UN 5.75 5.75 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES PPO [308136801] 4.6 percent of total billed charges 3.57 5.46 Technical (Hospital) Services BUSPIRONE 5 MG TABLET RX-9324 CDM 6370000100 HCPCS 250 RC 00904-7122-61 NDC outpatient 1 UN 5.75 5.75 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES HDHP [308136802] 4.6 percent of total billed charges 3.57 5.46 Technical (Hospital) Services BUSPIRONE 5 MG TABLET RX-9324 CDM 6370000100 HCPCS 250 RC 00904-7122-61 NDC outpatient 1 UN 5.75 5.75 UNITED HEALTHCARE (COMMERCIAL) [3081199] UNITED HEALTHCARE 87726 [308119901] 3.57 percent of total billed charges 3.57 5.46 Technical (Hospital) Services BUSPIRONE 5 MG TABLET RX-9324 CDM 6370000100 HCPCS 250 RC 00904-7122-61 NDC outpatient 1 UN 5.75 5.75 HEALTHPARTNERS SX009 HEALTHPARTNERS 4.6 percent of total billed charges 3.57 5.46 Technical (Hospital) Services BUSPIRONE 5 MG TABLET RX-9324 CDM 6370000100 HCPCS 250 RC 00904-7122-61 NDC outpatient 1 UN 5.75 5.75 MEDICA (COMMERCIAL) 94265 [3081118] MEDICA CLAIMS [308111801] 5.18 percent of total billed charges 3.57 5.46 Technical (Hospital) Services BUSPIRONE 5 MG TABLET RX-9324 CDM 6370000100 HCPCS 250 RC 00904-7122-61 NDC outpatient 1 UN 5.75 5.75 CIGNA 62308 [3081051] CIGNA 62308 [308105105] 4.6 percent of total billed charges 3.57 5.46 Technical (Hospital) Services BUSPIRONE 5 MG TABLET RX-9324 CDM 6370000100 HCPCS 250 RC 00904-7122-61 NDC outpatient 1 UN 5.75 5.75 CIGNA 62308 [3081051] CIGNA STATE OF WYOMING [308105107] 4.6 percent of total billed charges 3.57 5.46 Technical (Hospital) Services BUSPIRONE 5 MG TABLET RX-9324 CDM 6370000100 HCPCS 250 RC 00904-7122-61 NDC outpatient 1 UN 5.75 5.75 MULTIPLAN INC 34080 [3081285] MULTIPLAN INC [308128501] 5.46 percent of total billed charges 3.57 5.46 Technical (Hospital) Services BUSPIRONE 5 MG TABLET RX-9324 CDM 6370000100 HCPCS 250 RC 00904-7122-61 NDC outpatient 1 UN 5.75 5.75 BLUE CROSS BLUE SHIELD WELLMARK SB889 [3081026] BCBS WYOMING [308102603] 5.46 percent of total billed charges 3.57 5.46 Technical (Hospital) Services BUSPIRONE 5 MG TABLET RX-9324 CDM 6370000100 HCPCS 250 RC 00904-7122-61 NDC inpatient 1 UN 5.75 5.75 HEALTHPARTNERS SX009 HEALTHPARTNERS 4.55 percent of total billed charges 3.57 5.46 Technical (Hospital) Services BUSPIRONE 5 MG TABLET RX-9324 CDM 6370000100 HCPCS 250 RC 00904-7122-61 NDC inpatient 1 UN 5.75 5.75 MEDICA (COMMERCIAL) 94265 [3081118] MEDICA CLAIMS [308111801] 5.18 percent of total billed charges 3.57 5.46 Technical (Hospital) Services BUSPIRONE 5 MG TABLET RX-9324 CDM 6370000100 HCPCS 250 RC 00904-7122-61 NDC inpatient 1 UN 5.75 5.75 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES PPO [308136801] 4.55 percent of total billed charges 3.57 5.46 Technical (Hospital) Services BUSPIRONE 5 MG TABLET RX-9324 CDM 6370000100 HCPCS 250 RC 00904-7122-61 NDC inpatient 1 UN 5.75 5.75 BLUE CROSS BLUE SHIELD WELLMARK SB889 [3081026] BCBS WYOMING [308102603] 5.46 percent of total billed charges 3.57 5.46 Technical (Hospital) Services BUSPIRONE 5 MG TABLET RX-9324 CDM 6370000100 HCPCS 250 RC 00904-7122-61 NDC inpatient 1 UN 5.75 5.75 UNITED HEALTHCARE (COMMERCIAL) [3081199] UNITED HEALTHCARE 87726 [308119901] 3.57 percent of total billed charges 3.57 5.46 Technical (Hospital) Services BUSPIRONE 5 MG TABLET RX-9324 CDM 6370000100 HCPCS 250 RC 00904-7122-61 NDC inpatient 1 UN 5.75 5.75 CIGNA 62308 [3081051] CIGNA 62308 [308105105] 4.55 percent of total billed charges 3.57 5.46 Technical (Hospital) Services BUSPIRONE 5 MG TABLET RX-9324 CDM 6370000100 HCPCS 250 RC 00904-7122-61 NDC inpatient 1 UN 5.75 5.75 CIGNA 62308 [3081051] CIGNA STATE OF WYOMING [308105107] 4.55 percent of total billed charges 3.57 5.46 Technical (Hospital) Services BUSPIRONE 5 MG TABLET RX-9324 CDM 6370000100 HCPCS 250 RC 00904-7122-61 NDC inpatient 1 UN 5.75 5.75 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES EPO [308136803] 4.55 percent of total billed charges 3.57 5.46 Technical (Hospital) Services BUSPIRONE 5 MG TABLET RX-9324 CDM 6370000100 HCPCS 250 RC 00904-7122-61 NDC inpatient 1 UN 5.75 5.75 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES HDHP [308136802] 4.55 percent of total billed charges 3.57 5.46 Technical (Hospital) Services BUSPIRONE 5 MG TABLET RX-9324 CDM 6370000100 HCPCS 250 RC 00904-7122-61 NDC inpatient 1 UN 5.75 5.75 MULTIPLAN INC 34080 [3081285] MULTIPLAN INC [308128501] 5.46 percent of total billed charges 3.57 5.46 Technical (Hospital) Services BUTAMBEN-TETRACAINE-BENZOCAINE 2 %-2 %-14 % (200 MG/SEC) TOPICAL SPRAY RX-9328 CDM 6370000100 HCPCS 250 RC 10223-0201-03 NDC inpatient 20 GR 350.5 350.5 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES EPO [308136803] 277.53 percent of total billed charges 217.31 332.98 Technical (Hospital) Services BUTAMBEN-TETRACAINE-BENZOCAINE 2 %-2 %-14 % (200 MG/SEC) TOPICAL SPRAY RX-9328 CDM 6370000100 HCPCS 250 RC 10223-0201-03 NDC inpatient 20 GR 350.5 350.5 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES HDHP [308136802] 277.53 percent of total billed charges 217.31 332.98 Technical (Hospital) Services BUTAMBEN-TETRACAINE-BENZOCAINE 2 %-2 %-14 % (200 MG/SEC) TOPICAL SPRAY RX-9328 CDM 6370000100 HCPCS 250 RC 10223-0201-03 NDC inpatient 20 GR 350.5 350.5 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES PPO [308136801] 277.53 percent of total billed charges 217.31 332.98 Technical (Hospital) Services BUTAMBEN-TETRACAINE-BENZOCAINE 2 %-2 %-14 % (200 MG/SEC) TOPICAL SPRAY RX-9328 CDM 6370000100 HCPCS 250 RC 10223-0201-03 NDC inpatient 20 GR 350.5 350.5 CIGNA 62308 [3081051] CIGNA 62308 [308105105] 277.53 percent of total billed charges 217.31 332.98 Technical (Hospital) Services BUTAMBEN-TETRACAINE-BENZOCAINE 2 %-2 %-14 % (200 MG/SEC) TOPICAL SPRAY RX-9328 CDM 6370000100 HCPCS 250 RC 10223-0201-03 NDC inpatient 20 GR 350.5 350.5 CIGNA 62308 [3081051] CIGNA STATE OF WYOMING [308105107] 277.53 percent of total billed charges 217.31 332.98 Technical (Hospital) Services BUTAMBEN-TETRACAINE-BENZOCAINE 2 %-2 %-14 % (200 MG/SEC) TOPICAL SPRAY RX-9328 CDM 6370000100 HCPCS 250 RC 10223-0201-03 NDC inpatient 20 GR 350.5 350.5 HEALTHPARTNERS SX009 HEALTHPARTNERS 277.53 percent of total billed charges 217.31 332.98 Technical (Hospital) Services BUTAMBEN-TETRACAINE-BENZOCAINE 2 %-2 %-14 % (200 MG/SEC) TOPICAL SPRAY RX-9328 CDM 6370000100 HCPCS 250 RC 10223-0201-03 NDC inpatient 20 GR 350.5 350.5 MULTIPLAN INC 34080 [3081285] MULTIPLAN INC [308128501] 332.98 percent of total billed charges 217.31 332.98 Technical (Hospital) Services BUTAMBEN-TETRACAINE-BENZOCAINE 2 %-2 %-14 % (200 MG/SEC) TOPICAL SPRAY RX-9328 CDM 6370000100 HCPCS 250 RC 10223-0201-03 NDC inpatient 20 GR 350.5 350.5 MEDICA (COMMERCIAL) 94265 [3081118] MEDICA CLAIMS [308111801] 315.45 percent of total billed charges 217.31 332.98 Technical (Hospital) Services BUTAMBEN-TETRACAINE-BENZOCAINE 2 %-2 %-14 % (200 MG/SEC) TOPICAL SPRAY RX-9328 CDM 6370000100 HCPCS 250 RC 10223-0201-03 NDC inpatient 20 GR 350.5 350.5 UNITED HEALTHCARE (COMMERCIAL) [3081199] UNITED HEALTHCARE 87726 [308119901] 217.31 percent of total billed charges 217.31 332.98 Technical (Hospital) Services BUTAMBEN-TETRACAINE-BENZOCAINE 2 %-2 %-14 % (200 MG/SEC) TOPICAL SPRAY RX-9328 CDM 6370000100 HCPCS 250 RC 10223-0201-03 NDC inpatient 20 GR 350.5 350.5 BLUE CROSS BLUE SHIELD WELLMARK SB889 [3081026] BCBS WYOMING [308102603] 332.98 percent of total billed charges 217.31 332.98 Technical (Hospital) Services BUTAMBEN-TETRACAINE-BENZOCAINE 2 %-2 %-14 % (200 MG/SEC) TOPICAL SPRAY RX-9328 CDM 6370000100 HCPCS 250 RC 10223-0201-03 NDC outpatient 20 GR 350.5 350.5 CIGNA 62308 [3081051] CIGNA 62308 [308105105] 280.4 percent of total billed charges 217.31 332.98 Technical (Hospital) Services BUTAMBEN-TETRACAINE-BENZOCAINE 2 %-2 %-14 % (200 MG/SEC) TOPICAL SPRAY RX-9328 CDM 6370000100 HCPCS 250 RC 10223-0201-03 NDC outpatient 20 GR 350.5 350.5 CIGNA 62308 [3081051] CIGNA STATE OF WYOMING [308105107] 280.4 percent of total billed charges 217.31 332.98 Technical (Hospital) Services BUTAMBEN-TETRACAINE-BENZOCAINE 2 %-2 %-14 % (200 MG/SEC) TOPICAL SPRAY RX-9328 CDM 6370000100 HCPCS 250 RC 10223-0201-03 NDC outpatient 20 GR 350.5 350.5 MEDICA (COMMERCIAL) 94265 [3081118] MEDICA CLAIMS [308111801] 315.45 percent of total billed charges 217.31 332.98 Technical (Hospital) Services BUTAMBEN-TETRACAINE-BENZOCAINE 2 %-2 %-14 % (200 MG/SEC) TOPICAL SPRAY RX-9328 CDM 6370000100 HCPCS 250 RC 10223-0201-03 NDC outpatient 20 GR 350.5 350.5 MULTIPLAN INC 34080 [3081285] MULTIPLAN INC [308128501] 332.98 percent of total billed charges 217.31 332.98 Technical (Hospital) Services BUTAMBEN-TETRACAINE-BENZOCAINE 2 %-2 %-14 % (200 MG/SEC) TOPICAL SPRAY RX-9328 CDM 6370000100 HCPCS 250 RC 10223-0201-03 NDC outpatient 20 GR 350.5 350.5 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES PPO [308136801] 280.4 percent of total billed charges 217.31 332.98 Technical (Hospital) Services BUTAMBEN-TETRACAINE-BENZOCAINE 2 %-2 %-14 % (200 MG/SEC) TOPICAL SPRAY RX-9328 CDM 6370000100 HCPCS 250 RC 10223-0201-03 NDC outpatient 20 GR 350.5 350.5 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES EPO [308136803] 280.4 percent of total billed charges 217.31 332.98 Technical (Hospital) Services BUTAMBEN-TETRACAINE-BENZOCAINE 2 %-2 %-14 % (200 MG/SEC) TOPICAL SPRAY RX-9328 CDM 6370000100 HCPCS 250 RC 10223-0201-03 NDC outpatient 20 GR 350.5 350.5 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES HDHP [308136802] 280.4 percent of total billed charges 217.31 332.98 Technical (Hospital) Services BUTAMBEN-TETRACAINE-BENZOCAINE 2 %-2 %-14 % (200 MG/SEC) TOPICAL SPRAY RX-9328 CDM 6370000100 HCPCS 250 RC 10223-0201-03 NDC outpatient 20 GR 350.5 350.5 HEALTHPARTNERS SX009 HEALTHPARTNERS 280.4 percent of total billed charges 217.31 332.98 Technical (Hospital) Services BUTAMBEN-TETRACAINE-BENZOCAINE 2 %-2 %-14 % (200 MG/SEC) TOPICAL SPRAY RX-9328 CDM 6370000100 HCPCS 250 RC 10223-0201-03 NDC outpatient 20 GR 350.5 350.5 BLUE CROSS BLUE SHIELD WELLMARK SB889 [3081026] BCBS WYOMING [308102603] 332.98 percent of total billed charges 217.31 332.98 Technical (Hospital) Services BUTAMBEN-TETRACAINE-BENZOCAINE 2 %-2 %-14 % (200 MG/SEC) TOPICAL SPRAY RX-9328 CDM 6370000100 HCPCS 250 RC 10223-0201-03 NDC outpatient 20 GR 350.5 350.5 UNITED HEALTHCARE (COMMERCIAL) [3081199] UNITED HEALTHCARE 87726 [308119901] 217.31 percent of total billed charges 217.31 332.98 Technical (Hospital) Services CALCIUM 200 MG (AS CALCIUM CARBONATE 500 MG) CHEWABLE TABLET RX-9385 CDM 6370000100 HCPCS 250 RC 66553-0004-01 NDC inpatient 1 UN 5.69 5.69 MULTIPLAN INC 34080 [3081285] MULTIPLAN INC [308128501] 5.41 percent of total billed charges 3.53 5.41 Technical (Hospital) Services CALCIUM 200 MG (AS CALCIUM CARBONATE 500 MG) CHEWABLE TABLET RX-9385 CDM 6370000100 HCPCS 250 RC 66553-0004-01 NDC inpatient 1 UN 5.69 5.69 BLUE CROSS BLUE SHIELD WELLMARK SB889 [3081026] BCBS WYOMING [308102603] 5.41 percent of total billed charges 3.53 5.41 Technical (Hospital) Services CALCIUM 200 MG (AS CALCIUM CARBONATE 500 MG) CHEWABLE TABLET RX-9385 CDM 6370000100 HCPCS 250 RC 66553-0004-01 NDC inpatient 1 UN 5.69 5.69 CIGNA 62308 [3081051] CIGNA 62308 [308105105] 4.51 percent of total billed charges 3.53 5.41 Technical (Hospital) Services CALCIUM 200 MG (AS CALCIUM CARBONATE 500 MG) CHEWABLE TABLET RX-9385 CDM 6370000100 HCPCS 250 RC 66553-0004-01 NDC inpatient 1 UN 5.69 5.69 CIGNA 62308 [3081051] CIGNA STATE OF WYOMING [308105107] 4.51 percent of total billed charges 3.53 5.41 Technical (Hospital) Services CALCIUM 200 MG (AS CALCIUM CARBONATE 500 MG) CHEWABLE TABLET RX-9385 CDM 6370000100 HCPCS 250 RC 66553-0004-01 NDC inpatient 1 UN 5.69 5.69 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES EPO [308136803] 4.51 percent of total billed charges 3.53 5.41 Technical (Hospital) Services CALCIUM 200 MG (AS CALCIUM CARBONATE 500 MG) CHEWABLE TABLET RX-9385 CDM 6370000100 HCPCS 250 RC 66553-0004-01 NDC inpatient 1 UN 5.69 5.69 UNITED HEALTHCARE (COMMERCIAL) [3081199] UNITED HEALTHCARE 87726 [308119901] 3.53 percent of total billed charges 3.53 5.41 Technical (Hospital) Services CALCIUM 200 MG (AS CALCIUM CARBONATE 500 MG) CHEWABLE TABLET RX-9385 CDM 6370000100 HCPCS 250 RC 66553-0004-01 NDC inpatient 1 UN 5.69 5.69 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES HDHP [308136802] 4.51 percent of total billed charges 3.53 5.41 Technical (Hospital) Services CALCIUM 200 MG (AS CALCIUM CARBONATE 500 MG) CHEWABLE TABLET RX-9385 CDM 6370000100 HCPCS 250 RC 66553-0004-01 NDC inpatient 1 UN 5.69 5.69 HEALTHPARTNERS SX009 HEALTHPARTNERS 4.51 percent of total billed charges 3.53 5.41 Technical (Hospital) Services CALCIUM 200 MG (AS CALCIUM CARBONATE 500 MG) CHEWABLE TABLET RX-9385 CDM 6370000100 HCPCS 250 RC 66553-0004-01 NDC inpatient 1 UN 5.69 5.69 MEDICA (COMMERCIAL) 94265 [3081118] MEDICA CLAIMS [308111801] 5.12 percent of total billed charges 3.53 5.41 Technical (Hospital) Services CALCIUM 200 MG (AS CALCIUM CARBONATE 500 MG) CHEWABLE TABLET RX-9385 CDM 6370000100 HCPCS 250 RC 66553-0004-01 NDC inpatient 1 UN 5.69 5.69 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES PPO [308136801] 4.51 percent of total billed charges 3.53 5.41 Technical (Hospital) Services CALCIUM 200 MG (AS CALCIUM CARBONATE 500 MG) CHEWABLE TABLET RX-9385 CDM 6370000100 HCPCS 250 RC 66553-0004-01 NDC outpatient 1 UN 5.69 5.69 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES EPO [308136803] 4.55 percent of total billed charges 3.53 5.41 Technical (Hospital) Services CALCIUM 200 MG (AS CALCIUM CARBONATE 500 MG) CHEWABLE TABLET RX-9385 CDM 6370000100 HCPCS 250 RC 66553-0004-01 NDC outpatient 1 UN 5.69 5.69 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES HDHP [308136802] 4.55 percent of total billed charges 3.53 5.41 Technical (Hospital) Services CALCIUM 200 MG (AS CALCIUM CARBONATE 500 MG) CHEWABLE TABLET RX-9385 CDM 6370000100 HCPCS 250 RC 66553-0004-01 NDC outpatient 1 UN 5.69 5.69 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES PPO [308136801] 4.55 percent of total billed charges 3.53 5.41 Technical (Hospital) Services CALCIUM 200 MG (AS CALCIUM CARBONATE 500 MG) CHEWABLE TABLET RX-9385 CDM 6370000100 HCPCS 250 RC 66553-0004-01 NDC outpatient 1 UN 5.69 5.69 CIGNA 62308 [3081051] CIGNA 62308 [308105105] 4.55 percent of total billed charges 3.53 5.41 Technical (Hospital) Services CALCIUM 200 MG (AS CALCIUM CARBONATE 500 MG) CHEWABLE TABLET RX-9385 CDM 6370000100 HCPCS 250 RC 66553-0004-01 NDC outpatient 1 UN 5.69 5.69 CIGNA 62308 [3081051] CIGNA STATE OF WYOMING [308105107] 4.55 percent of total billed charges 3.53 5.41 Technical (Hospital) Services CALCIUM 200 MG (AS CALCIUM CARBONATE 500 MG) CHEWABLE TABLET RX-9385 CDM 6370000100 HCPCS 250 RC 66553-0004-01 NDC outpatient 1 UN 5.69 5.69 MULTIPLAN INC 34080 [3081285] MULTIPLAN INC [308128501] 5.41 percent of total billed charges 3.53 5.41 Technical (Hospital) Services CALCIUM 200 MG (AS CALCIUM CARBONATE 500 MG) CHEWABLE TABLET RX-9385 CDM 6370000100 HCPCS 250 RC 66553-0004-01 NDC outpatient 1 UN 5.69 5.69 MEDICA (COMMERCIAL) 94265 [3081118] MEDICA CLAIMS [308111801] 5.12 percent of total billed charges 3.53 5.41 Technical (Hospital) Services CALCIUM 200 MG (AS CALCIUM CARBONATE 500 MG) CHEWABLE TABLET RX-9385 CDM 6370000100 HCPCS 250 RC 66553-0004-01 NDC outpatient 1 UN 5.69 5.69 UNITED HEALTHCARE (COMMERCIAL) [3081199] UNITED HEALTHCARE 87726 [308119901] 3.53 percent of total billed charges 3.53 5.41 Technical (Hospital) Services CALCIUM 200 MG (AS CALCIUM CARBONATE 500 MG) CHEWABLE TABLET RX-9385 CDM 6370000100 HCPCS 250 RC 66553-0004-01 NDC outpatient 1 UN 5.69 5.69 BLUE CROSS BLUE SHIELD WELLMARK SB889 [3081026] BCBS WYOMING [308102603] 5.41 percent of total billed charges 3.53 5.41 Technical (Hospital) Services CALCIUM 200 MG (AS CALCIUM CARBONATE 500 MG) CHEWABLE TABLET RX-9385 CDM 6370000100 HCPCS 250 RC 66553-0004-01 NDC outpatient 1 UN 5.69 5.69 HEALTHPARTNERS SX009 HEALTHPARTNERS 4.55 percent of total billed charges 3.53 5.41 Technical (Hospital) Services CAPTOPRIL 25 MG TABLET RX-9402 CDM 6370000100 HCPCS 250 RC 00143-1172-01 NDC outpatient 1 UN 6.71 6.71 UNITED HEALTHCARE (COMMERCIAL) [3081199] UNITED HEALTHCARE 87726 [308119901] 4.16 percent of total billed charges 4.16 6.37 Technical (Hospital) Services CAPTOPRIL 25 MG TABLET RX-9402 CDM 6370000100 HCPCS 250 RC 00143-1172-01 NDC outpatient 1 UN 6.71 6.71 MULTIPLAN INC 34080 [3081285] MULTIPLAN INC [308128501] 6.37 percent of total billed charges 4.16 6.37 Technical (Hospital) Services CAPTOPRIL 25 MG TABLET RX-9402 CDM 6370000100 HCPCS 250 RC 00143-1172-01 NDC outpatient 1 UN 6.71 6.71 CIGNA 62308 [3081051] CIGNA 62308 [308105105] 5.37 percent of total billed charges 4.16 6.37 Technical (Hospital) Services CAPTOPRIL 25 MG TABLET RX-9402 CDM 6370000100 HCPCS 250 RC 00143-1172-01 NDC outpatient 1 UN 6.71 6.71 CIGNA 62308 [3081051] CIGNA STATE OF WYOMING [308105107] 5.37 percent of total billed charges 4.16 6.37 Technical (Hospital) Services CAPTOPRIL 25 MG TABLET RX-9402 CDM 6370000100 HCPCS 250 RC 00143-1172-01 NDC outpatient 1 UN 6.71 6.71 MEDICA (COMMERCIAL) 94265 [3081118] MEDICA CLAIMS [308111801] 6.04 percent of total billed charges 4.16 6.37 Technical (Hospital) Services CAPTOPRIL 25 MG TABLET RX-9402 CDM 6370000100 HCPCS 250 RC 00143-1172-01 NDC outpatient 1 UN 6.71 6.71 HEALTHPARTNERS SX009 HEALTHPARTNERS 5.37 percent of total billed charges 4.16 6.37 Technical (Hospital) Services CAPTOPRIL 25 MG TABLET RX-9402 CDM 6370000100 HCPCS 250 RC 00143-1172-01 NDC outpatient 1 UN 6.71 6.71 BLUE CROSS BLUE SHIELD WELLMARK SB889 [3081026] BCBS WYOMING [308102603] 6.37 percent of total billed charges 4.16 6.37 Technical (Hospital) Services CAPTOPRIL 25 MG TABLET RX-9402 CDM 6370000100 HCPCS 250 RC 00143-1172-01 NDC outpatient 1 UN 6.71 6.71 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES EPO [308136803] 5.37 percent of total billed charges 4.16 6.37 Technical (Hospital) Services CAPTOPRIL 25 MG TABLET RX-9402 CDM 6370000100 HCPCS 250 RC 00143-1172-01 NDC outpatient 1 UN 6.71 6.71 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES HDHP [308136802] 5.37 percent of total billed charges 4.16 6.37 Technical (Hospital) Services CAPTOPRIL 25 MG TABLET RX-9402 CDM 6370000100 HCPCS 250 RC 00143-1172-01 NDC outpatient 1 UN 6.71 6.71 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES PPO [308136801] 5.37 percent of total billed charges 4.16 6.37 Technical (Hospital) Services CAPTOPRIL 25 MG TABLET RX-9402 CDM 6370000100 HCPCS 250 RC 00143-1172-01 NDC inpatient 1 UN 6.71 6.71 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES PPO [308136801] 5.31 percent of total billed charges 4.16 6.37 Technical (Hospital) Services CAPTOPRIL 25 MG TABLET RX-9402 CDM 6370000100 HCPCS 250 RC 00143-1172-01 NDC inpatient 1 UN 6.71 6.71 MEDICA (COMMERCIAL) 94265 [3081118] MEDICA CLAIMS [308111801] 6.04 percent of total billed charges 4.16 6.37 Technical (Hospital) Services CAPTOPRIL 25 MG TABLET RX-9402 CDM 6370000100 HCPCS 250 RC 00143-1172-01 NDC inpatient 1 UN 6.71 6.71 HEALTHPARTNERS SX009 HEALTHPARTNERS 5.31 percent of total billed charges 4.16 6.37 Technical (Hospital) Services CAPTOPRIL 25 MG TABLET RX-9402 CDM 6370000100 HCPCS 250 RC 00143-1172-01 NDC inpatient 1 UN 6.71 6.71 MULTIPLAN INC 34080 [3081285] MULTIPLAN INC [308128501] 6.37 percent of total billed charges 4.16 6.37 Technical (Hospital) Services CAPTOPRIL 25 MG TABLET RX-9402 CDM 6370000100 HCPCS 250 RC 00143-1172-01 NDC inpatient 1 UN 6.71 6.71 CIGNA 62308 [3081051] CIGNA 62308 [308105105] 5.31 percent of total billed charges 4.16 6.37 Technical (Hospital) Services CAPTOPRIL 25 MG TABLET RX-9402 CDM 6370000100 HCPCS 250 RC 00143-1172-01 NDC inpatient 1 UN 6.71 6.71 CIGNA 62308 [3081051] CIGNA STATE OF WYOMING [308105107] 5.31 percent of total billed charges 4.16 6.37 Technical (Hospital) Services CAPTOPRIL 25 MG TABLET RX-9402 CDM 6370000100 HCPCS 250 RC 00143-1172-01 NDC inpatient 1 UN 6.71 6.71 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES EPO [308136803] 5.31 percent of total billed charges 4.16 6.37 Technical (Hospital) Services CAPTOPRIL 25 MG TABLET RX-9402 CDM 6370000100 HCPCS 250 RC 00143-1172-01 NDC inpatient 1 UN 6.71 6.71 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES HDHP [308136802] 5.31 percent of total billed charges 4.16 6.37 Technical (Hospital) Services CAPTOPRIL 25 MG TABLET RX-9402 CDM 6370000100 HCPCS 250 RC 00143-1172-01 NDC inpatient 1 UN 6.71 6.71 UNITED HEALTHCARE (COMMERCIAL) [3081199] UNITED HEALTHCARE 87726 [308119901] 4.16 percent of total billed charges 4.16 6.37 Technical (Hospital) Services CAPTOPRIL 25 MG TABLET RX-9402 CDM 6370000100 HCPCS 250 RC 00143-1172-01 NDC inpatient 1 UN 6.71 6.71 BLUE CROSS BLUE SHIELD WELLMARK SB889 [3081026] BCBS WYOMING [308102603] 6.37 percent of total billed charges 4.16 6.37 Technical (Hospital) Services CARBIDOPA 10 MG-LEVODOPA 100 MG TABLET RX-9406 CDM 6370000100 HCPCS 250 RC 00378-0078-01 NDC inpatient 1 UN 5.88 5.88 MEDICA (COMMERCIAL) 94265 [3081118] MEDICA CLAIMS [308111801] 5.29 percent of total billed charges 3.65 5.59 Technical (Hospital) Services CARBIDOPA 10 MG-LEVODOPA 100 MG TABLET RX-9406 CDM 6370000100 HCPCS 250 RC 00378-0078-01 NDC inpatient 1 UN 5.88 5.88 HEALTHPARTNERS SX009 HEALTHPARTNERS 4.66 percent of total billed charges 3.65 5.59 Technical (Hospital) Services CARBIDOPA 10 MG-LEVODOPA 100 MG TABLET RX-9406 CDM 6370000100 HCPCS 250 RC 00378-0078-01 NDC inpatient 1 UN 5.88 5.88 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES PPO [308136801] 4.66 percent of total billed charges 3.65 5.59 Technical (Hospital) Services CARBIDOPA 10 MG-LEVODOPA 100 MG TABLET RX-9406 CDM 6370000100 HCPCS 250 RC 00378-0078-01 NDC inpatient 1 UN 5.88 5.88 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES HDHP [308136802] 4.66 percent of total billed charges 3.65 5.59 Technical (Hospital) Services CARBIDOPA 10 MG-LEVODOPA 100 MG TABLET RX-9406 CDM 6370000100 HCPCS 250 RC 00378-0078-01 NDC inpatient 1 UN 5.88 5.88 UNITED HEALTHCARE (COMMERCIAL) [3081199] UNITED HEALTHCARE 87726 [308119901] 3.65 percent of total billed charges 3.65 5.59 Technical (Hospital) Services CARBIDOPA 10 MG-LEVODOPA 100 MG TABLET RX-9406 CDM 6370000100 HCPCS 250 RC 00378-0078-01 NDC inpatient 1 UN 5.88 5.88 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES EPO [308136803] 4.66 percent of total billed charges 3.65 5.59 Technical (Hospital) Services CARBIDOPA 10 MG-LEVODOPA 100 MG TABLET RX-9406 CDM 6370000100 HCPCS 250 RC 00378-0078-01 NDC inpatient 1 UN 5.88 5.88 CIGNA 62308 [3081051] CIGNA 62308 [308105105] 4.66 percent of total billed charges 3.65 5.59 Technical (Hospital) Services CARBIDOPA 10 MG-LEVODOPA 100 MG TABLET RX-9406 CDM 6370000100 HCPCS 250 RC 00378-0078-01 NDC inpatient 1 UN 5.88 5.88 CIGNA 62308 [3081051] CIGNA STATE OF WYOMING [308105107] 4.66 percent of total billed charges 3.65 5.59 Technical (Hospital) Services CARBIDOPA 10 MG-LEVODOPA 100 MG TABLET RX-9406 CDM 6370000100 HCPCS 250 RC 00378-0078-01 NDC inpatient 1 UN 5.88 5.88 BLUE CROSS BLUE SHIELD WELLMARK SB889 [3081026] BCBS WYOMING [308102603] 5.59 percent of total billed charges 3.65 5.59 Technical (Hospital) Services CARBIDOPA 10 MG-LEVODOPA 100 MG TABLET RX-9406 CDM 6370000100 HCPCS 250 RC 00378-0078-01 NDC inpatient 1 UN 5.88 5.88 MULTIPLAN INC 34080 [3081285] MULTIPLAN INC [308128501] 5.59 percent of total billed charges 3.65 5.59 Technical (Hospital) Services CARBIDOPA 10 MG-LEVODOPA 100 MG TABLET RX-9406 CDM 6370000100 HCPCS 250 RC 00378-0078-01 NDC outpatient 1 UN 5.88 5.88 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES PPO [308136801] 4.7 percent of total billed charges 3.65 5.59 Technical (Hospital) Services CARBIDOPA 10 MG-LEVODOPA 100 MG TABLET RX-9406 CDM 6370000100 HCPCS 250 RC 00378-0078-01 NDC outpatient 1 UN 5.88 5.88 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES HDHP [308136802] 4.7 percent of total billed charges 3.65 5.59 Technical (Hospital) Services CARBIDOPA 10 MG-LEVODOPA 100 MG TABLET RX-9406 CDM 6370000100 HCPCS 250 RC 00378-0078-01 NDC outpatient 1 UN 5.88 5.88 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES EPO [308136803] 4.7 percent of total billed charges 3.65 5.59 Technical (Hospital) Services CARBIDOPA 10 MG-LEVODOPA 100 MG TABLET RX-9406 CDM 6370000100 HCPCS 250 RC 00378-0078-01 NDC outpatient 1 UN 5.88 5.88 UNITED HEALTHCARE (COMMERCIAL) [3081199] UNITED HEALTHCARE 87726 [308119901] 3.65 percent of total billed charges 3.65 5.59 Technical (Hospital) Services CARBIDOPA 10 MG-LEVODOPA 100 MG TABLET RX-9406 CDM 6370000100 HCPCS 250 RC 00378-0078-01 NDC outpatient 1 UN 5.88 5.88 HEALTHPARTNERS SX009 HEALTHPARTNERS 4.7 percent of total billed charges 3.65 5.59 Technical (Hospital) Services CARBIDOPA 10 MG-LEVODOPA 100 MG TABLET RX-9406 CDM 6370000100 HCPCS 250 RC 00378-0078-01 NDC outpatient 1 UN 5.88 5.88 CIGNA 62308 [3081051] CIGNA 62308 [308105105] 4.7 percent of total billed charges 3.65 5.59 Technical (Hospital) Services CARBIDOPA 10 MG-LEVODOPA 100 MG TABLET RX-9406 CDM 6370000100 HCPCS 250 RC 00378-0078-01 NDC outpatient 1 UN 5.88 5.88 CIGNA 62308 [3081051] CIGNA STATE OF WYOMING [308105107] 4.7 percent of total billed charges 3.65 5.59 Technical (Hospital) Services CARBIDOPA 10 MG-LEVODOPA 100 MG TABLET RX-9406 CDM 6370000100 HCPCS 250 RC 00378-0078-01 NDC outpatient 1 UN 5.88 5.88 MULTIPLAN INC 34080 [3081285] MULTIPLAN INC [308128501] 5.59 percent of total billed charges 3.65 5.59 Technical (Hospital) Services CARBIDOPA 10 MG-LEVODOPA 100 MG TABLET RX-9406 CDM 6370000100 HCPCS 250 RC 00378-0078-01 NDC outpatient 1 UN 5.88 5.88 MEDICA (COMMERCIAL) 94265 [3081118] MEDICA CLAIMS [308111801] 5.29 percent of total billed charges 3.65 5.59 Technical (Hospital) Services CARBIDOPA 10 MG-LEVODOPA 100 MG TABLET RX-9406 CDM 6370000100 HCPCS 250 RC 00378-0078-01 NDC outpatient 1 UN 5.88 5.88 BLUE CROSS BLUE SHIELD WELLMARK SB889 [3081026] BCBS WYOMING [308102603] 5.59 percent of total billed charges 3.65 5.59 Technical (Hospital) Services CARBIDOPA 25 MG-LEVODOPA 100 MG TABLET RX-9407 CDM 6370000100 HCPCS 250 RC 60687-0661-11 NDC outpatient 1 UN 5.99 5.99 UNITED HEALTHCARE (COMMERCIAL) [3081199] UNITED HEALTHCARE 87726 [308119901] 3.71 percent of total billed charges 3.71 5.69 Technical (Hospital) Services CARBIDOPA 25 MG-LEVODOPA 100 MG TABLET RX-9407 CDM 6370000100 HCPCS 250 RC 60687-0661-11 NDC outpatient 1 UN 5.99 5.99 HEALTHPARTNERS SX009 HEALTHPARTNERS 4.79 percent of total billed charges 3.71 5.69 Technical (Hospital) Services CARBIDOPA 25 MG-LEVODOPA 100 MG TABLET RX-9407 CDM 6370000100 HCPCS 250 RC 60687-0661-11 NDC outpatient 1 UN 5.99 5.99 MEDICA (COMMERCIAL) 94265 [3081118] MEDICA CLAIMS [308111801] 5.39 percent of total billed charges 3.71 5.69 Technical (Hospital) Services CARBIDOPA 25 MG-LEVODOPA 100 MG TABLET RX-9407 CDM 6370000100 HCPCS 250 RC 60687-0661-11 NDC outpatient 1 UN 5.99 5.99 MULTIPLAN INC 34080 [3081285] MULTIPLAN INC [308128501] 5.69 percent of total billed charges 3.71 5.69 Technical (Hospital) Services CARBIDOPA 25 MG-LEVODOPA 100 MG TABLET RX-9407 CDM 6370000100 HCPCS 250 RC 60687-0661-11 NDC outpatient 1 UN 5.99 5.99 CIGNA 62308 [3081051] CIGNA 62308 [308105105] 4.79 percent of total billed charges 3.71 5.69 Technical (Hospital) Services CARBIDOPA 25 MG-LEVODOPA 100 MG TABLET RX-9407 CDM 6370000100 HCPCS 250 RC 60687-0661-11 NDC outpatient 1 UN 5.99 5.99 CIGNA 62308 [3081051] CIGNA STATE OF WYOMING [308105107] 4.79 percent of total billed charges 3.71 5.69 Technical (Hospital) Services CARBIDOPA 25 MG-LEVODOPA 100 MG TABLET RX-9407 CDM 6370000100 HCPCS 250 RC 60687-0661-11 NDC outpatient 1 UN 5.99 5.99 BLUE CROSS BLUE SHIELD WELLMARK SB889 [3081026] BCBS WYOMING [308102603] 5.69 percent of total billed charges 3.71 5.69 Technical (Hospital) Services CARBIDOPA 25 MG-LEVODOPA 100 MG TABLET RX-9407 CDM 6370000100 HCPCS 250 RC 60687-0661-11 NDC outpatient 1 UN 5.99 5.99 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES HDHP [308136802] 4.79 percent of total billed charges 3.71 5.69 Technical (Hospital) Services CARBIDOPA 25 MG-LEVODOPA 100 MG TABLET RX-9407 CDM 6370000100 HCPCS 250 RC 60687-0661-11 NDC outpatient 1 UN 5.99 5.99 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES PPO [308136801] 4.79 percent of total billed charges 3.71 5.69 Technical (Hospital) Services CARBIDOPA 25 MG-LEVODOPA 100 MG TABLET RX-9407 CDM 6370000100 HCPCS 250 RC 60687-0661-11 NDC outpatient 1 UN 5.99 5.99 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES EPO [308136803] 4.79 percent of total billed charges 3.71 5.69 Technical (Hospital) Services CARBIDOPA 25 MG-LEVODOPA 100 MG TABLET RX-9407 CDM 6370000100 HCPCS 250 RC 60687-0661-11 NDC inpatient 1 UN 5.99 5.99 MULTIPLAN INC 34080 [3081285] MULTIPLAN INC [308128501] 5.69 percent of total billed charges 3.71 5.69 Technical (Hospital) Services CARBIDOPA 25 MG-LEVODOPA 100 MG TABLET RX-9407 CDM 6370000100 HCPCS 250 RC 60687-0661-11 NDC inpatient 1 UN 5.99 5.99 BLUE CROSS BLUE SHIELD WELLMARK SB889 [3081026] BCBS WYOMING [308102603] 5.69 percent of total billed charges 3.71 5.69 Technical (Hospital) Services CARBIDOPA 25 MG-LEVODOPA 100 MG TABLET RX-9407 CDM 6370000100 HCPCS 250 RC 60687-0661-11 NDC inpatient 1 UN 5.99 5.99 CIGNA 62308 [3081051] CIGNA 62308 [308105105] 4.74 percent of total billed charges 3.71 5.69 Technical (Hospital) Services CARBIDOPA 25 MG-LEVODOPA 100 MG TABLET RX-9407 CDM 6370000100 HCPCS 250 RC 60687-0661-11 NDC inpatient 1 UN 5.99 5.99 CIGNA 62308 [3081051] CIGNA STATE OF WYOMING [308105107] 4.74 percent of total billed charges 3.71 5.69 Technical (Hospital) Services CARBIDOPA 25 MG-LEVODOPA 100 MG TABLET RX-9407 CDM 6370000100 HCPCS 250 RC 60687-0661-11 NDC inpatient 1 UN 5.99 5.99 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES EPO [308136803] 4.74 percent of total billed charges 3.71 5.69 Technical (Hospital) Services CARBIDOPA 25 MG-LEVODOPA 100 MG TABLET RX-9407 CDM 6370000100 HCPCS 250 RC 60687-0661-11 NDC inpatient 1 UN 5.99 5.99 UNITED HEALTHCARE (COMMERCIAL) [3081199] UNITED HEALTHCARE 87726 [308119901] 3.71 percent of total billed charges 3.71 5.69 Technical (Hospital) Services CARBIDOPA 25 MG-LEVODOPA 100 MG TABLET RX-9407 CDM 6370000100 HCPCS 250 RC 60687-0661-11 NDC inpatient 1 UN 5.99 5.99 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES HDHP [308136802] 4.74 percent of total billed charges 3.71 5.69 Technical (Hospital) Services CARBIDOPA 25 MG-LEVODOPA 100 MG TABLET RX-9407 CDM 6370000100 HCPCS 250 RC 60687-0661-11 NDC inpatient 1 UN 5.99 5.99 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES PPO [308136801] 4.74 percent of total billed charges 3.71 5.69 Technical (Hospital) Services CARBIDOPA 25 MG-LEVODOPA 100 MG TABLET RX-9407 CDM 6370000100 HCPCS 250 RC 60687-0661-11 NDC inpatient 1 UN 5.99 5.99 HEALTHPARTNERS SX009 HEALTHPARTNERS 4.74 percent of total billed charges 3.71 5.69 Technical (Hospital) Services CARBIDOPA 25 MG-LEVODOPA 100 MG TABLET RX-9407 CDM 6370000100 HCPCS 250 RC 60687-0661-11 NDC inpatient 1 UN 5.99 5.99 MEDICA (COMMERCIAL) 94265 [3081118] MEDICA CLAIMS [308111801] 5.39 percent of total billed charges 3.71 5.69 Technical (Hospital) Services CEFPROZIL 250 MG/5 ML ORAL SUSPENSION RX-9471 CDM 6370000100 HCPCS 250 RC 68180-0402-01 NDC outpatient 50 ML 111.8 111.8 BLUE CROSS BLUE SHIELD WELLMARK SB889 [3081026] BCBS WYOMING [308102603] 106.21 percent of total billed charges 69.32 106.21 Technical (Hospital) Services CEFPROZIL 250 MG/5 ML ORAL SUSPENSION RX-9471 CDM 6370000100 HCPCS 250 RC 68180-0402-01 NDC outpatient 50 ML 111.8 111.8 HEALTHPARTNERS SX009 HEALTHPARTNERS 89.44 percent of total billed charges 69.32 106.21 Technical (Hospital) Services CEFPROZIL 250 MG/5 ML ORAL SUSPENSION RX-9471 CDM 6370000100 HCPCS 250 RC 68180-0402-01 NDC outpatient 50 ML 111.8 111.8 UNITED HEALTHCARE (COMMERCIAL) [3081199] UNITED HEALTHCARE 87726 [308119901] 69.32 percent of total billed charges 69.32 106.21 Technical (Hospital) Services CEFPROZIL 250 MG/5 ML ORAL SUSPENSION RX-9471 CDM 6370000100 HCPCS 250 RC 68180-0402-01 NDC outpatient 50 ML 111.8 111.8 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES EPO [308136803] 89.44 percent of total billed charges 69.32 106.21 Technical (Hospital) Services CEFPROZIL 250 MG/5 ML ORAL SUSPENSION RX-9471 CDM 6370000100 HCPCS 250 RC 68180-0402-01 NDC outpatient 50 ML 111.8 111.8 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES HDHP [308136802] 89.44 percent of total billed charges 69.32 106.21 Technical (Hospital) Services CEFPROZIL 250 MG/5 ML ORAL SUSPENSION RX-9471 CDM 6370000100 HCPCS 250 RC 68180-0402-01 NDC outpatient 50 ML 111.8 111.8 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES PPO [308136801] 89.44 percent of total billed charges 69.32 106.21 Technical (Hospital) Services CEFPROZIL 250 MG/5 ML ORAL SUSPENSION RX-9471 CDM 6370000100 HCPCS 250 RC 68180-0402-01 NDC outpatient 50 ML 111.8 111.8 MEDICA (COMMERCIAL) 94265 [3081118] MEDICA CLAIMS [308111801] 100.62 percent of total billed charges 69.32 106.21 Technical (Hospital) Services CEFPROZIL 250 MG/5 ML ORAL SUSPENSION RX-9471 CDM 6370000100 HCPCS 250 RC 68180-0402-01 NDC outpatient 50 ML 111.8 111.8 MULTIPLAN INC 34080 [3081285] MULTIPLAN INC [308128501] 106.21 percent of total billed charges 69.32 106.21 Technical (Hospital) Services CEFPROZIL 250 MG/5 ML ORAL SUSPENSION RX-9471 CDM 6370000100 HCPCS 250 RC 68180-0402-01 NDC outpatient 50 ML 111.8 111.8 CIGNA 62308 [3081051] CIGNA 62308 [308105105] 89.44 percent of total billed charges 69.32 106.21 Technical (Hospital) Services CEFPROZIL 250 MG/5 ML ORAL SUSPENSION RX-9471 CDM 6370000100 HCPCS 250 RC 68180-0402-01 NDC outpatient 50 ML 111.8 111.8 CIGNA 62308 [3081051] CIGNA STATE OF WYOMING [308105107] 89.44 percent of total billed charges 69.32 106.21 Technical (Hospital) Services CEFPROZIL 250 MG/5 ML ORAL SUSPENSION RX-9471 CDM 6370000100 HCPCS 250 RC 68180-0402-01 NDC inpatient 50 ML 111.8 111.8 BLUE CROSS BLUE SHIELD WELLMARK SB889 [3081026] BCBS WYOMING [308102603] 106.21 percent of total billed charges 69.32 106.21 Technical (Hospital) Services CEFPROZIL 250 MG/5 ML ORAL SUSPENSION RX-9471 CDM 6370000100 HCPCS 250 RC 68180-0402-01 NDC inpatient 50 ML 111.8 111.8 UNITED HEALTHCARE (COMMERCIAL) [3081199] UNITED HEALTHCARE 87726 [308119901] 69.32 percent of total billed charges 69.32 106.21 Technical (Hospital) Services CEFPROZIL 250 MG/5 ML ORAL SUSPENSION RX-9471 CDM 6370000100 HCPCS 250 RC 68180-0402-01 NDC inpatient 50 ML 111.8 111.8 MULTIPLAN INC 34080 [3081285] MULTIPLAN INC [308128501] 106.21 percent of total billed charges 69.32 106.21 Technical (Hospital) Services CEFPROZIL 250 MG/5 ML ORAL SUSPENSION RX-9471 CDM 6370000100 HCPCS 250 RC 68180-0402-01 NDC inpatient 50 ML 111.8 111.8 MEDICA (COMMERCIAL) 94265 [3081118] MEDICA CLAIMS [308111801] 100.62 percent of total billed charges 69.32 106.21 Technical (Hospital) Services CEFPROZIL 250 MG/5 ML ORAL SUSPENSION RX-9471 CDM 6370000100 HCPCS 250 RC 68180-0402-01 NDC inpatient 50 ML 111.8 111.8 HEALTHPARTNERS SX009 HEALTHPARTNERS 88.52 percent of total billed charges 69.32 106.21 Technical (Hospital) Services CEFPROZIL 250 MG/5 ML ORAL SUSPENSION RX-9471 CDM 6370000100 HCPCS 250 RC 68180-0402-01 NDC inpatient 50 ML 111.8 111.8 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES EPO [308136803] 88.52 percent of total billed charges 69.32 106.21 Technical (Hospital) Services CEFPROZIL 250 MG/5 ML ORAL SUSPENSION RX-9471 CDM 6370000100 HCPCS 250 RC 68180-0402-01 NDC inpatient 50 ML 111.8 111.8 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES HDHP [308136802] 88.52 percent of total billed charges 69.32 106.21 Technical (Hospital) Services CEFPROZIL 250 MG/5 ML ORAL SUSPENSION RX-9471 CDM 6370000100 HCPCS 250 RC 68180-0402-01 NDC inpatient 50 ML 111.8 111.8 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES PPO [308136801] 88.52 percent of total billed charges 69.32 106.21 Technical (Hospital) Services CEFPROZIL 250 MG/5 ML ORAL SUSPENSION RX-9471 CDM 6370000100 HCPCS 250 RC 68180-0402-01 NDC inpatient 50 ML 111.8 111.8 CIGNA 62308 [3081051] CIGNA 62308 [308105105] 88.52 percent of total billed charges 69.32 106.21 Technical (Hospital) Services CEFPROZIL 250 MG/5 ML ORAL SUSPENSION RX-9471 CDM 6370000100 HCPCS 250 RC 68180-0402-01 NDC inpatient 50 ML 111.8 111.8 CIGNA 62308 [3081051] CIGNA STATE OF WYOMING [308105107] 88.52 percent of total billed charges 69.32 106.21 Technical (Hospital) Services CEFPROZIL 250 MG TABLET RX-9472 CDM 6370000100 HCPCS 250 RC 68180-0403-01 NDC outpatient 1 UN 6.32 6.32 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES HDHP [308136802] 5.06 percent of total billed charges 3.92 6 Technical (Hospital) Services CEFPROZIL 250 MG TABLET RX-9472 CDM 6370000100 HCPCS 250 RC 68180-0403-01 NDC outpatient 1 UN 6.32 6.32 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES PPO [308136801] 5.06 percent of total billed charges 3.92 6 Technical (Hospital) Services CEFPROZIL 250 MG TABLET RX-9472 CDM 6370000100 HCPCS 250 RC 68180-0403-01 NDC outpatient 1 UN 6.32 6.32 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES EPO [308136803] 5.06 percent of total billed charges 3.92 6 Technical (Hospital) Services CEFPROZIL 250 MG TABLET RX-9472 CDM 6370000100 HCPCS 250 RC 68180-0403-01 NDC outpatient 1 UN 6.32 6.32 MULTIPLAN INC 34080 [3081285] MULTIPLAN INC [308128501] 6 percent of total billed charges 3.92 6 Technical (Hospital) Services CEFPROZIL 250 MG TABLET RX-9472 CDM 6370000100 HCPCS 250 RC 68180-0403-01 NDC outpatient 1 UN 6.32 6.32 CIGNA 62308 [3081051] CIGNA 62308 [308105105] 5.06 percent of total billed charges 3.92 6 Technical (Hospital) Services CEFPROZIL 250 MG TABLET RX-9472 CDM 6370000100 HCPCS 250 RC 68180-0403-01 NDC outpatient 1 UN 6.32 6.32 CIGNA 62308 [3081051] CIGNA STATE OF WYOMING [308105107] 5.06 percent of total billed charges 3.92 6 Technical (Hospital) Services CEFPROZIL 250 MG TABLET RX-9472 CDM 6370000100 HCPCS 250 RC 68180-0403-01 NDC outpatient 1 UN 6.32 6.32 MEDICA (COMMERCIAL) 94265 [3081118] MEDICA CLAIMS [308111801] 5.69 percent of total billed charges 3.92 6 Technical (Hospital) Services CEFPROZIL 250 MG TABLET RX-9472 CDM 6370000100 HCPCS 250 RC 68180-0403-01 NDC outpatient 1 UN 6.32 6.32 UNITED HEALTHCARE (COMMERCIAL) [3081199] UNITED HEALTHCARE 87726 [308119901] 3.92 percent of total billed charges 3.92 6 Technical (Hospital) Services CEFPROZIL 250 MG TABLET RX-9472 CDM 6370000100 HCPCS 250 RC 68180-0403-01 NDC outpatient 1 UN 6.32 6.32 HEALTHPARTNERS SX009 HEALTHPARTNERS 5.06 percent of total billed charges 3.92 6 Technical (Hospital) Services CEFPROZIL 250 MG TABLET RX-9472 CDM 6370000100 HCPCS 250 RC 68180-0403-01 NDC outpatient 1 UN 6.32 6.32 BLUE CROSS BLUE SHIELD WELLMARK SB889 [3081026] BCBS WYOMING [308102603] 6 percent of total billed charges 3.92 6 Technical (Hospital) Services CEFPROZIL 250 MG TABLET RX-9472 CDM 6370000100 HCPCS 250 RC 68180-0403-01 NDC inpatient 1 UN 6.32 6.32 MULTIPLAN INC 34080 [3081285] MULTIPLAN INC [308128501] 6 percent of total billed charges 3.92 6 Technical (Hospital) Services CEFPROZIL 250 MG TABLET RX-9472 CDM 6370000100 HCPCS 250 RC 68180-0403-01 NDC inpatient 1 UN 6.32 6.32 UNITED HEALTHCARE (COMMERCIAL) [3081199] UNITED HEALTHCARE 87726 [308119901] 3.92 percent of total billed charges 3.92 6 Technical (Hospital) Services CEFPROZIL 250 MG TABLET RX-9472 CDM 6370000100 HCPCS 250 RC 68180-0403-01 NDC inpatient 1 UN 6.32 6.32 BLUE CROSS BLUE SHIELD WELLMARK SB889 [3081026] BCBS WYOMING [308102603] 6 percent of total billed charges 3.92 6 Technical (Hospital) Services CEFPROZIL 250 MG TABLET RX-9472 CDM 6370000100 HCPCS 250 RC 68180-0403-01 NDC inpatient 1 UN 6.32 6.32 CIGNA 62308 [3081051] CIGNA 62308 [308105105] 5 percent of total billed charges 3.92 6 Technical (Hospital) Services CEFPROZIL 250 MG TABLET RX-9472 CDM 6370000100 HCPCS 250 RC 68180-0403-01 NDC inpatient 1 UN 6.32 6.32 CIGNA 62308 [3081051] CIGNA STATE OF WYOMING [308105107] 5 percent of total billed charges 3.92 6 Technical (Hospital) Services CEFPROZIL 250 MG TABLET RX-9472 CDM 6370000100 HCPCS 250 RC 68180-0403-01 NDC inpatient 1 UN 6.32 6.32 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES EPO [308136803] 5 percent of total billed charges 3.92 6 Technical (Hospital) Services CEFPROZIL 250 MG TABLET RX-9472 CDM 6370000100 HCPCS 250 RC 68180-0403-01 NDC inpatient 1 UN 6.32 6.32 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES HDHP [308136802] 5 percent of total billed charges 3.92 6 Technical (Hospital) Services CEFPROZIL 250 MG TABLET RX-9472 CDM 6370000100 HCPCS 250 RC 68180-0403-01 NDC inpatient 1 UN 6.32 6.32 MEDICA (COMMERCIAL) 94265 [3081118] MEDICA CLAIMS [308111801] 5.69 percent of total billed charges 3.92 6 Technical (Hospital) Services CEFPROZIL 250 MG TABLET RX-9472 CDM 6370000100 HCPCS 250 RC 68180-0403-01 NDC inpatient 1 UN 6.32 6.32 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES PPO [308136801] 5 percent of total billed charges 3.92 6 Technical (Hospital) Services CEFPROZIL 250 MG TABLET RX-9472 CDM 6370000100 HCPCS 250 RC 68180-0403-01 NDC inpatient 1 UN 6.32 6.32 HEALTHPARTNERS SX009 HEALTHPARTNERS 5 percent of total billed charges 3.92 6 Technical (Hospital) Services CEFUROXIME AXETIL 250 MG TABLET RX-9495 CDM 6370000100 HCPCS 250 RC 65862-0699-20 NDC inpatient 1 UN 6.05 6.05 HEALTHPARTNERS SX009 HEALTHPARTNERS 4.79 percent of total billed charges 3.75 5.75 Technical (Hospital) Services CEFUROXIME AXETIL 250 MG TABLET RX-9495 CDM 6370000100 HCPCS 250 RC 65862-0699-20 NDC inpatient 1 UN 6.05 6.05 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES PPO [308136801] 4.79 percent of total billed charges 3.75 5.75 Technical (Hospital) Services CEFUROXIME AXETIL 250 MG TABLET RX-9495 CDM 6370000100 HCPCS 250 RC 65862-0699-20 NDC inpatient 1 UN 6.05 6.05 MEDICA (COMMERCIAL) 94265 [3081118] MEDICA CLAIMS [308111801] 5.45 percent of total billed charges 3.75 5.75 Technical (Hospital) Services CEFUROXIME AXETIL 250 MG TABLET RX-9495 CDM 6370000100 HCPCS 250 RC 65862-0699-20 NDC inpatient 1 UN 6.05 6.05 MULTIPLAN INC 34080 [3081285] MULTIPLAN INC [308128501] 5.75 percent of total billed charges 3.75 5.75 Technical (Hospital) Services CEFUROXIME AXETIL 250 MG TABLET RX-9495 CDM 6370000100 HCPCS 250 RC 65862-0699-20 NDC inpatient 1 UN 6.05 6.05 UNITED HEALTHCARE (COMMERCIAL) [3081199] UNITED HEALTHCARE 87726 [308119901] 3.75 percent of total billed charges 3.75 5.75 Technical (Hospital) Services CEFUROXIME AXETIL 250 MG TABLET RX-9495 CDM 6370000100 HCPCS 250 RC 65862-0699-20 NDC inpatient 1 UN 6.05 6.05 BLUE CROSS BLUE SHIELD WELLMARK SB889 [3081026] BCBS WYOMING [308102603] 5.75 percent of total billed charges 3.75 5.75 Technical (Hospital) Services CEFUROXIME AXETIL 250 MG TABLET RX-9495 CDM 6370000100 HCPCS 250 RC 65862-0699-20 NDC inpatient 1 UN 6.05 6.05 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES EPO [308136803] 4.79 percent of total billed charges 3.75 5.75 Technical (Hospital) Services CEFUROXIME AXETIL 250 MG TABLET RX-9495 CDM 6370000100 HCPCS 250 RC 65862-0699-20 NDC inpatient 1 UN 6.05 6.05 CIGNA 62308 [3081051] CIGNA 62308 [308105105] 4.79 percent of total billed charges 3.75 5.75 Technical (Hospital) Services CEFUROXIME AXETIL 250 MG TABLET RX-9495 CDM 6370000100 HCPCS 250 RC 65862-0699-20 NDC inpatient 1 UN 6.05 6.05 CIGNA 62308 [3081051] CIGNA STATE OF WYOMING [308105107] 4.79 percent of total billed charges 3.75 5.75 Technical (Hospital) Services CEFUROXIME AXETIL 250 MG TABLET RX-9495 CDM 6370000100 HCPCS 250 RC 65862-0699-20 NDC inpatient 1 UN 6.05 6.05 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES HDHP [308136802] 4.79 percent of total billed charges 3.75 5.75 Technical (Hospital) Services CEFUROXIME AXETIL 250 MG TABLET RX-9495 CDM 6370000100 HCPCS 250 RC 65862-0699-20 NDC outpatient 1 UN 6.05 6.05 HEALTHPARTNERS SX009 HEALTHPARTNERS 4.84 percent of total billed charges 3.75 5.75 Technical (Hospital) Services CEFUROXIME AXETIL 250 MG TABLET RX-9495 CDM 6370000100 HCPCS 250 RC 65862-0699-20 NDC outpatient 1 UN 6.05 6.05 UNITED HEALTHCARE (COMMERCIAL) [3081199] UNITED HEALTHCARE 87726 [308119901] 3.75 percent of total billed charges 3.75 5.75 Technical (Hospital) Services CEFUROXIME AXETIL 250 MG TABLET RX-9495 CDM 6370000100 HCPCS 250 RC 65862-0699-20 NDC outpatient 1 UN 6.05 6.05 MULTIPLAN INC 34080 [3081285] MULTIPLAN INC [308128501] 5.75 percent of total billed charges 3.75 5.75 Technical (Hospital) Services CEFUROXIME AXETIL 250 MG TABLET RX-9495 CDM 6370000100 HCPCS 250 RC 65862-0699-20 NDC outpatient 1 UN 6.05 6.05 CIGNA 62308 [3081051] CIGNA 62308 [308105105] 4.84 percent of total billed charges 3.75 5.75 Technical (Hospital) Services CEFUROXIME AXETIL 250 MG TABLET RX-9495 CDM 6370000100 HCPCS 250 RC 65862-0699-20 NDC outpatient 1 UN 6.05 6.05 CIGNA 62308 [3081051] CIGNA STATE OF WYOMING [308105107] 4.84 percent of total billed charges 3.75 5.75 Technical (Hospital) Services CEFUROXIME AXETIL 250 MG TABLET RX-9495 CDM 6370000100 HCPCS 250 RC 65862-0699-20 NDC outpatient 1 UN 6.05 6.05 BLUE CROSS BLUE SHIELD WELLMARK SB889 [3081026] BCBS WYOMING [308102603] 5.75 percent of total billed charges 3.75 5.75 Technical (Hospital) Services CEFUROXIME AXETIL 250 MG TABLET RX-9495 CDM 6370000100 HCPCS 250 RC 65862-0699-20 NDC outpatient 1 UN 6.05 6.05 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES EPO [308136803] 4.84 percent of total billed charges 3.75 5.75 Technical (Hospital) Services CEFUROXIME AXETIL 250 MG TABLET RX-9495 CDM 6370000100 HCPCS 250 RC 65862-0699-20 NDC outpatient 1 UN 6.05 6.05 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES HDHP [308136802] 4.84 percent of total billed charges 3.75 5.75 Technical (Hospital) Services CEFUROXIME AXETIL 250 MG TABLET RX-9495 CDM 6370000100 HCPCS 250 RC 65862-0699-20 NDC outpatient 1 UN 6.05 6.05 MEDICA (COMMERCIAL) 94265 [3081118] MEDICA CLAIMS [308111801] 5.45 percent of total billed charges 3.75 5.75 Technical (Hospital) Services CEFUROXIME AXETIL 250 MG TABLET RX-9495 CDM 6370000100 HCPCS 250 RC 65862-0699-20 NDC outpatient 1 UN 6.05 6.05 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES PPO [308136801] 4.84 percent of total billed charges 3.75 5.75 Technical (Hospital) Services CEFUROXIME AXETIL 500 MG TABLET RX-9496 CDM 6370000100 HCPCS 250 RC 68180-0303-20 NDC inpatient 1 UN 15.56 15.56 MEDICA (COMMERCIAL) 94265 [3081118] MEDICA CLAIMS [308111801] 14 percent of total billed charges 9.65 14.78 Technical (Hospital) Services CEFUROXIME AXETIL 500 MG TABLET RX-9496 CDM 6370000100 HCPCS 250 RC 68180-0303-20 NDC inpatient 1 UN 15.56 15.56 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES PPO [308136801] 12.32 percent of total billed charges 9.65 14.78 Technical (Hospital) Services CEFUROXIME AXETIL 500 MG TABLET RX-9496 CDM 6370000100 HCPCS 250 RC 68180-0303-20 NDC inpatient 1 UN 15.56 15.56 BLUE CROSS BLUE SHIELD WELLMARK SB889 [3081026] BCBS WYOMING [308102603] 14.78 percent of total billed charges 9.65 14.78 Technical (Hospital) Services CEFUROXIME AXETIL 500 MG TABLET RX-9496 CDM 6370000100 HCPCS 250 RC 68180-0303-20 NDC inpatient 1 UN 15.56 15.56 CIGNA 62308 [3081051] CIGNA 62308 [308105105] 12.32 percent of total billed charges 9.65 14.78 Technical (Hospital) Services CEFUROXIME AXETIL 500 MG TABLET RX-9496 CDM 6370000100 HCPCS 250 RC 68180-0303-20 NDC inpatient 1 UN 15.56 15.56 CIGNA 62308 [3081051] CIGNA STATE OF WYOMING [308105107] 12.32 percent of total billed charges 9.65 14.78 Technical (Hospital) Services CEFUROXIME AXETIL 500 MG TABLET RX-9496 CDM 6370000100 HCPCS 250 RC 68180-0303-20 NDC inpatient 1 UN 15.56 15.56 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES EPO [308136803] 12.32 percent of total billed charges 9.65 14.78 Technical (Hospital) Services CEFUROXIME AXETIL 500 MG TABLET RX-9496 CDM 6370000100 HCPCS 250 RC 68180-0303-20 NDC inpatient 1 UN 15.56 15.56 UNITED HEALTHCARE (COMMERCIAL) [3081199] UNITED HEALTHCARE 87726 [308119901] 9.65 percent of total billed charges 9.65 14.78 Technical (Hospital) Services CEFUROXIME AXETIL 500 MG TABLET RX-9496 CDM 6370000100 HCPCS 250 RC 68180-0303-20 NDC inpatient 1 UN 15.56 15.56 HEALTHPARTNERS SX009 HEALTHPARTNERS 12.32 percent of total billed charges 9.65 14.78 Technical (Hospital) Services CEFUROXIME AXETIL 500 MG TABLET RX-9496 CDM 6370000100 HCPCS 250 RC 68180-0303-20 NDC inpatient 1 UN 15.56 15.56 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES HDHP [308136802] 12.32 percent of total billed charges 9.65 14.78 Technical (Hospital) Services CEFUROXIME AXETIL 500 MG TABLET RX-9496 CDM 6370000100 HCPCS 250 RC 68180-0303-20 NDC inpatient 1 UN 15.56 15.56 MULTIPLAN INC 34080 [3081285] MULTIPLAN INC [308128501] 14.78 percent of total billed charges 9.65 14.78 Technical (Hospital) Services CEFUROXIME AXETIL 500 MG TABLET RX-9496 CDM 6370000100 HCPCS 250 RC 68180-0303-20 NDC outpatient 1 UN 15.56 15.56 BLUE CROSS BLUE SHIELD WELLMARK SB889 [3081026] BCBS WYOMING [308102603] 14.78 percent of total billed charges 9.65 14.78 Technical (Hospital) Services CEFUROXIME AXETIL 500 MG TABLET RX-9496 CDM 6370000100 HCPCS 250 RC 68180-0303-20 NDC outpatient 1 UN 15.56 15.56 MULTIPLAN INC 34080 [3081285] MULTIPLAN INC [308128501] 14.78 percent of total billed charges 9.65 14.78 Technical (Hospital) Services CEFUROXIME AXETIL 500 MG TABLET RX-9496 CDM 6370000100 HCPCS 250 RC 68180-0303-20 NDC outpatient 1 UN 15.56 15.56 CIGNA 62308 [3081051] CIGNA 62308 [308105105] 12.45 percent of total billed charges 9.65 14.78 Technical (Hospital) Services CEFUROXIME AXETIL 500 MG TABLET RX-9496 CDM 6370000100 HCPCS 250 RC 68180-0303-20 NDC outpatient 1 UN 15.56 15.56 CIGNA 62308 [3081051] CIGNA STATE OF WYOMING [308105107] 12.45 percent of total billed charges 9.65 14.78 Technical (Hospital) Services CEFUROXIME AXETIL 500 MG TABLET RX-9496 CDM 6370000100 HCPCS 250 RC 68180-0303-20 NDC outpatient 1 UN 15.56 15.56 MEDICA (COMMERCIAL) 94265 [3081118] MEDICA CLAIMS [308111801] 14 percent of total billed charges 9.65 14.78 Technical (Hospital) Services CEFUROXIME AXETIL 500 MG TABLET RX-9496 CDM 6370000100 HCPCS 250 RC 68180-0303-20 NDC outpatient 1 UN 15.56 15.56 UNITED HEALTHCARE (COMMERCIAL) [3081199] UNITED HEALTHCARE 87726 [308119901] 9.65 percent of total billed charges 9.65 14.78 Technical (Hospital) Services CEFUROXIME AXETIL 500 MG TABLET RX-9496 CDM 6370000100 HCPCS 250 RC 68180-0303-20 NDC outpatient 1 UN 15.56 15.56 HEALTHPARTNERS SX009 HEALTHPARTNERS 12.45 percent of total billed charges 9.65 14.78 Technical (Hospital) Services CEFUROXIME AXETIL 500 MG TABLET RX-9496 CDM 6370000100 HCPCS 250 RC 68180-0303-20 NDC outpatient 1 UN 15.56 15.56 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES EPO [308136803] 12.45 percent of total billed charges 9.65 14.78 Technical (Hospital) Services CEFUROXIME AXETIL 500 MG TABLET RX-9496 CDM 6370000100 HCPCS 250 RC 68180-0303-20 NDC outpatient 1 UN 15.56 15.56 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES HDHP [308136802] 12.45 percent of total billed charges 9.65 14.78 Technical (Hospital) Services CEFUROXIME AXETIL 500 MG TABLET RX-9496 CDM 6370000100 HCPCS 250 RC 68180-0303-20 NDC outpatient 1 UN 15.56 15.56 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES PPO [308136801] 12.45 percent of total billed charges 9.65 14.78 Technical (Hospital) Services CEPHALEXIN 250 MG CAPSULE RX-9499 CDM 6370000100 HCPCS 250 RC 00093-3145-01 NDC outpatient 1 UN 5.75 5.75 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES PPO [308136801] 4.6 percent of total billed charges 3.57 5.46 Technical (Hospital) Services CEPHALEXIN 250 MG CAPSULE RX-9499 CDM 6370000100 HCPCS 250 RC 00093-3145-01 NDC outpatient 1 UN 5.75 5.75 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES HDHP [308136802] 4.6 percent of total billed charges 3.57 5.46 Technical (Hospital) Services CEPHALEXIN 250 MG CAPSULE RX-9499 CDM 6370000100 HCPCS 250 RC 00093-3145-01 NDC outpatient 1 UN 5.75 5.75 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES EPO [308136803] 4.6 percent of total billed charges 3.57 5.46 Technical (Hospital) Services CEPHALEXIN 250 MG CAPSULE RX-9499 CDM 6370000100 HCPCS 250 RC 00093-3145-01 NDC outpatient 1 UN 5.75 5.75 HEALTHPARTNERS SX009 HEALTHPARTNERS 4.6 percent of total billed charges 3.57 5.46 Technical (Hospital) Services CEPHALEXIN 250 MG CAPSULE RX-9499 CDM 6370000100 HCPCS 250 RC 00093-3145-01 NDC outpatient 1 UN 5.75 5.75 UNITED HEALTHCARE (COMMERCIAL) [3081199] UNITED HEALTHCARE 87726 [308119901] 3.57 percent of total billed charges 3.57 5.46 Technical (Hospital) Services CEPHALEXIN 250 MG CAPSULE RX-9499 CDM 6370000100 HCPCS 250 RC 00093-3145-01 NDC outpatient 1 UN 5.75 5.75 MEDICA (COMMERCIAL) 94265 [3081118] MEDICA CLAIMS [308111801] 5.18 percent of total billed charges 3.57 5.46 Technical (Hospital) Services CEPHALEXIN 250 MG CAPSULE RX-9499 CDM 6370000100 HCPCS 250 RC 00093-3145-01 NDC outpatient 1 UN 5.75 5.75 CIGNA 62308 [3081051] CIGNA 62308 [308105105] 4.6 percent of total billed charges 3.57 5.46 Technical (Hospital) Services CEPHALEXIN 250 MG CAPSULE RX-9499 CDM 6370000100 HCPCS 250 RC 00093-3145-01 NDC outpatient 1 UN 5.75 5.75 CIGNA 62308 [3081051] CIGNA STATE OF WYOMING [308105107] 4.6 percent of total billed charges 3.57 5.46 Technical (Hospital) Services CEPHALEXIN 250 MG CAPSULE RX-9499 CDM 6370000100 HCPCS 250 RC 00093-3145-01 NDC outpatient 1 UN 5.75 5.75 MULTIPLAN INC 34080 [3081285] MULTIPLAN INC [308128501] 5.46 percent of total billed charges 3.57 5.46 Technical (Hospital) Services CEPHALEXIN 250 MG CAPSULE RX-9499 CDM 6370000100 HCPCS 250 RC 00093-3145-01 NDC outpatient 1 UN 5.75 5.75 BLUE CROSS BLUE SHIELD WELLMARK SB889 [3081026] BCBS WYOMING [308102603] 5.46 percent of total billed charges 3.57 5.46 Technical (Hospital) Services CEPHALEXIN 250 MG CAPSULE RX-9499 CDM 6370000100 HCPCS 250 RC 00093-3145-01 NDC inpatient 1 UN 5.75 5.75 HEALTHPARTNERS SX009 HEALTHPARTNERS 4.55 percent of total billed charges 3.57 5.46 Technical (Hospital) Services CEPHALEXIN 250 MG CAPSULE RX-9499 CDM 6370000100 HCPCS 250 RC 00093-3145-01 NDC inpatient 1 UN 5.75 5.75 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES PPO [308136801] 4.55 percent of total billed charges 3.57 5.46 Technical (Hospital) Services CEPHALEXIN 250 MG CAPSULE RX-9499 CDM 6370000100 HCPCS 250 RC 00093-3145-01 NDC inpatient 1 UN 5.75 5.75 MEDICA (COMMERCIAL) 94265 [3081118] MEDICA CLAIMS [308111801] 5.18 percent of total billed charges 3.57 5.46 Technical (Hospital) Services CEPHALEXIN 250 MG CAPSULE RX-9499 CDM 6370000100 HCPCS 250 RC 00093-3145-01 NDC inpatient 1 UN 5.75 5.75 UNITED HEALTHCARE (COMMERCIAL) [3081199] UNITED HEALTHCARE 87726 [308119901] 3.57 percent of total billed charges 3.57 5.46 Technical (Hospital) Services CEPHALEXIN 250 MG CAPSULE RX-9499 CDM 6370000100 HCPCS 250 RC 00093-3145-01 NDC inpatient 1 UN 5.75 5.75 BLUE CROSS BLUE SHIELD WELLMARK SB889 [3081026] BCBS WYOMING [308102603] 5.46 percent of total billed charges 3.57 5.46 Technical (Hospital) Services CEPHALEXIN 250 MG CAPSULE RX-9499 CDM 6370000100 HCPCS 250 RC 00093-3145-01 NDC inpatient 1 UN 5.75 5.75 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES HDHP [308136802] 4.55 percent of total billed charges 3.57 5.46 Technical (Hospital) Services CEPHALEXIN 250 MG CAPSULE RX-9499 CDM 6370000100 HCPCS 250 RC 00093-3145-01 NDC inpatient 1 UN 5.75 5.75 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES EPO [308136803] 4.55 percent of total billed charges 3.57 5.46 Technical (Hospital) Services CEPHALEXIN 250 MG CAPSULE RX-9499 CDM 6370000100 HCPCS 250 RC 00093-3145-01 NDC inpatient 1 UN 5.75 5.75 CIGNA 62308 [3081051] CIGNA 62308 [308105105] 4.55 percent of total billed charges 3.57 5.46 Technical (Hospital) Services CEPHALEXIN 250 MG CAPSULE RX-9499 CDM 6370000100 HCPCS 250 RC 00093-3145-01 NDC inpatient 1 UN 5.75 5.75 CIGNA 62308 [3081051] CIGNA STATE OF WYOMING [308105107] 4.55 percent of total billed charges 3.57 5.46 Technical (Hospital) Services CEPHALEXIN 250 MG CAPSULE RX-9499 CDM 6370000100 HCPCS 250 RC 00093-3145-01 NDC inpatient 1 UN 5.75 5.75 MULTIPLAN INC 34080 [3081285] MULTIPLAN INC [308128501] 5.46 percent of total billed charges 3.57 5.46 Technical (Hospital) Services CEPHALEXIN 500 MG CAPSULE RX-9500 CDM 6370000100 HCPCS 250 RC 00093-3147-01 NDC inpatient 1 UN 5.84 5.84 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES EPO [308136803] 4.62 percent of total billed charges 3.62 5.55 Technical (Hospital) Services CEPHALEXIN 500 MG CAPSULE RX-9500 CDM 6370000100 HCPCS 250 RC 00093-3147-01 NDC inpatient 1 UN 5.84 5.84 CIGNA 62308 [3081051] CIGNA 62308 [308105105] 4.62 percent of total billed charges 3.62 5.55 Technical (Hospital) Services CEPHALEXIN 500 MG CAPSULE RX-9500 CDM 6370000100 HCPCS 250 RC 00093-3147-01 NDC inpatient 1 UN 5.84 5.84 CIGNA 62308 [3081051] CIGNA STATE OF WYOMING [308105107] 4.62 percent of total billed charges 3.62 5.55 Technical (Hospital) Services CEPHALEXIN 500 MG CAPSULE RX-9500 CDM 6370000100 HCPCS 250 RC 00093-3147-01 NDC inpatient 1 UN 5.84 5.84 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES HDHP [308136802] 4.62 percent of total billed charges 3.62 5.55 Technical (Hospital) Services CEPHALEXIN 500 MG CAPSULE RX-9500 CDM 6370000100 HCPCS 250 RC 00093-3147-01 NDC inpatient 1 UN 5.84 5.84 UNITED HEALTHCARE (COMMERCIAL) [3081199] UNITED HEALTHCARE 87726 [308119901] 3.62 percent of total billed charges 3.62 5.55 Technical (Hospital) Services CEPHALEXIN 500 MG CAPSULE RX-9500 CDM 6370000100 HCPCS 250 RC 00093-3147-01 NDC inpatient 1 UN 5.84 5.84 BLUE CROSS BLUE SHIELD WELLMARK SB889 [3081026] BCBS WYOMING [308102603] 5.55 percent of total billed charges 3.62 5.55 Technical (Hospital) Services CEPHALEXIN 500 MG CAPSULE RX-9500 CDM 6370000100 HCPCS 250 RC 00093-3147-01 NDC inpatient 1 UN 5.84 5.84 MULTIPLAN INC 34080 [3081285] MULTIPLAN INC [308128501] 5.55 percent of total billed charges 3.62 5.55 Technical (Hospital) Services CEPHALEXIN 500 MG CAPSULE RX-9500 CDM 6370000100 HCPCS 250 RC 00093-3147-01 NDC inpatient 1 UN 5.84 5.84 MEDICA (COMMERCIAL) 94265 [3081118] MEDICA CLAIMS [308111801] 5.26 percent of total billed charges 3.62 5.55 Technical (Hospital) Services CEPHALEXIN 500 MG CAPSULE RX-9500 CDM 6370000100 HCPCS 250 RC 00093-3147-01 NDC inpatient 1 UN 5.84 5.84 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES PPO [308136801] 4.62 percent of total billed charges 3.62 5.55 Technical (Hospital) Services CEPHALEXIN 500 MG CAPSULE RX-9500 CDM 6370000100 HCPCS 250 RC 00093-3147-01 NDC inpatient 1 UN 5.84 5.84 HEALTHPARTNERS SX009 HEALTHPARTNERS 4.62 percent of total billed charges 3.62 5.55 Technical (Hospital) Services CEPHALEXIN 500 MG CAPSULE RX-9500 CDM 6370000100 HCPCS 250 RC 00093-3147-01 NDC outpatient 1 UN 5.84 5.84 BLUE CROSS BLUE SHIELD WELLMARK SB889 [3081026] BCBS WYOMING [308102603] 5.55 percent of total billed charges 3.62 5.55 Technical (Hospital) Services CEPHALEXIN 500 MG CAPSULE RX-9500 CDM 6370000100 HCPCS 250 RC 00093-3147-01 NDC outpatient 1 UN 5.84 5.84 MULTIPLAN INC 34080 [3081285] MULTIPLAN INC [308128501] 5.55 percent of total billed charges 3.62 5.55 Technical (Hospital) Services CEPHALEXIN 500 MG CAPSULE RX-9500 CDM 6370000100 HCPCS 250 RC 00093-3147-01 NDC outpatient 1 UN 5.84 5.84 CIGNA 62308 [3081051] CIGNA 62308 [308105105] 4.67 percent of total billed charges 3.62 5.55 Technical (Hospital) Services CEPHALEXIN 500 MG CAPSULE RX-9500 CDM 6370000100 HCPCS 250 RC 00093-3147-01 NDC outpatient 1 UN 5.84 5.84 CIGNA 62308 [3081051] CIGNA STATE OF WYOMING [308105107] 4.67 percent of total billed charges 3.62 5.55 Technical (Hospital) Services CEPHALEXIN 500 MG CAPSULE RX-9500 CDM 6370000100 HCPCS 250 RC 00093-3147-01 NDC outpatient 1 UN 5.84 5.84 MEDICA (COMMERCIAL) 94265 [3081118] MEDICA CLAIMS [308111801] 5.26 percent of total billed charges 3.62 5.55 Technical (Hospital) Services CEPHALEXIN 500 MG CAPSULE RX-9500 CDM 6370000100 HCPCS 250 RC 00093-3147-01 NDC outpatient 1 UN 5.84 5.84 HEALTHPARTNERS SX009 HEALTHPARTNERS 4.67 percent of total billed charges 3.62 5.55 Technical (Hospital) Services CEPHALEXIN 500 MG CAPSULE RX-9500 CDM 6370000100 HCPCS 250 RC 00093-3147-01 NDC outpatient 1 UN 5.84 5.84 UNITED HEALTHCARE (COMMERCIAL) [3081199] UNITED HEALTHCARE 87726 [308119901] 3.62 percent of total billed charges 3.62 5.55 Technical (Hospital) Services CEPHALEXIN 500 MG CAPSULE RX-9500 CDM 6370000100 HCPCS 250 RC 00093-3147-01 NDC outpatient 1 UN 5.84 5.84 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES PPO [308136801] 4.67 percent of total billed charges 3.62 5.55 Technical (Hospital) Services CEPHALEXIN 500 MG CAPSULE RX-9500 CDM 6370000100 HCPCS 250 RC 00093-3147-01 NDC outpatient 1 UN 5.84 5.84 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES HDHP [308136802] 4.67 percent of total billed charges 3.62 5.55 Technical (Hospital) Services CEPHALEXIN 500 MG CAPSULE RX-9500 CDM 6370000100 HCPCS 250 RC 00093-3147-01 NDC outpatient 1 UN 5.84 5.84 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES EPO [308136803] 4.67 percent of total billed charges 3.62 5.55 Technical (Hospital) Services CEPHALEXIN 250 MG/5 ML ORAL SUSPENSION RX-9502 CDM 6370000100 HCPCS 250 RC 00093-4177-73 NDC outpatient 100 ML 105.5 105.5 BLUE CROSS BLUE SHIELD WELLMARK SB889 [3081026] BCBS WYOMING [308102603] 100.23 percent of total billed charges 65.41 100.23 Technical (Hospital) Services CEPHALEXIN 250 MG/5 ML ORAL SUSPENSION RX-9502 CDM 6370000100 HCPCS 250 RC 00093-4177-73 NDC outpatient 100 ML 105.5 105.5 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES EPO [308136803] 84.4 percent of total billed charges 65.41 100.23 Technical (Hospital) Services CEPHALEXIN 250 MG/5 ML ORAL SUSPENSION RX-9502 CDM 6370000100 HCPCS 250 RC 00093-4177-73 NDC outpatient 100 ML 105.5 105.5 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES HDHP [308136802] 84.4 percent of total billed charges 65.41 100.23 Technical (Hospital) Services CEPHALEXIN 250 MG/5 ML ORAL SUSPENSION RX-9502 CDM 6370000100 HCPCS 250 RC 00093-4177-73 NDC outpatient 100 ML 105.5 105.5 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES PPO [308136801] 84.4 percent of total billed charges 65.41 100.23 Technical (Hospital) Services CEPHALEXIN 250 MG/5 ML ORAL SUSPENSION RX-9502 CDM 6370000100 HCPCS 250 RC 00093-4177-73 NDC outpatient 100 ML 105.5 105.5 HEALTHPARTNERS SX009 HEALTHPARTNERS 84.4 percent of total billed charges 65.41 100.23 Technical (Hospital) Services CEPHALEXIN 250 MG/5 ML ORAL SUSPENSION RX-9502 CDM 6370000100 HCPCS 250 RC 00093-4177-73 NDC outpatient 100 ML 105.5 105.5 UNITED HEALTHCARE (COMMERCIAL) [3081199] UNITED HEALTHCARE 87726 [308119901] 65.41 percent of total billed charges 65.41 100.23 Technical (Hospital) Services CEPHALEXIN 250 MG/5 ML ORAL SUSPENSION RX-9502 CDM 6370000100 HCPCS 250 RC 00093-4177-73 NDC outpatient 100 ML 105.5 105.5 MULTIPLAN INC 34080 [3081285] MULTIPLAN INC [308128501] 100.23 percent of total billed charges 65.41 100.23 Technical (Hospital) Services CEPHALEXIN 250 MG/5 ML ORAL SUSPENSION RX-9502 CDM 6370000100 HCPCS 250 RC 00093-4177-73 NDC outpatient 100 ML 105.5 105.5 MEDICA (COMMERCIAL) 94265 [3081118] MEDICA CLAIMS [308111801] 94.95 percent of total billed charges 65.41 100.23 Technical (Hospital) Services CEPHALEXIN 250 MG/5 ML ORAL SUSPENSION RX-9502 CDM 6370000100 HCPCS 250 RC 00093-4177-73 NDC outpatient 100 ML 105.5 105.5 CIGNA 62308 [3081051] CIGNA 62308 [308105105] 84.4 percent of total billed charges 65.41 100.23 Technical (Hospital) Services CEPHALEXIN 250 MG/5 ML ORAL SUSPENSION RX-9502 CDM 6370000100 HCPCS 250 RC 00093-4177-73 NDC outpatient 100 ML 105.5 105.5 CIGNA 62308 [3081051] CIGNA STATE OF WYOMING [308105107] 84.4 percent of total billed charges 65.41 100.23 Technical (Hospital) Services CEPHALEXIN 250 MG/5 ML ORAL SUSPENSION RX-9502 CDM 6370000100 HCPCS 250 RC 00093-4177-73 NDC inpatient 100 ML 105.5 105.5 UNITED HEALTHCARE (COMMERCIAL) [3081199] UNITED HEALTHCARE 87726 [308119901] 65.41 percent of total billed charges 65.41 100.23 Technical (Hospital) Services CEPHALEXIN 250 MG/5 ML ORAL SUSPENSION RX-9502 CDM 6370000100 HCPCS 250 RC 00093-4177-73 NDC inpatient 100 ML 105.5 105.5 BLUE CROSS BLUE SHIELD WELLMARK SB889 [3081026] BCBS WYOMING [308102603] 100.23 percent of total billed charges 65.41 100.23 Technical (Hospital) Services CEPHALEXIN 250 MG/5 ML ORAL SUSPENSION RX-9502 CDM 6370000100 HCPCS 250 RC 00093-4177-73 NDC inpatient 100 ML 105.5 105.5 HEALTHPARTNERS SX009 HEALTHPARTNERS 83.53 percent of total billed charges 65.41 100.23 Technical (Hospital) Services CEPHALEXIN 250 MG/5 ML ORAL SUSPENSION RX-9502 CDM 6370000100 HCPCS 250 RC 00093-4177-73 NDC inpatient 100 ML 105.5 105.5 MULTIPLAN INC 34080 [3081285] MULTIPLAN INC [308128501] 100.23 percent of total billed charges 65.41 100.23 Technical (Hospital) Services CEPHALEXIN 250 MG/5 ML ORAL SUSPENSION RX-9502 CDM 6370000100 HCPCS 250 RC 00093-4177-73 NDC inpatient 100 ML 105.5 105.5 MEDICA (COMMERCIAL) 94265 [3081118] MEDICA CLAIMS [308111801] 94.95 percent of total billed charges 65.41 100.23 Technical (Hospital) Services CEPHALEXIN 250 MG/5 ML ORAL SUSPENSION RX-9502 CDM 6370000100 HCPCS 250 RC 00093-4177-73 NDC inpatient 100 ML 105.5 105.5 CIGNA 62308 [3081051] CIGNA 62308 [308105105] 83.53 percent of total billed charges 65.41 100.23 Technical (Hospital) Services CEPHALEXIN 250 MG/5 ML ORAL SUSPENSION RX-9502 CDM 6370000100 HCPCS 250 RC 00093-4177-73 NDC inpatient 100 ML 105.5 105.5 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES EPO [308136803] 83.53 percent of total billed charges 65.41 100.23 Technical (Hospital) Services CEPHALEXIN 250 MG/5 ML ORAL SUSPENSION RX-9502 CDM 6370000100 HCPCS 250 RC 00093-4177-73 NDC inpatient 100 ML 105.5 105.5 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES HDHP [308136802] 83.53 percent of total billed charges 65.41 100.23 Technical (Hospital) Services CEPHALEXIN 250 MG/5 ML ORAL SUSPENSION RX-9502 CDM 6370000100 HCPCS 250 RC 00093-4177-73 NDC inpatient 100 ML 105.5 105.5 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES PPO [308136801] 83.53 percent of total billed charges 65.41 100.23 Technical (Hospital) Services CEPHALEXIN 250 MG/5 ML ORAL SUSPENSION RX-9502 CDM 6370000100 HCPCS 250 RC 00093-4177-73 NDC inpatient 100 ML 105.5 105.5 CIGNA 62308 [3081051] CIGNA STATE OF WYOMING [308105107] 83.53 percent of total billed charges 65.41 100.23 Technical (Hospital) Services CETIRIZINE 10 MG TABLET RX-9506 CDM 6370000100 HCPCS 250 RC 45802-0919-39 NDC outpatient 1 UN 5.88 5.88 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES PPO [308136801] 4.7 percent of total billed charges 3.65 5.59 Technical (Hospital) Services CETIRIZINE 10 MG TABLET RX-9506 CDM 6370000100 HCPCS 250 RC 45802-0919-39 NDC outpatient 1 UN 5.88 5.88 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES EPO [308136803] 4.7 percent of total billed charges 3.65 5.59 Technical (Hospital) Services CETIRIZINE 10 MG TABLET RX-9506 CDM 6370000100 HCPCS 250 RC 45802-0919-39 NDC outpatient 1 UN 5.88 5.88 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES HDHP [308136802] 4.7 percent of total billed charges 3.65 5.59 Technical (Hospital) Services CETIRIZINE 10 MG TABLET RX-9506 CDM 6370000100 HCPCS 250 RC 45802-0919-39 NDC outpatient 1 UN 5.88 5.88 HEALTHPARTNERS SX009 HEALTHPARTNERS 4.7 percent of total billed charges 3.65 5.59 Technical (Hospital) Services CETIRIZINE 10 MG TABLET RX-9506 CDM 6370000100 HCPCS 250 RC 45802-0919-39 NDC outpatient 1 UN 5.88 5.88 UNITED HEALTHCARE (COMMERCIAL) [3081199] UNITED HEALTHCARE 87726 [308119901] 3.65 percent of total billed charges 3.65 5.59 Technical (Hospital) Services CETIRIZINE 10 MG TABLET RX-9506 CDM 6370000100 HCPCS 250 RC 45802-0919-39 NDC outpatient 1 UN 5.88 5.88 MULTIPLAN INC 34080 [3081285] MULTIPLAN INC [308128501] 5.59 percent of total billed charges 3.65 5.59 Technical (Hospital) Services CETIRIZINE 10 MG TABLET RX-9506 CDM 6370000100 HCPCS 250 RC 45802-0919-39 NDC outpatient 1 UN 5.88 5.88 CIGNA 62308 [3081051] CIGNA 62308 [308105105] 4.7 percent of total billed charges 3.65 5.59 Technical (Hospital) Services CETIRIZINE 10 MG TABLET RX-9506 CDM 6370000100 HCPCS 250 RC 45802-0919-39 NDC outpatient 1 UN 5.88 5.88 CIGNA 62308 [3081051] CIGNA STATE OF WYOMING [308105107] 4.7 percent of total billed charges 3.65 5.59 Technical (Hospital) Services CETIRIZINE 10 MG TABLET RX-9506 CDM 6370000100 HCPCS 250 RC 45802-0919-39 NDC outpatient 1 UN 5.88 5.88 MEDICA (COMMERCIAL) 94265 [3081118] MEDICA CLAIMS [308111801] 5.29 percent of total billed charges 3.65 5.59 Technical (Hospital) Services CETIRIZINE 10 MG TABLET RX-9506 CDM 6370000100 HCPCS 250 RC 45802-0919-39 NDC outpatient 1 UN 5.88 5.88 BLUE CROSS BLUE SHIELD WELLMARK SB889 [3081026] BCBS WYOMING [308102603] 5.59 percent of total billed charges 3.65 5.59 Technical (Hospital) Services CETIRIZINE 10 MG TABLET RX-9506 CDM 6370000100 HCPCS 250 RC 45802-0919-39 NDC inpatient 1 UN 5.88 5.88 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES PPO [308136801] 4.66 percent of total billed charges 3.65 5.59 Technical (Hospital) Services CETIRIZINE 10 MG TABLET RX-9506 CDM 6370000100 HCPCS 250 RC 45802-0919-39 NDC inpatient 1 UN 5.88 5.88 HEALTHPARTNERS SX009 HEALTHPARTNERS 4.66 percent of total billed charges 3.65 5.59 Technical (Hospital) Services CETIRIZINE 10 MG TABLET RX-9506 CDM 6370000100 HCPCS 250 RC 45802-0919-39 NDC inpatient 1 UN 5.88 5.88 MEDICA (COMMERCIAL) 94265 [3081118] MEDICA CLAIMS [308111801] 5.29 percent of total billed charges 3.65 5.59 Technical (Hospital) Services CETIRIZINE 10 MG TABLET RX-9506 CDM 6370000100 HCPCS 250 RC 45802-0919-39 NDC inpatient 1 UN 5.88 5.88 MULTIPLAN INC 34080 [3081285] MULTIPLAN INC [308128501] 5.59 percent of total billed charges 3.65 5.59 Technical (Hospital) Services CETIRIZINE 10 MG TABLET RX-9506 CDM 6370000100 HCPCS 250 RC 45802-0919-39 NDC inpatient 1 UN 5.88 5.88 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES HDHP [308136802] 4.66 percent of total billed charges 3.65 5.59 Technical (Hospital) Services CETIRIZINE 10 MG TABLET RX-9506 CDM 6370000100 HCPCS 250 RC 45802-0919-39 NDC inpatient 1 UN 5.88 5.88 UNITED HEALTHCARE (COMMERCIAL) [3081199] UNITED HEALTHCARE 87726 [308119901] 3.65 percent of total billed charges 3.65 5.59 Technical (Hospital) Services CETIRIZINE 10 MG TABLET RX-9506 CDM 6370000100 HCPCS 250 RC 45802-0919-39 NDC inpatient 1 UN 5.88 5.88 CIGNA 62308 [3081051] CIGNA 62308 [308105105] 4.66 percent of total billed charges 3.65 5.59 Technical (Hospital) Services CETIRIZINE 10 MG TABLET RX-9506 CDM 6370000100 HCPCS 250 RC 45802-0919-39 NDC inpatient 1 UN 5.88 5.88 CIGNA 62308 [3081051] CIGNA STATE OF WYOMING [308105107] 4.66 percent of total billed charges 3.65 5.59 Technical (Hospital) Services CETIRIZINE 10 MG TABLET RX-9506 CDM 6370000100 HCPCS 250 RC 45802-0919-39 NDC inpatient 1 UN 5.88 5.88 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES EPO [308136803] 4.66 percent of total billed charges 3.65 5.59 Technical (Hospital) Services CETIRIZINE 10 MG TABLET RX-9506 CDM 6370000100 HCPCS 250 RC 45802-0919-39 NDC inpatient 1 UN 5.88 5.88 BLUE CROSS BLUE SHIELD WELLMARK SB889 [3081026] BCBS WYOMING [308102603] 5.59 percent of total billed charges 3.65 5.59 Technical (Hospital) Services CHLORHEXIDINE GLUCONATE 0.12 % MOUTHWASH RX-9516 CDM 6370000100 HCPCS 250 RC 00116-2001-16 NDC inpatient 473 ML 23.9 23.9 BLUE CROSS BLUE SHIELD WELLMARK SB889 [3081026] BCBS WYOMING [308102603] 22.71 percent of total billed charges 14.82 22.71 Technical (Hospital) Services CHLORHEXIDINE GLUCONATE 0.12 % MOUTHWASH RX-9516 CDM 6370000100 HCPCS 250 RC 00116-2001-16 NDC inpatient 473 ML 23.9 23.9 UNITED HEALTHCARE (COMMERCIAL) [3081199] UNITED HEALTHCARE 87726 [308119901] 14.82 percent of total billed charges 14.82 22.71 Technical (Hospital) Services CHLORHEXIDINE GLUCONATE 0.12 % MOUTHWASH RX-9516 CDM 6370000100 HCPCS 250 RC 00116-2001-16 NDC inpatient 473 ML 23.9 23.9 HEALTHPARTNERS SX009 HEALTHPARTNERS 18.92 percent of total billed charges 14.82 22.71 Technical (Hospital) Services CHLORHEXIDINE GLUCONATE 0.12 % MOUTHWASH RX-9516 CDM 6370000100 HCPCS 250 RC 00116-2001-16 NDC inpatient 473 ML 23.9 23.9 MULTIPLAN INC 34080 [3081285] MULTIPLAN INC [308128501] 22.71 percent of total billed charges 14.82 22.71 Technical (Hospital) Services CHLORHEXIDINE GLUCONATE 0.12 % MOUTHWASH RX-9516 CDM 6370000100 HCPCS 250 RC 00116-2001-16 NDC inpatient 473 ML 23.9 23.9 MEDICA (COMMERCIAL) 94265 [3081118] MEDICA CLAIMS [308111801] 21.51 percent of total billed charges 14.82 22.71 Technical (Hospital) Services CHLORHEXIDINE GLUCONATE 0.12 % MOUTHWASH RX-9516 CDM 6370000100 HCPCS 250 RC 00116-2001-16 NDC inpatient 473 ML 23.9 23.9 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES HDHP [308136802] 18.92 percent of total billed charges 14.82 22.71 Technical (Hospital) Services CHLORHEXIDINE GLUCONATE 0.12 % MOUTHWASH RX-9516 CDM 6370000100 HCPCS 250 RC 00116-2001-16 NDC inpatient 473 ML 23.9 23.9 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES PPO [308136801] 18.92 percent of total billed charges 14.82 22.71 Technical (Hospital) Services CHLORHEXIDINE GLUCONATE 0.12 % MOUTHWASH RX-9516 CDM 6370000100 HCPCS 250 RC 00116-2001-16 NDC inpatient 473 ML 23.9 23.9 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES EPO [308136803] 18.92 percent of total billed charges 14.82 22.71 Technical (Hospital) Services CHLORHEXIDINE GLUCONATE 0.12 % MOUTHWASH RX-9516 CDM 6370000100 HCPCS 250 RC 00116-2001-16 NDC inpatient 473 ML 23.9 23.9 CIGNA 62308 [3081051] CIGNA 62308 [308105105] 18.92 percent of total billed charges 14.82 22.71 Technical (Hospital) Services CHLORHEXIDINE GLUCONATE 0.12 % MOUTHWASH RX-9516 CDM 6370000100 HCPCS 250 RC 00116-2001-16 NDC inpatient 473 ML 23.9 23.9 CIGNA 62308 [3081051] CIGNA STATE OF WYOMING [308105107] 18.92 percent of total billed charges 14.82 22.71 Technical (Hospital) Services CHLORHEXIDINE GLUCONATE 0.12 % MOUTHWASH RX-9516 CDM 6370000100 HCPCS 250 RC 00116-2001-16 NDC outpatient 473 ML 23.9 23.9 UNITED HEALTHCARE (COMMERCIAL) [3081199] UNITED HEALTHCARE 87726 [308119901] 14.82 percent of total billed charges 14.82 22.71 Technical (Hospital) Services CHLORHEXIDINE GLUCONATE 0.12 % MOUTHWASH RX-9516 CDM 6370000100 HCPCS 250 RC 00116-2001-16 NDC outpatient 473 ML 23.9 23.9 BLUE CROSS BLUE SHIELD WELLMARK SB889 [3081026] BCBS WYOMING [308102603] 22.71 percent of total billed charges 14.82 22.71 Technical (Hospital) Services CHLORHEXIDINE GLUCONATE 0.12 % MOUTHWASH RX-9516 CDM 6370000100 HCPCS 250 RC 00116-2001-16 NDC outpatient 473 ML 23.9 23.9 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES EPO [308136803] 19.12 percent of total billed charges 14.82 22.71 Technical (Hospital) Services CHLORHEXIDINE GLUCONATE 0.12 % MOUTHWASH RX-9516 CDM 6370000100 HCPCS 250 RC 00116-2001-16 NDC outpatient 473 ML 23.9 23.9 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES HDHP [308136802] 19.12 percent of total billed charges 14.82 22.71 Technical (Hospital) Services CHLORHEXIDINE GLUCONATE 0.12 % MOUTHWASH RX-9516 CDM 6370000100 HCPCS 250 RC 00116-2001-16 NDC outpatient 473 ML 23.9 23.9 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES PPO [308136801] 19.12 percent of total billed charges 14.82 22.71 Technical (Hospital) Services CHLORHEXIDINE GLUCONATE 0.12 % MOUTHWASH RX-9516 CDM 6370000100 HCPCS 250 RC 00116-2001-16 NDC outpatient 473 ML 23.9 23.9 HEALTHPARTNERS SX009 HEALTHPARTNERS 19.12 percent of total billed charges 14.82 22.71 Technical (Hospital) Services CHLORHEXIDINE GLUCONATE 0.12 % MOUTHWASH RX-9516 CDM 6370000100 HCPCS 250 RC 00116-2001-16 NDC outpatient 473 ML 23.9 23.9 MULTIPLAN INC 34080 [3081285] MULTIPLAN INC [308128501] 22.71 percent of total billed charges 14.82 22.71 Technical (Hospital) Services CHLORHEXIDINE GLUCONATE 0.12 % MOUTHWASH RX-9516 CDM 6370000100 HCPCS 250 RC 00116-2001-16 NDC outpatient 473 ML 23.9 23.9 MEDICA (COMMERCIAL) 94265 [3081118] MEDICA CLAIMS [308111801] 21.51 percent of total billed charges 14.82 22.71 Technical (Hospital) Services CHLORHEXIDINE GLUCONATE 0.12 % MOUTHWASH RX-9516 CDM 6370000100 HCPCS 250 RC 00116-2001-16 NDC outpatient 473 ML 23.9 23.9 CIGNA 62308 [3081051] CIGNA 62308 [308105105] 19.12 percent of total billed charges 14.82 22.71 Technical (Hospital) Services CHLORHEXIDINE GLUCONATE 0.12 % MOUTHWASH RX-9516 CDM 6370000100 HCPCS 250 RC 00116-2001-16 NDC outpatient 473 ML 23.9 23.9 CIGNA 62308 [3081051] CIGNA STATE OF WYOMING [308105107] 19.12 percent of total billed charges 14.82 22.71 Technical (Hospital) Services "QUETIAPINE ER 150 MG TABLET,EXTENDED RELEASE 24 HR" RX-96233 CDM 6370000100 HCPCS 250 RC 00310-0281-60 NDC outpatient 1 UN 53.75 53.75 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES EPO [308136803] 43 percent of total billed charges 33.33 51.06 Technical (Hospital) Services "QUETIAPINE ER 150 MG TABLET,EXTENDED RELEASE 24 HR" RX-96233 CDM 6370000100 HCPCS 250 RC 00310-0281-60 NDC outpatient 1 UN 53.75 53.75 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES PPO [308136801] 43 percent of total billed charges 33.33 51.06 Technical (Hospital) Services "QUETIAPINE ER 150 MG TABLET,EXTENDED RELEASE 24 HR" RX-96233 CDM 6370000100 HCPCS 250 RC 00310-0281-60 NDC outpatient 1 UN 53.75 53.75 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES HDHP [308136802] 43 percent of total billed charges 33.33 51.06 Technical (Hospital) Services "QUETIAPINE ER 150 MG TABLET,EXTENDED RELEASE 24 HR" RX-96233 CDM 6370000100 HCPCS 250 RC 00310-0281-60 NDC outpatient 1 UN 53.75 53.75 MEDICA (COMMERCIAL) 94265 [3081118] MEDICA CLAIMS [308111801] 48.38 percent of total billed charges 33.33 51.06 Technical (Hospital) Services "QUETIAPINE ER 150 MG TABLET,EXTENDED RELEASE 24 HR" RX-96233 CDM 6370000100 HCPCS 250 RC 00310-0281-60 NDC outpatient 1 UN 53.75 53.75 MULTIPLAN INC 34080 [3081285] MULTIPLAN INC [308128501] 51.06 percent of total billed charges 33.33 51.06 Technical (Hospital) Services "QUETIAPINE ER 150 MG TABLET,EXTENDED RELEASE 24 HR" RX-96233 CDM 6370000100 HCPCS 250 RC 00310-0281-60 NDC outpatient 1 UN 53.75 53.75 CIGNA 62308 [3081051] CIGNA 62308 [308105105] 43 percent of total billed charges 33.33 51.06 Technical (Hospital) Services "QUETIAPINE ER 150 MG TABLET,EXTENDED RELEASE 24 HR" RX-96233 CDM 6370000100 HCPCS 250 RC 00310-0281-60 NDC outpatient 1 UN 53.75 53.75 CIGNA 62308 [3081051] CIGNA STATE OF WYOMING [308105107] 43 percent of total billed charges 33.33 51.06 Technical (Hospital) Services "QUETIAPINE ER 150 MG TABLET,EXTENDED RELEASE 24 HR" RX-96233 CDM 6370000100 HCPCS 250 RC 00310-0281-60 NDC outpatient 1 UN 53.75 53.75 UNITED HEALTHCARE (COMMERCIAL) [3081199] UNITED HEALTHCARE 87726 [308119901] 33.33 percent of total billed charges 33.33 51.06 Technical (Hospital) Services "QUETIAPINE ER 150 MG TABLET,EXTENDED RELEASE 24 HR" RX-96233 CDM 6370000100 HCPCS 250 RC 00310-0281-60 NDC outpatient 1 UN 53.75 53.75 HEALTHPARTNERS SX009 HEALTHPARTNERS 43 percent of total billed charges 33.33 51.06 Technical (Hospital) Services "QUETIAPINE ER 150 MG TABLET,EXTENDED RELEASE 24 HR" RX-96233 CDM 6370000100 HCPCS 250 RC 00310-0281-60 NDC outpatient 1 UN 53.75 53.75 BLUE CROSS BLUE SHIELD WELLMARK SB889 [3081026] BCBS WYOMING [308102603] 51.06 percent of total billed charges 33.33 51.06 Technical (Hospital) Services "QUETIAPINE ER 150 MG TABLET,EXTENDED RELEASE 24 HR" RX-96233 CDM 6370000100 HCPCS 250 RC 00310-0281-60 NDC inpatient 1 UN 53.75 53.75 MULTIPLAN INC 34080 [3081285] MULTIPLAN INC [308128501] 51.06 percent of total billed charges 33.33 51.06 Technical (Hospital) Services "QUETIAPINE ER 150 MG TABLET,EXTENDED RELEASE 24 HR" RX-96233 CDM 6370000100 HCPCS 250 RC 00310-0281-60 NDC inpatient 1 UN 53.75 53.75 BLUE CROSS BLUE SHIELD WELLMARK SB889 [3081026] BCBS WYOMING [308102603] 51.06 percent of total billed charges 33.33 51.06 Technical (Hospital) Services "QUETIAPINE ER 150 MG TABLET,EXTENDED RELEASE 24 HR" RX-96233 CDM 6370000100 HCPCS 250 RC 00310-0281-60 NDC inpatient 1 UN 53.75 53.75 UNITED HEALTHCARE (COMMERCIAL) [3081199] UNITED HEALTHCARE 87726 [308119901] 33.33 percent of total billed charges 33.33 51.06 Technical (Hospital) Services "QUETIAPINE ER 150 MG TABLET,EXTENDED RELEASE 24 HR" RX-96233 CDM 6370000100 HCPCS 250 RC 00310-0281-60 NDC inpatient 1 UN 53.75 53.75 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES HDHP [308136802] 42.56 percent of total billed charges 33.33 51.06 Technical (Hospital) Services "QUETIAPINE ER 150 MG TABLET,EXTENDED RELEASE 24 HR" RX-96233 CDM 6370000100 HCPCS 250 RC 00310-0281-60 NDC inpatient 1 UN 53.75 53.75 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES EPO [308136803] 42.56 percent of total billed charges 33.33 51.06 Technical (Hospital) Services "QUETIAPINE ER 150 MG TABLET,EXTENDED RELEASE 24 HR" RX-96233 CDM 6370000100 HCPCS 250 RC 00310-0281-60 NDC inpatient 1 UN 53.75 53.75 CIGNA 62308 [3081051] CIGNA 62308 [308105105] 42.56 percent of total billed charges 33.33 51.06 Technical (Hospital) Services "QUETIAPINE ER 150 MG TABLET,EXTENDED RELEASE 24 HR" RX-96233 CDM 6370000100 HCPCS 250 RC 00310-0281-60 NDC inpatient 1 UN 53.75 53.75 CIGNA 62308 [3081051] CIGNA STATE OF WYOMING [308105107] 42.56 percent of total billed charges 33.33 51.06 Technical (Hospital) Services "QUETIAPINE ER 150 MG TABLET,EXTENDED RELEASE 24 HR" RX-96233 CDM 6370000100 HCPCS 250 RC 00310-0281-60 NDC inpatient 1 UN 53.75 53.75 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES PPO [308136801] 42.56 percent of total billed charges 33.33 51.06 Technical (Hospital) Services "QUETIAPINE ER 150 MG TABLET,EXTENDED RELEASE 24 HR" RX-96233 CDM 6370000100 HCPCS 250 RC 00310-0281-60 NDC inpatient 1 UN 53.75 53.75 MEDICA (COMMERCIAL) 94265 [3081118] MEDICA CLAIMS [308111801] 48.38 percent of total billed charges 33.33 51.06 Technical (Hospital) Services "QUETIAPINE ER 150 MG TABLET,EXTENDED RELEASE 24 HR" RX-96233 CDM 6370000100 HCPCS 250 RC 00310-0281-60 NDC inpatient 1 UN 53.75 53.75 HEALTHPARTNERS SX009 HEALTHPARTNERS 42.56 percent of total billed charges 33.33 51.06 Technical (Hospital) Services CLOBETASOL 0.05 % TOPICAL CREAM RX-9630 CDM 6370000100 HCPCS 250 RC 51672-1258-02 NDC outpatient 1 GR 6.29 6.29 BLUE CROSS BLUE SHIELD WELLMARK SB889 [3081026] BCBS WYOMING [308102603] 5.98 percent of total billed charges 3.9 5.98 Technical (Hospital) Services CLOBETASOL 0.05 % TOPICAL CREAM RX-9630 CDM 6370000100 HCPCS 250 RC 51672-1258-02 NDC outpatient 1 GR 6.29 6.29 MULTIPLAN INC 34080 [3081285] MULTIPLAN INC [308128501] 5.98 percent of total billed charges 3.9 5.98 Technical (Hospital) Services CLOBETASOL 0.05 % TOPICAL CREAM RX-9630 CDM 6370000100 HCPCS 250 RC 51672-1258-02 NDC outpatient 1 GR 6.29 6.29 CIGNA 62308 [3081051] CIGNA 62308 [308105105] 5.03 percent of total billed charges 3.9 5.98 Technical (Hospital) Services CLOBETASOL 0.05 % TOPICAL CREAM RX-9630 CDM 6370000100 HCPCS 250 RC 51672-1258-02 NDC outpatient 1 GR 6.29 6.29 CIGNA 62308 [3081051] CIGNA STATE OF WYOMING [308105107] 5.03 percent of total billed charges 3.9 5.98 Technical (Hospital) Services CLOBETASOL 0.05 % TOPICAL CREAM RX-9630 CDM 6370000100 HCPCS 250 RC 51672-1258-02 NDC outpatient 1 GR 6.29 6.29 HEALTHPARTNERS SX009 HEALTHPARTNERS 5.03 percent of total billed charges 3.9 5.98 Technical (Hospital) Services CLOBETASOL 0.05 % TOPICAL CREAM RX-9630 CDM 6370000100 HCPCS 250 RC 51672-1258-02 NDC outpatient 1 GR 6.29 6.29 UNITED HEALTHCARE (COMMERCIAL) [3081199] UNITED HEALTHCARE 87726 [308119901] 3.9 percent of total billed charges 3.9 5.98 Technical (Hospital) Services CLOBETASOL 0.05 % TOPICAL CREAM RX-9630 CDM 6370000100 HCPCS 250 RC 51672-1258-02 NDC outpatient 1 GR 6.29 6.29 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES EPO [308136803] 5.03 percent of total billed charges 3.9 5.98 Technical (Hospital) Services CLOBETASOL 0.05 % TOPICAL CREAM RX-9630 CDM 6370000100 HCPCS 250 RC 51672-1258-02 NDC outpatient 1 GR 6.29 6.29 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES HDHP [308136802] 5.03 percent of total billed charges 3.9 5.98 Technical (Hospital) Services CLOBETASOL 0.05 % TOPICAL CREAM RX-9630 CDM 6370000100 HCPCS 250 RC 51672-1258-02 NDC outpatient 1 GR 6.29 6.29 MEDICA (COMMERCIAL) 94265 [3081118] MEDICA CLAIMS [308111801] 5.66 percent of total billed charges 3.9 5.98 Technical (Hospital) Services CLOBETASOL 0.05 % TOPICAL CREAM RX-9630 CDM 6370000100 HCPCS 250 RC 51672-1258-02 NDC outpatient 1 GR 6.29 6.29 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES PPO [308136801] 5.03 percent of total billed charges 3.9 5.98 Technical (Hospital) Services CLOBETASOL 0.05 % TOPICAL CREAM RX-9630 CDM 6370000100 HCPCS 250 RC 51672-1258-02 NDC inpatient 1 GR 6.29 6.29 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES PPO [308136801] 4.98 percent of total billed charges 3.9 5.98 Technical (Hospital) Services CLOBETASOL 0.05 % TOPICAL CREAM RX-9630 CDM 6370000100 HCPCS 250 RC 51672-1258-02 NDC inpatient 1 GR 6.29 6.29 HEALTHPARTNERS SX009 HEALTHPARTNERS 4.98 percent of total billed charges 3.9 5.98 Technical (Hospital) Services CLOBETASOL 0.05 % TOPICAL CREAM RX-9630 CDM 6370000100 HCPCS 250 RC 51672-1258-02 NDC inpatient 1 GR 6.29 6.29 MEDICA (COMMERCIAL) 94265 [3081118] MEDICA CLAIMS [308111801] 5.66 percent of total billed charges 3.9 5.98 Technical (Hospital) Services CLOBETASOL 0.05 % TOPICAL CREAM RX-9630 CDM 6370000100 HCPCS 250 RC 51672-1258-02 NDC inpatient 1 GR 6.29 6.29 MULTIPLAN INC 34080 [3081285] MULTIPLAN INC [308128501] 5.98 percent of total billed charges 3.9 5.98 Technical (Hospital) Services CLOBETASOL 0.05 % TOPICAL CREAM RX-9630 CDM 6370000100 HCPCS 250 RC 51672-1258-02 NDC inpatient 1 GR 6.29 6.29 BLUE CROSS BLUE SHIELD WELLMARK SB889 [3081026] BCBS WYOMING [308102603] 5.98 percent of total billed charges 3.9 5.98 Technical (Hospital) Services CLOBETASOL 0.05 % TOPICAL CREAM RX-9630 CDM 6370000100 HCPCS 250 RC 51672-1258-02 NDC inpatient 1 GR 6.29 6.29 UNITED HEALTHCARE (COMMERCIAL) [3081199] UNITED HEALTHCARE 87726 [308119901] 3.9 percent of total billed charges 3.9 5.98 Technical (Hospital) Services CLOBETASOL 0.05 % TOPICAL CREAM RX-9630 CDM 6370000100 HCPCS 250 RC 51672-1258-02 NDC inpatient 1 GR 6.29 6.29 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES HDHP [308136802] 4.98 percent of total billed charges 3.9 5.98 Technical (Hospital) Services CLOBETASOL 0.05 % TOPICAL CREAM RX-9630 CDM 6370000100 HCPCS 250 RC 51672-1258-02 NDC inpatient 1 GR 6.29 6.29 CIGNA 62308 [3081051] CIGNA 62308 [308105105] 4.98 percent of total billed charges 3.9 5.98 Technical (Hospital) Services CLOBETASOL 0.05 % TOPICAL CREAM RX-9630 CDM 6370000100 HCPCS 250 RC 51672-1258-02 NDC inpatient 1 GR 6.29 6.29 CIGNA 62308 [3081051] CIGNA STATE OF WYOMING [308105107] 4.98 percent of total billed charges 3.9 5.98 Technical (Hospital) Services CLOBETASOL 0.05 % TOPICAL CREAM RX-9630 CDM 6370000100 HCPCS 250 RC 51672-1258-02 NDC inpatient 1 GR 6.29 6.29 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES EPO [308136803] 4.98 percent of total billed charges 3.9 5.98 Technical (Hospital) Services CLONAZEPAM 0.5 MG TABLET RX-9637 CDM 6370000100 HCPCS 250 RC 16729-0136-16 NDC inpatient 1 UN 5.66 5.66 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES PPO [308136801] 4.48 percent of total billed charges 3.51 5.38 Technical (Hospital) Services CLONAZEPAM 0.5 MG TABLET RX-9637 CDM 6370000100 HCPCS 250 RC 16729-0136-16 NDC inpatient 1 UN 5.66 5.66 MEDICA (COMMERCIAL) 94265 [3081118] MEDICA CLAIMS [308111801] 5.09 percent of total billed charges 3.51 5.38 Technical (Hospital) Services CLONAZEPAM 0.5 MG TABLET RX-9637 CDM 6370000100 HCPCS 250 RC 16729-0136-16 NDC inpatient 1 UN 5.66 5.66 UNITED HEALTHCARE (COMMERCIAL) [3081199] UNITED HEALTHCARE 87726 [308119901] 3.51 percent of total billed charges 3.51 5.38 Technical (Hospital) Services CLONAZEPAM 0.5 MG TABLET RX-9637 CDM 6370000100 HCPCS 250 RC 16729-0136-16 NDC inpatient 1 UN 5.66 5.66 CIGNA 62308 [3081051] CIGNA 62308 [308105105] 4.48 percent of total billed charges 3.51 5.38 Technical (Hospital) Services CLONAZEPAM 0.5 MG TABLET RX-9637 CDM 6370000100 HCPCS 250 RC 16729-0136-16 NDC inpatient 1 UN 5.66 5.66 CIGNA 62308 [3081051] CIGNA STATE OF WYOMING [308105107] 4.48 percent of total billed charges 3.51 5.38 Technical (Hospital) Services CLONAZEPAM 0.5 MG TABLET RX-9637 CDM 6370000100 HCPCS 250 RC 16729-0136-16 NDC inpatient 1 UN 5.66 5.66 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES EPO [308136803] 4.48 percent of total billed charges 3.51 5.38 Technical (Hospital) Services CLONAZEPAM 0.5 MG TABLET RX-9637 CDM 6370000100 HCPCS 250 RC 16729-0136-16 NDC inpatient 1 UN 5.66 5.66 BLUE CROSS BLUE SHIELD WELLMARK SB889 [3081026] BCBS WYOMING [308102603] 5.38 percent of total billed charges 3.51 5.38 Technical (Hospital) Services CLONAZEPAM 0.5 MG TABLET RX-9637 CDM 6370000100 HCPCS 250 RC 16729-0136-16 NDC inpatient 1 UN 5.66 5.66 HEALTHPARTNERS SX009 HEALTHPARTNERS 4.48 percent of total billed charges 3.51 5.38 Technical (Hospital) Services CLONAZEPAM 0.5 MG TABLET RX-9637 CDM 6370000100 HCPCS 250 RC 16729-0136-16 NDC inpatient 1 UN 5.66 5.66 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES HDHP [308136802] 4.48 percent of total billed charges 3.51 5.38 Technical (Hospital) Services CLONAZEPAM 0.5 MG TABLET RX-9637 CDM 6370000100 HCPCS 250 RC 16729-0136-16 NDC inpatient 1 UN 5.66 5.66 MULTIPLAN INC 34080 [3081285] MULTIPLAN INC [308128501] 5.38 percent of total billed charges 3.51 5.38 Technical (Hospital) Services CLONAZEPAM 0.5 MG TABLET RX-9637 CDM 6370000100 HCPCS 250 RC 16729-0136-16 NDC outpatient 1 UN 5.66 5.66 MULTIPLAN INC 34080 [3081285] MULTIPLAN INC [308128501] 5.38 percent of total billed charges 3.51 5.38 Technical (Hospital) Services CLONAZEPAM 0.5 MG TABLET RX-9637 CDM 6370000100 HCPCS 250 RC 16729-0136-16 NDC outpatient 1 UN 5.66 5.66 CIGNA 62308 [3081051] CIGNA 62308 [308105105] 4.53 percent of total billed charges 3.51 5.38 Technical (Hospital) Services CLONAZEPAM 0.5 MG TABLET RX-9637 CDM 6370000100 HCPCS 250 RC 16729-0136-16 NDC outpatient 1 UN 5.66 5.66 CIGNA 62308 [3081051] CIGNA STATE OF WYOMING [308105107] 4.53 percent of total billed charges 3.51 5.38 Technical (Hospital) Services CLONAZEPAM 0.5 MG TABLET RX-9637 CDM 6370000100 HCPCS 250 RC 16729-0136-16 NDC outpatient 1 UN 5.66 5.66 MEDICA (COMMERCIAL) 94265 [3081118] MEDICA CLAIMS [308111801] 5.09 percent of total billed charges 3.51 5.38 Technical (Hospital) Services CLONAZEPAM 0.5 MG TABLET RX-9637 CDM 6370000100 HCPCS 250 RC 16729-0136-16 NDC outpatient 1 UN 5.66 5.66 UNITED HEALTHCARE (COMMERCIAL) [3081199] UNITED HEALTHCARE 87726 [308119901] 3.51 percent of total billed charges 3.51 5.38 Technical (Hospital) Services CLONAZEPAM 0.5 MG TABLET RX-9637 CDM 6370000100 HCPCS 250 RC 16729-0136-16 NDC outpatient 1 UN 5.66 5.66 HEALTHPARTNERS SX009 HEALTHPARTNERS 4.53 percent of total billed charges 3.51 5.38 Technical (Hospital) Services CLONAZEPAM 0.5 MG TABLET RX-9637 CDM 6370000100 HCPCS 250 RC 16729-0136-16 NDC outpatient 1 UN 5.66 5.66 BLUE CROSS BLUE SHIELD WELLMARK SB889 [3081026] BCBS WYOMING [308102603] 5.38 percent of total billed charges 3.51 5.38 Technical (Hospital) Services CLONAZEPAM 0.5 MG TABLET RX-9637 CDM 6370000100 HCPCS 250 RC 16729-0136-16 NDC outpatient 1 UN 5.66 5.66 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES HDHP [308136802] 4.53 percent of total billed charges 3.51 5.38 Technical (Hospital) Services CLONAZEPAM 0.5 MG TABLET RX-9637 CDM 6370000100 HCPCS 250 RC 16729-0136-16 NDC outpatient 1 UN 5.66 5.66 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES PPO [308136801] 4.53 percent of total billed charges 3.51 5.38 Technical (Hospital) Services CLONAZEPAM 0.5 MG TABLET RX-9637 CDM 6370000100 HCPCS 250 RC 16729-0136-16 NDC outpatient 1 UN 5.66 5.66 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES EPO [308136803] 4.53 percent of total billed charges 3.51 5.38 Technical (Hospital) Services CLOTRIMAZOLE 10 MG TROCHE RX-9644 CDM 6370000100 HCPCS 250 RC 00054-4146-22 NDC inpatient 1 UN 7.6 7.6 MULTIPLAN INC 34080 [3081285] MULTIPLAN INC [308128501] 7.22 percent of total billed charges 4.71 7.22 Technical (Hospital) Services CLOTRIMAZOLE 10 MG TROCHE RX-9644 CDM 6370000100 HCPCS 250 RC 00054-4146-22 NDC inpatient 1 UN 7.6 7.6 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES HDHP [308136802] 6.02 percent of total billed charges 4.71 7.22 Technical (Hospital) Services CLOTRIMAZOLE 10 MG TROCHE RX-9644 CDM 6370000100 HCPCS 250 RC 00054-4146-22 NDC inpatient 1 UN 7.6 7.6 HEALTHPARTNERS SX009 HEALTHPARTNERS 6.02 percent of total billed charges 4.71 7.22 Technical (Hospital) Services CLOTRIMAZOLE 10 MG TROCHE RX-9644 CDM 6370000100 HCPCS 250 RC 00054-4146-22 NDC inpatient 1 UN 7.6 7.6 BLUE CROSS BLUE SHIELD WELLMARK SB889 [3081026] BCBS WYOMING [308102603] 7.22 percent of total billed charges 4.71 7.22 Technical (Hospital) Services CLOTRIMAZOLE 10 MG TROCHE RX-9644 CDM 6370000100 HCPCS 250 RC 00054-4146-22 NDC inpatient 1 UN 7.6 7.6 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES EPO [308136803] 6.02 percent of total billed charges 4.71 7.22 Technical (Hospital) Services CLOTRIMAZOLE 10 MG TROCHE RX-9644 CDM 6370000100 HCPCS 250 RC 00054-4146-22 NDC inpatient 1 UN 7.6 7.6 CIGNA 62308 [3081051] CIGNA 62308 [308105105] 6.02 percent of total billed charges 4.71 7.22 Technical (Hospital) Services CLOTRIMAZOLE 10 MG TROCHE RX-9644 CDM 6370000100 HCPCS 250 RC 00054-4146-22 NDC inpatient 1 UN 7.6 7.6 CIGNA 62308 [3081051] CIGNA STATE OF WYOMING [308105107] 6.02 percent of total billed charges 4.71 7.22 Technical (Hospital) Services CLOTRIMAZOLE 10 MG TROCHE RX-9644 CDM 6370000100 HCPCS 250 RC 00054-4146-22 NDC inpatient 1 UN 7.6 7.6 UNITED HEALTHCARE (COMMERCIAL) [3081199] UNITED HEALTHCARE 87726 [308119901] 4.71 percent of total billed charges 4.71 7.22 Technical (Hospital) Services CLOTRIMAZOLE 10 MG TROCHE RX-9644 CDM 6370000100 HCPCS 250 RC 00054-4146-22 NDC inpatient 1 UN 7.6 7.6 MEDICA (COMMERCIAL) 94265 [3081118] MEDICA CLAIMS [308111801] 6.84 percent of total billed charges 4.71 7.22 Technical (Hospital) Services CLOTRIMAZOLE 10 MG TROCHE RX-9644 CDM 6370000100 HCPCS 250 RC 00054-4146-22 NDC inpatient 1 UN 7.6 7.6 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES PPO [308136801] 6.02 percent of total billed charges 4.71 7.22 Technical (Hospital) Services CLOTRIMAZOLE 10 MG TROCHE RX-9644 CDM 6370000100 HCPCS 250 RC 00054-4146-22 NDC outpatient 1 UN 7.6 7.6 BLUE CROSS BLUE SHIELD WELLMARK SB889 [3081026] BCBS WYOMING [308102603] 7.22 percent of total billed charges 4.71 7.22 Technical (Hospital) Services CLOTRIMAZOLE 10 MG TROCHE RX-9644 CDM 6370000100 HCPCS 250 RC 00054-4146-22 NDC outpatient 1 UN 7.6 7.6 MULTIPLAN INC 34080 [3081285] MULTIPLAN INC [308128501] 7.22 percent of total billed charges 4.71 7.22 Technical (Hospital) Services CLOTRIMAZOLE 10 MG TROCHE RX-9644 CDM 6370000100 HCPCS 250 RC 00054-4146-22 NDC outpatient 1 UN 7.6 7.6 CIGNA 62308 [3081051] CIGNA 62308 [308105105] 6.08 percent of total billed charges 4.71 7.22 Technical (Hospital) Services CLOTRIMAZOLE 10 MG TROCHE RX-9644 CDM 6370000100 HCPCS 250 RC 00054-4146-22 NDC outpatient 1 UN 7.6 7.6 CIGNA 62308 [3081051] CIGNA STATE OF WYOMING [308105107] 6.08 percent of total billed charges 4.71 7.22 Technical (Hospital) Services CLOTRIMAZOLE 10 MG TROCHE RX-9644 CDM 6370000100 HCPCS 250 RC 00054-4146-22 NDC outpatient 1 UN 7.6 7.6 HEALTHPARTNERS SX009 HEALTHPARTNERS 6.08 percent of total billed charges 4.71 7.22 Technical (Hospital) Services CLOTRIMAZOLE 10 MG TROCHE RX-9644 CDM 6370000100 HCPCS 250 RC 00054-4146-22 NDC outpatient 1 UN 7.6 7.6 UNITED HEALTHCARE (COMMERCIAL) [3081199] UNITED HEALTHCARE 87726 [308119901] 4.71 percent of total billed charges 4.71 7.22 Technical (Hospital) Services CLOTRIMAZOLE 10 MG TROCHE RX-9644 CDM 6370000100 HCPCS 250 RC 00054-4146-22 NDC outpatient 1 UN 7.6 7.6 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES HDHP [308136802] 6.08 percent of total billed charges 4.71 7.22 Technical (Hospital) Services CLOTRIMAZOLE 10 MG TROCHE RX-9644 CDM 6370000100 HCPCS 250 RC 00054-4146-22 NDC outpatient 1 UN 7.6 7.6 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES EPO [308136803] 6.08 percent of total billed charges 4.71 7.22 Technical (Hospital) Services CLOTRIMAZOLE 10 MG TROCHE RX-9644 CDM 6370000100 HCPCS 250 RC 00054-4146-22 NDC outpatient 1 UN 7.6 7.6 MEDICA (COMMERCIAL) 94265 [3081118] MEDICA CLAIMS [308111801] 6.84 percent of total billed charges 4.71 7.22 Technical (Hospital) Services CLOTRIMAZOLE 10 MG TROCHE RX-9644 CDM 6370000100 HCPCS 250 RC 00054-4146-22 NDC outpatient 1 UN 7.6 7.6 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES PPO [308136801] 6.08 percent of total billed charges 4.71 7.22 Technical (Hospital) Services COLLAGENASE CLOSTRIDIUM HISTOLYTICUM 250 UNIT/GRAM TOPICAL OINTMENT RX-9682 CDM 6370000100 HCPCS 250 RC 50484-0010-30 NDC inpatient 1 GR 38.48 38.48 BLUE CROSS BLUE SHIELD WELLMARK SB889 [3081026] BCBS WYOMING [308102603] 36.56 percent of total billed charges 23.86 36.56 Technical (Hospital) Services COLLAGENASE CLOSTRIDIUM HISTOLYTICUM 250 UNIT/GRAM TOPICAL OINTMENT RX-9682 CDM 6370000100 HCPCS 250 RC 50484-0010-30 NDC inpatient 1 GR 38.48 38.48 UNITED HEALTHCARE (COMMERCIAL) [3081199] UNITED HEALTHCARE 87726 [308119901] 23.86 percent of total billed charges 23.86 36.56 Technical (Hospital) Services COLLAGENASE CLOSTRIDIUM HISTOLYTICUM 250 UNIT/GRAM TOPICAL OINTMENT RX-9682 CDM 6370000100 HCPCS 250 RC 50484-0010-30 NDC inpatient 1 GR 38.48 38.48 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES EPO [308136803] 30.47 percent of total billed charges 23.86 36.56 Technical (Hospital) Services COLLAGENASE CLOSTRIDIUM HISTOLYTICUM 250 UNIT/GRAM TOPICAL OINTMENT RX-9682 CDM 6370000100 HCPCS 250 RC 50484-0010-30 NDC inpatient 1 GR 38.48 38.48 CIGNA 62308 [3081051] CIGNA 62308 [308105105] 30.47 percent of total billed charges 23.86 36.56 Technical (Hospital) Services COLLAGENASE CLOSTRIDIUM HISTOLYTICUM 250 UNIT/GRAM TOPICAL OINTMENT RX-9682 CDM 6370000100 HCPCS 250 RC 50484-0010-30 NDC inpatient 1 GR 38.48 38.48 CIGNA 62308 [3081051] CIGNA STATE OF WYOMING [308105107] 30.47 percent of total billed charges 23.86 36.56 Technical (Hospital) Services COLLAGENASE CLOSTRIDIUM HISTOLYTICUM 250 UNIT/GRAM TOPICAL OINTMENT RX-9682 CDM 6370000100 HCPCS 250 RC 50484-0010-30 NDC inpatient 1 GR 38.48 38.48 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES HDHP [308136802] 30.47 percent of total billed charges 23.86 36.56 Technical (Hospital) Services COLLAGENASE CLOSTRIDIUM HISTOLYTICUM 250 UNIT/GRAM TOPICAL OINTMENT RX-9682 CDM 6370000100 HCPCS 250 RC 50484-0010-30 NDC inpatient 1 GR 38.48 38.48 MULTIPLAN INC 34080 [3081285] MULTIPLAN INC [308128501] 36.56 percent of total billed charges 23.86 36.56 Technical (Hospital) Services COLLAGENASE CLOSTRIDIUM HISTOLYTICUM 250 UNIT/GRAM TOPICAL OINTMENT RX-9682 CDM 6370000100 HCPCS 250 RC 50484-0010-30 NDC inpatient 1 GR 38.48 38.48 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES PPO [308136801] 30.47 percent of total billed charges 23.86 36.56 Technical (Hospital) Services COLLAGENASE CLOSTRIDIUM HISTOLYTICUM 250 UNIT/GRAM TOPICAL OINTMENT RX-9682 CDM 6370000100 HCPCS 250 RC 50484-0010-30 NDC inpatient 1 GR 38.48 38.48 MEDICA (COMMERCIAL) 94265 [3081118] MEDICA CLAIMS [308111801] 34.63 percent of total billed charges 23.86 36.56 Technical (Hospital) Services COLLAGENASE CLOSTRIDIUM HISTOLYTICUM 250 UNIT/GRAM TOPICAL OINTMENT RX-9682 CDM 6370000100 HCPCS 250 RC 50484-0010-30 NDC inpatient 1 GR 38.48 38.48 HEALTHPARTNERS SX009 HEALTHPARTNERS 30.47 percent of total billed charges 23.86 36.56 Technical (Hospital) Services COLLAGENASE CLOSTRIDIUM HISTOLYTICUM 250 UNIT/GRAM TOPICAL OINTMENT RX-9682 CDM 6370000100 HCPCS 250 RC 50484-0010-30 NDC outpatient 1 GR 38.48 38.48 BLUE CROSS BLUE SHIELD WELLMARK SB889 [3081026] BCBS WYOMING [308102603] 36.56 percent of total billed charges 23.86 36.56 Technical (Hospital) Services COLLAGENASE CLOSTRIDIUM HISTOLYTICUM 250 UNIT/GRAM TOPICAL OINTMENT RX-9682 CDM 6370000100 HCPCS 250 RC 50484-0010-30 NDC outpatient 1 GR 38.48 38.48 UNITED HEALTHCARE (COMMERCIAL) [3081199] UNITED HEALTHCARE 87726 [308119901] 23.86 percent of total billed charges 23.86 36.56 Technical (Hospital) Services COLLAGENASE CLOSTRIDIUM HISTOLYTICUM 250 UNIT/GRAM TOPICAL OINTMENT RX-9682 CDM 6370000100 HCPCS 250 RC 50484-0010-30 NDC outpatient 1 GR 38.48 38.48 HEALTHPARTNERS SX009 HEALTHPARTNERS 30.78 percent of total billed charges 23.86 36.56 Technical (Hospital) Services COLLAGENASE CLOSTRIDIUM HISTOLYTICUM 250 UNIT/GRAM TOPICAL OINTMENT RX-9682 CDM 6370000100 HCPCS 250 RC 50484-0010-30 NDC outpatient 1 GR 38.48 38.48 MEDICA (COMMERCIAL) 94265 [3081118] MEDICA CLAIMS [308111801] 34.63 percent of total billed charges 23.86 36.56 Technical (Hospital) Services COLLAGENASE CLOSTRIDIUM HISTOLYTICUM 250 UNIT/GRAM TOPICAL OINTMENT RX-9682 CDM 6370000100 HCPCS 250 RC 50484-0010-30 NDC outpatient 1 GR 38.48 38.48 MULTIPLAN INC 34080 [3081285] MULTIPLAN INC [308128501] 36.56 percent of total billed charges 23.86 36.56 Technical (Hospital) Services COLLAGENASE CLOSTRIDIUM HISTOLYTICUM 250 UNIT/GRAM TOPICAL OINTMENT RX-9682 CDM 6370000100 HCPCS 250 RC 50484-0010-30 NDC outpatient 1 GR 38.48 38.48 CIGNA 62308 [3081051] CIGNA 62308 [308105105] 30.78 percent of total billed charges 23.86 36.56 Technical (Hospital) Services COLLAGENASE CLOSTRIDIUM HISTOLYTICUM 250 UNIT/GRAM TOPICAL OINTMENT RX-9682 CDM 6370000100 HCPCS 250 RC 50484-0010-30 NDC outpatient 1 GR 38.48 38.48 CIGNA 62308 [3081051] CIGNA STATE OF WYOMING [308105107] 30.78 percent of total billed charges 23.86 36.56 Technical (Hospital) Services COLLAGENASE CLOSTRIDIUM HISTOLYTICUM 250 UNIT/GRAM TOPICAL OINTMENT RX-9682 CDM 6370000100 HCPCS 250 RC 50484-0010-30 NDC outpatient 1 GR 38.48 38.48 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES HDHP [308136802] 30.78 percent of total billed charges 23.86 36.56 Technical (Hospital) Services COLLAGENASE CLOSTRIDIUM HISTOLYTICUM 250 UNIT/GRAM TOPICAL OINTMENT RX-9682 CDM 6370000100 HCPCS 250 RC 50484-0010-30 NDC outpatient 1 GR 38.48 38.48 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES PPO [308136801] 30.78 percent of total billed charges 23.86 36.56 Technical (Hospital) Services COLLAGENASE CLOSTRIDIUM HISTOLYTICUM 250 UNIT/GRAM TOPICAL OINTMENT RX-9682 CDM 6370000100 HCPCS 250 RC 50484-0010-30 NDC outpatient 1 GR 38.48 38.48 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES EPO [308136803] 30.78 percent of total billed charges 23.86 36.56 Technical (Hospital) Services LAMOTRIGINE 50 MG DISINTEGRATING TABLET RX-96940 CDM 6370000100 HCPCS 250 RC 49884-0485-11 NDC inpatient 1 UN 33.11 33.11 BLUE CROSS BLUE SHIELD WELLMARK SB889 [3081026] BCBS WYOMING [308102603] 31.45 percent of total billed charges 20.53 31.45 Technical (Hospital) Services LAMOTRIGINE 50 MG DISINTEGRATING TABLET RX-96940 CDM 6370000100 HCPCS 250 RC 49884-0485-11 NDC inpatient 1 UN 33.11 33.11 MULTIPLAN INC 34080 [3081285] MULTIPLAN INC [308128501] 31.45 percent of total billed charges 20.53 31.45 Technical (Hospital) Services LAMOTRIGINE 50 MG DISINTEGRATING TABLET RX-96940 CDM 6370000100 HCPCS 250 RC 49884-0485-11 NDC inpatient 1 UN 33.11 33.11 HEALTHPARTNERS SX009 HEALTHPARTNERS 26.22 percent of total billed charges 20.53 31.45 Technical (Hospital) Services LAMOTRIGINE 50 MG DISINTEGRATING TABLET RX-96940 CDM 6370000100 HCPCS 250 RC 49884-0485-11 NDC inpatient 1 UN 33.11 33.11 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES HDHP [308136802] 26.22 percent of total billed charges 20.53 31.45 Technical (Hospital) Services LAMOTRIGINE 50 MG DISINTEGRATING TABLET RX-96940 CDM 6370000100 HCPCS 250 RC 49884-0485-11 NDC inpatient 1 UN 33.11 33.11 UNITED HEALTHCARE (COMMERCIAL) [3081199] UNITED HEALTHCARE 87726 [308119901] 20.53 percent of total billed charges 20.53 31.45 Technical (Hospital) Services LAMOTRIGINE 50 MG DISINTEGRATING TABLET RX-96940 CDM 6370000100 HCPCS 250 RC 49884-0485-11 NDC inpatient 1 UN 33.11 33.11 CIGNA 62308 [3081051] CIGNA 62308 [308105105] 26.22 percent of total billed charges 20.53 31.45 Technical (Hospital) Services LAMOTRIGINE 50 MG DISINTEGRATING TABLET RX-96940 CDM 6370000100 HCPCS 250 RC 49884-0485-11 NDC inpatient 1 UN 33.11 33.11 CIGNA 62308 [3081051] CIGNA STATE OF WYOMING [308105107] 26.22 percent of total billed charges 20.53 31.45 Technical (Hospital) Services LAMOTRIGINE 50 MG DISINTEGRATING TABLET RX-96940 CDM 6370000100 HCPCS 250 RC 49884-0485-11 NDC inpatient 1 UN 33.11 33.11 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES EPO [308136803] 26.22 percent of total billed charges 20.53 31.45 Technical (Hospital) Services LAMOTRIGINE 50 MG DISINTEGRATING TABLET RX-96940 CDM 6370000100 HCPCS 250 RC 49884-0485-11 NDC inpatient 1 UN 33.11 33.11 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES PPO [308136801] 26.22 percent of total billed charges 20.53 31.45 Technical (Hospital) Services LAMOTRIGINE 50 MG DISINTEGRATING TABLET RX-96940 CDM 6370000100 HCPCS 250 RC 49884-0485-11 NDC inpatient 1 UN 33.11 33.11 MEDICA (COMMERCIAL) 94265 [3081118] MEDICA CLAIMS [308111801] 29.8 percent of total billed charges 20.53 31.45 Technical (Hospital) Services LAMOTRIGINE 50 MG DISINTEGRATING TABLET RX-96940 CDM 6370000100 HCPCS 250 RC 49884-0485-11 NDC outpatient 1 UN 33.11 33.11 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES EPO [308136803] 26.49 percent of total billed charges 20.53 31.45 Technical (Hospital) Services LAMOTRIGINE 50 MG DISINTEGRATING TABLET RX-96940 CDM 6370000100 HCPCS 250 RC 49884-0485-11 NDC outpatient 1 UN 33.11 33.11 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES HDHP [308136802] 26.49 percent of total billed charges 20.53 31.45 Technical (Hospital) Services LAMOTRIGINE 50 MG DISINTEGRATING TABLET RX-96940 CDM 6370000100 HCPCS 250 RC 49884-0485-11 NDC outpatient 1 UN 33.11 33.11 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES PPO [308136801] 26.49 percent of total billed charges 20.53 31.45 Technical (Hospital) Services LAMOTRIGINE 50 MG DISINTEGRATING TABLET RX-96940 CDM 6370000100 HCPCS 250 RC 49884-0485-11 NDC outpatient 1 UN 33.11 33.11 CIGNA 62308 [3081051] CIGNA 62308 [308105105] 26.49 percent of total billed charges 20.53 31.45 Technical (Hospital) Services LAMOTRIGINE 50 MG DISINTEGRATING TABLET RX-96940 CDM 6370000100 HCPCS 250 RC 49884-0485-11 NDC outpatient 1 UN 33.11 33.11 CIGNA 62308 [3081051] CIGNA STATE OF WYOMING [308105107] 26.49 percent of total billed charges 20.53 31.45 Technical (Hospital) Services LAMOTRIGINE 50 MG DISINTEGRATING TABLET RX-96940 CDM 6370000100 HCPCS 250 RC 49884-0485-11 NDC outpatient 1 UN 33.11 33.11 MULTIPLAN INC 34080 [3081285] MULTIPLAN INC [308128501] 31.45 percent of total billed charges 20.53 31.45 Technical (Hospital) Services LAMOTRIGINE 50 MG DISINTEGRATING TABLET RX-96940 CDM 6370000100 HCPCS 250 RC 49884-0485-11 NDC outpatient 1 UN 33.11 33.11 MEDICA (COMMERCIAL) 94265 [3081118] MEDICA CLAIMS [308111801] 29.8 percent of total billed charges 20.53 31.45 Technical (Hospital) Services LAMOTRIGINE 50 MG DISINTEGRATING TABLET RX-96940 CDM 6370000100 HCPCS 250 RC 49884-0485-11 NDC outpatient 1 UN 33.11 33.11 HEALTHPARTNERS SX009 HEALTHPARTNERS 26.49 percent of total billed charges 20.53 31.45 Technical (Hospital) Services LAMOTRIGINE 50 MG DISINTEGRATING TABLET RX-96940 CDM 6370000100 HCPCS 250 RC 49884-0485-11 NDC outpatient 1 UN 33.11 33.11 UNITED HEALTHCARE (COMMERCIAL) [3081199] UNITED HEALTHCARE 87726 [308119901] 20.53 percent of total billed charges 20.53 31.45 Technical (Hospital) Services LAMOTRIGINE 50 MG DISINTEGRATING TABLET RX-96940 CDM 6370000100 HCPCS 250 RC 49884-0485-11 NDC outpatient 1 UN 33.11 33.11 BLUE CROSS BLUE SHIELD WELLMARK SB889 [3081026] BCBS WYOMING [308102603] 31.45 percent of total billed charges 20.53 31.45 Technical (Hospital) Services LAMOTRIGINE 100 MG DISINTEGRATING TABLET RX-96941 CDM 6370000100 HCPCS 250 RC 49884-0486-11 NDC inpatient 1 UN 33.61 33.61 MULTIPLAN INC 34080 [3081285] MULTIPLAN INC [308128501] 31.93 percent of total billed charges 20.84 31.93 Technical (Hospital) Services LAMOTRIGINE 100 MG DISINTEGRATING TABLET RX-96941 CDM 6370000100 HCPCS 250 RC 49884-0486-11 NDC inpatient 1 UN 33.61 33.61 BLUE CROSS BLUE SHIELD WELLMARK SB889 [3081026] BCBS WYOMING [308102603] 31.93 percent of total billed charges 20.84 31.93 Technical (Hospital) Services LAMOTRIGINE 100 MG DISINTEGRATING TABLET RX-96941 CDM 6370000100 HCPCS 250 RC 49884-0486-11 NDC inpatient 1 UN 33.61 33.61 UNITED HEALTHCARE (COMMERCIAL) [3081199] UNITED HEALTHCARE 87726 [308119901] 20.84 percent of total billed charges 20.84 31.93 Technical (Hospital) Services LAMOTRIGINE 100 MG DISINTEGRATING TABLET RX-96941 CDM 6370000100 HCPCS 250 RC 49884-0486-11 NDC inpatient 1 UN 33.61 33.61 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES EPO [308136803] 26.61 percent of total billed charges 20.84 31.93 Technical (Hospital) Services LAMOTRIGINE 100 MG DISINTEGRATING TABLET RX-96941 CDM 6370000100 HCPCS 250 RC 49884-0486-11 NDC inpatient 1 UN 33.61 33.61 CIGNA 62308 [3081051] CIGNA 62308 [308105105] 26.61 percent of total billed charges 20.84 31.93 Technical (Hospital) Services LAMOTRIGINE 100 MG DISINTEGRATING TABLET RX-96941 CDM 6370000100 HCPCS 250 RC 49884-0486-11 NDC inpatient 1 UN 33.61 33.61 CIGNA 62308 [3081051] CIGNA STATE OF WYOMING [308105107] 26.61 percent of total billed charges 20.84 31.93 Technical (Hospital) Services LAMOTRIGINE 100 MG DISINTEGRATING TABLET RX-96941 CDM 6370000100 HCPCS 250 RC 49884-0486-11 NDC inpatient 1 UN 33.61 33.61 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES HDHP [308136802] 26.61 percent of total billed charges 20.84 31.93 Technical (Hospital) Services LAMOTRIGINE 100 MG DISINTEGRATING TABLET RX-96941 CDM 6370000100 HCPCS 250 RC 49884-0486-11 NDC inpatient 1 UN 33.61 33.61 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES PPO [308136801] 26.61 percent of total billed charges 20.84 31.93 Technical (Hospital) Services LAMOTRIGINE 100 MG DISINTEGRATING TABLET RX-96941 CDM 6370000100 HCPCS 250 RC 49884-0486-11 NDC inpatient 1 UN 33.61 33.61 HEALTHPARTNERS SX009 HEALTHPARTNERS 26.61 percent of total billed charges 20.84 31.93 Technical (Hospital) Services LAMOTRIGINE 100 MG DISINTEGRATING TABLET RX-96941 CDM 6370000100 HCPCS 250 RC 49884-0486-11 NDC inpatient 1 UN 33.61 33.61 MEDICA (COMMERCIAL) 94265 [3081118] MEDICA CLAIMS [308111801] 30.25 percent of total billed charges 20.84 31.93 Technical (Hospital) Services LAMOTRIGINE 100 MG DISINTEGRATING TABLET RX-96941 CDM 6370000100 HCPCS 250 RC 49884-0486-11 NDC outpatient 1 UN 33.61 33.61 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES HDHP [308136802] 26.89 percent of total billed charges 20.84 31.93 Technical (Hospital) Services LAMOTRIGINE 100 MG DISINTEGRATING TABLET RX-96941 CDM 6370000100 HCPCS 250 RC 49884-0486-11 NDC outpatient 1 UN 33.61 33.61 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES EPO [308136803] 26.89 percent of total billed charges 20.84 31.93 Technical (Hospital) Services LAMOTRIGINE 100 MG DISINTEGRATING TABLET RX-96941 CDM 6370000100 HCPCS 250 RC 49884-0486-11 NDC outpatient 1 UN 33.61 33.61 MEDICA (COMMERCIAL) 94265 [3081118] MEDICA CLAIMS [308111801] 30.25 percent of total billed charges 20.84 31.93 Technical (Hospital) Services LAMOTRIGINE 100 MG DISINTEGRATING TABLET RX-96941 CDM 6370000100 HCPCS 250 RC 49884-0486-11 NDC outpatient 1 UN 33.61 33.61 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES PPO [308136801] 26.89 percent of total billed charges 20.84 31.93 Technical (Hospital) Services LAMOTRIGINE 100 MG DISINTEGRATING TABLET RX-96941 CDM 6370000100 HCPCS 250 RC 49884-0486-11 NDC outpatient 1 UN 33.61 33.61 CIGNA 62308 [3081051] CIGNA STATE OF WYOMING [308105107] 26.89 percent of total billed charges 20.84 31.93 Technical (Hospital) Services LAMOTRIGINE 100 MG DISINTEGRATING TABLET RX-96941 CDM 6370000100 HCPCS 250 RC 49884-0486-11 NDC outpatient 1 UN 33.61 33.61 CIGNA 62308 [3081051] CIGNA 62308 [308105105] 26.89 percent of total billed charges 20.84 31.93 Technical (Hospital) Services LAMOTRIGINE 100 MG DISINTEGRATING TABLET RX-96941 CDM 6370000100 HCPCS 250 RC 49884-0486-11 NDC outpatient 1 UN 33.61 33.61 MULTIPLAN INC 34080 [3081285] MULTIPLAN INC [308128501] 31.93 percent of total billed charges 20.84 31.93 Technical (Hospital) Services LAMOTRIGINE 100 MG DISINTEGRATING TABLET RX-96941 CDM 6370000100 HCPCS 250 RC 49884-0486-11 NDC outpatient 1 UN 33.61 33.61 HEALTHPARTNERS SX009 HEALTHPARTNERS 26.89 percent of total billed charges 20.84 31.93 Technical (Hospital) Services LAMOTRIGINE 100 MG DISINTEGRATING TABLET RX-96941 CDM 6370000100 HCPCS 250 RC 49884-0486-11 NDC outpatient 1 UN 33.61 33.61 UNITED HEALTHCARE (COMMERCIAL) [3081199] UNITED HEALTHCARE 87726 [308119901] 20.84 percent of total billed charges 20.84 31.93 Technical (Hospital) Services LAMOTRIGINE 100 MG DISINTEGRATING TABLET RX-96941 CDM 6370000100 HCPCS 250 RC 49884-0486-11 NDC outpatient 1 UN 33.61 33.61 BLUE CROSS BLUE SHIELD WELLMARK SB889 [3081026] BCBS WYOMING [308102603] 31.93 percent of total billed charges 20.84 31.93 Technical (Hospital) Services LACOSAMIDE 200 MG TABLET RX-96971 CDM 6370000100 HCPCS 250 RC 00131-2480-35 NDC inpatient 1 UN 67.51 67.51 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES PPO [308136801] 53.45 percent of total billed charges 41.86 64.13 Technical (Hospital) Services LACOSAMIDE 200 MG TABLET RX-96971 CDM 6370000100 HCPCS 250 RC 00131-2480-35 NDC inpatient 1 UN 67.51 67.51 HEALTHPARTNERS SX009 HEALTHPARTNERS 53.45 percent of total billed charges 41.86 64.13 Technical (Hospital) Services LACOSAMIDE 200 MG TABLET RX-96971 CDM 6370000100 HCPCS 250 RC 00131-2480-35 NDC inpatient 1 UN 67.51 67.51 MEDICA (COMMERCIAL) 94265 [3081118] MEDICA CLAIMS [308111801] 60.76 percent of total billed charges 41.86 64.13 Technical (Hospital) Services LACOSAMIDE 200 MG TABLET RX-96971 CDM 6370000100 HCPCS 250 RC 00131-2480-35 NDC inpatient 1 UN 67.51 67.51 UNITED HEALTHCARE (COMMERCIAL) [3081199] UNITED HEALTHCARE 87726 [308119901] 41.86 percent of total billed charges 41.86 64.13 Technical (Hospital) Services LACOSAMIDE 200 MG TABLET RX-96971 CDM 6370000100 HCPCS 250 RC 00131-2480-35 NDC inpatient 1 UN 67.51 67.51 BLUE CROSS BLUE SHIELD WELLMARK SB889 [3081026] BCBS WYOMING [308102603] 64.13 percent of total billed charges 41.86 64.13 Technical (Hospital) Services LACOSAMIDE 200 MG TABLET RX-96971 CDM 6370000100 HCPCS 250 RC 00131-2480-35 NDC inpatient 1 UN 67.51 67.51 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES HDHP [308136802] 53.45 percent of total billed charges 41.86 64.13 Technical (Hospital) Services LACOSAMIDE 200 MG TABLET RX-96971 CDM 6370000100 HCPCS 250 RC 00131-2480-35 NDC inpatient 1 UN 67.51 67.51 CIGNA 62308 [3081051] CIGNA 62308 [308105105] 53.45 percent of total billed charges 41.86 64.13 Technical (Hospital) Services LACOSAMIDE 200 MG TABLET RX-96971 CDM 6370000100 HCPCS 250 RC 00131-2480-35 NDC inpatient 1 UN 67.51 67.51 CIGNA 62308 [3081051] CIGNA STATE OF WYOMING [308105107] 53.45 percent of total billed charges 41.86 64.13 Technical (Hospital) Services LACOSAMIDE 200 MG TABLET RX-96971 CDM 6370000100 HCPCS 250 RC 00131-2480-35 NDC inpatient 1 UN 67.51 67.51 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES EPO [308136803] 53.45 percent of total billed charges 41.86 64.13 Technical (Hospital) Services LACOSAMIDE 200 MG TABLET RX-96971 CDM 6370000100 HCPCS 250 RC 00131-2480-35 NDC inpatient 1 UN 67.51 67.51 MULTIPLAN INC 34080 [3081285] MULTIPLAN INC [308128501] 64.13 percent of total billed charges 41.86 64.13 Technical (Hospital) Services LACOSAMIDE 200 MG TABLET RX-96971 CDM 6370000100 HCPCS 250 RC 00131-2480-35 NDC outpatient 1 UN 67.51 67.51 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES EPO [308136803] 54.01 percent of total billed charges 41.86 64.13 Technical (Hospital) Services LACOSAMIDE 200 MG TABLET RX-96971 CDM 6370000100 HCPCS 250 RC 00131-2480-35 NDC outpatient 1 UN 67.51 67.51 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES HDHP [308136802] 54.01 percent of total billed charges 41.86 64.13 Technical (Hospital) Services LACOSAMIDE 200 MG TABLET RX-96971 CDM 6370000100 HCPCS 250 RC 00131-2480-35 NDC outpatient 1 UN 67.51 67.51 MEDICA (COMMERCIAL) 94265 [3081118] MEDICA CLAIMS [308111801] 60.76 percent of total billed charges 41.86 64.13 Technical (Hospital) Services LACOSAMIDE 200 MG TABLET RX-96971 CDM 6370000100 HCPCS 250 RC 00131-2480-35 NDC outpatient 1 UN 67.51 67.51 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES PPO [308136801] 54.01 percent of total billed charges 41.86 64.13 Technical (Hospital) Services LACOSAMIDE 200 MG TABLET RX-96971 CDM 6370000100 HCPCS 250 RC 00131-2480-35 NDC outpatient 1 UN 67.51 67.51 CIGNA 62308 [3081051] CIGNA 62308 [308105105] 54.01 percent of total billed charges 41.86 64.13 Technical (Hospital) Services LACOSAMIDE 200 MG TABLET RX-96971 CDM 6370000100 HCPCS 250 RC 00131-2480-35 NDC outpatient 1 UN 67.51 67.51 CIGNA 62308 [3081051] CIGNA STATE OF WYOMING [308105107] 54.01 percent of total billed charges 41.86 64.13 Technical (Hospital) Services LACOSAMIDE 200 MG TABLET RX-96971 CDM 6370000100 HCPCS 250 RC 00131-2480-35 NDC outpatient 1 UN 67.51 67.51 MULTIPLAN INC 34080 [3081285] MULTIPLAN INC [308128501] 64.13 percent of total billed charges 41.86 64.13 Technical (Hospital) Services LACOSAMIDE 200 MG TABLET RX-96971 CDM 6370000100 HCPCS 250 RC 00131-2480-35 NDC outpatient 1 UN 67.51 67.51 HEALTHPARTNERS SX009 HEALTHPARTNERS 54.01 percent of total billed charges 41.86 64.13 Technical (Hospital) Services LACOSAMIDE 200 MG TABLET RX-96971 CDM 6370000100 HCPCS 250 RC 00131-2480-35 NDC outpatient 1 UN 67.51 67.51 UNITED HEALTHCARE (COMMERCIAL) [3081199] UNITED HEALTHCARE 87726 [308119901] 41.86 percent of total billed charges 41.86 64.13 Technical (Hospital) Services LACOSAMIDE 200 MG TABLET RX-96971 CDM 6370000100 HCPCS 250 RC 00131-2480-35 NDC outpatient 1 UN 67.51 67.51 BLUE CROSS BLUE SHIELD WELLMARK SB889 [3081026] BCBS WYOMING [308102603] 64.13 percent of total billed charges 41.86 64.13 Technical (Hospital) Services "FESOTERODINE ER 4 MG TABLET,EXTENDED RELEASE 24 HR" RX-96973 CDM 6370000100 HCPCS 250 RC 00069-0242-30 NDC outpatient 1 UN 38.07 38.07 BLUE CROSS BLUE SHIELD WELLMARK SB889 [3081026] BCBS WYOMING [308102603] 36.17 percent of total billed charges 23.6 36.17 Technical (Hospital) Services "FESOTERODINE ER 4 MG TABLET,EXTENDED RELEASE 24 HR" RX-96973 CDM 6370000100 HCPCS 250 RC 00069-0242-30 NDC outpatient 1 UN 38.07 38.07 MULTIPLAN INC 34080 [3081285] MULTIPLAN INC [308128501] 36.17 percent of total billed charges 23.6 36.17 Technical (Hospital) Services "FESOTERODINE ER 4 MG TABLET,EXTENDED RELEASE 24 HR" RX-96973 CDM 6370000100 HCPCS 250 RC 00069-0242-30 NDC outpatient 1 UN 38.07 38.07 CIGNA 62308 [3081051] CIGNA 62308 [308105105] 30.46 percent of total billed charges 23.6 36.17 Technical (Hospital) Services "FESOTERODINE ER 4 MG TABLET,EXTENDED RELEASE 24 HR" RX-96973 CDM 6370000100 HCPCS 250 RC 00069-0242-30 NDC outpatient 1 UN 38.07 38.07 CIGNA 62308 [3081051] CIGNA STATE OF WYOMING [308105107] 30.46 percent of total billed charges 23.6 36.17 Technical (Hospital) Services "FESOTERODINE ER 4 MG TABLET,EXTENDED RELEASE 24 HR" RX-96973 CDM 6370000100 HCPCS 250 RC 00069-0242-30 NDC outpatient 1 UN 38.07 38.07 HEALTHPARTNERS SX009 HEALTHPARTNERS 30.46 percent of total billed charges 23.6 36.17 Technical (Hospital) Services "FESOTERODINE ER 4 MG TABLET,EXTENDED RELEASE 24 HR" RX-96973 CDM 6370000100 HCPCS 250 RC 00069-0242-30 NDC outpatient 1 UN 38.07 38.07 UNITED HEALTHCARE (COMMERCIAL) [3081199] UNITED HEALTHCARE 87726 [308119901] 23.6 percent of total billed charges 23.6 36.17 Technical (Hospital) Services "FESOTERODINE ER 4 MG TABLET,EXTENDED RELEASE 24 HR" RX-96973 CDM 6370000100 HCPCS 250 RC 00069-0242-30 NDC outpatient 1 UN 38.07 38.07 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES HDHP [308136802] 30.46 percent of total billed charges 23.6 36.17 Technical (Hospital) Services "FESOTERODINE ER 4 MG TABLET,EXTENDED RELEASE 24 HR" RX-96973 CDM 6370000100 HCPCS 250 RC 00069-0242-30 NDC outpatient 1 UN 38.07 38.07 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES EPO [308136803] 30.46 percent of total billed charges 23.6 36.17 Technical (Hospital) Services "FESOTERODINE ER 4 MG TABLET,EXTENDED RELEASE 24 HR" RX-96973 CDM 6370000100 HCPCS 250 RC 00069-0242-30 NDC outpatient 1 UN 38.07 38.07 MEDICA (COMMERCIAL) 94265 [3081118] MEDICA CLAIMS [308111801] 34.26 percent of total billed charges 23.6 36.17 Technical (Hospital) Services "FESOTERODINE ER 4 MG TABLET,EXTENDED RELEASE 24 HR" RX-96973 CDM 6370000100 HCPCS 250 RC 00069-0242-30 NDC outpatient 1 UN 38.07 38.07 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES PPO [308136801] 30.46 percent of total billed charges 23.6 36.17 Technical (Hospital) Services "FESOTERODINE ER 4 MG TABLET,EXTENDED RELEASE 24 HR" RX-96973 CDM 6370000100 HCPCS 250 RC 00069-0242-30 NDC inpatient 1 UN 38.07 38.07 HEALTHPARTNERS SX009 HEALTHPARTNERS 30.14 percent of total billed charges 23.6 36.17 Technical (Hospital) Services "FESOTERODINE ER 4 MG TABLET,EXTENDED RELEASE 24 HR" RX-96973 CDM 6370000100 HCPCS 250 RC 00069-0242-30 NDC inpatient 1 UN 38.07 38.07 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES PPO [308136801] 30.14 percent of total billed charges 23.6 36.17 Technical (Hospital) Services "FESOTERODINE ER 4 MG TABLET,EXTENDED RELEASE 24 HR" RX-96973 CDM 6370000100 HCPCS 250 RC 00069-0242-30 NDC inpatient 1 UN 38.07 38.07 MEDICA (COMMERCIAL) 94265 [3081118] MEDICA CLAIMS [308111801] 34.26 percent of total billed charges 23.6 36.17 Technical (Hospital) Services "FESOTERODINE ER 4 MG TABLET,EXTENDED RELEASE 24 HR" RX-96973 CDM 6370000100 HCPCS 250 RC 00069-0242-30 NDC inpatient 1 UN 38.07 38.07 BLUE CROSS BLUE SHIELD WELLMARK SB889 [3081026] BCBS WYOMING [308102603] 36.17 percent of total billed charges 23.6 36.17 Technical (Hospital) Services "FESOTERODINE ER 4 MG TABLET,EXTENDED RELEASE 24 HR" RX-96973 CDM 6370000100 HCPCS 250 RC 00069-0242-30 NDC inpatient 1 UN 38.07 38.07 UNITED HEALTHCARE (COMMERCIAL) [3081199] UNITED HEALTHCARE 87726 [308119901] 23.6 percent of total billed charges 23.6 36.17 Technical (Hospital) Services "FESOTERODINE ER 4 MG TABLET,EXTENDED RELEASE 24 HR" RX-96973 CDM 6370000100 HCPCS 250 RC 00069-0242-30 NDC inpatient 1 UN 38.07 38.07 CIGNA 62308 [3081051] CIGNA 62308 [308105105] 30.14 percent of total billed charges 23.6 36.17 Technical (Hospital) Services "FESOTERODINE ER 4 MG TABLET,EXTENDED RELEASE 24 HR" RX-96973 CDM 6370000100 HCPCS 250 RC 00069-0242-30 NDC inpatient 1 UN 38.07 38.07 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES EPO [308136803] 30.14 percent of total billed charges 23.6 36.17 Technical (Hospital) Services "FESOTERODINE ER 4 MG TABLET,EXTENDED RELEASE 24 HR" RX-96973 CDM 6370000100 HCPCS 250 RC 00069-0242-30 NDC inpatient 1 UN 38.07 38.07 CIGNA 62308 [3081051] CIGNA STATE OF WYOMING [308105107] 30.14 percent of total billed charges 23.6 36.17 Technical (Hospital) Services "FESOTERODINE ER 4 MG TABLET,EXTENDED RELEASE 24 HR" RX-96973 CDM 6370000100 HCPCS 250 RC 00069-0242-30 NDC inpatient 1 UN 38.07 38.07 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES HDHP [308136802] 30.14 percent of total billed charges 23.6 36.17 Technical (Hospital) Services "FESOTERODINE ER 4 MG TABLET,EXTENDED RELEASE 24 HR" RX-96973 CDM 6370000100 HCPCS 250 RC 00069-0242-30 NDC inpatient 1 UN 38.07 38.07 MULTIPLAN INC 34080 [3081285] MULTIPLAN INC [308128501] 36.17 percent of total billed charges 23.6 36.17 Technical (Hospital) Services "DEXLANSOPRAZOLE 30 MG CAPSULE,BIPHASE DELAYED RELEASE" RX-97008 CDM 6370000100 HCPCS 250 RC 64764-0171-30 NDC outpatient 1 UN 38.68 38.68 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES EPO [308136803] 30.94 percent of total billed charges 23.98 36.75 Technical (Hospital) Services "DEXLANSOPRAZOLE 30 MG CAPSULE,BIPHASE DELAYED RELEASE" RX-97008 CDM 6370000100 HCPCS 250 RC 64764-0171-30 NDC outpatient 1 UN 38.68 38.68 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES HDHP [308136802] 30.94 percent of total billed charges 23.98 36.75 Technical (Hospital) Services "DEXLANSOPRAZOLE 30 MG CAPSULE,BIPHASE DELAYED RELEASE" RX-97008 CDM 6370000100 HCPCS 250 RC 64764-0171-30 NDC outpatient 1 UN 38.68 38.68 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES PPO [308136801] 30.94 percent of total billed charges 23.98 36.75 Technical (Hospital) Services "DEXLANSOPRAZOLE 30 MG CAPSULE,BIPHASE DELAYED RELEASE" RX-97008 CDM 6370000100 HCPCS 250 RC 64764-0171-30 NDC outpatient 1 UN 38.68 38.68 BLUE CROSS BLUE SHIELD WELLMARK SB889 [3081026] BCBS WYOMING [308102603] 36.75 percent of total billed charges 23.98 36.75 Technical (Hospital) Services "DEXLANSOPRAZOLE 30 MG CAPSULE,BIPHASE DELAYED RELEASE" RX-97008 CDM 6370000100 HCPCS 250 RC 64764-0171-30 NDC outpatient 1 UN 38.68 38.68 HEALTHPARTNERS SX009 HEALTHPARTNERS 30.94 percent of total billed charges 23.98 36.75 Technical (Hospital) Services "DEXLANSOPRAZOLE 30 MG CAPSULE,BIPHASE DELAYED RELEASE" RX-97008 CDM 6370000100 HCPCS 250 RC 64764-0171-30 NDC outpatient 1 UN 38.68 38.68 UNITED HEALTHCARE (COMMERCIAL) [3081199] UNITED HEALTHCARE 87726 [308119901] 23.98 percent of total billed charges 23.98 36.75 Technical (Hospital) Services "DEXLANSOPRAZOLE 30 MG CAPSULE,BIPHASE DELAYED RELEASE" RX-97008 CDM 6370000100 HCPCS 250 RC 64764-0171-30 NDC outpatient 1 UN 38.68 38.68 MULTIPLAN INC 34080 [3081285] MULTIPLAN INC [308128501] 36.75 percent of total billed charges 23.98 36.75 Technical (Hospital) Services "DEXLANSOPRAZOLE 30 MG CAPSULE,BIPHASE DELAYED RELEASE" RX-97008 CDM 6370000100 HCPCS 250 RC 64764-0171-30 NDC outpatient 1 UN 38.68 38.68 CIGNA 62308 [3081051] CIGNA 62308 [308105105] 30.94 percent of total billed charges 23.98 36.75 Technical (Hospital) Services "DEXLANSOPRAZOLE 30 MG CAPSULE,BIPHASE DELAYED RELEASE" RX-97008 CDM 6370000100 HCPCS 250 RC 64764-0171-30 NDC outpatient 1 UN 38.68 38.68 CIGNA 62308 [3081051] CIGNA STATE OF WYOMING [308105107] 30.94 percent of total billed charges 23.98 36.75 Technical (Hospital) Services "DEXLANSOPRAZOLE 30 MG CAPSULE,BIPHASE DELAYED RELEASE" RX-97008 CDM 6370000100 HCPCS 250 RC 64764-0171-30 NDC outpatient 1 UN 38.68 38.68 MEDICA (COMMERCIAL) 94265 [3081118] MEDICA CLAIMS [308111801] 34.81 percent of total billed charges 23.98 36.75 Technical (Hospital) Services "DEXLANSOPRAZOLE 30 MG CAPSULE,BIPHASE DELAYED RELEASE" RX-97008 CDM 6370000100 HCPCS 250 RC 64764-0171-30 NDC inpatient 1 UN 38.68 38.68 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES PPO [308136801] 30.63 percent of total billed charges 23.98 36.75 Technical (Hospital) Services "DEXLANSOPRAZOLE 30 MG CAPSULE,BIPHASE DELAYED RELEASE" RX-97008 CDM 6370000100 HCPCS 250 RC 64764-0171-30 NDC inpatient 1 UN 38.68 38.68 HEALTHPARTNERS SX009 HEALTHPARTNERS 30.63 percent of total billed charges 23.98 36.75 Technical (Hospital) Services "DEXLANSOPRAZOLE 30 MG CAPSULE,BIPHASE DELAYED RELEASE" RX-97008 CDM 6370000100 HCPCS 250 RC 64764-0171-30 NDC inpatient 1 UN 38.68 38.68 MEDICA (COMMERCIAL) 94265 [3081118] MEDICA CLAIMS [308111801] 34.81 percent of total billed charges 23.98 36.75 Technical (Hospital) Services "DEXLANSOPRAZOLE 30 MG CAPSULE,BIPHASE DELAYED RELEASE" RX-97008 CDM 6370000100 HCPCS 250 RC 64764-0171-30 NDC inpatient 1 UN 38.68 38.68 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES HDHP [308136802] 30.63 percent of total billed charges 23.98 36.75 Technical (Hospital) Services "DEXLANSOPRAZOLE 30 MG CAPSULE,BIPHASE DELAYED RELEASE" RX-97008 CDM 6370000100 HCPCS 250 RC 64764-0171-30 NDC inpatient 1 UN 38.68 38.68 UNITED HEALTHCARE (COMMERCIAL) [3081199] UNITED HEALTHCARE 87726 [308119901] 23.98 percent of total billed charges 23.98 36.75 Technical (Hospital) Services "DEXLANSOPRAZOLE 30 MG CAPSULE,BIPHASE DELAYED RELEASE" RX-97008 CDM 6370000100 HCPCS 250 RC 64764-0171-30 NDC inpatient 1 UN 38.68 38.68 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES EPO [308136803] 30.63 percent of total billed charges 23.98 36.75 Technical (Hospital) Services "DEXLANSOPRAZOLE 30 MG CAPSULE,BIPHASE DELAYED RELEASE" RX-97008 CDM 6370000100 HCPCS 250 RC 64764-0171-30 NDC inpatient 1 UN 38.68 38.68 CIGNA 62308 [3081051] CIGNA 62308 [308105105] 30.63 percent of total billed charges 23.98 36.75 Technical (Hospital) Services "DEXLANSOPRAZOLE 30 MG CAPSULE,BIPHASE DELAYED RELEASE" RX-97008 CDM 6370000100 HCPCS 250 RC 64764-0171-30 NDC inpatient 1 UN 38.68 38.68 CIGNA 62308 [3081051] CIGNA STATE OF WYOMING [308105107] 30.63 percent of total billed charges 23.98 36.75 Technical (Hospital) Services "DEXLANSOPRAZOLE 30 MG CAPSULE,BIPHASE DELAYED RELEASE" RX-97008 CDM 6370000100 HCPCS 250 RC 64764-0171-30 NDC inpatient 1 UN 38.68 38.68 BLUE CROSS BLUE SHIELD WELLMARK SB889 [3081026] BCBS WYOMING [308102603] 36.75 percent of total billed charges 23.98 36.75 Technical (Hospital) Services "DEXLANSOPRAZOLE 30 MG CAPSULE,BIPHASE DELAYED RELEASE" RX-97008 CDM 6370000100 HCPCS 250 RC 64764-0171-30 NDC inpatient 1 UN 38.68 38.68 MULTIPLAN INC 34080 [3081285] MULTIPLAN INC [308128501] 36.75 percent of total billed charges 23.98 36.75 Technical (Hospital) Services TOLVAPTAN 15 MG TABLET RX-97893 CDM 6370000100 HCPCS 250 RC 59148-0020-50 NDC inpatient 1 UN 1155.2 1155.2 MULTIPLAN INC 34080 [3081285] MULTIPLAN INC [308128501] 1097.44 percent of total billed charges 716.22 1097.44 Technical (Hospital) Services TOLVAPTAN 15 MG TABLET RX-97893 CDM 6370000100 HCPCS 250 RC 59148-0020-50 NDC inpatient 1 UN 1155.2 1155.2 BLUE CROSS BLUE SHIELD WELLMARK SB889 [3081026] BCBS WYOMING [308102603] 1097.44 percent of total billed charges 716.22 1097.44 Technical (Hospital) Services TOLVAPTAN 15 MG TABLET RX-97893 CDM 6370000100 HCPCS 250 RC 59148-0020-50 NDC inpatient 1 UN 1155.2 1155.2 UNITED HEALTHCARE (COMMERCIAL) [3081199] UNITED HEALTHCARE 87726 [308119901] 716.22 percent of total billed charges 716.22 1097.44 Technical (Hospital) Services TOLVAPTAN 15 MG TABLET RX-97893 CDM 6370000100 HCPCS 250 RC 59148-0020-50 NDC inpatient 1 UN 1155.2 1155.2 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES EPO [308136803] 914.69 percent of total billed charges 716.22 1097.44 Technical (Hospital) Services TOLVAPTAN 15 MG TABLET RX-97893 CDM 6370000100 HCPCS 250 RC 59148-0020-50 NDC inpatient 1 UN 1155.2 1155.2 CIGNA 62308 [3081051] CIGNA 62308 [308105105] 914.69 percent of total billed charges 716.22 1097.44 Technical (Hospital) Services TOLVAPTAN 15 MG TABLET RX-97893 CDM 6370000100 HCPCS 250 RC 59148-0020-50 NDC inpatient 1 UN 1155.2 1155.2 CIGNA 62308 [3081051] CIGNA STATE OF WYOMING [308105107] 914.69 percent of total billed charges 716.22 1097.44 Technical (Hospital) Services TOLVAPTAN 15 MG TABLET RX-97893 CDM 6370000100 HCPCS 250 RC 59148-0020-50 NDC inpatient 1 UN 1155.2 1155.2 HEALTHPARTNERS SX009 HEALTHPARTNERS 914.69 percent of total billed charges 716.22 1097.44 Technical (Hospital) Services TOLVAPTAN 15 MG TABLET RX-97893 CDM 6370000100 HCPCS 250 RC 59148-0020-50 NDC inpatient 1 UN 1155.2 1155.2 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES HDHP [308136802] 914.69 percent of total billed charges 716.22 1097.44 Technical (Hospital) Services TOLVAPTAN 15 MG TABLET RX-97893 CDM 6370000100 HCPCS 250 RC 59148-0020-50 NDC inpatient 1 UN 1155.2 1155.2 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES PPO [308136801] 914.69 percent of total billed charges 716.22 1097.44 Technical (Hospital) Services TOLVAPTAN 15 MG TABLET RX-97893 CDM 6370000100 HCPCS 250 RC 59148-0020-50 NDC inpatient 1 UN 1155.2 1155.2 MEDICA (COMMERCIAL) 94265 [3081118] MEDICA CLAIMS [308111801] 1039.68 percent of total billed charges 716.22 1097.44 Technical (Hospital) Services TOLVAPTAN 15 MG TABLET RX-97893 CDM 6370000100 HCPCS 250 RC 59148-0020-50 NDC outpatient 1 UN 1155.2 1155.2 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES PPO [308136801] 924.16 percent of total billed charges 716.22 1097.44 Technical (Hospital) Services TOLVAPTAN 15 MG TABLET RX-97893 CDM 6370000100 HCPCS 250 RC 59148-0020-50 NDC outpatient 1 UN 1155.2 1155.2 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES HDHP [308136802] 924.16 percent of total billed charges 716.22 1097.44 Technical (Hospital) Services TOLVAPTAN 15 MG TABLET RX-97893 CDM 6370000100 HCPCS 250 RC 59148-0020-50 NDC outpatient 1 UN 1155.2 1155.2 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES EPO [308136803] 924.16 percent of total billed charges 716.22 1097.44 Technical (Hospital) Services TOLVAPTAN 15 MG TABLET RX-97893 CDM 6370000100 HCPCS 250 RC 59148-0020-50 NDC outpatient 1 UN 1155.2 1155.2 BLUE CROSS BLUE SHIELD WELLMARK SB889 [3081026] BCBS WYOMING [308102603] 1097.44 percent of total billed charges 716.22 1097.44 Technical (Hospital) Services TOLVAPTAN 15 MG TABLET RX-97893 CDM 6370000100 HCPCS 250 RC 59148-0020-50 NDC outpatient 1 UN 1155.2 1155.2 HEALTHPARTNERS SX009 HEALTHPARTNERS 924.16 percent of total billed charges 716.22 1097.44 Technical (Hospital) Services TOLVAPTAN 15 MG TABLET RX-97893 CDM 6370000100 HCPCS 250 RC 59148-0020-50 NDC outpatient 1 UN 1155.2 1155.2 UNITED HEALTHCARE (COMMERCIAL) [3081199] UNITED HEALTHCARE 87726 [308119901] 716.22 percent of total billed charges 716.22 1097.44 Technical (Hospital) Services TOLVAPTAN 15 MG TABLET RX-97893 CDM 6370000100 HCPCS 250 RC 59148-0020-50 NDC outpatient 1 UN 1155.2 1155.2 MEDICA (COMMERCIAL) 94265 [3081118] MEDICA CLAIMS [308111801] 1039.68 percent of total billed charges 716.22 1097.44 Technical (Hospital) Services TOLVAPTAN 15 MG TABLET RX-97893 CDM 6370000100 HCPCS 250 RC 59148-0020-50 NDC outpatient 1 UN 1155.2 1155.2 MULTIPLAN INC 34080 [3081285] MULTIPLAN INC [308128501] 1097.44 percent of total billed charges 716.22 1097.44 Technical (Hospital) Services TOLVAPTAN 15 MG TABLET RX-97893 CDM 6370000100 HCPCS 250 RC 59148-0020-50 NDC outpatient 1 UN 1155.2 1155.2 CIGNA 62308 [3081051] CIGNA 62308 [308105105] 924.16 percent of total billed charges 716.22 1097.44 Technical (Hospital) Services TOLVAPTAN 15 MG TABLET RX-97893 CDM 6370000100 HCPCS 250 RC 59148-0020-50 NDC outpatient 1 UN 1155.2 1155.2 CIGNA 62308 [3081051] CIGNA STATE OF WYOMING [308105107] 924.16 percent of total billed charges 716.22 1097.44 Technical (Hospital) Services TAPENTADOL 50 MG TABLET RX-98253 CDM 6370000100 HCPCS 250 RC 24510-0050-10 NDC inpatient 1 UN 38.99 38.99 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES PPO [308136801] 30.87 percent of total billed charges 24.17 37.04 Technical (Hospital) Services TAPENTADOL 50 MG TABLET RX-98253 CDM 6370000100 HCPCS 250 RC 24510-0050-10 NDC inpatient 1 UN 38.99 38.99 MEDICA (COMMERCIAL) 94265 [3081118] MEDICA CLAIMS [308111801] 35.09 percent of total billed charges 24.17 37.04 Technical (Hospital) Services TAPENTADOL 50 MG TABLET RX-98253 CDM 6370000100 HCPCS 250 RC 24510-0050-10 NDC inpatient 1 UN 38.99 38.99 BLUE CROSS BLUE SHIELD WELLMARK SB889 [3081026] BCBS WYOMING [308102603] 37.04 percent of total billed charges 24.17 37.04 Technical (Hospital) Services TAPENTADOL 50 MG TABLET RX-98253 CDM 6370000100 HCPCS 250 RC 24510-0050-10 NDC inpatient 1 UN 38.99 38.99 UNITED HEALTHCARE (COMMERCIAL) [3081199] UNITED HEALTHCARE 87726 [308119901] 24.17 percent of total billed charges 24.17 37.04 Technical (Hospital) Services TAPENTADOL 50 MG TABLET RX-98253 CDM 6370000100 HCPCS 250 RC 24510-0050-10 NDC inpatient 1 UN 38.99 38.99 CIGNA 62308 [3081051] CIGNA 62308 [308105105] 30.87 percent of total billed charges 24.17 37.04 Technical (Hospital) Services TAPENTADOL 50 MG TABLET RX-98253 CDM 6370000100 HCPCS 250 RC 24510-0050-10 NDC inpatient 1 UN 38.99 38.99 CIGNA 62308 [3081051] CIGNA STATE OF WYOMING [308105107] 30.87 percent of total billed charges 24.17 37.04 Technical (Hospital) Services TAPENTADOL 50 MG TABLET RX-98253 CDM 6370000100 HCPCS 250 RC 24510-0050-10 NDC inpatient 1 UN 38.99 38.99 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES EPO [308136803] 30.87 percent of total billed charges 24.17 37.04 Technical (Hospital) Services TAPENTADOL 50 MG TABLET RX-98253 CDM 6370000100 HCPCS 250 RC 24510-0050-10 NDC inpatient 1 UN 38.99 38.99 HEALTHPARTNERS SX009 HEALTHPARTNERS 30.87 percent of total billed charges 24.17 37.04 Technical (Hospital) Services TAPENTADOL 50 MG TABLET RX-98253 CDM 6370000100 HCPCS 250 RC 24510-0050-10 NDC inpatient 1 UN 38.99 38.99 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES HDHP [308136802] 30.87 percent of total billed charges 24.17 37.04 Technical (Hospital) Services TAPENTADOL 50 MG TABLET RX-98253 CDM 6370000100 HCPCS 250 RC 24510-0050-10 NDC inpatient 1 UN 38.99 38.99 MULTIPLAN INC 34080 [3081285] MULTIPLAN INC [308128501] 37.04 percent of total billed charges 24.17 37.04 Technical (Hospital) Services TAPENTADOL 50 MG TABLET RX-98253 CDM 6370000100 HCPCS 250 RC 24510-0050-10 NDC outpatient 1 UN 38.99 38.99 BLUE CROSS BLUE SHIELD WELLMARK SB889 [3081026] BCBS WYOMING [308102603] 37.04 percent of total billed charges 24.17 37.04 Technical (Hospital) Services TAPENTADOL 50 MG TABLET RX-98253 CDM 6370000100 HCPCS 250 RC 24510-0050-10 NDC outpatient 1 UN 38.99 38.99 CIGNA 62308 [3081051] CIGNA 62308 [308105105] 31.19 percent of total billed charges 24.17 37.04 Technical (Hospital) Services TAPENTADOL 50 MG TABLET RX-98253 CDM 6370000100 HCPCS 250 RC 24510-0050-10 NDC outpatient 1 UN 38.99 38.99 CIGNA 62308 [3081051] CIGNA STATE OF WYOMING [308105107] 31.19 percent of total billed charges 24.17 37.04 Technical (Hospital) Services TAPENTADOL 50 MG TABLET RX-98253 CDM 6370000100 HCPCS 250 RC 24510-0050-10 NDC outpatient 1 UN 38.99 38.99 MULTIPLAN INC 34080 [3081285] MULTIPLAN INC [308128501] 37.04 percent of total billed charges 24.17 37.04 Technical (Hospital) Services TAPENTADOL 50 MG TABLET RX-98253 CDM 6370000100 HCPCS 250 RC 24510-0050-10 NDC outpatient 1 UN 38.99 38.99 MEDICA (COMMERCIAL) 94265 [3081118] MEDICA CLAIMS [308111801] 35.09 percent of total billed charges 24.17 37.04 Technical (Hospital) Services TAPENTADOL 50 MG TABLET RX-98253 CDM 6370000100 HCPCS 250 RC 24510-0050-10 NDC outpatient 1 UN 38.99 38.99 UNITED HEALTHCARE (COMMERCIAL) [3081199] UNITED HEALTHCARE 87726 [308119901] 24.17 percent of total billed charges 24.17 37.04 Technical (Hospital) Services TAPENTADOL 50 MG TABLET RX-98253 CDM 6370000100 HCPCS 250 RC 24510-0050-10 NDC outpatient 1 UN 38.99 38.99 HEALTHPARTNERS SX009 HEALTHPARTNERS 31.19 percent of total billed charges 24.17 37.04 Technical (Hospital) Services TAPENTADOL 50 MG TABLET RX-98253 CDM 6370000100 HCPCS 250 RC 24510-0050-10 NDC outpatient 1 UN 38.99 38.99 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES HDHP [308136802] 31.19 percent of total billed charges 24.17 37.04 Technical (Hospital) Services TAPENTADOL 50 MG TABLET RX-98253 CDM 6370000100 HCPCS 250 RC 24510-0050-10 NDC outpatient 1 UN 38.99 38.99 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES EPO [308136803] 31.19 percent of total billed charges 24.17 37.04 Technical (Hospital) Services TAPENTADOL 50 MG TABLET RX-98253 CDM 6370000100 HCPCS 250 RC 24510-0050-10 NDC outpatient 1 UN 38.99 38.99 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES PPO [308136801] 31.19 percent of total billed charges 24.17 37.04 Technical (Hospital) Services PRASUGREL 5 MG TABLET RX-98372 CDM 6370000100 HCPCS 250 RC 60505-4642-03 NDC inpatient 1 UN 6.45 6.45 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES PPO [308136801] 5.11 percent of total billed charges 4 6.13 Technical (Hospital) Services PRASUGREL 5 MG TABLET RX-98372 CDM 6370000100 HCPCS 250 RC 60505-4642-03 NDC inpatient 1 UN 6.45 6.45 MEDICA (COMMERCIAL) 94265 [3081118] MEDICA CLAIMS [308111801] 5.81 percent of total billed charges 4 6.13 Technical (Hospital) Services PRASUGREL 5 MG TABLET RX-98372 CDM 6370000100 HCPCS 250 RC 60505-4642-03 NDC inpatient 1 UN 6.45 6.45 HEALTHPARTNERS SX009 HEALTHPARTNERS 5.11 percent of total billed charges 4 6.13 Technical (Hospital) Services PRASUGREL 5 MG TABLET RX-98372 CDM 6370000100 HCPCS 250 RC 60505-4642-03 NDC inpatient 1 UN 6.45 6.45 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES HDHP [308136802] 5.11 percent of total billed charges 4 6.13 Technical (Hospital) Services PRASUGREL 5 MG TABLET RX-98372 CDM 6370000100 HCPCS 250 RC 60505-4642-03 NDC inpatient 1 UN 6.45 6.45 CIGNA 62308 [3081051] CIGNA 62308 [308105105] 5.11 percent of total billed charges 4 6.13 Technical (Hospital) Services PRASUGREL 5 MG TABLET RX-98372 CDM 6370000100 HCPCS 250 RC 60505-4642-03 NDC inpatient 1 UN 6.45 6.45 CIGNA 62308 [3081051] CIGNA STATE OF WYOMING [308105107] 5.11 percent of total billed charges 4 6.13 Technical (Hospital) Services PRASUGREL 5 MG TABLET RX-98372 CDM 6370000100 HCPCS 250 RC 60505-4642-03 NDC inpatient 1 UN 6.45 6.45 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES EPO [308136803] 5.11 percent of total billed charges 4 6.13 Technical (Hospital) Services PRASUGREL 5 MG TABLET RX-98372 CDM 6370000100 HCPCS 250 RC 60505-4642-03 NDC inpatient 1 UN 6.45 6.45 UNITED HEALTHCARE (COMMERCIAL) [3081199] UNITED HEALTHCARE 87726 [308119901] 4 percent of total billed charges 4 6.13 Technical (Hospital) Services PRASUGREL 5 MG TABLET RX-98372 CDM 6370000100 HCPCS 250 RC 60505-4642-03 NDC inpatient 1 UN 6.45 6.45 BLUE CROSS BLUE SHIELD WELLMARK SB889 [3081026] BCBS WYOMING [308102603] 6.13 percent of total billed charges 4 6.13 Technical (Hospital) Services PRASUGREL 5 MG TABLET RX-98372 CDM 6370000100 HCPCS 250 RC 60505-4642-03 NDC inpatient 1 UN 6.45 6.45 MULTIPLAN INC 34080 [3081285] MULTIPLAN INC [308128501] 6.13 percent of total billed charges 4 6.13 Technical (Hospital) Services PRASUGREL 5 MG TABLET RX-98372 CDM 6370000100 HCPCS 250 RC 60505-4642-03 NDC outpatient 1 UN 6.45 6.45 BLUE CROSS BLUE SHIELD WELLMARK SB889 [3081026] BCBS WYOMING [308102603] 6.13 percent of total billed charges 4 6.13 Technical (Hospital) Services PRASUGREL 5 MG TABLET RX-98372 CDM 6370000100 HCPCS 250 RC 60505-4642-03 NDC outpatient 1 UN 6.45 6.45 MEDICA (COMMERCIAL) 94265 [3081118] MEDICA CLAIMS [308111801] 5.81 percent of total billed charges 4 6.13 Technical (Hospital) Services PRASUGREL 5 MG TABLET RX-98372 CDM 6370000100 HCPCS 250 RC 60505-4642-03 NDC outpatient 1 UN 6.45 6.45 MULTIPLAN INC 34080 [3081285] MULTIPLAN INC [308128501] 6.13 percent of total billed charges 4 6.13 Technical (Hospital) Services PRASUGREL 5 MG TABLET RX-98372 CDM 6370000100 HCPCS 250 RC 60505-4642-03 NDC outpatient 1 UN 6.45 6.45 CIGNA 62308 [3081051] CIGNA 62308 [308105105] 5.16 percent of total billed charges 4 6.13 Technical (Hospital) Services PRASUGREL 5 MG TABLET RX-98372 CDM 6370000100 HCPCS 250 RC 60505-4642-03 NDC outpatient 1 UN 6.45 6.45 CIGNA 62308 [3081051] CIGNA STATE OF WYOMING [308105107] 5.16 percent of total billed charges 4 6.13 Technical (Hospital) Services PRASUGREL 5 MG TABLET RX-98372 CDM 6370000100 HCPCS 250 RC 60505-4642-03 NDC outpatient 1 UN 6.45 6.45 UNITED HEALTHCARE (COMMERCIAL) [3081199] UNITED HEALTHCARE 87726 [308119901] 4 percent of total billed charges 4 6.13 Technical (Hospital) Services PRASUGREL 5 MG TABLET RX-98372 CDM 6370000100 HCPCS 250 RC 60505-4642-03 NDC outpatient 1 UN 6.45 6.45 HEALTHPARTNERS SX009 HEALTHPARTNERS 5.16 percent of total billed charges 4 6.13 Technical (Hospital) Services PRASUGREL 5 MG TABLET RX-98372 CDM 6370000100 HCPCS 250 RC 60505-4642-03 NDC outpatient 1 UN 6.45 6.45 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES HDHP [308136802] 5.16 percent of total billed charges 4 6.13 Technical (Hospital) Services PRASUGREL 5 MG TABLET RX-98372 CDM 6370000100 HCPCS 250 RC 60505-4642-03 NDC outpatient 1 UN 6.45 6.45 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES PPO [308136801] 5.16 percent of total billed charges 4 6.13 Technical (Hospital) Services PRASUGREL 5 MG TABLET RX-98372 CDM 6370000100 HCPCS 250 RC 60505-4642-03 NDC outpatient 1 UN 6.45 6.45 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES EPO [308136803] 5.16 percent of total billed charges 4 6.13 Technical (Hospital) Services DOXAZOSIN 1 MG TABLET RX-9894 CDM 6370000100 HCPCS 250 RC 16729-0211-01 NDC inpatient 1 UN 5.85 5.85 HEALTHPARTNERS SX009 HEALTHPARTNERS 4.63 percent of total billed charges 3.63 5.56 Technical (Hospital) Services DOXAZOSIN 1 MG TABLET RX-9894 CDM 6370000100 HCPCS 250 RC 16729-0211-01 NDC inpatient 1 UN 5.85 5.85 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES HDHP [308136802] 4.63 percent of total billed charges 3.63 5.56 Technical (Hospital) Services DOXAZOSIN 1 MG TABLET RX-9894 CDM 6370000100 HCPCS 250 RC 16729-0211-01 NDC inpatient 1 UN 5.85 5.85 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES EPO [308136803] 4.63 percent of total billed charges 3.63 5.56 Technical (Hospital) Services DOXAZOSIN 1 MG TABLET RX-9894 CDM 6370000100 HCPCS 250 RC 16729-0211-01 NDC inpatient 1 UN 5.85 5.85 CIGNA 62308 [3081051] CIGNA 62308 [308105105] 4.63 percent of total billed charges 3.63 5.56 Technical (Hospital) Services DOXAZOSIN 1 MG TABLET RX-9894 CDM 6370000100 HCPCS 250 RC 16729-0211-01 NDC inpatient 1 UN 5.85 5.85 CIGNA 62308 [3081051] CIGNA STATE OF WYOMING [308105107] 4.63 percent of total billed charges 3.63 5.56 Technical (Hospital) Services DOXAZOSIN 1 MG TABLET RX-9894 CDM 6370000100 HCPCS 250 RC 16729-0211-01 NDC inpatient 1 UN 5.85 5.85 UNITED HEALTHCARE (COMMERCIAL) [3081199] UNITED HEALTHCARE 87726 [308119901] 3.63 percent of total billed charges 3.63 5.56 Technical (Hospital) Services DOXAZOSIN 1 MG TABLET RX-9894 CDM 6370000100 HCPCS 250 RC 16729-0211-01 NDC inpatient 1 UN 5.85 5.85 BLUE CROSS BLUE SHIELD WELLMARK SB889 [3081026] BCBS WYOMING [308102603] 5.56 percent of total billed charges 3.63 5.56 Technical (Hospital) Services DOXAZOSIN 1 MG TABLET RX-9894 CDM 6370000100 HCPCS 250 RC 16729-0211-01 NDC inpatient 1 UN 5.85 5.85 MULTIPLAN INC 34080 [3081285] MULTIPLAN INC [308128501] 5.56 percent of total billed charges 3.63 5.56 Technical (Hospital) Services DOXAZOSIN 1 MG TABLET RX-9894 CDM 6370000100 HCPCS 250 RC 16729-0211-01 NDC inpatient 1 UN 5.85 5.85 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES PPO [308136801] 4.63 percent of total billed charges 3.63 5.56 Technical (Hospital) Services DOXAZOSIN 1 MG TABLET RX-9894 CDM 6370000100 HCPCS 250 RC 16729-0211-01 NDC inpatient 1 UN 5.85 5.85 MEDICA (COMMERCIAL) 94265 [3081118] MEDICA CLAIMS [308111801] 5.27 percent of total billed charges 3.63 5.56 Technical (Hospital) Services DOXAZOSIN 1 MG TABLET RX-9894 CDM 6370000100 HCPCS 250 RC 16729-0211-01 NDC outpatient 1 UN 5.85 5.85 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES PPO [308136801] 4.68 percent of total billed charges 3.63 5.56 Technical (Hospital) Services DOXAZOSIN 1 MG TABLET RX-9894 CDM 6370000100 HCPCS 250 RC 16729-0211-01 NDC outpatient 1 UN 5.85 5.85 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES HDHP [308136802] 4.68 percent of total billed charges 3.63 5.56 Technical (Hospital) Services DOXAZOSIN 1 MG TABLET RX-9894 CDM 6370000100 HCPCS 250 RC 16729-0211-01 NDC outpatient 1 UN 5.85 5.85 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES EPO [308136803] 4.68 percent of total billed charges 3.63 5.56 Technical (Hospital) Services DOXAZOSIN 1 MG TABLET RX-9894 CDM 6370000100 HCPCS 250 RC 16729-0211-01 NDC outpatient 1 UN 5.85 5.85 BLUE CROSS BLUE SHIELD WELLMARK SB889 [3081026] BCBS WYOMING [308102603] 5.56 percent of total billed charges 3.63 5.56 Technical (Hospital) Services DOXAZOSIN 1 MG TABLET RX-9894 CDM 6370000100 HCPCS 250 RC 16729-0211-01 NDC outpatient 1 UN 5.85 5.85 UNITED HEALTHCARE (COMMERCIAL) [3081199] UNITED HEALTHCARE 87726 [308119901] 3.63 percent of total billed charges 3.63 5.56 Technical (Hospital) Services DOXAZOSIN 1 MG TABLET RX-9894 CDM 6370000100 HCPCS 250 RC 16729-0211-01 NDC outpatient 1 UN 5.85 5.85 HEALTHPARTNERS SX009 HEALTHPARTNERS 4.68 percent of total billed charges 3.63 5.56 Technical (Hospital) Services DOXAZOSIN 1 MG TABLET RX-9894 CDM 6370000100 HCPCS 250 RC 16729-0211-01 NDC outpatient 1 UN 5.85 5.85 MULTIPLAN INC 34080 [3081285] MULTIPLAN INC [308128501] 5.56 percent of total billed charges 3.63 5.56 Technical (Hospital) Services DOXAZOSIN 1 MG TABLET RX-9894 CDM 6370000100 HCPCS 250 RC 16729-0211-01 NDC outpatient 1 UN 5.85 5.85 CIGNA 62308 [3081051] CIGNA 62308 [308105105] 4.68 percent of total billed charges 3.63 5.56 Technical (Hospital) Services DOXAZOSIN 1 MG TABLET RX-9894 CDM 6370000100 HCPCS 250 RC 16729-0211-01 NDC outpatient 1 UN 5.85 5.85 CIGNA 62308 [3081051] CIGNA STATE OF WYOMING [308105107] 4.68 percent of total billed charges 3.63 5.56 Technical (Hospital) Services DOXAZOSIN 1 MG TABLET RX-9894 CDM 6370000100 HCPCS 250 RC 16729-0211-01 NDC outpatient 1 UN 5.85 5.85 MEDICA (COMMERCIAL) 94265 [3081118] MEDICA CLAIMS [308111801] 5.27 percent of total billed charges 3.63 5.56 Technical (Hospital) Services DOXAZOSIN 4 MG TABLET RX-9896 CDM 6370000100 HCPCS 250 RC 16729-0213-01 NDC inpatient 1 UN 5.88 5.88 MULTIPLAN INC 34080 [3081285] MULTIPLAN INC [308128501] 5.59 percent of total billed charges 3.65 5.59 Technical (Hospital) Services DOXAZOSIN 4 MG TABLET RX-9896 CDM 6370000100 HCPCS 250 RC 16729-0213-01 NDC inpatient 1 UN 5.88 5.88 BLUE CROSS BLUE SHIELD WELLMARK SB889 [3081026] BCBS WYOMING [308102603] 5.59 percent of total billed charges 3.65 5.59 Technical (Hospital) Services DOXAZOSIN 4 MG TABLET RX-9896 CDM 6370000100 HCPCS 250 RC 16729-0213-01 NDC inpatient 1 UN 5.88 5.88 UNITED HEALTHCARE (COMMERCIAL) [3081199] UNITED HEALTHCARE 87726 [308119901] 3.65 percent of total billed charges 3.65 5.59 Technical (Hospital) Services DOXAZOSIN 4 MG TABLET RX-9896 CDM 6370000100 HCPCS 250 RC 16729-0213-01 NDC inpatient 1 UN 5.88 5.88 CIGNA 62308 [3081051] CIGNA 62308 [308105105] 4.66 percent of total billed charges 3.65 5.59 Technical (Hospital) Services DOXAZOSIN 4 MG TABLET RX-9896 CDM 6370000100 HCPCS 250 RC 16729-0213-01 NDC inpatient 1 UN 5.88 5.88 CIGNA 62308 [3081051] CIGNA STATE OF WYOMING [308105107] 4.66 percent of total billed charges 3.65 5.59 Technical (Hospital) Services DOXAZOSIN 4 MG TABLET RX-9896 CDM 6370000100 HCPCS 250 RC 16729-0213-01 NDC inpatient 1 UN 5.88 5.88 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES EPO [308136803] 4.66 percent of total billed charges 3.65 5.59 Technical (Hospital) Services DOXAZOSIN 4 MG TABLET RX-9896 CDM 6370000100 HCPCS 250 RC 16729-0213-01 NDC inpatient 1 UN 5.88 5.88 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES HDHP [308136802] 4.66 percent of total billed charges 3.65 5.59 Technical (Hospital) Services DOXAZOSIN 4 MG TABLET RX-9896 CDM 6370000100 HCPCS 250 RC 16729-0213-01 NDC inpatient 1 UN 5.88 5.88 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES PPO [308136801] 4.66 percent of total billed charges 3.65 5.59 Technical (Hospital) Services DOXAZOSIN 4 MG TABLET RX-9896 CDM 6370000100 HCPCS 250 RC 16729-0213-01 NDC inpatient 1 UN 5.88 5.88 MEDICA (COMMERCIAL) 94265 [3081118] MEDICA CLAIMS [308111801] 5.29 percent of total billed charges 3.65 5.59 Technical (Hospital) Services DOXAZOSIN 4 MG TABLET RX-9896 CDM 6370000100 HCPCS 250 RC 16729-0213-01 NDC inpatient 1 UN 5.88 5.88 HEALTHPARTNERS SX009 HEALTHPARTNERS 4.66 percent of total billed charges 3.65 5.59 Technical (Hospital) Services DOXAZOSIN 4 MG TABLET RX-9896 CDM 6370000100 HCPCS 250 RC 16729-0213-01 NDC outpatient 1 UN 5.88 5.88 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES HDHP [308136802] 4.7 percent of total billed charges 3.65 5.59 Technical (Hospital) Services DOXAZOSIN 4 MG TABLET RX-9896 CDM 6370000100 HCPCS 250 RC 16729-0213-01 NDC outpatient 1 UN 5.88 5.88 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES PPO [308136801] 4.7 percent of total billed charges 3.65 5.59 Technical (Hospital) Services DOXAZOSIN 4 MG TABLET RX-9896 CDM 6370000100 HCPCS 250 RC 16729-0213-01 NDC outpatient 1 UN 5.88 5.88 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES EPO [308136803] 4.7 percent of total billed charges 3.65 5.59 Technical (Hospital) Services DOXAZOSIN 4 MG TABLET RX-9896 CDM 6370000100 HCPCS 250 RC 16729-0213-01 NDC outpatient 1 UN 5.88 5.88 BLUE CROSS BLUE SHIELD WELLMARK SB889 [3081026] BCBS WYOMING [308102603] 5.59 percent of total billed charges 3.65 5.59 Technical (Hospital) Services DOXAZOSIN 4 MG TABLET RX-9896 CDM 6370000100 HCPCS 250 RC 16729-0213-01 NDC outpatient 1 UN 5.88 5.88 CIGNA 62308 [3081051] CIGNA 62308 [308105105] 4.7 percent of total billed charges 3.65 5.59 Technical (Hospital) Services DOXAZOSIN 4 MG TABLET RX-9896 CDM 6370000100 HCPCS 250 RC 16729-0213-01 NDC outpatient 1 UN 5.88 5.88 CIGNA 62308 [3081051] CIGNA STATE OF WYOMING [308105107] 4.7 percent of total billed charges 3.65 5.59 Technical (Hospital) Services DOXAZOSIN 4 MG TABLET RX-9896 CDM 6370000100 HCPCS 250 RC 16729-0213-01 NDC outpatient 1 UN 5.88 5.88 MULTIPLAN INC 34080 [3081285] MULTIPLAN INC [308128501] 5.59 percent of total billed charges 3.65 5.59 Technical (Hospital) Services DOXAZOSIN 4 MG TABLET RX-9896 CDM 6370000100 HCPCS 250 RC 16729-0213-01 NDC outpatient 1 UN 5.88 5.88 MEDICA (COMMERCIAL) 94265 [3081118] MEDICA CLAIMS [308111801] 5.29 percent of total billed charges 3.65 5.59 Technical (Hospital) Services DOXAZOSIN 4 MG TABLET RX-9896 CDM 6370000100 HCPCS 250 RC 16729-0213-01 NDC outpatient 1 UN 5.88 5.88 HEALTHPARTNERS SX009 HEALTHPARTNERS 4.7 percent of total billed charges 3.65 5.59 Technical (Hospital) Services DOXAZOSIN 4 MG TABLET RX-9896 CDM 6370000100 HCPCS 250 RC 16729-0213-01 NDC outpatient 1 UN 5.88 5.88 UNITED HEALTHCARE (COMMERCIAL) [3081199] UNITED HEALTHCARE 87726 [308119901] 3.65 percent of total billed charges 3.65 5.59 Technical (Hospital) Services DOXYCYCLINE MONOHYDRATE 100 MG CAPSULE RX-9900 CDM 6370000100 HCPCS 250 RC 68180-0652-08 NDC inpatient 1 UN 6.46 6.46 MEDICA (COMMERCIAL) 94265 [3081118] MEDICA CLAIMS [308111801] 5.81 percent of total billed charges 4.01 6.14 Technical (Hospital) Services DOXYCYCLINE MONOHYDRATE 100 MG CAPSULE RX-9900 CDM 6370000100 HCPCS 250 RC 68180-0652-08 NDC inpatient 1 UN 6.46 6.46 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES PPO [308136801] 5.12 percent of total billed charges 4.01 6.14 Technical (Hospital) Services DOXYCYCLINE MONOHYDRATE 100 MG CAPSULE RX-9900 CDM 6370000100 HCPCS 250 RC 68180-0652-08 NDC inpatient 1 UN 6.46 6.46 HEALTHPARTNERS SX009 HEALTHPARTNERS 5.12 percent of total billed charges 4.01 6.14 Technical (Hospital) Services DOXYCYCLINE MONOHYDRATE 100 MG CAPSULE RX-9900 CDM 6370000100 HCPCS 250 RC 68180-0652-08 NDC inpatient 1 UN 6.46 6.46 MULTIPLAN INC 34080 [3081285] MULTIPLAN INC [308128501] 6.14 percent of total billed charges 4.01 6.14 Technical (Hospital) Services DOXYCYCLINE MONOHYDRATE 100 MG CAPSULE RX-9900 CDM 6370000100 HCPCS 250 RC 68180-0652-08 NDC inpatient 1 UN 6.46 6.46 UNITED HEALTHCARE (COMMERCIAL) [3081199] UNITED HEALTHCARE 87726 [308119901] 4.01 percent of total billed charges 4.01 6.14 Technical (Hospital) Services DOXYCYCLINE MONOHYDRATE 100 MG CAPSULE RX-9900 CDM 6370000100 HCPCS 250 RC 68180-0652-08 NDC inpatient 1 UN 6.46 6.46 BLUE CROSS BLUE SHIELD WELLMARK SB889 [3081026] BCBS WYOMING [308102603] 6.14 percent of total billed charges 4.01 6.14 Technical (Hospital) Services DOXYCYCLINE MONOHYDRATE 100 MG CAPSULE RX-9900 CDM 6370000100 HCPCS 250 RC 68180-0652-08 NDC inpatient 1 UN 6.46 6.46 CIGNA 62308 [3081051] CIGNA 62308 [308105105] 5.12 percent of total billed charges 4.01 6.14 Technical (Hospital) Services DOXYCYCLINE MONOHYDRATE 100 MG CAPSULE RX-9900 CDM 6370000100 HCPCS 250 RC 68180-0652-08 NDC inpatient 1 UN 6.46 6.46 CIGNA 62308 [3081051] CIGNA STATE OF WYOMING [308105107] 5.12 percent of total billed charges 4.01 6.14 Technical (Hospital) Services DOXYCYCLINE MONOHYDRATE 100 MG CAPSULE RX-9900 CDM 6370000100 HCPCS 250 RC 68180-0652-08 NDC inpatient 1 UN 6.46 6.46 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES EPO [308136803] 5.12 percent of total billed charges 4.01 6.14 Technical (Hospital) Services DOXYCYCLINE MONOHYDRATE 100 MG CAPSULE RX-9900 CDM 6370000100 HCPCS 250 RC 68180-0652-08 NDC inpatient 1 UN 6.46 6.46 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES HDHP [308136802] 5.12 percent of total billed charges 4.01 6.14 Technical (Hospital) Services DOXYCYCLINE MONOHYDRATE 100 MG CAPSULE RX-9900 CDM 6370000100 HCPCS 250 RC 68180-0652-08 NDC outpatient 1 UN 6.46 6.46 CIGNA 62308 [3081051] CIGNA 62308 [308105105] 5.17 percent of total billed charges 4.01 6.14 Technical (Hospital) Services DOXYCYCLINE MONOHYDRATE 100 MG CAPSULE RX-9900 CDM 6370000100 HCPCS 250 RC 68180-0652-08 NDC outpatient 1 UN 6.46 6.46 CIGNA 62308 [3081051] CIGNA STATE OF WYOMING [308105107] 5.17 percent of total billed charges 4.01 6.14 Technical (Hospital) Services DOXYCYCLINE MONOHYDRATE 100 MG CAPSULE RX-9900 CDM 6370000100 HCPCS 250 RC 68180-0652-08 NDC outpatient 1 UN 6.46 6.46 MULTIPLAN INC 34080 [3081285] MULTIPLAN INC [308128501] 6.14 percent of total billed charges 4.01 6.14 Technical (Hospital) Services DOXYCYCLINE MONOHYDRATE 100 MG CAPSULE RX-9900 CDM 6370000100 HCPCS 250 RC 68180-0652-08 NDC outpatient 1 UN 6.46 6.46 MEDICA (COMMERCIAL) 94265 [3081118] MEDICA CLAIMS [308111801] 5.81 percent of total billed charges 4.01 6.14 Technical (Hospital) Services DOXYCYCLINE MONOHYDRATE 100 MG CAPSULE RX-9900 CDM 6370000100 HCPCS 250 RC 68180-0652-08 NDC outpatient 1 UN 6.46 6.46 HEALTHPARTNERS SX009 HEALTHPARTNERS 5.17 percent of total billed charges 4.01 6.14 Technical (Hospital) Services DOXYCYCLINE MONOHYDRATE 100 MG CAPSULE RX-9900 CDM 6370000100 HCPCS 250 RC 68180-0652-08 NDC outpatient 1 UN 6.46 6.46 UNITED HEALTHCARE (COMMERCIAL) [3081199] UNITED HEALTHCARE 87726 [308119901] 4.01 percent of total billed charges 4.01 6.14 Technical (Hospital) Services DOXYCYCLINE MONOHYDRATE 100 MG CAPSULE RX-9900 CDM 6370000100 HCPCS 250 RC 68180-0652-08 NDC outpatient 1 UN 6.46 6.46 BLUE CROSS BLUE SHIELD WELLMARK SB889 [3081026] BCBS WYOMING [308102603] 6.14 percent of total billed charges 4.01 6.14 Technical (Hospital) Services DOXYCYCLINE MONOHYDRATE 100 MG CAPSULE RX-9900 CDM 6370000100 HCPCS 250 RC 68180-0652-08 NDC outpatient 1 UN 6.46 6.46 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES EPO [308136803] 5.17 percent of total billed charges 4.01 6.14 Technical (Hospital) Services DOXYCYCLINE MONOHYDRATE 100 MG CAPSULE RX-9900 CDM 6370000100 HCPCS 250 RC 68180-0652-08 NDC outpatient 1 UN 6.46 6.46 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES HDHP [308136802] 5.17 percent of total billed charges 4.01 6.14 Technical (Hospital) Services DOXYCYCLINE MONOHYDRATE 100 MG CAPSULE RX-9900 CDM 6370000100 HCPCS 250 RC 68180-0652-08 NDC outpatient 1 UN 6.46 6.46 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES PPO [308136801] 5.17 percent of total billed charges 4.01 6.14 Technical (Hospital) Services ENALAPRIL MALEATE 10 MG TABLET RX-9924 CDM 6370000100 HCPCS 250 RC 64679-0925-02 NDC inpatient 1 UN 6.12 6.12 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES EPO [308136803] 4.85 percent of total billed charges 3.79 5.81 Technical (Hospital) Services ENALAPRIL MALEATE 10 MG TABLET RX-9924 CDM 6370000100 HCPCS 250 RC 64679-0925-02 NDC inpatient 1 UN 6.12 6.12 CIGNA 62308 [3081051] CIGNA 62308 [308105105] 4.85 percent of total billed charges 3.79 5.81 Technical (Hospital) Services ENALAPRIL MALEATE 10 MG TABLET RX-9924 CDM 6370000100 HCPCS 250 RC 64679-0925-02 NDC inpatient 1 UN 6.12 6.12 CIGNA 62308 [3081051] CIGNA STATE OF WYOMING [308105107] 4.85 percent of total billed charges 3.79 5.81 Technical (Hospital) Services ENALAPRIL MALEATE 10 MG TABLET RX-9924 CDM 6370000100 HCPCS 250 RC 64679-0925-02 NDC inpatient 1 UN 6.12 6.12 UNITED HEALTHCARE (COMMERCIAL) [3081199] UNITED HEALTHCARE 87726 [308119901] 3.79 percent of total billed charges 3.79 5.81 Technical (Hospital) Services ENALAPRIL MALEATE 10 MG TABLET RX-9924 CDM 6370000100 HCPCS 250 RC 64679-0925-02 NDC inpatient 1 UN 6.12 6.12 HEALTHPARTNERS SX009 HEALTHPARTNERS 4.85 percent of total billed charges 3.79 5.81 Technical (Hospital) Services ENALAPRIL MALEATE 10 MG TABLET RX-9924 CDM 6370000100 HCPCS 250 RC 64679-0925-02 NDC inpatient 1 UN 6.12 6.12 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES HDHP [308136802] 4.85 percent of total billed charges 3.79 5.81 Technical (Hospital) Services ENALAPRIL MALEATE 10 MG TABLET RX-9924 CDM 6370000100 HCPCS 250 RC 64679-0925-02 NDC inpatient 1 UN 6.12 6.12 BLUE CROSS BLUE SHIELD WELLMARK SB889 [3081026] BCBS WYOMING [308102603] 5.81 percent of total billed charges 3.79 5.81 Technical (Hospital) Services ENALAPRIL MALEATE 10 MG TABLET RX-9924 CDM 6370000100 HCPCS 250 RC 64679-0925-02 NDC inpatient 1 UN 6.12 6.12 MULTIPLAN INC 34080 [3081285] MULTIPLAN INC [308128501] 5.81 percent of total billed charges 3.79 5.81 Technical (Hospital) Services ENALAPRIL MALEATE 10 MG TABLET RX-9924 CDM 6370000100 HCPCS 250 RC 64679-0925-02 NDC inpatient 1 UN 6.12 6.12 MEDICA (COMMERCIAL) 94265 [3081118] MEDICA CLAIMS [308111801] 5.51 percent of total billed charges 3.79 5.81 Technical (Hospital) Services ENALAPRIL MALEATE 10 MG TABLET RX-9924 CDM 6370000100 HCPCS 250 RC 64679-0925-02 NDC inpatient 1 UN 6.12 6.12 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES PPO [308136801] 4.85 percent of total billed charges 3.79 5.81 Technical (Hospital) Services ENALAPRIL MALEATE 10 MG TABLET RX-9924 CDM 6370000100 HCPCS 250 RC 64679-0925-02 NDC outpatient 1 UN 6.12 6.12 HEALTHPARTNERS SX009 HEALTHPARTNERS 4.9 percent of total billed charges 3.79 5.81 Technical (Hospital) Services ENALAPRIL MALEATE 10 MG TABLET RX-9924 CDM 6370000100 HCPCS 250 RC 64679-0925-02 NDC outpatient 1 UN 6.12 6.12 UNITED HEALTHCARE (COMMERCIAL) [3081199] UNITED HEALTHCARE 87726 [308119901] 3.79 percent of total billed charges 3.79 5.81 Technical (Hospital) Services ENALAPRIL MALEATE 10 MG TABLET RX-9924 CDM 6370000100 HCPCS 250 RC 64679-0925-02 NDC outpatient 1 UN 6.12 6.12 CIGNA 62308 [3081051] CIGNA 62308 [308105105] 4.9 percent of total billed charges 3.79 5.81 Technical (Hospital) Services ENALAPRIL MALEATE 10 MG TABLET RX-9924 CDM 6370000100 HCPCS 250 RC 64679-0925-02 NDC outpatient 1 UN 6.12 6.12 CIGNA 62308 [3081051] CIGNA STATE OF WYOMING [308105107] 4.9 percent of total billed charges 3.79 5.81 Technical (Hospital) Services ENALAPRIL MALEATE 10 MG TABLET RX-9924 CDM 6370000100 HCPCS 250 RC 64679-0925-02 NDC outpatient 1 UN 6.12 6.12 MULTIPLAN INC 34080 [3081285] MULTIPLAN INC [308128501] 5.81 percent of total billed charges 3.79 5.81 Technical (Hospital) Services ENALAPRIL MALEATE 10 MG TABLET RX-9924 CDM 6370000100 HCPCS 250 RC 64679-0925-02 NDC outpatient 1 UN 6.12 6.12 MEDICA (COMMERCIAL) 94265 [3081118] MEDICA CLAIMS [308111801] 5.51 percent of total billed charges 3.79 5.81 Technical (Hospital) Services ENALAPRIL MALEATE 10 MG TABLET RX-9924 CDM 6370000100 HCPCS 250 RC 64679-0925-02 NDC outpatient 1 UN 6.12 6.12 BLUE CROSS BLUE SHIELD WELLMARK SB889 [3081026] BCBS WYOMING [308102603] 5.81 percent of total billed charges 3.79 5.81 Technical (Hospital) Services ENALAPRIL MALEATE 10 MG TABLET RX-9924 CDM 6370000100 HCPCS 250 RC 64679-0925-02 NDC outpatient 1 UN 6.12 6.12 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES HDHP [308136802] 4.9 percent of total billed charges 3.79 5.81 Technical (Hospital) Services ENALAPRIL MALEATE 10 MG TABLET RX-9924 CDM 6370000100 HCPCS 250 RC 64679-0925-02 NDC outpatient 1 UN 6.12 6.12 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES PPO [308136801] 4.9 percent of total billed charges 3.79 5.81 Technical (Hospital) Services ENALAPRIL MALEATE 10 MG TABLET RX-9924 CDM 6370000100 HCPCS 250 RC 64679-0925-02 NDC outpatient 1 UN 6.12 6.12 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES EPO [308136803] 4.9 percent of total billed charges 3.79 5.81 Technical (Hospital) Services ENALAPRIL MALEATE 2.5 MG TABLET RX-9925 CDM 6370000100 HCPCS 250 RC 64679-0923-02 NDC inpatient 1 UN 5.99 5.99 MULTIPLAN INC 34080 [3081285] MULTIPLAN INC [308128501] 5.69 percent of total billed charges 3.71 5.69 Technical (Hospital) Services ENALAPRIL MALEATE 2.5 MG TABLET RX-9925 CDM 6370000100 HCPCS 250 RC 64679-0923-02 NDC inpatient 1 UN 5.99 5.99 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES EPO [308136803] 4.74 percent of total billed charges 3.71 5.69 Technical (Hospital) Services ENALAPRIL MALEATE 2.5 MG TABLET RX-9925 CDM 6370000100 HCPCS 250 RC 64679-0923-02 NDC inpatient 1 UN 5.99 5.99 CIGNA 62308 [3081051] CIGNA 62308 [308105105] 4.74 percent of total billed charges 3.71 5.69 Technical (Hospital) Services ENALAPRIL MALEATE 2.5 MG TABLET RX-9925 CDM 6370000100 HCPCS 250 RC 64679-0923-02 NDC inpatient 1 UN 5.99 5.99 CIGNA 62308 [3081051] CIGNA STATE OF WYOMING [308105107] 4.74 percent of total billed charges 3.71 5.69 Technical (Hospital) Services ENALAPRIL MALEATE 2.5 MG TABLET RX-9925 CDM 6370000100 HCPCS 250 RC 64679-0923-02 NDC inpatient 1 UN 5.99 5.99 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES HDHP [308136802] 4.74 percent of total billed charges 3.71 5.69 Technical (Hospital) Services ENALAPRIL MALEATE 2.5 MG TABLET RX-9925 CDM 6370000100 HCPCS 250 RC 64679-0923-02 NDC inpatient 1 UN 5.99 5.99 UNITED HEALTHCARE (COMMERCIAL) [3081199] UNITED HEALTHCARE 87726 [308119901] 3.71 percent of total billed charges 3.71 5.69 Technical (Hospital) Services ENALAPRIL MALEATE 2.5 MG TABLET RX-9925 CDM 6370000100 HCPCS 250 RC 64679-0923-02 NDC inpatient 1 UN 5.99 5.99 BLUE CROSS BLUE SHIELD WELLMARK SB889 [3081026] BCBS WYOMING [308102603] 5.69 percent of total billed charges 3.71 5.69 Technical (Hospital) Services ENALAPRIL MALEATE 2.5 MG TABLET RX-9925 CDM 6370000100 HCPCS 250 RC 64679-0923-02 NDC inpatient 1 UN 5.99 5.99 MEDICA (COMMERCIAL) 94265 [3081118] MEDICA CLAIMS [308111801] 5.39 percent of total billed charges 3.71 5.69 Technical (Hospital) Services ENALAPRIL MALEATE 2.5 MG TABLET RX-9925 CDM 6370000100 HCPCS 250 RC 64679-0923-02 NDC inpatient 1 UN 5.99 5.99 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES PPO [308136801] 4.74 percent of total billed charges 3.71 5.69 Technical (Hospital) Services ENALAPRIL MALEATE 2.5 MG TABLET RX-9925 CDM 6370000100 HCPCS 250 RC 64679-0923-02 NDC inpatient 1 UN 5.99 5.99 HEALTHPARTNERS SX009 HEALTHPARTNERS 4.74 percent of total billed charges 3.71 5.69 Technical (Hospital) Services ENALAPRIL MALEATE 2.5 MG TABLET RX-9925 CDM 6370000100 HCPCS 250 RC 64679-0923-02 NDC outpatient 1 UN 5.99 5.99 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES EPO [308136803] 4.79 percent of total billed charges 3.71 5.69 Technical (Hospital) Services ENALAPRIL MALEATE 2.5 MG TABLET RX-9925 CDM 6370000100 HCPCS 250 RC 64679-0923-02 NDC outpatient 1 UN 5.99 5.99 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES HDHP [308136802] 4.79 percent of total billed charges 3.71 5.69 Technical (Hospital) Services ENALAPRIL MALEATE 2.5 MG TABLET RX-9925 CDM 6370000100 HCPCS 250 RC 64679-0923-02 NDC outpatient 1 UN 5.99 5.99 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES PPO [308136801] 4.79 percent of total billed charges 3.71 5.69 Technical (Hospital) Services ENALAPRIL MALEATE 2.5 MG TABLET RX-9925 CDM 6370000100 HCPCS 250 RC 64679-0923-02 NDC outpatient 1 UN 5.99 5.99 UNITED HEALTHCARE (COMMERCIAL) [3081199] UNITED HEALTHCARE 87726 [308119901] 3.71 percent of total billed charges 3.71 5.69 Technical (Hospital) Services ENALAPRIL MALEATE 2.5 MG TABLET RX-9925 CDM 6370000100 HCPCS 250 RC 64679-0923-02 NDC outpatient 1 UN 5.99 5.99 HEALTHPARTNERS SX009 HEALTHPARTNERS 4.79 percent of total billed charges 3.71 5.69 Technical (Hospital) Services ENALAPRIL MALEATE 2.5 MG TABLET RX-9925 CDM 6370000100 HCPCS 250 RC 64679-0923-02 NDC outpatient 1 UN 5.99 5.99 MEDICA (COMMERCIAL) 94265 [3081118] MEDICA CLAIMS [308111801] 5.39 percent of total billed charges 3.71 5.69 Technical (Hospital) Services ENALAPRIL MALEATE 2.5 MG TABLET RX-9925 CDM 6370000100 HCPCS 250 RC 64679-0923-02 NDC outpatient 1 UN 5.99 5.99 MULTIPLAN INC 34080 [3081285] MULTIPLAN INC [308128501] 5.69 percent of total billed charges 3.71 5.69 Technical (Hospital) Services ENALAPRIL MALEATE 2.5 MG TABLET RX-9925 CDM 6370000100 HCPCS 250 RC 64679-0923-02 NDC outpatient 1 UN 5.99 5.99 CIGNA 62308 [3081051] CIGNA 62308 [308105105] 4.79 percent of total billed charges 3.71 5.69 Technical (Hospital) Services ENALAPRIL MALEATE 2.5 MG TABLET RX-9925 CDM 6370000100 HCPCS 250 RC 64679-0923-02 NDC outpatient 1 UN 5.99 5.99 CIGNA 62308 [3081051] CIGNA STATE OF WYOMING [308105107] 4.79 percent of total billed charges 3.71 5.69 Technical (Hospital) Services ENALAPRIL MALEATE 2.5 MG TABLET RX-9925 CDM 6370000100 HCPCS 250 RC 64679-0923-02 NDC outpatient 1 UN 5.99 5.99 BLUE CROSS BLUE SHIELD WELLMARK SB889 [3081026] BCBS WYOMING [308102603] 5.69 percent of total billed charges 3.71 5.69 Technical (Hospital) Services ENALAPRIL MALEATE 20 MG TABLET RX-9926 CDM 6370000100 HCPCS 250 RC 51672-4040-01 NDC inpatient 1 UN 5.94 5.94 HEALTHPARTNERS SX009 HEALTHPARTNERS 4.7 percent of total billed charges 3.68 5.64 Technical (Hospital) Services ENALAPRIL MALEATE 20 MG TABLET RX-9926 CDM 6370000100 HCPCS 250 RC 51672-4040-01 NDC inpatient 1 UN 5.94 5.94 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES PPO [308136801] 4.7 percent of total billed charges 3.68 5.64 Technical (Hospital) Services ENALAPRIL MALEATE 20 MG TABLET RX-9926 CDM 6370000100 HCPCS 250 RC 51672-4040-01 NDC inpatient 1 UN 5.94 5.94 MEDICA (COMMERCIAL) 94265 [3081118] MEDICA CLAIMS [308111801] 5.35 percent of total billed charges 3.68 5.64 Technical (Hospital) Services ENALAPRIL MALEATE 20 MG TABLET RX-9926 CDM 6370000100 HCPCS 250 RC 51672-4040-01 NDC inpatient 1 UN 5.94 5.94 BLUE CROSS BLUE SHIELD WELLMARK SB889 [3081026] BCBS WYOMING [308102603] 5.64 percent of total billed charges 3.68 5.64 Technical (Hospital) Services ENALAPRIL MALEATE 20 MG TABLET RX-9926 CDM 6370000100 HCPCS 250 RC 51672-4040-01 NDC inpatient 1 UN 5.94 5.94 UNITED HEALTHCARE (COMMERCIAL) [3081199] UNITED HEALTHCARE 87726 [308119901] 3.68 percent of total billed charges 3.68 5.64 Technical (Hospital) Services ENALAPRIL MALEATE 20 MG TABLET RX-9926 CDM 6370000100 HCPCS 250 RC 51672-4040-01 NDC inpatient 1 UN 5.94 5.94 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES HDHP [308136802] 4.7 percent of total billed charges 3.68 5.64 Technical (Hospital) Services ENALAPRIL MALEATE 20 MG TABLET RX-9926 CDM 6370000100 HCPCS 250 RC 51672-4040-01 NDC inpatient 1 UN 5.94 5.94 CIGNA 62308 [3081051] CIGNA 62308 [308105105] 4.7 percent of total billed charges 3.68 5.64 Technical (Hospital) Services ENALAPRIL MALEATE 20 MG TABLET RX-9926 CDM 6370000100 HCPCS 250 RC 51672-4040-01 NDC inpatient 1 UN 5.94 5.94 CIGNA 62308 [3081051] CIGNA STATE OF WYOMING [308105107] 4.7 percent of total billed charges 3.68 5.64 Technical (Hospital) Services ENALAPRIL MALEATE 20 MG TABLET RX-9926 CDM 6370000100 HCPCS 250 RC 51672-4040-01 NDC inpatient 1 UN 5.94 5.94 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES EPO [308136803] 4.7 percent of total billed charges 3.68 5.64 Technical (Hospital) Services ENALAPRIL MALEATE 20 MG TABLET RX-9926 CDM 6370000100 HCPCS 250 RC 51672-4040-01 NDC inpatient 1 UN 5.94 5.94 MULTIPLAN INC 34080 [3081285] MULTIPLAN INC [308128501] 5.64 percent of total billed charges 3.68 5.64 Technical (Hospital) Services ENALAPRIL MALEATE 20 MG TABLET RX-9926 CDM 6370000100 HCPCS 250 RC 51672-4040-01 NDC outpatient 1 UN 5.94 5.94 BLUE CROSS BLUE SHIELD WELLMARK SB889 [3081026] BCBS WYOMING [308102603] 5.64 percent of total billed charges 3.68 5.64 Technical (Hospital) Services ENALAPRIL MALEATE 20 MG TABLET RX-9926 CDM 6370000100 HCPCS 250 RC 51672-4040-01 NDC outpatient 1 UN 5.94 5.94 UNITED HEALTHCARE (COMMERCIAL) [3081199] UNITED HEALTHCARE 87726 [308119901] 3.68 percent of total billed charges 3.68 5.64 Technical (Hospital) Services ENALAPRIL MALEATE 20 MG TABLET RX-9926 CDM 6370000100 HCPCS 250 RC 51672-4040-01 NDC outpatient 1 UN 5.94 5.94 HEALTHPARTNERS SX009 HEALTHPARTNERS 4.75 percent of total billed charges 3.68 5.64 Technical (Hospital) Services ENALAPRIL MALEATE 20 MG TABLET RX-9926 CDM 6370000100 HCPCS 250 RC 51672-4040-01 NDC outpatient 1 UN 5.94 5.94 CIGNA 62308 [3081051] CIGNA 62308 [308105105] 4.75 percent of total billed charges 3.68 5.64 Technical (Hospital) Services ENALAPRIL MALEATE 20 MG TABLET RX-9926 CDM 6370000100 HCPCS 250 RC 51672-4040-01 NDC outpatient 1 UN 5.94 5.94 MULTIPLAN INC 34080 [3081285] MULTIPLAN INC [308128501] 5.64 percent of total billed charges 3.68 5.64 Technical (Hospital) Services ENALAPRIL MALEATE 20 MG TABLET RX-9926 CDM 6370000100 HCPCS 250 RC 51672-4040-01 NDC outpatient 1 UN 5.94 5.94 MEDICA (COMMERCIAL) 94265 [3081118] MEDICA CLAIMS [308111801] 5.35 percent of total billed charges 3.68 5.64 Technical (Hospital) Services ENALAPRIL MALEATE 20 MG TABLET RX-9926 CDM 6370000100 HCPCS 250 RC 51672-4040-01 NDC outpatient 1 UN 5.94 5.94 CIGNA 62308 [3081051] CIGNA STATE OF WYOMING [308105107] 4.75 percent of total billed charges 3.68 5.64 Technical (Hospital) Services ENALAPRIL MALEATE 20 MG TABLET RX-9926 CDM 6370000100 HCPCS 250 RC 51672-4040-01 NDC outpatient 1 UN 5.94 5.94 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES HDHP [308136802] 4.75 percent of total billed charges 3.68 5.64 Technical (Hospital) Services ENALAPRIL MALEATE 20 MG TABLET RX-9926 CDM 6370000100 HCPCS 250 RC 51672-4040-01 NDC outpatient 1 UN 5.94 5.94 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES PPO [308136801] 4.75 percent of total billed charges 3.68 5.64 Technical (Hospital) Services ENALAPRIL MALEATE 20 MG TABLET RX-9926 CDM 6370000100 HCPCS 250 RC 51672-4040-01 NDC outpatient 1 UN 5.94 5.94 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES EPO [308136803] 4.75 percent of total billed charges 3.68 5.64 Technical (Hospital) Services ENALAPRIL MALEATE 5 MG TABLET RX-9927 CDM 6370000100 HCPCS 250 RC 51672-4038-01 NDC outpatient 1 UN 5.83 5.83 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES HDHP [308136802] 4.66 percent of total billed charges 3.61 5.54 Technical (Hospital) Services ENALAPRIL MALEATE 5 MG TABLET RX-9927 CDM 6370000100 HCPCS 250 RC 51672-4038-01 NDC outpatient 1 UN 5.83 5.83 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES PPO [308136801] 4.66 percent of total billed charges 3.61 5.54 Technical (Hospital) Services ENALAPRIL MALEATE 5 MG TABLET RX-9927 CDM 6370000100 HCPCS 250 RC 51672-4038-01 NDC outpatient 1 UN 5.83 5.83 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES EPO [308136803] 4.66 percent of total billed charges 3.61 5.54 Technical (Hospital) Services ENALAPRIL MALEATE 5 MG TABLET RX-9927 CDM 6370000100 HCPCS 250 RC 51672-4038-01 NDC outpatient 1 UN 5.83 5.83 BLUE CROSS BLUE SHIELD WELLMARK SB889 [3081026] BCBS WYOMING [308102603] 5.54 percent of total billed charges 3.61 5.54 Technical (Hospital) Services ENALAPRIL MALEATE 5 MG TABLET RX-9927 CDM 6370000100 HCPCS 250 RC 51672-4038-01 NDC outpatient 1 UN 5.83 5.83 CIGNA 62308 [3081051] CIGNA 62308 [308105105] 4.66 percent of total billed charges 3.61 5.54 Technical (Hospital) Services ENALAPRIL MALEATE 5 MG TABLET RX-9927 CDM 6370000100 HCPCS 250 RC 51672-4038-01 NDC outpatient 1 UN 5.83 5.83 CIGNA 62308 [3081051] CIGNA STATE OF WYOMING [308105107] 4.66 percent of total billed charges 3.61 5.54 Technical (Hospital) Services ENALAPRIL MALEATE 5 MG TABLET RX-9927 CDM 6370000100 HCPCS 250 RC 51672-4038-01 NDC outpatient 1 UN 5.83 5.83 MULTIPLAN INC 34080 [3081285] MULTIPLAN INC [308128501] 5.54 percent of total billed charges 3.61 5.54 Technical (Hospital) Services ENALAPRIL MALEATE 5 MG TABLET RX-9927 CDM 6370000100 HCPCS 250 RC 51672-4038-01 NDC outpatient 1 UN 5.83 5.83 MEDICA (COMMERCIAL) 94265 [3081118] MEDICA CLAIMS [308111801] 5.25 percent of total billed charges 3.61 5.54 Technical (Hospital) Services ENALAPRIL MALEATE 5 MG TABLET RX-9927 CDM 6370000100 HCPCS 250 RC 51672-4038-01 NDC outpatient 1 UN 5.83 5.83 HEALTHPARTNERS SX009 HEALTHPARTNERS 4.66 percent of total billed charges 3.61 5.54 Technical (Hospital) Services ENALAPRIL MALEATE 5 MG TABLET RX-9927 CDM 6370000100 HCPCS 250 RC 51672-4038-01 NDC outpatient 1 UN 5.83 5.83 UNITED HEALTHCARE (COMMERCIAL) [3081199] UNITED HEALTHCARE 87726 [308119901] 3.61 percent of total billed charges 3.61 5.54 Technical (Hospital) Services ENALAPRIL MALEATE 5 MG TABLET RX-9927 CDM 6370000100 HCPCS 250 RC 51672-4038-01 NDC inpatient 1 UN 5.83 5.83 HEALTHPARTNERS SX009 HEALTHPARTNERS 4.62 percent of total billed charges 3.61 5.54 Technical (Hospital) Services ENALAPRIL MALEATE 5 MG TABLET RX-9927 CDM 6370000100 HCPCS 250 RC 51672-4038-01 NDC inpatient 1 UN 5.83 5.83 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES PPO [308136801] 4.62 percent of total billed charges 3.61 5.54 Technical (Hospital) Services ENALAPRIL MALEATE 5 MG TABLET RX-9927 CDM 6370000100 HCPCS 250 RC 51672-4038-01 NDC inpatient 1 UN 5.83 5.83 MEDICA (COMMERCIAL) 94265 [3081118] MEDICA CLAIMS [308111801] 5.25 percent of total billed charges 3.61 5.54 Technical (Hospital) Services ENALAPRIL MALEATE 5 MG TABLET RX-9927 CDM 6370000100 HCPCS 250 RC 51672-4038-01 NDC inpatient 1 UN 5.83 5.83 MULTIPLAN INC 34080 [3081285] MULTIPLAN INC [308128501] 5.54 percent of total billed charges 3.61 5.54 Technical (Hospital) Services ENALAPRIL MALEATE 5 MG TABLET RX-9927 CDM 6370000100 HCPCS 250 RC 51672-4038-01 NDC inpatient 1 UN 5.83 5.83 CIGNA 62308 [3081051] CIGNA 62308 [308105105] 4.62 percent of total billed charges 3.61 5.54 Technical (Hospital) Services ENALAPRIL MALEATE 5 MG TABLET RX-9927 CDM 6370000100 HCPCS 250 RC 51672-4038-01 NDC inpatient 1 UN 5.83 5.83 CIGNA 62308 [3081051] CIGNA STATE OF WYOMING [308105107] 4.62 percent of total billed charges 3.61 5.54 Technical (Hospital) Services ENALAPRIL MALEATE 5 MG TABLET RX-9927 CDM 6370000100 HCPCS 250 RC 51672-4038-01 NDC inpatient 1 UN 5.83 5.83 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES EPO [308136803] 4.62 percent of total billed charges 3.61 5.54 Technical (Hospital) Services ENALAPRIL MALEATE 5 MG TABLET RX-9927 CDM 6370000100 HCPCS 250 RC 51672-4038-01 NDC inpatient 1 UN 5.83 5.83 UNITED HEALTHCARE (COMMERCIAL) [3081199] UNITED HEALTHCARE 87726 [308119901] 3.61 percent of total billed charges 3.61 5.54 Technical (Hospital) Services ENALAPRIL MALEATE 5 MG TABLET RX-9927 CDM 6370000100 HCPCS 250 RC 51672-4038-01 NDC inpatient 1 UN 5.83 5.83 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES HDHP [308136802] 4.62 percent of total billed charges 3.61 5.54 Technical (Hospital) Services ENALAPRIL MALEATE 5 MG TABLET RX-9927 CDM 6370000100 HCPCS 250 RC 51672-4038-01 NDC inpatient 1 UN 5.83 5.83 BLUE CROSS BLUE SHIELD WELLMARK SB889 [3081026] BCBS WYOMING [308102603] 5.54 percent of total billed charges 3.61 5.54 Technical (Hospital) Services LEVONORGESTREL 1.5 MG TABLET RX-99445 CDM 6370000100 HCPCS 250 RC 69536-0200-88 NDC inpatient 1 UN 84 84 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES EPO [308136803] 66.51 percent of total billed charges 52.08 79.8 Technical (Hospital) Services LEVONORGESTREL 1.5 MG TABLET RX-99445 CDM 6370000100 HCPCS 250 RC 69536-0200-88 NDC inpatient 1 UN 84 84 CIGNA 62308 [3081051] CIGNA 62308 [308105105] 66.51 percent of total billed charges 52.08 79.8 Technical (Hospital) Services LEVONORGESTREL 1.5 MG TABLET RX-99445 CDM 6370000100 HCPCS 250 RC 69536-0200-88 NDC inpatient 1 UN 84 84 CIGNA 62308 [3081051] CIGNA STATE OF WYOMING [308105107] 66.51 percent of total billed charges 52.08 79.8 Technical (Hospital) Services LEVONORGESTREL 1.5 MG TABLET RX-99445 CDM 6370000100 HCPCS 250 RC 69536-0200-88 NDC inpatient 1 UN 84 84 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES HDHP [308136802] 66.51 percent of total billed charges 52.08 79.8 Technical (Hospital) Services LEVONORGESTREL 1.5 MG TABLET RX-99445 CDM 6370000100 HCPCS 250 RC 69536-0200-88 NDC inpatient 1 UN 84 84 UNITED HEALTHCARE (COMMERCIAL) [3081199] UNITED HEALTHCARE 87726 [308119901] 52.08 percent of total billed charges 52.08 79.8 Technical (Hospital) Services LEVONORGESTREL 1.5 MG TABLET RX-99445 CDM 6370000100 HCPCS 250 RC 69536-0200-88 NDC inpatient 1 UN 84 84 BLUE CROSS BLUE SHIELD WELLMARK SB889 [3081026] BCBS WYOMING [308102603] 79.8 percent of total billed charges 52.08 79.8 Technical (Hospital) Services LEVONORGESTREL 1.5 MG TABLET RX-99445 CDM 6370000100 HCPCS 250 RC 69536-0200-88 NDC inpatient 1 UN 84 84 MULTIPLAN INC 34080 [3081285] MULTIPLAN INC [308128501] 79.8 percent of total billed charges 52.08 79.8 Technical (Hospital) Services LEVONORGESTREL 1.5 MG TABLET RX-99445 CDM 6370000100 HCPCS 250 RC 69536-0200-88 NDC inpatient 1 UN 84 84 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES PPO [308136801] 66.51 percent of total billed charges 52.08 79.8 Technical (Hospital) Services LEVONORGESTREL 1.5 MG TABLET RX-99445 CDM 6370000100 HCPCS 250 RC 69536-0200-88 NDC inpatient 1 UN 84 84 HEALTHPARTNERS SX009 HEALTHPARTNERS 66.51 percent of total billed charges 52.08 79.8 Technical (Hospital) Services LEVONORGESTREL 1.5 MG TABLET RX-99445 CDM 6370000100 HCPCS 250 RC 69536-0200-88 NDC inpatient 1 UN 84 84 MEDICA (COMMERCIAL) 94265 [3081118] MEDICA CLAIMS [308111801] 75.6 percent of total billed charges 52.08 79.8 Technical (Hospital) Services LEVONORGESTREL 1.5 MG TABLET RX-99445 CDM 6370000100 HCPCS 250 RC 69536-0200-88 NDC outpatient 1 UN 84 84 BLUE CROSS BLUE SHIELD WELLMARK SB889 [3081026] BCBS WYOMING [308102603] 79.8 percent of total billed charges 52.08 79.8 Technical (Hospital) Services LEVONORGESTREL 1.5 MG TABLET RX-99445 CDM 6370000100 HCPCS 250 RC 69536-0200-88 NDC outpatient 1 UN 84 84 UNITED HEALTHCARE (COMMERCIAL) [3081199] UNITED HEALTHCARE 87726 [308119901] 52.08 percent of total billed charges 52.08 79.8 Technical (Hospital) Services LEVONORGESTREL 1.5 MG TABLET RX-99445 CDM 6370000100 HCPCS 250 RC 69536-0200-88 NDC outpatient 1 UN 84 84 MULTIPLAN INC 34080 [3081285] MULTIPLAN INC [308128501] 79.8 percent of total billed charges 52.08 79.8 Technical (Hospital) Services LEVONORGESTREL 1.5 MG TABLET RX-99445 CDM 6370000100 HCPCS 250 RC 69536-0200-88 NDC outpatient 1 UN 84 84 CIGNA 62308 [3081051] CIGNA 62308 [308105105] 67.2 percent of total billed charges 52.08 79.8 Technical (Hospital) Services LEVONORGESTREL 1.5 MG TABLET RX-99445 CDM 6370000100 HCPCS 250 RC 69536-0200-88 NDC outpatient 1 UN 84 84 CIGNA 62308 [3081051] CIGNA STATE OF WYOMING [308105107] 67.2 percent of total billed charges 52.08 79.8 Technical (Hospital) Services LEVONORGESTREL 1.5 MG TABLET RX-99445 CDM 6370000100 HCPCS 250 RC 69536-0200-88 NDC outpatient 1 UN 84 84 HEALTHPARTNERS SX009 HEALTHPARTNERS 67.2 percent of total billed charges 52.08 79.8 Technical (Hospital) Services LEVONORGESTREL 1.5 MG TABLET RX-99445 CDM 6370000100 HCPCS 250 RC 69536-0200-88 NDC outpatient 1 UN 84 84 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES PPO [308136801] 67.2 percent of total billed charges 52.08 79.8 Technical (Hospital) Services LEVONORGESTREL 1.5 MG TABLET RX-99445 CDM 6370000100 HCPCS 250 RC 69536-0200-88 NDC outpatient 1 UN 84 84 MEDICA (COMMERCIAL) 94265 [3081118] MEDICA CLAIMS [308111801] 75.6 percent of total billed charges 52.08 79.8 Technical (Hospital) Services LEVONORGESTREL 1.5 MG TABLET RX-99445 CDM 6370000100 HCPCS 250 RC 69536-0200-88 NDC outpatient 1 UN 84 84 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES HDHP [308136802] 67.2 percent of total billed charges 52.08 79.8 Technical (Hospital) Services LEVONORGESTREL 1.5 MG TABLET RX-99445 CDM 6370000100 HCPCS 250 RC 69536-0200-88 NDC outpatient 1 UN 84 84 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES EPO [308136803] 67.2 percent of total billed charges 52.08 79.8 Technical (Hospital) Services ESTRADIOL 1 MG TABLET RX-9967 CDM 6370000100 HCPCS 250 RC 00378-1454-01 NDC outpatient 1 UN 5.79 5.79 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES EPO [308136803] 4.63 percent of total billed charges 3.59 5.5 Technical (Hospital) Services ESTRADIOL 1 MG TABLET RX-9967 CDM 6370000100 HCPCS 250 RC 00378-1454-01 NDC outpatient 1 UN 5.79 5.79 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES HDHP [308136802] 4.63 percent of total billed charges 3.59 5.5 Technical (Hospital) Services ESTRADIOL 1 MG TABLET RX-9967 CDM 6370000100 HCPCS 250 RC 00378-1454-01 NDC outpatient 1 UN 5.79 5.79 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES PPO [308136801] 4.63 percent of total billed charges 3.59 5.5 Technical (Hospital) Services ESTRADIOL 1 MG TABLET RX-9967 CDM 6370000100 HCPCS 250 RC 00378-1454-01 NDC outpatient 1 UN 5.79 5.79 UNITED HEALTHCARE (COMMERCIAL) [3081199] UNITED HEALTHCARE 87726 [308119901] 3.59 percent of total billed charges 3.59 5.5 Technical (Hospital) Services ESTRADIOL 1 MG TABLET RX-9967 CDM 6370000100 HCPCS 250 RC 00378-1454-01 NDC outpatient 1 UN 5.79 5.79 HEALTHPARTNERS SX009 HEALTHPARTNERS 4.63 percent of total billed charges 3.59 5.5 Technical (Hospital) Services ESTRADIOL 1 MG TABLET RX-9967 CDM 6370000100 HCPCS 250 RC 00378-1454-01 NDC outpatient 1 UN 5.79 5.79 MULTIPLAN INC 34080 [3081285] MULTIPLAN INC [308128501] 5.5 percent of total billed charges 3.59 5.5 Technical (Hospital) Services ESTRADIOL 1 MG TABLET RX-9967 CDM 6370000100 HCPCS 250 RC 00378-1454-01 NDC outpatient 1 UN 5.79 5.79 CIGNA 62308 [3081051] CIGNA 62308 [308105105] 4.63 percent of total billed charges 3.59 5.5 Technical (Hospital) Services ESTRADIOL 1 MG TABLET RX-9967 CDM 6370000100 HCPCS 250 RC 00378-1454-01 NDC outpatient 1 UN 5.79 5.79 CIGNA 62308 [3081051] CIGNA STATE OF WYOMING [308105107] 4.63 percent of total billed charges 3.59 5.5 Technical (Hospital) Services ESTRADIOL 1 MG TABLET RX-9967 CDM 6370000100 HCPCS 250 RC 00378-1454-01 NDC outpatient 1 UN 5.79 5.79 MEDICA (COMMERCIAL) 94265 [3081118] MEDICA CLAIMS [308111801] 5.21 percent of total billed charges 3.59 5.5 Technical (Hospital) Services ESTRADIOL 1 MG TABLET RX-9967 CDM 6370000100 HCPCS 250 RC 00378-1454-01 NDC outpatient 1 UN 5.79 5.79 BLUE CROSS BLUE SHIELD WELLMARK SB889 [3081026] BCBS WYOMING [308102603] 5.5 percent of total billed charges 3.59 5.5 Technical (Hospital) Services ESTRADIOL 1 MG TABLET RX-9967 CDM 6370000100 HCPCS 250 RC 00378-1454-01 NDC inpatient 1 UN 5.79 5.79 MEDICA (COMMERCIAL) 94265 [3081118] MEDICA CLAIMS [308111801] 5.21 percent of total billed charges 3.59 5.5 Technical (Hospital) Services ESTRADIOL 1 MG TABLET RX-9967 CDM 6370000100 HCPCS 250 RC 00378-1454-01 NDC inpatient 1 UN 5.79 5.79 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES PPO [308136801] 4.58 percent of total billed charges 3.59 5.5 Technical (Hospital) Services ESTRADIOL 1 MG TABLET RX-9967 CDM 6370000100 HCPCS 250 RC 00378-1454-01 NDC inpatient 1 UN 5.79 5.79 HEALTHPARTNERS SX009 HEALTHPARTNERS 4.58 percent of total billed charges 3.59 5.5 Technical (Hospital) Services ESTRADIOL 1 MG TABLET RX-9967 CDM 6370000100 HCPCS 250 RC 00378-1454-01 NDC inpatient 1 UN 5.79 5.79 MULTIPLAN INC 34080 [3081285] MULTIPLAN INC [308128501] 5.5 percent of total billed charges 3.59 5.5 Technical (Hospital) Services ESTRADIOL 1 MG TABLET RX-9967 CDM 6370000100 HCPCS 250 RC 00378-1454-01 NDC inpatient 1 UN 5.79 5.79 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES HDHP [308136802] 4.58 percent of total billed charges 3.59 5.5 Technical (Hospital) Services ESTRADIOL 1 MG TABLET RX-9967 CDM 6370000100 HCPCS 250 RC 00378-1454-01 NDC inpatient 1 UN 5.79 5.79 CIGNA 62308 [3081051] CIGNA 62308 [308105105] 4.58 percent of total billed charges 3.59 5.5 Technical (Hospital) Services ESTRADIOL 1 MG TABLET RX-9967 CDM 6370000100 HCPCS 250 RC 00378-1454-01 NDC inpatient 1 UN 5.79 5.79 CIGNA 62308 [3081051] CIGNA STATE OF WYOMING [308105107] 4.58 percent of total billed charges 3.59 5.5 Technical (Hospital) Services ESTRADIOL 1 MG TABLET RX-9967 CDM 6370000100 HCPCS 250 RC 00378-1454-01 NDC inpatient 1 UN 5.79 5.79 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES EPO [308136803] 4.58 percent of total billed charges 3.59 5.5 Technical (Hospital) Services ESTRADIOL 1 MG TABLET RX-9967 CDM 6370000100 HCPCS 250 RC 00378-1454-01 NDC inpatient 1 UN 5.79 5.79 BLUE CROSS BLUE SHIELD WELLMARK SB889 [3081026] BCBS WYOMING [308102603] 5.5 percent of total billed charges 3.59 5.5 Technical (Hospital) Services ESTRADIOL 1 MG TABLET RX-9967 CDM 6370000100 HCPCS 250 RC 00378-1454-01 NDC inpatient 1 UN 5.79 5.79 UNITED HEALTHCARE (COMMERCIAL) [3081199] UNITED HEALTHCARE 87726 [308119901] 3.59 percent of total billed charges 3.59 5.5 Technical (Hospital) Services ESTRADIOL 0.01% (0.1 MG/GRAM) VAGINAL CREAM RX-9969 CDM 6370000100 HCPCS 250 RC 00378-8770-35 NDC outpatient 2 GR 29.43 29.43 BLUE CROSS BLUE SHIELD WELLMARK SB889 [3081026] BCBS WYOMING [308102603] 27.96 percent of total billed charges 18.25 27.96 Technical (Hospital) Services ESTRADIOL 0.01% (0.1 MG/GRAM) VAGINAL CREAM RX-9969 CDM 6370000100 HCPCS 250 RC 00378-8770-35 NDC outpatient 2 GR 29.43 29.43 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES EPO [308136803] 23.54 percent of total billed charges 18.25 27.96 Technical (Hospital) Services ESTRADIOL 0.01% (0.1 MG/GRAM) VAGINAL CREAM RX-9969 CDM 6370000100 HCPCS 250 RC 00378-8770-35 NDC outpatient 2 GR 29.43 29.43 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES HDHP [308136802] 23.54 percent of total billed charges 18.25 27.96 Technical (Hospital) Services ESTRADIOL 0.01% (0.1 MG/GRAM) VAGINAL CREAM RX-9969 CDM 6370000100 HCPCS 250 RC 00378-8770-35 NDC outpatient 2 GR 29.43 29.43 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES PPO [308136801] 23.54 percent of total billed charges 18.25 27.96 Technical (Hospital) Services ESTRADIOL 0.01% (0.1 MG/GRAM) VAGINAL CREAM RX-9969 CDM 6370000100 HCPCS 250 RC 00378-8770-35 NDC outpatient 2 GR 29.43 29.43 CIGNA 62308 [3081051] CIGNA 62308 [308105105] 23.54 percent of total billed charges 18.25 27.96 Technical (Hospital) Services ESTRADIOL 0.01% (0.1 MG/GRAM) VAGINAL CREAM RX-9969 CDM 6370000100 HCPCS 250 RC 00378-8770-35 NDC outpatient 2 GR 29.43 29.43 CIGNA 62308 [3081051] CIGNA STATE OF WYOMING [308105107] 23.54 percent of total billed charges 18.25 27.96 Technical (Hospital) Services ESTRADIOL 0.01% (0.1 MG/GRAM) VAGINAL CREAM RX-9969 CDM 6370000100 HCPCS 250 RC 00378-8770-35 NDC outpatient 2 GR 29.43 29.43 UNITED HEALTHCARE (COMMERCIAL) [3081199] UNITED HEALTHCARE 87726 [308119901] 18.25 percent of total billed charges 18.25 27.96 Technical (Hospital) Services ESTRADIOL 0.01% (0.1 MG/GRAM) VAGINAL CREAM RX-9969 CDM 6370000100 HCPCS 250 RC 00378-8770-35 NDC outpatient 2 GR 29.43 29.43 HEALTHPARTNERS SX009 HEALTHPARTNERS 23.54 percent of total billed charges 18.25 27.96 Technical (Hospital) Services ESTRADIOL 0.01% (0.1 MG/GRAM) VAGINAL CREAM RX-9969 CDM 6370000100 HCPCS 250 RC 00378-8770-35 NDC outpatient 2 GR 29.43 29.43 MULTIPLAN INC 34080 [3081285] MULTIPLAN INC [308128501] 27.96 percent of total billed charges 18.25 27.96 Technical (Hospital) Services ESTRADIOL 0.01% (0.1 MG/GRAM) VAGINAL CREAM RX-9969 CDM 6370000100 HCPCS 250 RC 00378-8770-35 NDC outpatient 2 GR 29.43 29.43 MEDICA (COMMERCIAL) 94265 [3081118] MEDICA CLAIMS [308111801] 26.49 percent of total billed charges 18.25 27.96 Technical (Hospital) Services ESTRADIOL 0.01% (0.1 MG/GRAM) VAGINAL CREAM RX-9969 CDM 6370000100 HCPCS 250 RC 00378-8770-35 NDC inpatient 2 GR 29.43 29.43 HEALTHPARTNERS SX009 HEALTHPARTNERS 23.3 percent of total billed charges 18.25 27.96 Technical (Hospital) Services ESTRADIOL 0.01% (0.1 MG/GRAM) VAGINAL CREAM RX-9969 CDM 6370000100 HCPCS 250 RC 00378-8770-35 NDC inpatient 2 GR 29.43 29.43 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES PPO [308136801] 23.3 percent of total billed charges 18.25 27.96 Technical (Hospital) Services ESTRADIOL 0.01% (0.1 MG/GRAM) VAGINAL CREAM RX-9969 CDM 6370000100 HCPCS 250 RC 00378-8770-35 NDC inpatient 2 GR 29.43 29.43 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES EPO [308136803] 23.3 percent of total billed charges 18.25 27.96 Technical (Hospital) Services ESTRADIOL 0.01% (0.1 MG/GRAM) VAGINAL CREAM RX-9969 CDM 6370000100 HCPCS 250 RC 00378-8770-35 NDC inpatient 2 GR 29.43 29.43 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES HDHP [308136802] 23.3 percent of total billed charges 18.25 27.96 Technical (Hospital) Services ESTRADIOL 0.01% (0.1 MG/GRAM) VAGINAL CREAM RX-9969 CDM 6370000100 HCPCS 250 RC 00378-8770-35 NDC inpatient 2 GR 29.43 29.43 UNITED HEALTHCARE (COMMERCIAL) [3081199] UNITED HEALTHCARE 87726 [308119901] 18.25 percent of total billed charges 18.25 27.96 Technical (Hospital) Services ESTRADIOL 0.01% (0.1 MG/GRAM) VAGINAL CREAM RX-9969 CDM 6370000100 HCPCS 250 RC 00378-8770-35 NDC inpatient 2 GR 29.43 29.43 BLUE CROSS BLUE SHIELD WELLMARK SB889 [3081026] BCBS WYOMING [308102603] 27.96 percent of total billed charges 18.25 27.96 Technical (Hospital) Services ESTRADIOL 0.01% (0.1 MG/GRAM) VAGINAL CREAM RX-9969 CDM 6370000100 HCPCS 250 RC 00378-8770-35 NDC inpatient 2 GR 29.43 29.43 CIGNA 62308 [3081051] CIGNA 62308 [308105105] 23.3 percent of total billed charges 18.25 27.96 Technical (Hospital) Services ESTRADIOL 0.01% (0.1 MG/GRAM) VAGINAL CREAM RX-9969 CDM 6370000100 HCPCS 250 RC 00378-8770-35 NDC inpatient 2 GR 29.43 29.43 CIGNA 62308 [3081051] CIGNA STATE OF WYOMING [308105107] 23.3 percent of total billed charges 18.25 27.96 Technical (Hospital) Services ESTRADIOL 0.01% (0.1 MG/GRAM) VAGINAL CREAM RX-9969 CDM 6370000100 HCPCS 250 RC 00378-8770-35 NDC inpatient 2 GR 29.43 29.43 MEDICA (COMMERCIAL) 94265 [3081118] MEDICA CLAIMS [308111801] 26.49 percent of total billed charges 18.25 27.96 Technical (Hospital) Services ESTRADIOL 0.01% (0.1 MG/GRAM) VAGINAL CREAM RX-9969 CDM 6370000100 HCPCS 250 RC 00378-8770-35 NDC inpatient 2 GR 29.43 29.43 MULTIPLAN INC 34080 [3081285] MULTIPLAN INC [308128501] 27.96 percent of total billed charges 18.25 27.96 Technical (Hospital) Services CONJUGATED ESTROGENS 0.625 MG/GRAM VAGINAL CREAM RX-9977 CDM 6370000100 HCPCS 250 RC 00046-0872-21 NDC inpatient 1 GR 54 54 MEDICA (COMMERCIAL) 94265 [3081118] MEDICA CLAIMS [308111801] 48.6 percent of total billed charges 33.48 51.3 Technical (Hospital) Services CONJUGATED ESTROGENS 0.625 MG/GRAM VAGINAL CREAM RX-9977 CDM 6370000100 HCPCS 250 RC 00046-0872-21 NDC inpatient 1 GR 54 54 HEALTHPARTNERS SX009 HEALTHPARTNERS 42.76 percent of total billed charges 33.48 51.3 Technical (Hospital) Services CONJUGATED ESTROGENS 0.625 MG/GRAM VAGINAL CREAM RX-9977 CDM 6370000100 HCPCS 250 RC 00046-0872-21 NDC inpatient 1 GR 54 54 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES PPO [308136801] 42.76 percent of total billed charges 33.48 51.3 Technical (Hospital) Services CONJUGATED ESTROGENS 0.625 MG/GRAM VAGINAL CREAM RX-9977 CDM 6370000100 HCPCS 250 RC 00046-0872-21 NDC inpatient 1 GR 54 54 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES HDHP [308136802] 42.76 percent of total billed charges 33.48 51.3 Technical (Hospital) Services CONJUGATED ESTROGENS 0.625 MG/GRAM VAGINAL CREAM RX-9977 CDM 6370000100 HCPCS 250 RC 00046-0872-21 NDC inpatient 1 GR 54 54 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES EPO [308136803] 42.76 percent of total billed charges 33.48 51.3 Technical (Hospital) Services CONJUGATED ESTROGENS 0.625 MG/GRAM VAGINAL CREAM RX-9977 CDM 6370000100 HCPCS 250 RC 00046-0872-21 NDC inpatient 1 GR 54 54 CIGNA 62308 [3081051] CIGNA 62308 [308105105] 42.76 percent of total billed charges 33.48 51.3 Technical (Hospital) Services CONJUGATED ESTROGENS 0.625 MG/GRAM VAGINAL CREAM RX-9977 CDM 6370000100 HCPCS 250 RC 00046-0872-21 NDC inpatient 1 GR 54 54 CIGNA 62308 [3081051] CIGNA STATE OF WYOMING [308105107] 42.76 percent of total billed charges 33.48 51.3 Technical (Hospital) Services CONJUGATED ESTROGENS 0.625 MG/GRAM VAGINAL CREAM RX-9977 CDM 6370000100 HCPCS 250 RC 00046-0872-21 NDC inpatient 1 GR 54 54 UNITED HEALTHCARE (COMMERCIAL) [3081199] UNITED HEALTHCARE 87726 [308119901] 33.48 percent of total billed charges 33.48 51.3 Technical (Hospital) Services CONJUGATED ESTROGENS 0.625 MG/GRAM VAGINAL CREAM RX-9977 CDM 6370000100 HCPCS 250 RC 00046-0872-21 NDC inpatient 1 GR 54 54 BLUE CROSS BLUE SHIELD WELLMARK SB889 [3081026] BCBS WYOMING [308102603] 51.3 percent of total billed charges 33.48 51.3 Technical (Hospital) Services CONJUGATED ESTROGENS 0.625 MG/GRAM VAGINAL CREAM RX-9977 CDM 6370000100 HCPCS 250 RC 00046-0872-21 NDC inpatient 1 GR 54 54 MULTIPLAN INC 34080 [3081285] MULTIPLAN INC [308128501] 51.3 percent of total billed charges 33.48 51.3 Technical (Hospital) Services CONJUGATED ESTROGENS 0.625 MG/GRAM VAGINAL CREAM RX-9977 CDM 6370000100 HCPCS 250 RC 00046-0872-21 NDC outpatient 1 GR 54 54 HEALTHPARTNERS SX009 HEALTHPARTNERS 43.2 percent of total billed charges 33.48 51.3 Technical (Hospital) Services CONJUGATED ESTROGENS 0.625 MG/GRAM VAGINAL CREAM RX-9977 CDM 6370000100 HCPCS 250 RC 00046-0872-21 NDC outpatient 1 GR 54 54 UNITED HEALTHCARE (COMMERCIAL) [3081199] UNITED HEALTHCARE 87726 [308119901] 33.48 percent of total billed charges 33.48 51.3 Technical (Hospital) Services CONJUGATED ESTROGENS 0.625 MG/GRAM VAGINAL CREAM RX-9977 CDM 6370000100 HCPCS 250 RC 00046-0872-21 NDC outpatient 1 GR 54 54 MULTIPLAN INC 34080 [3081285] MULTIPLAN INC [308128501] 51.3 percent of total billed charges 33.48 51.3 Technical (Hospital) Services CONJUGATED ESTROGENS 0.625 MG/GRAM VAGINAL CREAM RX-9977 CDM 6370000100 HCPCS 250 RC 00046-0872-21 NDC outpatient 1 GR 54 54 CIGNA 62308 [3081051] CIGNA 62308 [308105105] 43.2 percent of total billed charges 33.48 51.3 Technical (Hospital) Services CONJUGATED ESTROGENS 0.625 MG/GRAM VAGINAL CREAM RX-9977 CDM 6370000100 HCPCS 250 RC 00046-0872-21 NDC outpatient 1 GR 54 54 CIGNA 62308 [3081051] CIGNA STATE OF WYOMING [308105107] 43.2 percent of total billed charges 33.48 51.3 Technical (Hospital) Services CONJUGATED ESTROGENS 0.625 MG/GRAM VAGINAL CREAM RX-9977 CDM 6370000100 HCPCS 250 RC 00046-0872-21 NDC outpatient 1 GR 54 54 MEDICA (COMMERCIAL) 94265 [3081118] MEDICA CLAIMS [308111801] 48.6 percent of total billed charges 33.48 51.3 Technical (Hospital) Services CONJUGATED ESTROGENS 0.625 MG/GRAM VAGINAL CREAM RX-9977 CDM 6370000100 HCPCS 250 RC 00046-0872-21 NDC outpatient 1 GR 54 54 BLUE CROSS BLUE SHIELD WELLMARK SB889 [3081026] BCBS WYOMING [308102603] 51.3 percent of total billed charges 33.48 51.3 Technical (Hospital) Services CONJUGATED ESTROGENS 0.625 MG/GRAM VAGINAL CREAM RX-9977 CDM 6370000100 HCPCS 250 RC 00046-0872-21 NDC outpatient 1 GR 54 54 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES PPO [308136801] 43.2 percent of total billed charges 33.48 51.3 Technical (Hospital) Services CONJUGATED ESTROGENS 0.625 MG/GRAM VAGINAL CREAM RX-9977 CDM 6370000100 HCPCS 250 RC 00046-0872-21 NDC outpatient 1 GR 54 54 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES HDHP [308136802] 43.2 percent of total billed charges 33.48 51.3 Technical (Hospital) Services CONJUGATED ESTROGENS 0.625 MG/GRAM VAGINAL CREAM RX-9977 CDM 6370000100 HCPCS 250 RC 00046-0872-21 NDC outpatient 1 GR 54 54 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES EPO [308136803] 43.2 percent of total billed charges 33.48 51.3 Technical (Hospital) Services FLU VACCINE TV2024(18YR UP)RCMB(PF)135 MCG(45 MCGX3)/0.5 ML IM SYRINGE RX-193615 CDM 6360000200 HCPCS 636 RC 49281-0724-88 NDC inpatient 0.5 ML 334.61 334.61 HEALTHPARTNERS SX009 HEALTHPARTNERS 264.94 percent of total billed charges 207.46 317.88 Technical (Hospital) Services FLU VACCINE TV2024(18YR UP)RCMB(PF)135 MCG(45 MCGX3)/0.5 ML IM SYRINGE RX-193615 CDM 6360000200 HCPCS 636 RC 49281-0724-88 NDC inpatient 0.5 ML 334.61 334.61 MULTIPLAN INC 34080 [3081285] MULTIPLAN INC [308128501] 317.88 percent of total billed charges 207.46 317.88 Technical (Hospital) Services FLU VACCINE TV2024(18YR UP)RCMB(PF)135 MCG(45 MCGX3)/0.5 ML IM SYRINGE RX-193615 CDM 6360000200 HCPCS 636 RC 49281-0724-88 NDC inpatient 0.5 ML 334.61 334.61 MEDICA (COMMERCIAL) 94265 [3081118] MEDICA CLAIMS [308111801] 301.15 percent of total billed charges 207.46 317.88 Technical (Hospital) Services FLU VACCINE TV2024(18YR UP)RCMB(PF)135 MCG(45 MCGX3)/0.5 ML IM SYRINGE RX-193615 CDM 6360000200 HCPCS 636 RC 49281-0724-88 NDC inpatient 0.5 ML 334.61 334.61 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES HDHP [308136802] 264.94 percent of total billed charges 207.46 317.88 Technical (Hospital) Services FLU VACCINE TV2024(18YR UP)RCMB(PF)135 MCG(45 MCGX3)/0.5 ML IM SYRINGE RX-193615 CDM 6360000200 HCPCS 636 RC 49281-0724-88 NDC inpatient 0.5 ML 334.61 334.61 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES PPO [308136801] 264.94 percent of total billed charges 207.46 317.88 Technical (Hospital) Services FLU VACCINE TV2024(18YR UP)RCMB(PF)135 MCG(45 MCGX3)/0.5 ML IM SYRINGE RX-193615 CDM 6360000200 HCPCS 636 RC 49281-0724-88 NDC inpatient 0.5 ML 334.61 334.61 CIGNA 62308 [3081051] CIGNA 62308 [308105105] 264.94 percent of total billed charges 207.46 317.88 Technical (Hospital) Services FLU VACCINE TV2024(18YR UP)RCMB(PF)135 MCG(45 MCGX3)/0.5 ML IM SYRINGE RX-193615 CDM 6360000200 HCPCS 636 RC 49281-0724-88 NDC inpatient 0.5 ML 334.61 334.61 CIGNA 62308 [3081051] CIGNA STATE OF WYOMING [308105107] 264.94 percent of total billed charges 207.46 317.88 Technical (Hospital) Services FLU VACCINE TV2024(18YR UP)RCMB(PF)135 MCG(45 MCGX3)/0.5 ML IM SYRINGE RX-193615 CDM 6360000200 HCPCS 636 RC 49281-0724-88 NDC inpatient 0.5 ML 334.61 334.61 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES EPO [308136803] 264.94 percent of total billed charges 207.46 317.88 Technical (Hospital) Services FLU VACCINE TV2024(18YR UP)RCMB(PF)135 MCG(45 MCGX3)/0.5 ML IM SYRINGE RX-193615 CDM 6360000200 HCPCS 636 RC 49281-0724-88 NDC inpatient 0.5 ML 334.61 334.61 UNITED HEALTHCARE (COMMERCIAL) [3081199] UNITED HEALTHCARE 87726 [308119901] 207.46 percent of total billed charges 207.46 317.88 Technical (Hospital) Services FLU VACCINE TV2024(18YR UP)RCMB(PF)135 MCG(45 MCGX3)/0.5 ML IM SYRINGE RX-193615 CDM 6360000200 HCPCS 636 RC 49281-0724-88 NDC inpatient 0.5 ML 334.61 334.61 BLUE CROSS BLUE SHIELD WELLMARK SB889 [3081026] BCBS WYOMING [308102603] 317.88 percent of total billed charges 207.46 317.88 Technical (Hospital) Services FLU VACCINE TV2024(18YR UP)RCMB(PF)135 MCG(45 MCGX3)/0.5 ML IM SYRINGE RX-193615 CDM 6360000200 HCPCS 636 RC 49281-0724-88 NDC outpatient 0.5 ML 334.61 334.61 HEALTHPARTNERS SX009 HEALTHPARTNERS 267.69 percent of total billed charges 207.46 317.88 Technical (Hospital) Services FLU VACCINE TV2024(18YR UP)RCMB(PF)135 MCG(45 MCGX3)/0.5 ML IM SYRINGE RX-193615 CDM 6360000200 HCPCS 636 RC 49281-0724-88 NDC outpatient 0.5 ML 334.61 334.61 BLUE CROSS BLUE SHIELD WELLMARK SB889 [3081026] BCBS WYOMING [308102603] 317.88 percent of total billed charges 207.46 317.88 Technical (Hospital) Services FLU VACCINE TV2024(18YR UP)RCMB(PF)135 MCG(45 MCGX3)/0.5 ML IM SYRINGE RX-193615 CDM 6360000200 HCPCS 636 RC 49281-0724-88 NDC outpatient 0.5 ML 334.61 334.61 CIGNA 62308 [3081051] CIGNA 62308 [308105105] 267.69 percent of total billed charges 207.46 317.88 Technical (Hospital) Services FLU VACCINE TV2024(18YR UP)RCMB(PF)135 MCG(45 MCGX3)/0.5 ML IM SYRINGE RX-193615 CDM 6360000200 HCPCS 636 RC 49281-0724-88 NDC outpatient 0.5 ML 334.61 334.61 CIGNA 62308 [3081051] CIGNA STATE OF WYOMING [308105107] 267.69 percent of total billed charges 207.46 317.88 Technical (Hospital) Services FLU VACCINE TV2024(18YR UP)RCMB(PF)135 MCG(45 MCGX3)/0.5 ML IM SYRINGE RX-193615 CDM 6360000200 HCPCS 636 RC 49281-0724-88 NDC outpatient 0.5 ML 334.61 334.61 MULTIPLAN INC 34080 [3081285] MULTIPLAN INC [308128501] 317.88 percent of total billed charges 207.46 317.88 Technical (Hospital) Services FLU VACCINE TV2024(18YR UP)RCMB(PF)135 MCG(45 MCGX3)/0.5 ML IM SYRINGE RX-193615 CDM 6360000200 HCPCS 636 RC 49281-0724-88 NDC outpatient 0.5 ML 334.61 334.61 UNITED HEALTHCARE (COMMERCIAL) [3081199] UNITED HEALTHCARE 87726 [308119901] 207.46 percent of total billed charges 207.46 317.88 Technical (Hospital) Services FLU VACCINE TV2024(18YR UP)RCMB(PF)135 MCG(45 MCGX3)/0.5 ML IM SYRINGE RX-193615 CDM 6360000200 HCPCS 636 RC 49281-0724-88 NDC outpatient 0.5 ML 334.61 334.61 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES HDHP [308136802] 267.69 percent of total billed charges 207.46 317.88 Technical (Hospital) Services FLU VACCINE TV2024(18YR UP)RCMB(PF)135 MCG(45 MCGX3)/0.5 ML IM SYRINGE RX-193615 CDM 6360000200 HCPCS 636 RC 49281-0724-88 NDC outpatient 0.5 ML 334.61 334.61 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES PPO [308136801] 267.69 percent of total billed charges 207.46 317.88 Technical (Hospital) Services FLU VACCINE TV2024(18YR UP)RCMB(PF)135 MCG(45 MCGX3)/0.5 ML IM SYRINGE RX-193615 CDM 6360000200 HCPCS 636 RC 49281-0724-88 NDC outpatient 0.5 ML 334.61 334.61 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES EPO [308136803] 267.69 percent of total billed charges 207.46 317.88 Technical (Hospital) Services FLU VACCINE TV2024(18YR UP)RCMB(PF)135 MCG(45 MCGX3)/0.5 ML IM SYRINGE RX-193615 CDM 6360000200 HCPCS 636 RC 49281-0724-88 NDC outpatient 0.5 ML 334.61 334.61 MEDICA (COMMERCIAL) 94265 [3081118] MEDICA CLAIMS [308111801] 301.15 percent of total billed charges 207.46 317.88 Technical (Hospital) Services LIDOCAINE (PF) 50 MG/5 ML (1 %) INTRAVENOUS SYRINGE RX-4457 CDM 6360000200 HCPCS 636 RC 00409-9137-05 NDC inpatient 5 ML 82.39 82.39 CIGNA 62308 [3081051] CIGNA STATE OF WYOMING [308105107] 65.24 percent of total billed charges 51.08 78.27 Technical (Hospital) Services LIDOCAINE (PF) 50 MG/5 ML (1 %) INTRAVENOUS SYRINGE RX-4457 CDM 6360000200 HCPCS 636 RC 00409-9137-05 NDC inpatient 5 ML 82.39 82.39 CIGNA 62308 [3081051] CIGNA 62308 [308105105] 65.24 percent of total billed charges 51.08 78.27 Technical (Hospital) Services LIDOCAINE (PF) 50 MG/5 ML (1 %) INTRAVENOUS SYRINGE RX-4457 CDM 6360000200 HCPCS 636 RC 00409-9137-05 NDC inpatient 5 ML 82.39 82.39 UNITED HEALTHCARE (COMMERCIAL) [3081199] UNITED HEALTHCARE 87726 [308119901] 51.08 percent of total billed charges 51.08 78.27 Technical (Hospital) Services LIDOCAINE (PF) 50 MG/5 ML (1 %) INTRAVENOUS SYRINGE RX-4457 CDM 6360000200 HCPCS 636 RC 00409-9137-05 NDC inpatient 5 ML 82.39 82.39 BLUE CROSS BLUE SHIELD WELLMARK SB889 [3081026] BCBS WYOMING [308102603] 78.27 percent of total billed charges 51.08 78.27 Technical (Hospital) Services LIDOCAINE (PF) 50 MG/5 ML (1 %) INTRAVENOUS SYRINGE RX-4457 CDM 6360000200 HCPCS 636 RC 00409-9137-05 NDC inpatient 5 ML 82.39 82.39 MULTIPLAN INC 34080 [3081285] MULTIPLAN INC [308128501] 78.27 percent of total billed charges 51.08 78.27 Technical (Hospital) Services LIDOCAINE (PF) 50 MG/5 ML (1 %) INTRAVENOUS SYRINGE RX-4457 CDM 6360000200 HCPCS 636 RC 00409-9137-05 NDC inpatient 5 ML 82.39 82.39 MEDICA (COMMERCIAL) 94265 [3081118] MEDICA CLAIMS [308111801] 74.15 percent of total billed charges 51.08 78.27 Technical (Hospital) Services LIDOCAINE (PF) 50 MG/5 ML (1 %) INTRAVENOUS SYRINGE RX-4457 CDM 6360000200 HCPCS 636 RC 00409-9137-05 NDC inpatient 5 ML 82.39 82.39 HEALTHPARTNERS SX009 HEALTHPARTNERS 65.24 percent of total billed charges 51.08 78.27 Technical (Hospital) Services LIDOCAINE (PF) 50 MG/5 ML (1 %) INTRAVENOUS SYRINGE RX-4457 CDM 6360000200 HCPCS 636 RC 00409-9137-05 NDC inpatient 5 ML 82.39 82.39 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES EPO [308136803] 65.24 percent of total billed charges 51.08 78.27 Technical (Hospital) Services LIDOCAINE (PF) 50 MG/5 ML (1 %) INTRAVENOUS SYRINGE RX-4457 CDM 6360000200 HCPCS 636 RC 00409-9137-05 NDC inpatient 5 ML 82.39 82.39 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES HDHP [308136802] 65.24 percent of total billed charges 51.08 78.27 Technical (Hospital) Services LIDOCAINE (PF) 50 MG/5 ML (1 %) INTRAVENOUS SYRINGE RX-4457 CDM 6360000200 HCPCS 636 RC 00409-9137-05 NDC inpatient 5 ML 82.39 82.39 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES PPO [308136801] 65.24 percent of total billed charges 51.08 78.27 Technical (Hospital) Services LIDOCAINE (PF) 50 MG/5 ML (1 %) INTRAVENOUS SYRINGE RX-4457 CDM 6360000200 HCPCS 636 RC 00409-9137-05 NDC outpatient 5 ML 82.39 82.39 UNITED HEALTHCARE (COMMERCIAL) [3081199] UNITED HEALTHCARE 87726 [308119901] 51.08 percent of total billed charges 51.08 78.27 Technical (Hospital) Services LIDOCAINE (PF) 50 MG/5 ML (1 %) INTRAVENOUS SYRINGE RX-4457 CDM 6360000200 HCPCS 636 RC 00409-9137-05 NDC outpatient 5 ML 82.39 82.39 HEALTHPARTNERS SX009 HEALTHPARTNERS 65.91 percent of total billed charges 51.08 78.27 Technical (Hospital) Services LIDOCAINE (PF) 50 MG/5 ML (1 %) INTRAVENOUS SYRINGE RX-4457 CDM 6360000200 HCPCS 636 RC 00409-9137-05 NDC outpatient 5 ML 82.39 82.39 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES HDHP [308136802] 65.91 percent of total billed charges 51.08 78.27 Technical (Hospital) Services LIDOCAINE (PF) 50 MG/5 ML (1 %) INTRAVENOUS SYRINGE RX-4457 CDM 6360000200 HCPCS 636 RC 00409-9137-05 NDC outpatient 5 ML 82.39 82.39 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES PPO [308136801] 65.91 percent of total billed charges 51.08 78.27 Technical (Hospital) Services LIDOCAINE (PF) 50 MG/5 ML (1 %) INTRAVENOUS SYRINGE RX-4457 CDM 6360000200 HCPCS 636 RC 00409-9137-05 NDC outpatient 5 ML 82.39 82.39 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES EPO [308136803] 65.91 percent of total billed charges 51.08 78.27 Technical (Hospital) Services LIDOCAINE (PF) 50 MG/5 ML (1 %) INTRAVENOUS SYRINGE RX-4457 CDM 6360000200 HCPCS 636 RC 00409-9137-05 NDC outpatient 5 ML 82.39 82.39 BLUE CROSS BLUE SHIELD WELLMARK SB889 [3081026] BCBS WYOMING [308102603] 78.27 percent of total billed charges 51.08 78.27 Technical (Hospital) Services LIDOCAINE (PF) 50 MG/5 ML (1 %) INTRAVENOUS SYRINGE RX-4457 CDM 6360000200 HCPCS 636 RC 00409-9137-05 NDC outpatient 5 ML 82.39 82.39 MEDICA (COMMERCIAL) 94265 [3081118] MEDICA CLAIMS [308111801] 74.15 percent of total billed charges 51.08 78.27 Technical (Hospital) Services LIDOCAINE (PF) 50 MG/5 ML (1 %) INTRAVENOUS SYRINGE RX-4457 CDM 6360000200 HCPCS 636 RC 00409-9137-05 NDC outpatient 5 ML 82.39 82.39 MULTIPLAN INC 34080 [3081285] MULTIPLAN INC [308128501] 78.27 percent of total billed charges 51.08 78.27 Technical (Hospital) Services LIDOCAINE (PF) 50 MG/5 ML (1 %) INTRAVENOUS SYRINGE RX-4457 CDM 6360000200 HCPCS 636 RC 00409-9137-05 NDC outpatient 5 ML 82.39 82.39 CIGNA 62308 [3081051] CIGNA 62308 [308105105] 65.91 percent of total billed charges 51.08 78.27 Technical (Hospital) Services LIDOCAINE (PF) 50 MG/5 ML (1 %) INTRAVENOUS SYRINGE RX-4457 CDM 6360000200 HCPCS 636 RC 00409-9137-05 NDC outpatient 5 ML 82.39 82.39 CIGNA 62308 [3081051] CIGNA STATE OF WYOMING [308105107] 65.91 percent of total billed charges 51.08 78.27 Technical (Hospital) Services ACETAMINOPHEN 160 MG/5 ML ORAL LIQUID RX-100 CDM 2590000100 HCPCS 259 RC 00485-0057-08 NDC outpatient 236 ML 28.61 28.61 CIGNA 62308 [3081051] CIGNA 62308 [308105105] 22.89 percent of total billed charges 17.74 27.18 Technical (Hospital) Services ACETAMINOPHEN 160 MG/5 ML ORAL LIQUID RX-100 CDM 2590000100 HCPCS 259 RC 00485-0057-08 NDC outpatient 236 ML 28.61 28.61 CIGNA 62308 [3081051] CIGNA STATE OF WYOMING [308105107] 22.89 percent of total billed charges 17.74 27.18 Technical (Hospital) Services ACETAMINOPHEN 160 MG/5 ML ORAL LIQUID RX-100 CDM 2590000100 HCPCS 259 RC 00485-0057-08 NDC outpatient 236 ML 28.61 28.61 MEDICA (COMMERCIAL) 94265 [3081118] MEDICA CLAIMS [308111801] 25.75 percent of total billed charges 17.74 27.18 Technical (Hospital) Services ACETAMINOPHEN 160 MG/5 ML ORAL LIQUID RX-100 CDM 2590000100 HCPCS 259 RC 00485-0057-08 NDC outpatient 236 ML 28.61 28.61 MULTIPLAN INC 34080 [3081285] MULTIPLAN INC [308128501] 27.18 percent of total billed charges 17.74 27.18 Technical (Hospital) Services ACETAMINOPHEN 160 MG/5 ML ORAL LIQUID RX-100 CDM 2590000100 HCPCS 259 RC 00485-0057-08 NDC outpatient 236 ML 28.61 28.61 UNITED HEALTHCARE (COMMERCIAL) [3081199] UNITED HEALTHCARE 87726 [308119901] 17.74 percent of total billed charges 17.74 27.18 Technical (Hospital) Services ACETAMINOPHEN 160 MG/5 ML ORAL LIQUID RX-100 CDM 2590000100 HCPCS 259 RC 00485-0057-08 NDC outpatient 236 ML 28.61 28.61 HEALTHPARTNERS SX009 HEALTHPARTNERS 22.89 percent of total billed charges 17.74 27.18 Technical (Hospital) Services ACETAMINOPHEN 160 MG/5 ML ORAL LIQUID RX-100 CDM 2590000100 HCPCS 259 RC 00485-0057-08 NDC outpatient 236 ML 28.61 28.61 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES EPO [308136803] 22.89 percent of total billed charges 17.74 27.18 Technical (Hospital) Services ACETAMINOPHEN 160 MG/5 ML ORAL LIQUID RX-100 CDM 2590000100 HCPCS 259 RC 00485-0057-08 NDC outpatient 236 ML 28.61 28.61 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES HDHP [308136802] 22.89 percent of total billed charges 17.74 27.18 Technical (Hospital) Services ACETAMINOPHEN 160 MG/5 ML ORAL LIQUID RX-100 CDM 2590000100 HCPCS 259 RC 00485-0057-08 NDC outpatient 236 ML 28.61 28.61 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES PPO [308136801] 22.89 percent of total billed charges 17.74 27.18 Technical (Hospital) Services ACETAMINOPHEN 160 MG/5 ML ORAL LIQUID RX-100 CDM 2590000100 HCPCS 259 RC 00485-0057-08 NDC outpatient 236 ML 28.61 28.61 BLUE CROSS BLUE SHIELD WELLMARK SB889 [3081026] BCBS WYOMING [308102603] 27.18 percent of total billed charges 17.74 27.18 Technical (Hospital) Services ACETAMINOPHEN 160 MG/5 ML ORAL LIQUID RX-100 CDM 2590000100 HCPCS 259 RC 00485-0057-08 NDC inpatient 236 ML 28.61 28.61 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES EPO [308136803] 22.65 percent of total billed charges 17.74 27.18 Technical (Hospital) Services ACETAMINOPHEN 160 MG/5 ML ORAL LIQUID RX-100 CDM 2590000100 HCPCS 259 RC 00485-0057-08 NDC inpatient 236 ML 28.61 28.61 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES HDHP [308136802] 22.65 percent of total billed charges 17.74 27.18 Technical (Hospital) Services ACETAMINOPHEN 160 MG/5 ML ORAL LIQUID RX-100 CDM 2590000100 HCPCS 259 RC 00485-0057-08 NDC inpatient 236 ML 28.61 28.61 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES PPO [308136801] 22.65 percent of total billed charges 17.74 27.18 Technical (Hospital) Services ACETAMINOPHEN 160 MG/5 ML ORAL LIQUID RX-100 CDM 2590000100 HCPCS 259 RC 00485-0057-08 NDC inpatient 236 ML 28.61 28.61 CIGNA 62308 [3081051] CIGNA 62308 [308105105] 22.65 percent of total billed charges 17.74 27.18 Technical (Hospital) Services ACETAMINOPHEN 160 MG/5 ML ORAL LIQUID RX-100 CDM 2590000100 HCPCS 259 RC 00485-0057-08 NDC inpatient 236 ML 28.61 28.61 CIGNA 62308 [3081051] CIGNA STATE OF WYOMING [308105107] 22.65 percent of total billed charges 17.74 27.18 Technical (Hospital) Services ACETAMINOPHEN 160 MG/5 ML ORAL LIQUID RX-100 CDM 2590000100 HCPCS 259 RC 00485-0057-08 NDC inpatient 236 ML 28.61 28.61 UNITED HEALTHCARE (COMMERCIAL) [3081199] UNITED HEALTHCARE 87726 [308119901] 17.74 percent of total billed charges 17.74 27.18 Technical (Hospital) Services ACETAMINOPHEN 160 MG/5 ML ORAL LIQUID RX-100 CDM 2590000100 HCPCS 259 RC 00485-0057-08 NDC inpatient 236 ML 28.61 28.61 BLUE CROSS BLUE SHIELD WELLMARK SB889 [3081026] BCBS WYOMING [308102603] 27.18 percent of total billed charges 17.74 27.18 Technical (Hospital) Services ACETAMINOPHEN 160 MG/5 ML ORAL LIQUID RX-100 CDM 2590000100 HCPCS 259 RC 00485-0057-08 NDC inpatient 236 ML 28.61 28.61 HEALTHPARTNERS SX009 HEALTHPARTNERS 22.65 percent of total billed charges 17.74 27.18 Technical (Hospital) Services ACETAMINOPHEN 160 MG/5 ML ORAL LIQUID RX-100 CDM 2590000100 HCPCS 259 RC 00485-0057-08 NDC inpatient 236 ML 28.61 28.61 MULTIPLAN INC 34080 [3081285] MULTIPLAN INC [308128501] 27.18 percent of total billed charges 17.74 27.18 Technical (Hospital) Services ACETAMINOPHEN 160 MG/5 ML ORAL LIQUID RX-100 CDM 2590000100 HCPCS 259 RC 00485-0057-08 NDC inpatient 236 ML 28.61 28.61 MEDICA (COMMERCIAL) 94265 [3081118] MEDICA CLAIMS [308111801] 25.75 percent of total billed charges 17.74 27.18 Technical (Hospital) Services ACETAMINOPHEN 325 MG TABLET RX-101 CDM 2590000100 HCPCS 259 RC 00904-6773-61 NDC inpatient 1 UN 5.67 5.67 MULTIPLAN INC 34080 [3081285] MULTIPLAN INC [308128501] 5.39 percent of total billed charges 3.52 5.39 Technical (Hospital) Services ACETAMINOPHEN 325 MG TABLET RX-101 CDM 2590000100 HCPCS 259 RC 00904-6773-61 NDC inpatient 1 UN 5.67 5.67 BLUE CROSS BLUE SHIELD WELLMARK SB889 [3081026] BCBS WYOMING [308102603] 5.39 percent of total billed charges 3.52 5.39 Technical (Hospital) Services ACETAMINOPHEN 325 MG TABLET RX-101 CDM 2590000100 HCPCS 259 RC 00904-6773-61 NDC inpatient 1 UN 5.67 5.67 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES EPO [308136803] 4.49 percent of total billed charges 3.52 5.39 Technical (Hospital) Services ACETAMINOPHEN 325 MG TABLET RX-101 CDM 2590000100 HCPCS 259 RC 00904-6773-61 NDC inpatient 1 UN 5.67 5.67 CIGNA 62308 [3081051] CIGNA 62308 [308105105] 4.49 percent of total billed charges 3.52 5.39 Technical (Hospital) Services ACETAMINOPHEN 325 MG TABLET RX-101 CDM 2590000100 HCPCS 259 RC 00904-6773-61 NDC outpatient 1 UN 5.67 5.67 MULTIPLAN INC 34080 [3081285] MULTIPLAN INC [308128501] 5.39 percent of total billed charges 3.52 5.39 Technical (Hospital) Services ACETAMINOPHEN 325 MG TABLET RX-101 CDM 2590000100 HCPCS 259 RC 00904-6773-61 NDC outpatient 1 UN 5.67 5.67 MEDICA (COMMERCIAL) 94265 [3081118] MEDICA CLAIMS [308111801] 5.1 percent of total billed charges 3.52 5.39 Technical (Hospital) Services ACETAMINOPHEN 325 MG TABLET RX-101 CDM 2590000100 HCPCS 259 RC 00904-6773-61 NDC outpatient 1 UN 5.67 5.67 CIGNA 62308 [3081051] CIGNA 62308 [308105105] 4.54 percent of total billed charges 3.52 5.39 Technical (Hospital) Services ACETAMINOPHEN 325 MG TABLET RX-101 CDM 2590000100 HCPCS 259 RC 00904-6773-61 NDC inpatient 1 UN 5.67 5.67 CIGNA 62308 [3081051] CIGNA STATE OF WYOMING [308105107] 4.49 percent of total billed charges 3.52 5.39 Technical (Hospital) Services ACETAMINOPHEN 325 MG TABLET RX-101 CDM 2590000100 HCPCS 259 RC 00904-6773-61 NDC inpatient 1 UN 5.67 5.67 UNITED HEALTHCARE (COMMERCIAL) [3081199] UNITED HEALTHCARE 87726 [308119901] 3.52 percent of total billed charges 3.52 5.39 Technical (Hospital) Services ACETAMINOPHEN 325 MG TABLET RX-101 CDM 2590000100 HCPCS 259 RC 00904-6773-61 NDC inpatient 1 UN 5.67 5.67 HEALTHPARTNERS SX009 HEALTHPARTNERS 4.49 percent of total billed charges 3.52 5.39 Technical (Hospital) Services ACETAMINOPHEN 325 MG TABLET RX-101 CDM 2590000100 HCPCS 259 RC 00904-6773-61 NDC inpatient 1 UN 5.67 5.67 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES HDHP [308136802] 4.49 percent of total billed charges 3.52 5.39 Technical (Hospital) Services ACETAMINOPHEN 325 MG TABLET RX-101 CDM 2590000100 HCPCS 259 RC 00904-6773-61 NDC inpatient 1 UN 5.67 5.67 MEDICA (COMMERCIAL) 94265 [3081118] MEDICA CLAIMS [308111801] 5.1 percent of total billed charges 3.52 5.39 Technical (Hospital) Services ACETAMINOPHEN 325 MG TABLET RX-101 CDM 2590000100 HCPCS 259 RC 00904-6773-61 NDC inpatient 1 UN 5.67 5.67 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES PPO [308136801] 4.49 percent of total billed charges 3.52 5.39 Technical (Hospital) Services ACETAMINOPHEN 325 MG TABLET RX-101 CDM 2590000100 HCPCS 259 RC 00904-6773-61 NDC outpatient 1 UN 5.67 5.67 CIGNA 62308 [3081051] CIGNA STATE OF WYOMING [308105107] 4.54 percent of total billed charges 3.52 5.39 Technical (Hospital) Services ACETAMINOPHEN 325 MG TABLET RX-101 CDM 2590000100 HCPCS 259 RC 00904-6773-61 NDC outpatient 1 UN 5.67 5.67 HEALTHPARTNERS SX009 HEALTHPARTNERS 4.54 percent of total billed charges 3.52 5.39 Technical (Hospital) Services ACETAMINOPHEN 325 MG TABLET RX-101 CDM 2590000100 HCPCS 259 RC 00904-6773-61 NDC outpatient 1 UN 5.67 5.67 UNITED HEALTHCARE (COMMERCIAL) [3081199] UNITED HEALTHCARE 87726 [308119901] 3.52 percent of total billed charges 3.52 5.39 Technical (Hospital) Services ACETAMINOPHEN 325 MG TABLET RX-101 CDM 2590000100 HCPCS 259 RC 00904-6773-61 NDC outpatient 1 UN 5.67 5.67 BLUE CROSS BLUE SHIELD WELLMARK SB889 [3081026] BCBS WYOMING [308102603] 5.39 percent of total billed charges 3.52 5.39 Technical (Hospital) Services ACETAMINOPHEN 325 MG TABLET RX-101 CDM 2590000100 HCPCS 259 RC 00904-6773-61 NDC outpatient 1 UN 5.67 5.67 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES EPO [308136803] 4.54 percent of total billed charges 3.52 5.39 Technical (Hospital) Services ACETAMINOPHEN 325 MG TABLET RX-101 CDM 2590000100 HCPCS 259 RC 00904-6773-61 NDC outpatient 1 UN 5.67 5.67 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES HDHP [308136802] 4.54 percent of total billed charges 3.52 5.39 Technical (Hospital) Services ACETAMINOPHEN 325 MG TABLET RX-101 CDM 2590000100 HCPCS 259 RC 00904-6773-61 NDC outpatient 1 UN 5.67 5.67 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES PPO [308136801] 4.54 percent of total billed charges 3.52 5.39 Technical (Hospital) Services ACETAMINOPHEN 500 MG TABLET RX-102 CDM 2590000100 HCPCS 259 RC 37864-0001-04 NDC outpatient 1 UN 5.64 5.64 BLUE CROSS BLUE SHIELD WELLMARK SB889 [3081026] BCBS WYOMING [308102603] 5.36 percent of total billed charges 3.5 5.36 Technical (Hospital) Services ACETAMINOPHEN 500 MG TABLET RX-102 CDM 2590000100 HCPCS 259 RC 37864-0001-04 NDC outpatient 1 UN 5.64 5.64 HEALTHPARTNERS SX009 HEALTHPARTNERS 4.51 percent of total billed charges 3.5 5.36 Technical (Hospital) Services ACETAMINOPHEN 500 MG TABLET RX-102 CDM 2590000100 HCPCS 259 RC 37864-0001-04 NDC outpatient 1 UN 5.64 5.64 UNITED HEALTHCARE (COMMERCIAL) [3081199] UNITED HEALTHCARE 87726 [308119901] 3.5 percent of total billed charges 3.5 5.36 Technical (Hospital) Services ACETAMINOPHEN 500 MG TABLET RX-102 CDM 2590000100 HCPCS 259 RC 37864-0001-04 NDC outpatient 1 UN 5.64 5.64 MEDICA (COMMERCIAL) 94265 [3081118] MEDICA CLAIMS [308111801] 5.08 percent of total billed charges 3.5 5.36 Technical (Hospital) Services ACETAMINOPHEN 500 MG TABLET RX-102 CDM 2590000100 HCPCS 259 RC 37864-0001-04 NDC outpatient 1 UN 5.64 5.64 CIGNA 62308 [3081051] CIGNA 62308 [308105105] 4.51 percent of total billed charges 3.5 5.36 Technical (Hospital) Services ACETAMINOPHEN 500 MG TABLET RX-102 CDM 2590000100 HCPCS 259 RC 37864-0001-04 NDC outpatient 1 UN 5.64 5.64 CIGNA 62308 [3081051] CIGNA STATE OF WYOMING [308105107] 4.51 percent of total billed charges 3.5 5.36 Technical (Hospital) Services ACETAMINOPHEN 500 MG TABLET RX-102 CDM 2590000100 HCPCS 259 RC 37864-0001-04 NDC outpatient 1 UN 5.64 5.64 MULTIPLAN INC 34080 [3081285] MULTIPLAN INC [308128501] 5.36 percent of total billed charges 3.5 5.36 Technical (Hospital) Services ACETAMINOPHEN 500 MG TABLET RX-102 CDM 2590000100 HCPCS 259 RC 37864-0001-04 NDC outpatient 1 UN 5.64 5.64 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES EPO [308136803] 4.51 percent of total billed charges 3.5 5.36 Technical (Hospital) Services ACETAMINOPHEN 500 MG TABLET RX-102 CDM 2590000100 HCPCS 259 RC 37864-0001-04 NDC outpatient 1 UN 5.64 5.64 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES PPO [308136801] 4.51 percent of total billed charges 3.5 5.36 Technical (Hospital) Services ACETAMINOPHEN 500 MG TABLET RX-102 CDM 2590000100 HCPCS 259 RC 37864-0001-04 NDC outpatient 1 UN 5.64 5.64 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES HDHP [308136802] 4.51 percent of total billed charges 3.5 5.36 Technical (Hospital) Services ACETAMINOPHEN 500 MG TABLET RX-102 CDM 2590000100 HCPCS 259 RC 37864-0001-04 NDC inpatient 1 UN 5.64 5.64 MULTIPLAN INC 34080 [3081285] MULTIPLAN INC [308128501] 5.36 percent of total billed charges 3.5 5.36 Technical (Hospital) Services ACETAMINOPHEN 500 MG TABLET RX-102 CDM 2590000100 HCPCS 259 RC 37864-0001-04 NDC inpatient 1 UN 5.64 5.64 BLUE CROSS BLUE SHIELD WELLMARK SB889 [3081026] BCBS WYOMING [308102603] 5.36 percent of total billed charges 3.5 5.36 Technical (Hospital) Services ACETAMINOPHEN 500 MG TABLET RX-102 CDM 2590000100 HCPCS 259 RC 37864-0001-04 NDC inpatient 1 UN 5.64 5.64 UNITED HEALTHCARE (COMMERCIAL) [3081199] UNITED HEALTHCARE 87726 [308119901] 3.5 percent of total billed charges 3.5 5.36 Technical (Hospital) Services ACETAMINOPHEN 500 MG TABLET RX-102 CDM 2590000100 HCPCS 259 RC 37864-0001-04 NDC inpatient 1 UN 5.64 5.64 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES EPO [308136803] 4.47 percent of total billed charges 3.5 5.36 Technical (Hospital) Services ACETAMINOPHEN 500 MG TABLET RX-102 CDM 2590000100 HCPCS 259 RC 37864-0001-04 NDC inpatient 1 UN 5.64 5.64 CIGNA 62308 [3081051] CIGNA 62308 [308105105] 4.47 percent of total billed charges 3.5 5.36 Technical (Hospital) Services ACETAMINOPHEN 500 MG TABLET RX-102 CDM 2590000100 HCPCS 259 RC 37864-0001-04 NDC inpatient 1 UN 5.64 5.64 CIGNA 62308 [3081051] CIGNA STATE OF WYOMING [308105107] 4.47 percent of total billed charges 3.5 5.36 Technical (Hospital) Services ACETAMINOPHEN 500 MG TABLET RX-102 CDM 2590000100 HCPCS 259 RC 37864-0001-04 NDC inpatient 1 UN 5.64 5.64 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES HDHP [308136802] 4.47 percent of total billed charges 3.5 5.36 Technical (Hospital) Services ACETAMINOPHEN 500 MG TABLET RX-102 CDM 2590000100 HCPCS 259 RC 37864-0001-04 NDC inpatient 1 UN 5.64 5.64 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES PPO [308136801] 4.47 percent of total billed charges 3.5 5.36 Technical (Hospital) Services ACETAMINOPHEN 500 MG TABLET RX-102 CDM 2590000100 HCPCS 259 RC 37864-0001-04 NDC inpatient 1 UN 5.64 5.64 HEALTHPARTNERS SX009 HEALTHPARTNERS 4.47 percent of total billed charges 3.5 5.36 Technical (Hospital) Services ACETAMINOPHEN 500 MG TABLET RX-102 CDM 2590000100 HCPCS 259 RC 37864-0001-04 NDC inpatient 1 UN 5.64 5.64 MEDICA (COMMERCIAL) 94265 [3081118] MEDICA CLAIMS [308111801] 5.08 percent of total billed charges 3.5 5.36 Technical (Hospital) Services IBUPROFEN 100 MG/5 ML ORAL SUSPENSION RX-10246 CDM 2590000100 HCPCS 259 RC 68094-0494-59 NDC inpatient 5 ML 6.4 6.4 BLUE CROSS BLUE SHIELD WELLMARK SB889 [3081026] BCBS WYOMING [308102603] 6.08 percent of total billed charges 3.97 6.08 Technical (Hospital) Services IBUPROFEN 100 MG/5 ML ORAL SUSPENSION RX-10246 CDM 2590000100 HCPCS 259 RC 68094-0494-59 NDC inpatient 5 ML 6.4 6.4 UNITED HEALTHCARE (COMMERCIAL) [3081199] UNITED HEALTHCARE 87726 [308119901] 3.97 percent of total billed charges 3.97 6.08 Technical (Hospital) Services IBUPROFEN 100 MG/5 ML ORAL SUSPENSION RX-10246 CDM 2590000100 HCPCS 259 RC 68094-0494-59 NDC inpatient 5 ML 6.4 6.4 CIGNA 62308 [3081051] CIGNA 62308 [308105105] 5.07 percent of total billed charges 3.97 6.08 Technical (Hospital) Services IBUPROFEN 100 MG/5 ML ORAL SUSPENSION RX-10246 CDM 2590000100 HCPCS 259 RC 68094-0494-59 NDC inpatient 5 ML 6.4 6.4 CIGNA 62308 [3081051] CIGNA STATE OF WYOMING [308105107] 5.07 percent of total billed charges 3.97 6.08 Technical (Hospital) Services IBUPROFEN 100 MG/5 ML ORAL SUSPENSION RX-10246 CDM 2590000100 HCPCS 259 RC 68094-0494-59 NDC inpatient 5 ML 6.4 6.4 MULTIPLAN INC 34080 [3081285] MULTIPLAN INC [308128501] 6.08 percent of total billed charges 3.97 6.08 Technical (Hospital) Services IBUPROFEN 100 MG/5 ML ORAL SUSPENSION RX-10246 CDM 2590000100 HCPCS 259 RC 68094-0494-59 NDC inpatient 5 ML 6.4 6.4 MEDICA (COMMERCIAL) 94265 [3081118] MEDICA CLAIMS [308111801] 5.76 percent of total billed charges 3.97 6.08 Technical (Hospital) Services IBUPROFEN 100 MG/5 ML ORAL SUSPENSION RX-10246 CDM 2590000100 HCPCS 259 RC 68094-0494-59 NDC inpatient 5 ML 6.4 6.4 HEALTHPARTNERS SX009 HEALTHPARTNERS 5.07 percent of total billed charges 3.97 6.08 Technical (Hospital) Services IBUPROFEN 100 MG/5 ML ORAL SUSPENSION RX-10246 CDM 2590000100 HCPCS 259 RC 68094-0494-59 NDC inpatient 5 ML 6.4 6.4 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES EPO [308136803] 5.07 percent of total billed charges 3.97 6.08 Technical (Hospital) Services IBUPROFEN 100 MG/5 ML ORAL SUSPENSION RX-10246 CDM 2590000100 HCPCS 259 RC 68094-0494-59 NDC inpatient 5 ML 6.4 6.4 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES PPO [308136801] 5.07 percent of total billed charges 3.97 6.08 Technical (Hospital) Services IBUPROFEN 100 MG/5 ML ORAL SUSPENSION RX-10246 CDM 2590000100 HCPCS 259 RC 68094-0494-59 NDC inpatient 5 ML 6.4 6.4 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES HDHP [308136802] 5.07 percent of total billed charges 3.97 6.08 Technical (Hospital) Services IBUPROFEN 100 MG/5 ML ORAL SUSPENSION RX-10246 CDM 2590000100 HCPCS 259 RC 68094-0494-59 NDC outpatient 5 ML 6.4 6.4 BLUE CROSS BLUE SHIELD WELLMARK SB889 [3081026] BCBS WYOMING [308102603] 6.08 percent of total billed charges 3.97 6.08 Technical (Hospital) Services IBUPROFEN 100 MG/5 ML ORAL SUSPENSION RX-10246 CDM 2590000100 HCPCS 259 RC 68094-0494-59 NDC outpatient 5 ML 6.4 6.4 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES EPO [308136803] 5.12 percent of total billed charges 3.97 6.08 Technical (Hospital) Services IBUPROFEN 100 MG/5 ML ORAL SUSPENSION RX-10246 CDM 2590000100 HCPCS 259 RC 68094-0494-59 NDC outpatient 5 ML 6.4 6.4 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES PPO [308136801] 5.12 percent of total billed charges 3.97 6.08 Technical (Hospital) Services IBUPROFEN 100 MG/5 ML ORAL SUSPENSION RX-10246 CDM 2590000100 HCPCS 259 RC 68094-0494-59 NDC outpatient 5 ML 6.4 6.4 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES HDHP [308136802] 5.12 percent of total billed charges 3.97 6.08 Technical (Hospital) Services IBUPROFEN 100 MG/5 ML ORAL SUSPENSION RX-10246 CDM 2590000100 HCPCS 259 RC 68094-0494-59 NDC outpatient 5 ML 6.4 6.4 CIGNA 62308 [3081051] CIGNA 62308 [308105105] 5.12 percent of total billed charges 3.97 6.08 Technical (Hospital) Services IBUPROFEN 100 MG/5 ML ORAL SUSPENSION RX-10246 CDM 2590000100 HCPCS 259 RC 68094-0494-59 NDC outpatient 5 ML 6.4 6.4 CIGNA 62308 [3081051] CIGNA STATE OF WYOMING [308105107] 5.12 percent of total billed charges 3.97 6.08 Technical (Hospital) Services IBUPROFEN 100 MG/5 ML ORAL SUSPENSION RX-10246 CDM 2590000100 HCPCS 259 RC 68094-0494-59 NDC outpatient 5 ML 6.4 6.4 MEDICA (COMMERCIAL) 94265 [3081118] MEDICA CLAIMS [308111801] 5.76 percent of total billed charges 3.97 6.08 Technical (Hospital) Services IBUPROFEN 100 MG/5 ML ORAL SUSPENSION RX-10246 CDM 2590000100 HCPCS 259 RC 68094-0494-59 NDC outpatient 5 ML 6.4 6.4 MULTIPLAN INC 34080 [3081285] MULTIPLAN INC [308128501] 6.08 percent of total billed charges 3.97 6.08 Technical (Hospital) Services IBUPROFEN 100 MG/5 ML ORAL SUSPENSION RX-10246 CDM 2590000100 HCPCS 259 RC 68094-0494-59 NDC outpatient 5 ML 6.4 6.4 UNITED HEALTHCARE (COMMERCIAL) [3081199] UNITED HEALTHCARE 87726 [308119901] 3.97 percent of total billed charges 3.97 6.08 Technical (Hospital) Services IBUPROFEN 100 MG/5 ML ORAL SUSPENSION RX-10246 CDM 2590000100 HCPCS 259 RC 68094-0494-59 NDC outpatient 5 ML 6.4 6.4 HEALTHPARTNERS SX009 HEALTHPARTNERS 5.12 percent of total billed charges 3.97 6.08 Technical (Hospital) Services ACETAMINOPHEN 120 MG RECTAL SUPPOSITORY RX-103 CDM 2590000100 HCPCS 259 RC 45802-0732-30 NDC outpatient 1 UN 5.93 5.93 BLUE CROSS BLUE SHIELD WELLMARK SB889 [3081026] BCBS WYOMING [308102603] 5.63 percent of total billed charges 3.68 5.63 Technical (Hospital) Services ACETAMINOPHEN 120 MG RECTAL SUPPOSITORY RX-103 CDM 2590000100 HCPCS 259 RC 45802-0732-30 NDC outpatient 1 UN 5.93 5.93 HEALTHPARTNERS SX009 HEALTHPARTNERS 4.74 percent of total billed charges 3.68 5.63 Technical (Hospital) Services ACETAMINOPHEN 120 MG RECTAL SUPPOSITORY RX-103 CDM 2590000100 HCPCS 259 RC 45802-0732-30 NDC outpatient 1 UN 5.93 5.93 UNITED HEALTHCARE (COMMERCIAL) [3081199] UNITED HEALTHCARE 87726 [308119901] 3.68 percent of total billed charges 3.68 5.63 Technical (Hospital) Services ACETAMINOPHEN 120 MG RECTAL SUPPOSITORY RX-103 CDM 2590000100 HCPCS 259 RC 45802-0732-30 NDC outpatient 1 UN 5.93 5.93 MULTIPLAN INC 34080 [3081285] MULTIPLAN INC [308128501] 5.63 percent of total billed charges 3.68 5.63 Technical (Hospital) Services ACETAMINOPHEN 120 MG RECTAL SUPPOSITORY RX-103 CDM 2590000100 HCPCS 259 RC 45802-0732-30 NDC outpatient 1 UN 5.93 5.93 CIGNA 62308 [3081051] CIGNA 62308 [308105105] 4.74 percent of total billed charges 3.68 5.63 Technical (Hospital) Services ACETAMINOPHEN 120 MG RECTAL SUPPOSITORY RX-103 CDM 2590000100 HCPCS 259 RC 45802-0732-30 NDC outpatient 1 UN 5.93 5.93 CIGNA 62308 [3081051] CIGNA STATE OF WYOMING [308105107] 4.74 percent of total billed charges 3.68 5.63 Technical (Hospital) Services ACETAMINOPHEN 120 MG RECTAL SUPPOSITORY RX-103 CDM 2590000100 HCPCS 259 RC 45802-0732-30 NDC outpatient 1 UN 5.93 5.93 MEDICA (COMMERCIAL) 94265 [3081118] MEDICA CLAIMS [308111801] 5.34 percent of total billed charges 3.68 5.63 Technical (Hospital) Services ACETAMINOPHEN 120 MG RECTAL SUPPOSITORY RX-103 CDM 2590000100 HCPCS 259 RC 45802-0732-30 NDC outpatient 1 UN 5.93 5.93 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES EPO [308136803] 4.74 percent of total billed charges 3.68 5.63 Technical (Hospital) Services ACETAMINOPHEN 120 MG RECTAL SUPPOSITORY RX-103 CDM 2590000100 HCPCS 259 RC 45802-0732-30 NDC inpatient 1 UN 5.93 5.93 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES EPO [308136803] 4.7 percent of total billed charges 3.68 5.63 Technical (Hospital) Services ACETAMINOPHEN 120 MG RECTAL SUPPOSITORY RX-103 CDM 2590000100 HCPCS 259 RC 45802-0732-30 NDC inpatient 1 UN 5.93 5.93 CIGNA 62308 [3081051] CIGNA 62308 [308105105] 4.7 percent of total billed charges 3.68 5.63 Technical (Hospital) Services ACETAMINOPHEN 120 MG RECTAL SUPPOSITORY RX-103 CDM 2590000100 HCPCS 259 RC 45802-0732-30 NDC inpatient 1 UN 5.93 5.93 CIGNA 62308 [3081051] CIGNA STATE OF WYOMING [308105107] 4.7 percent of total billed charges 3.68 5.63 Technical (Hospital) Services ACETAMINOPHEN 120 MG RECTAL SUPPOSITORY RX-103 CDM 2590000100 HCPCS 259 RC 45802-0732-30 NDC inpatient 1 UN 5.93 5.93 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES HDHP [308136802] 4.7 percent of total billed charges 3.68 5.63 Technical (Hospital) Services ACETAMINOPHEN 120 MG RECTAL SUPPOSITORY RX-103 CDM 2590000100 HCPCS 259 RC 45802-0732-30 NDC inpatient 1 UN 5.93 5.93 BLUE CROSS BLUE SHIELD WELLMARK SB889 [3081026] BCBS WYOMING [308102603] 5.63 percent of total billed charges 3.68 5.63 Technical (Hospital) Services ACETAMINOPHEN 120 MG RECTAL SUPPOSITORY RX-103 CDM 2590000100 HCPCS 259 RC 45802-0732-30 NDC inpatient 1 UN 5.93 5.93 UNITED HEALTHCARE (COMMERCIAL) [3081199] UNITED HEALTHCARE 87726 [308119901] 3.68 percent of total billed charges 3.68 5.63 Technical (Hospital) Services ACETAMINOPHEN 120 MG RECTAL SUPPOSITORY RX-103 CDM 2590000100 HCPCS 259 RC 45802-0732-30 NDC inpatient 1 UN 5.93 5.93 MULTIPLAN INC 34080 [3081285] MULTIPLAN INC [308128501] 5.63 percent of total billed charges 3.68 5.63 Technical (Hospital) Services ACETAMINOPHEN 120 MG RECTAL SUPPOSITORY RX-103 CDM 2590000100 HCPCS 259 RC 45802-0732-30 NDC outpatient 1 UN 5.93 5.93 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES HDHP [308136802] 4.74 percent of total billed charges 3.68 5.63 Technical (Hospital) Services ACETAMINOPHEN 120 MG RECTAL SUPPOSITORY RX-103 CDM 2590000100 HCPCS 259 RC 45802-0732-30 NDC outpatient 1 UN 5.93 5.93 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES PPO [308136801] 4.74 percent of total billed charges 3.68 5.63 Technical (Hospital) Services ACETAMINOPHEN 120 MG RECTAL SUPPOSITORY RX-103 CDM 2590000100 HCPCS 259 RC 45802-0732-30 NDC inpatient 1 UN 5.93 5.93 HEALTHPARTNERS SX009 HEALTHPARTNERS 4.7 percent of total billed charges 3.68 5.63 Technical (Hospital) Services ACETAMINOPHEN 120 MG RECTAL SUPPOSITORY RX-103 CDM 2590000100 HCPCS 259 RC 45802-0732-30 NDC inpatient 1 UN 5.93 5.93 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES PPO [308136801] 4.7 percent of total billed charges 3.68 5.63 Technical (Hospital) Services ACETAMINOPHEN 120 MG RECTAL SUPPOSITORY RX-103 CDM 2590000100 HCPCS 259 RC 45802-0732-30 NDC inpatient 1 UN 5.93 5.93 MEDICA (COMMERCIAL) 94265 [3081118] MEDICA CLAIMS [308111801] 5.34 percent of total billed charges 3.68 5.63 Technical (Hospital) Services ACETAMINOPHEN 325 MG RECTAL SUPPOSITORY RX-104 CDM 2590000100 HCPCS 259 RC 51672-2116-02 NDC inpatient 1 UN 6.32 6.32 MEDICA (COMMERCIAL) 94265 [3081118] MEDICA CLAIMS [308111801] 5.69 percent of total billed charges 3.92 6 Technical (Hospital) Services ACETAMINOPHEN 325 MG RECTAL SUPPOSITORY RX-104 CDM 2590000100 HCPCS 259 RC 51672-2116-02 NDC inpatient 1 UN 6.32 6.32 HEALTHPARTNERS SX009 HEALTHPARTNERS 5 percent of total billed charges 3.92 6 Technical (Hospital) Services ACETAMINOPHEN 325 MG RECTAL SUPPOSITORY RX-104 CDM 2590000100 HCPCS 259 RC 51672-2116-02 NDC inpatient 1 UN 6.32 6.32 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES PPO [308136801] 5 percent of total billed charges 3.92 6 Technical (Hospital) Services ACETAMINOPHEN 325 MG RECTAL SUPPOSITORY RX-104 CDM 2590000100 HCPCS 259 RC 51672-2116-02 NDC inpatient 1 UN 6.32 6.32 CIGNA 62308 [3081051] CIGNA 62308 [308105105] 5 percent of total billed charges 3.92 6 Technical (Hospital) Services ACETAMINOPHEN 325 MG RECTAL SUPPOSITORY RX-104 CDM 2590000100 HCPCS 259 RC 51672-2116-02 NDC inpatient 1 UN 6.32 6.32 CIGNA 62308 [3081051] CIGNA STATE OF WYOMING [308105107] 5 percent of total billed charges 3.92 6 Technical (Hospital) Services ACETAMINOPHEN 325 MG RECTAL SUPPOSITORY RX-104 CDM 2590000100 HCPCS 259 RC 51672-2116-02 NDC inpatient 1 UN 6.32 6.32 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES HDHP [308136802] 5 percent of total billed charges 3.92 6 Technical (Hospital) Services ACETAMINOPHEN 325 MG RECTAL SUPPOSITORY RX-104 CDM 2590000100 HCPCS 259 RC 51672-2116-02 NDC inpatient 1 UN 6.32 6.32 UNITED HEALTHCARE (COMMERCIAL) [3081199] UNITED HEALTHCARE 87726 [308119901] 3.92 percent of total billed charges 3.92 6 Technical (Hospital) Services ACETAMINOPHEN 325 MG RECTAL SUPPOSITORY RX-104 CDM 2590000100 HCPCS 259 RC 51672-2116-02 NDC inpatient 1 UN 6.32 6.32 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES EPO [308136803] 5 percent of total billed charges 3.92 6 Technical (Hospital) Services ACETAMINOPHEN 325 MG RECTAL SUPPOSITORY RX-104 CDM 2590000100 HCPCS 259 RC 51672-2116-02 NDC inpatient 1 UN 6.32 6.32 BLUE CROSS BLUE SHIELD WELLMARK SB889 [3081026] BCBS WYOMING [308102603] 6 percent of total billed charges 3.92 6 Technical (Hospital) Services ACETAMINOPHEN 325 MG RECTAL SUPPOSITORY RX-104 CDM 2590000100 HCPCS 259 RC 51672-2116-02 NDC inpatient 1 UN 6.32 6.32 MULTIPLAN INC 34080 [3081285] MULTIPLAN INC [308128501] 6 percent of total billed charges 3.92 6 Technical (Hospital) Services ACETAMINOPHEN 325 MG RECTAL SUPPOSITORY RX-104 CDM 2590000100 HCPCS 259 RC 51672-2116-02 NDC outpatient 1 UN 6.32 6.32 BLUE CROSS BLUE SHIELD WELLMARK SB889 [3081026] BCBS WYOMING [308102603] 6 percent of total billed charges 3.92 6 Technical (Hospital) Services ACETAMINOPHEN 325 MG RECTAL SUPPOSITORY RX-104 CDM 2590000100 HCPCS 259 RC 51672-2116-02 NDC outpatient 1 UN 6.32 6.32 HEALTHPARTNERS SX009 HEALTHPARTNERS 5.06 percent of total billed charges 3.92 6 Technical (Hospital) Services ACETAMINOPHEN 325 MG RECTAL SUPPOSITORY RX-104 CDM 2590000100 HCPCS 259 RC 51672-2116-02 NDC outpatient 1 UN 6.32 6.32 UNITED HEALTHCARE (COMMERCIAL) [3081199] UNITED HEALTHCARE 87726 [308119901] 3.92 percent of total billed charges 3.92 6 Technical (Hospital) Services ACETAMINOPHEN 325 MG RECTAL SUPPOSITORY RX-104 CDM 2590000100 HCPCS 259 RC 51672-2116-02 NDC outpatient 1 UN 6.32 6.32 CIGNA 62308 [3081051] CIGNA 62308 [308105105] 5.06 percent of total billed charges 3.92 6 Technical (Hospital) Services ACETAMINOPHEN 325 MG RECTAL SUPPOSITORY RX-104 CDM 2590000100 HCPCS 259 RC 51672-2116-02 NDC outpatient 1 UN 6.32 6.32 CIGNA 62308 [3081051] CIGNA STATE OF WYOMING [308105107] 5.06 percent of total billed charges 3.92 6 Technical (Hospital) Services ACETAMINOPHEN 325 MG RECTAL SUPPOSITORY RX-104 CDM 2590000100 HCPCS 259 RC 51672-2116-02 NDC outpatient 1 UN 6.32 6.32 MULTIPLAN INC 34080 [3081285] MULTIPLAN INC [308128501] 6 percent of total billed charges 3.92 6 Technical (Hospital) Services ACETAMINOPHEN 325 MG RECTAL SUPPOSITORY RX-104 CDM 2590000100 HCPCS 259 RC 51672-2116-02 NDC outpatient 1 UN 6.32 6.32 MEDICA (COMMERCIAL) 94265 [3081118] MEDICA CLAIMS [308111801] 5.69 percent of total billed charges 3.92 6 Technical (Hospital) Services ACETAMINOPHEN 325 MG RECTAL SUPPOSITORY RX-104 CDM 2590000100 HCPCS 259 RC 51672-2116-02 NDC outpatient 1 UN 6.32 6.32 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES EPO [308136803] 5.06 percent of total billed charges 3.92 6 Technical (Hospital) Services ACETAMINOPHEN 325 MG RECTAL SUPPOSITORY RX-104 CDM 2590000100 HCPCS 259 RC 51672-2116-02 NDC outpatient 1 UN 6.32 6.32 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES HDHP [308136802] 5.06 percent of total billed charges 3.92 6 Technical (Hospital) Services ACETAMINOPHEN 325 MG RECTAL SUPPOSITORY RX-104 CDM 2590000100 HCPCS 259 RC 51672-2116-02 NDC outpatient 1 UN 6.32 6.32 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES PPO [308136801] 5.06 percent of total billed charges 3.92 6 Technical (Hospital) Services ACETAMINOPHEN 650 MG RECTAL SUPPOSITORY RX-105 CDM 2590000100 HCPCS 259 RC 45802-0730-30 NDC inpatient 1 UN 6.29 6.29 MULTIPLAN INC 34080 [3081285] MULTIPLAN INC [308128501] 5.98 percent of total billed charges 3.9 5.98 Technical (Hospital) Services ACETAMINOPHEN 650 MG RECTAL SUPPOSITORY RX-105 CDM 2590000100 HCPCS 259 RC 45802-0730-30 NDC inpatient 1 UN 6.29 6.29 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES HDHP [308136802] 4.98 percent of total billed charges 3.9 5.98 Technical (Hospital) Services ACETAMINOPHEN 650 MG RECTAL SUPPOSITORY RX-105 CDM 2590000100 HCPCS 259 RC 45802-0730-30 NDC inpatient 1 UN 6.29 6.29 CIGNA 62308 [3081051] CIGNA 62308 [308105105] 4.98 percent of total billed charges 3.9 5.98 Technical (Hospital) Services ACETAMINOPHEN 650 MG RECTAL SUPPOSITORY RX-105 CDM 2590000100 HCPCS 259 RC 45802-0730-30 NDC inpatient 1 UN 6.29 6.29 CIGNA 62308 [3081051] CIGNA STATE OF WYOMING [308105107] 4.98 percent of total billed charges 3.9 5.98 Technical (Hospital) Services ACETAMINOPHEN 650 MG RECTAL SUPPOSITORY RX-105 CDM 2590000100 HCPCS 259 RC 45802-0730-30 NDC inpatient 1 UN 6.29 6.29 UNITED HEALTHCARE (COMMERCIAL) [3081199] UNITED HEALTHCARE 87726 [308119901] 3.9 percent of total billed charges 3.9 5.98 Technical (Hospital) Services ACETAMINOPHEN 650 MG RECTAL SUPPOSITORY RX-105 CDM 2590000100 HCPCS 259 RC 45802-0730-30 NDC inpatient 1 UN 6.29 6.29 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES EPO [308136803] 4.98 percent of total billed charges 3.9 5.98 Technical (Hospital) Services ACETAMINOPHEN 650 MG RECTAL SUPPOSITORY RX-105 CDM 2590000100 HCPCS 259 RC 45802-0730-30 NDC outpatient 1 UN 6.29 6.29 BLUE CROSS BLUE SHIELD WELLMARK SB889 [3081026] BCBS WYOMING [308102603] 5.98 percent of total billed charges 3.9 5.98 Technical (Hospital) Services ACETAMINOPHEN 650 MG RECTAL SUPPOSITORY RX-105 CDM 2590000100 HCPCS 259 RC 45802-0730-30 NDC outpatient 1 UN 6.29 6.29 UNITED HEALTHCARE (COMMERCIAL) [3081199] UNITED HEALTHCARE 87726 [308119901] 3.9 percent of total billed charges 3.9 5.98 Technical (Hospital) Services ACETAMINOPHEN 650 MG RECTAL SUPPOSITORY RX-105 CDM 2590000100 HCPCS 259 RC 45802-0730-30 NDC outpatient 1 UN 6.29 6.29 HEALTHPARTNERS SX009 HEALTHPARTNERS 5.03 percent of total billed charges 3.9 5.98 Technical (Hospital) Services ACETAMINOPHEN 650 MG RECTAL SUPPOSITORY RX-105 CDM 2590000100 HCPCS 259 RC 45802-0730-30 NDC outpatient 1 UN 6.29 6.29 MULTIPLAN INC 34080 [3081285] MULTIPLAN INC [308128501] 5.98 percent of total billed charges 3.9 5.98 Technical (Hospital) Services ACETAMINOPHEN 650 MG RECTAL SUPPOSITORY RX-105 CDM 2590000100 HCPCS 259 RC 45802-0730-30 NDC outpatient 1 UN 6.29 6.29 CIGNA 62308 [3081051] CIGNA STATE OF WYOMING [308105107] 5.03 percent of total billed charges 3.9 5.98 Technical (Hospital) Services ACETAMINOPHEN 650 MG RECTAL SUPPOSITORY RX-105 CDM 2590000100 HCPCS 259 RC 45802-0730-30 NDC inpatient 1 UN 6.29 6.29 BLUE CROSS BLUE SHIELD WELLMARK SB889 [3081026] BCBS WYOMING [308102603] 5.98 percent of total billed charges 3.9 5.98 Technical (Hospital) Services ACETAMINOPHEN 650 MG RECTAL SUPPOSITORY RX-105 CDM 2590000100 HCPCS 259 RC 45802-0730-30 NDC inpatient 1 UN 6.29 6.29 HEALTHPARTNERS SX009 HEALTHPARTNERS 4.98 percent of total billed charges 3.9 5.98 Technical (Hospital) Services ACETAMINOPHEN 650 MG RECTAL SUPPOSITORY RX-105 CDM 2590000100 HCPCS 259 RC 45802-0730-30 NDC inpatient 1 UN 6.29 6.29 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES PPO [308136801] 4.98 percent of total billed charges 3.9 5.98 Technical (Hospital) Services ACETAMINOPHEN 650 MG RECTAL SUPPOSITORY RX-105 CDM 2590000100 HCPCS 259 RC 45802-0730-30 NDC inpatient 1 UN 6.29 6.29 MEDICA (COMMERCIAL) 94265 [3081118] MEDICA CLAIMS [308111801] 5.66 percent of total billed charges 3.9 5.98 Technical (Hospital) Services ACETAMINOPHEN 650 MG RECTAL SUPPOSITORY RX-105 CDM 2590000100 HCPCS 259 RC 45802-0730-30 NDC outpatient 1 UN 6.29 6.29 CIGNA 62308 [3081051] CIGNA 62308 [308105105] 5.03 percent of total billed charges 3.9 5.98 Technical (Hospital) Services ACETAMINOPHEN 650 MG RECTAL SUPPOSITORY RX-105 CDM 2590000100 HCPCS 259 RC 45802-0730-30 NDC outpatient 1 UN 6.29 6.29 MEDICA (COMMERCIAL) 94265 [3081118] MEDICA CLAIMS [308111801] 5.66 percent of total billed charges 3.9 5.98 Technical (Hospital) Services ACETAMINOPHEN 650 MG RECTAL SUPPOSITORY RX-105 CDM 2590000100 HCPCS 259 RC 45802-0730-30 NDC outpatient 1 UN 6.29 6.29 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES EPO [308136803] 5.03 percent of total billed charges 3.9 5.98 Technical (Hospital) Services ACETAMINOPHEN 650 MG RECTAL SUPPOSITORY RX-105 CDM 2590000100 HCPCS 259 RC 45802-0730-30 NDC outpatient 1 UN 6.29 6.29 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES PPO [308136801] 5.03 percent of total billed charges 3.9 5.98 Technical (Hospital) Services ACETAMINOPHEN 650 MG RECTAL SUPPOSITORY RX-105 CDM 2590000100 HCPCS 259 RC 45802-0730-30 NDC outpatient 1 UN 6.29 6.29 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES HDHP [308136802] 5.03 percent of total billed charges 3.9 5.98 Technical (Hospital) Services "BISACODYL 5 MG TABLET,DELAYED RELEASE" RX-1079 CDM 2590000100 HCPCS 259 RC 00904-6407-61 NDC outpatient 1 UN 5.65 5.65 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES EPO [308136803] 4.52 percent of total billed charges 3.5 5.37 Technical (Hospital) Services "BISACODYL 5 MG TABLET,DELAYED RELEASE" RX-1079 CDM 2590000100 HCPCS 259 RC 00904-6407-61 NDC outpatient 1 UN 5.65 5.65 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES PPO [308136801] 4.52 percent of total billed charges 3.5 5.37 Technical (Hospital) Services "BISACODYL 5 MG TABLET,DELAYED RELEASE" RX-1079 CDM 2590000100 HCPCS 259 RC 00904-6407-61 NDC outpatient 1 UN 5.65 5.65 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES HDHP [308136802] 4.52 percent of total billed charges 3.5 5.37 Technical (Hospital) Services "BISACODYL 5 MG TABLET,DELAYED RELEASE" RX-1079 CDM 2590000100 HCPCS 259 RC 00904-6407-61 NDC outpatient 1 UN 5.65 5.65 BLUE CROSS BLUE SHIELD WELLMARK SB889 [3081026] BCBS WYOMING [308102603] 5.37 percent of total billed charges 3.5 5.37 Technical (Hospital) Services "BISACODYL 5 MG TABLET,DELAYED RELEASE" RX-1079 CDM 2590000100 HCPCS 259 RC 00904-6407-61 NDC outpatient 1 UN 5.65 5.65 HEALTHPARTNERS SX009 HEALTHPARTNERS 4.52 percent of total billed charges 3.5 5.37 Technical (Hospital) Services "BISACODYL 5 MG TABLET,DELAYED RELEASE" RX-1079 CDM 2590000100 HCPCS 259 RC 00904-6407-61 NDC outpatient 1 UN 5.65 5.65 UNITED HEALTHCARE (COMMERCIAL) [3081199] UNITED HEALTHCARE 87726 [308119901] 3.5 percent of total billed charges 3.5 5.37 Technical (Hospital) Services "BISACODYL 5 MG TABLET,DELAYED RELEASE" RX-1079 CDM 2590000100 HCPCS 259 RC 00904-6407-61 NDC outpatient 1 UN 5.65 5.65 MULTIPLAN INC 34080 [3081285] MULTIPLAN INC [308128501] 5.37 percent of total billed charges 3.5 5.37 Technical (Hospital) Services "BISACODYL 5 MG TABLET,DELAYED RELEASE" RX-1079 CDM 2590000100 HCPCS 259 RC 00904-6407-61 NDC outpatient 1 UN 5.65 5.65 CIGNA 62308 [3081051] CIGNA 62308 [308105105] 4.52 percent of total billed charges 3.5 5.37 Technical (Hospital) Services "BISACODYL 5 MG TABLET,DELAYED RELEASE" RX-1079 CDM 2590000100 HCPCS 259 RC 00904-6407-61 NDC outpatient 1 UN 5.65 5.65 CIGNA 62308 [3081051] CIGNA STATE OF WYOMING [308105107] 4.52 percent of total billed charges 3.5 5.37 Technical (Hospital) Services "BISACODYL 5 MG TABLET,DELAYED RELEASE" RX-1079 CDM 2590000100 HCPCS 259 RC 00904-6407-61 NDC outpatient 1 UN 5.65 5.65 MEDICA (COMMERCIAL) 94265 [3081118] MEDICA CLAIMS [308111801] 5.09 percent of total billed charges 3.5 5.37 Technical (Hospital) Services "BISACODYL 5 MG TABLET,DELAYED RELEASE" RX-1079 CDM 2590000100 HCPCS 259 RC 00904-6407-61 NDC inpatient 1 UN 5.65 5.65 MEDICA (COMMERCIAL) 94265 [3081118] MEDICA CLAIMS [308111801] 5.09 percent of total billed charges 3.5 5.37 Technical (Hospital) Services "BISACODYL 5 MG TABLET,DELAYED RELEASE" RX-1079 CDM 2590000100 HCPCS 259 RC 00904-6407-61 NDC inpatient 1 UN 5.65 5.65 HEALTHPARTNERS SX009 HEALTHPARTNERS 4.47 percent of total billed charges 3.5 5.37 Technical (Hospital) Services "BISACODYL 5 MG TABLET,DELAYED RELEASE" RX-1079 CDM 2590000100 HCPCS 259 RC 00904-6407-61 NDC inpatient 1 UN 5.65 5.65 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES PPO [308136801] 4.47 percent of total billed charges 3.5 5.37 Technical (Hospital) Services "BISACODYL 5 MG TABLET,DELAYED RELEASE" RX-1079 CDM 2590000100 HCPCS 259 RC 00904-6407-61 NDC inpatient 1 UN 5.65 5.65 MULTIPLAN INC 34080 [3081285] MULTIPLAN INC [308128501] 5.37 percent of total billed charges 3.5 5.37 Technical (Hospital) Services "BISACODYL 5 MG TABLET,DELAYED RELEASE" RX-1079 CDM 2590000100 HCPCS 259 RC 00904-6407-61 NDC inpatient 1 UN 5.65 5.65 CIGNA 62308 [3081051] CIGNA 62308 [308105105] 4.47 percent of total billed charges 3.5 5.37 Technical (Hospital) Services "BISACODYL 5 MG TABLET,DELAYED RELEASE" RX-1079 CDM 2590000100 HCPCS 259 RC 00904-6407-61 NDC inpatient 1 UN 5.65 5.65 CIGNA 62308 [3081051] CIGNA STATE OF WYOMING [308105107] 4.47 percent of total billed charges 3.5 5.37 Technical (Hospital) Services "BISACODYL 5 MG TABLET,DELAYED RELEASE" RX-1079 CDM 2590000100 HCPCS 259 RC 00904-6407-61 NDC inpatient 1 UN 5.65 5.65 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES HDHP [308136802] 4.47 percent of total billed charges 3.5 5.37 Technical (Hospital) Services "BISACODYL 5 MG TABLET,DELAYED RELEASE" RX-1079 CDM 2590000100 HCPCS 259 RC 00904-6407-61 NDC inpatient 1 UN 5.65 5.65 BLUE CROSS BLUE SHIELD WELLMARK SB889 [3081026] BCBS WYOMING [308102603] 5.37 percent of total billed charges 3.5 5.37 Technical (Hospital) Services "BISACODYL 5 MG TABLET,DELAYED RELEASE" RX-1079 CDM 2590000100 HCPCS 259 RC 00904-6407-61 NDC inpatient 1 UN 5.65 5.65 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES EPO [308136803] 4.47 percent of total billed charges 3.5 5.37 Technical (Hospital) Services "BISACODYL 5 MG TABLET,DELAYED RELEASE" RX-1079 CDM 2590000100 HCPCS 259 RC 00904-6407-61 NDC inpatient 1 UN 5.65 5.65 UNITED HEALTHCARE (COMMERCIAL) [3081199] UNITED HEALTHCARE 87726 [308119901] 3.5 percent of total billed charges 3.5 5.37 Technical (Hospital) Services BISACODYL 10 MG RECTAL SUPPOSITORY RX-1080 CDM 2590000100 HCPCS 259 RC 00574-7050-12 NDC inpatient 1 UN 5.97 5.97 MEDICA (COMMERCIAL) 94265 [3081118] MEDICA CLAIMS [308111801] 5.37 percent of total billed charges 3.7 5.67 Technical (Hospital) Services BISACODYL 10 MG RECTAL SUPPOSITORY RX-1080 CDM 2590000100 HCPCS 259 RC 00574-7050-12 NDC inpatient 1 UN 5.97 5.97 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES PPO [308136801] 4.73 percent of total billed charges 3.7 5.67 Technical (Hospital) Services BISACODYL 10 MG RECTAL SUPPOSITORY RX-1080 CDM 2590000100 HCPCS 259 RC 00574-7050-12 NDC inpatient 1 UN 5.97 5.97 HEALTHPARTNERS SX009 HEALTHPARTNERS 4.73 percent of total billed charges 3.7 5.67 Technical (Hospital) Services BISACODYL 10 MG RECTAL SUPPOSITORY RX-1080 CDM 2590000100 HCPCS 259 RC 00574-7050-12 NDC inpatient 1 UN 5.97 5.97 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES EPO [308136803] 4.73 percent of total billed charges 3.7 5.67 Technical (Hospital) Services BISACODYL 10 MG RECTAL SUPPOSITORY RX-1080 CDM 2590000100 HCPCS 259 RC 00574-7050-12 NDC inpatient 1 UN 5.97 5.97 CIGNA 62308 [3081051] CIGNA 62308 [308105105] 4.73 percent of total billed charges 3.7 5.67 Technical (Hospital) Services BISACODYL 10 MG RECTAL SUPPOSITORY RX-1080 CDM 2590000100 HCPCS 259 RC 00574-7050-12 NDC inpatient 1 UN 5.97 5.97 CIGNA 62308 [3081051] CIGNA STATE OF WYOMING [308105107] 4.73 percent of total billed charges 3.7 5.67 Technical (Hospital) Services BISACODYL 10 MG RECTAL SUPPOSITORY RX-1080 CDM 2590000100 HCPCS 259 RC 00574-7050-12 NDC inpatient 1 UN 5.97 5.97 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES HDHP [308136802] 4.73 percent of total billed charges 3.7 5.67 Technical (Hospital) Services BISACODYL 10 MG RECTAL SUPPOSITORY RX-1080 CDM 2590000100 HCPCS 259 RC 00574-7050-12 NDC inpatient 1 UN 5.97 5.97 UNITED HEALTHCARE (COMMERCIAL) [3081199] UNITED HEALTHCARE 87726 [308119901] 3.7 percent of total billed charges 3.7 5.67 Technical (Hospital) Services BISACODYL 10 MG RECTAL SUPPOSITORY RX-1080 CDM 2590000100 HCPCS 259 RC 00574-7050-12 NDC inpatient 1 UN 5.97 5.97 BLUE CROSS BLUE SHIELD WELLMARK SB889 [3081026] BCBS WYOMING [308102603] 5.67 percent of total billed charges 3.7 5.67 Technical (Hospital) Services BISACODYL 10 MG RECTAL SUPPOSITORY RX-1080 CDM 2590000100 HCPCS 259 RC 00574-7050-12 NDC inpatient 1 UN 5.97 5.97 MULTIPLAN INC 34080 [3081285] MULTIPLAN INC [308128501] 5.67 percent of total billed charges 3.7 5.67 Technical (Hospital) Services BISACODYL 10 MG RECTAL SUPPOSITORY RX-1080 CDM 2590000100 HCPCS 259 RC 00574-7050-12 NDC outpatient 1 UN 5.97 5.97 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES PPO [308136801] 4.78 percent of total billed charges 3.7 5.67 Technical (Hospital) Services BISACODYL 10 MG RECTAL SUPPOSITORY RX-1080 CDM 2590000100 HCPCS 259 RC 00574-7050-12 NDC outpatient 1 UN 5.97 5.97 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES HDHP [308136802] 4.78 percent of total billed charges 3.7 5.67 Technical (Hospital) Services BISACODYL 10 MG RECTAL SUPPOSITORY RX-1080 CDM 2590000100 HCPCS 259 RC 00574-7050-12 NDC outpatient 1 UN 5.97 5.97 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES EPO [308136803] 4.78 percent of total billed charges 3.7 5.67 Technical (Hospital) Services BISACODYL 10 MG RECTAL SUPPOSITORY RX-1080 CDM 2590000100 HCPCS 259 RC 00574-7050-12 NDC outpatient 1 UN 5.97 5.97 MEDICA (COMMERCIAL) 94265 [3081118] MEDICA CLAIMS [308111801] 5.37 percent of total billed charges 3.7 5.67 Technical (Hospital) Services BISACODYL 10 MG RECTAL SUPPOSITORY RX-1080 CDM 2590000100 HCPCS 259 RC 00574-7050-12 NDC outpatient 1 UN 5.97 5.97 BLUE CROSS BLUE SHIELD WELLMARK SB889 [3081026] BCBS WYOMING [308102603] 5.67 percent of total billed charges 3.7 5.67 Technical (Hospital) Services BISACODYL 10 MG RECTAL SUPPOSITORY RX-1080 CDM 2590000100 HCPCS 259 RC 00574-7050-12 NDC outpatient 1 UN 5.97 5.97 MULTIPLAN INC 34080 [3081285] MULTIPLAN INC [308128501] 5.67 percent of total billed charges 3.7 5.67 Technical (Hospital) Services BISACODYL 10 MG RECTAL SUPPOSITORY RX-1080 CDM 2590000100 HCPCS 259 RC 00574-7050-12 NDC outpatient 1 UN 5.97 5.97 CIGNA 62308 [3081051] CIGNA 62308 [308105105] 4.78 percent of total billed charges 3.7 5.67 Technical (Hospital) Services BISACODYL 10 MG RECTAL SUPPOSITORY RX-1080 CDM 2590000100 HCPCS 259 RC 00574-7050-12 NDC outpatient 1 UN 5.97 5.97 CIGNA 62308 [3081051] CIGNA STATE OF WYOMING [308105107] 4.78 percent of total billed charges 3.7 5.67 Technical (Hospital) Services BISACODYL 10 MG RECTAL SUPPOSITORY RX-1080 CDM 2590000100 HCPCS 259 RC 00574-7050-12 NDC outpatient 1 UN 5.97 5.97 HEALTHPARTNERS SX009 HEALTHPARTNERS 4.78 percent of total billed charges 3.7 5.67 Technical (Hospital) Services BISACODYL 10 MG RECTAL SUPPOSITORY RX-1080 CDM 2590000100 HCPCS 259 RC 00574-7050-12 NDC outpatient 1 UN 5.97 5.97 UNITED HEALTHCARE (COMMERCIAL) [3081199] UNITED HEALTHCARE 87726 [308119901] 3.7 percent of total billed charges 3.7 5.67 Technical (Hospital) Services PSYLLIUM HUSK (ASPARTAME) 3.4/5.8 GRAM ORAL POWDER PACKET RX-11218 CDM 2590000100 HCPCS 259 RC 37000-0024-10 NDC inpatient 1 UN 5.99 5.99 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES PPO [308136801] 4.74 percent of total billed charges 3.71 5.69 Technical (Hospital) Services PSYLLIUM HUSK (ASPARTAME) 3.4/5.8 GRAM ORAL POWDER PACKET RX-11218 CDM 2590000100 HCPCS 259 RC 37000-0024-10 NDC inpatient 1 UN 5.99 5.99 HEALTHPARTNERS SX009 HEALTHPARTNERS 4.74 percent of total billed charges 3.71 5.69 Technical (Hospital) Services PSYLLIUM HUSK (ASPARTAME) 3.4/5.8 GRAM ORAL POWDER PACKET RX-11218 CDM 2590000100 HCPCS 259 RC 37000-0024-10 NDC inpatient 1 UN 5.99 5.99 MEDICA (COMMERCIAL) 94265 [3081118] MEDICA CLAIMS [308111801] 5.39 percent of total billed charges 3.71 5.69 Technical (Hospital) Services PSYLLIUM HUSK (ASPARTAME) 3.4/5.8 GRAM ORAL POWDER PACKET RX-11218 CDM 2590000100 HCPCS 259 RC 37000-0024-10 NDC inpatient 1 UN 5.99 5.99 CIGNA 62308 [3081051] CIGNA 62308 [308105105] 4.74 percent of total billed charges 3.71 5.69 Technical (Hospital) Services PSYLLIUM HUSK (ASPARTAME) 3.4/5.8 GRAM ORAL POWDER PACKET RX-11218 CDM 2590000100 HCPCS 259 RC 37000-0024-10 NDC inpatient 1 UN 5.99 5.99 CIGNA 62308 [3081051] CIGNA STATE OF WYOMING [308105107] 4.74 percent of total billed charges 3.71 5.69 Technical (Hospital) Services PSYLLIUM HUSK (ASPARTAME) 3.4/5.8 GRAM ORAL POWDER PACKET RX-11218 CDM 2590000100 HCPCS 259 RC 37000-0024-10 NDC inpatient 1 UN 5.99 5.99 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES HDHP [308136802] 4.74 percent of total billed charges 3.71 5.69 Technical (Hospital) Services PSYLLIUM HUSK (ASPARTAME) 3.4/5.8 GRAM ORAL POWDER PACKET RX-11218 CDM 2590000100 HCPCS 259 RC 37000-0024-10 NDC inpatient 1 UN 5.99 5.99 UNITED HEALTHCARE (COMMERCIAL) [3081199] UNITED HEALTHCARE 87726 [308119901] 3.71 percent of total billed charges 3.71 5.69 Technical (Hospital) Services PSYLLIUM HUSK (ASPARTAME) 3.4/5.8 GRAM ORAL POWDER PACKET RX-11218 CDM 2590000100 HCPCS 259 RC 37000-0024-10 NDC inpatient 1 UN 5.99 5.99 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES EPO [308136803] 4.74 percent of total billed charges 3.71 5.69 Technical (Hospital) Services PSYLLIUM HUSK (ASPARTAME) 3.4/5.8 GRAM ORAL POWDER PACKET RX-11218 CDM 2590000100 HCPCS 259 RC 37000-0024-10 NDC inpatient 1 UN 5.99 5.99 BLUE CROSS BLUE SHIELD WELLMARK SB889 [3081026] BCBS WYOMING [308102603] 5.69 percent of total billed charges 3.71 5.69 Technical (Hospital) Services PSYLLIUM HUSK (ASPARTAME) 3.4/5.8 GRAM ORAL POWDER PACKET RX-11218 CDM 2590000100 HCPCS 259 RC 37000-0024-10 NDC inpatient 1 UN 5.99 5.99 MULTIPLAN INC 34080 [3081285] MULTIPLAN INC [308128501] 5.69 percent of total billed charges 3.71 5.69 Technical (Hospital) Services PSYLLIUM HUSK (ASPARTAME) 3.4/5.8 GRAM ORAL POWDER PACKET RX-11218 CDM 2590000100 HCPCS 259 RC 37000-0024-10 NDC outpatient 1 UN 5.99 5.99 CIGNA 62308 [3081051] CIGNA 62308 [308105105] 4.79 percent of total billed charges 3.71 5.69 Technical (Hospital) Services PSYLLIUM HUSK (ASPARTAME) 3.4/5.8 GRAM ORAL POWDER PACKET RX-11218 CDM 2590000100 HCPCS 259 RC 37000-0024-10 NDC outpatient 1 UN 5.99 5.99 CIGNA 62308 [3081051] CIGNA STATE OF WYOMING [308105107] 4.79 percent of total billed charges 3.71 5.69 Technical (Hospital) Services PSYLLIUM HUSK (ASPARTAME) 3.4/5.8 GRAM ORAL POWDER PACKET RX-11218 CDM 2590000100 HCPCS 259 RC 37000-0024-10 NDC outpatient 1 UN 5.99 5.99 MULTIPLAN INC 34080 [3081285] MULTIPLAN INC [308128501] 5.69 percent of total billed charges 3.71 5.69 Technical (Hospital) Services PSYLLIUM HUSK (ASPARTAME) 3.4/5.8 GRAM ORAL POWDER PACKET RX-11218 CDM 2590000100 HCPCS 259 RC 37000-0024-10 NDC outpatient 1 UN 5.99 5.99 HEALTHPARTNERS SX009 HEALTHPARTNERS 4.79 percent of total billed charges 3.71 5.69 Technical (Hospital) Services PSYLLIUM HUSK (ASPARTAME) 3.4/5.8 GRAM ORAL POWDER PACKET RX-11218 CDM 2590000100 HCPCS 259 RC 37000-0024-10 NDC outpatient 1 UN 5.99 5.99 UNITED HEALTHCARE (COMMERCIAL) [3081199] UNITED HEALTHCARE 87726 [308119901] 3.71 percent of total billed charges 3.71 5.69 Technical (Hospital) Services PSYLLIUM HUSK (ASPARTAME) 3.4/5.8 GRAM ORAL POWDER PACKET RX-11218 CDM 2590000100 HCPCS 259 RC 37000-0024-10 NDC outpatient 1 UN 5.99 5.99 BLUE CROSS BLUE SHIELD WELLMARK SB889 [3081026] BCBS WYOMING [308102603] 5.69 percent of total billed charges 3.71 5.69 Technical (Hospital) Services PSYLLIUM HUSK (ASPARTAME) 3.4/5.8 GRAM ORAL POWDER PACKET RX-11218 CDM 2590000100 HCPCS 259 RC 37000-0024-10 NDC outpatient 1 UN 5.99 5.99 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES EPO [308136803] 4.79 percent of total billed charges 3.71 5.69 Technical (Hospital) Services PSYLLIUM HUSK (ASPARTAME) 3.4/5.8 GRAM ORAL POWDER PACKET RX-11218 CDM 2590000100 HCPCS 259 RC 37000-0024-10 NDC outpatient 1 UN 5.99 5.99 MEDICA (COMMERCIAL) 94265 [3081118] MEDICA CLAIMS [308111801] 5.39 percent of total billed charges 3.71 5.69 Technical (Hospital) Services PSYLLIUM HUSK (ASPARTAME) 3.4/5.8 GRAM ORAL POWDER PACKET RX-11218 CDM 2590000100 HCPCS 259 RC 37000-0024-10 NDC outpatient 1 UN 5.99 5.99 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES PPO [308136801] 4.79 percent of total billed charges 3.71 5.69 Technical (Hospital) Services PSYLLIUM HUSK (ASPARTAME) 3.4/5.8 GRAM ORAL POWDER PACKET RX-11218 CDM 2590000100 HCPCS 259 RC 37000-0024-10 NDC outpatient 1 UN 5.99 5.99 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES HDHP [308136802] 4.79 percent of total billed charges 3.71 5.69 Technical (Hospital) Services SENNOSIDES 8.6 MG TABLET RX-11349 CDM 2590000100 HCPCS 259 RC 00904-7252-61 NDC outpatient 1 UN 5.66 5.66 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES HDHP [308136802] 4.53 percent of total billed charges 3.51 5.38 Technical (Hospital) Services SENNOSIDES 8.6 MG TABLET RX-11349 CDM 2590000100 HCPCS 259 RC 00904-7252-61 NDC outpatient 1 UN 5.66 5.66 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES PPO [308136801] 4.53 percent of total billed charges 3.51 5.38 Technical (Hospital) Services SENNOSIDES 8.6 MG TABLET RX-11349 CDM 2590000100 HCPCS 259 RC 00904-7252-61 NDC outpatient 1 UN 5.66 5.66 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES EPO [308136803] 4.53 percent of total billed charges 3.51 5.38 Technical (Hospital) Services SENNOSIDES 8.6 MG TABLET RX-11349 CDM 2590000100 HCPCS 259 RC 00904-7252-61 NDC outpatient 1 UN 5.66 5.66 HEALTHPARTNERS SX009 HEALTHPARTNERS 4.53 percent of total billed charges 3.51 5.38 Technical (Hospital) Services SENNOSIDES 8.6 MG TABLET RX-11349 CDM 2590000100 HCPCS 259 RC 00904-7252-61 NDC outpatient 1 UN 5.66 5.66 UNITED HEALTHCARE (COMMERCIAL) [3081199] UNITED HEALTHCARE 87726 [308119901] 3.51 percent of total billed charges 3.51 5.38 Technical (Hospital) Services SENNOSIDES 8.6 MG TABLET RX-11349 CDM 2590000100 HCPCS 259 RC 00904-7252-61 NDC outpatient 1 UN 5.66 5.66 CIGNA 62308 [3081051] CIGNA 62308 [308105105] 4.53 percent of total billed charges 3.51 5.38 Technical (Hospital) Services SENNOSIDES 8.6 MG TABLET RX-11349 CDM 2590000100 HCPCS 259 RC 00904-7252-61 NDC outpatient 1 UN 5.66 5.66 CIGNA 62308 [3081051] CIGNA STATE OF WYOMING [308105107] 4.53 percent of total billed charges 3.51 5.38 Technical (Hospital) Services SENNOSIDES 8.6 MG TABLET RX-11349 CDM 2590000100 HCPCS 259 RC 00904-7252-61 NDC outpatient 1 UN 5.66 5.66 MULTIPLAN INC 34080 [3081285] MULTIPLAN INC [308128501] 5.38 percent of total billed charges 3.51 5.38 Technical (Hospital) Services SENNOSIDES 8.6 MG TABLET RX-11349 CDM 2590000100 HCPCS 259 RC 00904-7252-61 NDC outpatient 1 UN 5.66 5.66 MEDICA (COMMERCIAL) 94265 [3081118] MEDICA CLAIMS [308111801] 5.09 percent of total billed charges 3.51 5.38 Technical (Hospital) Services SENNOSIDES 8.6 MG TABLET RX-11349 CDM 2590000100 HCPCS 259 RC 00904-7252-61 NDC outpatient 1 UN 5.66 5.66 BLUE CROSS BLUE SHIELD WELLMARK SB889 [3081026] BCBS WYOMING [308102603] 5.38 percent of total billed charges 3.51 5.38 Technical (Hospital) Services SENNOSIDES 8.6 MG TABLET RX-11349 CDM 2590000100 HCPCS 259 RC 00904-7252-61 NDC inpatient 1 UN 5.66 5.66 MULTIPLAN INC 34080 [3081285] MULTIPLAN INC [308128501] 5.38 percent of total billed charges 3.51 5.38 Technical (Hospital) Services SENNOSIDES 8.6 MG TABLET RX-11349 CDM 2590000100 HCPCS 259 RC 00904-7252-61 NDC inpatient 1 UN 5.66 5.66 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES HDHP [308136802] 4.48 percent of total billed charges 3.51 5.38 Technical (Hospital) Services SENNOSIDES 8.6 MG TABLET RX-11349 CDM 2590000100 HCPCS 259 RC 00904-7252-61 NDC inpatient 1 UN 5.66 5.66 CIGNA 62308 [3081051] CIGNA 62308 [308105105] 4.48 percent of total billed charges 3.51 5.38 Technical (Hospital) Services SENNOSIDES 8.6 MG TABLET RX-11349 CDM 2590000100 HCPCS 259 RC 00904-7252-61 NDC inpatient 1 UN 5.66 5.66 CIGNA 62308 [3081051] CIGNA STATE OF WYOMING [308105107] 4.48 percent of total billed charges 3.51 5.38 Technical (Hospital) Services SENNOSIDES 8.6 MG TABLET RX-11349 CDM 2590000100 HCPCS 259 RC 00904-7252-61 NDC inpatient 1 UN 5.66 5.66 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES EPO [308136803] 4.48 percent of total billed charges 3.51 5.38 Technical (Hospital) Services SENNOSIDES 8.6 MG TABLET RX-11349 CDM 2590000100 HCPCS 259 RC 00904-7252-61 NDC inpatient 1 UN 5.66 5.66 BLUE CROSS BLUE SHIELD WELLMARK SB889 [3081026] BCBS WYOMING [308102603] 5.38 percent of total billed charges 3.51 5.38 Technical (Hospital) Services SENNOSIDES 8.6 MG TABLET RX-11349 CDM 2590000100 HCPCS 259 RC 00904-7252-61 NDC inpatient 1 UN 5.66 5.66 UNITED HEALTHCARE (COMMERCIAL) [3081199] UNITED HEALTHCARE 87726 [308119901] 3.51 percent of total billed charges 3.51 5.38 Technical (Hospital) Services SENNOSIDES 8.6 MG TABLET RX-11349 CDM 2590000100 HCPCS 259 RC 00904-7252-61 NDC inpatient 1 UN 5.66 5.66 HEALTHPARTNERS SX009 HEALTHPARTNERS 4.48 percent of total billed charges 3.51 5.38 Technical (Hospital) Services SENNOSIDES 8.6 MG TABLET RX-11349 CDM 2590000100 HCPCS 259 RC 00904-7252-61 NDC inpatient 1 UN 5.66 5.66 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES PPO [308136801] 4.48 percent of total billed charges 3.51 5.38 Technical (Hospital) Services SENNOSIDES 8.6 MG TABLET RX-11349 CDM 2590000100 HCPCS 259 RC 00904-7252-61 NDC inpatient 1 UN 5.66 5.66 MEDICA (COMMERCIAL) 94265 [3081118] MEDICA CLAIMS [308111801] 5.09 percent of total billed charges 3.51 5.38 Technical (Hospital) Services CARBOXYMETHYLCELLULOSE SODIUM 0.5 % EYE DROPS RX-122011 CDM 2590000100 HCPCS 259 RC 00023-0798-15 NDC outpatient 0.05 ML 5.65 5.65 MEDICA (COMMERCIAL) 94265 [3081118] MEDICA CLAIMS [308111801] 5.09 percent of total billed charges 3.5 5.37 Technical (Hospital) Services CARBOXYMETHYLCELLULOSE SODIUM 0.5 % EYE DROPS RX-122011 CDM 2590000100 HCPCS 259 RC 00023-0798-15 NDC outpatient 0.05 ML 5.65 5.65 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES EPO [308136803] 4.52 percent of total billed charges 3.5 5.37 Technical (Hospital) Services CARBOXYMETHYLCELLULOSE SODIUM 0.5 % EYE DROPS RX-122011 CDM 2590000100 HCPCS 259 RC 00023-0798-15 NDC outpatient 0.05 ML 5.65 5.65 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES HDHP [308136802] 4.52 percent of total billed charges 3.5 5.37 Technical (Hospital) Services CARBOXYMETHYLCELLULOSE SODIUM 0.5 % EYE DROPS RX-122011 CDM 2590000100 HCPCS 259 RC 00023-0798-15 NDC outpatient 0.05 ML 5.65 5.65 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES PPO [308136801] 4.52 percent of total billed charges 3.5 5.37 Technical (Hospital) Services CARBOXYMETHYLCELLULOSE SODIUM 0.5 % EYE DROPS RX-122011 CDM 2590000100 HCPCS 259 RC 00023-0798-15 NDC outpatient 0.05 ML 5.65 5.65 UNITED HEALTHCARE (COMMERCIAL) [3081199] UNITED HEALTHCARE 87726 [308119901] 3.5 percent of total billed charges 3.5 5.37 Technical (Hospital) Services CARBOXYMETHYLCELLULOSE SODIUM 0.5 % EYE DROPS RX-122011 CDM 2590000100 HCPCS 259 RC 00023-0798-15 NDC outpatient 0.05 ML 5.65 5.65 CIGNA 62308 [3081051] CIGNA 62308 [308105105] 4.52 percent of total billed charges 3.5 5.37 Technical (Hospital) Services CARBOXYMETHYLCELLULOSE SODIUM 0.5 % EYE DROPS RX-122011 CDM 2590000100 HCPCS 259 RC 00023-0798-15 NDC outpatient 0.05 ML 5.65 5.65 CIGNA 62308 [3081051] CIGNA STATE OF WYOMING [308105107] 4.52 percent of total billed charges 3.5 5.37 Technical (Hospital) Services CARBOXYMETHYLCELLULOSE SODIUM 0.5 % EYE DROPS RX-122011 CDM 2590000100 HCPCS 259 RC 00023-0798-15 NDC outpatient 0.05 ML 5.65 5.65 MULTIPLAN INC 34080 [3081285] MULTIPLAN INC [308128501] 5.37 percent of total billed charges 3.5 5.37 Technical (Hospital) Services CARBOXYMETHYLCELLULOSE SODIUM 0.5 % EYE DROPS RX-122011 CDM 2590000100 HCPCS 259 RC 00023-0798-15 NDC outpatient 0.05 ML 5.65 5.65 HEALTHPARTNERS SX009 HEALTHPARTNERS 4.52 percent of total billed charges 3.5 5.37 Technical (Hospital) Services CARBOXYMETHYLCELLULOSE SODIUM 0.5 % EYE DROPS RX-122011 CDM 2590000100 HCPCS 259 RC 00023-0798-15 NDC outpatient 0.05 ML 5.65 5.65 BLUE CROSS BLUE SHIELD WELLMARK SB889 [3081026] BCBS WYOMING [308102603] 5.37 percent of total billed charges 3.5 5.37 Technical (Hospital) Services CARBOXYMETHYLCELLULOSE SODIUM 0.5 % EYE DROPS RX-122011 CDM 2590000100 HCPCS 259 RC 00023-0798-15 NDC inpatient 0.05 ML 5.65 5.65 UNITED HEALTHCARE (COMMERCIAL) [3081199] UNITED HEALTHCARE 87726 [308119901] 3.5 percent of total billed charges 3.5 5.37 Technical (Hospital) Services CARBOXYMETHYLCELLULOSE SODIUM 0.5 % EYE DROPS RX-122011 CDM 2590000100 HCPCS 259 RC 00023-0798-15 NDC inpatient 0.05 ML 5.65 5.65 BLUE CROSS BLUE SHIELD WELLMARK SB889 [3081026] BCBS WYOMING [308102603] 5.37 percent of total billed charges 3.5 5.37 Technical (Hospital) Services CARBOXYMETHYLCELLULOSE SODIUM 0.5 % EYE DROPS RX-122011 CDM 2590000100 HCPCS 259 RC 00023-0798-15 NDC inpatient 0.05 ML 5.65 5.65 CIGNA 62308 [3081051] CIGNA STATE OF WYOMING [308105107] 4.47 percent of total billed charges 3.5 5.37 Technical (Hospital) Services CARBOXYMETHYLCELLULOSE SODIUM 0.5 % EYE DROPS RX-122011 CDM 2590000100 HCPCS 259 RC 00023-0798-15 NDC inpatient 0.05 ML 5.65 5.65 CIGNA 62308 [3081051] CIGNA 62308 [308105105] 4.47 percent of total billed charges 3.5 5.37 Technical (Hospital) Services CARBOXYMETHYLCELLULOSE SODIUM 0.5 % EYE DROPS RX-122011 CDM 2590000100 HCPCS 259 RC 00023-0798-15 NDC inpatient 0.05 ML 5.65 5.65 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES HDHP [308136802] 4.47 percent of total billed charges 3.5 5.37 Technical (Hospital) Services CARBOXYMETHYLCELLULOSE SODIUM 0.5 % EYE DROPS RX-122011 CDM 2590000100 HCPCS 259 RC 00023-0798-15 NDC inpatient 0.05 ML 5.65 5.65 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES PPO [308136801] 4.47 percent of total billed charges 3.5 5.37 Technical (Hospital) Services CARBOXYMETHYLCELLULOSE SODIUM 0.5 % EYE DROPS RX-122011 CDM 2590000100 HCPCS 259 RC 00023-0798-15 NDC inpatient 0.05 ML 5.65 5.65 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES EPO [308136803] 4.47 percent of total billed charges 3.5 5.37 Technical (Hospital) Services CARBOXYMETHYLCELLULOSE SODIUM 0.5 % EYE DROPS RX-122011 CDM 2590000100 HCPCS 259 RC 00023-0798-15 NDC inpatient 0.05 ML 5.65 5.65 HEALTHPARTNERS SX009 HEALTHPARTNERS 4.47 percent of total billed charges 3.5 5.37 Technical (Hospital) Services CARBOXYMETHYLCELLULOSE SODIUM 0.5 % EYE DROPS RX-122011 CDM 2590000100 HCPCS 259 RC 00023-0798-15 NDC inpatient 0.05 ML 5.65 5.65 MEDICA (COMMERCIAL) 94265 [3081118] MEDICA CLAIMS [308111801] 5.09 percent of total billed charges 3.5 5.37 Technical (Hospital) Services CARBOXYMETHYLCELLULOSE SODIUM 0.5 % EYE DROPS RX-122011 CDM 2590000100 HCPCS 259 RC 00023-0798-15 NDC inpatient 0.05 ML 5.65 5.65 MULTIPLAN INC 34080 [3081285] MULTIPLAN INC [308128501] 5.37 percent of total billed charges 3.5 5.37 Technical (Hospital) Services DIPHENHYDRAMINE 12.5 MG/5 ML ORAL LIQUID RX-12556 CDM 2590000100 HCPCS 259 RC 00121-0865-05 NDC inpatient 5 ML 7.67 7.67 UNITED HEALTHCARE (COMMERCIAL) [3081199] UNITED HEALTHCARE 87726 [308119901] 4.76 percent of total billed charges 4.76 7.29 Technical (Hospital) Services DIPHENHYDRAMINE 12.5 MG/5 ML ORAL LIQUID RX-12556 CDM 2590000100 HCPCS 259 RC 00121-0865-05 NDC inpatient 5 ML 7.67 7.67 BLUE CROSS BLUE SHIELD WELLMARK SB889 [3081026] BCBS WYOMING [308102603] 7.29 percent of total billed charges 4.76 7.29 Technical (Hospital) Services DIPHENHYDRAMINE 12.5 MG/5 ML ORAL LIQUID RX-12556 CDM 2590000100 HCPCS 259 RC 00121-0865-05 NDC inpatient 5 ML 7.67 7.67 CIGNA 62308 [3081051] CIGNA 62308 [308105105] 6.07 percent of total billed charges 4.76 7.29 Technical (Hospital) Services DIPHENHYDRAMINE 12.5 MG/5 ML ORAL LIQUID RX-12556 CDM 2590000100 HCPCS 259 RC 00121-0865-05 NDC inpatient 5 ML 7.67 7.67 CIGNA 62308 [3081051] CIGNA STATE OF WYOMING [308105107] 6.07 percent of total billed charges 4.76 7.29 Technical (Hospital) Services DIPHENHYDRAMINE 12.5 MG/5 ML ORAL LIQUID RX-12556 CDM 2590000100 HCPCS 259 RC 00121-0865-05 NDC inpatient 5 ML 7.67 7.67 MULTIPLAN INC 34080 [3081285] MULTIPLAN INC [308128501] 7.29 percent of total billed charges 4.76 7.29 Technical (Hospital) Services DIPHENHYDRAMINE 12.5 MG/5 ML ORAL LIQUID RX-12556 CDM 2590000100 HCPCS 259 RC 00121-0865-05 NDC inpatient 5 ML 7.67 7.67 MEDICA (COMMERCIAL) 94265 [3081118] MEDICA CLAIMS [308111801] 6.9 percent of total billed charges 4.76 7.29 Technical (Hospital) Services DIPHENHYDRAMINE 12.5 MG/5 ML ORAL LIQUID RX-12556 CDM 2590000100 HCPCS 259 RC 00121-0865-05 NDC inpatient 5 ML 7.67 7.67 HEALTHPARTNERS SX009 HEALTHPARTNERS 6.07 percent of total billed charges 4.76 7.29 Technical (Hospital) Services DIPHENHYDRAMINE 12.5 MG/5 ML ORAL LIQUID RX-12556 CDM 2590000100 HCPCS 259 RC 00121-0865-05 NDC inpatient 5 ML 7.67 7.67 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES EPO [308136803] 6.07 percent of total billed charges 4.76 7.29 Technical (Hospital) Services DIPHENHYDRAMINE 12.5 MG/5 ML ORAL LIQUID RX-12556 CDM 2590000100 HCPCS 259 RC 00121-0865-05 NDC inpatient 5 ML 7.67 7.67 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES HDHP [308136802] 6.07 percent of total billed charges 4.76 7.29 Technical (Hospital) Services DIPHENHYDRAMINE 12.5 MG/5 ML ORAL LIQUID RX-12556 CDM 2590000100 HCPCS 259 RC 00121-0865-05 NDC inpatient 5 ML 7.67 7.67 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES PPO [308136801] 6.07 percent of total billed charges 4.76 7.29 Technical (Hospital) Services DIPHENHYDRAMINE 12.5 MG/5 ML ORAL LIQUID RX-12556 CDM 2590000100 HCPCS 259 RC 00121-0865-05 NDC outpatient 5 ML 7.67 7.67 CIGNA 62308 [3081051] CIGNA STATE OF WYOMING [308105107] 6.14 percent of total billed charges 4.76 7.29 Technical (Hospital) Services DIPHENHYDRAMINE 12.5 MG/5 ML ORAL LIQUID RX-12556 CDM 2590000100 HCPCS 259 RC 00121-0865-05 NDC outpatient 5 ML 7.67 7.67 BLUE CROSS BLUE SHIELD WELLMARK SB889 [3081026] BCBS WYOMING [308102603] 7.29 percent of total billed charges 4.76 7.29 Technical (Hospital) Services DIPHENHYDRAMINE 12.5 MG/5 ML ORAL LIQUID RX-12556 CDM 2590000100 HCPCS 259 RC 00121-0865-05 NDC outpatient 5 ML 7.67 7.67 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES EPO [308136803] 6.14 percent of total billed charges 4.76 7.29 Technical (Hospital) Services DIPHENHYDRAMINE 12.5 MG/5 ML ORAL LIQUID RX-12556 CDM 2590000100 HCPCS 259 RC 00121-0865-05 NDC outpatient 5 ML 7.67 7.67 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES PPO [308136801] 6.14 percent of total billed charges 4.76 7.29 Technical (Hospital) Services DIPHENHYDRAMINE 12.5 MG/5 ML ORAL LIQUID RX-12556 CDM 2590000100 HCPCS 259 RC 00121-0865-05 NDC outpatient 5 ML 7.67 7.67 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES HDHP [308136802] 6.14 percent of total billed charges 4.76 7.29 Technical (Hospital) Services DIPHENHYDRAMINE 12.5 MG/5 ML ORAL LIQUID RX-12556 CDM 2590000100 HCPCS 259 RC 00121-0865-05 NDC outpatient 5 ML 7.67 7.67 MULTIPLAN INC 34080 [3081285] MULTIPLAN INC [308128501] 7.29 percent of total billed charges 4.76 7.29 Technical (Hospital) Services DIPHENHYDRAMINE 12.5 MG/5 ML ORAL LIQUID RX-12556 CDM 2590000100 HCPCS 259 RC 00121-0865-05 NDC outpatient 5 ML 7.67 7.67 MEDICA (COMMERCIAL) 94265 [3081118] MEDICA CLAIMS [308111801] 6.9 percent of total billed charges 4.76 7.29 Technical (Hospital) Services DIPHENHYDRAMINE 12.5 MG/5 ML ORAL LIQUID RX-12556 CDM 2590000100 HCPCS 259 RC 00121-0865-05 NDC outpatient 5 ML 7.67 7.67 CIGNA 62308 [3081051] CIGNA 62308 [308105105] 6.14 percent of total billed charges 4.76 7.29 Technical (Hospital) Services DIPHENHYDRAMINE 12.5 MG/5 ML ORAL LIQUID RX-12556 CDM 2590000100 HCPCS 259 RC 00121-0865-05 NDC outpatient 5 ML 7.67 7.67 UNITED HEALTHCARE (COMMERCIAL) [3081199] UNITED HEALTHCARE 87726 [308119901] 4.76 percent of total billed charges 4.76 7.29 Technical (Hospital) Services DIPHENHYDRAMINE 12.5 MG/5 ML ORAL LIQUID RX-12556 CDM 2590000100 HCPCS 259 RC 00121-0865-05 NDC outpatient 5 ML 7.67 7.67 HEALTHPARTNERS SX009 HEALTHPARTNERS 6.14 percent of total billed charges 4.76 7.29 Technical (Hospital) Services DEXTROSE-DEXTRIN-MALTOSE 24 GRAM/31 GRAM ORAL GEL RX-126608 CDM 2590000100 HCPCS 259 RC 24208-0024-01 NDC outpatient 31 GR 18.99 18.99 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES EPO [308136803] 15.19 percent of total billed charges 11.77 18.04 Technical (Hospital) Services DEXTROSE-DEXTRIN-MALTOSE 24 GRAM/31 GRAM ORAL GEL RX-126608 CDM 2590000100 HCPCS 259 RC 24208-0024-01 NDC outpatient 31 GR 18.99 18.99 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES HDHP [308136802] 15.19 percent of total billed charges 11.77 18.04 Technical (Hospital) Services DEXTROSE-DEXTRIN-MALTOSE 24 GRAM/31 GRAM ORAL GEL RX-126608 CDM 2590000100 HCPCS 259 RC 24208-0024-01 NDC outpatient 31 GR 18.99 18.99 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES PPO [308136801] 15.19 percent of total billed charges 11.77 18.04 Technical (Hospital) Services DEXTROSE-DEXTRIN-MALTOSE 24 GRAM/31 GRAM ORAL GEL RX-126608 CDM 2590000100 HCPCS 259 RC 24208-0024-01 NDC outpatient 31 GR 18.99 18.99 BLUE CROSS BLUE SHIELD WELLMARK SB889 [3081026] BCBS WYOMING [308102603] 18.04 percent of total billed charges 11.77 18.04 Technical (Hospital) Services DEXTROSE-DEXTRIN-MALTOSE 24 GRAM/31 GRAM ORAL GEL RX-126608 CDM 2590000100 HCPCS 259 RC 24208-0024-01 NDC outpatient 31 GR 18.99 18.99 HEALTHPARTNERS SX009 HEALTHPARTNERS 15.19 percent of total billed charges 11.77 18.04 Technical (Hospital) Services DEXTROSE-DEXTRIN-MALTOSE 24 GRAM/31 GRAM ORAL GEL RX-126608 CDM 2590000100 HCPCS 259 RC 24208-0024-01 NDC outpatient 31 GR 18.99 18.99 UNITED HEALTHCARE (COMMERCIAL) [3081199] UNITED HEALTHCARE 87726 [308119901] 11.77 percent of total billed charges 11.77 18.04 Technical (Hospital) Services DEXTROSE-DEXTRIN-MALTOSE 24 GRAM/31 GRAM ORAL GEL RX-126608 CDM 2590000100 HCPCS 259 RC 24208-0024-01 NDC outpatient 31 GR 18.99 18.99 MULTIPLAN INC 34080 [3081285] MULTIPLAN INC [308128501] 18.04 percent of total billed charges 11.77 18.04 Technical (Hospital) Services DEXTROSE-DEXTRIN-MALTOSE 24 GRAM/31 GRAM ORAL GEL RX-126608 CDM 2590000100 HCPCS 259 RC 24208-0024-01 NDC outpatient 31 GR 18.99 18.99 MEDICA (COMMERCIAL) 94265 [3081118] MEDICA CLAIMS [308111801] 17.09 percent of total billed charges 11.77 18.04 Technical (Hospital) Services DEXTROSE-DEXTRIN-MALTOSE 24 GRAM/31 GRAM ORAL GEL RX-126608 CDM 2590000100 HCPCS 259 RC 24208-0024-01 NDC outpatient 31 GR 18.99 18.99 CIGNA 62308 [3081051] CIGNA 62308 [308105105] 15.19 percent of total billed charges 11.77 18.04 Technical (Hospital) Services DEXTROSE-DEXTRIN-MALTOSE 24 GRAM/31 GRAM ORAL GEL RX-126608 CDM 2590000100 HCPCS 259 RC 24208-0024-01 NDC outpatient 31 GR 18.99 18.99 CIGNA 62308 [3081051] CIGNA STATE OF WYOMING [308105107] 15.19 percent of total billed charges 11.77 18.04 Technical (Hospital) Services DEXTROSE-DEXTRIN-MALTOSE 24 GRAM/31 GRAM ORAL GEL RX-126608 CDM 2590000100 HCPCS 259 RC 24208-0024-01 NDC inpatient 31 GR 18.99 18.99 HEALTHPARTNERS SX009 HEALTHPARTNERS 15.04 percent of total billed charges 11.77 18.04 Technical (Hospital) Services DEXTROSE-DEXTRIN-MALTOSE 24 GRAM/31 GRAM ORAL GEL RX-126608 CDM 2590000100 HCPCS 259 RC 24208-0024-01 NDC inpatient 31 GR 18.99 18.99 MEDICA (COMMERCIAL) 94265 [3081118] MEDICA CLAIMS [308111801] 17.09 percent of total billed charges 11.77 18.04 Technical (Hospital) Services DEXTROSE-DEXTRIN-MALTOSE 24 GRAM/31 GRAM ORAL GEL RX-126608 CDM 2590000100 HCPCS 259 RC 24208-0024-01 NDC inpatient 31 GR 18.99 18.99 MULTIPLAN INC 34080 [3081285] MULTIPLAN INC [308128501] 18.04 percent of total billed charges 11.77 18.04 Technical (Hospital) Services DEXTROSE-DEXTRIN-MALTOSE 24 GRAM/31 GRAM ORAL GEL RX-126608 CDM 2590000100 HCPCS 259 RC 24208-0024-01 NDC inpatient 31 GR 18.99 18.99 UNITED HEALTHCARE (COMMERCIAL) [3081199] UNITED HEALTHCARE 87726 [308119901] 11.77 percent of total billed charges 11.77 18.04 Technical (Hospital) Services DEXTROSE-DEXTRIN-MALTOSE 24 GRAM/31 GRAM ORAL GEL RX-126608 CDM 2590000100 HCPCS 259 RC 24208-0024-01 NDC inpatient 31 GR 18.99 18.99 BLUE CROSS BLUE SHIELD WELLMARK SB889 [3081026] BCBS WYOMING [308102603] 18.04 percent of total billed charges 11.77 18.04 Technical (Hospital) Services DEXTROSE-DEXTRIN-MALTOSE 24 GRAM/31 GRAM ORAL GEL RX-126608 CDM 2590000100 HCPCS 259 RC 24208-0024-01 NDC inpatient 31 GR 18.99 18.99 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES EPO [308136803] 15.04 percent of total billed charges 11.77 18.04 Technical (Hospital) Services DEXTROSE-DEXTRIN-MALTOSE 24 GRAM/31 GRAM ORAL GEL RX-126608 CDM 2590000100 HCPCS 259 RC 24208-0024-01 NDC inpatient 31 GR 18.99 18.99 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES HDHP [308136802] 15.04 percent of total billed charges 11.77 18.04 Technical (Hospital) Services DEXTROSE-DEXTRIN-MALTOSE 24 GRAM/31 GRAM ORAL GEL RX-126608 CDM 2590000100 HCPCS 259 RC 24208-0024-01 NDC inpatient 31 GR 18.99 18.99 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES PPO [308136801] 15.04 percent of total billed charges 11.77 18.04 Technical (Hospital) Services DEXTROSE-DEXTRIN-MALTOSE 24 GRAM/31 GRAM ORAL GEL RX-126608 CDM 2590000100 HCPCS 259 RC 24208-0024-01 NDC inpatient 31 GR 18.99 18.99 CIGNA 62308 [3081051] CIGNA 62308 [308105105] 15.04 percent of total billed charges 11.77 18.04 Technical (Hospital) Services DEXTROSE-DEXTRIN-MALTOSE 24 GRAM/31 GRAM ORAL GEL RX-126608 CDM 2590000100 HCPCS 259 RC 24208-0024-01 NDC inpatient 31 GR 18.99 18.99 CIGNA 62308 [3081051] CIGNA STATE OF WYOMING [308105107] 15.04 percent of total billed charges 11.77 18.04 Technical (Hospital) Services LANOLIN ALCOHOLS-MINERAL OIL-W.PETROLATUM-CERESIN TOPICAL CREAM (MINERIN EQUIV) RX-128760 CDM 2590000100 HCPCS 259 RC 72140-0000-22 NDC outpatient 113 GR 29.35 29.35 CIGNA 62308 [3081051] CIGNA 62308 [308105105] 23.48 percent of total billed charges 18.2 27.88 Technical (Hospital) Services LANOLIN ALCOHOLS-MINERAL OIL-W.PETROLATUM-CERESIN TOPICAL CREAM (MINERIN EQUIV) RX-128760 CDM 2590000100 HCPCS 259 RC 72140-0000-22 NDC outpatient 113 GR 29.35 29.35 CIGNA 62308 [3081051] CIGNA STATE OF WYOMING [308105107] 23.48 percent of total billed charges 18.2 27.88 Technical (Hospital) Services LANOLIN ALCOHOLS-MINERAL OIL-W.PETROLATUM-CERESIN TOPICAL CREAM (MINERIN EQUIV) RX-128760 CDM 2590000100 HCPCS 259 RC 72140-0000-22 NDC outpatient 113 GR 29.35 29.35 HEALTHPARTNERS SX009 HEALTHPARTNERS 23.48 percent of total billed charges 18.2 27.88 Technical (Hospital) Services LANOLIN ALCOHOLS-MINERAL OIL-W.PETROLATUM-CERESIN TOPICAL CREAM (MINERIN EQUIV) RX-128760 CDM 2590000100 HCPCS 259 RC 72140-0000-22 NDC outpatient 113 GR 29.35 29.35 BLUE CROSS BLUE SHIELD WELLMARK SB889 [3081026] BCBS WYOMING [308102603] 27.88 percent of total billed charges 18.2 27.88 Technical (Hospital) Services LANOLIN ALCOHOLS-MINERAL OIL-W.PETROLATUM-CERESIN TOPICAL CREAM (MINERIN EQUIV) RX-128760 CDM 2590000100 HCPCS 259 RC 72140-0000-22 NDC outpatient 113 GR 29.35 29.35 UNITED HEALTHCARE (COMMERCIAL) [3081199] UNITED HEALTHCARE 87726 [308119901] 18.2 percent of total billed charges 18.2 27.88 Technical (Hospital) Services LANOLIN ALCOHOLS-MINERAL OIL-W.PETROLATUM-CERESIN TOPICAL CREAM (MINERIN EQUIV) RX-128760 CDM 2590000100 HCPCS 259 RC 72140-0000-22 NDC outpatient 113 GR 29.35 29.35 MULTIPLAN INC 34080 [3081285] MULTIPLAN INC [308128501] 27.88 percent of total billed charges 18.2 27.88 Technical (Hospital) Services LANOLIN ALCOHOLS-MINERAL OIL-W.PETROLATUM-CERESIN TOPICAL CREAM (MINERIN EQUIV) RX-128760 CDM 2590000100 HCPCS 259 RC 72140-0000-22 NDC outpatient 113 GR 29.35 29.35 MEDICA (COMMERCIAL) 94265 [3081118] MEDICA CLAIMS [308111801] 26.42 percent of total billed charges 18.2 27.88 Technical (Hospital) Services LANOLIN ALCOHOLS-MINERAL OIL-W.PETROLATUM-CERESIN TOPICAL CREAM (MINERIN EQUIV) RX-128760 CDM 2590000100 HCPCS 259 RC 72140-0000-22 NDC outpatient 113 GR 29.35 29.35 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES EPO [308136803] 23.48 percent of total billed charges 18.2 27.88 Technical (Hospital) Services LANOLIN ALCOHOLS-MINERAL OIL-W.PETROLATUM-CERESIN TOPICAL CREAM (MINERIN EQUIV) RX-128760 CDM 2590000100 HCPCS 259 RC 72140-0000-22 NDC outpatient 113 GR 29.35 29.35 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES HDHP [308136802] 23.48 percent of total billed charges 18.2 27.88 Technical (Hospital) Services LANOLIN ALCOHOLS-MINERAL OIL-W.PETROLATUM-CERESIN TOPICAL CREAM (MINERIN EQUIV) RX-128760 CDM 2590000100 HCPCS 259 RC 72140-0000-22 NDC outpatient 113 GR 29.35 29.35 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES PPO [308136801] 23.48 percent of total billed charges 18.2 27.88 Technical (Hospital) Services LANOLIN ALCOHOLS-MINERAL OIL-W.PETROLATUM-CERESIN TOPICAL CREAM (MINERIN EQUIV) RX-128760 CDM 2590000100 HCPCS 259 RC 72140-0000-22 NDC inpatient 113 GR 29.35 29.35 MEDICA (COMMERCIAL) 94265 [3081118] MEDICA CLAIMS [308111801] 26.42 percent of total billed charges 18.2 27.88 Technical (Hospital) Services LANOLIN ALCOHOLS-MINERAL OIL-W.PETROLATUM-CERESIN TOPICAL CREAM (MINERIN EQUIV) RX-128760 CDM 2590000100 HCPCS 259 RC 72140-0000-22 NDC inpatient 113 GR 29.35 29.35 MULTIPLAN INC 34080 [3081285] MULTIPLAN INC [308128501] 27.88 percent of total billed charges 18.2 27.88 Technical (Hospital) Services LANOLIN ALCOHOLS-MINERAL OIL-W.PETROLATUM-CERESIN TOPICAL CREAM (MINERIN EQUIV) RX-128760 CDM 2590000100 HCPCS 259 RC 72140-0000-22 NDC inpatient 113 GR 29.35 29.35 HEALTHPARTNERS SX009 HEALTHPARTNERS 23.24 percent of total billed charges 18.2 27.88 Technical (Hospital) Services LANOLIN ALCOHOLS-MINERAL OIL-W.PETROLATUM-CERESIN TOPICAL CREAM (MINERIN EQUIV) RX-128760 CDM 2590000100 HCPCS 259 RC 72140-0000-22 NDC inpatient 113 GR 29.35 29.35 BLUE CROSS BLUE SHIELD WELLMARK SB889 [3081026] BCBS WYOMING [308102603] 27.88 percent of total billed charges 18.2 27.88 Technical (Hospital) Services LANOLIN ALCOHOLS-MINERAL OIL-W.PETROLATUM-CERESIN TOPICAL CREAM (MINERIN EQUIV) RX-128760 CDM 2590000100 HCPCS 259 RC 72140-0000-22 NDC inpatient 113 GR 29.35 29.35 UNITED HEALTHCARE (COMMERCIAL) [3081199] UNITED HEALTHCARE 87726 [308119901] 18.2 percent of total billed charges 18.2 27.88 Technical (Hospital) Services LANOLIN ALCOHOLS-MINERAL OIL-W.PETROLATUM-CERESIN TOPICAL CREAM (MINERIN EQUIV) RX-128760 CDM 2590000100 HCPCS 259 RC 72140-0000-22 NDC inpatient 113 GR 29.35 29.35 CIGNA 62308 [3081051] CIGNA 62308 [308105105] 23.24 percent of total billed charges 18.2 27.88 Technical (Hospital) Services LANOLIN ALCOHOLS-MINERAL OIL-W.PETROLATUM-CERESIN TOPICAL CREAM (MINERIN EQUIV) RX-128760 CDM 2590000100 HCPCS 259 RC 72140-0000-22 NDC inpatient 113 GR 29.35 29.35 CIGNA 62308 [3081051] CIGNA STATE OF WYOMING [308105107] 23.24 percent of total billed charges 18.2 27.88 Technical (Hospital) Services LANOLIN ALCOHOLS-MINERAL OIL-W.PETROLATUM-CERESIN TOPICAL CREAM (MINERIN EQUIV) RX-128760 CDM 2590000100 HCPCS 259 RC 72140-0000-22 NDC inpatient 113 GR 29.35 29.35 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES EPO [308136803] 23.24 percent of total billed charges 18.2 27.88 Technical (Hospital) Services LANOLIN ALCOHOLS-MINERAL OIL-W.PETROLATUM-CERESIN TOPICAL CREAM (MINERIN EQUIV) RX-128760 CDM 2590000100 HCPCS 259 RC 72140-0000-22 NDC inpatient 113 GR 29.35 29.35 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES HDHP [308136802] 23.24 percent of total billed charges 18.2 27.88 Technical (Hospital) Services LANOLIN ALCOHOLS-MINERAL OIL-W.PETROLATUM-CERESIN TOPICAL CREAM (MINERIN EQUIV) RX-128760 CDM 2590000100 HCPCS 259 RC 72140-0000-22 NDC inpatient 113 GR 29.35 29.35 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES PPO [308136801] 23.24 percent of total billed charges 18.2 27.88 Technical (Hospital) Services "CARBOXYMETHYLCELLULOSE 0.5 %-GLYCERIN 0.9 % (PF) EYE DROPS,DROPPERETTE" RX-128816 CDM 2590000100 HCPCS 259 RC 00023-3416-30 NDC inpatient 1 UN 5.96 5.96 UNITED HEALTHCARE (COMMERCIAL) [3081199] UNITED HEALTHCARE 87726 [308119901] 3.7 percent of total billed charges 3.7 5.66 Technical (Hospital) Services "CARBOXYMETHYLCELLULOSE 0.5 %-GLYCERIN 0.9 % (PF) EYE DROPS,DROPPERETTE" RX-128816 CDM 2590000100 HCPCS 259 RC 00023-3416-30 NDC inpatient 1 UN 5.96 5.96 BLUE CROSS BLUE SHIELD WELLMARK SB889 [3081026] BCBS WYOMING [308102603] 5.66 percent of total billed charges 3.7 5.66 Technical (Hospital) Services "CARBOXYMETHYLCELLULOSE 0.5 %-GLYCERIN 0.9 % (PF) EYE DROPS,DROPPERETTE" RX-128816 CDM 2590000100 HCPCS 259 RC 00023-3416-30 NDC inpatient 1 UN 5.96 5.96 CIGNA 62308 [3081051] CIGNA 62308 [308105105] 4.72 percent of total billed charges 3.7 5.66 Technical (Hospital) Services "CARBOXYMETHYLCELLULOSE 0.5 %-GLYCERIN 0.9 % (PF) EYE DROPS,DROPPERETTE" RX-128816 CDM 2590000100 HCPCS 259 RC 00023-3416-30 NDC inpatient 1 UN 5.96 5.96 CIGNA 62308 [3081051] CIGNA STATE OF WYOMING [308105107] 4.72 percent of total billed charges 3.7 5.66 Technical (Hospital) Services "CARBOXYMETHYLCELLULOSE 0.5 %-GLYCERIN 0.9 % (PF) EYE DROPS,DROPPERETTE" RX-128816 CDM 2590000100 HCPCS 259 RC 00023-3416-30 NDC inpatient 1 UN 5.96 5.96 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES EPO [308136803] 4.72 percent of total billed charges 3.7 5.66 Technical (Hospital) Services "CARBOXYMETHYLCELLULOSE 0.5 %-GLYCERIN 0.9 % (PF) EYE DROPS,DROPPERETTE" RX-128816 CDM 2590000100 HCPCS 259 RC 00023-3416-30 NDC inpatient 1 UN 5.96 5.96 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES HDHP [308136802] 4.72 percent of total billed charges 3.7 5.66 Technical (Hospital) Services "CARBOXYMETHYLCELLULOSE 0.5 %-GLYCERIN 0.9 % (PF) EYE DROPS,DROPPERETTE" RX-128816 CDM 2590000100 HCPCS 259 RC 00023-3416-30 NDC inpatient 1 UN 5.96 5.96 MULTIPLAN INC 34080 [3081285] MULTIPLAN INC [308128501] 5.66 percent of total billed charges 3.7 5.66 Technical (Hospital) Services "CARBOXYMETHYLCELLULOSE 0.5 %-GLYCERIN 0.9 % (PF) EYE DROPS,DROPPERETTE" RX-128816 CDM 2590000100 HCPCS 259 RC 00023-3416-30 NDC inpatient 1 UN 5.96 5.96 HEALTHPARTNERS SX009 HEALTHPARTNERS 4.72 percent of total billed charges 3.7 5.66 Technical (Hospital) Services "CARBOXYMETHYLCELLULOSE 0.5 %-GLYCERIN 0.9 % (PF) EYE DROPS,DROPPERETTE" RX-128816 CDM 2590000100 HCPCS 259 RC 00023-3416-30 NDC inpatient 1 UN 5.96 5.96 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES PPO [308136801] 4.72 percent of total billed charges 3.7 5.66 Technical (Hospital) Services "CARBOXYMETHYLCELLULOSE 0.5 %-GLYCERIN 0.9 % (PF) EYE DROPS,DROPPERETTE" RX-128816 CDM 2590000100 HCPCS 259 RC 00023-3416-30 NDC inpatient 1 UN 5.96 5.96 MEDICA (COMMERCIAL) 94265 [3081118] MEDICA CLAIMS [308111801] 5.36 percent of total billed charges 3.7 5.66 Technical (Hospital) Services "CARBOXYMETHYLCELLULOSE 0.5 %-GLYCERIN 0.9 % (PF) EYE DROPS,DROPPERETTE" RX-128816 CDM 2590000100 HCPCS 259 RC 00023-3416-30 NDC outpatient 1 UN 5.96 5.96 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES PPO [308136801] 4.77 percent of total billed charges 3.7 5.66 Technical (Hospital) Services "CARBOXYMETHYLCELLULOSE 0.5 %-GLYCERIN 0.9 % (PF) EYE DROPS,DROPPERETTE" RX-128816 CDM 2590000100 HCPCS 259 RC 00023-3416-30 NDC outpatient 1 UN 5.96 5.96 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES HDHP [308136802] 4.77 percent of total billed charges 3.7 5.66 Technical (Hospital) Services "CARBOXYMETHYLCELLULOSE 0.5 %-GLYCERIN 0.9 % (PF) EYE DROPS,DROPPERETTE" RX-128816 CDM 2590000100 HCPCS 259 RC 00023-3416-30 NDC outpatient 1 UN 5.96 5.96 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES EPO [308136803] 4.77 percent of total billed charges 3.7 5.66 Technical (Hospital) Services "CARBOXYMETHYLCELLULOSE 0.5 %-GLYCERIN 0.9 % (PF) EYE DROPS,DROPPERETTE" RX-128816 CDM 2590000100 HCPCS 259 RC 00023-3416-30 NDC outpatient 1 UN 5.96 5.96 UNITED HEALTHCARE (COMMERCIAL) [3081199] UNITED HEALTHCARE 87726 [308119901] 3.7 percent of total billed charges 3.7 5.66 Technical (Hospital) Services "CARBOXYMETHYLCELLULOSE 0.5 %-GLYCERIN 0.9 % (PF) EYE DROPS,DROPPERETTE" RX-128816 CDM 2590000100 HCPCS 259 RC 00023-3416-30 NDC outpatient 1 UN 5.96 5.96 HEALTHPARTNERS SX009 HEALTHPARTNERS 4.77 percent of total billed charges 3.7 5.66 Technical (Hospital) Services "CARBOXYMETHYLCELLULOSE 0.5 %-GLYCERIN 0.9 % (PF) EYE DROPS,DROPPERETTE" RX-128816 CDM 2590000100 HCPCS 259 RC 00023-3416-30 NDC outpatient 1 UN 5.96 5.96 MULTIPLAN INC 34080 [3081285] MULTIPLAN INC [308128501] 5.66 percent of total billed charges 3.7 5.66 Technical (Hospital) Services "CARBOXYMETHYLCELLULOSE 0.5 %-GLYCERIN 0.9 % (PF) EYE DROPS,DROPPERETTE" RX-128816 CDM 2590000100 HCPCS 259 RC 00023-3416-30 NDC outpatient 1 UN 5.96 5.96 MEDICA (COMMERCIAL) 94265 [3081118] MEDICA CLAIMS [308111801] 5.36 percent of total billed charges 3.7 5.66 Technical (Hospital) Services "CARBOXYMETHYLCELLULOSE 0.5 %-GLYCERIN 0.9 % (PF) EYE DROPS,DROPPERETTE" RX-128816 CDM 2590000100 HCPCS 259 RC 00023-3416-30 NDC outpatient 1 UN 5.96 5.96 CIGNA 62308 [3081051] CIGNA 62308 [308105105] 4.77 percent of total billed charges 3.7 5.66 Technical (Hospital) Services "CARBOXYMETHYLCELLULOSE 0.5 %-GLYCERIN 0.9 % (PF) EYE DROPS,DROPPERETTE" RX-128816 CDM 2590000100 HCPCS 259 RC 00023-3416-30 NDC outpatient 1 UN 5.96 5.96 CIGNA 62308 [3081051] CIGNA STATE OF WYOMING [308105107] 4.77 percent of total billed charges 3.7 5.66 Technical (Hospital) Services "CARBOXYMETHYLCELLULOSE 0.5 %-GLYCERIN 0.9 % (PF) EYE DROPS,DROPPERETTE" RX-128816 CDM 2590000100 HCPCS 259 RC 00023-3416-30 NDC outpatient 1 UN 5.96 5.96 BLUE CROSS BLUE SHIELD WELLMARK SB889 [3081026] BCBS WYOMING [308102603] 5.66 percent of total billed charges 3.7 5.66 Technical (Hospital) Services MULTIVITAMIN-IRON 9 MG-FOLIC ACID 400 MCG-CALCIUM AND MINERALS TABLET RX-129057 CDM 2590000100 HCPCS 259 RC 40985-0223-68 NDC inpatient 1 UN 5.66 5.66 MEDICA (COMMERCIAL) 94265 [3081118] MEDICA CLAIMS [308111801] 5.09 percent of total billed charges 3.51 5.38 Technical (Hospital) Services MULTIVITAMIN-IRON 9 MG-FOLIC ACID 400 MCG-CALCIUM AND MINERALS TABLET RX-129057 CDM 2590000100 HCPCS 259 RC 40985-0223-68 NDC inpatient 1 UN 5.66 5.66 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES PPO [308136801] 4.48 percent of total billed charges 3.51 5.38 Technical (Hospital) Services MULTIVITAMIN-IRON 9 MG-FOLIC ACID 400 MCG-CALCIUM AND MINERALS TABLET RX-129057 CDM 2590000100 HCPCS 259 RC 40985-0223-68 NDC inpatient 1 UN 5.66 5.66 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES HDHP [308136802] 4.48 percent of total billed charges 3.51 5.38 Technical (Hospital) Services MULTIVITAMIN-IRON 9 MG-FOLIC ACID 400 MCG-CALCIUM AND MINERALS TABLET RX-129057 CDM 2590000100 HCPCS 259 RC 40985-0223-68 NDC inpatient 1 UN 5.66 5.66 HEALTHPARTNERS SX009 HEALTHPARTNERS 4.48 percent of total billed charges 3.51 5.38 Technical (Hospital) Services MULTIVITAMIN-IRON 9 MG-FOLIC ACID 400 MCG-CALCIUM AND MINERALS TABLET RX-129057 CDM 2590000100 HCPCS 259 RC 40985-0223-68 NDC inpatient 1 UN 5.66 5.66 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES EPO [308136803] 4.48 percent of total billed charges 3.51 5.38 Technical (Hospital) Services MULTIVITAMIN-IRON 9 MG-FOLIC ACID 400 MCG-CALCIUM AND MINERALS TABLET RX-129057 CDM 2590000100 HCPCS 259 RC 40985-0223-68 NDC inpatient 1 UN 5.66 5.66 CIGNA 62308 [3081051] CIGNA 62308 [308105105] 4.48 percent of total billed charges 3.51 5.38 Technical (Hospital) Services MULTIVITAMIN-IRON 9 MG-FOLIC ACID 400 MCG-CALCIUM AND MINERALS TABLET RX-129057 CDM 2590000100 HCPCS 259 RC 40985-0223-68 NDC inpatient 1 UN 5.66 5.66 CIGNA 62308 [3081051] CIGNA STATE OF WYOMING [308105107] 4.48 percent of total billed charges 3.51 5.38 Technical (Hospital) Services MULTIVITAMIN-IRON 9 MG-FOLIC ACID 400 MCG-CALCIUM AND MINERALS TABLET RX-129057 CDM 2590000100 HCPCS 259 RC 40985-0223-68 NDC inpatient 1 UN 5.66 5.66 UNITED HEALTHCARE (COMMERCIAL) [3081199] UNITED HEALTHCARE 87726 [308119901] 3.51 percent of total billed charges 3.51 5.38 Technical (Hospital) Services MULTIVITAMIN-IRON 9 MG-FOLIC ACID 400 MCG-CALCIUM AND MINERALS TABLET RX-129057 CDM 2590000100 HCPCS 259 RC 40985-0223-68 NDC inpatient 1 UN 5.66 5.66 MULTIPLAN INC 34080 [3081285] MULTIPLAN INC [308128501] 5.38 percent of total billed charges 3.51 5.38 Technical (Hospital) Services MULTIVITAMIN-IRON 9 MG-FOLIC ACID 400 MCG-CALCIUM AND MINERALS TABLET RX-129057 CDM 2590000100 HCPCS 259 RC 40985-0223-68 NDC inpatient 1 UN 5.66 5.66 BLUE CROSS BLUE SHIELD WELLMARK SB889 [3081026] BCBS WYOMING [308102603] 5.38 percent of total billed charges 3.51 5.38 Technical (Hospital) Services MULTIVITAMIN-IRON 9 MG-FOLIC ACID 400 MCG-CALCIUM AND MINERALS TABLET RX-129057 CDM 2590000100 HCPCS 259 RC 40985-0223-68 NDC outpatient 1 UN 5.66 5.66 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES PPO [308136801] 4.53 percent of total billed charges 3.51 5.38 Technical (Hospital) Services MULTIVITAMIN-IRON 9 MG-FOLIC ACID 400 MCG-CALCIUM AND MINERALS TABLET RX-129057 CDM 2590000100 HCPCS 259 RC 40985-0223-68 NDC outpatient 1 UN 5.66 5.66 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES EPO [308136803] 4.53 percent of total billed charges 3.51 5.38 Technical (Hospital) Services MULTIVITAMIN-IRON 9 MG-FOLIC ACID 400 MCG-CALCIUM AND MINERALS TABLET RX-129057 CDM 2590000100 HCPCS 259 RC 40985-0223-68 NDC outpatient 1 UN 5.66 5.66 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES HDHP [308136802] 4.53 percent of total billed charges 3.51 5.38 Technical (Hospital) Services MULTIVITAMIN-IRON 9 MG-FOLIC ACID 400 MCG-CALCIUM AND MINERALS TABLET RX-129057 CDM 2590000100 HCPCS 259 RC 40985-0223-68 NDC outpatient 1 UN 5.66 5.66 BLUE CROSS BLUE SHIELD WELLMARK SB889 [3081026] BCBS WYOMING [308102603] 5.38 percent of total billed charges 3.51 5.38 Technical (Hospital) Services MULTIVITAMIN-IRON 9 MG-FOLIC ACID 400 MCG-CALCIUM AND MINERALS TABLET RX-129057 CDM 2590000100 HCPCS 259 RC 40985-0223-68 NDC outpatient 1 UN 5.66 5.66 UNITED HEALTHCARE (COMMERCIAL) [3081199] UNITED HEALTHCARE 87726 [308119901] 3.51 percent of total billed charges 3.51 5.38 Technical (Hospital) Services MULTIVITAMIN-IRON 9 MG-FOLIC ACID 400 MCG-CALCIUM AND MINERALS TABLET RX-129057 CDM 2590000100 HCPCS 259 RC 40985-0223-68 NDC outpatient 1 UN 5.66 5.66 HEALTHPARTNERS SX009 HEALTHPARTNERS 4.53 percent of total billed charges 3.51 5.38 Technical (Hospital) Services MULTIVITAMIN-IRON 9 MG-FOLIC ACID 400 MCG-CALCIUM AND MINERALS TABLET RX-129057 CDM 2590000100 HCPCS 259 RC 40985-0223-68 NDC outpatient 1 UN 5.66 5.66 MULTIPLAN INC 34080 [3081285] MULTIPLAN INC [308128501] 5.38 percent of total billed charges 3.51 5.38 Technical (Hospital) Services MULTIVITAMIN-IRON 9 MG-FOLIC ACID 400 MCG-CALCIUM AND MINERALS TABLET RX-129057 CDM 2590000100 HCPCS 259 RC 40985-0223-68 NDC outpatient 1 UN 5.66 5.66 CIGNA 62308 [3081051] CIGNA 62308 [308105105] 4.53 percent of total billed charges 3.51 5.38 Technical (Hospital) Services MULTIVITAMIN-IRON 9 MG-FOLIC ACID 400 MCG-CALCIUM AND MINERALS TABLET RX-129057 CDM 2590000100 HCPCS 259 RC 40985-0223-68 NDC outpatient 1 UN 5.66 5.66 CIGNA 62308 [3081051] CIGNA STATE OF WYOMING [308105107] 4.53 percent of total billed charges 3.51 5.38 Technical (Hospital) Services MULTIVITAMIN-IRON 9 MG-FOLIC ACID 400 MCG-CALCIUM AND MINERALS TABLET RX-129057 CDM 2590000100 HCPCS 259 RC 40985-0223-68 NDC outpatient 1 UN 5.66 5.66 MEDICA (COMMERCIAL) 94265 [3081118] MEDICA CLAIMS [308111801] 5.09 percent of total billed charges 3.51 5.38 Technical (Hospital) Services ACETAMINOPHEN 160 MG/5 ML (5 ML) ORAL SUSPENSION RX-129285 CDM 2590000100 HCPCS 259 RC 00121-1781-05 NDC outpatient 5 ML 6.78 6.78 CIGNA 62308 [3081051] CIGNA 62308 [308105105] 5.42 percent of total billed charges 4.2 6.44 Technical (Hospital) Services ACETAMINOPHEN 160 MG/5 ML (5 ML) ORAL SUSPENSION RX-129285 CDM 2590000100 HCPCS 259 RC 00121-1781-05 NDC outpatient 5 ML 6.78 6.78 CIGNA 62308 [3081051] CIGNA STATE OF WYOMING [308105107] 5.42 percent of total billed charges 4.2 6.44 Technical (Hospital) Services ACETAMINOPHEN 160 MG/5 ML (5 ML) ORAL SUSPENSION RX-129285 CDM 2590000100 HCPCS 259 RC 00121-1781-05 NDC outpatient 5 ML 6.78 6.78 MEDICA (COMMERCIAL) 94265 [3081118] MEDICA CLAIMS [308111801] 6.1 percent of total billed charges 4.2 6.44 Technical (Hospital) Services ACETAMINOPHEN 160 MG/5 ML (5 ML) ORAL SUSPENSION RX-129285 CDM 2590000100 HCPCS 259 RC 00121-1781-05 NDC outpatient 5 ML 6.78 6.78 MULTIPLAN INC 34080 [3081285] MULTIPLAN INC [308128501] 6.44 percent of total billed charges 4.2 6.44 Technical (Hospital) Services ACETAMINOPHEN 160 MG/5 ML (5 ML) ORAL SUSPENSION RX-129285 CDM 2590000100 HCPCS 259 RC 00121-1781-05 NDC outpatient 5 ML 6.78 6.78 UNITED HEALTHCARE (COMMERCIAL) [3081199] UNITED HEALTHCARE 87726 [308119901] 4.2 percent of total billed charges 4.2 6.44 Technical (Hospital) Services ACETAMINOPHEN 160 MG/5 ML (5 ML) ORAL SUSPENSION RX-129285 CDM 2590000100 HCPCS 259 RC 00121-1781-05 NDC outpatient 5 ML 6.78 6.78 HEALTHPARTNERS SX009 HEALTHPARTNERS 5.42 percent of total billed charges 4.2 6.44 Technical (Hospital) Services ACETAMINOPHEN 160 MG/5 ML (5 ML) ORAL SUSPENSION RX-129285 CDM 2590000100 HCPCS 259 RC 00121-1781-05 NDC inpatient 5 ML 6.78 6.78 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES EPO [308136803] 5.37 percent of total billed charges 4.2 6.44 Technical (Hospital) Services ACETAMINOPHEN 160 MG/5 ML (5 ML) ORAL SUSPENSION RX-129285 CDM 2590000100 HCPCS 259 RC 00121-1781-05 NDC inpatient 5 ML 6.78 6.78 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES HDHP [308136802] 5.37 percent of total billed charges 4.2 6.44 Technical (Hospital) Services ACETAMINOPHEN 160 MG/5 ML (5 ML) ORAL SUSPENSION RX-129285 CDM 2590000100 HCPCS 259 RC 00121-1781-05 NDC inpatient 5 ML 6.78 6.78 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES PPO [308136801] 5.37 percent of total billed charges 4.2 6.44 Technical (Hospital) Services ACETAMINOPHEN 160 MG/5 ML (5 ML) ORAL SUSPENSION RX-129285 CDM 2590000100 HCPCS 259 RC 00121-1781-05 NDC inpatient 5 ML 6.78 6.78 HEALTHPARTNERS SX009 HEALTHPARTNERS 5.37 percent of total billed charges 4.2 6.44 Technical (Hospital) Services ACETAMINOPHEN 160 MG/5 ML (5 ML) ORAL SUSPENSION RX-129285 CDM 2590000100 HCPCS 259 RC 00121-1781-05 NDC inpatient 5 ML 6.78 6.78 MEDICA (COMMERCIAL) 94265 [3081118] MEDICA CLAIMS [308111801] 6.1 percent of total billed charges 4.2 6.44 Technical (Hospital) Services ACETAMINOPHEN 160 MG/5 ML (5 ML) ORAL SUSPENSION RX-129285 CDM 2590000100 HCPCS 259 RC 00121-1781-05 NDC outpatient 5 ML 6.78 6.78 BLUE CROSS BLUE SHIELD WELLMARK SB889 [3081026] BCBS WYOMING [308102603] 6.44 percent of total billed charges 4.2 6.44 Technical (Hospital) Services ACETAMINOPHEN 160 MG/5 ML (5 ML) ORAL SUSPENSION RX-129285 CDM 2590000100 HCPCS 259 RC 00121-1781-05 NDC outpatient 5 ML 6.78 6.78 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES EPO [308136803] 5.42 percent of total billed charges 4.2 6.44 Technical (Hospital) Services ACETAMINOPHEN 160 MG/5 ML (5 ML) ORAL SUSPENSION RX-129285 CDM 2590000100 HCPCS 259 RC 00121-1781-05 NDC outpatient 5 ML 6.78 6.78 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES HDHP [308136802] 5.42 percent of total billed charges 4.2 6.44 Technical (Hospital) Services ACETAMINOPHEN 160 MG/5 ML (5 ML) ORAL SUSPENSION RX-129285 CDM 2590000100 HCPCS 259 RC 00121-1781-05 NDC outpatient 5 ML 6.78 6.78 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES PPO [308136801] 5.42 percent of total billed charges 4.2 6.44 Technical (Hospital) Services ACETAMINOPHEN 160 MG/5 ML (5 ML) ORAL SUSPENSION RX-129285 CDM 2590000100 HCPCS 259 RC 00121-1781-05 NDC inpatient 5 ML 6.78 6.78 MULTIPLAN INC 34080 [3081285] MULTIPLAN INC [308128501] 6.44 percent of total billed charges 4.2 6.44 Technical (Hospital) Services ACETAMINOPHEN 160 MG/5 ML (5 ML) ORAL SUSPENSION RX-129285 CDM 2590000100 HCPCS 259 RC 00121-1781-05 NDC inpatient 5 ML 6.78 6.78 BLUE CROSS BLUE SHIELD WELLMARK SB889 [3081026] BCBS WYOMING [308102603] 6.44 percent of total billed charges 4.2 6.44 Technical (Hospital) Services ACETAMINOPHEN 160 MG/5 ML (5 ML) ORAL SUSPENSION RX-129285 CDM 2590000100 HCPCS 259 RC 00121-1781-05 NDC inpatient 5 ML 6.78 6.78 CIGNA 62308 [3081051] CIGNA 62308 [308105105] 5.37 percent of total billed charges 4.2 6.44 Technical (Hospital) Services ACETAMINOPHEN 160 MG/5 ML (5 ML) ORAL SUSPENSION RX-129285 CDM 2590000100 HCPCS 259 RC 00121-1781-05 NDC inpatient 5 ML 6.78 6.78 CIGNA 62308 [3081051] CIGNA STATE OF WYOMING [308105107] 5.37 percent of total billed charges 4.2 6.44 Technical (Hospital) Services ACETAMINOPHEN 160 MG/5 ML (5 ML) ORAL SUSPENSION RX-129285 CDM 2590000100 HCPCS 259 RC 00121-1781-05 NDC inpatient 5 ML 6.78 6.78 UNITED HEALTHCARE (COMMERCIAL) [3081199] UNITED HEALTHCARE 87726 [308119901] 4.2 percent of total billed charges 4.2 6.44 Technical (Hospital) Services PEG 400-PROPYLENE GLYCOL 0.4 %-0.3 % EYE GEL DROPS RX-130709 CDM 2590000100 HCPCS 259 RC 00065-0454-07 NDC outpatient 10 ML 38.76 38.76 HEALTHPARTNERS SX009 HEALTHPARTNERS 31.01 percent of total billed charges 24.03 36.82 Technical (Hospital) Services PEG 400-PROPYLENE GLYCOL 0.4 %-0.3 % EYE GEL DROPS RX-130709 CDM 2590000100 HCPCS 259 RC 00065-0454-07 NDC outpatient 10 ML 38.76 38.76 UNITED HEALTHCARE (COMMERCIAL) [3081199] UNITED HEALTHCARE 87726 [308119901] 24.03 percent of total billed charges 24.03 36.82 Technical (Hospital) Services PEG 400-PROPYLENE GLYCOL 0.4 %-0.3 % EYE GEL DROPS RX-130709 CDM 2590000100 HCPCS 259 RC 00065-0454-07 NDC outpatient 10 ML 38.76 38.76 MEDICA (COMMERCIAL) 94265 [3081118] MEDICA CLAIMS [308111801] 34.88 percent of total billed charges 24.03 36.82 Technical (Hospital) Services PEG 400-PROPYLENE GLYCOL 0.4 %-0.3 % EYE GEL DROPS RX-130709 CDM 2590000100 HCPCS 259 RC 00065-0454-07 NDC outpatient 10 ML 38.76 38.76 MULTIPLAN INC 34080 [3081285] MULTIPLAN INC [308128501] 36.82 percent of total billed charges 24.03 36.82 Technical (Hospital) Services PEG 400-PROPYLENE GLYCOL 0.4 %-0.3 % EYE GEL DROPS RX-130709 CDM 2590000100 HCPCS 259 RC 00065-0454-07 NDC outpatient 10 ML 38.76 38.76 BLUE CROSS BLUE SHIELD WELLMARK SB889 [3081026] BCBS WYOMING [308102603] 36.82 percent of total billed charges 24.03 36.82 Technical (Hospital) Services PEG 400-PROPYLENE GLYCOL 0.4 %-0.3 % EYE GEL DROPS RX-130709 CDM 2590000100 HCPCS 259 RC 00065-0454-07 NDC outpatient 10 ML 38.76 38.76 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES EPO [308136803] 31.01 percent of total billed charges 24.03 36.82 Technical (Hospital) Services PEG 400-PROPYLENE GLYCOL 0.4 %-0.3 % EYE GEL DROPS RX-130709 CDM 2590000100 HCPCS 259 RC 00065-0454-07 NDC outpatient 10 ML 38.76 38.76 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES HDHP [308136802] 31.01 percent of total billed charges 24.03 36.82 Technical (Hospital) Services PEG 400-PROPYLENE GLYCOL 0.4 %-0.3 % EYE GEL DROPS RX-130709 CDM 2590000100 HCPCS 259 RC 00065-0454-07 NDC outpatient 10 ML 38.76 38.76 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES PPO [308136801] 31.01 percent of total billed charges 24.03 36.82 Technical (Hospital) Services PEG 400-PROPYLENE GLYCOL 0.4 %-0.3 % EYE GEL DROPS RX-130709 CDM 2590000100 HCPCS 259 RC 00065-0454-07 NDC outpatient 10 ML 38.76 38.76 CIGNA 62308 [3081051] CIGNA 62308 [308105105] 31.01 percent of total billed charges 24.03 36.82 Technical (Hospital) Services PEG 400-PROPYLENE GLYCOL 0.4 %-0.3 % EYE GEL DROPS RX-130709 CDM 2590000100 HCPCS 259 RC 00065-0454-07 NDC outpatient 10 ML 38.76 38.76 CIGNA 62308 [3081051] CIGNA STATE OF WYOMING [308105107] 31.01 percent of total billed charges 24.03 36.82 Technical (Hospital) Services PEG 400-PROPYLENE GLYCOL 0.4 %-0.3 % EYE GEL DROPS RX-130709 CDM 2590000100 HCPCS 259 RC 00065-0454-07 NDC inpatient 10 ML 38.76 38.76 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES EPO [308136803] 30.69 percent of total billed charges 24.03 36.82 Technical (Hospital) Services PEG 400-PROPYLENE GLYCOL 0.4 %-0.3 % EYE GEL DROPS RX-130709 CDM 2590000100 HCPCS 259 RC 00065-0454-07 NDC inpatient 10 ML 38.76 38.76 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES HDHP [308136802] 30.69 percent of total billed charges 24.03 36.82 Technical (Hospital) Services PEG 400-PROPYLENE GLYCOL 0.4 %-0.3 % EYE GEL DROPS RX-130709 CDM 2590000100 HCPCS 259 RC 00065-0454-07 NDC inpatient 10 ML 38.76 38.76 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES PPO [308136801] 30.69 percent of total billed charges 24.03 36.82 Technical (Hospital) Services PEG 400-PROPYLENE GLYCOL 0.4 %-0.3 % EYE GEL DROPS RX-130709 CDM 2590000100 HCPCS 259 RC 00065-0454-07 NDC inpatient 10 ML 38.76 38.76 HEALTHPARTNERS SX009 HEALTHPARTNERS 30.69 percent of total billed charges 24.03 36.82 Technical (Hospital) Services PEG 400-PROPYLENE GLYCOL 0.4 %-0.3 % EYE GEL DROPS RX-130709 CDM 2590000100 HCPCS 259 RC 00065-0454-07 NDC inpatient 10 ML 38.76 38.76 BLUE CROSS BLUE SHIELD WELLMARK SB889 [3081026] BCBS WYOMING [308102603] 36.82 percent of total billed charges 24.03 36.82 Technical (Hospital) Services PEG 400-PROPYLENE GLYCOL 0.4 %-0.3 % EYE GEL DROPS RX-130709 CDM 2590000100 HCPCS 259 RC 00065-0454-07 NDC inpatient 10 ML 38.76 38.76 UNITED HEALTHCARE (COMMERCIAL) [3081199] UNITED HEALTHCARE 87726 [308119901] 24.03 percent of total billed charges 24.03 36.82 Technical (Hospital) Services PEG 400-PROPYLENE GLYCOL 0.4 %-0.3 % EYE GEL DROPS RX-130709 CDM 2590000100 HCPCS 259 RC 00065-0454-07 NDC inpatient 10 ML 38.76 38.76 CIGNA 62308 [3081051] CIGNA 62308 [308105105] 30.69 percent of total billed charges 24.03 36.82 Technical (Hospital) Services PEG 400-PROPYLENE GLYCOL 0.4 %-0.3 % EYE GEL DROPS RX-130709 CDM 2590000100 HCPCS 259 RC 00065-0454-07 NDC inpatient 10 ML 38.76 38.76 CIGNA 62308 [3081051] CIGNA STATE OF WYOMING [308105107] 30.69 percent of total billed charges 24.03 36.82 Technical (Hospital) Services PEG 400-PROPYLENE GLYCOL 0.4 %-0.3 % EYE GEL DROPS RX-130709 CDM 2590000100 HCPCS 259 RC 00065-0454-07 NDC inpatient 10 ML 38.76 38.76 MULTIPLAN INC 34080 [3081285] MULTIPLAN INC [308128501] 36.82 percent of total billed charges 24.03 36.82 Technical (Hospital) Services PEG 400-PROPYLENE GLYCOL 0.4 %-0.3 % EYE GEL DROPS RX-130709 CDM 2590000100 HCPCS 259 RC 00065-0454-07 NDC inpatient 10 ML 38.76 38.76 MEDICA (COMMERCIAL) 94265 [3081118] MEDICA CLAIMS [308111801] 34.88 percent of total billed charges 24.03 36.82 Technical (Hospital) Services MENTHOL 7.6 MG LOZENGES RX-130873 CDM 2590000100 HCPCS 259 RC 12546-0622-13 NDC inpatient 25 UN 18.95 18.95 CIGNA 62308 [3081051] CIGNA 62308 [308105105] 15 percent of total billed charges 11.75 18 Technical (Hospital) Services MENTHOL 7.6 MG LOZENGES RX-130873 CDM 2590000100 HCPCS 259 RC 12546-0622-13 NDC inpatient 25 UN 18.95 18.95 CIGNA 62308 [3081051] CIGNA STATE OF WYOMING [308105107] 15 percent of total billed charges 11.75 18 Technical (Hospital) Services MENTHOL 7.6 MG LOZENGES RX-130873 CDM 2590000100 HCPCS 259 RC 12546-0622-13 NDC inpatient 25 UN 18.95 18.95 HEALTHPARTNERS SX009 HEALTHPARTNERS 15 percent of total billed charges 11.75 18 Technical (Hospital) Services MENTHOL 7.6 MG LOZENGES RX-130873 CDM 2590000100 HCPCS 259 RC 12546-0622-13 NDC inpatient 25 UN 18.95 18.95 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES EPO [308136803] 15 percent of total billed charges 11.75 18 Technical (Hospital) Services MENTHOL 7.6 MG LOZENGES RX-130873 CDM 2590000100 HCPCS 259 RC 12546-0622-13 NDC inpatient 25 UN 18.95 18.95 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES HDHP [308136802] 15 percent of total billed charges 11.75 18 Technical (Hospital) Services MENTHOL 7.6 MG LOZENGES RX-130873 CDM 2590000100 HCPCS 259 RC 12546-0622-13 NDC inpatient 25 UN 18.95 18.95 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES PPO [308136801] 15 percent of total billed charges 11.75 18 Technical (Hospital) Services MENTHOL 7.6 MG LOZENGES RX-130873 CDM 2590000100 HCPCS 259 RC 12546-0622-13 NDC inpatient 25 UN 18.95 18.95 UNITED HEALTHCARE (COMMERCIAL) [3081199] UNITED HEALTHCARE 87726 [308119901] 11.75 percent of total billed charges 11.75 18 Technical (Hospital) Services MENTHOL 7.6 MG LOZENGES RX-130873 CDM 2590000100 HCPCS 259 RC 12546-0622-13 NDC inpatient 25 UN 18.95 18.95 BLUE CROSS BLUE SHIELD WELLMARK SB889 [3081026] BCBS WYOMING [308102603] 18 percent of total billed charges 11.75 18 Technical (Hospital) Services MENTHOL 7.6 MG LOZENGES RX-130873 CDM 2590000100 HCPCS 259 RC 12546-0622-13 NDC inpatient 25 UN 18.95 18.95 MULTIPLAN INC 34080 [3081285] MULTIPLAN INC [308128501] 18 percent of total billed charges 11.75 18 Technical (Hospital) Services MENTHOL 7.6 MG LOZENGES RX-130873 CDM 2590000100 HCPCS 259 RC 12546-0622-13 NDC inpatient 25 UN 18.95 18.95 MEDICA (COMMERCIAL) 94265 [3081118] MEDICA CLAIMS [308111801] 17.06 percent of total billed charges 11.75 18 Technical (Hospital) Services MENTHOL 7.6 MG LOZENGES RX-130873 CDM 2590000100 HCPCS 259 RC 12546-0622-13 NDC outpatient 25 UN 18.95 18.95 CIGNA 62308 [3081051] CIGNA STATE OF WYOMING [308105107] 15.16 percent of total billed charges 11.75 18 Technical (Hospital) Services MENTHOL 7.6 MG LOZENGES RX-130873 CDM 2590000100 HCPCS 259 RC 12546-0622-13 NDC outpatient 25 UN 18.95 18.95 CIGNA 62308 [3081051] CIGNA 62308 [308105105] 15.16 percent of total billed charges 11.75 18 Technical (Hospital) Services MENTHOL 7.6 MG LOZENGES RX-130873 CDM 2590000100 HCPCS 259 RC 12546-0622-13 NDC outpatient 25 UN 18.95 18.95 MULTIPLAN INC 34080 [3081285] MULTIPLAN INC [308128501] 18 percent of total billed charges 11.75 18 Technical (Hospital) Services MENTHOL 7.6 MG LOZENGES RX-130873 CDM 2590000100 HCPCS 259 RC 12546-0622-13 NDC outpatient 25 UN 18.95 18.95 MEDICA (COMMERCIAL) 94265 [3081118] MEDICA CLAIMS [308111801] 17.06 percent of total billed charges 11.75 18 Technical (Hospital) Services MENTHOL 7.6 MG LOZENGES RX-130873 CDM 2590000100 HCPCS 259 RC 12546-0622-13 NDC outpatient 25 UN 18.95 18.95 UNITED HEALTHCARE (COMMERCIAL) [3081199] UNITED HEALTHCARE 87726 [308119901] 11.75 percent of total billed charges 11.75 18 Technical (Hospital) Services MENTHOL 7.6 MG LOZENGES RX-130873 CDM 2590000100 HCPCS 259 RC 12546-0622-13 NDC outpatient 25 UN 18.95 18.95 BLUE CROSS BLUE SHIELD WELLMARK SB889 [3081026] BCBS WYOMING [308102603] 18 percent of total billed charges 11.75 18 Technical (Hospital) Services MENTHOL 7.6 MG LOZENGES RX-130873 CDM 2590000100 HCPCS 259 RC 12546-0622-13 NDC outpatient 25 UN 18.95 18.95 HEALTHPARTNERS SX009 HEALTHPARTNERS 15.16 percent of total billed charges 11.75 18 Technical (Hospital) Services MENTHOL 7.6 MG LOZENGES RX-130873 CDM 2590000100 HCPCS 259 RC 12546-0622-13 NDC outpatient 25 UN 18.95 18.95 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES EPO [308136803] 15.16 percent of total billed charges 11.75 18 Technical (Hospital) Services MENTHOL 7.6 MG LOZENGES RX-130873 CDM 2590000100 HCPCS 259 RC 12546-0622-13 NDC outpatient 25 UN 18.95 18.95 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES HDHP [308136802] 15.16 percent of total billed charges 11.75 18 Technical (Hospital) Services MENTHOL 7.6 MG LOZENGES RX-130873 CDM 2590000100 HCPCS 259 RC 12546-0622-13 NDC outpatient 25 UN 18.95 18.95 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES PPO [308136801] 15.16 percent of total billed charges 11.75 18 Technical (Hospital) Services VIT C 250 MG-VIT E 90 MG-ZINC 40 MG-COPPER 1 MG-LUTEIN-ZEAXAN CAPSULE RX-132493 CDM 2590000100 HCPCS 259 RC 24208-0697-62 NDC inpatient 1 UN 5.82 5.82 MULTIPLAN INC 34080 [3081285] MULTIPLAN INC [308128501] 5.53 percent of total billed charges 3.61 5.53 Technical (Hospital) Services VIT C 250 MG-VIT E 90 MG-ZINC 40 MG-COPPER 1 MG-LUTEIN-ZEAXAN CAPSULE RX-132493 CDM 2590000100 HCPCS 259 RC 24208-0697-62 NDC inpatient 1 UN 5.82 5.82 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES HDHP [308136802] 4.61 percent of total billed charges 3.61 5.53 Technical (Hospital) Services VIT C 250 MG-VIT E 90 MG-ZINC 40 MG-COPPER 1 MG-LUTEIN-ZEAXAN CAPSULE RX-132493 CDM 2590000100 HCPCS 259 RC 24208-0697-62 NDC inpatient 1 UN 5.82 5.82 HEALTHPARTNERS SX009 HEALTHPARTNERS 4.61 percent of total billed charges 3.61 5.53 Technical (Hospital) Services VIT C 250 MG-VIT E 90 MG-ZINC 40 MG-COPPER 1 MG-LUTEIN-ZEAXAN CAPSULE RX-132493 CDM 2590000100 HCPCS 259 RC 24208-0697-62 NDC inpatient 1 UN 5.82 5.82 UNITED HEALTHCARE (COMMERCIAL) [3081199] UNITED HEALTHCARE 87726 [308119901] 3.61 percent of total billed charges 3.61 5.53 Technical (Hospital) Services VIT C 250 MG-VIT E 90 MG-ZINC 40 MG-COPPER 1 MG-LUTEIN-ZEAXAN CAPSULE RX-132493 CDM 2590000100 HCPCS 259 RC 24208-0697-62 NDC inpatient 1 UN 5.82 5.82 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES EPO [308136803] 4.61 percent of total billed charges 3.61 5.53 Technical (Hospital) Services VIT C 250 MG-VIT E 90 MG-ZINC 40 MG-COPPER 1 MG-LUTEIN-ZEAXAN CAPSULE RX-132493 CDM 2590000100 HCPCS 259 RC 24208-0697-62 NDC inpatient 1 UN 5.82 5.82 CIGNA 62308 [3081051] CIGNA 62308 [308105105] 4.61 percent of total billed charges 3.61 5.53 Technical (Hospital) Services VIT C 250 MG-VIT E 90 MG-ZINC 40 MG-COPPER 1 MG-LUTEIN-ZEAXAN CAPSULE RX-132493 CDM 2590000100 HCPCS 259 RC 24208-0697-62 NDC inpatient 1 UN 5.82 5.82 CIGNA 62308 [3081051] CIGNA STATE OF WYOMING [308105107] 4.61 percent of total billed charges 3.61 5.53 Technical (Hospital) Services VIT C 250 MG-VIT E 90 MG-ZINC 40 MG-COPPER 1 MG-LUTEIN-ZEAXAN CAPSULE RX-132493 CDM 2590000100 HCPCS 259 RC 24208-0697-62 NDC inpatient 1 UN 5.82 5.82 BLUE CROSS BLUE SHIELD WELLMARK SB889 [3081026] BCBS WYOMING [308102603] 5.53 percent of total billed charges 3.61 5.53 Technical (Hospital) Services VIT C 250 MG-VIT E 90 MG-ZINC 40 MG-COPPER 1 MG-LUTEIN-ZEAXAN CAPSULE RX-132493 CDM 2590000100 HCPCS 259 RC 24208-0697-62 NDC inpatient 1 UN 5.82 5.82 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES PPO [308136801] 4.61 percent of total billed charges 3.61 5.53 Technical (Hospital) Services VIT C 250 MG-VIT E 90 MG-ZINC 40 MG-COPPER 1 MG-LUTEIN-ZEAXAN CAPSULE RX-132493 CDM 2590000100 HCPCS 259 RC 24208-0697-62 NDC inpatient 1 UN 5.82 5.82 MEDICA (COMMERCIAL) 94265 [3081118] MEDICA CLAIMS [308111801] 5.24 percent of total billed charges 3.61 5.53 Technical (Hospital) Services VIT C 250 MG-VIT E 90 MG-ZINC 40 MG-COPPER 1 MG-LUTEIN-ZEAXAN CAPSULE RX-132493 CDM 2590000100 HCPCS 259 RC 24208-0697-62 NDC outpatient 1 UN 5.82 5.82 UNITED HEALTHCARE (COMMERCIAL) [3081199] UNITED HEALTHCARE 87726 [308119901] 3.61 percent of total billed charges 3.61 5.53 Technical (Hospital) Services VIT C 250 MG-VIT E 90 MG-ZINC 40 MG-COPPER 1 MG-LUTEIN-ZEAXAN CAPSULE RX-132493 CDM 2590000100 HCPCS 259 RC 24208-0697-62 NDC outpatient 1 UN 5.82 5.82 HEALTHPARTNERS SX009 HEALTHPARTNERS 4.66 percent of total billed charges 3.61 5.53 Technical (Hospital) Services VIT C 250 MG-VIT E 90 MG-ZINC 40 MG-COPPER 1 MG-LUTEIN-ZEAXAN CAPSULE RX-132493 CDM 2590000100 HCPCS 259 RC 24208-0697-62 NDC outpatient 1 UN 5.82 5.82 MULTIPLAN INC 34080 [3081285] MULTIPLAN INC [308128501] 5.53 percent of total billed charges 3.61 5.53 Technical (Hospital) Services VIT C 250 MG-VIT E 90 MG-ZINC 40 MG-COPPER 1 MG-LUTEIN-ZEAXAN CAPSULE RX-132493 CDM 2590000100 HCPCS 259 RC 24208-0697-62 NDC outpatient 1 UN 5.82 5.82 CIGNA 62308 [3081051] CIGNA 62308 [308105105] 4.66 percent of total billed charges 3.61 5.53 Technical (Hospital) Services VIT C 250 MG-VIT E 90 MG-ZINC 40 MG-COPPER 1 MG-LUTEIN-ZEAXAN CAPSULE RX-132493 CDM 2590000100 HCPCS 259 RC 24208-0697-62 NDC outpatient 1 UN 5.82 5.82 CIGNA 62308 [3081051] CIGNA STATE OF WYOMING [308105107] 4.66 percent of total billed charges 3.61 5.53 Technical (Hospital) Services VIT C 250 MG-VIT E 90 MG-ZINC 40 MG-COPPER 1 MG-LUTEIN-ZEAXAN CAPSULE RX-132493 CDM 2590000100 HCPCS 259 RC 24208-0697-62 NDC outpatient 1 UN 5.82 5.82 MEDICA (COMMERCIAL) 94265 [3081118] MEDICA CLAIMS [308111801] 5.24 percent of total billed charges 3.61 5.53 Technical (Hospital) Services VIT C 250 MG-VIT E 90 MG-ZINC 40 MG-COPPER 1 MG-LUTEIN-ZEAXAN CAPSULE RX-132493 CDM 2590000100 HCPCS 259 RC 24208-0697-62 NDC outpatient 1 UN 5.82 5.82 BLUE CROSS BLUE SHIELD WELLMARK SB889 [3081026] BCBS WYOMING [308102603] 5.53 percent of total billed charges 3.61 5.53 Technical (Hospital) Services VIT C 250 MG-VIT E 90 MG-ZINC 40 MG-COPPER 1 MG-LUTEIN-ZEAXAN CAPSULE RX-132493 CDM 2590000100 HCPCS 259 RC 24208-0697-62 NDC outpatient 1 UN 5.82 5.82 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES HDHP [308136802] 4.66 percent of total billed charges 3.61 5.53 Technical (Hospital) Services VIT C 250 MG-VIT E 90 MG-ZINC 40 MG-COPPER 1 MG-LUTEIN-ZEAXAN CAPSULE RX-132493 CDM 2590000100 HCPCS 259 RC 24208-0697-62 NDC outpatient 1 UN 5.82 5.82 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES PPO [308136801] 4.66 percent of total billed charges 3.61 5.53 Technical (Hospital) Services VIT C 250 MG-VIT E 90 MG-ZINC 40 MG-COPPER 1 MG-LUTEIN-ZEAXAN CAPSULE RX-132493 CDM 2590000100 HCPCS 259 RC 24208-0697-62 NDC outpatient 1 UN 5.82 5.82 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES EPO [308136803] 4.66 percent of total billed charges 3.61 5.53 Technical (Hospital) Services DILUENT NO.1 FOR LIVE VIRUS VACCINES (STERILE WATER) VIAL RX-133524 CDM 2590000100 HCPCS 259 RC 00006-4309-00 NDC outpatient 0.7 ML 5.62 5.62 BLUE CROSS BLUE SHIELD WELLMARK SB889 [3081026] BCBS WYOMING [308102603] 5.34 percent of total billed charges 3.48 5.34 Technical (Hospital) Services DILUENT NO.1 FOR LIVE VIRUS VACCINES (STERILE WATER) VIAL RX-133524 CDM 2590000100 HCPCS 259 RC 00006-4309-00 NDC outpatient 0.7 ML 5.62 5.62 HEALTHPARTNERS SX009 HEALTHPARTNERS 4.5 percent of total billed charges 3.48 5.34 Technical (Hospital) Services DILUENT NO.1 FOR LIVE VIRUS VACCINES (STERILE WATER) VIAL RX-133524 CDM 2590000100 HCPCS 259 RC 00006-4309-00 NDC outpatient 0.7 ML 5.62 5.62 UNITED HEALTHCARE (COMMERCIAL) [3081199] UNITED HEALTHCARE 87726 [308119901] 3.48 percent of total billed charges 3.48 5.34 Technical (Hospital) Services DILUENT NO.1 FOR LIVE VIRUS VACCINES (STERILE WATER) VIAL RX-133524 CDM 2590000100 HCPCS 259 RC 00006-4309-00 NDC outpatient 0.7 ML 5.62 5.62 MULTIPLAN INC 34080 [3081285] MULTIPLAN INC [308128501] 5.34 percent of total billed charges 3.48 5.34 Technical (Hospital) Services DILUENT NO.1 FOR LIVE VIRUS VACCINES (STERILE WATER) VIAL RX-133524 CDM 2590000100 HCPCS 259 RC 00006-4309-00 NDC outpatient 0.7 ML 5.62 5.62 CIGNA 62308 [3081051] CIGNA 62308 [308105105] 4.5 percent of total billed charges 3.48 5.34 Technical (Hospital) Services DILUENT NO.1 FOR LIVE VIRUS VACCINES (STERILE WATER) VIAL RX-133524 CDM 2590000100 HCPCS 259 RC 00006-4309-00 NDC outpatient 0.7 ML 5.62 5.62 CIGNA 62308 [3081051] CIGNA STATE OF WYOMING [308105107] 4.5 percent of total billed charges 3.48 5.34 Technical (Hospital) Services DILUENT NO.1 FOR LIVE VIRUS VACCINES (STERILE WATER) VIAL RX-133524 CDM 2590000100 HCPCS 259 RC 00006-4309-00 NDC inpatient 0.7 ML 5.62 5.62 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES EPO [308136803] 4.45 percent of total billed charges 3.48 5.34 Technical (Hospital) Services DILUENT NO.1 FOR LIVE VIRUS VACCINES (STERILE WATER) VIAL RX-133524 CDM 2590000100 HCPCS 259 RC 00006-4309-00 NDC inpatient 0.7 ML 5.62 5.62 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES HDHP [308136802] 4.45 percent of total billed charges 3.48 5.34 Technical (Hospital) Services DILUENT NO.1 FOR LIVE VIRUS VACCINES (STERILE WATER) VIAL RX-133524 CDM 2590000100 HCPCS 259 RC 00006-4309-00 NDC inpatient 0.7 ML 5.62 5.62 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES PPO [308136801] 4.45 percent of total billed charges 3.48 5.34 Technical (Hospital) Services DILUENT NO.1 FOR LIVE VIRUS VACCINES (STERILE WATER) VIAL RX-133524 CDM 2590000100 HCPCS 259 RC 00006-4309-00 NDC inpatient 0.7 ML 5.62 5.62 CIGNA 62308 [3081051] CIGNA 62308 [308105105] 4.45 percent of total billed charges 3.48 5.34 Technical (Hospital) Services DILUENT NO.1 FOR LIVE VIRUS VACCINES (STERILE WATER) VIAL RX-133524 CDM 2590000100 HCPCS 259 RC 00006-4309-00 NDC inpatient 0.7 ML 5.62 5.62 CIGNA 62308 [3081051] CIGNA STATE OF WYOMING [308105107] 4.45 percent of total billed charges 3.48 5.34 Technical (Hospital) Services DILUENT NO.1 FOR LIVE VIRUS VACCINES (STERILE WATER) VIAL RX-133524 CDM 2590000100 HCPCS 259 RC 00006-4309-00 NDC inpatient 0.7 ML 5.62 5.62 HEALTHPARTNERS SX009 HEALTHPARTNERS 4.45 percent of total billed charges 3.48 5.34 Technical (Hospital) Services DILUENT NO.1 FOR LIVE VIRUS VACCINES (STERILE WATER) VIAL RX-133524 CDM 2590000100 HCPCS 259 RC 00006-4309-00 NDC inpatient 0.7 ML 5.62 5.62 MEDICA (COMMERCIAL) 94265 [3081118] MEDICA CLAIMS [308111801] 5.06 percent of total billed charges 3.48 5.34 Technical (Hospital) Services DILUENT NO.1 FOR LIVE VIRUS VACCINES (STERILE WATER) VIAL RX-133524 CDM 2590000100 HCPCS 259 RC 00006-4309-00 NDC inpatient 0.7 ML 5.62 5.62 BLUE CROSS BLUE SHIELD WELLMARK SB889 [3081026] BCBS WYOMING [308102603] 5.34 percent of total billed charges 3.48 5.34 Technical (Hospital) Services DILUENT NO.1 FOR LIVE VIRUS VACCINES (STERILE WATER) VIAL RX-133524 CDM 2590000100 HCPCS 259 RC 00006-4309-00 NDC inpatient 0.7 ML 5.62 5.62 UNITED HEALTHCARE (COMMERCIAL) [3081199] UNITED HEALTHCARE 87726 [308119901] 3.48 percent of total billed charges 3.48 5.34 Technical (Hospital) Services DILUENT NO.1 FOR LIVE VIRUS VACCINES (STERILE WATER) VIAL RX-133524 CDM 2590000100 HCPCS 259 RC 00006-4309-00 NDC inpatient 0.7 ML 5.62 5.62 MULTIPLAN INC 34080 [3081285] MULTIPLAN INC [308128501] 5.34 percent of total billed charges 3.48 5.34 Technical (Hospital) Services DILUENT NO.1 FOR LIVE VIRUS VACCINES (STERILE WATER) VIAL RX-133524 CDM 2590000100 HCPCS 259 RC 00006-4309-00 NDC outpatient 0.7 ML 5.62 5.62 MEDICA (COMMERCIAL) 94265 [3081118] MEDICA CLAIMS [308111801] 5.06 percent of total billed charges 3.48 5.34 Technical (Hospital) Services DILUENT NO.1 FOR LIVE VIRUS VACCINES (STERILE WATER) VIAL RX-133524 CDM 2590000100 HCPCS 259 RC 00006-4309-00 NDC outpatient 0.7 ML 5.62 5.62 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES EPO [308136803] 4.5 percent of total billed charges 3.48 5.34 Technical (Hospital) Services DILUENT NO.1 FOR LIVE VIRUS VACCINES (STERILE WATER) VIAL RX-133524 CDM 2590000100 HCPCS 259 RC 00006-4309-00 NDC outpatient 0.7 ML 5.62 5.62 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES HDHP [308136802] 4.5 percent of total billed charges 3.48 5.34 Technical (Hospital) Services DILUENT NO.1 FOR LIVE VIRUS VACCINES (STERILE WATER) VIAL RX-133524 CDM 2590000100 HCPCS 259 RC 00006-4309-00 NDC outpatient 0.7 ML 5.62 5.62 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES PPO [308136801] 4.5 percent of total billed charges 3.48 5.34 Technical (Hospital) Services PEDIATRIC MULTIVITAMIN NO.118 ORAL LIQUID RX-133780 CDM 2590000100 HCPCS 259 RC 54629-0800-98 NDC inpatient 5 ML 5.75 5.75 MULTIPLAN INC 34080 [3081285] MULTIPLAN INC [308128501] 5.46 percent of total billed charges 3.57 5.46 Technical (Hospital) Services PEDIATRIC MULTIVITAMIN NO.118 ORAL LIQUID RX-133780 CDM 2590000100 HCPCS 259 RC 54629-0800-98 NDC inpatient 5 ML 5.75 5.75 MEDICA (COMMERCIAL) 94265 [3081118] MEDICA CLAIMS [308111801] 5.18 percent of total billed charges 3.57 5.46 Technical (Hospital) Services PEDIATRIC MULTIVITAMIN NO.118 ORAL LIQUID RX-133780 CDM 2590000100 HCPCS 259 RC 54629-0800-98 NDC inpatient 5 ML 5.75 5.75 UNITED HEALTHCARE (COMMERCIAL) [3081199] UNITED HEALTHCARE 87726 [308119901] 3.57 percent of total billed charges 3.57 5.46 Technical (Hospital) Services PEDIATRIC MULTIVITAMIN NO.118 ORAL LIQUID RX-133780 CDM 2590000100 HCPCS 259 RC 54629-0800-98 NDC inpatient 5 ML 5.75 5.75 BLUE CROSS BLUE SHIELD WELLMARK SB889 [3081026] BCBS WYOMING [308102603] 5.46 percent of total billed charges 3.57 5.46 Technical (Hospital) Services PEDIATRIC MULTIVITAMIN NO.118 ORAL LIQUID RX-133780 CDM 2590000100 HCPCS 259 RC 54629-0800-98 NDC inpatient 5 ML 5.75 5.75 CIGNA 62308 [3081051] CIGNA 62308 [308105105] 4.55 percent of total billed charges 3.57 5.46 Technical (Hospital) Services PEDIATRIC MULTIVITAMIN NO.118 ORAL LIQUID RX-133780 CDM 2590000100 HCPCS 259 RC 54629-0800-98 NDC inpatient 5 ML 5.75 5.75 CIGNA 62308 [3081051] CIGNA STATE OF WYOMING [308105107] 4.55 percent of total billed charges 3.57 5.46 Technical (Hospital) Services PEDIATRIC MULTIVITAMIN NO.118 ORAL LIQUID RX-133780 CDM 2590000100 HCPCS 259 RC 54629-0800-98 NDC inpatient 5 ML 5.75 5.75 HEALTHPARTNERS SX009 HEALTHPARTNERS 4.55 percent of total billed charges 3.57 5.46 Technical (Hospital) Services PEDIATRIC MULTIVITAMIN NO.118 ORAL LIQUID RX-133780 CDM 2590000100 HCPCS 259 RC 54629-0800-98 NDC inpatient 5 ML 5.75 5.75 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES EPO [308136803] 4.55 percent of total billed charges 3.57 5.46 Technical (Hospital) Services PEDIATRIC MULTIVITAMIN NO.118 ORAL LIQUID RX-133780 CDM 2590000100 HCPCS 259 RC 54629-0800-98 NDC inpatient 5 ML 5.75 5.75 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES HDHP [308136802] 4.55 percent of total billed charges 3.57 5.46 Technical (Hospital) Services PEDIATRIC MULTIVITAMIN NO.118 ORAL LIQUID RX-133780 CDM 2590000100 HCPCS 259 RC 54629-0800-98 NDC inpatient 5 ML 5.75 5.75 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES PPO [308136801] 4.55 percent of total billed charges 3.57 5.46 Technical (Hospital) Services PEDIATRIC MULTIVITAMIN NO.118 ORAL LIQUID RX-133780 CDM 2590000100 HCPCS 259 RC 54629-0800-98 NDC outpatient 5 ML 5.75 5.75 UNITED HEALTHCARE (COMMERCIAL) [3081199] UNITED HEALTHCARE 87726 [308119901] 3.57 percent of total billed charges 3.57 5.46 Technical (Hospital) Services PEDIATRIC MULTIVITAMIN NO.118 ORAL LIQUID RX-133780 CDM 2590000100 HCPCS 259 RC 54629-0800-98 NDC outpatient 5 ML 5.75 5.75 HEALTHPARTNERS SX009 HEALTHPARTNERS 4.6 percent of total billed charges 3.57 5.46 Technical (Hospital) Services PEDIATRIC MULTIVITAMIN NO.118 ORAL LIQUID RX-133780 CDM 2590000100 HCPCS 259 RC 54629-0800-98 NDC outpatient 5 ML 5.75 5.75 BLUE CROSS BLUE SHIELD WELLMARK SB889 [3081026] BCBS WYOMING [308102603] 5.46 percent of total billed charges 3.57 5.46 Technical (Hospital) Services PEDIATRIC MULTIVITAMIN NO.118 ORAL LIQUID RX-133780 CDM 2590000100 HCPCS 259 RC 54629-0800-98 NDC outpatient 5 ML 5.75 5.75 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES PPO [308136801] 4.6 percent of total billed charges 3.57 5.46 Technical (Hospital) Services PEDIATRIC MULTIVITAMIN NO.118 ORAL LIQUID RX-133780 CDM 2590000100 HCPCS 259 RC 54629-0800-98 NDC outpatient 5 ML 5.75 5.75 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES EPO [308136803] 4.6 percent of total billed charges 3.57 5.46 Technical (Hospital) Services PEDIATRIC MULTIVITAMIN NO.118 ORAL LIQUID RX-133780 CDM 2590000100 HCPCS 259 RC 54629-0800-98 NDC outpatient 5 ML 5.75 5.75 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES HDHP [308136802] 4.6 percent of total billed charges 3.57 5.46 Technical (Hospital) Services PEDIATRIC MULTIVITAMIN NO.118 ORAL LIQUID RX-133780 CDM 2590000100 HCPCS 259 RC 54629-0800-98 NDC outpatient 5 ML 5.75 5.75 CIGNA 62308 [3081051] CIGNA 62308 [308105105] 4.6 percent of total billed charges 3.57 5.46 Technical (Hospital) Services PEDIATRIC MULTIVITAMIN NO.118 ORAL LIQUID RX-133780 CDM 2590000100 HCPCS 259 RC 54629-0800-98 NDC outpatient 5 ML 5.75 5.75 CIGNA 62308 [3081051] CIGNA STATE OF WYOMING [308105107] 4.6 percent of total billed charges 3.57 5.46 Technical (Hospital) Services PEDIATRIC MULTIVITAMIN NO.118 ORAL LIQUID RX-133780 CDM 2590000100 HCPCS 259 RC 54629-0800-98 NDC outpatient 5 ML 5.75 5.75 MULTIPLAN INC 34080 [3081285] MULTIPLAN INC [308128501] 5.46 percent of total billed charges 3.57 5.46 Technical (Hospital) Services PEDIATRIC MULTIVITAMIN NO.118 ORAL LIQUID RX-133780 CDM 2590000100 HCPCS 259 RC 54629-0800-98 NDC outpatient 5 ML 5.75 5.75 MEDICA (COMMERCIAL) 94265 [3081118] MEDICA CLAIMS [308111801] 5.18 percent of total billed charges 3.57 5.46 Technical (Hospital) Services GLUCOSE 4 GRAM CHEWABLE TABLET RX-16050 CDM 2590000100 HCPCS 259 RC 21292-0004-35 NDC outpatient 1 UN 5.82 5.82 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES EPO [308136803] 4.66 percent of total billed charges 3.61 5.53 Technical (Hospital) Services GLUCOSE 4 GRAM CHEWABLE TABLET RX-16050 CDM 2590000100 HCPCS 259 RC 21292-0004-35 NDC outpatient 1 UN 5.82 5.82 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES HDHP [308136802] 4.66 percent of total billed charges 3.61 5.53 Technical (Hospital) Services GLUCOSE 4 GRAM CHEWABLE TABLET RX-16050 CDM 2590000100 HCPCS 259 RC 21292-0004-35 NDC outpatient 1 UN 5.82 5.82 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES PPO [308136801] 4.66 percent of total billed charges 3.61 5.53 Technical (Hospital) Services GLUCOSE 4 GRAM CHEWABLE TABLET RX-16050 CDM 2590000100 HCPCS 259 RC 21292-0004-35 NDC outpatient 1 UN 5.82 5.82 BLUE CROSS BLUE SHIELD WELLMARK SB889 [3081026] BCBS WYOMING [308102603] 5.53 percent of total billed charges 3.61 5.53 Technical (Hospital) Services GLUCOSE 4 GRAM CHEWABLE TABLET RX-16050 CDM 2590000100 HCPCS 259 RC 21292-0004-35 NDC outpatient 1 UN 5.82 5.82 UNITED HEALTHCARE (COMMERCIAL) [3081199] UNITED HEALTHCARE 87726 [308119901] 3.61 percent of total billed charges 3.61 5.53 Technical (Hospital) Services GLUCOSE 4 GRAM CHEWABLE TABLET RX-16050 CDM 2590000100 HCPCS 259 RC 21292-0004-35 NDC outpatient 1 UN 5.82 5.82 HEALTHPARTNERS SX009 HEALTHPARTNERS 4.66 percent of total billed charges 3.61 5.53 Technical (Hospital) Services GLUCOSE 4 GRAM CHEWABLE TABLET RX-16050 CDM 2590000100 HCPCS 259 RC 21292-0004-35 NDC outpatient 1 UN 5.82 5.82 MULTIPLAN INC 34080 [3081285] MULTIPLAN INC [308128501] 5.53 percent of total billed charges 3.61 5.53 Technical (Hospital) Services GLUCOSE 4 GRAM CHEWABLE TABLET RX-16050 CDM 2590000100 HCPCS 259 RC 21292-0004-35 NDC outpatient 1 UN 5.82 5.82 CIGNA 62308 [3081051] CIGNA 62308 [308105105] 4.66 percent of total billed charges 3.61 5.53 Technical (Hospital) Services GLUCOSE 4 GRAM CHEWABLE TABLET RX-16050 CDM 2590000100 HCPCS 259 RC 21292-0004-35 NDC outpatient 1 UN 5.82 5.82 CIGNA 62308 [3081051] CIGNA STATE OF WYOMING [308105107] 4.66 percent of total billed charges 3.61 5.53 Technical (Hospital) Services GLUCOSE 4 GRAM CHEWABLE TABLET RX-16050 CDM 2590000100 HCPCS 259 RC 21292-0004-35 NDC outpatient 1 UN 5.82 5.82 MEDICA (COMMERCIAL) 94265 [3081118] MEDICA CLAIMS [308111801] 5.24 percent of total billed charges 3.61 5.53 Technical (Hospital) Services GLUCOSE 4 GRAM CHEWABLE TABLET RX-16050 CDM 2590000100 HCPCS 259 RC 21292-0004-35 NDC inpatient 1 UN 5.82 5.82 BLUE CROSS BLUE SHIELD WELLMARK SB889 [3081026] BCBS WYOMING [308102603] 5.53 percent of total billed charges 3.61 5.53 Technical (Hospital) Services GLUCOSE 4 GRAM CHEWABLE TABLET RX-16050 CDM 2590000100 HCPCS 259 RC 21292-0004-35 NDC inpatient 1 UN 5.82 5.82 UNITED HEALTHCARE (COMMERCIAL) [3081199] UNITED HEALTHCARE 87726 [308119901] 3.61 percent of total billed charges 3.61 5.53 Technical (Hospital) Services GLUCOSE 4 GRAM CHEWABLE TABLET RX-16050 CDM 2590000100 HCPCS 259 RC 21292-0004-35 NDC inpatient 1 UN 5.82 5.82 CIGNA 62308 [3081051] CIGNA 62308 [308105105] 4.61 percent of total billed charges 3.61 5.53 Technical (Hospital) Services GLUCOSE 4 GRAM CHEWABLE TABLET RX-16050 CDM 2590000100 HCPCS 259 RC 21292-0004-35 NDC inpatient 1 UN 5.82 5.82 CIGNA 62308 [3081051] CIGNA STATE OF WYOMING [308105107] 4.61 percent of total billed charges 3.61 5.53 Technical (Hospital) Services GLUCOSE 4 GRAM CHEWABLE TABLET RX-16050 CDM 2590000100 HCPCS 259 RC 21292-0004-35 NDC inpatient 1 UN 5.82 5.82 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES EPO [308136803] 4.61 percent of total billed charges 3.61 5.53 Technical (Hospital) Services GLUCOSE 4 GRAM CHEWABLE TABLET RX-16050 CDM 2590000100 HCPCS 259 RC 21292-0004-35 NDC inpatient 1 UN 5.82 5.82 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES HDHP [308136802] 4.61 percent of total billed charges 3.61 5.53 Technical (Hospital) Services GLUCOSE 4 GRAM CHEWABLE TABLET RX-16050 CDM 2590000100 HCPCS 259 RC 21292-0004-35 NDC inpatient 1 UN 5.82 5.82 MULTIPLAN INC 34080 [3081285] MULTIPLAN INC [308128501] 5.53 percent of total billed charges 3.61 5.53 Technical (Hospital) Services GLUCOSE 4 GRAM CHEWABLE TABLET RX-16050 CDM 2590000100 HCPCS 259 RC 21292-0004-35 NDC inpatient 1 UN 5.82 5.82 HEALTHPARTNERS SX009 HEALTHPARTNERS 4.61 percent of total billed charges 3.61 5.53 Technical (Hospital) Services GLUCOSE 4 GRAM CHEWABLE TABLET RX-16050 CDM 2590000100 HCPCS 259 RC 21292-0004-35 NDC inpatient 1 UN 5.82 5.82 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES PPO [308136801] 4.61 percent of total billed charges 3.61 5.53 Technical (Hospital) Services GLUCOSE 4 GRAM CHEWABLE TABLET RX-16050 CDM 2590000100 HCPCS 259 RC 21292-0004-35 NDC inpatient 1 UN 5.82 5.82 MEDICA (COMMERCIAL) 94265 [3081118] MEDICA CLAIMS [308111801] 5.24 percent of total billed charges 3.61 5.53 Technical (Hospital) Services CALCIUM ACETATE 667 MG TABLET RX-179064 CDM 2590000100 HCPCS 259 RC 71321-0803-20 NDC outpatient 1 UN 5.75 5.75 HEALTHPARTNERS SX009 HEALTHPARTNERS 4.6 percent of total billed charges 3.57 5.46 Technical (Hospital) Services CALCIUM ACETATE 667 MG TABLET RX-179064 CDM 2590000100 HCPCS 259 RC 71321-0803-20 NDC outpatient 1 UN 5.75 5.75 UNITED HEALTHCARE (COMMERCIAL) [3081199] UNITED HEALTHCARE 87726 [308119901] 3.57 percent of total billed charges 3.57 5.46 Technical (Hospital) Services CALCIUM ACETATE 667 MG TABLET RX-179064 CDM 2590000100 HCPCS 259 RC 71321-0803-20 NDC outpatient 1 UN 5.75 5.75 MEDICA (COMMERCIAL) 94265 [3081118] MEDICA CLAIMS [308111801] 5.18 percent of total billed charges 3.57 5.46 Technical (Hospital) Services CALCIUM ACETATE 667 MG TABLET RX-179064 CDM 2590000100 HCPCS 259 RC 71321-0803-20 NDC outpatient 1 UN 5.75 5.75 MULTIPLAN INC 34080 [3081285] MULTIPLAN INC [308128501] 5.46 percent of total billed charges 3.57 5.46 Technical (Hospital) Services CALCIUM ACETATE 667 MG TABLET RX-179064 CDM 2590000100 HCPCS 259 RC 71321-0803-20 NDC outpatient 1 UN 5.75 5.75 CIGNA 62308 [3081051] CIGNA 62308 [308105105] 4.6 percent of total billed charges 3.57 5.46 Technical (Hospital) Services CALCIUM ACETATE 667 MG TABLET RX-179064 CDM 2590000100 HCPCS 259 RC 71321-0803-20 NDC outpatient 1 UN 5.75 5.75 CIGNA 62308 [3081051] CIGNA STATE OF WYOMING [308105107] 4.6 percent of total billed charges 3.57 5.46 Technical (Hospital) Services CALCIUM ACETATE 667 MG TABLET RX-179064 CDM 2590000100 HCPCS 259 RC 71321-0803-20 NDC outpatient 1 UN 5.75 5.75 BLUE CROSS BLUE SHIELD WELLMARK SB889 [3081026] BCBS WYOMING [308102603] 5.46 percent of total billed charges 3.57 5.46 Technical (Hospital) Services CALCIUM ACETATE 667 MG TABLET RX-179064 CDM 2590000100 HCPCS 259 RC 71321-0803-20 NDC outpatient 1 UN 5.75 5.75 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES PPO [308136801] 4.6 percent of total billed charges 3.57 5.46 Technical (Hospital) Services CALCIUM ACETATE 667 MG TABLET RX-179064 CDM 2590000100 HCPCS 259 RC 71321-0803-20 NDC outpatient 1 UN 5.75 5.75 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES HDHP [308136802] 4.6 percent of total billed charges 3.57 5.46 Technical (Hospital) Services CALCIUM ACETATE 667 MG TABLET RX-179064 CDM 2590000100 HCPCS 259 RC 71321-0803-20 NDC outpatient 1 UN 5.75 5.75 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES EPO [308136803] 4.6 percent of total billed charges 3.57 5.46 Technical (Hospital) Services CALCIUM ACETATE 667 MG TABLET RX-179064 CDM 2590000100 HCPCS 259 RC 71321-0803-20 NDC inpatient 1 UN 5.75 5.75 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES PPO [308136801] 4.55 percent of total billed charges 3.57 5.46 Technical (Hospital) Services CALCIUM ACETATE 667 MG TABLET RX-179064 CDM 2590000100 HCPCS 259 RC 71321-0803-20 NDC inpatient 1 UN 5.75 5.75 MEDICA (COMMERCIAL) 94265 [3081118] MEDICA CLAIMS [308111801] 5.18 percent of total billed charges 3.57 5.46 Technical (Hospital) Services CALCIUM ACETATE 667 MG TABLET RX-179064 CDM 2590000100 HCPCS 259 RC 71321-0803-20 NDC inpatient 1 UN 5.75 5.75 MULTIPLAN INC 34080 [3081285] MULTIPLAN INC [308128501] 5.46 percent of total billed charges 3.57 5.46 Technical (Hospital) Services CALCIUM ACETATE 667 MG TABLET RX-179064 CDM 2590000100 HCPCS 259 RC 71321-0803-20 NDC inpatient 1 UN 5.75 5.75 HEALTHPARTNERS SX009 HEALTHPARTNERS 4.55 percent of total billed charges 3.57 5.46 Technical (Hospital) Services CALCIUM ACETATE 667 MG TABLET RX-179064 CDM 2590000100 HCPCS 259 RC 71321-0803-20 NDC inpatient 1 UN 5.75 5.75 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES HDHP [308136802] 4.55 percent of total billed charges 3.57 5.46 Technical (Hospital) Services CALCIUM ACETATE 667 MG TABLET RX-179064 CDM 2590000100 HCPCS 259 RC 71321-0803-20 NDC inpatient 1 UN 5.75 5.75 CIGNA 62308 [3081051] CIGNA STATE OF WYOMING [308105107] 4.55 percent of total billed charges 3.57 5.46 Technical (Hospital) Services CALCIUM ACETATE 667 MG TABLET RX-179064 CDM 2590000100 HCPCS 259 RC 71321-0803-20 NDC inpatient 1 UN 5.75 5.75 BLUE CROSS BLUE SHIELD WELLMARK SB889 [3081026] BCBS WYOMING [308102603] 5.46 percent of total billed charges 3.57 5.46 Technical (Hospital) Services CALCIUM ACETATE 667 MG TABLET RX-179064 CDM 2590000100 HCPCS 259 RC 71321-0803-20 NDC inpatient 1 UN 5.75 5.75 UNITED HEALTHCARE (COMMERCIAL) [3081199] UNITED HEALTHCARE 87726 [308119901] 3.57 percent of total billed charges 3.57 5.46 Technical (Hospital) Services CALCIUM ACETATE 667 MG TABLET RX-179064 CDM 2590000100 HCPCS 259 RC 71321-0803-20 NDC inpatient 1 UN 5.75 5.75 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES EPO [308136803] 4.55 percent of total billed charges 3.57 5.46 Technical (Hospital) Services CALCIUM ACETATE 667 MG TABLET RX-179064 CDM 2590000100 HCPCS 259 RC 71321-0803-20 NDC inpatient 1 UN 5.75 5.75 CIGNA 62308 [3081051] CIGNA 62308 [308105105] 4.55 percent of total billed charges 3.57 5.46 Technical (Hospital) Services SENNOSIDES 8.6 MG-DOCUSATE SODIUM 50 MG TABLET RX-24216 CDM 2590000100 HCPCS 259 RC 70000-0526-01 NDC outpatient 1 UN 5.72 5.72 HEALTHPARTNERS SX009 HEALTHPARTNERS 4.58 percent of total billed charges 3.55 5.43 Technical (Hospital) Services SENNOSIDES 8.6 MG-DOCUSATE SODIUM 50 MG TABLET RX-24216 CDM 2590000100 HCPCS 259 RC 70000-0526-01 NDC outpatient 1 UN 5.72 5.72 UNITED HEALTHCARE (COMMERCIAL) [3081199] UNITED HEALTHCARE 87726 [308119901] 3.55 percent of total billed charges 3.55 5.43 Technical (Hospital) Services SENNOSIDES 8.6 MG-DOCUSATE SODIUM 50 MG TABLET RX-24216 CDM 2590000100 HCPCS 259 RC 70000-0526-01 NDC outpatient 1 UN 5.72 5.72 CIGNA 62308 [3081051] CIGNA 62308 [308105105] 4.58 percent of total billed charges 3.55 5.43 Technical (Hospital) Services SENNOSIDES 8.6 MG-DOCUSATE SODIUM 50 MG TABLET RX-24216 CDM 2590000100 HCPCS 259 RC 70000-0526-01 NDC outpatient 1 UN 5.72 5.72 CIGNA 62308 [3081051] CIGNA STATE OF WYOMING [308105107] 4.58 percent of total billed charges 3.55 5.43 Technical (Hospital) Services SENNOSIDES 8.6 MG-DOCUSATE SODIUM 50 MG TABLET RX-24216 CDM 2590000100 HCPCS 259 RC 70000-0526-01 NDC outpatient 1 UN 5.72 5.72 MULTIPLAN INC 34080 [3081285] MULTIPLAN INC [308128501] 5.43 percent of total billed charges 3.55 5.43 Technical (Hospital) Services SENNOSIDES 8.6 MG-DOCUSATE SODIUM 50 MG TABLET RX-24216 CDM 2590000100 HCPCS 259 RC 70000-0526-01 NDC outpatient 1 UN 5.72 5.72 MEDICA (COMMERCIAL) 94265 [3081118] MEDICA CLAIMS [308111801] 5.15 percent of total billed charges 3.55 5.43 Technical (Hospital) Services SENNOSIDES 8.6 MG-DOCUSATE SODIUM 50 MG TABLET RX-24216 CDM 2590000100 HCPCS 259 RC 70000-0526-01 NDC outpatient 1 UN 5.72 5.72 BLUE CROSS BLUE SHIELD WELLMARK SB889 [3081026] BCBS WYOMING [308102603] 5.43 percent of total billed charges 3.55 5.43 Technical (Hospital) Services SENNOSIDES 8.6 MG-DOCUSATE SODIUM 50 MG TABLET RX-24216 CDM 2590000100 HCPCS 259 RC 70000-0526-01 NDC outpatient 1 UN 5.72 5.72 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES HDHP [308136802] 4.58 percent of total billed charges 3.55 5.43 Technical (Hospital) Services SENNOSIDES 8.6 MG-DOCUSATE SODIUM 50 MG TABLET RX-24216 CDM 2590000100 HCPCS 259 RC 70000-0526-01 NDC outpatient 1 UN 5.72 5.72 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES EPO [308136803] 4.58 percent of total billed charges 3.55 5.43 Technical (Hospital) Services SENNOSIDES 8.6 MG-DOCUSATE SODIUM 50 MG TABLET RX-24216 CDM 2590000100 HCPCS 259 RC 70000-0526-01 NDC outpatient 1 UN 5.72 5.72 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES PPO [308136801] 4.58 percent of total billed charges 3.55 5.43 Technical (Hospital) Services SENNOSIDES 8.6 MG-DOCUSATE SODIUM 50 MG TABLET RX-24216 CDM 2590000100 HCPCS 259 RC 70000-0526-01 NDC inpatient 1 UN 5.72 5.72 MULTIPLAN INC 34080 [3081285] MULTIPLAN INC [308128501] 5.43 percent of total billed charges 3.55 5.43 Technical (Hospital) Services SENNOSIDES 8.6 MG-DOCUSATE SODIUM 50 MG TABLET RX-24216 CDM 2590000100 HCPCS 259 RC 70000-0526-01 NDC inpatient 1 UN 5.72 5.72 CIGNA 62308 [3081051] CIGNA STATE OF WYOMING [308105107] 4.53 percent of total billed charges 3.55 5.43 Technical (Hospital) Services SENNOSIDES 8.6 MG-DOCUSATE SODIUM 50 MG TABLET RX-24216 CDM 2590000100 HCPCS 259 RC 70000-0526-01 NDC inpatient 1 UN 5.72 5.72 CIGNA 62308 [3081051] CIGNA 62308 [308105105] 4.53 percent of total billed charges 3.55 5.43 Technical (Hospital) Services SENNOSIDES 8.6 MG-DOCUSATE SODIUM 50 MG TABLET RX-24216 CDM 2590000100 HCPCS 259 RC 70000-0526-01 NDC inpatient 1 UN 5.72 5.72 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES EPO [308136803] 4.53 percent of total billed charges 3.55 5.43 Technical (Hospital) Services SENNOSIDES 8.6 MG-DOCUSATE SODIUM 50 MG TABLET RX-24216 CDM 2590000100 HCPCS 259 RC 70000-0526-01 NDC inpatient 1 UN 5.72 5.72 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES HDHP [308136802] 4.53 percent of total billed charges 3.55 5.43 Technical (Hospital) Services SENNOSIDES 8.6 MG-DOCUSATE SODIUM 50 MG TABLET RX-24216 CDM 2590000100 HCPCS 259 RC 70000-0526-01 NDC inpatient 1 UN 5.72 5.72 UNITED HEALTHCARE (COMMERCIAL) [3081199] UNITED HEALTHCARE 87726 [308119901] 3.55 percent of total billed charges 3.55 5.43 Technical (Hospital) Services SENNOSIDES 8.6 MG-DOCUSATE SODIUM 50 MG TABLET RX-24216 CDM 2590000100 HCPCS 259 RC 70000-0526-01 NDC inpatient 1 UN 5.72 5.72 BLUE CROSS BLUE SHIELD WELLMARK SB889 [3081026] BCBS WYOMING [308102603] 5.43 percent of total billed charges 3.55 5.43 Technical (Hospital) Services SENNOSIDES 8.6 MG-DOCUSATE SODIUM 50 MG TABLET RX-24216 CDM 2590000100 HCPCS 259 RC 70000-0526-01 NDC inpatient 1 UN 5.72 5.72 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES PPO [308136801] 4.53 percent of total billed charges 3.55 5.43 Technical (Hospital) Services SENNOSIDES 8.6 MG-DOCUSATE SODIUM 50 MG TABLET RX-24216 CDM 2590000100 HCPCS 259 RC 70000-0526-01 NDC inpatient 1 UN 5.72 5.72 HEALTHPARTNERS SX009 HEALTHPARTNERS 4.53 percent of total billed charges 3.55 5.43 Technical (Hospital) Services SENNOSIDES 8.6 MG-DOCUSATE SODIUM 50 MG TABLET RX-24216 CDM 2590000100 HCPCS 259 RC 70000-0526-01 NDC inpatient 1 UN 5.72 5.72 MEDICA (COMMERCIAL) 94265 [3081118] MEDICA CLAIMS [308111801] 5.15 percent of total billed charges 3.55 5.43 Technical (Hospital) Services CHOLECALCIFEROL (VITAMIN D3) 10 MCG (400 UNIT) TABLET RX-24559 CDM 2590000100 HCPCS 259 RC 00904-5823-60 NDC outpatient 1 UN 5.63 5.63 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES EPO [308136803] 4.5 percent of total billed charges 3.49 5.35 Technical (Hospital) Services CHOLECALCIFEROL (VITAMIN D3) 10 MCG (400 UNIT) TABLET RX-24559 CDM 2590000100 HCPCS 259 RC 00904-5823-60 NDC outpatient 1 UN 5.63 5.63 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES HDHP [308136802] 4.5 percent of total billed charges 3.49 5.35 Technical (Hospital) Services CHOLECALCIFEROL (VITAMIN D3) 10 MCG (400 UNIT) TABLET RX-24559 CDM 2590000100 HCPCS 259 RC 00904-5823-60 NDC outpatient 1 UN 5.63 5.63 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES PPO [308136801] 4.5 percent of total billed charges 3.49 5.35 Technical (Hospital) Services CHOLECALCIFEROL (VITAMIN D3) 10 MCG (400 UNIT) TABLET RX-24559 CDM 2590000100 HCPCS 259 RC 00904-5823-60 NDC outpatient 1 UN 5.63 5.63 BLUE CROSS BLUE SHIELD WELLMARK SB889 [3081026] BCBS WYOMING [308102603] 5.35 percent of total billed charges 3.49 5.35 Technical (Hospital) Services CHOLECALCIFEROL (VITAMIN D3) 10 MCG (400 UNIT) TABLET RX-24559 CDM 2590000100 HCPCS 259 RC 00904-5823-60 NDC outpatient 1 UN 5.63 5.63 MULTIPLAN INC 34080 [3081285] MULTIPLAN INC [308128501] 5.35 percent of total billed charges 3.49 5.35 Technical (Hospital) Services CHOLECALCIFEROL (VITAMIN D3) 10 MCG (400 UNIT) TABLET RX-24559 CDM 2590000100 HCPCS 259 RC 00904-5823-60 NDC outpatient 1 UN 5.63 5.63 MEDICA (COMMERCIAL) 94265 [3081118] MEDICA CLAIMS [308111801] 5.07 percent of total billed charges 3.49 5.35 Technical (Hospital) Services CHOLECALCIFEROL (VITAMIN D3) 10 MCG (400 UNIT) TABLET RX-24559 CDM 2590000100 HCPCS 259 RC 00904-5823-60 NDC outpatient 1 UN 5.63 5.63 CIGNA 62308 [3081051] CIGNA 62308 [308105105] 4.5 percent of total billed charges 3.49 5.35 Technical (Hospital) Services CHOLECALCIFEROL (VITAMIN D3) 10 MCG (400 UNIT) TABLET RX-24559 CDM 2590000100 HCPCS 259 RC 00904-5823-60 NDC outpatient 1 UN 5.63 5.63 CIGNA 62308 [3081051] CIGNA STATE OF WYOMING [308105107] 4.5 percent of total billed charges 3.49 5.35 Technical (Hospital) Services CHOLECALCIFEROL (VITAMIN D3) 10 MCG (400 UNIT) TABLET RX-24559 CDM 2590000100 HCPCS 259 RC 00904-5823-60 NDC outpatient 1 UN 5.63 5.63 HEALTHPARTNERS SX009 HEALTHPARTNERS 4.5 percent of total billed charges 3.49 5.35 Technical (Hospital) Services CHOLECALCIFEROL (VITAMIN D3) 10 MCG (400 UNIT) TABLET RX-24559 CDM 2590000100 HCPCS 259 RC 00904-5823-60 NDC outpatient 1 UN 5.63 5.63 UNITED HEALTHCARE (COMMERCIAL) [3081199] UNITED HEALTHCARE 87726 [308119901] 3.49 percent of total billed charges 3.49 5.35 Technical (Hospital) Services CHOLECALCIFEROL (VITAMIN D3) 10 MCG (400 UNIT) TABLET RX-24559 CDM 2590000100 HCPCS 259 RC 00904-5823-60 NDC inpatient 1 UN 5.63 5.63 MEDICA (COMMERCIAL) 94265 [3081118] MEDICA CLAIMS [308111801] 5.07 percent of total billed charges 3.49 5.35 Technical (Hospital) Services CHOLECALCIFEROL (VITAMIN D3) 10 MCG (400 UNIT) TABLET RX-24559 CDM 2590000100 HCPCS 259 RC 00904-5823-60 NDC inpatient 1 UN 5.63 5.63 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES PPO [308136801] 4.46 percent of total billed charges 3.49 5.35 Technical (Hospital) Services CHOLECALCIFEROL (VITAMIN D3) 10 MCG (400 UNIT) TABLET RX-24559 CDM 2590000100 HCPCS 259 RC 00904-5823-60 NDC inpatient 1 UN 5.63 5.63 HEALTHPARTNERS SX009 HEALTHPARTNERS 4.46 percent of total billed charges 3.49 5.35 Technical (Hospital) Services CHOLECALCIFEROL (VITAMIN D3) 10 MCG (400 UNIT) TABLET RX-24559 CDM 2590000100 HCPCS 259 RC 00904-5823-60 NDC inpatient 1 UN 5.63 5.63 BLUE CROSS BLUE SHIELD WELLMARK SB889 [3081026] BCBS WYOMING [308102603] 5.35 percent of total billed charges 3.49 5.35 Technical (Hospital) Services CHOLECALCIFEROL (VITAMIN D3) 10 MCG (400 UNIT) TABLET RX-24559 CDM 2590000100 HCPCS 259 RC 00904-5823-60 NDC inpatient 1 UN 5.63 5.63 UNITED HEALTHCARE (COMMERCIAL) [3081199] UNITED HEALTHCARE 87726 [308119901] 3.49 percent of total billed charges 3.49 5.35 Technical (Hospital) Services CHOLECALCIFEROL (VITAMIN D3) 10 MCG (400 UNIT) TABLET RX-24559 CDM 2590000100 HCPCS 259 RC 00904-5823-60 NDC inpatient 1 UN 5.63 5.63 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES EPO [308136803] 4.46 percent of total billed charges 3.49 5.35 Technical (Hospital) Services CHOLECALCIFEROL (VITAMIN D3) 10 MCG (400 UNIT) TABLET RX-24559 CDM 2590000100 HCPCS 259 RC 00904-5823-60 NDC inpatient 1 UN 5.63 5.63 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES HDHP [308136802] 4.46 percent of total billed charges 3.49 5.35 Technical (Hospital) Services CHOLECALCIFEROL (VITAMIN D3) 10 MCG (400 UNIT) TABLET RX-24559 CDM 2590000100 HCPCS 259 RC 00904-5823-60 NDC inpatient 1 UN 5.63 5.63 CIGNA 62308 [3081051] CIGNA 62308 [308105105] 4.46 percent of total billed charges 3.49 5.35 Technical (Hospital) Services CHOLECALCIFEROL (VITAMIN D3) 10 MCG (400 UNIT) TABLET RX-24559 CDM 2590000100 HCPCS 259 RC 00904-5823-60 NDC inpatient 1 UN 5.63 5.63 CIGNA 62308 [3081051] CIGNA STATE OF WYOMING [308105107] 4.46 percent of total billed charges 3.49 5.35 Technical (Hospital) Services CHOLECALCIFEROL (VITAMIN D3) 10 MCG (400 UNIT) TABLET RX-24559 CDM 2590000100 HCPCS 259 RC 00904-5823-60 NDC inpatient 1 UN 5.63 5.63 MULTIPLAN INC 34080 [3081285] MULTIPLAN INC [308128501] 5.35 percent of total billed charges 3.49 5.35 Technical (Hospital) Services DIPHENHYDRAMINE 12.5 MG/5 ML ORAL ELIXIR RX-2511 CDM 2590000100 HCPCS 259 RC 00121-0489-00 NDC outpatient 5 ML 18.69 18.69 CIGNA 62308 [3081051] CIGNA STATE OF WYOMING [308105107] 14.95 percent of total billed charges 11.59 17.76 Technical (Hospital) Services DIPHENHYDRAMINE 12.5 MG/5 ML ORAL ELIXIR RX-2511 CDM 2590000100 HCPCS 259 RC 00121-0489-00 NDC outpatient 5 ML 18.69 18.69 CIGNA 62308 [3081051] CIGNA 62308 [308105105] 14.95 percent of total billed charges 11.59 17.76 Technical (Hospital) Services DIPHENHYDRAMINE 12.5 MG/5 ML ORAL ELIXIR RX-2511 CDM 2590000100 HCPCS 259 RC 00121-0489-00 NDC outpatient 5 ML 18.69 18.69 MULTIPLAN INC 34080 [3081285] MULTIPLAN INC [308128501] 17.76 percent of total billed charges 11.59 17.76 Technical (Hospital) Services DIPHENHYDRAMINE 12.5 MG/5 ML ORAL ELIXIR RX-2511 CDM 2590000100 HCPCS 259 RC 00121-0489-00 NDC outpatient 5 ML 18.69 18.69 MEDICA (COMMERCIAL) 94265 [3081118] MEDICA CLAIMS [308111801] 16.82 percent of total billed charges 11.59 17.76 Technical (Hospital) Services DIPHENHYDRAMINE 12.5 MG/5 ML ORAL ELIXIR RX-2511 CDM 2590000100 HCPCS 259 RC 00121-0489-00 NDC outpatient 5 ML 18.69 18.69 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES EPO [308136803] 14.95 percent of total billed charges 11.59 17.76 Technical (Hospital) Services DIPHENHYDRAMINE 12.5 MG/5 ML ORAL ELIXIR RX-2511 CDM 2590000100 HCPCS 259 RC 00121-0489-00 NDC outpatient 5 ML 18.69 18.69 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES HDHP [308136802] 14.95 percent of total billed charges 11.59 17.76 Technical (Hospital) Services DIPHENHYDRAMINE 12.5 MG/5 ML ORAL ELIXIR RX-2511 CDM 2590000100 HCPCS 259 RC 00121-0489-00 NDC outpatient 5 ML 18.69 18.69 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES PPO [308136801] 14.95 percent of total billed charges 11.59 17.76 Technical (Hospital) Services DIPHENHYDRAMINE 12.5 MG/5 ML ORAL ELIXIR RX-2511 CDM 2590000100 HCPCS 259 RC 00121-0489-00 NDC outpatient 5 ML 18.69 18.69 BLUE CROSS BLUE SHIELD WELLMARK SB889 [3081026] BCBS WYOMING [308102603] 17.76 percent of total billed charges 11.59 17.76 Technical (Hospital) Services DIPHENHYDRAMINE 12.5 MG/5 ML ORAL ELIXIR RX-2511 CDM 2590000100 HCPCS 259 RC 00121-0489-00 NDC outpatient 5 ML 18.69 18.69 HEALTHPARTNERS SX009 HEALTHPARTNERS 14.95 percent of total billed charges 11.59 17.76 Technical (Hospital) Services DIPHENHYDRAMINE 12.5 MG/5 ML ORAL ELIXIR RX-2511 CDM 2590000100 HCPCS 259 RC 00121-0489-00 NDC outpatient 5 ML 18.69 18.69 UNITED HEALTHCARE (COMMERCIAL) [3081199] UNITED HEALTHCARE 87726 [308119901] 11.59 percent of total billed charges 11.59 17.76 Technical (Hospital) Services DIPHENHYDRAMINE 12.5 MG/5 ML ORAL ELIXIR RX-2511 CDM 2590000100 HCPCS 259 RC 00121-0489-00 NDC inpatient 5 ML 18.69 18.69 HEALTHPARTNERS SX009 HEALTHPARTNERS 14.8 percent of total billed charges 11.59 17.76 Technical (Hospital) Services DIPHENHYDRAMINE 12.5 MG/5 ML ORAL ELIXIR RX-2511 CDM 2590000100 HCPCS 259 RC 00121-0489-00 NDC inpatient 5 ML 18.69 18.69 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES EPO [308136803] 14.8 percent of total billed charges 11.59 17.76 Technical (Hospital) Services DIPHENHYDRAMINE 12.5 MG/5 ML ORAL ELIXIR RX-2511 CDM 2590000100 HCPCS 259 RC 00121-0489-00 NDC inpatient 5 ML 18.69 18.69 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES PPO [308136801] 14.8 percent of total billed charges 11.59 17.76 Technical (Hospital) Services DIPHENHYDRAMINE 12.5 MG/5 ML ORAL ELIXIR RX-2511 CDM 2590000100 HCPCS 259 RC 00121-0489-00 NDC inpatient 5 ML 18.69 18.69 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES HDHP [308136802] 14.8 percent of total billed charges 11.59 17.76 Technical (Hospital) Services DIPHENHYDRAMINE 12.5 MG/5 ML ORAL ELIXIR RX-2511 CDM 2590000100 HCPCS 259 RC 00121-0489-00 NDC inpatient 5 ML 18.69 18.69 CIGNA 62308 [3081051] CIGNA STATE OF WYOMING [308105107] 14.8 percent of total billed charges 11.59 17.76 Technical (Hospital) Services DIPHENHYDRAMINE 12.5 MG/5 ML ORAL ELIXIR RX-2511 CDM 2590000100 HCPCS 259 RC 00121-0489-00 NDC inpatient 5 ML 18.69 18.69 CIGNA 62308 [3081051] CIGNA 62308 [308105105] 14.8 percent of total billed charges 11.59 17.76 Technical (Hospital) Services DIPHENHYDRAMINE 12.5 MG/5 ML ORAL ELIXIR RX-2511 CDM 2590000100 HCPCS 259 RC 00121-0489-00 NDC inpatient 5 ML 18.69 18.69 UNITED HEALTHCARE (COMMERCIAL) [3081199] UNITED HEALTHCARE 87726 [308119901] 11.59 percent of total billed charges 11.59 17.76 Technical (Hospital) Services DIPHENHYDRAMINE 12.5 MG/5 ML ORAL ELIXIR RX-2511 CDM 2590000100 HCPCS 259 RC 00121-0489-00 NDC inpatient 5 ML 18.69 18.69 BLUE CROSS BLUE SHIELD WELLMARK SB889 [3081026] BCBS WYOMING [308102603] 17.76 percent of total billed charges 11.59 17.76 Technical (Hospital) Services DIPHENHYDRAMINE 12.5 MG/5 ML ORAL ELIXIR RX-2511 CDM 2590000100 HCPCS 259 RC 00121-0489-00 NDC inpatient 5 ML 18.69 18.69 MEDICA (COMMERCIAL) 94265 [3081118] MEDICA CLAIMS [308111801] 16.82 percent of total billed charges 11.59 17.76 Technical (Hospital) Services DIPHENHYDRAMINE 12.5 MG/5 ML ORAL ELIXIR RX-2511 CDM 2590000100 HCPCS 259 RC 00121-0489-00 NDC inpatient 5 ML 18.69 18.69 MULTIPLAN INC 34080 [3081285] MULTIPLAN INC [308128501] 17.76 percent of total billed charges 11.59 17.76 Technical (Hospital) Services DEXTROSE 40 % ORAL GEL RX-27466 CDM 2590000100 HCPCS 259 RC 00574-0069-30 NDC inpatient 38 GR 28.3 28.3 BLUE CROSS BLUE SHIELD WELLMARK SB889 [3081026] BCBS WYOMING [308102603] 26.89 percent of total billed charges 17.55 26.89 Technical (Hospital) Services DEXTROSE 40 % ORAL GEL RX-27466 CDM 2590000100 HCPCS 259 RC 00574-0069-30 NDC inpatient 38 GR 28.3 28.3 UNITED HEALTHCARE (COMMERCIAL) [3081199] UNITED HEALTHCARE 87726 [308119901] 17.55 percent of total billed charges 17.55 26.89 Technical (Hospital) Services DEXTROSE 40 % ORAL GEL RX-27466 CDM 2590000100 HCPCS 259 RC 00574-0069-30 NDC inpatient 38 GR 28.3 28.3 HEALTHPARTNERS SX009 HEALTHPARTNERS 22.41 percent of total billed charges 17.55 26.89 Technical (Hospital) Services DEXTROSE 40 % ORAL GEL RX-27466 CDM 2590000100 HCPCS 259 RC 00574-0069-30 NDC inpatient 38 GR 28.3 28.3 MEDICA (COMMERCIAL) 94265 [3081118] MEDICA CLAIMS [308111801] 25.47 percent of total billed charges 17.55 26.89 Technical (Hospital) Services DEXTROSE 40 % ORAL GEL RX-27466 CDM 2590000100 HCPCS 259 RC 00574-0069-30 NDC inpatient 38 GR 28.3 28.3 MULTIPLAN INC 34080 [3081285] MULTIPLAN INC [308128501] 26.89 percent of total billed charges 17.55 26.89 Technical (Hospital) Services DEXTROSE 40 % ORAL GEL RX-27466 CDM 2590000100 HCPCS 259 RC 00574-0069-30 NDC inpatient 38 GR 28.3 28.3 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES EPO [308136803] 22.41 percent of total billed charges 17.55 26.89 Technical (Hospital) Services DEXTROSE 40 % ORAL GEL RX-27466 CDM 2590000100 HCPCS 259 RC 00574-0069-30 NDC inpatient 38 GR 28.3 28.3 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES HDHP [308136802] 22.41 percent of total billed charges 17.55 26.89 Technical (Hospital) Services DEXTROSE 40 % ORAL GEL RX-27466 CDM 2590000100 HCPCS 259 RC 00574-0069-30 NDC inpatient 38 GR 28.3 28.3 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES PPO [308136801] 22.41 percent of total billed charges 17.55 26.89 Technical (Hospital) Services DEXTROSE 40 % ORAL GEL RX-27466 CDM 2590000100 HCPCS 259 RC 00574-0069-30 NDC inpatient 38 GR 28.3 28.3 CIGNA 62308 [3081051] CIGNA 62308 [308105105] 22.41 percent of total billed charges 17.55 26.89 Technical (Hospital) Services DEXTROSE 40 % ORAL GEL RX-27466 CDM 2590000100 HCPCS 259 RC 00574-0069-30 NDC inpatient 38 GR 28.3 28.3 CIGNA 62308 [3081051] CIGNA STATE OF WYOMING [308105107] 22.41 percent of total billed charges 17.55 26.89 Technical (Hospital) Services DEXTROSE 40 % ORAL GEL RX-27466 CDM 2590000100 HCPCS 259 RC 00574-0069-30 NDC outpatient 38 GR 28.3 28.3 CIGNA 62308 [3081051] CIGNA 62308 [308105105] 22.64 percent of total billed charges 17.55 26.89 Technical (Hospital) Services DEXTROSE 40 % ORAL GEL RX-27466 CDM 2590000100 HCPCS 259 RC 00574-0069-30 NDC outpatient 38 GR 28.3 28.3 CIGNA 62308 [3081051] CIGNA STATE OF WYOMING [308105107] 22.64 percent of total billed charges 17.55 26.89 Technical (Hospital) Services DEXTROSE 40 % ORAL GEL RX-27466 CDM 2590000100 HCPCS 259 RC 00574-0069-30 NDC outpatient 38 GR 28.3 28.3 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES EPO [308136803] 22.64 percent of total billed charges 17.55 26.89 Technical (Hospital) Services DEXTROSE 40 % ORAL GEL RX-27466 CDM 2590000100 HCPCS 259 RC 00574-0069-30 NDC outpatient 38 GR 28.3 28.3 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES HDHP [308136802] 22.64 percent of total billed charges 17.55 26.89 Technical (Hospital) Services DEXTROSE 40 % ORAL GEL RX-27466 CDM 2590000100 HCPCS 259 RC 00574-0069-30 NDC outpatient 38 GR 28.3 28.3 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES PPO [308136801] 22.64 percent of total billed charges 17.55 26.89 Technical (Hospital) Services DEXTROSE 40 % ORAL GEL RX-27466 CDM 2590000100 HCPCS 259 RC 00574-0069-30 NDC outpatient 38 GR 28.3 28.3 UNITED HEALTHCARE (COMMERCIAL) [3081199] UNITED HEALTHCARE 87726 [308119901] 17.55 percent of total billed charges 17.55 26.89 Technical (Hospital) Services DEXTROSE 40 % ORAL GEL RX-27466 CDM 2590000100 HCPCS 259 RC 00574-0069-30 NDC outpatient 38 GR 28.3 28.3 BLUE CROSS BLUE SHIELD WELLMARK SB889 [3081026] BCBS WYOMING [308102603] 26.89 percent of total billed charges 17.55 26.89 Technical (Hospital) Services DEXTROSE 40 % ORAL GEL RX-27466 CDM 2590000100 HCPCS 259 RC 00574-0069-30 NDC outpatient 38 GR 28.3 28.3 HEALTHPARTNERS SX009 HEALTHPARTNERS 22.64 percent of total billed charges 17.55 26.89 Technical (Hospital) Services DEXTROSE 40 % ORAL GEL RX-27466 CDM 2590000100 HCPCS 259 RC 00574-0069-30 NDC outpatient 38 GR 28.3 28.3 MEDICA (COMMERCIAL) 94265 [3081118] MEDICA CLAIMS [308111801] 25.47 percent of total billed charges 17.55 26.89 Technical (Hospital) Services DEXTROSE 40 % ORAL GEL RX-27466 CDM 2590000100 HCPCS 259 RC 00574-0069-30 NDC outpatient 38 GR 28.3 28.3 MULTIPLAN INC 34080 [3081285] MULTIPLAN INC [308128501] 26.89 percent of total billed charges 17.55 26.89 Technical (Hospital) Services NICOTINE 7 MG/24 HR DAILY TRANSDERMAL PATCH RX-27860 CDM 2590000100 HCPCS 259 RC 48985-0001-55 NDC outpatient 1 UN 7.4 7.4 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES HDHP [308136802] 5.92 percent of total billed charges 4.59 7.03 Technical (Hospital) Services NICOTINE 7 MG/24 HR DAILY TRANSDERMAL PATCH RX-27860 CDM 2590000100 HCPCS 259 RC 48985-0001-55 NDC outpatient 1 UN 7.4 7.4 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES EPO [308136803] 5.92 percent of total billed charges 4.59 7.03 Technical (Hospital) Services NICOTINE 7 MG/24 HR DAILY TRANSDERMAL PATCH RX-27860 CDM 2590000100 HCPCS 259 RC 48985-0001-55 NDC outpatient 1 UN 7.4 7.4 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES PPO [308136801] 5.92 percent of total billed charges 4.59 7.03 Technical (Hospital) Services NICOTINE 7 MG/24 HR DAILY TRANSDERMAL PATCH RX-27860 CDM 2590000100 HCPCS 259 RC 48985-0001-55 NDC outpatient 1 UN 7.4 7.4 HEALTHPARTNERS SX009 HEALTHPARTNERS 5.92 percent of total billed charges 4.59 7.03 Technical (Hospital) Services NICOTINE 7 MG/24 HR DAILY TRANSDERMAL PATCH RX-27860 CDM 2590000100 HCPCS 259 RC 48985-0001-55 NDC outpatient 1 UN 7.4 7.4 UNITED HEALTHCARE (COMMERCIAL) [3081199] UNITED HEALTHCARE 87726 [308119901] 4.59 percent of total billed charges 4.59 7.03 Technical (Hospital) Services NICOTINE 7 MG/24 HR DAILY TRANSDERMAL PATCH RX-27860 CDM 2590000100 HCPCS 259 RC 48985-0001-55 NDC outpatient 1 UN 7.4 7.4 CIGNA 62308 [3081051] CIGNA 62308 [308105105] 5.92 percent of total billed charges 4.59 7.03 Technical (Hospital) Services NICOTINE 7 MG/24 HR DAILY TRANSDERMAL PATCH RX-27860 CDM 2590000100 HCPCS 259 RC 48985-0001-55 NDC outpatient 1 UN 7.4 7.4 CIGNA 62308 [3081051] CIGNA STATE OF WYOMING [308105107] 5.92 percent of total billed charges 4.59 7.03 Technical (Hospital) Services NICOTINE 7 MG/24 HR DAILY TRANSDERMAL PATCH RX-27860 CDM 2590000100 HCPCS 259 RC 48985-0001-55 NDC outpatient 1 UN 7.4 7.4 MULTIPLAN INC 34080 [3081285] MULTIPLAN INC [308128501] 7.03 percent of total billed charges 4.59 7.03 Technical (Hospital) Services NICOTINE 7 MG/24 HR DAILY TRANSDERMAL PATCH RX-27860 CDM 2590000100 HCPCS 259 RC 48985-0001-55 NDC outpatient 1 UN 7.4 7.4 MEDICA (COMMERCIAL) 94265 [3081118] MEDICA CLAIMS [308111801] 6.66 percent of total billed charges 4.59 7.03 Technical (Hospital) Services NICOTINE 7 MG/24 HR DAILY TRANSDERMAL PATCH RX-27860 CDM 2590000100 HCPCS 259 RC 48985-0001-55 NDC outpatient 1 UN 7.4 7.4 BLUE CROSS BLUE SHIELD WELLMARK SB889 [3081026] BCBS WYOMING [308102603] 7.03 percent of total billed charges 4.59 7.03 Technical (Hospital) Services NICOTINE 7 MG/24 HR DAILY TRANSDERMAL PATCH RX-27860 CDM 2590000100 HCPCS 259 RC 48985-0001-55 NDC inpatient 1 UN 7.4 7.4 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES PPO [308136801] 5.86 percent of total billed charges 4.59 7.03 Technical (Hospital) Services NICOTINE 7 MG/24 HR DAILY TRANSDERMAL PATCH RX-27860 CDM 2590000100 HCPCS 259 RC 48985-0001-55 NDC inpatient 1 UN 7.4 7.4 HEALTHPARTNERS SX009 HEALTHPARTNERS 5.86 percent of total billed charges 4.59 7.03 Technical (Hospital) Services NICOTINE 7 MG/24 HR DAILY TRANSDERMAL PATCH RX-27860 CDM 2590000100 HCPCS 259 RC 48985-0001-55 NDC inpatient 1 UN 7.4 7.4 MEDICA (COMMERCIAL) 94265 [3081118] MEDICA CLAIMS [308111801] 6.66 percent of total billed charges 4.59 7.03 Technical (Hospital) Services NICOTINE 7 MG/24 HR DAILY TRANSDERMAL PATCH RX-27860 CDM 2590000100 HCPCS 259 RC 48985-0001-55 NDC inpatient 1 UN 7.4 7.4 BLUE CROSS BLUE SHIELD WELLMARK SB889 [3081026] BCBS WYOMING [308102603] 7.03 percent of total billed charges 4.59 7.03 Technical (Hospital) Services NICOTINE 7 MG/24 HR DAILY TRANSDERMAL PATCH RX-27860 CDM 2590000100 HCPCS 259 RC 48985-0001-55 NDC inpatient 1 UN 7.4 7.4 UNITED HEALTHCARE (COMMERCIAL) [3081199] UNITED HEALTHCARE 87726 [308119901] 4.59 percent of total billed charges 4.59 7.03 Technical (Hospital) Services NICOTINE 7 MG/24 HR DAILY TRANSDERMAL PATCH RX-27860 CDM 2590000100 HCPCS 259 RC 48985-0001-55 NDC inpatient 1 UN 7.4 7.4 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES HDHP [308136802] 5.86 percent of total billed charges 4.59 7.03 Technical (Hospital) Services NICOTINE 7 MG/24 HR DAILY TRANSDERMAL PATCH RX-27860 CDM 2590000100 HCPCS 259 RC 48985-0001-55 NDC inpatient 1 UN 7.4 7.4 CIGNA 62308 [3081051] CIGNA 62308 [308105105] 5.86 percent of total billed charges 4.59 7.03 Technical (Hospital) Services NICOTINE 7 MG/24 HR DAILY TRANSDERMAL PATCH RX-27860 CDM 2590000100 HCPCS 259 RC 48985-0001-55 NDC inpatient 1 UN 7.4 7.4 CIGNA 62308 [3081051] CIGNA STATE OF WYOMING [308105107] 5.86 percent of total billed charges 4.59 7.03 Technical (Hospital) Services NICOTINE 7 MG/24 HR DAILY TRANSDERMAL PATCH RX-27860 CDM 2590000100 HCPCS 259 RC 48985-0001-55 NDC inpatient 1 UN 7.4 7.4 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES EPO [308136803] 5.86 percent of total billed charges 4.59 7.03 Technical (Hospital) Services NICOTINE 7 MG/24 HR DAILY TRANSDERMAL PATCH RX-27860 CDM 2590000100 HCPCS 259 RC 48985-0001-55 NDC inpatient 1 UN 7.4 7.4 MULTIPLAN INC 34080 [3081285] MULTIPLAN INC [308128501] 7.03 percent of total billed charges 4.59 7.03 Technical (Hospital) Services NICOTINE 14 MG/24 HR DAILY TRANSDERMAL PATCH RX-27862 CDM 2590000100 HCPCS 259 RC 48985-0001-50 NDC outpatient 1 UN 7.4 7.4 BLUE CROSS BLUE SHIELD WELLMARK SB889 [3081026] BCBS WYOMING [308102603] 7.03 percent of total billed charges 4.59 7.03 Technical (Hospital) Services NICOTINE 14 MG/24 HR DAILY TRANSDERMAL PATCH RX-27862 CDM 2590000100 HCPCS 259 RC 48985-0001-50 NDC outpatient 1 UN 7.4 7.4 HEALTHPARTNERS SX009 HEALTHPARTNERS 5.92 percent of total billed charges 4.59 7.03 Technical (Hospital) Services NICOTINE 14 MG/24 HR DAILY TRANSDERMAL PATCH RX-27862 CDM 2590000100 HCPCS 259 RC 48985-0001-50 NDC outpatient 1 UN 7.4 7.4 UNITED HEALTHCARE (COMMERCIAL) [3081199] UNITED HEALTHCARE 87726 [308119901] 4.59 percent of total billed charges 4.59 7.03 Technical (Hospital) Services NICOTINE 14 MG/24 HR DAILY TRANSDERMAL PATCH RX-27862 CDM 2590000100 HCPCS 259 RC 48985-0001-50 NDC outpatient 1 UN 7.4 7.4 CIGNA 62308 [3081051] CIGNA 62308 [308105105] 5.92 percent of total billed charges 4.59 7.03 Technical (Hospital) Services NICOTINE 14 MG/24 HR DAILY TRANSDERMAL PATCH RX-27862 CDM 2590000100 HCPCS 259 RC 48985-0001-50 NDC outpatient 1 UN 7.4 7.4 CIGNA 62308 [3081051] CIGNA STATE OF WYOMING [308105107] 5.92 percent of total billed charges 4.59 7.03 Technical (Hospital) Services NICOTINE 14 MG/24 HR DAILY TRANSDERMAL PATCH RX-27862 CDM 2590000100 HCPCS 259 RC 48985-0001-50 NDC outpatient 1 UN 7.4 7.4 MULTIPLAN INC 34080 [3081285] MULTIPLAN INC [308128501] 7.03 percent of total billed charges 4.59 7.03 Technical (Hospital) Services NICOTINE 14 MG/24 HR DAILY TRANSDERMAL PATCH RX-27862 CDM 2590000100 HCPCS 259 RC 48985-0001-50 NDC outpatient 1 UN 7.4 7.4 MEDICA (COMMERCIAL) 94265 [3081118] MEDICA CLAIMS [308111801] 6.66 percent of total billed charges 4.59 7.03 Technical (Hospital) Services NICOTINE 14 MG/24 HR DAILY TRANSDERMAL PATCH RX-27862 CDM 2590000100 HCPCS 259 RC 48985-0001-50 NDC outpatient 1 UN 7.4 7.4 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES EPO [308136803] 5.92 percent of total billed charges 4.59 7.03 Technical (Hospital) Services NICOTINE 14 MG/24 HR DAILY TRANSDERMAL PATCH RX-27862 CDM 2590000100 HCPCS 259 RC 48985-0001-50 NDC outpatient 1 UN 7.4 7.4 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES HDHP [308136802] 5.92 percent of total billed charges 4.59 7.03 Technical (Hospital) Services NICOTINE 14 MG/24 HR DAILY TRANSDERMAL PATCH RX-27862 CDM 2590000100 HCPCS 259 RC 48985-0001-50 NDC outpatient 1 UN 7.4 7.4 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES PPO [308136801] 5.92 percent of total billed charges 4.59 7.03 Technical (Hospital) Services NICOTINE 14 MG/24 HR DAILY TRANSDERMAL PATCH RX-27862 CDM 2590000100 HCPCS 259 RC 48985-0001-50 NDC inpatient 1 UN 7.4 7.4 MEDICA (COMMERCIAL) 94265 [3081118] MEDICA CLAIMS [308111801] 6.66 percent of total billed charges 4.59 7.03 Technical (Hospital) Services NICOTINE 14 MG/24 HR DAILY TRANSDERMAL PATCH RX-27862 CDM 2590000100 HCPCS 259 RC 48985-0001-50 NDC inpatient 1 UN 7.4 7.4 HEALTHPARTNERS SX009 HEALTHPARTNERS 5.86 percent of total billed charges 4.59 7.03 Technical (Hospital) Services NICOTINE 14 MG/24 HR DAILY TRANSDERMAL PATCH RX-27862 CDM 2590000100 HCPCS 259 RC 48985-0001-50 NDC inpatient 1 UN 7.4 7.4 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES PPO [308136801] 5.86 percent of total billed charges 4.59 7.03 Technical (Hospital) Services NICOTINE 14 MG/24 HR DAILY TRANSDERMAL PATCH RX-27862 CDM 2590000100 HCPCS 259 RC 48985-0001-50 NDC inpatient 1 UN 7.4 7.4 CIGNA 62308 [3081051] CIGNA 62308 [308105105] 5.86 percent of total billed charges 4.59 7.03 Technical (Hospital) Services NICOTINE 14 MG/24 HR DAILY TRANSDERMAL PATCH RX-27862 CDM 2590000100 HCPCS 259 RC 48985-0001-50 NDC inpatient 1 UN 7.4 7.4 CIGNA 62308 [3081051] CIGNA STATE OF WYOMING [308105107] 5.86 percent of total billed charges 4.59 7.03 Technical (Hospital) Services NICOTINE 14 MG/24 HR DAILY TRANSDERMAL PATCH RX-27862 CDM 2590000100 HCPCS 259 RC 48985-0001-50 NDC inpatient 1 UN 7.4 7.4 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES HDHP [308136802] 5.86 percent of total billed charges 4.59 7.03 Technical (Hospital) Services NICOTINE 14 MG/24 HR DAILY TRANSDERMAL PATCH RX-27862 CDM 2590000100 HCPCS 259 RC 48985-0001-50 NDC inpatient 1 UN 7.4 7.4 UNITED HEALTHCARE (COMMERCIAL) [3081199] UNITED HEALTHCARE 87726 [308119901] 4.59 percent of total billed charges 4.59 7.03 Technical (Hospital) Services NICOTINE 14 MG/24 HR DAILY TRANSDERMAL PATCH RX-27862 CDM 2590000100 HCPCS 259 RC 48985-0001-50 NDC inpatient 1 UN 7.4 7.4 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES EPO [308136803] 5.86 percent of total billed charges 4.59 7.03 Technical (Hospital) Services NICOTINE 14 MG/24 HR DAILY TRANSDERMAL PATCH RX-27862 CDM 2590000100 HCPCS 259 RC 48985-0001-50 NDC inpatient 1 UN 7.4 7.4 BLUE CROSS BLUE SHIELD WELLMARK SB889 [3081026] BCBS WYOMING [308102603] 7.03 percent of total billed charges 4.59 7.03 Technical (Hospital) Services NICOTINE 14 MG/24 HR DAILY TRANSDERMAL PATCH RX-27862 CDM 2590000100 HCPCS 259 RC 48985-0001-50 NDC inpatient 1 UN 7.4 7.4 MULTIPLAN INC 34080 [3081285] MULTIPLAN INC [308128501] 7.03 percent of total billed charges 4.59 7.03 Technical (Hospital) Services NICOTINE 21 MG/24 HR DAILY TRANSDERMAL PATCH RX-27863 CDM 2590000100 HCPCS 259 RC 00536-1108-88 NDC inpatient 1 UN 7.33 7.33 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES PPO [308136801] 5.8 percent of total billed charges 4.54 6.96 Technical (Hospital) Services NICOTINE 21 MG/24 HR DAILY TRANSDERMAL PATCH RX-27863 CDM 2590000100 HCPCS 259 RC 00536-1108-88 NDC inpatient 1 UN 7.33 7.33 HEALTHPARTNERS SX009 HEALTHPARTNERS 5.8 percent of total billed charges 4.54 6.96 Technical (Hospital) Services NICOTINE 21 MG/24 HR DAILY TRANSDERMAL PATCH RX-27863 CDM 2590000100 HCPCS 259 RC 00536-1108-88 NDC inpatient 1 UN 7.33 7.33 MEDICA (COMMERCIAL) 94265 [3081118] MEDICA CLAIMS [308111801] 6.6 percent of total billed charges 4.54 6.96 Technical (Hospital) Services NICOTINE 21 MG/24 HR DAILY TRANSDERMAL PATCH RX-27863 CDM 2590000100 HCPCS 259 RC 00536-1108-88 NDC inpatient 1 UN 7.33 7.33 CIGNA 62308 [3081051] CIGNA 62308 [308105105] 5.8 percent of total billed charges 4.54 6.96 Technical (Hospital) Services NICOTINE 21 MG/24 HR DAILY TRANSDERMAL PATCH RX-27863 CDM 2590000100 HCPCS 259 RC 00536-1108-88 NDC inpatient 1 UN 7.33 7.33 CIGNA 62308 [3081051] CIGNA STATE OF WYOMING [308105107] 5.8 percent of total billed charges 4.54 6.96 Technical (Hospital) Services NICOTINE 21 MG/24 HR DAILY TRANSDERMAL PATCH RX-27863 CDM 2590000100 HCPCS 259 RC 00536-1108-88 NDC inpatient 1 UN 7.33 7.33 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES HDHP [308136802] 5.8 percent of total billed charges 4.54 6.96 Technical (Hospital) Services NICOTINE 21 MG/24 HR DAILY TRANSDERMAL PATCH RX-27863 CDM 2590000100 HCPCS 259 RC 00536-1108-88 NDC inpatient 1 UN 7.33 7.33 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES EPO [308136803] 5.8 percent of total billed charges 4.54 6.96 Technical (Hospital) Services NICOTINE 21 MG/24 HR DAILY TRANSDERMAL PATCH RX-27863 CDM 2590000100 HCPCS 259 RC 00536-1108-88 NDC inpatient 1 UN 7.33 7.33 UNITED HEALTHCARE (COMMERCIAL) [3081199] UNITED HEALTHCARE 87726 [308119901] 4.54 percent of total billed charges 4.54 6.96 Technical (Hospital) Services NICOTINE 21 MG/24 HR DAILY TRANSDERMAL PATCH RX-27863 CDM 2590000100 HCPCS 259 RC 00536-1108-88 NDC inpatient 1 UN 7.33 7.33 BLUE CROSS BLUE SHIELD WELLMARK SB889 [3081026] BCBS WYOMING [308102603] 6.96 percent of total billed charges 4.54 6.96 Technical (Hospital) Services NICOTINE 21 MG/24 HR DAILY TRANSDERMAL PATCH RX-27863 CDM 2590000100 HCPCS 259 RC 00536-1108-88 NDC inpatient 1 UN 7.33 7.33 MULTIPLAN INC 34080 [3081285] MULTIPLAN INC [308128501] 6.96 percent of total billed charges 4.54 6.96 Technical (Hospital) Services NICOTINE 21 MG/24 HR DAILY TRANSDERMAL PATCH RX-27863 CDM 2590000100 HCPCS 259 RC 00536-1108-88 NDC outpatient 1 UN 7.33 7.33 BLUE CROSS BLUE SHIELD WELLMARK SB889 [3081026] BCBS WYOMING [308102603] 6.96 percent of total billed charges 4.54 6.96 Technical (Hospital) Services NICOTINE 21 MG/24 HR DAILY TRANSDERMAL PATCH RX-27863 CDM 2590000100 HCPCS 259 RC 00536-1108-88 NDC outpatient 1 UN 7.33 7.33 HEALTHPARTNERS SX009 HEALTHPARTNERS 5.86 percent of total billed charges 4.54 6.96 Technical (Hospital) Services NICOTINE 21 MG/24 HR DAILY TRANSDERMAL PATCH RX-27863 CDM 2590000100 HCPCS 259 RC 00536-1108-88 NDC outpatient 1 UN 7.33 7.33 UNITED HEALTHCARE (COMMERCIAL) [3081199] UNITED HEALTHCARE 87726 [308119901] 4.54 percent of total billed charges 4.54 6.96 Technical (Hospital) Services NICOTINE 21 MG/24 HR DAILY TRANSDERMAL PATCH RX-27863 CDM 2590000100 HCPCS 259 RC 00536-1108-88 NDC outpatient 1 UN 7.33 7.33 CIGNA 62308 [3081051] CIGNA 62308 [308105105] 5.86 percent of total billed charges 4.54 6.96 Technical (Hospital) Services NICOTINE 21 MG/24 HR DAILY TRANSDERMAL PATCH RX-27863 CDM 2590000100 HCPCS 259 RC 00536-1108-88 NDC outpatient 1 UN 7.33 7.33 CIGNA 62308 [3081051] CIGNA STATE OF WYOMING [308105107] 5.86 percent of total billed charges 4.54 6.96 Technical (Hospital) Services NICOTINE 21 MG/24 HR DAILY TRANSDERMAL PATCH RX-27863 CDM 2590000100 HCPCS 259 RC 00536-1108-88 NDC outpatient 1 UN 7.33 7.33 MULTIPLAN INC 34080 [3081285] MULTIPLAN INC [308128501] 6.96 percent of total billed charges 4.54 6.96 Technical (Hospital) Services NICOTINE 21 MG/24 HR DAILY TRANSDERMAL PATCH RX-27863 CDM 2590000100 HCPCS 259 RC 00536-1108-88 NDC outpatient 1 UN 7.33 7.33 MEDICA (COMMERCIAL) 94265 [3081118] MEDICA CLAIMS [308111801] 6.6 percent of total billed charges 4.54 6.96 Technical (Hospital) Services NICOTINE 21 MG/24 HR DAILY TRANSDERMAL PATCH RX-27863 CDM 2590000100 HCPCS 259 RC 00536-1108-88 NDC outpatient 1 UN 7.33 7.33 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES EPO [308136803] 5.86 percent of total billed charges 4.54 6.96 Technical (Hospital) Services NICOTINE 21 MG/24 HR DAILY TRANSDERMAL PATCH RX-27863 CDM 2590000100 HCPCS 259 RC 00536-1108-88 NDC outpatient 1 UN 7.33 7.33 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES PPO [308136801] 5.86 percent of total billed charges 4.54 6.96 Technical (Hospital) Services NICOTINE 21 MG/24 HR DAILY TRANSDERMAL PATCH RX-27863 CDM 2590000100 HCPCS 259 RC 00536-1108-88 NDC outpatient 1 UN 7.33 7.33 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES HDHP [308136802] 5.86 percent of total billed charges 4.54 6.96 Technical (Hospital) Services PEG 400-PROPYLENE GLYCOL 0.4 %-0.3 % EYE DROPS RX-35891 CDM 2590000100 HCPCS 259 RC 00065-1431-05 NDC inpatient 10 ML 38.05 38.05 HEALTHPARTNERS SX009 HEALTHPARTNERS 30.13 percent of total billed charges 23.59 36.15 Technical (Hospital) Services PEG 400-PROPYLENE GLYCOL 0.4 %-0.3 % EYE DROPS RX-35891 CDM 2590000100 HCPCS 259 RC 00065-1431-05 NDC inpatient 10 ML 38.05 38.05 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES HDHP [308136802] 30.13 percent of total billed charges 23.59 36.15 Technical (Hospital) Services PEG 400-PROPYLENE GLYCOL 0.4 %-0.3 % EYE DROPS RX-35891 CDM 2590000100 HCPCS 259 RC 00065-1431-05 NDC inpatient 10 ML 38.05 38.05 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES PPO [308136801] 30.13 percent of total billed charges 23.59 36.15 Technical (Hospital) Services PEG 400-PROPYLENE GLYCOL 0.4 %-0.3 % EYE DROPS RX-35891 CDM 2590000100 HCPCS 259 RC 00065-1431-05 NDC inpatient 10 ML 38.05 38.05 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES EPO [308136803] 30.13 percent of total billed charges 23.59 36.15 Technical (Hospital) Services PEG 400-PROPYLENE GLYCOL 0.4 %-0.3 % EYE DROPS RX-35891 CDM 2590000100 HCPCS 259 RC 00065-1431-05 NDC inpatient 10 ML 38.05 38.05 BLUE CROSS BLUE SHIELD WELLMARK SB889 [3081026] BCBS WYOMING [308102603] 36.15 percent of total billed charges 23.59 36.15 Technical (Hospital) Services PEG 400-PROPYLENE GLYCOL 0.4 %-0.3 % EYE DROPS RX-35891 CDM 2590000100 HCPCS 259 RC 00065-1431-05 NDC inpatient 10 ML 38.05 38.05 UNITED HEALTHCARE (COMMERCIAL) [3081199] UNITED HEALTHCARE 87726 [308119901] 23.59 percent of total billed charges 23.59 36.15 Technical (Hospital) Services PEG 400-PROPYLENE GLYCOL 0.4 %-0.3 % EYE DROPS RX-35891 CDM 2590000100 HCPCS 259 RC 00065-1431-05 NDC inpatient 10 ML 38.05 38.05 CIGNA 62308 [3081051] CIGNA 62308 [308105105] 30.13 percent of total billed charges 23.59 36.15 Technical (Hospital) Services PEG 400-PROPYLENE GLYCOL 0.4 %-0.3 % EYE DROPS RX-35891 CDM 2590000100 HCPCS 259 RC 00065-1431-05 NDC inpatient 10 ML 38.05 38.05 CIGNA 62308 [3081051] CIGNA STATE OF WYOMING [308105107] 30.13 percent of total billed charges 23.59 36.15 Technical (Hospital) Services PEG 400-PROPYLENE GLYCOL 0.4 %-0.3 % EYE DROPS RX-35891 CDM 2590000100 HCPCS 259 RC 00065-1431-05 NDC inpatient 10 ML 38.05 38.05 MEDICA (COMMERCIAL) 94265 [3081118] MEDICA CLAIMS [308111801] 34.25 percent of total billed charges 23.59 36.15 Technical (Hospital) Services PEG 400-PROPYLENE GLYCOL 0.4 %-0.3 % EYE DROPS RX-35891 CDM 2590000100 HCPCS 259 RC 00065-1431-05 NDC inpatient 10 ML 38.05 38.05 MULTIPLAN INC 34080 [3081285] MULTIPLAN INC [308128501] 36.15 percent of total billed charges 23.59 36.15 Technical (Hospital) Services PEG 400-PROPYLENE GLYCOL 0.4 %-0.3 % EYE DROPS RX-35891 CDM 2590000100 HCPCS 259 RC 00065-1431-05 NDC outpatient 10 ML 38.05 38.05 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES PPO [308136801] 30.44 percent of total billed charges 23.59 36.15 Technical (Hospital) Services PEG 400-PROPYLENE GLYCOL 0.4 %-0.3 % EYE DROPS RX-35891 CDM 2590000100 HCPCS 259 RC 00065-1431-05 NDC outpatient 10 ML 38.05 38.05 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES HDHP [308136802] 30.44 percent of total billed charges 23.59 36.15 Technical (Hospital) Services PEG 400-PROPYLENE GLYCOL 0.4 %-0.3 % EYE DROPS RX-35891 CDM 2590000100 HCPCS 259 RC 00065-1431-05 NDC outpatient 10 ML 38.05 38.05 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES EPO [308136803] 30.44 percent of total billed charges 23.59 36.15 Technical (Hospital) Services PEG 400-PROPYLENE GLYCOL 0.4 %-0.3 % EYE DROPS RX-35891 CDM 2590000100 HCPCS 259 RC 00065-1431-05 NDC outpatient 10 ML 38.05 38.05 BLUE CROSS BLUE SHIELD WELLMARK SB889 [3081026] BCBS WYOMING [308102603] 36.15 percent of total billed charges 23.59 36.15 Technical (Hospital) Services PEG 400-PROPYLENE GLYCOL 0.4 %-0.3 % EYE DROPS RX-35891 CDM 2590000100 HCPCS 259 RC 00065-1431-05 NDC outpatient 10 ML 38.05 38.05 MEDICA (COMMERCIAL) 94265 [3081118] MEDICA CLAIMS [308111801] 34.25 percent of total billed charges 23.59 36.15 Technical (Hospital) Services PEG 400-PROPYLENE GLYCOL 0.4 %-0.3 % EYE DROPS RX-35891 CDM 2590000100 HCPCS 259 RC 00065-1431-05 NDC outpatient 10 ML 38.05 38.05 MULTIPLAN INC 34080 [3081285] MULTIPLAN INC [308128501] 36.15 percent of total billed charges 23.59 36.15 Technical (Hospital) Services PEG 400-PROPYLENE GLYCOL 0.4 %-0.3 % EYE DROPS RX-35891 CDM 2590000100 HCPCS 259 RC 00065-1431-05 NDC outpatient 10 ML 38.05 38.05 UNITED HEALTHCARE (COMMERCIAL) [3081199] UNITED HEALTHCARE 87726 [308119901] 23.59 percent of total billed charges 23.59 36.15 Technical (Hospital) Services PEG 400-PROPYLENE GLYCOL 0.4 %-0.3 % EYE DROPS RX-35891 CDM 2590000100 HCPCS 259 RC 00065-1431-05 NDC outpatient 10 ML 38.05 38.05 HEALTHPARTNERS SX009 HEALTHPARTNERS 30.44 percent of total billed charges 23.59 36.15 Technical (Hospital) Services PEG 400-PROPYLENE GLYCOL 0.4 %-0.3 % EYE DROPS RX-35891 CDM 2590000100 HCPCS 259 RC 00065-1431-05 NDC outpatient 10 ML 38.05 38.05 CIGNA 62308 [3081051] CIGNA 62308 [308105105] 30.44 percent of total billed charges 23.59 36.15 Technical (Hospital) Services PEG 400-PROPYLENE GLYCOL 0.4 %-0.3 % EYE DROPS RX-35891 CDM 2590000100 HCPCS 259 RC 00065-1431-05 NDC outpatient 10 ML 38.05 38.05 CIGNA 62308 [3081051] CIGNA STATE OF WYOMING [308105107] 30.44 percent of total billed charges 23.59 36.15 Technical (Hospital) Services HYDROGEN PEROXIDE 3 % SOLUTION RX-3752 CDM 2590000100 HCPCS 259 RC 41163-0871-43 NDC inpatient 473 ML 7.04 7.04 MULTIPLAN INC 34080 [3081285] MULTIPLAN INC [308128501] 6.69 percent of total billed charges 4.36 6.69 Technical (Hospital) Services HYDROGEN PEROXIDE 3 % SOLUTION RX-3752 CDM 2590000100 HCPCS 259 RC 41163-0871-43 NDC inpatient 473 ML 7.04 7.04 MEDICA (COMMERCIAL) 94265 [3081118] MEDICA CLAIMS [308111801] 6.34 percent of total billed charges 4.36 6.69 Technical (Hospital) Services HYDROGEN PEROXIDE 3 % SOLUTION RX-3752 CDM 2590000100 HCPCS 259 RC 41163-0871-43 NDC inpatient 473 ML 7.04 7.04 HEALTHPARTNERS SX009 HEALTHPARTNERS 5.57 percent of total billed charges 4.36 6.69 Technical (Hospital) Services HYDROGEN PEROXIDE 3 % SOLUTION RX-3752 CDM 2590000100 HCPCS 259 RC 41163-0871-43 NDC inpatient 473 ML 7.04 7.04 UNITED HEALTHCARE (COMMERCIAL) [3081199] UNITED HEALTHCARE 87726 [308119901] 4.36 percent of total billed charges 4.36 6.69 Technical (Hospital) Services HYDROGEN PEROXIDE 3 % SOLUTION RX-3752 CDM 2590000100 HCPCS 259 RC 41163-0871-43 NDC inpatient 473 ML 7.04 7.04 BLUE CROSS BLUE SHIELD WELLMARK SB889 [3081026] BCBS WYOMING [308102603] 6.69 percent of total billed charges 4.36 6.69 Technical (Hospital) Services HYDROGEN PEROXIDE 3 % SOLUTION RX-3752 CDM 2590000100 HCPCS 259 RC 41163-0871-43 NDC inpatient 473 ML 7.04 7.04 CIGNA 62308 [3081051] CIGNA 62308 [308105105] 5.57 percent of total billed charges 4.36 6.69 Technical (Hospital) Services HYDROGEN PEROXIDE 3 % SOLUTION RX-3752 CDM 2590000100 HCPCS 259 RC 41163-0871-43 NDC inpatient 473 ML 7.04 7.04 CIGNA 62308 [3081051] CIGNA STATE OF WYOMING [308105107] 5.57 percent of total billed charges 4.36 6.69 Technical (Hospital) Services HYDROGEN PEROXIDE 3 % SOLUTION RX-3752 CDM 2590000100 HCPCS 259 RC 41163-0871-43 NDC inpatient 473 ML 7.04 7.04 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES HDHP [308136802] 5.57 percent of total billed charges 4.36 6.69 Technical (Hospital) Services HYDROGEN PEROXIDE 3 % SOLUTION RX-3752 CDM 2590000100 HCPCS 259 RC 41163-0871-43 NDC inpatient 473 ML 7.04 7.04 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES EPO [308136803] 5.57 percent of total billed charges 4.36 6.69 Technical (Hospital) Services HYDROGEN PEROXIDE 3 % SOLUTION RX-3752 CDM 2590000100 HCPCS 259 RC 41163-0871-43 NDC inpatient 473 ML 7.04 7.04 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES PPO [308136801] 5.57 percent of total billed charges 4.36 6.69 Technical (Hospital) Services HYDROGEN PEROXIDE 3 % SOLUTION RX-3752 CDM 2590000100 HCPCS 259 RC 41163-0871-43 NDC outpatient 473 ML 7.04 7.04 MULTIPLAN INC 34080 [3081285] MULTIPLAN INC [308128501] 6.69 percent of total billed charges 4.36 6.69 Technical (Hospital) Services HYDROGEN PEROXIDE 3 % SOLUTION RX-3752 CDM 2590000100 HCPCS 259 RC 41163-0871-43 NDC outpatient 473 ML 7.04 7.04 MEDICA (COMMERCIAL) 94265 [3081118] MEDICA CLAIMS [308111801] 6.34 percent of total billed charges 4.36 6.69 Technical (Hospital) Services HYDROGEN PEROXIDE 3 % SOLUTION RX-3752 CDM 2590000100 HCPCS 259 RC 41163-0871-43 NDC outpatient 473 ML 7.04 7.04 CIGNA 62308 [3081051] CIGNA 62308 [308105105] 5.63 percent of total billed charges 4.36 6.69 Technical (Hospital) Services HYDROGEN PEROXIDE 3 % SOLUTION RX-3752 CDM 2590000100 HCPCS 259 RC 41163-0871-43 NDC outpatient 473 ML 7.04 7.04 CIGNA 62308 [3081051] CIGNA STATE OF WYOMING [308105107] 5.63 percent of total billed charges 4.36 6.69 Technical (Hospital) Services HYDROGEN PEROXIDE 3 % SOLUTION RX-3752 CDM 2590000100 HCPCS 259 RC 41163-0871-43 NDC outpatient 473 ML 7.04 7.04 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES HDHP [308136802] 5.63 percent of total billed charges 4.36 6.69 Technical (Hospital) Services HYDROGEN PEROXIDE 3 % SOLUTION RX-3752 CDM 2590000100 HCPCS 259 RC 41163-0871-43 NDC outpatient 473 ML 7.04 7.04 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES EPO [308136803] 5.63 percent of total billed charges 4.36 6.69 Technical (Hospital) Services HYDROGEN PEROXIDE 3 % SOLUTION RX-3752 CDM 2590000100 HCPCS 259 RC 41163-0871-43 NDC outpatient 473 ML 7.04 7.04 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES PPO [308136801] 5.63 percent of total billed charges 4.36 6.69 Technical (Hospital) Services HYDROGEN PEROXIDE 3 % SOLUTION RX-3752 CDM 2590000100 HCPCS 259 RC 41163-0871-43 NDC outpatient 473 ML 7.04 7.04 BLUE CROSS BLUE SHIELD WELLMARK SB889 [3081026] BCBS WYOMING [308102603] 6.69 percent of total billed charges 4.36 6.69 Technical (Hospital) Services HYDROGEN PEROXIDE 3 % SOLUTION RX-3752 CDM 2590000100 HCPCS 259 RC 41163-0871-43 NDC outpatient 473 ML 7.04 7.04 UNITED HEALTHCARE (COMMERCIAL) [3081199] UNITED HEALTHCARE 87726 [308119901] 4.36 percent of total billed charges 4.36 6.69 Technical (Hospital) Services HYDROGEN PEROXIDE 3 % SOLUTION RX-3752 CDM 2590000100 HCPCS 259 RC 41163-0871-43 NDC outpatient 473 ML 7.04 7.04 HEALTHPARTNERS SX009 HEALTHPARTNERS 5.63 percent of total billed charges 4.36 6.69 Technical (Hospital) Services ALUMINUM-MAG HYDROXIDE-SIMETHICONE 200 MG-200 MG-20 MG/5 ML ORAL SUSP RX-38285 CDM 2590000100 HCPCS 259 RC 00121-1761-30 NDC inpatient 15 ML 7.2 7.2 UNITED HEALTHCARE (COMMERCIAL) [3081199] UNITED HEALTHCARE 87726 [308119901] 4.46 percent of total billed charges 4.46 6.84 Technical (Hospital) Services ALUMINUM-MAG HYDROXIDE-SIMETHICONE 200 MG-200 MG-20 MG/5 ML ORAL SUSP RX-38285 CDM 2590000100 HCPCS 259 RC 00121-1761-30 NDC inpatient 15 ML 7.2 7.2 BLUE CROSS BLUE SHIELD WELLMARK SB889 [3081026] BCBS WYOMING [308102603] 6.84 percent of total billed charges 4.46 6.84 Technical (Hospital) Services ALUMINUM-MAG HYDROXIDE-SIMETHICONE 200 MG-200 MG-20 MG/5 ML ORAL SUSP RX-38285 CDM 2590000100 HCPCS 259 RC 00121-1761-30 NDC inpatient 15 ML 7.2 7.2 MULTIPLAN INC 34080 [3081285] MULTIPLAN INC [308128501] 6.84 percent of total billed charges 4.46 6.84 Technical (Hospital) Services ALUMINUM-MAG HYDROXIDE-SIMETHICONE 200 MG-200 MG-20 MG/5 ML ORAL SUSP RX-38285 CDM 2590000100 HCPCS 259 RC 00121-1761-30 NDC inpatient 15 ML 7.2 7.2 MEDICA (COMMERCIAL) 94265 [3081118] MEDICA CLAIMS [308111801] 6.48 percent of total billed charges 4.46 6.84 Technical (Hospital) Services ALUMINUM-MAG HYDROXIDE-SIMETHICONE 200 MG-200 MG-20 MG/5 ML ORAL SUSP RX-38285 CDM 2590000100 HCPCS 259 RC 00121-1761-30 NDC inpatient 15 ML 7.2 7.2 HEALTHPARTNERS SX009 HEALTHPARTNERS 5.7 percent of total billed charges 4.46 6.84 Technical (Hospital) Services ALUMINUM-MAG HYDROXIDE-SIMETHICONE 200 MG-200 MG-20 MG/5 ML ORAL SUSP RX-38285 CDM 2590000100 HCPCS 259 RC 00121-1761-30 NDC inpatient 15 ML 7.2 7.2 CIGNA 62308 [3081051] CIGNA 62308 [308105105] 5.7 percent of total billed charges 4.46 6.84 Technical (Hospital) Services ALUMINUM-MAG HYDROXIDE-SIMETHICONE 200 MG-200 MG-20 MG/5 ML ORAL SUSP RX-38285 CDM 2590000100 HCPCS 259 RC 00121-1761-30 NDC inpatient 15 ML 7.2 7.2 CIGNA 62308 [3081051] CIGNA STATE OF WYOMING [308105107] 5.7 percent of total billed charges 4.46 6.84 Technical (Hospital) Services ALUMINUM-MAG HYDROXIDE-SIMETHICONE 200 MG-200 MG-20 MG/5 ML ORAL SUSP RX-38285 CDM 2590000100 HCPCS 259 RC 00121-1761-30 NDC inpatient 15 ML 7.2 7.2 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES EPO [308136803] 5.7 percent of total billed charges 4.46 6.84 Technical (Hospital) Services ALUMINUM-MAG HYDROXIDE-SIMETHICONE 200 MG-200 MG-20 MG/5 ML ORAL SUSP RX-38285 CDM 2590000100 HCPCS 259 RC 00121-1761-30 NDC inpatient 15 ML 7.2 7.2 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES HDHP [308136802] 5.7 percent of total billed charges 4.46 6.84 Technical (Hospital) Services ALUMINUM-MAG HYDROXIDE-SIMETHICONE 200 MG-200 MG-20 MG/5 ML ORAL SUSP RX-38285 CDM 2590000100 HCPCS 259 RC 00121-1761-30 NDC inpatient 15 ML 7.2 7.2 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES PPO [308136801] 5.7 percent of total billed charges 4.46 6.84 Technical (Hospital) Services ALUMINUM-MAG HYDROXIDE-SIMETHICONE 200 MG-200 MG-20 MG/5 ML ORAL SUSP RX-38285 CDM 2590000100 HCPCS 259 RC 00121-1761-30 NDC outpatient 15 ML 7.2 7.2 MULTIPLAN INC 34080 [3081285] MULTIPLAN INC [308128501] 6.84 percent of total billed charges 4.46 6.84 Technical (Hospital) Services ALUMINUM-MAG HYDROXIDE-SIMETHICONE 200 MG-200 MG-20 MG/5 ML ORAL SUSP RX-38285 CDM 2590000100 HCPCS 259 RC 00121-1761-30 NDC outpatient 15 ML 7.2 7.2 MEDICA (COMMERCIAL) 94265 [3081118] MEDICA CLAIMS [308111801] 6.48 percent of total billed charges 4.46 6.84 Technical (Hospital) Services ALUMINUM-MAG HYDROXIDE-SIMETHICONE 200 MG-200 MG-20 MG/5 ML ORAL SUSP RX-38285 CDM 2590000100 HCPCS 259 RC 00121-1761-30 NDC outpatient 15 ML 7.2 7.2 CIGNA 62308 [3081051] CIGNA 62308 [308105105] 5.76 percent of total billed charges 4.46 6.84 Technical (Hospital) Services ALUMINUM-MAG HYDROXIDE-SIMETHICONE 200 MG-200 MG-20 MG/5 ML ORAL SUSP RX-38285 CDM 2590000100 HCPCS 259 RC 00121-1761-30 NDC outpatient 15 ML 7.2 7.2 CIGNA 62308 [3081051] CIGNA STATE OF WYOMING [308105107] 5.76 percent of total billed charges 4.46 6.84 Technical (Hospital) Services ALUMINUM-MAG HYDROXIDE-SIMETHICONE 200 MG-200 MG-20 MG/5 ML ORAL SUSP RX-38285 CDM 2590000100 HCPCS 259 RC 00121-1761-30 NDC outpatient 15 ML 7.2 7.2 UNITED HEALTHCARE (COMMERCIAL) [3081199] UNITED HEALTHCARE 87726 [308119901] 4.46 percent of total billed charges 4.46 6.84 Technical (Hospital) Services ALUMINUM-MAG HYDROXIDE-SIMETHICONE 200 MG-200 MG-20 MG/5 ML ORAL SUSP RX-38285 CDM 2590000100 HCPCS 259 RC 00121-1761-30 NDC outpatient 15 ML 7.2 7.2 HEALTHPARTNERS SX009 HEALTHPARTNERS 5.76 percent of total billed charges 4.46 6.84 Technical (Hospital) Services ALUMINUM-MAG HYDROXIDE-SIMETHICONE 200 MG-200 MG-20 MG/5 ML ORAL SUSP RX-38285 CDM 2590000100 HCPCS 259 RC 00121-1761-30 NDC outpatient 15 ML 7.2 7.2 BLUE CROSS BLUE SHIELD WELLMARK SB889 [3081026] BCBS WYOMING [308102603] 6.84 percent of total billed charges 4.46 6.84 Technical (Hospital) Services ALUMINUM-MAG HYDROXIDE-SIMETHICONE 200 MG-200 MG-20 MG/5 ML ORAL SUSP RX-38285 CDM 2590000100 HCPCS 259 RC 00121-1761-30 NDC outpatient 15 ML 7.2 7.2 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES EPO [308136803] 5.76 percent of total billed charges 4.46 6.84 Technical (Hospital) Services ALUMINUM-MAG HYDROXIDE-SIMETHICONE 200 MG-200 MG-20 MG/5 ML ORAL SUSP RX-38285 CDM 2590000100 HCPCS 259 RC 00121-1761-30 NDC outpatient 15 ML 7.2 7.2 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES PPO [308136801] 5.76 percent of total billed charges 4.46 6.84 Technical (Hospital) Services ALUMINUM-MAG HYDROXIDE-SIMETHICONE 200 MG-200 MG-20 MG/5 ML ORAL SUSP RX-38285 CDM 2590000100 HCPCS 259 RC 00121-1761-30 NDC outpatient 15 ML 7.2 7.2 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES HDHP [308136802] 5.76 percent of total billed charges 4.46 6.84 Technical (Hospital) Services IBUPROFEN 200 MG TABLET RX-3841 CDM 2590000100 HCPCS 259 RC 57896-0941-01 NDC inpatient 1 UN 5.64 5.64 UNITED HEALTHCARE (COMMERCIAL) [3081199] UNITED HEALTHCARE 87726 [308119901] 3.5 percent of total billed charges 3.5 5.36 Technical (Hospital) Services IBUPROFEN 200 MG TABLET RX-3841 CDM 2590000100 HCPCS 259 RC 57896-0941-01 NDC inpatient 1 UN 5.64 5.64 BLUE CROSS BLUE SHIELD WELLMARK SB889 [3081026] BCBS WYOMING [308102603] 5.36 percent of total billed charges 3.5 5.36 Technical (Hospital) Services IBUPROFEN 200 MG TABLET RX-3841 CDM 2590000100 HCPCS 259 RC 57896-0941-01 NDC inpatient 1 UN 5.64 5.64 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES HDHP [308136802] 4.47 percent of total billed charges 3.5 5.36 Technical (Hospital) Services IBUPROFEN 200 MG TABLET RX-3841 CDM 2590000100 HCPCS 259 RC 57896-0941-01 NDC inpatient 1 UN 5.64 5.64 CIGNA 62308 [3081051] CIGNA 62308 [308105105] 4.47 percent of total billed charges 3.5 5.36 Technical (Hospital) Services IBUPROFEN 200 MG TABLET RX-3841 CDM 2590000100 HCPCS 259 RC 57896-0941-01 NDC inpatient 1 UN 5.64 5.64 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES EPO [308136803] 4.47 percent of total billed charges 3.5 5.36 Technical (Hospital) Services IBUPROFEN 200 MG TABLET RX-3841 CDM 2590000100 HCPCS 259 RC 57896-0941-01 NDC inpatient 1 UN 5.64 5.64 CIGNA 62308 [3081051] CIGNA STATE OF WYOMING [308105107] 4.47 percent of total billed charges 3.5 5.36 Technical (Hospital) Services IBUPROFEN 200 MG TABLET RX-3841 CDM 2590000100 HCPCS 259 RC 57896-0941-01 NDC inpatient 1 UN 5.64 5.64 MULTIPLAN INC 34080 [3081285] MULTIPLAN INC [308128501] 5.36 percent of total billed charges 3.5 5.36 Technical (Hospital) Services IBUPROFEN 200 MG TABLET RX-3841 CDM 2590000100 HCPCS 259 RC 57896-0941-01 NDC inpatient 1 UN 5.64 5.64 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES PPO [308136801] 4.47 percent of total billed charges 3.5 5.36 Technical (Hospital) Services IBUPROFEN 200 MG TABLET RX-3841 CDM 2590000100 HCPCS 259 RC 57896-0941-01 NDC inpatient 1 UN 5.64 5.64 HEALTHPARTNERS SX009 HEALTHPARTNERS 4.47 percent of total billed charges 3.5 5.36 Technical (Hospital) Services IBUPROFEN 200 MG TABLET RX-3841 CDM 2590000100 HCPCS 259 RC 57896-0941-01 NDC inpatient 1 UN 5.64 5.64 MEDICA (COMMERCIAL) 94265 [3081118] MEDICA CLAIMS [308111801] 5.08 percent of total billed charges 3.5 5.36 Technical (Hospital) Services IBUPROFEN 200 MG TABLET RX-3841 CDM 2590000100 HCPCS 259 RC 57896-0941-01 NDC outpatient 1 UN 5.64 5.64 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES HDHP [308136802] 4.51 percent of total billed charges 3.5 5.36 Technical (Hospital) Services IBUPROFEN 200 MG TABLET RX-3841 CDM 2590000100 HCPCS 259 RC 57896-0941-01 NDC outpatient 1 UN 5.64 5.64 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES EPO [308136803] 4.51 percent of total billed charges 3.5 5.36 Technical (Hospital) Services IBUPROFEN 200 MG TABLET RX-3841 CDM 2590000100 HCPCS 259 RC 57896-0941-01 NDC outpatient 1 UN 5.64 5.64 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES PPO [308136801] 4.51 percent of total billed charges 3.5 5.36 Technical (Hospital) Services IBUPROFEN 200 MG TABLET RX-3841 CDM 2590000100 HCPCS 259 RC 57896-0941-01 NDC outpatient 1 UN 5.64 5.64 BLUE CROSS BLUE SHIELD WELLMARK SB889 [3081026] BCBS WYOMING [308102603] 5.36 percent of total billed charges 3.5 5.36 Technical (Hospital) Services IBUPROFEN 200 MG TABLET RX-3841 CDM 2590000100 HCPCS 259 RC 57896-0941-01 NDC outpatient 1 UN 5.64 5.64 MULTIPLAN INC 34080 [3081285] MULTIPLAN INC [308128501] 5.36 percent of total billed charges 3.5 5.36 Technical (Hospital) Services IBUPROFEN 200 MG TABLET RX-3841 CDM 2590000100 HCPCS 259 RC 57896-0941-01 NDC outpatient 1 UN 5.64 5.64 MEDICA (COMMERCIAL) 94265 [3081118] MEDICA CLAIMS [308111801] 5.08 percent of total billed charges 3.5 5.36 Technical (Hospital) Services IBUPROFEN 200 MG TABLET RX-3841 CDM 2590000100 HCPCS 259 RC 57896-0941-01 NDC outpatient 1 UN 5.64 5.64 CIGNA 62308 [3081051] CIGNA STATE OF WYOMING [308105107] 4.51 percent of total billed charges 3.5 5.36 Technical (Hospital) Services IBUPROFEN 200 MG TABLET RX-3841 CDM 2590000100 HCPCS 259 RC 57896-0941-01 NDC outpatient 1 UN 5.64 5.64 CIGNA 62308 [3081051] CIGNA 62308 [308105105] 4.51 percent of total billed charges 3.5 5.36 Technical (Hospital) Services IBUPROFEN 200 MG TABLET RX-3841 CDM 2590000100 HCPCS 259 RC 57896-0941-01 NDC outpatient 1 UN 5.64 5.64 HEALTHPARTNERS SX009 HEALTHPARTNERS 4.51 percent of total billed charges 3.5 5.36 Technical (Hospital) Services IBUPROFEN 200 MG TABLET RX-3841 CDM 2590000100 HCPCS 259 RC 57896-0941-01 NDC outpatient 1 UN 5.64 5.64 UNITED HEALTHCARE (COMMERCIAL) [3081199] UNITED HEALTHCARE 87726 [308119901] 3.5 percent of total billed charges 3.5 5.36 Technical (Hospital) Services "NYSTATIN 100,000 UNIT/GRAM TOPICAL POWDER" RX-39136 CDM 2590000100 HCPCS 259 RC 00832-0465-30 NDC outpatient 1 GR 6.33 6.33 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES EPO [308136803] 5.06 percent of total billed charges 3.92 6.01 Technical (Hospital) Services "NYSTATIN 100,000 UNIT/GRAM TOPICAL POWDER" RX-39136 CDM 2590000100 HCPCS 259 RC 00832-0465-30 NDC outpatient 1 GR 6.33 6.33 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES HDHP [308136802] 5.06 percent of total billed charges 3.92 6.01 Technical (Hospital) Services "NYSTATIN 100,000 UNIT/GRAM TOPICAL POWDER" RX-39136 CDM 2590000100 HCPCS 259 RC 00832-0465-30 NDC outpatient 1 GR 6.33 6.33 MEDICA (COMMERCIAL) 94265 [3081118] MEDICA CLAIMS [308111801] 5.7 percent of total billed charges 3.92 6.01 Technical (Hospital) Services "NYSTATIN 100,000 UNIT/GRAM TOPICAL POWDER" RX-39136 CDM 2590000100 HCPCS 259 RC 00832-0465-30 NDC outpatient 1 GR 6.33 6.33 MULTIPLAN INC 34080 [3081285] MULTIPLAN INC [308128501] 6.01 percent of total billed charges 3.92 6.01 Technical (Hospital) Services "NYSTATIN 100,000 UNIT/GRAM TOPICAL POWDER" RX-39136 CDM 2590000100 HCPCS 259 RC 00832-0465-30 NDC outpatient 1 GR 6.33 6.33 CIGNA 62308 [3081051] CIGNA 62308 [308105105] 5.06 percent of total billed charges 3.92 6.01 Technical (Hospital) Services "NYSTATIN 100,000 UNIT/GRAM TOPICAL POWDER" RX-39136 CDM 2590000100 HCPCS 259 RC 00832-0465-30 NDC outpatient 1 GR 6.33 6.33 CIGNA 62308 [3081051] CIGNA STATE OF WYOMING [308105107] 5.06 percent of total billed charges 3.92 6.01 Technical (Hospital) Services "NYSTATIN 100,000 UNIT/GRAM TOPICAL POWDER" RX-39136 CDM 2590000100 HCPCS 259 RC 00832-0465-30 NDC outpatient 1 GR 6.33 6.33 UNITED HEALTHCARE (COMMERCIAL) [3081199] UNITED HEALTHCARE 87726 [308119901] 3.92 percent of total billed charges 3.92 6.01 Technical (Hospital) Services "NYSTATIN 100,000 UNIT/GRAM TOPICAL POWDER" RX-39136 CDM 2590000100 HCPCS 259 RC 00832-0465-30 NDC outpatient 1 GR 6.33 6.33 HEALTHPARTNERS SX009 HEALTHPARTNERS 5.06 percent of total billed charges 3.92 6.01 Technical (Hospital) Services "NYSTATIN 100,000 UNIT/GRAM TOPICAL POWDER" RX-39136 CDM 2590000100 HCPCS 259 RC 00832-0465-30 NDC outpatient 1 GR 6.33 6.33 BLUE CROSS BLUE SHIELD WELLMARK SB889 [3081026] BCBS WYOMING [308102603] 6.01 percent of total billed charges 3.92 6.01 Technical (Hospital) Services "NYSTATIN 100,000 UNIT/GRAM TOPICAL POWDER" RX-39136 CDM 2590000100 HCPCS 259 RC 00832-0465-30 NDC outpatient 1 GR 6.33 6.33 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES PPO [308136801] 5.06 percent of total billed charges 3.92 6.01 Technical (Hospital) Services "NYSTATIN 100,000 UNIT/GRAM TOPICAL POWDER" RX-39136 CDM 2590000100 HCPCS 259 RC 00832-0465-30 NDC inpatient 1 GR 6.33 6.33 BLUE CROSS BLUE SHIELD WELLMARK SB889 [3081026] BCBS WYOMING [308102603] 6.01 percent of total billed charges 3.92 6.01 Technical (Hospital) Services "NYSTATIN 100,000 UNIT/GRAM TOPICAL POWDER" RX-39136 CDM 2590000100 HCPCS 259 RC 00832-0465-30 NDC inpatient 1 GR 6.33 6.33 UNITED HEALTHCARE (COMMERCIAL) [3081199] UNITED HEALTHCARE 87726 [308119901] 3.92 percent of total billed charges 3.92 6.01 Technical (Hospital) Services "NYSTATIN 100,000 UNIT/GRAM TOPICAL POWDER" RX-39136 CDM 2590000100 HCPCS 259 RC 00832-0465-30 NDC inpatient 1 GR 6.33 6.33 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES HDHP [308136802] 5.01 percent of total billed charges 3.92 6.01 Technical (Hospital) Services "NYSTATIN 100,000 UNIT/GRAM TOPICAL POWDER" RX-39136 CDM 2590000100 HCPCS 259 RC 00832-0465-30 NDC inpatient 1 GR 6.33 6.33 CIGNA 62308 [3081051] CIGNA 62308 [308105105] 5.01 percent of total billed charges 3.92 6.01 Technical (Hospital) Services "NYSTATIN 100,000 UNIT/GRAM TOPICAL POWDER" RX-39136 CDM 2590000100 HCPCS 259 RC 00832-0465-30 NDC inpatient 1 GR 6.33 6.33 CIGNA 62308 [3081051] CIGNA STATE OF WYOMING [308105107] 5.01 percent of total billed charges 3.92 6.01 Technical (Hospital) Services "NYSTATIN 100,000 UNIT/GRAM TOPICAL POWDER" RX-39136 CDM 2590000100 HCPCS 259 RC 00832-0465-30 NDC inpatient 1 GR 6.33 6.33 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES EPO [308136803] 5.01 percent of total billed charges 3.92 6.01 Technical (Hospital) Services "NYSTATIN 100,000 UNIT/GRAM TOPICAL POWDER" RX-39136 CDM 2590000100 HCPCS 259 RC 00832-0465-30 NDC inpatient 1 GR 6.33 6.33 MULTIPLAN INC 34080 [3081285] MULTIPLAN INC [308128501] 6.01 percent of total billed charges 3.92 6.01 Technical (Hospital) Services "NYSTATIN 100,000 UNIT/GRAM TOPICAL POWDER" RX-39136 CDM 2590000100 HCPCS 259 RC 00832-0465-30 NDC inpatient 1 GR 6.33 6.33 MEDICA (COMMERCIAL) 94265 [3081118] MEDICA CLAIMS [308111801] 5.7 percent of total billed charges 3.92 6.01 Technical (Hospital) Services "NYSTATIN 100,000 UNIT/GRAM TOPICAL POWDER" RX-39136 CDM 2590000100 HCPCS 259 RC 00832-0465-30 NDC inpatient 1 GR 6.33 6.33 HEALTHPARTNERS SX009 HEALTHPARTNERS 5.01 percent of total billed charges 3.92 6.01 Technical (Hospital) Services "NYSTATIN 100,000 UNIT/GRAM TOPICAL POWDER" RX-39136 CDM 2590000100 HCPCS 259 RC 00832-0465-30 NDC inpatient 1 GR 6.33 6.33 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES PPO [308136801] 5.01 percent of total billed charges 3.92 6.01 Technical (Hospital) Services ARTIFICIAL TEARS EYE DROPS WRAPPER RX-4080030042 CDM 2590000100 HCPCS 259 RC 10119-0020-03 NDC inpatient 15 ML 19.09 19.09 CIGNA 62308 [3081051] CIGNA 62308 [308105105] 15.12 percent of total billed charges 11.84 18.14 Technical (Hospital) Services ARTIFICIAL TEARS EYE DROPS WRAPPER RX-4080030042 CDM 2590000100 HCPCS 259 RC 10119-0020-03 NDC inpatient 15 ML 19.09 19.09 CIGNA 62308 [3081051] CIGNA STATE OF WYOMING [308105107] 15.12 percent of total billed charges 11.84 18.14 Technical (Hospital) Services ARTIFICIAL TEARS EYE DROPS WRAPPER RX-4080030042 CDM 2590000100 HCPCS 259 RC 10119-0020-03 NDC inpatient 15 ML 19.09 19.09 HEALTHPARTNERS SX009 HEALTHPARTNERS 15.12 percent of total billed charges 11.84 18.14 Technical (Hospital) Services ARTIFICIAL TEARS EYE DROPS WRAPPER RX-4080030042 CDM 2590000100 HCPCS 259 RC 10119-0020-03 NDC inpatient 15 ML 19.09 19.09 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES EPO [308136803] 15.12 percent of total billed charges 11.84 18.14 Technical (Hospital) Services ARTIFICIAL TEARS EYE DROPS WRAPPER RX-4080030042 CDM 2590000100 HCPCS 259 RC 10119-0020-03 NDC inpatient 15 ML 19.09 19.09 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES HDHP [308136802] 15.12 percent of total billed charges 11.84 18.14 Technical (Hospital) Services ARTIFICIAL TEARS EYE DROPS WRAPPER RX-4080030042 CDM 2590000100 HCPCS 259 RC 10119-0020-03 NDC inpatient 15 ML 19.09 19.09 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES PPO [308136801] 15.12 percent of total billed charges 11.84 18.14 Technical (Hospital) Services ARTIFICIAL TEARS EYE DROPS WRAPPER RX-4080030042 CDM 2590000100 HCPCS 259 RC 10119-0020-03 NDC inpatient 15 ML 19.09 19.09 BLUE CROSS BLUE SHIELD WELLMARK SB889 [3081026] BCBS WYOMING [308102603] 18.14 percent of total billed charges 11.84 18.14 Technical (Hospital) Services ARTIFICIAL TEARS EYE DROPS WRAPPER RX-4080030042 CDM 2590000100 HCPCS 259 RC 10119-0020-03 NDC inpatient 15 ML 19.09 19.09 UNITED HEALTHCARE (COMMERCIAL) [3081199] UNITED HEALTHCARE 87726 [308119901] 11.84 percent of total billed charges 11.84 18.14 Technical (Hospital) Services ARTIFICIAL TEARS EYE DROPS WRAPPER RX-4080030042 CDM 2590000100 HCPCS 259 RC 10119-0020-03 NDC inpatient 15 ML 19.09 19.09 MEDICA (COMMERCIAL) 94265 [3081118] MEDICA CLAIMS [308111801] 17.18 percent of total billed charges 11.84 18.14 Technical (Hospital) Services ARTIFICIAL TEARS EYE DROPS WRAPPER RX-4080030042 CDM 2590000100 HCPCS 259 RC 10119-0020-03 NDC inpatient 15 ML 19.09 19.09 MULTIPLAN INC 34080 [3081285] MULTIPLAN INC [308128501] 18.14 percent of total billed charges 11.84 18.14 Technical (Hospital) Services ARTIFICIAL TEARS EYE DROPS WRAPPER RX-4080030042 CDM 2590000100 HCPCS 259 RC 10119-0020-03 NDC outpatient 15 ML 19.09 19.09 CIGNA 62308 [3081051] CIGNA 62308 [308105105] 15.27 percent of total billed charges 11.84 18.14 Technical (Hospital) Services ARTIFICIAL TEARS EYE DROPS WRAPPER RX-4080030042 CDM 2590000100 HCPCS 259 RC 10119-0020-03 NDC outpatient 15 ML 19.09 19.09 CIGNA 62308 [3081051] CIGNA STATE OF WYOMING [308105107] 15.27 percent of total billed charges 11.84 18.14 Technical (Hospital) Services ARTIFICIAL TEARS EYE DROPS WRAPPER RX-4080030042 CDM 2590000100 HCPCS 259 RC 10119-0020-03 NDC outpatient 15 ML 19.09 19.09 MULTIPLAN INC 34080 [3081285] MULTIPLAN INC [308128501] 18.14 percent of total billed charges 11.84 18.14 Technical (Hospital) Services ARTIFICIAL TEARS EYE DROPS WRAPPER RX-4080030042 CDM 2590000100 HCPCS 259 RC 10119-0020-03 NDC outpatient 15 ML 19.09 19.09 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES EPO [308136803] 15.27 percent of total billed charges 11.84 18.14 Technical (Hospital) Services ARTIFICIAL TEARS EYE DROPS WRAPPER RX-4080030042 CDM 2590000100 HCPCS 259 RC 10119-0020-03 NDC outpatient 15 ML 19.09 19.09 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES PPO [308136801] 15.27 percent of total billed charges 11.84 18.14 Technical (Hospital) Services ARTIFICIAL TEARS EYE DROPS WRAPPER RX-4080030042 CDM 2590000100 HCPCS 259 RC 10119-0020-03 NDC outpatient 15 ML 19.09 19.09 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES HDHP [308136802] 15.27 percent of total billed charges 11.84 18.14 Technical (Hospital) Services ARTIFICIAL TEARS EYE DROPS WRAPPER RX-4080030042 CDM 2590000100 HCPCS 259 RC 10119-0020-03 NDC outpatient 15 ML 19.09 19.09 BLUE CROSS BLUE SHIELD WELLMARK SB889 [3081026] BCBS WYOMING [308102603] 18.14 percent of total billed charges 11.84 18.14 Technical (Hospital) Services ARTIFICIAL TEARS EYE DROPS WRAPPER RX-4080030042 CDM 2590000100 HCPCS 259 RC 10119-0020-03 NDC outpatient 15 ML 19.09 19.09 UNITED HEALTHCARE (COMMERCIAL) [3081199] UNITED HEALTHCARE 87726 [308119901] 11.84 percent of total billed charges 11.84 18.14 Technical (Hospital) Services ARTIFICIAL TEARS EYE DROPS WRAPPER RX-4080030042 CDM 2590000100 HCPCS 259 RC 10119-0020-03 NDC outpatient 15 ML 19.09 19.09 HEALTHPARTNERS SX009 HEALTHPARTNERS 15.27 percent of total billed charges 11.84 18.14 Technical (Hospital) Services ARTIFICIAL TEARS EYE DROPS WRAPPER RX-4080030042 CDM 2590000100 HCPCS 259 RC 10119-0020-03 NDC outpatient 15 ML 19.09 19.09 MEDICA (COMMERCIAL) 94265 [3081118] MEDICA CLAIMS [308111801] 17.18 percent of total billed charges 11.84 18.14 Technical (Hospital) Services WHITE PETROLATUM TOPICAL OINTMENT WRAPPER RX-4080070015 CDM 2590000100 HCPCS 259 RC 72140-0636-08 NDC outpatient 396 GR 53.65 53.65 CIGNA 62308 [3081051] CIGNA 62308 [308105105] 42.92 percent of total billed charges 33.26 50.97 Technical (Hospital) Services WHITE PETROLATUM TOPICAL OINTMENT WRAPPER RX-4080070015 CDM 2590000100 HCPCS 259 RC 72140-0636-08 NDC outpatient 396 GR 53.65 53.65 CIGNA 62308 [3081051] CIGNA STATE OF WYOMING [308105107] 42.92 percent of total billed charges 33.26 50.97 Technical (Hospital) Services WHITE PETROLATUM TOPICAL OINTMENT WRAPPER RX-4080070015 CDM 2590000100 HCPCS 259 RC 72140-0636-08 NDC outpatient 396 GR 53.65 53.65 HEALTHPARTNERS SX009 HEALTHPARTNERS 42.92 percent of total billed charges 33.26 50.97 Technical (Hospital) Services WHITE PETROLATUM TOPICAL OINTMENT WRAPPER RX-4080070015 CDM 2590000100 HCPCS 259 RC 72140-0636-08 NDC outpatient 396 GR 53.65 53.65 UNITED HEALTHCARE (COMMERCIAL) [3081199] UNITED HEALTHCARE 87726 [308119901] 33.26 percent of total billed charges 33.26 50.97 Technical (Hospital) Services WHITE PETROLATUM TOPICAL OINTMENT WRAPPER RX-4080070015 CDM 2590000100 HCPCS 259 RC 72140-0636-08 NDC outpatient 396 GR 53.65 53.65 MULTIPLAN INC 34080 [3081285] MULTIPLAN INC [308128501] 50.97 percent of total billed charges 33.26 50.97 Technical (Hospital) Services WHITE PETROLATUM TOPICAL OINTMENT WRAPPER RX-4080070015 CDM 2590000100 HCPCS 259 RC 72140-0636-08 NDC outpatient 396 GR 53.65 53.65 MEDICA (COMMERCIAL) 94265 [3081118] MEDICA CLAIMS [308111801] 48.29 percent of total billed charges 33.26 50.97 Technical (Hospital) Services WHITE PETROLATUM TOPICAL OINTMENT WRAPPER RX-4080070015 CDM 2590000100 HCPCS 259 RC 72140-0636-08 NDC outpatient 396 GR 53.65 53.65 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES HDHP [308136802] 42.92 percent of total billed charges 33.26 50.97 Technical (Hospital) Services WHITE PETROLATUM TOPICAL OINTMENT WRAPPER RX-4080070015 CDM 2590000100 HCPCS 259 RC 72140-0636-08 NDC outpatient 396 GR 53.65 53.65 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES PPO [308136801] 42.92 percent of total billed charges 33.26 50.97 Technical (Hospital) Services WHITE PETROLATUM TOPICAL OINTMENT WRAPPER RX-4080070015 CDM 2590000100 HCPCS 259 RC 72140-0636-08 NDC outpatient 396 GR 53.65 53.65 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES EPO [308136803] 42.92 percent of total billed charges 33.26 50.97 Technical (Hospital) Services WHITE PETROLATUM TOPICAL OINTMENT WRAPPER RX-4080070015 CDM 2590000100 HCPCS 259 RC 72140-0636-08 NDC outpatient 396 GR 53.65 53.65 BLUE CROSS BLUE SHIELD WELLMARK SB889 [3081026] BCBS WYOMING [308102603] 50.97 percent of total billed charges 33.26 50.97 Technical (Hospital) Services WHITE PETROLATUM TOPICAL OINTMENT WRAPPER RX-4080070015 CDM 2590000100 HCPCS 259 RC 72140-0636-08 NDC inpatient 396 GR 53.65 53.65 MULTIPLAN INC 34080 [3081285] MULTIPLAN INC [308128501] 50.97 percent of total billed charges 33.26 50.97 Technical (Hospital) Services WHITE PETROLATUM TOPICAL OINTMENT WRAPPER RX-4080070015 CDM 2590000100 HCPCS 259 RC 72140-0636-08 NDC inpatient 396 GR 53.65 53.65 MEDICA (COMMERCIAL) 94265 [3081118] MEDICA CLAIMS [308111801] 48.29 percent of total billed charges 33.26 50.97 Technical (Hospital) Services WHITE PETROLATUM TOPICAL OINTMENT WRAPPER RX-4080070015 CDM 2590000100 HCPCS 259 RC 72140-0636-08 NDC inpatient 396 GR 53.65 53.65 HEALTHPARTNERS SX009 HEALTHPARTNERS 42.48 percent of total billed charges 33.26 50.97 Technical (Hospital) Services WHITE PETROLATUM TOPICAL OINTMENT WRAPPER RX-4080070015 CDM 2590000100 HCPCS 259 RC 72140-0636-08 NDC inpatient 396 GR 53.65 53.65 BLUE CROSS BLUE SHIELD WELLMARK SB889 [3081026] BCBS WYOMING [308102603] 50.97 percent of total billed charges 33.26 50.97 Technical (Hospital) Services WHITE PETROLATUM TOPICAL OINTMENT WRAPPER RX-4080070015 CDM 2590000100 HCPCS 259 RC 72140-0636-08 NDC inpatient 396 GR 53.65 53.65 UNITED HEALTHCARE (COMMERCIAL) [3081199] UNITED HEALTHCARE 87726 [308119901] 33.26 percent of total billed charges 33.26 50.97 Technical (Hospital) Services WHITE PETROLATUM TOPICAL OINTMENT WRAPPER RX-4080070015 CDM 2590000100 HCPCS 259 RC 72140-0636-08 NDC inpatient 396 GR 53.65 53.65 CIGNA 62308 [3081051] CIGNA 62308 [308105105] 42.48 percent of total billed charges 33.26 50.97 Technical (Hospital) Services WHITE PETROLATUM TOPICAL OINTMENT WRAPPER RX-4080070015 CDM 2590000100 HCPCS 259 RC 72140-0636-08 NDC inpatient 396 GR 53.65 53.65 CIGNA 62308 [3081051] CIGNA STATE OF WYOMING [308105107] 42.48 percent of total billed charges 33.26 50.97 Technical (Hospital) Services WHITE PETROLATUM TOPICAL OINTMENT WRAPPER RX-4080070015 CDM 2590000100 HCPCS 259 RC 72140-0636-08 NDC inpatient 396 GR 53.65 53.65 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES EPO [308136803] 42.48 percent of total billed charges 33.26 50.97 Technical (Hospital) Services WHITE PETROLATUM TOPICAL OINTMENT WRAPPER RX-4080070015 CDM 2590000100 HCPCS 259 RC 72140-0636-08 NDC inpatient 396 GR 53.65 53.65 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES HDHP [308136802] 42.48 percent of total billed charges 33.26 50.97 Technical (Hospital) Services WHITE PETROLATUM TOPICAL OINTMENT WRAPPER RX-4080070015 CDM 2590000100 HCPCS 259 RC 72140-0636-08 NDC inpatient 396 GR 53.65 53.65 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES PPO [308136801] 42.48 percent of total billed charges 33.26 50.97 Technical (Hospital) Services POLYETHYLENE GLYCOL 3350 17 GRAM/DOSE ORAL POWDER WRAPPER RX-4080070016 CDM 2590000100 HCPCS 259 RC 00904-6931-86 NDC outpatient 17 GR 7.18 7.18 UNITED HEALTHCARE (COMMERCIAL) [3081199] UNITED HEALTHCARE 87726 [308119901] 4.45 percent of total billed charges 4.45 6.82 Technical (Hospital) Services POLYETHYLENE GLYCOL 3350 17 GRAM/DOSE ORAL POWDER WRAPPER RX-4080070016 CDM 2590000100 HCPCS 259 RC 00904-6931-86 NDC outpatient 17 GR 7.18 7.18 BLUE CROSS BLUE SHIELD WELLMARK SB889 [3081026] BCBS WYOMING [308102603] 6.82 percent of total billed charges 4.45 6.82 Technical (Hospital) Services POLYETHYLENE GLYCOL 3350 17 GRAM/DOSE ORAL POWDER WRAPPER RX-4080070016 CDM 2590000100 HCPCS 259 RC 00904-6931-86 NDC outpatient 17 GR 7.18 7.18 HEALTHPARTNERS SX009 HEALTHPARTNERS 5.74 percent of total billed charges 4.45 6.82 Technical (Hospital) Services POLYETHYLENE GLYCOL 3350 17 GRAM/DOSE ORAL POWDER WRAPPER RX-4080070016 CDM 2590000100 HCPCS 259 RC 00904-6931-86 NDC outpatient 17 GR 7.18 7.18 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES EPO [308136803] 5.74 percent of total billed charges 4.45 6.82 Technical (Hospital) Services POLYETHYLENE GLYCOL 3350 17 GRAM/DOSE ORAL POWDER WRAPPER RX-4080070016 CDM 2590000100 HCPCS 259 RC 00904-6931-86 NDC outpatient 17 GR 7.18 7.18 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES HDHP [308136802] 5.74 percent of total billed charges 4.45 6.82 Technical (Hospital) Services POLYETHYLENE GLYCOL 3350 17 GRAM/DOSE ORAL POWDER WRAPPER RX-4080070016 CDM 2590000100 HCPCS 259 RC 00904-6931-86 NDC outpatient 17 GR 7.18 7.18 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES PPO [308136801] 5.74 percent of total billed charges 4.45 6.82 Technical (Hospital) Services POLYETHYLENE GLYCOL 3350 17 GRAM/DOSE ORAL POWDER WRAPPER RX-4080070016 CDM 2590000100 HCPCS 259 RC 00904-6931-86 NDC outpatient 17 GR 7.18 7.18 CIGNA 62308 [3081051] CIGNA 62308 [308105105] 5.74 percent of total billed charges 4.45 6.82 Technical (Hospital) Services POLYETHYLENE GLYCOL 3350 17 GRAM/DOSE ORAL POWDER WRAPPER RX-4080070016 CDM 2590000100 HCPCS 259 RC 00904-6931-86 NDC outpatient 17 GR 7.18 7.18 CIGNA 62308 [3081051] CIGNA STATE OF WYOMING [308105107] 5.74 percent of total billed charges 4.45 6.82 Technical (Hospital) Services POLYETHYLENE GLYCOL 3350 17 GRAM/DOSE ORAL POWDER WRAPPER RX-4080070016 CDM 2590000100 HCPCS 259 RC 00904-6931-86 NDC outpatient 17 GR 7.18 7.18 MEDICA (COMMERCIAL) 94265 [3081118] MEDICA CLAIMS [308111801] 6.46 percent of total billed charges 4.45 6.82 Technical (Hospital) Services POLYETHYLENE GLYCOL 3350 17 GRAM/DOSE ORAL POWDER WRAPPER RX-4080070016 CDM 2590000100 HCPCS 259 RC 00904-6931-86 NDC outpatient 17 GR 7.18 7.18 MULTIPLAN INC 34080 [3081285] MULTIPLAN INC [308128501] 6.82 percent of total billed charges 4.45 6.82 Technical (Hospital) Services POLYETHYLENE GLYCOL 3350 17 GRAM/DOSE ORAL POWDER WRAPPER RX-4080070016 CDM 2590000100 HCPCS 259 RC 00904-6931-86 NDC inpatient 17 GR 7.18 7.18 CIGNA 62308 [3081051] CIGNA 62308 [308105105] 5.69 percent of total billed charges 4.45 6.82 Technical (Hospital) Services POLYETHYLENE GLYCOL 3350 17 GRAM/DOSE ORAL POWDER WRAPPER RX-4080070016 CDM 2590000100 HCPCS 259 RC 00904-6931-86 NDC inpatient 17 GR 7.18 7.18 CIGNA 62308 [3081051] CIGNA STATE OF WYOMING [308105107] 5.69 percent of total billed charges 4.45 6.82 Technical (Hospital) Services POLYETHYLENE GLYCOL 3350 17 GRAM/DOSE ORAL POWDER WRAPPER RX-4080070016 CDM 2590000100 HCPCS 259 RC 00904-6931-86 NDC inpatient 17 GR 7.18 7.18 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES EPO [308136803] 5.69 percent of total billed charges 4.45 6.82 Technical (Hospital) Services POLYETHYLENE GLYCOL 3350 17 GRAM/DOSE ORAL POWDER WRAPPER RX-4080070016 CDM 2590000100 HCPCS 259 RC 00904-6931-86 NDC inpatient 17 GR 7.18 7.18 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES HDHP [308136802] 5.69 percent of total billed charges 4.45 6.82 Technical (Hospital) Services POLYETHYLENE GLYCOL 3350 17 GRAM/DOSE ORAL POWDER WRAPPER RX-4080070016 CDM 2590000100 HCPCS 259 RC 00904-6931-86 NDC inpatient 17 GR 7.18 7.18 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES PPO [308136801] 5.69 percent of total billed charges 4.45 6.82 Technical (Hospital) Services POLYETHYLENE GLYCOL 3350 17 GRAM/DOSE ORAL POWDER WRAPPER RX-4080070016 CDM 2590000100 HCPCS 259 RC 00904-6931-86 NDC inpatient 17 GR 7.18 7.18 HEALTHPARTNERS SX009 HEALTHPARTNERS 5.69 percent of total billed charges 4.45 6.82 Technical (Hospital) Services POLYETHYLENE GLYCOL 3350 17 GRAM/DOSE ORAL POWDER WRAPPER RX-4080070016 CDM 2590000100 HCPCS 259 RC 00904-6931-86 NDC inpatient 17 GR 7.18 7.18 BLUE CROSS BLUE SHIELD WELLMARK SB889 [3081026] BCBS WYOMING [308102603] 6.82 percent of total billed charges 4.45 6.82 Technical (Hospital) Services POLYETHYLENE GLYCOL 3350 17 GRAM/DOSE ORAL POWDER WRAPPER RX-4080070016 CDM 2590000100 HCPCS 259 RC 00904-6931-86 NDC inpatient 17 GR 7.18 7.18 UNITED HEALTHCARE (COMMERCIAL) [3081199] UNITED HEALTHCARE 87726 [308119901] 4.45 percent of total billed charges 4.45 6.82 Technical (Hospital) Services POLYETHYLENE GLYCOL 3350 17 GRAM/DOSE ORAL POWDER WRAPPER RX-4080070016 CDM 2590000100 HCPCS 259 RC 00904-6931-86 NDC inpatient 17 GR 7.18 7.18 MULTIPLAN INC 34080 [3081285] MULTIPLAN INC [308128501] 6.82 percent of total billed charges 4.45 6.82 Technical (Hospital) Services POLYETHYLENE GLYCOL 3350 17 GRAM/DOSE ORAL POWDER WRAPPER RX-4080070016 CDM 2590000100 HCPCS 259 RC 00904-6931-86 NDC inpatient 17 GR 7.18 7.18 MEDICA (COMMERCIAL) 94265 [3081118] MEDICA CLAIMS [308111801] 6.46 percent of total billed charges 4.45 6.82 Technical (Hospital) Services AMITRIPTYLINE 25 MG TABLET RX-435 CDM 2590000100 HCPCS 259 RC 50268-0038-11 NDC inpatient 1 UN 6.04 6.04 MEDICA (COMMERCIAL) 94265 [3081118] MEDICA CLAIMS [308111801] 5.44 percent of total billed charges 3.74 5.74 Technical (Hospital) Services AMITRIPTYLINE 25 MG TABLET RX-435 CDM 2590000100 HCPCS 259 RC 50268-0038-11 NDC inpatient 1 UN 6.04 6.04 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES PPO [308136801] 4.78 percent of total billed charges 3.74 5.74 Technical (Hospital) Services AMITRIPTYLINE 25 MG TABLET RX-435 CDM 2590000100 HCPCS 259 RC 50268-0038-11 NDC inpatient 1 UN 6.04 6.04 HEALTHPARTNERS SX009 HEALTHPARTNERS 4.78 percent of total billed charges 3.74 5.74 Technical (Hospital) Services AMITRIPTYLINE 25 MG TABLET RX-435 CDM 2590000100 HCPCS 259 RC 50268-0038-11 NDC inpatient 1 UN 6.04 6.04 MULTIPLAN INC 34080 [3081285] MULTIPLAN INC [308128501] 5.74 percent of total billed charges 3.74 5.74 Technical (Hospital) Services AMITRIPTYLINE 25 MG TABLET RX-435 CDM 2590000100 HCPCS 259 RC 50268-0038-11 NDC inpatient 1 UN 6.04 6.04 BLUE CROSS BLUE SHIELD WELLMARK SB889 [3081026] BCBS WYOMING [308102603] 5.74 percent of total billed charges 3.74 5.74 Technical (Hospital) Services AMITRIPTYLINE 25 MG TABLET RX-435 CDM 2590000100 HCPCS 259 RC 50268-0038-11 NDC inpatient 1 UN 6.04 6.04 UNITED HEALTHCARE (COMMERCIAL) [3081199] UNITED HEALTHCARE 87726 [308119901] 3.74 percent of total billed charges 3.74 5.74 Technical (Hospital) Services AMITRIPTYLINE 25 MG TABLET RX-435 CDM 2590000100 HCPCS 259 RC 50268-0038-11 NDC inpatient 1 UN 6.04 6.04 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES EPO [308136803] 4.78 percent of total billed charges 3.74 5.74 Technical (Hospital) Services AMITRIPTYLINE 25 MG TABLET RX-435 CDM 2590000100 HCPCS 259 RC 50268-0038-11 NDC inpatient 1 UN 6.04 6.04 CIGNA 62308 [3081051] CIGNA 62308 [308105105] 4.78 percent of total billed charges 3.74 5.74 Technical (Hospital) Services AMITRIPTYLINE 25 MG TABLET RX-435 CDM 2590000100 HCPCS 259 RC 50268-0038-11 NDC inpatient 1 UN 6.04 6.04 CIGNA 62308 [3081051] CIGNA STATE OF WYOMING [308105107] 4.78 percent of total billed charges 3.74 5.74 Technical (Hospital) Services AMITRIPTYLINE 25 MG TABLET RX-435 CDM 2590000100 HCPCS 259 RC 50268-0038-11 NDC inpatient 1 UN 6.04 6.04 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES HDHP [308136802] 4.78 percent of total billed charges 3.74 5.74 Technical (Hospital) Services AMITRIPTYLINE 25 MG TABLET RX-435 CDM 2590000100 HCPCS 259 RC 50268-0038-11 NDC outpatient 1 UN 6.04 6.04 BLUE CROSS BLUE SHIELD WELLMARK SB889 [3081026] BCBS WYOMING [308102603] 5.74 percent of total billed charges 3.74 5.74 Technical (Hospital) Services AMITRIPTYLINE 25 MG TABLET RX-435 CDM 2590000100 HCPCS 259 RC 50268-0038-11 NDC outpatient 1 UN 6.04 6.04 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES PPO [308136801] 4.83 percent of total billed charges 3.74 5.74 Technical (Hospital) Services AMITRIPTYLINE 25 MG TABLET RX-435 CDM 2590000100 HCPCS 259 RC 50268-0038-11 NDC outpatient 1 UN 6.04 6.04 CIGNA 62308 [3081051] CIGNA 62308 [308105105] 4.83 percent of total billed charges 3.74 5.74 Technical (Hospital) Services AMITRIPTYLINE 25 MG TABLET RX-435 CDM 2590000100 HCPCS 259 RC 50268-0038-11 NDC outpatient 1 UN 6.04 6.04 CIGNA 62308 [3081051] CIGNA STATE OF WYOMING [308105107] 4.83 percent of total billed charges 3.74 5.74 Technical (Hospital) Services AMITRIPTYLINE 25 MG TABLET RX-435 CDM 2590000100 HCPCS 259 RC 50268-0038-11 NDC outpatient 1 UN 6.04 6.04 MULTIPLAN INC 34080 [3081285] MULTIPLAN INC [308128501] 5.74 percent of total billed charges 3.74 5.74 Technical (Hospital) Services AMITRIPTYLINE 25 MG TABLET RX-435 CDM 2590000100 HCPCS 259 RC 50268-0038-11 NDC outpatient 1 UN 6.04 6.04 UNITED HEALTHCARE (COMMERCIAL) [3081199] UNITED HEALTHCARE 87726 [308119901] 3.74 percent of total billed charges 3.74 5.74 Technical (Hospital) Services AMITRIPTYLINE 25 MG TABLET RX-435 CDM 2590000100 HCPCS 259 RC 50268-0038-11 NDC outpatient 1 UN 6.04 6.04 HEALTHPARTNERS SX009 HEALTHPARTNERS 4.83 percent of total billed charges 3.74 5.74 Technical (Hospital) Services AMITRIPTYLINE 25 MG TABLET RX-435 CDM 2590000100 HCPCS 259 RC 50268-0038-11 NDC outpatient 1 UN 6.04 6.04 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES EPO [308136803] 4.83 percent of total billed charges 3.74 5.74 Technical (Hospital) Services AMITRIPTYLINE 25 MG TABLET RX-435 CDM 2590000100 HCPCS 259 RC 50268-0038-11 NDC outpatient 1 UN 6.04 6.04 MEDICA (COMMERCIAL) 94265 [3081118] MEDICA CLAIMS [308111801] 5.44 percent of total billed charges 3.74 5.74 Technical (Hospital) Services AMITRIPTYLINE 25 MG TABLET RX-435 CDM 2590000100 HCPCS 259 RC 50268-0038-11 NDC outpatient 1 UN 6.04 6.04 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES HDHP [308136802] 4.83 percent of total billed charges 3.74 5.74 Technical (Hospital) Services MINERAL OIL ORAL RX-5086 CDM 2590000100 HCPCS 259 RC 48433-0202-30 NDC outpatient 15 ML 6.45 6.45 HEALTHPARTNERS SX009 HEALTHPARTNERS 5.16 percent of total billed charges 4 6.13 Technical (Hospital) Services MINERAL OIL ORAL RX-5086 CDM 2590000100 HCPCS 259 RC 48433-0202-30 NDC outpatient 15 ML 6.45 6.45 UNITED HEALTHCARE (COMMERCIAL) [3081199] UNITED HEALTHCARE 87726 [308119901] 4 percent of total billed charges 4 6.13 Technical (Hospital) Services MINERAL OIL ORAL RX-5086 CDM 2590000100 HCPCS 259 RC 48433-0202-30 NDC outpatient 15 ML 6.45 6.45 MEDICA (COMMERCIAL) 94265 [3081118] MEDICA CLAIMS [308111801] 5.81 percent of total billed charges 4 6.13 Technical (Hospital) Services MINERAL OIL ORAL RX-5086 CDM 2590000100 HCPCS 259 RC 48433-0202-30 NDC outpatient 15 ML 6.45 6.45 BLUE CROSS BLUE SHIELD WELLMARK SB889 [3081026] BCBS WYOMING [308102603] 6.13 percent of total billed charges 4 6.13 Technical (Hospital) Services MINERAL OIL ORAL RX-5086 CDM 2590000100 HCPCS 259 RC 48433-0202-30 NDC outpatient 15 ML 6.45 6.45 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES HDHP [308136802] 5.16 percent of total billed charges 4 6.13 Technical (Hospital) Services MINERAL OIL ORAL RX-5086 CDM 2590000100 HCPCS 259 RC 48433-0202-30 NDC outpatient 15 ML 6.45 6.45 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES PPO [308136801] 5.16 percent of total billed charges 4 6.13 Technical (Hospital) Services MINERAL OIL ORAL RX-5086 CDM 2590000100 HCPCS 259 RC 48433-0202-30 NDC outpatient 15 ML 6.45 6.45 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES EPO [308136803] 5.16 percent of total billed charges 4 6.13 Technical (Hospital) Services MINERAL OIL ORAL RX-5086 CDM 2590000100 HCPCS 259 RC 48433-0202-30 NDC outpatient 15 ML 6.45 6.45 CIGNA 62308 [3081051] CIGNA 62308 [308105105] 5.16 percent of total billed charges 4 6.13 Technical (Hospital) Services MINERAL OIL ORAL RX-5086 CDM 2590000100 HCPCS 259 RC 48433-0202-30 NDC outpatient 15 ML 6.45 6.45 CIGNA 62308 [3081051] CIGNA STATE OF WYOMING [308105107] 5.16 percent of total billed charges 4 6.13 Technical (Hospital) Services MINERAL OIL ORAL RX-5086 CDM 2590000100 HCPCS 259 RC 48433-0202-30 NDC outpatient 15 ML 6.45 6.45 MULTIPLAN INC 34080 [3081285] MULTIPLAN INC [308128501] 6.13 percent of total billed charges 4 6.13 Technical (Hospital) Services MINERAL OIL ORAL RX-5086 CDM 2590000100 HCPCS 259 RC 48433-0202-30 NDC inpatient 15 ML 6.45 6.45 CIGNA 62308 [3081051] CIGNA 62308 [308105105] 5.11 percent of total billed charges 4 6.13 Technical (Hospital) Services MINERAL OIL ORAL RX-5086 CDM 2590000100 HCPCS 259 RC 48433-0202-30 NDC inpatient 15 ML 6.45 6.45 CIGNA 62308 [3081051] CIGNA STATE OF WYOMING [308105107] 5.11 percent of total billed charges 4 6.13 Technical (Hospital) Services MINERAL OIL ORAL RX-5086 CDM 2590000100 HCPCS 259 RC 48433-0202-30 NDC inpatient 15 ML 6.45 6.45 HEALTHPARTNERS SX009 HEALTHPARTNERS 5.11 percent of total billed charges 4 6.13 Technical (Hospital) Services MINERAL OIL ORAL RX-5086 CDM 2590000100 HCPCS 259 RC 48433-0202-30 NDC inpatient 15 ML 6.45 6.45 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES HDHP [308136802] 5.11 percent of total billed charges 4 6.13 Technical (Hospital) Services MINERAL OIL ORAL RX-5086 CDM 2590000100 HCPCS 259 RC 48433-0202-30 NDC inpatient 15 ML 6.45 6.45 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES EPO [308136803] 5.11 percent of total billed charges 4 6.13 Technical (Hospital) Services MINERAL OIL ORAL RX-5086 CDM 2590000100 HCPCS 259 RC 48433-0202-30 NDC inpatient 15 ML 6.45 6.45 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES PPO [308136801] 5.11 percent of total billed charges 4 6.13 Technical (Hospital) Services MINERAL OIL ORAL RX-5086 CDM 2590000100 HCPCS 259 RC 48433-0202-30 NDC inpatient 15 ML 6.45 6.45 MEDICA (COMMERCIAL) 94265 [3081118] MEDICA CLAIMS [308111801] 5.81 percent of total billed charges 4 6.13 Technical (Hospital) Services MINERAL OIL ORAL RX-5086 CDM 2590000100 HCPCS 259 RC 48433-0202-30 NDC inpatient 15 ML 6.45 6.45 MULTIPLAN INC 34080 [3081285] MULTIPLAN INC [308128501] 6.13 percent of total billed charges 4 6.13 Technical (Hospital) Services MINERAL OIL ORAL RX-5086 CDM 2590000100 HCPCS 259 RC 48433-0202-30 NDC inpatient 15 ML 6.45 6.45 UNITED HEALTHCARE (COMMERCIAL) [3081199] UNITED HEALTHCARE 87726 [308119901] 4 percent of total billed charges 4 6.13 Technical (Hospital) Services MINERAL OIL ORAL RX-5086 CDM 2590000100 HCPCS 259 RC 48433-0202-30 NDC inpatient 15 ML 6.45 6.45 BLUE CROSS BLUE SHIELD WELLMARK SB889 [3081026] BCBS WYOMING [308102603] 6.13 percent of total billed charges 4 6.13 Technical (Hospital) Services ASPIRIN 81 MG CHEWABLE TABLET RX-679 CDM 2590000100 HCPCS 259 RC 57896-0911-36 NDC inpatient 1 UN 5.64 5.64 CIGNA 62308 [3081051] CIGNA 62308 [308105105] 4.47 percent of total billed charges 3.5 5.36 Technical (Hospital) Services ASPIRIN 81 MG CHEWABLE TABLET RX-679 CDM 2590000100 HCPCS 259 RC 57896-0911-36 NDC inpatient 1 UN 5.64 5.64 CIGNA 62308 [3081051] CIGNA STATE OF WYOMING [308105107] 4.47 percent of total billed charges 3.5 5.36 Technical (Hospital) Services ASPIRIN 81 MG CHEWABLE TABLET RX-679 CDM 2590000100 HCPCS 259 RC 57896-0911-36 NDC inpatient 1 UN 5.64 5.64 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES HDHP [308136802] 4.47 percent of total billed charges 3.5 5.36 Technical (Hospital) Services ASPIRIN 81 MG CHEWABLE TABLET RX-679 CDM 2590000100 HCPCS 259 RC 57896-0911-36 NDC inpatient 1 UN 5.64 5.64 BLUE CROSS BLUE SHIELD WELLMARK SB889 [3081026] BCBS WYOMING [308102603] 5.36 percent of total billed charges 3.5 5.36 Technical (Hospital) Services ASPIRIN 81 MG CHEWABLE TABLET RX-679 CDM 2590000100 HCPCS 259 RC 57896-0911-36 NDC inpatient 1 UN 5.64 5.64 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES EPO [308136803] 4.47 percent of total billed charges 3.5 5.36 Technical (Hospital) Services ASPIRIN 81 MG CHEWABLE TABLET RX-679 CDM 2590000100 HCPCS 259 RC 57896-0911-36 NDC inpatient 1 UN 5.64 5.64 UNITED HEALTHCARE (COMMERCIAL) [3081199] UNITED HEALTHCARE 87726 [308119901] 3.5 percent of total billed charges 3.5 5.36 Technical (Hospital) Services ASPIRIN 81 MG CHEWABLE TABLET RX-679 CDM 2590000100 HCPCS 259 RC 57896-0911-36 NDC inpatient 1 UN 5.64 5.64 MULTIPLAN INC 34080 [3081285] MULTIPLAN INC [308128501] 5.36 percent of total billed charges 3.5 5.36 Technical (Hospital) Services ASPIRIN 81 MG CHEWABLE TABLET RX-679 CDM 2590000100 HCPCS 259 RC 57896-0911-36 NDC inpatient 1 UN 5.64 5.64 MEDICA (COMMERCIAL) 94265 [3081118] MEDICA CLAIMS [308111801] 5.08 percent of total billed charges 3.5 5.36 Technical (Hospital) Services ASPIRIN 81 MG CHEWABLE TABLET RX-679 CDM 2590000100 HCPCS 259 RC 57896-0911-36 NDC inpatient 1 UN 5.64 5.64 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES PPO [308136801] 4.47 percent of total billed charges 3.5 5.36 Technical (Hospital) Services ASPIRIN 81 MG CHEWABLE TABLET RX-679 CDM 2590000100 HCPCS 259 RC 57896-0911-36 NDC inpatient 1 UN 5.64 5.64 HEALTHPARTNERS SX009 HEALTHPARTNERS 4.47 percent of total billed charges 3.5 5.36 Technical (Hospital) Services ASPIRIN 81 MG CHEWABLE TABLET RX-679 CDM 2590000100 HCPCS 259 RC 57896-0911-36 NDC outpatient 1 UN 5.64 5.64 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES HDHP [308136802] 4.51 percent of total billed charges 3.5 5.36 Technical (Hospital) Services ASPIRIN 81 MG CHEWABLE TABLET RX-679 CDM 2590000100 HCPCS 259 RC 57896-0911-36 NDC outpatient 1 UN 5.64 5.64 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES EPO [308136803] 4.51 percent of total billed charges 3.5 5.36 Technical (Hospital) Services ASPIRIN 81 MG CHEWABLE TABLET RX-679 CDM 2590000100 HCPCS 259 RC 57896-0911-36 NDC outpatient 1 UN 5.64 5.64 BLUE CROSS BLUE SHIELD WELLMARK SB889 [3081026] BCBS WYOMING [308102603] 5.36 percent of total billed charges 3.5 5.36 Technical (Hospital) Services ASPIRIN 81 MG CHEWABLE TABLET RX-679 CDM 2590000100 HCPCS 259 RC 57896-0911-36 NDC outpatient 1 UN 5.64 5.64 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES PPO [308136801] 4.51 percent of total billed charges 3.5 5.36 Technical (Hospital) Services ASPIRIN 81 MG CHEWABLE TABLET RX-679 CDM 2590000100 HCPCS 259 RC 57896-0911-36 NDC outpatient 1 UN 5.64 5.64 UNITED HEALTHCARE (COMMERCIAL) [3081199] UNITED HEALTHCARE 87726 [308119901] 3.5 percent of total billed charges 3.5 5.36 Technical (Hospital) Services ASPIRIN 81 MG CHEWABLE TABLET RX-679 CDM 2590000100 HCPCS 259 RC 57896-0911-36 NDC outpatient 1 UN 5.64 5.64 HEALTHPARTNERS SX009 HEALTHPARTNERS 4.51 percent of total billed charges 3.5 5.36 Technical (Hospital) Services ASPIRIN 81 MG CHEWABLE TABLET RX-679 CDM 2590000100 HCPCS 259 RC 57896-0911-36 NDC outpatient 1 UN 5.64 5.64 CIGNA 62308 [3081051] CIGNA 62308 [308105105] 4.51 percent of total billed charges 3.5 5.36 Technical (Hospital) Services ASPIRIN 81 MG CHEWABLE TABLET RX-679 CDM 2590000100 HCPCS 259 RC 57896-0911-36 NDC outpatient 1 UN 5.64 5.64 CIGNA 62308 [3081051] CIGNA STATE OF WYOMING [308105107] 4.51 percent of total billed charges 3.5 5.36 Technical (Hospital) Services ASPIRIN 81 MG CHEWABLE TABLET RX-679 CDM 2590000100 HCPCS 259 RC 57896-0911-36 NDC outpatient 1 UN 5.64 5.64 MULTIPLAN INC 34080 [3081285] MULTIPLAN INC [308128501] 5.36 percent of total billed charges 3.5 5.36 Technical (Hospital) Services ASPIRIN 81 MG CHEWABLE TABLET RX-679 CDM 2590000100 HCPCS 259 RC 57896-0911-36 NDC outpatient 1 UN 5.64 5.64 MEDICA (COMMERCIAL) 94265 [3081118] MEDICA CLAIMS [308111801] 5.08 percent of total billed charges 3.5 5.36 Technical (Hospital) Services ASPIRIN 325 MG TABLET RX-681 CDM 2590000100 HCPCS 259 RC 57896-0901-01 NDC inpatient 1 UN 5.64 5.64 HEALTHPARTNERS SX009 HEALTHPARTNERS 4.47 percent of total billed charges 3.5 5.36 Technical (Hospital) Services ASPIRIN 325 MG TABLET RX-681 CDM 2590000100 HCPCS 259 RC 57896-0901-01 NDC inpatient 1 UN 5.64 5.64 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES PPO [308136801] 4.47 percent of total billed charges 3.5 5.36 Technical (Hospital) Services ASPIRIN 325 MG TABLET RX-681 CDM 2590000100 HCPCS 259 RC 57896-0901-01 NDC inpatient 1 UN 5.64 5.64 MEDICA (COMMERCIAL) 94265 [3081118] MEDICA CLAIMS [308111801] 5.08 percent of total billed charges 3.5 5.36 Technical (Hospital) Services ASPIRIN 325 MG TABLET RX-681 CDM 2590000100 HCPCS 259 RC 57896-0901-01 NDC inpatient 1 UN 5.64 5.64 MULTIPLAN INC 34080 [3081285] MULTIPLAN INC [308128501] 5.36 percent of total billed charges 3.5 5.36 Technical (Hospital) Services ASPIRIN 325 MG TABLET RX-681 CDM 2590000100 HCPCS 259 RC 57896-0901-01 NDC inpatient 1 UN 5.64 5.64 UNITED HEALTHCARE (COMMERCIAL) [3081199] UNITED HEALTHCARE 87726 [308119901] 3.5 percent of total billed charges 3.5 5.36 Technical (Hospital) Services ASPIRIN 325 MG TABLET RX-681 CDM 2590000100 HCPCS 259 RC 57896-0901-01 NDC inpatient 1 UN 5.64 5.64 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES EPO [308136803] 4.47 percent of total billed charges 3.5 5.36 Technical (Hospital) Services ASPIRIN 325 MG TABLET RX-681 CDM 2590000100 HCPCS 259 RC 57896-0901-01 NDC inpatient 1 UN 5.64 5.64 BLUE CROSS BLUE SHIELD WELLMARK SB889 [3081026] BCBS WYOMING [308102603] 5.36 percent of total billed charges 3.5 5.36 Technical (Hospital) Services ASPIRIN 325 MG TABLET RX-681 CDM 2590000100 HCPCS 259 RC 57896-0901-01 NDC inpatient 1 UN 5.64 5.64 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES HDHP [308136802] 4.47 percent of total billed charges 3.5 5.36 Technical (Hospital) Services ASPIRIN 325 MG TABLET RX-681 CDM 2590000100 HCPCS 259 RC 57896-0901-01 NDC inpatient 1 UN 5.64 5.64 CIGNA 62308 [3081051] CIGNA 62308 [308105105] 4.47 percent of total billed charges 3.5 5.36 Technical (Hospital) Services ASPIRIN 325 MG TABLET RX-681 CDM 2590000100 HCPCS 259 RC 57896-0901-01 NDC inpatient 1 UN 5.64 5.64 CIGNA 62308 [3081051] CIGNA STATE OF WYOMING [308105107] 4.47 percent of total billed charges 3.5 5.36 Technical (Hospital) Services ASPIRIN 325 MG TABLET RX-681 CDM 2590000100 HCPCS 259 RC 57896-0901-01 NDC outpatient 1 UN 5.64 5.64 MEDICA (COMMERCIAL) 94265 [3081118] MEDICA CLAIMS [308111801] 5.08 percent of total billed charges 3.5 5.36 Technical (Hospital) Services ASPIRIN 325 MG TABLET RX-681 CDM 2590000100 HCPCS 259 RC 57896-0901-01 NDC outpatient 1 UN 5.64 5.64 MULTIPLAN INC 34080 [3081285] MULTIPLAN INC [308128501] 5.36 percent of total billed charges 3.5 5.36 Technical (Hospital) Services ASPIRIN 325 MG TABLET RX-681 CDM 2590000100 HCPCS 259 RC 57896-0901-01 NDC outpatient 1 UN 5.64 5.64 CIGNA 62308 [3081051] CIGNA 62308 [308105105] 4.51 percent of total billed charges 3.5 5.36 Technical (Hospital) Services ASPIRIN 325 MG TABLET RX-681 CDM 2590000100 HCPCS 259 RC 57896-0901-01 NDC outpatient 1 UN 5.64 5.64 CIGNA 62308 [3081051] CIGNA STATE OF WYOMING [308105107] 4.51 percent of total billed charges 3.5 5.36 Technical (Hospital) Services ASPIRIN 325 MG TABLET RX-681 CDM 2590000100 HCPCS 259 RC 57896-0901-01 NDC outpatient 1 UN 5.64 5.64 HEALTHPARTNERS SX009 HEALTHPARTNERS 4.51 percent of total billed charges 3.5 5.36 Technical (Hospital) Services ASPIRIN 325 MG TABLET RX-681 CDM 2590000100 HCPCS 259 RC 57896-0901-01 NDC outpatient 1 UN 5.64 5.64 UNITED HEALTHCARE (COMMERCIAL) [3081199] UNITED HEALTHCARE 87726 [308119901] 3.5 percent of total billed charges 3.5 5.36 Technical (Hospital) Services ASPIRIN 325 MG TABLET RX-681 CDM 2590000100 HCPCS 259 RC 57896-0901-01 NDC outpatient 1 UN 5.64 5.64 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES PPO [308136801] 4.51 percent of total billed charges 3.5 5.36 Technical (Hospital) Services ASPIRIN 325 MG TABLET RX-681 CDM 2590000100 HCPCS 259 RC 57896-0901-01 NDC outpatient 1 UN 5.64 5.64 BLUE CROSS BLUE SHIELD WELLMARK SB889 [3081026] BCBS WYOMING [308102603] 5.36 percent of total billed charges 3.5 5.36 Technical (Hospital) Services ASPIRIN 325 MG TABLET RX-681 CDM 2590000100 HCPCS 259 RC 57896-0901-01 NDC outpatient 1 UN 5.64 5.64 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES EPO [308136803] 4.51 percent of total billed charges 3.5 5.36 Technical (Hospital) Services ASPIRIN 325 MG TABLET RX-681 CDM 2590000100 HCPCS 259 RC 57896-0901-01 NDC outpatient 1 UN 5.64 5.64 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES HDHP [308136802] 4.51 percent of total billed charges 3.5 5.36 Technical (Hospital) Services "ASPIRIN 325 MG TABLET,DELAYED RELEASE" RX-685 CDM 2590000100 HCPCS 259 RC 57896-0921-01 NDC inpatient 1 UN 5.64 5.64 CIGNA 62308 [3081051] CIGNA 62308 [308105105] 4.47 percent of total billed charges 3.5 5.36 Technical (Hospital) Services "ASPIRIN 325 MG TABLET,DELAYED RELEASE" RX-685 CDM 2590000100 HCPCS 259 RC 57896-0921-01 NDC inpatient 1 UN 5.64 5.64 CIGNA 62308 [3081051] CIGNA STATE OF WYOMING [308105107] 4.47 percent of total billed charges 3.5 5.36 Technical (Hospital) Services "ASPIRIN 325 MG TABLET,DELAYED RELEASE" RX-685 CDM 2590000100 HCPCS 259 RC 57896-0921-01 NDC inpatient 1 UN 5.64 5.64 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES EPO [308136803] 4.47 percent of total billed charges 3.5 5.36 Technical (Hospital) Services "ASPIRIN 325 MG TABLET,DELAYED RELEASE" RX-685 CDM 2590000100 HCPCS 259 RC 57896-0921-01 NDC inpatient 1 UN 5.64 5.64 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES HDHP [308136802] 4.47 percent of total billed charges 3.5 5.36 Technical (Hospital) Services "ASPIRIN 325 MG TABLET,DELAYED RELEASE" RX-685 CDM 2590000100 HCPCS 259 RC 57896-0921-01 NDC inpatient 1 UN 5.64 5.64 BLUE CROSS BLUE SHIELD WELLMARK SB889 [3081026] BCBS WYOMING [308102603] 5.36 percent of total billed charges 3.5 5.36 Technical (Hospital) Services "ASPIRIN 325 MG TABLET,DELAYED RELEASE" RX-685 CDM 2590000100 HCPCS 259 RC 57896-0921-01 NDC inpatient 1 UN 5.64 5.64 UNITED HEALTHCARE (COMMERCIAL) [3081199] UNITED HEALTHCARE 87726 [308119901] 3.5 percent of total billed charges 3.5 5.36 Technical (Hospital) Services "ASPIRIN 325 MG TABLET,DELAYED RELEASE" RX-685 CDM 2590000100 HCPCS 259 RC 57896-0921-01 NDC inpatient 1 UN 5.64 5.64 MULTIPLAN INC 34080 [3081285] MULTIPLAN INC [308128501] 5.36 percent of total billed charges 3.5 5.36 Technical (Hospital) Services "ASPIRIN 325 MG TABLET,DELAYED RELEASE" RX-685 CDM 2590000100 HCPCS 259 RC 57896-0921-01 NDC inpatient 1 UN 5.64 5.64 MEDICA (COMMERCIAL) 94265 [3081118] MEDICA CLAIMS [308111801] 5.08 percent of total billed charges 3.5 5.36 Technical (Hospital) Services "ASPIRIN 325 MG TABLET,DELAYED RELEASE" RX-685 CDM 2590000100 HCPCS 259 RC 57896-0921-01 NDC inpatient 1 UN 5.64 5.64 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES PPO [308136801] 4.47 percent of total billed charges 3.5 5.36 Technical (Hospital) Services "ASPIRIN 325 MG TABLET,DELAYED RELEASE" RX-685 CDM 2590000100 HCPCS 259 RC 57896-0921-01 NDC inpatient 1 UN 5.64 5.64 HEALTHPARTNERS SX009 HEALTHPARTNERS 4.47 percent of total billed charges 3.5 5.36 Technical (Hospital) Services "ASPIRIN 325 MG TABLET,DELAYED RELEASE" RX-685 CDM 2590000100 HCPCS 259 RC 57896-0921-01 NDC outpatient 1 UN 5.64 5.64 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES HDHP [308136802] 4.51 percent of total billed charges 3.5 5.36 Technical (Hospital) Services "ASPIRIN 325 MG TABLET,DELAYED RELEASE" RX-685 CDM 2590000100 HCPCS 259 RC 57896-0921-01 NDC outpatient 1 UN 5.64 5.64 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES EPO [308136803] 4.51 percent of total billed charges 3.5 5.36 Technical (Hospital) Services "ASPIRIN 325 MG TABLET,DELAYED RELEASE" RX-685 CDM 2590000100 HCPCS 259 RC 57896-0921-01 NDC outpatient 1 UN 5.64 5.64 BLUE CROSS BLUE SHIELD WELLMARK SB889 [3081026] BCBS WYOMING [308102603] 5.36 percent of total billed charges 3.5 5.36 Technical (Hospital) Services "ASPIRIN 325 MG TABLET,DELAYED RELEASE" RX-685 CDM 2590000100 HCPCS 259 RC 57896-0921-01 NDC outpatient 1 UN 5.64 5.64 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES PPO [308136801] 4.51 percent of total billed charges 3.5 5.36 Technical (Hospital) Services "ASPIRIN 325 MG TABLET,DELAYED RELEASE" RX-685 CDM 2590000100 HCPCS 259 RC 57896-0921-01 NDC outpatient 1 UN 5.64 5.64 UNITED HEALTHCARE (COMMERCIAL) [3081199] UNITED HEALTHCARE 87726 [308119901] 3.5 percent of total billed charges 3.5 5.36 Technical (Hospital) Services "ASPIRIN 325 MG TABLET,DELAYED RELEASE" RX-685 CDM 2590000100 HCPCS 259 RC 57896-0921-01 NDC outpatient 1 UN 5.64 5.64 HEALTHPARTNERS SX009 HEALTHPARTNERS 4.51 percent of total billed charges 3.5 5.36 Technical (Hospital) Services "ASPIRIN 325 MG TABLET,DELAYED RELEASE" RX-685 CDM 2590000100 HCPCS 259 RC 57896-0921-01 NDC outpatient 1 UN 5.64 5.64 CIGNA 62308 [3081051] CIGNA 62308 [308105105] 4.51 percent of total billed charges 3.5 5.36 Technical (Hospital) Services "ASPIRIN 325 MG TABLET,DELAYED RELEASE" RX-685 CDM 2590000100 HCPCS 259 RC 57896-0921-01 NDC outpatient 1 UN 5.64 5.64 CIGNA 62308 [3081051] CIGNA STATE OF WYOMING [308105107] 4.51 percent of total billed charges 3.5 5.36 Technical (Hospital) Services "ASPIRIN 325 MG TABLET,DELAYED RELEASE" RX-685 CDM 2590000100 HCPCS 259 RC 57896-0921-01 NDC outpatient 1 UN 5.64 5.64 MULTIPLAN INC 34080 [3081285] MULTIPLAN INC [308128501] 5.36 percent of total billed charges 3.5 5.36 Technical (Hospital) Services "ASPIRIN 325 MG TABLET,DELAYED RELEASE" RX-685 CDM 2590000100 HCPCS 259 RC 57896-0921-01 NDC outpatient 1 UN 5.64 5.64 MEDICA (COMMERCIAL) 94265 [3081118] MEDICA CLAIMS [308111801] 5.08 percent of total billed charges 3.5 5.36 Technical (Hospital) Services ASPIRIN 300 MG RECTAL SUPPOSITORY RX-693 CDM 2590000100 HCPCS 259 RC 00574-7034-12 NDC inpatient 1 UN 6.79 6.79 BLUE CROSS BLUE SHIELD WELLMARK SB889 [3081026] BCBS WYOMING [308102603] 6.45 percent of total billed charges 4.21 6.45 Technical (Hospital) Services ASPIRIN 300 MG RECTAL SUPPOSITORY RX-693 CDM 2590000100 HCPCS 259 RC 00574-7034-12 NDC inpatient 1 UN 6.79 6.79 UNITED HEALTHCARE (COMMERCIAL) [3081199] UNITED HEALTHCARE 87726 [308119901] 4.21 percent of total billed charges 4.21 6.45 Technical (Hospital) Services ASPIRIN 300 MG RECTAL SUPPOSITORY RX-693 CDM 2590000100 HCPCS 259 RC 00574-7034-12 NDC inpatient 1 UN 6.79 6.79 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES EPO [308136803] 5.38 percent of total billed charges 4.21 6.45 Technical (Hospital) Services ASPIRIN 300 MG RECTAL SUPPOSITORY RX-693 CDM 2590000100 HCPCS 259 RC 00574-7034-12 NDC inpatient 1 UN 6.79 6.79 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES HDHP [308136802] 5.38 percent of total billed charges 4.21 6.45 Technical (Hospital) Services ASPIRIN 300 MG RECTAL SUPPOSITORY RX-693 CDM 2590000100 HCPCS 259 RC 00574-7034-12 NDC inpatient 1 UN 6.79 6.79 CIGNA 62308 [3081051] CIGNA 62308 [308105105] 5.38 percent of total billed charges 4.21 6.45 Technical (Hospital) Services ASPIRIN 300 MG RECTAL SUPPOSITORY RX-693 CDM 2590000100 HCPCS 259 RC 00574-7034-12 NDC inpatient 1 UN 6.79 6.79 CIGNA 62308 [3081051] CIGNA STATE OF WYOMING [308105107] 5.38 percent of total billed charges 4.21 6.45 Technical (Hospital) Services ASPIRIN 300 MG RECTAL SUPPOSITORY RX-693 CDM 2590000100 HCPCS 259 RC 00574-7034-12 NDC inpatient 1 UN 6.79 6.79 MULTIPLAN INC 34080 [3081285] MULTIPLAN INC [308128501] 6.45 percent of total billed charges 4.21 6.45 Technical (Hospital) Services ASPIRIN 300 MG RECTAL SUPPOSITORY RX-693 CDM 2590000100 HCPCS 259 RC 00574-7034-12 NDC inpatient 1 UN 6.79 6.79 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES PPO [308136801] 5.38 percent of total billed charges 4.21 6.45 Technical (Hospital) Services ASPIRIN 300 MG RECTAL SUPPOSITORY RX-693 CDM 2590000100 HCPCS 259 RC 00574-7034-12 NDC inpatient 1 UN 6.79 6.79 HEALTHPARTNERS SX009 HEALTHPARTNERS 5.38 percent of total billed charges 4.21 6.45 Technical (Hospital) Services ASPIRIN 300 MG RECTAL SUPPOSITORY RX-693 CDM 2590000100 HCPCS 259 RC 00574-7034-12 NDC inpatient 1 UN 6.79 6.79 MEDICA (COMMERCIAL) 94265 [3081118] MEDICA CLAIMS [308111801] 6.11 percent of total billed charges 4.21 6.45 Technical (Hospital) Services ASPIRIN 300 MG RECTAL SUPPOSITORY RX-693 CDM 2590000100 HCPCS 259 RC 00574-7034-12 NDC outpatient 1 UN 6.79 6.79 MEDICA (COMMERCIAL) 94265 [3081118] MEDICA CLAIMS [308111801] 6.11 percent of total billed charges 4.21 6.45 Technical (Hospital) Services ASPIRIN 300 MG RECTAL SUPPOSITORY RX-693 CDM 2590000100 HCPCS 259 RC 00574-7034-12 NDC outpatient 1 UN 6.79 6.79 MULTIPLAN INC 34080 [3081285] MULTIPLAN INC [308128501] 6.45 percent of total billed charges 4.21 6.45 Technical (Hospital) Services ASPIRIN 300 MG RECTAL SUPPOSITORY RX-693 CDM 2590000100 HCPCS 259 RC 00574-7034-12 NDC outpatient 1 UN 6.79 6.79 CIGNA 62308 [3081051] CIGNA 62308 [308105105] 5.43 percent of total billed charges 4.21 6.45 Technical (Hospital) Services ASPIRIN 300 MG RECTAL SUPPOSITORY RX-693 CDM 2590000100 HCPCS 259 RC 00574-7034-12 NDC outpatient 1 UN 6.79 6.79 CIGNA 62308 [3081051] CIGNA STATE OF WYOMING [308105107] 5.43 percent of total billed charges 4.21 6.45 Technical (Hospital) Services ASPIRIN 300 MG RECTAL SUPPOSITORY RX-693 CDM 2590000100 HCPCS 259 RC 00574-7034-12 NDC outpatient 1 UN 6.79 6.79 HEALTHPARTNERS SX009 HEALTHPARTNERS 5.43 percent of total billed charges 4.21 6.45 Technical (Hospital) Services ASPIRIN 300 MG RECTAL SUPPOSITORY RX-693 CDM 2590000100 HCPCS 259 RC 00574-7034-12 NDC outpatient 1 UN 6.79 6.79 UNITED HEALTHCARE (COMMERCIAL) [3081199] UNITED HEALTHCARE 87726 [308119901] 4.21 percent of total billed charges 4.21 6.45 Technical (Hospital) Services ASPIRIN 300 MG RECTAL SUPPOSITORY RX-693 CDM 2590000100 HCPCS 259 RC 00574-7034-12 NDC outpatient 1 UN 6.79 6.79 BLUE CROSS BLUE SHIELD WELLMARK SB889 [3081026] BCBS WYOMING [308102603] 6.45 percent of total billed charges 4.21 6.45 Technical (Hospital) Services ASPIRIN 300 MG RECTAL SUPPOSITORY RX-693 CDM 2590000100 HCPCS 259 RC 00574-7034-12 NDC outpatient 1 UN 6.79 6.79 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES PPO [308136801] 5.43 percent of total billed charges 4.21 6.45 Technical (Hospital) Services ASPIRIN 300 MG RECTAL SUPPOSITORY RX-693 CDM 2590000100 HCPCS 259 RC 00574-7034-12 NDC outpatient 1 UN 6.79 6.79 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES EPO [308136803] 5.43 percent of total billed charges 4.21 6.45 Technical (Hospital) Services ASPIRIN 300 MG RECTAL SUPPOSITORY RX-693 CDM 2590000100 HCPCS 259 RC 00574-7034-12 NDC outpatient 1 UN 6.79 6.79 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES HDHP [308136802] 5.43 percent of total billed charges 4.21 6.45 Technical (Hospital) Services "CHOLECALCIFEROL (VITAMIN D3) 25 MCG (1,000 UNIT) TABLET" RX-76950 CDM 2590000100 HCPCS 259 RC 79854-0050-23 NDC inpatient 1 UN 5.65 5.65 UNITED HEALTHCARE (COMMERCIAL) [3081199] UNITED HEALTHCARE 87726 [308119901] 3.5 percent of total billed charges 3.5 5.37 Technical (Hospital) Services "CHOLECALCIFEROL (VITAMIN D3) 25 MCG (1,000 UNIT) TABLET" RX-76950 CDM 2590000100 HCPCS 259 RC 79854-0050-23 NDC inpatient 1 UN 5.65 5.65 BLUE CROSS BLUE SHIELD WELLMARK SB889 [3081026] BCBS WYOMING [308102603] 5.37 percent of total billed charges 3.5 5.37 Technical (Hospital) Services "CHOLECALCIFEROL (VITAMIN D3) 25 MCG (1,000 UNIT) TABLET" RX-76950 CDM 2590000100 HCPCS 259 RC 79854-0050-23 NDC inpatient 1 UN 5.65 5.65 CIGNA 62308 [3081051] CIGNA 62308 [308105105] 4.47 percent of total billed charges 3.5 5.37 Technical (Hospital) Services "CHOLECALCIFEROL (VITAMIN D3) 25 MCG (1,000 UNIT) TABLET" RX-76950 CDM 2590000100 HCPCS 259 RC 79854-0050-23 NDC inpatient 1 UN 5.65 5.65 CIGNA 62308 [3081051] CIGNA STATE OF WYOMING [308105107] 4.47 percent of total billed charges 3.5 5.37 Technical (Hospital) Services "CHOLECALCIFEROL (VITAMIN D3) 25 MCG (1,000 UNIT) TABLET" RX-76950 CDM 2590000100 HCPCS 259 RC 79854-0050-23 NDC inpatient 1 UN 5.65 5.65 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES EPO [308136803] 4.47 percent of total billed charges 3.5 5.37 Technical (Hospital) Services "CHOLECALCIFEROL (VITAMIN D3) 25 MCG (1,000 UNIT) TABLET" RX-76950 CDM 2590000100 HCPCS 259 RC 79854-0050-23 NDC inpatient 1 UN 5.65 5.65 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES HDHP [308136802] 4.47 percent of total billed charges 3.5 5.37 Technical (Hospital) Services "CHOLECALCIFEROL (VITAMIN D3) 25 MCG (1,000 UNIT) TABLET" RX-76950 CDM 2590000100 HCPCS 259 RC 79854-0050-23 NDC inpatient 1 UN 5.65 5.65 MULTIPLAN INC 34080 [3081285] MULTIPLAN INC [308128501] 5.37 percent of total billed charges 3.5 5.37 Technical (Hospital) Services "CHOLECALCIFEROL (VITAMIN D3) 25 MCG (1,000 UNIT) TABLET" RX-76950 CDM 2590000100 HCPCS 259 RC 79854-0050-23 NDC inpatient 1 UN 5.65 5.65 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES PPO [308136801] 4.47 percent of total billed charges 3.5 5.37 Technical (Hospital) Services "CHOLECALCIFEROL (VITAMIN D3) 25 MCG (1,000 UNIT) TABLET" RX-76950 CDM 2590000100 HCPCS 259 RC 79854-0050-23 NDC inpatient 1 UN 5.65 5.65 MEDICA (COMMERCIAL) 94265 [3081118] MEDICA CLAIMS [308111801] 5.09 percent of total billed charges 3.5 5.37 Technical (Hospital) Services "CHOLECALCIFEROL (VITAMIN D3) 25 MCG (1,000 UNIT) TABLET" RX-76950 CDM 2590000100 HCPCS 259 RC 79854-0050-23 NDC inpatient 1 UN 5.65 5.65 HEALTHPARTNERS SX009 HEALTHPARTNERS 4.47 percent of total billed charges 3.5 5.37 Technical (Hospital) Services "CHOLECALCIFEROL (VITAMIN D3) 25 MCG (1,000 UNIT) TABLET" RX-76950 CDM 2590000100 HCPCS 259 RC 79854-0050-23 NDC outpatient 1 UN 5.65 5.65 MULTIPLAN INC 34080 [3081285] MULTIPLAN INC [308128501] 5.37 percent of total billed charges 3.5 5.37 Technical (Hospital) Services "CHOLECALCIFEROL (VITAMIN D3) 25 MCG (1,000 UNIT) TABLET" RX-76950 CDM 2590000100 HCPCS 259 RC 79854-0050-23 NDC outpatient 1 UN 5.65 5.65 CIGNA 62308 [3081051] CIGNA 62308 [308105105] 4.52 percent of total billed charges 3.5 5.37 Technical (Hospital) Services "CHOLECALCIFEROL (VITAMIN D3) 25 MCG (1,000 UNIT) TABLET" RX-76950 CDM 2590000100 HCPCS 259 RC 79854-0050-23 NDC outpatient 1 UN 5.65 5.65 CIGNA 62308 [3081051] CIGNA STATE OF WYOMING [308105107] 4.52 percent of total billed charges 3.5 5.37 Technical (Hospital) Services "CHOLECALCIFEROL (VITAMIN D3) 25 MCG (1,000 UNIT) TABLET" RX-76950 CDM 2590000100 HCPCS 259 RC 79854-0050-23 NDC outpatient 1 UN 5.65 5.65 MEDICA (COMMERCIAL) 94265 [3081118] MEDICA CLAIMS [308111801] 5.09 percent of total billed charges 3.5 5.37 Technical (Hospital) Services "CHOLECALCIFEROL (VITAMIN D3) 25 MCG (1,000 UNIT) TABLET" RX-76950 CDM 2590000100 HCPCS 259 RC 79854-0050-23 NDC outpatient 1 UN 5.65 5.65 HEALTHPARTNERS SX009 HEALTHPARTNERS 4.52 percent of total billed charges 3.5 5.37 Technical (Hospital) Services "CHOLECALCIFEROL (VITAMIN D3) 25 MCG (1,000 UNIT) TABLET" RX-76950 CDM 2590000100 HCPCS 259 RC 79854-0050-23 NDC outpatient 1 UN 5.65 5.65 UNITED HEALTHCARE (COMMERCIAL) [3081199] UNITED HEALTHCARE 87726 [308119901] 3.5 percent of total billed charges 3.5 5.37 Technical (Hospital) Services "CHOLECALCIFEROL (VITAMIN D3) 25 MCG (1,000 UNIT) TABLET" RX-76950 CDM 2590000100 HCPCS 259 RC 79854-0050-23 NDC outpatient 1 UN 5.65 5.65 BLUE CROSS BLUE SHIELD WELLMARK SB889 [3081026] BCBS WYOMING [308102603] 5.37 percent of total billed charges 3.5 5.37 Technical (Hospital) Services "CHOLECALCIFEROL (VITAMIN D3) 25 MCG (1,000 UNIT) TABLET" RX-76950 CDM 2590000100 HCPCS 259 RC 79854-0050-23 NDC outpatient 1 UN 5.65 5.65 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES PPO [308136801] 4.52 percent of total billed charges 3.5 5.37 Technical (Hospital) Services "CHOLECALCIFEROL (VITAMIN D3) 25 MCG (1,000 UNIT) TABLET" RX-76950 CDM 2590000100 HCPCS 259 RC 79854-0050-23 NDC outpatient 1 UN 5.65 5.65 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES HDHP [308136802] 4.52 percent of total billed charges 3.5 5.37 Technical (Hospital) Services "CHOLECALCIFEROL (VITAMIN D3) 25 MCG (1,000 UNIT) TABLET" RX-76950 CDM 2590000100 HCPCS 259 RC 79854-0050-23 NDC outpatient 1 UN 5.65 5.65 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES EPO [308136803] 4.52 percent of total billed charges 3.5 5.37 Technical (Hospital) Services ZINC GLUCONATE 50 MG TABLET RX-8872 CDM 2590000100 HCPCS 259 RC 74312-0020-60 NDC inpatient 1 UN 5.66 5.66 BLUE CROSS BLUE SHIELD WELLMARK SB889 [3081026] BCBS WYOMING [308102603] 5.38 percent of total billed charges 3.51 5.38 Technical (Hospital) Services ZINC GLUCONATE 50 MG TABLET RX-8872 CDM 2590000100 HCPCS 259 RC 74312-0020-60 NDC inpatient 1 UN 5.66 5.66 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES EPO [308136803] 4.48 percent of total billed charges 3.51 5.38 Technical (Hospital) Services ZINC GLUCONATE 50 MG TABLET RX-8872 CDM 2590000100 HCPCS 259 RC 74312-0020-60 NDC inpatient 1 UN 5.66 5.66 UNITED HEALTHCARE (COMMERCIAL) [3081199] UNITED HEALTHCARE 87726 [308119901] 3.51 percent of total billed charges 3.51 5.38 Technical (Hospital) Services ZINC GLUCONATE 50 MG TABLET RX-8872 CDM 2590000100 HCPCS 259 RC 74312-0020-60 NDC outpatient 1 UN 5.66 5.66 HEALTHPARTNERS SX009 HEALTHPARTNERS 4.53 percent of total billed charges 3.51 5.38 Technical (Hospital) Services ZINC GLUCONATE 50 MG TABLET RX-8872 CDM 2590000100 HCPCS 259 RC 74312-0020-60 NDC outpatient 1 UN 5.66 5.66 UNITED HEALTHCARE (COMMERCIAL) [3081199] UNITED HEALTHCARE 87726 [308119901] 3.51 percent of total billed charges 3.51 5.38 Technical (Hospital) Services ZINC GLUCONATE 50 MG TABLET RX-8872 CDM 2590000100 HCPCS 259 RC 74312-0020-60 NDC outpatient 1 UN 5.66 5.66 MULTIPLAN INC 34080 [3081285] MULTIPLAN INC [308128501] 5.38 percent of total billed charges 3.51 5.38 Technical (Hospital) Services ZINC GLUCONATE 50 MG TABLET RX-8872 CDM 2590000100 HCPCS 259 RC 74312-0020-60 NDC inpatient 1 UN 5.66 5.66 CIGNA 62308 [3081051] CIGNA 62308 [308105105] 4.48 percent of total billed charges 3.51 5.38 Technical (Hospital) Services ZINC GLUCONATE 50 MG TABLET RX-8872 CDM 2590000100 HCPCS 259 RC 74312-0020-60 NDC inpatient 1 UN 5.66 5.66 CIGNA 62308 [3081051] CIGNA STATE OF WYOMING [308105107] 4.48 percent of total billed charges 3.51 5.38 Technical (Hospital) Services ZINC GLUCONATE 50 MG TABLET RX-8872 CDM 2590000100 HCPCS 259 RC 74312-0020-60 NDC inpatient 1 UN 5.66 5.66 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES HDHP [308136802] 4.48 percent of total billed charges 3.51 5.38 Technical (Hospital) Services ZINC GLUCONATE 50 MG TABLET RX-8872 CDM 2590000100 HCPCS 259 RC 74312-0020-60 NDC inpatient 1 UN 5.66 5.66 MULTIPLAN INC 34080 [3081285] MULTIPLAN INC [308128501] 5.38 percent of total billed charges 3.51 5.38 Technical (Hospital) Services ZINC GLUCONATE 50 MG TABLET RX-8872 CDM 2590000100 HCPCS 259 RC 74312-0020-60 NDC inpatient 1 UN 5.66 5.66 MEDICA (COMMERCIAL) 94265 [3081118] MEDICA CLAIMS [308111801] 5.09 percent of total billed charges 3.51 5.38 Technical (Hospital) Services ZINC GLUCONATE 50 MG TABLET RX-8872 CDM 2590000100 HCPCS 259 RC 74312-0020-60 NDC inpatient 1 UN 5.66 5.66 HEALTHPARTNERS SX009 HEALTHPARTNERS 4.48 percent of total billed charges 3.51 5.38 Technical (Hospital) Services ZINC GLUCONATE 50 MG TABLET RX-8872 CDM 2590000100 HCPCS 259 RC 74312-0020-60 NDC inpatient 1 UN 5.66 5.66 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES PPO [308136801] 4.48 percent of total billed charges 3.51 5.38 Technical (Hospital) Services ZINC GLUCONATE 50 MG TABLET RX-8872 CDM 2590000100 HCPCS 259 RC 74312-0020-60 NDC outpatient 1 UN 5.66 5.66 CIGNA 62308 [3081051] CIGNA 62308 [308105105] 4.53 percent of total billed charges 3.51 5.38 Technical (Hospital) Services ZINC GLUCONATE 50 MG TABLET RX-8872 CDM 2590000100 HCPCS 259 RC 74312-0020-60 NDC outpatient 1 UN 5.66 5.66 CIGNA 62308 [3081051] CIGNA STATE OF WYOMING [308105107] 4.53 percent of total billed charges 3.51 5.38 Technical (Hospital) Services ZINC GLUCONATE 50 MG TABLET RX-8872 CDM 2590000100 HCPCS 259 RC 74312-0020-60 NDC outpatient 1 UN 5.66 5.66 MEDICA (COMMERCIAL) 94265 [3081118] MEDICA CLAIMS [308111801] 5.09 percent of total billed charges 3.51 5.38 Technical (Hospital) Services ZINC GLUCONATE 50 MG TABLET RX-8872 CDM 2590000100 HCPCS 259 RC 74312-0020-60 NDC outpatient 1 UN 5.66 5.66 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES PPO [308136801] 4.53 percent of total billed charges 3.51 5.38 Technical (Hospital) Services ZINC GLUCONATE 50 MG TABLET RX-8872 CDM 2590000100 HCPCS 259 RC 74312-0020-60 NDC outpatient 1 UN 5.66 5.66 BLUE CROSS BLUE SHIELD WELLMARK SB889 [3081026] BCBS WYOMING [308102603] 5.38 percent of total billed charges 3.51 5.38 Technical (Hospital) Services ZINC GLUCONATE 50 MG TABLET RX-8872 CDM 2590000100 HCPCS 259 RC 74312-0020-60 NDC outpatient 1 UN 5.66 5.66 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES HDHP [308136802] 4.53 percent of total billed charges 3.51 5.38 Technical (Hospital) Services ZINC GLUCONATE 50 MG TABLET RX-8872 CDM 2590000100 HCPCS 259 RC 74312-0020-60 NDC outpatient 1 UN 5.66 5.66 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES EPO [308136803] 4.53 percent of total billed charges 3.51 5.38 Technical (Hospital) Services NON FORMULARY RX-900003 CDM 2590000100 HCPCS 259 RC 99999-9999-99 NDC outpatient 1 UN 5.62 5.62 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES EPO [308136803] 4.5 percent of total billed charges 3.48 5.34 Technical (Hospital) Services NON FORMULARY RX-900003 CDM 2590000100 HCPCS 259 RC 99999-9999-99 NDC outpatient 1 UN 5.62 5.62 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES HDHP [308136802] 4.5 percent of total billed charges 3.48 5.34 Technical (Hospital) Services NON FORMULARY RX-900003 CDM 2590000100 HCPCS 259 RC 99999-9999-99 NDC outpatient 1 UN 5.62 5.62 HEALTHPARTNERS SX009 HEALTHPARTNERS 4.5 percent of total billed charges 3.48 5.34 Technical (Hospital) Services NON FORMULARY RX-900003 CDM 2590000100 HCPCS 259 RC 99999-9999-99 NDC outpatient 1 UN 5.62 5.62 UNITED HEALTHCARE (COMMERCIAL) [3081199] UNITED HEALTHCARE 87726 [308119901] 3.48 percent of total billed charges 3.48 5.34 Technical (Hospital) Services NON FORMULARY RX-900003 CDM 2590000100 HCPCS 259 RC 99999-9999-99 NDC outpatient 1 UN 5.62 5.62 MEDICA (COMMERCIAL) 94265 [3081118] MEDICA CLAIMS [308111801] 5.06 percent of total billed charges 3.48 5.34 Technical (Hospital) Services NON FORMULARY RX-900003 CDM 2590000100 HCPCS 259 RC 99999-9999-99 NDC outpatient 1 UN 5.62 5.62 MULTIPLAN INC 34080 [3081285] MULTIPLAN INC [308128501] 5.34 percent of total billed charges 3.48 5.34 Technical (Hospital) Services NON FORMULARY RX-900003 CDM 2590000100 HCPCS 259 RC 99999-9999-99 NDC outpatient 1 UN 5.62 5.62 CIGNA 62308 [3081051] CIGNA 62308 [308105105] 4.5 percent of total billed charges 3.48 5.34 Technical (Hospital) Services NON FORMULARY RX-900003 CDM 2590000100 HCPCS 259 RC 99999-9999-99 NDC outpatient 1 UN 5.62 5.62 CIGNA 62308 [3081051] CIGNA STATE OF WYOMING [308105107] 4.5 percent of total billed charges 3.48 5.34 Technical (Hospital) Services NON FORMULARY RX-900003 CDM 2590000100 HCPCS 259 RC 99999-9999-99 NDC outpatient 1 UN 5.62 5.62 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES PPO [308136801] 4.5 percent of total billed charges 3.48 5.34 Technical (Hospital) Services NON FORMULARY RX-900003 CDM 2590000100 HCPCS 259 RC 99999-9999-99 NDC outpatient 1 UN 5.62 5.62 BLUE CROSS BLUE SHIELD WELLMARK SB889 [3081026] BCBS WYOMING [308102603] 5.34 percent of total billed charges 3.48 5.34 Technical (Hospital) Services NON FORMULARY RX-900003 CDM 2590000100 HCPCS 259 RC 99999-9999-99 NDC inpatient 1 UN 5.62 5.62 MULTIPLAN INC 34080 [3081285] MULTIPLAN INC [308128501] 5.34 percent of total billed charges 3.48 5.34 Technical (Hospital) Services NON FORMULARY RX-900003 CDM 2590000100 HCPCS 259 RC 99999-9999-99 NDC inpatient 1 UN 5.62 5.62 BLUE CROSS BLUE SHIELD WELLMARK SB889 [3081026] BCBS WYOMING [308102603] 5.34 percent of total billed charges 3.48 5.34 Technical (Hospital) Services NON FORMULARY RX-900003 CDM 2590000100 HCPCS 259 RC 99999-9999-99 NDC inpatient 1 UN 5.62 5.62 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES EPO [308136803] 4.45 percent of total billed charges 3.48 5.34 Technical (Hospital) Services NON FORMULARY RX-900003 CDM 2590000100 HCPCS 259 RC 99999-9999-99 NDC inpatient 1 UN 5.62 5.62 UNITED HEALTHCARE (COMMERCIAL) [3081199] UNITED HEALTHCARE 87726 [308119901] 3.48 percent of total billed charges 3.48 5.34 Technical (Hospital) Services NON FORMULARY RX-900003 CDM 2590000100 HCPCS 259 RC 99999-9999-99 NDC inpatient 1 UN 5.62 5.62 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES HDHP [308136802] 4.45 percent of total billed charges 3.48 5.34 Technical (Hospital) Services NON FORMULARY RX-900003 CDM 2590000100 HCPCS 259 RC 99999-9999-99 NDC inpatient 1 UN 5.62 5.62 CIGNA 62308 [3081051] CIGNA 62308 [308105105] 4.45 percent of total billed charges 3.48 5.34 Technical (Hospital) Services NON FORMULARY RX-900003 CDM 2590000100 HCPCS 259 RC 99999-9999-99 NDC inpatient 1 UN 5.62 5.62 CIGNA 62308 [3081051] CIGNA STATE OF WYOMING [308105107] 4.45 percent of total billed charges 3.48 5.34 Technical (Hospital) Services NON FORMULARY RX-900003 CDM 2590000100 HCPCS 259 RC 99999-9999-99 NDC inpatient 1 UN 5.62 5.62 HEALTHPARTNERS SX009 HEALTHPARTNERS 4.45 percent of total billed charges 3.48 5.34 Technical (Hospital) Services NON FORMULARY RX-900003 CDM 2590000100 HCPCS 259 RC 99999-9999-99 NDC inpatient 1 UN 5.62 5.62 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES PPO [308136801] 4.45 percent of total billed charges 3.48 5.34 Technical (Hospital) Services NON FORMULARY RX-900003 CDM 2590000100 HCPCS 259 RC 99999-9999-99 NDC inpatient 1 UN 5.62 5.62 MEDICA (COMMERCIAL) 94265 [3081118] MEDICA CLAIMS [308111801] 5.06 percent of total billed charges 3.48 5.34 Technical (Hospital) Services MENTHOL 0.44 %-ZINC OXIDE 20.6 % TOPICAL OINTMENT RX-91352 CDM 2590000100 HCPCS 259 RC 46876-0000-40 NDC outpatient 1 GR 5.66 5.66 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES EPO [308136803] 4.53 percent of total billed charges 3.51 5.38 Technical (Hospital) Services MENTHOL 0.44 %-ZINC OXIDE 20.6 % TOPICAL OINTMENT RX-91352 CDM 2590000100 HCPCS 259 RC 46876-0000-40 NDC outpatient 1 GR 5.66 5.66 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES HDHP [308136802] 4.53 percent of total billed charges 3.51 5.38 Technical (Hospital) Services MENTHOL 0.44 %-ZINC OXIDE 20.6 % TOPICAL OINTMENT RX-91352 CDM 2590000100 HCPCS 259 RC 46876-0000-40 NDC outpatient 1 GR 5.66 5.66 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES PPO [308136801] 4.53 percent of total billed charges 3.51 5.38 Technical (Hospital) Services MENTHOL 0.44 %-ZINC OXIDE 20.6 % TOPICAL OINTMENT RX-91352 CDM 2590000100 HCPCS 259 RC 46876-0000-40 NDC outpatient 1 GR 5.66 5.66 BLUE CROSS BLUE SHIELD WELLMARK SB889 [3081026] BCBS WYOMING [308102603] 5.38 percent of total billed charges 3.51 5.38 Technical (Hospital) Services MENTHOL 0.44 %-ZINC OXIDE 20.6 % TOPICAL OINTMENT RX-91352 CDM 2590000100 HCPCS 259 RC 46876-0000-40 NDC outpatient 1 GR 5.66 5.66 UNITED HEALTHCARE (COMMERCIAL) [3081199] UNITED HEALTHCARE 87726 [308119901] 3.51 percent of total billed charges 3.51 5.38 Technical (Hospital) Services MENTHOL 0.44 %-ZINC OXIDE 20.6 % TOPICAL OINTMENT RX-91352 CDM 2590000100 HCPCS 259 RC 46876-0000-40 NDC outpatient 1 GR 5.66 5.66 HEALTHPARTNERS SX009 HEALTHPARTNERS 4.53 percent of total billed charges 3.51 5.38 Technical (Hospital) Services MENTHOL 0.44 %-ZINC OXIDE 20.6 % TOPICAL OINTMENT RX-91352 CDM 2590000100 HCPCS 259 RC 46876-0000-40 NDC outpatient 1 GR 5.66 5.66 MULTIPLAN INC 34080 [3081285] MULTIPLAN INC [308128501] 5.38 percent of total billed charges 3.51 5.38 Technical (Hospital) Services MENTHOL 0.44 %-ZINC OXIDE 20.6 % TOPICAL OINTMENT RX-91352 CDM 2590000100 HCPCS 259 RC 46876-0000-40 NDC outpatient 1 GR 5.66 5.66 CIGNA 62308 [3081051] CIGNA 62308 [308105105] 4.53 percent of total billed charges 3.51 5.38 Technical (Hospital) Services MENTHOL 0.44 %-ZINC OXIDE 20.6 % TOPICAL OINTMENT RX-91352 CDM 2590000100 HCPCS 259 RC 46876-0000-40 NDC outpatient 1 GR 5.66 5.66 CIGNA 62308 [3081051] CIGNA STATE OF WYOMING [308105107] 4.53 percent of total billed charges 3.51 5.38 Technical (Hospital) Services MENTHOL 0.44 %-ZINC OXIDE 20.6 % TOPICAL OINTMENT RX-91352 CDM 2590000100 HCPCS 259 RC 46876-0000-40 NDC outpatient 1 GR 5.66 5.66 MEDICA (COMMERCIAL) 94265 [3081118] MEDICA CLAIMS [308111801] 5.09 percent of total billed charges 3.51 5.38 Technical (Hospital) Services MENTHOL 0.44 %-ZINC OXIDE 20.6 % TOPICAL OINTMENT RX-91352 CDM 2590000100 HCPCS 259 RC 46876-0000-40 NDC inpatient 1 GR 5.66 5.66 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES PPO [308136801] 4.48 percent of total billed charges 3.51 5.38 Technical (Hospital) Services MENTHOL 0.44 %-ZINC OXIDE 20.6 % TOPICAL OINTMENT RX-91352 CDM 2590000100 HCPCS 259 RC 46876-0000-40 NDC inpatient 1 GR 5.66 5.66 HEALTHPARTNERS SX009 HEALTHPARTNERS 4.48 percent of total billed charges 3.51 5.38 Technical (Hospital) Services MENTHOL 0.44 %-ZINC OXIDE 20.6 % TOPICAL OINTMENT RX-91352 CDM 2590000100 HCPCS 259 RC 46876-0000-40 NDC inpatient 1 GR 5.66 5.66 MEDICA (COMMERCIAL) 94265 [3081118] MEDICA CLAIMS [308111801] 5.09 percent of total billed charges 3.51 5.38 Technical (Hospital) Services MENTHOL 0.44 %-ZINC OXIDE 20.6 % TOPICAL OINTMENT RX-91352 CDM 2590000100 HCPCS 259 RC 46876-0000-40 NDC inpatient 1 GR 5.66 5.66 MULTIPLAN INC 34080 [3081285] MULTIPLAN INC [308128501] 5.38 percent of total billed charges 3.51 5.38 Technical (Hospital) Services MENTHOL 0.44 %-ZINC OXIDE 20.6 % TOPICAL OINTMENT RX-91352 CDM 2590000100 HCPCS 259 RC 46876-0000-40 NDC inpatient 1 GR 5.66 5.66 UNITED HEALTHCARE (COMMERCIAL) [3081199] UNITED HEALTHCARE 87726 [308119901] 3.51 percent of total billed charges 3.51 5.38 Technical (Hospital) Services MENTHOL 0.44 %-ZINC OXIDE 20.6 % TOPICAL OINTMENT RX-91352 CDM 2590000100 HCPCS 259 RC 46876-0000-40 NDC inpatient 1 GR 5.66 5.66 BLUE CROSS BLUE SHIELD WELLMARK SB889 [3081026] BCBS WYOMING [308102603] 5.38 percent of total billed charges 3.51 5.38 Technical (Hospital) Services MENTHOL 0.44 %-ZINC OXIDE 20.6 % TOPICAL OINTMENT RX-91352 CDM 2590000100 HCPCS 259 RC 46876-0000-40 NDC inpatient 1 GR 5.66 5.66 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES HDHP [308136802] 4.48 percent of total billed charges 3.51 5.38 Technical (Hospital) Services MENTHOL 0.44 %-ZINC OXIDE 20.6 % TOPICAL OINTMENT RX-91352 CDM 2590000100 HCPCS 259 RC 46876-0000-40 NDC inpatient 1 GR 5.66 5.66 CIGNA 62308 [3081051] CIGNA 62308 [308105105] 4.48 percent of total billed charges 3.51 5.38 Technical (Hospital) Services MENTHOL 0.44 %-ZINC OXIDE 20.6 % TOPICAL OINTMENT RX-91352 CDM 2590000100 HCPCS 259 RC 46876-0000-40 NDC inpatient 1 GR 5.66 5.66 CIGNA 62308 [3081051] CIGNA STATE OF WYOMING [308105107] 4.48 percent of total billed charges 3.51 5.38 Technical (Hospital) Services MENTHOL 0.44 %-ZINC OXIDE 20.6 % TOPICAL OINTMENT RX-91352 CDM 2590000100 HCPCS 259 RC 46876-0000-40 NDC inpatient 1 GR 5.66 5.66 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES EPO [308136803] 4.48 percent of total billed charges 3.51 5.38 Technical (Hospital) Services BENZOCAINE 15 MG-MENTHOL 3.6 MG LOZENGES RX-94141 CDM 2590000100 HCPCS 259 RC 00904-6255-49 NDC outpatient 1 UN 5.78 5.78 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES HDHP [308136802] 4.62 percent of total billed charges 3.58 5.49 Technical (Hospital) Services BENZOCAINE 15 MG-MENTHOL 3.6 MG LOZENGES RX-94141 CDM 2590000100 HCPCS 259 RC 00904-6255-49 NDC outpatient 1 UN 5.78 5.78 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES EPO [308136803] 4.62 percent of total billed charges 3.58 5.49 Technical (Hospital) Services BENZOCAINE 15 MG-MENTHOL 3.6 MG LOZENGES RX-94141 CDM 2590000100 HCPCS 259 RC 00904-6255-49 NDC outpatient 1 UN 5.78 5.78 BLUE CROSS BLUE SHIELD WELLMARK SB889 [3081026] BCBS WYOMING [308102603] 5.49 percent of total billed charges 3.58 5.49 Technical (Hospital) Services BENZOCAINE 15 MG-MENTHOL 3.6 MG LOZENGES RX-94141 CDM 2590000100 HCPCS 259 RC 00904-6255-49 NDC outpatient 1 UN 5.78 5.78 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES PPO [308136801] 4.62 percent of total billed charges 3.58 5.49 Technical (Hospital) Services BENZOCAINE 15 MG-MENTHOL 3.6 MG LOZENGES RX-94141 CDM 2590000100 HCPCS 259 RC 00904-6255-49 NDC outpatient 1 UN 5.78 5.78 UNITED HEALTHCARE (COMMERCIAL) [3081199] UNITED HEALTHCARE 87726 [308119901] 3.58 percent of total billed charges 3.58 5.49 Technical (Hospital) Services BENZOCAINE 15 MG-MENTHOL 3.6 MG LOZENGES RX-94141 CDM 2590000100 HCPCS 259 RC 00904-6255-49 NDC outpatient 1 UN 5.78 5.78 HEALTHPARTNERS SX009 HEALTHPARTNERS 4.62 percent of total billed charges 3.58 5.49 Technical (Hospital) Services BENZOCAINE 15 MG-MENTHOL 3.6 MG LOZENGES RX-94141 CDM 2590000100 HCPCS 259 RC 00904-6255-49 NDC outpatient 1 UN 5.78 5.78 MEDICA (COMMERCIAL) 94265 [3081118] MEDICA CLAIMS [308111801] 5.2 percent of total billed charges 3.58 5.49 Technical (Hospital) Services BENZOCAINE 15 MG-MENTHOL 3.6 MG LOZENGES RX-94141 CDM 2590000100 HCPCS 259 RC 00904-6255-49 NDC outpatient 1 UN 5.78 5.78 MULTIPLAN INC 34080 [3081285] MULTIPLAN INC [308128501] 5.49 percent of total billed charges 3.58 5.49 Technical (Hospital) Services BENZOCAINE 15 MG-MENTHOL 3.6 MG LOZENGES RX-94141 CDM 2590000100 HCPCS 259 RC 00904-6255-49 NDC outpatient 1 UN 5.78 5.78 CIGNA 62308 [3081051] CIGNA 62308 [308105105] 4.62 percent of total billed charges 3.58 5.49 Technical (Hospital) Services BENZOCAINE 15 MG-MENTHOL 3.6 MG LOZENGES RX-94141 CDM 2590000100 HCPCS 259 RC 00904-6255-49 NDC outpatient 1 UN 5.78 5.78 CIGNA 62308 [3081051] CIGNA STATE OF WYOMING [308105107] 4.62 percent of total billed charges 3.58 5.49 Technical (Hospital) Services BENZOCAINE 15 MG-MENTHOL 3.6 MG LOZENGES RX-94141 CDM 2590000100 HCPCS 259 RC 00904-6255-49 NDC inpatient 1 UN 5.78 5.78 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES PPO [308136801] 4.58 percent of total billed charges 3.58 5.49 Technical (Hospital) Services BENZOCAINE 15 MG-MENTHOL 3.6 MG LOZENGES RX-94141 CDM 2590000100 HCPCS 259 RC 00904-6255-49 NDC inpatient 1 UN 5.78 5.78 HEALTHPARTNERS SX009 HEALTHPARTNERS 4.58 percent of total billed charges 3.58 5.49 Technical (Hospital) Services BENZOCAINE 15 MG-MENTHOL 3.6 MG LOZENGES RX-94141 CDM 2590000100 HCPCS 259 RC 00904-6255-49 NDC inpatient 1 UN 5.78 5.78 MEDICA (COMMERCIAL) 94265 [3081118] MEDICA CLAIMS [308111801] 5.2 percent of total billed charges 3.58 5.49 Technical (Hospital) Services BENZOCAINE 15 MG-MENTHOL 3.6 MG LOZENGES RX-94141 CDM 2590000100 HCPCS 259 RC 00904-6255-49 NDC inpatient 1 UN 5.78 5.78 MULTIPLAN INC 34080 [3081285] MULTIPLAN INC [308128501] 5.49 percent of total billed charges 3.58 5.49 Technical (Hospital) Services BENZOCAINE 15 MG-MENTHOL 3.6 MG LOZENGES RX-94141 CDM 2590000100 HCPCS 259 RC 00904-6255-49 NDC inpatient 1 UN 5.78 5.78 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES EPO [308136803] 4.58 percent of total billed charges 3.58 5.49 Technical (Hospital) Services BENZOCAINE 15 MG-MENTHOL 3.6 MG LOZENGES RX-94141 CDM 2590000100 HCPCS 259 RC 00904-6255-49 NDC inpatient 1 UN 5.78 5.78 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES HDHP [308136802] 4.58 percent of total billed charges 3.58 5.49 Technical (Hospital) Services BENZOCAINE 15 MG-MENTHOL 3.6 MG LOZENGES RX-94141 CDM 2590000100 HCPCS 259 RC 00904-6255-49 NDC inpatient 1 UN 5.78 5.78 CIGNA 62308 [3081051] CIGNA 62308 [308105105] 4.58 percent of total billed charges 3.58 5.49 Technical (Hospital) Services BENZOCAINE 15 MG-MENTHOL 3.6 MG LOZENGES RX-94141 CDM 2590000100 HCPCS 259 RC 00904-6255-49 NDC inpatient 1 UN 5.78 5.78 CIGNA 62308 [3081051] CIGNA STATE OF WYOMING [308105107] 4.58 percent of total billed charges 3.58 5.49 Technical (Hospital) Services BENZOCAINE 15 MG-MENTHOL 3.6 MG LOZENGES RX-94141 CDM 2590000100 HCPCS 259 RC 00904-6255-49 NDC inpatient 1 UN 5.78 5.78 BLUE CROSS BLUE SHIELD WELLMARK SB889 [3081026] BCBS WYOMING [308102603] 5.49 percent of total billed charges 3.58 5.49 Technical (Hospital) Services BENZOCAINE 15 MG-MENTHOL 3.6 MG LOZENGES RX-94141 CDM 2590000100 HCPCS 259 RC 00904-6255-49 NDC inpatient 1 UN 5.78 5.78 UNITED HEALTHCARE (COMMERCIAL) [3081199] UNITED HEALTHCARE 87726 [308119901] 3.58 percent of total billed charges 3.58 5.49 Technical (Hospital) Services "OMEGA 3-DHA-EPA-FISH OIL 300 MG-1,000 MG CAPSULE" RX-94548 CDM 2590000100 HCPCS 259 RC 40985-0229-21 NDC outpatient 1 UN 5.66 5.66 BLUE CROSS BLUE SHIELD WELLMARK SB889 [3081026] BCBS WYOMING [308102603] 5.38 percent of total billed charges 3.51 5.38 Technical (Hospital) Services "OMEGA 3-DHA-EPA-FISH OIL 300 MG-1,000 MG CAPSULE" RX-94548 CDM 2590000100 HCPCS 259 RC 40985-0229-21 NDC outpatient 1 UN 5.66 5.66 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES PPO [308136801] 4.53 percent of total billed charges 3.51 5.38 Technical (Hospital) Services "OMEGA 3-DHA-EPA-FISH OIL 300 MG-1,000 MG CAPSULE" RX-94548 CDM 2590000100 HCPCS 259 RC 40985-0229-21 NDC outpatient 1 UN 5.66 5.66 HEALTHPARTNERS SX009 HEALTHPARTNERS 4.53 percent of total billed charges 3.51 5.38 Technical (Hospital) Services "OMEGA 3-DHA-EPA-FISH OIL 300 MG-1,000 MG CAPSULE" RX-94548 CDM 2590000100 HCPCS 259 RC 40985-0229-21 NDC outpatient 1 UN 5.66 5.66 UNITED HEALTHCARE (COMMERCIAL) [3081199] UNITED HEALTHCARE 87726 [308119901] 3.51 percent of total billed charges 3.51 5.38 Technical (Hospital) Services "OMEGA 3-DHA-EPA-FISH OIL 300 MG-1,000 MG CAPSULE" RX-94548 CDM 2590000100 HCPCS 259 RC 40985-0229-21 NDC outpatient 1 UN 5.66 5.66 MEDICA (COMMERCIAL) 94265 [3081118] MEDICA CLAIMS [308111801] 5.09 percent of total billed charges 3.51 5.38 Technical (Hospital) Services "OMEGA 3-DHA-EPA-FISH OIL 300 MG-1,000 MG CAPSULE" RX-94548 CDM 2590000100 HCPCS 259 RC 40985-0229-21 NDC outpatient 1 UN 5.66 5.66 MULTIPLAN INC 34080 [3081285] MULTIPLAN INC [308128501] 5.38 percent of total billed charges 3.51 5.38 Technical (Hospital) Services "OMEGA 3-DHA-EPA-FISH OIL 300 MG-1,000 MG CAPSULE" RX-94548 CDM 2590000100 HCPCS 259 RC 40985-0229-21 NDC outpatient 1 UN 5.66 5.66 CIGNA 62308 [3081051] CIGNA 62308 [308105105] 4.53 percent of total billed charges 3.51 5.38 Technical (Hospital) Services "OMEGA 3-DHA-EPA-FISH OIL 300 MG-1,000 MG CAPSULE" RX-94548 CDM 2590000100 HCPCS 259 RC 40985-0229-21 NDC outpatient 1 UN 5.66 5.66 CIGNA 62308 [3081051] CIGNA STATE OF WYOMING [308105107] 4.53 percent of total billed charges 3.51 5.38 Technical (Hospital) Services "OMEGA 3-DHA-EPA-FISH OIL 300 MG-1,000 MG CAPSULE" RX-94548 CDM 2590000100 HCPCS 259 RC 40985-0229-21 NDC outpatient 1 UN 5.66 5.66 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES HDHP [308136802] 4.53 percent of total billed charges 3.51 5.38 Technical (Hospital) Services "OMEGA 3-DHA-EPA-FISH OIL 300 MG-1,000 MG CAPSULE" RX-94548 CDM 2590000100 HCPCS 259 RC 40985-0229-21 NDC outpatient 1 UN 5.66 5.66 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES EPO [308136803] 4.53 percent of total billed charges 3.51 5.38 Technical (Hospital) Services "OMEGA 3-DHA-EPA-FISH OIL 300 MG-1,000 MG CAPSULE" RX-94548 CDM 2590000100 HCPCS 259 RC 40985-0229-21 NDC inpatient 1 UN 5.66 5.66 MEDICA (COMMERCIAL) 94265 [3081118] MEDICA CLAIMS [308111801] 5.09 percent of total billed charges 3.51 5.38 Technical (Hospital) Services "OMEGA 3-DHA-EPA-FISH OIL 300 MG-1,000 MG CAPSULE" RX-94548 CDM 2590000100 HCPCS 259 RC 40985-0229-21 NDC inpatient 1 UN 5.66 5.66 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES PPO [308136801] 4.48 percent of total billed charges 3.51 5.38 Technical (Hospital) Services "OMEGA 3-DHA-EPA-FISH OIL 300 MG-1,000 MG CAPSULE" RX-94548 CDM 2590000100 HCPCS 259 RC 40985-0229-21 NDC inpatient 1 UN 5.66 5.66 HEALTHPARTNERS SX009 HEALTHPARTNERS 4.48 percent of total billed charges 3.51 5.38 Technical (Hospital) Services "OMEGA 3-DHA-EPA-FISH OIL 300 MG-1,000 MG CAPSULE" RX-94548 CDM 2590000100 HCPCS 259 RC 40985-0229-21 NDC inpatient 1 UN 5.66 5.66 MULTIPLAN INC 34080 [3081285] MULTIPLAN INC [308128501] 5.38 percent of total billed charges 3.51 5.38 Technical (Hospital) Services "OMEGA 3-DHA-EPA-FISH OIL 300 MG-1,000 MG CAPSULE" RX-94548 CDM 2590000100 HCPCS 259 RC 40985-0229-21 NDC inpatient 1 UN 5.66 5.66 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES HDHP [308136802] 4.48 percent of total billed charges 3.51 5.38 Technical (Hospital) Services "OMEGA 3-DHA-EPA-FISH OIL 300 MG-1,000 MG CAPSULE" RX-94548 CDM 2590000100 HCPCS 259 RC 40985-0229-21 NDC inpatient 1 UN 5.66 5.66 UNITED HEALTHCARE (COMMERCIAL) [3081199] UNITED HEALTHCARE 87726 [308119901] 3.51 percent of total billed charges 3.51 5.38 Technical (Hospital) Services "OMEGA 3-DHA-EPA-FISH OIL 300 MG-1,000 MG CAPSULE" RX-94548 CDM 2590000100 HCPCS 259 RC 40985-0229-21 NDC inpatient 1 UN 5.66 5.66 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES EPO [308136803] 4.48 percent of total billed charges 3.51 5.38 Technical (Hospital) Services "OMEGA 3-DHA-EPA-FISH OIL 300 MG-1,000 MG CAPSULE" RX-94548 CDM 2590000100 HCPCS 259 RC 40985-0229-21 NDC inpatient 1 UN 5.66 5.66 CIGNA 62308 [3081051] CIGNA 62308 [308105105] 4.48 percent of total billed charges 3.51 5.38 Technical (Hospital) Services "OMEGA 3-DHA-EPA-FISH OIL 300 MG-1,000 MG CAPSULE" RX-94548 CDM 2590000100 HCPCS 259 RC 40985-0229-21 NDC inpatient 1 UN 5.66 5.66 CIGNA 62308 [3081051] CIGNA STATE OF WYOMING [308105107] 4.48 percent of total billed charges 3.51 5.38 Technical (Hospital) Services "OMEGA 3-DHA-EPA-FISH OIL 300 MG-1,000 MG CAPSULE" RX-94548 CDM 2590000100 HCPCS 259 RC 40985-0229-21 NDC inpatient 1 UN 5.66 5.66 BLUE CROSS BLUE SHIELD WELLMARK SB889 [3081026] BCBS WYOMING [308102603] 5.38 percent of total billed charges 3.51 5.38 Technical (Hospital) Services SODIUM CHLORIDE 0.9 % INTRAVENOUS PIGGYBACK RX-125739 CDM 2580000300 HCPCS 250 RC 00338-0553-18 NDC outpatient 100 ML 0.01 BLUE CROSS BLUE SHIELD WELLMARK SB889 [3081026] BCBS WYOMING [308102603] 0.01 percent of total billed charges 0.01 0.01 Technical (Hospital) Services SODIUM CHLORIDE 0.9 % INTRAVENOUS PIGGYBACK RX-125739 CDM 2580000300 HCPCS 250 RC 00338-0553-18 NDC inpatient 100 ML 0.01 BLUE CROSS BLUE SHIELD WELLMARK SB889 [3081026] BCBS WYOMING [308102603] 0.01 percent of total billed charges 0.01 0.01 Technical (Hospital) Services DEXTROSE 10 % IN WATER (D10W) INTRAVENOUS SOLUTION RX-2357 CDM 2580000300 HCPCS 250 RC 00338-0023-04 NDC outpatient 1000 ML 72.5 BLUE CROSS BLUE SHIELD WELLMARK SB889 [3081026] BCBS WYOMING [308102603] 68.88 percent of total billed charges 68.88 68.88 Technical (Hospital) Services DEXTROSE 10 % IN WATER (D10W) INTRAVENOUS SOLUTION RX-2357 CDM 2580000300 HCPCS 250 RC 00338-0023-04 NDC inpatient 1000 ML 72.5 BLUE CROSS BLUE SHIELD WELLMARK SB889 [3081026] BCBS WYOMING [308102603] 68.88 percent of total billed charges 68.88 68.88 Technical (Hospital) Services DEXTROSE 5 % AND 0.9 % SODIUM CHLORIDE INTRAVENOUS BOLUS RX-4080060007 CDM 2580000300 HCPCS 250 RC 00338-0089-04 NDC outpatient 250 ML 59.8 BLUE CROSS BLUE SHIELD WELLMARK SB889 [3081026] BCBS WYOMING [308102603] 56.81 percent of total billed charges 56.81 56.81 Technical (Hospital) Services DEXTROSE 5 % AND 0.9 % SODIUM CHLORIDE INTRAVENOUS BOLUS RX-4080060007 CDM 2580000300 HCPCS 250 RC 00338-0089-04 NDC inpatient 250 ML 59.8 BLUE CROSS BLUE SHIELD WELLMARK SB889 [3081026] BCBS WYOMING [308102603] 56.81 percent of total billed charges 56.81 56.81 Technical (Hospital) Services SODIUM CHLORIDE 0.45 % INTRAVENOUS SOLUTION RX-7318 CDM 2580000300 HCPCS 250 RC 00338-0043-04 NDC outpatient 1000 ML 70.5 BLUE CROSS BLUE SHIELD WELLMARK SB889 [3081026] BCBS WYOMING [308102603] 66.98 percent of total billed charges 66.98 66.98 Technical (Hospital) Services SODIUM CHLORIDE 0.45 % INTRAVENOUS SOLUTION RX-7318 CDM 2580000300 HCPCS 250 RC 00338-0043-04 NDC inpatient 1000 ML 70.5 BLUE CROSS BLUE SHIELD WELLMARK SB889 [3081026] BCBS WYOMING [308102603] 66.98 percent of total billed charges 66.98 66.98 Technical (Hospital) Services SODIUM CHLORIDE 3 % HYPERTONIC INTRAVENOUS INJECTION SOLUTION RX-7321 CDM 2580000300 HCPCS 250 RC 00338-0054-03 NDC inpatient 500 ML 71 BLUE CROSS BLUE SHIELD WELLMARK SB889 [3081026] BCBS WYOMING [308102603] 67.45 percent of total billed charges 67.45 67.45 Technical (Hospital) Services SODIUM CHLORIDE 3 % HYPERTONIC INTRAVENOUS INJECTION SOLUTION RX-7321 CDM 2580000300 HCPCS 250 RC 00338-0054-03 NDC outpatient 500 ML 71 BLUE CROSS BLUE SHIELD WELLMARK SB889 [3081026] BCBS WYOMING [308102603] 67.45 percent of total billed charges 67.45 67.45 Technical (Hospital) Services DEXTROSE 5 % AND 0.9 % SODIUM CHLORIDE INTRAVENOUS SOLUTION RX-9815 CDM 2580000300 HCPCS 250 RC 00338-0089-04 NDC inpatient 1000 ML 70.5 BLUE CROSS BLUE SHIELD WELLMARK SB889 [3081026] BCBS WYOMING [308102603] 66.98 percent of total billed charges 66.98 66.98 Technical (Hospital) Services DEXTROSE 5 % AND 0.9 % SODIUM CHLORIDE INTRAVENOUS SOLUTION RX-9815 CDM 2580000300 HCPCS 250 RC 00338-0089-04 NDC outpatient 1000 ML 70.5 BLUE CROSS BLUE SHIELD WELLMARK SB889 [3081026] BCBS WYOMING [308102603] 66.98 percent of total billed charges 66.98 66.98 Technical (Hospital) Services SODIUM CHLORIDE 0.9 % INTRAVENOUS PIGGYBACK RX-125739 CDM 2580000300 HCPCS 258 RC 00338-0553-18 NDC inpatient 100 ML 0.01 0.01 HEALTHPARTNERS SX009 HEALTHPARTNERS 0.01 percent of total billed charges 0.01 0.01 Technical (Hospital) Services SODIUM CHLORIDE 0.9 % INTRAVENOUS PIGGYBACK RX-125739 CDM 2580000300 HCPCS 258 RC 00338-0553-18 NDC inpatient 100 ML 0.01 0.01 MULTIPLAN INC 34080 [3081285] MULTIPLAN INC [308128501] 0.01 percent of total billed charges 0.01 0.01 Technical (Hospital) Services SODIUM CHLORIDE 0.9 % INTRAVENOUS PIGGYBACK RX-125739 CDM 2580000300 HCPCS 258 RC 00338-0553-18 NDC inpatient 100 ML 0.01 0.01 MEDICA (COMMERCIAL) 94265 [3081118] MEDICA CLAIMS [308111801] 0.01 percent of total billed charges 0.01 0.01 Technical (Hospital) Services SODIUM CHLORIDE 0.9 % INTRAVENOUS PIGGYBACK RX-125739 CDM 2580000300 HCPCS 258 RC 00338-0553-18 NDC inpatient 100 ML 0.01 0.01 UNITED HEALTHCARE (COMMERCIAL) [3081199] UNITED HEALTHCARE 87726 [308119901] 0.01 percent of total billed charges 0.01 0.01 Technical (Hospital) Services SODIUM CHLORIDE 0.9 % INTRAVENOUS PIGGYBACK RX-125739 CDM 2580000300 HCPCS 258 RC 00338-0553-18 NDC inpatient 100 ML 0.01 0.01 CIGNA 62308 [3081051] CIGNA 62308 [308105105] 0.01 percent of total billed charges 0.01 0.01 Technical (Hospital) Services SODIUM CHLORIDE 0.9 % INTRAVENOUS PIGGYBACK RX-125739 CDM 2580000300 HCPCS 258 RC 00338-0553-18 NDC inpatient 100 ML 0.01 0.01 CIGNA 62308 [3081051] CIGNA STATE OF WYOMING [308105107] 0.01 percent of total billed charges 0.01 0.01 Technical (Hospital) Services SODIUM CHLORIDE 0.9 % INTRAVENOUS PIGGYBACK RX-125739 CDM 2580000300 HCPCS 258 RC 00338-0553-18 NDC inpatient 100 ML 0.01 0.01 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES EPO [308136803] 0.01 percent of total billed charges 0.01 0.01 Technical (Hospital) Services SODIUM CHLORIDE 0.9 % INTRAVENOUS PIGGYBACK RX-125739 CDM 2580000300 HCPCS 258 RC 00338-0553-18 NDC inpatient 100 ML 0.01 0.01 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES HDHP [308136802] 0.01 percent of total billed charges 0.01 0.01 Technical (Hospital) Services SODIUM CHLORIDE 0.9 % INTRAVENOUS PIGGYBACK RX-125739 CDM 2580000300 HCPCS 258 RC 00338-0553-18 NDC inpatient 100 ML 0.01 0.01 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES PPO [308136801] 0.01 percent of total billed charges 0.01 0.01 Technical (Hospital) Services SODIUM CHLORIDE 0.9 % INTRAVENOUS PIGGYBACK RX-125739 CDM 2580000300 HCPCS 258 RC 00338-0553-18 NDC outpatient 100 ML 0.01 0.01 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES PPO [308136801] 0.01 percent of total billed charges 0.01 0.01 Technical (Hospital) Services SODIUM CHLORIDE 0.9 % INTRAVENOUS PIGGYBACK RX-125739 CDM 2580000300 HCPCS 258 RC 00338-0553-18 NDC outpatient 100 ML 0.01 0.01 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES EPO [308136803] 0.01 percent of total billed charges 0.01 0.01 Technical (Hospital) Services SODIUM CHLORIDE 0.9 % INTRAVENOUS PIGGYBACK RX-125739 CDM 2580000300 HCPCS 258 RC 00338-0553-18 NDC outpatient 100 ML 0.01 0.01 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES HDHP [308136802] 0.01 percent of total billed charges 0.01 0.01 Technical (Hospital) Services SODIUM CHLORIDE 0.9 % INTRAVENOUS PIGGYBACK RX-125739 CDM 2580000300 HCPCS 258 RC 00338-0553-18 NDC outpatient 100 ML 0.01 0.01 HEALTHPARTNERS SX009 HEALTHPARTNERS 0.01 percent of total billed charges 0.01 0.01 Technical (Hospital) Services SODIUM CHLORIDE 0.9 % INTRAVENOUS PIGGYBACK RX-125739 CDM 2580000300 HCPCS 258 RC 00338-0553-18 NDC outpatient 100 ML 0.01 0.01 UNITED HEALTHCARE (COMMERCIAL) [3081199] UNITED HEALTHCARE 87726 [308119901] 0.01 percent of total billed charges 0.01 0.01 Technical (Hospital) Services SODIUM CHLORIDE 0.9 % INTRAVENOUS PIGGYBACK RX-125739 CDM 2580000300 HCPCS 258 RC 00338-0553-18 NDC outpatient 100 ML 0.01 0.01 MULTIPLAN INC 34080 [3081285] MULTIPLAN INC [308128501] 0.01 percent of total billed charges 0.01 0.01 Technical (Hospital) Services SODIUM CHLORIDE 0.9 % INTRAVENOUS PIGGYBACK RX-125739 CDM 2580000300 HCPCS 258 RC 00338-0553-18 NDC outpatient 100 ML 0.01 0.01 MEDICA (COMMERCIAL) 94265 [3081118] MEDICA CLAIMS [308111801] 0.01 percent of total billed charges 0.01 0.01 Technical (Hospital) Services SODIUM CHLORIDE 0.9 % INTRAVENOUS PIGGYBACK RX-125739 CDM 2580000300 HCPCS 258 RC 00338-0553-18 NDC outpatient 100 ML 0.01 0.01 CIGNA 62308 [3081051] CIGNA 62308 [308105105] 0.01 percent of total billed charges 0.01 0.01 Technical (Hospital) Services SODIUM CHLORIDE 0.9 % INTRAVENOUS PIGGYBACK RX-125739 CDM 2580000300 HCPCS 258 RC 00338-0553-18 NDC outpatient 100 ML 0.01 0.01 CIGNA 62308 [3081051] CIGNA STATE OF WYOMING [308105107] 0.01 percent of total billed charges 0.01 0.01 Technical (Hospital) Services DEXTROSE 10 % IN WATER (D10W) INTRAVENOUS SOLUTION RX-2357 CDM 2580000300 HCPCS 258 RC 00338-0023-04 NDC outpatient 1000 ML 72.5 72.5 MULTIPLAN INC 34080 [3081285] MULTIPLAN INC [308128501] 68.88 percent of total billed charges 44.95 68.88 Technical (Hospital) Services DEXTROSE 10 % IN WATER (D10W) INTRAVENOUS SOLUTION RX-2357 CDM 2580000300 HCPCS 258 RC 00338-0023-04 NDC outpatient 1000 ML 72.5 72.5 MEDICA (COMMERCIAL) 94265 [3081118] MEDICA CLAIMS [308111801] 65.25 percent of total billed charges 44.95 68.88 Technical (Hospital) Services DEXTROSE 10 % IN WATER (D10W) INTRAVENOUS SOLUTION RX-2357 CDM 2580000300 HCPCS 258 RC 00338-0023-04 NDC outpatient 1000 ML 72.5 72.5 CIGNA 62308 [3081051] CIGNA 62308 [308105105] 58 percent of total billed charges 44.95 68.88 Technical (Hospital) Services DEXTROSE 10 % IN WATER (D10W) INTRAVENOUS SOLUTION RX-2357 CDM 2580000300 HCPCS 258 RC 00338-0023-04 NDC outpatient 1000 ML 72.5 72.5 CIGNA 62308 [3081051] CIGNA STATE OF WYOMING [308105107] 58 percent of total billed charges 44.95 68.88 Technical (Hospital) Services DEXTROSE 10 % IN WATER (D10W) INTRAVENOUS SOLUTION RX-2357 CDM 2580000300 HCPCS 258 RC 00338-0023-04 NDC outpatient 1000 ML 72.5 72.5 UNITED HEALTHCARE (COMMERCIAL) [3081199] UNITED HEALTHCARE 87726 [308119901] 44.95 percent of total billed charges 44.95 68.88 Technical (Hospital) Services DEXTROSE 10 % IN WATER (D10W) INTRAVENOUS SOLUTION RX-2357 CDM 2580000300 HCPCS 258 RC 00338-0023-04 NDC outpatient 1000 ML 72.5 72.5 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES PPO [308136801] 58 percent of total billed charges 44.95 68.88 Technical (Hospital) Services DEXTROSE 10 % IN WATER (D10W) INTRAVENOUS SOLUTION RX-2357 CDM 2580000300 HCPCS 258 RC 00338-0023-04 NDC outpatient 1000 ML 72.5 72.5 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES EPO [308136803] 58 percent of total billed charges 44.95 68.88 Technical (Hospital) Services DEXTROSE 10 % IN WATER (D10W) INTRAVENOUS SOLUTION RX-2357 CDM 2580000300 HCPCS 258 RC 00338-0023-04 NDC outpatient 1000 ML 72.5 72.5 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES HDHP [308136802] 58 percent of total billed charges 44.95 68.88 Technical (Hospital) Services DEXTROSE 10 % IN WATER (D10W) INTRAVENOUS SOLUTION RX-2357 CDM 2580000300 HCPCS 258 RC 00338-0023-04 NDC outpatient 1000 ML 72.5 72.5 HEALTHPARTNERS SX009 HEALTHPARTNERS 58 percent of total billed charges 44.95 68.88 Technical (Hospital) Services DEXTROSE 10 % IN WATER (D10W) INTRAVENOUS SOLUTION RX-2357 CDM 2580000300 HCPCS 258 RC 00338-0023-04 NDC inpatient 1000 ML 72.5 72.5 UNITED HEALTHCARE (COMMERCIAL) [3081199] UNITED HEALTHCARE 87726 [308119901] 44.95 percent of total billed charges 44.95 68.88 Technical (Hospital) Services DEXTROSE 10 % IN WATER (D10W) INTRAVENOUS SOLUTION RX-2357 CDM 2580000300 HCPCS 258 RC 00338-0023-04 NDC inpatient 1000 ML 72.5 72.5 MEDICA (COMMERCIAL) 94265 [3081118] MEDICA CLAIMS [308111801] 65.25 percent of total billed charges 44.95 68.88 Technical (Hospital) Services DEXTROSE 10 % IN WATER (D10W) INTRAVENOUS SOLUTION RX-2357 CDM 2580000300 HCPCS 258 RC 00338-0023-04 NDC inpatient 1000 ML 72.5 72.5 MULTIPLAN INC 34080 [3081285] MULTIPLAN INC [308128501] 68.88 percent of total billed charges 44.95 68.88 Technical (Hospital) Services DEXTROSE 10 % IN WATER (D10W) INTRAVENOUS SOLUTION RX-2357 CDM 2580000300 HCPCS 258 RC 00338-0023-04 NDC inpatient 1000 ML 72.5 72.5 HEALTHPARTNERS SX009 HEALTHPARTNERS 57.41 percent of total billed charges 44.95 68.88 Technical (Hospital) Services DEXTROSE 10 % IN WATER (D10W) INTRAVENOUS SOLUTION RX-2357 CDM 2580000300 HCPCS 258 RC 00338-0023-04 NDC inpatient 1000 ML 72.5 72.5 CIGNA 62308 [3081051] CIGNA 62308 [308105105] 57.41 percent of total billed charges 44.95 68.88 Technical (Hospital) Services DEXTROSE 10 % IN WATER (D10W) INTRAVENOUS SOLUTION RX-2357 CDM 2580000300 HCPCS 258 RC 00338-0023-04 NDC inpatient 1000 ML 72.5 72.5 CIGNA 62308 [3081051] CIGNA STATE OF WYOMING [308105107] 57.41 percent of total billed charges 44.95 68.88 Technical (Hospital) Services DEXTROSE 10 % IN WATER (D10W) INTRAVENOUS SOLUTION RX-2357 CDM 2580000300 HCPCS 258 RC 00338-0023-04 NDC inpatient 1000 ML 72.5 72.5 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES HDHP [308136802] 57.41 percent of total billed charges 44.95 68.88 Technical (Hospital) Services DEXTROSE 10 % IN WATER (D10W) INTRAVENOUS SOLUTION RX-2357 CDM 2580000300 HCPCS 258 RC 00338-0023-04 NDC inpatient 1000 ML 72.5 72.5 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES PPO [308136801] 57.41 percent of total billed charges 44.95 68.88 Technical (Hospital) Services DEXTROSE 10 % IN WATER (D10W) INTRAVENOUS SOLUTION RX-2357 CDM 2580000300 HCPCS 258 RC 00338-0023-04 NDC inpatient 1000 ML 72.5 72.5 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES EPO [308136803] 57.41 percent of total billed charges 44.95 68.88 Technical (Hospital) Services DEXTROSE 5 % AND 0.9 % SODIUM CHLORIDE INTRAVENOUS BOLUS RX-4080060007 CDM 2580000300 HCPCS 258 RC 00338-0089-04 NDC outpatient 250 ML 59.8 59.8 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES PPO [308136801] 47.84 percent of total billed charges 37.08 56.81 Technical (Hospital) Services DEXTROSE 5 % AND 0.9 % SODIUM CHLORIDE INTRAVENOUS BOLUS RX-4080060007 CDM 2580000300 HCPCS 258 RC 00338-0089-04 NDC outpatient 250 ML 59.8 59.8 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES EPO [308136803] 47.84 percent of total billed charges 37.08 56.81 Technical (Hospital) Services DEXTROSE 5 % AND 0.9 % SODIUM CHLORIDE INTRAVENOUS BOLUS RX-4080060007 CDM 2580000300 HCPCS 258 RC 00338-0089-04 NDC outpatient 250 ML 59.8 59.8 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES HDHP [308136802] 47.84 percent of total billed charges 37.08 56.81 Technical (Hospital) Services DEXTROSE 5 % AND 0.9 % SODIUM CHLORIDE INTRAVENOUS BOLUS RX-4080060007 CDM 2580000300 HCPCS 258 RC 00338-0089-04 NDC outpatient 250 ML 59.8 59.8 HEALTHPARTNERS SX009 HEALTHPARTNERS 47.84 percent of total billed charges 37.08 56.81 Technical (Hospital) Services DEXTROSE 5 % AND 0.9 % SODIUM CHLORIDE INTRAVENOUS BOLUS RX-4080060007 CDM 2580000300 HCPCS 258 RC 00338-0089-04 NDC outpatient 250 ML 59.8 59.8 UNITED HEALTHCARE (COMMERCIAL) [3081199] UNITED HEALTHCARE 87726 [308119901] 37.08 percent of total billed charges 37.08 56.81 Technical (Hospital) Services DEXTROSE 5 % AND 0.9 % SODIUM CHLORIDE INTRAVENOUS BOLUS RX-4080060007 CDM 2580000300 HCPCS 258 RC 00338-0089-04 NDC outpatient 250 ML 59.8 59.8 CIGNA 62308 [3081051] CIGNA 62308 [308105105] 47.84 percent of total billed charges 37.08 56.81 Technical (Hospital) Services DEXTROSE 5 % AND 0.9 % SODIUM CHLORIDE INTRAVENOUS BOLUS RX-4080060007 CDM 2580000300 HCPCS 258 RC 00338-0089-04 NDC outpatient 250 ML 59.8 59.8 CIGNA 62308 [3081051] CIGNA STATE OF WYOMING [308105107] 47.84 percent of total billed charges 37.08 56.81 Technical (Hospital) Services DEXTROSE 5 % AND 0.9 % SODIUM CHLORIDE INTRAVENOUS BOLUS RX-4080060007 CDM 2580000300 HCPCS 258 RC 00338-0089-04 NDC outpatient 250 ML 59.8 59.8 MEDICA (COMMERCIAL) 94265 [3081118] MEDICA CLAIMS [308111801] 53.82 percent of total billed charges 37.08 56.81 Technical (Hospital) Services DEXTROSE 5 % AND 0.9 % SODIUM CHLORIDE INTRAVENOUS BOLUS RX-4080060007 CDM 2580000300 HCPCS 258 RC 00338-0089-04 NDC outpatient 250 ML 59.8 59.8 MULTIPLAN INC 34080 [3081285] MULTIPLAN INC [308128501] 56.81 percent of total billed charges 37.08 56.81 Technical (Hospital) Services DEXTROSE 5 % AND 0.9 % SODIUM CHLORIDE INTRAVENOUS BOLUS RX-4080060007 CDM 2580000300 HCPCS 258 RC 00338-0089-04 NDC inpatient 250 ML 59.8 59.8 HEALTHPARTNERS SX009 HEALTHPARTNERS 47.35 percent of total billed charges 37.08 56.81 Technical (Hospital) Services DEXTROSE 5 % AND 0.9 % SODIUM CHLORIDE INTRAVENOUS BOLUS RX-4080060007 CDM 2580000300 HCPCS 258 RC 00338-0089-04 NDC inpatient 250 ML 59.8 59.8 MULTIPLAN INC 34080 [3081285] MULTIPLAN INC [308128501] 56.81 percent of total billed charges 37.08 56.81 Technical (Hospital) Services DEXTROSE 5 % AND 0.9 % SODIUM CHLORIDE INTRAVENOUS BOLUS RX-4080060007 CDM 2580000300 HCPCS 258 RC 00338-0089-04 NDC inpatient 250 ML 59.8 59.8 MEDICA (COMMERCIAL) 94265 [3081118] MEDICA CLAIMS [308111801] 53.82 percent of total billed charges 37.08 56.81 Technical (Hospital) Services DEXTROSE 5 % AND 0.9 % SODIUM CHLORIDE INTRAVENOUS BOLUS RX-4080060007 CDM 2580000300 HCPCS 258 RC 00338-0089-04 NDC inpatient 250 ML 59.8 59.8 UNITED HEALTHCARE (COMMERCIAL) [3081199] UNITED HEALTHCARE 87726 [308119901] 37.08 percent of total billed charges 37.08 56.81 Technical (Hospital) Services DEXTROSE 5 % AND 0.9 % SODIUM CHLORIDE INTRAVENOUS BOLUS RX-4080060007 CDM 2580000300 HCPCS 258 RC 00338-0089-04 NDC inpatient 250 ML 59.8 59.8 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES HDHP [308136802] 47.35 percent of total billed charges 37.08 56.81 Technical (Hospital) Services DEXTROSE 5 % AND 0.9 % SODIUM CHLORIDE INTRAVENOUS BOLUS RX-4080060007 CDM 2580000300 HCPCS 258 RC 00338-0089-04 NDC inpatient 250 ML 59.8 59.8 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES PPO [308136801] 47.35 percent of total billed charges 37.08 56.81 Technical (Hospital) Services DEXTROSE 5 % AND 0.9 % SODIUM CHLORIDE INTRAVENOUS BOLUS RX-4080060007 CDM 2580000300 HCPCS 258 RC 00338-0089-04 NDC inpatient 250 ML 59.8 59.8 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES EPO [308136803] 47.35 percent of total billed charges 37.08 56.81 Technical (Hospital) Services DEXTROSE 5 % AND 0.9 % SODIUM CHLORIDE INTRAVENOUS BOLUS RX-4080060007 CDM 2580000300 HCPCS 258 RC 00338-0089-04 NDC inpatient 250 ML 59.8 59.8 CIGNA 62308 [3081051] CIGNA 62308 [308105105] 47.35 percent of total billed charges 37.08 56.81 Technical (Hospital) Services DEXTROSE 5 % AND 0.9 % SODIUM CHLORIDE INTRAVENOUS BOLUS RX-4080060007 CDM 2580000300 HCPCS 258 RC 00338-0089-04 NDC inpatient 250 ML 59.8 59.8 CIGNA 62308 [3081051] CIGNA STATE OF WYOMING [308105107] 47.35 percent of total billed charges 37.08 56.81 Technical (Hospital) Services SODIUM CHLORIDE 0.45 % INTRAVENOUS SOLUTION RX-7318 CDM 2580000300 HCPCS 258 RC 00338-0043-04 NDC outpatient 1000 ML 70.5 70.5 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES PPO [308136801] 56.4 percent of total billed charges 43.71 66.98 Technical (Hospital) Services SODIUM CHLORIDE 0.45 % INTRAVENOUS SOLUTION RX-7318 CDM 2580000300 HCPCS 258 RC 00338-0043-04 NDC outpatient 1000 ML 70.5 70.5 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES HDHP [308136802] 56.4 percent of total billed charges 43.71 66.98 Technical (Hospital) Services SODIUM CHLORIDE 0.45 % INTRAVENOUS SOLUTION RX-7318 CDM 2580000300 HCPCS 258 RC 00338-0043-04 NDC outpatient 1000 ML 70.5 70.5 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES EPO [308136803] 56.4 percent of total billed charges 43.71 66.98 Technical (Hospital) Services SODIUM CHLORIDE 0.45 % INTRAVENOUS SOLUTION RX-7318 CDM 2580000300 HCPCS 258 RC 00338-0043-04 NDC outpatient 1000 ML 70.5 70.5 UNITED HEALTHCARE (COMMERCIAL) [3081199] UNITED HEALTHCARE 87726 [308119901] 43.71 percent of total billed charges 43.71 66.98 Technical (Hospital) Services SODIUM CHLORIDE 0.45 % INTRAVENOUS SOLUTION RX-7318 CDM 2580000300 HCPCS 258 RC 00338-0043-04 NDC outpatient 1000 ML 70.5 70.5 HEALTHPARTNERS SX009 HEALTHPARTNERS 56.4 percent of total billed charges 43.71 66.98 Technical (Hospital) Services SODIUM CHLORIDE 0.45 % INTRAVENOUS SOLUTION RX-7318 CDM 2580000300 HCPCS 258 RC 00338-0043-04 NDC outpatient 1000 ML 70.5 70.5 CIGNA 62308 [3081051] CIGNA 62308 [308105105] 56.4 percent of total billed charges 43.71 66.98 Technical (Hospital) Services SODIUM CHLORIDE 0.45 % INTRAVENOUS SOLUTION RX-7318 CDM 2580000300 HCPCS 258 RC 00338-0043-04 NDC outpatient 1000 ML 70.5 70.5 CIGNA 62308 [3081051] CIGNA STATE OF WYOMING [308105107] 56.4 percent of total billed charges 43.71 66.98 Technical (Hospital) Services SODIUM CHLORIDE 0.45 % INTRAVENOUS SOLUTION RX-7318 CDM 2580000300 HCPCS 258 RC 00338-0043-04 NDC outpatient 1000 ML 70.5 70.5 MULTIPLAN INC 34080 [3081285] MULTIPLAN INC [308128501] 66.98 percent of total billed charges 43.71 66.98 Technical (Hospital) Services SODIUM CHLORIDE 0.45 % INTRAVENOUS SOLUTION RX-7318 CDM 2580000300 HCPCS 258 RC 00338-0043-04 NDC outpatient 1000 ML 70.5 70.5 MEDICA (COMMERCIAL) 94265 [3081118] MEDICA CLAIMS [308111801] 63.45 percent of total billed charges 43.71 66.98 Technical (Hospital) Services SODIUM CHLORIDE 0.45 % INTRAVENOUS SOLUTION RX-7318 CDM 2580000300 HCPCS 258 RC 00338-0043-04 NDC inpatient 1000 ML 70.5 70.5 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES PPO [308136801] 55.82 percent of total billed charges 43.71 66.98 Technical (Hospital) Services SODIUM CHLORIDE 0.45 % INTRAVENOUS SOLUTION RX-7318 CDM 2580000300 HCPCS 258 RC 00338-0043-04 NDC inpatient 1000 ML 70.5 70.5 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES HDHP [308136802] 55.82 percent of total billed charges 43.71 66.98 Technical (Hospital) Services SODIUM CHLORIDE 0.45 % INTRAVENOUS SOLUTION RX-7318 CDM 2580000300 HCPCS 258 RC 00338-0043-04 NDC inpatient 1000 ML 70.5 70.5 CIGNA 62308 [3081051] CIGNA 62308 [308105105] 55.82 percent of total billed charges 43.71 66.98 Technical (Hospital) Services SODIUM CHLORIDE 0.45 % INTRAVENOUS SOLUTION RX-7318 CDM 2580000300 HCPCS 258 RC 00338-0043-04 NDC inpatient 1000 ML 70.5 70.5 CIGNA 62308 [3081051] CIGNA STATE OF WYOMING [308105107] 55.82 percent of total billed charges 43.71 66.98 Technical (Hospital) Services SODIUM CHLORIDE 0.45 % INTRAVENOUS SOLUTION RX-7318 CDM 2580000300 HCPCS 258 RC 00338-0043-04 NDC inpatient 1000 ML 70.5 70.5 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES EPO [308136803] 55.82 percent of total billed charges 43.71 66.98 Technical (Hospital) Services SODIUM CHLORIDE 0.45 % INTRAVENOUS SOLUTION RX-7318 CDM 2580000300 HCPCS 258 RC 00338-0043-04 NDC inpatient 1000 ML 70.5 70.5 UNITED HEALTHCARE (COMMERCIAL) [3081199] UNITED HEALTHCARE 87726 [308119901] 43.71 percent of total billed charges 43.71 66.98 Technical (Hospital) Services SODIUM CHLORIDE 0.45 % INTRAVENOUS SOLUTION RX-7318 CDM 2580000300 HCPCS 258 RC 00338-0043-04 NDC inpatient 1000 ML 70.5 70.5 MULTIPLAN INC 34080 [3081285] MULTIPLAN INC [308128501] 66.98 percent of total billed charges 43.71 66.98 Technical (Hospital) Services SODIUM CHLORIDE 0.45 % INTRAVENOUS SOLUTION RX-7318 CDM 2580000300 HCPCS 258 RC 00338-0043-04 NDC inpatient 1000 ML 70.5 70.5 MEDICA (COMMERCIAL) 94265 [3081118] MEDICA CLAIMS [308111801] 63.45 percent of total billed charges 43.71 66.98 Technical (Hospital) Services SODIUM CHLORIDE 0.45 % INTRAVENOUS SOLUTION RX-7318 CDM 2580000300 HCPCS 258 RC 00338-0043-04 NDC inpatient 1000 ML 70.5 70.5 HEALTHPARTNERS SX009 HEALTHPARTNERS 55.82 percent of total billed charges 43.71 66.98 Technical (Hospital) Services SODIUM CHLORIDE 3 % HYPERTONIC INTRAVENOUS INJECTION SOLUTION RX-7321 CDM 2580000300 HCPCS 258 RC 00338-0054-03 NDC inpatient 500 ML 71 71 CIGNA 62308 [3081051] CIGNA 62308 [308105105] 56.22 percent of total billed charges 44.02 67.45 Technical (Hospital) Services SODIUM CHLORIDE 3 % HYPERTONIC INTRAVENOUS INJECTION SOLUTION RX-7321 CDM 2580000300 HCPCS 258 RC 00338-0054-03 NDC inpatient 500 ML 71 71 CIGNA 62308 [3081051] CIGNA STATE OF WYOMING [308105107] 56.22 percent of total billed charges 44.02 67.45 Technical (Hospital) Services SODIUM CHLORIDE 3 % HYPERTONIC INTRAVENOUS INJECTION SOLUTION RX-7321 CDM 2580000300 HCPCS 258 RC 00338-0054-03 NDC inpatient 500 ML 71 71 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES EPO [308136803] 56.22 percent of total billed charges 44.02 67.45 Technical (Hospital) Services SODIUM CHLORIDE 3 % HYPERTONIC INTRAVENOUS INJECTION SOLUTION RX-7321 CDM 2580000300 HCPCS 258 RC 00338-0054-03 NDC inpatient 500 ML 71 71 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES HDHP [308136802] 56.22 percent of total billed charges 44.02 67.45 Technical (Hospital) Services SODIUM CHLORIDE 3 % HYPERTONIC INTRAVENOUS INJECTION SOLUTION RX-7321 CDM 2580000300 HCPCS 258 RC 00338-0054-03 NDC inpatient 500 ML 71 71 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES PPO [308136801] 56.22 percent of total billed charges 44.02 67.45 Technical (Hospital) Services SODIUM CHLORIDE 3 % HYPERTONIC INTRAVENOUS INJECTION SOLUTION RX-7321 CDM 2580000300 HCPCS 258 RC 00338-0054-03 NDC inpatient 500 ML 71 71 UNITED HEALTHCARE (COMMERCIAL) [3081199] UNITED HEALTHCARE 87726 [308119901] 44.02 percent of total billed charges 44.02 67.45 Technical (Hospital) Services SODIUM CHLORIDE 3 % HYPERTONIC INTRAVENOUS INJECTION SOLUTION RX-7321 CDM 2580000300 HCPCS 258 RC 00338-0054-03 NDC inpatient 500 ML 71 71 HEALTHPARTNERS SX009 HEALTHPARTNERS 56.22 percent of total billed charges 44.02 67.45 Technical (Hospital) Services SODIUM CHLORIDE 3 % HYPERTONIC INTRAVENOUS INJECTION SOLUTION RX-7321 CDM 2580000300 HCPCS 258 RC 00338-0054-03 NDC inpatient 500 ML 71 71 MEDICA (COMMERCIAL) 94265 [3081118] MEDICA CLAIMS [308111801] 63.9 percent of total billed charges 44.02 67.45 Technical (Hospital) Services SODIUM CHLORIDE 3 % HYPERTONIC INTRAVENOUS INJECTION SOLUTION RX-7321 CDM 2580000300 HCPCS 258 RC 00338-0054-03 NDC inpatient 500 ML 71 71 MULTIPLAN INC 34080 [3081285] MULTIPLAN INC [308128501] 67.45 percent of total billed charges 44.02 67.45 Technical (Hospital) Services SODIUM CHLORIDE 3 % HYPERTONIC INTRAVENOUS INJECTION SOLUTION RX-7321 CDM 2580000300 HCPCS 258 RC 00338-0054-03 NDC outpatient 500 ML 71 71 UNITED HEALTHCARE (COMMERCIAL) [3081199] UNITED HEALTHCARE 87726 [308119901] 44.02 percent of total billed charges 44.02 67.45 Technical (Hospital) Services SODIUM CHLORIDE 3 % HYPERTONIC INTRAVENOUS INJECTION SOLUTION RX-7321 CDM 2580000300 HCPCS 258 RC 00338-0054-03 NDC outpatient 500 ML 71 71 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES HDHP [308136802] 56.8 percent of total billed charges 44.02 67.45 Technical (Hospital) Services SODIUM CHLORIDE 3 % HYPERTONIC INTRAVENOUS INJECTION SOLUTION RX-7321 CDM 2580000300 HCPCS 258 RC 00338-0054-03 NDC outpatient 500 ML 71 71 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES PPO [308136801] 56.8 percent of total billed charges 44.02 67.45 Technical (Hospital) Services SODIUM CHLORIDE 3 % HYPERTONIC INTRAVENOUS INJECTION SOLUTION RX-7321 CDM 2580000300 HCPCS 258 RC 00338-0054-03 NDC outpatient 500 ML 71 71 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES EPO [308136803] 56.8 percent of total billed charges 44.02 67.45 Technical (Hospital) Services SODIUM CHLORIDE 3 % HYPERTONIC INTRAVENOUS INJECTION SOLUTION RX-7321 CDM 2580000300 HCPCS 258 RC 00338-0054-03 NDC outpatient 500 ML 71 71 HEALTHPARTNERS SX009 HEALTHPARTNERS 56.8 percent of total billed charges 44.02 67.45 Technical (Hospital) Services SODIUM CHLORIDE 3 % HYPERTONIC INTRAVENOUS INJECTION SOLUTION RX-7321 CDM 2580000300 HCPCS 258 RC 00338-0054-03 NDC outpatient 500 ML 71 71 MEDICA (COMMERCIAL) 94265 [3081118] MEDICA CLAIMS [308111801] 63.9 percent of total billed charges 44.02 67.45 Technical (Hospital) Services SODIUM CHLORIDE 3 % HYPERTONIC INTRAVENOUS INJECTION SOLUTION RX-7321 CDM 2580000300 HCPCS 258 RC 00338-0054-03 NDC outpatient 500 ML 71 71 MULTIPLAN INC 34080 [3081285] MULTIPLAN INC [308128501] 67.45 percent of total billed charges 44.02 67.45 Technical (Hospital) Services SODIUM CHLORIDE 3 % HYPERTONIC INTRAVENOUS INJECTION SOLUTION RX-7321 CDM 2580000300 HCPCS 258 RC 00338-0054-03 NDC outpatient 500 ML 71 71 CIGNA 62308 [3081051] CIGNA 62308 [308105105] 56.8 percent of total billed charges 44.02 67.45 Technical (Hospital) Services SODIUM CHLORIDE 3 % HYPERTONIC INTRAVENOUS INJECTION SOLUTION RX-7321 CDM 2580000300 HCPCS 258 RC 00338-0054-03 NDC outpatient 500 ML 71 71 CIGNA 62308 [3081051] CIGNA STATE OF WYOMING [308105107] 56.8 percent of total billed charges 44.02 67.45 Technical (Hospital) Services DEXTROSE 5 % AND 0.9 % SODIUM CHLORIDE INTRAVENOUS SOLUTION RX-9815 CDM 2580000300 HCPCS 258 RC 00338-0089-04 NDC outpatient 1000 ML 70.5 70.5 MULTIPLAN INC 34080 [3081285] MULTIPLAN INC [308128501] 66.98 percent of total billed charges 43.71 66.98 Technical (Hospital) Services DEXTROSE 5 % AND 0.9 % SODIUM CHLORIDE INTRAVENOUS SOLUTION RX-9815 CDM 2580000300 HCPCS 258 RC 00338-0089-04 NDC outpatient 1000 ML 70.5 70.5 MEDICA (COMMERCIAL) 94265 [3081118] MEDICA CLAIMS [308111801] 63.45 percent of total billed charges 43.71 66.98 Technical (Hospital) Services DEXTROSE 5 % AND 0.9 % SODIUM CHLORIDE INTRAVENOUS SOLUTION RX-9815 CDM 2580000300 HCPCS 258 RC 00338-0089-04 NDC outpatient 1000 ML 70.5 70.5 CIGNA 62308 [3081051] CIGNA 62308 [308105105] 56.4 percent of total billed charges 43.71 66.98 Technical (Hospital) Services DEXTROSE 5 % AND 0.9 % SODIUM CHLORIDE INTRAVENOUS SOLUTION RX-9815 CDM 2580000300 HCPCS 258 RC 00338-0089-04 NDC outpatient 1000 ML 70.5 70.5 CIGNA 62308 [3081051] CIGNA STATE OF WYOMING [308105107] 56.4 percent of total billed charges 43.71 66.98 Technical (Hospital) Services DEXTROSE 5 % AND 0.9 % SODIUM CHLORIDE INTRAVENOUS SOLUTION RX-9815 CDM 2580000300 HCPCS 258 RC 00338-0089-04 NDC outpatient 1000 ML 70.5 70.5 HEALTHPARTNERS SX009 HEALTHPARTNERS 56.4 percent of total billed charges 43.71 66.98 Technical (Hospital) Services DEXTROSE 5 % AND 0.9 % SODIUM CHLORIDE INTRAVENOUS SOLUTION RX-9815 CDM 2580000300 HCPCS 258 RC 00338-0089-04 NDC outpatient 1000 ML 70.5 70.5 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES EPO [308136803] 56.4 percent of total billed charges 43.71 66.98 Technical (Hospital) Services DEXTROSE 5 % AND 0.9 % SODIUM CHLORIDE INTRAVENOUS SOLUTION RX-9815 CDM 2580000300 HCPCS 258 RC 00338-0089-04 NDC outpatient 1000 ML 70.5 70.5 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES PPO [308136801] 56.4 percent of total billed charges 43.71 66.98 Technical (Hospital) Services DEXTROSE 5 % AND 0.9 % SODIUM CHLORIDE INTRAVENOUS SOLUTION RX-9815 CDM 2580000300 HCPCS 258 RC 00338-0089-04 NDC outpatient 1000 ML 70.5 70.5 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES HDHP [308136802] 56.4 percent of total billed charges 43.71 66.98 Technical (Hospital) Services DEXTROSE 5 % AND 0.9 % SODIUM CHLORIDE INTRAVENOUS SOLUTION RX-9815 CDM 2580000300 HCPCS 258 RC 00338-0089-04 NDC outpatient 1000 ML 70.5 70.5 UNITED HEALTHCARE (COMMERCIAL) [3081199] UNITED HEALTHCARE 87726 [308119901] 43.71 percent of total billed charges 43.71 66.98 Technical (Hospital) Services DEXTROSE 5 % AND 0.9 % SODIUM CHLORIDE INTRAVENOUS SOLUTION RX-9815 CDM 2580000300 HCPCS 258 RC 00338-0089-04 NDC inpatient 1000 ML 70.5 70.5 UNITED HEALTHCARE (COMMERCIAL) [3081199] UNITED HEALTHCARE 87726 [308119901] 43.71 percent of total billed charges 43.71 66.98 Technical (Hospital) Services DEXTROSE 5 % AND 0.9 % SODIUM CHLORIDE INTRAVENOUS SOLUTION RX-9815 CDM 2580000300 HCPCS 258 RC 00338-0089-04 NDC inpatient 1000 ML 70.5 70.5 MEDICA (COMMERCIAL) 94265 [3081118] MEDICA CLAIMS [308111801] 63.45 percent of total billed charges 43.71 66.98 Technical (Hospital) Services DEXTROSE 5 % AND 0.9 % SODIUM CHLORIDE INTRAVENOUS SOLUTION RX-9815 CDM 2580000300 HCPCS 258 RC 00338-0089-04 NDC inpatient 1000 ML 70.5 70.5 MULTIPLAN INC 34080 [3081285] MULTIPLAN INC [308128501] 66.98 percent of total billed charges 43.71 66.98 Technical (Hospital) Services DEXTROSE 5 % AND 0.9 % SODIUM CHLORIDE INTRAVENOUS SOLUTION RX-9815 CDM 2580000300 HCPCS 258 RC 00338-0089-04 NDC inpatient 1000 ML 70.5 70.5 HEALTHPARTNERS SX009 HEALTHPARTNERS 55.82 percent of total billed charges 43.71 66.98 Technical (Hospital) Services DEXTROSE 5 % AND 0.9 % SODIUM CHLORIDE INTRAVENOUS SOLUTION RX-9815 CDM 2580000300 HCPCS 258 RC 00338-0089-04 NDC inpatient 1000 ML 70.5 70.5 CIGNA 62308 [3081051] CIGNA 62308 [308105105] 55.82 percent of total billed charges 43.71 66.98 Technical (Hospital) Services DEXTROSE 5 % AND 0.9 % SODIUM CHLORIDE INTRAVENOUS SOLUTION RX-9815 CDM 2580000300 HCPCS 258 RC 00338-0089-04 NDC inpatient 1000 ML 70.5 70.5 CIGNA 62308 [3081051] CIGNA STATE OF WYOMING [308105107] 55.82 percent of total billed charges 43.71 66.98 Technical (Hospital) Services DEXTROSE 5 % AND 0.9 % SODIUM CHLORIDE INTRAVENOUS SOLUTION RX-9815 CDM 2580000300 HCPCS 258 RC 00338-0089-04 NDC inpatient 1000 ML 70.5 70.5 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES PPO [308136801] 55.82 percent of total billed charges 43.71 66.98 Technical (Hospital) Services DEXTROSE 5 % AND 0.9 % SODIUM CHLORIDE INTRAVENOUS SOLUTION RX-9815 CDM 2580000300 HCPCS 258 RC 00338-0089-04 NDC inpatient 1000 ML 70.5 70.5 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES EPO [308136803] 55.82 percent of total billed charges 43.71 66.98 Technical (Hospital) Services DEXTROSE 5 % AND 0.9 % SODIUM CHLORIDE INTRAVENOUS SOLUTION RX-9815 CDM 2580000300 HCPCS 258 RC 00338-0089-04 NDC inpatient 1000 ML 70.5 70.5 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES HDHP [308136802] 55.82 percent of total billed charges 43.71 66.98 Technical (Hospital) Services LABETALOL 5 MG/ML INTRAVENOUS SOLUTION RX-10372 CDM 2500000200 HCPCS 250 RC 00409-2267-54 NDC inpatient 40 ML 80.36 80.36 CIGNA 62308 [3081051] CIGNA 62308 [308105105] 63.63 percent of total billed charges 49.82 76.34 Technical (Hospital) Services LABETALOL 5 MG/ML INTRAVENOUS SOLUTION RX-10372 CDM 2500000200 HCPCS 250 RC 00409-2267-54 NDC inpatient 40 ML 80.36 80.36 CIGNA 62308 [3081051] CIGNA STATE OF WYOMING [308105107] 63.63 percent of total billed charges 49.82 76.34 Technical (Hospital) Services LABETALOL 5 MG/ML INTRAVENOUS SOLUTION RX-10372 CDM 2500000200 HCPCS 250 RC 00409-2267-54 NDC inpatient 40 ML 80.36 80.36 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES EPO [308136803] 63.63 percent of total billed charges 49.82 76.34 Technical (Hospital) Services LABETALOL 5 MG/ML INTRAVENOUS SOLUTION RX-10372 CDM 2500000200 HCPCS 250 RC 00409-2267-54 NDC inpatient 40 ML 80.36 80.36 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES HDHP [308136802] 63.63 percent of total billed charges 49.82 76.34 Technical (Hospital) Services LABETALOL 5 MG/ML INTRAVENOUS SOLUTION RX-10372 CDM 2500000200 HCPCS 250 RC 00409-2267-54 NDC inpatient 40 ML 80.36 80.36 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES PPO [308136801] 63.63 percent of total billed charges 49.82 76.34 Technical (Hospital) Services LABETALOL 5 MG/ML INTRAVENOUS SOLUTION RX-10372 CDM 2500000200 HCPCS 250 RC 00409-2267-54 NDC inpatient 40 ML 80.36 80.36 MULTIPLAN INC 34080 [3081285] MULTIPLAN INC [308128501] 76.34 percent of total billed charges 49.82 76.34 Technical (Hospital) Services LABETALOL 5 MG/ML INTRAVENOUS SOLUTION RX-10372 CDM 2500000200 HCPCS 250 RC 00409-2267-54 NDC inpatient 40 ML 80.36 80.36 MEDICA (COMMERCIAL) 94265 [3081118] MEDICA CLAIMS [308111801] 72.32 percent of total billed charges 49.82 76.34 Technical (Hospital) Services LABETALOL 5 MG/ML INTRAVENOUS SOLUTION RX-10372 CDM 2500000200 HCPCS 250 RC 00409-2267-54 NDC inpatient 40 ML 80.36 80.36 HEALTHPARTNERS SX009 HEALTHPARTNERS 63.63 percent of total billed charges 49.82 76.34 Technical (Hospital) Services LABETALOL 5 MG/ML INTRAVENOUS SOLUTION RX-10372 CDM 2500000200 HCPCS 250 RC 00409-2267-54 NDC inpatient 40 ML 80.36 80.36 UNITED HEALTHCARE (COMMERCIAL) [3081199] UNITED HEALTHCARE 87726 [308119901] 49.82 percent of total billed charges 49.82 76.34 Technical (Hospital) Services LABETALOL 5 MG/ML INTRAVENOUS SOLUTION RX-10372 CDM 2500000200 HCPCS 250 RC 00409-2267-54 NDC inpatient 40 ML 80.36 80.36 BLUE CROSS BLUE SHIELD WELLMARK SB889 [3081026] BCBS WYOMING [308102603] 76.34 percent of total billed charges 49.82 76.34 Technical (Hospital) Services LABETALOL 5 MG/ML INTRAVENOUS SOLUTION RX-10372 CDM 2500000200 HCPCS 250 RC 00409-2267-54 NDC outpatient 40 ML 80.36 80.36 BLUE CROSS BLUE SHIELD WELLMARK SB889 [3081026] BCBS WYOMING [308102603] 76.34 percent of total billed charges 49.82 76.34 Technical (Hospital) Services LABETALOL 5 MG/ML INTRAVENOUS SOLUTION RX-10372 CDM 2500000200 HCPCS 250 RC 00409-2267-54 NDC outpatient 40 ML 80.36 80.36 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES EPO [308136803] 64.29 percent of total billed charges 49.82 76.34 Technical (Hospital) Services LABETALOL 5 MG/ML INTRAVENOUS SOLUTION RX-10372 CDM 2500000200 HCPCS 250 RC 00409-2267-54 NDC outpatient 40 ML 80.36 80.36 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES HDHP [308136802] 64.29 percent of total billed charges 49.82 76.34 Technical (Hospital) Services LABETALOL 5 MG/ML INTRAVENOUS SOLUTION RX-10372 CDM 2500000200 HCPCS 250 RC 00409-2267-54 NDC outpatient 40 ML 80.36 80.36 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES PPO [308136801] 64.29 percent of total billed charges 49.82 76.34 Technical (Hospital) Services LABETALOL 5 MG/ML INTRAVENOUS SOLUTION RX-10372 CDM 2500000200 HCPCS 250 RC 00409-2267-54 NDC outpatient 40 ML 80.36 80.36 UNITED HEALTHCARE (COMMERCIAL) [3081199] UNITED HEALTHCARE 87726 [308119901] 49.82 percent of total billed charges 49.82 76.34 Technical (Hospital) Services LABETALOL 5 MG/ML INTRAVENOUS SOLUTION RX-10372 CDM 2500000200 HCPCS 250 RC 00409-2267-54 NDC outpatient 40 ML 80.36 80.36 HEALTHPARTNERS SX009 HEALTHPARTNERS 64.29 percent of total billed charges 49.82 76.34 Technical (Hospital) Services LABETALOL 5 MG/ML INTRAVENOUS SOLUTION RX-10372 CDM 2500000200 HCPCS 250 RC 00409-2267-54 NDC outpatient 40 ML 80.36 80.36 MULTIPLAN INC 34080 [3081285] MULTIPLAN INC [308128501] 76.34 percent of total billed charges 49.82 76.34 Technical (Hospital) Services LABETALOL 5 MG/ML INTRAVENOUS SOLUTION RX-10372 CDM 2500000200 HCPCS 250 RC 00409-2267-54 NDC outpatient 40 ML 80.36 80.36 MEDICA (COMMERCIAL) 94265 [3081118] MEDICA CLAIMS [308111801] 72.32 percent of total billed charges 49.82 76.34 Technical (Hospital) Services LABETALOL 5 MG/ML INTRAVENOUS SOLUTION RX-10372 CDM 2500000200 HCPCS 250 RC 00409-2267-54 NDC outpatient 40 ML 80.36 80.36 CIGNA 62308 [3081051] CIGNA 62308 [308105105] 64.29 percent of total billed charges 49.82 76.34 Technical (Hospital) Services LABETALOL 5 MG/ML INTRAVENOUS SOLUTION RX-10372 CDM 2500000200 HCPCS 250 RC 00409-2267-54 NDC outpatient 40 ML 80.36 80.36 CIGNA 62308 [3081051] CIGNA STATE OF WYOMING [308105107] 64.29 percent of total billed charges 49.82 76.34 Technical (Hospital) Services "LIDOCAINE 1 %-EPINEPHRINE 1:100,000 INJECTION SOLUTION" RX-10427 CDM 2500000200 HCPCS 250 RC 63323-0482-26 NDC outpatient 20 ML 7.52 7.52 CIGNA 62308 [3081051] CIGNA 62308 [308105105] 6.02 percent of total billed charges 4.66 7.14 Technical (Hospital) Services "LIDOCAINE 1 %-EPINEPHRINE 1:100,000 INJECTION SOLUTION" RX-10427 CDM 2500000200 HCPCS 250 RC 63323-0482-26 NDC outpatient 20 ML 7.52 7.52 CIGNA 62308 [3081051] CIGNA STATE OF WYOMING [308105107] 6.02 percent of total billed charges 4.66 7.14 Technical (Hospital) Services "LIDOCAINE 1 %-EPINEPHRINE 1:100,000 INJECTION SOLUTION" RX-10427 CDM 2500000200 HCPCS 250 RC 63323-0482-26 NDC outpatient 20 ML 7.52 7.52 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES EPO [308136803] 6.02 percent of total billed charges 4.66 7.14 Technical (Hospital) Services "LIDOCAINE 1 %-EPINEPHRINE 1:100,000 INJECTION SOLUTION" RX-10427 CDM 2500000200 HCPCS 250 RC 63323-0482-26 NDC outpatient 20 ML 7.52 7.52 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES HDHP [308136802] 6.02 percent of total billed charges 4.66 7.14 Technical (Hospital) Services "LIDOCAINE 1 %-EPINEPHRINE 1:100,000 INJECTION SOLUTION" RX-10427 CDM 2500000200 HCPCS 250 RC 63323-0482-26 NDC outpatient 20 ML 7.52 7.52 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES PPO [308136801] 6.02 percent of total billed charges 4.66 7.14 Technical (Hospital) Services "LIDOCAINE 1 %-EPINEPHRINE 1:100,000 INJECTION SOLUTION" RX-10427 CDM 2500000200 HCPCS 250 RC 63323-0482-26 NDC outpatient 20 ML 7.52 7.52 BLUE CROSS BLUE SHIELD WELLMARK SB889 [3081026] BCBS WYOMING [308102603] 7.14 percent of total billed charges 4.66 7.14 Technical (Hospital) Services "LIDOCAINE 1 %-EPINEPHRINE 1:100,000 INJECTION SOLUTION" RX-10427 CDM 2500000200 HCPCS 250 RC 63323-0482-26 NDC outpatient 20 ML 7.52 7.52 HEALTHPARTNERS SX009 HEALTHPARTNERS 6.02 percent of total billed charges 4.66 7.14 Technical (Hospital) Services "LIDOCAINE 1 %-EPINEPHRINE 1:100,000 INJECTION SOLUTION" RX-10427 CDM 2500000200 HCPCS 250 RC 63323-0482-26 NDC outpatient 20 ML 7.52 7.52 UNITED HEALTHCARE (COMMERCIAL) [3081199] UNITED HEALTHCARE 87726 [308119901] 4.66 percent of total billed charges 4.66 7.14 Technical (Hospital) Services "LIDOCAINE 1 %-EPINEPHRINE 1:100,000 INJECTION SOLUTION" RX-10427 CDM 2500000200 HCPCS 250 RC 63323-0482-26 NDC outpatient 20 ML 7.52 7.52 MULTIPLAN INC 34080 [3081285] MULTIPLAN INC [308128501] 7.14 percent of total billed charges 4.66 7.14 Technical (Hospital) Services "LIDOCAINE 1 %-EPINEPHRINE 1:100,000 INJECTION SOLUTION" RX-10427 CDM 2500000200 HCPCS 250 RC 63323-0482-26 NDC outpatient 20 ML 7.52 7.52 MEDICA (COMMERCIAL) 94265 [3081118] MEDICA CLAIMS [308111801] 6.77 percent of total billed charges 4.66 7.14 Technical (Hospital) Services "LIDOCAINE 1 %-EPINEPHRINE 1:100,000 INJECTION SOLUTION" RX-10427 CDM 2500000200 HCPCS 250 RC 63323-0482-26 NDC inpatient 20 ML 7.52 7.52 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES EPO [308136803] 5.95 percent of total billed charges 4.66 7.14 Technical (Hospital) Services "LIDOCAINE 1 %-EPINEPHRINE 1:100,000 INJECTION SOLUTION" RX-10427 CDM 2500000200 HCPCS 250 RC 63323-0482-26 NDC inpatient 20 ML 7.52 7.52 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES HDHP [308136802] 5.95 percent of total billed charges 4.66 7.14 Technical (Hospital) Services "LIDOCAINE 1 %-EPINEPHRINE 1:100,000 INJECTION SOLUTION" RX-10427 CDM 2500000200 HCPCS 250 RC 63323-0482-26 NDC inpatient 20 ML 7.52 7.52 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES PPO [308136801] 5.95 percent of total billed charges 4.66 7.14 Technical (Hospital) Services "LIDOCAINE 1 %-EPINEPHRINE 1:100,000 INJECTION SOLUTION" RX-10427 CDM 2500000200 HCPCS 250 RC 63323-0482-26 NDC inpatient 20 ML 7.52 7.52 HEALTHPARTNERS SX009 HEALTHPARTNERS 5.95 percent of total billed charges 4.66 7.14 Technical (Hospital) Services "LIDOCAINE 1 %-EPINEPHRINE 1:100,000 INJECTION SOLUTION" RX-10427 CDM 2500000200 HCPCS 250 RC 63323-0482-26 NDC inpatient 20 ML 7.52 7.52 CIGNA 62308 [3081051] CIGNA 62308 [308105105] 5.95 percent of total billed charges 4.66 7.14 Technical (Hospital) Services "LIDOCAINE 1 %-EPINEPHRINE 1:100,000 INJECTION SOLUTION" RX-10427 CDM 2500000200 HCPCS 250 RC 63323-0482-26 NDC inpatient 20 ML 7.52 7.52 CIGNA 62308 [3081051] CIGNA STATE OF WYOMING [308105107] 5.95 percent of total billed charges 4.66 7.14 Technical (Hospital) Services "LIDOCAINE 1 %-EPINEPHRINE 1:100,000 INJECTION SOLUTION" RX-10427 CDM 2500000200 HCPCS 250 RC 63323-0482-26 NDC inpatient 20 ML 7.52 7.52 MULTIPLAN INC 34080 [3081285] MULTIPLAN INC [308128501] 7.14 percent of total billed charges 4.66 7.14 Technical (Hospital) Services "LIDOCAINE 1 %-EPINEPHRINE 1:100,000 INJECTION SOLUTION" RX-10427 CDM 2500000200 HCPCS 250 RC 63323-0482-26 NDC inpatient 20 ML 7.52 7.52 MEDICA (COMMERCIAL) 94265 [3081118] MEDICA CLAIMS [308111801] 6.77 percent of total billed charges 4.66 7.14 Technical (Hospital) Services "LIDOCAINE 1 %-EPINEPHRINE 1:100,000 INJECTION SOLUTION" RX-10427 CDM 2500000200 HCPCS 250 RC 63323-0482-26 NDC inpatient 20 ML 7.52 7.52 BLUE CROSS BLUE SHIELD WELLMARK SB889 [3081026] BCBS WYOMING [308102603] 7.14 percent of total billed charges 4.66 7.14 Technical (Hospital) Services "LIDOCAINE 1 %-EPINEPHRINE 1:100,000 INJECTION SOLUTION" RX-10427 CDM 2500000200 HCPCS 250 RC 63323-0482-26 NDC inpatient 20 ML 7.52 7.52 UNITED HEALTHCARE (COMMERCIAL) [3081199] UNITED HEALTHCARE 87726 [308119901] 4.66 percent of total billed charges 4.66 7.14 Technical (Hospital) Services "BUPIVACAINE-EPINEPHRINE (PF) 0.5 %-1:200,000 INJECTION SOLUTION" RX-105634 CDM 2500000200 HCPCS 250 RC 00409-9045-01 NDC outpatient 10 ML 14.65 14.65 MEDICA (COMMERCIAL) 94265 [3081118] MEDICA CLAIMS [308111801] 13.19 percent of total billed charges 9.08 13.92 Technical (Hospital) Services "BUPIVACAINE-EPINEPHRINE (PF) 0.5 %-1:200,000 INJECTION SOLUTION" RX-105634 CDM 2500000200 HCPCS 250 RC 00409-9045-01 NDC outpatient 10 ML 14.65 14.65 MULTIPLAN INC 34080 [3081285] MULTIPLAN INC [308128501] 13.92 percent of total billed charges 9.08 13.92 Technical (Hospital) Services "BUPIVACAINE-EPINEPHRINE (PF) 0.5 %-1:200,000 INJECTION SOLUTION" RX-105634 CDM 2500000200 HCPCS 250 RC 00409-9045-01 NDC outpatient 10 ML 14.65 14.65 HEALTHPARTNERS SX009 HEALTHPARTNERS 11.72 percent of total billed charges 9.08 13.92 Technical (Hospital) Services "BUPIVACAINE-EPINEPHRINE (PF) 0.5 %-1:200,000 INJECTION SOLUTION" RX-105634 CDM 2500000200 HCPCS 250 RC 00409-9045-01 NDC outpatient 10 ML 14.65 14.65 UNITED HEALTHCARE (COMMERCIAL) [3081199] UNITED HEALTHCARE 87726 [308119901] 9.08 percent of total billed charges 9.08 13.92 Technical (Hospital) Services "BUPIVACAINE-EPINEPHRINE (PF) 0.5 %-1:200,000 INJECTION SOLUTION" RX-105634 CDM 2500000200 HCPCS 250 RC 00409-9045-01 NDC outpatient 10 ML 14.65 14.65 BLUE CROSS BLUE SHIELD WELLMARK SB889 [3081026] BCBS WYOMING [308102603] 13.92 percent of total billed charges 9.08 13.92 Technical (Hospital) Services "BUPIVACAINE-EPINEPHRINE (PF) 0.5 %-1:200,000 INJECTION SOLUTION" RX-105634 CDM 2500000200 HCPCS 250 RC 00409-9045-01 NDC outpatient 10 ML 14.65 14.65 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES EPO [308136803] 11.72 percent of total billed charges 9.08 13.92 Technical (Hospital) Services "BUPIVACAINE-EPINEPHRINE (PF) 0.5 %-1:200,000 INJECTION SOLUTION" RX-105634 CDM 2500000200 HCPCS 250 RC 00409-9045-01 NDC outpatient 10 ML 14.65 14.65 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES HDHP [308136802] 11.72 percent of total billed charges 9.08 13.92 Technical (Hospital) Services "BUPIVACAINE-EPINEPHRINE (PF) 0.5 %-1:200,000 INJECTION SOLUTION" RX-105634 CDM 2500000200 HCPCS 250 RC 00409-9045-01 NDC outpatient 10 ML 14.65 14.65 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES PPO [308136801] 11.72 percent of total billed charges 9.08 13.92 Technical (Hospital) Services "BUPIVACAINE-EPINEPHRINE (PF) 0.5 %-1:200,000 INJECTION SOLUTION" RX-105634 CDM 2500000200 HCPCS 250 RC 00409-9045-01 NDC outpatient 10 ML 14.65 14.65 CIGNA 62308 [3081051] CIGNA 62308 [308105105] 11.72 percent of total billed charges 9.08 13.92 Technical (Hospital) Services "BUPIVACAINE-EPINEPHRINE (PF) 0.5 %-1:200,000 INJECTION SOLUTION" RX-105634 CDM 2500000200 HCPCS 250 RC 00409-9045-01 NDC outpatient 10 ML 14.65 14.65 CIGNA 62308 [3081051] CIGNA STATE OF WYOMING [308105107] 11.72 percent of total billed charges 9.08 13.92 Technical (Hospital) Services "BUPIVACAINE-EPINEPHRINE (PF) 0.5 %-1:200,000 INJECTION SOLUTION" RX-105634 CDM 2500000200 HCPCS 250 RC 00409-9045-01 NDC inpatient 10 ML 14.65 14.65 BLUE CROSS BLUE SHIELD WELLMARK SB889 [3081026] BCBS WYOMING [308102603] 13.92 percent of total billed charges 9.08 13.92 Technical (Hospital) Services "BUPIVACAINE-EPINEPHRINE (PF) 0.5 %-1:200,000 INJECTION SOLUTION" RX-105634 CDM 2500000200 HCPCS 250 RC 00409-9045-01 NDC inpatient 10 ML 14.65 14.65 UNITED HEALTHCARE (COMMERCIAL) [3081199] UNITED HEALTHCARE 87726 [308119901] 9.08 percent of total billed charges 9.08 13.92 Technical (Hospital) Services "BUPIVACAINE-EPINEPHRINE (PF) 0.5 %-1:200,000 INJECTION SOLUTION" RX-105634 CDM 2500000200 HCPCS 250 RC 00409-9045-01 NDC inpatient 10 ML 14.65 14.65 CIGNA 62308 [3081051] CIGNA 62308 [308105105] 11.6 percent of total billed charges 9.08 13.92 Technical (Hospital) Services "BUPIVACAINE-EPINEPHRINE (PF) 0.5 %-1:200,000 INJECTION SOLUTION" RX-105634 CDM 2500000200 HCPCS 250 RC 00409-9045-01 NDC inpatient 10 ML 14.65 14.65 CIGNA 62308 [3081051] CIGNA STATE OF WYOMING [308105107] 11.6 percent of total billed charges 9.08 13.92 Technical (Hospital) Services "BUPIVACAINE-EPINEPHRINE (PF) 0.5 %-1:200,000 INJECTION SOLUTION" RX-105634 CDM 2500000200 HCPCS 250 RC 00409-9045-01 NDC inpatient 10 ML 14.65 14.65 MEDICA (COMMERCIAL) 94265 [3081118] MEDICA CLAIMS [308111801] 13.19 percent of total billed charges 9.08 13.92 Technical (Hospital) Services "BUPIVACAINE-EPINEPHRINE (PF) 0.5 %-1:200,000 INJECTION SOLUTION" RX-105634 CDM 2500000200 HCPCS 250 RC 00409-9045-01 NDC inpatient 10 ML 14.65 14.65 MULTIPLAN INC 34080 [3081285] MULTIPLAN INC [308128501] 13.92 percent of total billed charges 9.08 13.92 Technical (Hospital) Services "BUPIVACAINE-EPINEPHRINE (PF) 0.5 %-1:200,000 INJECTION SOLUTION" RX-105634 CDM 2500000200 HCPCS 250 RC 00409-9045-01 NDC inpatient 10 ML 14.65 14.65 HEALTHPARTNERS SX009 HEALTHPARTNERS 11.6 percent of total billed charges 9.08 13.92 Technical (Hospital) Services "BUPIVACAINE-EPINEPHRINE (PF) 0.5 %-1:200,000 INJECTION SOLUTION" RX-105634 CDM 2500000200 HCPCS 250 RC 00409-9045-01 NDC inpatient 10 ML 14.65 14.65 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES HDHP [308136802] 11.6 percent of total billed charges 9.08 13.92 Technical (Hospital) Services "BUPIVACAINE-EPINEPHRINE (PF) 0.5 %-1:200,000 INJECTION SOLUTION" RX-105634 CDM 2500000200 HCPCS 250 RC 00409-9045-01 NDC inpatient 10 ML 14.65 14.65 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES EPO [308136803] 11.6 percent of total billed charges 9.08 13.92 Technical (Hospital) Services "BUPIVACAINE-EPINEPHRINE (PF) 0.5 %-1:200,000 INJECTION SOLUTION" RX-105634 CDM 2500000200 HCPCS 250 RC 00409-9045-01 NDC inpatient 10 ML 14.65 14.65 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES PPO [308136801] 11.6 percent of total billed charges 9.08 13.92 Technical (Hospital) Services BUPIVACAINE (PF) 0.5 % (5 MG/ML) INJECTION SOLUTION RX-105640 CDM 2500000200 HCPCS 250 RC 00409-1162-19 NDC outpatient 30 ML 7.87 7.87 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES EPO [308136803] 6.3 percent of total billed charges 4.88 7.48 Technical (Hospital) Services BUPIVACAINE (PF) 0.5 % (5 MG/ML) INJECTION SOLUTION RX-105640 CDM 2500000200 HCPCS 250 RC 00409-1162-19 NDC outpatient 30 ML 7.87 7.87 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES HDHP [308136802] 6.3 percent of total billed charges 4.88 7.48 Technical (Hospital) Services BUPIVACAINE (PF) 0.5 % (5 MG/ML) INJECTION SOLUTION RX-105640 CDM 2500000200 HCPCS 250 RC 00409-1162-19 NDC outpatient 30 ML 7.87 7.87 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES PPO [308136801] 6.3 percent of total billed charges 4.88 7.48 Technical (Hospital) Services BUPIVACAINE (PF) 0.5 % (5 MG/ML) INJECTION SOLUTION RX-105640 CDM 2500000200 HCPCS 250 RC 00409-1162-19 NDC outpatient 30 ML 7.87 7.87 BLUE CROSS BLUE SHIELD WELLMARK SB889 [3081026] BCBS WYOMING [308102603] 7.48 percent of total billed charges 4.88 7.48 Technical (Hospital) Services BUPIVACAINE (PF) 0.5 % (5 MG/ML) INJECTION SOLUTION RX-105640 CDM 2500000200 HCPCS 250 RC 00409-1162-19 NDC outpatient 30 ML 7.87 7.87 UNITED HEALTHCARE (COMMERCIAL) [3081199] UNITED HEALTHCARE 87726 [308119901] 4.88 percent of total billed charges 4.88 7.48 Technical (Hospital) Services BUPIVACAINE (PF) 0.5 % (5 MG/ML) INJECTION SOLUTION RX-105640 CDM 2500000200 HCPCS 250 RC 00409-1162-19 NDC outpatient 30 ML 7.87 7.87 HEALTHPARTNERS SX009 HEALTHPARTNERS 6.3 percent of total billed charges 4.88 7.48 Technical (Hospital) Services BUPIVACAINE (PF) 0.5 % (5 MG/ML) INJECTION SOLUTION RX-105640 CDM 2500000200 HCPCS 250 RC 00409-1162-19 NDC outpatient 30 ML 7.87 7.87 CIGNA 62308 [3081051] CIGNA 62308 [308105105] 6.3 percent of total billed charges 4.88 7.48 Technical (Hospital) Services BUPIVACAINE (PF) 0.5 % (5 MG/ML) INJECTION SOLUTION RX-105640 CDM 2500000200 HCPCS 250 RC 00409-1162-19 NDC outpatient 30 ML 7.87 7.87 CIGNA 62308 [3081051] CIGNA STATE OF WYOMING [308105107] 6.3 percent of total billed charges 4.88 7.48 Technical (Hospital) Services BUPIVACAINE (PF) 0.5 % (5 MG/ML) INJECTION SOLUTION RX-105640 CDM 2500000200 HCPCS 250 RC 00409-1162-19 NDC outpatient 30 ML 7.87 7.87 MULTIPLAN INC 34080 [3081285] MULTIPLAN INC [308128501] 7.48 percent of total billed charges 4.88 7.48 Technical (Hospital) Services BUPIVACAINE (PF) 0.5 % (5 MG/ML) INJECTION SOLUTION RX-105640 CDM 2500000200 HCPCS 250 RC 00409-1162-19 NDC outpatient 30 ML 7.87 7.87 MEDICA (COMMERCIAL) 94265 [3081118] MEDICA CLAIMS [308111801] 7.08 percent of total billed charges 4.88 7.48 Technical (Hospital) Services BUPIVACAINE (PF) 0.5 % (5 MG/ML) INJECTION SOLUTION RX-105640 CDM 2500000200 HCPCS 250 RC 00409-1162-19 NDC inpatient 30 ML 7.87 7.87 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES EPO [308136803] 6.23 percent of total billed charges 4.88 7.48 Technical (Hospital) Services BUPIVACAINE (PF) 0.5 % (5 MG/ML) INJECTION SOLUTION RX-105640 CDM 2500000200 HCPCS 250 RC 00409-1162-19 NDC inpatient 30 ML 7.87 7.87 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES HDHP [308136802] 6.23 percent of total billed charges 4.88 7.48 Technical (Hospital) Services BUPIVACAINE (PF) 0.5 % (5 MG/ML) INJECTION SOLUTION RX-105640 CDM 2500000200 HCPCS 250 RC 00409-1162-19 NDC inpatient 30 ML 7.87 7.87 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES PPO [308136801] 6.23 percent of total billed charges 4.88 7.48 Technical (Hospital) Services BUPIVACAINE (PF) 0.5 % (5 MG/ML) INJECTION SOLUTION RX-105640 CDM 2500000200 HCPCS 250 RC 00409-1162-19 NDC inpatient 30 ML 7.87 7.87 CIGNA 62308 [3081051] CIGNA 62308 [308105105] 6.23 percent of total billed charges 4.88 7.48 Technical (Hospital) Services BUPIVACAINE (PF) 0.5 % (5 MG/ML) INJECTION SOLUTION RX-105640 CDM 2500000200 HCPCS 250 RC 00409-1162-19 NDC inpatient 30 ML 7.87 7.87 CIGNA 62308 [3081051] CIGNA STATE OF WYOMING [308105107] 6.23 percent of total billed charges 4.88 7.48 Technical (Hospital) Services BUPIVACAINE (PF) 0.5 % (5 MG/ML) INJECTION SOLUTION RX-105640 CDM 2500000200 HCPCS 250 RC 00409-1162-19 NDC inpatient 30 ML 7.87 7.87 HEALTHPARTNERS SX009 HEALTHPARTNERS 6.23 percent of total billed charges 4.88 7.48 Technical (Hospital) Services BUPIVACAINE (PF) 0.5 % (5 MG/ML) INJECTION SOLUTION RX-105640 CDM 2500000200 HCPCS 250 RC 00409-1162-19 NDC inpatient 30 ML 7.87 7.87 BLUE CROSS BLUE SHIELD WELLMARK SB889 [3081026] BCBS WYOMING [308102603] 7.48 percent of total billed charges 4.88 7.48 Technical (Hospital) Services BUPIVACAINE (PF) 0.5 % (5 MG/ML) INJECTION SOLUTION RX-105640 CDM 2500000200 HCPCS 250 RC 00409-1162-19 NDC inpatient 30 ML 7.87 7.87 UNITED HEALTHCARE (COMMERCIAL) [3081199] UNITED HEALTHCARE 87726 [308119901] 4.88 percent of total billed charges 4.88 7.48 Technical (Hospital) Services BUPIVACAINE (PF) 0.5 % (5 MG/ML) INJECTION SOLUTION RX-105640 CDM 2500000200 HCPCS 250 RC 00409-1162-19 NDC inpatient 30 ML 7.87 7.87 MEDICA (COMMERCIAL) 94265 [3081118] MEDICA CLAIMS [308111801] 7.08 percent of total billed charges 4.88 7.48 Technical (Hospital) Services BUPIVACAINE (PF) 0.5 % (5 MG/ML) INJECTION SOLUTION RX-105640 CDM 2500000200 HCPCS 250 RC 00409-1162-19 NDC inpatient 30 ML 7.87 7.87 MULTIPLAN INC 34080 [3081285] MULTIPLAN INC [308128501] 7.48 percent of total billed charges 4.88 7.48 Technical (Hospital) Services BALANCED SALT SOLUTION NON-SURGICAL NO.3 EYE WASH RX-10780 CDM 2500000200 HCPCS 250 RC 00065-0530-01 NDC outpatient 30 ML 108.45 108.45 MEDICA (COMMERCIAL) 94265 [3081118] MEDICA CLAIMS [308111801] 97.61 percent of total billed charges 67.24 103.03 Technical (Hospital) Services BALANCED SALT SOLUTION NON-SURGICAL NO.3 EYE WASH RX-10780 CDM 2500000200 HCPCS 250 RC 00065-0530-01 NDC outpatient 30 ML 108.45 108.45 MULTIPLAN INC 34080 [3081285] MULTIPLAN INC [308128501] 103.03 percent of total billed charges 67.24 103.03 Technical (Hospital) Services BALANCED SALT SOLUTION NON-SURGICAL NO.3 EYE WASH RX-10780 CDM 2500000200 HCPCS 250 RC 00065-0530-01 NDC outpatient 30 ML 108.45 108.45 HEALTHPARTNERS SX009 HEALTHPARTNERS 86.76 percent of total billed charges 67.24 103.03 Technical (Hospital) Services BALANCED SALT SOLUTION NON-SURGICAL NO.3 EYE WASH RX-10780 CDM 2500000200 HCPCS 250 RC 00065-0530-01 NDC outpatient 30 ML 108.45 108.45 UNITED HEALTHCARE (COMMERCIAL) [3081199] UNITED HEALTHCARE 87726 [308119901] 67.24 percent of total billed charges 67.24 103.03 Technical (Hospital) Services BALANCED SALT SOLUTION NON-SURGICAL NO.3 EYE WASH RX-10780 CDM 2500000200 HCPCS 250 RC 00065-0530-01 NDC outpatient 30 ML 108.45 108.45 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES HDHP [308136802] 86.76 percent of total billed charges 67.24 103.03 Technical (Hospital) Services BALANCED SALT SOLUTION NON-SURGICAL NO.3 EYE WASH RX-10780 CDM 2500000200 HCPCS 250 RC 00065-0530-01 NDC outpatient 30 ML 108.45 108.45 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES PPO [308136801] 86.76 percent of total billed charges 67.24 103.03 Technical (Hospital) Services BALANCED SALT SOLUTION NON-SURGICAL NO.3 EYE WASH RX-10780 CDM 2500000200 HCPCS 250 RC 00065-0530-01 NDC outpatient 30 ML 108.45 108.45 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES EPO [308136803] 86.76 percent of total billed charges 67.24 103.03 Technical (Hospital) Services BALANCED SALT SOLUTION NON-SURGICAL NO.3 EYE WASH RX-10780 CDM 2500000200 HCPCS 250 RC 00065-0530-01 NDC outpatient 30 ML 108.45 108.45 BLUE CROSS BLUE SHIELD WELLMARK SB889 [3081026] BCBS WYOMING [308102603] 103.03 percent of total billed charges 67.24 103.03 Technical (Hospital) Services BALANCED SALT SOLUTION NON-SURGICAL NO.3 EYE WASH RX-10780 CDM 2500000200 HCPCS 250 RC 00065-0530-01 NDC outpatient 30 ML 108.45 108.45 CIGNA 62308 [3081051] CIGNA 62308 [308105105] 86.76 percent of total billed charges 67.24 103.03 Technical (Hospital) Services BALANCED SALT SOLUTION NON-SURGICAL NO.3 EYE WASH RX-10780 CDM 2500000200 HCPCS 250 RC 00065-0530-01 NDC outpatient 30 ML 108.45 108.45 CIGNA 62308 [3081051] CIGNA STATE OF WYOMING [308105107] 86.76 percent of total billed charges 67.24 103.03 Technical (Hospital) Services BALANCED SALT SOLUTION NON-SURGICAL NO.3 EYE WASH RX-10780 CDM 2500000200 HCPCS 250 RC 00065-0530-01 NDC inpatient 30 ML 108.45 108.45 BLUE CROSS BLUE SHIELD WELLMARK SB889 [3081026] BCBS WYOMING [308102603] 103.03 percent of total billed charges 67.24 103.03 Technical (Hospital) Services BALANCED SALT SOLUTION NON-SURGICAL NO.3 EYE WASH RX-10780 CDM 2500000200 HCPCS 250 RC 00065-0530-01 NDC inpatient 30 ML 108.45 108.45 UNITED HEALTHCARE (COMMERCIAL) [3081199] UNITED HEALTHCARE 87726 [308119901] 67.24 percent of total billed charges 67.24 103.03 Technical (Hospital) Services BALANCED SALT SOLUTION NON-SURGICAL NO.3 EYE WASH RX-10780 CDM 2500000200 HCPCS 250 RC 00065-0530-01 NDC inpatient 30 ML 108.45 108.45 MULTIPLAN INC 34080 [3081285] MULTIPLAN INC [308128501] 103.03 percent of total billed charges 67.24 103.03 Technical (Hospital) Services BALANCED SALT SOLUTION NON-SURGICAL NO.3 EYE WASH RX-10780 CDM 2500000200 HCPCS 250 RC 00065-0530-01 NDC inpatient 30 ML 108.45 108.45 MEDICA (COMMERCIAL) 94265 [3081118] MEDICA CLAIMS [308111801] 97.61 percent of total billed charges 67.24 103.03 Technical (Hospital) Services BALANCED SALT SOLUTION NON-SURGICAL NO.3 EYE WASH RX-10780 CDM 2500000200 HCPCS 250 RC 00065-0530-01 NDC inpatient 30 ML 108.45 108.45 HEALTHPARTNERS SX009 HEALTHPARTNERS 85.87 percent of total billed charges 67.24 103.03 Technical (Hospital) Services BALANCED SALT SOLUTION NON-SURGICAL NO.3 EYE WASH RX-10780 CDM 2500000200 HCPCS 250 RC 00065-0530-01 NDC inpatient 30 ML 108.45 108.45 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES EPO [308136803] 85.87 percent of total billed charges 67.24 103.03 Technical (Hospital) Services BALANCED SALT SOLUTION NON-SURGICAL NO.3 EYE WASH RX-10780 CDM 2500000200 HCPCS 250 RC 00065-0530-01 NDC inpatient 30 ML 108.45 108.45 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES HDHP [308136802] 85.87 percent of total billed charges 67.24 103.03 Technical (Hospital) Services BALANCED SALT SOLUTION NON-SURGICAL NO.3 EYE WASH RX-10780 CDM 2500000200 HCPCS 250 RC 00065-0530-01 NDC inpatient 30 ML 108.45 108.45 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES PPO [308136801] 85.87 percent of total billed charges 67.24 103.03 Technical (Hospital) Services BALANCED SALT SOLUTION NON-SURGICAL NO.3 EYE WASH RX-10780 CDM 2500000200 HCPCS 250 RC 00065-0530-01 NDC inpatient 30 ML 108.45 108.45 CIGNA 62308 [3081051] CIGNA 62308 [308105105] 85.87 percent of total billed charges 67.24 103.03 Technical (Hospital) Services BALANCED SALT SOLUTION NON-SURGICAL NO.3 EYE WASH RX-10780 CDM 2500000200 HCPCS 250 RC 00065-0530-01 NDC inpatient 30 ML 108.45 108.45 CIGNA 62308 [3081051] CIGNA STATE OF WYOMING [308105107] 85.87 percent of total billed charges 67.24 103.03 Technical (Hospital) Services SODIUM BORATE-BORIC ACID-SODIUM CHLORIDE-WATER EYE WASH SOLN RX-10782 CDM 2500000200 HCPCS 250 RC 10119-0002-52 NDC outpatient 1 ML 58.33 58.33 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES EPO [308136803] 46.66 percent of total billed charges 36.16 55.41 Technical (Hospital) Services SODIUM BORATE-BORIC ACID-SODIUM CHLORIDE-WATER EYE WASH SOLN RX-10782 CDM 2500000200 HCPCS 250 RC 10119-0002-52 NDC outpatient 1 ML 58.33 58.33 MEDICA (COMMERCIAL) 94265 [3081118] MEDICA CLAIMS [308111801] 52.5 percent of total billed charges 36.16 55.41 Technical (Hospital) Services SODIUM BORATE-BORIC ACID-SODIUM CHLORIDE-WATER EYE WASH SOLN RX-10782 CDM 2500000200 HCPCS 250 RC 10119-0002-52 NDC outpatient 1 ML 58.33 58.33 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES HDHP [308136802] 46.66 percent of total billed charges 36.16 55.41 Technical (Hospital) Services SODIUM BORATE-BORIC ACID-SODIUM CHLORIDE-WATER EYE WASH SOLN RX-10782 CDM 2500000200 HCPCS 250 RC 10119-0002-52 NDC outpatient 1 ML 58.33 58.33 UNITED HEALTHCARE (COMMERCIAL) [3081199] UNITED HEALTHCARE 87726 [308119901] 36.16 percent of total billed charges 36.16 55.41 Technical (Hospital) Services SODIUM BORATE-BORIC ACID-SODIUM CHLORIDE-WATER EYE WASH SOLN RX-10782 CDM 2500000200 HCPCS 250 RC 10119-0002-52 NDC outpatient 1 ML 58.33 58.33 MULTIPLAN INC 34080 [3081285] MULTIPLAN INC [308128501] 55.41 percent of total billed charges 36.16 55.41 Technical (Hospital) Services SODIUM BORATE-BORIC ACID-SODIUM CHLORIDE-WATER EYE WASH SOLN RX-10782 CDM 2500000200 HCPCS 250 RC 10119-0002-52 NDC outpatient 1 ML 58.33 58.33 CIGNA 62308 [3081051] CIGNA 62308 [308105105] 46.66 percent of total billed charges 36.16 55.41 Technical (Hospital) Services SODIUM BORATE-BORIC ACID-SODIUM CHLORIDE-WATER EYE WASH SOLN RX-10782 CDM 2500000200 HCPCS 250 RC 10119-0002-52 NDC outpatient 1 ML 58.33 58.33 CIGNA 62308 [3081051] CIGNA STATE OF WYOMING [308105107] 46.66 percent of total billed charges 36.16 55.41 Technical (Hospital) Services SODIUM BORATE-BORIC ACID-SODIUM CHLORIDE-WATER EYE WASH SOLN RX-10782 CDM 2500000200 HCPCS 250 RC 10119-0002-52 NDC outpatient 1 ML 58.33 58.33 HEALTHPARTNERS SX009 HEALTHPARTNERS 46.66 percent of total billed charges 36.16 55.41 Technical (Hospital) Services SODIUM BORATE-BORIC ACID-SODIUM CHLORIDE-WATER EYE WASH SOLN RX-10782 CDM 2500000200 HCPCS 250 RC 10119-0002-52 NDC outpatient 1 ML 58.33 58.33 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES PPO [308136801] 46.66 percent of total billed charges 36.16 55.41 Technical (Hospital) Services SODIUM BORATE-BORIC ACID-SODIUM CHLORIDE-WATER EYE WASH SOLN RX-10782 CDM 2500000200 HCPCS 250 RC 10119-0002-52 NDC outpatient 1 ML 58.33 58.33 BLUE CROSS BLUE SHIELD WELLMARK SB889 [3081026] BCBS WYOMING [308102603] 55.41 percent of total billed charges 36.16 55.41 Technical (Hospital) Services SODIUM BORATE-BORIC ACID-SODIUM CHLORIDE-WATER EYE WASH SOLN RX-10782 CDM 2500000200 HCPCS 250 RC 10119-0002-52 NDC inpatient 1 ML 58.33 58.33 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES PPO [308136801] 46.19 percent of total billed charges 36.16 55.41 Technical (Hospital) Services SODIUM BORATE-BORIC ACID-SODIUM CHLORIDE-WATER EYE WASH SOLN RX-10782 CDM 2500000200 HCPCS 250 RC 10119-0002-52 NDC inpatient 1 ML 58.33 58.33 HEALTHPARTNERS SX009 HEALTHPARTNERS 46.19 percent of total billed charges 36.16 55.41 Technical (Hospital) Services SODIUM BORATE-BORIC ACID-SODIUM CHLORIDE-WATER EYE WASH SOLN RX-10782 CDM 2500000200 HCPCS 250 RC 10119-0002-52 NDC inpatient 1 ML 58.33 58.33 MEDICA (COMMERCIAL) 94265 [3081118] MEDICA CLAIMS [308111801] 52.5 percent of total billed charges 36.16 55.41 Technical (Hospital) Services SODIUM BORATE-BORIC ACID-SODIUM CHLORIDE-WATER EYE WASH SOLN RX-10782 CDM 2500000200 HCPCS 250 RC 10119-0002-52 NDC inpatient 1 ML 58.33 58.33 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES EPO [308136803] 46.19 percent of total billed charges 36.16 55.41 Technical (Hospital) Services SODIUM BORATE-BORIC ACID-SODIUM CHLORIDE-WATER EYE WASH SOLN RX-10782 CDM 2500000200 HCPCS 250 RC 10119-0002-52 NDC inpatient 1 ML 58.33 58.33 UNITED HEALTHCARE (COMMERCIAL) [3081199] UNITED HEALTHCARE 87726 [308119901] 36.16 percent of total billed charges 36.16 55.41 Technical (Hospital) Services SODIUM BORATE-BORIC ACID-SODIUM CHLORIDE-WATER EYE WASH SOLN RX-10782 CDM 2500000200 HCPCS 250 RC 10119-0002-52 NDC inpatient 1 ML 58.33 58.33 BLUE CROSS BLUE SHIELD WELLMARK SB889 [3081026] BCBS WYOMING [308102603] 55.41 percent of total billed charges 36.16 55.41 Technical (Hospital) Services SODIUM BORATE-BORIC ACID-SODIUM CHLORIDE-WATER EYE WASH SOLN RX-10782 CDM 2500000200 HCPCS 250 RC 10119-0002-52 NDC inpatient 1 ML 58.33 58.33 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES HDHP [308136802] 46.19 percent of total billed charges 36.16 55.41 Technical (Hospital) Services SODIUM BORATE-BORIC ACID-SODIUM CHLORIDE-WATER EYE WASH SOLN RX-10782 CDM 2500000200 HCPCS 250 RC 10119-0002-52 NDC inpatient 1 ML 58.33 58.33 CIGNA 62308 [3081051] CIGNA 62308 [308105105] 46.19 percent of total billed charges 36.16 55.41 Technical (Hospital) Services SODIUM BORATE-BORIC ACID-SODIUM CHLORIDE-WATER EYE WASH SOLN RX-10782 CDM 2500000200 HCPCS 250 RC 10119-0002-52 NDC inpatient 1 ML 58.33 58.33 CIGNA 62308 [3081051] CIGNA STATE OF WYOMING [308105107] 46.19 percent of total billed charges 36.16 55.41 Technical (Hospital) Services SODIUM BORATE-BORIC ACID-SODIUM CHLORIDE-WATER EYE WASH SOLN RX-10782 CDM 2500000200 HCPCS 250 RC 10119-0002-52 NDC inpatient 1 ML 58.33 58.33 MULTIPLAN INC 34080 [3081285] MULTIPLAN INC [308128501] 55.41 percent of total billed charges 36.16 55.41 Technical (Hospital) Services SODIUM CHLORIDE 0.9 % IRRIGATION SOLUTION RX-11403 CDM 2500000200 HCPCS 250 RC 00264-2201-00 NDC inpatient 1000 ML 18.9 18.9 CIGNA 62308 [3081051] CIGNA 62308 [308105105] 14.97 percent of total billed charges 11.72 17.96 Technical (Hospital) Services SODIUM CHLORIDE 0.9 % IRRIGATION SOLUTION RX-11403 CDM 2500000200 HCPCS 250 RC 00264-2201-00 NDC inpatient 1000 ML 18.9 18.9 CIGNA 62308 [3081051] CIGNA STATE OF WYOMING [308105107] 14.97 percent of total billed charges 11.72 17.96 Technical (Hospital) Services SODIUM CHLORIDE 0.9 % IRRIGATION SOLUTION RX-11403 CDM 2500000200 HCPCS 250 RC 00264-2201-00 NDC inpatient 1000 ML 18.9 18.9 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES EPO [308136803] 14.97 percent of total billed charges 11.72 17.96 Technical (Hospital) Services SODIUM CHLORIDE 0.9 % IRRIGATION SOLUTION RX-11403 CDM 2500000200 HCPCS 250 RC 00264-2201-00 NDC inpatient 1000 ML 18.9 18.9 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES HDHP [308136802] 14.97 percent of total billed charges 11.72 17.96 Technical (Hospital) Services SODIUM CHLORIDE 0.9 % IRRIGATION SOLUTION RX-11403 CDM 2500000200 HCPCS 250 RC 00264-2201-00 NDC inpatient 1000 ML 18.9 18.9 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES PPO [308136801] 14.97 percent of total billed charges 11.72 17.96 Technical (Hospital) Services SODIUM CHLORIDE 0.9 % IRRIGATION SOLUTION RX-11403 CDM 2500000200 HCPCS 250 RC 00264-2201-00 NDC inpatient 1000 ML 18.9 18.9 UNITED HEALTHCARE (COMMERCIAL) [3081199] UNITED HEALTHCARE 87726 [308119901] 11.72 percent of total billed charges 11.72 17.96 Technical (Hospital) Services SODIUM CHLORIDE 0.9 % IRRIGATION SOLUTION RX-11403 CDM 2500000200 HCPCS 250 RC 00264-2201-00 NDC inpatient 1000 ML 18.9 18.9 BLUE CROSS BLUE SHIELD WELLMARK SB889 [3081026] BCBS WYOMING [308102603] 17.96 percent of total billed charges 11.72 17.96 Technical (Hospital) Services SODIUM CHLORIDE 0.9 % IRRIGATION SOLUTION RX-11403 CDM 2500000200 HCPCS 250 RC 00264-2201-00 NDC inpatient 1000 ML 18.9 18.9 MEDICA (COMMERCIAL) 94265 [3081118] MEDICA CLAIMS [308111801] 17.01 percent of total billed charges 11.72 17.96 Technical (Hospital) Services SODIUM CHLORIDE 0.9 % IRRIGATION SOLUTION RX-11403 CDM 2500000200 HCPCS 250 RC 00264-2201-00 NDC inpatient 1000 ML 18.9 18.9 MULTIPLAN INC 34080 [3081285] MULTIPLAN INC [308128501] 17.96 percent of total billed charges 11.72 17.96 Technical (Hospital) Services SODIUM CHLORIDE 0.9 % IRRIGATION SOLUTION RX-11403 CDM 2500000200 HCPCS 250 RC 00264-2201-00 NDC inpatient 1000 ML 18.9 18.9 HEALTHPARTNERS SX009 HEALTHPARTNERS 14.97 percent of total billed charges 11.72 17.96 Technical (Hospital) Services SODIUM CHLORIDE 0.9 % IRRIGATION SOLUTION RX-11403 CDM 2500000200 HCPCS 250 RC 00264-2201-00 NDC outpatient 1000 ML 18.9 18.9 HEALTHPARTNERS SX009 HEALTHPARTNERS 15.12 percent of total billed charges 11.72 17.96 Technical (Hospital) Services SODIUM CHLORIDE 0.9 % IRRIGATION SOLUTION RX-11403 CDM 2500000200 HCPCS 250 RC 00264-2201-00 NDC outpatient 1000 ML 18.9 18.9 UNITED HEALTHCARE (COMMERCIAL) [3081199] UNITED HEALTHCARE 87726 [308119901] 11.72 percent of total billed charges 11.72 17.96 Technical (Hospital) Services SODIUM CHLORIDE 0.9 % IRRIGATION SOLUTION RX-11403 CDM 2500000200 HCPCS 250 RC 00264-2201-00 NDC outpatient 1000 ML 18.9 18.9 BLUE CROSS BLUE SHIELD WELLMARK SB889 [3081026] BCBS WYOMING [308102603] 17.96 percent of total billed charges 11.72 17.96 Technical (Hospital) Services SODIUM CHLORIDE 0.9 % IRRIGATION SOLUTION RX-11403 CDM 2500000200 HCPCS 250 RC 00264-2201-00 NDC outpatient 1000 ML 18.9 18.9 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES HDHP [308136802] 15.12 percent of total billed charges 11.72 17.96 Technical (Hospital) Services SODIUM CHLORIDE 0.9 % IRRIGATION SOLUTION RX-11403 CDM 2500000200 HCPCS 250 RC 00264-2201-00 NDC outpatient 1000 ML 18.9 18.9 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES EPO [308136803] 15.12 percent of total billed charges 11.72 17.96 Technical (Hospital) Services SODIUM CHLORIDE 0.9 % IRRIGATION SOLUTION RX-11403 CDM 2500000200 HCPCS 250 RC 00264-2201-00 NDC outpatient 1000 ML 18.9 18.9 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES PPO [308136801] 15.12 percent of total billed charges 11.72 17.96 Technical (Hospital) Services SODIUM CHLORIDE 0.9 % IRRIGATION SOLUTION RX-11403 CDM 2500000200 HCPCS 250 RC 00264-2201-00 NDC outpatient 1000 ML 18.9 18.9 MULTIPLAN INC 34080 [3081285] MULTIPLAN INC [308128501] 17.96 percent of total billed charges 11.72 17.96 Technical (Hospital) Services SODIUM CHLORIDE 0.9 % IRRIGATION SOLUTION RX-11403 CDM 2500000200 HCPCS 250 RC 00264-2201-00 NDC outpatient 1000 ML 18.9 18.9 MEDICA (COMMERCIAL) 94265 [3081118] MEDICA CLAIMS [308111801] 17.01 percent of total billed charges 11.72 17.96 Technical (Hospital) Services SODIUM CHLORIDE 0.9 % IRRIGATION SOLUTION RX-11403 CDM 2500000200 HCPCS 250 RC 00264-2201-00 NDC outpatient 1000 ML 18.9 18.9 CIGNA 62308 [3081051] CIGNA 62308 [308105105] 15.12 percent of total billed charges 11.72 17.96 Technical (Hospital) Services SODIUM CHLORIDE 0.9 % IRRIGATION SOLUTION RX-11403 CDM 2500000200 HCPCS 250 RC 00264-2201-00 NDC outpatient 1000 ML 18.9 18.9 CIGNA 62308 [3081051] CIGNA STATE OF WYOMING [308105107] 15.12 percent of total billed charges 11.72 17.96 Technical (Hospital) Services "TRANEXAMIC ACID 1,000 MG/10 ML (100 MG/ML) INTRAVENOUS SOLUTION" RX-11573 CDM 2500000200 HCPCS 250 RC 23155-0524-31 NDC inpatient 1 ML 58.84 58.84 MEDICA (COMMERCIAL) 94265 [3081118] MEDICA CLAIMS [308111801] 52.96 percent of total billed charges 36.48 55.9 Technical (Hospital) Services "TRANEXAMIC ACID 1,000 MG/10 ML (100 MG/ML) INTRAVENOUS SOLUTION" RX-11573 CDM 2500000200 HCPCS 250 RC 23155-0524-31 NDC inpatient 1 ML 58.84 58.84 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES PPO [308136801] 46.59 percent of total billed charges 36.48 55.9 Technical (Hospital) Services "TRANEXAMIC ACID 1,000 MG/10 ML (100 MG/ML) INTRAVENOUS SOLUTION" RX-11573 CDM 2500000200 HCPCS 250 RC 23155-0524-31 NDC inpatient 1 ML 58.84 58.84 HEALTHPARTNERS SX009 HEALTHPARTNERS 46.59 percent of total billed charges 36.48 55.9 Technical (Hospital) Services "TRANEXAMIC ACID 1,000 MG/10 ML (100 MG/ML) INTRAVENOUS SOLUTION" RX-11573 CDM 2500000200 HCPCS 250 RC 23155-0524-31 NDC inpatient 1 ML 58.84 58.84 MULTIPLAN INC 34080 [3081285] MULTIPLAN INC [308128501] 55.9 percent of total billed charges 36.48 55.9 Technical (Hospital) Services "TRANEXAMIC ACID 1,000 MG/10 ML (100 MG/ML) INTRAVENOUS SOLUTION" RX-11573 CDM 2500000200 HCPCS 250 RC 23155-0524-31 NDC inpatient 1 ML 58.84 58.84 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES EPO [308136803] 46.59 percent of total billed charges 36.48 55.9 Technical (Hospital) Services "TRANEXAMIC ACID 1,000 MG/10 ML (100 MG/ML) INTRAVENOUS SOLUTION" RX-11573 CDM 2500000200 HCPCS 250 RC 23155-0524-31 NDC inpatient 1 ML 58.84 58.84 CIGNA 62308 [3081051] CIGNA 62308 [308105105] 46.59 percent of total billed charges 36.48 55.9 Technical (Hospital) Services "TRANEXAMIC ACID 1,000 MG/10 ML (100 MG/ML) INTRAVENOUS SOLUTION" RX-11573 CDM 2500000200 HCPCS 250 RC 23155-0524-31 NDC inpatient 1 ML 58.84 58.84 CIGNA 62308 [3081051] CIGNA STATE OF WYOMING [308105107] 46.59 percent of total billed charges 36.48 55.9 Technical (Hospital) Services "TRANEXAMIC ACID 1,000 MG/10 ML (100 MG/ML) INTRAVENOUS SOLUTION" RX-11573 CDM 2500000200 HCPCS 250 RC 23155-0524-31 NDC inpatient 1 ML 58.84 58.84 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES HDHP [308136802] 46.59 percent of total billed charges 36.48 55.9 Technical (Hospital) Services "TRANEXAMIC ACID 1,000 MG/10 ML (100 MG/ML) INTRAVENOUS SOLUTION" RX-11573 CDM 2500000200 HCPCS 250 RC 23155-0524-31 NDC inpatient 1 ML 58.84 58.84 UNITED HEALTHCARE (COMMERCIAL) [3081199] UNITED HEALTHCARE 87726 [308119901] 36.48 percent of total billed charges 36.48 55.9 Technical (Hospital) Services "TRANEXAMIC ACID 1,000 MG/10 ML (100 MG/ML) INTRAVENOUS SOLUTION" RX-11573 CDM 2500000200 HCPCS 250 RC 23155-0524-31 NDC inpatient 1 ML 58.84 58.84 BLUE CROSS BLUE SHIELD WELLMARK SB889 [3081026] BCBS WYOMING [308102603] 55.9 percent of total billed charges 36.48 55.9 Technical (Hospital) Services "TRANEXAMIC ACID 1,000 MG/10 ML (100 MG/ML) INTRAVENOUS SOLUTION" RX-11573 CDM 2500000200 HCPCS 250 RC 23155-0524-31 NDC outpatient 1 ML 58.84 58.84 BLUE CROSS BLUE SHIELD WELLMARK SB889 [3081026] BCBS WYOMING [308102603] 55.9 percent of total billed charges 36.48 55.9 Technical (Hospital) Services "TRANEXAMIC ACID 1,000 MG/10 ML (100 MG/ML) INTRAVENOUS SOLUTION" RX-11573 CDM 2500000200 HCPCS 250 RC 23155-0524-31 NDC outpatient 1 ML 58.84 58.84 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES PPO [308136801] 47.07 percent of total billed charges 36.48 55.9 Technical (Hospital) Services "TRANEXAMIC ACID 1,000 MG/10 ML (100 MG/ML) INTRAVENOUS SOLUTION" RX-11573 CDM 2500000200 HCPCS 250 RC 23155-0524-31 NDC outpatient 1 ML 58.84 58.84 UNITED HEALTHCARE (COMMERCIAL) [3081199] UNITED HEALTHCARE 87726 [308119901] 36.48 percent of total billed charges 36.48 55.9 Technical (Hospital) Services "TRANEXAMIC ACID 1,000 MG/10 ML (100 MG/ML) INTRAVENOUS SOLUTION" RX-11573 CDM 2500000200 HCPCS 250 RC 23155-0524-31 NDC outpatient 1 ML 58.84 58.84 HEALTHPARTNERS SX009 HEALTHPARTNERS 47.07 percent of total billed charges 36.48 55.9 Technical (Hospital) Services "TRANEXAMIC ACID 1,000 MG/10 ML (100 MG/ML) INTRAVENOUS SOLUTION" RX-11573 CDM 2500000200 HCPCS 250 RC 23155-0524-31 NDC outpatient 1 ML 58.84 58.84 MULTIPLAN INC 34080 [3081285] MULTIPLAN INC [308128501] 55.9 percent of total billed charges 36.48 55.9 Technical (Hospital) Services "TRANEXAMIC ACID 1,000 MG/10 ML (100 MG/ML) INTRAVENOUS SOLUTION" RX-11573 CDM 2500000200 HCPCS 250 RC 23155-0524-31 NDC outpatient 1 ML 58.84 58.84 CIGNA 62308 [3081051] CIGNA 62308 [308105105] 47.07 percent of total billed charges 36.48 55.9 Technical (Hospital) Services "TRANEXAMIC ACID 1,000 MG/10 ML (100 MG/ML) INTRAVENOUS SOLUTION" RX-11573 CDM 2500000200 HCPCS 250 RC 23155-0524-31 NDC outpatient 1 ML 58.84 58.84 CIGNA 62308 [3081051] CIGNA STATE OF WYOMING [308105107] 47.07 percent of total billed charges 36.48 55.9 Technical (Hospital) Services "TRANEXAMIC ACID 1,000 MG/10 ML (100 MG/ML) INTRAVENOUS SOLUTION" RX-11573 CDM 2500000200 HCPCS 250 RC 23155-0524-31 NDC outpatient 1 ML 58.84 58.84 MEDICA (COMMERCIAL) 94265 [3081118] MEDICA CLAIMS [308111801] 52.96 percent of total billed charges 36.48 55.9 Technical (Hospital) Services "TRANEXAMIC ACID 1,000 MG/10 ML (100 MG/ML) INTRAVENOUS SOLUTION" RX-11573 CDM 2500000200 HCPCS 250 RC 23155-0524-31 NDC outpatient 1 ML 58.84 58.84 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES HDHP [308136802] 47.07 percent of total billed charges 36.48 55.9 Technical (Hospital) Services "TRANEXAMIC ACID 1,000 MG/10 ML (100 MG/ML) INTRAVENOUS SOLUTION" RX-11573 CDM 2500000200 HCPCS 250 RC 23155-0524-31 NDC outpatient 1 ML 58.84 58.84 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES EPO [308136803] 47.07 percent of total billed charges 36.48 55.9 Technical (Hospital) Services VECURONIUM BROMIDE 10 MG INTRAVENOUS SOLUTION RX-11634 CDM 2500000200 HCPCS 250 RC 67457-0438-10 NDC outpatient 10 ML 80.63 80.63 CIGNA 62308 [3081051] CIGNA 62308 [308105105] 64.5 percent of total billed charges 49.99 76.6 Technical (Hospital) Services VECURONIUM BROMIDE 10 MG INTRAVENOUS SOLUTION RX-11634 CDM 2500000200 HCPCS 250 RC 67457-0438-10 NDC outpatient 10 ML 80.63 80.63 CIGNA 62308 [3081051] CIGNA STATE OF WYOMING [308105107] 64.5 percent of total billed charges 49.99 76.6 Technical (Hospital) Services VECURONIUM BROMIDE 10 MG INTRAVENOUS SOLUTION RX-11634 CDM 2500000200 HCPCS 250 RC 67457-0438-10 NDC outpatient 10 ML 80.63 80.63 MEDICA (COMMERCIAL) 94265 [3081118] MEDICA CLAIMS [308111801] 72.57 percent of total billed charges 49.99 76.6 Technical (Hospital) Services VECURONIUM BROMIDE 10 MG INTRAVENOUS SOLUTION RX-11634 CDM 2500000200 HCPCS 250 RC 67457-0438-10 NDC outpatient 10 ML 80.63 80.63 MULTIPLAN INC 34080 [3081285] MULTIPLAN INC [308128501] 76.6 percent of total billed charges 49.99 76.6 Technical (Hospital) Services VECURONIUM BROMIDE 10 MG INTRAVENOUS SOLUTION RX-11634 CDM 2500000200 HCPCS 250 RC 67457-0438-10 NDC outpatient 10 ML 80.63 80.63 UNITED HEALTHCARE (COMMERCIAL) [3081199] UNITED HEALTHCARE 87726 [308119901] 49.99 percent of total billed charges 49.99 76.6 Technical (Hospital) Services VECURONIUM BROMIDE 10 MG INTRAVENOUS SOLUTION RX-11634 CDM 2500000200 HCPCS 250 RC 67457-0438-10 NDC outpatient 10 ML 80.63 80.63 HEALTHPARTNERS SX009 HEALTHPARTNERS 64.5 percent of total billed charges 49.99 76.6 Technical (Hospital) Services VECURONIUM BROMIDE 10 MG INTRAVENOUS SOLUTION RX-11634 CDM 2500000200 HCPCS 250 RC 67457-0438-10 NDC outpatient 10 ML 80.63 80.63 BLUE CROSS BLUE SHIELD WELLMARK SB889 [3081026] BCBS WYOMING [308102603] 76.6 percent of total billed charges 49.99 76.6 Technical (Hospital) Services VECURONIUM BROMIDE 10 MG INTRAVENOUS SOLUTION RX-11634 CDM 2500000200 HCPCS 250 RC 67457-0438-10 NDC outpatient 10 ML 80.63 80.63 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES HDHP [308136802] 64.5 percent of total billed charges 49.99 76.6 Technical (Hospital) Services VECURONIUM BROMIDE 10 MG INTRAVENOUS SOLUTION RX-11634 CDM 2500000200 HCPCS 250 RC 67457-0438-10 NDC outpatient 10 ML 80.63 80.63 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES EPO [308136803] 64.5 percent of total billed charges 49.99 76.6 Technical (Hospital) Services VECURONIUM BROMIDE 10 MG INTRAVENOUS SOLUTION RX-11634 CDM 2500000200 HCPCS 250 RC 67457-0438-10 NDC outpatient 10 ML 80.63 80.63 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES PPO [308136801] 64.5 percent of total billed charges 49.99 76.6 Technical (Hospital) Services VECURONIUM BROMIDE 10 MG INTRAVENOUS SOLUTION RX-11634 CDM 2500000200 HCPCS 250 RC 67457-0438-10 NDC inpatient 10 ML 80.63 80.63 BLUE CROSS BLUE SHIELD WELLMARK SB889 [3081026] BCBS WYOMING [308102603] 76.6 percent of total billed charges 49.99 76.6 Technical (Hospital) Services VECURONIUM BROMIDE 10 MG INTRAVENOUS SOLUTION RX-11634 CDM 2500000200 HCPCS 250 RC 67457-0438-10 NDC inpatient 10 ML 80.63 80.63 CIGNA 62308 [3081051] CIGNA 62308 [308105105] 63.84 percent of total billed charges 49.99 76.6 Technical (Hospital) Services VECURONIUM BROMIDE 10 MG INTRAVENOUS SOLUTION RX-11634 CDM 2500000200 HCPCS 250 RC 67457-0438-10 NDC inpatient 10 ML 80.63 80.63 CIGNA 62308 [3081051] CIGNA STATE OF WYOMING [308105107] 63.84 percent of total billed charges 49.99 76.6 Technical (Hospital) Services VECURONIUM BROMIDE 10 MG INTRAVENOUS SOLUTION RX-11634 CDM 2500000200 HCPCS 250 RC 67457-0438-10 NDC inpatient 10 ML 80.63 80.63 UNITED HEALTHCARE (COMMERCIAL) [3081199] UNITED HEALTHCARE 87726 [308119901] 49.99 percent of total billed charges 49.99 76.6 Technical (Hospital) Services VECURONIUM BROMIDE 10 MG INTRAVENOUS SOLUTION RX-11634 CDM 2500000200 HCPCS 250 RC 67457-0438-10 NDC inpatient 10 ML 80.63 80.63 MEDICA (COMMERCIAL) 94265 [3081118] MEDICA CLAIMS [308111801] 72.57 percent of total billed charges 49.99 76.6 Technical (Hospital) Services VECURONIUM BROMIDE 10 MG INTRAVENOUS SOLUTION RX-11634 CDM 2500000200 HCPCS 250 RC 67457-0438-10 NDC inpatient 10 ML 80.63 80.63 MULTIPLAN INC 34080 [3081285] MULTIPLAN INC [308128501] 76.6 percent of total billed charges 49.99 76.6 Technical (Hospital) Services VECURONIUM BROMIDE 10 MG INTRAVENOUS SOLUTION RX-11634 CDM 2500000200 HCPCS 250 RC 67457-0438-10 NDC inpatient 10 ML 80.63 80.63 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES EPO [308136803] 63.84 percent of total billed charges 49.99 76.6 Technical (Hospital) Services VECURONIUM BROMIDE 10 MG INTRAVENOUS SOLUTION RX-11634 CDM 2500000200 HCPCS 250 RC 67457-0438-10 NDC inpatient 10 ML 80.63 80.63 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES HDHP [308136802] 63.84 percent of total billed charges 49.99 76.6 Technical (Hospital) Services VECURONIUM BROMIDE 10 MG INTRAVENOUS SOLUTION RX-11634 CDM 2500000200 HCPCS 250 RC 67457-0438-10 NDC inpatient 10 ML 80.63 80.63 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES PPO [308136801] 63.84 percent of total billed charges 49.99 76.6 Technical (Hospital) Services VECURONIUM BROMIDE 10 MG INTRAVENOUS SOLUTION RX-11634 CDM 2500000200 HCPCS 250 RC 67457-0438-10 NDC inpatient 10 ML 80.63 80.63 HEALTHPARTNERS SX009 HEALTHPARTNERS 63.84 percent of total billed charges 49.99 76.6 Technical (Hospital) Services VECURONIUM BROMIDE 20 MG INTRAVENOUS SOLUTION RX-11635 CDM 2500000200 HCPCS 250 RC 67457-0475-20 NDC inpatient 20 ME 81.4 81.4 MULTIPLAN INC 34080 [3081285] MULTIPLAN INC [308128501] 77.33 percent of total billed charges 50.47 77.33 Technical (Hospital) Services VECURONIUM BROMIDE 20 MG INTRAVENOUS SOLUTION RX-11635 CDM 2500000200 HCPCS 250 RC 67457-0475-20 NDC inpatient 20 ME 81.4 81.4 MEDICA (COMMERCIAL) 94265 [3081118] MEDICA CLAIMS [308111801] 73.26 percent of total billed charges 50.47 77.33 Technical (Hospital) Services VECURONIUM BROMIDE 20 MG INTRAVENOUS SOLUTION RX-11635 CDM 2500000200 HCPCS 250 RC 67457-0475-20 NDC inpatient 20 ME 81.4 81.4 UNITED HEALTHCARE (COMMERCIAL) [3081199] UNITED HEALTHCARE 87726 [308119901] 50.47 percent of total billed charges 50.47 77.33 Technical (Hospital) Services VECURONIUM BROMIDE 20 MG INTRAVENOUS SOLUTION RX-11635 CDM 2500000200 HCPCS 250 RC 67457-0475-20 NDC inpatient 20 ME 81.4 81.4 BLUE CROSS BLUE SHIELD WELLMARK SB889 [3081026] BCBS WYOMING [308102603] 77.33 percent of total billed charges 50.47 77.33 Technical (Hospital) Services VECURONIUM BROMIDE 20 MG INTRAVENOUS SOLUTION RX-11635 CDM 2500000200 HCPCS 250 RC 67457-0475-20 NDC inpatient 20 ME 81.4 81.4 HEALTHPARTNERS SX009 HEALTHPARTNERS 64.45 percent of total billed charges 50.47 77.33 Technical (Hospital) Services VECURONIUM BROMIDE 20 MG INTRAVENOUS SOLUTION RX-11635 CDM 2500000200 HCPCS 250 RC 67457-0475-20 NDC inpatient 20 ME 81.4 81.4 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES EPO [308136803] 64.45 percent of total billed charges 50.47 77.33 Technical (Hospital) Services VECURONIUM BROMIDE 20 MG INTRAVENOUS SOLUTION RX-11635 CDM 2500000200 HCPCS 250 RC 67457-0475-20 NDC inpatient 20 ME 81.4 81.4 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES HDHP [308136802] 64.45 percent of total billed charges 50.47 77.33 Technical (Hospital) Services VECURONIUM BROMIDE 20 MG INTRAVENOUS SOLUTION RX-11635 CDM 2500000200 HCPCS 250 RC 67457-0475-20 NDC inpatient 20 ME 81.4 81.4 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES PPO [308136801] 64.45 percent of total billed charges 50.47 77.33 Technical (Hospital) Services VECURONIUM BROMIDE 20 MG INTRAVENOUS SOLUTION RX-11635 CDM 2500000200 HCPCS 250 RC 67457-0475-20 NDC inpatient 20 ME 81.4 81.4 CIGNA 62308 [3081051] CIGNA 62308 [308105105] 64.45 percent of total billed charges 50.47 77.33 Technical (Hospital) Services VECURONIUM BROMIDE 20 MG INTRAVENOUS SOLUTION RX-11635 CDM 2500000200 HCPCS 250 RC 67457-0475-20 NDC inpatient 20 ME 81.4 81.4 CIGNA 62308 [3081051] CIGNA STATE OF WYOMING [308105107] 64.45 percent of total billed charges 50.47 77.33 Technical (Hospital) Services VECURONIUM BROMIDE 20 MG INTRAVENOUS SOLUTION RX-11635 CDM 2500000200 HCPCS 250 RC 67457-0475-20 NDC outpatient 20 ME 81.4 81.4 MULTIPLAN INC 34080 [3081285] MULTIPLAN INC [308128501] 77.33 percent of total billed charges 50.47 77.33 Technical (Hospital) Services VECURONIUM BROMIDE 20 MG INTRAVENOUS SOLUTION RX-11635 CDM 2500000200 HCPCS 250 RC 67457-0475-20 NDC outpatient 20 ME 81.4 81.4 MEDICA (COMMERCIAL) 94265 [3081118] MEDICA CLAIMS [308111801] 73.26 percent of total billed charges 50.47 77.33 Technical (Hospital) Services VECURONIUM BROMIDE 20 MG INTRAVENOUS SOLUTION RX-11635 CDM 2500000200 HCPCS 250 RC 67457-0475-20 NDC outpatient 20 ME 81.4 81.4 CIGNA 62308 [3081051] CIGNA 62308 [308105105] 65.12 percent of total billed charges 50.47 77.33 Technical (Hospital) Services VECURONIUM BROMIDE 20 MG INTRAVENOUS SOLUTION RX-11635 CDM 2500000200 HCPCS 250 RC 67457-0475-20 NDC outpatient 20 ME 81.4 81.4 CIGNA 62308 [3081051] CIGNA STATE OF WYOMING [308105107] 65.12 percent of total billed charges 50.47 77.33 Technical (Hospital) Services VECURONIUM BROMIDE 20 MG INTRAVENOUS SOLUTION RX-11635 CDM 2500000200 HCPCS 250 RC 67457-0475-20 NDC outpatient 20 ME 81.4 81.4 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES EPO [308136803] 65.12 percent of total billed charges 50.47 77.33 Technical (Hospital) Services VECURONIUM BROMIDE 20 MG INTRAVENOUS SOLUTION RX-11635 CDM 2500000200 HCPCS 250 RC 67457-0475-20 NDC outpatient 20 ME 81.4 81.4 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES PPO [308136801] 65.12 percent of total billed charges 50.47 77.33 Technical (Hospital) Services VECURONIUM BROMIDE 20 MG INTRAVENOUS SOLUTION RX-11635 CDM 2500000200 HCPCS 250 RC 67457-0475-20 NDC outpatient 20 ME 81.4 81.4 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES HDHP [308136802] 65.12 percent of total billed charges 50.47 77.33 Technical (Hospital) Services VECURONIUM BROMIDE 20 MG INTRAVENOUS SOLUTION RX-11635 CDM 2500000200 HCPCS 250 RC 67457-0475-20 NDC outpatient 20 ME 81.4 81.4 UNITED HEALTHCARE (COMMERCIAL) [3081199] UNITED HEALTHCARE 87726 [308119901] 50.47 percent of total billed charges 50.47 77.33 Technical (Hospital) Services VECURONIUM BROMIDE 20 MG INTRAVENOUS SOLUTION RX-11635 CDM 2500000200 HCPCS 250 RC 67457-0475-20 NDC outpatient 20 ME 81.4 81.4 BLUE CROSS BLUE SHIELD WELLMARK SB889 [3081026] BCBS WYOMING [308102603] 77.33 percent of total billed charges 50.47 77.33 Technical (Hospital) Services VECURONIUM BROMIDE 20 MG INTRAVENOUS SOLUTION RX-11635 CDM 2500000200 HCPCS 250 RC 67457-0475-20 NDC outpatient 20 ME 81.4 81.4 HEALTHPARTNERS SX009 HEALTHPARTNERS 65.12 percent of total billed charges 50.47 77.33 Technical (Hospital) Services "WATER FOR INJECTION, STERILE INJECTION SOLUTION" RX-11671 CDM 2500000200 HCPCS 250 RC 00409-4887-17 NDC outpatient 10 ML 59.34 59.34 MULTIPLAN INC 34080 [3081285] MULTIPLAN INC [308128501] 56.37 percent of total billed charges 36.79 56.37 Technical (Hospital) Services "WATER FOR INJECTION, STERILE INJECTION SOLUTION" RX-11671 CDM 2500000200 HCPCS 250 RC 00409-4887-17 NDC outpatient 10 ML 59.34 59.34 MEDICA (COMMERCIAL) 94265 [3081118] MEDICA CLAIMS [308111801] 53.41 percent of total billed charges 36.79 56.37 Technical (Hospital) Services "WATER FOR INJECTION, STERILE INJECTION SOLUTION" RX-11671 CDM 2500000200 HCPCS 250 RC 00409-4887-17 NDC outpatient 10 ML 59.34 59.34 CIGNA 62308 [3081051] CIGNA 62308 [308105105] 47.47 percent of total billed charges 36.79 56.37 Technical (Hospital) Services "WATER FOR INJECTION, STERILE INJECTION SOLUTION" RX-11671 CDM 2500000200 HCPCS 250 RC 00409-4887-17 NDC outpatient 10 ML 59.34 59.34 CIGNA 62308 [3081051] CIGNA STATE OF WYOMING [308105107] 47.47 percent of total billed charges 36.79 56.37 Technical (Hospital) Services "WATER FOR INJECTION, STERILE INJECTION SOLUTION" RX-11671 CDM 2500000200 HCPCS 250 RC 00409-4887-17 NDC outpatient 10 ML 59.34 59.34 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES EPO [308136803] 47.47 percent of total billed charges 36.79 56.37 Technical (Hospital) Services "WATER FOR INJECTION, STERILE INJECTION SOLUTION" RX-11671 CDM 2500000200 HCPCS 250 RC 00409-4887-17 NDC outpatient 10 ML 59.34 59.34 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES PPO [308136801] 47.47 percent of total billed charges 36.79 56.37 Technical (Hospital) Services "WATER FOR INJECTION, STERILE INJECTION SOLUTION" RX-11671 CDM 2500000200 HCPCS 250 RC 00409-4887-17 NDC outpatient 10 ML 59.34 59.34 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES HDHP [308136802] 47.47 percent of total billed charges 36.79 56.37 Technical (Hospital) Services "WATER FOR INJECTION, STERILE INJECTION SOLUTION" RX-11671 CDM 2500000200 HCPCS 250 RC 00409-4887-17 NDC outpatient 10 ML 59.34 59.34 UNITED HEALTHCARE (COMMERCIAL) [3081199] UNITED HEALTHCARE 87726 [308119901] 36.79 percent of total billed charges 36.79 56.37 Technical (Hospital) Services "WATER FOR INJECTION, STERILE INJECTION SOLUTION" RX-11671 CDM 2500000200 HCPCS 250 RC 00409-4887-17 NDC outpatient 10 ML 59.34 59.34 HEALTHPARTNERS SX009 HEALTHPARTNERS 47.47 percent of total billed charges 36.79 56.37 Technical (Hospital) Services "WATER FOR INJECTION, STERILE INJECTION SOLUTION" RX-11671 CDM 2500000200 HCPCS 250 RC 00409-4887-17 NDC outpatient 10 ML 59.34 59.34 BLUE CROSS BLUE SHIELD WELLMARK SB889 [3081026] BCBS WYOMING [308102603] 56.37 percent of total billed charges 36.79 56.37 Technical (Hospital) Services "WATER FOR INJECTION, STERILE INJECTION SOLUTION" RX-11671 CDM 2500000200 HCPCS 250 RC 00409-4887-17 NDC inpatient 10 ML 59.34 59.34 HEALTHPARTNERS SX009 HEALTHPARTNERS 46.99 percent of total billed charges 36.79 56.37 Technical (Hospital) Services "WATER FOR INJECTION, STERILE INJECTION SOLUTION" RX-11671 CDM 2500000200 HCPCS 250 RC 00409-4887-17 NDC inpatient 10 ML 59.34 59.34 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES EPO [308136803] 46.99 percent of total billed charges 36.79 56.37 Technical (Hospital) Services "WATER FOR INJECTION, STERILE INJECTION SOLUTION" RX-11671 CDM 2500000200 HCPCS 250 RC 00409-4887-17 NDC inpatient 10 ML 59.34 59.34 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES PPO [308136801] 46.99 percent of total billed charges 36.79 56.37 Technical (Hospital) Services "WATER FOR INJECTION, STERILE INJECTION SOLUTION" RX-11671 CDM 2500000200 HCPCS 250 RC 00409-4887-17 NDC inpatient 10 ML 59.34 59.34 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES HDHP [308136802] 46.99 percent of total billed charges 36.79 56.37 Technical (Hospital) Services "WATER FOR INJECTION, STERILE INJECTION SOLUTION" RX-11671 CDM 2500000200 HCPCS 250 RC 00409-4887-17 NDC inpatient 10 ML 59.34 59.34 UNITED HEALTHCARE (COMMERCIAL) [3081199] UNITED HEALTHCARE 87726 [308119901] 36.79 percent of total billed charges 36.79 56.37 Technical (Hospital) Services "WATER FOR INJECTION, STERILE INJECTION SOLUTION" RX-11671 CDM 2500000200 HCPCS 250 RC 00409-4887-17 NDC inpatient 10 ML 59.34 59.34 CIGNA 62308 [3081051] CIGNA 62308 [308105105] 46.99 percent of total billed charges 36.79 56.37 Technical (Hospital) Services "WATER FOR INJECTION, STERILE INJECTION SOLUTION" RX-11671 CDM 2500000200 HCPCS 250 RC 00409-4887-17 NDC inpatient 10 ML 59.34 59.34 CIGNA 62308 [3081051] CIGNA STATE OF WYOMING [308105107] 46.99 percent of total billed charges 36.79 56.37 Technical (Hospital) Services "WATER FOR INJECTION, STERILE INJECTION SOLUTION" RX-11671 CDM 2500000200 HCPCS 250 RC 00409-4887-17 NDC inpatient 10 ML 59.34 59.34 BLUE CROSS BLUE SHIELD WELLMARK SB889 [3081026] BCBS WYOMING [308102603] 56.37 percent of total billed charges 36.79 56.37 Technical (Hospital) Services "WATER FOR INJECTION, STERILE INJECTION SOLUTION" RX-11671 CDM 2500000200 HCPCS 250 RC 00409-4887-17 NDC inpatient 10 ML 59.34 59.34 MEDICA (COMMERCIAL) 94265 [3081118] MEDICA CLAIMS [308111801] 53.41 percent of total billed charges 36.79 56.37 Technical (Hospital) Services "WATER FOR INJECTION, STERILE INJECTION SOLUTION" RX-11671 CDM 2500000200 HCPCS 250 RC 00409-4887-17 NDC inpatient 10 ML 59.34 59.34 MULTIPLAN INC 34080 [3081285] MULTIPLAN INC [308128501] 56.37 percent of total billed charges 36.79 56.37 Technical (Hospital) Services ZIDOVUDINE 100 MG CAPSULE RX-11692 CDM 2500000200 HCPCS 250 RC 65862-0107-01 NDC outpatient 1 UN 7.14 7.14 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES HDHP [308136802] 5.71 percent of total billed charges 4.43 6.78 Technical (Hospital) Services ZIDOVUDINE 100 MG CAPSULE RX-11692 CDM 2500000200 HCPCS 250 RC 65862-0107-01 NDC outpatient 1 UN 7.14 7.14 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES PPO [308136801] 5.71 percent of total billed charges 4.43 6.78 Technical (Hospital) Services ZIDOVUDINE 100 MG CAPSULE RX-11692 CDM 2500000200 HCPCS 250 RC 65862-0107-01 NDC outpatient 1 UN 7.14 7.14 HEALTHPARTNERS SX009 HEALTHPARTNERS 5.71 percent of total billed charges 4.43 6.78 Technical (Hospital) Services ZIDOVUDINE 100 MG CAPSULE RX-11692 CDM 2500000200 HCPCS 250 RC 65862-0107-01 NDC outpatient 1 UN 7.14 7.14 BLUE CROSS BLUE SHIELD WELLMARK SB889 [3081026] BCBS WYOMING [308102603] 6.78 percent of total billed charges 4.43 6.78 Technical (Hospital) Services ZIDOVUDINE 100 MG CAPSULE RX-11692 CDM 2500000200 HCPCS 250 RC 65862-0107-01 NDC outpatient 1 UN 7.14 7.14 MEDICA (COMMERCIAL) 94265 [3081118] MEDICA CLAIMS [308111801] 6.43 percent of total billed charges 4.43 6.78 Technical (Hospital) Services ZIDOVUDINE 100 MG CAPSULE RX-11692 CDM 2500000200 HCPCS 250 RC 65862-0107-01 NDC outpatient 1 UN 7.14 7.14 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES EPO [308136803] 5.71 percent of total billed charges 4.43 6.78 Technical (Hospital) Services ZIDOVUDINE 100 MG CAPSULE RX-11692 CDM 2500000200 HCPCS 250 RC 65862-0107-01 NDC outpatient 1 UN 7.14 7.14 MULTIPLAN INC 34080 [3081285] MULTIPLAN INC [308128501] 6.78 percent of total billed charges 4.43 6.78 Technical (Hospital) Services ZIDOVUDINE 100 MG CAPSULE RX-11692 CDM 2500000200 HCPCS 250 RC 65862-0107-01 NDC outpatient 1 UN 7.14 7.14 CIGNA 62308 [3081051] CIGNA 62308 [308105105] 5.71 percent of total billed charges 4.43 6.78 Technical (Hospital) Services ZIDOVUDINE 100 MG CAPSULE RX-11692 CDM 2500000200 HCPCS 250 RC 65862-0107-01 NDC outpatient 1 UN 7.14 7.14 CIGNA 62308 [3081051] CIGNA STATE OF WYOMING [308105107] 5.71 percent of total billed charges 4.43 6.78 Technical (Hospital) Services ZIDOVUDINE 100 MG CAPSULE RX-11692 CDM 2500000200 HCPCS 250 RC 65862-0107-01 NDC outpatient 1 UN 7.14 7.14 UNITED HEALTHCARE (COMMERCIAL) [3081199] UNITED HEALTHCARE 87726 [308119901] 4.43 percent of total billed charges 4.43 6.78 Technical (Hospital) Services ZIDOVUDINE 100 MG CAPSULE RX-11692 CDM 2500000200 HCPCS 250 RC 65862-0107-01 NDC inpatient 1 UN 7.14 7.14 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES PPO [308136801] 5.65 percent of total billed charges 4.43 6.78 Technical (Hospital) Services ZIDOVUDINE 100 MG CAPSULE RX-11692 CDM 2500000200 HCPCS 250 RC 65862-0107-01 NDC inpatient 1 UN 7.14 7.14 MULTIPLAN INC 34080 [3081285] MULTIPLAN INC [308128501] 6.78 percent of total billed charges 4.43 6.78 Technical (Hospital) Services ZIDOVUDINE 100 MG CAPSULE RX-11692 CDM 2500000200 HCPCS 250 RC 65862-0107-01 NDC inpatient 1 UN 7.14 7.14 UNITED HEALTHCARE (COMMERCIAL) [3081199] UNITED HEALTHCARE 87726 [308119901] 4.43 percent of total billed charges 4.43 6.78 Technical (Hospital) Services ZIDOVUDINE 100 MG CAPSULE RX-11692 CDM 2500000200 HCPCS 250 RC 65862-0107-01 NDC inpatient 1 UN 7.14 7.14 BLUE CROSS BLUE SHIELD WELLMARK SB889 [3081026] BCBS WYOMING [308102603] 6.78 percent of total billed charges 4.43 6.78 Technical (Hospital) Services ZIDOVUDINE 100 MG CAPSULE RX-11692 CDM 2500000200 HCPCS 250 RC 65862-0107-01 NDC inpatient 1 UN 7.14 7.14 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES EPO [308136803] 5.65 percent of total billed charges 4.43 6.78 Technical (Hospital) Services ZIDOVUDINE 100 MG CAPSULE RX-11692 CDM 2500000200 HCPCS 250 RC 65862-0107-01 NDC inpatient 1 UN 7.14 7.14 CIGNA 62308 [3081051] CIGNA 62308 [308105105] 5.65 percent of total billed charges 4.43 6.78 Technical (Hospital) Services ZIDOVUDINE 100 MG CAPSULE RX-11692 CDM 2500000200 HCPCS 250 RC 65862-0107-01 NDC inpatient 1 UN 7.14 7.14 CIGNA 62308 [3081051] CIGNA STATE OF WYOMING [308105107] 5.65 percent of total billed charges 4.43 6.78 Technical (Hospital) Services ZIDOVUDINE 100 MG CAPSULE RX-11692 CDM 2500000200 HCPCS 250 RC 65862-0107-01 NDC inpatient 1 UN 7.14 7.14 MEDICA (COMMERCIAL) 94265 [3081118] MEDICA CLAIMS [308111801] 6.43 percent of total billed charges 4.43 6.78 Technical (Hospital) Services ZIDOVUDINE 100 MG CAPSULE RX-11692 CDM 2500000200 HCPCS 250 RC 65862-0107-01 NDC inpatient 1 UN 7.14 7.14 HEALTHPARTNERS SX009 HEALTHPARTNERS 5.65 percent of total billed charges 4.43 6.78 Technical (Hospital) Services ZIDOVUDINE 100 MG CAPSULE RX-11692 CDM 2500000200 HCPCS 250 RC 65862-0107-01 NDC inpatient 1 UN 7.14 7.14 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES HDHP [308136802] 5.65 percent of total billed charges 4.43 6.78 Technical (Hospital) Services BUPIVACAINE (PF) 0.25 % (2.5 MG/ML) INJECTION SOLUTION RX-1222 CDM 2500000200 HCPCS 250 RC 55150-0167-10 NDC inpatient 10 ML 7.91 7.91 MULTIPLAN INC 34080 [3081285] MULTIPLAN INC [308128501] 7.51 percent of total billed charges 4.9 7.51 Technical (Hospital) Services BUPIVACAINE (PF) 0.25 % (2.5 MG/ML) INJECTION SOLUTION RX-1222 CDM 2500000200 HCPCS 250 RC 55150-0167-10 NDC inpatient 10 ML 7.91 7.91 MEDICA (COMMERCIAL) 94265 [3081118] MEDICA CLAIMS [308111801] 7.12 percent of total billed charges 4.9 7.51 Technical (Hospital) Services BUPIVACAINE (PF) 0.25 % (2.5 MG/ML) INJECTION SOLUTION RX-1222 CDM 2500000200 HCPCS 250 RC 55150-0167-10 NDC inpatient 10 ML 7.91 7.91 UNITED HEALTHCARE (COMMERCIAL) [3081199] UNITED HEALTHCARE 87726 [308119901] 4.9 percent of total billed charges 4.9 7.51 Technical (Hospital) Services BUPIVACAINE (PF) 0.25 % (2.5 MG/ML) INJECTION SOLUTION RX-1222 CDM 2500000200 HCPCS 250 RC 55150-0167-10 NDC inpatient 10 ML 7.91 7.91 BLUE CROSS BLUE SHIELD WELLMARK SB889 [3081026] BCBS WYOMING [308102603] 7.51 percent of total billed charges 4.9 7.51 Technical (Hospital) Services BUPIVACAINE (PF) 0.25 % (2.5 MG/ML) INJECTION SOLUTION RX-1222 CDM 2500000200 HCPCS 250 RC 55150-0167-10 NDC inpatient 10 ML 7.91 7.91 CIGNA 62308 [3081051] CIGNA 62308 [308105105] 6.26 percent of total billed charges 4.9 7.51 Technical (Hospital) Services BUPIVACAINE (PF) 0.25 % (2.5 MG/ML) INJECTION SOLUTION RX-1222 CDM 2500000200 HCPCS 250 RC 55150-0167-10 NDC inpatient 10 ML 7.91 7.91 CIGNA 62308 [3081051] CIGNA STATE OF WYOMING [308105107] 6.26 percent of total billed charges 4.9 7.51 Technical (Hospital) Services BUPIVACAINE (PF) 0.25 % (2.5 MG/ML) INJECTION SOLUTION RX-1222 CDM 2500000200 HCPCS 250 RC 55150-0167-10 NDC inpatient 10 ML 7.91 7.91 HEALTHPARTNERS SX009 HEALTHPARTNERS 6.26 percent of total billed charges 4.9 7.51 Technical (Hospital) Services BUPIVACAINE (PF) 0.25 % (2.5 MG/ML) INJECTION SOLUTION RX-1222 CDM 2500000200 HCPCS 250 RC 55150-0167-10 NDC inpatient 10 ML 7.91 7.91 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES EPO [308136803] 6.26 percent of total billed charges 4.9 7.51 Technical (Hospital) Services BUPIVACAINE (PF) 0.25 % (2.5 MG/ML) INJECTION SOLUTION RX-1222 CDM 2500000200 HCPCS 250 RC 55150-0167-10 NDC inpatient 10 ML 7.91 7.91 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES PPO [308136801] 6.26 percent of total billed charges 4.9 7.51 Technical (Hospital) Services BUPIVACAINE (PF) 0.25 % (2.5 MG/ML) INJECTION SOLUTION RX-1222 CDM 2500000200 HCPCS 250 RC 55150-0167-10 NDC inpatient 10 ML 7.91 7.91 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES HDHP [308136802] 6.26 percent of total billed charges 4.9 7.51 Technical (Hospital) Services BUPIVACAINE (PF) 0.25 % (2.5 MG/ML) INJECTION SOLUTION RX-1222 CDM 2500000200 HCPCS 250 RC 55150-0167-10 NDC outpatient 10 ML 7.91 7.91 UNITED HEALTHCARE (COMMERCIAL) [3081199] UNITED HEALTHCARE 87726 [308119901] 4.9 percent of total billed charges 4.9 7.51 Technical (Hospital) Services BUPIVACAINE (PF) 0.25 % (2.5 MG/ML) INJECTION SOLUTION RX-1222 CDM 2500000200 HCPCS 250 RC 55150-0167-10 NDC outpatient 10 ML 7.91 7.91 HEALTHPARTNERS SX009 HEALTHPARTNERS 6.33 percent of total billed charges 4.9 7.51 Technical (Hospital) Services BUPIVACAINE (PF) 0.25 % (2.5 MG/ML) INJECTION SOLUTION RX-1222 CDM 2500000200 HCPCS 250 RC 55150-0167-10 NDC outpatient 10 ML 7.91 7.91 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES EPO [308136803] 6.33 percent of total billed charges 4.9 7.51 Technical (Hospital) Services BUPIVACAINE (PF) 0.25 % (2.5 MG/ML) INJECTION SOLUTION RX-1222 CDM 2500000200 HCPCS 250 RC 55150-0167-10 NDC outpatient 10 ML 7.91 7.91 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES PPO [308136801] 6.33 percent of total billed charges 4.9 7.51 Technical (Hospital) Services BUPIVACAINE (PF) 0.25 % (2.5 MG/ML) INJECTION SOLUTION RX-1222 CDM 2500000200 HCPCS 250 RC 55150-0167-10 NDC outpatient 10 ML 7.91 7.91 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES HDHP [308136802] 6.33 percent of total billed charges 4.9 7.51 Technical (Hospital) Services BUPIVACAINE (PF) 0.25 % (2.5 MG/ML) INJECTION SOLUTION RX-1222 CDM 2500000200 HCPCS 250 RC 55150-0167-10 NDC outpatient 10 ML 7.91 7.91 BLUE CROSS BLUE SHIELD WELLMARK SB889 [3081026] BCBS WYOMING [308102603] 7.51 percent of total billed charges 4.9 7.51 Technical (Hospital) Services BUPIVACAINE (PF) 0.25 % (2.5 MG/ML) INJECTION SOLUTION RX-1222 CDM 2500000200 HCPCS 250 RC 55150-0167-10 NDC outpatient 10 ML 7.91 7.91 MULTIPLAN INC 34080 [3081285] MULTIPLAN INC [308128501] 7.51 percent of total billed charges 4.9 7.51 Technical (Hospital) Services BUPIVACAINE (PF) 0.25 % (2.5 MG/ML) INJECTION SOLUTION RX-1222 CDM 2500000200 HCPCS 250 RC 55150-0167-10 NDC outpatient 10 ML 7.91 7.91 MEDICA (COMMERCIAL) 94265 [3081118] MEDICA CLAIMS [308111801] 7.12 percent of total billed charges 4.9 7.51 Technical (Hospital) Services BUPIVACAINE (PF) 0.25 % (2.5 MG/ML) INJECTION SOLUTION RX-1222 CDM 2500000200 HCPCS 250 RC 55150-0167-10 NDC outpatient 10 ML 7.91 7.91 CIGNA 62308 [3081051] CIGNA 62308 [308105105] 6.33 percent of total billed charges 4.9 7.51 Technical (Hospital) Services BUPIVACAINE (PF) 0.25 % (2.5 MG/ML) INJECTION SOLUTION RX-1222 CDM 2500000200 HCPCS 250 RC 55150-0167-10 NDC outpatient 10 ML 7.91 7.91 CIGNA 62308 [3081051] CIGNA STATE OF WYOMING [308105107] 6.33 percent of total billed charges 4.9 7.51 Technical (Hospital) Services VASOPRESSIN 20 UNIT/ML INTRAVENOUS SOLUTION RX-127636 CDM 2500000200 HCPCS 250 RC 42023-0164-01 NDC inpatient 1 ML 343 343 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES EPO [308136803] 271.59 percent of total billed charges 212.66 325.85 Technical (Hospital) Services VASOPRESSIN 20 UNIT/ML INTRAVENOUS SOLUTION RX-127636 CDM 2500000200 HCPCS 250 RC 42023-0164-01 NDC inpatient 1 ML 343 343 CIGNA 62308 [3081051] CIGNA 62308 [308105105] 271.59 percent of total billed charges 212.66 325.85 Technical (Hospital) Services VASOPRESSIN 20 UNIT/ML INTRAVENOUS SOLUTION RX-127636 CDM 2500000200 HCPCS 250 RC 42023-0164-01 NDC inpatient 1 ML 343 343 CIGNA 62308 [3081051] CIGNA STATE OF WYOMING [308105107] 271.59 percent of total billed charges 212.66 325.85 Technical (Hospital) Services VASOPRESSIN 20 UNIT/ML INTRAVENOUS SOLUTION RX-127636 CDM 2500000200 HCPCS 250 RC 42023-0164-01 NDC inpatient 1 ML 343 343 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES HDHP [308136802] 271.59 percent of total billed charges 212.66 325.85 Technical (Hospital) Services VASOPRESSIN 20 UNIT/ML INTRAVENOUS SOLUTION RX-127636 CDM 2500000200 HCPCS 250 RC 42023-0164-01 NDC inpatient 1 ML 343 343 BLUE CROSS BLUE SHIELD WELLMARK SB889 [3081026] BCBS WYOMING [308102603] 325.85 percent of total billed charges 212.66 325.85 Technical (Hospital) Services VASOPRESSIN 20 UNIT/ML INTRAVENOUS SOLUTION RX-127636 CDM 2500000200 HCPCS 250 RC 42023-0164-01 NDC inpatient 1 ML 343 343 UNITED HEALTHCARE (COMMERCIAL) [3081199] UNITED HEALTHCARE 87726 [308119901] 212.66 percent of total billed charges 212.66 325.85 Technical (Hospital) Services VASOPRESSIN 20 UNIT/ML INTRAVENOUS SOLUTION RX-127636 CDM 2500000200 HCPCS 250 RC 42023-0164-01 NDC inpatient 1 ML 343 343 MULTIPLAN INC 34080 [3081285] MULTIPLAN INC [308128501] 325.85 percent of total billed charges 212.66 325.85 Technical (Hospital) Services VASOPRESSIN 20 UNIT/ML INTRAVENOUS SOLUTION RX-127636 CDM 2500000200 HCPCS 250 RC 42023-0164-01 NDC inpatient 1 ML 343 343 MEDICA (COMMERCIAL) 94265 [3081118] MEDICA CLAIMS [308111801] 308.7 percent of total billed charges 212.66 325.85 Technical (Hospital) Services VASOPRESSIN 20 UNIT/ML INTRAVENOUS SOLUTION RX-127636 CDM 2500000200 HCPCS 250 RC 42023-0164-01 NDC inpatient 1 ML 343 343 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES PPO [308136801] 271.59 percent of total billed charges 212.66 325.85 Technical (Hospital) Services VASOPRESSIN 20 UNIT/ML INTRAVENOUS SOLUTION RX-127636 CDM 2500000200 HCPCS 250 RC 42023-0164-01 NDC inpatient 1 ML 343 343 HEALTHPARTNERS SX009 HEALTHPARTNERS 271.59 percent of total billed charges 212.66 325.85 Technical (Hospital) Services VASOPRESSIN 20 UNIT/ML INTRAVENOUS SOLUTION RX-127636 CDM 2500000200 HCPCS 250 RC 42023-0164-01 NDC outpatient 1 ML 343 343 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES PPO [308136801] 274.4 percent of total billed charges 212.66 325.85 Technical (Hospital) Services VASOPRESSIN 20 UNIT/ML INTRAVENOUS SOLUTION RX-127636 CDM 2500000200 HCPCS 250 RC 42023-0164-01 NDC outpatient 1 ML 343 343 BLUE CROSS BLUE SHIELD WELLMARK SB889 [3081026] BCBS WYOMING [308102603] 325.85 percent of total billed charges 212.66 325.85 Technical (Hospital) Services VASOPRESSIN 20 UNIT/ML INTRAVENOUS SOLUTION RX-127636 CDM 2500000200 HCPCS 250 RC 42023-0164-01 NDC outpatient 1 ML 343 343 HEALTHPARTNERS SX009 HEALTHPARTNERS 274.4 percent of total billed charges 212.66 325.85 Technical (Hospital) Services VASOPRESSIN 20 UNIT/ML INTRAVENOUS SOLUTION RX-127636 CDM 2500000200 HCPCS 250 RC 42023-0164-01 NDC outpatient 1 ML 343 343 UNITED HEALTHCARE (COMMERCIAL) [3081199] UNITED HEALTHCARE 87726 [308119901] 212.66 percent of total billed charges 212.66 325.85 Technical (Hospital) Services VASOPRESSIN 20 UNIT/ML INTRAVENOUS SOLUTION RX-127636 CDM 2500000200 HCPCS 250 RC 42023-0164-01 NDC outpatient 1 ML 343 343 MULTIPLAN INC 34080 [3081285] MULTIPLAN INC [308128501] 325.85 percent of total billed charges 212.66 325.85 Technical (Hospital) Services VASOPRESSIN 20 UNIT/ML INTRAVENOUS SOLUTION RX-127636 CDM 2500000200 HCPCS 250 RC 42023-0164-01 NDC outpatient 1 ML 343 343 CIGNA 62308 [3081051] CIGNA 62308 [308105105] 274.4 percent of total billed charges 212.66 325.85 Technical (Hospital) Services VASOPRESSIN 20 UNIT/ML INTRAVENOUS SOLUTION RX-127636 CDM 2500000200 HCPCS 250 RC 42023-0164-01 NDC outpatient 1 ML 343 343 CIGNA 62308 [3081051] CIGNA STATE OF WYOMING [308105107] 274.4 percent of total billed charges 212.66 325.85 Technical (Hospital) Services VASOPRESSIN 20 UNIT/ML INTRAVENOUS SOLUTION RX-127636 CDM 2500000200 HCPCS 250 RC 42023-0164-01 NDC outpatient 1 ML 343 343 MEDICA (COMMERCIAL) 94265 [3081118] MEDICA CLAIMS [308111801] 308.7 percent of total billed charges 212.66 325.85 Technical (Hospital) Services VASOPRESSIN 20 UNIT/ML INTRAVENOUS SOLUTION RX-127636 CDM 2500000200 HCPCS 250 RC 42023-0164-01 NDC outpatient 1 ML 343 343 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES HDHP [308136802] 274.4 percent of total billed charges 212.66 325.85 Technical (Hospital) Services VASOPRESSIN 20 UNIT/ML INTRAVENOUS SOLUTION RX-127636 CDM 2500000200 HCPCS 250 RC 42023-0164-01 NDC outpatient 1 ML 343 343 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES EPO [308136803] 274.4 percent of total billed charges 212.66 325.85 Technical (Hospital) Services NOREPINEPHRINE BITARTRATE 1 MG/ML INTRAVENOUS SOLUTION RX-128328 CDM 2500000200 HCPCS 250 RC 00409-3375-04 NDC inpatient 4 ML 144.98 144.98 HEALTHPARTNERS SX009 HEALTHPARTNERS 114.8 percent of total billed charges 89.89 137.73 Technical (Hospital) Services NOREPINEPHRINE BITARTRATE 1 MG/ML INTRAVENOUS SOLUTION RX-128328 CDM 2500000200 HCPCS 250 RC 00409-3375-04 NDC inpatient 4 ML 144.98 144.98 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES HDHP [308136802] 114.8 percent of total billed charges 89.89 137.73 Technical (Hospital) Services NOREPINEPHRINE BITARTRATE 1 MG/ML INTRAVENOUS SOLUTION RX-128328 CDM 2500000200 HCPCS 250 RC 00409-3375-04 NDC inpatient 4 ML 144.98 144.98 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES PPO [308136801] 114.8 percent of total billed charges 89.89 137.73 Technical (Hospital) Services NOREPINEPHRINE BITARTRATE 1 MG/ML INTRAVENOUS SOLUTION RX-128328 CDM 2500000200 HCPCS 250 RC 00409-3375-04 NDC inpatient 4 ML 144.98 144.98 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES EPO [308136803] 114.8 percent of total billed charges 89.89 137.73 Technical (Hospital) Services NOREPINEPHRINE BITARTRATE 1 MG/ML INTRAVENOUS SOLUTION RX-128328 CDM 2500000200 HCPCS 250 RC 00409-3375-04 NDC inpatient 4 ML 144.98 144.98 MULTIPLAN INC 34080 [3081285] MULTIPLAN INC [308128501] 137.73 percent of total billed charges 89.89 137.73 Technical (Hospital) Services NOREPINEPHRINE BITARTRATE 1 MG/ML INTRAVENOUS SOLUTION RX-128328 CDM 2500000200 HCPCS 250 RC 00409-3375-04 NDC inpatient 4 ML 144.98 144.98 MEDICA (COMMERCIAL) 94265 [3081118] MEDICA CLAIMS [308111801] 130.48 percent of total billed charges 89.89 137.73 Technical (Hospital) Services NOREPINEPHRINE BITARTRATE 1 MG/ML INTRAVENOUS SOLUTION RX-128328 CDM 2500000200 HCPCS 250 RC 00409-3375-04 NDC inpatient 4 ML 144.98 144.98 BLUE CROSS BLUE SHIELD WELLMARK SB889 [3081026] BCBS WYOMING [308102603] 137.73 percent of total billed charges 89.89 137.73 Technical (Hospital) Services NOREPINEPHRINE BITARTRATE 1 MG/ML INTRAVENOUS SOLUTION RX-128328 CDM 2500000200 HCPCS 250 RC 00409-3375-04 NDC inpatient 4 ML 144.98 144.98 UNITED HEALTHCARE (COMMERCIAL) [3081199] UNITED HEALTHCARE 87726 [308119901] 89.89 percent of total billed charges 89.89 137.73 Technical (Hospital) Services NOREPINEPHRINE BITARTRATE 1 MG/ML INTRAVENOUS SOLUTION RX-128328 CDM 2500000200 HCPCS 250 RC 00409-3375-04 NDC inpatient 4 ML 144.98 144.98 CIGNA 62308 [3081051] CIGNA 62308 [308105105] 114.8 percent of total billed charges 89.89 137.73 Technical (Hospital) Services NOREPINEPHRINE BITARTRATE 1 MG/ML INTRAVENOUS SOLUTION RX-128328 CDM 2500000200 HCPCS 250 RC 00409-3375-04 NDC inpatient 4 ML 144.98 144.98 CIGNA 62308 [3081051] CIGNA STATE OF WYOMING [308105107] 114.8 percent of total billed charges 89.89 137.73 Technical (Hospital) Services NOREPINEPHRINE BITARTRATE 1 MG/ML INTRAVENOUS SOLUTION RX-128328 CDM 2500000200 HCPCS 250 RC 00409-3375-04 NDC outpatient 4 ML 144.98 144.98 HEALTHPARTNERS SX009 HEALTHPARTNERS 115.98 percent of total billed charges 89.89 137.73 Technical (Hospital) Services NOREPINEPHRINE BITARTRATE 1 MG/ML INTRAVENOUS SOLUTION RX-128328 CDM 2500000200 HCPCS 250 RC 00409-3375-04 NDC outpatient 4 ML 144.98 144.98 CIGNA 62308 [3081051] CIGNA STATE OF WYOMING [308105107] 115.98 percent of total billed charges 89.89 137.73 Technical (Hospital) Services NOREPINEPHRINE BITARTRATE 1 MG/ML INTRAVENOUS SOLUTION RX-128328 CDM 2500000200 HCPCS 250 RC 00409-3375-04 NDC outpatient 4 ML 144.98 144.98 CIGNA 62308 [3081051] CIGNA 62308 [308105105] 115.98 percent of total billed charges 89.89 137.73 Technical (Hospital) Services NOREPINEPHRINE BITARTRATE 1 MG/ML INTRAVENOUS SOLUTION RX-128328 CDM 2500000200 HCPCS 250 RC 00409-3375-04 NDC outpatient 4 ML 144.98 144.98 UNITED HEALTHCARE (COMMERCIAL) [3081199] UNITED HEALTHCARE 87726 [308119901] 89.89 percent of total billed charges 89.89 137.73 Technical (Hospital) Services NOREPINEPHRINE BITARTRATE 1 MG/ML INTRAVENOUS SOLUTION RX-128328 CDM 2500000200 HCPCS 250 RC 00409-3375-04 NDC outpatient 4 ML 144.98 144.98 BLUE CROSS BLUE SHIELD WELLMARK SB889 [3081026] BCBS WYOMING [308102603] 137.73 percent of total billed charges 89.89 137.73 Technical (Hospital) Services NOREPINEPHRINE BITARTRATE 1 MG/ML INTRAVENOUS SOLUTION RX-128328 CDM 2500000200 HCPCS 250 RC 00409-3375-04 NDC outpatient 4 ML 144.98 144.98 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES EPO [308136803] 115.98 percent of total billed charges 89.89 137.73 Technical (Hospital) Services NOREPINEPHRINE BITARTRATE 1 MG/ML INTRAVENOUS SOLUTION RX-128328 CDM 2500000200 HCPCS 250 RC 00409-3375-04 NDC outpatient 4 ML 144.98 144.98 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES HDHP [308136802] 115.98 percent of total billed charges 89.89 137.73 Technical (Hospital) Services NOREPINEPHRINE BITARTRATE 1 MG/ML INTRAVENOUS SOLUTION RX-128328 CDM 2500000200 HCPCS 250 RC 00409-3375-04 NDC outpatient 4 ML 144.98 144.98 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES PPO [308136801] 115.98 percent of total billed charges 89.89 137.73 Technical (Hospital) Services NOREPINEPHRINE BITARTRATE 1 MG/ML INTRAVENOUS SOLUTION RX-128328 CDM 2500000200 HCPCS 250 RC 00409-3375-04 NDC outpatient 4 ML 144.98 144.98 MULTIPLAN INC 34080 [3081285] MULTIPLAN INC [308128501] 137.73 percent of total billed charges 89.89 137.73 Technical (Hospital) Services NOREPINEPHRINE BITARTRATE 1 MG/ML INTRAVENOUS SOLUTION RX-128328 CDM 2500000200 HCPCS 250 RC 00409-3375-04 NDC outpatient 4 ML 144.98 144.98 MEDICA (COMMERCIAL) 94265 [3081118] MEDICA CLAIMS [308111801] 130.48 percent of total billed charges 89.89 137.73 Technical (Hospital) Services LIDOCAINE 2 % MUCOSAL JELLY IN APPLICATOR (URO-JET) RX-128756 CDM 2500000200 HCPCS 250 RC 76329-3013-05 NDC inpatient 5 ML 61.82 61.82 BLUE CROSS BLUE SHIELD WELLMARK SB889 [3081026] BCBS WYOMING [308102603] 58.73 percent of total billed charges 38.33 58.73 Technical (Hospital) Services LIDOCAINE 2 % MUCOSAL JELLY IN APPLICATOR (URO-JET) RX-128756 CDM 2500000200 HCPCS 250 RC 76329-3013-05 NDC inpatient 5 ML 61.82 61.82 UNITED HEALTHCARE (COMMERCIAL) [3081199] UNITED HEALTHCARE 87726 [308119901] 38.33 percent of total billed charges 38.33 58.73 Technical (Hospital) Services LIDOCAINE 2 % MUCOSAL JELLY IN APPLICATOR (URO-JET) RX-128756 CDM 2500000200 HCPCS 250 RC 76329-3013-05 NDC inpatient 5 ML 61.82 61.82 CIGNA 62308 [3081051] CIGNA 62308 [308105105] 48.95 percent of total billed charges 38.33 58.73 Technical (Hospital) Services LIDOCAINE 2 % MUCOSAL JELLY IN APPLICATOR (URO-JET) RX-128756 CDM 2500000200 HCPCS 250 RC 76329-3013-05 NDC inpatient 5 ML 61.82 61.82 CIGNA 62308 [3081051] CIGNA STATE OF WYOMING [308105107] 48.95 percent of total billed charges 38.33 58.73 Technical (Hospital) Services LIDOCAINE 2 % MUCOSAL JELLY IN APPLICATOR (URO-JET) RX-128756 CDM 2500000200 HCPCS 250 RC 76329-3013-05 NDC inpatient 5 ML 61.82 61.82 MULTIPLAN INC 34080 [3081285] MULTIPLAN INC [308128501] 58.73 percent of total billed charges 38.33 58.73 Technical (Hospital) Services LIDOCAINE 2 % MUCOSAL JELLY IN APPLICATOR (URO-JET) RX-128756 CDM 2500000200 HCPCS 250 RC 76329-3013-05 NDC inpatient 5 ML 61.82 61.82 MEDICA (COMMERCIAL) 94265 [3081118] MEDICA CLAIMS [308111801] 55.64 percent of total billed charges 38.33 58.73 Technical (Hospital) Services LIDOCAINE 2 % MUCOSAL JELLY IN APPLICATOR (URO-JET) RX-128756 CDM 2500000200 HCPCS 250 RC 76329-3013-05 NDC inpatient 5 ML 61.82 61.82 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES EPO [308136803] 48.95 percent of total billed charges 38.33 58.73 Technical (Hospital) Services LIDOCAINE 2 % MUCOSAL JELLY IN APPLICATOR (URO-JET) RX-128756 CDM 2500000200 HCPCS 250 RC 76329-3013-05 NDC inpatient 5 ML 61.82 61.82 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES HDHP [308136802] 48.95 percent of total billed charges 38.33 58.73 Technical (Hospital) Services LIDOCAINE 2 % MUCOSAL JELLY IN APPLICATOR (URO-JET) RX-128756 CDM 2500000200 HCPCS 250 RC 76329-3013-05 NDC inpatient 5 ML 61.82 61.82 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES PPO [308136801] 48.95 percent of total billed charges 38.33 58.73 Technical (Hospital) Services LIDOCAINE 2 % MUCOSAL JELLY IN APPLICATOR (URO-JET) RX-128756 CDM 2500000200 HCPCS 250 RC 76329-3013-05 NDC inpatient 5 ML 61.82 61.82 HEALTHPARTNERS SX009 HEALTHPARTNERS 48.95 percent of total billed charges 38.33 58.73 Technical (Hospital) Services LIDOCAINE 2 % MUCOSAL JELLY IN APPLICATOR (URO-JET) RX-128756 CDM 2500000200 HCPCS 250 RC 76329-3013-05 NDC outpatient 5 ML 61.82 61.82 CIGNA 62308 [3081051] CIGNA 62308 [308105105] 49.46 percent of total billed charges 38.33 58.73 Technical (Hospital) Services LIDOCAINE 2 % MUCOSAL JELLY IN APPLICATOR (URO-JET) RX-128756 CDM 2500000200 HCPCS 250 RC 76329-3013-05 NDC outpatient 5 ML 61.82 61.82 CIGNA 62308 [3081051] CIGNA STATE OF WYOMING [308105107] 49.46 percent of total billed charges 38.33 58.73 Technical (Hospital) Services LIDOCAINE 2 % MUCOSAL JELLY IN APPLICATOR (URO-JET) RX-128756 CDM 2500000200 HCPCS 250 RC 76329-3013-05 NDC outpatient 5 ML 61.82 61.82 HEALTHPARTNERS SX009 HEALTHPARTNERS 49.46 percent of total billed charges 38.33 58.73 Technical (Hospital) Services LIDOCAINE 2 % MUCOSAL JELLY IN APPLICATOR (URO-JET) RX-128756 CDM 2500000200 HCPCS 250 RC 76329-3013-05 NDC outpatient 5 ML 61.82 61.82 UNITED HEALTHCARE (COMMERCIAL) [3081199] UNITED HEALTHCARE 87726 [308119901] 38.33 percent of total billed charges 38.33 58.73 Technical (Hospital) Services LIDOCAINE 2 % MUCOSAL JELLY IN APPLICATOR (URO-JET) RX-128756 CDM 2500000200 HCPCS 250 RC 76329-3013-05 NDC outpatient 5 ML 61.82 61.82 MEDICA (COMMERCIAL) 94265 [3081118] MEDICA CLAIMS [308111801] 55.64 percent of total billed charges 38.33 58.73 Technical (Hospital) Services LIDOCAINE 2 % MUCOSAL JELLY IN APPLICATOR (URO-JET) RX-128756 CDM 2500000200 HCPCS 250 RC 76329-3013-05 NDC outpatient 5 ML 61.82 61.82 MULTIPLAN INC 34080 [3081285] MULTIPLAN INC [308128501] 58.73 percent of total billed charges 38.33 58.73 Technical (Hospital) Services LIDOCAINE 2 % MUCOSAL JELLY IN APPLICATOR (URO-JET) RX-128756 CDM 2500000200 HCPCS 250 RC 76329-3013-05 NDC outpatient 5 ML 61.82 61.82 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES EPO [308136803] 49.46 percent of total billed charges 38.33 58.73 Technical (Hospital) Services LIDOCAINE 2 % MUCOSAL JELLY IN APPLICATOR (URO-JET) RX-128756 CDM 2500000200 HCPCS 250 RC 76329-3013-05 NDC outpatient 5 ML 61.82 61.82 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES HDHP [308136802] 49.46 percent of total billed charges 38.33 58.73 Technical (Hospital) Services LIDOCAINE 2 % MUCOSAL JELLY IN APPLICATOR (URO-JET) RX-128756 CDM 2500000200 HCPCS 250 RC 76329-3013-05 NDC outpatient 5 ML 61.82 61.82 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES PPO [308136801] 49.46 percent of total billed charges 38.33 58.73 Technical (Hospital) Services LIDOCAINE 2 % MUCOSAL JELLY IN APPLICATOR (URO-JET) RX-128756 CDM 2500000200 HCPCS 250 RC 76329-3013-05 NDC outpatient 5 ML 61.82 61.82 BLUE CROSS BLUE SHIELD WELLMARK SB889 [3081026] BCBS WYOMING [308102603] 58.73 percent of total billed charges 38.33 58.73 Technical (Hospital) Services IDARUCIZUMAB 2.5 GRAM/50 ML INTRAVENOUS SOLUTION RX-130445 CDM 2500000200 HCPCS 250 RC 00597-0197-05 NDC outpatient 50 ML 4903.1 4903.1 BLUE CROSS BLUE SHIELD WELLMARK SB889 [3081026] BCBS WYOMING [308102603] 4657.95 percent of total billed charges 3039.92 4657.95 Technical (Hospital) Services IDARUCIZUMAB 2.5 GRAM/50 ML INTRAVENOUS SOLUTION RX-130445 CDM 2500000200 HCPCS 250 RC 00597-0197-05 NDC outpatient 50 ML 4903.1 4903.1 HEALTHPARTNERS SX009 HEALTHPARTNERS 3922.48 percent of total billed charges 3039.92 4657.95 Technical (Hospital) Services IDARUCIZUMAB 2.5 GRAM/50 ML INTRAVENOUS SOLUTION RX-130445 CDM 2500000200 HCPCS 250 RC 00597-0197-05 NDC outpatient 50 ML 4903.1 4903.1 UNITED HEALTHCARE (COMMERCIAL) [3081199] UNITED HEALTHCARE 87726 [308119901] 3039.92 percent of total billed charges 3039.92 4657.95 Technical (Hospital) Services IDARUCIZUMAB 2.5 GRAM/50 ML INTRAVENOUS SOLUTION RX-130445 CDM 2500000200 HCPCS 250 RC 00597-0197-05 NDC outpatient 50 ML 4903.1 4903.1 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES HDHP [308136802] 3922.48 percent of total billed charges 3039.92 4657.95 Technical (Hospital) Services IDARUCIZUMAB 2.5 GRAM/50 ML INTRAVENOUS SOLUTION RX-130445 CDM 2500000200 HCPCS 250 RC 00597-0197-05 NDC outpatient 50 ML 4903.1 4903.1 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES EPO [308136803] 3922.48 percent of total billed charges 3039.92 4657.95 Technical (Hospital) Services IDARUCIZUMAB 2.5 GRAM/50 ML INTRAVENOUS SOLUTION RX-130445 CDM 2500000200 HCPCS 250 RC 00597-0197-05 NDC outpatient 50 ML 4903.1 4903.1 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES PPO [308136801] 3922.48 percent of total billed charges 3039.92 4657.95 Technical (Hospital) Services IDARUCIZUMAB 2.5 GRAM/50 ML INTRAVENOUS SOLUTION RX-130445 CDM 2500000200 HCPCS 250 RC 00597-0197-05 NDC outpatient 50 ML 4903.1 4903.1 MULTIPLAN INC 34080 [3081285] MULTIPLAN INC [308128501] 4657.95 percent of total billed charges 3039.92 4657.95 Technical (Hospital) Services IDARUCIZUMAB 2.5 GRAM/50 ML INTRAVENOUS SOLUTION RX-130445 CDM 2500000200 HCPCS 250 RC 00597-0197-05 NDC outpatient 50 ML 4903.1 4903.1 MEDICA (COMMERCIAL) 94265 [3081118] MEDICA CLAIMS [308111801] 4412.79 percent of total billed charges 3039.92 4657.95 Technical (Hospital) Services IDARUCIZUMAB 2.5 GRAM/50 ML INTRAVENOUS SOLUTION RX-130445 CDM 2500000200 HCPCS 250 RC 00597-0197-05 NDC outpatient 50 ML 4903.1 4903.1 CIGNA 62308 [3081051] CIGNA 62308 [308105105] 3922.48 percent of total billed charges 3039.92 4657.95 Technical (Hospital) Services IDARUCIZUMAB 2.5 GRAM/50 ML INTRAVENOUS SOLUTION RX-130445 CDM 2500000200 HCPCS 250 RC 00597-0197-05 NDC outpatient 50 ML 4903.1 4903.1 CIGNA 62308 [3081051] CIGNA STATE OF WYOMING [308105107] 3922.48 percent of total billed charges 3039.92 4657.95 Technical (Hospital) Services IDARUCIZUMAB 2.5 GRAM/50 ML INTRAVENOUS SOLUTION RX-130445 CDM 2500000200 HCPCS 250 RC 00597-0197-05 NDC inpatient 50 ML 4903.1 4903.1 MEDICA (COMMERCIAL) 94265 [3081118] MEDICA CLAIMS [308111801] 4412.79 percent of total billed charges 3039.92 4657.95 Technical (Hospital) Services IDARUCIZUMAB 2.5 GRAM/50 ML INTRAVENOUS SOLUTION RX-130445 CDM 2500000200 HCPCS 250 RC 00597-0197-05 NDC inpatient 50 ML 4903.1 4903.1 MULTIPLAN INC 34080 [3081285] MULTIPLAN INC [308128501] 4657.95 percent of total billed charges 3039.92 4657.95 Technical (Hospital) Services IDARUCIZUMAB 2.5 GRAM/50 ML INTRAVENOUS SOLUTION RX-130445 CDM 2500000200 HCPCS 250 RC 00597-0197-05 NDC inpatient 50 ML 4903.1 4903.1 HEALTHPARTNERS SX009 HEALTHPARTNERS 3882.27 percent of total billed charges 3039.92 4657.95 Technical (Hospital) Services IDARUCIZUMAB 2.5 GRAM/50 ML INTRAVENOUS SOLUTION RX-130445 CDM 2500000200 HCPCS 250 RC 00597-0197-05 NDC inpatient 50 ML 4903.1 4903.1 BLUE CROSS BLUE SHIELD WELLMARK SB889 [3081026] BCBS WYOMING [308102603] 4657.95 percent of total billed charges 3039.92 4657.95 Technical (Hospital) Services IDARUCIZUMAB 2.5 GRAM/50 ML INTRAVENOUS SOLUTION RX-130445 CDM 2500000200 HCPCS 250 RC 00597-0197-05 NDC inpatient 50 ML 4903.1 4903.1 UNITED HEALTHCARE (COMMERCIAL) [3081199] UNITED HEALTHCARE 87726 [308119901] 3039.92 percent of total billed charges 3039.92 4657.95 Technical (Hospital) Services IDARUCIZUMAB 2.5 GRAM/50 ML INTRAVENOUS SOLUTION RX-130445 CDM 2500000200 HCPCS 250 RC 00597-0197-05 NDC inpatient 50 ML 4903.1 4903.1 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES PPO [308136801] 3882.27 percent of total billed charges 3039.92 4657.95 Technical (Hospital) Services IDARUCIZUMAB 2.5 GRAM/50 ML INTRAVENOUS SOLUTION RX-130445 CDM 2500000200 HCPCS 250 RC 00597-0197-05 NDC inpatient 50 ML 4903.1 4903.1 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES EPO [308136803] 3882.27 percent of total billed charges 3039.92 4657.95 Technical (Hospital) Services IDARUCIZUMAB 2.5 GRAM/50 ML INTRAVENOUS SOLUTION RX-130445 CDM 2500000200 HCPCS 250 RC 00597-0197-05 NDC inpatient 50 ML 4903.1 4903.1 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES HDHP [308136802] 3882.27 percent of total billed charges 3039.92 4657.95 Technical (Hospital) Services IDARUCIZUMAB 2.5 GRAM/50 ML INTRAVENOUS SOLUTION RX-130445 CDM 2500000200 HCPCS 250 RC 00597-0197-05 NDC inpatient 50 ML 4903.1 4903.1 CIGNA 62308 [3081051] CIGNA 62308 [308105105] 3882.27 percent of total billed charges 3039.92 4657.95 Technical (Hospital) Services IDARUCIZUMAB 2.5 GRAM/50 ML INTRAVENOUS SOLUTION RX-130445 CDM 2500000200 HCPCS 250 RC 00597-0197-05 NDC inpatient 50 ML 4903.1 4903.1 CIGNA 62308 [3081051] CIGNA STATE OF WYOMING [308105107] 3882.27 percent of total billed charges 3039.92 4657.95 Technical (Hospital) Services CALCIUM CHLORIDE 100 MG/ML (10 %) INTRAVENOUS SYRINGE RX-1306 CDM 2500000200 HCPCS 250 RC 00409-1631-10 NDC inpatient 10 ML 82.62 82.62 BLUE CROSS BLUE SHIELD WELLMARK SB889 [3081026] BCBS WYOMING [308102603] 78.49 percent of total billed charges 51.22 78.49 Technical (Hospital) Services CALCIUM CHLORIDE 100 MG/ML (10 %) INTRAVENOUS SYRINGE RX-1306 CDM 2500000200 HCPCS 250 RC 00409-1631-10 NDC inpatient 10 ML 82.62 82.62 CIGNA 62308 [3081051] CIGNA 62308 [308105105] 65.42 percent of total billed charges 51.22 78.49 Technical (Hospital) Services CALCIUM CHLORIDE 100 MG/ML (10 %) INTRAVENOUS SYRINGE RX-1306 CDM 2500000200 HCPCS 250 RC 00409-1631-10 NDC inpatient 10 ML 82.62 82.62 CIGNA 62308 [3081051] CIGNA STATE OF WYOMING [308105107] 65.42 percent of total billed charges 51.22 78.49 Technical (Hospital) Services CALCIUM CHLORIDE 100 MG/ML (10 %) INTRAVENOUS SYRINGE RX-1306 CDM 2500000200 HCPCS 250 RC 00409-1631-10 NDC inpatient 10 ML 82.62 82.62 UNITED HEALTHCARE (COMMERCIAL) [3081199] UNITED HEALTHCARE 87726 [308119901] 51.22 percent of total billed charges 51.22 78.49 Technical (Hospital) Services CALCIUM CHLORIDE 100 MG/ML (10 %) INTRAVENOUS SYRINGE RX-1306 CDM 2500000200 HCPCS 250 RC 00409-1631-10 NDC inpatient 10 ML 82.62 82.62 MULTIPLAN INC 34080 [3081285] MULTIPLAN INC [308128501] 78.49 percent of total billed charges 51.22 78.49 Technical (Hospital) Services CALCIUM CHLORIDE 100 MG/ML (10 %) INTRAVENOUS SYRINGE RX-1306 CDM 2500000200 HCPCS 250 RC 00409-1631-10 NDC inpatient 10 ML 82.62 82.62 MEDICA (COMMERCIAL) 94265 [3081118] MEDICA CLAIMS [308111801] 74.36 percent of total billed charges 51.22 78.49 Technical (Hospital) Services CALCIUM CHLORIDE 100 MG/ML (10 %) INTRAVENOUS SYRINGE RX-1306 CDM 2500000200 HCPCS 250 RC 00409-1631-10 NDC inpatient 10 ML 82.62 82.62 HEALTHPARTNERS SX009 HEALTHPARTNERS 65.42 percent of total billed charges 51.22 78.49 Technical (Hospital) Services CALCIUM CHLORIDE 100 MG/ML (10 %) INTRAVENOUS SYRINGE RX-1306 CDM 2500000200 HCPCS 250 RC 00409-1631-10 NDC inpatient 10 ML 82.62 82.62 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES EPO [308136803] 65.42 percent of total billed charges 51.22 78.49 Technical (Hospital) Services CALCIUM CHLORIDE 100 MG/ML (10 %) INTRAVENOUS SYRINGE RX-1306 CDM 2500000200 HCPCS 250 RC 00409-1631-10 NDC inpatient 10 ML 82.62 82.62 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES HDHP [308136802] 65.42 percent of total billed charges 51.22 78.49 Technical (Hospital) Services CALCIUM CHLORIDE 100 MG/ML (10 %) INTRAVENOUS SYRINGE RX-1306 CDM 2500000200 HCPCS 250 RC 00409-1631-10 NDC inpatient 10 ML 82.62 82.62 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES PPO [308136801] 65.42 percent of total billed charges 51.22 78.49 Technical (Hospital) Services CALCIUM CHLORIDE 100 MG/ML (10 %) INTRAVENOUS SYRINGE RX-1306 CDM 2500000200 HCPCS 250 RC 00409-1631-10 NDC outpatient 10 ML 82.62 82.62 CIGNA 62308 [3081051] CIGNA 62308 [308105105] 66.1 percent of total billed charges 51.22 78.49 Technical (Hospital) Services CALCIUM CHLORIDE 100 MG/ML (10 %) INTRAVENOUS SYRINGE RX-1306 CDM 2500000200 HCPCS 250 RC 00409-1631-10 NDC outpatient 10 ML 82.62 82.62 CIGNA 62308 [3081051] CIGNA STATE OF WYOMING [308105107] 66.1 percent of total billed charges 51.22 78.49 Technical (Hospital) Services CALCIUM CHLORIDE 100 MG/ML (10 %) INTRAVENOUS SYRINGE RX-1306 CDM 2500000200 HCPCS 250 RC 00409-1631-10 NDC outpatient 10 ML 82.62 82.62 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES EPO [308136803] 66.1 percent of total billed charges 51.22 78.49 Technical (Hospital) Services CALCIUM CHLORIDE 100 MG/ML (10 %) INTRAVENOUS SYRINGE RX-1306 CDM 2500000200 HCPCS 250 RC 00409-1631-10 NDC outpatient 10 ML 82.62 82.62 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES HDHP [308136802] 66.1 percent of total billed charges 51.22 78.49 Technical (Hospital) Services CALCIUM CHLORIDE 100 MG/ML (10 %) INTRAVENOUS SYRINGE RX-1306 CDM 2500000200 HCPCS 250 RC 00409-1631-10 NDC outpatient 10 ML 82.62 82.62 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES PPO [308136801] 66.1 percent of total billed charges 51.22 78.49 Technical (Hospital) Services CALCIUM CHLORIDE 100 MG/ML (10 %) INTRAVENOUS SYRINGE RX-1306 CDM 2500000200 HCPCS 250 RC 00409-1631-10 NDC outpatient 10 ML 82.62 82.62 BLUE CROSS BLUE SHIELD WELLMARK SB889 [3081026] BCBS WYOMING [308102603] 78.49 percent of total billed charges 51.22 78.49 Technical (Hospital) Services CALCIUM CHLORIDE 100 MG/ML (10 %) INTRAVENOUS SYRINGE RX-1306 CDM 2500000200 HCPCS 250 RC 00409-1631-10 NDC outpatient 10 ML 82.62 82.62 MEDICA (COMMERCIAL) 94265 [3081118] MEDICA CLAIMS [308111801] 74.36 percent of total billed charges 51.22 78.49 Technical (Hospital) Services CALCIUM CHLORIDE 100 MG/ML (10 %) INTRAVENOUS SYRINGE RX-1306 CDM 2500000200 HCPCS 250 RC 00409-1631-10 NDC outpatient 10 ML 82.62 82.62 MULTIPLAN INC 34080 [3081285] MULTIPLAN INC [308128501] 78.49 percent of total billed charges 51.22 78.49 Technical (Hospital) Services CALCIUM CHLORIDE 100 MG/ML (10 %) INTRAVENOUS SYRINGE RX-1306 CDM 2500000200 HCPCS 250 RC 00409-1631-10 NDC outpatient 10 ML 82.62 82.62 HEALTHPARTNERS SX009 HEALTHPARTNERS 66.1 percent of total billed charges 51.22 78.49 Technical (Hospital) Services CALCIUM CHLORIDE 100 MG/ML (10 %) INTRAVENOUS SYRINGE RX-1306 CDM 2500000200 HCPCS 250 RC 00409-1631-10 NDC outpatient 10 ML 82.62 82.62 UNITED HEALTHCARE (COMMERCIAL) [3081199] UNITED HEALTHCARE 87726 [308119901] 51.22 percent of total billed charges 51.22 78.49 Technical (Hospital) Services "MVI,ADULT NO.4 WITH VIT K 3300 UNIT-150 MCG/10 ML INTRAVENOUS SOLUTION" RX-131229 CDM 2500000200 HCPCS 250 RC 54643-5649-01 NDC inpatient 10 ML 85.38 85.38 CIGNA 62308 [3081051] CIGNA 62308 [308105105] 67.6 percent of total billed charges 52.94 81.11 Technical (Hospital) Services "MVI,ADULT NO.4 WITH VIT K 3300 UNIT-150 MCG/10 ML INTRAVENOUS SOLUTION" RX-131229 CDM 2500000200 HCPCS 250 RC 54643-5649-01 NDC inpatient 10 ML 85.38 85.38 CIGNA 62308 [3081051] CIGNA STATE OF WYOMING [308105107] 67.6 percent of total billed charges 52.94 81.11 Technical (Hospital) Services "MVI,ADULT NO.4 WITH VIT K 3300 UNIT-150 MCG/10 ML INTRAVENOUS SOLUTION" RX-131229 CDM 2500000200 HCPCS 250 RC 54643-5649-01 NDC inpatient 10 ML 85.38 85.38 BLUE CROSS BLUE SHIELD WELLMARK SB889 [3081026] BCBS WYOMING [308102603] 81.11 percent of total billed charges 52.94 81.11 Technical (Hospital) Services "MVI,ADULT NO.4 WITH VIT K 3300 UNIT-150 MCG/10 ML INTRAVENOUS SOLUTION" RX-131229 CDM 2500000200 HCPCS 250 RC 54643-5649-01 NDC inpatient 10 ML 85.38 85.38 UNITED HEALTHCARE (COMMERCIAL) [3081199] UNITED HEALTHCARE 87726 [308119901] 52.94 percent of total billed charges 52.94 81.11 Technical (Hospital) Services "MVI,ADULT NO.4 WITH VIT K 3300 UNIT-150 MCG/10 ML INTRAVENOUS SOLUTION" RX-131229 CDM 2500000200 HCPCS 250 RC 54643-5649-01 NDC inpatient 10 ML 85.38 85.38 MULTIPLAN INC 34080 [3081285] MULTIPLAN INC [308128501] 81.11 percent of total billed charges 52.94 81.11 Technical (Hospital) Services "MVI,ADULT NO.4 WITH VIT K 3300 UNIT-150 MCG/10 ML INTRAVENOUS SOLUTION" RX-131229 CDM 2500000200 HCPCS 250 RC 54643-5649-01 NDC inpatient 10 ML 85.38 85.38 MEDICA (COMMERCIAL) 94265 [3081118] MEDICA CLAIMS [308111801] 76.84 percent of total billed charges 52.94 81.11 Technical (Hospital) Services "MVI,ADULT NO.4 WITH VIT K 3300 UNIT-150 MCG/10 ML INTRAVENOUS SOLUTION" RX-131229 CDM 2500000200 HCPCS 250 RC 54643-5649-01 NDC inpatient 10 ML 85.38 85.38 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES EPO [308136803] 67.6 percent of total billed charges 52.94 81.11 Technical (Hospital) Services "MVI,ADULT NO.4 WITH VIT K 3300 UNIT-150 MCG/10 ML INTRAVENOUS SOLUTION" RX-131229 CDM 2500000200 HCPCS 250 RC 54643-5649-01 NDC inpatient 10 ML 85.38 85.38 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES HDHP [308136802] 67.6 percent of total billed charges 52.94 81.11 Technical (Hospital) Services "MVI,ADULT NO.4 WITH VIT K 3300 UNIT-150 MCG/10 ML INTRAVENOUS SOLUTION" RX-131229 CDM 2500000200 HCPCS 250 RC 54643-5649-01 NDC inpatient 10 ML 85.38 85.38 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES PPO [308136801] 67.6 percent of total billed charges 52.94 81.11 Technical (Hospital) Services "MVI,ADULT NO.4 WITH VIT K 3300 UNIT-150 MCG/10 ML INTRAVENOUS SOLUTION" RX-131229 CDM 2500000200 HCPCS 250 RC 54643-5649-01 NDC inpatient 10 ML 85.38 85.38 HEALTHPARTNERS SX009 HEALTHPARTNERS 67.6 percent of total billed charges 52.94 81.11 Technical (Hospital) Services "MVI,ADULT NO.4 WITH VIT K 3300 UNIT-150 MCG/10 ML INTRAVENOUS SOLUTION" RX-131229 CDM 2500000200 HCPCS 250 RC 54643-5649-01 NDC outpatient 10 ML 85.38 85.38 HEALTHPARTNERS SX009 HEALTHPARTNERS 68.3 percent of total billed charges 52.94 81.11 Technical (Hospital) Services "MVI,ADULT NO.4 WITH VIT K 3300 UNIT-150 MCG/10 ML INTRAVENOUS SOLUTION" RX-131229 CDM 2500000200 HCPCS 250 RC 54643-5649-01 NDC outpatient 10 ML 85.38 85.38 UNITED HEALTHCARE (COMMERCIAL) [3081199] UNITED HEALTHCARE 87726 [308119901] 52.94 percent of total billed charges 52.94 81.11 Technical (Hospital) Services "MVI,ADULT NO.4 WITH VIT K 3300 UNIT-150 MCG/10 ML INTRAVENOUS SOLUTION" RX-131229 CDM 2500000200 HCPCS 250 RC 54643-5649-01 NDC outpatient 10 ML 85.38 85.38 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES PPO [308136801] 68.3 percent of total billed charges 52.94 81.11 Technical (Hospital) Services "MVI,ADULT NO.4 WITH VIT K 3300 UNIT-150 MCG/10 ML INTRAVENOUS SOLUTION" RX-131229 CDM 2500000200 HCPCS 250 RC 54643-5649-01 NDC outpatient 10 ML 85.38 85.38 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES EPO [308136803] 68.3 percent of total billed charges 52.94 81.11 Technical (Hospital) Services "MVI,ADULT NO.4 WITH VIT K 3300 UNIT-150 MCG/10 ML INTRAVENOUS SOLUTION" RX-131229 CDM 2500000200 HCPCS 250 RC 54643-5649-01 NDC outpatient 10 ML 85.38 85.38 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES HDHP [308136802] 68.3 percent of total billed charges 52.94 81.11 Technical (Hospital) Services "MVI,ADULT NO.4 WITH VIT K 3300 UNIT-150 MCG/10 ML INTRAVENOUS SOLUTION" RX-131229 CDM 2500000200 HCPCS 250 RC 54643-5649-01 NDC outpatient 10 ML 85.38 85.38 BLUE CROSS BLUE SHIELD WELLMARK SB889 [3081026] BCBS WYOMING [308102603] 81.11 percent of total billed charges 52.94 81.11 Technical (Hospital) Services "MVI,ADULT NO.4 WITH VIT K 3300 UNIT-150 MCG/10 ML INTRAVENOUS SOLUTION" RX-131229 CDM 2500000200 HCPCS 250 RC 54643-5649-01 NDC outpatient 10 ML 85.38 85.38 MULTIPLAN INC 34080 [3081285] MULTIPLAN INC [308128501] 81.11 percent of total billed charges 52.94 81.11 Technical (Hospital) Services "MVI,ADULT NO.4 WITH VIT K 3300 UNIT-150 MCG/10 ML INTRAVENOUS SOLUTION" RX-131229 CDM 2500000200 HCPCS 250 RC 54643-5649-01 NDC outpatient 10 ML 85.38 85.38 MEDICA (COMMERCIAL) 94265 [3081118] MEDICA CLAIMS [308111801] 76.84 percent of total billed charges 52.94 81.11 Technical (Hospital) Services "MVI,ADULT NO.4 WITH VIT K 3300 UNIT-150 MCG/10 ML INTRAVENOUS SOLUTION" RX-131229 CDM 2500000200 HCPCS 250 RC 54643-5649-01 NDC outpatient 10 ML 85.38 85.38 CIGNA 62308 [3081051] CIGNA STATE OF WYOMING [308105107] 68.3 percent of total billed charges 52.94 81.11 Technical (Hospital) Services "MVI,ADULT NO.4 WITH VIT K 3300 UNIT-150 MCG/10 ML INTRAVENOUS SOLUTION" RX-131229 CDM 2500000200 HCPCS 250 RC 54643-5649-01 NDC outpatient 10 ML 85.38 85.38 CIGNA 62308 [3081051] CIGNA 62308 [308105105] 68.3 percent of total billed charges 52.94 81.11 Technical (Hospital) Services SUGAMMADEX 100 MG/ML INTRAVENOUS SOLUTION RX-133312 CDM 2500000200 HCPCS 250 RC 00006-5423-12 NDC outpatient 2 ML 391.66 391.66 UNITED HEALTHCARE (COMMERCIAL) [3081199] UNITED HEALTHCARE 87726 [308119901] 242.83 percent of total billed charges 242.83 372.08 Technical (Hospital) Services SUGAMMADEX 100 MG/ML INTRAVENOUS SOLUTION RX-133312 CDM 2500000200 HCPCS 250 RC 00006-5423-12 NDC outpatient 2 ML 391.66 391.66 HEALTHPARTNERS SX009 HEALTHPARTNERS 313.33 percent of total billed charges 242.83 372.08 Technical (Hospital) Services SUGAMMADEX 100 MG/ML INTRAVENOUS SOLUTION RX-133312 CDM 2500000200 HCPCS 250 RC 00006-5423-12 NDC outpatient 2 ML 391.66 391.66 MEDICA (COMMERCIAL) 94265 [3081118] MEDICA CLAIMS [308111801] 352.49 percent of total billed charges 242.83 372.08 Technical (Hospital) Services SUGAMMADEX 100 MG/ML INTRAVENOUS SOLUTION RX-133312 CDM 2500000200 HCPCS 250 RC 00006-5423-12 NDC outpatient 2 ML 391.66 391.66 MULTIPLAN INC 34080 [3081285] MULTIPLAN INC [308128501] 372.08 percent of total billed charges 242.83 372.08 Technical (Hospital) Services SUGAMMADEX 100 MG/ML INTRAVENOUS SOLUTION RX-133312 CDM 2500000200 HCPCS 250 RC 00006-5423-12 NDC outpatient 2 ML 391.66 391.66 CIGNA 62308 [3081051] CIGNA 62308 [308105105] 313.33 percent of total billed charges 242.83 372.08 Technical (Hospital) Services SUGAMMADEX 100 MG/ML INTRAVENOUS SOLUTION RX-133312 CDM 2500000200 HCPCS 250 RC 00006-5423-12 NDC outpatient 2 ML 391.66 391.66 CIGNA 62308 [3081051] CIGNA STATE OF WYOMING [308105107] 313.33 percent of total billed charges 242.83 372.08 Technical (Hospital) Services SUGAMMADEX 100 MG/ML INTRAVENOUS SOLUTION RX-133312 CDM 2500000200 HCPCS 250 RC 00006-5423-12 NDC outpatient 2 ML 391.66 391.66 BLUE CROSS BLUE SHIELD WELLMARK SB889 [3081026] BCBS WYOMING [308102603] 372.08 percent of total billed charges 242.83 372.08 Technical (Hospital) Services SUGAMMADEX 100 MG/ML INTRAVENOUS SOLUTION RX-133312 CDM 2500000200 HCPCS 250 RC 00006-5423-12 NDC outpatient 2 ML 391.66 391.66 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES HDHP [308136802] 313.33 percent of total billed charges 242.83 372.08 Technical (Hospital) Services SUGAMMADEX 100 MG/ML INTRAVENOUS SOLUTION RX-133312 CDM 2500000200 HCPCS 250 RC 00006-5423-12 NDC outpatient 2 ML 391.66 391.66 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES PPO [308136801] 313.33 percent of total billed charges 242.83 372.08 Technical (Hospital) Services SUGAMMADEX 100 MG/ML INTRAVENOUS SOLUTION RX-133312 CDM 2500000200 HCPCS 250 RC 00006-5423-12 NDC outpatient 2 ML 391.66 391.66 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES EPO [308136803] 313.33 percent of total billed charges 242.83 372.08 Technical (Hospital) Services SUGAMMADEX 100 MG/ML INTRAVENOUS SOLUTION RX-133312 CDM 2500000200 HCPCS 250 RC 00006-5423-12 NDC inpatient 2 ML 391.66 391.66 MEDICA (COMMERCIAL) 94265 [3081118] MEDICA CLAIMS [308111801] 352.49 percent of total billed charges 242.83 372.08 Technical (Hospital) Services SUGAMMADEX 100 MG/ML INTRAVENOUS SOLUTION RX-133312 CDM 2500000200 HCPCS 250 RC 00006-5423-12 NDC inpatient 2 ML 391.66 391.66 MULTIPLAN INC 34080 [3081285] MULTIPLAN INC [308128501] 372.08 percent of total billed charges 242.83 372.08 Technical (Hospital) Services SUGAMMADEX 100 MG/ML INTRAVENOUS SOLUTION RX-133312 CDM 2500000200 HCPCS 250 RC 00006-5423-12 NDC inpatient 2 ML 391.66 391.66 CIGNA 62308 [3081051] CIGNA 62308 [308105105] 310.12 percent of total billed charges 242.83 372.08 Technical (Hospital) Services SUGAMMADEX 100 MG/ML INTRAVENOUS SOLUTION RX-133312 CDM 2500000200 HCPCS 250 RC 00006-5423-12 NDC inpatient 2 ML 391.66 391.66 CIGNA 62308 [3081051] CIGNA STATE OF WYOMING [308105107] 310.12 percent of total billed charges 242.83 372.08 Technical (Hospital) Services SUGAMMADEX 100 MG/ML INTRAVENOUS SOLUTION RX-133312 CDM 2500000200 HCPCS 250 RC 00006-5423-12 NDC inpatient 2 ML 391.66 391.66 BLUE CROSS BLUE SHIELD WELLMARK SB889 [3081026] BCBS WYOMING [308102603] 372.08 percent of total billed charges 242.83 372.08 Technical (Hospital) Services SUGAMMADEX 100 MG/ML INTRAVENOUS SOLUTION RX-133312 CDM 2500000200 HCPCS 250 RC 00006-5423-12 NDC inpatient 2 ML 391.66 391.66 UNITED HEALTHCARE (COMMERCIAL) [3081199] UNITED HEALTHCARE 87726 [308119901] 242.83 percent of total billed charges 242.83 372.08 Technical (Hospital) Services SUGAMMADEX 100 MG/ML INTRAVENOUS SOLUTION RX-133312 CDM 2500000200 HCPCS 250 RC 00006-5423-12 NDC inpatient 2 ML 391.66 391.66 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES PPO [308136801] 310.12 percent of total billed charges 242.83 372.08 Technical (Hospital) Services SUGAMMADEX 100 MG/ML INTRAVENOUS SOLUTION RX-133312 CDM 2500000200 HCPCS 250 RC 00006-5423-12 NDC inpatient 2 ML 391.66 391.66 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES EPO [308136803] 310.12 percent of total billed charges 242.83 372.08 Technical (Hospital) Services SUGAMMADEX 100 MG/ML INTRAVENOUS SOLUTION RX-133312 CDM 2500000200 HCPCS 250 RC 00006-5423-12 NDC inpatient 2 ML 391.66 391.66 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES HDHP [308136802] 310.12 percent of total billed charges 242.83 372.08 Technical (Hospital) Services SUGAMMADEX 100 MG/ML INTRAVENOUS SOLUTION RX-133312 CDM 2500000200 HCPCS 250 RC 00006-5423-12 NDC inpatient 2 ML 391.66 391.66 HEALTHPARTNERS SX009 HEALTHPARTNERS 310.12 percent of total billed charges 242.83 372.08 Technical (Hospital) Services NITROGLYCERIN 50 MG/250 ML (200 MCG/ML) IN 5 % DEXTROSE INTRAVENOUS RX-15859 CDM 2500000200 HCPCS 250 RC 00338-1049-02 NDC outpatient 250 ML 145 145 UNITED HEALTHCARE (COMMERCIAL) [3081199] UNITED HEALTHCARE 87726 [308119901] 89.9 percent of total billed charges 89.9 137.75 Technical (Hospital) Services NITROGLYCERIN 50 MG/250 ML (200 MCG/ML) IN 5 % DEXTROSE INTRAVENOUS RX-15859 CDM 2500000200 HCPCS 250 RC 00338-1049-02 NDC outpatient 250 ML 145 145 HEALTHPARTNERS SX009 HEALTHPARTNERS 116 percent of total billed charges 89.9 137.75 Technical (Hospital) Services NITROGLYCERIN 50 MG/250 ML (200 MCG/ML) IN 5 % DEXTROSE INTRAVENOUS RX-15859 CDM 2500000200 HCPCS 250 RC 00338-1049-02 NDC outpatient 250 ML 145 145 BLUE CROSS BLUE SHIELD WELLMARK SB889 [3081026] BCBS WYOMING [308102603] 137.75 percent of total billed charges 89.9 137.75 Technical (Hospital) Services NITROGLYCERIN 50 MG/250 ML (200 MCG/ML) IN 5 % DEXTROSE INTRAVENOUS RX-15859 CDM 2500000200 HCPCS 250 RC 00338-1049-02 NDC outpatient 250 ML 145 145 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES EPO [308136803] 116 percent of total billed charges 89.9 137.75 Technical (Hospital) Services NITROGLYCERIN 50 MG/250 ML (200 MCG/ML) IN 5 % DEXTROSE INTRAVENOUS RX-15859 CDM 2500000200 HCPCS 250 RC 00338-1049-02 NDC outpatient 250 ML 145 145 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES HDHP [308136802] 116 percent of total billed charges 89.9 137.75 Technical (Hospital) Services NITROGLYCERIN 50 MG/250 ML (200 MCG/ML) IN 5 % DEXTROSE INTRAVENOUS RX-15859 CDM 2500000200 HCPCS 250 RC 00338-1049-02 NDC outpatient 250 ML 145 145 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES PPO [308136801] 116 percent of total billed charges 89.9 137.75 Technical (Hospital) Services NITROGLYCERIN 50 MG/250 ML (200 MCG/ML) IN 5 % DEXTROSE INTRAVENOUS RX-15859 CDM 2500000200 HCPCS 250 RC 00338-1049-02 NDC outpatient 250 ML 145 145 MULTIPLAN INC 34080 [3081285] MULTIPLAN INC [308128501] 137.75 percent of total billed charges 89.9 137.75 Technical (Hospital) Services NITROGLYCERIN 50 MG/250 ML (200 MCG/ML) IN 5 % DEXTROSE INTRAVENOUS RX-15859 CDM 2500000200 HCPCS 250 RC 00338-1049-02 NDC outpatient 250 ML 145 145 MEDICA (COMMERCIAL) 94265 [3081118] MEDICA CLAIMS [308111801] 130.5 percent of total billed charges 89.9 137.75 Technical (Hospital) Services NITROGLYCERIN 50 MG/250 ML (200 MCG/ML) IN 5 % DEXTROSE INTRAVENOUS RX-15859 CDM 2500000200 HCPCS 250 RC 00338-1049-02 NDC outpatient 250 ML 145 145 CIGNA 62308 [3081051] CIGNA 62308 [308105105] 116 percent of total billed charges 89.9 137.75 Technical (Hospital) Services NITROGLYCERIN 50 MG/250 ML (200 MCG/ML) IN 5 % DEXTROSE INTRAVENOUS RX-15859 CDM 2500000200 HCPCS 250 RC 00338-1049-02 NDC outpatient 250 ML 145 145 CIGNA 62308 [3081051] CIGNA STATE OF WYOMING [308105107] 116 percent of total billed charges 89.9 137.75 Technical (Hospital) Services NITROGLYCERIN 50 MG/250 ML (200 MCG/ML) IN 5 % DEXTROSE INTRAVENOUS RX-15859 CDM 2500000200 HCPCS 250 RC 00338-1049-02 NDC inpatient 250 ML 145 145 HEALTHPARTNERS SX009 HEALTHPARTNERS 114.81 percent of total billed charges 89.9 137.75 Technical (Hospital) Services NITROGLYCERIN 50 MG/250 ML (200 MCG/ML) IN 5 % DEXTROSE INTRAVENOUS RX-15859 CDM 2500000200 HCPCS 250 RC 00338-1049-02 NDC inpatient 250 ML 145 145 MEDICA (COMMERCIAL) 94265 [3081118] MEDICA CLAIMS [308111801] 130.5 percent of total billed charges 89.9 137.75 Technical (Hospital) Services NITROGLYCERIN 50 MG/250 ML (200 MCG/ML) IN 5 % DEXTROSE INTRAVENOUS RX-15859 CDM 2500000200 HCPCS 250 RC 00338-1049-02 NDC inpatient 250 ML 145 145 MULTIPLAN INC 34080 [3081285] MULTIPLAN INC [308128501] 137.75 percent of total billed charges 89.9 137.75 Technical (Hospital) Services NITROGLYCERIN 50 MG/250 ML (200 MCG/ML) IN 5 % DEXTROSE INTRAVENOUS RX-15859 CDM 2500000200 HCPCS 250 RC 00338-1049-02 NDC inpatient 250 ML 145 145 UNITED HEALTHCARE (COMMERCIAL) [3081199] UNITED HEALTHCARE 87726 [308119901] 89.9 percent of total billed charges 89.9 137.75 Technical (Hospital) Services NITROGLYCERIN 50 MG/250 ML (200 MCG/ML) IN 5 % DEXTROSE INTRAVENOUS RX-15859 CDM 2500000200 HCPCS 250 RC 00338-1049-02 NDC inpatient 250 ML 145 145 BLUE CROSS BLUE SHIELD WELLMARK SB889 [3081026] BCBS WYOMING [308102603] 137.75 percent of total billed charges 89.9 137.75 Technical (Hospital) Services NITROGLYCERIN 50 MG/250 ML (200 MCG/ML) IN 5 % DEXTROSE INTRAVENOUS RX-15859 CDM 2500000200 HCPCS 250 RC 00338-1049-02 NDC inpatient 250 ML 145 145 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES EPO [308136803] 114.81 percent of total billed charges 89.9 137.75 Technical (Hospital) Services NITROGLYCERIN 50 MG/250 ML (200 MCG/ML) IN 5 % DEXTROSE INTRAVENOUS RX-15859 CDM 2500000200 HCPCS 250 RC 00338-1049-02 NDC inpatient 250 ML 145 145 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES HDHP [308136802] 114.81 percent of total billed charges 89.9 137.75 Technical (Hospital) Services NITROGLYCERIN 50 MG/250 ML (200 MCG/ML) IN 5 % DEXTROSE INTRAVENOUS RX-15859 CDM 2500000200 HCPCS 250 RC 00338-1049-02 NDC inpatient 250 ML 145 145 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES PPO [308136801] 114.81 percent of total billed charges 89.9 137.75 Technical (Hospital) Services NITROGLYCERIN 50 MG/250 ML (200 MCG/ML) IN 5 % DEXTROSE INTRAVENOUS RX-15859 CDM 2500000200 HCPCS 250 RC 00338-1049-02 NDC inpatient 250 ML 145 145 CIGNA 62308 [3081051] CIGNA 62308 [308105105] 114.81 percent of total billed charges 89.9 137.75 Technical (Hospital) Services NITROGLYCERIN 50 MG/250 ML (200 MCG/ML) IN 5 % DEXTROSE INTRAVENOUS RX-15859 CDM 2500000200 HCPCS 250 RC 00338-1049-02 NDC inpatient 250 ML 145 145 CIGNA 62308 [3081051] CIGNA STATE OF WYOMING [308105107] 114.81 percent of total billed charges 89.9 137.75 Technical (Hospital) Services SODIUM HYPOCHLORITE 0.25 % SOLUTION RX-15950 CDM 2500000200 HCPCS 250 RC 39328-0063-25 NDC inpatient 1 ML 5.66 5.66 CIGNA 62308 [3081051] CIGNA 62308 [308105105] 4.48 percent of total billed charges 3.51 5.38 Technical (Hospital) Services SODIUM HYPOCHLORITE 0.25 % SOLUTION RX-15950 CDM 2500000200 HCPCS 250 RC 39328-0063-25 NDC inpatient 1 ML 5.66 5.66 CIGNA 62308 [3081051] CIGNA STATE OF WYOMING [308105107] 4.48 percent of total billed charges 3.51 5.38 Technical (Hospital) Services SODIUM HYPOCHLORITE 0.25 % SOLUTION RX-15950 CDM 2500000200 HCPCS 250 RC 39328-0063-25 NDC inpatient 1 ML 5.66 5.66 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES EPO [308136803] 4.48 percent of total billed charges 3.51 5.38 Technical (Hospital) Services SODIUM HYPOCHLORITE 0.25 % SOLUTION RX-15950 CDM 2500000200 HCPCS 250 RC 39328-0063-25 NDC inpatient 1 ML 5.66 5.66 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES HDHP [308136802] 4.48 percent of total billed charges 3.51 5.38 Technical (Hospital) Services SODIUM HYPOCHLORITE 0.25 % SOLUTION RX-15950 CDM 2500000200 HCPCS 250 RC 39328-0063-25 NDC inpatient 1 ML 5.66 5.66 MEDICA (COMMERCIAL) 94265 [3081118] MEDICA CLAIMS [308111801] 5.09 percent of total billed charges 3.51 5.38 Technical (Hospital) Services SODIUM HYPOCHLORITE 0.25 % SOLUTION RX-15950 CDM 2500000200 HCPCS 250 RC 39328-0063-25 NDC inpatient 1 ML 5.66 5.66 HEALTHPARTNERS SX009 HEALTHPARTNERS 4.48 percent of total billed charges 3.51 5.38 Technical (Hospital) Services SODIUM HYPOCHLORITE 0.25 % SOLUTION RX-15950 CDM 2500000200 HCPCS 250 RC 39328-0063-25 NDC inpatient 1 ML 5.66 5.66 BLUE CROSS BLUE SHIELD WELLMARK SB889 [3081026] BCBS WYOMING [308102603] 5.38 percent of total billed charges 3.51 5.38 Technical (Hospital) Services SODIUM HYPOCHLORITE 0.25 % SOLUTION RX-15950 CDM 2500000200 HCPCS 250 RC 39328-0063-25 NDC inpatient 1 ML 5.66 5.66 MULTIPLAN INC 34080 [3081285] MULTIPLAN INC [308128501] 5.38 percent of total billed charges 3.51 5.38 Technical (Hospital) Services SODIUM HYPOCHLORITE 0.25 % SOLUTION RX-15950 CDM 2500000200 HCPCS 250 RC 39328-0063-25 NDC inpatient 1 ML 5.66 5.66 UNITED HEALTHCARE (COMMERCIAL) [3081199] UNITED HEALTHCARE 87726 [308119901] 3.51 percent of total billed charges 3.51 5.38 Technical (Hospital) Services SODIUM HYPOCHLORITE 0.25 % SOLUTION RX-15950 CDM 2500000200 HCPCS 250 RC 39328-0063-25 NDC inpatient 1 ML 5.66 5.66 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES PPO [308136801] 4.48 percent of total billed charges 3.51 5.38 Technical (Hospital) Services SODIUM HYPOCHLORITE 0.25 % SOLUTION RX-15950 CDM 2500000200 HCPCS 250 RC 39328-0063-25 NDC outpatient 1 ML 5.66 5.66 UNITED HEALTHCARE (COMMERCIAL) [3081199] UNITED HEALTHCARE 87726 [308119901] 3.51 percent of total billed charges 3.51 5.38 Technical (Hospital) Services SODIUM HYPOCHLORITE 0.25 % SOLUTION RX-15950 CDM 2500000200 HCPCS 250 RC 39328-0063-25 NDC outpatient 1 ML 5.66 5.66 HEALTHPARTNERS SX009 HEALTHPARTNERS 4.53 percent of total billed charges 3.51 5.38 Technical (Hospital) Services SODIUM HYPOCHLORITE 0.25 % SOLUTION RX-15950 CDM 2500000200 HCPCS 250 RC 39328-0063-25 NDC outpatient 1 ML 5.66 5.66 CIGNA 62308 [3081051] CIGNA 62308 [308105105] 4.53 percent of total billed charges 3.51 5.38 Technical (Hospital) Services SODIUM HYPOCHLORITE 0.25 % SOLUTION RX-15950 CDM 2500000200 HCPCS 250 RC 39328-0063-25 NDC outpatient 1 ML 5.66 5.66 CIGNA 62308 [3081051] CIGNA STATE OF WYOMING [308105107] 4.53 percent of total billed charges 3.51 5.38 Technical (Hospital) Services SODIUM HYPOCHLORITE 0.25 % SOLUTION RX-15950 CDM 2500000200 HCPCS 250 RC 39328-0063-25 NDC outpatient 1 ML 5.66 5.66 MULTIPLAN INC 34080 [3081285] MULTIPLAN INC [308128501] 5.38 percent of total billed charges 3.51 5.38 Technical (Hospital) Services SODIUM HYPOCHLORITE 0.25 % SOLUTION RX-15950 CDM 2500000200 HCPCS 250 RC 39328-0063-25 NDC outpatient 1 ML 5.66 5.66 MEDICA (COMMERCIAL) 94265 [3081118] MEDICA CLAIMS [308111801] 5.09 percent of total billed charges 3.51 5.38 Technical (Hospital) Services SODIUM HYPOCHLORITE 0.25 % SOLUTION RX-15950 CDM 2500000200 HCPCS 250 RC 39328-0063-25 NDC outpatient 1 ML 5.66 5.66 BLUE CROSS BLUE SHIELD WELLMARK SB889 [3081026] BCBS WYOMING [308102603] 5.38 percent of total billed charges 3.51 5.38 Technical (Hospital) Services SODIUM HYPOCHLORITE 0.25 % SOLUTION RX-15950 CDM 2500000200 HCPCS 250 RC 39328-0063-25 NDC outpatient 1 ML 5.66 5.66 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES HDHP [308136802] 4.53 percent of total billed charges 3.51 5.38 Technical (Hospital) Services SODIUM HYPOCHLORITE 0.25 % SOLUTION RX-15950 CDM 2500000200 HCPCS 250 RC 39328-0063-25 NDC outpatient 1 ML 5.66 5.66 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES PPO [308136801] 4.53 percent of total billed charges 3.51 5.38 Technical (Hospital) Services SODIUM HYPOCHLORITE 0.25 % SOLUTION RX-15950 CDM 2500000200 HCPCS 250 RC 39328-0063-25 NDC outpatient 1 ML 5.66 5.66 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES EPO [308136803] 4.53 percent of total billed charges 3.51 5.38 Technical (Hospital) Services SARILUMAB 200 MG/1.14 ML SUBCUTANEOUS SYRINGE RX-169256 CDM 2500000200 HCPCS 250 RC 00024-5910-01 NDC inpatient 1.15 ML 4640.61 4640.61 MULTIPLAN INC 34080 [3081285] MULTIPLAN INC [308128501] 4408.58 percent of total billed charges 2877.18 4408.58 Technical (Hospital) Services SARILUMAB 200 MG/1.14 ML SUBCUTANEOUS SYRINGE RX-169256 CDM 2500000200 HCPCS 250 RC 00024-5910-01 NDC inpatient 1.15 ML 4640.61 4640.61 BLUE CROSS BLUE SHIELD WELLMARK SB889 [3081026] BCBS WYOMING [308102603] 4408.58 percent of total billed charges 2877.18 4408.58 Technical (Hospital) Services SARILUMAB 200 MG/1.14 ML SUBCUTANEOUS SYRINGE RX-169256 CDM 2500000200 HCPCS 250 RC 00024-5910-01 NDC inpatient 1.15 ML 4640.61 4640.61 UNITED HEALTHCARE (COMMERCIAL) [3081199] UNITED HEALTHCARE 87726 [308119901] 2877.18 percent of total billed charges 2877.18 4408.58 Technical (Hospital) Services SARILUMAB 200 MG/1.14 ML SUBCUTANEOUS SYRINGE RX-169256 CDM 2500000200 HCPCS 250 RC 00024-5910-01 NDC inpatient 1.15 ML 4640.61 4640.61 CIGNA 62308 [3081051] CIGNA 62308 [308105105] 3674.43 percent of total billed charges 2877.18 4408.58 Technical (Hospital) Services SARILUMAB 200 MG/1.14 ML SUBCUTANEOUS SYRINGE RX-169256 CDM 2500000200 HCPCS 250 RC 00024-5910-01 NDC inpatient 1.15 ML 4640.61 4640.61 CIGNA 62308 [3081051] CIGNA STATE OF WYOMING [308105107] 3674.43 percent of total billed charges 2877.18 4408.58 Technical (Hospital) Services SARILUMAB 200 MG/1.14 ML SUBCUTANEOUS SYRINGE RX-169256 CDM 2500000200 HCPCS 250 RC 00024-5910-01 NDC inpatient 1.15 ML 4640.61 4640.61 MEDICA (COMMERCIAL) 94265 [3081118] MEDICA CLAIMS [308111801] 4176.55 percent of total billed charges 2877.18 4408.58 Technical (Hospital) Services SARILUMAB 200 MG/1.14 ML SUBCUTANEOUS SYRINGE RX-169256 CDM 2500000200 HCPCS 250 RC 00024-5910-01 NDC inpatient 1.15 ML 4640.61 4640.61 HEALTHPARTNERS SX009 HEALTHPARTNERS 3674.43 percent of total billed charges 2877.18 4408.58 Technical (Hospital) Services SARILUMAB 200 MG/1.14 ML SUBCUTANEOUS SYRINGE RX-169256 CDM 2500000200 HCPCS 250 RC 00024-5910-01 NDC inpatient 1.15 ML 4640.61 4640.61 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES EPO [308136803] 3674.43 percent of total billed charges 2877.18 4408.58 Technical (Hospital) Services SARILUMAB 200 MG/1.14 ML SUBCUTANEOUS SYRINGE RX-169256 CDM 2500000200 HCPCS 250 RC 00024-5910-01 NDC inpatient 1.15 ML 4640.61 4640.61 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES HDHP [308136802] 3674.43 percent of total billed charges 2877.18 4408.58 Technical (Hospital) Services SARILUMAB 200 MG/1.14 ML SUBCUTANEOUS SYRINGE RX-169256 CDM 2500000200 HCPCS 250 RC 00024-5910-01 NDC inpatient 1.15 ML 4640.61 4640.61 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES PPO [308136801] 3674.43 percent of total billed charges 2877.18 4408.58 Technical (Hospital) Services SARILUMAB 200 MG/1.14 ML SUBCUTANEOUS SYRINGE RX-169256 CDM 2500000200 HCPCS 250 RC 00024-5910-01 NDC outpatient 1.15 ML 4640.61 4640.61 BLUE CROSS BLUE SHIELD WELLMARK SB889 [3081026] BCBS WYOMING [308102603] 4408.58 percent of total billed charges 2877.18 4408.58 Technical (Hospital) Services SARILUMAB 200 MG/1.14 ML SUBCUTANEOUS SYRINGE RX-169256 CDM 2500000200 HCPCS 250 RC 00024-5910-01 NDC outpatient 1.15 ML 4640.61 4640.61 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES EPO [308136803] 3712.49 percent of total billed charges 2877.18 4408.58 Technical (Hospital) Services SARILUMAB 200 MG/1.14 ML SUBCUTANEOUS SYRINGE RX-169256 CDM 2500000200 HCPCS 250 RC 00024-5910-01 NDC outpatient 1.15 ML 4640.61 4640.61 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES HDHP [308136802] 3712.49 percent of total billed charges 2877.18 4408.58 Technical (Hospital) Services SARILUMAB 200 MG/1.14 ML SUBCUTANEOUS SYRINGE RX-169256 CDM 2500000200 HCPCS 250 RC 00024-5910-01 NDC outpatient 1.15 ML 4640.61 4640.61 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES PPO [308136801] 3712.49 percent of total billed charges 2877.18 4408.58 Technical (Hospital) Services SARILUMAB 200 MG/1.14 ML SUBCUTANEOUS SYRINGE RX-169256 CDM 2500000200 HCPCS 250 RC 00024-5910-01 NDC outpatient 1.15 ML 4640.61 4640.61 HEALTHPARTNERS SX009 HEALTHPARTNERS 3712.49 percent of total billed charges 2877.18 4408.58 Technical (Hospital) Services SARILUMAB 200 MG/1.14 ML SUBCUTANEOUS SYRINGE RX-169256 CDM 2500000200 HCPCS 250 RC 00024-5910-01 NDC outpatient 1.15 ML 4640.61 4640.61 MULTIPLAN INC 34080 [3081285] MULTIPLAN INC [308128501] 4408.58 percent of total billed charges 2877.18 4408.58 Technical (Hospital) Services SARILUMAB 200 MG/1.14 ML SUBCUTANEOUS SYRINGE RX-169256 CDM 2500000200 HCPCS 250 RC 00024-5910-01 NDC outpatient 1.15 ML 4640.61 4640.61 UNITED HEALTHCARE (COMMERCIAL) [3081199] UNITED HEALTHCARE 87726 [308119901] 2877.18 percent of total billed charges 2877.18 4408.58 Technical (Hospital) Services SARILUMAB 200 MG/1.14 ML SUBCUTANEOUS SYRINGE RX-169256 CDM 2500000200 HCPCS 250 RC 00024-5910-01 NDC outpatient 1.15 ML 4640.61 4640.61 CIGNA 62308 [3081051] CIGNA 62308 [308105105] 3712.49 percent of total billed charges 2877.18 4408.58 Technical (Hospital) Services SARILUMAB 200 MG/1.14 ML SUBCUTANEOUS SYRINGE RX-169256 CDM 2500000200 HCPCS 250 RC 00024-5910-01 NDC outpatient 1.15 ML 4640.61 4640.61 CIGNA 62308 [3081051] CIGNA STATE OF WYOMING [308105107] 3712.49 percent of total billed charges 2877.18 4408.58 Technical (Hospital) Services SARILUMAB 200 MG/1.14 ML SUBCUTANEOUS SYRINGE RX-169256 CDM 2500000200 HCPCS 250 RC 00024-5910-01 NDC outpatient 1.15 ML 4640.61 4640.61 MEDICA (COMMERCIAL) 94265 [3081118] MEDICA CLAIMS [308111801] 4176.55 percent of total billed charges 2877.18 4408.58 Technical (Hospital) Services CLINDAMYCIN 600 MG/50 ML IN 0.9% SODIUM CHLORIDE INTRAVENOUS PIGGYBACK RX-169337 CDM 2500000200 HCPCS 250 RC 00338-9549-50 NDC outpatient 50 ML 80.7 80.7 CIGNA 62308 [3081051] CIGNA 62308 [308105105] 64.56 percent of total billed charges 50.03 76.67 Technical (Hospital) Services CLINDAMYCIN 600 MG/50 ML IN 0.9% SODIUM CHLORIDE INTRAVENOUS PIGGYBACK RX-169337 CDM 2500000200 HCPCS 250 RC 00338-9549-50 NDC outpatient 50 ML 80.7 80.7 CIGNA 62308 [3081051] CIGNA STATE OF WYOMING [308105107] 64.56 percent of total billed charges 50.03 76.67 Technical (Hospital) Services CLINDAMYCIN 600 MG/50 ML IN 0.9% SODIUM CHLORIDE INTRAVENOUS PIGGYBACK RX-169337 CDM 2500000200 HCPCS 250 RC 00338-9549-50 NDC outpatient 50 ML 80.7 80.7 MULTIPLAN INC 34080 [3081285] MULTIPLAN INC [308128501] 76.67 percent of total billed charges 50.03 76.67 Technical (Hospital) Services CLINDAMYCIN 600 MG/50 ML IN 0.9% SODIUM CHLORIDE INTRAVENOUS PIGGYBACK RX-169337 CDM 2500000200 HCPCS 250 RC 00338-9549-50 NDC outpatient 50 ML 80.7 80.7 MEDICA (COMMERCIAL) 94265 [3081118] MEDICA CLAIMS [308111801] 72.63 percent of total billed charges 50.03 76.67 Technical (Hospital) Services CLINDAMYCIN 600 MG/50 ML IN 0.9% SODIUM CHLORIDE INTRAVENOUS PIGGYBACK RX-169337 CDM 2500000200 HCPCS 250 RC 00338-9549-50 NDC outpatient 50 ML 80.7 80.7 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES HDHP [308136802] 64.56 percent of total billed charges 50.03 76.67 Technical (Hospital) Services CLINDAMYCIN 600 MG/50 ML IN 0.9% SODIUM CHLORIDE INTRAVENOUS PIGGYBACK RX-169337 CDM 2500000200 HCPCS 250 RC 00338-9549-50 NDC outpatient 50 ML 80.7 80.7 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES PPO [308136801] 64.56 percent of total billed charges 50.03 76.67 Technical (Hospital) Services CLINDAMYCIN 600 MG/50 ML IN 0.9% SODIUM CHLORIDE INTRAVENOUS PIGGYBACK RX-169337 CDM 2500000200 HCPCS 250 RC 00338-9549-50 NDC outpatient 50 ML 80.7 80.7 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES EPO [308136803] 64.56 percent of total billed charges 50.03 76.67 Technical (Hospital) Services CLINDAMYCIN 600 MG/50 ML IN 0.9% SODIUM CHLORIDE INTRAVENOUS PIGGYBACK RX-169337 CDM 2500000200 HCPCS 250 RC 00338-9549-50 NDC outpatient 50 ML 80.7 80.7 UNITED HEALTHCARE (COMMERCIAL) [3081199] UNITED HEALTHCARE 87726 [308119901] 50.03 percent of total billed charges 50.03 76.67 Technical (Hospital) Services CLINDAMYCIN 600 MG/50 ML IN 0.9% SODIUM CHLORIDE INTRAVENOUS PIGGYBACK RX-169337 CDM 2500000200 HCPCS 250 RC 00338-9549-50 NDC outpatient 50 ML 80.7 80.7 BLUE CROSS BLUE SHIELD WELLMARK SB889 [3081026] BCBS WYOMING [308102603] 76.67 percent of total billed charges 50.03 76.67 Technical (Hospital) Services CLINDAMYCIN 600 MG/50 ML IN 0.9% SODIUM CHLORIDE INTRAVENOUS PIGGYBACK RX-169337 CDM 2500000200 HCPCS 250 RC 00338-9549-50 NDC outpatient 50 ML 80.7 80.7 HEALTHPARTNERS SX009 HEALTHPARTNERS 64.56 percent of total billed charges 50.03 76.67 Technical (Hospital) Services CLINDAMYCIN 600 MG/50 ML IN 0.9% SODIUM CHLORIDE INTRAVENOUS PIGGYBACK RX-169337 CDM 2500000200 HCPCS 250 RC 00338-9549-50 NDC inpatient 50 ML 80.7 80.7 MULTIPLAN INC 34080 [3081285] MULTIPLAN INC [308128501] 76.67 percent of total billed charges 50.03 76.67 Technical (Hospital) Services CLINDAMYCIN 600 MG/50 ML IN 0.9% SODIUM CHLORIDE INTRAVENOUS PIGGYBACK RX-169337 CDM 2500000200 HCPCS 250 RC 00338-9549-50 NDC inpatient 50 ML 80.7 80.7 MEDICA (COMMERCIAL) 94265 [3081118] MEDICA CLAIMS [308111801] 72.63 percent of total billed charges 50.03 76.67 Technical (Hospital) Services CLINDAMYCIN 600 MG/50 ML IN 0.9% SODIUM CHLORIDE INTRAVENOUS PIGGYBACK RX-169337 CDM 2500000200 HCPCS 250 RC 00338-9549-50 NDC inpatient 50 ML 80.7 80.7 HEALTHPARTNERS SX009 HEALTHPARTNERS 63.9 percent of total billed charges 50.03 76.67 Technical (Hospital) Services CLINDAMYCIN 600 MG/50 ML IN 0.9% SODIUM CHLORIDE INTRAVENOUS PIGGYBACK RX-169337 CDM 2500000200 HCPCS 250 RC 00338-9549-50 NDC inpatient 50 ML 80.7 80.7 BLUE CROSS BLUE SHIELD WELLMARK SB889 [3081026] BCBS WYOMING [308102603] 76.67 percent of total billed charges 50.03 76.67 Technical (Hospital) Services CLINDAMYCIN 600 MG/50 ML IN 0.9% SODIUM CHLORIDE INTRAVENOUS PIGGYBACK RX-169337 CDM 2500000200 HCPCS 250 RC 00338-9549-50 NDC inpatient 50 ML 80.7 80.7 UNITED HEALTHCARE (COMMERCIAL) [3081199] UNITED HEALTHCARE 87726 [308119901] 50.03 percent of total billed charges 50.03 76.67 Technical (Hospital) Services CLINDAMYCIN 600 MG/50 ML IN 0.9% SODIUM CHLORIDE INTRAVENOUS PIGGYBACK RX-169337 CDM 2500000200 HCPCS 250 RC 00338-9549-50 NDC inpatient 50 ML 80.7 80.7 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES EPO [308136803] 63.9 percent of total billed charges 50.03 76.67 Technical (Hospital) Services CLINDAMYCIN 600 MG/50 ML IN 0.9% SODIUM CHLORIDE INTRAVENOUS PIGGYBACK RX-169337 CDM 2500000200 HCPCS 250 RC 00338-9549-50 NDC inpatient 50 ML 80.7 80.7 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES PPO [308136801] 63.9 percent of total billed charges 50.03 76.67 Technical (Hospital) Services CLINDAMYCIN 600 MG/50 ML IN 0.9% SODIUM CHLORIDE INTRAVENOUS PIGGYBACK RX-169337 CDM 2500000200 HCPCS 250 RC 00338-9549-50 NDC inpatient 50 ML 80.7 80.7 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES HDHP [308136802] 63.9 percent of total billed charges 50.03 76.67 Technical (Hospital) Services CLINDAMYCIN 600 MG/50 ML IN 0.9% SODIUM CHLORIDE INTRAVENOUS PIGGYBACK RX-169337 CDM 2500000200 HCPCS 250 RC 00338-9549-50 NDC inpatient 50 ML 80.7 80.7 CIGNA 62308 [3081051] CIGNA 62308 [308105105] 63.9 percent of total billed charges 50.03 76.67 Technical (Hospital) Services CLINDAMYCIN 600 MG/50 ML IN 0.9% SODIUM CHLORIDE INTRAVENOUS PIGGYBACK RX-169337 CDM 2500000200 HCPCS 250 RC 00338-9549-50 NDC inpatient 50 ML 80.7 80.7 CIGNA 62308 [3081051] CIGNA STATE OF WYOMING [308105107] 63.9 percent of total billed charges 50.03 76.67 Technical (Hospital) Services "MVI,ADULT NO.4,VIT K,COMP(VIAL 1 OF 2) 3,300 UNIT-150 MCG/5 ML IV SOLN" RX-171825 CDM 2500000200 HCPCS 250 RC 54643-7862-08 NDC inpatient 5 ML 72.19 72.19 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES EPO [308136803] 57.16 percent of total billed charges 44.76 68.58 Technical (Hospital) Services "MVI,ADULT NO.4,VIT K,COMP(VIAL 1 OF 2) 3,300 UNIT-150 MCG/5 ML IV SOLN" RX-171825 CDM 2500000200 HCPCS 250 RC 54643-7862-08 NDC inpatient 5 ML 72.19 72.19 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES HDHP [308136802] 57.16 percent of total billed charges 44.76 68.58 Technical (Hospital) Services "MVI,ADULT NO.4,VIT K,COMP(VIAL 1 OF 2) 3,300 UNIT-150 MCG/5 ML IV SOLN" RX-171825 CDM 2500000200 HCPCS 250 RC 54643-7862-08 NDC inpatient 5 ML 72.19 72.19 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES PPO [308136801] 57.16 percent of total billed charges 44.76 68.58 Technical (Hospital) Services "MVI,ADULT NO.4,VIT K,COMP(VIAL 1 OF 2) 3,300 UNIT-150 MCG/5 ML IV SOLN" RX-171825 CDM 2500000200 HCPCS 250 RC 54643-7862-08 NDC inpatient 5 ML 72.19 72.19 HEALTHPARTNERS SX009 HEALTHPARTNERS 57.16 percent of total billed charges 44.76 68.58 Technical (Hospital) Services "MVI,ADULT NO.4,VIT K,COMP(VIAL 1 OF 2) 3,300 UNIT-150 MCG/5 ML IV SOLN" RX-171825 CDM 2500000200 HCPCS 250 RC 54643-7862-08 NDC inpatient 5 ML 72.19 72.19 MULTIPLAN INC 34080 [3081285] MULTIPLAN INC [308128501] 68.58 percent of total billed charges 44.76 68.58 Technical (Hospital) Services "MVI,ADULT NO.4,VIT K,COMP(VIAL 1 OF 2) 3,300 UNIT-150 MCG/5 ML IV SOLN" RX-171825 CDM 2500000200 HCPCS 250 RC 54643-7862-08 NDC inpatient 5 ML 72.19 72.19 MEDICA (COMMERCIAL) 94265 [3081118] MEDICA CLAIMS [308111801] 64.97 percent of total billed charges 44.76 68.58 Technical (Hospital) Services "MVI,ADULT NO.4,VIT K,COMP(VIAL 1 OF 2) 3,300 UNIT-150 MCG/5 ML IV SOLN" RX-171825 CDM 2500000200 HCPCS 250 RC 54643-7862-08 NDC inpatient 5 ML 72.19 72.19 UNITED HEALTHCARE (COMMERCIAL) [3081199] UNITED HEALTHCARE 87726 [308119901] 44.76 percent of total billed charges 44.76 68.58 Technical (Hospital) Services "MVI,ADULT NO.4,VIT K,COMP(VIAL 1 OF 2) 3,300 UNIT-150 MCG/5 ML IV SOLN" RX-171825 CDM 2500000200 HCPCS 250 RC 54643-7862-08 NDC inpatient 5 ML 72.19 72.19 BLUE CROSS BLUE SHIELD WELLMARK SB889 [3081026] BCBS WYOMING [308102603] 68.58 percent of total billed charges 44.76 68.58 Technical (Hospital) Services "MVI,ADULT NO.4,VIT K,COMP(VIAL 1 OF 2) 3,300 UNIT-150 MCG/5 ML IV SOLN" RX-171825 CDM 2500000200 HCPCS 250 RC 54643-7862-08 NDC inpatient 5 ML 72.19 72.19 CIGNA 62308 [3081051] CIGNA 62308 [308105105] 57.16 percent of total billed charges 44.76 68.58 Technical (Hospital) Services "MVI,ADULT NO.4,VIT K,COMP(VIAL 1 OF 2) 3,300 UNIT-150 MCG/5 ML IV SOLN" RX-171825 CDM 2500000200 HCPCS 250 RC 54643-7862-08 NDC inpatient 5 ML 72.19 72.19 CIGNA 62308 [3081051] CIGNA STATE OF WYOMING [308105107] 57.16 percent of total billed charges 44.76 68.58 Technical (Hospital) Services "MVI,ADULT NO.4,VIT K,COMP(VIAL 1 OF 2) 3,300 UNIT-150 MCG/5 ML IV SOLN" RX-171825 CDM 2500000200 HCPCS 250 RC 54643-7862-08 NDC outpatient 5 ML 72.19 72.19 MULTIPLAN INC 34080 [3081285] MULTIPLAN INC [308128501] 68.58 percent of total billed charges 44.76 68.58 Technical (Hospital) Services "MVI,ADULT NO.4,VIT K,COMP(VIAL 1 OF 2) 3,300 UNIT-150 MCG/5 ML IV SOLN" RX-171825 CDM 2500000200 HCPCS 250 RC 54643-7862-08 NDC outpatient 5 ML 72.19 72.19 MEDICA (COMMERCIAL) 94265 [3081118] MEDICA CLAIMS [308111801] 64.97 percent of total billed charges 44.76 68.58 Technical (Hospital) Services "MVI,ADULT NO.4,VIT K,COMP(VIAL 1 OF 2) 3,300 UNIT-150 MCG/5 ML IV SOLN" RX-171825 CDM 2500000200 HCPCS 250 RC 54643-7862-08 NDC outpatient 5 ML 72.19 72.19 CIGNA 62308 [3081051] CIGNA 62308 [308105105] 57.75 percent of total billed charges 44.76 68.58 Technical (Hospital) Services "MVI,ADULT NO.4,VIT K,COMP(VIAL 1 OF 2) 3,300 UNIT-150 MCG/5 ML IV SOLN" RX-171825 CDM 2500000200 HCPCS 250 RC 54643-7862-08 NDC outpatient 5 ML 72.19 72.19 CIGNA 62308 [3081051] CIGNA STATE OF WYOMING [308105107] 57.75 percent of total billed charges 44.76 68.58 Technical (Hospital) Services "MVI,ADULT NO.4,VIT K,COMP(VIAL 1 OF 2) 3,300 UNIT-150 MCG/5 ML IV SOLN" RX-171825 CDM 2500000200 HCPCS 250 RC 54643-7862-08 NDC outpatient 5 ML 72.19 72.19 BLUE CROSS BLUE SHIELD WELLMARK SB889 [3081026] BCBS WYOMING [308102603] 68.58 percent of total billed charges 44.76 68.58 Technical (Hospital) Services "MVI,ADULT NO.4,VIT K,COMP(VIAL 1 OF 2) 3,300 UNIT-150 MCG/5 ML IV SOLN" RX-171825 CDM 2500000200 HCPCS 250 RC 54643-7862-08 NDC outpatient 5 ML 72.19 72.19 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES EPO [308136803] 57.75 percent of total billed charges 44.76 68.58 Technical (Hospital) Services "MVI,ADULT NO.4,VIT K,COMP(VIAL 1 OF 2) 3,300 UNIT-150 MCG/5 ML IV SOLN" RX-171825 CDM 2500000200 HCPCS 250 RC 54643-7862-08 NDC outpatient 5 ML 72.19 72.19 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES HDHP [308136802] 57.75 percent of total billed charges 44.76 68.58 Technical (Hospital) Services "MVI,ADULT NO.4,VIT K,COMP(VIAL 1 OF 2) 3,300 UNIT-150 MCG/5 ML IV SOLN" RX-171825 CDM 2500000200 HCPCS 250 RC 54643-7862-08 NDC outpatient 5 ML 72.19 72.19 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES PPO [308136801] 57.75 percent of total billed charges 44.76 68.58 Technical (Hospital) Services "MVI,ADULT NO.4,VIT K,COMP(VIAL 1 OF 2) 3,300 UNIT-150 MCG/5 ML IV SOLN" RX-171825 CDM 2500000200 HCPCS 250 RC 54643-7862-08 NDC outpatient 5 ML 72.19 72.19 UNITED HEALTHCARE (COMMERCIAL) [3081199] UNITED HEALTHCARE 87726 [308119901] 44.76 percent of total billed charges 44.76 68.58 Technical (Hospital) Services "MVI,ADULT NO.4,VIT K,COMP(VIAL 1 OF 2) 3,300 UNIT-150 MCG/5 ML IV SOLN" RX-171825 CDM 2500000200 HCPCS 250 RC 54643-7862-08 NDC outpatient 5 ML 72.19 72.19 HEALTHPARTNERS SX009 HEALTHPARTNERS 57.75 percent of total billed charges 44.76 68.58 Technical (Hospital) Services "MVI, ADULT NO.4, VIT K (VIAL 2 OF 2) 600 MCG-60 MCG-5 MCG/5 ML IV SOLN" RX-171826 CDM 2500000200 HCPCS 250 RC 54643-7862-09 NDC inpatient 5 ML 72.19 72.19 CIGNA 62308 [3081051] CIGNA 62308 [308105105] 57.16 percent of total billed charges 44.76 68.58 Technical (Hospital) Services "MVI, ADULT NO.4, VIT K (VIAL 2 OF 2) 600 MCG-60 MCG-5 MCG/5 ML IV SOLN" RX-171826 CDM 2500000200 HCPCS 250 RC 54643-7862-09 NDC inpatient 5 ML 72.19 72.19 CIGNA 62308 [3081051] CIGNA STATE OF WYOMING [308105107] 57.16 percent of total billed charges 44.76 68.58 Technical (Hospital) Services "MVI, ADULT NO.4, VIT K (VIAL 2 OF 2) 600 MCG-60 MCG-5 MCG/5 ML IV SOLN" RX-171826 CDM 2500000200 HCPCS 250 RC 54643-7862-09 NDC inpatient 5 ML 72.19 72.19 BLUE CROSS BLUE SHIELD WELLMARK SB889 [3081026] BCBS WYOMING [308102603] 68.58 percent of total billed charges 44.76 68.58 Technical (Hospital) Services "MVI, ADULT NO.4, VIT K (VIAL 2 OF 2) 600 MCG-60 MCG-5 MCG/5 ML IV SOLN" RX-171826 CDM 2500000200 HCPCS 250 RC 54643-7862-09 NDC inpatient 5 ML 72.19 72.19 UNITED HEALTHCARE (COMMERCIAL) [3081199] UNITED HEALTHCARE 87726 [308119901] 44.76 percent of total billed charges 44.76 68.58 Technical (Hospital) Services "MVI, ADULT NO.4, VIT K (VIAL 2 OF 2) 600 MCG-60 MCG-5 MCG/5 ML IV SOLN" RX-171826 CDM 2500000200 HCPCS 250 RC 54643-7862-09 NDC inpatient 5 ML 72.19 72.19 MEDICA (COMMERCIAL) 94265 [3081118] MEDICA CLAIMS [308111801] 64.97 percent of total billed charges 44.76 68.58 Technical (Hospital) Services "MVI, ADULT NO.4, VIT K (VIAL 2 OF 2) 600 MCG-60 MCG-5 MCG/5 ML IV SOLN" RX-171826 CDM 2500000200 HCPCS 250 RC 54643-7862-09 NDC inpatient 5 ML 72.19 72.19 MULTIPLAN INC 34080 [3081285] MULTIPLAN INC [308128501] 68.58 percent of total billed charges 44.76 68.58 Technical (Hospital) Services "MVI, ADULT NO.4, VIT K (VIAL 2 OF 2) 600 MCG-60 MCG-5 MCG/5 ML IV SOLN" RX-171826 CDM 2500000200 HCPCS 250 RC 54643-7862-09 NDC inpatient 5 ML 72.19 72.19 HEALTHPARTNERS SX009 HEALTHPARTNERS 57.16 percent of total billed charges 44.76 68.58 Technical (Hospital) Services "MVI, ADULT NO.4, VIT K (VIAL 2 OF 2) 600 MCG-60 MCG-5 MCG/5 ML IV SOLN" RX-171826 CDM 2500000200 HCPCS 250 RC 54643-7862-09 NDC inpatient 5 ML 72.19 72.19 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES EPO [308136803] 57.16 percent of total billed charges 44.76 68.58 Technical (Hospital) Services "MVI, ADULT NO.4, VIT K (VIAL 2 OF 2) 600 MCG-60 MCG-5 MCG/5 ML IV SOLN" RX-171826 CDM 2500000200 HCPCS 250 RC 54643-7862-09 NDC inpatient 5 ML 72.19 72.19 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES HDHP [308136802] 57.16 percent of total billed charges 44.76 68.58 Technical (Hospital) Services "MVI, ADULT NO.4, VIT K (VIAL 2 OF 2) 600 MCG-60 MCG-5 MCG/5 ML IV SOLN" RX-171826 CDM 2500000200 HCPCS 250 RC 54643-7862-09 NDC inpatient 5 ML 72.19 72.19 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES PPO [308136801] 57.16 percent of total billed charges 44.76 68.58 Technical (Hospital) Services "MVI, ADULT NO.4, VIT K (VIAL 2 OF 2) 600 MCG-60 MCG-5 MCG/5 ML IV SOLN" RX-171826 CDM 2500000200 HCPCS 250 RC 54643-7862-09 NDC outpatient 5 ML 72.19 72.19 CIGNA 62308 [3081051] CIGNA 62308 [308105105] 57.75 percent of total billed charges 44.76 68.58 Technical (Hospital) Services "MVI, ADULT NO.4, VIT K (VIAL 2 OF 2) 600 MCG-60 MCG-5 MCG/5 ML IV SOLN" RX-171826 CDM 2500000200 HCPCS 250 RC 54643-7862-09 NDC outpatient 5 ML 72.19 72.19 CIGNA 62308 [3081051] CIGNA STATE OF WYOMING [308105107] 57.75 percent of total billed charges 44.76 68.58 Technical (Hospital) Services "MVI, ADULT NO.4, VIT K (VIAL 2 OF 2) 600 MCG-60 MCG-5 MCG/5 ML IV SOLN" RX-171826 CDM 2500000200 HCPCS 250 RC 54643-7862-09 NDC outpatient 5 ML 72.19 72.19 MULTIPLAN INC 34080 [3081285] MULTIPLAN INC [308128501] 68.58 percent of total billed charges 44.76 68.58 Technical (Hospital) Services "MVI, ADULT NO.4, VIT K (VIAL 2 OF 2) 600 MCG-60 MCG-5 MCG/5 ML IV SOLN" RX-171826 CDM 2500000200 HCPCS 250 RC 54643-7862-09 NDC outpatient 5 ML 72.19 72.19 MEDICA (COMMERCIAL) 94265 [3081118] MEDICA CLAIMS [308111801] 64.97 percent of total billed charges 44.76 68.58 Technical (Hospital) Services "MVI, ADULT NO.4, VIT K (VIAL 2 OF 2) 600 MCG-60 MCG-5 MCG/5 ML IV SOLN" RX-171826 CDM 2500000200 HCPCS 250 RC 54643-7862-09 NDC outpatient 5 ML 72.19 72.19 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES HDHP [308136802] 57.75 percent of total billed charges 44.76 68.58 Technical (Hospital) Services "MVI, ADULT NO.4, VIT K (VIAL 2 OF 2) 600 MCG-60 MCG-5 MCG/5 ML IV SOLN" RX-171826 CDM 2500000200 HCPCS 250 RC 54643-7862-09 NDC outpatient 5 ML 72.19 72.19 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES EPO [308136803] 57.75 percent of total billed charges 44.76 68.58 Technical (Hospital) Services "MVI, ADULT NO.4, VIT K (VIAL 2 OF 2) 600 MCG-60 MCG-5 MCG/5 ML IV SOLN" RX-171826 CDM 2500000200 HCPCS 250 RC 54643-7862-09 NDC outpatient 5 ML 72.19 72.19 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES PPO [308136801] 57.75 percent of total billed charges 44.76 68.58 Technical (Hospital) Services "MVI, ADULT NO.4, VIT K (VIAL 2 OF 2) 600 MCG-60 MCG-5 MCG/5 ML IV SOLN" RX-171826 CDM 2500000200 HCPCS 250 RC 54643-7862-09 NDC outpatient 5 ML 72.19 72.19 BLUE CROSS BLUE SHIELD WELLMARK SB889 [3081026] BCBS WYOMING [308102603] 68.58 percent of total billed charges 44.76 68.58 Technical (Hospital) Services "MVI, ADULT NO.4, VIT K (VIAL 2 OF 2) 600 MCG-60 MCG-5 MCG/5 ML IV SOLN" RX-171826 CDM 2500000200 HCPCS 250 RC 54643-7862-09 NDC outpatient 5 ML 72.19 72.19 UNITED HEALTHCARE (COMMERCIAL) [3081199] UNITED HEALTHCARE 87726 [308119901] 44.76 percent of total billed charges 44.76 68.58 Technical (Hospital) Services "MVI, ADULT NO.4, VIT K (VIAL 2 OF 2) 600 MCG-60 MCG-5 MCG/5 ML IV SOLN" RX-171826 CDM 2500000200 HCPCS 250 RC 54643-7862-09 NDC outpatient 5 ML 72.19 72.19 HEALTHPARTNERS SX009 HEALTHPARTNERS 57.75 percent of total billed charges 44.76 68.58 Technical (Hospital) Services SODIUM NITROPRUSSIDE 25 MG/ML INTRAVENOUS SOLUTION RX-18908 CDM 2500000200 HCPCS 250 RC 67457-0839-02 NDC inpatient 2 ML 392 392 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES PPO [308136801] 310.39 percent of total billed charges 243.04 372.4 Technical (Hospital) Services SODIUM NITROPRUSSIDE 25 MG/ML INTRAVENOUS SOLUTION RX-18908 CDM 2500000200 HCPCS 250 RC 67457-0839-02 NDC inpatient 2 ML 392 392 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES HDHP [308136802] 310.39 percent of total billed charges 243.04 372.4 Technical (Hospital) Services SODIUM NITROPRUSSIDE 25 MG/ML INTRAVENOUS SOLUTION RX-18908 CDM 2500000200 HCPCS 250 RC 67457-0839-02 NDC inpatient 2 ML 392 392 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES EPO [308136803] 310.39 percent of total billed charges 243.04 372.4 Technical (Hospital) Services SODIUM NITROPRUSSIDE 25 MG/ML INTRAVENOUS SOLUTION RX-18908 CDM 2500000200 HCPCS 250 RC 67457-0839-02 NDC inpatient 2 ML 392 392 HEALTHPARTNERS SX009 HEALTHPARTNERS 310.39 percent of total billed charges 243.04 372.4 Technical (Hospital) Services SODIUM NITROPRUSSIDE 25 MG/ML INTRAVENOUS SOLUTION RX-18908 CDM 2500000200 HCPCS 250 RC 67457-0839-02 NDC inpatient 2 ML 392 392 BLUE CROSS BLUE SHIELD WELLMARK SB889 [3081026] BCBS WYOMING [308102603] 372.4 percent of total billed charges 243.04 372.4 Technical (Hospital) Services SODIUM NITROPRUSSIDE 25 MG/ML INTRAVENOUS SOLUTION RX-18908 CDM 2500000200 HCPCS 250 RC 67457-0839-02 NDC inpatient 2 ML 392 392 UNITED HEALTHCARE (COMMERCIAL) [3081199] UNITED HEALTHCARE 87726 [308119901] 243.04 percent of total billed charges 243.04 372.4 Technical (Hospital) Services SODIUM NITROPRUSSIDE 25 MG/ML INTRAVENOUS SOLUTION RX-18908 CDM 2500000200 HCPCS 250 RC 67457-0839-02 NDC inpatient 2 ML 392 392 CIGNA 62308 [3081051] CIGNA 62308 [308105105] 310.39 percent of total billed charges 243.04 372.4 Technical (Hospital) Services SODIUM NITROPRUSSIDE 25 MG/ML INTRAVENOUS SOLUTION RX-18908 CDM 2500000200 HCPCS 250 RC 67457-0839-02 NDC inpatient 2 ML 392 392 CIGNA 62308 [3081051] CIGNA STATE OF WYOMING [308105107] 310.39 percent of total billed charges 243.04 372.4 Technical (Hospital) Services SODIUM NITROPRUSSIDE 25 MG/ML INTRAVENOUS SOLUTION RX-18908 CDM 2500000200 HCPCS 250 RC 67457-0839-02 NDC inpatient 2 ML 392 392 MULTIPLAN INC 34080 [3081285] MULTIPLAN INC [308128501] 372.4 percent of total billed charges 243.04 372.4 Technical (Hospital) Services SODIUM NITROPRUSSIDE 25 MG/ML INTRAVENOUS SOLUTION RX-18908 CDM 2500000200 HCPCS 250 RC 67457-0839-02 NDC inpatient 2 ML 392 392 MEDICA (COMMERCIAL) 94265 [3081118] MEDICA CLAIMS [308111801] 352.8 percent of total billed charges 243.04 372.4 Technical (Hospital) Services SODIUM NITROPRUSSIDE 25 MG/ML INTRAVENOUS SOLUTION RX-18908 CDM 2500000200 HCPCS 250 RC 67457-0839-02 NDC outpatient 2 ML 392 392 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES EPO [308136803] 313.6 percent of total billed charges 243.04 372.4 Technical (Hospital) Services SODIUM NITROPRUSSIDE 25 MG/ML INTRAVENOUS SOLUTION RX-18908 CDM 2500000200 HCPCS 250 RC 67457-0839-02 NDC outpatient 2 ML 392 392 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES PPO [308136801] 313.6 percent of total billed charges 243.04 372.4 Technical (Hospital) Services SODIUM NITROPRUSSIDE 25 MG/ML INTRAVENOUS SOLUTION RX-18908 CDM 2500000200 HCPCS 250 RC 67457-0839-02 NDC outpatient 2 ML 392 392 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES HDHP [308136802] 313.6 percent of total billed charges 243.04 372.4 Technical (Hospital) Services SODIUM NITROPRUSSIDE 25 MG/ML INTRAVENOUS SOLUTION RX-18908 CDM 2500000200 HCPCS 250 RC 67457-0839-02 NDC outpatient 2 ML 392 392 BLUE CROSS BLUE SHIELD WELLMARK SB889 [3081026] BCBS WYOMING [308102603] 372.4 percent of total billed charges 243.04 372.4 Technical (Hospital) Services SODIUM NITROPRUSSIDE 25 MG/ML INTRAVENOUS SOLUTION RX-18908 CDM 2500000200 HCPCS 250 RC 67457-0839-02 NDC outpatient 2 ML 392 392 MULTIPLAN INC 34080 [3081285] MULTIPLAN INC [308128501] 372.4 percent of total billed charges 243.04 372.4 Technical (Hospital) Services SODIUM NITROPRUSSIDE 25 MG/ML INTRAVENOUS SOLUTION RX-18908 CDM 2500000200 HCPCS 250 RC 67457-0839-02 NDC outpatient 2 ML 392 392 MEDICA (COMMERCIAL) 94265 [3081118] MEDICA CLAIMS [308111801] 352.8 percent of total billed charges 243.04 372.4 Technical (Hospital) Services SODIUM NITROPRUSSIDE 25 MG/ML INTRAVENOUS SOLUTION RX-18908 CDM 2500000200 HCPCS 250 RC 67457-0839-02 NDC outpatient 2 ML 392 392 CIGNA 62308 [3081051] CIGNA 62308 [308105105] 313.6 percent of total billed charges 243.04 372.4 Technical (Hospital) Services SODIUM NITROPRUSSIDE 25 MG/ML INTRAVENOUS SOLUTION RX-18908 CDM 2500000200 HCPCS 250 RC 67457-0839-02 NDC outpatient 2 ML 392 392 CIGNA 62308 [3081051] CIGNA STATE OF WYOMING [308105107] 313.6 percent of total billed charges 243.04 372.4 Technical (Hospital) Services SODIUM NITROPRUSSIDE 25 MG/ML INTRAVENOUS SOLUTION RX-18908 CDM 2500000200 HCPCS 250 RC 67457-0839-02 NDC outpatient 2 ML 392 392 UNITED HEALTHCARE (COMMERCIAL) [3081199] UNITED HEALTHCARE 87726 [308119901] 243.04 percent of total billed charges 243.04 372.4 Technical (Hospital) Services SODIUM NITROPRUSSIDE 25 MG/ML INTRAVENOUS SOLUTION RX-18908 CDM 2500000200 HCPCS 250 RC 67457-0839-02 NDC outpatient 2 ML 392 392 HEALTHPARTNERS SX009 HEALTHPARTNERS 313.6 percent of total billed charges 243.04 372.4 Technical (Hospital) Services BENZOCAINE 20 % MUCOSAL AEROSOL SPRAY RX-19696 CDM 2500000200 HCPCS 250 RC 00283-0679-02 NDC inpatient 57 GR 111.86 111.86 CIGNA 62308 [3081051] CIGNA 62308 [308105105] 88.57 percent of total billed charges 69.35 106.27 Technical (Hospital) Services BENZOCAINE 20 % MUCOSAL AEROSOL SPRAY RX-19696 CDM 2500000200 HCPCS 250 RC 00283-0679-02 NDC inpatient 57 GR 111.86 111.86 CIGNA 62308 [3081051] CIGNA STATE OF WYOMING [308105107] 88.57 percent of total billed charges 69.35 106.27 Technical (Hospital) Services BENZOCAINE 20 % MUCOSAL AEROSOL SPRAY RX-19696 CDM 2500000200 HCPCS 250 RC 00283-0679-02 NDC inpatient 57 GR 111.86 111.86 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES EPO [308136803] 88.57 percent of total billed charges 69.35 106.27 Technical (Hospital) Services BENZOCAINE 20 % MUCOSAL AEROSOL SPRAY RX-19696 CDM 2500000200 HCPCS 250 RC 00283-0679-02 NDC inpatient 57 GR 111.86 111.86 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES HDHP [308136802] 88.57 percent of total billed charges 69.35 106.27 Technical (Hospital) Services BENZOCAINE 20 % MUCOSAL AEROSOL SPRAY RX-19696 CDM 2500000200 HCPCS 250 RC 00283-0679-02 NDC inpatient 57 GR 111.86 111.86 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES PPO [308136801] 88.57 percent of total billed charges 69.35 106.27 Technical (Hospital) Services BENZOCAINE 20 % MUCOSAL AEROSOL SPRAY RX-19696 CDM 2500000200 HCPCS 250 RC 00283-0679-02 NDC inpatient 57 GR 111.86 111.86 MULTIPLAN INC 34080 [3081285] MULTIPLAN INC [308128501] 106.27 percent of total billed charges 69.35 106.27 Technical (Hospital) Services BENZOCAINE 20 % MUCOSAL AEROSOL SPRAY RX-19696 CDM 2500000200 HCPCS 250 RC 00283-0679-02 NDC inpatient 57 GR 111.86 111.86 HEALTHPARTNERS SX009 HEALTHPARTNERS 88.57 percent of total billed charges 69.35 106.27 Technical (Hospital) Services BENZOCAINE 20 % MUCOSAL AEROSOL SPRAY RX-19696 CDM 2500000200 HCPCS 250 RC 00283-0679-02 NDC inpatient 57 GR 111.86 111.86 MEDICA (COMMERCIAL) 94265 [3081118] MEDICA CLAIMS [308111801] 100.67 percent of total billed charges 69.35 106.27 Technical (Hospital) Services BENZOCAINE 20 % MUCOSAL AEROSOL SPRAY RX-19696 CDM 2500000200 HCPCS 250 RC 00283-0679-02 NDC inpatient 57 GR 111.86 111.86 BLUE CROSS BLUE SHIELD WELLMARK SB889 [3081026] BCBS WYOMING [308102603] 106.27 percent of total billed charges 69.35 106.27 Technical (Hospital) Services BENZOCAINE 20 % MUCOSAL AEROSOL SPRAY RX-19696 CDM 2500000200 HCPCS 250 RC 00283-0679-02 NDC inpatient 57 GR 111.86 111.86 UNITED HEALTHCARE (COMMERCIAL) [3081199] UNITED HEALTHCARE 87726 [308119901] 69.35 percent of total billed charges 69.35 106.27 Technical (Hospital) Services BENZOCAINE 20 % MUCOSAL AEROSOL SPRAY RX-19696 CDM 2500000200 HCPCS 250 RC 00283-0679-02 NDC outpatient 57 GR 111.86 111.86 MULTIPLAN INC 34080 [3081285] MULTIPLAN INC [308128501] 106.27 percent of total billed charges 69.35 106.27 Technical (Hospital) Services BENZOCAINE 20 % MUCOSAL AEROSOL SPRAY RX-19696 CDM 2500000200 HCPCS 250 RC 00283-0679-02 NDC outpatient 57 GR 111.86 111.86 MEDICA (COMMERCIAL) 94265 [3081118] MEDICA CLAIMS [308111801] 100.67 percent of total billed charges 69.35 106.27 Technical (Hospital) Services BENZOCAINE 20 % MUCOSAL AEROSOL SPRAY RX-19696 CDM 2500000200 HCPCS 250 RC 00283-0679-02 NDC outpatient 57 GR 111.86 111.86 BLUE CROSS BLUE SHIELD WELLMARK SB889 [3081026] BCBS WYOMING [308102603] 106.27 percent of total billed charges 69.35 106.27 Technical (Hospital) Services BENZOCAINE 20 % MUCOSAL AEROSOL SPRAY RX-19696 CDM 2500000200 HCPCS 250 RC 00283-0679-02 NDC outpatient 57 GR 111.86 111.86 HEALTHPARTNERS SX009 HEALTHPARTNERS 89.49 percent of total billed charges 69.35 106.27 Technical (Hospital) Services BENZOCAINE 20 % MUCOSAL AEROSOL SPRAY RX-19696 CDM 2500000200 HCPCS 250 RC 00283-0679-02 NDC outpatient 57 GR 111.86 111.86 UNITED HEALTHCARE (COMMERCIAL) [3081199] UNITED HEALTHCARE 87726 [308119901] 69.35 percent of total billed charges 69.35 106.27 Technical (Hospital) Services BENZOCAINE 20 % MUCOSAL AEROSOL SPRAY RX-19696 CDM 2500000200 HCPCS 250 RC 00283-0679-02 NDC outpatient 57 GR 111.86 111.86 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES EPO [308136803] 89.49 percent of total billed charges 69.35 106.27 Technical (Hospital) Services BENZOCAINE 20 % MUCOSAL AEROSOL SPRAY RX-19696 CDM 2500000200 HCPCS 250 RC 00283-0679-02 NDC outpatient 57 GR 111.86 111.86 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES HDHP [308136802] 89.49 percent of total billed charges 69.35 106.27 Technical (Hospital) Services BENZOCAINE 20 % MUCOSAL AEROSOL SPRAY RX-19696 CDM 2500000200 HCPCS 250 RC 00283-0679-02 NDC outpatient 57 GR 111.86 111.86 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES PPO [308136801] 89.49 percent of total billed charges 69.35 106.27 Technical (Hospital) Services BENZOCAINE 20 % MUCOSAL AEROSOL SPRAY RX-19696 CDM 2500000200 HCPCS 250 RC 00283-0679-02 NDC outpatient 57 GR 111.86 111.86 CIGNA 62308 [3081051] CIGNA 62308 [308105105] 89.49 percent of total billed charges 69.35 106.27 Technical (Hospital) Services BENZOCAINE 20 % MUCOSAL AEROSOL SPRAY RX-19696 CDM 2500000200 HCPCS 250 RC 00283-0679-02 NDC outpatient 57 GR 111.86 111.86 CIGNA 62308 [3081051] CIGNA STATE OF WYOMING [308105107] 89.49 percent of total billed charges 69.35 106.27 Technical (Hospital) Services ETOMIDATE 2 MG/ML INTRAVENOUS SOLUTION RX-20472 CDM 2500000200 HCPCS 250 RC 00409-6695-02 NDC outpatient 20 ML 70.98 70.98 CIGNA 62308 [3081051] CIGNA 62308 [308105105] 56.78 percent of total billed charges 44.01 67.43 Technical (Hospital) Services ETOMIDATE 2 MG/ML INTRAVENOUS SOLUTION RX-20472 CDM 2500000200 HCPCS 250 RC 00409-6695-02 NDC outpatient 20 ML 70.98 70.98 CIGNA 62308 [3081051] CIGNA STATE OF WYOMING [308105107] 56.78 percent of total billed charges 44.01 67.43 Technical (Hospital) Services ETOMIDATE 2 MG/ML INTRAVENOUS SOLUTION RX-20472 CDM 2500000200 HCPCS 250 RC 00409-6695-02 NDC outpatient 20 ML 70.98 70.98 MULTIPLAN INC 34080 [3081285] MULTIPLAN INC [308128501] 67.43 percent of total billed charges 44.01 67.43 Technical (Hospital) Services ETOMIDATE 2 MG/ML INTRAVENOUS SOLUTION RX-20472 CDM 2500000200 HCPCS 250 RC 00409-6695-02 NDC outpatient 20 ML 70.98 70.98 MEDICA (COMMERCIAL) 94265 [3081118] MEDICA CLAIMS [308111801] 63.88 percent of total billed charges 44.01 67.43 Technical (Hospital) Services ETOMIDATE 2 MG/ML INTRAVENOUS SOLUTION RX-20472 CDM 2500000200 HCPCS 250 RC 00409-6695-02 NDC outpatient 20 ML 70.98 70.98 UNITED HEALTHCARE (COMMERCIAL) [3081199] UNITED HEALTHCARE 87726 [308119901] 44.01 percent of total billed charges 44.01 67.43 Technical (Hospital) Services ETOMIDATE 2 MG/ML INTRAVENOUS SOLUTION RX-20472 CDM 2500000200 HCPCS 250 RC 00409-6695-02 NDC outpatient 20 ML 70.98 70.98 HEALTHPARTNERS SX009 HEALTHPARTNERS 56.78 percent of total billed charges 44.01 67.43 Technical (Hospital) Services ETOMIDATE 2 MG/ML INTRAVENOUS SOLUTION RX-20472 CDM 2500000200 HCPCS 250 RC 00409-6695-02 NDC outpatient 20 ML 70.98 70.98 BLUE CROSS BLUE SHIELD WELLMARK SB889 [3081026] BCBS WYOMING [308102603] 67.43 percent of total billed charges 44.01 67.43 Technical (Hospital) Services ETOMIDATE 2 MG/ML INTRAVENOUS SOLUTION RX-20472 CDM 2500000200 HCPCS 250 RC 00409-6695-02 NDC outpatient 20 ML 70.98 70.98 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES PPO [308136801] 56.78 percent of total billed charges 44.01 67.43 Technical (Hospital) Services ETOMIDATE 2 MG/ML INTRAVENOUS SOLUTION RX-20472 CDM 2500000200 HCPCS 250 RC 00409-6695-02 NDC outpatient 20 ML 70.98 70.98 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES HDHP [308136802] 56.78 percent of total billed charges 44.01 67.43 Technical (Hospital) Services ETOMIDATE 2 MG/ML INTRAVENOUS SOLUTION RX-20472 CDM 2500000200 HCPCS 250 RC 00409-6695-02 NDC outpatient 20 ML 70.98 70.98 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES EPO [308136803] 56.78 percent of total billed charges 44.01 67.43 Technical (Hospital) Services ETOMIDATE 2 MG/ML INTRAVENOUS SOLUTION RX-20472 CDM 2500000200 HCPCS 250 RC 00409-6695-02 NDC inpatient 20 ML 70.98 70.98 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES PPO [308136801] 56.2 percent of total billed charges 44.01 67.43 Technical (Hospital) Services ETOMIDATE 2 MG/ML INTRAVENOUS SOLUTION RX-20472 CDM 2500000200 HCPCS 250 RC 00409-6695-02 NDC inpatient 20 ML 70.98 70.98 HEALTHPARTNERS SX009 HEALTHPARTNERS 56.2 percent of total billed charges 44.01 67.43 Technical (Hospital) Services ETOMIDATE 2 MG/ML INTRAVENOUS SOLUTION RX-20472 CDM 2500000200 HCPCS 250 RC 00409-6695-02 NDC inpatient 20 ML 70.98 70.98 CIGNA 62308 [3081051] CIGNA 62308 [308105105] 56.2 percent of total billed charges 44.01 67.43 Technical (Hospital) Services ETOMIDATE 2 MG/ML INTRAVENOUS SOLUTION RX-20472 CDM 2500000200 HCPCS 250 RC 00409-6695-02 NDC inpatient 20 ML 70.98 70.98 CIGNA 62308 [3081051] CIGNA STATE OF WYOMING [308105107] 56.2 percent of total billed charges 44.01 67.43 Technical (Hospital) Services ETOMIDATE 2 MG/ML INTRAVENOUS SOLUTION RX-20472 CDM 2500000200 HCPCS 250 RC 00409-6695-02 NDC inpatient 20 ML 70.98 70.98 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES EPO [308136803] 56.2 percent of total billed charges 44.01 67.43 Technical (Hospital) Services ETOMIDATE 2 MG/ML INTRAVENOUS SOLUTION RX-20472 CDM 2500000200 HCPCS 250 RC 00409-6695-02 NDC inpatient 20 ML 70.98 70.98 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES HDHP [308136802] 56.2 percent of total billed charges 44.01 67.43 Technical (Hospital) Services ETOMIDATE 2 MG/ML INTRAVENOUS SOLUTION RX-20472 CDM 2500000200 HCPCS 250 RC 00409-6695-02 NDC inpatient 20 ML 70.98 70.98 BLUE CROSS BLUE SHIELD WELLMARK SB889 [3081026] BCBS WYOMING [308102603] 67.43 percent of total billed charges 44.01 67.43 Technical (Hospital) Services ETOMIDATE 2 MG/ML INTRAVENOUS SOLUTION RX-20472 CDM 2500000200 HCPCS 250 RC 00409-6695-02 NDC inpatient 20 ML 70.98 70.98 UNITED HEALTHCARE (COMMERCIAL) [3081199] UNITED HEALTHCARE 87726 [308119901] 44.01 percent of total billed charges 44.01 67.43 Technical (Hospital) Services ETOMIDATE 2 MG/ML INTRAVENOUS SOLUTION RX-20472 CDM 2500000200 HCPCS 250 RC 00409-6695-02 NDC inpatient 20 ML 70.98 70.98 MEDICA (COMMERCIAL) 94265 [3081118] MEDICA CLAIMS [308111801] 63.88 percent of total billed charges 44.01 67.43 Technical (Hospital) Services ETOMIDATE 2 MG/ML INTRAVENOUS SOLUTION RX-20472 CDM 2500000200 HCPCS 250 RC 00409-6695-02 NDC inpatient 20 ML 70.98 70.98 MULTIPLAN INC 34080 [3081285] MULTIPLAN INC [308128501] 67.43 percent of total billed charges 44.01 67.43 Technical (Hospital) Services VALPROATE SODIUM 500 MG/5 ML (100 MG/ML) INTRAVENOUS SOLUTION RX-20887 CDM 2500000200 HCPCS 250 RC 63323-0494-01 NDC inpatient 5 ML 71.2 71.2 UNITED HEALTHCARE (COMMERCIAL) [3081199] UNITED HEALTHCARE 87726 [308119901] 44.14 percent of total billed charges 44.14 67.64 Technical (Hospital) Services VALPROATE SODIUM 500 MG/5 ML (100 MG/ML) INTRAVENOUS SOLUTION RX-20887 CDM 2500000200 HCPCS 250 RC 63323-0494-01 NDC inpatient 5 ML 71.2 71.2 BLUE CROSS BLUE SHIELD WELLMARK SB889 [3081026] BCBS WYOMING [308102603] 67.64 percent of total billed charges 44.14 67.64 Technical (Hospital) Services VALPROATE SODIUM 500 MG/5 ML (100 MG/ML) INTRAVENOUS SOLUTION RX-20887 CDM 2500000200 HCPCS 250 RC 63323-0494-01 NDC inpatient 5 ML 71.2 71.2 CIGNA 62308 [3081051] CIGNA 62308 [308105105] 56.38 percent of total billed charges 44.14 67.64 Technical (Hospital) Services VALPROATE SODIUM 500 MG/5 ML (100 MG/ML) INTRAVENOUS SOLUTION RX-20887 CDM 2500000200 HCPCS 250 RC 63323-0494-01 NDC inpatient 5 ML 71.2 71.2 CIGNA 62308 [3081051] CIGNA STATE OF WYOMING [308105107] 56.38 percent of total billed charges 44.14 67.64 Technical (Hospital) Services VALPROATE SODIUM 500 MG/5 ML (100 MG/ML) INTRAVENOUS SOLUTION RX-20887 CDM 2500000200 HCPCS 250 RC 63323-0494-01 NDC inpatient 5 ML 71.2 71.2 MULTIPLAN INC 34080 [3081285] MULTIPLAN INC [308128501] 67.64 percent of total billed charges 44.14 67.64 Technical (Hospital) Services VALPROATE SODIUM 500 MG/5 ML (100 MG/ML) INTRAVENOUS SOLUTION RX-20887 CDM 2500000200 HCPCS 250 RC 63323-0494-01 NDC inpatient 5 ML 71.2 71.2 MEDICA (COMMERCIAL) 94265 [3081118] MEDICA CLAIMS [308111801] 64.08 percent of total billed charges 44.14 67.64 Technical (Hospital) Services VALPROATE SODIUM 500 MG/5 ML (100 MG/ML) INTRAVENOUS SOLUTION RX-20887 CDM 2500000200 HCPCS 250 RC 63323-0494-01 NDC inpatient 5 ML 71.2 71.2 HEALTHPARTNERS SX009 HEALTHPARTNERS 56.38 percent of total billed charges 44.14 67.64 Technical (Hospital) Services VALPROATE SODIUM 500 MG/5 ML (100 MG/ML) INTRAVENOUS SOLUTION RX-20887 CDM 2500000200 HCPCS 250 RC 63323-0494-01 NDC inpatient 5 ML 71.2 71.2 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES HDHP [308136802] 56.38 percent of total billed charges 44.14 67.64 Technical (Hospital) Services VALPROATE SODIUM 500 MG/5 ML (100 MG/ML) INTRAVENOUS SOLUTION RX-20887 CDM 2500000200 HCPCS 250 RC 63323-0494-01 NDC inpatient 5 ML 71.2 71.2 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES EPO [308136803] 56.38 percent of total billed charges 44.14 67.64 Technical (Hospital) Services VALPROATE SODIUM 500 MG/5 ML (100 MG/ML) INTRAVENOUS SOLUTION RX-20887 CDM 2500000200 HCPCS 250 RC 63323-0494-01 NDC inpatient 5 ML 71.2 71.2 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES PPO [308136801] 56.38 percent of total billed charges 44.14 67.64 Technical (Hospital) Services VALPROATE SODIUM 500 MG/5 ML (100 MG/ML) INTRAVENOUS SOLUTION RX-20887 CDM 2500000200 HCPCS 250 RC 63323-0494-01 NDC outpatient 5 ML 71.2 71.2 CIGNA 62308 [3081051] CIGNA 62308 [308105105] 56.96 percent of total billed charges 44.14 67.64 Technical (Hospital) Services VALPROATE SODIUM 500 MG/5 ML (100 MG/ML) INTRAVENOUS SOLUTION RX-20887 CDM 2500000200 HCPCS 250 RC 63323-0494-01 NDC outpatient 5 ML 71.2 71.2 CIGNA 62308 [3081051] CIGNA STATE OF WYOMING [308105107] 56.96 percent of total billed charges 44.14 67.64 Technical (Hospital) Services VALPROATE SODIUM 500 MG/5 ML (100 MG/ML) INTRAVENOUS SOLUTION RX-20887 CDM 2500000200 HCPCS 250 RC 63323-0494-01 NDC outpatient 5 ML 71.2 71.2 BLUE CROSS BLUE SHIELD WELLMARK SB889 [3081026] BCBS WYOMING [308102603] 67.64 percent of total billed charges 44.14 67.64 Technical (Hospital) Services VALPROATE SODIUM 500 MG/5 ML (100 MG/ML) INTRAVENOUS SOLUTION RX-20887 CDM 2500000200 HCPCS 250 RC 63323-0494-01 NDC outpatient 5 ML 71.2 71.2 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES HDHP [308136802] 56.96 percent of total billed charges 44.14 67.64 Technical (Hospital) Services VALPROATE SODIUM 500 MG/5 ML (100 MG/ML) INTRAVENOUS SOLUTION RX-20887 CDM 2500000200 HCPCS 250 RC 63323-0494-01 NDC outpatient 5 ML 71.2 71.2 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES PPO [308136801] 56.96 percent of total billed charges 44.14 67.64 Technical (Hospital) Services VALPROATE SODIUM 500 MG/5 ML (100 MG/ML) INTRAVENOUS SOLUTION RX-20887 CDM 2500000200 HCPCS 250 RC 63323-0494-01 NDC outpatient 5 ML 71.2 71.2 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES EPO [308136803] 56.96 percent of total billed charges 44.14 67.64 Technical (Hospital) Services VALPROATE SODIUM 500 MG/5 ML (100 MG/ML) INTRAVENOUS SOLUTION RX-20887 CDM 2500000200 HCPCS 250 RC 63323-0494-01 NDC outpatient 5 ML 71.2 71.2 MEDICA (COMMERCIAL) 94265 [3081118] MEDICA CLAIMS [308111801] 64.08 percent of total billed charges 44.14 67.64 Technical (Hospital) Services VALPROATE SODIUM 500 MG/5 ML (100 MG/ML) INTRAVENOUS SOLUTION RX-20887 CDM 2500000200 HCPCS 250 RC 63323-0494-01 NDC outpatient 5 ML 71.2 71.2 MULTIPLAN INC 34080 [3081285] MULTIPLAN INC [308128501] 67.64 percent of total billed charges 44.14 67.64 Technical (Hospital) Services VALPROATE SODIUM 500 MG/5 ML (100 MG/ML) INTRAVENOUS SOLUTION RX-20887 CDM 2500000200 HCPCS 250 RC 63323-0494-01 NDC outpatient 5 ML 71.2 71.2 UNITED HEALTHCARE (COMMERCIAL) [3081199] UNITED HEALTHCARE 87726 [308119901] 44.14 percent of total billed charges 44.14 67.64 Technical (Hospital) Services VALPROATE SODIUM 500 MG/5 ML (100 MG/ML) INTRAVENOUS SOLUTION RX-20887 CDM 2500000200 HCPCS 250 RC 63323-0494-01 NDC outpatient 5 ML 71.2 71.2 HEALTHPARTNERS SX009 HEALTHPARTNERS 56.96 percent of total billed charges 44.14 67.64 Technical (Hospital) Services FOLIC ACID 5 MG/ML INJECTION SOLUTION RX-3232 CDM 2500000200 HCPCS 250 RC 63323-0184-10 NDC outpatient 0.2 ML 59.42 59.42 BLUE CROSS BLUE SHIELD WELLMARK SB889 [3081026] BCBS WYOMING [308102603] 56.45 percent of total billed charges 36.84 56.45 Technical (Hospital) Services FOLIC ACID 5 MG/ML INJECTION SOLUTION RX-3232 CDM 2500000200 HCPCS 250 RC 63323-0184-10 NDC outpatient 0.2 ML 59.42 59.42 HEALTHPARTNERS SX009 HEALTHPARTNERS 47.54 percent of total billed charges 36.84 56.45 Technical (Hospital) Services FOLIC ACID 5 MG/ML INJECTION SOLUTION RX-3232 CDM 2500000200 HCPCS 250 RC 63323-0184-10 NDC outpatient 0.2 ML 59.42 59.42 UNITED HEALTHCARE (COMMERCIAL) [3081199] UNITED HEALTHCARE 87726 [308119901] 36.84 percent of total billed charges 36.84 56.45 Technical (Hospital) Services FOLIC ACID 5 MG/ML INJECTION SOLUTION RX-3232 CDM 2500000200 HCPCS 250 RC 63323-0184-10 NDC outpatient 0.2 ML 59.42 59.42 MULTIPLAN INC 34080 [3081285] MULTIPLAN INC [308128501] 56.45 percent of total billed charges 36.84 56.45 Technical (Hospital) Services FOLIC ACID 5 MG/ML INJECTION SOLUTION RX-3232 CDM 2500000200 HCPCS 250 RC 63323-0184-10 NDC outpatient 0.2 ML 59.42 59.42 CIGNA 62308 [3081051] CIGNA 62308 [308105105] 47.54 percent of total billed charges 36.84 56.45 Technical (Hospital) Services FOLIC ACID 5 MG/ML INJECTION SOLUTION RX-3232 CDM 2500000200 HCPCS 250 RC 63323-0184-10 NDC outpatient 0.2 ML 59.42 59.42 CIGNA 62308 [3081051] CIGNA STATE OF WYOMING [308105107] 47.54 percent of total billed charges 36.84 56.45 Technical (Hospital) Services FOLIC ACID 5 MG/ML INJECTION SOLUTION RX-3232 CDM 2500000200 HCPCS 250 RC 63323-0184-10 NDC outpatient 0.2 ML 59.42 59.42 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES EPO [308136803] 47.54 percent of total billed charges 36.84 56.45 Technical (Hospital) Services FOLIC ACID 5 MG/ML INJECTION SOLUTION RX-3232 CDM 2500000200 HCPCS 250 RC 63323-0184-10 NDC outpatient 0.2 ML 59.42 59.42 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES HDHP [308136802] 47.54 percent of total billed charges 36.84 56.45 Technical (Hospital) Services FOLIC ACID 5 MG/ML INJECTION SOLUTION RX-3232 CDM 2500000200 HCPCS 250 RC 63323-0184-10 NDC outpatient 0.2 ML 59.42 59.42 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES PPO [308136801] 47.54 percent of total billed charges 36.84 56.45 Technical (Hospital) Services FOLIC ACID 5 MG/ML INJECTION SOLUTION RX-3232 CDM 2500000200 HCPCS 250 RC 63323-0184-10 NDC outpatient 0.2 ML 59.42 59.42 MEDICA (COMMERCIAL) 94265 [3081118] MEDICA CLAIMS [308111801] 53.48 percent of total billed charges 36.84 56.45 Technical (Hospital) Services FOLIC ACID 5 MG/ML INJECTION SOLUTION RX-3232 CDM 2500000200 HCPCS 250 RC 63323-0184-10 NDC inpatient 0.2 ML 59.42 59.42 MULTIPLAN INC 34080 [3081285] MULTIPLAN INC [308128501] 56.45 percent of total billed charges 36.84 56.45 Technical (Hospital) Services FOLIC ACID 5 MG/ML INJECTION SOLUTION RX-3232 CDM 2500000200 HCPCS 250 RC 63323-0184-10 NDC inpatient 0.2 ML 59.42 59.42 BLUE CROSS BLUE SHIELD WELLMARK SB889 [3081026] BCBS WYOMING [308102603] 56.45 percent of total billed charges 36.84 56.45 Technical (Hospital) Services FOLIC ACID 5 MG/ML INJECTION SOLUTION RX-3232 CDM 2500000200 HCPCS 250 RC 63323-0184-10 NDC inpatient 0.2 ML 59.42 59.42 UNITED HEALTHCARE (COMMERCIAL) [3081199] UNITED HEALTHCARE 87726 [308119901] 36.84 percent of total billed charges 36.84 56.45 Technical (Hospital) Services FOLIC ACID 5 MG/ML INJECTION SOLUTION RX-3232 CDM 2500000200 HCPCS 250 RC 63323-0184-10 NDC inpatient 0.2 ML 59.42 59.42 CIGNA 62308 [3081051] CIGNA 62308 [308105105] 47.05 percent of total billed charges 36.84 56.45 Technical (Hospital) Services FOLIC ACID 5 MG/ML INJECTION SOLUTION RX-3232 CDM 2500000200 HCPCS 250 RC 63323-0184-10 NDC inpatient 0.2 ML 59.42 59.42 CIGNA 62308 [3081051] CIGNA STATE OF WYOMING [308105107] 47.05 percent of total billed charges 36.84 56.45 Technical (Hospital) Services FOLIC ACID 5 MG/ML INJECTION SOLUTION RX-3232 CDM 2500000200 HCPCS 250 RC 63323-0184-10 NDC inpatient 0.2 ML 59.42 59.42 HEALTHPARTNERS SX009 HEALTHPARTNERS 47.05 percent of total billed charges 36.84 56.45 Technical (Hospital) Services FOLIC ACID 5 MG/ML INJECTION SOLUTION RX-3232 CDM 2500000200 HCPCS 250 RC 63323-0184-10 NDC inpatient 0.2 ML 59.42 59.42 MEDICA (COMMERCIAL) 94265 [3081118] MEDICA CLAIMS [308111801] 53.48 percent of total billed charges 36.84 56.45 Technical (Hospital) Services FOLIC ACID 5 MG/ML INJECTION SOLUTION RX-3232 CDM 2500000200 HCPCS 250 RC 63323-0184-10 NDC inpatient 0.2 ML 59.42 59.42 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES PPO [308136801] 47.05 percent of total billed charges 36.84 56.45 Technical (Hospital) Services FOLIC ACID 5 MG/ML INJECTION SOLUTION RX-3232 CDM 2500000200 HCPCS 250 RC 63323-0184-10 NDC inpatient 0.2 ML 59.42 59.42 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES EPO [308136803] 47.05 percent of total billed charges 36.84 56.45 Technical (Hospital) Services FOLIC ACID 5 MG/ML INJECTION SOLUTION RX-3232 CDM 2500000200 HCPCS 250 RC 63323-0184-10 NDC inpatient 0.2 ML 59.42 59.42 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES HDHP [308136802] 47.05 percent of total billed charges 36.84 56.45 Technical (Hospital) Services FLUMAZENIL 0.1 MG/ML INTRAVENOUS SOLUTION RX-39744 CDM 2500000200 HCPCS 250 RC 63323-0424-05 NDC inpatient 5 ML 71.92 71.92 HEALTHPARTNERS SX009 HEALTHPARTNERS 56.95 percent of total billed charges 44.59 68.32 Technical (Hospital) Services FLUMAZENIL 0.1 MG/ML INTRAVENOUS SOLUTION RX-39744 CDM 2500000200 HCPCS 250 RC 63323-0424-05 NDC inpatient 5 ML 71.92 71.92 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES HDHP [308136802] 56.95 percent of total billed charges 44.59 68.32 Technical (Hospital) Services FLUMAZENIL 0.1 MG/ML INTRAVENOUS SOLUTION RX-39744 CDM 2500000200 HCPCS 250 RC 63323-0424-05 NDC inpatient 5 ML 71.92 71.92 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES EPO [308136803] 56.95 percent of total billed charges 44.59 68.32 Technical (Hospital) Services FLUMAZENIL 0.1 MG/ML INTRAVENOUS SOLUTION RX-39744 CDM 2500000200 HCPCS 250 RC 63323-0424-05 NDC inpatient 5 ML 71.92 71.92 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES PPO [308136801] 56.95 percent of total billed charges 44.59 68.32 Technical (Hospital) Services FLUMAZENIL 0.1 MG/ML INTRAVENOUS SOLUTION RX-39744 CDM 2500000200 HCPCS 250 RC 63323-0424-05 NDC inpatient 5 ML 71.92 71.92 BLUE CROSS BLUE SHIELD WELLMARK SB889 [3081026] BCBS WYOMING [308102603] 68.32 percent of total billed charges 44.59 68.32 Technical (Hospital) Services FLUMAZENIL 0.1 MG/ML INTRAVENOUS SOLUTION RX-39744 CDM 2500000200 HCPCS 250 RC 63323-0424-05 NDC inpatient 5 ML 71.92 71.92 UNITED HEALTHCARE (COMMERCIAL) [3081199] UNITED HEALTHCARE 87726 [308119901] 44.59 percent of total billed charges 44.59 68.32 Technical (Hospital) Services FLUMAZENIL 0.1 MG/ML INTRAVENOUS SOLUTION RX-39744 CDM 2500000200 HCPCS 250 RC 63323-0424-05 NDC inpatient 5 ML 71.92 71.92 CIGNA 62308 [3081051] CIGNA 62308 [308105105] 56.95 percent of total billed charges 44.59 68.32 Technical (Hospital) Services FLUMAZENIL 0.1 MG/ML INTRAVENOUS SOLUTION RX-39744 CDM 2500000200 HCPCS 250 RC 63323-0424-05 NDC inpatient 5 ML 71.92 71.92 CIGNA 62308 [3081051] CIGNA STATE OF WYOMING [308105107] 56.95 percent of total billed charges 44.59 68.32 Technical (Hospital) Services FLUMAZENIL 0.1 MG/ML INTRAVENOUS SOLUTION RX-39744 CDM 2500000200 HCPCS 250 RC 63323-0424-05 NDC inpatient 5 ML 71.92 71.92 MEDICA (COMMERCIAL) 94265 [3081118] MEDICA CLAIMS [308111801] 64.73 percent of total billed charges 44.59 68.32 Technical (Hospital) Services FLUMAZENIL 0.1 MG/ML INTRAVENOUS SOLUTION RX-39744 CDM 2500000200 HCPCS 250 RC 63323-0424-05 NDC inpatient 5 ML 71.92 71.92 MULTIPLAN INC 34080 [3081285] MULTIPLAN INC [308128501] 68.32 percent of total billed charges 44.59 68.32 Technical (Hospital) Services FLUMAZENIL 0.1 MG/ML INTRAVENOUS SOLUTION RX-39744 CDM 2500000200 HCPCS 250 RC 63323-0424-05 NDC outpatient 5 ML 71.92 71.92 MULTIPLAN INC 34080 [3081285] MULTIPLAN INC [308128501] 68.32 percent of total billed charges 44.59 68.32 Technical (Hospital) Services FLUMAZENIL 0.1 MG/ML INTRAVENOUS SOLUTION RX-39744 CDM 2500000200 HCPCS 250 RC 63323-0424-05 NDC outpatient 5 ML 71.92 71.92 MEDICA (COMMERCIAL) 94265 [3081118] MEDICA CLAIMS [308111801] 64.73 percent of total billed charges 44.59 68.32 Technical (Hospital) Services FLUMAZENIL 0.1 MG/ML INTRAVENOUS SOLUTION RX-39744 CDM 2500000200 HCPCS 250 RC 63323-0424-05 NDC outpatient 5 ML 71.92 71.92 CIGNA 62308 [3081051] CIGNA 62308 [308105105] 57.54 percent of total billed charges 44.59 68.32 Technical (Hospital) Services FLUMAZENIL 0.1 MG/ML INTRAVENOUS SOLUTION RX-39744 CDM 2500000200 HCPCS 250 RC 63323-0424-05 NDC outpatient 5 ML 71.92 71.92 CIGNA 62308 [3081051] CIGNA STATE OF WYOMING [308105107] 57.54 percent of total billed charges 44.59 68.32 Technical (Hospital) Services FLUMAZENIL 0.1 MG/ML INTRAVENOUS SOLUTION RX-39744 CDM 2500000200 HCPCS 250 RC 63323-0424-05 NDC outpatient 5 ML 71.92 71.92 BLUE CROSS BLUE SHIELD WELLMARK SB889 [3081026] BCBS WYOMING [308102603] 68.32 percent of total billed charges 44.59 68.32 Technical (Hospital) Services FLUMAZENIL 0.1 MG/ML INTRAVENOUS SOLUTION RX-39744 CDM 2500000200 HCPCS 250 RC 63323-0424-05 NDC outpatient 5 ML 71.92 71.92 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES HDHP [308136802] 57.54 percent of total billed charges 44.59 68.32 Technical (Hospital) Services FLUMAZENIL 0.1 MG/ML INTRAVENOUS SOLUTION RX-39744 CDM 2500000200 HCPCS 250 RC 63323-0424-05 NDC outpatient 5 ML 71.92 71.92 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES PPO [308136801] 57.54 percent of total billed charges 44.59 68.32 Technical (Hospital) Services FLUMAZENIL 0.1 MG/ML INTRAVENOUS SOLUTION RX-39744 CDM 2500000200 HCPCS 250 RC 63323-0424-05 NDC outpatient 5 ML 71.92 71.92 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES EPO [308136803] 57.54 percent of total billed charges 44.59 68.32 Technical (Hospital) Services FLUMAZENIL 0.1 MG/ML INTRAVENOUS SOLUTION RX-39744 CDM 2500000200 HCPCS 250 RC 63323-0424-05 NDC outpatient 5 ML 71.92 71.92 UNITED HEALTHCARE (COMMERCIAL) [3081199] UNITED HEALTHCARE 87726 [308119901] 44.59 percent of total billed charges 44.59 68.32 Technical (Hospital) Services FLUMAZENIL 0.1 MG/ML INTRAVENOUS SOLUTION RX-39744 CDM 2500000200 HCPCS 250 RC 63323-0424-05 NDC outpatient 5 ML 71.92 71.92 HEALTHPARTNERS SX009 HEALTHPARTNERS 57.54 percent of total billed charges 44.59 68.32 Technical (Hospital) Services DIPHENHYDRAMINE 25 MG TAB/CAP RX-4080010097 CDM 2500000200 HCPCS 250 RC 00904-5551-59 NDC outpatient 25 ME 5.64 5.64 CIGNA 62308 [3081051] CIGNA 62308 [308105105] 4.51 percent of total billed charges 3.5 5.36 Technical (Hospital) Services DIPHENHYDRAMINE 25 MG TAB/CAP RX-4080010097 CDM 2500000200 HCPCS 250 RC 00904-5551-59 NDC outpatient 25 ME 5.64 5.64 CIGNA 62308 [3081051] CIGNA STATE OF WYOMING [308105107] 4.51 percent of total billed charges 3.5 5.36 Technical (Hospital) Services DIPHENHYDRAMINE 25 MG TAB/CAP RX-4080010097 CDM 2500000200 HCPCS 250 RC 00904-5551-59 NDC outpatient 25 ME 5.64 5.64 MULTIPLAN INC 34080 [3081285] MULTIPLAN INC [308128501] 5.36 percent of total billed charges 3.5 5.36 Technical (Hospital) Services DIPHENHYDRAMINE 25 MG TAB/CAP RX-4080010097 CDM 2500000200 HCPCS 250 RC 00904-5551-59 NDC outpatient 25 ME 5.64 5.64 MEDICA (COMMERCIAL) 94265 [3081118] MEDICA CLAIMS [308111801] 5.08 percent of total billed charges 3.5 5.36 Technical (Hospital) Services DIPHENHYDRAMINE 25 MG TAB/CAP RX-4080010097 CDM 2500000200 HCPCS 250 RC 00904-5551-59 NDC outpatient 25 ME 5.64 5.64 UNITED HEALTHCARE (COMMERCIAL) [3081199] UNITED HEALTHCARE 87726 [308119901] 3.5 percent of total billed charges 3.5 5.36 Technical (Hospital) Services DIPHENHYDRAMINE 25 MG TAB/CAP RX-4080010097 CDM 2500000200 HCPCS 250 RC 00904-5551-59 NDC outpatient 25 ME 5.64 5.64 HEALTHPARTNERS SX009 HEALTHPARTNERS 4.51 percent of total billed charges 3.5 5.36 Technical (Hospital) Services DIPHENHYDRAMINE 25 MG TAB/CAP RX-4080010097 CDM 2500000200 HCPCS 250 RC 00904-5551-59 NDC outpatient 25 ME 5.64 5.64 BLUE CROSS BLUE SHIELD WELLMARK SB889 [3081026] BCBS WYOMING [308102603] 5.36 percent of total billed charges 3.5 5.36 Technical (Hospital) Services DIPHENHYDRAMINE 25 MG TAB/CAP RX-4080010097 CDM 2500000200 HCPCS 250 RC 00904-5551-59 NDC outpatient 25 ME 5.64 5.64 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES EPO [308136803] 4.51 percent of total billed charges 3.5 5.36 Technical (Hospital) Services DIPHENHYDRAMINE 25 MG TAB/CAP RX-4080010097 CDM 2500000200 HCPCS 250 RC 00904-5551-59 NDC outpatient 25 ME 5.64 5.64 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES HDHP [308136802] 4.51 percent of total billed charges 3.5 5.36 Technical (Hospital) Services DIPHENHYDRAMINE 25 MG TAB/CAP RX-4080010097 CDM 2500000200 HCPCS 250 RC 00904-5551-59 NDC outpatient 25 ME 5.64 5.64 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES PPO [308136801] 4.51 percent of total billed charges 3.5 5.36 Technical (Hospital) Services DIPHENHYDRAMINE 25 MG TAB/CAP RX-4080010097 CDM 2500000200 HCPCS 250 RC 00904-5551-59 NDC inpatient 25 ME 5.64 5.64 BLUE CROSS BLUE SHIELD WELLMARK SB889 [3081026] BCBS WYOMING [308102603] 5.36 percent of total billed charges 3.5 5.36 Technical (Hospital) Services DIPHENHYDRAMINE 25 MG TAB/CAP RX-4080010097 CDM 2500000200 HCPCS 250 RC 00904-5551-59 NDC inpatient 25 ME 5.64 5.64 UNITED HEALTHCARE (COMMERCIAL) [3081199] UNITED HEALTHCARE 87726 [308119901] 3.5 percent of total billed charges 3.5 5.36 Technical (Hospital) Services DIPHENHYDRAMINE 25 MG TAB/CAP RX-4080010097 CDM 2500000200 HCPCS 250 RC 00904-5551-59 NDC inpatient 25 ME 5.64 5.64 MEDICA (COMMERCIAL) 94265 [3081118] MEDICA CLAIMS [308111801] 5.08 percent of total billed charges 3.5 5.36 Technical (Hospital) Services DIPHENHYDRAMINE 25 MG TAB/CAP RX-4080010097 CDM 2500000200 HCPCS 250 RC 00904-5551-59 NDC inpatient 25 ME 5.64 5.64 MULTIPLAN INC 34080 [3081285] MULTIPLAN INC [308128501] 5.36 percent of total billed charges 3.5 5.36 Technical (Hospital) Services DIPHENHYDRAMINE 25 MG TAB/CAP RX-4080010097 CDM 2500000200 HCPCS 250 RC 00904-5551-59 NDC inpatient 25 ME 5.64 5.64 CIGNA 62308 [3081051] CIGNA 62308 [308105105] 4.47 percent of total billed charges 3.5 5.36 Technical (Hospital) Services DIPHENHYDRAMINE 25 MG TAB/CAP RX-4080010097 CDM 2500000200 HCPCS 250 RC 00904-5551-59 NDC inpatient 25 ME 5.64 5.64 CIGNA 62308 [3081051] CIGNA STATE OF WYOMING [308105107] 4.47 percent of total billed charges 3.5 5.36 Technical (Hospital) Services DIPHENHYDRAMINE 25 MG TAB/CAP RX-4080010097 CDM 2500000200 HCPCS 250 RC 00904-5551-59 NDC inpatient 25 ME 5.64 5.64 HEALTHPARTNERS SX009 HEALTHPARTNERS 4.47 percent of total billed charges 3.5 5.36 Technical (Hospital) Services DIPHENHYDRAMINE 25 MG TAB/CAP RX-4080010097 CDM 2500000200 HCPCS 250 RC 00904-5551-59 NDC inpatient 25 ME 5.64 5.64 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES EPO [308136803] 4.47 percent of total billed charges 3.5 5.36 Technical (Hospital) Services DIPHENHYDRAMINE 25 MG TAB/CAP RX-4080010097 CDM 2500000200 HCPCS 250 RC 00904-5551-59 NDC inpatient 25 ME 5.64 5.64 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES HDHP [308136802] 4.47 percent of total billed charges 3.5 5.36 Technical (Hospital) Services DIPHENHYDRAMINE 25 MG TAB/CAP RX-4080010097 CDM 2500000200 HCPCS 250 RC 00904-5551-59 NDC inpatient 25 ME 5.64 5.64 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES PPO [308136801] 4.47 percent of total billed charges 3.5 5.36 Technical (Hospital) Services CALCIUM CHLORIDE 100 MG/ML (10 %) INTRAVENOUS SOLUTION WRAPPER RX-4080030048 CDM 2500000200 HCPCS 250 RC 00409-1631-10 NDC inpatient 10 ML 82.62 82.62 HEALTHPARTNERS SX009 HEALTHPARTNERS 65.42 percent of total billed charges 51.22 78.49 Technical (Hospital) Services CALCIUM CHLORIDE 100 MG/ML (10 %) INTRAVENOUS SOLUTION WRAPPER RX-4080030048 CDM 2500000200 HCPCS 250 RC 00409-1631-10 NDC inpatient 10 ML 82.62 82.62 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES PPO [308136801] 65.42 percent of total billed charges 51.22 78.49 Technical (Hospital) Services CALCIUM CHLORIDE 100 MG/ML (10 %) INTRAVENOUS SOLUTION WRAPPER RX-4080030048 CDM 2500000200 HCPCS 250 RC 00409-1631-10 NDC inpatient 10 ML 82.62 82.62 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES HDHP [308136802] 65.42 percent of total billed charges 51.22 78.49 Technical (Hospital) Services CALCIUM CHLORIDE 100 MG/ML (10 %) INTRAVENOUS SOLUTION WRAPPER RX-4080030048 CDM 2500000200 HCPCS 250 RC 00409-1631-10 NDC inpatient 10 ML 82.62 82.62 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES EPO [308136803] 65.42 percent of total billed charges 51.22 78.49 Technical (Hospital) Services CALCIUM CHLORIDE 100 MG/ML (10 %) INTRAVENOUS SOLUTION WRAPPER RX-4080030048 CDM 2500000200 HCPCS 250 RC 00409-1631-10 NDC inpatient 10 ML 82.62 82.62 MULTIPLAN INC 34080 [3081285] MULTIPLAN INC [308128501] 78.49 percent of total billed charges 51.22 78.49 Technical (Hospital) Services CALCIUM CHLORIDE 100 MG/ML (10 %) INTRAVENOUS SOLUTION WRAPPER RX-4080030048 CDM 2500000200 HCPCS 250 RC 00409-1631-10 NDC inpatient 10 ML 82.62 82.62 MEDICA (COMMERCIAL) 94265 [3081118] MEDICA CLAIMS [308111801] 74.36 percent of total billed charges 51.22 78.49 Technical (Hospital) Services CALCIUM CHLORIDE 100 MG/ML (10 %) INTRAVENOUS SOLUTION WRAPPER RX-4080030048 CDM 2500000200 HCPCS 250 RC 00409-1631-10 NDC inpatient 10 ML 82.62 82.62 CIGNA 62308 [3081051] CIGNA 62308 [308105105] 65.42 percent of total billed charges 51.22 78.49 Technical (Hospital) Services CALCIUM CHLORIDE 100 MG/ML (10 %) INTRAVENOUS SOLUTION WRAPPER RX-4080030048 CDM 2500000200 HCPCS 250 RC 00409-1631-10 NDC inpatient 10 ML 82.62 82.62 CIGNA 62308 [3081051] CIGNA STATE OF WYOMING [308105107] 65.42 percent of total billed charges 51.22 78.49 Technical (Hospital) Services CALCIUM CHLORIDE 100 MG/ML (10 %) INTRAVENOUS SOLUTION WRAPPER RX-4080030048 CDM 2500000200 HCPCS 250 RC 00409-1631-10 NDC inpatient 10 ML 82.62 82.62 UNITED HEALTHCARE (COMMERCIAL) [3081199] UNITED HEALTHCARE 87726 [308119901] 51.22 percent of total billed charges 51.22 78.49 Technical (Hospital) Services CALCIUM CHLORIDE 100 MG/ML (10 %) INTRAVENOUS SOLUTION WRAPPER RX-4080030048 CDM 2500000200 HCPCS 250 RC 00409-1631-10 NDC inpatient 10 ML 82.62 82.62 BLUE CROSS BLUE SHIELD WELLMARK SB889 [3081026] BCBS WYOMING [308102603] 78.49 percent of total billed charges 51.22 78.49 Technical (Hospital) Services CALCIUM CHLORIDE 100 MG/ML (10 %) INTRAVENOUS SOLUTION WRAPPER RX-4080030048 CDM 2500000200 HCPCS 250 RC 00409-1631-10 NDC outpatient 10 ML 82.62 82.62 HEALTHPARTNERS SX009 HEALTHPARTNERS 66.1 percent of total billed charges 51.22 78.49 Technical (Hospital) Services CALCIUM CHLORIDE 100 MG/ML (10 %) INTRAVENOUS SOLUTION WRAPPER RX-4080030048 CDM 2500000200 HCPCS 250 RC 00409-1631-10 NDC outpatient 10 ML 82.62 82.62 UNITED HEALTHCARE (COMMERCIAL) [3081199] UNITED HEALTHCARE 87726 [308119901] 51.22 percent of total billed charges 51.22 78.49 Technical (Hospital) Services CALCIUM CHLORIDE 100 MG/ML (10 %) INTRAVENOUS SOLUTION WRAPPER RX-4080030048 CDM 2500000200 HCPCS 250 RC 00409-1631-10 NDC outpatient 10 ML 82.62 82.62 MULTIPLAN INC 34080 [3081285] MULTIPLAN INC [308128501] 78.49 percent of total billed charges 51.22 78.49 Technical (Hospital) Services CALCIUM CHLORIDE 100 MG/ML (10 %) INTRAVENOUS SOLUTION WRAPPER RX-4080030048 CDM 2500000200 HCPCS 250 RC 00409-1631-10 NDC outpatient 10 ML 82.62 82.62 MEDICA (COMMERCIAL) 94265 [3081118] MEDICA CLAIMS [308111801] 74.36 percent of total billed charges 51.22 78.49 Technical (Hospital) Services CALCIUM CHLORIDE 100 MG/ML (10 %) INTRAVENOUS SOLUTION WRAPPER RX-4080030048 CDM 2500000200 HCPCS 250 RC 00409-1631-10 NDC outpatient 10 ML 82.62 82.62 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES PPO [308136801] 66.1 percent of total billed charges 51.22 78.49 Technical (Hospital) Services CALCIUM CHLORIDE 100 MG/ML (10 %) INTRAVENOUS SOLUTION WRAPPER RX-4080030048 CDM 2500000200 HCPCS 250 RC 00409-1631-10 NDC outpatient 10 ML 82.62 82.62 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES EPO [308136803] 66.1 percent of total billed charges 51.22 78.49 Technical (Hospital) Services CALCIUM CHLORIDE 100 MG/ML (10 %) INTRAVENOUS SOLUTION WRAPPER RX-4080030048 CDM 2500000200 HCPCS 250 RC 00409-1631-10 NDC outpatient 10 ML 82.62 82.62 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES HDHP [308136802] 66.1 percent of total billed charges 51.22 78.49 Technical (Hospital) Services CALCIUM CHLORIDE 100 MG/ML (10 %) INTRAVENOUS SOLUTION WRAPPER RX-4080030048 CDM 2500000200 HCPCS 250 RC 00409-1631-10 NDC outpatient 10 ML 82.62 82.62 BLUE CROSS BLUE SHIELD WELLMARK SB889 [3081026] BCBS WYOMING [308102603] 78.49 percent of total billed charges 51.22 78.49 Technical (Hospital) Services CALCIUM CHLORIDE 100 MG/ML (10 %) INTRAVENOUS SOLUTION WRAPPER RX-4080030048 CDM 2500000200 HCPCS 250 RC 00409-1631-10 NDC outpatient 10 ML 82.62 82.62 CIGNA 62308 [3081051] CIGNA 62308 [308105105] 66.1 percent of total billed charges 51.22 78.49 Technical (Hospital) Services CALCIUM CHLORIDE 100 MG/ML (10 %) INTRAVENOUS SOLUTION WRAPPER RX-4080030048 CDM 2500000200 HCPCS 250 RC 00409-1631-10 NDC outpatient 10 ML 82.62 82.62 CIGNA 62308 [3081051] CIGNA STATE OF WYOMING [308105107] 66.1 percent of total billed charges 51.22 78.49 Technical (Hospital) Services METOPROLOL TARTRATE 5 MG/5 ML INTRAVENOUS SOLUTION WRAPPER RX-4080050001 CDM 2500000200 HCPCS 250 RC 00143-9873-25 NDC outpatient 5 ML 61 61 BLUE CROSS BLUE SHIELD WELLMARK SB889 [3081026] BCBS WYOMING [308102603] 57.95 percent of total billed charges 37.82 57.95 Technical (Hospital) Services METOPROLOL TARTRATE 5 MG/5 ML INTRAVENOUS SOLUTION WRAPPER RX-4080050001 CDM 2500000200 HCPCS 250 RC 00143-9873-25 NDC outpatient 5 ML 61 61 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES PPO [308136801] 48.8 percent of total billed charges 37.82 57.95 Technical (Hospital) Services METOPROLOL TARTRATE 5 MG/5 ML INTRAVENOUS SOLUTION WRAPPER RX-4080050001 CDM 2500000200 HCPCS 250 RC 00143-9873-25 NDC outpatient 5 ML 61 61 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES HDHP [308136802] 48.8 percent of total billed charges 37.82 57.95 Technical (Hospital) Services METOPROLOL TARTRATE 5 MG/5 ML INTRAVENOUS SOLUTION WRAPPER RX-4080050001 CDM 2500000200 HCPCS 250 RC 00143-9873-25 NDC outpatient 5 ML 61 61 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES EPO [308136803] 48.8 percent of total billed charges 37.82 57.95 Technical (Hospital) Services METOPROLOL TARTRATE 5 MG/5 ML INTRAVENOUS SOLUTION WRAPPER RX-4080050001 CDM 2500000200 HCPCS 250 RC 00143-9873-25 NDC outpatient 5 ML 61 61 MEDICA (COMMERCIAL) 94265 [3081118] MEDICA CLAIMS [308111801] 54.9 percent of total billed charges 37.82 57.95 Technical (Hospital) Services METOPROLOL TARTRATE 5 MG/5 ML INTRAVENOUS SOLUTION WRAPPER RX-4080050001 CDM 2500000200 HCPCS 250 RC 00143-9873-25 NDC outpatient 5 ML 61 61 MULTIPLAN INC 34080 [3081285] MULTIPLAN INC [308128501] 57.95 percent of total billed charges 37.82 57.95 Technical (Hospital) Services METOPROLOL TARTRATE 5 MG/5 ML INTRAVENOUS SOLUTION WRAPPER RX-4080050001 CDM 2500000200 HCPCS 250 RC 00143-9873-25 NDC outpatient 5 ML 61 61 UNITED HEALTHCARE (COMMERCIAL) [3081199] UNITED HEALTHCARE 87726 [308119901] 37.82 percent of total billed charges 37.82 57.95 Technical (Hospital) Services METOPROLOL TARTRATE 5 MG/5 ML INTRAVENOUS SOLUTION WRAPPER RX-4080050001 CDM 2500000200 HCPCS 250 RC 00143-9873-25 NDC outpatient 5 ML 61 61 HEALTHPARTNERS SX009 HEALTHPARTNERS 48.8 percent of total billed charges 37.82 57.95 Technical (Hospital) Services METOPROLOL TARTRATE 5 MG/5 ML INTRAVENOUS SOLUTION WRAPPER RX-4080050001 CDM 2500000200 HCPCS 250 RC 00143-9873-25 NDC outpatient 5 ML 61 61 CIGNA 62308 [3081051] CIGNA 62308 [308105105] 48.8 percent of total billed charges 37.82 57.95 Technical (Hospital) Services METOPROLOL TARTRATE 5 MG/5 ML INTRAVENOUS SOLUTION WRAPPER RX-4080050001 CDM 2500000200 HCPCS 250 RC 00143-9873-25 NDC outpatient 5 ML 61 61 CIGNA 62308 [3081051] CIGNA STATE OF WYOMING [308105107] 48.8 percent of total billed charges 37.82 57.95 Technical (Hospital) Services METOPROLOL TARTRATE 5 MG/5 ML INTRAVENOUS SOLUTION WRAPPER RX-4080050001 CDM 2500000200 HCPCS 250 RC 00143-9873-25 NDC inpatient 5 ML 61 61 HEALTHPARTNERS SX009 HEALTHPARTNERS 48.3 percent of total billed charges 37.82 57.95 Technical (Hospital) Services METOPROLOL TARTRATE 5 MG/5 ML INTRAVENOUS SOLUTION WRAPPER RX-4080050001 CDM 2500000200 HCPCS 250 RC 00143-9873-25 NDC inpatient 5 ML 61 61 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES HDHP [308136802] 48.3 percent of total billed charges 37.82 57.95 Technical (Hospital) Services METOPROLOL TARTRATE 5 MG/5 ML INTRAVENOUS SOLUTION WRAPPER RX-4080050001 CDM 2500000200 HCPCS 250 RC 00143-9873-25 NDC inpatient 5 ML 61 61 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES EPO [308136803] 48.3 percent of total billed charges 37.82 57.95 Technical (Hospital) Services METOPROLOL TARTRATE 5 MG/5 ML INTRAVENOUS SOLUTION WRAPPER RX-4080050001 CDM 2500000200 HCPCS 250 RC 00143-9873-25 NDC inpatient 5 ML 61 61 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES PPO [308136801] 48.3 percent of total billed charges 37.82 57.95 Technical (Hospital) Services METOPROLOL TARTRATE 5 MG/5 ML INTRAVENOUS SOLUTION WRAPPER RX-4080050001 CDM 2500000200 HCPCS 250 RC 00143-9873-25 NDC inpatient 5 ML 61 61 CIGNA 62308 [3081051] CIGNA 62308 [308105105] 48.3 percent of total billed charges 37.82 57.95 Technical (Hospital) Services METOPROLOL TARTRATE 5 MG/5 ML INTRAVENOUS SOLUTION WRAPPER RX-4080050001 CDM 2500000200 HCPCS 250 RC 00143-9873-25 NDC inpatient 5 ML 61 61 CIGNA 62308 [3081051] CIGNA STATE OF WYOMING [308105107] 48.3 percent of total billed charges 37.82 57.95 Technical (Hospital) Services METOPROLOL TARTRATE 5 MG/5 ML INTRAVENOUS SOLUTION WRAPPER RX-4080050001 CDM 2500000200 HCPCS 250 RC 00143-9873-25 NDC inpatient 5 ML 61 61 UNITED HEALTHCARE (COMMERCIAL) [3081199] UNITED HEALTHCARE 87726 [308119901] 37.82 percent of total billed charges 37.82 57.95 Technical (Hospital) Services METOPROLOL TARTRATE 5 MG/5 ML INTRAVENOUS SOLUTION WRAPPER RX-4080050001 CDM 2500000200 HCPCS 250 RC 00143-9873-25 NDC inpatient 5 ML 61 61 BLUE CROSS BLUE SHIELD WELLMARK SB889 [3081026] BCBS WYOMING [308102603] 57.95 percent of total billed charges 37.82 57.95 Technical (Hospital) Services METOPROLOL TARTRATE 5 MG/5 ML INTRAVENOUS SOLUTION WRAPPER RX-4080050001 CDM 2500000200 HCPCS 250 RC 00143-9873-25 NDC inpatient 5 ML 61 61 MULTIPLAN INC 34080 [3081285] MULTIPLAN INC [308128501] 57.95 percent of total billed charges 37.82 57.95 Technical (Hospital) Services METOPROLOL TARTRATE 5 MG/5 ML INTRAVENOUS SOLUTION WRAPPER RX-4080050001 CDM 2500000200 HCPCS 250 RC 00143-9873-25 NDC inpatient 5 ML 61 61 MEDICA (COMMERCIAL) 94265 [3081118] MEDICA CLAIMS [308111801] 54.9 percent of total billed charges 37.82 57.95 Technical (Hospital) Services WCH ED ONDANSETRON 4 MG ODT #4 RX-408840024 CDM 2500000200 HCPCS 250 RC outpatient 16 ME 15.59 15.59 MULTIPLAN INC 34080 [3081285] MULTIPLAN INC [308128501] 14.81 percent of total billed charges 9.67 14.81 Technical (Hospital) Services WCH ED ONDANSETRON 4 MG ODT #4 RX-408840024 CDM 2500000200 HCPCS 250 RC outpatient 16 ME 15.59 15.59 MEDICA (COMMERCIAL) 94265 [3081118] MEDICA CLAIMS [308111801] 14.03 percent of total billed charges 9.67 14.81 Technical (Hospital) Services WCH ED ONDANSETRON 4 MG ODT #4 RX-408840024 CDM 2500000200 HCPCS 250 RC outpatient 16 ME 15.59 15.59 CIGNA 62308 [3081051] CIGNA 62308 [308105105] 12.47 percent of total billed charges 9.67 14.81 Technical (Hospital) Services WCH ED ONDANSETRON 4 MG ODT #4 RX-408840024 CDM 2500000200 HCPCS 250 RC outpatient 16 ME 15.59 15.59 CIGNA 62308 [3081051] CIGNA STATE OF WYOMING [308105107] 12.47 percent of total billed charges 9.67 14.81 Technical (Hospital) Services WCH ED ONDANSETRON 4 MG ODT #4 RX-408840024 CDM 2500000200 HCPCS 250 RC outpatient 16 ME 15.59 15.59 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES PPO [308136801] 12.47 percent of total billed charges 9.67 14.81 Technical (Hospital) Services WCH ED ONDANSETRON 4 MG ODT #4 RX-408840024 CDM 2500000200 HCPCS 250 RC outpatient 16 ME 15.59 15.59 HEALTHPARTNERS SX009 HEALTHPARTNERS 12.47 percent of total billed charges 9.67 14.81 Technical (Hospital) Services WCH ED ONDANSETRON 4 MG ODT #4 RX-408840024 CDM 2500000200 HCPCS 250 RC outpatient 16 ME 15.59 15.59 UNITED HEALTHCARE (COMMERCIAL) [3081199] UNITED HEALTHCARE 87726 [308119901] 9.67 percent of total billed charges 9.67 14.81 Technical (Hospital) Services WCH ED ONDANSETRON 4 MG ODT #4 RX-408840024 CDM 2500000200 HCPCS 250 RC outpatient 16 ME 15.59 15.59 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES HDHP [308136802] 12.47 percent of total billed charges 9.67 14.81 Technical (Hospital) Services WCH ED ONDANSETRON 4 MG ODT #4 RX-408840024 CDM 2500000200 HCPCS 250 RC outpatient 16 ME 15.59 15.59 BLUE CROSS BLUE SHIELD WELLMARK SB889 [3081026] BCBS WYOMING [308102603] 14.81 percent of total billed charges 9.67 14.81 Technical (Hospital) Services WCH ED ONDANSETRON 4 MG ODT #4 RX-408840024 CDM 2500000200 HCPCS 250 RC outpatient 16 ME 15.59 15.59 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES EPO [308136803] 12.47 percent of total billed charges 9.67 14.81 Technical (Hospital) Services WCH ED ONDANSETRON 4 MG ODT #4 RX-408840024 CDM 2500000200 HCPCS 250 RC inpatient 16 ME 15.59 15.59 MULTIPLAN INC 34080 [3081285] MULTIPLAN INC [308128501] 14.81 percent of total billed charges 9.67 14.81 Technical (Hospital) Services WCH ED ONDANSETRON 4 MG ODT #4 RX-408840024 CDM 2500000200 HCPCS 250 RC inpatient 16 ME 15.59 15.59 BLUE CROSS BLUE SHIELD WELLMARK SB889 [3081026] BCBS WYOMING [308102603] 14.81 percent of total billed charges 9.67 14.81 Technical (Hospital) Services WCH ED ONDANSETRON 4 MG ODT #4 RX-408840024 CDM 2500000200 HCPCS 250 RC inpatient 16 ME 15.59 15.59 HEALTHPARTNERS SX009 HEALTHPARTNERS 12.34 percent of total billed charges 9.67 14.81 Technical (Hospital) Services WCH ED ONDANSETRON 4 MG ODT #4 RX-408840024 CDM 2500000200 HCPCS 250 RC inpatient 16 ME 15.59 15.59 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES EPO [308136803] 12.34 percent of total billed charges 9.67 14.81 Technical (Hospital) Services WCH ED ONDANSETRON 4 MG ODT #4 RX-408840024 CDM 2500000200 HCPCS 250 RC inpatient 16 ME 15.59 15.59 CIGNA 62308 [3081051] CIGNA 62308 [308105105] 12.34 percent of total billed charges 9.67 14.81 Technical (Hospital) Services WCH ED ONDANSETRON 4 MG ODT #4 RX-408840024 CDM 2500000200 HCPCS 250 RC inpatient 16 ME 15.59 15.59 CIGNA 62308 [3081051] CIGNA STATE OF WYOMING [308105107] 12.34 percent of total billed charges 9.67 14.81 Technical (Hospital) Services WCH ED ONDANSETRON 4 MG ODT #4 RX-408840024 CDM 2500000200 HCPCS 250 RC inpatient 16 ME 15.59 15.59 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES HDHP [308136802] 12.34 percent of total billed charges 9.67 14.81 Technical (Hospital) Services WCH ED ONDANSETRON 4 MG ODT #4 RX-408840024 CDM 2500000200 HCPCS 250 RC inpatient 16 ME 15.59 15.59 UNITED HEALTHCARE (COMMERCIAL) [3081199] UNITED HEALTHCARE 87726 [308119901] 9.67 percent of total billed charges 9.67 14.81 Technical (Hospital) Services WCH ED ONDANSETRON 4 MG ODT #4 RX-408840024 CDM 2500000200 HCPCS 250 RC inpatient 16 ME 15.59 15.59 MEDICA (COMMERCIAL) 94265 [3081118] MEDICA CLAIMS [308111801] 14.03 percent of total billed charges 9.67 14.81 Technical (Hospital) Services WCH ED ONDANSETRON 4 MG ODT #4 RX-408840024 CDM 2500000200 HCPCS 250 RC inpatient 16 ME 15.59 15.59 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES PPO [308136801] 12.34 percent of total billed charges 9.67 14.81 Technical (Hospital) Services WCH ED PROMETHAZINE 25 MG ORAL TAB #6 RX-408840029 CDM 2500000200 HCPCS 250 RC 09999-9990-27 NDC outpatient 150 ME 14.94 14.94 CIGNA 62308 [3081051] CIGNA 62308 [308105105] 11.95 percent of total billed charges 9.26 14.19 Technical (Hospital) Services WCH ED PROMETHAZINE 25 MG ORAL TAB #6 RX-408840029 CDM 2500000200 HCPCS 250 RC 09999-9990-27 NDC outpatient 150 ME 14.94 14.94 CIGNA 62308 [3081051] CIGNA STATE OF WYOMING [308105107] 11.95 percent of total billed charges 9.26 14.19 Technical (Hospital) Services WCH ED PROMETHAZINE 25 MG ORAL TAB #6 RX-408840029 CDM 2500000200 HCPCS 250 RC 09999-9990-27 NDC outpatient 150 ME 14.94 14.94 MEDICA (COMMERCIAL) 94265 [3081118] MEDICA CLAIMS [308111801] 13.45 percent of total billed charges 9.26 14.19 Technical (Hospital) Services WCH ED PROMETHAZINE 25 MG ORAL TAB #6 RX-408840029 CDM 2500000200 HCPCS 250 RC 09999-9990-27 NDC outpatient 150 ME 14.94 14.94 MULTIPLAN INC 34080 [3081285] MULTIPLAN INC [308128501] 14.19 percent of total billed charges 9.26 14.19 Technical (Hospital) Services WCH ED PROMETHAZINE 25 MG ORAL TAB #6 RX-408840029 CDM 2500000200 HCPCS 250 RC 09999-9990-27 NDC outpatient 150 ME 14.94 14.94 HEALTHPARTNERS SX009 HEALTHPARTNERS 11.95 percent of total billed charges 9.26 14.19 Technical (Hospital) Services WCH ED PROMETHAZINE 25 MG ORAL TAB #6 RX-408840029 CDM 2500000200 HCPCS 250 RC 09999-9990-27 NDC outpatient 150 ME 14.94 14.94 UNITED HEALTHCARE (COMMERCIAL) [3081199] UNITED HEALTHCARE 87726 [308119901] 9.26 percent of total billed charges 9.26 14.19 Technical (Hospital) Services WCH ED PROMETHAZINE 25 MG ORAL TAB #6 RX-408840029 CDM 2500000200 HCPCS 250 RC 09999-9990-27 NDC outpatient 150 ME 14.94 14.94 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES PPO [308136801] 11.95 percent of total billed charges 9.26 14.19 Technical (Hospital) Services WCH ED PROMETHAZINE 25 MG ORAL TAB #6 RX-408840029 CDM 2500000200 HCPCS 250 RC 09999-9990-27 NDC outpatient 150 ME 14.94 14.94 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES HDHP [308136802] 11.95 percent of total billed charges 9.26 14.19 Technical (Hospital) Services WCH ED PROMETHAZINE 25 MG ORAL TAB #6 RX-408840029 CDM 2500000200 HCPCS 250 RC 09999-9990-27 NDC outpatient 150 ME 14.94 14.94 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES EPO [308136803] 11.95 percent of total billed charges 9.26 14.19 Technical (Hospital) Services WCH ED PROMETHAZINE 25 MG ORAL TAB #6 RX-408840029 CDM 2500000200 HCPCS 250 RC 09999-9990-27 NDC outpatient 150 ME 14.94 14.94 BLUE CROSS BLUE SHIELD WELLMARK SB889 [3081026] BCBS WYOMING [308102603] 14.19 percent of total billed charges 9.26 14.19 Technical (Hospital) Services WCH ED PROMETHAZINE 25 MG ORAL TAB #6 RX-408840029 CDM 2500000200 HCPCS 250 RC 09999-9990-27 NDC inpatient 150 ME 14.94 14.94 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES EPO [308136803] 11.83 percent of total billed charges 9.26 14.19 Technical (Hospital) Services WCH ED PROMETHAZINE 25 MG ORAL TAB #6 RX-408840029 CDM 2500000200 HCPCS 250 RC 09999-9990-27 NDC inpatient 150 ME 14.94 14.94 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES HDHP [308136802] 11.83 percent of total billed charges 9.26 14.19 Technical (Hospital) Services WCH ED PROMETHAZINE 25 MG ORAL TAB #6 RX-408840029 CDM 2500000200 HCPCS 250 RC 09999-9990-27 NDC inpatient 150 ME 14.94 14.94 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES PPO [308136801] 11.83 percent of total billed charges 9.26 14.19 Technical (Hospital) Services WCH ED PROMETHAZINE 25 MG ORAL TAB #6 RX-408840029 CDM 2500000200 HCPCS 250 RC 09999-9990-27 NDC inpatient 150 ME 14.94 14.94 CIGNA 62308 [3081051] CIGNA 62308 [308105105] 11.83 percent of total billed charges 9.26 14.19 Technical (Hospital) Services WCH ED PROMETHAZINE 25 MG ORAL TAB #6 RX-408840029 CDM 2500000200 HCPCS 250 RC 09999-9990-27 NDC inpatient 150 ME 14.94 14.94 CIGNA 62308 [3081051] CIGNA STATE OF WYOMING [308105107] 11.83 percent of total billed charges 9.26 14.19 Technical (Hospital) Services WCH ED PROMETHAZINE 25 MG ORAL TAB #6 RX-408840029 CDM 2500000200 HCPCS 250 RC 09999-9990-27 NDC inpatient 150 ME 14.94 14.94 BLUE CROSS BLUE SHIELD WELLMARK SB889 [3081026] BCBS WYOMING [308102603] 14.19 percent of total billed charges 9.26 14.19 Technical (Hospital) Services WCH ED PROMETHAZINE 25 MG ORAL TAB #6 RX-408840029 CDM 2500000200 HCPCS 250 RC 09999-9990-27 NDC inpatient 150 ME 14.94 14.94 UNITED HEALTHCARE (COMMERCIAL) [3081199] UNITED HEALTHCARE 87726 [308119901] 9.26 percent of total billed charges 9.26 14.19 Technical (Hospital) Services WCH ED PROMETHAZINE 25 MG ORAL TAB #6 RX-408840029 CDM 2500000200 HCPCS 250 RC 09999-9990-27 NDC inpatient 150 ME 14.94 14.94 HEALTHPARTNERS SX009 HEALTHPARTNERS 11.83 percent of total billed charges 9.26 14.19 Technical (Hospital) Services WCH ED PROMETHAZINE 25 MG ORAL TAB #6 RX-408840029 CDM 2500000200 HCPCS 250 RC 09999-9990-27 NDC inpatient 150 ME 14.94 14.94 MEDICA (COMMERCIAL) 94265 [3081118] MEDICA CLAIMS [308111801] 13.45 percent of total billed charges 9.26 14.19 Technical (Hospital) Services WCH ED PROMETHAZINE 25 MG ORAL TAB #6 RX-408840029 CDM 2500000200 HCPCS 250 RC 09999-9990-27 NDC inpatient 150 ME 14.94 14.94 MULTIPLAN INC 34080 [3081285] MULTIPLAN INC [308128501] 14.19 percent of total billed charges 9.26 14.19 Technical (Hospital) Services SODIUM CHLORIDE 0.9 % INJECTION SOLUTION RX-41463 CDM 2500000200 HCPCS 250 RC 00409-4888-03 NDC outpatient 20 ML 59.6 59.6 CIGNA 62308 [3081051] CIGNA 62308 [308105105] 47.68 percent of total billed charges 36.95 56.62 Technical (Hospital) Services SODIUM CHLORIDE 0.9 % INJECTION SOLUTION RX-41463 CDM 2500000200 HCPCS 250 RC 00409-4888-03 NDC outpatient 20 ML 59.6 59.6 CIGNA 62308 [3081051] CIGNA STATE OF WYOMING [308105107] 47.68 percent of total billed charges 36.95 56.62 Technical (Hospital) Services SODIUM CHLORIDE 0.9 % INJECTION SOLUTION RX-41463 CDM 2500000200 HCPCS 250 RC 00409-4888-03 NDC outpatient 20 ML 59.6 59.6 MEDICA (COMMERCIAL) 94265 [3081118] MEDICA CLAIMS [308111801] 53.64 percent of total billed charges 36.95 56.62 Technical (Hospital) Services SODIUM CHLORIDE 0.9 % INJECTION SOLUTION RX-41463 CDM 2500000200 HCPCS 250 RC 00409-4888-03 NDC outpatient 20 ML 59.6 59.6 MULTIPLAN INC 34080 [3081285] MULTIPLAN INC [308128501] 56.62 percent of total billed charges 36.95 56.62 Technical (Hospital) Services SODIUM CHLORIDE 0.9 % INJECTION SOLUTION RX-41463 CDM 2500000200 HCPCS 250 RC 00409-4888-03 NDC outpatient 20 ML 59.6 59.6 BLUE CROSS BLUE SHIELD WELLMARK SB889 [3081026] BCBS WYOMING [308102603] 56.62 percent of total billed charges 36.95 56.62 Technical (Hospital) Services SODIUM CHLORIDE 0.9 % INJECTION SOLUTION RX-41463 CDM 2500000200 HCPCS 250 RC 00409-4888-03 NDC outpatient 20 ML 59.6 59.6 HEALTHPARTNERS SX009 HEALTHPARTNERS 47.68 percent of total billed charges 36.95 56.62 Technical (Hospital) Services SODIUM CHLORIDE 0.9 % INJECTION SOLUTION RX-41463 CDM 2500000200 HCPCS 250 RC 00409-4888-03 NDC outpatient 20 ML 59.6 59.6 UNITED HEALTHCARE (COMMERCIAL) [3081199] UNITED HEALTHCARE 87726 [308119901] 36.95 percent of total billed charges 36.95 56.62 Technical (Hospital) Services SODIUM CHLORIDE 0.9 % INJECTION SOLUTION RX-41463 CDM 2500000200 HCPCS 250 RC 00409-4888-03 NDC outpatient 20 ML 59.6 59.6 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES PPO [308136801] 47.68 percent of total billed charges 36.95 56.62 Technical (Hospital) Services SODIUM CHLORIDE 0.9 % INJECTION SOLUTION RX-41463 CDM 2500000200 HCPCS 250 RC 00409-4888-03 NDC outpatient 20 ML 59.6 59.6 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES EPO [308136803] 47.68 percent of total billed charges 36.95 56.62 Technical (Hospital) Services SODIUM CHLORIDE 0.9 % INJECTION SOLUTION RX-41463 CDM 2500000200 HCPCS 250 RC 00409-4888-03 NDC outpatient 20 ML 59.6 59.6 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES HDHP [308136802] 47.68 percent of total billed charges 36.95 56.62 Technical (Hospital) Services SODIUM CHLORIDE 0.9 % INJECTION SOLUTION RX-41463 CDM 2500000200 HCPCS 250 RC 00409-4888-03 NDC inpatient 20 ML 59.6 59.6 CIGNA 62308 [3081051] CIGNA 62308 [308105105] 47.19 percent of total billed charges 36.95 56.62 Technical (Hospital) Services SODIUM CHLORIDE 0.9 % INJECTION SOLUTION RX-41463 CDM 2500000200 HCPCS 250 RC 00409-4888-03 NDC inpatient 20 ML 59.6 59.6 CIGNA 62308 [3081051] CIGNA STATE OF WYOMING [308105107] 47.19 percent of total billed charges 36.95 56.62 Technical (Hospital) Services SODIUM CHLORIDE 0.9 % INJECTION SOLUTION RX-41463 CDM 2500000200 HCPCS 250 RC 00409-4888-03 NDC inpatient 20 ML 59.6 59.6 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES PPO [308136801] 47.19 percent of total billed charges 36.95 56.62 Technical (Hospital) Services SODIUM CHLORIDE 0.9 % INJECTION SOLUTION RX-41463 CDM 2500000200 HCPCS 250 RC 00409-4888-03 NDC inpatient 20 ML 59.6 59.6 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES HDHP [308136802] 47.19 percent of total billed charges 36.95 56.62 Technical (Hospital) Services SODIUM CHLORIDE 0.9 % INJECTION SOLUTION RX-41463 CDM 2500000200 HCPCS 250 RC 00409-4888-03 NDC inpatient 20 ML 59.6 59.6 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES EPO [308136803] 47.19 percent of total billed charges 36.95 56.62 Technical (Hospital) Services SODIUM CHLORIDE 0.9 % INJECTION SOLUTION RX-41463 CDM 2500000200 HCPCS 250 RC 00409-4888-03 NDC inpatient 20 ML 59.6 59.6 HEALTHPARTNERS SX009 HEALTHPARTNERS 47.19 percent of total billed charges 36.95 56.62 Technical (Hospital) Services SODIUM CHLORIDE 0.9 % INJECTION SOLUTION RX-41463 CDM 2500000200 HCPCS 250 RC 00409-4888-03 NDC inpatient 20 ML 59.6 59.6 BLUE CROSS BLUE SHIELD WELLMARK SB889 [3081026] BCBS WYOMING [308102603] 56.62 percent of total billed charges 36.95 56.62 Technical (Hospital) Services SODIUM CHLORIDE 0.9 % INJECTION SOLUTION RX-41463 CDM 2500000200 HCPCS 250 RC 00409-4888-03 NDC inpatient 20 ML 59.6 59.6 UNITED HEALTHCARE (COMMERCIAL) [3081199] UNITED HEALTHCARE 87726 [308119901] 36.95 percent of total billed charges 36.95 56.62 Technical (Hospital) Services SODIUM CHLORIDE 0.9 % INJECTION SOLUTION RX-41463 CDM 2500000200 HCPCS 250 RC 00409-4888-03 NDC inpatient 20 ML 59.6 59.6 MULTIPLAN INC 34080 [3081285] MULTIPLAN INC [308128501] 56.62 percent of total billed charges 36.95 56.62 Technical (Hospital) Services SODIUM CHLORIDE 0.9 % INJECTION SOLUTION RX-41463 CDM 2500000200 HCPCS 250 RC 00409-4888-03 NDC inpatient 20 ML 59.6 59.6 MEDICA (COMMERCIAL) 94265 [3081118] MEDICA CLAIMS [308111801] 53.64 percent of total billed charges 36.95 56.62 Technical (Hospital) Services KETAMINE 10 MG/ML INJECTION SOLUTION RX-4236 CDM 2500000200 HCPCS 250 RC 42023-0113-10 NDC outpatient 20 ML 108.28 108.28 CIGNA 62308 [3081051] CIGNA 62308 [308105105] 86.62 percent of total billed charges 67.13 102.87 Technical (Hospital) Services KETAMINE 10 MG/ML INJECTION SOLUTION RX-4236 CDM 2500000200 HCPCS 250 RC 42023-0113-10 NDC outpatient 20 ML 108.28 108.28 CIGNA 62308 [3081051] CIGNA STATE OF WYOMING [308105107] 86.62 percent of total billed charges 67.13 102.87 Technical (Hospital) Services KETAMINE 10 MG/ML INJECTION SOLUTION RX-4236 CDM 2500000200 HCPCS 250 RC 42023-0113-10 NDC outpatient 20 ML 108.28 108.28 HEALTHPARTNERS SX009 HEALTHPARTNERS 86.62 percent of total billed charges 67.13 102.87 Technical (Hospital) Services KETAMINE 10 MG/ML INJECTION SOLUTION RX-4236 CDM 2500000200 HCPCS 250 RC 42023-0113-10 NDC outpatient 20 ML 108.28 108.28 UNITED HEALTHCARE (COMMERCIAL) [3081199] UNITED HEALTHCARE 87726 [308119901] 67.13 percent of total billed charges 67.13 102.87 Technical (Hospital) Services KETAMINE 10 MG/ML INJECTION SOLUTION RX-4236 CDM 2500000200 HCPCS 250 RC 42023-0113-10 NDC outpatient 20 ML 108.28 108.28 MULTIPLAN INC 34080 [3081285] MULTIPLAN INC [308128501] 102.87 percent of total billed charges 67.13 102.87 Technical (Hospital) Services KETAMINE 10 MG/ML INJECTION SOLUTION RX-4236 CDM 2500000200 HCPCS 250 RC 42023-0113-10 NDC outpatient 20 ML 108.28 108.28 MEDICA (COMMERCIAL) 94265 [3081118] MEDICA CLAIMS [308111801] 97.45 percent of total billed charges 67.13 102.87 Technical (Hospital) Services KETAMINE 10 MG/ML INJECTION SOLUTION RX-4236 CDM 2500000200 HCPCS 250 RC 42023-0113-10 NDC outpatient 20 ML 108.28 108.28 BLUE CROSS BLUE SHIELD WELLMARK SB889 [3081026] BCBS WYOMING [308102603] 102.87 percent of total billed charges 67.13 102.87 Technical (Hospital) Services KETAMINE 10 MG/ML INJECTION SOLUTION RX-4236 CDM 2500000200 HCPCS 250 RC 42023-0113-10 NDC outpatient 20 ML 108.28 108.28 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES PPO [308136801] 86.62 percent of total billed charges 67.13 102.87 Technical (Hospital) Services KETAMINE 10 MG/ML INJECTION SOLUTION RX-4236 CDM 2500000200 HCPCS 250 RC 42023-0113-10 NDC outpatient 20 ML 108.28 108.28 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES HDHP [308136802] 86.62 percent of total billed charges 67.13 102.87 Technical (Hospital) Services KETAMINE 10 MG/ML INJECTION SOLUTION RX-4236 CDM 2500000200 HCPCS 250 RC 42023-0113-10 NDC outpatient 20 ML 108.28 108.28 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES EPO [308136803] 86.62 percent of total billed charges 67.13 102.87 Technical (Hospital) Services KETAMINE 10 MG/ML INJECTION SOLUTION RX-4236 CDM 2500000200 HCPCS 250 RC 42023-0113-10 NDC inpatient 20 ML 108.28 108.28 HEALTHPARTNERS SX009 HEALTHPARTNERS 85.74 percent of total billed charges 67.13 102.87 Technical (Hospital) Services KETAMINE 10 MG/ML INJECTION SOLUTION RX-4236 CDM 2500000200 HCPCS 250 RC 42023-0113-10 NDC inpatient 20 ML 108.28 108.28 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES EPO [308136803] 85.74 percent of total billed charges 67.13 102.87 Technical (Hospital) Services KETAMINE 10 MG/ML INJECTION SOLUTION RX-4236 CDM 2500000200 HCPCS 250 RC 42023-0113-10 NDC inpatient 20 ML 108.28 108.28 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES HDHP [308136802] 85.74 percent of total billed charges 67.13 102.87 Technical (Hospital) Services KETAMINE 10 MG/ML INJECTION SOLUTION RX-4236 CDM 2500000200 HCPCS 250 RC 42023-0113-10 NDC inpatient 20 ML 108.28 108.28 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES PPO [308136801] 85.74 percent of total billed charges 67.13 102.87 Technical (Hospital) Services KETAMINE 10 MG/ML INJECTION SOLUTION RX-4236 CDM 2500000200 HCPCS 250 RC 42023-0113-10 NDC inpatient 20 ML 108.28 108.28 CIGNA 62308 [3081051] CIGNA 62308 [308105105] 85.74 percent of total billed charges 67.13 102.87 Technical (Hospital) Services KETAMINE 10 MG/ML INJECTION SOLUTION RX-4236 CDM 2500000200 HCPCS 250 RC 42023-0113-10 NDC inpatient 20 ML 108.28 108.28 CIGNA 62308 [3081051] CIGNA STATE OF WYOMING [308105107] 85.74 percent of total billed charges 67.13 102.87 Technical (Hospital) Services KETAMINE 10 MG/ML INJECTION SOLUTION RX-4236 CDM 2500000200 HCPCS 250 RC 42023-0113-10 NDC inpatient 20 ML 108.28 108.28 BLUE CROSS BLUE SHIELD WELLMARK SB889 [3081026] BCBS WYOMING [308102603] 102.87 percent of total billed charges 67.13 102.87 Technical (Hospital) Services KETAMINE 10 MG/ML INJECTION SOLUTION RX-4236 CDM 2500000200 HCPCS 250 RC 42023-0113-10 NDC inpatient 20 ML 108.28 108.28 UNITED HEALTHCARE (COMMERCIAL) [3081199] UNITED HEALTHCARE 87726 [308119901] 67.13 percent of total billed charges 67.13 102.87 Technical (Hospital) Services KETAMINE 10 MG/ML INJECTION SOLUTION RX-4236 CDM 2500000200 HCPCS 250 RC 42023-0113-10 NDC inpatient 20 ML 108.28 108.28 MULTIPLAN INC 34080 [3081285] MULTIPLAN INC [308128501] 102.87 percent of total billed charges 67.13 102.87 Technical (Hospital) Services KETAMINE 10 MG/ML INJECTION SOLUTION RX-4236 CDM 2500000200 HCPCS 250 RC 42023-0113-10 NDC inpatient 20 ML 108.28 108.28 MEDICA (COMMERCIAL) 94265 [3081118] MEDICA CLAIMS [308111801] 97.45 percent of total billed charges 67.13 102.87 Technical (Hospital) Services KETAMINE 50 MG/ML INJECTION SOLUTION RX-4238 CDM 2500000200 HCPCS 250 RC 00143-9508-01 NDC outpatient 10 ML 70.9 70.9 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES PPO [308136801] 56.72 percent of total billed charges 43.96 67.36 Technical (Hospital) Services KETAMINE 50 MG/ML INJECTION SOLUTION RX-4238 CDM 2500000200 HCPCS 250 RC 00143-9508-01 NDC outpatient 10 ML 70.9 70.9 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES EPO [308136803] 56.72 percent of total billed charges 43.96 67.36 Technical (Hospital) Services KETAMINE 50 MG/ML INJECTION SOLUTION RX-4238 CDM 2500000200 HCPCS 250 RC 00143-9508-01 NDC outpatient 10 ML 70.9 70.9 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES HDHP [308136802] 56.72 percent of total billed charges 43.96 67.36 Technical (Hospital) Services KETAMINE 50 MG/ML INJECTION SOLUTION RX-4238 CDM 2500000200 HCPCS 250 RC 00143-9508-01 NDC outpatient 10 ML 70.9 70.9 BLUE CROSS BLUE SHIELD WELLMARK SB889 [3081026] BCBS WYOMING [308102603] 67.36 percent of total billed charges 43.96 67.36 Technical (Hospital) Services KETAMINE 50 MG/ML INJECTION SOLUTION RX-4238 CDM 2500000200 HCPCS 250 RC 00143-9508-01 NDC outpatient 10 ML 70.9 70.9 UNITED HEALTHCARE (COMMERCIAL) [3081199] UNITED HEALTHCARE 87726 [308119901] 43.96 percent of total billed charges 43.96 67.36 Technical (Hospital) Services KETAMINE 50 MG/ML INJECTION SOLUTION RX-4238 CDM 2500000200 HCPCS 250 RC 00143-9508-01 NDC outpatient 10 ML 70.9 70.9 HEALTHPARTNERS SX009 HEALTHPARTNERS 56.72 percent of total billed charges 43.96 67.36 Technical (Hospital) Services KETAMINE 50 MG/ML INJECTION SOLUTION RX-4238 CDM 2500000200 HCPCS 250 RC 00143-9508-01 NDC outpatient 10 ML 70.9 70.9 MEDICA (COMMERCIAL) 94265 [3081118] MEDICA CLAIMS [308111801] 63.81 percent of total billed charges 43.96 67.36 Technical (Hospital) Services KETAMINE 50 MG/ML INJECTION SOLUTION RX-4238 CDM 2500000200 HCPCS 250 RC 00143-9508-01 NDC outpatient 10 ML 70.9 70.9 MULTIPLAN INC 34080 [3081285] MULTIPLAN INC [308128501] 67.36 percent of total billed charges 43.96 67.36 Technical (Hospital) Services KETAMINE 50 MG/ML INJECTION SOLUTION RX-4238 CDM 2500000200 HCPCS 250 RC 00143-9508-01 NDC outpatient 10 ML 70.9 70.9 CIGNA 62308 [3081051] CIGNA 62308 [308105105] 56.72 percent of total billed charges 43.96 67.36 Technical (Hospital) Services KETAMINE 50 MG/ML INJECTION SOLUTION RX-4238 CDM 2500000200 HCPCS 250 RC 00143-9508-01 NDC outpatient 10 ML 70.9 70.9 CIGNA 62308 [3081051] CIGNA STATE OF WYOMING [308105107] 56.72 percent of total billed charges 43.96 67.36 Technical (Hospital) Services KETAMINE 50 MG/ML INJECTION SOLUTION RX-4238 CDM 2500000200 HCPCS 250 RC 00143-9508-01 NDC inpatient 10 ML 70.9 70.9 MULTIPLAN INC 34080 [3081285] MULTIPLAN INC [308128501] 67.36 percent of total billed charges 43.96 67.36 Technical (Hospital) Services KETAMINE 50 MG/ML INJECTION SOLUTION RX-4238 CDM 2500000200 HCPCS 250 RC 00143-9508-01 NDC inpatient 10 ML 70.9 70.9 MEDICA (COMMERCIAL) 94265 [3081118] MEDICA CLAIMS [308111801] 63.81 percent of total billed charges 43.96 67.36 Technical (Hospital) Services KETAMINE 50 MG/ML INJECTION SOLUTION RX-4238 CDM 2500000200 HCPCS 250 RC 00143-9508-01 NDC inpatient 10 ML 70.9 70.9 BLUE CROSS BLUE SHIELD WELLMARK SB889 [3081026] BCBS WYOMING [308102603] 67.36 percent of total billed charges 43.96 67.36 Technical (Hospital) Services KETAMINE 50 MG/ML INJECTION SOLUTION RX-4238 CDM 2500000200 HCPCS 250 RC 00143-9508-01 NDC inpatient 10 ML 70.9 70.9 UNITED HEALTHCARE (COMMERCIAL) [3081199] UNITED HEALTHCARE 87726 [308119901] 43.96 percent of total billed charges 43.96 67.36 Technical (Hospital) Services KETAMINE 50 MG/ML INJECTION SOLUTION RX-4238 CDM 2500000200 HCPCS 250 RC 00143-9508-01 NDC inpatient 10 ML 70.9 70.9 CIGNA 62308 [3081051] CIGNA 62308 [308105105] 56.14 percent of total billed charges 43.96 67.36 Technical (Hospital) Services KETAMINE 50 MG/ML INJECTION SOLUTION RX-4238 CDM 2500000200 HCPCS 250 RC 00143-9508-01 NDC inpatient 10 ML 70.9 70.9 CIGNA 62308 [3081051] CIGNA STATE OF WYOMING [308105107] 56.14 percent of total billed charges 43.96 67.36 Technical (Hospital) Services KETAMINE 50 MG/ML INJECTION SOLUTION RX-4238 CDM 2500000200 HCPCS 250 RC 00143-9508-01 NDC inpatient 10 ML 70.9 70.9 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES HDHP [308136802] 56.14 percent of total billed charges 43.96 67.36 Technical (Hospital) Services KETAMINE 50 MG/ML INJECTION SOLUTION RX-4238 CDM 2500000200 HCPCS 250 RC 00143-9508-01 NDC inpatient 10 ML 70.9 70.9 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES PPO [308136801] 56.14 percent of total billed charges 43.96 67.36 Technical (Hospital) Services KETAMINE 50 MG/ML INJECTION SOLUTION RX-4238 CDM 2500000200 HCPCS 250 RC 00143-9508-01 NDC inpatient 10 ML 70.9 70.9 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES EPO [308136803] 56.14 percent of total billed charges 43.96 67.36 Technical (Hospital) Services KETAMINE 50 MG/ML INJECTION SOLUTION RX-4238 CDM 2500000200 HCPCS 250 RC 00143-9508-01 NDC inpatient 10 ML 70.9 70.9 HEALTHPARTNERS SX009 HEALTHPARTNERS 56.14 percent of total billed charges 43.96 67.36 Technical (Hospital) Services LIDOCAINE HCL 10 MG/ML (1 %) INJECTION SOLUTION RX-4452 CDM 2500000200 HCPCS 250 RC 63323-0201-03 NDC outpatient 10 ML 8.06 8.06 UNITED HEALTHCARE (COMMERCIAL) [3081199] UNITED HEALTHCARE 87726 [308119901] 5 percent of total billed charges 5 7.66 Technical (Hospital) Services LIDOCAINE HCL 10 MG/ML (1 %) INJECTION SOLUTION RX-4452 CDM 2500000200 HCPCS 250 RC 63323-0201-03 NDC outpatient 10 ML 8.06 8.06 HEALTHPARTNERS SX009 HEALTHPARTNERS 6.45 percent of total billed charges 5 7.66 Technical (Hospital) Services LIDOCAINE HCL 10 MG/ML (1 %) INJECTION SOLUTION RX-4452 CDM 2500000200 HCPCS 250 RC 63323-0201-03 NDC outpatient 10 ML 8.06 8.06 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES HDHP [308136802] 6.45 percent of total billed charges 5 7.66 Technical (Hospital) Services LIDOCAINE HCL 10 MG/ML (1 %) INJECTION SOLUTION RX-4452 CDM 2500000200 HCPCS 250 RC 63323-0201-03 NDC outpatient 10 ML 8.06 8.06 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES EPO [308136803] 6.45 percent of total billed charges 5 7.66 Technical (Hospital) Services LIDOCAINE HCL 10 MG/ML (1 %) INJECTION SOLUTION RX-4452 CDM 2500000200 HCPCS 250 RC 63323-0201-03 NDC outpatient 10 ML 8.06 8.06 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES PPO [308136801] 6.45 percent of total billed charges 5 7.66 Technical (Hospital) Services LIDOCAINE HCL 10 MG/ML (1 %) INJECTION SOLUTION RX-4452 CDM 2500000200 HCPCS 250 RC 63323-0201-03 NDC outpatient 10 ML 8.06 8.06 BLUE CROSS BLUE SHIELD WELLMARK SB889 [3081026] BCBS WYOMING [308102603] 7.66 percent of total billed charges 5 7.66 Technical (Hospital) Services LIDOCAINE HCL 10 MG/ML (1 %) INJECTION SOLUTION RX-4452 CDM 2500000200 HCPCS 250 RC 63323-0201-03 NDC outpatient 10 ML 8.06 8.06 MEDICA (COMMERCIAL) 94265 [3081118] MEDICA CLAIMS [308111801] 7.25 percent of total billed charges 5 7.66 Technical (Hospital) Services LIDOCAINE HCL 10 MG/ML (1 %) INJECTION SOLUTION RX-4452 CDM 2500000200 HCPCS 250 RC 63323-0201-03 NDC outpatient 10 ML 8.06 8.06 MULTIPLAN INC 34080 [3081285] MULTIPLAN INC [308128501] 7.66 percent of total billed charges 5 7.66 Technical (Hospital) Services LIDOCAINE HCL 10 MG/ML (1 %) INJECTION SOLUTION RX-4452 CDM 2500000200 HCPCS 250 RC 63323-0201-03 NDC outpatient 10 ML 8.06 8.06 CIGNA 62308 [3081051] CIGNA 62308 [308105105] 6.45 percent of total billed charges 5 7.66 Technical (Hospital) Services LIDOCAINE HCL 10 MG/ML (1 %) INJECTION SOLUTION RX-4452 CDM 2500000200 HCPCS 250 RC 63323-0201-03 NDC outpatient 10 ML 8.06 8.06 CIGNA 62308 [3081051] CIGNA STATE OF WYOMING [308105107] 6.45 percent of total billed charges 5 7.66 Technical (Hospital) Services LIDOCAINE HCL 10 MG/ML (1 %) INJECTION SOLUTION RX-4452 CDM 2500000200 HCPCS 250 RC 63323-0201-03 NDC inpatient 10 ML 8.06 8.06 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES EPO [308136803] 6.38 percent of total billed charges 5 7.66 Technical (Hospital) Services LIDOCAINE HCL 10 MG/ML (1 %) INJECTION SOLUTION RX-4452 CDM 2500000200 HCPCS 250 RC 63323-0201-03 NDC inpatient 10 ML 8.06 8.06 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES PPO [308136801] 6.38 percent of total billed charges 5 7.66 Technical (Hospital) Services LIDOCAINE HCL 10 MG/ML (1 %) INJECTION SOLUTION RX-4452 CDM 2500000200 HCPCS 250 RC 63323-0201-03 NDC inpatient 10 ML 8.06 8.06 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES HDHP [308136802] 6.38 percent of total billed charges 5 7.66 Technical (Hospital) Services LIDOCAINE HCL 10 MG/ML (1 %) INJECTION SOLUTION RX-4452 CDM 2500000200 HCPCS 250 RC 63323-0201-03 NDC inpatient 10 ML 8.06 8.06 HEALTHPARTNERS SX009 HEALTHPARTNERS 6.38 percent of total billed charges 5 7.66 Technical (Hospital) Services LIDOCAINE HCL 10 MG/ML (1 %) INJECTION SOLUTION RX-4452 CDM 2500000200 HCPCS 250 RC 63323-0201-03 NDC inpatient 10 ML 8.06 8.06 CIGNA 62308 [3081051] CIGNA 62308 [308105105] 6.38 percent of total billed charges 5 7.66 Technical (Hospital) Services LIDOCAINE HCL 10 MG/ML (1 %) INJECTION SOLUTION RX-4452 CDM 2500000200 HCPCS 250 RC 63323-0201-03 NDC inpatient 10 ML 8.06 8.06 CIGNA 62308 [3081051] CIGNA STATE OF WYOMING [308105107] 6.38 percent of total billed charges 5 7.66 Technical (Hospital) Services LIDOCAINE HCL 10 MG/ML (1 %) INJECTION SOLUTION RX-4452 CDM 2500000200 HCPCS 250 RC 63323-0201-03 NDC inpatient 10 ML 8.06 8.06 UNITED HEALTHCARE (COMMERCIAL) [3081199] UNITED HEALTHCARE 87726 [308119901] 5 percent of total billed charges 5 7.66 Technical (Hospital) Services LIDOCAINE HCL 10 MG/ML (1 %) INJECTION SOLUTION RX-4452 CDM 2500000200 HCPCS 250 RC 63323-0201-03 NDC inpatient 10 ML 8.06 8.06 BLUE CROSS BLUE SHIELD WELLMARK SB889 [3081026] BCBS WYOMING [308102603] 7.66 percent of total billed charges 5 7.66 Technical (Hospital) Services LIDOCAINE HCL 10 MG/ML (1 %) INJECTION SOLUTION RX-4452 CDM 2500000200 HCPCS 250 RC 63323-0201-03 NDC inpatient 10 ML 8.06 8.06 MULTIPLAN INC 34080 [3081285] MULTIPLAN INC [308128501] 7.66 percent of total billed charges 5 7.66 Technical (Hospital) Services LIDOCAINE HCL 10 MG/ML (1 %) INJECTION SOLUTION RX-4452 CDM 2500000200 HCPCS 250 RC 63323-0201-03 NDC inpatient 10 ML 8.06 8.06 MEDICA (COMMERCIAL) 94265 [3081118] MEDICA CLAIMS [308111801] 7.25 percent of total billed charges 5 7.66 Technical (Hospital) Services PROCHLORPERAZINE MALEATE 5 MG TABLET RX-6583 CDM 2500000200 HCPCS 250 RC 00378-5105-01 NDC inpatient 1 UN 5.94 5.94 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES PPO [308136801] 4.7 percent of total billed charges 3.68 5.64 Technical (Hospital) Services PROCHLORPERAZINE MALEATE 5 MG TABLET RX-6583 CDM 2500000200 HCPCS 250 RC 00378-5105-01 NDC inpatient 1 UN 5.94 5.94 MEDICA (COMMERCIAL) 94265 [3081118] MEDICA CLAIMS [308111801] 5.35 percent of total billed charges 3.68 5.64 Technical (Hospital) Services PROCHLORPERAZINE MALEATE 5 MG TABLET RX-6583 CDM 2500000200 HCPCS 250 RC 00378-5105-01 NDC inpatient 1 UN 5.94 5.94 HEALTHPARTNERS SX009 HEALTHPARTNERS 4.7 percent of total billed charges 3.68 5.64 Technical (Hospital) Services PROCHLORPERAZINE MALEATE 5 MG TABLET RX-6583 CDM 2500000200 HCPCS 250 RC 00378-5105-01 NDC inpatient 1 UN 5.94 5.94 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES HDHP [308136802] 4.7 percent of total billed charges 3.68 5.64 Technical (Hospital) Services PROCHLORPERAZINE MALEATE 5 MG TABLET RX-6583 CDM 2500000200 HCPCS 250 RC 00378-5105-01 NDC inpatient 1 UN 5.94 5.94 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES EPO [308136803] 4.7 percent of total billed charges 3.68 5.64 Technical (Hospital) Services PROCHLORPERAZINE MALEATE 5 MG TABLET RX-6583 CDM 2500000200 HCPCS 250 RC 00378-5105-01 NDC inpatient 1 UN 5.94 5.94 CIGNA 62308 [3081051] CIGNA 62308 [308105105] 4.7 percent of total billed charges 3.68 5.64 Technical (Hospital) Services PROCHLORPERAZINE MALEATE 5 MG TABLET RX-6583 CDM 2500000200 HCPCS 250 RC 00378-5105-01 NDC inpatient 1 UN 5.94 5.94 CIGNA 62308 [3081051] CIGNA STATE OF WYOMING [308105107] 4.7 percent of total billed charges 3.68 5.64 Technical (Hospital) Services PROCHLORPERAZINE MALEATE 5 MG TABLET RX-6583 CDM 2500000200 HCPCS 250 RC 00378-5105-01 NDC inpatient 1 UN 5.94 5.94 UNITED HEALTHCARE (COMMERCIAL) [3081199] UNITED HEALTHCARE 87726 [308119901] 3.68 percent of total billed charges 3.68 5.64 Technical (Hospital) Services PROCHLORPERAZINE MALEATE 5 MG TABLET RX-6583 CDM 2500000200 HCPCS 250 RC 00378-5105-01 NDC inpatient 1 UN 5.94 5.94 BLUE CROSS BLUE SHIELD WELLMARK SB889 [3081026] BCBS WYOMING [308102603] 5.64 percent of total billed charges 3.68 5.64 Technical (Hospital) Services PROCHLORPERAZINE MALEATE 5 MG TABLET RX-6583 CDM 2500000200 HCPCS 250 RC 00378-5105-01 NDC inpatient 1 UN 5.94 5.94 MULTIPLAN INC 34080 [3081285] MULTIPLAN INC [308128501] 5.64 percent of total billed charges 3.68 5.64 Technical (Hospital) Services PROCHLORPERAZINE MALEATE 5 MG TABLET RX-6583 CDM 2500000200 HCPCS 250 RC 00378-5105-01 NDC outpatient 1 UN 5.94 5.94 CIGNA 62308 [3081051] CIGNA 62308 [308105105] 4.75 percent of total billed charges 3.68 5.64 Technical (Hospital) Services PROCHLORPERAZINE MALEATE 5 MG TABLET RX-6583 CDM 2500000200 HCPCS 250 RC 00378-5105-01 NDC outpatient 1 UN 5.94 5.94 CIGNA 62308 [3081051] CIGNA STATE OF WYOMING [308105107] 4.75 percent of total billed charges 3.68 5.64 Technical (Hospital) Services PROCHLORPERAZINE MALEATE 5 MG TABLET RX-6583 CDM 2500000200 HCPCS 250 RC 00378-5105-01 NDC outpatient 1 UN 5.94 5.94 MULTIPLAN INC 34080 [3081285] MULTIPLAN INC [308128501] 5.64 percent of total billed charges 3.68 5.64 Technical (Hospital) Services PROCHLORPERAZINE MALEATE 5 MG TABLET RX-6583 CDM 2500000200 HCPCS 250 RC 00378-5105-01 NDC outpatient 1 UN 5.94 5.94 HEALTHPARTNERS SX009 HEALTHPARTNERS 4.75 percent of total billed charges 3.68 5.64 Technical (Hospital) Services PROCHLORPERAZINE MALEATE 5 MG TABLET RX-6583 CDM 2500000200 HCPCS 250 RC 00378-5105-01 NDC outpatient 1 UN 5.94 5.94 UNITED HEALTHCARE (COMMERCIAL) [3081199] UNITED HEALTHCARE 87726 [308119901] 3.68 percent of total billed charges 3.68 5.64 Technical (Hospital) Services PROCHLORPERAZINE MALEATE 5 MG TABLET RX-6583 CDM 2500000200 HCPCS 250 RC 00378-5105-01 NDC outpatient 1 UN 5.94 5.94 BLUE CROSS BLUE SHIELD WELLMARK SB889 [3081026] BCBS WYOMING [308102603] 5.64 percent of total billed charges 3.68 5.64 Technical (Hospital) Services PROCHLORPERAZINE MALEATE 5 MG TABLET RX-6583 CDM 2500000200 HCPCS 250 RC 00378-5105-01 NDC outpatient 1 UN 5.94 5.94 MEDICA (COMMERCIAL) 94265 [3081118] MEDICA CLAIMS [308111801] 5.35 percent of total billed charges 3.68 5.64 Technical (Hospital) Services PROCHLORPERAZINE MALEATE 5 MG TABLET RX-6583 CDM 2500000200 HCPCS 250 RC 00378-5105-01 NDC outpatient 1 UN 5.94 5.94 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES EPO [308136803] 4.75 percent of total billed charges 3.68 5.64 Technical (Hospital) Services PROCHLORPERAZINE MALEATE 5 MG TABLET RX-6583 CDM 2500000200 HCPCS 250 RC 00378-5105-01 NDC outpatient 1 UN 5.94 5.94 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES HDHP [308136802] 4.75 percent of total billed charges 3.68 5.64 Technical (Hospital) Services PROCHLORPERAZINE MALEATE 5 MG TABLET RX-6583 CDM 2500000200 HCPCS 250 RC 00378-5105-01 NDC outpatient 1 UN 5.94 5.94 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES PPO [308136801] 4.75 percent of total billed charges 3.68 5.64 Technical (Hospital) Services PROMETHAZINE 25 MG TABLET RX-6622 CDM 2500000200 HCPCS 250 RC 65162-0521-10 NDC outpatient 1 UN 5.72 5.72 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES HDHP [308136802] 4.58 percent of total billed charges 3.55 5.43 Technical (Hospital) Services PROMETHAZINE 25 MG TABLET RX-6622 CDM 2500000200 HCPCS 250 RC 65162-0521-10 NDC outpatient 1 UN 5.72 5.72 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES EPO [308136803] 4.58 percent of total billed charges 3.55 5.43 Technical (Hospital) Services PROMETHAZINE 25 MG TABLET RX-6622 CDM 2500000200 HCPCS 250 RC 65162-0521-10 NDC outpatient 1 UN 5.72 5.72 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES PPO [308136801] 4.58 percent of total billed charges 3.55 5.43 Technical (Hospital) Services PROMETHAZINE 25 MG TABLET RX-6622 CDM 2500000200 HCPCS 250 RC 65162-0521-10 NDC outpatient 1 UN 5.72 5.72 HEALTHPARTNERS SX009 HEALTHPARTNERS 4.58 percent of total billed charges 3.55 5.43 Technical (Hospital) Services PROMETHAZINE 25 MG TABLET RX-6622 CDM 2500000200 HCPCS 250 RC 65162-0521-10 NDC outpatient 1 UN 5.72 5.72 BLUE CROSS BLUE SHIELD WELLMARK SB889 [3081026] BCBS WYOMING [308102603] 5.43 percent of total billed charges 3.55 5.43 Technical (Hospital) Services PROMETHAZINE 25 MG TABLET RX-6622 CDM 2500000200 HCPCS 250 RC 65162-0521-10 NDC outpatient 1 UN 5.72 5.72 CIGNA 62308 [3081051] CIGNA 62308 [308105105] 4.58 percent of total billed charges 3.55 5.43 Technical (Hospital) Services PROMETHAZINE 25 MG TABLET RX-6622 CDM 2500000200 HCPCS 250 RC 65162-0521-10 NDC outpatient 1 UN 5.72 5.72 CIGNA 62308 [3081051] CIGNA STATE OF WYOMING [308105107] 4.58 percent of total billed charges 3.55 5.43 Technical (Hospital) Services PROMETHAZINE 25 MG TABLET RX-6622 CDM 2500000200 HCPCS 250 RC 65162-0521-10 NDC outpatient 1 UN 5.72 5.72 MULTIPLAN INC 34080 [3081285] MULTIPLAN INC [308128501] 5.43 percent of total billed charges 3.55 5.43 Technical (Hospital) Services PROMETHAZINE 25 MG TABLET RX-6622 CDM 2500000200 HCPCS 250 RC 65162-0521-10 NDC outpatient 1 UN 5.72 5.72 MEDICA (COMMERCIAL) 94265 [3081118] MEDICA CLAIMS [308111801] 5.15 percent of total billed charges 3.55 5.43 Technical (Hospital) Services PROMETHAZINE 25 MG TABLET RX-6622 CDM 2500000200 HCPCS 250 RC 65162-0521-10 NDC outpatient 1 UN 5.72 5.72 UNITED HEALTHCARE (COMMERCIAL) [3081199] UNITED HEALTHCARE 87726 [308119901] 3.55 percent of total billed charges 3.55 5.43 Technical (Hospital) Services PROMETHAZINE 25 MG TABLET RX-6622 CDM 2500000200 HCPCS 250 RC 65162-0521-10 NDC inpatient 1 UN 5.72 5.72 MULTIPLAN INC 34080 [3081285] MULTIPLAN INC [308128501] 5.43 percent of total billed charges 3.55 5.43 Technical (Hospital) Services PROMETHAZINE 25 MG TABLET RX-6622 CDM 2500000200 HCPCS 250 RC 65162-0521-10 NDC inpatient 1 UN 5.72 5.72 BLUE CROSS BLUE SHIELD WELLMARK SB889 [3081026] BCBS WYOMING [308102603] 5.43 percent of total billed charges 3.55 5.43 Technical (Hospital) Services PROMETHAZINE 25 MG TABLET RX-6622 CDM 2500000200 HCPCS 250 RC 65162-0521-10 NDC inpatient 1 UN 5.72 5.72 UNITED HEALTHCARE (COMMERCIAL) [3081199] UNITED HEALTHCARE 87726 [308119901] 3.55 percent of total billed charges 3.55 5.43 Technical (Hospital) Services PROMETHAZINE 25 MG TABLET RX-6622 CDM 2500000200 HCPCS 250 RC 65162-0521-10 NDC inpatient 1 UN 5.72 5.72 CIGNA 62308 [3081051] CIGNA 62308 [308105105] 4.53 percent of total billed charges 3.55 5.43 Technical (Hospital) Services PROMETHAZINE 25 MG TABLET RX-6622 CDM 2500000200 HCPCS 250 RC 65162-0521-10 NDC inpatient 1 UN 5.72 5.72 CIGNA 62308 [3081051] CIGNA STATE OF WYOMING [308105107] 4.53 percent of total billed charges 3.55 5.43 Technical (Hospital) Services PROMETHAZINE 25 MG TABLET RX-6622 CDM 2500000200 HCPCS 250 RC 65162-0521-10 NDC inpatient 1 UN 5.72 5.72 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES EPO [308136803] 4.53 percent of total billed charges 3.55 5.43 Technical (Hospital) Services PROMETHAZINE 25 MG TABLET RX-6622 CDM 2500000200 HCPCS 250 RC 65162-0521-10 NDC inpatient 1 UN 5.72 5.72 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES HDHP [308136802] 4.53 percent of total billed charges 3.55 5.43 Technical (Hospital) Services PROMETHAZINE 25 MG TABLET RX-6622 CDM 2500000200 HCPCS 250 RC 65162-0521-10 NDC inpatient 1 UN 5.72 5.72 HEALTHPARTNERS SX009 HEALTHPARTNERS 4.53 percent of total billed charges 3.55 5.43 Technical (Hospital) Services PROMETHAZINE 25 MG TABLET RX-6622 CDM 2500000200 HCPCS 250 RC 65162-0521-10 NDC inpatient 1 UN 5.72 5.72 MEDICA (COMMERCIAL) 94265 [3081118] MEDICA CLAIMS [308111801] 5.15 percent of total billed charges 3.55 5.43 Technical (Hospital) Services PROMETHAZINE 25 MG TABLET RX-6622 CDM 2500000200 HCPCS 250 RC 65162-0521-10 NDC inpatient 1 UN 5.72 5.72 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES PPO [308136801] 4.53 percent of total billed charges 3.55 5.43 Technical (Hospital) Services SODIUM BICARBONATE 8.4 % (1 MEQ/ML) INTRAVENOUS SYRINGE RX-7309 CDM 2500000200 HCPCS 250 RC 76329-3352-01 NDC outpatient 50 ML 106.4 106.4 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES PPO [308136801] 85.12 percent of total billed charges 65.97 101.08 Technical (Hospital) Services SODIUM BICARBONATE 8.4 % (1 MEQ/ML) INTRAVENOUS SYRINGE RX-7309 CDM 2500000200 HCPCS 250 RC 76329-3352-01 NDC outpatient 50 ML 106.4 106.4 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES HDHP [308136802] 85.12 percent of total billed charges 65.97 101.08 Technical (Hospital) Services SODIUM BICARBONATE 8.4 % (1 MEQ/ML) INTRAVENOUS SYRINGE RX-7309 CDM 2500000200 HCPCS 250 RC 76329-3352-01 NDC outpatient 50 ML 106.4 106.4 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES EPO [308136803] 85.12 percent of total billed charges 65.97 101.08 Technical (Hospital) Services SODIUM BICARBONATE 8.4 % (1 MEQ/ML) INTRAVENOUS SYRINGE RX-7309 CDM 2500000200 HCPCS 250 RC 76329-3352-01 NDC outpatient 50 ML 106.4 106.4 HEALTHPARTNERS SX009 HEALTHPARTNERS 85.12 percent of total billed charges 65.97 101.08 Technical (Hospital) Services SODIUM BICARBONATE 8.4 % (1 MEQ/ML) INTRAVENOUS SYRINGE RX-7309 CDM 2500000200 HCPCS 250 RC 76329-3352-01 NDC outpatient 50 ML 106.4 106.4 BLUE CROSS BLUE SHIELD WELLMARK SB889 [3081026] BCBS WYOMING [308102603] 101.08 percent of total billed charges 65.97 101.08 Technical (Hospital) Services SODIUM BICARBONATE 8.4 % (1 MEQ/ML) INTRAVENOUS SYRINGE RX-7309 CDM 2500000200 HCPCS 250 RC 76329-3352-01 NDC outpatient 50 ML 106.4 106.4 UNITED HEALTHCARE (COMMERCIAL) [3081199] UNITED HEALTHCARE 87726 [308119901] 65.97 percent of total billed charges 65.97 101.08 Technical (Hospital) Services SODIUM BICARBONATE 8.4 % (1 MEQ/ML) INTRAVENOUS SYRINGE RX-7309 CDM 2500000200 HCPCS 250 RC 76329-3352-01 NDC outpatient 50 ML 106.4 106.4 MEDICA (COMMERCIAL) 94265 [3081118] MEDICA CLAIMS [308111801] 95.76 percent of total billed charges 65.97 101.08 Technical (Hospital) Services SODIUM BICARBONATE 8.4 % (1 MEQ/ML) INTRAVENOUS SYRINGE RX-7309 CDM 2500000200 HCPCS 250 RC 76329-3352-01 NDC outpatient 50 ML 106.4 106.4 MULTIPLAN INC 34080 [3081285] MULTIPLAN INC [308128501] 101.08 percent of total billed charges 65.97 101.08 Technical (Hospital) Services SODIUM BICARBONATE 8.4 % (1 MEQ/ML) INTRAVENOUS SYRINGE RX-7309 CDM 2500000200 HCPCS 250 RC 76329-3352-01 NDC outpatient 50 ML 106.4 106.4 CIGNA 62308 [3081051] CIGNA 62308 [308105105] 85.12 percent of total billed charges 65.97 101.08 Technical (Hospital) Services SODIUM BICARBONATE 8.4 % (1 MEQ/ML) INTRAVENOUS SYRINGE RX-7309 CDM 2500000200 HCPCS 250 RC 76329-3352-01 NDC outpatient 50 ML 106.4 106.4 CIGNA 62308 [3081051] CIGNA STATE OF WYOMING [308105107] 85.12 percent of total billed charges 65.97 101.08 Technical (Hospital) Services SODIUM BICARBONATE 8.4 % (1 MEQ/ML) INTRAVENOUS SYRINGE RX-7309 CDM 2500000200 HCPCS 250 RC 76329-3352-01 NDC inpatient 50 ML 106.4 106.4 HEALTHPARTNERS SX009 HEALTHPARTNERS 84.25 percent of total billed charges 65.97 101.08 Technical (Hospital) Services SODIUM BICARBONATE 8.4 % (1 MEQ/ML) INTRAVENOUS SYRINGE RX-7309 CDM 2500000200 HCPCS 250 RC 76329-3352-01 NDC inpatient 50 ML 106.4 106.4 MULTIPLAN INC 34080 [3081285] MULTIPLAN INC [308128501] 101.08 percent of total billed charges 65.97 101.08 Technical (Hospital) Services SODIUM BICARBONATE 8.4 % (1 MEQ/ML) INTRAVENOUS SYRINGE RX-7309 CDM 2500000200 HCPCS 250 RC 76329-3352-01 NDC inpatient 50 ML 106.4 106.4 MEDICA (COMMERCIAL) 94265 [3081118] MEDICA CLAIMS [308111801] 95.76 percent of total billed charges 65.97 101.08 Technical (Hospital) Services SODIUM BICARBONATE 8.4 % (1 MEQ/ML) INTRAVENOUS SYRINGE RX-7309 CDM 2500000200 HCPCS 250 RC 76329-3352-01 NDC inpatient 50 ML 106.4 106.4 BLUE CROSS BLUE SHIELD WELLMARK SB889 [3081026] BCBS WYOMING [308102603] 101.08 percent of total billed charges 65.97 101.08 Technical (Hospital) Services SODIUM BICARBONATE 8.4 % (1 MEQ/ML) INTRAVENOUS SYRINGE RX-7309 CDM 2500000200 HCPCS 250 RC 76329-3352-01 NDC inpatient 50 ML 106.4 106.4 UNITED HEALTHCARE (COMMERCIAL) [3081199] UNITED HEALTHCARE 87726 [308119901] 65.97 percent of total billed charges 65.97 101.08 Technical (Hospital) Services SODIUM BICARBONATE 8.4 % (1 MEQ/ML) INTRAVENOUS SYRINGE RX-7309 CDM 2500000200 HCPCS 250 RC 76329-3352-01 NDC inpatient 50 ML 106.4 106.4 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES HDHP [308136802] 84.25 percent of total billed charges 65.97 101.08 Technical (Hospital) Services SODIUM BICARBONATE 8.4 % (1 MEQ/ML) INTRAVENOUS SYRINGE RX-7309 CDM 2500000200 HCPCS 250 RC 76329-3352-01 NDC inpatient 50 ML 106.4 106.4 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES EPO [308136803] 84.25 percent of total billed charges 65.97 101.08 Technical (Hospital) Services SODIUM BICARBONATE 8.4 % (1 MEQ/ML) INTRAVENOUS SYRINGE RX-7309 CDM 2500000200 HCPCS 250 RC 76329-3352-01 NDC inpatient 50 ML 106.4 106.4 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES PPO [308136801] 84.25 percent of total billed charges 65.97 101.08 Technical (Hospital) Services SODIUM BICARBONATE 8.4 % (1 MEQ/ML) INTRAVENOUS SYRINGE RX-7309 CDM 2500000200 HCPCS 250 RC 76329-3352-01 NDC inpatient 50 ML 106.4 106.4 CIGNA 62308 [3081051] CIGNA 62308 [308105105] 84.25 percent of total billed charges 65.97 101.08 Technical (Hospital) Services SODIUM BICARBONATE 8.4 % (1 MEQ/ML) INTRAVENOUS SYRINGE RX-7309 CDM 2500000200 HCPCS 250 RC 76329-3352-01 NDC inpatient 50 ML 106.4 106.4 CIGNA 62308 [3081051] CIGNA STATE OF WYOMING [308105107] 84.25 percent of total billed charges 65.97 101.08 Technical (Hospital) Services SODIUM CHLORIDE 0.9 % (FLUSH) INJECTION SYRINGE RX-7319 CDM 2500000200 HCPCS 250 RC 63807-0100-01 NDC outpatient 2 ML 5.7 5.7 HEALTHPARTNERS SX009 HEALTHPARTNERS 4.56 percent of total billed charges 3.53 5.42 Technical (Hospital) Services SODIUM CHLORIDE 0.9 % (FLUSH) INJECTION SYRINGE RX-7319 CDM 2500000200 HCPCS 250 RC 63807-0100-01 NDC outpatient 2 ML 5.7 5.7 UNITED HEALTHCARE (COMMERCIAL) [3081199] UNITED HEALTHCARE 87726 [308119901] 3.53 percent of total billed charges 3.53 5.42 Technical (Hospital) Services SODIUM CHLORIDE 0.9 % (FLUSH) INJECTION SYRINGE RX-7319 CDM 2500000200 HCPCS 250 RC 63807-0100-01 NDC outpatient 2 ML 5.7 5.7 MULTIPLAN INC 34080 [3081285] MULTIPLAN INC [308128501] 5.42 percent of total billed charges 3.53 5.42 Technical (Hospital) Services SODIUM CHLORIDE 0.9 % (FLUSH) INJECTION SYRINGE RX-7319 CDM 2500000200 HCPCS 250 RC 63807-0100-01 NDC outpatient 2 ML 5.7 5.7 MEDICA (COMMERCIAL) 94265 [3081118] MEDICA CLAIMS [308111801] 5.13 percent of total billed charges 3.53 5.42 Technical (Hospital) Services SODIUM CHLORIDE 0.9 % (FLUSH) INJECTION SYRINGE RX-7319 CDM 2500000200 HCPCS 250 RC 63807-0100-01 NDC outpatient 2 ML 5.7 5.7 CIGNA 62308 [3081051] CIGNA 62308 [308105105] 4.56 percent of total billed charges 3.53 5.42 Technical (Hospital) Services SODIUM CHLORIDE 0.9 % (FLUSH) INJECTION SYRINGE RX-7319 CDM 2500000200 HCPCS 250 RC 63807-0100-01 NDC outpatient 2 ML 5.7 5.7 CIGNA 62308 [3081051] CIGNA STATE OF WYOMING [308105107] 4.56 percent of total billed charges 3.53 5.42 Technical (Hospital) Services SODIUM CHLORIDE 0.9 % (FLUSH) INJECTION SYRINGE RX-7319 CDM 2500000200 HCPCS 250 RC 63807-0100-01 NDC outpatient 2 ML 5.7 5.7 BLUE CROSS BLUE SHIELD WELLMARK SB889 [3081026] BCBS WYOMING [308102603] 5.42 percent of total billed charges 3.53 5.42 Technical (Hospital) Services SODIUM CHLORIDE 0.9 % (FLUSH) INJECTION SYRINGE RX-7319 CDM 2500000200 HCPCS 250 RC 63807-0100-01 NDC outpatient 2 ML 5.7 5.7 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES EPO [308136803] 4.56 percent of total billed charges 3.53 5.42 Technical (Hospital) Services SODIUM CHLORIDE 0.9 % (FLUSH) INJECTION SYRINGE RX-7319 CDM 2500000200 HCPCS 250 RC 63807-0100-01 NDC outpatient 2 ML 5.7 5.7 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES HDHP [308136802] 4.56 percent of total billed charges 3.53 5.42 Technical (Hospital) Services SODIUM CHLORIDE 0.9 % (FLUSH) INJECTION SYRINGE RX-7319 CDM 2500000200 HCPCS 250 RC 63807-0100-01 NDC outpatient 2 ML 5.7 5.7 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES PPO [308136801] 4.56 percent of total billed charges 3.53 5.42 Technical (Hospital) Services SODIUM CHLORIDE 0.9 % (FLUSH) INJECTION SYRINGE RX-7319 CDM 2500000200 HCPCS 250 RC 63807-0100-01 NDC inpatient 2 ML 5.7 5.7 BLUE CROSS BLUE SHIELD WELLMARK SB889 [3081026] BCBS WYOMING [308102603] 5.42 percent of total billed charges 3.53 5.42 Technical (Hospital) Services SODIUM CHLORIDE 0.9 % (FLUSH) INJECTION SYRINGE RX-7319 CDM 2500000200 HCPCS 250 RC 63807-0100-01 NDC inpatient 2 ML 5.7 5.7 CIGNA 62308 [3081051] CIGNA 62308 [308105105] 4.51 percent of total billed charges 3.53 5.42 Technical (Hospital) Services SODIUM CHLORIDE 0.9 % (FLUSH) INJECTION SYRINGE RX-7319 CDM 2500000200 HCPCS 250 RC 63807-0100-01 NDC inpatient 2 ML 5.7 5.7 CIGNA 62308 [3081051] CIGNA STATE OF WYOMING [308105107] 4.51 percent of total billed charges 3.53 5.42 Technical (Hospital) Services SODIUM CHLORIDE 0.9 % (FLUSH) INJECTION SYRINGE RX-7319 CDM 2500000200 HCPCS 250 RC 63807-0100-01 NDC inpatient 2 ML 5.7 5.7 UNITED HEALTHCARE (COMMERCIAL) [3081199] UNITED HEALTHCARE 87726 [308119901] 3.53 percent of total billed charges 3.53 5.42 Technical (Hospital) Services SODIUM CHLORIDE 0.9 % (FLUSH) INJECTION SYRINGE RX-7319 CDM 2500000200 HCPCS 250 RC 63807-0100-01 NDC inpatient 2 ML 5.7 5.7 MULTIPLAN INC 34080 [3081285] MULTIPLAN INC [308128501] 5.42 percent of total billed charges 3.53 5.42 Technical (Hospital) Services SODIUM CHLORIDE 0.9 % (FLUSH) INJECTION SYRINGE RX-7319 CDM 2500000200 HCPCS 250 RC 63807-0100-01 NDC inpatient 2 ML 5.7 5.7 MEDICA (COMMERCIAL) 94265 [3081118] MEDICA CLAIMS [308111801] 5.13 percent of total billed charges 3.53 5.42 Technical (Hospital) Services SODIUM CHLORIDE 0.9 % (FLUSH) INJECTION SYRINGE RX-7319 CDM 2500000200 HCPCS 250 RC 63807-0100-01 NDC inpatient 2 ML 5.7 5.7 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES EPO [308136803] 4.51 percent of total billed charges 3.53 5.42 Technical (Hospital) Services SODIUM CHLORIDE 0.9 % (FLUSH) INJECTION SYRINGE RX-7319 CDM 2500000200 HCPCS 250 RC 63807-0100-01 NDC inpatient 2 ML 5.7 5.7 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES PPO [308136801] 4.51 percent of total billed charges 3.53 5.42 Technical (Hospital) Services SODIUM CHLORIDE 0.9 % (FLUSH) INJECTION SYRINGE RX-7319 CDM 2500000200 HCPCS 250 RC 63807-0100-01 NDC inpatient 2 ML 5.7 5.7 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES HDHP [308136802] 4.51 percent of total billed charges 3.53 5.42 Technical (Hospital) Services SODIUM CHLORIDE 0.9 % (FLUSH) INJECTION SYRINGE RX-7319 CDM 2500000200 HCPCS 250 RC 63807-0100-01 NDC inpatient 2 ML 5.7 5.7 HEALTHPARTNERS SX009 HEALTHPARTNERS 4.51 percent of total billed charges 3.53 5.42 Technical (Hospital) Services "WATER FOR IRRIGATION, STERILE SOLUTION" RX-7485 CDM 2500000200 HCPCS 250 RC 00338-0004-02 NDC inpatient 500 ML 37.9 37.9 CIGNA 62308 [3081051] CIGNA 62308 [308105105] 30.01 percent of total billed charges 23.5 36.01 Technical (Hospital) Services "WATER FOR IRRIGATION, STERILE SOLUTION" RX-7485 CDM 2500000200 HCPCS 250 RC 00338-0004-02 NDC inpatient 500 ML 37.9 37.9 CIGNA 62308 [3081051] CIGNA STATE OF WYOMING [308105107] 30.01 percent of total billed charges 23.5 36.01 Technical (Hospital) Services "WATER FOR IRRIGATION, STERILE SOLUTION" RX-7485 CDM 2500000200 HCPCS 250 RC 00338-0004-02 NDC inpatient 500 ML 37.9 37.9 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES EPO [308136803] 30.01 percent of total billed charges 23.5 36.01 Technical (Hospital) Services "WATER FOR IRRIGATION, STERILE SOLUTION" RX-7485 CDM 2500000200 HCPCS 250 RC 00338-0004-02 NDC inpatient 500 ML 37.9 37.9 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES HDHP [308136802] 30.01 percent of total billed charges 23.5 36.01 Technical (Hospital) Services "WATER FOR IRRIGATION, STERILE SOLUTION" RX-7485 CDM 2500000200 HCPCS 250 RC 00338-0004-02 NDC inpatient 500 ML 37.9 37.9 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES PPO [308136801] 30.01 percent of total billed charges 23.5 36.01 Technical (Hospital) Services "WATER FOR IRRIGATION, STERILE SOLUTION" RX-7485 CDM 2500000200 HCPCS 250 RC 00338-0004-02 NDC inpatient 500 ML 37.9 37.9 HEALTHPARTNERS SX009 HEALTHPARTNERS 30.01 percent of total billed charges 23.5 36.01 Technical (Hospital) Services "WATER FOR IRRIGATION, STERILE SOLUTION" RX-7485 CDM 2500000200 HCPCS 250 RC 00338-0004-02 NDC inpatient 500 ML 37.9 37.9 MEDICA (COMMERCIAL) 94265 [3081118] MEDICA CLAIMS [308111801] 34.11 percent of total billed charges 23.5 36.01 Technical (Hospital) Services "WATER FOR IRRIGATION, STERILE SOLUTION" RX-7485 CDM 2500000200 HCPCS 250 RC 00338-0004-02 NDC inpatient 500 ML 37.9 37.9 MULTIPLAN INC 34080 [3081285] MULTIPLAN INC [308128501] 36.01 percent of total billed charges 23.5 36.01 Technical (Hospital) Services "WATER FOR IRRIGATION, STERILE SOLUTION" RX-7485 CDM 2500000200 HCPCS 250 RC 00338-0004-02 NDC inpatient 500 ML 37.9 37.9 UNITED HEALTHCARE (COMMERCIAL) [3081199] UNITED HEALTHCARE 87726 [308119901] 23.5 percent of total billed charges 23.5 36.01 Technical (Hospital) Services "WATER FOR IRRIGATION, STERILE SOLUTION" RX-7485 CDM 2500000200 HCPCS 250 RC 00338-0004-02 NDC inpatient 500 ML 37.9 37.9 BLUE CROSS BLUE SHIELD WELLMARK SB889 [3081026] BCBS WYOMING [308102603] 36.01 percent of total billed charges 23.5 36.01 Technical (Hospital) Services "WATER FOR IRRIGATION, STERILE SOLUTION" RX-7485 CDM 2500000200 HCPCS 250 RC 00338-0004-02 NDC outpatient 500 ML 37.9 37.9 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES HDHP [308136802] 30.32 percent of total billed charges 23.5 36.01 Technical (Hospital) Services "WATER FOR IRRIGATION, STERILE SOLUTION" RX-7485 CDM 2500000200 HCPCS 250 RC 00338-0004-02 NDC outpatient 500 ML 37.9 37.9 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES EPO [308136803] 30.32 percent of total billed charges 23.5 36.01 Technical (Hospital) Services "WATER FOR IRRIGATION, STERILE SOLUTION" RX-7485 CDM 2500000200 HCPCS 250 RC 00338-0004-02 NDC outpatient 500 ML 37.9 37.9 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES PPO [308136801] 30.32 percent of total billed charges 23.5 36.01 Technical (Hospital) Services "WATER FOR IRRIGATION, STERILE SOLUTION" RX-7485 CDM 2500000200 HCPCS 250 RC 00338-0004-02 NDC outpatient 500 ML 37.9 37.9 UNITED HEALTHCARE (COMMERCIAL) [3081199] UNITED HEALTHCARE 87726 [308119901] 23.5 percent of total billed charges 23.5 36.01 Technical (Hospital) Services "WATER FOR IRRIGATION, STERILE SOLUTION" RX-7485 CDM 2500000200 HCPCS 250 RC 00338-0004-02 NDC outpatient 500 ML 37.9 37.9 BLUE CROSS BLUE SHIELD WELLMARK SB889 [3081026] BCBS WYOMING [308102603] 36.01 percent of total billed charges 23.5 36.01 Technical (Hospital) Services "WATER FOR IRRIGATION, STERILE SOLUTION" RX-7485 CDM 2500000200 HCPCS 250 RC 00338-0004-02 NDC outpatient 500 ML 37.9 37.9 HEALTHPARTNERS SX009 HEALTHPARTNERS 30.32 percent of total billed charges 23.5 36.01 Technical (Hospital) Services "WATER FOR IRRIGATION, STERILE SOLUTION" RX-7485 CDM 2500000200 HCPCS 250 RC 00338-0004-02 NDC outpatient 500 ML 37.9 37.9 CIGNA 62308 [3081051] CIGNA 62308 [308105105] 30.32 percent of total billed charges 23.5 36.01 Technical (Hospital) Services "WATER FOR IRRIGATION, STERILE SOLUTION" RX-7485 CDM 2500000200 HCPCS 250 RC 00338-0004-02 NDC outpatient 500 ML 37.9 37.9 CIGNA 62308 [3081051] CIGNA STATE OF WYOMING [308105107] 30.32 percent of total billed charges 23.5 36.01 Technical (Hospital) Services "WATER FOR IRRIGATION, STERILE SOLUTION" RX-7485 CDM 2500000200 HCPCS 250 RC 00338-0004-02 NDC outpatient 500 ML 37.9 37.9 MULTIPLAN INC 34080 [3081285] MULTIPLAN INC [308128501] 36.01 percent of total billed charges 23.5 36.01 Technical (Hospital) Services "WATER FOR IRRIGATION, STERILE SOLUTION" RX-7485 CDM 2500000200 HCPCS 250 RC 00338-0004-02 NDC outpatient 500 ML 37.9 37.9 MEDICA (COMMERCIAL) 94265 [3081118] MEDICA CLAIMS [308111801] 34.11 percent of total billed charges 23.5 36.01 Technical (Hospital) Services VERAPAMIL 2.5 MG/ML INTRAVENOUS SOLUTION RX-8527 CDM 2500000200 HCPCS 250 RC 00409-4011-01 NDC outpatient 2 ML 68.67 68.67 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES PPO [308136801] 54.94 percent of total billed charges 42.58 65.24 Technical (Hospital) Services VERAPAMIL 2.5 MG/ML INTRAVENOUS SOLUTION RX-8527 CDM 2500000200 HCPCS 250 RC 00409-4011-01 NDC outpatient 2 ML 68.67 68.67 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES HDHP [308136802] 54.94 percent of total billed charges 42.58 65.24 Technical (Hospital) Services VERAPAMIL 2.5 MG/ML INTRAVENOUS SOLUTION RX-8527 CDM 2500000200 HCPCS 250 RC 00409-4011-01 NDC outpatient 2 ML 68.67 68.67 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES EPO [308136803] 54.94 percent of total billed charges 42.58 65.24 Technical (Hospital) Services VERAPAMIL 2.5 MG/ML INTRAVENOUS SOLUTION RX-8527 CDM 2500000200 HCPCS 250 RC 00409-4011-01 NDC outpatient 2 ML 68.67 68.67 BLUE CROSS BLUE SHIELD WELLMARK SB889 [3081026] BCBS WYOMING [308102603] 65.24 percent of total billed charges 42.58 65.24 Technical (Hospital) Services VERAPAMIL 2.5 MG/ML INTRAVENOUS SOLUTION RX-8527 CDM 2500000200 HCPCS 250 RC 00409-4011-01 NDC outpatient 2 ML 68.67 68.67 HEALTHPARTNERS SX009 HEALTHPARTNERS 54.94 percent of total billed charges 42.58 65.24 Technical (Hospital) Services VERAPAMIL 2.5 MG/ML INTRAVENOUS SOLUTION RX-8527 CDM 2500000200 HCPCS 250 RC 00409-4011-01 NDC outpatient 2 ML 68.67 68.67 UNITED HEALTHCARE (COMMERCIAL) [3081199] UNITED HEALTHCARE 87726 [308119901] 42.58 percent of total billed charges 42.58 65.24 Technical (Hospital) Services VERAPAMIL 2.5 MG/ML INTRAVENOUS SOLUTION RX-8527 CDM 2500000200 HCPCS 250 RC 00409-4011-01 NDC outpatient 2 ML 68.67 68.67 CIGNA 62308 [3081051] CIGNA 62308 [308105105] 54.94 percent of total billed charges 42.58 65.24 Technical (Hospital) Services VERAPAMIL 2.5 MG/ML INTRAVENOUS SOLUTION RX-8527 CDM 2500000200 HCPCS 250 RC 00409-4011-01 NDC outpatient 2 ML 68.67 68.67 CIGNA 62308 [3081051] CIGNA STATE OF WYOMING [308105107] 54.94 percent of total billed charges 42.58 65.24 Technical (Hospital) Services VERAPAMIL 2.5 MG/ML INTRAVENOUS SOLUTION RX-8527 CDM 2500000200 HCPCS 250 RC 00409-4011-01 NDC outpatient 2 ML 68.67 68.67 MULTIPLAN INC 34080 [3081285] MULTIPLAN INC [308128501] 65.24 percent of total billed charges 42.58 65.24 Technical (Hospital) Services VERAPAMIL 2.5 MG/ML INTRAVENOUS SOLUTION RX-8527 CDM 2500000200 HCPCS 250 RC 00409-4011-01 NDC outpatient 2 ML 68.67 68.67 MEDICA (COMMERCIAL) 94265 [3081118] MEDICA CLAIMS [308111801] 61.8 percent of total billed charges 42.58 65.24 Technical (Hospital) Services VERAPAMIL 2.5 MG/ML INTRAVENOUS SOLUTION RX-8527 CDM 2500000200 HCPCS 250 RC 00409-4011-01 NDC inpatient 2 ML 68.67 68.67 MULTIPLAN INC 34080 [3081285] MULTIPLAN INC [308128501] 65.24 percent of total billed charges 42.58 65.24 Technical (Hospital) Services VERAPAMIL 2.5 MG/ML INTRAVENOUS SOLUTION RX-8527 CDM 2500000200 HCPCS 250 RC 00409-4011-01 NDC inpatient 2 ML 68.67 68.67 MEDICA (COMMERCIAL) 94265 [3081118] MEDICA CLAIMS [308111801] 61.8 percent of total billed charges 42.58 65.24 Technical (Hospital) Services VERAPAMIL 2.5 MG/ML INTRAVENOUS SOLUTION RX-8527 CDM 2500000200 HCPCS 250 RC 00409-4011-01 NDC inpatient 2 ML 68.67 68.67 CIGNA 62308 [3081051] CIGNA 62308 [308105105] 54.37 percent of total billed charges 42.58 65.24 Technical (Hospital) Services VERAPAMIL 2.5 MG/ML INTRAVENOUS SOLUTION RX-8527 CDM 2500000200 HCPCS 250 RC 00409-4011-01 NDC inpatient 2 ML 68.67 68.67 CIGNA 62308 [3081051] CIGNA STATE OF WYOMING [308105107] 54.37 percent of total billed charges 42.58 65.24 Technical (Hospital) Services VERAPAMIL 2.5 MG/ML INTRAVENOUS SOLUTION RX-8527 CDM 2500000200 HCPCS 250 RC 00409-4011-01 NDC inpatient 2 ML 68.67 68.67 BLUE CROSS BLUE SHIELD WELLMARK SB889 [3081026] BCBS WYOMING [308102603] 65.24 percent of total billed charges 42.58 65.24 Technical (Hospital) Services VERAPAMIL 2.5 MG/ML INTRAVENOUS SOLUTION RX-8527 CDM 2500000200 HCPCS 250 RC 00409-4011-01 NDC inpatient 2 ML 68.67 68.67 UNITED HEALTHCARE (COMMERCIAL) [3081199] UNITED HEALTHCARE 87726 [308119901] 42.58 percent of total billed charges 42.58 65.24 Technical (Hospital) Services VERAPAMIL 2.5 MG/ML INTRAVENOUS SOLUTION RX-8527 CDM 2500000200 HCPCS 250 RC 00409-4011-01 NDC inpatient 2 ML 68.67 68.67 HEALTHPARTNERS SX009 HEALTHPARTNERS 54.37 percent of total billed charges 42.58 65.24 Technical (Hospital) Services VERAPAMIL 2.5 MG/ML INTRAVENOUS SOLUTION RX-8527 CDM 2500000200 HCPCS 250 RC 00409-4011-01 NDC inpatient 2 ML 68.67 68.67 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES EPO [308136803] 54.37 percent of total billed charges 42.58 65.24 Technical (Hospital) Services VERAPAMIL 2.5 MG/ML INTRAVENOUS SOLUTION RX-8527 CDM 2500000200 HCPCS 250 RC 00409-4011-01 NDC inpatient 2 ML 68.67 68.67 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES HDHP [308136802] 54.37 percent of total billed charges 42.58 65.24 Technical (Hospital) Services VERAPAMIL 2.5 MG/ML INTRAVENOUS SOLUTION RX-8527 CDM 2500000200 HCPCS 250 RC 00409-4011-01 NDC inpatient 2 ML 68.67 68.67 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES PPO [308136801] 54.37 percent of total billed charges 42.58 65.24 Technical (Hospital) Services CALCITRIOL 0.25 MCG CAPSULE RX-9350 CDM 2500000200 HCPCS 250 RC 23155-0662-03 NDC outpatient 1 UN 5.89 5.89 MEDICA (COMMERCIAL) 94265 [3081118] MEDICA CLAIMS [308111801] 5.3 percent of total billed charges 3.65 5.6 Technical (Hospital) Services CALCITRIOL 0.25 MCG CAPSULE RX-9350 CDM 2500000200 HCPCS 250 RC 23155-0662-03 NDC outpatient 1 UN 5.89 5.89 CIGNA 62308 [3081051] CIGNA 62308 [308105105] 4.71 percent of total billed charges 3.65 5.6 Technical (Hospital) Services CALCITRIOL 0.25 MCG CAPSULE RX-9350 CDM 2500000200 HCPCS 250 RC 23155-0662-03 NDC outpatient 1 UN 5.89 5.89 CIGNA 62308 [3081051] CIGNA STATE OF WYOMING [308105107] 4.71 percent of total billed charges 3.65 5.6 Technical (Hospital) Services CALCITRIOL 0.25 MCG CAPSULE RX-9350 CDM 2500000200 HCPCS 250 RC 23155-0662-03 NDC outpatient 1 UN 5.89 5.89 MULTIPLAN INC 34080 [3081285] MULTIPLAN INC [308128501] 5.6 percent of total billed charges 3.65 5.6 Technical (Hospital) Services CALCITRIOL 0.25 MCG CAPSULE RX-9350 CDM 2500000200 HCPCS 250 RC 23155-0662-03 NDC outpatient 1 UN 5.89 5.89 UNITED HEALTHCARE (COMMERCIAL) [3081199] UNITED HEALTHCARE 87726 [308119901] 3.65 percent of total billed charges 3.65 5.6 Technical (Hospital) Services CALCITRIOL 0.25 MCG CAPSULE RX-9350 CDM 2500000200 HCPCS 250 RC 23155-0662-03 NDC outpatient 1 UN 5.89 5.89 HEALTHPARTNERS SX009 HEALTHPARTNERS 4.71 percent of total billed charges 3.65 5.6 Technical (Hospital) Services CALCITRIOL 0.25 MCG CAPSULE RX-9350 CDM 2500000200 HCPCS 250 RC 23155-0662-03 NDC outpatient 1 UN 5.89 5.89 BLUE CROSS BLUE SHIELD WELLMARK SB889 [3081026] BCBS WYOMING [308102603] 5.6 percent of total billed charges 3.65 5.6 Technical (Hospital) Services CALCITRIOL 0.25 MCG CAPSULE RX-9350 CDM 2500000200 HCPCS 250 RC 23155-0662-03 NDC outpatient 1 UN 5.89 5.89 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES PPO [308136801] 4.71 percent of total billed charges 3.65 5.6 Technical (Hospital) Services CALCITRIOL 0.25 MCG CAPSULE RX-9350 CDM 2500000200 HCPCS 250 RC 23155-0662-03 NDC outpatient 1 UN 5.89 5.89 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES HDHP [308136802] 4.71 percent of total billed charges 3.65 5.6 Technical (Hospital) Services CALCITRIOL 0.25 MCG CAPSULE RX-9350 CDM 2500000200 HCPCS 250 RC 23155-0662-03 NDC outpatient 1 UN 5.89 5.89 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES EPO [308136803] 4.71 percent of total billed charges 3.65 5.6 Technical (Hospital) Services CALCITRIOL 0.25 MCG CAPSULE RX-9350 CDM 2500000200 HCPCS 250 RC 23155-0662-03 NDC inpatient 1 UN 5.89 5.89 HEALTHPARTNERS SX009 HEALTHPARTNERS 4.66 percent of total billed charges 3.65 5.6 Technical (Hospital) Services CALCITRIOL 0.25 MCG CAPSULE RX-9350 CDM 2500000200 HCPCS 250 RC 23155-0662-03 NDC inpatient 1 UN 5.89 5.89 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES PPO [308136801] 4.66 percent of total billed charges 3.65 5.6 Technical (Hospital) Services CALCITRIOL 0.25 MCG CAPSULE RX-9350 CDM 2500000200 HCPCS 250 RC 23155-0662-03 NDC inpatient 1 UN 5.89 5.89 MEDICA (COMMERCIAL) 94265 [3081118] MEDICA CLAIMS [308111801] 5.3 percent of total billed charges 3.65 5.6 Technical (Hospital) Services CALCITRIOL 0.25 MCG CAPSULE RX-9350 CDM 2500000200 HCPCS 250 RC 23155-0662-03 NDC inpatient 1 UN 5.89 5.89 MULTIPLAN INC 34080 [3081285] MULTIPLAN INC [308128501] 5.6 percent of total billed charges 3.65 5.6 Technical (Hospital) Services CALCITRIOL 0.25 MCG CAPSULE RX-9350 CDM 2500000200 HCPCS 250 RC 23155-0662-03 NDC inpatient 1 UN 5.89 5.89 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES HDHP [308136802] 4.66 percent of total billed charges 3.65 5.6 Technical (Hospital) Services CALCITRIOL 0.25 MCG CAPSULE RX-9350 CDM 2500000200 HCPCS 250 RC 23155-0662-03 NDC inpatient 1 UN 5.89 5.89 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES EPO [308136803] 4.66 percent of total billed charges 3.65 5.6 Technical (Hospital) Services CALCITRIOL 0.25 MCG CAPSULE RX-9350 CDM 2500000200 HCPCS 250 RC 23155-0662-03 NDC inpatient 1 UN 5.89 5.89 CIGNA 62308 [3081051] CIGNA 62308 [308105105] 4.66 percent of total billed charges 3.65 5.6 Technical (Hospital) Services CALCITRIOL 0.25 MCG CAPSULE RX-9350 CDM 2500000200 HCPCS 250 RC 23155-0662-03 NDC inpatient 1 UN 5.89 5.89 CIGNA 62308 [3081051] CIGNA STATE OF WYOMING [308105107] 4.66 percent of total billed charges 3.65 5.6 Technical (Hospital) Services CALCITRIOL 0.25 MCG CAPSULE RX-9350 CDM 2500000200 HCPCS 250 RC 23155-0662-03 NDC inpatient 1 UN 5.89 5.89 UNITED HEALTHCARE (COMMERCIAL) [3081199] UNITED HEALTHCARE 87726 [308119901] 3.65 percent of total billed charges 3.65 5.6 Technical (Hospital) Services CALCITRIOL 0.25 MCG CAPSULE RX-9350 CDM 2500000200 HCPCS 250 RC 23155-0662-03 NDC inpatient 1 UN 5.89 5.89 BLUE CROSS BLUE SHIELD WELLMARK SB889 [3081026] BCBS WYOMING [308102603] 5.6 percent of total billed charges 3.65 5.6 Technical (Hospital) Services ROCURONIUM 10 MG/ML INTRAVENOUS SOLUTION RX-95811 CDM 2500000200 HCPCS 250 RC 00409-9558-10 NDC inpatient 10 ML 71.66 71.66 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES PPO [308136801] 56.74 percent of total billed charges 44.43 68.08 Technical (Hospital) Services ROCURONIUM 10 MG/ML INTRAVENOUS SOLUTION RX-95811 CDM 2500000200 HCPCS 250 RC 00409-9558-10 NDC inpatient 10 ML 71.66 71.66 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES EPO [308136803] 56.74 percent of total billed charges 44.43 68.08 Technical (Hospital) Services ROCURONIUM 10 MG/ML INTRAVENOUS SOLUTION RX-95811 CDM 2500000200 HCPCS 250 RC 00409-9558-10 NDC inpatient 10 ML 71.66 71.66 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES HDHP [308136802] 56.74 percent of total billed charges 44.43 68.08 Technical (Hospital) Services ROCURONIUM 10 MG/ML INTRAVENOUS SOLUTION RX-95811 CDM 2500000200 HCPCS 250 RC 00409-9558-10 NDC inpatient 10 ML 71.66 71.66 HEALTHPARTNERS SX009 HEALTHPARTNERS 56.74 percent of total billed charges 44.43 68.08 Technical (Hospital) Services ROCURONIUM 10 MG/ML INTRAVENOUS SOLUTION RX-95811 CDM 2500000200 HCPCS 250 RC 00409-9558-10 NDC inpatient 10 ML 71.66 71.66 CIGNA 62308 [3081051] CIGNA 62308 [308105105] 56.74 percent of total billed charges 44.43 68.08 Technical (Hospital) Services ROCURONIUM 10 MG/ML INTRAVENOUS SOLUTION RX-95811 CDM 2500000200 HCPCS 250 RC 00409-9558-10 NDC inpatient 10 ML 71.66 71.66 CIGNA 62308 [3081051] CIGNA STATE OF WYOMING [308105107] 56.74 percent of total billed charges 44.43 68.08 Technical (Hospital) Services ROCURONIUM 10 MG/ML INTRAVENOUS SOLUTION RX-95811 CDM 2500000200 HCPCS 250 RC 00409-9558-10 NDC inpatient 10 ML 71.66 71.66 BLUE CROSS BLUE SHIELD WELLMARK SB889 [3081026] BCBS WYOMING [308102603] 68.08 percent of total billed charges 44.43 68.08 Technical (Hospital) Services ROCURONIUM 10 MG/ML INTRAVENOUS SOLUTION RX-95811 CDM 2500000200 HCPCS 250 RC 00409-9558-10 NDC inpatient 10 ML 71.66 71.66 UNITED HEALTHCARE (COMMERCIAL) [3081199] UNITED HEALTHCARE 87726 [308119901] 44.43 percent of total billed charges 44.43 68.08 Technical (Hospital) Services ROCURONIUM 10 MG/ML INTRAVENOUS SOLUTION RX-95811 CDM 2500000200 HCPCS 250 RC 00409-9558-10 NDC inpatient 10 ML 71.66 71.66 MULTIPLAN INC 34080 [3081285] MULTIPLAN INC [308128501] 68.08 percent of total billed charges 44.43 68.08 Technical (Hospital) Services ROCURONIUM 10 MG/ML INTRAVENOUS SOLUTION RX-95811 CDM 2500000200 HCPCS 250 RC 00409-9558-10 NDC inpatient 10 ML 71.66 71.66 MEDICA (COMMERCIAL) 94265 [3081118] MEDICA CLAIMS [308111801] 64.49 percent of total billed charges 44.43 68.08 Technical (Hospital) Services ROCURONIUM 10 MG/ML INTRAVENOUS SOLUTION RX-95811 CDM 2500000200 HCPCS 250 RC 00409-9558-10 NDC outpatient 10 ML 71.66 71.66 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES EPO [308136803] 57.33 percent of total billed charges 44.43 68.08 Technical (Hospital) Services ROCURONIUM 10 MG/ML INTRAVENOUS SOLUTION RX-95811 CDM 2500000200 HCPCS 250 RC 00409-9558-10 NDC outpatient 10 ML 71.66 71.66 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES HDHP [308136802] 57.33 percent of total billed charges 44.43 68.08 Technical (Hospital) Services ROCURONIUM 10 MG/ML INTRAVENOUS SOLUTION RX-95811 CDM 2500000200 HCPCS 250 RC 00409-9558-10 NDC outpatient 10 ML 71.66 71.66 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES PPO [308136801] 57.33 percent of total billed charges 44.43 68.08 Technical (Hospital) Services ROCURONIUM 10 MG/ML INTRAVENOUS SOLUTION RX-95811 CDM 2500000200 HCPCS 250 RC 00409-9558-10 NDC outpatient 10 ML 71.66 71.66 BLUE CROSS BLUE SHIELD WELLMARK SB889 [3081026] BCBS WYOMING [308102603] 68.08 percent of total billed charges 44.43 68.08 Technical (Hospital) Services ROCURONIUM 10 MG/ML INTRAVENOUS SOLUTION RX-95811 CDM 2500000200 HCPCS 250 RC 00409-9558-10 NDC outpatient 10 ML 71.66 71.66 UNITED HEALTHCARE (COMMERCIAL) [3081199] UNITED HEALTHCARE 87726 [308119901] 44.43 percent of total billed charges 44.43 68.08 Technical (Hospital) Services ROCURONIUM 10 MG/ML INTRAVENOUS SOLUTION RX-95811 CDM 2500000200 HCPCS 250 RC 00409-9558-10 NDC outpatient 10 ML 71.66 71.66 HEALTHPARTNERS SX009 HEALTHPARTNERS 57.33 percent of total billed charges 44.43 68.08 Technical (Hospital) Services ROCURONIUM 10 MG/ML INTRAVENOUS SOLUTION RX-95811 CDM 2500000200 HCPCS 250 RC 00409-9558-10 NDC outpatient 10 ML 71.66 71.66 MULTIPLAN INC 34080 [3081285] MULTIPLAN INC [308128501] 68.08 percent of total billed charges 44.43 68.08 Technical (Hospital) Services ROCURONIUM 10 MG/ML INTRAVENOUS SOLUTION RX-95811 CDM 2500000200 HCPCS 250 RC 00409-9558-10 NDC outpatient 10 ML 71.66 71.66 MEDICA (COMMERCIAL) 94265 [3081118] MEDICA CLAIMS [308111801] 64.49 percent of total billed charges 44.43 68.08 Technical (Hospital) Services ROCURONIUM 10 MG/ML INTRAVENOUS SOLUTION RX-95811 CDM 2500000200 HCPCS 250 RC 00409-9558-10 NDC outpatient 10 ML 71.66 71.66 CIGNA 62308 [3081051] CIGNA 62308 [308105105] 57.33 percent of total billed charges 44.43 68.08 Technical (Hospital) Services ROCURONIUM 10 MG/ML INTRAVENOUS SOLUTION RX-95811 CDM 2500000200 HCPCS 250 RC 00409-9558-10 NDC outpatient 10 ML 71.66 71.66 CIGNA 62308 [3081051] CIGNA STATE OF WYOMING [308105107] 57.33 percent of total billed charges 44.43 68.08 Technical (Hospital) Services DRONABINOL 5 MG CAPSULE RX-9905 CDM 2500000200 HCPCS 250 RC 42858-0868-06 NDC outpatient 1 UN 15.1 15.1 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES EPO [308136803] 12.08 percent of total billed charges 9.36 14.35 Technical (Hospital) Services DRONABINOL 5 MG CAPSULE RX-9905 CDM 2500000200 HCPCS 250 RC 42858-0868-06 NDC outpatient 1 UN 15.1 15.1 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES HDHP [308136802] 12.08 percent of total billed charges 9.36 14.35 Technical (Hospital) Services DRONABINOL 5 MG CAPSULE RX-9905 CDM 2500000200 HCPCS 250 RC 42858-0868-06 NDC outpatient 1 UN 15.1 15.1 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES PPO [308136801] 12.08 percent of total billed charges 9.36 14.35 Technical (Hospital) Services DRONABINOL 5 MG CAPSULE RX-9905 CDM 2500000200 HCPCS 250 RC 42858-0868-06 NDC outpatient 1 UN 15.1 15.1 CIGNA 62308 [3081051] CIGNA 62308 [308105105] 12.08 percent of total billed charges 9.36 14.35 Technical (Hospital) Services DRONABINOL 5 MG CAPSULE RX-9905 CDM 2500000200 HCPCS 250 RC 42858-0868-06 NDC outpatient 1 UN 15.1 15.1 CIGNA 62308 [3081051] CIGNA STATE OF WYOMING [308105107] 12.08 percent of total billed charges 9.36 14.35 Technical (Hospital) Services DRONABINOL 5 MG CAPSULE RX-9905 CDM 2500000200 HCPCS 250 RC 42858-0868-06 NDC outpatient 1 UN 15.1 15.1 MULTIPLAN INC 34080 [3081285] MULTIPLAN INC [308128501] 14.35 percent of total billed charges 9.36 14.35 Technical (Hospital) Services DRONABINOL 5 MG CAPSULE RX-9905 CDM 2500000200 HCPCS 250 RC 42858-0868-06 NDC outpatient 1 UN 15.1 15.1 MEDICA (COMMERCIAL) 94265 [3081118] MEDICA CLAIMS [308111801] 13.59 percent of total billed charges 9.36 14.35 Technical (Hospital) Services DRONABINOL 5 MG CAPSULE RX-9905 CDM 2500000200 HCPCS 250 RC 42858-0868-06 NDC outpatient 1 UN 15.1 15.1 UNITED HEALTHCARE (COMMERCIAL) [3081199] UNITED HEALTHCARE 87726 [308119901] 9.36 percent of total billed charges 9.36 14.35 Technical (Hospital) Services DRONABINOL 5 MG CAPSULE RX-9905 CDM 2500000200 HCPCS 250 RC 42858-0868-06 NDC outpatient 1 UN 15.1 15.1 HEALTHPARTNERS SX009 HEALTHPARTNERS 12.08 percent of total billed charges 9.36 14.35 Technical (Hospital) Services DRONABINOL 5 MG CAPSULE RX-9905 CDM 2500000200 HCPCS 250 RC 42858-0868-06 NDC outpatient 1 UN 15.1 15.1 BLUE CROSS BLUE SHIELD WELLMARK SB889 [3081026] BCBS WYOMING [308102603] 14.35 percent of total billed charges 9.36 14.35 Technical (Hospital) Services DRONABINOL 5 MG CAPSULE RX-9905 CDM 2500000200 HCPCS 250 RC 42858-0868-06 NDC inpatient 1 UN 15.1 15.1 HEALTHPARTNERS SX009 HEALTHPARTNERS 11.96 percent of total billed charges 9.36 14.35 Technical (Hospital) Services DRONABINOL 5 MG CAPSULE RX-9905 CDM 2500000200 HCPCS 250 RC 42858-0868-06 NDC inpatient 1 UN 15.1 15.1 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES PPO [308136801] 11.96 percent of total billed charges 9.36 14.35 Technical (Hospital) Services DRONABINOL 5 MG CAPSULE RX-9905 CDM 2500000200 HCPCS 250 RC 42858-0868-06 NDC inpatient 1 UN 15.1 15.1 MEDICA (COMMERCIAL) 94265 [3081118] MEDICA CLAIMS [308111801] 13.59 percent of total billed charges 9.36 14.35 Technical (Hospital) Services DRONABINOL 5 MG CAPSULE RX-9905 CDM 2500000200 HCPCS 250 RC 42858-0868-06 NDC inpatient 1 UN 15.1 15.1 CIGNA 62308 [3081051] CIGNA 62308 [308105105] 11.96 percent of total billed charges 9.36 14.35 Technical (Hospital) Services DRONABINOL 5 MG CAPSULE RX-9905 CDM 2500000200 HCPCS 250 RC 42858-0868-06 NDC inpatient 1 UN 15.1 15.1 CIGNA 62308 [3081051] CIGNA STATE OF WYOMING [308105107] 11.96 percent of total billed charges 9.36 14.35 Technical (Hospital) Services DRONABINOL 5 MG CAPSULE RX-9905 CDM 2500000200 HCPCS 250 RC 42858-0868-06 NDC inpatient 1 UN 15.1 15.1 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES HDHP [308136802] 11.96 percent of total billed charges 9.36 14.35 Technical (Hospital) Services DRONABINOL 5 MG CAPSULE RX-9905 CDM 2500000200 HCPCS 250 RC 42858-0868-06 NDC inpatient 1 UN 15.1 15.1 UNITED HEALTHCARE (COMMERCIAL) [3081199] UNITED HEALTHCARE 87726 [308119901] 9.36 percent of total billed charges 9.36 14.35 Technical (Hospital) Services DRONABINOL 5 MG CAPSULE RX-9905 CDM 2500000200 HCPCS 250 RC 42858-0868-06 NDC inpatient 1 UN 15.1 15.1 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES EPO [308136803] 11.96 percent of total billed charges 9.36 14.35 Technical (Hospital) Services DRONABINOL 5 MG CAPSULE RX-9905 CDM 2500000200 HCPCS 250 RC 42858-0868-06 NDC inpatient 1 UN 15.1 15.1 BLUE CROSS BLUE SHIELD WELLMARK SB889 [3081026] BCBS WYOMING [308102603] 14.35 percent of total billed charges 9.36 14.35 Technical (Hospital) Services DRONABINOL 5 MG CAPSULE RX-9905 CDM 2500000200 HCPCS 250 RC 42858-0868-06 NDC inpatient 1 UN 15.1 15.1 MULTIPLAN INC 34080 [3081285] MULTIPLAN INC [308128501] 14.35 percent of total billed charges 9.36 14.35 Technical (Hospital) Services ENALAPRILAT 1.25 MG/ML INTRAVENOUS SOLUTION RX-9929 CDM 2500000200 HCPCS 250 RC 00143-9787-01 NDC inpatient 1 ML 69.81 69.81 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES PPO [308136801] 55.28 percent of total billed charges 43.28 66.32 Technical (Hospital) Services ENALAPRILAT 1.25 MG/ML INTRAVENOUS SOLUTION RX-9929 CDM 2500000200 HCPCS 250 RC 00143-9787-01 NDC inpatient 1 ML 69.81 69.81 HEALTHPARTNERS SX009 HEALTHPARTNERS 55.28 percent of total billed charges 43.28 66.32 Technical (Hospital) Services ENALAPRILAT 1.25 MG/ML INTRAVENOUS SOLUTION RX-9929 CDM 2500000200 HCPCS 250 RC 00143-9787-01 NDC inpatient 1 ML 69.81 69.81 MEDICA (COMMERCIAL) 94265 [3081118] MEDICA CLAIMS [308111801] 62.83 percent of total billed charges 43.28 66.32 Technical (Hospital) Services ENALAPRILAT 1.25 MG/ML INTRAVENOUS SOLUTION RX-9929 CDM 2500000200 HCPCS 250 RC 00143-9787-01 NDC inpatient 1 ML 69.81 69.81 MULTIPLAN INC 34080 [3081285] MULTIPLAN INC [308128501] 66.32 percent of total billed charges 43.28 66.32 Technical (Hospital) Services ENALAPRILAT 1.25 MG/ML INTRAVENOUS SOLUTION RX-9929 CDM 2500000200 HCPCS 250 RC 00143-9787-01 NDC inpatient 1 ML 69.81 69.81 CIGNA 62308 [3081051] CIGNA 62308 [308105105] 55.28 percent of total billed charges 43.28 66.32 Technical (Hospital) Services ENALAPRILAT 1.25 MG/ML INTRAVENOUS SOLUTION RX-9929 CDM 2500000200 HCPCS 250 RC 00143-9787-01 NDC inpatient 1 ML 69.81 69.81 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES EPO [308136803] 55.28 percent of total billed charges 43.28 66.32 Technical (Hospital) Services ENALAPRILAT 1.25 MG/ML INTRAVENOUS SOLUTION RX-9929 CDM 2500000200 HCPCS 250 RC 00143-9787-01 NDC inpatient 1 ML 69.81 69.81 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES HDHP [308136802] 55.28 percent of total billed charges 43.28 66.32 Technical (Hospital) Services ENALAPRILAT 1.25 MG/ML INTRAVENOUS SOLUTION RX-9929 CDM 2500000200 HCPCS 250 RC 00143-9787-01 NDC inpatient 1 ML 69.81 69.81 CIGNA 62308 [3081051] CIGNA STATE OF WYOMING [308105107] 55.28 percent of total billed charges 43.28 66.32 Technical (Hospital) Services ENALAPRILAT 1.25 MG/ML INTRAVENOUS SOLUTION RX-9929 CDM 2500000200 HCPCS 250 RC 00143-9787-01 NDC inpatient 1 ML 69.81 69.81 UNITED HEALTHCARE (COMMERCIAL) [3081199] UNITED HEALTHCARE 87726 [308119901] 43.28 percent of total billed charges 43.28 66.32 Technical (Hospital) Services ENALAPRILAT 1.25 MG/ML INTRAVENOUS SOLUTION RX-9929 CDM 2500000200 HCPCS 250 RC 00143-9787-01 NDC inpatient 1 ML 69.81 69.81 BLUE CROSS BLUE SHIELD WELLMARK SB889 [3081026] BCBS WYOMING [308102603] 66.32 percent of total billed charges 43.28 66.32 Technical (Hospital) Services ENALAPRILAT 1.25 MG/ML INTRAVENOUS SOLUTION RX-9929 CDM 2500000200 HCPCS 250 RC 00143-9787-01 NDC outpatient 1 ML 69.81 69.81 HEALTHPARTNERS SX009 HEALTHPARTNERS 55.85 percent of total billed charges 43.28 66.32 Technical (Hospital) Services ENALAPRILAT 1.25 MG/ML INTRAVENOUS SOLUTION RX-9929 CDM 2500000200 HCPCS 250 RC 00143-9787-01 NDC outpatient 1 ML 69.81 69.81 UNITED HEALTHCARE (COMMERCIAL) [3081199] UNITED HEALTHCARE 87726 [308119901] 43.28 percent of total billed charges 43.28 66.32 Technical (Hospital) Services ENALAPRILAT 1.25 MG/ML INTRAVENOUS SOLUTION RX-9929 CDM 2500000200 HCPCS 250 RC 00143-9787-01 NDC outpatient 1 ML 69.81 69.81 CIGNA 62308 [3081051] CIGNA 62308 [308105105] 55.85 percent of total billed charges 43.28 66.32 Technical (Hospital) Services ENALAPRILAT 1.25 MG/ML INTRAVENOUS SOLUTION RX-9929 CDM 2500000200 HCPCS 250 RC 00143-9787-01 NDC outpatient 1 ML 69.81 69.81 CIGNA 62308 [3081051] CIGNA STATE OF WYOMING [308105107] 55.85 percent of total billed charges 43.28 66.32 Technical (Hospital) Services ENALAPRILAT 1.25 MG/ML INTRAVENOUS SOLUTION RX-9929 CDM 2500000200 HCPCS 250 RC 00143-9787-01 NDC outpatient 1 ML 69.81 69.81 MULTIPLAN INC 34080 [3081285] MULTIPLAN INC [308128501] 66.32 percent of total billed charges 43.28 66.32 Technical (Hospital) Services ENALAPRILAT 1.25 MG/ML INTRAVENOUS SOLUTION RX-9929 CDM 2500000200 HCPCS 250 RC 00143-9787-01 NDC outpatient 1 ML 69.81 69.81 MEDICA (COMMERCIAL) 94265 [3081118] MEDICA CLAIMS [308111801] 62.83 percent of total billed charges 43.28 66.32 Technical (Hospital) Services ENALAPRILAT 1.25 MG/ML INTRAVENOUS SOLUTION RX-9929 CDM 2500000200 HCPCS 250 RC 00143-9787-01 NDC outpatient 1 ML 69.81 69.81 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES PPO [308136801] 55.85 percent of total billed charges 43.28 66.32 Technical (Hospital) Services ENALAPRILAT 1.25 MG/ML INTRAVENOUS SOLUTION RX-9929 CDM 2500000200 HCPCS 250 RC 00143-9787-01 NDC outpatient 1 ML 69.81 69.81 BLUE CROSS BLUE SHIELD WELLMARK SB889 [3081026] BCBS WYOMING [308102603] 66.32 percent of total billed charges 43.28 66.32 Technical (Hospital) Services ENALAPRILAT 1.25 MG/ML INTRAVENOUS SOLUTION RX-9929 CDM 2500000200 HCPCS 250 RC 00143-9787-01 NDC outpatient 1 ML 69.81 69.81 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES HDHP [308136802] 55.85 percent of total billed charges 43.28 66.32 Technical (Hospital) Services ENALAPRILAT 1.25 MG/ML INTRAVENOUS SOLUTION RX-9929 CDM 2500000200 HCPCS 250 RC 00143-9787-01 NDC outpatient 1 ML 69.81 69.81 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES EPO [308136803] 55.85 percent of total billed charges 43.28 66.32 Technical (Hospital) Services "VARICELLA-ZOSTER VACC-AS01B ADJ(PF) 50 MCG/0.5 ML IM SUSP, KIT" RX-172032 CDM 90750 HCPCS 636 RC 58160-0823-11 NDC inpatient 1 UN 547.9 547.9 MEDICA (COMMERCIAL) 94265 [3081118] MEDICA CLAIMS [308111801] 493.11 percent of total billed charges 339.7 520.51 Technical (Hospital) Services "VARICELLA-ZOSTER VACC-AS01B ADJ(PF) 50 MCG/0.5 ML IM SUSP, KIT" RX-172032 CDM 90750 HCPCS 636 RC 58160-0823-11 NDC inpatient 1 UN 547.9 547.9 HEALTHPARTNERS SX009 HEALTHPARTNERS 433.83 percent of total billed charges 339.7 520.51 Technical (Hospital) Services "VARICELLA-ZOSTER VACC-AS01B ADJ(PF) 50 MCG/0.5 ML IM SUSP, KIT" RX-172032 CDM 90750 HCPCS 636 RC 58160-0823-11 NDC inpatient 1 UN 547.9 547.9 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES PPO [308136801] 433.83 percent of total billed charges 339.7 520.51 Technical (Hospital) Services "VARICELLA-ZOSTER VACC-AS01B ADJ(PF) 50 MCG/0.5 ML IM SUSP, KIT" RX-172032 CDM 90750 HCPCS 636 RC 58160-0823-11 NDC inpatient 1 UN 547.9 547.9 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES EPO [308136803] 433.83 percent of total billed charges 339.7 520.51 Technical (Hospital) Services "VARICELLA-ZOSTER VACC-AS01B ADJ(PF) 50 MCG/0.5 ML IM SUSP, KIT" RX-172032 CDM 90750 HCPCS 636 RC 58160-0823-11 NDC inpatient 1 UN 547.9 547.9 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES HDHP [308136802] 433.83 percent of total billed charges 339.7 520.51 Technical (Hospital) Services "VARICELLA-ZOSTER VACC-AS01B ADJ(PF) 50 MCG/0.5 ML IM SUSP, KIT" RX-172032 CDM 90750 HCPCS 636 RC 58160-0823-11 NDC inpatient 1 UN 547.9 547.9 CIGNA 62308 [3081051] CIGNA 62308 [308105105] 433.83 percent of total billed charges 339.7 520.51 Technical (Hospital) Services "VARICELLA-ZOSTER VACC-AS01B ADJ(PF) 50 MCG/0.5 ML IM SUSP, KIT" RX-172032 CDM 90750 HCPCS 636 RC 58160-0823-11 NDC inpatient 1 UN 547.9 547.9 CIGNA 62308 [3081051] CIGNA STATE OF WYOMING [308105107] 433.83 percent of total billed charges 339.7 520.51 Technical (Hospital) Services "VARICELLA-ZOSTER VACC-AS01B ADJ(PF) 50 MCG/0.5 ML IM SUSP, KIT" RX-172032 CDM 90750 HCPCS 636 RC 58160-0823-11 NDC inpatient 1 UN 547.9 547.9 UNITED HEALTHCARE (COMMERCIAL) [3081199] UNITED HEALTHCARE 87726 [308119901] 339.7 percent of total billed charges 339.7 520.51 Technical (Hospital) Services "VARICELLA-ZOSTER VACC-AS01B ADJ(PF) 50 MCG/0.5 ML IM SUSP, KIT" RX-172032 CDM 90750 HCPCS 636 RC 58160-0823-11 NDC inpatient 1 UN 547.9 547.9 BLUE CROSS BLUE SHIELD WELLMARK SB889 [3081026] BCBS WYOMING [308102603] 520.51 percent of total billed charges 339.7 520.51 Technical (Hospital) Services "VARICELLA-ZOSTER VACC-AS01B ADJ(PF) 50 MCG/0.5 ML IM SUSP, KIT" RX-172032 CDM 90750 HCPCS 636 RC 58160-0823-11 NDC inpatient 1 UN 547.9 547.9 MULTIPLAN INC 34080 [3081285] MULTIPLAN INC [308128501] 520.51 percent of total billed charges 339.7 520.51 Technical (Hospital) Services "VARICELLA-ZOSTER VACC-AS01B ADJ(PF) 50 MCG/0.5 ML IM SUSP, KIT" RX-172032 CDM 90750 HCPCS 636 RC 58160-0823-11 NDC outpatient 1 UN 547.9 547.9 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES PPO [308136801] 438.32 percent of total billed charges 339.7 520.51 Technical (Hospital) Services "VARICELLA-ZOSTER VACC-AS01B ADJ(PF) 50 MCG/0.5 ML IM SUSP, KIT" RX-172032 CDM 90750 HCPCS 636 RC 58160-0823-11 NDC outpatient 1 UN 547.9 547.9 BLUE CROSS BLUE SHIELD WELLMARK SB889 [3081026] BCBS WYOMING [308102603] 520.51 percent of total billed charges 339.7 520.51 Technical (Hospital) Services "VARICELLA-ZOSTER VACC-AS01B ADJ(PF) 50 MCG/0.5 ML IM SUSP, KIT" RX-172032 CDM 90750 HCPCS 636 RC 58160-0823-11 NDC outpatient 1 UN 547.9 547.9 CIGNA 62308 [3081051] CIGNA 62308 [308105105] 438.32 percent of total billed charges 339.7 520.51 Technical (Hospital) Services "VARICELLA-ZOSTER VACC-AS01B ADJ(PF) 50 MCG/0.5 ML IM SUSP, KIT" RX-172032 CDM 90750 HCPCS 636 RC 58160-0823-11 NDC outpatient 1 UN 547.9 547.9 CIGNA 62308 [3081051] CIGNA STATE OF WYOMING [308105107] 438.32 percent of total billed charges 339.7 520.51 Technical (Hospital) Services "VARICELLA-ZOSTER VACC-AS01B ADJ(PF) 50 MCG/0.5 ML IM SUSP, KIT" RX-172032 CDM 90750 HCPCS 636 RC 58160-0823-11 NDC outpatient 1 UN 547.9 547.9 MULTIPLAN INC 34080 [3081285] MULTIPLAN INC [308128501] 520.51 percent of total billed charges 339.7 520.51 Technical (Hospital) Services "VARICELLA-ZOSTER VACC-AS01B ADJ(PF) 50 MCG/0.5 ML IM SUSP, KIT" RX-172032 CDM 90750 HCPCS 636 RC 58160-0823-11 NDC outpatient 1 UN 547.9 547.9 MEDICA (COMMERCIAL) 94265 [3081118] MEDICA CLAIMS [308111801] 493.11 percent of total billed charges 339.7 520.51 Technical (Hospital) Services "VARICELLA-ZOSTER VACC-AS01B ADJ(PF) 50 MCG/0.5 ML IM SUSP, KIT" RX-172032 CDM 90750 HCPCS 636 RC 58160-0823-11 NDC outpatient 1 UN 547.9 547.9 HEALTHPARTNERS SX009 HEALTHPARTNERS 438.32 percent of total billed charges 339.7 520.51 Technical (Hospital) Services "VARICELLA-ZOSTER VACC-AS01B ADJ(PF) 50 MCG/0.5 ML IM SUSP, KIT" RX-172032 CDM 90750 HCPCS 636 RC 58160-0823-11 NDC outpatient 1 UN 547.9 547.9 UNITED HEALTHCARE (COMMERCIAL) [3081199] UNITED HEALTHCARE 87726 [308119901] 339.7 percent of total billed charges 339.7 520.51 Technical (Hospital) Services "VARICELLA-ZOSTER VACC-AS01B ADJ(PF) 50 MCG/0.5 ML IM SUSP, KIT" RX-172032 CDM 90750 HCPCS 636 RC 58160-0823-11 NDC outpatient 1 UN 547.9 547.9 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES EPO [308136803] 438.32 percent of total billed charges 339.7 520.51 Technical (Hospital) Services "VARICELLA-ZOSTER VACC-AS01B ADJ(PF) 50 MCG/0.5 ML IM SUSP, KIT" RX-172032 CDM 90750 HCPCS 636 RC 58160-0823-11 NDC outpatient 1 UN 547.9 547.9 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES HDHP [308136802] 438.32 percent of total billed charges 339.7 520.51 Technical (Hospital) Services HEPATITIS B VIRUS VACCINE RECOMB (PF) 20 MCG/ML INTRAMUSCULAR SYRINGE RX-126851 CDM 90747 HCPCS 636 RC 58160-0821-52 NDC outpatient 1 ML 330.74 330.74 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES HDHP [308136802] 264.59 percent of total billed charges 205.06 314.2 Technical (Hospital) Services HEPATITIS B VIRUS VACCINE RECOMB (PF) 20 MCG/ML INTRAMUSCULAR SYRINGE RX-126851 CDM 90747 HCPCS 636 RC 58160-0821-52 NDC outpatient 1 ML 330.74 330.74 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES EPO [308136803] 264.59 percent of total billed charges 205.06 314.2 Technical (Hospital) Services HEPATITIS B VIRUS VACCINE RECOMB (PF) 20 MCG/ML INTRAMUSCULAR SYRINGE RX-126851 CDM 90747 HCPCS 636 RC 58160-0821-52 NDC outpatient 1 ML 330.74 330.74 HEALTHPARTNERS SX009 HEALTHPARTNERS 264.59 percent of total billed charges 205.06 314.2 Technical (Hospital) Services HEPATITIS B VIRUS VACCINE RECOMB (PF) 20 MCG/ML INTRAMUSCULAR SYRINGE RX-126851 CDM 90747 HCPCS 636 RC 58160-0821-52 NDC outpatient 1 ML 330.74 330.74 UNITED HEALTHCARE (COMMERCIAL) [3081199] UNITED HEALTHCARE 87726 [308119901] 205.06 percent of total billed charges 205.06 314.2 Technical (Hospital) Services HEPATITIS B VIRUS VACCINE RECOMB (PF) 20 MCG/ML INTRAMUSCULAR SYRINGE RX-126851 CDM 90747 HCPCS 636 RC 58160-0821-52 NDC outpatient 1 ML 330.74 330.74 CIGNA 62308 [3081051] CIGNA 62308 [308105105] 264.59 percent of total billed charges 205.06 314.2 Technical (Hospital) Services HEPATITIS B VIRUS VACCINE RECOMB (PF) 20 MCG/ML INTRAMUSCULAR SYRINGE RX-126851 CDM 90747 HCPCS 636 RC 58160-0821-52 NDC outpatient 1 ML 330.74 330.74 CIGNA 62308 [3081051] CIGNA STATE OF WYOMING [308105107] 264.59 percent of total billed charges 205.06 314.2 Technical (Hospital) Services HEPATITIS B VIRUS VACCINE RECOMB (PF) 20 MCG/ML INTRAMUSCULAR SYRINGE RX-126851 CDM 90747 HCPCS 636 RC 58160-0821-52 NDC outpatient 1 ML 330.74 330.74 MULTIPLAN INC 34080 [3081285] MULTIPLAN INC [308128501] 314.2 percent of total billed charges 205.06 314.2 Technical (Hospital) Services HEPATITIS B VIRUS VACCINE RECOMB (PF) 20 MCG/ML INTRAMUSCULAR SYRINGE RX-126851 CDM 90747 HCPCS 636 RC 58160-0821-52 NDC outpatient 1 ML 330.74 330.74 MEDICA (COMMERCIAL) 94265 [3081118] MEDICA CLAIMS [308111801] 297.67 percent of total billed charges 205.06 314.2 Technical (Hospital) Services HEPATITIS B VIRUS VACCINE RECOMB (PF) 20 MCG/ML INTRAMUSCULAR SYRINGE RX-126851 CDM 90747 HCPCS 636 RC 58160-0821-52 NDC outpatient 1 ML 330.74 330.74 BLUE CROSS BLUE SHIELD WELLMARK SB889 [3081026] BCBS WYOMING [308102603] 314.2 percent of total billed charges 205.06 314.2 Technical (Hospital) Services HEPATITIS B VIRUS VACCINE RECOMB (PF) 20 MCG/ML INTRAMUSCULAR SYRINGE RX-126851 CDM 90747 HCPCS 636 RC 58160-0821-52 NDC outpatient 1 ML 330.74 330.74 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES PPO [308136801] 264.59 percent of total billed charges 205.06 314.2 Technical (Hospital) Services HEPATITIS B VIRUS VACCINE RECOMB (PF) 20 MCG/ML INTRAMUSCULAR SYRINGE RX-126851 CDM 90747 HCPCS 636 RC 58160-0821-52 NDC inpatient 1 ML 330.74 330.74 MULTIPLAN INC 34080 [3081285] MULTIPLAN INC [308128501] 314.2 percent of total billed charges 205.06 314.2 Technical (Hospital) Services HEPATITIS B VIRUS VACCINE RECOMB (PF) 20 MCG/ML INTRAMUSCULAR SYRINGE RX-126851 CDM 90747 HCPCS 636 RC 58160-0821-52 NDC inpatient 1 ML 330.74 330.74 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES EPO [308136803] 261.88 percent of total billed charges 205.06 314.2 Technical (Hospital) Services HEPATITIS B VIRUS VACCINE RECOMB (PF) 20 MCG/ML INTRAMUSCULAR SYRINGE RX-126851 CDM 90747 HCPCS 636 RC 58160-0821-52 NDC inpatient 1 ML 330.74 330.74 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES HDHP [308136802] 261.88 percent of total billed charges 205.06 314.2 Technical (Hospital) Services HEPATITIS B VIRUS VACCINE RECOMB (PF) 20 MCG/ML INTRAMUSCULAR SYRINGE RX-126851 CDM 90747 HCPCS 636 RC 58160-0821-52 NDC inpatient 1 ML 330.74 330.74 CIGNA 62308 [3081051] CIGNA 62308 [308105105] 261.88 percent of total billed charges 205.06 314.2 Technical (Hospital) Services HEPATITIS B VIRUS VACCINE RECOMB (PF) 20 MCG/ML INTRAMUSCULAR SYRINGE RX-126851 CDM 90747 HCPCS 636 RC 58160-0821-52 NDC inpatient 1 ML 330.74 330.74 CIGNA 62308 [3081051] CIGNA STATE OF WYOMING [308105107] 261.88 percent of total billed charges 205.06 314.2 Technical (Hospital) Services HEPATITIS B VIRUS VACCINE RECOMB (PF) 20 MCG/ML INTRAMUSCULAR SYRINGE RX-126851 CDM 90747 HCPCS 636 RC 58160-0821-52 NDC inpatient 1 ML 330.74 330.74 UNITED HEALTHCARE (COMMERCIAL) [3081199] UNITED HEALTHCARE 87726 [308119901] 205.06 percent of total billed charges 205.06 314.2 Technical (Hospital) Services HEPATITIS B VIRUS VACCINE RECOMB (PF) 20 MCG/ML INTRAMUSCULAR SYRINGE RX-126851 CDM 90747 HCPCS 636 RC 58160-0821-52 NDC inpatient 1 ML 330.74 330.74 BLUE CROSS BLUE SHIELD WELLMARK SB889 [3081026] BCBS WYOMING [308102603] 314.2 percent of total billed charges 205.06 314.2 Technical (Hospital) Services HEPATITIS B VIRUS VACCINE RECOMB (PF) 20 MCG/ML INTRAMUSCULAR SYRINGE RX-126851 CDM 90747 HCPCS 636 RC 58160-0821-52 NDC inpatient 1 ML 330.74 330.74 MEDICA (COMMERCIAL) 94265 [3081118] MEDICA CLAIMS [308111801] 297.67 percent of total billed charges 205.06 314.2 Technical (Hospital) Services HEPATITIS B VIRUS VACCINE RECOMB (PF) 20 MCG/ML INTRAMUSCULAR SYRINGE RX-126851 CDM 90747 HCPCS 636 RC 58160-0821-52 NDC inpatient 1 ML 330.74 330.74 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES PPO [308136801] 261.88 percent of total billed charges 205.06 314.2 Technical (Hospital) Services HEPATITIS B VIRUS VACCINE RECOMB (PF) 20 MCG/ML INTRAMUSCULAR SYRINGE RX-126851 CDM 90747 HCPCS 636 RC 58160-0821-52 NDC inpatient 1 ML 330.74 330.74 HEALTHPARTNERS SX009 HEALTHPARTNERS 261.88 percent of total billed charges 205.06 314.2 Technical (Hospital) Services HEPATITIS B VIRUS VACCINE RECOM (PF) 20 MCG/ML INTRAMUSCULAR WRAPPER RX-4080070009 CDM 90746 HCPCS 636 RC 58160-0821-52 NDC outpatient 1 ML 330.74 330.74 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES HDHP [308136802] 264.59 percent of total billed charges 205.06 314.2 Technical (Hospital) Services HEPATITIS B VIRUS VACCINE RECOM (PF) 20 MCG/ML INTRAMUSCULAR WRAPPER RX-4080070009 CDM 90746 HCPCS 636 RC 58160-0821-52 NDC outpatient 1 ML 330.74 330.74 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES EPO [308136803] 264.59 percent of total billed charges 205.06 314.2 Technical (Hospital) Services HEPATITIS B VIRUS VACCINE RECOM (PF) 20 MCG/ML INTRAMUSCULAR WRAPPER RX-4080070009 CDM 90746 HCPCS 636 RC 58160-0821-52 NDC outpatient 1 ML 330.74 330.74 MEDICA (COMMERCIAL) 94265 [3081118] MEDICA CLAIMS [308111801] 297.67 percent of total billed charges 205.06 314.2 Technical (Hospital) Services HEPATITIS B VIRUS VACCINE RECOM (PF) 20 MCG/ML INTRAMUSCULAR WRAPPER RX-4080070009 CDM 90746 HCPCS 636 RC 58160-0821-52 NDC outpatient 1 ML 330.74 330.74 CIGNA 62308 [3081051] CIGNA 62308 [308105105] 264.59 percent of total billed charges 205.06 314.2 Technical (Hospital) Services HEPATITIS B VIRUS VACCINE RECOM (PF) 20 MCG/ML INTRAMUSCULAR WRAPPER RX-4080070009 CDM 90746 HCPCS 636 RC 58160-0821-52 NDC outpatient 1 ML 330.74 330.74 CIGNA 62308 [3081051] CIGNA STATE OF WYOMING [308105107] 264.59 percent of total billed charges 205.06 314.2 Technical (Hospital) Services HEPATITIS B VIRUS VACCINE RECOM (PF) 20 MCG/ML INTRAMUSCULAR WRAPPER RX-4080070009 CDM 90746 HCPCS 636 RC 58160-0821-52 NDC outpatient 1 ML 330.74 330.74 MULTIPLAN INC 34080 [3081285] MULTIPLAN INC [308128501] 314.2 percent of total billed charges 205.06 314.2 Technical (Hospital) Services HEPATITIS B VIRUS VACCINE RECOM (PF) 20 MCG/ML INTRAMUSCULAR WRAPPER RX-4080070009 CDM 90746 HCPCS 636 RC 58160-0821-52 NDC outpatient 1 ML 330.74 330.74 HEALTHPARTNERS SX009 HEALTHPARTNERS 264.59 percent of total billed charges 205.06 314.2 Technical (Hospital) Services HEPATITIS B VIRUS VACCINE RECOM (PF) 20 MCG/ML INTRAMUSCULAR WRAPPER RX-4080070009 CDM 90746 HCPCS 636 RC 58160-0821-52 NDC outpatient 1 ML 330.74 330.74 UNITED HEALTHCARE (COMMERCIAL) [3081199] UNITED HEALTHCARE 87726 [308119901] 205.06 percent of total billed charges 205.06 314.2 Technical (Hospital) Services HEPATITIS B VIRUS VACCINE RECOM (PF) 20 MCG/ML INTRAMUSCULAR WRAPPER RX-4080070009 CDM 90746 HCPCS 636 RC 58160-0821-52 NDC outpatient 1 ML 330.74 330.74 BLUE CROSS BLUE SHIELD WELLMARK SB889 [3081026] BCBS WYOMING [308102603] 314.2 percent of total billed charges 205.06 314.2 Technical (Hospital) Services HEPATITIS B VIRUS VACCINE RECOM (PF) 20 MCG/ML INTRAMUSCULAR WRAPPER RX-4080070009 CDM 90746 HCPCS 636 RC 58160-0821-52 NDC outpatient 1 ML 330.74 330.74 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES PPO [308136801] 264.59 percent of total billed charges 205.06 314.2 Technical (Hospital) Services HEPATITIS B VIRUS VACCINE RECOM (PF) 20 MCG/ML INTRAMUSCULAR WRAPPER RX-4080070009 CDM 90746 HCPCS 636 RC 58160-0821-52 NDC inpatient 1 ML 330.74 330.74 MULTIPLAN INC 34080 [3081285] MULTIPLAN INC [308128501] 314.2 percent of total billed charges 205.06 314.2 Technical (Hospital) Services HEPATITIS B VIRUS VACCINE RECOM (PF) 20 MCG/ML INTRAMUSCULAR WRAPPER RX-4080070009 CDM 90746 HCPCS 636 RC 58160-0821-52 NDC inpatient 1 ML 330.74 330.74 BLUE CROSS BLUE SHIELD WELLMARK SB889 [3081026] BCBS WYOMING [308102603] 314.2 percent of total billed charges 205.06 314.2 Technical (Hospital) Services HEPATITIS B VIRUS VACCINE RECOM (PF) 20 MCG/ML INTRAMUSCULAR WRAPPER RX-4080070009 CDM 90746 HCPCS 636 RC 58160-0821-52 NDC inpatient 1 ML 330.74 330.74 UNITED HEALTHCARE (COMMERCIAL) [3081199] UNITED HEALTHCARE 87726 [308119901] 205.06 percent of total billed charges 205.06 314.2 Technical (Hospital) Services HEPATITIS B VIRUS VACCINE RECOM (PF) 20 MCG/ML INTRAMUSCULAR WRAPPER RX-4080070009 CDM 90746 HCPCS 636 RC 58160-0821-52 NDC inpatient 1 ML 330.74 330.74 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES EPO [308136803] 261.88 percent of total billed charges 205.06 314.2 Technical (Hospital) Services HEPATITIS B VIRUS VACCINE RECOM (PF) 20 MCG/ML INTRAMUSCULAR WRAPPER RX-4080070009 CDM 90746 HCPCS 636 RC 58160-0821-52 NDC inpatient 1 ML 330.74 330.74 CIGNA 62308 [3081051] CIGNA 62308 [308105105] 261.88 percent of total billed charges 205.06 314.2 Technical (Hospital) Services HEPATITIS B VIRUS VACCINE RECOM (PF) 20 MCG/ML INTRAMUSCULAR WRAPPER RX-4080070009 CDM 90746 HCPCS 636 RC 58160-0821-52 NDC inpatient 1 ML 330.74 330.74 CIGNA 62308 [3081051] CIGNA STATE OF WYOMING [308105107] 261.88 percent of total billed charges 205.06 314.2 Technical (Hospital) Services HEPATITIS B VIRUS VACCINE RECOM (PF) 20 MCG/ML INTRAMUSCULAR WRAPPER RX-4080070009 CDM 90746 HCPCS 636 RC 58160-0821-52 NDC inpatient 1 ML 330.74 330.74 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES PPO [308136801] 261.88 percent of total billed charges 205.06 314.2 Technical (Hospital) Services HEPATITIS B VIRUS VACCINE RECOM (PF) 20 MCG/ML INTRAMUSCULAR WRAPPER RX-4080070009 CDM 90746 HCPCS 636 RC 58160-0821-52 NDC inpatient 1 ML 330.74 330.74 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES HDHP [308136802] 261.88 percent of total billed charges 205.06 314.2 Technical (Hospital) Services HEPATITIS B VIRUS VACCINE RECOM (PF) 20 MCG/ML INTRAMUSCULAR WRAPPER RX-4080070009 CDM 90746 HCPCS 636 RC 58160-0821-52 NDC inpatient 1 ML 330.74 330.74 HEALTHPARTNERS SX009 HEALTHPARTNERS 261.88 percent of total billed charges 205.06 314.2 Technical (Hospital) Services HEPATITIS B VIRUS VACCINE RECOM (PF) 20 MCG/ML INTRAMUSCULAR WRAPPER RX-4080070009 CDM 90746 HCPCS 636 RC 58160-0821-52 NDC inpatient 1 ML 330.74 330.74 MEDICA (COMMERCIAL) 94265 [3081118] MEDICA CLAIMS [308111801] 297.67 percent of total billed charges 205.06 314.2 Technical (Hospital) Services HEPATITIS B VIRUS VACCINE RECOMB (PF) 10 MCG/0.5 ML IM SYRINGE RX-126911 CDM 90740 HCPCS 636 RC 58160-0820-52 NDC inpatient 0.5 ML 150.17 150.17 UNITED HEALTHCARE (COMMERCIAL) [3081199] UNITED HEALTHCARE 87726 [308119901] 93.11 percent of total billed charges 93.11 142.66 Technical (Hospital) Services HEPATITIS B VIRUS VACCINE RECOMB (PF) 10 MCG/0.5 ML IM SYRINGE RX-126911 CDM 90740 HCPCS 636 RC 58160-0820-52 NDC inpatient 0.5 ML 150.17 150.17 BLUE CROSS BLUE SHIELD WELLMARK SB889 [3081026] BCBS WYOMING [308102603] 142.66 percent of total billed charges 93.11 142.66 Technical (Hospital) Services HEPATITIS B VIRUS VACCINE RECOMB (PF) 10 MCG/0.5 ML IM SYRINGE RX-126911 CDM 90740 HCPCS 636 RC 58160-0820-52 NDC inpatient 0.5 ML 150.17 150.17 CIGNA 62308 [3081051] CIGNA 62308 [308105105] 118.9 percent of total billed charges 93.11 142.66 Technical (Hospital) Services HEPATITIS B VIRUS VACCINE RECOMB (PF) 10 MCG/0.5 ML IM SYRINGE RX-126911 CDM 90740 HCPCS 636 RC 58160-0820-52 NDC inpatient 0.5 ML 150.17 150.17 CIGNA 62308 [3081051] CIGNA STATE OF WYOMING [308105107] 118.9 percent of total billed charges 93.11 142.66 Technical (Hospital) Services HEPATITIS B VIRUS VACCINE RECOMB (PF) 10 MCG/0.5 ML IM SYRINGE RX-126911 CDM 90740 HCPCS 636 RC 58160-0820-52 NDC inpatient 0.5 ML 150.17 150.17 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES PPO [308136801] 118.9 percent of total billed charges 93.11 142.66 Technical (Hospital) Services HEPATITIS B VIRUS VACCINE RECOMB (PF) 10 MCG/0.5 ML IM SYRINGE RX-126911 CDM 90740 HCPCS 636 RC 58160-0820-52 NDC inpatient 0.5 ML 150.17 150.17 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES HDHP [308136802] 118.9 percent of total billed charges 93.11 142.66 Technical (Hospital) Services HEPATITIS B VIRUS VACCINE RECOMB (PF) 10 MCG/0.5 ML IM SYRINGE RX-126911 CDM 90740 HCPCS 636 RC 58160-0820-52 NDC inpatient 0.5 ML 150.17 150.17 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES EPO [308136803] 118.9 percent of total billed charges 93.11 142.66 Technical (Hospital) Services HEPATITIS B VIRUS VACCINE RECOMB (PF) 10 MCG/0.5 ML IM SYRINGE RX-126911 CDM 90740 HCPCS 636 RC 58160-0820-52 NDC inpatient 0.5 ML 150.17 150.17 MEDICA (COMMERCIAL) 94265 [3081118] MEDICA CLAIMS [308111801] 135.15 percent of total billed charges 93.11 142.66 Technical (Hospital) Services HEPATITIS B VIRUS VACCINE RECOMB (PF) 10 MCG/0.5 ML IM SYRINGE RX-126911 CDM 90740 HCPCS 636 RC 58160-0820-52 NDC inpatient 0.5 ML 150.17 150.17 HEALTHPARTNERS SX009 HEALTHPARTNERS 118.9 percent of total billed charges 93.11 142.66 Technical (Hospital) Services HEPATITIS B VIRUS VACCINE RECOMB (PF) 10 MCG/0.5 ML IM SYRINGE RX-126911 CDM 90740 HCPCS 636 RC 58160-0820-52 NDC inpatient 0.5 ML 150.17 150.17 MULTIPLAN INC 34080 [3081285] MULTIPLAN INC [308128501] 142.66 percent of total billed charges 93.11 142.66 Technical (Hospital) Services HEPATITIS B VIRUS VACCINE RECOMB (PF) 10 MCG/0.5 ML IM SYRINGE RX-126911 CDM 90740 HCPCS 636 RC 58160-0820-52 NDC outpatient 0.5 ML 150.17 150.17 CIGNA 62308 [3081051] CIGNA 62308 [308105105] 120.14 percent of total billed charges 93.11 142.66 Technical (Hospital) Services HEPATITIS B VIRUS VACCINE RECOMB (PF) 10 MCG/0.5 ML IM SYRINGE RX-126911 CDM 90740 HCPCS 636 RC 58160-0820-52 NDC outpatient 0.5 ML 150.17 150.17 CIGNA 62308 [3081051] CIGNA STATE OF WYOMING [308105107] 120.14 percent of total billed charges 93.11 142.66 Technical (Hospital) Services HEPATITIS B VIRUS VACCINE RECOMB (PF) 10 MCG/0.5 ML IM SYRINGE RX-126911 CDM 90740 HCPCS 636 RC 58160-0820-52 NDC outpatient 0.5 ML 150.17 150.17 MULTIPLAN INC 34080 [3081285] MULTIPLAN INC [308128501] 142.66 percent of total billed charges 93.11 142.66 Technical (Hospital) Services HEPATITIS B VIRUS VACCINE RECOMB (PF) 10 MCG/0.5 ML IM SYRINGE RX-126911 CDM 90740 HCPCS 636 RC 58160-0820-52 NDC outpatient 0.5 ML 150.17 150.17 UNITED HEALTHCARE (COMMERCIAL) [3081199] UNITED HEALTHCARE 87726 [308119901] 93.11 percent of total billed charges 93.11 142.66 Technical (Hospital) Services HEPATITIS B VIRUS VACCINE RECOMB (PF) 10 MCG/0.5 ML IM SYRINGE RX-126911 CDM 90740 HCPCS 636 RC 58160-0820-52 NDC outpatient 0.5 ML 150.17 150.17 MEDICA (COMMERCIAL) 94265 [3081118] MEDICA CLAIMS [308111801] 135.15 percent of total billed charges 93.11 142.66 Technical (Hospital) Services HEPATITIS B VIRUS VACCINE RECOMB (PF) 10 MCG/0.5 ML IM SYRINGE RX-126911 CDM 90740 HCPCS 636 RC 58160-0820-52 NDC outpatient 0.5 ML 150.17 150.17 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES PPO [308136801] 120.14 percent of total billed charges 93.11 142.66 Technical (Hospital) Services HEPATITIS B VIRUS VACCINE RECOMB (PF) 10 MCG/0.5 ML IM SYRINGE RX-126911 CDM 90740 HCPCS 636 RC 58160-0820-52 NDC outpatient 0.5 ML 150.17 150.17 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES EPO [308136803] 120.14 percent of total billed charges 93.11 142.66 Technical (Hospital) Services HEPATITIS B VIRUS VACCINE RECOMB (PF) 10 MCG/0.5 ML IM SYRINGE RX-126911 CDM 90740 HCPCS 636 RC 58160-0820-52 NDC outpatient 0.5 ML 150.17 150.17 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES HDHP [308136802] 120.14 percent of total billed charges 93.11 142.66 Technical (Hospital) Services HEPATITIS B VIRUS VACCINE RECOMB (PF) 10 MCG/0.5 ML IM SYRINGE RX-126911 CDM 90740 HCPCS 636 RC 58160-0820-52 NDC outpatient 0.5 ML 150.17 150.17 HEALTHPARTNERS SX009 HEALTHPARTNERS 120.14 percent of total billed charges 93.11 142.66 Technical (Hospital) Services HEPATITIS B VIRUS VACCINE RECOMB (PF) 10 MCG/0.5 ML IM SYRINGE RX-126911 CDM 90740 HCPCS 636 RC 58160-0820-52 NDC outpatient 0.5 ML 150.17 150.17 BLUE CROSS BLUE SHIELD WELLMARK SB889 [3081026] BCBS WYOMING [308102603] 142.66 percent of total billed charges 93.11 142.66 Technical (Hospital) Services PNEUMOCOCCAL 23 POLYVALENT VACCINE 25 MCG/0.5 ML INJECTION SYRINGE RX-123362 CDM 90732 HCPCS 636 RC 00006-4837-01 NDC outpatient 0.5 ML 364.11 364.11 HEALTHPARTNERS SX009 HEALTHPARTNERS 291.29 percent of total billed charges 225.75 345.9 Technical (Hospital) Services PNEUMOCOCCAL 23 POLYVALENT VACCINE 25 MCG/0.5 ML INJECTION SYRINGE RX-123362 CDM 90732 HCPCS 636 RC 00006-4837-01 NDC outpatient 0.5 ML 364.11 364.11 BLUE CROSS BLUE SHIELD WELLMARK SB889 [3081026] BCBS WYOMING [308102603] 345.9 percent of total billed charges 225.75 345.9 Technical (Hospital) Services PNEUMOCOCCAL 23 POLYVALENT VACCINE 25 MCG/0.5 ML INJECTION SYRINGE RX-123362 CDM 90732 HCPCS 636 RC 00006-4837-01 NDC outpatient 0.5 ML 364.11 364.11 CIGNA 62308 [3081051] CIGNA 62308 [308105105] 291.29 percent of total billed charges 225.75 345.9 Technical (Hospital) Services PNEUMOCOCCAL 23 POLYVALENT VACCINE 25 MCG/0.5 ML INJECTION SYRINGE RX-123362 CDM 90732 HCPCS 636 RC 00006-4837-01 NDC outpatient 0.5 ML 364.11 364.11 CIGNA 62308 [3081051] CIGNA STATE OF WYOMING [308105107] 291.29 percent of total billed charges 225.75 345.9 Technical (Hospital) Services PNEUMOCOCCAL 23 POLYVALENT VACCINE 25 MCG/0.5 ML INJECTION SYRINGE RX-123362 CDM 90732 HCPCS 636 RC 00006-4837-01 NDC outpatient 0.5 ML 364.11 364.11 MULTIPLAN INC 34080 [3081285] MULTIPLAN INC [308128501] 345.9 percent of total billed charges 225.75 345.9 Technical (Hospital) Services PNEUMOCOCCAL 23 POLYVALENT VACCINE 25 MCG/0.5 ML INJECTION SYRINGE RX-123362 CDM 90732 HCPCS 636 RC 00006-4837-01 NDC outpatient 0.5 ML 364.11 364.11 UNITED HEALTHCARE (COMMERCIAL) [3081199] UNITED HEALTHCARE 87726 [308119901] 225.75 percent of total billed charges 225.75 345.9 Technical (Hospital) Services PNEUMOCOCCAL 23 POLYVALENT VACCINE 25 MCG/0.5 ML INJECTION SYRINGE RX-123362 CDM 90732 HCPCS 636 RC 00006-4837-01 NDC outpatient 0.5 ML 364.11 364.11 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES EPO [308136803] 291.29 percent of total billed charges 225.75 345.9 Technical (Hospital) Services PNEUMOCOCCAL 23 POLYVALENT VACCINE 25 MCG/0.5 ML INJECTION SYRINGE RX-123362 CDM 90732 HCPCS 636 RC 00006-4837-01 NDC outpatient 0.5 ML 364.11 364.11 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES PPO [308136801] 291.29 percent of total billed charges 225.75 345.9 Technical (Hospital) Services PNEUMOCOCCAL 23 POLYVALENT VACCINE 25 MCG/0.5 ML INJECTION SYRINGE RX-123362 CDM 90732 HCPCS 636 RC 00006-4837-01 NDC outpatient 0.5 ML 364.11 364.11 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES HDHP [308136802] 291.29 percent of total billed charges 225.75 345.9 Technical (Hospital) Services PNEUMOCOCCAL 23 POLYVALENT VACCINE 25 MCG/0.5 ML INJECTION SYRINGE RX-123362 CDM 90732 HCPCS 636 RC 00006-4837-01 NDC outpatient 0.5 ML 364.11 364.11 MEDICA (COMMERCIAL) 94265 [3081118] MEDICA CLAIMS [308111801] 327.7 percent of total billed charges 225.75 345.9 Technical (Hospital) Services PNEUMOCOCCAL 23 POLYVALENT VACCINE 25 MCG/0.5 ML INJECTION SYRINGE RX-123362 CDM 90732 HCPCS 636 RC 00006-4837-01 NDC inpatient 0.5 ML 364.11 364.11 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES EPO [308136803] 288.3 percent of total billed charges 225.75 345.9 Technical (Hospital) Services PNEUMOCOCCAL 23 POLYVALENT VACCINE 25 MCG/0.5 ML INJECTION SYRINGE RX-123362 CDM 90732 HCPCS 636 RC 00006-4837-01 NDC inpatient 0.5 ML 364.11 364.11 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES HDHP [308136802] 288.3 percent of total billed charges 225.75 345.9 Technical (Hospital) Services PNEUMOCOCCAL 23 POLYVALENT VACCINE 25 MCG/0.5 ML INJECTION SYRINGE RX-123362 CDM 90732 HCPCS 636 RC 00006-4837-01 NDC inpatient 0.5 ML 364.11 364.11 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES PPO [308136801] 288.3 percent of total billed charges 225.75 345.9 Technical (Hospital) Services PNEUMOCOCCAL 23 POLYVALENT VACCINE 25 MCG/0.5 ML INJECTION SYRINGE RX-123362 CDM 90732 HCPCS 636 RC 00006-4837-01 NDC inpatient 0.5 ML 364.11 364.11 CIGNA 62308 [3081051] CIGNA 62308 [308105105] 288.3 percent of total billed charges 225.75 345.9 Technical (Hospital) Services PNEUMOCOCCAL 23 POLYVALENT VACCINE 25 MCG/0.5 ML INJECTION SYRINGE RX-123362 CDM 90732 HCPCS 636 RC 00006-4837-01 NDC inpatient 0.5 ML 364.11 364.11 CIGNA 62308 [3081051] CIGNA STATE OF WYOMING [308105107] 288.3 percent of total billed charges 225.75 345.9 Technical (Hospital) Services PNEUMOCOCCAL 23 POLYVALENT VACCINE 25 MCG/0.5 ML INJECTION SYRINGE RX-123362 CDM 90732 HCPCS 636 RC 00006-4837-01 NDC inpatient 0.5 ML 364.11 364.11 UNITED HEALTHCARE (COMMERCIAL) [3081199] UNITED HEALTHCARE 87726 [308119901] 225.75 percent of total billed charges 225.75 345.9 Technical (Hospital) Services PNEUMOCOCCAL 23 POLYVALENT VACCINE 25 MCG/0.5 ML INJECTION SYRINGE RX-123362 CDM 90732 HCPCS 636 RC 00006-4837-01 NDC inpatient 0.5 ML 364.11 364.11 BLUE CROSS BLUE SHIELD WELLMARK SB889 [3081026] BCBS WYOMING [308102603] 345.9 percent of total billed charges 225.75 345.9 Technical (Hospital) Services PNEUMOCOCCAL 23 POLYVALENT VACCINE 25 MCG/0.5 ML INJECTION SYRINGE RX-123362 CDM 90732 HCPCS 636 RC 00006-4837-01 NDC inpatient 0.5 ML 364.11 364.11 HEALTHPARTNERS SX009 HEALTHPARTNERS 288.3 percent of total billed charges 225.75 345.9 Technical (Hospital) Services PNEUMOCOCCAL 23 POLYVALENT VACCINE 25 MCG/0.5 ML INJECTION SYRINGE RX-123362 CDM 90732 HCPCS 636 RC 00006-4837-01 NDC inpatient 0.5 ML 364.11 364.11 MEDICA (COMMERCIAL) 94265 [3081118] MEDICA CLAIMS [308111801] 327.7 percent of total billed charges 225.75 345.9 Technical (Hospital) Services PNEUMOCOCCAL 23 POLYVALENT VACCINE 25 MCG/0.5 ML INJECTION SYRINGE RX-123362 CDM 90732 HCPCS 636 RC 00006-4837-01 NDC inpatient 0.5 ML 364.11 364.11 MULTIPLAN INC 34080 [3081285] MULTIPLAN INC [308128501] 345.9 percent of total billed charges 225.75 345.9 Technical (Hospital) Services "DIPHTH,PERTUS(AC)TETANUS(PF)2 LF-(2.5-5-3-5MCG)-5 LF/0.5 ML IM SYRINGE" RX-128561 CDM 90715 HCPCS 636 RC 49281-0400-20 NDC outpatient 0.5 ML 227.58 227.58 UNITED HEALTHCARE (COMMERCIAL) [3081199] UNITED HEALTHCARE 87726 [308119901] 141.1 percent of total billed charges 141.1 216.2 Technical (Hospital) Services "DIPHTH,PERTUS(AC)TETANUS(PF)2 LF-(2.5-5-3-5MCG)-5 LF/0.5 ML IM SYRINGE" RX-128561 CDM 90715 HCPCS 636 RC 49281-0400-20 NDC outpatient 0.5 ML 227.58 227.58 CIGNA 62308 [3081051] CIGNA 62308 [308105105] 182.06 percent of total billed charges 141.1 216.2 Technical (Hospital) Services "DIPHTH,PERTUS(AC)TETANUS(PF)2 LF-(2.5-5-3-5MCG)-5 LF/0.5 ML IM SYRINGE" RX-128561 CDM 90715 HCPCS 636 RC 49281-0400-20 NDC outpatient 0.5 ML 227.58 227.58 CIGNA 62308 [3081051] CIGNA STATE OF WYOMING [308105107] 182.06 percent of total billed charges 141.1 216.2 Technical (Hospital) Services "DIPHTH,PERTUS(AC)TETANUS(PF)2 LF-(2.5-5-3-5MCG)-5 LF/0.5 ML IM SYRINGE" RX-128561 CDM 90715 HCPCS 636 RC 49281-0400-20 NDC inpatient 0.5 ML 227.58 227.58 BLUE CROSS BLUE SHIELD WELLMARK SB889 [3081026] BCBS WYOMING [308102603] 216.2 percent of total billed charges 141.1 216.2 Technical (Hospital) Services "DIPHTH,PERTUS(AC)TETANUS(PF)2 LF-(2.5-5-3-5MCG)-5 LF/0.5 ML IM SYRINGE" RX-128561 CDM 90715 HCPCS 636 RC 49281-0400-20 NDC inpatient 0.5 ML 227.58 227.58 UNITED HEALTHCARE (COMMERCIAL) [3081199] UNITED HEALTHCARE 87726 [308119901] 141.1 percent of total billed charges 141.1 216.2 Technical (Hospital) Services "DIPHTH,PERTUS(AC)TETANUS(PF)2 LF-(2.5-5-3-5MCG)-5 LF/0.5 ML IM SYRINGE" RX-128561 CDM 90715 HCPCS 636 RC 49281-0400-20 NDC outpatient 0.5 ML 227.58 227.58 MULTIPLAN INC 34080 [3081285] MULTIPLAN INC [308128501] 216.2 percent of total billed charges 141.1 216.2 Technical (Hospital) Services "DIPHTH,PERTUS(AC)TETANUS(PF)2 LF-(2.5-5-3-5MCG)-5 LF/0.5 ML IM SYRINGE" RX-128561 CDM 90715 HCPCS 636 RC 49281-0400-20 NDC outpatient 0.5 ML 227.58 227.58 MEDICA (COMMERCIAL) 94265 [3081118] MEDICA CLAIMS [308111801] 204.82 percent of total billed charges 141.1 216.2 Technical (Hospital) Services "DIPHTH,PERTUS(AC)TETANUS(PF)2 LF-(2.5-5-3-5MCG)-5 LF/0.5 ML IM SYRINGE" RX-128561 CDM 90715 HCPCS 636 RC 49281-0400-20 NDC outpatient 0.5 ML 227.58 227.58 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES EPO [308136803] 182.06 percent of total billed charges 141.1 216.2 Technical (Hospital) Services "DIPHTH,PERTUS(AC)TETANUS(PF)2 LF-(2.5-5-3-5MCG)-5 LF/0.5 ML IM SYRINGE" RX-128561 CDM 90715 HCPCS 636 RC 49281-0400-20 NDC outpatient 0.5 ML 227.58 227.58 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES HDHP [308136802] 182.06 percent of total billed charges 141.1 216.2 Technical (Hospital) Services "DIPHTH,PERTUS(AC)TETANUS(PF)2 LF-(2.5-5-3-5MCG)-5 LF/0.5 ML IM SYRINGE" RX-128561 CDM 90715 HCPCS 636 RC 49281-0400-20 NDC outpatient 0.5 ML 227.58 227.58 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES PPO [308136801] 182.06 percent of total billed charges 141.1 216.2 Technical (Hospital) Services "DIPHTH,PERTUS(AC)TETANUS(PF)2 LF-(2.5-5-3-5MCG)-5 LF/0.5 ML IM SYRINGE" RX-128561 CDM 90715 HCPCS 636 RC 49281-0400-20 NDC outpatient 0.5 ML 227.58 227.58 BLUE CROSS BLUE SHIELD WELLMARK SB889 [3081026] BCBS WYOMING [308102603] 216.2 percent of total billed charges 141.1 216.2 Technical (Hospital) Services "DIPHTH,PERTUS(AC)TETANUS(PF)2 LF-(2.5-5-3-5MCG)-5 LF/0.5 ML IM SYRINGE" RX-128561 CDM 90715 HCPCS 636 RC 49281-0400-20 NDC outpatient 0.5 ML 227.58 227.58 HEALTHPARTNERS SX009 HEALTHPARTNERS 182.06 percent of total billed charges 141.1 216.2 Technical (Hospital) Services "DIPHTH,PERTUS(AC)TETANUS(PF)2 LF-(2.5-5-3-5MCG)-5 LF/0.5 ML IM SYRINGE" RX-128561 CDM 90715 HCPCS 636 RC 49281-0400-20 NDC inpatient 0.5 ML 227.58 227.58 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES HDHP [308136802] 180.2 percent of total billed charges 141.1 216.2 Technical (Hospital) Services "DIPHTH,PERTUS(AC)TETANUS(PF)2 LF-(2.5-5-3-5MCG)-5 LF/0.5 ML IM SYRINGE" RX-128561 CDM 90715 HCPCS 636 RC 49281-0400-20 NDC inpatient 0.5 ML 227.58 227.58 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES PPO [308136801] 180.2 percent of total billed charges 141.1 216.2 Technical (Hospital) Services "DIPHTH,PERTUS(AC)TETANUS(PF)2 LF-(2.5-5-3-5MCG)-5 LF/0.5 ML IM SYRINGE" RX-128561 CDM 90715 HCPCS 636 RC 49281-0400-20 NDC inpatient 0.5 ML 227.58 227.58 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES EPO [308136803] 180.2 percent of total billed charges 141.1 216.2 Technical (Hospital) Services "DIPHTH,PERTUS(AC)TETANUS(PF)2 LF-(2.5-5-3-5MCG)-5 LF/0.5 ML IM SYRINGE" RX-128561 CDM 90715 HCPCS 636 RC 49281-0400-20 NDC inpatient 0.5 ML 227.58 227.58 CIGNA 62308 [3081051] CIGNA 62308 [308105105] 180.2 percent of total billed charges 141.1 216.2 Technical (Hospital) Services "DIPHTH,PERTUS(AC)TETANUS(PF)2 LF-(2.5-5-3-5MCG)-5 LF/0.5 ML IM SYRINGE" RX-128561 CDM 90715 HCPCS 636 RC 49281-0400-20 NDC inpatient 0.5 ML 227.58 227.58 CIGNA 62308 [3081051] CIGNA STATE OF WYOMING [308105107] 180.2 percent of total billed charges 141.1 216.2 Technical (Hospital) Services "DIPHTH,PERTUS(AC)TETANUS(PF)2 LF-(2.5-5-3-5MCG)-5 LF/0.5 ML IM SYRINGE" RX-128561 CDM 90715 HCPCS 636 RC 49281-0400-20 NDC inpatient 0.5 ML 227.58 227.58 MEDICA (COMMERCIAL) 94265 [3081118] MEDICA CLAIMS [308111801] 204.82 percent of total billed charges 141.1 216.2 Technical (Hospital) Services "DIPHTH,PERTUS(AC)TETANUS(PF)2 LF-(2.5-5-3-5MCG)-5 LF/0.5 ML IM SYRINGE" RX-128561 CDM 90715 HCPCS 636 RC 49281-0400-20 NDC inpatient 0.5 ML 227.58 227.58 HEALTHPARTNERS SX009 HEALTHPARTNERS 180.2 percent of total billed charges 141.1 216.2 Technical (Hospital) Services "DIPHTH,PERTUS(AC)TETANUS(PF)2 LF-(2.5-5-3-5MCG)-5 LF/0.5 ML IM SYRINGE" RX-128561 CDM 90715 HCPCS 636 RC 49281-0400-20 NDC inpatient 0.5 ML 227.58 227.58 MULTIPLAN INC 34080 [3081285] MULTIPLAN INC [308128501] 216.2 percent of total billed charges 141.1 216.2 Technical (Hospital) Services "DIPHTH,PERTUSSIS(ACEL),TETANUS 2.5 LF UNIT-8 MCG-5 LF/0.5ML IM SYRINGE" RX-41293 CDM 90715 HCPCS 636 RC 58160-0842-52 NDC inpatient 0.5 ML 227.14 227.14 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES PPO [308136801] 179.85 percent of total billed charges 140.83 215.78 Technical (Hospital) Services "DIPHTH,PERTUSSIS(ACEL),TETANUS 2.5 LF UNIT-8 MCG-5 LF/0.5ML IM SYRINGE" RX-41293 CDM 90715 HCPCS 636 RC 58160-0842-52 NDC inpatient 0.5 ML 227.14 227.14 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES HDHP [308136802] 179.85 percent of total billed charges 140.83 215.78 Technical (Hospital) Services "DIPHTH,PERTUSSIS(ACEL),TETANUS 2.5 LF UNIT-8 MCG-5 LF/0.5ML IM SYRINGE" RX-41293 CDM 90715 HCPCS 636 RC 58160-0842-52 NDC inpatient 0.5 ML 227.14 227.14 CIGNA 62308 [3081051] CIGNA 62308 [308105105] 179.85 percent of total billed charges 140.83 215.78 Technical (Hospital) Services "DIPHTH,PERTUSSIS(ACEL),TETANUS 2.5 LF UNIT-8 MCG-5 LF/0.5ML IM SYRINGE" RX-41293 CDM 90715 HCPCS 636 RC 58160-0842-52 NDC inpatient 0.5 ML 227.14 227.14 CIGNA 62308 [3081051] CIGNA STATE OF WYOMING [308105107] 179.85 percent of total billed charges 140.83 215.78 Technical (Hospital) Services "DIPHTH,PERTUSSIS(ACEL),TETANUS 2.5 LF UNIT-8 MCG-5 LF/0.5ML IM SYRINGE" RX-41293 CDM 90715 HCPCS 636 RC 58160-0842-52 NDC inpatient 0.5 ML 227.14 227.14 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES EPO [308136803] 179.85 percent of total billed charges 140.83 215.78 Technical (Hospital) Services "DIPHTH,PERTUSSIS(ACEL),TETANUS 2.5 LF UNIT-8 MCG-5 LF/0.5ML IM SYRINGE" RX-41293 CDM 90715 HCPCS 636 RC 58160-0842-52 NDC inpatient 0.5 ML 227.14 227.14 MEDICA (COMMERCIAL) 94265 [3081118] MEDICA CLAIMS [308111801] 204.43 percent of total billed charges 140.83 215.78 Technical (Hospital) Services "DIPHTH,PERTUSSIS(ACEL),TETANUS 2.5 LF UNIT-8 MCG-5 LF/0.5ML IM SYRINGE" RX-41293 CDM 90715 HCPCS 636 RC 58160-0842-52 NDC inpatient 0.5 ML 227.14 227.14 BLUE CROSS BLUE SHIELD WELLMARK SB889 [3081026] BCBS WYOMING [308102603] 215.78 percent of total billed charges 140.83 215.78 Technical (Hospital) Services "DIPHTH,PERTUSSIS(ACEL),TETANUS 2.5 LF UNIT-8 MCG-5 LF/0.5ML IM SYRINGE" RX-41293 CDM 90715 HCPCS 636 RC 58160-0842-52 NDC inpatient 0.5 ML 227.14 227.14 UNITED HEALTHCARE (COMMERCIAL) [3081199] UNITED HEALTHCARE 87726 [308119901] 140.83 percent of total billed charges 140.83 215.78 Technical (Hospital) Services "DIPHTH,PERTUSSIS(ACEL),TETANUS 2.5 LF UNIT-8 MCG-5 LF/0.5ML IM SYRINGE" RX-41293 CDM 90715 HCPCS 636 RC 58160-0842-52 NDC inpatient 0.5 ML 227.14 227.14 HEALTHPARTNERS SX009 HEALTHPARTNERS 179.85 percent of total billed charges 140.83 215.78 Technical (Hospital) Services "DIPHTH,PERTUSSIS(ACEL),TETANUS 2.5 LF UNIT-8 MCG-5 LF/0.5ML IM SYRINGE" RX-41293 CDM 90715 HCPCS 636 RC 58160-0842-52 NDC inpatient 0.5 ML 227.14 227.14 MULTIPLAN INC 34080 [3081285] MULTIPLAN INC [308128501] 215.78 percent of total billed charges 140.83 215.78 Technical (Hospital) Services "DIPHTH,PERTUSSIS(ACEL),TETANUS 2.5 LF UNIT-8 MCG-5 LF/0.5ML IM SYRINGE" RX-41293 CDM 90715 HCPCS 636 RC 58160-0842-52 NDC outpatient 0.5 ML 227.14 227.14 BLUE CROSS BLUE SHIELD WELLMARK SB889 [3081026] BCBS WYOMING [308102603] 215.78 percent of total billed charges 140.83 215.78 Technical (Hospital) Services "DIPHTH,PERTUSSIS(ACEL),TETANUS 2.5 LF UNIT-8 MCG-5 LF/0.5ML IM SYRINGE" RX-41293 CDM 90715 HCPCS 636 RC 58160-0842-52 NDC outpatient 0.5 ML 227.14 227.14 HEALTHPARTNERS SX009 HEALTHPARTNERS 181.71 percent of total billed charges 140.83 215.78 Technical (Hospital) Services "DIPHTH,PERTUSSIS(ACEL),TETANUS 2.5 LF UNIT-8 MCG-5 LF/0.5ML IM SYRINGE" RX-41293 CDM 90715 HCPCS 636 RC 58160-0842-52 NDC outpatient 0.5 ML 227.14 227.14 CIGNA 62308 [3081051] CIGNA 62308 [308105105] 181.71 percent of total billed charges 140.83 215.78 Technical (Hospital) Services "DIPHTH,PERTUSSIS(ACEL),TETANUS 2.5 LF UNIT-8 MCG-5 LF/0.5ML IM SYRINGE" RX-41293 CDM 90715 HCPCS 636 RC 58160-0842-52 NDC outpatient 0.5 ML 227.14 227.14 CIGNA 62308 [3081051] CIGNA STATE OF WYOMING [308105107] 181.71 percent of total billed charges 140.83 215.78 Technical (Hospital) Services "DIPHTH,PERTUSSIS(ACEL),TETANUS 2.5 LF UNIT-8 MCG-5 LF/0.5ML IM SYRINGE" RX-41293 CDM 90715 HCPCS 636 RC 58160-0842-52 NDC outpatient 0.5 ML 227.14 227.14 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES EPO [308136803] 181.71 percent of total billed charges 140.83 215.78 Technical (Hospital) Services "DIPHTH,PERTUSSIS(ACEL),TETANUS 2.5 LF UNIT-8 MCG-5 LF/0.5ML IM SYRINGE" RX-41293 CDM 90715 HCPCS 636 RC 58160-0842-52 NDC outpatient 0.5 ML 227.14 227.14 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES HDHP [308136802] 181.71 percent of total billed charges 140.83 215.78 Technical (Hospital) Services "DIPHTH,PERTUSSIS(ACEL),TETANUS 2.5 LF UNIT-8 MCG-5 LF/0.5ML IM SYRINGE" RX-41293 CDM 90715 HCPCS 636 RC 58160-0842-52 NDC outpatient 0.5 ML 227.14 227.14 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES PPO [308136801] 181.71 percent of total billed charges 140.83 215.78 Technical (Hospital) Services "DIPHTH,PERTUSSIS(ACEL),TETANUS 2.5 LF UNIT-8 MCG-5 LF/0.5ML IM SYRINGE" RX-41293 CDM 90715 HCPCS 636 RC 58160-0842-52 NDC outpatient 0.5 ML 227.14 227.14 MEDICA (COMMERCIAL) 94265 [3081118] MEDICA CLAIMS [308111801] 204.43 percent of total billed charges 140.83 215.78 Technical (Hospital) Services "DIPHTH,PERTUSSIS(ACEL),TETANUS 2.5 LF UNIT-8 MCG-5 LF/0.5ML IM SYRINGE" RX-41293 CDM 90715 HCPCS 636 RC 58160-0842-52 NDC outpatient 0.5 ML 227.14 227.14 MULTIPLAN INC 34080 [3081285] MULTIPLAN INC [308128501] 215.78 percent of total billed charges 140.83 215.78 Technical (Hospital) Services "DIPHTH,PERTUSSIS(ACEL),TETANUS 2.5 LF UNIT-8 MCG-5 LF/0.5ML IM SYRINGE" RX-41293 CDM 90715 HCPCS 636 RC 58160-0842-52 NDC outpatient 0.5 ML 227.14 227.14 UNITED HEALTHCARE (COMMERCIAL) [3081199] UNITED HEALTHCARE 87726 [308119901] 140.83 percent of total billed charges 140.83 215.78 Technical (Hospital) Services TETANUS AND DIPHTHERIA TOX (PF) 5 LF UNIT-2 LF UNIT/0.5 ML IM SYRINGE RX-128427 CDM 90714 HCPCS 636 RC 49281-0215-88 NDC inpatient 0.5 ML 172.6 172.6 MULTIPLAN INC 34080 [3081285] MULTIPLAN INC [308128501] 163.97 percent of total billed charges 107.01 163.97 Technical (Hospital) Services TETANUS AND DIPHTHERIA TOX (PF) 5 LF UNIT-2 LF UNIT/0.5 ML IM SYRINGE RX-128427 CDM 90714 HCPCS 636 RC 49281-0215-88 NDC inpatient 0.5 ML 172.6 172.6 HEALTHPARTNERS SX009 HEALTHPARTNERS 136.66 percent of total billed charges 107.01 163.97 Technical (Hospital) Services TETANUS AND DIPHTHERIA TOX (PF) 5 LF UNIT-2 LF UNIT/0.5 ML IM SYRINGE RX-128427 CDM 90714 HCPCS 636 RC 49281-0215-88 NDC inpatient 0.5 ML 172.6 172.6 UNITED HEALTHCARE (COMMERCIAL) [3081199] UNITED HEALTHCARE 87726 [308119901] 107.01 percent of total billed charges 107.01 163.97 Technical (Hospital) Services TETANUS AND DIPHTHERIA TOX (PF) 5 LF UNIT-2 LF UNIT/0.5 ML IM SYRINGE RX-128427 CDM 90714 HCPCS 636 RC 49281-0215-88 NDC inpatient 0.5 ML 172.6 172.6 BLUE CROSS BLUE SHIELD WELLMARK SB889 [3081026] BCBS WYOMING [308102603] 163.97 percent of total billed charges 107.01 163.97 Technical (Hospital) Services TETANUS AND DIPHTHERIA TOX (PF) 5 LF UNIT-2 LF UNIT/0.5 ML IM SYRINGE RX-128427 CDM 90714 HCPCS 636 RC 49281-0215-88 NDC inpatient 0.5 ML 172.6 172.6 MEDICA (COMMERCIAL) 94265 [3081118] MEDICA CLAIMS [308111801] 155.34 percent of total billed charges 107.01 163.97 Technical (Hospital) Services TETANUS AND DIPHTHERIA TOX (PF) 5 LF UNIT-2 LF UNIT/0.5 ML IM SYRINGE RX-128427 CDM 90714 HCPCS 636 RC 49281-0215-88 NDC inpatient 0.5 ML 172.6 172.6 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES PPO [308136801] 136.66 percent of total billed charges 107.01 163.97 Technical (Hospital) Services TETANUS AND DIPHTHERIA TOX (PF) 5 LF UNIT-2 LF UNIT/0.5 ML IM SYRINGE RX-128427 CDM 90714 HCPCS 636 RC 49281-0215-88 NDC inpatient 0.5 ML 172.6 172.6 CIGNA 62308 [3081051] CIGNA 62308 [308105105] 136.66 percent of total billed charges 107.01 163.97 Technical (Hospital) Services TETANUS AND DIPHTHERIA TOX (PF) 5 LF UNIT-2 LF UNIT/0.5 ML IM SYRINGE RX-128427 CDM 90714 HCPCS 636 RC 49281-0215-88 NDC inpatient 0.5 ML 172.6 172.6 CIGNA 62308 [3081051] CIGNA STATE OF WYOMING [308105107] 136.66 percent of total billed charges 107.01 163.97 Technical (Hospital) Services TETANUS AND DIPHTHERIA TOX (PF) 5 LF UNIT-2 LF UNIT/0.5 ML IM SYRINGE RX-128427 CDM 90714 HCPCS 636 RC 49281-0215-88 NDC inpatient 0.5 ML 172.6 172.6 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES HDHP [308136802] 136.66 percent of total billed charges 107.01 163.97 Technical (Hospital) Services TETANUS AND DIPHTHERIA TOX (PF) 5 LF UNIT-2 LF UNIT/0.5 ML IM SYRINGE RX-128427 CDM 90714 HCPCS 636 RC 49281-0215-88 NDC inpatient 0.5 ML 172.6 172.6 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES EPO [308136803] 136.66 percent of total billed charges 107.01 163.97 Technical (Hospital) Services TETANUS AND DIPHTHERIA TOX (PF) 5 LF UNIT-2 LF UNIT/0.5 ML IM SYRINGE RX-128427 CDM 90714 HCPCS 636 RC 49281-0215-88 NDC outpatient 0.5 ML 172.6 172.6 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES HDHP [308136802] 138.08 percent of total billed charges 107.01 163.97 Technical (Hospital) Services TETANUS AND DIPHTHERIA TOX (PF) 5 LF UNIT-2 LF UNIT/0.5 ML IM SYRINGE RX-128427 CDM 90714 HCPCS 636 RC 49281-0215-88 NDC outpatient 0.5 ML 172.6 172.6 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES PPO [308136801] 138.08 percent of total billed charges 107.01 163.97 Technical (Hospital) Services TETANUS AND DIPHTHERIA TOX (PF) 5 LF UNIT-2 LF UNIT/0.5 ML IM SYRINGE RX-128427 CDM 90714 HCPCS 636 RC 49281-0215-88 NDC outpatient 0.5 ML 172.6 172.6 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES EPO [308136803] 138.08 percent of total billed charges 107.01 163.97 Technical (Hospital) Services TETANUS AND DIPHTHERIA TOX (PF) 5 LF UNIT-2 LF UNIT/0.5 ML IM SYRINGE RX-128427 CDM 90714 HCPCS 636 RC 49281-0215-88 NDC outpatient 0.5 ML 172.6 172.6 UNITED HEALTHCARE (COMMERCIAL) [3081199] UNITED HEALTHCARE 87726 [308119901] 107.01 percent of total billed charges 107.01 163.97 Technical (Hospital) Services TETANUS AND DIPHTHERIA TOX (PF) 5 LF UNIT-2 LF UNIT/0.5 ML IM SYRINGE RX-128427 CDM 90714 HCPCS 636 RC 49281-0215-88 NDC outpatient 0.5 ML 172.6 172.6 CIGNA 62308 [3081051] CIGNA STATE OF WYOMING [308105107] 138.08 percent of total billed charges 107.01 163.97 Technical (Hospital) Services TETANUS AND DIPHTHERIA TOX (PF) 5 LF UNIT-2 LF UNIT/0.5 ML IM SYRINGE RX-128427 CDM 90714 HCPCS 636 RC 49281-0215-88 NDC outpatient 0.5 ML 172.6 172.6 CIGNA 62308 [3081051] CIGNA 62308 [308105105] 138.08 percent of total billed charges 107.01 163.97 Technical (Hospital) Services TETANUS AND DIPHTHERIA TOX (PF) 5 LF UNIT-2 LF UNIT/0.5 ML IM SYRINGE RX-128427 CDM 90714 HCPCS 636 RC 49281-0215-88 NDC outpatient 0.5 ML 172.6 172.6 MULTIPLAN INC 34080 [3081285] MULTIPLAN INC [308128501] 163.97 percent of total billed charges 107.01 163.97 Technical (Hospital) Services TETANUS AND DIPHTHERIA TOX (PF) 5 LF UNIT-2 LF UNIT/0.5 ML IM SYRINGE RX-128427 CDM 90714 HCPCS 636 RC 49281-0215-88 NDC outpatient 0.5 ML 172.6 172.6 MEDICA (COMMERCIAL) 94265 [3081118] MEDICA CLAIMS [308111801] 155.34 percent of total billed charges 107.01 163.97 Technical (Hospital) Services TETANUS AND DIPHTHERIA TOX (PF) 5 LF UNIT-2 LF UNIT/0.5 ML IM SYRINGE RX-128427 CDM 90714 HCPCS 636 RC 49281-0215-88 NDC outpatient 0.5 ML 172.6 172.6 HEALTHPARTNERS SX009 HEALTHPARTNERS 138.08 percent of total billed charges 107.01 163.97 Technical (Hospital) Services TETANUS AND DIPHTHERIA TOX (PF) 5 LF UNIT-2 LF UNIT/0.5 ML IM SYRINGE RX-128427 CDM 90714 HCPCS 636 RC 49281-0215-88 NDC outpatient 0.5 ML 172.6 172.6 BLUE CROSS BLUE SHIELD WELLMARK SB889 [3081026] BCBS WYOMING [308102603] 163.97 percent of total billed charges 107.01 163.97 Technical (Hospital) Services TETANUS AND DIPHTHERIA TOX (PF) 5 LF UNIT-2 LF UNIT/0.5 ML IM SUSP RX-128440 CDM 90714 HCPCS 636 RC 49281-0215-10 NDC outpatient 0.5 ML 172.6 172.6 BLUE CROSS BLUE SHIELD WELLMARK SB889 [3081026] BCBS WYOMING [308102603] 163.97 percent of total billed charges 107.01 163.97 Technical (Hospital) Services TETANUS AND DIPHTHERIA TOX (PF) 5 LF UNIT-2 LF UNIT/0.5 ML IM SUSP RX-128440 CDM 90714 HCPCS 636 RC 49281-0215-10 NDC outpatient 0.5 ML 172.6 172.6 HEALTHPARTNERS SX009 HEALTHPARTNERS 138.08 percent of total billed charges 107.01 163.97 Technical (Hospital) Services TETANUS AND DIPHTHERIA TOX (PF) 5 LF UNIT-2 LF UNIT/0.5 ML IM SUSP RX-128440 CDM 90714 HCPCS 636 RC 49281-0215-10 NDC outpatient 0.5 ML 172.6 172.6 MEDICA (COMMERCIAL) 94265 [3081118] MEDICA CLAIMS [308111801] 155.34 percent of total billed charges 107.01 163.97 Technical (Hospital) Services TETANUS AND DIPHTHERIA TOX (PF) 5 LF UNIT-2 LF UNIT/0.5 ML IM SUSP RX-128440 CDM 90714 HCPCS 636 RC 49281-0215-10 NDC outpatient 0.5 ML 172.6 172.6 CIGNA 62308 [3081051] CIGNA 62308 [308105105] 138.08 percent of total billed charges 107.01 163.97 Technical (Hospital) Services TETANUS AND DIPHTHERIA TOX (PF) 5 LF UNIT-2 LF UNIT/0.5 ML IM SUSP RX-128440 CDM 90714 HCPCS 636 RC 49281-0215-10 NDC outpatient 0.5 ML 172.6 172.6 CIGNA 62308 [3081051] CIGNA STATE OF WYOMING [308105107] 138.08 percent of total billed charges 107.01 163.97 Technical (Hospital) Services TETANUS AND DIPHTHERIA TOX (PF) 5 LF UNIT-2 LF UNIT/0.5 ML IM SUSP RX-128440 CDM 90714 HCPCS 636 RC 49281-0215-10 NDC outpatient 0.5 ML 172.6 172.6 MULTIPLAN INC 34080 [3081285] MULTIPLAN INC [308128501] 163.97 percent of total billed charges 107.01 163.97 Technical (Hospital) Services TETANUS AND DIPHTHERIA TOX (PF) 5 LF UNIT-2 LF UNIT/0.5 ML IM SUSP RX-128440 CDM 90714 HCPCS 636 RC 49281-0215-10 NDC outpatient 0.5 ML 172.6 172.6 UNITED HEALTHCARE (COMMERCIAL) [3081199] UNITED HEALTHCARE 87726 [308119901] 107.01 percent of total billed charges 107.01 163.97 Technical (Hospital) Services TETANUS AND DIPHTHERIA TOX (PF) 5 LF UNIT-2 LF UNIT/0.5 ML IM SUSP RX-128440 CDM 90714 HCPCS 636 RC 49281-0215-10 NDC outpatient 0.5 ML 172.6 172.6 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES PPO [308136801] 138.08 percent of total billed charges 107.01 163.97 Technical (Hospital) Services TETANUS AND DIPHTHERIA TOX (PF) 5 LF UNIT-2 LF UNIT/0.5 ML IM SUSP RX-128440 CDM 90714 HCPCS 636 RC 49281-0215-10 NDC outpatient 0.5 ML 172.6 172.6 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES HDHP [308136802] 138.08 percent of total billed charges 107.01 163.97 Technical (Hospital) Services TETANUS AND DIPHTHERIA TOX (PF) 5 LF UNIT-2 LF UNIT/0.5 ML IM SUSP RX-128440 CDM 90714 HCPCS 636 RC 49281-0215-10 NDC outpatient 0.5 ML 172.6 172.6 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES EPO [308136803] 138.08 percent of total billed charges 107.01 163.97 Technical (Hospital) Services TETANUS AND DIPHTHERIA TOX (PF) 5 LF UNIT-2 LF UNIT/0.5 ML IM SUSP RX-128440 CDM 90714 HCPCS 636 RC 49281-0215-10 NDC inpatient 0.5 ML 172.6 172.6 MULTIPLAN INC 34080 [3081285] MULTIPLAN INC [308128501] 163.97 percent of total billed charges 107.01 163.97 Technical (Hospital) Services TETANUS AND DIPHTHERIA TOX (PF) 5 LF UNIT-2 LF UNIT/0.5 ML IM SUSP RX-128440 CDM 90714 HCPCS 636 RC 49281-0215-10 NDC inpatient 0.5 ML 172.6 172.6 MEDICA (COMMERCIAL) 94265 [3081118] MEDICA CLAIMS [308111801] 155.34 percent of total billed charges 107.01 163.97 Technical (Hospital) Services TETANUS AND DIPHTHERIA TOX (PF) 5 LF UNIT-2 LF UNIT/0.5 ML IM SUSP RX-128440 CDM 90714 HCPCS 636 RC 49281-0215-10 NDC inpatient 0.5 ML 172.6 172.6 HEALTHPARTNERS SX009 HEALTHPARTNERS 136.66 percent of total billed charges 107.01 163.97 Technical (Hospital) Services TETANUS AND DIPHTHERIA TOX (PF) 5 LF UNIT-2 LF UNIT/0.5 ML IM SUSP RX-128440 CDM 90714 HCPCS 636 RC 49281-0215-10 NDC inpatient 0.5 ML 172.6 172.6 BLUE CROSS BLUE SHIELD WELLMARK SB889 [3081026] BCBS WYOMING [308102603] 163.97 percent of total billed charges 107.01 163.97 Technical (Hospital) Services TETANUS AND DIPHTHERIA TOX (PF) 5 LF UNIT-2 LF UNIT/0.5 ML IM SUSP RX-128440 CDM 90714 HCPCS 636 RC 49281-0215-10 NDC inpatient 0.5 ML 172.6 172.6 UNITED HEALTHCARE (COMMERCIAL) [3081199] UNITED HEALTHCARE 87726 [308119901] 107.01 percent of total billed charges 107.01 163.97 Technical (Hospital) Services TETANUS AND DIPHTHERIA TOX (PF) 5 LF UNIT-2 LF UNIT/0.5 ML IM SUSP RX-128440 CDM 90714 HCPCS 636 RC 49281-0215-10 NDC inpatient 0.5 ML 172.6 172.6 CIGNA 62308 [3081051] CIGNA 62308 [308105105] 136.66 percent of total billed charges 107.01 163.97 Technical (Hospital) Services TETANUS AND DIPHTHERIA TOX (PF) 5 LF UNIT-2 LF UNIT/0.5 ML IM SUSP RX-128440 CDM 90714 HCPCS 636 RC 49281-0215-10 NDC inpatient 0.5 ML 172.6 172.6 CIGNA 62308 [3081051] CIGNA STATE OF WYOMING [308105107] 136.66 percent of total billed charges 107.01 163.97 Technical (Hospital) Services TETANUS AND DIPHTHERIA TOX (PF) 5 LF UNIT-2 LF UNIT/0.5 ML IM SUSP RX-128440 CDM 90714 HCPCS 636 RC 49281-0215-10 NDC inpatient 0.5 ML 172.6 172.6 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES HDHP [308136802] 136.66 percent of total billed charges 107.01 163.97 Technical (Hospital) Services TETANUS AND DIPHTHERIA TOX (PF) 5 LF UNIT-2 LF UNIT/0.5 ML IM SUSP RX-128440 CDM 90714 HCPCS 636 RC 49281-0215-10 NDC inpatient 0.5 ML 172.6 172.6 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES PPO [308136801] 136.66 percent of total billed charges 107.01 163.97 Technical (Hospital) Services TETANUS AND DIPHTHERIA TOX (PF) 5 LF UNIT-2 LF UNIT/0.5 ML IM SUSP RX-128440 CDM 90714 HCPCS 636 RC 49281-0215-10 NDC inpatient 0.5 ML 172.6 172.6 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES EPO [308136803] 136.66 percent of total billed charges 107.01 163.97 Technical (Hospital) Services "MEASLES,MUMPS,RUBELLA VACCINE LIVE(PF)1,000-12,500TCID50/0.5 ML SUBCUT" RX-10512 CDM 90707 HCPCS 636 RC 00006-4681-00 NDC inpatient 0.5 ML 352.24 352.24 MULTIPLAN INC 34080 [3081285] MULTIPLAN INC [308128501] 334.63 percent of total billed charges 218.39 334.63 Technical (Hospital) Services "MEASLES,MUMPS,RUBELLA VACCINE LIVE(PF)1,000-12,500TCID50/0.5 ML SUBCUT" RX-10512 CDM 90707 HCPCS 636 RC 00006-4681-00 NDC inpatient 0.5 ML 352.24 352.24 HEALTHPARTNERS SX009 HEALTHPARTNERS 278.9 percent of total billed charges 218.39 334.63 Technical (Hospital) Services "MEASLES,MUMPS,RUBELLA VACCINE LIVE(PF)1,000-12,500TCID50/0.5 ML SUBCUT" RX-10512 CDM 90707 HCPCS 636 RC 00006-4681-00 NDC inpatient 0.5 ML 352.24 352.24 UNITED HEALTHCARE (COMMERCIAL) [3081199] UNITED HEALTHCARE 87726 [308119901] 218.39 percent of total billed charges 218.39 334.63 Technical (Hospital) Services "MEASLES,MUMPS,RUBELLA VACCINE LIVE(PF)1,000-12,500TCID50/0.5 ML SUBCUT" RX-10512 CDM 90707 HCPCS 636 RC 00006-4681-00 NDC inpatient 0.5 ML 352.24 352.24 BLUE CROSS BLUE SHIELD WELLMARK SB889 [3081026] BCBS WYOMING [308102603] 334.63 percent of total billed charges 218.39 334.63 Technical (Hospital) Services "MEASLES,MUMPS,RUBELLA VACCINE LIVE(PF)1,000-12,500TCID50/0.5 ML SUBCUT" RX-10512 CDM 90707 HCPCS 636 RC 00006-4681-00 NDC inpatient 0.5 ML 352.24 352.24 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES HDHP [308136802] 278.9 percent of total billed charges 218.39 334.63 Technical (Hospital) Services "MEASLES,MUMPS,RUBELLA VACCINE LIVE(PF)1,000-12,500TCID50/0.5 ML SUBCUT" RX-10512 CDM 90707 HCPCS 636 RC 00006-4681-00 NDC inpatient 0.5 ML 352.24 352.24 CIGNA 62308 [3081051] CIGNA 62308 [308105105] 278.9 percent of total billed charges 218.39 334.63 Technical (Hospital) Services "MEASLES,MUMPS,RUBELLA VACCINE LIVE(PF)1,000-12,500TCID50/0.5 ML SUBCUT" RX-10512 CDM 90707 HCPCS 636 RC 00006-4681-00 NDC inpatient 0.5 ML 352.24 352.24 CIGNA 62308 [3081051] CIGNA STATE OF WYOMING [308105107] 278.9 percent of total billed charges 218.39 334.63 Technical (Hospital) Services "MEASLES,MUMPS,RUBELLA VACCINE LIVE(PF)1,000-12,500TCID50/0.5 ML SUBCUT" RX-10512 CDM 90707 HCPCS 636 RC 00006-4681-00 NDC inpatient 0.5 ML 352.24 352.24 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES PPO [308136801] 278.9 percent of total billed charges 218.39 334.63 Technical (Hospital) Services "MEASLES,MUMPS,RUBELLA VACCINE LIVE(PF)1,000-12,500TCID50/0.5 ML SUBCUT" RX-10512 CDM 90707 HCPCS 636 RC 00006-4681-00 NDC inpatient 0.5 ML 352.24 352.24 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES EPO [308136803] 278.9 percent of total billed charges 218.39 334.63 Technical (Hospital) Services "MEASLES,MUMPS,RUBELLA VACCINE LIVE(PF)1,000-12,500TCID50/0.5 ML SUBCUT" RX-10512 CDM 90707 HCPCS 636 RC 00006-4681-00 NDC inpatient 0.5 ML 352.24 352.24 MEDICA (COMMERCIAL) 94265 [3081118] MEDICA CLAIMS [308111801] 317.02 percent of total billed charges 218.39 334.63 Technical (Hospital) Services "MEASLES,MUMPS,RUBELLA VACCINE LIVE(PF)1,000-12,500TCID50/0.5 ML SUBCUT" RX-10512 CDM 90707 HCPCS 636 RC 00006-4681-00 NDC outpatient 0.5 ML 352.24 352.24 HEALTHPARTNERS SX009 HEALTHPARTNERS 281.79 percent of total billed charges 218.39 334.63 Technical (Hospital) Services "MEASLES,MUMPS,RUBELLA VACCINE LIVE(PF)1,000-12,500TCID50/0.5 ML SUBCUT" RX-10512 CDM 90707 HCPCS 636 RC 00006-4681-00 NDC outpatient 0.5 ML 352.24 352.24 BLUE CROSS BLUE SHIELD WELLMARK SB889 [3081026] BCBS WYOMING [308102603] 334.63 percent of total billed charges 218.39 334.63 Technical (Hospital) Services "MEASLES,MUMPS,RUBELLA VACCINE LIVE(PF)1,000-12,500TCID50/0.5 ML SUBCUT" RX-10512 CDM 90707 HCPCS 636 RC 00006-4681-00 NDC outpatient 0.5 ML 352.24 352.24 UNITED HEALTHCARE (COMMERCIAL) [3081199] UNITED HEALTHCARE 87726 [308119901] 218.39 percent of total billed charges 218.39 334.63 Technical (Hospital) Services "MEASLES,MUMPS,RUBELLA VACCINE LIVE(PF)1,000-12,500TCID50/0.5 ML SUBCUT" RX-10512 CDM 90707 HCPCS 636 RC 00006-4681-00 NDC outpatient 0.5 ML 352.24 352.24 MULTIPLAN INC 34080 [3081285] MULTIPLAN INC [308128501] 334.63 percent of total billed charges 218.39 334.63 Technical (Hospital) Services "MEASLES,MUMPS,RUBELLA VACCINE LIVE(PF)1,000-12,500TCID50/0.5 ML SUBCUT" RX-10512 CDM 90707 HCPCS 636 RC 00006-4681-00 NDC outpatient 0.5 ML 352.24 352.24 CIGNA 62308 [3081051] CIGNA 62308 [308105105] 281.79 percent of total billed charges 218.39 334.63 Technical (Hospital) Services "MEASLES,MUMPS,RUBELLA VACCINE LIVE(PF)1,000-12,500TCID50/0.5 ML SUBCUT" RX-10512 CDM 90707 HCPCS 636 RC 00006-4681-00 NDC outpatient 0.5 ML 352.24 352.24 CIGNA 62308 [3081051] CIGNA STATE OF WYOMING [308105107] 281.79 percent of total billed charges 218.39 334.63 Technical (Hospital) Services "MEASLES,MUMPS,RUBELLA VACCINE LIVE(PF)1,000-12,500TCID50/0.5 ML SUBCUT" RX-10512 CDM 90707 HCPCS 636 RC 00006-4681-00 NDC outpatient 0.5 ML 352.24 352.24 MEDICA (COMMERCIAL) 94265 [3081118] MEDICA CLAIMS [308111801] 317.02 percent of total billed charges 218.39 334.63 Technical (Hospital) Services "MEASLES,MUMPS,RUBELLA VACCINE LIVE(PF)1,000-12,500TCID50/0.5 ML SUBCUT" RX-10512 CDM 90707 HCPCS 636 RC 00006-4681-00 NDC outpatient 0.5 ML 352.24 352.24 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES HDHP [308136802] 281.79 percent of total billed charges 218.39 334.63 Technical (Hospital) Services "MEASLES,MUMPS,RUBELLA VACCINE LIVE(PF)1,000-12,500TCID50/0.5 ML SUBCUT" RX-10512 CDM 90707 HCPCS 636 RC 00006-4681-00 NDC outpatient 0.5 ML 352.24 352.24 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES PPO [308136801] 281.79 percent of total billed charges 218.39 334.63 Technical (Hospital) Services "MEASLES,MUMPS,RUBELLA VACCINE LIVE(PF)1,000-12,500TCID50/0.5 ML SUBCUT" RX-10512 CDM 90707 HCPCS 636 RC 00006-4681-00 NDC outpatient 0.5 ML 352.24 352.24 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES EPO [308136803] 281.79 percent of total billed charges 218.39 334.63 Technical (Hospital) Services "RESP SYNCYTIAL VIRUS VAC, PREF A AND B (PF) 120 MCG/0.5 ML IM SOLUTION" RX-190377 CDM 90678 HCPCS 636 RC 00069-0344-01 NDC outpatient 0.5 ML 458 458 BLUE CROSS BLUE SHIELD WELLMARK SB889 [3081026] BCBS WYOMING [308102603] 435.1 percent of total billed charges 283.96 435.1 Technical (Hospital) Services "RESP SYNCYTIAL VIRUS VAC, PREF A AND B (PF) 120 MCG/0.5 ML IM SOLUTION" RX-190377 CDM 90678 HCPCS 636 RC 00069-0344-01 NDC outpatient 0.5 ML 458 458 HEALTHPARTNERS SX009 HEALTHPARTNERS 366.4 percent of total billed charges 283.96 435.1 Technical (Hospital) Services "RESP SYNCYTIAL VIRUS VAC, PREF A AND B (PF) 120 MCG/0.5 ML IM SOLUTION" RX-190377 CDM 90678 HCPCS 636 RC 00069-0344-01 NDC outpatient 0.5 ML 458 458 MEDICA (COMMERCIAL) 94265 [3081118] MEDICA CLAIMS [308111801] 412.2 percent of total billed charges 283.96 435.1 Technical (Hospital) Services "RESP SYNCYTIAL VIRUS VAC, PREF A AND B (PF) 120 MCG/0.5 ML IM SOLUTION" RX-190377 CDM 90678 HCPCS 636 RC 00069-0344-01 NDC outpatient 0.5 ML 458 458 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES EPO [308136803] 366.4 percent of total billed charges 283.96 435.1 Technical (Hospital) Services "RESP SYNCYTIAL VIRUS VAC, PREF A AND B (PF) 120 MCG/0.5 ML IM SOLUTION" RX-190377 CDM 90678 HCPCS 636 RC 00069-0344-01 NDC outpatient 0.5 ML 458 458 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES HDHP [308136802] 366.4 percent of total billed charges 283.96 435.1 Technical (Hospital) Services "RESP SYNCYTIAL VIRUS VAC, PREF A AND B (PF) 120 MCG/0.5 ML IM SOLUTION" RX-190377 CDM 90678 HCPCS 636 RC 00069-0344-01 NDC outpatient 0.5 ML 458 458 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES PPO [308136801] 366.4 percent of total billed charges 283.96 435.1 Technical (Hospital) Services "RESP SYNCYTIAL VIRUS VAC, PREF A AND B (PF) 120 MCG/0.5 ML IM SOLUTION" RX-190377 CDM 90678 HCPCS 636 RC 00069-0344-01 NDC outpatient 0.5 ML 458 458 UNITED HEALTHCARE (COMMERCIAL) [3081199] UNITED HEALTHCARE 87726 [308119901] 283.96 percent of total billed charges 283.96 435.1 Technical (Hospital) Services "RESP SYNCYTIAL VIRUS VAC, PREF A AND B (PF) 120 MCG/0.5 ML IM SOLUTION" RX-190377 CDM 90678 HCPCS 636 RC 00069-0344-01 NDC outpatient 0.5 ML 458 458 MULTIPLAN INC 34080 [3081285] MULTIPLAN INC [308128501] 435.1 percent of total billed charges 283.96 435.1 Technical (Hospital) Services "RESP SYNCYTIAL VIRUS VAC, PREF A AND B (PF) 120 MCG/0.5 ML IM SOLUTION" RX-190377 CDM 90678 HCPCS 636 RC 00069-0344-01 NDC outpatient 0.5 ML 458 458 CIGNA 62308 [3081051] CIGNA 62308 [308105105] 366.4 percent of total billed charges 283.96 435.1 Technical (Hospital) Services "RESP SYNCYTIAL VIRUS VAC, PREF A AND B (PF) 120 MCG/0.5 ML IM SOLUTION" RX-190377 CDM 90678 HCPCS 636 RC 00069-0344-01 NDC outpatient 0.5 ML 458 458 CIGNA 62308 [3081051] CIGNA STATE OF WYOMING [308105107] 366.4 percent of total billed charges 283.96 435.1 Technical (Hospital) Services "RESP SYNCYTIAL VIRUS VAC, PREF A AND B (PF) 120 MCG/0.5 ML IM SOLUTION" RX-190377 CDM 90678 HCPCS 636 RC 00069-0344-01 NDC inpatient 0.5 ML 458 458 MULTIPLAN INC 34080 [3081285] MULTIPLAN INC [308128501] 435.1 percent of total billed charges 283.96 435.1 Technical (Hospital) Services "RESP SYNCYTIAL VIRUS VAC, PREF A AND B (PF) 120 MCG/0.5 ML IM SOLUTION" RX-190377 CDM 90678 HCPCS 636 RC 00069-0344-01 NDC inpatient 0.5 ML 458 458 HEALTHPARTNERS SX009 HEALTHPARTNERS 362.64 percent of total billed charges 283.96 435.1 Technical (Hospital) Services "RESP SYNCYTIAL VIRUS VAC, PREF A AND B (PF) 120 MCG/0.5 ML IM SOLUTION" RX-190377 CDM 90678 HCPCS 636 RC 00069-0344-01 NDC inpatient 0.5 ML 458 458 MEDICA (COMMERCIAL) 94265 [3081118] MEDICA CLAIMS [308111801] 412.2 percent of total billed charges 283.96 435.1 Technical (Hospital) Services "RESP SYNCYTIAL VIRUS VAC, PREF A AND B (PF) 120 MCG/0.5 ML IM SOLUTION" RX-190377 CDM 90678 HCPCS 636 RC 00069-0344-01 NDC inpatient 0.5 ML 458 458 UNITED HEALTHCARE (COMMERCIAL) [3081199] UNITED HEALTHCARE 87726 [308119901] 283.96 percent of total billed charges 283.96 435.1 Technical (Hospital) Services "RESP SYNCYTIAL VIRUS VAC, PREF A AND B (PF) 120 MCG/0.5 ML IM SOLUTION" RX-190377 CDM 90678 HCPCS 636 RC 00069-0344-01 NDC inpatient 0.5 ML 458 458 BLUE CROSS BLUE SHIELD WELLMARK SB889 [3081026] BCBS WYOMING [308102603] 435.1 percent of total billed charges 283.96 435.1 Technical (Hospital) Services "RESP SYNCYTIAL VIRUS VAC, PREF A AND B (PF) 120 MCG/0.5 ML IM SOLUTION" RX-190377 CDM 90678 HCPCS 636 RC 00069-0344-01 NDC inpatient 0.5 ML 458 458 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES PPO [308136801] 362.64 percent of total billed charges 283.96 435.1 Technical (Hospital) Services "RESP SYNCYTIAL VIRUS VAC, PREF A AND B (PF) 120 MCG/0.5 ML IM SOLUTION" RX-190377 CDM 90678 HCPCS 636 RC 00069-0344-01 NDC inpatient 0.5 ML 458 458 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES HDHP [308136802] 362.64 percent of total billed charges 283.96 435.1 Technical (Hospital) Services "RESP SYNCYTIAL VIRUS VAC, PREF A AND B (PF) 120 MCG/0.5 ML IM SOLUTION" RX-190377 CDM 90678 HCPCS 636 RC 00069-0344-01 NDC inpatient 0.5 ML 458 458 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES EPO [308136803] 362.64 percent of total billed charges 283.96 435.1 Technical (Hospital) Services "RESP SYNCYTIAL VIRUS VAC, PREF A AND B (PF) 120 MCG/0.5 ML IM SOLUTION" RX-190377 CDM 90678 HCPCS 636 RC 00069-0344-01 NDC inpatient 0.5 ML 458 458 CIGNA 62308 [3081051] CIGNA 62308 [308105105] 362.64 percent of total billed charges 283.96 435.1 Technical (Hospital) Services "RESP SYNCYTIAL VIRUS VAC, PREF A AND B (PF) 120 MCG/0.5 ML IM SOLUTION" RX-190377 CDM 90678 HCPCS 636 RC 00069-0344-01 NDC inpatient 0.5 ML 458 458 CIGNA 62308 [3081051] CIGNA STATE OF WYOMING [308105107] 362.64 percent of total billed charges 283.96 435.1 Technical (Hospital) Services PNEUMOCOCCAL 20-VALENT CONJ VACCINE-DIP CRM (PF) 0.5 ML IM SYRINGE RX-183812 CDM 90677 HCPCS 636 RC 00005-2000-01 NDC outpatient 0.5 ML 669.01 669.01 MEDICA (COMMERCIAL) 94265 [3081118] MEDICA CLAIMS [308111801] 602.11 percent of total billed charges 414.79 635.56 Technical (Hospital) Services PNEUMOCOCCAL 20-VALENT CONJ VACCINE-DIP CRM (PF) 0.5 ML IM SYRINGE RX-183812 CDM 90677 HCPCS 636 RC 00005-2000-01 NDC outpatient 0.5 ML 669.01 669.01 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES HDHP [308136802] 535.21 percent of total billed charges 414.79 635.56 Technical (Hospital) Services PNEUMOCOCCAL 20-VALENT CONJ VACCINE-DIP CRM (PF) 0.5 ML IM SYRINGE RX-183812 CDM 90677 HCPCS 636 RC 00005-2000-01 NDC outpatient 0.5 ML 669.01 669.01 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES PPO [308136801] 535.21 percent of total billed charges 414.79 635.56 Technical (Hospital) Services PNEUMOCOCCAL 20-VALENT CONJ VACCINE-DIP CRM (PF) 0.5 ML IM SYRINGE RX-183812 CDM 90677 HCPCS 636 RC 00005-2000-01 NDC outpatient 0.5 ML 669.01 669.01 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES EPO [308136803] 535.21 percent of total billed charges 414.79 635.56 Technical (Hospital) Services PNEUMOCOCCAL 20-VALENT CONJ VACCINE-DIP CRM (PF) 0.5 ML IM SYRINGE RX-183812 CDM 90677 HCPCS 636 RC 00005-2000-01 NDC outpatient 0.5 ML 669.01 669.01 CIGNA 62308 [3081051] CIGNA 62308 [308105105] 535.21 percent of total billed charges 414.79 635.56 Technical (Hospital) Services PNEUMOCOCCAL 20-VALENT CONJ VACCINE-DIP CRM (PF) 0.5 ML IM SYRINGE RX-183812 CDM 90677 HCPCS 636 RC 00005-2000-01 NDC outpatient 0.5 ML 669.01 669.01 CIGNA 62308 [3081051] CIGNA STATE OF WYOMING [308105107] 535.21 percent of total billed charges 414.79 635.56 Technical (Hospital) Services PNEUMOCOCCAL 20-VALENT CONJ VACCINE-DIP CRM (PF) 0.5 ML IM SYRINGE RX-183812 CDM 90677 HCPCS 636 RC 00005-2000-01 NDC outpatient 0.5 ML 669.01 669.01 MULTIPLAN INC 34080 [3081285] MULTIPLAN INC [308128501] 635.56 percent of total billed charges 414.79 635.56 Technical (Hospital) Services PNEUMOCOCCAL 20-VALENT CONJ VACCINE-DIP CRM (PF) 0.5 ML IM SYRINGE RX-183812 CDM 90677 HCPCS 636 RC 00005-2000-01 NDC outpatient 0.5 ML 669.01 669.01 UNITED HEALTHCARE (COMMERCIAL) [3081199] UNITED HEALTHCARE 87726 [308119901] 414.79 percent of total billed charges 414.79 635.56 Technical (Hospital) Services PNEUMOCOCCAL 20-VALENT CONJ VACCINE-DIP CRM (PF) 0.5 ML IM SYRINGE RX-183812 CDM 90677 HCPCS 636 RC 00005-2000-01 NDC outpatient 0.5 ML 669.01 669.01 BLUE CROSS BLUE SHIELD WELLMARK SB889 [3081026] BCBS WYOMING [308102603] 635.56 percent of total billed charges 414.79 635.56 Technical (Hospital) Services PNEUMOCOCCAL 20-VALENT CONJ VACCINE-DIP CRM (PF) 0.5 ML IM SYRINGE RX-183812 CDM 90677 HCPCS 636 RC 00005-2000-01 NDC outpatient 0.5 ML 669.01 669.01 HEALTHPARTNERS SX009 HEALTHPARTNERS 535.21 percent of total billed charges 414.79 635.56 Technical (Hospital) Services PNEUMOCOCCAL 20-VALENT CONJ VACCINE-DIP CRM (PF) 0.5 ML IM SYRINGE RX-183812 CDM 90677 HCPCS 636 RC 00005-2000-01 NDC inpatient 0.5 ML 669.01 669.01 BLUE CROSS BLUE SHIELD WELLMARK SB889 [3081026] BCBS WYOMING [308102603] 635.56 percent of total billed charges 414.79 635.56 Technical (Hospital) Services PNEUMOCOCCAL 20-VALENT CONJ VACCINE-DIP CRM (PF) 0.5 ML IM SYRINGE RX-183812 CDM 90677 HCPCS 636 RC 00005-2000-01 NDC inpatient 0.5 ML 669.01 669.01 UNITED HEALTHCARE (COMMERCIAL) [3081199] UNITED HEALTHCARE 87726 [308119901] 414.79 percent of total billed charges 414.79 635.56 Technical (Hospital) Services PNEUMOCOCCAL 20-VALENT CONJ VACCINE-DIP CRM (PF) 0.5 ML IM SYRINGE RX-183812 CDM 90677 HCPCS 636 RC 00005-2000-01 NDC inpatient 0.5 ML 669.01 669.01 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES EPO [308136803] 529.72 percent of total billed charges 414.79 635.56 Technical (Hospital) Services PNEUMOCOCCAL 20-VALENT CONJ VACCINE-DIP CRM (PF) 0.5 ML IM SYRINGE RX-183812 CDM 90677 HCPCS 636 RC 00005-2000-01 NDC inpatient 0.5 ML 669.01 669.01 CIGNA 62308 [3081051] CIGNA 62308 [308105105] 529.72 percent of total billed charges 414.79 635.56 Technical (Hospital) Services PNEUMOCOCCAL 20-VALENT CONJ VACCINE-DIP CRM (PF) 0.5 ML IM SYRINGE RX-183812 CDM 90677 HCPCS 636 RC 00005-2000-01 NDC inpatient 0.5 ML 669.01 669.01 CIGNA 62308 [3081051] CIGNA STATE OF WYOMING [308105107] 529.72 percent of total billed charges 414.79 635.56 Technical (Hospital) Services PNEUMOCOCCAL 20-VALENT CONJ VACCINE-DIP CRM (PF) 0.5 ML IM SYRINGE RX-183812 CDM 90677 HCPCS 636 RC 00005-2000-01 NDC inpatient 0.5 ML 669.01 669.01 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES HDHP [308136802] 529.72 percent of total billed charges 414.79 635.56 Technical (Hospital) Services PNEUMOCOCCAL 20-VALENT CONJ VACCINE-DIP CRM (PF) 0.5 ML IM SYRINGE RX-183812 CDM 90677 HCPCS 636 RC 00005-2000-01 NDC inpatient 0.5 ML 669.01 669.01 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES PPO [308136801] 529.72 percent of total billed charges 414.79 635.56 Technical (Hospital) Services PNEUMOCOCCAL 20-VALENT CONJ VACCINE-DIP CRM (PF) 0.5 ML IM SYRINGE RX-183812 CDM 90677 HCPCS 636 RC 00005-2000-01 NDC inpatient 0.5 ML 669.01 669.01 MULTIPLAN INC 34080 [3081285] MULTIPLAN INC [308128501] 635.56 percent of total billed charges 414.79 635.56 Technical (Hospital) Services PNEUMOCOCCAL 20-VALENT CONJ VACCINE-DIP CRM (PF) 0.5 ML IM SYRINGE RX-183812 CDM 90677 HCPCS 636 RC 00005-2000-01 NDC inpatient 0.5 ML 669.01 669.01 MEDICA (COMMERCIAL) 94265 [3081118] MEDICA CLAIMS [308111801] 602.11 percent of total billed charges 414.79 635.56 Technical (Hospital) Services PNEUMOCOCCAL 20-VALENT CONJ VACCINE-DIP CRM (PF) 0.5 ML IM SYRINGE RX-183812 CDM 90677 HCPCS 636 RC 00005-2000-01 NDC inpatient 0.5 ML 669.01 669.01 HEALTHPARTNERS SX009 HEALTHPARTNERS 529.72 percent of total billed charges 414.79 635.56 Technical (Hospital) Services "RABIES VACCINE, PURIFIED CHICKEN EMBRYO CELL (PF) 2.5 UNIT IM SUSP" RX-22120 CDM 90675 HCPCS 636 RC 50632-0010-01 NDC outpatient 1 ML 1063.91 1063.91 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES EPO [308136803] 851.13 percent of total billed charges 659.62 1010.71 Technical (Hospital) Services "RABIES VACCINE, PURIFIED CHICKEN EMBRYO CELL (PF) 2.5 UNIT IM SUSP" RX-22120 CDM 90675 HCPCS 636 RC 50632-0010-01 NDC outpatient 1 ML 1063.91 1063.91 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES HDHP [308136802] 851.13 percent of total billed charges 659.62 1010.71 Technical (Hospital) Services "RABIES VACCINE, PURIFIED CHICKEN EMBRYO CELL (PF) 2.5 UNIT IM SUSP" RX-22120 CDM 90675 HCPCS 636 RC 50632-0010-01 NDC outpatient 1 ML 1063.91 1063.91 UNITED HEALTHCARE (COMMERCIAL) [3081199] UNITED HEALTHCARE 87726 [308119901] 659.62 percent of total billed charges 659.62 1010.71 Technical (Hospital) Services "RABIES VACCINE, PURIFIED CHICKEN EMBRYO CELL (PF) 2.5 UNIT IM SUSP" RX-22120 CDM 90675 HCPCS 636 RC 50632-0010-01 NDC outpatient 1 ML 1063.91 1063.91 HEALTHPARTNERS SX009 HEALTHPARTNERS 851.13 percent of total billed charges 659.62 1010.71 Technical (Hospital) Services "RABIES VACCINE, PURIFIED CHICKEN EMBRYO CELL (PF) 2.5 UNIT IM SUSP" RX-22120 CDM 90675 HCPCS 636 RC 50632-0010-01 NDC outpatient 1 ML 1063.91 1063.91 MULTIPLAN INC 34080 [3081285] MULTIPLAN INC [308128501] 1010.71 percent of total billed charges 659.62 1010.71 Technical (Hospital) Services "RABIES VACCINE, PURIFIED CHICKEN EMBRYO CELL (PF) 2.5 UNIT IM SUSP" RX-22120 CDM 90675 HCPCS 636 RC 50632-0010-01 NDC outpatient 1 ML 1063.91 1063.91 CIGNA 62308 [3081051] CIGNA 62308 [308105105] 851.13 percent of total billed charges 659.62 1010.71 Technical (Hospital) Services "RABIES VACCINE, PURIFIED CHICKEN EMBRYO CELL (PF) 2.5 UNIT IM SUSP" RX-22120 CDM 90675 HCPCS 636 RC 50632-0010-01 NDC outpatient 1 ML 1063.91 1063.91 CIGNA 62308 [3081051] CIGNA STATE OF WYOMING [308105107] 851.13 percent of total billed charges 659.62 1010.71 Technical (Hospital) Services "RABIES VACCINE, PURIFIED CHICKEN EMBRYO CELL (PF) 2.5 UNIT IM SUSP" RX-22120 CDM 90675 HCPCS 636 RC 50632-0010-01 NDC outpatient 1 ML 1063.91 1063.91 MEDICA (COMMERCIAL) 94265 [3081118] MEDICA CLAIMS [308111801] 957.52 percent of total billed charges 659.62 1010.71 Technical (Hospital) Services "RABIES VACCINE, PURIFIED CHICKEN EMBRYO CELL (PF) 2.5 UNIT IM SUSP" RX-22120 CDM 90675 HCPCS 636 RC 50632-0010-01 NDC outpatient 1 ML 1063.91 1063.91 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES PPO [308136801] 851.13 percent of total billed charges 659.62 1010.71 Technical (Hospital) Services "RABIES VACCINE, PURIFIED CHICKEN EMBRYO CELL (PF) 2.5 UNIT IM SUSP" RX-22120 CDM 90675 HCPCS 636 RC 50632-0010-01 NDC outpatient 1 ML 1063.91 1063.91 BLUE CROSS BLUE SHIELD WELLMARK SB889 [3081026] BCBS WYOMING [308102603] 1010.71 percent of total billed charges 659.62 1010.71 Technical (Hospital) Services "RABIES VACCINE, PURIFIED CHICKEN EMBRYO CELL (PF) 2.5 UNIT IM SUSP" RX-22120 CDM 90675 HCPCS 636 RC 50632-0010-01 NDC inpatient 1 ML 1063.91 1063.91 HEALTHPARTNERS SX009 HEALTHPARTNERS 842.4 percent of total billed charges 659.62 1010.71 Technical (Hospital) Services "RABIES VACCINE, PURIFIED CHICKEN EMBRYO CELL (PF) 2.5 UNIT IM SUSP" RX-22120 CDM 90675 HCPCS 636 RC 50632-0010-01 NDC inpatient 1 ML 1063.91 1063.91 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES PPO [308136801] 842.4 percent of total billed charges 659.62 1010.71 Technical (Hospital) Services "RABIES VACCINE, PURIFIED CHICKEN EMBRYO CELL (PF) 2.5 UNIT IM SUSP" RX-22120 CDM 90675 HCPCS 636 RC 50632-0010-01 NDC inpatient 1 ML 1063.91 1063.91 MEDICA (COMMERCIAL) 94265 [3081118] MEDICA CLAIMS [308111801] 957.52 percent of total billed charges 659.62 1010.71 Technical (Hospital) Services "RABIES VACCINE, PURIFIED CHICKEN EMBRYO CELL (PF) 2.5 UNIT IM SUSP" RX-22120 CDM 90675 HCPCS 636 RC 50632-0010-01 NDC inpatient 1 ML 1063.91 1063.91 MULTIPLAN INC 34080 [3081285] MULTIPLAN INC [308128501] 1010.71 percent of total billed charges 659.62 1010.71 Technical (Hospital) Services "RABIES VACCINE, PURIFIED CHICKEN EMBRYO CELL (PF) 2.5 UNIT IM SUSP" RX-22120 CDM 90675 HCPCS 636 RC 50632-0010-01 NDC inpatient 1 ML 1063.91 1063.91 BLUE CROSS BLUE SHIELD WELLMARK SB889 [3081026] BCBS WYOMING [308102603] 1010.71 percent of total billed charges 659.62 1010.71 Technical (Hospital) Services "RABIES VACCINE, PURIFIED CHICKEN EMBRYO CELL (PF) 2.5 UNIT IM SUSP" RX-22120 CDM 90675 HCPCS 636 RC 50632-0010-01 NDC inpatient 1 ML 1063.91 1063.91 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES HDHP [308136802] 842.4 percent of total billed charges 659.62 1010.71 Technical (Hospital) Services "RABIES VACCINE, PURIFIED CHICKEN EMBRYO CELL (PF) 2.5 UNIT IM SUSP" RX-22120 CDM 90675 HCPCS 636 RC 50632-0010-01 NDC inpatient 1 ML 1063.91 1063.91 CIGNA 62308 [3081051] CIGNA STATE OF WYOMING [308105107] 842.4 percent of total billed charges 659.62 1010.71 Technical (Hospital) Services "RABIES VACCINE, PURIFIED CHICKEN EMBRYO CELL (PF) 2.5 UNIT IM SUSP" RX-22120 CDM 90675 HCPCS 636 RC 50632-0010-01 NDC inpatient 1 ML 1063.91 1063.91 UNITED HEALTHCARE (COMMERCIAL) [3081199] UNITED HEALTHCARE 87726 [308119901] 659.62 percent of total billed charges 659.62 1010.71 Technical (Hospital) Services "RABIES VACCINE, PURIFIED CHICKEN EMBRYO CELL (PF) 2.5 UNIT IM SUSP" RX-22120 CDM 90675 HCPCS 636 RC 50632-0010-01 NDC inpatient 1 ML 1063.91 1063.91 CIGNA 62308 [3081051] CIGNA 62308 [308105105] 842.4 percent of total billed charges 659.62 1010.71 Technical (Hospital) Services "RABIES VACCINE, PURIFIED CHICKEN EMBRYO CELL (PF) 2.5 UNIT IM SUSP" RX-22120 CDM 90675 HCPCS 636 RC 50632-0010-01 NDC inpatient 1 ML 1063.91 1063.91 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES EPO [308136803] 842.4 percent of total billed charges 659.62 1010.71 Technical (Hospital) Services FLU VACCINE TS2024-25(65YR UP)(PF)180 MCG/0.5 ML INTRAMUSCULAR SYRINGE RX-193617 CDM 90662 HCPCS 636 RC 49281-0124-88 NDC inpatient 0.5 ML 334.61 334.61 MULTIPLAN INC 34080 [3081285] MULTIPLAN INC [308128501] 317.88 percent of total billed charges 207.46 317.88 Technical (Hospital) Services FLU VACCINE TS2024-25(65YR UP)(PF)180 MCG/0.5 ML INTRAMUSCULAR SYRINGE RX-193617 CDM 90662 HCPCS 636 RC 49281-0124-88 NDC inpatient 0.5 ML 334.61 334.61 HEALTHPARTNERS SX009 HEALTHPARTNERS 264.94 percent of total billed charges 207.46 317.88 Technical (Hospital) Services FLU VACCINE TS2024-25(65YR UP)(PF)180 MCG/0.5 ML INTRAMUSCULAR SYRINGE RX-193617 CDM 90662 HCPCS 636 RC 49281-0124-88 NDC inpatient 0.5 ML 334.61 334.61 MEDICA (COMMERCIAL) 94265 [3081118] MEDICA CLAIMS [308111801] 301.15 percent of total billed charges 207.46 317.88 Technical (Hospital) Services FLU VACCINE TS2024-25(65YR UP)(PF)180 MCG/0.5 ML INTRAMUSCULAR SYRINGE RX-193617 CDM 90662 HCPCS 636 RC 49281-0124-88 NDC inpatient 0.5 ML 334.61 334.61 UNITED HEALTHCARE (COMMERCIAL) [3081199] UNITED HEALTHCARE 87726 [308119901] 207.46 percent of total billed charges 207.46 317.88 Technical (Hospital) Services FLU VACCINE TS2024-25(65YR UP)(PF)180 MCG/0.5 ML INTRAMUSCULAR SYRINGE RX-193617 CDM 90662 HCPCS 636 RC 49281-0124-88 NDC inpatient 0.5 ML 334.61 334.61 BLUE CROSS BLUE SHIELD WELLMARK SB889 [3081026] BCBS WYOMING [308102603] 317.88 percent of total billed charges 207.46 317.88 Technical (Hospital) Services FLU VACCINE TS2024-25(65YR UP)(PF)180 MCG/0.5 ML INTRAMUSCULAR SYRINGE RX-193617 CDM 90662 HCPCS 636 RC 49281-0124-88 NDC inpatient 0.5 ML 334.61 334.61 CIGNA 62308 [3081051] CIGNA 62308 [308105105] 264.94 percent of total billed charges 207.46 317.88 Technical (Hospital) Services FLU VACCINE TS2024-25(65YR UP)(PF)180 MCG/0.5 ML INTRAMUSCULAR SYRINGE RX-193617 CDM 90662 HCPCS 636 RC 49281-0124-88 NDC inpatient 0.5 ML 334.61 334.61 CIGNA 62308 [3081051] CIGNA STATE OF WYOMING [308105107] 264.94 percent of total billed charges 207.46 317.88 Technical (Hospital) Services FLU VACCINE TS2024-25(65YR UP)(PF)180 MCG/0.5 ML INTRAMUSCULAR SYRINGE RX-193617 CDM 90662 HCPCS 636 RC 49281-0124-88 NDC inpatient 0.5 ML 334.61 334.61 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES HDHP [308136802] 264.94 percent of total billed charges 207.46 317.88 Technical (Hospital) Services FLU VACCINE TS2024-25(65YR UP)(PF)180 MCG/0.5 ML INTRAMUSCULAR SYRINGE RX-193617 CDM 90662 HCPCS 636 RC 49281-0124-88 NDC inpatient 0.5 ML 334.61 334.61 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES PPO [308136801] 264.94 percent of total billed charges 207.46 317.88 Technical (Hospital) Services FLU VACCINE TS2024-25(65YR UP)(PF)180 MCG/0.5 ML INTRAMUSCULAR SYRINGE RX-193617 CDM 90662 HCPCS 636 RC 49281-0124-88 NDC inpatient 0.5 ML 334.61 334.61 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES EPO [308136803] 264.94 percent of total billed charges 207.46 317.88 Technical (Hospital) Services FLU VACCINE TS2024-25(65YR UP)(PF)180 MCG/0.5 ML INTRAMUSCULAR SYRINGE RX-193617 CDM 90662 HCPCS 636 RC 49281-0124-88 NDC outpatient 0.5 ML 334.61 334.61 HEALTHPARTNERS SX009 HEALTHPARTNERS 267.69 percent of total billed charges 207.46 317.88 Technical (Hospital) Services FLU VACCINE TS2024-25(65YR UP)(PF)180 MCG/0.5 ML INTRAMUSCULAR SYRINGE RX-193617 CDM 90662 HCPCS 636 RC 49281-0124-88 NDC outpatient 0.5 ML 334.61 334.61 BLUE CROSS BLUE SHIELD WELLMARK SB889 [3081026] BCBS WYOMING [308102603] 317.88 percent of total billed charges 207.46 317.88 Technical (Hospital) Services FLU VACCINE TS2024-25(65YR UP)(PF)180 MCG/0.5 ML INTRAMUSCULAR SYRINGE RX-193617 CDM 90662 HCPCS 636 RC 49281-0124-88 NDC outpatient 0.5 ML 334.61 334.61 MULTIPLAN INC 34080 [3081285] MULTIPLAN INC [308128501] 317.88 percent of total billed charges 207.46 317.88 Technical (Hospital) Services FLU VACCINE TS2024-25(65YR UP)(PF)180 MCG/0.5 ML INTRAMUSCULAR SYRINGE RX-193617 CDM 90662 HCPCS 636 RC 49281-0124-88 NDC outpatient 0.5 ML 334.61 334.61 UNITED HEALTHCARE (COMMERCIAL) [3081199] UNITED HEALTHCARE 87726 [308119901] 207.46 percent of total billed charges 207.46 317.88 Technical (Hospital) Services FLU VACCINE TS2024-25(65YR UP)(PF)180 MCG/0.5 ML INTRAMUSCULAR SYRINGE RX-193617 CDM 90662 HCPCS 636 RC 49281-0124-88 NDC outpatient 0.5 ML 334.61 334.61 CIGNA 62308 [3081051] CIGNA STATE OF WYOMING [308105107] 267.69 percent of total billed charges 207.46 317.88 Technical (Hospital) Services FLU VACCINE TS2024-25(65YR UP)(PF)180 MCG/0.5 ML INTRAMUSCULAR SYRINGE RX-193617 CDM 90662 HCPCS 636 RC 49281-0124-88 NDC outpatient 0.5 ML 334.61 334.61 CIGNA 62308 [3081051] CIGNA 62308 [308105105] 267.69 percent of total billed charges 207.46 317.88 Technical (Hospital) Services FLU VACCINE TS2024-25(65YR UP)(PF)180 MCG/0.5 ML INTRAMUSCULAR SYRINGE RX-193617 CDM 90662 HCPCS 636 RC 49281-0124-88 NDC outpatient 0.5 ML 334.61 334.61 MEDICA (COMMERCIAL) 94265 [3081118] MEDICA CLAIMS [308111801] 301.15 percent of total billed charges 207.46 317.88 Technical (Hospital) Services FLU VACCINE TS2024-25(65YR UP)(PF)180 MCG/0.5 ML INTRAMUSCULAR SYRINGE RX-193617 CDM 90662 HCPCS 636 RC 49281-0124-88 NDC outpatient 0.5 ML 334.61 334.61 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES PPO [308136801] 267.69 percent of total billed charges 207.46 317.88 Technical (Hospital) Services FLU VACCINE TS2024-25(65YR UP)(PF)180 MCG/0.5 ML INTRAMUSCULAR SYRINGE RX-193617 CDM 90662 HCPCS 636 RC 49281-0124-88 NDC outpatient 0.5 ML 334.61 334.61 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES EPO [308136803] 267.69 percent of total billed charges 207.46 317.88 Technical (Hospital) Services FLU VACCINE TS2024-25(65YR UP)(PF)180 MCG/0.5 ML INTRAMUSCULAR SYRINGE RX-193617 CDM 90662 HCPCS 636 RC 49281-0124-88 NDC outpatient 0.5 ML 334.61 334.61 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES HDHP [308136802] 267.69 percent of total billed charges 207.46 317.88 Technical (Hospital) Services FLU VACCINE TS 2024-25(6MOS UP)(PF) 45 MCG(15MCG X3)/0.5 ML IM SYRINGE RX-193616 CDM 90656 HCPCS 636 RC 19515-0810-41 NDC outpatient 0.5 ML 107.48 107.48 BLUE CROSS BLUE SHIELD WELLMARK SB889 [3081026] BCBS WYOMING [308102603] 102.11 percent of total billed charges 66.64 102.11 Technical (Hospital) Services FLU VACCINE TS 2024-25(6MOS UP)(PF) 45 MCG(15MCG X3)/0.5 ML IM SYRINGE RX-193616 CDM 90656 HCPCS 636 RC 19515-0810-41 NDC outpatient 0.5 ML 107.48 107.48 HEALTHPARTNERS SX009 HEALTHPARTNERS 85.98 percent of total billed charges 66.64 102.11 Technical (Hospital) Services FLU VACCINE TS 2024-25(6MOS UP)(PF) 45 MCG(15MCG X3)/0.5 ML IM SYRINGE RX-193616 CDM 90656 HCPCS 636 RC 19515-0810-41 NDC outpatient 0.5 ML 107.48 107.48 UNITED HEALTHCARE (COMMERCIAL) [3081199] UNITED HEALTHCARE 87726 [308119901] 66.64 percent of total billed charges 66.64 102.11 Technical (Hospital) Services FLU VACCINE TS 2024-25(6MOS UP)(PF) 45 MCG(15MCG X3)/0.5 ML IM SYRINGE RX-193616 CDM 90656 HCPCS 636 RC 19515-0810-41 NDC outpatient 0.5 ML 107.48 107.48 CIGNA 62308 [3081051] CIGNA 62308 [308105105] 85.98 percent of total billed charges 66.64 102.11 Technical (Hospital) Services FLU VACCINE TS 2024-25(6MOS UP)(PF) 45 MCG(15MCG X3)/0.5 ML IM SYRINGE RX-193616 CDM 90656 HCPCS 636 RC 19515-0810-41 NDC outpatient 0.5 ML 107.48 107.48 CIGNA 62308 [3081051] CIGNA STATE OF WYOMING [308105107] 85.98 percent of total billed charges 66.64 102.11 Technical (Hospital) Services FLU VACCINE TS 2024-25(6MOS UP)(PF) 45 MCG(15MCG X3)/0.5 ML IM SYRINGE RX-193616 CDM 90656 HCPCS 636 RC 19515-0810-41 NDC outpatient 0.5 ML 107.48 107.48 MULTIPLAN INC 34080 [3081285] MULTIPLAN INC [308128501] 102.11 percent of total billed charges 66.64 102.11 Technical (Hospital) Services FLU VACCINE TS 2024-25(6MOS UP)(PF) 45 MCG(15MCG X3)/0.5 ML IM SYRINGE RX-193616 CDM 90656 HCPCS 636 RC 19515-0810-41 NDC outpatient 0.5 ML 107.48 107.48 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES EPO [308136803] 85.98 percent of total billed charges 66.64 102.11 Technical (Hospital) Services FLU VACCINE TS 2024-25(6MOS UP)(PF) 45 MCG(15MCG X3)/0.5 ML IM SYRINGE RX-193616 CDM 90656 HCPCS 636 RC 19515-0810-41 NDC outpatient 0.5 ML 107.48 107.48 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES PPO [308136801] 85.98 percent of total billed charges 66.64 102.11 Technical (Hospital) Services FLU VACCINE TS 2024-25(6MOS UP)(PF) 45 MCG(15MCG X3)/0.5 ML IM SYRINGE RX-193616 CDM 90656 HCPCS 636 RC 19515-0810-41 NDC outpatient 0.5 ML 107.48 107.48 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES HDHP [308136802] 85.98 percent of total billed charges 66.64 102.11 Technical (Hospital) Services FLU VACCINE TS 2024-25(6MOS UP)(PF) 45 MCG(15MCG X3)/0.5 ML IM SYRINGE RX-193616 CDM 90656 HCPCS 636 RC 19515-0810-41 NDC outpatient 0.5 ML 107.48 107.48 MEDICA (COMMERCIAL) 94265 [3081118] MEDICA CLAIMS [308111801] 96.73 percent of total billed charges 66.64 102.11 Technical (Hospital) Services FLU VACCINE TS 2024-25(6MOS UP)(PF) 45 MCG(15MCG X3)/0.5 ML IM SYRINGE RX-193616 CDM 90656 HCPCS 636 RC 19515-0810-41 NDC inpatient 0.5 ML 107.48 107.48 BLUE CROSS BLUE SHIELD WELLMARK SB889 [3081026] BCBS WYOMING [308102603] 102.11 percent of total billed charges 66.64 102.11 Technical (Hospital) Services FLU VACCINE TS 2024-25(6MOS UP)(PF) 45 MCG(15MCG X3)/0.5 ML IM SYRINGE RX-193616 CDM 90656 HCPCS 636 RC 19515-0810-41 NDC inpatient 0.5 ML 107.48 107.48 UNITED HEALTHCARE (COMMERCIAL) [3081199] UNITED HEALTHCARE 87726 [308119901] 66.64 percent of total billed charges 66.64 102.11 Technical (Hospital) Services FLU VACCINE TS 2024-25(6MOS UP)(PF) 45 MCG(15MCG X3)/0.5 ML IM SYRINGE RX-193616 CDM 90656 HCPCS 636 RC 19515-0810-41 NDC inpatient 0.5 ML 107.48 107.48 CIGNA 62308 [3081051] CIGNA 62308 [308105105] 85.1 percent of total billed charges 66.64 102.11 Technical (Hospital) Services FLU VACCINE TS 2024-25(6MOS UP)(PF) 45 MCG(15MCG X3)/0.5 ML IM SYRINGE RX-193616 CDM 90656 HCPCS 636 RC 19515-0810-41 NDC inpatient 0.5 ML 107.48 107.48 CIGNA 62308 [3081051] CIGNA STATE OF WYOMING [308105107] 85.1 percent of total billed charges 66.64 102.11 Technical (Hospital) Services FLU VACCINE TS 2024-25(6MOS UP)(PF) 45 MCG(15MCG X3)/0.5 ML IM SYRINGE RX-193616 CDM 90656 HCPCS 636 RC 19515-0810-41 NDC inpatient 0.5 ML 107.48 107.48 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES PPO [308136801] 85.1 percent of total billed charges 66.64 102.11 Technical (Hospital) Services FLU VACCINE TS 2024-25(6MOS UP)(PF) 45 MCG(15MCG X3)/0.5 ML IM SYRINGE RX-193616 CDM 90656 HCPCS 636 RC 19515-0810-41 NDC inpatient 0.5 ML 107.48 107.48 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES HDHP [308136802] 85.1 percent of total billed charges 66.64 102.11 Technical (Hospital) Services FLU VACCINE TS 2024-25(6MOS UP)(PF) 45 MCG(15MCG X3)/0.5 ML IM SYRINGE RX-193616 CDM 90656 HCPCS 636 RC 19515-0810-41 NDC inpatient 0.5 ML 107.48 107.48 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES EPO [308136803] 85.1 percent of total billed charges 66.64 102.11 Technical (Hospital) Services FLU VACCINE TS 2024-25(6MOS UP)(PF) 45 MCG(15MCG X3)/0.5 ML IM SYRINGE RX-193616 CDM 90656 HCPCS 636 RC 19515-0810-41 NDC inpatient 0.5 ML 107.48 107.48 MEDICA (COMMERCIAL) 94265 [3081118] MEDICA CLAIMS [308111801] 96.73 percent of total billed charges 66.64 102.11 Technical (Hospital) Services FLU VACCINE TS 2024-25(6MOS UP)(PF) 45 MCG(15MCG X3)/0.5 ML IM SYRINGE RX-193616 CDM 90656 HCPCS 636 RC 19515-0810-41 NDC inpatient 0.5 ML 107.48 107.48 MULTIPLAN INC 34080 [3081285] MULTIPLAN INC [308128501] 102.11 percent of total billed charges 66.64 102.11 Technical (Hospital) Services FLU VACCINE TS 2024-25(6MOS UP)(PF) 45 MCG(15MCG X3)/0.5 ML IM SYRINGE RX-193616 CDM 90656 HCPCS 636 RC 19515-0810-41 NDC inpatient 0.5 ML 107.48 107.48 HEALTHPARTNERS SX009 HEALTHPARTNERS 85.1 percent of total billed charges 66.64 102.11 Technical (Hospital) Services "MENINGOCOCCAL B VAC,4-CMP 50 MCG-50 MCG-50 MCG-25 MCG/0.5ML IM SYRINGE" RX-127348 CDM 90620 HCPCS 636 RC 58160-0976-20 NDC inpatient 0.5 ML 623 623 CIGNA 62308 [3081051] CIGNA 62308 [308105105] 493.29 percent of total billed charges 386.26 591.85 Technical (Hospital) Services "MENINGOCOCCAL B VAC,4-CMP 50 MCG-50 MCG-50 MCG-25 MCG/0.5ML IM SYRINGE" RX-127348 CDM 90620 HCPCS 636 RC 58160-0976-20 NDC inpatient 0.5 ML 623 623 CIGNA 62308 [3081051] CIGNA STATE OF WYOMING [308105107] 493.29 percent of total billed charges 386.26 591.85 Technical (Hospital) Services "MENINGOCOCCAL B VAC,4-CMP 50 MCG-50 MCG-50 MCG-25 MCG/0.5ML IM SYRINGE" RX-127348 CDM 90620 HCPCS 636 RC 58160-0976-20 NDC inpatient 0.5 ML 623 623 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES HDHP [308136802] 493.29 percent of total billed charges 386.26 591.85 Technical (Hospital) Services "MENINGOCOCCAL B VAC,4-CMP 50 MCG-50 MCG-50 MCG-25 MCG/0.5ML IM SYRINGE" RX-127348 CDM 90620 HCPCS 636 RC 58160-0976-20 NDC inpatient 0.5 ML 623 623 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES PPO [308136801] 493.29 percent of total billed charges 386.26 591.85 Technical (Hospital) Services "MENINGOCOCCAL B VAC,4-CMP 50 MCG-50 MCG-50 MCG-25 MCG/0.5ML IM SYRINGE" RX-127348 CDM 90620 HCPCS 636 RC 58160-0976-20 NDC inpatient 0.5 ML 623 623 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES EPO [308136803] 493.29 percent of total billed charges 386.26 591.85 Technical (Hospital) Services "MENINGOCOCCAL B VAC,4-CMP 50 MCG-50 MCG-50 MCG-25 MCG/0.5ML IM SYRINGE" RX-127348 CDM 90620 HCPCS 636 RC 58160-0976-20 NDC inpatient 0.5 ML 623 623 UNITED HEALTHCARE (COMMERCIAL) [3081199] UNITED HEALTHCARE 87726 [308119901] 386.26 percent of total billed charges 386.26 591.85 Technical (Hospital) Services "MENINGOCOCCAL B VAC,4-CMP 50 MCG-50 MCG-50 MCG-25 MCG/0.5ML IM SYRINGE" RX-127348 CDM 90620 HCPCS 636 RC 58160-0976-20 NDC inpatient 0.5 ML 623 623 BLUE CROSS BLUE SHIELD WELLMARK SB889 [3081026] BCBS WYOMING [308102603] 591.85 percent of total billed charges 386.26 591.85 Technical (Hospital) Services "MENINGOCOCCAL B VAC,4-CMP 50 MCG-50 MCG-50 MCG-25 MCG/0.5ML IM SYRINGE" RX-127348 CDM 90620 HCPCS 636 RC 58160-0976-20 NDC inpatient 0.5 ML 623 623 MEDICA (COMMERCIAL) 94265 [3081118] MEDICA CLAIMS [308111801] 560.7 percent of total billed charges 386.26 591.85 Technical (Hospital) Services "MENINGOCOCCAL B VAC,4-CMP 50 MCG-50 MCG-50 MCG-25 MCG/0.5ML IM SYRINGE" RX-127348 CDM 90620 HCPCS 636 RC 58160-0976-20 NDC inpatient 0.5 ML 623 623 HEALTHPARTNERS SX009 HEALTHPARTNERS 493.29 percent of total billed charges 386.26 591.85 Technical (Hospital) Services "MENINGOCOCCAL B VAC,4-CMP 50 MCG-50 MCG-50 MCG-25 MCG/0.5ML IM SYRINGE" RX-127348 CDM 90620 HCPCS 636 RC 58160-0976-20 NDC inpatient 0.5 ML 623 623 MULTIPLAN INC 34080 [3081285] MULTIPLAN INC [308128501] 591.85 percent of total billed charges 386.26 591.85 Technical (Hospital) Services "MENINGOCOCCAL B VAC,4-CMP 50 MCG-50 MCG-50 MCG-25 MCG/0.5ML IM SYRINGE" RX-127348 CDM 90620 HCPCS 636 RC 58160-0976-20 NDC outpatient 0.5 ML 623 623 HEALTHPARTNERS SX009 HEALTHPARTNERS 498.4 percent of total billed charges 386.26 591.85 Technical (Hospital) Services "MENINGOCOCCAL B VAC,4-CMP 50 MCG-50 MCG-50 MCG-25 MCG/0.5ML IM SYRINGE" RX-127348 CDM 90620 HCPCS 636 RC 58160-0976-20 NDC outpatient 0.5 ML 623 623 BLUE CROSS BLUE SHIELD WELLMARK SB889 [3081026] BCBS WYOMING [308102603] 591.85 percent of total billed charges 386.26 591.85 Technical (Hospital) Services "MENINGOCOCCAL B VAC,4-CMP 50 MCG-50 MCG-50 MCG-25 MCG/0.5ML IM SYRINGE" RX-127348 CDM 90620 HCPCS 636 RC 58160-0976-20 NDC outpatient 0.5 ML 623 623 UNITED HEALTHCARE (COMMERCIAL) [3081199] UNITED HEALTHCARE 87726 [308119901] 386.26 percent of total billed charges 386.26 591.85 Technical (Hospital) Services "MENINGOCOCCAL B VAC,4-CMP 50 MCG-50 MCG-50 MCG-25 MCG/0.5ML IM SYRINGE" RX-127348 CDM 90620 HCPCS 636 RC 58160-0976-20 NDC outpatient 0.5 ML 623 623 CIGNA 62308 [3081051] CIGNA 62308 [308105105] 498.4 percent of total billed charges 386.26 591.85 Technical (Hospital) Services "MENINGOCOCCAL B VAC,4-CMP 50 MCG-50 MCG-50 MCG-25 MCG/0.5ML IM SYRINGE" RX-127348 CDM 90620 HCPCS 636 RC 58160-0976-20 NDC outpatient 0.5 ML 623 623 CIGNA 62308 [3081051] CIGNA STATE OF WYOMING [308105107] 498.4 percent of total billed charges 386.26 591.85 Technical (Hospital) Services "MENINGOCOCCAL B VAC,4-CMP 50 MCG-50 MCG-50 MCG-25 MCG/0.5ML IM SYRINGE" RX-127348 CDM 90620 HCPCS 636 RC 58160-0976-20 NDC outpatient 0.5 ML 623 623 MULTIPLAN INC 34080 [3081285] MULTIPLAN INC [308128501] 591.85 percent of total billed charges 386.26 591.85 Technical (Hospital) Services "MENINGOCOCCAL B VAC,4-CMP 50 MCG-50 MCG-50 MCG-25 MCG/0.5ML IM SYRINGE" RX-127348 CDM 90620 HCPCS 636 RC 58160-0976-20 NDC outpatient 0.5 ML 623 623 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES HDHP [308136802] 498.4 percent of total billed charges 386.26 591.85 Technical (Hospital) Services "MENINGOCOCCAL B VAC,4-CMP 50 MCG-50 MCG-50 MCG-25 MCG/0.5ML IM SYRINGE" RX-127348 CDM 90620 HCPCS 636 RC 58160-0976-20 NDC outpatient 0.5 ML 623 623 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES EPO [308136803] 498.4 percent of total billed charges 386.26 591.85 Technical (Hospital) Services "MENINGOCOCCAL B VAC,4-CMP 50 MCG-50 MCG-50 MCG-25 MCG/0.5ML IM SYRINGE" RX-127348 CDM 90620 HCPCS 636 RC 58160-0976-20 NDC outpatient 0.5 ML 623 623 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES PPO [308136801] 498.4 percent of total billed charges 386.26 591.85 Technical (Hospital) Services "MENINGOCOCCAL B VAC,4-CMP 50 MCG-50 MCG-50 MCG-25 MCG/0.5ML IM SYRINGE" RX-127348 CDM 90620 HCPCS 636 RC 58160-0976-20 NDC outpatient 0.5 ML 623 623 MEDICA (COMMERCIAL) 94265 [3081118] MEDICA CLAIMS [308111801] 560.7 percent of total billed charges 386.26 591.85 Technical (Hospital) Services PALIVIZUMAB 100 MG/ML INTRAMUSCULAR SOLUTION RX-41675 CDM 90378 HCPCS 636 RC 66658-0231-01 NDC inpatient 1 ML 5887.92 5887.92 MULTIPLAN INC 34080 [3081285] MULTIPLAN INC [308128501] 5593.52 percent of total billed charges 3650.51 5593.52 Technical (Hospital) Services PALIVIZUMAB 100 MG/ML INTRAMUSCULAR SOLUTION RX-41675 CDM 90378 HCPCS 636 RC 66658-0231-01 NDC inpatient 1 ML 5887.92 5887.92 BLUE CROSS BLUE SHIELD WELLMARK SB889 [3081026] BCBS WYOMING [308102603] 5593.52 percent of total billed charges 3650.51 5593.52 Technical (Hospital) Services PALIVIZUMAB 100 MG/ML INTRAMUSCULAR SOLUTION RX-41675 CDM 90378 HCPCS 636 RC 66658-0231-01 NDC inpatient 1 ML 5887.92 5887.92 UNITED HEALTHCARE (COMMERCIAL) [3081199] UNITED HEALTHCARE 87726 [308119901] 3650.51 percent of total billed charges 3650.51 5593.52 Technical (Hospital) Services PALIVIZUMAB 100 MG/ML INTRAMUSCULAR SOLUTION RX-41675 CDM 90378 HCPCS 636 RC 66658-0231-01 NDC inpatient 1 ML 5887.92 5887.92 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES EPO [308136803] 4662.06 percent of total billed charges 3650.51 5593.52 Technical (Hospital) Services PALIVIZUMAB 100 MG/ML INTRAMUSCULAR SOLUTION RX-41675 CDM 90378 HCPCS 636 RC 66658-0231-01 NDC inpatient 1 ML 5887.92 5887.92 CIGNA 62308 [3081051] CIGNA 62308 [308105105] 4662.06 percent of total billed charges 3650.51 5593.52 Technical (Hospital) Services PALIVIZUMAB 100 MG/ML INTRAMUSCULAR SOLUTION RX-41675 CDM 90378 HCPCS 636 RC 66658-0231-01 NDC inpatient 1 ML 5887.92 5887.92 CIGNA 62308 [3081051] CIGNA STATE OF WYOMING [308105107] 4662.06 percent of total billed charges 3650.51 5593.52 Technical (Hospital) Services PALIVIZUMAB 100 MG/ML INTRAMUSCULAR SOLUTION RX-41675 CDM 90378 HCPCS 636 RC 66658-0231-01 NDC inpatient 1 ML 5887.92 5887.92 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES HDHP [308136802] 4662.06 percent of total billed charges 3650.51 5593.52 Technical (Hospital) Services PALIVIZUMAB 100 MG/ML INTRAMUSCULAR SOLUTION RX-41675 CDM 90378 HCPCS 636 RC 66658-0231-01 NDC inpatient 1 ML 5887.92 5887.92 HEALTHPARTNERS SX009 HEALTHPARTNERS 4662.06 percent of total billed charges 3650.51 5593.52 Technical (Hospital) Services PALIVIZUMAB 100 MG/ML INTRAMUSCULAR SOLUTION RX-41675 CDM 90378 HCPCS 636 RC 66658-0231-01 NDC inpatient 1 ML 5887.92 5887.92 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES PPO [308136801] 4662.06 percent of total billed charges 3650.51 5593.52 Technical (Hospital) Services PALIVIZUMAB 100 MG/ML INTRAMUSCULAR SOLUTION RX-41675 CDM 90378 HCPCS 636 RC 66658-0231-01 NDC inpatient 1 ML 5887.92 5887.92 MEDICA (COMMERCIAL) 94265 [3081118] MEDICA CLAIMS [308111801] 5299.13 percent of total billed charges 3650.51 5593.52 Technical (Hospital) Services PALIVIZUMAB 100 MG/ML INTRAMUSCULAR SOLUTION RX-41675 CDM 90378 HCPCS 636 RC 66658-0231-01 NDC outpatient 1 ML 5887.92 5887.92 BLUE CROSS BLUE SHIELD WELLMARK SB889 [3081026] BCBS WYOMING [308102603] 5593.52 percent of total billed charges 3650.51 5593.52 Technical (Hospital) Services PALIVIZUMAB 100 MG/ML INTRAMUSCULAR SOLUTION RX-41675 CDM 90378 HCPCS 636 RC 66658-0231-01 NDC outpatient 1 ML 5887.92 5887.92 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES PPO [308136801] 4710.34 percent of total billed charges 3650.51 5593.52 Technical (Hospital) Services PALIVIZUMAB 100 MG/ML INTRAMUSCULAR SOLUTION RX-41675 CDM 90378 HCPCS 636 RC 66658-0231-01 NDC outpatient 1 ML 5887.92 5887.92 CIGNA 62308 [3081051] CIGNA 62308 [308105105] 4710.34 percent of total billed charges 3650.51 5593.52 Technical (Hospital) Services PALIVIZUMAB 100 MG/ML INTRAMUSCULAR SOLUTION RX-41675 CDM 90378 HCPCS 636 RC 66658-0231-01 NDC outpatient 1 ML 5887.92 5887.92 CIGNA 62308 [3081051] CIGNA STATE OF WYOMING [308105107] 4710.34 percent of total billed charges 3650.51 5593.52 Technical (Hospital) Services PALIVIZUMAB 100 MG/ML INTRAMUSCULAR SOLUTION RX-41675 CDM 90378 HCPCS 636 RC 66658-0231-01 NDC outpatient 1 ML 5887.92 5887.92 MULTIPLAN INC 34080 [3081285] MULTIPLAN INC [308128501] 5593.52 percent of total billed charges 3650.51 5593.52 Technical (Hospital) Services PALIVIZUMAB 100 MG/ML INTRAMUSCULAR SOLUTION RX-41675 CDM 90378 HCPCS 636 RC 66658-0231-01 NDC outpatient 1 ML 5887.92 5887.92 MEDICA (COMMERCIAL) 94265 [3081118] MEDICA CLAIMS [308111801] 5299.13 percent of total billed charges 3650.51 5593.52 Technical (Hospital) Services PALIVIZUMAB 100 MG/ML INTRAMUSCULAR SOLUTION RX-41675 CDM 90378 HCPCS 636 RC 66658-0231-01 NDC outpatient 1 ML 5887.92 5887.92 UNITED HEALTHCARE (COMMERCIAL) [3081199] UNITED HEALTHCARE 87726 [308119901] 3650.51 percent of total billed charges 3650.51 5593.52 Technical (Hospital) Services PALIVIZUMAB 100 MG/ML INTRAMUSCULAR SOLUTION RX-41675 CDM 90378 HCPCS 636 RC 66658-0231-01 NDC outpatient 1 ML 5887.92 5887.92 HEALTHPARTNERS SX009 HEALTHPARTNERS 4710.34 percent of total billed charges 3650.51 5593.52 Technical (Hospital) Services PALIVIZUMAB 100 MG/ML INTRAMUSCULAR SOLUTION RX-41675 CDM 90378 HCPCS 636 RC 66658-0231-01 NDC outpatient 1 ML 5887.92 5887.92 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES HDHP [308136802] 4710.34 percent of total billed charges 3650.51 5593.52 Technical (Hospital) Services PALIVIZUMAB 100 MG/ML INTRAMUSCULAR SOLUTION RX-41675 CDM 90378 HCPCS 636 RC 66658-0231-01 NDC outpatient 1 ML 5887.92 5887.92 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES EPO [308136803] 4710.34 percent of total billed charges 3650.51 5593.52 Technical (Hospital) Services RABIES IMMUNE GLOBULIN (PF) 300 UNIT/ML INTRAMUSCULAR SOLUTION RX-173528 CDM 90375 HCPCS 636 RC 13533-0318-03 NDC inpatient 3 ML 4491.49 4491.49 MEDICA (COMMERCIAL) 94265 [3081118] MEDICA CLAIMS [308111801] 4042.34 percent of total billed charges 2784.72 4266.92 Technical (Hospital) Services RABIES IMMUNE GLOBULIN (PF) 300 UNIT/ML INTRAMUSCULAR SOLUTION RX-173528 CDM 90375 HCPCS 636 RC 13533-0318-03 NDC inpatient 3 ML 4491.49 4491.49 MULTIPLAN INC 34080 [3081285] MULTIPLAN INC [308128501] 4266.92 percent of total billed charges 2784.72 4266.92 Technical (Hospital) Services RABIES IMMUNE GLOBULIN (PF) 300 UNIT/ML INTRAMUSCULAR SOLUTION RX-173528 CDM 90375 HCPCS 636 RC 13533-0318-03 NDC inpatient 3 ML 4491.49 4491.49 CIGNA 62308 [3081051] CIGNA 62308 [308105105] 3556.36 percent of total billed charges 2784.72 4266.92 Technical (Hospital) Services RABIES IMMUNE GLOBULIN (PF) 300 UNIT/ML INTRAMUSCULAR SOLUTION RX-173528 CDM 90375 HCPCS 636 RC 13533-0318-03 NDC inpatient 3 ML 4491.49 4491.49 CIGNA 62308 [3081051] CIGNA STATE OF WYOMING [308105107] 3556.36 percent of total billed charges 2784.72 4266.92 Technical (Hospital) Services RABIES IMMUNE GLOBULIN (PF) 300 UNIT/ML INTRAMUSCULAR SOLUTION RX-173528 CDM 90375 HCPCS 636 RC 13533-0318-03 NDC inpatient 3 ML 4491.49 4491.49 BLUE CROSS BLUE SHIELD WELLMARK SB889 [3081026] BCBS WYOMING [308102603] 4266.92 percent of total billed charges 2784.72 4266.92 Technical (Hospital) Services RABIES IMMUNE GLOBULIN (PF) 300 UNIT/ML INTRAMUSCULAR SOLUTION RX-173528 CDM 90375 HCPCS 636 RC 13533-0318-03 NDC inpatient 3 ML 4491.49 4491.49 UNITED HEALTHCARE (COMMERCIAL) [3081199] UNITED HEALTHCARE 87726 [308119901] 2784.72 percent of total billed charges 2784.72 4266.92 Technical (Hospital) Services RABIES IMMUNE GLOBULIN (PF) 300 UNIT/ML INTRAMUSCULAR SOLUTION RX-173528 CDM 90375 HCPCS 636 RC 13533-0318-03 NDC inpatient 3 ML 4491.49 4491.49 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES PPO [308136801] 3556.36 percent of total billed charges 2784.72 4266.92 Technical (Hospital) Services RABIES IMMUNE GLOBULIN (PF) 300 UNIT/ML INTRAMUSCULAR SOLUTION RX-173528 CDM 90375 HCPCS 636 RC 13533-0318-03 NDC inpatient 3 ML 4491.49 4491.49 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES HDHP [308136802] 3556.36 percent of total billed charges 2784.72 4266.92 Technical (Hospital) Services RABIES IMMUNE GLOBULIN (PF) 300 UNIT/ML INTRAMUSCULAR SOLUTION RX-173528 CDM 90375 HCPCS 636 RC 13533-0318-03 NDC inpatient 3 ML 4491.49 4491.49 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES EPO [308136803] 3556.36 percent of total billed charges 2784.72 4266.92 Technical (Hospital) Services RABIES IMMUNE GLOBULIN (PF) 300 UNIT/ML INTRAMUSCULAR SOLUTION RX-173528 CDM 90375 HCPCS 636 RC 13533-0318-03 NDC inpatient 3 ML 4491.49 4491.49 HEALTHPARTNERS SX009 HEALTHPARTNERS 3556.36 percent of total billed charges 2784.72 4266.92 Technical (Hospital) Services RABIES IMMUNE GLOBULIN (PF) 300 UNIT/ML INTRAMUSCULAR SOLUTION RX-173528 CDM 90375 HCPCS 636 RC 13533-0318-03 NDC outpatient 3 ML 4491.49 4491.49 UNITED HEALTHCARE (COMMERCIAL) [3081199] UNITED HEALTHCARE 87726 [308119901] 2784.72 percent of total billed charges 2784.72 4266.92 Technical (Hospital) Services RABIES IMMUNE GLOBULIN (PF) 300 UNIT/ML INTRAMUSCULAR SOLUTION RX-173528 CDM 90375 HCPCS 636 RC 13533-0318-03 NDC outpatient 3 ML 4491.49 4491.49 CIGNA 62308 [3081051] CIGNA 62308 [308105105] 3593.19 percent of total billed charges 2784.72 4266.92 Technical (Hospital) Services RABIES IMMUNE GLOBULIN (PF) 300 UNIT/ML INTRAMUSCULAR SOLUTION RX-173528 CDM 90375 HCPCS 636 RC 13533-0318-03 NDC outpatient 3 ML 4491.49 4491.49 CIGNA 62308 [3081051] CIGNA STATE OF WYOMING [308105107] 3593.19 percent of total billed charges 2784.72 4266.92 Technical (Hospital) Services RABIES IMMUNE GLOBULIN (PF) 300 UNIT/ML INTRAMUSCULAR SOLUTION RX-173528 CDM 90375 HCPCS 636 RC 13533-0318-03 NDC outpatient 3 ML 4491.49 4491.49 HEALTHPARTNERS SX009 HEALTHPARTNERS 3593.19 percent of total billed charges 2784.72 4266.92 Technical (Hospital) Services RABIES IMMUNE GLOBULIN (PF) 300 UNIT/ML INTRAMUSCULAR SOLUTION RX-173528 CDM 90375 HCPCS 636 RC 13533-0318-03 NDC outpatient 3 ML 4491.49 4491.49 BLUE CROSS BLUE SHIELD WELLMARK SB889 [3081026] BCBS WYOMING [308102603] 4266.92 percent of total billed charges 2784.72 4266.92 Technical (Hospital) Services RABIES IMMUNE GLOBULIN (PF) 300 UNIT/ML INTRAMUSCULAR SOLUTION RX-173528 CDM 90375 HCPCS 636 RC 13533-0318-03 NDC outpatient 3 ML 4491.49 4491.49 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES EPO [308136803] 3593.19 percent of total billed charges 2784.72 4266.92 Technical (Hospital) Services RABIES IMMUNE GLOBULIN (PF) 300 UNIT/ML INTRAMUSCULAR SOLUTION RX-173528 CDM 90375 HCPCS 636 RC 13533-0318-03 NDC outpatient 3 ML 4491.49 4491.49 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES HDHP [308136802] 3593.19 percent of total billed charges 2784.72 4266.92 Technical (Hospital) Services RABIES IMMUNE GLOBULIN (PF) 300 UNIT/ML INTRAMUSCULAR SOLUTION RX-173528 CDM 90375 HCPCS 636 RC 13533-0318-03 NDC outpatient 3 ML 4491.49 4491.49 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES PPO [308136801] 3593.19 percent of total billed charges 2784.72 4266.92 Technical (Hospital) Services RABIES IMMUNE GLOBULIN (PF) 300 UNIT/ML INTRAMUSCULAR SOLUTION RX-173528 CDM 90375 HCPCS 636 RC 13533-0318-03 NDC outpatient 3 ML 4491.49 4491.49 MULTIPLAN INC 34080 [3081285] MULTIPLAN INC [308128501] 4266.92 percent of total billed charges 2784.72 4266.92 Technical (Hospital) Services RABIES IMMUNE GLOBULIN (PF) 300 UNIT/ML INTRAMUSCULAR SOLUTION RX-173528 CDM 90375 HCPCS 636 RC 13533-0318-03 NDC outpatient 3 ML 4491.49 4491.49 MEDICA (COMMERCIAL) 94265 [3081118] MEDICA CLAIMS [308111801] 4042.34 percent of total billed charges 2784.72 4266.92 Technical (Hospital) Services "IV Infusion, Bamlanivimab and Etesevimab, Includes Infusion and Post Administration Monitoring" PX-2600024500 CDM M0245 CPT 260 RC outpatient 1053 1053 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES PPO [308136801] 842.4 percent of total billed charges 652.86 1000.35 Technical (Hospital) Services "IV Infusion, Bamlanivimab and Etesevimab, Includes Infusion and Post Administration Monitoring" PX-2600024500 CDM M0245 CPT 260 RC outpatient 1053 1053 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES EPO [308136803] 842.4 percent of total billed charges 652.86 1000.35 Technical (Hospital) Services "IV Infusion, Bamlanivimab and Etesevimab, Includes Infusion and Post Administration Monitoring" PX-2600024500 CDM M0245 CPT 260 RC outpatient 1053 1053 BLUE CROSS BLUE SHIELD WELLMARK SB889 [3081026] BCBS WYOMING [308102603] 1000.35 percent of total billed charges 652.86 1000.35 Technical (Hospital) Services "IV Infusion, Bamlanivimab and Etesevimab, Includes Infusion and Post Administration Monitoring" PX-2600024500 CDM M0245 CPT 260 RC outpatient 1053 1053 UNITED HEALTHCARE (COMMERCIAL) [3081199] UNITED HEALTHCARE 87726 [308119901] 652.86 percent of total billed charges 652.86 1000.35 Technical (Hospital) Services "IV Infusion, Bamlanivimab and Etesevimab, Includes Infusion and Post Administration Monitoring" PX-2600024500 CDM M0245 CPT 260 RC outpatient 1053 1053 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES HDHP [308136802] 842.4 percent of total billed charges 652.86 1000.35 Technical (Hospital) Services "IV Infusion, Bamlanivimab and Etesevimab, Includes Infusion and Post Administration Monitoring" PX-2600024500 CDM M0245 CPT 260 RC outpatient 1053 1053 MULTIPLAN INC 34080 [3081285] MULTIPLAN INC [308128501] 1000.35 percent of total billed charges 652.86 1000.35 Technical (Hospital) Services "IV Infusion, Bamlanivimab and Etesevimab, Includes Infusion and Post Administration Monitoring" PX-2600024500 CDM M0245 CPT 260 RC outpatient 1053 1053 MEDICA (COMMERCIAL) 94265 [3081118] MEDICA CLAIMS [308111801] 947.7 percent of total billed charges 652.86 1000.35 Technical (Hospital) Services "IV Infusion, Bamlanivimab and Etesevimab, Includes Infusion and Post Administration Monitoring" PX-2600024500 CDM M0245 CPT 260 RC outpatient 1053 1053 HEALTHPARTNERS SX009 HEALTHPARTNERS 842.4 percent of total billed charges 652.86 1000.35 Technical (Hospital) Services "IV Infusion, Bamlanivimab and Etesevimab, Includes Infusion and Post Administration Monitoring" PX-2600024500 CDM M0245 CPT 260 RC outpatient 1053 1053 CIGNA 62308 [3081051] CIGNA 62308 [308105105] 842.4 percent of total billed charges 652.86 1000.35 Technical (Hospital) Services "IV Infusion, Bamlanivimab and Etesevimab, Includes Infusion and Post Administration Monitoring" PX-2600024500 CDM M0245 CPT 260 RC outpatient 1053 1053 CIGNA 62308 [3081051] CIGNA STATE OF WYOMING [308105107] 842.4 percent of total billed charges 652.86 1000.35 Technical (Hospital) Services "IV Infusion, Bamlanivimab and Etesevimab, Includes Infusion and Post Administration Monitoring" PX-2600024500 CDM M0245 CPT 260 RC inpatient 1053 1053 CIGNA 62308 [3081051] CIGNA 62308 [308105105] 833.77 percent of total billed charges 652.86 1000.35 Technical (Hospital) Services "IV Infusion, Bamlanivimab and Etesevimab, Includes Infusion and Post Administration Monitoring" PX-2600024500 CDM M0245 CPT 260 RC inpatient 1053 1053 CIGNA 62308 [3081051] CIGNA STATE OF WYOMING [308105107] 833.77 percent of total billed charges 652.86 1000.35 Technical (Hospital) Services "IV Infusion, Bamlanivimab and Etesevimab, Includes Infusion and Post Administration Monitoring" PX-2600024500 CDM M0245 CPT 260 RC inpatient 1053 1053 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES EPO [308136803] 833.77 percent of total billed charges 652.86 1000.35 Technical (Hospital) Services "IV Infusion, Bamlanivimab and Etesevimab, Includes Infusion and Post Administration Monitoring" PX-2600024500 CDM M0245 CPT 260 RC inpatient 1053 1053 MEDICA (COMMERCIAL) 94265 [3081118] MEDICA CLAIMS [308111801] 947.7 percent of total billed charges 652.86 1000.35 Technical (Hospital) Services "IV Infusion, Bamlanivimab and Etesevimab, Includes Infusion and Post Administration Monitoring" PX-2600024500 CDM M0245 CPT 260 RC inpatient 1053 1053 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES HDHP [308136802] 833.77 percent of total billed charges 652.86 1000.35 Technical (Hospital) Services "IV Infusion, Bamlanivimab and Etesevimab, Includes Infusion and Post Administration Monitoring" PX-2600024500 CDM M0245 CPT 260 RC inpatient 1053 1053 MULTIPLAN INC 34080 [3081285] MULTIPLAN INC [308128501] 1000.35 percent of total billed charges 652.86 1000.35 Technical (Hospital) Services "IV Infusion, Bamlanivimab and Etesevimab, Includes Infusion and Post Administration Monitoring" PX-2600024500 CDM M0245 CPT 260 RC inpatient 1053 1053 HEALTHPARTNERS SX009 HEALTHPARTNERS 833.77 percent of total billed charges 652.86 1000.35 Technical (Hospital) Services "IV Infusion, Bamlanivimab and Etesevimab, Includes Infusion and Post Administration Monitoring" PX-2600024500 CDM M0245 CPT 260 RC inpatient 1053 1053 UNITED HEALTHCARE (COMMERCIAL) [3081199] UNITED HEALTHCARE 87726 [308119901] 652.86 percent of total billed charges 652.86 1000.35 Technical (Hospital) Services "IV Infusion, Bamlanivimab and Etesevimab, Includes Infusion and Post Administration Monitoring" PX-2600024500 CDM M0245 CPT 260 RC inpatient 1053 1053 BLUE CROSS BLUE SHIELD WELLMARK SB889 [3081026] BCBS WYOMING [308102603] 1000.35 percent of total billed charges 652.86 1000.35 Technical (Hospital) Services "IV Infusion, Bamlanivimab and Etesevimab, Includes Infusion and Post Administration Monitoring" PX-2600024500 CDM M0245 CPT 260 RC inpatient 1053 1053 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES PPO [308136801] 833.77 percent of total billed charges 652.86 1000.35 Technical (Hospital) Services Most Recent Hg A1c>Equal to 8.0%&Equal to 8.0%&Equal to 8.0%&Equal to 8.0%&Equal to 8.0%&Equal to 8.0%&Equal to 8.0%&Equal to 8.0%&Equal to 8.0%&Equal to 8.0%&Equal to 8.0%&Equal to 8.0%&Equal to 8.0%&Equal to 8.0%&Equal to 8.0%&Equal to 8.0%&Equal to 8.0%&Equal to 8.0%&Equal to 8.0%&Equal to 8.0%&Equal to 7.0%&<8.0% PX-3003051000 CDM 3051F CPT 300 RC inpatient 0.01 0.01 CIGNA 62308 [3081051] CIGNA 62308 [308105105] 0.01 percent of total billed charges 0.01 0.01 Technical (Hospital) Services Most Recent Hg A1c>Equal to 7.0%&<8.0% PX-3003051000 CDM 3051F CPT 300 RC inpatient 0.01 0.01 CIGNA 62308 [3081051] CIGNA STATE OF WYOMING [308105107] 0.01 percent of total billed charges 0.01 0.01 Technical (Hospital) Services Most Recent Hg A1c>Equal to 7.0%&<8.0% PX-3003051000 CDM 3051F CPT 300 RC inpatient 0.01 0.01 BLUE CROSS BLUE SHIELD WELLMARK SB889 [3081026] BCBS WYOMING [308102603] 0.01 percent of total billed charges 0.01 0.01 Technical (Hospital) Services Most Recent Hg A1c>Equal to 7.0%&<8.0% PX-3003051000 CDM 3051F CPT 300 RC inpatient 0.01 0.01 UNITED HEALTHCARE (COMMERCIAL) [3081199] UNITED HEALTHCARE 87726 [308119901] 0.01 percent of total billed charges 0.01 0.01 Technical (Hospital) Services Most Recent Hg A1c>Equal to 7.0%&<8.0% PX-3003051000 CDM 3051F CPT 300 RC inpatient 0.01 0.01 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES PPO [308136801] 0.01 percent of total billed charges 0.01 0.01 Technical (Hospital) Services Most Recent Hg A1c>Equal to 7.0%&<8.0% PX-3003051000 CDM 3051F CPT 300 RC inpatient 0.01 0.01 HEALTHPARTNERS SX009 HEALTHPARTNERS 0.01 percent of total billed charges 0.01 0.01 Technical (Hospital) Services Most Recent Hg A1c>Equal to 7.0%&<8.0% PX-3003051000 CDM 3051F CPT 300 RC inpatient 0.01 0.01 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES EPO [308136803] 0.01 percent of total billed charges 0.01 0.01 Technical (Hospital) Services Most Recent Hg A1c>Equal to 7.0%&<8.0% PX-3003051000 CDM 3051F CPT 300 RC inpatient 0.01 0.01 MULTIPLAN INC 34080 [3081285] MULTIPLAN INC [308128501] 0.01 percent of total billed charges 0.01 0.01 Technical (Hospital) Services Most Recent Hg A1c>Equal to 7.0%&<8.0% PX-3003051000 CDM 3051F CPT 300 RC inpatient 0.01 0.01 MEDICA (COMMERCIAL) 94265 [3081118] MEDICA CLAIMS [308111801] 0.01 percent of total billed charges 0.01 0.01 Technical (Hospital) Services Most Recent Hg A1c>Equal to 7.0%&<8.0% PX-3003051000 CDM 3051F CPT 300 RC inpatient 0.01 0.01 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES HDHP [308136802] 0.01 percent of total billed charges 0.01 0.01 Technical (Hospital) Services Most Recent Hg A1c>Equal to 7.0%&<8.0% PX-3003051000 CDM 3051F CPT 300 RC outpatient 0.01 0.01 HEALTHPARTNERS SX009 HEALTHPARTNERS 0.01 percent of total billed charges 0.01 0.01 Technical (Hospital) Services Most Recent Hg A1c>Equal to 7.0%&<8.0% PX-3003051000 CDM 3051F CPT 300 RC outpatient 0.01 0.01 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES EPO [308136803] 0.01 percent of total billed charges 0.01 0.01 Technical (Hospital) Services Most Recent Hg A1c>Equal to 7.0%&<8.0% PX-3003051000 CDM 3051F CPT 300 RC outpatient 0.01 0.01 UNITED HEALTHCARE (COMMERCIAL) [3081199] UNITED HEALTHCARE 87726 [308119901] 0.01 percent of total billed charges 0.01 0.01 Technical (Hospital) Services Most Recent Hg A1c>Equal to 7.0%&<8.0% PX-3003051000 CDM 3051F CPT 300 RC outpatient 0.01 0.01 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES PPO [308136801] 0.01 percent of total billed charges 0.01 0.01 Technical (Hospital) Services Most Recent Hg A1c>Equal to 7.0%&<8.0% PX-3003051000 CDM 3051F CPT 300 RC outpatient 0.01 0.01 BLUE CROSS BLUE SHIELD WELLMARK SB889 [3081026] BCBS WYOMING [308102603] 0.01 percent of total billed charges 0.01 0.01 Technical (Hospital) Services Most Recent Hg A1c>Equal to 7.0%&<8.0% PX-3003051000 CDM 3051F CPT 300 RC outpatient 0.01 0.01 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES HDHP [308136802] 0.01 percent of total billed charges 0.01 0.01 Technical (Hospital) Services Most Recent Hg A1c>Equal to 7.0%&<8.0% PX-3003051000 CDM 3051F CPT 300 RC outpatient 0.01 0.01 CIGNA 62308 [3081051] CIGNA 62308 [308105105] 0.01 percent of total billed charges 0.01 0.01 Technical (Hospital) Services Most Recent Hg A1c>Equal to 7.0%&<8.0% PX-3003051000 CDM 3051F CPT 300 RC outpatient 0.01 0.01 CIGNA 62308 [3081051] CIGNA STATE OF WYOMING [308105107] 0.01 percent of total billed charges 0.01 0.01 Technical (Hospital) Services Most Recent Hg A1c>Equal to 7.0%&<8.0% PX-3003051000 CDM 3051F CPT 300 RC outpatient 0.01 0.01 MEDICA (COMMERCIAL) 94265 [3081118] MEDICA CLAIMS [308111801] 0.01 percent of total billed charges 0.01 0.01 Technical (Hospital) Services Most Recent Hg A1c>Equal to 7.0%&<8.0% PX-3003051000 CDM 3051F CPT 300 RC outpatient 0.01 0.01 MULTIPLAN INC 34080 [3081285] MULTIPLAN INC [308128501] 0.01 percent of total billed charges 0.01 0.01 Technical (Hospital) Services Most Recent Hemoglobin A1c Level > 9.0% PX-3003046000 CDM 3046F CPT 300 RC inpatient 0.01 0.01 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES HDHP [308136802] 0.01 percent of total billed charges 0.01 0.01 Technical (Hospital) Services Most Recent Hemoglobin A1c Level > 9.0% PX-3003046000 CDM 3046F CPT 300 RC inpatient 0.01 0.01 MEDICA (COMMERCIAL) 94265 [3081118] MEDICA CLAIMS [308111801] 0.01 percent of total billed charges 0.01 0.01 Technical (Hospital) Services Most Recent Hemoglobin A1c Level > 9.0% PX-3003046000 CDM 3046F CPT 300 RC inpatient 0.01 0.01 MULTIPLAN INC 34080 [3081285] MULTIPLAN INC [308128501] 0.01 percent of total billed charges 0.01 0.01 Technical (Hospital) Services Most Recent Hemoglobin A1c Level > 9.0% PX-3003046000 CDM 3046F CPT 300 RC inpatient 0.01 0.01 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES EPO [308136803] 0.01 percent of total billed charges 0.01 0.01 Technical (Hospital) Services Most Recent Hemoglobin A1c Level > 9.0% PX-3003046000 CDM 3046F CPT 300 RC inpatient 0.01 0.01 HEALTHPARTNERS SX009 HEALTHPARTNERS 0.01 percent of total billed charges 0.01 0.01 Technical (Hospital) Services Most Recent Hemoglobin A1c Level > 9.0% PX-3003046000 CDM 3046F CPT 300 RC inpatient 0.01 0.01 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES PPO [308136801] 0.01 percent of total billed charges 0.01 0.01 Technical (Hospital) Services Most Recent Hemoglobin A1c Level > 9.0% PX-3003046000 CDM 3046F CPT 300 RC inpatient 0.01 0.01 UNITED HEALTHCARE (COMMERCIAL) [3081199] UNITED HEALTHCARE 87726 [308119901] 0.01 percent of total billed charges 0.01 0.01 Technical (Hospital) Services Most Recent Hemoglobin A1c Level > 9.0% PX-3003046000 CDM 3046F CPT 300 RC inpatient 0.01 0.01 BLUE CROSS BLUE SHIELD WELLMARK SB889 [3081026] BCBS WYOMING [308102603] 0.01 percent of total billed charges 0.01 0.01 Technical (Hospital) Services Most Recent Hemoglobin A1c Level > 9.0% PX-3003046000 CDM 3046F CPT 300 RC inpatient 0.01 0.01 CIGNA 62308 [3081051] CIGNA 62308 [308105105] 0.01 percent of total billed charges 0.01 0.01 Technical (Hospital) Services Most Recent Hemoglobin A1c Level > 9.0% PX-3003046000 CDM 3046F CPT 300 RC inpatient 0.01 0.01 CIGNA 62308 [3081051] CIGNA STATE OF WYOMING [308105107] 0.01 percent of total billed charges 0.01 0.01 Technical (Hospital) Services Most Recent Hemoglobin A1c Level > 9.0% PX-3003046000 CDM 3046F CPT 300 RC outpatient 0.01 0.01 CIGNA 62308 [3081051] CIGNA 62308 [308105105] 0.01 percent of total billed charges 0.01 0.01 Technical (Hospital) Services Most Recent Hemoglobin A1c Level > 9.0% PX-3003046000 CDM 3046F CPT 300 RC outpatient 0.01 0.01 CIGNA 62308 [3081051] CIGNA STATE OF WYOMING [308105107] 0.01 percent of total billed charges 0.01 0.01 Technical (Hospital) Services Most Recent Hemoglobin A1c Level > 9.0% PX-3003046000 CDM 3046F CPT 300 RC outpatient 0.01 0.01 MULTIPLAN INC 34080 [3081285] MULTIPLAN INC [308128501] 0.01 percent of total billed charges 0.01 0.01 Technical (Hospital) Services Most Recent Hemoglobin A1c Level > 9.0% PX-3003046000 CDM 3046F CPT 300 RC outpatient 0.01 0.01 MEDICA (COMMERCIAL) 94265 [3081118] MEDICA CLAIMS [308111801] 0.01 percent of total billed charges 0.01 0.01 Technical (Hospital) Services Most Recent Hemoglobin A1c Level > 9.0% PX-3003046000 CDM 3046F CPT 300 RC outpatient 0.01 0.01 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES HDHP [308136802] 0.01 percent of total billed charges 0.01 0.01 Technical (Hospital) Services Most Recent Hemoglobin A1c Level > 9.0% PX-3003046000 CDM 3046F CPT 300 RC outpatient 0.01 0.01 BLUE CROSS BLUE SHIELD WELLMARK SB889 [3081026] BCBS WYOMING [308102603] 0.01 percent of total billed charges 0.01 0.01 Technical (Hospital) Services Most Recent Hemoglobin A1c Level > 9.0% PX-3003046000 CDM 3046F CPT 300 RC outpatient 0.01 0.01 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES EPO [308136803] 0.01 percent of total billed charges 0.01 0.01 Technical (Hospital) Services Most Recent Hemoglobin A1c Level > 9.0% PX-3003046000 CDM 3046F CPT 300 RC outpatient 0.01 0.01 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES PPO [308136801] 0.01 percent of total billed charges 0.01 0.01 Technical (Hospital) Services Most Recent Hemoglobin A1c Level > 9.0% PX-3003046000 CDM 3046F CPT 300 RC outpatient 0.01 0.01 UNITED HEALTHCARE (COMMERCIAL) [3081199] UNITED HEALTHCARE 87726 [308119901] 0.01 percent of total billed charges 0.01 0.01 Technical (Hospital) Services Most Recent Hemoglobin A1c Level > 9.0% PX-3003046000 CDM 3046F CPT 300 RC outpatient 0.01 0.01 HEALTHPARTNERS SX009 HEALTHPARTNERS 0.01 percent of total billed charges 0.01 0.01 Technical (Hospital) Services Most Recent Hemoglobin A1c Level < 7.0% PX-3003044000 CDM 3044F CPT 300 RC inpatient 0.01 0.01 CIGNA 62308 [3081051] CIGNA 62308 [308105105] 0.01 percent of total billed charges 0.01 0.01 Technical (Hospital) Services Most Recent Hemoglobin A1c Level < 7.0% PX-3003044000 CDM 3044F CPT 300 RC inpatient 0.01 0.01 CIGNA 62308 [3081051] CIGNA STATE OF WYOMING [308105107] 0.01 percent of total billed charges 0.01 0.01 Technical (Hospital) Services Most Recent Hemoglobin A1c Level < 7.0% PX-3003044000 CDM 3044F CPT 300 RC inpatient 0.01 0.01 MULTIPLAN INC 34080 [3081285] MULTIPLAN INC [308128501] 0.01 percent of total billed charges 0.01 0.01 Technical (Hospital) Services Most Recent Hemoglobin A1c Level < 7.0% PX-3003044000 CDM 3044F CPT 300 RC inpatient 0.01 0.01 MEDICA (COMMERCIAL) 94265 [3081118] MEDICA CLAIMS [308111801] 0.01 percent of total billed charges 0.01 0.01 Technical (Hospital) Services Most Recent Hemoglobin A1c Level < 7.0% PX-3003044000 CDM 3044F CPT 300 RC inpatient 0.01 0.01 HEALTHPARTNERS SX009 HEALTHPARTNERS 0.01 percent of total billed charges 0.01 0.01 Technical (Hospital) Services Most Recent Hemoglobin A1c Level < 7.0% PX-3003044000 CDM 3044F CPT 300 RC inpatient 0.01 0.01 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES EPO [308136803] 0.01 percent of total billed charges 0.01 0.01 Technical (Hospital) Services Most Recent Hemoglobin A1c Level < 7.0% PX-3003044000 CDM 3044F CPT 300 RC inpatient 0.01 0.01 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES HDHP [308136802] 0.01 percent of total billed charges 0.01 0.01 Technical (Hospital) Services Most Recent Hemoglobin A1c Level < 7.0% PX-3003044000 CDM 3044F CPT 300 RC inpatient 0.01 0.01 BLUE CROSS BLUE SHIELD WELLMARK SB889 [3081026] BCBS WYOMING [308102603] 0.01 percent of total billed charges 0.01 0.01 Technical (Hospital) Services Most Recent Hemoglobin A1c Level < 7.0% PX-3003044000 CDM 3044F CPT 300 RC inpatient 0.01 0.01 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES PPO [308136801] 0.01 percent of total billed charges 0.01 0.01 Technical (Hospital) Services Most Recent Hemoglobin A1c Level < 7.0% PX-3003044000 CDM 3044F CPT 300 RC inpatient 0.01 0.01 UNITED HEALTHCARE (COMMERCIAL) [3081199] UNITED HEALTHCARE 87726 [308119901] 0.01 percent of total billed charges 0.01 0.01 Technical (Hospital) Services Most Recent Hemoglobin A1c Level < 7.0% PX-3003044000 CDM 3044F CPT 300 RC outpatient 0.01 0.01 CIGNA 62308 [3081051] CIGNA 62308 [308105105] 0.01 percent of total billed charges 0.01 0.01 Technical (Hospital) Services Most Recent Hemoglobin A1c Level < 7.0% PX-3003044000 CDM 3044F CPT 300 RC outpatient 0.01 0.01 CIGNA 62308 [3081051] CIGNA STATE OF WYOMING [308105107] 0.01 percent of total billed charges 0.01 0.01 Technical (Hospital) Services Most Recent Hemoglobin A1c Level < 7.0% PX-3003044000 CDM 3044F CPT 300 RC outpatient 0.01 0.01 MULTIPLAN INC 34080 [3081285] MULTIPLAN INC [308128501] 0.01 percent of total billed charges 0.01 0.01 Technical (Hospital) Services Most Recent Hemoglobin A1c Level < 7.0% PX-3003044000 CDM 3044F CPT 300 RC outpatient 0.01 0.01 MEDICA (COMMERCIAL) 94265 [3081118] MEDICA CLAIMS [308111801] 0.01 percent of total billed charges 0.01 0.01 Technical (Hospital) Services Most Recent Hemoglobin A1c Level < 7.0% PX-3003044000 CDM 3044F CPT 300 RC outpatient 0.01 0.01 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES HDHP [308136802] 0.01 percent of total billed charges 0.01 0.01 Technical (Hospital) Services Most Recent Hemoglobin A1c Level < 7.0% PX-3003044000 CDM 3044F CPT 300 RC outpatient 0.01 0.01 BLUE CROSS BLUE SHIELD WELLMARK SB889 [3081026] BCBS WYOMING [308102603] 0.01 percent of total billed charges 0.01 0.01 Technical (Hospital) Services Most Recent Hemoglobin A1c Level < 7.0% PX-3003044000 CDM 3044F CPT 300 RC outpatient 0.01 0.01 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES PPO [308136801] 0.01 percent of total billed charges 0.01 0.01 Technical (Hospital) Services Most Recent Hemoglobin A1c Level < 7.0% PX-3003044000 CDM 3044F CPT 300 RC outpatient 0.01 0.01 HEALTHPARTNERS SX009 HEALTHPARTNERS 0.01 percent of total billed charges 0.01 0.01 Technical (Hospital) Services Most Recent Hemoglobin A1c Level < 7.0% PX-3003044000 CDM 3044F CPT 300 RC outpatient 0.01 0.01 UNITED HEALTHCARE (COMMERCIAL) [3081199] UNITED HEALTHCARE 87726 [308119901] 0.01 percent of total billed charges 0.01 0.01 Technical (Hospital) Services Most Recent Hemoglobin A1c Level < 7.0% PX-3003044000 CDM 3044F CPT 300 RC outpatient 0.01 0.01 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES EPO [308136803] 0.01 percent of total billed charges 0.01 0.01 Technical (Hospital) Services "HC Ref Prot Electrophoresis and Isotype, S (Mayo) Peiso" PX-3100077001 CDM 0077U CPT 310 RC outpatient 394 394 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES HDHP [308136802] 315.2 percent of total billed charges 244.28 374.3 Technical (Hospital) Services "HC Ref Prot Electrophoresis and Isotype, S (Mayo) Peiso" PX-3100077001 CDM 0077U CPT 310 RC outpatient 394 394 BLUE CROSS BLUE SHIELD WELLMARK SB889 [3081026] BCBS WYOMING [308102603] 374.3 percent of total billed charges 244.28 374.3 Technical (Hospital) Services "HC Ref Prot Electrophoresis and Isotype, S (Mayo) Peiso" PX-3100077001 CDM 0077U CPT 310 RC outpatient 394 394 CIGNA 62308 [3081051] CIGNA 62308 [308105105] 315.2 percent of total billed charges 244.28 374.3 Technical (Hospital) Services "HC Ref Prot Electrophoresis and Isotype, S (Mayo) Peiso" PX-3100077001 CDM 0077U CPT 310 RC outpatient 394 394 CIGNA 62308 [3081051] CIGNA STATE OF WYOMING [308105107] 315.2 percent of total billed charges 244.28 374.3 Technical (Hospital) Services "HC Ref Prot Electrophoresis and Isotype, S (Mayo) Peiso" PX-3100077001 CDM 0077U CPT 310 RC outpatient 394 394 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES EPO [308136803] 315.2 percent of total billed charges 244.28 374.3 Technical (Hospital) Services "HC Ref Prot Electrophoresis and Isotype, S (Mayo) Peiso" PX-3100077001 CDM 0077U CPT 310 RC outpatient 394 394 UNITED HEALTHCARE (COMMERCIAL) [3081199] UNITED HEALTHCARE 87726 [308119901] 244.28 percent of total billed charges 244.28 374.3 Technical (Hospital) Services "HC Ref Prot Electrophoresis and Isotype, S (Mayo) Peiso" PX-3100077001 CDM 0077U CPT 310 RC outpatient 394 394 HEALTHPARTNERS SX009 HEALTHPARTNERS 315.2 percent of total billed charges 244.28 374.3 Technical (Hospital) Services "HC Ref Prot Electrophoresis and Isotype, S (Mayo) Peiso" PX-3100077001 CDM 0077U CPT 310 RC outpatient 394 394 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES PPO [308136801] 315.2 percent of total billed charges 244.28 374.3 Technical (Hospital) Services "HC Ref Prot Electrophoresis and Isotype, S (Mayo) Peiso" PX-3100077001 CDM 0077U CPT 310 RC outpatient 394 394 MEDICA (COMMERCIAL) 94265 [3081118] MEDICA CLAIMS [308111801] 354.6 percent of total billed charges 244.28 374.3 Technical (Hospital) Services "HC Ref Prot Electrophoresis and Isotype, S (Mayo) Peiso" PX-3100077001 CDM 0077U CPT 310 RC outpatient 394 394 MULTIPLAN INC 34080 [3081285] MULTIPLAN INC [308128501] 374.3 percent of total billed charges 244.28 374.3 Technical (Hospital) Services "HC Ref Prot Electrophoresis and Isotype, S (Mayo) Peiso" PX-3100077001 CDM 0077U CPT 310 RC inpatient 394 394 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES PPO [308136801] 311.97 percent of total billed charges 244.28 374.3 Technical (Hospital) Services "HC Ref Prot Electrophoresis and Isotype, S (Mayo) Peiso" PX-3100077001 CDM 0077U CPT 310 RC inpatient 394 394 MEDICA (COMMERCIAL) 94265 [3081118] MEDICA CLAIMS [308111801] 354.6 percent of total billed charges 244.28 374.3 Technical (Hospital) Services "HC Ref Prot Electrophoresis and Isotype, S (Mayo) Peiso" PX-3100077001 CDM 0077U CPT 310 RC inpatient 394 394 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES HDHP [308136802] 311.97 percent of total billed charges 244.28 374.3 Technical (Hospital) Services "HC Ref Prot Electrophoresis and Isotype, S (Mayo) Peiso" PX-3100077001 CDM 0077U CPT 310 RC inpatient 394 394 UNITED HEALTHCARE (COMMERCIAL) [3081199] UNITED HEALTHCARE 87726 [308119901] 244.28 percent of total billed charges 244.28 374.3 Technical (Hospital) Services "HC Ref Prot Electrophoresis and Isotype, S (Mayo) Peiso" PX-3100077001 CDM 0077U CPT 310 RC inpatient 394 394 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES EPO [308136803] 311.97 percent of total billed charges 244.28 374.3 Technical (Hospital) Services "HC Ref Prot Electrophoresis and Isotype, S (Mayo) Peiso" PX-3100077001 CDM 0077U CPT 310 RC inpatient 394 394 HEALTHPARTNERS SX009 HEALTHPARTNERS 311.97 percent of total billed charges 244.28 374.3 Technical (Hospital) Services "HC Ref Prot Electrophoresis and Isotype, S (Mayo) Peiso" PX-3100077001 CDM 0077U CPT 310 RC inpatient 394 394 MULTIPLAN INC 34080 [3081285] MULTIPLAN INC [308128501] 374.3 percent of total billed charges 244.28 374.3 Technical (Hospital) Services "HC Ref Prot Electrophoresis and Isotype, S (Mayo) Peiso" PX-3100077001 CDM 0077U CPT 310 RC inpatient 394 394 BLUE CROSS BLUE SHIELD WELLMARK SB889 [3081026] BCBS WYOMING [308102603] 374.3 percent of total billed charges 244.28 374.3 Technical (Hospital) Services "HC Ref Prot Electrophoresis and Isotype, S (Mayo) Peiso" PX-3100077001 CDM 0077U CPT 310 RC inpatient 394 394 CIGNA 62308 [3081051] CIGNA 62308 [308105105] 311.97 percent of total billed charges 244.28 374.3 Technical (Hospital) Services "HC Ref Prot Electrophoresis and Isotype, S (Mayo) Peiso" PX-3100077001 CDM 0077U CPT 310 RC inpatient 394 394 CIGNA 62308 [3081051] CIGNA STATE OF WYOMING [308105107] 311.97 percent of total billed charges 244.28 374.3 Technical (Hospital) Services Ref Tpmt and Nudt15 Genotype PX-3100034000 CDM 0034U CPT 310 RC outpatient 707 707 HEALTHPARTNERS SX009 HEALTHPARTNERS 565.6 percent of total billed charges 438.34 671.65 Technical (Hospital) Services Ref Tpmt and Nudt15 Genotype PX-3100034000 CDM 0034U CPT 310 RC outpatient 707 707 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES PPO [308136801] 565.6 percent of total billed charges 438.34 671.65 Technical (Hospital) Services Ref Tpmt and Nudt15 Genotype PX-3100034000 CDM 0034U CPT 310 RC outpatient 707 707 UNITED HEALTHCARE (COMMERCIAL) [3081199] UNITED HEALTHCARE 87726 [308119901] 438.34 percent of total billed charges 438.34 671.65 Technical (Hospital) Services Ref Tpmt and Nudt15 Genotype PX-3100034000 CDM 0034U CPT 310 RC outpatient 707 707 CIGNA 62308 [3081051] CIGNA 62308 [308105105] 565.6 percent of total billed charges 438.34 671.65 Technical (Hospital) Services Ref Tpmt and Nudt15 Genotype PX-3100034000 CDM 0034U CPT 310 RC outpatient 707 707 CIGNA 62308 [3081051] CIGNA STATE OF WYOMING [308105107] 565.6 percent of total billed charges 438.34 671.65 Technical (Hospital) Services Ref Tpmt and Nudt15 Genotype PX-3100034000 CDM 0034U CPT 310 RC outpatient 707 707 BLUE CROSS BLUE SHIELD WELLMARK SB889 [3081026] BCBS WYOMING [308102603] 671.65 percent of total billed charges 438.34 671.65 Technical (Hospital) Services Ref Tpmt and Nudt15 Genotype PX-3100034000 CDM 0034U CPT 310 RC outpatient 707 707 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES HDHP [308136802] 565.6 percent of total billed charges 438.34 671.65 Technical (Hospital) Services Ref Tpmt and Nudt15 Genotype PX-3100034000 CDM 0034U CPT 310 RC outpatient 707 707 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES EPO [308136803] 565.6 percent of total billed charges 438.34 671.65 Technical (Hospital) Services Ref Tpmt and Nudt15 Genotype PX-3100034000 CDM 0034U CPT 310 RC outpatient 707 707 MULTIPLAN INC 34080 [3081285] MULTIPLAN INC [308128501] 671.65 percent of total billed charges 438.34 671.65 Technical (Hospital) Services Ref Tpmt and Nudt15 Genotype PX-3100034000 CDM 0034U CPT 310 RC outpatient 707 707 MEDICA (COMMERCIAL) 94265 [3081118] MEDICA CLAIMS [308111801] 636.3 percent of total billed charges 438.34 671.65 Technical (Hospital) Services Ref Tpmt and Nudt15 Genotype PX-3100034000 CDM 0034U CPT 310 RC inpatient 707 707 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES PPO [308136801] 559.8 percent of total billed charges 438.34 671.65 Technical (Hospital) Services Ref Tpmt and Nudt15 Genotype PX-3100034000 CDM 0034U CPT 310 RC inpatient 707 707 HEALTHPARTNERS SX009 HEALTHPARTNERS 559.8 percent of total billed charges 438.34 671.65 Technical (Hospital) Services Ref Tpmt and Nudt15 Genotype PX-3100034000 CDM 0034U CPT 310 RC inpatient 707 707 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES EPO [308136803] 559.8 percent of total billed charges 438.34 671.65 Technical (Hospital) Services Ref Tpmt and Nudt15 Genotype PX-3100034000 CDM 0034U CPT 310 RC inpatient 707 707 CIGNA 62308 [3081051] CIGNA 62308 [308105105] 559.8 percent of total billed charges 438.34 671.65 Technical (Hospital) Services Ref Tpmt and Nudt15 Genotype PX-3100034000 CDM 0034U CPT 310 RC inpatient 707 707 CIGNA 62308 [3081051] CIGNA STATE OF WYOMING [308105107] 559.8 percent of total billed charges 438.34 671.65 Technical (Hospital) Services Ref Tpmt and Nudt15 Genotype PX-3100034000 CDM 0034U CPT 310 RC inpatient 707 707 BLUE CROSS BLUE SHIELD WELLMARK SB889 [3081026] BCBS WYOMING [308102603] 671.65 percent of total billed charges 438.34 671.65 Technical (Hospital) Services Ref Tpmt and Nudt15 Genotype PX-3100034000 CDM 0034U CPT 310 RC inpatient 707 707 MULTIPLAN INC 34080 [3081285] MULTIPLAN INC [308128501] 671.65 percent of total billed charges 438.34 671.65 Technical (Hospital) Services Ref Tpmt and Nudt15 Genotype PX-3100034000 CDM 0034U CPT 310 RC inpatient 707 707 UNITED HEALTHCARE (COMMERCIAL) [3081199] UNITED HEALTHCARE 87726 [308119901] 438.34 percent of total billed charges 438.34 671.65 Technical (Hospital) Services Ref Tpmt and Nudt15 Genotype PX-3100034000 CDM 0034U CPT 310 RC inpatient 707 707 MEDICA (COMMERCIAL) 94265 [3081118] MEDICA CLAIMS [308111801] 636.3 percent of total billed charges 438.34 671.65 Technical (Hospital) Services Ref Tpmt and Nudt15 Genotype PX-3100034000 CDM 0034U CPT 310 RC inpatient 707 707 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES HDHP [308136802] 559.8 percent of total billed charges 438.34 671.65 Technical (Hospital) Services Ref Focused Pharmacogenomics Panel PX-3000029000 CDM 0029U CPT 300 RC outpatient 533 533 HEALTHPARTNERS SX009 HEALTHPARTNERS 426.4 percent of total billed charges 330.46 506.35 Technical (Hospital) Services Ref Focused Pharmacogenomics Panel PX-3000029000 CDM 0029U CPT 300 RC outpatient 533 533 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES HDHP [308136802] 426.4 percent of total billed charges 330.46 506.35 Technical (Hospital) Services Ref Focused Pharmacogenomics Panel PX-3000029000 CDM 0029U CPT 300 RC outpatient 533 533 BLUE CROSS BLUE SHIELD WELLMARK SB889 [3081026] BCBS WYOMING [308102603] 506.35 percent of total billed charges 330.46 506.35 Technical (Hospital) Services Ref Focused Pharmacogenomics Panel PX-3000029000 CDM 0029U CPT 300 RC outpatient 533 533 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES PPO [308136801] 426.4 percent of total billed charges 330.46 506.35 Technical (Hospital) Services Ref Focused Pharmacogenomics Panel PX-3000029000 CDM 0029U CPT 300 RC outpatient 533 533 UNITED HEALTHCARE (COMMERCIAL) [3081199] UNITED HEALTHCARE 87726 [308119901] 330.46 percent of total billed charges 330.46 506.35 Technical (Hospital) Services Ref Focused Pharmacogenomics Panel PX-3000029000 CDM 0029U CPT 300 RC outpatient 533 533 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES EPO [308136803] 426.4 percent of total billed charges 330.46 506.35 Technical (Hospital) Services Ref Focused Pharmacogenomics Panel PX-3000029000 CDM 0029U CPT 300 RC outpatient 533 533 MULTIPLAN INC 34080 [3081285] MULTIPLAN INC [308128501] 506.35 percent of total billed charges 330.46 506.35 Technical (Hospital) Services Ref Focused Pharmacogenomics Panel PX-3000029000 CDM 0029U CPT 300 RC outpatient 533 533 MEDICA (COMMERCIAL) 94265 [3081118] MEDICA CLAIMS [308111801] 479.7 percent of total billed charges 330.46 506.35 Technical (Hospital) Services Ref Focused Pharmacogenomics Panel PX-3000029000 CDM 0029U CPT 300 RC outpatient 533 533 CIGNA 62308 [3081051] CIGNA 62308 [308105105] 426.4 percent of total billed charges 330.46 506.35 Technical (Hospital) Services Ref Focused Pharmacogenomics Panel PX-3000029000 CDM 0029U CPT 300 RC outpatient 533 533 CIGNA 62308 [3081051] CIGNA STATE OF WYOMING [308105107] 426.4 percent of total billed charges 330.46 506.35 Technical (Hospital) Services Ref Focused Pharmacogenomics Panel PX-3000029000 CDM 0029U CPT 300 RC inpatient 533 533 CIGNA 62308 [3081051] CIGNA STATE OF WYOMING [308105107] 422.03 percent of total billed charges 330.46 506.35 Technical (Hospital) Services Ref Focused Pharmacogenomics Panel PX-3000029000 CDM 0029U CPT 300 RC inpatient 533 533 CIGNA 62308 [3081051] CIGNA 62308 [308105105] 422.03 percent of total billed charges 330.46 506.35 Technical (Hospital) Services Ref Focused Pharmacogenomics Panel PX-3000029000 CDM 0029U CPT 300 RC inpatient 533 533 MEDICA (COMMERCIAL) 94265 [3081118] MEDICA CLAIMS [308111801] 479.7 percent of total billed charges 330.46 506.35 Technical (Hospital) Services Ref Focused Pharmacogenomics Panel PX-3000029000 CDM 0029U CPT 300 RC inpatient 533 533 MULTIPLAN INC 34080 [3081285] MULTIPLAN INC [308128501] 506.35 percent of total billed charges 330.46 506.35 Technical (Hospital) Services Ref Focused Pharmacogenomics Panel PX-3000029000 CDM 0029U CPT 300 RC inpatient 533 533 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES HDHP [308136802] 422.03 percent of total billed charges 330.46 506.35 Technical (Hospital) Services Ref Focused Pharmacogenomics Panel PX-3000029000 CDM 0029U CPT 300 RC inpatient 533 533 HEALTHPARTNERS SX009 HEALTHPARTNERS 422.03 percent of total billed charges 330.46 506.35 Technical (Hospital) Services Ref Focused Pharmacogenomics Panel PX-3000029000 CDM 0029U CPT 300 RC inpatient 533 533 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES EPO [308136803] 422.03 percent of total billed charges 330.46 506.35 Technical (Hospital) Services Ref Focused Pharmacogenomics Panel PX-3000029000 CDM 0029U CPT 300 RC inpatient 533 533 BLUE CROSS BLUE SHIELD WELLMARK SB889 [3081026] BCBS WYOMING [308102603] 506.35 percent of total billed charges 330.46 506.35 Technical (Hospital) Services Ref Focused Pharmacogenomics Panel PX-3000029000 CDM 0029U CPT 300 RC inpatient 533 533 UNITED HEALTHCARE (COMMERCIAL) [3081199] UNITED HEALTHCARE 87726 [308119901] 330.46 percent of total billed charges 330.46 506.35 Technical (Hospital) Services Ref Focused Pharmacogenomics Panel PX-3000029000 CDM 0029U CPT 300 RC inpatient 533 533 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES PPO [308136801] 422.03 percent of total billed charges 330.46 506.35 Technical (Hospital) Services "Ref Jak2 Exon 12 and Other Non-V617f Mutation Detection, Blood" PX-3100027000 CDM 0027U CPT 310 RC inpatient 605 605 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES EPO [308136803] 479.04 percent of total billed charges 375.1 574.75 Technical (Hospital) Services "Ref Jak2 Exon 12 and Other Non-V617f Mutation Detection, Blood" PX-3100027000 CDM 0027U CPT 310 RC inpatient 605 605 HEALTHPARTNERS SX009 HEALTHPARTNERS 479.04 percent of total billed charges 375.1 574.75 Technical (Hospital) Services "Ref Jak2 Exon 12 and Other Non-V617f Mutation Detection, Blood" PX-3100027000 CDM 0027U CPT 310 RC inpatient 605 605 BLUE CROSS BLUE SHIELD WELLMARK SB889 [3081026] BCBS WYOMING [308102603] 574.75 percent of total billed charges 375.1 574.75 Technical (Hospital) Services "Ref Jak2 Exon 12 and Other Non-V617f Mutation Detection, Blood" PX-3100027000 CDM 0027U CPT 310 RC inpatient 605 605 MULTIPLAN INC 34080 [3081285] MULTIPLAN INC [308128501] 574.75 percent of total billed charges 375.1 574.75 Technical (Hospital) Services "Ref Jak2 Exon 12 and Other Non-V617f Mutation Detection, Blood" PX-3100027000 CDM 0027U CPT 310 RC inpatient 605 605 CIGNA 62308 [3081051] CIGNA 62308 [308105105] 479.04 percent of total billed charges 375.1 574.75 Technical (Hospital) Services "Ref Jak2 Exon 12 and Other Non-V617f Mutation Detection, Blood" PX-3100027000 CDM 0027U CPT 310 RC inpatient 605 605 CIGNA 62308 [3081051] CIGNA STATE OF WYOMING [308105107] 479.04 percent of total billed charges 375.1 574.75 Technical (Hospital) Services "Ref Jak2 Exon 12 and Other Non-V617f Mutation Detection, Blood" PX-3100027000 CDM 0027U CPT 310 RC inpatient 605 605 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES PPO [308136801] 479.04 percent of total billed charges 375.1 574.75 Technical (Hospital) Services "Ref Jak2 Exon 12 and Other Non-V617f Mutation Detection, Blood" PX-3100027000 CDM 0027U CPT 310 RC inpatient 605 605 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES HDHP [308136802] 479.04 percent of total billed charges 375.1 574.75 Technical (Hospital) Services "Ref Jak2 Exon 12 and Other Non-V617f Mutation Detection, Blood" PX-3100027000 CDM 0027U CPT 310 RC inpatient 605 605 UNITED HEALTHCARE (COMMERCIAL) [3081199] UNITED HEALTHCARE 87726 [308119901] 375.1 percent of total billed charges 375.1 574.75 Technical (Hospital) Services "Ref Jak2 Exon 12 and Other Non-V617f Mutation Detection, Blood" PX-3100027000 CDM 0027U CPT 310 RC inpatient 605 605 MEDICA (COMMERCIAL) 94265 [3081118] MEDICA CLAIMS [308111801] 544.5 percent of total billed charges 375.1 574.75 Technical (Hospital) Services "Ref Jak2 Exon 12 and Other Non-V617f Mutation Detection, Blood" PX-3100027000 CDM 0027U CPT 310 RC outpatient 605 605 HEALTHPARTNERS SX009 HEALTHPARTNERS 484 percent of total billed charges 375.1 574.75 Technical (Hospital) Services "Ref Jak2 Exon 12 and Other Non-V617f Mutation Detection, Blood" PX-3100027000 CDM 0027U CPT 310 RC outpatient 605 605 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES PPO [308136801] 484 percent of total billed charges 375.1 574.75 Technical (Hospital) Services "Ref Jak2 Exon 12 and Other Non-V617f Mutation Detection, Blood" PX-3100027000 CDM 0027U CPT 310 RC outpatient 605 605 UNITED HEALTHCARE (COMMERCIAL) [3081199] UNITED HEALTHCARE 87726 [308119901] 375.1 percent of total billed charges 375.1 574.75 Technical (Hospital) Services "Ref Jak2 Exon 12 and Other Non-V617f Mutation Detection, Blood" PX-3100027000 CDM 0027U CPT 310 RC outpatient 605 605 CIGNA 62308 [3081051] CIGNA 62308 [308105105] 484 percent of total billed charges 375.1 574.75 Technical (Hospital) Services "Ref Jak2 Exon 12 and Other Non-V617f Mutation Detection, Blood" PX-3100027000 CDM 0027U CPT 310 RC outpatient 605 605 CIGNA 62308 [3081051] CIGNA STATE OF WYOMING [308105107] 484 percent of total billed charges 375.1 574.75 Technical (Hospital) Services "Ref Jak2 Exon 12 and Other Non-V617f Mutation Detection, Blood" PX-3100027000 CDM 0027U CPT 310 RC outpatient 605 605 BLUE CROSS BLUE SHIELD WELLMARK SB889 [3081026] BCBS WYOMING [308102603] 574.75 percent of total billed charges 375.1 574.75 Technical (Hospital) Services "Ref Jak2 Exon 12 and Other Non-V617f Mutation Detection, Blood" PX-3100027000 CDM 0027U CPT 310 RC outpatient 605 605 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES HDHP [308136802] 484 percent of total billed charges 375.1 574.75 Technical (Hospital) Services "Ref Jak2 Exon 12 and Other Non-V617f Mutation Detection, Blood" PX-3100027000 CDM 0027U CPT 310 RC outpatient 605 605 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES EPO [308136803] 484 percent of total billed charges 375.1 574.75 Technical (Hospital) Services "Ref Jak2 Exon 12 and Other Non-V617f Mutation Detection, Blood" PX-3100027000 CDM 0027U CPT 310 RC outpatient 605 605 MEDICA (COMMERCIAL) 94265 [3081118] MEDICA CLAIMS [308111801] 544.5 percent of total billed charges 375.1 574.75 Technical (Hospital) Services "Ref Jak2 Exon 12 and Other Non-V617f Mutation Detection, Blood" PX-3100027000 CDM 0027U CPT 310 RC outpatient 605 605 MULTIPLAN INC 34080 [3081285] MULTIPLAN INC [308128501] 574.75 percent of total billed charges 375.1 574.75 Technical (Hospital) Services Ref Nash Fibrosure PX-3100003000 CDM 0003M CPT 310 RC outpatient 977 977 HEALTHPARTNERS SX009 HEALTHPARTNERS 781.6 percent of total billed charges 605.74 928.15 Technical (Hospital) Services Ref Nash Fibrosure PX-3100003000 CDM 0003M CPT 310 RC outpatient 977 977 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES PPO [308136801] 781.6 percent of total billed charges 605.74 928.15 Technical (Hospital) Services Ref Nash Fibrosure PX-3100003000 CDM 0003M CPT 310 RC outpatient 977 977 UNITED HEALTHCARE (COMMERCIAL) [3081199] UNITED HEALTHCARE 87726 [308119901] 605.74 percent of total billed charges 605.74 928.15 Technical (Hospital) Services Ref Nash Fibrosure PX-3100003000 CDM 0003M CPT 310 RC outpatient 977 977 BLUE CROSS BLUE SHIELD WELLMARK SB889 [3081026] BCBS WYOMING [308102603] 928.15 percent of total billed charges 605.74 928.15 Technical (Hospital) Services Ref Nash Fibrosure PX-3100003000 CDM 0003M CPT 310 RC outpatient 977 977 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES HDHP [308136802] 781.6 percent of total billed charges 605.74 928.15 Technical (Hospital) Services Ref Nash Fibrosure PX-3100003000 CDM 0003M CPT 310 RC outpatient 977 977 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES EPO [308136803] 781.6 percent of total billed charges 605.74 928.15 Technical (Hospital) Services Ref Nash Fibrosure PX-3100003000 CDM 0003M CPT 310 RC outpatient 977 977 CIGNA 62308 [3081051] CIGNA 62308 [308105105] 781.6 percent of total billed charges 605.74 928.15 Technical (Hospital) Services Ref Nash Fibrosure PX-3100003000 CDM 0003M CPT 310 RC outpatient 977 977 CIGNA 62308 [3081051] CIGNA STATE OF WYOMING [308105107] 781.6 percent of total billed charges 605.74 928.15 Technical (Hospital) Services Ref Nash Fibrosure PX-3100003000 CDM 0003M CPT 310 RC outpatient 977 977 MULTIPLAN INC 34080 [3081285] MULTIPLAN INC [308128501] 928.15 percent of total billed charges 605.74 928.15 Technical (Hospital) Services Ref Nash Fibrosure PX-3100003000 CDM 0003M CPT 310 RC outpatient 977 977 MEDICA (COMMERCIAL) 94265 [3081118] MEDICA CLAIMS [308111801] 879.3 percent of total billed charges 605.74 928.15 Technical (Hospital) Services Ref Nash Fibrosure PX-3100003000 CDM 0003M CPT 310 RC inpatient 977 977 CIGNA 62308 [3081051] CIGNA 62308 [308105105] 773.59 percent of total billed charges 605.74 928.15 Technical (Hospital) Services Ref Nash Fibrosure PX-3100003000 CDM 0003M CPT 310 RC inpatient 977 977 CIGNA 62308 [3081051] CIGNA STATE OF WYOMING [308105107] 773.59 percent of total billed charges 605.74 928.15 Technical (Hospital) Services Ref Nash Fibrosure PX-3100003000 CDM 0003M CPT 310 RC inpatient 977 977 BLUE CROSS BLUE SHIELD WELLMARK SB889 [3081026] BCBS WYOMING [308102603] 928.15 percent of total billed charges 605.74 928.15 Technical (Hospital) Services Ref Nash Fibrosure PX-3100003000 CDM 0003M CPT 310 RC inpatient 977 977 MULTIPLAN INC 34080 [3081285] MULTIPLAN INC [308128501] 928.15 percent of total billed charges 605.74 928.15 Technical (Hospital) Services Ref Nash Fibrosure PX-3100003000 CDM 0003M CPT 310 RC inpatient 977 977 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES EPO [308136803] 773.59 percent of total billed charges 605.74 928.15 Technical (Hospital) Services Ref Nash Fibrosure PX-3100003000 CDM 0003M CPT 310 RC inpatient 977 977 HEALTHPARTNERS SX009 HEALTHPARTNERS 773.59 percent of total billed charges 605.74 928.15 Technical (Hospital) Services Ref Nash Fibrosure PX-3100003000 CDM 0003M CPT 310 RC inpatient 977 977 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES PPO [308136801] 773.59 percent of total billed charges 605.74 928.15 Technical (Hospital) Services Ref Nash Fibrosure PX-3100003000 CDM 0003M CPT 310 RC inpatient 977 977 UNITED HEALTHCARE (COMMERCIAL) [3081199] UNITED HEALTHCARE 87726 [308119901] 605.74 percent of total billed charges 605.74 928.15 Technical (Hospital) Services Ref Nash Fibrosure PX-3100003000 CDM 0003M CPT 310 RC inpatient 977 977 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES HDHP [308136802] 773.59 percent of total billed charges 605.74 928.15 Technical (Hospital) Services Ref Nash Fibrosure PX-3100003000 CDM 0003M CPT 310 RC inpatient 977 977 MEDICA (COMMERCIAL) 94265 [3081118] MEDICA CLAIMS [308111801] 879.3 percent of total billed charges 605.74 928.15 Technical (Hospital) Services Tobacco Use Cessation Intensive >10 Minutes PX-5109940700 CDM 99407 CPT 510 RC inpatient 140 140 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES PPO [308136801] 110.85 percent of total billed charges 86.8 133 Technical (Hospital) Services Tobacco Use Cessation Intensive >10 Minutes PX-5109940700 CDM 99407 CPT 510 RC inpatient 140 140 UNITED HEALTHCARE (COMMERCIAL) [3081199] UNITED HEALTHCARE 87726 [308119901] 86.8 percent of total billed charges 86.8 133 Technical (Hospital) Services Tobacco Use Cessation Intensive >10 Minutes PX-5109940700 CDM 99407 CPT 510 RC inpatient 140 140 BLUE CROSS BLUE SHIELD WELLMARK SB889 [3081026] BCBS WYOMING [308102603] 133 percent of total billed charges 86.8 133 Technical (Hospital) Services Tobacco Use Cessation Intensive >10 Minutes PX-5109940700 CDM 99407 CPT 510 RC inpatient 140 140 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES HDHP [308136802] 110.85 percent of total billed charges 86.8 133 Technical (Hospital) Services Tobacco Use Cessation Intensive >10 Minutes PX-5109940700 CDM 99407 CPT 510 RC inpatient 140 140 MULTIPLAN INC 34080 [3081285] MULTIPLAN INC [308128501] 133 percent of total billed charges 86.8 133 Technical (Hospital) Services Tobacco Use Cessation Intensive >10 Minutes PX-5109940700 CDM 99407 CPT 510 RC inpatient 140 140 MEDICA (COMMERCIAL) 94265 [3081118] MEDICA CLAIMS [308111801] 126 percent of total billed charges 86.8 133 Technical (Hospital) Services Tobacco Use Cessation Intensive >10 Minutes PX-5109940700 CDM 99407 CPT 510 RC inpatient 140 140 HEALTHPARTNERS SX009 HEALTHPARTNERS 110.85 percent of total billed charges 86.8 133 Technical (Hospital) Services Tobacco Use Cessation Intensive >10 Minutes PX-5109940700 CDM 99407 CPT 510 RC inpatient 140 140 CIGNA 62308 [3081051] CIGNA 62308 [308105105] 110.85 percent of total billed charges 86.8 133 Technical (Hospital) Services Tobacco Use Cessation Intensive >10 Minutes PX-5109940700 CDM 99407 CPT 510 RC inpatient 140 140 CIGNA 62308 [3081051] CIGNA STATE OF WYOMING [308105107] 110.85 percent of total billed charges 86.8 133 Technical (Hospital) Services Tobacco Use Cessation Intensive >10 Minutes PX-5109940700 CDM 99407 CPT 510 RC inpatient 140 140 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES EPO [308136803] 110.85 percent of total billed charges 86.8 133 Technical (Hospital) Services Tobacco Use Cessation Intensive >10 Minutes PX-5109940700 CDM 99407 CPT 510 RC outpatient 140 140 UNITED HEALTHCARE (COMMERCIAL) [3081199] UNITED HEALTHCARE 87726 [308119901] 86.8 percent of total billed charges 86.8 133 Technical (Hospital) Services Tobacco Use Cessation Intensive >10 Minutes PX-5109940700 CDM 99407 CPT 510 RC outpatient 140 140 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES EPO [308136803] 112 percent of total billed charges 86.8 133 Technical (Hospital) Services Tobacco Use Cessation Intensive >10 Minutes PX-5109940700 CDM 99407 CPT 510 RC outpatient 140 140 HEALTHPARTNERS SX009 HEALTHPARTNERS 112 percent of total billed charges 86.8 133 Technical (Hospital) Services Tobacco Use Cessation Intensive >10 Minutes PX-5109940700 CDM 99407 CPT 510 RC outpatient 140 140 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES PPO [308136801] 112 percent of total billed charges 86.8 133 Technical (Hospital) Services Tobacco Use Cessation Intensive >10 Minutes PX-5109940700 CDM 99407 CPT 510 RC outpatient 140 140 BLUE CROSS BLUE SHIELD WELLMARK SB889 [3081026] BCBS WYOMING [308102603] 133 percent of total billed charges 86.8 133 Technical (Hospital) Services Tobacco Use Cessation Intensive >10 Minutes PX-5109940700 CDM 99407 CPT 510 RC outpatient 140 140 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES HDHP [308136802] 112 percent of total billed charges 86.8 133 Technical (Hospital) Services Tobacco Use Cessation Intensive >10 Minutes PX-5109940700 CDM 99407 CPT 510 RC outpatient 140 140 CIGNA 62308 [3081051] CIGNA 62308 [308105105] 112 percent of total billed charges 86.8 133 Technical (Hospital) Services Tobacco Use Cessation Intensive >10 Minutes PX-5109940700 CDM 99407 CPT 510 RC outpatient 140 140 CIGNA 62308 [3081051] CIGNA STATE OF WYOMING [308105107] 112 percent of total billed charges 86.8 133 Technical (Hospital) Services Tobacco Use Cessation Intensive >10 Minutes PX-5109940700 CDM 99407 CPT 510 RC outpatient 140 140 MULTIPLAN INC 34080 [3081285] MULTIPLAN INC [308128501] 133 percent of total billed charges 86.8 133 Technical (Hospital) Services Tobacco Use Cessation Intensive >10 Minutes PX-5109940700 CDM 99407 CPT 510 RC outpatient 140 140 MEDICA (COMMERCIAL) 94265 [3081118] MEDICA CLAIMS [308111801] 126 percent of total billed charges 86.8 133 Technical (Hospital) Services Tobacco Use Cessation Intermediate 3-10 Minutes PX-5109940600 CDM 99406 CPT 510 RC inpatient 70 70 CIGNA 62308 [3081051] CIGNA 62308 [308105105] 55.43 percent of total billed charges 43.4 66.5 Technical (Hospital) Services Tobacco Use Cessation Intermediate 3-10 Minutes PX-5109940600 CDM 99406 CPT 510 RC inpatient 70 70 CIGNA 62308 [3081051] CIGNA STATE OF WYOMING [308105107] 55.43 percent of total billed charges 43.4 66.5 Technical (Hospital) Services Tobacco Use Cessation Intermediate 3-10 Minutes PX-5109940600 CDM 99406 CPT 510 RC inpatient 70 70 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES EPO [308136803] 55.43 percent of total billed charges 43.4 66.5 Technical (Hospital) Services Tobacco Use Cessation Intermediate 3-10 Minutes PX-5109940600 CDM 99406 CPT 510 RC inpatient 70 70 MEDICA (COMMERCIAL) 94265 [3081118] MEDICA CLAIMS [308111801] 63 percent of total billed charges 43.4 66.5 Technical (Hospital) Services Tobacco Use Cessation Intermediate 3-10 Minutes PX-5109940600 CDM 99406 CPT 510 RC inpatient 70 70 MULTIPLAN INC 34080 [3081285] MULTIPLAN INC [308128501] 66.5 percent of total billed charges 43.4 66.5 Technical (Hospital) Services Tobacco Use Cessation Intermediate 3-10 Minutes PX-5109940600 CDM 99406 CPT 510 RC inpatient 70 70 HEALTHPARTNERS SX009 HEALTHPARTNERS 55.43 percent of total billed charges 43.4 66.5 Technical (Hospital) Services Tobacco Use Cessation Intermediate 3-10 Minutes PX-5109940600 CDM 99406 CPT 510 RC inpatient 70 70 BLUE CROSS BLUE SHIELD WELLMARK SB889 [3081026] BCBS WYOMING [308102603] 66.5 percent of total billed charges 43.4 66.5 Technical (Hospital) Services Tobacco Use Cessation Intermediate 3-10 Minutes PX-5109940600 CDM 99406 CPT 510 RC inpatient 70 70 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES HDHP [308136802] 55.43 percent of total billed charges 43.4 66.5 Technical (Hospital) Services Tobacco Use Cessation Intermediate 3-10 Minutes PX-5109940600 CDM 99406 CPT 510 RC inpatient 70 70 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES PPO [308136801] 55.43 percent of total billed charges 43.4 66.5 Technical (Hospital) Services Tobacco Use Cessation Intermediate 3-10 Minutes PX-5109940600 CDM 99406 CPT 510 RC inpatient 70 70 UNITED HEALTHCARE (COMMERCIAL) [3081199] UNITED HEALTHCARE 87726 [308119901] 43.4 percent of total billed charges 43.4 66.5 Technical (Hospital) Services Tobacco Use Cessation Intermediate 3-10 Minutes PX-5109940600 CDM 99406 CPT 510 RC outpatient 70 70 MULTIPLAN INC 34080 [3081285] MULTIPLAN INC [308128501] 66.5 percent of total billed charges 43.4 66.5 Technical (Hospital) Services Tobacco Use Cessation Intermediate 3-10 Minutes PX-5109940600 CDM 99406 CPT 510 RC outpatient 70 70 MEDICA (COMMERCIAL) 94265 [3081118] MEDICA CLAIMS [308111801] 63 percent of total billed charges 43.4 66.5 Technical (Hospital) Services Tobacco Use Cessation Intermediate 3-10 Minutes PX-5109940600 CDM 99406 CPT 510 RC outpatient 70 70 CIGNA 62308 [3081051] CIGNA 62308 [308105105] 56 percent of total billed charges 43.4 66.5 Technical (Hospital) Services Tobacco Use Cessation Intermediate 3-10 Minutes PX-5109940600 CDM 99406 CPT 510 RC outpatient 70 70 CIGNA 62308 [3081051] CIGNA STATE OF WYOMING [308105107] 56 percent of total billed charges 43.4 66.5 Technical (Hospital) Services Tobacco Use Cessation Intermediate 3-10 Minutes PX-5109940600 CDM 99406 CPT 510 RC outpatient 70 70 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES EPO [308136803] 56 percent of total billed charges 43.4 66.5 Technical (Hospital) Services Tobacco Use Cessation Intermediate 3-10 Minutes PX-5109940600 CDM 99406 CPT 510 RC outpatient 70 70 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES PPO [308136801] 56 percent of total billed charges 43.4 66.5 Technical (Hospital) Services Tobacco Use Cessation Intermediate 3-10 Minutes PX-5109940600 CDM 99406 CPT 510 RC outpatient 70 70 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES HDHP [308136802] 56 percent of total billed charges 43.4 66.5 Technical (Hospital) Services Tobacco Use Cessation Intermediate 3-10 Minutes PX-5109940600 CDM 99406 CPT 510 RC outpatient 70 70 BLUE CROSS BLUE SHIELD WELLMARK SB889 [3081026] BCBS WYOMING [308102603] 66.5 percent of total billed charges 43.4 66.5 Technical (Hospital) Services Tobacco Use Cessation Intermediate 3-10 Minutes PX-5109940600 CDM 99406 CPT 510 RC outpatient 70 70 HEALTHPARTNERS SX009 HEALTHPARTNERS 56 percent of total billed charges 43.4 66.5 Technical (Hospital) Services Tobacco Use Cessation Intermediate 3-10 Minutes PX-5109940600 CDM 99406 CPT 510 RC outpatient 70 70 UNITED HEALTHCARE (COMMERCIAL) [3081199] UNITED HEALTHCARE 87726 [308119901] 43.4 percent of total billed charges 43.4 66.5 Technical (Hospital) Services "Critical Care, Addl 30 Min" PX-99292 CDM 99292 CPT inpatient 877 877 CIGNA 62308 [3081051] CIGNA 62308 [308105105] 701.6 percent of total billed charges 543.74 833.15 Professional (doctor) services "Critical Care, Addl 30 Min" PX-99292 CDM 99292 CPT inpatient 877 877 CIGNA 62308 [3081051] CIGNA STATE OF WYOMING [308105107] 701.6 percent of total billed charges 543.74 833.15 Professional (doctor) services "Critical Care, Addl 30 Min" PX-99292 CDM 99292 CPT outpatient 877 877 CIGNA 62308 [3081051] CIGNA 62308 [308105105] 701.6 percent of total billed charges 543.74 833.15 Professional (doctor) services "Critical Care, Addl 30 Min" PX-99292 CDM 99292 CPT outpatient 877 877 CIGNA 62308 [3081051] CIGNA STATE OF WYOMING [308105107] 701.6 percent of total billed charges 543.74 833.15 Professional (doctor) services "Critical Care, Addl 30 Min" PX-99292 CDM 99292 CPT inpatient 877 877 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES EPO [308136803] 701.6 percent of total billed charges 543.74 833.15 Professional (doctor) services "Critical Care, Addl 30 Min" PX-99292 CDM 99292 CPT inpatient 877 877 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES HDHP [308136802] 701.6 percent of total billed charges 543.74 833.15 Professional (doctor) services "Critical Care, Addl 30 Min" PX-99292 CDM 99292 CPT inpatient 877 877 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES PPO [308136801] 701.6 percent of total billed charges 543.74 833.15 Professional (doctor) services "Critical Care, Addl 30 Min" PX-99292 CDM 99292 CPT outpatient 877 877 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES EPO [308136803] 701.6 percent of total billed charges 543.74 833.15 Professional (doctor) services "Critical Care, Addl 30 Min" PX-99292 CDM 99292 CPT outpatient 877 877 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES HDHP [308136802] 701.6 percent of total billed charges 543.74 833.15 Professional (doctor) services "Critical Care, Addl 30 Min" PX-99292 CDM 99292 CPT outpatient 877 877 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES PPO [308136801] 701.6 percent of total billed charges 543.74 833.15 Professional (doctor) services "Critical Care, Addl 30 Min" PX-99292 CDM 99292 CPT inpatient 877 877 HEALTHPARTNERS SX009 HEALTHPARTNERS 701.6 percent of total billed charges 543.74 833.15 Professional (doctor) services "Critical Care, Addl 30 Min" PX-99292 CDM 99292 CPT outpatient 877 877 HEALTHPARTNERS SX009 HEALTHPARTNERS 701.6 percent of total billed charges 543.74 833.15 Professional (doctor) services "Critical Care, Addl 30 Min" PX-99292 CDM 99292 CPT inpatient 877 877 MEDICA (COMMERCIAL) 94265 [3081118] MEDICA CLAIMS [308111801] 789.3 percent of total billed charges 543.74 833.15 Professional (doctor) services "Critical Care, Addl 30 Min" PX-99292 CDM 99292 CPT outpatient 877 877 MEDICA (COMMERCIAL) 94265 [3081118] MEDICA CLAIMS [308111801] 789.3 percent of total billed charges 543.74 833.15 Professional (doctor) services "Critical Care, Addl 30 Min" PX-99292 CDM 99292 CPT inpatient 877 877 MULTIPLAN INC 34080 [3081285] MULTIPLAN INC [308128501] 833.15 percent of total billed charges 543.74 833.15 Professional (doctor) services "Critical Care, Addl 30 Min" PX-99292 CDM 99292 CPT outpatient 877 877 MULTIPLAN INC 34080 [3081285] MULTIPLAN INC [308128501] 833.15 percent of total billed charges 543.74 833.15 Professional (doctor) services "Critical Care, Addl 30 Min" PX-99292 CDM 99292 CPT inpatient 877 877 UNITED HEALTHCARE (COMMERCIAL) [3081199] UNITED HEALTHCARE 87726 [308119901] 543.74 percent of total billed charges 543.74 833.15 Professional (doctor) services "Critical Care, Addl 30 Min" PX-99292 CDM 99292 CPT outpatient 877 877 UNITED HEALTHCARE (COMMERCIAL) [3081199] UNITED HEALTHCARE 87726 [308119901] 543.74 percent of total billed charges 543.74 833.15 Professional (doctor) services "Critical Care, E/M 30-74 Minutes" PX-99291 CDM 99291 CPT inpatient 2381 2381 CIGNA 62308 [3081051] CIGNA 62308 [308105105] 1904.8 percent of total billed charges 1476.22 2261.95 Professional (doctor) services "Critical Care, E/M 30-74 Minutes" PX-99291 CDM 99291 CPT inpatient 2381 2381 CIGNA 62308 [3081051] CIGNA STATE OF WYOMING [308105107] 1904.8 percent of total billed charges 1476.22 2261.95 Professional (doctor) services "Critical Care, E/M 30-74 Minutes" PX-99291 CDM 99291 CPT outpatient 2381 2381 CIGNA 62308 [3081051] CIGNA 62308 [308105105] 1904.8 percent of total billed charges 1476.22 2261.95 Professional (doctor) services "Critical Care, E/M 30-74 Minutes" PX-99291 CDM 99291 CPT outpatient 2381 2381 CIGNA 62308 [3081051] CIGNA STATE OF WYOMING [308105107] 1904.8 percent of total billed charges 1476.22 2261.95 Professional (doctor) services "Critical Care, E/M 30-74 Minutes" PX-99291 CDM 99291 CPT inpatient 2381 2381 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES EPO [308136803] 1904.8 percent of total billed charges 1476.22 2261.95 Professional (doctor) services "Critical Care, E/M 30-74 Minutes" PX-99291 CDM 99291 CPT inpatient 2381 2381 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES HDHP [308136802] 1904.8 percent of total billed charges 1476.22 2261.95 Professional (doctor) services "Critical Care, E/M 30-74 Minutes" PX-99291 CDM 99291 CPT inpatient 2381 2381 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES PPO [308136801] 1904.8 percent of total billed charges 1476.22 2261.95 Professional (doctor) services "Critical Care, E/M 30-74 Minutes" PX-99291 CDM 99291 CPT outpatient 2381 2381 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES EPO [308136803] 1904.8 percent of total billed charges 1476.22 2261.95 Professional (doctor) services "Critical Care, E/M 30-74 Minutes" PX-99291 CDM 99291 CPT outpatient 2381 2381 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES HDHP [308136802] 1904.8 percent of total billed charges 1476.22 2261.95 Professional (doctor) services "Critical Care, E/M 30-74 Minutes" PX-99291 CDM 99291 CPT outpatient 2381 2381 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES PPO [308136801] 1904.8 percent of total billed charges 1476.22 2261.95 Professional (doctor) services "Critical Care, E/M 30-74 Minutes" PX-99291 CDM 99291 CPT inpatient 2381 2381 HEALTHPARTNERS SX009 HEALTHPARTNERS 1904.8 percent of total billed charges 1476.22 2261.95 Professional (doctor) services "Critical Care, E/M 30-74 Minutes" PX-99291 CDM 99291 CPT outpatient 2381 2381 HEALTHPARTNERS SX009 HEALTHPARTNERS 1904.8 percent of total billed charges 1476.22 2261.95 Professional (doctor) services "Critical Care, E/M 30-74 Minutes" PX-99291 CDM 99291 CPT inpatient 2381 2381 MEDICA (COMMERCIAL) 94265 [3081118] MEDICA CLAIMS [308111801] 2142.9 percent of total billed charges 1476.22 2261.95 Professional (doctor) services "Critical Care, E/M 30-74 Minutes" PX-99291 CDM 99291 CPT outpatient 2381 2381 MEDICA (COMMERCIAL) 94265 [3081118] MEDICA CLAIMS [308111801] 2142.9 percent of total billed charges 1476.22 2261.95 Professional (doctor) services "Critical Care, E/M 30-74 Minutes" PX-99291 CDM 99291 CPT inpatient 2381 2381 MULTIPLAN INC 34080 [3081285] MULTIPLAN INC [308128501] 2261.95 percent of total billed charges 1476.22 2261.95 Professional (doctor) services "Critical Care, E/M 30-74 Minutes" PX-99291 CDM 99291 CPT outpatient 2381 2381 MULTIPLAN INC 34080 [3081285] MULTIPLAN INC [308128501] 2261.95 percent of total billed charges 1476.22 2261.95 Professional (doctor) services "Critical Care, E/M 30-74 Minutes" PX-99291 CDM 99291 CPT inpatient 2381 2381 UNITED HEALTHCARE (COMMERCIAL) [3081199] UNITED HEALTHCARE 87726 [308119901] 1476.22 percent of total billed charges 1476.22 2261.95 Professional (doctor) services "Critical Care, E/M 30-74 Minutes" PX-99291 CDM 99291 CPT outpatient 2381 2381 UNITED HEALTHCARE (COMMERCIAL) [3081199] UNITED HEALTHCARE 87726 [308119901] 1476.22 percent of total billed charges 1476.22 2261.95 Professional (doctor) services PR ED Visit High Mdm PX-99285 CDM 99285 CPT inpatient 1824 1824 CIGNA 62308 [3081051] CIGNA 62308 [308105105] 1459.2 percent of total billed charges 1130.88 1732.8 Professional (doctor) services PR ED Visit High Mdm PX-99285 CDM 99285 CPT inpatient 1824 1824 CIGNA 62308 [3081051] CIGNA STATE OF WYOMING [308105107] 1459.2 percent of total billed charges 1130.88 1732.8 Professional (doctor) services PR ED Visit High Mdm PX-99285 CDM 99285 CPT outpatient 1824 1824 CIGNA 62308 [3081051] CIGNA 62308 [308105105] 1459.2 percent of total billed charges 1130.88 1732.8 Professional (doctor) services PR ED Visit High Mdm PX-99285 CDM 99285 CPT outpatient 1824 1824 CIGNA 62308 [3081051] CIGNA STATE OF WYOMING [308105107] 1459.2 percent of total billed charges 1130.88 1732.8 Professional (doctor) services PR ED Visit High Mdm PX-99285 CDM 99285 CPT inpatient 1824 1824 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES EPO [308136803] 1459.2 percent of total billed charges 1130.88 1732.8 Professional (doctor) services PR ED Visit High Mdm PX-99285 CDM 99285 CPT inpatient 1824 1824 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES HDHP [308136802] 1459.2 percent of total billed charges 1130.88 1732.8 Professional (doctor) services PR ED Visit High Mdm PX-99285 CDM 99285 CPT inpatient 1824 1824 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES PPO [308136801] 1459.2 percent of total billed charges 1130.88 1732.8 Professional (doctor) services PR ED Visit High Mdm PX-99285 CDM 99285 CPT outpatient 1824 1824 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES EPO [308136803] 1459.2 percent of total billed charges 1130.88 1732.8 Professional (doctor) services PR ED Visit High Mdm PX-99285 CDM 99285 CPT outpatient 1824 1824 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES HDHP [308136802] 1459.2 percent of total billed charges 1130.88 1732.8 Professional (doctor) services PR ED Visit High Mdm PX-99285 CDM 99285 CPT outpatient 1824 1824 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES PPO [308136801] 1459.2 percent of total billed charges 1130.88 1732.8 Professional (doctor) services PR ED Visit High Mdm PX-99285 CDM 99285 CPT inpatient 1824 1824 HEALTHPARTNERS SX009 HEALTHPARTNERS 1459.2 percent of total billed charges 1130.88 1732.8 Professional (doctor) services PR ED Visit High Mdm PX-99285 CDM 99285 CPT outpatient 1824 1824 HEALTHPARTNERS SX009 HEALTHPARTNERS 1459.2 percent of total billed charges 1130.88 1732.8 Professional (doctor) services PR ED Visit High Mdm PX-99285 CDM 99285 CPT inpatient 1824 1824 MEDICA (COMMERCIAL) 94265 [3081118] MEDICA CLAIMS [308111801] 1641.6 percent of total billed charges 1130.88 1732.8 Professional (doctor) services PR ED Visit High Mdm PX-99285 CDM 99285 CPT outpatient 1824 1824 MEDICA (COMMERCIAL) 94265 [3081118] MEDICA CLAIMS [308111801] 1641.6 percent of total billed charges 1130.88 1732.8 Professional (doctor) services PR ED Visit High Mdm PX-99285 CDM 99285 CPT inpatient 1824 1824 MULTIPLAN INC 34080 [3081285] MULTIPLAN INC [308128501] 1732.8 percent of total billed charges 1130.88 1732.8 Professional (doctor) services PR ED Visit High Mdm PX-99285 CDM 99285 CPT outpatient 1824 1824 MULTIPLAN INC 34080 [3081285] MULTIPLAN INC [308128501] 1732.8 percent of total billed charges 1130.88 1732.8 Professional (doctor) services PR ED Visit High Mdm PX-99285 CDM 99285 CPT inpatient 1824 1824 UNITED HEALTHCARE (COMMERCIAL) [3081199] UNITED HEALTHCARE 87726 [308119901] 1130.88 percent of total billed charges 1130.88 1732.8 Professional (doctor) services PR ED Visit High Mdm PX-99285 CDM 99285 CPT outpatient 1824 1824 UNITED HEALTHCARE (COMMERCIAL) [3081199] UNITED HEALTHCARE 87726 [308119901] 1130.88 percent of total billed charges 1130.88 1732.8 Professional (doctor) services PR ED Visit Mod Severity PX-99284 CDM 99284 CPT inpatient 1222 1222 CIGNA 62308 [3081051] CIGNA 62308 [308105105] 977.6 percent of total billed charges 757.64 1160.9 Professional (doctor) services PR ED Visit Mod Severity PX-99284 CDM 99284 CPT inpatient 1222 1222 CIGNA 62308 [3081051] CIGNA STATE OF WYOMING [308105107] 977.6 percent of total billed charges 757.64 1160.9 Professional (doctor) services PR ED Visit Mod Severity PX-99284 CDM 99284 CPT outpatient 1222 1222 CIGNA 62308 [3081051] CIGNA 62308 [308105105] 977.6 percent of total billed charges 757.64 1160.9 Professional (doctor) services PR ED Visit Mod Severity PX-99284 CDM 99284 CPT outpatient 1222 1222 CIGNA 62308 [3081051] CIGNA STATE OF WYOMING [308105107] 977.6 percent of total billed charges 757.64 1160.9 Professional (doctor) services PR ED Visit Mod Severity PX-99284 CDM 99284 CPT inpatient 1222 1222 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES EPO [308136803] 977.6 percent of total billed charges 757.64 1160.9 Professional (doctor) services PR ED Visit Mod Severity PX-99284 CDM 99284 CPT inpatient 1222 1222 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES HDHP [308136802] 977.6 percent of total billed charges 757.64 1160.9 Professional (doctor) services PR ED Visit Mod Severity PX-99284 CDM 99284 CPT inpatient 1222 1222 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES PPO [308136801] 977.6 percent of total billed charges 757.64 1160.9 Professional (doctor) services PR ED Visit Mod Severity PX-99284 CDM 99284 CPT outpatient 1222 1222 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES EPO [308136803] 977.6 percent of total billed charges 757.64 1160.9 Professional (doctor) services PR ED Visit Mod Severity PX-99284 CDM 99284 CPT outpatient 1222 1222 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES HDHP [308136802] 977.6 percent of total billed charges 757.64 1160.9 Professional (doctor) services PR ED Visit Mod Severity PX-99284 CDM 99284 CPT outpatient 1222 1222 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES PPO [308136801] 977.6 percent of total billed charges 757.64 1160.9 Professional (doctor) services PR ED Visit Mod Severity PX-99284 CDM 99284 CPT inpatient 1222 1222 HEALTHPARTNERS SX009 HEALTHPARTNERS 977.6 percent of total billed charges 757.64 1160.9 Professional (doctor) services PR ED Visit Mod Severity PX-99284 CDM 99284 CPT outpatient 1222 1222 HEALTHPARTNERS SX009 HEALTHPARTNERS 977.6 percent of total billed charges 757.64 1160.9 Professional (doctor) services PR ED Visit Mod Severity PX-99284 CDM 99284 CPT inpatient 1222 1222 MEDICA (COMMERCIAL) 94265 [3081118] MEDICA CLAIMS [308111801] 1099.8 percent of total billed charges 757.64 1160.9 Professional (doctor) services PR ED Visit Mod Severity PX-99284 CDM 99284 CPT outpatient 1222 1222 MEDICA (COMMERCIAL) 94265 [3081118] MEDICA CLAIMS [308111801] 1099.8 percent of total billed charges 757.64 1160.9 Professional (doctor) services PR ED Visit Mod Severity PX-99284 CDM 99284 CPT inpatient 1222 1222 MULTIPLAN INC 34080 [3081285] MULTIPLAN INC [308128501] 1160.9 percent of total billed charges 757.64 1160.9 Professional (doctor) services PR ED Visit Mod Severity PX-99284 CDM 99284 CPT outpatient 1222 1222 MULTIPLAN INC 34080 [3081285] MULTIPLAN INC [308128501] 1160.9 percent of total billed charges 757.64 1160.9 Professional (doctor) services PR ED Visit Mod Severity PX-99284 CDM 99284 CPT inpatient 1222 1222 UNITED HEALTHCARE (COMMERCIAL) [3081199] UNITED HEALTHCARE 87726 [308119901] 757.64 percent of total billed charges 757.64 1160.9 Professional (doctor) services PR ED Visit Mod Severity PX-99284 CDM 99284 CPT outpatient 1222 1222 UNITED HEALTHCARE (COMMERCIAL) [3081199] UNITED HEALTHCARE 87726 [308119901] 757.64 percent of total billed charges 757.64 1160.9 Professional (doctor) services PR ED Visit Low Mdm PX-99283 CDM 99283 CPT inpatient 819 819 CIGNA 62308 [3081051] CIGNA 62308 [308105105] 655.2 percent of total billed charges 507.78 778.05 Professional (doctor) services PR ED Visit Low Mdm PX-99283 CDM 99283 CPT inpatient 819 819 CIGNA 62308 [3081051] CIGNA STATE OF WYOMING [308105107] 655.2 percent of total billed charges 507.78 778.05 Professional (doctor) services PR ED Visit Low Mdm PX-99283 CDM 99283 CPT outpatient 819 819 CIGNA 62308 [3081051] CIGNA 62308 [308105105] 655.2 percent of total billed charges 507.78 778.05 Professional (doctor) services PR ED Visit Low Mdm PX-99283 CDM 99283 CPT outpatient 819 819 CIGNA 62308 [3081051] CIGNA STATE OF WYOMING [308105107] 655.2 percent of total billed charges 507.78 778.05 Professional (doctor) services PR ED Visit Low Mdm PX-99283 CDM 99283 CPT inpatient 819 819 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES EPO [308136803] 655.2 percent of total billed charges 507.78 778.05 Professional (doctor) services PR ED Visit Low Mdm PX-99283 CDM 99283 CPT inpatient 819 819 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES HDHP [308136802] 655.2 percent of total billed charges 507.78 778.05 Professional (doctor) services PR ED Visit Low Mdm PX-99283 CDM 99283 CPT inpatient 819 819 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES PPO [308136801] 655.2 percent of total billed charges 507.78 778.05 Professional (doctor) services PR ED Visit Low Mdm PX-99283 CDM 99283 CPT outpatient 819 819 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES EPO [308136803] 655.2 percent of total billed charges 507.78 778.05 Professional (doctor) services PR ED Visit Low Mdm PX-99283 CDM 99283 CPT outpatient 819 819 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES HDHP [308136802] 655.2 percent of total billed charges 507.78 778.05 Professional (doctor) services PR ED Visit Low Mdm PX-99283 CDM 99283 CPT outpatient 819 819 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES PPO [308136801] 655.2 percent of total billed charges 507.78 778.05 Professional (doctor) services PR ED Visit Low Mdm PX-99283 CDM 99283 CPT inpatient 819 819 HEALTHPARTNERS SX009 HEALTHPARTNERS 655.2 percent of total billed charges 507.78 778.05 Professional (doctor) services PR ED Visit Low Mdm PX-99283 CDM 99283 CPT outpatient 819 819 HEALTHPARTNERS SX009 HEALTHPARTNERS 655.2 percent of total billed charges 507.78 778.05 Professional (doctor) services PR ED Visit Low Mdm PX-99283 CDM 99283 CPT inpatient 819 819 MEDICA (COMMERCIAL) 94265 [3081118] MEDICA CLAIMS [308111801] 737.1 percent of total billed charges 507.78 778.05 Professional (doctor) services PR ED Visit Low Mdm PX-99283 CDM 99283 CPT outpatient 819 819 MEDICA (COMMERCIAL) 94265 [3081118] MEDICA CLAIMS [308111801] 737.1 percent of total billed charges 507.78 778.05 Professional (doctor) services PR ED Visit Low Mdm PX-99283 CDM 99283 CPT inpatient 819 819 MULTIPLAN INC 34080 [3081285] MULTIPLAN INC [308128501] 778.05 percent of total billed charges 507.78 778.05 Professional (doctor) services PR ED Visit Low Mdm PX-99283 CDM 99283 CPT outpatient 819 819 MULTIPLAN INC 34080 [3081285] MULTIPLAN INC [308128501] 778.05 percent of total billed charges 507.78 778.05 Professional (doctor) services PR ED Visit Low Mdm PX-99283 CDM 99283 CPT inpatient 819 819 UNITED HEALTHCARE (COMMERCIAL) [3081199] UNITED HEALTHCARE 87726 [308119901] 507.78 percent of total billed charges 507.78 778.05 Professional (doctor) services PR ED Visit Low Mdm PX-99283 CDM 99283 CPT outpatient 819 819 UNITED HEALTHCARE (COMMERCIAL) [3081199] UNITED HEALTHCARE 87726 [308119901] 507.78 percent of total billed charges 507.78 778.05 Professional (doctor) services PR Emergency Department Visit Low/Moder Severity PX-99282 CDM 99282 CPT inpatient 544 544 CIGNA 62308 [3081051] CIGNA 62308 [308105105] 435.2 percent of total billed charges 337.28 516.8 Professional (doctor) services PR Emergency Department Visit Low/Moder Severity PX-99282 CDM 99282 CPT inpatient 544 544 CIGNA 62308 [3081051] CIGNA STATE OF WYOMING [308105107] 435.2 percent of total billed charges 337.28 516.8 Professional (doctor) services PR Emergency Department Visit Low/Moder Severity PX-99282 CDM 99282 CPT outpatient 544 544 CIGNA 62308 [3081051] CIGNA 62308 [308105105] 435.2 percent of total billed charges 337.28 516.8 Professional (doctor) services PR Emergency Department Visit Low/Moder Severity PX-99282 CDM 99282 CPT outpatient 544 544 CIGNA 62308 [3081051] CIGNA STATE OF WYOMING [308105107] 435.2 percent of total billed charges 337.28 516.8 Professional (doctor) services PR Emergency Department Visit Low/Moder Severity PX-99282 CDM 99282 CPT inpatient 544 544 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES EPO [308136803] 435.2 percent of total billed charges 337.28 516.8 Professional (doctor) services PR Emergency Department Visit Low/Moder Severity PX-99282 CDM 99282 CPT inpatient 544 544 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES HDHP [308136802] 435.2 percent of total billed charges 337.28 516.8 Professional (doctor) services PR Emergency Department Visit Low/Moder Severity PX-99282 CDM 99282 CPT inpatient 544 544 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES PPO [308136801] 435.2 percent of total billed charges 337.28 516.8 Professional (doctor) services PR Emergency Department Visit Low/Moder Severity PX-99282 CDM 99282 CPT outpatient 544 544 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES EPO [308136803] 435.2 percent of total billed charges 337.28 516.8 Professional (doctor) services PR Emergency Department Visit Low/Moder Severity PX-99282 CDM 99282 CPT outpatient 544 544 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES HDHP [308136802] 435.2 percent of total billed charges 337.28 516.8 Professional (doctor) services PR Emergency Department Visit Low/Moder Severity PX-99282 CDM 99282 CPT outpatient 544 544 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES PPO [308136801] 435.2 percent of total billed charges 337.28 516.8 Professional (doctor) services PR Emergency Department Visit Low/Moder Severity PX-99282 CDM 99282 CPT inpatient 544 544 HEALTHPARTNERS SX009 HEALTHPARTNERS 435.2 percent of total billed charges 337.28 516.8 Professional (doctor) services PR Emergency Department Visit Low/Moder Severity PX-99282 CDM 99282 CPT outpatient 544 544 HEALTHPARTNERS SX009 HEALTHPARTNERS 435.2 percent of total billed charges 337.28 516.8 Professional (doctor) services PR Emergency Department Visit Low/Moder Severity PX-99282 CDM 99282 CPT inpatient 544 544 MEDICA (COMMERCIAL) 94265 [3081118] MEDICA CLAIMS [308111801] 489.6 percent of total billed charges 337.28 516.8 Professional (doctor) services PR Emergency Department Visit Low/Moder Severity PX-99282 CDM 99282 CPT outpatient 544 544 MEDICA (COMMERCIAL) 94265 [3081118] MEDICA CLAIMS [308111801] 489.6 percent of total billed charges 337.28 516.8 Professional (doctor) services PR Emergency Department Visit Low/Moder Severity PX-99282 CDM 99282 CPT inpatient 544 544 MULTIPLAN INC 34080 [3081285] MULTIPLAN INC [308128501] 516.8 percent of total billed charges 337.28 516.8 Professional (doctor) services PR Emergency Department Visit Low/Moder Severity PX-99282 CDM 99282 CPT outpatient 544 544 MULTIPLAN INC 34080 [3081285] MULTIPLAN INC [308128501] 516.8 percent of total billed charges 337.28 516.8 Professional (doctor) services PR Emergency Department Visit Low/Moder Severity PX-99282 CDM 99282 CPT inpatient 544 544 UNITED HEALTHCARE (COMMERCIAL) [3081199] UNITED HEALTHCARE 87726 [308119901] 337.28 percent of total billed charges 337.28 516.8 Professional (doctor) services PR Emergency Department Visit Low/Moder Severity PX-99282 CDM 99282 CPT outpatient 544 544 UNITED HEALTHCARE (COMMERCIAL) [3081199] UNITED HEALTHCARE 87726 [308119901] 337.28 percent of total billed charges 337.28 516.8 Professional (doctor) services PR Emergency Department Visit Limited/Minor Prob PX-99281 CDM 99281 CPT inpatient 402 402 CIGNA 62308 [3081051] CIGNA 62308 [308105105] 321.6 percent of total billed charges 249.24 381.9 Professional (doctor) services PR Emergency Department Visit Limited/Minor Prob PX-99281 CDM 99281 CPT inpatient 402 402 CIGNA 62308 [3081051] CIGNA STATE OF WYOMING [308105107] 321.6 percent of total billed charges 249.24 381.9 Professional (doctor) services PR Emergency Department Visit Limited/Minor Prob PX-99281 CDM 99281 CPT outpatient 402 402 CIGNA 62308 [3081051] CIGNA 62308 [308105105] 321.6 percent of total billed charges 249.24 381.9 Professional (doctor) services PR Emergency Department Visit Limited/Minor Prob PX-99281 CDM 99281 CPT outpatient 402 402 CIGNA 62308 [3081051] CIGNA STATE OF WYOMING [308105107] 321.6 percent of total billed charges 249.24 381.9 Professional (doctor) services PR Emergency Department Visit Limited/Minor Prob PX-99281 CDM 99281 CPT inpatient 402 402 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES EPO [308136803] 321.6 percent of total billed charges 249.24 381.9 Professional (doctor) services PR Emergency Department Visit Limited/Minor Prob PX-99281 CDM 99281 CPT inpatient 402 402 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES HDHP [308136802] 321.6 percent of total billed charges 249.24 381.9 Professional (doctor) services PR Emergency Department Visit Limited/Minor Prob PX-99281 CDM 99281 CPT inpatient 402 402 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES PPO [308136801] 321.6 percent of total billed charges 249.24 381.9 Professional (doctor) services PR Emergency Department Visit Limited/Minor Prob PX-99281 CDM 99281 CPT outpatient 402 402 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES EPO [308136803] 321.6 percent of total billed charges 249.24 381.9 Professional (doctor) services PR Emergency Department Visit Limited/Minor Prob PX-99281 CDM 99281 CPT outpatient 402 402 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES HDHP [308136802] 321.6 percent of total billed charges 249.24 381.9 Professional (doctor) services PR Emergency Department Visit Limited/Minor Prob PX-99281 CDM 99281 CPT outpatient 402 402 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES PPO [308136801] 321.6 percent of total billed charges 249.24 381.9 Professional (doctor) services PR Emergency Department Visit Limited/Minor Prob PX-99281 CDM 99281 CPT inpatient 402 402 HEALTHPARTNERS SX009 HEALTHPARTNERS 321.6 percent of total billed charges 249.24 381.9 Professional (doctor) services PR Emergency Department Visit Limited/Minor Prob PX-99281 CDM 99281 CPT outpatient 402 402 HEALTHPARTNERS SX009 HEALTHPARTNERS 321.6 percent of total billed charges 249.24 381.9 Professional (doctor) services PR Emergency Department Visit Limited/Minor Prob PX-99281 CDM 99281 CPT inpatient 402 402 MEDICA (COMMERCIAL) 94265 [3081118] MEDICA CLAIMS [308111801] 361.8 percent of total billed charges 249.24 381.9 Professional (doctor) services PR Emergency Department Visit Limited/Minor Prob PX-99281 CDM 99281 CPT outpatient 402 402 MEDICA (COMMERCIAL) 94265 [3081118] MEDICA CLAIMS [308111801] 361.8 percent of total billed charges 249.24 381.9 Professional (doctor) services PR Emergency Department Visit Limited/Minor Prob PX-99281 CDM 99281 CPT inpatient 402 402 MULTIPLAN INC 34080 [3081285] MULTIPLAN INC [308128501] 381.9 percent of total billed charges 249.24 381.9 Professional (doctor) services PR Emergency Department Visit Limited/Minor Prob PX-99281 CDM 99281 CPT outpatient 402 402 MULTIPLAN INC 34080 [3081285] MULTIPLAN INC [308128501] 381.9 percent of total billed charges 249.24 381.9 Professional (doctor) services PR Emergency Department Visit Limited/Minor Prob PX-99281 CDM 99281 CPT inpatient 402 402 UNITED HEALTHCARE (COMMERCIAL) [3081199] UNITED HEALTHCARE 87726 [308119901] 249.24 percent of total billed charges 249.24 381.9 Professional (doctor) services PR Emergency Department Visit Limited/Minor Prob PX-99281 CDM 99281 CPT outpatient 402 402 UNITED HEALTHCARE (COMMERCIAL) [3081199] UNITED HEALTHCARE 87726 [308119901] 249.24 percent of total billed charges 249.24 381.9 Professional (doctor) services Hospital IP/Obs Discharge Day Mgmt > 30 Min PX-99239 CDM 99239 CPT inpatient 377 377 CIGNA 62308 [3081051] CIGNA 62308 [308105105] 301.6 percent of total billed charges 233.74 358.15 Professional (doctor) services Hospital IP/Obs Discharge Day Mgmt > 30 Min PX-99239 CDM 99239 CPT inpatient 377 377 CIGNA 62308 [3081051] CIGNA STATE OF WYOMING [308105107] 301.6 percent of total billed charges 233.74 358.15 Professional (doctor) services Hospital IP/Obs Discharge Day Mgmt > 30 Min PX-99239 CDM 99239 CPT outpatient 377 377 CIGNA 62308 [3081051] CIGNA 62308 [308105105] 301.6 percent of total billed charges 233.74 358.15 Professional (doctor) services Hospital IP/Obs Discharge Day Mgmt > 30 Min PX-99239 CDM 99239 CPT outpatient 377 377 CIGNA 62308 [3081051] CIGNA STATE OF WYOMING [308105107] 301.6 percent of total billed charges 233.74 358.15 Professional (doctor) services Hospital IP/Obs Discharge Day Mgmt > 30 Min PX-99239 CDM 99239 CPT inpatient 377 377 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES EPO [308136803] 301.6 percent of total billed charges 233.74 358.15 Professional (doctor) services Hospital IP/Obs Discharge Day Mgmt > 30 Min PX-99239 CDM 99239 CPT inpatient 377 377 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES HDHP [308136802] 301.6 percent of total billed charges 233.74 358.15 Professional (doctor) services Hospital IP/Obs Discharge Day Mgmt > 30 Min PX-99239 CDM 99239 CPT inpatient 377 377 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES PPO [308136801] 301.6 percent of total billed charges 233.74 358.15 Professional (doctor) services Hospital IP/Obs Discharge Day Mgmt > 30 Min PX-99239 CDM 99239 CPT outpatient 377 377 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES EPO [308136803] 301.6 percent of total billed charges 233.74 358.15 Professional (doctor) services Hospital IP/Obs Discharge Day Mgmt > 30 Min PX-99239 CDM 99239 CPT outpatient 377 377 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES HDHP [308136802] 301.6 percent of total billed charges 233.74 358.15 Professional (doctor) services Hospital IP/Obs Discharge Day Mgmt > 30 Min PX-99239 CDM 99239 CPT outpatient 377 377 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES PPO [308136801] 301.6 percent of total billed charges 233.74 358.15 Professional (doctor) services Hospital IP/Obs Discharge Day Mgmt > 30 Min PX-99239 CDM 99239 CPT inpatient 377 377 HEALTHPARTNERS SX009 HEALTHPARTNERS 301.6 percent of total billed charges 233.74 358.15 Professional (doctor) services Hospital IP/Obs Discharge Day Mgmt > 30 Min PX-99239 CDM 99239 CPT outpatient 377 377 HEALTHPARTNERS SX009 HEALTHPARTNERS 301.6 percent of total billed charges 233.74 358.15 Professional (doctor) services Hospital IP/Obs Discharge Day Mgmt > 30 Min PX-99239 CDM 99239 CPT inpatient 377 377 MEDICA (COMMERCIAL) 94265 [3081118] MEDICA CLAIMS [308111801] 339.3 percent of total billed charges 233.74 358.15 Professional (doctor) services Hospital IP/Obs Discharge Day Mgmt > 30 Min PX-99239 CDM 99239 CPT outpatient 377 377 MEDICA (COMMERCIAL) 94265 [3081118] MEDICA CLAIMS [308111801] 339.3 percent of total billed charges 233.74 358.15 Professional (doctor) services Hospital IP/Obs Discharge Day Mgmt > 30 Min PX-99239 CDM 99239 CPT inpatient 377 377 MULTIPLAN INC 34080 [3081285] MULTIPLAN INC [308128501] 358.15 percent of total billed charges 233.74 358.15 Professional (doctor) services Hospital IP/Obs Discharge Day Mgmt > 30 Min PX-99239 CDM 99239 CPT outpatient 377 377 MULTIPLAN INC 34080 [3081285] MULTIPLAN INC [308128501] 358.15 percent of total billed charges 233.74 358.15 Professional (doctor) services Hospital IP/Obs Discharge Day Mgmt > 30 Min PX-99239 CDM 99239 CPT inpatient 377 377 UNITED HEALTHCARE (COMMERCIAL) [3081199] UNITED HEALTHCARE 87726 [308119901] 233.74 percent of total billed charges 233.74 358.15 Professional (doctor) services Hospital IP/Obs Discharge Day Mgmt > 30 Min PX-99239 CDM 99239 CPT outpatient 377 377 UNITED HEALTHCARE (COMMERCIAL) [3081199] UNITED HEALTHCARE 87726 [308119901] 233.74 percent of total billed charges 233.74 358.15 Professional (doctor) services Hospital IP/Obs Discharge Day Mgmt 30 Min/< PX-99238 CDM 99238 CPT inpatient 301 301 CIGNA 62308 [3081051] CIGNA 62308 [308105105] 240.8 percent of total billed charges 186.62 285.95 Professional (doctor) services Hospital IP/Obs Discharge Day Mgmt 30 Min/< PX-99238 CDM 99238 CPT inpatient 301 301 CIGNA 62308 [3081051] CIGNA STATE OF WYOMING [308105107] 240.8 percent of total billed charges 186.62 285.95 Professional (doctor) services Hospital IP/Obs Discharge Day Mgmt 30 Min/< PX-99238 CDM 99238 CPT outpatient 301 301 CIGNA 62308 [3081051] CIGNA 62308 [308105105] 240.8 percent of total billed charges 186.62 285.95 Professional (doctor) services Hospital IP/Obs Discharge Day Mgmt 30 Min/< PX-99238 CDM 99238 CPT outpatient 301 301 CIGNA 62308 [3081051] CIGNA STATE OF WYOMING [308105107] 240.8 percent of total billed charges 186.62 285.95 Professional (doctor) services Hospital IP/Obs Discharge Day Mgmt 30 Min/< PX-99238 CDM 99238 CPT inpatient 301 301 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES EPO [308136803] 240.8 percent of total billed charges 186.62 285.95 Professional (doctor) services Hospital IP/Obs Discharge Day Mgmt 30 Min/< PX-99238 CDM 99238 CPT inpatient 301 301 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES HDHP [308136802] 240.8 percent of total billed charges 186.62 285.95 Professional (doctor) services Hospital IP/Obs Discharge Day Mgmt 30 Min/< PX-99238 CDM 99238 CPT inpatient 301 301 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES PPO [308136801] 240.8 percent of total billed charges 186.62 285.95 Professional (doctor) services Hospital IP/Obs Discharge Day Mgmt 30 Min/< PX-99238 CDM 99238 CPT outpatient 301 301 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES EPO [308136803] 240.8 percent of total billed charges 186.62 285.95 Professional (doctor) services Hospital IP/Obs Discharge Day Mgmt 30 Min/< PX-99238 CDM 99238 CPT outpatient 301 301 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES HDHP [308136802] 240.8 percent of total billed charges 186.62 285.95 Professional (doctor) services Hospital IP/Obs Discharge Day Mgmt 30 Min/< PX-99238 CDM 99238 CPT outpatient 301 301 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES PPO [308136801] 240.8 percent of total billed charges 186.62 285.95 Professional (doctor) services Hospital IP/Obs Discharge Day Mgmt 30 Min/< PX-99238 CDM 99238 CPT inpatient 301 301 HEALTHPARTNERS SX009 HEALTHPARTNERS 240.8 percent of total billed charges 186.62 285.95 Professional (doctor) services Hospital IP/Obs Discharge Day Mgmt 30 Min/< PX-99238 CDM 99238 CPT outpatient 301 301 HEALTHPARTNERS SX009 HEALTHPARTNERS 240.8 percent of total billed charges 186.62 285.95 Professional (doctor) services Hospital IP/Obs Discharge Day Mgmt 30 Min/< PX-99238 CDM 99238 CPT inpatient 301 301 MEDICA (COMMERCIAL) 94265 [3081118] MEDICA CLAIMS [308111801] 270.9 percent of total billed charges 186.62 285.95 Professional (doctor) services Hospital IP/Obs Discharge Day Mgmt 30 Min/< PX-99238 CDM 99238 CPT outpatient 301 301 MEDICA (COMMERCIAL) 94265 [3081118] MEDICA CLAIMS [308111801] 270.9 percent of total billed charges 186.62 285.95 Professional (doctor) services Hospital IP/Obs Discharge Day Mgmt 30 Min/< PX-99238 CDM 99238 CPT inpatient 301 301 MULTIPLAN INC 34080 [3081285] MULTIPLAN INC [308128501] 285.95 percent of total billed charges 186.62 285.95 Professional (doctor) services Hospital IP/Obs Discharge Day Mgmt 30 Min/< PX-99238 CDM 99238 CPT outpatient 301 301 MULTIPLAN INC 34080 [3081285] MULTIPLAN INC [308128501] 285.95 percent of total billed charges 186.62 285.95 Professional (doctor) services Hospital IP/Obs Discharge Day Mgmt 30 Min/< PX-99238 CDM 99238 CPT inpatient 301 301 UNITED HEALTHCARE (COMMERCIAL) [3081199] UNITED HEALTHCARE 87726 [308119901] 186.62 percent of total billed charges 186.62 285.95 Professional (doctor) services Hospital IP/Obs Discharge Day Mgmt 30 Min/< PX-99238 CDM 99238 CPT outpatient 301 301 UNITED HEALTHCARE (COMMERCIAL) [3081199] UNITED HEALTHCARE 87726 [308119901] 186.62 percent of total billed charges 186.62 285.95 Professional (doctor) services PR HOSPITAL IP/OBS CARE SAME DATE HIGH MDM 85 MINutes PX-99236 CDM 99236 CPT inpatient 1148 1148 CIGNA 62308 [3081051] CIGNA 62308 [308105105] 918.4 percent of total billed charges 711.76 1090.6 Professional (doctor) services PR HOSPITAL IP/OBS CARE SAME DATE HIGH MDM 85 MINutes PX-99236 CDM 99236 CPT inpatient 1148 1148 CIGNA 62308 [3081051] CIGNA STATE OF WYOMING [308105107] 918.4 percent of total billed charges 711.76 1090.6 Professional (doctor) services PR HOSPITAL IP/OBS CARE SAME DATE HIGH MDM 85 MINutes PX-99236 CDM 99236 CPT outpatient 1148 1148 CIGNA 62308 [3081051] CIGNA 62308 [308105105] 918.4 percent of total billed charges 711.76 1090.6 Professional (doctor) services PR HOSPITAL IP/OBS CARE SAME DATE HIGH MDM 85 MINutes PX-99236 CDM 99236 CPT outpatient 1148 1148 CIGNA 62308 [3081051] CIGNA STATE OF WYOMING [308105107] 918.4 percent of total billed charges 711.76 1090.6 Professional (doctor) services PR HOSPITAL IP/OBS CARE SAME DATE HIGH MDM 85 MINutes PX-99236 CDM 99236 CPT inpatient 1148 1148 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES EPO [308136803] 918.4 percent of total billed charges 711.76 1090.6 Professional (doctor) services PR HOSPITAL IP/OBS CARE SAME DATE HIGH MDM 85 MINutes PX-99236 CDM 99236 CPT inpatient 1148 1148 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES HDHP [308136802] 918.4 percent of total billed charges 711.76 1090.6 Professional (doctor) services PR HOSPITAL IP/OBS CARE SAME DATE HIGH MDM 85 MINutes PX-99236 CDM 99236 CPT inpatient 1148 1148 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES PPO [308136801] 918.4 percent of total billed charges 711.76 1090.6 Professional (doctor) services PR HOSPITAL IP/OBS CARE SAME DATE HIGH MDM 85 MINutes PX-99236 CDM 99236 CPT outpatient 1148 1148 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES EPO [308136803] 918.4 percent of total billed charges 711.76 1090.6 Professional (doctor) services PR HOSPITAL IP/OBS CARE SAME DATE HIGH MDM 85 MINutes PX-99236 CDM 99236 CPT outpatient 1148 1148 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES HDHP [308136802] 918.4 percent of total billed charges 711.76 1090.6 Professional (doctor) services PR HOSPITAL IP/OBS CARE SAME DATE HIGH MDM 85 MINutes PX-99236 CDM 99236 CPT outpatient 1148 1148 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES PPO [308136801] 918.4 percent of total billed charges 711.76 1090.6 Professional (doctor) services PR HOSPITAL IP/OBS CARE SAME DATE HIGH MDM 85 MINutes PX-99236 CDM 99236 CPT inpatient 1148 1148 HEALTHPARTNERS SX009 HEALTHPARTNERS 918.4 percent of total billed charges 711.76 1090.6 Professional (doctor) services PR HOSPITAL IP/OBS CARE SAME DATE HIGH MDM 85 MINutes PX-99236 CDM 99236 CPT outpatient 1148 1148 HEALTHPARTNERS SX009 HEALTHPARTNERS 918.4 percent of total billed charges 711.76 1090.6 Professional (doctor) services PR HOSPITAL IP/OBS CARE SAME DATE HIGH MDM 85 MINutes PX-99236 CDM 99236 CPT inpatient 1148 1148 MEDICA (COMMERCIAL) 94265 [3081118] MEDICA CLAIMS [308111801] 1033.2 percent of total billed charges 711.76 1090.6 Professional (doctor) services PR HOSPITAL IP/OBS CARE SAME DATE HIGH MDM 85 MINutes PX-99236 CDM 99236 CPT outpatient 1148 1148 MEDICA (COMMERCIAL) 94265 [3081118] MEDICA CLAIMS [308111801] 1033.2 percent of total billed charges 711.76 1090.6 Professional (doctor) services PR HOSPITAL IP/OBS CARE SAME DATE HIGH MDM 85 MINutes PX-99236 CDM 99236 CPT inpatient 1148 1148 MULTIPLAN INC 34080 [3081285] MULTIPLAN INC [308128501] 1090.6 percent of total billed charges 711.76 1090.6 Professional (doctor) services PR HOSPITAL IP/OBS CARE SAME DATE HIGH MDM 85 MINutes PX-99236 CDM 99236 CPT outpatient 1148 1148 MULTIPLAN INC 34080 [3081285] MULTIPLAN INC [308128501] 1090.6 percent of total billed charges 711.76 1090.6 Professional (doctor) services PR HOSPITAL IP/OBS CARE SAME DATE HIGH MDM 85 MINutes PX-99236 CDM 99236 CPT inpatient 1148 1148 UNITED HEALTHCARE (COMMERCIAL) [3081199] UNITED HEALTHCARE 87726 [308119901] 711.76 percent of total billed charges 711.76 1090.6 Professional (doctor) services PR HOSPITAL IP/OBS CARE SAME DATE HIGH MDM 85 MINutes PX-99236 CDM 99236 CPT outpatient 1148 1148 UNITED HEALTHCARE (COMMERCIAL) [3081199] UNITED HEALTHCARE 87726 [308119901] 711.76 percent of total billed charges 711.76 1090.6 Professional (doctor) services PR HOSPITAL IP/OBS CARE SAME DATE MOD MDM 70 MINutes PX-99235 CDM 99235 CPT inpatient 756 756 CIGNA 62308 [3081051] CIGNA 62308 [308105105] 604.8 percent of total billed charges 468.72 718.2 Professional (doctor) services PR HOSPITAL IP/OBS CARE SAME DATE MOD MDM 70 MINutes PX-99235 CDM 99235 CPT inpatient 756 756 CIGNA 62308 [3081051] CIGNA STATE OF WYOMING [308105107] 604.8 percent of total billed charges 468.72 718.2 Professional (doctor) services PR HOSPITAL IP/OBS CARE SAME DATE MOD MDM 70 MINutes PX-99235 CDM 99235 CPT outpatient 756 756 CIGNA 62308 [3081051] CIGNA 62308 [308105105] 604.8 percent of total billed charges 468.72 718.2 Professional (doctor) services PR HOSPITAL IP/OBS CARE SAME DATE MOD MDM 70 MINutes PX-99235 CDM 99235 CPT outpatient 756 756 CIGNA 62308 [3081051] CIGNA STATE OF WYOMING [308105107] 604.8 percent of total billed charges 468.72 718.2 Professional (doctor) services PR HOSPITAL IP/OBS CARE SAME DATE MOD MDM 70 MINutes PX-99235 CDM 99235 CPT inpatient 756 756 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES EPO [308136803] 604.8 percent of total billed charges 468.72 718.2 Professional (doctor) services PR HOSPITAL IP/OBS CARE SAME DATE MOD MDM 70 MINutes PX-99235 CDM 99235 CPT inpatient 756 756 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES HDHP [308136802] 604.8 percent of total billed charges 468.72 718.2 Professional (doctor) services PR HOSPITAL IP/OBS CARE SAME DATE MOD MDM 70 MINutes PX-99235 CDM 99235 CPT inpatient 756 756 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES PPO [308136801] 604.8 percent of total billed charges 468.72 718.2 Professional (doctor) services PR HOSPITAL IP/OBS CARE SAME DATE MOD MDM 70 MINutes PX-99235 CDM 99235 CPT outpatient 756 756 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES EPO [308136803] 604.8 percent of total billed charges 468.72 718.2 Professional (doctor) services PR HOSPITAL IP/OBS CARE SAME DATE MOD MDM 70 MINutes PX-99235 CDM 99235 CPT outpatient 756 756 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES HDHP [308136802] 604.8 percent of total billed charges 468.72 718.2 Professional (doctor) services PR HOSPITAL IP/OBS CARE SAME DATE MOD MDM 70 MINutes PX-99235 CDM 99235 CPT outpatient 756 756 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES PPO [308136801] 604.8 percent of total billed charges 468.72 718.2 Professional (doctor) services PR HOSPITAL IP/OBS CARE SAME DATE MOD MDM 70 MINutes PX-99235 CDM 99235 CPT inpatient 756 756 HEALTHPARTNERS SX009 HEALTHPARTNERS 604.8 percent of total billed charges 468.72 718.2 Professional (doctor) services PR HOSPITAL IP/OBS CARE SAME DATE MOD MDM 70 MINutes PX-99235 CDM 99235 CPT outpatient 756 756 HEALTHPARTNERS SX009 HEALTHPARTNERS 604.8 percent of total billed charges 468.72 718.2 Professional (doctor) services PR HOSPITAL IP/OBS CARE SAME DATE MOD MDM 70 MINutes PX-99235 CDM 99235 CPT inpatient 756 756 MEDICA (COMMERCIAL) 94265 [3081118] MEDICA CLAIMS [308111801] 680.4 percent of total billed charges 468.72 718.2 Professional (doctor) services PR HOSPITAL IP/OBS CARE SAME DATE MOD MDM 70 MINutes PX-99235 CDM 99235 CPT outpatient 756 756 MEDICA (COMMERCIAL) 94265 [3081118] MEDICA CLAIMS [308111801] 680.4 percent of total billed charges 468.72 718.2 Professional (doctor) services PR HOSPITAL IP/OBS CARE SAME DATE MOD MDM 70 MINutes PX-99235 CDM 99235 CPT inpatient 756 756 MULTIPLAN INC 34080 [3081285] MULTIPLAN INC [308128501] 718.2 percent of total billed charges 468.72 718.2 Professional (doctor) services PR HOSPITAL IP/OBS CARE SAME DATE MOD MDM 70 MINutes PX-99235 CDM 99235 CPT outpatient 756 756 MULTIPLAN INC 34080 [3081285] MULTIPLAN INC [308128501] 718.2 percent of total billed charges 468.72 718.2 Professional (doctor) services PR HOSPITAL IP/OBS CARE SAME DATE MOD MDM 70 MINutes PX-99235 CDM 99235 CPT inpatient 756 756 UNITED HEALTHCARE (COMMERCIAL) [3081199] UNITED HEALTHCARE 87726 [308119901] 468.72 percent of total billed charges 468.72 718.2 Professional (doctor) services PR HOSPITAL IP/OBS CARE SAME DATE MOD MDM 70 MINutes PX-99235 CDM 99235 CPT outpatient 756 756 UNITED HEALTHCARE (COMMERCIAL) [3081199] UNITED HEALTHCARE 87726 [308119901] 468.72 percent of total billed charges 468.72 718.2 Professional (doctor) services PR HOSPITAL IP/OBS CARE SAME DATE SF/LOW MDM 45 MINutes PX-99234 CDM 99234 CPT inpatient 482 482 CIGNA 62308 [3081051] CIGNA 62308 [308105105] 385.6 percent of total billed charges 298.84 457.9 Professional (doctor) services PR HOSPITAL IP/OBS CARE SAME DATE SF/LOW MDM 45 MINutes PX-99234 CDM 99234 CPT inpatient 482 482 CIGNA 62308 [3081051] CIGNA STATE OF WYOMING [308105107] 385.6 percent of total billed charges 298.84 457.9 Professional (doctor) services PR HOSPITAL IP/OBS CARE SAME DATE SF/LOW MDM 45 MINutes PX-99234 CDM 99234 CPT outpatient 482 482 CIGNA 62308 [3081051] CIGNA 62308 [308105105] 385.6 percent of total billed charges 298.84 457.9 Professional (doctor) services PR HOSPITAL IP/OBS CARE SAME DATE SF/LOW MDM 45 MINutes PX-99234 CDM 99234 CPT outpatient 482 482 CIGNA 62308 [3081051] CIGNA STATE OF WYOMING [308105107] 385.6 percent of total billed charges 298.84 457.9 Professional (doctor) services PR HOSPITAL IP/OBS CARE SAME DATE SF/LOW MDM 45 MINutes PX-99234 CDM 99234 CPT inpatient 482 482 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES EPO [308136803] 385.6 percent of total billed charges 298.84 457.9 Professional (doctor) services PR HOSPITAL IP/OBS CARE SAME DATE SF/LOW MDM 45 MINutes PX-99234 CDM 99234 CPT inpatient 482 482 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES HDHP [308136802] 385.6 percent of total billed charges 298.84 457.9 Professional (doctor) services PR HOSPITAL IP/OBS CARE SAME DATE SF/LOW MDM 45 MINutes PX-99234 CDM 99234 CPT inpatient 482 482 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES PPO [308136801] 385.6 percent of total billed charges 298.84 457.9 Professional (doctor) services PR HOSPITAL IP/OBS CARE SAME DATE SF/LOW MDM 45 MINutes PX-99234 CDM 99234 CPT outpatient 482 482 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES EPO [308136803] 385.6 percent of total billed charges 298.84 457.9 Professional (doctor) services PR HOSPITAL IP/OBS CARE SAME DATE SF/LOW MDM 45 MINutes PX-99234 CDM 99234 CPT outpatient 482 482 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES HDHP [308136802] 385.6 percent of total billed charges 298.84 457.9 Professional (doctor) services PR HOSPITAL IP/OBS CARE SAME DATE SF/LOW MDM 45 MINutes PX-99234 CDM 99234 CPT outpatient 482 482 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES PPO [308136801] 385.6 percent of total billed charges 298.84 457.9 Professional (doctor) services PR HOSPITAL IP/OBS CARE SAME DATE SF/LOW MDM 45 MINutes PX-99234 CDM 99234 CPT inpatient 482 482 HEALTHPARTNERS SX009 HEALTHPARTNERS 385.6 percent of total billed charges 298.84 457.9 Professional (doctor) services PR HOSPITAL IP/OBS CARE SAME DATE SF/LOW MDM 45 MINutes PX-99234 CDM 99234 CPT outpatient 482 482 HEALTHPARTNERS SX009 HEALTHPARTNERS 385.6 percent of total billed charges 298.84 457.9 Professional (doctor) services PR HOSPITAL IP/OBS CARE SAME DATE SF/LOW MDM 45 MINutes PX-99234 CDM 99234 CPT inpatient 482 482 MEDICA (COMMERCIAL) 94265 [3081118] MEDICA CLAIMS [308111801] 433.8 percent of total billed charges 298.84 457.9 Professional (doctor) services PR HOSPITAL IP/OBS CARE SAME DATE SF/LOW MDM 45 MINutes PX-99234 CDM 99234 CPT outpatient 482 482 MEDICA (COMMERCIAL) 94265 [3081118] MEDICA CLAIMS [308111801] 433.8 percent of total billed charges 298.84 457.9 Professional (doctor) services PR HOSPITAL IP/OBS CARE SAME DATE SF/LOW MDM 45 MINutes PX-99234 CDM 99234 CPT inpatient 482 482 MULTIPLAN INC 34080 [3081285] MULTIPLAN INC [308128501] 457.9 percent of total billed charges 298.84 457.9 Professional (doctor) services PR HOSPITAL IP/OBS CARE SAME DATE SF/LOW MDM 45 MINutes PX-99234 CDM 99234 CPT outpatient 482 482 MULTIPLAN INC 34080 [3081285] MULTIPLAN INC [308128501] 457.9 percent of total billed charges 298.84 457.9 Professional (doctor) services PR HOSPITAL IP/OBS CARE SAME DATE SF/LOW MDM 45 MINutes PX-99234 CDM 99234 CPT inpatient 482 482 UNITED HEALTHCARE (COMMERCIAL) [3081199] UNITED HEALTHCARE 87726 [308119901] 298.84 percent of total billed charges 298.84 457.9 Professional (doctor) services PR HOSPITAL IP/OBS CARE SAME DATE SF/LOW MDM 45 MINutes PX-99234 CDM 99234 CPT outpatient 482 482 UNITED HEALTHCARE (COMMERCIAL) [3081199] UNITED HEALTHCARE 87726 [308119901] 298.84 percent of total billed charges 298.84 457.9 Professional (doctor) services PR Sbsq Hospital IP/Obs Care High Mdm 50 Mins PX-99233 CDM 99233 CPT inpatient 364 364 CIGNA 62308 [3081051] CIGNA 62308 [308105105] 291.2 percent of total billed charges 225.68 345.8 Professional (doctor) services PR Sbsq Hospital IP/Obs Care High Mdm 50 Mins PX-99233 CDM 99233 CPT inpatient 364 364 CIGNA 62308 [3081051] CIGNA STATE OF WYOMING [308105107] 291.2 percent of total billed charges 225.68 345.8 Professional (doctor) services PR Sbsq Hospital IP/Obs Care High Mdm 50 Mins PX-99233 CDM 99233 CPT outpatient 364 364 CIGNA 62308 [3081051] CIGNA 62308 [308105105] 291.2 percent of total billed charges 225.68 345.8 Professional (doctor) services PR Sbsq Hospital IP/Obs Care High Mdm 50 Mins PX-99233 CDM 99233 CPT outpatient 364 364 CIGNA 62308 [3081051] CIGNA STATE OF WYOMING [308105107] 291.2 percent of total billed charges 225.68 345.8 Professional (doctor) services PR Sbsq Hospital IP/Obs Care High Mdm 50 Mins PX-99233 CDM 99233 CPT inpatient 364 364 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES EPO [308136803] 291.2 percent of total billed charges 225.68 345.8 Professional (doctor) services PR Sbsq Hospital IP/Obs Care High Mdm 50 Mins PX-99233 CDM 99233 CPT inpatient 364 364 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES HDHP [308136802] 291.2 percent of total billed charges 225.68 345.8 Professional (doctor) services PR Sbsq Hospital IP/Obs Care High Mdm 50 Mins PX-99233 CDM 99233 CPT inpatient 364 364 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES PPO [308136801] 291.2 percent of total billed charges 225.68 345.8 Professional (doctor) services PR Sbsq Hospital IP/Obs Care High Mdm 50 Mins PX-99233 CDM 99233 CPT outpatient 364 364 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES EPO [308136803] 291.2 percent of total billed charges 225.68 345.8 Professional (doctor) services PR Sbsq Hospital IP/Obs Care High Mdm 50 Mins PX-99233 CDM 99233 CPT outpatient 364 364 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES HDHP [308136802] 291.2 percent of total billed charges 225.68 345.8 Professional (doctor) services PR Sbsq Hospital IP/Obs Care High Mdm 50 Mins PX-99233 CDM 99233 CPT outpatient 364 364 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES PPO [308136801] 291.2 percent of total billed charges 225.68 345.8 Professional (doctor) services PR Sbsq Hospital IP/Obs Care High Mdm 50 Mins PX-99233 CDM 99233 CPT inpatient 364 364 HEALTHPARTNERS SX009 HEALTHPARTNERS 291.2 percent of total billed charges 225.68 345.8 Professional (doctor) services PR Sbsq Hospital IP/Obs Care High Mdm 50 Mins PX-99233 CDM 99233 CPT outpatient 364 364 HEALTHPARTNERS SX009 HEALTHPARTNERS 291.2 percent of total billed charges 225.68 345.8 Professional (doctor) services PR Sbsq Hospital IP/Obs Care High Mdm 50 Mins PX-99233 CDM 99233 CPT inpatient 364 364 MEDICA (COMMERCIAL) 94265 [3081118] MEDICA CLAIMS [308111801] 327.6 percent of total billed charges 225.68 345.8 Professional (doctor) services PR Sbsq Hospital IP/Obs Care High Mdm 50 Mins PX-99233 CDM 99233 CPT outpatient 364 364 MEDICA (COMMERCIAL) 94265 [3081118] MEDICA CLAIMS [308111801] 327.6 percent of total billed charges 225.68 345.8 Professional (doctor) services PR Sbsq Hospital IP/Obs Care High Mdm 50 Mins PX-99233 CDM 99233 CPT inpatient 364 364 MULTIPLAN INC 34080 [3081285] MULTIPLAN INC [308128501] 345.8 percent of total billed charges 225.68 345.8 Professional (doctor) services PR Sbsq Hospital IP/Obs Care High Mdm 50 Mins PX-99233 CDM 99233 CPT outpatient 364 364 MULTIPLAN INC 34080 [3081285] MULTIPLAN INC [308128501] 345.8 percent of total billed charges 225.68 345.8 Professional (doctor) services PR Sbsq Hospital IP/Obs Care High Mdm 50 Mins PX-99233 CDM 99233 CPT inpatient 364 364 UNITED HEALTHCARE (COMMERCIAL) [3081199] UNITED HEALTHCARE 87726 [308119901] 225.68 percent of total billed charges 225.68 345.8 Professional (doctor) services PR Sbsq Hospital IP/Obs Care High Mdm 50 Mins PX-99233 CDM 99233 CPT outpatient 364 364 UNITED HEALTHCARE (COMMERCIAL) [3081199] UNITED HEALTHCARE 87726 [308119901] 225.68 percent of total billed charges 225.68 345.8 Professional (doctor) services PR Sbsq Hospital IP/Obs Care Mod Mdm 35 Min PX-99232 CDM 99232 CPT inpatient 267 267 CIGNA 62308 [3081051] CIGNA 62308 [308105105] 213.6 percent of total billed charges 165.54 253.65 Professional (doctor) services PR Sbsq Hospital IP/Obs Care Mod Mdm 35 Min PX-99232 CDM 99232 CPT inpatient 267 267 CIGNA 62308 [3081051] CIGNA STATE OF WYOMING [308105107] 213.6 percent of total billed charges 165.54 253.65 Professional (doctor) services PR Sbsq Hospital IP/Obs Care Mod Mdm 35 Min PX-99232 CDM 99232 CPT outpatient 267 267 CIGNA 62308 [3081051] CIGNA 62308 [308105105] 213.6 percent of total billed charges 165.54 253.65 Professional (doctor) services PR Sbsq Hospital IP/Obs Care Mod Mdm 35 Min PX-99232 CDM 99232 CPT outpatient 267 267 CIGNA 62308 [3081051] CIGNA STATE OF WYOMING [308105107] 213.6 percent of total billed charges 165.54 253.65 Professional (doctor) services PR Sbsq Hospital IP/Obs Care Mod Mdm 35 Min PX-99232 CDM 99232 CPT inpatient 267 267 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES EPO [308136803] 213.6 percent of total billed charges 165.54 253.65 Professional (doctor) services PR Sbsq Hospital IP/Obs Care Mod Mdm 35 Min PX-99232 CDM 99232 CPT inpatient 267 267 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES HDHP [308136802] 213.6 percent of total billed charges 165.54 253.65 Professional (doctor) services PR Sbsq Hospital IP/Obs Care Mod Mdm 35 Min PX-99232 CDM 99232 CPT inpatient 267 267 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES PPO [308136801] 213.6 percent of total billed charges 165.54 253.65 Professional (doctor) services PR Sbsq Hospital IP/Obs Care Mod Mdm 35 Min PX-99232 CDM 99232 CPT outpatient 267 267 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES EPO [308136803] 213.6 percent of total billed charges 165.54 253.65 Professional (doctor) services PR Sbsq Hospital IP/Obs Care Mod Mdm 35 Min PX-99232 CDM 99232 CPT outpatient 267 267 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES HDHP [308136802] 213.6 percent of total billed charges 165.54 253.65 Professional (doctor) services PR Sbsq Hospital IP/Obs Care Mod Mdm 35 Min PX-99232 CDM 99232 CPT outpatient 267 267 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES PPO [308136801] 213.6 percent of total billed charges 165.54 253.65 Professional (doctor) services PR Sbsq Hospital IP/Obs Care Mod Mdm 35 Min PX-99232 CDM 99232 CPT inpatient 267 267 HEALTHPARTNERS SX009 HEALTHPARTNERS 213.6 percent of total billed charges 165.54 253.65 Professional (doctor) services PR Sbsq Hospital IP/Obs Care Mod Mdm 35 Min PX-99232 CDM 99232 CPT outpatient 267 267 HEALTHPARTNERS SX009 HEALTHPARTNERS 213.6 percent of total billed charges 165.54 253.65 Professional (doctor) services PR Sbsq Hospital IP/Obs Care Mod Mdm 35 Min PX-99232 CDM 99232 CPT inpatient 267 267 MEDICA (COMMERCIAL) 94265 [3081118] MEDICA CLAIMS [308111801] 240.3 percent of total billed charges 165.54 253.65 Professional (doctor) services PR Sbsq Hospital IP/Obs Care Mod Mdm 35 Min PX-99232 CDM 99232 CPT outpatient 267 267 MEDICA (COMMERCIAL) 94265 [3081118] MEDICA CLAIMS [308111801] 240.3 percent of total billed charges 165.54 253.65 Professional (doctor) services PR Sbsq Hospital IP/Obs Care Mod Mdm 35 Min PX-99232 CDM 99232 CPT inpatient 267 267 MULTIPLAN INC 34080 [3081285] MULTIPLAN INC [308128501] 253.65 percent of total billed charges 165.54 253.65 Professional (doctor) services PR Sbsq Hospital IP/Obs Care Mod Mdm 35 Min PX-99232 CDM 99232 CPT outpatient 267 267 MULTIPLAN INC 34080 [3081285] MULTIPLAN INC [308128501] 253.65 percent of total billed charges 165.54 253.65 Professional (doctor) services PR Sbsq Hospital IP/Obs Care Mod Mdm 35 Min PX-99232 CDM 99232 CPT inpatient 267 267 UNITED HEALTHCARE (COMMERCIAL) [3081199] UNITED HEALTHCARE 87726 [308119901] 165.54 percent of total billed charges 165.54 253.65 Professional (doctor) services PR Sbsq Hospital IP/Obs Care Mod Mdm 35 Min PX-99232 CDM 99232 CPT outpatient 267 267 UNITED HEALTHCARE (COMMERCIAL) [3081199] UNITED HEALTHCARE 87726 [308119901] 165.54 percent of total billed charges 165.54 253.65 Professional (doctor) services PR Sbsq Hospital IP/Obs Care Sf/Low Mdm 25 Min PX-99231 CDM 99231 CPT inpatient 190 190 CIGNA 62308 [3081051] CIGNA 62308 [308105105] 152 percent of total billed charges 117.8 180.5 Professional (doctor) services PR Sbsq Hospital IP/Obs Care Sf/Low Mdm 25 Min PX-99231 CDM 99231 CPT inpatient 190 190 CIGNA 62308 [3081051] CIGNA STATE OF WYOMING [308105107] 152 percent of total billed charges 117.8 180.5 Professional (doctor) services PR Sbsq Hospital IP/Obs Care Sf/Low Mdm 25 Min PX-99231 CDM 99231 CPT outpatient 190 190 CIGNA 62308 [3081051] CIGNA 62308 [308105105] 152 percent of total billed charges 117.8 180.5 Professional (doctor) services PR Sbsq Hospital IP/Obs Care Sf/Low Mdm 25 Min PX-99231 CDM 99231 CPT outpatient 190 190 CIGNA 62308 [3081051] CIGNA STATE OF WYOMING [308105107] 152 percent of total billed charges 117.8 180.5 Professional (doctor) services PR Sbsq Hospital IP/Obs Care Sf/Low Mdm 25 Min PX-99231 CDM 99231 CPT inpatient 190 190 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES EPO [308136803] 152 percent of total billed charges 117.8 180.5 Professional (doctor) services PR Sbsq Hospital IP/Obs Care Sf/Low Mdm 25 Min PX-99231 CDM 99231 CPT inpatient 190 190 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES HDHP [308136802] 152 percent of total billed charges 117.8 180.5 Professional (doctor) services PR Sbsq Hospital IP/Obs Care Sf/Low Mdm 25 Min PX-99231 CDM 99231 CPT inpatient 190 190 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES PPO [308136801] 152 percent of total billed charges 117.8 180.5 Professional (doctor) services PR Sbsq Hospital IP/Obs Care Sf/Low Mdm 25 Min PX-99231 CDM 99231 CPT outpatient 190 190 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES EPO [308136803] 152 percent of total billed charges 117.8 180.5 Professional (doctor) services PR Sbsq Hospital IP/Obs Care Sf/Low Mdm 25 Min PX-99231 CDM 99231 CPT outpatient 190 190 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES HDHP [308136802] 152 percent of total billed charges 117.8 180.5 Professional (doctor) services PR Sbsq Hospital IP/Obs Care Sf/Low Mdm 25 Min PX-99231 CDM 99231 CPT outpatient 190 190 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES PPO [308136801] 152 percent of total billed charges 117.8 180.5 Professional (doctor) services PR Sbsq Hospital IP/Obs Care Sf/Low Mdm 25 Min PX-99231 CDM 99231 CPT inpatient 190 190 HEALTHPARTNERS SX009 HEALTHPARTNERS 152 percent of total billed charges 117.8 180.5 Professional (doctor) services PR Sbsq Hospital IP/Obs Care Sf/Low Mdm 25 Min PX-99231 CDM 99231 CPT outpatient 190 190 HEALTHPARTNERS SX009 HEALTHPARTNERS 152 percent of total billed charges 117.8 180.5 Professional (doctor) services PR Sbsq Hospital IP/Obs Care Sf/Low Mdm 25 Min PX-99231 CDM 99231 CPT inpatient 190 190 MEDICA (COMMERCIAL) 94265 [3081118] MEDICA CLAIMS [308111801] 171 percent of total billed charges 117.8 180.5 Professional (doctor) services PR Sbsq Hospital IP/Obs Care Sf/Low Mdm 25 Min PX-99231 CDM 99231 CPT outpatient 190 190 MEDICA (COMMERCIAL) 94265 [3081118] MEDICA CLAIMS [308111801] 171 percent of total billed charges 117.8 180.5 Professional (doctor) services PR Sbsq Hospital IP/Obs Care Sf/Low Mdm 25 Min PX-99231 CDM 99231 CPT inpatient 190 190 MULTIPLAN INC 34080 [3081285] MULTIPLAN INC [308128501] 180.5 percent of total billed charges 117.8 180.5 Professional (doctor) services PR Sbsq Hospital IP/Obs Care Sf/Low Mdm 25 Min PX-99231 CDM 99231 CPT outpatient 190 190 MULTIPLAN INC 34080 [3081285] MULTIPLAN INC [308128501] 180.5 percent of total billed charges 117.8 180.5 Professional (doctor) services PR Sbsq Hospital IP/Obs Care Sf/Low Mdm 25 Min PX-99231 CDM 99231 CPT inpatient 190 190 UNITED HEALTHCARE (COMMERCIAL) [3081199] UNITED HEALTHCARE 87726 [308119901] 117.8 percent of total billed charges 117.8 180.5 Professional (doctor) services PR Sbsq Hospital IP/Obs Care Sf/Low Mdm 25 Min PX-99231 CDM 99231 CPT outpatient 190 190 UNITED HEALTHCARE (COMMERCIAL) [3081199] UNITED HEALTHCARE 87726 [308119901] 117.8 percent of total billed charges 117.8 180.5 Professional (doctor) services Sbsq Observation Care/Day 15 Minutes PX-99224 CDM 99224 CPT inpatient 116 116 CIGNA 62308 [3081051] CIGNA 62308 [308105105] 92.8 percent of total billed charges 71.92 110.2 Professional (doctor) services Sbsq Observation Care/Day 15 Minutes PX-99224 CDM 99224 CPT inpatient 116 116 CIGNA 62308 [3081051] CIGNA STATE OF WYOMING [308105107] 92.8 percent of total billed charges 71.92 110.2 Professional (doctor) services Sbsq Observation Care/Day 15 Minutes PX-99224 CDM 99224 CPT outpatient 116 116 CIGNA 62308 [3081051] CIGNA 62308 [308105105] 92.8 percent of total billed charges 71.92 110.2 Professional (doctor) services Sbsq Observation Care/Day 15 Minutes PX-99224 CDM 99224 CPT outpatient 116 116 CIGNA 62308 [3081051] CIGNA STATE OF WYOMING [308105107] 92.8 percent of total billed charges 71.92 110.2 Professional (doctor) services Sbsq Observation Care/Day 15 Minutes PX-99224 CDM 99224 CPT inpatient 116 116 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES EPO [308136803] 92.8 percent of total billed charges 71.92 110.2 Professional (doctor) services Sbsq Observation Care/Day 15 Minutes PX-99224 CDM 99224 CPT inpatient 116 116 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES HDHP [308136802] 92.8 percent of total billed charges 71.92 110.2 Professional (doctor) services Sbsq Observation Care/Day 15 Minutes PX-99224 CDM 99224 CPT inpatient 116 116 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES PPO [308136801] 92.8 percent of total billed charges 71.92 110.2 Professional (doctor) services Sbsq Observation Care/Day 15 Minutes PX-99224 CDM 99224 CPT outpatient 116 116 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES EPO [308136803] 92.8 percent of total billed charges 71.92 110.2 Professional (doctor) services Sbsq Observation Care/Day 15 Minutes PX-99224 CDM 99224 CPT outpatient 116 116 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES HDHP [308136802] 92.8 percent of total billed charges 71.92 110.2 Professional (doctor) services Sbsq Observation Care/Day 15 Minutes PX-99224 CDM 99224 CPT outpatient 116 116 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES PPO [308136801] 92.8 percent of total billed charges 71.92 110.2 Professional (doctor) services Sbsq Observation Care/Day 15 Minutes PX-99224 CDM 99224 CPT inpatient 116 116 HEALTHPARTNERS SX009 HEALTHPARTNERS 92.8 percent of total billed charges 71.92 110.2 Professional (doctor) services Sbsq Observation Care/Day 15 Minutes PX-99224 CDM 99224 CPT outpatient 116 116 HEALTHPARTNERS SX009 HEALTHPARTNERS 92.8 percent of total billed charges 71.92 110.2 Professional (doctor) services Sbsq Observation Care/Day 15 Minutes PX-99224 CDM 99224 CPT inpatient 116 116 MEDICA (COMMERCIAL) 94265 [3081118] MEDICA CLAIMS [308111801] 104.4 percent of total billed charges 71.92 110.2 Professional (doctor) services Sbsq Observation Care/Day 15 Minutes PX-99224 CDM 99224 CPT outpatient 116 116 MEDICA (COMMERCIAL) 94265 [3081118] MEDICA CLAIMS [308111801] 104.4 percent of total billed charges 71.92 110.2 Professional (doctor) services Sbsq Observation Care/Day 15 Minutes PX-99224 CDM 99224 CPT inpatient 116 116 MULTIPLAN INC 34080 [3081285] MULTIPLAN INC [308128501] 110.2 percent of total billed charges 71.92 110.2 Professional (doctor) services Sbsq Observation Care/Day 15 Minutes PX-99224 CDM 99224 CPT outpatient 116 116 MULTIPLAN INC 34080 [3081285] MULTIPLAN INC [308128501] 110.2 percent of total billed charges 71.92 110.2 Professional (doctor) services Sbsq Observation Care/Day 15 Minutes PX-99224 CDM 99224 CPT inpatient 116 116 UNITED HEALTHCARE (COMMERCIAL) [3081199] UNITED HEALTHCARE 87726 [308119901] 71.92 percent of total billed charges 71.92 110.2 Professional (doctor) services Sbsq Observation Care/Day 15 Minutes PX-99224 CDM 99224 CPT outpatient 116 116 UNITED HEALTHCARE (COMMERCIAL) [3081199] UNITED HEALTHCARE 87726 [308119901] 71.92 percent of total billed charges 71.92 110.2 Professional (doctor) services PR 1st Hospital IP/Obs Care High Mdm 75 Min PX-99223 CDM 99223 CPT inpatient 664 664 CIGNA 62308 [3081051] CIGNA 62308 [308105105] 531.2 percent of total billed charges 411.68 630.8 Professional (doctor) services PR 1st Hospital IP/Obs Care High Mdm 75 Min PX-99223 CDM 99223 CPT inpatient 664 664 CIGNA 62308 [3081051] CIGNA STATE OF WYOMING [308105107] 531.2 percent of total billed charges 411.68 630.8 Professional (doctor) services PR 1st Hospital IP/Obs Care High Mdm 75 Min PX-99223 CDM 99223 CPT outpatient 664 664 CIGNA 62308 [3081051] CIGNA 62308 [308105105] 531.2 percent of total billed charges 411.68 630.8 Professional (doctor) services PR 1st Hospital IP/Obs Care High Mdm 75 Min PX-99223 CDM 99223 CPT outpatient 664 664 CIGNA 62308 [3081051] CIGNA STATE OF WYOMING [308105107] 531.2 percent of total billed charges 411.68 630.8 Professional (doctor) services PR 1st Hospital IP/Obs Care High Mdm 75 Min PX-99223 CDM 99223 CPT inpatient 664 664 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES EPO [308136803] 531.2 percent of total billed charges 411.68 630.8 Professional (doctor) services PR 1st Hospital IP/Obs Care High Mdm 75 Min PX-99223 CDM 99223 CPT inpatient 664 664 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES HDHP [308136802] 531.2 percent of total billed charges 411.68 630.8 Professional (doctor) services PR 1st Hospital IP/Obs Care High Mdm 75 Min PX-99223 CDM 99223 CPT inpatient 664 664 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES PPO [308136801] 531.2 percent of total billed charges 411.68 630.8 Professional (doctor) services PR 1st Hospital IP/Obs Care High Mdm 75 Min PX-99223 CDM 99223 CPT outpatient 664 664 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES EPO [308136803] 531.2 percent of total billed charges 411.68 630.8 Professional (doctor) services PR 1st Hospital IP/Obs Care High Mdm 75 Min PX-99223 CDM 99223 CPT outpatient 664 664 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES HDHP [308136802] 531.2 percent of total billed charges 411.68 630.8 Professional (doctor) services PR 1st Hospital IP/Obs Care High Mdm 75 Min PX-99223 CDM 99223 CPT outpatient 664 664 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES PPO [308136801] 531.2 percent of total billed charges 411.68 630.8 Professional (doctor) services PR 1st Hospital IP/Obs Care High Mdm 75 Min PX-99223 CDM 99223 CPT inpatient 664 664 HEALTHPARTNERS SX009 HEALTHPARTNERS 531.2 percent of total billed charges 411.68 630.8 Professional (doctor) services PR 1st Hospital IP/Obs Care High Mdm 75 Min PX-99223 CDM 99223 CPT outpatient 664 664 HEALTHPARTNERS SX009 HEALTHPARTNERS 531.2 percent of total billed charges 411.68 630.8 Professional (doctor) services PR 1st Hospital IP/Obs Care High Mdm 75 Min PX-99223 CDM 99223 CPT inpatient 664 664 MEDICA (COMMERCIAL) 94265 [3081118] MEDICA CLAIMS [308111801] 597.6 percent of total billed charges 411.68 630.8 Professional (doctor) services PR 1st Hospital IP/Obs Care High Mdm 75 Min PX-99223 CDM 99223 CPT outpatient 664 664 MEDICA (COMMERCIAL) 94265 [3081118] MEDICA CLAIMS [308111801] 597.6 percent of total billed charges 411.68 630.8 Professional (doctor) services PR 1st Hospital IP/Obs Care High Mdm 75 Min PX-99223 CDM 99223 CPT inpatient 664 664 MULTIPLAN INC 34080 [3081285] MULTIPLAN INC [308128501] 630.8 percent of total billed charges 411.68 630.8 Professional (doctor) services PR 1st Hospital IP/Obs Care High Mdm 75 Min PX-99223 CDM 99223 CPT outpatient 664 664 MULTIPLAN INC 34080 [3081285] MULTIPLAN INC [308128501] 630.8 percent of total billed charges 411.68 630.8 Professional (doctor) services PR 1st Hospital IP/Obs Care High Mdm 75 Min PX-99223 CDM 99223 CPT inpatient 664 664 UNITED HEALTHCARE (COMMERCIAL) [3081199] UNITED HEALTHCARE 87726 [308119901] 411.68 percent of total billed charges 411.68 630.8 Professional (doctor) services PR 1st Hospital IP/Obs Care High Mdm 75 Min PX-99223 CDM 99223 CPT outpatient 664 664 UNITED HEALTHCARE (COMMERCIAL) [3081199] UNITED HEALTHCARE 87726 [308119901] 411.68 percent of total billed charges 411.68 630.8 Professional (doctor) services PR 1st Hospital IP/Obs Care Moderate Mdm 55 PX-99222 CDM 99222 CPT inpatient 541 541 CIGNA 62308 [3081051] CIGNA 62308 [308105105] 432.8 percent of total billed charges 335.42 513.95 Professional (doctor) services PR 1st Hospital IP/Obs Care Moderate Mdm 55 PX-99222 CDM 99222 CPT inpatient 541 541 CIGNA 62308 [3081051] CIGNA STATE OF WYOMING [308105107] 432.8 percent of total billed charges 335.42 513.95 Professional (doctor) services PR 1st Hospital IP/Obs Care Moderate Mdm 55 PX-99222 CDM 99222 CPT outpatient 541 541 CIGNA 62308 [3081051] CIGNA 62308 [308105105] 432.8 percent of total billed charges 335.42 513.95 Professional (doctor) services PR 1st Hospital IP/Obs Care Moderate Mdm 55 PX-99222 CDM 99222 CPT outpatient 541 541 CIGNA 62308 [3081051] CIGNA STATE OF WYOMING [308105107] 432.8 percent of total billed charges 335.42 513.95 Professional (doctor) services PR 1st Hospital IP/Obs Care Moderate Mdm 55 PX-99222 CDM 99222 CPT inpatient 541 541 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES EPO [308136803] 432.8 percent of total billed charges 335.42 513.95 Professional (doctor) services PR 1st Hospital IP/Obs Care Moderate Mdm 55 PX-99222 CDM 99222 CPT inpatient 541 541 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES HDHP [308136802] 432.8 percent of total billed charges 335.42 513.95 Professional (doctor) services PR 1st Hospital IP/Obs Care Moderate Mdm 55 PX-99222 CDM 99222 CPT inpatient 541 541 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES PPO [308136801] 432.8 percent of total billed charges 335.42 513.95 Professional (doctor) services PR 1st Hospital IP/Obs Care Moderate Mdm 55 PX-99222 CDM 99222 CPT outpatient 541 541 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES EPO [308136803] 432.8 percent of total billed charges 335.42 513.95 Professional (doctor) services PR 1st Hospital IP/Obs Care Moderate Mdm 55 PX-99222 CDM 99222 CPT outpatient 541 541 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES HDHP [308136802] 432.8 percent of total billed charges 335.42 513.95 Professional (doctor) services PR 1st Hospital IP/Obs Care Moderate Mdm 55 PX-99222 CDM 99222 CPT outpatient 541 541 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES PPO [308136801] 432.8 percent of total billed charges 335.42 513.95 Professional (doctor) services PR 1st Hospital IP/Obs Care Moderate Mdm 55 PX-99222 CDM 99222 CPT inpatient 541 541 HEALTHPARTNERS SX009 HEALTHPARTNERS 432.8 percent of total billed charges 335.42 513.95 Professional (doctor) services PR 1st Hospital IP/Obs Care Moderate Mdm 55 PX-99222 CDM 99222 CPT outpatient 541 541 HEALTHPARTNERS SX009 HEALTHPARTNERS 432.8 percent of total billed charges 335.42 513.95 Professional (doctor) services PR 1st Hospital IP/Obs Care Moderate Mdm 55 PX-99222 CDM 99222 CPT inpatient 541 541 MEDICA (COMMERCIAL) 94265 [3081118] MEDICA CLAIMS [308111801] 486.9 percent of total billed charges 335.42 513.95 Professional (doctor) services PR 1st Hospital IP/Obs Care Moderate Mdm 55 PX-99222 CDM 99222 CPT outpatient 541 541 MEDICA (COMMERCIAL) 94265 [3081118] MEDICA CLAIMS [308111801] 486.9 percent of total billed charges 335.42 513.95 Professional (doctor) services PR 1st Hospital IP/Obs Care Moderate Mdm 55 PX-99222 CDM 99222 CPT inpatient 541 541 MULTIPLAN INC 34080 [3081285] MULTIPLAN INC [308128501] 513.95 percent of total billed charges 335.42 513.95 Professional (doctor) services PR 1st Hospital IP/Obs Care Moderate Mdm 55 PX-99222 CDM 99222 CPT outpatient 541 541 MULTIPLAN INC 34080 [3081285] MULTIPLAN INC [308128501] 513.95 percent of total billed charges 335.42 513.95 Professional (doctor) services PR 1st Hospital IP/Obs Care Moderate Mdm 55 PX-99222 CDM 99222 CPT inpatient 541 541 UNITED HEALTHCARE (COMMERCIAL) [3081199] UNITED HEALTHCARE 87726 [308119901] 335.42 percent of total billed charges 335.42 513.95 Professional (doctor) services PR 1st Hospital IP/Obs Care Moderate Mdm 55 PX-99222 CDM 99222 CPT outpatient 541 541 UNITED HEALTHCARE (COMMERCIAL) [3081199] UNITED HEALTHCARE 87726 [308119901] 335.42 percent of total billed charges 335.42 513.95 Professional (doctor) services PR 1st Hospital IP/Obs Care Sf/Low Mdm 40 Minutes PX-99221 CDM 99221 CPT inpatient 400 400 CIGNA 62308 [3081051] CIGNA 62308 [308105105] 320 percent of total billed charges 248 380 Professional (doctor) services PR 1st Hospital IP/Obs Care Sf/Low Mdm 40 Minutes PX-99221 CDM 99221 CPT inpatient 400 400 CIGNA 62308 [3081051] CIGNA STATE OF WYOMING [308105107] 320 percent of total billed charges 248 380 Professional (doctor) services PR 1st Hospital IP/Obs Care Sf/Low Mdm 40 Minutes PX-99221 CDM 99221 CPT outpatient 400 400 CIGNA 62308 [3081051] CIGNA 62308 [308105105] 320 percent of total billed charges 248 380 Professional (doctor) services PR 1st Hospital IP/Obs Care Sf/Low Mdm 40 Minutes PX-99221 CDM 99221 CPT outpatient 400 400 CIGNA 62308 [3081051] CIGNA STATE OF WYOMING [308105107] 320 percent of total billed charges 248 380 Professional (doctor) services PR 1st Hospital IP/Obs Care Sf/Low Mdm 40 Minutes PX-99221 CDM 99221 CPT inpatient 400 400 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES EPO [308136803] 320 percent of total billed charges 248 380 Professional (doctor) services PR 1st Hospital IP/Obs Care Sf/Low Mdm 40 Minutes PX-99221 CDM 99221 CPT inpatient 400 400 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES HDHP [308136802] 320 percent of total billed charges 248 380 Professional (doctor) services PR 1st Hospital IP/Obs Care Sf/Low Mdm 40 Minutes PX-99221 CDM 99221 CPT inpatient 400 400 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES PPO [308136801] 320 percent of total billed charges 248 380 Professional (doctor) services PR 1st Hospital IP/Obs Care Sf/Low Mdm 40 Minutes PX-99221 CDM 99221 CPT outpatient 400 400 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES EPO [308136803] 320 percent of total billed charges 248 380 Professional (doctor) services PR 1st Hospital IP/Obs Care Sf/Low Mdm 40 Minutes PX-99221 CDM 99221 CPT outpatient 400 400 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES HDHP [308136802] 320 percent of total billed charges 248 380 Professional (doctor) services PR 1st Hospital IP/Obs Care Sf/Low Mdm 40 Minutes PX-99221 CDM 99221 CPT outpatient 400 400 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES PPO [308136801] 320 percent of total billed charges 248 380 Professional (doctor) services PR 1st Hospital IP/Obs Care Sf/Low Mdm 40 Minutes PX-99221 CDM 99221 CPT inpatient 400 400 HEALTHPARTNERS SX009 HEALTHPARTNERS 320 percent of total billed charges 248 380 Professional (doctor) services PR 1st Hospital IP/Obs Care Sf/Low Mdm 40 Minutes PX-99221 CDM 99221 CPT outpatient 400 400 HEALTHPARTNERS SX009 HEALTHPARTNERS 320 percent of total billed charges 248 380 Professional (doctor) services PR 1st Hospital IP/Obs Care Sf/Low Mdm 40 Minutes PX-99221 CDM 99221 CPT inpatient 400 400 MEDICA (COMMERCIAL) 94265 [3081118] MEDICA CLAIMS [308111801] 360 percent of total billed charges 248 380 Professional (doctor) services PR 1st Hospital IP/Obs Care Sf/Low Mdm 40 Minutes PX-99221 CDM 99221 CPT outpatient 400 400 MEDICA (COMMERCIAL) 94265 [3081118] MEDICA CLAIMS [308111801] 360 percent of total billed charges 248 380 Professional (doctor) services PR 1st Hospital IP/Obs Care Sf/Low Mdm 40 Minutes PX-99221 CDM 99221 CPT inpatient 400 400 MULTIPLAN INC 34080 [3081285] MULTIPLAN INC [308128501] 380 percent of total billed charges 248 380 Professional (doctor) services PR 1st Hospital IP/Obs Care Sf/Low Mdm 40 Minutes PX-99221 CDM 99221 CPT outpatient 400 400 MULTIPLAN INC 34080 [3081285] MULTIPLAN INC [308128501] 380 percent of total billed charges 248 380 Professional (doctor) services PR 1st Hospital IP/Obs Care Sf/Low Mdm 40 Minutes PX-99221 CDM 99221 CPT inpatient 400 400 UNITED HEALTHCARE (COMMERCIAL) [3081199] UNITED HEALTHCARE 87726 [308119901] 248 percent of total billed charges 248 380 Professional (doctor) services PR 1st Hospital IP/Obs Care Sf/Low Mdm 40 Minutes PX-99221 CDM 99221 CPT outpatient 400 400 UNITED HEALTHCARE (COMMERCIAL) [3081199] UNITED HEALTHCARE 87726 [308119901] 248 percent of total billed charges 248 380 Professional (doctor) services Initial Observation Care/Day 50 Minutes PX-99219 CDM 99219 CPT inpatient 492 492 CIGNA 62308 [3081051] CIGNA 62308 [308105105] 393.6 percent of total billed charges 305.04 467.4 Professional (doctor) services Initial Observation Care/Day 50 Minutes PX-99219 CDM 99219 CPT inpatient 492 492 CIGNA 62308 [3081051] CIGNA STATE OF WYOMING [308105107] 393.6 percent of total billed charges 305.04 467.4 Professional (doctor) services Initial Observation Care/Day 50 Minutes PX-99219 CDM 99219 CPT outpatient 492 492 CIGNA 62308 [3081051] CIGNA 62308 [308105105] 393.6 percent of total billed charges 305.04 467.4 Professional (doctor) services Initial Observation Care/Day 50 Minutes PX-99219 CDM 99219 CPT outpatient 492 492 CIGNA 62308 [3081051] CIGNA STATE OF WYOMING [308105107] 393.6 percent of total billed charges 305.04 467.4 Professional (doctor) services Initial Observation Care/Day 50 Minutes PX-99219 CDM 99219 CPT inpatient 492 492 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES EPO [308136803] 393.6 percent of total billed charges 305.04 467.4 Professional (doctor) services Initial Observation Care/Day 50 Minutes PX-99219 CDM 99219 CPT inpatient 492 492 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES HDHP [308136802] 393.6 percent of total billed charges 305.04 467.4 Professional (doctor) services Initial Observation Care/Day 50 Minutes PX-99219 CDM 99219 CPT inpatient 492 492 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES PPO [308136801] 393.6 percent of total billed charges 305.04 467.4 Professional (doctor) services Initial Observation Care/Day 50 Minutes PX-99219 CDM 99219 CPT outpatient 492 492 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES EPO [308136803] 393.6 percent of total billed charges 305.04 467.4 Professional (doctor) services Initial Observation Care/Day 50 Minutes PX-99219 CDM 99219 CPT outpatient 492 492 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES HDHP [308136802] 393.6 percent of total billed charges 305.04 467.4 Professional (doctor) services Initial Observation Care/Day 50 Minutes PX-99219 CDM 99219 CPT outpatient 492 492 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES PPO [308136801] 393.6 percent of total billed charges 305.04 467.4 Professional (doctor) services Initial Observation Care/Day 50 Minutes PX-99219 CDM 99219 CPT inpatient 492 492 HEALTHPARTNERS SX009 HEALTHPARTNERS 393.6 percent of total billed charges 305.04 467.4 Professional (doctor) services Initial Observation Care/Day 50 Minutes PX-99219 CDM 99219 CPT outpatient 492 492 HEALTHPARTNERS SX009 HEALTHPARTNERS 393.6 percent of total billed charges 305.04 467.4 Professional (doctor) services Initial Observation Care/Day 50 Minutes PX-99219 CDM 99219 CPT inpatient 492 492 MEDICA (COMMERCIAL) 94265 [3081118] MEDICA CLAIMS [308111801] 442.8 percent of total billed charges 305.04 467.4 Professional (doctor) services Initial Observation Care/Day 50 Minutes PX-99219 CDM 99219 CPT outpatient 492 492 MEDICA (COMMERCIAL) 94265 [3081118] MEDICA CLAIMS [308111801] 442.8 percent of total billed charges 305.04 467.4 Professional (doctor) services Initial Observation Care/Day 50 Minutes PX-99219 CDM 99219 CPT inpatient 492 492 MULTIPLAN INC 34080 [3081285] MULTIPLAN INC [308128501] 467.4 percent of total billed charges 305.04 467.4 Professional (doctor) services Initial Observation Care/Day 50 Minutes PX-99219 CDM 99219 CPT outpatient 492 492 MULTIPLAN INC 34080 [3081285] MULTIPLAN INC [308128501] 467.4 percent of total billed charges 305.04 467.4 Professional (doctor) services Initial Observation Care/Day 50 Minutes PX-99219 CDM 99219 CPT inpatient 492 492 UNITED HEALTHCARE (COMMERCIAL) [3081199] UNITED HEALTHCARE 87726 [308119901] 305.04 percent of total billed charges 305.04 467.4 Professional (doctor) services Initial Observation Care/Day 50 Minutes PX-99219 CDM 99219 CPT outpatient 492 492 UNITED HEALTHCARE (COMMERCIAL) [3081199] UNITED HEALTHCARE 87726 [308119901] 305.04 percent of total billed charges 305.04 467.4 Professional (doctor) services Initial Observation Care/Day 30 Minutes PX-99218 CDM 99218 CPT inpatient 360 360 CIGNA 62308 [3081051] CIGNA 62308 [308105105] 288 percent of total billed charges 223.2 342 Professional (doctor) services Initial Observation Care/Day 30 Minutes PX-99218 CDM 99218 CPT inpatient 360 360 CIGNA 62308 [3081051] CIGNA STATE OF WYOMING [308105107] 288 percent of total billed charges 223.2 342 Professional (doctor) services Initial Observation Care/Day 30 Minutes PX-99218 CDM 99218 CPT outpatient 360 360 CIGNA 62308 [3081051] CIGNA 62308 [308105105] 288 percent of total billed charges 223.2 342 Professional (doctor) services Initial Observation Care/Day 30 Minutes PX-99218 CDM 99218 CPT outpatient 360 360 CIGNA 62308 [3081051] CIGNA STATE OF WYOMING [308105107] 288 percent of total billed charges 223.2 342 Professional (doctor) services Initial Observation Care/Day 30 Minutes PX-99218 CDM 99218 CPT inpatient 360 360 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES EPO [308136803] 288 percent of total billed charges 223.2 342 Professional (doctor) services Initial Observation Care/Day 30 Minutes PX-99218 CDM 99218 CPT inpatient 360 360 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES HDHP [308136802] 288 percent of total billed charges 223.2 342 Professional (doctor) services Initial Observation Care/Day 30 Minutes PX-99218 CDM 99218 CPT inpatient 360 360 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES PPO [308136801] 288 percent of total billed charges 223.2 342 Professional (doctor) services Initial Observation Care/Day 30 Minutes PX-99218 CDM 99218 CPT outpatient 360 360 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES EPO [308136803] 288 percent of total billed charges 223.2 342 Professional (doctor) services Initial Observation Care/Day 30 Minutes PX-99218 CDM 99218 CPT outpatient 360 360 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES HDHP [308136802] 288 percent of total billed charges 223.2 342 Professional (doctor) services Initial Observation Care/Day 30 Minutes PX-99218 CDM 99218 CPT outpatient 360 360 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES PPO [308136801] 288 percent of total billed charges 223.2 342 Professional (doctor) services Initial Observation Care/Day 30 Minutes PX-99218 CDM 99218 CPT inpatient 360 360 HEALTHPARTNERS SX009 HEALTHPARTNERS 288 percent of total billed charges 223.2 342 Professional (doctor) services Initial Observation Care/Day 30 Minutes PX-99218 CDM 99218 CPT outpatient 360 360 HEALTHPARTNERS SX009 HEALTHPARTNERS 288 percent of total billed charges 223.2 342 Professional (doctor) services Initial Observation Care/Day 30 Minutes PX-99218 CDM 99218 CPT inpatient 360 360 MEDICA (COMMERCIAL) 94265 [3081118] MEDICA CLAIMS [308111801] 324 percent of total billed charges 223.2 342 Professional (doctor) services Initial Observation Care/Day 30 Minutes PX-99218 CDM 99218 CPT outpatient 360 360 MEDICA (COMMERCIAL) 94265 [3081118] MEDICA CLAIMS [308111801] 324 percent of total billed charges 223.2 342 Professional (doctor) services Initial Observation Care/Day 30 Minutes PX-99218 CDM 99218 CPT inpatient 360 360 MULTIPLAN INC 34080 [3081285] MULTIPLAN INC [308128501] 342 percent of total billed charges 223.2 342 Professional (doctor) services Initial Observation Care/Day 30 Minutes PX-99218 CDM 99218 CPT outpatient 360 360 MULTIPLAN INC 34080 [3081285] MULTIPLAN INC [308128501] 342 percent of total billed charges 223.2 342 Professional (doctor) services Initial Observation Care/Day 30 Minutes PX-99218 CDM 99218 CPT inpatient 360 360 UNITED HEALTHCARE (COMMERCIAL) [3081199] UNITED HEALTHCARE 87726 [308119901] 223.2 percent of total billed charges 223.2 342 Professional (doctor) services Initial Observation Care/Day 30 Minutes PX-99218 CDM 99218 CPT outpatient 360 360 UNITED HEALTHCARE (COMMERCIAL) [3081199] UNITED HEALTHCARE 87726 [308119901] 223.2 percent of total billed charges 223.2 342 Professional (doctor) services Observation Care Discharge Management PX-99217 CDM 99217 CPT inpatient 290 290 CIGNA 62308 [3081051] CIGNA 62308 [308105105] 232 percent of total billed charges 179.8 275.5 Professional (doctor) services Observation Care Discharge Management PX-99217 CDM 99217 CPT inpatient 290 290 CIGNA 62308 [3081051] CIGNA STATE OF WYOMING [308105107] 232 percent of total billed charges 179.8 275.5 Professional (doctor) services Observation Care Discharge Management PX-99217 CDM 99217 CPT outpatient 290 290 CIGNA 62308 [3081051] CIGNA 62308 [308105105] 232 percent of total billed charges 179.8 275.5 Professional (doctor) services Observation Care Discharge Management PX-99217 CDM 99217 CPT outpatient 290 290 CIGNA 62308 [3081051] CIGNA STATE OF WYOMING [308105107] 232 percent of total billed charges 179.8 275.5 Professional (doctor) services Observation Care Discharge Management PX-99217 CDM 99217 CPT inpatient 290 290 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES EPO [308136803] 232 percent of total billed charges 179.8 275.5 Professional (doctor) services Observation Care Discharge Management PX-99217 CDM 99217 CPT inpatient 290 290 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES HDHP [308136802] 232 percent of total billed charges 179.8 275.5 Professional (doctor) services Observation Care Discharge Management PX-99217 CDM 99217 CPT inpatient 290 290 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES PPO [308136801] 232 percent of total billed charges 179.8 275.5 Professional (doctor) services Observation Care Discharge Management PX-99217 CDM 99217 CPT outpatient 290 290 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES EPO [308136803] 232 percent of total billed charges 179.8 275.5 Professional (doctor) services Observation Care Discharge Management PX-99217 CDM 99217 CPT outpatient 290 290 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES HDHP [308136802] 232 percent of total billed charges 179.8 275.5 Professional (doctor) services Observation Care Discharge Management PX-99217 CDM 99217 CPT outpatient 290 290 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES PPO [308136801] 232 percent of total billed charges 179.8 275.5 Professional (doctor) services Observation Care Discharge Management PX-99217 CDM 99217 CPT inpatient 290 290 HEALTHPARTNERS SX009 HEALTHPARTNERS 232 percent of total billed charges 179.8 275.5 Professional (doctor) services Observation Care Discharge Management PX-99217 CDM 99217 CPT outpatient 290 290 HEALTHPARTNERS SX009 HEALTHPARTNERS 232 percent of total billed charges 179.8 275.5 Professional (doctor) services Observation Care Discharge Management PX-99217 CDM 99217 CPT inpatient 290 290 MEDICA (COMMERCIAL) 94265 [3081118] MEDICA CLAIMS [308111801] 261 percent of total billed charges 179.8 275.5 Professional (doctor) services Observation Care Discharge Management PX-99217 CDM 99217 CPT outpatient 290 290 MEDICA (COMMERCIAL) 94265 [3081118] MEDICA CLAIMS [308111801] 261 percent of total billed charges 179.8 275.5 Professional (doctor) services Observation Care Discharge Management PX-99217 CDM 99217 CPT inpatient 290 290 MULTIPLAN INC 34080 [3081285] MULTIPLAN INC [308128501] 275.5 percent of total billed charges 179.8 275.5 Professional (doctor) services Observation Care Discharge Management PX-99217 CDM 99217 CPT outpatient 290 290 MULTIPLAN INC 34080 [3081285] MULTIPLAN INC [308128501] 275.5 percent of total billed charges 179.8 275.5 Professional (doctor) services Observation Care Discharge Management PX-99217 CDM 99217 CPT inpatient 290 290 UNITED HEALTHCARE (COMMERCIAL) [3081199] UNITED HEALTHCARE 87726 [308119901] 179.8 percent of total billed charges 179.8 275.5 Professional (doctor) services Observation Care Discharge Management PX-99217 CDM 99217 CPT outpatient 290 290 UNITED HEALTHCARE (COMMERCIAL) [3081199] UNITED HEALTHCARE 87726 [308119901] 179.8 percent of total billed charges 179.8 275.5 Professional (doctor) services Phlebotomy Therapeutic Separate Procedure PX-9409919500 CDM 99195 CPT 940 RC inpatient 204 204 CIGNA 62308 [3081051] CIGNA 62308 [308105105] 161.53 percent of total billed charges 126.48 193.8 Technical (Hospital) Services Phlebotomy Therapeutic Separate Procedure PX-9409919500 CDM 99195 CPT 940 RC inpatient 204 204 CIGNA 62308 [3081051] CIGNA STATE OF WYOMING [308105107] 161.53 percent of total billed charges 126.48 193.8 Technical (Hospital) Services Phlebotomy Therapeutic Separate Procedure PX-9409919500 CDM 99195 CPT 940 RC inpatient 204 204 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES EPO [308136803] 161.53 percent of total billed charges 126.48 193.8 Technical (Hospital) Services Phlebotomy Therapeutic Separate Procedure PX-9409919500 CDM 99195 CPT 940 RC inpatient 204 204 HEALTHPARTNERS SX009 HEALTHPARTNERS 161.53 percent of total billed charges 126.48 193.8 Technical (Hospital) Services Phlebotomy Therapeutic Separate Procedure PX-9409919500 CDM 99195 CPT 940 RC inpatient 204 204 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES HDHP [308136802] 161.53 percent of total billed charges 126.48 193.8 Technical (Hospital) Services Phlebotomy Therapeutic Separate Procedure PX-9409919500 CDM 99195 CPT 940 RC inpatient 204 204 MEDICA (COMMERCIAL) 94265 [3081118] MEDICA CLAIMS [308111801] 183.6 percent of total billed charges 126.48 193.8 Technical (Hospital) Services Phlebotomy Therapeutic Separate Procedure PX-9409919500 CDM 99195 CPT 940 RC inpatient 204 204 MULTIPLAN INC 34080 [3081285] MULTIPLAN INC [308128501] 193.8 percent of total billed charges 126.48 193.8 Technical (Hospital) Services Phlebotomy Therapeutic Separate Procedure PX-9409919500 CDM 99195 CPT 940 RC inpatient 204 204 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES PPO [308136801] 161.53 percent of total billed charges 126.48 193.8 Technical (Hospital) Services Phlebotomy Therapeutic Separate Procedure PX-9409919500 CDM 99195 CPT 940 RC inpatient 204 204 UNITED HEALTHCARE (COMMERCIAL) [3081199] UNITED HEALTHCARE 87726 [308119901] 126.48 percent of total billed charges 126.48 193.8 Technical (Hospital) Services Phlebotomy Therapeutic Separate Procedure PX-9409919500 CDM 99195 CPT 940 RC inpatient 204 204 BLUE CROSS BLUE SHIELD WELLMARK SB889 [3081026] BCBS WYOMING [308102603] 193.8 percent of total billed charges 126.48 193.8 Technical (Hospital) Services Phlebotomy Therapeutic Separate Procedure PX-9409919500 CDM 99195 CPT 940 RC outpatient 204 204 MULTIPLAN INC 34080 [3081285] MULTIPLAN INC [308128501] 193.8 percent of total billed charges 126.48 193.8 Technical (Hospital) Services Phlebotomy Therapeutic Separate Procedure PX-9409919500 CDM 99195 CPT 940 RC outpatient 204 204 MEDICA (COMMERCIAL) 94265 [3081118] MEDICA CLAIMS [308111801] 183.6 percent of total billed charges 126.48 193.8 Technical (Hospital) Services Phlebotomy Therapeutic Separate Procedure PX-9409919500 CDM 99195 CPT 940 RC outpatient 204 204 CIGNA 62308 [3081051] CIGNA STATE OF WYOMING [308105107] 163.2 percent of total billed charges 126.48 193.8 Technical (Hospital) Services Phlebotomy Therapeutic Separate Procedure PX-9409919500 CDM 99195 CPT 940 RC outpatient 204 204 CIGNA 62308 [3081051] CIGNA 62308 [308105105] 163.2 percent of total billed charges 126.48 193.8 Technical (Hospital) Services Phlebotomy Therapeutic Separate Procedure PX-9409919500 CDM 99195 CPT 940 RC outpatient 204 204 HEALTHPARTNERS SX009 HEALTHPARTNERS 163.2 percent of total billed charges 126.48 193.8 Technical (Hospital) Services Phlebotomy Therapeutic Separate Procedure PX-9409919500 CDM 99195 CPT 940 RC outpatient 204 204 UNITED HEALTHCARE (COMMERCIAL) [3081199] UNITED HEALTHCARE 87726 [308119901] 126.48 percent of total billed charges 126.48 193.8 Technical (Hospital) Services Phlebotomy Therapeutic Separate Procedure PX-9409919500 CDM 99195 CPT 940 RC outpatient 204 204 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES HDHP [308136802] 163.2 percent of total billed charges 126.48 193.8 Technical (Hospital) Services Phlebotomy Therapeutic Separate Procedure PX-9409919500 CDM 99195 CPT 940 RC outpatient 204 204 BLUE CROSS BLUE SHIELD WELLMARK SB889 [3081026] BCBS WYOMING [308102603] 193.8 percent of total billed charges 126.48 193.8 Technical (Hospital) Services Phlebotomy Therapeutic Separate Procedure PX-9409919500 CDM 99195 CPT 940 RC outpatient 204 204 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES PPO [308136801] 163.2 percent of total billed charges 126.48 193.8 Technical (Hospital) Services Phlebotomy Therapeutic Separate Procedure PX-9409919500 CDM 99195 CPT 940 RC outpatient 204 204 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES EPO [308136803] 163.2 percent of total billed charges 126.48 193.8 Technical (Hospital) Services Mod Sed Same Phys/Qhp Each Addl 15 Mins PX-99153 CDM 99153 CPT inpatient 69 69 CIGNA 62308 [3081051] CIGNA 62308 [308105105] 55.2 percent of total billed charges 42.78 65.55 Professional (doctor) services Mod Sed Same Phys/Qhp Each Addl 15 Mins PX-99153 CDM 99153 CPT inpatient 69 69 CIGNA 62308 [3081051] CIGNA STATE OF WYOMING [308105107] 55.2 percent of total billed charges 42.78 65.55 Professional (doctor) services Mod Sed Same Phys/Qhp Each Addl 15 Mins PX-99153 CDM 99153 CPT outpatient 69 69 CIGNA 62308 [3081051] CIGNA 62308 [308105105] 55.2 percent of total billed charges 42.78 65.55 Professional (doctor) services Mod Sed Same Phys/Qhp Each Addl 15 Mins PX-99153 CDM 99153 CPT outpatient 69 69 CIGNA 62308 [3081051] CIGNA STATE OF WYOMING [308105107] 55.2 percent of total billed charges 42.78 65.55 Professional (doctor) services Mod Sed Same Phys/Qhp Each Addl 15 Mins PX-99153 CDM 99153 CPT inpatient 69 69 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES EPO [308136803] 55.2 percent of total billed charges 42.78 65.55 Professional (doctor) services Mod Sed Same Phys/Qhp Each Addl 15 Mins PX-99153 CDM 99153 CPT inpatient 69 69 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES HDHP [308136802] 55.2 percent of total billed charges 42.78 65.55 Professional (doctor) services Mod Sed Same Phys/Qhp Each Addl 15 Mins PX-99153 CDM 99153 CPT inpatient 69 69 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES PPO [308136801] 55.2 percent of total billed charges 42.78 65.55 Professional (doctor) services Mod Sed Same Phys/Qhp Each Addl 15 Mins PX-99153 CDM 99153 CPT outpatient 69 69 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES EPO [308136803] 55.2 percent of total billed charges 42.78 65.55 Professional (doctor) services Mod Sed Same Phys/Qhp Each Addl 15 Mins PX-99153 CDM 99153 CPT outpatient 69 69 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES HDHP [308136802] 55.2 percent of total billed charges 42.78 65.55 Professional (doctor) services Mod Sed Same Phys/Qhp Each Addl 15 Mins PX-99153 CDM 99153 CPT outpatient 69 69 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES PPO [308136801] 55.2 percent of total billed charges 42.78 65.55 Professional (doctor) services Mod Sed Same Phys/Qhp Each Addl 15 Mins PX-99153 CDM 99153 CPT inpatient 69 69 HEALTHPARTNERS SX009 HEALTHPARTNERS 55.2 percent of total billed charges 42.78 65.55 Professional (doctor) services Mod Sed Same Phys/Qhp Each Addl 15 Mins PX-99153 CDM 99153 CPT outpatient 69 69 HEALTHPARTNERS SX009 HEALTHPARTNERS 55.2 percent of total billed charges 42.78 65.55 Professional (doctor) services Mod Sed Same Phys/Qhp Each Addl 15 Mins PX-99153 CDM 99153 CPT inpatient 69 69 MEDICA (COMMERCIAL) 94265 [3081118] MEDICA CLAIMS [308111801] 62.1 percent of total billed charges 42.78 65.55 Professional (doctor) services Mod Sed Same Phys/Qhp Each Addl 15 Mins PX-99153 CDM 99153 CPT outpatient 69 69 MEDICA (COMMERCIAL) 94265 [3081118] MEDICA CLAIMS [308111801] 62.1 percent of total billed charges 42.78 65.55 Professional (doctor) services Mod Sed Same Phys/Qhp Each Addl 15 Mins PX-99153 CDM 99153 CPT inpatient 69 69 MULTIPLAN INC 34080 [3081285] MULTIPLAN INC [308128501] 65.55 percent of total billed charges 42.78 65.55 Professional (doctor) services Mod Sed Same Phys/Qhp Each Addl 15 Mins PX-99153 CDM 99153 CPT outpatient 69 69 MULTIPLAN INC 34080 [3081285] MULTIPLAN INC [308128501] 65.55 percent of total billed charges 42.78 65.55 Professional (doctor) services Mod Sed Same Phys/Qhp Each Addl 15 Mins PX-99153 CDM 99153 CPT inpatient 69 69 UNITED HEALTHCARE (COMMERCIAL) [3081199] UNITED HEALTHCARE 87726 [308119901] 42.78 percent of total billed charges 42.78 65.55 Professional (doctor) services Mod Sed Same Phys/Qhp Each Addl 15 Mins PX-99153 CDM 99153 CPT outpatient 69 69 UNITED HEALTHCARE (COMMERCIAL) [3081199] UNITED HEALTHCARE 87726 [308119901] 42.78 percent of total billed charges 42.78 65.55 Professional (doctor) services Mod Sed Same Phys/Qhp Initial 15 Mins 5/> Yrs PX-3709915200 CDM 99152 CPT 370 RC inpatient 194 194 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES HDHP [308136802] 153.61 percent of total billed charges 120.28 184.3 Technical (Hospital) Services Mod Sed Same Phys/Qhp Initial 15 Mins 5/> Yrs PX-3709915200 CDM 99152 CPT 370 RC inpatient 194 194 MULTIPLAN INC 34080 [3081285] MULTIPLAN INC [308128501] 184.3 percent of total billed charges 120.28 184.3 Technical (Hospital) Services Mod Sed Same Phys/Qhp Initial 15 Mins 5/> Yrs PX-3709915200 CDM 99152 CPT 370 RC inpatient 194 194 MEDICA (COMMERCIAL) 94265 [3081118] MEDICA CLAIMS [308111801] 174.6 percent of total billed charges 120.28 184.3 Technical (Hospital) Services Mod Sed Same Phys/Qhp Initial 15 Mins 5/> Yrs PX-3709915200 CDM 99152 CPT 370 RC inpatient 194 194 HEALTHPARTNERS SX009 HEALTHPARTNERS 153.61 percent of total billed charges 120.28 184.3 Technical (Hospital) Services Mod Sed Same Phys/Qhp Initial 15 Mins 5/> Yrs PX-3709915200 CDM 99152 CPT 370 RC inpatient 194 194 UNITED HEALTHCARE (COMMERCIAL) [3081199] UNITED HEALTHCARE 87726 [308119901] 120.28 percent of total billed charges 120.28 184.3 Technical (Hospital) Services Mod Sed Same Phys/Qhp Initial 15 Mins 5/> Yrs PX-3709915200 CDM 99152 CPT 370 RC inpatient 194 194 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES PPO [308136801] 153.61 percent of total billed charges 120.28 184.3 Technical (Hospital) Services Mod Sed Same Phys/Qhp Initial 15 Mins 5/> Yrs PX-3709915200 CDM 99152 CPT 370 RC inpatient 194 194 BLUE CROSS BLUE SHIELD WELLMARK SB889 [3081026] BCBS WYOMING [308102603] 184.3 percent of total billed charges 120.28 184.3 Technical (Hospital) Services Mod Sed Same Phys/Qhp Initial 15 Mins 5/> Yrs PX-3709915200 CDM 99152 CPT 370 RC inpatient 194 194 CIGNA 62308 [3081051] CIGNA 62308 [308105105] 153.61 percent of total billed charges 120.28 184.3 Technical (Hospital) Services Mod Sed Same Phys/Qhp Initial 15 Mins 5/> Yrs PX-3709915200 CDM 99152 CPT 370 RC inpatient 194 194 CIGNA 62308 [3081051] CIGNA STATE OF WYOMING [308105107] 153.61 percent of total billed charges 120.28 184.3 Technical (Hospital) Services Mod Sed Same Phys/Qhp Initial 15 Mins 5/> Yrs PX-3709915200 CDM 99152 CPT 370 RC inpatient 194 194 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES EPO [308136803] 153.61 percent of total billed charges 120.28 184.3 Technical (Hospital) Services Mod Sed Same Phys/Qhp Initial 15 Mins 5/> Yrs PX-3709915200 CDM 99152 CPT 370 RC outpatient 194 194 UNITED HEALTHCARE (COMMERCIAL) [3081199] UNITED HEALTHCARE 87726 [308119901] 120.28 percent of total billed charges 120.28 184.3 Technical (Hospital) Services Mod Sed Same Phys/Qhp Initial 15 Mins 5/> Yrs PX-3709915200 CDM 99152 CPT 370 RC outpatient 194 194 HEALTHPARTNERS SX009 HEALTHPARTNERS 155.2 percent of total billed charges 120.28 184.3 Technical (Hospital) Services Mod Sed Same Phys/Qhp Initial 15 Mins 5/> Yrs PX-3709915200 CDM 99152 CPT 370 RC outpatient 194 194 BLUE CROSS BLUE SHIELD WELLMARK SB889 [3081026] BCBS WYOMING [308102603] 184.3 percent of total billed charges 120.28 184.3 Technical (Hospital) Services Mod Sed Same Phys/Qhp Initial 15 Mins 5/> Yrs PX-3709915200 CDM 99152 CPT 370 RC outpatient 194 194 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES HDHP [308136802] 155.2 percent of total billed charges 120.28 184.3 Technical (Hospital) Services Mod Sed Same Phys/Qhp Initial 15 Mins 5/> Yrs PX-3709915200 CDM 99152 CPT 370 RC outpatient 194 194 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES EPO [308136803] 155.2 percent of total billed charges 120.28 184.3 Technical (Hospital) Services Mod Sed Same Phys/Qhp Initial 15 Mins 5/> Yrs PX-3709915200 CDM 99152 CPT 370 RC outpatient 194 194 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES PPO [308136801] 155.2 percent of total billed charges 120.28 184.3 Technical (Hospital) Services Mod Sed Same Phys/Qhp Initial 15 Mins 5/> Yrs PX-3709915200 CDM 99152 CPT 370 RC outpatient 194 194 MULTIPLAN INC 34080 [3081285] MULTIPLAN INC [308128501] 184.3 percent of total billed charges 120.28 184.3 Technical (Hospital) Services Mod Sed Same Phys/Qhp Initial 15 Mins 5/> Yrs PX-3709915200 CDM 99152 CPT 370 RC outpatient 194 194 CIGNA 62308 [3081051] CIGNA 62308 [308105105] 155.2 percent of total billed charges 120.28 184.3 Technical (Hospital) Services Mod Sed Same Phys/Qhp Initial 15 Mins 5/> Yrs PX-3709915200 CDM 99152 CPT 370 RC outpatient 194 194 CIGNA 62308 [3081051] CIGNA STATE OF WYOMING [308105107] 155.2 percent of total billed charges 120.28 184.3 Technical (Hospital) Services Mod Sed Same Phys/Qhp Initial 15 Mins 5/> Yrs PX-3709915200 CDM 99152 CPT 370 RC outpatient 194 194 MEDICA (COMMERCIAL) 94265 [3081118] MEDICA CLAIMS [308111801] 174.6 percent of total billed charges 120.28 184.3 Technical (Hospital) Services Mod Sed Same Phys/Qhp Initial 15 Mins 5/> Yrs PX-99152 CDM 99152 CPT inpatient 233 233 CIGNA 62308 [3081051] CIGNA 62308 [308105105] 186.4 percent of total billed charges 144.46 221.35 Professional (doctor) services Mod Sed Same Phys/Qhp Initial 15 Mins 5/> Yrs PX-99152 CDM 99152 CPT inpatient 233 233 CIGNA 62308 [3081051] CIGNA STATE OF WYOMING [308105107] 186.4 percent of total billed charges 144.46 221.35 Professional (doctor) services Mod Sed Same Phys/Qhp Initial 15 Mins 5/> Yrs PX-99152 CDM 99152 CPT outpatient 233 233 CIGNA 62308 [3081051] CIGNA 62308 [308105105] 186.4 percent of total billed charges 144.46 221.35 Professional (doctor) services Mod Sed Same Phys/Qhp Initial 15 Mins 5/> Yrs PX-99152 CDM 99152 CPT outpatient 233 233 CIGNA 62308 [3081051] CIGNA STATE OF WYOMING [308105107] 186.4 percent of total billed charges 144.46 221.35 Professional (doctor) services Mod Sed Same Phys/Qhp Initial 15 Mins 5/> Yrs PX-99152 CDM 99152 CPT inpatient 233 233 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES EPO [308136803] 186.4 percent of total billed charges 144.46 221.35 Professional (doctor) services Mod Sed Same Phys/Qhp Initial 15 Mins 5/> Yrs PX-99152 CDM 99152 CPT inpatient 233 233 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES HDHP [308136802] 186.4 percent of total billed charges 144.46 221.35 Professional (doctor) services Mod Sed Same Phys/Qhp Initial 15 Mins 5/> Yrs PX-99152 CDM 99152 CPT inpatient 233 233 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES PPO [308136801] 186.4 percent of total billed charges 144.46 221.35 Professional (doctor) services Mod Sed Same Phys/Qhp Initial 15 Mins 5/> Yrs PX-99152 CDM 99152 CPT outpatient 233 233 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES EPO [308136803] 186.4 percent of total billed charges 144.46 221.35 Professional (doctor) services Mod Sed Same Phys/Qhp Initial 15 Mins 5/> Yrs PX-99152 CDM 99152 CPT outpatient 233 233 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES HDHP [308136802] 186.4 percent of total billed charges 144.46 221.35 Professional (doctor) services Mod Sed Same Phys/Qhp Initial 15 Mins 5/> Yrs PX-99152 CDM 99152 CPT outpatient 233 233 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES PPO [308136801] 186.4 percent of total billed charges 144.46 221.35 Professional (doctor) services Mod Sed Same Phys/Qhp Initial 15 Mins 5/> Yrs PX-99152 CDM 99152 CPT inpatient 233 233 HEALTHPARTNERS SX009 HEALTHPARTNERS 186.4 percent of total billed charges 144.46 221.35 Professional (doctor) services Mod Sed Same Phys/Qhp Initial 15 Mins 5/> Yrs PX-99152 CDM 99152 CPT outpatient 233 233 HEALTHPARTNERS SX009 HEALTHPARTNERS 186.4 percent of total billed charges 144.46 221.35 Professional (doctor) services Mod Sed Same Phys/Qhp Initial 15 Mins 5/> Yrs PX-99152 CDM 99152 CPT inpatient 233 233 MEDICA (COMMERCIAL) 94265 [3081118] MEDICA CLAIMS [308111801] 209.7 percent of total billed charges 144.46 221.35 Professional (doctor) services Mod Sed Same Phys/Qhp Initial 15 Mins 5/> Yrs PX-99152 CDM 99152 CPT outpatient 233 233 MEDICA (COMMERCIAL) 94265 [3081118] MEDICA CLAIMS [308111801] 209.7 percent of total billed charges 144.46 221.35 Professional (doctor) services Mod Sed Same Phys/Qhp Initial 15 Mins 5/> Yrs PX-99152 CDM 99152 CPT inpatient 233 233 MULTIPLAN INC 34080 [3081285] MULTIPLAN INC [308128501] 221.35 percent of total billed charges 144.46 221.35 Professional (doctor) services Mod Sed Same Phys/Qhp Initial 15 Mins 5/> Yrs PX-99152 CDM 99152 CPT outpatient 233 233 MULTIPLAN INC 34080 [3081285] MULTIPLAN INC [308128501] 221.35 percent of total billed charges 144.46 221.35 Professional (doctor) services Mod Sed Same Phys/Qhp Initial 15 Mins 5/> Yrs PX-99152 CDM 99152 CPT inpatient 233 233 UNITED HEALTHCARE (COMMERCIAL) [3081199] UNITED HEALTHCARE 87726 [308119901] 144.46 percent of total billed charges 144.46 221.35 Professional (doctor) services Mod Sed Same Phys/Qhp Initial 15 Mins 5/> Yrs PX-99152 CDM 99152 CPT outpatient 233 233 UNITED HEALTHCARE (COMMERCIAL) [3081199] UNITED HEALTHCARE 87726 [308119901] 144.46 percent of total billed charges 144.46 221.35 Professional (doctor) services Mod Sed Same Phys/Qhp Initial 15 Mins <5 Yrs PX-99151 CDM 99151 CPT inpatient 124 124 CIGNA 62308 [3081051] CIGNA 62308 [308105105] 99.2 percent of total billed charges 76.88 117.8 Professional (doctor) services Mod Sed Same Phys/Qhp Initial 15 Mins <5 Yrs PX-99151 CDM 99151 CPT inpatient 124 124 CIGNA 62308 [3081051] CIGNA STATE OF WYOMING [308105107] 99.2 percent of total billed charges 76.88 117.8 Professional (doctor) services Mod Sed Same Phys/Qhp Initial 15 Mins <5 Yrs PX-99151 CDM 99151 CPT outpatient 124 124 CIGNA 62308 [3081051] CIGNA 62308 [308105105] 99.2 percent of total billed charges 76.88 117.8 Professional (doctor) services Mod Sed Same Phys/Qhp Initial 15 Mins <5 Yrs PX-99151 CDM 99151 CPT outpatient 124 124 CIGNA 62308 [3081051] CIGNA STATE OF WYOMING [308105107] 99.2 percent of total billed charges 76.88 117.8 Professional (doctor) services Mod Sed Same Phys/Qhp Initial 15 Mins <5 Yrs PX-99151 CDM 99151 CPT inpatient 124 124 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES EPO [308136803] 99.2 percent of total billed charges 76.88 117.8 Professional (doctor) services Mod Sed Same Phys/Qhp Initial 15 Mins <5 Yrs PX-99151 CDM 99151 CPT inpatient 124 124 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES HDHP [308136802] 99.2 percent of total billed charges 76.88 117.8 Professional (doctor) services Mod Sed Same Phys/Qhp Initial 15 Mins <5 Yrs PX-99151 CDM 99151 CPT inpatient 124 124 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES PPO [308136801] 99.2 percent of total billed charges 76.88 117.8 Professional (doctor) services Mod Sed Same Phys/Qhp Initial 15 Mins <5 Yrs PX-99151 CDM 99151 CPT outpatient 124 124 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES EPO [308136803] 99.2 percent of total billed charges 76.88 117.8 Professional (doctor) services Mod Sed Same Phys/Qhp Initial 15 Mins <5 Yrs PX-99151 CDM 99151 CPT outpatient 124 124 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES HDHP [308136802] 99.2 percent of total billed charges 76.88 117.8 Professional (doctor) services Mod Sed Same Phys/Qhp Initial 15 Mins <5 Yrs PX-99151 CDM 99151 CPT outpatient 124 124 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES PPO [308136801] 99.2 percent of total billed charges 76.88 117.8 Professional (doctor) services Mod Sed Same Phys/Qhp Initial 15 Mins <5 Yrs PX-99151 CDM 99151 CPT inpatient 124 124 HEALTHPARTNERS SX009 HEALTHPARTNERS 99.2 percent of total billed charges 76.88 117.8 Professional (doctor) services Mod Sed Same Phys/Qhp Initial 15 Mins <5 Yrs PX-99151 CDM 99151 CPT outpatient 124 124 HEALTHPARTNERS SX009 HEALTHPARTNERS 99.2 percent of total billed charges 76.88 117.8 Professional (doctor) services Mod Sed Same Phys/Qhp Initial 15 Mins <5 Yrs PX-99151 CDM 99151 CPT inpatient 124 124 MEDICA (COMMERCIAL) 94265 [3081118] MEDICA CLAIMS [308111801] 111.6 percent of total billed charges 76.88 117.8 Professional (doctor) services Mod Sed Same Phys/Qhp Initial 15 Mins <5 Yrs PX-99151 CDM 99151 CPT outpatient 124 124 MEDICA (COMMERCIAL) 94265 [3081118] MEDICA CLAIMS [308111801] 111.6 percent of total billed charges 76.88 117.8 Professional (doctor) services Mod Sed Same Phys/Qhp Initial 15 Mins <5 Yrs PX-99151 CDM 99151 CPT inpatient 124 124 MULTIPLAN INC 34080 [3081285] MULTIPLAN INC [308128501] 117.8 percent of total billed charges 76.88 117.8 Professional (doctor) services Mod Sed Same Phys/Qhp Initial 15 Mins <5 Yrs PX-99151 CDM 99151 CPT outpatient 124 124 MULTIPLAN INC 34080 [3081285] MULTIPLAN INC [308128501] 117.8 percent of total billed charges 76.88 117.8 Professional (doctor) services Mod Sed Same Phys/Qhp Initial 15 Mins <5 Yrs PX-99151 CDM 99151 CPT inpatient 124 124 UNITED HEALTHCARE (COMMERCIAL) [3081199] UNITED HEALTHCARE 87726 [308119901] 76.88 percent of total billed charges 76.88 117.8 Professional (doctor) services Mod Sed Same Phys/Qhp Initial 15 Mins <5 Yrs PX-99151 CDM 99151 CPT outpatient 124 124 UNITED HEALTHCARE (COMMERCIAL) [3081199] UNITED HEALTHCARE 87726 [308119901] 76.88 percent of total billed charges 76.88 117.8 Professional (doctor) services Handling or Conveyance Spec PX-3009900100 CDM 99001 CPT 300 RC inpatient 63 63 CIGNA 62308 [3081051] CIGNA 62308 [308105105] 49.88 percent of total billed charges 39.06 59.85 Technical (Hospital) Services Handling or Conveyance Spec PX-3009900100 CDM 99001 CPT 300 RC inpatient 63 63 CIGNA 62308 [3081051] CIGNA STATE OF WYOMING [308105107] 49.88 percent of total billed charges 39.06 59.85 Technical (Hospital) Services Handling or Conveyance Spec PX-3009900100 CDM 99001 CPT 300 RC inpatient 63 63 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES EPO [308136803] 49.88 percent of total billed charges 39.06 59.85 Technical (Hospital) Services Handling or Conveyance Spec PX-3009900100 CDM 99001 CPT 300 RC inpatient 63 63 HEALTHPARTNERS SX009 HEALTHPARTNERS 49.88 percent of total billed charges 39.06 59.85 Technical (Hospital) Services Handling or Conveyance Spec PX-3009900100 CDM 99001 CPT 300 RC inpatient 63 63 MEDICA (COMMERCIAL) 94265 [3081118] MEDICA CLAIMS [308111801] 56.7 percent of total billed charges 39.06 59.85 Technical (Hospital) Services Handling or Conveyance Spec PX-3009900100 CDM 99001 CPT 300 RC inpatient 63 63 MULTIPLAN INC 34080 [3081285] MULTIPLAN INC [308128501] 59.85 percent of total billed charges 39.06 59.85 Technical (Hospital) Services Handling or Conveyance Spec PX-3009900100 CDM 99001 CPT 300 RC inpatient 63 63 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES HDHP [308136802] 49.88 percent of total billed charges 39.06 59.85 Technical (Hospital) Services Handling or Conveyance Spec PX-3009900100 CDM 99001 CPT 300 RC inpatient 63 63 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES PPO [308136801] 49.88 percent of total billed charges 39.06 59.85 Technical (Hospital) Services Handling or Conveyance Spec PX-3009900100 CDM 99001 CPT 300 RC inpatient 63 63 UNITED HEALTHCARE (COMMERCIAL) [3081199] UNITED HEALTHCARE 87726 [308119901] 39.06 percent of total billed charges 39.06 59.85 Technical (Hospital) Services Handling or Conveyance Spec PX-3009900100 CDM 99001 CPT 300 RC inpatient 63 63 BLUE CROSS BLUE SHIELD WELLMARK SB889 [3081026] BCBS WYOMING [308102603] 59.85 percent of total billed charges 39.06 59.85 Technical (Hospital) Services Handling or Conveyance Spec PX-3009900100 CDM 99001 CPT 300 RC outpatient 63 63 MULTIPLAN INC 34080 [3081285] MULTIPLAN INC [308128501] 59.85 percent of total billed charges 39.06 59.85 Technical (Hospital) Services Handling or Conveyance Spec PX-3009900100 CDM 99001 CPT 300 RC outpatient 63 63 MEDICA (COMMERCIAL) 94265 [3081118] MEDICA CLAIMS [308111801] 56.7 percent of total billed charges 39.06 59.85 Technical (Hospital) Services Handling or Conveyance Spec PX-3009900100 CDM 99001 CPT 300 RC outpatient 63 63 CIGNA 62308 [3081051] CIGNA 62308 [308105105] 50.4 percent of total billed charges 39.06 59.85 Technical (Hospital) Services Handling or Conveyance Spec PX-3009900100 CDM 99001 CPT 300 RC outpatient 63 63 CIGNA 62308 [3081051] CIGNA STATE OF WYOMING [308105107] 50.4 percent of total billed charges 39.06 59.85 Technical (Hospital) Services Handling or Conveyance Spec PX-3009900100 CDM 99001 CPT 300 RC outpatient 63 63 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES HDHP [308136802] 50.4 percent of total billed charges 39.06 59.85 Technical (Hospital) Services Handling or Conveyance Spec PX-3009900100 CDM 99001 CPT 300 RC outpatient 63 63 BLUE CROSS BLUE SHIELD WELLMARK SB889 [3081026] BCBS WYOMING [308102603] 59.85 percent of total billed charges 39.06 59.85 Technical (Hospital) Services Handling or Conveyance Spec PX-3009900100 CDM 99001 CPT 300 RC outpatient 63 63 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES EPO [308136803] 50.4 percent of total billed charges 39.06 59.85 Technical (Hospital) Services Handling or Conveyance Spec PX-3009900100 CDM 99001 CPT 300 RC outpatient 63 63 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES PPO [308136801] 50.4 percent of total billed charges 39.06 59.85 Technical (Hospital) Services Handling or Conveyance Spec PX-3009900100 CDM 99001 CPT 300 RC outpatient 63 63 UNITED HEALTHCARE (COMMERCIAL) [3081199] UNITED HEALTHCARE 87726 [308119901] 39.06 percent of total billed charges 39.06 59.85 Technical (Hospital) Services Handling or Conveyance Spec PX-3009900100 CDM 99001 CPT 300 RC outpatient 63 63 HEALTHPARTNERS SX009 HEALTHPARTNERS 50.4 percent of total billed charges 39.06 59.85 Technical (Hospital) Services Handling of Specimen PX-3009900000 CDM 99000 CPT 300 RC inpatient 79 79 BLUE CROSS BLUE SHIELD WELLMARK SB889 [3081026] BCBS WYOMING [308102603] 75.05 percent of total billed charges 48.98 75.05 Technical (Hospital) Services Handling of Specimen PX-3009900000 CDM 99000 CPT 300 RC inpatient 79 79 UNITED HEALTHCARE (COMMERCIAL) [3081199] UNITED HEALTHCARE 87726 [308119901] 48.98 percent of total billed charges 48.98 75.05 Technical (Hospital) Services Handling of Specimen PX-3009900000 CDM 99000 CPT 300 RC inpatient 79 79 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES PPO [308136801] 62.55 percent of total billed charges 48.98 75.05 Technical (Hospital) Services Handling of Specimen PX-3009900000 CDM 99000 CPT 300 RC inpatient 79 79 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES HDHP [308136802] 62.55 percent of total billed charges 48.98 75.05 Technical (Hospital) Services Handling of Specimen PX-3009900000 CDM 99000 CPT 300 RC inpatient 79 79 MULTIPLAN INC 34080 [3081285] MULTIPLAN INC [308128501] 75.05 percent of total billed charges 48.98 75.05 Technical (Hospital) Services Handling of Specimen PX-3009900000 CDM 99000 CPT 300 RC inpatient 79 79 MEDICA (COMMERCIAL) 94265 [3081118] MEDICA CLAIMS [308111801] 71.1 percent of total billed charges 48.98 75.05 Technical (Hospital) Services Handling of Specimen PX-3009900000 CDM 99000 CPT 300 RC inpatient 79 79 HEALTHPARTNERS SX009 HEALTHPARTNERS 62.55 percent of total billed charges 48.98 75.05 Technical (Hospital) Services Handling of Specimen PX-3009900000 CDM 99000 CPT 300 RC inpatient 79 79 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES EPO [308136803] 62.55 percent of total billed charges 48.98 75.05 Technical (Hospital) Services Handling of Specimen PX-3009900000 CDM 99000 CPT 300 RC inpatient 79 79 CIGNA 62308 [3081051] CIGNA 62308 [308105105] 62.55 percent of total billed charges 48.98 75.05 Technical (Hospital) Services Handling of Specimen PX-3009900000 CDM 99000 CPT 300 RC inpatient 79 79 CIGNA 62308 [3081051] CIGNA STATE OF WYOMING [308105107] 62.55 percent of total billed charges 48.98 75.05 Technical (Hospital) Services Handling of Specimen PX-3009900000 CDM 99000 CPT 300 RC outpatient 79 79 HEALTHPARTNERS SX009 HEALTHPARTNERS 63.2 percent of total billed charges 48.98 75.05 Technical (Hospital) Services Handling of Specimen PX-3009900000 CDM 99000 CPT 300 RC outpatient 79 79 UNITED HEALTHCARE (COMMERCIAL) [3081199] UNITED HEALTHCARE 87726 [308119901] 48.98 percent of total billed charges 48.98 75.05 Technical (Hospital) Services Handling of Specimen PX-3009900000 CDM 99000 CPT 300 RC outpatient 79 79 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES PPO [308136801] 63.2 percent of total billed charges 48.98 75.05 Technical (Hospital) Services Handling of Specimen PX-3009900000 CDM 99000 CPT 300 RC outpatient 79 79 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES EPO [308136803] 63.2 percent of total billed charges 48.98 75.05 Technical (Hospital) Services Handling of Specimen PX-3009900000 CDM 99000 CPT 300 RC outpatient 79 79 BLUE CROSS BLUE SHIELD WELLMARK SB889 [3081026] BCBS WYOMING [308102603] 75.05 percent of total billed charges 48.98 75.05 Technical (Hospital) Services Handling of Specimen PX-3009900000 CDM 99000 CPT 300 RC outpatient 79 79 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES HDHP [308136802] 63.2 percent of total billed charges 48.98 75.05 Technical (Hospital) Services Handling of Specimen PX-3009900000 CDM 99000 CPT 300 RC outpatient 79 79 CIGNA 62308 [3081051] CIGNA 62308 [308105105] 63.2 percent of total billed charges 48.98 75.05 Technical (Hospital) Services Handling of Specimen PX-3009900000 CDM 99000 CPT 300 RC outpatient 79 79 CIGNA 62308 [3081051] CIGNA STATE OF WYOMING [308105107] 63.2 percent of total billed charges 48.98 75.05 Technical (Hospital) Services Handling of Specimen PX-3009900000 CDM 99000 CPT 300 RC outpatient 79 79 MEDICA (COMMERCIAL) 94265 [3081118] MEDICA CLAIMS [308111801] 71.1 percent of total billed charges 48.98 75.05 Technical (Hospital) Services Handling of Specimen PX-3009900000 CDM 99000 CPT 300 RC outpatient 79 79 MULTIPLAN INC 34080 [3081285] MULTIPLAN INC [308128501] 75.05 percent of total billed charges 48.98 75.05 Technical (Hospital) Services Workplace Urine Drug Screen Collection Only PX-3009900001 CDM 99000 CPT 300 RC inpatient 50 50 HEALTHPARTNERS SX009 HEALTHPARTNERS 39.59 percent of total billed charges 31 47.5 Technical (Hospital) Services Workplace Urine Drug Screen Collection Only PX-3009900001 CDM 99000 CPT 300 RC inpatient 50 50 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES EPO [308136803] 39.59 percent of total billed charges 31 47.5 Technical (Hospital) Services Workplace Urine Drug Screen Collection Only PX-3009900001 CDM 99000 CPT 300 RC inpatient 50 50 MEDICA (COMMERCIAL) 94265 [3081118] MEDICA CLAIMS [308111801] 45 percent of total billed charges 31 47.5 Technical (Hospital) Services Workplace Urine Drug Screen Collection Only PX-3009900001 CDM 99000 CPT 300 RC inpatient 50 50 MULTIPLAN INC 34080 [3081285] MULTIPLAN INC [308128501] 47.5 percent of total billed charges 31 47.5 Technical (Hospital) Services Workplace Urine Drug Screen Collection Only PX-3009900001 CDM 99000 CPT 300 RC inpatient 50 50 UNITED HEALTHCARE (COMMERCIAL) [3081199] UNITED HEALTHCARE 87726 [308119901] 31 percent of total billed charges 31 47.5 Technical (Hospital) Services Workplace Urine Drug Screen Collection Only PX-3009900001 CDM 99000 CPT 300 RC inpatient 50 50 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES PPO [308136801] 39.59 percent of total billed charges 31 47.5 Technical (Hospital) Services Workplace Urine Drug Screen Collection Only PX-3009900001 CDM 99000 CPT 300 RC inpatient 50 50 BLUE CROSS BLUE SHIELD WELLMARK SB889 [3081026] BCBS WYOMING [308102603] 47.5 percent of total billed charges 31 47.5 Technical (Hospital) Services Workplace Urine Drug Screen Collection Only PX-3009900001 CDM 99000 CPT 300 RC inpatient 50 50 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES HDHP [308136802] 39.59 percent of total billed charges 31 47.5 Technical (Hospital) Services Workplace Urine Drug Screen Collection Only PX-3009900001 CDM 99000 CPT 300 RC inpatient 50 50 CIGNA 62308 [3081051] CIGNA 62308 [308105105] 39.59 percent of total billed charges 31 47.5 Technical (Hospital) Services Workplace Urine Drug Screen Collection Only PX-3009900001 CDM 99000 CPT 300 RC inpatient 50 50 CIGNA 62308 [3081051] CIGNA STATE OF WYOMING [308105107] 39.59 percent of total billed charges 31 47.5 Technical (Hospital) Services Workplace Urine Drug Screen Collection Only PX-3009900001 CDM 99000 CPT 300 RC outpatient 50 50 UNITED HEALTHCARE (COMMERCIAL) [3081199] UNITED HEALTHCARE 87726 [308119901] 31 percent of total billed charges 31 47.5 Technical (Hospital) Services Workplace Urine Drug Screen Collection Only PX-3009900001 CDM 99000 CPT 300 RC outpatient 50 50 HEALTHPARTNERS SX009 HEALTHPARTNERS 40 percent of total billed charges 31 47.5 Technical (Hospital) Services Workplace Urine Drug Screen Collection Only PX-3009900001 CDM 99000 CPT 300 RC outpatient 50 50 BLUE CROSS BLUE SHIELD WELLMARK SB889 [3081026] BCBS WYOMING [308102603] 47.5 percent of total billed charges 31 47.5 Technical (Hospital) Services Workplace Urine Drug Screen Collection Only PX-3009900001 CDM 99000 CPT 300 RC outpatient 50 50 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES HDHP [308136802] 40 percent of total billed charges 31 47.5 Technical (Hospital) Services Workplace Urine Drug Screen Collection Only PX-3009900001 CDM 99000 CPT 300 RC outpatient 50 50 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES PPO [308136801] 40 percent of total billed charges 31 47.5 Technical (Hospital) Services Workplace Urine Drug Screen Collection Only PX-3009900001 CDM 99000 CPT 300 RC outpatient 50 50 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES EPO [308136803] 40 percent of total billed charges 31 47.5 Technical (Hospital) Services Workplace Urine Drug Screen Collection Only PX-3009900001 CDM 99000 CPT 300 RC outpatient 50 50 CIGNA 62308 [3081051] CIGNA 62308 [308105105] 40 percent of total billed charges 31 47.5 Technical (Hospital) Services Workplace Urine Drug Screen Collection Only PX-3009900001 CDM 99000 CPT 300 RC outpatient 50 50 CIGNA 62308 [3081051] CIGNA STATE OF WYOMING [308105107] 40 percent of total billed charges 31 47.5 Technical (Hospital) Services Workplace Urine Drug Screen Collection Only PX-3009900001 CDM 99000 CPT 300 RC outpatient 50 50 MULTIPLAN INC 34080 [3081285] MULTIPLAN INC [308128501] 47.5 percent of total billed charges 31 47.5 Technical (Hospital) Services Workplace Urine Drug Screen Collection Only PX-3009900001 CDM 99000 CPT 300 RC outpatient 50 50 MEDICA (COMMERCIAL) 94265 [3081118] MEDICA CLAIMS [308111801] 45 percent of total billed charges 31 47.5 Technical (Hospital) Services Legal Blood Draw PX-3009900002 CDM 99000 CPT 300 RC outpatient 25 25 MULTIPLAN INC 34080 [3081285] MULTIPLAN INC [308128501] 23.75 percent of total billed charges 15.5 23.75 Technical (Hospital) Services Legal Blood Draw PX-3009900002 CDM 99000 CPT 300 RC outpatient 25 25 CIGNA 62308 [3081051] CIGNA 62308 [308105105] 20 percent of total billed charges 15.5 23.75 Technical (Hospital) Services Legal Blood Draw PX-3009900002 CDM 99000 CPT 300 RC outpatient 25 25 CIGNA 62308 [3081051] CIGNA STATE OF WYOMING [308105107] 20 percent of total billed charges 15.5 23.75 Technical (Hospital) Services Legal Blood Draw PX-3009900002 CDM 99000 CPT 300 RC outpatient 25 25 HEALTHPARTNERS SX009 HEALTHPARTNERS 20 percent of total billed charges 15.5 23.75 Technical (Hospital) Services Legal Blood Draw PX-3009900002 CDM 99000 CPT 300 RC outpatient 25 25 MEDICA (COMMERCIAL) 94265 [3081118] MEDICA CLAIMS [308111801] 22.5 percent of total billed charges 15.5 23.75 Technical (Hospital) Services Legal Blood Draw PX-3009900002 CDM 99000 CPT 300 RC outpatient 25 25 UNITED HEALTHCARE (COMMERCIAL) [3081199] UNITED HEALTHCARE 87726 [308119901] 15.5 percent of total billed charges 15.5 23.75 Technical (Hospital) Services Legal Blood Draw PX-3009900002 CDM 99000 CPT 300 RC outpatient 25 25 BLUE CROSS BLUE SHIELD WELLMARK SB889 [3081026] BCBS WYOMING [308102603] 23.75 percent of total billed charges 15.5 23.75 Technical (Hospital) Services Legal Blood Draw PX-3009900002 CDM 99000 CPT 300 RC outpatient 25 25 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES HDHP [308136802] 20 percent of total billed charges 15.5 23.75 Technical (Hospital) Services Legal Blood Draw PX-3009900002 CDM 99000 CPT 300 RC outpatient 25 25 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES EPO [308136803] 20 percent of total billed charges 15.5 23.75 Technical (Hospital) Services Legal Blood Draw PX-3009900002 CDM 99000 CPT 300 RC outpatient 25 25 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES PPO [308136801] 20 percent of total billed charges 15.5 23.75 Technical (Hospital) Services Legal Blood Draw PX-3009900002 CDM 99000 CPT 300 RC inpatient 25 25 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES EPO [308136803] 19.8 percent of total billed charges 15.5 23.75 Technical (Hospital) Services Legal Blood Draw PX-3009900002 CDM 99000 CPT 300 RC inpatient 25 25 CIGNA 62308 [3081051] CIGNA 62308 [308105105] 19.8 percent of total billed charges 15.5 23.75 Technical (Hospital) Services Legal Blood Draw PX-3009900002 CDM 99000 CPT 300 RC inpatient 25 25 CIGNA 62308 [3081051] CIGNA STATE OF WYOMING [308105107] 19.8 percent of total billed charges 15.5 23.75 Technical (Hospital) Services Legal Blood Draw PX-3009900002 CDM 99000 CPT 300 RC inpatient 25 25 UNITED HEALTHCARE (COMMERCIAL) [3081199] UNITED HEALTHCARE 87726 [308119901] 15.5 percent of total billed charges 15.5 23.75 Technical (Hospital) Services Legal Blood Draw PX-3009900002 CDM 99000 CPT 300 RC inpatient 25 25 BLUE CROSS BLUE SHIELD WELLMARK SB889 [3081026] BCBS WYOMING [308102603] 23.75 percent of total billed charges 15.5 23.75 Technical (Hospital) Services Legal Blood Draw PX-3009900002 CDM 99000 CPT 300 RC inpatient 25 25 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES PPO [308136801] 19.8 percent of total billed charges 15.5 23.75 Technical (Hospital) Services Legal Blood Draw PX-3009900002 CDM 99000 CPT 300 RC inpatient 25 25 HEALTHPARTNERS SX009 HEALTHPARTNERS 19.8 percent of total billed charges 15.5 23.75 Technical (Hospital) Services Legal Blood Draw PX-3009900002 CDM 99000 CPT 300 RC inpatient 25 25 MULTIPLAN INC 34080 [3081285] MULTIPLAN INC [308128501] 23.75 percent of total billed charges 15.5 23.75 Technical (Hospital) Services Legal Blood Draw PX-3009900002 CDM 99000 CPT 300 RC inpatient 25 25 MEDICA (COMMERCIAL) 94265 [3081118] MEDICA CLAIMS [308111801] 22.5 percent of total billed charges 15.5 23.75 Technical (Hospital) Services Legal Blood Draw PX-3009900002 CDM 99000 CPT 300 RC inpatient 25 25 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES HDHP [308136802] 19.8 percent of total billed charges 15.5 23.75 Technical (Hospital) Services Education&Training Self-Mgmt Nonphys 1 Pt PX-9429896000 CDM 98960 CPT 942 RC inpatient 116 116 MULTIPLAN INC 34080 [3081285] MULTIPLAN INC [308128501] 110.2 percent of total billed charges 71.92 110.2 Technical (Hospital) Services Education&Training Self-Mgmt Nonphys 1 Pt PX-9429896000 CDM 98960 CPT 942 RC inpatient 116 116 MEDICA (COMMERCIAL) 94265 [3081118] MEDICA CLAIMS [308111801] 104.4 percent of total billed charges 71.92 110.2 Technical (Hospital) Services Education&Training Self-Mgmt Nonphys 1 Pt PX-9429896000 CDM 98960 CPT 942 RC inpatient 116 116 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES HDHP [308136802] 91.85 percent of total billed charges 71.92 110.2 Technical (Hospital) Services Education&Training Self-Mgmt Nonphys 1 Pt PX-9429896000 CDM 98960 CPT 942 RC inpatient 116 116 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES EPO [308136803] 91.85 percent of total billed charges 71.92 110.2 Technical (Hospital) Services Education&Training Self-Mgmt Nonphys 1 Pt PX-9429896000 CDM 98960 CPT 942 RC inpatient 116 116 HEALTHPARTNERS SX009 HEALTHPARTNERS 91.85 percent of total billed charges 71.92 110.2 Technical (Hospital) Services Education&Training Self-Mgmt Nonphys 1 Pt PX-9429896000 CDM 98960 CPT 942 RC inpatient 116 116 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES PPO [308136801] 91.85 percent of total billed charges 71.92 110.2 Technical (Hospital) Services Education&Training Self-Mgmt Nonphys 1 Pt PX-9429896000 CDM 98960 CPT 942 RC inpatient 116 116 UNITED HEALTHCARE (COMMERCIAL) [3081199] UNITED HEALTHCARE 87726 [308119901] 71.92 percent of total billed charges 71.92 110.2 Technical (Hospital) Services Education&Training Self-Mgmt Nonphys 1 Pt PX-9429896000 CDM 98960 CPT 942 RC inpatient 116 116 BLUE CROSS BLUE SHIELD WELLMARK SB889 [3081026] BCBS WYOMING [308102603] 110.2 percent of total billed charges 71.92 110.2 Technical (Hospital) Services Education&Training Self-Mgmt Nonphys 1 Pt PX-9429896000 CDM 98960 CPT 942 RC inpatient 116 116 CIGNA 62308 [3081051] CIGNA 62308 [308105105] 91.85 percent of total billed charges 71.92 110.2 Technical (Hospital) Services Education&Training Self-Mgmt Nonphys 1 Pt PX-9429896000 CDM 98960 CPT 942 RC inpatient 116 116 CIGNA 62308 [3081051] CIGNA STATE OF WYOMING [308105107] 91.85 percent of total billed charges 71.92 110.2 Technical (Hospital) Services Education&Training Self-Mgmt Nonphys 1 Pt PX-9429896000 CDM 98960 CPT 942 RC outpatient 116 116 CIGNA 62308 [3081051] CIGNA 62308 [308105105] 92.8 percent of total billed charges 71.92 110.2 Technical (Hospital) Services Education&Training Self-Mgmt Nonphys 1 Pt PX-9429896000 CDM 98960 CPT 942 RC outpatient 116 116 CIGNA 62308 [3081051] CIGNA STATE OF WYOMING [308105107] 92.8 percent of total billed charges 71.92 110.2 Technical (Hospital) Services Education&Training Self-Mgmt Nonphys 1 Pt PX-9429896000 CDM 98960 CPT 942 RC outpatient 116 116 MULTIPLAN INC 34080 [3081285] MULTIPLAN INC [308128501] 110.2 percent of total billed charges 71.92 110.2 Technical (Hospital) Services Education&Training Self-Mgmt Nonphys 1 Pt PX-9429896000 CDM 98960 CPT 942 RC outpatient 116 116 MEDICA (COMMERCIAL) 94265 [3081118] MEDICA CLAIMS [308111801] 104.4 percent of total billed charges 71.92 110.2 Technical (Hospital) Services Education&Training Self-Mgmt Nonphys 1 Pt PX-9429896000 CDM 98960 CPT 942 RC outpatient 116 116 HEALTHPARTNERS SX009 HEALTHPARTNERS 92.8 percent of total billed charges 71.92 110.2 Technical (Hospital) Services Education&Training Self-Mgmt Nonphys 1 Pt PX-9429896000 CDM 98960 CPT 942 RC outpatient 116 116 UNITED HEALTHCARE (COMMERCIAL) [3081199] UNITED HEALTHCARE 87726 [308119901] 71.92 percent of total billed charges 71.92 110.2 Technical (Hospital) Services Education&Training Self-Mgmt Nonphys 1 Pt PX-9429896000 CDM 98960 CPT 942 RC outpatient 116 116 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES HDHP [308136802] 92.8 percent of total billed charges 71.92 110.2 Technical (Hospital) Services Education&Training Self-Mgmt Nonphys 1 Pt PX-9429896000 CDM 98960 CPT 942 RC outpatient 116 116 BLUE CROSS BLUE SHIELD WELLMARK SB889 [3081026] BCBS WYOMING [308102603] 110.2 percent of total billed charges 71.92 110.2 Technical (Hospital) Services Education&Training Self-Mgmt Nonphys 1 Pt PX-9429896000 CDM 98960 CPT 942 RC outpatient 116 116 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES EPO [308136803] 92.8 percent of total billed charges 71.92 110.2 Technical (Hospital) Services Education&Training Self-Mgmt Nonphys 1 Pt PX-9429896000 CDM 98960 CPT 942 RC outpatient 116 116 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES PPO [308136801] 92.8 percent of total billed charges 71.92 110.2 Technical (Hospital) Services Orthotics/Prosth Mgmt &/Trainj Sbsq Enctr 15 Min PX-4309776300 CDM 97763 CPT 430 RC outpatient 165 165 MULTIPLAN INC 34080 [3081285] MULTIPLAN INC [308128501] 156.75 percent of total billed charges 102.3 156.75 Technical (Hospital) Services Orthotics/Prosth Mgmt &/Trainj Sbsq Enctr 15 Min PX-4309776300 CDM 97763 CPT 430 RC outpatient 165 165 CIGNA 62308 [3081051] CIGNA 62308 [308105105] 132 percent of total billed charges 102.3 156.75 Technical (Hospital) Services Orthotics/Prosth Mgmt &/Trainj Sbsq Enctr 15 Min PX-4309776300 CDM 97763 CPT 430 RC outpatient 165 165 CIGNA 62308 [3081051] CIGNA STATE OF WYOMING [308105107] 132 percent of total billed charges 102.3 156.75 Technical (Hospital) Services Orthotics/Prosth Mgmt &/Trainj Sbsq Enctr 15 Min PX-4309776300 CDM 97763 CPT 430 RC outpatient 165 165 MEDICA (COMMERCIAL) 94265 [3081118] MEDICA CLAIMS [308111801] 148.5 percent of total billed charges 102.3 156.75 Technical (Hospital) Services Orthotics/Prosth Mgmt &/Trainj Sbsq Enctr 15 Min PX-4309776300 CDM 97763 CPT 430 RC outpatient 165 165 UNITED HEALTHCARE (COMMERCIAL) [3081199] UNITED HEALTHCARE 87726 [308119901] 102.3 percent of total billed charges 102.3 156.75 Technical (Hospital) Services Orthotics/Prosth Mgmt &/Trainj Sbsq Enctr 15 Min PX-4309776300 CDM 97763 CPT 430 RC outpatient 165 165 HEALTHPARTNERS SX009 HEALTHPARTNERS 132 percent of total billed charges 102.3 156.75 Technical (Hospital) Services Orthotics/Prosth Mgmt &/Trainj Sbsq Enctr 15 Min PX-4309776300 CDM 97763 CPT 430 RC outpatient 165 165 BLUE CROSS BLUE SHIELD WELLMARK SB889 [3081026] BCBS WYOMING [308102603] 156.75 percent of total billed charges 102.3 156.75 Technical (Hospital) Services Orthotics/Prosth Mgmt &/Trainj Sbsq Enctr 15 Min PX-4309776300 CDM 97763 CPT 430 RC outpatient 165 165 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES HDHP [308136802] 132 percent of total billed charges 102.3 156.75 Technical (Hospital) Services Orthotics/Prosth Mgmt &/Trainj Sbsq Enctr 15 Min PX-4309776300 CDM 97763 CPT 430 RC outpatient 165 165 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES PPO [308136801] 132 percent of total billed charges 102.3 156.75 Technical (Hospital) Services Orthotics/Prosth Mgmt &/Trainj Sbsq Enctr 15 Min PX-4309776300 CDM 97763 CPT 430 RC outpatient 165 165 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES EPO [308136803] 132 percent of total billed charges 102.3 156.75 Technical (Hospital) Services Orthotics/Prosth Mgmt &/Trainj Sbsq Enctr 15 Min PX-4309776300 CDM 97763 CPT 430 RC inpatient 165 165 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES HDHP [308136802] 130.65 percent of total billed charges 102.3 156.75 Technical (Hospital) Services Orthotics/Prosth Mgmt &/Trainj Sbsq Enctr 15 Min PX-4309776300 CDM 97763 CPT 430 RC inpatient 165 165 BLUE CROSS BLUE SHIELD WELLMARK SB889 [3081026] BCBS WYOMING [308102603] 156.75 percent of total billed charges 102.3 156.75 Technical (Hospital) Services Orthotics/Prosth Mgmt &/Trainj Sbsq Enctr 15 Min PX-4309776300 CDM 97763 CPT 430 RC inpatient 165 165 UNITED HEALTHCARE (COMMERCIAL) [3081199] UNITED HEALTHCARE 87726 [308119901] 102.3 percent of total billed charges 102.3 156.75 Technical (Hospital) Services Orthotics/Prosth Mgmt &/Trainj Sbsq Enctr 15 Min PX-4309776300 CDM 97763 CPT 430 RC inpatient 165 165 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES PPO [308136801] 130.65 percent of total billed charges 102.3 156.75 Technical (Hospital) Services Orthotics/Prosth Mgmt &/Trainj Sbsq Enctr 15 Min PX-4309776300 CDM 97763 CPT 430 RC inpatient 165 165 MULTIPLAN INC 34080 [3081285] MULTIPLAN INC [308128501] 156.75 percent of total billed charges 102.3 156.75 Technical (Hospital) Services Orthotics/Prosth Mgmt &/Trainj Sbsq Enctr 15 Min PX-4309776300 CDM 97763 CPT 430 RC inpatient 165 165 MEDICA (COMMERCIAL) 94265 [3081118] MEDICA CLAIMS [308111801] 148.5 percent of total billed charges 102.3 156.75 Technical (Hospital) Services Orthotics/Prosth Mgmt &/Trainj Sbsq Enctr 15 Min PX-4309776300 CDM 97763 CPT 430 RC inpatient 165 165 HEALTHPARTNERS SX009 HEALTHPARTNERS 130.65 percent of total billed charges 102.3 156.75 Technical (Hospital) Services Orthotics/Prosth Mgmt &/Trainj Sbsq Enctr 15 Min PX-4309776300 CDM 97763 CPT 430 RC inpatient 165 165 CIGNA 62308 [3081051] CIGNA 62308 [308105105] 130.65 percent of total billed charges 102.3 156.75 Technical (Hospital) Services Orthotics/Prosth Mgmt &/Trainj Sbsq Enctr 15 Min PX-4309776300 CDM 97763 CPT 430 RC inpatient 165 165 CIGNA 62308 [3081051] CIGNA STATE OF WYOMING [308105107] 130.65 percent of total billed charges 102.3 156.75 Technical (Hospital) Services Orthotics/Prosth Mgmt &/Trainj Sbsq Enctr 15 Min PX-4309776300 CDM 97763 CPT 430 RC inpatient 165 165 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES EPO [308136803] 130.65 percent of total billed charges 102.3 156.75 Technical (Hospital) Services Prosthetic Training Uppr&/Lower Extrem Ea 15 M PX-4209776100 CDM 97761 CPT 420 RC outpatient 181 181 MEDICA (COMMERCIAL) 94265 [3081118] MEDICA CLAIMS [308111801] 162.9 percent of total billed charges 112.22 171.95 Technical (Hospital) Services Prosthetic Training Uppr&/Lower Extrem Ea 15 M PX-4209776100 CDM 97761 CPT 420 RC outpatient 181 181 HEALTHPARTNERS SX009 HEALTHPARTNERS 144.8 percent of total billed charges 112.22 171.95 Technical (Hospital) Services Prosthetic Training Uppr&/Lower Extrem Ea 15 M PX-4209776100 CDM 97761 CPT 420 RC outpatient 181 181 UNITED HEALTHCARE (COMMERCIAL) [3081199] UNITED HEALTHCARE 87726 [308119901] 112.22 percent of total billed charges 112.22 171.95 Technical (Hospital) Services Prosthetic Training Uppr&/Lower Extrem Ea 15 M PX-4209776100 CDM 97761 CPT 420 RC outpatient 181 181 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES PPO [308136801] 144.8 percent of total billed charges 112.22 171.95 Technical (Hospital) Services Prosthetic Training Uppr&/Lower Extrem Ea 15 M PX-4209776100 CDM 97761 CPT 420 RC outpatient 181 181 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES EPO [308136803] 144.8 percent of total billed charges 112.22 171.95 Technical (Hospital) Services Prosthetic Training Uppr&/Lower Extrem Ea 15 M PX-4209776100 CDM 97761 CPT 420 RC outpatient 181 181 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES HDHP [308136802] 144.8 percent of total billed charges 112.22 171.95 Technical (Hospital) Services Prosthetic Training Uppr&/Lower Extrem Ea 15 M PX-4209776100 CDM 97761 CPT 420 RC outpatient 181 181 BLUE CROSS BLUE SHIELD WELLMARK SB889 [3081026] BCBS WYOMING [308102603] 171.95 percent of total billed charges 112.22 171.95 Technical (Hospital) Services Prosthetic Training Uppr&/Lower Extrem Ea 15 M PX-4209776100 CDM 97761 CPT 420 RC outpatient 181 181 MULTIPLAN INC 34080 [3081285] MULTIPLAN INC [308128501] 171.95 percent of total billed charges 112.22 171.95 Technical (Hospital) Services Prosthetic Training Uppr&/Lower Extrem Ea 15 M PX-4209776100 CDM 97761 CPT 420 RC outpatient 181 181 CIGNA 62308 [3081051] CIGNA 62308 [308105105] 144.8 percent of total billed charges 112.22 171.95 Technical (Hospital) Services Prosthetic Training Uppr&/Lower Extrem Ea 15 M PX-4209776100 CDM 97761 CPT 420 RC outpatient 181 181 CIGNA 62308 [3081051] CIGNA STATE OF WYOMING [308105107] 144.8 percent of total billed charges 112.22 171.95 Technical (Hospital) Services Prosthetic Training Uppr&/Lower Extrem Ea 15 M PX-4209776100 CDM 97761 CPT 420 RC inpatient 181 181 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES HDHP [308136802] 143.32 percent of total billed charges 112.22 171.95 Technical (Hospital) Services Prosthetic Training Uppr&/Lower Extrem Ea 15 M PX-4209776100 CDM 97761 CPT 420 RC inpatient 181 181 MEDICA (COMMERCIAL) 94265 [3081118] MEDICA CLAIMS [308111801] 162.9 percent of total billed charges 112.22 171.95 Technical (Hospital) Services Prosthetic Training Uppr&/Lower Extrem Ea 15 M PX-4209776100 CDM 97761 CPT 420 RC inpatient 181 181 MULTIPLAN INC 34080 [3081285] MULTIPLAN INC [308128501] 171.95 percent of total billed charges 112.22 171.95 Technical (Hospital) Services Prosthetic Training Uppr&/Lower Extrem Ea 15 M PX-4209776100 CDM 97761 CPT 420 RC inpatient 181 181 HEALTHPARTNERS SX009 HEALTHPARTNERS 143.32 percent of total billed charges 112.22 171.95 Technical (Hospital) Services Prosthetic Training Uppr&/Lower Extrem Ea 15 M PX-4209776100 CDM 97761 CPT 420 RC inpatient 181 181 BLUE CROSS BLUE SHIELD WELLMARK SB889 [3081026] BCBS WYOMING [308102603] 171.95 percent of total billed charges 112.22 171.95 Technical (Hospital) Services Prosthetic Training Uppr&/Lower Extrem Ea 15 M PX-4209776100 CDM 97761 CPT 420 RC inpatient 181 181 UNITED HEALTHCARE (COMMERCIAL) [3081199] UNITED HEALTHCARE 87726 [308119901] 112.22 percent of total billed charges 112.22 171.95 Technical (Hospital) Services Prosthetic Training Uppr&/Lower Extrem Ea 15 M PX-4209776100 CDM 97761 CPT 420 RC inpatient 181 181 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES PPO [308136801] 143.32 percent of total billed charges 112.22 171.95 Technical (Hospital) Services Prosthetic Training Uppr&/Lower Extrem Ea 15 M PX-4209776100 CDM 97761 CPT 420 RC inpatient 181 181 CIGNA 62308 [3081051] CIGNA 62308 [308105105] 143.32 percent of total billed charges 112.22 171.95 Technical (Hospital) Services Prosthetic Training Uppr&/Lower Extrem Ea 15 M PX-4209776100 CDM 97761 CPT 420 RC inpatient 181 181 CIGNA 62308 [3081051] CIGNA STATE OF WYOMING [308105107] 143.32 percent of total billed charges 112.22 171.95 Technical (Hospital) Services Prosthetic Training Uppr&/Lower Extrem Ea 15 M PX-4209776100 CDM 97761 CPT 420 RC inpatient 181 181 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES EPO [308136803] 143.32 percent of total billed charges 112.22 171.95 Technical (Hospital) Services Prosthetic Training Uppr&/Lower Extrem Ea 15 M PX-4309776100 CDM 97761 CPT 430 RC inpatient 181 181 CIGNA 62308 [3081051] CIGNA 62308 [308105105] 143.32 percent of total billed charges 112.22 171.95 Technical (Hospital) Services Prosthetic Training Uppr&/Lower Extrem Ea 15 M PX-4309776100 CDM 97761 CPT 430 RC inpatient 181 181 CIGNA 62308 [3081051] CIGNA STATE OF WYOMING [308105107] 143.32 percent of total billed charges 112.22 171.95 Technical (Hospital) Services Prosthetic Training Uppr&/Lower Extrem Ea 15 M PX-4309776100 CDM 97761 CPT 430 RC inpatient 181 181 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES EPO [308136803] 143.32 percent of total billed charges 112.22 171.95 Technical (Hospital) Services Prosthetic Training Uppr&/Lower Extrem Ea 15 M PX-4309776100 CDM 97761 CPT 430 RC inpatient 181 181 BLUE CROSS BLUE SHIELD WELLMARK SB889 [3081026] BCBS WYOMING [308102603] 171.95 percent of total billed charges 112.22 171.95 Technical (Hospital) Services Prosthetic Training Uppr&/Lower Extrem Ea 15 M PX-4309776100 CDM 97761 CPT 430 RC inpatient 181 181 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES PPO [308136801] 143.32 percent of total billed charges 112.22 171.95 Technical (Hospital) Services Prosthetic Training Uppr&/Lower Extrem Ea 15 M PX-4309776100 CDM 97761 CPT 430 RC inpatient 181 181 UNITED HEALTHCARE (COMMERCIAL) [3081199] UNITED HEALTHCARE 87726 [308119901] 112.22 percent of total billed charges 112.22 171.95 Technical (Hospital) Services Prosthetic Training Uppr&/Lower Extrem Ea 15 M PX-4309776100 CDM 97761 CPT 430 RC inpatient 181 181 MEDICA (COMMERCIAL) 94265 [3081118] MEDICA CLAIMS [308111801] 162.9 percent of total billed charges 112.22 171.95 Technical (Hospital) Services Prosthetic Training Uppr&/Lower Extrem Ea 15 M PX-4309776100 CDM 97761 CPT 430 RC inpatient 181 181 MULTIPLAN INC 34080 [3081285] MULTIPLAN INC [308128501] 171.95 percent of total billed charges 112.22 171.95 Technical (Hospital) Services Prosthetic Training Uppr&/Lower Extrem Ea 15 M PX-4309776100 CDM 97761 CPT 430 RC inpatient 181 181 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES HDHP [308136802] 143.32 percent of total billed charges 112.22 171.95 Technical (Hospital) Services Prosthetic Training Uppr&/Lower Extrem Ea 15 M PX-4309776100 CDM 97761 CPT 430 RC inpatient 181 181 HEALTHPARTNERS SX009 HEALTHPARTNERS 143.32 percent of total billed charges 112.22 171.95 Technical (Hospital) Services Prosthetic Training Uppr&/Lower Extrem Ea 15 M PX-4309776100 CDM 97761 CPT 430 RC outpatient 181 181 MULTIPLAN INC 34080 [3081285] MULTIPLAN INC [308128501] 171.95 percent of total billed charges 112.22 171.95 Technical (Hospital) Services Prosthetic Training Uppr&/Lower Extrem Ea 15 M PX-4309776100 CDM 97761 CPT 430 RC outpatient 181 181 CIGNA 62308 [3081051] CIGNA 62308 [308105105] 144.8 percent of total billed charges 112.22 171.95 Technical (Hospital) Services Prosthetic Training Uppr&/Lower Extrem Ea 15 M PX-4309776100 CDM 97761 CPT 430 RC outpatient 181 181 CIGNA 62308 [3081051] CIGNA STATE OF WYOMING [308105107] 144.8 percent of total billed charges 112.22 171.95 Technical (Hospital) Services Prosthetic Training Uppr&/Lower Extrem Ea 15 M PX-4309776100 CDM 97761 CPT 430 RC outpatient 181 181 BLUE CROSS BLUE SHIELD WELLMARK SB889 [3081026] BCBS WYOMING [308102603] 171.95 percent of total billed charges 112.22 171.95 Technical (Hospital) Services Prosthetic Training Uppr&/Lower Extrem Ea 15 M PX-4309776100 CDM 97761 CPT 430 RC outpatient 181 181 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES HDHP [308136802] 144.8 percent of total billed charges 112.22 171.95 Technical (Hospital) Services Prosthetic Training Uppr&/Lower Extrem Ea 15 M PX-4309776100 CDM 97761 CPT 430 RC outpatient 181 181 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES EPO [308136803] 144.8 percent of total billed charges 112.22 171.95 Technical (Hospital) Services Prosthetic Training Uppr&/Lower Extrem Ea 15 M PX-4309776100 CDM 97761 CPT 430 RC outpatient 181 181 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES PPO [308136801] 144.8 percent of total billed charges 112.22 171.95 Technical (Hospital) Services Prosthetic Training Uppr&/Lower Extrem Ea 15 M PX-4309776100 CDM 97761 CPT 430 RC outpatient 181 181 UNITED HEALTHCARE (COMMERCIAL) [3081199] UNITED HEALTHCARE 87726 [308119901] 112.22 percent of total billed charges 112.22 171.95 Technical (Hospital) Services Prosthetic Training Uppr&/Lower Extrem Ea 15 M PX-4309776100 CDM 97761 CPT 430 RC outpatient 181 181 HEALTHPARTNERS SX009 HEALTHPARTNERS 144.8 percent of total billed charges 112.22 171.95 Technical (Hospital) Services Prosthetic Training Uppr&/Lower Extrem Ea 15 M PX-4309776100 CDM 97761 CPT 430 RC outpatient 181 181 MEDICA (COMMERCIAL) 94265 [3081118] MEDICA CLAIMS [308111801] 162.9 percent of total billed charges 112.22 171.95 Technical (Hospital) Services Orthotic Mgmt&Trainj Uxtr Lxtr&/Trnk Ea 15 PX-4209776000 CDM 97760 CPT 420 RC inpatient 194 194 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES HDHP [308136802] 153.61 percent of total billed charges 120.28 184.3 Technical (Hospital) Services Orthotic Mgmt&Trainj Uxtr Lxtr&/Trnk Ea 15 PX-4209776000 CDM 97760 CPT 420 RC inpatient 194 194 MULTIPLAN INC 34080 [3081285] MULTIPLAN INC [308128501] 184.3 percent of total billed charges 120.28 184.3 Technical (Hospital) Services Orthotic Mgmt&Trainj Uxtr Lxtr&/Trnk Ea 15 PX-4209776000 CDM 97760 CPT 420 RC inpatient 194 194 MEDICA (COMMERCIAL) 94265 [3081118] MEDICA CLAIMS [308111801] 174.6 percent of total billed charges 120.28 184.3 Technical (Hospital) Services Orthotic Mgmt&Trainj Uxtr Lxtr&/Trnk Ea 15 PX-4209776000 CDM 97760 CPT 420 RC inpatient 194 194 HEALTHPARTNERS SX009 HEALTHPARTNERS 153.61 percent of total billed charges 120.28 184.3 Technical (Hospital) Services Orthotic Mgmt&Trainj Uxtr Lxtr&/Trnk Ea 15 PX-4209776000 CDM 97760 CPT 420 RC inpatient 194 194 BLUE CROSS BLUE SHIELD WELLMARK SB889 [3081026] BCBS WYOMING [308102603] 184.3 percent of total billed charges 120.28 184.3 Technical (Hospital) Services Orthotic Mgmt&Trainj Uxtr Lxtr&/Trnk Ea 15 PX-4209776000 CDM 97760 CPT 420 RC inpatient 194 194 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES PPO [308136801] 153.61 percent of total billed charges 120.28 184.3 Technical (Hospital) Services Orthotic Mgmt&Trainj Uxtr Lxtr&/Trnk Ea 15 PX-4209776000 CDM 97760 CPT 420 RC inpatient 194 194 UNITED HEALTHCARE (COMMERCIAL) [3081199] UNITED HEALTHCARE 87726 [308119901] 120.28 percent of total billed charges 120.28 184.3 Technical (Hospital) Services Orthotic Mgmt&Trainj Uxtr Lxtr&/Trnk Ea 15 PX-4209776000 CDM 97760 CPT 420 RC inpatient 194 194 CIGNA 62308 [3081051] CIGNA 62308 [308105105] 153.61 percent of total billed charges 120.28 184.3 Technical (Hospital) Services Orthotic Mgmt&Trainj Uxtr Lxtr&/Trnk Ea 15 PX-4209776000 CDM 97760 CPT 420 RC inpatient 194 194 CIGNA 62308 [3081051] CIGNA STATE OF WYOMING [308105107] 153.61 percent of total billed charges 120.28 184.3 Technical (Hospital) Services Orthotic Mgmt&Trainj Uxtr Lxtr&/Trnk Ea 15 PX-4209776000 CDM 97760 CPT 420 RC inpatient 194 194 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES EPO [308136803] 153.61 percent of total billed charges 120.28 184.3 Technical (Hospital) Services Orthotic Mgmt&Trainj Uxtr Lxtr&/Trnk Ea 15 PX-4209776000 CDM 97760 CPT 420 RC outpatient 194 194 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES EPO [308136803] 155.2 percent of total billed charges 120.28 184.3 Technical (Hospital) Services Orthotic Mgmt&Trainj Uxtr Lxtr&/Trnk Ea 15 PX-4209776000 CDM 97760 CPT 420 RC outpatient 194 194 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES PPO [308136801] 155.2 percent of total billed charges 120.28 184.3 Technical (Hospital) Services Orthotic Mgmt&Trainj Uxtr Lxtr&/Trnk Ea 15 PX-4209776000 CDM 97760 CPT 420 RC outpatient 194 194 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES HDHP [308136802] 155.2 percent of total billed charges 120.28 184.3 Technical (Hospital) Services Orthotic Mgmt&Trainj Uxtr Lxtr&/Trnk Ea 15 PX-4209776000 CDM 97760 CPT 420 RC outpatient 194 194 BLUE CROSS BLUE SHIELD WELLMARK SB889 [3081026] BCBS WYOMING [308102603] 184.3 percent of total billed charges 120.28 184.3 Technical (Hospital) Services Orthotic Mgmt&Trainj Uxtr Lxtr&/Trnk Ea 15 PX-4209776000 CDM 97760 CPT 420 RC outpatient 194 194 HEALTHPARTNERS SX009 HEALTHPARTNERS 155.2 percent of total billed charges 120.28 184.3 Technical (Hospital) Services Orthotic Mgmt&Trainj Uxtr Lxtr&/Trnk Ea 15 PX-4209776000 CDM 97760 CPT 420 RC outpatient 194 194 UNITED HEALTHCARE (COMMERCIAL) [3081199] UNITED HEALTHCARE 87726 [308119901] 120.28 percent of total billed charges 120.28 184.3 Technical (Hospital) Services Orthotic Mgmt&Trainj Uxtr Lxtr&/Trnk Ea 15 PX-4209776000 CDM 97760 CPT 420 RC outpatient 194 194 MEDICA (COMMERCIAL) 94265 [3081118] MEDICA CLAIMS [308111801] 174.6 percent of total billed charges 120.28 184.3 Technical (Hospital) Services Orthotic Mgmt&Trainj Uxtr Lxtr&/Trnk Ea 15 PX-4209776000 CDM 97760 CPT 420 RC outpatient 194 194 CIGNA 62308 [3081051] CIGNA 62308 [308105105] 155.2 percent of total billed charges 120.28 184.3 Technical (Hospital) Services Orthotic Mgmt&Trainj Uxtr Lxtr&/Trnk Ea 15 PX-4209776000 CDM 97760 CPT 420 RC outpatient 194 194 CIGNA 62308 [3081051] CIGNA STATE OF WYOMING [308105107] 155.2 percent of total billed charges 120.28 184.3 Technical (Hospital) Services Orthotic Mgmt&Trainj Uxtr Lxtr&/Trnk Ea 15 PX-4209776000 CDM 97760 CPT 420 RC outpatient 194 194 MULTIPLAN INC 34080 [3081285] MULTIPLAN INC [308128501] 184.3 percent of total billed charges 120.28 184.3 Technical (Hospital) Services Orthotic Mgmt&Trainj Uxtr Lxtr&/Trnk Ea 15 PX-4309776000 CDM 97760 CPT 430 RC inpatient 194 194 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES EPO [308136803] 153.61 percent of total billed charges 120.28 184.3 Technical (Hospital) Services Orthotic Mgmt&Trainj Uxtr Lxtr&/Trnk Ea 15 PX-4309776000 CDM 97760 CPT 430 RC inpatient 194 194 CIGNA 62308 [3081051] CIGNA 62308 [308105105] 153.61 percent of total billed charges 120.28 184.3 Technical (Hospital) Services Orthotic Mgmt&Trainj Uxtr Lxtr&/Trnk Ea 15 PX-4309776000 CDM 97760 CPT 430 RC inpatient 194 194 CIGNA 62308 [3081051] CIGNA STATE OF WYOMING [308105107] 153.61 percent of total billed charges 120.28 184.3 Technical (Hospital) Services Orthotic Mgmt&Trainj Uxtr Lxtr&/Trnk Ea 15 PX-4309776000 CDM 97760 CPT 430 RC inpatient 194 194 UNITED HEALTHCARE (COMMERCIAL) [3081199] UNITED HEALTHCARE 87726 [308119901] 120.28 percent of total billed charges 120.28 184.3 Technical (Hospital) Services Orthotic Mgmt&Trainj Uxtr Lxtr&/Trnk Ea 15 PX-4309776000 CDM 97760 CPT 430 RC inpatient 194 194 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES PPO [308136801] 153.61 percent of total billed charges 120.28 184.3 Technical (Hospital) Services Orthotic Mgmt&Trainj Uxtr Lxtr&/Trnk Ea 15 PX-4309776000 CDM 97760 CPT 430 RC inpatient 194 194 BLUE CROSS BLUE SHIELD WELLMARK SB889 [3081026] BCBS WYOMING [308102603] 184.3 percent of total billed charges 120.28 184.3 Technical (Hospital) Services Orthotic Mgmt&Trainj Uxtr Lxtr&/Trnk Ea 15 PX-4309776000 CDM 97760 CPT 430 RC inpatient 194 194 HEALTHPARTNERS SX009 HEALTHPARTNERS 153.61 percent of total billed charges 120.28 184.3 Technical (Hospital) Services Orthotic Mgmt&Trainj Uxtr Lxtr&/Trnk Ea 15 PX-4309776000 CDM 97760 CPT 430 RC inpatient 194 194 MEDICA (COMMERCIAL) 94265 [3081118] MEDICA CLAIMS [308111801] 174.6 percent of total billed charges 120.28 184.3 Technical (Hospital) Services Orthotic Mgmt&Trainj Uxtr Lxtr&/Trnk Ea 15 PX-4309776000 CDM 97760 CPT 430 RC inpatient 194 194 MULTIPLAN INC 34080 [3081285] MULTIPLAN INC [308128501] 184.3 percent of total billed charges 120.28 184.3 Technical (Hospital) Services Orthotic Mgmt&Trainj Uxtr Lxtr&/Trnk Ea 15 PX-4309776000 CDM 97760 CPT 430 RC inpatient 194 194 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES HDHP [308136802] 153.61 percent of total billed charges 120.28 184.3 Technical (Hospital) Services Orthotic Mgmt&Trainj Uxtr Lxtr&/Trnk Ea 15 PX-4309776000 CDM 97760 CPT 430 RC outpatient 194 194 UNITED HEALTHCARE (COMMERCIAL) [3081199] UNITED HEALTHCARE 87726 [308119901] 120.28 percent of total billed charges 120.28 184.3 Technical (Hospital) Services Orthotic Mgmt&Trainj Uxtr Lxtr&/Trnk Ea 15 PX-4309776000 CDM 97760 CPT 430 RC outpatient 194 194 HEALTHPARTNERS SX009 HEALTHPARTNERS 155.2 percent of total billed charges 120.28 184.3 Technical (Hospital) Services Orthotic Mgmt&Trainj Uxtr Lxtr&/Trnk Ea 15 PX-4309776000 CDM 97760 CPT 430 RC outpatient 194 194 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES HDHP [308136802] 155.2 percent of total billed charges 120.28 184.3 Technical (Hospital) Services Orthotic Mgmt&Trainj Uxtr Lxtr&/Trnk Ea 15 PX-4309776000 CDM 97760 CPT 430 RC outpatient 194 194 BLUE CROSS BLUE SHIELD WELLMARK SB889 [3081026] BCBS WYOMING [308102603] 184.3 percent of total billed charges 120.28 184.3 Technical (Hospital) Services Orthotic Mgmt&Trainj Uxtr Lxtr&/Trnk Ea 15 PX-4309776000 CDM 97760 CPT 430 RC outpatient 194 194 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES EPO [308136803] 155.2 percent of total billed charges 120.28 184.3 Technical (Hospital) Services Orthotic Mgmt&Trainj Uxtr Lxtr&/Trnk Ea 15 PX-4309776000 CDM 97760 CPT 430 RC outpatient 194 194 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES PPO [308136801] 155.2 percent of total billed charges 120.28 184.3 Technical (Hospital) Services Orthotic Mgmt&Trainj Uxtr Lxtr&/Trnk Ea 15 PX-4309776000 CDM 97760 CPT 430 RC outpatient 194 194 MEDICA (COMMERCIAL) 94265 [3081118] MEDICA CLAIMS [308111801] 174.6 percent of total billed charges 120.28 184.3 Technical (Hospital) Services Orthotic Mgmt&Trainj Uxtr Lxtr&/Trnk Ea 15 PX-4309776000 CDM 97760 CPT 430 RC outpatient 194 194 CIGNA 62308 [3081051] CIGNA 62308 [308105105] 155.2 percent of total billed charges 120.28 184.3 Technical (Hospital) Services Orthotic Mgmt&Trainj Uxtr Lxtr&/Trnk Ea 15 PX-4309776000 CDM 97760 CPT 430 RC outpatient 194 194 CIGNA 62308 [3081051] CIGNA STATE OF WYOMING [308105107] 155.2 percent of total billed charges 120.28 184.3 Technical (Hospital) Services Orthotic Mgmt&Trainj Uxtr Lxtr&/Trnk Ea 15 PX-4309776000 CDM 97760 CPT 430 RC outpatient 194 194 MULTIPLAN INC 34080 [3081285] MULTIPLAN INC [308128501] 184.3 percent of total billed charges 120.28 184.3 Technical (Hospital) Services Physical Performance Test/Meas W/Reprt Ea 15 Min PX-4209775000 CDM 97750 CPT 420 RC outpatient 105 105 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES EPO [308136803] 84 percent of total billed charges 65.1 99.75 Technical (Hospital) Services Physical Performance Test/Meas W/Reprt Ea 15 Min PX-4209775000 CDM 97750 CPT 420 RC outpatient 105 105 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES PPO [308136801] 84 percent of total billed charges 65.1 99.75 Technical (Hospital) Services Physical Performance Test/Meas W/Reprt Ea 15 Min PX-4209775000 CDM 97750 CPT 420 RC outpatient 105 105 BLUE CROSS BLUE SHIELD WELLMARK SB889 [3081026] BCBS WYOMING [308102603] 99.75 percent of total billed charges 65.1 99.75 Technical (Hospital) Services Physical Performance Test/Meas W/Reprt Ea 15 Min PX-4209775000 CDM 97750 CPT 420 RC outpatient 105 105 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES HDHP [308136802] 84 percent of total billed charges 65.1 99.75 Technical (Hospital) Services Physical Performance Test/Meas W/Reprt Ea 15 Min PX-4209775000 CDM 97750 CPT 420 RC outpatient 105 105 UNITED HEALTHCARE (COMMERCIAL) [3081199] UNITED HEALTHCARE 87726 [308119901] 65.1 percent of total billed charges 65.1 99.75 Technical (Hospital) Services Physical Performance Test/Meas W/Reprt Ea 15 Min PX-4209775000 CDM 97750 CPT 420 RC outpatient 105 105 HEALTHPARTNERS SX009 HEALTHPARTNERS 84 percent of total billed charges 65.1 99.75 Technical (Hospital) Services Physical Performance Test/Meas W/Reprt Ea 15 Min PX-4209775000 CDM 97750 CPT 420 RC outpatient 105 105 MEDICA (COMMERCIAL) 94265 [3081118] MEDICA CLAIMS [308111801] 94.5 percent of total billed charges 65.1 99.75 Technical (Hospital) Services Physical Performance Test/Meas W/Reprt Ea 15 Min PX-4209775000 CDM 97750 CPT 420 RC outpatient 105 105 CIGNA 62308 [3081051] CIGNA 62308 [308105105] 84 percent of total billed charges 65.1 99.75 Technical (Hospital) Services Physical Performance Test/Meas W/Reprt Ea 15 Min PX-4209775000 CDM 97750 CPT 420 RC outpatient 105 105 CIGNA 62308 [3081051] CIGNA STATE OF WYOMING [308105107] 84 percent of total billed charges 65.1 99.75 Technical (Hospital) Services Physical Performance Test/Meas W/Reprt Ea 15 Min PX-4209775000 CDM 97750 CPT 420 RC outpatient 105 105 MULTIPLAN INC 34080 [3081285] MULTIPLAN INC [308128501] 99.75 percent of total billed charges 65.1 99.75 Technical (Hospital) Services Physical Performance Test/Meas W/Reprt Ea 15 Min PX-4209775000 CDM 97750 CPT 420 RC inpatient 105 105 HEALTHPARTNERS SX009 HEALTHPARTNERS 83.14 percent of total billed charges 65.1 99.75 Technical (Hospital) Services Physical Performance Test/Meas W/Reprt Ea 15 Min PX-4209775000 CDM 97750 CPT 420 RC inpatient 105 105 MULTIPLAN INC 34080 [3081285] MULTIPLAN INC [308128501] 99.75 percent of total billed charges 65.1 99.75 Technical (Hospital) Services Physical Performance Test/Meas W/Reprt Ea 15 Min PX-4209775000 CDM 97750 CPT 420 RC inpatient 105 105 MEDICA (COMMERCIAL) 94265 [3081118] MEDICA CLAIMS [308111801] 94.5 percent of total billed charges 65.1 99.75 Technical (Hospital) Services Physical Performance Test/Meas W/Reprt Ea 15 Min PX-4209775000 CDM 97750 CPT 420 RC inpatient 105 105 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES PPO [308136801] 83.14 percent of total billed charges 65.1 99.75 Technical (Hospital) Services Physical Performance Test/Meas W/Reprt Ea 15 Min PX-4209775000 CDM 97750 CPT 420 RC inpatient 105 105 UNITED HEALTHCARE (COMMERCIAL) [3081199] UNITED HEALTHCARE 87726 [308119901] 65.1 percent of total billed charges 65.1 99.75 Technical (Hospital) Services Physical Performance Test/Meas W/Reprt Ea 15 Min PX-4209775000 CDM 97750 CPT 420 RC inpatient 105 105 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES HDHP [308136802] 83.14 percent of total billed charges 65.1 99.75 Technical (Hospital) Services Physical Performance Test/Meas W/Reprt Ea 15 Min PX-4209775000 CDM 97750 CPT 420 RC inpatient 105 105 BLUE CROSS BLUE SHIELD WELLMARK SB889 [3081026] BCBS WYOMING [308102603] 99.75 percent of total billed charges 65.1 99.75 Technical (Hospital) Services Physical Performance Test/Meas W/Reprt Ea 15 Min PX-4209775000 CDM 97750 CPT 420 RC inpatient 105 105 CIGNA 62308 [3081051] CIGNA 62308 [308105105] 83.14 percent of total billed charges 65.1 99.75 Technical (Hospital) Services Physical Performance Test/Meas W/Reprt Ea 15 Min PX-4209775000 CDM 97750 CPT 420 RC inpatient 105 105 CIGNA 62308 [3081051] CIGNA STATE OF WYOMING [308105107] 83.14 percent of total billed charges 65.1 99.75 Technical (Hospital) Services Physical Performance Test/Meas W/Reprt Ea 15 Min PX-4209775000 CDM 97750 CPT 420 RC inpatient 105 105 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES EPO [308136803] 83.14 percent of total billed charges 65.1 99.75 Technical (Hospital) Services Physical Performance Test/Meas W/Reprt Ea 15 Min PX-4309775000 CDM 97750 CPT 430 RC inpatient 105 105 CIGNA 62308 [3081051] CIGNA 62308 [308105105] 83.14 percent of total billed charges 65.1 99.75 Technical (Hospital) Services Physical Performance Test/Meas W/Reprt Ea 15 Min PX-4309775000 CDM 97750 CPT 430 RC inpatient 105 105 CIGNA 62308 [3081051] CIGNA STATE OF WYOMING [308105107] 83.14 percent of total billed charges 65.1 99.75 Technical (Hospital) Services Physical Performance Test/Meas W/Reprt Ea 15 Min PX-4309775000 CDM 97750 CPT 430 RC inpatient 105 105 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES EPO [308136803] 83.14 percent of total billed charges 65.1 99.75 Technical (Hospital) Services Physical Performance Test/Meas W/Reprt Ea 15 Min PX-4309775000 CDM 97750 CPT 430 RC inpatient 105 105 UNITED HEALTHCARE (COMMERCIAL) [3081199] UNITED HEALTHCARE 87726 [308119901] 65.1 percent of total billed charges 65.1 99.75 Technical (Hospital) Services Physical Performance Test/Meas W/Reprt Ea 15 Min PX-4309775000 CDM 97750 CPT 430 RC inpatient 105 105 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES PPO [308136801] 83.14 percent of total billed charges 65.1 99.75 Technical (Hospital) Services Physical Performance Test/Meas W/Reprt Ea 15 Min PX-4309775000 CDM 97750 CPT 430 RC inpatient 105 105 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES HDHP [308136802] 83.14 percent of total billed charges 65.1 99.75 Technical (Hospital) Services Physical Performance Test/Meas W/Reprt Ea 15 Min PX-4309775000 CDM 97750 CPT 430 RC inpatient 105 105 BLUE CROSS BLUE SHIELD WELLMARK SB889 [3081026] BCBS WYOMING [308102603] 99.75 percent of total billed charges 65.1 99.75 Technical (Hospital) Services Physical Performance Test/Meas W/Reprt Ea 15 Min PX-4309775000 CDM 97750 CPT 430 RC inpatient 105 105 MULTIPLAN INC 34080 [3081285] MULTIPLAN INC [308128501] 99.75 percent of total billed charges 65.1 99.75 Technical (Hospital) Services Physical Performance Test/Meas W/Reprt Ea 15 Min PX-4309775000 CDM 97750 CPT 430 RC inpatient 105 105 MEDICA (COMMERCIAL) 94265 [3081118] MEDICA CLAIMS [308111801] 94.5 percent of total billed charges 65.1 99.75 Technical (Hospital) Services Physical Performance Test/Meas W/Reprt Ea 15 Min PX-4309775000 CDM 97750 CPT 430 RC inpatient 105 105 HEALTHPARTNERS SX009 HEALTHPARTNERS 83.14 percent of total billed charges 65.1 99.75 Technical (Hospital) Services Physical Performance Test/Meas W/Reprt Ea 15 Min PX-4309775000 CDM 97750 CPT 430 RC outpatient 105 105 CIGNA 62308 [3081051] CIGNA 62308 [308105105] 84 percent of total billed charges 65.1 99.75 Technical (Hospital) Services Physical Performance Test/Meas W/Reprt Ea 15 Min PX-4309775000 CDM 97750 CPT 430 RC outpatient 105 105 CIGNA 62308 [3081051] CIGNA STATE OF WYOMING [308105107] 84 percent of total billed charges 65.1 99.75 Technical (Hospital) Services Physical Performance Test/Meas W/Reprt Ea 15 Min PX-4309775000 CDM 97750 CPT 430 RC outpatient 105 105 MULTIPLAN INC 34080 [3081285] MULTIPLAN INC [308128501] 99.75 percent of total billed charges 65.1 99.75 Technical (Hospital) Services Physical Performance Test/Meas W/Reprt Ea 15 Min PX-4309775000 CDM 97750 CPT 430 RC outpatient 105 105 MEDICA (COMMERCIAL) 94265 [3081118] MEDICA CLAIMS [308111801] 94.5 percent of total billed charges 65.1 99.75 Technical (Hospital) Services Physical Performance Test/Meas W/Reprt Ea 15 Min PX-4309775000 CDM 97750 CPT 430 RC outpatient 105 105 HEALTHPARTNERS SX009 HEALTHPARTNERS 84 percent of total billed charges 65.1 99.75 Technical (Hospital) Services Physical Performance Test/Meas W/Reprt Ea 15 Min PX-4309775000 CDM 97750 CPT 430 RC outpatient 105 105 UNITED HEALTHCARE (COMMERCIAL) [3081199] UNITED HEALTHCARE 87726 [308119901] 65.1 percent of total billed charges 65.1 99.75 Technical (Hospital) Services Physical Performance Test/Meas W/Reprt Ea 15 Min PX-4309775000 CDM 97750 CPT 430 RC outpatient 105 105 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES PPO [308136801] 84 percent of total billed charges 65.1 99.75 Technical (Hospital) Services Physical Performance Test/Meas W/Reprt Ea 15 Min PX-4309775000 CDM 97750 CPT 430 RC outpatient 105 105 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES EPO [308136803] 84 percent of total billed charges 65.1 99.75 Technical (Hospital) Services Physical Performance Test/Meas W/Reprt Ea 15 Min PX-4309775000 CDM 97750 CPT 430 RC outpatient 105 105 BLUE CROSS BLUE SHIELD WELLMARK SB889 [3081026] BCBS WYOMING [308102603] 99.75 percent of total billed charges 65.1 99.75 Technical (Hospital) Services Physical Performance Test/Meas W/Reprt Ea 15 Min PX-4309775000 CDM 97750 CPT 430 RC outpatient 105 105 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES HDHP [308136802] 84 percent of total billed charges 65.1 99.75 Technical (Hospital) Services Negative Pressure Wound Therapy Dme >50 Sq Cm PX-5109760600 CDM 97606 CPT 360 RC inpatient 331 331 CIGNA 62308 [3081051] CIGNA 62308 [308105105] 262.09 percent of total billed charges 205.22 314.45 Technical (Hospital) Services Negative Pressure Wound Therapy Dme >50 Sq Cm PX-5109760600 CDM 97606 CPT 360 RC inpatient 331 331 CIGNA 62308 [3081051] CIGNA STATE OF WYOMING [308105107] 262.09 percent of total billed charges 205.22 314.45 Technical (Hospital) Services Negative Pressure Wound Therapy Dme >50 Sq Cm PX-5109760600 CDM 97606 CPT 360 RC inpatient 331 331 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES EPO [308136803] 262.09 percent of total billed charges 205.22 314.45 Technical (Hospital) Services Negative Pressure Wound Therapy Dme >50 Sq Cm PX-5109760600 CDM 97606 CPT 360 RC inpatient 331 331 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES PPO [308136801] 262.09 percent of total billed charges 205.22 314.45 Technical (Hospital) Services Negative Pressure Wound Therapy Dme >50 Sq Cm PX-5109760600 CDM 97606 CPT 360 RC inpatient 331 331 UNITED HEALTHCARE (COMMERCIAL) [3081199] UNITED HEALTHCARE 87726 [308119901] 205.22 percent of total billed charges 205.22 314.45 Technical (Hospital) Services Negative Pressure Wound Therapy Dme >50 Sq Cm PX-5109760600 CDM 97606 CPT 360 RC inpatient 331 331 BLUE CROSS BLUE SHIELD WELLMARK SB889 [3081026] BCBS WYOMING [308102603] 314.45 percent of total billed charges 205.22 314.45 Technical (Hospital) Services Negative Pressure Wound Therapy Dme >50 Sq Cm PX-5109760600 CDM 97606 CPT 360 RC inpatient 331 331 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES HDHP [308136802] 262.09 percent of total billed charges 205.22 314.45 Technical (Hospital) Services Negative Pressure Wound Therapy Dme >50 Sq Cm PX-5109760600 CDM 97606 CPT 360 RC inpatient 331 331 MEDICA (COMMERCIAL) 94265 [3081118] MEDICA CLAIMS [308111801] 297.9 percent of total billed charges 205.22 314.45 Technical (Hospital) Services Negative Pressure Wound Therapy Dme >50 Sq Cm PX-5109760600 CDM 97606 CPT 360 RC inpatient 331 331 MULTIPLAN INC 34080 [3081285] MULTIPLAN INC [308128501] 314.45 percent of total billed charges 205.22 314.45 Technical (Hospital) Services Negative Pressure Wound Therapy Dme >50 Sq Cm PX-5109760600 CDM 97606 CPT 360 RC inpatient 331 331 HEALTHPARTNERS SX009 HEALTHPARTNERS 262.09 percent of total billed charges 205.22 314.45 Technical (Hospital) Services Negative Pressure Wound Therapy Dme >50 Sq Cm PX-5109760600 CDM 97606 CPT 360 RC outpatient 331 331 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES EPO [308136803] 264.8 percent of total billed charges 205.22 314.45 Technical (Hospital) Services Negative Pressure Wound Therapy Dme >50 Sq Cm PX-5109760600 CDM 97606 CPT 360 RC outpatient 331 331 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES PPO [308136801] 264.8 percent of total billed charges 205.22 314.45 Technical (Hospital) Services Negative Pressure Wound Therapy Dme >50 Sq Cm PX-5109760600 CDM 97606 CPT 360 RC outpatient 331 331 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES HDHP [308136802] 264.8 percent of total billed charges 205.22 314.45 Technical (Hospital) Services Negative Pressure Wound Therapy Dme >50 Sq Cm PX-5109760600 CDM 97606 CPT 360 RC outpatient 331 331 BLUE CROSS BLUE SHIELD WELLMARK SB889 [3081026] BCBS WYOMING [308102603] 314.45 percent of total billed charges 205.22 314.45 Technical (Hospital) Services Negative Pressure Wound Therapy Dme >50 Sq Cm PX-5109760600 CDM 97606 CPT 360 RC outpatient 331 331 HEALTHPARTNERS SX009 HEALTHPARTNERS 264.8 percent of total billed charges 205.22 314.45 Technical (Hospital) Services Negative Pressure Wound Therapy Dme >50 Sq Cm PX-5109760600 CDM 97606 CPT 360 RC outpatient 331 331 UNITED HEALTHCARE (COMMERCIAL) [3081199] UNITED HEALTHCARE 87726 [308119901] 205.22 percent of total billed charges 205.22 314.45 Technical (Hospital) Services Negative Pressure Wound Therapy Dme >50 Sq Cm PX-5109760600 CDM 97606 CPT 360 RC outpatient 331 331 MEDICA (COMMERCIAL) 94265 [3081118] MEDICA CLAIMS [308111801] 297.9 percent of total billed charges 205.22 314.45 Technical (Hospital) Services Negative Pressure Wound Therapy Dme >50 Sq Cm PX-5109760600 CDM 97606 CPT 360 RC outpatient 331 331 CIGNA 62308 [3081051] CIGNA 62308 [308105105] 264.8 percent of total billed charges 205.22 314.45 Technical (Hospital) Services Negative Pressure Wound Therapy Dme >50 Sq Cm PX-5109760600 CDM 97606 CPT 360 RC outpatient 331 331 CIGNA 62308 [3081051] CIGNA STATE OF WYOMING [308105107] 264.8 percent of total billed charges 205.22 314.45 Technical (Hospital) Services Negative Pressure Wound Therapy Dme >50 Sq Cm PX-5109760600 CDM 97606 CPT 360 RC outpatient 331 331 MULTIPLAN INC 34080 [3081285] MULTIPLAN INC [308128501] 314.45 percent of total billed charges 205.22 314.45 Technical (Hospital) Services Negative Pressure Wound Therapy Dme Individuals PX-4239715000 CDM 97150 CPT 423 RC outpatient 125 125 MEDICA (COMMERCIAL) 94265 [3081118] MEDICA CLAIMS [308111801] 112.5 percent of total billed charges 77.5 118.75 Technical (Hospital) Services Therapeutic Procedures Group 2/> Individuals PX-4239715000 CDM 97150 CPT 423 RC outpatient 125 125 CIGNA 62308 [3081051] CIGNA 62308 [308105105] 100 percent of total billed charges 77.5 118.75 Technical (Hospital) Services Therapeutic Procedures Group 2/> Individuals PX-4239715000 CDM 97150 CPT 423 RC outpatient 125 125 CIGNA 62308 [3081051] CIGNA STATE OF WYOMING [308105107] 100 percent of total billed charges 77.5 118.75 Technical (Hospital) Services Therapeutic Procedures Group 2/> Individuals PX-4239715000 CDM 97150 CPT 423 RC outpatient 125 125 MULTIPLAN INC 34080 [3081285] MULTIPLAN INC [308128501] 118.75 percent of total billed charges 77.5 118.75 Technical (Hospital) Services Therapeutic Procedures Group 2/> Individuals PX-4239715000 CDM 97150 CPT 423 RC outpatient 125 125 UNITED HEALTHCARE (COMMERCIAL) [3081199] UNITED HEALTHCARE 87726 [308119901] 77.5 percent of total billed charges 77.5 118.75 Technical (Hospital) Services Therapeutic Procedures Group 2/> Individuals PX-4239715000 CDM 97150 CPT 423 RC outpatient 125 125 HEALTHPARTNERS SX009 HEALTHPARTNERS 100 percent of total billed charges 77.5 118.75 Technical (Hospital) Services Therapeutic Procedures Group 2/> Individuals PX-4239715000 CDM 97150 CPT 423 RC outpatient 125 125 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES PPO [308136801] 100 percent of total billed charges 77.5 118.75 Technical (Hospital) Services Therapeutic Procedures Group 2/> Individuals PX-4239715000 CDM 97150 CPT 423 RC outpatient 125 125 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES EPO [308136803] 100 percent of total billed charges 77.5 118.75 Technical (Hospital) Services Therapeutic Procedures Group 2/> Individuals PX-4239715000 CDM 97150 CPT 423 RC outpatient 125 125 BLUE CROSS BLUE SHIELD WELLMARK SB889 [3081026] BCBS WYOMING [308102603] 118.75 percent of total billed charges 77.5 118.75 Technical (Hospital) Services Therapeutic Procedures Group 2/> Individuals PX-4239715000 CDM 97150 CPT 423 RC outpatient 125 125 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES HDHP [308136802] 100 percent of total billed charges 77.5 118.75 Technical (Hospital) Services Therapeutic Procedures Group 2/> Individuals PX-4239715000 CDM 97150 CPT 423 RC inpatient 125 125 CIGNA 62308 [3081051] CIGNA 62308 [308105105] 98.98 percent of total billed charges 77.5 118.75 Technical (Hospital) Services Therapeutic Procedures Group 2/> Individuals PX-4239715000 CDM 97150 CPT 423 RC inpatient 125 125 CIGNA 62308 [3081051] CIGNA STATE OF WYOMING [308105107] 98.98 percent of total billed charges 77.5 118.75 Technical (Hospital) Services Therapeutic Procedures Group 2/> Individuals PX-4239715000 CDM 97150 CPT 423 RC inpatient 125 125 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES EPO [308136803] 98.98 percent of total billed charges 77.5 118.75 Technical (Hospital) Services Therapeutic Procedures Group 2/> Individuals PX-4239715000 CDM 97150 CPT 423 RC inpatient 125 125 MEDICA (COMMERCIAL) 94265 [3081118] MEDICA CLAIMS [308111801] 112.5 percent of total billed charges 77.5 118.75 Technical (Hospital) Services Therapeutic Procedures Group 2/> Individuals PX-4239715000 CDM 97150 CPT 423 RC inpatient 125 125 MULTIPLAN INC 34080 [3081285] MULTIPLAN INC [308128501] 118.75 percent of total billed charges 77.5 118.75 Technical (Hospital) Services Therapeutic Procedures Group 2/> Individuals PX-4239715000 CDM 97150 CPT 423 RC inpatient 125 125 HEALTHPARTNERS SX009 HEALTHPARTNERS 98.98 percent of total billed charges 77.5 118.75 Technical (Hospital) Services Therapeutic Procedures Group 2/> Individuals PX-4239715000 CDM 97150 CPT 423 RC inpatient 125 125 BLUE CROSS BLUE SHIELD WELLMARK SB889 [3081026] BCBS WYOMING [308102603] 118.75 percent of total billed charges 77.5 118.75 Technical (Hospital) Services Therapeutic Procedures Group 2/> Individuals PX-4239715000 CDM 97150 CPT 423 RC inpatient 125 125 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES HDHP [308136802] 98.98 percent of total billed charges 77.5 118.75 Technical (Hospital) Services Therapeutic Procedures Group 2/> Individuals PX-4239715000 CDM 97150 CPT 423 RC inpatient 125 125 UNITED HEALTHCARE (COMMERCIAL) [3081199] UNITED HEALTHCARE 87726 [308119901] 77.5 percent of total billed charges 77.5 118.75 Technical (Hospital) Services Therapeutic Procedures Group 2/> Individuals PX-4239715000 CDM 97150 CPT 423 RC inpatient 125 125 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES PPO [308136801] 98.98 percent of total billed charges 77.5 118.75 Technical (Hospital) Services Therapeutic Procedures Group 2/> Individuals PX-4339715000 CDM 97150 CPT 433 RC inpatient 125 125 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES HDHP [308136802] 98.98 percent of total billed charges 77.5 118.75 Technical (Hospital) Services Therapeutic Procedures Group 2/> Individuals PX-4339715000 CDM 97150 CPT 433 RC inpatient 125 125 MULTIPLAN INC 34080 [3081285] MULTIPLAN INC [308128501] 118.75 percent of total billed charges 77.5 118.75 Technical (Hospital) Services Therapeutic Procedures Group 2/> Individuals PX-4339715000 CDM 97150 CPT 433 RC inpatient 125 125 MEDICA (COMMERCIAL) 94265 [3081118] MEDICA CLAIMS [308111801] 112.5 percent of total billed charges 77.5 118.75 Technical (Hospital) Services Therapeutic Procedures Group 2/> Individuals PX-4339715000 CDM 97150 CPT 433 RC inpatient 125 125 HEALTHPARTNERS SX009 HEALTHPARTNERS 98.98 percent of total billed charges 77.5 118.75 Technical (Hospital) Services Therapeutic Procedures Group 2/> Individuals PX-4339715000 CDM 97150 CPT 433 RC inpatient 125 125 BLUE CROSS BLUE SHIELD WELLMARK SB889 [3081026] BCBS WYOMING [308102603] 118.75 percent of total billed charges 77.5 118.75 Technical (Hospital) Services Therapeutic Procedures Group 2/> Individuals PX-4339715000 CDM 97150 CPT 433 RC inpatient 125 125 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES PPO [308136801] 98.98 percent of total billed charges 77.5 118.75 Technical (Hospital) Services Therapeutic Procedures Group 2/> Individuals PX-4339715000 CDM 97150 CPT 433 RC inpatient 125 125 UNITED HEALTHCARE (COMMERCIAL) [3081199] UNITED HEALTHCARE 87726 [308119901] 77.5 percent of total billed charges 77.5 118.75 Technical (Hospital) Services Therapeutic Procedures Group 2/> Individuals PX-4339715000 CDM 97150 CPT 433 RC inpatient 125 125 CIGNA 62308 [3081051] CIGNA 62308 [308105105] 98.98 percent of total billed charges 77.5 118.75 Technical (Hospital) Services Therapeutic Procedures Group 2/> Individuals PX-4339715000 CDM 97150 CPT 433 RC inpatient 125 125 CIGNA 62308 [3081051] CIGNA STATE OF WYOMING [308105107] 98.98 percent of total billed charges 77.5 118.75 Technical (Hospital) Services Therapeutic Procedures Group 2/> Individuals PX-4339715000 CDM 97150 CPT 433 RC inpatient 125 125 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES EPO [308136803] 98.98 percent of total billed charges 77.5 118.75 Technical (Hospital) Services Therapeutic Procedures Group 2/> Individuals PX-4339715000 CDM 97150 CPT 433 RC outpatient 125 125 UNITED HEALTHCARE (COMMERCIAL) [3081199] UNITED HEALTHCARE 87726 [308119901] 77.5 percent of total billed charges 77.5 118.75 Technical (Hospital) Services Therapeutic Procedures Group 2/> Individuals PX-4339715000 CDM 97150 CPT 433 RC outpatient 125 125 HEALTHPARTNERS SX009 HEALTHPARTNERS 100 percent of total billed charges 77.5 118.75 Technical (Hospital) Services Therapeutic Procedures Group 2/> Individuals PX-4339715000 CDM 97150 CPT 433 RC outpatient 125 125 BLUE CROSS BLUE SHIELD WELLMARK SB889 [3081026] BCBS WYOMING [308102603] 118.75 percent of total billed charges 77.5 118.75 Technical (Hospital) Services Therapeutic Procedures Group 2/> Individuals PX-4339715000 CDM 97150 CPT 433 RC outpatient 125 125 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES HDHP [308136802] 100 percent of total billed charges 77.5 118.75 Technical (Hospital) Services Therapeutic Procedures Group 2/> Individuals PX-4339715000 CDM 97150 CPT 433 RC outpatient 125 125 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES EPO [308136803] 100 percent of total billed charges 77.5 118.75 Technical (Hospital) Services Therapeutic Procedures Group 2/> Individuals PX-4339715000 CDM 97150 CPT 433 RC outpatient 125 125 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES PPO [308136801] 100 percent of total billed charges 77.5 118.75 Technical (Hospital) Services Therapeutic Procedures Group 2/> Individuals PX-4339715000 CDM 97150 CPT 433 RC outpatient 125 125 MULTIPLAN INC 34080 [3081285] MULTIPLAN INC [308128501] 118.75 percent of total billed charges 77.5 118.75 Technical (Hospital) Services Therapeutic Procedures Group 2/> Individuals PX-4339715000 CDM 97150 CPT 433 RC outpatient 125 125 CIGNA 62308 [3081051] CIGNA 62308 [308105105] 100 percent of total billed charges 77.5 118.75 Technical (Hospital) Services Therapeutic Procedures Group 2/> Individuals PX-4339715000 CDM 97150 CPT 433 RC outpatient 125 125 CIGNA 62308 [3081051] CIGNA STATE OF WYOMING [308105107] 100 percent of total billed charges 77.5 118.75 Technical (Hospital) Services Therapeutic Procedures Group 2/> Individuals PX-4339715000 CDM 97150 CPT 433 RC outpatient 125 125 MEDICA (COMMERCIAL) 94265 [3081118] MEDICA CLAIMS [308111801] 112.5 percent of total billed charges 77.5 118.75 Technical (Hospital) Services Manual Therapy Tqs 1/> Regions Each 15 Minutes PX-4209714000 CDM 97140 CPT 420 RC inpatient 127 127 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES HDHP [308136802] 100.56 percent of total billed charges 78.74 120.65 Technical (Hospital) Services Manual Therapy Tqs 1/> Regions Each 15 Minutes PX-4209714000 CDM 97140 CPT 420 RC inpatient 127 127 MEDICA (COMMERCIAL) 94265 [3081118] MEDICA CLAIMS [308111801] 114.3 percent of total billed charges 78.74 120.65 Technical (Hospital) Services Manual Therapy Tqs 1/> Regions Each 15 Minutes PX-4209714000 CDM 97140 CPT 420 RC inpatient 127 127 MULTIPLAN INC 34080 [3081285] MULTIPLAN INC [308128501] 120.65 percent of total billed charges 78.74 120.65 Technical (Hospital) Services Manual Therapy Tqs 1/> Regions Each 15 Minutes PX-4209714000 CDM 97140 CPT 420 RC inpatient 127 127 HEALTHPARTNERS SX009 HEALTHPARTNERS 100.56 percent of total billed charges 78.74 120.65 Technical (Hospital) Services Manual Therapy Tqs 1/> Regions Each 15 Minutes PX-4209714000 CDM 97140 CPT 420 RC inpatient 127 127 UNITED HEALTHCARE (COMMERCIAL) [3081199] UNITED HEALTHCARE 87726 [308119901] 78.74 percent of total billed charges 78.74 120.65 Technical (Hospital) Services Manual Therapy Tqs 1/> Regions Each 15 Minutes PX-4209714000 CDM 97140 CPT 420 RC inpatient 127 127 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES PPO [308136801] 100.56 percent of total billed charges 78.74 120.65 Technical (Hospital) Services Manual Therapy Tqs 1/> Regions Each 15 Minutes PX-4209714000 CDM 97140 CPT 420 RC inpatient 127 127 BLUE CROSS BLUE SHIELD WELLMARK SB889 [3081026] BCBS WYOMING [308102603] 120.65 percent of total billed charges 78.74 120.65 Technical (Hospital) Services Manual Therapy Tqs 1/> Regions Each 15 Minutes PX-4209714000 CDM 97140 CPT 420 RC inpatient 127 127 CIGNA 62308 [3081051] CIGNA 62308 [308105105] 100.56 percent of total billed charges 78.74 120.65 Technical (Hospital) Services Manual Therapy Tqs 1/> Regions Each 15 Minutes PX-4209714000 CDM 97140 CPT 420 RC inpatient 127 127 CIGNA 62308 [3081051] CIGNA STATE OF WYOMING [308105107] 100.56 percent of total billed charges 78.74 120.65 Technical (Hospital) Services Manual Therapy Tqs 1/> Regions Each 15 Minutes PX-4209714000 CDM 97140 CPT 420 RC inpatient 127 127 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES EPO [308136803] 100.56 percent of total billed charges 78.74 120.65 Technical (Hospital) Services Manual Therapy Tqs 1/> Regions Each 15 Minutes PX-4209714000 CDM 97140 CPT 420 RC outpatient 127 127 UNITED HEALTHCARE (COMMERCIAL) [3081199] UNITED HEALTHCARE 87726 [308119901] 78.74 percent of total billed charges 78.74 120.65 Technical (Hospital) Services Manual Therapy Tqs 1/> Regions Each 15 Minutes PX-4209714000 CDM 97140 CPT 420 RC outpatient 127 127 HEALTHPARTNERS SX009 HEALTHPARTNERS 101.6 percent of total billed charges 78.74 120.65 Technical (Hospital) Services Manual Therapy Tqs 1/> Regions Each 15 Minutes PX-4209714000 CDM 97140 CPT 420 RC outpatient 127 127 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES EPO [308136803] 101.6 percent of total billed charges 78.74 120.65 Technical (Hospital) Services Manual Therapy Tqs 1/> Regions Each 15 Minutes PX-4209714000 CDM 97140 CPT 420 RC outpatient 127 127 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES PPO [308136801] 101.6 percent of total billed charges 78.74 120.65 Technical (Hospital) Services Manual Therapy Tqs 1/> Regions Each 15 Minutes PX-4209714000 CDM 97140 CPT 420 RC outpatient 127 127 BLUE CROSS BLUE SHIELD WELLMARK SB889 [3081026] BCBS WYOMING [308102603] 120.65 percent of total billed charges 78.74 120.65 Technical (Hospital) Services Manual Therapy Tqs 1/> Regions Each 15 Minutes PX-4209714000 CDM 97140 CPT 420 RC outpatient 127 127 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES HDHP [308136802] 101.6 percent of total billed charges 78.74 120.65 Technical (Hospital) Services Manual Therapy Tqs 1/> Regions Each 15 Minutes PX-4209714000 CDM 97140 CPT 420 RC outpatient 127 127 MEDICA (COMMERCIAL) 94265 [3081118] MEDICA CLAIMS [308111801] 114.3 percent of total billed charges 78.74 120.65 Technical (Hospital) Services Manual Therapy Tqs 1/> Regions Each 15 Minutes PX-4209714000 CDM 97140 CPT 420 RC outpatient 127 127 CIGNA 62308 [3081051] CIGNA 62308 [308105105] 101.6 percent of total billed charges 78.74 120.65 Technical (Hospital) Services Manual Therapy Tqs 1/> Regions Each 15 Minutes PX-4209714000 CDM 97140 CPT 420 RC outpatient 127 127 CIGNA 62308 [3081051] CIGNA STATE OF WYOMING [308105107] 101.6 percent of total billed charges 78.74 120.65 Technical (Hospital) Services Manual Therapy Tqs 1/> Regions Each 15 Minutes PX-4209714000 CDM 97140 CPT 420 RC outpatient 127 127 MULTIPLAN INC 34080 [3081285] MULTIPLAN INC [308128501] 120.65 percent of total billed charges 78.74 120.65 Technical (Hospital) Services Manual Therapy Tqs 1/> Regions Each 15 Minutes PX-4309714000 CDM 97140 CPT 430 RC outpatient 127 127 UNITED HEALTHCARE (COMMERCIAL) [3081199] UNITED HEALTHCARE 87726 [308119901] 78.74 percent of total billed charges 78.74 120.65 Technical (Hospital) Services Manual Therapy Tqs 1/> Regions Each 15 Minutes PX-4309714000 CDM 97140 CPT 430 RC outpatient 127 127 HEALTHPARTNERS SX009 HEALTHPARTNERS 101.6 percent of total billed charges 78.74 120.65 Technical (Hospital) Services Manual Therapy Tqs 1/> Regions Each 15 Minutes PX-4309714000 CDM 97140 CPT 430 RC outpatient 127 127 BLUE CROSS BLUE SHIELD WELLMARK SB889 [3081026] BCBS WYOMING [308102603] 120.65 percent of total billed charges 78.74 120.65 Technical (Hospital) Services Manual Therapy Tqs 1/> Regions Each 15 Minutes PX-4309714000 CDM 97140 CPT 430 RC outpatient 127 127 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES HDHP [308136802] 101.6 percent of total billed charges 78.74 120.65 Technical (Hospital) Services Manual Therapy Tqs 1/> Regions Each 15 Minutes PX-4309714000 CDM 97140 CPT 430 RC outpatient 127 127 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES EPO [308136803] 101.6 percent of total billed charges 78.74 120.65 Technical (Hospital) Services Manual Therapy Tqs 1/> Regions Each 15 Minutes PX-4309714000 CDM 97140 CPT 430 RC outpatient 127 127 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES PPO [308136801] 101.6 percent of total billed charges 78.74 120.65 Technical (Hospital) Services Manual Therapy Tqs 1/> Regions Each 15 Minutes PX-4309714000 CDM 97140 CPT 430 RC outpatient 127 127 CIGNA 62308 [3081051] CIGNA 62308 [308105105] 101.6 percent of total billed charges 78.74 120.65 Technical (Hospital) Services Manual Therapy Tqs 1/> Regions Each 15 Minutes PX-4309714000 CDM 97140 CPT 430 RC outpatient 127 127 CIGNA 62308 [3081051] CIGNA STATE OF WYOMING [308105107] 101.6 percent of total billed charges 78.74 120.65 Technical (Hospital) Services Manual Therapy Tqs 1/> Regions Each 15 Minutes PX-4309714000 CDM 97140 CPT 430 RC outpatient 127 127 MULTIPLAN INC 34080 [3081285] MULTIPLAN INC [308128501] 120.65 percent of total billed charges 78.74 120.65 Technical (Hospital) Services Manual Therapy Tqs 1/> Regions Each 15 Minutes PX-4309714000 CDM 97140 CPT 430 RC outpatient 127 127 MEDICA (COMMERCIAL) 94265 [3081118] MEDICA CLAIMS [308111801] 114.3 percent of total billed charges 78.74 120.65 Technical (Hospital) Services Manual Therapy Tqs 1/> Regions Each 15 Minutes PX-4309714000 CDM 97140 CPT 430 RC inpatient 127 127 HEALTHPARTNERS SX009 HEALTHPARTNERS 100.56 percent of total billed charges 78.74 120.65 Technical (Hospital) Services Manual Therapy Tqs 1/> Regions Each 15 Minutes PX-4309714000 CDM 97140 CPT 430 RC inpatient 127 127 MEDICA (COMMERCIAL) 94265 [3081118] MEDICA CLAIMS [308111801] 114.3 percent of total billed charges 78.74 120.65 Technical (Hospital) Services Manual Therapy Tqs 1/> Regions Each 15 Minutes PX-4309714000 CDM 97140 CPT 430 RC inpatient 127 127 MULTIPLAN INC 34080 [3081285] MULTIPLAN INC [308128501] 120.65 percent of total billed charges 78.74 120.65 Technical (Hospital) Services Manual Therapy Tqs 1/> Regions Each 15 Minutes PX-4309714000 CDM 97140 CPT 430 RC inpatient 127 127 BLUE CROSS BLUE SHIELD WELLMARK SB889 [3081026] BCBS WYOMING [308102603] 120.65 percent of total billed charges 78.74 120.65 Technical (Hospital) Services Manual Therapy Tqs 1/> Regions Each 15 Minutes PX-4309714000 CDM 97140 CPT 430 RC inpatient 127 127 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES HDHP [308136802] 100.56 percent of total billed charges 78.74 120.65 Technical (Hospital) Services Manual Therapy Tqs 1/> Regions Each 15 Minutes PX-4309714000 CDM 97140 CPT 430 RC inpatient 127 127 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES PPO [308136801] 100.56 percent of total billed charges 78.74 120.65 Technical (Hospital) Services Manual Therapy Tqs 1/> Regions Each 15 Minutes PX-4309714000 CDM 97140 CPT 430 RC inpatient 127 127 UNITED HEALTHCARE (COMMERCIAL) [3081199] UNITED HEALTHCARE 87726 [308119901] 78.74 percent of total billed charges 78.74 120.65 Technical (Hospital) Services Manual Therapy Tqs 1/> Regions Each 15 Minutes PX-4309714000 CDM 97140 CPT 430 RC inpatient 127 127 CIGNA 62308 [3081051] CIGNA 62308 [308105105] 100.56 percent of total billed charges 78.74 120.65 Technical (Hospital) Services Manual Therapy Tqs 1/> Regions Each 15 Minutes PX-4309714000 CDM 97140 CPT 430 RC inpatient 127 127 CIGNA 62308 [3081051] CIGNA STATE OF WYOMING [308105107] 100.56 percent of total billed charges 78.74 120.65 Technical (Hospital) Services Manual Therapy Tqs 1/> Regions Each 15 Minutes PX-4309714000 CDM 97140 CPT 430 RC inpatient 127 127 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES EPO [308136803] 100.56 percent of total billed charges 78.74 120.65 Technical (Hospital) Services Ther Ivntj Cog Funcj Cntct 1st 15 Minutes PX-4309712900 CDM 97129 CPT 430 RC inpatient 138 138 BLUE CROSS BLUE SHIELD WELLMARK SB889 [3081026] BCBS WYOMING [308102603] 131.1 percent of total billed charges 85.56 131.1 Technical (Hospital) Services Ther Ivntj Cog Funcj Cntct 1st 15 Minutes PX-4309712900 CDM 97129 CPT 430 RC inpatient 138 138 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES PPO [308136801] 109.27 percent of total billed charges 85.56 131.1 Technical (Hospital) Services Ther Ivntj Cog Funcj Cntct 1st 15 Minutes PX-4309712900 CDM 97129 CPT 430 RC inpatient 138 138 UNITED HEALTHCARE (COMMERCIAL) [3081199] UNITED HEALTHCARE 87726 [308119901] 85.56 percent of total billed charges 85.56 131.1 Technical (Hospital) Services Ther Ivntj Cog Funcj Cntct 1st 15 Minutes PX-4309712900 CDM 97129 CPT 430 RC inpatient 138 138 HEALTHPARTNERS SX009 HEALTHPARTNERS 109.27 percent of total billed charges 85.56 131.1 Technical (Hospital) Services Ther Ivntj Cog Funcj Cntct 1st 15 Minutes PX-4309712900 CDM 97129 CPT 430 RC inpatient 138 138 MEDICA (COMMERCIAL) 94265 [3081118] MEDICA CLAIMS [308111801] 124.2 percent of total billed charges 85.56 131.1 Technical (Hospital) Services Ther Ivntj Cog Funcj Cntct 1st 15 Minutes PX-4309712900 CDM 97129 CPT 430 RC inpatient 138 138 MULTIPLAN INC 34080 [3081285] MULTIPLAN INC [308128501] 131.1 percent of total billed charges 85.56 131.1 Technical (Hospital) Services Ther Ivntj Cog Funcj Cntct 1st 15 Minutes PX-4309712900 CDM 97129 CPT 430 RC inpatient 138 138 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES HDHP [308136802] 109.27 percent of total billed charges 85.56 131.1 Technical (Hospital) Services Ther Ivntj Cog Funcj Cntct 1st 15 Minutes PX-4309712900 CDM 97129 CPT 430 RC inpatient 138 138 CIGNA 62308 [3081051] CIGNA 62308 [308105105] 109.27 percent of total billed charges 85.56 131.1 Technical (Hospital) Services Ther Ivntj Cog Funcj Cntct 1st 15 Minutes PX-4309712900 CDM 97129 CPT 430 RC inpatient 138 138 CIGNA 62308 [3081051] CIGNA STATE OF WYOMING [308105107] 109.27 percent of total billed charges 85.56 131.1 Technical (Hospital) Services Ther Ivntj Cog Funcj Cntct 1st 15 Minutes PX-4309712900 CDM 97129 CPT 430 RC inpatient 138 138 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES EPO [308136803] 109.27 percent of total billed charges 85.56 131.1 Technical (Hospital) Services Ther Ivntj Cog Funcj Cntct 1st 15 Minutes PX-4309712900 CDM 97129 CPT 430 RC outpatient 138 138 CIGNA 62308 [3081051] CIGNA 62308 [308105105] 110.4 percent of total billed charges 85.56 131.1 Technical (Hospital) Services Ther Ivntj Cog Funcj Cntct 1st 15 Minutes PX-4309712900 CDM 97129 CPT 430 RC outpatient 138 138 CIGNA 62308 [3081051] CIGNA STATE OF WYOMING [308105107] 110.4 percent of total billed charges 85.56 131.1 Technical (Hospital) Services Ther Ivntj Cog Funcj Cntct 1st 15 Minutes PX-4309712900 CDM 97129 CPT 430 RC outpatient 138 138 MULTIPLAN INC 34080 [3081285] MULTIPLAN INC [308128501] 131.1 percent of total billed charges 85.56 131.1 Technical (Hospital) Services Ther Ivntj Cog Funcj Cntct 1st 15 Minutes PX-4309712900 CDM 97129 CPT 430 RC outpatient 138 138 MEDICA (COMMERCIAL) 94265 [3081118] MEDICA CLAIMS [308111801] 124.2 percent of total billed charges 85.56 131.1 Technical (Hospital) Services Ther Ivntj Cog Funcj Cntct 1st 15 Minutes PX-4309712900 CDM 97129 CPT 430 RC outpatient 138 138 HEALTHPARTNERS SX009 HEALTHPARTNERS 110.4 percent of total billed charges 85.56 131.1 Technical (Hospital) Services Ther Ivntj Cog Funcj Cntct 1st 15 Minutes PX-4309712900 CDM 97129 CPT 430 RC outpatient 138 138 UNITED HEALTHCARE (COMMERCIAL) [3081199] UNITED HEALTHCARE 87726 [308119901] 85.56 percent of total billed charges 85.56 131.1 Technical (Hospital) Services Ther Ivntj Cog Funcj Cntct 1st 15 Minutes PX-4309712900 CDM 97129 CPT 430 RC outpatient 138 138 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES EPO [308136803] 110.4 percent of total billed charges 85.56 131.1 Technical (Hospital) Services Ther Ivntj Cog Funcj Cntct 1st 15 Minutes PX-4309712900 CDM 97129 CPT 430 RC outpatient 138 138 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES PPO [308136801] 110.4 percent of total billed charges 85.56 131.1 Technical (Hospital) Services Ther Ivntj Cog Funcj Cntct 1st 15 Minutes PX-4309712900 CDM 97129 CPT 430 RC outpatient 138 138 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES HDHP [308136802] 110.4 percent of total billed charges 85.56 131.1 Technical (Hospital) Services Ther Ivntj Cog Funcj Cntct 1st 15 Minutes PX-4309712900 CDM 97129 CPT 430 RC outpatient 138 138 BLUE CROSS BLUE SHIELD WELLMARK SB889 [3081026] BCBS WYOMING [308102603] 131.1 percent of total billed charges 85.56 131.1 Technical (Hospital) Services Ther Px 1/> Areas Each 15 Minutes Massage PX-4209712400 CDM 97124 CPT 420 RC inpatient 65 65 HEALTHPARTNERS SX009 HEALTHPARTNERS 51.47 percent of total billed charges 40.3 61.75 Technical (Hospital) Services Ther Px 1/> Areas Each 15 Minutes Massage PX-4209712400 CDM 97124 CPT 420 RC inpatient 65 65 MEDICA (COMMERCIAL) 94265 [3081118] MEDICA CLAIMS [308111801] 58.5 percent of total billed charges 40.3 61.75 Technical (Hospital) Services Ther Px 1/> Areas Each 15 Minutes Massage PX-4209712400 CDM 97124 CPT 420 RC inpatient 65 65 MULTIPLAN INC 34080 [3081285] MULTIPLAN INC [308128501] 61.75 percent of total billed charges 40.3 61.75 Technical (Hospital) Services Ther Px 1/> Areas Each 15 Minutes Massage PX-4209712400 CDM 97124 CPT 420 RC inpatient 65 65 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES HDHP [308136802] 51.47 percent of total billed charges 40.3 61.75 Technical (Hospital) Services Ther Px 1/> Areas Each 15 Minutes Massage PX-4209712400 CDM 97124 CPT 420 RC inpatient 65 65 BLUE CROSS BLUE SHIELD WELLMARK SB889 [3081026] BCBS WYOMING [308102603] 61.75 percent of total billed charges 40.3 61.75 Technical (Hospital) Services Ther Px 1/> Areas Each 15 Minutes Massage PX-4209712400 CDM 97124 CPT 420 RC inpatient 65 65 UNITED HEALTHCARE (COMMERCIAL) [3081199] UNITED HEALTHCARE 87726 [308119901] 40.3 percent of total billed charges 40.3 61.75 Technical (Hospital) Services Ther Px 1/> Areas Each 15 Minutes Massage PX-4209712400 CDM 97124 CPT 420 RC inpatient 65 65 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES PPO [308136801] 51.47 percent of total billed charges 40.3 61.75 Technical (Hospital) Services Ther Px 1/> Areas Each 15 Minutes Massage PX-4209712400 CDM 97124 CPT 420 RC inpatient 65 65 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES EPO [308136803] 51.47 percent of total billed charges 40.3 61.75 Technical (Hospital) Services Ther Px 1/> Areas Each 15 Minutes Massage PX-4209712400 CDM 97124 CPT 420 RC inpatient 65 65 CIGNA 62308 [3081051] CIGNA 62308 [308105105] 51.47 percent of total billed charges 40.3 61.75 Technical (Hospital) Services Ther Px 1/> Areas Each 15 Minutes Massage PX-4209712400 CDM 97124 CPT 420 RC inpatient 65 65 CIGNA 62308 [3081051] CIGNA STATE OF WYOMING [308105107] 51.47 percent of total billed charges 40.3 61.75 Technical (Hospital) Services Ther Px 1/> Areas Each 15 Minutes Massage PX-4209712400 CDM 97124 CPT 420 RC outpatient 65 65 CIGNA 62308 [3081051] CIGNA 62308 [308105105] 52 percent of total billed charges 40.3 61.75 Technical (Hospital) Services Ther Px 1/> Areas Each 15 Minutes Massage PX-4209712400 CDM 97124 CPT 420 RC outpatient 65 65 CIGNA 62308 [3081051] CIGNA STATE OF WYOMING [308105107] 52 percent of total billed charges 40.3 61.75 Technical (Hospital) Services Ther Px 1/> Areas Each 15 Minutes Massage PX-4209712400 CDM 97124 CPT 420 RC outpatient 65 65 MULTIPLAN INC 34080 [3081285] MULTIPLAN INC [308128501] 61.75 percent of total billed charges 40.3 61.75 Technical (Hospital) Services Ther Px 1/> Areas Each 15 Minutes Massage PX-4209712400 CDM 97124 CPT 420 RC outpatient 65 65 MEDICA (COMMERCIAL) 94265 [3081118] MEDICA CLAIMS [308111801] 58.5 percent of total billed charges 40.3 61.75 Technical (Hospital) Services Ther Px 1/> Areas Each 15 Minutes Massage PX-4209712400 CDM 97124 CPT 420 RC outpatient 65 65 UNITED HEALTHCARE (COMMERCIAL) [3081199] UNITED HEALTHCARE 87726 [308119901] 40.3 percent of total billed charges 40.3 61.75 Technical (Hospital) Services Ther Px 1/> Areas Each 15 Minutes Massage PX-4209712400 CDM 97124 CPT 420 RC outpatient 65 65 HEALTHPARTNERS SX009 HEALTHPARTNERS 52 percent of total billed charges 40.3 61.75 Technical (Hospital) Services Ther Px 1/> Areas Each 15 Minutes Massage PX-4209712400 CDM 97124 CPT 420 RC outpatient 65 65 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES HDHP [308136802] 52 percent of total billed charges 40.3 61.75 Technical (Hospital) Services Ther Px 1/> Areas Each 15 Minutes Massage PX-4209712400 CDM 97124 CPT 420 RC outpatient 65 65 BLUE CROSS BLUE SHIELD WELLMARK SB889 [3081026] BCBS WYOMING [308102603] 61.75 percent of total billed charges 40.3 61.75 Technical (Hospital) Services Ther Px 1/> Areas Each 15 Minutes Massage PX-4209712400 CDM 97124 CPT 420 RC outpatient 65 65 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES EPO [308136803] 52 percent of total billed charges 40.3 61.75 Technical (Hospital) Services Ther Px 1/> Areas Each 15 Minutes Massage PX-4209712400 CDM 97124 CPT 420 RC outpatient 65 65 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES PPO [308136801] 52 percent of total billed charges 40.3 61.75 Technical (Hospital) Services Pt Gait Training Birth to 3 PX-4209711600 CDM 97116 CPT 420 RC inpatient 110 110 BLUE CROSS BLUE SHIELD WELLMARK SB889 [3081026] BCBS WYOMING [308102603] 104.5 percent of total billed charges 68.2 104.5 Technical (Hospital) Services Pt Gait Training Birth to 3 PX-4209711600 CDM 97116 CPT 420 RC inpatient 110 110 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES HDHP [308136802] 87.1 percent of total billed charges 68.2 104.5 Technical (Hospital) Services Pt Gait Training Birth to 3 PX-4209711600 CDM 97116 CPT 420 RC inpatient 110 110 UNITED HEALTHCARE (COMMERCIAL) [3081199] UNITED HEALTHCARE 87726 [308119901] 68.2 percent of total billed charges 68.2 104.5 Technical (Hospital) Services Pt Gait Training Birth to 3 PX-4209711600 CDM 97116 CPT 420 RC inpatient 110 110 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES PPO [308136801] 87.1 percent of total billed charges 68.2 104.5 Technical (Hospital) Services Pt Gait Training Birth to 3 PX-4209711600 CDM 97116 CPT 420 RC inpatient 110 110 HEALTHPARTNERS SX009 HEALTHPARTNERS 87.1 percent of total billed charges 68.2 104.5 Technical (Hospital) Services Pt Gait Training Birth to 3 PX-4209711600 CDM 97116 CPT 420 RC inpatient 110 110 MEDICA (COMMERCIAL) 94265 [3081118] MEDICA CLAIMS [308111801] 99 percent of total billed charges 68.2 104.5 Technical (Hospital) Services Pt Gait Training Birth to 3 PX-4209711600 CDM 97116 CPT 420 RC inpatient 110 110 MULTIPLAN INC 34080 [3081285] MULTIPLAN INC [308128501] 104.5 percent of total billed charges 68.2 104.5 Technical (Hospital) Services Pt Gait Training Birth to 3 PX-4209711600 CDM 97116 CPT 420 RC inpatient 110 110 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES EPO [308136803] 87.1 percent of total billed charges 68.2 104.5 Technical (Hospital) Services Pt Gait Training Birth to 3 PX-4209711600 CDM 97116 CPT 420 RC inpatient 110 110 CIGNA 62308 [3081051] CIGNA 62308 [308105105] 87.1 percent of total billed charges 68.2 104.5 Technical (Hospital) Services Pt Gait Training Birth to 3 PX-4209711600 CDM 97116 CPT 420 RC inpatient 110 110 CIGNA 62308 [3081051] CIGNA STATE OF WYOMING [308105107] 87.1 percent of total billed charges 68.2 104.5 Technical (Hospital) Services Pt Gait Training Birth to 3 PX-4209711600 CDM 97116 CPT 420 RC outpatient 110 110 BLUE CROSS BLUE SHIELD WELLMARK SB889 [3081026] BCBS WYOMING [308102603] 104.5 percent of total billed charges 68.2 104.5 Technical (Hospital) Services Pt Gait Training Birth to 3 PX-4209711600 CDM 97116 CPT 420 RC outpatient 110 110 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES HDHP [308136802] 88 percent of total billed charges 68.2 104.5 Technical (Hospital) Services Pt Gait Training Birth to 3 PX-4209711600 CDM 97116 CPT 420 RC outpatient 110 110 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES PPO [308136801] 88 percent of total billed charges 68.2 104.5 Technical (Hospital) Services Pt Gait Training Birth to 3 PX-4209711600 CDM 97116 CPT 420 RC outpatient 110 110 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES EPO [308136803] 88 percent of total billed charges 68.2 104.5 Technical (Hospital) Services Pt Gait Training Birth to 3 PX-4209711600 CDM 97116 CPT 420 RC outpatient 110 110 UNITED HEALTHCARE (COMMERCIAL) [3081199] UNITED HEALTHCARE 87726 [308119901] 68.2 percent of total billed charges 68.2 104.5 Technical (Hospital) Services Pt Gait Training Birth to 3 PX-4209711600 CDM 97116 CPT 420 RC outpatient 110 110 HEALTHPARTNERS SX009 HEALTHPARTNERS 88 percent of total billed charges 68.2 104.5 Technical (Hospital) Services Pt Gait Training Birth to 3 PX-4209711600 CDM 97116 CPT 420 RC outpatient 110 110 CIGNA 62308 [3081051] CIGNA 62308 [308105105] 88 percent of total billed charges 68.2 104.5 Technical (Hospital) Services Pt Gait Training Birth to 3 PX-4209711600 CDM 97116 CPT 420 RC outpatient 110 110 CIGNA 62308 [3081051] CIGNA STATE OF WYOMING [308105107] 88 percent of total billed charges 68.2 104.5 Technical (Hospital) Services Pt Gait Training Birth to 3 PX-4209711600 CDM 97116 CPT 420 RC outpatient 110 110 MULTIPLAN INC 34080 [3081285] MULTIPLAN INC [308128501] 104.5 percent of total billed charges 68.2 104.5 Technical (Hospital) Services Pt Gait Training Birth to 3 PX-4209711600 CDM 97116 CPT 420 RC outpatient 110 110 MEDICA (COMMERCIAL) 94265 [3081118] MEDICA CLAIMS [308111801] 99 percent of total billed charges 68.2 104.5 Technical (Hospital) Services Ther Px 1/> Areas Ea 15 Min Gait Trainj W/Stair PX-4219711600 CDM 97116 CPT 421 RC inpatient 110 110 HEALTHPARTNERS SX009 HEALTHPARTNERS 87.1 percent of total billed charges 68.2 104.5 Technical (Hospital) Services Ther Px 1/> Areas Ea 15 Min Gait Trainj W/Stair PX-4219711600 CDM 97116 CPT 421 RC inpatient 110 110 MULTIPLAN INC 34080 [3081285] MULTIPLAN INC [308128501] 104.5 percent of total billed charges 68.2 104.5 Technical (Hospital) Services Ther Px 1/> Areas Ea 15 Min Gait Trainj W/Stair PX-4219711600 CDM 97116 CPT 421 RC inpatient 110 110 MEDICA (COMMERCIAL) 94265 [3081118] MEDICA CLAIMS [308111801] 99 percent of total billed charges 68.2 104.5 Technical (Hospital) Services Ther Px 1/> Areas Ea 15 Min Gait Trainj W/Stair PX-4219711600 CDM 97116 CPT 421 RC inpatient 110 110 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES HDHP [308136802] 87.1 percent of total billed charges 68.2 104.5 Technical (Hospital) Services Ther Px 1/> Areas Ea 15 Min Gait Trainj W/Stair PX-4219711600 CDM 97116 CPT 421 RC inpatient 110 110 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES PPO [308136801] 87.1 percent of total billed charges 68.2 104.5 Technical (Hospital) Services Ther Px 1/> Areas Ea 15 Min Gait Trainj W/Stair PX-4219711600 CDM 97116 CPT 421 RC inpatient 110 110 UNITED HEALTHCARE (COMMERCIAL) [3081199] UNITED HEALTHCARE 87726 [308119901] 68.2 percent of total billed charges 68.2 104.5 Technical (Hospital) Services Ther Px 1/> Areas Ea 15 Min Gait Trainj W/Stair PX-4219711600 CDM 97116 CPT 421 RC inpatient 110 110 BLUE CROSS BLUE SHIELD WELLMARK SB889 [3081026] BCBS WYOMING [308102603] 104.5 percent of total billed charges 68.2 104.5 Technical (Hospital) Services Ther Px 1/> Areas Ea 15 Min Gait Trainj W/Stair PX-4219711600 CDM 97116 CPT 421 RC inpatient 110 110 CIGNA 62308 [3081051] CIGNA 62308 [308105105] 87.1 percent of total billed charges 68.2 104.5 Technical (Hospital) Services Ther Px 1/> Areas Ea 15 Min Gait Trainj W/Stair PX-4219711600 CDM 97116 CPT 421 RC inpatient 110 110 CIGNA 62308 [3081051] CIGNA STATE OF WYOMING [308105107] 87.1 percent of total billed charges 68.2 104.5 Technical (Hospital) Services Ther Px 1/> Areas Ea 15 Min Gait Trainj W/Stair PX-4219711600 CDM 97116 CPT 421 RC inpatient 110 110 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES EPO [308136803] 87.1 percent of total billed charges 68.2 104.5 Technical (Hospital) Services Ther Px 1/> Areas Ea 15 Min Gait Trainj W/Stair PX-4219711600 CDM 97116 CPT 421 RC outpatient 110 110 MULTIPLAN INC 34080 [3081285] MULTIPLAN INC [308128501] 104.5 percent of total billed charges 68.2 104.5 Technical (Hospital) Services Ther Px 1/> Areas Ea 15 Min Gait Trainj W/Stair PX-4219711600 CDM 97116 CPT 421 RC outpatient 110 110 CIGNA 62308 [3081051] CIGNA 62308 [308105105] 88 percent of total billed charges 68.2 104.5 Technical (Hospital) Services Ther Px 1/> Areas Ea 15 Min Gait Trainj W/Stair PX-4219711600 CDM 97116 CPT 421 RC outpatient 110 110 CIGNA 62308 [3081051] CIGNA STATE OF WYOMING [308105107] 88 percent of total billed charges 68.2 104.5 Technical (Hospital) Services Ther Px 1/> Areas Ea 15 Min Gait Trainj W/Stair PX-4219711600 CDM 97116 CPT 421 RC outpatient 110 110 MEDICA (COMMERCIAL) 94265 [3081118] MEDICA CLAIMS [308111801] 99 percent of total billed charges 68.2 104.5 Technical (Hospital) Services Ther Px 1/> Areas Ea 15 Min Gait Trainj W/Stair PX-4219711600 CDM 97116 CPT 421 RC outpatient 110 110 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES EPO [308136803] 88 percent of total billed charges 68.2 104.5 Technical (Hospital) Services Ther Px 1/> Areas Ea 15 Min Gait Trainj W/Stair PX-4219711600 CDM 97116 CPT 421 RC outpatient 110 110 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES PPO [308136801] 88 percent of total billed charges 68.2 104.5 Technical (Hospital) Services Ther Px 1/> Areas Ea 15 Min Gait Trainj W/Stair PX-4219711600 CDM 97116 CPT 421 RC outpatient 110 110 BLUE CROSS BLUE SHIELD WELLMARK SB889 [3081026] BCBS WYOMING [308102603] 104.5 percent of total billed charges 68.2 104.5 Technical (Hospital) Services Ther Px 1/> Areas Ea 15 Min Gait Trainj W/Stair PX-4219711600 CDM 97116 CPT 421 RC outpatient 110 110 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES HDHP [308136802] 88 percent of total billed charges 68.2 104.5 Technical (Hospital) Services Ther Px 1/> Areas Ea 15 Min Gait Trainj W/Stair PX-4219711600 CDM 97116 CPT 421 RC outpatient 110 110 UNITED HEALTHCARE (COMMERCIAL) [3081199] UNITED HEALTHCARE 87726 [308119901] 68.2 percent of total billed charges 68.2 104.5 Technical (Hospital) Services Ther Px 1/> Areas Ea 15 Min Gait Trainj W/Stair PX-4219711600 CDM 97116 CPT 421 RC outpatient 110 110 HEALTHPARTNERS SX009 HEALTHPARTNERS 88 percent of total billed charges 68.2 104.5 Technical (Hospital) Services Ther Px 1/> Areas Each 15 Min Aqua Ther W/Xerss PX-4219711300 CDM 97113 CPT 421 RC inpatient 139 139 CIGNA 62308 [3081051] CIGNA 62308 [308105105] 110.06 percent of total billed charges 86.18 132.05 Technical (Hospital) Services Ther Px 1/> Areas Each 15 Min Aqua Ther W/Xerss PX-4219711300 CDM 97113 CPT 421 RC inpatient 139 139 CIGNA 62308 [3081051] CIGNA STATE OF WYOMING [308105107] 110.06 percent of total billed charges 86.18 132.05 Technical (Hospital) Services Ther Px 1/> Areas Each 15 Min Aqua Ther W/Xerss PX-4219711300 CDM 97113 CPT 421 RC inpatient 139 139 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES EPO [308136803] 110.06 percent of total billed charges 86.18 132.05 Technical (Hospital) Services Ther Px 1/> Areas Each 15 Min Aqua Ther W/Xerss PX-4219711300 CDM 97113 CPT 421 RC inpatient 139 139 MULTIPLAN INC 34080 [3081285] MULTIPLAN INC [308128501] 132.05 percent of total billed charges 86.18 132.05 Technical (Hospital) Services Ther Px 1/> Areas Each 15 Min Aqua Ther W/Xerss PX-4219711300 CDM 97113 CPT 421 RC inpatient 139 139 MEDICA (COMMERCIAL) 94265 [3081118] MEDICA CLAIMS [308111801] 125.1 percent of total billed charges 86.18 132.05 Technical (Hospital) Services Ther Px 1/> Areas Each 15 Min Aqua Ther W/Xerss PX-4219711300 CDM 97113 CPT 421 RC inpatient 139 139 HEALTHPARTNERS SX009 HEALTHPARTNERS 110.06 percent of total billed charges 86.18 132.05 Technical (Hospital) Services Ther Px 1/> Areas Each 15 Min Aqua Ther W/Xerss PX-4219711300 CDM 97113 CPT 421 RC inpatient 139 139 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES PPO [308136801] 110.06 percent of total billed charges 86.18 132.05 Technical (Hospital) Services Ther Px 1/> Areas Each 15 Min Aqua Ther W/Xerss PX-4219711300 CDM 97113 CPT 421 RC inpatient 139 139 UNITED HEALTHCARE (COMMERCIAL) [3081199] UNITED HEALTHCARE 87726 [308119901] 86.18 percent of total billed charges 86.18 132.05 Technical (Hospital) Services Ther Px 1/> Areas Each 15 Min Aqua Ther W/Xerss PX-4219711300 CDM 97113 CPT 421 RC inpatient 139 139 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES HDHP [308136802] 110.06 percent of total billed charges 86.18 132.05 Technical (Hospital) Services Ther Px 1/> Areas Each 15 Min Aqua Ther W/Xerss PX-4219711300 CDM 97113 CPT 421 RC inpatient 139 139 BLUE CROSS BLUE SHIELD WELLMARK SB889 [3081026] BCBS WYOMING [308102603] 132.05 percent of total billed charges 86.18 132.05 Technical (Hospital) Services Ther Px 1/> Areas Each 15 Min Aqua Ther W/Xerss PX-4219711300 CDM 97113 CPT 421 RC outpatient 139 139 UNITED HEALTHCARE (COMMERCIAL) [3081199] UNITED HEALTHCARE 87726 [308119901] 86.18 percent of total billed charges 86.18 132.05 Technical (Hospital) Services Ther Px 1/> Areas Each 15 Min Aqua Ther W/Xerss PX-4219711300 CDM 97113 CPT 421 RC outpatient 139 139 HEALTHPARTNERS SX009 HEALTHPARTNERS 111.2 percent of total billed charges 86.18 132.05 Technical (Hospital) Services Ther Px 1/> Areas Each 15 Min Aqua Ther W/Xerss PX-4219711300 CDM 97113 CPT 421 RC outpatient 139 139 BLUE CROSS BLUE SHIELD WELLMARK SB889 [3081026] BCBS WYOMING [308102603] 132.05 percent of total billed charges 86.18 132.05 Technical (Hospital) Services Ther Px 1/> Areas Each 15 Min Aqua Ther W/Xerss PX-4219711300 CDM 97113 CPT 421 RC outpatient 139 139 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES HDHP [308136802] 111.2 percent of total billed charges 86.18 132.05 Technical (Hospital) Services Ther Px 1/> Areas Each 15 Min Aqua Ther W/Xerss PX-4219711300 CDM 97113 CPT 421 RC outpatient 139 139 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES PPO [308136801] 111.2 percent of total billed charges 86.18 132.05 Technical (Hospital) Services Ther Px 1/> Areas Each 15 Min Aqua Ther W/Xerss PX-4219711300 CDM 97113 CPT 421 RC outpatient 139 139 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES EPO [308136803] 111.2 percent of total billed charges 86.18 132.05 Technical (Hospital) Services Ther Px 1/> Areas Each 15 Min Aqua Ther W/Xerss PX-4219711300 CDM 97113 CPT 421 RC outpatient 139 139 CIGNA 62308 [3081051] CIGNA 62308 [308105105] 111.2 percent of total billed charges 86.18 132.05 Technical (Hospital) Services Ther Px 1/> Areas Each 15 Min Aqua Ther W/Xerss PX-4219711300 CDM 97113 CPT 421 RC outpatient 139 139 CIGNA 62308 [3081051] CIGNA STATE OF WYOMING [308105107] 111.2 percent of total billed charges 86.18 132.05 Technical (Hospital) Services Ther Px 1/> Areas Each 15 Min Aqua Ther W/Xerss PX-4219711300 CDM 97113 CPT 421 RC outpatient 139 139 MULTIPLAN INC 34080 [3081285] MULTIPLAN INC [308128501] 132.05 percent of total billed charges 86.18 132.05 Technical (Hospital) Services Ther Px 1/> Areas Each 15 Min Aqua Ther W/Xerss PX-4219711300 CDM 97113 CPT 421 RC outpatient 139 139 MEDICA (COMMERCIAL) 94265 [3081118] MEDICA CLAIMS [308111801] 125.1 percent of total billed charges 86.18 132.05 Technical (Hospital) Services Ther Px 1/> Areas Each 15 Min Aqua Ther W/Xerss PX-4319711300 CDM 97113 CPT 431 RC inpatient 139 139 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES EPO [308136803] 110.06 percent of total billed charges 86.18 132.05 Technical (Hospital) Services Ther Px 1/> Areas Each 15 Min Aqua Ther W/Xerss PX-4319711300 CDM 97113 CPT 431 RC inpatient 139 139 CIGNA 62308 [3081051] CIGNA 62308 [308105105] 110.06 percent of total billed charges 86.18 132.05 Technical (Hospital) Services Ther Px 1/> Areas Each 15 Min Aqua Ther W/Xerss PX-4319711300 CDM 97113 CPT 431 RC inpatient 139 139 CIGNA 62308 [3081051] CIGNA STATE OF WYOMING [308105107] 110.06 percent of total billed charges 86.18 132.05 Technical (Hospital) Services Ther Px 1/> Areas Each 15 Min Aqua Ther W/Xerss PX-4319711300 CDM 97113 CPT 431 RC inpatient 139 139 BLUE CROSS BLUE SHIELD WELLMARK SB889 [3081026] BCBS WYOMING [308102603] 132.05 percent of total billed charges 86.18 132.05 Technical (Hospital) Services Ther Px 1/> Areas Each 15 Min Aqua Ther W/Xerss PX-4319711300 CDM 97113 CPT 431 RC inpatient 139 139 UNITED HEALTHCARE (COMMERCIAL) [3081199] UNITED HEALTHCARE 87726 [308119901] 86.18 percent of total billed charges 86.18 132.05 Technical (Hospital) Services Ther Px 1/> Areas Each 15 Min Aqua Ther W/Xerss PX-4319711300 CDM 97113 CPT 431 RC inpatient 139 139 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES PPO [308136801] 110.06 percent of total billed charges 86.18 132.05 Technical (Hospital) Services Ther Px 1/> Areas Each 15 Min Aqua Ther W/Xerss PX-4319711300 CDM 97113 CPT 431 RC inpatient 139 139 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES HDHP [308136802] 110.06 percent of total billed charges 86.18 132.05 Technical (Hospital) Services Ther Px 1/> Areas Each 15 Min Aqua Ther W/Xerss PX-4319711300 CDM 97113 CPT 431 RC inpatient 139 139 MEDICA (COMMERCIAL) 94265 [3081118] MEDICA CLAIMS [308111801] 125.1 percent of total billed charges 86.18 132.05 Technical (Hospital) Services Ther Px 1/> Areas Each 15 Min Aqua Ther W/Xerss PX-4319711300 CDM 97113 CPT 431 RC inpatient 139 139 MULTIPLAN INC 34080 [3081285] MULTIPLAN INC [308128501] 132.05 percent of total billed charges 86.18 132.05 Technical (Hospital) Services Ther Px 1/> Areas Each 15 Min Aqua Ther W/Xerss PX-4319711300 CDM 97113 CPT 431 RC inpatient 139 139 HEALTHPARTNERS SX009 HEALTHPARTNERS 110.06 percent of total billed charges 86.18 132.05 Technical (Hospital) Services Ther Px 1/> Areas Each 15 Min Aqua Ther W/Xerss PX-4319711300 CDM 97113 CPT 431 RC outpatient 139 139 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES PPO [308136801] 111.2 percent of total billed charges 86.18 132.05 Technical (Hospital) Services Ther Px 1/> Areas Each 15 Min Aqua Ther W/Xerss PX-4319711300 CDM 97113 CPT 431 RC outpatient 139 139 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES EPO [308136803] 111.2 percent of total billed charges 86.18 132.05 Technical (Hospital) Services Ther Px 1/> Areas Each 15 Min Aqua Ther W/Xerss PX-4319711300 CDM 97113 CPT 431 RC outpatient 139 139 BLUE CROSS BLUE SHIELD WELLMARK SB889 [3081026] BCBS WYOMING [308102603] 132.05 percent of total billed charges 86.18 132.05 Technical (Hospital) Services Ther Px 1/> Areas Each 15 Min Aqua Ther W/Xerss PX-4319711300 CDM 97113 CPT 431 RC outpatient 139 139 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES HDHP [308136802] 111.2 percent of total billed charges 86.18 132.05 Technical (Hospital) Services Ther Px 1/> Areas Each 15 Min Aqua Ther W/Xerss PX-4319711300 CDM 97113 CPT 431 RC outpatient 139 139 HEALTHPARTNERS SX009 HEALTHPARTNERS 111.2 percent of total billed charges 86.18 132.05 Technical (Hospital) Services Ther Px 1/> Areas Each 15 Min Aqua Ther W/Xerss PX-4319711300 CDM 97113 CPT 431 RC outpatient 139 139 UNITED HEALTHCARE (COMMERCIAL) [3081199] UNITED HEALTHCARE 87726 [308119901] 86.18 percent of total billed charges 86.18 132.05 Technical (Hospital) Services Ther Px 1/> Areas Each 15 Min Aqua Ther W/Xerss PX-4319711300 CDM 97113 CPT 431 RC outpatient 139 139 MEDICA (COMMERCIAL) 94265 [3081118] MEDICA CLAIMS [308111801] 125.1 percent of total billed charges 86.18 132.05 Technical (Hospital) Services Ther Px 1/> Areas Each 15 Min Aqua Ther W/Xerss PX-4319711300 CDM 97113 CPT 431 RC outpatient 139 139 CIGNA 62308 [3081051] CIGNA 62308 [308105105] 111.2 percent of total billed charges 86.18 132.05 Technical (Hospital) Services Ther Px 1/> Areas Each 15 Min Aqua Ther W/Xerss PX-4319711300 CDM 97113 CPT 431 RC outpatient 139 139 CIGNA 62308 [3081051] CIGNA STATE OF WYOMING [308105107] 111.2 percent of total billed charges 86.18 132.05 Technical (Hospital) Services Ther Px 1/> Areas Each 15 Min Aqua Ther W/Xerss PX-4319711300 CDM 97113 CPT 431 RC outpatient 139 139 MULTIPLAN INC 34080 [3081285] MULTIPLAN INC [308128501] 132.05 percent of total billed charges 86.18 132.05 Technical (Hospital) Services Ther Px 1/> Areas Each 15 Min Neuromusc Reeduca PX-4219711200 CDM 97112 CPT 421 RC outpatient 120 120 BLUE CROSS BLUE SHIELD WELLMARK SB889 [3081026] BCBS WYOMING [308102603] 114 percent of total billed charges 74.4 114 Technical (Hospital) Services Ther Px 1/> Areas Each 15 Min Neuromusc Reeduca PX-4219711200 CDM 97112 CPT 421 RC outpatient 120 120 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES HDHP [308136802] 96 percent of total billed charges 74.4 114 Technical (Hospital) Services Ther Px 1/> Areas Each 15 Min Neuromusc Reeduca PX-4219711200 CDM 97112 CPT 421 RC outpatient 120 120 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES EPO [308136803] 96 percent of total billed charges 74.4 114 Technical (Hospital) Services Ther Px 1/> Areas Each 15 Min Neuromusc Reeduca PX-4219711200 CDM 97112 CPT 421 RC outpatient 120 120 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES PPO [308136801] 96 percent of total billed charges 74.4 114 Technical (Hospital) Services Ther Px 1/> Areas Each 15 Min Neuromusc Reeduca PX-4219711200 CDM 97112 CPT 421 RC outpatient 120 120 UNITED HEALTHCARE (COMMERCIAL) [3081199] UNITED HEALTHCARE 87726 [308119901] 74.4 percent of total billed charges 74.4 114 Technical (Hospital) Services Ther Px 1/> Areas Each 15 Min Neuromusc Reeduca PX-4219711200 CDM 97112 CPT 421 RC outpatient 120 120 HEALTHPARTNERS SX009 HEALTHPARTNERS 96 percent of total billed charges 74.4 114 Technical (Hospital) Services Ther Px 1/> Areas Each 15 Min Neuromusc Reeduca PX-4219711200 CDM 97112 CPT 421 RC outpatient 120 120 MEDICA (COMMERCIAL) 94265 [3081118] MEDICA CLAIMS [308111801] 108 percent of total billed charges 74.4 114 Technical (Hospital) Services Ther Px 1/> Areas Each 15 Min Neuromusc Reeduca PX-4219711200 CDM 97112 CPT 421 RC outpatient 120 120 CIGNA 62308 [3081051] CIGNA 62308 [308105105] 96 percent of total billed charges 74.4 114 Technical (Hospital) Services Ther Px 1/> Areas Each 15 Min Neuromusc Reeduca PX-4219711200 CDM 97112 CPT 421 RC outpatient 120 120 CIGNA 62308 [3081051] CIGNA STATE OF WYOMING [308105107] 96 percent of total billed charges 74.4 114 Technical (Hospital) Services Ther Px 1/> Areas Each 15 Min Neuromusc Reeduca PX-4219711200 CDM 97112 CPT 421 RC outpatient 120 120 MULTIPLAN INC 34080 [3081285] MULTIPLAN INC [308128501] 114 percent of total billed charges 74.4 114 Technical (Hospital) Services Ther Px 1/> Areas Each 15 Min Neuromusc Reeduca PX-4219711200 CDM 97112 CPT 421 RC inpatient 120 120 HEALTHPARTNERS SX009 HEALTHPARTNERS 95.02 percent of total billed charges 74.4 114 Technical (Hospital) Services Ther Px 1/> Areas Each 15 Min Neuromusc Reeduca PX-4219711200 CDM 97112 CPT 421 RC inpatient 120 120 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES HDHP [308136802] 95.02 percent of total billed charges 74.4 114 Technical (Hospital) Services Ther Px 1/> Areas Each 15 Min Neuromusc Reeduca PX-4219711200 CDM 97112 CPT 421 RC inpatient 120 120 MULTIPLAN INC 34080 [3081285] MULTIPLAN INC [308128501] 114 percent of total billed charges 74.4 114 Technical (Hospital) Services Ther Px 1/> Areas Each 15 Min Neuromusc Reeduca PX-4219711200 CDM 97112 CPT 421 RC inpatient 120 120 MEDICA (COMMERCIAL) 94265 [3081118] MEDICA CLAIMS [308111801] 108 percent of total billed charges 74.4 114 Technical (Hospital) Services Ther Px 1/> Areas Each 15 Min Neuromusc Reeduca PX-4219711200 CDM 97112 CPT 421 RC inpatient 120 120 BLUE CROSS BLUE SHIELD WELLMARK SB889 [3081026] BCBS WYOMING [308102603] 114 percent of total billed charges 74.4 114 Technical (Hospital) Services Ther Px 1/> Areas Each 15 Min Neuromusc Reeduca PX-4219711200 CDM 97112 CPT 421 RC inpatient 120 120 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES PPO [308136801] 95.02 percent of total billed charges 74.4 114 Technical (Hospital) Services Ther Px 1/> Areas Each 15 Min Neuromusc Reeduca PX-4219711200 CDM 97112 CPT 421 RC inpatient 120 120 UNITED HEALTHCARE (COMMERCIAL) [3081199] UNITED HEALTHCARE 87726 [308119901] 74.4 percent of total billed charges 74.4 114 Technical (Hospital) Services Ther Px 1/> Areas Each 15 Min Neuromusc Reeduca PX-4219711200 CDM 97112 CPT 421 RC inpatient 120 120 CIGNA 62308 [3081051] CIGNA 62308 [308105105] 95.02 percent of total billed charges 74.4 114 Technical (Hospital) Services Ther Px 1/> Areas Each 15 Min Neuromusc Reeduca PX-4219711200 CDM 97112 CPT 421 RC inpatient 120 120 CIGNA 62308 [3081051] CIGNA STATE OF WYOMING [308105107] 95.02 percent of total billed charges 74.4 114 Technical (Hospital) Services Ther Px 1/> Areas Each 15 Min Neuromusc Reeduca PX-4219711200 CDM 97112 CPT 421 RC inpatient 120 120 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES EPO [308136803] 95.02 percent of total billed charges 74.4 114 Technical (Hospital) Services Ther Px 1/> Areas Each 15 Min Neuromusc Reeduca PX-4319711200 CDM 97112 CPT 431 RC inpatient 120 120 BLUE CROSS BLUE SHIELD WELLMARK SB889 [3081026] BCBS WYOMING [308102603] 114 percent of total billed charges 74.4 114 Technical (Hospital) Services Ther Px 1/> Areas Each 15 Min Neuromusc Reeduca PX-4319711200 CDM 97112 CPT 431 RC inpatient 120 120 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES HDHP [308136802] 95.02 percent of total billed charges 74.4 114 Technical (Hospital) Services Ther Px 1/> Areas Each 15 Min Neuromusc Reeduca PX-4319711200 CDM 97112 CPT 431 RC inpatient 120 120 UNITED HEALTHCARE (COMMERCIAL) [3081199] UNITED HEALTHCARE 87726 [308119901] 74.4 percent of total billed charges 74.4 114 Technical (Hospital) Services Ther Px 1/> Areas Each 15 Min Neuromusc Reeduca PX-4319711200 CDM 97112 CPT 431 RC inpatient 120 120 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES PPO [308136801] 95.02 percent of total billed charges 74.4 114 Technical (Hospital) Services Ther Px 1/> Areas Each 15 Min Neuromusc Reeduca PX-4319711200 CDM 97112 CPT 431 RC inpatient 120 120 HEALTHPARTNERS SX009 HEALTHPARTNERS 95.02 percent of total billed charges 74.4 114 Technical (Hospital) Services Ther Px 1/> Areas Each 15 Min Neuromusc Reeduca PX-4319711200 CDM 97112 CPT 431 RC inpatient 120 120 MEDICA (COMMERCIAL) 94265 [3081118] MEDICA CLAIMS [308111801] 108 percent of total billed charges 74.4 114 Technical (Hospital) Services Ther Px 1/> Areas Each 15 Min Neuromusc Reeduca PX-4319711200 CDM 97112 CPT 431 RC inpatient 120 120 MULTIPLAN INC 34080 [3081285] MULTIPLAN INC [308128501] 114 percent of total billed charges 74.4 114 Technical (Hospital) Services Ther Px 1/> Areas Each 15 Min Neuromusc Reeduca PX-4319711200 CDM 97112 CPT 431 RC inpatient 120 120 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES EPO [308136803] 95.02 percent of total billed charges 74.4 114 Technical (Hospital) Services Ther Px 1/> Areas Each 15 Min Neuromusc Reeduca PX-4319711200 CDM 97112 CPT 431 RC inpatient 120 120 CIGNA 62308 [3081051] CIGNA 62308 [308105105] 95.02 percent of total billed charges 74.4 114 Technical (Hospital) Services Ther Px 1/> Areas Each 15 Min Neuromusc Reeduca PX-4319711200 CDM 97112 CPT 431 RC inpatient 120 120 CIGNA 62308 [3081051] CIGNA STATE OF WYOMING [308105107] 95.02 percent of total billed charges 74.4 114 Technical (Hospital) Services Ther Px 1/> Areas Each 15 Min Neuromusc Reeduca PX-4319711200 CDM 97112 CPT 431 RC outpatient 120 120 MEDICA (COMMERCIAL) 94265 [3081118] MEDICA CLAIMS [308111801] 108 percent of total billed charges 74.4 114 Technical (Hospital) Services Ther Px 1/> Areas Each 15 Min Neuromusc Reeduca PX-4319711200 CDM 97112 CPT 431 RC outpatient 120 120 MULTIPLAN INC 34080 [3081285] MULTIPLAN INC [308128501] 114 percent of total billed charges 74.4 114 Technical (Hospital) Services Ther Px 1/> Areas Each 15 Min Neuromusc Reeduca PX-4319711200 CDM 97112 CPT 431 RC outpatient 120 120 CIGNA 62308 [3081051] CIGNA 62308 [308105105] 96 percent of total billed charges 74.4 114 Technical (Hospital) Services Ther Px 1/> Areas Each 15 Min Neuromusc Reeduca PX-4319711200 CDM 97112 CPT 431 RC outpatient 120 120 CIGNA 62308 [3081051] CIGNA STATE OF WYOMING [308105107] 96 percent of total billed charges 74.4 114 Technical (Hospital) Services Ther Px 1/> Areas Each 15 Min Neuromusc Reeduca PX-4319711200 CDM 97112 CPT 431 RC outpatient 120 120 UNITED HEALTHCARE (COMMERCIAL) [3081199] UNITED HEALTHCARE 87726 [308119901] 74.4 percent of total billed charges 74.4 114 Technical (Hospital) Services Ther Px 1/> Areas Each 15 Min Neuromusc Reeduca PX-4319711200 CDM 97112 CPT 431 RC outpatient 120 120 HEALTHPARTNERS SX009 HEALTHPARTNERS 96 percent of total billed charges 74.4 114 Technical (Hospital) Services Ther Px 1/> Areas Each 15 Min Neuromusc Reeduca PX-4319711200 CDM 97112 CPT 431 RC outpatient 120 120 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES EPO [308136803] 96 percent of total billed charges 74.4 114 Technical (Hospital) Services Ther Px 1/> Areas Each 15 Min Neuromusc Reeduca PX-4319711200 CDM 97112 CPT 431 RC outpatient 120 120 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES PPO [308136801] 96 percent of total billed charges 74.4 114 Technical (Hospital) Services Ther Px 1/> Areas Each 15 Min Neuromusc Reeduca PX-4319711200 CDM 97112 CPT 431 RC outpatient 120 120 BLUE CROSS BLUE SHIELD WELLMARK SB889 [3081026] BCBS WYOMING [308102603] 114 percent of total billed charges 74.4 114 Technical (Hospital) Services Ther Px 1/> Areas Each 15 Min Neuromusc Reeduca PX-4319711200 CDM 97112 CPT 431 RC outpatient 120 120 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES HDHP [308136802] 96 percent of total billed charges 74.4 114 Technical (Hospital) Services Therapeutic Px 1/> Areas Each 15 Min Exercises PX-4219711000 CDM 97110 CPT 421 RC inpatient 125 125 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES EPO [308136803] 98.98 percent of total billed charges 77.5 118.75 Technical (Hospital) Services Therapeutic Px 1/> Areas Each 15 Min Exercises PX-4219711000 CDM 97110 CPT 421 RC inpatient 125 125 CIGNA 62308 [3081051] CIGNA 62308 [308105105] 98.98 percent of total billed charges 77.5 118.75 Technical (Hospital) Services Therapeutic Px 1/> Areas Each 15 Min Exercises PX-4219711000 CDM 97110 CPT 421 RC inpatient 125 125 CIGNA 62308 [3081051] CIGNA STATE OF WYOMING [308105107] 98.98 percent of total billed charges 77.5 118.75 Technical (Hospital) Services Therapeutic Px 1/> Areas Each 15 Min Exercises PX-4219711000 CDM 97110 CPT 421 RC inpatient 125 125 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES HDHP [308136802] 98.98 percent of total billed charges 77.5 118.75 Technical (Hospital) Services Therapeutic Px 1/> Areas Each 15 Min Exercises PX-4219711000 CDM 97110 CPT 421 RC inpatient 125 125 MULTIPLAN INC 34080 [3081285] MULTIPLAN INC [308128501] 118.75 percent of total billed charges 77.5 118.75 Technical (Hospital) Services Therapeutic Px 1/> Areas Each 15 Min Exercises PX-4219711000 CDM 97110 CPT 421 RC inpatient 125 125 MEDICA (COMMERCIAL) 94265 [3081118] MEDICA CLAIMS [308111801] 112.5 percent of total billed charges 77.5 118.75 Technical (Hospital) Services Therapeutic Px 1/> Areas Each 15 Min Exercises PX-4219711000 CDM 97110 CPT 421 RC inpatient 125 125 HEALTHPARTNERS SX009 HEALTHPARTNERS 98.98 percent of total billed charges 77.5 118.75 Technical (Hospital) Services Therapeutic Px 1/> Areas Each 15 Min Exercises PX-4219711000 CDM 97110 CPT 421 RC inpatient 125 125 BLUE CROSS BLUE SHIELD WELLMARK SB889 [3081026] BCBS WYOMING [308102603] 118.75 percent of total billed charges 77.5 118.75 Technical (Hospital) Services Therapeutic Px 1/> Areas Each 15 Min Exercises PX-4219711000 CDM 97110 CPT 421 RC inpatient 125 125 UNITED HEALTHCARE (COMMERCIAL) [3081199] UNITED HEALTHCARE 87726 [308119901] 77.5 percent of total billed charges 77.5 118.75 Technical (Hospital) Services Therapeutic Px 1/> Areas Each 15 Min Exercises PX-4219711000 CDM 97110 CPT 421 RC inpatient 125 125 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES PPO [308136801] 98.98 percent of total billed charges 77.5 118.75 Technical (Hospital) Services Therapeutic Px 1/> Areas Each 15 Min Exercises PX-4219711000 CDM 97110 CPT 421 RC outpatient 125 125 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES HDHP [308136802] 100 percent of total billed charges 77.5 118.75 Technical (Hospital) Services Therapeutic Px 1/> Areas Each 15 Min Exercises PX-4219711000 CDM 97110 CPT 421 RC outpatient 125 125 BLUE CROSS BLUE SHIELD WELLMARK SB889 [3081026] BCBS WYOMING [308102603] 118.75 percent of total billed charges 77.5 118.75 Technical (Hospital) Services Therapeutic Px 1/> Areas Each 15 Min Exercises PX-4219711000 CDM 97110 CPT 421 RC outpatient 125 125 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES PPO [308136801] 100 percent of total billed charges 77.5 118.75 Technical (Hospital) Services Therapeutic Px 1/> Areas Each 15 Min Exercises PX-4219711000 CDM 97110 CPT 421 RC outpatient 125 125 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES EPO [308136803] 100 percent of total billed charges 77.5 118.75 Technical (Hospital) Services Therapeutic Px 1/> Areas Each 15 Min Exercises PX-4219711000 CDM 97110 CPT 421 RC outpatient 125 125 HEALTHPARTNERS SX009 HEALTHPARTNERS 100 percent of total billed charges 77.5 118.75 Technical (Hospital) Services Therapeutic Px 1/> Areas Each 15 Min Exercises PX-4219711000 CDM 97110 CPT 421 RC outpatient 125 125 UNITED HEALTHCARE (COMMERCIAL) [3081199] UNITED HEALTHCARE 87726 [308119901] 77.5 percent of total billed charges 77.5 118.75 Technical (Hospital) Services Therapeutic Px 1/> Areas Each 15 Min Exercises PX-4219711000 CDM 97110 CPT 421 RC outpatient 125 125 MEDICA (COMMERCIAL) 94265 [3081118] MEDICA CLAIMS [308111801] 112.5 percent of total billed charges 77.5 118.75 Technical (Hospital) Services Therapeutic Px 1/> Areas Each 15 Min Exercises PX-4219711000 CDM 97110 CPT 421 RC outpatient 125 125 CIGNA 62308 [3081051] CIGNA 62308 [308105105] 100 percent of total billed charges 77.5 118.75 Technical (Hospital) Services Therapeutic Px 1/> Areas Each 15 Min Exercises PX-4219711000 CDM 97110 CPT 421 RC outpatient 125 125 CIGNA 62308 [3081051] CIGNA STATE OF WYOMING [308105107] 100 percent of total billed charges 77.5 118.75 Technical (Hospital) Services Therapeutic Px 1/> Areas Each 15 Min Exercises PX-4219711000 CDM 97110 CPT 421 RC outpatient 125 125 MULTIPLAN INC 34080 [3081285] MULTIPLAN INC [308128501] 118.75 percent of total billed charges 77.5 118.75 Technical (Hospital) Services Therapeutic Px 1/> Areas Each 15 Min Exercises PX-4319711000 CDM 97110 CPT 431 RC outpatient 125 125 CIGNA 62308 [3081051] CIGNA 62308 [308105105] 100 percent of total billed charges 77.5 118.75 Technical (Hospital) Services Therapeutic Px 1/> Areas Each 15 Min Exercises PX-4319711000 CDM 97110 CPT 431 RC outpatient 125 125 CIGNA 62308 [3081051] CIGNA STATE OF WYOMING [308105107] 100 percent of total billed charges 77.5 118.75 Technical (Hospital) Services Therapeutic Px 1/> Areas Each 15 Min Exercises PX-4319711000 CDM 97110 CPT 431 RC outpatient 125 125 MEDICA (COMMERCIAL) 94265 [3081118] MEDICA CLAIMS [308111801] 112.5 percent of total billed charges 77.5 118.75 Technical (Hospital) Services Therapeutic Px 1/> Areas Each 15 Min Exercises PX-4319711000 CDM 97110 CPT 431 RC outpatient 125 125 MULTIPLAN INC 34080 [3081285] MULTIPLAN INC [308128501] 118.75 percent of total billed charges 77.5 118.75 Technical (Hospital) Services Therapeutic Px 1/> Areas Each 15 Min Exercises PX-4319711000 CDM 97110 CPT 431 RC outpatient 125 125 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES EPO [308136803] 100 percent of total billed charges 77.5 118.75 Technical (Hospital) Services Therapeutic Px 1/> Areas Each 15 Min Exercises PX-4319711000 CDM 97110 CPT 431 RC outpatient 125 125 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES PPO [308136801] 100 percent of total billed charges 77.5 118.75 Technical (Hospital) Services Therapeutic Px 1/> Areas Each 15 Min Exercises PX-4319711000 CDM 97110 CPT 431 RC outpatient 125 125 BLUE CROSS BLUE SHIELD WELLMARK SB889 [3081026] BCBS WYOMING [308102603] 118.75 percent of total billed charges 77.5 118.75 Technical (Hospital) Services Therapeutic Px 1/> Areas Each 15 Min Exercises PX-4319711000 CDM 97110 CPT 431 RC outpatient 125 125 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES HDHP [308136802] 100 percent of total billed charges 77.5 118.75 Technical (Hospital) Services Therapeutic Px 1/> Areas Each 15 Min Exercises PX-4319711000 CDM 97110 CPT 431 RC outpatient 125 125 UNITED HEALTHCARE (COMMERCIAL) [3081199] UNITED HEALTHCARE 87726 [308119901] 77.5 percent of total billed charges 77.5 118.75 Technical (Hospital) Services Therapeutic Px 1/> Areas Each 15 Min Exercises PX-4319711000 CDM 97110 CPT 431 RC outpatient 125 125 HEALTHPARTNERS SX009 HEALTHPARTNERS 100 percent of total billed charges 77.5 118.75 Technical (Hospital) Services Therapeutic Px 1/> Areas Each 15 Min Exercises PX-4319711000 CDM 97110 CPT 431 RC inpatient 125 125 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES EPO [308136803] 98.98 percent of total billed charges 77.5 118.75 Technical (Hospital) Services Therapeutic Px 1/> Areas Each 15 Min Exercises PX-4319711000 CDM 97110 CPT 431 RC inpatient 125 125 CIGNA 62308 [3081051] CIGNA 62308 [308105105] 98.98 percent of total billed charges 77.5 118.75 Technical (Hospital) Services Therapeutic Px 1/> Areas Each 15 Min Exercises PX-4319711000 CDM 97110 CPT 431 RC inpatient 125 125 CIGNA 62308 [3081051] CIGNA STATE OF WYOMING [308105107] 98.98 percent of total billed charges 77.5 118.75 Technical (Hospital) Services Therapeutic Px 1/> Areas Each 15 Min Exercises PX-4319711000 CDM 97110 CPT 431 RC inpatient 125 125 BLUE CROSS BLUE SHIELD WELLMARK SB889 [3081026] BCBS WYOMING [308102603] 118.75 percent of total billed charges 77.5 118.75 Technical (Hospital) Services Therapeutic Px 1/> Areas Each 15 Min Exercises PX-4319711000 CDM 97110 CPT 431 RC inpatient 125 125 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES HDHP [308136802] 98.98 percent of total billed charges 77.5 118.75 Technical (Hospital) Services Therapeutic Px 1/> Areas Each 15 Min Exercises PX-4319711000 CDM 97110 CPT 431 RC inpatient 125 125 UNITED HEALTHCARE (COMMERCIAL) [3081199] UNITED HEALTHCARE 87726 [308119901] 77.5 percent of total billed charges 77.5 118.75 Technical (Hospital) Services Therapeutic Px 1/> Areas Each 15 Min Exercises PX-4319711000 CDM 97110 CPT 431 RC inpatient 125 125 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES PPO [308136801] 98.98 percent of total billed charges 77.5 118.75 Technical (Hospital) Services Therapeutic Px 1/> Areas Each 15 Min Exercises PX-4319711000 CDM 97110 CPT 431 RC inpatient 125 125 HEALTHPARTNERS SX009 HEALTHPARTNERS 98.98 percent of total billed charges 77.5 118.75 Technical (Hospital) Services Therapeutic Px 1/> Areas Each 15 Min Exercises PX-4319711000 CDM 97110 CPT 431 RC inpatient 125 125 MEDICA (COMMERCIAL) 94265 [3081118] MEDICA CLAIMS [308111801] 112.5 percent of total billed charges 77.5 118.75 Technical (Hospital) Services Therapeutic Px 1/> Areas Each 15 Min Exercises PX-4319711000 CDM 97110 CPT 431 RC inpatient 125 125 MULTIPLAN INC 34080 [3081285] MULTIPLAN INC [308128501] 118.75 percent of total billed charges 77.5 118.75 Technical (Hospital) Services Appl Modality 1/> Areas Ultrasound Ea 15 Min PX-4209703500 CDM 97035 CPT 420 RC inpatient 87 87 CIGNA 62308 [3081051] CIGNA 62308 [308105105] 68.89 percent of total billed charges 53.94 82.65 Technical (Hospital) Services Appl Modality 1/> Areas Ultrasound Ea 15 Min PX-4209703500 CDM 97035 CPT 420 RC inpatient 87 87 CIGNA 62308 [3081051] CIGNA STATE OF WYOMING [308105107] 68.89 percent of total billed charges 53.94 82.65 Technical (Hospital) Services Appl Modality 1/> Areas Ultrasound Ea 15 Min PX-4209703500 CDM 97035 CPT 420 RC inpatient 87 87 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES EPO [308136803] 68.89 percent of total billed charges 53.94 82.65 Technical (Hospital) Services Appl Modality 1/> Areas Ultrasound Ea 15 Min PX-4209703500 CDM 97035 CPT 420 RC inpatient 87 87 MEDICA (COMMERCIAL) 94265 [3081118] MEDICA CLAIMS [308111801] 78.3 percent of total billed charges 53.94 82.65 Technical (Hospital) Services Appl Modality 1/> Areas Ultrasound Ea 15 Min PX-4209703500 CDM 97035 CPT 420 RC inpatient 87 87 MULTIPLAN INC 34080 [3081285] MULTIPLAN INC [308128501] 82.65 percent of total billed charges 53.94 82.65 Technical (Hospital) Services Appl Modality 1/> Areas Ultrasound Ea 15 Min PX-4209703500 CDM 97035 CPT 420 RC inpatient 87 87 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES HDHP [308136802] 68.89 percent of total billed charges 53.94 82.65 Technical (Hospital) Services Appl Modality 1/> Areas Ultrasound Ea 15 Min PX-4209703500 CDM 97035 CPT 420 RC inpatient 87 87 HEALTHPARTNERS SX009 HEALTHPARTNERS 68.89 percent of total billed charges 53.94 82.65 Technical (Hospital) Services Appl Modality 1/> Areas Ultrasound Ea 15 Min PX-4209703500 CDM 97035 CPT 420 RC inpatient 87 87 UNITED HEALTHCARE (COMMERCIAL) [3081199] UNITED HEALTHCARE 87726 [308119901] 53.94 percent of total billed charges 53.94 82.65 Technical (Hospital) Services Appl Modality 1/> Areas Ultrasound Ea 15 Min PX-4209703500 CDM 97035 CPT 420 RC inpatient 87 87 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES PPO [308136801] 68.89 percent of total billed charges 53.94 82.65 Technical (Hospital) Services Appl Modality 1/> Areas Ultrasound Ea 15 Min PX-4209703500 CDM 97035 CPT 420 RC inpatient 87 87 BLUE CROSS BLUE SHIELD WELLMARK SB889 [3081026] BCBS WYOMING [308102603] 82.65 percent of total billed charges 53.94 82.65 Technical (Hospital) Services Appl Modality 1/> Areas Ultrasound Ea 15 Min PX-4209703500 CDM 97035 CPT 420 RC outpatient 87 87 MEDICA (COMMERCIAL) 94265 [3081118] MEDICA CLAIMS [308111801] 78.3 percent of total billed charges 53.94 82.65 Technical (Hospital) Services Appl Modality 1/> Areas Ultrasound Ea 15 Min PX-4209703500 CDM 97035 CPT 420 RC outpatient 87 87 MULTIPLAN INC 34080 [3081285] MULTIPLAN INC [308128501] 82.65 percent of total billed charges 53.94 82.65 Technical (Hospital) Services Appl Modality 1/> Areas Ultrasound Ea 15 Min PX-4209703500 CDM 97035 CPT 420 RC outpatient 87 87 CIGNA 62308 [3081051] CIGNA 62308 [308105105] 69.6 percent of total billed charges 53.94 82.65 Technical (Hospital) Services Appl Modality 1/> Areas Ultrasound Ea 15 Min PX-4209703500 CDM 97035 CPT 420 RC outpatient 87 87 CIGNA 62308 [3081051] CIGNA STATE OF WYOMING [308105107] 69.6 percent of total billed charges 53.94 82.65 Technical (Hospital) Services Appl Modality 1/> Areas Ultrasound Ea 15 Min PX-4209703500 CDM 97035 CPT 420 RC outpatient 87 87 BLUE CROSS BLUE SHIELD WELLMARK SB889 [3081026] BCBS WYOMING [308102603] 82.65 percent of total billed charges 53.94 82.65 Technical (Hospital) Services Appl Modality 1/> Areas Ultrasound Ea 15 Min PX-4209703500 CDM 97035 CPT 420 RC outpatient 87 87 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES HDHP [308136802] 69.6 percent of total billed charges 53.94 82.65 Technical (Hospital) Services Appl Modality 1/> Areas Ultrasound Ea 15 Min PX-4209703500 CDM 97035 CPT 420 RC outpatient 87 87 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES EPO [308136803] 69.6 percent of total billed charges 53.94 82.65 Technical (Hospital) Services Appl Modality 1/> Areas Ultrasound Ea 15 Min PX-4209703500 CDM 97035 CPT 420 RC outpatient 87 87 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES PPO [308136801] 69.6 percent of total billed charges 53.94 82.65 Technical (Hospital) Services Appl Modality 1/> Areas Ultrasound Ea 15 Min PX-4209703500 CDM 97035 CPT 420 RC outpatient 87 87 UNITED HEALTHCARE (COMMERCIAL) [3081199] UNITED HEALTHCARE 87726 [308119901] 53.94 percent of total billed charges 53.94 82.65 Technical (Hospital) Services Appl Modality 1/> Areas Ultrasound Ea 15 Min PX-4209703500 CDM 97035 CPT 420 RC outpatient 87 87 HEALTHPARTNERS SX009 HEALTHPARTNERS 69.6 percent of total billed charges 53.94 82.65 Technical (Hospital) Services Appl Modality 1/> Areas Ultrasound Ea 15 Min PX-4309703500 CDM 97035 CPT 430 RC inpatient 87 87 CIGNA 62308 [3081051] CIGNA 62308 [308105105] 68.89 percent of total billed charges 53.94 82.65 Technical (Hospital) Services Appl Modality 1/> Areas Ultrasound Ea 15 Min PX-4309703500 CDM 97035 CPT 430 RC inpatient 87 87 CIGNA 62308 [3081051] CIGNA STATE OF WYOMING [308105107] 68.89 percent of total billed charges 53.94 82.65 Technical (Hospital) Services Appl Modality 1/> Areas Ultrasound Ea 15 Min PX-4309703500 CDM 97035 CPT 430 RC inpatient 87 87 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES EPO [308136803] 68.89 percent of total billed charges 53.94 82.65 Technical (Hospital) Services Appl Modality 1/> Areas Ultrasound Ea 15 Min PX-4309703500 CDM 97035 CPT 430 RC inpatient 87 87 HEALTHPARTNERS SX009 HEALTHPARTNERS 68.89 percent of total billed charges 53.94 82.65 Technical (Hospital) Services Appl Modality 1/> Areas Ultrasound Ea 15 Min PX-4309703500 CDM 97035 CPT 430 RC inpatient 87 87 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES HDHP [308136802] 68.89 percent of total billed charges 53.94 82.65 Technical (Hospital) Services Appl Modality 1/> Areas Ultrasound Ea 15 Min PX-4309703500 CDM 97035 CPT 430 RC inpatient 87 87 MULTIPLAN INC 34080 [3081285] MULTIPLAN INC [308128501] 82.65 percent of total billed charges 53.94 82.65 Technical (Hospital) Services Appl Modality 1/> Areas Ultrasound Ea 15 Min PX-4309703500 CDM 97035 CPT 430 RC inpatient 87 87 MEDICA (COMMERCIAL) 94265 [3081118] MEDICA CLAIMS [308111801] 78.3 percent of total billed charges 53.94 82.65 Technical (Hospital) Services Appl Modality 1/> Areas Ultrasound Ea 15 Min PX-4309703500 CDM 97035 CPT 430 RC inpatient 87 87 BLUE CROSS BLUE SHIELD WELLMARK SB889 [3081026] BCBS WYOMING [308102603] 82.65 percent of total billed charges 53.94 82.65 Technical (Hospital) Services Appl Modality 1/> Areas Ultrasound Ea 15 Min PX-4309703500 CDM 97035 CPT 430 RC inpatient 87 87 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES PPO [308136801] 68.89 percent of total billed charges 53.94 82.65 Technical (Hospital) Services Appl Modality 1/> Areas Ultrasound Ea 15 Min PX-4309703500 CDM 97035 CPT 430 RC inpatient 87 87 UNITED HEALTHCARE (COMMERCIAL) [3081199] UNITED HEALTHCARE 87726 [308119901] 53.94 percent of total billed charges 53.94 82.65 Technical (Hospital) Services Appl Modality 1/> Areas Ultrasound Ea 15 Min PX-4309703500 CDM 97035 CPT 430 RC outpatient 87 87 UNITED HEALTHCARE (COMMERCIAL) [3081199] UNITED HEALTHCARE 87726 [308119901] 53.94 percent of total billed charges 53.94 82.65 Technical (Hospital) Services Appl Modality 1/> Areas Ultrasound Ea 15 Min PX-4309703500 CDM 97035 CPT 430 RC outpatient 87 87 HEALTHPARTNERS SX009 HEALTHPARTNERS 69.6 percent of total billed charges 53.94 82.65 Technical (Hospital) Services Appl Modality 1/> Areas Ultrasound Ea 15 Min PX-4309703500 CDM 97035 CPT 430 RC outpatient 87 87 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES EPO [308136803] 69.6 percent of total billed charges 53.94 82.65 Technical (Hospital) Services Appl Modality 1/> Areas Ultrasound Ea 15 Min PX-4309703500 CDM 97035 CPT 430 RC outpatient 87 87 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES PPO [308136801] 69.6 percent of total billed charges 53.94 82.65 Technical (Hospital) Services Appl Modality 1/> Areas Ultrasound Ea 15 Min PX-4309703500 CDM 97035 CPT 430 RC outpatient 87 87 BLUE CROSS BLUE SHIELD WELLMARK SB889 [3081026] BCBS WYOMING [308102603] 82.65 percent of total billed charges 53.94 82.65 Technical (Hospital) Services Appl Modality 1/> Areas Ultrasound Ea 15 Min PX-4309703500 CDM 97035 CPT 430 RC outpatient 87 87 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES HDHP [308136802] 69.6 percent of total billed charges 53.94 82.65 Technical (Hospital) Services Appl Modality 1/> Areas Ultrasound Ea 15 Min PX-4309703500 CDM 97035 CPT 430 RC outpatient 87 87 MULTIPLAN INC 34080 [3081285] MULTIPLAN INC [308128501] 82.65 percent of total billed charges 53.94 82.65 Technical (Hospital) Services Appl Modality 1/> Areas Ultrasound Ea 15 Min PX-4309703500 CDM 97035 CPT 430 RC outpatient 87 87 CIGNA 62308 [3081051] CIGNA 62308 [308105105] 69.6 percent of total billed charges 53.94 82.65 Technical (Hospital) Services Appl Modality 1/> Areas Ultrasound Ea 15 Min PX-4309703500 CDM 97035 CPT 430 RC outpatient 87 87 CIGNA 62308 [3081051] CIGNA STATE OF WYOMING [308105107] 69.6 percent of total billed charges 53.94 82.65 Technical (Hospital) Services Appl Modality 1/> Areas Ultrasound Ea 15 Min PX-4309703500 CDM 97035 CPT 430 RC outpatient 87 87 MEDICA (COMMERCIAL) 94265 [3081118] MEDICA CLAIMS [308111801] 78.3 percent of total billed charges 53.94 82.65 Technical (Hospital) Services Appl Modality 1/> Areas Iontophoresis Ea 15 Min PX-4209703300 CDM 97033 CPT 420 RC inpatient 103 103 HEALTHPARTNERS SX009 HEALTHPARTNERS 81.56 percent of total billed charges 63.86 97.85 Technical (Hospital) Services Appl Modality 1/> Areas Iontophoresis Ea 15 Min PX-4209703300 CDM 97033 CPT 420 RC inpatient 103 103 MEDICA (COMMERCIAL) 94265 [3081118] MEDICA CLAIMS [308111801] 92.7 percent of total billed charges 63.86 97.85 Technical (Hospital) Services Appl Modality 1/> Areas Iontophoresis Ea 15 Min PX-4209703300 CDM 97033 CPT 420 RC inpatient 103 103 MULTIPLAN INC 34080 [3081285] MULTIPLAN INC [308128501] 97.85 percent of total billed charges 63.86 97.85 Technical (Hospital) Services Appl Modality 1/> Areas Iontophoresis Ea 15 Min PX-4209703300 CDM 97033 CPT 420 RC inpatient 103 103 UNITED HEALTHCARE (COMMERCIAL) [3081199] UNITED HEALTHCARE 87726 [308119901] 63.86 percent of total billed charges 63.86 97.85 Technical (Hospital) Services Appl Modality 1/> Areas Iontophoresis Ea 15 Min PX-4209703300 CDM 97033 CPT 420 RC inpatient 103 103 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES PPO [308136801] 81.56 percent of total billed charges 63.86 97.85 Technical (Hospital) Services Appl Modality 1/> Areas Iontophoresis Ea 15 Min PX-4209703300 CDM 97033 CPT 420 RC inpatient 103 103 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES HDHP [308136802] 81.56 percent of total billed charges 63.86 97.85 Technical (Hospital) Services Appl Modality 1/> Areas Iontophoresis Ea 15 Min PX-4209703300 CDM 97033 CPT 420 RC inpatient 103 103 BLUE CROSS BLUE SHIELD WELLMARK SB889 [3081026] BCBS WYOMING [308102603] 97.85 percent of total billed charges 63.86 97.85 Technical (Hospital) Services Appl Modality 1/> Areas Iontophoresis Ea 15 Min PX-4209703300 CDM 97033 CPT 420 RC inpatient 103 103 CIGNA 62308 [3081051] CIGNA 62308 [308105105] 81.56 percent of total billed charges 63.86 97.85 Technical (Hospital) Services Appl Modality 1/> Areas Iontophoresis Ea 15 Min PX-4209703300 CDM 97033 CPT 420 RC inpatient 103 103 CIGNA 62308 [3081051] CIGNA STATE OF WYOMING [308105107] 81.56 percent of total billed charges 63.86 97.85 Technical (Hospital) Services Appl Modality 1/> Areas Iontophoresis Ea 15 Min PX-4209703300 CDM 97033 CPT 420 RC inpatient 103 103 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES EPO [308136803] 81.56 percent of total billed charges 63.86 97.85 Technical (Hospital) Services Appl Modality 1/> Areas Iontophoresis Ea 15 Min PX-4209703300 CDM 97033 CPT 420 RC outpatient 103 103 MULTIPLAN INC 34080 [3081285] MULTIPLAN INC [308128501] 97.85 percent of total billed charges 63.86 97.85 Technical (Hospital) Services Appl Modality 1/> Areas Iontophoresis Ea 15 Min PX-4209703300 CDM 97033 CPT 420 RC outpatient 103 103 CIGNA 62308 [3081051] CIGNA 62308 [308105105] 82.4 percent of total billed charges 63.86 97.85 Technical (Hospital) Services Appl Modality 1/> Areas Iontophoresis Ea 15 Min PX-4209703300 CDM 97033 CPT 420 RC outpatient 103 103 CIGNA 62308 [3081051] CIGNA STATE OF WYOMING [308105107] 82.4 percent of total billed charges 63.86 97.85 Technical (Hospital) Services Appl Modality 1/> Areas Iontophoresis Ea 15 Min PX-4209703300 CDM 97033 CPT 420 RC outpatient 103 103 MEDICA (COMMERCIAL) 94265 [3081118] MEDICA CLAIMS [308111801] 92.7 percent of total billed charges 63.86 97.85 Technical (Hospital) Services Appl Modality 1/> Areas Iontophoresis Ea 15 Min PX-4209703300 CDM 97033 CPT 420 RC outpatient 103 103 HEALTHPARTNERS SX009 HEALTHPARTNERS 82.4 percent of total billed charges 63.86 97.85 Technical (Hospital) Services Appl Modality 1/> Areas Iontophoresis Ea 15 Min PX-4209703300 CDM 97033 CPT 420 RC outpatient 103 103 UNITED HEALTHCARE (COMMERCIAL) [3081199] UNITED HEALTHCARE 87726 [308119901] 63.86 percent of total billed charges 63.86 97.85 Technical (Hospital) Services Appl Modality 1/> Areas Iontophoresis Ea 15 Min PX-4209703300 CDM 97033 CPT 420 RC outpatient 103 103 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES PPO [308136801] 82.4 percent of total billed charges 63.86 97.85 Technical (Hospital) Services Appl Modality 1/> Areas Iontophoresis Ea 15 Min PX-4209703300 CDM 97033 CPT 420 RC outpatient 103 103 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES EPO [308136803] 82.4 percent of total billed charges 63.86 97.85 Technical (Hospital) Services Appl Modality 1/> Areas Iontophoresis Ea 15 Min PX-4209703300 CDM 97033 CPT 420 RC outpatient 103 103 BLUE CROSS BLUE SHIELD WELLMARK SB889 [3081026] BCBS WYOMING [308102603] 97.85 percent of total billed charges 63.86 97.85 Technical (Hospital) Services Appl Modality 1/> Areas Iontophoresis Ea 15 Min PX-4209703300 CDM 97033 CPT 420 RC outpatient 103 103 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES HDHP [308136802] 82.4 percent of total billed charges 63.86 97.85 Technical (Hospital) Services Appl Modality 1/> Areas Iontophoresis Ea 15 Min PX-4309703300 CDM 97033 CPT 430 RC inpatient 103 103 BLUE CROSS BLUE SHIELD WELLMARK SB889 [3081026] BCBS WYOMING [308102603] 97.85 percent of total billed charges 63.86 97.85 Technical (Hospital) Services Appl Modality 1/> Areas Iontophoresis Ea 15 Min PX-4309703300 CDM 97033 CPT 430 RC inpatient 103 103 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES PPO [308136801] 81.56 percent of total billed charges 63.86 97.85 Technical (Hospital) Services Appl Modality 1/> Areas Iontophoresis Ea 15 Min PX-4309703300 CDM 97033 CPT 430 RC inpatient 103 103 UNITED HEALTHCARE (COMMERCIAL) [3081199] UNITED HEALTHCARE 87726 [308119901] 63.86 percent of total billed charges 63.86 97.85 Technical (Hospital) Services Appl Modality 1/> Areas Iontophoresis Ea 15 Min PX-4309703300 CDM 97033 CPT 430 RC inpatient 103 103 HEALTHPARTNERS SX009 HEALTHPARTNERS 81.56 percent of total billed charges 63.86 97.85 Technical (Hospital) Services Appl Modality 1/> Areas Iontophoresis Ea 15 Min PX-4309703300 CDM 97033 CPT 430 RC inpatient 103 103 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES HDHP [308136802] 81.56 percent of total billed charges 63.86 97.85 Technical (Hospital) Services Appl Modality 1/> Areas Iontophoresis Ea 15 Min PX-4309703300 CDM 97033 CPT 430 RC inpatient 103 103 MULTIPLAN INC 34080 [3081285] MULTIPLAN INC [308128501] 97.85 percent of total billed charges 63.86 97.85 Technical (Hospital) Services Appl Modality 1/> Areas Iontophoresis Ea 15 Min PX-4309703300 CDM 97033 CPT 430 RC inpatient 103 103 MEDICA (COMMERCIAL) 94265 [3081118] MEDICA CLAIMS [308111801] 92.7 percent of total billed charges 63.86 97.85 Technical (Hospital) Services Appl Modality 1/> Areas Iontophoresis Ea 15 Min PX-4309703300 CDM 97033 CPT 430 RC inpatient 103 103 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES EPO [308136803] 81.56 percent of total billed charges 63.86 97.85 Technical (Hospital) Services Appl Modality 1/> Areas Iontophoresis Ea 15 Min PX-4309703300 CDM 97033 CPT 430 RC inpatient 103 103 CIGNA 62308 [3081051] CIGNA 62308 [308105105] 81.56 percent of total billed charges 63.86 97.85 Technical (Hospital) Services Appl Modality 1/> Areas Iontophoresis Ea 15 Min PX-4309703300 CDM 97033 CPT 430 RC inpatient 103 103 CIGNA 62308 [3081051] CIGNA STATE OF WYOMING [308105107] 81.56 percent of total billed charges 63.86 97.85 Technical (Hospital) Services Appl Modality 1/> Areas Iontophoresis Ea 15 Min PX-4309703300 CDM 97033 CPT 430 RC outpatient 103 103 MEDICA (COMMERCIAL) 94265 [3081118] MEDICA CLAIMS [308111801] 92.7 percent of total billed charges 63.86 97.85 Technical (Hospital) Services Appl Modality 1/> Areas Iontophoresis Ea 15 Min PX-4309703300 CDM 97033 CPT 430 RC outpatient 103 103 MULTIPLAN INC 34080 [3081285] MULTIPLAN INC [308128501] 97.85 percent of total billed charges 63.86 97.85 Technical (Hospital) Services Appl Modality 1/> Areas Iontophoresis Ea 15 Min PX-4309703300 CDM 97033 CPT 430 RC outpatient 103 103 CIGNA 62308 [3081051] CIGNA 62308 [308105105] 82.4 percent of total billed charges 63.86 97.85 Technical (Hospital) Services Appl Modality 1/> Areas Iontophoresis Ea 15 Min PX-4309703300 CDM 97033 CPT 430 RC outpatient 103 103 CIGNA 62308 [3081051] CIGNA STATE OF WYOMING [308105107] 82.4 percent of total billed charges 63.86 97.85 Technical (Hospital) Services Appl Modality 1/> Areas Iontophoresis Ea 15 Min PX-4309703300 CDM 97033 CPT 430 RC outpatient 103 103 BLUE CROSS BLUE SHIELD WELLMARK SB889 [3081026] BCBS WYOMING [308102603] 97.85 percent of total billed charges 63.86 97.85 Technical (Hospital) Services Appl Modality 1/> Areas Iontophoresis Ea 15 Min PX-4309703300 CDM 97033 CPT 430 RC outpatient 103 103 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES HDHP [308136802] 82.4 percent of total billed charges 63.86 97.85 Technical (Hospital) Services Appl Modality 1/> Areas Iontophoresis Ea 15 Min PX-4309703300 CDM 97033 CPT 430 RC outpatient 103 103 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES EPO [308136803] 82.4 percent of total billed charges 63.86 97.85 Technical (Hospital) Services Appl Modality 1/> Areas Iontophoresis Ea 15 Min PX-4309703300 CDM 97033 CPT 430 RC outpatient 103 103 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES PPO [308136801] 82.4 percent of total billed charges 63.86 97.85 Technical (Hospital) Services Appl Modality 1/> Areas Iontophoresis Ea 15 Min PX-4309703300 CDM 97033 CPT 430 RC outpatient 103 103 UNITED HEALTHCARE (COMMERCIAL) [3081199] UNITED HEALTHCARE 87726 [308119901] 63.86 percent of total billed charges 63.86 97.85 Technical (Hospital) Services Appl Modality 1/> Areas Iontophoresis Ea 15 Min PX-4309703300 CDM 97033 CPT 430 RC outpatient 103 103 HEALTHPARTNERS SX009 HEALTHPARTNERS 82.4 percent of total billed charges 63.86 97.85 Technical (Hospital) Services Appl Modality 1/> Areas Elec Stimj Ea 15 Min PX-4209703200 CDM 97032 CPT 420 RC inpatient 72 72 CIGNA 62308 [3081051] CIGNA 62308 [308105105] 57.01 percent of total billed charges 44.64 68.4 Technical (Hospital) Services Appl Modality 1/> Areas Elec Stimj Ea 15 Min PX-4209703200 CDM 97032 CPT 420 RC inpatient 72 72 CIGNA 62308 [3081051] CIGNA STATE OF WYOMING [308105107] 57.01 percent of total billed charges 44.64 68.4 Technical (Hospital) Services Appl Modality 1/> Areas Elec Stimj Ea 15 Min PX-4209703200 CDM 97032 CPT 420 RC inpatient 72 72 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES EPO [308136803] 57.01 percent of total billed charges 44.64 68.4 Technical (Hospital) Services Appl Modality 1/> Areas Elec Stimj Ea 15 Min PX-4209703200 CDM 97032 CPT 420 RC inpatient 72 72 HEALTHPARTNERS SX009 HEALTHPARTNERS 57.01 percent of total billed charges 44.64 68.4 Technical (Hospital) Services Appl Modality 1/> Areas Elec Stimj Ea 15 Min PX-4209703200 CDM 97032 CPT 420 RC inpatient 72 72 MEDICA (COMMERCIAL) 94265 [3081118] MEDICA CLAIMS [308111801] 64.8 percent of total billed charges 44.64 68.4 Technical (Hospital) Services Appl Modality 1/> Areas Elec Stimj Ea 15 Min PX-4209703200 CDM 97032 CPT 420 RC inpatient 72 72 MULTIPLAN INC 34080 [3081285] MULTIPLAN INC [308128501] 68.4 percent of total billed charges 44.64 68.4 Technical (Hospital) Services Appl Modality 1/> Areas Elec Stimj Ea 15 Min PX-4209703200 CDM 97032 CPT 420 RC inpatient 72 72 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES HDHP [308136802] 57.01 percent of total billed charges 44.64 68.4 Technical (Hospital) Services Appl Modality 1/> Areas Elec Stimj Ea 15 Min PX-4209703200 CDM 97032 CPT 420 RC inpatient 72 72 UNITED HEALTHCARE (COMMERCIAL) [3081199] UNITED HEALTHCARE 87726 [308119901] 44.64 percent of total billed charges 44.64 68.4 Technical (Hospital) Services Appl Modality 1/> Areas Elec Stimj Ea 15 Min PX-4209703200 CDM 97032 CPT 420 RC inpatient 72 72 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES PPO [308136801] 57.01 percent of total billed charges 44.64 68.4 Technical (Hospital) Services Appl Modality 1/> Areas Elec Stimj Ea 15 Min PX-4209703200 CDM 97032 CPT 420 RC inpatient 72 72 BLUE CROSS BLUE SHIELD WELLMARK SB889 [3081026] BCBS WYOMING [308102603] 68.4 percent of total billed charges 44.64 68.4 Technical (Hospital) Services Appl Modality 1/> Areas Elec Stimj Ea 15 Min PX-4209703200 CDM 97032 CPT 420 RC outpatient 72 72 MEDICA (COMMERCIAL) 94265 [3081118] MEDICA CLAIMS [308111801] 64.8 percent of total billed charges 44.64 68.4 Technical (Hospital) Services Appl Modality 1/> Areas Elec Stimj Ea 15 Min PX-4209703200 CDM 97032 CPT 420 RC outpatient 72 72 MULTIPLAN INC 34080 [3081285] MULTIPLAN INC [308128501] 68.4 percent of total billed charges 44.64 68.4 Technical (Hospital) Services Appl Modality 1/> Areas Elec Stimj Ea 15 Min PX-4209703200 CDM 97032 CPT 420 RC outpatient 72 72 CIGNA 62308 [3081051] CIGNA 62308 [308105105] 57.6 percent of total billed charges 44.64 68.4 Technical (Hospital) Services Appl Modality 1/> Areas Elec Stimj Ea 15 Min PX-4209703200 CDM 97032 CPT 420 RC outpatient 72 72 CIGNA 62308 [3081051] CIGNA STATE OF WYOMING [308105107] 57.6 percent of total billed charges 44.64 68.4 Technical (Hospital) Services Appl Modality 1/> Areas Elec Stimj Ea 15 Min PX-4209703200 CDM 97032 CPT 420 RC outpatient 72 72 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES HDHP [308136802] 57.6 percent of total billed charges 44.64 68.4 Technical (Hospital) Services Appl Modality 1/> Areas Elec Stimj Ea 15 Min PX-4209703200 CDM 97032 CPT 420 RC outpatient 72 72 BLUE CROSS BLUE SHIELD WELLMARK SB889 [3081026] BCBS WYOMING [308102603] 68.4 percent of total billed charges 44.64 68.4 Technical (Hospital) Services Appl Modality 1/> Areas Elec Stimj Ea 15 Min PX-4209703200 CDM 97032 CPT 420 RC outpatient 72 72 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES PPO [308136801] 57.6 percent of total billed charges 44.64 68.4 Technical (Hospital) Services Appl Modality 1/> Areas Elec Stimj Ea 15 Min PX-4209703200 CDM 97032 CPT 420 RC outpatient 72 72 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES EPO [308136803] 57.6 percent of total billed charges 44.64 68.4 Technical (Hospital) Services Appl Modality 1/> Areas Elec Stimj Ea 15 Min PX-4209703200 CDM 97032 CPT 420 RC outpatient 72 72 UNITED HEALTHCARE (COMMERCIAL) [3081199] UNITED HEALTHCARE 87726 [308119901] 44.64 percent of total billed charges 44.64 68.4 Technical (Hospital) Services Appl Modality 1/> Areas Elec Stimj Ea 15 Min PX-4209703200 CDM 97032 CPT 420 RC outpatient 72 72 HEALTHPARTNERS SX009 HEALTHPARTNERS 57.6 percent of total billed charges 44.64 68.4 Technical (Hospital) Services Appl Modality 1/> Areas Elec Stimj Ea 15 Min PX-4309703200 CDM 97032 CPT 430 RC outpatient 72 72 MULTIPLAN INC 34080 [3081285] MULTIPLAN INC [308128501] 68.4 percent of total billed charges 44.64 68.4 Technical (Hospital) Services Appl Modality 1/> Areas Elec Stimj Ea 15 Min PX-4309703200 CDM 97032 CPT 430 RC outpatient 72 72 MEDICA (COMMERCIAL) 94265 [3081118] MEDICA CLAIMS [308111801] 64.8 percent of total billed charges 44.64 68.4 Technical (Hospital) Services Appl Modality 1/> Areas Elec Stimj Ea 15 Min PX-4309703200 CDM 97032 CPT 430 RC outpatient 72 72 CIGNA 62308 [3081051] CIGNA 62308 [308105105] 57.6 percent of total billed charges 44.64 68.4 Technical (Hospital) Services Appl Modality 1/> Areas Elec Stimj Ea 15 Min PX-4309703200 CDM 97032 CPT 430 RC outpatient 72 72 CIGNA 62308 [3081051] CIGNA STATE OF WYOMING [308105107] 57.6 percent of total billed charges 44.64 68.4 Technical (Hospital) Services Appl Modality 1/> Areas Elec Stimj Ea 15 Min PX-4309703200 CDM 97032 CPT 430 RC outpatient 72 72 HEALTHPARTNERS SX009 HEALTHPARTNERS 57.6 percent of total billed charges 44.64 68.4 Technical (Hospital) Services Appl Modality 1/> Areas Elec Stimj Ea 15 Min PX-4309703200 CDM 97032 CPT 430 RC outpatient 72 72 UNITED HEALTHCARE (COMMERCIAL) [3081199] UNITED HEALTHCARE 87726 [308119901] 44.64 percent of total billed charges 44.64 68.4 Technical (Hospital) Services Appl Modality 1/> Areas Elec Stimj Ea 15 Min PX-4309703200 CDM 97032 CPT 430 RC outpatient 72 72 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES EPO [308136803] 57.6 percent of total billed charges 44.64 68.4 Technical (Hospital) Services Appl Modality 1/> Areas Elec Stimj Ea 15 Min PX-4309703200 CDM 97032 CPT 430 RC outpatient 72 72 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES PPO [308136801] 57.6 percent of total billed charges 44.64 68.4 Technical (Hospital) Services Appl Modality 1/> Areas Elec Stimj Ea 15 Min PX-4309703200 CDM 97032 CPT 430 RC outpatient 72 72 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES HDHP [308136802] 57.6 percent of total billed charges 44.64 68.4 Technical (Hospital) Services Appl Modality 1/> Areas Elec Stimj Ea 15 Min PX-4309703200 CDM 97032 CPT 430 RC outpatient 72 72 BLUE CROSS BLUE SHIELD WELLMARK SB889 [3081026] BCBS WYOMING [308102603] 68.4 percent of total billed charges 44.64 68.4 Technical (Hospital) Services Appl Modality 1/> Areas Elec Stimj Ea 15 Min PX-4309703200 CDM 97032 CPT 430 RC inpatient 72 72 BLUE CROSS BLUE SHIELD WELLMARK SB889 [3081026] BCBS WYOMING [308102603] 68.4 percent of total billed charges 44.64 68.4 Technical (Hospital) Services Appl Modality 1/> Areas Elec Stimj Ea 15 Min PX-4309703200 CDM 97032 CPT 430 RC inpatient 72 72 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES PPO [308136801] 57.01 percent of total billed charges 44.64 68.4 Technical (Hospital) Services Appl Modality 1/> Areas Elec Stimj Ea 15 Min PX-4309703200 CDM 97032 CPT 430 RC inpatient 72 72 UNITED HEALTHCARE (COMMERCIAL) [3081199] UNITED HEALTHCARE 87726 [308119901] 44.64 percent of total billed charges 44.64 68.4 Technical (Hospital) Services Appl Modality 1/> Areas Elec Stimj Ea 15 Min PX-4309703200 CDM 97032 CPT 430 RC inpatient 72 72 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES HDHP [308136802] 57.01 percent of total billed charges 44.64 68.4 Technical (Hospital) Services Appl Modality 1/> Areas Elec Stimj Ea 15 Min PX-4309703200 CDM 97032 CPT 430 RC inpatient 72 72 MULTIPLAN INC 34080 [3081285] MULTIPLAN INC [308128501] 68.4 percent of total billed charges 44.64 68.4 Technical (Hospital) Services Appl Modality 1/> Areas Elec Stimj Ea 15 Min PX-4309703200 CDM 97032 CPT 430 RC inpatient 72 72 MEDICA (COMMERCIAL) 94265 [3081118] MEDICA CLAIMS [308111801] 64.8 percent of total billed charges 44.64 68.4 Technical (Hospital) Services Appl Modality 1/> Areas Elec Stimj Ea 15 Min PX-4309703200 CDM 97032 CPT 430 RC inpatient 72 72 HEALTHPARTNERS SX009 HEALTHPARTNERS 57.01 percent of total billed charges 44.64 68.4 Technical (Hospital) Services Appl Modality 1/> Areas Elec Stimj Ea 15 Min PX-4309703200 CDM 97032 CPT 430 RC inpatient 72 72 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES EPO [308136803] 57.01 percent of total billed charges 44.64 68.4 Technical (Hospital) Services Appl Modality 1/> Areas Elec Stimj Ea 15 Min PX-4309703200 CDM 97032 CPT 430 RC inpatient 72 72 CIGNA 62308 [3081051] CIGNA 62308 [308105105] 57.01 percent of total billed charges 44.64 68.4 Technical (Hospital) Services Appl Modality 1/> Areas Elec Stimj Ea 15 Min PX-4309703200 CDM 97032 CPT 430 RC inpatient 72 72 CIGNA 62308 [3081051] CIGNA STATE OF WYOMING [308105107] 57.01 percent of total billed charges 44.64 68.4 Technical (Hospital) Services Application Modality 1/> Areas Infrared PX-4209702600 CDM 97026 CPT 420 RC inpatient 61 61 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES PPO [308136801] 48.3 percent of total billed charges 37.82 57.95 Technical (Hospital) Services Application Modality 1/> Areas Infrared PX-4209702600 CDM 97026 CPT 420 RC inpatient 61 61 UNITED HEALTHCARE (COMMERCIAL) [3081199] UNITED HEALTHCARE 87726 [308119901] 37.82 percent of total billed charges 37.82 57.95 Technical (Hospital) Services Application Modality 1/> Areas Infrared PX-4209702600 CDM 97026 CPT 420 RC inpatient 61 61 BLUE CROSS BLUE SHIELD WELLMARK SB889 [3081026] BCBS WYOMING [308102603] 57.95 percent of total billed charges 37.82 57.95 Technical (Hospital) Services Application Modality 1/> Areas Infrared PX-4209702600 CDM 97026 CPT 420 RC inpatient 61 61 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES HDHP [308136802] 48.3 percent of total billed charges 37.82 57.95 Technical (Hospital) Services Application Modality 1/> Areas Infrared PX-4209702600 CDM 97026 CPT 420 RC inpatient 61 61 MEDICA (COMMERCIAL) 94265 [3081118] MEDICA CLAIMS [308111801] 54.9 percent of total billed charges 37.82 57.95 Technical (Hospital) Services Application Modality 1/> Areas Infrared PX-4209702600 CDM 97026 CPT 420 RC inpatient 61 61 MULTIPLAN INC 34080 [3081285] MULTIPLAN INC [308128501] 57.95 percent of total billed charges 37.82 57.95 Technical (Hospital) Services Application Modality 1/> Areas Infrared PX-4209702600 CDM 97026 CPT 420 RC inpatient 61 61 HEALTHPARTNERS SX009 HEALTHPARTNERS 48.3 percent of total billed charges 37.82 57.95 Technical (Hospital) Services Application Modality 1/> Areas Infrared PX-4209702600 CDM 97026 CPT 420 RC inpatient 61 61 CIGNA 62308 [3081051] CIGNA 62308 [308105105] 48.3 percent of total billed charges 37.82 57.95 Technical (Hospital) Services Application Modality 1/> Areas Infrared PX-4209702600 CDM 97026 CPT 420 RC inpatient 61 61 CIGNA 62308 [3081051] CIGNA STATE OF WYOMING [308105107] 48.3 percent of total billed charges 37.82 57.95 Technical (Hospital) Services Application Modality 1/> Areas Infrared PX-4209702600 CDM 97026 CPT 420 RC inpatient 61 61 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES EPO [308136803] 48.3 percent of total billed charges 37.82 57.95 Technical (Hospital) Services Application Modality 1/> Areas Infrared PX-4209702600 CDM 97026 CPT 420 RC outpatient 61 61 MULTIPLAN INC 34080 [3081285] MULTIPLAN INC [308128501] 57.95 percent of total billed charges 37.82 57.95 Technical (Hospital) Services Application Modality 1/> Areas Infrared PX-4209702600 CDM 97026 CPT 420 RC outpatient 61 61 CIGNA 62308 [3081051] CIGNA 62308 [308105105] 48.8 percent of total billed charges 37.82 57.95 Technical (Hospital) Services Application Modality 1/> Areas Infrared PX-4209702600 CDM 97026 CPT 420 RC outpatient 61 61 CIGNA 62308 [3081051] CIGNA STATE OF WYOMING [308105107] 48.8 percent of total billed charges 37.82 57.95 Technical (Hospital) Services Application Modality 1/> Areas Infrared PX-4209702600 CDM 97026 CPT 420 RC outpatient 61 61 MEDICA (COMMERCIAL) 94265 [3081118] MEDICA CLAIMS [308111801] 54.9 percent of total billed charges 37.82 57.95 Technical (Hospital) Services Application Modality 1/> Areas Infrared PX-4209702600 CDM 97026 CPT 420 RC outpatient 61 61 BLUE CROSS BLUE SHIELD WELLMARK SB889 [3081026] BCBS WYOMING [308102603] 57.95 percent of total billed charges 37.82 57.95 Technical (Hospital) Services Application Modality 1/> Areas Infrared PX-4209702600 CDM 97026 CPT 420 RC outpatient 61 61 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES HDHP [308136802] 48.8 percent of total billed charges 37.82 57.95 Technical (Hospital) Services Application Modality 1/> Areas Infrared PX-4209702600 CDM 97026 CPT 420 RC outpatient 61 61 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES PPO [308136801] 48.8 percent of total billed charges 37.82 57.95 Technical (Hospital) Services Application Modality 1/> Areas Infrared PX-4209702600 CDM 97026 CPT 420 RC outpatient 61 61 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES EPO [308136803] 48.8 percent of total billed charges 37.82 57.95 Technical (Hospital) Services Application Modality 1/> Areas Infrared PX-4209702600 CDM 97026 CPT 420 RC outpatient 61 61 UNITED HEALTHCARE (COMMERCIAL) [3081199] UNITED HEALTHCARE 87726 [308119901] 37.82 percent of total billed charges 37.82 57.95 Technical (Hospital) Services Application Modality 1/> Areas Infrared PX-4209702600 CDM 97026 CPT 420 RC outpatient 61 61 HEALTHPARTNERS SX009 HEALTHPARTNERS 48.8 percent of total billed charges 37.82 57.95 Technical (Hospital) Services Appl Modality 1/> Areas Paraffin Bath PX-4209701800 CDM 97018 CPT 420 RC inpatient 65 65 MEDICA (COMMERCIAL) 94265 [3081118] MEDICA CLAIMS [308111801] 58.5 percent of total billed charges 40.3 61.75 Technical (Hospital) Services Appl Modality 1/> Areas Paraffin Bath PX-4209701800 CDM 97018 CPT 420 RC inpatient 65 65 MULTIPLAN INC 34080 [3081285] MULTIPLAN INC [308128501] 61.75 percent of total billed charges 40.3 61.75 Technical (Hospital) Services Appl Modality 1/> Areas Paraffin Bath PX-4209701800 CDM 97018 CPT 420 RC inpatient 65 65 HEALTHPARTNERS SX009 HEALTHPARTNERS 51.47 percent of total billed charges 40.3 61.75 Technical (Hospital) Services Appl Modality 1/> Areas Paraffin Bath PX-4209701800 CDM 97018 CPT 420 RC inpatient 65 65 BLUE CROSS BLUE SHIELD WELLMARK SB889 [3081026] BCBS WYOMING [308102603] 61.75 percent of total billed charges 40.3 61.75 Technical (Hospital) Services Appl Modality 1/> Areas Paraffin Bath PX-4209701800 CDM 97018 CPT 420 RC inpatient 65 65 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES HDHP [308136802] 51.47 percent of total billed charges 40.3 61.75 Technical (Hospital) Services Appl Modality 1/> Areas Paraffin Bath PX-4209701800 CDM 97018 CPT 420 RC inpatient 65 65 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES PPO [308136801] 51.47 percent of total billed charges 40.3 61.75 Technical (Hospital) Services Appl Modality 1/> Areas Paraffin Bath PX-4209701800 CDM 97018 CPT 420 RC inpatient 65 65 UNITED HEALTHCARE (COMMERCIAL) [3081199] UNITED HEALTHCARE 87726 [308119901] 40.3 percent of total billed charges 40.3 61.75 Technical (Hospital) Services Appl Modality 1/> Areas Paraffin Bath PX-4209701800 CDM 97018 CPT 420 RC inpatient 65 65 CIGNA 62308 [3081051] CIGNA 62308 [308105105] 51.47 percent of total billed charges 40.3 61.75 Technical (Hospital) Services Appl Modality 1/> Areas Paraffin Bath PX-4209701800 CDM 97018 CPT 420 RC inpatient 65 65 CIGNA 62308 [3081051] CIGNA STATE OF WYOMING [308105107] 51.47 percent of total billed charges 40.3 61.75 Technical (Hospital) Services Appl Modality 1/> Areas Paraffin Bath PX-4209701800 CDM 97018 CPT 420 RC inpatient 65 65 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES EPO [308136803] 51.47 percent of total billed charges 40.3 61.75 Technical (Hospital) Services Appl Modality 1/> Areas Paraffin Bath PX-4209701800 CDM 97018 CPT 420 RC outpatient 65 65 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES HDHP [308136802] 52 percent of total billed charges 40.3 61.75 Technical (Hospital) Services Appl Modality 1/> Areas Paraffin Bath PX-4209701800 CDM 97018 CPT 420 RC outpatient 65 65 BLUE CROSS BLUE SHIELD WELLMARK SB889 [3081026] BCBS WYOMING [308102603] 61.75 percent of total billed charges 40.3 61.75 Technical (Hospital) Services Appl Modality 1/> Areas Paraffin Bath PX-4209701800 CDM 97018 CPT 420 RC outpatient 65 65 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES EPO [308136803] 52 percent of total billed charges 40.3 61.75 Technical (Hospital) Services Appl Modality 1/> Areas Paraffin Bath PX-4209701800 CDM 97018 CPT 420 RC outpatient 65 65 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES PPO [308136801] 52 percent of total billed charges 40.3 61.75 Technical (Hospital) Services Appl Modality 1/> Areas Paraffin Bath PX-4209701800 CDM 97018 CPT 420 RC outpatient 65 65 UNITED HEALTHCARE (COMMERCIAL) [3081199] UNITED HEALTHCARE 87726 [308119901] 40.3 percent of total billed charges 40.3 61.75 Technical (Hospital) Services Appl Modality 1/> Areas Paraffin Bath PX-4209701800 CDM 97018 CPT 420 RC outpatient 65 65 HEALTHPARTNERS SX009 HEALTHPARTNERS 52 percent of total billed charges 40.3 61.75 Technical (Hospital) Services Appl Modality 1/> Areas Paraffin Bath PX-4209701800 CDM 97018 CPT 420 RC outpatient 65 65 MEDICA (COMMERCIAL) 94265 [3081118] MEDICA CLAIMS [308111801] 58.5 percent of total billed charges 40.3 61.75 Technical (Hospital) Services Appl Modality 1/> Areas Paraffin Bath PX-4209701800 CDM 97018 CPT 420 RC outpatient 65 65 CIGNA 62308 [3081051] CIGNA 62308 [308105105] 52 percent of total billed charges 40.3 61.75 Technical (Hospital) Services Appl Modality 1/> Areas Paraffin Bath PX-4209701800 CDM 97018 CPT 420 RC outpatient 65 65 CIGNA 62308 [3081051] CIGNA STATE OF WYOMING [308105107] 52 percent of total billed charges 40.3 61.75 Technical (Hospital) Services Appl Modality 1/> Areas Paraffin Bath PX-4209701800 CDM 97018 CPT 420 RC outpatient 65 65 MULTIPLAN INC 34080 [3081285] MULTIPLAN INC [308128501] 61.75 percent of total billed charges 40.3 61.75 Technical (Hospital) Services Appl Modality 1/> Areas Paraffin Bath PX-4309701800 CDM 97018 CPT 430 RC inpatient 65 65 UNITED HEALTHCARE (COMMERCIAL) [3081199] UNITED HEALTHCARE 87726 [308119901] 40.3 percent of total billed charges 40.3 61.75 Technical (Hospital) Services Appl Modality 1/> Areas Paraffin Bath PX-4309701800 CDM 97018 CPT 430 RC inpatient 65 65 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES PPO [308136801] 51.47 percent of total billed charges 40.3 61.75 Technical (Hospital) Services Appl Modality 1/> Areas Paraffin Bath PX-4309701800 CDM 97018 CPT 430 RC inpatient 65 65 BLUE CROSS BLUE SHIELD WELLMARK SB889 [3081026] BCBS WYOMING [308102603] 61.75 percent of total billed charges 40.3 61.75 Technical (Hospital) Services Appl Modality 1/> Areas Paraffin Bath PX-4309701800 CDM 97018 CPT 430 RC inpatient 65 65 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES HDHP [308136802] 51.47 percent of total billed charges 40.3 61.75 Technical (Hospital) Services Appl Modality 1/> Areas Paraffin Bath PX-4309701800 CDM 97018 CPT 430 RC inpatient 65 65 MULTIPLAN INC 34080 [3081285] MULTIPLAN INC [308128501] 61.75 percent of total billed charges 40.3 61.75 Technical (Hospital) Services Appl Modality 1/> Areas Paraffin Bath PX-4309701800 CDM 97018 CPT 430 RC inpatient 65 65 MEDICA (COMMERCIAL) 94265 [3081118] MEDICA CLAIMS [308111801] 58.5 percent of total billed charges 40.3 61.75 Technical (Hospital) Services Appl Modality 1/> Areas Paraffin Bath PX-4309701800 CDM 97018 CPT 430 RC inpatient 65 65 HEALTHPARTNERS SX009 HEALTHPARTNERS 51.47 percent of total billed charges 40.3 61.75 Technical (Hospital) Services Appl Modality 1/> Areas Paraffin Bath PX-4309701800 CDM 97018 CPT 430 RC inpatient 65 65 CIGNA 62308 [3081051] CIGNA 62308 [308105105] 51.47 percent of total billed charges 40.3 61.75 Technical (Hospital) Services Appl Modality 1/> Areas Paraffin Bath PX-4309701800 CDM 97018 CPT 430 RC inpatient 65 65 CIGNA 62308 [3081051] CIGNA STATE OF WYOMING [308105107] 51.47 percent of total billed charges 40.3 61.75 Technical (Hospital) Services Appl Modality 1/> Areas Paraffin Bath PX-4309701800 CDM 97018 CPT 430 RC inpatient 65 65 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES EPO [308136803] 51.47 percent of total billed charges 40.3 61.75 Technical (Hospital) Services Appl Modality 1/> Areas Paraffin Bath PX-4309701800 CDM 97018 CPT 430 RC outpatient 65 65 MULTIPLAN INC 34080 [3081285] MULTIPLAN INC [308128501] 61.75 percent of total billed charges 40.3 61.75 Technical (Hospital) Services Appl Modality 1/> Areas Paraffin Bath PX-4309701800 CDM 97018 CPT 430 RC outpatient 65 65 CIGNA 62308 [3081051] CIGNA 62308 [308105105] 52 percent of total billed charges 40.3 61.75 Technical (Hospital) Services Appl Modality 1/> Areas Paraffin Bath PX-4309701800 CDM 97018 CPT 430 RC outpatient 65 65 CIGNA 62308 [3081051] CIGNA STATE OF WYOMING [308105107] 52 percent of total billed charges 40.3 61.75 Technical (Hospital) Services Appl Modality 1/> Areas Paraffin Bath PX-4309701800 CDM 97018 CPT 430 RC outpatient 65 65 MEDICA (COMMERCIAL) 94265 [3081118] MEDICA CLAIMS [308111801] 58.5 percent of total billed charges 40.3 61.75 Technical (Hospital) Services Appl Modality 1/> Areas Paraffin Bath PX-4309701800 CDM 97018 CPT 430 RC outpatient 65 65 UNITED HEALTHCARE (COMMERCIAL) [3081199] UNITED HEALTHCARE 87726 [308119901] 40.3 percent of total billed charges 40.3 61.75 Technical (Hospital) Services Appl Modality 1/> Areas Paraffin Bath PX-4309701800 CDM 97018 CPT 430 RC outpatient 65 65 HEALTHPARTNERS SX009 HEALTHPARTNERS 52 percent of total billed charges 40.3 61.75 Technical (Hospital) Services Appl Modality 1/> Areas Paraffin Bath PX-4309701800 CDM 97018 CPT 430 RC outpatient 65 65 BLUE CROSS BLUE SHIELD WELLMARK SB889 [3081026] BCBS WYOMING [308102603] 61.75 percent of total billed charges 40.3 61.75 Technical (Hospital) Services Appl Modality 1/> Areas Paraffin Bath PX-4309701800 CDM 97018 CPT 430 RC outpatient 65 65 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES HDHP [308136802] 52 percent of total billed charges 40.3 61.75 Technical (Hospital) Services Appl Modality 1/> Areas Paraffin Bath PX-4309701800 CDM 97018 CPT 430 RC outpatient 65 65 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES PPO [308136801] 52 percent of total billed charges 40.3 61.75 Technical (Hospital) Services Appl Modality 1/> Areas Paraffin Bath PX-4309701800 CDM 97018 CPT 430 RC outpatient 65 65 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES EPO [308136803] 52 percent of total billed charges 40.3 61.75 Technical (Hospital) Services Appl Modality 1/> Areas Elec Stimj Unattended PX-4209701400 CDM 97014 CPT 420 RC inpatient 60 60 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES EPO [308136803] 47.51 percent of total billed charges 37.2 57 Technical (Hospital) Services Appl Modality 1/> Areas Elec Stimj Unattended PX-4209701400 CDM 97014 CPT 420 RC inpatient 60 60 CIGNA 62308 [3081051] CIGNA 62308 [308105105] 47.51 percent of total billed charges 37.2 57 Technical (Hospital) Services Appl Modality 1/> Areas Elec Stimj Unattended PX-4209701400 CDM 97014 CPT 420 RC inpatient 60 60 CIGNA 62308 [3081051] CIGNA STATE OF WYOMING [308105107] 47.51 percent of total billed charges 37.2 57 Technical (Hospital) Services Appl Modality 1/> Areas Elec Stimj Unattended PX-4209701400 CDM 97014 CPT 420 RC inpatient 60 60 UNITED HEALTHCARE (COMMERCIAL) [3081199] UNITED HEALTHCARE 87726 [308119901] 37.2 percent of total billed charges 37.2 57 Technical (Hospital) Services Appl Modality 1/> Areas Elec Stimj Unattended PX-4209701400 CDM 97014 CPT 420 RC inpatient 60 60 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES PPO [308136801] 47.51 percent of total billed charges 37.2 57 Technical (Hospital) Services Appl Modality 1/> Areas Elec Stimj Unattended PX-4209701400 CDM 97014 CPT 420 RC inpatient 60 60 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES HDHP [308136802] 47.51 percent of total billed charges 37.2 57 Technical (Hospital) Services Appl Modality 1/> Areas Elec Stimj Unattended PX-4209701400 CDM 97014 CPT 420 RC inpatient 60 60 BLUE CROSS BLUE SHIELD WELLMARK SB889 [3081026] BCBS WYOMING [308102603] 57 percent of total billed charges 37.2 57 Technical (Hospital) Services Appl Modality 1/> Areas Elec Stimj Unattended PX-4209701400 CDM 97014 CPT 420 RC inpatient 60 60 HEALTHPARTNERS SX009 HEALTHPARTNERS 47.51 percent of total billed charges 37.2 57 Technical (Hospital) Services Appl Modality 1/> Areas Elec Stimj Unattended PX-4209701400 CDM 97014 CPT 420 RC inpatient 60 60 MEDICA (COMMERCIAL) 94265 [3081118] MEDICA CLAIMS [308111801] 54 percent of total billed charges 37.2 57 Technical (Hospital) Services Appl Modality 1/> Areas Elec Stimj Unattended PX-4209701400 CDM 97014 CPT 420 RC inpatient 60 60 MULTIPLAN INC 34080 [3081285] MULTIPLAN INC [308128501] 57 percent of total billed charges 37.2 57 Technical (Hospital) Services Appl Modality 1/> Areas Elec Stimj Unattended PX-4209701400 CDM 97014 CPT 420 RC outpatient 60 60 MULTIPLAN INC 34080 [3081285] MULTIPLAN INC [308128501] 57 percent of total billed charges 37.2 57 Technical (Hospital) Services Appl Modality 1/> Areas Elec Stimj Unattended PX-4209701400 CDM 97014 CPT 420 RC outpatient 60 60 CIGNA 62308 [3081051] CIGNA 62308 [308105105] 48 percent of total billed charges 37.2 57 Technical (Hospital) Services Appl Modality 1/> Areas Elec Stimj Unattended PX-4209701400 CDM 97014 CPT 420 RC outpatient 60 60 CIGNA 62308 [3081051] CIGNA STATE OF WYOMING [308105107] 48 percent of total billed charges 37.2 57 Technical (Hospital) Services Appl Modality 1/> Areas Elec Stimj Unattended PX-4209701400 CDM 97014 CPT 420 RC outpatient 60 60 BLUE CROSS BLUE SHIELD WELLMARK SB889 [3081026] BCBS WYOMING [308102603] 57 percent of total billed charges 37.2 57 Technical (Hospital) Services Appl Modality 1/> Areas Elec Stimj Unattended PX-4209701400 CDM 97014 CPT 420 RC outpatient 60 60 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES HDHP [308136802] 48 percent of total billed charges 37.2 57 Technical (Hospital) Services Appl Modality 1/> Areas Elec Stimj Unattended PX-4209701400 CDM 97014 CPT 420 RC outpatient 60 60 UNITED HEALTHCARE (COMMERCIAL) [3081199] UNITED HEALTHCARE 87726 [308119901] 37.2 percent of total billed charges 37.2 57 Technical (Hospital) Services Appl Modality 1/> Areas Elec Stimj Unattended PX-4209701400 CDM 97014 CPT 420 RC outpatient 60 60 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES PPO [308136801] 48 percent of total billed charges 37.2 57 Technical (Hospital) Services Appl Modality 1/> Areas Elec Stimj Unattended PX-4209701400 CDM 97014 CPT 420 RC outpatient 60 60 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES EPO [308136803] 48 percent of total billed charges 37.2 57 Technical (Hospital) Services Appl Modality 1/> Areas Elec Stimj Unattended PX-4209701400 CDM 97014 CPT 420 RC outpatient 60 60 MEDICA (COMMERCIAL) 94265 [3081118] MEDICA CLAIMS [308111801] 54 percent of total billed charges 37.2 57 Technical (Hospital) Services Appl Modality 1/> Areas Elec Stimj Unattended PX-4209701400 CDM 97014 CPT 420 RC outpatient 60 60 HEALTHPARTNERS SX009 HEALTHPARTNERS 48 percent of total billed charges 37.2 57 Technical (Hospital) Services Appl Modality 1/> Areas Elec Stimj Unattended PX-4309701400 CDM 97014 CPT 430 RC outpatient 55 55 HEALTHPARTNERS SX009 HEALTHPARTNERS 44 percent of total billed charges 34.1 52.25 Technical (Hospital) Services Appl Modality 1/> Areas Elec Stimj Unattended PX-4309701400 CDM 97014 CPT 430 RC outpatient 55 55 MEDICA (COMMERCIAL) 94265 [3081118] MEDICA CLAIMS [308111801] 49.5 percent of total billed charges 34.1 52.25 Technical (Hospital) Services Appl Modality 1/> Areas Elec Stimj Unattended PX-4309701400 CDM 97014 CPT 430 RC outpatient 55 55 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES EPO [308136803] 44 percent of total billed charges 34.1 52.25 Technical (Hospital) Services Appl Modality 1/> Areas Elec Stimj Unattended PX-4309701400 CDM 97014 CPT 430 RC outpatient 55 55 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES PPO [308136801] 44 percent of total billed charges 34.1 52.25 Technical (Hospital) Services Appl Modality 1/> Areas Elec Stimj Unattended PX-4309701400 CDM 97014 CPT 430 RC outpatient 55 55 UNITED HEALTHCARE (COMMERCIAL) [3081199] UNITED HEALTHCARE 87726 [308119901] 34.1 percent of total billed charges 34.1 52.25 Technical (Hospital) Services Appl Modality 1/> Areas Elec Stimj Unattended PX-4309701400 CDM 97014 CPT 430 RC outpatient 55 55 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES HDHP [308136802] 44 percent of total billed charges 34.1 52.25 Technical (Hospital) Services Appl Modality 1/> Areas Elec Stimj Unattended PX-4309701400 CDM 97014 CPT 430 RC outpatient 55 55 BLUE CROSS BLUE SHIELD WELLMARK SB889 [3081026] BCBS WYOMING [308102603] 52.25 percent of total billed charges 34.1 52.25 Technical (Hospital) Services Appl Modality 1/> Areas Elec Stimj Unattended PX-4309701400 CDM 97014 CPT 430 RC outpatient 55 55 CIGNA 62308 [3081051] CIGNA 62308 [308105105] 44 percent of total billed charges 34.1 52.25 Technical (Hospital) Services Appl Modality 1/> Areas Elec Stimj Unattended PX-4309701400 CDM 97014 CPT 430 RC outpatient 55 55 CIGNA 62308 [3081051] CIGNA STATE OF WYOMING [308105107] 44 percent of total billed charges 34.1 52.25 Technical (Hospital) Services Appl Modality 1/> Areas Elec Stimj Unattended PX-4309701400 CDM 97014 CPT 430 RC outpatient 55 55 MULTIPLAN INC 34080 [3081285] MULTIPLAN INC [308128501] 52.25 percent of total billed charges 34.1 52.25 Technical (Hospital) Services Appl Modality 1/> Areas Elec Stimj Unattended PX-4309701400 CDM 97014 CPT 430 RC inpatient 55 55 BLUE CROSS BLUE SHIELD WELLMARK SB889 [3081026] BCBS WYOMING [308102603] 52.25 percent of total billed charges 34.1 52.25 Technical (Hospital) Services Appl Modality 1/> Areas Elec Stimj Unattended PX-4309701400 CDM 97014 CPT 430 RC inpatient 55 55 UNITED HEALTHCARE (COMMERCIAL) [3081199] UNITED HEALTHCARE 87726 [308119901] 34.1 percent of total billed charges 34.1 52.25 Technical (Hospital) Services Appl Modality 1/> Areas Elec Stimj Unattended PX-4309701400 CDM 97014 CPT 430 RC inpatient 55 55 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES PPO [308136801] 43.55 percent of total billed charges 34.1 52.25 Technical (Hospital) Services Appl Modality 1/> Areas Elec Stimj Unattended PX-4309701400 CDM 97014 CPT 430 RC inpatient 55 55 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES HDHP [308136802] 43.55 percent of total billed charges 34.1 52.25 Technical (Hospital) Services Appl Modality 1/> Areas Elec Stimj Unattended PX-4309701400 CDM 97014 CPT 430 RC inpatient 55 55 MEDICA (COMMERCIAL) 94265 [3081118] MEDICA CLAIMS [308111801] 49.5 percent of total billed charges 34.1 52.25 Technical (Hospital) Services Appl Modality 1/> Areas Elec Stimj Unattended PX-4309701400 CDM 97014 CPT 430 RC inpatient 55 55 MULTIPLAN INC 34080 [3081285] MULTIPLAN INC [308128501] 52.25 percent of total billed charges 34.1 52.25 Technical (Hospital) Services Appl Modality 1/> Areas Elec Stimj Unattended PX-4309701400 CDM 97014 CPT 430 RC inpatient 55 55 HEALTHPARTNERS SX009 HEALTHPARTNERS 43.55 percent of total billed charges 34.1 52.25 Technical (Hospital) Services Appl Modality 1/> Areas Elec Stimj Unattended PX-4309701400 CDM 97014 CPT 430 RC inpatient 55 55 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES EPO [308136803] 43.55 percent of total billed charges 34.1 52.25 Technical (Hospital) Services Appl Modality 1/> Areas Elec Stimj Unattended PX-4309701400 CDM 97014 CPT 430 RC inpatient 55 55 CIGNA 62308 [3081051] CIGNA 62308 [308105105] 43.55 percent of total billed charges 34.1 52.25 Technical (Hospital) Services Appl Modality 1/> Areas Elec Stimj Unattended PX-4309701400 CDM 97014 CPT 430 RC inpatient 55 55 CIGNA 62308 [3081051] CIGNA STATE OF WYOMING [308105107] 43.55 percent of total billed charges 34.1 52.25 Technical (Hospital) Services Appl Modality 1/> Areas Traction Mechanical PX-4209701200 CDM 97012 CPT 420 RC inpatient 65 65 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES HDHP [308136802] 51.47 percent of total billed charges 40.3 61.75 Technical (Hospital) Services Appl Modality 1/> Areas Traction Mechanical PX-4209701200 CDM 97012 CPT 420 RC inpatient 65 65 MULTIPLAN INC 34080 [3081285] MULTIPLAN INC [308128501] 61.75 percent of total billed charges 40.3 61.75 Technical (Hospital) Services Appl Modality 1/> Areas Traction Mechanical PX-4209701200 CDM 97012 CPT 420 RC inpatient 65 65 MEDICA (COMMERCIAL) 94265 [3081118] MEDICA CLAIMS [308111801] 58.5 percent of total billed charges 40.3 61.75 Technical (Hospital) Services Appl Modality 1/> Areas Traction Mechanical PX-4209701200 CDM 97012 CPT 420 RC inpatient 65 65 HEALTHPARTNERS SX009 HEALTHPARTNERS 51.47 percent of total billed charges 40.3 61.75 Technical (Hospital) Services Appl Modality 1/> Areas Traction Mechanical PX-4209701200 CDM 97012 CPT 420 RC inpatient 65 65 BLUE CROSS BLUE SHIELD WELLMARK SB889 [3081026] BCBS WYOMING [308102603] 61.75 percent of total billed charges 40.3 61.75 Technical (Hospital) Services Appl Modality 1/> Areas Traction Mechanical PX-4209701200 CDM 97012 CPT 420 RC inpatient 65 65 UNITED HEALTHCARE (COMMERCIAL) [3081199] UNITED HEALTHCARE 87726 [308119901] 40.3 percent of total billed charges 40.3 61.75 Technical (Hospital) Services Appl Modality 1/> Areas Traction Mechanical PX-4209701200 CDM 97012 CPT 420 RC inpatient 65 65 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES PPO [308136801] 51.47 percent of total billed charges 40.3 61.75 Technical (Hospital) Services Appl Modality 1/> Areas Traction Mechanical PX-4209701200 CDM 97012 CPT 420 RC inpatient 65 65 CIGNA 62308 [3081051] CIGNA 62308 [308105105] 51.47 percent of total billed charges 40.3 61.75 Technical (Hospital) Services Appl Modality 1/> Areas Traction Mechanical PX-4209701200 CDM 97012 CPT 420 RC inpatient 65 65 CIGNA 62308 [3081051] CIGNA STATE OF WYOMING [308105107] 51.47 percent of total billed charges 40.3 61.75 Technical (Hospital) Services Appl Modality 1/> Areas Traction Mechanical PX-4209701200 CDM 97012 CPT 420 RC inpatient 65 65 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES EPO [308136803] 51.47 percent of total billed charges 40.3 61.75 Technical (Hospital) Services Appl Modality 1/> Areas Traction Mechanical PX-4209701200 CDM 97012 CPT 420 RC outpatient 65 65 HEALTHPARTNERS SX009 HEALTHPARTNERS 52 percent of total billed charges 40.3 61.75 Technical (Hospital) Services Appl Modality 1/> Areas Traction Mechanical PX-4209701200 CDM 97012 CPT 420 RC outpatient 65 65 UNITED HEALTHCARE (COMMERCIAL) [3081199] UNITED HEALTHCARE 87726 [308119901] 40.3 percent of total billed charges 40.3 61.75 Technical (Hospital) Services Appl Modality 1/> Areas Traction Mechanical PX-4209701200 CDM 97012 CPT 420 RC outpatient 65 65 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES PPO [308136801] 52 percent of total billed charges 40.3 61.75 Technical (Hospital) Services Appl Modality 1/> Areas Traction Mechanical PX-4209701200 CDM 97012 CPT 420 RC outpatient 65 65 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES EPO [308136803] 52 percent of total billed charges 40.3 61.75 Technical (Hospital) Services Appl Modality 1/> Areas Traction Mechanical PX-4209701200 CDM 97012 CPT 420 RC outpatient 65 65 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES HDHP [308136802] 52 percent of total billed charges 40.3 61.75 Technical (Hospital) Services Appl Modality 1/> Areas Traction Mechanical PX-4209701200 CDM 97012 CPT 420 RC outpatient 65 65 BLUE CROSS BLUE SHIELD WELLMARK SB889 [3081026] BCBS WYOMING [308102603] 61.75 percent of total billed charges 40.3 61.75 Technical (Hospital) Services Appl Modality 1/> Areas Traction Mechanical PX-4209701200 CDM 97012 CPT 420 RC outpatient 65 65 MULTIPLAN INC 34080 [3081285] MULTIPLAN INC [308128501] 61.75 percent of total billed charges 40.3 61.75 Technical (Hospital) Services Appl Modality 1/> Areas Traction Mechanical PX-4209701200 CDM 97012 CPT 420 RC outpatient 65 65 CIGNA 62308 [3081051] CIGNA 62308 [308105105] 52 percent of total billed charges 40.3 61.75 Technical (Hospital) Services Appl Modality 1/> Areas Traction Mechanical PX-4209701200 CDM 97012 CPT 420 RC outpatient 65 65 CIGNA 62308 [3081051] CIGNA STATE OF WYOMING [308105107] 52 percent of total billed charges 40.3 61.75 Technical (Hospital) Services Appl Modality 1/> Areas Traction Mechanical PX-4209701200 CDM 97012 CPT 420 RC outpatient 65 65 MEDICA (COMMERCIAL) 94265 [3081118] MEDICA CLAIMS [308111801] 58.5 percent of total billed charges 40.3 61.75 Technical (Hospital) Services Irrigaj Implntd Venous Access Drug Delivery Syst PX-9409652300 CDM 96523 CPT 940 RC inpatient 161 161 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES HDHP [308136802] 127.48 percent of total billed charges 99.82 152.95 Technical (Hospital) Services Irrigaj Implntd Venous Access Drug Delivery Syst PX-9409652300 CDM 96523 CPT 940 RC inpatient 161 161 MULTIPLAN INC 34080 [3081285] MULTIPLAN INC [308128501] 152.95 percent of total billed charges 99.82 152.95 Technical (Hospital) Services Irrigaj Implntd Venous Access Drug Delivery Syst PX-9409652300 CDM 96523 CPT 940 RC inpatient 161 161 MEDICA (COMMERCIAL) 94265 [3081118] MEDICA CLAIMS [308111801] 144.9 percent of total billed charges 99.82 152.95 Technical (Hospital) Services Irrigaj Implntd Venous Access Drug Delivery Syst PX-9409652300 CDM 96523 CPT 940 RC inpatient 161 161 HEALTHPARTNERS SX009 HEALTHPARTNERS 127.48 percent of total billed charges 99.82 152.95 Technical (Hospital) Services Irrigaj Implntd Venous Access Drug Delivery Syst PX-9409652300 CDM 96523 CPT 940 RC inpatient 161 161 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES EPO [308136803] 127.48 percent of total billed charges 99.82 152.95 Technical (Hospital) Services Irrigaj Implntd Venous Access Drug Delivery Syst PX-9409652300 CDM 96523 CPT 940 RC inpatient 161 161 BLUE CROSS BLUE SHIELD WELLMARK SB889 [3081026] BCBS WYOMING [308102603] 152.95 percent of total billed charges 99.82 152.95 Technical (Hospital) Services Irrigaj Implntd Venous Access Drug Delivery Syst PX-9409652300 CDM 96523 CPT 940 RC inpatient 161 161 UNITED HEALTHCARE (COMMERCIAL) [3081199] UNITED HEALTHCARE 87726 [308119901] 99.82 percent of total billed charges 99.82 152.95 Technical (Hospital) Services Irrigaj Implntd Venous Access Drug Delivery Syst PX-9409652300 CDM 96523 CPT 940 RC inpatient 161 161 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES PPO [308136801] 127.48 percent of total billed charges 99.82 152.95 Technical (Hospital) Services Irrigaj Implntd Venous Access Drug Delivery Syst PX-9409652300 CDM 96523 CPT 940 RC inpatient 161 161 CIGNA 62308 [3081051] CIGNA 62308 [308105105] 127.48 percent of total billed charges 99.82 152.95 Technical (Hospital) Services Irrigaj Implntd Venous Access Drug Delivery Syst PX-9409652300 CDM 96523 CPT 940 RC inpatient 161 161 CIGNA 62308 [3081051] CIGNA STATE OF WYOMING [308105107] 127.48 percent of total billed charges 99.82 152.95 Technical (Hospital) Services Irrigaj Implntd Venous Access Drug Delivery Syst PX-9409652300 CDM 96523 CPT 940 RC outpatient 161 161 CIGNA 62308 [3081051] CIGNA 62308 [308105105] 128.8 percent of total billed charges 99.82 152.95 Technical (Hospital) Services Irrigaj Implntd Venous Access Drug Delivery Syst PX-9409652300 CDM 96523 CPT 940 RC outpatient 161 161 CIGNA 62308 [3081051] CIGNA STATE OF WYOMING [308105107] 128.8 percent of total billed charges 99.82 152.95 Technical (Hospital) Services Irrigaj Implntd Venous Access Drug Delivery Syst PX-9409652300 CDM 96523 CPT 940 RC outpatient 161 161 MULTIPLAN INC 34080 [3081285] MULTIPLAN INC [308128501] 152.95 percent of total billed charges 99.82 152.95 Technical (Hospital) Services Irrigaj Implntd Venous Access Drug Delivery Syst PX-9409652300 CDM 96523 CPT 940 RC outpatient 161 161 MEDICA (COMMERCIAL) 94265 [3081118] MEDICA CLAIMS [308111801] 144.9 percent of total billed charges 99.82 152.95 Technical (Hospital) Services Irrigaj Implntd Venous Access Drug Delivery Syst PX-9409652300 CDM 96523 CPT 940 RC outpatient 161 161 HEALTHPARTNERS SX009 HEALTHPARTNERS 128.8 percent of total billed charges 99.82 152.95 Technical (Hospital) Services Irrigaj Implntd Venous Access Drug Delivery Syst PX-9409652300 CDM 96523 CPT 940 RC outpatient 161 161 UNITED HEALTHCARE (COMMERCIAL) [3081199] UNITED HEALTHCARE 87726 [308119901] 99.82 percent of total billed charges 99.82 152.95 Technical (Hospital) Services Irrigaj Implntd Venous Access Drug Delivery Syst PX-9409652300 CDM 96523 CPT 940 RC outpatient 161 161 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES EPO [308136803] 128.8 percent of total billed charges 99.82 152.95 Technical (Hospital) Services Irrigaj Implntd Venous Access Drug Delivery Syst PX-9409652300 CDM 96523 CPT 940 RC outpatient 161 161 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES PPO [308136801] 128.8 percent of total billed charges 99.82 152.95 Technical (Hospital) Services Irrigaj Implntd Venous Access Drug Delivery Syst PX-9409652300 CDM 96523 CPT 940 RC outpatient 161 161 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES HDHP [308136802] 128.8 percent of total billed charges 99.82 152.95 Technical (Hospital) Services Irrigaj Implntd Venous Access Drug Delivery Syst PX-9409652300 CDM 96523 CPT 940 RC outpatient 161 161 BLUE CROSS BLUE SHIELD WELLMARK SB889 [3081026] BCBS WYOMING [308102603] 152.95 percent of total billed charges 99.82 152.95 Technical (Hospital) Services Chemotherapy Admn IV Infusion Tq Ea Hr PX-3359641500 CDM 96415 CPT 335 RC inpatient 197 197 BLUE CROSS BLUE SHIELD WELLMARK SB889 [3081026] BCBS WYOMING [308102603] 187.15 percent of total billed charges 122.14 187.15 Technical (Hospital) Services Chemotherapy Admn IV Infusion Tq Ea Hr PX-3359641500 CDM 96415 CPT 335 RC inpatient 197 197 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES PPO [308136801] 155.98 percent of total billed charges 122.14 187.15 Technical (Hospital) Services Chemotherapy Admn IV Infusion Tq Ea Hr PX-3359641500 CDM 96415 CPT 335 RC inpatient 197 197 UNITED HEALTHCARE (COMMERCIAL) [3081199] UNITED HEALTHCARE 87726 [308119901] 122.14 percent of total billed charges 122.14 187.15 Technical (Hospital) Services Chemotherapy Admn IV Infusion Tq Ea Hr PX-3359641500 CDM 96415 CPT 335 RC inpatient 197 197 HEALTHPARTNERS SX009 HEALTHPARTNERS 155.98 percent of total billed charges 122.14 187.15 Technical (Hospital) Services Chemotherapy Admn IV Infusion Tq Ea Hr PX-3359641500 CDM 96415 CPT 335 RC inpatient 197 197 MEDICA (COMMERCIAL) 94265 [3081118] MEDICA CLAIMS [308111801] 177.3 percent of total billed charges 122.14 187.15 Technical (Hospital) Services Chemotherapy Admn IV Infusion Tq Ea Hr PX-3359641500 CDM 96415 CPT 335 RC inpatient 197 197 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES HDHP [308136802] 155.98 percent of total billed charges 122.14 187.15 Technical (Hospital) Services Chemotherapy Admn IV Infusion Tq Ea Hr PX-3359641500 CDM 96415 CPT 335 RC inpatient 197 197 MULTIPLAN INC 34080 [3081285] MULTIPLAN INC [308128501] 187.15 percent of total billed charges 122.14 187.15 Technical (Hospital) Services Chemotherapy Admn IV Infusion Tq Ea Hr PX-3359641500 CDM 96415 CPT 335 RC inpatient 197 197 CIGNA 62308 [3081051] CIGNA 62308 [308105105] 155.98 percent of total billed charges 122.14 187.15 Technical (Hospital) Services Chemotherapy Admn IV Infusion Tq Ea Hr PX-3359641500 CDM 96415 CPT 335 RC inpatient 197 197 CIGNA 62308 [3081051] CIGNA STATE OF WYOMING [308105107] 155.98 percent of total billed charges 122.14 187.15 Technical (Hospital) Services Chemotherapy Admn IV Infusion Tq Ea Hr PX-3359641500 CDM 96415 CPT 335 RC inpatient 197 197 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES EPO [308136803] 155.98 percent of total billed charges 122.14 187.15 Technical (Hospital) Services Chemotherapy Admn IV Infusion Tq Ea Hr PX-3359641500 CDM 96415 CPT 335 RC outpatient 197 197 BLUE CROSS BLUE SHIELD WELLMARK SB889 [3081026] BCBS WYOMING [308102603] 187.15 percent of total billed charges 122.14 187.15 Technical (Hospital) Services Chemotherapy Admn IV Infusion Tq Ea Hr PX-3359641500 CDM 96415 CPT 335 RC outpatient 197 197 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES HDHP [308136802] 157.6 percent of total billed charges 122.14 187.15 Technical (Hospital) Services Chemotherapy Admn IV Infusion Tq Ea Hr PX-3359641500 CDM 96415 CPT 335 RC outpatient 197 197 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES PPO [308136801] 157.6 percent of total billed charges 122.14 187.15 Technical (Hospital) Services Chemotherapy Admn IV Infusion Tq Ea Hr PX-3359641500 CDM 96415 CPT 335 RC outpatient 197 197 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES EPO [308136803] 157.6 percent of total billed charges 122.14 187.15 Technical (Hospital) Services Chemotherapy Admn IV Infusion Tq Ea Hr PX-3359641500 CDM 96415 CPT 335 RC outpatient 197 197 UNITED HEALTHCARE (COMMERCIAL) [3081199] UNITED HEALTHCARE 87726 [308119901] 122.14 percent of total billed charges 122.14 187.15 Technical (Hospital) Services Chemotherapy Admn IV Infusion Tq Ea Hr PX-3359641500 CDM 96415 CPT 335 RC outpatient 197 197 HEALTHPARTNERS SX009 HEALTHPARTNERS 157.6 percent of total billed charges 122.14 187.15 Technical (Hospital) Services Chemotherapy Admn IV Infusion Tq Ea Hr PX-3359641500 CDM 96415 CPT 335 RC outpatient 197 197 MEDICA (COMMERCIAL) 94265 [3081118] MEDICA CLAIMS [308111801] 177.3 percent of total billed charges 122.14 187.15 Technical (Hospital) Services Chemotherapy Admn IV Infusion Tq Ea Hr PX-3359641500 CDM 96415 CPT 335 RC outpatient 197 197 MULTIPLAN INC 34080 [3081285] MULTIPLAN INC [308128501] 187.15 percent of total billed charges 122.14 187.15 Technical (Hospital) Services Chemotherapy Admn IV Infusion Tq Ea Hr PX-3359641500 CDM 96415 CPT 335 RC outpatient 197 197 CIGNA 62308 [3081051] CIGNA 62308 [308105105] 157.6 percent of total billed charges 122.14 187.15 Technical (Hospital) Services Chemotherapy Admn IV Infusion Tq Ea Hr PX-3359641500 CDM 96415 CPT 335 RC outpatient 197 197 CIGNA 62308 [3081051] CIGNA STATE OF WYOMING [308105107] 157.6 percent of total billed charges 122.14 187.15 Technical (Hospital) Services Chemotx Admn IV Nfs Tq Up 1 Hr 1/1st Sbst/Drug PX-3359641300 CDM 96413 CPT 335 RC inpatient 737 737 BLUE CROSS BLUE SHIELD WELLMARK SB889 [3081026] BCBS WYOMING [308102603] 700.15 percent of total billed charges 456.94 700.15 Technical (Hospital) Services Chemotx Admn IV Nfs Tq Up 1 Hr 1/1st Sbst/Drug PX-3359641300 CDM 96413 CPT 335 RC inpatient 737 737 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES PPO [308136801] 583.56 percent of total billed charges 456.94 700.15 Technical (Hospital) Services Chemotx Admn IV Nfs Tq Up 1 Hr 1/1st Sbst/Drug PX-3359641300 CDM 96413 CPT 335 RC inpatient 737 737 UNITED HEALTHCARE (COMMERCIAL) [3081199] UNITED HEALTHCARE 87726 [308119901] 456.94 percent of total billed charges 456.94 700.15 Technical (Hospital) Services Chemotx Admn IV Nfs Tq Up 1 Hr 1/1st Sbst/Drug PX-3359641300 CDM 96413 CPT 335 RC inpatient 737 737 HEALTHPARTNERS SX009 HEALTHPARTNERS 583.56 percent of total billed charges 456.94 700.15 Technical (Hospital) Services Chemotx Admn IV Nfs Tq Up 1 Hr 1/1st Sbst/Drug PX-3359641300 CDM 96413 CPT 335 RC inpatient 737 737 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES HDHP [308136802] 583.56 percent of total billed charges 456.94 700.15 Technical (Hospital) Services Chemotx Admn IV Nfs Tq Up 1 Hr 1/1st Sbst/Drug PX-3359641300 CDM 96413 CPT 335 RC inpatient 737 737 MEDICA (COMMERCIAL) 94265 [3081118] MEDICA CLAIMS [308111801] 663.3 percent of total billed charges 456.94 700.15 Technical (Hospital) Services Chemotx Admn IV Nfs Tq Up 1 Hr 1/1st Sbst/Drug PX-3359641300 CDM 96413 CPT 335 RC inpatient 737 737 MULTIPLAN INC 34080 [3081285] MULTIPLAN INC [308128501] 700.15 percent of total billed charges 456.94 700.15 Technical (Hospital) Services Chemotx Admn IV Nfs Tq Up 1 Hr 1/1st Sbst/Drug PX-3359641300 CDM 96413 CPT 335 RC inpatient 737 737 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES EPO [308136803] 583.56 percent of total billed charges 456.94 700.15 Technical (Hospital) Services Chemotx Admn IV Nfs Tq Up 1 Hr 1/1st Sbst/Drug PX-3359641300 CDM 96413 CPT 335 RC inpatient 737 737 CIGNA 62308 [3081051] CIGNA 62308 [308105105] 583.56 percent of total billed charges 456.94 700.15 Technical (Hospital) Services Chemotx Admn IV Nfs Tq Up 1 Hr 1/1st Sbst/Drug PX-3359641300 CDM 96413 CPT 335 RC inpatient 737 737 CIGNA 62308 [3081051] CIGNA STATE OF WYOMING [308105107] 583.56 percent of total billed charges 456.94 700.15 Technical (Hospital) Services Chemotx Admn IV Nfs Tq Up 1 Hr 1/1st Sbst/Drug PX-3359641300 CDM 96413 CPT 335 RC outpatient 737 737 MULTIPLAN INC 34080 [3081285] MULTIPLAN INC [308128501] 700.15 percent of total billed charges 456.94 700.15 Technical (Hospital) Services Chemotx Admn IV Nfs Tq Up 1 Hr 1/1st Sbst/Drug PX-3359641300 CDM 96413 CPT 335 RC outpatient 737 737 CIGNA 62308 [3081051] CIGNA 62308 [308105105] 589.6 percent of total billed charges 456.94 700.15 Technical (Hospital) Services Chemotx Admn IV Nfs Tq Up 1 Hr 1/1st Sbst/Drug PX-3359641300 CDM 96413 CPT 335 RC outpatient 737 737 CIGNA 62308 [3081051] CIGNA STATE OF WYOMING [308105107] 589.6 percent of total billed charges 456.94 700.15 Technical (Hospital) Services Chemotx Admn IV Nfs Tq Up 1 Hr 1/1st Sbst/Drug PX-3359641300 CDM 96413 CPT 335 RC outpatient 737 737 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES PPO [308136801] 589.6 percent of total billed charges 456.94 700.15 Technical (Hospital) Services Chemotx Admn IV Nfs Tq Up 1 Hr 1/1st Sbst/Drug PX-3359641300 CDM 96413 CPT 335 RC outpatient 737 737 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES EPO [308136803] 589.6 percent of total billed charges 456.94 700.15 Technical (Hospital) Services Chemotx Admn IV Nfs Tq Up 1 Hr 1/1st Sbst/Drug PX-3359641300 CDM 96413 CPT 335 RC outpatient 737 737 UNITED HEALTHCARE (COMMERCIAL) [3081199] UNITED HEALTHCARE 87726 [308119901] 456.94 percent of total billed charges 456.94 700.15 Technical (Hospital) Services Chemotx Admn IV Nfs Tq Up 1 Hr 1/1st Sbst/Drug PX-3359641300 CDM 96413 CPT 335 RC outpatient 737 737 BLUE CROSS BLUE SHIELD WELLMARK SB889 [3081026] BCBS WYOMING [308102603] 700.15 percent of total billed charges 456.94 700.15 Technical (Hospital) Services Chemotx Admn IV Nfs Tq Up 1 Hr 1/1st Sbst/Drug PX-3359641300 CDM 96413 CPT 335 RC outpatient 737 737 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES HDHP [308136802] 589.6 percent of total billed charges 456.94 700.15 Technical (Hospital) Services Chemotx Admn IV Nfs Tq Up 1 Hr 1/1st Sbst/Drug PX-3359641300 CDM 96413 CPT 335 RC outpatient 737 737 HEALTHPARTNERS SX009 HEALTHPARTNERS 589.6 percent of total billed charges 456.94 700.15 Technical (Hospital) Services Chemotx Admn IV Nfs Tq Up 1 Hr 1/1st Sbst/Drug PX-3359641300 CDM 96413 CPT 335 RC outpatient 737 737 MEDICA (COMMERCIAL) 94265 [3081118] MEDICA CLAIMS [308111801] 663.3 percent of total billed charges 456.94 700.15 Technical (Hospital) Services Chemotx Admn Subq/Im Hormonal Anti-Neo PX-3319640200 CDM 96402 CPT 331 RC outpatient 176 176 MULTIPLAN INC 34080 [3081285] MULTIPLAN INC [308128501] 167.2 percent of total billed charges 109.12 167.2 Technical (Hospital) Services Chemotx Admn Subq/Im Hormonal Anti-Neo PX-3319640200 CDM 96402 CPT 331 RC outpatient 176 176 MEDICA (COMMERCIAL) 94265 [3081118] MEDICA CLAIMS [308111801] 158.4 percent of total billed charges 109.12 167.2 Technical (Hospital) Services Chemotx Admn Subq/Im Hormonal Anti-Neo PX-3319640200 CDM 96402 CPT 331 RC outpatient 176 176 CIGNA 62308 [3081051] CIGNA 62308 [308105105] 140.8 percent of total billed charges 109.12 167.2 Technical (Hospital) Services Chemotx Admn Subq/Im Hormonal Anti-Neo PX-3319640200 CDM 96402 CPT 331 RC outpatient 176 176 CIGNA 62308 [3081051] CIGNA STATE OF WYOMING [308105107] 140.8 percent of total billed charges 109.12 167.2 Technical (Hospital) Services Chemotx Admn Subq/Im Hormonal Anti-Neo PX-3319640200 CDM 96402 CPT 331 RC outpatient 176 176 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES PPO [308136801] 140.8 percent of total billed charges 109.12 167.2 Technical (Hospital) Services Chemotx Admn Subq/Im Hormonal Anti-Neo PX-3319640200 CDM 96402 CPT 331 RC outpatient 176 176 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES EPO [308136803] 140.8 percent of total billed charges 109.12 167.2 Technical (Hospital) Services Chemotx Admn Subq/Im Hormonal Anti-Neo PX-3319640200 CDM 96402 CPT 331 RC outpatient 176 176 BLUE CROSS BLUE SHIELD WELLMARK SB889 [3081026] BCBS WYOMING [308102603] 167.2 percent of total billed charges 109.12 167.2 Technical (Hospital) Services Chemotx Admn Subq/Im Hormonal Anti-Neo PX-3319640200 CDM 96402 CPT 331 RC outpatient 176 176 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES HDHP [308136802] 140.8 percent of total billed charges 109.12 167.2 Technical (Hospital) Services Chemotx Admn Subq/Im Hormonal Anti-Neo PX-3319640200 CDM 96402 CPT 331 RC outpatient 176 176 HEALTHPARTNERS SX009 HEALTHPARTNERS 140.8 percent of total billed charges 109.12 167.2 Technical (Hospital) Services Chemotx Admn Subq/Im Hormonal Anti-Neo PX-3319640200 CDM 96402 CPT 331 RC outpatient 176 176 UNITED HEALTHCARE (COMMERCIAL) [3081199] UNITED HEALTHCARE 87726 [308119901] 109.12 percent of total billed charges 109.12 167.2 Technical (Hospital) Services Chemotx Admn Subq/Im Hormonal Anti-Neo PX-3319640200 CDM 96402 CPT 331 RC inpatient 176 176 CIGNA 62308 [3081051] CIGNA 62308 [308105105] 139.36 percent of total billed charges 109.12 167.2 Technical (Hospital) Services Chemotx Admn Subq/Im Hormonal Anti-Neo PX-3319640200 CDM 96402 CPT 331 RC inpatient 176 176 CIGNA 62308 [3081051] CIGNA STATE OF WYOMING [308105107] 139.36 percent of total billed charges 109.12 167.2 Technical (Hospital) Services Chemotx Admn Subq/Im Hormonal Anti-Neo PX-3319640200 CDM 96402 CPT 331 RC inpatient 176 176 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES EPO [308136803] 139.36 percent of total billed charges 109.12 167.2 Technical (Hospital) Services Chemotx Admn Subq/Im Hormonal Anti-Neo PX-3319640200 CDM 96402 CPT 331 RC inpatient 176 176 MULTIPLAN INC 34080 [3081285] MULTIPLAN INC [308128501] 167.2 percent of total billed charges 109.12 167.2 Technical (Hospital) Services Chemotx Admn Subq/Im Hormonal Anti-Neo PX-3319640200 CDM 96402 CPT 331 RC inpatient 176 176 MEDICA (COMMERCIAL) 94265 [3081118] MEDICA CLAIMS [308111801] 158.4 percent of total billed charges 109.12 167.2 Technical (Hospital) Services Chemotx Admn Subq/Im Hormonal Anti-Neo PX-3319640200 CDM 96402 CPT 331 RC inpatient 176 176 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES HDHP [308136802] 139.36 percent of total billed charges 109.12 167.2 Technical (Hospital) Services Chemotx Admn Subq/Im Hormonal Anti-Neo PX-3319640200 CDM 96402 CPT 331 RC inpatient 176 176 HEALTHPARTNERS SX009 HEALTHPARTNERS 139.36 percent of total billed charges 109.12 167.2 Technical (Hospital) Services Chemotx Admn Subq/Im Hormonal Anti-Neo PX-3319640200 CDM 96402 CPT 331 RC inpatient 176 176 UNITED HEALTHCARE (COMMERCIAL) [3081199] UNITED HEALTHCARE 87726 [308119901] 109.12 percent of total billed charges 109.12 167.2 Technical (Hospital) Services Chemotx Admn Subq/Im Hormonal Anti-Neo PX-3319640200 CDM 96402 CPT 331 RC inpatient 176 176 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES PPO [308136801] 139.36 percent of total billed charges 109.12 167.2 Technical (Hospital) Services Chemotx Admn Subq/Im Hormonal Anti-Neo PX-3319640200 CDM 96402 CPT 331 RC inpatient 176 176 BLUE CROSS BLUE SHIELD WELLMARK SB889 [3081026] BCBS WYOMING [308102603] 167.2 percent of total billed charges 109.12 167.2 Technical (Hospital) Services Ther Proph/Dx Njx Ea Seql IV Push Sbst/Drug Fac PX-2609637600 CDM 96376 CPT 260 RC outpatient 188 188 CIGNA 62308 [3081051] CIGNA 62308 [308105105] 150.4 percent of total billed charges 116.56 178.6 Technical (Hospital) Services Ther Proph/Dx Njx Ea Seql IV Push Sbst/Drug Fac PX-2609637600 CDM 96376 CPT 260 RC outpatient 188 188 CIGNA 62308 [3081051] CIGNA STATE OF WYOMING [308105107] 150.4 percent of total billed charges 116.56 178.6 Technical (Hospital) Services Ther Proph/Dx Njx Ea Seql IV Push Sbst/Drug Fac PX-2609637600 CDM 96376 CPT 260 RC outpatient 188 188 MEDICA (COMMERCIAL) 94265 [3081118] MEDICA CLAIMS [308111801] 169.2 percent of total billed charges 116.56 178.6 Technical (Hospital) Services Ther Proph/Dx Njx Ea Seql IV Push Sbst/Drug Fac PX-2609637600 CDM 96376 CPT 260 RC outpatient 188 188 MULTIPLAN INC 34080 [3081285] MULTIPLAN INC [308128501] 178.6 percent of total billed charges 116.56 178.6 Technical (Hospital) Services Ther Proph/Dx Njx Ea Seql IV Push Sbst/Drug Fac PX-2609637600 CDM 96376 CPT 260 RC outpatient 188 188 HEALTHPARTNERS SX009 HEALTHPARTNERS 150.4 percent of total billed charges 116.56 178.6 Technical (Hospital) Services Ther Proph/Dx Njx Ea Seql IV Push Sbst/Drug Fac PX-2609637600 CDM 96376 CPT 260 RC outpatient 188 188 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES EPO [308136803] 150.4 percent of total billed charges 116.56 178.6 Technical (Hospital) Services Ther Proph/Dx Njx Ea Seql IV Push Sbst/Drug Fac PX-2609637600 CDM 96376 CPT 260 RC outpatient 188 188 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES PPO [308136801] 150.4 percent of total billed charges 116.56 178.6 Technical (Hospital) Services Ther Proph/Dx Njx Ea Seql IV Push Sbst/Drug Fac PX-2609637600 CDM 96376 CPT 260 RC outpatient 188 188 UNITED HEALTHCARE (COMMERCIAL) [3081199] UNITED HEALTHCARE 87726 [308119901] 116.56 percent of total billed charges 116.56 178.6 Technical (Hospital) Services Ther Proph/Dx Njx Ea Seql IV Push Sbst/Drug Fac PX-2609637600 CDM 96376 CPT 260 RC outpatient 188 188 BLUE CROSS BLUE SHIELD WELLMARK SB889 [3081026] BCBS WYOMING [308102603] 178.6 percent of total billed charges 116.56 178.6 Technical (Hospital) Services Ther Proph/Dx Njx Ea Seql IV Push Sbst/Drug Fac PX-2609637600 CDM 96376 CPT 260 RC outpatient 188 188 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES HDHP [308136802] 150.4 percent of total billed charges 116.56 178.6 Technical (Hospital) Services Ther Proph/Dx Njx Ea Seql IV Push Sbst/Drug Fac PX-2609637600 CDM 96376 CPT 260 RC inpatient 188 188 CIGNA 62308 [3081051] CIGNA 62308 [308105105] 148.86 percent of total billed charges 116.56 178.6 Technical (Hospital) Services Ther Proph/Dx Njx Ea Seql IV Push Sbst/Drug Fac PX-2609637600 CDM 96376 CPT 260 RC inpatient 188 188 CIGNA 62308 [3081051] CIGNA STATE OF WYOMING [308105107] 148.86 percent of total billed charges 116.56 178.6 Technical (Hospital) Services Ther Proph/Dx Njx Ea Seql IV Push Sbst/Drug Fac PX-2609637600 CDM 96376 CPT 260 RC inpatient 188 188 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES EPO [308136803] 148.86 percent of total billed charges 116.56 178.6 Technical (Hospital) Services Ther Proph/Dx Njx Ea Seql IV Push Sbst/Drug Fac PX-2609637600 CDM 96376 CPT 260 RC inpatient 188 188 MULTIPLAN INC 34080 [3081285] MULTIPLAN INC [308128501] 178.6 percent of total billed charges 116.56 178.6 Technical (Hospital) Services Ther Proph/Dx Njx Ea Seql IV Push Sbst/Drug Fac PX-2609637600 CDM 96376 CPT 260 RC inpatient 188 188 MEDICA (COMMERCIAL) 94265 [3081118] MEDICA CLAIMS [308111801] 169.2 percent of total billed charges 116.56 178.6 Technical (Hospital) Services Ther Proph/Dx Njx Ea Seql IV Push Sbst/Drug Fac PX-2609637600 CDM 96376 CPT 260 RC inpatient 188 188 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES HDHP [308136802] 148.86 percent of total billed charges 116.56 178.6 Technical (Hospital) Services Ther Proph/Dx Njx Ea Seql IV Push Sbst/Drug Fac PX-2609637600 CDM 96376 CPT 260 RC inpatient 188 188 HEALTHPARTNERS SX009 HEALTHPARTNERS 148.86 percent of total billed charges 116.56 178.6 Technical (Hospital) Services Ther Proph/Dx Njx Ea Seql IV Push Sbst/Drug Fac PX-2609637600 CDM 96376 CPT 260 RC inpatient 188 188 UNITED HEALTHCARE (COMMERCIAL) [3081199] UNITED HEALTHCARE 87726 [308119901] 116.56 percent of total billed charges 116.56 178.6 Technical (Hospital) Services Ther Proph/Dx Njx Ea Seql IV Push Sbst/Drug Fac PX-2609637600 CDM 96376 CPT 260 RC inpatient 188 188 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES PPO [308136801] 148.86 percent of total billed charges 116.56 178.6 Technical (Hospital) Services Ther Proph/Dx Njx Ea Seql IV Push Sbst/Drug Fac PX-2609637600 CDM 96376 CPT 260 RC inpatient 188 188 BLUE CROSS BLUE SHIELD WELLMARK SB889 [3081026] BCBS WYOMING [308102603] 178.6 percent of total billed charges 116.56 178.6 Technical (Hospital) Services Therapeutic Injection IV Push Each New Drug PX-2609637500 CDM 96375 CPT 260 RC inpatient 213 213 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES EPO [308136803] 168.65 percent of total billed charges 132.06 202.35 Technical (Hospital) Services Therapeutic Injection IV Push Each New Drug PX-2609637500 CDM 96375 CPT 260 RC inpatient 213 213 CIGNA 62308 [3081051] CIGNA 62308 [308105105] 168.65 percent of total billed charges 132.06 202.35 Technical (Hospital) Services Therapeutic Injection IV Push Each New Drug PX-2609637500 CDM 96375 CPT 260 RC inpatient 213 213 CIGNA 62308 [3081051] CIGNA STATE OF WYOMING [308105107] 168.65 percent of total billed charges 132.06 202.35 Technical (Hospital) Services Therapeutic Injection IV Push Each New Drug PX-2609637500 CDM 96375 CPT 260 RC inpatient 213 213 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES PPO [308136801] 168.65 percent of total billed charges 132.06 202.35 Technical (Hospital) Services Therapeutic Injection IV Push Each New Drug PX-2609637500 CDM 96375 CPT 260 RC inpatient 213 213 BLUE CROSS BLUE SHIELD WELLMARK SB889 [3081026] BCBS WYOMING [308102603] 202.35 percent of total billed charges 132.06 202.35 Technical (Hospital) Services Therapeutic Injection IV Push Each New Drug PX-2609637500 CDM 96375 CPT 260 RC inpatient 213 213 UNITED HEALTHCARE (COMMERCIAL) [3081199] UNITED HEALTHCARE 87726 [308119901] 132.06 percent of total billed charges 132.06 202.35 Technical (Hospital) Services Therapeutic Injection IV Push Each New Drug PX-2609637500 CDM 96375 CPT 260 RC inpatient 213 213 MULTIPLAN INC 34080 [3081285] MULTIPLAN INC [308128501] 202.35 percent of total billed charges 132.06 202.35 Technical (Hospital) Services Therapeutic Injection IV Push Each New Drug PX-2609637500 CDM 96375 CPT 260 RC inpatient 213 213 MEDICA (COMMERCIAL) 94265 [3081118] MEDICA CLAIMS [308111801] 191.7 percent of total billed charges 132.06 202.35 Technical (Hospital) Services Therapeutic Injection IV Push Each New Drug PX-2609637500 CDM 96375 CPT 260 RC inpatient 213 213 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES HDHP [308136802] 168.65 percent of total billed charges 132.06 202.35 Technical (Hospital) Services Therapeutic Injection IV Push Each New Drug PX-2609637500 CDM 96375 CPT 260 RC inpatient 213 213 HEALTHPARTNERS SX009 HEALTHPARTNERS 168.65 percent of total billed charges 132.06 202.35 Technical (Hospital) Services Therapeutic Injection IV Push Each New Drug PX-2609637500 CDM 96375 CPT 260 RC outpatient 213 213 MULTIPLAN INC 34080 [3081285] MULTIPLAN INC [308128501] 202.35 percent of total billed charges 132.06 202.35 Technical (Hospital) Services Therapeutic Injection IV Push Each New Drug PX-2609637500 CDM 96375 CPT 260 RC outpatient 213 213 CIGNA 62308 [3081051] CIGNA 62308 [308105105] 170.4 percent of total billed charges 132.06 202.35 Technical (Hospital) Services Therapeutic Injection IV Push Each New Drug PX-2609637500 CDM 96375 CPT 260 RC outpatient 213 213 CIGNA 62308 [3081051] CIGNA STATE OF WYOMING [308105107] 170.4 percent of total billed charges 132.06 202.35 Technical (Hospital) Services Therapeutic Injection IV Push Each New Drug PX-2609637500 CDM 96375 CPT 260 RC outpatient 213 213 MEDICA (COMMERCIAL) 94265 [3081118] MEDICA CLAIMS [308111801] 191.7 percent of total billed charges 132.06 202.35 Technical (Hospital) Services Therapeutic Injection IV Push Each New Drug PX-2609637500 CDM 96375 CPT 260 RC outpatient 213 213 HEALTHPARTNERS SX009 HEALTHPARTNERS 170.4 percent of total billed charges 132.06 202.35 Technical (Hospital) Services Therapeutic Injection IV Push Each New Drug PX-2609637500 CDM 96375 CPT 260 RC outpatient 213 213 BLUE CROSS BLUE SHIELD WELLMARK SB889 [3081026] BCBS WYOMING [308102603] 202.35 percent of total billed charges 132.06 202.35 Technical (Hospital) Services Therapeutic Injection IV Push Each New Drug PX-2609637500 CDM 96375 CPT 260 RC outpatient 213 213 UNITED HEALTHCARE (COMMERCIAL) [3081199] UNITED HEALTHCARE 87726 [308119901] 132.06 percent of total billed charges 132.06 202.35 Technical (Hospital) Services Therapeutic Injection IV Push Each New Drug PX-2609637500 CDM 96375 CPT 260 RC outpatient 213 213 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES HDHP [308136802] 170.4 percent of total billed charges 132.06 202.35 Technical (Hospital) Services Therapeutic Injection IV Push Each New Drug PX-2609637500 CDM 96375 CPT 260 RC outpatient 213 213 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES PPO [308136801] 170.4 percent of total billed charges 132.06 202.35 Technical (Hospital) Services Therapeutic Injection IV Push Each New Drug PX-2609637500 CDM 96375 CPT 260 RC outpatient 213 213 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES EPO [308136803] 170.4 percent of total billed charges 132.06 202.35 Technical (Hospital) Services Ther Proph/Dx Njx IV Push Single/1st Sbst/Drug PX-2609637400 CDM 96374 CPT 260 RC inpatient 300 300 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES EPO [308136803] 237.54 percent of total billed charges 186 285 Technical (Hospital) Services Ther Proph/Dx Njx IV Push Single/1st Sbst/Drug PX-2609637400 CDM 96374 CPT 260 RC inpatient 300 300 CIGNA 62308 [3081051] CIGNA 62308 [308105105] 237.54 percent of total billed charges 186 285 Technical (Hospital) Services Ther Proph/Dx Njx IV Push Single/1st Sbst/Drug PX-2609637400 CDM 96374 CPT 260 RC inpatient 300 300 CIGNA 62308 [3081051] CIGNA STATE OF WYOMING [308105107] 237.54 percent of total billed charges 186 285 Technical (Hospital) Services Ther Proph/Dx Njx IV Push Single/1st Sbst/Drug PX-2609637400 CDM 96374 CPT 260 RC inpatient 300 300 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES PPO [308136801] 237.54 percent of total billed charges 186 285 Technical (Hospital) Services Ther Proph/Dx Njx IV Push Single/1st Sbst/Drug PX-2609637400 CDM 96374 CPT 260 RC inpatient 300 300 BLUE CROSS BLUE SHIELD WELLMARK SB889 [3081026] BCBS WYOMING [308102603] 285 percent of total billed charges 186 285 Technical (Hospital) Services Ther Proph/Dx Njx IV Push Single/1st Sbst/Drug PX-2609637400 CDM 96374 CPT 260 RC inpatient 300 300 UNITED HEALTHCARE (COMMERCIAL) [3081199] UNITED HEALTHCARE 87726 [308119901] 186 percent of total billed charges 186 285 Technical (Hospital) Services Ther Proph/Dx Njx IV Push Single/1st Sbst/Drug PX-2609637400 CDM 96374 CPT 260 RC inpatient 300 300 MULTIPLAN INC 34080 [3081285] MULTIPLAN INC [308128501] 285 percent of total billed charges 186 285 Technical (Hospital) Services Ther Proph/Dx Njx IV Push Single/1st Sbst/Drug PX-2609637400 CDM 96374 CPT 260 RC inpatient 300 300 MEDICA (COMMERCIAL) 94265 [3081118] MEDICA CLAIMS [308111801] 270 percent of total billed charges 186 285 Technical (Hospital) Services Ther Proph/Dx Njx IV Push Single/1st Sbst/Drug PX-2609637400 CDM 96374 CPT 260 RC inpatient 300 300 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES HDHP [308136802] 237.54 percent of total billed charges 186 285 Technical (Hospital) Services Ther Proph/Dx Njx IV Push Single/1st Sbst/Drug PX-2609637400 CDM 96374 CPT 260 RC inpatient 300 300 HEALTHPARTNERS SX009 HEALTHPARTNERS 237.54 percent of total billed charges 186 285 Technical (Hospital) Services Ther Proph/Dx Njx IV Push Single/1st Sbst/Drug PX-2609637400 CDM 96374 CPT 260 RC outpatient 300 300 CIGNA 62308 [3081051] CIGNA 62308 [308105105] 240 percent of total billed charges 186 285 Technical (Hospital) Services Ther Proph/Dx Njx IV Push Single/1st Sbst/Drug PX-2609637400 CDM 96374 CPT 260 RC outpatient 300 300 CIGNA 62308 [3081051] CIGNA STATE OF WYOMING [308105107] 240 percent of total billed charges 186 285 Technical (Hospital) Services Ther Proph/Dx Njx IV Push Single/1st Sbst/Drug PX-2609637400 CDM 96374 CPT 260 RC outpatient 300 300 MULTIPLAN INC 34080 [3081285] MULTIPLAN INC [308128501] 285 percent of total billed charges 186 285 Technical (Hospital) Services Ther Proph/Dx Njx IV Push Single/1st Sbst/Drug PX-2609637400 CDM 96374 CPT 260 RC outpatient 300 300 MEDICA (COMMERCIAL) 94265 [3081118] MEDICA CLAIMS [308111801] 270 percent of total billed charges 186 285 Technical (Hospital) Services Ther Proph/Dx Njx IV Push Single/1st Sbst/Drug PX-2609637400 CDM 96374 CPT 260 RC outpatient 300 300 HEALTHPARTNERS SX009 HEALTHPARTNERS 240 percent of total billed charges 186 285 Technical (Hospital) Services Ther Proph/Dx Njx IV Push Single/1st Sbst/Drug PX-2609637400 CDM 96374 CPT 260 RC outpatient 300 300 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES HDHP [308136802] 240 percent of total billed charges 186 285 Technical (Hospital) Services Ther Proph/Dx Njx IV Push Single/1st Sbst/Drug PX-2609637400 CDM 96374 CPT 260 RC outpatient 300 300 UNITED HEALTHCARE (COMMERCIAL) [3081199] UNITED HEALTHCARE 87726 [308119901] 186 percent of total billed charges 186 285 Technical (Hospital) Services Ther Proph/Dx Njx IV Push Single/1st Sbst/Drug PX-2609637400 CDM 96374 CPT 260 RC outpatient 300 300 BLUE CROSS BLUE SHIELD WELLMARK SB889 [3081026] BCBS WYOMING [308102603] 285 percent of total billed charges 186 285 Technical (Hospital) Services Ther Proph/Dx Njx IV Push Single/1st Sbst/Drug PX-2609637400 CDM 96374 CPT 260 RC outpatient 300 300 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES EPO [308136803] 240 percent of total billed charges 186 285 Technical (Hospital) Services Ther Proph/Dx Njx IV Push Single/1st Sbst/Drug PX-2609637400 CDM 96374 CPT 260 RC outpatient 300 300 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES PPO [308136801] 240 percent of total billed charges 186 285 Technical (Hospital) Services Therapeutic Prophylactic/Dx Injection Subq/Im PX-2609637200 CDM 96372 CPT 260 RC inpatient 96 96 HEALTHPARTNERS SX009 HEALTHPARTNERS 76.01 percent of total billed charges 59.52 91.2 Technical (Hospital) Services Therapeutic Prophylactic/Dx Injection Subq/Im PX-2609637200 CDM 96372 CPT 260 RC inpatient 96 96 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES HDHP [308136802] 76.01 percent of total billed charges 59.52 91.2 Technical (Hospital) Services Therapeutic Prophylactic/Dx Injection Subq/Im PX-2609637200 CDM 96372 CPT 260 RC inpatient 96 96 MEDICA (COMMERCIAL) 94265 [3081118] MEDICA CLAIMS [308111801] 86.4 percent of total billed charges 59.52 91.2 Technical (Hospital) Services Therapeutic Prophylactic/Dx Injection Subq/Im PX-2609637200 CDM 96372 CPT 260 RC inpatient 96 96 MULTIPLAN INC 34080 [3081285] MULTIPLAN INC [308128501] 91.2 percent of total billed charges 59.52 91.2 Technical (Hospital) Services Therapeutic Prophylactic/Dx Injection Subq/Im PX-2609637200 CDM 96372 CPT 260 RC inpatient 96 96 UNITED HEALTHCARE (COMMERCIAL) [3081199] UNITED HEALTHCARE 87726 [308119901] 59.52 percent of total billed charges 59.52 91.2 Technical (Hospital) Services Therapeutic Prophylactic/Dx Injection Subq/Im PX-2609637200 CDM 96372 CPT 260 RC inpatient 96 96 BLUE CROSS BLUE SHIELD WELLMARK SB889 [3081026] BCBS WYOMING [308102603] 91.2 percent of total billed charges 59.52 91.2 Technical (Hospital) Services Therapeutic Prophylactic/Dx Injection Subq/Im PX-2609637200 CDM 96372 CPT 260 RC inpatient 96 96 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES PPO [308136801] 76.01 percent of total billed charges 59.52 91.2 Technical (Hospital) Services Therapeutic Prophylactic/Dx Injection Subq/Im PX-2609637200 CDM 96372 CPT 260 RC inpatient 96 96 CIGNA 62308 [3081051] CIGNA 62308 [308105105] 76.01 percent of total billed charges 59.52 91.2 Technical (Hospital) Services Therapeutic Prophylactic/Dx Injection Subq/Im PX-2609637200 CDM 96372 CPT 260 RC inpatient 96 96 CIGNA 62308 [3081051] CIGNA STATE OF WYOMING [308105107] 76.01 percent of total billed charges 59.52 91.2 Technical (Hospital) Services Therapeutic Prophylactic/Dx Injection Subq/Im PX-2609637200 CDM 96372 CPT 260 RC inpatient 96 96 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES EPO [308136803] 76.01 percent of total billed charges 59.52 91.2 Technical (Hospital) Services Therapeutic Prophylactic/Dx Injection Subq/Im PX-2609637200 CDM 96372 CPT 260 RC outpatient 96 96 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES EPO [308136803] 76.8 percent of total billed charges 59.52 91.2 Technical (Hospital) Services Therapeutic Prophylactic/Dx Injection Subq/Im PX-2609637200 CDM 96372 CPT 260 RC outpatient 96 96 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES PPO [308136801] 76.8 percent of total billed charges 59.52 91.2 Technical (Hospital) Services Therapeutic Prophylactic/Dx Injection Subq/Im PX-2609637200 CDM 96372 CPT 260 RC outpatient 96 96 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES HDHP [308136802] 76.8 percent of total billed charges 59.52 91.2 Technical (Hospital) Services Therapeutic Prophylactic/Dx Injection Subq/Im PX-2609637200 CDM 96372 CPT 260 RC outpatient 96 96 UNITED HEALTHCARE (COMMERCIAL) [3081199] UNITED HEALTHCARE 87726 [308119901] 59.52 percent of total billed charges 59.52 91.2 Technical (Hospital) Services Therapeutic Prophylactic/Dx Injection Subq/Im PX-2609637200 CDM 96372 CPT 260 RC outpatient 96 96 BLUE CROSS BLUE SHIELD WELLMARK SB889 [3081026] BCBS WYOMING [308102603] 91.2 percent of total billed charges 59.52 91.2 Technical (Hospital) Services Therapeutic Prophylactic/Dx Injection Subq/Im PX-2609637200 CDM 96372 CPT 260 RC outpatient 96 96 HEALTHPARTNERS SX009 HEALTHPARTNERS 76.8 percent of total billed charges 59.52 91.2 Technical (Hospital) Services Therapeutic Prophylactic/Dx Injection Subq/Im PX-2609637200 CDM 96372 CPT 260 RC outpatient 96 96 MEDICA (COMMERCIAL) 94265 [3081118] MEDICA CLAIMS [308111801] 86.4 percent of total billed charges 59.52 91.2 Technical (Hospital) Services Therapeutic Prophylactic/Dx Injection Subq/Im PX-2609637200 CDM 96372 CPT 260 RC outpatient 96 96 MULTIPLAN INC 34080 [3081285] MULTIPLAN INC [308128501] 91.2 percent of total billed charges 59.52 91.2 Technical (Hospital) Services Therapeutic Prophylactic/Dx Injection Subq/Im PX-2609637200 CDM 96372 CPT 260 RC outpatient 96 96 CIGNA 62308 [3081051] CIGNA 62308 [308105105] 76.8 percent of total billed charges 59.52 91.2 Technical (Hospital) Services Therapeutic Prophylactic/Dx Injection Subq/Im PX-2609637200 CDM 96372 CPT 260 RC outpatient 96 96 CIGNA 62308 [3081051] CIGNA STATE OF WYOMING [308105107] 76.8 percent of total billed charges 59.52 91.2 Technical (Hospital) Services IV Nfs Therapy Prophylaxis/Dx Concurrent Nfs PX-2609636800 CDM 96368 CPT 260 RC inpatient 151 151 CIGNA 62308 [3081051] CIGNA 62308 [308105105] 119.56 percent of total billed charges 93.62 143.45 Technical (Hospital) Services IV Nfs Therapy Prophylaxis/Dx Concurrent Nfs PX-2609636800 CDM 96368 CPT 260 RC inpatient 151 151 CIGNA 62308 [3081051] CIGNA STATE OF WYOMING [308105107] 119.56 percent of total billed charges 93.62 143.45 Technical (Hospital) Services IV Nfs Therapy Prophylaxis/Dx Concurrent Nfs PX-2609636800 CDM 96368 CPT 260 RC inpatient 151 151 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES EPO [308136803] 119.56 percent of total billed charges 93.62 143.45 Technical (Hospital) Services IV Nfs Therapy Prophylaxis/Dx Concurrent Nfs PX-2609636800 CDM 96368 CPT 260 RC inpatient 151 151 HEALTHPARTNERS SX009 HEALTHPARTNERS 119.56 percent of total billed charges 93.62 143.45 Technical (Hospital) Services IV Nfs Therapy Prophylaxis/Dx Concurrent Nfs PX-2609636800 CDM 96368 CPT 260 RC inpatient 151 151 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES HDHP [308136802] 119.56 percent of total billed charges 93.62 143.45 Technical (Hospital) Services IV Nfs Therapy Prophylaxis/Dx Concurrent Nfs PX-2609636800 CDM 96368 CPT 260 RC inpatient 151 151 MULTIPLAN INC 34080 [3081285] MULTIPLAN INC [308128501] 143.45 percent of total billed charges 93.62 143.45 Technical (Hospital) Services IV Nfs Therapy Prophylaxis/Dx Concurrent Nfs PX-2609636800 CDM 96368 CPT 260 RC inpatient 151 151 MEDICA (COMMERCIAL) 94265 [3081118] MEDICA CLAIMS [308111801] 135.9 percent of total billed charges 93.62 143.45 Technical (Hospital) Services IV Nfs Therapy Prophylaxis/Dx Concurrent Nfs PX-2609636800 CDM 96368 CPT 260 RC inpatient 151 151 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES PPO [308136801] 119.56 percent of total billed charges 93.62 143.45 Technical (Hospital) Services IV Nfs Therapy Prophylaxis/Dx Concurrent Nfs PX-2609636800 CDM 96368 CPT 260 RC inpatient 151 151 BLUE CROSS BLUE SHIELD WELLMARK SB889 [3081026] BCBS WYOMING [308102603] 143.45 percent of total billed charges 93.62 143.45 Technical (Hospital) Services IV Nfs Therapy Prophylaxis/Dx Concurrent Nfs PX-2609636800 CDM 96368 CPT 260 RC inpatient 151 151 UNITED HEALTHCARE (COMMERCIAL) [3081199] UNITED HEALTHCARE 87726 [308119901] 93.62 percent of total billed charges 93.62 143.45 Technical (Hospital) Services IV Nfs Therapy Prophylaxis/Dx Concurrent Nfs PX-2609636800 CDM 96368 CPT 260 RC outpatient 151 151 MEDICA (COMMERCIAL) 94265 [3081118] MEDICA CLAIMS [308111801] 135.9 percent of total billed charges 93.62 143.45 Technical (Hospital) Services IV Nfs Therapy Prophylaxis/Dx Concurrent Nfs PX-2609636800 CDM 96368 CPT 260 RC outpatient 151 151 MULTIPLAN INC 34080 [3081285] MULTIPLAN INC [308128501] 143.45 percent of total billed charges 93.62 143.45 Technical (Hospital) Services IV Nfs Therapy Prophylaxis/Dx Concurrent Nfs PX-2609636800 CDM 96368 CPT 260 RC outpatient 151 151 CIGNA 62308 [3081051] CIGNA 62308 [308105105] 120.8 percent of total billed charges 93.62 143.45 Technical (Hospital) Services IV Nfs Therapy Prophylaxis/Dx Concurrent Nfs PX-2609636800 CDM 96368 CPT 260 RC outpatient 151 151 CIGNA 62308 [3081051] CIGNA STATE OF WYOMING [308105107] 120.8 percent of total billed charges 93.62 143.45 Technical (Hospital) Services IV Nfs Therapy Prophylaxis/Dx Concurrent Nfs PX-2609636800 CDM 96368 CPT 260 RC outpatient 151 151 HEALTHPARTNERS SX009 HEALTHPARTNERS 120.8 percent of total billed charges 93.62 143.45 Technical (Hospital) Services IV Nfs Therapy Prophylaxis/Dx Concurrent Nfs PX-2609636800 CDM 96368 CPT 260 RC outpatient 151 151 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES PPO [308136801] 120.8 percent of total billed charges 93.62 143.45 Technical (Hospital) Services IV Nfs Therapy Prophylaxis/Dx Concurrent Nfs PX-2609636800 CDM 96368 CPT 260 RC outpatient 151 151 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES EPO [308136803] 120.8 percent of total billed charges 93.62 143.45 Technical (Hospital) Services IV Nfs Therapy Prophylaxis/Dx Concurrent Nfs PX-2609636800 CDM 96368 CPT 260 RC outpatient 151 151 BLUE CROSS BLUE SHIELD WELLMARK SB889 [3081026] BCBS WYOMING [308102603] 143.45 percent of total billed charges 93.62 143.45 Technical (Hospital) Services IV Nfs Therapy Prophylaxis/Dx Concurrent Nfs PX-2609636800 CDM 96368 CPT 260 RC outpatient 151 151 UNITED HEALTHCARE (COMMERCIAL) [3081199] UNITED HEALTHCARE 87726 [308119901] 93.62 percent of total billed charges 93.62 143.45 Technical (Hospital) Services IV Nfs Therapy Prophylaxis/Dx Concurrent Nfs PX-2609636800 CDM 96368 CPT 260 RC outpatient 151 151 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES HDHP [308136802] 120.8 percent of total billed charges 93.62 143.45 Technical (Hospital) Services IV Infusion Ther Proph Addl Sequential to 1 Hr PX-2609636700 CDM 96367 CPT 260 RC inpatient 264 264 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES EPO [308136803] 209.04 percent of total billed charges 163.68 250.8 Technical (Hospital) Services IV Infusion Ther Proph Addl Sequential to 1 Hr PX-2609636700 CDM 96367 CPT 260 RC inpatient 264 264 CIGNA 62308 [3081051] CIGNA 62308 [308105105] 209.04 percent of total billed charges 163.68 250.8 Technical (Hospital) Services IV Infusion Ther Proph Addl Sequential to 1 Hr PX-2609636700 CDM 96367 CPT 260 RC inpatient 264 264 CIGNA 62308 [3081051] CIGNA STATE OF WYOMING [308105107] 209.04 percent of total billed charges 163.68 250.8 Technical (Hospital) Services IV Infusion Ther Proph Addl Sequential to 1 Hr PX-2609636700 CDM 96367 CPT 260 RC inpatient 264 264 BLUE CROSS BLUE SHIELD WELLMARK SB889 [3081026] BCBS WYOMING [308102603] 250.8 percent of total billed charges 163.68 250.8 Technical (Hospital) Services IV Infusion Ther Proph Addl Sequential to 1 Hr PX-2609636700 CDM 96367 CPT 260 RC inpatient 264 264 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES PPO [308136801] 209.04 percent of total billed charges 163.68 250.8 Technical (Hospital) Services IV Infusion Ther Proph Addl Sequential to 1 Hr PX-2609636700 CDM 96367 CPT 260 RC inpatient 264 264 UNITED HEALTHCARE (COMMERCIAL) [3081199] UNITED HEALTHCARE 87726 [308119901] 163.68 percent of total billed charges 163.68 250.8 Technical (Hospital) Services IV Infusion Ther Proph Addl Sequential to 1 Hr PX-2609636700 CDM 96367 CPT 260 RC inpatient 264 264 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES HDHP [308136802] 209.04 percent of total billed charges 163.68 250.8 Technical (Hospital) Services IV Infusion Ther Proph Addl Sequential to 1 Hr PX-2609636700 CDM 96367 CPT 260 RC inpatient 264 264 HEALTHPARTNERS SX009 HEALTHPARTNERS 209.04 percent of total billed charges 163.68 250.8 Technical (Hospital) Services IV Infusion Ther Proph Addl Sequential to 1 Hr PX-2609636700 CDM 96367 CPT 260 RC inpatient 264 264 MEDICA (COMMERCIAL) 94265 [3081118] MEDICA CLAIMS [308111801] 237.6 percent of total billed charges 163.68 250.8 Technical (Hospital) Services IV Infusion Ther Proph Addl Sequential to 1 Hr PX-2609636700 CDM 96367 CPT 260 RC inpatient 264 264 MULTIPLAN INC 34080 [3081285] MULTIPLAN INC [308128501] 250.8 percent of total billed charges 163.68 250.8 Technical (Hospital) Services IV Infusion Ther Proph Addl Sequential to 1 Hr PX-2609636700 CDM 96367 CPT 260 RC outpatient 264 264 MEDICA (COMMERCIAL) 94265 [3081118] MEDICA CLAIMS [308111801] 237.6 percent of total billed charges 163.68 250.8 Technical (Hospital) Services IV Infusion Ther Proph Addl Sequential to 1 Hr PX-2609636700 CDM 96367 CPT 260 RC outpatient 264 264 MULTIPLAN INC 34080 [3081285] MULTIPLAN INC [308128501] 250.8 percent of total billed charges 163.68 250.8 Technical (Hospital) Services IV Infusion Ther Proph Addl Sequential to 1 Hr PX-2609636700 CDM 96367 CPT 260 RC outpatient 264 264 CIGNA 62308 [3081051] CIGNA 62308 [308105105] 211.2 percent of total billed charges 163.68 250.8 Technical (Hospital) Services IV Infusion Ther Proph Addl Sequential to 1 Hr PX-2609636700 CDM 96367 CPT 260 RC outpatient 264 264 CIGNA 62308 [3081051] CIGNA STATE OF WYOMING [308105107] 211.2 percent of total billed charges 163.68 250.8 Technical (Hospital) Services IV Infusion Ther Proph Addl Sequential to 1 Hr PX-2609636700 CDM 96367 CPT 260 RC outpatient 264 264 HEALTHPARTNERS SX009 HEALTHPARTNERS 211.2 percent of total billed charges 163.68 250.8 Technical (Hospital) Services IV Infusion Ther Proph Addl Sequential to 1 Hr PX-2609636700 CDM 96367 CPT 260 RC outpatient 264 264 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES PPO [308136801] 211.2 percent of total billed charges 163.68 250.8 Technical (Hospital) Services IV Infusion Ther Proph Addl Sequential to 1 Hr PX-2609636700 CDM 96367 CPT 260 RC outpatient 264 264 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES EPO [308136803] 211.2 percent of total billed charges 163.68 250.8 Technical (Hospital) Services IV Infusion Ther Proph Addl Sequential to 1 Hr PX-2609636700 CDM 96367 CPT 260 RC outpatient 264 264 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES HDHP [308136802] 211.2 percent of total billed charges 163.68 250.8 Technical (Hospital) Services IV Infusion Ther Proph Addl Sequential to 1 Hr PX-2609636700 CDM 96367 CPT 260 RC outpatient 264 264 UNITED HEALTHCARE (COMMERCIAL) [3081199] UNITED HEALTHCARE 87726 [308119901] 163.68 percent of total billed charges 163.68 250.8 Technical (Hospital) Services IV Infusion Ther Proph Addl Sequential to 1 Hr PX-2609636700 CDM 96367 CPT 260 RC outpatient 264 264 BLUE CROSS BLUE SHIELD WELLMARK SB889 [3081026] BCBS WYOMING [308102603] 250.8 percent of total billed charges 163.68 250.8 Technical (Hospital) Services IV Infusion Therapy Prophylaxis/Dx Ea Addl Hour PX-2609636600 CDM 96366 CPT 260 RC outpatient 182 182 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES PPO [308136801] 145.6 percent of total billed charges 112.84 172.9 Technical (Hospital) Services IV Infusion Therapy Prophylaxis/Dx Ea Addl Hour PX-2609636600 CDM 96366 CPT 260 RC outpatient 182 182 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES EPO [308136803] 145.6 percent of total billed charges 112.84 172.9 Technical (Hospital) Services IV Infusion Therapy Prophylaxis/Dx Ea Addl Hour PX-2609636600 CDM 96366 CPT 260 RC outpatient 182 182 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES HDHP [308136802] 145.6 percent of total billed charges 112.84 172.9 Technical (Hospital) Services IV Infusion Therapy Prophylaxis/Dx Ea Addl Hour PX-2609636600 CDM 96366 CPT 260 RC outpatient 182 182 UNITED HEALTHCARE (COMMERCIAL) [3081199] UNITED HEALTHCARE 87726 [308119901] 112.84 percent of total billed charges 112.84 172.9 Technical (Hospital) Services IV Infusion Therapy Prophylaxis/Dx Ea Addl Hour PX-2609636600 CDM 96366 CPT 260 RC outpatient 182 182 BLUE CROSS BLUE SHIELD WELLMARK SB889 [3081026] BCBS WYOMING [308102603] 172.9 percent of total billed charges 112.84 172.9 Technical (Hospital) Services IV Infusion Therapy Prophylaxis/Dx Ea Addl Hour PX-2609636600 CDM 96366 CPT 260 RC outpatient 182 182 HEALTHPARTNERS SX009 HEALTHPARTNERS 145.6 percent of total billed charges 112.84 172.9 Technical (Hospital) Services IV Infusion Therapy Prophylaxis/Dx Ea Addl Hour PX-2609636600 CDM 96366 CPT 260 RC outpatient 182 182 CIGNA 62308 [3081051] CIGNA 62308 [308105105] 145.6 percent of total billed charges 112.84 172.9 Technical (Hospital) Services IV Infusion Therapy Prophylaxis/Dx Ea Addl Hour PX-2609636600 CDM 96366 CPT 260 RC outpatient 182 182 CIGNA 62308 [3081051] CIGNA STATE OF WYOMING [308105107] 145.6 percent of total billed charges 112.84 172.9 Technical (Hospital) Services IV Infusion Therapy Prophylaxis/Dx Ea Addl Hour PX-2609636600 CDM 96366 CPT 260 RC outpatient 182 182 MEDICA (COMMERCIAL) 94265 [3081118] MEDICA CLAIMS [308111801] 163.8 percent of total billed charges 112.84 172.9 Technical (Hospital) Services IV Infusion Therapy Prophylaxis/Dx Ea Addl Hour PX-2609636600 CDM 96366 CPT 260 RC outpatient 182 182 MULTIPLAN INC 34080 [3081285] MULTIPLAN INC [308128501] 172.9 percent of total billed charges 112.84 172.9 Technical (Hospital) Services IV Infusion Therapy Prophylaxis/Dx Ea Addl Hour PX-2609636600 CDM 96366 CPT 260 RC inpatient 182 182 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES PPO [308136801] 144.11 percent of total billed charges 112.84 172.9 Technical (Hospital) Services IV Infusion Therapy Prophylaxis/Dx Ea Addl Hour PX-2609636600 CDM 96366 CPT 260 RC inpatient 182 182 BLUE CROSS BLUE SHIELD WELLMARK SB889 [3081026] BCBS WYOMING [308102603] 172.9 percent of total billed charges 112.84 172.9 Technical (Hospital) Services IV Infusion Therapy Prophylaxis/Dx Ea Addl Hour PX-2609636600 CDM 96366 CPT 260 RC inpatient 182 182 UNITED HEALTHCARE (COMMERCIAL) [3081199] UNITED HEALTHCARE 87726 [308119901] 112.84 percent of total billed charges 112.84 172.9 Technical (Hospital) Services IV Infusion Therapy Prophylaxis/Dx Ea Addl Hour PX-2609636600 CDM 96366 CPT 260 RC inpatient 182 182 HEALTHPARTNERS SX009 HEALTHPARTNERS 144.11 percent of total billed charges 112.84 172.9 Technical (Hospital) Services IV Infusion Therapy Prophylaxis/Dx Ea Addl Hour PX-2609636600 CDM 96366 CPT 260 RC inpatient 182 182 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES HDHP [308136802] 144.11 percent of total billed charges 112.84 172.9 Technical (Hospital) Services IV Infusion Therapy Prophylaxis/Dx Ea Addl Hour PX-2609636600 CDM 96366 CPT 260 RC inpatient 182 182 MEDICA (COMMERCIAL) 94265 [3081118] MEDICA CLAIMS [308111801] 163.8 percent of total billed charges 112.84 172.9 Technical (Hospital) Services IV Infusion Therapy Prophylaxis/Dx Ea Addl Hour PX-2609636600 CDM 96366 CPT 260 RC inpatient 182 182 MULTIPLAN INC 34080 [3081285] MULTIPLAN INC [308128501] 172.9 percent of total billed charges 112.84 172.9 Technical (Hospital) Services IV Infusion Therapy Prophylaxis/Dx Ea Addl Hour PX-2609636600 CDM 96366 CPT 260 RC inpatient 182 182 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES EPO [308136803] 144.11 percent of total billed charges 112.84 172.9 Technical (Hospital) Services IV Infusion Therapy Prophylaxis/Dx Ea Addl Hour PX-2609636600 CDM 96366 CPT 260 RC inpatient 182 182 CIGNA 62308 [3081051] CIGNA 62308 [308105105] 144.11 percent of total billed charges 112.84 172.9 Technical (Hospital) Services IV Infusion Therapy Prophylaxis/Dx Ea Addl Hour PX-2609636600 CDM 96366 CPT 260 RC inpatient 182 182 CIGNA 62308 [3081051] CIGNA STATE OF WYOMING [308105107] 144.11 percent of total billed charges 112.84 172.9 Technical (Hospital) Services IV Infusion Therapy/Prophylaxis /Dx 1st to 1 Hr PX-2609636500 CDM 96365 CPT 260 RC outpatient 441 441 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES PPO [308136801] 352.8 percent of total billed charges 273.42 418.95 Technical (Hospital) Services IV Infusion Therapy/Prophylaxis /Dx 1st to 1 Hr PX-2609636500 CDM 96365 CPT 260 RC outpatient 441 441 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES EPO [308136803] 352.8 percent of total billed charges 273.42 418.95 Technical (Hospital) Services IV Infusion Therapy/Prophylaxis /Dx 1st to 1 Hr PX-2609636500 CDM 96365 CPT 260 RC outpatient 441 441 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES HDHP [308136802] 352.8 percent of total billed charges 273.42 418.95 Technical (Hospital) Services IV Infusion Therapy/Prophylaxis /Dx 1st to 1 Hr PX-2609636500 CDM 96365 CPT 260 RC outpatient 441 441 BLUE CROSS BLUE SHIELD WELLMARK SB889 [3081026] BCBS WYOMING [308102603] 418.95 percent of total billed charges 273.42 418.95 Technical (Hospital) Services IV Infusion Therapy/Prophylaxis /Dx 1st to 1 Hr PX-2609636500 CDM 96365 CPT 260 RC outpatient 441 441 UNITED HEALTHCARE (COMMERCIAL) [3081199] UNITED HEALTHCARE 87726 [308119901] 273.42 percent of total billed charges 273.42 418.95 Technical (Hospital) Services IV Infusion Therapy/Prophylaxis /Dx 1st to 1 Hr PX-2609636500 CDM 96365 CPT 260 RC outpatient 441 441 HEALTHPARTNERS SX009 HEALTHPARTNERS 352.8 percent of total billed charges 273.42 418.95 Technical (Hospital) Services IV Infusion Therapy/Prophylaxis /Dx 1st to 1 Hr PX-2609636500 CDM 96365 CPT 260 RC outpatient 441 441 MEDICA (COMMERCIAL) 94265 [3081118] MEDICA CLAIMS [308111801] 396.9 percent of total billed charges 273.42 418.95 Technical (Hospital) Services IV Infusion Therapy/Prophylaxis /Dx 1st to 1 Hr PX-2609636500 CDM 96365 CPT 260 RC outpatient 441 441 MULTIPLAN INC 34080 [3081285] MULTIPLAN INC [308128501] 418.95 percent of total billed charges 273.42 418.95 Technical (Hospital) Services IV Infusion Therapy/Prophylaxis /Dx 1st to 1 Hr PX-2609636500 CDM 96365 CPT 260 RC outpatient 441 441 CIGNA 62308 [3081051] CIGNA 62308 [308105105] 352.8 percent of total billed charges 273.42 418.95 Technical (Hospital) Services IV Infusion Therapy/Prophylaxis /Dx 1st to 1 Hr PX-2609636500 CDM 96365 CPT 260 RC outpatient 441 441 CIGNA 62308 [3081051] CIGNA STATE OF WYOMING [308105107] 352.8 percent of total billed charges 273.42 418.95 Technical (Hospital) Services IV Infusion Therapy/Prophylaxis /Dx 1st to 1 Hr PX-2609636500 CDM 96365 CPT 260 RC inpatient 441 441 HEALTHPARTNERS SX009 HEALTHPARTNERS 349.18 percent of total billed charges 273.42 418.95 Technical (Hospital) Services IV Infusion Therapy/Prophylaxis /Dx 1st to 1 Hr PX-2609636500 CDM 96365 CPT 260 RC inpatient 441 441 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES HDHP [308136802] 349.18 percent of total billed charges 273.42 418.95 Technical (Hospital) Services IV Infusion Therapy/Prophylaxis /Dx 1st to 1 Hr PX-2609636500 CDM 96365 CPT 260 RC inpatient 441 441 MULTIPLAN INC 34080 [3081285] MULTIPLAN INC [308128501] 418.95 percent of total billed charges 273.42 418.95 Technical (Hospital) Services IV Infusion Therapy/Prophylaxis /Dx 1st to 1 Hr PX-2609636500 CDM 96365 CPT 260 RC inpatient 441 441 MEDICA (COMMERCIAL) 94265 [3081118] MEDICA CLAIMS [308111801] 396.9 percent of total billed charges 273.42 418.95 Technical (Hospital) Services IV Infusion Therapy/Prophylaxis /Dx 1st to 1 Hr PX-2609636500 CDM 96365 CPT 260 RC inpatient 441 441 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES PPO [308136801] 349.18 percent of total billed charges 273.42 418.95 Technical (Hospital) Services IV Infusion Therapy/Prophylaxis /Dx 1st to 1 Hr PX-2609636500 CDM 96365 CPT 260 RC inpatient 441 441 BLUE CROSS BLUE SHIELD WELLMARK SB889 [3081026] BCBS WYOMING [308102603] 418.95 percent of total billed charges 273.42 418.95 Technical (Hospital) Services IV Infusion Therapy/Prophylaxis /Dx 1st to 1 Hr PX-2609636500 CDM 96365 CPT 260 RC inpatient 441 441 UNITED HEALTHCARE (COMMERCIAL) [3081199] UNITED HEALTHCARE 87726 [308119901] 273.42 percent of total billed charges 273.42 418.95 Technical (Hospital) Services IV Infusion Therapy/Prophylaxis /Dx 1st to 1 Hr PX-2609636500 CDM 96365 CPT 260 RC inpatient 441 441 CIGNA 62308 [3081051] CIGNA 62308 [308105105] 349.18 percent of total billed charges 273.42 418.95 Technical (Hospital) Services IV Infusion Therapy/Prophylaxis /Dx 1st to 1 Hr PX-2609636500 CDM 96365 CPT 260 RC inpatient 441 441 CIGNA 62308 [3081051] CIGNA STATE OF WYOMING [308105107] 349.18 percent of total billed charges 273.42 418.95 Technical (Hospital) Services IV Infusion Therapy/Prophylaxis /Dx 1st to 1 Hr PX-2609636500 CDM 96365 CPT 260 RC inpatient 441 441 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES EPO [308136803] 349.18 percent of total billed charges 273.42 418.95 Technical (Hospital) Services IV Infusion Hydration Each Additional Hour PX-2609636100 CDM 96361 CPT 260 RC outpatient 147 147 MEDICA (COMMERCIAL) 94265 [3081118] MEDICA CLAIMS [308111801] 132.3 percent of total billed charges 91.14 139.65 Technical (Hospital) Services IV Infusion Hydration Each Additional Hour PX-2609636100 CDM 96361 CPT 260 RC outpatient 147 147 CIGNA 62308 [3081051] CIGNA 62308 [308105105] 117.6 percent of total billed charges 91.14 139.65 Technical (Hospital) Services IV Infusion Hydration Each Additional Hour PX-2609636100 CDM 96361 CPT 260 RC outpatient 147 147 CIGNA 62308 [3081051] CIGNA STATE OF WYOMING [308105107] 117.6 percent of total billed charges 91.14 139.65 Technical (Hospital) Services IV Infusion Hydration Each Additional Hour PX-2609636100 CDM 96361 CPT 260 RC outpatient 147 147 MULTIPLAN INC 34080 [3081285] MULTIPLAN INC [308128501] 139.65 percent of total billed charges 91.14 139.65 Technical (Hospital) Services IV Infusion Hydration Each Additional Hour PX-2609636100 CDM 96361 CPT 260 RC outpatient 147 147 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES EPO [308136803] 117.6 percent of total billed charges 91.14 139.65 Technical (Hospital) Services IV Infusion Hydration Each Additional Hour PX-2609636100 CDM 96361 CPT 260 RC outpatient 147 147 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES PPO [308136801] 117.6 percent of total billed charges 91.14 139.65 Technical (Hospital) Services IV Infusion Hydration Each Additional Hour PX-2609636100 CDM 96361 CPT 260 RC outpatient 147 147 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES HDHP [308136802] 117.6 percent of total billed charges 91.14 139.65 Technical (Hospital) Services IV Infusion Hydration Each Additional Hour PX-2609636100 CDM 96361 CPT 260 RC outpatient 147 147 BLUE CROSS BLUE SHIELD WELLMARK SB889 [3081026] BCBS WYOMING [308102603] 139.65 percent of total billed charges 91.14 139.65 Technical (Hospital) Services IV Infusion Hydration Each Additional Hour PX-2609636100 CDM 96361 CPT 260 RC outpatient 147 147 UNITED HEALTHCARE (COMMERCIAL) [3081199] UNITED HEALTHCARE 87726 [308119901] 91.14 percent of total billed charges 91.14 139.65 Technical (Hospital) Services IV Infusion Hydration Each Additional Hour PX-2609636100 CDM 96361 CPT 260 RC outpatient 147 147 HEALTHPARTNERS SX009 HEALTHPARTNERS 117.6 percent of total billed charges 91.14 139.65 Technical (Hospital) Services IV Infusion Hydration Each Additional Hour PX-2609636100 CDM 96361 CPT 260 RC inpatient 147 147 UNITED HEALTHCARE (COMMERCIAL) [3081199] UNITED HEALTHCARE 87726 [308119901] 91.14 percent of total billed charges 91.14 139.65 Technical (Hospital) Services IV Infusion Hydration Each Additional Hour PX-2609636100 CDM 96361 CPT 260 RC inpatient 147 147 BLUE CROSS BLUE SHIELD WELLMARK SB889 [3081026] BCBS WYOMING [308102603] 139.65 percent of total billed charges 91.14 139.65 Technical (Hospital) Services IV Infusion Hydration Each Additional Hour PX-2609636100 CDM 96361 CPT 260 RC inpatient 147 147 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES PPO [308136801] 116.39 percent of total billed charges 91.14 139.65 Technical (Hospital) Services IV Infusion Hydration Each Additional Hour PX-2609636100 CDM 96361 CPT 260 RC inpatient 147 147 MEDICA (COMMERCIAL) 94265 [3081118] MEDICA CLAIMS [308111801] 132.3 percent of total billed charges 91.14 139.65 Technical (Hospital) Services IV Infusion Hydration Each Additional Hour PX-2609636100 CDM 96361 CPT 260 RC inpatient 147 147 MULTIPLAN INC 34080 [3081285] MULTIPLAN INC [308128501] 139.65 percent of total billed charges 91.14 139.65 Technical (Hospital) Services IV Infusion Hydration Each Additional Hour PX-2609636100 CDM 96361 CPT 260 RC inpatient 147 147 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES HDHP [308136802] 116.39 percent of total billed charges 91.14 139.65 Technical (Hospital) Services IV Infusion Hydration Each Additional Hour PX-2609636100 CDM 96361 CPT 260 RC inpatient 147 147 HEALTHPARTNERS SX009 HEALTHPARTNERS 116.39 percent of total billed charges 91.14 139.65 Technical (Hospital) Services IV Infusion Hydration Each Additional Hour PX-2609636100 CDM 96361 CPT 260 RC inpatient 147 147 CIGNA 62308 [3081051] CIGNA 62308 [308105105] 116.39 percent of total billed charges 91.14 139.65 Technical (Hospital) Services IV Infusion Hydration Each Additional Hour PX-2609636100 CDM 96361 CPT 260 RC inpatient 147 147 CIGNA 62308 [3081051] CIGNA STATE OF WYOMING [308105107] 116.39 percent of total billed charges 91.14 139.65 Technical (Hospital) Services IV Infusion Hydration Each Additional Hour PX-2609636100 CDM 96361 CPT 260 RC inpatient 147 147 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES EPO [308136803] 116.39 percent of total billed charges 91.14 139.65 Technical (Hospital) Services IV Infusion Hydration Initial 31 Min-1 Hour PX-2609636000 CDM 96360 CPT 260 RC outpatient 441 441 MULTIPLAN INC 34080 [3081285] MULTIPLAN INC [308128501] 418.95 percent of total billed charges 273.42 418.95 Technical (Hospital) Services IV Infusion Hydration Initial 31 Min-1 Hour PX-2609636000 CDM 96360 CPT 260 RC outpatient 441 441 MEDICA (COMMERCIAL) 94265 [3081118] MEDICA CLAIMS [308111801] 396.9 percent of total billed charges 273.42 418.95 Technical (Hospital) Services IV Infusion Hydration Initial 31 Min-1 Hour PX-2609636000 CDM 96360 CPT 260 RC outpatient 441 441 CIGNA 62308 [3081051] CIGNA 62308 [308105105] 352.8 percent of total billed charges 273.42 418.95 Technical (Hospital) Services IV Infusion Hydration Initial 31 Min-1 Hour PX-2609636000 CDM 96360 CPT 260 RC outpatient 441 441 CIGNA 62308 [3081051] CIGNA STATE OF WYOMING [308105107] 352.8 percent of total billed charges 273.42 418.95 Technical (Hospital) Services IV Infusion Hydration Initial 31 Min-1 Hour PX-2609636000 CDM 96360 CPT 260 RC outpatient 441 441 UNITED HEALTHCARE (COMMERCIAL) [3081199] UNITED HEALTHCARE 87726 [308119901] 273.42 percent of total billed charges 273.42 418.95 Technical (Hospital) Services IV Infusion Hydration Initial 31 Min-1 Hour PX-2609636000 CDM 96360 CPT 260 RC outpatient 441 441 BLUE CROSS BLUE SHIELD WELLMARK SB889 [3081026] BCBS WYOMING [308102603] 418.95 percent of total billed charges 273.42 418.95 Technical (Hospital) Services IV Infusion Hydration Initial 31 Min-1 Hour PX-2609636000 CDM 96360 CPT 260 RC outpatient 441 441 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES HDHP [308136802] 352.8 percent of total billed charges 273.42 418.95 Technical (Hospital) Services IV Infusion Hydration Initial 31 Min-1 Hour PX-2609636000 CDM 96360 CPT 260 RC outpatient 441 441 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES PPO [308136801] 352.8 percent of total billed charges 273.42 418.95 Technical (Hospital) Services IV Infusion Hydration Initial 31 Min-1 Hour PX-2609636000 CDM 96360 CPT 260 RC outpatient 441 441 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES EPO [308136803] 352.8 percent of total billed charges 273.42 418.95 Technical (Hospital) Services IV Infusion Hydration Initial 31 Min-1 Hour PX-2609636000 CDM 96360 CPT 260 RC outpatient 441 441 HEALTHPARTNERS SX009 HEALTHPARTNERS 352.8 percent of total billed charges 273.42 418.95 Technical (Hospital) Services IV Infusion Hydration Initial 31 Min-1 Hour PX-2609636000 CDM 96360 CPT 260 RC inpatient 441 441 CIGNA 62308 [3081051] CIGNA 62308 [308105105] 349.18 percent of total billed charges 273.42 418.95 Technical (Hospital) Services IV Infusion Hydration Initial 31 Min-1 Hour PX-2609636000 CDM 96360 CPT 260 RC inpatient 441 441 CIGNA 62308 [3081051] CIGNA STATE OF WYOMING [308105107] 349.18 percent of total billed charges 273.42 418.95 Technical (Hospital) Services IV Infusion Hydration Initial 31 Min-1 Hour PX-2609636000 CDM 96360 CPT 260 RC inpatient 441 441 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES EPO [308136803] 349.18 percent of total billed charges 273.42 418.95 Technical (Hospital) Services IV Infusion Hydration Initial 31 Min-1 Hour PX-2609636000 CDM 96360 CPT 260 RC inpatient 441 441 UNITED HEALTHCARE (COMMERCIAL) [3081199] UNITED HEALTHCARE 87726 [308119901] 273.42 percent of total billed charges 273.42 418.95 Technical (Hospital) Services IV Infusion Hydration Initial 31 Min-1 Hour PX-2609636000 CDM 96360 CPT 260 RC inpatient 441 441 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES PPO [308136801] 349.18 percent of total billed charges 273.42 418.95 Technical (Hospital) Services IV Infusion Hydration Initial 31 Min-1 Hour PX-2609636000 CDM 96360 CPT 260 RC inpatient 441 441 BLUE CROSS BLUE SHIELD WELLMARK SB889 [3081026] BCBS WYOMING [308102603] 418.95 percent of total billed charges 273.42 418.95 Technical (Hospital) Services IV Infusion Hydration Initial 31 Min-1 Hour PX-2609636000 CDM 96360 CPT 260 RC inpatient 441 441 HEALTHPARTNERS SX009 HEALTHPARTNERS 349.18 percent of total billed charges 273.42 418.95 Technical (Hospital) Services IV Infusion Hydration Initial 31 Min-1 Hour PX-2609636000 CDM 96360 CPT 260 RC inpatient 441 441 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES HDHP [308136802] 349.18 percent of total billed charges 273.42 418.95 Technical (Hospital) Services IV Infusion Hydration Initial 31 Min-1 Hour PX-2609636000 CDM 96360 CPT 260 RC inpatient 441 441 MULTIPLAN INC 34080 [3081285] MULTIPLAN INC [308128501] 418.95 percent of total billed charges 273.42 418.95 Technical (Hospital) Services IV Infusion Hydration Initial 31 Min-1 Hour PX-2609636000 CDM 96360 CPT 260 RC inpatient 441 441 MEDICA (COMMERCIAL) 94265 [3081118] MEDICA CLAIMS [308111801] 396.9 percent of total billed charges 273.42 418.95 Technical (Hospital) Services Standardized Cognitive Performance Testing PX-4449612500 CDM 96125 CPT 444 RC outpatient 496 496 MEDICA (COMMERCIAL) 94265 [3081118] MEDICA CLAIMS [308111801] 446.4 percent of total billed charges 307.52 471.2 Technical (Hospital) Services Standardized Cognitive Performance Testing PX-4449612500 CDM 96125 CPT 444 RC outpatient 496 496 MULTIPLAN INC 34080 [3081285] MULTIPLAN INC [308128501] 471.2 percent of total billed charges 307.52 471.2 Technical (Hospital) Services Standardized Cognitive Performance Testing PX-4449612500 CDM 96125 CPT 444 RC outpatient 496 496 CIGNA 62308 [3081051] CIGNA 62308 [308105105] 396.8 percent of total billed charges 307.52 471.2 Technical (Hospital) Services Standardized Cognitive Performance Testing PX-4449612500 CDM 96125 CPT 444 RC outpatient 496 496 CIGNA 62308 [3081051] CIGNA STATE OF WYOMING [308105107] 396.8 percent of total billed charges 307.52 471.2 Technical (Hospital) Services Standardized Cognitive Performance Testing PX-4449612500 CDM 96125 CPT 444 RC outpatient 496 496 BLUE CROSS BLUE SHIELD WELLMARK SB889 [3081026] BCBS WYOMING [308102603] 471.2 percent of total billed charges 307.52 471.2 Technical (Hospital) Services Standardized Cognitive Performance Testing PX-4449612500 CDM 96125 CPT 444 RC outpatient 496 496 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES HDHP [308136802] 396.8 percent of total billed charges 307.52 471.2 Technical (Hospital) Services Standardized Cognitive Performance Testing PX-4449612500 CDM 96125 CPT 444 RC outpatient 496 496 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES PPO [308136801] 396.8 percent of total billed charges 307.52 471.2 Technical (Hospital) Services Standardized Cognitive Performance Testing PX-4449612500 CDM 96125 CPT 444 RC outpatient 496 496 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES EPO [308136803] 396.8 percent of total billed charges 307.52 471.2 Technical (Hospital) Services Standardized Cognitive Performance Testing PX-4449612500 CDM 96125 CPT 444 RC outpatient 496 496 HEALTHPARTNERS SX009 HEALTHPARTNERS 396.8 percent of total billed charges 307.52 471.2 Technical (Hospital) Services Standardized Cognitive Performance Testing PX-4449612500 CDM 96125 CPT 444 RC outpatient 496 496 UNITED HEALTHCARE (COMMERCIAL) [3081199] UNITED HEALTHCARE 87726 [308119901] 307.52 percent of total billed charges 307.52 471.2 Technical (Hospital) Services Standardized Cognitive Performance Testing PX-4449612500 CDM 96125 CPT 444 RC inpatient 496 496 MEDICA (COMMERCIAL) 94265 [3081118] MEDICA CLAIMS [308111801] 446.4 percent of total billed charges 307.52 471.2 Technical (Hospital) Services Standardized Cognitive Performance Testing PX-4449612500 CDM 96125 CPT 444 RC inpatient 496 496 MULTIPLAN INC 34080 [3081285] MULTIPLAN INC [308128501] 471.2 percent of total billed charges 307.52 471.2 Technical (Hospital) Services Standardized Cognitive Performance Testing PX-4449612500 CDM 96125 CPT 444 RC inpatient 496 496 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES HDHP [308136802] 392.73 percent of total billed charges 307.52 471.2 Technical (Hospital) Services Standardized Cognitive Performance Testing PX-4449612500 CDM 96125 CPT 444 RC inpatient 496 496 HEALTHPARTNERS SX009 HEALTHPARTNERS 392.73 percent of total billed charges 307.52 471.2 Technical (Hospital) Services Standardized Cognitive Performance Testing PX-4449612500 CDM 96125 CPT 444 RC inpatient 496 496 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES PPO [308136801] 392.73 percent of total billed charges 307.52 471.2 Technical (Hospital) Services Standardized Cognitive Performance Testing PX-4449612500 CDM 96125 CPT 444 RC inpatient 496 496 UNITED HEALTHCARE (COMMERCIAL) [3081199] UNITED HEALTHCARE 87726 [308119901] 307.52 percent of total billed charges 307.52 471.2 Technical (Hospital) Services Standardized Cognitive Performance Testing PX-4449612500 CDM 96125 CPT 444 RC inpatient 496 496 BLUE CROSS BLUE SHIELD WELLMARK SB889 [3081026] BCBS WYOMING [308102603] 471.2 percent of total billed charges 307.52 471.2 Technical (Hospital) Services Standardized Cognitive Performance Testing PX-4449612500 CDM 96125 CPT 444 RC inpatient 496 496 CIGNA 62308 [3081051] CIGNA 62308 [308105105] 392.73 percent of total billed charges 307.52 471.2 Technical (Hospital) Services Standardized Cognitive Performance Testing PX-4449612500 CDM 96125 CPT 444 RC inpatient 496 496 CIGNA 62308 [3081051] CIGNA STATE OF WYOMING [308105107] 392.73 percent of total billed charges 307.52 471.2 Technical (Hospital) Services Standardized Cognitive Performance Testing PX-4449612500 CDM 96125 CPT 444 RC inpatient 496 496 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES EPO [308136803] 392.73 percent of total billed charges 307.52 471.2 Technical (Hospital) Services Assessment Aphasia W/Interp & Report per Hour PX-4449610500 CDM 96105 CPT 444 RC inpatient 351 351 HEALTHPARTNERS SX009 HEALTHPARTNERS 277.92 percent of total billed charges 217.62 333.45 Technical (Hospital) Services Assessment Aphasia W/Interp & Report per Hour PX-4449610500 CDM 96105 CPT 444 RC inpatient 351 351 MEDICA (COMMERCIAL) 94265 [3081118] MEDICA CLAIMS [308111801] 315.9 percent of total billed charges 217.62 333.45 Technical (Hospital) Services Assessment Aphasia W/Interp & Report per Hour PX-4449610500 CDM 96105 CPT 444 RC inpatient 351 351 MULTIPLAN INC 34080 [3081285] MULTIPLAN INC [308128501] 333.45 percent of total billed charges 217.62 333.45 Technical (Hospital) Services Assessment Aphasia W/Interp & Report per Hour PX-4449610500 CDM 96105 CPT 444 RC inpatient 351 351 UNITED HEALTHCARE (COMMERCIAL) [3081199] UNITED HEALTHCARE 87726 [308119901] 217.62 percent of total billed charges 217.62 333.45 Technical (Hospital) Services Assessment Aphasia W/Interp & Report per Hour PX-4449610500 CDM 96105 CPT 444 RC inpatient 351 351 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES PPO [308136801] 277.92 percent of total billed charges 217.62 333.45 Technical (Hospital) Services Assessment Aphasia W/Interp & Report per Hour PX-4449610500 CDM 96105 CPT 444 RC inpatient 351 351 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES HDHP [308136802] 277.92 percent of total billed charges 217.62 333.45 Technical (Hospital) Services Assessment Aphasia W/Interp & Report per Hour PX-4449610500 CDM 96105 CPT 444 RC inpatient 351 351 BLUE CROSS BLUE SHIELD WELLMARK SB889 [3081026] BCBS WYOMING [308102603] 333.45 percent of total billed charges 217.62 333.45 Technical (Hospital) Services Assessment Aphasia W/Interp & Report per Hour PX-4449610500 CDM 96105 CPT 444 RC inpatient 351 351 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES EPO [308136803] 277.92 percent of total billed charges 217.62 333.45 Technical (Hospital) Services Assessment Aphasia W/Interp & Report per Hour PX-4449610500 CDM 96105 CPT 444 RC inpatient 351 351 CIGNA 62308 [3081051] CIGNA 62308 [308105105] 277.92 percent of total billed charges 217.62 333.45 Technical (Hospital) Services Assessment Aphasia W/Interp & Report per Hour PX-4449610500 CDM 96105 CPT 444 RC inpatient 351 351 CIGNA 62308 [3081051] CIGNA STATE OF WYOMING [308105107] 277.92 percent of total billed charges 217.62 333.45 Technical (Hospital) Services Assessment Aphasia W/Interp & Report per Hour PX-4449610500 CDM 96105 CPT 444 RC outpatient 351 351 MEDICA (COMMERCIAL) 94265 [3081118] MEDICA CLAIMS [308111801] 315.9 percent of total billed charges 217.62 333.45 Technical (Hospital) Services Assessment Aphasia W/Interp & Report per Hour PX-4449610500 CDM 96105 CPT 444 RC outpatient 351 351 CIGNA 62308 [3081051] CIGNA 62308 [308105105] 280.8 percent of total billed charges 217.62 333.45 Technical (Hospital) Services Assessment Aphasia W/Interp & Report per Hour PX-4449610500 CDM 96105 CPT 444 RC outpatient 351 351 CIGNA 62308 [3081051] CIGNA STATE OF WYOMING [308105107] 280.8 percent of total billed charges 217.62 333.45 Technical (Hospital) Services Assessment Aphasia W/Interp & Report per Hour PX-4449610500 CDM 96105 CPT 444 RC outpatient 351 351 MULTIPLAN INC 34080 [3081285] MULTIPLAN INC [308128501] 333.45 percent of total billed charges 217.62 333.45 Technical (Hospital) Services Assessment Aphasia W/Interp & Report per Hour PX-4449610500 CDM 96105 CPT 444 RC outpatient 351 351 BLUE CROSS BLUE SHIELD WELLMARK SB889 [3081026] BCBS WYOMING [308102603] 333.45 percent of total billed charges 217.62 333.45 Technical (Hospital) Services Assessment Aphasia W/Interp & Report per Hour PX-4449610500 CDM 96105 CPT 444 RC outpatient 351 351 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES HDHP [308136802] 280.8 percent of total billed charges 217.62 333.45 Technical (Hospital) Services Assessment Aphasia W/Interp & Report per Hour PX-4449610500 CDM 96105 CPT 444 RC outpatient 351 351 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES EPO [308136803] 280.8 percent of total billed charges 217.62 333.45 Technical (Hospital) Services Assessment Aphasia W/Interp & Report per Hour PX-4449610500 CDM 96105 CPT 444 RC outpatient 351 351 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES PPO [308136801] 280.8 percent of total billed charges 217.62 333.45 Technical (Hospital) Services Assessment Aphasia W/Interp & Report per Hour PX-4449610500 CDM 96105 CPT 444 RC outpatient 351 351 HEALTHPARTNERS SX009 HEALTHPARTNERS 280.8 percent of total billed charges 217.62 333.45 Technical (Hospital) Services Assessment Aphasia W/Interp & Report per Hour PX-4449610500 CDM 96105 CPT 444 RC outpatient 351 351 UNITED HEALTHCARE (COMMERCIAL) [3081199] UNITED HEALTHCARE 87726 [308119901] 217.62 percent of total billed charges 217.62 333.45 Technical (Hospital) Services Canalith Repositioning Procedure PX-4219599200 CDM 95992 CPT 421 RC outpatient 145 145 CIGNA 62308 [3081051] CIGNA 62308 [308105105] 116 percent of total billed charges 89.9 137.75 Technical (Hospital) Services Canalith Repositioning Procedure PX-4219599200 CDM 95992 CPT 421 RC outpatient 145 145 CIGNA 62308 [3081051] CIGNA STATE OF WYOMING [308105107] 116 percent of total billed charges 89.9 137.75 Technical (Hospital) Services Canalith Repositioning Procedure PX-4219599200 CDM 95992 CPT 421 RC outpatient 145 145 MEDICA (COMMERCIAL) 94265 [3081118] MEDICA CLAIMS [308111801] 130.5 percent of total billed charges 89.9 137.75 Technical (Hospital) Services Canalith Repositioning Procedure PX-4219599200 CDM 95992 CPT 421 RC outpatient 145 145 MULTIPLAN INC 34080 [3081285] MULTIPLAN INC [308128501] 137.75 percent of total billed charges 89.9 137.75 Technical (Hospital) Services Canalith Repositioning Procedure PX-4219599200 CDM 95992 CPT 421 RC outpatient 145 145 BLUE CROSS BLUE SHIELD WELLMARK SB889 [3081026] BCBS WYOMING [308102603] 137.75 percent of total billed charges 89.9 137.75 Technical (Hospital) Services Canalith Repositioning Procedure PX-4219599200 CDM 95992 CPT 421 RC outpatient 145 145 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES HDHP [308136802] 116 percent of total billed charges 89.9 137.75 Technical (Hospital) Services Canalith Repositioning Procedure PX-4219599200 CDM 95992 CPT 421 RC outpatient 145 145 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES EPO [308136803] 116 percent of total billed charges 89.9 137.75 Technical (Hospital) Services Canalith Repositioning Procedure PX-4219599200 CDM 95992 CPT 421 RC outpatient 145 145 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES PPO [308136801] 116 percent of total billed charges 89.9 137.75 Technical (Hospital) Services Canalith Repositioning Procedure PX-4219599200 CDM 95992 CPT 421 RC outpatient 145 145 UNITED HEALTHCARE (COMMERCIAL) [3081199] UNITED HEALTHCARE 87726 [308119901] 89.9 percent of total billed charges 89.9 137.75 Technical (Hospital) Services Canalith Repositioning Procedure PX-4219599200 CDM 95992 CPT 421 RC outpatient 145 145 HEALTHPARTNERS SX009 HEALTHPARTNERS 116 percent of total billed charges 89.9 137.75 Technical (Hospital) Services Canalith Repositioning Procedure PX-4219599200 CDM 95992 CPT 421 RC inpatient 145 145 MULTIPLAN INC 34080 [3081285] MULTIPLAN INC [308128501] 137.75 percent of total billed charges 89.9 137.75 Technical (Hospital) Services Canalith Repositioning Procedure PX-4219599200 CDM 95992 CPT 421 RC inpatient 145 145 MEDICA (COMMERCIAL) 94265 [3081118] MEDICA CLAIMS [308111801] 130.5 percent of total billed charges 89.9 137.75 Technical (Hospital) Services Canalith Repositioning Procedure PX-4219599200 CDM 95992 CPT 421 RC inpatient 145 145 HEALTHPARTNERS SX009 HEALTHPARTNERS 114.81 percent of total billed charges 89.9 137.75 Technical (Hospital) Services Canalith Repositioning Procedure PX-4219599200 CDM 95992 CPT 421 RC inpatient 145 145 UNITED HEALTHCARE (COMMERCIAL) [3081199] UNITED HEALTHCARE 87726 [308119901] 89.9 percent of total billed charges 89.9 137.75 Technical (Hospital) Services Canalith Repositioning Procedure PX-4219599200 CDM 95992 CPT 421 RC inpatient 145 145 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES PPO [308136801] 114.81 percent of total billed charges 89.9 137.75 Technical (Hospital) Services Canalith Repositioning Procedure PX-4219599200 CDM 95992 CPT 421 RC inpatient 145 145 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES HDHP [308136802] 114.81 percent of total billed charges 89.9 137.75 Technical (Hospital) Services Canalith Repositioning Procedure PX-4219599200 CDM 95992 CPT 421 RC inpatient 145 145 BLUE CROSS BLUE SHIELD WELLMARK SB889 [3081026] BCBS WYOMING [308102603] 137.75 percent of total billed charges 89.9 137.75 Technical (Hospital) Services Canalith Repositioning Procedure PX-4219599200 CDM 95992 CPT 421 RC inpatient 145 145 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES EPO [308136803] 114.81 percent of total billed charges 89.9 137.75 Technical (Hospital) Services Canalith Repositioning Procedure PX-4219599200 CDM 95992 CPT 421 RC inpatient 145 145 CIGNA 62308 [3081051] CIGNA 62308 [308105105] 114.81 percent of total billed charges 89.9 137.75 Technical (Hospital) Services Canalith Repositioning Procedure PX-4219599200 CDM 95992 CPT 421 RC inpatient 145 145 CIGNA 62308 [3081051] CIGNA STATE OF WYOMING [308105107] 114.81 percent of total billed charges 89.9 137.75 Technical (Hospital) Services Polysom 6/>Yrs Sleep W/Cpap 4/> Addl Param Attnd PX-9209581100 CDM 95811 CPT 920 RC outpatient 4509 4509 MEDICA (COMMERCIAL) 94265 [3081118] MEDICA CLAIMS [308111801] 4058.1 percent of total billed charges 2795.58 4283.55 Technical (Hospital) Services Polysom 6/>Yrs Sleep W/Cpap 4/> Addl Param Attnd PX-9209581100 CDM 95811 CPT 920 RC outpatient 4509 4509 MULTIPLAN INC 34080 [3081285] MULTIPLAN INC [308128501] 4283.55 percent of total billed charges 2795.58 4283.55 Technical (Hospital) Services Polysom 6/>Yrs Sleep W/Cpap 4/> Addl Param Attnd PX-9209581100 CDM 95811 CPT 920 RC outpatient 4509 4509 CIGNA 62308 [3081051] CIGNA 62308 [308105105] 3607.2 percent of total billed charges 2795.58 4283.55 Technical (Hospital) Services Polysom 6/>Yrs Sleep W/Cpap 4/> Addl Param Attnd PX-9209581100 CDM 95811 CPT 920 RC outpatient 4509 4509 CIGNA 62308 [3081051] CIGNA STATE OF WYOMING [308105107] 3607.2 percent of total billed charges 2795.58 4283.55 Technical (Hospital) Services Polysom 6/>Yrs Sleep W/Cpap 4/> Addl Param Attnd PX-9209581100 CDM 95811 CPT 920 RC outpatient 4509 4509 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES PPO [308136801] 3607.2 percent of total billed charges 2795.58 4283.55 Technical (Hospital) Services Polysom 6/>Yrs Sleep W/Cpap 4/> Addl Param Attnd PX-9209581100 CDM 95811 CPT 920 RC outpatient 4509 4509 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES EPO [308136803] 3607.2 percent of total billed charges 2795.58 4283.55 Technical (Hospital) Services Polysom 6/>Yrs Sleep W/Cpap 4/> Addl Param Attnd PX-9209581100 CDM 95811 CPT 920 RC outpatient 4509 4509 BLUE CROSS BLUE SHIELD WELLMARK SB889 [3081026] BCBS WYOMING [308102603] 4283.55 percent of total billed charges 2795.58 4283.55 Technical (Hospital) Services Polysom 6/>Yrs Sleep W/Cpap 4/> Addl Param Attnd PX-9209581100 CDM 95811 CPT 920 RC outpatient 4509 4509 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES HDHP [308136802] 3607.2 percent of total billed charges 2795.58 4283.55 Technical (Hospital) Services Polysom 6/>Yrs Sleep W/Cpap 4/> Addl Param Attnd PX-9209581100 CDM 95811 CPT 920 RC outpatient 4509 4509 UNITED HEALTHCARE (COMMERCIAL) [3081199] UNITED HEALTHCARE 87726 [308119901] 2795.58 percent of total billed charges 2795.58 4283.55 Technical (Hospital) Services Polysom 6/>Yrs Sleep W/Cpap 4/> Addl Param Attnd PX-9209581100 CDM 95811 CPT 920 RC outpatient 4509 4509 HEALTHPARTNERS SX009 HEALTHPARTNERS 3607.2 percent of total billed charges 2795.58 4283.55 Technical (Hospital) Services Polysom 6/>Yrs Sleep W/Cpap 4/> Addl Param Attnd PX-9209581100 CDM 95811 CPT 920 RC inpatient 4509 4509 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES HDHP [308136802] 3570.23 percent of total billed charges 2795.58 4283.55 Technical (Hospital) Services Polysom 6/>Yrs Sleep W/Cpap 4/> Addl Param Attnd PX-9209581100 CDM 95811 CPT 920 RC inpatient 4509 4509 MEDICA (COMMERCIAL) 94265 [3081118] MEDICA CLAIMS [308111801] 4058.1 percent of total billed charges 2795.58 4283.55 Technical (Hospital) Services Polysom 6/>Yrs Sleep W/Cpap 4/> Addl Param Attnd PX-9209581100 CDM 95811 CPT 920 RC inpatient 4509 4509 MULTIPLAN INC 34080 [3081285] MULTIPLAN INC [308128501] 4283.55 percent of total billed charges 2795.58 4283.55 Technical (Hospital) Services Polysom 6/>Yrs Sleep W/Cpap 4/> Addl Param Attnd PX-9209581100 CDM 95811 CPT 920 RC inpatient 4509 4509 HEALTHPARTNERS SX009 HEALTHPARTNERS 3570.23 percent of total billed charges 2795.58 4283.55 Technical (Hospital) Services Polysom 6/>Yrs Sleep W/Cpap 4/> Addl Param Attnd PX-9209581100 CDM 95811 CPT 920 RC inpatient 4509 4509 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES EPO [308136803] 3570.23 percent of total billed charges 2795.58 4283.55 Technical (Hospital) Services Polysom 6/>Yrs Sleep W/Cpap 4/> Addl Param Attnd PX-9209581100 CDM 95811 CPT 920 RC inpatient 4509 4509 UNITED HEALTHCARE (COMMERCIAL) [3081199] UNITED HEALTHCARE 87726 [308119901] 2795.58 percent of total billed charges 2795.58 4283.55 Technical (Hospital) Services Polysom 6/>Yrs Sleep W/Cpap 4/> Addl Param Attnd PX-9209581100 CDM 95811 CPT 920 RC inpatient 4509 4509 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES PPO [308136801] 3570.23 percent of total billed charges 2795.58 4283.55 Technical (Hospital) Services Polysom 6/>Yrs Sleep W/Cpap 4/> Addl Param Attnd PX-9209581100 CDM 95811 CPT 920 RC inpatient 4509 4509 BLUE CROSS BLUE SHIELD WELLMARK SB889 [3081026] BCBS WYOMING [308102603] 4283.55 percent of total billed charges 2795.58 4283.55 Technical (Hospital) Services Polysom 6/>Yrs Sleep W/Cpap 4/> Addl Param Attnd PX-9209581100 CDM 95811 CPT 920 RC inpatient 4509 4509 CIGNA 62308 [3081051] CIGNA 62308 [308105105] 3570.23 percent of total billed charges 2795.58 4283.55 Technical (Hospital) Services Polysom 6/>Yrs Sleep W/Cpap 4/> Addl Param Attnd PX-9209581100 CDM 95811 CPT 920 RC inpatient 4509 4509 CIGNA 62308 [3081051] CIGNA STATE OF WYOMING [308105107] 3570.23 percent of total billed charges 2795.58 4283.55 Technical (Hospital) Services Polysom 6/>Yrs Sleep 4/> Addl Param Attnd PX-9209581000 CDM 95810 CPT 920 RC inpatient 3994 3994 CIGNA 62308 [3081051] CIGNA 62308 [308105105] 3162.45 percent of total billed charges 2476.28 3794.3 Technical (Hospital) Services Polysom 6/>Yrs Sleep 4/> Addl Param Attnd PX-9209581000 CDM 95810 CPT 920 RC inpatient 3994 3994 CIGNA 62308 [3081051] CIGNA STATE OF WYOMING [308105107] 3162.45 percent of total billed charges 2476.28 3794.3 Technical (Hospital) Services Polysom 6/>Yrs Sleep 4/> Addl Param Attnd PX-9209581000 CDM 95810 CPT 920 RC inpatient 3994 3994 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES EPO [308136803] 3162.45 percent of total billed charges 2476.28 3794.3 Technical (Hospital) Services Polysom 6/>Yrs Sleep 4/> Addl Param Attnd PX-9209581000 CDM 95810 CPT 920 RC inpatient 3994 3994 HEALTHPARTNERS SX009 HEALTHPARTNERS 3162.45 percent of total billed charges 2476.28 3794.3 Technical (Hospital) Services Polysom 6/>Yrs Sleep 4/> Addl Param Attnd PX-9209581000 CDM 95810 CPT 920 RC inpatient 3994 3994 MULTIPLAN INC 34080 [3081285] MULTIPLAN INC [308128501] 3794.3 percent of total billed charges 2476.28 3794.3 Technical (Hospital) Services Polysom 6/>Yrs Sleep 4/> Addl Param Attnd PX-9209581000 CDM 95810 CPT 920 RC inpatient 3994 3994 MEDICA (COMMERCIAL) 94265 [3081118] MEDICA CLAIMS [308111801] 3594.6 percent of total billed charges 2476.28 3794.3 Technical (Hospital) Services Polysom 6/>Yrs Sleep 4/> Addl Param Attnd PX-9209581000 CDM 95810 CPT 920 RC inpatient 3994 3994 BLUE CROSS BLUE SHIELD WELLMARK SB889 [3081026] BCBS WYOMING [308102603] 3794.3 percent of total billed charges 2476.28 3794.3 Technical (Hospital) Services Polysom 6/>Yrs Sleep 4/> Addl Param Attnd PX-9209581000 CDM 95810 CPT 920 RC inpatient 3994 3994 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES HDHP [308136802] 3162.45 percent of total billed charges 2476.28 3794.3 Technical (Hospital) Services Polysom 6/>Yrs Sleep 4/> Addl Param Attnd PX-9209581000 CDM 95810 CPT 920 RC inpatient 3994 3994 UNITED HEALTHCARE (COMMERCIAL) [3081199] UNITED HEALTHCARE 87726 [308119901] 2476.28 percent of total billed charges 2476.28 3794.3 Technical (Hospital) Services Polysom 6/>Yrs Sleep 4/> Addl Param Attnd PX-9209581000 CDM 95810 CPT 920 RC inpatient 3994 3994 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES PPO [308136801] 3162.45 percent of total billed charges 2476.28 3794.3 Technical (Hospital) Services Polysom 6/>Yrs Sleep 4/> Addl Param Attnd PX-9209581000 CDM 95810 CPT 920 RC outpatient 3994 3994 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES EPO [308136803] 3195.2 percent of total billed charges 2476.28 3794.3 Technical (Hospital) Services Polysom 6/>Yrs Sleep 4/> Addl Param Attnd PX-9209581000 CDM 95810 CPT 920 RC outpatient 3994 3994 UNITED HEALTHCARE (COMMERCIAL) [3081199] UNITED HEALTHCARE 87726 [308119901] 2476.28 percent of total billed charges 2476.28 3794.3 Technical (Hospital) Services Polysom 6/>Yrs Sleep 4/> Addl Param Attnd PX-9209581000 CDM 95810 CPT 920 RC outpatient 3994 3994 HEALTHPARTNERS SX009 HEALTHPARTNERS 3195.2 percent of total billed charges 2476.28 3794.3 Technical (Hospital) Services Polysom 6/>Yrs Sleep 4/> Addl Param Attnd PX-9209581000 CDM 95810 CPT 920 RC outpatient 3994 3994 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES PPO [308136801] 3195.2 percent of total billed charges 2476.28 3794.3 Technical (Hospital) Services Polysom 6/>Yrs Sleep 4/> Addl Param Attnd PX-9209581000 CDM 95810 CPT 920 RC outpatient 3994 3994 BLUE CROSS BLUE SHIELD WELLMARK SB889 [3081026] BCBS WYOMING [308102603] 3794.3 percent of total billed charges 2476.28 3794.3 Technical (Hospital) Services Polysom 6/>Yrs Sleep 4/> Addl Param Attnd PX-9209581000 CDM 95810 CPT 920 RC outpatient 3994 3994 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES HDHP [308136802] 3195.2 percent of total billed charges 2476.28 3794.3 Technical (Hospital) Services Polysom 6/>Yrs Sleep 4/> Addl Param Attnd PX-9209581000 CDM 95810 CPT 920 RC outpatient 3994 3994 CIGNA 62308 [3081051] CIGNA 62308 [308105105] 3195.2 percent of total billed charges 2476.28 3794.3 Technical (Hospital) Services Polysom 6/>Yrs Sleep 4/> Addl Param Attnd PX-9209581000 CDM 95810 CPT 920 RC outpatient 3994 3994 CIGNA 62308 [3081051] CIGNA STATE OF WYOMING [308105107] 3195.2 percent of total billed charges 2476.28 3794.3 Technical (Hospital) Services Polysom 6/>Yrs Sleep 4/> Addl Param Attnd PX-9209581000 CDM 95810 CPT 920 RC outpatient 3994 3994 MULTIPLAN INC 34080 [3081285] MULTIPLAN INC [308128501] 3794.3 percent of total billed charges 2476.28 3794.3 Technical (Hospital) Services Polysom 6/>Yrs Sleep 4/> Addl Param Attnd PX-9209581000 CDM 95810 CPT 920 RC outpatient 3994 3994 MEDICA (COMMERCIAL) 94265 [3081118] MEDICA CLAIMS [308111801] 3594.6 percent of total billed charges 2476.28 3794.3 Technical (Hospital) Services Mlt Sleep Latency/Maint of Wakefulness Tstg PX-9209580500 CDM 95805 CPT 920 RC outpatient 3569 3569 MEDICA (COMMERCIAL) 94265 [3081118] MEDICA CLAIMS [308111801] 3212.1 percent of total billed charges 2212.78 3390.55 Technical (Hospital) Services Mlt Sleep Latency/Maint of Wakefulness Tstg PX-9209580500 CDM 95805 CPT 920 RC outpatient 3569 3569 CIGNA 62308 [3081051] CIGNA 62308 [308105105] 2855.2 percent of total billed charges 2212.78 3390.55 Technical (Hospital) Services Mlt Sleep Latency/Maint of Wakefulness Tstg PX-9209580500 CDM 95805 CPT 920 RC outpatient 3569 3569 CIGNA 62308 [3081051] CIGNA STATE OF WYOMING [308105107] 2855.2 percent of total billed charges 2212.78 3390.55 Technical (Hospital) Services Mlt Sleep Latency/Maint of Wakefulness Tstg PX-9209580500 CDM 95805 CPT 920 RC outpatient 3569 3569 MULTIPLAN INC 34080 [3081285] MULTIPLAN INC [308128501] 3390.55 percent of total billed charges 2212.78 3390.55 Technical (Hospital) Services Mlt Sleep Latency/Maint of Wakefulness Tstg PX-9209580500 CDM 95805 CPT 920 RC outpatient 3569 3569 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES PPO [308136801] 2855.2 percent of total billed charges 2212.78 3390.55 Technical (Hospital) Services Mlt Sleep Latency/Maint of Wakefulness Tstg PX-9209580500 CDM 95805 CPT 920 RC outpatient 3569 3569 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES EPO [308136803] 2855.2 percent of total billed charges 2212.78 3390.55 Technical (Hospital) Services Mlt Sleep Latency/Maint of Wakefulness Tstg PX-9209580500 CDM 95805 CPT 920 RC outpatient 3569 3569 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES HDHP [308136802] 2855.2 percent of total billed charges 2212.78 3390.55 Technical (Hospital) Services Mlt Sleep Latency/Maint of Wakefulness Tstg PX-9209580500 CDM 95805 CPT 920 RC outpatient 3569 3569 BLUE CROSS BLUE SHIELD WELLMARK SB889 [3081026] BCBS WYOMING [308102603] 3390.55 percent of total billed charges 2212.78 3390.55 Technical (Hospital) Services Mlt Sleep Latency/Maint of Wakefulness Tstg PX-9209580500 CDM 95805 CPT 920 RC outpatient 3569 3569 HEALTHPARTNERS SX009 HEALTHPARTNERS 2855.2 percent of total billed charges 2212.78 3390.55 Technical (Hospital) Services Mlt Sleep Latency/Maint of Wakefulness Tstg PX-9209580500 CDM 95805 CPT 920 RC outpatient 3569 3569 UNITED HEALTHCARE (COMMERCIAL) [3081199] UNITED HEALTHCARE 87726 [308119901] 2212.78 percent of total billed charges 2212.78 3390.55 Technical (Hospital) Services Mlt Sleep Latency/Maint of Wakefulness Tstg PX-9209580500 CDM 95805 CPT 920 RC inpatient 3569 3569 BLUE CROSS BLUE SHIELD WELLMARK SB889 [3081026] BCBS WYOMING [308102603] 3390.55 percent of total billed charges 2212.78 3390.55 Technical (Hospital) Services Mlt Sleep Latency/Maint of Wakefulness Tstg PX-9209580500 CDM 95805 CPT 920 RC inpatient 3569 3569 UNITED HEALTHCARE (COMMERCIAL) [3081199] UNITED HEALTHCARE 87726 [308119901] 2212.78 percent of total billed charges 2212.78 3390.55 Technical (Hospital) Services Mlt Sleep Latency/Maint of Wakefulness Tstg PX-9209580500 CDM 95805 CPT 920 RC inpatient 3569 3569 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES PPO [308136801] 2825.93 percent of total billed charges 2212.78 3390.55 Technical (Hospital) Services Mlt Sleep Latency/Maint of Wakefulness Tstg PX-9209580500 CDM 95805 CPT 920 RC inpatient 3569 3569 MULTIPLAN INC 34080 [3081285] MULTIPLAN INC [308128501] 3390.55 percent of total billed charges 2212.78 3390.55 Technical (Hospital) Services Mlt Sleep Latency/Maint of Wakefulness Tstg PX-9209580500 CDM 95805 CPT 920 RC inpatient 3569 3569 MEDICA (COMMERCIAL) 94265 [3081118] MEDICA CLAIMS [308111801] 3212.1 percent of total billed charges 2212.78 3390.55 Technical (Hospital) Services Mlt Sleep Latency/Maint of Wakefulness Tstg PX-9209580500 CDM 95805 CPT 920 RC inpatient 3569 3569 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES HDHP [308136802] 2825.93 percent of total billed charges 2212.78 3390.55 Technical (Hospital) Services Mlt Sleep Latency/Maint of Wakefulness Tstg PX-9209580500 CDM 95805 CPT 920 RC inpatient 3569 3569 HEALTHPARTNERS SX009 HEALTHPARTNERS 2825.93 percent of total billed charges 2212.78 3390.55 Technical (Hospital) Services Mlt Sleep Latency/Maint of Wakefulness Tstg PX-9209580500 CDM 95805 CPT 920 RC inpatient 3569 3569 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES EPO [308136803] 2825.93 percent of total billed charges 2212.78 3390.55 Technical (Hospital) Services Mlt Sleep Latency/Maint of Wakefulness Tstg PX-9209580500 CDM 95805 CPT 920 RC inpatient 3569 3569 CIGNA 62308 [3081051] CIGNA 62308 [308105105] 2825.93 percent of total billed charges 2212.78 3390.55 Technical (Hospital) Services Mlt Sleep Latency/Maint of Wakefulness Tstg PX-9209580500 CDM 95805 CPT 920 RC inpatient 3569 3569 CIGNA 62308 [3081051] CIGNA STATE OF WYOMING [308105107] 2825.93 percent of total billed charges 2212.78 3390.55 Technical (Hospital) Services Noninvasive Ear/Pulse Oximetry Overnight Monitor PX-4609476200 CDM 94762 CPT 460 RC inpatient 509 509 MULTIPLAN INC 34080 [3081285] MULTIPLAN INC [308128501] 483.55 percent of total billed charges 315.58 483.55 Technical (Hospital) Services Noninvasive Ear/Pulse Oximetry Overnight Monitor PX-4609476200 CDM 94762 CPT 460 RC inpatient 509 509 MEDICA (COMMERCIAL) 94265 [3081118] MEDICA CLAIMS [308111801] 458.1 percent of total billed charges 315.58 483.55 Technical (Hospital) Services Noninvasive Ear/Pulse Oximetry Overnight Monitor PX-4609476200 CDM 94762 CPT 460 RC inpatient 509 509 HEALTHPARTNERS SX009 HEALTHPARTNERS 403.03 percent of total billed charges 315.58 483.55 Technical (Hospital) Services Noninvasive Ear/Pulse Oximetry Overnight Monitor PX-4609476200 CDM 94762 CPT 460 RC inpatient 509 509 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES PPO [308136801] 403.03 percent of total billed charges 315.58 483.55 Technical (Hospital) Services Noninvasive Ear/Pulse Oximetry Overnight Monitor PX-4609476200 CDM 94762 CPT 460 RC inpatient 509 509 UNITED HEALTHCARE (COMMERCIAL) [3081199] UNITED HEALTHCARE 87726 [308119901] 315.58 percent of total billed charges 315.58 483.55 Technical (Hospital) Services Noninvasive Ear/Pulse Oximetry Overnight Monitor PX-4609476200 CDM 94762 CPT 460 RC inpatient 509 509 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES HDHP [308136802] 403.03 percent of total billed charges 315.58 483.55 Technical (Hospital) Services Noninvasive Ear/Pulse Oximetry Overnight Monitor PX-4609476200 CDM 94762 CPT 460 RC inpatient 509 509 BLUE CROSS BLUE SHIELD WELLMARK SB889 [3081026] BCBS WYOMING [308102603] 483.55 percent of total billed charges 315.58 483.55 Technical (Hospital) Services Noninvasive Ear/Pulse Oximetry Overnight Monitor PX-4609476200 CDM 94762 CPT 460 RC inpatient 509 509 CIGNA 62308 [3081051] CIGNA 62308 [308105105] 403.03 percent of total billed charges 315.58 483.55 Technical (Hospital) Services Noninvasive Ear/Pulse Oximetry Overnight Monitor PX-4609476200 CDM 94762 CPT 460 RC inpatient 509 509 CIGNA 62308 [3081051] CIGNA STATE OF WYOMING [308105107] 403.03 percent of total billed charges 315.58 483.55 Technical (Hospital) Services Noninvasive Ear/Pulse Oximetry Overnight Monitor PX-4609476200 CDM 94762 CPT 460 RC inpatient 509 509 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES EPO [308136803] 403.03 percent of total billed charges 315.58 483.55 Technical (Hospital) Services Noninvasive Ear/Pulse Oximetry Overnight Monitor PX-4609476200 CDM 94762 CPT 460 RC outpatient 509 509 MEDICA (COMMERCIAL) 94265 [3081118] MEDICA CLAIMS [308111801] 458.1 percent of total billed charges 315.58 483.55 Technical (Hospital) Services Noninvasive Ear/Pulse Oximetry Overnight Monitor PX-4609476200 CDM 94762 CPT 460 RC outpatient 509 509 CIGNA 62308 [3081051] CIGNA 62308 [308105105] 407.2 percent of total billed charges 315.58 483.55 Technical (Hospital) Services Noninvasive Ear/Pulse Oximetry Overnight Monitor PX-4609476200 CDM 94762 CPT 460 RC outpatient 509 509 CIGNA 62308 [3081051] CIGNA STATE OF WYOMING [308105107] 407.2 percent of total billed charges 315.58 483.55 Technical (Hospital) Services Noninvasive Ear/Pulse Oximetry Overnight Monitor PX-4609476200 CDM 94762 CPT 460 RC outpatient 509 509 MULTIPLAN INC 34080 [3081285] MULTIPLAN INC [308128501] 483.55 percent of total billed charges 315.58 483.55 Technical (Hospital) Services Noninvasive Ear/Pulse Oximetry Overnight Monitor PX-4609476200 CDM 94762 CPT 460 RC outpatient 509 509 HEALTHPARTNERS SX009 HEALTHPARTNERS 407.2 percent of total billed charges 315.58 483.55 Technical (Hospital) Services Noninvasive Ear/Pulse Oximetry Overnight Monitor PX-4609476200 CDM 94762 CPT 460 RC outpatient 509 509 UNITED HEALTHCARE (COMMERCIAL) [3081199] UNITED HEALTHCARE 87726 [308119901] 315.58 percent of total billed charges 315.58 483.55 Technical (Hospital) Services Noninvasive Ear/Pulse Oximetry Overnight Monitor PX-4609476200 CDM 94762 CPT 460 RC outpatient 509 509 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES PPO [308136801] 407.2 percent of total billed charges 315.58 483.55 Technical (Hospital) Services Noninvasive Ear/Pulse Oximetry Overnight Monitor PX-4609476200 CDM 94762 CPT 460 RC outpatient 509 509 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES EPO [308136803] 407.2 percent of total billed charges 315.58 483.55 Technical (Hospital) Services Noninvasive Ear/Pulse Oximetry Overnight Monitor PX-4609476200 CDM 94762 CPT 460 RC outpatient 509 509 BLUE CROSS BLUE SHIELD WELLMARK SB889 [3081026] BCBS WYOMING [308102603] 483.55 percent of total billed charges 315.58 483.55 Technical (Hospital) Services Noninvasive Ear/Pulse Oximetry Overnight Monitor PX-4609476200 CDM 94762 CPT 460 RC outpatient 509 509 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES HDHP [308136802] 407.2 percent of total billed charges 315.58 483.55 Technical (Hospital) Services Noninvasive Ear/Pulse Oximetry Single Deter PX-4609476000 CDM 94760 CPT 460 RC outpatient 66 66 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES EPO [308136803] 52.8 percent of total billed charges 40.92 62.7 Technical (Hospital) Services Noninvasive Ear/Pulse Oximetry Single Deter PX-4609476000 CDM 94760 CPT 460 RC outpatient 66 66 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES PPO [308136801] 52.8 percent of total billed charges 40.92 62.7 Technical (Hospital) Services Noninvasive Ear/Pulse Oximetry Single Deter PX-4609476000 CDM 94760 CPT 460 RC outpatient 66 66 UNITED HEALTHCARE (COMMERCIAL) [3081199] UNITED HEALTHCARE 87726 [308119901] 40.92 percent of total billed charges 40.92 62.7 Technical (Hospital) Services Noninvasive Ear/Pulse Oximetry Single Deter PX-4609476000 CDM 94760 CPT 460 RC outpatient 66 66 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES HDHP [308136802] 52.8 percent of total billed charges 40.92 62.7 Technical (Hospital) Services Noninvasive Ear/Pulse Oximetry Single Deter PX-4609476000 CDM 94760 CPT 460 RC outpatient 66 66 BLUE CROSS BLUE SHIELD WELLMARK SB889 [3081026] BCBS WYOMING [308102603] 62.7 percent of total billed charges 40.92 62.7 Technical (Hospital) Services Noninvasive Ear/Pulse Oximetry Single Deter PX-4609476000 CDM 94760 CPT 460 RC outpatient 66 66 MEDICA (COMMERCIAL) 94265 [3081118] MEDICA CLAIMS [308111801] 59.4 percent of total billed charges 40.92 62.7 Technical (Hospital) Services Noninvasive Ear/Pulse Oximetry Single Deter PX-4609476000 CDM 94760 CPT 460 RC outpatient 66 66 HEALTHPARTNERS SX009 HEALTHPARTNERS 52.8 percent of total billed charges 40.92 62.7 Technical (Hospital) Services Noninvasive Ear/Pulse Oximetry Single Deter PX-4609476000 CDM 94760 CPT 460 RC outpatient 66 66 CIGNA 62308 [3081051] CIGNA 62308 [308105105] 52.8 percent of total billed charges 40.92 62.7 Technical (Hospital) Services Noninvasive Ear/Pulse Oximetry Single Deter PX-4609476000 CDM 94760 CPT 460 RC outpatient 66 66 CIGNA 62308 [3081051] CIGNA STATE OF WYOMING [308105107] 52.8 percent of total billed charges 40.92 62.7 Technical (Hospital) Services Noninvasive Ear/Pulse Oximetry Single Deter PX-4609476000 CDM 94760 CPT 460 RC outpatient 66 66 MULTIPLAN INC 34080 [3081285] MULTIPLAN INC [308128501] 62.7 percent of total billed charges 40.92 62.7 Technical (Hospital) Services Noninvasive Ear/Pulse Oximetry Single Deter PX-4609476000 CDM 94760 CPT 460 RC inpatient 66 66 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES EPO [308136803] 52.26 percent of total billed charges 40.92 62.7 Technical (Hospital) Services Noninvasive Ear/Pulse Oximetry Single Deter PX-4609476000 CDM 94760 CPT 460 RC inpatient 66 66 CIGNA 62308 [3081051] CIGNA 62308 [308105105] 52.26 percent of total billed charges 40.92 62.7 Technical (Hospital) Services Noninvasive Ear/Pulse Oximetry Single Deter PX-4609476000 CDM 94760 CPT 460 RC inpatient 66 66 CIGNA 62308 [3081051] CIGNA STATE OF WYOMING [308105107] 52.26 percent of total billed charges 40.92 62.7 Technical (Hospital) Services Noninvasive Ear/Pulse Oximetry Single Deter PX-4609476000 CDM 94760 CPT 460 RC inpatient 66 66 MEDICA (COMMERCIAL) 94265 [3081118] MEDICA CLAIMS [308111801] 59.4 percent of total billed charges 40.92 62.7 Technical (Hospital) Services Noninvasive Ear/Pulse Oximetry Single Deter PX-4609476000 CDM 94760 CPT 460 RC inpatient 66 66 MULTIPLAN INC 34080 [3081285] MULTIPLAN INC [308128501] 62.7 percent of total billed charges 40.92 62.7 Technical (Hospital) Services Noninvasive Ear/Pulse Oximetry Single Deter PX-4609476000 CDM 94760 CPT 460 RC inpatient 66 66 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES HDHP [308136802] 52.26 percent of total billed charges 40.92 62.7 Technical (Hospital) Services Noninvasive Ear/Pulse Oximetry Single Deter PX-4609476000 CDM 94760 CPT 460 RC inpatient 66 66 HEALTHPARTNERS SX009 HEALTHPARTNERS 52.26 percent of total billed charges 40.92 62.7 Technical (Hospital) Services Noninvasive Ear/Pulse Oximetry Single Deter PX-4609476000 CDM 94760 CPT 460 RC inpatient 66 66 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES PPO [308136801] 52.26 percent of total billed charges 40.92 62.7 Technical (Hospital) Services Noninvasive Ear/Pulse Oximetry Single Deter PX-4609476000 CDM 94760 CPT 460 RC inpatient 66 66 UNITED HEALTHCARE (COMMERCIAL) [3081199] UNITED HEALTHCARE 87726 [308119901] 40.92 percent of total billed charges 40.92 62.7 Technical (Hospital) Services Noninvasive Ear/Pulse Oximetry Single Deter PX-4609476000 CDM 94760 CPT 460 RC inpatient 66 66 BLUE CROSS BLUE SHIELD WELLMARK SB889 [3081026] BCBS WYOMING [308102603] 62.7 percent of total billed charges 40.92 62.7 Technical (Hospital) Services Manj Chest Wall Facilitate Lung Function Subsq PX-4109466800 CDM 94668 CPT 410 RC inpatient 100 100 BLUE CROSS BLUE SHIELD WELLMARK SB889 [3081026] BCBS WYOMING [308102603] 95 percent of total billed charges 62 95 Technical (Hospital) Services Manj Chest Wall Facilitate Lung Function Subsq PX-4109466800 CDM 94668 CPT 410 RC inpatient 100 100 UNITED HEALTHCARE (COMMERCIAL) [3081199] UNITED HEALTHCARE 87726 [308119901] 62 percent of total billed charges 62 95 Technical (Hospital) Services Manj Chest Wall Facilitate Lung Function Subsq PX-4109466800 CDM 94668 CPT 410 RC inpatient 100 100 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES PPO [308136801] 79.18 percent of total billed charges 62 95 Technical (Hospital) Services Manj Chest Wall Facilitate Lung Function Subsq PX-4109466800 CDM 94668 CPT 410 RC inpatient 100 100 MEDICA (COMMERCIAL) 94265 [3081118] MEDICA CLAIMS [308111801] 90 percent of total billed charges 62 95 Technical (Hospital) Services Manj Chest Wall Facilitate Lung Function Subsq PX-4109466800 CDM 94668 CPT 410 RC inpatient 100 100 MULTIPLAN INC 34080 [3081285] MULTIPLAN INC [308128501] 95 percent of total billed charges 62 95 Technical (Hospital) Services Manj Chest Wall Facilitate Lung Function Subsq PX-4109466800 CDM 94668 CPT 410 RC inpatient 100 100 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES HDHP [308136802] 79.18 percent of total billed charges 62 95 Technical (Hospital) Services Manj Chest Wall Facilitate Lung Function Subsq PX-4109466800 CDM 94668 CPT 410 RC inpatient 100 100 HEALTHPARTNERS SX009 HEALTHPARTNERS 79.18 percent of total billed charges 62 95 Technical (Hospital) Services Manj Chest Wall Facilitate Lung Function Subsq PX-4109466800 CDM 94668 CPT 410 RC inpatient 100 100 CIGNA 62308 [3081051] CIGNA 62308 [308105105] 79.18 percent of total billed charges 62 95 Technical (Hospital) Services Manj Chest Wall Facilitate Lung Function Subsq PX-4109466800 CDM 94668 CPT 410 RC inpatient 100 100 CIGNA 62308 [3081051] CIGNA STATE OF WYOMING [308105107] 79.18 percent of total billed charges 62 95 Technical (Hospital) Services Manj Chest Wall Facilitate Lung Function Subsq PX-4109466800 CDM 94668 CPT 410 RC inpatient 100 100 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES EPO [308136803] 79.18 percent of total billed charges 62 95 Technical (Hospital) Services Manj Chest Wall Facilitate Lung Function Subsq PX-4109466800 CDM 94668 CPT 410 RC outpatient 100 100 MULTIPLAN INC 34080 [3081285] MULTIPLAN INC [308128501] 95 percent of total billed charges 62 95 Technical (Hospital) Services Manj Chest Wall Facilitate Lung Function Subsq PX-4109466800 CDM 94668 CPT 410 RC outpatient 100 100 CIGNA 62308 [3081051] CIGNA 62308 [308105105] 80 percent of total billed charges 62 95 Technical (Hospital) Services Manj Chest Wall Facilitate Lung Function Subsq PX-4109466800 CDM 94668 CPT 410 RC outpatient 100 100 CIGNA 62308 [3081051] CIGNA STATE OF WYOMING [308105107] 80 percent of total billed charges 62 95 Technical (Hospital) Services Manj Chest Wall Facilitate Lung Function Subsq PX-4109466800 CDM 94668 CPT 410 RC outpatient 100 100 BLUE CROSS BLUE SHIELD WELLMARK SB889 [3081026] BCBS WYOMING [308102603] 95 percent of total billed charges 62 95 Technical (Hospital) Services Manj Chest Wall Facilitate Lung Function Subsq PX-4109466800 CDM 94668 CPT 410 RC outpatient 100 100 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES HDHP [308136802] 80 percent of total billed charges 62 95 Technical (Hospital) Services Manj Chest Wall Facilitate Lung Function Subsq PX-4109466800 CDM 94668 CPT 410 RC outpatient 100 100 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES PPO [308136801] 80 percent of total billed charges 62 95 Technical (Hospital) Services Manj Chest Wall Facilitate Lung Function Subsq PX-4109466800 CDM 94668 CPT 410 RC outpatient 100 100 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES EPO [308136803] 80 percent of total billed charges 62 95 Technical (Hospital) Services Manj Chest Wall Facilitate Lung Function Subsq PX-4109466800 CDM 94668 CPT 410 RC outpatient 100 100 MEDICA (COMMERCIAL) 94265 [3081118] MEDICA CLAIMS [308111801] 90 percent of total billed charges 62 95 Technical (Hospital) Services Manj Chest Wall Facilitate Lung Function Subsq PX-4109466800 CDM 94668 CPT 410 RC outpatient 100 100 UNITED HEALTHCARE (COMMERCIAL) [3081199] UNITED HEALTHCARE 87726 [308119901] 62 percent of total billed charges 62 95 Technical (Hospital) Services Manj Chest Wall Facilitate Lung Function Subsq PX-4109466800 CDM 94668 CPT 410 RC outpatient 100 100 HEALTHPARTNERS SX009 HEALTHPARTNERS 80 percent of total billed charges 62 95 Technical (Hospital) Services Manj Ch Wall Facilitate Lng Funcj 1 Demo&/Eval PX-4109466700 CDM 94667 CPT 410 RC outpatient 249 249 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES PPO [308136801] 199.2 percent of total billed charges 154.38 236.55 Technical (Hospital) Services Manj Ch Wall Facilitate Lng Funcj 1 Demo&/Eval PX-4109466700 CDM 94667 CPT 410 RC outpatient 249 249 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES EPO [308136803] 199.2 percent of total billed charges 154.38 236.55 Technical (Hospital) Services Manj Ch Wall Facilitate Lng Funcj 1 Demo&/Eval PX-4109466700 CDM 94667 CPT 410 RC outpatient 249 249 BLUE CROSS BLUE SHIELD WELLMARK SB889 [3081026] BCBS WYOMING [308102603] 236.55 percent of total billed charges 154.38 236.55 Technical (Hospital) Services Manj Ch Wall Facilitate Lng Funcj 1 Demo&/Eval PX-4109466700 CDM 94667 CPT 410 RC outpatient 249 249 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES HDHP [308136802] 199.2 percent of total billed charges 154.38 236.55 Technical (Hospital) Services Manj Ch Wall Facilitate Lng Funcj 1 Demo&/Eval PX-4109466700 CDM 94667 CPT 410 RC outpatient 249 249 HEALTHPARTNERS SX009 HEALTHPARTNERS 199.2 percent of total billed charges 154.38 236.55 Technical (Hospital) Services Manj Ch Wall Facilitate Lng Funcj 1 Demo&/Eval PX-4109466700 CDM 94667 CPT 410 RC outpatient 249 249 UNITED HEALTHCARE (COMMERCIAL) [3081199] UNITED HEALTHCARE 87726 [308119901] 154.38 percent of total billed charges 154.38 236.55 Technical (Hospital) Services Manj Ch Wall Facilitate Lng Funcj 1 Demo&/Eval PX-4109466700 CDM 94667 CPT 410 RC outpatient 249 249 MEDICA (COMMERCIAL) 94265 [3081118] MEDICA CLAIMS [308111801] 224.1 percent of total billed charges 154.38 236.55 Technical (Hospital) Services Manj Ch Wall Facilitate Lng Funcj 1 Demo&/Eval PX-4109466700 CDM 94667 CPT 410 RC outpatient 249 249 MULTIPLAN INC 34080 [3081285] MULTIPLAN INC [308128501] 236.55 percent of total billed charges 154.38 236.55 Technical (Hospital) Services Manj Ch Wall Facilitate Lng Funcj 1 Demo&/Eval PX-4109466700 CDM 94667 CPT 410 RC outpatient 249 249 CIGNA 62308 [3081051] CIGNA 62308 [308105105] 199.2 percent of total billed charges 154.38 236.55 Technical (Hospital) Services Manj Ch Wall Facilitate Lng Funcj 1 Demo&/Eval PX-4109466700 CDM 94667 CPT 410 RC outpatient 249 249 CIGNA 62308 [3081051] CIGNA STATE OF WYOMING [308105107] 199.2 percent of total billed charges 154.38 236.55 Technical (Hospital) Services Manj Ch Wall Facilitate Lng Funcj 1 Demo&/Eval PX-4109466700 CDM 94667 CPT 410 RC inpatient 249 249 CIGNA 62308 [3081051] CIGNA 62308 [308105105] 197.16 percent of total billed charges 154.38 236.55 Technical (Hospital) Services Manj Ch Wall Facilitate Lng Funcj 1 Demo&/Eval PX-4109466700 CDM 94667 CPT 410 RC inpatient 249 249 CIGNA 62308 [3081051] CIGNA STATE OF WYOMING [308105107] 197.16 percent of total billed charges 154.38 236.55 Technical (Hospital) Services Manj Ch Wall Facilitate Lng Funcj 1 Demo&/Eval PX-4109466700 CDM 94667 CPT 410 RC inpatient 249 249 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES EPO [308136803] 197.16 percent of total billed charges 154.38 236.55 Technical (Hospital) Services Manj Ch Wall Facilitate Lng Funcj 1 Demo&/Eval PX-4109466700 CDM 94667 CPT 410 RC inpatient 249 249 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES HDHP [308136802] 197.16 percent of total billed charges 154.38 236.55 Technical (Hospital) Services Manj Ch Wall Facilitate Lng Funcj 1 Demo&/Eval PX-4109466700 CDM 94667 CPT 410 RC inpatient 249 249 MEDICA (COMMERCIAL) 94265 [3081118] MEDICA CLAIMS [308111801] 224.1 percent of total billed charges 154.38 236.55 Technical (Hospital) Services Manj Ch Wall Facilitate Lng Funcj 1 Demo&/Eval PX-4109466700 CDM 94667 CPT 410 RC inpatient 249 249 MULTIPLAN INC 34080 [3081285] MULTIPLAN INC [308128501] 236.55 percent of total billed charges 154.38 236.55 Technical (Hospital) Services Manj Ch Wall Facilitate Lng Funcj 1 Demo&/Eval PX-4109466700 CDM 94667 CPT 410 RC inpatient 249 249 HEALTHPARTNERS SX009 HEALTHPARTNERS 197.16 percent of total billed charges 154.38 236.55 Technical (Hospital) Services Manj Ch Wall Facilitate Lng Funcj 1 Demo&/Eval PX-4109466700 CDM 94667 CPT 410 RC inpatient 249 249 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES PPO [308136801] 197.16 percent of total billed charges 154.38 236.55 Technical (Hospital) Services Manj Ch Wall Facilitate Lng Funcj 1 Demo&/Eval PX-4109466700 CDM 94667 CPT 410 RC inpatient 249 249 UNITED HEALTHCARE (COMMERCIAL) [3081199] UNITED HEALTHCARE 87726 [308119901] 154.38 percent of total billed charges 154.38 236.55 Technical (Hospital) Services Manj Ch Wall Facilitate Lng Funcj 1 Demo&/Eval PX-4109466700 CDM 94667 CPT 410 RC inpatient 249 249 BLUE CROSS BLUE SHIELD WELLMARK SB889 [3081026] BCBS WYOMING [308102603] 236.55 percent of total billed charges 154.38 236.55 Technical (Hospital) Services Demo&/Eval of Pt Utiliz Aersl Gen/Neb/Inhlr/IP PX-4109466400 CDM 94664 CPT 410 RC inpatient 180 180 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES HDHP [308136802] 142.52 percent of total billed charges 111.6 171 Technical (Hospital) Services Demo&/Eval of Pt Utiliz Aersl Gen/Neb/Inhlr/IP PX-4109466400 CDM 94664 CPT 410 RC inpatient 180 180 BLUE CROSS BLUE SHIELD WELLMARK SB889 [3081026] BCBS WYOMING [308102603] 171 percent of total billed charges 111.6 171 Technical (Hospital) Services Demo&/Eval of Pt Utiliz Aersl Gen/Neb/Inhlr/IP PX-4109466400 CDM 94664 CPT 410 RC inpatient 180 180 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES PPO [308136801] 142.52 percent of total billed charges 111.6 171 Technical (Hospital) Services Demo&/Eval of Pt Utiliz Aersl Gen/Neb/Inhlr/IP PX-4109466400 CDM 94664 CPT 410 RC inpatient 180 180 UNITED HEALTHCARE (COMMERCIAL) [3081199] UNITED HEALTHCARE 87726 [308119901] 111.6 percent of total billed charges 111.6 171 Technical (Hospital) Services Demo&/Eval of Pt Utiliz Aersl Gen/Neb/Inhlr/IP PX-4109466400 CDM 94664 CPT 410 RC inpatient 180 180 MULTIPLAN INC 34080 [3081285] MULTIPLAN INC [308128501] 171 percent of total billed charges 111.6 171 Technical (Hospital) Services Demo&/Eval of Pt Utiliz Aersl Gen/Neb/Inhlr/IP PX-4109466400 CDM 94664 CPT 410 RC inpatient 180 180 MEDICA (COMMERCIAL) 94265 [3081118] MEDICA CLAIMS [308111801] 162 percent of total billed charges 111.6 171 Technical (Hospital) Services Demo&/Eval of Pt Utiliz Aersl Gen/Neb/Inhlr/IP PX-4109466400 CDM 94664 CPT 410 RC inpatient 180 180 HEALTHPARTNERS SX009 HEALTHPARTNERS 142.52 percent of total billed charges 111.6 171 Technical (Hospital) Services Demo&/Eval of Pt Utiliz Aersl Gen/Neb/Inhlr/IP PX-4109466400 CDM 94664 CPT 410 RC inpatient 180 180 CIGNA 62308 [3081051] CIGNA 62308 [308105105] 142.52 percent of total billed charges 111.6 171 Technical (Hospital) Services Demo&/Eval of Pt Utiliz Aersl Gen/Neb/Inhlr/IP PX-4109466400 CDM 94664 CPT 410 RC inpatient 180 180 CIGNA 62308 [3081051] CIGNA STATE OF WYOMING [308105107] 142.52 percent of total billed charges 111.6 171 Technical (Hospital) Services Demo&/Eval of Pt Utiliz Aersl Gen/Neb/Inhlr/IP PX-4109466400 CDM 94664 CPT 410 RC inpatient 180 180 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES EPO [308136803] 142.52 percent of total billed charges 111.6 171 Technical (Hospital) Services Demo&/Eval of Pt Utiliz Aersl Gen/Neb/Inhlr/IP PX-4109466400 CDM 94664 CPT 410 RC outpatient 180 180 MULTIPLAN INC 34080 [3081285] MULTIPLAN INC [308128501] 171 percent of total billed charges 111.6 171 Technical (Hospital) Services Demo&/Eval of Pt Utiliz Aersl Gen/Neb/Inhlr/IP PX-4109466400 CDM 94664 CPT 410 RC outpatient 180 180 CIGNA 62308 [3081051] CIGNA 62308 [308105105] 144 percent of total billed charges 111.6 171 Technical (Hospital) Services Demo&/Eval of Pt Utiliz Aersl Gen/Neb/Inhlr/IP PX-4109466400 CDM 94664 CPT 410 RC outpatient 180 180 CIGNA 62308 [3081051] CIGNA STATE OF WYOMING [308105107] 144 percent of total billed charges 111.6 171 Technical (Hospital) Services Demo&/Eval of Pt Utiliz Aersl Gen/Neb/Inhlr/IP PX-4109466400 CDM 94664 CPT 410 RC outpatient 180 180 MEDICA (COMMERCIAL) 94265 [3081118] MEDICA CLAIMS [308111801] 162 percent of total billed charges 111.6 171 Technical (Hospital) Services Demo&/Eval of Pt Utiliz Aersl Gen/Neb/Inhlr/IP PX-4109466400 CDM 94664 CPT 410 RC outpatient 180 180 BLUE CROSS BLUE SHIELD WELLMARK SB889 [3081026] BCBS WYOMING [308102603] 171 percent of total billed charges 111.6 171 Technical (Hospital) Services Demo&/Eval of Pt Utiliz Aersl Gen/Neb/Inhlr/IP PX-4109466400 CDM 94664 CPT 410 RC outpatient 180 180 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES HDHP [308136802] 144 percent of total billed charges 111.6 171 Technical (Hospital) Services Demo&/Eval of Pt Utiliz Aersl Gen/Neb/Inhlr/IP PX-4109466400 CDM 94664 CPT 410 RC outpatient 180 180 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES PPO [308136801] 144 percent of total billed charges 111.6 171 Technical (Hospital) Services Demo&/Eval of Pt Utiliz Aersl Gen/Neb/Inhlr/IP PX-4109466400 CDM 94664 CPT 410 RC outpatient 180 180 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES EPO [308136803] 144 percent of total billed charges 111.6 171 Technical (Hospital) Services Demo&/Eval of Pt Utiliz Aersl Gen/Neb/Inhlr/IP PX-4109466400 CDM 94664 CPT 410 RC outpatient 180 180 HEALTHPARTNERS SX009 HEALTHPARTNERS 144 percent of total billed charges 111.6 171 Technical (Hospital) Services Demo&/Eval of Pt Utiliz Aersl Gen/Neb/Inhlr/IP PX-4109466400 CDM 94664 CPT 410 RC outpatient 180 180 UNITED HEALTHCARE (COMMERCIAL) [3081199] UNITED HEALTHCARE 87726 [308119901] 111.6 percent of total billed charges 111.6 171 Technical (Hospital) Services Cpap Ventilation Cpap Initiation&Mgmt PX-4109466000 CDM 94660 CPT 410 RC inpatient 316 316 BLUE CROSS BLUE SHIELD WELLMARK SB889 [3081026] BCBS WYOMING [308102603] 300.2 percent of total billed charges 195.92 300.2 Technical (Hospital) Services Cpap Ventilation Cpap Initiation&Mgmt PX-4109466000 CDM 94660 CPT 410 RC inpatient 316 316 UNITED HEALTHCARE (COMMERCIAL) [3081199] UNITED HEALTHCARE 87726 [308119901] 195.92 percent of total billed charges 195.92 300.2 Technical (Hospital) Services Cpap Ventilation Cpap Initiation&Mgmt PX-4109466000 CDM 94660 CPT 410 RC inpatient 316 316 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES PPO [308136801] 250.21 percent of total billed charges 195.92 300.2 Technical (Hospital) Services Cpap Ventilation Cpap Initiation&Mgmt PX-4109466000 CDM 94660 CPT 410 RC inpatient 316 316 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES HDHP [308136802] 250.21 percent of total billed charges 195.92 300.2 Technical (Hospital) Services Cpap Ventilation Cpap Initiation&Mgmt PX-4109466000 CDM 94660 CPT 410 RC inpatient 316 316 MEDICA (COMMERCIAL) 94265 [3081118] MEDICA CLAIMS [308111801] 284.4 percent of total billed charges 195.92 300.2 Technical (Hospital) Services Cpap Ventilation Cpap Initiation&Mgmt PX-4109466000 CDM 94660 CPT 410 RC inpatient 316 316 MULTIPLAN INC 34080 [3081285] MULTIPLAN INC [308128501] 300.2 percent of total billed charges 195.92 300.2 Technical (Hospital) Services Cpap Ventilation Cpap Initiation&Mgmt PX-4109466000 CDM 94660 CPT 410 RC inpatient 316 316 HEALTHPARTNERS SX009 HEALTHPARTNERS 250.21 percent of total billed charges 195.92 300.2 Technical (Hospital) Services Cpap Ventilation Cpap Initiation&Mgmt PX-4109466000 CDM 94660 CPT 410 RC inpatient 316 316 CIGNA 62308 [3081051] CIGNA 62308 [308105105] 250.21 percent of total billed charges 195.92 300.2 Technical (Hospital) Services Cpap Ventilation Cpap Initiation&Mgmt PX-4109466000 CDM 94660 CPT 410 RC inpatient 316 316 CIGNA 62308 [3081051] CIGNA STATE OF WYOMING [308105107] 250.21 percent of total billed charges 195.92 300.2 Technical (Hospital) Services Cpap Ventilation Cpap Initiation&Mgmt PX-4109466000 CDM 94660 CPT 410 RC inpatient 316 316 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES EPO [308136803] 250.21 percent of total billed charges 195.92 300.2 Technical (Hospital) Services Cpap Ventilation Cpap Initiation&Mgmt PX-4109466000 CDM 94660 CPT 410 RC outpatient 316 316 MEDICA (COMMERCIAL) 94265 [3081118] MEDICA CLAIMS [308111801] 284.4 percent of total billed charges 195.92 300.2 Technical (Hospital) Services Cpap Ventilation Cpap Initiation&Mgmt PX-4109466000 CDM 94660 CPT 410 RC outpatient 316 316 MULTIPLAN INC 34080 [3081285] MULTIPLAN INC [308128501] 300.2 percent of total billed charges 195.92 300.2 Technical (Hospital) Services Cpap Ventilation Cpap Initiation&Mgmt PX-4109466000 CDM 94660 CPT 410 RC outpatient 316 316 CIGNA 62308 [3081051] CIGNA 62308 [308105105] 252.8 percent of total billed charges 195.92 300.2 Technical (Hospital) Services Cpap Ventilation Cpap Initiation&Mgmt PX-4109466000 CDM 94660 CPT 410 RC outpatient 316 316 CIGNA 62308 [3081051] CIGNA STATE OF WYOMING [308105107] 252.8 percent of total billed charges 195.92 300.2 Technical (Hospital) Services Cpap Ventilation Cpap Initiation&Mgmt PX-4109466000 CDM 94660 CPT 410 RC outpatient 316 316 BLUE CROSS BLUE SHIELD WELLMARK SB889 [3081026] BCBS WYOMING [308102603] 300.2 percent of total billed charges 195.92 300.2 Technical (Hospital) Services Cpap Ventilation Cpap Initiation&Mgmt PX-4109466000 CDM 94660 CPT 410 RC outpatient 316 316 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES HDHP [308136802] 252.8 percent of total billed charges 195.92 300.2 Technical (Hospital) Services Cpap Ventilation Cpap Initiation&Mgmt PX-4109466000 CDM 94660 CPT 410 RC outpatient 316 316 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES EPO [308136803] 252.8 percent of total billed charges 195.92 300.2 Technical (Hospital) Services Cpap Ventilation Cpap Initiation&Mgmt PX-4109466000 CDM 94660 CPT 410 RC outpatient 316 316 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES PPO [308136801] 252.8 percent of total billed charges 195.92 300.2 Technical (Hospital) Services Cpap Ventilation Cpap Initiation&Mgmt PX-4109466000 CDM 94660 CPT 410 RC outpatient 316 316 UNITED HEALTHCARE (COMMERCIAL) [3081199] UNITED HEALTHCARE 87726 [308119901] 195.92 percent of total billed charges 195.92 300.2 Technical (Hospital) Services Cpap Ventilation Cpap Initiation&Mgmt PX-4109466000 CDM 94660 CPT 410 RC outpatient 316 316 HEALTHPARTNERS SX009 HEALTHPARTNERS 252.8 percent of total billed charges 195.92 300.2 Technical (Hospital) Services Pressurized/Nonpressurized Inhalation Treatment PX-4109464000 CDM 94640 CPT 410 RC inpatient 222 222 CIGNA 62308 [3081051] CIGNA 62308 [308105105] 175.78 percent of total billed charges 137.64 210.9 Technical (Hospital) Services Pressurized/Nonpressurized Inhalation Treatment PX-4109464000 CDM 94640 CPT 410 RC inpatient 222 222 CIGNA 62308 [3081051] CIGNA STATE OF WYOMING [308105107] 175.78 percent of total billed charges 137.64 210.9 Technical (Hospital) Services Pressurized/Nonpressurized Inhalation Treatment PX-4109464000 CDM 94640 CPT 410 RC inpatient 222 222 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES EPO [308136803] 175.78 percent of total billed charges 137.64 210.9 Technical (Hospital) Services Pressurized/Nonpressurized Inhalation Treatment PX-4109464000 CDM 94640 CPT 410 RC inpatient 222 222 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES PPO [308136801] 175.78 percent of total billed charges 137.64 210.9 Technical (Hospital) Services Pressurized/Nonpressurized Inhalation Treatment PX-4109464000 CDM 94640 CPT 410 RC inpatient 222 222 UNITED HEALTHCARE (COMMERCIAL) [3081199] UNITED HEALTHCARE 87726 [308119901] 137.64 percent of total billed charges 137.64 210.9 Technical (Hospital) Services Pressurized/Nonpressurized Inhalation Treatment PX-4109464000 CDM 94640 CPT 410 RC inpatient 222 222 BLUE CROSS BLUE SHIELD WELLMARK SB889 [3081026] BCBS WYOMING [308102603] 210.9 percent of total billed charges 137.64 210.9 Technical (Hospital) Services Pressurized/Nonpressurized Inhalation Treatment PX-4109464000 CDM 94640 CPT 410 RC inpatient 222 222 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES HDHP [308136802] 175.78 percent of total billed charges 137.64 210.9 Technical (Hospital) Services Pressurized/Nonpressurized Inhalation Treatment PX-4109464000 CDM 94640 CPT 410 RC inpatient 222 222 MULTIPLAN INC 34080 [3081285] MULTIPLAN INC [308128501] 210.9 percent of total billed charges 137.64 210.9 Technical (Hospital) Services Pressurized/Nonpressurized Inhalation Treatment PX-4109464000 CDM 94640 CPT 410 RC inpatient 222 222 MEDICA (COMMERCIAL) 94265 [3081118] MEDICA CLAIMS [308111801] 199.8 percent of total billed charges 137.64 210.9 Technical (Hospital) Services Pressurized/Nonpressurized Inhalation Treatment PX-4109464000 CDM 94640 CPT 410 RC inpatient 222 222 HEALTHPARTNERS SX009 HEALTHPARTNERS 175.78 percent of total billed charges 137.64 210.9 Technical (Hospital) Services Pressurized/Nonpressurized Inhalation Treatment PX-4109464000 CDM 94640 CPT 410 RC outpatient 222 222 CIGNA 62308 [3081051] CIGNA 62308 [308105105] 177.6 percent of total billed charges 137.64 210.9 Technical (Hospital) Services Pressurized/Nonpressurized Inhalation Treatment PX-4109464000 CDM 94640 CPT 410 RC outpatient 222 222 CIGNA 62308 [3081051] CIGNA STATE OF WYOMING [308105107] 177.6 percent of total billed charges 137.64 210.9 Technical (Hospital) Services Pressurized/Nonpressurized Inhalation Treatment PX-4109464000 CDM 94640 CPT 410 RC outpatient 222 222 MULTIPLAN INC 34080 [3081285] MULTIPLAN INC [308128501] 210.9 percent of total billed charges 137.64 210.9 Technical (Hospital) Services Pressurized/Nonpressurized Inhalation Treatment PX-4109464000 CDM 94640 CPT 410 RC outpatient 222 222 MEDICA (COMMERCIAL) 94265 [3081118] MEDICA CLAIMS [308111801] 199.8 percent of total billed charges 137.64 210.9 Technical (Hospital) Services Pressurized/Nonpressurized Inhalation Treatment PX-4109464000 CDM 94640 CPT 410 RC outpatient 222 222 HEALTHPARTNERS SX009 HEALTHPARTNERS 177.6 percent of total billed charges 137.64 210.9 Technical (Hospital) Services Pressurized/Nonpressurized Inhalation Treatment PX-4109464000 CDM 94640 CPT 410 RC outpatient 222 222 UNITED HEALTHCARE (COMMERCIAL) [3081199] UNITED HEALTHCARE 87726 [308119901] 137.64 percent of total billed charges 137.64 210.9 Technical (Hospital) Services Pressurized/Nonpressurized Inhalation Treatment PX-4109464000 CDM 94640 CPT 410 RC outpatient 222 222 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES EPO [308136803] 177.6 percent of total billed charges 137.64 210.9 Technical (Hospital) Services Pressurized/Nonpressurized Inhalation Treatment PX-4109464000 CDM 94640 CPT 410 RC outpatient 222 222 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES PPO [308136801] 177.6 percent of total billed charges 137.64 210.9 Technical (Hospital) Services Pressurized/Nonpressurized Inhalation Treatment PX-4109464000 CDM 94640 CPT 410 RC outpatient 222 222 BLUE CROSS BLUE SHIELD WELLMARK SB889 [3081026] BCBS WYOMING [308102603] 210.9 percent of total billed charges 137.64 210.9 Technical (Hospital) Services Pressurized/Nonpressurized Inhalation Treatment PX-4109464000 CDM 94640 CPT 410 RC outpatient 222 222 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES HDHP [308136802] 177.6 percent of total billed charges 137.64 210.9 Technical (Hospital) Services Lung Function Test (Mbc/Mvv) PX-5109420000 CDM 94200 CPT 510 RC inpatient 104 104 CIGNA 62308 [3081051] CIGNA 62308 [308105105] 82.35 percent of total billed charges 64.48 98.8 Technical (Hospital) Services Lung Function Test (Mbc/Mvv) PX-5109420000 CDM 94200 CPT 510 RC inpatient 104 104 CIGNA 62308 [3081051] CIGNA STATE OF WYOMING [308105107] 82.35 percent of total billed charges 64.48 98.8 Technical (Hospital) Services Lung Function Test (Mbc/Mvv) PX-5109420000 CDM 94200 CPT 510 RC inpatient 104 104 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES EPO [308136803] 82.35 percent of total billed charges 64.48 98.8 Technical (Hospital) Services Lung Function Test (Mbc/Mvv) PX-5109420000 CDM 94200 CPT 510 RC inpatient 104 104 BLUE CROSS BLUE SHIELD WELLMARK SB889 [3081026] BCBS WYOMING [308102603] 98.8 percent of total billed charges 64.48 98.8 Technical (Hospital) Services Lung Function Test (Mbc/Mvv) PX-5109420000 CDM 94200 CPT 510 RC inpatient 104 104 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES HDHP [308136802] 82.35 percent of total billed charges 64.48 98.8 Technical (Hospital) Services Lung Function Test (Mbc/Mvv) PX-5109420000 CDM 94200 CPT 510 RC inpatient 104 104 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES PPO [308136801] 82.35 percent of total billed charges 64.48 98.8 Technical (Hospital) Services Lung Function Test (Mbc/Mvv) PX-5109420000 CDM 94200 CPT 510 RC inpatient 104 104 UNITED HEALTHCARE (COMMERCIAL) [3081199] UNITED HEALTHCARE 87726 [308119901] 64.48 percent of total billed charges 64.48 98.8 Technical (Hospital) Services Lung Function Test (Mbc/Mvv) PX-5109420000 CDM 94200 CPT 510 RC inpatient 104 104 MULTIPLAN INC 34080 [3081285] MULTIPLAN INC [308128501] 98.8 percent of total billed charges 64.48 98.8 Technical (Hospital) Services Lung Function Test (Mbc/Mvv) PX-5109420000 CDM 94200 CPT 510 RC inpatient 104 104 MEDICA (COMMERCIAL) 94265 [3081118] MEDICA CLAIMS [308111801] 93.6 percent of total billed charges 64.48 98.8 Technical (Hospital) Services Lung Function Test (Mbc/Mvv) PX-5109420000 CDM 94200 CPT 510 RC inpatient 104 104 HEALTHPARTNERS SX009 HEALTHPARTNERS 82.35 percent of total billed charges 64.48 98.8 Technical (Hospital) Services Lung Function Test (Mbc/Mvv) PX-5109420000 CDM 94200 CPT 510 RC outpatient 104 104 MEDICA (COMMERCIAL) 94265 [3081118] MEDICA CLAIMS [308111801] 93.6 percent of total billed charges 64.48 98.8 Technical (Hospital) Services Lung Function Test (Mbc/Mvv) PX-5109420000 CDM 94200 CPT 510 RC outpatient 104 104 CIGNA 62308 [3081051] CIGNA 62308 [308105105] 83.2 percent of total billed charges 64.48 98.8 Technical (Hospital) Services Lung Function Test (Mbc/Mvv) PX-5109420000 CDM 94200 CPT 510 RC outpatient 104 104 CIGNA 62308 [3081051] CIGNA STATE OF WYOMING [308105107] 83.2 percent of total billed charges 64.48 98.8 Technical (Hospital) Services Lung Function Test (Mbc/Mvv) PX-5109420000 CDM 94200 CPT 510 RC outpatient 104 104 MULTIPLAN INC 34080 [3081285] MULTIPLAN INC [308128501] 98.8 percent of total billed charges 64.48 98.8 Technical (Hospital) Services Lung Function Test (Mbc/Mvv) PX-5109420000 CDM 94200 CPT 510 RC outpatient 104 104 UNITED HEALTHCARE (COMMERCIAL) [3081199] UNITED HEALTHCARE 87726 [308119901] 64.48 percent of total billed charges 64.48 98.8 Technical (Hospital) Services Lung Function Test (Mbc/Mvv) PX-5109420000 CDM 94200 CPT 510 RC outpatient 104 104 HEALTHPARTNERS SX009 HEALTHPARTNERS 83.2 percent of total billed charges 64.48 98.8 Technical (Hospital) Services Lung Function Test (Mbc/Mvv) PX-5109420000 CDM 94200 CPT 510 RC outpatient 104 104 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES EPO [308136803] 83.2 percent of total billed charges 64.48 98.8 Technical (Hospital) Services Lung Function Test (Mbc/Mvv) PX-5109420000 CDM 94200 CPT 510 RC outpatient 104 104 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES PPO [308136801] 83.2 percent of total billed charges 64.48 98.8 Technical (Hospital) Services Lung Function Test (Mbc/Mvv) PX-5109420000 CDM 94200 CPT 510 RC outpatient 104 104 BLUE CROSS BLUE SHIELD WELLMARK SB889 [3081026] BCBS WYOMING [308102603] 98.8 percent of total billed charges 64.48 98.8 Technical (Hospital) Services Lung Function Test (Mbc/Mvv) PX-5109420000 CDM 94200 CPT 510 RC outpatient 104 104 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES HDHP [308136802] 83.2 percent of total billed charges 64.48 98.8 Technical (Hospital) Services Spmtry W/Vc Expiratory Flo W/WO Mxml Vol Vntj PX-4609401000 CDM 94010 CPT 460 RC outpatient 160 160 MEDICA (COMMERCIAL) 94265 [3081118] MEDICA CLAIMS [308111801] 144 percent of total billed charges 99.2 152 Technical (Hospital) Services Spmtry W/Vc Expiratory Flo W/WO Mxml Vol Vntj PX-4609401000 CDM 94010 CPT 460 RC outpatient 160 160 CIGNA 62308 [3081051] CIGNA 62308 [308105105] 128 percent of total billed charges 99.2 152 Technical (Hospital) Services Spmtry W/Vc Expiratory Flo W/WO Mxml Vol Vntj PX-4609401000 CDM 94010 CPT 460 RC outpatient 160 160 CIGNA 62308 [3081051] CIGNA STATE OF WYOMING [308105107] 128 percent of total billed charges 99.2 152 Technical (Hospital) Services Spmtry W/Vc Expiratory Flo W/WO Mxml Vol Vntj PX-4609401000 CDM 94010 CPT 460 RC outpatient 160 160 MULTIPLAN INC 34080 [3081285] MULTIPLAN INC [308128501] 152 percent of total billed charges 99.2 152 Technical (Hospital) Services Spmtry W/Vc Expiratory Flo W/WO Mxml Vol Vntj PX-4609401000 CDM 94010 CPT 460 RC outpatient 160 160 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES EPO [308136803] 128 percent of total billed charges 99.2 152 Technical (Hospital) Services Spmtry W/Vc Expiratory Flo W/WO Mxml Vol Vntj PX-4609401000 CDM 94010 CPT 460 RC outpatient 160 160 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES PPO [308136801] 128 percent of total billed charges 99.2 152 Technical (Hospital) Services Spmtry W/Vc Expiratory Flo W/WO Mxml Vol Vntj PX-4609401000 CDM 94010 CPT 460 RC outpatient 160 160 BLUE CROSS BLUE SHIELD WELLMARK SB889 [3081026] BCBS WYOMING [308102603] 152 percent of total billed charges 99.2 152 Technical (Hospital) Services Spmtry W/Vc Expiratory Flo W/WO Mxml Vol Vntj PX-4609401000 CDM 94010 CPT 460 RC outpatient 160 160 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES HDHP [308136802] 128 percent of total billed charges 99.2 152 Technical (Hospital) Services Spmtry W/Vc Expiratory Flo W/WO Mxml Vol Vntj PX-4609401000 CDM 94010 CPT 460 RC outpatient 160 160 UNITED HEALTHCARE (COMMERCIAL) [3081199] UNITED HEALTHCARE 87726 [308119901] 99.2 percent of total billed charges 99.2 152 Technical (Hospital) Services Spmtry W/Vc Expiratory Flo W/WO Mxml Vol Vntj PX-4609401000 CDM 94010 CPT 460 RC outpatient 160 160 HEALTHPARTNERS SX009 HEALTHPARTNERS 128 percent of total billed charges 99.2 152 Technical (Hospital) Services Spmtry W/Vc Expiratory Flo W/WO Mxml Vol Vntj PX-4609401000 CDM 94010 CPT 460 RC inpatient 160 160 BLUE CROSS BLUE SHIELD WELLMARK SB889 [3081026] BCBS WYOMING [308102603] 152 percent of total billed charges 99.2 152 Technical (Hospital) Services Spmtry W/Vc Expiratory Flo W/WO Mxml Vol Vntj PX-4609401000 CDM 94010 CPT 460 RC inpatient 160 160 UNITED HEALTHCARE (COMMERCIAL) [3081199] UNITED HEALTHCARE 87726 [308119901] 99.2 percent of total billed charges 99.2 152 Technical (Hospital) Services Spmtry W/Vc Expiratory Flo W/WO Mxml Vol Vntj PX-4609401000 CDM 94010 CPT 460 RC inpatient 160 160 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES PPO [308136801] 126.69 percent of total billed charges 99.2 152 Technical (Hospital) Services Spmtry W/Vc Expiratory Flo W/WO Mxml Vol Vntj PX-4609401000 CDM 94010 CPT 460 RC inpatient 160 160 MULTIPLAN INC 34080 [3081285] MULTIPLAN INC [308128501] 152 percent of total billed charges 99.2 152 Technical (Hospital) Services Spmtry W/Vc Expiratory Flo W/WO Mxml Vol Vntj PX-4609401000 CDM 94010 CPT 460 RC inpatient 160 160 MEDICA (COMMERCIAL) 94265 [3081118] MEDICA CLAIMS [308111801] 144 percent of total billed charges 99.2 152 Technical (Hospital) Services Spmtry W/Vc Expiratory Flo W/WO Mxml Vol Vntj PX-4609401000 CDM 94010 CPT 460 RC inpatient 160 160 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES HDHP [308136802] 126.69 percent of total billed charges 99.2 152 Technical (Hospital) Services Spmtry W/Vc Expiratory Flo W/WO Mxml Vol Vntj PX-4609401000 CDM 94010 CPT 460 RC inpatient 160 160 HEALTHPARTNERS SX009 HEALTHPARTNERS 126.69 percent of total billed charges 99.2 152 Technical (Hospital) Services Spmtry W/Vc Expiratory Flo W/WO Mxml Vol Vntj PX-4609401000 CDM 94010 CPT 460 RC inpatient 160 160 CIGNA 62308 [3081051] CIGNA 62308 [308105105] 126.69 percent of total billed charges 99.2 152 Technical (Hospital) Services Spmtry W/Vc Expiratory Flo W/WO Mxml Vol Vntj PX-4609401000 CDM 94010 CPT 460 RC inpatient 160 160 CIGNA 62308 [3081051] CIGNA STATE OF WYOMING [308105107] 126.69 percent of total billed charges 99.2 152 Technical (Hospital) Services Spmtry W/Vc Expiratory Flo W/WO Mxml Vol Vntj PX-4609401000 CDM 94010 CPT 460 RC inpatient 160 160 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES EPO [308136803] 126.69 percent of total billed charges 99.2 152 Technical (Hospital) Services Ventilation Assist & Mgmt Inpatient 1st Day PX-4109400200 CDM 94002 CPT 410 RC inpatient 537 537 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES PPO [308136801] 425.2 percent of total billed charges 332.94 510.15 Technical (Hospital) Services Ventilation Assist & Mgmt Inpatient 1st Day PX-4109400200 CDM 94002 CPT 410 RC inpatient 537 537 UNITED HEALTHCARE (COMMERCIAL) [3081199] UNITED HEALTHCARE 87726 [308119901] 332.94 percent of total billed charges 332.94 510.15 Technical (Hospital) Services Ventilation Assist & Mgmt Inpatient 1st Day PX-4109400200 CDM 94002 CPT 410 RC inpatient 537 537 BLUE CROSS BLUE SHIELD WELLMARK SB889 [3081026] BCBS WYOMING [308102603] 510.15 percent of total billed charges 332.94 510.15 Technical (Hospital) Services Ventilation Assist & Mgmt Inpatient 1st Day PX-4109400200 CDM 94002 CPT 410 RC inpatient 537 537 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES HDHP [308136802] 425.2 percent of total billed charges 332.94 510.15 Technical (Hospital) Services Ventilation Assist & Mgmt Inpatient 1st Day PX-4109400200 CDM 94002 CPT 410 RC inpatient 537 537 MEDICA (COMMERCIAL) 94265 [3081118] MEDICA CLAIMS [308111801] 483.3 percent of total billed charges 332.94 510.15 Technical (Hospital) Services Ventilation Assist & Mgmt Inpatient 1st Day PX-4109400200 CDM 94002 CPT 410 RC inpatient 537 537 MULTIPLAN INC 34080 [3081285] MULTIPLAN INC [308128501] 510.15 percent of total billed charges 332.94 510.15 Technical (Hospital) Services Ventilation Assist & Mgmt Inpatient 1st Day PX-4109400200 CDM 94002 CPT 410 RC inpatient 537 537 HEALTHPARTNERS SX009 HEALTHPARTNERS 425.2 percent of total billed charges 332.94 510.15 Technical (Hospital) Services Ventilation Assist & Mgmt Inpatient 1st Day PX-4109400200 CDM 94002 CPT 410 RC inpatient 537 537 CIGNA 62308 [3081051] CIGNA 62308 [308105105] 425.2 percent of total billed charges 332.94 510.15 Technical (Hospital) Services Ventilation Assist & Mgmt Inpatient 1st Day PX-4109400200 CDM 94002 CPT 410 RC inpatient 537 537 CIGNA 62308 [3081051] CIGNA STATE OF WYOMING [308105107] 425.2 percent of total billed charges 332.94 510.15 Technical (Hospital) Services Ventilation Assist & Mgmt Inpatient 1st Day PX-4109400200 CDM 94002 CPT 410 RC inpatient 537 537 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES EPO [308136803] 425.2 percent of total billed charges 332.94 510.15 Technical (Hospital) Services Ventilation Assist & Mgmt Inpatient 1st Day PX-4109400200 CDM 94002 CPT 410 RC outpatient 537 537 MULTIPLAN INC 34080 [3081285] MULTIPLAN INC [308128501] 510.15 percent of total billed charges 332.94 510.15 Technical (Hospital) Services Ventilation Assist & Mgmt Inpatient 1st Day PX-4109400200 CDM 94002 CPT 410 RC outpatient 537 537 CIGNA 62308 [3081051] CIGNA 62308 [308105105] 429.6 percent of total billed charges 332.94 510.15 Technical (Hospital) Services Ventilation Assist & Mgmt Inpatient 1st Day PX-4109400200 CDM 94002 CPT 410 RC outpatient 537 537 CIGNA 62308 [3081051] CIGNA STATE OF WYOMING [308105107] 429.6 percent of total billed charges 332.94 510.15 Technical (Hospital) Services Ventilation Assist & Mgmt Inpatient 1st Day PX-4109400200 CDM 94002 CPT 410 RC outpatient 537 537 HEALTHPARTNERS SX009 HEALTHPARTNERS 429.6 percent of total billed charges 332.94 510.15 Technical (Hospital) Services Ventilation Assist & Mgmt Inpatient 1st Day PX-4109400200 CDM 94002 CPT 410 RC outpatient 537 537 UNITED HEALTHCARE (COMMERCIAL) [3081199] UNITED HEALTHCARE 87726 [308119901] 332.94 percent of total billed charges 332.94 510.15 Technical (Hospital) Services Ventilation Assist & Mgmt Inpatient 1st Day PX-4109400200 CDM 94002 CPT 410 RC outpatient 537 537 MEDICA (COMMERCIAL) 94265 [3081118] MEDICA CLAIMS [308111801] 483.3 percent of total billed charges 332.94 510.15 Technical (Hospital) Services Ventilation Assist & Mgmt Inpatient 1st Day PX-4109400200 CDM 94002 CPT 410 RC outpatient 537 537 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES HDHP [308136802] 429.6 percent of total billed charges 332.94 510.15 Technical (Hospital) Services Ventilation Assist & Mgmt Inpatient 1st Day PX-4109400200 CDM 94002 CPT 410 RC outpatient 537 537 BLUE CROSS BLUE SHIELD WELLMARK SB889 [3081026] BCBS WYOMING [308102603] 510.15 percent of total billed charges 332.94 510.15 Technical (Hospital) Services Ventilation Assist & Mgmt Inpatient 1st Day PX-4109400200 CDM 94002 CPT 410 RC outpatient 537 537 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES EPO [308136803] 429.6 percent of total billed charges 332.94 510.15 Technical (Hospital) Services Ventilation Assist & Mgmt Inpatient 1st Day PX-4109400200 CDM 94002 CPT 410 RC outpatient 537 537 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES PPO [308136801] 429.6 percent of total billed charges 332.94 510.15 Technical (Hospital) Services Dup-Scan Aorta Ivc Iliac Vascl/Bpgs Complete PX-9219397800 CDM 93978 CPT 921 RC inpatient 691 691 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES PPO [308136801] 547.13 percent of total billed charges 428.42 656.45 Technical (Hospital) Services Dup-Scan Aorta Ivc Iliac Vascl/Bpgs Complete PX-9219397800 CDM 93978 CPT 921 RC inpatient 691 691 UNITED HEALTHCARE (COMMERCIAL) [3081199] UNITED HEALTHCARE 87726 [308119901] 428.42 percent of total billed charges 428.42 656.45 Technical (Hospital) Services Dup-Scan Aorta Ivc Iliac Vascl/Bpgs Complete PX-9219397800 CDM 93978 CPT 921 RC inpatient 691 691 BLUE CROSS BLUE SHIELD WELLMARK SB889 [3081026] BCBS WYOMING [308102603] 656.45 percent of total billed charges 428.42 656.45 Technical (Hospital) Services Dup-Scan Aorta Ivc Iliac Vascl/Bpgs Complete PX-9219397800 CDM 93978 CPT 921 RC inpatient 691 691 MULTIPLAN INC 34080 [3081285] MULTIPLAN INC [308128501] 656.45 percent of total billed charges 428.42 656.45 Technical (Hospital) Services Dup-Scan Aorta Ivc Iliac Vascl/Bpgs Complete PX-9219397800 CDM 93978 CPT 921 RC inpatient 691 691 MEDICA (COMMERCIAL) 94265 [3081118] MEDICA CLAIMS [308111801] 621.9 percent of total billed charges 428.42 656.45 Technical (Hospital) Services Dup-Scan Aorta Ivc Iliac Vascl/Bpgs Complete PX-9219397800 CDM 93978 CPT 921 RC inpatient 691 691 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES HDHP [308136802] 547.13 percent of total billed charges 428.42 656.45 Technical (Hospital) Services Dup-Scan Aorta Ivc Iliac Vascl/Bpgs Complete PX-9219397800 CDM 93978 CPT 921 RC inpatient 691 691 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES EPO [308136803] 547.13 percent of total billed charges 428.42 656.45 Technical (Hospital) Services Dup-Scan Aorta Ivc Iliac Vascl/Bpgs Complete PX-9219397800 CDM 93978 CPT 921 RC outpatient 691 691 HEALTHPARTNERS SX009 HEALTHPARTNERS 552.8 percent of total billed charges 428.42 656.45 Technical (Hospital) Services Dup-Scan Aorta Ivc Iliac Vascl/Bpgs Complete PX-9219397800 CDM 93978 CPT 921 RC outpatient 691 691 UNITED HEALTHCARE (COMMERCIAL) [3081199] UNITED HEALTHCARE 87726 [308119901] 428.42 percent of total billed charges 428.42 656.45 Technical (Hospital) Services Dup-Scan Aorta Ivc Iliac Vascl/Bpgs Complete PX-9219397800 CDM 93978 CPT 921 RC outpatient 691 691 BLUE CROSS BLUE SHIELD WELLMARK SB889 [3081026] BCBS WYOMING [308102603] 656.45 percent of total billed charges 428.42 656.45 Technical (Hospital) Services Dup-Scan Aorta Ivc Iliac Vascl/Bpgs Complete PX-9219397800 CDM 93978 CPT 921 RC outpatient 691 691 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES HDHP [308136802] 552.8 percent of total billed charges 428.42 656.45 Technical (Hospital) Services Dup-Scan Aorta Ivc Iliac Vascl/Bpgs Complete PX-9219397800 CDM 93978 CPT 921 RC outpatient 691 691 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES EPO [308136803] 552.8 percent of total billed charges 428.42 656.45 Technical (Hospital) Services Dup-Scan Aorta Ivc Iliac Vascl/Bpgs Complete PX-9219397800 CDM 93978 CPT 921 RC outpatient 691 691 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES PPO [308136801] 552.8 percent of total billed charges 428.42 656.45 Technical (Hospital) Services Dup-Scan Aorta Ivc Iliac Vascl/Bpgs Complete PX-9219397800 CDM 93978 CPT 921 RC outpatient 691 691 MEDICA (COMMERCIAL) 94265 [3081118] MEDICA CLAIMS [308111801] 621.9 percent of total billed charges 428.42 656.45 Technical (Hospital) Services Dup-Scan Aorta Ivc Iliac Vascl/Bpgs Complete PX-9219397800 CDM 93978 CPT 921 RC outpatient 691 691 MULTIPLAN INC 34080 [3081285] MULTIPLAN INC [308128501] 656.45 percent of total billed charges 428.42 656.45 Technical (Hospital) Services Dup-Scan Aorta Ivc Iliac Vascl/Bpgs Complete PX-9219397800 CDM 93978 CPT 921 RC inpatient 691 691 HEALTHPARTNERS SX009 HEALTHPARTNERS 547.13 percent of total billed charges 428.42 656.45 Technical (Hospital) Services Dup-Scan Aorta Ivc Iliac Vascl/Bpgs Complete PX-9219397800 CDM 93978 CPT 921 RC inpatient 691 691 CIGNA 62308 [3081051] CIGNA 62308 [308105105] 547.13 percent of total billed charges 428.42 656.45 Technical (Hospital) Services Dup-Scan Aorta Ivc Iliac Vascl/Bpgs Complete PX-9219397800 CDM 93978 CPT 921 RC inpatient 691 691 CIGNA 62308 [3081051] CIGNA STATE OF WYOMING [308105107] 547.13 percent of total billed charges 428.42 656.45 Technical (Hospital) Services Dup-Scan Aorta Ivc Iliac Vascl/Bpgs Complete PX-9219397800 CDM 93978 CPT 921 RC outpatient 691 691 CIGNA 62308 [3081051] CIGNA 62308 [308105105] 552.8 percent of total billed charges 428.42 656.45 Technical (Hospital) Services Dup-Scan Aorta Ivc Iliac Vascl/Bpgs Complete PX-9219397800 CDM 93978 CPT 921 RC outpatient 691 691 CIGNA 62308 [3081051] CIGNA STATE OF WYOMING [308105107] 552.8 percent of total billed charges 428.42 656.45 Technical (Hospital) Services Dup-Scan Artl Flo Abdl/Pel/Scrot&/Rpr Orgn Lmt PX-9219397600 CDM 93976 CPT 921 RC inpatient 1224 1224 CIGNA 62308 [3081051] CIGNA 62308 [308105105] 969.16 percent of total billed charges 758.88 1162.8 Technical (Hospital) Services Dup-Scan Artl Flo Abdl/Pel/Scrot&/Rpr Orgn Lmt PX-9219397600 CDM 93976 CPT 921 RC inpatient 1224 1224 CIGNA 62308 [3081051] CIGNA STATE OF WYOMING [308105107] 969.16 percent of total billed charges 758.88 1162.8 Technical (Hospital) Services Dup-Scan Artl Flo Abdl/Pel/Scrot&/Rpr Orgn Lmt PX-9219397600 CDM 93976 CPT 921 RC inpatient 1224 1224 HEALTHPARTNERS SX009 HEALTHPARTNERS 969.16 percent of total billed charges 758.88 1162.8 Technical (Hospital) Services Dup-Scan Artl Flo Abdl/Pel/Scrot&/Rpr Orgn Lmt PX-9219397600 CDM 93976 CPT 921 RC inpatient 1224 1224 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES EPO [308136803] 969.16 percent of total billed charges 758.88 1162.8 Technical (Hospital) Services Dup-Scan Artl Flo Abdl/Pel/Scrot&/Rpr Orgn Lmt PX-9219397600 CDM 93976 CPT 921 RC inpatient 1224 1224 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES HDHP [308136802] 969.16 percent of total billed charges 758.88 1162.8 Technical (Hospital) Services Dup-Scan Artl Flo Abdl/Pel/Scrot&/Rpr Orgn Lmt PX-9219397600 CDM 93976 CPT 921 RC inpatient 1224 1224 MEDICA (COMMERCIAL) 94265 [3081118] MEDICA CLAIMS [308111801] 1101.6 percent of total billed charges 758.88 1162.8 Technical (Hospital) Services Dup-Scan Artl Flo Abdl/Pel/Scrot&/Rpr Orgn Lmt PX-9219397600 CDM 93976 CPT 921 RC inpatient 1224 1224 MULTIPLAN INC 34080 [3081285] MULTIPLAN INC [308128501] 1162.8 percent of total billed charges 758.88 1162.8 Technical (Hospital) Services Dup-Scan Artl Flo Abdl/Pel/Scrot&/Rpr Orgn Lmt PX-9219397600 CDM 93976 CPT 921 RC inpatient 1224 1224 BLUE CROSS BLUE SHIELD WELLMARK SB889 [3081026] BCBS WYOMING [308102603] 1162.8 percent of total billed charges 758.88 1162.8 Technical (Hospital) Services Dup-Scan Artl Flo Abdl/Pel/Scrot&/Rpr Orgn Lmt PX-9219397600 CDM 93976 CPT 921 RC inpatient 1224 1224 UNITED HEALTHCARE (COMMERCIAL) [3081199] UNITED HEALTHCARE 87726 [308119901] 758.88 percent of total billed charges 758.88 1162.8 Technical (Hospital) Services Dup-Scan Artl Flo Abdl/Pel/Scrot&/Rpr Orgn Lmt PX-9219397600 CDM 93976 CPT 921 RC inpatient 1224 1224 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES PPO [308136801] 969.16 percent of total billed charges 758.88 1162.8 Technical (Hospital) Services Dup-Scan Artl Flo Abdl/Pel/Scrot&/Rpr Orgn Lmt PX-9219397600 CDM 93976 CPT 921 RC outpatient 1224 1224 MEDICA (COMMERCIAL) 94265 [3081118] MEDICA CLAIMS [308111801] 1101.6 percent of total billed charges 758.88 1162.8 Technical (Hospital) Services Dup-Scan Artl Flo Abdl/Pel/Scrot&/Rpr Orgn Lmt PX-9219397600 CDM 93976 CPT 921 RC outpatient 1224 1224 MULTIPLAN INC 34080 [3081285] MULTIPLAN INC [308128501] 1162.8 percent of total billed charges 758.88 1162.8 Technical (Hospital) Services Dup-Scan Artl Flo Abdl/Pel/Scrot&/Rpr Orgn Lmt PX-9219397600 CDM 93976 CPT 921 RC outpatient 1224 1224 CIGNA 62308 [3081051] CIGNA 62308 [308105105] 979.2 percent of total billed charges 758.88 1162.8 Technical (Hospital) Services Dup-Scan Artl Flo Abdl/Pel/Scrot&/Rpr Orgn Lmt PX-9219397600 CDM 93976 CPT 921 RC outpatient 1224 1224 CIGNA 62308 [3081051] CIGNA STATE OF WYOMING [308105107] 979.2 percent of total billed charges 758.88 1162.8 Technical (Hospital) Services Dup-Scan Artl Flo Abdl/Pel/Scrot&/Rpr Orgn Lmt PX-9219397600 CDM 93976 CPT 921 RC outpatient 1224 1224 UNITED HEALTHCARE (COMMERCIAL) [3081199] UNITED HEALTHCARE 87726 [308119901] 758.88 percent of total billed charges 758.88 1162.8 Technical (Hospital) Services Dup-Scan Artl Flo Abdl/Pel/Scrot&/Rpr Orgn Lmt PX-9219397600 CDM 93976 CPT 921 RC outpatient 1224 1224 HEALTHPARTNERS SX009 HEALTHPARTNERS 979.2 percent of total billed charges 758.88 1162.8 Technical (Hospital) Services Dup-Scan Artl Flo Abdl/Pel/Scrot&/Rpr Orgn Lmt PX-9219397600 CDM 93976 CPT 921 RC outpatient 1224 1224 BLUE CROSS BLUE SHIELD WELLMARK SB889 [3081026] BCBS WYOMING [308102603] 1162.8 percent of total billed charges 758.88 1162.8 Technical (Hospital) Services Dup-Scan Artl Flo Abdl/Pel/Scrot&/Rpr Orgn Lmt PX-9219397600 CDM 93976 CPT 921 RC outpatient 1224 1224 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES HDHP [308136802] 979.2 percent of total billed charges 758.88 1162.8 Technical (Hospital) Services Dup-Scan Artl Flo Abdl/Pel/Scrot&/Rpr Orgn Lmt PX-9219397600 CDM 93976 CPT 921 RC outpatient 1224 1224 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES PPO [308136801] 979.2 percent of total billed charges 758.88 1162.8 Technical (Hospital) Services Dup-Scan Artl Flo Abdl/Pel/Scrot&/Rpr Orgn Lmt PX-9219397600 CDM 93976 CPT 921 RC outpatient 1224 1224 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES EPO [308136803] 979.2 percent of total billed charges 758.88 1162.8 Technical (Hospital) Services Dup-Scan Artl Flo Abdl/Pel/Scrot&/Rpr Orgn Com PX-9219397500 CDM 93975 CPT 921 RC outpatient 2041 2041 CIGNA 62308 [3081051] CIGNA 62308 [308105105] 1632.8 percent of total billed charges 1265.42 1938.95 Technical (Hospital) Services Dup-Scan Artl Flo Abdl/Pel/Scrot&/Rpr Orgn Com PX-9219397500 CDM 93975 CPT 921 RC outpatient 2041 2041 CIGNA 62308 [3081051] CIGNA STATE OF WYOMING [308105107] 1632.8 percent of total billed charges 1265.42 1938.95 Technical (Hospital) Services Dup-Scan Artl Flo Abdl/Pel/Scrot&/Rpr Orgn Com PX-9219397500 CDM 93975 CPT 921 RC outpatient 2041 2041 MULTIPLAN INC 34080 [3081285] MULTIPLAN INC [308128501] 1938.95 percent of total billed charges 1265.42 1938.95 Technical (Hospital) Services Dup-Scan Artl Flo Abdl/Pel/Scrot&/Rpr Orgn Com PX-9219397500 CDM 93975 CPT 921 RC outpatient 2041 2041 MEDICA (COMMERCIAL) 94265 [3081118] MEDICA CLAIMS [308111801] 1836.9 percent of total billed charges 1265.42 1938.95 Technical (Hospital) Services Dup-Scan Artl Flo Abdl/Pel/Scrot&/Rpr Orgn Com PX-9219397500 CDM 93975 CPT 921 RC outpatient 2041 2041 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES PPO [308136801] 1632.8 percent of total billed charges 1265.42 1938.95 Technical (Hospital) Services Dup-Scan Artl Flo Abdl/Pel/Scrot&/Rpr Orgn Com PX-9219397500 CDM 93975 CPT 921 RC outpatient 2041 2041 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES EPO [308136803] 1632.8 percent of total billed charges 1265.42 1938.95 Technical (Hospital) Services Dup-Scan Artl Flo Abdl/Pel/Scrot&/Rpr Orgn Com PX-9219397500 CDM 93975 CPT 921 RC outpatient 2041 2041 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES HDHP [308136802] 1632.8 percent of total billed charges 1265.42 1938.95 Technical (Hospital) Services Dup-Scan Artl Flo Abdl/Pel/Scrot&/Rpr Orgn Com PX-9219397500 CDM 93975 CPT 921 RC outpatient 2041 2041 BLUE CROSS BLUE SHIELD WELLMARK SB889 [3081026] BCBS WYOMING [308102603] 1938.95 percent of total billed charges 1265.42 1938.95 Technical (Hospital) Services Dup-Scan Artl Flo Abdl/Pel/Scrot&/Rpr Orgn Com PX-9219397500 CDM 93975 CPT 921 RC outpatient 2041 2041 UNITED HEALTHCARE (COMMERCIAL) [3081199] UNITED HEALTHCARE 87726 [308119901] 1265.42 percent of total billed charges 1265.42 1938.95 Technical (Hospital) Services Dup-Scan Artl Flo Abdl/Pel/Scrot&/Rpr Orgn Com PX-9219397500 CDM 93975 CPT 921 RC outpatient 2041 2041 HEALTHPARTNERS SX009 HEALTHPARTNERS 1632.8 percent of total billed charges 1265.42 1938.95 Technical (Hospital) Services Dup-Scan Artl Flo Abdl/Pel/Scrot&/Rpr Orgn Com PX-9219397500 CDM 93975 CPT 921 RC inpatient 2041 2041 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES HDHP [308136802] 1616.06 percent of total billed charges 1265.42 1938.95 Technical (Hospital) Services Dup-Scan Artl Flo Abdl/Pel/Scrot&/Rpr Orgn Com PX-9219397500 CDM 93975 CPT 921 RC inpatient 2041 2041 MULTIPLAN INC 34080 [3081285] MULTIPLAN INC [308128501] 1938.95 percent of total billed charges 1265.42 1938.95 Technical (Hospital) Services Dup-Scan Artl Flo Abdl/Pel/Scrot&/Rpr Orgn Com PX-9219397500 CDM 93975 CPT 921 RC inpatient 2041 2041 MEDICA (COMMERCIAL) 94265 [3081118] MEDICA CLAIMS [308111801] 1836.9 percent of total billed charges 1265.42 1938.95 Technical (Hospital) Services Dup-Scan Artl Flo Abdl/Pel/Scrot&/Rpr Orgn Com PX-9219397500 CDM 93975 CPT 921 RC inpatient 2041 2041 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES EPO [308136803] 1616.06 percent of total billed charges 1265.42 1938.95 Technical (Hospital) Services Dup-Scan Artl Flo Abdl/Pel/Scrot&/Rpr Orgn Com PX-9219397500 CDM 93975 CPT 921 RC inpatient 2041 2041 HEALTHPARTNERS SX009 HEALTHPARTNERS 1616.06 percent of total billed charges 1265.42 1938.95 Technical (Hospital) Services Dup-Scan Artl Flo Abdl/Pel/Scrot&/Rpr Orgn Com PX-9219397500 CDM 93975 CPT 921 RC inpatient 2041 2041 BLUE CROSS BLUE SHIELD WELLMARK SB889 [3081026] BCBS WYOMING [308102603] 1938.95 percent of total billed charges 1265.42 1938.95 Technical (Hospital) Services Dup-Scan Artl Flo Abdl/Pel/Scrot&/Rpr Orgn Com PX-9219397500 CDM 93975 CPT 921 RC inpatient 2041 2041 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES PPO [308136801] 1616.06 percent of total billed charges 1265.42 1938.95 Technical (Hospital) Services Dup-Scan Artl Flo Abdl/Pel/Scrot&/Rpr Orgn Com PX-9219397500 CDM 93975 CPT 921 RC inpatient 2041 2041 UNITED HEALTHCARE (COMMERCIAL) [3081199] UNITED HEALTHCARE 87726 [308119901] 1265.42 percent of total billed charges 1265.42 1938.95 Technical (Hospital) Services Dup-Scan Artl Flo Abdl/Pel/Scrot&/Rpr Orgn Com PX-9219397500 CDM 93975 CPT 921 RC inpatient 2041 2041 CIGNA 62308 [3081051] CIGNA 62308 [308105105] 1616.06 percent of total billed charges 1265.42 1938.95 Technical (Hospital) Services Dup-Scan Artl Flo Abdl/Pel/Scrot&/Rpr Orgn Com PX-9219397500 CDM 93975 CPT 921 RC inpatient 2041 2041 CIGNA 62308 [3081051] CIGNA STATE OF WYOMING [308105107] 1616.06 percent of total billed charges 1265.42 1938.95 Technical (Hospital) Services Dup-Scan Xtr Veins Unilateral/Limited Study PX-9219397100 CDM 93971 CPT 921 RC outpatient 894 894 MEDICA (COMMERCIAL) 94265 [3081118] MEDICA CLAIMS [308111801] 804.6 percent of total billed charges 554.28 849.3 Technical (Hospital) Services Dup-Scan Xtr Veins Unilateral/Limited Study PX-9219397100 CDM 93971 CPT 921 RC outpatient 894 894 MULTIPLAN INC 34080 [3081285] MULTIPLAN INC [308128501] 849.3 percent of total billed charges 554.28 849.3 Technical (Hospital) Services Dup-Scan Xtr Veins Unilateral/Limited Study PX-9219397100 CDM 93971 CPT 921 RC outpatient 894 894 CIGNA 62308 [3081051] CIGNA 62308 [308105105] 715.2 percent of total billed charges 554.28 849.3 Technical (Hospital) Services Dup-Scan Xtr Veins Unilateral/Limited Study PX-9219397100 CDM 93971 CPT 921 RC outpatient 894 894 CIGNA 62308 [3081051] CIGNA STATE OF WYOMING [308105107] 715.2 percent of total billed charges 554.28 849.3 Technical (Hospital) Services Dup-Scan Xtr Veins Unilateral/Limited Study PX-9219397100 CDM 93971 CPT 921 RC outpatient 894 894 BLUE CROSS BLUE SHIELD WELLMARK SB889 [3081026] BCBS WYOMING [308102603] 849.3 percent of total billed charges 554.28 849.3 Technical (Hospital) Services Dup-Scan Xtr Veins Unilateral/Limited Study PX-9219397100 CDM 93971 CPT 921 RC outpatient 894 894 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES HDHP [308136802] 715.2 percent of total billed charges 554.28 849.3 Technical (Hospital) Services Dup-Scan Xtr Veins Unilateral/Limited Study PX-9219397100 CDM 93971 CPT 921 RC outpatient 894 894 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES EPO [308136803] 715.2 percent of total billed charges 554.28 849.3 Technical (Hospital) Services Dup-Scan Xtr Veins Unilateral/Limited Study PX-9219397100 CDM 93971 CPT 921 RC outpatient 894 894 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES PPO [308136801] 715.2 percent of total billed charges 554.28 849.3 Technical (Hospital) Services Dup-Scan Xtr Veins Unilateral/Limited Study PX-9219397100 CDM 93971 CPT 921 RC outpatient 894 894 UNITED HEALTHCARE (COMMERCIAL) [3081199] UNITED HEALTHCARE 87726 [308119901] 554.28 percent of total billed charges 554.28 849.3 Technical (Hospital) Services Dup-Scan Xtr Veins Unilateral/Limited Study PX-9219397100 CDM 93971 CPT 921 RC outpatient 894 894 HEALTHPARTNERS SX009 HEALTHPARTNERS 715.2 percent of total billed charges 554.28 849.3 Technical (Hospital) Services Dup-Scan Xtr Veins Unilateral/Limited Study PX-9219397100 CDM 93971 CPT 921 RC inpatient 894 894 CIGNA 62308 [3081051] CIGNA 62308 [308105105] 707.87 percent of total billed charges 554.28 849.3 Technical (Hospital) Services Dup-Scan Xtr Veins Unilateral/Limited Study PX-9219397100 CDM 93971 CPT 921 RC inpatient 894 894 CIGNA 62308 [3081051] CIGNA STATE OF WYOMING [308105107] 707.87 percent of total billed charges 554.28 849.3 Technical (Hospital) Services Dup-Scan Xtr Veins Unilateral/Limited Study PX-9219397100 CDM 93971 CPT 921 RC inpatient 894 894 UNITED HEALTHCARE (COMMERCIAL) [3081199] UNITED HEALTHCARE 87726 [308119901] 554.28 percent of total billed charges 554.28 849.3 Technical (Hospital) Services Dup-Scan Xtr Veins Unilateral/Limited Study PX-9219397100 CDM 93971 CPT 921 RC inpatient 894 894 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES PPO [308136801] 707.87 percent of total billed charges 554.28 849.3 Technical (Hospital) Services Dup-Scan Xtr Veins Unilateral/Limited Study PX-9219397100 CDM 93971 CPT 921 RC inpatient 894 894 BLUE CROSS BLUE SHIELD WELLMARK SB889 [3081026] BCBS WYOMING [308102603] 849.3 percent of total billed charges 554.28 849.3 Technical (Hospital) Services Dup-Scan Xtr Veins Unilateral/Limited Study PX-9219397100 CDM 93971 CPT 921 RC inpatient 894 894 HEALTHPARTNERS SX009 HEALTHPARTNERS 707.87 percent of total billed charges 554.28 849.3 Technical (Hospital) Services Dup-Scan Xtr Veins Unilateral/Limited Study PX-9219397100 CDM 93971 CPT 921 RC inpatient 894 894 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES EPO [308136803] 707.87 percent of total billed charges 554.28 849.3 Technical (Hospital) Services Dup-Scan Xtr Veins Unilateral/Limited Study PX-9219397100 CDM 93971 CPT 921 RC inpatient 894 894 MEDICA (COMMERCIAL) 94265 [3081118] MEDICA CLAIMS [308111801] 804.6 percent of total billed charges 554.28 849.3 Technical (Hospital) Services Dup-Scan Xtr Veins Unilateral/Limited Study PX-9219397100 CDM 93971 CPT 921 RC inpatient 894 894 MULTIPLAN INC 34080 [3081285] MULTIPLAN INC [308128501] 849.3 percent of total billed charges 554.28 849.3 Technical (Hospital) Services Dup-Scan Xtr Veins Unilateral/Limited Study PX-9219397100 CDM 93971 CPT 921 RC inpatient 894 894 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES HDHP [308136802] 707.87 percent of total billed charges 554.28 849.3 Technical (Hospital) Services Dup-Scan Xtr Veins Complete Bilateral Study PX-9219397000 CDM 93970 CPT 921 RC outpatient 952 952 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES HDHP [308136802] 761.6 percent of total billed charges 590.24 904.4 Technical (Hospital) Services Dup-Scan Xtr Veins Complete Bilateral Study PX-9219397000 CDM 93970 CPT 921 RC outpatient 952 952 BLUE CROSS BLUE SHIELD WELLMARK SB889 [3081026] BCBS WYOMING [308102603] 904.4 percent of total billed charges 590.24 904.4 Technical (Hospital) Services Dup-Scan Xtr Veins Complete Bilateral Study PX-9219397000 CDM 93970 CPT 921 RC outpatient 952 952 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES PPO [308136801] 761.6 percent of total billed charges 590.24 904.4 Technical (Hospital) Services Dup-Scan Xtr Veins Complete Bilateral Study PX-9219397000 CDM 93970 CPT 921 RC outpatient 952 952 UNITED HEALTHCARE (COMMERCIAL) [3081199] UNITED HEALTHCARE 87726 [308119901] 590.24 percent of total billed charges 590.24 904.4 Technical (Hospital) Services Dup-Scan Xtr Veins Complete Bilateral Study PX-9219397000 CDM 93970 CPT 921 RC outpatient 952 952 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES EPO [308136803] 761.6 percent of total billed charges 590.24 904.4 Technical (Hospital) Services Dup-Scan Xtr Veins Complete Bilateral Study PX-9219397000 CDM 93970 CPT 921 RC outpatient 952 952 HEALTHPARTNERS SX009 HEALTHPARTNERS 761.6 percent of total billed charges 590.24 904.4 Technical (Hospital) Services Dup-Scan Xtr Veins Complete Bilateral Study PX-9219397000 CDM 93970 CPT 921 RC outpatient 952 952 MEDICA (COMMERCIAL) 94265 [3081118] MEDICA CLAIMS [308111801] 856.8 percent of total billed charges 590.24 904.4 Technical (Hospital) Services Dup-Scan Xtr Veins Complete Bilateral Study PX-9219397000 CDM 93970 CPT 921 RC outpatient 952 952 MULTIPLAN INC 34080 [3081285] MULTIPLAN INC [308128501] 904.4 percent of total billed charges 590.24 904.4 Technical (Hospital) Services Dup-Scan Xtr Veins Complete Bilateral Study PX-9219397000 CDM 93970 CPT 921 RC outpatient 952 952 CIGNA 62308 [3081051] CIGNA STATE OF WYOMING [308105107] 761.6 percent of total billed charges 590.24 904.4 Technical (Hospital) Services Dup-Scan Xtr Veins Complete Bilateral Study PX-9219397000 CDM 93970 CPT 921 RC outpatient 952 952 CIGNA 62308 [3081051] CIGNA 62308 [308105105] 761.6 percent of total billed charges 590.24 904.4 Technical (Hospital) Services Dup-Scan Xtr Veins Complete Bilateral Study PX-9219397000 CDM 93970 CPT 921 RC inpatient 952 952 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES HDHP [308136802] 753.79 percent of total billed charges 590.24 904.4 Technical (Hospital) Services Dup-Scan Xtr Veins Complete Bilateral Study PX-9219397000 CDM 93970 CPT 921 RC inpatient 952 952 BLUE CROSS BLUE SHIELD WELLMARK SB889 [3081026] BCBS WYOMING [308102603] 904.4 percent of total billed charges 590.24 904.4 Technical (Hospital) Services Dup-Scan Xtr Veins Complete Bilateral Study PX-9219397000 CDM 93970 CPT 921 RC inpatient 952 952 UNITED HEALTHCARE (COMMERCIAL) [3081199] UNITED HEALTHCARE 87726 [308119901] 590.24 percent of total billed charges 590.24 904.4 Technical (Hospital) Services Dup-Scan Xtr Veins Complete Bilateral Study PX-9219397000 CDM 93970 CPT 921 RC inpatient 952 952 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES PPO [308136801] 753.79 percent of total billed charges 590.24 904.4 Technical (Hospital) Services Dup-Scan Xtr Veins Complete Bilateral Study PX-9219397000 CDM 93970 CPT 921 RC inpatient 952 952 MEDICA (COMMERCIAL) 94265 [3081118] MEDICA CLAIMS [308111801] 856.8 percent of total billed charges 590.24 904.4 Technical (Hospital) Services Dup-Scan Xtr Veins Complete Bilateral Study PX-9219397000 CDM 93970 CPT 921 RC inpatient 952 952 MULTIPLAN INC 34080 [3081285] MULTIPLAN INC [308128501] 904.4 percent of total billed charges 590.24 904.4 Technical (Hospital) Services Dup-Scan Xtr Veins Complete Bilateral Study PX-9219397000 CDM 93970 CPT 921 RC inpatient 952 952 HEALTHPARTNERS SX009 HEALTHPARTNERS 753.79 percent of total billed charges 590.24 904.4 Technical (Hospital) Services Dup-Scan Xtr Veins Complete Bilateral Study PX-9219397000 CDM 93970 CPT 921 RC inpatient 952 952 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES EPO [308136803] 753.79 percent of total billed charges 590.24 904.4 Technical (Hospital) Services Dup-Scan Xtr Veins Complete Bilateral Study PX-9219397000 CDM 93970 CPT 921 RC inpatient 952 952 CIGNA 62308 [3081051] CIGNA 62308 [308105105] 753.79 percent of total billed charges 590.24 904.4 Technical (Hospital) Services Dup-Scan Xtr Veins Complete Bilateral Study PX-9219397000 CDM 93970 CPT 921 RC inpatient 952 952 CIGNA 62308 [3081051] CIGNA STATE OF WYOMING [308105107] 753.79 percent of total billed charges 590.24 904.4 Technical (Hospital) Services Dup-Scan Uxtr Art/Artl Bpgs Uni/Lmtd Study PX-9219393100 CDM 93931 CPT 921 RC outpatient 747 747 CIGNA 62308 [3081051] CIGNA 62308 [308105105] 597.6 percent of total billed charges 463.14 709.65 Technical (Hospital) Services Dup-Scan Uxtr Art/Artl Bpgs Uni/Lmtd Study PX-9219393100 CDM 93931 CPT 921 RC outpatient 747 747 CIGNA 62308 [3081051] CIGNA STATE OF WYOMING [308105107] 597.6 percent of total billed charges 463.14 709.65 Technical (Hospital) Services Dup-Scan Uxtr Art/Artl Bpgs Uni/Lmtd Study PX-9219393100 CDM 93931 CPT 921 RC outpatient 747 747 MULTIPLAN INC 34080 [3081285] MULTIPLAN INC [308128501] 709.65 percent of total billed charges 463.14 709.65 Technical (Hospital) Services Dup-Scan Uxtr Art/Artl Bpgs Uni/Lmtd Study PX-9219393100 CDM 93931 CPT 921 RC outpatient 747 747 MEDICA (COMMERCIAL) 94265 [3081118] MEDICA CLAIMS [308111801] 672.3 percent of total billed charges 463.14 709.65 Technical (Hospital) Services Dup-Scan Uxtr Art/Artl Bpgs Uni/Lmtd Study PX-9219393100 CDM 93931 CPT 921 RC outpatient 747 747 HEALTHPARTNERS SX009 HEALTHPARTNERS 597.6 percent of total billed charges 463.14 709.65 Technical (Hospital) Services Dup-Scan Uxtr Art/Artl Bpgs Uni/Lmtd Study PX-9219393100 CDM 93931 CPT 921 RC outpatient 747 747 UNITED HEALTHCARE (COMMERCIAL) [3081199] UNITED HEALTHCARE 87726 [308119901] 463.14 percent of total billed charges 463.14 709.65 Technical (Hospital) Services Dup-Scan Uxtr Art/Artl Bpgs Uni/Lmtd Study PX-9219393100 CDM 93931 CPT 921 RC outpatient 747 747 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES EPO [308136803] 597.6 percent of total billed charges 463.14 709.65 Technical (Hospital) Services Dup-Scan Uxtr Art/Artl Bpgs Uni/Lmtd Study PX-9219393100 CDM 93931 CPT 921 RC outpatient 747 747 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES PPO [308136801] 597.6 percent of total billed charges 463.14 709.65 Technical (Hospital) Services Dup-Scan Uxtr Art/Artl Bpgs Uni/Lmtd Study PX-9219393100 CDM 93931 CPT 921 RC outpatient 747 747 BLUE CROSS BLUE SHIELD WELLMARK SB889 [3081026] BCBS WYOMING [308102603] 709.65 percent of total billed charges 463.14 709.65 Technical (Hospital) Services Dup-Scan Uxtr Art/Artl Bpgs Uni/Lmtd Study PX-9219393100 CDM 93931 CPT 921 RC outpatient 747 747 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES HDHP [308136802] 597.6 percent of total billed charges 463.14 709.65 Technical (Hospital) Services Dup-Scan Uxtr Art/Artl Bpgs Uni/Lmtd Study PX-9219393100 CDM 93931 CPT 921 RC inpatient 747 747 UNITED HEALTHCARE (COMMERCIAL) [3081199] UNITED HEALTHCARE 87726 [308119901] 463.14 percent of total billed charges 463.14 709.65 Technical (Hospital) Services Dup-Scan Uxtr Art/Artl Bpgs Uni/Lmtd Study PX-9219393100 CDM 93931 CPT 921 RC inpatient 747 747 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES PPO [308136801] 591.47 percent of total billed charges 463.14 709.65 Technical (Hospital) Services Dup-Scan Uxtr Art/Artl Bpgs Uni/Lmtd Study PX-9219393100 CDM 93931 CPT 921 RC inpatient 747 747 BLUE CROSS BLUE SHIELD WELLMARK SB889 [3081026] BCBS WYOMING [308102603] 709.65 percent of total billed charges 463.14 709.65 Technical (Hospital) Services Dup-Scan Uxtr Art/Artl Bpgs Uni/Lmtd Study PX-9219393100 CDM 93931 CPT 921 RC inpatient 747 747 MEDICA (COMMERCIAL) 94265 [3081118] MEDICA CLAIMS [308111801] 672.3 percent of total billed charges 463.14 709.65 Technical (Hospital) Services Dup-Scan Uxtr Art/Artl Bpgs Uni/Lmtd Study PX-9219393100 CDM 93931 CPT 921 RC inpatient 747 747 MULTIPLAN INC 34080 [3081285] MULTIPLAN INC [308128501] 709.65 percent of total billed charges 463.14 709.65 Technical (Hospital) Services Dup-Scan Uxtr Art/Artl Bpgs Uni/Lmtd Study PX-9219393100 CDM 93931 CPT 921 RC inpatient 747 747 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES HDHP [308136802] 591.47 percent of total billed charges 463.14 709.65 Technical (Hospital) Services Dup-Scan Uxtr Art/Artl Bpgs Uni/Lmtd Study PX-9219393100 CDM 93931 CPT 921 RC inpatient 747 747 HEALTHPARTNERS SX009 HEALTHPARTNERS 591.47 percent of total billed charges 463.14 709.65 Technical (Hospital) Services Dup-Scan Uxtr Art/Artl Bpgs Uni/Lmtd Study PX-9219393100 CDM 93931 CPT 921 RC inpatient 747 747 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES EPO [308136803] 591.47 percent of total billed charges 463.14 709.65 Technical (Hospital) Services Dup-Scan Uxtr Art/Artl Bpgs Uni/Lmtd Study PX-9219393100 CDM 93931 CPT 921 RC inpatient 747 747 CIGNA 62308 [3081051] CIGNA 62308 [308105105] 591.47 percent of total billed charges 463.14 709.65 Technical (Hospital) Services Dup-Scan Uxtr Art/Artl Bpgs Uni/Lmtd Study PX-9219393100 CDM 93931 CPT 921 RC inpatient 747 747 CIGNA 62308 [3081051] CIGNA STATE OF WYOMING [308105107] 591.47 percent of total billed charges 463.14 709.65 Technical (Hospital) Services Dup-Scan Uxtr Art/Artl Bpgs Compl Bi Study PX-9219393000 CDM 93930 CPT 921 RC inpatient 1236 1236 CIGNA 62308 [3081051] CIGNA 62308 [308105105] 978.66 percent of total billed charges 766.32 1174.2 Technical (Hospital) Services Dup-Scan Uxtr Art/Artl Bpgs Compl Bi Study PX-9219393000 CDM 93930 CPT 921 RC inpatient 1236 1236 CIGNA 62308 [3081051] CIGNA STATE OF WYOMING [308105107] 978.66 percent of total billed charges 766.32 1174.2 Technical (Hospital) Services Dup-Scan Uxtr Art/Artl Bpgs Compl Bi Study PX-9219393000 CDM 93930 CPT 921 RC inpatient 1236 1236 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES EPO [308136803] 978.66 percent of total billed charges 766.32 1174.2 Technical (Hospital) Services Dup-Scan Uxtr Art/Artl Bpgs Compl Bi Study PX-9219393000 CDM 93930 CPT 921 RC inpatient 1236 1236 HEALTHPARTNERS SX009 HEALTHPARTNERS 978.66 percent of total billed charges 766.32 1174.2 Technical (Hospital) Services Dup-Scan Uxtr Art/Artl Bpgs Compl Bi Study PX-9219393000 CDM 93930 CPT 921 RC inpatient 1236 1236 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES HDHP [308136802] 978.66 percent of total billed charges 766.32 1174.2 Technical (Hospital) Services Dup-Scan Uxtr Art/Artl Bpgs Compl Bi Study PX-9219393000 CDM 93930 CPT 921 RC inpatient 1236 1236 MULTIPLAN INC 34080 [3081285] MULTIPLAN INC [308128501] 1174.2 percent of total billed charges 766.32 1174.2 Technical (Hospital) Services Dup-Scan Uxtr Art/Artl Bpgs Compl Bi Study PX-9219393000 CDM 93930 CPT 921 RC inpatient 1236 1236 MEDICA (COMMERCIAL) 94265 [3081118] MEDICA CLAIMS [308111801] 1112.4 percent of total billed charges 766.32 1174.2 Technical (Hospital) Services Dup-Scan Uxtr Art/Artl Bpgs Compl Bi Study PX-9219393000 CDM 93930 CPT 921 RC inpatient 1236 1236 BLUE CROSS BLUE SHIELD WELLMARK SB889 [3081026] BCBS WYOMING [308102603] 1174.2 percent of total billed charges 766.32 1174.2 Technical (Hospital) Services Dup-Scan Uxtr Art/Artl Bpgs Compl Bi Study PX-9219393000 CDM 93930 CPT 921 RC inpatient 1236 1236 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES PPO [308136801] 978.66 percent of total billed charges 766.32 1174.2 Technical (Hospital) Services Dup-Scan Uxtr Art/Artl Bpgs Compl Bi Study PX-9219393000 CDM 93930 CPT 921 RC inpatient 1236 1236 UNITED HEALTHCARE (COMMERCIAL) [3081199] UNITED HEALTHCARE 87726 [308119901] 766.32 percent of total billed charges 766.32 1174.2 Technical (Hospital) Services Dup-Scan Uxtr Art/Artl Bpgs Compl Bi Study PX-9219393000 CDM 93930 CPT 921 RC outpatient 1236 1236 CIGNA 62308 [3081051] CIGNA STATE OF WYOMING [308105107] 988.8 percent of total billed charges 766.32 1174.2 Technical (Hospital) Services Dup-Scan Uxtr Art/Artl Bpgs Compl Bi Study PX-9219393000 CDM 93930 CPT 921 RC outpatient 1236 1236 CIGNA 62308 [3081051] CIGNA 62308 [308105105] 988.8 percent of total billed charges 766.32 1174.2 Technical (Hospital) Services Dup-Scan Uxtr Art/Artl Bpgs Compl Bi Study PX-9219393000 CDM 93930 CPT 921 RC outpatient 1236 1236 MULTIPLAN INC 34080 [3081285] MULTIPLAN INC [308128501] 1174.2 percent of total billed charges 766.32 1174.2 Technical (Hospital) Services Dup-Scan Uxtr Art/Artl Bpgs Compl Bi Study PX-9219393000 CDM 93930 CPT 921 RC outpatient 1236 1236 MEDICA (COMMERCIAL) 94265 [3081118] MEDICA CLAIMS [308111801] 1112.4 percent of total billed charges 766.32 1174.2 Technical (Hospital) Services Dup-Scan Uxtr Art/Artl Bpgs Compl Bi Study PX-9219393000 CDM 93930 CPT 921 RC outpatient 1236 1236 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES PPO [308136801] 988.8 percent of total billed charges 766.32 1174.2 Technical (Hospital) Services Dup-Scan Uxtr Art/Artl Bpgs Compl Bi Study PX-9219393000 CDM 93930 CPT 921 RC outpatient 1236 1236 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES EPO [308136803] 988.8 percent of total billed charges 766.32 1174.2 Technical (Hospital) Services Dup-Scan Uxtr Art/Artl Bpgs Compl Bi Study PX-9219393000 CDM 93930 CPT 921 RC outpatient 1236 1236 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES HDHP [308136802] 988.8 percent of total billed charges 766.32 1174.2 Technical (Hospital) Services Dup-Scan Uxtr Art/Artl Bpgs Compl Bi Study PX-9219393000 CDM 93930 CPT 921 RC outpatient 1236 1236 BLUE CROSS BLUE SHIELD WELLMARK SB889 [3081026] BCBS WYOMING [308102603] 1174.2 percent of total billed charges 766.32 1174.2 Technical (Hospital) Services Dup-Scan Uxtr Art/Artl Bpgs Compl Bi Study PX-9219393000 CDM 93930 CPT 921 RC outpatient 1236 1236 UNITED HEALTHCARE (COMMERCIAL) [3081199] UNITED HEALTHCARE 87726 [308119901] 766.32 percent of total billed charges 766.32 1174.2 Technical (Hospital) Services Dup-Scan Uxtr Art/Artl Bpgs Compl Bi Study PX-9219393000 CDM 93930 CPT 921 RC outpatient 1236 1236 HEALTHPARTNERS SX009 HEALTHPARTNERS 988.8 percent of total billed charges 766.32 1174.2 Technical (Hospital) Services Dup-Scan Lxtr Art/Artl Bpgs Uni/Lmtd Study PX-9219392600 CDM 93926 CPT 921 RC inpatient 861 861 CIGNA 62308 [3081051] CIGNA 62308 [308105105] 681.74 percent of total billed charges 533.82 817.95 Technical (Hospital) Services Dup-Scan Lxtr Art/Artl Bpgs Uni/Lmtd Study PX-9219392600 CDM 93926 CPT 921 RC inpatient 861 861 CIGNA 62308 [3081051] CIGNA STATE OF WYOMING [308105107] 681.74 percent of total billed charges 533.82 817.95 Technical (Hospital) Services Dup-Scan Lxtr Art/Artl Bpgs Uni/Lmtd Study PX-9219392600 CDM 93926 CPT 921 RC inpatient 861 861 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES HDHP [308136802] 681.74 percent of total billed charges 533.82 817.95 Technical (Hospital) Services Dup-Scan Lxtr Art/Artl Bpgs Uni/Lmtd Study PX-9219392600 CDM 93926 CPT 921 RC inpatient 861 861 MULTIPLAN INC 34080 [3081285] MULTIPLAN INC [308128501] 817.95 percent of total billed charges 533.82 817.95 Technical (Hospital) Services Dup-Scan Lxtr Art/Artl Bpgs Uni/Lmtd Study PX-9219392600 CDM 93926 CPT 921 RC inpatient 861 861 MEDICA (COMMERCIAL) 94265 [3081118] MEDICA CLAIMS [308111801] 774.9 percent of total billed charges 533.82 817.95 Technical (Hospital) Services Dup-Scan Lxtr Art/Artl Bpgs Uni/Lmtd Study PX-9219392600 CDM 93926 CPT 921 RC inpatient 861 861 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES EPO [308136803] 681.74 percent of total billed charges 533.82 817.95 Technical (Hospital) Services Dup-Scan Lxtr Art/Artl Bpgs Uni/Lmtd Study PX-9219392600 CDM 93926 CPT 921 RC inpatient 861 861 HEALTHPARTNERS SX009 HEALTHPARTNERS 681.74 percent of total billed charges 533.82 817.95 Technical (Hospital) Services Dup-Scan Lxtr Art/Artl Bpgs Uni/Lmtd Study PX-9219392600 CDM 93926 CPT 921 RC inpatient 861 861 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES PPO [308136801] 681.74 percent of total billed charges 533.82 817.95 Technical (Hospital) Services Dup-Scan Lxtr Art/Artl Bpgs Uni/Lmtd Study PX-9219392600 CDM 93926 CPT 921 RC inpatient 861 861 UNITED HEALTHCARE (COMMERCIAL) [3081199] UNITED HEALTHCARE 87726 [308119901] 533.82 percent of total billed charges 533.82 817.95 Technical (Hospital) Services Dup-Scan Lxtr Art/Artl Bpgs Uni/Lmtd Study PX-9219392600 CDM 93926 CPT 921 RC inpatient 861 861 BLUE CROSS BLUE SHIELD WELLMARK SB889 [3081026] BCBS WYOMING [308102603] 817.95 percent of total billed charges 533.82 817.95 Technical (Hospital) Services Dup-Scan Lxtr Art/Artl Bpgs Uni/Lmtd Study PX-9219392600 CDM 93926 CPT 921 RC outpatient 861 861 UNITED HEALTHCARE (COMMERCIAL) [3081199] UNITED HEALTHCARE 87726 [308119901] 533.82 percent of total billed charges 533.82 817.95 Technical (Hospital) Services Dup-Scan Lxtr Art/Artl Bpgs Uni/Lmtd Study PX-9219392600 CDM 93926 CPT 921 RC outpatient 861 861 HEALTHPARTNERS SX009 HEALTHPARTNERS 688.8 percent of total billed charges 533.82 817.95 Technical (Hospital) Services Dup-Scan Lxtr Art/Artl Bpgs Uni/Lmtd Study PX-9219392600 CDM 93926 CPT 921 RC outpatient 861 861 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES PPO [308136801] 688.8 percent of total billed charges 533.82 817.95 Technical (Hospital) Services Dup-Scan Lxtr Art/Artl Bpgs Uni/Lmtd Study PX-9219392600 CDM 93926 CPT 921 RC outpatient 861 861 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES EPO [308136803] 688.8 percent of total billed charges 533.82 817.95 Technical (Hospital) Services Dup-Scan Lxtr Art/Artl Bpgs Uni/Lmtd Study PX-9219392600 CDM 93926 CPT 921 RC outpatient 861 861 BLUE CROSS BLUE SHIELD WELLMARK SB889 [3081026] BCBS WYOMING [308102603] 817.95 percent of total billed charges 533.82 817.95 Technical (Hospital) Services Dup-Scan Lxtr Art/Artl Bpgs Uni/Lmtd Study PX-9219392600 CDM 93926 CPT 921 RC outpatient 861 861 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES HDHP [308136802] 688.8 percent of total billed charges 533.82 817.95 Technical (Hospital) Services Dup-Scan Lxtr Art/Artl Bpgs Uni/Lmtd Study PX-9219392600 CDM 93926 CPT 921 RC outpatient 861 861 MEDICA (COMMERCIAL) 94265 [3081118] MEDICA CLAIMS [308111801] 774.9 percent of total billed charges 533.82 817.95 Technical (Hospital) Services Dup-Scan Lxtr Art/Artl Bpgs Uni/Lmtd Study PX-9219392600 CDM 93926 CPT 921 RC outpatient 861 861 CIGNA 62308 [3081051] CIGNA 62308 [308105105] 688.8 percent of total billed charges 533.82 817.95 Technical (Hospital) Services Dup-Scan Lxtr Art/Artl Bpgs Uni/Lmtd Study PX-9219392600 CDM 93926 CPT 921 RC outpatient 861 861 CIGNA 62308 [3081051] CIGNA STATE OF WYOMING [308105107] 688.8 percent of total billed charges 533.82 817.95 Technical (Hospital) Services Dup-Scan Lxtr Art/Artl Bpgs Uni/Lmtd Study PX-9219392600 CDM 93926 CPT 921 RC outpatient 861 861 MULTIPLAN INC 34080 [3081285] MULTIPLAN INC [308128501] 817.95 percent of total billed charges 533.82 817.95 Technical (Hospital) Services Dup-Scan Lxtr Art/Artl Bpgs Compl Bi Study PX-9219392500 CDM 93925 CPT 921 RC outpatient 1414 1414 HEALTHPARTNERS SX009 HEALTHPARTNERS 1131.2 percent of total billed charges 876.68 1343.3 Technical (Hospital) Services Dup-Scan Lxtr Art/Artl Bpgs Compl Bi Study PX-9219392500 CDM 93925 CPT 921 RC outpatient 1414 1414 UNITED HEALTHCARE (COMMERCIAL) [3081199] UNITED HEALTHCARE 87726 [308119901] 876.68 percent of total billed charges 876.68 1343.3 Technical (Hospital) Services Dup-Scan Lxtr Art/Artl Bpgs Compl Bi Study PX-9219392500 CDM 93925 CPT 921 RC outpatient 1414 1414 BLUE CROSS BLUE SHIELD WELLMARK SB889 [3081026] BCBS WYOMING [308102603] 1343.3 percent of total billed charges 876.68 1343.3 Technical (Hospital) Services Dup-Scan Lxtr Art/Artl Bpgs Compl Bi Study PX-9219392500 CDM 93925 CPT 921 RC outpatient 1414 1414 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES HDHP [308136802] 1131.2 percent of total billed charges 876.68 1343.3 Technical (Hospital) Services Dup-Scan Lxtr Art/Artl Bpgs Compl Bi Study PX-9219392500 CDM 93925 CPT 921 RC outpatient 1414 1414 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES EPO [308136803] 1131.2 percent of total billed charges 876.68 1343.3 Technical (Hospital) Services Dup-Scan Lxtr Art/Artl Bpgs Compl Bi Study PX-9219392500 CDM 93925 CPT 921 RC outpatient 1414 1414 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES PPO [308136801] 1131.2 percent of total billed charges 876.68 1343.3 Technical (Hospital) Services Dup-Scan Lxtr Art/Artl Bpgs Compl Bi Study PX-9219392500 CDM 93925 CPT 921 RC outpatient 1414 1414 MEDICA (COMMERCIAL) 94265 [3081118] MEDICA CLAIMS [308111801] 1272.6 percent of total billed charges 876.68 1343.3 Technical (Hospital) Services Dup-Scan Lxtr Art/Artl Bpgs Compl Bi Study PX-9219392500 CDM 93925 CPT 921 RC outpatient 1414 1414 CIGNA 62308 [3081051] CIGNA 62308 [308105105] 1131.2 percent of total billed charges 876.68 1343.3 Technical (Hospital) Services Dup-Scan Lxtr Art/Artl Bpgs Compl Bi Study PX-9219392500 CDM 93925 CPT 921 RC outpatient 1414 1414 CIGNA 62308 [3081051] CIGNA STATE OF WYOMING [308105107] 1131.2 percent of total billed charges 876.68 1343.3 Technical (Hospital) Services Dup-Scan Lxtr Art/Artl Bpgs Compl Bi Study PX-9219392500 CDM 93925 CPT 921 RC outpatient 1414 1414 MULTIPLAN INC 34080 [3081285] MULTIPLAN INC [308128501] 1343.3 percent of total billed charges 876.68 1343.3 Technical (Hospital) Services Dup-Scan Lxtr Art/Artl Bpgs Compl Bi Study PX-9219392500 CDM 93925 CPT 921 RC inpatient 1414 1414 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES HDHP [308136802] 1119.61 percent of total billed charges 876.68 1343.3 Technical (Hospital) Services Dup-Scan Lxtr Art/Artl Bpgs Compl Bi Study PX-9219392500 CDM 93925 CPT 921 RC inpatient 1414 1414 MULTIPLAN INC 34080 [3081285] MULTIPLAN INC [308128501] 1343.3 percent of total billed charges 876.68 1343.3 Technical (Hospital) Services Dup-Scan Lxtr Art/Artl Bpgs Compl Bi Study PX-9219392500 CDM 93925 CPT 921 RC inpatient 1414 1414 MEDICA (COMMERCIAL) 94265 [3081118] MEDICA CLAIMS [308111801] 1272.6 percent of total billed charges 876.68 1343.3 Technical (Hospital) Services Dup-Scan Lxtr Art/Artl Bpgs Compl Bi Study PX-9219392500 CDM 93925 CPT 921 RC inpatient 1414 1414 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES EPO [308136803] 1119.61 percent of total billed charges 876.68 1343.3 Technical (Hospital) Services Dup-Scan Lxtr Art/Artl Bpgs Compl Bi Study PX-9219392500 CDM 93925 CPT 921 RC inpatient 1414 1414 HEALTHPARTNERS SX009 HEALTHPARTNERS 1119.61 percent of total billed charges 876.68 1343.3 Technical (Hospital) Services Dup-Scan Lxtr Art/Artl Bpgs Compl Bi Study PX-9219392500 CDM 93925 CPT 921 RC inpatient 1414 1414 BLUE CROSS BLUE SHIELD WELLMARK SB889 [3081026] BCBS WYOMING [308102603] 1343.3 percent of total billed charges 876.68 1343.3 Technical (Hospital) Services Dup-Scan Lxtr Art/Artl Bpgs Compl Bi Study PX-9219392500 CDM 93925 CPT 921 RC inpatient 1414 1414 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES PPO [308136801] 1119.61 percent of total billed charges 876.68 1343.3 Technical (Hospital) Services Dup-Scan Lxtr Art/Artl Bpgs Compl Bi Study PX-9219392500 CDM 93925 CPT 921 RC inpatient 1414 1414 UNITED HEALTHCARE (COMMERCIAL) [3081199] UNITED HEALTHCARE 87726 [308119901] 876.68 percent of total billed charges 876.68 1343.3 Technical (Hospital) Services Dup-Scan Lxtr Art/Artl Bpgs Compl Bi Study PX-9219392500 CDM 93925 CPT 921 RC inpatient 1414 1414 CIGNA 62308 [3081051] CIGNA 62308 [308105105] 1119.61 percent of total billed charges 876.68 1343.3 Technical (Hospital) Services Dup-Scan Lxtr Art/Artl Bpgs Compl Bi Study PX-9219392500 CDM 93925 CPT 921 RC inpatient 1414 1414 CIGNA 62308 [3081051] CIGNA STATE OF WYOMING [308105107] 1119.61 percent of total billed charges 876.68 1343.3 Technical (Hospital) Services Non-Invas Physiologic Std Extremity Art 2 Level PX-9219392200 CDM 93922 CPT 921 RC inpatient 357 357 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES PPO [308136801] 282.67 percent of total billed charges 221.34 339.15 Technical (Hospital) Services Non-Invas Physiologic Std Extremity Art 2 Level PX-9219392200 CDM 93922 CPT 921 RC inpatient 357 357 UNITED HEALTHCARE (COMMERCIAL) [3081199] UNITED HEALTHCARE 87726 [308119901] 221.34 percent of total billed charges 221.34 339.15 Technical (Hospital) Services Non-Invas Physiologic Std Extremity Art 2 Level PX-9219392200 CDM 93922 CPT 921 RC inpatient 357 357 BLUE CROSS BLUE SHIELD WELLMARK SB889 [3081026] BCBS WYOMING [308102603] 339.15 percent of total billed charges 221.34 339.15 Technical (Hospital) Services Non-Invas Physiologic Std Extremity Art 2 Level PX-9219392200 CDM 93922 CPT 921 RC inpatient 357 357 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES HDHP [308136802] 282.67 percent of total billed charges 221.34 339.15 Technical (Hospital) Services Non-Invas Physiologic Std Extremity Art 2 Level PX-9219392200 CDM 93922 CPT 921 RC inpatient 357 357 MULTIPLAN INC 34080 [3081285] MULTIPLAN INC [308128501] 339.15 percent of total billed charges 221.34 339.15 Technical (Hospital) Services Non-Invas Physiologic Std Extremity Art 2 Level PX-9219392200 CDM 93922 CPT 921 RC inpatient 357 357 MEDICA (COMMERCIAL) 94265 [3081118] MEDICA CLAIMS [308111801] 321.3 percent of total billed charges 221.34 339.15 Technical (Hospital) Services Non-Invas Physiologic Std Extremity Art 2 Level PX-9219392200 CDM 93922 CPT 921 RC inpatient 357 357 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES EPO [308136803] 282.67 percent of total billed charges 221.34 339.15 Technical (Hospital) Services Non-Invas Physiologic Std Extremity Art 2 Level PX-9219392200 CDM 93922 CPT 921 RC inpatient 357 357 HEALTHPARTNERS SX009 HEALTHPARTNERS 282.67 percent of total billed charges 221.34 339.15 Technical (Hospital) Services Non-Invas Physiologic Std Extremity Art 2 Level PX-9219392200 CDM 93922 CPT 921 RC inpatient 357 357 CIGNA 62308 [3081051] CIGNA 62308 [308105105] 282.67 percent of total billed charges 221.34 339.15 Technical (Hospital) Services Non-Invas Physiologic Std Extremity Art 2 Level PX-9219392200 CDM 93922 CPT 921 RC inpatient 357 357 CIGNA 62308 [3081051] CIGNA STATE OF WYOMING [308105107] 282.67 percent of total billed charges 221.34 339.15 Technical (Hospital) Services Non-Invas Physiologic Std Extremity Art 2 Level PX-9219392200 CDM 93922 CPT 921 RC outpatient 357 357 MEDICA (COMMERCIAL) 94265 [3081118] MEDICA CLAIMS [308111801] 321.3 percent of total billed charges 221.34 339.15 Technical (Hospital) Services Non-Invas Physiologic Std Extremity Art 2 Level PX-9219392200 CDM 93922 CPT 921 RC outpatient 357 357 MULTIPLAN INC 34080 [3081285] MULTIPLAN INC [308128501] 339.15 percent of total billed charges 221.34 339.15 Technical (Hospital) Services Non-Invas Physiologic Std Extremity Art 2 Level PX-9219392200 CDM 93922 CPT 921 RC outpatient 357 357 CIGNA 62308 [3081051] CIGNA 62308 [308105105] 285.6 percent of total billed charges 221.34 339.15 Technical (Hospital) Services Non-Invas Physiologic Std Extremity Art 2 Level PX-9219392200 CDM 93922 CPT 921 RC outpatient 357 357 CIGNA 62308 [3081051] CIGNA STATE OF WYOMING [308105107] 285.6 percent of total billed charges 221.34 339.15 Technical (Hospital) Services Non-Invas Physiologic Std Extremity Art 2 Level PX-9219392200 CDM 93922 CPT 921 RC outpatient 357 357 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES PPO [308136801] 285.6 percent of total billed charges 221.34 339.15 Technical (Hospital) Services Non-Invas Physiologic Std Extremity Art 2 Level PX-9219392200 CDM 93922 CPT 921 RC outpatient 357 357 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES HDHP [308136802] 285.6 percent of total billed charges 221.34 339.15 Technical (Hospital) Services Non-Invas Physiologic Std Extremity Art 2 Level PX-9219392200 CDM 93922 CPT 921 RC outpatient 357 357 BLUE CROSS BLUE SHIELD WELLMARK SB889 [3081026] BCBS WYOMING [308102603] 339.15 percent of total billed charges 221.34 339.15 Technical (Hospital) Services Non-Invas Physiologic Std Extremity Art 2 Level PX-9219392200 CDM 93922 CPT 921 RC outpatient 357 357 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES EPO [308136803] 285.6 percent of total billed charges 221.34 339.15 Technical (Hospital) Services Non-Invas Physiologic Std Extremity Art 2 Level PX-9219392200 CDM 93922 CPT 921 RC outpatient 357 357 UNITED HEALTHCARE (COMMERCIAL) [3081199] UNITED HEALTHCARE 87726 [308119901] 221.34 percent of total billed charges 221.34 339.15 Technical (Hospital) Services Non-Invas Physiologic Std Extremity Art 2 Level PX-9219392200 CDM 93922 CPT 921 RC outpatient 357 357 HEALTHPARTNERS SX009 HEALTHPARTNERS 285.6 percent of total billed charges 221.34 339.15 Technical (Hospital) Services Duplex Scan Extracranial Art Uni/Lmtd Study PX-9219388200 CDM 93882 CPT 921 RC outpatient 537 537 CIGNA 62308 [3081051] CIGNA 62308 [308105105] 429.6 percent of total billed charges 332.94 510.15 Technical (Hospital) Services Duplex Scan Extracranial Art Uni/Lmtd Study PX-9219388200 CDM 93882 CPT 921 RC outpatient 537 537 CIGNA 62308 [3081051] CIGNA STATE OF WYOMING [308105107] 429.6 percent of total billed charges 332.94 510.15 Technical (Hospital) Services Duplex Scan Extracranial Art Uni/Lmtd Study PX-9219388200 CDM 93882 CPT 921 RC outpatient 537 537 MULTIPLAN INC 34080 [3081285] MULTIPLAN INC [308128501] 510.15 percent of total billed charges 332.94 510.15 Technical (Hospital) Services Duplex Scan Extracranial Art Uni/Lmtd Study PX-9219388200 CDM 93882 CPT 921 RC outpatient 537 537 MEDICA (COMMERCIAL) 94265 [3081118] MEDICA CLAIMS [308111801] 483.3 percent of total billed charges 332.94 510.15 Technical (Hospital) Services Duplex Scan Extracranial Art Uni/Lmtd Study PX-9219388200 CDM 93882 CPT 921 RC outpatient 537 537 HEALTHPARTNERS SX009 HEALTHPARTNERS 429.6 percent of total billed charges 332.94 510.15 Technical (Hospital) Services Duplex Scan Extracranial Art Uni/Lmtd Study PX-9219388200 CDM 93882 CPT 921 RC outpatient 537 537 UNITED HEALTHCARE (COMMERCIAL) [3081199] UNITED HEALTHCARE 87726 [308119901] 332.94 percent of total billed charges 332.94 510.15 Technical (Hospital) Services Duplex Scan Extracranial Art Uni/Lmtd Study PX-9219388200 CDM 93882 CPT 921 RC outpatient 537 537 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES PPO [308136801] 429.6 percent of total billed charges 332.94 510.15 Technical (Hospital) Services Duplex Scan Extracranial Art Uni/Lmtd Study PX-9219388200 CDM 93882 CPT 921 RC outpatient 537 537 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES EPO [308136803] 429.6 percent of total billed charges 332.94 510.15 Technical (Hospital) Services Duplex Scan Extracranial Art Uni/Lmtd Study PX-9219388200 CDM 93882 CPT 921 RC outpatient 537 537 BLUE CROSS BLUE SHIELD WELLMARK SB889 [3081026] BCBS WYOMING [308102603] 510.15 percent of total billed charges 332.94 510.15 Technical (Hospital) Services Duplex Scan Extracranial Art Uni/Lmtd Study PX-9219388200 CDM 93882 CPT 921 RC outpatient 537 537 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES HDHP [308136802] 429.6 percent of total billed charges 332.94 510.15 Technical (Hospital) Services Duplex Scan Extracranial Art Uni/Lmtd Study PX-9219388200 CDM 93882 CPT 921 RC inpatient 537 537 CIGNA 62308 [3081051] CIGNA 62308 [308105105] 425.2 percent of total billed charges 332.94 510.15 Technical (Hospital) Services Duplex Scan Extracranial Art Uni/Lmtd Study PX-9219388200 CDM 93882 CPT 921 RC inpatient 537 537 CIGNA 62308 [3081051] CIGNA STATE OF WYOMING [308105107] 425.2 percent of total billed charges 332.94 510.15 Technical (Hospital) Services Duplex Scan Extracranial Art Uni/Lmtd Study PX-9219388200 CDM 93882 CPT 921 RC inpatient 537 537 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES PPO [308136801] 425.2 percent of total billed charges 332.94 510.15 Technical (Hospital) Services Duplex Scan Extracranial Art Uni/Lmtd Study PX-9219388200 CDM 93882 CPT 921 RC inpatient 537 537 UNITED HEALTHCARE (COMMERCIAL) [3081199] UNITED HEALTHCARE 87726 [308119901] 332.94 percent of total billed charges 332.94 510.15 Technical (Hospital) Services Duplex Scan Extracranial Art Uni/Lmtd Study PX-9219388200 CDM 93882 CPT 921 RC inpatient 537 537 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES HDHP [308136802] 425.2 percent of total billed charges 332.94 510.15 Technical (Hospital) Services Duplex Scan Extracranial Art Uni/Lmtd Study PX-9219388200 CDM 93882 CPT 921 RC inpatient 537 537 BLUE CROSS BLUE SHIELD WELLMARK SB889 [3081026] BCBS WYOMING [308102603] 510.15 percent of total billed charges 332.94 510.15 Technical (Hospital) Services Duplex Scan Extracranial Art Uni/Lmtd Study PX-9219388200 CDM 93882 CPT 921 RC inpatient 537 537 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES EPO [308136803] 425.2 percent of total billed charges 332.94 510.15 Technical (Hospital) Services Duplex Scan Extracranial Art Uni/Lmtd Study PX-9219388200 CDM 93882 CPT 921 RC inpatient 537 537 HEALTHPARTNERS SX009 HEALTHPARTNERS 425.2 percent of total billed charges 332.94 510.15 Technical (Hospital) Services Duplex Scan Extracranial Art Uni/Lmtd Study PX-9219388200 CDM 93882 CPT 921 RC inpatient 537 537 MULTIPLAN INC 34080 [3081285] MULTIPLAN INC [308128501] 510.15 percent of total billed charges 332.94 510.15 Technical (Hospital) Services Duplex Scan Extracranial Art Uni/Lmtd Study PX-9219388200 CDM 93882 CPT 921 RC inpatient 537 537 MEDICA (COMMERCIAL) 94265 [3081118] MEDICA CLAIMS [308111801] 483.3 percent of total billed charges 332.94 510.15 Technical (Hospital) Services Duplex Scan Extracranial Art Compl Bi Study PX-9219388000 CDM 93880 CPT 921 RC outpatient 894 894 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES EPO [308136803] 715.2 percent of total billed charges 554.28 849.3 Technical (Hospital) Services Duplex Scan Extracranial Art Compl Bi Study PX-9219388000 CDM 93880 CPT 921 RC outpatient 894 894 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES PPO [308136801] 715.2 percent of total billed charges 554.28 849.3 Technical (Hospital) Services Duplex Scan Extracranial Art Compl Bi Study PX-9219388000 CDM 93880 CPT 921 RC outpatient 894 894 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES HDHP [308136802] 715.2 percent of total billed charges 554.28 849.3 Technical (Hospital) Services Duplex Scan Extracranial Art Compl Bi Study PX-9219388000 CDM 93880 CPT 921 RC outpatient 894 894 BLUE CROSS BLUE SHIELD WELLMARK SB889 [3081026] BCBS WYOMING [308102603] 849.3 percent of total billed charges 554.28 849.3 Technical (Hospital) Services Duplex Scan Extracranial Art Compl Bi Study PX-9219388000 CDM 93880 CPT 921 RC outpatient 894 894 HEALTHPARTNERS SX009 HEALTHPARTNERS 715.2 percent of total billed charges 554.28 849.3 Technical (Hospital) Services Duplex Scan Extracranial Art Compl Bi Study PX-9219388000 CDM 93880 CPT 921 RC outpatient 894 894 UNITED HEALTHCARE (COMMERCIAL) [3081199] UNITED HEALTHCARE 87726 [308119901] 554.28 percent of total billed charges 554.28 849.3 Technical (Hospital) Services Duplex Scan Extracranial Art Compl Bi Study PX-9219388000 CDM 93880 CPT 921 RC outpatient 894 894 MEDICA (COMMERCIAL) 94265 [3081118] MEDICA CLAIMS [308111801] 804.6 percent of total billed charges 554.28 849.3 Technical (Hospital) Services Duplex Scan Extracranial Art Compl Bi Study PX-9219388000 CDM 93880 CPT 921 RC outpatient 894 894 MULTIPLAN INC 34080 [3081285] MULTIPLAN INC [308128501] 849.3 percent of total billed charges 554.28 849.3 Technical (Hospital) Services Duplex Scan Extracranial Art Compl Bi Study PX-9219388000 CDM 93880 CPT 921 RC outpatient 894 894 CIGNA 62308 [3081051] CIGNA 62308 [308105105] 715.2 percent of total billed charges 554.28 849.3 Technical (Hospital) Services Duplex Scan Extracranial Art Compl Bi Study PX-9219388000 CDM 93880 CPT 921 RC outpatient 894 894 CIGNA 62308 [3081051] CIGNA STATE OF WYOMING [308105107] 715.2 percent of total billed charges 554.28 849.3 Technical (Hospital) Services Duplex Scan Extracranial Art Compl Bi Study PX-9219388000 CDM 93880 CPT 921 RC inpatient 894 894 MEDICA (COMMERCIAL) 94265 [3081118] MEDICA CLAIMS [308111801] 804.6 percent of total billed charges 554.28 849.3 Technical (Hospital) Services Duplex Scan Extracranial Art Compl Bi Study PX-9219388000 CDM 93880 CPT 921 RC inpatient 894 894 MULTIPLAN INC 34080 [3081285] MULTIPLAN INC [308128501] 849.3 percent of total billed charges 554.28 849.3 Technical (Hospital) Services Duplex Scan Extracranial Art Compl Bi Study PX-9219388000 CDM 93880 CPT 921 RC inpatient 894 894 HEALTHPARTNERS SX009 HEALTHPARTNERS 707.87 percent of total billed charges 554.28 849.3 Technical (Hospital) Services Duplex Scan Extracranial Art Compl Bi Study PX-9219388000 CDM 93880 CPT 921 RC inpatient 894 894 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES EPO [308136803] 707.87 percent of total billed charges 554.28 849.3 Technical (Hospital) Services Duplex Scan Extracranial Art Compl Bi Study PX-9219388000 CDM 93880 CPT 921 RC inpatient 894 894 BLUE CROSS BLUE SHIELD WELLMARK SB889 [3081026] BCBS WYOMING [308102603] 849.3 percent of total billed charges 554.28 849.3 Technical (Hospital) Services Duplex Scan Extracranial Art Compl Bi Study PX-9219388000 CDM 93880 CPT 921 RC inpatient 894 894 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES HDHP [308136802] 707.87 percent of total billed charges 554.28 849.3 Technical (Hospital) Services Duplex Scan Extracranial Art Compl Bi Study PX-9219388000 CDM 93880 CPT 921 RC inpatient 894 894 UNITED HEALTHCARE (COMMERCIAL) [3081199] UNITED HEALTHCARE 87726 [308119901] 554.28 percent of total billed charges 554.28 849.3 Technical (Hospital) Services Duplex Scan Extracranial Art Compl Bi Study PX-9219388000 CDM 93880 CPT 921 RC inpatient 894 894 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES PPO [308136801] 707.87 percent of total billed charges 554.28 849.3 Technical (Hospital) Services Duplex Scan Extracranial Art Compl Bi Study PX-9219388000 CDM 93880 CPT 921 RC inpatient 894 894 CIGNA 62308 [3081051] CIGNA 62308 [308105105] 707.87 percent of total billed charges 554.28 849.3 Technical (Hospital) Services Duplex Scan Extracranial Art Compl Bi Study PX-9219388000 CDM 93880 CPT 921 RC inpatient 894 894 CIGNA 62308 [3081051] CIGNA STATE OF WYOMING [308105107] 707.87 percent of total billed charges 554.28 849.3 Technical (Hospital) Services Outpatient Cardiac Rehab W/Cont Ecg Monitoring PX-9439379800 CDM 93798 CPT 943 RC outpatient 284 284 MEDICA (COMMERCIAL) 94265 [3081118] MEDICA CLAIMS [308111801] 255.6 percent of total billed charges 176.08 269.8 Technical (Hospital) Services Outpatient Cardiac Rehab W/Cont Ecg Monitoring PX-9439379800 CDM 93798 CPT 943 RC outpatient 284 284 MULTIPLAN INC 34080 [3081285] MULTIPLAN INC [308128501] 269.8 percent of total billed charges 176.08 269.8 Technical (Hospital) Services Outpatient Cardiac Rehab W/Cont Ecg Monitoring PX-9439379800 CDM 93798 CPT 943 RC outpatient 284 284 CIGNA 62308 [3081051] CIGNA 62308 [308105105] 227.2 percent of total billed charges 176.08 269.8 Technical (Hospital) Services Outpatient Cardiac Rehab W/Cont Ecg Monitoring PX-9439379800 CDM 93798 CPT 943 RC outpatient 284 284 CIGNA 62308 [3081051] CIGNA STATE OF WYOMING [308105107] 227.2 percent of total billed charges 176.08 269.8 Technical (Hospital) Services Outpatient Cardiac Rehab W/Cont Ecg Monitoring PX-9439379800 CDM 93798 CPT 943 RC outpatient 284 284 HEALTHPARTNERS SX009 HEALTHPARTNERS 227.2 percent of total billed charges 176.08 269.8 Technical (Hospital) Services Outpatient Cardiac Rehab W/Cont Ecg Monitoring PX-9439379800 CDM 93798 CPT 943 RC outpatient 284 284 BLUE CROSS BLUE SHIELD WELLMARK SB889 [3081026] BCBS WYOMING [308102603] 269.8 percent of total billed charges 176.08 269.8 Technical (Hospital) Services Outpatient Cardiac Rehab W/Cont Ecg Monitoring PX-9439379800 CDM 93798 CPT 943 RC outpatient 284 284 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES HDHP [308136802] 227.2 percent of total billed charges 176.08 269.8 Technical (Hospital) Services Outpatient Cardiac Rehab W/Cont Ecg Monitoring PX-9439379800 CDM 93798 CPT 943 RC outpatient 284 284 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES EPO [308136803] 227.2 percent of total billed charges 176.08 269.8 Technical (Hospital) Services Outpatient Cardiac Rehab W/Cont Ecg Monitoring PX-9439379800 CDM 93798 CPT 943 RC outpatient 284 284 UNITED HEALTHCARE (COMMERCIAL) [3081199] UNITED HEALTHCARE 87726 [308119901] 176.08 percent of total billed charges 176.08 269.8 Technical (Hospital) Services Outpatient Cardiac Rehab W/Cont Ecg Monitoring PX-9439379800 CDM 93798 CPT 943 RC outpatient 284 284 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES PPO [308136801] 227.2 percent of total billed charges 176.08 269.8 Technical (Hospital) Services Outpatient Cardiac Rehab W/Cont Ecg Monitoring PX-9439379800 CDM 93798 CPT 943 RC inpatient 284 284 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES HDHP [308136802] 224.87 percent of total billed charges 176.08 269.8 Technical (Hospital) Services Outpatient Cardiac Rehab W/Cont Ecg Monitoring PX-9439379800 CDM 93798 CPT 943 RC inpatient 284 284 MEDICA (COMMERCIAL) 94265 [3081118] MEDICA CLAIMS [308111801] 255.6 percent of total billed charges 176.08 269.8 Technical (Hospital) Services Outpatient Cardiac Rehab W/Cont Ecg Monitoring PX-9439379800 CDM 93798 CPT 943 RC inpatient 284 284 MULTIPLAN INC 34080 [3081285] MULTIPLAN INC [308128501] 269.8 percent of total billed charges 176.08 269.8 Technical (Hospital) Services Outpatient Cardiac Rehab W/Cont Ecg Monitoring PX-9439379800 CDM 93798 CPT 943 RC inpatient 284 284 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES EPO [308136803] 224.87 percent of total billed charges 176.08 269.8 Technical (Hospital) Services Outpatient Cardiac Rehab W/Cont Ecg Monitoring PX-9439379800 CDM 93798 CPT 943 RC inpatient 284 284 HEALTHPARTNERS SX009 HEALTHPARTNERS 224.87 percent of total billed charges 176.08 269.8 Technical (Hospital) Services Outpatient Cardiac Rehab W/Cont Ecg Monitoring PX-9439379800 CDM 93798 CPT 943 RC inpatient 284 284 BLUE CROSS BLUE SHIELD WELLMARK SB889 [3081026] BCBS WYOMING [308102603] 269.8 percent of total billed charges 176.08 269.8 Technical (Hospital) Services Outpatient Cardiac Rehab W/Cont Ecg Monitoring PX-9439379800 CDM 93798 CPT 943 RC inpatient 284 284 UNITED HEALTHCARE (COMMERCIAL) [3081199] UNITED HEALTHCARE 87726 [308119901] 176.08 percent of total billed charges 176.08 269.8 Technical (Hospital) Services Outpatient Cardiac Rehab W/Cont Ecg Monitoring PX-9439379800 CDM 93798 CPT 943 RC inpatient 284 284 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES PPO [308136801] 224.87 percent of total billed charges 176.08 269.8 Technical (Hospital) Services Outpatient Cardiac Rehab W/Cont Ecg Monitoring PX-9439379800 CDM 93798 CPT 943 RC inpatient 284 284 CIGNA 62308 [3081051] CIGNA 62308 [308105105] 224.87 percent of total billed charges 176.08 269.8 Technical (Hospital) Services Outpatient Cardiac Rehab W/Cont Ecg Monitoring PX-9439379800 CDM 93798 CPT 943 RC inpatient 284 284 CIGNA 62308 [3081051] CIGNA STATE OF WYOMING [308105107] 224.87 percent of total billed charges 176.08 269.8 Technical (Hospital) Services Outpatient Cardiac Rehab W/O Cont Ecg Monitor PX-9439379700 CDM 93797 CPT 943 RC inpatient 284 284 CIGNA 62308 [3081051] CIGNA 62308 [308105105] 224.87 percent of total billed charges 176.08 269.8 Technical (Hospital) Services Outpatient Cardiac Rehab W/O Cont Ecg Monitor PX-9439379700 CDM 93797 CPT 943 RC inpatient 284 284 CIGNA 62308 [3081051] CIGNA STATE OF WYOMING [308105107] 224.87 percent of total billed charges 176.08 269.8 Technical (Hospital) Services Outpatient Cardiac Rehab W/O Cont Ecg Monitor PX-9439379700 CDM 93797 CPT 943 RC inpatient 284 284 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES PPO [308136801] 224.87 percent of total billed charges 176.08 269.8 Technical (Hospital) Services Outpatient Cardiac Rehab W/O Cont Ecg Monitor PX-9439379700 CDM 93797 CPT 943 RC inpatient 284 284 UNITED HEALTHCARE (COMMERCIAL) [3081199] UNITED HEALTHCARE 87726 [308119901] 176.08 percent of total billed charges 176.08 269.8 Technical (Hospital) Services Outpatient Cardiac Rehab W/O Cont Ecg Monitor PX-9439379700 CDM 93797 CPT 943 RC inpatient 284 284 BLUE CROSS BLUE SHIELD WELLMARK SB889 [3081026] BCBS WYOMING [308102603] 269.8 percent of total billed charges 176.08 269.8 Technical (Hospital) Services Outpatient Cardiac Rehab W/O Cont Ecg Monitor PX-9439379700 CDM 93797 CPT 943 RC inpatient 284 284 HEALTHPARTNERS SX009 HEALTHPARTNERS 224.87 percent of total billed charges 176.08 269.8 Technical (Hospital) Services Outpatient Cardiac Rehab W/O Cont Ecg Monitor PX-9439379700 CDM 93797 CPT 943 RC inpatient 284 284 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES EPO [308136803] 224.87 percent of total billed charges 176.08 269.8 Technical (Hospital) Services Outpatient Cardiac Rehab W/O Cont Ecg Monitor PX-9439379700 CDM 93797 CPT 943 RC inpatient 284 284 MULTIPLAN INC 34080 [3081285] MULTIPLAN INC [308128501] 269.8 percent of total billed charges 176.08 269.8 Technical (Hospital) Services Outpatient Cardiac Rehab W/O Cont Ecg Monitor PX-9439379700 CDM 93797 CPT 943 RC inpatient 284 284 MEDICA (COMMERCIAL) 94265 [3081118] MEDICA CLAIMS [308111801] 255.6 percent of total billed charges 176.08 269.8 Technical (Hospital) Services Outpatient Cardiac Rehab W/O Cont Ecg Monitor PX-9439379700 CDM 93797 CPT 943 RC inpatient 284 284 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES HDHP [308136802] 224.87 percent of total billed charges 176.08 269.8 Technical (Hospital) Services Outpatient Cardiac Rehab W/O Cont Ecg Monitor PX-9439379700 CDM 93797 CPT 943 RC outpatient 284 284 CIGNA 62308 [3081051] CIGNA 62308 [308105105] 227.2 percent of total billed charges 176.08 269.8 Technical (Hospital) Services Outpatient Cardiac Rehab W/O Cont Ecg Monitor PX-9439379700 CDM 93797 CPT 943 RC outpatient 284 284 CIGNA 62308 [3081051] CIGNA STATE OF WYOMING [308105107] 227.2 percent of total billed charges 176.08 269.8 Technical (Hospital) Services Outpatient Cardiac Rehab W/O Cont Ecg Monitor PX-9439379700 CDM 93797 CPT 943 RC outpatient 284 284 MULTIPLAN INC 34080 [3081285] MULTIPLAN INC [308128501] 269.8 percent of total billed charges 176.08 269.8 Technical (Hospital) Services Outpatient Cardiac Rehab W/O Cont Ecg Monitor PX-9439379700 CDM 93797 CPT 943 RC outpatient 284 284 MEDICA (COMMERCIAL) 94265 [3081118] MEDICA CLAIMS [308111801] 255.6 percent of total billed charges 176.08 269.8 Technical (Hospital) Services Outpatient Cardiac Rehab W/O Cont Ecg Monitor PX-9439379700 CDM 93797 CPT 943 RC outpatient 284 284 UNITED HEALTHCARE (COMMERCIAL) [3081199] UNITED HEALTHCARE 87726 [308119901] 176.08 percent of total billed charges 176.08 269.8 Technical (Hospital) Services Outpatient Cardiac Rehab W/O Cont Ecg Monitor PX-9439379700 CDM 93797 CPT 943 RC outpatient 284 284 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES EPO [308136803] 227.2 percent of total billed charges 176.08 269.8 Technical (Hospital) Services Outpatient Cardiac Rehab W/O Cont Ecg Monitor PX-9439379700 CDM 93797 CPT 943 RC outpatient 284 284 HEALTHPARTNERS SX009 HEALTHPARTNERS 227.2 percent of total billed charges 176.08 269.8 Technical (Hospital) Services Outpatient Cardiac Rehab W/O Cont Ecg Monitor PX-9439379700 CDM 93797 CPT 943 RC outpatient 284 284 BLUE CROSS BLUE SHIELD WELLMARK SB889 [3081026] BCBS WYOMING [308102603] 269.8 percent of total billed charges 176.08 269.8 Technical (Hospital) Services Outpatient Cardiac Rehab W/O Cont Ecg Monitor PX-9439379700 CDM 93797 CPT 943 RC outpatient 284 284 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES HDHP [308136802] 227.2 percent of total billed charges 176.08 269.8 Technical (Hospital) Services Outpatient Cardiac Rehab W/O Cont Ecg Monitor PX-9439379700 CDM 93797 CPT 943 RC outpatient 284 284 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES PPO [308136801] 227.2 percent of total billed charges 176.08 269.8 Technical (Hospital) Services Doppler Echocardiography Color Flow Velocity Mapping PX-4839332500 CDM 93325 CPT 483 RC inpatient 477 477 BLUE CROSS BLUE SHIELD WELLMARK SB889 [3081026] BCBS WYOMING [308102603] 453.15 percent of total billed charges 295.74 453.15 Technical (Hospital) Services Doppler Echocardiography Color Flow Velocity Mapping PX-4839332500 CDM 93325 CPT 483 RC inpatient 477 477 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES PPO [308136801] 377.69 percent of total billed charges 295.74 453.15 Technical (Hospital) Services Doppler Echocardiography Color Flow Velocity Mapping PX-4839332500 CDM 93325 CPT 483 RC inpatient 477 477 UNITED HEALTHCARE (COMMERCIAL) [3081199] UNITED HEALTHCARE 87726 [308119901] 295.74 percent of total billed charges 295.74 453.15 Technical (Hospital) Services Doppler Echocardiography Color Flow Velocity Mapping PX-4839332500 CDM 93325 CPT 483 RC inpatient 477 477 MEDICA (COMMERCIAL) 94265 [3081118] MEDICA CLAIMS [308111801] 429.3 percent of total billed charges 295.74 453.15 Technical (Hospital) Services Doppler Echocardiography Color Flow Velocity Mapping PX-4839332500 CDM 93325 CPT 483 RC inpatient 477 477 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES HDHP [308136802] 377.69 percent of total billed charges 295.74 453.15 Technical (Hospital) Services Doppler Echocardiography Color Flow Velocity Mapping PX-4839332500 CDM 93325 CPT 483 RC inpatient 477 477 MULTIPLAN INC 34080 [3081285] MULTIPLAN INC [308128501] 453.15 percent of total billed charges 295.74 453.15 Technical (Hospital) Services Doppler Echocardiography Color Flow Velocity Mapping PX-4839332500 CDM 93325 CPT 483 RC inpatient 477 477 HEALTHPARTNERS SX009 HEALTHPARTNERS 377.69 percent of total billed charges 295.74 453.15 Technical (Hospital) Services Doppler Echocardiography Color Flow Velocity Mapping PX-4839332500 CDM 93325 CPT 483 RC inpatient 477 477 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES EPO [308136803] 377.69 percent of total billed charges 295.74 453.15 Technical (Hospital) Services Doppler Echocardiography Color Flow Velocity Mapping PX-4839332500 CDM 93325 CPT 483 RC inpatient 477 477 CIGNA 62308 [3081051] CIGNA 62308 [308105105] 377.69 percent of total billed charges 295.74 453.15 Technical (Hospital) Services Doppler Echocardiography Color Flow Velocity Mapping PX-4839332500 CDM 93325 CPT 483 RC inpatient 477 477 CIGNA 62308 [3081051] CIGNA STATE OF WYOMING [308105107] 377.69 percent of total billed charges 295.74 453.15 Technical (Hospital) Services Doppler Echocardiography Color Flow Velocity Mapping PX-4839332500 CDM 93325 CPT 483 RC outpatient 477 477 MEDICA (COMMERCIAL) 94265 [3081118] MEDICA CLAIMS [308111801] 429.3 percent of total billed charges 295.74 453.15 Technical (Hospital) Services Doppler Echocardiography Color Flow Velocity Mapping PX-4839332500 CDM 93325 CPT 483 RC outpatient 477 477 CIGNA 62308 [3081051] CIGNA 62308 [308105105] 381.6 percent of total billed charges 295.74 453.15 Technical (Hospital) Services Doppler Echocardiography Color Flow Velocity Mapping PX-4839332500 CDM 93325 CPT 483 RC outpatient 477 477 CIGNA 62308 [3081051] CIGNA STATE OF WYOMING [308105107] 381.6 percent of total billed charges 295.74 453.15 Technical (Hospital) Services Doppler Echocardiography Color Flow Velocity Mapping PX-4839332500 CDM 93325 CPT 483 RC outpatient 477 477 MULTIPLAN INC 34080 [3081285] MULTIPLAN INC [308128501] 453.15 percent of total billed charges 295.74 453.15 Technical (Hospital) Services Doppler Echocardiography Color Flow Velocity Mapping PX-4839332500 CDM 93325 CPT 483 RC outpatient 477 477 UNITED HEALTHCARE (COMMERCIAL) [3081199] UNITED HEALTHCARE 87726 [308119901] 295.74 percent of total billed charges 295.74 453.15 Technical (Hospital) Services Doppler Echocardiography Color Flow Velocity Mapping PX-4839332500 CDM 93325 CPT 483 RC outpatient 477 477 HEALTHPARTNERS SX009 HEALTHPARTNERS 381.6 percent of total billed charges 295.74 453.15 Technical (Hospital) Services Doppler Echocardiography Color Flow Velocity Mapping PX-4839332500 CDM 93325 CPT 483 RC outpatient 477 477 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES PPO [308136801] 381.6 percent of total billed charges 295.74 453.15 Technical (Hospital) Services Doppler Echocardiography Color Flow Velocity Mapping PX-4839332500 CDM 93325 CPT 483 RC outpatient 477 477 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES EPO [308136803] 381.6 percent of total billed charges 295.74 453.15 Technical (Hospital) Services Doppler Echocardiography Color Flow Velocity Mapping PX-4839332500 CDM 93325 CPT 483 RC outpatient 477 477 BLUE CROSS BLUE SHIELD WELLMARK SB889 [3081026] BCBS WYOMING [308102603] 453.15 percent of total billed charges 295.74 453.15 Technical (Hospital) Services Doppler Echocardiography Color Flow Velocity Mapping PX-4839332500 CDM 93325 CPT 483 RC outpatient 477 477 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES HDHP [308136802] 381.6 percent of total billed charges 295.74 453.15 Technical (Hospital) Services Dop Echocard Pulse Wave W/Spectral F-Up/Lmtd Std PX-4839332100 CDM 93321 CPT 483 RC inpatient 238 238 HEALTHPARTNERS SX009 HEALTHPARTNERS 188.45 percent of total billed charges 147.56 226.1 Technical (Hospital) Services Dop Echocard Pulse Wave W/Spectral F-Up/Lmtd Std PX-4839332100 CDM 93321 CPT 483 RC inpatient 238 238 MEDICA (COMMERCIAL) 94265 [3081118] MEDICA CLAIMS [308111801] 214.2 percent of total billed charges 147.56 226.1 Technical (Hospital) Services Dop Echocard Pulse Wave W/Spectral F-Up/Lmtd Std PX-4839332100 CDM 93321 CPT 483 RC inpatient 238 238 MULTIPLAN INC 34080 [3081285] MULTIPLAN INC [308128501] 226.1 percent of total billed charges 147.56 226.1 Technical (Hospital) Services Dop Echocard Pulse Wave W/Spectral F-Up/Lmtd Std PX-4839332100 CDM 93321 CPT 483 RC inpatient 238 238 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES PPO [308136801] 188.45 percent of total billed charges 147.56 226.1 Technical (Hospital) Services Dop Echocard Pulse Wave W/Spectral F-Up/Lmtd Std PX-4839332100 CDM 93321 CPT 483 RC inpatient 238 238 UNITED HEALTHCARE (COMMERCIAL) [3081199] UNITED HEALTHCARE 87726 [308119901] 147.56 percent of total billed charges 147.56 226.1 Technical (Hospital) Services Dop Echocard Pulse Wave W/Spectral F-Up/Lmtd Std PX-4839332100 CDM 93321 CPT 483 RC inpatient 238 238 BLUE CROSS BLUE SHIELD WELLMARK SB889 [3081026] BCBS WYOMING [308102603] 226.1 percent of total billed charges 147.56 226.1 Technical (Hospital) Services Dop Echocard Pulse Wave W/Spectral F-Up/Lmtd Std PX-4839332100 CDM 93321 CPT 483 RC inpatient 238 238 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES HDHP [308136802] 188.45 percent of total billed charges 147.56 226.1 Technical (Hospital) Services Dop Echocard Pulse Wave W/Spectral F-Up/Lmtd Std PX-4839332100 CDM 93321 CPT 483 RC inpatient 238 238 CIGNA 62308 [3081051] CIGNA 62308 [308105105] 188.45 percent of total billed charges 147.56 226.1 Technical (Hospital) Services Dop Echocard Pulse Wave W/Spectral F-Up/Lmtd Std PX-4839332100 CDM 93321 CPT 483 RC outpatient 238 238 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES HDHP [308136802] 190.4 percent of total billed charges 147.56 226.1 Technical (Hospital) Services Dop Echocard Pulse Wave W/Spectral F-Up/Lmtd Std PX-4839332100 CDM 93321 CPT 483 RC outpatient 238 238 BLUE CROSS BLUE SHIELD WELLMARK SB889 [3081026] BCBS WYOMING [308102603] 226.1 percent of total billed charges 147.56 226.1 Technical (Hospital) Services Dop Echocard Pulse Wave W/Spectral F-Up/Lmtd Std PX-4839332100 CDM 93321 CPT 483 RC outpatient 238 238 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES EPO [308136803] 190.4 percent of total billed charges 147.56 226.1 Technical (Hospital) Services Dop Echocard Pulse Wave W/Spectral F-Up/Lmtd Std PX-4839332100 CDM 93321 CPT 483 RC outpatient 238 238 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES PPO [308136801] 190.4 percent of total billed charges 147.56 226.1 Technical (Hospital) Services Dop Echocard Pulse Wave W/Spectral F-Up/Lmtd Std PX-4839332100 CDM 93321 CPT 483 RC outpatient 238 238 HEALTHPARTNERS SX009 HEALTHPARTNERS 190.4 percent of total billed charges 147.56 226.1 Technical (Hospital) Services Dop Echocard Pulse Wave W/Spectral F-Up/Lmtd Std PX-4839332100 CDM 93321 CPT 483 RC outpatient 238 238 UNITED HEALTHCARE (COMMERCIAL) [3081199] UNITED HEALTHCARE 87726 [308119901] 147.56 percent of total billed charges 147.56 226.1 Technical (Hospital) Services Dop Echocard Pulse Wave W/Spectral F-Up/Lmtd Std PX-4839332100 CDM 93321 CPT 483 RC outpatient 238 238 MULTIPLAN INC 34080 [3081285] MULTIPLAN INC [308128501] 226.1 percent of total billed charges 147.56 226.1 Technical (Hospital) Services Dop Echocard Pulse Wave W/Spectral F-Up/Lmtd Std PX-4839332100 CDM 93321 CPT 483 RC outpatient 238 238 CIGNA 62308 [3081051] CIGNA 62308 [308105105] 190.4 percent of total billed charges 147.56 226.1 Technical (Hospital) Services Dop Echocard Pulse Wave W/Spectral F-Up/Lmtd Std PX-4839332100 CDM 93321 CPT 483 RC outpatient 238 238 CIGNA 62308 [3081051] CIGNA STATE OF WYOMING [308105107] 190.4 percent of total billed charges 147.56 226.1 Technical (Hospital) Services Dop Echocard Pulse Wave W/Spectral F-Up/Lmtd Std PX-4839332100 CDM 93321 CPT 483 RC outpatient 238 238 MEDICA (COMMERCIAL) 94265 [3081118] MEDICA CLAIMS [308111801] 214.2 percent of total billed charges 147.56 226.1 Technical (Hospital) Services Dop Echocard Pulse Wave W/Spectral F-Up/Lmtd Std PX-4839332100 CDM 93321 CPT 483 RC inpatient 238 238 CIGNA 62308 [3081051] CIGNA STATE OF WYOMING [308105107] 188.45 percent of total billed charges 147.56 226.1 Technical (Hospital) Services Dop Echocard Pulse Wave W/Spectral F-Up/Lmtd Std PX-4839332100 CDM 93321 CPT 483 RC inpatient 238 238 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES EPO [308136803] 188.45 percent of total billed charges 147.56 226.1 Technical (Hospital) Services Doppler Echocard Pulse Wave W/Spectral Display PX-4839332000 CDM 93320 CPT 483 RC inpatient 695 695 CIGNA 62308 [3081051] CIGNA STATE OF WYOMING [308105107] 550.3 percent of total billed charges 430.9 660.25 Technical (Hospital) Services Doppler Echocard Pulse Wave W/Spectral Display PX-4839332000 CDM 93320 CPT 483 RC inpatient 695 695 CIGNA 62308 [3081051] CIGNA 62308 [308105105] 550.3 percent of total billed charges 430.9 660.25 Technical (Hospital) Services Doppler Echocard Pulse Wave W/Spectral Display PX-4839332000 CDM 93320 CPT 483 RC inpatient 695 695 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES EPO [308136803] 550.3 percent of total billed charges 430.9 660.25 Technical (Hospital) Services Doppler Echocard Pulse Wave W/Spectral Display PX-4839332000 CDM 93320 CPT 483 RC inpatient 695 695 HEALTHPARTNERS SX009 HEALTHPARTNERS 550.3 percent of total billed charges 430.9 660.25 Technical (Hospital) Services Doppler Echocard Pulse Wave W/Spectral Display PX-4839332000 CDM 93320 CPT 483 RC inpatient 695 695 MULTIPLAN INC 34080 [3081285] MULTIPLAN INC [308128501] 660.25 percent of total billed charges 430.9 660.25 Technical (Hospital) Services Doppler Echocard Pulse Wave W/Spectral Display PX-4839332000 CDM 93320 CPT 483 RC inpatient 695 695 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES HDHP [308136802] 550.3 percent of total billed charges 430.9 660.25 Technical (Hospital) Services Doppler Echocard Pulse Wave W/Spectral Display PX-4839332000 CDM 93320 CPT 483 RC inpatient 695 695 MEDICA (COMMERCIAL) 94265 [3081118] MEDICA CLAIMS [308111801] 625.5 percent of total billed charges 430.9 660.25 Technical (Hospital) Services Doppler Echocard Pulse Wave W/Spectral Display PX-4839332000 CDM 93320 CPT 483 RC inpatient 695 695 UNITED HEALTHCARE (COMMERCIAL) [3081199] UNITED HEALTHCARE 87726 [308119901] 430.9 percent of total billed charges 430.9 660.25 Technical (Hospital) Services Doppler Echocard Pulse Wave W/Spectral Display PX-4839332000 CDM 93320 CPT 483 RC inpatient 695 695 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES PPO [308136801] 550.3 percent of total billed charges 430.9 660.25 Technical (Hospital) Services Doppler Echocard Pulse Wave W/Spectral Display PX-4839332000 CDM 93320 CPT 483 RC inpatient 695 695 BLUE CROSS BLUE SHIELD WELLMARK SB889 [3081026] BCBS WYOMING [308102603] 660.25 percent of total billed charges 430.9 660.25 Technical (Hospital) Services Doppler Echocard Pulse Wave W/Spectral Display PX-4839332000 CDM 93320 CPT 483 RC outpatient 695 695 MULTIPLAN INC 34080 [3081285] MULTIPLAN INC [308128501] 660.25 percent of total billed charges 430.9 660.25 Technical (Hospital) Services Doppler Echocard Pulse Wave W/Spectral Display PX-4839332000 CDM 93320 CPT 483 RC outpatient 695 695 CIGNA 62308 [3081051] CIGNA 62308 [308105105] 556 percent of total billed charges 430.9 660.25 Technical (Hospital) Services Doppler Echocard Pulse Wave W/Spectral Display PX-4839332000 CDM 93320 CPT 483 RC outpatient 695 695 CIGNA 62308 [3081051] CIGNA STATE OF WYOMING [308105107] 556 percent of total billed charges 430.9 660.25 Technical (Hospital) Services Doppler Echocard Pulse Wave W/Spectral Display PX-4839332000 CDM 93320 CPT 483 RC outpatient 695 695 MEDICA (COMMERCIAL) 94265 [3081118] MEDICA CLAIMS [308111801] 625.5 percent of total billed charges 430.9 660.25 Technical (Hospital) Services Doppler Echocard Pulse Wave W/Spectral Display PX-4839332000 CDM 93320 CPT 483 RC outpatient 695 695 UNITED HEALTHCARE (COMMERCIAL) [3081199] UNITED HEALTHCARE 87726 [308119901] 430.9 percent of total billed charges 430.9 660.25 Technical (Hospital) Services Doppler Echocard Pulse Wave W/Spectral Display PX-4839332000 CDM 93320 CPT 483 RC outpatient 695 695 HEALTHPARTNERS SX009 HEALTHPARTNERS 556 percent of total billed charges 430.9 660.25 Technical (Hospital) Services Doppler Echocard Pulse Wave W/Spectral Display PX-4839332000 CDM 93320 CPT 483 RC outpatient 695 695 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES EPO [308136803] 556 percent of total billed charges 430.9 660.25 Technical (Hospital) Services Doppler Echocard Pulse Wave W/Spectral Display PX-4839332000 CDM 93320 CPT 483 RC outpatient 695 695 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES PPO [308136801] 556 percent of total billed charges 430.9 660.25 Technical (Hospital) Services Doppler Echocard Pulse Wave W/Spectral Display PX-4839332000 CDM 93320 CPT 483 RC outpatient 695 695 BLUE CROSS BLUE SHIELD WELLMARK SB889 [3081026] BCBS WYOMING [308102603] 660.25 percent of total billed charges 430.9 660.25 Technical (Hospital) Services Doppler Echocard Pulse Wave W/Spectral Display PX-4839332000 CDM 93320 CPT 483 RC outpatient 695 695 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES HDHP [308136802] 556 percent of total billed charges 430.9 660.25 Technical (Hospital) Services Echo Transthorc R-T 2d W/WO M-Mode Rec F-Up/Lmtd PX-4839330800 CDM 93308 CPT 483 RC inpatient 595 595 CIGNA 62308 [3081051] CIGNA 62308 [308105105] 471.12 percent of total billed charges 368.9 565.25 Technical (Hospital) Services Echo Transthorc R-T 2d W/WO M-Mode Rec F-Up/Lmtd PX-4839330800 CDM 93308 CPT 483 RC inpatient 595 595 CIGNA 62308 [3081051] CIGNA STATE OF WYOMING [308105107] 471.12 percent of total billed charges 368.9 565.25 Technical (Hospital) Services Echo Transthorc R-T 2d W/WO M-Mode Rec F-Up/Lmtd PX-4839330800 CDM 93308 CPT 483 RC inpatient 595 595 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES EPO [308136803] 471.12 percent of total billed charges 368.9 565.25 Technical (Hospital) Services Echo Transthorc R-T 2d W/WO M-Mode Rec F-Up/Lmtd PX-4839330800 CDM 93308 CPT 483 RC inpatient 595 595 MEDICA (COMMERCIAL) 94265 [3081118] MEDICA CLAIMS [308111801] 535.5 percent of total billed charges 368.9 565.25 Technical (Hospital) Services Echo Transthorc R-T 2d W/WO M-Mode Rec F-Up/Lmtd PX-4839330800 CDM 93308 CPT 483 RC inpatient 595 595 MULTIPLAN INC 34080 [3081285] MULTIPLAN INC [308128501] 565.25 percent of total billed charges 368.9 565.25 Technical (Hospital) Services Echo Transthorc R-T 2d W/WO M-Mode Rec F-Up/Lmtd PX-4839330800 CDM 93308 CPT 483 RC inpatient 595 595 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES HDHP [308136802] 471.12 percent of total billed charges 368.9 565.25 Technical (Hospital) Services Echo Transthorc R-T 2d W/WO M-Mode Rec F-Up/Lmtd PX-4839330800 CDM 93308 CPT 483 RC inpatient 595 595 HEALTHPARTNERS SX009 HEALTHPARTNERS 471.12 percent of total billed charges 368.9 565.25 Technical (Hospital) Services Echo Transthorc R-T 2d W/WO M-Mode Rec F-Up/Lmtd PX-4839330800 CDM 93308 CPT 483 RC inpatient 595 595 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES PPO [308136801] 471.12 percent of total billed charges 368.9 565.25 Technical (Hospital) Services Echo Transthorc R-T 2d W/WO M-Mode Rec F-Up/Lmtd PX-4839330800 CDM 93308 CPT 483 RC inpatient 595 595 UNITED HEALTHCARE (COMMERCIAL) [3081199] UNITED HEALTHCARE 87726 [308119901] 368.9 percent of total billed charges 368.9 565.25 Technical (Hospital) Services Echo Transthorc R-T 2d W/WO M-Mode Rec F-Up/Lmtd PX-4839330800 CDM 93308 CPT 483 RC inpatient 595 595 BLUE CROSS BLUE SHIELD WELLMARK SB889 [3081026] BCBS WYOMING [308102603] 565.25 percent of total billed charges 368.9 565.25 Technical (Hospital) Services Echo Transthorc R-T 2d W/WO M-Mode Rec F-Up/Lmtd PX-4839330800 CDM 93308 CPT 483 RC outpatient 595 595 CIGNA 62308 [3081051] CIGNA 62308 [308105105] 476 percent of total billed charges 368.9 565.25 Technical (Hospital) Services Echo Transthorc R-T 2d W/WO M-Mode Rec F-Up/Lmtd PX-4839330800 CDM 93308 CPT 483 RC outpatient 595 595 CIGNA 62308 [3081051] CIGNA STATE OF WYOMING [308105107] 476 percent of total billed charges 368.9 565.25 Technical (Hospital) Services Echo Transthorc R-T 2d W/WO M-Mode Rec F-Up/Lmtd PX-4839330800 CDM 93308 CPT 483 RC outpatient 595 595 MULTIPLAN INC 34080 [3081285] MULTIPLAN INC [308128501] 565.25 percent of total billed charges 368.9 565.25 Technical (Hospital) Services Echo Transthorc R-T 2d W/WO M-Mode Rec F-Up/Lmtd PX-4839330800 CDM 93308 CPT 483 RC outpatient 595 595 MEDICA (COMMERCIAL) 94265 [3081118] MEDICA CLAIMS [308111801] 535.5 percent of total billed charges 368.9 565.25 Technical (Hospital) Services Echo Transthorc R-T 2d W/WO M-Mode Rec F-Up/Lmtd PX-4839330800 CDM 93308 CPT 483 RC outpatient 595 595 BLUE CROSS BLUE SHIELD WELLMARK SB889 [3081026] BCBS WYOMING [308102603] 565.25 percent of total billed charges 368.9 565.25 Technical (Hospital) Services Echo Transthorc R-T 2d W/WO M-Mode Rec F-Up/Lmtd PX-4839330800 CDM 93308 CPT 483 RC outpatient 595 595 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES HDHP [308136802] 476 percent of total billed charges 368.9 565.25 Technical (Hospital) Services Echo Transthorc R-T 2d W/WO M-Mode Rec F-Up/Lmtd PX-4839330800 CDM 93308 CPT 483 RC outpatient 595 595 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES PPO [308136801] 476 percent of total billed charges 368.9 565.25 Technical (Hospital) Services Echo Transthorc R-T 2d W/WO M-Mode Rec F-Up/Lmtd PX-4839330800 CDM 93308 CPT 483 RC outpatient 595 595 HEALTHPARTNERS SX009 HEALTHPARTNERS 476 percent of total billed charges 368.9 565.25 Technical (Hospital) Services Echo Transthorc R-T 2d W/WO M-Mode Rec F-Up/Lmtd PX-4839330800 CDM 93308 CPT 483 RC outpatient 595 595 UNITED HEALTHCARE (COMMERCIAL) [3081199] UNITED HEALTHCARE 87726 [308119901] 368.9 percent of total billed charges 368.9 565.25 Technical (Hospital) Services Echo Transthorc R-T 2d W/WO M-Mode Rec F-Up/Lmtd PX-4839330800 CDM 93308 CPT 483 RC outpatient 595 595 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES EPO [308136803] 476 percent of total billed charges 368.9 565.25 Technical (Hospital) Services Echo Tthrc R-T 2d W/Wom-Mode Compl Spec&Colr D PX-4839330600 CDM 93306 CPT 483 RC outpatient 2381 2381 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES HDHP [308136802] 1904.8 percent of total billed charges 1476.22 2261.95 Technical (Hospital) Services Echo Tthrc R-T 2d W/Wom-Mode Compl Spec&Colr D PX-4839330600 CDM 93306 CPT 483 RC outpatient 2381 2381 BLUE CROSS BLUE SHIELD WELLMARK SB889 [3081026] BCBS WYOMING [308102603] 2261.95 percent of total billed charges 1476.22 2261.95 Technical (Hospital) Services Echo Tthrc R-T 2d W/Wom-Mode Compl Spec&Colr D PX-4839330600 CDM 93306 CPT 483 RC outpatient 2381 2381 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES EPO [308136803] 1904.8 percent of total billed charges 1476.22 2261.95 Technical (Hospital) Services Echo Tthrc R-T 2d W/Wom-Mode Compl Spec&Colr D PX-4839330600 CDM 93306 CPT 483 RC outpatient 2381 2381 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES PPO [308136801] 1904.8 percent of total billed charges 1476.22 2261.95 Technical (Hospital) Services Echo Tthrc R-T 2d W/Wom-Mode Compl Spec&Colr D PX-4839330600 CDM 93306 CPT 483 RC outpatient 2381 2381 UNITED HEALTHCARE (COMMERCIAL) [3081199] UNITED HEALTHCARE 87726 [308119901] 1476.22 percent of total billed charges 1476.22 2261.95 Technical (Hospital) Services Echo Tthrc R-T 2d W/Wom-Mode Compl Spec&Colr D PX-4839330600 CDM 93306 CPT 483 RC outpatient 2381 2381 HEALTHPARTNERS SX009 HEALTHPARTNERS 1904.8 percent of total billed charges 1476.22 2261.95 Technical (Hospital) Services Echo Tthrc R-T 2d W/Wom-Mode Compl Spec&Colr D PX-4839330600 CDM 93306 CPT 483 RC outpatient 2381 2381 CIGNA 62308 [3081051] CIGNA 62308 [308105105] 1904.8 percent of total billed charges 1476.22 2261.95 Technical (Hospital) Services Echo Tthrc R-T 2d W/Wom-Mode Compl Spec&Colr D PX-4839330600 CDM 93306 CPT 483 RC outpatient 2381 2381 CIGNA 62308 [3081051] CIGNA STATE OF WYOMING [308105107] 1904.8 percent of total billed charges 1476.22 2261.95 Technical (Hospital) Services Echo Tthrc R-T 2d W/Wom-Mode Compl Spec&Colr D PX-4839330600 CDM 93306 CPT 483 RC outpatient 2381 2381 MEDICA (COMMERCIAL) 94265 [3081118] MEDICA CLAIMS [308111801] 2142.9 percent of total billed charges 1476.22 2261.95 Technical (Hospital) Services Echo Tthrc R-T 2d W/Wom-Mode Compl Spec&Colr D PX-4839330600 CDM 93306 CPT 483 RC outpatient 2381 2381 MULTIPLAN INC 34080 [3081285] MULTIPLAN INC [308128501] 2261.95 percent of total billed charges 1476.22 2261.95 Technical (Hospital) Services Echo Tthrc R-T 2d W/Wom-Mode Compl Spec&Colr D PX-4839330600 CDM 93306 CPT 483 RC inpatient 2381 2381 BLUE CROSS BLUE SHIELD WELLMARK SB889 [3081026] BCBS WYOMING [308102603] 2261.95 percent of total billed charges 1476.22 2261.95 Technical (Hospital) Services Echo Tthrc R-T 2d W/Wom-Mode Compl Spec&Colr D PX-4839330600 CDM 93306 CPT 483 RC inpatient 2381 2381 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES PPO [308136801] 1885.28 percent of total billed charges 1476.22 2261.95 Technical (Hospital) Services Echo Tthrc R-T 2d W/Wom-Mode Compl Spec&Colr D PX-4839330600 CDM 93306 CPT 483 RC inpatient 2381 2381 UNITED HEALTHCARE (COMMERCIAL) [3081199] UNITED HEALTHCARE 87726 [308119901] 1476.22 percent of total billed charges 1476.22 2261.95 Technical (Hospital) Services Echo Tthrc R-T 2d W/Wom-Mode Compl Spec&Colr D PX-4839330600 CDM 93306 CPT 483 RC inpatient 2381 2381 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES HDHP [308136802] 1885.28 percent of total billed charges 1476.22 2261.95 Technical (Hospital) Services Echo Tthrc R-T 2d W/Wom-Mode Compl Spec&Colr D PX-4839330600 CDM 93306 CPT 483 RC inpatient 2381 2381 MULTIPLAN INC 34080 [3081285] MULTIPLAN INC [308128501] 2261.95 percent of total billed charges 1476.22 2261.95 Technical (Hospital) Services Echo Tthrc R-T 2d W/Wom-Mode Compl Spec&Colr D PX-4839330600 CDM 93306 CPT 483 RC inpatient 2381 2381 MEDICA (COMMERCIAL) 94265 [3081118] MEDICA CLAIMS [308111801] 2142.9 percent of total billed charges 1476.22 2261.95 Technical (Hospital) Services Echo Tthrc R-T 2d W/Wom-Mode Compl Spec&Colr D PX-4839330600 CDM 93306 CPT 483 RC inpatient 2381 2381 HEALTHPARTNERS SX009 HEALTHPARTNERS 1885.28 percent of total billed charges 1476.22 2261.95 Technical (Hospital) Services Echo Tthrc R-T 2d W/Wom-Mode Compl Spec&Colr D PX-4839330600 CDM 93306 CPT 483 RC inpatient 2381 2381 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES EPO [308136803] 1885.28 percent of total billed charges 1476.22 2261.95 Technical (Hospital) Services Echo Tthrc R-T 2d W/Wom-Mode Compl Spec&Colr D PX-4839330600 CDM 93306 CPT 483 RC inpatient 2381 2381 CIGNA 62308 [3081051] CIGNA 62308 [308105105] 1885.28 percent of total billed charges 1476.22 2261.95 Technical (Hospital) Services Echo Tthrc R-T 2d W/Wom-Mode Compl Spec&Colr D PX-4839330600 CDM 93306 CPT 483 RC inpatient 2381 2381 CIGNA 62308 [3081051] CIGNA STATE OF WYOMING [308105107] 1885.28 percent of total billed charges 1476.22 2261.95 Technical (Hospital) Services Xtrnl Pt Activated Ecg Record Monitor 30 Days PX-7319327000 CDM 93270 CPT 731 RC inpatient 251 251 CIGNA 62308 [3081051] CIGNA 62308 [308105105] 198.74 percent of total billed charges 155.62 238.45 Technical (Hospital) Services Xtrnl Pt Activated Ecg Record Monitor 30 Days PX-7319327000 CDM 93270 CPT 731 RC inpatient 251 251 CIGNA 62308 [3081051] CIGNA STATE OF WYOMING [308105107] 198.74 percent of total billed charges 155.62 238.45 Technical (Hospital) Services Xtrnl Pt Activated Ecg Record Monitor 30 Days PX-7319327000 CDM 93270 CPT 731 RC inpatient 251 251 HEALTHPARTNERS SX009 HEALTHPARTNERS 198.74 percent of total billed charges 155.62 238.45 Technical (Hospital) Services Xtrnl Pt Activated Ecg Record Monitor 30 Days PX-7319327000 CDM 93270 CPT 731 RC inpatient 251 251 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES EPO [308136803] 198.74 percent of total billed charges 155.62 238.45 Technical (Hospital) Services Xtrnl Pt Activated Ecg Record Monitor 30 Days PX-7319327000 CDM 93270 CPT 731 RC inpatient 251 251 MEDICA (COMMERCIAL) 94265 [3081118] MEDICA CLAIMS [308111801] 225.9 percent of total billed charges 155.62 238.45 Technical (Hospital) Services Xtrnl Pt Activated Ecg Record Monitor 30 Days PX-7319327000 CDM 93270 CPT 731 RC inpatient 251 251 MULTIPLAN INC 34080 [3081285] MULTIPLAN INC [308128501] 238.45 percent of total billed charges 155.62 238.45 Technical (Hospital) Services Xtrnl Pt Activated Ecg Record Monitor 30 Days PX-7319327000 CDM 93270 CPT 731 RC inpatient 251 251 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES HDHP [308136802] 198.74 percent of total billed charges 155.62 238.45 Technical (Hospital) Services Xtrnl Pt Activated Ecg Record Monitor 30 Days PX-7319327000 CDM 93270 CPT 731 RC inpatient 251 251 UNITED HEALTHCARE (COMMERCIAL) [3081199] UNITED HEALTHCARE 87726 [308119901] 155.62 percent of total billed charges 155.62 238.45 Technical (Hospital) Services Xtrnl Pt Activated Ecg Record Monitor 30 Days PX-7319327000 CDM 93270 CPT 731 RC inpatient 251 251 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES PPO [308136801] 198.74 percent of total billed charges 155.62 238.45 Technical (Hospital) Services Xtrnl Pt Activated Ecg Record Monitor 30 Days PX-7319327000 CDM 93270 CPT 731 RC inpatient 251 251 BLUE CROSS BLUE SHIELD WELLMARK SB889 [3081026] BCBS WYOMING [308102603] 238.45 percent of total billed charges 155.62 238.45 Technical (Hospital) Services Xtrnl Pt Activated Ecg Record Monitor 30 Days PX-7319327000 CDM 93270 CPT 731 RC outpatient 251 251 UNITED HEALTHCARE (COMMERCIAL) [3081199] UNITED HEALTHCARE 87726 [308119901] 155.62 percent of total billed charges 155.62 238.45 Technical (Hospital) Services Xtrnl Pt Activated Ecg Record Monitor 30 Days PX-7319327000 CDM 93270 CPT 731 RC outpatient 251 251 HEALTHPARTNERS SX009 HEALTHPARTNERS 200.8 percent of total billed charges 155.62 238.45 Technical (Hospital) Services Xtrnl Pt Activated Ecg Record Monitor 30 Days PX-7319327000 CDM 93270 CPT 731 RC outpatient 251 251 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES HDHP [308136802] 200.8 percent of total billed charges 155.62 238.45 Technical (Hospital) Services Xtrnl Pt Activated Ecg Record Monitor 30 Days PX-7319327000 CDM 93270 CPT 731 RC outpatient 251 251 BLUE CROSS BLUE SHIELD WELLMARK SB889 [3081026] BCBS WYOMING [308102603] 238.45 percent of total billed charges 155.62 238.45 Technical (Hospital) Services Xtrnl Pt Activated Ecg Record Monitor 30 Days PX-7319327000 CDM 93270 CPT 731 RC outpatient 251 251 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES PPO [308136801] 200.8 percent of total billed charges 155.62 238.45 Technical (Hospital) Services Xtrnl Pt Activated Ecg Record Monitor 30 Days PX-7319327000 CDM 93270 CPT 731 RC outpatient 251 251 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES EPO [308136803] 200.8 percent of total billed charges 155.62 238.45 Technical (Hospital) Services Xtrnl Pt Activated Ecg Record Monitor 30 Days PX-7319327000 CDM 93270 CPT 731 RC outpatient 251 251 CIGNA 62308 [3081051] CIGNA 62308 [308105105] 200.8 percent of total billed charges 155.62 238.45 Technical (Hospital) Services Xtrnl Pt Activated Ecg Record Monitor 30 Days PX-7319327000 CDM 93270 CPT 731 RC outpatient 251 251 CIGNA 62308 [3081051] CIGNA STATE OF WYOMING [308105107] 200.8 percent of total billed charges 155.62 238.45 Technical (Hospital) Services Xtrnl Pt Activated Ecg Record Monitor 30 Days PX-7319327000 CDM 93270 CPT 731 RC outpatient 251 251 MULTIPLAN INC 34080 [3081285] MULTIPLAN INC [308128501] 238.45 percent of total billed charges 155.62 238.45 Technical (Hospital) Services Xtrnl Pt Activated Ecg Record Monitor 30 Days PX-7319327000 CDM 93270 CPT 731 RC outpatient 251 251 MEDICA (COMMERCIAL) 94265 [3081118] MEDICA CLAIMS [308111801] 225.9 percent of total billed charges 155.62 238.45 Technical (Hospital) Services External Ecg Scanning Analysis Report PX-7319322600 CDM 93226 CPT 731 RC inpatient 417 417 HEALTHPARTNERS SX009 HEALTHPARTNERS 330.18 percent of total billed charges 258.54 396.15 Technical (Hospital) Services External Ecg Scanning Analysis Report PX-7319322600 CDM 93226 CPT 731 RC inpatient 417 417 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES EPO [308136803] 330.18 percent of total billed charges 258.54 396.15 Technical (Hospital) Services External Ecg Scanning Analysis Report PX-7319322600 CDM 93226 CPT 731 RC inpatient 417 417 MEDICA (COMMERCIAL) 94265 [3081118] MEDICA CLAIMS [308111801] 375.3 percent of total billed charges 258.54 396.15 Technical (Hospital) Services External Ecg Scanning Analysis Report PX-7319322600 CDM 93226 CPT 731 RC inpatient 417 417 MULTIPLAN INC 34080 [3081285] MULTIPLAN INC [308128501] 396.15 percent of total billed charges 258.54 396.15 Technical (Hospital) Services External Ecg Scanning Analysis Report PX-7319322600 CDM 93226 CPT 731 RC inpatient 417 417 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES PPO [308136801] 330.18 percent of total billed charges 258.54 396.15 Technical (Hospital) Services External Ecg Scanning Analysis Report PX-7319322600 CDM 93226 CPT 731 RC inpatient 417 417 UNITED HEALTHCARE (COMMERCIAL) [3081199] UNITED HEALTHCARE 87726 [308119901] 258.54 percent of total billed charges 258.54 396.15 Technical (Hospital) Services External Ecg Scanning Analysis Report PX-7319322600 CDM 93226 CPT 731 RC inpatient 417 417 BLUE CROSS BLUE SHIELD WELLMARK SB889 [3081026] BCBS WYOMING [308102603] 396.15 percent of total billed charges 258.54 396.15 Technical (Hospital) Services External Ecg Scanning Analysis Report PX-7319322600 CDM 93226 CPT 731 RC inpatient 417 417 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES HDHP [308136802] 330.18 percent of total billed charges 258.54 396.15 Technical (Hospital) Services External Ecg Scanning Analysis Report PX-7319322600 CDM 93226 CPT 731 RC inpatient 417 417 CIGNA 62308 [3081051] CIGNA 62308 [308105105] 330.18 percent of total billed charges 258.54 396.15 Technical (Hospital) Services External Ecg Scanning Analysis Report PX-7319322600 CDM 93226 CPT 731 RC inpatient 417 417 CIGNA 62308 [3081051] CIGNA STATE OF WYOMING [308105107] 330.18 percent of total billed charges 258.54 396.15 Technical (Hospital) Services External Ecg Scanning Analysis Report PX-7319322600 CDM 93226 CPT 731 RC outpatient 417 417 HEALTHPARTNERS SX009 HEALTHPARTNERS 333.6 percent of total billed charges 258.54 396.15 Technical (Hospital) Services External Ecg Scanning Analysis Report PX-7319322600 CDM 93226 CPT 731 RC outpatient 417 417 UNITED HEALTHCARE (COMMERCIAL) [3081199] UNITED HEALTHCARE 87726 [308119901] 258.54 percent of total billed charges 258.54 396.15 Technical (Hospital) Services External Ecg Scanning Analysis Report PX-7319322600 CDM 93226 CPT 731 RC outpatient 417 417 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES EPO [308136803] 333.6 percent of total billed charges 258.54 396.15 Technical (Hospital) Services External Ecg Scanning Analysis Report PX-7319322600 CDM 93226 CPT 731 RC outpatient 417 417 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES PPO [308136801] 333.6 percent of total billed charges 258.54 396.15 Technical (Hospital) Services External Ecg Scanning Analysis Report PX-7319322600 CDM 93226 CPT 731 RC outpatient 417 417 BLUE CROSS BLUE SHIELD WELLMARK SB889 [3081026] BCBS WYOMING [308102603] 396.15 percent of total billed charges 258.54 396.15 Technical (Hospital) Services External Ecg Scanning Analysis Report PX-7319322600 CDM 93226 CPT 731 RC outpatient 417 417 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES HDHP [308136802] 333.6 percent of total billed charges 258.54 396.15 Technical (Hospital) Services External Ecg Scanning Analysis Report PX-7319322600 CDM 93226 CPT 731 RC outpatient 417 417 MEDICA (COMMERCIAL) 94265 [3081118] MEDICA CLAIMS [308111801] 375.3 percent of total billed charges 258.54 396.15 Technical (Hospital) Services External Ecg Scanning Analysis Report PX-7319322600 CDM 93226 CPT 731 RC outpatient 417 417 MULTIPLAN INC 34080 [3081285] MULTIPLAN INC [308128501] 396.15 percent of total billed charges 258.54 396.15 Technical (Hospital) Services External Ecg Scanning Analysis Report PX-7319322600 CDM 93226 CPT 731 RC outpatient 417 417 CIGNA 62308 [3081051] CIGNA 62308 [308105105] 333.6 percent of total billed charges 258.54 396.15 Technical (Hospital) Services External Ecg Scanning Analysis Report PX-7319322600 CDM 93226 CPT 731 RC outpatient 417 417 CIGNA 62308 [3081051] CIGNA STATE OF WYOMING [308105107] 333.6 percent of total billed charges 258.54 396.15 Technical (Hospital) Services Ecg Monit/Reprt Up to 48 Hrs PX-7319322500 CDM 93225 CPT 731 RC outpatient 460 460 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES HDHP [308136802] 368 percent of total billed charges 285.2 437 Technical (Hospital) Services Ecg Monit/Reprt Up to 48 Hrs PX-7319322500 CDM 93225 CPT 731 RC outpatient 460 460 BLUE CROSS BLUE SHIELD WELLMARK SB889 [3081026] BCBS WYOMING [308102603] 437 percent of total billed charges 285.2 437 Technical (Hospital) Services Ecg Monit/Reprt Up to 48 Hrs PX-7319322500 CDM 93225 CPT 731 RC outpatient 460 460 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES EPO [308136803] 368 percent of total billed charges 285.2 437 Technical (Hospital) Services Ecg Monit/Reprt Up to 48 Hrs PX-7319322500 CDM 93225 CPT 731 RC outpatient 460 460 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES PPO [308136801] 368 percent of total billed charges 285.2 437 Technical (Hospital) Services Ecg Monit/Reprt Up to 48 Hrs PX-7319322500 CDM 93225 CPT 731 RC outpatient 460 460 UNITED HEALTHCARE (COMMERCIAL) [3081199] UNITED HEALTHCARE 87726 [308119901] 285.2 percent of total billed charges 285.2 437 Technical (Hospital) Services Ecg Monit/Reprt Up to 48 Hrs PX-7319322500 CDM 93225 CPT 731 RC outpatient 460 460 HEALTHPARTNERS SX009 HEALTHPARTNERS 368 percent of total billed charges 285.2 437 Technical (Hospital) Services Ecg Monit/Reprt Up to 48 Hrs PX-7319322500 CDM 93225 CPT 731 RC outpatient 460 460 MEDICA (COMMERCIAL) 94265 [3081118] MEDICA CLAIMS [308111801] 414 percent of total billed charges 285.2 437 Technical (Hospital) Services Ecg Monit/Reprt Up to 48 Hrs PX-7319322500 CDM 93225 CPT 731 RC outpatient 460 460 MULTIPLAN INC 34080 [3081285] MULTIPLAN INC [308128501] 437 percent of total billed charges 285.2 437 Technical (Hospital) Services Ecg Monit/Reprt Up to 48 Hrs PX-7319322500 CDM 93225 CPT 731 RC outpatient 460 460 CIGNA 62308 [3081051] CIGNA 62308 [308105105] 368 percent of total billed charges 285.2 437 Technical (Hospital) Services Ecg Monit/Reprt Up to 48 Hrs PX-7319322500 CDM 93225 CPT 731 RC outpatient 460 460 CIGNA 62308 [3081051] CIGNA STATE OF WYOMING [308105107] 368 percent of total billed charges 285.2 437 Technical (Hospital) Services Ecg Monit/Reprt Up to 48 Hrs PX-7319322500 CDM 93225 CPT 731 RC inpatient 460 460 MEDICA (COMMERCIAL) 94265 [3081118] MEDICA CLAIMS [308111801] 414 percent of total billed charges 285.2 437 Technical (Hospital) Services Ecg Monit/Reprt Up to 48 Hrs PX-7319322500 CDM 93225 CPT 731 RC inpatient 460 460 MULTIPLAN INC 34080 [3081285] MULTIPLAN INC [308128501] 437 percent of total billed charges 285.2 437 Technical (Hospital) Services Ecg Monit/Reprt Up to 48 Hrs PX-7319322500 CDM 93225 CPT 731 RC inpatient 460 460 HEALTHPARTNERS SX009 HEALTHPARTNERS 364.23 percent of total billed charges 285.2 437 Technical (Hospital) Services Ecg Monit/Reprt Up to 48 Hrs PX-7319322500 CDM 93225 CPT 731 RC inpatient 460 460 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES EPO [308136803] 364.23 percent of total billed charges 285.2 437 Technical (Hospital) Services Ecg Monit/Reprt Up to 48 Hrs PX-7319322500 CDM 93225 CPT 731 RC inpatient 460 460 BLUE CROSS BLUE SHIELD WELLMARK SB889 [3081026] BCBS WYOMING [308102603] 437 percent of total billed charges 285.2 437 Technical (Hospital) Services Ecg Monit/Reprt Up to 48 Hrs PX-7319322500 CDM 93225 CPT 731 RC inpatient 460 460 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES HDHP [308136802] 364.23 percent of total billed charges 285.2 437 Technical (Hospital) Services Ecg Monit/Reprt Up to 48 Hrs PX-7319322500 CDM 93225 CPT 731 RC inpatient 460 460 UNITED HEALTHCARE (COMMERCIAL) [3081199] UNITED HEALTHCARE 87726 [308119901] 285.2 percent of total billed charges 285.2 437 Technical (Hospital) Services Ecg Monit/Reprt Up to 48 Hrs PX-7319322500 CDM 93225 CPT 731 RC inpatient 460 460 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES PPO [308136801] 364.23 percent of total billed charges 285.2 437 Technical (Hospital) Services Ecg Monit/Reprt Up to 48 Hrs PX-7319322500 CDM 93225 CPT 731 RC inpatient 460 460 CIGNA 62308 [3081051] CIGNA 62308 [308105105] 364.23 percent of total billed charges 285.2 437 Technical (Hospital) Services Ecg Monit/Reprt Up to 48 Hrs PX-7319322500 CDM 93225 CPT 731 RC inpatient 460 460 CIGNA 62308 [3081051] CIGNA STATE OF WYOMING [308105107] 364.23 percent of total billed charges 285.2 437 Technical (Hospital) Services Cv Strs Tst Xers&/or Rx Cont Ecg Trcg Only PX-4829301700 CDM 93017 CPT 482 RC outpatient 568 568 MULTIPLAN INC 34080 [3081285] MULTIPLAN INC [308128501] 539.6 percent of total billed charges 352.16 539.6 Technical (Hospital) Services Cv Strs Tst Xers&/or Rx Cont Ecg Trcg Only PX-4829301700 CDM 93017 CPT 482 RC outpatient 568 568 CIGNA 62308 [3081051] CIGNA 62308 [308105105] 454.4 percent of total billed charges 352.16 539.6 Technical (Hospital) Services Cv Strs Tst Xers&/or Rx Cont Ecg Trcg Only PX-4829301700 CDM 93017 CPT 482 RC outpatient 568 568 CIGNA 62308 [3081051] CIGNA STATE OF WYOMING [308105107] 454.4 percent of total billed charges 352.16 539.6 Technical (Hospital) Services Cv Strs Tst Xers&/or Rx Cont Ecg Trcg Only PX-4829301700 CDM 93017 CPT 482 RC outpatient 568 568 MEDICA (COMMERCIAL) 94265 [3081118] MEDICA CLAIMS [308111801] 511.2 percent of total billed charges 352.16 539.6 Technical (Hospital) Services Cv Strs Tst Xers&/or Rx Cont Ecg Trcg Only PX-4829301700 CDM 93017 CPT 482 RC outpatient 568 568 UNITED HEALTHCARE (COMMERCIAL) [3081199] UNITED HEALTHCARE 87726 [308119901] 352.16 percent of total billed charges 352.16 539.6 Technical (Hospital) Services Cv Strs Tst Xers&/or Rx Cont Ecg Trcg Only PX-4829301700 CDM 93017 CPT 482 RC outpatient 568 568 HEALTHPARTNERS SX009 HEALTHPARTNERS 454.4 percent of total billed charges 352.16 539.6 Technical (Hospital) Services Cv Strs Tst Xers&/or Rx Cont Ecg Trcg Only PX-4829301700 CDM 93017 CPT 482 RC outpatient 568 568 BLUE CROSS BLUE SHIELD WELLMARK SB889 [3081026] BCBS WYOMING [308102603] 539.6 percent of total billed charges 352.16 539.6 Technical (Hospital) Services Cv Strs Tst Xers&/or Rx Cont Ecg Trcg Only PX-4829301700 CDM 93017 CPT 482 RC outpatient 568 568 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES HDHP [308136802] 454.4 percent of total billed charges 352.16 539.6 Technical (Hospital) Services Cv Strs Tst Xers&/or Rx Cont Ecg Trcg Only PX-4829301700 CDM 93017 CPT 482 RC outpatient 568 568 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES PPO [308136801] 454.4 percent of total billed charges 352.16 539.6 Technical (Hospital) Services Cv Strs Tst Xers&/or Rx Cont Ecg Trcg Only PX-4829301700 CDM 93017 CPT 482 RC outpatient 568 568 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES EPO [308136803] 454.4 percent of total billed charges 352.16 539.6 Technical (Hospital) Services Cv Strs Tst Xers&/or Rx Cont Ecg Trcg Only PX-4829301700 CDM 93017 CPT 482 RC inpatient 568 568 CIGNA 62308 [3081051] CIGNA 62308 [308105105] 449.74 percent of total billed charges 352.16 539.6 Technical (Hospital) Services Cv Strs Tst Xers&/or Rx Cont Ecg Trcg Only PX-4829301700 CDM 93017 CPT 482 RC inpatient 568 568 CIGNA 62308 [3081051] CIGNA STATE OF WYOMING [308105107] 449.74 percent of total billed charges 352.16 539.6 Technical (Hospital) Services Cv Strs Tst Xers&/or Rx Cont Ecg Trcg Only PX-4829301700 CDM 93017 CPT 482 RC inpatient 568 568 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES EPO [308136803] 449.74 percent of total billed charges 352.16 539.6 Technical (Hospital) Services Cv Strs Tst Xers&/or Rx Cont Ecg Trcg Only PX-4829301700 CDM 93017 CPT 482 RC inpatient 568 568 MEDICA (COMMERCIAL) 94265 [3081118] MEDICA CLAIMS [308111801] 511.2 percent of total billed charges 352.16 539.6 Technical (Hospital) Services Cv Strs Tst Xers&/or Rx Cont Ecg Trcg Only PX-4829301700 CDM 93017 CPT 482 RC inpatient 568 568 MULTIPLAN INC 34080 [3081285] MULTIPLAN INC [308128501] 539.6 percent of total billed charges 352.16 539.6 Technical (Hospital) Services Cv Strs Tst Xers&/or Rx Cont Ecg Trcg Only PX-4829301700 CDM 93017 CPT 482 RC inpatient 568 568 HEALTHPARTNERS SX009 HEALTHPARTNERS 449.74 percent of total billed charges 352.16 539.6 Technical (Hospital) Services Cv Strs Tst Xers&/or Rx Cont Ecg Trcg Only PX-4829301700 CDM 93017 CPT 482 RC inpatient 568 568 UNITED HEALTHCARE (COMMERCIAL) [3081199] UNITED HEALTHCARE 87726 [308119901] 352.16 percent of total billed charges 352.16 539.6 Technical (Hospital) Services Cv Strs Tst Xers&/or Rx Cont Ecg Trcg Only PX-4829301700 CDM 93017 CPT 482 RC inpatient 568 568 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES PPO [308136801] 449.74 percent of total billed charges 352.16 539.6 Technical (Hospital) Services Cv Strs Tst Xers&/or Rx Cont Ecg Trcg Only PX-4829301700 CDM 93017 CPT 482 RC inpatient 568 568 BLUE CROSS BLUE SHIELD WELLMARK SB889 [3081026] BCBS WYOMING [308102603] 539.6 percent of total billed charges 352.16 539.6 Technical (Hospital) Services Cv Strs Tst Xers&/or Rx Cont Ecg Trcg Only PX-4829301700 CDM 93017 CPT 482 RC inpatient 568 568 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES HDHP [308136802] 449.74 percent of total billed charges 352.16 539.6 Technical (Hospital) Services Electrocardiogram Report PX-93010 CDM 93010 CPT inpatient 72 72 CIGNA 62308 [3081051] CIGNA 62308 [308105105] 57.6 percent of total billed charges 44.64 68.4 Professional (doctor) services Electrocardiogram Report PX-93010 CDM 93010 CPT inpatient 72 72 CIGNA 62308 [3081051] CIGNA STATE OF WYOMING [308105107] 57.6 percent of total billed charges 44.64 68.4 Professional (doctor) services Electrocardiogram Report PX-93010 CDM 93010 CPT outpatient 72 72 CIGNA 62308 [3081051] CIGNA 62308 [308105105] 57.6 percent of total billed charges 44.64 68.4 Professional (doctor) services Electrocardiogram Report PX-93010 CDM 93010 CPT outpatient 72 72 CIGNA 62308 [3081051] CIGNA STATE OF WYOMING [308105107] 57.6 percent of total billed charges 44.64 68.4 Professional (doctor) services Electrocardiogram Report PX-93010 CDM 93010 CPT inpatient 72 72 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES EPO [308136803] 57.6 percent of total billed charges 44.64 68.4 Professional (doctor) services Electrocardiogram Report PX-93010 CDM 93010 CPT inpatient 72 72 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES HDHP [308136802] 57.6 percent of total billed charges 44.64 68.4 Professional (doctor) services Electrocardiogram Report PX-93010 CDM 93010 CPT inpatient 72 72 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES PPO [308136801] 57.6 percent of total billed charges 44.64 68.4 Professional (doctor) services Electrocardiogram Report PX-93010 CDM 93010 CPT outpatient 72 72 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES EPO [308136803] 57.6 percent of total billed charges 44.64 68.4 Professional (doctor) services Electrocardiogram Report PX-93010 CDM 93010 CPT outpatient 72 72 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES HDHP [308136802] 57.6 percent of total billed charges 44.64 68.4 Professional (doctor) services Electrocardiogram Report PX-93010 CDM 93010 CPT outpatient 72 72 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES PPO [308136801] 57.6 percent of total billed charges 44.64 68.4 Professional (doctor) services Electrocardiogram Report PX-93010 CDM 93010 CPT inpatient 72 72 HEALTHPARTNERS SX009 HEALTHPARTNERS 57.6 percent of total billed charges 44.64 68.4 Professional (doctor) services Electrocardiogram Report PX-93010 CDM 93010 CPT outpatient 72 72 HEALTHPARTNERS SX009 HEALTHPARTNERS 57.6 percent of total billed charges 44.64 68.4 Professional (doctor) services Electrocardiogram Report PX-93010 CDM 93010 CPT inpatient 72 72 MEDICA (COMMERCIAL) 94265 [3081118] MEDICA CLAIMS [308111801] 64.8 percent of total billed charges 44.64 68.4 Professional (doctor) services Electrocardiogram Report PX-93010 CDM 93010 CPT outpatient 72 72 MEDICA (COMMERCIAL) 94265 [3081118] MEDICA CLAIMS [308111801] 64.8 percent of total billed charges 44.64 68.4 Professional (doctor) services Electrocardiogram Report PX-93010 CDM 93010 CPT inpatient 72 72 MULTIPLAN INC 34080 [3081285] MULTIPLAN INC [308128501] 68.4 percent of total billed charges 44.64 68.4 Professional (doctor) services Electrocardiogram Report PX-93010 CDM 93010 CPT outpatient 72 72 MULTIPLAN INC 34080 [3081285] MULTIPLAN INC [308128501] 68.4 percent of total billed charges 44.64 68.4 Professional (doctor) services Electrocardiogram Report PX-93010 CDM 93010 CPT inpatient 72 72 UNITED HEALTHCARE (COMMERCIAL) [3081199] UNITED HEALTHCARE 87726 [308119901] 44.64 percent of total billed charges 44.64 68.4 Professional (doctor) services Electrocardiogram Report PX-93010 CDM 93010 CPT outpatient 72 72 UNITED HEALTHCARE (COMMERCIAL) [3081199] UNITED HEALTHCARE 87726 [308119901] 44.64 percent of total billed charges 44.64 68.4 Professional (doctor) services Ecg Routine Ecg W/Least 12 Lds Trcg Only W/O I&R PX-7309300500 CDM 93005 CPT 730 RC outpatient 156 156 CIGNA 62308 [3081051] CIGNA 62308 [308105105] 124.8 percent of total billed charges 96.72 148.2 Technical (Hospital) Services Ecg Routine Ecg W/Least 12 Lds Trcg Only W/O I&R PX-7309300500 CDM 93005 CPT 730 RC outpatient 156 156 CIGNA 62308 [3081051] CIGNA STATE OF WYOMING [308105107] 124.8 percent of total billed charges 96.72 148.2 Technical (Hospital) Services Ecg Routine Ecg W/Least 12 Lds Trcg Only W/O I&R PX-7309300500 CDM 93005 CPT 730 RC outpatient 156 156 MULTIPLAN INC 34080 [3081285] MULTIPLAN INC [308128501] 148.2 percent of total billed charges 96.72 148.2 Technical (Hospital) Services Ecg Routine Ecg W/Least 12 Lds Trcg Only W/O I&R PX-7309300500 CDM 93005 CPT 730 RC outpatient 156 156 MEDICA (COMMERCIAL) 94265 [3081118] MEDICA CLAIMS [308111801] 140.4 percent of total billed charges 96.72 148.2 Technical (Hospital) Services Ecg Routine Ecg W/Least 12 Lds Trcg Only W/O I&R PX-7309300500 CDM 93005 CPT 730 RC outpatient 156 156 HEALTHPARTNERS SX009 HEALTHPARTNERS 124.8 percent of total billed charges 96.72 148.2 Technical (Hospital) Services Ecg Routine Ecg W/Least 12 Lds Trcg Only W/O I&R PX-7309300500 CDM 93005 CPT 730 RC outpatient 156 156 UNITED HEALTHCARE (COMMERCIAL) [3081199] UNITED HEALTHCARE 87726 [308119901] 96.72 percent of total billed charges 96.72 148.2 Technical (Hospital) Services Ecg Routine Ecg W/Least 12 Lds Trcg Only W/O I&R PX-7309300500 CDM 93005 CPT 730 RC outpatient 156 156 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES PPO [308136801] 124.8 percent of total billed charges 96.72 148.2 Technical (Hospital) Services Ecg Routine Ecg W/Least 12 Lds Trcg Only W/O I&R PX-7309300500 CDM 93005 CPT 730 RC outpatient 156 156 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES EPO [308136803] 124.8 percent of total billed charges 96.72 148.2 Technical (Hospital) Services Ecg Routine Ecg W/Least 12 Lds Trcg Only W/O I&R PX-7309300500 CDM 93005 CPT 730 RC outpatient 156 156 BLUE CROSS BLUE SHIELD WELLMARK SB889 [3081026] BCBS WYOMING [308102603] 148.2 percent of total billed charges 96.72 148.2 Technical (Hospital) Services Ecg Routine Ecg W/Least 12 Lds Trcg Only W/O I&R PX-7309300500 CDM 93005 CPT 730 RC outpatient 156 156 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES HDHP [308136802] 124.8 percent of total billed charges 96.72 148.2 Technical (Hospital) Services Ecg Routine Ecg W/Least 12 Lds Trcg Only W/O I&R PX-7309300500 CDM 93005 CPT 730 RC inpatient 156 156 BLUE CROSS BLUE SHIELD WELLMARK SB889 [3081026] BCBS WYOMING [308102603] 148.2 percent of total billed charges 96.72 148.2 Technical (Hospital) Services Ecg Routine Ecg W/Least 12 Lds Trcg Only W/O I&R PX-7309300500 CDM 93005 CPT 730 RC inpatient 156 156 UNITED HEALTHCARE (COMMERCIAL) [3081199] UNITED HEALTHCARE 87726 [308119901] 96.72 percent of total billed charges 96.72 148.2 Technical (Hospital) Services Ecg Routine Ecg W/Least 12 Lds Trcg Only W/O I&R PX-7309300500 CDM 93005 CPT 730 RC inpatient 156 156 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES PPO [308136801] 123.52 percent of total billed charges 96.72 148.2 Technical (Hospital) Services Ecg Routine Ecg W/Least 12 Lds Trcg Only W/O I&R PX-7309300500 CDM 93005 CPT 730 RC inpatient 156 156 HEALTHPARTNERS SX009 HEALTHPARTNERS 123.52 percent of total billed charges 96.72 148.2 Technical (Hospital) Services Ecg Routine Ecg W/Least 12 Lds Trcg Only W/O I&R PX-7309300500 CDM 93005 CPT 730 RC inpatient 156 156 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES EPO [308136803] 123.52 percent of total billed charges 96.72 148.2 Technical (Hospital) Services Ecg Routine Ecg W/Least 12 Lds Trcg Only W/O I&R PX-7309300500 CDM 93005 CPT 730 RC inpatient 156 156 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES HDHP [308136802] 123.52 percent of total billed charges 96.72 148.2 Technical (Hospital) Services Ecg Routine Ecg W/Least 12 Lds Trcg Only W/O I&R PX-7309300500 CDM 93005 CPT 730 RC inpatient 156 156 MULTIPLAN INC 34080 [3081285] MULTIPLAN INC [308128501] 148.2 percent of total billed charges 96.72 148.2 Technical (Hospital) Services Ecg Routine Ecg W/Least 12 Lds Trcg Only W/O I&R PX-7309300500 CDM 93005 CPT 730 RC inpatient 156 156 MEDICA (COMMERCIAL) 94265 [3081118] MEDICA CLAIMS [308111801] 140.4 percent of total billed charges 96.72 148.2 Technical (Hospital) Services Ecg Routine Ecg W/Least 12 Lds Trcg Only W/O I&R PX-7309300500 CDM 93005 CPT 730 RC inpatient 156 156 CIGNA 62308 [3081051] CIGNA 62308 [308105105] 123.52 percent of total billed charges 96.72 148.2 Technical (Hospital) Services Ecg Routine Ecg W/Least 12 Lds Trcg Only W/O I&R PX-7309300500 CDM 93005 CPT 730 RC inpatient 156 156 CIGNA 62308 [3081051] CIGNA STATE OF WYOMING [308105107] 123.52 percent of total billed charges 96.72 148.2 Technical (Hospital) Services Cardiopulmonary Resuscitation PX-4809295000 CDM 92950 CPT 480 RC outpatient 1429 1429 MULTIPLAN INC 34080 [3081285] MULTIPLAN INC [308128501] 1357.55 percent of total billed charges 885.98 1357.55 Technical (Hospital) Services Cardiopulmonary Resuscitation PX-4809295000 CDM 92950 CPT 480 RC outpatient 1429 1429 CIGNA 62308 [3081051] CIGNA 62308 [308105105] 1143.2 percent of total billed charges 885.98 1357.55 Technical (Hospital) Services Cardiopulmonary Resuscitation PX-4809295000 CDM 92950 CPT 480 RC outpatient 1429 1429 CIGNA 62308 [3081051] CIGNA STATE OF WYOMING [308105107] 1143.2 percent of total billed charges 885.98 1357.55 Technical (Hospital) Services Cardiopulmonary Resuscitation PX-4809295000 CDM 92950 CPT 480 RC outpatient 1429 1429 MEDICA (COMMERCIAL) 94265 [3081118] MEDICA CLAIMS [308111801] 1286.1 percent of total billed charges 885.98 1357.55 Technical (Hospital) Services Cardiopulmonary Resuscitation PX-4809295000 CDM 92950 CPT 480 RC outpatient 1429 1429 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES EPO [308136803] 1143.2 percent of total billed charges 885.98 1357.55 Technical (Hospital) Services Cardiopulmonary Resuscitation PX-4809295000 CDM 92950 CPT 480 RC outpatient 1429 1429 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES PPO [308136801] 1143.2 percent of total billed charges 885.98 1357.55 Technical (Hospital) Services Cardiopulmonary Resuscitation PX-4809295000 CDM 92950 CPT 480 RC outpatient 1429 1429 BLUE CROSS BLUE SHIELD WELLMARK SB889 [3081026] BCBS WYOMING [308102603] 1357.55 percent of total billed charges 885.98 1357.55 Technical (Hospital) Services Cardiopulmonary Resuscitation PX-4809295000 CDM 92950 CPT 480 RC outpatient 1429 1429 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES HDHP [308136802] 1143.2 percent of total billed charges 885.98 1357.55 Technical (Hospital) Services Cardiopulmonary Resuscitation PX-4809295000 CDM 92950 CPT 480 RC outpatient 1429 1429 UNITED HEALTHCARE (COMMERCIAL) [3081199] UNITED HEALTHCARE 87726 [308119901] 885.98 percent of total billed charges 885.98 1357.55 Technical (Hospital) Services Cardiopulmonary Resuscitation PX-4809295000 CDM 92950 CPT 480 RC outpatient 1429 1429 HEALTHPARTNERS SX009 HEALTHPARTNERS 1143.2 percent of total billed charges 885.98 1357.55 Technical (Hospital) Services Cardiopulmonary Resuscitation PX-4809295000 CDM 92950 CPT 480 RC inpatient 1429 1429 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES HDHP [308136802] 1131.48 percent of total billed charges 885.98 1357.55 Technical (Hospital) Services Cardiopulmonary Resuscitation PX-4809295000 CDM 92950 CPT 480 RC inpatient 1429 1429 BLUE CROSS BLUE SHIELD WELLMARK SB889 [3081026] BCBS WYOMING [308102603] 1357.55 percent of total billed charges 885.98 1357.55 Technical (Hospital) Services Cardiopulmonary Resuscitation PX-4809295000 CDM 92950 CPT 480 RC inpatient 1429 1429 UNITED HEALTHCARE (COMMERCIAL) [3081199] UNITED HEALTHCARE 87726 [308119901] 885.98 percent of total billed charges 885.98 1357.55 Technical (Hospital) Services Cardiopulmonary Resuscitation PX-4809295000 CDM 92950 CPT 480 RC inpatient 1429 1429 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES PPO [308136801] 1131.48 percent of total billed charges 885.98 1357.55 Technical (Hospital) Services Cardiopulmonary Resuscitation PX-4809295000 CDM 92950 CPT 480 RC inpatient 1429 1429 HEALTHPARTNERS SX009 HEALTHPARTNERS 1131.48 percent of total billed charges 885.98 1357.55 Technical (Hospital) Services Cardiopulmonary Resuscitation PX-4809295000 CDM 92950 CPT 480 RC inpatient 1429 1429 MULTIPLAN INC 34080 [3081285] MULTIPLAN INC [308128501] 1357.55 percent of total billed charges 885.98 1357.55 Technical (Hospital) Services Cardiopulmonary Resuscitation PX-4809295000 CDM 92950 CPT 480 RC inpatient 1429 1429 MEDICA (COMMERCIAL) 94265 [3081118] MEDICA CLAIMS [308111801] 1286.1 percent of total billed charges 885.98 1357.55 Technical (Hospital) Services Cardiopulmonary Resuscitation PX-4809295000 CDM 92950 CPT 480 RC inpatient 1429 1429 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES EPO [308136803] 1131.48 percent of total billed charges 885.98 1357.55 Technical (Hospital) Services Cardiopulmonary Resuscitation PX-4809295000 CDM 92950 CPT 480 RC inpatient 1429 1429 CIGNA 62308 [3081051] CIGNA 62308 [308105105] 1131.48 percent of total billed charges 885.98 1357.55 Technical (Hospital) Services Cardiopulmonary Resuscitation PX-4809295000 CDM 92950 CPT 480 RC inpatient 1429 1429 CIGNA 62308 [3081051] CIGNA STATE OF WYOMING [308105107] 1131.48 percent of total billed charges 885.98 1357.55 Technical (Hospital) Services Heart/Lung Resuscitation (Cpr) PX-92950 CDM 92950 CPT inpatient 1020 1020 CIGNA 62308 [3081051] CIGNA 62308 [308105105] 816 percent of total billed charges 632.4 969 Professional (doctor) services Heart/Lung Resuscitation (Cpr) PX-92950 CDM 92950 CPT inpatient 1020 1020 CIGNA 62308 [3081051] CIGNA STATE OF WYOMING [308105107] 816 percent of total billed charges 632.4 969 Professional (doctor) services Heart/Lung Resuscitation (Cpr) PX-92950 CDM 92950 CPT outpatient 1020 1020 CIGNA 62308 [3081051] CIGNA 62308 [308105105] 816 percent of total billed charges 632.4 969 Professional (doctor) services Heart/Lung Resuscitation (Cpr) PX-92950 CDM 92950 CPT outpatient 1020 1020 CIGNA 62308 [3081051] CIGNA STATE OF WYOMING [308105107] 816 percent of total billed charges 632.4 969 Professional (doctor) services Heart/Lung Resuscitation (Cpr) PX-92950 CDM 92950 CPT inpatient 1020 1020 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES EPO [308136803] 816 percent of total billed charges 632.4 969 Professional (doctor) services Heart/Lung Resuscitation (Cpr) PX-92950 CDM 92950 CPT inpatient 1020 1020 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES HDHP [308136802] 816 percent of total billed charges 632.4 969 Professional (doctor) services Heart/Lung Resuscitation (Cpr) PX-92950 CDM 92950 CPT inpatient 1020 1020 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES PPO [308136801] 816 percent of total billed charges 632.4 969 Professional (doctor) services Heart/Lung Resuscitation (Cpr) PX-92950 CDM 92950 CPT outpatient 1020 1020 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES EPO [308136803] 816 percent of total billed charges 632.4 969 Professional (doctor) services Heart/Lung Resuscitation (Cpr) PX-92950 CDM 92950 CPT outpatient 1020 1020 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES HDHP [308136802] 816 percent of total billed charges 632.4 969 Professional (doctor) services Heart/Lung Resuscitation (Cpr) PX-92950 CDM 92950 CPT outpatient 1020 1020 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES PPO [308136801] 816 percent of total billed charges 632.4 969 Professional (doctor) services Heart/Lung Resuscitation (Cpr) PX-92950 CDM 92950 CPT inpatient 1020 1020 HEALTHPARTNERS SX009 HEALTHPARTNERS 816 percent of total billed charges 632.4 969 Professional (doctor) services Heart/Lung Resuscitation (Cpr) PX-92950 CDM 92950 CPT outpatient 1020 1020 HEALTHPARTNERS SX009 HEALTHPARTNERS 816 percent of total billed charges 632.4 969 Professional (doctor) services Heart/Lung Resuscitation (Cpr) PX-92950 CDM 92950 CPT inpatient 1020 1020 MEDICA (COMMERCIAL) 94265 [3081118] MEDICA CLAIMS [308111801] 918 percent of total billed charges 632.4 969 Professional (doctor) services Heart/Lung Resuscitation (Cpr) PX-92950 CDM 92950 CPT outpatient 1020 1020 MEDICA (COMMERCIAL) 94265 [3081118] MEDICA CLAIMS [308111801] 918 percent of total billed charges 632.4 969 Professional (doctor) services Heart/Lung Resuscitation (Cpr) PX-92950 CDM 92950 CPT inpatient 1020 1020 MULTIPLAN INC 34080 [3081285] MULTIPLAN INC [308128501] 969 percent of total billed charges 632.4 969 Professional (doctor) services Heart/Lung Resuscitation (Cpr) PX-92950 CDM 92950 CPT outpatient 1020 1020 MULTIPLAN INC 34080 [3081285] MULTIPLAN INC [308128501] 969 percent of total billed charges 632.4 969 Professional (doctor) services Heart/Lung Resuscitation (Cpr) PX-92950 CDM 92950 CPT inpatient 1020 1020 UNITED HEALTHCARE (COMMERCIAL) [3081199] UNITED HEALTHCARE 87726 [308119901] 632.4 percent of total billed charges 632.4 969 Professional (doctor) services Heart/Lung Resuscitation (Cpr) PX-92950 CDM 92950 CPT outpatient 1020 1020 UNITED HEALTHCARE (COMMERCIAL) [3081199] UNITED HEALTHCARE 87726 [308119901] 632.4 percent of total billed charges 632.4 969 Professional (doctor) services Eval Oral&Pharyngeal Swlng Funcj PX-4449261000 CDM 92610 CPT 444 RC inpatient 477 477 MULTIPLAN INC 34080 [3081285] MULTIPLAN INC [308128501] 453.15 percent of total billed charges 295.74 453.15 Technical (Hospital) Services Eval Oral&Pharyngeal Swlng Funcj PX-4449261000 CDM 92610 CPT 444 RC inpatient 477 477 MEDICA (COMMERCIAL) 94265 [3081118] MEDICA CLAIMS [308111801] 429.3 percent of total billed charges 295.74 453.15 Technical (Hospital) Services Eval Oral&Pharyngeal Swlng Funcj PX-4449261000 CDM 92610 CPT 444 RC inpatient 477 477 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES HDHP [308136802] 377.69 percent of total billed charges 295.74 453.15 Technical (Hospital) Services Eval Oral&Pharyngeal Swlng Funcj PX-4449261000 CDM 92610 CPT 444 RC inpatient 477 477 HEALTHPARTNERS SX009 HEALTHPARTNERS 377.69 percent of total billed charges 295.74 453.15 Technical (Hospital) Services Eval Oral&Pharyngeal Swlng Funcj PX-4449261000 CDM 92610 CPT 444 RC inpatient 477 477 BLUE CROSS BLUE SHIELD WELLMARK SB889 [3081026] BCBS WYOMING [308102603] 453.15 percent of total billed charges 295.74 453.15 Technical (Hospital) Services Eval Oral&Pharyngeal Swlng Funcj PX-4449261000 CDM 92610 CPT 444 RC inpatient 477 477 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES PPO [308136801] 377.69 percent of total billed charges 295.74 453.15 Technical (Hospital) Services Eval Oral&Pharyngeal Swlng Funcj PX-4449261000 CDM 92610 CPT 444 RC inpatient 477 477 UNITED HEALTHCARE (COMMERCIAL) [3081199] UNITED HEALTHCARE 87726 [308119901] 295.74 percent of total billed charges 295.74 453.15 Technical (Hospital) Services Eval Oral&Pharyngeal Swlng Funcj PX-4449261000 CDM 92610 CPT 444 RC inpatient 477 477 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES EPO [308136803] 377.69 percent of total billed charges 295.74 453.15 Technical (Hospital) Services Eval Oral&Pharyngeal Swlng Funcj PX-4449261000 CDM 92610 CPT 444 RC inpatient 477 477 CIGNA 62308 [3081051] CIGNA 62308 [308105105] 377.69 percent of total billed charges 295.74 453.15 Technical (Hospital) Services Eval Oral&Pharyngeal Swlng Funcj PX-4449261000 CDM 92610 CPT 444 RC inpatient 477 477 CIGNA 62308 [3081051] CIGNA STATE OF WYOMING [308105107] 377.69 percent of total billed charges 295.74 453.15 Technical (Hospital) Services Eval Oral&Pharyngeal Swlng Funcj PX-4449261000 CDM 92610 CPT 444 RC outpatient 477 477 MULTIPLAN INC 34080 [3081285] MULTIPLAN INC [308128501] 453.15 percent of total billed charges 295.74 453.15 Technical (Hospital) Services Eval Oral&Pharyngeal Swlng Funcj PX-4449261000 CDM 92610 CPT 444 RC outpatient 477 477 CIGNA 62308 [3081051] CIGNA 62308 [308105105] 381.6 percent of total billed charges 295.74 453.15 Technical (Hospital) Services Eval Oral&Pharyngeal Swlng Funcj PX-4449261000 CDM 92610 CPT 444 RC outpatient 477 477 CIGNA 62308 [3081051] CIGNA STATE OF WYOMING [308105107] 381.6 percent of total billed charges 295.74 453.15 Technical (Hospital) Services Eval Oral&Pharyngeal Swlng Funcj PX-4449261000 CDM 92610 CPT 444 RC outpatient 477 477 MEDICA (COMMERCIAL) 94265 [3081118] MEDICA CLAIMS [308111801] 429.3 percent of total billed charges 295.74 453.15 Technical (Hospital) Services Eval Oral&Pharyngeal Swlng Funcj PX-4449261000 CDM 92610 CPT 444 RC outpatient 477 477 HEALTHPARTNERS SX009 HEALTHPARTNERS 381.6 percent of total billed charges 295.74 453.15 Technical (Hospital) Services Eval Oral&Pharyngeal Swlng Funcj PX-4449261000 CDM 92610 CPT 444 RC outpatient 477 477 UNITED HEALTHCARE (COMMERCIAL) [3081199] UNITED HEALTHCARE 87726 [308119901] 295.74 percent of total billed charges 295.74 453.15 Technical (Hospital) Services Eval Oral&Pharyngeal Swlng Funcj PX-4449261000 CDM 92610 CPT 444 RC outpatient 477 477 BLUE CROSS BLUE SHIELD WELLMARK SB889 [3081026] BCBS WYOMING [308102603] 453.15 percent of total billed charges 295.74 453.15 Technical (Hospital) Services Eval Oral&Pharyngeal Swlng Funcj PX-4449261000 CDM 92610 CPT 444 RC outpatient 477 477 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES HDHP [308136802] 381.6 percent of total billed charges 295.74 453.15 Technical (Hospital) Services Eval Oral&Pharyngeal Swlng Funcj PX-4449261000 CDM 92610 CPT 444 RC outpatient 477 477 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES EPO [308136803] 381.6 percent of total billed charges 295.74 453.15 Technical (Hospital) Services Eval Oral&Pharyngeal Swlng Funcj PX-4449261000 CDM 92610 CPT 444 RC outpatient 477 477 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES PPO [308136801] 381.6 percent of total billed charges 295.74 453.15 Technical (Hospital) Services Ther Sp-Genratj Dev Prgrmg&Modificaj PX-4409260900 CDM 92609 CPT 440 RC outpatient 314 314 MULTIPLAN INC 34080 [3081285] MULTIPLAN INC [308128501] 298.3 percent of total billed charges 194.68 298.3 Technical (Hospital) Services Ther Sp-Genratj Dev Prgrmg&Modificaj PX-4409260900 CDM 92609 CPT 440 RC outpatient 314 314 CIGNA 62308 [3081051] CIGNA 62308 [308105105] 251.2 percent of total billed charges 194.68 298.3 Technical (Hospital) Services Ther Sp-Genratj Dev Prgrmg&Modificaj PX-4409260900 CDM 92609 CPT 440 RC outpatient 314 314 CIGNA 62308 [3081051] CIGNA STATE OF WYOMING [308105107] 251.2 percent of total billed charges 194.68 298.3 Technical (Hospital) Services Ther Sp-Genratj Dev Prgrmg&Modificaj PX-4409260900 CDM 92609 CPT 440 RC outpatient 314 314 MEDICA (COMMERCIAL) 94265 [3081118] MEDICA CLAIMS [308111801] 282.6 percent of total billed charges 194.68 298.3 Technical (Hospital) Services Ther Sp-Genratj Dev Prgrmg&Modificaj PX-4409260900 CDM 92609 CPT 440 RC outpatient 314 314 HEALTHPARTNERS SX009 HEALTHPARTNERS 251.2 percent of total billed charges 194.68 298.3 Technical (Hospital) Services Ther Sp-Genratj Dev Prgrmg&Modificaj PX-4409260900 CDM 92609 CPT 440 RC outpatient 314 314 UNITED HEALTHCARE (COMMERCIAL) [3081199] UNITED HEALTHCARE 87726 [308119901] 194.68 percent of total billed charges 194.68 298.3 Technical (Hospital) Services Ther Sp-Genratj Dev Prgrmg&Modificaj PX-4409260900 CDM 92609 CPT 440 RC outpatient 314 314 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES PPO [308136801] 251.2 percent of total billed charges 194.68 298.3 Technical (Hospital) Services Ther Sp-Genratj Dev Prgrmg&Modificaj PX-4409260900 CDM 92609 CPT 440 RC outpatient 314 314 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES EPO [308136803] 251.2 percent of total billed charges 194.68 298.3 Technical (Hospital) Services Ther Sp-Genratj Dev Prgrmg&Modificaj PX-4409260900 CDM 92609 CPT 440 RC outpatient 314 314 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES HDHP [308136802] 251.2 percent of total billed charges 194.68 298.3 Technical (Hospital) Services Ther Sp-Genratj Dev Prgrmg&Modificaj PX-4409260900 CDM 92609 CPT 440 RC outpatient 314 314 BLUE CROSS BLUE SHIELD WELLMARK SB889 [3081026] BCBS WYOMING [308102603] 298.3 percent of total billed charges 194.68 298.3 Technical (Hospital) Services Ther Sp-Genratj Dev Prgrmg&Modificaj PX-4409260900 CDM 92609 CPT 440 RC inpatient 314 314 MULTIPLAN INC 34080 [3081285] MULTIPLAN INC [308128501] 298.3 percent of total billed charges 194.68 298.3 Technical (Hospital) Services Ther Sp-Genratj Dev Prgrmg&Modificaj PX-4409260900 CDM 92609 CPT 440 RC inpatient 314 314 MEDICA (COMMERCIAL) 94265 [3081118] MEDICA CLAIMS [308111801] 282.6 percent of total billed charges 194.68 298.3 Technical (Hospital) Services Ther Sp-Genratj Dev Prgrmg&Modificaj PX-4409260900 CDM 92609 CPT 440 RC inpatient 314 314 HEALTHPARTNERS SX009 HEALTHPARTNERS 248.63 percent of total billed charges 194.68 298.3 Technical (Hospital) Services Ther Sp-Genratj Dev Prgrmg&Modificaj PX-4409260900 CDM 92609 CPT 440 RC inpatient 314 314 BLUE CROSS BLUE SHIELD WELLMARK SB889 [3081026] BCBS WYOMING [308102603] 298.3 percent of total billed charges 194.68 298.3 Technical (Hospital) Services Ther Sp-Genratj Dev Prgrmg&Modificaj PX-4409260900 CDM 92609 CPT 440 RC inpatient 314 314 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES HDHP [308136802] 248.63 percent of total billed charges 194.68 298.3 Technical (Hospital) Services Ther Sp-Genratj Dev Prgrmg&Modificaj PX-4409260900 CDM 92609 CPT 440 RC inpatient 314 314 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES PPO [308136801] 248.63 percent of total billed charges 194.68 298.3 Technical (Hospital) Services Ther Sp-Genratj Dev Prgrmg&Modificaj PX-4409260900 CDM 92609 CPT 440 RC inpatient 314 314 UNITED HEALTHCARE (COMMERCIAL) [3081199] UNITED HEALTHCARE 87726 [308119901] 194.68 percent of total billed charges 194.68 298.3 Technical (Hospital) Services Ther Sp-Genratj Dev Prgrmg&Modificaj PX-4409260900 CDM 92609 CPT 440 RC inpatient 314 314 CIGNA 62308 [3081051] CIGNA 62308 [308105105] 248.63 percent of total billed charges 194.68 298.3 Technical (Hospital) Services Ther Sp-Genratj Dev Prgrmg&Modificaj PX-4409260900 CDM 92609 CPT 440 RC inpatient 314 314 CIGNA 62308 [3081051] CIGNA STATE OF WYOMING [308105107] 248.63 percent of total billed charges 194.68 298.3 Technical (Hospital) Services Ther Sp-Genratj Dev Prgrmg&Modificaj PX-4409260900 CDM 92609 CPT 440 RC inpatient 314 314 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES EPO [308136803] 248.63 percent of total billed charges 194.68 298.3 Technical (Hospital) Services Rx Sp-Genratj Augmnt&Comunicaj Dev 1st Hr PX-4449260700 CDM 92607 CPT 444 RC outpatient 610 610 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES EPO [308136803] 488 percent of total billed charges 378.2 579.5 Technical (Hospital) Services Rx Sp-Genratj Augmnt&Comunicaj Dev 1st Hr PX-4449260700 CDM 92607 CPT 444 RC outpatient 610 610 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES PPO [308136801] 488 percent of total billed charges 378.2 579.5 Technical (Hospital) Services Rx Sp-Genratj Augmnt&Comunicaj Dev 1st Hr PX-4449260700 CDM 92607 CPT 444 RC outpatient 610 610 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES HDHP [308136802] 488 percent of total billed charges 378.2 579.5 Technical (Hospital) Services Rx Sp-Genratj Augmnt&Comunicaj Dev 1st Hr PX-4449260700 CDM 92607 CPT 444 RC outpatient 610 610 BLUE CROSS BLUE SHIELD WELLMARK SB889 [3081026] BCBS WYOMING [308102603] 579.5 percent of total billed charges 378.2 579.5 Technical (Hospital) Services Rx Sp-Genratj Augmnt&Comunicaj Dev 1st Hr PX-4449260700 CDM 92607 CPT 444 RC outpatient 610 610 UNITED HEALTHCARE (COMMERCIAL) [3081199] UNITED HEALTHCARE 87726 [308119901] 378.2 percent of total billed charges 378.2 579.5 Technical (Hospital) Services Rx Sp-Genratj Augmnt&Comunicaj Dev 1st Hr PX-4449260700 CDM 92607 CPT 444 RC outpatient 610 610 HEALTHPARTNERS SX009 HEALTHPARTNERS 488 percent of total billed charges 378.2 579.5 Technical (Hospital) Services Rx Sp-Genratj Augmnt&Comunicaj Dev 1st Hr PX-4449260700 CDM 92607 CPT 444 RC outpatient 610 610 MEDICA (COMMERCIAL) 94265 [3081118] MEDICA CLAIMS [308111801] 549 percent of total billed charges 378.2 579.5 Technical (Hospital) Services Rx Sp-Genratj Augmnt&Comunicaj Dev 1st Hr PX-4449260700 CDM 92607 CPT 444 RC outpatient 610 610 CIGNA 62308 [3081051] CIGNA 62308 [308105105] 488 percent of total billed charges 378.2 579.5 Technical (Hospital) Services Rx Sp-Genratj Augmnt&Comunicaj Dev 1st Hr PX-4449260700 CDM 92607 CPT 444 RC outpatient 610 610 CIGNA 62308 [3081051] CIGNA STATE OF WYOMING [308105107] 488 percent of total billed charges 378.2 579.5 Technical (Hospital) Services Rx Sp-Genratj Augmnt&Comunicaj Dev 1st Hr PX-4449260700 CDM 92607 CPT 444 RC outpatient 610 610 MULTIPLAN INC 34080 [3081285] MULTIPLAN INC [308128501] 579.5 percent of total billed charges 378.2 579.5 Technical (Hospital) Services Rx Sp-Genratj Augmnt&Comunicaj Dev 1st Hr PX-4449260700 CDM 92607 CPT 444 RC inpatient 610 610 CIGNA 62308 [3081051] CIGNA 62308 [308105105] 483 percent of total billed charges 378.2 579.5 Technical (Hospital) Services Rx Sp-Genratj Augmnt&Comunicaj Dev 1st Hr PX-4449260700 CDM 92607 CPT 444 RC inpatient 610 610 CIGNA 62308 [3081051] CIGNA STATE OF WYOMING [308105107] 483 percent of total billed charges 378.2 579.5 Technical (Hospital) Services Rx Sp-Genratj Augmnt&Comunicaj Dev 1st Hr PX-4449260700 CDM 92607 CPT 444 RC inpatient 610 610 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES EPO [308136803] 483 percent of total billed charges 378.2 579.5 Technical (Hospital) Services Rx Sp-Genratj Augmnt&Comunicaj Dev 1st Hr PX-4449260700 CDM 92607 CPT 444 RC inpatient 610 610 HEALTHPARTNERS SX009 HEALTHPARTNERS 483 percent of total billed charges 378.2 579.5 Technical (Hospital) Services Rx Sp-Genratj Augmnt&Comunicaj Dev 1st Hr PX-4449260700 CDM 92607 CPT 444 RC inpatient 610 610 MULTIPLAN INC 34080 [3081285] MULTIPLAN INC [308128501] 579.5 percent of total billed charges 378.2 579.5 Technical (Hospital) Services Rx Sp-Genratj Augmnt&Comunicaj Dev 1st Hr PX-4449260700 CDM 92607 CPT 444 RC inpatient 610 610 MEDICA (COMMERCIAL) 94265 [3081118] MEDICA CLAIMS [308111801] 549 percent of total billed charges 378.2 579.5 Technical (Hospital) Services Rx Sp-Genratj Augmnt&Comunicaj Dev 1st Hr PX-4449260700 CDM 92607 CPT 444 RC inpatient 610 610 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES PPO [308136801] 483 percent of total billed charges 378.2 579.5 Technical (Hospital) Services Rx Sp-Genratj Augmnt&Comunicaj Dev 1st Hr PX-4449260700 CDM 92607 CPT 444 RC inpatient 610 610 UNITED HEALTHCARE (COMMERCIAL) [3081199] UNITED HEALTHCARE 87726 [308119901] 378.2 percent of total billed charges 378.2 579.5 Technical (Hospital) Services Rx Sp-Genratj Augmnt&Comunicaj Dev 1st Hr PX-4449260700 CDM 92607 CPT 444 RC inpatient 610 610 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES HDHP [308136802] 483 percent of total billed charges 378.2 579.5 Technical (Hospital) Services Rx Sp-Genratj Augmnt&Comunicaj Dev 1st Hr PX-4449260700 CDM 92607 CPT 444 RC inpatient 610 610 BLUE CROSS BLUE SHIELD WELLMARK SB889 [3081026] BCBS WYOMING [308102603] 579.5 percent of total billed charges 378.2 579.5 Technical (Hospital) Services Tx Swallowing Dysfunction&/Oral Funcj Feeding PX-4409252600 CDM 92526 CPT 440 RC inpatient 322 322 HEALTHPARTNERS SX009 HEALTHPARTNERS 254.96 percent of total billed charges 199.64 305.9 Technical (Hospital) Services Tx Swallowing Dysfunction&/Oral Funcj Feeding PX-4409252600 CDM 92526 CPT 440 RC inpatient 322 322 MULTIPLAN INC 34080 [3081285] MULTIPLAN INC [308128501] 305.9 percent of total billed charges 199.64 305.9 Technical (Hospital) Services Tx Swallowing Dysfunction&/Oral Funcj Feeding PX-4409252600 CDM 92526 CPT 440 RC inpatient 322 322 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES HDHP [308136802] 254.96 percent of total billed charges 199.64 305.9 Technical (Hospital) Services Tx Swallowing Dysfunction&/Oral Funcj Feeding PX-4409252600 CDM 92526 CPT 440 RC inpatient 322 322 MEDICA (COMMERCIAL) 94265 [3081118] MEDICA CLAIMS [308111801] 289.8 percent of total billed charges 199.64 305.9 Technical (Hospital) Services Tx Swallowing Dysfunction&/Oral Funcj Feeding PX-4409252600 CDM 92526 CPT 440 RC inpatient 322 322 BLUE CROSS BLUE SHIELD WELLMARK SB889 [3081026] BCBS WYOMING [308102603] 305.9 percent of total billed charges 199.64 305.9 Technical (Hospital) Services Tx Swallowing Dysfunction&/Oral Funcj Feeding PX-4409252600 CDM 92526 CPT 440 RC inpatient 322 322 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES PPO [308136801] 254.96 percent of total billed charges 199.64 305.9 Technical (Hospital) Services Tx Swallowing Dysfunction&/Oral Funcj Feeding PX-4409252600 CDM 92526 CPT 440 RC inpatient 322 322 UNITED HEALTHCARE (COMMERCIAL) [3081199] UNITED HEALTHCARE 87726 [308119901] 199.64 percent of total billed charges 199.64 305.9 Technical (Hospital) Services Tx Swallowing Dysfunction&/Oral Funcj Feeding PX-4409252600 CDM 92526 CPT 440 RC inpatient 322 322 CIGNA 62308 [3081051] CIGNA 62308 [308105105] 254.96 percent of total billed charges 199.64 305.9 Technical (Hospital) Services Tx Swallowing Dysfunction&/Oral Funcj Feeding PX-4409252600 CDM 92526 CPT 440 RC inpatient 322 322 CIGNA 62308 [3081051] CIGNA STATE OF WYOMING [308105107] 254.96 percent of total billed charges 199.64 305.9 Technical (Hospital) Services Tx Swallowing Dysfunction&/Oral Funcj Feeding PX-4409252600 CDM 92526 CPT 440 RC inpatient 322 322 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES EPO [308136803] 254.96 percent of total billed charges 199.64 305.9 Technical (Hospital) Services Tx Swallowing Dysfunction&/Oral Funcj Feeding PX-4409252600 CDM 92526 CPT 440 RC outpatient 322 322 HEALTHPARTNERS SX009 HEALTHPARTNERS 257.6 percent of total billed charges 199.64 305.9 Technical (Hospital) Services Tx Swallowing Dysfunction&/Oral Funcj Feeding PX-4409252600 CDM 92526 CPT 440 RC outpatient 322 322 UNITED HEALTHCARE (COMMERCIAL) [3081199] UNITED HEALTHCARE 87726 [308119901] 199.64 percent of total billed charges 199.64 305.9 Technical (Hospital) Services Tx Swallowing Dysfunction&/Oral Funcj Feeding PX-4409252600 CDM 92526 CPT 440 RC outpatient 322 322 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES PPO [308136801] 257.6 percent of total billed charges 199.64 305.9 Technical (Hospital) Services Tx Swallowing Dysfunction&/Oral Funcj Feeding PX-4409252600 CDM 92526 CPT 440 RC outpatient 322 322 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES EPO [308136803] 257.6 percent of total billed charges 199.64 305.9 Technical (Hospital) Services Tx Swallowing Dysfunction&/Oral Funcj Feeding PX-4409252600 CDM 92526 CPT 440 RC outpatient 322 322 BLUE CROSS BLUE SHIELD WELLMARK SB889 [3081026] BCBS WYOMING [308102603] 305.9 percent of total billed charges 199.64 305.9 Technical (Hospital) Services Tx Swallowing Dysfunction&/Oral Funcj Feeding PX-4409252600 CDM 92526 CPT 440 RC outpatient 322 322 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES HDHP [308136802] 257.6 percent of total billed charges 199.64 305.9 Technical (Hospital) Services Tx Swallowing Dysfunction&/Oral Funcj Feeding PX-4409252600 CDM 92526 CPT 440 RC outpatient 322 322 MULTIPLAN INC 34080 [3081285] MULTIPLAN INC [308128501] 305.9 percent of total billed charges 199.64 305.9 Technical (Hospital) Services Tx Swallowing Dysfunction&/Oral Funcj Feeding PX-4409252600 CDM 92526 CPT 440 RC outpatient 322 322 CIGNA 62308 [3081051] CIGNA 62308 [308105105] 257.6 percent of total billed charges 199.64 305.9 Technical (Hospital) Services Tx Swallowing Dysfunction&/Oral Funcj Feeding PX-4409252600 CDM 92526 CPT 440 RC outpatient 322 322 CIGNA 62308 [3081051] CIGNA STATE OF WYOMING [308105107] 257.6 percent of total billed charges 199.64 305.9 Technical (Hospital) Services Tx Swallowing Dysfunction&/Oral Funcj Feeding PX-4409252600 CDM 92526 CPT 440 RC outpatient 322 322 MEDICA (COMMERCIAL) 94265 [3081118] MEDICA CLAIMS [308111801] 289.8 percent of total billed charges 199.64 305.9 Technical (Hospital) Services Behavioral & Qualit Analysis Voice and Resonance PX-4449252400 CDM 92524 CPT 444 RC outpatient 443 443 MEDICA (COMMERCIAL) 94265 [3081118] MEDICA CLAIMS [308111801] 398.7 percent of total billed charges 274.66 420.85 Technical (Hospital) Services Behavioral & Qualit Analysis Voice and Resonance PX-4449252400 CDM 92524 CPT 444 RC outpatient 443 443 HEALTHPARTNERS SX009 HEALTHPARTNERS 354.4 percent of total billed charges 274.66 420.85 Technical (Hospital) Services Behavioral & Qualit Analysis Voice and Resonance PX-4449252400 CDM 92524 CPT 444 RC outpatient 443 443 UNITED HEALTHCARE (COMMERCIAL) [3081199] UNITED HEALTHCARE 87726 [308119901] 274.66 percent of total billed charges 274.66 420.85 Technical (Hospital) Services Behavioral & Qualit Analysis Voice and Resonance PX-4449252400 CDM 92524 CPT 444 RC outpatient 443 443 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES PPO [308136801] 354.4 percent of total billed charges 274.66 420.85 Technical (Hospital) Services Behavioral & Qualit Analysis Voice and Resonance PX-4449252400 CDM 92524 CPT 444 RC outpatient 443 443 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES EPO [308136803] 354.4 percent of total billed charges 274.66 420.85 Technical (Hospital) Services Behavioral & Qualit Analysis Voice and Resonance PX-4449252400 CDM 92524 CPT 444 RC outpatient 443 443 BLUE CROSS BLUE SHIELD WELLMARK SB889 [3081026] BCBS WYOMING [308102603] 420.85 percent of total billed charges 274.66 420.85 Technical (Hospital) Services Behavioral & Qualit Analysis Voice and Resonance PX-4449252400 CDM 92524 CPT 444 RC outpatient 443 443 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES HDHP [308136802] 354.4 percent of total billed charges 274.66 420.85 Technical (Hospital) Services Behavioral & Qualit Analysis Voice and Resonance PX-4449252400 CDM 92524 CPT 444 RC outpatient 443 443 MULTIPLAN INC 34080 [3081285] MULTIPLAN INC [308128501] 420.85 percent of total billed charges 274.66 420.85 Technical (Hospital) Services Behavioral & Qualit Analysis Voice and Resonance PX-4449252400 CDM 92524 CPT 444 RC outpatient 443 443 CIGNA 62308 [3081051] CIGNA 62308 [308105105] 354.4 percent of total billed charges 274.66 420.85 Technical (Hospital) Services Behavioral & Qualit Analysis Voice and Resonance PX-4449252400 CDM 92524 CPT 444 RC outpatient 443 443 CIGNA 62308 [3081051] CIGNA STATE OF WYOMING [308105107] 354.4 percent of total billed charges 274.66 420.85 Technical (Hospital) Services Behavioral & Qualit Analysis Voice and Resonance PX-4449252400 CDM 92524 CPT 444 RC inpatient 443 443 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES EPO [308136803] 350.77 percent of total billed charges 274.66 420.85 Technical (Hospital) Services Behavioral & Qualit Analysis Voice and Resonance PX-4449252400 CDM 92524 CPT 444 RC inpatient 443 443 CIGNA 62308 [3081051] CIGNA 62308 [308105105] 350.77 percent of total billed charges 274.66 420.85 Technical (Hospital) Services Behavioral & Qualit Analysis Voice and Resonance PX-4449252400 CDM 92524 CPT 444 RC inpatient 443 443 CIGNA 62308 [3081051] CIGNA STATE OF WYOMING [308105107] 350.77 percent of total billed charges 274.66 420.85 Technical (Hospital) Services Behavioral & Qualit Analysis Voice and Resonance PX-4449252400 CDM 92524 CPT 444 RC inpatient 443 443 MEDICA (COMMERCIAL) 94265 [3081118] MEDICA CLAIMS [308111801] 398.7 percent of total billed charges 274.66 420.85 Technical (Hospital) Services Behavioral & Qualit Analysis Voice and Resonance PX-4449252400 CDM 92524 CPT 444 RC inpatient 443 443 MULTIPLAN INC 34080 [3081285] MULTIPLAN INC [308128501] 420.85 percent of total billed charges 274.66 420.85 Technical (Hospital) Services Behavioral & Qualit Analysis Voice and Resonance PX-4449252400 CDM 92524 CPT 444 RC inpatient 443 443 HEALTHPARTNERS SX009 HEALTHPARTNERS 350.77 percent of total billed charges 274.66 420.85 Technical (Hospital) Services Behavioral & Qualit Analysis Voice and Resonance PX-4449252400 CDM 92524 CPT 444 RC inpatient 443 443 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES PPO [308136801] 350.77 percent of total billed charges 274.66 420.85 Technical (Hospital) Services Behavioral & Qualit Analysis Voice and Resonance PX-4449252400 CDM 92524 CPT 444 RC inpatient 443 443 UNITED HEALTHCARE (COMMERCIAL) [3081199] UNITED HEALTHCARE 87726 [308119901] 274.66 percent of total billed charges 274.66 420.85 Technical (Hospital) Services Behavioral & Qualit Analysis Voice and Resonance PX-4449252400 CDM 92524 CPT 444 RC inpatient 443 443 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES HDHP [308136802] 350.77 percent of total billed charges 274.66 420.85 Technical (Hospital) Services Behavioral & Qualit Analysis Voice and Resonance PX-4449252400 CDM 92524 CPT 444 RC inpatient 443 443 BLUE CROSS BLUE SHIELD WELLMARK SB889 [3081026] BCBS WYOMING [308102603] 420.85 percent of total billed charges 274.66 420.85 Technical (Hospital) Services Eval Speech Sound Product Language Comprehension PX-4449252300 CDM 92523 CPT 444 RC inpatient 477 477 CIGNA 62308 [3081051] CIGNA 62308 [308105105] 377.69 percent of total billed charges 295.74 453.15 Technical (Hospital) Services Eval Speech Sound Product Language Comprehension PX-4449252300 CDM 92523 CPT 444 RC inpatient 477 477 CIGNA 62308 [3081051] CIGNA STATE OF WYOMING [308105107] 377.69 percent of total billed charges 295.74 453.15 Technical (Hospital) Services Eval Speech Sound Product Language Comprehension PX-4449252300 CDM 92523 CPT 444 RC inpatient 477 477 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES EPO [308136803] 377.69 percent of total billed charges 295.74 453.15 Technical (Hospital) Services Eval Speech Sound Product Language Comprehension PX-4449252300 CDM 92523 CPT 444 RC inpatient 477 477 BLUE CROSS BLUE SHIELD WELLMARK SB889 [3081026] BCBS WYOMING [308102603] 453.15 percent of total billed charges 295.74 453.15 Technical (Hospital) Services Eval Speech Sound Product Language Comprehension PX-4449252300 CDM 92523 CPT 444 RC inpatient 477 477 UNITED HEALTHCARE (COMMERCIAL) [3081199] UNITED HEALTHCARE 87726 [308119901] 295.74 percent of total billed charges 295.74 453.15 Technical (Hospital) Services Eval Speech Sound Product Language Comprehension PX-4449252300 CDM 92523 CPT 444 RC inpatient 477 477 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES PPO [308136801] 377.69 percent of total billed charges 295.74 453.15 Technical (Hospital) Services Eval Speech Sound Product Language Comprehension PX-4449252300 CDM 92523 CPT 444 RC inpatient 477 477 HEALTHPARTNERS SX009 HEALTHPARTNERS 377.69 percent of total billed charges 295.74 453.15 Technical (Hospital) Services Eval Speech Sound Product Language Comprehension PX-4449252300 CDM 92523 CPT 444 RC inpatient 477 477 MULTIPLAN INC 34080 [3081285] MULTIPLAN INC [308128501] 453.15 percent of total billed charges 295.74 453.15 Technical (Hospital) Services Eval Speech Sound Product Language Comprehension PX-4449252300 CDM 92523 CPT 444 RC inpatient 477 477 MEDICA (COMMERCIAL) 94265 [3081118] MEDICA CLAIMS [308111801] 429.3 percent of total billed charges 295.74 453.15 Technical (Hospital) Services Eval Speech Sound Product Language Comprehension PX-4449252300 CDM 92523 CPT 444 RC inpatient 477 477 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES HDHP [308136802] 377.69 percent of total billed charges 295.74 453.15 Technical (Hospital) Services Eval Speech Sound Product Language Comprehension PX-4449252300 CDM 92523 CPT 444 RC outpatient 477 477 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES EPO [308136803] 381.6 percent of total billed charges 295.74 453.15 Technical (Hospital) Services Eval Speech Sound Product Language Comprehension PX-4449252300 CDM 92523 CPT 444 RC outpatient 477 477 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES PPO [308136801] 381.6 percent of total billed charges 295.74 453.15 Technical (Hospital) Services Eval Speech Sound Product Language Comprehension PX-4449252300 CDM 92523 CPT 444 RC outpatient 477 477 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES HDHP [308136802] 381.6 percent of total billed charges 295.74 453.15 Technical (Hospital) Services Eval Speech Sound Product Language Comprehension PX-4449252300 CDM 92523 CPT 444 RC outpatient 477 477 BLUE CROSS BLUE SHIELD WELLMARK SB889 [3081026] BCBS WYOMING [308102603] 453.15 percent of total billed charges 295.74 453.15 Technical (Hospital) Services Eval Speech Sound Product Language Comprehension PX-4449252300 CDM 92523 CPT 444 RC outpatient 477 477 UNITED HEALTHCARE (COMMERCIAL) [3081199] UNITED HEALTHCARE 87726 [308119901] 295.74 percent of total billed charges 295.74 453.15 Technical (Hospital) Services Eval Speech Sound Product Language Comprehension PX-4449252300 CDM 92523 CPT 444 RC outpatient 477 477 HEALTHPARTNERS SX009 HEALTHPARTNERS 381.6 percent of total billed charges 295.74 453.15 Technical (Hospital) Services Eval Speech Sound Product Language Comprehension PX-4449252300 CDM 92523 CPT 444 RC outpatient 477 477 MEDICA (COMMERCIAL) 94265 [3081118] MEDICA CLAIMS [308111801] 429.3 percent of total billed charges 295.74 453.15 Technical (Hospital) Services Eval Speech Sound Product Language Comprehension PX-4449252300 CDM 92523 CPT 444 RC outpatient 477 477 MULTIPLAN INC 34080 [3081285] MULTIPLAN INC [308128501] 453.15 percent of total billed charges 295.74 453.15 Technical (Hospital) Services Eval Speech Sound Product Language Comprehension PX-4449252300 CDM 92523 CPT 444 RC outpatient 477 477 CIGNA 62308 [3081051] CIGNA 62308 [308105105] 381.6 percent of total billed charges 295.74 453.15 Technical (Hospital) Services Eval Speech Sound Product Language Comprehension PX-4449252300 CDM 92523 CPT 444 RC outpatient 477 477 CIGNA 62308 [3081051] CIGNA STATE OF WYOMING [308105107] 381.6 percent of total billed charges 295.74 453.15 Technical (Hospital) Services Evaluation of Speech Sound Production Articulate PX-4449252200 CDM 92522 CPT 444 RC inpatient 424 424 CIGNA 62308 [3081051] CIGNA 62308 [308105105] 335.72 percent of total billed charges 262.88 402.8 Technical (Hospital) Services Evaluation of Speech Sound Production Articulate PX-4449252200 CDM 92522 CPT 444 RC inpatient 424 424 CIGNA 62308 [3081051] CIGNA STATE OF WYOMING [308105107] 335.72 percent of total billed charges 262.88 402.8 Technical (Hospital) Services Evaluation of Speech Sound Production Articulate PX-4449252200 CDM 92522 CPT 444 RC inpatient 424 424 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES EPO [308136803] 335.72 percent of total billed charges 262.88 402.8 Technical (Hospital) Services Evaluation of Speech Sound Production Articulate PX-4449252200 CDM 92522 CPT 444 RC inpatient 424 424 UNITED HEALTHCARE (COMMERCIAL) [3081199] UNITED HEALTHCARE 87726 [308119901] 262.88 percent of total billed charges 262.88 402.8 Technical (Hospital) Services Evaluation of Speech Sound Production Articulate PX-4449252200 CDM 92522 CPT 444 RC inpatient 424 424 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES PPO [308136801] 335.72 percent of total billed charges 262.88 402.8 Technical (Hospital) Services Evaluation of Speech Sound Production Articulate PX-4449252200 CDM 92522 CPT 444 RC inpatient 424 424 BLUE CROSS BLUE SHIELD WELLMARK SB889 [3081026] BCBS WYOMING [308102603] 402.8 percent of total billed charges 262.88 402.8 Technical (Hospital) Services Evaluation of Speech Sound Production Articulate PX-4449252200 CDM 92522 CPT 444 RC inpatient 424 424 HEALTHPARTNERS SX009 HEALTHPARTNERS 335.72 percent of total billed charges 262.88 402.8 Technical (Hospital) Services Evaluation of Speech Sound Production Articulate PX-4449252200 CDM 92522 CPT 444 RC inpatient 424 424 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES HDHP [308136802] 335.72 percent of total billed charges 262.88 402.8 Technical (Hospital) Services Evaluation of Speech Sound Production Articulate PX-4449252200 CDM 92522 CPT 444 RC inpatient 424 424 MEDICA (COMMERCIAL) 94265 [3081118] MEDICA CLAIMS [308111801] 381.6 percent of total billed charges 262.88 402.8 Technical (Hospital) Services Evaluation of Speech Sound Production Articulate PX-4449252200 CDM 92522 CPT 444 RC inpatient 424 424 MULTIPLAN INC 34080 [3081285] MULTIPLAN INC [308128501] 402.8 percent of total billed charges 262.88 402.8 Technical (Hospital) Services Evaluation of Speech Sound Production Articulate PX-4449252200 CDM 92522 CPT 444 RC outpatient 424 424 CIGNA 62308 [3081051] CIGNA 62308 [308105105] 339.2 percent of total billed charges 262.88 402.8 Technical (Hospital) Services Evaluation of Speech Sound Production Articulate PX-4449252200 CDM 92522 CPT 444 RC outpatient 424 424 CIGNA 62308 [3081051] CIGNA STATE OF WYOMING [308105107] 339.2 percent of total billed charges 262.88 402.8 Technical (Hospital) Services Evaluation of Speech Sound Production Articulate PX-4449252200 CDM 92522 CPT 444 RC outpatient 424 424 MULTIPLAN INC 34080 [3081285] MULTIPLAN INC [308128501] 402.8 percent of total billed charges 262.88 402.8 Technical (Hospital) Services Evaluation of Speech Sound Production Articulate PX-4449252200 CDM 92522 CPT 444 RC outpatient 424 424 MEDICA (COMMERCIAL) 94265 [3081118] MEDICA CLAIMS [308111801] 381.6 percent of total billed charges 262.88 402.8 Technical (Hospital) Services Evaluation of Speech Sound Production Articulate PX-4449252200 CDM 92522 CPT 444 RC outpatient 424 424 HEALTHPARTNERS SX009 HEALTHPARTNERS 339.2 percent of total billed charges 262.88 402.8 Technical (Hospital) Services Evaluation of Speech Sound Production Articulate PX-4449252200 CDM 92522 CPT 444 RC outpatient 424 424 UNITED HEALTHCARE (COMMERCIAL) [3081199] UNITED HEALTHCARE 87726 [308119901] 262.88 percent of total billed charges 262.88 402.8 Technical (Hospital) Services Evaluation of Speech Sound Production Articulate PX-4449252200 CDM 92522 CPT 444 RC outpatient 424 424 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES HDHP [308136802] 339.2 percent of total billed charges 262.88 402.8 Technical (Hospital) Services Evaluation of Speech Sound Production Articulate PX-4449252200 CDM 92522 CPT 444 RC outpatient 424 424 BLUE CROSS BLUE SHIELD WELLMARK SB889 [3081026] BCBS WYOMING [308102603] 402.8 percent of total billed charges 262.88 402.8 Technical (Hospital) Services Evaluation of Speech Sound Production Articulate PX-4449252200 CDM 92522 CPT 444 RC outpatient 424 424 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES PPO [308136801] 339.2 percent of total billed charges 262.88 402.8 Technical (Hospital) Services Evaluation of Speech Sound Production Articulate PX-4449252200 CDM 92522 CPT 444 RC outpatient 424 424 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES EPO [308136803] 339.2 percent of total billed charges 262.88 402.8 Technical (Hospital) Services Evaluation of Speech Fluency (Stutter Clutter) PX-4449252100 CDM 92521 CPT 444 RC outpatient 524 524 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES EPO [308136803] 419.2 percent of total billed charges 324.88 497.8 Technical (Hospital) Services Evaluation of Speech Fluency (Stutter Clutter) PX-4449252100 CDM 92521 CPT 444 RC outpatient 524 524 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES PPO [308136801] 419.2 percent of total billed charges 324.88 497.8 Technical (Hospital) Services Evaluation of Speech Fluency (Stutter Clutter) PX-4449252100 CDM 92521 CPT 444 RC outpatient 524 524 BLUE CROSS BLUE SHIELD WELLMARK SB889 [3081026] BCBS WYOMING [308102603] 497.8 percent of total billed charges 324.88 497.8 Technical (Hospital) Services Evaluation of Speech Fluency (Stutter Clutter) PX-4449252100 CDM 92521 CPT 444 RC outpatient 524 524 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES HDHP [308136802] 419.2 percent of total billed charges 324.88 497.8 Technical (Hospital) Services Evaluation of Speech Fluency (Stutter Clutter) PX-4449252100 CDM 92521 CPT 444 RC outpatient 524 524 UNITED HEALTHCARE (COMMERCIAL) [3081199] UNITED HEALTHCARE 87726 [308119901] 324.88 percent of total billed charges 324.88 497.8 Technical (Hospital) Services Evaluation of Speech Fluency (Stutter Clutter) PX-4449252100 CDM 92521 CPT 444 RC outpatient 524 524 HEALTHPARTNERS SX009 HEALTHPARTNERS 419.2 percent of total billed charges 324.88 497.8 Technical (Hospital) Services Evaluation of Speech Fluency (Stutter Clutter) PX-4449252100 CDM 92521 CPT 444 RC outpatient 524 524 MEDICA (COMMERCIAL) 94265 [3081118] MEDICA CLAIMS [308111801] 471.6 percent of total billed charges 324.88 497.8 Technical (Hospital) Services Evaluation of Speech Fluency (Stutter Clutter) PX-4449252100 CDM 92521 CPT 444 RC outpatient 524 524 CIGNA 62308 [3081051] CIGNA 62308 [308105105] 419.2 percent of total billed charges 324.88 497.8 Technical (Hospital) Services Evaluation of Speech Fluency (Stutter Clutter) PX-4449252100 CDM 92521 CPT 444 RC outpatient 524 524 CIGNA 62308 [3081051] CIGNA STATE OF WYOMING [308105107] 419.2 percent of total billed charges 324.88 497.8 Technical (Hospital) Services Evaluation of Speech Fluency (Stutter Clutter) PX-4449252100 CDM 92521 CPT 444 RC outpatient 524 524 MULTIPLAN INC 34080 [3081285] MULTIPLAN INC [308128501] 497.8 percent of total billed charges 324.88 497.8 Technical (Hospital) Services Evaluation of Speech Fluency (Stutter Clutter) PX-4449252100 CDM 92521 CPT 444 RC inpatient 524 524 CIGNA 62308 [3081051] CIGNA 62308 [308105105] 414.9 percent of total billed charges 324.88 497.8 Technical (Hospital) Services Evaluation of Speech Fluency (Stutter Clutter) PX-4449252100 CDM 92521 CPT 444 RC inpatient 524 524 CIGNA 62308 [3081051] CIGNA STATE OF WYOMING [308105107] 414.9 percent of total billed charges 324.88 497.8 Technical (Hospital) Services Evaluation of Speech Fluency (Stutter Clutter) PX-4449252100 CDM 92521 CPT 444 RC inpatient 524 524 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES EPO [308136803] 414.9 percent of total billed charges 324.88 497.8 Technical (Hospital) Services Evaluation of Speech Fluency (Stutter Clutter) PX-4449252100 CDM 92521 CPT 444 RC inpatient 524 524 BLUE CROSS BLUE SHIELD WELLMARK SB889 [3081026] BCBS WYOMING [308102603] 497.8 percent of total billed charges 324.88 497.8 Technical (Hospital) Services Evaluation of Speech Fluency (Stutter Clutter) PX-4449252100 CDM 92521 CPT 444 RC inpatient 524 524 UNITED HEALTHCARE (COMMERCIAL) [3081199] UNITED HEALTHCARE 87726 [308119901] 324.88 percent of total billed charges 324.88 497.8 Technical (Hospital) Services Evaluation of Speech Fluency (Stutter Clutter) PX-4449252100 CDM 92521 CPT 444 RC inpatient 524 524 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES PPO [308136801] 414.9 percent of total billed charges 324.88 497.8 Technical (Hospital) Services Evaluation of Speech Fluency (Stutter Clutter) PX-4449252100 CDM 92521 CPT 444 RC inpatient 524 524 HEALTHPARTNERS SX009 HEALTHPARTNERS 414.9 percent of total billed charges 324.88 497.8 Technical (Hospital) Services Evaluation of Speech Fluency (Stutter Clutter) PX-4449252100 CDM 92521 CPT 444 RC inpatient 524 524 MULTIPLAN INC 34080 [3081285] MULTIPLAN INC [308128501] 497.8 percent of total billed charges 324.88 497.8 Technical (Hospital) Services Evaluation of Speech Fluency (Stutter Clutter) PX-4449252100 CDM 92521 CPT 444 RC inpatient 524 524 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES HDHP [308136802] 414.9 percent of total billed charges 324.88 497.8 Technical (Hospital) Services Evaluation of Speech Fluency (Stutter Clutter) PX-4449252100 CDM 92521 CPT 444 RC inpatient 524 524 MEDICA (COMMERCIAL) 94265 [3081118] MEDICA CLAIMS [308111801] 471.6 percent of total billed charges 324.88 497.8 Technical (Hospital) Services Tx Speech Lang Voice Commj &/Auditory Proc Ind PX-4409250700 CDM 92507 CPT 440 RC inpatient 231 231 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES EPO [308136803] 182.91 percent of total billed charges 143.22 219.45 Technical (Hospital) Services Tx Speech Lang Voice Commj &/Auditory Proc Ind PX-4409250700 CDM 92507 CPT 440 RC inpatient 231 231 CIGNA 62308 [3081051] CIGNA 62308 [308105105] 182.91 percent of total billed charges 143.22 219.45 Technical (Hospital) Services Tx Speech Lang Voice Commj &/Auditory Proc Ind PX-4409250700 CDM 92507 CPT 440 RC inpatient 231 231 CIGNA 62308 [3081051] CIGNA STATE OF WYOMING [308105107] 182.91 percent of total billed charges 143.22 219.45 Technical (Hospital) Services Tx Speech Lang Voice Commj &/Auditory Proc Ind PX-4409250700 CDM 92507 CPT 440 RC inpatient 231 231 UNITED HEALTHCARE (COMMERCIAL) [3081199] UNITED HEALTHCARE 87726 [308119901] 143.22 percent of total billed charges 143.22 219.45 Technical (Hospital) Services Tx Speech Lang Voice Commj &/Auditory Proc Ind PX-4409250700 CDM 92507 CPT 440 RC inpatient 231 231 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES PPO [308136801] 182.91 percent of total billed charges 143.22 219.45 Technical (Hospital) Services Tx Speech Lang Voice Commj &/Auditory Proc Ind PX-4409250700 CDM 92507 CPT 440 RC inpatient 231 231 BLUE CROSS BLUE SHIELD WELLMARK SB889 [3081026] BCBS WYOMING [308102603] 219.45 percent of total billed charges 143.22 219.45 Technical (Hospital) Services Tx Speech Lang Voice Commj &/Auditory Proc Ind PX-4409250700 CDM 92507 CPT 440 RC inpatient 231 231 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES HDHP [308136802] 182.91 percent of total billed charges 143.22 219.45 Technical (Hospital) Services Tx Speech Lang Voice Commj &/Auditory Proc Ind PX-4409250700 CDM 92507 CPT 440 RC inpatient 231 231 MEDICA (COMMERCIAL) 94265 [3081118] MEDICA CLAIMS [308111801] 207.9 percent of total billed charges 143.22 219.45 Technical (Hospital) Services Tx Speech Lang Voice Commj &/Auditory Proc Ind PX-4409250700 CDM 92507 CPT 440 RC inpatient 231 231 MULTIPLAN INC 34080 [3081285] MULTIPLAN INC [308128501] 219.45 percent of total billed charges 143.22 219.45 Technical (Hospital) Services Tx Speech Lang Voice Commj &/Auditory Proc Ind PX-4409250700 CDM 92507 CPT 440 RC inpatient 231 231 HEALTHPARTNERS SX009 HEALTHPARTNERS 182.91 percent of total billed charges 143.22 219.45 Technical (Hospital) Services Tx Speech Lang Voice Commj &/Auditory Proc Ind PX-4409250700 CDM 92507 CPT 440 RC outpatient 231 231 UNITED HEALTHCARE (COMMERCIAL) [3081199] UNITED HEALTHCARE 87726 [308119901] 143.22 percent of total billed charges 143.22 219.45 Technical (Hospital) Services Tx Speech Lang Voice Commj &/Auditory Proc Ind PX-4409250700 CDM 92507 CPT 440 RC outpatient 231 231 HEALTHPARTNERS SX009 HEALTHPARTNERS 184.8 percent of total billed charges 143.22 219.45 Technical (Hospital) Services Tx Speech Lang Voice Commj &/Auditory Proc Ind PX-4409250700 CDM 92507 CPT 440 RC outpatient 231 231 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES EPO [308136803] 184.8 percent of total billed charges 143.22 219.45 Technical (Hospital) Services Tx Speech Lang Voice Commj &/Auditory Proc Ind PX-4409250700 CDM 92507 CPT 440 RC outpatient 231 231 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES PPO [308136801] 184.8 percent of total billed charges 143.22 219.45 Technical (Hospital) Services Tx Speech Lang Voice Commj &/Auditory Proc Ind PX-4409250700 CDM 92507 CPT 440 RC outpatient 231 231 BLUE CROSS BLUE SHIELD WELLMARK SB889 [3081026] BCBS WYOMING [308102603] 219.45 percent of total billed charges 143.22 219.45 Technical (Hospital) Services Tx Speech Lang Voice Commj &/Auditory Proc Ind PX-4409250700 CDM 92507 CPT 440 RC outpatient 231 231 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES HDHP [308136802] 184.8 percent of total billed charges 143.22 219.45 Technical (Hospital) Services Tx Speech Lang Voice Commj &/Auditory Proc Ind PX-4409250700 CDM 92507 CPT 440 RC outpatient 231 231 CIGNA 62308 [3081051] CIGNA 62308 [308105105] 184.8 percent of total billed charges 143.22 219.45 Technical (Hospital) Services Tx Speech Lang Voice Commj &/Auditory Proc Ind PX-4409250700 CDM 92507 CPT 440 RC outpatient 231 231 CIGNA 62308 [3081051] CIGNA STATE OF WYOMING [308105107] 184.8 percent of total billed charges 143.22 219.45 Technical (Hospital) Services Tx Speech Lang Voice Commj &/Auditory Proc Ind PX-4409250700 CDM 92507 CPT 440 RC outpatient 231 231 MULTIPLAN INC 34080 [3081285] MULTIPLAN INC [308128501] 219.45 percent of total billed charges 143.22 219.45 Technical (Hospital) Services Tx Speech Lang Voice Commj &/Auditory Proc Ind PX-4409250700 CDM 92507 CPT 440 RC outpatient 231 231 MEDICA (COMMERCIAL) 94265 [3081118] MEDICA CLAIMS [308111801] 207.9 percent of total billed charges 143.22 219.45 Technical (Hospital) Services Im Adm Prq ID Subq/Im Njxs Ea Vaccine PX-7719047200 CDM 90472 CPT 771 RC outpatient 75 75 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES HDHP [308136802] 60 percent of total billed charges 46.5 71.25 Technical (Hospital) Services Im Adm Prq ID Subq/Im Njxs Ea Vaccine PX-7719047200 CDM 90472 CPT 771 RC outpatient 75 75 BLUE CROSS BLUE SHIELD WELLMARK SB889 [3081026] BCBS WYOMING [308102603] 71.25 percent of total billed charges 46.5 71.25 Technical (Hospital) Services Im Adm Prq ID Subq/Im Njxs Ea Vaccine PX-7719047200 CDM 90472 CPT 771 RC outpatient 75 75 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES PPO [308136801] 60 percent of total billed charges 46.5 71.25 Technical (Hospital) Services Im Adm Prq ID Subq/Im Njxs Ea Vaccine PX-7719047200 CDM 90472 CPT 771 RC outpatient 75 75 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES EPO [308136803] 60 percent of total billed charges 46.5 71.25 Technical (Hospital) Services Im Adm Prq ID Subq/Im Njxs Ea Vaccine PX-7719047200 CDM 90472 CPT 771 RC outpatient 75 75 UNITED HEALTHCARE (COMMERCIAL) [3081199] UNITED HEALTHCARE 87726 [308119901] 46.5 percent of total billed charges 46.5 71.25 Technical (Hospital) Services Im Adm Prq ID Subq/Im Njxs Ea Vaccine PX-7719047200 CDM 90472 CPT 771 RC outpatient 75 75 HEALTHPARTNERS SX009 HEALTHPARTNERS 60 percent of total billed charges 46.5 71.25 Technical (Hospital) Services Im Adm Prq ID Subq/Im Njxs Ea Vaccine PX-7719047200 CDM 90472 CPT 771 RC outpatient 75 75 MEDICA (COMMERCIAL) 94265 [3081118] MEDICA CLAIMS [308111801] 67.5 percent of total billed charges 46.5 71.25 Technical (Hospital) Services Im Adm Prq ID Subq/Im Njxs Ea Vaccine PX-7719047200 CDM 90472 CPT 771 RC outpatient 75 75 CIGNA 62308 [3081051] CIGNA 62308 [308105105] 60 percent of total billed charges 46.5 71.25 Technical (Hospital) Services Im Adm Prq ID Subq/Im Njxs Ea Vaccine PX-7719047200 CDM 90472 CPT 771 RC outpatient 75 75 CIGNA 62308 [3081051] CIGNA STATE OF WYOMING [308105107] 60 percent of total billed charges 46.5 71.25 Technical (Hospital) Services Im Adm Prq ID Subq/Im Njxs Ea Vaccine PX-7719047200 CDM 90472 CPT 771 RC outpatient 75 75 MULTIPLAN INC 34080 [3081285] MULTIPLAN INC [308128501] 71.25 percent of total billed charges 46.5 71.25 Technical (Hospital) Services Im Adm Prq ID Subq/Im Njxs Ea Vaccine PX-7719047200 CDM 90472 CPT 771 RC inpatient 75 75 CIGNA 62308 [3081051] CIGNA 62308 [308105105] 59.39 percent of total billed charges 46.5 71.25 Technical (Hospital) Services Im Adm Prq ID Subq/Im Njxs Ea Vaccine PX-7719047200 CDM 90472 CPT 771 RC inpatient 75 75 CIGNA 62308 [3081051] CIGNA STATE OF WYOMING [308105107] 59.39 percent of total billed charges 46.5 71.25 Technical (Hospital) Services Im Adm Prq ID Subq/Im Njxs Ea Vaccine PX-7719047200 CDM 90472 CPT 771 RC inpatient 75 75 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES PPO [308136801] 59.39 percent of total billed charges 46.5 71.25 Technical (Hospital) Services Im Adm Prq ID Subq/Im Njxs Ea Vaccine PX-7719047200 CDM 90472 CPT 771 RC inpatient 75 75 UNITED HEALTHCARE (COMMERCIAL) [3081199] UNITED HEALTHCARE 87726 [308119901] 46.5 percent of total billed charges 46.5 71.25 Technical (Hospital) Services Im Adm Prq ID Subq/Im Njxs Ea Vaccine PX-7719047200 CDM 90472 CPT 771 RC inpatient 75 75 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES HDHP [308136802] 59.39 percent of total billed charges 46.5 71.25 Technical (Hospital) Services Im Adm Prq ID Subq/Im Njxs Ea Vaccine PX-7719047200 CDM 90472 CPT 771 RC inpatient 75 75 BLUE CROSS BLUE SHIELD WELLMARK SB889 [3081026] BCBS WYOMING [308102603] 71.25 percent of total billed charges 46.5 71.25 Technical (Hospital) Services Im Adm Prq ID Subq/Im Njxs Ea Vaccine PX-7719047200 CDM 90472 CPT 771 RC inpatient 75 75 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES EPO [308136803] 59.39 percent of total billed charges 46.5 71.25 Technical (Hospital) Services Im Adm Prq ID Subq/Im Njxs Ea Vaccine PX-7719047200 CDM 90472 CPT 771 RC inpatient 75 75 HEALTHPARTNERS SX009 HEALTHPARTNERS 59.39 percent of total billed charges 46.5 71.25 Technical (Hospital) Services Im Adm Prq ID Subq/Im Njxs Ea Vaccine PX-7719047200 CDM 90472 CPT 771 RC inpatient 75 75 MULTIPLAN INC 34080 [3081285] MULTIPLAN INC [308128501] 71.25 percent of total billed charges 46.5 71.25 Technical (Hospital) Services Im Adm Prq ID Subq/Im Njxs Ea Vaccine PX-7719047200 CDM 90472 CPT 771 RC inpatient 75 75 MEDICA (COMMERCIAL) 94265 [3081118] MEDICA CLAIMS [308111801] 67.5 percent of total billed charges 46.5 71.25 Technical (Hospital) Services Subsequent Administration of Influenza Virus Vaccine PX-7719047201 CDM 90472 CPT 771 RC outpatient 75 75 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES HDHP [308136802] 60 percent of total billed charges 46.5 71.25 Technical (Hospital) Services Subsequent Administration of Influenza Virus Vaccine PX-7719047201 CDM 90472 CPT 771 RC outpatient 75 75 BLUE CROSS BLUE SHIELD WELLMARK SB889 [3081026] BCBS WYOMING [308102603] 71.25 percent of total billed charges 46.5 71.25 Technical (Hospital) Services Subsequent Administration of Influenza Virus Vaccine PX-7719047201 CDM 90472 CPT 771 RC outpatient 75 75 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES EPO [308136803] 60 percent of total billed charges 46.5 71.25 Technical (Hospital) Services Subsequent Administration of Influenza Virus Vaccine PX-7719047201 CDM 90472 CPT 771 RC outpatient 75 75 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES PPO [308136801] 60 percent of total billed charges 46.5 71.25 Technical (Hospital) Services Subsequent Administration of Influenza Virus Vaccine PX-7719047201 CDM 90472 CPT 771 RC outpatient 75 75 UNITED HEALTHCARE (COMMERCIAL) [3081199] UNITED HEALTHCARE 87726 [308119901] 46.5 percent of total billed charges 46.5 71.25 Technical (Hospital) Services Subsequent Administration of Influenza Virus Vaccine PX-7719047201 CDM 90472 CPT 771 RC outpatient 75 75 HEALTHPARTNERS SX009 HEALTHPARTNERS 60 percent of total billed charges 46.5 71.25 Technical (Hospital) Services Subsequent Administration of Influenza Virus Vaccine PX-7719047201 CDM 90472 CPT 771 RC outpatient 75 75 CIGNA 62308 [3081051] CIGNA 62308 [308105105] 60 percent of total billed charges 46.5 71.25 Technical (Hospital) Services Subsequent Administration of Influenza Virus Vaccine PX-7719047201 CDM 90472 CPT 771 RC outpatient 75 75 CIGNA 62308 [3081051] CIGNA STATE OF WYOMING [308105107] 60 percent of total billed charges 46.5 71.25 Technical (Hospital) Services Subsequent Administration of Influenza Virus Vaccine PX-7719047201 CDM 90472 CPT 771 RC outpatient 75 75 MULTIPLAN INC 34080 [3081285] MULTIPLAN INC [308128501] 71.25 percent of total billed charges 46.5 71.25 Technical (Hospital) Services Subsequent Administration of Influenza Virus Vaccine PX-7719047201 CDM 90472 CPT 771 RC outpatient 75 75 MEDICA (COMMERCIAL) 94265 [3081118] MEDICA CLAIMS [308111801] 67.5 percent of total billed charges 46.5 71.25 Technical (Hospital) Services Subsequent Administration of Influenza Virus Vaccine PX-7719047201 CDM 90472 CPT 771 RC inpatient 75 75 CIGNA 62308 [3081051] CIGNA 62308 [308105105] 59.39 percent of total billed charges 46.5 71.25 Technical (Hospital) Services Subsequent Administration of Influenza Virus Vaccine PX-7719047201 CDM 90472 CPT 771 RC inpatient 75 75 CIGNA 62308 [3081051] CIGNA STATE OF WYOMING [308105107] 59.39 percent of total billed charges 46.5 71.25 Technical (Hospital) Services Subsequent Administration of Influenza Virus Vaccine PX-7719047201 CDM 90472 CPT 771 RC inpatient 75 75 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES EPO [308136803] 59.39 percent of total billed charges 46.5 71.25 Technical (Hospital) Services Subsequent Administration of Influenza Virus Vaccine PX-7719047201 CDM 90472 CPT 771 RC inpatient 75 75 HEALTHPARTNERS SX009 HEALTHPARTNERS 59.39 percent of total billed charges 46.5 71.25 Technical (Hospital) Services Subsequent Administration of Influenza Virus Vaccine PX-7719047201 CDM 90472 CPT 771 RC inpatient 75 75 MULTIPLAN INC 34080 [3081285] MULTIPLAN INC [308128501] 71.25 percent of total billed charges 46.5 71.25 Technical (Hospital) Services Subsequent Administration of Influenza Virus Vaccine PX-7719047201 CDM 90472 CPT 771 RC inpatient 75 75 MEDICA (COMMERCIAL) 94265 [3081118] MEDICA CLAIMS [308111801] 67.5 percent of total billed charges 46.5 71.25 Technical (Hospital) Services Subsequent Administration of Influenza Virus Vaccine PX-7719047201 CDM 90472 CPT 771 RC inpatient 75 75 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES PPO [308136801] 59.39 percent of total billed charges 46.5 71.25 Technical (Hospital) Services Subsequent Administration of Influenza Virus Vaccine PX-7719047201 CDM 90472 CPT 771 RC inpatient 75 75 UNITED HEALTHCARE (COMMERCIAL) [3081199] UNITED HEALTHCARE 87726 [308119901] 46.5 percent of total billed charges 46.5 71.25 Technical (Hospital) Services Subsequent Administration of Influenza Virus Vaccine PX-7719047201 CDM 90472 CPT 771 RC inpatient 75 75 BLUE CROSS BLUE SHIELD WELLMARK SB889 [3081026] BCBS WYOMING [308102603] 71.25 percent of total billed charges 46.5 71.25 Technical (Hospital) Services Subsequent Administration of Influenza Virus Vaccine PX-7719047201 CDM 90472 CPT 771 RC inpatient 75 75 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES HDHP [308136802] 59.39 percent of total billed charges 46.5 71.25 Technical (Hospital) Services Subsequent Administration of Pneumococcal Vaccine PX-7719047202 CDM 90472 CPT 771 RC outpatient 75 75 BLUE CROSS BLUE SHIELD WELLMARK SB889 [3081026] BCBS WYOMING [308102603] 71.25 percent of total billed charges 46.5 71.25 Technical (Hospital) Services Subsequent Administration of Pneumococcal Vaccine PX-7719047202 CDM 90472 CPT 771 RC outpatient 75 75 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES HDHP [308136802] 60 percent of total billed charges 46.5 71.25 Technical (Hospital) Services Subsequent Administration of Pneumococcal Vaccine PX-7719047202 CDM 90472 CPT 771 RC outpatient 75 75 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES PPO [308136801] 60 percent of total billed charges 46.5 71.25 Technical (Hospital) Services Subsequent Administration of Pneumococcal Vaccine PX-7719047202 CDM 90472 CPT 771 RC outpatient 75 75 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES EPO [308136803] 60 percent of total billed charges 46.5 71.25 Technical (Hospital) Services Subsequent Administration of Pneumococcal Vaccine PX-7719047202 CDM 90472 CPT 771 RC outpatient 75 75 HEALTHPARTNERS SX009 HEALTHPARTNERS 60 percent of total billed charges 46.5 71.25 Technical (Hospital) Services Subsequent Administration of Pneumococcal Vaccine PX-7719047202 CDM 90472 CPT 771 RC outpatient 75 75 UNITED HEALTHCARE (COMMERCIAL) [3081199] UNITED HEALTHCARE 87726 [308119901] 46.5 percent of total billed charges 46.5 71.25 Technical (Hospital) Services Subsequent Administration of Pneumococcal Vaccine PX-7719047202 CDM 90472 CPT 771 RC outpatient 75 75 MEDICA (COMMERCIAL) 94265 [3081118] MEDICA CLAIMS [308111801] 67.5 percent of total billed charges 46.5 71.25 Technical (Hospital) Services Subsequent Administration of Pneumococcal Vaccine PX-7719047202 CDM 90472 CPT 771 RC outpatient 75 75 CIGNA 62308 [3081051] CIGNA 62308 [308105105] 60 percent of total billed charges 46.5 71.25 Technical (Hospital) Services Subsequent Administration of Pneumococcal Vaccine PX-7719047202 CDM 90472 CPT 771 RC outpatient 75 75 CIGNA 62308 [3081051] CIGNA STATE OF WYOMING [308105107] 60 percent of total billed charges 46.5 71.25 Technical (Hospital) Services Subsequent Administration of Pneumococcal Vaccine PX-7719047202 CDM 90472 CPT 771 RC outpatient 75 75 MULTIPLAN INC 34080 [3081285] MULTIPLAN INC [308128501] 71.25 percent of total billed charges 46.5 71.25 Technical (Hospital) Services Subsequent Administration of Pneumococcal Vaccine PX-7719047202 CDM 90472 CPT 771 RC inpatient 75 75 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES EPO [308136803] 59.39 percent of total billed charges 46.5 71.25 Technical (Hospital) Services Subsequent Administration of Pneumococcal Vaccine PX-7719047202 CDM 90472 CPT 771 RC inpatient 75 75 HEALTHPARTNERS SX009 HEALTHPARTNERS 59.39 percent of total billed charges 46.5 71.25 Technical (Hospital) Services Subsequent Administration of Pneumococcal Vaccine PX-7719047202 CDM 90472 CPT 771 RC inpatient 75 75 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES HDHP [308136802] 59.39 percent of total billed charges 46.5 71.25 Technical (Hospital) Services Subsequent Administration of Pneumococcal Vaccine PX-7719047202 CDM 90472 CPT 771 RC inpatient 75 75 MULTIPLAN INC 34080 [3081285] MULTIPLAN INC [308128501] 71.25 percent of total billed charges 46.5 71.25 Technical (Hospital) Services Subsequent Administration of Pneumococcal Vaccine PX-7719047202 CDM 90472 CPT 771 RC inpatient 75 75 MEDICA (COMMERCIAL) 94265 [3081118] MEDICA CLAIMS [308111801] 67.5 percent of total billed charges 46.5 71.25 Technical (Hospital) Services Subsequent Administration of Pneumococcal Vaccine PX-7719047202 CDM 90472 CPT 771 RC inpatient 75 75 UNITED HEALTHCARE (COMMERCIAL) [3081199] UNITED HEALTHCARE 87726 [308119901] 46.5 percent of total billed charges 46.5 71.25 Technical (Hospital) Services Subsequent Administration of Pneumococcal Vaccine PX-7719047202 CDM 90472 CPT 771 RC inpatient 75 75 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES PPO [308136801] 59.39 percent of total billed charges 46.5 71.25 Technical (Hospital) Services Subsequent Administration of Pneumococcal Vaccine PX-7719047202 CDM 90472 CPT 771 RC inpatient 75 75 BLUE CROSS BLUE SHIELD WELLMARK SB889 [3081026] BCBS WYOMING [308102603] 71.25 percent of total billed charges 46.5 71.25 Technical (Hospital) Services Subsequent Administration of Pneumococcal Vaccine PX-7719047202 CDM 90472 CPT 771 RC inpatient 75 75 CIGNA 62308 [3081051] CIGNA 62308 [308105105] 59.39 percent of total billed charges 46.5 71.25 Technical (Hospital) Services Subsequent Administration of Pneumococcal Vaccine PX-7719047202 CDM 90472 CPT 771 RC inpatient 75 75 CIGNA 62308 [3081051] CIGNA STATE OF WYOMING [308105107] 59.39 percent of total billed charges 46.5 71.25 Technical (Hospital) Services Subsequent Administration of Hepatitis B Vaccine PX-7719047203 CDM 90472 CPT 771 RC outpatient 75 75 MULTIPLAN INC 34080 [3081285] MULTIPLAN INC [308128501] 71.25 percent of total billed charges 46.5 71.25 Technical (Hospital) Services Subsequent Administration of Hepatitis B Vaccine PX-7719047203 CDM 90472 CPT 771 RC outpatient 75 75 CIGNA 62308 [3081051] CIGNA 62308 [308105105] 60 percent of total billed charges 46.5 71.25 Technical (Hospital) Services Subsequent Administration of Hepatitis B Vaccine PX-7719047203 CDM 90472 CPT 771 RC outpatient 75 75 CIGNA 62308 [3081051] CIGNA STATE OF WYOMING [308105107] 60 percent of total billed charges 46.5 71.25 Technical (Hospital) Services Subsequent Administration of Hepatitis B Vaccine PX-7719047203 CDM 90472 CPT 771 RC outpatient 75 75 MEDICA (COMMERCIAL) 94265 [3081118] MEDICA CLAIMS [308111801] 67.5 percent of total billed charges 46.5 71.25 Technical (Hospital) Services Subsequent Administration of Hepatitis B Vaccine PX-7719047203 CDM 90472 CPT 771 RC outpatient 75 75 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES PPO [308136801] 60 percent of total billed charges 46.5 71.25 Technical (Hospital) Services Subsequent Administration of Hepatitis B Vaccine PX-7719047203 CDM 90472 CPT 771 RC outpatient 75 75 UNITED HEALTHCARE (COMMERCIAL) [3081199] UNITED HEALTHCARE 87726 [308119901] 46.5 percent of total billed charges 46.5 71.25 Technical (Hospital) Services Subsequent Administration of Hepatitis B Vaccine PX-7719047203 CDM 90472 CPT 771 RC outpatient 75 75 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES EPO [308136803] 60 percent of total billed charges 46.5 71.25 Technical (Hospital) Services Subsequent Administration of Hepatitis B Vaccine PX-7719047203 CDM 90472 CPT 771 RC outpatient 75 75 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES HDHP [308136802] 60 percent of total billed charges 46.5 71.25 Technical (Hospital) Services Subsequent Administration of Hepatitis B Vaccine PX-7719047203 CDM 90472 CPT 771 RC outpatient 75 75 BLUE CROSS BLUE SHIELD WELLMARK SB889 [3081026] BCBS WYOMING [308102603] 71.25 percent of total billed charges 46.5 71.25 Technical (Hospital) Services Subsequent Administration of Hepatitis B Vaccine PX-7719047203 CDM 90472 CPT 771 RC outpatient 75 75 HEALTHPARTNERS SX009 HEALTHPARTNERS 60 percent of total billed charges 46.5 71.25 Technical (Hospital) Services Subsequent Administration of Hepatitis B Vaccine PX-7719047203 CDM 90472 CPT 771 RC inpatient 75 75 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES HDHP [308136802] 59.39 percent of total billed charges 46.5 71.25 Technical (Hospital) Services Subsequent Administration of Hepatitis B Vaccine PX-7719047203 CDM 90472 CPT 771 RC inpatient 75 75 BLUE CROSS BLUE SHIELD WELLMARK SB889 [3081026] BCBS WYOMING [308102603] 71.25 percent of total billed charges 46.5 71.25 Technical (Hospital) Services Subsequent Administration of Hepatitis B Vaccine PX-7719047203 CDM 90472 CPT 771 RC inpatient 75 75 UNITED HEALTHCARE (COMMERCIAL) [3081199] UNITED HEALTHCARE 87726 [308119901] 46.5 percent of total billed charges 46.5 71.25 Technical (Hospital) Services Subsequent Administration of Hepatitis B Vaccine PX-7719047203 CDM 90472 CPT 771 RC inpatient 75 75 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES PPO [308136801] 59.39 percent of total billed charges 46.5 71.25 Technical (Hospital) Services Subsequent Administration of Hepatitis B Vaccine PX-7719047203 CDM 90472 CPT 771 RC inpatient 75 75 MULTIPLAN INC 34080 [3081285] MULTIPLAN INC [308128501] 71.25 percent of total billed charges 46.5 71.25 Technical (Hospital) Services Subsequent Administration of Hepatitis B Vaccine PX-7719047203 CDM 90472 CPT 771 RC inpatient 75 75 MEDICA (COMMERCIAL) 94265 [3081118] MEDICA CLAIMS [308111801] 67.5 percent of total billed charges 46.5 71.25 Technical (Hospital) Services Subsequent Administration of Hepatitis B Vaccine PX-7719047203 CDM 90472 CPT 771 RC inpatient 75 75 HEALTHPARTNERS SX009 HEALTHPARTNERS 59.39 percent of total billed charges 46.5 71.25 Technical (Hospital) Services Subsequent Administration of Hepatitis B Vaccine PX-7719047203 CDM 90472 CPT 771 RC inpatient 75 75 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES EPO [308136803] 59.39 percent of total billed charges 46.5 71.25 Technical (Hospital) Services Subsequent Administration of Hepatitis B Vaccine PX-7719047203 CDM 90472 CPT 771 RC inpatient 75 75 CIGNA 62308 [3081051] CIGNA 62308 [308105105] 59.39 percent of total billed charges 46.5 71.25 Technical (Hospital) Services Subsequent Administration of Hepatitis B Vaccine PX-7719047203 CDM 90472 CPT 771 RC inpatient 75 75 CIGNA 62308 [3081051] CIGNA STATE OF WYOMING [308105107] 59.39 percent of total billed charges 46.5 71.25 Technical (Hospital) Services Im Adm Prq ID Subq/Im Njxs 1 Vaccine PX-7719047100 CDM 90471 CPT 771 RC inpatient 75 75 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES PPO [308136801] 59.39 percent of total billed charges 46.5 71.25 Technical (Hospital) Services Im Adm Prq ID Subq/Im Njxs 1 Vaccine PX-7719047100 CDM 90471 CPT 771 RC inpatient 75 75 UNITED HEALTHCARE (COMMERCIAL) [3081199] UNITED HEALTHCARE 87726 [308119901] 46.5 percent of total billed charges 46.5 71.25 Technical (Hospital) Services Im Adm Prq ID Subq/Im Njxs 1 Vaccine PX-7719047100 CDM 90471 CPT 771 RC inpatient 75 75 BLUE CROSS BLUE SHIELD WELLMARK SB889 [3081026] BCBS WYOMING [308102603] 71.25 percent of total billed charges 46.5 71.25 Technical (Hospital) Services Im Adm Prq ID Subq/Im Njxs 1 Vaccine PX-7719047100 CDM 90471 CPT 771 RC inpatient 75 75 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES HDHP [308136802] 59.39 percent of total billed charges 46.5 71.25 Technical (Hospital) Services Im Adm Prq ID Subq/Im Njxs 1 Vaccine PX-7719047100 CDM 90471 CPT 771 RC inpatient 75 75 HEALTHPARTNERS SX009 HEALTHPARTNERS 59.39 percent of total billed charges 46.5 71.25 Technical (Hospital) Services Im Adm Prq ID Subq/Im Njxs 1 Vaccine PX-7719047100 CDM 90471 CPT 771 RC inpatient 75 75 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES EPO [308136803] 59.39 percent of total billed charges 46.5 71.25 Technical (Hospital) Services Im Adm Prq ID Subq/Im Njxs 1 Vaccine PX-7719047100 CDM 90471 CPT 771 RC inpatient 75 75 MULTIPLAN INC 34080 [3081285] MULTIPLAN INC [308128501] 71.25 percent of total billed charges 46.5 71.25 Technical (Hospital) Services Im Adm Prq ID Subq/Im Njxs 1 Vaccine PX-7719047100 CDM 90471 CPT 771 RC inpatient 75 75 MEDICA (COMMERCIAL) 94265 [3081118] MEDICA CLAIMS [308111801] 67.5 percent of total billed charges 46.5 71.25 Technical (Hospital) Services Im Adm Prq ID Subq/Im Njxs 1 Vaccine PX-7719047100 CDM 90471 CPT 771 RC inpatient 75 75 CIGNA 62308 [3081051] CIGNA 62308 [308105105] 59.39 percent of total billed charges 46.5 71.25 Technical (Hospital) Services Im Adm Prq ID Subq/Im Njxs 1 Vaccine PX-7719047100 CDM 90471 CPT 771 RC inpatient 75 75 CIGNA 62308 [3081051] CIGNA STATE OF WYOMING [308105107] 59.39 percent of total billed charges 46.5 71.25 Technical (Hospital) Services Im Adm Prq ID Subq/Im Njxs 1 Vaccine PX-7719047100 CDM 90471 CPT 771 RC outpatient 75 75 HEALTHPARTNERS SX009 HEALTHPARTNERS 60 percent of total billed charges 46.5 71.25 Technical (Hospital) Services Im Adm Prq ID Subq/Im Njxs 1 Vaccine PX-7719047100 CDM 90471 CPT 771 RC outpatient 75 75 UNITED HEALTHCARE (COMMERCIAL) [3081199] UNITED HEALTHCARE 87726 [308119901] 46.5 percent of total billed charges 46.5 71.25 Technical (Hospital) Services Im Adm Prq ID Subq/Im Njxs 1 Vaccine PX-7719047100 CDM 90471 CPT 771 RC outpatient 75 75 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES EPO [308136803] 60 percent of total billed charges 46.5 71.25 Technical (Hospital) Services Im Adm Prq ID Subq/Im Njxs 1 Vaccine PX-7719047100 CDM 90471 CPT 771 RC outpatient 75 75 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES PPO [308136801] 60 percent of total billed charges 46.5 71.25 Technical (Hospital) Services Im Adm Prq ID Subq/Im Njxs 1 Vaccine PX-7719047100 CDM 90471 CPT 771 RC outpatient 75 75 BLUE CROSS BLUE SHIELD WELLMARK SB889 [3081026] BCBS WYOMING [308102603] 71.25 percent of total billed charges 46.5 71.25 Technical (Hospital) Services Im Adm Prq ID Subq/Im Njxs 1 Vaccine PX-7719047100 CDM 90471 CPT 771 RC outpatient 75 75 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES HDHP [308136802] 60 percent of total billed charges 46.5 71.25 Technical (Hospital) Services Im Adm Prq ID Subq/Im Njxs 1 Vaccine PX-7719047100 CDM 90471 CPT 771 RC outpatient 75 75 MEDICA (COMMERCIAL) 94265 [3081118] MEDICA CLAIMS [308111801] 67.5 percent of total billed charges 46.5 71.25 Technical (Hospital) Services Im Adm Prq ID Subq/Im Njxs 1 Vaccine PX-7719047100 CDM 90471 CPT 771 RC outpatient 75 75 MULTIPLAN INC 34080 [3081285] MULTIPLAN INC [308128501] 71.25 percent of total billed charges 46.5 71.25 Technical (Hospital) Services Im Adm Prq ID Subq/Im Njxs 1 Vaccine PX-7719047100 CDM 90471 CPT 771 RC outpatient 75 75 CIGNA 62308 [3081051] CIGNA 62308 [308105105] 60 percent of total billed charges 46.5 71.25 Technical (Hospital) Services Im Adm Prq ID Subq/Im Njxs 1 Vaccine PX-7719047100 CDM 90471 CPT 771 RC outpatient 75 75 CIGNA 62308 [3081051] CIGNA STATE OF WYOMING [308105107] 60 percent of total billed charges 46.5 71.25 Technical (Hospital) Services Administration of Influenza Virus Vaccine PX-7719047101 CDM 90471 CPT 771 RC inpatient 75 75 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES EPO [308136803] 59.39 percent of total billed charges 46.5 71.25 Technical (Hospital) Services Administration of Influenza Virus Vaccine PX-7719047101 CDM 90471 CPT 771 RC inpatient 75 75 HEALTHPARTNERS SX009 HEALTHPARTNERS 59.39 percent of total billed charges 46.5 71.25 Technical (Hospital) Services Administration of Influenza Virus Vaccine PX-7719047101 CDM 90471 CPT 771 RC inpatient 75 75 MEDICA (COMMERCIAL) 94265 [3081118] MEDICA CLAIMS [308111801] 67.5 percent of total billed charges 46.5 71.25 Technical (Hospital) Services Administration of Influenza Virus Vaccine PX-7719047101 CDM 90471 CPT 771 RC inpatient 75 75 MULTIPLAN INC 34080 [3081285] MULTIPLAN INC [308128501] 71.25 percent of total billed charges 46.5 71.25 Technical (Hospital) Services Administration of Influenza Virus Vaccine PX-7719047101 CDM 90471 CPT 771 RC inpatient 75 75 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES HDHP [308136802] 59.39 percent of total billed charges 46.5 71.25 Technical (Hospital) Services Administration of Influenza Virus Vaccine PX-7719047101 CDM 90471 CPT 771 RC inpatient 75 75 BLUE CROSS BLUE SHIELD WELLMARK SB889 [3081026] BCBS WYOMING [308102603] 71.25 percent of total billed charges 46.5 71.25 Technical (Hospital) Services Administration of Influenza Virus Vaccine PX-7719047101 CDM 90471 CPT 771 RC inpatient 75 75 UNITED HEALTHCARE (COMMERCIAL) [3081199] UNITED HEALTHCARE 87726 [308119901] 46.5 percent of total billed charges 46.5 71.25 Technical (Hospital) Services Administration of Influenza Virus Vaccine PX-7719047101 CDM 90471 CPT 771 RC inpatient 75 75 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES PPO [308136801] 59.39 percent of total billed charges 46.5 71.25 Technical (Hospital) Services Administration of Influenza Virus Vaccine PX-7719047101 CDM 90471 CPT 771 RC inpatient 75 75 CIGNA 62308 [3081051] CIGNA 62308 [308105105] 59.39 percent of total billed charges 46.5 71.25 Technical (Hospital) Services Administration of Influenza Virus Vaccine PX-7719047101 CDM 90471 CPT 771 RC inpatient 75 75 CIGNA 62308 [3081051] CIGNA STATE OF WYOMING [308105107] 59.39 percent of total billed charges 46.5 71.25 Technical (Hospital) Services Administration of Influenza Virus Vaccine PX-7719047101 CDM 90471 CPT 771 RC outpatient 75 75 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES PPO [308136801] 60 percent of total billed charges 46.5 71.25 Technical (Hospital) Services Administration of Influenza Virus Vaccine PX-7719047101 CDM 90471 CPT 771 RC outpatient 75 75 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES EPO [308136803] 60 percent of total billed charges 46.5 71.25 Technical (Hospital) Services Administration of Influenza Virus Vaccine PX-7719047101 CDM 90471 CPT 771 RC outpatient 75 75 BLUE CROSS BLUE SHIELD WELLMARK SB889 [3081026] BCBS WYOMING [308102603] 71.25 percent of total billed charges 46.5 71.25 Technical (Hospital) Services Administration of Influenza Virus Vaccine PX-7719047101 CDM 90471 CPT 771 RC outpatient 75 75 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES HDHP [308136802] 60 percent of total billed charges 46.5 71.25 Technical (Hospital) Services Administration of Influenza Virus Vaccine PX-7719047101 CDM 90471 CPT 771 RC outpatient 75 75 UNITED HEALTHCARE (COMMERCIAL) [3081199] UNITED HEALTHCARE 87726 [308119901] 46.5 percent of total billed charges 46.5 71.25 Technical (Hospital) Services Administration of Influenza Virus Vaccine PX-7719047101 CDM 90471 CPT 771 RC outpatient 75 75 HEALTHPARTNERS SX009 HEALTHPARTNERS 60 percent of total billed charges 46.5 71.25 Technical (Hospital) Services Administration of Influenza Virus Vaccine PX-7719047101 CDM 90471 CPT 771 RC outpatient 75 75 MEDICA (COMMERCIAL) 94265 [3081118] MEDICA CLAIMS [308111801] 67.5 percent of total billed charges 46.5 71.25 Technical (Hospital) Services Administration of Influenza Virus Vaccine PX-7719047101 CDM 90471 CPT 771 RC outpatient 75 75 MULTIPLAN INC 34080 [3081285] MULTIPLAN INC [308128501] 71.25 percent of total billed charges 46.5 71.25 Technical (Hospital) Services Administration of Influenza Virus Vaccine PX-7719047101 CDM 90471 CPT 771 RC outpatient 75 75 CIGNA 62308 [3081051] CIGNA 62308 [308105105] 60 percent of total billed charges 46.5 71.25 Technical (Hospital) Services Administration of Influenza Virus Vaccine PX-7719047101 CDM 90471 CPT 771 RC outpatient 75 75 CIGNA 62308 [3081051] CIGNA STATE OF WYOMING [308105107] 60 percent of total billed charges 46.5 71.25 Technical (Hospital) Services Administration of Pneumococcal Vaccine PX-7719047102 CDM 90471 CPT 771 RC inpatient 75 75 HEALTHPARTNERS SX009 HEALTHPARTNERS 59.39 percent of total billed charges 46.5 71.25 Technical (Hospital) Services Administration of Pneumococcal Vaccine PX-7719047102 CDM 90471 CPT 771 RC inpatient 75 75 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES EPO [308136803] 59.39 percent of total billed charges 46.5 71.25 Technical (Hospital) Services Administration of Pneumococcal Vaccine PX-7719047102 CDM 90471 CPT 771 RC inpatient 75 75 MEDICA (COMMERCIAL) 94265 [3081118] MEDICA CLAIMS [308111801] 67.5 percent of total billed charges 46.5 71.25 Technical (Hospital) Services Administration of Pneumococcal Vaccine PX-7719047102 CDM 90471 CPT 771 RC inpatient 75 75 MULTIPLAN INC 34080 [3081285] MULTIPLAN INC [308128501] 71.25 percent of total billed charges 46.5 71.25 Technical (Hospital) Services Administration of Pneumococcal Vaccine PX-7719047102 CDM 90471 CPT 771 RC inpatient 75 75 UNITED HEALTHCARE (COMMERCIAL) [3081199] UNITED HEALTHCARE 87726 [308119901] 46.5 percent of total billed charges 46.5 71.25 Technical (Hospital) Services Administration of Pneumococcal Vaccine PX-7719047102 CDM 90471 CPT 771 RC inpatient 75 75 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES PPO [308136801] 59.39 percent of total billed charges 46.5 71.25 Technical (Hospital) Services Administration of Pneumococcal Vaccine PX-7719047102 CDM 90471 CPT 771 RC inpatient 75 75 BLUE CROSS BLUE SHIELD WELLMARK SB889 [3081026] BCBS WYOMING [308102603] 71.25 percent of total billed charges 46.5 71.25 Technical (Hospital) Services Administration of Pneumococcal Vaccine PX-7719047102 CDM 90471 CPT 771 RC inpatient 75 75 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES HDHP [308136802] 59.39 percent of total billed charges 46.5 71.25 Technical (Hospital) Services Administration of Pneumococcal Vaccine PX-7719047102 CDM 90471 CPT 771 RC inpatient 75 75 CIGNA 62308 [3081051] CIGNA 62308 [308105105] 59.39 percent of total billed charges 46.5 71.25 Technical (Hospital) Services Administration of Pneumococcal Vaccine PX-7719047102 CDM 90471 CPT 771 RC inpatient 75 75 CIGNA 62308 [3081051] CIGNA STATE OF WYOMING [308105107] 59.39 percent of total billed charges 46.5 71.25 Technical (Hospital) Services Administration of Pneumococcal Vaccine PX-7719047102 CDM 90471 CPT 771 RC outpatient 75 75 MULTIPLAN INC 34080 [3081285] MULTIPLAN INC [308128501] 71.25 percent of total billed charges 46.5 71.25 Technical (Hospital) Services Administration of Pneumococcal Vaccine PX-7719047102 CDM 90471 CPT 771 RC outpatient 75 75 CIGNA 62308 [3081051] CIGNA 62308 [308105105] 60 percent of total billed charges 46.5 71.25 Technical (Hospital) Services Administration of Pneumococcal Vaccine PX-7719047102 CDM 90471 CPT 771 RC outpatient 75 75 CIGNA 62308 [3081051] CIGNA STATE OF WYOMING [308105107] 60 percent of total billed charges 46.5 71.25 Technical (Hospital) Services Administration of Pneumococcal Vaccine PX-7719047102 CDM 90471 CPT 771 RC outpatient 75 75 MEDICA (COMMERCIAL) 94265 [3081118] MEDICA CLAIMS [308111801] 67.5 percent of total billed charges 46.5 71.25 Technical (Hospital) Services Administration of Pneumococcal Vaccine PX-7719047102 CDM 90471 CPT 771 RC outpatient 75 75 UNITED HEALTHCARE (COMMERCIAL) [3081199] UNITED HEALTHCARE 87726 [308119901] 46.5 percent of total billed charges 46.5 71.25 Technical (Hospital) Services Administration of Pneumococcal Vaccine PX-7719047102 CDM 90471 CPT 771 RC outpatient 75 75 HEALTHPARTNERS SX009 HEALTHPARTNERS 60 percent of total billed charges 46.5 71.25 Technical (Hospital) Services Administration of Pneumococcal Vaccine PX-7719047102 CDM 90471 CPT 771 RC outpatient 75 75 BLUE CROSS BLUE SHIELD WELLMARK SB889 [3081026] BCBS WYOMING [308102603] 71.25 percent of total billed charges 46.5 71.25 Technical (Hospital) Services Administration of Pneumococcal Vaccine PX-7719047102 CDM 90471 CPT 771 RC outpatient 75 75 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES HDHP [308136802] 60 percent of total billed charges 46.5 71.25 Technical (Hospital) Services Administration of Pneumococcal Vaccine PX-7719047102 CDM 90471 CPT 771 RC outpatient 75 75 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES PPO [308136801] 60 percent of total billed charges 46.5 71.25 Technical (Hospital) Services Administration of Pneumococcal Vaccine PX-7719047102 CDM 90471 CPT 771 RC outpatient 75 75 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES EPO [308136803] 60 percent of total billed charges 46.5 71.25 Technical (Hospital) Services Administration of Hepatitis B Vaccine PX-7719047103 CDM 90471 CPT 771 RC inpatient 75 75 CIGNA 62308 [3081051] CIGNA 62308 [308105105] 59.39 percent of total billed charges 46.5 71.25 Technical (Hospital) Services Administration of Hepatitis B Vaccine PX-7719047103 CDM 90471 CPT 771 RC inpatient 75 75 CIGNA 62308 [3081051] CIGNA STATE OF WYOMING [308105107] 59.39 percent of total billed charges 46.5 71.25 Technical (Hospital) Services Administration of Hepatitis B Vaccine PX-7719047103 CDM 90471 CPT 771 RC inpatient 75 75 UNITED HEALTHCARE (COMMERCIAL) [3081199] UNITED HEALTHCARE 87726 [308119901] 46.5 percent of total billed charges 46.5 71.25 Technical (Hospital) Services Administration of Hepatitis B Vaccine PX-7719047103 CDM 90471 CPT 771 RC inpatient 75 75 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES PPO [308136801] 59.39 percent of total billed charges 46.5 71.25 Technical (Hospital) Services Administration of Hepatitis B Vaccine PX-7719047103 CDM 90471 CPT 771 RC inpatient 75 75 BLUE CROSS BLUE SHIELD WELLMARK SB889 [3081026] BCBS WYOMING [308102603] 71.25 percent of total billed charges 46.5 71.25 Technical (Hospital) Services Administration of Hepatitis B Vaccine PX-7719047103 CDM 90471 CPT 771 RC inpatient 75 75 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES HDHP [308136802] 59.39 percent of total billed charges 46.5 71.25 Technical (Hospital) Services Administration of Hepatitis B Vaccine PX-7719047103 CDM 90471 CPT 771 RC inpatient 75 75 MULTIPLAN INC 34080 [3081285] MULTIPLAN INC [308128501] 71.25 percent of total billed charges 46.5 71.25 Technical (Hospital) Services Administration of Hepatitis B Vaccine PX-7719047103 CDM 90471 CPT 771 RC inpatient 75 75 MEDICA (COMMERCIAL) 94265 [3081118] MEDICA CLAIMS [308111801] 67.5 percent of total billed charges 46.5 71.25 Technical (Hospital) Services Administration of Hepatitis B Vaccine PX-7719047103 CDM 90471 CPT 771 RC inpatient 75 75 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES EPO [308136803] 59.39 percent of total billed charges 46.5 71.25 Technical (Hospital) Services Administration of Hepatitis B Vaccine PX-7719047103 CDM 90471 CPT 771 RC inpatient 75 75 HEALTHPARTNERS SX009 HEALTHPARTNERS 59.39 percent of total billed charges 46.5 71.25 Technical (Hospital) Services Administration of Hepatitis B Vaccine PX-7719047103 CDM 90471 CPT 771 RC outpatient 75 75 UNITED HEALTHCARE (COMMERCIAL) [3081199] UNITED HEALTHCARE 87726 [308119901] 46.5 percent of total billed charges 46.5 71.25 Technical (Hospital) Services Administration of Hepatitis B Vaccine PX-7719047103 CDM 90471 CPT 771 RC outpatient 75 75 HEALTHPARTNERS SX009 HEALTHPARTNERS 60 percent of total billed charges 46.5 71.25 Technical (Hospital) Services Administration of Hepatitis B Vaccine PX-7719047103 CDM 90471 CPT 771 RC outpatient 75 75 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES HDHP [308136802] 60 percent of total billed charges 46.5 71.25 Technical (Hospital) Services Administration of Hepatitis B Vaccine PX-7719047103 CDM 90471 CPT 771 RC outpatient 75 75 BLUE CROSS BLUE SHIELD WELLMARK SB889 [3081026] BCBS WYOMING [308102603] 71.25 percent of total billed charges 46.5 71.25 Technical (Hospital) Services Administration of Hepatitis B Vaccine PX-7719047103 CDM 90471 CPT 771 RC outpatient 75 75 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES EPO [308136803] 60 percent of total billed charges 46.5 71.25 Technical (Hospital) Services Administration of Hepatitis B Vaccine PX-7719047103 CDM 90471 CPT 771 RC outpatient 75 75 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES PPO [308136801] 60 percent of total billed charges 46.5 71.25 Technical (Hospital) Services Administration of Hepatitis B Vaccine PX-7719047103 CDM 90471 CPT 771 RC outpatient 75 75 MEDICA (COMMERCIAL) 94265 [3081118] MEDICA CLAIMS [308111801] 67.5 percent of total billed charges 46.5 71.25 Technical (Hospital) Services Administration of Hepatitis B Vaccine PX-7719047103 CDM 90471 CPT 771 RC outpatient 75 75 CIGNA 62308 [3081051] CIGNA 62308 [308105105] 60 percent of total billed charges 46.5 71.25 Technical (Hospital) Services Administration of Hepatitis B Vaccine PX-7719047103 CDM 90471 CPT 771 RC outpatient 75 75 CIGNA 62308 [3081051] CIGNA STATE OF WYOMING [308105107] 60 percent of total billed charges 46.5 71.25 Technical (Hospital) Services Administration of Hepatitis B Vaccine PX-7719047103 CDM 90471 CPT 771 RC outpatient 75 75 MULTIPLAN INC 34080 [3081285] MULTIPLAN INC [308128501] 71.25 percent of total billed charges 46.5 71.25 Technical (Hospital) Services "Semen Analysis, Presence and or Moti" PX-3018932100 CDM 89321 CPT 301 RC inpatient 105 105 BLUE CROSS BLUE SHIELD WELLMARK SB889 [3081026] BCBS WYOMING [308102603] 99.75 percent of total billed charges 65.1 99.75 Technical (Hospital) Services "Semen Analysis, Presence and or Moti" PX-3018932100 CDM 89321 CPT 301 RC inpatient 105 105 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES HDHP [308136802] 83.14 percent of total billed charges 65.1 99.75 Technical (Hospital) Services "Semen Analysis, Presence and or Moti" PX-3018932100 CDM 89321 CPT 301 RC inpatient 105 105 UNITED HEALTHCARE (COMMERCIAL) [3081199] UNITED HEALTHCARE 87726 [308119901] 65.1 percent of total billed charges 65.1 99.75 Technical (Hospital) Services "Semen Analysis, Presence and or Moti" PX-3018932100 CDM 89321 CPT 301 RC inpatient 105 105 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES PPO [308136801] 83.14 percent of total billed charges 65.1 99.75 Technical (Hospital) Services "Semen Analysis, Presence and or Moti" PX-3018932100 CDM 89321 CPT 301 RC inpatient 105 105 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES EPO [308136803] 83.14 percent of total billed charges 65.1 99.75 Technical (Hospital) Services "Semen Analysis, Presence and or Moti" PX-3018932100 CDM 89321 CPT 301 RC inpatient 105 105 HEALTHPARTNERS SX009 HEALTHPARTNERS 83.14 percent of total billed charges 65.1 99.75 Technical (Hospital) Services "Semen Analysis, Presence and or Moti" PX-3018932100 CDM 89321 CPT 301 RC inpatient 105 105 MEDICA (COMMERCIAL) 94265 [3081118] MEDICA CLAIMS [308111801] 94.5 percent of total billed charges 65.1 99.75 Technical (Hospital) Services "Semen Analysis, Presence and or Moti" PX-3018932100 CDM 89321 CPT 301 RC inpatient 105 105 MULTIPLAN INC 34080 [3081285] MULTIPLAN INC [308128501] 99.75 percent of total billed charges 65.1 99.75 Technical (Hospital) Services "Semen Analysis, Presence and or Moti" PX-3018932100 CDM 89321 CPT 301 RC inpatient 105 105 CIGNA 62308 [3081051] CIGNA 62308 [308105105] 83.14 percent of total billed charges 65.1 99.75 Technical (Hospital) Services "Semen Analysis, Presence and or Moti" PX-3018932100 CDM 89321 CPT 301 RC inpatient 105 105 CIGNA 62308 [3081051] CIGNA STATE OF WYOMING [308105107] 83.14 percent of total billed charges 65.1 99.75 Technical (Hospital) Services "Semen Analysis, Presence and or Moti" PX-3018932100 CDM 89321 CPT 301 RC outpatient 105 105 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES EPO [308136803] 84 percent of total billed charges 65.1 99.75 Technical (Hospital) Services "Semen Analysis, Presence and or Moti" PX-3018932100 CDM 89321 CPT 301 RC outpatient 105 105 CIGNA 62308 [3081051] CIGNA 62308 [308105105] 84 percent of total billed charges 65.1 99.75 Technical (Hospital) Services "Semen Analysis, Presence and or Moti" PX-3018932100 CDM 89321 CPT 301 RC outpatient 105 105 CIGNA 62308 [3081051] CIGNA STATE OF WYOMING [308105107] 84 percent of total billed charges 65.1 99.75 Technical (Hospital) Services "Semen Analysis, Presence and or Moti" PX-3018932100 CDM 89321 CPT 301 RC outpatient 105 105 BLUE CROSS BLUE SHIELD WELLMARK SB889 [3081026] BCBS WYOMING [308102603] 99.75 percent of total billed charges 65.1 99.75 Technical (Hospital) Services "Semen Analysis, Presence and or Moti" PX-3018932100 CDM 89321 CPT 301 RC outpatient 105 105 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES HDHP [308136802] 84 percent of total billed charges 65.1 99.75 Technical (Hospital) Services "Semen Analysis, Presence and or Moti" PX-3018932100 CDM 89321 CPT 301 RC outpatient 105 105 UNITED HEALTHCARE (COMMERCIAL) [3081199] UNITED HEALTHCARE 87726 [308119901] 65.1 percent of total billed charges 65.1 99.75 Technical (Hospital) Services "Semen Analysis, Presence and or Moti" PX-3018932100 CDM 89321 CPT 301 RC outpatient 105 105 HEALTHPARTNERS SX009 HEALTHPARTNERS 84 percent of total billed charges 65.1 99.75 Technical (Hospital) Services "Semen Analysis, Presence and or Moti" PX-3018932100 CDM 89321 CPT 301 RC outpatient 105 105 MEDICA (COMMERCIAL) 94265 [3081118] MEDICA CLAIMS [308111801] 94.5 percent of total billed charges 65.1 99.75 Technical (Hospital) Services "Semen Analysis, Presence and or Moti" PX-3018932100 CDM 89321 CPT 301 RC outpatient 105 105 MULTIPLAN INC 34080 [3081285] MULTIPLAN INC [308128501] 99.75 percent of total billed charges 65.1 99.75 Technical (Hospital) Services "Semen Analysis, Presence and or Moti" PX-3018932100 CDM 89321 CPT 301 RC outpatient 105 105 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES PPO [308136801] 84 percent of total billed charges 65.1 99.75 Technical (Hospital) Services Fat Stain Feces Urine Resp PX-3018912500 CDM 89125 CPT 300 RC outpatient 97 97 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES PPO [308136801] 77.6 percent of total billed charges 60.14 92.15 Technical (Hospital) Services Fat Stain Feces Urine Resp PX-3018912500 CDM 89125 CPT 300 RC outpatient 97 97 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES EPO [308136803] 77.6 percent of total billed charges 60.14 92.15 Technical (Hospital) Services Fat Stain Feces Urine Resp PX-3018912500 CDM 89125 CPT 300 RC outpatient 97 97 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES HDHP [308136802] 77.6 percent of total billed charges 60.14 92.15 Technical (Hospital) Services Fat Stain Feces Urine Resp PX-3018912500 CDM 89125 CPT 300 RC outpatient 97 97 BLUE CROSS BLUE SHIELD WELLMARK SB889 [3081026] BCBS WYOMING [308102603] 92.15 percent of total billed charges 60.14 92.15 Technical (Hospital) Services Fat Stain Feces Urine Resp PX-3018912500 CDM 89125 CPT 300 RC outpatient 97 97 UNITED HEALTHCARE (COMMERCIAL) [3081199] UNITED HEALTHCARE 87726 [308119901] 60.14 percent of total billed charges 60.14 92.15 Technical (Hospital) Services Fat Stain Feces Urine Resp PX-3018912500 CDM 89125 CPT 300 RC outpatient 97 97 HEALTHPARTNERS SX009 HEALTHPARTNERS 77.6 percent of total billed charges 60.14 92.15 Technical (Hospital) Services Fat Stain Feces Urine Resp PX-3018912500 CDM 89125 CPT 300 RC outpatient 97 97 MEDICA (COMMERCIAL) 94265 [3081118] MEDICA CLAIMS [308111801] 87.3 percent of total billed charges 60.14 92.15 Technical (Hospital) Services Fat Stain Feces Urine Resp PX-3018912500 CDM 89125 CPT 300 RC outpatient 97 97 MULTIPLAN INC 34080 [3081285] MULTIPLAN INC [308128501] 92.15 percent of total billed charges 60.14 92.15 Technical (Hospital) Services Fat Stain Feces Urine Resp PX-3018912500 CDM 89125 CPT 300 RC outpatient 97 97 CIGNA 62308 [3081051] CIGNA 62308 [308105105] 77.6 percent of total billed charges 60.14 92.15 Technical (Hospital) Services Fat Stain Feces Urine Resp PX-3018912500 CDM 89125 CPT 300 RC outpatient 97 97 CIGNA 62308 [3081051] CIGNA STATE OF WYOMING [308105107] 77.6 percent of total billed charges 60.14 92.15 Technical (Hospital) Services Fat Stain Feces Urine Resp PX-3018912500 CDM 89125 CPT 300 RC inpatient 97 97 MEDICA (COMMERCIAL) 94265 [3081118] MEDICA CLAIMS [308111801] 87.3 percent of total billed charges 60.14 92.15 Technical (Hospital) Services Fat Stain Feces Urine Resp PX-3018912500 CDM 89125 CPT 300 RC inpatient 97 97 MULTIPLAN INC 34080 [3081285] MULTIPLAN INC [308128501] 92.15 percent of total billed charges 60.14 92.15 Technical (Hospital) Services Fat Stain Feces Urine Resp PX-3018912500 CDM 89125 CPT 300 RC inpatient 97 97 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES EPO [308136803] 76.8 percent of total billed charges 60.14 92.15 Technical (Hospital) Services Fat Stain Feces Urine Resp PX-3018912500 CDM 89125 CPT 300 RC inpatient 97 97 HEALTHPARTNERS SX009 HEALTHPARTNERS 76.8 percent of total billed charges 60.14 92.15 Technical (Hospital) Services Fat Stain Feces Urine Resp PX-3018912500 CDM 89125 CPT 300 RC inpatient 97 97 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES HDHP [308136802] 76.8 percent of total billed charges 60.14 92.15 Technical (Hospital) Services Fat Stain Feces Urine Resp PX-3018912500 CDM 89125 CPT 300 RC inpatient 97 97 BLUE CROSS BLUE SHIELD WELLMARK SB889 [3081026] BCBS WYOMING [308102603] 92.15 percent of total billed charges 60.14 92.15 Technical (Hospital) Services Fat Stain Feces Urine Resp PX-3018912500 CDM 89125 CPT 300 RC inpatient 97 97 UNITED HEALTHCARE (COMMERCIAL) [3081199] UNITED HEALTHCARE 87726 [308119901] 60.14 percent of total billed charges 60.14 92.15 Technical (Hospital) Services Fat Stain Feces Urine Resp PX-3018912500 CDM 89125 CPT 300 RC inpatient 97 97 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES PPO [308136801] 76.8 percent of total billed charges 60.14 92.15 Technical (Hospital) Services Fat Stain Feces Urine Resp PX-3018912500 CDM 89125 CPT 300 RC inpatient 97 97 CIGNA 62308 [3081051] CIGNA 62308 [308105105] 76.8 percent of total billed charges 60.14 92.15 Technical (Hospital) Services Fat Stain Feces Urine Resp PX-3018912500 CDM 89125 CPT 300 RC inpatient 97 97 CIGNA 62308 [3081051] CIGNA STATE OF WYOMING [308105107] 76.8 percent of total billed charges 60.14 92.15 Technical (Hospital) Services Crystal Study Technical PX-3018906000 CDM 89060 CPT 301 RC inpatient 101 101 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES PPO [308136801] 79.97 percent of total billed charges 62.62 95.95 Technical (Hospital) Services Crystal Study Technical PX-3018906000 CDM 89060 CPT 301 RC inpatient 101 101 UNITED HEALTHCARE (COMMERCIAL) [3081199] UNITED HEALTHCARE 87726 [308119901] 62.62 percent of total billed charges 62.62 95.95 Technical (Hospital) Services Crystal Study Technical PX-3018906000 CDM 89060 CPT 301 RC inpatient 101 101 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES HDHP [308136802] 79.97 percent of total billed charges 62.62 95.95 Technical (Hospital) Services Crystal Study Technical PX-3018906000 CDM 89060 CPT 301 RC inpatient 101 101 BLUE CROSS BLUE SHIELD WELLMARK SB889 [3081026] BCBS WYOMING [308102603] 95.95 percent of total billed charges 62.62 95.95 Technical (Hospital) Services Crystal Study Technical PX-3018906000 CDM 89060 CPT 301 RC inpatient 101 101 HEALTHPARTNERS SX009 HEALTHPARTNERS 79.97 percent of total billed charges 62.62 95.95 Technical (Hospital) Services Crystal Study Technical PX-3018906000 CDM 89060 CPT 301 RC inpatient 101 101 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES EPO [308136803] 79.97 percent of total billed charges 62.62 95.95 Technical (Hospital) Services Crystal Study Technical PX-3018906000 CDM 89060 CPT 301 RC inpatient 101 101 CIGNA 62308 [3081051] CIGNA 62308 [308105105] 79.97 percent of total billed charges 62.62 95.95 Technical (Hospital) Services Crystal Study Technical PX-3018906000 CDM 89060 CPT 301 RC inpatient 101 101 CIGNA 62308 [3081051] CIGNA STATE OF WYOMING [308105107] 79.97 percent of total billed charges 62.62 95.95 Technical (Hospital) Services Crystal Study Technical PX-3018906000 CDM 89060 CPT 301 RC inpatient 101 101 MULTIPLAN INC 34080 [3081285] MULTIPLAN INC [308128501] 95.95 percent of total billed charges 62.62 95.95 Technical (Hospital) Services Crystal Study Technical PX-3018906000 CDM 89060 CPT 301 RC inpatient 101 101 MEDICA (COMMERCIAL) 94265 [3081118] MEDICA CLAIMS [308111801] 90.9 percent of total billed charges 62.62 95.95 Technical (Hospital) Services Crystal Study Technical PX-3018906000 CDM 89060 CPT 301 RC outpatient 101 101 MEDICA (COMMERCIAL) 94265 [3081118] MEDICA CLAIMS [308111801] 90.9 percent of total billed charges 62.62 95.95 Technical (Hospital) Services Crystal Study Technical PX-3018906000 CDM 89060 CPT 301 RC outpatient 101 101 MULTIPLAN INC 34080 [3081285] MULTIPLAN INC [308128501] 95.95 percent of total billed charges 62.62 95.95 Technical (Hospital) Services Crystal Study Technical PX-3018906000 CDM 89060 CPT 301 RC outpatient 101 101 HEALTHPARTNERS SX009 HEALTHPARTNERS 80.8 percent of total billed charges 62.62 95.95 Technical (Hospital) Services Crystal Study Technical PX-3018906000 CDM 89060 CPT 301 RC outpatient 101 101 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES PPO [308136801] 80.8 percent of total billed charges 62.62 95.95 Technical (Hospital) Services Crystal Study Technical PX-3018906000 CDM 89060 CPT 301 RC outpatient 101 101 UNITED HEALTHCARE (COMMERCIAL) [3081199] UNITED HEALTHCARE 87726 [308119901] 62.62 percent of total billed charges 62.62 95.95 Technical (Hospital) Services Crystal Study Technical PX-3018906000 CDM 89060 CPT 301 RC outpatient 101 101 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES HDHP [308136802] 80.8 percent of total billed charges 62.62 95.95 Technical (Hospital) Services Crystal Study Technical PX-3018906000 CDM 89060 CPT 301 RC outpatient 101 101 CIGNA 62308 [3081051] CIGNA 62308 [308105105] 80.8 percent of total billed charges 62.62 95.95 Technical (Hospital) Services Crystal Study Technical PX-3018906000 CDM 89060 CPT 301 RC outpatient 101 101 CIGNA 62308 [3081051] CIGNA STATE OF WYOMING [308105107] 80.8 percent of total billed charges 62.62 95.95 Technical (Hospital) Services Crystal Study Technical PX-3018906000 CDM 89060 CPT 301 RC outpatient 101 101 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES EPO [308136803] 80.8 percent of total billed charges 62.62 95.95 Technical (Hospital) Services Crystal Study Technical PX-3018906000 CDM 89060 CPT 301 RC outpatient 101 101 BLUE CROSS BLUE SHIELD WELLMARK SB889 [3081026] BCBS WYOMING [308102603] 95.95 percent of total billed charges 62.62 95.95 Technical (Hospital) Services Fecal Leukocyte Assessment PX-3018905500 CDM 89055 CPT 300 RC outpatient 80 80 BLUE CROSS BLUE SHIELD WELLMARK SB889 [3081026] BCBS WYOMING [308102603] 76 percent of total billed charges 49.6 76 Technical (Hospital) Services Fecal Leukocyte Assessment PX-3018905500 CDM 89055 CPT 300 RC outpatient 80 80 UNITED HEALTHCARE (COMMERCIAL) [3081199] UNITED HEALTHCARE 87726 [308119901] 49.6 percent of total billed charges 49.6 76 Technical (Hospital) Services Fecal Leukocyte Assessment PX-3018905500 CDM 89055 CPT 300 RC outpatient 80 80 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES HDHP [308136802] 64 percent of total billed charges 49.6 76 Technical (Hospital) Services Fecal Leukocyte Assessment PX-3018905500 CDM 89055 CPT 300 RC outpatient 80 80 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES EPO [308136803] 64 percent of total billed charges 49.6 76 Technical (Hospital) Services Fecal Leukocyte Assessment PX-3018905500 CDM 89055 CPT 300 RC outpatient 80 80 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES PPO [308136801] 64 percent of total billed charges 49.6 76 Technical (Hospital) Services Fecal Leukocyte Assessment PX-3018905500 CDM 89055 CPT 300 RC outpatient 80 80 MEDICA (COMMERCIAL) 94265 [3081118] MEDICA CLAIMS [308111801] 72 percent of total billed charges 49.6 76 Technical (Hospital) Services Fecal Leukocyte Assessment PX-3018905500 CDM 89055 CPT 300 RC outpatient 80 80 HEALTHPARTNERS SX009 HEALTHPARTNERS 64 percent of total billed charges 49.6 76 Technical (Hospital) Services Fecal Leukocyte Assessment PX-3018905500 CDM 89055 CPT 300 RC outpatient 80 80 CIGNA 62308 [3081051] CIGNA 62308 [308105105] 64 percent of total billed charges 49.6 76 Technical (Hospital) Services Fecal Leukocyte Assessment PX-3018905500 CDM 89055 CPT 300 RC outpatient 80 80 CIGNA 62308 [3081051] CIGNA STATE OF WYOMING [308105107] 64 percent of total billed charges 49.6 76 Technical (Hospital) Services Fecal Leukocyte Assessment PX-3018905500 CDM 89055 CPT 300 RC outpatient 80 80 MULTIPLAN INC 34080 [3081285] MULTIPLAN INC [308128501] 76 percent of total billed charges 49.6 76 Technical (Hospital) Services Fecal Leukocyte Assessment PX-3018905500 CDM 89055 CPT 300 RC inpatient 80 80 UNITED HEALTHCARE (COMMERCIAL) [3081199] UNITED HEALTHCARE 87726 [308119901] 49.6 percent of total billed charges 49.6 76 Technical (Hospital) Services Fecal Leukocyte Assessment PX-3018905500 CDM 89055 CPT 300 RC inpatient 80 80 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES PPO [308136801] 63.34 percent of total billed charges 49.6 76 Technical (Hospital) Services Fecal Leukocyte Assessment PX-3018905500 CDM 89055 CPT 300 RC inpatient 80 80 BLUE CROSS BLUE SHIELD WELLMARK SB889 [3081026] BCBS WYOMING [308102603] 76 percent of total billed charges 49.6 76 Technical (Hospital) Services Fecal Leukocyte Assessment PX-3018905500 CDM 89055 CPT 300 RC inpatient 80 80 HEALTHPARTNERS SX009 HEALTHPARTNERS 63.34 percent of total billed charges 49.6 76 Technical (Hospital) Services Fecal Leukocyte Assessment PX-3018905500 CDM 89055 CPT 300 RC inpatient 80 80 MULTIPLAN INC 34080 [3081285] MULTIPLAN INC [308128501] 76 percent of total billed charges 49.6 76 Technical (Hospital) Services Fecal Leukocyte Assessment PX-3018905500 CDM 89055 CPT 300 RC inpatient 80 80 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES HDHP [308136802] 63.34 percent of total billed charges 49.6 76 Technical (Hospital) Services Fecal Leukocyte Assessment PX-3018905500 CDM 89055 CPT 300 RC inpatient 80 80 MEDICA (COMMERCIAL) 94265 [3081118] MEDICA CLAIMS [308111801] 72 percent of total billed charges 49.6 76 Technical (Hospital) Services Fecal Leukocyte Assessment PX-3018905500 CDM 89055 CPT 300 RC inpatient 80 80 CIGNA 62308 [3081051] CIGNA 62308 [308105105] 63.34 percent of total billed charges 49.6 76 Technical (Hospital) Services Fecal Leukocyte Assessment PX-3018905500 CDM 89055 CPT 300 RC inpatient 80 80 CIGNA 62308 [3081051] CIGNA STATE OF WYOMING [308105107] 63.34 percent of total billed charges 49.6 76 Technical (Hospital) Services Fecal Leukocyte Assessment PX-3018905500 CDM 89055 CPT 300 RC inpatient 80 80 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES EPO [308136803] 63.34 percent of total billed charges 49.6 76 Technical (Hospital) Services Fecal Leukocyte Assess Qual PX-3018905501 CDM 89055 CPT 300 RC outpatient 80 80 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES PPO [308136801] 64 percent of total billed charges 49.6 76 Technical (Hospital) Services Fecal Leukocyte Assess Qual PX-3018905501 CDM 89055 CPT 300 RC outpatient 80 80 BLUE CROSS BLUE SHIELD WELLMARK SB889 [3081026] BCBS WYOMING [308102603] 76 percent of total billed charges 49.6 76 Technical (Hospital) Services Fecal Leukocyte Assess Qual PX-3018905501 CDM 89055 CPT 300 RC outpatient 80 80 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES HDHP [308136802] 64 percent of total billed charges 49.6 76 Technical (Hospital) Services Fecal Leukocyte Assess Qual PX-3018905501 CDM 89055 CPT 300 RC outpatient 80 80 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES EPO [308136803] 64 percent of total billed charges 49.6 76 Technical (Hospital) Services Fecal Leukocyte Assess Qual PX-3018905501 CDM 89055 CPT 300 RC outpatient 80 80 UNITED HEALTHCARE (COMMERCIAL) [3081199] UNITED HEALTHCARE 87726 [308119901] 49.6 percent of total billed charges 49.6 76 Technical (Hospital) Services Fecal Leukocyte Assess Qual PX-3018905501 CDM 89055 CPT 300 RC outpatient 80 80 HEALTHPARTNERS SX009 HEALTHPARTNERS 64 percent of total billed charges 49.6 76 Technical (Hospital) Services Fecal Leukocyte Assess Qual PX-3018905501 CDM 89055 CPT 300 RC outpatient 80 80 MEDICA (COMMERCIAL) 94265 [3081118] MEDICA CLAIMS [308111801] 72 percent of total billed charges 49.6 76 Technical (Hospital) Services Fecal Leukocyte Assess Qual PX-3018905501 CDM 89055 CPT 300 RC outpatient 80 80 MULTIPLAN INC 34080 [3081285] MULTIPLAN INC [308128501] 76 percent of total billed charges 49.6 76 Technical (Hospital) Services Fecal Leukocyte Assess Qual PX-3018905501 CDM 89055 CPT 300 RC outpatient 80 80 CIGNA 62308 [3081051] CIGNA 62308 [308105105] 64 percent of total billed charges 49.6 76 Technical (Hospital) Services Fecal Leukocyte Assess Qual PX-3018905501 CDM 89055 CPT 300 RC outpatient 80 80 CIGNA 62308 [3081051] CIGNA STATE OF WYOMING [308105107] 64 percent of total billed charges 49.6 76 Technical (Hospital) Services Fecal Leukocyte Assess Qual PX-3018905501 CDM 89055 CPT 300 RC inpatient 80 80 MEDICA (COMMERCIAL) 94265 [3081118] MEDICA CLAIMS [308111801] 72 percent of total billed charges 49.6 76 Technical (Hospital) Services Fecal Leukocyte Assess Qual PX-3018905501 CDM 89055 CPT 300 RC inpatient 80 80 MULTIPLAN INC 34080 [3081285] MULTIPLAN INC [308128501] 76 percent of total billed charges 49.6 76 Technical (Hospital) Services Fecal Leukocyte Assess Qual PX-3018905501 CDM 89055 CPT 300 RC inpatient 80 80 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES HDHP [308136802] 63.34 percent of total billed charges 49.6 76 Technical (Hospital) Services Fecal Leukocyte Assess Qual PX-3018905501 CDM 89055 CPT 300 RC inpatient 80 80 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES EPO [308136803] 63.34 percent of total billed charges 49.6 76 Technical (Hospital) Services Fecal Leukocyte Assess Qual PX-3018905501 CDM 89055 CPT 300 RC inpatient 80 80 HEALTHPARTNERS SX009 HEALTHPARTNERS 63.34 percent of total billed charges 49.6 76 Technical (Hospital) Services Fecal Leukocyte Assess Qual PX-3018905501 CDM 89055 CPT 300 RC inpatient 80 80 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES PPO [308136801] 63.34 percent of total billed charges 49.6 76 Technical (Hospital) Services Fecal Leukocyte Assess Qual PX-3018905501 CDM 89055 CPT 300 RC inpatient 80 80 UNITED HEALTHCARE (COMMERCIAL) [3081199] UNITED HEALTHCARE 87726 [308119901] 49.6 percent of total billed charges 49.6 76 Technical (Hospital) Services Fecal Leukocyte Assess Qual PX-3018905501 CDM 89055 CPT 300 RC inpatient 80 80 BLUE CROSS BLUE SHIELD WELLMARK SB889 [3081026] BCBS WYOMING [308102603] 76 percent of total billed charges 49.6 76 Technical (Hospital) Services Fecal Leukocyte Assess Qual PX-3018905501 CDM 89055 CPT 300 RC inpatient 80 80 CIGNA 62308 [3081051] CIGNA 62308 [308105105] 63.34 percent of total billed charges 49.6 76 Technical (Hospital) Services Fecal Leukocyte Assess Qual PX-3018905501 CDM 89055 CPT 300 RC inpatient 80 80 CIGNA 62308 [3081051] CIGNA STATE OF WYOMING [308105107] 63.34 percent of total billed charges 49.6 76 Technical (Hospital) Services Cell Count Misc Bdyfluid W Dif PX-3018905100 CDM 89051 CPT 301 RC outpatient 97 97 MEDICA (COMMERCIAL) 94265 [3081118] MEDICA CLAIMS [308111801] 87.3 percent of total billed charges 60.14 92.15 Technical (Hospital) Services Cell Count Misc Bdyfluid W Dif PX-3018905100 CDM 89051 CPT 301 RC outpatient 97 97 MULTIPLAN INC 34080 [3081285] MULTIPLAN INC [308128501] 92.15 percent of total billed charges 60.14 92.15 Technical (Hospital) Services Cell Count Misc Bdyfluid W Dif PX-3018905100 CDM 89051 CPT 301 RC outpatient 97 97 HEALTHPARTNERS SX009 HEALTHPARTNERS 77.6 percent of total billed charges 60.14 92.15 Technical (Hospital) Services Cell Count Misc Bdyfluid W Dif PX-3018905100 CDM 89051 CPT 301 RC outpatient 97 97 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES PPO [308136801] 77.6 percent of total billed charges 60.14 92.15 Technical (Hospital) Services Cell Count Misc Bdyfluid W Dif PX-3018905100 CDM 89051 CPT 301 RC outpatient 97 97 UNITED HEALTHCARE (COMMERCIAL) [3081199] UNITED HEALTHCARE 87726 [308119901] 60.14 percent of total billed charges 60.14 92.15 Technical (Hospital) Services Cell Count Misc Bdyfluid W Dif PX-3018905100 CDM 89051 CPT 301 RC outpatient 97 97 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES HDHP [308136802] 77.6 percent of total billed charges 60.14 92.15 Technical (Hospital) Services Cell Count Misc Bdyfluid W Dif PX-3018905100 CDM 89051 CPT 301 RC outpatient 97 97 CIGNA 62308 [3081051] CIGNA STATE OF WYOMING [308105107] 77.6 percent of total billed charges 60.14 92.15 Technical (Hospital) Services Cell Count Misc Bdyfluid W Dif PX-3018905100 CDM 89051 CPT 301 RC outpatient 97 97 CIGNA 62308 [3081051] CIGNA 62308 [308105105] 77.6 percent of total billed charges 60.14 92.15 Technical (Hospital) Services Cell Count Misc Bdyfluid W Dif PX-3018905100 CDM 89051 CPT 301 RC outpatient 97 97 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES EPO [308136803] 77.6 percent of total billed charges 60.14 92.15 Technical (Hospital) Services Cell Count Misc Bdyfluid W Dif PX-3018905100 CDM 89051 CPT 301 RC outpatient 97 97 BLUE CROSS BLUE SHIELD WELLMARK SB889 [3081026] BCBS WYOMING [308102603] 92.15 percent of total billed charges 60.14 92.15 Technical (Hospital) Services Cell Count Misc Bdyfluid W Dif PX-3018905100 CDM 89051 CPT 301 RC inpatient 97 97 MEDICA (COMMERCIAL) 94265 [3081118] MEDICA CLAIMS [308111801] 87.3 percent of total billed charges 60.14 92.15 Technical (Hospital) Services Cell Count Misc Bdyfluid W Dif PX-3018905100 CDM 89051 CPT 301 RC inpatient 97 97 MULTIPLAN INC 34080 [3081285] MULTIPLAN INC [308128501] 92.15 percent of total billed charges 60.14 92.15 Technical (Hospital) Services Cell Count Misc Bdyfluid W Dif PX-3018905100 CDM 89051 CPT 301 RC inpatient 97 97 CIGNA 62308 [3081051] CIGNA 62308 [308105105] 76.8 percent of total billed charges 60.14 92.15 Technical (Hospital) Services Cell Count Misc Bdyfluid W Dif PX-3018905100 CDM 89051 CPT 301 RC inpatient 97 97 CIGNA 62308 [3081051] CIGNA STATE OF WYOMING [308105107] 76.8 percent of total billed charges 60.14 92.15 Technical (Hospital) Services Cell Count Misc Bdyfluid W Dif PX-3018905100 CDM 89051 CPT 301 RC inpatient 97 97 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES EPO [308136803] 76.8 percent of total billed charges 60.14 92.15 Technical (Hospital) Services Cell Count Misc Bdyfluid W Dif PX-3018905100 CDM 89051 CPT 301 RC inpatient 97 97 HEALTHPARTNERS SX009 HEALTHPARTNERS 76.8 percent of total billed charges 60.14 92.15 Technical (Hospital) Services Cell Count Misc Bdyfluid W Dif PX-3018905100 CDM 89051 CPT 301 RC inpatient 97 97 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES HDHP [308136802] 76.8 percent of total billed charges 60.14 92.15 Technical (Hospital) Services Cell Count Misc Bdyfluid W Dif PX-3018905100 CDM 89051 CPT 301 RC inpatient 97 97 BLUE CROSS BLUE SHIELD WELLMARK SB889 [3081026] BCBS WYOMING [308102603] 92.15 percent of total billed charges 60.14 92.15 Technical (Hospital) Services Cell Count Misc Bdyfluid W Dif PX-3018905100 CDM 89051 CPT 301 RC inpatient 97 97 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES PPO [308136801] 76.8 percent of total billed charges 60.14 92.15 Technical (Hospital) Services Cell Count Misc Bdyfluid W Dif PX-3018905100 CDM 89051 CPT 301 RC inpatient 97 97 UNITED HEALTHCARE (COMMERCIAL) [3081199] UNITED HEALTHCARE 87726 [308119901] 60.14 percent of total billed charges 60.14 92.15 Technical (Hospital) Services Consltj&Reprt Slides Prepared Elsewhere PX-3128832100 CDM 88321 CPT 312 RC inpatient 600 600 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES HDHP [308136802] 475.08 percent of total billed charges 372 570 Technical (Hospital) Services Consltj&Reprt Slides Prepared Elsewhere PX-3128832100 CDM 88321 CPT 312 RC inpatient 600 600 UNITED HEALTHCARE (COMMERCIAL) [3081199] UNITED HEALTHCARE 87726 [308119901] 372 percent of total billed charges 372 570 Technical (Hospital) Services Consltj&Reprt Slides Prepared Elsewhere PX-3128832100 CDM 88321 CPT 312 RC inpatient 600 600 MEDICA (COMMERCIAL) 94265 [3081118] MEDICA CLAIMS [308111801] 540 percent of total billed charges 372 570 Technical (Hospital) Services Consltj&Reprt Slides Prepared Elsewhere PX-3128832100 CDM 88321 CPT 312 RC inpatient 600 600 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES PPO [308136801] 475.08 percent of total billed charges 372 570 Technical (Hospital) Services Consltj&Reprt Slides Prepared Elsewhere PX-3128832100 CDM 88321 CPT 312 RC inpatient 600 600 HEALTHPARTNERS SX009 HEALTHPARTNERS 475.08 percent of total billed charges 372 570 Technical (Hospital) Services Consltj&Reprt Slides Prepared Elsewhere PX-3128832100 CDM 88321 CPT 312 RC inpatient 600 600 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES EPO [308136803] 475.08 percent of total billed charges 372 570 Technical (Hospital) Services Consltj&Reprt Slides Prepared Elsewhere PX-3128832100 CDM 88321 CPT 312 RC inpatient 600 600 MULTIPLAN INC 34080 [3081285] MULTIPLAN INC [308128501] 570 percent of total billed charges 372 570 Technical (Hospital) Services Consltj&Reprt Slides Prepared Elsewhere PX-3128832100 CDM 88321 CPT 312 RC inpatient 600 600 CIGNA 62308 [3081051] CIGNA 62308 [308105105] 475.08 percent of total billed charges 372 570 Technical (Hospital) Services Consltj&Reprt Slides Prepared Elsewhere PX-3128832100 CDM 88321 CPT 312 RC inpatient 600 600 CIGNA 62308 [3081051] CIGNA STATE OF WYOMING [308105107] 475.08 percent of total billed charges 372 570 Technical (Hospital) Services Consltj&Reprt Slides Prepared Elsewhere PX-3128832100 CDM 88321 CPT 312 RC inpatient 600 600 BLUE CROSS BLUE SHIELD WELLMARK SB889 [3081026] BCBS WYOMING [308102603] 570 percent of total billed charges 372 570 Technical (Hospital) Services Consltj&Reprt Slides Prepared Elsewhere PX-3128832100 CDM 88321 CPT 312 RC outpatient 600 600 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES PPO [308136801] 480 percent of total billed charges 372 570 Technical (Hospital) Services Consltj&Reprt Slides Prepared Elsewhere PX-3128832100 CDM 88321 CPT 312 RC outpatient 600 600 HEALTHPARTNERS SX009 HEALTHPARTNERS 480 percent of total billed charges 372 570 Technical (Hospital) Services Consltj&Reprt Slides Prepared Elsewhere PX-3128832100 CDM 88321 CPT 312 RC outpatient 600 600 UNITED HEALTHCARE (COMMERCIAL) [3081199] UNITED HEALTHCARE 87726 [308119901] 372 percent of total billed charges 372 570 Technical (Hospital) Services Consltj&Reprt Slides Prepared Elsewhere PX-3128832100 CDM 88321 CPT 312 RC outpatient 600 600 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES HDHP [308136802] 480 percent of total billed charges 372 570 Technical (Hospital) Services Consltj&Reprt Slides Prepared Elsewhere PX-3128832100 CDM 88321 CPT 312 RC outpatient 600 600 BLUE CROSS BLUE SHIELD WELLMARK SB889 [3081026] BCBS WYOMING [308102603] 570 percent of total billed charges 372 570 Technical (Hospital) Services Consltj&Reprt Slides Prepared Elsewhere PX-3128832100 CDM 88321 CPT 312 RC outpatient 600 600 CIGNA 62308 [3081051] CIGNA STATE OF WYOMING [308105107] 480 percent of total billed charges 372 570 Technical (Hospital) Services Consltj&Reprt Slides Prepared Elsewhere PX-3128832100 CDM 88321 CPT 312 RC outpatient 600 600 CIGNA 62308 [3081051] CIGNA 62308 [308105105] 480 percent of total billed charges 372 570 Technical (Hospital) Services Consltj&Reprt Slides Prepared Elsewhere PX-3128832100 CDM 88321 CPT 312 RC outpatient 600 600 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES EPO [308136803] 480 percent of total billed charges 372 570 Technical (Hospital) Services Consltj&Reprt Slides Prepared Elsewhere PX-3128832100 CDM 88321 CPT 312 RC outpatient 600 600 MEDICA (COMMERCIAL) 94265 [3081118] MEDICA CLAIMS [308111801] 540 percent of total billed charges 372 570 Technical (Hospital) Services Consltj&Reprt Slides Prepared Elsewhere PX-3128832100 CDM 88321 CPT 312 RC outpatient 600 600 MULTIPLAN INC 34080 [3081285] MULTIPLAN INC [308128501] 570 percent of total billed charges 372 570 Technical (Hospital) Services Ref Chromhem Interp & Report PX-3118829105 CDM 88291 CPT 311 RC outpatient 213 213 CIGNA 62308 [3081051] CIGNA 62308 [308105105] 170.4 percent of total billed charges 132.06 202.35 Technical (Hospital) Services Ref Chromhem Interp & Report PX-3118829105 CDM 88291 CPT 311 RC outpatient 213 213 CIGNA 62308 [3081051] CIGNA STATE OF WYOMING [308105107] 170.4 percent of total billed charges 132.06 202.35 Technical (Hospital) Services Ref Chromhem Interp & Report PX-3118829105 CDM 88291 CPT 311 RC outpatient 213 213 BLUE CROSS BLUE SHIELD WELLMARK SB889 [3081026] BCBS WYOMING [308102603] 202.35 percent of total billed charges 132.06 202.35 Technical (Hospital) Services Ref Chromhem Interp & Report PX-3118829105 CDM 88291 CPT 311 RC outpatient 213 213 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES EPO [308136803] 170.4 percent of total billed charges 132.06 202.35 Technical (Hospital) Services Ref Chromhem Interp & Report PX-3118829105 CDM 88291 CPT 311 RC outpatient 213 213 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES HDHP [308136802] 170.4 percent of total billed charges 132.06 202.35 Technical (Hospital) Services Ref Chromhem Interp & Report PX-3118829105 CDM 88291 CPT 311 RC outpatient 213 213 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES PPO [308136801] 170.4 percent of total billed charges 132.06 202.35 Technical (Hospital) Services Ref Chromhem Interp & Report PX-3118829105 CDM 88291 CPT 311 RC outpatient 213 213 HEALTHPARTNERS SX009 HEALTHPARTNERS 170.4 percent of total billed charges 132.06 202.35 Technical (Hospital) Services Ref Chromhem Interp & Report PX-3118829105 CDM 88291 CPT 311 RC outpatient 213 213 UNITED HEALTHCARE (COMMERCIAL) [3081199] UNITED HEALTHCARE 87726 [308119901] 132.06 percent of total billed charges 132.06 202.35 Technical (Hospital) Services Ref Chromhem Interp & Report PX-3118829105 CDM 88291 CPT 311 RC outpatient 213 213 MEDICA (COMMERCIAL) 94265 [3081118] MEDICA CLAIMS [308111801] 191.7 percent of total billed charges 132.06 202.35 Technical (Hospital) Services Ref Chromhem Interp & Report PX-3118829105 CDM 88291 CPT 311 RC outpatient 213 213 MULTIPLAN INC 34080 [3081285] MULTIPLAN INC [308128501] 202.35 percent of total billed charges 132.06 202.35 Technical (Hospital) Services Ref Chromhem Interp & Report PX-3118829105 CDM 88291 CPT 311 RC inpatient 213 213 UNITED HEALTHCARE (COMMERCIAL) [3081199] UNITED HEALTHCARE 87726 [308119901] 132.06 percent of total billed charges 132.06 202.35 Technical (Hospital) Services Ref Chromhem Interp & Report PX-3118829105 CDM 88291 CPT 311 RC inpatient 213 213 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES HDHP [308136802] 168.65 percent of total billed charges 132.06 202.35 Technical (Hospital) Services Ref Chromhem Interp & Report PX-3118829105 CDM 88291 CPT 311 RC inpatient 213 213 MEDICA (COMMERCIAL) 94265 [3081118] MEDICA CLAIMS [308111801] 191.7 percent of total billed charges 132.06 202.35 Technical (Hospital) Services Ref Chromhem Interp & Report PX-3118829105 CDM 88291 CPT 311 RC inpatient 213 213 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES PPO [308136801] 168.65 percent of total billed charges 132.06 202.35 Technical (Hospital) Services Ref Chromhem Interp & Report PX-3118829105 CDM 88291 CPT 311 RC inpatient 213 213 HEALTHPARTNERS SX009 HEALTHPARTNERS 168.65 percent of total billed charges 132.06 202.35 Technical (Hospital) Services Ref Chromhem Interp & Report PX-3118829105 CDM 88291 CPT 311 RC inpatient 213 213 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES EPO [308136803] 168.65 percent of total billed charges 132.06 202.35 Technical (Hospital) Services Ref Chromhem Interp & Report PX-3118829105 CDM 88291 CPT 311 RC inpatient 213 213 CIGNA 62308 [3081051] CIGNA STATE OF WYOMING [308105107] 168.65 percent of total billed charges 132.06 202.35 Technical (Hospital) Services Ref Chromhem Interp & Report PX-3118829105 CDM 88291 CPT 311 RC inpatient 213 213 CIGNA 62308 [3081051] CIGNA 62308 [308105105] 168.65 percent of total billed charges 132.06 202.35 Technical (Hospital) Services Ref Chromhem Interp & Report PX-3118829105 CDM 88291 CPT 311 RC inpatient 213 213 MULTIPLAN INC 34080 [3081285] MULTIPLAN INC [308128501] 202.35 percent of total billed charges 132.06 202.35 Technical (Hospital) Services Ref Chromhem Interp & Report PX-3118829105 CDM 88291 CPT 311 RC inpatient 213 213 BLUE CROSS BLUE SHIELD WELLMARK SB889 [3081026] BCBS WYOMING [308102603] 202.35 percent of total billed charges 132.06 202.35 Technical (Hospital) Services Ref Cll Fish Interp & Report PX-3118829106 CDM 88291 CPT 311 RC inpatient 204 204 BLUE CROSS BLUE SHIELD WELLMARK SB889 [3081026] BCBS WYOMING [308102603] 193.8 percent of total billed charges 126.48 193.8 Technical (Hospital) Services Ref Cll Fish Interp & Report PX-3118829106 CDM 88291 CPT 311 RC inpatient 204 204 MULTIPLAN INC 34080 [3081285] MULTIPLAN INC [308128501] 193.8 percent of total billed charges 126.48 193.8 Technical (Hospital) Services Ref Cll Fish Interp & Report PX-3118829106 CDM 88291 CPT 311 RC inpatient 204 204 CIGNA 62308 [3081051] CIGNA 62308 [308105105] 161.53 percent of total billed charges 126.48 193.8 Technical (Hospital) Services Ref Cll Fish Interp & Report PX-3118829106 CDM 88291 CPT 311 RC inpatient 204 204 CIGNA 62308 [3081051] CIGNA STATE OF WYOMING [308105107] 161.53 percent of total billed charges 126.48 193.8 Technical (Hospital) Services Ref Cll Fish Interp & Report PX-3118829106 CDM 88291 CPT 311 RC inpatient 204 204 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES EPO [308136803] 161.53 percent of total billed charges 126.48 193.8 Technical (Hospital) Services Ref Cll Fish Interp & Report PX-3118829106 CDM 88291 CPT 311 RC inpatient 204 204 HEALTHPARTNERS SX009 HEALTHPARTNERS 161.53 percent of total billed charges 126.48 193.8 Technical (Hospital) Services Ref Cll Fish Interp & Report PX-3118829106 CDM 88291 CPT 311 RC inpatient 204 204 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES PPO [308136801] 161.53 percent of total billed charges 126.48 193.8 Technical (Hospital) Services Ref Cll Fish Interp & Report PX-3118829106 CDM 88291 CPT 311 RC inpatient 204 204 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES HDHP [308136802] 161.53 percent of total billed charges 126.48 193.8 Technical (Hospital) Services Ref Cll Fish Interp & Report PX-3118829106 CDM 88291 CPT 311 RC inpatient 204 204 UNITED HEALTHCARE (COMMERCIAL) [3081199] UNITED HEALTHCARE 87726 [308119901] 126.48 percent of total billed charges 126.48 193.8 Technical (Hospital) Services Ref Cll Fish Interp & Report PX-3118829106 CDM 88291 CPT 311 RC inpatient 204 204 MEDICA (COMMERCIAL) 94265 [3081118] MEDICA CLAIMS [308111801] 183.6 percent of total billed charges 126.48 193.8 Technical (Hospital) Services Ref Cll Fish Interp & Report PX-3118829106 CDM 88291 CPT 311 RC outpatient 204 204 MULTIPLAN INC 34080 [3081285] MULTIPLAN INC [308128501] 193.8 percent of total billed charges 126.48 193.8 Technical (Hospital) Services Ref Cll Fish Interp & Report PX-3118829106 CDM 88291 CPT 311 RC outpatient 204 204 MEDICA (COMMERCIAL) 94265 [3081118] MEDICA CLAIMS [308111801] 183.6 percent of total billed charges 126.48 193.8 Technical (Hospital) Services Ref Cll Fish Interp & Report PX-3118829106 CDM 88291 CPT 311 RC outpatient 204 204 UNITED HEALTHCARE (COMMERCIAL) [3081199] UNITED HEALTHCARE 87726 [308119901] 126.48 percent of total billed charges 126.48 193.8 Technical (Hospital) Services Ref Cll Fish Interp & Report PX-3118829106 CDM 88291 CPT 311 RC outpatient 204 204 HEALTHPARTNERS SX009 HEALTHPARTNERS 163.2 percent of total billed charges 126.48 193.8 Technical (Hospital) Services Ref Cll Fish Interp & Report PX-3118829106 CDM 88291 CPT 311 RC outpatient 204 204 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES PPO [308136801] 163.2 percent of total billed charges 126.48 193.8 Technical (Hospital) Services Ref Cll Fish Interp & Report PX-3118829106 CDM 88291 CPT 311 RC outpatient 204 204 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES EPO [308136803] 163.2 percent of total billed charges 126.48 193.8 Technical (Hospital) Services Ref Cll Fish Interp & Report PX-3118829106 CDM 88291 CPT 311 RC outpatient 204 204 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES HDHP [308136802] 163.2 percent of total billed charges 126.48 193.8 Technical (Hospital) Services Ref Cll Fish Interp & Report PX-3118829106 CDM 88291 CPT 311 RC outpatient 204 204 BLUE CROSS BLUE SHIELD WELLMARK SB889 [3081026] BCBS WYOMING [308102603] 193.8 percent of total billed charges 126.48 193.8 Technical (Hospital) Services Ref Cll Fish Interp & Report PX-3118829106 CDM 88291 CPT 311 RC outpatient 204 204 CIGNA 62308 [3081051] CIGNA 62308 [308105105] 163.2 percent of total billed charges 126.48 193.8 Technical (Hospital) Services Ref Cll Fish Interp & Report PX-3118829106 CDM 88291 CPT 311 RC outpatient 204 204 CIGNA 62308 [3081051] CIGNA STATE OF WYOMING [308105107] 163.2 percent of total billed charges 126.48 193.8 Technical (Hospital) Services Ref Cll Fish PX-3118827102 CDM 88271 CPT 311 RC inpatient 151 151 MEDICA (COMMERCIAL) 94265 [3081118] MEDICA CLAIMS [308111801] 135.9 percent of total billed charges 93.62 143.45 Technical (Hospital) Services Ref Cll Fish PX-3118827102 CDM 88271 CPT 311 RC inpatient 151 151 UNITED HEALTHCARE (COMMERCIAL) [3081199] UNITED HEALTHCARE 87726 [308119901] 93.62 percent of total billed charges 93.62 143.45 Technical (Hospital) Services Ref Cll Fish PX-3118827102 CDM 88271 CPT 311 RC inpatient 151 151 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES HDHP [308136802] 119.56 percent of total billed charges 93.62 143.45 Technical (Hospital) Services Ref Cll Fish PX-3118827102 CDM 88271 CPT 311 RC inpatient 151 151 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES PPO [308136801] 119.56 percent of total billed charges 93.62 143.45 Technical (Hospital) Services Ref Cll Fish PX-3118827102 CDM 88271 CPT 311 RC inpatient 151 151 HEALTHPARTNERS SX009 HEALTHPARTNERS 119.56 percent of total billed charges 93.62 143.45 Technical (Hospital) Services Ref Cll Fish PX-3118827102 CDM 88271 CPT 311 RC inpatient 151 151 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES EPO [308136803] 119.56 percent of total billed charges 93.62 143.45 Technical (Hospital) Services Ref Cll Fish PX-3118827102 CDM 88271 CPT 311 RC inpatient 151 151 CIGNA 62308 [3081051] CIGNA 62308 [308105105] 119.56 percent of total billed charges 93.62 143.45 Technical (Hospital) Services Ref Cll Fish PX-3118827102 CDM 88271 CPT 311 RC inpatient 151 151 CIGNA 62308 [3081051] CIGNA STATE OF WYOMING [308105107] 119.56 percent of total billed charges 93.62 143.45 Technical (Hospital) Services Ref Cll Fish PX-3118827102 CDM 88271 CPT 311 RC inpatient 151 151 MULTIPLAN INC 34080 [3081285] MULTIPLAN INC [308128501] 143.45 percent of total billed charges 93.62 143.45 Technical (Hospital) Services Ref Cll Fish PX-3118827102 CDM 88271 CPT 311 RC inpatient 151 151 BLUE CROSS BLUE SHIELD WELLMARK SB889 [3081026] BCBS WYOMING [308102603] 143.45 percent of total billed charges 93.62 143.45 Technical (Hospital) Services Ref Cll Fish PX-3118827102 CDM 88271 CPT 311 RC outpatient 151 151 CIGNA 62308 [3081051] CIGNA STATE OF WYOMING [308105107] 120.8 percent of total billed charges 93.62 143.45 Technical (Hospital) Services Ref Cll Fish PX-3118827102 CDM 88271 CPT 311 RC outpatient 151 151 CIGNA 62308 [3081051] CIGNA 62308 [308105105] 120.8 percent of total billed charges 93.62 143.45 Technical (Hospital) Services Ref Cll Fish PX-3118827102 CDM 88271 CPT 311 RC outpatient 151 151 BLUE CROSS BLUE SHIELD WELLMARK SB889 [3081026] BCBS WYOMING [308102603] 143.45 percent of total billed charges 93.62 143.45 Technical (Hospital) Services Ref Cll Fish PX-3118827102 CDM 88271 CPT 311 RC outpatient 151 151 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES HDHP [308136802] 120.8 percent of total billed charges 93.62 143.45 Technical (Hospital) Services Ref Cll Fish PX-3118827102 CDM 88271 CPT 311 RC outpatient 151 151 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES EPO [308136803] 120.8 percent of total billed charges 93.62 143.45 Technical (Hospital) Services Ref Cll Fish PX-3118827102 CDM 88271 CPT 311 RC outpatient 151 151 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES PPO [308136801] 120.8 percent of total billed charges 93.62 143.45 Technical (Hospital) Services Ref Cll Fish PX-3118827102 CDM 88271 CPT 311 RC outpatient 151 151 HEALTHPARTNERS SX009 HEALTHPARTNERS 120.8 percent of total billed charges 93.62 143.45 Technical (Hospital) Services Ref Cll Fish PX-3118827102 CDM 88271 CPT 311 RC outpatient 151 151 UNITED HEALTHCARE (COMMERCIAL) [3081199] UNITED HEALTHCARE 87726 [308119901] 93.62 percent of total billed charges 93.62 143.45 Technical (Hospital) Services Ref Cll Fish PX-3118827102 CDM 88271 CPT 311 RC outpatient 151 151 MEDICA (COMMERCIAL) 94265 [3081118] MEDICA CLAIMS [308111801] 135.9 percent of total billed charges 93.62 143.45 Technical (Hospital) Services Ref Cll Fish PX-3118827102 CDM 88271 CPT 311 RC outpatient 151 151 MULTIPLAN INC 34080 [3081285] MULTIPLAN INC [308128501] 143.45 percent of total billed charges 93.62 143.45 Technical (Hospital) Services Ref Chromosomes Congenital Blood PX-3118826200 CDM 88262 CPT 311 RC outpatient 802 802 UNITED HEALTHCARE (COMMERCIAL) [3081199] UNITED HEALTHCARE 87726 [308119901] 497.24 percent of total billed charges 497.24 761.9 Technical (Hospital) Services Ref Chromosomes Congenital Blood PX-3118826200 CDM 88262 CPT 311 RC outpatient 802 802 HEALTHPARTNERS SX009 HEALTHPARTNERS 641.6 percent of total billed charges 497.24 761.9 Technical (Hospital) Services Ref Chromosomes Congenital Blood PX-3118826200 CDM 88262 CPT 311 RC outpatient 802 802 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES PPO [308136801] 641.6 percent of total billed charges 497.24 761.9 Technical (Hospital) Services Ref Chromosomes Congenital Blood PX-3118826200 CDM 88262 CPT 311 RC outpatient 802 802 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES HDHP [308136802] 641.6 percent of total billed charges 497.24 761.9 Technical (Hospital) Services Ref Chromosomes Congenital Blood PX-3118826200 CDM 88262 CPT 311 RC outpatient 802 802 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES EPO [308136803] 641.6 percent of total billed charges 497.24 761.9 Technical (Hospital) Services Ref Chromosomes Congenital Blood PX-3118826200 CDM 88262 CPT 311 RC outpatient 802 802 CIGNA 62308 [3081051] CIGNA 62308 [308105105] 641.6 percent of total billed charges 497.24 761.9 Technical (Hospital) Services Ref Chromosomes Congenital Blood PX-3118826200 CDM 88262 CPT 311 RC outpatient 802 802 CIGNA 62308 [3081051] CIGNA STATE OF WYOMING [308105107] 641.6 percent of total billed charges 497.24 761.9 Technical (Hospital) Services Ref Chromosomes Congenital Blood PX-3118826200 CDM 88262 CPT 311 RC outpatient 802 802 BLUE CROSS BLUE SHIELD WELLMARK SB889 [3081026] BCBS WYOMING [308102603] 761.9 percent of total billed charges 497.24 761.9 Technical (Hospital) Services Ref Chromosomes Congenital Blood PX-3118826200 CDM 88262 CPT 311 RC outpatient 802 802 MULTIPLAN INC 34080 [3081285] MULTIPLAN INC [308128501] 761.9 percent of total billed charges 497.24 761.9 Technical (Hospital) Services Ref Chromosomes Congenital Blood PX-3118826200 CDM 88262 CPT 311 RC outpatient 802 802 MEDICA (COMMERCIAL) 94265 [3081118] MEDICA CLAIMS [308111801] 721.8 percent of total billed charges 497.24 761.9 Technical (Hospital) Services Ref Chromosomes Congenital Blood PX-3118826200 CDM 88262 CPT 311 RC inpatient 802 802 UNITED HEALTHCARE (COMMERCIAL) [3081199] UNITED HEALTHCARE 87726 [308119901] 497.24 percent of total billed charges 497.24 761.9 Technical (Hospital) Services Ref Chromosomes Congenital Blood PX-3118826200 CDM 88262 CPT 311 RC inpatient 802 802 MEDICA (COMMERCIAL) 94265 [3081118] MEDICA CLAIMS [308111801] 721.8 percent of total billed charges 497.24 761.9 Technical (Hospital) Services Ref Chromosomes Congenital Blood PX-3118826200 CDM 88262 CPT 311 RC inpatient 802 802 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES HDHP [308136802] 635.02 percent of total billed charges 497.24 761.9 Technical (Hospital) Services Ref Chromosomes Congenital Blood PX-3118826200 CDM 88262 CPT 311 RC inpatient 802 802 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES EPO [308136803] 635.02 percent of total billed charges 497.24 761.9 Technical (Hospital) Services Ref Chromosomes Congenital Blood PX-3118826200 CDM 88262 CPT 311 RC inpatient 802 802 HEALTHPARTNERS SX009 HEALTHPARTNERS 635.02 percent of total billed charges 497.24 761.9 Technical (Hospital) Services Ref Chromosomes Congenital Blood PX-3118826200 CDM 88262 CPT 311 RC inpatient 802 802 BLUE CROSS BLUE SHIELD WELLMARK SB889 [3081026] BCBS WYOMING [308102603] 761.9 percent of total billed charges 497.24 761.9 Technical (Hospital) Services Ref Chromosomes Congenital Blood PX-3118826200 CDM 88262 CPT 311 RC inpatient 802 802 MULTIPLAN INC 34080 [3081285] MULTIPLAN INC [308128501] 761.9 percent of total billed charges 497.24 761.9 Technical (Hospital) Services Ref Chromosomes Congenital Blood PX-3118826200 CDM 88262 CPT 311 RC inpatient 802 802 CIGNA 62308 [3081051] CIGNA 62308 [308105105] 635.02 percent of total billed charges 497.24 761.9 Technical (Hospital) Services Ref Chromosomes Congenital Blood PX-3118826200 CDM 88262 CPT 311 RC inpatient 802 802 CIGNA 62308 [3081051] CIGNA STATE OF WYOMING [308105107] 635.02 percent of total billed charges 497.24 761.9 Technical (Hospital) Services Ref Chromosomes Congenital Blood PX-3118826200 CDM 88262 CPT 311 RC inpatient 802 802 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES PPO [308136801] 635.02 percent of total billed charges 497.24 761.9 Technical (Hospital) Services "Ref Chromosomes, Hematologic Blood" PX-3118823702 CDM 88237 CPT 311 RC inpatient 784 784 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES PPO [308136801] 620.77 percent of total billed charges 486.08 744.8 Technical (Hospital) Services "Ref Chromosomes, Hematologic Blood" PX-3118823702 CDM 88237 CPT 311 RC inpatient 784 784 CIGNA 62308 [3081051] CIGNA 62308 [308105105] 620.77 percent of total billed charges 486.08 744.8 Technical (Hospital) Services "Ref Chromosomes, Hematologic Blood" PX-3118823702 CDM 88237 CPT 311 RC inpatient 784 784 CIGNA 62308 [3081051] CIGNA STATE OF WYOMING [308105107] 620.77 percent of total billed charges 486.08 744.8 Technical (Hospital) Services "Ref Chromosomes, Hematologic Blood" PX-3118823702 CDM 88237 CPT 311 RC inpatient 784 784 MULTIPLAN INC 34080 [3081285] MULTIPLAN INC [308128501] 744.8 percent of total billed charges 486.08 744.8 Technical (Hospital) Services "Ref Chromosomes, Hematologic Blood" PX-3118823702 CDM 88237 CPT 311 RC inpatient 784 784 BLUE CROSS BLUE SHIELD WELLMARK SB889 [3081026] BCBS WYOMING [308102603] 744.8 percent of total billed charges 486.08 744.8 Technical (Hospital) Services "Ref Chromosomes, Hematologic Blood" PX-3118823702 CDM 88237 CPT 311 RC inpatient 784 784 HEALTHPARTNERS SX009 HEALTHPARTNERS 620.77 percent of total billed charges 486.08 744.8 Technical (Hospital) Services "Ref Chromosomes, Hematologic Blood" PX-3118823702 CDM 88237 CPT 311 RC inpatient 784 784 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES EPO [308136803] 620.77 percent of total billed charges 486.08 744.8 Technical (Hospital) Services "Ref Chromosomes, Hematologic Blood" PX-3118823702 CDM 88237 CPT 311 RC inpatient 784 784 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES HDHP [308136802] 620.77 percent of total billed charges 486.08 744.8 Technical (Hospital) Services "Ref Chromosomes, Hematologic Blood" PX-3118823702 CDM 88237 CPT 311 RC inpatient 784 784 MEDICA (COMMERCIAL) 94265 [3081118] MEDICA CLAIMS [308111801] 705.6 percent of total billed charges 486.08 744.8 Technical (Hospital) Services "Ref Chromosomes, Hematologic Blood" PX-3118823702 CDM 88237 CPT 311 RC inpatient 784 784 UNITED HEALTHCARE (COMMERCIAL) [3081199] UNITED HEALTHCARE 87726 [308119901] 486.08 percent of total billed charges 486.08 744.8 Technical (Hospital) Services "Ref Chromosomes, Hematologic Blood" PX-3118823702 CDM 88237 CPT 311 RC outpatient 784 784 UNITED HEALTHCARE (COMMERCIAL) [3081199] UNITED HEALTHCARE 87726 [308119901] 486.08 percent of total billed charges 486.08 744.8 Technical (Hospital) Services "Ref Chromosomes, Hematologic Blood" PX-3118823702 CDM 88237 CPT 311 RC outpatient 784 784 BLUE CROSS BLUE SHIELD WELLMARK SB889 [3081026] BCBS WYOMING [308102603] 744.8 percent of total billed charges 486.08 744.8 Technical (Hospital) Services "Ref Chromosomes, Hematologic Blood" PX-3118823702 CDM 88237 CPT 311 RC outpatient 784 784 CIGNA 62308 [3081051] CIGNA 62308 [308105105] 627.2 percent of total billed charges 486.08 744.8 Technical (Hospital) Services "Ref Chromosomes, Hematologic Blood" PX-3118823702 CDM 88237 CPT 311 RC outpatient 784 784 CIGNA 62308 [3081051] CIGNA STATE OF WYOMING [308105107] 627.2 percent of total billed charges 486.08 744.8 Technical (Hospital) Services "Ref Chromosomes, Hematologic Blood" PX-3118823702 CDM 88237 CPT 311 RC outpatient 784 784 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES EPO [308136803] 627.2 percent of total billed charges 486.08 744.8 Technical (Hospital) Services "Ref Chromosomes, Hematologic Blood" PX-3118823702 CDM 88237 CPT 311 RC outpatient 784 784 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES HDHP [308136802] 627.2 percent of total billed charges 486.08 744.8 Technical (Hospital) Services "Ref Chromosomes, Hematologic Blood" PX-3118823702 CDM 88237 CPT 311 RC outpatient 784 784 HEALTHPARTNERS SX009 HEALTHPARTNERS 627.2 percent of total billed charges 486.08 744.8 Technical (Hospital) Services "Ref Chromosomes, Hematologic Blood" PX-3118823702 CDM 88237 CPT 311 RC outpatient 784 784 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES PPO [308136801] 627.2 percent of total billed charges 486.08 744.8 Technical (Hospital) Services "Ref Chromosomes, Hematologic Blood" PX-3118823702 CDM 88237 CPT 311 RC outpatient 784 784 MULTIPLAN INC 34080 [3081285] MULTIPLAN INC [308128501] 744.8 percent of total billed charges 486.08 744.8 Technical (Hospital) Services "Ref Chromosomes, Hematologic Blood" PX-3118823702 CDM 88237 CPT 311 RC outpatient 784 784 MEDICA (COMMERCIAL) 94265 [3081118] MEDICA CLAIMS [308111801] 705.6 percent of total billed charges 486.08 744.8 Technical (Hospital) Services "Ref Chromosome Analysis, Congenital Disorders, Blood" PX-3118823002 CDM 88230 CPT 311 RC inpatient 573 573 CIGNA 62308 [3081051] CIGNA 62308 [308105105] 453.7 percent of total billed charges 355.26 544.35 Technical (Hospital) Services "Ref Chromosome Analysis, Congenital Disorders, Blood" PX-3118823002 CDM 88230 CPT 311 RC inpatient 573 573 CIGNA 62308 [3081051] CIGNA STATE OF WYOMING [308105107] 453.7 percent of total billed charges 355.26 544.35 Technical (Hospital) Services "Ref Chromosome Analysis, Congenital Disorders, Blood" PX-3118823002 CDM 88230 CPT 311 RC inpatient 573 573 MULTIPLAN INC 34080 [3081285] MULTIPLAN INC [308128501] 544.35 percent of total billed charges 355.26 544.35 Technical (Hospital) Services "Ref Chromosome Analysis, Congenital Disorders, Blood" PX-3118823002 CDM 88230 CPT 311 RC inpatient 573 573 BLUE CROSS BLUE SHIELD WELLMARK SB889 [3081026] BCBS WYOMING [308102603] 544.35 percent of total billed charges 355.26 544.35 Technical (Hospital) Services "Ref Chromosome Analysis, Congenital Disorders, Blood" PX-3118823002 CDM 88230 CPT 311 RC inpatient 573 573 HEALTHPARTNERS SX009 HEALTHPARTNERS 453.7 percent of total billed charges 355.26 544.35 Technical (Hospital) Services "Ref Chromosome Analysis, Congenital Disorders, Blood" PX-3118823002 CDM 88230 CPT 311 RC inpatient 573 573 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES EPO [308136803] 453.7 percent of total billed charges 355.26 544.35 Technical (Hospital) Services "Ref Chromosome Analysis, Congenital Disorders, Blood" PX-3118823002 CDM 88230 CPT 311 RC inpatient 573 573 MEDICA (COMMERCIAL) 94265 [3081118] MEDICA CLAIMS [308111801] 515.7 percent of total billed charges 355.26 544.35 Technical (Hospital) Services "Ref Chromosome Analysis, Congenital Disorders, Blood" PX-3118823002 CDM 88230 CPT 311 RC inpatient 573 573 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES HDHP [308136802] 453.7 percent of total billed charges 355.26 544.35 Technical (Hospital) Services "Ref Chromosome Analysis, Congenital Disorders, Blood" PX-3118823002 CDM 88230 CPT 311 RC inpatient 573 573 UNITED HEALTHCARE (COMMERCIAL) [3081199] UNITED HEALTHCARE 87726 [308119901] 355.26 percent of total billed charges 355.26 544.35 Technical (Hospital) Services "Ref Chromosome Analysis, Congenital Disorders, Blood" PX-3118823002 CDM 88230 CPT 311 RC inpatient 573 573 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES PPO [308136801] 453.7 percent of total billed charges 355.26 544.35 Technical (Hospital) Services "Ref Chromosome Analysis, Congenital Disorders, Blood" PX-3118823002 CDM 88230 CPT 311 RC outpatient 573 573 UNITED HEALTHCARE (COMMERCIAL) [3081199] UNITED HEALTHCARE 87726 [308119901] 355.26 percent of total billed charges 355.26 544.35 Technical (Hospital) Services "Ref Chromosome Analysis, Congenital Disorders, Blood" PX-3118823002 CDM 88230 CPT 311 RC outpatient 573 573 HEALTHPARTNERS SX009 HEALTHPARTNERS 458.4 percent of total billed charges 355.26 544.35 Technical (Hospital) Services "Ref Chromosome Analysis, Congenital Disorders, Blood" PX-3118823002 CDM 88230 CPT 311 RC outpatient 573 573 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES PPO [308136801] 458.4 percent of total billed charges 355.26 544.35 Technical (Hospital) Services "Ref Chromosome Analysis, Congenital Disorders, Blood" PX-3118823002 CDM 88230 CPT 311 RC outpatient 573 573 BLUE CROSS BLUE SHIELD WELLMARK SB889 [3081026] BCBS WYOMING [308102603] 544.35 percent of total billed charges 355.26 544.35 Technical (Hospital) Services "Ref Chromosome Analysis, Congenital Disorders, Blood" PX-3118823002 CDM 88230 CPT 311 RC outpatient 573 573 CIGNA 62308 [3081051] CIGNA 62308 [308105105] 458.4 percent of total billed charges 355.26 544.35 Technical (Hospital) Services "Ref Chromosome Analysis, Congenital Disorders, Blood" PX-3118823002 CDM 88230 CPT 311 RC outpatient 573 573 CIGNA 62308 [3081051] CIGNA STATE OF WYOMING [308105107] 458.4 percent of total billed charges 355.26 544.35 Technical (Hospital) Services "Ref Chromosome Analysis, Congenital Disorders, Blood" PX-3118823002 CDM 88230 CPT 311 RC outpatient 573 573 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES EPO [308136803] 458.4 percent of total billed charges 355.26 544.35 Technical (Hospital) Services "Ref Chromosome Analysis, Congenital Disorders, Blood" PX-3118823002 CDM 88230 CPT 311 RC outpatient 573 573 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES HDHP [308136802] 458.4 percent of total billed charges 355.26 544.35 Technical (Hospital) Services "Ref Chromosome Analysis, Congenital Disorders, Blood" PX-3118823002 CDM 88230 CPT 311 RC outpatient 573 573 MEDICA (COMMERCIAL) 94265 [3081118] MEDICA CLAIMS [308111801] 515.7 percent of total billed charges 355.26 544.35 Technical (Hospital) Services "Ref Chromosome Analysis, Congenital Disorders, Blood" PX-3118823002 CDM 88230 CPT 311 RC outpatient 573 573 MULTIPLAN INC 34080 [3081285] MULTIPLAN INC [308128501] 544.35 percent of total billed charges 355.26 544.35 Technical (Hospital) Services "Ref Flowcytometry/Read, 16 & > Markers" PX-3118818900 CDM 88189 CPT 311 RC inpatient 521 521 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES EPO [308136803] 412.53 percent of total billed charges 323.02 494.95 Technical (Hospital) Services "Ref Flowcytometry/Read, 16 & > Markers" PX-3118818900 CDM 88189 CPT 311 RC inpatient 521 521 HEALTHPARTNERS SX009 HEALTHPARTNERS 412.53 percent of total billed charges 323.02 494.95 Technical (Hospital) Services "Ref Flowcytometry/Read, 16 & > Markers" PX-3118818900 CDM 88189 CPT 311 RC inpatient 521 521 MULTIPLAN INC 34080 [3081285] MULTIPLAN INC [308128501] 494.95 percent of total billed charges 323.02 494.95 Technical (Hospital) Services "Ref Flowcytometry/Read, 16 & > Markers" PX-3118818900 CDM 88189 CPT 311 RC inpatient 521 521 BLUE CROSS BLUE SHIELD WELLMARK SB889 [3081026] BCBS WYOMING [308102603] 494.95 percent of total billed charges 323.02 494.95 Technical (Hospital) Services "Ref Flowcytometry/Read, 16 & > Markers" PX-3118818900 CDM 88189 CPT 311 RC inpatient 521 521 CIGNA 62308 [3081051] CIGNA 62308 [308105105] 412.53 percent of total billed charges 323.02 494.95 Technical (Hospital) Services "Ref Flowcytometry/Read, 16 & > Markers" PX-3118818900 CDM 88189 CPT 311 RC inpatient 521 521 CIGNA 62308 [3081051] CIGNA STATE OF WYOMING [308105107] 412.53 percent of total billed charges 323.02 494.95 Technical (Hospital) Services "Ref Flowcytometry/Read, 16 & > Markers" PX-3118818900 CDM 88189 CPT 311 RC inpatient 521 521 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES PPO [308136801] 412.53 percent of total billed charges 323.02 494.95 Technical (Hospital) Services "Ref Flowcytometry/Read, 16 & > Markers" PX-3118818900 CDM 88189 CPT 311 RC inpatient 521 521 UNITED HEALTHCARE (COMMERCIAL) [3081199] UNITED HEALTHCARE 87726 [308119901] 323.02 percent of total billed charges 323.02 494.95 Technical (Hospital) Services "Ref Flowcytometry/Read, 16 & > Markers" PX-3118818900 CDM 88189 CPT 311 RC inpatient 521 521 MEDICA (COMMERCIAL) 94265 [3081118] MEDICA CLAIMS [308111801] 468.9 percent of total billed charges 323.02 494.95 Technical (Hospital) Services "Ref Flowcytometry/Read, 16 & > Markers" PX-3118818900 CDM 88189 CPT 311 RC inpatient 521 521 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES HDHP [308136802] 412.53 percent of total billed charges 323.02 494.95 Technical (Hospital) Services "Ref Flowcytometry/Read, 16 & > Markers" PX-3118818900 CDM 88189 CPT 311 RC outpatient 521 521 MULTIPLAN INC 34080 [3081285] MULTIPLAN INC [308128501] 494.95 percent of total billed charges 323.02 494.95 Technical (Hospital) Services "Ref Flowcytometry/Read, 16 & > Markers" PX-3118818900 CDM 88189 CPT 311 RC outpatient 521 521 MEDICA (COMMERCIAL) 94265 [3081118] MEDICA CLAIMS [308111801] 468.9 percent of total billed charges 323.02 494.95 Technical (Hospital) Services "Ref Flowcytometry/Read, 16 & > Markers" PX-3118818900 CDM 88189 CPT 311 RC outpatient 521 521 UNITED HEALTHCARE (COMMERCIAL) [3081199] UNITED HEALTHCARE 87726 [308119901] 323.02 percent of total billed charges 323.02 494.95 Technical (Hospital) Services "Ref Flowcytometry/Read, 16 & > Markers" PX-3118818900 CDM 88189 CPT 311 RC outpatient 521 521 HEALTHPARTNERS SX009 HEALTHPARTNERS 416.8 percent of total billed charges 323.02 494.95 Technical (Hospital) Services "Ref Flowcytometry/Read, 16 & > Markers" PX-3118818900 CDM 88189 CPT 311 RC outpatient 521 521 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES PPO [308136801] 416.8 percent of total billed charges 323.02 494.95 Technical (Hospital) Services "Ref Flowcytometry/Read, 16 & > Markers" PX-3118818900 CDM 88189 CPT 311 RC outpatient 521 521 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES EPO [308136803] 416.8 percent of total billed charges 323.02 494.95 Technical (Hospital) Services "Ref Flowcytometry/Read, 16 & > Markers" PX-3118818900 CDM 88189 CPT 311 RC outpatient 521 521 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES HDHP [308136802] 416.8 percent of total billed charges 323.02 494.95 Technical (Hospital) Services "Ref Flowcytometry/Read, 16 & > Markers" PX-3118818900 CDM 88189 CPT 311 RC outpatient 521 521 CIGNA 62308 [3081051] CIGNA STATE OF WYOMING [308105107] 416.8 percent of total billed charges 323.02 494.95 Technical (Hospital) Services "Ref Flowcytometry/Read, 16 & > Markers" PX-3118818900 CDM 88189 CPT 311 RC outpatient 521 521 CIGNA 62308 [3081051] CIGNA 62308 [308105105] 416.8 percent of total billed charges 323.02 494.95 Technical (Hospital) Services "Ref Flowcytometry/Read, 16 & > Markers" PX-3118818900 CDM 88189 CPT 311 RC outpatient 521 521 BLUE CROSS BLUE SHIELD WELLMARK SB889 [3081026] BCBS WYOMING [308102603] 494.95 percent of total billed charges 323.02 494.95 Technical (Hospital) Services Additional Marker PX-3118818500 CDM 88185 CPT 311 RC inpatient 326 326 CIGNA 62308 [3081051] CIGNA 62308 [308105105] 258.13 percent of total billed charges 202.12 309.7 Technical (Hospital) Services Additional Marker PX-3118818500 CDM 88185 CPT 311 RC inpatient 326 326 CIGNA 62308 [3081051] CIGNA STATE OF WYOMING [308105107] 258.13 percent of total billed charges 202.12 309.7 Technical (Hospital) Services Additional Marker PX-3118818500 CDM 88185 CPT 311 RC inpatient 326 326 BLUE CROSS BLUE SHIELD WELLMARK SB889 [3081026] BCBS WYOMING [308102603] 309.7 percent of total billed charges 202.12 309.7 Technical (Hospital) Services Additional Marker PX-3118818500 CDM 88185 CPT 311 RC inpatient 326 326 MULTIPLAN INC 34080 [3081285] MULTIPLAN INC [308128501] 309.7 percent of total billed charges 202.12 309.7 Technical (Hospital) Services Additional Marker PX-3118818500 CDM 88185 CPT 311 RC inpatient 326 326 HEALTHPARTNERS SX009 HEALTHPARTNERS 258.13 percent of total billed charges 202.12 309.7 Technical (Hospital) Services Additional Marker PX-3118818500 CDM 88185 CPT 311 RC inpatient 326 326 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES EPO [308136803] 258.13 percent of total billed charges 202.12 309.7 Technical (Hospital) Services Additional Marker PX-3118818500 CDM 88185 CPT 311 RC inpatient 326 326 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES PPO [308136801] 258.13 percent of total billed charges 202.12 309.7 Technical (Hospital) Services Additional Marker PX-3118818500 CDM 88185 CPT 311 RC inpatient 326 326 MEDICA (COMMERCIAL) 94265 [3081118] MEDICA CLAIMS [308111801] 293.4 percent of total billed charges 202.12 309.7 Technical (Hospital) Services Additional Marker PX-3118818500 CDM 88185 CPT 311 RC inpatient 326 326 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES HDHP [308136802] 258.13 percent of total billed charges 202.12 309.7 Technical (Hospital) Services Additional Marker PX-3118818500 CDM 88185 CPT 311 RC inpatient 326 326 UNITED HEALTHCARE (COMMERCIAL) [3081199] UNITED HEALTHCARE 87726 [308119901] 202.12 percent of total billed charges 202.12 309.7 Technical (Hospital) Services Additional Marker PX-3118818500 CDM 88185 CPT 311 RC outpatient 326 326 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES HDHP [308136802] 260.8 percent of total billed charges 202.12 309.7 Technical (Hospital) Services Additional Marker PX-3118818500 CDM 88185 CPT 311 RC outpatient 326 326 BLUE CROSS BLUE SHIELD WELLMARK SB889 [3081026] BCBS WYOMING [308102603] 309.7 percent of total billed charges 202.12 309.7 Technical (Hospital) Services Additional Marker PX-3118818500 CDM 88185 CPT 311 RC outpatient 326 326 CIGNA 62308 [3081051] CIGNA 62308 [308105105] 260.8 percent of total billed charges 202.12 309.7 Technical (Hospital) Services Additional Marker PX-3118818500 CDM 88185 CPT 311 RC outpatient 326 326 CIGNA 62308 [3081051] CIGNA STATE OF WYOMING [308105107] 260.8 percent of total billed charges 202.12 309.7 Technical (Hospital) Services Additional Marker PX-3118818500 CDM 88185 CPT 311 RC outpatient 326 326 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES EPO [308136803] 260.8 percent of total billed charges 202.12 309.7 Technical (Hospital) Services Additional Marker PX-3118818500 CDM 88185 CPT 311 RC outpatient 326 326 HEALTHPARTNERS SX009 HEALTHPARTNERS 260.8 percent of total billed charges 202.12 309.7 Technical (Hospital) Services Additional Marker PX-3118818500 CDM 88185 CPT 311 RC outpatient 326 326 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES PPO [308136801] 260.8 percent of total billed charges 202.12 309.7 Technical (Hospital) Services Additional Marker PX-3118818500 CDM 88185 CPT 311 RC outpatient 326 326 UNITED HEALTHCARE (COMMERCIAL) [3081199] UNITED HEALTHCARE 87726 [308119901] 202.12 percent of total billed charges 202.12 309.7 Technical (Hospital) Services Additional Marker PX-3118818500 CDM 88185 CPT 311 RC outpatient 326 326 MEDICA (COMMERCIAL) 94265 [3081118] MEDICA CLAIMS [308111801] 293.4 percent of total billed charges 202.12 309.7 Technical (Hospital) Services Additional Marker PX-3118818500 CDM 88185 CPT 311 RC outpatient 326 326 MULTIPLAN INC 34080 [3081285] MULTIPLAN INC [308128501] 309.7 percent of total billed charges 202.12 309.7 Technical (Hospital) Services Ref Leukemia/Lymphoma Immunophenotyping by Flow Cytometry Add On PX-3118818502 CDM 88185 CPT 311 RC inpatient 188 188 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES EPO [308136803] 148.86 percent of total billed charges 116.56 178.6 Technical (Hospital) Services Ref Leukemia/Lymphoma Immunophenotyping by Flow Cytometry Add On PX-3118818502 CDM 88185 CPT 311 RC inpatient 188 188 HEALTHPARTNERS SX009 HEALTHPARTNERS 148.86 percent of total billed charges 116.56 178.6 Technical (Hospital) Services Ref Leukemia/Lymphoma Immunophenotyping by Flow Cytometry Add On PX-3118818502 CDM 88185 CPT 311 RC inpatient 188 188 MULTIPLAN INC 34080 [3081285] MULTIPLAN INC [308128501] 178.6 percent of total billed charges 116.56 178.6 Technical (Hospital) Services Ref Leukemia/Lymphoma Immunophenotyping by Flow Cytometry Add On PX-3118818502 CDM 88185 CPT 311 RC inpatient 188 188 CIGNA 62308 [3081051] CIGNA 62308 [308105105] 148.86 percent of total billed charges 116.56 178.6 Technical (Hospital) Services Ref Leukemia/Lymphoma Immunophenotyping by Flow Cytometry Add On PX-3118818502 CDM 88185 CPT 311 RC inpatient 188 188 CIGNA 62308 [3081051] CIGNA STATE OF WYOMING [308105107] 148.86 percent of total billed charges 116.56 178.6 Technical (Hospital) Services Ref Leukemia/Lymphoma Immunophenotyping by Flow Cytometry Add On PX-3118818502 CDM 88185 CPT 311 RC inpatient 188 188 BLUE CROSS BLUE SHIELD WELLMARK SB889 [3081026] BCBS WYOMING [308102603] 178.6 percent of total billed charges 116.56 178.6 Technical (Hospital) Services Ref Leukemia/Lymphoma Immunophenotyping by Flow Cytometry Add On PX-3118818502 CDM 88185 CPT 311 RC inpatient 188 188 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES PPO [308136801] 148.86 percent of total billed charges 116.56 178.6 Technical (Hospital) Services Ref Leukemia/Lymphoma Immunophenotyping by Flow Cytometry Add On PX-3118818502 CDM 88185 CPT 311 RC inpatient 188 188 MEDICA (COMMERCIAL) 94265 [3081118] MEDICA CLAIMS [308111801] 169.2 percent of total billed charges 116.56 178.6 Technical (Hospital) Services Ref Leukemia/Lymphoma Immunophenotyping by Flow Cytometry Add On PX-3118818502 CDM 88185 CPT 311 RC inpatient 188 188 UNITED HEALTHCARE (COMMERCIAL) [3081199] UNITED HEALTHCARE 87726 [308119901] 116.56 percent of total billed charges 116.56 178.6 Technical (Hospital) Services Ref Leukemia/Lymphoma Immunophenotyping by Flow Cytometry Add On PX-3118818502 CDM 88185 CPT 311 RC inpatient 188 188 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES HDHP [308136802] 148.86 percent of total billed charges 116.56 178.6 Technical (Hospital) Services Ref Leukemia/Lymphoma Immunophenotyping by Flow Cytometry Add On PX-3118818502 CDM 88185 CPT 311 RC outpatient 188 188 HEALTHPARTNERS SX009 HEALTHPARTNERS 150.4 percent of total billed charges 116.56 178.6 Technical (Hospital) Services Ref Leukemia/Lymphoma Immunophenotyping by Flow Cytometry Add On PX-3118818502 CDM 88185 CPT 311 RC outpatient 188 188 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES PPO [308136801] 150.4 percent of total billed charges 116.56 178.6 Technical (Hospital) Services Ref Leukemia/Lymphoma Immunophenotyping by Flow Cytometry Add On PX-3118818502 CDM 88185 CPT 311 RC outpatient 188 188 UNITED HEALTHCARE (COMMERCIAL) [3081199] UNITED HEALTHCARE 87726 [308119901] 116.56 percent of total billed charges 116.56 178.6 Technical (Hospital) Services Ref Leukemia/Lymphoma Immunophenotyping by Flow Cytometry Add On PX-3118818502 CDM 88185 CPT 311 RC outpatient 188 188 BLUE CROSS BLUE SHIELD WELLMARK SB889 [3081026] BCBS WYOMING [308102603] 178.6 percent of total billed charges 116.56 178.6 Technical (Hospital) Services Ref Leukemia/Lymphoma Immunophenotyping by Flow Cytometry Add On PX-3118818502 CDM 88185 CPT 311 RC outpatient 188 188 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES HDHP [308136802] 150.4 percent of total billed charges 116.56 178.6 Technical (Hospital) Services Ref Leukemia/Lymphoma Immunophenotyping by Flow Cytometry Add On PX-3118818502 CDM 88185 CPT 311 RC outpatient 188 188 CIGNA 62308 [3081051] CIGNA 62308 [308105105] 150.4 percent of total billed charges 116.56 178.6 Technical (Hospital) Services Ref Leukemia/Lymphoma Immunophenotyping by Flow Cytometry Add On PX-3118818502 CDM 88185 CPT 311 RC outpatient 188 188 CIGNA 62308 [3081051] CIGNA STATE OF WYOMING [308105107] 150.4 percent of total billed charges 116.56 178.6 Technical (Hospital) Services Ref Leukemia/Lymphoma Immunophenotyping by Flow Cytometry Add On PX-3118818502 CDM 88185 CPT 311 RC outpatient 188 188 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES EPO [308136803] 150.4 percent of total billed charges 116.56 178.6 Technical (Hospital) Services Ref Leukemia/Lymphoma Immunophenotyping by Flow Cytometry Add On PX-3118818502 CDM 88185 CPT 311 RC outpatient 188 188 MEDICA (COMMERCIAL) 94265 [3081118] MEDICA CLAIMS [308111801] 169.2 percent of total billed charges 116.56 178.6 Technical (Hospital) Services Ref Leukemia/Lymphoma Immunophenotyping by Flow Cytometry Add On PX-3118818502 CDM 88185 CPT 311 RC outpatient 188 188 MULTIPLAN INC 34080 [3081285] MULTIPLAN INC [308128501] 178.6 percent of total billed charges 116.56 178.6 Technical (Hospital) Services First Marker PX-3118818400 CDM 88184 CPT 311 RC inpatient 119 119 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES PPO [308136801] 94.22 percent of total billed charges 73.78 113.05 Technical (Hospital) Services First Marker PX-3118818400 CDM 88184 CPT 311 RC inpatient 119 119 UNITED HEALTHCARE (COMMERCIAL) [3081199] UNITED HEALTHCARE 87726 [308119901] 73.78 percent of total billed charges 73.78 113.05 Technical (Hospital) Services First Marker PX-3118818400 CDM 88184 CPT 311 RC inpatient 119 119 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES HDHP [308136802] 94.22 percent of total billed charges 73.78 113.05 Technical (Hospital) Services First Marker PX-3118818400 CDM 88184 CPT 311 RC inpatient 119 119 MEDICA (COMMERCIAL) 94265 [3081118] MEDICA CLAIMS [308111801] 107.1 percent of total billed charges 73.78 113.05 Technical (Hospital) Services First Marker PX-3118818400 CDM 88184 CPT 311 RC outpatient 119 119 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES PPO [308136801] 95.2 percent of total billed charges 73.78 113.05 Technical (Hospital) Services First Marker PX-3118818400 CDM 88184 CPT 311 RC outpatient 119 119 HEALTHPARTNERS SX009 HEALTHPARTNERS 95.2 percent of total billed charges 73.78 113.05 Technical (Hospital) Services First Marker PX-3118818400 CDM 88184 CPT 311 RC outpatient 119 119 UNITED HEALTHCARE (COMMERCIAL) [3081199] UNITED HEALTHCARE 87726 [308119901] 73.78 percent of total billed charges 73.78 113.05 Technical (Hospital) Services First Marker PX-3118818400 CDM 88184 CPT 311 RC inpatient 119 119 MULTIPLAN INC 34080 [3081285] MULTIPLAN INC [308128501] 113.05 percent of total billed charges 73.78 113.05 Technical (Hospital) Services First Marker PX-3118818400 CDM 88184 CPT 311 RC inpatient 119 119 CIGNA 62308 [3081051] CIGNA 62308 [308105105] 94.22 percent of total billed charges 73.78 113.05 Technical (Hospital) Services First Marker PX-3118818400 CDM 88184 CPT 311 RC inpatient 119 119 CIGNA 62308 [3081051] CIGNA STATE OF WYOMING [308105107] 94.22 percent of total billed charges 73.78 113.05 Technical (Hospital) Services First Marker PX-3118818400 CDM 88184 CPT 311 RC inpatient 119 119 BLUE CROSS BLUE SHIELD WELLMARK SB889 [3081026] BCBS WYOMING [308102603] 113.05 percent of total billed charges 73.78 113.05 Technical (Hospital) Services First Marker PX-3118818400 CDM 88184 CPT 311 RC inpatient 119 119 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES EPO [308136803] 94.22 percent of total billed charges 73.78 113.05 Technical (Hospital) Services First Marker PX-3118818400 CDM 88184 CPT 311 RC inpatient 119 119 HEALTHPARTNERS SX009 HEALTHPARTNERS 94.22 percent of total billed charges 73.78 113.05 Technical (Hospital) Services First Marker PX-3118818400 CDM 88184 CPT 311 RC outpatient 119 119 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES HDHP [308136802] 95.2 percent of total billed charges 73.78 113.05 Technical (Hospital) Services First Marker PX-3118818400 CDM 88184 CPT 311 RC outpatient 119 119 BLUE CROSS BLUE SHIELD WELLMARK SB889 [3081026] BCBS WYOMING [308102603] 113.05 percent of total billed charges 73.78 113.05 Technical (Hospital) Services First Marker PX-3118818400 CDM 88184 CPT 311 RC outpatient 119 119 CIGNA 62308 [3081051] CIGNA 62308 [308105105] 95.2 percent of total billed charges 73.78 113.05 Technical (Hospital) Services First Marker PX-3118818400 CDM 88184 CPT 311 RC outpatient 119 119 CIGNA 62308 [3081051] CIGNA STATE OF WYOMING [308105107] 95.2 percent of total billed charges 73.78 113.05 Technical (Hospital) Services First Marker PX-3118818400 CDM 88184 CPT 311 RC outpatient 119 119 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES EPO [308136803] 95.2 percent of total billed charges 73.78 113.05 Technical (Hospital) Services First Marker PX-3118818400 CDM 88184 CPT 311 RC outpatient 119 119 MEDICA (COMMERCIAL) 94265 [3081118] MEDICA CLAIMS [308111801] 107.1 percent of total billed charges 73.78 113.05 Technical (Hospital) Services First Marker PX-3118818400 CDM 88184 CPT 311 RC outpatient 119 119 MULTIPLAN INC 34080 [3081285] MULTIPLAN INC [308128501] 113.05 percent of total billed charges 73.78 113.05 Technical (Hospital) Services Ref Leukemia/Lymphoma Immunophenotyping by Flow Cytometry 1st PX-3118818404 CDM 88184 CPT 311 RC inpatient 429 429 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES EPO [308136803] 339.68 percent of total billed charges 265.98 407.55 Technical (Hospital) Services Ref Leukemia/Lymphoma Immunophenotyping by Flow Cytometry 1st PX-3118818404 CDM 88184 CPT 311 RC inpatient 429 429 HEALTHPARTNERS SX009 HEALTHPARTNERS 339.68 percent of total billed charges 265.98 407.55 Technical (Hospital) Services Ref Leukemia/Lymphoma Immunophenotyping by Flow Cytometry 1st PX-3118818404 CDM 88184 CPT 311 RC inpatient 429 429 BLUE CROSS BLUE SHIELD WELLMARK SB889 [3081026] BCBS WYOMING [308102603] 407.55 percent of total billed charges 265.98 407.55 Technical (Hospital) Services Ref Leukemia/Lymphoma Immunophenotyping by Flow Cytometry 1st PX-3118818404 CDM 88184 CPT 311 RC inpatient 429 429 CIGNA 62308 [3081051] CIGNA 62308 [308105105] 339.68 percent of total billed charges 265.98 407.55 Technical (Hospital) Services Ref Leukemia/Lymphoma Immunophenotyping by Flow Cytometry 1st PX-3118818404 CDM 88184 CPT 311 RC inpatient 429 429 CIGNA 62308 [3081051] CIGNA STATE OF WYOMING [308105107] 339.68 percent of total billed charges 265.98 407.55 Technical (Hospital) Services Ref Leukemia/Lymphoma Immunophenotyping by Flow Cytometry 1st PX-3118818404 CDM 88184 CPT 311 RC inpatient 429 429 MULTIPLAN INC 34080 [3081285] MULTIPLAN INC [308128501] 407.55 percent of total billed charges 265.98 407.55 Technical (Hospital) Services Ref Leukemia/Lymphoma Immunophenotyping by Flow Cytometry 1st PX-3118818404 CDM 88184 CPT 311 RC inpatient 429 429 UNITED HEALTHCARE (COMMERCIAL) [3081199] UNITED HEALTHCARE 87726 [308119901] 265.98 percent of total billed charges 265.98 407.55 Technical (Hospital) Services Ref Leukemia/Lymphoma Immunophenotyping by Flow Cytometry 1st PX-3118818404 CDM 88184 CPT 311 RC inpatient 429 429 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES HDHP [308136802] 339.68 percent of total billed charges 265.98 407.55 Technical (Hospital) Services Ref Leukemia/Lymphoma Immunophenotyping by Flow Cytometry 1st PX-3118818404 CDM 88184 CPT 311 RC inpatient 429 429 MEDICA (COMMERCIAL) 94265 [3081118] MEDICA CLAIMS [308111801] 386.1 percent of total billed charges 265.98 407.55 Technical (Hospital) Services Ref Leukemia/Lymphoma Immunophenotyping by Flow Cytometry 1st PX-3118818404 CDM 88184 CPT 311 RC inpatient 429 429 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES PPO [308136801] 339.68 percent of total billed charges 265.98 407.55 Technical (Hospital) Services Ref Leukemia/Lymphoma Immunophenotyping by Flow Cytometry 1st PX-3118818404 CDM 88184 CPT 311 RC outpatient 429 429 HEALTHPARTNERS SX009 HEALTHPARTNERS 343.2 percent of total billed charges 265.98 407.55 Technical (Hospital) Services Ref Leukemia/Lymphoma Immunophenotyping by Flow Cytometry 1st PX-3118818404 CDM 88184 CPT 311 RC outpatient 429 429 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES PPO [308136801] 343.2 percent of total billed charges 265.98 407.55 Technical (Hospital) Services Ref Leukemia/Lymphoma Immunophenotyping by Flow Cytometry 1st PX-3118818404 CDM 88184 CPT 311 RC outpatient 429 429 MULTIPLAN INC 34080 [3081285] MULTIPLAN INC [308128501] 407.55 percent of total billed charges 265.98 407.55 Technical (Hospital) Services Ref Leukemia/Lymphoma Immunophenotyping by Flow Cytometry 1st PX-3118818404 CDM 88184 CPT 311 RC outpatient 429 429 MEDICA (COMMERCIAL) 94265 [3081118] MEDICA CLAIMS [308111801] 386.1 percent of total billed charges 265.98 407.55 Technical (Hospital) Services Ref Leukemia/Lymphoma Immunophenotyping by Flow Cytometry 1st PX-3118818404 CDM 88184 CPT 311 RC outpatient 429 429 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES EPO [308136803] 343.2 percent of total billed charges 265.98 407.55 Technical (Hospital) Services Ref Leukemia/Lymphoma Immunophenotyping by Flow Cytometry 1st PX-3118818404 CDM 88184 CPT 311 RC outpatient 429 429 CIGNA 62308 [3081051] CIGNA 62308 [308105105] 343.2 percent of total billed charges 265.98 407.55 Technical (Hospital) Services Ref Leukemia/Lymphoma Immunophenotyping by Flow Cytometry 1st PX-3118818404 CDM 88184 CPT 311 RC outpatient 429 429 CIGNA 62308 [3081051] CIGNA STATE OF WYOMING [308105107] 343.2 percent of total billed charges 265.98 407.55 Technical (Hospital) Services Ref Leukemia/Lymphoma Immunophenotyping by Flow Cytometry 1st PX-3118818404 CDM 88184 CPT 311 RC outpatient 429 429 BLUE CROSS BLUE SHIELD WELLMARK SB889 [3081026] BCBS WYOMING [308102603] 407.55 percent of total billed charges 265.98 407.55 Technical (Hospital) Services Ref Leukemia/Lymphoma Immunophenotyping by Flow Cytometry 1st PX-3118818404 CDM 88184 CPT 311 RC outpatient 429 429 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES HDHP [308136802] 343.2 percent of total billed charges 265.98 407.55 Technical (Hospital) Services Ref Leukemia/Lymphoma Immunophenotyping by Flow Cytometry 1st PX-3118818404 CDM 88184 CPT 311 RC outpatient 429 429 UNITED HEALTHCARE (COMMERCIAL) [3081199] UNITED HEALTHCARE 87726 [308119901] 265.98 percent of total billed charges 265.98 407.55 Technical (Hospital) Services Ref Hcv Genotype PX-3068790201 CDM 87902 CPT 306 RC inpatient 918 918 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES PPO [308136801] 726.87 percent of total billed charges 569.16 872.1 Technical (Hospital) Services Ref Hcv Genotype PX-3068790201 CDM 87902 CPT 306 RC inpatient 918 918 MEDICA (COMMERCIAL) 94265 [3081118] MEDICA CLAIMS [308111801] 826.2 percent of total billed charges 569.16 872.1 Technical (Hospital) Services Ref Hcv Genotype PX-3068790201 CDM 87902 CPT 306 RC inpatient 918 918 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES HDHP [308136802] 726.87 percent of total billed charges 569.16 872.1 Technical (Hospital) Services Ref Hcv Genotype PX-3068790201 CDM 87902 CPT 306 RC inpatient 918 918 UNITED HEALTHCARE (COMMERCIAL) [3081199] UNITED HEALTHCARE 87726 [308119901] 569.16 percent of total billed charges 569.16 872.1 Technical (Hospital) Services Ref Hcv Genotype PX-3068790201 CDM 87902 CPT 306 RC inpatient 918 918 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES EPO [308136803] 726.87 percent of total billed charges 569.16 872.1 Technical (Hospital) Services Ref Hcv Genotype PX-3068790201 CDM 87902 CPT 306 RC inpatient 918 918 HEALTHPARTNERS SX009 HEALTHPARTNERS 726.87 percent of total billed charges 569.16 872.1 Technical (Hospital) Services Ref Hcv Genotype PX-3068790201 CDM 87902 CPT 306 RC inpatient 918 918 BLUE CROSS BLUE SHIELD WELLMARK SB889 [3081026] BCBS WYOMING [308102603] 872.1 percent of total billed charges 569.16 872.1 Technical (Hospital) Services Ref Hcv Genotype PX-3068790201 CDM 87902 CPT 306 RC inpatient 918 918 CIGNA 62308 [3081051] CIGNA 62308 [308105105] 726.87 percent of total billed charges 569.16 872.1 Technical (Hospital) Services Ref Hcv Genotype PX-3068790201 CDM 87902 CPT 306 RC inpatient 918 918 CIGNA 62308 [3081051] CIGNA STATE OF WYOMING [308105107] 726.87 percent of total billed charges 569.16 872.1 Technical (Hospital) Services Ref Hcv Genotype PX-3068790201 CDM 87902 CPT 306 RC inpatient 918 918 MULTIPLAN INC 34080 [3081285] MULTIPLAN INC [308128501] 872.1 percent of total billed charges 569.16 872.1 Technical (Hospital) Services Ref Hcv Genotype PX-3068790201 CDM 87902 CPT 306 RC outpatient 918 918 BLUE CROSS BLUE SHIELD WELLMARK SB889 [3081026] BCBS WYOMING [308102603] 872.1 percent of total billed charges 569.16 872.1 Technical (Hospital) Services Ref Hcv Genotype PX-3068790201 CDM 87902 CPT 306 RC outpatient 918 918 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES HDHP [308136802] 734.4 percent of total billed charges 569.16 872.1 Technical (Hospital) Services Ref Hcv Genotype PX-3068790201 CDM 87902 CPT 306 RC outpatient 918 918 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES EPO [308136803] 734.4 percent of total billed charges 569.16 872.1 Technical (Hospital) Services Ref Hcv Genotype PX-3068790201 CDM 87902 CPT 306 RC outpatient 918 918 CIGNA 62308 [3081051] CIGNA 62308 [308105105] 734.4 percent of total billed charges 569.16 872.1 Technical (Hospital) Services Ref Hcv Genotype PX-3068790201 CDM 87902 CPT 306 RC outpatient 918 918 CIGNA 62308 [3081051] CIGNA STATE OF WYOMING [308105107] 734.4 percent of total billed charges 569.16 872.1 Technical (Hospital) Services Ref Hcv Genotype PX-3068790201 CDM 87902 CPT 306 RC outpatient 918 918 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES PPO [308136801] 734.4 percent of total billed charges 569.16 872.1 Technical (Hospital) Services Ref Hcv Genotype PX-3068790201 CDM 87902 CPT 306 RC outpatient 918 918 HEALTHPARTNERS SX009 HEALTHPARTNERS 734.4 percent of total billed charges 569.16 872.1 Technical (Hospital) Services Ref Hcv Genotype PX-3068790201 CDM 87902 CPT 306 RC outpatient 918 918 UNITED HEALTHCARE (COMMERCIAL) [3081199] UNITED HEALTHCARE 87726 [308119901] 569.16 percent of total billed charges 569.16 872.1 Technical (Hospital) Services Ref Hcv Genotype PX-3068790201 CDM 87902 CPT 306 RC outpatient 918 918 MEDICA (COMMERCIAL) 94265 [3081118] MEDICA CLAIMS [308111801] 826.2 percent of total billed charges 569.16 872.1 Technical (Hospital) Services Ref Hcv Genotype PX-3068790201 CDM 87902 CPT 306 RC outpatient 918 918 MULTIPLAN INC 34080 [3081285] MULTIPLAN INC [308128501] 872.1 percent of total billed charges 569.16 872.1 Technical (Hospital) Services Ref Hiv 1 Genotypic Drug Resist PX-3068790100 CDM 87901 CPT 306 RC inpatient 1109 1109 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES PPO [308136801] 878.11 percent of total billed charges 687.58 1053.55 Technical (Hospital) Services Ref Hiv 1 Genotypic Drug Resist PX-3068790100 CDM 87901 CPT 306 RC inpatient 1109 1109 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES HDHP [308136802] 878.11 percent of total billed charges 687.58 1053.55 Technical (Hospital) Services Ref Hiv 1 Genotypic Drug Resist PX-3068790100 CDM 87901 CPT 306 RC inpatient 1109 1109 UNITED HEALTHCARE (COMMERCIAL) [3081199] UNITED HEALTHCARE 87726 [308119901] 687.58 percent of total billed charges 687.58 1053.55 Technical (Hospital) Services Ref Hiv 1 Genotypic Drug Resist PX-3068790100 CDM 87901 CPT 306 RC inpatient 1109 1109 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES EPO [308136803] 878.11 percent of total billed charges 687.58 1053.55 Technical (Hospital) Services Ref Hiv 1 Genotypic Drug Resist PX-3068790100 CDM 87901 CPT 306 RC inpatient 1109 1109 HEALTHPARTNERS SX009 HEALTHPARTNERS 878.11 percent of total billed charges 687.58 1053.55 Technical (Hospital) Services Ref Hiv 1 Genotypic Drug Resist PX-3068790100 CDM 87901 CPT 306 RC inpatient 1109 1109 BLUE CROSS BLUE SHIELD WELLMARK SB889 [3081026] BCBS WYOMING [308102603] 1053.55 percent of total billed charges 687.58 1053.55 Technical (Hospital) Services Ref Hiv 1 Genotypic Drug Resist PX-3068790100 CDM 87901 CPT 306 RC inpatient 1109 1109 CIGNA 62308 [3081051] CIGNA 62308 [308105105] 878.11 percent of total billed charges 687.58 1053.55 Technical (Hospital) Services Ref Hiv 1 Genotypic Drug Resist PX-3068790100 CDM 87901 CPT 306 RC inpatient 1109 1109 CIGNA 62308 [3081051] CIGNA STATE OF WYOMING [308105107] 878.11 percent of total billed charges 687.58 1053.55 Technical (Hospital) Services Ref Hiv 1 Genotypic Drug Resist PX-3068790100 CDM 87901 CPT 306 RC inpatient 1109 1109 MULTIPLAN INC 34080 [3081285] MULTIPLAN INC [308128501] 1053.55 percent of total billed charges 687.58 1053.55 Technical (Hospital) Services Ref Hiv 1 Genotypic Drug Resist PX-3068790100 CDM 87901 CPT 306 RC inpatient 1109 1109 MEDICA (COMMERCIAL) 94265 [3081118] MEDICA CLAIMS [308111801] 998.1 percent of total billed charges 687.58 1053.55 Technical (Hospital) Services Ref Hiv 1 Genotypic Drug Resist PX-3068790100 CDM 87901 CPT 306 RC outpatient 1109 1109 HEALTHPARTNERS SX009 HEALTHPARTNERS 887.2 percent of total billed charges 687.58 1053.55 Technical (Hospital) Services Ref Hiv 1 Genotypic Drug Resist PX-3068790100 CDM 87901 CPT 306 RC outpatient 1109 1109 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES PPO [308136801] 887.2 percent of total billed charges 687.58 1053.55 Technical (Hospital) Services Ref Hiv 1 Genotypic Drug Resist PX-3068790100 CDM 87901 CPT 306 RC outpatient 1109 1109 UNITED HEALTHCARE (COMMERCIAL) [3081199] UNITED HEALTHCARE 87726 [308119901] 687.58 percent of total billed charges 687.58 1053.55 Technical (Hospital) Services Ref Hiv 1 Genotypic Drug Resist PX-3068790100 CDM 87901 CPT 306 RC outpatient 1109 1109 BLUE CROSS BLUE SHIELD WELLMARK SB889 [3081026] BCBS WYOMING [308102603] 1053.55 percent of total billed charges 687.58 1053.55 Technical (Hospital) Services Ref Hiv 1 Genotypic Drug Resist PX-3068790100 CDM 87901 CPT 306 RC outpatient 1109 1109 CIGNA 62308 [3081051] CIGNA 62308 [308105105] 887.2 percent of total billed charges 687.58 1053.55 Technical (Hospital) Services Ref Hiv 1 Genotypic Drug Resist PX-3068790100 CDM 87901 CPT 306 RC outpatient 1109 1109 CIGNA 62308 [3081051] CIGNA STATE OF WYOMING [308105107] 887.2 percent of total billed charges 687.58 1053.55 Technical (Hospital) Services Ref Hiv 1 Genotypic Drug Resist PX-3068790100 CDM 87901 CPT 306 RC outpatient 1109 1109 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES EPO [308136803] 887.2 percent of total billed charges 687.58 1053.55 Technical (Hospital) Services Ref Hiv 1 Genotypic Drug Resist PX-3068790100 CDM 87901 CPT 306 RC outpatient 1109 1109 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES HDHP [308136802] 887.2 percent of total billed charges 687.58 1053.55 Technical (Hospital) Services Ref Hiv 1 Genotypic Drug Resist PX-3068790100 CDM 87901 CPT 306 RC outpatient 1109 1109 MEDICA (COMMERCIAL) 94265 [3081118] MEDICA CLAIMS [308111801] 998.1 percent of total billed charges 687.58 1053.55 Technical (Hospital) Services Ref Hiv 1 Genotypic Drug Resist PX-3068790100 CDM 87901 CPT 306 RC outpatient 1109 1109 MULTIPLAN INC 34080 [3081285] MULTIPLAN INC [308128501] 1053.55 percent of total billed charges 687.58 1053.55 Technical (Hospital) Services Infect Agent by Ia Direct Obs PX-3068789900 CDM 87899 CPT 306 RC inpatient 105 105 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES HDHP [308136802] 83.14 percent of total billed charges 65.1 99.75 Technical (Hospital) Services Infect Agent by Ia Direct Obs PX-3068789900 CDM 87899 CPT 306 RC inpatient 105 105 UNITED HEALTHCARE (COMMERCIAL) [3081199] UNITED HEALTHCARE 87726 [308119901] 65.1 percent of total billed charges 65.1 99.75 Technical (Hospital) Services Infect Agent by Ia Direct Obs PX-3068789900 CDM 87899 CPT 306 RC inpatient 105 105 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES PPO [308136801] 83.14 percent of total billed charges 65.1 99.75 Technical (Hospital) Services Infect Agent by Ia Direct Obs PX-3068789900 CDM 87899 CPT 306 RC inpatient 105 105 MULTIPLAN INC 34080 [3081285] MULTIPLAN INC [308128501] 99.75 percent of total billed charges 65.1 99.75 Technical (Hospital) Services Infect Agent by Ia Direct Obs PX-3068789900 CDM 87899 CPT 306 RC inpatient 105 105 MEDICA (COMMERCIAL) 94265 [3081118] MEDICA CLAIMS [308111801] 94.5 percent of total billed charges 65.1 99.75 Technical (Hospital) Services Infect Agent by Ia Direct Obs PX-3068789900 CDM 87899 CPT 306 RC inpatient 105 105 CIGNA 62308 [3081051] CIGNA 62308 [308105105] 83.14 percent of total billed charges 65.1 99.75 Technical (Hospital) Services Infect Agent by Ia Direct Obs PX-3068789900 CDM 87899 CPT 306 RC inpatient 105 105 CIGNA 62308 [3081051] CIGNA STATE OF WYOMING [308105107] 83.14 percent of total billed charges 65.1 99.75 Technical (Hospital) Services Infect Agent by Ia Direct Obs PX-3068789900 CDM 87899 CPT 306 RC inpatient 105 105 BLUE CROSS BLUE SHIELD WELLMARK SB889 [3081026] BCBS WYOMING [308102603] 99.75 percent of total billed charges 65.1 99.75 Technical (Hospital) Services Infect Agent by Ia Direct Obs PX-3068789900 CDM 87899 CPT 306 RC inpatient 105 105 HEALTHPARTNERS SX009 HEALTHPARTNERS 83.14 percent of total billed charges 65.1 99.75 Technical (Hospital) Services Infect Agent by Ia Direct Obs PX-3068789900 CDM 87899 CPT 306 RC inpatient 105 105 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES EPO [308136803] 83.14 percent of total billed charges 65.1 99.75 Technical (Hospital) Services Infect Agent by Ia Direct Obs PX-3068789900 CDM 87899 CPT 306 RC outpatient 105 105 BLUE CROSS BLUE SHIELD WELLMARK SB889 [3081026] BCBS WYOMING [308102603] 99.75 percent of total billed charges 65.1 99.75 Technical (Hospital) Services Infect Agent by Ia Direct Obs PX-3068789900 CDM 87899 CPT 306 RC outpatient 105 105 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES HDHP [308136802] 84 percent of total billed charges 65.1 99.75 Technical (Hospital) Services Infect Agent by Ia Direct Obs PX-3068789900 CDM 87899 CPT 306 RC outpatient 105 105 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES EPO [308136803] 84 percent of total billed charges 65.1 99.75 Technical (Hospital) Services Infect Agent by Ia Direct Obs PX-3068789900 CDM 87899 CPT 306 RC outpatient 105 105 MULTIPLAN INC 34080 [3081285] MULTIPLAN INC [308128501] 99.75 percent of total billed charges 65.1 99.75 Technical (Hospital) Services Infect Agent by Ia Direct Obs PX-3068789900 CDM 87899 CPT 306 RC outpatient 105 105 CIGNA 62308 [3081051] CIGNA 62308 [308105105] 84 percent of total billed charges 65.1 99.75 Technical (Hospital) Services Infect Agent by Ia Direct Obs PX-3068789900 CDM 87899 CPT 306 RC outpatient 105 105 CIGNA 62308 [3081051] CIGNA STATE OF WYOMING [308105107] 84 percent of total billed charges 65.1 99.75 Technical (Hospital) Services Infect Agent by Ia Direct Obs PX-3068789900 CDM 87899 CPT 306 RC outpatient 105 105 HEALTHPARTNERS SX009 HEALTHPARTNERS 84 percent of total billed charges 65.1 99.75 Technical (Hospital) Services Infect Agent by Ia Direct Obs PX-3068789900 CDM 87899 CPT 306 RC outpatient 105 105 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES PPO [308136801] 84 percent of total billed charges 65.1 99.75 Technical (Hospital) Services Infect Agent by Ia Direct Obs PX-3068789900 CDM 87899 CPT 306 RC outpatient 105 105 UNITED HEALTHCARE (COMMERCIAL) [3081199] UNITED HEALTHCARE 87726 [308119901] 65.1 percent of total billed charges 65.1 99.75 Technical (Hospital) Services Infect Agent by Ia Direct Obs PX-3068789900 CDM 87899 CPT 306 RC outpatient 105 105 MEDICA (COMMERCIAL) 94265 [3081118] MEDICA CLAIMS [308111801] 94.5 percent of total billed charges 65.1 99.75 Technical (Hospital) Services HC Strep a Pcr PX-3028788001 CDM 87880 CPT 302 RC inpatient 61 61 MULTIPLAN INC 34080 [3081285] MULTIPLAN INC [308128501] 57.95 percent of total billed charges 37.82 57.95 Technical (Hospital) Services HC Strep a Pcr PX-3028788001 CDM 87880 CPT 302 RC inpatient 61 61 MEDICA (COMMERCIAL) 94265 [3081118] MEDICA CLAIMS [308111801] 54.9 percent of total billed charges 37.82 57.95 Technical (Hospital) Services HC Strep a Pcr PX-3028788001 CDM 87880 CPT 302 RC inpatient 61 61 BLUE CROSS BLUE SHIELD WELLMARK SB889 [3081026] BCBS WYOMING [308102603] 57.95 percent of total billed charges 37.82 57.95 Technical (Hospital) Services HC Strep a Pcr PX-3028788001 CDM 87880 CPT 302 RC inpatient 61 61 CIGNA 62308 [3081051] CIGNA 62308 [308105105] 48.3 percent of total billed charges 37.82 57.95 Technical (Hospital) Services HC Strep a Pcr PX-3028788001 CDM 87880 CPT 302 RC inpatient 61 61 CIGNA 62308 [3081051] CIGNA STATE OF WYOMING [308105107] 48.3 percent of total billed charges 37.82 57.95 Technical (Hospital) Services HC Strep a Pcr PX-3028788001 CDM 87880 CPT 302 RC inpatient 61 61 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES EPO [308136803] 48.3 percent of total billed charges 37.82 57.95 Technical (Hospital) Services HC Strep a Pcr PX-3028788001 CDM 87880 CPT 302 RC inpatient 61 61 HEALTHPARTNERS SX009 HEALTHPARTNERS 48.3 percent of total billed charges 37.82 57.95 Technical (Hospital) Services HC Strep a Pcr PX-3028788001 CDM 87880 CPT 302 RC inpatient 61 61 UNITED HEALTHCARE (COMMERCIAL) [3081199] UNITED HEALTHCARE 87726 [308119901] 37.82 percent of total billed charges 37.82 57.95 Technical (Hospital) Services HC Strep a Pcr PX-3028788001 CDM 87880 CPT 302 RC inpatient 61 61 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES PPO [308136801] 48.3 percent of total billed charges 37.82 57.95 Technical (Hospital) Services HC Strep a Pcr PX-3028788001 CDM 87880 CPT 302 RC inpatient 61 61 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES HDHP [308136802] 48.3 percent of total billed charges 37.82 57.95 Technical (Hospital) Services HC Strep a Pcr PX-3028788001 CDM 87880 CPT 302 RC outpatient 61 61 UNITED HEALTHCARE (COMMERCIAL) [3081199] UNITED HEALTHCARE 87726 [308119901] 37.82 percent of total billed charges 37.82 57.95 Technical (Hospital) Services HC Strep a Pcr PX-3028788001 CDM 87880 CPT 302 RC outpatient 61 61 HEALTHPARTNERS SX009 HEALTHPARTNERS 48.8 percent of total billed charges 37.82 57.95 Technical (Hospital) Services HC Strep a Pcr PX-3028788001 CDM 87880 CPT 302 RC outpatient 61 61 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES PPO [308136801] 48.8 percent of total billed charges 37.82 57.95 Technical (Hospital) Services HC Strep a Pcr PX-3028788001 CDM 87880 CPT 302 RC outpatient 61 61 BLUE CROSS BLUE SHIELD WELLMARK SB889 [3081026] BCBS WYOMING [308102603] 57.95 percent of total billed charges 37.82 57.95 Technical (Hospital) Services HC Strep a Pcr PX-3028788001 CDM 87880 CPT 302 RC outpatient 61 61 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES HDHP [308136802] 48.8 percent of total billed charges 37.82 57.95 Technical (Hospital) Services HC Strep a Pcr PX-3028788001 CDM 87880 CPT 302 RC outpatient 61 61 MULTIPLAN INC 34080 [3081285] MULTIPLAN INC [308128501] 57.95 percent of total billed charges 37.82 57.95 Technical (Hospital) Services HC Strep a Pcr PX-3028788001 CDM 87880 CPT 302 RC outpatient 61 61 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES EPO [308136803] 48.8 percent of total billed charges 37.82 57.95 Technical (Hospital) Services HC Strep a Pcr PX-3028788001 CDM 87880 CPT 302 RC outpatient 61 61 CIGNA 62308 [3081051] CIGNA 62308 [308105105] 48.8 percent of total billed charges 37.82 57.95 Technical (Hospital) Services HC Strep a Pcr PX-3028788001 CDM 87880 CPT 302 RC outpatient 61 61 CIGNA 62308 [3081051] CIGNA STATE OF WYOMING [308105107] 48.8 percent of total billed charges 37.82 57.95 Technical (Hospital) Services HC Strep a Pcr PX-3028788001 CDM 87880 CPT 302 RC outpatient 61 61 MEDICA (COMMERCIAL) 94265 [3081118] MEDICA CLAIMS [308111801] 54.9 percent of total billed charges 37.82 57.95 Technical (Hospital) Services Strep Screen Group a Waived PX-3068788000 CDM 87880 CPT 306 RC inpatient 114 114 MEDICA (COMMERCIAL) 94265 [3081118] MEDICA CLAIMS [308111801] 102.6 percent of total billed charges 70.68 108.3 Technical (Hospital) Services Strep Screen Group a Waived PX-3068788000 CDM 87880 CPT 306 RC inpatient 114 114 UNITED HEALTHCARE (COMMERCIAL) [3081199] UNITED HEALTHCARE 87726 [308119901] 70.68 percent of total billed charges 70.68 108.3 Technical (Hospital) Services Strep Screen Group a Waived PX-3068788000 CDM 87880 CPT 306 RC inpatient 114 114 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES HDHP [308136802] 90.27 percent of total billed charges 70.68 108.3 Technical (Hospital) Services Strep Screen Group a Waived PX-3068788000 CDM 87880 CPT 306 RC inpatient 114 114 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES PPO [308136801] 90.27 percent of total billed charges 70.68 108.3 Technical (Hospital) Services Strep Screen Group a Waived PX-3068788000 CDM 87880 CPT 306 RC inpatient 114 114 MULTIPLAN INC 34080 [3081285] MULTIPLAN INC [308128501] 108.3 percent of total billed charges 70.68 108.3 Technical (Hospital) Services Strep Screen Group a Waived PX-3068788000 CDM 87880 CPT 306 RC inpatient 114 114 CIGNA 62308 [3081051] CIGNA 62308 [308105105] 90.27 percent of total billed charges 70.68 108.3 Technical (Hospital) Services Strep Screen Group a Waived PX-3068788000 CDM 87880 CPT 306 RC inpatient 114 114 CIGNA 62308 [3081051] CIGNA STATE OF WYOMING [308105107] 90.27 percent of total billed charges 70.68 108.3 Technical (Hospital) Services Strep Screen Group a Waived PX-3068788000 CDM 87880 CPT 306 RC inpatient 114 114 BLUE CROSS BLUE SHIELD WELLMARK SB889 [3081026] BCBS WYOMING [308102603] 108.3 percent of total billed charges 70.68 108.3 Technical (Hospital) Services Strep Screen Group a Waived PX-3068788000 CDM 87880 CPT 306 RC inpatient 114 114 HEALTHPARTNERS SX009 HEALTHPARTNERS 90.27 percent of total billed charges 70.68 108.3 Technical (Hospital) Services Strep Screen Group a Waived PX-3068788000 CDM 87880 CPT 306 RC inpatient 114 114 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES EPO [308136803] 90.27 percent of total billed charges 70.68 108.3 Technical (Hospital) Services Strep Screen Group a Waived PX-3068788000 CDM 87880 CPT 306 RC outpatient 114 114 MEDICA (COMMERCIAL) 94265 [3081118] MEDICA CLAIMS [308111801] 102.6 percent of total billed charges 70.68 108.3 Technical (Hospital) Services Strep Screen Group a Waived PX-3068788000 CDM 87880 CPT 306 RC outpatient 114 114 UNITED HEALTHCARE (COMMERCIAL) [3081199] UNITED HEALTHCARE 87726 [308119901] 70.68 percent of total billed charges 70.68 108.3 Technical (Hospital) Services Strep Screen Group a Waived PX-3068788000 CDM 87880 CPT 306 RC outpatient 114 114 HEALTHPARTNERS SX009 HEALTHPARTNERS 91.2 percent of total billed charges 70.68 108.3 Technical (Hospital) Services Strep Screen Group a Waived PX-3068788000 CDM 87880 CPT 306 RC outpatient 114 114 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES PPO [308136801] 91.2 percent of total billed charges 70.68 108.3 Technical (Hospital) Services Strep Screen Group a Waived PX-3068788000 CDM 87880 CPT 306 RC outpatient 114 114 BLUE CROSS BLUE SHIELD WELLMARK SB889 [3081026] BCBS WYOMING [308102603] 108.3 percent of total billed charges 70.68 108.3 Technical (Hospital) Services Strep Screen Group a Waived PX-3068788000 CDM 87880 CPT 306 RC outpatient 114 114 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES HDHP [308136802] 91.2 percent of total billed charges 70.68 108.3 Technical (Hospital) Services Strep Screen Group a Waived PX-3068788000 CDM 87880 CPT 306 RC outpatient 114 114 MULTIPLAN INC 34080 [3081285] MULTIPLAN INC [308128501] 108.3 percent of total billed charges 70.68 108.3 Technical (Hospital) Services Strep Screen Group a Waived PX-3068788000 CDM 87880 CPT 306 RC outpatient 114 114 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES EPO [308136803] 91.2 percent of total billed charges 70.68 108.3 Technical (Hospital) Services Strep Screen Group a Waived PX-3068788000 CDM 87880 CPT 306 RC outpatient 114 114 CIGNA 62308 [3081051] CIGNA 62308 [308105105] 91.2 percent of total billed charges 70.68 108.3 Technical (Hospital) Services Strep Screen Group a Waived PX-3068788000 CDM 87880 CPT 306 RC outpatient 114 114 CIGNA 62308 [3081051] CIGNA STATE OF WYOMING [308105107] 91.2 percent of total billed charges 70.68 108.3 Technical (Hospital) Services POCT Trichomonas PX-3068780800 CDM 87808 CPT 306 RC inpatient 62 62 UNITED HEALTHCARE (COMMERCIAL) [3081199] UNITED HEALTHCARE 87726 [308119901] 38.44 percent of total billed charges 38.44 58.9 Technical (Hospital) Services POCT Trichomonas PX-3068780800 CDM 87808 CPT 306 RC inpatient 62 62 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES HDHP [308136802] 49.09 percent of total billed charges 38.44 58.9 Technical (Hospital) Services POCT Trichomonas PX-3068780800 CDM 87808 CPT 306 RC inpatient 62 62 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES PPO [308136801] 49.09 percent of total billed charges 38.44 58.9 Technical (Hospital) Services POCT Trichomonas PX-3068780800 CDM 87808 CPT 306 RC inpatient 62 62 BLUE CROSS BLUE SHIELD WELLMARK SB889 [3081026] BCBS WYOMING [308102603] 58.9 percent of total billed charges 38.44 58.9 Technical (Hospital) Services POCT Trichomonas PX-3068780800 CDM 87808 CPT 306 RC inpatient 62 62 CIGNA 62308 [3081051] CIGNA 62308 [308105105] 49.09 percent of total billed charges 38.44 58.9 Technical (Hospital) Services POCT Trichomonas PX-3068780800 CDM 87808 CPT 306 RC inpatient 62 62 CIGNA 62308 [3081051] CIGNA STATE OF WYOMING [308105107] 49.09 percent of total billed charges 38.44 58.9 Technical (Hospital) Services POCT Trichomonas PX-3068780800 CDM 87808 CPT 306 RC inpatient 62 62 MULTIPLAN INC 34080 [3081285] MULTIPLAN INC [308128501] 58.9 percent of total billed charges 38.44 58.9 Technical (Hospital) Services POCT Trichomonas PX-3068780800 CDM 87808 CPT 306 RC inpatient 62 62 MEDICA (COMMERCIAL) 94265 [3081118] MEDICA CLAIMS [308111801] 55.8 percent of total billed charges 38.44 58.9 Technical (Hospital) Services POCT Trichomonas PX-3068780800 CDM 87808 CPT 306 RC inpatient 62 62 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES EPO [308136803] 49.09 percent of total billed charges 38.44 58.9 Technical (Hospital) Services POCT Trichomonas PX-3068780800 CDM 87808 CPT 306 RC inpatient 62 62 HEALTHPARTNERS SX009 HEALTHPARTNERS 49.09 percent of total billed charges 38.44 58.9 Technical (Hospital) Services POCT Trichomonas PX-3068780800 CDM 87808 CPT 306 RC outpatient 62 62 BLUE CROSS BLUE SHIELD WELLMARK SB889 [3081026] BCBS WYOMING [308102603] 58.9 percent of total billed charges 38.44 58.9 Technical (Hospital) Services POCT Trichomonas PX-3068780800 CDM 87808 CPT 306 RC outpatient 62 62 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES HDHP [308136802] 49.6 percent of total billed charges 38.44 58.9 Technical (Hospital) Services POCT Trichomonas PX-3068780800 CDM 87808 CPT 306 RC outpatient 62 62 MULTIPLAN INC 34080 [3081285] MULTIPLAN INC [308128501] 58.9 percent of total billed charges 38.44 58.9 Technical (Hospital) Services POCT Trichomonas PX-3068780800 CDM 87808 CPT 306 RC outpatient 62 62 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES EPO [308136803] 49.6 percent of total billed charges 38.44 58.9 Technical (Hospital) Services POCT Trichomonas PX-3068780800 CDM 87808 CPT 306 RC outpatient 62 62 CIGNA 62308 [3081051] CIGNA 62308 [308105105] 49.6 percent of total billed charges 38.44 58.9 Technical (Hospital) Services POCT Trichomonas PX-3068780800 CDM 87808 CPT 306 RC outpatient 62 62 CIGNA 62308 [3081051] CIGNA STATE OF WYOMING [308105107] 49.6 percent of total billed charges 38.44 58.9 Technical (Hospital) Services POCT Trichomonas PX-3068780800 CDM 87808 CPT 306 RC outpatient 62 62 HEALTHPARTNERS SX009 HEALTHPARTNERS 49.6 percent of total billed charges 38.44 58.9 Technical (Hospital) Services POCT Trichomonas PX-3068780800 CDM 87808 CPT 306 RC outpatient 62 62 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES PPO [308136801] 49.6 percent of total billed charges 38.44 58.9 Technical (Hospital) Services POCT Trichomonas PX-3068780800 CDM 87808 CPT 306 RC outpatient 62 62 UNITED HEALTHCARE (COMMERCIAL) [3081199] UNITED HEALTHCARE 87726 [308119901] 38.44 percent of total billed charges 38.44 58.9 Technical (Hospital) Services POCT Trichomonas PX-3068780800 CDM 87808 CPT 306 RC outpatient 62 62 MEDICA (COMMERCIAL) 94265 [3081118] MEDICA CLAIMS [308111801] 55.8 percent of total billed charges 38.44 58.9 Technical (Hospital) Services Hiv Ag With Hiv I & II Ab PX-3068780600 CDM 87806 CPT 306 RC outpatient 89 89 UNITED HEALTHCARE (COMMERCIAL) [3081199] UNITED HEALTHCARE 87726 [308119901] 55.18 percent of total billed charges 55.18 84.55 Technical (Hospital) Services Hiv Ag With Hiv I & II Ab PX-3068780600 CDM 87806 CPT 306 RC outpatient 89 89 HEALTHPARTNERS SX009 HEALTHPARTNERS 71.2 percent of total billed charges 55.18 84.55 Technical (Hospital) Services Hiv Ag With Hiv I & II Ab PX-3068780600 CDM 87806 CPT 306 RC outpatient 89 89 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES PPO [308136801] 71.2 percent of total billed charges 55.18 84.55 Technical (Hospital) Services Hiv Ag With Hiv I & II Ab PX-3068780600 CDM 87806 CPT 306 RC outpatient 89 89 BLUE CROSS BLUE SHIELD WELLMARK SB889 [3081026] BCBS WYOMING [308102603] 84.55 percent of total billed charges 55.18 84.55 Technical (Hospital) Services Hiv Ag With Hiv I & II Ab PX-3068780600 CDM 87806 CPT 306 RC outpatient 89 89 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES HDHP [308136802] 71.2 percent of total billed charges 55.18 84.55 Technical (Hospital) Services Hiv Ag With Hiv I & II Ab PX-3068780600 CDM 87806 CPT 306 RC outpatient 89 89 MULTIPLAN INC 34080 [3081285] MULTIPLAN INC [308128501] 84.55 percent of total billed charges 55.18 84.55 Technical (Hospital) Services Hiv Ag With Hiv I & II Ab PX-3068780600 CDM 87806 CPT 306 RC outpatient 89 89 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES EPO [308136803] 71.2 percent of total billed charges 55.18 84.55 Technical (Hospital) Services Hiv Ag With Hiv I & II Ab PX-3068780600 CDM 87806 CPT 306 RC outpatient 89 89 CIGNA 62308 [3081051] CIGNA 62308 [308105105] 71.2 percent of total billed charges 55.18 84.55 Technical (Hospital) Services Hiv Ag With Hiv I & II Ab PX-3068780600 CDM 87806 CPT 306 RC outpatient 89 89 CIGNA 62308 [3081051] CIGNA STATE OF WYOMING [308105107] 71.2 percent of total billed charges 55.18 84.55 Technical (Hospital) Services Hiv Ag With Hiv I & II Ab PX-3068780600 CDM 87806 CPT 306 RC outpatient 89 89 MEDICA (COMMERCIAL) 94265 [3081118] MEDICA CLAIMS [308111801] 80.1 percent of total billed charges 55.18 84.55 Technical (Hospital) Services Hiv Ag With Hiv I & II Ab PX-3068780600 CDM 87806 CPT 306 RC inpatient 89 89 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES PPO [308136801] 70.47 percent of total billed charges 55.18 84.55 Technical (Hospital) Services Hiv Ag With Hiv I & II Ab PX-3068780600 CDM 87806 CPT 306 RC inpatient 89 89 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES HDHP [308136802] 70.47 percent of total billed charges 55.18 84.55 Technical (Hospital) Services Hiv Ag With Hiv I & II Ab PX-3068780600 CDM 87806 CPT 306 RC inpatient 89 89 UNITED HEALTHCARE (COMMERCIAL) [3081199] UNITED HEALTHCARE 87726 [308119901] 55.18 percent of total billed charges 55.18 84.55 Technical (Hospital) Services Hiv Ag With Hiv I & II Ab PX-3068780600 CDM 87806 CPT 306 RC inpatient 89 89 MEDICA (COMMERCIAL) 94265 [3081118] MEDICA CLAIMS [308111801] 80.1 percent of total billed charges 55.18 84.55 Technical (Hospital) Services Hiv Ag With Hiv I & II Ab PX-3068780600 CDM 87806 CPT 306 RC inpatient 89 89 BLUE CROSS BLUE SHIELD WELLMARK SB889 [3081026] BCBS WYOMING [308102603] 84.55 percent of total billed charges 55.18 84.55 Technical (Hospital) Services Hiv Ag With Hiv I & II Ab PX-3068780600 CDM 87806 CPT 306 RC inpatient 89 89 MULTIPLAN INC 34080 [3081285] MULTIPLAN INC [308128501] 84.55 percent of total billed charges 55.18 84.55 Technical (Hospital) Services Hiv Ag With Hiv I & II Ab PX-3068780600 CDM 87806 CPT 306 RC inpatient 89 89 CIGNA 62308 [3081051] CIGNA 62308 [308105105] 70.47 percent of total billed charges 55.18 84.55 Technical (Hospital) Services Hiv Ag With Hiv I & II Ab PX-3068780600 CDM 87806 CPT 306 RC inpatient 89 89 CIGNA 62308 [3081051] CIGNA STATE OF WYOMING [308105107] 70.47 percent of total billed charges 55.18 84.55 Technical (Hospital) Services Hiv Ag With Hiv I & II Ab PX-3068780600 CDM 87806 CPT 306 RC inpatient 89 89 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES EPO [308136803] 70.47 percent of total billed charges 55.18 84.55 Technical (Hospital) Services Hiv Ag With Hiv I & II Ab PX-3068780600 CDM 87806 CPT 306 RC inpatient 89 89 HEALTHPARTNERS SX009 HEALTHPARTNERS 70.47 percent of total billed charges 55.18 84.55 Technical (Hospital) Services Influenza a&B Waived PX-3068780400 CDM 87804 CPT 306 RC outpatient 105 105 UNITED HEALTHCARE (COMMERCIAL) [3081199] UNITED HEALTHCARE 87726 [308119901] 65.1 percent of total billed charges 65.1 99.75 Technical (Hospital) Services Influenza a&B Waived PX-3068780400 CDM 87804 CPT 306 RC outpatient 105 105 HEALTHPARTNERS SX009 HEALTHPARTNERS 84 percent of total billed charges 65.1 99.75 Technical (Hospital) Services Influenza a&B Waived PX-3068780400 CDM 87804 CPT 306 RC outpatient 105 105 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES PPO [308136801] 84 percent of total billed charges 65.1 99.75 Technical (Hospital) Services Influenza a&B Waived PX-3068780400 CDM 87804 CPT 306 RC outpatient 105 105 MULTIPLAN INC 34080 [3081285] MULTIPLAN INC [308128501] 99.75 percent of total billed charges 65.1 99.75 Technical (Hospital) Services Influenza a&B Waived PX-3068780400 CDM 87804 CPT 306 RC outpatient 105 105 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES EPO [308136803] 84 percent of total billed charges 65.1 99.75 Technical (Hospital) Services Influenza a&B Waived PX-3068780400 CDM 87804 CPT 306 RC outpatient 105 105 CIGNA 62308 [3081051] CIGNA 62308 [308105105] 84 percent of total billed charges 65.1 99.75 Technical (Hospital) Services Influenza a&B Waived PX-3068780400 CDM 87804 CPT 306 RC outpatient 105 105 CIGNA 62308 [3081051] CIGNA STATE OF WYOMING [308105107] 84 percent of total billed charges 65.1 99.75 Technical (Hospital) Services Influenza a&B Waived PX-3068780400 CDM 87804 CPT 306 RC outpatient 105 105 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES HDHP [308136802] 84 percent of total billed charges 65.1 99.75 Technical (Hospital) Services Influenza a&B Waived PX-3068780400 CDM 87804 CPT 306 RC outpatient 105 105 BLUE CROSS BLUE SHIELD WELLMARK SB889 [3081026] BCBS WYOMING [308102603] 99.75 percent of total billed charges 65.1 99.75 Technical (Hospital) Services Influenza a&B Waived PX-3068780400 CDM 87804 CPT 306 RC outpatient 105 105 MEDICA (COMMERCIAL) 94265 [3081118] MEDICA CLAIMS [308111801] 94.5 percent of total billed charges 65.1 99.75 Technical (Hospital) Services Influenza a&B Waived PX-3068780400 CDM 87804 CPT 306 RC inpatient 105 105 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES PPO [308136801] 83.14 percent of total billed charges 65.1 99.75 Technical (Hospital) Services Influenza a&B Waived PX-3068780400 CDM 87804 CPT 306 RC inpatient 105 105 MEDICA (COMMERCIAL) 94265 [3081118] MEDICA CLAIMS [308111801] 94.5 percent of total billed charges 65.1 99.75 Technical (Hospital) Services Influenza a&B Waived PX-3068780400 CDM 87804 CPT 306 RC inpatient 105 105 UNITED HEALTHCARE (COMMERCIAL) [3081199] UNITED HEALTHCARE 87726 [308119901] 65.1 percent of total billed charges 65.1 99.75 Technical (Hospital) Services Influenza a&B Waived PX-3068780400 CDM 87804 CPT 306 RC inpatient 105 105 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES HDHP [308136802] 83.14 percent of total billed charges 65.1 99.75 Technical (Hospital) Services Influenza a&B Waived PX-3068780400 CDM 87804 CPT 306 RC inpatient 105 105 BLUE CROSS BLUE SHIELD WELLMARK SB889 [3081026] BCBS WYOMING [308102603] 99.75 percent of total billed charges 65.1 99.75 Technical (Hospital) Services Influenza a&B Waived PX-3068780400 CDM 87804 CPT 306 RC inpatient 105 105 CIGNA 62308 [3081051] CIGNA 62308 [308105105] 83.14 percent of total billed charges 65.1 99.75 Technical (Hospital) Services Influenza a&B Waived PX-3068780400 CDM 87804 CPT 306 RC inpatient 105 105 CIGNA 62308 [3081051] CIGNA STATE OF WYOMING [308105107] 83.14 percent of total billed charges 65.1 99.75 Technical (Hospital) Services Influenza a&B Waived PX-3068780400 CDM 87804 CPT 306 RC inpatient 105 105 MULTIPLAN INC 34080 [3081285] MULTIPLAN INC [308128501] 99.75 percent of total billed charges 65.1 99.75 Technical (Hospital) Services Influenza a&B Waived PX-3068780400 CDM 87804 CPT 306 RC inpatient 105 105 HEALTHPARTNERS SX009 HEALTHPARTNERS 83.14 percent of total billed charges 65.1 99.75 Technical (Hospital) Services Influenza a&B Waived PX-3068780400 CDM 87804 CPT 306 RC inpatient 105 105 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES EPO [308136803] 83.14 percent of total billed charges 65.1 99.75 Technical (Hospital) Services HC Influenza a Waived PX-3068780403 CDM 87804 CPT 306 RC outpatient 105 105 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES PPO [308136801] 84 percent of total billed charges 65.1 99.75 Technical (Hospital) Services HC Influenza a Waived PX-3068780403 CDM 87804 CPT 306 RC outpatient 105 105 HEALTHPARTNERS SX009 HEALTHPARTNERS 84 percent of total billed charges 65.1 99.75 Technical (Hospital) Services HC Influenza a Waived PX-3068780403 CDM 87804 CPT 306 RC outpatient 105 105 UNITED HEALTHCARE (COMMERCIAL) [3081199] UNITED HEALTHCARE 87726 [308119901] 65.1 percent of total billed charges 65.1 99.75 Technical (Hospital) Services HC Influenza a Waived PX-3068780403 CDM 87804 CPT 306 RC outpatient 105 105 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES EPO [308136803] 84 percent of total billed charges 65.1 99.75 Technical (Hospital) Services HC Influenza a Waived PX-3068780403 CDM 87804 CPT 306 RC outpatient 105 105 CIGNA 62308 [3081051] CIGNA 62308 [308105105] 84 percent of total billed charges 65.1 99.75 Technical (Hospital) Services HC Influenza a Waived PX-3068780403 CDM 87804 CPT 306 RC outpatient 105 105 CIGNA 62308 [3081051] CIGNA STATE OF WYOMING [308105107] 84 percent of total billed charges 65.1 99.75 Technical (Hospital) Services HC Influenza a Waived PX-3068780403 CDM 87804 CPT 306 RC outpatient 105 105 MULTIPLAN INC 34080 [3081285] MULTIPLAN INC [308128501] 99.75 percent of total billed charges 65.1 99.75 Technical (Hospital) Services HC Influenza a Waived PX-3068780403 CDM 87804 CPT 306 RC outpatient 105 105 BLUE CROSS BLUE SHIELD WELLMARK SB889 [3081026] BCBS WYOMING [308102603] 99.75 percent of total billed charges 65.1 99.75 Technical (Hospital) Services HC Influenza a Waived PX-3068780403 CDM 87804 CPT 306 RC outpatient 105 105 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES HDHP [308136802] 84 percent of total billed charges 65.1 99.75 Technical (Hospital) Services HC Influenza a Waived PX-3068780403 CDM 87804 CPT 306 RC outpatient 105 105 MEDICA (COMMERCIAL) 94265 [3081118] MEDICA CLAIMS [308111801] 94.5 percent of total billed charges 65.1 99.75 Technical (Hospital) Services HC Influenza a Waived PX-3068780403 CDM 87804 CPT 306 RC inpatient 105 105 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES EPO [308136803] 83.14 percent of total billed charges 65.1 99.75 Technical (Hospital) Services HC Influenza a Waived PX-3068780403 CDM 87804 CPT 306 RC inpatient 105 105 HEALTHPARTNERS SX009 HEALTHPARTNERS 83.14 percent of total billed charges 65.1 99.75 Technical (Hospital) Services HC Influenza a Waived PX-3068780403 CDM 87804 CPT 306 RC inpatient 105 105 BLUE CROSS BLUE SHIELD WELLMARK SB889 [3081026] BCBS WYOMING [308102603] 99.75 percent of total billed charges 65.1 99.75 Technical (Hospital) Services HC Influenza a Waived PX-3068780403 CDM 87804 CPT 306 RC inpatient 105 105 MULTIPLAN INC 34080 [3081285] MULTIPLAN INC [308128501] 99.75 percent of total billed charges 65.1 99.75 Technical (Hospital) Services HC Influenza a Waived PX-3068780403 CDM 87804 CPT 306 RC inpatient 105 105 CIGNA 62308 [3081051] CIGNA 62308 [308105105] 83.14 percent of total billed charges 65.1 99.75 Technical (Hospital) Services HC Influenza a Waived PX-3068780403 CDM 87804 CPT 306 RC inpatient 105 105 CIGNA 62308 [3081051] CIGNA STATE OF WYOMING [308105107] 83.14 percent of total billed charges 65.1 99.75 Technical (Hospital) Services HC Influenza a Waived PX-3068780403 CDM 87804 CPT 306 RC inpatient 105 105 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES PPO [308136801] 83.14 percent of total billed charges 65.1 99.75 Technical (Hospital) Services HC Influenza a Waived PX-3068780403 CDM 87804 CPT 306 RC inpatient 105 105 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES HDHP [308136802] 83.14 percent of total billed charges 65.1 99.75 Technical (Hospital) Services HC Influenza a Waived PX-3068780403 CDM 87804 CPT 306 RC inpatient 105 105 UNITED HEALTHCARE (COMMERCIAL) [3081199] UNITED HEALTHCARE 87726 [308119901] 65.1 percent of total billed charges 65.1 99.75 Technical (Hospital) Services HC Influenza a Waived PX-3068780403 CDM 87804 CPT 306 RC inpatient 105 105 MEDICA (COMMERCIAL) 94265 [3081118] MEDICA CLAIMS [308111801] 94.5 percent of total billed charges 65.1 99.75 Technical (Hospital) Services HC Influenza B Waived PX-3068780404 CDM 87804 CPT 306 RC outpatient 105 105 MEDICA (COMMERCIAL) 94265 [3081118] MEDICA CLAIMS [308111801] 94.5 percent of total billed charges 65.1 99.75 Technical (Hospital) Services HC Influenza B Waived PX-3068780404 CDM 87804 CPT 306 RC outpatient 105 105 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES HDHP [308136802] 84 percent of total billed charges 65.1 99.75 Technical (Hospital) Services HC Influenza B Waived PX-3068780404 CDM 87804 CPT 306 RC outpatient 105 105 BLUE CROSS BLUE SHIELD WELLMARK SB889 [3081026] BCBS WYOMING [308102603] 99.75 percent of total billed charges 65.1 99.75 Technical (Hospital) Services HC Influenza B Waived PX-3068780404 CDM 87804 CPT 306 RC outpatient 105 105 MULTIPLAN INC 34080 [3081285] MULTIPLAN INC [308128501] 99.75 percent of total billed charges 65.1 99.75 Technical (Hospital) Services HC Influenza B Waived PX-3068780404 CDM 87804 CPT 306 RC outpatient 105 105 CIGNA 62308 [3081051] CIGNA 62308 [308105105] 84 percent of total billed charges 65.1 99.75 Technical (Hospital) Services HC Influenza B Waived PX-3068780404 CDM 87804 CPT 306 RC outpatient 105 105 CIGNA 62308 [3081051] CIGNA STATE OF WYOMING [308105107] 84 percent of total billed charges 65.1 99.75 Technical (Hospital) Services HC Influenza B Waived PX-3068780404 CDM 87804 CPT 306 RC outpatient 105 105 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES EPO [308136803] 84 percent of total billed charges 65.1 99.75 Technical (Hospital) Services HC Influenza B Waived PX-3068780404 CDM 87804 CPT 306 RC outpatient 105 105 UNITED HEALTHCARE (COMMERCIAL) [3081199] UNITED HEALTHCARE 87726 [308119901] 65.1 percent of total billed charges 65.1 99.75 Technical (Hospital) Services HC Influenza B Waived PX-3068780404 CDM 87804 CPT 306 RC outpatient 105 105 HEALTHPARTNERS SX009 HEALTHPARTNERS 84 percent of total billed charges 65.1 99.75 Technical (Hospital) Services HC Influenza B Waived PX-3068780404 CDM 87804 CPT 306 RC outpatient 105 105 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES PPO [308136801] 84 percent of total billed charges 65.1 99.75 Technical (Hospital) Services HC Influenza B Waived PX-3068780404 CDM 87804 CPT 306 RC inpatient 105 105 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES PPO [308136801] 83.14 percent of total billed charges 65.1 99.75 Technical (Hospital) Services HC Influenza B Waived PX-3068780404 CDM 87804 CPT 306 RC inpatient 105 105 UNITED HEALTHCARE (COMMERCIAL) [3081199] UNITED HEALTHCARE 87726 [308119901] 65.1 percent of total billed charges 65.1 99.75 Technical (Hospital) Services HC Influenza B Waived PX-3068780404 CDM 87804 CPT 306 RC inpatient 105 105 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES HDHP [308136802] 83.14 percent of total billed charges 65.1 99.75 Technical (Hospital) Services HC Influenza B Waived PX-3068780404 CDM 87804 CPT 306 RC inpatient 105 105 MEDICA (COMMERCIAL) 94265 [3081118] MEDICA CLAIMS [308111801] 94.5 percent of total billed charges 65.1 99.75 Technical (Hospital) Services HC Influenza B Waived PX-3068780404 CDM 87804 CPT 306 RC inpatient 105 105 HEALTHPARTNERS SX009 HEALTHPARTNERS 83.14 percent of total billed charges 65.1 99.75 Technical (Hospital) Services HC Influenza B Waived PX-3068780404 CDM 87804 CPT 306 RC inpatient 105 105 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES EPO [308136803] 83.14 percent of total billed charges 65.1 99.75 Technical (Hospital) Services HC Influenza B Waived PX-3068780404 CDM 87804 CPT 306 RC inpatient 105 105 MULTIPLAN INC 34080 [3081285] MULTIPLAN INC [308128501] 99.75 percent of total billed charges 65.1 99.75 Technical (Hospital) Services HC Influenza B Waived PX-3068780404 CDM 87804 CPT 306 RC inpatient 105 105 CIGNA 62308 [3081051] CIGNA 62308 [308105105] 83.14 percent of total billed charges 65.1 99.75 Technical (Hospital) Services HC Influenza B Waived PX-3068780404 CDM 87804 CPT 306 RC inpatient 105 105 CIGNA 62308 [3081051] CIGNA STATE OF WYOMING [308105107] 83.14 percent of total billed charges 65.1 99.75 Technical (Hospital) Services HC Influenza B Waived PX-3068780404 CDM 87804 CPT 306 RC inpatient 105 105 BLUE CROSS BLUE SHIELD WELLMARK SB889 [3081026] BCBS WYOMING [308102603] 99.75 percent of total billed charges 65.1 99.75 Technical (Hospital) Services Grp B Vaginal PX-3068780200 CDM 87802 CPT 306 RC inpatient 114 114 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES HDHP [308136802] 90.27 percent of total billed charges 70.68 108.3 Technical (Hospital) Services Grp B Vaginal PX-3068780200 CDM 87802 CPT 306 RC inpatient 114 114 MEDICA (COMMERCIAL) 94265 [3081118] MEDICA CLAIMS [308111801] 102.6 percent of total billed charges 70.68 108.3 Technical (Hospital) Services Grp B Vaginal PX-3068780200 CDM 87802 CPT 306 RC inpatient 114 114 UNITED HEALTHCARE (COMMERCIAL) [3081199] UNITED HEALTHCARE 87726 [308119901] 70.68 percent of total billed charges 70.68 108.3 Technical (Hospital) Services Grp B Vaginal PX-3068780200 CDM 87802 CPT 306 RC inpatient 114 114 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES PPO [308136801] 90.27 percent of total billed charges 70.68 108.3 Technical (Hospital) Services Grp B Vaginal PX-3068780200 CDM 87802 CPT 306 RC inpatient 114 114 BLUE CROSS BLUE SHIELD WELLMARK SB889 [3081026] BCBS WYOMING [308102603] 108.3 percent of total billed charges 70.68 108.3 Technical (Hospital) Services Grp B Vaginal PX-3068780200 CDM 87802 CPT 306 RC inpatient 114 114 CIGNA 62308 [3081051] CIGNA 62308 [308105105] 90.27 percent of total billed charges 70.68 108.3 Technical (Hospital) Services Grp B Vaginal PX-3068780200 CDM 87802 CPT 306 RC inpatient 114 114 CIGNA 62308 [3081051] CIGNA STATE OF WYOMING [308105107] 90.27 percent of total billed charges 70.68 108.3 Technical (Hospital) Services Grp B Vaginal PX-3068780200 CDM 87802 CPT 306 RC inpatient 114 114 MULTIPLAN INC 34080 [3081285] MULTIPLAN INC [308128501] 108.3 percent of total billed charges 70.68 108.3 Technical (Hospital) Services Grp B Vaginal PX-3068780200 CDM 87802 CPT 306 RC inpatient 114 114 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES EPO [308136803] 90.27 percent of total billed charges 70.68 108.3 Technical (Hospital) Services Grp B Vaginal PX-3068780200 CDM 87802 CPT 306 RC inpatient 114 114 HEALTHPARTNERS SX009 HEALTHPARTNERS 90.27 percent of total billed charges 70.68 108.3 Technical (Hospital) Services Grp B Vaginal PX-3068780200 CDM 87802 CPT 306 RC outpatient 114 114 MULTIPLAN INC 34080 [3081285] MULTIPLAN INC [308128501] 108.3 percent of total billed charges 70.68 108.3 Technical (Hospital) Services Grp B Vaginal PX-3068780200 CDM 87802 CPT 306 RC outpatient 114 114 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES EPO [308136803] 91.2 percent of total billed charges 70.68 108.3 Technical (Hospital) Services Grp B Vaginal PX-3068780200 CDM 87802 CPT 306 RC outpatient 114 114 CIGNA 62308 [3081051] CIGNA 62308 [308105105] 91.2 percent of total billed charges 70.68 108.3 Technical (Hospital) Services Grp B Vaginal PX-3068780200 CDM 87802 CPT 306 RC outpatient 114 114 CIGNA 62308 [3081051] CIGNA STATE OF WYOMING [308105107] 91.2 percent of total billed charges 70.68 108.3 Technical (Hospital) Services Grp B Vaginal PX-3068780200 CDM 87802 CPT 306 RC outpatient 114 114 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES HDHP [308136802] 91.2 percent of total billed charges 70.68 108.3 Technical (Hospital) Services Grp B Vaginal PX-3068780200 CDM 87802 CPT 306 RC outpatient 114 114 BLUE CROSS BLUE SHIELD WELLMARK SB889 [3081026] BCBS WYOMING [308102603] 108.3 percent of total billed charges 70.68 108.3 Technical (Hospital) Services Grp B Vaginal PX-3068780200 CDM 87802 CPT 306 RC outpatient 114 114 HEALTHPARTNERS SX009 HEALTHPARTNERS 91.2 percent of total billed charges 70.68 108.3 Technical (Hospital) Services Grp B Vaginal PX-3068780200 CDM 87802 CPT 306 RC outpatient 114 114 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES PPO [308136801] 91.2 percent of total billed charges 70.68 108.3 Technical (Hospital) Services Grp B Vaginal PX-3068780200 CDM 87802 CPT 306 RC outpatient 114 114 UNITED HEALTHCARE (COMMERCIAL) [3081199] UNITED HEALTHCARE 87726 [308119901] 70.68 percent of total billed charges 70.68 108.3 Technical (Hospital) Services Grp B Vaginal PX-3068780200 CDM 87802 CPT 306 RC outpatient 114 114 MEDICA (COMMERCIAL) 94265 [3081118] MEDICA CLAIMS [308111801] 102.6 percent of total billed charges 70.68 108.3 Technical (Hospital) Services "Ref Detect Agent Nos, Dna, Quant" PX-3068779900 CDM 87799 CPT 306 RC inpatient 266 266 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES PPO [308136801] 210.62 percent of total billed charges 164.92 252.7 Technical (Hospital) Services "Ref Detect Agent Nos, Dna, Quant" PX-3068779900 CDM 87799 CPT 306 RC inpatient 266 266 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES HDHP [308136802] 210.62 percent of total billed charges 164.92 252.7 Technical (Hospital) Services "Ref Detect Agent Nos, Dna, Quant" PX-3068779900 CDM 87799 CPT 306 RC inpatient 266 266 MEDICA (COMMERCIAL) 94265 [3081118] MEDICA CLAIMS [308111801] 239.4 percent of total billed charges 164.92 252.7 Technical (Hospital) Services "Ref Detect Agent Nos, Dna, Quant" PX-3068779900 CDM 87799 CPT 306 RC inpatient 266 266 UNITED HEALTHCARE (COMMERCIAL) [3081199] UNITED HEALTHCARE 87726 [308119901] 164.92 percent of total billed charges 164.92 252.7 Technical (Hospital) Services "Ref Detect Agent Nos, Dna, Quant" PX-3068779900 CDM 87799 CPT 306 RC inpatient 266 266 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES EPO [308136803] 210.62 percent of total billed charges 164.92 252.7 Technical (Hospital) Services "Ref Detect Agent Nos, Dna, Quant" PX-3068779900 CDM 87799 CPT 306 RC inpatient 266 266 HEALTHPARTNERS SX009 HEALTHPARTNERS 210.62 percent of total billed charges 164.92 252.7 Technical (Hospital) Services "Ref Detect Agent Nos, Dna, Quant" PX-3068779900 CDM 87799 CPT 306 RC inpatient 266 266 MULTIPLAN INC 34080 [3081285] MULTIPLAN INC [308128501] 252.7 percent of total billed charges 164.92 252.7 Technical (Hospital) Services "Ref Detect Agent Nos, Dna, Quant" PX-3068779900 CDM 87799 CPT 306 RC inpatient 266 266 BLUE CROSS BLUE SHIELD WELLMARK SB889 [3081026] BCBS WYOMING [308102603] 252.7 percent of total billed charges 164.92 252.7 Technical (Hospital) Services "Ref Detect Agent Nos, Dna, Quant" PX-3068779900 CDM 87799 CPT 306 RC inpatient 266 266 CIGNA 62308 [3081051] CIGNA 62308 [308105105] 210.62 percent of total billed charges 164.92 252.7 Technical (Hospital) Services "Ref Detect Agent Nos, Dna, Quant" PX-3068779900 CDM 87799 CPT 306 RC inpatient 266 266 CIGNA 62308 [3081051] CIGNA STATE OF WYOMING [308105107] 210.62 percent of total billed charges 164.92 252.7 Technical (Hospital) Services "Ref Detect Agent Nos, Dna, Quant" PX-3068779900 CDM 87799 CPT 306 RC outpatient 266 266 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES HDHP [308136802] 212.8 percent of total billed charges 164.92 252.7 Technical (Hospital) Services "Ref Detect Agent Nos, Dna, Quant" PX-3068779900 CDM 87799 CPT 306 RC outpatient 266 266 BLUE CROSS BLUE SHIELD WELLMARK SB889 [3081026] BCBS WYOMING [308102603] 252.7 percent of total billed charges 164.92 252.7 Technical (Hospital) Services "Ref Detect Agent Nos, Dna, Quant" PX-3068779900 CDM 87799 CPT 306 RC outpatient 266 266 CIGNA 62308 [3081051] CIGNA 62308 [308105105] 212.8 percent of total billed charges 164.92 252.7 Technical (Hospital) Services "Ref Detect Agent Nos, Dna, Quant" PX-3068779900 CDM 87799 CPT 306 RC outpatient 266 266 CIGNA 62308 [3081051] CIGNA STATE OF WYOMING [308105107] 212.8 percent of total billed charges 164.92 252.7 Technical (Hospital) Services "Ref Detect Agent Nos, Dna, Quant" PX-3068779900 CDM 87799 CPT 306 RC outpatient 266 266 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES EPO [308136803] 212.8 percent of total billed charges 164.92 252.7 Technical (Hospital) Services "Ref Detect Agent Nos, Dna, Quant" PX-3068779900 CDM 87799 CPT 306 RC outpatient 266 266 MULTIPLAN INC 34080 [3081285] MULTIPLAN INC [308128501] 252.7 percent of total billed charges 164.92 252.7 Technical (Hospital) Services "Ref Detect Agent Nos, Dna, Quant" PX-3068779900 CDM 87799 CPT 306 RC outpatient 266 266 UNITED HEALTHCARE (COMMERCIAL) [3081199] UNITED HEALTHCARE 87726 [308119901] 164.92 percent of total billed charges 164.92 252.7 Technical (Hospital) Services "Ref Detect Agent Nos, Dna, Quant" PX-3068779900 CDM 87799 CPT 306 RC outpatient 266 266 HEALTHPARTNERS SX009 HEALTHPARTNERS 212.8 percent of total billed charges 164.92 252.7 Technical (Hospital) Services "Ref Detect Agent Nos, Dna, Quant" PX-3068779900 CDM 87799 CPT 306 RC outpatient 266 266 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES PPO [308136801] 212.8 percent of total billed charges 164.92 252.7 Technical (Hospital) Services "Ref Detect Agent Nos, Dna, Quant" PX-3068779900 CDM 87799 CPT 306 RC outpatient 266 266 MEDICA (COMMERCIAL) 94265 [3081118] MEDICA CLAIMS [308111801] 239.4 percent of total billed charges 164.92 252.7 Technical (Hospital) Services Ref Bk Virus Dna by Rapid Pcr PX-3068779902 CDM 87799 CPT 306 RC outpatient 169 169 HEALTHPARTNERS SX009 HEALTHPARTNERS 135.2 percent of total billed charges 104.78 160.55 Technical (Hospital) Services Ref Bk Virus Dna by Rapid Pcr PX-3068779902 CDM 87799 CPT 306 RC outpatient 169 169 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES PPO [308136801] 135.2 percent of total billed charges 104.78 160.55 Technical (Hospital) Services Ref Bk Virus Dna by Rapid Pcr PX-3068779902 CDM 87799 CPT 306 RC outpatient 169 169 UNITED HEALTHCARE (COMMERCIAL) [3081199] UNITED HEALTHCARE 87726 [308119901] 104.78 percent of total billed charges 104.78 160.55 Technical (Hospital) Services Ref Bk Virus Dna by Rapid Pcr PX-3068779902 CDM 87799 CPT 306 RC outpatient 169 169 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES HDHP [308136802] 135.2 percent of total billed charges 104.78 160.55 Technical (Hospital) Services Ref Bk Virus Dna by Rapid Pcr PX-3068779902 CDM 87799 CPT 306 RC outpatient 169 169 BLUE CROSS BLUE SHIELD WELLMARK SB889 [3081026] BCBS WYOMING [308102603] 160.55 percent of total billed charges 104.78 160.55 Technical (Hospital) Services Ref Bk Virus Dna by Rapid Pcr PX-3068779902 CDM 87799 CPT 306 RC outpatient 169 169 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES EPO [308136803] 135.2 percent of total billed charges 104.78 160.55 Technical (Hospital) Services Ref Bk Virus Dna by Rapid Pcr PX-3068779902 CDM 87799 CPT 306 RC outpatient 169 169 MULTIPLAN INC 34080 [3081285] MULTIPLAN INC [308128501] 160.55 percent of total billed charges 104.78 160.55 Technical (Hospital) Services Ref Bk Virus Dna by Rapid Pcr PX-3068779902 CDM 87799 CPT 306 RC outpatient 169 169 CIGNA 62308 [3081051] CIGNA 62308 [308105105] 135.2 percent of total billed charges 104.78 160.55 Technical (Hospital) Services Ref Bk Virus Dna by Rapid Pcr PX-3068779902 CDM 87799 CPT 306 RC outpatient 169 169 CIGNA 62308 [3081051] CIGNA STATE OF WYOMING [308105107] 135.2 percent of total billed charges 104.78 160.55 Technical (Hospital) Services Ref Bk Virus Dna by Rapid Pcr PX-3068779902 CDM 87799 CPT 306 RC outpatient 169 169 MEDICA (COMMERCIAL) 94265 [3081118] MEDICA CLAIMS [308111801] 152.1 percent of total billed charges 104.78 160.55 Technical (Hospital) Services Ref Bk Virus Dna by Rapid Pcr PX-3068779902 CDM 87799 CPT 306 RC inpatient 169 169 UNITED HEALTHCARE (COMMERCIAL) [3081199] UNITED HEALTHCARE 87726 [308119901] 104.78 percent of total billed charges 104.78 160.55 Technical (Hospital) Services Ref Bk Virus Dna by Rapid Pcr PX-3068779902 CDM 87799 CPT 306 RC inpatient 169 169 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES HDHP [308136802] 133.81 percent of total billed charges 104.78 160.55 Technical (Hospital) Services Ref Bk Virus Dna by Rapid Pcr PX-3068779902 CDM 87799 CPT 306 RC inpatient 169 169 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES PPO [308136801] 133.81 percent of total billed charges 104.78 160.55 Technical (Hospital) Services Ref Bk Virus Dna by Rapid Pcr PX-3068779902 CDM 87799 CPT 306 RC inpatient 169 169 MEDICA (COMMERCIAL) 94265 [3081118] MEDICA CLAIMS [308111801] 152.1 percent of total billed charges 104.78 160.55 Technical (Hospital) Services Ref Bk Virus Dna by Rapid Pcr PX-3068779902 CDM 87799 CPT 306 RC inpatient 169 169 MULTIPLAN INC 34080 [3081285] MULTIPLAN INC [308128501] 160.55 percent of total billed charges 104.78 160.55 Technical (Hospital) Services Ref Bk Virus Dna by Rapid Pcr PX-3068779902 CDM 87799 CPT 306 RC inpatient 169 169 CIGNA 62308 [3081051] CIGNA 62308 [308105105] 133.81 percent of total billed charges 104.78 160.55 Technical (Hospital) Services Ref Bk Virus Dna by Rapid Pcr PX-3068779902 CDM 87799 CPT 306 RC inpatient 169 169 CIGNA 62308 [3081051] CIGNA STATE OF WYOMING [308105107] 133.81 percent of total billed charges 104.78 160.55 Technical (Hospital) Services Ref Bk Virus Dna by Rapid Pcr PX-3068779902 CDM 87799 CPT 306 RC inpatient 169 169 BLUE CROSS BLUE SHIELD WELLMARK SB889 [3081026] BCBS WYOMING [308102603] 160.55 percent of total billed charges 104.78 160.55 Technical (Hospital) Services Ref Bk Virus Dna by Rapid Pcr PX-3068779902 CDM 87799 CPT 306 RC inpatient 169 169 HEALTHPARTNERS SX009 HEALTHPARTNERS 133.81 percent of total billed charges 104.78 160.55 Technical (Hospital) Services Ref Bk Virus Dna by Rapid Pcr PX-3068779902 CDM 87799 CPT 306 RC inpatient 169 169 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES EPO [308136803] 133.81 percent of total billed charges 104.78 160.55 Technical (Hospital) Services Ref Epstein Barr Virus Dna PX-3068779903 CDM 87799 CPT 306 RC inpatient 266 266 HEALTHPARTNERS SX009 HEALTHPARTNERS 210.62 percent of total billed charges 164.92 252.7 Technical (Hospital) Services Ref Epstein Barr Virus Dna PX-3068779903 CDM 87799 CPT 306 RC inpatient 266 266 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES EPO [308136803] 210.62 percent of total billed charges 164.92 252.7 Technical (Hospital) Services Ref Epstein Barr Virus Dna PX-3068779903 CDM 87799 CPT 306 RC inpatient 266 266 MEDICA (COMMERCIAL) 94265 [3081118] MEDICA CLAIMS [308111801] 239.4 percent of total billed charges 164.92 252.7 Technical (Hospital) Services Ref Epstein Barr Virus Dna PX-3068779903 CDM 87799 CPT 306 RC inpatient 266 266 MULTIPLAN INC 34080 [3081285] MULTIPLAN INC [308128501] 252.7 percent of total billed charges 164.92 252.7 Technical (Hospital) Services Ref Epstein Barr Virus Dna PX-3068779903 CDM 87799 CPT 306 RC inpatient 266 266 CIGNA 62308 [3081051] CIGNA 62308 [308105105] 210.62 percent of total billed charges 164.92 252.7 Technical (Hospital) Services Ref Epstein Barr Virus Dna PX-3068779903 CDM 87799 CPT 306 RC inpatient 266 266 CIGNA 62308 [3081051] CIGNA STATE OF WYOMING [308105107] 210.62 percent of total billed charges 164.92 252.7 Technical (Hospital) Services Ref Epstein Barr Virus Dna PX-3068779903 CDM 87799 CPT 306 RC inpatient 266 266 BLUE CROSS BLUE SHIELD WELLMARK SB889 [3081026] BCBS WYOMING [308102603] 252.7 percent of total billed charges 164.92 252.7 Technical (Hospital) Services Ref Epstein Barr Virus Dna PX-3068779903 CDM 87799 CPT 306 RC inpatient 266 266 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES PPO [308136801] 210.62 percent of total billed charges 164.92 252.7 Technical (Hospital) Services Ref Epstein Barr Virus Dna PX-3068779903 CDM 87799 CPT 306 RC inpatient 266 266 UNITED HEALTHCARE (COMMERCIAL) [3081199] UNITED HEALTHCARE 87726 [308119901] 164.92 percent of total billed charges 164.92 252.7 Technical (Hospital) Services Ref Epstein Barr Virus Dna PX-3068779903 CDM 87799 CPT 306 RC inpatient 266 266 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES HDHP [308136802] 210.62 percent of total billed charges 164.92 252.7 Technical (Hospital) Services Ref Epstein Barr Virus Dna PX-3068779903 CDM 87799 CPT 306 RC outpatient 266 266 HEALTHPARTNERS SX009 HEALTHPARTNERS 212.8 percent of total billed charges 164.92 252.7 Technical (Hospital) Services Ref Epstein Barr Virus Dna PX-3068779903 CDM 87799 CPT 306 RC outpatient 266 266 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES PPO [308136801] 212.8 percent of total billed charges 164.92 252.7 Technical (Hospital) Services Ref Epstein Barr Virus Dna PX-3068779903 CDM 87799 CPT 306 RC outpatient 266 266 UNITED HEALTHCARE (COMMERCIAL) [3081199] UNITED HEALTHCARE 87726 [308119901] 164.92 percent of total billed charges 164.92 252.7 Technical (Hospital) Services Ref Epstein Barr Virus Dna PX-3068779903 CDM 87799 CPT 306 RC outpatient 266 266 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES HDHP [308136802] 212.8 percent of total billed charges 164.92 252.7 Technical (Hospital) Services Ref Epstein Barr Virus Dna PX-3068779903 CDM 87799 CPT 306 RC outpatient 266 266 BLUE CROSS BLUE SHIELD WELLMARK SB889 [3081026] BCBS WYOMING [308102603] 252.7 percent of total billed charges 164.92 252.7 Technical (Hospital) Services Ref Epstein Barr Virus Dna PX-3068779903 CDM 87799 CPT 306 RC outpatient 266 266 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES EPO [308136803] 212.8 percent of total billed charges 164.92 252.7 Technical (Hospital) Services Ref Epstein Barr Virus Dna PX-3068779903 CDM 87799 CPT 306 RC outpatient 266 266 MULTIPLAN INC 34080 [3081285] MULTIPLAN INC [308128501] 252.7 percent of total billed charges 164.92 252.7 Technical (Hospital) Services Ref Epstein Barr Virus Dna PX-3068779903 CDM 87799 CPT 306 RC outpatient 266 266 CIGNA 62308 [3081051] CIGNA 62308 [308105105] 212.8 percent of total billed charges 164.92 252.7 Technical (Hospital) Services Ref Epstein Barr Virus Dna PX-3068779903 CDM 87799 CPT 306 RC outpatient 266 266 CIGNA 62308 [3081051] CIGNA STATE OF WYOMING [308105107] 212.8 percent of total billed charges 164.92 252.7 Technical (Hospital) Services Ref Epstein Barr Virus Dna PX-3068779903 CDM 87799 CPT 306 RC outpatient 266 266 MEDICA (COMMERCIAL) 94265 [3081118] MEDICA CLAIMS [308111801] 239.4 percent of total billed charges 164.92 252.7 Technical (Hospital) Services B Pertussis by Pcr PX-3068779800 CDM 87798 CPT 306 RC outpatient 410 410 MULTIPLAN INC 34080 [3081285] MULTIPLAN INC [308128501] 389.5 percent of total billed charges 254.2 389.5 Technical (Hospital) Services B Pertussis by Pcr PX-3068779800 CDM 87798 CPT 306 RC outpatient 410 410 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES EPO [308136803] 328 percent of total billed charges 254.2 389.5 Technical (Hospital) Services B Pertussis by Pcr PX-3068779800 CDM 87798 CPT 306 RC outpatient 410 410 CIGNA 62308 [3081051] CIGNA 62308 [308105105] 328 percent of total billed charges 254.2 389.5 Technical (Hospital) Services B Pertussis by Pcr PX-3068779800 CDM 87798 CPT 306 RC outpatient 410 410 CIGNA 62308 [3081051] CIGNA STATE OF WYOMING [308105107] 328 percent of total billed charges 254.2 389.5 Technical (Hospital) Services B Pertussis by Pcr PX-3068779800 CDM 87798 CPT 306 RC outpatient 410 410 BLUE CROSS BLUE SHIELD WELLMARK SB889 [3081026] BCBS WYOMING [308102603] 389.5 percent of total billed charges 254.2 389.5 Technical (Hospital) Services B Pertussis by Pcr PX-3068779800 CDM 87798 CPT 306 RC outpatient 410 410 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES HDHP [308136802] 328 percent of total billed charges 254.2 389.5 Technical (Hospital) Services B Pertussis by Pcr PX-3068779800 CDM 87798 CPT 306 RC outpatient 410 410 UNITED HEALTHCARE (COMMERCIAL) [3081199] UNITED HEALTHCARE 87726 [308119901] 254.2 percent of total billed charges 254.2 389.5 Technical (Hospital) Services B Pertussis by Pcr PX-3068779800 CDM 87798 CPT 306 RC outpatient 410 410 HEALTHPARTNERS SX009 HEALTHPARTNERS 328 percent of total billed charges 254.2 389.5 Technical (Hospital) Services B Pertussis by Pcr PX-3068779800 CDM 87798 CPT 306 RC outpatient 410 410 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES PPO [308136801] 328 percent of total billed charges 254.2 389.5 Technical (Hospital) Services B Pertussis by Pcr PX-3068779800 CDM 87798 CPT 306 RC outpatient 410 410 MEDICA (COMMERCIAL) 94265 [3081118] MEDICA CLAIMS [308111801] 369 percent of total billed charges 254.2 389.5 Technical (Hospital) Services B Pertussis by Pcr PX-3068779800 CDM 87798 CPT 306 RC inpatient 410 410 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES PPO [308136801] 324.64 percent of total billed charges 254.2 389.5 Technical (Hospital) Services B Pertussis by Pcr PX-3068779800 CDM 87798 CPT 306 RC inpatient 410 410 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES HDHP [308136802] 324.64 percent of total billed charges 254.2 389.5 Technical (Hospital) Services B Pertussis by Pcr PX-3068779800 CDM 87798 CPT 306 RC inpatient 410 410 UNITED HEALTHCARE (COMMERCIAL) [3081199] UNITED HEALTHCARE 87726 [308119901] 254.2 percent of total billed charges 254.2 389.5 Technical (Hospital) Services B Pertussis by Pcr PX-3068779800 CDM 87798 CPT 306 RC inpatient 410 410 MEDICA (COMMERCIAL) 94265 [3081118] MEDICA CLAIMS [308111801] 369 percent of total billed charges 254.2 389.5 Technical (Hospital) Services B Pertussis by Pcr PX-3068779800 CDM 87798 CPT 306 RC inpatient 410 410 BLUE CROSS BLUE SHIELD WELLMARK SB889 [3081026] BCBS WYOMING [308102603] 389.5 percent of total billed charges 254.2 389.5 Technical (Hospital) Services B Pertussis by Pcr PX-3068779800 CDM 87798 CPT 306 RC inpatient 410 410 MULTIPLAN INC 34080 [3081285] MULTIPLAN INC [308128501] 389.5 percent of total billed charges 254.2 389.5 Technical (Hospital) Services B Pertussis by Pcr PX-3068779800 CDM 87798 CPT 306 RC inpatient 410 410 CIGNA 62308 [3081051] CIGNA 62308 [308105105] 324.64 percent of total billed charges 254.2 389.5 Technical (Hospital) Services B Pertussis by Pcr PX-3068779800 CDM 87798 CPT 306 RC inpatient 410 410 CIGNA 62308 [3081051] CIGNA STATE OF WYOMING [308105107] 324.64 percent of total billed charges 254.2 389.5 Technical (Hospital) Services B Pertussis by Pcr PX-3068779800 CDM 87798 CPT 306 RC inpatient 410 410 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES EPO [308136803] 324.64 percent of total billed charges 254.2 389.5 Technical (Hospital) Services B Pertussis by Pcr PX-3068779800 CDM 87798 CPT 306 RC inpatient 410 410 HEALTHPARTNERS SX009 HEALTHPARTNERS 324.64 percent of total billed charges 254.2 389.5 Technical (Hospital) Services HC Ref H. Pylori With Clarithromycin Resistance Stool PX-3068779822 CDM 87798 CPT 306 RC outpatient 71 71 MEDICA (COMMERCIAL) 94265 [3081118] MEDICA CLAIMS [308111801] 63.9 percent of total billed charges 44.02 67.45 Technical (Hospital) Services HC Ref H. Pylori With Clarithromycin Resistance Stool PX-3068779822 CDM 87798 CPT 306 RC outpatient 71 71 CIGNA 62308 [3081051] CIGNA 62308 [308105105] 56.8 percent of total billed charges 44.02 67.45 Technical (Hospital) Services HC Ref H. Pylori With Clarithromycin Resistance Stool PX-3068779822 CDM 87798 CPT 306 RC outpatient 71 71 CIGNA 62308 [3081051] CIGNA STATE OF WYOMING [308105107] 56.8 percent of total billed charges 44.02 67.45 Technical (Hospital) Services HC Ref H. Pylori With Clarithromycin Resistance Stool PX-3068779822 CDM 87798 CPT 306 RC outpatient 71 71 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES EPO [308136803] 56.8 percent of total billed charges 44.02 67.45 Technical (Hospital) Services HC Ref H. Pylori With Clarithromycin Resistance Stool PX-3068779822 CDM 87798 CPT 306 RC outpatient 71 71 MULTIPLAN INC 34080 [3081285] MULTIPLAN INC [308128501] 67.45 percent of total billed charges 44.02 67.45 Technical (Hospital) Services HC Ref H. Pylori With Clarithromycin Resistance Stool PX-3068779822 CDM 87798 CPT 306 RC outpatient 71 71 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES HDHP [308136802] 56.8 percent of total billed charges 44.02 67.45 Technical (Hospital) Services HC Ref H. Pylori With Clarithromycin Resistance Stool PX-3068779822 CDM 87798 CPT 306 RC outpatient 71 71 BLUE CROSS BLUE SHIELD WELLMARK SB889 [3081026] BCBS WYOMING [308102603] 67.45 percent of total billed charges 44.02 67.45 Technical (Hospital) Services HC Ref H. Pylori With Clarithromycin Resistance Stool PX-3068779822 CDM 87798 CPT 306 RC outpatient 71 71 UNITED HEALTHCARE (COMMERCIAL) [3081199] UNITED HEALTHCARE 87726 [308119901] 44.02 percent of total billed charges 44.02 67.45 Technical (Hospital) Services HC Ref H. Pylori With Clarithromycin Resistance Stool PX-3068779822 CDM 87798 CPT 306 RC outpatient 71 71 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES PPO [308136801] 56.8 percent of total billed charges 44.02 67.45 Technical (Hospital) Services HC Ref H. Pylori With Clarithromycin Resistance Stool PX-3068779822 CDM 87798 CPT 306 RC outpatient 71 71 HEALTHPARTNERS SX009 HEALTHPARTNERS 56.8 percent of total billed charges 44.02 67.45 Technical (Hospital) Services HC Ref H. Pylori With Clarithromycin Resistance Stool PX-3068779822 CDM 87798 CPT 306 RC inpatient 71 71 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES HDHP [308136802] 56.22 percent of total billed charges 44.02 67.45 Technical (Hospital) Services HC Ref H. Pylori With Clarithromycin Resistance Stool PX-3068779822 CDM 87798 CPT 306 RC inpatient 71 71 UNITED HEALTHCARE (COMMERCIAL) [3081199] UNITED HEALTHCARE 87726 [308119901] 44.02 percent of total billed charges 44.02 67.45 Technical (Hospital) Services HC Ref H. Pylori With Clarithromycin Resistance Stool PX-3068779822 CDM 87798 CPT 306 RC inpatient 71 71 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES PPO [308136801] 56.22 percent of total billed charges 44.02 67.45 Technical (Hospital) Services HC Ref H. Pylori With Clarithromycin Resistance Stool PX-3068779822 CDM 87798 CPT 306 RC inpatient 71 71 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES EPO [308136803] 56.22 percent of total billed charges 44.02 67.45 Technical (Hospital) Services HC Ref H. Pylori With Clarithromycin Resistance Stool PX-3068779822 CDM 87798 CPT 306 RC inpatient 71 71 HEALTHPARTNERS SX009 HEALTHPARTNERS 56.22 percent of total billed charges 44.02 67.45 Technical (Hospital) Services HC Ref H. Pylori With Clarithromycin Resistance Stool PX-3068779822 CDM 87798 CPT 306 RC inpatient 71 71 MULTIPLAN INC 34080 [3081285] MULTIPLAN INC [308128501] 67.45 percent of total billed charges 44.02 67.45 Technical (Hospital) Services HC Ref H. Pylori With Clarithromycin Resistance Stool PX-3068779822 CDM 87798 CPT 306 RC inpatient 71 71 MEDICA (COMMERCIAL) 94265 [3081118] MEDICA CLAIMS [308111801] 63.9 percent of total billed charges 44.02 67.45 Technical (Hospital) Services HC Ref H. Pylori With Clarithromycin Resistance Stool PX-3068779822 CDM 87798 CPT 306 RC inpatient 71 71 BLUE CROSS BLUE SHIELD WELLMARK SB889 [3081026] BCBS WYOMING [308102603] 67.45 percent of total billed charges 44.02 67.45 Technical (Hospital) Services HC Ref H. Pylori With Clarithromycin Resistance Stool PX-3068779822 CDM 87798 CPT 306 RC inpatient 71 71 CIGNA 62308 [3081051] CIGNA 62308 [308105105] 56.22 percent of total billed charges 44.02 67.45 Technical (Hospital) Services HC Ref H. Pylori With Clarithromycin Resistance Stool PX-3068779822 CDM 87798 CPT 306 RC inpatient 71 71 CIGNA 62308 [3081051] CIGNA STATE OF WYOMING [308105107] 56.22 percent of total billed charges 44.02 67.45 Technical (Hospital) Services Trichomonas Vaginalis Amplfied PX-3068766100 CDM 87661 CPT 306 RC outpatient 184 184 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES PPO [308136801] 147.2 percent of total billed charges 114.08 174.8 Technical (Hospital) Services Trichomonas Vaginalis Amplfied PX-3068766100 CDM 87661 CPT 306 RC outpatient 184 184 HEALTHPARTNERS SX009 HEALTHPARTNERS 147.2 percent of total billed charges 114.08 174.8 Technical (Hospital) Services Trichomonas Vaginalis Amplfied PX-3068766100 CDM 87661 CPT 306 RC outpatient 184 184 UNITED HEALTHCARE (COMMERCIAL) [3081199] UNITED HEALTHCARE 87726 [308119901] 114.08 percent of total billed charges 114.08 174.8 Technical (Hospital) Services Trichomonas Vaginalis Amplfied PX-3068766100 CDM 87661 CPT 306 RC outpatient 184 184 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES HDHP [308136802] 147.2 percent of total billed charges 114.08 174.8 Technical (Hospital) Services Trichomonas Vaginalis Amplfied PX-3068766100 CDM 87661 CPT 306 RC outpatient 184 184 BLUE CROSS BLUE SHIELD WELLMARK SB889 [3081026] BCBS WYOMING [308102603] 174.8 percent of total billed charges 114.08 174.8 Technical (Hospital) Services Trichomonas Vaginalis Amplfied PX-3068766100 CDM 87661 CPT 306 RC outpatient 184 184 MULTIPLAN INC 34080 [3081285] MULTIPLAN INC [308128501] 174.8 percent of total billed charges 114.08 174.8 Technical (Hospital) Services Trichomonas Vaginalis Amplfied PX-3068766100 CDM 87661 CPT 306 RC outpatient 184 184 CIGNA 62308 [3081051] CIGNA 62308 [308105105] 147.2 percent of total billed charges 114.08 174.8 Technical (Hospital) Services Trichomonas Vaginalis Amplfied PX-3068766100 CDM 87661 CPT 306 RC outpatient 184 184 CIGNA 62308 [3081051] CIGNA STATE OF WYOMING [308105107] 147.2 percent of total billed charges 114.08 174.8 Technical (Hospital) Services Trichomonas Vaginalis Amplfied PX-3068766100 CDM 87661 CPT 306 RC outpatient 184 184 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES EPO [308136803] 147.2 percent of total billed charges 114.08 174.8 Technical (Hospital) Services Trichomonas Vaginalis Amplfied PX-3068766100 CDM 87661 CPT 306 RC outpatient 184 184 MEDICA (COMMERCIAL) 94265 [3081118] MEDICA CLAIMS [308111801] 165.6 percent of total billed charges 114.08 174.8 Technical (Hospital) Services Trichomonas Vaginalis Amplfied PX-3068766100 CDM 87661 CPT 306 RC inpatient 184 184 UNITED HEALTHCARE (COMMERCIAL) [3081199] UNITED HEALTHCARE 87726 [308119901] 114.08 percent of total billed charges 114.08 174.8 Technical (Hospital) Services Trichomonas Vaginalis Amplfied PX-3068766100 CDM 87661 CPT 306 RC inpatient 184 184 MEDICA (COMMERCIAL) 94265 [3081118] MEDICA CLAIMS [308111801] 165.6 percent of total billed charges 114.08 174.8 Technical (Hospital) Services Trichomonas Vaginalis Amplfied PX-3068766100 CDM 87661 CPT 306 RC inpatient 184 184 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES HDHP [308136802] 145.69 percent of total billed charges 114.08 174.8 Technical (Hospital) Services Trichomonas Vaginalis Amplfied PX-3068766100 CDM 87661 CPT 306 RC inpatient 184 184 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES PPO [308136801] 145.69 percent of total billed charges 114.08 174.8 Technical (Hospital) Services Trichomonas Vaginalis Amplfied PX-3068766100 CDM 87661 CPT 306 RC inpatient 184 184 HEALTHPARTNERS SX009 HEALTHPARTNERS 145.69 percent of total billed charges 114.08 174.8 Technical (Hospital) Services Trichomonas Vaginalis Amplfied PX-3068766100 CDM 87661 CPT 306 RC inpatient 184 184 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES EPO [308136803] 145.69 percent of total billed charges 114.08 174.8 Technical (Hospital) Services Trichomonas Vaginalis Amplfied PX-3068766100 CDM 87661 CPT 306 RC inpatient 184 184 MULTIPLAN INC 34080 [3081285] MULTIPLAN INC [308128501] 174.8 percent of total billed charges 114.08 174.8 Technical (Hospital) Services Trichomonas Vaginalis Amplfied PX-3068766100 CDM 87661 CPT 306 RC inpatient 184 184 CIGNA 62308 [3081051] CIGNA 62308 [308105105] 145.69 percent of total billed charges 114.08 174.8 Technical (Hospital) Services Trichomonas Vaginalis Amplfied PX-3068766100 CDM 87661 CPT 306 RC inpatient 184 184 CIGNA 62308 [3081051] CIGNA STATE OF WYOMING [308105107] 145.69 percent of total billed charges 114.08 174.8 Technical (Hospital) Services Trichomonas Vaginalis Amplfied PX-3068766100 CDM 87661 CPT 306 RC inpatient 184 184 BLUE CROSS BLUE SHIELD WELLMARK SB889 [3081026] BCBS WYOMING [308102603] 174.8 percent of total billed charges 114.08 174.8 Technical (Hospital) Services Mrsa Pcr PX-3068764100 CDM 87641 CPT 306 RC outpatient 238 238 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES HDHP [308136802] 190.4 percent of total billed charges 147.56 226.1 Technical (Hospital) Services Mrsa Pcr PX-3068764100 CDM 87641 CPT 306 RC outpatient 238 238 BLUE CROSS BLUE SHIELD WELLMARK SB889 [3081026] BCBS WYOMING [308102603] 226.1 percent of total billed charges 147.56 226.1 Technical (Hospital) Services Mrsa Pcr PX-3068764100 CDM 87641 CPT 306 RC outpatient 238 238 MULTIPLAN INC 34080 [3081285] MULTIPLAN INC [308128501] 226.1 percent of total billed charges 147.56 226.1 Technical (Hospital) Services Mrsa Pcr PX-3068764100 CDM 87641 CPT 306 RC outpatient 238 238 CIGNA 62308 [3081051] CIGNA 62308 [308105105] 190.4 percent of total billed charges 147.56 226.1 Technical (Hospital) Services Mrsa Pcr PX-3068764100 CDM 87641 CPT 306 RC outpatient 238 238 CIGNA 62308 [3081051] CIGNA STATE OF WYOMING [308105107] 190.4 percent of total billed charges 147.56 226.1 Technical (Hospital) Services Mrsa Pcr PX-3068764100 CDM 87641 CPT 306 RC outpatient 238 238 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES EPO [308136803] 190.4 percent of total billed charges 147.56 226.1 Technical (Hospital) Services Mrsa Pcr PX-3068764100 CDM 87641 CPT 306 RC outpatient 238 238 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES PPO [308136801] 190.4 percent of total billed charges 147.56 226.1 Technical (Hospital) Services Mrsa Pcr PX-3068764100 CDM 87641 CPT 306 RC outpatient 238 238 HEALTHPARTNERS SX009 HEALTHPARTNERS 190.4 percent of total billed charges 147.56 226.1 Technical (Hospital) Services Mrsa Pcr PX-3068764100 CDM 87641 CPT 306 RC outpatient 238 238 UNITED HEALTHCARE (COMMERCIAL) [3081199] UNITED HEALTHCARE 87726 [308119901] 147.56 percent of total billed charges 147.56 226.1 Technical (Hospital) Services Mrsa Pcr PX-3068764100 CDM 87641 CPT 306 RC outpatient 238 238 MEDICA (COMMERCIAL) 94265 [3081118] MEDICA CLAIMS [308111801] 214.2 percent of total billed charges 147.56 226.1 Technical (Hospital) Services Mrsa Pcr PX-3068764100 CDM 87641 CPT 306 RC inpatient 238 238 UNITED HEALTHCARE (COMMERCIAL) [3081199] UNITED HEALTHCARE 87726 [308119901] 147.56 percent of total billed charges 147.56 226.1 Technical (Hospital) Services Mrsa Pcr PX-3068764100 CDM 87641 CPT 306 RC inpatient 238 238 MEDICA (COMMERCIAL) 94265 [3081118] MEDICA CLAIMS [308111801] 214.2 percent of total billed charges 147.56 226.1 Technical (Hospital) Services Mrsa Pcr PX-3068764100 CDM 87641 CPT 306 RC inpatient 238 238 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES HDHP [308136802] 188.45 percent of total billed charges 147.56 226.1 Technical (Hospital) Services Mrsa Pcr PX-3068764100 CDM 87641 CPT 306 RC inpatient 238 238 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES PPO [308136801] 188.45 percent of total billed charges 147.56 226.1 Technical (Hospital) Services Mrsa Pcr PX-3068764100 CDM 87641 CPT 306 RC inpatient 238 238 MULTIPLAN INC 34080 [3081285] MULTIPLAN INC [308128501] 226.1 percent of total billed charges 147.56 226.1 Technical (Hospital) Services Mrsa Pcr PX-3068764100 CDM 87641 CPT 306 RC inpatient 238 238 CIGNA 62308 [3081051] CIGNA 62308 [308105105] 188.45 percent of total billed charges 147.56 226.1 Technical (Hospital) Services Mrsa Pcr PX-3068764100 CDM 87641 CPT 306 RC inpatient 238 238 CIGNA 62308 [3081051] CIGNA STATE OF WYOMING [308105107] 188.45 percent of total billed charges 147.56 226.1 Technical (Hospital) Services Mrsa Pcr PX-3068764100 CDM 87641 CPT 306 RC inpatient 238 238 BLUE CROSS BLUE SHIELD WELLMARK SB889 [3081026] BCBS WYOMING [308102603] 226.1 percent of total billed charges 147.56 226.1 Technical (Hospital) Services Mrsa Pcr PX-3068764100 CDM 87641 CPT 306 RC inpatient 238 238 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES EPO [308136803] 188.45 percent of total billed charges 147.56 226.1 Technical (Hospital) Services Mrsa Pcr PX-3068764100 CDM 87641 CPT 306 RC inpatient 238 238 HEALTHPARTNERS SX009 HEALTHPARTNERS 188.45 percent of total billed charges 147.56 226.1 Technical (Hospital) Services "Ref Coronavirus With Cov-2 Rna, Qualitative Real-Time Rt-Pcr" PX-3068763500 CDM 87635 CPT 306 RC outpatient 221 221 MULTIPLAN INC 34080 [3081285] MULTIPLAN INC [308128501] 209.95 percent of total billed charges 137.02 209.95 Technical (Hospital) Services "Ref Coronavirus With Cov-2 Rna, Qualitative Real-Time Rt-Pcr" PX-3068763500 CDM 87635 CPT 306 RC outpatient 221 221 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES EPO [308136803] 176.8 percent of total billed charges 137.02 209.95 Technical (Hospital) Services "Ref Coronavirus With Cov-2 Rna, Qualitative Real-Time Rt-Pcr" PX-3068763500 CDM 87635 CPT 306 RC outpatient 221 221 CIGNA 62308 [3081051] CIGNA 62308 [308105105] 176.8 percent of total billed charges 137.02 209.95 Technical (Hospital) Services "Ref Coronavirus With Cov-2 Rna, Qualitative Real-Time Rt-Pcr" PX-3068763500 CDM 87635 CPT 306 RC outpatient 221 221 CIGNA 62308 [3081051] CIGNA STATE OF WYOMING [308105107] 176.8 percent of total billed charges 137.02 209.95 Technical (Hospital) Services "Ref Coronavirus With Cov-2 Rna, Qualitative Real-Time Rt-Pcr" PX-3068763500 CDM 87635 CPT 306 RC outpatient 221 221 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES HDHP [308136802] 176.8 percent of total billed charges 137.02 209.95 Technical (Hospital) Services "Ref Coronavirus With Cov-2 Rna, Qualitative Real-Time Rt-Pcr" PX-3068763500 CDM 87635 CPT 306 RC outpatient 221 221 BLUE CROSS BLUE SHIELD WELLMARK SB889 [3081026] BCBS WYOMING [308102603] 209.95 percent of total billed charges 137.02 209.95 Technical (Hospital) Services "Ref Coronavirus With Cov-2 Rna, Qualitative Real-Time Rt-Pcr" PX-3068763500 CDM 87635 CPT 306 RC outpatient 221 221 UNITED HEALTHCARE (COMMERCIAL) [3081199] UNITED HEALTHCARE 87726 [308119901] 137.02 percent of total billed charges 137.02 209.95 Technical (Hospital) Services "Ref Coronavirus With Cov-2 Rna, Qualitative Real-Time Rt-Pcr" PX-3068763500 CDM 87635 CPT 306 RC outpatient 221 221 HEALTHPARTNERS SX009 HEALTHPARTNERS 176.8 percent of total billed charges 137.02 209.95 Technical (Hospital) Services "Ref Coronavirus With Cov-2 Rna, Qualitative Real-Time Rt-Pcr" PX-3068763500 CDM 87635 CPT 306 RC outpatient 221 221 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES PPO [308136801] 176.8 percent of total billed charges 137.02 209.95 Technical (Hospital) Services "Ref Coronavirus With Cov-2 Rna, Qualitative Real-Time Rt-Pcr" PX-3068763500 CDM 87635 CPT 306 RC outpatient 221 221 MEDICA (COMMERCIAL) 94265 [3081118] MEDICA CLAIMS [308111801] 198.9 percent of total billed charges 137.02 209.95 Technical (Hospital) Services "Ref Coronavirus With Cov-2 Rna, Qualitative Real-Time Rt-Pcr" PX-3068763500 CDM 87635 CPT 306 RC inpatient 221 221 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES HDHP [308136802] 174.99 percent of total billed charges 137.02 209.95 Technical (Hospital) Services "Ref Coronavirus With Cov-2 Rna, Qualitative Real-Time Rt-Pcr" PX-3068763500 CDM 87635 CPT 306 RC inpatient 221 221 UNITED HEALTHCARE (COMMERCIAL) [3081199] UNITED HEALTHCARE 87726 [308119901] 137.02 percent of total billed charges 137.02 209.95 Technical (Hospital) Services "Ref Coronavirus With Cov-2 Rna, Qualitative Real-Time Rt-Pcr" PX-3068763500 CDM 87635 CPT 306 RC inpatient 221 221 MEDICA (COMMERCIAL) 94265 [3081118] MEDICA CLAIMS [308111801] 198.9 percent of total billed charges 137.02 209.95 Technical (Hospital) Services "Ref Coronavirus With Cov-2 Rna, Qualitative Real-Time Rt-Pcr" PX-3068763500 CDM 87635 CPT 306 RC inpatient 221 221 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES PPO [308136801] 174.99 percent of total billed charges 137.02 209.95 Technical (Hospital) Services "Ref Coronavirus With Cov-2 Rna, Qualitative Real-Time Rt-Pcr" PX-3068763500 CDM 87635 CPT 306 RC inpatient 221 221 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES EPO [308136803] 174.99 percent of total billed charges 137.02 209.95 Technical (Hospital) Services "Ref Coronavirus With Cov-2 Rna, Qualitative Real-Time Rt-Pcr" PX-3068763500 CDM 87635 CPT 306 RC inpatient 221 221 HEALTHPARTNERS SX009 HEALTHPARTNERS 174.99 percent of total billed charges 137.02 209.95 Technical (Hospital) Services "Ref Coronavirus With Cov-2 Rna, Qualitative Real-Time Rt-Pcr" PX-3068763500 CDM 87635 CPT 306 RC inpatient 221 221 CIGNA 62308 [3081051] CIGNA 62308 [308105105] 174.99 percent of total billed charges 137.02 209.95 Technical (Hospital) Services "Ref Coronavirus With Cov-2 Rna, Qualitative Real-Time Rt-Pcr" PX-3068763500 CDM 87635 CPT 306 RC inpatient 221 221 CIGNA 62308 [3081051] CIGNA STATE OF WYOMING [308105107] 174.99 percent of total billed charges 137.02 209.95 Technical (Hospital) Services "Ref Coronavirus With Cov-2 Rna, Qualitative Real-Time Rt-Pcr" PX-3068763500 CDM 87635 CPT 306 RC inpatient 221 221 BLUE CROSS BLUE SHIELD WELLMARK SB889 [3081026] BCBS WYOMING [308102603] 209.95 percent of total billed charges 137.02 209.95 Technical (Hospital) Services "Ref Coronavirus With Cov-2 Rna, Qualitative Real-Time Rt-Pcr" PX-3068763500 CDM 87635 CPT 306 RC inpatient 221 221 MULTIPLAN INC 34080 [3081285] MULTIPLAN INC [308128501] 209.95 percent of total billed charges 137.02 209.95 Technical (Hospital) Services "Covid-19 Pcr, High Throughput Technologies" PX-3068763501 CDM 87635 CPT 306 RC inpatient 221 221 HEALTHPARTNERS SX009 HEALTHPARTNERS 174.99 percent of total billed charges 137.02 209.95 Technical (Hospital) Services "Covid-19 Pcr, High Throughput Technologies" PX-3068763501 CDM 87635 CPT 306 RC inpatient 221 221 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES EPO [308136803] 174.99 percent of total billed charges 137.02 209.95 Technical (Hospital) Services "Covid-19 Pcr, High Throughput Technologies" PX-3068763501 CDM 87635 CPT 306 RC inpatient 221 221 BLUE CROSS BLUE SHIELD WELLMARK SB889 [3081026] BCBS WYOMING [308102603] 209.95 percent of total billed charges 137.02 209.95 Technical (Hospital) Services "Covid-19 Pcr, High Throughput Technologies" PX-3068763501 CDM 87635 CPT 306 RC inpatient 221 221 CIGNA 62308 [3081051] CIGNA 62308 [308105105] 174.99 percent of total billed charges 137.02 209.95 Technical (Hospital) Services "Covid-19 Pcr, High Throughput Technologies" PX-3068763501 CDM 87635 CPT 306 RC inpatient 221 221 CIGNA 62308 [3081051] CIGNA STATE OF WYOMING [308105107] 174.99 percent of total billed charges 137.02 209.95 Technical (Hospital) Services "Covid-19 Pcr, High Throughput Technologies" PX-3068763501 CDM 87635 CPT 306 RC inpatient 221 221 MULTIPLAN INC 34080 [3081285] MULTIPLAN INC [308128501] 209.95 percent of total billed charges 137.02 209.95 Technical (Hospital) Services "Covid-19 Pcr, High Throughput Technologies" PX-3068763501 CDM 87635 CPT 306 RC inpatient 221 221 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES PPO [308136801] 174.99 percent of total billed charges 137.02 209.95 Technical (Hospital) Services "Covid-19 Pcr, High Throughput Technologies" PX-3068763501 CDM 87635 CPT 306 RC inpatient 221 221 MEDICA (COMMERCIAL) 94265 [3081118] MEDICA CLAIMS [308111801] 198.9 percent of total billed charges 137.02 209.95 Technical (Hospital) Services "Covid-19 Pcr, High Throughput Technologies" PX-3068763501 CDM 87635 CPT 306 RC inpatient 221 221 UNITED HEALTHCARE (COMMERCIAL) [3081199] UNITED HEALTHCARE 87726 [308119901] 137.02 percent of total billed charges 137.02 209.95 Technical (Hospital) Services "Covid-19 Pcr, High Throughput Technologies" PX-3068763501 CDM 87635 CPT 306 RC inpatient 221 221 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES HDHP [308136802] 174.99 percent of total billed charges 137.02 209.95 Technical (Hospital) Services "Covid-19 Pcr, High Throughput Technologies" PX-3068763501 CDM 87635 CPT 306 RC outpatient 221 221 UNITED HEALTHCARE (COMMERCIAL) [3081199] UNITED HEALTHCARE 87726 [308119901] 137.02 percent of total billed charges 137.02 209.95 Technical (Hospital) Services "Covid-19 Pcr, High Throughput Technologies" PX-3068763501 CDM 87635 CPT 306 RC outpatient 221 221 BLUE CROSS BLUE SHIELD WELLMARK SB889 [3081026] BCBS WYOMING [308102603] 209.95 percent of total billed charges 137.02 209.95 Technical (Hospital) Services "Covid-19 Pcr, High Throughput Technologies" PX-3068763501 CDM 87635 CPT 306 RC outpatient 221 221 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES HDHP [308136802] 176.8 percent of total billed charges 137.02 209.95 Technical (Hospital) Services "Covid-19 Pcr, High Throughput Technologies" PX-3068763501 CDM 87635 CPT 306 RC outpatient 221 221 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES EPO [308136803] 176.8 percent of total billed charges 137.02 209.95 Technical (Hospital) Services "Covid-19 Pcr, High Throughput Technologies" PX-3068763501 CDM 87635 CPT 306 RC outpatient 221 221 CIGNA 62308 [3081051] CIGNA 62308 [308105105] 176.8 percent of total billed charges 137.02 209.95 Technical (Hospital) Services "Covid-19 Pcr, High Throughput Technologies" PX-3068763501 CDM 87635 CPT 306 RC outpatient 221 221 CIGNA 62308 [3081051] CIGNA STATE OF WYOMING [308105107] 176.8 percent of total billed charges 137.02 209.95 Technical (Hospital) Services "Covid-19 Pcr, High Throughput Technologies" PX-3068763501 CDM 87635 CPT 306 RC outpatient 221 221 MULTIPLAN INC 34080 [3081285] MULTIPLAN INC [308128501] 209.95 percent of total billed charges 137.02 209.95 Technical (Hospital) Services "Covid-19 Pcr, High Throughput Technologies" PX-3068763501 CDM 87635 CPT 306 RC outpatient 221 221 MEDICA (COMMERCIAL) 94265 [3081118] MEDICA CLAIMS [308111801] 198.9 percent of total billed charges 137.02 209.95 Technical (Hospital) Services "Covid-19 Pcr, High Throughput Technologies" PX-3068763501 CDM 87635 CPT 306 RC outpatient 221 221 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES PPO [308136801] 176.8 percent of total billed charges 137.02 209.95 Technical (Hospital) Services "Covid-19 Pcr, High Throughput Technologies" PX-3068763501 CDM 87635 CPT 306 RC outpatient 221 221 HEALTHPARTNERS SX009 HEALTHPARTNERS 176.8 percent of total billed charges 137.02 209.95 Technical (Hospital) Services Covid-19 Pcr PX-3068763502 CDM 87635 CPT 306 RC inpatient 221 221 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES PPO [308136801] 174.99 percent of total billed charges 137.02 209.95 Technical (Hospital) Services Covid-19 Pcr PX-3068763502 CDM 87635 CPT 306 RC inpatient 221 221 MEDICA (COMMERCIAL) 94265 [3081118] MEDICA CLAIMS [308111801] 198.9 percent of total billed charges 137.02 209.95 Technical (Hospital) Services Covid-19 Pcr PX-3068763502 CDM 87635 CPT 306 RC inpatient 221 221 UNITED HEALTHCARE (COMMERCIAL) [3081199] UNITED HEALTHCARE 87726 [308119901] 137.02 percent of total billed charges 137.02 209.95 Technical (Hospital) Services Covid-19 Pcr PX-3068763502 CDM 87635 CPT 306 RC inpatient 221 221 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES HDHP [308136802] 174.99 percent of total billed charges 137.02 209.95 Technical (Hospital) Services Covid-19 Pcr PX-3068763502 CDM 87635 CPT 306 RC inpatient 221 221 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES EPO [308136803] 174.99 percent of total billed charges 137.02 209.95 Technical (Hospital) Services Covid-19 Pcr PX-3068763502 CDM 87635 CPT 306 RC inpatient 221 221 HEALTHPARTNERS SX009 HEALTHPARTNERS 174.99 percent of total billed charges 137.02 209.95 Technical (Hospital) Services Covid-19 Pcr PX-3068763502 CDM 87635 CPT 306 RC inpatient 221 221 CIGNA 62308 [3081051] CIGNA 62308 [308105105] 174.99 percent of total billed charges 137.02 209.95 Technical (Hospital) Services Covid-19 Pcr PX-3068763502 CDM 87635 CPT 306 RC inpatient 221 221 CIGNA 62308 [3081051] CIGNA STATE OF WYOMING [308105107] 174.99 percent of total billed charges 137.02 209.95 Technical (Hospital) Services Covid-19 Pcr PX-3068763502 CDM 87635 CPT 306 RC inpatient 221 221 BLUE CROSS BLUE SHIELD WELLMARK SB889 [3081026] BCBS WYOMING [308102603] 209.95 percent of total billed charges 137.02 209.95 Technical (Hospital) Services Covid-19 Pcr PX-3068763502 CDM 87635 CPT 306 RC inpatient 221 221 MULTIPLAN INC 34080 [3081285] MULTIPLAN INC [308128501] 209.95 percent of total billed charges 137.02 209.95 Technical (Hospital) Services Covid-19 Pcr PX-3068763502 CDM 87635 CPT 306 RC outpatient 221 221 BLUE CROSS BLUE SHIELD WELLMARK SB889 [3081026] BCBS WYOMING [308102603] 209.95 percent of total billed charges 137.02 209.95 Technical (Hospital) Services Covid-19 Pcr PX-3068763502 CDM 87635 CPT 306 RC outpatient 221 221 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES HDHP [308136802] 176.8 percent of total billed charges 137.02 209.95 Technical (Hospital) Services Covid-19 Pcr PX-3068763502 CDM 87635 CPT 306 RC outpatient 221 221 MULTIPLAN INC 34080 [3081285] MULTIPLAN INC [308128501] 209.95 percent of total billed charges 137.02 209.95 Technical (Hospital) Services Covid-19 Pcr PX-3068763502 CDM 87635 CPT 306 RC outpatient 221 221 CIGNA 62308 [3081051] CIGNA 62308 [308105105] 176.8 percent of total billed charges 137.02 209.95 Technical (Hospital) Services Covid-19 Pcr PX-3068763502 CDM 87635 CPT 306 RC outpatient 221 221 CIGNA 62308 [3081051] CIGNA STATE OF WYOMING [308105107] 176.8 percent of total billed charges 137.02 209.95 Technical (Hospital) Services Covid-19 Pcr PX-3068763502 CDM 87635 CPT 306 RC outpatient 221 221 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES EPO [308136803] 176.8 percent of total billed charges 137.02 209.95 Technical (Hospital) Services Covid-19 Pcr PX-3068763502 CDM 87635 CPT 306 RC outpatient 221 221 HEALTHPARTNERS SX009 HEALTHPARTNERS 176.8 percent of total billed charges 137.02 209.95 Technical (Hospital) Services Covid-19 Pcr PX-3068763502 CDM 87635 CPT 306 RC outpatient 221 221 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES PPO [308136801] 176.8 percent of total billed charges 137.02 209.95 Technical (Hospital) Services Covid-19 Pcr PX-3068763502 CDM 87635 CPT 306 RC outpatient 221 221 UNITED HEALTHCARE (COMMERCIAL) [3081199] UNITED HEALTHCARE 87726 [308119901] 137.02 percent of total billed charges 137.02 209.95 Technical (Hospital) Services Covid-19 Pcr PX-3068763502 CDM 87635 CPT 306 RC outpatient 221 221 MEDICA (COMMERCIAL) 94265 [3081118] MEDICA CLAIMS [308111801] 198.9 percent of total billed charges 137.02 209.95 Technical (Hospital) Services Covid Pcr Testing Asymptomatic Non-Covered- Self Pay Only PX-3068763503 CDM 87635 CPT 306 RC inpatient 221 221 HEALTHPARTNERS SX009 HEALTHPARTNERS 174.99 percent of total billed charges 137.02 209.95 Technical (Hospital) Services Covid Pcr Testing Asymptomatic Non-Covered- Self Pay Only PX-3068763503 CDM 87635 CPT 306 RC inpatient 221 221 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES EPO [308136803] 174.99 percent of total billed charges 137.02 209.95 Technical (Hospital) Services Covid Pcr Testing Asymptomatic Non-Covered- Self Pay Only PX-3068763503 CDM 87635 CPT 306 RC inpatient 221 221 BLUE CROSS BLUE SHIELD WELLMARK SB889 [3081026] BCBS WYOMING [308102603] 209.95 percent of total billed charges 137.02 209.95 Technical (Hospital) Services Covid Pcr Testing Asymptomatic Non-Covered- Self Pay Only PX-3068763503 CDM 87635 CPT 306 RC inpatient 221 221 CIGNA 62308 [3081051] CIGNA 62308 [308105105] 174.99 percent of total billed charges 137.02 209.95 Technical (Hospital) Services Covid Pcr Testing Asymptomatic Non-Covered- Self Pay Only PX-3068763503 CDM 87635 CPT 306 RC inpatient 221 221 CIGNA 62308 [3081051] CIGNA STATE OF WYOMING [308105107] 174.99 percent of total billed charges 137.02 209.95 Technical (Hospital) Services Covid Pcr Testing Asymptomatic Non-Covered- Self Pay Only PX-3068763503 CDM 87635 CPT 306 RC inpatient 221 221 MULTIPLAN INC 34080 [3081285] MULTIPLAN INC [308128501] 209.95 percent of total billed charges 137.02 209.95 Technical (Hospital) Services Covid Pcr Testing Asymptomatic Non-Covered- Self Pay Only PX-3068763503 CDM 87635 CPT 306 RC inpatient 221 221 MEDICA (COMMERCIAL) 94265 [3081118] MEDICA CLAIMS [308111801] 198.9 percent of total billed charges 137.02 209.95 Technical (Hospital) Services Covid Pcr Testing Asymptomatic Non-Covered- Self Pay Only PX-3068763503 CDM 87635 CPT 306 RC inpatient 221 221 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES PPO [308136801] 174.99 percent of total billed charges 137.02 209.95 Technical (Hospital) Services Covid Pcr Testing Asymptomatic Non-Covered- Self Pay Only PX-3068763503 CDM 87635 CPT 306 RC inpatient 221 221 UNITED HEALTHCARE (COMMERCIAL) [3081199] UNITED HEALTHCARE 87726 [308119901] 137.02 percent of total billed charges 137.02 209.95 Technical (Hospital) Services Covid Pcr Testing Asymptomatic Non-Covered- Self Pay Only PX-3068763503 CDM 87635 CPT 306 RC inpatient 221 221 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES HDHP [308136802] 174.99 percent of total billed charges 137.02 209.95 Technical (Hospital) Services Covid Pcr Testing Asymptomatic Non-Covered- Self Pay Only PX-3068763503 CDM 87635 CPT 306 RC outpatient 221 221 HEALTHPARTNERS SX009 HEALTHPARTNERS 176.8 percent of total billed charges 137.02 209.95 Technical (Hospital) Services Covid Pcr Testing Asymptomatic Non-Covered- Self Pay Only PX-3068763503 CDM 87635 CPT 306 RC outpatient 221 221 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES PPO [308136801] 176.8 percent of total billed charges 137.02 209.95 Technical (Hospital) Services Covid Pcr Testing Asymptomatic Non-Covered- Self Pay Only PX-3068763503 CDM 87635 CPT 306 RC outpatient 221 221 MEDICA (COMMERCIAL) 94265 [3081118] MEDICA CLAIMS [308111801] 198.9 percent of total billed charges 137.02 209.95 Technical (Hospital) Services Covid Pcr Testing Asymptomatic Non-Covered- Self Pay Only PX-3068763503 CDM 87635 CPT 306 RC outpatient 221 221 UNITED HEALTHCARE (COMMERCIAL) [3081199] UNITED HEALTHCARE 87726 [308119901] 137.02 percent of total billed charges 137.02 209.95 Technical (Hospital) Services Covid Pcr Testing Asymptomatic Non-Covered- Self Pay Only PX-3068763503 CDM 87635 CPT 306 RC outpatient 221 221 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES HDHP [308136802] 176.8 percent of total billed charges 137.02 209.95 Technical (Hospital) Services Covid Pcr Testing Asymptomatic Non-Covered- Self Pay Only PX-3068763503 CDM 87635 CPT 306 RC outpatient 221 221 MULTIPLAN INC 34080 [3081285] MULTIPLAN INC [308128501] 209.95 percent of total billed charges 137.02 209.95 Technical (Hospital) Services Covid Pcr Testing Asymptomatic Non-Covered- Self Pay Only PX-3068763503 CDM 87635 CPT 306 RC outpatient 221 221 CIGNA 62308 [3081051] CIGNA 62308 [308105105] 176.8 percent of total billed charges 137.02 209.95 Technical (Hospital) Services Covid Pcr Testing Asymptomatic Non-Covered- Self Pay Only PX-3068763503 CDM 87635 CPT 306 RC outpatient 221 221 CIGNA 62308 [3081051] CIGNA STATE OF WYOMING [308105107] 176.8 percent of total billed charges 137.02 209.95 Technical (Hospital) Services Covid Pcr Testing Asymptomatic Non-Covered- Self Pay Only PX-3068763503 CDM 87635 CPT 306 RC outpatient 221 221 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES EPO [308136803] 176.8 percent of total billed charges 137.02 209.95 Technical (Hospital) Services Covid Pcr Testing Asymptomatic Non-Covered- Self Pay Only PX-3068763503 CDM 87635 CPT 306 RC outpatient 221 221 BLUE CROSS BLUE SHIELD WELLMARK SB889 [3081026] BCBS WYOMING [308102603] 209.95 percent of total billed charges 137.02 209.95 Technical (Hospital) Services Covid Test for the Biofire Pcr Panel PX-3068763504 CDM 87635 CPT 306 RC inpatient 221 221 MEDICA (COMMERCIAL) 94265 [3081118] MEDICA CLAIMS [308111801] 198.9 percent of total billed charges 137.02 209.95 Technical (Hospital) Services Covid Test for the Biofire Pcr Panel PX-3068763504 CDM 87635 CPT 306 RC inpatient 221 221 UNITED HEALTHCARE (COMMERCIAL) [3081199] UNITED HEALTHCARE 87726 [308119901] 137.02 percent of total billed charges 137.02 209.95 Technical (Hospital) Services Covid Test for the Biofire Pcr Panel PX-3068763504 CDM 87635 CPT 306 RC inpatient 221 221 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES HDHP [308136802] 174.99 percent of total billed charges 137.02 209.95 Technical (Hospital) Services Covid Test for the Biofire Pcr Panel PX-3068763504 CDM 87635 CPT 306 RC inpatient 221 221 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES PPO [308136801] 174.99 percent of total billed charges 137.02 209.95 Technical (Hospital) Services Covid Test for the Biofire Pcr Panel PX-3068763504 CDM 87635 CPT 306 RC inpatient 221 221 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES EPO [308136803] 174.99 percent of total billed charges 137.02 209.95 Technical (Hospital) Services Covid Test for the Biofire Pcr Panel PX-3068763504 CDM 87635 CPT 306 RC inpatient 221 221 HEALTHPARTNERS SX009 HEALTHPARTNERS 174.99 percent of total billed charges 137.02 209.95 Technical (Hospital) Services Covid Test for the Biofire Pcr Panel PX-3068763504 CDM 87635 CPT 306 RC inpatient 221 221 MULTIPLAN INC 34080 [3081285] MULTIPLAN INC [308128501] 209.95 percent of total billed charges 137.02 209.95 Technical (Hospital) Services Covid Test for the Biofire Pcr Panel PX-3068763504 CDM 87635 CPT 306 RC inpatient 221 221 CIGNA 62308 [3081051] CIGNA 62308 [308105105] 174.99 percent of total billed charges 137.02 209.95 Technical (Hospital) Services Covid Test for the Biofire Pcr Panel PX-3068763504 CDM 87635 CPT 306 RC inpatient 221 221 CIGNA 62308 [3081051] CIGNA STATE OF WYOMING [308105107] 174.99 percent of total billed charges 137.02 209.95 Technical (Hospital) Services Covid Test for the Biofire Pcr Panel PX-3068763504 CDM 87635 CPT 306 RC inpatient 221 221 BLUE CROSS BLUE SHIELD WELLMARK SB889 [3081026] BCBS WYOMING [308102603] 209.95 percent of total billed charges 137.02 209.95 Technical (Hospital) Services Covid Test for the Biofire Pcr Panel PX-3068763504 CDM 87635 CPT 306 RC outpatient 221 221 UNITED HEALTHCARE (COMMERCIAL) [3081199] UNITED HEALTHCARE 87726 [308119901] 137.02 percent of total billed charges 137.02 209.95 Technical (Hospital) Services Covid Test for the Biofire Pcr Panel PX-3068763504 CDM 87635 CPT 306 RC outpatient 221 221 HEALTHPARTNERS SX009 HEALTHPARTNERS 176.8 percent of total billed charges 137.02 209.95 Technical (Hospital) Services Covid Test for the Biofire Pcr Panel PX-3068763504 CDM 87635 CPT 306 RC outpatient 221 221 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES PPO [308136801] 176.8 percent of total billed charges 137.02 209.95 Technical (Hospital) Services Covid Test for the Biofire Pcr Panel PX-3068763504 CDM 87635 CPT 306 RC outpatient 221 221 BLUE CROSS BLUE SHIELD WELLMARK SB889 [3081026] BCBS WYOMING [308102603] 209.95 percent of total billed charges 137.02 209.95 Technical (Hospital) Services Covid Test for the Biofire Pcr Panel PX-3068763504 CDM 87635 CPT 306 RC outpatient 221 221 MULTIPLAN INC 34080 [3081285] MULTIPLAN INC [308128501] 209.95 percent of total billed charges 137.02 209.95 Technical (Hospital) Services Covid Test for the Biofire Pcr Panel PX-3068763504 CDM 87635 CPT 306 RC outpatient 221 221 CIGNA 62308 [3081051] CIGNA 62308 [308105105] 176.8 percent of total billed charges 137.02 209.95 Technical (Hospital) Services Covid Test for the Biofire Pcr Panel PX-3068763504 CDM 87635 CPT 306 RC outpatient 221 221 CIGNA 62308 [3081051] CIGNA STATE OF WYOMING [308105107] 176.8 percent of total billed charges 137.02 209.95 Technical (Hospital) Services Covid Test for the Biofire Pcr Panel PX-3068763504 CDM 87635 CPT 306 RC outpatient 221 221 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES EPO [308136803] 176.8 percent of total billed charges 137.02 209.95 Technical (Hospital) Services Covid Test for the Biofire Pcr Panel PX-3068763504 CDM 87635 CPT 306 RC outpatient 221 221 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES HDHP [308136802] 176.8 percent of total billed charges 137.02 209.95 Technical (Hospital) Services Covid Test for the Biofire Pcr Panel PX-3068763504 CDM 87635 CPT 306 RC outpatient 221 221 MEDICA (COMMERCIAL) 94265 [3081118] MEDICA CLAIMS [308111801] 198.9 percent of total billed charges 137.02 209.95 Technical (Hospital) Services "Rsv, Molecular Detection" PX-3068763400 CDM 87634 CPT 306 RC outpatient 181 181 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES HDHP [308136802] 144.8 percent of total billed charges 112.22 171.95 Technical (Hospital) Services "Rsv, Molecular Detection" PX-3068763400 CDM 87634 CPT 306 RC outpatient 181 181 BLUE CROSS BLUE SHIELD WELLMARK SB889 [3081026] BCBS WYOMING [308102603] 171.95 percent of total billed charges 112.22 171.95 Technical (Hospital) Services "Rsv, Molecular Detection" PX-3068763400 CDM 87634 CPT 306 RC outpatient 181 181 MULTIPLAN INC 34080 [3081285] MULTIPLAN INC [308128501] 171.95 percent of total billed charges 112.22 171.95 Technical (Hospital) Services "Rsv, Molecular Detection" PX-3068763400 CDM 87634 CPT 306 RC outpatient 181 181 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES EPO [308136803] 144.8 percent of total billed charges 112.22 171.95 Technical (Hospital) Services "Rsv, Molecular Detection" PX-3068763400 CDM 87634 CPT 306 RC outpatient 181 181 CIGNA 62308 [3081051] CIGNA 62308 [308105105] 144.8 percent of total billed charges 112.22 171.95 Technical (Hospital) Services "Rsv, Molecular Detection" PX-3068763400 CDM 87634 CPT 306 RC outpatient 181 181 CIGNA 62308 [3081051] CIGNA STATE OF WYOMING [308105107] 144.8 percent of total billed charges 112.22 171.95 Technical (Hospital) Services "Rsv, Molecular Detection" PX-3068763400 CDM 87634 CPT 306 RC outpatient 181 181 UNITED HEALTHCARE (COMMERCIAL) [3081199] UNITED HEALTHCARE 87726 [308119901] 112.22 percent of total billed charges 112.22 171.95 Technical (Hospital) Services "Rsv, Molecular Detection" PX-3068763400 CDM 87634 CPT 306 RC outpatient 181 181 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES PPO [308136801] 144.8 percent of total billed charges 112.22 171.95 Technical (Hospital) Services "Rsv, Molecular Detection" PX-3068763400 CDM 87634 CPT 306 RC outpatient 181 181 HEALTHPARTNERS SX009 HEALTHPARTNERS 144.8 percent of total billed charges 112.22 171.95 Technical (Hospital) Services "Rsv, Molecular Detection" PX-3068763400 CDM 87634 CPT 306 RC outpatient 181 181 MEDICA (COMMERCIAL) 94265 [3081118] MEDICA CLAIMS [308111801] 162.9 percent of total billed charges 112.22 171.95 Technical (Hospital) Services "Rsv, Molecular Detection" PX-3068763400 CDM 87634 CPT 306 RC inpatient 181 181 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES EPO [308136803] 143.32 percent of total billed charges 112.22 171.95 Technical (Hospital) Services "Rsv, Molecular Detection" PX-3068763400 CDM 87634 CPT 306 RC inpatient 181 181 HEALTHPARTNERS SX009 HEALTHPARTNERS 143.32 percent of total billed charges 112.22 171.95 Technical (Hospital) Services "Rsv, Molecular Detection" PX-3068763400 CDM 87634 CPT 306 RC inpatient 181 181 BLUE CROSS BLUE SHIELD WELLMARK SB889 [3081026] BCBS WYOMING [308102603] 171.95 percent of total billed charges 112.22 171.95 Technical (Hospital) Services "Rsv, Molecular Detection" PX-3068763400 CDM 87634 CPT 306 RC inpatient 181 181 CIGNA 62308 [3081051] CIGNA 62308 [308105105] 143.32 percent of total billed charges 112.22 171.95 Technical (Hospital) Services "Rsv, Molecular Detection" PX-3068763400 CDM 87634 CPT 306 RC inpatient 181 181 CIGNA 62308 [3081051] CIGNA STATE OF WYOMING [308105107] 143.32 percent of total billed charges 112.22 171.95 Technical (Hospital) Services "Rsv, Molecular Detection" PX-3068763400 CDM 87634 CPT 306 RC inpatient 181 181 MULTIPLAN INC 34080 [3081285] MULTIPLAN INC [308128501] 171.95 percent of total billed charges 112.22 171.95 Technical (Hospital) Services "Rsv, Molecular Detection" PX-3068763400 CDM 87634 CPT 306 RC inpatient 181 181 MEDICA (COMMERCIAL) 94265 [3081118] MEDICA CLAIMS [308111801] 162.9 percent of total billed charges 112.22 171.95 Technical (Hospital) Services "Rsv, Molecular Detection" PX-3068763400 CDM 87634 CPT 306 RC inpatient 181 181 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES PPO [308136801] 143.32 percent of total billed charges 112.22 171.95 Technical (Hospital) Services "Rsv, Molecular Detection" PX-3068763400 CDM 87634 CPT 306 RC inpatient 181 181 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES HDHP [308136802] 143.32 percent of total billed charges 112.22 171.95 Technical (Hospital) Services "Rsv, Molecular Detection" PX-3068763400 CDM 87634 CPT 306 RC inpatient 181 181 UNITED HEALTHCARE (COMMERCIAL) [3081199] UNITED HEALTHCARE 87726 [308119901] 112.22 percent of total billed charges 112.22 171.95 Technical (Hospital) Services Resp Panel Virus by Pcr 12-25 PX-3068763300 CDM 87633 CPT 306 RC inpatient 937 937 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES HDHP [308136802] 741.92 percent of total billed charges 580.94 890.15 Technical (Hospital) Services Resp Panel Virus by Pcr 12-25 PX-3068763300 CDM 87633 CPT 306 RC inpatient 937 937 MEDICA (COMMERCIAL) 94265 [3081118] MEDICA CLAIMS [308111801] 843.3 percent of total billed charges 580.94 890.15 Technical (Hospital) Services Resp Panel Virus by Pcr 12-25 PX-3068763300 CDM 87633 CPT 306 RC inpatient 937 937 UNITED HEALTHCARE (COMMERCIAL) [3081199] UNITED HEALTHCARE 87726 [308119901] 580.94 percent of total billed charges 580.94 890.15 Technical (Hospital) Services Resp Panel Virus by Pcr 12-25 PX-3068763300 CDM 87633 CPT 306 RC inpatient 937 937 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES PPO [308136801] 741.92 percent of total billed charges 580.94 890.15 Technical (Hospital) Services Resp Panel Virus by Pcr 12-25 PX-3068763300 CDM 87633 CPT 306 RC inpatient 937 937 BLUE CROSS BLUE SHIELD WELLMARK SB889 [3081026] BCBS WYOMING [308102603] 890.15 percent of total billed charges 580.94 890.15 Technical (Hospital) Services Resp Panel Virus by Pcr 12-25 PX-3068763300 CDM 87633 CPT 306 RC inpatient 937 937 MULTIPLAN INC 34080 [3081285] MULTIPLAN INC [308128501] 890.15 percent of total billed charges 580.94 890.15 Technical (Hospital) Services Resp Panel Virus by Pcr 12-25 PX-3068763300 CDM 87633 CPT 306 RC inpatient 937 937 CIGNA 62308 [3081051] CIGNA 62308 [308105105] 741.92 percent of total billed charges 580.94 890.15 Technical (Hospital) Services Resp Panel Virus by Pcr 12-25 PX-3068763300 CDM 87633 CPT 306 RC inpatient 937 937 CIGNA 62308 [3081051] CIGNA STATE OF WYOMING [308105107] 741.92 percent of total billed charges 580.94 890.15 Technical (Hospital) Services Resp Panel Virus by Pcr 12-25 PX-3068763300 CDM 87633 CPT 306 RC inpatient 937 937 HEALTHPARTNERS SX009 HEALTHPARTNERS 741.92 percent of total billed charges 580.94 890.15 Technical (Hospital) Services Resp Panel Virus by Pcr 12-25 PX-3068763300 CDM 87633 CPT 306 RC inpatient 937 937 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES EPO [308136803] 741.92 percent of total billed charges 580.94 890.15 Technical (Hospital) Services Resp Panel Virus by Pcr 12-25 PX-3068763300 CDM 87633 CPT 306 RC outpatient 937 937 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES HDHP [308136802] 749.6 percent of total billed charges 580.94 890.15 Technical (Hospital) Services Resp Panel Virus by Pcr 12-25 PX-3068763300 CDM 87633 CPT 306 RC outpatient 937 937 BLUE CROSS BLUE SHIELD WELLMARK SB889 [3081026] BCBS WYOMING [308102603] 890.15 percent of total billed charges 580.94 890.15 Technical (Hospital) Services Resp Panel Virus by Pcr 12-25 PX-3068763300 CDM 87633 CPT 306 RC outpatient 937 937 MULTIPLAN INC 34080 [3081285] MULTIPLAN INC [308128501] 890.15 percent of total billed charges 580.94 890.15 Technical (Hospital) Services Resp Panel Virus by Pcr 12-25 PX-3068763300 CDM 87633 CPT 306 RC outpatient 937 937 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES EPO [308136803] 749.6 percent of total billed charges 580.94 890.15 Technical (Hospital) Services Resp Panel Virus by Pcr 12-25 PX-3068763300 CDM 87633 CPT 306 RC outpatient 937 937 CIGNA 62308 [3081051] CIGNA 62308 [308105105] 749.6 percent of total billed charges 580.94 890.15 Technical (Hospital) Services Resp Panel Virus by Pcr 12-25 PX-3068763300 CDM 87633 CPT 306 RC outpatient 937 937 CIGNA 62308 [3081051] CIGNA STATE OF WYOMING [308105107] 749.6 percent of total billed charges 580.94 890.15 Technical (Hospital) Services Resp Panel Virus by Pcr 12-25 PX-3068763300 CDM 87633 CPT 306 RC outpatient 937 937 HEALTHPARTNERS SX009 HEALTHPARTNERS 749.6 percent of total billed charges 580.94 890.15 Technical (Hospital) Services Resp Panel Virus by Pcr 12-25 PX-3068763300 CDM 87633 CPT 306 RC outpatient 937 937 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES PPO [308136801] 749.6 percent of total billed charges 580.94 890.15 Technical (Hospital) Services Resp Panel Virus by Pcr 12-25 PX-3068763300 CDM 87633 CPT 306 RC outpatient 937 937 UNITED HEALTHCARE (COMMERCIAL) [3081199] UNITED HEALTHCARE 87726 [308119901] 580.94 percent of total billed charges 580.94 890.15 Technical (Hospital) Services Resp Panel Virus by Pcr 12-25 PX-3068763300 CDM 87633 CPT 306 RC outpatient 937 937 MEDICA (COMMERCIAL) 94265 [3081118] MEDICA CLAIMS [308111801] 843.3 percent of total billed charges 580.94 890.15 Technical (Hospital) Services Resp Panel Virus by Pcr 12-25 (Resp Pcr Panel With Covid 19) PX-3068763301 CDM 87633 CPT 306 RC inpatient 1505 1505 MEDICA (COMMERCIAL) 94265 [3081118] MEDICA CLAIMS [308111801] 1354.5 percent of total billed charges 933.1 1429.75 Technical (Hospital) Services Resp Panel Virus by Pcr 12-25 (Resp Pcr Panel With Covid 19) PX-3068763301 CDM 87633 CPT 306 RC inpatient 1505 1505 UNITED HEALTHCARE (COMMERCIAL) [3081199] UNITED HEALTHCARE 87726 [308119901] 933.1 percent of total billed charges 933.1 1429.75 Technical (Hospital) Services Resp Panel Virus by Pcr 12-25 (Resp Pcr Panel With Covid 19) PX-3068763301 CDM 87633 CPT 306 RC inpatient 1505 1505 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES HDHP [308136802] 1191.66 percent of total billed charges 933.1 1429.75 Technical (Hospital) Services Resp Panel Virus by Pcr 12-25 (Resp Pcr Panel With Covid 19) PX-3068763301 CDM 87633 CPT 306 RC inpatient 1505 1505 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES PPO [308136801] 1191.66 percent of total billed charges 933.1 1429.75 Technical (Hospital) Services Resp Panel Virus by Pcr 12-25 (Resp Pcr Panel With Covid 19) PX-3068763301 CDM 87633 CPT 306 RC inpatient 1505 1505 HEALTHPARTNERS SX009 HEALTHPARTNERS 1191.66 percent of total billed charges 933.1 1429.75 Technical (Hospital) Services Resp Panel Virus by Pcr 12-25 (Resp Pcr Panel With Covid 19) PX-3068763301 CDM 87633 CPT 306 RC inpatient 1505 1505 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES EPO [308136803] 1191.66 percent of total billed charges 933.1 1429.75 Technical (Hospital) Services Resp Panel Virus by Pcr 12-25 (Resp Pcr Panel With Covid 19) PX-3068763301 CDM 87633 CPT 306 RC inpatient 1505 1505 MULTIPLAN INC 34080 [3081285] MULTIPLAN INC [308128501] 1429.75 percent of total billed charges 933.1 1429.75 Technical (Hospital) Services Resp Panel Virus by Pcr 12-25 (Resp Pcr Panel With Covid 19) PX-3068763301 CDM 87633 CPT 306 RC inpatient 1505 1505 CIGNA 62308 [3081051] CIGNA 62308 [308105105] 1191.66 percent of total billed charges 933.1 1429.75 Technical (Hospital) Services Resp Panel Virus by Pcr 12-25 (Resp Pcr Panel With Covid 19) PX-3068763301 CDM 87633 CPT 306 RC inpatient 1505 1505 CIGNA 62308 [3081051] CIGNA STATE OF WYOMING [308105107] 1191.66 percent of total billed charges 933.1 1429.75 Technical (Hospital) Services Resp Panel Virus by Pcr 12-25 (Resp Pcr Panel With Covid 19) PX-3068763301 CDM 87633 CPT 306 RC inpatient 1505 1505 BLUE CROSS BLUE SHIELD WELLMARK SB889 [3081026] BCBS WYOMING [308102603] 1429.75 percent of total billed charges 933.1 1429.75 Technical (Hospital) Services Resp Panel Virus by Pcr 12-25 (Resp Pcr Panel With Covid 19) PX-3068763301 CDM 87633 CPT 306 RC outpatient 1505 1505 HEALTHPARTNERS SX009 HEALTHPARTNERS 1204 percent of total billed charges 933.1 1429.75 Technical (Hospital) Services Resp Panel Virus by Pcr 12-25 (Resp Pcr Panel With Covid 19) PX-3068763301 CDM 87633 CPT 306 RC outpatient 1505 1505 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES PPO [308136801] 1204 percent of total billed charges 933.1 1429.75 Technical (Hospital) Services Resp Panel Virus by Pcr 12-25 (Resp Pcr Panel With Covid 19) PX-3068763301 CDM 87633 CPT 306 RC outpatient 1505 1505 UNITED HEALTHCARE (COMMERCIAL) [3081199] UNITED HEALTHCARE 87726 [308119901] 933.1 percent of total billed charges 933.1 1429.75 Technical (Hospital) Services Resp Panel Virus by Pcr 12-25 (Resp Pcr Panel With Covid 19) PX-3068763301 CDM 87633 CPT 306 RC outpatient 1505 1505 MULTIPLAN INC 34080 [3081285] MULTIPLAN INC [308128501] 1429.75 percent of total billed charges 933.1 1429.75 Technical (Hospital) Services Resp Panel Virus by Pcr 12-25 (Resp Pcr Panel With Covid 19) PX-3068763301 CDM 87633 CPT 306 RC outpatient 1505 1505 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES EPO [308136803] 1204 percent of total billed charges 933.1 1429.75 Technical (Hospital) Services Resp Panel Virus by Pcr 12-25 (Resp Pcr Panel With Covid 19) PX-3068763301 CDM 87633 CPT 306 RC outpatient 1505 1505 CIGNA 62308 [3081051] CIGNA 62308 [308105105] 1204 percent of total billed charges 933.1 1429.75 Technical (Hospital) Services Resp Panel Virus by Pcr 12-25 (Resp Pcr Panel With Covid 19) PX-3068763301 CDM 87633 CPT 306 RC outpatient 1505 1505 CIGNA 62308 [3081051] CIGNA STATE OF WYOMING [308105107] 1204 percent of total billed charges 933.1 1429.75 Technical (Hospital) Services Resp Panel Virus by Pcr 12-25 (Resp Pcr Panel With Covid 19) PX-3068763301 CDM 87633 CPT 306 RC outpatient 1505 1505 BLUE CROSS BLUE SHIELD WELLMARK SB889 [3081026] BCBS WYOMING [308102603] 1429.75 percent of total billed charges 933.1 1429.75 Technical (Hospital) Services Resp Panel Virus by Pcr 12-25 (Resp Pcr Panel With Covid 19) PX-3068763301 CDM 87633 CPT 306 RC outpatient 1505 1505 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES HDHP [308136802] 1204 percent of total billed charges 933.1 1429.75 Technical (Hospital) Services Resp Panel Virus by Pcr 12-25 (Resp Pcr Panel With Covid 19) PX-3068763301 CDM 87633 CPT 306 RC outpatient 1505 1505 MEDICA (COMMERCIAL) 94265 [3081118] MEDICA CLAIMS [308111801] 1354.5 percent of total billed charges 933.1 1429.75 Technical (Hospital) Services N Gonorrhoeae Amplified Probe PX-3068759102 CDM 87591 CPT 306 RC outpatient 222 222 UNITED HEALTHCARE (COMMERCIAL) [3081199] UNITED HEALTHCARE 87726 [308119901] 137.64 percent of total billed charges 137.64 210.9 Technical (Hospital) Services N Gonorrhoeae Amplified Probe PX-3068759102 CDM 87591 CPT 306 RC outpatient 222 222 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES PPO [308136801] 177.6 percent of total billed charges 137.64 210.9 Technical (Hospital) Services N Gonorrhoeae Amplified Probe PX-3068759102 CDM 87591 CPT 306 RC outpatient 222 222 HEALTHPARTNERS SX009 HEALTHPARTNERS 177.6 percent of total billed charges 137.64 210.9 Technical (Hospital) Services N Gonorrhoeae Amplified Probe PX-3068759102 CDM 87591 CPT 306 RC outpatient 222 222 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES HDHP [308136802] 177.6 percent of total billed charges 137.64 210.9 Technical (Hospital) Services N Gonorrhoeae Amplified Probe PX-3068759102 CDM 87591 CPT 306 RC outpatient 222 222 BLUE CROSS BLUE SHIELD WELLMARK SB889 [3081026] BCBS WYOMING [308102603] 210.9 percent of total billed charges 137.64 210.9 Technical (Hospital) Services N Gonorrhoeae Amplified Probe PX-3068759102 CDM 87591 CPT 306 RC outpatient 222 222 CIGNA 62308 [3081051] CIGNA 62308 [308105105] 177.6 percent of total billed charges 137.64 210.9 Technical (Hospital) Services N Gonorrhoeae Amplified Probe PX-3068759102 CDM 87591 CPT 306 RC outpatient 222 222 CIGNA 62308 [3081051] CIGNA STATE OF WYOMING [308105107] 177.6 percent of total billed charges 137.64 210.9 Technical (Hospital) Services N Gonorrhoeae Amplified Probe PX-3068759102 CDM 87591 CPT 306 RC outpatient 222 222 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES EPO [308136803] 177.6 percent of total billed charges 137.64 210.9 Technical (Hospital) Services N Gonorrhoeae Amplified Probe PX-3068759102 CDM 87591 CPT 306 RC outpatient 222 222 MULTIPLAN INC 34080 [3081285] MULTIPLAN INC [308128501] 210.9 percent of total billed charges 137.64 210.9 Technical (Hospital) Services N Gonorrhoeae Amplified Probe PX-3068759102 CDM 87591 CPT 306 RC outpatient 222 222 MEDICA (COMMERCIAL) 94265 [3081118] MEDICA CLAIMS [308111801] 199.8 percent of total billed charges 137.64 210.9 Technical (Hospital) Services N Gonorrhoeae Amplified Probe PX-3068759102 CDM 87591 CPT 306 RC inpatient 222 222 UNITED HEALTHCARE (COMMERCIAL) [3081199] UNITED HEALTHCARE 87726 [308119901] 137.64 percent of total billed charges 137.64 210.9 Technical (Hospital) Services N Gonorrhoeae Amplified Probe PX-3068759102 CDM 87591 CPT 306 RC inpatient 222 222 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES HDHP [308136802] 175.78 percent of total billed charges 137.64 210.9 Technical (Hospital) Services N Gonorrhoeae Amplified Probe PX-3068759102 CDM 87591 CPT 306 RC inpatient 222 222 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES PPO [308136801] 175.78 percent of total billed charges 137.64 210.9 Technical (Hospital) Services N Gonorrhoeae Amplified Probe PX-3068759102 CDM 87591 CPT 306 RC inpatient 222 222 CIGNA 62308 [3081051] CIGNA 62308 [308105105] 175.78 percent of total billed charges 137.64 210.9 Technical (Hospital) Services N Gonorrhoeae Amplified Probe PX-3068759102 CDM 87591 CPT 306 RC inpatient 222 222 CIGNA 62308 [3081051] CIGNA STATE OF WYOMING [308105107] 175.78 percent of total billed charges 137.64 210.9 Technical (Hospital) Services N Gonorrhoeae Amplified Probe PX-3068759102 CDM 87591 CPT 306 RC inpatient 222 222 BLUE CROSS BLUE SHIELD WELLMARK SB889 [3081026] BCBS WYOMING [308102603] 210.9 percent of total billed charges 137.64 210.9 Technical (Hospital) Services N Gonorrhoeae Amplified Probe PX-3068759102 CDM 87591 CPT 306 RC inpatient 222 222 MEDICA (COMMERCIAL) 94265 [3081118] MEDICA CLAIMS [308111801] 199.8 percent of total billed charges 137.64 210.9 Technical (Hospital) Services N Gonorrhoeae Amplified Probe PX-3068759102 CDM 87591 CPT 306 RC inpatient 222 222 MULTIPLAN INC 34080 [3081285] MULTIPLAN INC [308128501] 210.9 percent of total billed charges 137.64 210.9 Technical (Hospital) Services N Gonorrhoeae Amplified Probe PX-3068759102 CDM 87591 CPT 306 RC inpatient 222 222 HEALTHPARTNERS SX009 HEALTHPARTNERS 175.78 percent of total billed charges 137.64 210.9 Technical (Hospital) Services N Gonorrhoeae Amplified Probe PX-3068759102 CDM 87591 CPT 306 RC inpatient 222 222 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES EPO [308136803] 175.78 percent of total billed charges 137.64 210.9 Technical (Hospital) Services M Pneumoniae by Pcr PX-3068758100 CDM 87581 CPT 306 RC inpatient 158 158 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES EPO [308136803] 125.1 percent of total billed charges 97.96 150.1 Technical (Hospital) Services M Pneumoniae by Pcr PX-3068758100 CDM 87581 CPT 306 RC inpatient 158 158 HEALTHPARTNERS SX009 HEALTHPARTNERS 125.1 percent of total billed charges 97.96 150.1 Technical (Hospital) Services M Pneumoniae by Pcr PX-3068758100 CDM 87581 CPT 306 RC inpatient 158 158 MULTIPLAN INC 34080 [3081285] MULTIPLAN INC [308128501] 150.1 percent of total billed charges 97.96 150.1 Technical (Hospital) Services M Pneumoniae by Pcr PX-3068758100 CDM 87581 CPT 306 RC inpatient 158 158 BLUE CROSS BLUE SHIELD WELLMARK SB889 [3081026] BCBS WYOMING [308102603] 150.1 percent of total billed charges 97.96 150.1 Technical (Hospital) Services M Pneumoniae by Pcr PX-3068758100 CDM 87581 CPT 306 RC inpatient 158 158 CIGNA 62308 [3081051] CIGNA 62308 [308105105] 125.1 percent of total billed charges 97.96 150.1 Technical (Hospital) Services M Pneumoniae by Pcr PX-3068758100 CDM 87581 CPT 306 RC inpatient 158 158 CIGNA 62308 [3081051] CIGNA STATE OF WYOMING [308105107] 125.1 percent of total billed charges 97.96 150.1 Technical (Hospital) Services M Pneumoniae by Pcr PX-3068758100 CDM 87581 CPT 306 RC inpatient 158 158 UNITED HEALTHCARE (COMMERCIAL) [3081199] UNITED HEALTHCARE 87726 [308119901] 97.96 percent of total billed charges 97.96 150.1 Technical (Hospital) Services M Pneumoniae by Pcr PX-3068758100 CDM 87581 CPT 306 RC inpatient 158 158 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES HDHP [308136802] 125.1 percent of total billed charges 97.96 150.1 Technical (Hospital) Services M Pneumoniae by Pcr PX-3068758100 CDM 87581 CPT 306 RC inpatient 158 158 MEDICA (COMMERCIAL) 94265 [3081118] MEDICA CLAIMS [308111801] 142.2 percent of total billed charges 97.96 150.1 Technical (Hospital) Services M Pneumoniae by Pcr PX-3068758100 CDM 87581 CPT 306 RC inpatient 158 158 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES PPO [308136801] 125.1 percent of total billed charges 97.96 150.1 Technical (Hospital) Services M Pneumoniae by Pcr PX-3068758100 CDM 87581 CPT 306 RC outpatient 158 158 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES HDHP [308136802] 126.4 percent of total billed charges 97.96 150.1 Technical (Hospital) Services M Pneumoniae by Pcr PX-3068758100 CDM 87581 CPT 306 RC outpatient 158 158 BLUE CROSS BLUE SHIELD WELLMARK SB889 [3081026] BCBS WYOMING [308102603] 150.1 percent of total billed charges 97.96 150.1 Technical (Hospital) Services M Pneumoniae by Pcr PX-3068758100 CDM 87581 CPT 306 RC outpatient 158 158 CIGNA 62308 [3081051] CIGNA STATE OF WYOMING [308105107] 126.4 percent of total billed charges 97.96 150.1 Technical (Hospital) Services M Pneumoniae by Pcr PX-3068758100 CDM 87581 CPT 306 RC outpatient 158 158 CIGNA 62308 [3081051] CIGNA 62308 [308105105] 126.4 percent of total billed charges 97.96 150.1 Technical (Hospital) Services M Pneumoniae by Pcr PX-3068758100 CDM 87581 CPT 306 RC outpatient 158 158 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES EPO [308136803] 126.4 percent of total billed charges 97.96 150.1 Technical (Hospital) Services M Pneumoniae by Pcr PX-3068758100 CDM 87581 CPT 306 RC outpatient 158 158 MULTIPLAN INC 34080 [3081285] MULTIPLAN INC [308128501] 150.1 percent of total billed charges 97.96 150.1 Technical (Hospital) Services M Pneumoniae by Pcr PX-3068758100 CDM 87581 CPT 306 RC outpatient 158 158 UNITED HEALTHCARE (COMMERCIAL) [3081199] UNITED HEALTHCARE 87726 [308119901] 97.96 percent of total billed charges 97.96 150.1 Technical (Hospital) Services M Pneumoniae by Pcr PX-3068758100 CDM 87581 CPT 306 RC outpatient 158 158 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES PPO [308136801] 126.4 percent of total billed charges 97.96 150.1 Technical (Hospital) Services M Pneumoniae by Pcr PX-3068758100 CDM 87581 CPT 306 RC outpatient 158 158 HEALTHPARTNERS SX009 HEALTHPARTNERS 126.4 percent of total billed charges 97.96 150.1 Technical (Hospital) Services M Pneumoniae by Pcr PX-3068758100 CDM 87581 CPT 306 RC outpatient 158 158 MEDICA (COMMERCIAL) 94265 [3081118] MEDICA CLAIMS [308111801] 142.2 percent of total billed charges 97.96 150.1 Technical (Hospital) Services Ref Hiv 1 Rna by Ultra Sens Pcr Q PX-3068753601 CDM 87536 CPT 306 RC inpatient 238 238 HEALTHPARTNERS SX009 HEALTHPARTNERS 188.45 percent of total billed charges 147.56 226.1 Technical (Hospital) Services Ref Hiv 1 Rna by Ultra Sens Pcr Q PX-3068753601 CDM 87536 CPT 306 RC inpatient 238 238 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES EPO [308136803] 188.45 percent of total billed charges 147.56 226.1 Technical (Hospital) Services Ref Hiv 1 Rna by Ultra Sens Pcr Q PX-3068753601 CDM 87536 CPT 306 RC inpatient 238 238 MULTIPLAN INC 34080 [3081285] MULTIPLAN INC [308128501] 226.1 percent of total billed charges 147.56 226.1 Technical (Hospital) Services Ref Hiv 1 Rna by Ultra Sens Pcr Q PX-3068753601 CDM 87536 CPT 306 RC inpatient 238 238 CIGNA 62308 [3081051] CIGNA 62308 [308105105] 188.45 percent of total billed charges 147.56 226.1 Technical (Hospital) Services Ref Hiv 1 Rna by Ultra Sens Pcr Q PX-3068753601 CDM 87536 CPT 306 RC inpatient 238 238 CIGNA 62308 [3081051] CIGNA STATE OF WYOMING [308105107] 188.45 percent of total billed charges 147.56 226.1 Technical (Hospital) Services Ref Hiv 1 Rna by Ultra Sens Pcr Q PX-3068753601 CDM 87536 CPT 306 RC inpatient 238 238 BLUE CROSS BLUE SHIELD WELLMARK SB889 [3081026] BCBS WYOMING [308102603] 226.1 percent of total billed charges 147.56 226.1 Technical (Hospital) Services Ref Hiv 1 Rna by Ultra Sens Pcr Q PX-3068753601 CDM 87536 CPT 306 RC inpatient 238 238 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES PPO [308136801] 188.45 percent of total billed charges 147.56 226.1 Technical (Hospital) Services Ref Hiv 1 Rna by Ultra Sens Pcr Q PX-3068753601 CDM 87536 CPT 306 RC inpatient 238 238 MEDICA (COMMERCIAL) 94265 [3081118] MEDICA CLAIMS [308111801] 214.2 percent of total billed charges 147.56 226.1 Technical (Hospital) Services Ref Hiv 1 Rna by Ultra Sens Pcr Q PX-3068753601 CDM 87536 CPT 306 RC inpatient 238 238 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES HDHP [308136802] 188.45 percent of total billed charges 147.56 226.1 Technical (Hospital) Services Ref Hiv 1 Rna by Ultra Sens Pcr Q PX-3068753601 CDM 87536 CPT 306 RC inpatient 238 238 UNITED HEALTHCARE (COMMERCIAL) [3081199] UNITED HEALTHCARE 87726 [308119901] 147.56 percent of total billed charges 147.56 226.1 Technical (Hospital) Services Ref Hiv 1 Rna by Ultra Sens Pcr Q PX-3068753601 CDM 87536 CPT 306 RC outpatient 238 238 MEDICA (COMMERCIAL) 94265 [3081118] MEDICA CLAIMS [308111801] 214.2 percent of total billed charges 147.56 226.1 Technical (Hospital) Services Ref Hiv 1 Rna by Ultra Sens Pcr Q PX-3068753601 CDM 87536 CPT 306 RC outpatient 238 238 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES EPO [308136803] 190.4 percent of total billed charges 147.56 226.1 Technical (Hospital) Services Ref Hiv 1 Rna by Ultra Sens Pcr Q PX-3068753601 CDM 87536 CPT 306 RC outpatient 238 238 CIGNA 62308 [3081051] CIGNA 62308 [308105105] 190.4 percent of total billed charges 147.56 226.1 Technical (Hospital) Services Ref Hiv 1 Rna by Ultra Sens Pcr Q PX-3068753601 CDM 87536 CPT 306 RC outpatient 238 238 CIGNA 62308 [3081051] CIGNA STATE OF WYOMING [308105107] 190.4 percent of total billed charges 147.56 226.1 Technical (Hospital) Services Ref Hiv 1 Rna by Ultra Sens Pcr Q PX-3068753601 CDM 87536 CPT 306 RC outpatient 238 238 MULTIPLAN INC 34080 [3081285] MULTIPLAN INC [308128501] 226.1 percent of total billed charges 147.56 226.1 Technical (Hospital) Services Ref Hiv 1 Rna by Ultra Sens Pcr Q PX-3068753601 CDM 87536 CPT 306 RC outpatient 238 238 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES HDHP [308136802] 190.4 percent of total billed charges 147.56 226.1 Technical (Hospital) Services Ref Hiv 1 Rna by Ultra Sens Pcr Q PX-3068753601 CDM 87536 CPT 306 RC outpatient 238 238 BLUE CROSS BLUE SHIELD WELLMARK SB889 [3081026] BCBS WYOMING [308102603] 226.1 percent of total billed charges 147.56 226.1 Technical (Hospital) Services Ref Hiv 1 Rna by Ultra Sens Pcr Q PX-3068753601 CDM 87536 CPT 306 RC outpatient 238 238 HEALTHPARTNERS SX009 HEALTHPARTNERS 190.4 percent of total billed charges 147.56 226.1 Technical (Hospital) Services Ref Hiv 1 Rna by Ultra Sens Pcr Q PX-3068753601 CDM 87536 CPT 306 RC outpatient 238 238 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES PPO [308136801] 190.4 percent of total billed charges 147.56 226.1 Technical (Hospital) Services Ref Hiv 1 Rna by Ultra Sens Pcr Q PX-3068753601 CDM 87536 CPT 306 RC outpatient 238 238 UNITED HEALTHCARE (COMMERCIAL) [3081199] UNITED HEALTHCARE 87726 [308119901] 147.56 percent of total billed charges 147.56 226.1 Technical (Hospital) Services Hsvi Hsvii Amp Prob Technique PX-3068752903 CDM 87529 CPT 306 RC inpatient 163 163 CIGNA 62308 [3081051] CIGNA 62308 [308105105] 129.06 percent of total billed charges 101.06 154.85 Technical (Hospital) Services Hsvi Hsvii Amp Prob Technique PX-3068752903 CDM 87529 CPT 306 RC inpatient 163 163 CIGNA 62308 [3081051] CIGNA STATE OF WYOMING [308105107] 129.06 percent of total billed charges 101.06 154.85 Technical (Hospital) Services Hsvi Hsvii Amp Prob Technique PX-3068752903 CDM 87529 CPT 306 RC inpatient 163 163 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES EPO [308136803] 129.06 percent of total billed charges 101.06 154.85 Technical (Hospital) Services Hsvi Hsvii Amp Prob Technique PX-3068752903 CDM 87529 CPT 306 RC inpatient 163 163 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES HDHP [308136802] 129.06 percent of total billed charges 101.06 154.85 Technical (Hospital) Services Hsvi Hsvii Amp Prob Technique PX-3068752903 CDM 87529 CPT 306 RC inpatient 163 163 HEALTHPARTNERS SX009 HEALTHPARTNERS 129.06 percent of total billed charges 101.06 154.85 Technical (Hospital) Services Hsvi Hsvii Amp Prob Technique PX-3068752903 CDM 87529 CPT 306 RC inpatient 163 163 MEDICA (COMMERCIAL) 94265 [3081118] MEDICA CLAIMS [308111801] 146.7 percent of total billed charges 101.06 154.85 Technical (Hospital) Services Hsvi Hsvii Amp Prob Technique PX-3068752903 CDM 87529 CPT 306 RC inpatient 163 163 MULTIPLAN INC 34080 [3081285] MULTIPLAN INC [308128501] 154.85 percent of total billed charges 101.06 154.85 Technical (Hospital) Services Hsvi Hsvii Amp Prob Technique PX-3068752903 CDM 87529 CPT 306 RC inpatient 163 163 UNITED HEALTHCARE (COMMERCIAL) [3081199] UNITED HEALTHCARE 87726 [308119901] 101.06 percent of total billed charges 101.06 154.85 Technical (Hospital) Services Hsvi Hsvii Amp Prob Technique PX-3068752903 CDM 87529 CPT 306 RC inpatient 163 163 BLUE CROSS BLUE SHIELD WELLMARK SB889 [3081026] BCBS WYOMING [308102603] 154.85 percent of total billed charges 101.06 154.85 Technical (Hospital) Services Hsvi Hsvii Amp Prob Technique PX-3068752903 CDM 87529 CPT 306 RC inpatient 163 163 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES PPO [308136801] 129.06 percent of total billed charges 101.06 154.85 Technical (Hospital) Services Hsvi Hsvii Amp Prob Technique PX-3068752903 CDM 87529 CPT 306 RC outpatient 163 163 HEALTHPARTNERS SX009 HEALTHPARTNERS 130.4 percent of total billed charges 101.06 154.85 Technical (Hospital) Services Hsvi Hsvii Amp Prob Technique PX-3068752903 CDM 87529 CPT 306 RC outpatient 163 163 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES PPO [308136801] 130.4 percent of total billed charges 101.06 154.85 Technical (Hospital) Services Hsvi Hsvii Amp Prob Technique PX-3068752903 CDM 87529 CPT 306 RC outpatient 163 163 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES EPO [308136803] 130.4 percent of total billed charges 101.06 154.85 Technical (Hospital) Services Hsvi Hsvii Amp Prob Technique PX-3068752903 CDM 87529 CPT 306 RC outpatient 163 163 BLUE CROSS BLUE SHIELD WELLMARK SB889 [3081026] BCBS WYOMING [308102603] 154.85 percent of total billed charges 101.06 154.85 Technical (Hospital) Services Hsvi Hsvii Amp Prob Technique PX-3068752903 CDM 87529 CPT 306 RC outpatient 163 163 UNITED HEALTHCARE (COMMERCIAL) [3081199] UNITED HEALTHCARE 87726 [308119901] 101.06 percent of total billed charges 101.06 154.85 Technical (Hospital) Services Hsvi Hsvii Amp Prob Technique PX-3068752903 CDM 87529 CPT 306 RC outpatient 163 163 MULTIPLAN INC 34080 [3081285] MULTIPLAN INC [308128501] 154.85 percent of total billed charges 101.06 154.85 Technical (Hospital) Services Hsvi Hsvii Amp Prob Technique PX-3068752903 CDM 87529 CPT 306 RC outpatient 163 163 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES HDHP [308136802] 130.4 percent of total billed charges 101.06 154.85 Technical (Hospital) Services Hsvi Hsvii Amp Prob Technique PX-3068752903 CDM 87529 CPT 306 RC outpatient 163 163 CIGNA 62308 [3081051] CIGNA 62308 [308105105] 130.4 percent of total billed charges 101.06 154.85 Technical (Hospital) Services Hsvi Hsvii Amp Prob Technique PX-3068752903 CDM 87529 CPT 306 RC outpatient 163 163 CIGNA 62308 [3081051] CIGNA STATE OF WYOMING [308105107] 130.4 percent of total billed charges 101.06 154.85 Technical (Hospital) Services Hsvi Hsvii Amp Prob Technique PX-3068752903 CDM 87529 CPT 306 RC outpatient 163 163 MEDICA (COMMERCIAL) 94265 [3081118] MEDICA CLAIMS [308111801] 146.7 percent of total billed charges 101.06 154.85 Technical (Hospital) Services Ref Hcv Viral Load PX-3068752201 CDM 87522 CPT 306 RC outpatient 268 268 CIGNA 62308 [3081051] CIGNA STATE OF WYOMING [308105107] 214.4 percent of total billed charges 166.16 254.6 Technical (Hospital) Services Ref Hcv Viral Load PX-3068752201 CDM 87522 CPT 306 RC outpatient 268 268 CIGNA 62308 [3081051] CIGNA 62308 [308105105] 214.4 percent of total billed charges 166.16 254.6 Technical (Hospital) Services Ref Hcv Viral Load PX-3068752201 CDM 87522 CPT 306 RC outpatient 268 268 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES EPO [308136803] 214.4 percent of total billed charges 166.16 254.6 Technical (Hospital) Services Ref Hcv Viral Load PX-3068752201 CDM 87522 CPT 306 RC outpatient 268 268 MULTIPLAN INC 34080 [3081285] MULTIPLAN INC [308128501] 254.6 percent of total billed charges 166.16 254.6 Technical (Hospital) Services Ref Hcv Viral Load PX-3068752201 CDM 87522 CPT 306 RC outpatient 268 268 BLUE CROSS BLUE SHIELD WELLMARK SB889 [3081026] BCBS WYOMING [308102603] 254.6 percent of total billed charges 166.16 254.6 Technical (Hospital) Services Ref Hcv Viral Load PX-3068752201 CDM 87522 CPT 306 RC outpatient 268 268 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES HDHP [308136802] 214.4 percent of total billed charges 166.16 254.6 Technical (Hospital) Services Ref Hcv Viral Load PX-3068752201 CDM 87522 CPT 306 RC outpatient 268 268 UNITED HEALTHCARE (COMMERCIAL) [3081199] UNITED HEALTHCARE 87726 [308119901] 166.16 percent of total billed charges 166.16 254.6 Technical (Hospital) Services Ref Hcv Viral Load PX-3068752201 CDM 87522 CPT 306 RC outpatient 268 268 HEALTHPARTNERS SX009 HEALTHPARTNERS 214.4 percent of total billed charges 166.16 254.6 Technical (Hospital) Services Ref Hcv Viral Load PX-3068752201 CDM 87522 CPT 306 RC outpatient 268 268 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES PPO [308136801] 214.4 percent of total billed charges 166.16 254.6 Technical (Hospital) Services Ref Hcv Viral Load PX-3068752201 CDM 87522 CPT 306 RC outpatient 268 268 MEDICA (COMMERCIAL) 94265 [3081118] MEDICA CLAIMS [308111801] 241.2 percent of total billed charges 166.16 254.6 Technical (Hospital) Services Ref Hcv Viral Load PX-3068752201 CDM 87522 CPT 306 RC inpatient 268 268 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES EPO [308136803] 212.2 percent of total billed charges 166.16 254.6 Technical (Hospital) Services Ref Hcv Viral Load PX-3068752201 CDM 87522 CPT 306 RC inpatient 268 268 HEALTHPARTNERS SX009 HEALTHPARTNERS 212.2 percent of total billed charges 166.16 254.6 Technical (Hospital) Services Ref Hcv Viral Load PX-3068752201 CDM 87522 CPT 306 RC inpatient 268 268 MEDICA (COMMERCIAL) 94265 [3081118] MEDICA CLAIMS [308111801] 241.2 percent of total billed charges 166.16 254.6 Technical (Hospital) Services Ref Hcv Viral Load PX-3068752201 CDM 87522 CPT 306 RC inpatient 268 268 MULTIPLAN INC 34080 [3081285] MULTIPLAN INC [308128501] 254.6 percent of total billed charges 166.16 254.6 Technical (Hospital) Services Ref Hcv Viral Load PX-3068752201 CDM 87522 CPT 306 RC inpatient 268 268 BLUE CROSS BLUE SHIELD WELLMARK SB889 [3081026] BCBS WYOMING [308102603] 254.6 percent of total billed charges 166.16 254.6 Technical (Hospital) Services Ref Hcv Viral Load PX-3068752201 CDM 87522 CPT 306 RC inpatient 268 268 CIGNA 62308 [3081051] CIGNA 62308 [308105105] 212.2 percent of total billed charges 166.16 254.6 Technical (Hospital) Services Ref Hcv Viral Load PX-3068752201 CDM 87522 CPT 306 RC inpatient 268 268 CIGNA 62308 [3081051] CIGNA STATE OF WYOMING [308105107] 212.2 percent of total billed charges 166.16 254.6 Technical (Hospital) Services Ref Hcv Viral Load PX-3068752201 CDM 87522 CPT 306 RC inpatient 268 268 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES PPO [308136801] 212.2 percent of total billed charges 166.16 254.6 Technical (Hospital) Services Ref Hcv Viral Load PX-3068752201 CDM 87522 CPT 306 RC inpatient 268 268 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES HDHP [308136802] 212.2 percent of total billed charges 166.16 254.6 Technical (Hospital) Services Ref Hcv Viral Load PX-3068752201 CDM 87522 CPT 306 RC inpatient 268 268 UNITED HEALTHCARE (COMMERCIAL) [3081199] UNITED HEALTHCARE 87726 [308119901] 166.16 percent of total billed charges 166.16 254.6 Technical (Hospital) Services "Ref Hepatitis B, Dna, Quant" PX-3068751700 CDM 87517 CPT 306 RC outpatient 330 330 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES EPO [308136803] 264 percent of total billed charges 204.6 313.5 Technical (Hospital) Services "Ref Hepatitis B, Dna, Quant" PX-3068751700 CDM 87517 CPT 306 RC outpatient 330 330 CIGNA 62308 [3081051] CIGNA 62308 [308105105] 264 percent of total billed charges 204.6 313.5 Technical (Hospital) Services "Ref Hepatitis B, Dna, Quant" PX-3068751700 CDM 87517 CPT 306 RC outpatient 330 330 CIGNA 62308 [3081051] CIGNA STATE OF WYOMING [308105107] 264 percent of total billed charges 204.6 313.5 Technical (Hospital) Services "Ref Hepatitis B, Dna, Quant" PX-3068751700 CDM 87517 CPT 306 RC outpatient 330 330 MULTIPLAN INC 34080 [3081285] MULTIPLAN INC [308128501] 313.5 percent of total billed charges 204.6 313.5 Technical (Hospital) Services "Ref Hepatitis B, Dna, Quant" PX-3068751700 CDM 87517 CPT 306 RC outpatient 330 330 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES HDHP [308136802] 264 percent of total billed charges 204.6 313.5 Technical (Hospital) Services "Ref Hepatitis B, Dna, Quant" PX-3068751700 CDM 87517 CPT 306 RC outpatient 330 330 BLUE CROSS BLUE SHIELD WELLMARK SB889 [3081026] BCBS WYOMING [308102603] 313.5 percent of total billed charges 204.6 313.5 Technical (Hospital) Services "Ref Hepatitis B, Dna, Quant" PX-3068751700 CDM 87517 CPT 306 RC outpatient 330 330 UNITED HEALTHCARE (COMMERCIAL) [3081199] UNITED HEALTHCARE 87726 [308119901] 204.6 percent of total billed charges 204.6 313.5 Technical (Hospital) Services "Ref Hepatitis B, Dna, Quant" PX-3068751700 CDM 87517 CPT 306 RC outpatient 330 330 HEALTHPARTNERS SX009 HEALTHPARTNERS 264 percent of total billed charges 204.6 313.5 Technical (Hospital) Services "Ref Hepatitis B, Dna, Quant" PX-3068751700 CDM 87517 CPT 306 RC outpatient 330 330 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES PPO [308136801] 264 percent of total billed charges 204.6 313.5 Technical (Hospital) Services "Ref Hepatitis B, Dna, Quant" PX-3068751700 CDM 87517 CPT 306 RC outpatient 330 330 MEDICA (COMMERCIAL) 94265 [3081118] MEDICA CLAIMS [308111801] 297 percent of total billed charges 204.6 313.5 Technical (Hospital) Services "Ref Hepatitis B, Dna, Quant" PX-3068751700 CDM 87517 CPT 306 RC inpatient 330 330 MULTIPLAN INC 34080 [3081285] MULTIPLAN INC [308128501] 313.5 percent of total billed charges 204.6 313.5 Technical (Hospital) Services "Ref Hepatitis B, Dna, Quant" PX-3068751700 CDM 87517 CPT 306 RC inpatient 330 330 BLUE CROSS BLUE SHIELD WELLMARK SB889 [3081026] BCBS WYOMING [308102603] 313.5 percent of total billed charges 204.6 313.5 Technical (Hospital) Services "Ref Hepatitis B, Dna, Quant" PX-3068751700 CDM 87517 CPT 306 RC inpatient 330 330 CIGNA 62308 [3081051] CIGNA 62308 [308105105] 261.29 percent of total billed charges 204.6 313.5 Technical (Hospital) Services "Ref Hepatitis B, Dna, Quant" PX-3068751700 CDM 87517 CPT 306 RC inpatient 330 330 CIGNA 62308 [3081051] CIGNA STATE OF WYOMING [308105107] 261.29 percent of total billed charges 204.6 313.5 Technical (Hospital) Services "Ref Hepatitis B, Dna, Quant" PX-3068751700 CDM 87517 CPT 306 RC inpatient 330 330 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES EPO [308136803] 261.29 percent of total billed charges 204.6 313.5 Technical (Hospital) Services "Ref Hepatitis B, Dna, Quant" PX-3068751700 CDM 87517 CPT 306 RC inpatient 330 330 HEALTHPARTNERS SX009 HEALTHPARTNERS 261.29 percent of total billed charges 204.6 313.5 Technical (Hospital) Services "Ref Hepatitis B, Dna, Quant" PX-3068751700 CDM 87517 CPT 306 RC inpatient 330 330 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES HDHP [308136802] 261.29 percent of total billed charges 204.6 313.5 Technical (Hospital) Services "Ref Hepatitis B, Dna, Quant" PX-3068751700 CDM 87517 CPT 306 RC inpatient 330 330 UNITED HEALTHCARE (COMMERCIAL) [3081199] UNITED HEALTHCARE 87726 [308119901] 204.6 percent of total billed charges 204.6 313.5 Technical (Hospital) Services "Ref Hepatitis B, Dna, Quant" PX-3068751700 CDM 87517 CPT 306 RC inpatient 330 330 MEDICA (COMMERCIAL) 94265 [3081118] MEDICA CLAIMS [308111801] 297 percent of total billed charges 204.6 313.5 Technical (Hospital) Services "Ref Hepatitis B, Dna, Quant" PX-3068751700 CDM 87517 CPT 306 RC inpatient 330 330 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES PPO [308136801] 261.29 percent of total billed charges 204.6 313.5 Technical (Hospital) Services GI Pcr Panel 12-25 Targets PX-3068750700 CDM 87507 CPT 306 RC inpatient 1640 1640 MULTIPLAN INC 34080 [3081285] MULTIPLAN INC [308128501] 1558 percent of total billed charges 1016.8 1558 Technical (Hospital) Services GI Pcr Panel 12-25 Targets PX-3068750700 CDM 87507 CPT 306 RC inpatient 1640 1640 BLUE CROSS BLUE SHIELD WELLMARK SB889 [3081026] BCBS WYOMING [308102603] 1558 percent of total billed charges 1016.8 1558 Technical (Hospital) Services GI Pcr Panel 12-25 Targets PX-3068750700 CDM 87507 CPT 306 RC inpatient 1640 1640 CIGNA 62308 [3081051] CIGNA 62308 [308105105] 1298.55 percent of total billed charges 1016.8 1558 Technical (Hospital) Services GI Pcr Panel 12-25 Targets PX-3068750700 CDM 87507 CPT 306 RC outpatient 1640 1640 MEDICA (COMMERCIAL) 94265 [3081118] MEDICA CLAIMS [308111801] 1476 percent of total billed charges 1016.8 1558 Technical (Hospital) Services GI Pcr Panel 12-25 Targets PX-3068750700 CDM 87507 CPT 306 RC outpatient 1640 1640 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES PPO [308136801] 1312 percent of total billed charges 1016.8 1558 Technical (Hospital) Services GI Pcr Panel 12-25 Targets PX-3068750700 CDM 87507 CPT 306 RC outpatient 1640 1640 HEALTHPARTNERS SX009 HEALTHPARTNERS 1312 percent of total billed charges 1016.8 1558 Technical (Hospital) Services GI Pcr Panel 12-25 Targets PX-3068750700 CDM 87507 CPT 306 RC outpatient 1640 1640 UNITED HEALTHCARE (COMMERCIAL) [3081199] UNITED HEALTHCARE 87726 [308119901] 1016.8 percent of total billed charges 1016.8 1558 Technical (Hospital) Services GI Pcr Panel 12-25 Targets PX-3068750700 CDM 87507 CPT 306 RC outpatient 1640 1640 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES EPO [308136803] 1312 percent of total billed charges 1016.8 1558 Technical (Hospital) Services GI Pcr Panel 12-25 Targets PX-3068750700 CDM 87507 CPT 306 RC outpatient 1640 1640 CIGNA 62308 [3081051] CIGNA 62308 [308105105] 1312 percent of total billed charges 1016.8 1558 Technical (Hospital) Services GI Pcr Panel 12-25 Targets PX-3068750700 CDM 87507 CPT 306 RC outpatient 1640 1640 CIGNA 62308 [3081051] CIGNA STATE OF WYOMING [308105107] 1312 percent of total billed charges 1016.8 1558 Technical (Hospital) Services GI Pcr Panel 12-25 Targets PX-3068750700 CDM 87507 CPT 306 RC outpatient 1640 1640 MULTIPLAN INC 34080 [3081285] MULTIPLAN INC [308128501] 1558 percent of total billed charges 1016.8 1558 Technical (Hospital) Services GI Pcr Panel 12-25 Targets PX-3068750700 CDM 87507 CPT 306 RC inpatient 1640 1640 CIGNA 62308 [3081051] CIGNA STATE OF WYOMING [308105107] 1298.55 percent of total billed charges 1016.8 1558 Technical (Hospital) Services GI Pcr Panel 12-25 Targets PX-3068750700 CDM 87507 CPT 306 RC inpatient 1640 1640 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES EPO [308136803] 1298.55 percent of total billed charges 1016.8 1558 Technical (Hospital) Services GI Pcr Panel 12-25 Targets PX-3068750700 CDM 87507 CPT 306 RC inpatient 1640 1640 HEALTHPARTNERS SX009 HEALTHPARTNERS 1298.55 percent of total billed charges 1016.8 1558 Technical (Hospital) Services GI Pcr Panel 12-25 Targets PX-3068750700 CDM 87507 CPT 306 RC inpatient 1640 1640 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES PPO [308136801] 1298.55 percent of total billed charges 1016.8 1558 Technical (Hospital) Services GI Pcr Panel 12-25 Targets PX-3068750700 CDM 87507 CPT 306 RC inpatient 1640 1640 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES HDHP [308136802] 1298.55 percent of total billed charges 1016.8 1558 Technical (Hospital) Services GI Pcr Panel 12-25 Targets PX-3068750700 CDM 87507 CPT 306 RC inpatient 1640 1640 UNITED HEALTHCARE (COMMERCIAL) [3081199] UNITED HEALTHCARE 87726 [308119901] 1016.8 percent of total billed charges 1016.8 1558 Technical (Hospital) Services GI Pcr Panel 12-25 Targets PX-3068750700 CDM 87507 CPT 306 RC inpatient 1640 1640 MEDICA (COMMERCIAL) 94265 [3081118] MEDICA CLAIMS [308111801] 1476 percent of total billed charges 1016.8 1558 Technical (Hospital) Services GI Pcr Panel 12-25 Targets PX-3068750700 CDM 87507 CPT 306 RC outpatient 1640 1640 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES HDHP [308136802] 1312 percent of total billed charges 1016.8 1558 Technical (Hospital) Services GI Pcr Panel 12-25 Targets PX-3068750700 CDM 87507 CPT 306 RC outpatient 1640 1640 BLUE CROSS BLUE SHIELD WELLMARK SB889 [3081026] BCBS WYOMING [308102603] 1558 percent of total billed charges 1016.8 1558 Technical (Hospital) Services "Influenza a/B, Molecular Detection" PX-3068750200 CDM 87502 CPT 306 RC inpatient 334 334 MULTIPLAN INC 34080 [3081285] MULTIPLAN INC [308128501] 317.3 percent of total billed charges 207.08 317.3 Technical (Hospital) Services "Influenza a/B, Molecular Detection" PX-3068750200 CDM 87502 CPT 306 RC inpatient 334 334 CIGNA 62308 [3081051] CIGNA 62308 [308105105] 264.46 percent of total billed charges 207.08 317.3 Technical (Hospital) Services "Influenza a/B, Molecular Detection" PX-3068750200 CDM 87502 CPT 306 RC inpatient 334 334 CIGNA 62308 [3081051] CIGNA STATE OF WYOMING [308105107] 264.46 percent of total billed charges 207.08 317.3 Technical (Hospital) Services "Influenza a/B, Molecular Detection" PX-3068750200 CDM 87502 CPT 306 RC inpatient 334 334 BLUE CROSS BLUE SHIELD WELLMARK SB889 [3081026] BCBS WYOMING [308102603] 317.3 percent of total billed charges 207.08 317.3 Technical (Hospital) Services "Influenza a/B, Molecular Detection" PX-3068750200 CDM 87502 CPT 306 RC inpatient 334 334 HEALTHPARTNERS SX009 HEALTHPARTNERS 264.46 percent of total billed charges 207.08 317.3 Technical (Hospital) Services "Influenza a/B, Molecular Detection" PX-3068750200 CDM 87502 CPT 306 RC inpatient 334 334 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES EPO [308136803] 264.46 percent of total billed charges 207.08 317.3 Technical (Hospital) Services "Influenza a/B, Molecular Detection" PX-3068750200 CDM 87502 CPT 306 RC inpatient 334 334 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES HDHP [308136802] 264.46 percent of total billed charges 207.08 317.3 Technical (Hospital) Services "Influenza a/B, Molecular Detection" PX-3068750200 CDM 87502 CPT 306 RC inpatient 334 334 UNITED HEALTHCARE (COMMERCIAL) [3081199] UNITED HEALTHCARE 87726 [308119901] 207.08 percent of total billed charges 207.08 317.3 Technical (Hospital) Services "Influenza a/B, Molecular Detection" PX-3068750200 CDM 87502 CPT 306 RC inpatient 334 334 MEDICA (COMMERCIAL) 94265 [3081118] MEDICA CLAIMS [308111801] 300.6 percent of total billed charges 207.08 317.3 Technical (Hospital) Services "Influenza a/B, Molecular Detection" PX-3068750200 CDM 87502 CPT 306 RC inpatient 334 334 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES PPO [308136801] 264.46 percent of total billed charges 207.08 317.3 Technical (Hospital) Services "Influenza a/B, Molecular Detection" PX-3068750200 CDM 87502 CPT 306 RC outpatient 334 334 MEDICA (COMMERCIAL) 94265 [3081118] MEDICA CLAIMS [308111801] 300.6 percent of total billed charges 207.08 317.3 Technical (Hospital) Services "Influenza a/B, Molecular Detection" PX-3068750200 CDM 87502 CPT 306 RC outpatient 334 334 UNITED HEALTHCARE (COMMERCIAL) [3081199] UNITED HEALTHCARE 87726 [308119901] 207.08 percent of total billed charges 207.08 317.3 Technical (Hospital) Services "Influenza a/B, Molecular Detection" PX-3068750200 CDM 87502 CPT 306 RC outpatient 334 334 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES PPO [308136801] 267.2 percent of total billed charges 207.08 317.3 Technical (Hospital) Services "Influenza a/B, Molecular Detection" PX-3068750200 CDM 87502 CPT 306 RC outpatient 334 334 HEALTHPARTNERS SX009 HEALTHPARTNERS 267.2 percent of total billed charges 207.08 317.3 Technical (Hospital) Services "Influenza a/B, Molecular Detection" PX-3068750200 CDM 87502 CPT 306 RC outpatient 334 334 CIGNA 62308 [3081051] CIGNA 62308 [308105105] 267.2 percent of total billed charges 207.08 317.3 Technical (Hospital) Services "Influenza a/B, Molecular Detection" PX-3068750200 CDM 87502 CPT 306 RC outpatient 334 334 CIGNA 62308 [3081051] CIGNA STATE OF WYOMING [308105107] 267.2 percent of total billed charges 207.08 317.3 Technical (Hospital) Services "Influenza a/B, Molecular Detection" PX-3068750200 CDM 87502 CPT 306 RC outpatient 334 334 MULTIPLAN INC 34080 [3081285] MULTIPLAN INC [308128501] 317.3 percent of total billed charges 207.08 317.3 Technical (Hospital) Services "Influenza a/B, Molecular Detection" PX-3068750200 CDM 87502 CPT 306 RC outpatient 334 334 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES EPO [308136803] 267.2 percent of total billed charges 207.08 317.3 Technical (Hospital) Services "Influenza a/B, Molecular Detection" PX-3068750200 CDM 87502 CPT 306 RC outpatient 334 334 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES HDHP [308136802] 267.2 percent of total billed charges 207.08 317.3 Technical (Hospital) Services "Influenza a/B, Molecular Detection" PX-3068750200 CDM 87502 CPT 306 RC outpatient 334 334 BLUE CROSS BLUE SHIELD WELLMARK SB889 [3081026] BCBS WYOMING [308102603] 317.3 percent of total billed charges 207.08 317.3 Technical (Hospital) Services Enterovirus Pcr CSF PX-3068749800 CDM 87498 CPT 306 RC inpatient 506 506 HEALTHPARTNERS SX009 HEALTHPARTNERS 400.65 percent of total billed charges 313.72 480.7 Technical (Hospital) Services Enterovirus Pcr CSF PX-3068749800 CDM 87498 CPT 306 RC inpatient 506 506 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES EPO [308136803] 400.65 percent of total billed charges 313.72 480.7 Technical (Hospital) Services Enterovirus Pcr CSF PX-3068749800 CDM 87498 CPT 306 RC inpatient 506 506 BLUE CROSS BLUE SHIELD WELLMARK SB889 [3081026] BCBS WYOMING [308102603] 480.7 percent of total billed charges 313.72 480.7 Technical (Hospital) Services Enterovirus Pcr CSF PX-3068749800 CDM 87498 CPT 306 RC inpatient 506 506 CIGNA 62308 [3081051] CIGNA 62308 [308105105] 400.65 percent of total billed charges 313.72 480.7 Technical (Hospital) Services Enterovirus Pcr CSF PX-3068749800 CDM 87498 CPT 306 RC inpatient 506 506 CIGNA 62308 [3081051] CIGNA STATE OF WYOMING [308105107] 400.65 percent of total billed charges 313.72 480.7 Technical (Hospital) Services Enterovirus Pcr CSF PX-3068749800 CDM 87498 CPT 306 RC inpatient 506 506 MULTIPLAN INC 34080 [3081285] MULTIPLAN INC [308128501] 480.7 percent of total billed charges 313.72 480.7 Technical (Hospital) Services Enterovirus Pcr CSF PX-3068749800 CDM 87498 CPT 306 RC inpatient 506 506 UNITED HEALTHCARE (COMMERCIAL) [3081199] UNITED HEALTHCARE 87726 [308119901] 313.72 percent of total billed charges 313.72 480.7 Technical (Hospital) Services Enterovirus Pcr CSF PX-3068749800 CDM 87498 CPT 306 RC inpatient 506 506 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES HDHP [308136802] 400.65 percent of total billed charges 313.72 480.7 Technical (Hospital) Services Enterovirus Pcr CSF PX-3068749800 CDM 87498 CPT 306 RC inpatient 506 506 MEDICA (COMMERCIAL) 94265 [3081118] MEDICA CLAIMS [308111801] 455.4 percent of total billed charges 313.72 480.7 Technical (Hospital) Services Enterovirus Pcr CSF PX-3068749800 CDM 87498 CPT 306 RC inpatient 506 506 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES PPO [308136801] 400.65 percent of total billed charges 313.72 480.7 Technical (Hospital) Services Enterovirus Pcr CSF PX-3068749800 CDM 87498 CPT 306 RC outpatient 506 506 MEDICA (COMMERCIAL) 94265 [3081118] MEDICA CLAIMS [308111801] 455.4 percent of total billed charges 313.72 480.7 Technical (Hospital) Services Enterovirus Pcr CSF PX-3068749800 CDM 87498 CPT 306 RC outpatient 506 506 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES PPO [308136801] 404.8 percent of total billed charges 313.72 480.7 Technical (Hospital) Services Enterovirus Pcr CSF PX-3068749800 CDM 87498 CPT 306 RC outpatient 506 506 HEALTHPARTNERS SX009 HEALTHPARTNERS 404.8 percent of total billed charges 313.72 480.7 Technical (Hospital) Services Enterovirus Pcr CSF PX-3068749800 CDM 87498 CPT 306 RC outpatient 506 506 UNITED HEALTHCARE (COMMERCIAL) [3081199] UNITED HEALTHCARE 87726 [308119901] 313.72 percent of total billed charges 313.72 480.7 Technical (Hospital) Services Enterovirus Pcr CSF PX-3068749800 CDM 87498 CPT 306 RC outpatient 506 506 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES HDHP [308136802] 404.8 percent of total billed charges 313.72 480.7 Technical (Hospital) Services Enterovirus Pcr CSF PX-3068749800 CDM 87498 CPT 306 RC outpatient 506 506 BLUE CROSS BLUE SHIELD WELLMARK SB889 [3081026] BCBS WYOMING [308102603] 480.7 percent of total billed charges 313.72 480.7 Technical (Hospital) Services Enterovirus Pcr CSF PX-3068749800 CDM 87498 CPT 306 RC outpatient 506 506 CIGNA 62308 [3081051] CIGNA 62308 [308105105] 404.8 percent of total billed charges 313.72 480.7 Technical (Hospital) Services Enterovirus Pcr CSF PX-3068749800 CDM 87498 CPT 306 RC outpatient 506 506 CIGNA 62308 [3081051] CIGNA STATE OF WYOMING [308105107] 404.8 percent of total billed charges 313.72 480.7 Technical (Hospital) Services Enterovirus Pcr CSF PX-3068749800 CDM 87498 CPT 306 RC outpatient 506 506 MULTIPLAN INC 34080 [3081285] MULTIPLAN INC [308128501] 480.7 percent of total billed charges 313.72 480.7 Technical (Hospital) Services Enterovirus Pcr CSF PX-3068749800 CDM 87498 CPT 306 RC outpatient 506 506 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES EPO [308136803] 404.8 percent of total billed charges 313.72 480.7 Technical (Hospital) Services "Ref Cytomeg, Dna, Quant" PX-3068749700 CDM 87497 CPT 306 RC outpatient 298 298 UNITED HEALTHCARE (COMMERCIAL) [3081199] UNITED HEALTHCARE 87726 [308119901] 184.76 percent of total billed charges 184.76 283.1 Technical (Hospital) Services "Ref Cytomeg, Dna, Quant" PX-3068749700 CDM 87497 CPT 306 RC outpatient 298 298 HEALTHPARTNERS SX009 HEALTHPARTNERS 238.4 percent of total billed charges 184.76 283.1 Technical (Hospital) Services "Ref Cytomeg, Dna, Quant" PX-3068749700 CDM 87497 CPT 306 RC outpatient 298 298 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES PPO [308136801] 238.4 percent of total billed charges 184.76 283.1 Technical (Hospital) Services "Ref Cytomeg, Dna, Quant" PX-3068749700 CDM 87497 CPT 306 RC outpatient 298 298 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES HDHP [308136802] 238.4 percent of total billed charges 184.76 283.1 Technical (Hospital) Services "Ref Cytomeg, Dna, Quant" PX-3068749700 CDM 87497 CPT 306 RC outpatient 298 298 CIGNA 62308 [3081051] CIGNA 62308 [308105105] 238.4 percent of total billed charges 184.76 283.1 Technical (Hospital) Services "Ref Cytomeg, Dna, Quant" PX-3068749700 CDM 87497 CPT 306 RC outpatient 298 298 CIGNA 62308 [3081051] CIGNA STATE OF WYOMING [308105107] 238.4 percent of total billed charges 184.76 283.1 Technical (Hospital) Services "Ref Cytomeg, Dna, Quant" PX-3068749700 CDM 87497 CPT 306 RC outpatient 298 298 MULTIPLAN INC 34080 [3081285] MULTIPLAN INC [308128501] 283.1 percent of total billed charges 184.76 283.1 Technical (Hospital) Services "Ref Cytomeg, Dna, Quant" PX-3068749700 CDM 87497 CPT 306 RC outpatient 298 298 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES EPO [308136803] 238.4 percent of total billed charges 184.76 283.1 Technical (Hospital) Services "Ref Cytomeg, Dna, Quant" PX-3068749700 CDM 87497 CPT 306 RC outpatient 298 298 BLUE CROSS BLUE SHIELD WELLMARK SB889 [3081026] BCBS WYOMING [308102603] 283.1 percent of total billed charges 184.76 283.1 Technical (Hospital) Services "Ref Cytomeg, Dna, Quant" PX-3068749700 CDM 87497 CPT 306 RC outpatient 298 298 MEDICA (COMMERCIAL) 94265 [3081118] MEDICA CLAIMS [308111801] 268.2 percent of total billed charges 184.76 283.1 Technical (Hospital) Services "Ref Cytomeg, Dna, Quant" PX-3068749700 CDM 87497 CPT 306 RC inpatient 298 298 CIGNA 62308 [3081051] CIGNA 62308 [308105105] 235.96 percent of total billed charges 184.76 283.1 Technical (Hospital) Services "Ref Cytomeg, Dna, Quant" PX-3068749700 CDM 87497 CPT 306 RC inpatient 298 298 BLUE CROSS BLUE SHIELD WELLMARK SB889 [3081026] BCBS WYOMING [308102603] 283.1 percent of total billed charges 184.76 283.1 Technical (Hospital) Services "Ref Cytomeg, Dna, Quant" PX-3068749700 CDM 87497 CPT 306 RC inpatient 298 298 MULTIPLAN INC 34080 [3081285] MULTIPLAN INC [308128501] 283.1 percent of total billed charges 184.76 283.1 Technical (Hospital) Services "Ref Cytomeg, Dna, Quant" PX-3068749700 CDM 87497 CPT 306 RC inpatient 298 298 CIGNA 62308 [3081051] CIGNA STATE OF WYOMING [308105107] 235.96 percent of total billed charges 184.76 283.1 Technical (Hospital) Services "Ref Cytomeg, Dna, Quant" PX-3068749700 CDM 87497 CPT 306 RC inpatient 298 298 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES EPO [308136803] 235.96 percent of total billed charges 184.76 283.1 Technical (Hospital) Services "Ref Cytomeg, Dna, Quant" PX-3068749700 CDM 87497 CPT 306 RC inpatient 298 298 HEALTHPARTNERS SX009 HEALTHPARTNERS 235.96 percent of total billed charges 184.76 283.1 Technical (Hospital) Services "Ref Cytomeg, Dna, Quant" PX-3068749700 CDM 87497 CPT 306 RC inpatient 298 298 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES HDHP [308136802] 235.96 percent of total billed charges 184.76 283.1 Technical (Hospital) Services "Ref Cytomeg, Dna, Quant" PX-3068749700 CDM 87497 CPT 306 RC inpatient 298 298 UNITED HEALTHCARE (COMMERCIAL) [3081199] UNITED HEALTHCARE 87726 [308119901] 184.76 percent of total billed charges 184.76 283.1 Technical (Hospital) Services "Ref Cytomeg, Dna, Quant" PX-3068749700 CDM 87497 CPT 306 RC inpatient 298 298 MEDICA (COMMERCIAL) 94265 [3081118] MEDICA CLAIMS [308111801] 268.2 percent of total billed charges 184.76 283.1 Technical (Hospital) Services "Ref Cytomeg, Dna, Quant" PX-3068749700 CDM 87497 CPT 306 RC inpatient 298 298 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES PPO [308136801] 235.96 percent of total billed charges 184.76 283.1 Technical (Hospital) Services Ref Cmv Dna Quan by Rapid Pcr PX-3068749701 CDM 87497 CPT 306 RC inpatient 298 298 BLUE CROSS BLUE SHIELD WELLMARK SB889 [3081026] BCBS WYOMING [308102603] 283.1 percent of total billed charges 184.76 283.1 Technical (Hospital) Services Ref Cmv Dna Quan by Rapid Pcr PX-3068749701 CDM 87497 CPT 306 RC inpatient 298 298 CIGNA 62308 [3081051] CIGNA 62308 [308105105] 235.96 percent of total billed charges 184.76 283.1 Technical (Hospital) Services Ref Cmv Dna Quan by Rapid Pcr PX-3068749701 CDM 87497 CPT 306 RC inpatient 298 298 CIGNA 62308 [3081051] CIGNA STATE OF WYOMING [308105107] 235.96 percent of total billed charges 184.76 283.1 Technical (Hospital) Services Ref Cmv Dna Quan by Rapid Pcr PX-3068749701 CDM 87497 CPT 306 RC inpatient 298 298 MULTIPLAN INC 34080 [3081285] MULTIPLAN INC [308128501] 283.1 percent of total billed charges 184.76 283.1 Technical (Hospital) Services Ref Cmv Dna Quan by Rapid Pcr PX-3068749701 CDM 87497 CPT 306 RC inpatient 298 298 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES EPO [308136803] 235.96 percent of total billed charges 184.76 283.1 Technical (Hospital) Services Ref Cmv Dna Quan by Rapid Pcr PX-3068749701 CDM 87497 CPT 306 RC inpatient 298 298 HEALTHPARTNERS SX009 HEALTHPARTNERS 235.96 percent of total billed charges 184.76 283.1 Technical (Hospital) Services Ref Cmv Dna Quan by Rapid Pcr PX-3068749701 CDM 87497 CPT 306 RC inpatient 298 298 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES PPO [308136801] 235.96 percent of total billed charges 184.76 283.1 Technical (Hospital) Services Ref Cmv Dna Quan by Rapid Pcr PX-3068749701 CDM 87497 CPT 306 RC inpatient 298 298 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES HDHP [308136802] 235.96 percent of total billed charges 184.76 283.1 Technical (Hospital) Services Ref Cmv Dna Quan by Rapid Pcr PX-3068749701 CDM 87497 CPT 306 RC inpatient 298 298 UNITED HEALTHCARE (COMMERCIAL) [3081199] UNITED HEALTHCARE 87726 [308119901] 184.76 percent of total billed charges 184.76 283.1 Technical (Hospital) Services Ref Cmv Dna Quan by Rapid Pcr PX-3068749701 CDM 87497 CPT 306 RC inpatient 298 298 MEDICA (COMMERCIAL) 94265 [3081118] MEDICA CLAIMS [308111801] 268.2 percent of total billed charges 184.76 283.1 Technical (Hospital) Services Ref Cmv Dna Quan by Rapid Pcr PX-3068749701 CDM 87497 CPT 306 RC outpatient 298 298 HEALTHPARTNERS SX009 HEALTHPARTNERS 238.4 percent of total billed charges 184.76 283.1 Technical (Hospital) Services Ref Cmv Dna Quan by Rapid Pcr PX-3068749701 CDM 87497 CPT 306 RC outpatient 298 298 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES PPO [308136801] 238.4 percent of total billed charges 184.76 283.1 Technical (Hospital) Services Ref Cmv Dna Quan by Rapid Pcr PX-3068749701 CDM 87497 CPT 306 RC outpatient 298 298 MEDICA (COMMERCIAL) 94265 [3081118] MEDICA CLAIMS [308111801] 268.2 percent of total billed charges 184.76 283.1 Technical (Hospital) Services Ref Cmv Dna Quan by Rapid Pcr PX-3068749701 CDM 87497 CPT 306 RC outpatient 298 298 UNITED HEALTHCARE (COMMERCIAL) [3081199] UNITED HEALTHCARE 87726 [308119901] 184.76 percent of total billed charges 184.76 283.1 Technical (Hospital) Services Ref Cmv Dna Quan by Rapid Pcr PX-3068749701 CDM 87497 CPT 306 RC outpatient 298 298 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES EPO [308136803] 238.4 percent of total billed charges 184.76 283.1 Technical (Hospital) Services Ref Cmv Dna Quan by Rapid Pcr PX-3068749701 CDM 87497 CPT 306 RC outpatient 298 298 MULTIPLAN INC 34080 [3081285] MULTIPLAN INC [308128501] 283.1 percent of total billed charges 184.76 283.1 Technical (Hospital) Services Ref Cmv Dna Quan by Rapid Pcr PX-3068749701 CDM 87497 CPT 306 RC outpatient 298 298 CIGNA 62308 [3081051] CIGNA 62308 [308105105] 238.4 percent of total billed charges 184.76 283.1 Technical (Hospital) Services Ref Cmv Dna Quan by Rapid Pcr PX-3068749701 CDM 87497 CPT 306 RC outpatient 298 298 CIGNA 62308 [3081051] CIGNA STATE OF WYOMING [308105107] 238.4 percent of total billed charges 184.76 283.1 Technical (Hospital) Services Ref Cmv Dna Quan by Rapid Pcr PX-3068749701 CDM 87497 CPT 306 RC outpatient 298 298 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES HDHP [308136802] 238.4 percent of total billed charges 184.76 283.1 Technical (Hospital) Services Ref Cmv Dna Quan by Rapid Pcr PX-3068749701 CDM 87497 CPT 306 RC outpatient 298 298 BLUE CROSS BLUE SHIELD WELLMARK SB889 [3081026] BCBS WYOMING [308102603] 283.1 percent of total billed charges 184.76 283.1 Technical (Hospital) Services C Diff Amplified Probe PX-3068749300 CDM 87493 CPT 306 RC outpatient 217 217 UNITED HEALTHCARE (COMMERCIAL) [3081199] UNITED HEALTHCARE 87726 [308119901] 134.54 percent of total billed charges 134.54 206.15 Technical (Hospital) Services C Diff Amplified Probe PX-3068749300 CDM 87493 CPT 306 RC outpatient 217 217 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES HDHP [308136802] 173.6 percent of total billed charges 134.54 206.15 Technical (Hospital) Services C Diff Amplified Probe PX-3068749300 CDM 87493 CPT 306 RC outpatient 217 217 BLUE CROSS BLUE SHIELD WELLMARK SB889 [3081026] BCBS WYOMING [308102603] 206.15 percent of total billed charges 134.54 206.15 Technical (Hospital) Services C Diff Amplified Probe PX-3068749300 CDM 87493 CPT 306 RC outpatient 217 217 CIGNA 62308 [3081051] CIGNA 62308 [308105105] 173.6 percent of total billed charges 134.54 206.15 Technical (Hospital) Services C Diff Amplified Probe PX-3068749300 CDM 87493 CPT 306 RC outpatient 217 217 CIGNA 62308 [3081051] CIGNA STATE OF WYOMING [308105107] 173.6 percent of total billed charges 134.54 206.15 Technical (Hospital) Services C Diff Amplified Probe PX-3068749300 CDM 87493 CPT 306 RC outpatient 217 217 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES EPO [308136803] 173.6 percent of total billed charges 134.54 206.15 Technical (Hospital) Services C Diff Amplified Probe PX-3068749300 CDM 87493 CPT 306 RC outpatient 217 217 MULTIPLAN INC 34080 [3081285] MULTIPLAN INC [308128501] 206.15 percent of total billed charges 134.54 206.15 Technical (Hospital) Services C Diff Amplified Probe PX-3068749300 CDM 87493 CPT 306 RC outpatient 217 217 MEDICA (COMMERCIAL) 94265 [3081118] MEDICA CLAIMS [308111801] 195.3 percent of total billed charges 134.54 206.15 Technical (Hospital) Services C Diff Amplified Probe PX-3068749300 CDM 87493 CPT 306 RC outpatient 217 217 HEALTHPARTNERS SX009 HEALTHPARTNERS 173.6 percent of total billed charges 134.54 206.15 Technical (Hospital) Services C Diff Amplified Probe PX-3068749300 CDM 87493 CPT 306 RC outpatient 217 217 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES PPO [308136801] 173.6 percent of total billed charges 134.54 206.15 Technical (Hospital) Services C Diff Amplified Probe PX-3068749300 CDM 87493 CPT 306 RC inpatient 217 217 HEALTHPARTNERS SX009 HEALTHPARTNERS 171.82 percent of total billed charges 134.54 206.15 Technical (Hospital) Services C Diff Amplified Probe PX-3068749300 CDM 87493 CPT 306 RC inpatient 217 217 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES EPO [308136803] 171.82 percent of total billed charges 134.54 206.15 Technical (Hospital) Services C Diff Amplified Probe PX-3068749300 CDM 87493 CPT 306 RC inpatient 217 217 MULTIPLAN INC 34080 [3081285] MULTIPLAN INC [308128501] 206.15 percent of total billed charges 134.54 206.15 Technical (Hospital) Services C Diff Amplified Probe PX-3068749300 CDM 87493 CPT 306 RC inpatient 217 217 BLUE CROSS BLUE SHIELD WELLMARK SB889 [3081026] BCBS WYOMING [308102603] 206.15 percent of total billed charges 134.54 206.15 Technical (Hospital) Services C Diff Amplified Probe PX-3068749300 CDM 87493 CPT 306 RC inpatient 217 217 CIGNA 62308 [3081051] CIGNA 62308 [308105105] 171.82 percent of total billed charges 134.54 206.15 Technical (Hospital) Services C Diff Amplified Probe PX-3068749300 CDM 87493 CPT 306 RC inpatient 217 217 CIGNA 62308 [3081051] CIGNA STATE OF WYOMING [308105107] 171.82 percent of total billed charges 134.54 206.15 Technical (Hospital) Services C Diff Amplified Probe PX-3068749300 CDM 87493 CPT 306 RC inpatient 217 217 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES PPO [308136801] 171.82 percent of total billed charges 134.54 206.15 Technical (Hospital) Services C Diff Amplified Probe PX-3068749300 CDM 87493 CPT 306 RC inpatient 217 217 MEDICA (COMMERCIAL) 94265 [3081118] MEDICA CLAIMS [308111801] 195.3 percent of total billed charges 134.54 206.15 Technical (Hospital) Services C Diff Amplified Probe PX-3068749300 CDM 87493 CPT 306 RC inpatient 217 217 UNITED HEALTHCARE (COMMERCIAL) [3081199] UNITED HEALTHCARE 87726 [308119901] 134.54 percent of total billed charges 134.54 206.15 Technical (Hospital) Services C Diff Amplified Probe PX-3068749300 CDM 87493 CPT 306 RC inpatient 217 217 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES HDHP [308136802] 171.82 percent of total billed charges 134.54 206.15 Technical (Hospital) Services Ref Chlamydia Trachomatis-Amplified Prob PX-3068749100 CDM 87491 CPT 306 RC inpatient 218 218 HEALTHPARTNERS SX009 HEALTHPARTNERS 172.61 percent of total billed charges 135.16 207.1 Technical (Hospital) Services Ref Chlamydia Trachomatis-Amplified Prob PX-3068749100 CDM 87491 CPT 306 RC inpatient 218 218 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES EPO [308136803] 172.61 percent of total billed charges 135.16 207.1 Technical (Hospital) Services Ref Chlamydia Trachomatis-Amplified Prob PX-3068749100 CDM 87491 CPT 306 RC inpatient 218 218 MULTIPLAN INC 34080 [3081285] MULTIPLAN INC [308128501] 207.1 percent of total billed charges 135.16 207.1 Technical (Hospital) Services Ref Chlamydia Trachomatis-Amplified Prob PX-3068749100 CDM 87491 CPT 306 RC inpatient 218 218 BLUE CROSS BLUE SHIELD WELLMARK SB889 [3081026] BCBS WYOMING [308102603] 207.1 percent of total billed charges 135.16 207.1 Technical (Hospital) Services Ref Chlamydia Trachomatis-Amplified Prob PX-3068749100 CDM 87491 CPT 306 RC inpatient 218 218 CIGNA 62308 [3081051] CIGNA 62308 [308105105] 172.61 percent of total billed charges 135.16 207.1 Technical (Hospital) Services Ref Chlamydia Trachomatis-Amplified Prob PX-3068749100 CDM 87491 CPT 306 RC inpatient 218 218 CIGNA 62308 [3081051] CIGNA STATE OF WYOMING [308105107] 172.61 percent of total billed charges 135.16 207.1 Technical (Hospital) Services Ref Chlamydia Trachomatis-Amplified Prob PX-3068749100 CDM 87491 CPT 306 RC inpatient 218 218 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES PPO [308136801] 172.61 percent of total billed charges 135.16 207.1 Technical (Hospital) Services Ref Chlamydia Trachomatis-Amplified Prob PX-3068749100 CDM 87491 CPT 306 RC inpatient 218 218 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES HDHP [308136802] 172.61 percent of total billed charges 135.16 207.1 Technical (Hospital) Services Ref Chlamydia Trachomatis-Amplified Prob PX-3068749100 CDM 87491 CPT 306 RC inpatient 218 218 UNITED HEALTHCARE (COMMERCIAL) [3081199] UNITED HEALTHCARE 87726 [308119901] 135.16 percent of total billed charges 135.16 207.1 Technical (Hospital) Services Ref Chlamydia Trachomatis-Amplified Prob PX-3068749100 CDM 87491 CPT 306 RC inpatient 218 218 MEDICA (COMMERCIAL) 94265 [3081118] MEDICA CLAIMS [308111801] 196.2 percent of total billed charges 135.16 207.1 Technical (Hospital) Services Ref Chlamydia Trachomatis-Amplified Prob PX-3068749100 CDM 87491 CPT 306 RC outpatient 218 218 UNITED HEALTHCARE (COMMERCIAL) [3081199] UNITED HEALTHCARE 87726 [308119901] 135.16 percent of total billed charges 135.16 207.1 Technical (Hospital) Services Ref Chlamydia Trachomatis-Amplified Prob PX-3068749100 CDM 87491 CPT 306 RC outpatient 218 218 BLUE CROSS BLUE SHIELD WELLMARK SB889 [3081026] BCBS WYOMING [308102603] 207.1 percent of total billed charges 135.16 207.1 Technical (Hospital) Services Ref Chlamydia Trachomatis-Amplified Prob PX-3068749100 CDM 87491 CPT 306 RC outpatient 218 218 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES HDHP [308136802] 174.4 percent of total billed charges 135.16 207.1 Technical (Hospital) Services Ref Chlamydia Trachomatis-Amplified Prob PX-3068749100 CDM 87491 CPT 306 RC outpatient 218 218 MULTIPLAN INC 34080 [3081285] MULTIPLAN INC [308128501] 207.1 percent of total billed charges 135.16 207.1 Technical (Hospital) Services Ref Chlamydia Trachomatis-Amplified Prob PX-3068749100 CDM 87491 CPT 306 RC outpatient 218 218 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES EPO [308136803] 174.4 percent of total billed charges 135.16 207.1 Technical (Hospital) Services Ref Chlamydia Trachomatis-Amplified Prob PX-3068749100 CDM 87491 CPT 306 RC outpatient 218 218 CIGNA 62308 [3081051] CIGNA 62308 [308105105] 174.4 percent of total billed charges 135.16 207.1 Technical (Hospital) Services Ref Chlamydia Trachomatis-Amplified Prob PX-3068749100 CDM 87491 CPT 306 RC outpatient 218 218 CIGNA 62308 [3081051] CIGNA STATE OF WYOMING [308105107] 174.4 percent of total billed charges 135.16 207.1 Technical (Hospital) Services Ref Chlamydia Trachomatis-Amplified Prob PX-3068749100 CDM 87491 CPT 306 RC outpatient 218 218 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES PPO [308136801] 174.4 percent of total billed charges 135.16 207.1 Technical (Hospital) Services Ref Chlamydia Trachomatis-Amplified Prob PX-3068749100 CDM 87491 CPT 306 RC outpatient 218 218 HEALTHPARTNERS SX009 HEALTHPARTNERS 174.4 percent of total billed charges 135.16 207.1 Technical (Hospital) Services Ref Chlamydia Trachomatis-Amplified Prob PX-3068749100 CDM 87491 CPT 306 RC outpatient 218 218 MEDICA (COMMERCIAL) 94265 [3081118] MEDICA CLAIMS [308111801] 196.2 percent of total billed charges 135.16 207.1 Technical (Hospital) Services C Trachomatis Apmlified Probe PX-3068749103 CDM 87491 CPT 306 RC inpatient 218 218 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES EPO [308136803] 172.61 percent of total billed charges 135.16 207.1 Technical (Hospital) Services C Trachomatis Apmlified Probe PX-3068749103 CDM 87491 CPT 306 RC inpatient 218 218 HEALTHPARTNERS SX009 HEALTHPARTNERS 172.61 percent of total billed charges 135.16 207.1 Technical (Hospital) Services C Trachomatis Apmlified Probe PX-3068749103 CDM 87491 CPT 306 RC inpatient 218 218 MULTIPLAN INC 34080 [3081285] MULTIPLAN INC [308128501] 207.1 percent of total billed charges 135.16 207.1 Technical (Hospital) Services C Trachomatis Apmlified Probe PX-3068749103 CDM 87491 CPT 306 RC inpatient 218 218 BLUE CROSS BLUE SHIELD WELLMARK SB889 [3081026] BCBS WYOMING [308102603] 207.1 percent of total billed charges 135.16 207.1 Technical (Hospital) Services C Trachomatis Apmlified Probe PX-3068749103 CDM 87491 CPT 306 RC inpatient 218 218 CIGNA 62308 [3081051] CIGNA STATE OF WYOMING [308105107] 172.61 percent of total billed charges 135.16 207.1 Technical (Hospital) Services C Trachomatis Apmlified Probe PX-3068749103 CDM 87491 CPT 306 RC inpatient 218 218 CIGNA 62308 [3081051] CIGNA 62308 [308105105] 172.61 percent of total billed charges 135.16 207.1 Technical (Hospital) Services C Trachomatis Apmlified Probe PX-3068749103 CDM 87491 CPT 306 RC inpatient 218 218 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES PPO [308136801] 172.61 percent of total billed charges 135.16 207.1 Technical (Hospital) Services C Trachomatis Apmlified Probe PX-3068749103 CDM 87491 CPT 306 RC inpatient 218 218 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES HDHP [308136802] 172.61 percent of total billed charges 135.16 207.1 Technical (Hospital) Services C Trachomatis Apmlified Probe PX-3068749103 CDM 87491 CPT 306 RC inpatient 218 218 MEDICA (COMMERCIAL) 94265 [3081118] MEDICA CLAIMS [308111801] 196.2 percent of total billed charges 135.16 207.1 Technical (Hospital) Services C Trachomatis Apmlified Probe PX-3068749103 CDM 87491 CPT 306 RC inpatient 218 218 UNITED HEALTHCARE (COMMERCIAL) [3081199] UNITED HEALTHCARE 87726 [308119901] 135.16 percent of total billed charges 135.16 207.1 Technical (Hospital) Services C Trachomatis Apmlified Probe PX-3068749103 CDM 87491 CPT 306 RC outpatient 218 218 UNITED HEALTHCARE (COMMERCIAL) [3081199] UNITED HEALTHCARE 87726 [308119901] 135.16 percent of total billed charges 135.16 207.1 Technical (Hospital) Services C Trachomatis Apmlified Probe PX-3068749103 CDM 87491 CPT 306 RC outpatient 218 218 BLUE CROSS BLUE SHIELD WELLMARK SB889 [3081026] BCBS WYOMING [308102603] 207.1 percent of total billed charges 135.16 207.1 Technical (Hospital) Services C Trachomatis Apmlified Probe PX-3068749103 CDM 87491 CPT 306 RC outpatient 218 218 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES HDHP [308136802] 174.4 percent of total billed charges 135.16 207.1 Technical (Hospital) Services C Trachomatis Apmlified Probe PX-3068749103 CDM 87491 CPT 306 RC outpatient 218 218 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES EPO [308136803] 174.4 percent of total billed charges 135.16 207.1 Technical (Hospital) Services C Trachomatis Apmlified Probe PX-3068749103 CDM 87491 CPT 306 RC outpatient 218 218 MULTIPLAN INC 34080 [3081285] MULTIPLAN INC [308128501] 207.1 percent of total billed charges 135.16 207.1 Technical (Hospital) Services C Trachomatis Apmlified Probe PX-3068749103 CDM 87491 CPT 306 RC outpatient 218 218 CIGNA 62308 [3081051] CIGNA 62308 [308105105] 174.4 percent of total billed charges 135.16 207.1 Technical (Hospital) Services C Trachomatis Apmlified Probe PX-3068749103 CDM 87491 CPT 306 RC outpatient 218 218 CIGNA 62308 [3081051] CIGNA STATE OF WYOMING [308105107] 174.4 percent of total billed charges 135.16 207.1 Technical (Hospital) Services C Trachomatis Apmlified Probe PX-3068749103 CDM 87491 CPT 306 RC outpatient 218 218 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES PPO [308136801] 174.4 percent of total billed charges 135.16 207.1 Technical (Hospital) Services C Trachomatis Apmlified Probe PX-3068749103 CDM 87491 CPT 306 RC outpatient 218 218 HEALTHPARTNERS SX009 HEALTHPARTNERS 174.4 percent of total billed charges 135.16 207.1 Technical (Hospital) Services C Trachomatis Apmlified Probe PX-3068749103 CDM 87491 CPT 306 RC outpatient 218 218 MEDICA (COMMERCIAL) 94265 [3081118] MEDICA CLAIMS [308111801] 196.2 percent of total billed charges 135.16 207.1 Technical (Hospital) Services C Pneumoniae by Pcr PX-3068748600 CDM 87486 CPT 306 RC inpatient 126 126 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES EPO [308136803] 99.77 percent of total billed charges 78.12 119.7 Technical (Hospital) Services C Pneumoniae by Pcr PX-3068748600 CDM 87486 CPT 306 RC inpatient 126 126 HEALTHPARTNERS SX009 HEALTHPARTNERS 99.77 percent of total billed charges 78.12 119.7 Technical (Hospital) Services C Pneumoniae by Pcr PX-3068748600 CDM 87486 CPT 306 RC inpatient 126 126 BLUE CROSS BLUE SHIELD WELLMARK SB889 [3081026] BCBS WYOMING [308102603] 119.7 percent of total billed charges 78.12 119.7 Technical (Hospital) Services C Pneumoniae by Pcr PX-3068748600 CDM 87486 CPT 306 RC inpatient 126 126 CIGNA 62308 [3081051] CIGNA 62308 [308105105] 99.77 percent of total billed charges 78.12 119.7 Technical (Hospital) Services C Pneumoniae by Pcr PX-3068748600 CDM 87486 CPT 306 RC inpatient 126 126 CIGNA 62308 [3081051] CIGNA STATE OF WYOMING [308105107] 99.77 percent of total billed charges 78.12 119.7 Technical (Hospital) Services C Pneumoniae by Pcr PX-3068748600 CDM 87486 CPT 306 RC inpatient 126 126 MULTIPLAN INC 34080 [3081285] MULTIPLAN INC [308128501] 119.7 percent of total billed charges 78.12 119.7 Technical (Hospital) Services C Pneumoniae by Pcr PX-3068748600 CDM 87486 CPT 306 RC inpatient 126 126 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES PPO [308136801] 99.77 percent of total billed charges 78.12 119.7 Technical (Hospital) Services C Pneumoniae by Pcr PX-3068748600 CDM 87486 CPT 306 RC inpatient 126 126 MEDICA (COMMERCIAL) 94265 [3081118] MEDICA CLAIMS [308111801] 113.4 percent of total billed charges 78.12 119.7 Technical (Hospital) Services C Pneumoniae by Pcr PX-3068748600 CDM 87486 CPT 306 RC inpatient 126 126 UNITED HEALTHCARE (COMMERCIAL) [3081199] UNITED HEALTHCARE 87726 [308119901] 78.12 percent of total billed charges 78.12 119.7 Technical (Hospital) Services C Pneumoniae by Pcr PX-3068748600 CDM 87486 CPT 306 RC inpatient 126 126 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES HDHP [308136802] 99.77 percent of total billed charges 78.12 119.7 Technical (Hospital) Services C Pneumoniae by Pcr PX-3068748600 CDM 87486 CPT 306 RC outpatient 126 126 UNITED HEALTHCARE (COMMERCIAL) [3081199] UNITED HEALTHCARE 87726 [308119901] 78.12 percent of total billed charges 78.12 119.7 Technical (Hospital) Services C Pneumoniae by Pcr PX-3068748600 CDM 87486 CPT 306 RC outpatient 126 126 HEALTHPARTNERS SX009 HEALTHPARTNERS 100.8 percent of total billed charges 78.12 119.7 Technical (Hospital) Services C Pneumoniae by Pcr PX-3068748600 CDM 87486 CPT 306 RC outpatient 126 126 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES PPO [308136801] 100.8 percent of total billed charges 78.12 119.7 Technical (Hospital) Services C Pneumoniae by Pcr PX-3068748600 CDM 87486 CPT 306 RC outpatient 126 126 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES HDHP [308136802] 100.8 percent of total billed charges 78.12 119.7 Technical (Hospital) Services C Pneumoniae by Pcr PX-3068748600 CDM 87486 CPT 306 RC outpatient 126 126 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES EPO [308136803] 100.8 percent of total billed charges 78.12 119.7 Technical (Hospital) Services C Pneumoniae by Pcr PX-3068748600 CDM 87486 CPT 306 RC outpatient 126 126 MULTIPLAN INC 34080 [3081285] MULTIPLAN INC [308128501] 119.7 percent of total billed charges 78.12 119.7 Technical (Hospital) Services C Pneumoniae by Pcr PX-3068748600 CDM 87486 CPT 306 RC outpatient 126 126 CIGNA 62308 [3081051] CIGNA 62308 [308105105] 100.8 percent of total billed charges 78.12 119.7 Technical (Hospital) Services C Pneumoniae by Pcr PX-3068748600 CDM 87486 CPT 306 RC outpatient 126 126 CIGNA 62308 [3081051] CIGNA STATE OF WYOMING [308105107] 100.8 percent of total billed charges 78.12 119.7 Technical (Hospital) Services C Pneumoniae by Pcr PX-3068748600 CDM 87486 CPT 306 RC outpatient 126 126 BLUE CROSS BLUE SHIELD WELLMARK SB889 [3081026] BCBS WYOMING [308102603] 119.7 percent of total billed charges 78.12 119.7 Technical (Hospital) Services C Pneumoniae by Pcr PX-3068748600 CDM 87486 CPT 306 RC outpatient 126 126 MEDICA (COMMERCIAL) 94265 [3081118] MEDICA CLAIMS [308111801] 113.4 percent of total billed charges 78.12 119.7 Technical (Hospital) Services Strep Pneumo Antigen Urine PX-3068744900 CDM 87449 CPT 306 RC inpatient 102 102 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES HDHP [308136802] 80.76 percent of total billed charges 63.24 96.9 Technical (Hospital) Services Strep Pneumo Antigen Urine PX-3068744900 CDM 87449 CPT 306 RC inpatient 102 102 UNITED HEALTHCARE (COMMERCIAL) [3081199] UNITED HEALTHCARE 87726 [308119901] 63.24 percent of total billed charges 63.24 96.9 Technical (Hospital) Services Strep Pneumo Antigen Urine PX-3068744900 CDM 87449 CPT 306 RC inpatient 102 102 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES PPO [308136801] 80.76 percent of total billed charges 63.24 96.9 Technical (Hospital) Services Strep Pneumo Antigen Urine PX-3068744900 CDM 87449 CPT 306 RC inpatient 102 102 BLUE CROSS BLUE SHIELD WELLMARK SB889 [3081026] BCBS WYOMING [308102603] 96.9 percent of total billed charges 63.24 96.9 Technical (Hospital) Services Strep Pneumo Antigen Urine PX-3068744900 CDM 87449 CPT 306 RC inpatient 102 102 CIGNA 62308 [3081051] CIGNA 62308 [308105105] 80.76 percent of total billed charges 63.24 96.9 Technical (Hospital) Services Strep Pneumo Antigen Urine PX-3068744900 CDM 87449 CPT 306 RC inpatient 102 102 CIGNA 62308 [3081051] CIGNA STATE OF WYOMING [308105107] 80.76 percent of total billed charges 63.24 96.9 Technical (Hospital) Services Strep Pneumo Antigen Urine PX-3068744900 CDM 87449 CPT 306 RC inpatient 102 102 MEDICA (COMMERCIAL) 94265 [3081118] MEDICA CLAIMS [308111801] 91.8 percent of total billed charges 63.24 96.9 Technical (Hospital) Services Strep Pneumo Antigen Urine PX-3068744900 CDM 87449 CPT 306 RC inpatient 102 102 MULTIPLAN INC 34080 [3081285] MULTIPLAN INC [308128501] 96.9 percent of total billed charges 63.24 96.9 Technical (Hospital) Services Strep Pneumo Antigen Urine PX-3068744900 CDM 87449 CPT 306 RC inpatient 102 102 HEALTHPARTNERS SX009 HEALTHPARTNERS 80.76 percent of total billed charges 63.24 96.9 Technical (Hospital) Services Strep Pneumo Antigen Urine PX-3068744900 CDM 87449 CPT 306 RC inpatient 102 102 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES EPO [308136803] 80.76 percent of total billed charges 63.24 96.9 Technical (Hospital) Services Strep Pneumo Antigen Urine PX-3068744900 CDM 87449 CPT 306 RC outpatient 102 102 MEDICA (COMMERCIAL) 94265 [3081118] MEDICA CLAIMS [308111801] 91.8 percent of total billed charges 63.24 96.9 Technical (Hospital) Services Strep Pneumo Antigen Urine PX-3068744900 CDM 87449 CPT 306 RC outpatient 102 102 UNITED HEALTHCARE (COMMERCIAL) [3081199] UNITED HEALTHCARE 87726 [308119901] 63.24 percent of total billed charges 63.24 96.9 Technical (Hospital) Services Strep Pneumo Antigen Urine PX-3068744900 CDM 87449 CPT 306 RC outpatient 102 102 HEALTHPARTNERS SX009 HEALTHPARTNERS 81.6 percent of total billed charges 63.24 96.9 Technical (Hospital) Services Strep Pneumo Antigen Urine PX-3068744900 CDM 87449 CPT 306 RC outpatient 102 102 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES PPO [308136801] 81.6 percent of total billed charges 63.24 96.9 Technical (Hospital) Services Strep Pneumo Antigen Urine PX-3068744900 CDM 87449 CPT 306 RC outpatient 102 102 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES EPO [308136803] 81.6 percent of total billed charges 63.24 96.9 Technical (Hospital) Services Strep Pneumo Antigen Urine PX-3068744900 CDM 87449 CPT 306 RC outpatient 102 102 CIGNA 62308 [3081051] CIGNA 62308 [308105105] 81.6 percent of total billed charges 63.24 96.9 Technical (Hospital) Services Strep Pneumo Antigen Urine PX-3068744900 CDM 87449 CPT 306 RC outpatient 102 102 CIGNA 62308 [3081051] CIGNA STATE OF WYOMING [308105107] 81.6 percent of total billed charges 63.24 96.9 Technical (Hospital) Services Strep Pneumo Antigen Urine PX-3068744900 CDM 87449 CPT 306 RC outpatient 102 102 MULTIPLAN INC 34080 [3081285] MULTIPLAN INC [308128501] 96.9 percent of total billed charges 63.24 96.9 Technical (Hospital) Services Strep Pneumo Antigen Urine PX-3068744900 CDM 87449 CPT 306 RC outpatient 102 102 BLUE CROSS BLUE SHIELD WELLMARK SB889 [3081026] BCBS WYOMING [308102603] 96.9 percent of total billed charges 63.24 96.9 Technical (Hospital) Services Strep Pneumo Antigen Urine PX-3068744900 CDM 87449 CPT 306 RC outpatient 102 102 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES HDHP [308136802] 81.6 percent of total billed charges 63.24 96.9 Technical (Hospital) Services Legionella Antigen Urine PX-3068744904 CDM 87449 CPT 306 RC inpatient 135 135 UNITED HEALTHCARE (COMMERCIAL) [3081199] UNITED HEALTHCARE 87726 [308119901] 83.7 percent of total billed charges 83.7 128.25 Technical (Hospital) Services Legionella Antigen Urine PX-3068744904 CDM 87449 CPT 306 RC inpatient 135 135 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES HDHP [308136802] 106.89 percent of total billed charges 83.7 128.25 Technical (Hospital) Services Legionella Antigen Urine PX-3068744904 CDM 87449 CPT 306 RC inpatient 135 135 MEDICA (COMMERCIAL) 94265 [3081118] MEDICA CLAIMS [308111801] 121.5 percent of total billed charges 83.7 128.25 Technical (Hospital) Services Legionella Antigen Urine PX-3068744904 CDM 87449 CPT 306 RC inpatient 135 135 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES PPO [308136801] 106.89 percent of total billed charges 83.7 128.25 Technical (Hospital) Services Legionella Antigen Urine PX-3068744904 CDM 87449 CPT 306 RC inpatient 135 135 HEALTHPARTNERS SX009 HEALTHPARTNERS 106.89 percent of total billed charges 83.7 128.25 Technical (Hospital) Services Legionella Antigen Urine PX-3068744904 CDM 87449 CPT 306 RC inpatient 135 135 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES EPO [308136803] 106.89 percent of total billed charges 83.7 128.25 Technical (Hospital) Services Legionella Antigen Urine PX-3068744904 CDM 87449 CPT 306 RC inpatient 135 135 MULTIPLAN INC 34080 [3081285] MULTIPLAN INC [308128501] 128.25 percent of total billed charges 83.7 128.25 Technical (Hospital) Services Legionella Antigen Urine PX-3068744904 CDM 87449 CPT 306 RC inpatient 135 135 BLUE CROSS BLUE SHIELD WELLMARK SB889 [3081026] BCBS WYOMING [308102603] 128.25 percent of total billed charges 83.7 128.25 Technical (Hospital) Services Legionella Antigen Urine PX-3068744904 CDM 87449 CPT 306 RC inpatient 135 135 CIGNA 62308 [3081051] CIGNA 62308 [308105105] 106.89 percent of total billed charges 83.7 128.25 Technical (Hospital) Services Legionella Antigen Urine PX-3068744904 CDM 87449 CPT 306 RC inpatient 135 135 CIGNA 62308 [3081051] CIGNA STATE OF WYOMING [308105107] 106.89 percent of total billed charges 83.7 128.25 Technical (Hospital) Services Legionella Antigen Urine PX-3068744904 CDM 87449 CPT 306 RC outpatient 135 135 MEDICA (COMMERCIAL) 94265 [3081118] MEDICA CLAIMS [308111801] 121.5 percent of total billed charges 83.7 128.25 Technical (Hospital) Services Legionella Antigen Urine PX-3068744904 CDM 87449 CPT 306 RC outpatient 135 135 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES PPO [308136801] 108 percent of total billed charges 83.7 128.25 Technical (Hospital) Services Legionella Antigen Urine PX-3068744904 CDM 87449 CPT 306 RC outpatient 135 135 HEALTHPARTNERS SX009 HEALTHPARTNERS 108 percent of total billed charges 83.7 128.25 Technical (Hospital) Services Legionella Antigen Urine PX-3068744904 CDM 87449 CPT 306 RC outpatient 135 135 UNITED HEALTHCARE (COMMERCIAL) [3081199] UNITED HEALTHCARE 87726 [308119901] 83.7 percent of total billed charges 83.7 128.25 Technical (Hospital) Services Legionella Antigen Urine PX-3068744904 CDM 87449 CPT 306 RC outpatient 135 135 BLUE CROSS BLUE SHIELD WELLMARK SB889 [3081026] BCBS WYOMING [308102603] 128.25 percent of total billed charges 83.7 128.25 Technical (Hospital) Services Legionella Antigen Urine PX-3068744904 CDM 87449 CPT 306 RC outpatient 135 135 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES HDHP [308136802] 108 percent of total billed charges 83.7 128.25 Technical (Hospital) Services Legionella Antigen Urine PX-3068744904 CDM 87449 CPT 306 RC outpatient 135 135 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES EPO [308136803] 108 percent of total billed charges 83.7 128.25 Technical (Hospital) Services Legionella Antigen Urine PX-3068744904 CDM 87449 CPT 306 RC outpatient 135 135 CIGNA 62308 [3081051] CIGNA 62308 [308105105] 108 percent of total billed charges 83.7 128.25 Technical (Hospital) Services Legionella Antigen Urine PX-3068744904 CDM 87449 CPT 306 RC outpatient 135 135 CIGNA 62308 [3081051] CIGNA STATE OF WYOMING [308105107] 108 percent of total billed charges 83.7 128.25 Technical (Hospital) Services Legionella Antigen Urine PX-3068744904 CDM 87449 CPT 306 RC outpatient 135 135 MULTIPLAN INC 34080 [3081285] MULTIPLAN INC [308128501] 128.25 percent of total billed charges 83.7 128.25 Technical (Hospital) Services Rapid Detection of Sars-Cov-2 PX-3068742600 CDM 87426 CPT 306 RC outpatient 142 142 BLUE CROSS BLUE SHIELD WELLMARK SB889 [3081026] BCBS WYOMING [308102603] 134.9 percent of total billed charges 88.04 134.9 Technical (Hospital) Services Rapid Detection of Sars-Cov-2 PX-3068742600 CDM 87426 CPT 306 RC outpatient 142 142 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES HDHP [308136802] 113.6 percent of total billed charges 88.04 134.9 Technical (Hospital) Services Rapid Detection of Sars-Cov-2 PX-3068742600 CDM 87426 CPT 306 RC outpatient 142 142 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES EPO [308136803] 113.6 percent of total billed charges 88.04 134.9 Technical (Hospital) Services Rapid Detection of Sars-Cov-2 PX-3068742600 CDM 87426 CPT 306 RC outpatient 142 142 MULTIPLAN INC 34080 [3081285] MULTIPLAN INC [308128501] 134.9 percent of total billed charges 88.04 134.9 Technical (Hospital) Services Rapid Detection of Sars-Cov-2 PX-3068742600 CDM 87426 CPT 306 RC outpatient 142 142 CIGNA 62308 [3081051] CIGNA 62308 [308105105] 113.6 percent of total billed charges 88.04 134.9 Technical (Hospital) Services Rapid Detection of Sars-Cov-2 PX-3068742600 CDM 87426 CPT 306 RC outpatient 142 142 CIGNA 62308 [3081051] CIGNA STATE OF WYOMING [308105107] 113.6 percent of total billed charges 88.04 134.9 Technical (Hospital) Services Rapid Detection of Sars-Cov-2 PX-3068742600 CDM 87426 CPT 306 RC outpatient 142 142 HEALTHPARTNERS SX009 HEALTHPARTNERS 113.6 percent of total billed charges 88.04 134.9 Technical (Hospital) Services Rapid Detection of Sars-Cov-2 PX-3068742600 CDM 87426 CPT 306 RC outpatient 142 142 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES PPO [308136801] 113.6 percent of total billed charges 88.04 134.9 Technical (Hospital) Services Rapid Detection of Sars-Cov-2 PX-3068742600 CDM 87426 CPT 306 RC outpatient 142 142 UNITED HEALTHCARE (COMMERCIAL) [3081199] UNITED HEALTHCARE 87726 [308119901] 88.04 percent of total billed charges 88.04 134.9 Technical (Hospital) Services Rapid Detection of Sars-Cov-2 PX-3068742600 CDM 87426 CPT 306 RC outpatient 142 142 MEDICA (COMMERCIAL) 94265 [3081118] MEDICA CLAIMS [308111801] 127.8 percent of total billed charges 88.04 134.9 Technical (Hospital) Services Rapid Detection of Sars-Cov-2 PX-3068742600 CDM 87426 CPT 306 RC inpatient 142 142 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES EPO [308136803] 112.44 percent of total billed charges 88.04 134.9 Technical (Hospital) Services Rapid Detection of Sars-Cov-2 PX-3068742600 CDM 87426 CPT 306 RC inpatient 142 142 HEALTHPARTNERS SX009 HEALTHPARTNERS 112.44 percent of total billed charges 88.04 134.9 Technical (Hospital) Services Rapid Detection of Sars-Cov-2 PX-3068742600 CDM 87426 CPT 306 RC inpatient 142 142 MEDICA (COMMERCIAL) 94265 [3081118] MEDICA CLAIMS [308111801] 127.8 percent of total billed charges 88.04 134.9 Technical (Hospital) Services Rapid Detection of Sars-Cov-2 PX-3068742600 CDM 87426 CPT 306 RC inpatient 142 142 MULTIPLAN INC 34080 [3081285] MULTIPLAN INC [308128501] 134.9 percent of total billed charges 88.04 134.9 Technical (Hospital) Services Rapid Detection of Sars-Cov-2 PX-3068742600 CDM 87426 CPT 306 RC inpatient 142 142 CIGNA 62308 [3081051] CIGNA 62308 [308105105] 112.44 percent of total billed charges 88.04 134.9 Technical (Hospital) Services Rapid Detection of Sars-Cov-2 PX-3068742600 CDM 87426 CPT 306 RC inpatient 142 142 CIGNA 62308 [3081051] CIGNA STATE OF WYOMING [308105107] 112.44 percent of total billed charges 88.04 134.9 Technical (Hospital) Services Rapid Detection of Sars-Cov-2 PX-3068742600 CDM 87426 CPT 306 RC inpatient 142 142 BLUE CROSS BLUE SHIELD WELLMARK SB889 [3081026] BCBS WYOMING [308102603] 134.9 percent of total billed charges 88.04 134.9 Technical (Hospital) Services Rapid Detection of Sars-Cov-2 PX-3068742600 CDM 87426 CPT 306 RC inpatient 142 142 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES HDHP [308136802] 112.44 percent of total billed charges 88.04 134.9 Technical (Hospital) Services Rapid Detection of Sars-Cov-2 PX-3068742600 CDM 87426 CPT 306 RC inpatient 142 142 UNITED HEALTHCARE (COMMERCIAL) [3081199] UNITED HEALTHCARE 87726 [308119901] 88.04 percent of total billed charges 88.04 134.9 Technical (Hospital) Services Rapid Detection of Sars-Cov-2 PX-3068742600 CDM 87426 CPT 306 RC inpatient 142 142 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES PPO [308136801] 112.44 percent of total billed charges 88.04 134.9 Technical (Hospital) Services Rotavir PX-3068742500 CDM 87425 CPT 306 RC outpatient 182 182 MEDICA (COMMERCIAL) 94265 [3081118] MEDICA CLAIMS [308111801] 163.8 percent of total billed charges 112.84 172.9 Technical (Hospital) Services Rotavir PX-3068742500 CDM 87425 CPT 306 RC outpatient 182 182 UNITED HEALTHCARE (COMMERCIAL) [3081199] UNITED HEALTHCARE 87726 [308119901] 112.84 percent of total billed charges 112.84 172.9 Technical (Hospital) Services Rotavir PX-3068742500 CDM 87425 CPT 306 RC outpatient 182 182 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES PPO [308136801] 145.6 percent of total billed charges 112.84 172.9 Technical (Hospital) Services Rotavir PX-3068742500 CDM 87425 CPT 306 RC outpatient 182 182 HEALTHPARTNERS SX009 HEALTHPARTNERS 145.6 percent of total billed charges 112.84 172.9 Technical (Hospital) Services Rotavir PX-3068742500 CDM 87425 CPT 306 RC outpatient 182 182 BLUE CROSS BLUE SHIELD WELLMARK SB889 [3081026] BCBS WYOMING [308102603] 172.9 percent of total billed charges 112.84 172.9 Technical (Hospital) Services Rotavir PX-3068742500 CDM 87425 CPT 306 RC outpatient 182 182 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES HDHP [308136802] 145.6 percent of total billed charges 112.84 172.9 Technical (Hospital) Services Rotavir PX-3068742500 CDM 87425 CPT 306 RC outpatient 182 182 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES EPO [308136803] 145.6 percent of total billed charges 112.84 172.9 Technical (Hospital) Services Rotavir PX-3068742500 CDM 87425 CPT 306 RC outpatient 182 182 CIGNA 62308 [3081051] CIGNA 62308 [308105105] 145.6 percent of total billed charges 112.84 172.9 Technical (Hospital) Services Rotavir PX-3068742500 CDM 87425 CPT 306 RC outpatient 182 182 CIGNA 62308 [3081051] CIGNA STATE OF WYOMING [308105107] 145.6 percent of total billed charges 112.84 172.9 Technical (Hospital) Services Rotavir PX-3068742500 CDM 87425 CPT 306 RC outpatient 182 182 MULTIPLAN INC 34080 [3081285] MULTIPLAN INC [308128501] 172.9 percent of total billed charges 112.84 172.9 Technical (Hospital) Services Rotavir PX-3068742500 CDM 87425 CPT 306 RC inpatient 182 182 MEDICA (COMMERCIAL) 94265 [3081118] MEDICA CLAIMS [308111801] 163.8 percent of total billed charges 112.84 172.9 Technical (Hospital) Services Rotavir PX-3068742500 CDM 87425 CPT 306 RC inpatient 182 182 MULTIPLAN INC 34080 [3081285] MULTIPLAN INC [308128501] 172.9 percent of total billed charges 112.84 172.9 Technical (Hospital) Services Rotavir PX-3068742500 CDM 87425 CPT 306 RC inpatient 182 182 BLUE CROSS BLUE SHIELD WELLMARK SB889 [3081026] BCBS WYOMING [308102603] 172.9 percent of total billed charges 112.84 172.9 Technical (Hospital) Services Rotavir PX-3068742500 CDM 87425 CPT 306 RC inpatient 182 182 CIGNA 62308 [3081051] CIGNA 62308 [308105105] 144.11 percent of total billed charges 112.84 172.9 Technical (Hospital) Services Rotavir PX-3068742500 CDM 87425 CPT 306 RC inpatient 182 182 CIGNA 62308 [3081051] CIGNA STATE OF WYOMING [308105107] 144.11 percent of total billed charges 112.84 172.9 Technical (Hospital) Services Rotavir PX-3068742500 CDM 87425 CPT 306 RC inpatient 182 182 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES EPO [308136803] 144.11 percent of total billed charges 112.84 172.9 Technical (Hospital) Services Rotavir PX-3068742500 CDM 87425 CPT 306 RC inpatient 182 182 HEALTHPARTNERS SX009 HEALTHPARTNERS 144.11 percent of total billed charges 112.84 172.9 Technical (Hospital) Services Rotavir PX-3068742500 CDM 87425 CPT 306 RC inpatient 182 182 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES HDHP [308136802] 144.11 percent of total billed charges 112.84 172.9 Technical (Hospital) Services Rotavir PX-3068742500 CDM 87425 CPT 306 RC inpatient 182 182 UNITED HEALTHCARE (COMMERCIAL) [3081199] UNITED HEALTHCARE 87726 [308119901] 112.84 percent of total billed charges 112.84 172.9 Technical (Hospital) Services Rotavir PX-3068742500 CDM 87425 CPT 306 RC inpatient 182 182 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES PPO [308136801] 144.11 percent of total billed charges 112.84 172.9 Technical (Hospital) Services Rsv Resp Synctial Virus PX-3068742000 CDM 87420 CPT 306 RC outpatient 142 142 HEALTHPARTNERS SX009 HEALTHPARTNERS 113.6 percent of total billed charges 88.04 134.9 Technical (Hospital) Services Rsv Resp Synctial Virus PX-3068742000 CDM 87420 CPT 306 RC outpatient 142 142 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES PPO [308136801] 113.6 percent of total billed charges 88.04 134.9 Technical (Hospital) Services Rsv Resp Synctial Virus PX-3068742000 CDM 87420 CPT 306 RC outpatient 142 142 UNITED HEALTHCARE (COMMERCIAL) [3081199] UNITED HEALTHCARE 87726 [308119901] 88.04 percent of total billed charges 88.04 134.9 Technical (Hospital) Services Rsv Resp Synctial Virus PX-3068742000 CDM 87420 CPT 306 RC outpatient 142 142 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES HDHP [308136802] 113.6 percent of total billed charges 88.04 134.9 Technical (Hospital) Services Rsv Resp Synctial Virus PX-3068742000 CDM 87420 CPT 306 RC outpatient 142 142 MULTIPLAN INC 34080 [3081285] MULTIPLAN INC [308128501] 134.9 percent of total billed charges 88.04 134.9 Technical (Hospital) Services Rsv Resp Synctial Virus PX-3068742000 CDM 87420 CPT 306 RC outpatient 142 142 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES EPO [308136803] 113.6 percent of total billed charges 88.04 134.9 Technical (Hospital) Services Rsv Resp Synctial Virus PX-3068742000 CDM 87420 CPT 306 RC outpatient 142 142 CIGNA 62308 [3081051] CIGNA 62308 [308105105] 113.6 percent of total billed charges 88.04 134.9 Technical (Hospital) Services Rsv Resp Synctial Virus PX-3068742000 CDM 87420 CPT 306 RC outpatient 142 142 CIGNA 62308 [3081051] CIGNA STATE OF WYOMING [308105107] 113.6 percent of total billed charges 88.04 134.9 Technical (Hospital) Services Rsv Resp Synctial Virus PX-3068742000 CDM 87420 CPT 306 RC outpatient 142 142 BLUE CROSS BLUE SHIELD WELLMARK SB889 [3081026] BCBS WYOMING [308102603] 134.9 percent of total billed charges 88.04 134.9 Technical (Hospital) Services Rsv Resp Synctial Virus PX-3068742000 CDM 87420 CPT 306 RC outpatient 142 142 MEDICA (COMMERCIAL) 94265 [3081118] MEDICA CLAIMS [308111801] 127.8 percent of total billed charges 88.04 134.9 Technical (Hospital) Services Rsv Resp Synctial Virus PX-3068742000 CDM 87420 CPT 306 RC inpatient 142 142 MULTIPLAN INC 34080 [3081285] MULTIPLAN INC [308128501] 134.9 percent of total billed charges 88.04 134.9 Technical (Hospital) Services Rsv Resp Synctial Virus PX-3068742000 CDM 87420 CPT 306 RC inpatient 142 142 CIGNA 62308 [3081051] CIGNA 62308 [308105105] 112.44 percent of total billed charges 88.04 134.9 Technical (Hospital) Services Rsv Resp Synctial Virus PX-3068742000 CDM 87420 CPT 306 RC inpatient 142 142 CIGNA 62308 [3081051] CIGNA STATE OF WYOMING [308105107] 112.44 percent of total billed charges 88.04 134.9 Technical (Hospital) Services Rsv Resp Synctial Virus PX-3068742000 CDM 87420 CPT 306 RC inpatient 142 142 BLUE CROSS BLUE SHIELD WELLMARK SB889 [3081026] BCBS WYOMING [308102603] 134.9 percent of total billed charges 88.04 134.9 Technical (Hospital) Services Rsv Resp Synctial Virus PX-3068742000 CDM 87420 CPT 306 RC inpatient 142 142 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES EPO [308136803] 112.44 percent of total billed charges 88.04 134.9 Technical (Hospital) Services Rsv Resp Synctial Virus PX-3068742000 CDM 87420 CPT 306 RC inpatient 142 142 HEALTHPARTNERS SX009 HEALTHPARTNERS 112.44 percent of total billed charges 88.04 134.9 Technical (Hospital) Services Rsv Resp Synctial Virus PX-3068742000 CDM 87420 CPT 306 RC inpatient 142 142 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES PPO [308136801] 112.44 percent of total billed charges 88.04 134.9 Technical (Hospital) Services Rsv Resp Synctial Virus PX-3068742000 CDM 87420 CPT 306 RC inpatient 142 142 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES HDHP [308136802] 112.44 percent of total billed charges 88.04 134.9 Technical (Hospital) Services Rsv Resp Synctial Virus PX-3068742000 CDM 87420 CPT 306 RC inpatient 142 142 UNITED HEALTHCARE (COMMERCIAL) [3081199] UNITED HEALTHCARE 87726 [308119901] 88.04 percent of total billed charges 88.04 134.9 Technical (Hospital) Services Rsv Resp Synctial Virus PX-3068742000 CDM 87420 CPT 306 RC inpatient 142 142 MEDICA (COMMERCIAL) 94265 [3081118] MEDICA CLAIMS [308111801] 127.8 percent of total billed charges 88.04 134.9 Technical (Hospital) Services Hiv-1 P24 Antigen PX-3068739000 CDM 87390 CPT 306 RC inpatient 253 253 BLUE CROSS BLUE SHIELD WELLMARK SB889 [3081026] BCBS WYOMING [308102603] 240.35 percent of total billed charges 156.86 240.35 Technical (Hospital) Services Hiv-1 P24 Antigen PX-3068739000 CDM 87390 CPT 306 RC inpatient 253 253 CIGNA 62308 [3081051] CIGNA 62308 [308105105] 200.33 percent of total billed charges 156.86 240.35 Technical (Hospital) Services Hiv-1 P24 Antigen PX-3068739000 CDM 87390 CPT 306 RC inpatient 253 253 CIGNA 62308 [3081051] CIGNA STATE OF WYOMING [308105107] 200.33 percent of total billed charges 156.86 240.35 Technical (Hospital) Services Hiv-1 P24 Antigen PX-3068739000 CDM 87390 CPT 306 RC inpatient 253 253 MULTIPLAN INC 34080 [3081285] MULTIPLAN INC [308128501] 240.35 percent of total billed charges 156.86 240.35 Technical (Hospital) Services Hiv-1 P24 Antigen PX-3068739000 CDM 87390 CPT 306 RC inpatient 253 253 MEDICA (COMMERCIAL) 94265 [3081118] MEDICA CLAIMS [308111801] 227.7 percent of total billed charges 156.86 240.35 Technical (Hospital) Services Hiv-1 P24 Antigen PX-3068739000 CDM 87390 CPT 306 RC inpatient 253 253 UNITED HEALTHCARE (COMMERCIAL) [3081199] UNITED HEALTHCARE 87726 [308119901] 156.86 percent of total billed charges 156.86 240.35 Technical (Hospital) Services Hiv-1 P24 Antigen PX-3068739000 CDM 87390 CPT 306 RC inpatient 253 253 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES EPO [308136803] 200.33 percent of total billed charges 156.86 240.35 Technical (Hospital) Services Hiv-1 P24 Antigen PX-3068739000 CDM 87390 CPT 306 RC inpatient 253 253 HEALTHPARTNERS SX009 HEALTHPARTNERS 200.33 percent of total billed charges 156.86 240.35 Technical (Hospital) Services Hiv-1 P24 Antigen PX-3068739000 CDM 87390 CPT 306 RC inpatient 253 253 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES HDHP [308136802] 200.33 percent of total billed charges 156.86 240.35 Technical (Hospital) Services Hiv-1 P24 Antigen PX-3068739000 CDM 87390 CPT 306 RC inpatient 253 253 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES PPO [308136801] 200.33 percent of total billed charges 156.86 240.35 Technical (Hospital) Services Hiv-1 P24 Antigen PX-3068739000 CDM 87390 CPT 306 RC outpatient 253 253 UNITED HEALTHCARE (COMMERCIAL) [3081199] UNITED HEALTHCARE 87726 [308119901] 156.86 percent of total billed charges 156.86 240.35 Technical (Hospital) Services Hiv-1 P24 Antigen PX-3068739000 CDM 87390 CPT 306 RC outpatient 253 253 HEALTHPARTNERS SX009 HEALTHPARTNERS 202.4 percent of total billed charges 156.86 240.35 Technical (Hospital) Services Hiv-1 P24 Antigen PX-3068739000 CDM 87390 CPT 306 RC outpatient 253 253 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES PPO [308136801] 202.4 percent of total billed charges 156.86 240.35 Technical (Hospital) Services Hiv-1 P24 Antigen PX-3068739000 CDM 87390 CPT 306 RC outpatient 253 253 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES HDHP [308136802] 202.4 percent of total billed charges 156.86 240.35 Technical (Hospital) Services Hiv-1 P24 Antigen PX-3068739000 CDM 87390 CPT 306 RC outpatient 253 253 BLUE CROSS BLUE SHIELD WELLMARK SB889 [3081026] BCBS WYOMING [308102603] 240.35 percent of total billed charges 156.86 240.35 Technical (Hospital) Services Hiv-1 P24 Antigen PX-3068739000 CDM 87390 CPT 306 RC outpatient 253 253 CIGNA 62308 [3081051] CIGNA STATE OF WYOMING [308105107] 202.4 percent of total billed charges 156.86 240.35 Technical (Hospital) Services Hiv-1 P24 Antigen PX-3068739000 CDM 87390 CPT 306 RC outpatient 253 253 CIGNA 62308 [3081051] CIGNA 62308 [308105105] 202.4 percent of total billed charges 156.86 240.35 Technical (Hospital) Services Hiv-1 P24 Antigen PX-3068739000 CDM 87390 CPT 306 RC outpatient 253 253 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES EPO [308136803] 202.4 percent of total billed charges 156.86 240.35 Technical (Hospital) Services Hiv-1 P24 Antigen PX-3068739000 CDM 87390 CPT 306 RC outpatient 253 253 MULTIPLAN INC 34080 [3081285] MULTIPLAN INC [308128501] 240.35 percent of total billed charges 156.86 240.35 Technical (Hospital) Services Hiv-1 P24 Antigen PX-3068739000 CDM 87390 CPT 306 RC outpatient 253 253 MEDICA (COMMERCIAL) 94265 [3081118] MEDICA CLAIMS [308111801] 227.7 percent of total billed charges 156.86 240.35 Technical (Hospital) Services Hiv 1 and 2 Ag & Ab Screen PX-3068738900 CDM 87389 CPT 306 RC outpatient 249 249 MEDICA (COMMERCIAL) 94265 [3081118] MEDICA CLAIMS [308111801] 224.1 percent of total billed charges 154.38 236.55 Technical (Hospital) Services Hiv 1 and 2 Ag & Ab Screen PX-3068738900 CDM 87389 CPT 306 RC outpatient 249 249 UNITED HEALTHCARE (COMMERCIAL) [3081199] UNITED HEALTHCARE 87726 [308119901] 154.38 percent of total billed charges 154.38 236.55 Technical (Hospital) Services Hiv 1 and 2 Ag & Ab Screen PX-3068738900 CDM 87389 CPT 306 RC outpatient 249 249 HEALTHPARTNERS SX009 HEALTHPARTNERS 199.2 percent of total billed charges 154.38 236.55 Technical (Hospital) Services Hiv 1 and 2 Ag & Ab Screen PX-3068738900 CDM 87389 CPT 306 RC outpatient 249 249 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES PPO [308136801] 199.2 percent of total billed charges 154.38 236.55 Technical (Hospital) Services Hiv 1 and 2 Ag & Ab Screen PX-3068738900 CDM 87389 CPT 306 RC outpatient 249 249 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES EPO [308136803] 199.2 percent of total billed charges 154.38 236.55 Technical (Hospital) Services Hiv 1 and 2 Ag & Ab Screen PX-3068738900 CDM 87389 CPT 306 RC outpatient 249 249 CIGNA 62308 [3081051] CIGNA 62308 [308105105] 199.2 percent of total billed charges 154.38 236.55 Technical (Hospital) Services Hiv 1 and 2 Ag & Ab Screen PX-3068738900 CDM 87389 CPT 306 RC outpatient 249 249 CIGNA 62308 [3081051] CIGNA STATE OF WYOMING [308105107] 199.2 percent of total billed charges 154.38 236.55 Technical (Hospital) Services Hiv 1 and 2 Ag & Ab Screen PX-3068738900 CDM 87389 CPT 306 RC outpatient 249 249 MULTIPLAN INC 34080 [3081285] MULTIPLAN INC [308128501] 236.55 percent of total billed charges 154.38 236.55 Technical (Hospital) Services Hiv 1 and 2 Ag & Ab Screen PX-3068738900 CDM 87389 CPT 306 RC outpatient 249 249 BLUE CROSS BLUE SHIELD WELLMARK SB889 [3081026] BCBS WYOMING [308102603] 236.55 percent of total billed charges 154.38 236.55 Technical (Hospital) Services Hiv 1 and 2 Ag & Ab Screen PX-3068738900 CDM 87389 CPT 306 RC outpatient 249 249 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES HDHP [308136802] 199.2 percent of total billed charges 154.38 236.55 Technical (Hospital) Services Hiv 1 and 2 Ag & Ab Screen PX-3068738900 CDM 87389 CPT 306 RC inpatient 249 249 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES EPO [308136803] 197.16 percent of total billed charges 154.38 236.55 Technical (Hospital) Services Hiv 1 and 2 Ag & Ab Screen PX-3068738900 CDM 87389 CPT 306 RC inpatient 249 249 HEALTHPARTNERS SX009 HEALTHPARTNERS 197.16 percent of total billed charges 154.38 236.55 Technical (Hospital) Services Hiv 1 and 2 Ag & Ab Screen PX-3068738900 CDM 87389 CPT 306 RC inpatient 249 249 MULTIPLAN INC 34080 [3081285] MULTIPLAN INC [308128501] 236.55 percent of total billed charges 154.38 236.55 Technical (Hospital) Services Hiv 1 and 2 Ag & Ab Screen PX-3068738900 CDM 87389 CPT 306 RC inpatient 249 249 BLUE CROSS BLUE SHIELD WELLMARK SB889 [3081026] BCBS WYOMING [308102603] 236.55 percent of total billed charges 154.38 236.55 Technical (Hospital) Services Hiv 1 and 2 Ag & Ab Screen PX-3068738900 CDM 87389 CPT 306 RC inpatient 249 249 CIGNA 62308 [3081051] CIGNA 62308 [308105105] 197.16 percent of total billed charges 154.38 236.55 Technical (Hospital) Services Hiv 1 and 2 Ag & Ab Screen PX-3068738900 CDM 87389 CPT 306 RC inpatient 249 249 CIGNA 62308 [3081051] CIGNA STATE OF WYOMING [308105107] 197.16 percent of total billed charges 154.38 236.55 Technical (Hospital) Services Hiv 1 and 2 Ag & Ab Screen PX-3068738900 CDM 87389 CPT 306 RC inpatient 249 249 MEDICA (COMMERCIAL) 94265 [3081118] MEDICA CLAIMS [308111801] 224.1 percent of total billed charges 154.38 236.55 Technical (Hospital) Services Hiv 1 and 2 Ag & Ab Screen PX-3068738900 CDM 87389 CPT 306 RC inpatient 249 249 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES PPO [308136801] 197.16 percent of total billed charges 154.38 236.55 Technical (Hospital) Services Hiv 1 and 2 Ag & Ab Screen PX-3068738900 CDM 87389 CPT 306 RC inpatient 249 249 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES HDHP [308136802] 197.16 percent of total billed charges 154.38 236.55 Technical (Hospital) Services Hiv 1 and 2 Ag & Ab Screen PX-3068738900 CDM 87389 CPT 306 RC inpatient 249 249 UNITED HEALTHCARE (COMMERCIAL) [3081199] UNITED HEALTHCARE 87726 [308119901] 154.38 percent of total billed charges 154.38 236.55 Technical (Hospital) Services Ref Hepatitis Be Antigen PX-3028735001 CDM 87350 CPT 306 RC inpatient 108 108 UNITED HEALTHCARE (COMMERCIAL) [3081199] UNITED HEALTHCARE 87726 [308119901] 66.96 percent of total billed charges 66.96 102.6 Technical (Hospital) Services Ref Hepatitis Be Antigen PX-3028735001 CDM 87350 CPT 306 RC inpatient 108 108 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES HDHP [308136802] 85.51 percent of total billed charges 66.96 102.6 Technical (Hospital) Services Ref Hepatitis Be Antigen PX-3028735001 CDM 87350 CPT 306 RC inpatient 108 108 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES PPO [308136801] 85.51 percent of total billed charges 66.96 102.6 Technical (Hospital) Services Ref Hepatitis Be Antigen PX-3028735001 CDM 87350 CPT 306 RC inpatient 108 108 MEDICA (COMMERCIAL) 94265 [3081118] MEDICA CLAIMS [308111801] 97.2 percent of total billed charges 66.96 102.6 Technical (Hospital) Services Ref Hepatitis Be Antigen PX-3028735001 CDM 87350 CPT 306 RC inpatient 108 108 MULTIPLAN INC 34080 [3081285] MULTIPLAN INC [308128501] 102.6 percent of total billed charges 66.96 102.6 Technical (Hospital) Services Ref Hepatitis Be Antigen PX-3028735001 CDM 87350 CPT 306 RC inpatient 108 108 CIGNA 62308 [3081051] CIGNA 62308 [308105105] 85.51 percent of total billed charges 66.96 102.6 Technical (Hospital) Services Ref Hepatitis Be Antigen PX-3028735001 CDM 87350 CPT 306 RC inpatient 108 108 CIGNA 62308 [3081051] CIGNA STATE OF WYOMING [308105107] 85.51 percent of total billed charges 66.96 102.6 Technical (Hospital) Services Ref Hepatitis Be Antigen PX-3028735001 CDM 87350 CPT 306 RC inpatient 108 108 BLUE CROSS BLUE SHIELD WELLMARK SB889 [3081026] BCBS WYOMING [308102603] 102.6 percent of total billed charges 66.96 102.6 Technical (Hospital) Services Ref Hepatitis Be Antigen PX-3028735001 CDM 87350 CPT 306 RC inpatient 108 108 HEALTHPARTNERS SX009 HEALTHPARTNERS 85.51 percent of total billed charges 66.96 102.6 Technical (Hospital) Services Ref Hepatitis Be Antigen PX-3028735001 CDM 87350 CPT 306 RC inpatient 108 108 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES EPO [308136803] 85.51 percent of total billed charges 66.96 102.6 Technical (Hospital) Services Ref Hepatitis Be Antigen PX-3028735001 CDM 87350 CPT 306 RC outpatient 108 108 UNITED HEALTHCARE (COMMERCIAL) [3081199] UNITED HEALTHCARE 87726 [308119901] 66.96 percent of total billed charges 66.96 102.6 Technical (Hospital) Services Ref Hepatitis Be Antigen PX-3028735001 CDM 87350 CPT 306 RC outpatient 108 108 HEALTHPARTNERS SX009 HEALTHPARTNERS 86.4 percent of total billed charges 66.96 102.6 Technical (Hospital) Services Ref Hepatitis Be Antigen PX-3028735001 CDM 87350 CPT 306 RC outpatient 108 108 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES PPO [308136801] 86.4 percent of total billed charges 66.96 102.6 Technical (Hospital) Services Ref Hepatitis Be Antigen PX-3028735001 CDM 87350 CPT 306 RC outpatient 108 108 MULTIPLAN INC 34080 [3081285] MULTIPLAN INC [308128501] 102.6 percent of total billed charges 66.96 102.6 Technical (Hospital) Services Ref Hepatitis Be Antigen PX-3028735001 CDM 87350 CPT 306 RC outpatient 108 108 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES EPO [308136803] 86.4 percent of total billed charges 66.96 102.6 Technical (Hospital) Services Ref Hepatitis Be Antigen PX-3028735001 CDM 87350 CPT 306 RC outpatient 108 108 CIGNA 62308 [3081051] CIGNA 62308 [308105105] 86.4 percent of total billed charges 66.96 102.6 Technical (Hospital) Services Ref Hepatitis Be Antigen PX-3028735001 CDM 87350 CPT 306 RC outpatient 108 108 CIGNA 62308 [3081051] CIGNA STATE OF WYOMING [308105107] 86.4 percent of total billed charges 66.96 102.6 Technical (Hospital) Services Ref Hepatitis Be Antigen PX-3028735001 CDM 87350 CPT 306 RC outpatient 108 108 BLUE CROSS BLUE SHIELD WELLMARK SB889 [3081026] BCBS WYOMING [308102603] 102.6 percent of total billed charges 66.96 102.6 Technical (Hospital) Services Ref Hepatitis Be Antigen PX-3028735001 CDM 87350 CPT 306 RC outpatient 108 108 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES HDHP [308136802] 86.4 percent of total billed charges 66.96 102.6 Technical (Hospital) Services Ref Hepatitis Be Antigen PX-3028735001 CDM 87350 CPT 306 RC outpatient 108 108 MEDICA (COMMERCIAL) 94265 [3081118] MEDICA CLAIMS [308111801] 97.2 percent of total billed charges 66.96 102.6 Technical (Hospital) Services "Hepatitis Be Ag, Eia" PX-3068735000 CDM 87350 CPT 306 RC outpatient 91 91 MEDICA (COMMERCIAL) 94265 [3081118] MEDICA CLAIMS [308111801] 81.9 percent of total billed charges 56.42 86.45 Technical (Hospital) Services "Hepatitis Be Ag, Eia" PX-3068735000 CDM 87350 CPT 306 RC outpatient 91 91 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES PPO [308136801] 72.8 percent of total billed charges 56.42 86.45 Technical (Hospital) Services "Hepatitis Be Ag, Eia" PX-3068735000 CDM 87350 CPT 306 RC outpatient 91 91 HEALTHPARTNERS SX009 HEALTHPARTNERS 72.8 percent of total billed charges 56.42 86.45 Technical (Hospital) Services "Hepatitis Be Ag, Eia" PX-3068735000 CDM 87350 CPT 306 RC outpatient 91 91 UNITED HEALTHCARE (COMMERCIAL) [3081199] UNITED HEALTHCARE 87726 [308119901] 56.42 percent of total billed charges 56.42 86.45 Technical (Hospital) Services "Hepatitis Be Ag, Eia" PX-3068735000 CDM 87350 CPT 306 RC outpatient 91 91 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES HDHP [308136802] 72.8 percent of total billed charges 56.42 86.45 Technical (Hospital) Services "Hepatitis Be Ag, Eia" PX-3068735000 CDM 87350 CPT 306 RC outpatient 91 91 BLUE CROSS BLUE SHIELD WELLMARK SB889 [3081026] BCBS WYOMING [308102603] 86.45 percent of total billed charges 56.42 86.45 Technical (Hospital) Services "Hepatitis Be Ag, Eia" PX-3068735000 CDM 87350 CPT 306 RC outpatient 91 91 MULTIPLAN INC 34080 [3081285] MULTIPLAN INC [308128501] 86.45 percent of total billed charges 56.42 86.45 Technical (Hospital) Services "Hepatitis Be Ag, Eia" PX-3068735000 CDM 87350 CPT 306 RC outpatient 91 91 CIGNA 62308 [3081051] CIGNA 62308 [308105105] 72.8 percent of total billed charges 56.42 86.45 Technical (Hospital) Services "Hepatitis Be Ag, Eia" PX-3068735000 CDM 87350 CPT 306 RC outpatient 91 91 CIGNA 62308 [3081051] CIGNA STATE OF WYOMING [308105107] 72.8 percent of total billed charges 56.42 86.45 Technical (Hospital) Services "Hepatitis Be Ag, Eia" PX-3068735000 CDM 87350 CPT 306 RC outpatient 91 91 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES EPO [308136803] 72.8 percent of total billed charges 56.42 86.45 Technical (Hospital) Services "Hepatitis Be Ag, Eia" PX-3068735000 CDM 87350 CPT 306 RC inpatient 91 91 UNITED HEALTHCARE (COMMERCIAL) [3081199] UNITED HEALTHCARE 87726 [308119901] 56.42 percent of total billed charges 56.42 86.45 Technical (Hospital) Services "Hepatitis Be Ag, Eia" PX-3068735000 CDM 87350 CPT 306 RC inpatient 91 91 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES HDHP [308136802] 72.05 percent of total billed charges 56.42 86.45 Technical (Hospital) Services "Hepatitis Be Ag, Eia" PX-3068735000 CDM 87350 CPT 306 RC inpatient 91 91 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES PPO [308136801] 72.05 percent of total billed charges 56.42 86.45 Technical (Hospital) Services "Hepatitis Be Ag, Eia" PX-3068735000 CDM 87350 CPT 306 RC inpatient 91 91 BLUE CROSS BLUE SHIELD WELLMARK SB889 [3081026] BCBS WYOMING [308102603] 86.45 percent of total billed charges 56.42 86.45 Technical (Hospital) Services "Hepatitis Be Ag, Eia" PX-3068735000 CDM 87350 CPT 306 RC inpatient 91 91 CIGNA 62308 [3081051] CIGNA 62308 [308105105] 72.05 percent of total billed charges 56.42 86.45 Technical (Hospital) Services "Hepatitis Be Ag, Eia" PX-3068735000 CDM 87350 CPT 306 RC inpatient 91 91 CIGNA 62308 [3081051] CIGNA STATE OF WYOMING [308105107] 72.05 percent of total billed charges 56.42 86.45 Technical (Hospital) Services "Hepatitis Be Ag, Eia" PX-3068735000 CDM 87350 CPT 306 RC inpatient 91 91 MULTIPLAN INC 34080 [3081285] MULTIPLAN INC [308128501] 86.45 percent of total billed charges 56.42 86.45 Technical (Hospital) Services "Hepatitis Be Ag, Eia" PX-3068735000 CDM 87350 CPT 306 RC inpatient 91 91 MEDICA (COMMERCIAL) 94265 [3081118] MEDICA CLAIMS [308111801] 81.9 percent of total billed charges 56.42 86.45 Technical (Hospital) Services "Hepatitis Be Ag, Eia" PX-3068735000 CDM 87350 CPT 306 RC inpatient 91 91 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES EPO [308136803] 72.05 percent of total billed charges 56.42 86.45 Technical (Hospital) Services "Hepatitis Be Ag, Eia" PX-3068735000 CDM 87350 CPT 306 RC inpatient 91 91 HEALTHPARTNERS SX009 HEALTHPARTNERS 72.05 percent of total billed charges 56.42 86.45 Technical (Hospital) Services Ref Hbs Ag PX-3068734000 CDM 87340 CPT 306 RC outpatient 87 87 MEDICA (COMMERCIAL) 94265 [3081118] MEDICA CLAIMS [308111801] 78.3 percent of total billed charges 53.94 82.65 Technical (Hospital) Services Ref Hbs Ag PX-3068734000 CDM 87340 CPT 306 RC outpatient 87 87 CIGNA 62308 [3081051] CIGNA STATE OF WYOMING [308105107] 69.6 percent of total billed charges 53.94 82.65 Technical (Hospital) Services Ref Hbs Ag PX-3068734000 CDM 87340 CPT 306 RC outpatient 87 87 CIGNA 62308 [3081051] CIGNA 62308 [308105105] 69.6 percent of total billed charges 53.94 82.65 Technical (Hospital) Services Ref Hbs Ag PX-3068734000 CDM 87340 CPT 306 RC outpatient 87 87 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES EPO [308136803] 69.6 percent of total billed charges 53.94 82.65 Technical (Hospital) Services Ref Hbs Ag PX-3068734000 CDM 87340 CPT 306 RC outpatient 87 87 MULTIPLAN INC 34080 [3081285] MULTIPLAN INC [308128501] 82.65 percent of total billed charges 53.94 82.65 Technical (Hospital) Services Ref Hbs Ag PX-3068734000 CDM 87340 CPT 306 RC outpatient 87 87 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES HDHP [308136802] 69.6 percent of total billed charges 53.94 82.65 Technical (Hospital) Services Ref Hbs Ag PX-3068734000 CDM 87340 CPT 306 RC outpatient 87 87 BLUE CROSS BLUE SHIELD WELLMARK SB889 [3081026] BCBS WYOMING [308102603] 82.65 percent of total billed charges 53.94 82.65 Technical (Hospital) Services Ref Hbs Ag PX-3068734000 CDM 87340 CPT 306 RC outpatient 87 87 UNITED HEALTHCARE (COMMERCIAL) [3081199] UNITED HEALTHCARE 87726 [308119901] 53.94 percent of total billed charges 53.94 82.65 Technical (Hospital) Services Ref Hbs Ag PX-3068734000 CDM 87340 CPT 306 RC outpatient 87 87 HEALTHPARTNERS SX009 HEALTHPARTNERS 69.6 percent of total billed charges 53.94 82.65 Technical (Hospital) Services Ref Hbs Ag PX-3068734000 CDM 87340 CPT 306 RC outpatient 87 87 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES PPO [308136801] 69.6 percent of total billed charges 53.94 82.65 Technical (Hospital) Services Ref Hbs Ag PX-3068734000 CDM 87340 CPT 306 RC inpatient 87 87 MULTIPLAN INC 34080 [3081285] MULTIPLAN INC [308128501] 82.65 percent of total billed charges 53.94 82.65 Technical (Hospital) Services Ref Hbs Ag PX-3068734000 CDM 87340 CPT 306 RC inpatient 87 87 BLUE CROSS BLUE SHIELD WELLMARK SB889 [3081026] BCBS WYOMING [308102603] 82.65 percent of total billed charges 53.94 82.65 Technical (Hospital) Services Ref Hbs Ag PX-3068734000 CDM 87340 CPT 306 RC inpatient 87 87 CIGNA 62308 [3081051] CIGNA 62308 [308105105] 68.89 percent of total billed charges 53.94 82.65 Technical (Hospital) Services Ref Hbs Ag PX-3068734000 CDM 87340 CPT 306 RC inpatient 87 87 CIGNA 62308 [3081051] CIGNA STATE OF WYOMING [308105107] 68.89 percent of total billed charges 53.94 82.65 Technical (Hospital) Services Ref Hbs Ag PX-3068734000 CDM 87340 CPT 306 RC inpatient 87 87 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES EPO [308136803] 68.89 percent of total billed charges 53.94 82.65 Technical (Hospital) Services Ref Hbs Ag PX-3068734000 CDM 87340 CPT 306 RC inpatient 87 87 HEALTHPARTNERS SX009 HEALTHPARTNERS 68.89 percent of total billed charges 53.94 82.65 Technical (Hospital) Services Ref Hbs Ag PX-3068734000 CDM 87340 CPT 306 RC inpatient 87 87 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES HDHP [308136802] 68.89 percent of total billed charges 53.94 82.65 Technical (Hospital) Services Ref Hbs Ag PX-3068734000 CDM 87340 CPT 306 RC inpatient 87 87 UNITED HEALTHCARE (COMMERCIAL) [3081199] UNITED HEALTHCARE 87726 [308119901] 53.94 percent of total billed charges 53.94 82.65 Technical (Hospital) Services Ref Hbs Ag PX-3068734000 CDM 87340 CPT 306 RC inpatient 87 87 MEDICA (COMMERCIAL) 94265 [3081118] MEDICA CLAIMS [308111801] 78.3 percent of total billed charges 53.94 82.65 Technical (Hospital) Services Ref Hbs Ag PX-3068734000 CDM 87340 CPT 306 RC inpatient 87 87 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES PPO [308136801] 68.89 percent of total billed charges 53.94 82.65 Technical (Hospital) Services Hep B Surface Ag PX-3068734001 CDM 87340 CPT 306 RC outpatient 87 87 MEDICA (COMMERCIAL) 94265 [3081118] MEDICA CLAIMS [308111801] 78.3 percent of total billed charges 53.94 82.65 Technical (Hospital) Services Hep B Surface Ag PX-3068734001 CDM 87340 CPT 306 RC outpatient 87 87 MULTIPLAN INC 34080 [3081285] MULTIPLAN INC [308128501] 82.65 percent of total billed charges 53.94 82.65 Technical (Hospital) Services Hep B Surface Ag PX-3068734001 CDM 87340 CPT 306 RC outpatient 87 87 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES EPO [308136803] 69.6 percent of total billed charges 53.94 82.65 Technical (Hospital) Services Hep B Surface Ag PX-3068734001 CDM 87340 CPT 306 RC outpatient 87 87 CIGNA 62308 [3081051] CIGNA 62308 [308105105] 69.6 percent of total billed charges 53.94 82.65 Technical (Hospital) Services Hep B Surface Ag PX-3068734001 CDM 87340 CPT 306 RC outpatient 87 87 CIGNA 62308 [3081051] CIGNA STATE OF WYOMING [308105107] 69.6 percent of total billed charges 53.94 82.65 Technical (Hospital) Services Hep B Surface Ag PX-3068734001 CDM 87340 CPT 306 RC outpatient 87 87 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES HDHP [308136802] 69.6 percent of total billed charges 53.94 82.65 Technical (Hospital) Services Hep B Surface Ag PX-3068734001 CDM 87340 CPT 306 RC outpatient 87 87 BLUE CROSS BLUE SHIELD WELLMARK SB889 [3081026] BCBS WYOMING [308102603] 82.65 percent of total billed charges 53.94 82.65 Technical (Hospital) Services Hep B Surface Ag PX-3068734001 CDM 87340 CPT 306 RC outpatient 87 87 HEALTHPARTNERS SX009 HEALTHPARTNERS 69.6 percent of total billed charges 53.94 82.65 Technical (Hospital) Services Hep B Surface Ag PX-3068734001 CDM 87340 CPT 306 RC outpatient 87 87 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES PPO [308136801] 69.6 percent of total billed charges 53.94 82.65 Technical (Hospital) Services Hep B Surface Ag PX-3068734001 CDM 87340 CPT 306 RC outpatient 87 87 UNITED HEALTHCARE (COMMERCIAL) [3081199] UNITED HEALTHCARE 87726 [308119901] 53.94 percent of total billed charges 53.94 82.65 Technical (Hospital) Services Hep B Surface Ag PX-3068734001 CDM 87340 CPT 306 RC inpatient 87 87 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES PPO [308136801] 68.89 percent of total billed charges 53.94 82.65 Technical (Hospital) Services Hep B Surface Ag PX-3068734001 CDM 87340 CPT 306 RC inpatient 87 87 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES HDHP [308136802] 68.89 percent of total billed charges 53.94 82.65 Technical (Hospital) Services Hep B Surface Ag PX-3068734001 CDM 87340 CPT 306 RC inpatient 87 87 UNITED HEALTHCARE (COMMERCIAL) [3081199] UNITED HEALTHCARE 87726 [308119901] 53.94 percent of total billed charges 53.94 82.65 Technical (Hospital) Services Hep B Surface Ag PX-3068734001 CDM 87340 CPT 306 RC inpatient 87 87 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES EPO [308136803] 68.89 percent of total billed charges 53.94 82.65 Technical (Hospital) Services Hep B Surface Ag PX-3068734001 CDM 87340 CPT 306 RC inpatient 87 87 HEALTHPARTNERS SX009 HEALTHPARTNERS 68.89 percent of total billed charges 53.94 82.65 Technical (Hospital) Services Hep B Surface Ag PX-3068734001 CDM 87340 CPT 306 RC inpatient 87 87 MEDICA (COMMERCIAL) 94265 [3081118] MEDICA CLAIMS [308111801] 78.3 percent of total billed charges 53.94 82.65 Technical (Hospital) Services Hep B Surface Ag PX-3068734001 CDM 87340 CPT 306 RC inpatient 87 87 MULTIPLAN INC 34080 [3081285] MULTIPLAN INC [308128501] 82.65 percent of total billed charges 53.94 82.65 Technical (Hospital) Services Hep B Surface Ag PX-3068734001 CDM 87340 CPT 306 RC inpatient 87 87 CIGNA 62308 [3081051] CIGNA 62308 [308105105] 68.89 percent of total billed charges 53.94 82.65 Technical (Hospital) Services Hep B Surface Ag PX-3068734001 CDM 87340 CPT 306 RC inpatient 87 87 CIGNA 62308 [3081051] CIGNA STATE OF WYOMING [308105107] 68.89 percent of total billed charges 53.94 82.65 Technical (Hospital) Services Hep B Surface Ag PX-3068734001 CDM 87340 CPT 306 RC inpatient 87 87 BLUE CROSS BLUE SHIELD WELLMARK SB889 [3081026] BCBS WYOMING [308102603] 82.65 percent of total billed charges 53.94 82.65 Technical (Hospital) Services Ref Stl for H Pylori PX-3068733801 CDM 87338 CPT 306 RC inpatient 180 180 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES HDHP [308136802] 142.52 percent of total billed charges 111.6 171 Technical (Hospital) Services Ref Stl for H Pylori PX-3068733801 CDM 87338 CPT 306 RC inpatient 180 180 UNITED HEALTHCARE (COMMERCIAL) [3081199] UNITED HEALTHCARE 87726 [308119901] 111.6 percent of total billed charges 111.6 171 Technical (Hospital) Services Ref Stl for H Pylori PX-3068733801 CDM 87338 CPT 306 RC inpatient 180 180 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES PPO [308136801] 142.52 percent of total billed charges 111.6 171 Technical (Hospital) Services Ref Stl for H Pylori PX-3068733801 CDM 87338 CPT 306 RC inpatient 180 180 HEALTHPARTNERS SX009 HEALTHPARTNERS 142.52 percent of total billed charges 111.6 171 Technical (Hospital) Services Ref Stl for H Pylori PX-3068733801 CDM 87338 CPT 306 RC inpatient 180 180 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES EPO [308136803] 142.52 percent of total billed charges 111.6 171 Technical (Hospital) Services Ref Stl for H Pylori PX-3068733801 CDM 87338 CPT 306 RC inpatient 180 180 MEDICA (COMMERCIAL) 94265 [3081118] MEDICA CLAIMS [308111801] 162 percent of total billed charges 111.6 171 Technical (Hospital) Services Ref Stl for H Pylori PX-3068733801 CDM 87338 CPT 306 RC inpatient 180 180 MULTIPLAN INC 34080 [3081285] MULTIPLAN INC [308128501] 171 percent of total billed charges 111.6 171 Technical (Hospital) Services Ref Stl for H Pylori PX-3068733801 CDM 87338 CPT 306 RC inpatient 180 180 BLUE CROSS BLUE SHIELD WELLMARK SB889 [3081026] BCBS WYOMING [308102603] 171 percent of total billed charges 111.6 171 Technical (Hospital) Services Ref Stl for H Pylori PX-3068733801 CDM 87338 CPT 306 RC inpatient 180 180 CIGNA 62308 [3081051] CIGNA 62308 [308105105] 142.52 percent of total billed charges 111.6 171 Technical (Hospital) Services Ref Stl for H Pylori PX-3068733801 CDM 87338 CPT 306 RC inpatient 180 180 CIGNA 62308 [3081051] CIGNA STATE OF WYOMING [308105107] 142.52 percent of total billed charges 111.6 171 Technical (Hospital) Services Ref Stl for H Pylori PX-3068733801 CDM 87338 CPT 306 RC outpatient 180 180 MEDICA (COMMERCIAL) 94265 [3081118] MEDICA CLAIMS [308111801] 162 percent of total billed charges 111.6 171 Technical (Hospital) Services Ref Stl for H Pylori PX-3068733801 CDM 87338 CPT 306 RC outpatient 180 180 UNITED HEALTHCARE (COMMERCIAL) [3081199] UNITED HEALTHCARE 87726 [308119901] 111.6 percent of total billed charges 111.6 171 Technical (Hospital) Services Ref Stl for H Pylori PX-3068733801 CDM 87338 CPT 306 RC outpatient 180 180 HEALTHPARTNERS SX009 HEALTHPARTNERS 144 percent of total billed charges 111.6 171 Technical (Hospital) Services Ref Stl for H Pylori PX-3068733801 CDM 87338 CPT 306 RC outpatient 180 180 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES PPO [308136801] 144 percent of total billed charges 111.6 171 Technical (Hospital) Services Ref Stl for H Pylori PX-3068733801 CDM 87338 CPT 306 RC outpatient 180 180 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES HDHP [308136802] 144 percent of total billed charges 111.6 171 Technical (Hospital) Services Ref Stl for H Pylori PX-3068733801 CDM 87338 CPT 306 RC outpatient 180 180 BLUE CROSS BLUE SHIELD WELLMARK SB889 [3081026] BCBS WYOMING [308102603] 171 percent of total billed charges 111.6 171 Technical (Hospital) Services Ref Stl for H Pylori PX-3068733801 CDM 87338 CPT 306 RC outpatient 180 180 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES EPO [308136803] 144 percent of total billed charges 111.6 171 Technical (Hospital) Services Ref Stl for H Pylori PX-3068733801 CDM 87338 CPT 306 RC outpatient 180 180 CIGNA 62308 [3081051] CIGNA 62308 [308105105] 144 percent of total billed charges 111.6 171 Technical (Hospital) Services Ref Stl for H Pylori PX-3068733801 CDM 87338 CPT 306 RC outpatient 180 180 CIGNA 62308 [3081051] CIGNA STATE OF WYOMING [308105107] 144 percent of total billed charges 111.6 171 Technical (Hospital) Services Ref Stl for H Pylori PX-3068733801 CDM 87338 CPT 306 RC outpatient 180 180 MULTIPLAN INC 34080 [3081285] MULTIPLAN INC [308128501] 171 percent of total billed charges 111.6 171 Technical (Hospital) Services Giardia Eia PX-3068732900 CDM 87329 CPT 306 RC inpatient 171 171 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES HDHP [308136802] 135.4 percent of total billed charges 106.02 162.45 Technical (Hospital) Services Giardia Eia PX-3068732900 CDM 87329 CPT 306 RC inpatient 171 171 UNITED HEALTHCARE (COMMERCIAL) [3081199] UNITED HEALTHCARE 87726 [308119901] 106.02 percent of total billed charges 106.02 162.45 Technical (Hospital) Services Giardia Eia PX-3068732900 CDM 87329 CPT 306 RC inpatient 171 171 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES PPO [308136801] 135.4 percent of total billed charges 106.02 162.45 Technical (Hospital) Services Giardia Eia PX-3068732900 CDM 87329 CPT 306 RC inpatient 171 171 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES EPO [308136803] 135.4 percent of total billed charges 106.02 162.45 Technical (Hospital) Services Giardia Eia PX-3068732900 CDM 87329 CPT 306 RC inpatient 171 171 HEALTHPARTNERS SX009 HEALTHPARTNERS 135.4 percent of total billed charges 106.02 162.45 Technical (Hospital) Services Giardia Eia PX-3068732900 CDM 87329 CPT 306 RC inpatient 171 171 BLUE CROSS BLUE SHIELD WELLMARK SB889 [3081026] BCBS WYOMING [308102603] 162.45 percent of total billed charges 106.02 162.45 Technical (Hospital) Services Giardia Eia PX-3068732900 CDM 87329 CPT 306 RC inpatient 171 171 CIGNA 62308 [3081051] CIGNA 62308 [308105105] 135.4 percent of total billed charges 106.02 162.45 Technical (Hospital) Services Giardia Eia PX-3068732900 CDM 87329 CPT 306 RC inpatient 171 171 CIGNA 62308 [3081051] CIGNA STATE OF WYOMING [308105107] 135.4 percent of total billed charges 106.02 162.45 Technical (Hospital) Services Giardia Eia PX-3068732900 CDM 87329 CPT 306 RC inpatient 171 171 MULTIPLAN INC 34080 [3081285] MULTIPLAN INC [308128501] 162.45 percent of total billed charges 106.02 162.45 Technical (Hospital) Services Giardia Eia PX-3068732900 CDM 87329 CPT 306 RC inpatient 171 171 MEDICA (COMMERCIAL) 94265 [3081118] MEDICA CLAIMS [308111801] 153.9 percent of total billed charges 106.02 162.45 Technical (Hospital) Services Giardia Eia PX-3068732900 CDM 87329 CPT 306 RC outpatient 171 171 BLUE CROSS BLUE SHIELD WELLMARK SB889 [3081026] BCBS WYOMING [308102603] 162.45 percent of total billed charges 106.02 162.45 Technical (Hospital) Services Giardia Eia PX-3068732900 CDM 87329 CPT 306 RC outpatient 171 171 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES HDHP [308136802] 136.8 percent of total billed charges 106.02 162.45 Technical (Hospital) Services Giardia Eia PX-3068732900 CDM 87329 CPT 306 RC outpatient 171 171 CIGNA 62308 [3081051] CIGNA 62308 [308105105] 136.8 percent of total billed charges 106.02 162.45 Technical (Hospital) Services Giardia Eia PX-3068732900 CDM 87329 CPT 306 RC outpatient 171 171 CIGNA 62308 [3081051] CIGNA STATE OF WYOMING [308105107] 136.8 percent of total billed charges 106.02 162.45 Technical (Hospital) Services Giardia Eia PX-3068732900 CDM 87329 CPT 306 RC outpatient 171 171 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES EPO [308136803] 136.8 percent of total billed charges 106.02 162.45 Technical (Hospital) Services Giardia Eia PX-3068732900 CDM 87329 CPT 306 RC outpatient 171 171 MULTIPLAN INC 34080 [3081285] MULTIPLAN INC [308128501] 162.45 percent of total billed charges 106.02 162.45 Technical (Hospital) Services Giardia Eia PX-3068732900 CDM 87329 CPT 306 RC outpatient 171 171 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES PPO [308136801] 136.8 percent of total billed charges 106.02 162.45 Technical (Hospital) Services Giardia Eia PX-3068732900 CDM 87329 CPT 306 RC outpatient 171 171 HEALTHPARTNERS SX009 HEALTHPARTNERS 136.8 percent of total billed charges 106.02 162.45 Technical (Hospital) Services Giardia Eia PX-3068732900 CDM 87329 CPT 306 RC outpatient 171 171 UNITED HEALTHCARE (COMMERCIAL) [3081199] UNITED HEALTHCARE 87726 [308119901] 106.02 percent of total billed charges 106.02 162.45 Technical (Hospital) Services Giardia Eia PX-3068732900 CDM 87329 CPT 306 RC outpatient 171 171 MEDICA (COMMERCIAL) 94265 [3081118] MEDICA CLAIMS [308111801] 153.9 percent of total billed charges 106.02 162.45 Technical (Hospital) Services Cryptosporidium Crsp Eia PX-3068732800 CDM 87328 CPT 306 RC inpatient 84 84 MULTIPLAN INC 34080 [3081285] MULTIPLAN INC [308128501] 79.8 percent of total billed charges 52.08 79.8 Technical (Hospital) Services Cryptosporidium Crsp Eia PX-3068732800 CDM 87328 CPT 306 RC inpatient 84 84 MEDICA (COMMERCIAL) 94265 [3081118] MEDICA CLAIMS [308111801] 75.6 percent of total billed charges 52.08 79.8 Technical (Hospital) Services Cryptosporidium Crsp Eia PX-3068732800 CDM 87328 CPT 306 RC inpatient 84 84 BLUE CROSS BLUE SHIELD WELLMARK SB889 [3081026] BCBS WYOMING [308102603] 79.8 percent of total billed charges 52.08 79.8 Technical (Hospital) Services Cryptosporidium Crsp Eia PX-3068732800 CDM 87328 CPT 306 RC inpatient 84 84 CIGNA 62308 [3081051] CIGNA 62308 [308105105] 66.51 percent of total billed charges 52.08 79.8 Technical (Hospital) Services Cryptosporidium Crsp Eia PX-3068732800 CDM 87328 CPT 306 RC inpatient 84 84 CIGNA 62308 [3081051] CIGNA STATE OF WYOMING [308105107] 66.51 percent of total billed charges 52.08 79.8 Technical (Hospital) Services Cryptosporidium Crsp Eia PX-3068732800 CDM 87328 CPT 306 RC inpatient 84 84 HEALTHPARTNERS SX009 HEALTHPARTNERS 66.51 percent of total billed charges 52.08 79.8 Technical (Hospital) Services Cryptosporidium Crsp Eia PX-3068732800 CDM 87328 CPT 306 RC inpatient 84 84 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES EPO [308136803] 66.51 percent of total billed charges 52.08 79.8 Technical (Hospital) Services Cryptosporidium Crsp Eia PX-3068732800 CDM 87328 CPT 306 RC inpatient 84 84 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES HDHP [308136802] 66.51 percent of total billed charges 52.08 79.8 Technical (Hospital) Services Cryptosporidium Crsp Eia PX-3068732800 CDM 87328 CPT 306 RC inpatient 84 84 UNITED HEALTHCARE (COMMERCIAL) [3081199] UNITED HEALTHCARE 87726 [308119901] 52.08 percent of total billed charges 52.08 79.8 Technical (Hospital) Services Cryptosporidium Crsp Eia PX-3068732800 CDM 87328 CPT 306 RC inpatient 84 84 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES PPO [308136801] 66.51 percent of total billed charges 52.08 79.8 Technical (Hospital) Services Cryptosporidium Crsp Eia PX-3068732800 CDM 87328 CPT 306 RC outpatient 84 84 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES PPO [308136801] 67.2 percent of total billed charges 52.08 79.8 Technical (Hospital) Services Cryptosporidium Crsp Eia PX-3068732800 CDM 87328 CPT 306 RC outpatient 84 84 HEALTHPARTNERS SX009 HEALTHPARTNERS 67.2 percent of total billed charges 52.08 79.8 Technical (Hospital) Services Cryptosporidium Crsp Eia PX-3068732800 CDM 87328 CPT 306 RC outpatient 84 84 UNITED HEALTHCARE (COMMERCIAL) [3081199] UNITED HEALTHCARE 87726 [308119901] 52.08 percent of total billed charges 52.08 79.8 Technical (Hospital) Services Cryptosporidium Crsp Eia PX-3068732800 CDM 87328 CPT 306 RC outpatient 84 84 BLUE CROSS BLUE SHIELD WELLMARK SB889 [3081026] BCBS WYOMING [308102603] 79.8 percent of total billed charges 52.08 79.8 Technical (Hospital) Services Cryptosporidium Crsp Eia PX-3068732800 CDM 87328 CPT 306 RC outpatient 84 84 CIGNA 62308 [3081051] CIGNA 62308 [308105105] 67.2 percent of total billed charges 52.08 79.8 Technical (Hospital) Services Cryptosporidium Crsp Eia PX-3068732800 CDM 87328 CPT 306 RC outpatient 84 84 CIGNA 62308 [3081051] CIGNA STATE OF WYOMING [308105107] 67.2 percent of total billed charges 52.08 79.8 Technical (Hospital) Services Cryptosporidium Crsp Eia PX-3068732800 CDM 87328 CPT 306 RC outpatient 84 84 MULTIPLAN INC 34080 [3081285] MULTIPLAN INC [308128501] 79.8 percent of total billed charges 52.08 79.8 Technical (Hospital) Services Cryptosporidium Crsp Eia PX-3068732800 CDM 87328 CPT 306 RC outpatient 84 84 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES EPO [308136803] 67.2 percent of total billed charges 52.08 79.8 Technical (Hospital) Services Cryptosporidium Crsp Eia PX-3068732800 CDM 87328 CPT 306 RC outpatient 84 84 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES HDHP [308136802] 67.2 percent of total billed charges 52.08 79.8 Technical (Hospital) Services Cryptosporidium Crsp Eia PX-3068732800 CDM 87328 CPT 306 RC outpatient 84 84 MEDICA (COMMERCIAL) 94265 [3081118] MEDICA CLAIMS [308111801] 75.6 percent of total billed charges 52.08 79.8 Technical (Hospital) Services C Difficile Toxin PX-3068732400 CDM 87324 CPT 306 RC inpatient 158 158 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES PPO [308136801] 125.1 percent of total billed charges 97.96 150.1 Technical (Hospital) Services C Difficile Toxin PX-3068732400 CDM 87324 CPT 306 RC inpatient 158 158 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES HDHP [308136802] 125.1 percent of total billed charges 97.96 150.1 Technical (Hospital) Services C Difficile Toxin PX-3068732400 CDM 87324 CPT 306 RC inpatient 158 158 UNITED HEALTHCARE (COMMERCIAL) [3081199] UNITED HEALTHCARE 87726 [308119901] 97.96 percent of total billed charges 97.96 150.1 Technical (Hospital) Services C Difficile Toxin PX-3068732400 CDM 87324 CPT 306 RC inpatient 158 158 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES EPO [308136803] 125.1 percent of total billed charges 97.96 150.1 Technical (Hospital) Services C Difficile Toxin PX-3068732400 CDM 87324 CPT 306 RC inpatient 158 158 HEALTHPARTNERS SX009 HEALTHPARTNERS 125.1 percent of total billed charges 97.96 150.1 Technical (Hospital) Services C Difficile Toxin PX-3068732400 CDM 87324 CPT 306 RC inpatient 158 158 MEDICA (COMMERCIAL) 94265 [3081118] MEDICA CLAIMS [308111801] 142.2 percent of total billed charges 97.96 150.1 Technical (Hospital) Services C Difficile Toxin PX-3068732400 CDM 87324 CPT 306 RC inpatient 158 158 MULTIPLAN INC 34080 [3081285] MULTIPLAN INC [308128501] 150.1 percent of total billed charges 97.96 150.1 Technical (Hospital) Services C Difficile Toxin PX-3068732400 CDM 87324 CPT 306 RC inpatient 158 158 BLUE CROSS BLUE SHIELD WELLMARK SB889 [3081026] BCBS WYOMING [308102603] 150.1 percent of total billed charges 97.96 150.1 Technical (Hospital) Services C Difficile Toxin PX-3068732400 CDM 87324 CPT 306 RC inpatient 158 158 CIGNA 62308 [3081051] CIGNA 62308 [308105105] 125.1 percent of total billed charges 97.96 150.1 Technical (Hospital) Services C Difficile Toxin PX-3068732400 CDM 87324 CPT 306 RC inpatient 158 158 CIGNA 62308 [3081051] CIGNA STATE OF WYOMING [308105107] 125.1 percent of total billed charges 97.96 150.1 Technical (Hospital) Services C Difficile Toxin PX-3068732400 CDM 87324 CPT 306 RC outpatient 158 158 UNITED HEALTHCARE (COMMERCIAL) [3081199] UNITED HEALTHCARE 87726 [308119901] 97.96 percent of total billed charges 97.96 150.1 Technical (Hospital) Services C Difficile Toxin PX-3068732400 CDM 87324 CPT 306 RC outpatient 158 158 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES PPO [308136801] 126.4 percent of total billed charges 97.96 150.1 Technical (Hospital) Services C Difficile Toxin PX-3068732400 CDM 87324 CPT 306 RC outpatient 158 158 HEALTHPARTNERS SX009 HEALTHPARTNERS 126.4 percent of total billed charges 97.96 150.1 Technical (Hospital) Services C Difficile Toxin PX-3068732400 CDM 87324 CPT 306 RC outpatient 158 158 BLUE CROSS BLUE SHIELD WELLMARK SB889 [3081026] BCBS WYOMING [308102603] 150.1 percent of total billed charges 97.96 150.1 Technical (Hospital) Services C Difficile Toxin PX-3068732400 CDM 87324 CPT 306 RC outpatient 158 158 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES HDHP [308136802] 126.4 percent of total billed charges 97.96 150.1 Technical (Hospital) Services C Difficile Toxin PX-3068732400 CDM 87324 CPT 306 RC outpatient 158 158 MULTIPLAN INC 34080 [3081285] MULTIPLAN INC [308128501] 150.1 percent of total billed charges 97.96 150.1 Technical (Hospital) Services C Difficile Toxin PX-3068732400 CDM 87324 CPT 306 RC outpatient 158 158 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES EPO [308136803] 126.4 percent of total billed charges 97.96 150.1 Technical (Hospital) Services C Difficile Toxin PX-3068732400 CDM 87324 CPT 306 RC outpatient 158 158 CIGNA 62308 [3081051] CIGNA 62308 [308105105] 126.4 percent of total billed charges 97.96 150.1 Technical (Hospital) Services C Difficile Toxin PX-3068732400 CDM 87324 CPT 306 RC outpatient 158 158 CIGNA 62308 [3081051] CIGNA STATE OF WYOMING [308105107] 126.4 percent of total billed charges 97.96 150.1 Technical (Hospital) Services C Difficile Toxin PX-3068732400 CDM 87324 CPT 306 RC outpatient 158 158 MEDICA (COMMERCIAL) 94265 [3081118] MEDICA CLAIMS [308111801] 142.2 percent of total billed charges 97.96 150.1 Technical (Hospital) Services C Difficile Toxin a/B PX-3068732401 CDM 87324 CPT 306 RC outpatient 173 173 UNITED HEALTHCARE (COMMERCIAL) [3081199] UNITED HEALTHCARE 87726 [308119901] 107.26 percent of total billed charges 107.26 164.35 Technical (Hospital) Services C Difficile Toxin a/B PX-3068732401 CDM 87324 CPT 306 RC outpatient 173 173 HEALTHPARTNERS SX009 HEALTHPARTNERS 138.4 percent of total billed charges 107.26 164.35 Technical (Hospital) Services C Difficile Toxin a/B PX-3068732401 CDM 87324 CPT 306 RC outpatient 173 173 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES PPO [308136801] 138.4 percent of total billed charges 107.26 164.35 Technical (Hospital) Services C Difficile Toxin a/B PX-3068732401 CDM 87324 CPT 306 RC inpatient 173 173 MULTIPLAN INC 34080 [3081285] MULTIPLAN INC [308128501] 164.35 percent of total billed charges 107.26 164.35 Technical (Hospital) Services C Difficile Toxin a/B PX-3068732401 CDM 87324 CPT 306 RC inpatient 173 173 MEDICA (COMMERCIAL) 94265 [3081118] MEDICA CLAIMS [308111801] 155.7 percent of total billed charges 107.26 164.35 Technical (Hospital) Services C Difficile Toxin a/B PX-3068732401 CDM 87324 CPT 306 RC inpatient 173 173 BLUE CROSS BLUE SHIELD WELLMARK SB889 [3081026] BCBS WYOMING [308102603] 164.35 percent of total billed charges 107.26 164.35 Technical (Hospital) Services C Difficile Toxin a/B PX-3068732401 CDM 87324 CPT 306 RC inpatient 173 173 CIGNA 62308 [3081051] CIGNA 62308 [308105105] 136.98 percent of total billed charges 107.26 164.35 Technical (Hospital) Services C Difficile Toxin a/B PX-3068732401 CDM 87324 CPT 306 RC inpatient 173 173 CIGNA 62308 [3081051] CIGNA STATE OF WYOMING [308105107] 136.98 percent of total billed charges 107.26 164.35 Technical (Hospital) Services C Difficile Toxin a/B PX-3068732401 CDM 87324 CPT 306 RC inpatient 173 173 HEALTHPARTNERS SX009 HEALTHPARTNERS 136.98 percent of total billed charges 107.26 164.35 Technical (Hospital) Services C Difficile Toxin a/B PX-3068732401 CDM 87324 CPT 306 RC inpatient 173 173 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES EPO [308136803] 136.98 percent of total billed charges 107.26 164.35 Technical (Hospital) Services C Difficile Toxin a/B PX-3068732401 CDM 87324 CPT 306 RC inpatient 173 173 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES PPO [308136801] 136.98 percent of total billed charges 107.26 164.35 Technical (Hospital) Services C Difficile Toxin a/B PX-3068732401 CDM 87324 CPT 306 RC inpatient 173 173 UNITED HEALTHCARE (COMMERCIAL) [3081199] UNITED HEALTHCARE 87726 [308119901] 107.26 percent of total billed charges 107.26 164.35 Technical (Hospital) Services C Difficile Toxin a/B PX-3068732401 CDM 87324 CPT 306 RC outpatient 173 173 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES EPO [308136803] 138.4 percent of total billed charges 107.26 164.35 Technical (Hospital) Services C Difficile Toxin a/B PX-3068732401 CDM 87324 CPT 306 RC outpatient 173 173 MULTIPLAN INC 34080 [3081285] MULTIPLAN INC [308128501] 164.35 percent of total billed charges 107.26 164.35 Technical (Hospital) Services C Difficile Toxin a/B PX-3068732401 CDM 87324 CPT 306 RC outpatient 173 173 CIGNA 62308 [3081051] CIGNA 62308 [308105105] 138.4 percent of total billed charges 107.26 164.35 Technical (Hospital) Services C Difficile Toxin a/B PX-3068732401 CDM 87324 CPT 306 RC outpatient 173 173 CIGNA 62308 [3081051] CIGNA STATE OF WYOMING [308105107] 138.4 percent of total billed charges 107.26 164.35 Technical (Hospital) Services C Difficile Toxin a/B PX-3068732401 CDM 87324 CPT 306 RC outpatient 173 173 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES HDHP [308136802] 138.4 percent of total billed charges 107.26 164.35 Technical (Hospital) Services C Difficile Toxin a/B PX-3068732401 CDM 87324 CPT 306 RC outpatient 173 173 BLUE CROSS BLUE SHIELD WELLMARK SB889 [3081026] BCBS WYOMING [308102603] 164.35 percent of total billed charges 107.26 164.35 Technical (Hospital) Services C Difficile Toxin a/B PX-3068732401 CDM 87324 CPT 306 RC outpatient 173 173 MEDICA (COMMERCIAL) 94265 [3081118] MEDICA CLAIMS [308111801] 155.7 percent of total billed charges 107.26 164.35 Technical (Hospital) Services C Difficile Toxin a/B PX-3068732401 CDM 87324 CPT 306 RC inpatient 173 173 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES HDHP [308136802] 136.98 percent of total billed charges 107.26 164.35 Technical (Hospital) Services Ref Aspergillus Galactomannan Ag PX-3068730501 CDM 87305 CPT 306 RC inpatient 272 272 MEDICA (COMMERCIAL) 94265 [3081118] MEDICA CLAIMS [308111801] 244.8 percent of total billed charges 168.64 258.4 Technical (Hospital) Services Ref Aspergillus Galactomannan Ag PX-3068730501 CDM 87305 CPT 306 RC inpatient 272 272 MULTIPLAN INC 34080 [3081285] MULTIPLAN INC [308128501] 258.4 percent of total billed charges 168.64 258.4 Technical (Hospital) Services Ref Aspergillus Galactomannan Ag PX-3068730501 CDM 87305 CPT 306 RC inpatient 272 272 BLUE CROSS BLUE SHIELD WELLMARK SB889 [3081026] BCBS WYOMING [308102603] 258.4 percent of total billed charges 168.64 258.4 Technical (Hospital) Services Ref Aspergillus Galactomannan Ag PX-3068730501 CDM 87305 CPT 306 RC inpatient 272 272 CIGNA 62308 [3081051] CIGNA 62308 [308105105] 215.37 percent of total billed charges 168.64 258.4 Technical (Hospital) Services Ref Aspergillus Galactomannan Ag PX-3068730501 CDM 87305 CPT 306 RC inpatient 272 272 CIGNA 62308 [3081051] CIGNA STATE OF WYOMING [308105107] 215.37 percent of total billed charges 168.64 258.4 Technical (Hospital) Services Ref Aspergillus Galactomannan Ag PX-3068730501 CDM 87305 CPT 306 RC inpatient 272 272 HEALTHPARTNERS SX009 HEALTHPARTNERS 215.37 percent of total billed charges 168.64 258.4 Technical (Hospital) Services Ref Aspergillus Galactomannan Ag PX-3068730501 CDM 87305 CPT 306 RC inpatient 272 272 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES EPO [308136803] 215.37 percent of total billed charges 168.64 258.4 Technical (Hospital) Services Ref Aspergillus Galactomannan Ag PX-3068730501 CDM 87305 CPT 306 RC inpatient 272 272 UNITED HEALTHCARE (COMMERCIAL) [3081199] UNITED HEALTHCARE 87726 [308119901] 168.64 percent of total billed charges 168.64 258.4 Technical (Hospital) Services Ref Aspergillus Galactomannan Ag PX-3068730501 CDM 87305 CPT 306 RC inpatient 272 272 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES HDHP [308136802] 215.37 percent of total billed charges 168.64 258.4 Technical (Hospital) Services Ref Aspergillus Galactomannan Ag PX-3068730501 CDM 87305 CPT 306 RC inpatient 272 272 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES PPO [308136801] 215.37 percent of total billed charges 168.64 258.4 Technical (Hospital) Services Ref Aspergillus Galactomannan Ag PX-3068730501 CDM 87305 CPT 306 RC outpatient 272 272 HEALTHPARTNERS SX009 HEALTHPARTNERS 217.6 percent of total billed charges 168.64 258.4 Technical (Hospital) Services Ref Aspergillus Galactomannan Ag PX-3068730501 CDM 87305 CPT 306 RC outpatient 272 272 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES PPO [308136801] 217.6 percent of total billed charges 168.64 258.4 Technical (Hospital) Services Ref Aspergillus Galactomannan Ag PX-3068730501 CDM 87305 CPT 306 RC outpatient 272 272 UNITED HEALTHCARE (COMMERCIAL) [3081199] UNITED HEALTHCARE 87726 [308119901] 168.64 percent of total billed charges 168.64 258.4 Technical (Hospital) Services Ref Aspergillus Galactomannan Ag PX-3068730501 CDM 87305 CPT 306 RC outpatient 272 272 BLUE CROSS BLUE SHIELD WELLMARK SB889 [3081026] BCBS WYOMING [308102603] 258.4 percent of total billed charges 168.64 258.4 Technical (Hospital) Services Ref Aspergillus Galactomannan Ag PX-3068730501 CDM 87305 CPT 306 RC outpatient 272 272 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES HDHP [308136802] 217.6 percent of total billed charges 168.64 258.4 Technical (Hospital) Services Ref Aspergillus Galactomannan Ag PX-3068730501 CDM 87305 CPT 306 RC outpatient 272 272 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES EPO [308136803] 217.6 percent of total billed charges 168.64 258.4 Technical (Hospital) Services Ref Aspergillus Galactomannan Ag PX-3068730501 CDM 87305 CPT 306 RC outpatient 272 272 MULTIPLAN INC 34080 [3081285] MULTIPLAN INC [308128501] 258.4 percent of total billed charges 168.64 258.4 Technical (Hospital) Services Ref Aspergillus Galactomannan Ag PX-3068730501 CDM 87305 CPT 306 RC outpatient 272 272 CIGNA 62308 [3081051] CIGNA 62308 [308105105] 217.6 percent of total billed charges 168.64 258.4 Technical (Hospital) Services Ref Aspergillus Galactomannan Ag PX-3068730501 CDM 87305 CPT 306 RC outpatient 272 272 CIGNA 62308 [3081051] CIGNA STATE OF WYOMING [308105107] 217.6 percent of total billed charges 168.64 258.4 Technical (Hospital) Services Ref Aspergillus Galactomannan Ag PX-3068730501 CDM 87305 CPT 306 RC outpatient 272 272 MEDICA (COMMERCIAL) 94265 [3081118] MEDICA CLAIMS [308111801] 244.8 percent of total billed charges 168.64 258.4 Technical (Hospital) Services Rsv Dfa PX-3068728000 CDM 87280 CPT 306 RC outpatient 109 109 MULTIPLAN INC 34080 [3081285] MULTIPLAN INC [308128501] 103.55 percent of total billed charges 67.58 103.55 Technical (Hospital) Services Rsv Dfa PX-3068728000 CDM 87280 CPT 306 RC outpatient 109 109 CIGNA 62308 [3081051] CIGNA 62308 [308105105] 87.2 percent of total billed charges 67.58 103.55 Technical (Hospital) Services Rsv Dfa PX-3068728000 CDM 87280 CPT 306 RC outpatient 109 109 CIGNA 62308 [3081051] CIGNA STATE OF WYOMING [308105107] 87.2 percent of total billed charges 67.58 103.55 Technical (Hospital) Services Rsv Dfa PX-3068728000 CDM 87280 CPT 306 RC outpatient 109 109 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES EPO [308136803] 87.2 percent of total billed charges 67.58 103.55 Technical (Hospital) Services Rsv Dfa PX-3068728000 CDM 87280 CPT 306 RC outpatient 109 109 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES HDHP [308136802] 87.2 percent of total billed charges 67.58 103.55 Technical (Hospital) Services Rsv Dfa PX-3068728000 CDM 87280 CPT 306 RC outpatient 109 109 BLUE CROSS BLUE SHIELD WELLMARK SB889 [3081026] BCBS WYOMING [308102603] 103.55 percent of total billed charges 67.58 103.55 Technical (Hospital) Services Rsv Dfa PX-3068728000 CDM 87280 CPT 306 RC outpatient 109 109 HEALTHPARTNERS SX009 HEALTHPARTNERS 87.2 percent of total billed charges 67.58 103.55 Technical (Hospital) Services Rsv Dfa PX-3068728000 CDM 87280 CPT 306 RC outpatient 109 109 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES PPO [308136801] 87.2 percent of total billed charges 67.58 103.55 Technical (Hospital) Services Rsv Dfa PX-3068728000 CDM 87280 CPT 306 RC outpatient 109 109 UNITED HEALTHCARE (COMMERCIAL) [3081199] UNITED HEALTHCARE 87726 [308119901] 67.58 percent of total billed charges 67.58 103.55 Technical (Hospital) Services Rsv Dfa PX-3068728000 CDM 87280 CPT 306 RC outpatient 109 109 MEDICA (COMMERCIAL) 94265 [3081118] MEDICA CLAIMS [308111801] 98.1 percent of total billed charges 67.58 103.55 Technical (Hospital) Services Rsv Dfa PX-3068728000 CDM 87280 CPT 306 RC inpatient 109 109 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES PPO [308136801] 86.31 percent of total billed charges 67.58 103.55 Technical (Hospital) Services Rsv Dfa PX-3068728000 CDM 87280 CPT 306 RC inpatient 109 109 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES HDHP [308136802] 86.31 percent of total billed charges 67.58 103.55 Technical (Hospital) Services Rsv Dfa PX-3068728000 CDM 87280 CPT 306 RC inpatient 109 109 UNITED HEALTHCARE (COMMERCIAL) [3081199] UNITED HEALTHCARE 87726 [308119901] 67.58 percent of total billed charges 67.58 103.55 Technical (Hospital) Services Rsv Dfa PX-3068728000 CDM 87280 CPT 306 RC inpatient 109 109 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES EPO [308136803] 86.31 percent of total billed charges 67.58 103.55 Technical (Hospital) Services Rsv Dfa PX-3068728000 CDM 87280 CPT 306 RC inpatient 109 109 HEALTHPARTNERS SX009 HEALTHPARTNERS 86.31 percent of total billed charges 67.58 103.55 Technical (Hospital) Services Rsv Dfa PX-3068728000 CDM 87280 CPT 306 RC inpatient 109 109 BLUE CROSS BLUE SHIELD WELLMARK SB889 [3081026] BCBS WYOMING [308102603] 103.55 percent of total billed charges 67.58 103.55 Technical (Hospital) Services Rsv Dfa PX-3068728000 CDM 87280 CPT 306 RC inpatient 109 109 CIGNA 62308 [3081051] CIGNA 62308 [308105105] 86.31 percent of total billed charges 67.58 103.55 Technical (Hospital) Services Rsv Dfa PX-3068728000 CDM 87280 CPT 306 RC inpatient 109 109 CIGNA 62308 [3081051] CIGNA STATE OF WYOMING [308105107] 86.31 percent of total billed charges 67.58 103.55 Technical (Hospital) Services Rsv Dfa PX-3068728000 CDM 87280 CPT 306 RC inpatient 109 109 MEDICA (COMMERCIAL) 94265 [3081118] MEDICA CLAIMS [308111801] 98.1 percent of total billed charges 67.58 103.55 Technical (Hospital) Services Rsv Dfa PX-3068728000 CDM 87280 CPT 306 RC inpatient 109 109 MULTIPLAN INC 34080 [3081285] MULTIPLAN INC [308128501] 103.55 percent of total billed charges 67.58 103.55 Technical (Hospital) Services Parainfluenza Virus Any Type PX-3068727900 CDM 87279 CPT 306 RC inpatient 109 109 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES PPO [308136801] 86.31 percent of total billed charges 67.58 103.55 Technical (Hospital) Services Parainfluenza Virus Any Type PX-3068727900 CDM 87279 CPT 306 RC inpatient 109 109 UNITED HEALTHCARE (COMMERCIAL) [3081199] UNITED HEALTHCARE 87726 [308119901] 67.58 percent of total billed charges 67.58 103.55 Technical (Hospital) Services Parainfluenza Virus Any Type PX-3068727900 CDM 87279 CPT 306 RC inpatient 109 109 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES HDHP [308136802] 86.31 percent of total billed charges 67.58 103.55 Technical (Hospital) Services Parainfluenza Virus Any Type PX-3068727900 CDM 87279 CPT 306 RC inpatient 109 109 HEALTHPARTNERS SX009 HEALTHPARTNERS 86.31 percent of total billed charges 67.58 103.55 Technical (Hospital) Services Parainfluenza Virus Any Type PX-3068727900 CDM 87279 CPT 306 RC inpatient 109 109 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES EPO [308136803] 86.31 percent of total billed charges 67.58 103.55 Technical (Hospital) Services Parainfluenza Virus Any Type PX-3068727900 CDM 87279 CPT 306 RC inpatient 109 109 MULTIPLAN INC 34080 [3081285] MULTIPLAN INC [308128501] 103.55 percent of total billed charges 67.58 103.55 Technical (Hospital) Services Parainfluenza Virus Any Type PX-3068727900 CDM 87279 CPT 306 RC inpatient 109 109 MEDICA (COMMERCIAL) 94265 [3081118] MEDICA CLAIMS [308111801] 98.1 percent of total billed charges 67.58 103.55 Technical (Hospital) Services Parainfluenza Virus Any Type PX-3068727900 CDM 87279 CPT 306 RC inpatient 109 109 BLUE CROSS BLUE SHIELD WELLMARK SB889 [3081026] BCBS WYOMING [308102603] 103.55 percent of total billed charges 67.58 103.55 Technical (Hospital) Services Parainfluenza Virus Any Type PX-3068727900 CDM 87279 CPT 306 RC inpatient 109 109 CIGNA 62308 [3081051] CIGNA 62308 [308105105] 86.31 percent of total billed charges 67.58 103.55 Technical (Hospital) Services Parainfluenza Virus Any Type PX-3068727900 CDM 87279 CPT 306 RC inpatient 109 109 CIGNA 62308 [3081051] CIGNA STATE OF WYOMING [308105107] 86.31 percent of total billed charges 67.58 103.55 Technical (Hospital) Services Parainfluenza Virus Any Type PX-3068727900 CDM 87279 CPT 306 RC outpatient 109 109 MEDICA (COMMERCIAL) 94265 [3081118] MEDICA CLAIMS [308111801] 98.1 percent of total billed charges 67.58 103.55 Technical (Hospital) Services Parainfluenza Virus Any Type PX-3068727900 CDM 87279 CPT 306 RC outpatient 109 109 UNITED HEALTHCARE (COMMERCIAL) [3081199] UNITED HEALTHCARE 87726 [308119901] 67.58 percent of total billed charges 67.58 103.55 Technical (Hospital) Services Parainfluenza Virus Any Type PX-3068727900 CDM 87279 CPT 306 RC outpatient 109 109 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES PPO [308136801] 87.2 percent of total billed charges 67.58 103.55 Technical (Hospital) Services Parainfluenza Virus Any Type PX-3068727900 CDM 87279 CPT 306 RC outpatient 109 109 HEALTHPARTNERS SX009 HEALTHPARTNERS 87.2 percent of total billed charges 67.58 103.55 Technical (Hospital) Services Parainfluenza Virus Any Type PX-3068727900 CDM 87279 CPT 306 RC outpatient 109 109 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES HDHP [308136802] 87.2 percent of total billed charges 67.58 103.55 Technical (Hospital) Services Parainfluenza Virus Any Type PX-3068727900 CDM 87279 CPT 306 RC outpatient 109 109 BLUE CROSS BLUE SHIELD WELLMARK SB889 [3081026] BCBS WYOMING [308102603] 103.55 percent of total billed charges 67.58 103.55 Technical (Hospital) Services Parainfluenza Virus Any Type PX-3068727900 CDM 87279 CPT 306 RC outpatient 109 109 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES EPO [308136803] 87.2 percent of total billed charges 67.58 103.55 Technical (Hospital) Services Parainfluenza Virus Any Type PX-3068727900 CDM 87279 CPT 306 RC outpatient 109 109 CIGNA 62308 [3081051] CIGNA 62308 [308105105] 87.2 percent of total billed charges 67.58 103.55 Technical (Hospital) Services Parainfluenza Virus Any Type PX-3068727900 CDM 87279 CPT 306 RC outpatient 109 109 CIGNA 62308 [3081051] CIGNA STATE OF WYOMING [308105107] 87.2 percent of total billed charges 67.58 103.55 Technical (Hospital) Services Parainfluenza Virus Any Type PX-3068727900 CDM 87279 CPT 306 RC outpatient 109 109 MULTIPLAN INC 34080 [3081285] MULTIPLAN INC [308128501] 103.55 percent of total billed charges 67.58 103.55 Technical (Hospital) Services Influenza a Dfa PX-3068727600 CDM 87276 CPT 306 RC inpatient 109 109 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES HDHP [308136802] 86.31 percent of total billed charges 67.58 103.55 Technical (Hospital) Services Influenza a Dfa PX-3068727600 CDM 87276 CPT 306 RC inpatient 109 109 UNITED HEALTHCARE (COMMERCIAL) [3081199] UNITED HEALTHCARE 87726 [308119901] 67.58 percent of total billed charges 67.58 103.55 Technical (Hospital) Services Influenza a Dfa PX-3068727600 CDM 87276 CPT 306 RC inpatient 109 109 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES PPO [308136801] 86.31 percent of total billed charges 67.58 103.55 Technical (Hospital) Services Influenza a Dfa PX-3068727600 CDM 87276 CPT 306 RC inpatient 109 109 MULTIPLAN INC 34080 [3081285] MULTIPLAN INC [308128501] 103.55 percent of total billed charges 67.58 103.55 Technical (Hospital) Services Influenza a Dfa PX-3068727600 CDM 87276 CPT 306 RC inpatient 109 109 MEDICA (COMMERCIAL) 94265 [3081118] MEDICA CLAIMS [308111801] 98.1 percent of total billed charges 67.58 103.55 Technical (Hospital) Services Influenza a Dfa PX-3068727600 CDM 87276 CPT 306 RC inpatient 109 109 BLUE CROSS BLUE SHIELD WELLMARK SB889 [3081026] BCBS WYOMING [308102603] 103.55 percent of total billed charges 67.58 103.55 Technical (Hospital) Services Influenza a Dfa PX-3068727600 CDM 87276 CPT 306 RC inpatient 109 109 CIGNA 62308 [3081051] CIGNA 62308 [308105105] 86.31 percent of total billed charges 67.58 103.55 Technical (Hospital) Services Influenza a Dfa PX-3068727600 CDM 87276 CPT 306 RC inpatient 109 109 CIGNA 62308 [3081051] CIGNA STATE OF WYOMING [308105107] 86.31 percent of total billed charges 67.58 103.55 Technical (Hospital) Services Influenza a Dfa PX-3068727600 CDM 87276 CPT 306 RC inpatient 109 109 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES EPO [308136803] 86.31 percent of total billed charges 67.58 103.55 Technical (Hospital) Services Influenza a Dfa PX-3068727600 CDM 87276 CPT 306 RC inpatient 109 109 HEALTHPARTNERS SX009 HEALTHPARTNERS 86.31 percent of total billed charges 67.58 103.55 Technical (Hospital) Services Influenza a Dfa PX-3068727600 CDM 87276 CPT 306 RC outpatient 109 109 BLUE CROSS BLUE SHIELD WELLMARK SB889 [3081026] BCBS WYOMING [308102603] 103.55 percent of total billed charges 67.58 103.55 Technical (Hospital) Services Influenza a Dfa PX-3068727600 CDM 87276 CPT 306 RC outpatient 109 109 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES HDHP [308136802] 87.2 percent of total billed charges 67.58 103.55 Technical (Hospital) Services Influenza a Dfa PX-3068727600 CDM 87276 CPT 306 RC outpatient 109 109 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES EPO [308136803] 87.2 percent of total billed charges 67.58 103.55 Technical (Hospital) Services Influenza a Dfa PX-3068727600 CDM 87276 CPT 306 RC outpatient 109 109 MULTIPLAN INC 34080 [3081285] MULTIPLAN INC [308128501] 103.55 percent of total billed charges 67.58 103.55 Technical (Hospital) Services Influenza a Dfa PX-3068727600 CDM 87276 CPT 306 RC outpatient 109 109 CIGNA 62308 [3081051] CIGNA 62308 [308105105] 87.2 percent of total billed charges 67.58 103.55 Technical (Hospital) Services Influenza a Dfa PX-3068727600 CDM 87276 CPT 306 RC outpatient 109 109 CIGNA 62308 [3081051] CIGNA STATE OF WYOMING [308105107] 87.2 percent of total billed charges 67.58 103.55 Technical (Hospital) Services Influenza a Dfa PX-3068727600 CDM 87276 CPT 306 RC outpatient 109 109 HEALTHPARTNERS SX009 HEALTHPARTNERS 87.2 percent of total billed charges 67.58 103.55 Technical (Hospital) Services Influenza a Dfa PX-3068727600 CDM 87276 CPT 306 RC outpatient 109 109 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES PPO [308136801] 87.2 percent of total billed charges 67.58 103.55 Technical (Hospital) Services Influenza a Dfa PX-3068727600 CDM 87276 CPT 306 RC outpatient 109 109 UNITED HEALTHCARE (COMMERCIAL) [3081199] UNITED HEALTHCARE 87726 [308119901] 67.58 percent of total billed charges 67.58 103.55 Technical (Hospital) Services Influenza a Dfa PX-3068727600 CDM 87276 CPT 306 RC outpatient 109 109 MEDICA (COMMERCIAL) 94265 [3081118] MEDICA CLAIMS [308111801] 98.1 percent of total billed charges 67.58 103.55 Technical (Hospital) Services Influenza B Dfa PX-3068727500 CDM 87275 CPT 306 RC outpatient 109 109 MEDICA (COMMERCIAL) 94265 [3081118] MEDICA CLAIMS [308111801] 98.1 percent of total billed charges 67.58 103.55 Technical (Hospital) Services Influenza B Dfa PX-3068727500 CDM 87275 CPT 306 RC outpatient 109 109 MULTIPLAN INC 34080 [3081285] MULTIPLAN INC [308128501] 103.55 percent of total billed charges 67.58 103.55 Technical (Hospital) Services Influenza B Dfa PX-3068727500 CDM 87275 CPT 306 RC outpatient 109 109 CIGNA 62308 [3081051] CIGNA 62308 [308105105] 87.2 percent of total billed charges 67.58 103.55 Technical (Hospital) Services Influenza B Dfa PX-3068727500 CDM 87275 CPT 306 RC outpatient 109 109 CIGNA 62308 [3081051] CIGNA STATE OF WYOMING [308105107] 87.2 percent of total billed charges 67.58 103.55 Technical (Hospital) Services Influenza B Dfa PX-3068727500 CDM 87275 CPT 306 RC outpatient 109 109 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES EPO [308136803] 87.2 percent of total billed charges 67.58 103.55 Technical (Hospital) Services Influenza B Dfa PX-3068727500 CDM 87275 CPT 306 RC outpatient 109 109 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES HDHP [308136802] 87.2 percent of total billed charges 67.58 103.55 Technical (Hospital) Services Influenza B Dfa PX-3068727500 CDM 87275 CPT 306 RC outpatient 109 109 BLUE CROSS BLUE SHIELD WELLMARK SB889 [3081026] BCBS WYOMING [308102603] 103.55 percent of total billed charges 67.58 103.55 Technical (Hospital) Services Influenza B Dfa PX-3068727500 CDM 87275 CPT 306 RC outpatient 109 109 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES PPO [308136801] 87.2 percent of total billed charges 67.58 103.55 Technical (Hospital) Services Influenza B Dfa PX-3068727500 CDM 87275 CPT 306 RC outpatient 109 109 HEALTHPARTNERS SX009 HEALTHPARTNERS 87.2 percent of total billed charges 67.58 103.55 Technical (Hospital) Services Influenza B Dfa PX-3068727500 CDM 87275 CPT 306 RC outpatient 109 109 UNITED HEALTHCARE (COMMERCIAL) [3081199] UNITED HEALTHCARE 87726 [308119901] 67.58 percent of total billed charges 67.58 103.55 Technical (Hospital) Services Influenza B Dfa PX-3068727500 CDM 87275 CPT 306 RC inpatient 109 109 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES PPO [308136801] 86.31 percent of total billed charges 67.58 103.55 Technical (Hospital) Services Influenza B Dfa PX-3068727500 CDM 87275 CPT 306 RC inpatient 109 109 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES HDHP [308136802] 86.31 percent of total billed charges 67.58 103.55 Technical (Hospital) Services Influenza B Dfa PX-3068727500 CDM 87275 CPT 306 RC inpatient 109 109 UNITED HEALTHCARE (COMMERCIAL) [3081199] UNITED HEALTHCARE 87726 [308119901] 67.58 percent of total billed charges 67.58 103.55 Technical (Hospital) Services Influenza B Dfa PX-3068727500 CDM 87275 CPT 306 RC inpatient 109 109 HEALTHPARTNERS SX009 HEALTHPARTNERS 86.31 percent of total billed charges 67.58 103.55 Technical (Hospital) Services Influenza B Dfa PX-3068727500 CDM 87275 CPT 306 RC inpatient 109 109 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES EPO [308136803] 86.31 percent of total billed charges 67.58 103.55 Technical (Hospital) Services Influenza B Dfa PX-3068727500 CDM 87275 CPT 306 RC inpatient 109 109 CIGNA 62308 [3081051] CIGNA 62308 [308105105] 86.31 percent of total billed charges 67.58 103.55 Technical (Hospital) Services Influenza B Dfa PX-3068727500 CDM 87275 CPT 306 RC inpatient 109 109 CIGNA 62308 [3081051] CIGNA STATE OF WYOMING [308105107] 86.31 percent of total billed charges 67.58 103.55 Technical (Hospital) Services Influenza B Dfa PX-3068727500 CDM 87275 CPT 306 RC inpatient 109 109 BLUE CROSS BLUE SHIELD WELLMARK SB889 [3081026] BCBS WYOMING [308102603] 103.55 percent of total billed charges 67.58 103.55 Technical (Hospital) Services Influenza B Dfa PX-3068727500 CDM 87275 CPT 306 RC inpatient 109 109 MEDICA (COMMERCIAL) 94265 [3081118] MEDICA CLAIMS [308111801] 98.1 percent of total billed charges 67.58 103.55 Technical (Hospital) Services Influenza B Dfa PX-3068727500 CDM 87275 CPT 306 RC inpatient 109 109 MULTIPLAN INC 34080 [3081285] MULTIPLAN INC [308128501] 103.55 percent of total billed charges 67.58 103.55 Technical (Hospital) Services Adenovirus Dfa PX-3068726000 CDM 87260 CPT 306 RC outpatient 109 109 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES PPO [308136801] 87.2 percent of total billed charges 67.58 103.55 Technical (Hospital) Services Adenovirus Dfa PX-3068726000 CDM 87260 CPT 306 RC outpatient 109 109 HEALTHPARTNERS SX009 HEALTHPARTNERS 87.2 percent of total billed charges 67.58 103.55 Technical (Hospital) Services Adenovirus Dfa PX-3068726000 CDM 87260 CPT 306 RC outpatient 109 109 MEDICA (COMMERCIAL) 94265 [3081118] MEDICA CLAIMS [308111801] 98.1 percent of total billed charges 67.58 103.55 Technical (Hospital) Services Adenovirus Dfa PX-3068726000 CDM 87260 CPT 306 RC inpatient 109 109 HEALTHPARTNERS SX009 HEALTHPARTNERS 86.31 percent of total billed charges 67.58 103.55 Technical (Hospital) Services Adenovirus Dfa PX-3068726000 CDM 87260 CPT 306 RC inpatient 109 109 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES EPO [308136803] 86.31 percent of total billed charges 67.58 103.55 Technical (Hospital) Services Adenovirus Dfa PX-3068726000 CDM 87260 CPT 306 RC outpatient 109 109 UNITED HEALTHCARE (COMMERCIAL) [3081199] UNITED HEALTHCARE 87726 [308119901] 67.58 percent of total billed charges 67.58 103.55 Technical (Hospital) Services Adenovirus Dfa PX-3068726000 CDM 87260 CPT 306 RC outpatient 109 109 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES HDHP [308136802] 87.2 percent of total billed charges 67.58 103.55 Technical (Hospital) Services Adenovirus Dfa PX-3068726000 CDM 87260 CPT 306 RC outpatient 109 109 BLUE CROSS BLUE SHIELD WELLMARK SB889 [3081026] BCBS WYOMING [308102603] 103.55 percent of total billed charges 67.58 103.55 Technical (Hospital) Services Adenovirus Dfa PX-3068726000 CDM 87260 CPT 306 RC outpatient 109 109 CIGNA 62308 [3081051] CIGNA 62308 [308105105] 87.2 percent of total billed charges 67.58 103.55 Technical (Hospital) Services Adenovirus Dfa PX-3068726000 CDM 87260 CPT 306 RC outpatient 109 109 CIGNA 62308 [3081051] CIGNA STATE OF WYOMING [308105107] 87.2 percent of total billed charges 67.58 103.55 Technical (Hospital) Services Adenovirus Dfa PX-3068726000 CDM 87260 CPT 306 RC outpatient 109 109 MULTIPLAN INC 34080 [3081285] MULTIPLAN INC [308128501] 103.55 percent of total billed charges 67.58 103.55 Technical (Hospital) Services Adenovirus Dfa PX-3068726000 CDM 87260 CPT 306 RC outpatient 109 109 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES EPO [308136803] 87.2 percent of total billed charges 67.58 103.55 Technical (Hospital) Services Adenovirus Dfa PX-3068726000 CDM 87260 CPT 306 RC inpatient 109 109 BLUE CROSS BLUE SHIELD WELLMARK SB889 [3081026] BCBS WYOMING [308102603] 103.55 percent of total billed charges 67.58 103.55 Technical (Hospital) Services Adenovirus Dfa PX-3068726000 CDM 87260 CPT 306 RC inpatient 109 109 CIGNA 62308 [3081051] CIGNA 62308 [308105105] 86.31 percent of total billed charges 67.58 103.55 Technical (Hospital) Services Adenovirus Dfa PX-3068726000 CDM 87260 CPT 306 RC inpatient 109 109 CIGNA 62308 [3081051] CIGNA STATE OF WYOMING [308105107] 86.31 percent of total billed charges 67.58 103.55 Technical (Hospital) Services Adenovirus Dfa PX-3068726000 CDM 87260 CPT 306 RC inpatient 109 109 MULTIPLAN INC 34080 [3081285] MULTIPLAN INC [308128501] 103.55 percent of total billed charges 67.58 103.55 Technical (Hospital) Services Adenovirus Dfa PX-3068726000 CDM 87260 CPT 306 RC inpatient 109 109 MEDICA (COMMERCIAL) 94265 [3081118] MEDICA CLAIMS [308111801] 98.1 percent of total billed charges 67.58 103.55 Technical (Hospital) Services Adenovirus Dfa PX-3068726000 CDM 87260 CPT 306 RC inpatient 109 109 UNITED HEALTHCARE (COMMERCIAL) [3081199] UNITED HEALTHCARE 87726 [308119901] 67.58 percent of total billed charges 67.58 103.55 Technical (Hospital) Services Adenovirus Dfa PX-3068726000 CDM 87260 CPT 306 RC inpatient 109 109 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES HDHP [308136802] 86.31 percent of total billed charges 67.58 103.55 Technical (Hospital) Services Adenovirus Dfa PX-3068726000 CDM 87260 CPT 306 RC inpatient 109 109 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES PPO [308136801] 86.31 percent of total billed charges 67.58 103.55 Technical (Hospital) Services Viral Culture PX-3068725200 CDM 87252 CPT 306 RC outpatient 236 236 UNITED HEALTHCARE (COMMERCIAL) [3081199] UNITED HEALTHCARE 87726 [308119901] 146.32 percent of total billed charges 146.32 224.2 Technical (Hospital) Services Viral Culture PX-3068725200 CDM 87252 CPT 306 RC outpatient 236 236 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES HDHP [308136802] 188.8 percent of total billed charges 146.32 224.2 Technical (Hospital) Services Viral Culture PX-3068725200 CDM 87252 CPT 306 RC outpatient 236 236 BLUE CROSS BLUE SHIELD WELLMARK SB889 [3081026] BCBS WYOMING [308102603] 224.2 percent of total billed charges 146.32 224.2 Technical (Hospital) Services Viral Culture PX-3068725200 CDM 87252 CPT 306 RC outpatient 236 236 MULTIPLAN INC 34080 [3081285] MULTIPLAN INC [308128501] 224.2 percent of total billed charges 146.32 224.2 Technical (Hospital) Services Viral Culture PX-3068725200 CDM 87252 CPT 306 RC outpatient 236 236 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES EPO [308136803] 188.8 percent of total billed charges 146.32 224.2 Technical (Hospital) Services Viral Culture PX-3068725200 CDM 87252 CPT 306 RC outpatient 236 236 CIGNA 62308 [3081051] CIGNA 62308 [308105105] 188.8 percent of total billed charges 146.32 224.2 Technical (Hospital) Services Viral Culture PX-3068725200 CDM 87252 CPT 306 RC outpatient 236 236 CIGNA 62308 [3081051] CIGNA STATE OF WYOMING [308105107] 188.8 percent of total billed charges 146.32 224.2 Technical (Hospital) Services Viral Culture PX-3068725200 CDM 87252 CPT 306 RC outpatient 236 236 MEDICA (COMMERCIAL) 94265 [3081118] MEDICA CLAIMS [308111801] 212.4 percent of total billed charges 146.32 224.2 Technical (Hospital) Services Viral Culture PX-3068725200 CDM 87252 CPT 306 RC outpatient 236 236 HEALTHPARTNERS SX009 HEALTHPARTNERS 188.8 percent of total billed charges 146.32 224.2 Technical (Hospital) Services Viral Culture PX-3068725200 CDM 87252 CPT 306 RC outpatient 236 236 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES PPO [308136801] 188.8 percent of total billed charges 146.32 224.2 Technical (Hospital) Services Viral Culture PX-3068725200 CDM 87252 CPT 306 RC inpatient 236 236 UNITED HEALTHCARE (COMMERCIAL) [3081199] UNITED HEALTHCARE 87726 [308119901] 146.32 percent of total billed charges 146.32 224.2 Technical (Hospital) Services Viral Culture PX-3068725200 CDM 87252 CPT 306 RC inpatient 236 236 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES HDHP [308136802] 186.86 percent of total billed charges 146.32 224.2 Technical (Hospital) Services Viral Culture PX-3068725200 CDM 87252 CPT 306 RC inpatient 236 236 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES PPO [308136801] 186.86 percent of total billed charges 146.32 224.2 Technical (Hospital) Services Viral Culture PX-3068725200 CDM 87252 CPT 306 RC inpatient 236 236 HEALTHPARTNERS SX009 HEALTHPARTNERS 186.86 percent of total billed charges 146.32 224.2 Technical (Hospital) Services Viral Culture PX-3068725200 CDM 87252 CPT 306 RC inpatient 236 236 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES EPO [308136803] 186.86 percent of total billed charges 146.32 224.2 Technical (Hospital) Services Viral Culture PX-3068725200 CDM 87252 CPT 306 RC inpatient 236 236 BLUE CROSS BLUE SHIELD WELLMARK SB889 [3081026] BCBS WYOMING [308102603] 224.2 percent of total billed charges 146.32 224.2 Technical (Hospital) Services Viral Culture PX-3068725200 CDM 87252 CPT 306 RC inpatient 236 236 CIGNA 62308 [3081051] CIGNA 62308 [308105105] 186.86 percent of total billed charges 146.32 224.2 Technical (Hospital) Services Viral Culture PX-3068725200 CDM 87252 CPT 306 RC inpatient 236 236 CIGNA 62308 [3081051] CIGNA STATE OF WYOMING [308105107] 186.86 percent of total billed charges 146.32 224.2 Technical (Hospital) Services Viral Culture PX-3068725200 CDM 87252 CPT 306 RC inpatient 236 236 MULTIPLAN INC 34080 [3081285] MULTIPLAN INC [308128501] 224.2 percent of total billed charges 146.32 224.2 Technical (Hospital) Services Viral Culture PX-3068725200 CDM 87252 CPT 306 RC inpatient 236 236 MEDICA (COMMERCIAL) 94265 [3081118] MEDICA CLAIMS [308111801] 212.4 percent of total billed charges 146.32 224.2 Technical (Hospital) Services Ref Viral Culture Non Respiratory PX-3068725201 CDM 87252 CPT 306 RC outpatient 326 326 MEDICA (COMMERCIAL) 94265 [3081118] MEDICA CLAIMS [308111801] 293.4 percent of total billed charges 202.12 309.7 Technical (Hospital) Services Ref Viral Culture Non Respiratory PX-3068725201 CDM 87252 CPT 306 RC outpatient 326 326 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES EPO [308136803] 260.8 percent of total billed charges 202.12 309.7 Technical (Hospital) Services Ref Viral Culture Non Respiratory PX-3068725201 CDM 87252 CPT 306 RC outpatient 326 326 MULTIPLAN INC 34080 [3081285] MULTIPLAN INC [308128501] 309.7 percent of total billed charges 202.12 309.7 Technical (Hospital) Services Ref Viral Culture Non Respiratory PX-3068725201 CDM 87252 CPT 306 RC outpatient 326 326 CIGNA 62308 [3081051] CIGNA 62308 [308105105] 260.8 percent of total billed charges 202.12 309.7 Technical (Hospital) Services Ref Viral Culture Non Respiratory PX-3068725201 CDM 87252 CPT 306 RC outpatient 326 326 CIGNA 62308 [3081051] CIGNA STATE OF WYOMING [308105107] 260.8 percent of total billed charges 202.12 309.7 Technical (Hospital) Services Ref Viral Culture Non Respiratory PX-3068725201 CDM 87252 CPT 306 RC outpatient 326 326 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES HDHP [308136802] 260.8 percent of total billed charges 202.12 309.7 Technical (Hospital) Services Ref Viral Culture Non Respiratory PX-3068725201 CDM 87252 CPT 306 RC outpatient 326 326 BLUE CROSS BLUE SHIELD WELLMARK SB889 [3081026] BCBS WYOMING [308102603] 309.7 percent of total billed charges 202.12 309.7 Technical (Hospital) Services Ref Viral Culture Non Respiratory PX-3068725201 CDM 87252 CPT 306 RC outpatient 326 326 UNITED HEALTHCARE (COMMERCIAL) [3081199] UNITED HEALTHCARE 87726 [308119901] 202.12 percent of total billed charges 202.12 309.7 Technical (Hospital) Services Ref Viral Culture Non Respiratory PX-3068725201 CDM 87252 CPT 306 RC outpatient 326 326 HEALTHPARTNERS SX009 HEALTHPARTNERS 260.8 percent of total billed charges 202.12 309.7 Technical (Hospital) Services Ref Viral Culture Non Respiratory PX-3068725201 CDM 87252 CPT 306 RC outpatient 326 326 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES PPO [308136801] 260.8 percent of total billed charges 202.12 309.7 Technical (Hospital) Services Ref Viral Culture Non Respiratory PX-3068725201 CDM 87252 CPT 306 RC inpatient 326 326 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES HDHP [308136802] 258.13 percent of total billed charges 202.12 309.7 Technical (Hospital) Services Ref Viral Culture Non Respiratory PX-3068725201 CDM 87252 CPT 306 RC inpatient 326 326 UNITED HEALTHCARE (COMMERCIAL) [3081199] UNITED HEALTHCARE 87726 [308119901] 202.12 percent of total billed charges 202.12 309.7 Technical (Hospital) Services Ref Viral Culture Non Respiratory PX-3068725201 CDM 87252 CPT 306 RC inpatient 326 326 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES PPO [308136801] 258.13 percent of total billed charges 202.12 309.7 Technical (Hospital) Services Ref Viral Culture Non Respiratory PX-3068725201 CDM 87252 CPT 306 RC inpatient 326 326 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES EPO [308136803] 258.13 percent of total billed charges 202.12 309.7 Technical (Hospital) Services Ref Viral Culture Non Respiratory PX-3068725201 CDM 87252 CPT 306 RC inpatient 326 326 HEALTHPARTNERS SX009 HEALTHPARTNERS 258.13 percent of total billed charges 202.12 309.7 Technical (Hospital) Services Ref Viral Culture Non Respiratory PX-3068725201 CDM 87252 CPT 306 RC inpatient 326 326 MEDICA (COMMERCIAL) 94265 [3081118] MEDICA CLAIMS [308111801] 293.4 percent of total billed charges 202.12 309.7 Technical (Hospital) Services Ref Viral Culture Non Respiratory PX-3068725201 CDM 87252 CPT 306 RC inpatient 326 326 MULTIPLAN INC 34080 [3081285] MULTIPLAN INC [308128501] 309.7 percent of total billed charges 202.12 309.7 Technical (Hospital) Services Ref Viral Culture Non Respiratory PX-3068725201 CDM 87252 CPT 306 RC inpatient 326 326 BLUE CROSS BLUE SHIELD WELLMARK SB889 [3081026] BCBS WYOMING [308102603] 309.7 percent of total billed charges 202.12 309.7 Technical (Hospital) Services Ref Viral Culture Non Respiratory PX-3068725201 CDM 87252 CPT 306 RC inpatient 326 326 CIGNA 62308 [3081051] CIGNA 62308 [308105105] 258.13 percent of total billed charges 202.12 309.7 Technical (Hospital) Services Ref Viral Culture Non Respiratory PX-3068725201 CDM 87252 CPT 306 RC inpatient 326 326 CIGNA 62308 [3081051] CIGNA STATE OF WYOMING [308105107] 258.13 percent of total billed charges 202.12 309.7 Technical (Hospital) Services Koh Fungal Wet Mount PX-3068722000 CDM 87220 CPT 306 RC outpatient 53 53 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES HDHP [308136802] 42.4 percent of total billed charges 32.86 50.35 Technical (Hospital) Services Koh Fungal Wet Mount PX-3068722000 CDM 87220 CPT 306 RC outpatient 53 53 BLUE CROSS BLUE SHIELD WELLMARK SB889 [3081026] BCBS WYOMING [308102603] 50.35 percent of total billed charges 32.86 50.35 Technical (Hospital) Services Koh Fungal Wet Mount PX-3068722000 CDM 87220 CPT 306 RC outpatient 53 53 MULTIPLAN INC 34080 [3081285] MULTIPLAN INC [308128501] 50.35 percent of total billed charges 32.86 50.35 Technical (Hospital) Services Koh Fungal Wet Mount PX-3068722000 CDM 87220 CPT 306 RC outpatient 53 53 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES EPO [308136803] 42.4 percent of total billed charges 32.86 50.35 Technical (Hospital) Services Koh Fungal Wet Mount PX-3068722000 CDM 87220 CPT 306 RC outpatient 53 53 CIGNA 62308 [3081051] CIGNA 62308 [308105105] 42.4 percent of total billed charges 32.86 50.35 Technical (Hospital) Services Koh Fungal Wet Mount PX-3068722000 CDM 87220 CPT 306 RC outpatient 53 53 CIGNA 62308 [3081051] CIGNA STATE OF WYOMING [308105107] 42.4 percent of total billed charges 32.86 50.35 Technical (Hospital) Services Koh Fungal Wet Mount PX-3068722000 CDM 87220 CPT 306 RC outpatient 53 53 UNITED HEALTHCARE (COMMERCIAL) [3081199] UNITED HEALTHCARE 87726 [308119901] 32.86 percent of total billed charges 32.86 50.35 Technical (Hospital) Services Koh Fungal Wet Mount PX-3068722000 CDM 87220 CPT 306 RC outpatient 53 53 HEALTHPARTNERS SX009 HEALTHPARTNERS 42.4 percent of total billed charges 32.86 50.35 Technical (Hospital) Services Koh Fungal Wet Mount PX-3068722000 CDM 87220 CPT 306 RC outpatient 53 53 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES PPO [308136801] 42.4 percent of total billed charges 32.86 50.35 Technical (Hospital) Services Koh Fungal Wet Mount PX-3068722000 CDM 87220 CPT 306 RC outpatient 53 53 MEDICA (COMMERCIAL) 94265 [3081118] MEDICA CLAIMS [308111801] 47.7 percent of total billed charges 32.86 50.35 Technical (Hospital) Services Koh Fungal Wet Mount PX-3068722000 CDM 87220 CPT 306 RC inpatient 53 53 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES EPO [308136803] 41.97 percent of total billed charges 32.86 50.35 Technical (Hospital) Services Koh Fungal Wet Mount PX-3068722000 CDM 87220 CPT 306 RC inpatient 53 53 HEALTHPARTNERS SX009 HEALTHPARTNERS 41.97 percent of total billed charges 32.86 50.35 Technical (Hospital) Services Koh Fungal Wet Mount PX-3068722000 CDM 87220 CPT 306 RC inpatient 53 53 MULTIPLAN INC 34080 [3081285] MULTIPLAN INC [308128501] 50.35 percent of total billed charges 32.86 50.35 Technical (Hospital) Services Koh Fungal Wet Mount PX-3068722000 CDM 87220 CPT 306 RC inpatient 53 53 CIGNA 62308 [3081051] CIGNA 62308 [308105105] 41.97 percent of total billed charges 32.86 50.35 Technical (Hospital) Services Koh Fungal Wet Mount PX-3068722000 CDM 87220 CPT 306 RC inpatient 53 53 CIGNA 62308 [3081051] CIGNA STATE OF WYOMING [308105107] 41.97 percent of total billed charges 32.86 50.35 Technical (Hospital) Services Koh Fungal Wet Mount PX-3068722000 CDM 87220 CPT 306 RC inpatient 53 53 BLUE CROSS BLUE SHIELD WELLMARK SB889 [3081026] BCBS WYOMING [308102603] 50.35 percent of total billed charges 32.86 50.35 Technical (Hospital) Services Koh Fungal Wet Mount PX-3068722000 CDM 87220 CPT 306 RC inpatient 53 53 MEDICA (COMMERCIAL) 94265 [3081118] MEDICA CLAIMS [308111801] 47.7 percent of total billed charges 32.86 50.35 Technical (Hospital) Services Koh Fungal Wet Mount PX-3068722000 CDM 87220 CPT 306 RC inpatient 53 53 UNITED HEALTHCARE (COMMERCIAL) [3081199] UNITED HEALTHCARE 87726 [308119901] 32.86 percent of total billed charges 32.86 50.35 Technical (Hospital) Services Koh Fungal Wet Mount PX-3068722000 CDM 87220 CPT 306 RC inpatient 53 53 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES HDHP [308136802] 41.97 percent of total billed charges 32.86 50.35 Technical (Hospital) Services Koh Fungal Wet Mount PX-3068722000 CDM 87220 CPT 306 RC inpatient 53 53 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES PPO [308136801] 41.97 percent of total billed charges 32.86 50.35 Technical (Hospital) Services Wet Mount Cervical or Skin PX-3068721000 CDM 87210 CPT 306 RC outpatient 62 62 MULTIPLAN INC 34080 [3081285] MULTIPLAN INC [308128501] 58.9 percent of total billed charges 38.44 58.9 Technical (Hospital) Services Wet Mount Cervical or Skin PX-3068721000 CDM 87210 CPT 306 RC outpatient 62 62 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES EPO [308136803] 49.6 percent of total billed charges 38.44 58.9 Technical (Hospital) Services Wet Mount Cervical or Skin PX-3068721000 CDM 87210 CPT 306 RC outpatient 62 62 CIGNA 62308 [3081051] CIGNA 62308 [308105105] 49.6 percent of total billed charges 38.44 58.9 Technical (Hospital) Services Wet Mount Cervical or Skin PX-3068721000 CDM 87210 CPT 306 RC outpatient 62 62 CIGNA 62308 [3081051] CIGNA STATE OF WYOMING [308105107] 49.6 percent of total billed charges 38.44 58.9 Technical (Hospital) Services Wet Mount Cervical or Skin PX-3068721000 CDM 87210 CPT 306 RC outpatient 62 62 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES HDHP [308136802] 49.6 percent of total billed charges 38.44 58.9 Technical (Hospital) Services Wet Mount Cervical or Skin PX-3068721000 CDM 87210 CPT 306 RC outpatient 62 62 BLUE CROSS BLUE SHIELD WELLMARK SB889 [3081026] BCBS WYOMING [308102603] 58.9 percent of total billed charges 38.44 58.9 Technical (Hospital) Services Wet Mount Cervical or Skin PX-3068721000 CDM 87210 CPT 306 RC outpatient 62 62 HEALTHPARTNERS SX009 HEALTHPARTNERS 49.6 percent of total billed charges 38.44 58.9 Technical (Hospital) Services Wet Mount Cervical or Skin PX-3068721000 CDM 87210 CPT 306 RC outpatient 62 62 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES PPO [308136801] 49.6 percent of total billed charges 38.44 58.9 Technical (Hospital) Services Wet Mount Cervical or Skin PX-3068721000 CDM 87210 CPT 306 RC outpatient 62 62 UNITED HEALTHCARE (COMMERCIAL) [3081199] UNITED HEALTHCARE 87726 [308119901] 38.44 percent of total billed charges 38.44 58.9 Technical (Hospital) Services Wet Mount Cervical or Skin PX-3068721000 CDM 87210 CPT 306 RC outpatient 62 62 MEDICA (COMMERCIAL) 94265 [3081118] MEDICA CLAIMS [308111801] 55.8 percent of total billed charges 38.44 58.9 Technical (Hospital) Services Wet Mount Cervical or Skin PX-3068721000 CDM 87210 CPT 306 RC inpatient 62 62 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES PPO [308136801] 49.09 percent of total billed charges 38.44 58.9 Technical (Hospital) Services Wet Mount Cervical or Skin PX-3068721000 CDM 87210 CPT 306 RC inpatient 62 62 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES HDHP [308136802] 49.09 percent of total billed charges 38.44 58.9 Technical (Hospital) Services Wet Mount Cervical or Skin PX-3068721000 CDM 87210 CPT 306 RC inpatient 62 62 UNITED HEALTHCARE (COMMERCIAL) [3081199] UNITED HEALTHCARE 87726 [308119901] 38.44 percent of total billed charges 38.44 58.9 Technical (Hospital) Services Wet Mount Cervical or Skin PX-3068721000 CDM 87210 CPT 306 RC inpatient 62 62 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES EPO [308136803] 49.09 percent of total billed charges 38.44 58.9 Technical (Hospital) Services Wet Mount Cervical or Skin PX-3068721000 CDM 87210 CPT 306 RC inpatient 62 62 HEALTHPARTNERS SX009 HEALTHPARTNERS 49.09 percent of total billed charges 38.44 58.9 Technical (Hospital) Services Wet Mount Cervical or Skin PX-3068721000 CDM 87210 CPT 306 RC inpatient 62 62 MEDICA (COMMERCIAL) 94265 [3081118] MEDICA CLAIMS [308111801] 55.8 percent of total billed charges 38.44 58.9 Technical (Hospital) Services Wet Mount Cervical or Skin PX-3068721000 CDM 87210 CPT 306 RC inpatient 62 62 MULTIPLAN INC 34080 [3081285] MULTIPLAN INC [308128501] 58.9 percent of total billed charges 38.44 58.9 Technical (Hospital) Services Wet Mount Cervical or Skin PX-3068721000 CDM 87210 CPT 306 RC inpatient 62 62 BLUE CROSS BLUE SHIELD WELLMARK SB889 [3081026] BCBS WYOMING [308102603] 58.9 percent of total billed charges 38.44 58.9 Technical (Hospital) Services Wet Mount Cervical or Skin PX-3068721000 CDM 87210 CPT 306 RC inpatient 62 62 CIGNA 62308 [3081051] CIGNA 62308 [308105105] 49.09 percent of total billed charges 38.44 58.9 Technical (Hospital) Services Wet Mount Cervical or Skin PX-3068721000 CDM 87210 CPT 306 RC inpatient 62 62 CIGNA 62308 [3081051] CIGNA STATE OF WYOMING [308105107] 49.09 percent of total billed charges 38.44 58.9 Technical (Hospital) Services Ref Parasitic Examination Smear PX-3068720900 CDM 87209 CPT 306 RC inpatient 119 119 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES PPO [308136801] 94.22 percent of total billed charges 73.78 113.05 Technical (Hospital) Services Ref Parasitic Examination Smear PX-3068720900 CDM 87209 CPT 306 RC inpatient 119 119 UNITED HEALTHCARE (COMMERCIAL) [3081199] UNITED HEALTHCARE 87726 [308119901] 73.78 percent of total billed charges 73.78 113.05 Technical (Hospital) Services Ref Parasitic Examination Smear PX-3068720900 CDM 87209 CPT 306 RC inpatient 119 119 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES HDHP [308136802] 94.22 percent of total billed charges 73.78 113.05 Technical (Hospital) Services Ref Parasitic Examination Smear PX-3068720900 CDM 87209 CPT 306 RC inpatient 119 119 MEDICA (COMMERCIAL) 94265 [3081118] MEDICA CLAIMS [308111801] 107.1 percent of total billed charges 73.78 113.05 Technical (Hospital) Services Ref Parasitic Examination Smear PX-3068720900 CDM 87209 CPT 306 RC inpatient 119 119 MULTIPLAN INC 34080 [3081285] MULTIPLAN INC [308128501] 113.05 percent of total billed charges 73.78 113.05 Technical (Hospital) Services Ref Parasitic Examination Smear PX-3068720900 CDM 87209 CPT 306 RC inpatient 119 119 CIGNA 62308 [3081051] CIGNA 62308 [308105105] 94.22 percent of total billed charges 73.78 113.05 Technical (Hospital) Services Ref Parasitic Examination Smear PX-3068720900 CDM 87209 CPT 306 RC inpatient 119 119 CIGNA 62308 [3081051] CIGNA STATE OF WYOMING [308105107] 94.22 percent of total billed charges 73.78 113.05 Technical (Hospital) Services Ref Parasitic Examination Smear PX-3068720900 CDM 87209 CPT 306 RC inpatient 119 119 BLUE CROSS BLUE SHIELD WELLMARK SB889 [3081026] BCBS WYOMING [308102603] 113.05 percent of total billed charges 73.78 113.05 Technical (Hospital) Services Ref Parasitic Examination Smear PX-3068720900 CDM 87209 CPT 306 RC inpatient 119 119 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES EPO [308136803] 94.22 percent of total billed charges 73.78 113.05 Technical (Hospital) Services Ref Parasitic Examination Smear PX-3068720900 CDM 87209 CPT 306 RC inpatient 119 119 HEALTHPARTNERS SX009 HEALTHPARTNERS 94.22 percent of total billed charges 73.78 113.05 Technical (Hospital) Services Ref Parasitic Examination Smear PX-3068720900 CDM 87209 CPT 306 RC outpatient 119 119 MEDICA (COMMERCIAL) 94265 [3081118] MEDICA CLAIMS [308111801] 107.1 percent of total billed charges 73.78 113.05 Technical (Hospital) Services Ref Parasitic Examination Smear PX-3068720900 CDM 87209 CPT 306 RC outpatient 119 119 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES HDHP [308136802] 95.2 percent of total billed charges 73.78 113.05 Technical (Hospital) Services Ref Parasitic Examination Smear PX-3068720900 CDM 87209 CPT 306 RC outpatient 119 119 BLUE CROSS BLUE SHIELD WELLMARK SB889 [3081026] BCBS WYOMING [308102603] 113.05 percent of total billed charges 73.78 113.05 Technical (Hospital) Services Ref Parasitic Examination Smear PX-3068720900 CDM 87209 CPT 306 RC outpatient 119 119 CIGNA 62308 [3081051] CIGNA 62308 [308105105] 95.2 percent of total billed charges 73.78 113.05 Technical (Hospital) Services Ref Parasitic Examination Smear PX-3068720900 CDM 87209 CPT 306 RC outpatient 119 119 CIGNA 62308 [3081051] CIGNA STATE OF WYOMING [308105107] 95.2 percent of total billed charges 73.78 113.05 Technical (Hospital) Services Ref Parasitic Examination Smear PX-3068720900 CDM 87209 CPT 306 RC outpatient 119 119 MULTIPLAN INC 34080 [3081285] MULTIPLAN INC [308128501] 113.05 percent of total billed charges 73.78 113.05 Technical (Hospital) Services Ref Parasitic Examination Smear PX-3068720900 CDM 87209 CPT 306 RC outpatient 119 119 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES EPO [308136803] 95.2 percent of total billed charges 73.78 113.05 Technical (Hospital) Services Ref Parasitic Examination Smear PX-3068720900 CDM 87209 CPT 306 RC outpatient 119 119 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES PPO [308136801] 95.2 percent of total billed charges 73.78 113.05 Technical (Hospital) Services Ref Parasitic Examination Smear PX-3068720900 CDM 87209 CPT 306 RC outpatient 119 119 HEALTHPARTNERS SX009 HEALTHPARTNERS 95.2 percent of total billed charges 73.78 113.05 Technical (Hospital) Services Ref Parasitic Examination Smear PX-3068720900 CDM 87209 CPT 306 RC outpatient 119 119 UNITED HEALTHCARE (COMMERCIAL) [3081199] UNITED HEALTHCARE 87726 [308119901] 73.78 percent of total billed charges 73.78 113.05 Technical (Hospital) Services Ref Parasitic Examination Smear PX-3068720901 CDM 87209 CPT 306 RC outpatient 266 266 HEALTHPARTNERS SX009 HEALTHPARTNERS 212.8 percent of total billed charges 164.92 252.7 Technical (Hospital) Services Ref Parasitic Examination Smear PX-3068720901 CDM 87209 CPT 306 RC outpatient 266 266 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES PPO [308136801] 212.8 percent of total billed charges 164.92 252.7 Technical (Hospital) Services Ref Parasitic Examination Smear PX-3068720901 CDM 87209 CPT 306 RC outpatient 266 266 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES EPO [308136803] 212.8 percent of total billed charges 164.92 252.7 Technical (Hospital) Services Ref Parasitic Examination Smear PX-3068720901 CDM 87209 CPT 306 RC outpatient 266 266 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES HDHP [308136802] 212.8 percent of total billed charges 164.92 252.7 Technical (Hospital) Services Ref Parasitic Examination Smear PX-3068720901 CDM 87209 CPT 306 RC outpatient 266 266 MULTIPLAN INC 34080 [3081285] MULTIPLAN INC [308128501] 252.7 percent of total billed charges 164.92 252.7 Technical (Hospital) Services Ref Parasitic Examination Smear PX-3068720901 CDM 87209 CPT 306 RC outpatient 266 266 BLUE CROSS BLUE SHIELD WELLMARK SB889 [3081026] BCBS WYOMING [308102603] 252.7 percent of total billed charges 164.92 252.7 Technical (Hospital) Services Ref Parasitic Examination Smear PX-3068720901 CDM 87209 CPT 306 RC outpatient 266 266 UNITED HEALTHCARE (COMMERCIAL) [3081199] UNITED HEALTHCARE 87726 [308119901] 164.92 percent of total billed charges 164.92 252.7 Technical (Hospital) Services Ref Parasitic Examination Smear PX-3068720901 CDM 87209 CPT 306 RC outpatient 266 266 CIGNA 62308 [3081051] CIGNA 62308 [308105105] 212.8 percent of total billed charges 164.92 252.7 Technical (Hospital) Services Ref Parasitic Examination Smear PX-3068720901 CDM 87209 CPT 306 RC outpatient 266 266 CIGNA 62308 [3081051] CIGNA STATE OF WYOMING [308105107] 212.8 percent of total billed charges 164.92 252.7 Technical (Hospital) Services Ref Parasitic Examination Smear PX-3068720901 CDM 87209 CPT 306 RC outpatient 266 266 MEDICA (COMMERCIAL) 94265 [3081118] MEDICA CLAIMS [308111801] 239.4 percent of total billed charges 164.92 252.7 Technical (Hospital) Services Ref Parasitic Examination Smear PX-3068720901 CDM 87209 CPT 306 RC inpatient 266 266 UNITED HEALTHCARE (COMMERCIAL) [3081199] UNITED HEALTHCARE 87726 [308119901] 164.92 percent of total billed charges 164.92 252.7 Technical (Hospital) Services Ref Parasitic Examination Smear PX-3068720901 CDM 87209 CPT 306 RC inpatient 266 266 BLUE CROSS BLUE SHIELD WELLMARK SB889 [3081026] BCBS WYOMING [308102603] 252.7 percent of total billed charges 164.92 252.7 Technical (Hospital) Services Ref Parasitic Examination Smear PX-3068720901 CDM 87209 CPT 306 RC inpatient 266 266 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES PPO [308136801] 210.62 percent of total billed charges 164.92 252.7 Technical (Hospital) Services Ref Parasitic Examination Smear PX-3068720901 CDM 87209 CPT 306 RC inpatient 266 266 HEALTHPARTNERS SX009 HEALTHPARTNERS 210.62 percent of total billed charges 164.92 252.7 Technical (Hospital) Services Ref Parasitic Examination Smear PX-3068720901 CDM 87209 CPT 306 RC inpatient 266 266 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES HDHP [308136802] 210.62 percent of total billed charges 164.92 252.7 Technical (Hospital) Services Ref Parasitic Examination Smear PX-3068720901 CDM 87209 CPT 306 RC inpatient 266 266 MULTIPLAN INC 34080 [3081285] MULTIPLAN INC [308128501] 252.7 percent of total billed charges 164.92 252.7 Technical (Hospital) Services Ref Parasitic Examination Smear PX-3068720901 CDM 87209 CPT 306 RC inpatient 266 266 MEDICA (COMMERCIAL) 94265 [3081118] MEDICA CLAIMS [308111801] 239.4 percent of total billed charges 164.92 252.7 Technical (Hospital) Services Ref Parasitic Examination Smear PX-3068720901 CDM 87209 CPT 306 RC inpatient 266 266 CIGNA 62308 [3081051] CIGNA 62308 [308105105] 210.62 percent of total billed charges 164.92 252.7 Technical (Hospital) Services Ref Parasitic Examination Smear PX-3068720901 CDM 87209 CPT 306 RC inpatient 266 266 CIGNA 62308 [3081051] CIGNA STATE OF WYOMING [308105107] 210.62 percent of total billed charges 164.92 252.7 Technical (Hospital) Services Ref Parasitic Examination Smear PX-3068720901 CDM 87209 CPT 306 RC inpatient 266 266 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES EPO [308136803] 210.62 percent of total billed charges 164.92 252.7 Technical (Hospital) Services Bld Parasites PX-3068720700 CDM 87207 CPT 306 RC inpatient 118 118 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES HDHP [308136802] 93.43 percent of total billed charges 73.16 112.1 Technical (Hospital) Services Bld Parasites PX-3068720700 CDM 87207 CPT 306 RC inpatient 118 118 MEDICA (COMMERCIAL) 94265 [3081118] MEDICA CLAIMS [308111801] 106.2 percent of total billed charges 73.16 112.1 Technical (Hospital) Services Bld Parasites PX-3068720700 CDM 87207 CPT 306 RC inpatient 118 118 MULTIPLAN INC 34080 [3081285] MULTIPLAN INC [308128501] 112.1 percent of total billed charges 73.16 112.1 Technical (Hospital) Services Bld Parasites PX-3068720700 CDM 87207 CPT 306 RC inpatient 118 118 HEALTHPARTNERS SX009 HEALTHPARTNERS 93.43 percent of total billed charges 73.16 112.1 Technical (Hospital) Services Bld Parasites PX-3068720700 CDM 87207 CPT 306 RC inpatient 118 118 BLUE CROSS BLUE SHIELD WELLMARK SB889 [3081026] BCBS WYOMING [308102603] 112.1 percent of total billed charges 73.16 112.1 Technical (Hospital) Services Bld Parasites PX-3068720700 CDM 87207 CPT 306 RC inpatient 118 118 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES PPO [308136801] 93.43 percent of total billed charges 73.16 112.1 Technical (Hospital) Services Bld Parasites PX-3068720700 CDM 87207 CPT 306 RC inpatient 118 118 UNITED HEALTHCARE (COMMERCIAL) [3081199] UNITED HEALTHCARE 87726 [308119901] 73.16 percent of total billed charges 73.16 112.1 Technical (Hospital) Services Bld Parasites PX-3068720700 CDM 87207 CPT 306 RC inpatient 118 118 CIGNA 62308 [3081051] CIGNA 62308 [308105105] 93.43 percent of total billed charges 73.16 112.1 Technical (Hospital) Services Bld Parasites PX-3068720700 CDM 87207 CPT 306 RC inpatient 118 118 CIGNA 62308 [3081051] CIGNA STATE OF WYOMING [308105107] 93.43 percent of total billed charges 73.16 112.1 Technical (Hospital) Services Bld Parasites PX-3068720700 CDM 87207 CPT 306 RC inpatient 118 118 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES EPO [308136803] 93.43 percent of total billed charges 73.16 112.1 Technical (Hospital) Services Bld Parasites PX-3068720700 CDM 87207 CPT 306 RC outpatient 118 118 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES EPO [308136803] 94.4 percent of total billed charges 73.16 112.1 Technical (Hospital) Services Bld Parasites PX-3068720700 CDM 87207 CPT 306 RC outpatient 118 118 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES PPO [308136801] 94.4 percent of total billed charges 73.16 112.1 Technical (Hospital) Services Bld Parasites PX-3068720700 CDM 87207 CPT 306 RC outpatient 118 118 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES HDHP [308136802] 94.4 percent of total billed charges 73.16 112.1 Technical (Hospital) Services Bld Parasites PX-3068720700 CDM 87207 CPT 306 RC outpatient 118 118 UNITED HEALTHCARE (COMMERCIAL) [3081199] UNITED HEALTHCARE 87726 [308119901] 73.16 percent of total billed charges 73.16 112.1 Technical (Hospital) Services Bld Parasites PX-3068720700 CDM 87207 CPT 306 RC outpatient 118 118 BLUE CROSS BLUE SHIELD WELLMARK SB889 [3081026] BCBS WYOMING [308102603] 112.1 percent of total billed charges 73.16 112.1 Technical (Hospital) Services Bld Parasites PX-3068720700 CDM 87207 CPT 306 RC outpatient 118 118 MULTIPLAN INC 34080 [3081285] MULTIPLAN INC [308128501] 112.1 percent of total billed charges 73.16 112.1 Technical (Hospital) Services Bld Parasites PX-3068720700 CDM 87207 CPT 306 RC outpatient 118 118 HEALTHPARTNERS SX009 HEALTHPARTNERS 94.4 percent of total billed charges 73.16 112.1 Technical (Hospital) Services Bld Parasites PX-3068720700 CDM 87207 CPT 306 RC outpatient 118 118 MEDICA (COMMERCIAL) 94265 [3081118] MEDICA CLAIMS [308111801] 106.2 percent of total billed charges 73.16 112.1 Technical (Hospital) Services Bld Parasites PX-3068720700 CDM 87207 CPT 306 RC outpatient 118 118 CIGNA 62308 [3081051] CIGNA 62308 [308105105] 94.4 percent of total billed charges 73.16 112.1 Technical (Hospital) Services Bld Parasites PX-3068720700 CDM 87207 CPT 306 RC outpatient 118 118 CIGNA 62308 [3081051] CIGNA STATE OF WYOMING [308105107] 94.4 percent of total billed charges 73.16 112.1 Technical (Hospital) Services Stain Florescent Acid Fast PX-3068720600 CDM 87206 CPT 306 RC outpatient 84 84 MEDICA (COMMERCIAL) 94265 [3081118] MEDICA CLAIMS [308111801] 75.6 percent of total billed charges 52.08 79.8 Technical (Hospital) Services Stain Florescent Acid Fast PX-3068720600 CDM 87206 CPT 306 RC outpatient 84 84 UNITED HEALTHCARE (COMMERCIAL) [3081199] UNITED HEALTHCARE 87726 [308119901] 52.08 percent of total billed charges 52.08 79.8 Technical (Hospital) Services Stain Florescent Acid Fast PX-3068720600 CDM 87206 CPT 306 RC outpatient 84 84 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES PPO [308136801] 67.2 percent of total billed charges 52.08 79.8 Technical (Hospital) Services Stain Florescent Acid Fast PX-3068720600 CDM 87206 CPT 306 RC outpatient 84 84 HEALTHPARTNERS SX009 HEALTHPARTNERS 67.2 percent of total billed charges 52.08 79.8 Technical (Hospital) Services Stain Florescent Acid Fast PX-3068720600 CDM 87206 CPT 306 RC outpatient 84 84 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES HDHP [308136802] 67.2 percent of total billed charges 52.08 79.8 Technical (Hospital) Services Stain Florescent Acid Fast PX-3068720600 CDM 87206 CPT 306 RC outpatient 84 84 BLUE CROSS BLUE SHIELD WELLMARK SB889 [3081026] BCBS WYOMING [308102603] 79.8 percent of total billed charges 52.08 79.8 Technical (Hospital) Services Stain Florescent Acid Fast PX-3068720600 CDM 87206 CPT 306 RC outpatient 84 84 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES EPO [308136803] 67.2 percent of total billed charges 52.08 79.8 Technical (Hospital) Services Stain Florescent Acid Fast PX-3068720600 CDM 87206 CPT 306 RC outpatient 84 84 CIGNA 62308 [3081051] CIGNA 62308 [308105105] 67.2 percent of total billed charges 52.08 79.8 Technical (Hospital) Services Stain Florescent Acid Fast PX-3068720600 CDM 87206 CPT 306 RC outpatient 84 84 CIGNA 62308 [3081051] CIGNA STATE OF WYOMING [308105107] 67.2 percent of total billed charges 52.08 79.8 Technical (Hospital) Services Stain Florescent Acid Fast PX-3068720600 CDM 87206 CPT 306 RC outpatient 84 84 MULTIPLAN INC 34080 [3081285] MULTIPLAN INC [308128501] 79.8 percent of total billed charges 52.08 79.8 Technical (Hospital) Services Stain Florescent Acid Fast PX-3068720600 CDM 87206 CPT 306 RC inpatient 84 84 UNITED HEALTHCARE (COMMERCIAL) [3081199] UNITED HEALTHCARE 87726 [308119901] 52.08 percent of total billed charges 52.08 79.8 Technical (Hospital) Services Stain Florescent Acid Fast PX-3068720600 CDM 87206 CPT 306 RC inpatient 84 84 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES HDHP [308136802] 66.51 percent of total billed charges 52.08 79.8 Technical (Hospital) Services Stain Florescent Acid Fast PX-3068720600 CDM 87206 CPT 306 RC inpatient 84 84 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES PPO [308136801] 66.51 percent of total billed charges 52.08 79.8 Technical (Hospital) Services Stain Florescent Acid Fast PX-3068720600 CDM 87206 CPT 306 RC inpatient 84 84 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES EPO [308136803] 66.51 percent of total billed charges 52.08 79.8 Technical (Hospital) Services Stain Florescent Acid Fast PX-3068720600 CDM 87206 CPT 306 RC inpatient 84 84 HEALTHPARTNERS SX009 HEALTHPARTNERS 66.51 percent of total billed charges 52.08 79.8 Technical (Hospital) Services Stain Florescent Acid Fast PX-3068720600 CDM 87206 CPT 306 RC inpatient 84 84 MEDICA (COMMERCIAL) 94265 [3081118] MEDICA CLAIMS [308111801] 75.6 percent of total billed charges 52.08 79.8 Technical (Hospital) Services Stain Florescent Acid Fast PX-3068720600 CDM 87206 CPT 306 RC inpatient 84 84 MULTIPLAN INC 34080 [3081285] MULTIPLAN INC [308128501] 79.8 percent of total billed charges 52.08 79.8 Technical (Hospital) Services Stain Florescent Acid Fast PX-3068720600 CDM 87206 CPT 306 RC inpatient 84 84 CIGNA 62308 [3081051] CIGNA 62308 [308105105] 66.51 percent of total billed charges 52.08 79.8 Technical (Hospital) Services Stain Florescent Acid Fast PX-3068720600 CDM 87206 CPT 306 RC inpatient 84 84 CIGNA 62308 [3081051] CIGNA STATE OF WYOMING [308105107] 66.51 percent of total billed charges 52.08 79.8 Technical (Hospital) Services Stain Florescent Acid Fast PX-3068720600 CDM 87206 CPT 306 RC inpatient 84 84 BLUE CROSS BLUE SHIELD WELLMARK SB889 [3081026] BCBS WYOMING [308102603] 79.8 percent of total billed charges 52.08 79.8 Technical (Hospital) Services Direct Smear Only PX-3068720500 CDM 87205 CPT 306 RC inpatient 70 70 MULTIPLAN INC 34080 [3081285] MULTIPLAN INC [308128501] 66.5 percent of total billed charges 43.4 66.5 Technical (Hospital) Services Direct Smear Only PX-3068720500 CDM 87205 CPT 306 RC inpatient 70 70 CIGNA 62308 [3081051] CIGNA 62308 [308105105] 55.43 percent of total billed charges 43.4 66.5 Technical (Hospital) Services Direct Smear Only PX-3068720500 CDM 87205 CPT 306 RC inpatient 70 70 CIGNA 62308 [3081051] CIGNA STATE OF WYOMING [308105107] 55.43 percent of total billed charges 43.4 66.5 Technical (Hospital) Services Direct Smear Only PX-3068720500 CDM 87205 CPT 306 RC inpatient 70 70 BLUE CROSS BLUE SHIELD WELLMARK SB889 [3081026] BCBS WYOMING [308102603] 66.5 percent of total billed charges 43.4 66.5 Technical (Hospital) Services Direct Smear Only PX-3068720500 CDM 87205 CPT 306 RC inpatient 70 70 MEDICA (COMMERCIAL) 94265 [3081118] MEDICA CLAIMS [308111801] 63 percent of total billed charges 43.4 66.5 Technical (Hospital) Services Direct Smear Only PX-3068720500 CDM 87205 CPT 306 RC inpatient 70 70 HEALTHPARTNERS SX009 HEALTHPARTNERS 55.43 percent of total billed charges 43.4 66.5 Technical (Hospital) Services Direct Smear Only PX-3068720500 CDM 87205 CPT 306 RC inpatient 70 70 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES EPO [308136803] 55.43 percent of total billed charges 43.4 66.5 Technical (Hospital) Services Direct Smear Only PX-3068720500 CDM 87205 CPT 306 RC inpatient 70 70 UNITED HEALTHCARE (COMMERCIAL) [3081199] UNITED HEALTHCARE 87726 [308119901] 43.4 percent of total billed charges 43.4 66.5 Technical (Hospital) Services Direct Smear Only PX-3068720500 CDM 87205 CPT 306 RC inpatient 70 70 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES HDHP [308136802] 55.43 percent of total billed charges 43.4 66.5 Technical (Hospital) Services Direct Smear Only PX-3068720500 CDM 87205 CPT 306 RC inpatient 70 70 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES PPO [308136801] 55.43 percent of total billed charges 43.4 66.5 Technical (Hospital) Services Direct Smear Only PX-3068720500 CDM 87205 CPT 306 RC outpatient 70 70 MEDICA (COMMERCIAL) 94265 [3081118] MEDICA CLAIMS [308111801] 63 percent of total billed charges 43.4 66.5 Technical (Hospital) Services Direct Smear Only PX-3068720500 CDM 87205 CPT 306 RC outpatient 70 70 UNITED HEALTHCARE (COMMERCIAL) [3081199] UNITED HEALTHCARE 87726 [308119901] 43.4 percent of total billed charges 43.4 66.5 Technical (Hospital) Services Direct Smear Only PX-3068720500 CDM 87205 CPT 306 RC outpatient 70 70 HEALTHPARTNERS SX009 HEALTHPARTNERS 56 percent of total billed charges 43.4 66.5 Technical (Hospital) Services Direct Smear Only PX-3068720500 CDM 87205 CPT 306 RC outpatient 70 70 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES PPO [308136801] 56 percent of total billed charges 43.4 66.5 Technical (Hospital) Services Direct Smear Only PX-3068720500 CDM 87205 CPT 306 RC outpatient 70 70 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES EPO [308136803] 56 percent of total billed charges 43.4 66.5 Technical (Hospital) Services Direct Smear Only PX-3068720500 CDM 87205 CPT 306 RC outpatient 70 70 MULTIPLAN INC 34080 [3081285] MULTIPLAN INC [308128501] 66.5 percent of total billed charges 43.4 66.5 Technical (Hospital) Services Direct Smear Only PX-3068720500 CDM 87205 CPT 306 RC outpatient 70 70 CIGNA 62308 [3081051] CIGNA 62308 [308105105] 56 percent of total billed charges 43.4 66.5 Technical (Hospital) Services Direct Smear Only PX-3068720500 CDM 87205 CPT 306 RC outpatient 70 70 CIGNA 62308 [3081051] CIGNA STATE OF WYOMING [308105107] 56 percent of total billed charges 43.4 66.5 Technical (Hospital) Services Direct Smear Only PX-3068720500 CDM 87205 CPT 306 RC outpatient 70 70 BLUE CROSS BLUE SHIELD WELLMARK SB889 [3081026] BCBS WYOMING [308102603] 66.5 percent of total billed charges 43.4 66.5 Technical (Hospital) Services Direct Smear Only PX-3068720500 CDM 87205 CPT 306 RC outpatient 70 70 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES HDHP [308136802] 56 percent of total billed charges 43.4 66.5 Technical (Hospital) Services Susceptability Aerobic Mic PX-3068718600 CDM 87186 CPT 306 RC outpatient 137 137 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES PPO [308136801] 109.6 percent of total billed charges 84.94 130.15 Technical (Hospital) Services Susceptability Aerobic Mic PX-3068718600 CDM 87186 CPT 306 RC outpatient 137 137 HEALTHPARTNERS SX009 HEALTHPARTNERS 109.6 percent of total billed charges 84.94 130.15 Technical (Hospital) Services Susceptability Aerobic Mic PX-3068718600 CDM 87186 CPT 306 RC outpatient 137 137 UNITED HEALTHCARE (COMMERCIAL) [3081199] UNITED HEALTHCARE 87726 [308119901] 84.94 percent of total billed charges 84.94 130.15 Technical (Hospital) Services Susceptability Aerobic Mic PX-3068718600 CDM 87186 CPT 306 RC outpatient 137 137 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES HDHP [308136802] 109.6 percent of total billed charges 84.94 130.15 Technical (Hospital) Services Susceptability Aerobic Mic PX-3068718600 CDM 87186 CPT 306 RC outpatient 137 137 BLUE CROSS BLUE SHIELD WELLMARK SB889 [3081026] BCBS WYOMING [308102603] 130.15 percent of total billed charges 84.94 130.15 Technical (Hospital) Services Susceptability Aerobic Mic PX-3068718600 CDM 87186 CPT 306 RC outpatient 137 137 CIGNA 62308 [3081051] CIGNA 62308 [308105105] 109.6 percent of total billed charges 84.94 130.15 Technical (Hospital) Services Susceptability Aerobic Mic PX-3068718600 CDM 87186 CPT 306 RC outpatient 137 137 CIGNA 62308 [3081051] CIGNA STATE OF WYOMING [308105107] 109.6 percent of total billed charges 84.94 130.15 Technical (Hospital) Services Susceptability Aerobic Mic PX-3068718600 CDM 87186 CPT 306 RC outpatient 137 137 MULTIPLAN INC 34080 [3081285] MULTIPLAN INC [308128501] 130.15 percent of total billed charges 84.94 130.15 Technical (Hospital) Services Susceptability Aerobic Mic PX-3068718600 CDM 87186 CPT 306 RC outpatient 137 137 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES EPO [308136803] 109.6 percent of total billed charges 84.94 130.15 Technical (Hospital) Services Susceptability Aerobic Mic PX-3068718600 CDM 87186 CPT 306 RC outpatient 137 137 MEDICA (COMMERCIAL) 94265 [3081118] MEDICA CLAIMS [308111801] 123.3 percent of total billed charges 84.94 130.15 Technical (Hospital) Services Susceptability Aerobic Mic PX-3068718600 CDM 87186 CPT 306 RC inpatient 137 137 MULTIPLAN INC 34080 [3081285] MULTIPLAN INC [308128501] 130.15 percent of total billed charges 84.94 130.15 Technical (Hospital) Services Susceptability Aerobic Mic PX-3068718600 CDM 87186 CPT 306 RC inpatient 137 137 MEDICA (COMMERCIAL) 94265 [3081118] MEDICA CLAIMS [308111801] 123.3 percent of total billed charges 84.94 130.15 Technical (Hospital) Services Susceptability Aerobic Mic PX-3068718600 CDM 87186 CPT 306 RC inpatient 137 137 CIGNA 62308 [3081051] CIGNA 62308 [308105105] 108.48 percent of total billed charges 84.94 130.15 Technical (Hospital) Services Susceptability Aerobic Mic PX-3068718600 CDM 87186 CPT 306 RC inpatient 137 137 CIGNA 62308 [3081051] CIGNA STATE OF WYOMING [308105107] 108.48 percent of total billed charges 84.94 130.15 Technical (Hospital) Services Susceptability Aerobic Mic PX-3068718600 CDM 87186 CPT 306 RC inpatient 137 137 BLUE CROSS BLUE SHIELD WELLMARK SB889 [3081026] BCBS WYOMING [308102603] 130.15 percent of total billed charges 84.94 130.15 Technical (Hospital) Services Susceptability Aerobic Mic PX-3068718600 CDM 87186 CPT 306 RC inpatient 137 137 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES EPO [308136803] 108.48 percent of total billed charges 84.94 130.15 Technical (Hospital) Services Susceptability Aerobic Mic PX-3068718600 CDM 87186 CPT 306 RC inpatient 137 137 HEALTHPARTNERS SX009 HEALTHPARTNERS 108.48 percent of total billed charges 84.94 130.15 Technical (Hospital) Services Susceptability Aerobic Mic PX-3068718600 CDM 87186 CPT 306 RC inpatient 137 137 UNITED HEALTHCARE (COMMERCIAL) [3081199] UNITED HEALTHCARE 87726 [308119901] 84.94 percent of total billed charges 84.94 130.15 Technical (Hospital) Services Susceptability Aerobic Mic PX-3068718600 CDM 87186 CPT 306 RC inpatient 137 137 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES HDHP [308136802] 108.48 percent of total billed charges 84.94 130.15 Technical (Hospital) Services Susceptability Aerobic Mic PX-3068718600 CDM 87186 CPT 306 RC inpatient 137 137 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES PPO [308136801] 108.48 percent of total billed charges 84.94 130.15 Technical (Hospital) Services Ref Aerobic Susceptibility per Org PX-3068718603 CDM 87186 CPT 306 RC outpatient 141 141 MEDICA (COMMERCIAL) 94265 [3081118] MEDICA CLAIMS [308111801] 126.9 percent of total billed charges 87.42 133.95 Technical (Hospital) Services Ref Aerobic Susceptibility per Org PX-3068718603 CDM 87186 CPT 306 RC outpatient 141 141 UNITED HEALTHCARE (COMMERCIAL) [3081199] UNITED HEALTHCARE 87726 [308119901] 87.42 percent of total billed charges 87.42 133.95 Technical (Hospital) Services Ref Aerobic Susceptibility per Org PX-3068718603 CDM 87186 CPT 306 RC outpatient 141 141 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES PPO [308136801] 112.8 percent of total billed charges 87.42 133.95 Technical (Hospital) Services Ref Aerobic Susceptibility per Org PX-3068718603 CDM 87186 CPT 306 RC outpatient 141 141 HEALTHPARTNERS SX009 HEALTHPARTNERS 112.8 percent of total billed charges 87.42 133.95 Technical (Hospital) Services Ref Aerobic Susceptibility per Org PX-3068718603 CDM 87186 CPT 306 RC outpatient 141 141 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES EPO [308136803] 112.8 percent of total billed charges 87.42 133.95 Technical (Hospital) Services Ref Aerobic Susceptibility per Org PX-3068718603 CDM 87186 CPT 306 RC outpatient 141 141 MULTIPLAN INC 34080 [3081285] MULTIPLAN INC [308128501] 133.95 percent of total billed charges 87.42 133.95 Technical (Hospital) Services Ref Aerobic Susceptibility per Org PX-3068718603 CDM 87186 CPT 306 RC outpatient 141 141 CIGNA 62308 [3081051] CIGNA 62308 [308105105] 112.8 percent of total billed charges 87.42 133.95 Technical (Hospital) Services Ref Aerobic Susceptibility per Org PX-3068718603 CDM 87186 CPT 306 RC outpatient 141 141 CIGNA 62308 [3081051] CIGNA STATE OF WYOMING [308105107] 112.8 percent of total billed charges 87.42 133.95 Technical (Hospital) Services Ref Aerobic Susceptibility per Org PX-3068718603 CDM 87186 CPT 306 RC outpatient 141 141 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES HDHP [308136802] 112.8 percent of total billed charges 87.42 133.95 Technical (Hospital) Services Ref Aerobic Susceptibility per Org PX-3068718603 CDM 87186 CPT 306 RC outpatient 141 141 BLUE CROSS BLUE SHIELD WELLMARK SB889 [3081026] BCBS WYOMING [308102603] 133.95 percent of total billed charges 87.42 133.95 Technical (Hospital) Services Ref Aerobic Susceptibility per Org PX-3068718603 CDM 87186 CPT 306 RC inpatient 141 141 UNITED HEALTHCARE (COMMERCIAL) [3081199] UNITED HEALTHCARE 87726 [308119901] 87.42 percent of total billed charges 87.42 133.95 Technical (Hospital) Services Ref Aerobic Susceptibility per Org PX-3068718603 CDM 87186 CPT 306 RC inpatient 141 141 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES HDHP [308136802] 111.64 percent of total billed charges 87.42 133.95 Technical (Hospital) Services Ref Aerobic Susceptibility per Org PX-3068718603 CDM 87186 CPT 306 RC inpatient 141 141 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES PPO [308136801] 111.64 percent of total billed charges 87.42 133.95 Technical (Hospital) Services Ref Aerobic Susceptibility per Org PX-3068718603 CDM 87186 CPT 306 RC inpatient 141 141 CIGNA 62308 [3081051] CIGNA 62308 [308105105] 111.64 percent of total billed charges 87.42 133.95 Technical (Hospital) Services Ref Aerobic Susceptibility per Org PX-3068718603 CDM 87186 CPT 306 RC inpatient 141 141 CIGNA 62308 [3081051] CIGNA STATE OF WYOMING [308105107] 111.64 percent of total billed charges 87.42 133.95 Technical (Hospital) Services Ref Aerobic Susceptibility per Org PX-3068718603 CDM 87186 CPT 306 RC inpatient 141 141 BLUE CROSS BLUE SHIELD WELLMARK SB889 [3081026] BCBS WYOMING [308102603] 133.95 percent of total billed charges 87.42 133.95 Technical (Hospital) Services Ref Aerobic Susceptibility per Org PX-3068718603 CDM 87186 CPT 306 RC inpatient 141 141 MEDICA (COMMERCIAL) 94265 [3081118] MEDICA CLAIMS [308111801] 126.9 percent of total billed charges 87.42 133.95 Technical (Hospital) Services Ref Aerobic Susceptibility per Org PX-3068718603 CDM 87186 CPT 306 RC inpatient 141 141 MULTIPLAN INC 34080 [3081285] MULTIPLAN INC [308128501] 133.95 percent of total billed charges 87.42 133.95 Technical (Hospital) Services Ref Aerobic Susceptibility per Org PX-3068718603 CDM 87186 CPT 306 RC inpatient 141 141 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES EPO [308136803] 111.64 percent of total billed charges 87.42 133.95 Technical (Hospital) Services Ref Aerobic Susceptibility per Org PX-3068718603 CDM 87186 CPT 306 RC inpatient 141 141 HEALTHPARTNERS SX009 HEALTHPARTNERS 111.64 percent of total billed charges 87.42 133.95 Technical (Hospital) Services PR Susceptability Aerobic Mic PX-8718600 CDM 87186 CPT 306 RC inpatient 137 137 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES PPO [308136801] 108.48 percent of total billed charges 84.94 130.15 Technical (Hospital) Services PR Susceptability Aerobic Mic PX-8718600 CDM 87186 CPT 306 RC inpatient 137 137 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES HDHP [308136802] 108.48 percent of total billed charges 84.94 130.15 Technical (Hospital) Services PR Susceptability Aerobic Mic PX-8718600 CDM 87186 CPT 306 RC inpatient 137 137 MEDICA (COMMERCIAL) 94265 [3081118] MEDICA CLAIMS [308111801] 123.3 percent of total billed charges 84.94 130.15 Technical (Hospital) Services PR Susceptability Aerobic Mic PX-8718600 CDM 87186 CPT 306 RC inpatient 137 137 UNITED HEALTHCARE (COMMERCIAL) [3081199] UNITED HEALTHCARE 87726 [308119901] 84.94 percent of total billed charges 84.94 130.15 Technical (Hospital) Services PR Susceptability Aerobic Mic PX-8718600 CDM 87186 CPT 306 RC inpatient 137 137 CIGNA 62308 [3081051] CIGNA 62308 [308105105] 108.48 percent of total billed charges 84.94 130.15 Technical (Hospital) Services PR Susceptability Aerobic Mic PX-8718600 CDM 87186 CPT 306 RC inpatient 137 137 CIGNA 62308 [3081051] CIGNA STATE OF WYOMING [308105107] 108.48 percent of total billed charges 84.94 130.15 Technical (Hospital) Services PR Susceptability Aerobic Mic PX-8718600 CDM 87186 CPT 306 RC inpatient 137 137 BLUE CROSS BLUE SHIELD WELLMARK SB889 [3081026] BCBS WYOMING [308102603] 130.15 percent of total billed charges 84.94 130.15 Technical (Hospital) Services PR Susceptability Aerobic Mic PX-8718600 CDM 87186 CPT 306 RC inpatient 137 137 MULTIPLAN INC 34080 [3081285] MULTIPLAN INC [308128501] 130.15 percent of total billed charges 84.94 130.15 Technical (Hospital) Services PR Susceptability Aerobic Mic PX-8718600 CDM 87186 CPT 306 RC inpatient 137 137 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES EPO [308136803] 108.48 percent of total billed charges 84.94 130.15 Technical (Hospital) Services PR Susceptability Aerobic Mic PX-8718600 CDM 87186 CPT 306 RC inpatient 137 137 HEALTHPARTNERS SX009 HEALTHPARTNERS 108.48 percent of total billed charges 84.94 130.15 Technical (Hospital) Services PR Susceptability Aerobic Mic PX-8718600 CDM 87186 CPT 306 RC outpatient 137 137 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES EPO [308136803] 109.6 percent of total billed charges 84.94 130.15 Technical (Hospital) Services PR Susceptability Aerobic Mic PX-8718600 CDM 87186 CPT 306 RC outpatient 137 137 CIGNA 62308 [3081051] CIGNA 62308 [308105105] 109.6 percent of total billed charges 84.94 130.15 Technical (Hospital) Services PR Susceptability Aerobic Mic PX-8718600 CDM 87186 CPT 306 RC outpatient 137 137 CIGNA 62308 [3081051] CIGNA STATE OF WYOMING [308105107] 109.6 percent of total billed charges 84.94 130.15 Technical (Hospital) Services PR Susceptability Aerobic Mic PX-8718600 CDM 87186 CPT 306 RC outpatient 137 137 MULTIPLAN INC 34080 [3081285] MULTIPLAN INC [308128501] 130.15 percent of total billed charges 84.94 130.15 Technical (Hospital) Services PR Susceptability Aerobic Mic PX-8718600 CDM 87186 CPT 306 RC outpatient 137 137 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES HDHP [308136802] 109.6 percent of total billed charges 84.94 130.15 Technical (Hospital) Services PR Susceptability Aerobic Mic PX-8718600 CDM 87186 CPT 306 RC outpatient 137 137 BLUE CROSS BLUE SHIELD WELLMARK SB889 [3081026] BCBS WYOMING [308102603] 130.15 percent of total billed charges 84.94 130.15 Technical (Hospital) Services PR Susceptability Aerobic Mic PX-8718600 CDM 87186 CPT 306 RC outpatient 137 137 UNITED HEALTHCARE (COMMERCIAL) [3081199] UNITED HEALTHCARE 87726 [308119901] 84.94 percent of total billed charges 84.94 130.15 Technical (Hospital) Services PR Susceptability Aerobic Mic PX-8718600 CDM 87186 CPT 306 RC outpatient 137 137 HEALTHPARTNERS SX009 HEALTHPARTNERS 109.6 percent of total billed charges 84.94 130.15 Technical (Hospital) Services PR Susceptability Aerobic Mic PX-8718600 CDM 87186 CPT 306 RC outpatient 137 137 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES PPO [308136801] 109.6 percent of total billed charges 84.94 130.15 Technical (Hospital) Services PR Susceptability Aerobic Mic PX-8718600 CDM 87186 CPT 306 RC outpatient 137 137 MEDICA (COMMERCIAL) 94265 [3081118] MEDICA CLAIMS [308111801] 123.3 percent of total billed charges 84.94 130.15 Technical (Hospital) Services Blac Beta Lactamase PX-3068718500 CDM 87185 CPT 306 RC inpatient 75 75 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES PPO [308136801] 59.39 percent of total billed charges 46.5 71.25 Technical (Hospital) Services Blac Beta Lactamase PX-3068718500 CDM 87185 CPT 306 RC inpatient 75 75 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES HDHP [308136802] 59.39 percent of total billed charges 46.5 71.25 Technical (Hospital) Services Blac Beta Lactamase PX-3068718500 CDM 87185 CPT 306 RC inpatient 75 75 UNITED HEALTHCARE (COMMERCIAL) [3081199] UNITED HEALTHCARE 87726 [308119901] 46.5 percent of total billed charges 46.5 71.25 Technical (Hospital) Services Blac Beta Lactamase PX-3068718500 CDM 87185 CPT 306 RC inpatient 75 75 MULTIPLAN INC 34080 [3081285] MULTIPLAN INC [308128501] 71.25 percent of total billed charges 46.5 71.25 Technical (Hospital) Services Blac Beta Lactamase PX-3068718500 CDM 87185 CPT 306 RC inpatient 75 75 MEDICA (COMMERCIAL) 94265 [3081118] MEDICA CLAIMS [308111801] 67.5 percent of total billed charges 46.5 71.25 Technical (Hospital) Services Blac Beta Lactamase PX-3068718500 CDM 87185 CPT 306 RC inpatient 75 75 BLUE CROSS BLUE SHIELD WELLMARK SB889 [3081026] BCBS WYOMING [308102603] 71.25 percent of total billed charges 46.5 71.25 Technical (Hospital) Services Blac Beta Lactamase PX-3068718500 CDM 87185 CPT 306 RC inpatient 75 75 CIGNA 62308 [3081051] CIGNA 62308 [308105105] 59.39 percent of total billed charges 46.5 71.25 Technical (Hospital) Services Blac Beta Lactamase PX-3068718500 CDM 87185 CPT 306 RC inpatient 75 75 CIGNA 62308 [3081051] CIGNA STATE OF WYOMING [308105107] 59.39 percent of total billed charges 46.5 71.25 Technical (Hospital) Services Blac Beta Lactamase PX-3068718500 CDM 87185 CPT 306 RC inpatient 75 75 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES EPO [308136803] 59.39 percent of total billed charges 46.5 71.25 Technical (Hospital) Services Blac Beta Lactamase PX-3068718500 CDM 87185 CPT 306 RC inpatient 75 75 HEALTHPARTNERS SX009 HEALTHPARTNERS 59.39 percent of total billed charges 46.5 71.25 Technical (Hospital) Services Blac Beta Lactamase PX-3068718500 CDM 87185 CPT 306 RC outpatient 75 75 MEDICA (COMMERCIAL) 94265 [3081118] MEDICA CLAIMS [308111801] 67.5 percent of total billed charges 46.5 71.25 Technical (Hospital) Services Blac Beta Lactamase PX-3068718500 CDM 87185 CPT 306 RC outpatient 75 75 CIGNA 62308 [3081051] CIGNA 62308 [308105105] 60 percent of total billed charges 46.5 71.25 Technical (Hospital) Services Blac Beta Lactamase PX-3068718500 CDM 87185 CPT 306 RC outpatient 75 75 CIGNA 62308 [3081051] CIGNA STATE OF WYOMING [308105107] 60 percent of total billed charges 46.5 71.25 Technical (Hospital) Services Blac Beta Lactamase PX-3068718500 CDM 87185 CPT 306 RC outpatient 75 75 MULTIPLAN INC 34080 [3081285] MULTIPLAN INC [308128501] 71.25 percent of total billed charges 46.5 71.25 Technical (Hospital) Services Blac Beta Lactamase PX-3068718500 CDM 87185 CPT 306 RC outpatient 75 75 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES EPO [308136803] 60 percent of total billed charges 46.5 71.25 Technical (Hospital) Services Blac Beta Lactamase PX-3068718500 CDM 87185 CPT 306 RC outpatient 75 75 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES HDHP [308136802] 60 percent of total billed charges 46.5 71.25 Technical (Hospital) Services Blac Beta Lactamase PX-3068718500 CDM 87185 CPT 306 RC outpatient 75 75 BLUE CROSS BLUE SHIELD WELLMARK SB889 [3081026] BCBS WYOMING [308102603] 71.25 percent of total billed charges 46.5 71.25 Technical (Hospital) Services Blac Beta Lactamase PX-3068718500 CDM 87185 CPT 306 RC outpatient 75 75 UNITED HEALTHCARE (COMMERCIAL) [3081199] UNITED HEALTHCARE 87726 [308119901] 46.5 percent of total billed charges 46.5 71.25 Technical (Hospital) Services Blac Beta Lactamase PX-3068718500 CDM 87185 CPT 306 RC outpatient 75 75 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES PPO [308136801] 60 percent of total billed charges 46.5 71.25 Technical (Hospital) Services Blac Beta Lactamase PX-3068718500 CDM 87185 CPT 306 RC outpatient 75 75 HEALTHPARTNERS SX009 HEALTHPARTNERS 60 percent of total billed charges 46.5 71.25 Technical (Hospital) Services D Test Clindamycin PX-3068718400 CDM 87184 CPT 306 RC outpatient 95 95 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES HDHP [308136802] 76 percent of total billed charges 58.9 90.25 Technical (Hospital) Services D Test Clindamycin PX-3068718400 CDM 87184 CPT 306 RC outpatient 95 95 BLUE CROSS BLUE SHIELD WELLMARK SB889 [3081026] BCBS WYOMING [308102603] 90.25 percent of total billed charges 58.9 90.25 Technical (Hospital) Services D Test Clindamycin PX-3068718400 CDM 87184 CPT 306 RC outpatient 95 95 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES EPO [308136803] 76 percent of total billed charges 58.9 90.25 Technical (Hospital) Services D Test Clindamycin PX-3068718400 CDM 87184 CPT 306 RC outpatient 95 95 MULTIPLAN INC 34080 [3081285] MULTIPLAN INC [308128501] 90.25 percent of total billed charges 58.9 90.25 Technical (Hospital) Services D Test Clindamycin PX-3068718400 CDM 87184 CPT 306 RC outpatient 95 95 CIGNA 62308 [3081051] CIGNA 62308 [308105105] 76 percent of total billed charges 58.9 90.25 Technical (Hospital) Services D Test Clindamycin PX-3068718400 CDM 87184 CPT 306 RC outpatient 95 95 CIGNA 62308 [3081051] CIGNA STATE OF WYOMING [308105107] 76 percent of total billed charges 58.9 90.25 Technical (Hospital) Services D Test Clindamycin PX-3068718400 CDM 87184 CPT 306 RC outpatient 95 95 UNITED HEALTHCARE (COMMERCIAL) [3081199] UNITED HEALTHCARE 87726 [308119901] 58.9 percent of total billed charges 58.9 90.25 Technical (Hospital) Services D Test Clindamycin PX-3068718400 CDM 87184 CPT 306 RC outpatient 95 95 HEALTHPARTNERS SX009 HEALTHPARTNERS 76 percent of total billed charges 58.9 90.25 Technical (Hospital) Services D Test Clindamycin PX-3068718400 CDM 87184 CPT 306 RC inpatient 95 95 UNITED HEALTHCARE (COMMERCIAL) [3081199] UNITED HEALTHCARE 87726 [308119901] 58.9 percent of total billed charges 58.9 90.25 Technical (Hospital) Services D Test Clindamycin PX-3068718400 CDM 87184 CPT 306 RC inpatient 95 95 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES HDHP [308136802] 75.22 percent of total billed charges 58.9 90.25 Technical (Hospital) Services D Test Clindamycin PX-3068718400 CDM 87184 CPT 306 RC inpatient 95 95 MEDICA (COMMERCIAL) 94265 [3081118] MEDICA CLAIMS [308111801] 85.5 percent of total billed charges 58.9 90.25 Technical (Hospital) Services D Test Clindamycin PX-3068718400 CDM 87184 CPT 306 RC inpatient 95 95 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES PPO [308136801] 75.22 percent of total billed charges 58.9 90.25 Technical (Hospital) Services D Test Clindamycin PX-3068718400 CDM 87184 CPT 306 RC inpatient 95 95 MULTIPLAN INC 34080 [3081285] MULTIPLAN INC [308128501] 90.25 percent of total billed charges 58.9 90.25 Technical (Hospital) Services D Test Clindamycin PX-3068718400 CDM 87184 CPT 306 RC inpatient 95 95 BLUE CROSS BLUE SHIELD WELLMARK SB889 [3081026] BCBS WYOMING [308102603] 90.25 percent of total billed charges 58.9 90.25 Technical (Hospital) Services D Test Clindamycin PX-3068718400 CDM 87184 CPT 306 RC inpatient 95 95 CIGNA 62308 [3081051] CIGNA 62308 [308105105] 75.22 percent of total billed charges 58.9 90.25 Technical (Hospital) Services D Test Clindamycin PX-3068718400 CDM 87184 CPT 306 RC inpatient 95 95 CIGNA 62308 [3081051] CIGNA STATE OF WYOMING [308105107] 75.22 percent of total billed charges 58.9 90.25 Technical (Hospital) Services D Test Clindamycin PX-3068718400 CDM 87184 CPT 306 RC inpatient 95 95 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES EPO [308136803] 75.22 percent of total billed charges 58.9 90.25 Technical (Hospital) Services D Test Clindamycin PX-3068718400 CDM 87184 CPT 306 RC outpatient 95 95 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES PPO [308136801] 76 percent of total billed charges 58.9 90.25 Technical (Hospital) Services D Test Clindamycin PX-3068718400 CDM 87184 CPT 306 RC outpatient 95 95 MEDICA (COMMERCIAL) 94265 [3081118] MEDICA CLAIMS [308111801] 85.5 percent of total billed charges 58.9 90.25 Technical (Hospital) Services D Test Clindamycin PX-3068718400 CDM 87184 CPT 306 RC inpatient 95 95 HEALTHPARTNERS SX009 HEALTHPARTNERS 75.22 percent of total billed charges 58.9 90.25 Technical (Hospital) Services Ref Ova & Parasite Examination PX-3068717700 CDM 87177 CPT 306 RC inpatient 127 127 CIGNA 62308 [3081051] CIGNA 62308 [308105105] 100.56 percent of total billed charges 78.74 120.65 Technical (Hospital) Services Ref Ova & Parasite Examination PX-3068717700 CDM 87177 CPT 306 RC inpatient 127 127 CIGNA 62308 [3081051] CIGNA STATE OF WYOMING [308105107] 100.56 percent of total billed charges 78.74 120.65 Technical (Hospital) Services Ref Ova & Parasite Examination PX-3068717700 CDM 87177 CPT 306 RC inpatient 127 127 BLUE CROSS BLUE SHIELD WELLMARK SB889 [3081026] BCBS WYOMING [308102603] 120.65 percent of total billed charges 78.74 120.65 Technical (Hospital) Services Ref Ova & Parasite Examination PX-3068717700 CDM 87177 CPT 306 RC inpatient 127 127 MEDICA (COMMERCIAL) 94265 [3081118] MEDICA CLAIMS [308111801] 114.3 percent of total billed charges 78.74 120.65 Technical (Hospital) Services Ref Ova & Parasite Examination PX-3068717700 CDM 87177 CPT 306 RC inpatient 127 127 MULTIPLAN INC 34080 [3081285] MULTIPLAN INC [308128501] 120.65 percent of total billed charges 78.74 120.65 Technical (Hospital) Services Ref Ova & Parasite Examination PX-3068717700 CDM 87177 CPT 306 RC inpatient 127 127 HEALTHPARTNERS SX009 HEALTHPARTNERS 100.56 percent of total billed charges 78.74 120.65 Technical (Hospital) Services Ref Ova & Parasite Examination PX-3068717700 CDM 87177 CPT 306 RC inpatient 127 127 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES EPO [308136803] 100.56 percent of total billed charges 78.74 120.65 Technical (Hospital) Services Ref Ova & Parasite Examination PX-3068717700 CDM 87177 CPT 306 RC inpatient 127 127 UNITED HEALTHCARE (COMMERCIAL) [3081199] UNITED HEALTHCARE 87726 [308119901] 78.74 percent of total billed charges 78.74 120.65 Technical (Hospital) Services Ref Ova & Parasite Examination PX-3068717700 CDM 87177 CPT 306 RC inpatient 127 127 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES HDHP [308136802] 100.56 percent of total billed charges 78.74 120.65 Technical (Hospital) Services Ref Ova & Parasite Examination PX-3068717700 CDM 87177 CPT 306 RC inpatient 127 127 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES PPO [308136801] 100.56 percent of total billed charges 78.74 120.65 Technical (Hospital) Services Ref Ova & Parasite Examination PX-3068717700 CDM 87177 CPT 306 RC outpatient 127 127 HEALTHPARTNERS SX009 HEALTHPARTNERS 101.6 percent of total billed charges 78.74 120.65 Technical (Hospital) Services Ref Ova & Parasite Examination PX-3068717700 CDM 87177 CPT 306 RC outpatient 127 127 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES PPO [308136801] 101.6 percent of total billed charges 78.74 120.65 Technical (Hospital) Services Ref Ova & Parasite Examination PX-3068717700 CDM 87177 CPT 306 RC outpatient 127 127 MEDICA (COMMERCIAL) 94265 [3081118] MEDICA CLAIMS [308111801] 114.3 percent of total billed charges 78.74 120.65 Technical (Hospital) Services Ref Ova & Parasite Examination PX-3068717700 CDM 87177 CPT 306 RC outpatient 127 127 UNITED HEALTHCARE (COMMERCIAL) [3081199] UNITED HEALTHCARE 87726 [308119901] 78.74 percent of total billed charges 78.74 120.65 Technical (Hospital) Services Ref Ova & Parasite Examination PX-3068717700 CDM 87177 CPT 306 RC outpatient 127 127 BLUE CROSS BLUE SHIELD WELLMARK SB889 [3081026] BCBS WYOMING [308102603] 120.65 percent of total billed charges 78.74 120.65 Technical (Hospital) Services Ref Ova & Parasite Examination PX-3068717700 CDM 87177 CPT 306 RC outpatient 127 127 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES HDHP [308136802] 101.6 percent of total billed charges 78.74 120.65 Technical (Hospital) Services Ref Ova & Parasite Examination PX-3068717700 CDM 87177 CPT 306 RC outpatient 127 127 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES EPO [308136803] 101.6 percent of total billed charges 78.74 120.65 Technical (Hospital) Services Ref Ova & Parasite Examination PX-3068717700 CDM 87177 CPT 306 RC outpatient 127 127 MULTIPLAN INC 34080 [3081285] MULTIPLAN INC [308128501] 120.65 percent of total billed charges 78.74 120.65 Technical (Hospital) Services Ref Ova & Parasite Examination PX-3068717700 CDM 87177 CPT 306 RC outpatient 127 127 CIGNA 62308 [3081051] CIGNA 62308 [308105105] 101.6 percent of total billed charges 78.74 120.65 Technical (Hospital) Services Ref Ova & Parasite Examination PX-3068717700 CDM 87177 CPT 306 RC outpatient 127 127 CIGNA 62308 [3081051] CIGNA STATE OF WYOMING [308105107] 101.6 percent of total billed charges 78.74 120.65 Technical (Hospital) Services Ref Ova & Parasite Examination PX-3068717701 CDM 87177 CPT 306 RC outpatient 131 131 HEALTHPARTNERS SX009 HEALTHPARTNERS 104.8 percent of total billed charges 81.22 124.45 Technical (Hospital) Services Ref Ova & Parasite Examination PX-3068717701 CDM 87177 CPT 306 RC outpatient 131 131 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES HDHP [308136802] 104.8 percent of total billed charges 81.22 124.45 Technical (Hospital) Services Ref Ova & Parasite Examination PX-3068717701 CDM 87177 CPT 306 RC outpatient 131 131 BLUE CROSS BLUE SHIELD WELLMARK SB889 [3081026] BCBS WYOMING [308102603] 124.45 percent of total billed charges 81.22 124.45 Technical (Hospital) Services Ref Ova & Parasite Examination PX-3068717701 CDM 87177 CPT 306 RC outpatient 131 131 UNITED HEALTHCARE (COMMERCIAL) [3081199] UNITED HEALTHCARE 87726 [308119901] 81.22 percent of total billed charges 81.22 124.45 Technical (Hospital) Services Ref Ova & Parasite Examination PX-3068717701 CDM 87177 CPT 306 RC outpatient 131 131 MULTIPLAN INC 34080 [3081285] MULTIPLAN INC [308128501] 124.45 percent of total billed charges 81.22 124.45 Technical (Hospital) Services Ref Ova & Parasite Examination PX-3068717701 CDM 87177 CPT 306 RC outpatient 131 131 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES EPO [308136803] 104.8 percent of total billed charges 81.22 124.45 Technical (Hospital) Services Ref Ova & Parasite Examination PX-3068717701 CDM 87177 CPT 306 RC outpatient 131 131 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES PPO [308136801] 104.8 percent of total billed charges 81.22 124.45 Technical (Hospital) Services Ref Ova & Parasite Examination PX-3068717701 CDM 87177 CPT 306 RC outpatient 131 131 MEDICA (COMMERCIAL) 94265 [3081118] MEDICA CLAIMS [308111801] 117.9 percent of total billed charges 81.22 124.45 Technical (Hospital) Services Ref Ova & Parasite Examination PX-3068717701 CDM 87177 CPT 306 RC outpatient 131 131 CIGNA 62308 [3081051] CIGNA 62308 [308105105] 104.8 percent of total billed charges 81.22 124.45 Technical (Hospital) Services Ref Ova & Parasite Examination PX-3068717701 CDM 87177 CPT 306 RC outpatient 131 131 CIGNA 62308 [3081051] CIGNA STATE OF WYOMING [308105107] 104.8 percent of total billed charges 81.22 124.45 Technical (Hospital) Services Ref Ova & Parasite Examination PX-3068717701 CDM 87177 CPT 306 RC inpatient 131 131 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES PPO [308136801] 103.73 percent of total billed charges 81.22 124.45 Technical (Hospital) Services Ref Ova & Parasite Examination PX-3068717701 CDM 87177 CPT 306 RC inpatient 131 131 BLUE CROSS BLUE SHIELD WELLMARK SB889 [3081026] BCBS WYOMING [308102603] 124.45 percent of total billed charges 81.22 124.45 Technical (Hospital) Services Ref Ova & Parasite Examination PX-3068717701 CDM 87177 CPT 306 RC inpatient 131 131 UNITED HEALTHCARE (COMMERCIAL) [3081199] UNITED HEALTHCARE 87726 [308119901] 81.22 percent of total billed charges 81.22 124.45 Technical (Hospital) Services Ref Ova & Parasite Examination PX-3068717701 CDM 87177 CPT 306 RC inpatient 131 131 MULTIPLAN INC 34080 [3081285] MULTIPLAN INC [308128501] 124.45 percent of total billed charges 81.22 124.45 Technical (Hospital) Services Ref Ova & Parasite Examination PX-3068717701 CDM 87177 CPT 306 RC inpatient 131 131 MEDICA (COMMERCIAL) 94265 [3081118] MEDICA CLAIMS [308111801] 117.9 percent of total billed charges 81.22 124.45 Technical (Hospital) Services Ref Ova & Parasite Examination PX-3068717701 CDM 87177 CPT 306 RC inpatient 131 131 HEALTHPARTNERS SX009 HEALTHPARTNERS 103.73 percent of total billed charges 81.22 124.45 Technical (Hospital) Services Ref Ova & Parasite Examination PX-3068717701 CDM 87177 CPT 306 RC inpatient 131 131 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES HDHP [308136802] 103.73 percent of total billed charges 81.22 124.45 Technical (Hospital) Services Ref Ova & Parasite Examination PX-3068717701 CDM 87177 CPT 306 RC inpatient 131 131 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES EPO [308136803] 103.73 percent of total billed charges 81.22 124.45 Technical (Hospital) Services Ref Ova & Parasite Examination PX-3068717701 CDM 87177 CPT 306 RC inpatient 131 131 CIGNA 62308 [3081051] CIGNA 62308 [308105105] 103.73 percent of total billed charges 81.22 124.45 Technical (Hospital) Services Ref Ova & Parasite Examination PX-3068717701 CDM 87177 CPT 306 RC inpatient 131 131 CIGNA 62308 [3081051] CIGNA STATE OF WYOMING [308105107] 103.73 percent of total billed charges 81.22 124.45 Technical (Hospital) Services Pinworm Prep PX-3068717200 CDM 87172 CPT 306 RC inpatient 70 70 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES PPO [308136801] 55.43 percent of total billed charges 43.4 66.5 Technical (Hospital) Services Pinworm Prep PX-3068717200 CDM 87172 CPT 306 RC inpatient 70 70 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES HDHP [308136802] 55.43 percent of total billed charges 43.4 66.5 Technical (Hospital) Services Pinworm Prep PX-3068717200 CDM 87172 CPT 306 RC inpatient 70 70 MEDICA (COMMERCIAL) 94265 [3081118] MEDICA CLAIMS [308111801] 63 percent of total billed charges 43.4 66.5 Technical (Hospital) Services Pinworm Prep PX-3068717200 CDM 87172 CPT 306 RC inpatient 70 70 UNITED HEALTHCARE (COMMERCIAL) [3081199] UNITED HEALTHCARE 87726 [308119901] 43.4 percent of total billed charges 43.4 66.5 Technical (Hospital) Services Pinworm Prep PX-3068717200 CDM 87172 CPT 306 RC inpatient 70 70 MULTIPLAN INC 34080 [3081285] MULTIPLAN INC [308128501] 66.5 percent of total billed charges 43.4 66.5 Technical (Hospital) Services Pinworm Prep PX-3068717200 CDM 87172 CPT 306 RC inpatient 70 70 BLUE CROSS BLUE SHIELD WELLMARK SB889 [3081026] BCBS WYOMING [308102603] 66.5 percent of total billed charges 43.4 66.5 Technical (Hospital) Services Pinworm Prep PX-3068717200 CDM 87172 CPT 306 RC inpatient 70 70 CIGNA 62308 [3081051] CIGNA 62308 [308105105] 55.43 percent of total billed charges 43.4 66.5 Technical (Hospital) Services Pinworm Prep PX-3068717200 CDM 87172 CPT 306 RC inpatient 70 70 CIGNA 62308 [3081051] CIGNA STATE OF WYOMING [308105107] 55.43 percent of total billed charges 43.4 66.5 Technical (Hospital) Services Pinworm Prep PX-3068717200 CDM 87172 CPT 306 RC inpatient 70 70 HEALTHPARTNERS SX009 HEALTHPARTNERS 55.43 percent of total billed charges 43.4 66.5 Technical (Hospital) Services Pinworm Prep PX-3068717200 CDM 87172 CPT 306 RC inpatient 70 70 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES EPO [308136803] 55.43 percent of total billed charges 43.4 66.5 Technical (Hospital) Services Pinworm Prep PX-3068717200 CDM 87172 CPT 306 RC outpatient 70 70 MEDICA (COMMERCIAL) 94265 [3081118] MEDICA CLAIMS [308111801] 63 percent of total billed charges 43.4 66.5 Technical (Hospital) Services Pinworm Prep PX-3068717200 CDM 87172 CPT 306 RC outpatient 70 70 UNITED HEALTHCARE (COMMERCIAL) [3081199] UNITED HEALTHCARE 87726 [308119901] 43.4 percent of total billed charges 43.4 66.5 Technical (Hospital) Services Pinworm Prep PX-3068717200 CDM 87172 CPT 306 RC outpatient 70 70 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES PPO [308136801] 56 percent of total billed charges 43.4 66.5 Technical (Hospital) Services Pinworm Prep PX-3068717200 CDM 87172 CPT 306 RC outpatient 70 70 HEALTHPARTNERS SX009 HEALTHPARTNERS 56 percent of total billed charges 43.4 66.5 Technical (Hospital) Services Pinworm Prep PX-3068717200 CDM 87172 CPT 306 RC outpatient 70 70 CIGNA 62308 [3081051] CIGNA STATE OF WYOMING [308105107] 56 percent of total billed charges 43.4 66.5 Technical (Hospital) Services Pinworm Prep PX-3068717200 CDM 87172 CPT 306 RC outpatient 70 70 CIGNA 62308 [3081051] CIGNA 62308 [308105105] 56 percent of total billed charges 43.4 66.5 Technical (Hospital) Services Pinworm Prep PX-3068717200 CDM 87172 CPT 306 RC outpatient 70 70 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES EPO [308136803] 56 percent of total billed charges 43.4 66.5 Technical (Hospital) Services Pinworm Prep PX-3068717200 CDM 87172 CPT 306 RC outpatient 70 70 MULTIPLAN INC 34080 [3081285] MULTIPLAN INC [308128501] 66.5 percent of total billed charges 43.4 66.5 Technical (Hospital) Services Pinworm Prep PX-3068717200 CDM 87172 CPT 306 RC outpatient 70 70 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES HDHP [308136802] 56 percent of total billed charges 43.4 66.5 Technical (Hospital) Services Pinworm Prep PX-3068717200 CDM 87172 CPT 306 RC outpatient 70 70 BLUE CROSS BLUE SHIELD WELLMARK SB889 [3081026] BCBS WYOMING [308102603] 66.5 percent of total billed charges 43.4 66.5 Technical (Hospital) Services Macro Worm Macroscopic Parasit PX-3068716900 CDM 87169 CPT 306 RC outpatient 70 70 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES PPO [308136801] 56 percent of total billed charges 43.4 66.5 Technical (Hospital) Services Macro Worm Macroscopic Parasit PX-3068716900 CDM 87169 CPT 306 RC outpatient 70 70 HEALTHPARTNERS SX009 HEALTHPARTNERS 56 percent of total billed charges 43.4 66.5 Technical (Hospital) Services Macro Worm Macroscopic Parasit PX-3068716900 CDM 87169 CPT 306 RC outpatient 70 70 UNITED HEALTHCARE (COMMERCIAL) [3081199] UNITED HEALTHCARE 87726 [308119901] 43.4 percent of total billed charges 43.4 66.5 Technical (Hospital) Services Macro Worm Macroscopic Parasit PX-3068716900 CDM 87169 CPT 306 RC outpatient 70 70 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES HDHP [308136802] 56 percent of total billed charges 43.4 66.5 Technical (Hospital) Services Macro Worm Macroscopic Parasit PX-3068716900 CDM 87169 CPT 306 RC outpatient 70 70 BLUE CROSS BLUE SHIELD WELLMARK SB889 [3081026] BCBS WYOMING [308102603] 66.5 percent of total billed charges 43.4 66.5 Technical (Hospital) Services Macro Worm Macroscopic Parasit PX-3068716900 CDM 87169 CPT 306 RC outpatient 70 70 MULTIPLAN INC 34080 [3081285] MULTIPLAN INC [308128501] 66.5 percent of total billed charges 43.4 66.5 Technical (Hospital) Services Macro Worm Macroscopic Parasit PX-3068716900 CDM 87169 CPT 306 RC outpatient 70 70 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES EPO [308136803] 56 percent of total billed charges 43.4 66.5 Technical (Hospital) Services Macro Worm Macroscopic Parasit PX-3068716900 CDM 87169 CPT 306 RC outpatient 70 70 CIGNA 62308 [3081051] CIGNA 62308 [308105105] 56 percent of total billed charges 43.4 66.5 Technical (Hospital) Services Macro Worm Macroscopic Parasit PX-3068716900 CDM 87169 CPT 306 RC outpatient 70 70 CIGNA 62308 [3081051] CIGNA STATE OF WYOMING [308105107] 56 percent of total billed charges 43.4 66.5 Technical (Hospital) Services Macro Worm Macroscopic Parasit PX-3068716900 CDM 87169 CPT 306 RC outpatient 70 70 MEDICA (COMMERCIAL) 94265 [3081118] MEDICA CLAIMS [308111801] 63 percent of total billed charges 43.4 66.5 Technical (Hospital) Services Macro Worm Macroscopic Parasit PX-3068716900 CDM 87169 CPT 306 RC inpatient 70 70 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES EPO [308136803] 55.43 percent of total billed charges 43.4 66.5 Technical (Hospital) Services Macro Worm Macroscopic Parasit PX-3068716900 CDM 87169 CPT 306 RC inpatient 70 70 HEALTHPARTNERS SX009 HEALTHPARTNERS 55.43 percent of total billed charges 43.4 66.5 Technical (Hospital) Services Macro Worm Macroscopic Parasit PX-3068716900 CDM 87169 CPT 306 RC inpatient 70 70 MULTIPLAN INC 34080 [3081285] MULTIPLAN INC [308128501] 66.5 percent of total billed charges 43.4 66.5 Technical (Hospital) Services Macro Worm Macroscopic Parasit PX-3068716900 CDM 87169 CPT 306 RC inpatient 70 70 MEDICA (COMMERCIAL) 94265 [3081118] MEDICA CLAIMS [308111801] 63 percent of total billed charges 43.4 66.5 Technical (Hospital) Services Macro Worm Macroscopic Parasit PX-3068716900 CDM 87169 CPT 306 RC inpatient 70 70 CIGNA 62308 [3081051] CIGNA 62308 [308105105] 55.43 percent of total billed charges 43.4 66.5 Technical (Hospital) Services Macro Worm Macroscopic Parasit PX-3068716900 CDM 87169 CPT 306 RC inpatient 70 70 CIGNA 62308 [3081051] CIGNA STATE OF WYOMING [308105107] 55.43 percent of total billed charges 43.4 66.5 Technical (Hospital) Services Macro Worm Macroscopic Parasit PX-3068716900 CDM 87169 CPT 306 RC inpatient 70 70 BLUE CROSS BLUE SHIELD WELLMARK SB889 [3081026] BCBS WYOMING [308102603] 66.5 percent of total billed charges 43.4 66.5 Technical (Hospital) Services Macro Worm Macroscopic Parasit PX-3068716900 CDM 87169 CPT 306 RC inpatient 70 70 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES PPO [308136801] 55.43 percent of total billed charges 43.4 66.5 Technical (Hospital) Services Macro Worm Macroscopic Parasit PX-3068716900 CDM 87169 CPT 306 RC inpatient 70 70 UNITED HEALTHCARE (COMMERCIAL) [3081199] UNITED HEALTHCARE 87726 [308119901] 43.4 percent of total billed charges 43.4 66.5 Technical (Hospital) Services Macro Worm Macroscopic Parasit PX-3068716900 CDM 87169 CPT 306 RC inpatient 70 70 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES HDHP [308136802] 55.43 percent of total billed charges 43.4 66.5 Technical (Hospital) Services ID by Nucleic Acid Ea Org Prob PX-3098715001 CDM 87150 CPT 306 RC outpatient 214 214 UNITED HEALTHCARE (COMMERCIAL) [3081199] UNITED HEALTHCARE 87726 [308119901] 132.68 percent of total billed charges 132.68 203.3 Technical (Hospital) Services ID by Nucleic Acid Ea Org Prob PX-3098715001 CDM 87150 CPT 306 RC outpatient 214 214 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES PPO [308136801] 171.2 percent of total billed charges 132.68 203.3 Technical (Hospital) Services ID by Nucleic Acid Ea Org Prob PX-3098715001 CDM 87150 CPT 306 RC outpatient 214 214 HEALTHPARTNERS SX009 HEALTHPARTNERS 171.2 percent of total billed charges 132.68 203.3 Technical (Hospital) Services ID by Nucleic Acid Ea Org Prob PX-3098715001 CDM 87150 CPT 306 RC outpatient 214 214 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES HDHP [308136802] 171.2 percent of total billed charges 132.68 203.3 Technical (Hospital) Services ID by Nucleic Acid Ea Org Prob PX-3098715001 CDM 87150 CPT 306 RC outpatient 214 214 BLUE CROSS BLUE SHIELD WELLMARK SB889 [3081026] BCBS WYOMING [308102603] 203.3 percent of total billed charges 132.68 203.3 Technical (Hospital) Services ID by Nucleic Acid Ea Org Prob PX-3098715001 CDM 87150 CPT 306 RC outpatient 214 214 MULTIPLAN INC 34080 [3081285] MULTIPLAN INC [308128501] 203.3 percent of total billed charges 132.68 203.3 Technical (Hospital) Services ID by Nucleic Acid Ea Org Prob PX-3098715001 CDM 87150 CPT 306 RC outpatient 214 214 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES EPO [308136803] 171.2 percent of total billed charges 132.68 203.3 Technical (Hospital) Services ID by Nucleic Acid Ea Org Prob PX-3098715001 CDM 87150 CPT 306 RC outpatient 214 214 CIGNA 62308 [3081051] CIGNA 62308 [308105105] 171.2 percent of total billed charges 132.68 203.3 Technical (Hospital) Services ID by Nucleic Acid Ea Org Prob PX-3098715001 CDM 87150 CPT 306 RC outpatient 214 214 CIGNA 62308 [3081051] CIGNA STATE OF WYOMING [308105107] 171.2 percent of total billed charges 132.68 203.3 Technical (Hospital) Services ID by Nucleic Acid Ea Org Prob PX-3098715001 CDM 87150 CPT 306 RC outpatient 214 214 MEDICA (COMMERCIAL) 94265 [3081118] MEDICA CLAIMS [308111801] 192.6 percent of total billed charges 132.68 203.3 Technical (Hospital) Services ID by Nucleic Acid Ea Org Prob PX-3098715001 CDM 87150 CPT 306 RC inpatient 214 214 MEDICA (COMMERCIAL) 94265 [3081118] MEDICA CLAIMS [308111801] 192.6 percent of total billed charges 132.68 203.3 Technical (Hospital) Services ID by Nucleic Acid Ea Org Prob PX-3098715001 CDM 87150 CPT 306 RC inpatient 214 214 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES HDHP [308136802] 169.45 percent of total billed charges 132.68 203.3 Technical (Hospital) Services ID by Nucleic Acid Ea Org Prob PX-3098715001 CDM 87150 CPT 306 RC inpatient 214 214 UNITED HEALTHCARE (COMMERCIAL) [3081199] UNITED HEALTHCARE 87726 [308119901] 132.68 percent of total billed charges 132.68 203.3 Technical (Hospital) Services ID by Nucleic Acid Ea Org Prob PX-3098715001 CDM 87150 CPT 306 RC inpatient 214 214 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES PPO [308136801] 169.45 percent of total billed charges 132.68 203.3 Technical (Hospital) Services ID by Nucleic Acid Ea Org Prob PX-3098715001 CDM 87150 CPT 306 RC inpatient 214 214 MULTIPLAN INC 34080 [3081285] MULTIPLAN INC [308128501] 203.3 percent of total billed charges 132.68 203.3 Technical (Hospital) Services ID by Nucleic Acid Ea Org Prob PX-3098715001 CDM 87150 CPT 306 RC inpatient 214 214 BLUE CROSS BLUE SHIELD WELLMARK SB889 [3081026] BCBS WYOMING [308102603] 203.3 percent of total billed charges 132.68 203.3 Technical (Hospital) Services ID by Nucleic Acid Ea Org Prob PX-3098715001 CDM 87150 CPT 306 RC inpatient 214 214 CIGNA 62308 [3081051] CIGNA 62308 [308105105] 169.45 percent of total billed charges 132.68 203.3 Technical (Hospital) Services ID by Nucleic Acid Ea Org Prob PX-3098715001 CDM 87150 CPT 306 RC inpatient 214 214 CIGNA 62308 [3081051] CIGNA STATE OF WYOMING [308105107] 169.45 percent of total billed charges 132.68 203.3 Technical (Hospital) Services ID by Nucleic Acid Ea Org Prob PX-3098715001 CDM 87150 CPT 306 RC inpatient 214 214 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES EPO [308136803] 169.45 percent of total billed charges 132.68 203.3 Technical (Hospital) Services ID by Nucleic Acid Ea Org Prob PX-3098715001 CDM 87150 CPT 306 RC inpatient 214 214 HEALTHPARTNERS SX009 HEALTHPARTNERS 169.45 percent of total billed charges 132.68 203.3 Technical (Hospital) Services Serotype PX-3068714700 CDM 87147 CPT 306 RC inpatient 70 70 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES EPO [308136803] 55.43 percent of total billed charges 43.4 66.5 Technical (Hospital) Services Serotype PX-3068714700 CDM 87147 CPT 306 RC inpatient 70 70 HEALTHPARTNERS SX009 HEALTHPARTNERS 55.43 percent of total billed charges 43.4 66.5 Technical (Hospital) Services Serotype PX-3068714700 CDM 87147 CPT 306 RC inpatient 70 70 CIGNA 62308 [3081051] CIGNA 62308 [308105105] 55.43 percent of total billed charges 43.4 66.5 Technical (Hospital) Services Serotype PX-3068714700 CDM 87147 CPT 306 RC inpatient 70 70 CIGNA 62308 [3081051] CIGNA STATE OF WYOMING [308105107] 55.43 percent of total billed charges 43.4 66.5 Technical (Hospital) Services Serotype PX-3068714700 CDM 87147 CPT 306 RC inpatient 70 70 BLUE CROSS BLUE SHIELD WELLMARK SB889 [3081026] BCBS WYOMING [308102603] 66.5 percent of total billed charges 43.4 66.5 Technical (Hospital) Services Serotype PX-3068714700 CDM 87147 CPT 306 RC inpatient 70 70 MULTIPLAN INC 34080 [3081285] MULTIPLAN INC [308128501] 66.5 percent of total billed charges 43.4 66.5 Technical (Hospital) Services Serotype PX-3068714700 CDM 87147 CPT 306 RC inpatient 70 70 MEDICA (COMMERCIAL) 94265 [3081118] MEDICA CLAIMS [308111801] 63 percent of total billed charges 43.4 66.5 Technical (Hospital) Services Serotype PX-3068714700 CDM 87147 CPT 306 RC inpatient 70 70 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES PPO [308136801] 55.43 percent of total billed charges 43.4 66.5 Technical (Hospital) Services Serotype PX-3068714700 CDM 87147 CPT 306 RC inpatient 70 70 UNITED HEALTHCARE (COMMERCIAL) [3081199] UNITED HEALTHCARE 87726 [308119901] 43.4 percent of total billed charges 43.4 66.5 Technical (Hospital) Services Serotype PX-3068714700 CDM 87147 CPT 306 RC inpatient 70 70 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES HDHP [308136802] 55.43 percent of total billed charges 43.4 66.5 Technical (Hospital) Services Serotype PX-3068714700 CDM 87147 CPT 306 RC outpatient 70 70 MEDICA (COMMERCIAL) 94265 [3081118] MEDICA CLAIMS [308111801] 63 percent of total billed charges 43.4 66.5 Technical (Hospital) Services Serotype PX-3068714700 CDM 87147 CPT 306 RC outpatient 70 70 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES PPO [308136801] 56 percent of total billed charges 43.4 66.5 Technical (Hospital) Services Serotype PX-3068714700 CDM 87147 CPT 306 RC outpatient 70 70 HEALTHPARTNERS SX009 HEALTHPARTNERS 56 percent of total billed charges 43.4 66.5 Technical (Hospital) Services Serotype PX-3068714700 CDM 87147 CPT 306 RC outpatient 70 70 UNITED HEALTHCARE (COMMERCIAL) [3081199] UNITED HEALTHCARE 87726 [308119901] 43.4 percent of total billed charges 43.4 66.5 Technical (Hospital) Services Serotype PX-3068714700 CDM 87147 CPT 306 RC outpatient 70 70 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES HDHP [308136802] 56 percent of total billed charges 43.4 66.5 Technical (Hospital) Services Serotype PX-3068714700 CDM 87147 CPT 306 RC outpatient 70 70 BLUE CROSS BLUE SHIELD WELLMARK SB889 [3081026] BCBS WYOMING [308102603] 66.5 percent of total billed charges 43.4 66.5 Technical (Hospital) Services Serotype PX-3068714700 CDM 87147 CPT 306 RC outpatient 70 70 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES EPO [308136803] 56 percent of total billed charges 43.4 66.5 Technical (Hospital) Services Serotype PX-3068714700 CDM 87147 CPT 306 RC outpatient 70 70 CIGNA 62308 [3081051] CIGNA 62308 [308105105] 56 percent of total billed charges 43.4 66.5 Technical (Hospital) Services Serotype PX-3068714700 CDM 87147 CPT 306 RC outpatient 70 70 CIGNA 62308 [3081051] CIGNA STATE OF WYOMING [308105107] 56 percent of total billed charges 43.4 66.5 Technical (Hospital) Services Serotype PX-3068714700 CDM 87147 CPT 306 RC outpatient 70 70 MULTIPLAN INC 34080 [3081285] MULTIPLAN INC [308128501] 66.5 percent of total billed charges 43.4 66.5 Technical (Hospital) Services Ref Acid Fast Culture Afbx PX-3068711600 CDM 87116 CPT 306 RC outpatient 128 128 BLUE CROSS BLUE SHIELD WELLMARK SB889 [3081026] BCBS WYOMING [308102603] 121.6 percent of total billed charges 79.36 121.6 Technical (Hospital) Services Ref Acid Fast Culture Afbx PX-3068711600 CDM 87116 CPT 306 RC outpatient 128 128 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES HDHP [308136802] 102.4 percent of total billed charges 79.36 121.6 Technical (Hospital) Services Ref Acid Fast Culture Afbx PX-3068711600 CDM 87116 CPT 306 RC outpatient 128 128 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES EPO [308136803] 102.4 percent of total billed charges 79.36 121.6 Technical (Hospital) Services Ref Acid Fast Culture Afbx PX-3068711600 CDM 87116 CPT 306 RC outpatient 128 128 CIGNA 62308 [3081051] CIGNA 62308 [308105105] 102.4 percent of total billed charges 79.36 121.6 Technical (Hospital) Services Ref Acid Fast Culture Afbx PX-3068711600 CDM 87116 CPT 306 RC outpatient 128 128 CIGNA 62308 [3081051] CIGNA STATE OF WYOMING [308105107] 102.4 percent of total billed charges 79.36 121.6 Technical (Hospital) Services Ref Acid Fast Culture Afbx PX-3068711600 CDM 87116 CPT 306 RC outpatient 128 128 MULTIPLAN INC 34080 [3081285] MULTIPLAN INC [308128501] 121.6 percent of total billed charges 79.36 121.6 Technical (Hospital) Services Ref Acid Fast Culture Afbx PX-3068711600 CDM 87116 CPT 306 RC outpatient 128 128 HEALTHPARTNERS SX009 HEALTHPARTNERS 102.4 percent of total billed charges 79.36 121.6 Technical (Hospital) Services Ref Acid Fast Culture Afbx PX-3068711600 CDM 87116 CPT 306 RC outpatient 128 128 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES PPO [308136801] 102.4 percent of total billed charges 79.36 121.6 Technical (Hospital) Services Ref Acid Fast Culture Afbx PX-3068711600 CDM 87116 CPT 306 RC outpatient 128 128 UNITED HEALTHCARE (COMMERCIAL) [3081199] UNITED HEALTHCARE 87726 [308119901] 79.36 percent of total billed charges 79.36 121.6 Technical (Hospital) Services Ref Acid Fast Culture Afbx PX-3068711600 CDM 87116 CPT 306 RC outpatient 128 128 MEDICA (COMMERCIAL) 94265 [3081118] MEDICA CLAIMS [308111801] 115.2 percent of total billed charges 79.36 121.6 Technical (Hospital) Services Ref Acid Fast Culture Afbx PX-3068711600 CDM 87116 CPT 306 RC inpatient 128 128 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES PPO [308136801] 101.35 percent of total billed charges 79.36 121.6 Technical (Hospital) Services Ref Acid Fast Culture Afbx PX-3068711600 CDM 87116 CPT 306 RC inpatient 128 128 UNITED HEALTHCARE (COMMERCIAL) [3081199] UNITED HEALTHCARE 87726 [308119901] 79.36 percent of total billed charges 79.36 121.6 Technical (Hospital) Services Ref Acid Fast Culture Afbx PX-3068711600 CDM 87116 CPT 306 RC inpatient 128 128 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES HDHP [308136802] 101.35 percent of total billed charges 79.36 121.6 Technical (Hospital) Services Ref Acid Fast Culture Afbx PX-3068711600 CDM 87116 CPT 306 RC inpatient 128 128 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES EPO [308136803] 101.35 percent of total billed charges 79.36 121.6 Technical (Hospital) Services Ref Acid Fast Culture Afbx PX-3068711600 CDM 87116 CPT 306 RC inpatient 128 128 HEALTHPARTNERS SX009 HEALTHPARTNERS 101.35 percent of total billed charges 79.36 121.6 Technical (Hospital) Services Ref Acid Fast Culture Afbx PX-3068711600 CDM 87116 CPT 306 RC inpatient 128 128 MEDICA (COMMERCIAL) 94265 [3081118] MEDICA CLAIMS [308111801] 115.2 percent of total billed charges 79.36 121.6 Technical (Hospital) Services Ref Acid Fast Culture Afbx PX-3068711600 CDM 87116 CPT 306 RC inpatient 128 128 MULTIPLAN INC 34080 [3081285] MULTIPLAN INC [308128501] 121.6 percent of total billed charges 79.36 121.6 Technical (Hospital) Services Ref Acid Fast Culture Afbx PX-3068711600 CDM 87116 CPT 306 RC inpatient 128 128 BLUE CROSS BLUE SHIELD WELLMARK SB889 [3081026] BCBS WYOMING [308102603] 121.6 percent of total billed charges 79.36 121.6 Technical (Hospital) Services Ref Acid Fast Culture Afbx PX-3068711600 CDM 87116 CPT 306 RC inpatient 128 128 CIGNA 62308 [3081051] CIGNA 62308 [308105105] 101.35 percent of total billed charges 79.36 121.6 Technical (Hospital) Services Ref Acid Fast Culture Afbx PX-3068711600 CDM 87116 CPT 306 RC inpatient 128 128 CIGNA 62308 [3081051] CIGNA STATE OF WYOMING [308105107] 101.35 percent of total billed charges 79.36 121.6 Technical (Hospital) Services Yeast ID PX-3068710600 CDM 87106 CPT 306 RC outpatient 108 108 HEALTHPARTNERS SX009 HEALTHPARTNERS 86.4 percent of total billed charges 66.96 102.6 Technical (Hospital) Services Yeast ID PX-3068710600 CDM 87106 CPT 306 RC outpatient 108 108 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES PPO [308136801] 86.4 percent of total billed charges 66.96 102.6 Technical (Hospital) Services Yeast ID PX-3068710600 CDM 87106 CPT 306 RC outpatient 108 108 UNITED HEALTHCARE (COMMERCIAL) [3081199] UNITED HEALTHCARE 87726 [308119901] 66.96 percent of total billed charges 66.96 102.6 Technical (Hospital) Services Yeast ID PX-3068710600 CDM 87106 CPT 306 RC outpatient 108 108 BLUE CROSS BLUE SHIELD WELLMARK SB889 [3081026] BCBS WYOMING [308102603] 102.6 percent of total billed charges 66.96 102.6 Technical (Hospital) Services Yeast ID PX-3068710600 CDM 87106 CPT 306 RC outpatient 108 108 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES HDHP [308136802] 86.4 percent of total billed charges 66.96 102.6 Technical (Hospital) Services Yeast ID PX-3068710600 CDM 87106 CPT 306 RC outpatient 108 108 CIGNA 62308 [3081051] CIGNA 62308 [308105105] 86.4 percent of total billed charges 66.96 102.6 Technical (Hospital) Services Yeast ID PX-3068710600 CDM 87106 CPT 306 RC outpatient 108 108 CIGNA 62308 [3081051] CIGNA STATE OF WYOMING [308105107] 86.4 percent of total billed charges 66.96 102.6 Technical (Hospital) Services Yeast ID PX-3068710600 CDM 87106 CPT 306 RC outpatient 108 108 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES EPO [308136803] 86.4 percent of total billed charges 66.96 102.6 Technical (Hospital) Services Yeast ID PX-3068710600 CDM 87106 CPT 306 RC outpatient 108 108 MULTIPLAN INC 34080 [3081285] MULTIPLAN INC [308128501] 102.6 percent of total billed charges 66.96 102.6 Technical (Hospital) Services Yeast ID PX-3068710600 CDM 87106 CPT 306 RC outpatient 108 108 MEDICA (COMMERCIAL) 94265 [3081118] MEDICA CLAIMS [308111801] 97.2 percent of total billed charges 66.96 102.6 Technical (Hospital) Services Yeast ID PX-3068710600 CDM 87106 CPT 306 RC inpatient 108 108 MEDICA (COMMERCIAL) 94265 [3081118] MEDICA CLAIMS [308111801] 97.2 percent of total billed charges 66.96 102.6 Technical (Hospital) Services Yeast ID PX-3068710600 CDM 87106 CPT 306 RC inpatient 108 108 MULTIPLAN INC 34080 [3081285] MULTIPLAN INC [308128501] 102.6 percent of total billed charges 66.96 102.6 Technical (Hospital) Services Yeast ID PX-3068710600 CDM 87106 CPT 306 RC inpatient 108 108 BLUE CROSS BLUE SHIELD WELLMARK SB889 [3081026] BCBS WYOMING [308102603] 102.6 percent of total billed charges 66.96 102.6 Technical (Hospital) Services Yeast ID PX-3068710600 CDM 87106 CPT 306 RC inpatient 108 108 CIGNA 62308 [3081051] CIGNA 62308 [308105105] 85.51 percent of total billed charges 66.96 102.6 Technical (Hospital) Services Yeast ID PX-3068710600 CDM 87106 CPT 306 RC inpatient 108 108 CIGNA 62308 [3081051] CIGNA STATE OF WYOMING [308105107] 85.51 percent of total billed charges 66.96 102.6 Technical (Hospital) Services Yeast ID PX-3068710600 CDM 87106 CPT 306 RC inpatient 108 108 HEALTHPARTNERS SX009 HEALTHPARTNERS 85.51 percent of total billed charges 66.96 102.6 Technical (Hospital) Services Yeast ID PX-3068710600 CDM 87106 CPT 306 RC inpatient 108 108 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES EPO [308136803] 85.51 percent of total billed charges 66.96 102.6 Technical (Hospital) Services Yeast ID PX-3068710600 CDM 87106 CPT 306 RC inpatient 108 108 UNITED HEALTHCARE (COMMERCIAL) [3081199] UNITED HEALTHCARE 87726 [308119901] 66.96 percent of total billed charges 66.96 102.6 Technical (Hospital) Services Yeast ID PX-3068710600 CDM 87106 CPT 306 RC inpatient 108 108 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES HDHP [308136802] 85.51 percent of total billed charges 66.96 102.6 Technical (Hospital) Services Yeast ID PX-3068710600 CDM 87106 CPT 306 RC inpatient 108 108 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES PPO [308136801] 85.51 percent of total billed charges 66.96 102.6 Technical (Hospital) Services Fungal Culture PX-3068710200 CDM 87102 CPT 306 RC outpatient 103 103 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES PPO [308136801] 82.4 percent of total billed charges 63.86 97.85 Technical (Hospital) Services Fungal Culture PX-3068710200 CDM 87102 CPT 306 RC outpatient 103 103 HEALTHPARTNERS SX009 HEALTHPARTNERS 82.4 percent of total billed charges 63.86 97.85 Technical (Hospital) Services Fungal Culture PX-3068710200 CDM 87102 CPT 306 RC outpatient 103 103 UNITED HEALTHCARE (COMMERCIAL) [3081199] UNITED HEALTHCARE 87726 [308119901] 63.86 percent of total billed charges 63.86 97.85 Technical (Hospital) Services Fungal Culture PX-3068710200 CDM 87102 CPT 306 RC outpatient 103 103 BLUE CROSS BLUE SHIELD WELLMARK SB889 [3081026] BCBS WYOMING [308102603] 97.85 percent of total billed charges 63.86 97.85 Technical (Hospital) Services Fungal Culture PX-3068710200 CDM 87102 CPT 306 RC outpatient 103 103 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES HDHP [308136802] 82.4 percent of total billed charges 63.86 97.85 Technical (Hospital) Services Fungal Culture PX-3068710200 CDM 87102 CPT 306 RC outpatient 103 103 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES EPO [308136803] 82.4 percent of total billed charges 63.86 97.85 Technical (Hospital) Services Fungal Culture PX-3068710200 CDM 87102 CPT 306 RC outpatient 103 103 MULTIPLAN INC 34080 [3081285] MULTIPLAN INC [308128501] 97.85 percent of total billed charges 63.86 97.85 Technical (Hospital) Services Fungal Culture PX-3068710200 CDM 87102 CPT 306 RC outpatient 103 103 CIGNA 62308 [3081051] CIGNA 62308 [308105105] 82.4 percent of total billed charges 63.86 97.85 Technical (Hospital) Services Fungal Culture PX-3068710200 CDM 87102 CPT 306 RC outpatient 103 103 CIGNA 62308 [3081051] CIGNA STATE OF WYOMING [308105107] 82.4 percent of total billed charges 63.86 97.85 Technical (Hospital) Services Fungal Culture PX-3068710200 CDM 87102 CPT 306 RC outpatient 103 103 MEDICA (COMMERCIAL) 94265 [3081118] MEDICA CLAIMS [308111801] 92.7 percent of total billed charges 63.86 97.85 Technical (Hospital) Services Fungal Culture PX-3068710200 CDM 87102 CPT 306 RC inpatient 103 103 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES HDHP [308136802] 81.56 percent of total billed charges 63.86 97.85 Technical (Hospital) Services Fungal Culture PX-3068710200 CDM 87102 CPT 306 RC inpatient 103 103 UNITED HEALTHCARE (COMMERCIAL) [3081199] UNITED HEALTHCARE 87726 [308119901] 63.86 percent of total billed charges 63.86 97.85 Technical (Hospital) Services Fungal Culture PX-3068710200 CDM 87102 CPT 306 RC inpatient 103 103 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES PPO [308136801] 81.56 percent of total billed charges 63.86 97.85 Technical (Hospital) Services Fungal Culture PX-3068710200 CDM 87102 CPT 306 RC inpatient 103 103 HEALTHPARTNERS SX009 HEALTHPARTNERS 81.56 percent of total billed charges 63.86 97.85 Technical (Hospital) Services Fungal Culture PX-3068710200 CDM 87102 CPT 306 RC inpatient 103 103 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES EPO [308136803] 81.56 percent of total billed charges 63.86 97.85 Technical (Hospital) Services Fungal Culture PX-3068710200 CDM 87102 CPT 306 RC inpatient 103 103 MEDICA (COMMERCIAL) 94265 [3081118] MEDICA CLAIMS [308111801] 92.7 percent of total billed charges 63.86 97.85 Technical (Hospital) Services Fungal Culture PX-3068710200 CDM 87102 CPT 306 RC inpatient 103 103 MULTIPLAN INC 34080 [3081285] MULTIPLAN INC [308128501] 97.85 percent of total billed charges 63.86 97.85 Technical (Hospital) Services Fungal Culture PX-3068710200 CDM 87102 CPT 306 RC inpatient 103 103 BLUE CROSS BLUE SHIELD WELLMARK SB889 [3081026] BCBS WYOMING [308102603] 97.85 percent of total billed charges 63.86 97.85 Technical (Hospital) Services Fungal Culture PX-3068710200 CDM 87102 CPT 306 RC inpatient 103 103 CIGNA 62308 [3081051] CIGNA 62308 [308105105] 81.56 percent of total billed charges 63.86 97.85 Technical (Hospital) Services Fungal Culture PX-3068710200 CDM 87102 CPT 306 RC inpatient 103 103 CIGNA 62308 [3081051] CIGNA STATE OF WYOMING [308105107] 81.56 percent of total billed charges 63.86 97.85 Technical (Hospital) Services Fng Dermat Culture Fungi PX-3068710100 CDM 87101 CPT 306 RC inpatient 100 100 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES PPO [308136801] 79.18 percent of total billed charges 62 95 Technical (Hospital) Services Fng Dermat Culture Fungi PX-3068710100 CDM 87101 CPT 306 RC inpatient 100 100 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES HDHP [308136802] 79.18 percent of total billed charges 62 95 Technical (Hospital) Services Fng Dermat Culture Fungi PX-3068710100 CDM 87101 CPT 306 RC inpatient 100 100 HEALTHPARTNERS SX009 HEALTHPARTNERS 79.18 percent of total billed charges 62 95 Technical (Hospital) Services Fng Dermat Culture Fungi PX-3068710100 CDM 87101 CPT 306 RC inpatient 100 100 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES EPO [308136803] 79.18 percent of total billed charges 62 95 Technical (Hospital) Services Fng Dermat Culture Fungi PX-3068710100 CDM 87101 CPT 306 RC inpatient 100 100 MEDICA (COMMERCIAL) 94265 [3081118] MEDICA CLAIMS [308111801] 90 percent of total billed charges 62 95 Technical (Hospital) Services Fng Dermat Culture Fungi PX-3068710100 CDM 87101 CPT 306 RC inpatient 100 100 UNITED HEALTHCARE (COMMERCIAL) [3081199] UNITED HEALTHCARE 87726 [308119901] 62 percent of total billed charges 62 95 Technical (Hospital) Services Fng Dermat Culture Fungi PX-3068710100 CDM 87101 CPT 306 RC inpatient 100 100 MULTIPLAN INC 34080 [3081285] MULTIPLAN INC [308128501] 95 percent of total billed charges 62 95 Technical (Hospital) Services Fng Dermat Culture Fungi PX-3068710100 CDM 87101 CPT 306 RC inpatient 100 100 BLUE CROSS BLUE SHIELD WELLMARK SB889 [3081026] BCBS WYOMING [308102603] 95 percent of total billed charges 62 95 Technical (Hospital) Services Fng Dermat Culture Fungi PX-3068710100 CDM 87101 CPT 306 RC inpatient 100 100 CIGNA 62308 [3081051] CIGNA 62308 [308105105] 79.18 percent of total billed charges 62 95 Technical (Hospital) Services Fng Dermat Culture Fungi PX-3068710100 CDM 87101 CPT 306 RC inpatient 100 100 CIGNA 62308 [3081051] CIGNA STATE OF WYOMING [308105107] 79.18 percent of total billed charges 62 95 Technical (Hospital) Services Fng Dermat Culture Fungi PX-3068710100 CDM 87101 CPT 306 RC outpatient 100 100 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES HDHP [308136802] 80 percent of total billed charges 62 95 Technical (Hospital) Services Fng Dermat Culture Fungi PX-3068710100 CDM 87101 CPT 306 RC outpatient 100 100 BLUE CROSS BLUE SHIELD WELLMARK SB889 [3081026] BCBS WYOMING [308102603] 95 percent of total billed charges 62 95 Technical (Hospital) Services Fng Dermat Culture Fungi PX-3068710100 CDM 87101 CPT 306 RC outpatient 100 100 CIGNA 62308 [3081051] CIGNA 62308 [308105105] 80 percent of total billed charges 62 95 Technical (Hospital) Services Fng Dermat Culture Fungi PX-3068710100 CDM 87101 CPT 306 RC outpatient 100 100 CIGNA 62308 [3081051] CIGNA STATE OF WYOMING [308105107] 80 percent of total billed charges 62 95 Technical (Hospital) Services Fng Dermat Culture Fungi PX-3068710100 CDM 87101 CPT 306 RC outpatient 100 100 MULTIPLAN INC 34080 [3081285] MULTIPLAN INC [308128501] 95 percent of total billed charges 62 95 Technical (Hospital) Services Fng Dermat Culture Fungi PX-3068710100 CDM 87101 CPT 306 RC outpatient 100 100 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES EPO [308136803] 80 percent of total billed charges 62 95 Technical (Hospital) Services Fng Dermat Culture Fungi PX-3068710100 CDM 87101 CPT 306 RC outpatient 100 100 UNITED HEALTHCARE (COMMERCIAL) [3081199] UNITED HEALTHCARE 87726 [308119901] 62 percent of total billed charges 62 95 Technical (Hospital) Services Fng Dermat Culture Fungi PX-3068710100 CDM 87101 CPT 306 RC outpatient 100 100 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES PPO [308136801] 80 percent of total billed charges 62 95 Technical (Hospital) Services Fng Dermat Culture Fungi PX-3068710100 CDM 87101 CPT 306 RC outpatient 100 100 HEALTHPARTNERS SX009 HEALTHPARTNERS 80 percent of total billed charges 62 95 Technical (Hospital) Services Fng Dermat Culture Fungi PX-3068710100 CDM 87101 CPT 306 RC outpatient 100 100 MEDICA (COMMERCIAL) 94265 [3081118] MEDICA CLAIMS [308111801] 90 percent of total billed charges 62 95 Technical (Hospital) Services Urine Culture PX-3068708800 CDM 87088 CPT 306 RC outpatient 105 105 MEDICA (COMMERCIAL) 94265 [3081118] MEDICA CLAIMS [308111801] 94.5 percent of total billed charges 65.1 99.75 Technical (Hospital) Services Urine Culture PX-3068708800 CDM 87088 CPT 306 RC outpatient 105 105 UNITED HEALTHCARE (COMMERCIAL) [3081199] UNITED HEALTHCARE 87726 [308119901] 65.1 percent of total billed charges 65.1 99.75 Technical (Hospital) Services Urine Culture PX-3068708800 CDM 87088 CPT 306 RC outpatient 105 105 HEALTHPARTNERS SX009 HEALTHPARTNERS 84 percent of total billed charges 65.1 99.75 Technical (Hospital) Services Urine Culture PX-3068708800 CDM 87088 CPT 306 RC outpatient 105 105 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES PPO [308136801] 84 percent of total billed charges 65.1 99.75 Technical (Hospital) Services Urine Culture PX-3068708800 CDM 87088 CPT 306 RC outpatient 105 105 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES HDHP [308136802] 84 percent of total billed charges 65.1 99.75 Technical (Hospital) Services Urine Culture PX-3068708800 CDM 87088 CPT 306 RC outpatient 105 105 BLUE CROSS BLUE SHIELD WELLMARK SB889 [3081026] BCBS WYOMING [308102603] 99.75 percent of total billed charges 65.1 99.75 Technical (Hospital) Services Urine Culture PX-3068708800 CDM 87088 CPT 306 RC outpatient 105 105 CIGNA 62308 [3081051] CIGNA 62308 [308105105] 84 percent of total billed charges 65.1 99.75 Technical (Hospital) Services Urine Culture PX-3068708800 CDM 87088 CPT 306 RC outpatient 105 105 CIGNA 62308 [3081051] CIGNA STATE OF WYOMING [308105107] 84 percent of total billed charges 65.1 99.75 Technical (Hospital) Services Urine Culture PX-3068708800 CDM 87088 CPT 306 RC outpatient 105 105 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES EPO [308136803] 84 percent of total billed charges 65.1 99.75 Technical (Hospital) Services Urine Culture PX-3068708800 CDM 87088 CPT 306 RC outpatient 105 105 MULTIPLAN INC 34080 [3081285] MULTIPLAN INC [308128501] 99.75 percent of total billed charges 65.1 99.75 Technical (Hospital) Services Urine Culture PX-3068708800 CDM 87088 CPT 306 RC inpatient 105 105 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES HDHP [308136802] 83.14 percent of total billed charges 65.1 99.75 Technical (Hospital) Services Urine Culture PX-3068708800 CDM 87088 CPT 306 RC inpatient 105 105 UNITED HEALTHCARE (COMMERCIAL) [3081199] UNITED HEALTHCARE 87726 [308119901] 65.1 percent of total billed charges 65.1 99.75 Technical (Hospital) Services Urine Culture PX-3068708800 CDM 87088 CPT 306 RC inpatient 105 105 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES PPO [308136801] 83.14 percent of total billed charges 65.1 99.75 Technical (Hospital) Services Urine Culture PX-3068708800 CDM 87088 CPT 306 RC inpatient 105 105 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES EPO [308136803] 83.14 percent of total billed charges 65.1 99.75 Technical (Hospital) Services Urine Culture PX-3068708800 CDM 87088 CPT 306 RC inpatient 105 105 HEALTHPARTNERS SX009 HEALTHPARTNERS 83.14 percent of total billed charges 65.1 99.75 Technical (Hospital) Services Urine Culture PX-3068708800 CDM 87088 CPT 306 RC inpatient 105 105 BLUE CROSS BLUE SHIELD WELLMARK SB889 [3081026] BCBS WYOMING [308102603] 99.75 percent of total billed charges 65.1 99.75 Technical (Hospital) Services Urine Culture PX-3068708800 CDM 87088 CPT 306 RC inpatient 105 105 CIGNA 62308 [3081051] CIGNA 62308 [308105105] 83.14 percent of total billed charges 65.1 99.75 Technical (Hospital) Services Urine Culture PX-3068708800 CDM 87088 CPT 306 RC inpatient 105 105 CIGNA 62308 [3081051] CIGNA STATE OF WYOMING [308105107] 83.14 percent of total billed charges 65.1 99.75 Technical (Hospital) Services Urine Culture PX-3068708800 CDM 87088 CPT 306 RC inpatient 105 105 MULTIPLAN INC 34080 [3081285] MULTIPLAN INC [308128501] 99.75 percent of total billed charges 65.1 99.75 Technical (Hospital) Services Urine Culture PX-3068708800 CDM 87088 CPT 306 RC inpatient 105 105 MEDICA (COMMERCIAL) 94265 [3081118] MEDICA CLAIMS [308111801] 94.5 percent of total billed charges 65.1 99.75 Technical (Hospital) Services Ref Urine Culture Quant Cc PX-3068708600 CDM 87086 CPT 306 RC inpatient 105 105 BLUE CROSS BLUE SHIELD WELLMARK SB889 [3081026] BCBS WYOMING [308102603] 99.75 percent of total billed charges 65.1 99.75 Technical (Hospital) Services Ref Urine Culture Quant Cc PX-3068708600 CDM 87086 CPT 306 RC inpatient 105 105 CIGNA 62308 [3081051] CIGNA 62308 [308105105] 83.14 percent of total billed charges 65.1 99.75 Technical (Hospital) Services Ref Urine Culture Quant Cc PX-3068708600 CDM 87086 CPT 306 RC inpatient 105 105 CIGNA 62308 [3081051] CIGNA STATE OF WYOMING [308105107] 83.14 percent of total billed charges 65.1 99.75 Technical (Hospital) Services Ref Urine Culture Quant Cc PX-3068708600 CDM 87086 CPT 306 RC inpatient 105 105 MULTIPLAN INC 34080 [3081285] MULTIPLAN INC [308128501] 99.75 percent of total billed charges 65.1 99.75 Technical (Hospital) Services Ref Urine Culture Quant Cc PX-3068708600 CDM 87086 CPT 306 RC inpatient 105 105 MEDICA (COMMERCIAL) 94265 [3081118] MEDICA CLAIMS [308111801] 94.5 percent of total billed charges 65.1 99.75 Technical (Hospital) Services Ref Urine Culture Quant Cc PX-3068708600 CDM 87086 CPT 306 RC inpatient 105 105 UNITED HEALTHCARE (COMMERCIAL) [3081199] UNITED HEALTHCARE 87726 [308119901] 65.1 percent of total billed charges 65.1 99.75 Technical (Hospital) Services Ref Urine Culture Quant Cc PX-3068708600 CDM 87086 CPT 306 RC inpatient 105 105 HEALTHPARTNERS SX009 HEALTHPARTNERS 83.14 percent of total billed charges 65.1 99.75 Technical (Hospital) Services Ref Urine Culture Quant Cc PX-3068708600 CDM 87086 CPT 306 RC inpatient 105 105 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES EPO [308136803] 83.14 percent of total billed charges 65.1 99.75 Technical (Hospital) Services Ref Urine Culture Quant Cc PX-3068708600 CDM 87086 CPT 306 RC inpatient 105 105 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES HDHP [308136802] 83.14 percent of total billed charges 65.1 99.75 Technical (Hospital) Services Ref Urine Culture Quant Cc PX-3068708600 CDM 87086 CPT 306 RC inpatient 105 105 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES PPO [308136801] 83.14 percent of total billed charges 65.1 99.75 Technical (Hospital) Services Ref Urine Culture Quant Cc PX-3068708600 CDM 87086 CPT 306 RC outpatient 105 105 HEALTHPARTNERS SX009 HEALTHPARTNERS 84 percent of total billed charges 65.1 99.75 Technical (Hospital) Services Ref Urine Culture Quant Cc PX-3068708600 CDM 87086 CPT 306 RC outpatient 105 105 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES PPO [308136801] 84 percent of total billed charges 65.1 99.75 Technical (Hospital) Services Ref Urine Culture Quant Cc PX-3068708600 CDM 87086 CPT 306 RC outpatient 105 105 UNITED HEALTHCARE (COMMERCIAL) [3081199] UNITED HEALTHCARE 87726 [308119901] 65.1 percent of total billed charges 65.1 99.75 Technical (Hospital) Services Ref Urine Culture Quant Cc PX-3068708600 CDM 87086 CPT 306 RC outpatient 105 105 MULTIPLAN INC 34080 [3081285] MULTIPLAN INC [308128501] 99.75 percent of total billed charges 65.1 99.75 Technical (Hospital) Services Ref Urine Culture Quant Cc PX-3068708600 CDM 87086 CPT 306 RC outpatient 105 105 CIGNA 62308 [3081051] CIGNA 62308 [308105105] 84 percent of total billed charges 65.1 99.75 Technical (Hospital) Services Ref Urine Culture Quant Cc PX-3068708600 CDM 87086 CPT 306 RC outpatient 105 105 CIGNA 62308 [3081051] CIGNA STATE OF WYOMING [308105107] 84 percent of total billed charges 65.1 99.75 Technical (Hospital) Services Ref Urine Culture Quant Cc PX-3068708600 CDM 87086 CPT 306 RC outpatient 105 105 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES EPO [308136803] 84 percent of total billed charges 65.1 99.75 Technical (Hospital) Services Ref Urine Culture Quant Cc PX-3068708600 CDM 87086 CPT 306 RC outpatient 105 105 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES HDHP [308136802] 84 percent of total billed charges 65.1 99.75 Technical (Hospital) Services Ref Urine Culture Quant Cc PX-3068708600 CDM 87086 CPT 306 RC outpatient 105 105 BLUE CROSS BLUE SHIELD WELLMARK SB889 [3081026] BCBS WYOMING [308102603] 99.75 percent of total billed charges 65.1 99.75 Technical (Hospital) Services Ref Urine Culture Quant Cc PX-3068708600 CDM 87086 CPT 306 RC outpatient 105 105 MEDICA (COMMERCIAL) 94265 [3081118] MEDICA CLAIMS [308111801] 94.5 percent of total billed charges 65.1 99.75 Technical (Hospital) Services Culture Screening PX-3068708100 CDM 87081 CPT 306 RC inpatient 167 167 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES PPO [308136801] 132.23 percent of total billed charges 103.54 158.65 Technical (Hospital) Services Culture Screening PX-3068708100 CDM 87081 CPT 306 RC inpatient 167 167 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES HDHP [308136802] 132.23 percent of total billed charges 103.54 158.65 Technical (Hospital) Services Culture Screening PX-3068708100 CDM 87081 CPT 306 RC inpatient 167 167 UNITED HEALTHCARE (COMMERCIAL) [3081199] UNITED HEALTHCARE 87726 [308119901] 103.54 percent of total billed charges 103.54 158.65 Technical (Hospital) Services Culture Screening PX-3068708100 CDM 87081 CPT 306 RC inpatient 167 167 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES EPO [308136803] 132.23 percent of total billed charges 103.54 158.65 Technical (Hospital) Services Culture Screening PX-3068708100 CDM 87081 CPT 306 RC inpatient 167 167 HEALTHPARTNERS SX009 HEALTHPARTNERS 132.23 percent of total billed charges 103.54 158.65 Technical (Hospital) Services Culture Screening PX-3068708100 CDM 87081 CPT 306 RC inpatient 167 167 BLUE CROSS BLUE SHIELD WELLMARK SB889 [3081026] BCBS WYOMING [308102603] 158.65 percent of total billed charges 103.54 158.65 Technical (Hospital) Services Culture Screening PX-3068708100 CDM 87081 CPT 306 RC inpatient 167 167 CIGNA 62308 [3081051] CIGNA 62308 [308105105] 132.23 percent of total billed charges 103.54 158.65 Technical (Hospital) Services Culture Screening PX-3068708100 CDM 87081 CPT 306 RC inpatient 167 167 CIGNA 62308 [3081051] CIGNA STATE OF WYOMING [308105107] 132.23 percent of total billed charges 103.54 158.65 Technical (Hospital) Services Culture Screening PX-3068708100 CDM 87081 CPT 306 RC inpatient 167 167 MEDICA (COMMERCIAL) 94265 [3081118] MEDICA CLAIMS [308111801] 150.3 percent of total billed charges 103.54 158.65 Technical (Hospital) Services Culture Screening PX-3068708100 CDM 87081 CPT 306 RC inpatient 167 167 MULTIPLAN INC 34080 [3081285] MULTIPLAN INC [308128501] 158.65 percent of total billed charges 103.54 158.65 Technical (Hospital) Services Culture Screening PX-3068708100 CDM 87081 CPT 306 RC outpatient 167 167 BLUE CROSS BLUE SHIELD WELLMARK SB889 [3081026] BCBS WYOMING [308102603] 158.65 percent of total billed charges 103.54 158.65 Technical (Hospital) Services Culture Screening PX-3068708100 CDM 87081 CPT 306 RC outpatient 167 167 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES HDHP [308136802] 133.6 percent of total billed charges 103.54 158.65 Technical (Hospital) Services Culture Screening PX-3068708100 CDM 87081 CPT 306 RC outpatient 167 167 CIGNA 62308 [3081051] CIGNA 62308 [308105105] 133.6 percent of total billed charges 103.54 158.65 Technical (Hospital) Services Culture Screening PX-3068708100 CDM 87081 CPT 306 RC outpatient 167 167 CIGNA 62308 [3081051] CIGNA STATE OF WYOMING [308105107] 133.6 percent of total billed charges 103.54 158.65 Technical (Hospital) Services Culture Screening PX-3068708100 CDM 87081 CPT 306 RC outpatient 167 167 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES EPO [308136803] 133.6 percent of total billed charges 103.54 158.65 Technical (Hospital) Services Culture Screening PX-3068708100 CDM 87081 CPT 306 RC outpatient 167 167 MULTIPLAN INC 34080 [3081285] MULTIPLAN INC [308128501] 158.65 percent of total billed charges 103.54 158.65 Technical (Hospital) Services Culture Screening PX-3068708100 CDM 87081 CPT 306 RC outpatient 167 167 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES PPO [308136801] 133.6 percent of total billed charges 103.54 158.65 Technical (Hospital) Services Culture Screening PX-3068708100 CDM 87081 CPT 306 RC outpatient 167 167 HEALTHPARTNERS SX009 HEALTHPARTNERS 133.6 percent of total billed charges 103.54 158.65 Technical (Hospital) Services Culture Screening PX-3068708100 CDM 87081 CPT 306 RC outpatient 167 167 UNITED HEALTHCARE (COMMERCIAL) [3081199] UNITED HEALTHCARE 87726 [308119901] 103.54 percent of total billed charges 103.54 158.65 Technical (Hospital) Services Culture Screening PX-3068708100 CDM 87081 CPT 306 RC outpatient 167 167 MEDICA (COMMERCIAL) 94265 [3081118] MEDICA CLAIMS [308111801] 150.3 percent of total billed charges 103.54 158.65 Technical (Hospital) Services Bacterial ID PX-3068707700 CDM 87077 CPT 306 RC inpatient 125 125 CIGNA 62308 [3081051] CIGNA 62308 [308105105] 98.98 percent of total billed charges 77.5 118.75 Technical (Hospital) Services Bacterial ID PX-3068707700 CDM 87077 CPT 306 RC inpatient 125 125 CIGNA 62308 [3081051] CIGNA STATE OF WYOMING [308105107] 98.98 percent of total billed charges 77.5 118.75 Technical (Hospital) Services Bacterial ID PX-3068707700 CDM 87077 CPT 306 RC inpatient 125 125 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES EPO [308136803] 98.98 percent of total billed charges 77.5 118.75 Technical (Hospital) Services Bacterial ID PX-3068707700 CDM 87077 CPT 306 RC inpatient 125 125 UNITED HEALTHCARE (COMMERCIAL) [3081199] UNITED HEALTHCARE 87726 [308119901] 77.5 percent of total billed charges 77.5 118.75 Technical (Hospital) Services Bacterial ID PX-3068707700 CDM 87077 CPT 306 RC inpatient 125 125 BLUE CROSS BLUE SHIELD WELLMARK SB889 [3081026] BCBS WYOMING [308102603] 118.75 percent of total billed charges 77.5 118.75 Technical (Hospital) Services Bacterial ID PX-3068707700 CDM 87077 CPT 306 RC inpatient 125 125 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES PPO [308136801] 98.98 percent of total billed charges 77.5 118.75 Technical (Hospital) Services Bacterial ID PX-3068707700 CDM 87077 CPT 306 RC inpatient 125 125 HEALTHPARTNERS SX009 HEALTHPARTNERS 98.98 percent of total billed charges 77.5 118.75 Technical (Hospital) Services Bacterial ID PX-3068707700 CDM 87077 CPT 306 RC inpatient 125 125 MULTIPLAN INC 34080 [3081285] MULTIPLAN INC [308128501] 118.75 percent of total billed charges 77.5 118.75 Technical (Hospital) Services Bacterial ID PX-3068707700 CDM 87077 CPT 306 RC inpatient 125 125 MEDICA (COMMERCIAL) 94265 [3081118] MEDICA CLAIMS [308111801] 112.5 percent of total billed charges 77.5 118.75 Technical (Hospital) Services Bacterial ID PX-3068707700 CDM 87077 CPT 306 RC inpatient 125 125 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES HDHP [308136802] 98.98 percent of total billed charges 77.5 118.75 Technical (Hospital) Services Bacterial ID PX-3068707700 CDM 87077 CPT 306 RC outpatient 125 125 MEDICA (COMMERCIAL) 94265 [3081118] MEDICA CLAIMS [308111801] 112.5 percent of total billed charges 77.5 118.75 Technical (Hospital) Services Bacterial ID PX-3068707700 CDM 87077 CPT 306 RC outpatient 125 125 HEALTHPARTNERS SX009 HEALTHPARTNERS 100 percent of total billed charges 77.5 118.75 Technical (Hospital) Services Bacterial ID PX-3068707700 CDM 87077 CPT 306 RC outpatient 125 125 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES HDHP [308136802] 100 percent of total billed charges 77.5 118.75 Technical (Hospital) Services Bacterial ID PX-3068707700 CDM 87077 CPT 306 RC outpatient 125 125 UNITED HEALTHCARE (COMMERCIAL) [3081199] UNITED HEALTHCARE 87726 [308119901] 77.5 percent of total billed charges 77.5 118.75 Technical (Hospital) Services Bacterial ID PX-3068707700 CDM 87077 CPT 306 RC outpatient 125 125 BLUE CROSS BLUE SHIELD WELLMARK SB889 [3081026] BCBS WYOMING [308102603] 118.75 percent of total billed charges 77.5 118.75 Technical (Hospital) Services Bacterial ID PX-3068707700 CDM 87077 CPT 306 RC outpatient 125 125 MULTIPLAN INC 34080 [3081285] MULTIPLAN INC [308128501] 118.75 percent of total billed charges 77.5 118.75 Technical (Hospital) Services Bacterial ID PX-3068707700 CDM 87077 CPT 306 RC outpatient 125 125 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES EPO [308136803] 100 percent of total billed charges 77.5 118.75 Technical (Hospital) Services Bacterial ID PX-3068707700 CDM 87077 CPT 306 RC outpatient 125 125 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES PPO [308136801] 100 percent of total billed charges 77.5 118.75 Technical (Hospital) Services Bacterial ID PX-3068707700 CDM 87077 CPT 306 RC outpatient 125 125 CIGNA 62308 [3081051] CIGNA 62308 [308105105] 100 percent of total billed charges 77.5 118.75 Technical (Hospital) Services Bacterial ID PX-3068707700 CDM 87077 CPT 306 RC outpatient 125 125 CIGNA 62308 [3081051] CIGNA STATE OF WYOMING [308105107] 100 percent of total billed charges 77.5 118.75 Technical (Hospital) Services Ref Organism Refer for ID Aerobic PX-3068707701 CDM 87077 CPT 306 RC inpatient 331 331 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES PPO [308136801] 262.09 percent of total billed charges 205.22 314.45 Technical (Hospital) Services Ref Organism Refer for ID Aerobic PX-3068707701 CDM 87077 CPT 306 RC inpatient 331 331 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES HDHP [308136802] 262.09 percent of total billed charges 205.22 314.45 Technical (Hospital) Services Ref Organism Refer for ID Aerobic PX-3068707701 CDM 87077 CPT 306 RC inpatient 331 331 UNITED HEALTHCARE (COMMERCIAL) [3081199] UNITED HEALTHCARE 87726 [308119901] 205.22 percent of total billed charges 205.22 314.45 Technical (Hospital) Services Ref Organism Refer for ID Aerobic PX-3068707701 CDM 87077 CPT 306 RC inpatient 331 331 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES EPO [308136803] 262.09 percent of total billed charges 205.22 314.45 Technical (Hospital) Services Ref Organism Refer for ID Aerobic PX-3068707701 CDM 87077 CPT 306 RC inpatient 331 331 HEALTHPARTNERS SX009 HEALTHPARTNERS 262.09 percent of total billed charges 205.22 314.45 Technical (Hospital) Services Ref Organism Refer for ID Aerobic PX-3068707701 CDM 87077 CPT 306 RC inpatient 331 331 MULTIPLAN INC 34080 [3081285] MULTIPLAN INC [308128501] 314.45 percent of total billed charges 205.22 314.45 Technical (Hospital) Services Ref Organism Refer for ID Aerobic PX-3068707701 CDM 87077 CPT 306 RC inpatient 331 331 MEDICA (COMMERCIAL) 94265 [3081118] MEDICA CLAIMS [308111801] 297.9 percent of total billed charges 205.22 314.45 Technical (Hospital) Services Ref Organism Refer for ID Aerobic PX-3068707701 CDM 87077 CPT 306 RC inpatient 331 331 BLUE CROSS BLUE SHIELD WELLMARK SB889 [3081026] BCBS WYOMING [308102603] 314.45 percent of total billed charges 205.22 314.45 Technical (Hospital) Services Ref Organism Refer for ID Aerobic PX-3068707701 CDM 87077 CPT 306 RC inpatient 331 331 CIGNA 62308 [3081051] CIGNA 62308 [308105105] 262.09 percent of total billed charges 205.22 314.45 Technical (Hospital) Services Ref Organism Refer for ID Aerobic PX-3068707701 CDM 87077 CPT 306 RC inpatient 331 331 CIGNA 62308 [3081051] CIGNA STATE OF WYOMING [308105107] 262.09 percent of total billed charges 205.22 314.45 Technical (Hospital) Services Ref Organism Refer for ID Aerobic PX-3068707701 CDM 87077 CPT 306 RC outpatient 331 331 MULTIPLAN INC 34080 [3081285] MULTIPLAN INC [308128501] 314.45 percent of total billed charges 205.22 314.45 Technical (Hospital) Services Ref Organism Refer for ID Aerobic PX-3068707701 CDM 87077 CPT 306 RC outpatient 331 331 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES EPO [308136803] 264.8 percent of total billed charges 205.22 314.45 Technical (Hospital) Services Ref Organism Refer for ID Aerobic PX-3068707701 CDM 87077 CPT 306 RC outpatient 331 331 CIGNA 62308 [3081051] CIGNA 62308 [308105105] 264.8 percent of total billed charges 205.22 314.45 Technical (Hospital) Services Ref Organism Refer for ID Aerobic PX-3068707701 CDM 87077 CPT 306 RC outpatient 331 331 CIGNA 62308 [3081051] CIGNA STATE OF WYOMING [308105107] 264.8 percent of total billed charges 205.22 314.45 Technical (Hospital) Services Ref Organism Refer for ID Aerobic PX-3068707701 CDM 87077 CPT 306 RC outpatient 331 331 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES HDHP [308136802] 264.8 percent of total billed charges 205.22 314.45 Technical (Hospital) Services Ref Organism Refer for ID Aerobic PX-3068707701 CDM 87077 CPT 306 RC outpatient 331 331 BLUE CROSS BLUE SHIELD WELLMARK SB889 [3081026] BCBS WYOMING [308102603] 314.45 percent of total billed charges 205.22 314.45 Technical (Hospital) Services Ref Organism Refer for ID Aerobic PX-3068707701 CDM 87077 CPT 306 RC outpatient 331 331 UNITED HEALTHCARE (COMMERCIAL) [3081199] UNITED HEALTHCARE 87726 [308119901] 205.22 percent of total billed charges 205.22 314.45 Technical (Hospital) Services Ref Organism Refer for ID Aerobic PX-3068707701 CDM 87077 CPT 306 RC outpatient 331 331 MEDICA (COMMERCIAL) 94265 [3081118] MEDICA CLAIMS [308111801] 297.9 percent of total billed charges 205.22 314.45 Technical (Hospital) Services Ref Organism Refer for ID Aerobic PX-3068707701 CDM 87077 CPT 306 RC outpatient 331 331 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES PPO [308136801] 264.8 percent of total billed charges 205.22 314.45 Technical (Hospital) Services Ref Organism Refer for ID Aerobic PX-3068707701 CDM 87077 CPT 306 RC outpatient 331 331 HEALTHPARTNERS SX009 HEALTHPARTNERS 264.8 percent of total billed charges 205.22 314.45 Technical (Hospital) Services Anaerobe ID PX-3068707600 CDM 87076 CPT 306 RC inpatient 119 119 MEDICA (COMMERCIAL) 94265 [3081118] MEDICA CLAIMS [308111801] 107.1 percent of total billed charges 73.78 113.05 Technical (Hospital) Services Anaerobe ID PX-3068707600 CDM 87076 CPT 306 RC inpatient 119 119 MULTIPLAN INC 34080 [3081285] MULTIPLAN INC [308128501] 113.05 percent of total billed charges 73.78 113.05 Technical (Hospital) Services Anaerobe ID PX-3068707600 CDM 87076 CPT 306 RC inpatient 119 119 CIGNA 62308 [3081051] CIGNA 62308 [308105105] 94.22 percent of total billed charges 73.78 113.05 Technical (Hospital) Services Anaerobe ID PX-3068707600 CDM 87076 CPT 306 RC inpatient 119 119 CIGNA 62308 [3081051] CIGNA STATE OF WYOMING [308105107] 94.22 percent of total billed charges 73.78 113.05 Technical (Hospital) Services Anaerobe ID PX-3068707600 CDM 87076 CPT 306 RC inpatient 119 119 BLUE CROSS BLUE SHIELD WELLMARK SB889 [3081026] BCBS WYOMING [308102603] 113.05 percent of total billed charges 73.78 113.05 Technical (Hospital) Services Anaerobe ID PX-3068707600 CDM 87076 CPT 306 RC inpatient 119 119 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES EPO [308136803] 94.22 percent of total billed charges 73.78 113.05 Technical (Hospital) Services Anaerobe ID PX-3068707600 CDM 87076 CPT 306 RC inpatient 119 119 HEALTHPARTNERS SX009 HEALTHPARTNERS 94.22 percent of total billed charges 73.78 113.05 Technical (Hospital) Services Anaerobe ID PX-3068707600 CDM 87076 CPT 306 RC inpatient 119 119 UNITED HEALTHCARE (COMMERCIAL) [3081199] UNITED HEALTHCARE 87726 [308119901] 73.78 percent of total billed charges 73.78 113.05 Technical (Hospital) Services Anaerobe ID PX-3068707600 CDM 87076 CPT 306 RC inpatient 119 119 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES HDHP [308136802] 94.22 percent of total billed charges 73.78 113.05 Technical (Hospital) Services Anaerobe ID PX-3068707600 CDM 87076 CPT 306 RC inpatient 119 119 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES PPO [308136801] 94.22 percent of total billed charges 73.78 113.05 Technical (Hospital) Services Anaerobe ID PX-3068707600 CDM 87076 CPT 306 RC outpatient 119 119 UNITED HEALTHCARE (COMMERCIAL) [3081199] UNITED HEALTHCARE 87726 [308119901] 73.78 percent of total billed charges 73.78 113.05 Technical (Hospital) Services Anaerobe ID PX-3068707600 CDM 87076 CPT 306 RC outpatient 119 119 HEALTHPARTNERS SX009 HEALTHPARTNERS 95.2 percent of total billed charges 73.78 113.05 Technical (Hospital) Services Anaerobe ID PX-3068707600 CDM 87076 CPT 306 RC outpatient 119 119 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES PPO [308136801] 95.2 percent of total billed charges 73.78 113.05 Technical (Hospital) Services Anaerobe ID PX-3068707600 CDM 87076 CPT 306 RC outpatient 119 119 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES EPO [308136803] 95.2 percent of total billed charges 73.78 113.05 Technical (Hospital) Services Anaerobe ID PX-3068707600 CDM 87076 CPT 306 RC outpatient 119 119 CIGNA 62308 [3081051] CIGNA 62308 [308105105] 95.2 percent of total billed charges 73.78 113.05 Technical (Hospital) Services Anaerobe ID PX-3068707600 CDM 87076 CPT 306 RC outpatient 119 119 CIGNA 62308 [3081051] CIGNA STATE OF WYOMING [308105107] 95.2 percent of total billed charges 73.78 113.05 Technical (Hospital) Services Anaerobe ID PX-3068707600 CDM 87076 CPT 306 RC outpatient 119 119 MULTIPLAN INC 34080 [3081285] MULTIPLAN INC [308128501] 113.05 percent of total billed charges 73.78 113.05 Technical (Hospital) Services Anaerobe ID PX-3068707600 CDM 87076 CPT 306 RC outpatient 119 119 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES HDHP [308136802] 95.2 percent of total billed charges 73.78 113.05 Technical (Hospital) Services Anaerobe ID PX-3068707600 CDM 87076 CPT 306 RC outpatient 119 119 BLUE CROSS BLUE SHIELD WELLMARK SB889 [3081026] BCBS WYOMING [308102603] 113.05 percent of total billed charges 73.78 113.05 Technical (Hospital) Services Anaerobe ID PX-3068707600 CDM 87076 CPT 306 RC outpatient 119 119 MEDICA (COMMERCIAL) 94265 [3081118] MEDICA CLAIMS [308111801] 107.1 percent of total billed charges 73.78 113.05 Technical (Hospital) Services Culture Anaerobic Any Source PX-3068707500 CDM 87075 CPT 306 RC outpatient 170 170 MULTIPLAN INC 34080 [3081285] MULTIPLAN INC [308128501] 161.5 percent of total billed charges 105.4 161.5 Technical (Hospital) Services Culture Anaerobic Any Source PX-3068707500 CDM 87075 CPT 306 RC outpatient 170 170 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES EPO [308136803] 136 percent of total billed charges 105.4 161.5 Technical (Hospital) Services Culture Anaerobic Any Source PX-3068707500 CDM 87075 CPT 306 RC outpatient 170 170 CIGNA 62308 [3081051] CIGNA 62308 [308105105] 136 percent of total billed charges 105.4 161.5 Technical (Hospital) Services Culture Anaerobic Any Source PX-3068707500 CDM 87075 CPT 306 RC outpatient 170 170 CIGNA 62308 [3081051] CIGNA STATE OF WYOMING [308105107] 136 percent of total billed charges 105.4 161.5 Technical (Hospital) Services Culture Anaerobic Any Source PX-3068707500 CDM 87075 CPT 306 RC outpatient 170 170 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES HDHP [308136802] 136 percent of total billed charges 105.4 161.5 Technical (Hospital) Services Culture Anaerobic Any Source PX-3068707500 CDM 87075 CPT 306 RC outpatient 170 170 BLUE CROSS BLUE SHIELD WELLMARK SB889 [3081026] BCBS WYOMING [308102603] 161.5 percent of total billed charges 105.4 161.5 Technical (Hospital) Services Culture Anaerobic Any Source PX-3068707500 CDM 87075 CPT 306 RC outpatient 170 170 UNITED HEALTHCARE (COMMERCIAL) [3081199] UNITED HEALTHCARE 87726 [308119901] 105.4 percent of total billed charges 105.4 161.5 Technical (Hospital) Services Culture Anaerobic Any Source PX-3068707500 CDM 87075 CPT 306 RC outpatient 170 170 HEALTHPARTNERS SX009 HEALTHPARTNERS 136 percent of total billed charges 105.4 161.5 Technical (Hospital) Services Culture Anaerobic Any Source PX-3068707500 CDM 87075 CPT 306 RC outpatient 170 170 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES PPO [308136801] 136 percent of total billed charges 105.4 161.5 Technical (Hospital) Services Culture Anaerobic Any Source PX-3068707500 CDM 87075 CPT 306 RC outpatient 170 170 MEDICA (COMMERCIAL) 94265 [3081118] MEDICA CLAIMS [308111801] 153 percent of total billed charges 105.4 161.5 Technical (Hospital) Services Culture Anaerobic Any Source PX-3068707500 CDM 87075 CPT 306 RC inpatient 170 170 CIGNA 62308 [3081051] CIGNA 62308 [308105105] 134.61 percent of total billed charges 105.4 161.5 Technical (Hospital) Services Culture Anaerobic Any Source PX-3068707500 CDM 87075 CPT 306 RC inpatient 170 170 CIGNA 62308 [3081051] CIGNA STATE OF WYOMING [308105107] 134.61 percent of total billed charges 105.4 161.5 Technical (Hospital) Services Culture Anaerobic Any Source PX-3068707500 CDM 87075 CPT 306 RC inpatient 170 170 BLUE CROSS BLUE SHIELD WELLMARK SB889 [3081026] BCBS WYOMING [308102603] 161.5 percent of total billed charges 105.4 161.5 Technical (Hospital) Services Culture Anaerobic Any Source PX-3068707500 CDM 87075 CPT 306 RC inpatient 170 170 MEDICA (COMMERCIAL) 94265 [3081118] MEDICA CLAIMS [308111801] 153 percent of total billed charges 105.4 161.5 Technical (Hospital) Services Culture Anaerobic Any Source PX-3068707500 CDM 87075 CPT 306 RC inpatient 170 170 MULTIPLAN INC 34080 [3081285] MULTIPLAN INC [308128501] 161.5 percent of total billed charges 105.4 161.5 Technical (Hospital) Services Culture Anaerobic Any Source PX-3068707500 CDM 87075 CPT 306 RC inpatient 170 170 HEALTHPARTNERS SX009 HEALTHPARTNERS 134.61 percent of total billed charges 105.4 161.5 Technical (Hospital) Services Culture Anaerobic Any Source PX-3068707500 CDM 87075 CPT 306 RC inpatient 170 170 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES EPO [308136803] 134.61 percent of total billed charges 105.4 161.5 Technical (Hospital) Services Culture Anaerobic Any Source PX-3068707500 CDM 87075 CPT 306 RC inpatient 170 170 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES PPO [308136801] 134.61 percent of total billed charges 105.4 161.5 Technical (Hospital) Services Culture Anaerobic Any Source PX-3068707500 CDM 87075 CPT 306 RC inpatient 170 170 UNITED HEALTHCARE (COMMERCIAL) [3081199] UNITED HEALTHCARE 87726 [308119901] 105.4 percent of total billed charges 105.4 161.5 Technical (Hospital) Services Culture Anaerobic Any Source PX-3068707500 CDM 87075 CPT 306 RC inpatient 170 170 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES HDHP [308136802] 134.61 percent of total billed charges 105.4 161.5 Technical (Hospital) Services Culture Aerobic Any Source PX-3068707000 CDM 87070 CPT 306 RC outpatient 127 127 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES HDHP [308136802] 101.6 percent of total billed charges 78.74 120.65 Technical (Hospital) Services Culture Aerobic Any Source PX-3068707000 CDM 87070 CPT 306 RC outpatient 127 127 BLUE CROSS BLUE SHIELD WELLMARK SB889 [3081026] BCBS WYOMING [308102603] 120.65 percent of total billed charges 78.74 120.65 Technical (Hospital) Services Culture Aerobic Any Source PX-3068707000 CDM 87070 CPT 306 RC outpatient 127 127 UNITED HEALTHCARE (COMMERCIAL) [3081199] UNITED HEALTHCARE 87726 [308119901] 78.74 percent of total billed charges 78.74 120.65 Technical (Hospital) Services Culture Aerobic Any Source PX-3068707000 CDM 87070 CPT 306 RC outpatient 127 127 MULTIPLAN INC 34080 [3081285] MULTIPLAN INC [308128501] 120.65 percent of total billed charges 78.74 120.65 Technical (Hospital) Services Culture Aerobic Any Source PX-3068707000 CDM 87070 CPT 306 RC outpatient 127 127 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES EPO [308136803] 101.6 percent of total billed charges 78.74 120.65 Technical (Hospital) Services Culture Aerobic Any Source PX-3068707000 CDM 87070 CPT 306 RC outpatient 127 127 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES PPO [308136801] 101.6 percent of total billed charges 78.74 120.65 Technical (Hospital) Services Culture Aerobic Any Source PX-3068707000 CDM 87070 CPT 306 RC outpatient 127 127 HEALTHPARTNERS SX009 HEALTHPARTNERS 101.6 percent of total billed charges 78.74 120.65 Technical (Hospital) Services Culture Aerobic Any Source PX-3068707000 CDM 87070 CPT 306 RC outpatient 127 127 MEDICA (COMMERCIAL) 94265 [3081118] MEDICA CLAIMS [308111801] 114.3 percent of total billed charges 78.74 120.65 Technical (Hospital) Services Culture Aerobic Any Source PX-3068707000 CDM 87070 CPT 306 RC outpatient 127 127 CIGNA 62308 [3081051] CIGNA 62308 [308105105] 101.6 percent of total billed charges 78.74 120.65 Technical (Hospital) Services Culture Aerobic Any Source PX-3068707000 CDM 87070 CPT 306 RC outpatient 127 127 CIGNA 62308 [3081051] CIGNA STATE OF WYOMING [308105107] 101.6 percent of total billed charges 78.74 120.65 Technical (Hospital) Services Culture Aerobic Any Source PX-3068707000 CDM 87070 CPT 306 RC inpatient 127 127 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES PPO [308136801] 100.56 percent of total billed charges 78.74 120.65 Technical (Hospital) Services Culture Aerobic Any Source PX-3068707000 CDM 87070 CPT 306 RC inpatient 127 127 BLUE CROSS BLUE SHIELD WELLMARK SB889 [3081026] BCBS WYOMING [308102603] 120.65 percent of total billed charges 78.74 120.65 Technical (Hospital) Services Culture Aerobic Any Source PX-3068707000 CDM 87070 CPT 306 RC inpatient 127 127 UNITED HEALTHCARE (COMMERCIAL) [3081199] UNITED HEALTHCARE 87726 [308119901] 78.74 percent of total billed charges 78.74 120.65 Technical (Hospital) Services Culture Aerobic Any Source PX-3068707000 CDM 87070 CPT 306 RC inpatient 127 127 MULTIPLAN INC 34080 [3081285] MULTIPLAN INC [308128501] 120.65 percent of total billed charges 78.74 120.65 Technical (Hospital) Services Culture Aerobic Any Source PX-3068707000 CDM 87070 CPT 306 RC inpatient 127 127 MEDICA (COMMERCIAL) 94265 [3081118] MEDICA CLAIMS [308111801] 114.3 percent of total billed charges 78.74 120.65 Technical (Hospital) Services Culture Aerobic Any Source PX-3068707000 CDM 87070 CPT 306 RC inpatient 127 127 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES HDHP [308136802] 100.56 percent of total billed charges 78.74 120.65 Technical (Hospital) Services Culture Aerobic Any Source PX-3068707000 CDM 87070 CPT 306 RC inpatient 127 127 HEALTHPARTNERS SX009 HEALTHPARTNERS 100.56 percent of total billed charges 78.74 120.65 Technical (Hospital) Services Culture Aerobic Any Source PX-3068707000 CDM 87070 CPT 306 RC inpatient 127 127 CIGNA 62308 [3081051] CIGNA STATE OF WYOMING [308105107] 100.56 percent of total billed charges 78.74 120.65 Technical (Hospital) Services Culture Aerobic Any Source PX-3068707000 CDM 87070 CPT 306 RC inpatient 127 127 CIGNA 62308 [3081051] CIGNA 62308 [308105105] 100.56 percent of total billed charges 78.74 120.65 Technical (Hospital) Services Culture Aerobic Any Source PX-3068707000 CDM 87070 CPT 306 RC inpatient 127 127 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES EPO [308136803] 100.56 percent of total billed charges 78.74 120.65 Technical (Hospital) Services Campylobacter PX-3068704600 CDM 87046 CPT 306 RC outpatient 105 105 UNITED HEALTHCARE (COMMERCIAL) [3081199] UNITED HEALTHCARE 87726 [308119901] 65.1 percent of total billed charges 65.1 99.75 Technical (Hospital) Services Campylobacter PX-3068704600 CDM 87046 CPT 306 RC outpatient 105 105 HEALTHPARTNERS SX009 HEALTHPARTNERS 84 percent of total billed charges 65.1 99.75 Technical (Hospital) Services Campylobacter PX-3068704600 CDM 87046 CPT 306 RC outpatient 105 105 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES PPO [308136801] 84 percent of total billed charges 65.1 99.75 Technical (Hospital) Services Campylobacter PX-3068704600 CDM 87046 CPT 306 RC outpatient 105 105 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES HDHP [308136802] 84 percent of total billed charges 65.1 99.75 Technical (Hospital) Services Campylobacter PX-3068704600 CDM 87046 CPT 306 RC outpatient 105 105 BLUE CROSS BLUE SHIELD WELLMARK SB889 [3081026] BCBS WYOMING [308102603] 99.75 percent of total billed charges 65.1 99.75 Technical (Hospital) Services Campylobacter PX-3068704600 CDM 87046 CPT 306 RC outpatient 105 105 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES EPO [308136803] 84 percent of total billed charges 65.1 99.75 Technical (Hospital) Services Campylobacter PX-3068704600 CDM 87046 CPT 306 RC outpatient 105 105 MULTIPLAN INC 34080 [3081285] MULTIPLAN INC [308128501] 99.75 percent of total billed charges 65.1 99.75 Technical (Hospital) Services Campylobacter PX-3068704600 CDM 87046 CPT 306 RC outpatient 105 105 CIGNA 62308 [3081051] CIGNA 62308 [308105105] 84 percent of total billed charges 65.1 99.75 Technical (Hospital) Services Campylobacter PX-3068704600 CDM 87046 CPT 306 RC outpatient 105 105 CIGNA 62308 [3081051] CIGNA STATE OF WYOMING [308105107] 84 percent of total billed charges 65.1 99.75 Technical (Hospital) Services Campylobacter PX-3068704600 CDM 87046 CPT 306 RC outpatient 105 105 MEDICA (COMMERCIAL) 94265 [3081118] MEDICA CLAIMS [308111801] 94.5 percent of total billed charges 65.1 99.75 Technical (Hospital) Services Campylobacter PX-3068704600 CDM 87046 CPT 306 RC inpatient 105 105 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES HDHP [308136802] 83.14 percent of total billed charges 65.1 99.75 Technical (Hospital) Services Campylobacter PX-3068704600 CDM 87046 CPT 306 RC inpatient 105 105 UNITED HEALTHCARE (COMMERCIAL) [3081199] UNITED HEALTHCARE 87726 [308119901] 65.1 percent of total billed charges 65.1 99.75 Technical (Hospital) Services Campylobacter PX-3068704600 CDM 87046 CPT 306 RC inpatient 105 105 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES PPO [308136801] 83.14 percent of total billed charges 65.1 99.75 Technical (Hospital) Services Campylobacter PX-3068704600 CDM 87046 CPT 306 RC inpatient 105 105 HEALTHPARTNERS SX009 HEALTHPARTNERS 83.14 percent of total billed charges 65.1 99.75 Technical (Hospital) Services Campylobacter PX-3068704600 CDM 87046 CPT 306 RC inpatient 105 105 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES EPO [308136803] 83.14 percent of total billed charges 65.1 99.75 Technical (Hospital) Services Campylobacter PX-3068704600 CDM 87046 CPT 306 RC inpatient 105 105 BLUE CROSS BLUE SHIELD WELLMARK SB889 [3081026] BCBS WYOMING [308102603] 99.75 percent of total billed charges 65.1 99.75 Technical (Hospital) Services Campylobacter PX-3068704600 CDM 87046 CPT 306 RC inpatient 105 105 CIGNA 62308 [3081051] CIGNA 62308 [308105105] 83.14 percent of total billed charges 65.1 99.75 Technical (Hospital) Services Campylobacter PX-3068704600 CDM 87046 CPT 306 RC inpatient 105 105 CIGNA 62308 [3081051] CIGNA STATE OF WYOMING [308105107] 83.14 percent of total billed charges 65.1 99.75 Technical (Hospital) Services Campylobacter PX-3068704600 CDM 87046 CPT 306 RC inpatient 105 105 MULTIPLAN INC 34080 [3081285] MULTIPLAN INC [308128501] 99.75 percent of total billed charges 65.1 99.75 Technical (Hospital) Services Campylobacter PX-3068704600 CDM 87046 CPT 306 RC inpatient 105 105 MEDICA (COMMERCIAL) 94265 [3081118] MEDICA CLAIMS [308111801] 94.5 percent of total billed charges 65.1 99.75 Technical (Hospital) Services Ref Enteric Pathogen Stool Culture (Not by Pcr) (Stool Additional Pathogens) PX-3068704602 CDM 87046 CPT 306 RC outpatient 104 104 MEDICA (COMMERCIAL) 94265 [3081118] MEDICA CLAIMS [308111801] 93.6 percent of total billed charges 64.48 98.8 Technical (Hospital) Services Ref Enteric Pathogen Stool Culture (Not by Pcr) (Stool Additional Pathogens) PX-3068704602 CDM 87046 CPT 306 RC outpatient 104 104 HEALTHPARTNERS SX009 HEALTHPARTNERS 83.2 percent of total billed charges 64.48 98.8 Technical (Hospital) Services Ref Enteric Pathogen Stool Culture (Not by Pcr) (Stool Additional Pathogens) PX-3068704602 CDM 87046 CPT 306 RC outpatient 104 104 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES PPO [308136801] 83.2 percent of total billed charges 64.48 98.8 Technical (Hospital) Services Ref Enteric Pathogen Stool Culture (Not by Pcr) (Stool Additional Pathogens) PX-3068704602 CDM 87046 CPT 306 RC outpatient 104 104 UNITED HEALTHCARE (COMMERCIAL) [3081199] UNITED HEALTHCARE 87726 [308119901] 64.48 percent of total billed charges 64.48 98.8 Technical (Hospital) Services Ref Enteric Pathogen Stool Culture (Not by Pcr) (Stool Additional Pathogens) PX-3068704602 CDM 87046 CPT 306 RC outpatient 104 104 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES EPO [308136803] 83.2 percent of total billed charges 64.48 98.8 Technical (Hospital) Services Ref Enteric Pathogen Stool Culture (Not by Pcr) (Stool Additional Pathogens) PX-3068704602 CDM 87046 CPT 306 RC outpatient 104 104 CIGNA 62308 [3081051] CIGNA 62308 [308105105] 83.2 percent of total billed charges 64.48 98.8 Technical (Hospital) Services Ref Enteric Pathogen Stool Culture (Not by Pcr) (Stool Additional Pathogens) PX-3068704602 CDM 87046 CPT 306 RC outpatient 104 104 CIGNA 62308 [3081051] CIGNA STATE OF WYOMING [308105107] 83.2 percent of total billed charges 64.48 98.8 Technical (Hospital) Services Ref Enteric Pathogen Stool Culture (Not by Pcr) (Stool Additional Pathogens) PX-3068704602 CDM 87046 CPT 306 RC outpatient 104 104 MULTIPLAN INC 34080 [3081285] MULTIPLAN INC [308128501] 98.8 percent of total billed charges 64.48 98.8 Technical (Hospital) Services Ref Enteric Pathogen Stool Culture (Not by Pcr) (Stool Additional Pathogens) PX-3068704602 CDM 87046 CPT 306 RC outpatient 104 104 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES HDHP [308136802] 83.2 percent of total billed charges 64.48 98.8 Technical (Hospital) Services Ref Enteric Pathogen Stool Culture (Not by Pcr) (Stool Additional Pathogens) PX-3068704602 CDM 87046 CPT 306 RC outpatient 104 104 BLUE CROSS BLUE SHIELD WELLMARK SB889 [3081026] BCBS WYOMING [308102603] 98.8 percent of total billed charges 64.48 98.8 Technical (Hospital) Services Ref Enteric Pathogen Stool Culture (Not by Pcr) (Stool Additional Pathogens) PX-3068704602 CDM 87046 CPT 306 RC inpatient 104 104 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES PPO [308136801] 82.35 percent of total billed charges 64.48 98.8 Technical (Hospital) Services Ref Enteric Pathogen Stool Culture (Not by Pcr) (Stool Additional Pathogens) PX-3068704602 CDM 87046 CPT 306 RC inpatient 104 104 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES HDHP [308136802] 82.35 percent of total billed charges 64.48 98.8 Technical (Hospital) Services Ref Enteric Pathogen Stool Culture (Not by Pcr) (Stool Additional Pathogens) PX-3068704602 CDM 87046 CPT 306 RC inpatient 104 104 UNITED HEALTHCARE (COMMERCIAL) [3081199] UNITED HEALTHCARE 87726 [308119901] 64.48 percent of total billed charges 64.48 98.8 Technical (Hospital) Services Ref Enteric Pathogen Stool Culture (Not by Pcr) (Stool Additional Pathogens) PX-3068704602 CDM 87046 CPT 306 RC inpatient 104 104 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES EPO [308136803] 82.35 percent of total billed charges 64.48 98.8 Technical (Hospital) Services Ref Enteric Pathogen Stool Culture (Not by Pcr) (Stool Additional Pathogens) PX-3068704602 CDM 87046 CPT 306 RC inpatient 104 104 HEALTHPARTNERS SX009 HEALTHPARTNERS 82.35 percent of total billed charges 64.48 98.8 Technical (Hospital) Services Ref Enteric Pathogen Stool Culture (Not by Pcr) (Stool Additional Pathogens) PX-3068704602 CDM 87046 CPT 306 RC inpatient 104 104 MULTIPLAN INC 34080 [3081285] MULTIPLAN INC [308128501] 98.8 percent of total billed charges 64.48 98.8 Technical (Hospital) Services Ref Enteric Pathogen Stool Culture (Not by Pcr) (Stool Additional Pathogens) PX-3068704602 CDM 87046 CPT 306 RC inpatient 104 104 MEDICA (COMMERCIAL) 94265 [3081118] MEDICA CLAIMS [308111801] 93.6 percent of total billed charges 64.48 98.8 Technical (Hospital) Services Ref Enteric Pathogen Stool Culture (Not by Pcr) (Stool Additional Pathogens) PX-3068704602 CDM 87046 CPT 306 RC inpatient 104 104 CIGNA 62308 [3081051] CIGNA 62308 [308105105] 82.35 percent of total billed charges 64.48 98.8 Technical (Hospital) Services Ref Enteric Pathogen Stool Culture (Not by Pcr) (Stool Additional Pathogens) PX-3068704602 CDM 87046 CPT 306 RC inpatient 104 104 CIGNA 62308 [3081051] CIGNA STATE OF WYOMING [308105107] 82.35 percent of total billed charges 64.48 98.8 Technical (Hospital) Services Ref Enteric Pathogen Stool Culture (Not by Pcr) (Stool Additional Pathogens) PX-3068704602 CDM 87046 CPT 306 RC inpatient 104 104 BLUE CROSS BLUE SHIELD WELLMARK SB889 [3081026] BCBS WYOMING [308102603] 98.8 percent of total billed charges 64.48 98.8 Technical (Hospital) Services Fecal Culture PX-3068704500 CDM 87045 CPT 306 RC inpatient 158 158 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES EPO [308136803] 125.1 percent of total billed charges 97.96 150.1 Technical (Hospital) Services Fecal Culture PX-3068704500 CDM 87045 CPT 306 RC outpatient 158 158 CIGNA 62308 [3081051] CIGNA 62308 [308105105] 126.4 percent of total billed charges 97.96 150.1 Technical (Hospital) Services Fecal Culture PX-3068704500 CDM 87045 CPT 306 RC outpatient 158 158 CIGNA 62308 [3081051] CIGNA STATE OF WYOMING [308105107] 126.4 percent of total billed charges 97.96 150.1 Technical (Hospital) Services Fecal Culture PX-3068704500 CDM 87045 CPT 306 RC outpatient 158 158 MEDICA (COMMERCIAL) 94265 [3081118] MEDICA CLAIMS [308111801] 142.2 percent of total billed charges 97.96 150.1 Technical (Hospital) Services Fecal Culture PX-3068704500 CDM 87045 CPT 306 RC outpatient 158 158 HEALTHPARTNERS SX009 HEALTHPARTNERS 126.4 percent of total billed charges 97.96 150.1 Technical (Hospital) Services Fecal Culture PX-3068704500 CDM 87045 CPT 306 RC outpatient 158 158 MULTIPLAN INC 34080 [3081285] MULTIPLAN INC [308128501] 150.1 percent of total billed charges 97.96 150.1 Technical (Hospital) Services Fecal Culture PX-3068704500 CDM 87045 CPT 306 RC outpatient 158 158 UNITED HEALTHCARE (COMMERCIAL) [3081199] UNITED HEALTHCARE 87726 [308119901] 97.96 percent of total billed charges 97.96 150.1 Technical (Hospital) Services Fecal Culture PX-3068704500 CDM 87045 CPT 306 RC outpatient 158 158 BLUE CROSS BLUE SHIELD WELLMARK SB889 [3081026] BCBS WYOMING [308102603] 150.1 percent of total billed charges 97.96 150.1 Technical (Hospital) Services Fecal Culture PX-3068704500 CDM 87045 CPT 306 RC inpatient 158 158 CIGNA 62308 [3081051] CIGNA 62308 [308105105] 125.1 percent of total billed charges 97.96 150.1 Technical (Hospital) Services Fecal Culture PX-3068704500 CDM 87045 CPT 306 RC inpatient 158 158 CIGNA 62308 [3081051] CIGNA STATE OF WYOMING [308105107] 125.1 percent of total billed charges 97.96 150.1 Technical (Hospital) Services Fecal Culture PX-3068704500 CDM 87045 CPT 306 RC inpatient 158 158 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES PPO [308136801] 125.1 percent of total billed charges 97.96 150.1 Technical (Hospital) Services Fecal Culture PX-3068704500 CDM 87045 CPT 306 RC inpatient 158 158 BLUE CROSS BLUE SHIELD WELLMARK SB889 [3081026] BCBS WYOMING [308102603] 150.1 percent of total billed charges 97.96 150.1 Technical (Hospital) Services Fecal Culture PX-3068704500 CDM 87045 CPT 306 RC inpatient 158 158 UNITED HEALTHCARE (COMMERCIAL) [3081199] UNITED HEALTHCARE 87726 [308119901] 97.96 percent of total billed charges 97.96 150.1 Technical (Hospital) Services Fecal Culture PX-3068704500 CDM 87045 CPT 306 RC inpatient 158 158 HEALTHPARTNERS SX009 HEALTHPARTNERS 125.1 percent of total billed charges 97.96 150.1 Technical (Hospital) Services Fecal Culture PX-3068704500 CDM 87045 CPT 306 RC inpatient 158 158 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES HDHP [308136802] 125.1 percent of total billed charges 97.96 150.1 Technical (Hospital) Services Fecal Culture PX-3068704500 CDM 87045 CPT 306 RC inpatient 158 158 MULTIPLAN INC 34080 [3081285] MULTIPLAN INC [308128501] 150.1 percent of total billed charges 97.96 150.1 Technical (Hospital) Services Fecal Culture PX-3068704500 CDM 87045 CPT 306 RC inpatient 158 158 MEDICA (COMMERCIAL) 94265 [3081118] MEDICA CLAIMS [308111801] 142.2 percent of total billed charges 97.96 150.1 Technical (Hospital) Services Fecal Culture PX-3068704500 CDM 87045 CPT 306 RC outpatient 158 158 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES HDHP [308136802] 126.4 percent of total billed charges 97.96 150.1 Technical (Hospital) Services Fecal Culture PX-3068704500 CDM 87045 CPT 306 RC outpatient 158 158 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES EPO [308136803] 126.4 percent of total billed charges 97.96 150.1 Technical (Hospital) Services Fecal Culture PX-3068704500 CDM 87045 CPT 306 RC outpatient 158 158 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES PPO [308136801] 126.4 percent of total billed charges 97.96 150.1 Technical (Hospital) Services Ref Enteric Pathogen Stool Culture (Not by Pcr) (Stool With Isolation) PX-3068704501 CDM 87045 CPT 306 RC inpatient 104 104 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES HDHP [308136802] 82.35 percent of total billed charges 64.48 98.8 Technical (Hospital) Services Ref Enteric Pathogen Stool Culture (Not by Pcr) (Stool With Isolation) PX-3068704501 CDM 87045 CPT 306 RC inpatient 104 104 MEDICA (COMMERCIAL) 94265 [3081118] MEDICA CLAIMS [308111801] 93.6 percent of total billed charges 64.48 98.8 Technical (Hospital) Services Ref Enteric Pathogen Stool Culture (Not by Pcr) (Stool With Isolation) PX-3068704501 CDM 87045 CPT 306 RC inpatient 104 104 UNITED HEALTHCARE (COMMERCIAL) [3081199] UNITED HEALTHCARE 87726 [308119901] 64.48 percent of total billed charges 64.48 98.8 Technical (Hospital) Services Ref Enteric Pathogen Stool Culture (Not by Pcr) (Stool With Isolation) PX-3068704501 CDM 87045 CPT 306 RC inpatient 104 104 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES PPO [308136801] 82.35 percent of total billed charges 64.48 98.8 Technical (Hospital) Services Ref Enteric Pathogen Stool Culture (Not by Pcr) (Stool With Isolation) PX-3068704501 CDM 87045 CPT 306 RC inpatient 104 104 MULTIPLAN INC 34080 [3081285] MULTIPLAN INC [308128501] 98.8 percent of total billed charges 64.48 98.8 Technical (Hospital) Services Ref Enteric Pathogen Stool Culture (Not by Pcr) (Stool With Isolation) PX-3068704501 CDM 87045 CPT 306 RC inpatient 104 104 BLUE CROSS BLUE SHIELD WELLMARK SB889 [3081026] BCBS WYOMING [308102603] 98.8 percent of total billed charges 64.48 98.8 Technical (Hospital) Services Ref Enteric Pathogen Stool Culture (Not by Pcr) (Stool With Isolation) PX-3068704501 CDM 87045 CPT 306 RC inpatient 104 104 CIGNA 62308 [3081051] CIGNA 62308 [308105105] 82.35 percent of total billed charges 64.48 98.8 Technical (Hospital) Services Ref Enteric Pathogen Stool Culture (Not by Pcr) (Stool With Isolation) PX-3068704501 CDM 87045 CPT 306 RC inpatient 104 104 CIGNA 62308 [3081051] CIGNA STATE OF WYOMING [308105107] 82.35 percent of total billed charges 64.48 98.8 Technical (Hospital) Services Ref Enteric Pathogen Stool Culture (Not by Pcr) (Stool With Isolation) PX-3068704501 CDM 87045 CPT 306 RC inpatient 104 104 HEALTHPARTNERS SX009 HEALTHPARTNERS 82.35 percent of total billed charges 64.48 98.8 Technical (Hospital) Services Ref Enteric Pathogen Stool Culture (Not by Pcr) (Stool With Isolation) PX-3068704501 CDM 87045 CPT 306 RC inpatient 104 104 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES EPO [308136803] 82.35 percent of total billed charges 64.48 98.8 Technical (Hospital) Services Ref Enteric Pathogen Stool Culture (Not by Pcr) (Stool With Isolation) PX-3068704501 CDM 87045 CPT 306 RC outpatient 104 104 BLUE CROSS BLUE SHIELD WELLMARK SB889 [3081026] BCBS WYOMING [308102603] 98.8 percent of total billed charges 64.48 98.8 Technical (Hospital) Services Ref Enteric Pathogen Stool Culture (Not by Pcr) (Stool With Isolation) PX-3068704501 CDM 87045 CPT 306 RC outpatient 104 104 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES HDHP [308136802] 83.2 percent of total billed charges 64.48 98.8 Technical (Hospital) Services Ref Enteric Pathogen Stool Culture (Not by Pcr) (Stool With Isolation) PX-3068704501 CDM 87045 CPT 306 RC outpatient 104 104 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES EPO [308136803] 83.2 percent of total billed charges 64.48 98.8 Technical (Hospital) Services Ref Enteric Pathogen Stool Culture (Not by Pcr) (Stool With Isolation) PX-3068704501 CDM 87045 CPT 306 RC outpatient 104 104 CIGNA 62308 [3081051] CIGNA 62308 [308105105] 83.2 percent of total billed charges 64.48 98.8 Technical (Hospital) Services Ref Enteric Pathogen Stool Culture (Not by Pcr) (Stool With Isolation) PX-3068704501 CDM 87045 CPT 306 RC outpatient 104 104 CIGNA 62308 [3081051] CIGNA STATE OF WYOMING [308105107] 83.2 percent of total billed charges 64.48 98.8 Technical (Hospital) Services Ref Enteric Pathogen Stool Culture (Not by Pcr) (Stool With Isolation) PX-3068704501 CDM 87045 CPT 306 RC outpatient 104 104 MULTIPLAN INC 34080 [3081285] MULTIPLAN INC [308128501] 98.8 percent of total billed charges 64.48 98.8 Technical (Hospital) Services Ref Enteric Pathogen Stool Culture (Not by Pcr) (Stool With Isolation) PX-3068704501 CDM 87045 CPT 306 RC outpatient 104 104 UNITED HEALTHCARE (COMMERCIAL) [3081199] UNITED HEALTHCARE 87726 [308119901] 64.48 percent of total billed charges 64.48 98.8 Technical (Hospital) Services Ref Enteric Pathogen Stool Culture (Not by Pcr) (Stool With Isolation) PX-3068704501 CDM 87045 CPT 306 RC outpatient 104 104 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES PPO [308136801] 83.2 percent of total billed charges 64.48 98.8 Technical (Hospital) Services Ref Enteric Pathogen Stool Culture (Not by Pcr) (Stool With Isolation) PX-3068704501 CDM 87045 CPT 306 RC outpatient 104 104 HEALTHPARTNERS SX009 HEALTHPARTNERS 83.2 percent of total billed charges 64.48 98.8 Technical (Hospital) Services Ref Enteric Pathogen Stool Culture (Not by Pcr) (Stool With Isolation) PX-3068704501 CDM 87045 CPT 306 RC outpatient 104 104 MEDICA (COMMERCIAL) 94265 [3081118] MEDICA CLAIMS [308111801] 93.6 percent of total billed charges 64.48 98.8 Technical (Hospital) Services Culture Bact Bld Aer Anaer PX-3068704000 CDM 87040 CPT 306 RC outpatient 251 251 HEALTHPARTNERS SX009 HEALTHPARTNERS 200.8 percent of total billed charges 155.62 238.45 Technical (Hospital) Services Culture Bact Bld Aer Anaer PX-3068704000 CDM 87040 CPT 306 RC outpatient 251 251 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES EPO [308136803] 200.8 percent of total billed charges 155.62 238.45 Technical (Hospital) Services Culture Bact Bld Aer Anaer PX-3068704000 CDM 87040 CPT 306 RC outpatient 251 251 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES PPO [308136801] 200.8 percent of total billed charges 155.62 238.45 Technical (Hospital) Services Culture Bact Bld Aer Anaer PX-3068704000 CDM 87040 CPT 306 RC outpatient 251 251 BLUE CROSS BLUE SHIELD WELLMARK SB889 [3081026] BCBS WYOMING [308102603] 238.45 percent of total billed charges 155.62 238.45 Technical (Hospital) Services Culture Bact Bld Aer Anaer PX-3068704000 CDM 87040 CPT 306 RC outpatient 251 251 UNITED HEALTHCARE (COMMERCIAL) [3081199] UNITED HEALTHCARE 87726 [308119901] 155.62 percent of total billed charges 155.62 238.45 Technical (Hospital) Services Culture Bact Bld Aer Anaer PX-3068704000 CDM 87040 CPT 306 RC outpatient 251 251 MULTIPLAN INC 34080 [3081285] MULTIPLAN INC [308128501] 238.45 percent of total billed charges 155.62 238.45 Technical (Hospital) Services Culture Bact Bld Aer Anaer PX-3068704000 CDM 87040 CPT 306 RC outpatient 251 251 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES HDHP [308136802] 200.8 percent of total billed charges 155.62 238.45 Technical (Hospital) Services Culture Bact Bld Aer Anaer PX-3068704000 CDM 87040 CPT 306 RC outpatient 251 251 MEDICA (COMMERCIAL) 94265 [3081118] MEDICA CLAIMS [308111801] 225.9 percent of total billed charges 155.62 238.45 Technical (Hospital) Services Culture Bact Bld Aer Anaer PX-3068704000 CDM 87040 CPT 306 RC outpatient 251 251 CIGNA 62308 [3081051] CIGNA STATE OF WYOMING [308105107] 200.8 percent of total billed charges 155.62 238.45 Technical (Hospital) Services Culture Bact Bld Aer Anaer PX-3068704000 CDM 87040 CPT 306 RC outpatient 251 251 CIGNA 62308 [3081051] CIGNA 62308 [308105105] 200.8 percent of total billed charges 155.62 238.45 Technical (Hospital) Services Culture Bact Bld Aer Anaer PX-3068704000 CDM 87040 CPT 306 RC inpatient 251 251 BLUE CROSS BLUE SHIELD WELLMARK SB889 [3081026] BCBS WYOMING [308102603] 238.45 percent of total billed charges 155.62 238.45 Technical (Hospital) Services Culture Bact Bld Aer Anaer PX-3068704000 CDM 87040 CPT 306 RC inpatient 251 251 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES PPO [308136801] 198.74 percent of total billed charges 155.62 238.45 Technical (Hospital) Services Culture Bact Bld Aer Anaer PX-3068704000 CDM 87040 CPT 306 RC inpatient 251 251 UNITED HEALTHCARE (COMMERCIAL) [3081199] UNITED HEALTHCARE 87726 [308119901] 155.62 percent of total billed charges 155.62 238.45 Technical (Hospital) Services Culture Bact Bld Aer Anaer PX-3068704000 CDM 87040 CPT 306 RC inpatient 251 251 HEALTHPARTNERS SX009 HEALTHPARTNERS 198.74 percent of total billed charges 155.62 238.45 Technical (Hospital) Services Culture Bact Bld Aer Anaer PX-3068704000 CDM 87040 CPT 306 RC inpatient 251 251 MULTIPLAN INC 34080 [3081285] MULTIPLAN INC [308128501] 238.45 percent of total billed charges 155.62 238.45 Technical (Hospital) Services Culture Bact Bld Aer Anaer PX-3068704000 CDM 87040 CPT 306 RC inpatient 251 251 MEDICA (COMMERCIAL) 94265 [3081118] MEDICA CLAIMS [308111801] 225.9 percent of total billed charges 155.62 238.45 Technical (Hospital) Services Culture Bact Bld Aer Anaer PX-3068704000 CDM 87040 CPT 306 RC inpatient 251 251 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES HDHP [308136802] 198.74 percent of total billed charges 155.62 238.45 Technical (Hospital) Services Culture Bact Bld Aer Anaer PX-3068704000 CDM 87040 CPT 306 RC inpatient 251 251 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES EPO [308136803] 198.74 percent of total billed charges 155.62 238.45 Technical (Hospital) Services Culture Bact Bld Aer Anaer PX-3068704000 CDM 87040 CPT 306 RC inpatient 251 251 CIGNA 62308 [3081051] CIGNA 62308 [308105105] 198.74 percent of total billed charges 155.62 238.45 Technical (Hospital) Services Culture Bact Bld Aer Anaer PX-3068704000 CDM 87040 CPT 306 RC inpatient 251 251 CIGNA 62308 [3081051] CIGNA STATE OF WYOMING [308105107] 198.74 percent of total billed charges 155.62 238.45 Technical (Hospital) Services X Match Ahg PX-3098692200 CDM 86922 CPT 309 RC inpatient 173 173 HEALTHPARTNERS SX009 HEALTHPARTNERS 136.98 percent of total billed charges 107.26 164.35 Technical (Hospital) Services X Match Ahg PX-3098692200 CDM 86922 CPT 309 RC inpatient 173 173 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES EPO [308136803] 136.98 percent of total billed charges 107.26 164.35 Technical (Hospital) Services X Match Ahg PX-3098692200 CDM 86922 CPT 309 RC inpatient 173 173 CIGNA 62308 [3081051] CIGNA 62308 [308105105] 136.98 percent of total billed charges 107.26 164.35 Technical (Hospital) Services X Match Ahg PX-3098692200 CDM 86922 CPT 309 RC inpatient 173 173 CIGNA 62308 [3081051] CIGNA STATE OF WYOMING [308105107] 136.98 percent of total billed charges 107.26 164.35 Technical (Hospital) Services X Match Ahg PX-3098692200 CDM 86922 CPT 309 RC inpatient 173 173 BLUE CROSS BLUE SHIELD WELLMARK SB889 [3081026] BCBS WYOMING [308102603] 164.35 percent of total billed charges 107.26 164.35 Technical (Hospital) Services X Match Ahg PX-3098692200 CDM 86922 CPT 309 RC inpatient 173 173 MULTIPLAN INC 34080 [3081285] MULTIPLAN INC [308128501] 164.35 percent of total billed charges 107.26 164.35 Technical (Hospital) Services X Match Ahg PX-3098692200 CDM 86922 CPT 309 RC inpatient 173 173 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES PPO [308136801] 136.98 percent of total billed charges 107.26 164.35 Technical (Hospital) Services X Match Ahg PX-3098692200 CDM 86922 CPT 309 RC inpatient 173 173 UNITED HEALTHCARE (COMMERCIAL) [3081199] UNITED HEALTHCARE 87726 [308119901] 107.26 percent of total billed charges 107.26 164.35 Technical (Hospital) Services X Match Ahg PX-3098692200 CDM 86922 CPT 309 RC inpatient 173 173 MEDICA (COMMERCIAL) 94265 [3081118] MEDICA CLAIMS [308111801] 155.7 percent of total billed charges 107.26 164.35 Technical (Hospital) Services X Match Ahg PX-3098692200 CDM 86922 CPT 309 RC inpatient 173 173 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES HDHP [308136802] 136.98 percent of total billed charges 107.26 164.35 Technical (Hospital) Services X Match Ahg PX-3098692200 CDM 86922 CPT 309 RC outpatient 173 173 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES PPO [308136801] 138.4 percent of total billed charges 107.26 164.35 Technical (Hospital) Services X Match Ahg PX-3098692200 CDM 86922 CPT 309 RC outpatient 173 173 HEALTHPARTNERS SX009 HEALTHPARTNERS 138.4 percent of total billed charges 107.26 164.35 Technical (Hospital) Services X Match Ahg PX-3098692200 CDM 86922 CPT 309 RC outpatient 173 173 MEDICA (COMMERCIAL) 94265 [3081118] MEDICA CLAIMS [308111801] 155.7 percent of total billed charges 107.26 164.35 Technical (Hospital) Services X Match Ahg PX-3098692200 CDM 86922 CPT 309 RC outpatient 173 173 UNITED HEALTHCARE (COMMERCIAL) [3081199] UNITED HEALTHCARE 87726 [308119901] 107.26 percent of total billed charges 107.26 164.35 Technical (Hospital) Services X Match Ahg PX-3098692200 CDM 86922 CPT 309 RC outpatient 173 173 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES HDHP [308136802] 138.4 percent of total billed charges 107.26 164.35 Technical (Hospital) Services X Match Ahg PX-3098692200 CDM 86922 CPT 309 RC outpatient 173 173 BLUE CROSS BLUE SHIELD WELLMARK SB889 [3081026] BCBS WYOMING [308102603] 164.35 percent of total billed charges 107.26 164.35 Technical (Hospital) Services X Match Ahg PX-3098692200 CDM 86922 CPT 309 RC outpatient 173 173 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES EPO [308136803] 138.4 percent of total billed charges 107.26 164.35 Technical (Hospital) Services X Match Ahg PX-3098692200 CDM 86922 CPT 309 RC outpatient 173 173 CIGNA 62308 [3081051] CIGNA 62308 [308105105] 138.4 percent of total billed charges 107.26 164.35 Technical (Hospital) Services X Match Ahg PX-3098692200 CDM 86922 CPT 309 RC outpatient 173 173 CIGNA 62308 [3081051] CIGNA STATE OF WYOMING [308105107] 138.4 percent of total billed charges 107.26 164.35 Technical (Hospital) Services X Match Ahg PX-3098692200 CDM 86922 CPT 309 RC outpatient 173 173 MULTIPLAN INC 34080 [3081285] MULTIPLAN INC [308128501] 164.35 percent of total billed charges 107.26 164.35 Technical (Hospital) Services Immediate Spin Crossmatch PX-3098692000 CDM 86920 CPT 309 RC inpatient 173 173 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES EPO [308136803] 136.98 percent of total billed charges 107.26 164.35 Technical (Hospital) Services Immediate Spin Crossmatch PX-3098692000 CDM 86920 CPT 309 RC inpatient 173 173 HEALTHPARTNERS SX009 HEALTHPARTNERS 136.98 percent of total billed charges 107.26 164.35 Technical (Hospital) Services Immediate Spin Crossmatch PX-3098692000 CDM 86920 CPT 309 RC inpatient 173 173 CIGNA 62308 [3081051] CIGNA 62308 [308105105] 136.98 percent of total billed charges 107.26 164.35 Technical (Hospital) Services Immediate Spin Crossmatch PX-3098692000 CDM 86920 CPT 309 RC inpatient 173 173 CIGNA 62308 [3081051] CIGNA STATE OF WYOMING [308105107] 136.98 percent of total billed charges 107.26 164.35 Technical (Hospital) Services Immediate Spin Crossmatch PX-3098692000 CDM 86920 CPT 309 RC inpatient 173 173 MULTIPLAN INC 34080 [3081285] MULTIPLAN INC [308128501] 164.35 percent of total billed charges 107.26 164.35 Technical (Hospital) Services Immediate Spin Crossmatch PX-3098692000 CDM 86920 CPT 309 RC inpatient 173 173 BLUE CROSS BLUE SHIELD WELLMARK SB889 [3081026] BCBS WYOMING [308102603] 164.35 percent of total billed charges 107.26 164.35 Technical (Hospital) Services Immediate Spin Crossmatch PX-3098692000 CDM 86920 CPT 309 RC inpatient 173 173 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES PPO [308136801] 136.98 percent of total billed charges 107.26 164.35 Technical (Hospital) Services Immediate Spin Crossmatch PX-3098692000 CDM 86920 CPT 309 RC inpatient 173 173 MEDICA (COMMERCIAL) 94265 [3081118] MEDICA CLAIMS [308111801] 155.7 percent of total billed charges 107.26 164.35 Technical (Hospital) Services Immediate Spin Crossmatch PX-3098692000 CDM 86920 CPT 309 RC inpatient 173 173 UNITED HEALTHCARE (COMMERCIAL) [3081199] UNITED HEALTHCARE 87726 [308119901] 107.26 percent of total billed charges 107.26 164.35 Technical (Hospital) Services Immediate Spin Crossmatch PX-3098692000 CDM 86920 CPT 309 RC inpatient 173 173 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES HDHP [308136802] 136.98 percent of total billed charges 107.26 164.35 Technical (Hospital) Services Immediate Spin Crossmatch PX-3098692000 CDM 86920 CPT 309 RC outpatient 173 173 UNITED HEALTHCARE (COMMERCIAL) [3081199] UNITED HEALTHCARE 87726 [308119901] 107.26 percent of total billed charges 107.26 164.35 Technical (Hospital) Services Immediate Spin Crossmatch PX-3098692000 CDM 86920 CPT 309 RC outpatient 173 173 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES PPO [308136801] 138.4 percent of total billed charges 107.26 164.35 Technical (Hospital) Services Immediate Spin Crossmatch PX-3098692000 CDM 86920 CPT 309 RC outpatient 173 173 HEALTHPARTNERS SX009 HEALTHPARTNERS 138.4 percent of total billed charges 107.26 164.35 Technical (Hospital) Services Immediate Spin Crossmatch PX-3098692000 CDM 86920 CPT 309 RC outpatient 173 173 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES HDHP [308136802] 138.4 percent of total billed charges 107.26 164.35 Technical (Hospital) Services Immediate Spin Crossmatch PX-3098692000 CDM 86920 CPT 309 RC outpatient 173 173 BLUE CROSS BLUE SHIELD WELLMARK SB889 [3081026] BCBS WYOMING [308102603] 164.35 percent of total billed charges 107.26 164.35 Technical (Hospital) Services Immediate Spin Crossmatch PX-3098692000 CDM 86920 CPT 309 RC outpatient 173 173 MULTIPLAN INC 34080 [3081285] MULTIPLAN INC [308128501] 164.35 percent of total billed charges 107.26 164.35 Technical (Hospital) Services Immediate Spin Crossmatch PX-3098692000 CDM 86920 CPT 309 RC outpatient 173 173 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES EPO [308136803] 138.4 percent of total billed charges 107.26 164.35 Technical (Hospital) Services Immediate Spin Crossmatch PX-3098692000 CDM 86920 CPT 309 RC outpatient 173 173 CIGNA 62308 [3081051] CIGNA 62308 [308105105] 138.4 percent of total billed charges 107.26 164.35 Technical (Hospital) Services Immediate Spin Crossmatch PX-3098692000 CDM 86920 CPT 309 RC outpatient 173 173 CIGNA 62308 [3081051] CIGNA STATE OF WYOMING [308105107] 138.4 percent of total billed charges 107.26 164.35 Technical (Hospital) Services Immediate Spin Crossmatch PX-3098692000 CDM 86920 CPT 309 RC outpatient 173 173 MEDICA (COMMERCIAL) 94265 [3081118] MEDICA CLAIMS [308111801] 155.7 percent of total billed charges 107.26 164.35 Technical (Hospital) Services "Ref Ref RBC Antigen Typing, Rh" PX-3098690600 CDM 86906 CPT 309 RC inpatient 128 128 BLUE CROSS BLUE SHIELD WELLMARK SB889 [3081026] BCBS WYOMING [308102603] 121.6 percent of total billed charges 79.36 121.6 Technical (Hospital) Services "Ref Ref RBC Antigen Typing, Rh" PX-3098690600 CDM 86906 CPT 309 RC inpatient 128 128 CIGNA 62308 [3081051] CIGNA 62308 [308105105] 101.35 percent of total billed charges 79.36 121.6 Technical (Hospital) Services "Ref Ref RBC Antigen Typing, Rh" PX-3098690600 CDM 86906 CPT 309 RC inpatient 128 128 CIGNA 62308 [3081051] CIGNA STATE OF WYOMING [308105107] 101.35 percent of total billed charges 79.36 121.6 Technical (Hospital) Services "Ref Ref RBC Antigen Typing, Rh" PX-3098690600 CDM 86906 CPT 309 RC inpatient 128 128 MULTIPLAN INC 34080 [3081285] MULTIPLAN INC [308128501] 121.6 percent of total billed charges 79.36 121.6 Technical (Hospital) Services "Ref Ref RBC Antigen Typing, Rh" PX-3098690600 CDM 86906 CPT 309 RC inpatient 128 128 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES EPO [308136803] 101.35 percent of total billed charges 79.36 121.6 Technical (Hospital) Services "Ref Ref RBC Antigen Typing, Rh" PX-3098690600 CDM 86906 CPT 309 RC inpatient 128 128 HEALTHPARTNERS SX009 HEALTHPARTNERS 101.35 percent of total billed charges 79.36 121.6 Technical (Hospital) Services "Ref Ref RBC Antigen Typing, Rh" PX-3098690600 CDM 86906 CPT 309 RC inpatient 128 128 UNITED HEALTHCARE (COMMERCIAL) [3081199] UNITED HEALTHCARE 87726 [308119901] 79.36 percent of total billed charges 79.36 121.6 Technical (Hospital) Services "Ref Ref RBC Antigen Typing, Rh" PX-3098690600 CDM 86906 CPT 309 RC inpatient 128 128 MEDICA (COMMERCIAL) 94265 [3081118] MEDICA CLAIMS [308111801] 115.2 percent of total billed charges 79.36 121.6 Technical (Hospital) Services "Ref Ref RBC Antigen Typing, Rh" PX-3098690600 CDM 86906 CPT 309 RC inpatient 128 128 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES HDHP [308136802] 101.35 percent of total billed charges 79.36 121.6 Technical (Hospital) Services "Ref Ref RBC Antigen Typing, Rh" PX-3098690600 CDM 86906 CPT 309 RC inpatient 128 128 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES PPO [308136801] 101.35 percent of total billed charges 79.36 121.6 Technical (Hospital) Services "Ref Ref RBC Antigen Typing, Rh" PX-3098690600 CDM 86906 CPT 309 RC outpatient 128 128 UNITED HEALTHCARE (COMMERCIAL) [3081199] UNITED HEALTHCARE 87726 [308119901] 79.36 percent of total billed charges 79.36 121.6 Technical (Hospital) Services "Ref Ref RBC Antigen Typing, Rh" PX-3098690600 CDM 86906 CPT 309 RC outpatient 128 128 HEALTHPARTNERS SX009 HEALTHPARTNERS 102.4 percent of total billed charges 79.36 121.6 Technical (Hospital) Services "Ref Ref RBC Antigen Typing, Rh" PX-3098690600 CDM 86906 CPT 309 RC outpatient 128 128 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES PPO [308136801] 102.4 percent of total billed charges 79.36 121.6 Technical (Hospital) Services "Ref Ref RBC Antigen Typing, Rh" PX-3098690600 CDM 86906 CPT 309 RC outpatient 128 128 CIGNA 62308 [3081051] CIGNA 62308 [308105105] 102.4 percent of total billed charges 79.36 121.6 Technical (Hospital) Services "Ref Ref RBC Antigen Typing, Rh" PX-3098690600 CDM 86906 CPT 309 RC outpatient 128 128 CIGNA 62308 [3081051] CIGNA STATE OF WYOMING [308105107] 102.4 percent of total billed charges 79.36 121.6 Technical (Hospital) Services "Ref Ref RBC Antigen Typing, Rh" PX-3098690600 CDM 86906 CPT 309 RC outpatient 128 128 BLUE CROSS BLUE SHIELD WELLMARK SB889 [3081026] BCBS WYOMING [308102603] 121.6 percent of total billed charges 79.36 121.6 Technical (Hospital) Services "Ref Ref RBC Antigen Typing, Rh" PX-3098690600 CDM 86906 CPT 309 RC outpatient 128 128 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES EPO [308136803] 102.4 percent of total billed charges 79.36 121.6 Technical (Hospital) Services "Ref Ref RBC Antigen Typing, Rh" PX-3098690600 CDM 86906 CPT 309 RC outpatient 128 128 MULTIPLAN INC 34080 [3081285] MULTIPLAN INC [308128501] 121.6 percent of total billed charges 79.36 121.6 Technical (Hospital) Services "Ref Ref RBC Antigen Typing, Rh" PX-3098690600 CDM 86906 CPT 309 RC outpatient 128 128 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES HDHP [308136802] 102.4 percent of total billed charges 79.36 121.6 Technical (Hospital) Services "Ref Ref RBC Antigen Typing, Rh" PX-3098690600 CDM 86906 CPT 309 RC outpatient 128 128 MEDICA (COMMERCIAL) 94265 [3081118] MEDICA CLAIMS [308111801] 115.2 percent of total billed charges 79.36 121.6 Technical (Hospital) Services CAGP PX-3098690500 CDM 86905 CPT 309 RC outpatient 237 237 UNITED HEALTHCARE (COMMERCIAL) [3081199] UNITED HEALTHCARE 87726 [308119901] 146.94 percent of total billed charges 146.94 225.15 Technical (Hospital) Services CAGP PX-3098690500 CDM 86905 CPT 309 RC outpatient 237 237 BLUE CROSS BLUE SHIELD WELLMARK SB889 [3081026] BCBS WYOMING [308102603] 225.15 percent of total billed charges 146.94 225.15 Technical (Hospital) Services CAGP PX-3098690500 CDM 86905 CPT 309 RC outpatient 237 237 MULTIPLAN INC 34080 [3081285] MULTIPLAN INC [308128501] 225.15 percent of total billed charges 146.94 225.15 Technical (Hospital) Services CAGP PX-3098690500 CDM 86905 CPT 309 RC outpatient 237 237 CIGNA 62308 [3081051] CIGNA 62308 [308105105] 189.6 percent of total billed charges 146.94 225.15 Technical (Hospital) Services CAGP PX-3098690500 CDM 86905 CPT 309 RC outpatient 237 237 CIGNA 62308 [3081051] CIGNA STATE OF WYOMING [308105107] 189.6 percent of total billed charges 146.94 225.15 Technical (Hospital) Services CAGP PX-3098690500 CDM 86905 CPT 309 RC outpatient 237 237 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES EPO [308136803] 189.6 percent of total billed charges 146.94 225.15 Technical (Hospital) Services CAGP PX-3098690500 CDM 86905 CPT 309 RC outpatient 237 237 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES HDHP [308136802] 189.6 percent of total billed charges 146.94 225.15 Technical (Hospital) Services CAGP PX-3098690500 CDM 86905 CPT 309 RC outpatient 237 237 HEALTHPARTNERS SX009 HEALTHPARTNERS 189.6 percent of total billed charges 146.94 225.15 Technical (Hospital) Services CAGP PX-3098690500 CDM 86905 CPT 309 RC outpatient 237 237 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES PPO [308136801] 189.6 percent of total billed charges 146.94 225.15 Technical (Hospital) Services CAGP PX-3098690500 CDM 86905 CPT 309 RC outpatient 237 237 MEDICA (COMMERCIAL) 94265 [3081118] MEDICA CLAIMS [308111801] 213.3 percent of total billed charges 146.94 225.15 Technical (Hospital) Services CAGP PX-3098690500 CDM 86905 CPT 309 RC inpatient 237 237 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES EPO [308136803] 187.66 percent of total billed charges 146.94 225.15 Technical (Hospital) Services CAGP PX-3098690500 CDM 86905 CPT 309 RC inpatient 237 237 HEALTHPARTNERS SX009 HEALTHPARTNERS 187.66 percent of total billed charges 146.94 225.15 Technical (Hospital) Services CAGP PX-3098690500 CDM 86905 CPT 309 RC inpatient 237 237 BLUE CROSS BLUE SHIELD WELLMARK SB889 [3081026] BCBS WYOMING [308102603] 225.15 percent of total billed charges 146.94 225.15 Technical (Hospital) Services CAGP PX-3098690500 CDM 86905 CPT 309 RC inpatient 237 237 CIGNA 62308 [3081051] CIGNA 62308 [308105105] 187.66 percent of total billed charges 146.94 225.15 Technical (Hospital) Services CAGP PX-3098690500 CDM 86905 CPT 309 RC inpatient 237 237 CIGNA 62308 [3081051] CIGNA STATE OF WYOMING [308105107] 187.66 percent of total billed charges 146.94 225.15 Technical (Hospital) Services CAGP PX-3098690500 CDM 86905 CPT 309 RC inpatient 237 237 MULTIPLAN INC 34080 [3081285] MULTIPLAN INC [308128501] 225.15 percent of total billed charges 146.94 225.15 Technical (Hospital) Services CAGP PX-3098690500 CDM 86905 CPT 309 RC inpatient 237 237 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES PPO [308136801] 187.66 percent of total billed charges 146.94 225.15 Technical (Hospital) Services CAGP PX-3098690500 CDM 86905 CPT 309 RC inpatient 237 237 MEDICA (COMMERCIAL) 94265 [3081118] MEDICA CLAIMS [308111801] 213.3 percent of total billed charges 146.94 225.15 Technical (Hospital) Services CAGP PX-3098690500 CDM 86905 CPT 309 RC inpatient 237 237 UNITED HEALTHCARE (COMMERCIAL) [3081199] UNITED HEALTHCARE 87726 [308119901] 146.94 percent of total billed charges 146.94 225.15 Technical (Hospital) Services CAGP PX-3098690500 CDM 86905 CPT 309 RC inpatient 237 237 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES HDHP [308136802] 187.66 percent of total billed charges 146.94 225.15 Technical (Hospital) Services Antigen Test Donor Bld Ea Unit PX-3098690200 CDM 86902 CPT 309 RC inpatient 377 377 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES EPO [308136803] 298.51 percent of total billed charges 233.74 358.15 Technical (Hospital) Services Antigen Test Donor Bld Ea Unit PX-3098690200 CDM 86902 CPT 309 RC inpatient 377 377 HEALTHPARTNERS SX009 HEALTHPARTNERS 298.51 percent of total billed charges 233.74 358.15 Technical (Hospital) Services Antigen Test Donor Bld Ea Unit PX-3098690200 CDM 86902 CPT 309 RC inpatient 377 377 MULTIPLAN INC 34080 [3081285] MULTIPLAN INC [308128501] 358.15 percent of total billed charges 233.74 358.15 Technical (Hospital) Services Antigen Test Donor Bld Ea Unit PX-3098690200 CDM 86902 CPT 309 RC inpatient 377 377 CIGNA 62308 [3081051] CIGNA 62308 [308105105] 298.51 percent of total billed charges 233.74 358.15 Technical (Hospital) Services Antigen Test Donor Bld Ea Unit PX-3098690200 CDM 86902 CPT 309 RC inpatient 377 377 CIGNA 62308 [3081051] CIGNA STATE OF WYOMING [308105107] 298.51 percent of total billed charges 233.74 358.15 Technical (Hospital) Services Antigen Test Donor Bld Ea Unit PX-3098690200 CDM 86902 CPT 309 RC inpatient 377 377 BLUE CROSS BLUE SHIELD WELLMARK SB889 [3081026] BCBS WYOMING [308102603] 358.15 percent of total billed charges 233.74 358.15 Technical (Hospital) Services Antigen Test Donor Bld Ea Unit PX-3098690200 CDM 86902 CPT 309 RC inpatient 377 377 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES PPO [308136801] 298.51 percent of total billed charges 233.74 358.15 Technical (Hospital) Services Antigen Test Donor Bld Ea Unit PX-3098690200 CDM 86902 CPT 309 RC inpatient 377 377 UNITED HEALTHCARE (COMMERCIAL) [3081199] UNITED HEALTHCARE 87726 [308119901] 233.74 percent of total billed charges 233.74 358.15 Technical (Hospital) Services Antigen Test Donor Bld Ea Unit PX-3098690200 CDM 86902 CPT 309 RC inpatient 377 377 MEDICA (COMMERCIAL) 94265 [3081118] MEDICA CLAIMS [308111801] 339.3 percent of total billed charges 233.74 358.15 Technical (Hospital) Services Antigen Test Donor Bld Ea Unit PX-3098690200 CDM 86902 CPT 309 RC outpatient 377 377 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES HDHP [308136802] 301.6 percent of total billed charges 233.74 358.15 Technical (Hospital) Services Antigen Test Donor Bld Ea Unit PX-3098690200 CDM 86902 CPT 309 RC outpatient 377 377 BLUE CROSS BLUE SHIELD WELLMARK SB889 [3081026] BCBS WYOMING [308102603] 358.15 percent of total billed charges 233.74 358.15 Technical (Hospital) Services Antigen Test Donor Bld Ea Unit PX-3098690200 CDM 86902 CPT 309 RC outpatient 377 377 CIGNA 62308 [3081051] CIGNA 62308 [308105105] 301.6 percent of total billed charges 233.74 358.15 Technical (Hospital) Services Antigen Test Donor Bld Ea Unit PX-3098690200 CDM 86902 CPT 309 RC outpatient 377 377 CIGNA 62308 [3081051] CIGNA STATE OF WYOMING [308105107] 301.6 percent of total billed charges 233.74 358.15 Technical (Hospital) Services Antigen Test Donor Bld Ea Unit PX-3098690200 CDM 86902 CPT 309 RC inpatient 377 377 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES HDHP [308136802] 298.51 percent of total billed charges 233.74 358.15 Technical (Hospital) Services Antigen Test Donor Bld Ea Unit PX-3098690200 CDM 86902 CPT 309 RC outpatient 377 377 MULTIPLAN INC 34080 [3081285] MULTIPLAN INC [308128501] 358.15 percent of total billed charges 233.74 358.15 Technical (Hospital) Services Antigen Test Donor Bld Ea Unit PX-3098690200 CDM 86902 CPT 309 RC outpatient 377 377 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES EPO [308136803] 301.6 percent of total billed charges 233.74 358.15 Technical (Hospital) Services Antigen Test Donor Bld Ea Unit PX-3098690200 CDM 86902 CPT 309 RC outpatient 377 377 UNITED HEALTHCARE (COMMERCIAL) [3081199] UNITED HEALTHCARE 87726 [308119901] 233.74 percent of total billed charges 233.74 358.15 Technical (Hospital) Services Antigen Test Donor Bld Ea Unit PX-3098690200 CDM 86902 CPT 309 RC outpatient 377 377 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES PPO [308136801] 301.6 percent of total billed charges 233.74 358.15 Technical (Hospital) Services Antigen Test Donor Bld Ea Unit PX-3098690200 CDM 86902 CPT 309 RC outpatient 377 377 HEALTHPARTNERS SX009 HEALTHPARTNERS 301.6 percent of total billed charges 233.74 358.15 Technical (Hospital) Services Antigen Test Donor Bld Ea Unit PX-3098690200 CDM 86902 CPT 309 RC outpatient 377 377 MEDICA (COMMERCIAL) 94265 [3081118] MEDICA CLAIMS [308111801] 339.3 percent of total billed charges 233.74 358.15 Technical (Hospital) Services Rh Blood Typing PX-3098690101 CDM 86901 CPT 309 RC outpatient 72 72 BLUE CROSS BLUE SHIELD WELLMARK SB889 [3081026] BCBS WYOMING [308102603] 68.4 percent of total billed charges 44.64 68.4 Technical (Hospital) Services Rh Blood Typing PX-3098690101 CDM 86901 CPT 309 RC outpatient 72 72 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES HDHP [308136802] 57.6 percent of total billed charges 44.64 68.4 Technical (Hospital) Services Rh Blood Typing PX-3098690101 CDM 86901 CPT 309 RC outpatient 72 72 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES EPO [308136803] 57.6 percent of total billed charges 44.64 68.4 Technical (Hospital) Services Rh Blood Typing PX-3098690101 CDM 86901 CPT 309 RC outpatient 72 72 MULTIPLAN INC 34080 [3081285] MULTIPLAN INC [308128501] 68.4 percent of total billed charges 44.64 68.4 Technical (Hospital) Services Rh Blood Typing PX-3098690101 CDM 86901 CPT 309 RC outpatient 72 72 CIGNA 62308 [3081051] CIGNA 62308 [308105105] 57.6 percent of total billed charges 44.64 68.4 Technical (Hospital) Services Rh Blood Typing PX-3098690101 CDM 86901 CPT 309 RC outpatient 72 72 CIGNA 62308 [3081051] CIGNA STATE OF WYOMING [308105107] 57.6 percent of total billed charges 44.64 68.4 Technical (Hospital) Services Rh Blood Typing PX-3098690101 CDM 86901 CPT 309 RC outpatient 72 72 UNITED HEALTHCARE (COMMERCIAL) [3081199] UNITED HEALTHCARE 87726 [308119901] 44.64 percent of total billed charges 44.64 68.4 Technical (Hospital) Services Rh Blood Typing PX-3098690101 CDM 86901 CPT 309 RC outpatient 72 72 HEALTHPARTNERS SX009 HEALTHPARTNERS 57.6 percent of total billed charges 44.64 68.4 Technical (Hospital) Services Rh Blood Typing PX-3098690101 CDM 86901 CPT 309 RC outpatient 72 72 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES PPO [308136801] 57.6 percent of total billed charges 44.64 68.4 Technical (Hospital) Services Rh Blood Typing PX-3098690101 CDM 86901 CPT 309 RC outpatient 72 72 MEDICA (COMMERCIAL) 94265 [3081118] MEDICA CLAIMS [308111801] 64.8 percent of total billed charges 44.64 68.4 Technical (Hospital) Services Rh Blood Typing PX-3098690101 CDM 86901 CPT 309 RC inpatient 72 72 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES PPO [308136801] 57.01 percent of total billed charges 44.64 68.4 Technical (Hospital) Services Rh Blood Typing PX-3098690101 CDM 86901 CPT 309 RC inpatient 72 72 MEDICA (COMMERCIAL) 94265 [3081118] MEDICA CLAIMS [308111801] 64.8 percent of total billed charges 44.64 68.4 Technical (Hospital) Services Rh Blood Typing PX-3098690101 CDM 86901 CPT 309 RC inpatient 72 72 UNITED HEALTHCARE (COMMERCIAL) [3081199] UNITED HEALTHCARE 87726 [308119901] 44.64 percent of total billed charges 44.64 68.4 Technical (Hospital) Services Rh Blood Typing PX-3098690101 CDM 86901 CPT 309 RC inpatient 72 72 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES HDHP [308136802] 57.01 percent of total billed charges 44.64 68.4 Technical (Hospital) Services Rh Blood Typing PX-3098690101 CDM 86901 CPT 309 RC inpatient 72 72 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES EPO [308136803] 57.01 percent of total billed charges 44.64 68.4 Technical (Hospital) Services Rh Blood Typing PX-3098690101 CDM 86901 CPT 309 RC inpatient 72 72 HEALTHPARTNERS SX009 HEALTHPARTNERS 57.01 percent of total billed charges 44.64 68.4 Technical (Hospital) Services Rh Blood Typing PX-3098690101 CDM 86901 CPT 309 RC inpatient 72 72 BLUE CROSS BLUE SHIELD WELLMARK SB889 [3081026] BCBS WYOMING [308102603] 68.4 percent of total billed charges 44.64 68.4 Technical (Hospital) Services Rh Blood Typing PX-3098690101 CDM 86901 CPT 309 RC inpatient 72 72 MULTIPLAN INC 34080 [3081285] MULTIPLAN INC [308128501] 68.4 percent of total billed charges 44.64 68.4 Technical (Hospital) Services Rh Blood Typing PX-3098690101 CDM 86901 CPT 309 RC inpatient 72 72 CIGNA 62308 [3081051] CIGNA 62308 [308105105] 57.01 percent of total billed charges 44.64 68.4 Technical (Hospital) Services Rh Blood Typing PX-3098690101 CDM 86901 CPT 309 RC inpatient 72 72 CIGNA 62308 [3081051] CIGNA STATE OF WYOMING [308105107] 57.01 percent of total billed charges 44.64 68.4 Technical (Hospital) Services Abo Type Serologic-OB Group PX-3098690000 CDM 86900 CPT 309 RC inpatient 72 72 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES EPO [308136803] 57.01 percent of total billed charges 44.64 68.4 Technical (Hospital) Services Abo Type Serologic-OB Group PX-3098690000 CDM 86900 CPT 309 RC inpatient 72 72 HEALTHPARTNERS SX009 HEALTHPARTNERS 57.01 percent of total billed charges 44.64 68.4 Technical (Hospital) Services Abo Type Serologic-OB Group PX-3098690000 CDM 86900 CPT 309 RC inpatient 72 72 BLUE CROSS BLUE SHIELD WELLMARK SB889 [3081026] BCBS WYOMING [308102603] 68.4 percent of total billed charges 44.64 68.4 Technical (Hospital) Services Abo Type Serologic-OB Group PX-3098690000 CDM 86900 CPT 309 RC inpatient 72 72 CIGNA 62308 [3081051] CIGNA 62308 [308105105] 57.01 percent of total billed charges 44.64 68.4 Technical (Hospital) Services Abo Type Serologic-OB Group PX-3098690000 CDM 86900 CPT 309 RC inpatient 72 72 CIGNA 62308 [3081051] CIGNA STATE OF WYOMING [308105107] 57.01 percent of total billed charges 44.64 68.4 Technical (Hospital) Services Abo Type Serologic-OB Group PX-3098690000 CDM 86900 CPT 309 RC inpatient 72 72 MULTIPLAN INC 34080 [3081285] MULTIPLAN INC [308128501] 68.4 percent of total billed charges 44.64 68.4 Technical (Hospital) Services Abo Type Serologic-OB Group PX-3098690000 CDM 86900 CPT 309 RC inpatient 72 72 MEDICA (COMMERCIAL) 94265 [3081118] MEDICA CLAIMS [308111801] 64.8 percent of total billed charges 44.64 68.4 Technical (Hospital) Services Abo Type Serologic-OB Group PX-3098690000 CDM 86900 CPT 309 RC inpatient 72 72 UNITED HEALTHCARE (COMMERCIAL) [3081199] UNITED HEALTHCARE 87726 [308119901] 44.64 percent of total billed charges 44.64 68.4 Technical (Hospital) Services Abo Type Serologic-OB Group PX-3098690000 CDM 86900 CPT 309 RC inpatient 72 72 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES HDHP [308136802] 57.01 percent of total billed charges 44.64 68.4 Technical (Hospital) Services Abo Type Serologic-OB Group PX-3098690000 CDM 86900 CPT 309 RC inpatient 72 72 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES PPO [308136801] 57.01 percent of total billed charges 44.64 68.4 Technical (Hospital) Services Abo Type Serologic-OB Group PX-3098690000 CDM 86900 CPT 309 RC outpatient 72 72 MEDICA (COMMERCIAL) 94265 [3081118] MEDICA CLAIMS [308111801] 64.8 percent of total billed charges 44.64 68.4 Technical (Hospital) Services Abo Type Serologic-OB Group PX-3098690000 CDM 86900 CPT 309 RC outpatient 72 72 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES PPO [308136801] 57.6 percent of total billed charges 44.64 68.4 Technical (Hospital) Services Abo Type Serologic-OB Group PX-3098690000 CDM 86900 CPT 309 RC outpatient 72 72 HEALTHPARTNERS SX009 HEALTHPARTNERS 57.6 percent of total billed charges 44.64 68.4 Technical (Hospital) Services Abo Type Serologic-OB Group PX-3098690000 CDM 86900 CPT 309 RC outpatient 72 72 UNITED HEALTHCARE (COMMERCIAL) [3081199] UNITED HEALTHCARE 87726 [308119901] 44.64 percent of total billed charges 44.64 68.4 Technical (Hospital) Services Abo Type Serologic-OB Group PX-3098690000 CDM 86900 CPT 309 RC outpatient 72 72 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES HDHP [308136802] 57.6 percent of total billed charges 44.64 68.4 Technical (Hospital) Services Abo Type Serologic-OB Group PX-3098690000 CDM 86900 CPT 309 RC outpatient 72 72 BLUE CROSS BLUE SHIELD WELLMARK SB889 [3081026] BCBS WYOMING [308102603] 68.4 percent of total billed charges 44.64 68.4 Technical (Hospital) Services Abo Type Serologic-OB Group PX-3098690000 CDM 86900 CPT 309 RC outpatient 72 72 MULTIPLAN INC 34080 [3081285] MULTIPLAN INC [308128501] 68.4 percent of total billed charges 44.64 68.4 Technical (Hospital) Services Abo Type Serologic-OB Group PX-3098690000 CDM 86900 CPT 309 RC outpatient 72 72 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES EPO [308136803] 57.6 percent of total billed charges 44.64 68.4 Technical (Hospital) Services Abo Type Serologic-OB Group PX-3098690000 CDM 86900 CPT 309 RC outpatient 72 72 CIGNA 62308 [3081051] CIGNA 62308 [308105105] 57.6 percent of total billed charges 44.64 68.4 Technical (Hospital) Services Abo Type Serologic-OB Group PX-3098690000 CDM 86900 CPT 309 RC outpatient 72 72 CIGNA 62308 [3081051] CIGNA STATE OF WYOMING [308105107] 57.6 percent of total billed charges 44.64 68.4 Technical (Hospital) Services Abo Type Serologic PX-3098690001 CDM 86900 CPT 309 RC inpatient 72 72 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES PPO [308136801] 57.01 percent of total billed charges 44.64 68.4 Technical (Hospital) Services Abo Type Serologic PX-3098690001 CDM 86900 CPT 309 RC inpatient 72 72 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES HDHP [308136802] 57.01 percent of total billed charges 44.64 68.4 Technical (Hospital) Services Abo Type Serologic PX-3098690001 CDM 86900 CPT 309 RC inpatient 72 72 UNITED HEALTHCARE (COMMERCIAL) [3081199] UNITED HEALTHCARE 87726 [308119901] 44.64 percent of total billed charges 44.64 68.4 Technical (Hospital) Services Abo Type Serologic PX-3098690001 CDM 86900 CPT 309 RC inpatient 72 72 MEDICA (COMMERCIAL) 94265 [3081118] MEDICA CLAIMS [308111801] 64.8 percent of total billed charges 44.64 68.4 Technical (Hospital) Services Abo Type Serologic PX-3098690001 CDM 86900 CPT 309 RC inpatient 72 72 MULTIPLAN INC 34080 [3081285] MULTIPLAN INC [308128501] 68.4 percent of total billed charges 44.64 68.4 Technical (Hospital) Services Abo Type Serologic PX-3098690001 CDM 86900 CPT 309 RC inpatient 72 72 CIGNA 62308 [3081051] CIGNA 62308 [308105105] 57.01 percent of total billed charges 44.64 68.4 Technical (Hospital) Services Abo Type Serologic PX-3098690001 CDM 86900 CPT 309 RC inpatient 72 72 CIGNA 62308 [3081051] CIGNA STATE OF WYOMING [308105107] 57.01 percent of total billed charges 44.64 68.4 Technical (Hospital) Services Abo Type Serologic PX-3098690001 CDM 86900 CPT 309 RC inpatient 72 72 BLUE CROSS BLUE SHIELD WELLMARK SB889 [3081026] BCBS WYOMING [308102603] 68.4 percent of total billed charges 44.64 68.4 Technical (Hospital) Services Abo Type Serologic PX-3098690001 CDM 86900 CPT 309 RC inpatient 72 72 HEALTHPARTNERS SX009 HEALTHPARTNERS 57.01 percent of total billed charges 44.64 68.4 Technical (Hospital) Services Abo Type Serologic PX-3098690001 CDM 86900 CPT 309 RC inpatient 72 72 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES EPO [308136803] 57.01 percent of total billed charges 44.64 68.4 Technical (Hospital) Services Abo Type Serologic PX-3098690001 CDM 86900 CPT 309 RC outpatient 72 72 BLUE CROSS BLUE SHIELD WELLMARK SB889 [3081026] BCBS WYOMING [308102603] 68.4 percent of total billed charges 44.64 68.4 Technical (Hospital) Services Abo Type Serologic PX-3098690001 CDM 86900 CPT 309 RC outpatient 72 72 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES HDHP [308136802] 57.6 percent of total billed charges 44.64 68.4 Technical (Hospital) Services Abo Type Serologic PX-3098690001 CDM 86900 CPT 309 RC outpatient 72 72 MULTIPLAN INC 34080 [3081285] MULTIPLAN INC [308128501] 68.4 percent of total billed charges 44.64 68.4 Technical (Hospital) Services Abo Type Serologic PX-3098690001 CDM 86900 CPT 309 RC outpatient 72 72 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES EPO [308136803] 57.6 percent of total billed charges 44.64 68.4 Technical (Hospital) Services Abo Type Serologic PX-3098690001 CDM 86900 CPT 309 RC outpatient 72 72 CIGNA 62308 [3081051] CIGNA 62308 [308105105] 57.6 percent of total billed charges 44.64 68.4 Technical (Hospital) Services Abo Type Serologic PX-3098690001 CDM 86900 CPT 309 RC outpatient 72 72 CIGNA 62308 [3081051] CIGNA STATE OF WYOMING [308105107] 57.6 percent of total billed charges 44.64 68.4 Technical (Hospital) Services Abo Type Serologic PX-3098690001 CDM 86900 CPT 309 RC outpatient 72 72 UNITED HEALTHCARE (COMMERCIAL) [3081199] UNITED HEALTHCARE 87726 [308119901] 44.64 percent of total billed charges 44.64 68.4 Technical (Hospital) Services Abo Type Serologic PX-3098690001 CDM 86900 CPT 309 RC outpatient 72 72 HEALTHPARTNERS SX009 HEALTHPARTNERS 57.6 percent of total billed charges 44.64 68.4 Technical (Hospital) Services Abo Type Serologic PX-3098690001 CDM 86900 CPT 309 RC outpatient 72 72 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES PPO [308136801] 57.6 percent of total billed charges 44.64 68.4 Technical (Hospital) Services Abo Type Serologic PX-3098690001 CDM 86900 CPT 309 RC outpatient 72 72 MEDICA (COMMERCIAL) 94265 [3081118] MEDICA CLAIMS [308111801] 64.8 percent of total billed charges 44.64 68.4 Technical (Hospital) Services Ab Titer Indirect PX-3098688600 CDM 86886 CPT 309 RC inpatient 208 208 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES EPO [308136803] 164.69 percent of total billed charges 128.96 197.6 Technical (Hospital) Services Ab Titer Indirect PX-3098688600 CDM 86886 CPT 309 RC inpatient 208 208 HEALTHPARTNERS SX009 HEALTHPARTNERS 164.69 percent of total billed charges 128.96 197.6 Technical (Hospital) Services Ab Titer Indirect PX-3098688600 CDM 86886 CPT 309 RC inpatient 208 208 BLUE CROSS BLUE SHIELD WELLMARK SB889 [3081026] BCBS WYOMING [308102603] 197.6 percent of total billed charges 128.96 197.6 Technical (Hospital) Services Ab Titer Indirect PX-3098688600 CDM 86886 CPT 309 RC inpatient 208 208 CIGNA 62308 [3081051] CIGNA 62308 [308105105] 164.69 percent of total billed charges 128.96 197.6 Technical (Hospital) Services Ab Titer Indirect PX-3098688600 CDM 86886 CPT 309 RC inpatient 208 208 CIGNA 62308 [3081051] CIGNA STATE OF WYOMING [308105107] 164.69 percent of total billed charges 128.96 197.6 Technical (Hospital) Services Ab Titer Indirect PX-3098688600 CDM 86886 CPT 309 RC inpatient 208 208 MULTIPLAN INC 34080 [3081285] MULTIPLAN INC [308128501] 197.6 percent of total billed charges 128.96 197.6 Technical (Hospital) Services Ab Titer Indirect PX-3098688600 CDM 86886 CPT 309 RC inpatient 208 208 MEDICA (COMMERCIAL) 94265 [3081118] MEDICA CLAIMS [308111801] 187.2 percent of total billed charges 128.96 197.6 Technical (Hospital) Services Ab Titer Indirect PX-3098688600 CDM 86886 CPT 309 RC inpatient 208 208 UNITED HEALTHCARE (COMMERCIAL) [3081199] UNITED HEALTHCARE 87726 [308119901] 128.96 percent of total billed charges 128.96 197.6 Technical (Hospital) Services Ab Titer Indirect PX-3098688600 CDM 86886 CPT 309 RC inpatient 208 208 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES HDHP [308136802] 164.69 percent of total billed charges 128.96 197.6 Technical (Hospital) Services Ab Titer Indirect PX-3098688600 CDM 86886 CPT 309 RC outpatient 208 208 MULTIPLAN INC 34080 [3081285] MULTIPLAN INC [308128501] 197.6 percent of total billed charges 128.96 197.6 Technical (Hospital) Services Ab Titer Indirect PX-3098688600 CDM 86886 CPT 309 RC outpatient 208 208 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES EPO [308136803] 166.4 percent of total billed charges 128.96 197.6 Technical (Hospital) Services Ab Titer Indirect PX-3098688600 CDM 86886 CPT 309 RC outpatient 208 208 CIGNA 62308 [3081051] CIGNA 62308 [308105105] 166.4 percent of total billed charges 128.96 197.6 Technical (Hospital) Services Ab Titer Indirect PX-3098688600 CDM 86886 CPT 309 RC outpatient 208 208 CIGNA 62308 [3081051] CIGNA STATE OF WYOMING [308105107] 166.4 percent of total billed charges 128.96 197.6 Technical (Hospital) Services Ab Titer Indirect PX-3098688600 CDM 86886 CPT 309 RC outpatient 208 208 BLUE CROSS BLUE SHIELD WELLMARK SB889 [3081026] BCBS WYOMING [308102603] 197.6 percent of total billed charges 128.96 197.6 Technical (Hospital) Services Ab Titer Indirect PX-3098688600 CDM 86886 CPT 309 RC outpatient 208 208 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES HDHP [308136802] 166.4 percent of total billed charges 128.96 197.6 Technical (Hospital) Services Ab Titer Indirect PX-3098688600 CDM 86886 CPT 309 RC outpatient 208 208 UNITED HEALTHCARE (COMMERCIAL) [3081199] UNITED HEALTHCARE 87726 [308119901] 128.96 percent of total billed charges 128.96 197.6 Technical (Hospital) Services Ab Titer Indirect PX-3098688600 CDM 86886 CPT 309 RC outpatient 208 208 HEALTHPARTNERS SX009 HEALTHPARTNERS 166.4 percent of total billed charges 128.96 197.6 Technical (Hospital) Services Ab Titer Indirect PX-3098688600 CDM 86886 CPT 309 RC outpatient 208 208 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES PPO [308136801] 166.4 percent of total billed charges 128.96 197.6 Technical (Hospital) Services Ab Titer Indirect PX-3098688600 CDM 86886 CPT 309 RC inpatient 208 208 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES PPO [308136801] 164.69 percent of total billed charges 128.96 197.6 Technical (Hospital) Services Ab Titer Indirect PX-3098688600 CDM 86886 CPT 309 RC outpatient 208 208 MEDICA (COMMERCIAL) 94265 [3081118] MEDICA CLAIMS [308111801] 187.2 percent of total billed charges 128.96 197.6 Technical (Hospital) Services Ahg Indirect Qual Reagent RBC*2 PX-3098688501 CDM 86885 CPT 309 RC inpatient 120 120 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES EPO [308136803] 95.02 percent of total billed charges 74.4 114 Technical (Hospital) Services Ahg Indirect Qual Reagent RBC*2 PX-3098688501 CDM 86885 CPT 309 RC inpatient 120 120 HEALTHPARTNERS SX009 HEALTHPARTNERS 95.02 percent of total billed charges 74.4 114 Technical (Hospital) Services Ahg Indirect Qual Reagent RBC*2 PX-3098688501 CDM 86885 CPT 309 RC inpatient 120 120 CIGNA 62308 [3081051] CIGNA 62308 [308105105] 95.02 percent of total billed charges 74.4 114 Technical (Hospital) Services Ahg Indirect Qual Reagent RBC*2 PX-3098688501 CDM 86885 CPT 309 RC inpatient 120 120 CIGNA 62308 [3081051] CIGNA STATE OF WYOMING [308105107] 95.02 percent of total billed charges 74.4 114 Technical (Hospital) Services Ahg Indirect Qual Reagent RBC*2 PX-3098688501 CDM 86885 CPT 309 RC inpatient 120 120 BLUE CROSS BLUE SHIELD WELLMARK SB889 [3081026] BCBS WYOMING [308102603] 114 percent of total billed charges 74.4 114 Technical (Hospital) Services Ahg Indirect Qual Reagent RBC*2 PX-3098688501 CDM 86885 CPT 309 RC inpatient 120 120 MULTIPLAN INC 34080 [3081285] MULTIPLAN INC [308128501] 114 percent of total billed charges 74.4 114 Technical (Hospital) Services Ahg Indirect Qual Reagent RBC*2 PX-3098688501 CDM 86885 CPT 309 RC inpatient 120 120 MEDICA (COMMERCIAL) 94265 [3081118] MEDICA CLAIMS [308111801] 108 percent of total billed charges 74.4 114 Technical (Hospital) Services Ahg Indirect Qual Reagent RBC*2 PX-3098688501 CDM 86885 CPT 309 RC inpatient 120 120 UNITED HEALTHCARE (COMMERCIAL) [3081199] UNITED HEALTHCARE 87726 [308119901] 74.4 percent of total billed charges 74.4 114 Technical (Hospital) Services Ahg Indirect Qual Reagent RBC*2 PX-3098688501 CDM 86885 CPT 309 RC inpatient 120 120 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES HDHP [308136802] 95.02 percent of total billed charges 74.4 114 Technical (Hospital) Services Ahg Indirect Qual Reagent RBC*2 PX-3098688501 CDM 86885 CPT 309 RC inpatient 120 120 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES PPO [308136801] 95.02 percent of total billed charges 74.4 114 Technical (Hospital) Services Ahg Indirect Qual Reagent RBC*2 PX-3098688501 CDM 86885 CPT 309 RC outpatient 120 120 MEDICA (COMMERCIAL) 94265 [3081118] MEDICA CLAIMS [308111801] 108 percent of total billed charges 74.4 114 Technical (Hospital) Services Ahg Indirect Qual Reagent RBC*2 PX-3098688501 CDM 86885 CPT 309 RC outpatient 120 120 BLUE CROSS BLUE SHIELD WELLMARK SB889 [3081026] BCBS WYOMING [308102603] 114 percent of total billed charges 74.4 114 Technical (Hospital) Services Ahg Indirect Qual Reagent RBC*2 PX-3098688501 CDM 86885 CPT 309 RC outpatient 120 120 CIGNA 62308 [3081051] CIGNA STATE OF WYOMING [308105107] 96 percent of total billed charges 74.4 114 Technical (Hospital) Services Ahg Indirect Qual Reagent RBC*2 PX-3098688501 CDM 86885 CPT 309 RC outpatient 120 120 MULTIPLAN INC 34080 [3081285] MULTIPLAN INC [308128501] 114 percent of total billed charges 74.4 114 Technical (Hospital) Services Ahg Indirect Qual Reagent RBC*2 PX-3098688501 CDM 86885 CPT 309 RC outpatient 120 120 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES EPO [308136803] 96 percent of total billed charges 74.4 114 Technical (Hospital) Services Ahg Indirect Qual Reagent RBC*2 PX-3098688501 CDM 86885 CPT 309 RC outpatient 120 120 CIGNA 62308 [3081051] CIGNA 62308 [308105105] 96 percent of total billed charges 74.4 114 Technical (Hospital) Services Ahg Indirect Qual Reagent RBC*2 PX-3098688501 CDM 86885 CPT 309 RC outpatient 120 120 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES HDHP [308136802] 96 percent of total billed charges 74.4 114 Technical (Hospital) Services Ahg Indirect Qual Reagent RBC*2 PX-3098688501 CDM 86885 CPT 309 RC outpatient 120 120 UNITED HEALTHCARE (COMMERCIAL) [3081199] UNITED HEALTHCARE 87726 [308119901] 74.4 percent of total billed charges 74.4 114 Technical (Hospital) Services Ahg Indirect Qual Reagent RBC*2 PX-3098688501 CDM 86885 CPT 309 RC outpatient 120 120 HEALTHPARTNERS SX009 HEALTHPARTNERS 96 percent of total billed charges 74.4 114 Technical (Hospital) Services Ahg Indirect Qual Reagent RBC*2 PX-3098688501 CDM 86885 CPT 309 RC outpatient 120 120 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES PPO [308136801] 96 percent of total billed charges 74.4 114 Technical (Hospital) Services Direct Coombs Poly PX-3098688000 CDM 86880 CPT 309 RC outpatient 91 91 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES HDHP [308136802] 72.8 percent of total billed charges 56.42 86.45 Technical (Hospital) Services Direct Coombs Poly PX-3098688000 CDM 86880 CPT 309 RC inpatient 91 91 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES HDHP [308136802] 72.05 percent of total billed charges 56.42 86.45 Technical (Hospital) Services Direct Coombs Poly PX-3098688000 CDM 86880 CPT 309 RC inpatient 91 91 UNITED HEALTHCARE (COMMERCIAL) [3081199] UNITED HEALTHCARE 87726 [308119901] 56.42 percent of total billed charges 56.42 86.45 Technical (Hospital) Services Direct Coombs Poly PX-3098688000 CDM 86880 CPT 309 RC inpatient 91 91 MEDICA (COMMERCIAL) 94265 [3081118] MEDICA CLAIMS [308111801] 81.9 percent of total billed charges 56.42 86.45 Technical (Hospital) Services Direct Coombs Poly PX-3098688000 CDM 86880 CPT 309 RC outpatient 91 91 BLUE CROSS BLUE SHIELD WELLMARK SB889 [3081026] BCBS WYOMING [308102603] 86.45 percent of total billed charges 56.42 86.45 Technical (Hospital) Services Direct Coombs Poly PX-3098688000 CDM 86880 CPT 309 RC outpatient 91 91 CIGNA 62308 [3081051] CIGNA 62308 [308105105] 72.8 percent of total billed charges 56.42 86.45 Technical (Hospital) Services Direct Coombs Poly PX-3098688000 CDM 86880 CPT 309 RC outpatient 91 91 CIGNA 62308 [3081051] CIGNA STATE OF WYOMING [308105107] 72.8 percent of total billed charges 56.42 86.45 Technical (Hospital) Services Direct Coombs Poly PX-3098688000 CDM 86880 CPT 309 RC outpatient 91 91 MULTIPLAN INC 34080 [3081285] MULTIPLAN INC [308128501] 86.45 percent of total billed charges 56.42 86.45 Technical (Hospital) Services Direct Coombs Poly PX-3098688000 CDM 86880 CPT 309 RC outpatient 91 91 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES EPO [308136803] 72.8 percent of total billed charges 56.42 86.45 Technical (Hospital) Services Direct Coombs Poly PX-3098688000 CDM 86880 CPT 309 RC outpatient 91 91 HEALTHPARTNERS SX009 HEALTHPARTNERS 72.8 percent of total billed charges 56.42 86.45 Technical (Hospital) Services Direct Coombs Poly PX-3098688000 CDM 86880 CPT 309 RC outpatient 91 91 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES PPO [308136801] 72.8 percent of total billed charges 56.42 86.45 Technical (Hospital) Services Direct Coombs Poly PX-3098688000 CDM 86880 CPT 309 RC outpatient 91 91 UNITED HEALTHCARE (COMMERCIAL) [3081199] UNITED HEALTHCARE 87726 [308119901] 56.42 percent of total billed charges 56.42 86.45 Technical (Hospital) Services Direct Coombs Poly PX-3098688000 CDM 86880 CPT 309 RC outpatient 91 91 MEDICA (COMMERCIAL) 94265 [3081118] MEDICA CLAIMS [308111801] 81.9 percent of total billed charges 56.42 86.45 Technical (Hospital) Services Direct Coombs Poly PX-3098688000 CDM 86880 CPT 309 RC inpatient 91 91 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES PPO [308136801] 72.05 percent of total billed charges 56.42 86.45 Technical (Hospital) Services Direct Coombs Poly PX-3098688000 CDM 86880 CPT 309 RC inpatient 91 91 MULTIPLAN INC 34080 [3081285] MULTIPLAN INC [308128501] 86.45 percent of total billed charges 56.42 86.45 Technical (Hospital) Services Direct Coombs Poly PX-3098688000 CDM 86880 CPT 309 RC inpatient 91 91 BLUE CROSS BLUE SHIELD WELLMARK SB889 [3081026] BCBS WYOMING [308102603] 86.45 percent of total billed charges 56.42 86.45 Technical (Hospital) Services Direct Coombs Poly PX-3098688000 CDM 86880 CPT 309 RC inpatient 91 91 CIGNA 62308 [3081051] CIGNA 62308 [308105105] 72.05 percent of total billed charges 56.42 86.45 Technical (Hospital) Services Direct Coombs Poly PX-3098688000 CDM 86880 CPT 309 RC inpatient 91 91 CIGNA 62308 [3081051] CIGNA STATE OF WYOMING [308105107] 72.05 percent of total billed charges 56.42 86.45 Technical (Hospital) Services Direct Coombs Poly PX-3098688000 CDM 86880 CPT 309 RC inpatient 91 91 HEALTHPARTNERS SX009 HEALTHPARTNERS 72.05 percent of total billed charges 56.42 86.45 Technical (Hospital) Services Direct Coombs Poly PX-3098688000 CDM 86880 CPT 309 RC inpatient 91 91 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES EPO [308136803] 72.05 percent of total billed charges 56.42 86.45 Technical (Hospital) Services Direct Coombs Gamma PX-3098688002 CDM 86880 CPT 309 RC outpatient 57 57 MEDICA (COMMERCIAL) 94265 [3081118] MEDICA CLAIMS [308111801] 51.3 percent of total billed charges 35.34 54.15 Technical (Hospital) Services Direct Coombs Gamma PX-3098688002 CDM 86880 CPT 309 RC outpatient 57 57 BLUE CROSS BLUE SHIELD WELLMARK SB889 [3081026] BCBS WYOMING [308102603] 54.15 percent of total billed charges 35.34 54.15 Technical (Hospital) Services Direct Coombs Gamma PX-3098688002 CDM 86880 CPT 309 RC outpatient 57 57 MULTIPLAN INC 34080 [3081285] MULTIPLAN INC [308128501] 54.15 percent of total billed charges 35.34 54.15 Technical (Hospital) Services Direct Coombs Gamma PX-3098688002 CDM 86880 CPT 309 RC outpatient 57 57 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES EPO [308136803] 45.6 percent of total billed charges 35.34 54.15 Technical (Hospital) Services Direct Coombs Gamma PX-3098688002 CDM 86880 CPT 309 RC outpatient 57 57 CIGNA 62308 [3081051] CIGNA 62308 [308105105] 45.6 percent of total billed charges 35.34 54.15 Technical (Hospital) Services Direct Coombs Gamma PX-3098688002 CDM 86880 CPT 309 RC outpatient 57 57 CIGNA 62308 [3081051] CIGNA STATE OF WYOMING [308105107] 45.6 percent of total billed charges 35.34 54.15 Technical (Hospital) Services Direct Coombs Gamma PX-3098688002 CDM 86880 CPT 309 RC outpatient 57 57 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES HDHP [308136802] 45.6 percent of total billed charges 35.34 54.15 Technical (Hospital) Services Direct Coombs Gamma PX-3098688002 CDM 86880 CPT 309 RC outpatient 57 57 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES PPO [308136801] 45.6 percent of total billed charges 35.34 54.15 Technical (Hospital) Services Direct Coombs Gamma PX-3098688002 CDM 86880 CPT 309 RC outpatient 57 57 HEALTHPARTNERS SX009 HEALTHPARTNERS 45.6 percent of total billed charges 35.34 54.15 Technical (Hospital) Services Direct Coombs Gamma PX-3098688002 CDM 86880 CPT 309 RC outpatient 57 57 UNITED HEALTHCARE (COMMERCIAL) [3081199] UNITED HEALTHCARE 87726 [308119901] 35.34 percent of total billed charges 35.34 54.15 Technical (Hospital) Services Direct Coombs Gamma PX-3098688002 CDM 86880 CPT 309 RC inpatient 57 57 CIGNA 62308 [3081051] CIGNA 62308 [308105105] 45.13 percent of total billed charges 35.34 54.15 Technical (Hospital) Services Direct Coombs Gamma PX-3098688002 CDM 86880 CPT 309 RC inpatient 57 57 CIGNA 62308 [3081051] CIGNA STATE OF WYOMING [308105107] 45.13 percent of total billed charges 35.34 54.15 Technical (Hospital) Services Direct Coombs Gamma PX-3098688002 CDM 86880 CPT 309 RC inpatient 57 57 BLUE CROSS BLUE SHIELD WELLMARK SB889 [3081026] BCBS WYOMING [308102603] 54.15 percent of total billed charges 35.34 54.15 Technical (Hospital) Services Direct Coombs Gamma PX-3098688002 CDM 86880 CPT 309 RC inpatient 57 57 MULTIPLAN INC 34080 [3081285] MULTIPLAN INC [308128501] 54.15 percent of total billed charges 35.34 54.15 Technical (Hospital) Services Direct Coombs Gamma PX-3098688002 CDM 86880 CPT 309 RC inpatient 57 57 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES EPO [308136803] 45.13 percent of total billed charges 35.34 54.15 Technical (Hospital) Services Direct Coombs Gamma PX-3098688002 CDM 86880 CPT 309 RC inpatient 57 57 HEALTHPARTNERS SX009 HEALTHPARTNERS 45.13 percent of total billed charges 35.34 54.15 Technical (Hospital) Services Direct Coombs Gamma PX-3098688002 CDM 86880 CPT 309 RC inpatient 57 57 MEDICA (COMMERCIAL) 94265 [3081118] MEDICA CLAIMS [308111801] 51.3 percent of total billed charges 35.34 54.15 Technical (Hospital) Services Direct Coombs Gamma PX-3098688002 CDM 86880 CPT 309 RC inpatient 57 57 UNITED HEALTHCARE (COMMERCIAL) [3081199] UNITED HEALTHCARE 87726 [308119901] 35.34 percent of total billed charges 35.34 54.15 Technical (Hospital) Services Direct Coombs Gamma PX-3098688002 CDM 86880 CPT 309 RC inpatient 57 57 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES HDHP [308136802] 45.13 percent of total billed charges 35.34 54.15 Technical (Hospital) Services Direct Coombs Gamma PX-3098688002 CDM 86880 CPT 309 RC inpatient 57 57 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES PPO [308136801] 45.13 percent of total billed charges 35.34 54.15 Technical (Hospital) Services Antibody ID PX-3098687000 CDM 86870 CPT 309 RC inpatient 213 213 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES EPO [308136803] 168.65 percent of total billed charges 132.06 202.35 Technical (Hospital) Services Antibody ID PX-3098687000 CDM 86870 CPT 309 RC inpatient 213 213 HEALTHPARTNERS SX009 HEALTHPARTNERS 168.65 percent of total billed charges 132.06 202.35 Technical (Hospital) Services Antibody ID PX-3098687000 CDM 86870 CPT 309 RC inpatient 213 213 BLUE CROSS BLUE SHIELD WELLMARK SB889 [3081026] BCBS WYOMING [308102603] 202.35 percent of total billed charges 132.06 202.35 Technical (Hospital) Services Antibody ID PX-3098687000 CDM 86870 CPT 309 RC inpatient 213 213 CIGNA 62308 [3081051] CIGNA 62308 [308105105] 168.65 percent of total billed charges 132.06 202.35 Technical (Hospital) Services Antibody ID PX-3098687000 CDM 86870 CPT 309 RC inpatient 213 213 CIGNA 62308 [3081051] CIGNA STATE OF WYOMING [308105107] 168.65 percent of total billed charges 132.06 202.35 Technical (Hospital) Services Antibody ID PX-3098687000 CDM 86870 CPT 309 RC inpatient 213 213 MULTIPLAN INC 34080 [3081285] MULTIPLAN INC [308128501] 202.35 percent of total billed charges 132.06 202.35 Technical (Hospital) Services Antibody ID PX-3098687000 CDM 86870 CPT 309 RC inpatient 213 213 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES PPO [308136801] 168.65 percent of total billed charges 132.06 202.35 Technical (Hospital) Services Antibody ID PX-3098687000 CDM 86870 CPT 309 RC inpatient 213 213 UNITED HEALTHCARE (COMMERCIAL) [3081199] UNITED HEALTHCARE 87726 [308119901] 132.06 percent of total billed charges 132.06 202.35 Technical (Hospital) Services Antibody ID PX-3098687000 CDM 86870 CPT 309 RC inpatient 213 213 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES HDHP [308136802] 168.65 percent of total billed charges 132.06 202.35 Technical (Hospital) Services Antibody ID PX-3098687000 CDM 86870 CPT 309 RC inpatient 213 213 MEDICA (COMMERCIAL) 94265 [3081118] MEDICA CLAIMS [308111801] 191.7 percent of total billed charges 132.06 202.35 Technical (Hospital) Services Antibody ID PX-3098687000 CDM 86870 CPT 309 RC outpatient 213 213 UNITED HEALTHCARE (COMMERCIAL) [3081199] UNITED HEALTHCARE 87726 [308119901] 132.06 percent of total billed charges 132.06 202.35 Technical (Hospital) Services Antibody ID PX-3098687000 CDM 86870 CPT 309 RC outpatient 213 213 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES PPO [308136801] 170.4 percent of total billed charges 132.06 202.35 Technical (Hospital) Services Antibody ID PX-3098687000 CDM 86870 CPT 309 RC outpatient 213 213 HEALTHPARTNERS SX009 HEALTHPARTNERS 170.4 percent of total billed charges 132.06 202.35 Technical (Hospital) Services Antibody ID PX-3098687000 CDM 86870 CPT 309 RC outpatient 213 213 CIGNA 62308 [3081051] CIGNA 62308 [308105105] 170.4 percent of total billed charges 132.06 202.35 Technical (Hospital) Services Antibody ID PX-3098687000 CDM 86870 CPT 309 RC outpatient 213 213 CIGNA 62308 [3081051] CIGNA STATE OF WYOMING [308105107] 170.4 percent of total billed charges 132.06 202.35 Technical (Hospital) Services Antibody ID PX-3098687000 CDM 86870 CPT 309 RC outpatient 213 213 MULTIPLAN INC 34080 [3081285] MULTIPLAN INC [308128501] 202.35 percent of total billed charges 132.06 202.35 Technical (Hospital) Services Antibody ID PX-3098687000 CDM 86870 CPT 309 RC outpatient 213 213 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES EPO [308136803] 170.4 percent of total billed charges 132.06 202.35 Technical (Hospital) Services Antibody ID PX-3098687000 CDM 86870 CPT 309 RC outpatient 213 213 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES HDHP [308136802] 170.4 percent of total billed charges 132.06 202.35 Technical (Hospital) Services Antibody ID PX-3098687000 CDM 86870 CPT 309 RC outpatient 213 213 BLUE CROSS BLUE SHIELD WELLMARK SB889 [3081026] BCBS WYOMING [308102603] 202.35 percent of total billed charges 132.06 202.35 Technical (Hospital) Services Antibody ID PX-3098687000 CDM 86870 CPT 309 RC outpatient 213 213 MEDICA (COMMERCIAL) 94265 [3081118] MEDICA CLAIMS [308111801] 191.7 percent of total billed charges 132.06 202.35 Technical (Hospital) Services Antibody Screen PX-3098685000 CDM 86850 CPT 309 RC outpatient 120 120 CIGNA 62308 [3081051] CIGNA 62308 [308105105] 96 percent of total billed charges 74.4 114 Technical (Hospital) Services Antibody Screen PX-3098685000 CDM 86850 CPT 309 RC outpatient 120 120 CIGNA 62308 [3081051] CIGNA STATE OF WYOMING [308105107] 96 percent of total billed charges 74.4 114 Technical (Hospital) Services Antibody Screen PX-3098685000 CDM 86850 CPT 309 RC outpatient 120 120 UNITED HEALTHCARE (COMMERCIAL) [3081199] UNITED HEALTHCARE 87726 [308119901] 74.4 percent of total billed charges 74.4 114 Technical (Hospital) Services Antibody Screen PX-3098685000 CDM 86850 CPT 309 RC outpatient 120 120 BLUE CROSS BLUE SHIELD WELLMARK SB889 [3081026] BCBS WYOMING [308102603] 114 percent of total billed charges 74.4 114 Technical (Hospital) Services Antibody Screen PX-3098685000 CDM 86850 CPT 309 RC outpatient 120 120 MULTIPLAN INC 34080 [3081285] MULTIPLAN INC [308128501] 114 percent of total billed charges 74.4 114 Technical (Hospital) Services Antibody Screen PX-3098685000 CDM 86850 CPT 309 RC outpatient 120 120 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES HDHP [308136802] 96 percent of total billed charges 74.4 114 Technical (Hospital) Services Antibody Screen PX-3098685000 CDM 86850 CPT 309 RC outpatient 120 120 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES PPO [308136801] 96 percent of total billed charges 74.4 114 Technical (Hospital) Services Antibody Screen PX-3098685000 CDM 86850 CPT 309 RC outpatient 120 120 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES EPO [308136803] 96 percent of total billed charges 74.4 114 Technical (Hospital) Services Antibody Screen PX-3098685000 CDM 86850 CPT 309 RC outpatient 120 120 HEALTHPARTNERS SX009 HEALTHPARTNERS 96 percent of total billed charges 74.4 114 Technical (Hospital) Services Antibody Screen PX-3098685000 CDM 86850 CPT 309 RC outpatient 120 120 MEDICA (COMMERCIAL) 94265 [3081118] MEDICA CLAIMS [308111801] 108 percent of total billed charges 74.4 114 Technical (Hospital) Services Antibody Screen PX-3098685000 CDM 86850 CPT 309 RC inpatient 120 120 CIGNA 62308 [3081051] CIGNA STATE OF WYOMING [308105107] 95.02 percent of total billed charges 74.4 114 Technical (Hospital) Services Antibody Screen PX-3098685000 CDM 86850 CPT 309 RC inpatient 120 120 CIGNA 62308 [3081051] CIGNA 62308 [308105105] 95.02 percent of total billed charges 74.4 114 Technical (Hospital) Services Antibody Screen PX-3098685000 CDM 86850 CPT 309 RC inpatient 120 120 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES EPO [308136803] 95.02 percent of total billed charges 74.4 114 Technical (Hospital) Services Antibody Screen PX-3098685000 CDM 86850 CPT 309 RC inpatient 120 120 MULTIPLAN INC 34080 [3081285] MULTIPLAN INC [308128501] 114 percent of total billed charges 74.4 114 Technical (Hospital) Services Antibody Screen PX-3098685000 CDM 86850 CPT 309 RC inpatient 120 120 MEDICA (COMMERCIAL) 94265 [3081118] MEDICA CLAIMS [308111801] 108 percent of total billed charges 74.4 114 Technical (Hospital) Services Antibody Screen PX-3098685000 CDM 86850 CPT 309 RC inpatient 120 120 HEALTHPARTNERS SX009 HEALTHPARTNERS 95.02 percent of total billed charges 74.4 114 Technical (Hospital) Services Antibody Screen PX-3098685000 CDM 86850 CPT 309 RC inpatient 120 120 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES HDHP [308136802] 95.02 percent of total billed charges 74.4 114 Technical (Hospital) Services Antibody Screen PX-3098685000 CDM 86850 CPT 309 RC inpatient 120 120 BLUE CROSS BLUE SHIELD WELLMARK SB889 [3081026] BCBS WYOMING [308102603] 114 percent of total billed charges 74.4 114 Technical (Hospital) Services Antibody Screen PX-3098685000 CDM 86850 CPT 309 RC inpatient 120 120 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES PPO [308136801] 95.02 percent of total billed charges 74.4 114 Technical (Hospital) Services Antibody Screen PX-3098685000 CDM 86850 CPT 309 RC inpatient 120 120 UNITED HEALTHCARE (COMMERCIAL) [3081199] UNITED HEALTHCARE 87726 [308119901] 74.4 percent of total billed charges 74.4 114 Technical (Hospital) Services Ref Hla B27 Rl PX-3028681200 CDM 86812 CPT 302 RC outpatient 119 119 MEDICA (COMMERCIAL) 94265 [3081118] MEDICA CLAIMS [308111801] 107.1 percent of total billed charges 73.78 113.05 Technical (Hospital) Services Ref Hla B27 Rl PX-3028681200 CDM 86812 CPT 302 RC outpatient 119 119 UNITED HEALTHCARE (COMMERCIAL) [3081199] UNITED HEALTHCARE 87726 [308119901] 73.78 percent of total billed charges 73.78 113.05 Technical (Hospital) Services Ref Hla B27 Rl PX-3028681200 CDM 86812 CPT 302 RC outpatient 119 119 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES PPO [308136801] 95.2 percent of total billed charges 73.78 113.05 Technical (Hospital) Services Ref Hla B27 Rl PX-3028681200 CDM 86812 CPT 302 RC outpatient 119 119 HEALTHPARTNERS SX009 HEALTHPARTNERS 95.2 percent of total billed charges 73.78 113.05 Technical (Hospital) Services Ref Hla B27 Rl PX-3028681200 CDM 86812 CPT 302 RC outpatient 119 119 MULTIPLAN INC 34080 [3081285] MULTIPLAN INC [308128501] 113.05 percent of total billed charges 73.78 113.05 Technical (Hospital) Services Ref Hla B27 Rl PX-3028681200 CDM 86812 CPT 302 RC outpatient 119 119 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES EPO [308136803] 95.2 percent of total billed charges 73.78 113.05 Technical (Hospital) Services Ref Hla B27 Rl PX-3028681200 CDM 86812 CPT 302 RC outpatient 119 119 CIGNA 62308 [3081051] CIGNA 62308 [308105105] 95.2 percent of total billed charges 73.78 113.05 Technical (Hospital) Services Ref Hla B27 Rl PX-3028681200 CDM 86812 CPT 302 RC outpatient 119 119 CIGNA 62308 [3081051] CIGNA STATE OF WYOMING [308105107] 95.2 percent of total billed charges 73.78 113.05 Technical (Hospital) Services Ref Hla B27 Rl PX-3028681200 CDM 86812 CPT 302 RC outpatient 119 119 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES HDHP [308136802] 95.2 percent of total billed charges 73.78 113.05 Technical (Hospital) Services Ref Hla B27 Rl PX-3028681200 CDM 86812 CPT 302 RC outpatient 119 119 BLUE CROSS BLUE SHIELD WELLMARK SB889 [3081026] BCBS WYOMING [308102603] 113.05 percent of total billed charges 73.78 113.05 Technical (Hospital) Services Ref Hla B27 Rl PX-3028681200 CDM 86812 CPT 302 RC inpatient 119 119 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES EPO [308136803] 94.22 percent of total billed charges 73.78 113.05 Technical (Hospital) Services Ref Hla B27 Rl PX-3028681200 CDM 86812 CPT 302 RC inpatient 119 119 HEALTHPARTNERS SX009 HEALTHPARTNERS 94.22 percent of total billed charges 73.78 113.05 Technical (Hospital) Services Ref Hla B27 Rl PX-3028681200 CDM 86812 CPT 302 RC inpatient 119 119 MEDICA (COMMERCIAL) 94265 [3081118] MEDICA CLAIMS [308111801] 107.1 percent of total billed charges 73.78 113.05 Technical (Hospital) Services Ref Hla B27 Rl PX-3028681200 CDM 86812 CPT 302 RC inpatient 119 119 MULTIPLAN INC 34080 [3081285] MULTIPLAN INC [308128501] 113.05 percent of total billed charges 73.78 113.05 Technical (Hospital) Services Ref Hla B27 Rl PX-3028681200 CDM 86812 CPT 302 RC inpatient 119 119 BLUE CROSS BLUE SHIELD WELLMARK SB889 [3081026] BCBS WYOMING [308102603] 113.05 percent of total billed charges 73.78 113.05 Technical (Hospital) Services Ref Hla B27 Rl PX-3028681200 CDM 86812 CPT 302 RC inpatient 119 119 CIGNA 62308 [3081051] CIGNA 62308 [308105105] 94.22 percent of total billed charges 73.78 113.05 Technical (Hospital) Services Ref Hla B27 Rl PX-3028681200 CDM 86812 CPT 302 RC inpatient 119 119 CIGNA 62308 [3081051] CIGNA STATE OF WYOMING [308105107] 94.22 percent of total billed charges 73.78 113.05 Technical (Hospital) Services Ref Hla B27 Rl PX-3028681200 CDM 86812 CPT 302 RC inpatient 119 119 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES PPO [308136801] 94.22 percent of total billed charges 73.78 113.05 Technical (Hospital) Services Ref Hla B27 Rl PX-3028681200 CDM 86812 CPT 302 RC inpatient 119 119 UNITED HEALTHCARE (COMMERCIAL) [3081199] UNITED HEALTHCARE 87726 [308119901] 73.78 percent of total billed charges 73.78 113.05 Technical (Hospital) Services Ref Hla B27 Rl PX-3028681200 CDM 86812 CPT 302 RC inpatient 119 119 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES HDHP [308136802] 94.22 percent of total billed charges 73.78 113.05 Technical (Hospital) Services Hcv Ab PX-3028680300 CDM 86803 CPT 302 RC outpatient 221 221 MEDICA (COMMERCIAL) 94265 [3081118] MEDICA CLAIMS [308111801] 198.9 percent of total billed charges 137.02 209.95 Technical (Hospital) Services Hcv Ab PX-3028680300 CDM 86803 CPT 302 RC outpatient 221 221 MULTIPLAN INC 34080 [3081285] MULTIPLAN INC [308128501] 209.95 percent of total billed charges 137.02 209.95 Technical (Hospital) Services Hcv Ab PX-3028680300 CDM 86803 CPT 302 RC outpatient 221 221 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES EPO [308136803] 176.8 percent of total billed charges 137.02 209.95 Technical (Hospital) Services Hcv Ab PX-3028680300 CDM 86803 CPT 302 RC outpatient 221 221 CIGNA 62308 [3081051] CIGNA 62308 [308105105] 176.8 percent of total billed charges 137.02 209.95 Technical (Hospital) Services Hcv Ab PX-3028680300 CDM 86803 CPT 302 RC outpatient 221 221 CIGNA 62308 [3081051] CIGNA STATE OF WYOMING [308105107] 176.8 percent of total billed charges 137.02 209.95 Technical (Hospital) Services Hcv Ab PX-3028680300 CDM 86803 CPT 302 RC outpatient 221 221 BLUE CROSS BLUE SHIELD WELLMARK SB889 [3081026] BCBS WYOMING [308102603] 209.95 percent of total billed charges 137.02 209.95 Technical (Hospital) Services Hcv Ab PX-3028680300 CDM 86803 CPT 302 RC outpatient 221 221 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES HDHP [308136802] 176.8 percent of total billed charges 137.02 209.95 Technical (Hospital) Services Hcv Ab PX-3028680300 CDM 86803 CPT 302 RC outpatient 221 221 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES PPO [308136801] 176.8 percent of total billed charges 137.02 209.95 Technical (Hospital) Services Hcv Ab PX-3028680300 CDM 86803 CPT 302 RC outpatient 221 221 HEALTHPARTNERS SX009 HEALTHPARTNERS 176.8 percent of total billed charges 137.02 209.95 Technical (Hospital) Services Hcv Ab PX-3028680300 CDM 86803 CPT 302 RC outpatient 221 221 UNITED HEALTHCARE (COMMERCIAL) [3081199] UNITED HEALTHCARE 87726 [308119901] 137.02 percent of total billed charges 137.02 209.95 Technical (Hospital) Services Hcv Ab PX-3028680300 CDM 86803 CPT 302 RC inpatient 221 221 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES HDHP [308136802] 174.99 percent of total billed charges 137.02 209.95 Technical (Hospital) Services Hcv Ab PX-3028680300 CDM 86803 CPT 302 RC inpatient 221 221 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES PPO [308136801] 174.99 percent of total billed charges 137.02 209.95 Technical (Hospital) Services Hcv Ab PX-3028680300 CDM 86803 CPT 302 RC inpatient 221 221 UNITED HEALTHCARE (COMMERCIAL) [3081199] UNITED HEALTHCARE 87726 [308119901] 137.02 percent of total billed charges 137.02 209.95 Technical (Hospital) Services Hcv Ab PX-3028680300 CDM 86803 CPT 302 RC inpatient 221 221 MULTIPLAN INC 34080 [3081285] MULTIPLAN INC [308128501] 209.95 percent of total billed charges 137.02 209.95 Technical (Hospital) Services Hcv Ab PX-3028680300 CDM 86803 CPT 302 RC inpatient 221 221 MEDICA (COMMERCIAL) 94265 [3081118] MEDICA CLAIMS [308111801] 198.9 percent of total billed charges 137.02 209.95 Technical (Hospital) Services Hcv Ab PX-3028680300 CDM 86803 CPT 302 RC inpatient 221 221 BLUE CROSS BLUE SHIELD WELLMARK SB889 [3081026] BCBS WYOMING [308102603] 209.95 percent of total billed charges 137.02 209.95 Technical (Hospital) Services Hcv Ab PX-3028680300 CDM 86803 CPT 302 RC inpatient 221 221 CIGNA 62308 [3081051] CIGNA 62308 [308105105] 174.99 percent of total billed charges 137.02 209.95 Technical (Hospital) Services Hcv Ab PX-3028680300 CDM 86803 CPT 302 RC inpatient 221 221 CIGNA 62308 [3081051] CIGNA STATE OF WYOMING [308105107] 174.99 percent of total billed charges 137.02 209.95 Technical (Hospital) Services Hcv Ab PX-3028680300 CDM 86803 CPT 302 RC inpatient 221 221 HEALTHPARTNERS SX009 HEALTHPARTNERS 174.99 percent of total billed charges 137.02 209.95 Technical (Hospital) Services Hcv Ab PX-3028680300 CDM 86803 CPT 302 RC inpatient 221 221 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES EPO [308136803] 174.99 percent of total billed charges 137.02 209.95 Technical (Hospital) Services Ref Thyroglobulin Ab Scrn PX-3028680000 CDM 86800 CPT 302 RC outpatient 193 193 MULTIPLAN INC 34080 [3081285] MULTIPLAN INC [308128501] 183.35 percent of total billed charges 119.66 183.35 Technical (Hospital) Services Ref Thyroglobulin Ab Scrn PX-3028680000 CDM 86800 CPT 302 RC outpatient 193 193 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES EPO [308136803] 154.4 percent of total billed charges 119.66 183.35 Technical (Hospital) Services Ref Thyroglobulin Ab Scrn PX-3028680000 CDM 86800 CPT 302 RC outpatient 193 193 CIGNA 62308 [3081051] CIGNA 62308 [308105105] 154.4 percent of total billed charges 119.66 183.35 Technical (Hospital) Services Ref Thyroglobulin Ab Scrn PX-3028680000 CDM 86800 CPT 302 RC outpatient 193 193 CIGNA 62308 [3081051] CIGNA STATE OF WYOMING [308105107] 154.4 percent of total billed charges 119.66 183.35 Technical (Hospital) Services Ref Thyroglobulin Ab Scrn PX-3028680000 CDM 86800 CPT 302 RC outpatient 193 193 BLUE CROSS BLUE SHIELD WELLMARK SB889 [3081026] BCBS WYOMING [308102603] 183.35 percent of total billed charges 119.66 183.35 Technical (Hospital) Services Ref Thyroglobulin Ab Scrn PX-3028680000 CDM 86800 CPT 302 RC outpatient 193 193 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES HDHP [308136802] 154.4 percent of total billed charges 119.66 183.35 Technical (Hospital) Services Ref Thyroglobulin Ab Scrn PX-3028680000 CDM 86800 CPT 302 RC outpatient 193 193 UNITED HEALTHCARE (COMMERCIAL) [3081199] UNITED HEALTHCARE 87726 [308119901] 119.66 percent of total billed charges 119.66 183.35 Technical (Hospital) Services Ref Thyroglobulin Ab Scrn PX-3028680000 CDM 86800 CPT 302 RC outpatient 193 193 HEALTHPARTNERS SX009 HEALTHPARTNERS 154.4 percent of total billed charges 119.66 183.35 Technical (Hospital) Services Ref Thyroglobulin Ab Scrn PX-3028680000 CDM 86800 CPT 302 RC outpatient 193 193 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES PPO [308136801] 154.4 percent of total billed charges 119.66 183.35 Technical (Hospital) Services Ref Thyroglobulin Ab Scrn PX-3028680000 CDM 86800 CPT 302 RC outpatient 193 193 MEDICA (COMMERCIAL) 94265 [3081118] MEDICA CLAIMS [308111801] 173.7 percent of total billed charges 119.66 183.35 Technical (Hospital) Services Ref Thyroglobulin Ab Scrn PX-3028680000 CDM 86800 CPT 302 RC inpatient 193 193 CIGNA 62308 [3081051] CIGNA 62308 [308105105] 152.82 percent of total billed charges 119.66 183.35 Technical (Hospital) Services Ref Thyroglobulin Ab Scrn PX-3028680000 CDM 86800 CPT 302 RC inpatient 193 193 CIGNA 62308 [3081051] CIGNA STATE OF WYOMING [308105107] 152.82 percent of total billed charges 119.66 183.35 Technical (Hospital) Services Ref Thyroglobulin Ab Scrn PX-3028680000 CDM 86800 CPT 302 RC inpatient 193 193 MULTIPLAN INC 34080 [3081285] MULTIPLAN INC [308128501] 183.35 percent of total billed charges 119.66 183.35 Technical (Hospital) Services Ref Thyroglobulin Ab Scrn PX-3028680000 CDM 86800 CPT 302 RC inpatient 193 193 MEDICA (COMMERCIAL) 94265 [3081118] MEDICA CLAIMS [308111801] 173.7 percent of total billed charges 119.66 183.35 Technical (Hospital) Services Ref Thyroglobulin Ab Scrn PX-3028680000 CDM 86800 CPT 302 RC inpatient 193 193 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES EPO [308136803] 152.82 percent of total billed charges 119.66 183.35 Technical (Hospital) Services Ref Thyroglobulin Ab Scrn PX-3028680000 CDM 86800 CPT 302 RC inpatient 193 193 HEALTHPARTNERS SX009 HEALTHPARTNERS 152.82 percent of total billed charges 119.66 183.35 Technical (Hospital) Services Ref Thyroglobulin Ab Scrn PX-3028680000 CDM 86800 CPT 302 RC inpatient 193 193 BLUE CROSS BLUE SHIELD WELLMARK SB889 [3081026] BCBS WYOMING [308102603] 183.35 percent of total billed charges 119.66 183.35 Technical (Hospital) Services Ref Thyroglobulin Ab Scrn PX-3028680000 CDM 86800 CPT 302 RC inpatient 193 193 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES HDHP [308136802] 152.82 percent of total billed charges 119.66 183.35 Technical (Hospital) Services Ref Thyroglobulin Ab Scrn PX-3028680000 CDM 86800 CPT 302 RC inpatient 193 193 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES PPO [308136801] 152.82 percent of total billed charges 119.66 183.35 Technical (Hospital) Services Ref Thyroglobulin Ab Scrn PX-3028680000 CDM 86800 CPT 302 RC inpatient 193 193 UNITED HEALTHCARE (COMMERCIAL) [3081199] UNITED HEALTHCARE 87726 [308119901] 119.66 percent of total billed charges 119.66 183.35 Technical (Hospital) Services Ref Thyroglobulin Ab Scrn PX-3028680001 CDM 86800 CPT 302 RC outpatient 193 193 MEDICA (COMMERCIAL) 94265 [3081118] MEDICA CLAIMS [308111801] 173.7 percent of total billed charges 119.66 183.35 Technical (Hospital) Services Ref Thyroglobulin Ab Scrn PX-3028680001 CDM 86800 CPT 302 RC outpatient 193 193 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES PPO [308136801] 154.4 percent of total billed charges 119.66 183.35 Technical (Hospital) Services Ref Thyroglobulin Ab Scrn PX-3028680001 CDM 86800 CPT 302 RC outpatient 193 193 HEALTHPARTNERS SX009 HEALTHPARTNERS 154.4 percent of total billed charges 119.66 183.35 Technical (Hospital) Services Ref Thyroglobulin Ab Scrn PX-3028680001 CDM 86800 CPT 302 RC outpatient 193 193 UNITED HEALTHCARE (COMMERCIAL) [3081199] UNITED HEALTHCARE 87726 [308119901] 119.66 percent of total billed charges 119.66 183.35 Technical (Hospital) Services Ref Thyroglobulin Ab Scrn PX-3028680001 CDM 86800 CPT 302 RC outpatient 193 193 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES HDHP [308136802] 154.4 percent of total billed charges 119.66 183.35 Technical (Hospital) Services Ref Thyroglobulin Ab Scrn PX-3028680001 CDM 86800 CPT 302 RC outpatient 193 193 BLUE CROSS BLUE SHIELD WELLMARK SB889 [3081026] BCBS WYOMING [308102603] 183.35 percent of total billed charges 119.66 183.35 Technical (Hospital) Services Ref Thyroglobulin Ab Scrn PX-3028680001 CDM 86800 CPT 302 RC outpatient 193 193 MULTIPLAN INC 34080 [3081285] MULTIPLAN INC [308128501] 183.35 percent of total billed charges 119.66 183.35 Technical (Hospital) Services Ref Thyroglobulin Ab Scrn PX-3028680001 CDM 86800 CPT 302 RC outpatient 193 193 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES EPO [308136803] 154.4 percent of total billed charges 119.66 183.35 Technical (Hospital) Services Ref Thyroglobulin Ab Scrn PX-3028680001 CDM 86800 CPT 302 RC outpatient 193 193 CIGNA 62308 [3081051] CIGNA 62308 [308105105] 154.4 percent of total billed charges 119.66 183.35 Technical (Hospital) Services Ref Thyroglobulin Ab Scrn PX-3028680001 CDM 86800 CPT 302 RC outpatient 193 193 CIGNA 62308 [3081051] CIGNA STATE OF WYOMING [308105107] 154.4 percent of total billed charges 119.66 183.35 Technical (Hospital) Services Ref Thyroglobulin Ab Scrn PX-3028680001 CDM 86800 CPT 302 RC inpatient 193 193 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES HDHP [308136802] 152.82 percent of total billed charges 119.66 183.35 Technical (Hospital) Services Ref Thyroglobulin Ab Scrn PX-3028680001 CDM 86800 CPT 302 RC inpatient 193 193 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES PPO [308136801] 152.82 percent of total billed charges 119.66 183.35 Technical (Hospital) Services Ref Thyroglobulin Ab Scrn PX-3028680001 CDM 86800 CPT 302 RC inpatient 193 193 UNITED HEALTHCARE (COMMERCIAL) [3081199] UNITED HEALTHCARE 87726 [308119901] 119.66 percent of total billed charges 119.66 183.35 Technical (Hospital) Services Ref Thyroglobulin Ab Scrn PX-3028680001 CDM 86800 CPT 302 RC inpatient 193 193 CIGNA 62308 [3081051] CIGNA 62308 [308105105] 152.82 percent of total billed charges 119.66 183.35 Technical (Hospital) Services Ref Thyroglobulin Ab Scrn PX-3028680001 CDM 86800 CPT 302 RC inpatient 193 193 CIGNA 62308 [3081051] CIGNA STATE OF WYOMING [308105107] 152.82 percent of total billed charges 119.66 183.35 Technical (Hospital) Services Ref Thyroglobulin Ab Scrn PX-3028680001 CDM 86800 CPT 302 RC inpatient 193 193 BLUE CROSS BLUE SHIELD WELLMARK SB889 [3081026] BCBS WYOMING [308102603] 183.35 percent of total billed charges 119.66 183.35 Technical (Hospital) Services Ref Thyroglobulin Ab Scrn PX-3028680001 CDM 86800 CPT 302 RC inpatient 193 193 MULTIPLAN INC 34080 [3081285] MULTIPLAN INC [308128501] 183.35 percent of total billed charges 119.66 183.35 Technical (Hospital) Services Ref Thyroglobulin Ab Scrn PX-3028680001 CDM 86800 CPT 302 RC inpatient 193 193 MEDICA (COMMERCIAL) 94265 [3081118] MEDICA CLAIMS [308111801] 173.7 percent of total billed charges 119.66 183.35 Technical (Hospital) Services Ref Thyroglobulin Ab Scrn PX-3028680001 CDM 86800 CPT 302 RC inpatient 193 193 HEALTHPARTNERS SX009 HEALTHPARTNERS 152.82 percent of total billed charges 119.66 183.35 Technical (Hospital) Services Ref Thyroglobulin Ab Scrn PX-3028680001 CDM 86800 CPT 302 RC inpatient 193 193 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES EPO [308136803] 152.82 percent of total billed charges 119.66 183.35 Technical (Hospital) Services Thyroglobulin Antibody Scrn PX-3028680002 CDM 86800 CPT 302 RC outpatient 160 160 MEDICA (COMMERCIAL) 94265 [3081118] MEDICA CLAIMS [308111801] 144 percent of total billed charges 99.2 152 Technical (Hospital) Services Thyroglobulin Antibody Scrn PX-3028680002 CDM 86800 CPT 302 RC outpatient 160 160 MULTIPLAN INC 34080 [3081285] MULTIPLAN INC [308128501] 152 percent of total billed charges 99.2 152 Technical (Hospital) Services Thyroglobulin Antibody Scrn PX-3028680002 CDM 86800 CPT 302 RC outpatient 160 160 CIGNA 62308 [3081051] CIGNA 62308 [308105105] 128 percent of total billed charges 99.2 152 Technical (Hospital) Services Thyroglobulin Antibody Scrn PX-3028680002 CDM 86800 CPT 302 RC outpatient 160 160 CIGNA 62308 [3081051] CIGNA STATE OF WYOMING [308105107] 128 percent of total billed charges 99.2 152 Technical (Hospital) Services Thyroglobulin Antibody Scrn PX-3028680002 CDM 86800 CPT 302 RC outpatient 160 160 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES EPO [308136803] 128 percent of total billed charges 99.2 152 Technical (Hospital) Services Thyroglobulin Antibody Scrn PX-3028680002 CDM 86800 CPT 302 RC outpatient 160 160 BLUE CROSS BLUE SHIELD WELLMARK SB889 [3081026] BCBS WYOMING [308102603] 152 percent of total billed charges 99.2 152 Technical (Hospital) Services Thyroglobulin Antibody Scrn PX-3028680002 CDM 86800 CPT 302 RC outpatient 160 160 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES HDHP [308136802] 128 percent of total billed charges 99.2 152 Technical (Hospital) Services Thyroglobulin Antibody Scrn PX-3028680002 CDM 86800 CPT 302 RC outpatient 160 160 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES PPO [308136801] 128 percent of total billed charges 99.2 152 Technical (Hospital) Services Thyroglobulin Antibody Scrn PX-3028680002 CDM 86800 CPT 302 RC outpatient 160 160 HEALTHPARTNERS SX009 HEALTHPARTNERS 128 percent of total billed charges 99.2 152 Technical (Hospital) Services Thyroglobulin Antibody Scrn PX-3028680002 CDM 86800 CPT 302 RC outpatient 160 160 UNITED HEALTHCARE (COMMERCIAL) [3081199] UNITED HEALTHCARE 87726 [308119901] 99.2 percent of total billed charges 99.2 152 Technical (Hospital) Services Thyroglobulin Antibody Scrn PX-3028680002 CDM 86800 CPT 302 RC inpatient 160 160 MULTIPLAN INC 34080 [3081285] MULTIPLAN INC [308128501] 152 percent of total billed charges 99.2 152 Technical (Hospital) Services Thyroglobulin Antibody Scrn PX-3028680002 CDM 86800 CPT 302 RC inpatient 160 160 MEDICA (COMMERCIAL) 94265 [3081118] MEDICA CLAIMS [308111801] 144 percent of total billed charges 99.2 152 Technical (Hospital) Services Thyroglobulin Antibody Scrn PX-3028680002 CDM 86800 CPT 302 RC inpatient 160 160 BLUE CROSS BLUE SHIELD WELLMARK SB889 [3081026] BCBS WYOMING [308102603] 152 percent of total billed charges 99.2 152 Technical (Hospital) Services Thyroglobulin Antibody Scrn PX-3028680002 CDM 86800 CPT 302 RC inpatient 160 160 CIGNA 62308 [3081051] CIGNA 62308 [308105105] 126.69 percent of total billed charges 99.2 152 Technical (Hospital) Services Thyroglobulin Antibody Scrn PX-3028680002 CDM 86800 CPT 302 RC inpatient 160 160 CIGNA 62308 [3081051] CIGNA STATE OF WYOMING [308105107] 126.69 percent of total billed charges 99.2 152 Technical (Hospital) Services Thyroglobulin Antibody Scrn PX-3028680002 CDM 86800 CPT 302 RC inpatient 160 160 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES EPO [308136803] 126.69 percent of total billed charges 99.2 152 Technical (Hospital) Services Thyroglobulin Antibody Scrn PX-3028680002 CDM 86800 CPT 302 RC inpatient 160 160 HEALTHPARTNERS SX009 HEALTHPARTNERS 126.69 percent of total billed charges 99.2 152 Technical (Hospital) Services Thyroglobulin Antibody Scrn PX-3028680002 CDM 86800 CPT 302 RC inpatient 160 160 UNITED HEALTHCARE (COMMERCIAL) [3081199] UNITED HEALTHCARE 87726 [308119901] 99.2 percent of total billed charges 99.2 152 Technical (Hospital) Services Thyroglobulin Antibody Scrn PX-3028680002 CDM 86800 CPT 302 RC inpatient 160 160 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES PPO [308136801] 126.69 percent of total billed charges 99.2 152 Technical (Hospital) Services Thyroglobulin Antibody Scrn PX-3028680002 CDM 86800 CPT 302 RC inpatient 160 160 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES HDHP [308136802] 126.69 percent of total billed charges 99.2 152 Technical (Hospital) Services Ref Hantavirus Ab Igg PX-3028679003 CDM 86790 CPT 302 RC inpatient 214 214 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES EPO [308136803] 169.45 percent of total billed charges 132.68 203.3 Technical (Hospital) Services Ref Hantavirus Ab Igg PX-3028679003 CDM 86790 CPT 302 RC inpatient 214 214 HEALTHPARTNERS SX009 HEALTHPARTNERS 169.45 percent of total billed charges 132.68 203.3 Technical (Hospital) Services Ref Hantavirus Ab Igg PX-3028679003 CDM 86790 CPT 302 RC inpatient 214 214 MEDICA (COMMERCIAL) 94265 [3081118] MEDICA CLAIMS [308111801] 192.6 percent of total billed charges 132.68 203.3 Technical (Hospital) Services Ref Hantavirus Ab Igg PX-3028679003 CDM 86790 CPT 302 RC inpatient 214 214 MULTIPLAN INC 34080 [3081285] MULTIPLAN INC [308128501] 203.3 percent of total billed charges 132.68 203.3 Technical (Hospital) Services Ref Hantavirus Ab Igg PX-3028679003 CDM 86790 CPT 302 RC inpatient 214 214 BLUE CROSS BLUE SHIELD WELLMARK SB889 [3081026] BCBS WYOMING [308102603] 203.3 percent of total billed charges 132.68 203.3 Technical (Hospital) Services Ref Hantavirus Ab Igg PX-3028679003 CDM 86790 CPT 302 RC inpatient 214 214 CIGNA 62308 [3081051] CIGNA 62308 [308105105] 169.45 percent of total billed charges 132.68 203.3 Technical (Hospital) Services Ref Hantavirus Ab Igg PX-3028679003 CDM 86790 CPT 302 RC inpatient 214 214 CIGNA 62308 [3081051] CIGNA STATE OF WYOMING [308105107] 169.45 percent of total billed charges 132.68 203.3 Technical (Hospital) Services Ref Hantavirus Ab Igg PX-3028679003 CDM 86790 CPT 302 RC inpatient 214 214 UNITED HEALTHCARE (COMMERCIAL) [3081199] UNITED HEALTHCARE 87726 [308119901] 132.68 percent of total billed charges 132.68 203.3 Technical (Hospital) Services Ref Hantavirus Ab Igg PX-3028679003 CDM 86790 CPT 302 RC inpatient 214 214 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES PPO [308136801] 169.45 percent of total billed charges 132.68 203.3 Technical (Hospital) Services Ref Hantavirus Ab Igg PX-3028679003 CDM 86790 CPT 302 RC inpatient 214 214 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES HDHP [308136802] 169.45 percent of total billed charges 132.68 203.3 Technical (Hospital) Services Ref Hantavirus Ab Igg PX-3028679003 CDM 86790 CPT 302 RC outpatient 214 214 MEDICA (COMMERCIAL) 94265 [3081118] MEDICA CLAIMS [308111801] 192.6 percent of total billed charges 132.68 203.3 Technical (Hospital) Services Ref Hantavirus Ab Igg PX-3028679003 CDM 86790 CPT 302 RC outpatient 214 214 UNITED HEALTHCARE (COMMERCIAL) [3081199] UNITED HEALTHCARE 87726 [308119901] 132.68 percent of total billed charges 132.68 203.3 Technical (Hospital) Services Ref Hantavirus Ab Igg PX-3028679003 CDM 86790 CPT 302 RC outpatient 214 214 HEALTHPARTNERS SX009 HEALTHPARTNERS 171.2 percent of total billed charges 132.68 203.3 Technical (Hospital) Services Ref Hantavirus Ab Igg PX-3028679003 CDM 86790 CPT 302 RC outpatient 214 214 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES PPO [308136801] 171.2 percent of total billed charges 132.68 203.3 Technical (Hospital) Services Ref Hantavirus Ab Igg PX-3028679003 CDM 86790 CPT 302 RC outpatient 214 214 CIGNA 62308 [3081051] CIGNA 62308 [308105105] 171.2 percent of total billed charges 132.68 203.3 Technical (Hospital) Services Ref Hantavirus Ab Igg PX-3028679003 CDM 86790 CPT 302 RC outpatient 214 214 CIGNA 62308 [3081051] CIGNA STATE OF WYOMING [308105107] 171.2 percent of total billed charges 132.68 203.3 Technical (Hospital) Services Ref Hantavirus Ab Igg PX-3028679003 CDM 86790 CPT 302 RC outpatient 214 214 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES EPO [308136803] 171.2 percent of total billed charges 132.68 203.3 Technical (Hospital) Services Ref Hantavirus Ab Igg PX-3028679003 CDM 86790 CPT 302 RC outpatient 214 214 MULTIPLAN INC 34080 [3081285] MULTIPLAN INC [308128501] 203.3 percent of total billed charges 132.68 203.3 Technical (Hospital) Services Ref Hantavirus Ab Igg PX-3028679003 CDM 86790 CPT 302 RC outpatient 214 214 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES HDHP [308136802] 171.2 percent of total billed charges 132.68 203.3 Technical (Hospital) Services Ref Hantavirus Ab Igg PX-3028679003 CDM 86790 CPT 302 RC outpatient 214 214 BLUE CROSS BLUE SHIELD WELLMARK SB889 [3081026] BCBS WYOMING [308102603] 203.3 percent of total billed charges 132.68 203.3 Technical (Hospital) Services Ref Human T-Cell Lymphotropic Virus Types I and II (Htlv-II) Antibody Screen With Confirm PX-3028679005 CDM 86790 CPT 302 RC outpatient 270 270 MEDICA (COMMERCIAL) 94265 [3081118] MEDICA CLAIMS [308111801] 243 percent of total billed charges 167.4 256.5 Technical (Hospital) Services Ref Human T-Cell Lymphotropic Virus Types I and II (Htlv-II) Antibody Screen With Confirm PX-3028679005 CDM 86790 CPT 302 RC outpatient 270 270 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES PPO [308136801] 216 percent of total billed charges 167.4 256.5 Technical (Hospital) Services Ref Human T-Cell Lymphotropic Virus Types I and II (Htlv-II) Antibody Screen With Confirm PX-3028679005 CDM 86790 CPT 302 RC outpatient 270 270 HEALTHPARTNERS SX009 HEALTHPARTNERS 216 percent of total billed charges 167.4 256.5 Technical (Hospital) Services Ref Human T-Cell Lymphotropic Virus Types I and II (Htlv-II) Antibody Screen With Confirm PX-3028679005 CDM 86790 CPT 302 RC outpatient 270 270 UNITED HEALTHCARE (COMMERCIAL) [3081199] UNITED HEALTHCARE 87726 [308119901] 167.4 percent of total billed charges 167.4 256.5 Technical (Hospital) Services Ref Human T-Cell Lymphotropic Virus Types I and II (Htlv-II) Antibody Screen With Confirm PX-3028679005 CDM 86790 CPT 302 RC outpatient 270 270 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES HDHP [308136802] 216 percent of total billed charges 167.4 256.5 Technical (Hospital) Services Ref Human T-Cell Lymphotropic Virus Types I and II (Htlv-II) Antibody Screen With Confirm PX-3028679005 CDM 86790 CPT 302 RC outpatient 270 270 MULTIPLAN INC 34080 [3081285] MULTIPLAN INC [308128501] 256.5 percent of total billed charges 167.4 256.5 Technical (Hospital) Services Ref Human T-Cell Lymphotropic Virus Types I and II (Htlv-II) Antibody Screen With Confirm PX-3028679005 CDM 86790 CPT 302 RC outpatient 270 270 BLUE CROSS BLUE SHIELD WELLMARK SB889 [3081026] BCBS WYOMING [308102603] 256.5 percent of total billed charges 167.4 256.5 Technical (Hospital) Services Ref Human T-Cell Lymphotropic Virus Types I and II (Htlv-II) Antibody Screen With Confirm PX-3028679005 CDM 86790 CPT 302 RC outpatient 270 270 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES EPO [308136803] 216 percent of total billed charges 167.4 256.5 Technical (Hospital) Services Ref Human T-Cell Lymphotropic Virus Types I and II (Htlv-II) Antibody Screen With Confirm PX-3028679005 CDM 86790 CPT 302 RC outpatient 270 270 CIGNA 62308 [3081051] CIGNA 62308 [308105105] 216 percent of total billed charges 167.4 256.5 Technical (Hospital) Services Ref Human T-Cell Lymphotropic Virus Types I and II (Htlv-II) Antibody Screen With Confirm PX-3028679005 CDM 86790 CPT 302 RC outpatient 270 270 CIGNA 62308 [3081051] CIGNA STATE OF WYOMING [308105107] 216 percent of total billed charges 167.4 256.5 Technical (Hospital) Services Ref Human T-Cell Lymphotropic Virus Types I and II (Htlv-II) Antibody Screen With Confirm PX-3028679005 CDM 86790 CPT 302 RC inpatient 270 270 BLUE CROSS BLUE SHIELD WELLMARK SB889 [3081026] BCBS WYOMING [308102603] 256.5 percent of total billed charges 167.4 256.5 Technical (Hospital) Services Ref Human T-Cell Lymphotropic Virus Types I and II (Htlv-II) Antibody Screen With Confirm PX-3028679005 CDM 86790 CPT 302 RC inpatient 270 270 CIGNA 62308 [3081051] CIGNA 62308 [308105105] 213.79 percent of total billed charges 167.4 256.5 Technical (Hospital) Services Ref Human T-Cell Lymphotropic Virus Types I and II (Htlv-II) Antibody Screen With Confirm PX-3028679005 CDM 86790 CPT 302 RC inpatient 270 270 CIGNA 62308 [3081051] CIGNA STATE OF WYOMING [308105107] 213.79 percent of total billed charges 167.4 256.5 Technical (Hospital) Services Ref Human T-Cell Lymphotropic Virus Types I and II (Htlv-II) Antibody Screen With Confirm PX-3028679005 CDM 86790 CPT 302 RC inpatient 270 270 MULTIPLAN INC 34080 [3081285] MULTIPLAN INC [308128501] 256.5 percent of total billed charges 167.4 256.5 Technical (Hospital) Services Ref Human T-Cell Lymphotropic Virus Types I and II (Htlv-II) Antibody Screen With Confirm PX-3028679005 CDM 86790 CPT 302 RC inpatient 270 270 MEDICA (COMMERCIAL) 94265 [3081118] MEDICA CLAIMS [308111801] 243 percent of total billed charges 167.4 256.5 Technical (Hospital) Services Ref Human T-Cell Lymphotropic Virus Types I and II (Htlv-II) Antibody Screen With Confirm PX-3028679005 CDM 86790 CPT 302 RC inpatient 270 270 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES EPO [308136803] 213.79 percent of total billed charges 167.4 256.5 Technical (Hospital) Services Ref Human T-Cell Lymphotropic Virus Types I and II (Htlv-II) Antibody Screen With Confirm PX-3028679005 CDM 86790 CPT 302 RC inpatient 270 270 HEALTHPARTNERS SX009 HEALTHPARTNERS 213.79 percent of total billed charges 167.4 256.5 Technical (Hospital) Services Ref Human T-Cell Lymphotropic Virus Types I and II (Htlv-II) Antibody Screen With Confirm PX-3028679005 CDM 86790 CPT 302 RC inpatient 270 270 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES PPO [308136801] 213.79 percent of total billed charges 167.4 256.5 Technical (Hospital) Services Ref Human T-Cell Lymphotropic Virus Types I and II (Htlv-II) Antibody Screen With Confirm PX-3028679005 CDM 86790 CPT 302 RC inpatient 270 270 UNITED HEALTHCARE (COMMERCIAL) [3081199] UNITED HEALTHCARE 87726 [308119901] 167.4 percent of total billed charges 167.4 256.5 Technical (Hospital) Services Ref Human T-Cell Lymphotropic Virus Types I and II (Htlv-II) Antibody Screen With Confirm PX-3028679005 CDM 86790 CPT 302 RC inpatient 270 270 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES HDHP [308136802] 213.79 percent of total billed charges 167.4 256.5 Technical (Hospital) Services Ref West Nile Virus Igg PX-3028678900 CDM 86789 CPT 302 RC inpatient 194 194 UNITED HEALTHCARE (COMMERCIAL) [3081199] UNITED HEALTHCARE 87726 [308119901] 120.28 percent of total billed charges 120.28 184.3 Technical (Hospital) Services Ref West Nile Virus Igg PX-3028678900 CDM 86789 CPT 302 RC inpatient 194 194 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES PPO [308136801] 153.61 percent of total billed charges 120.28 184.3 Technical (Hospital) Services Ref West Nile Virus Igg PX-3028678900 CDM 86789 CPT 302 RC inpatient 194 194 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES HDHP [308136802] 153.61 percent of total billed charges 120.28 184.3 Technical (Hospital) Services Ref West Nile Virus Igg PX-3028678900 CDM 86789 CPT 302 RC inpatient 194 194 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES EPO [308136803] 153.61 percent of total billed charges 120.28 184.3 Technical (Hospital) Services Ref West Nile Virus Igg PX-3028678900 CDM 86789 CPT 302 RC inpatient 194 194 HEALTHPARTNERS SX009 HEALTHPARTNERS 153.61 percent of total billed charges 120.28 184.3 Technical (Hospital) Services Ref West Nile Virus Igg PX-3028678900 CDM 86789 CPT 302 RC inpatient 194 194 MEDICA (COMMERCIAL) 94265 [3081118] MEDICA CLAIMS [308111801] 174.6 percent of total billed charges 120.28 184.3 Technical (Hospital) Services Ref West Nile Virus Igg PX-3028678900 CDM 86789 CPT 302 RC inpatient 194 194 MULTIPLAN INC 34080 [3081285] MULTIPLAN INC [308128501] 184.3 percent of total billed charges 120.28 184.3 Technical (Hospital) Services Ref West Nile Virus Igg PX-3028678900 CDM 86789 CPT 302 RC inpatient 194 194 BLUE CROSS BLUE SHIELD WELLMARK SB889 [3081026] BCBS WYOMING [308102603] 184.3 percent of total billed charges 120.28 184.3 Technical (Hospital) Services Ref West Nile Virus Igg PX-3028678900 CDM 86789 CPT 302 RC inpatient 194 194 CIGNA 62308 [3081051] CIGNA 62308 [308105105] 153.61 percent of total billed charges 120.28 184.3 Technical (Hospital) Services Ref West Nile Virus Igg PX-3028678900 CDM 86789 CPT 302 RC inpatient 194 194 CIGNA 62308 [3081051] CIGNA STATE OF WYOMING [308105107] 153.61 percent of total billed charges 120.28 184.3 Technical (Hospital) Services Ref West Nile Virus Igg PX-3028678900 CDM 86789 CPT 302 RC outpatient 194 194 BLUE CROSS BLUE SHIELD WELLMARK SB889 [3081026] BCBS WYOMING [308102603] 184.3 percent of total billed charges 120.28 184.3 Technical (Hospital) Services Ref West Nile Virus Igg PX-3028678900 CDM 86789 CPT 302 RC outpatient 194 194 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES HDHP [308136802] 155.2 percent of total billed charges 120.28 184.3 Technical (Hospital) Services Ref West Nile Virus Igg PX-3028678900 CDM 86789 CPT 302 RC outpatient 194 194 MULTIPLAN INC 34080 [3081285] MULTIPLAN INC [308128501] 184.3 percent of total billed charges 120.28 184.3 Technical (Hospital) Services Ref West Nile Virus Igg PX-3028678900 CDM 86789 CPT 302 RC outpatient 194 194 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES EPO [308136803] 155.2 percent of total billed charges 120.28 184.3 Technical (Hospital) Services Ref West Nile Virus Igg PX-3028678900 CDM 86789 CPT 302 RC outpatient 194 194 CIGNA 62308 [3081051] CIGNA 62308 [308105105] 155.2 percent of total billed charges 120.28 184.3 Technical (Hospital) Services Ref West Nile Virus Igg PX-3028678900 CDM 86789 CPT 302 RC outpatient 194 194 CIGNA 62308 [3081051] CIGNA STATE OF WYOMING [308105107] 155.2 percent of total billed charges 120.28 184.3 Technical (Hospital) Services Ref West Nile Virus Igg PX-3028678900 CDM 86789 CPT 302 RC outpatient 194 194 UNITED HEALTHCARE (COMMERCIAL) [3081199] UNITED HEALTHCARE 87726 [308119901] 120.28 percent of total billed charges 120.28 184.3 Technical (Hospital) Services Ref West Nile Virus Igg PX-3028678900 CDM 86789 CPT 302 RC outpatient 194 194 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES PPO [308136801] 155.2 percent of total billed charges 120.28 184.3 Technical (Hospital) Services Ref West Nile Virus Igg PX-3028678900 CDM 86789 CPT 302 RC outpatient 194 194 HEALTHPARTNERS SX009 HEALTHPARTNERS 155.2 percent of total billed charges 120.28 184.3 Technical (Hospital) Services Ref West Nile Virus Igg PX-3028678900 CDM 86789 CPT 302 RC outpatient 194 194 MEDICA (COMMERCIAL) 94265 [3081118] MEDICA CLAIMS [308111801] 174.6 percent of total billed charges 120.28 184.3 Technical (Hospital) Services West Nile Virus Igm PX-3028678800 CDM 86788 CPT 302 RC inpatient 193 193 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES EPO [308136803] 152.82 percent of total billed charges 119.66 183.35 Technical (Hospital) Services West Nile Virus Igm PX-3028678800 CDM 86788 CPT 302 RC inpatient 193 193 HEALTHPARTNERS SX009 HEALTHPARTNERS 152.82 percent of total billed charges 119.66 183.35 Technical (Hospital) Services West Nile Virus Igm PX-3028678800 CDM 86788 CPT 302 RC inpatient 193 193 CIGNA 62308 [3081051] CIGNA 62308 [308105105] 152.82 percent of total billed charges 119.66 183.35 Technical (Hospital) Services West Nile Virus Igm PX-3028678800 CDM 86788 CPT 302 RC inpatient 193 193 CIGNA 62308 [3081051] CIGNA STATE OF WYOMING [308105107] 152.82 percent of total billed charges 119.66 183.35 Technical (Hospital) Services West Nile Virus Igm PX-3028678800 CDM 86788 CPT 302 RC inpatient 193 193 BLUE CROSS BLUE SHIELD WELLMARK SB889 [3081026] BCBS WYOMING [308102603] 183.35 percent of total billed charges 119.66 183.35 Technical (Hospital) Services West Nile Virus Igm PX-3028678800 CDM 86788 CPT 302 RC inpatient 193 193 MULTIPLAN INC 34080 [3081285] MULTIPLAN INC [308128501] 183.35 percent of total billed charges 119.66 183.35 Technical (Hospital) Services West Nile Virus Igm PX-3028678800 CDM 86788 CPT 302 RC inpatient 193 193 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES HDHP [308136802] 152.82 percent of total billed charges 119.66 183.35 Technical (Hospital) Services West Nile Virus Igm PX-3028678800 CDM 86788 CPT 302 RC inpatient 193 193 MEDICA (COMMERCIAL) 94265 [3081118] MEDICA CLAIMS [308111801] 173.7 percent of total billed charges 119.66 183.35 Technical (Hospital) Services West Nile Virus Igm PX-3028678800 CDM 86788 CPT 302 RC inpatient 193 193 UNITED HEALTHCARE (COMMERCIAL) [3081199] UNITED HEALTHCARE 87726 [308119901] 119.66 percent of total billed charges 119.66 183.35 Technical (Hospital) Services West Nile Virus Igm PX-3028678800 CDM 86788 CPT 302 RC inpatient 193 193 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES PPO [308136801] 152.82 percent of total billed charges 119.66 183.35 Technical (Hospital) Services West Nile Virus Igm PX-3028678800 CDM 86788 CPT 302 RC outpatient 193 193 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES HDHP [308136802] 154.4 percent of total billed charges 119.66 183.35 Technical (Hospital) Services West Nile Virus Igm PX-3028678800 CDM 86788 CPT 302 RC outpatient 193 193 BLUE CROSS BLUE SHIELD WELLMARK SB889 [3081026] BCBS WYOMING [308102603] 183.35 percent of total billed charges 119.66 183.35 Technical (Hospital) Services West Nile Virus Igm PX-3028678800 CDM 86788 CPT 302 RC outpatient 193 193 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES EPO [308136803] 154.4 percent of total billed charges 119.66 183.35 Technical (Hospital) Services West Nile Virus Igm PX-3028678800 CDM 86788 CPT 302 RC outpatient 193 193 CIGNA 62308 [3081051] CIGNA 62308 [308105105] 154.4 percent of total billed charges 119.66 183.35 Technical (Hospital) Services West Nile Virus Igm PX-3028678800 CDM 86788 CPT 302 RC outpatient 193 193 CIGNA 62308 [3081051] CIGNA STATE OF WYOMING [308105107] 154.4 percent of total billed charges 119.66 183.35 Technical (Hospital) Services West Nile Virus Igm PX-3028678800 CDM 86788 CPT 302 RC outpatient 193 193 MULTIPLAN INC 34080 [3081285] MULTIPLAN INC [308128501] 183.35 percent of total billed charges 119.66 183.35 Technical (Hospital) Services West Nile Virus Igm PX-3028678800 CDM 86788 CPT 302 RC outpatient 193 193 UNITED HEALTHCARE (COMMERCIAL) [3081199] UNITED HEALTHCARE 87726 [308119901] 119.66 percent of total billed charges 119.66 183.35 Technical (Hospital) Services West Nile Virus Igm PX-3028678800 CDM 86788 CPT 302 RC outpatient 193 193 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES PPO [308136801] 154.4 percent of total billed charges 119.66 183.35 Technical (Hospital) Services West Nile Virus Igm PX-3028678800 CDM 86788 CPT 302 RC outpatient 193 193 HEALTHPARTNERS SX009 HEALTHPARTNERS 154.4 percent of total billed charges 119.66 183.35 Technical (Hospital) Services West Nile Virus Igm PX-3028678800 CDM 86788 CPT 302 RC outpatient 193 193 MEDICA (COMMERCIAL) 94265 [3081118] MEDICA CLAIMS [308111801] 173.7 percent of total billed charges 119.66 183.35 Technical (Hospital) Services Ref West Nile Virus Igm PX-3028678801 CDM 86788 CPT 302 RC inpatient 193 193 CIGNA 62308 [3081051] CIGNA 62308 [308105105] 152.82 percent of total billed charges 119.66 183.35 Technical (Hospital) Services Ref West Nile Virus Igm PX-3028678801 CDM 86788 CPT 302 RC inpatient 193 193 CIGNA 62308 [3081051] CIGNA STATE OF WYOMING [308105107] 152.82 percent of total billed charges 119.66 183.35 Technical (Hospital) Services Ref West Nile Virus Igm PX-3028678801 CDM 86788 CPT 302 RC inpatient 193 193 BLUE CROSS BLUE SHIELD WELLMARK SB889 [3081026] BCBS WYOMING [308102603] 183.35 percent of total billed charges 119.66 183.35 Technical (Hospital) Services Ref West Nile Virus Igm PX-3028678801 CDM 86788 CPT 302 RC inpatient 193 193 MULTIPLAN INC 34080 [3081285] MULTIPLAN INC [308128501] 183.35 percent of total billed charges 119.66 183.35 Technical (Hospital) Services Ref West Nile Virus Igm PX-3028678801 CDM 86788 CPT 302 RC inpatient 193 193 MEDICA (COMMERCIAL) 94265 [3081118] MEDICA CLAIMS [308111801] 173.7 percent of total billed charges 119.66 183.35 Technical (Hospital) Services Ref West Nile Virus Igm PX-3028678801 CDM 86788 CPT 302 RC inpatient 193 193 HEALTHPARTNERS SX009 HEALTHPARTNERS 152.82 percent of total billed charges 119.66 183.35 Technical (Hospital) Services Ref West Nile Virus Igm PX-3028678801 CDM 86788 CPT 302 RC inpatient 193 193 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES EPO [308136803] 152.82 percent of total billed charges 119.66 183.35 Technical (Hospital) Services Ref West Nile Virus Igm PX-3028678801 CDM 86788 CPT 302 RC inpatient 193 193 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES HDHP [308136802] 152.82 percent of total billed charges 119.66 183.35 Technical (Hospital) Services Ref West Nile Virus Igm PX-3028678801 CDM 86788 CPT 302 RC inpatient 193 193 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES PPO [308136801] 152.82 percent of total billed charges 119.66 183.35 Technical (Hospital) Services Ref West Nile Virus Igm PX-3028678801 CDM 86788 CPT 302 RC inpatient 193 193 UNITED HEALTHCARE (COMMERCIAL) [3081199] UNITED HEALTHCARE 87726 [308119901] 119.66 percent of total billed charges 119.66 183.35 Technical (Hospital) Services Ref West Nile Virus Igm PX-3028678801 CDM 86788 CPT 302 RC outpatient 193 193 UNITED HEALTHCARE (COMMERCIAL) [3081199] UNITED HEALTHCARE 87726 [308119901] 119.66 percent of total billed charges 119.66 183.35 Technical (Hospital) Services Ref West Nile Virus Igm PX-3028678801 CDM 86788 CPT 302 RC outpatient 193 193 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES PPO [308136801] 154.4 percent of total billed charges 119.66 183.35 Technical (Hospital) Services Ref West Nile Virus Igm PX-3028678801 CDM 86788 CPT 302 RC outpatient 193 193 HEALTHPARTNERS SX009 HEALTHPARTNERS 154.4 percent of total billed charges 119.66 183.35 Technical (Hospital) Services Ref West Nile Virus Igm PX-3028678801 CDM 86788 CPT 302 RC outpatient 193 193 BLUE CROSS BLUE SHIELD WELLMARK SB889 [3081026] BCBS WYOMING [308102603] 183.35 percent of total billed charges 119.66 183.35 Technical (Hospital) Services Ref West Nile Virus Igm PX-3028678801 CDM 86788 CPT 302 RC outpatient 193 193 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES HDHP [308136802] 154.4 percent of total billed charges 119.66 183.35 Technical (Hospital) Services Ref West Nile Virus Igm PX-3028678801 CDM 86788 CPT 302 RC outpatient 193 193 MULTIPLAN INC 34080 [3081285] MULTIPLAN INC [308128501] 183.35 percent of total billed charges 119.66 183.35 Technical (Hospital) Services Ref West Nile Virus Igm PX-3028678801 CDM 86788 CPT 302 RC outpatient 193 193 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES EPO [308136803] 154.4 percent of total billed charges 119.66 183.35 Technical (Hospital) Services Ref West Nile Virus Igm PX-3028678801 CDM 86788 CPT 302 RC outpatient 193 193 CIGNA 62308 [3081051] CIGNA 62308 [308105105] 154.4 percent of total billed charges 119.66 183.35 Technical (Hospital) Services Ref West Nile Virus Igm PX-3028678801 CDM 86788 CPT 302 RC outpatient 193 193 CIGNA 62308 [3081051] CIGNA STATE OF WYOMING [308105107] 154.4 percent of total billed charges 119.66 183.35 Technical (Hospital) Services Ref West Nile Virus Igm PX-3028678801 CDM 86788 CPT 302 RC outpatient 193 193 MEDICA (COMMERCIAL) 94265 [3081118] MEDICA CLAIMS [308111801] 173.7 percent of total billed charges 119.66 183.35 Technical (Hospital) Services Varicella Zoster Ab Igm PX-3028678700 CDM 86787 CPT 302 RC inpatient 185 185 MEDICA (COMMERCIAL) 94265 [3081118] MEDICA CLAIMS [308111801] 166.5 percent of total billed charges 114.7 175.75 Technical (Hospital) Services Varicella Zoster Ab Igm PX-3028678700 CDM 86787 CPT 302 RC inpatient 185 185 MULTIPLAN INC 34080 [3081285] MULTIPLAN INC [308128501] 175.75 percent of total billed charges 114.7 175.75 Technical (Hospital) Services Varicella Zoster Ab Igm PX-3028678700 CDM 86787 CPT 302 RC inpatient 185 185 BLUE CROSS BLUE SHIELD WELLMARK SB889 [3081026] BCBS WYOMING [308102603] 175.75 percent of total billed charges 114.7 175.75 Technical (Hospital) Services Varicella Zoster Ab Igm PX-3028678700 CDM 86787 CPT 302 RC inpatient 185 185 CIGNA 62308 [3081051] CIGNA 62308 [308105105] 146.48 percent of total billed charges 114.7 175.75 Technical (Hospital) Services Varicella Zoster Ab Igm PX-3028678700 CDM 86787 CPT 302 RC inpatient 185 185 CIGNA 62308 [3081051] CIGNA STATE OF WYOMING [308105107] 146.48 percent of total billed charges 114.7 175.75 Technical (Hospital) Services Varicella Zoster Ab Igm PX-3028678700 CDM 86787 CPT 302 RC inpatient 185 185 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES EPO [308136803] 146.48 percent of total billed charges 114.7 175.75 Technical (Hospital) Services Varicella Zoster Ab Igm PX-3028678700 CDM 86787 CPT 302 RC inpatient 185 185 HEALTHPARTNERS SX009 HEALTHPARTNERS 146.48 percent of total billed charges 114.7 175.75 Technical (Hospital) Services Varicella Zoster Ab Igm PX-3028678700 CDM 86787 CPT 302 RC inpatient 185 185 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES HDHP [308136802] 146.48 percent of total billed charges 114.7 175.75 Technical (Hospital) Services Varicella Zoster Ab Igm PX-3028678700 CDM 86787 CPT 302 RC inpatient 185 185 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES PPO [308136801] 146.48 percent of total billed charges 114.7 175.75 Technical (Hospital) Services Varicella Zoster Ab Igm PX-3028678700 CDM 86787 CPT 302 RC inpatient 185 185 UNITED HEALTHCARE (COMMERCIAL) [3081199] UNITED HEALTHCARE 87726 [308119901] 114.7 percent of total billed charges 114.7 175.75 Technical (Hospital) Services Varicella Zoster Ab Igm PX-3028678700 CDM 86787 CPT 302 RC outpatient 185 185 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES HDHP [308136802] 148 percent of total billed charges 114.7 175.75 Technical (Hospital) Services Varicella Zoster Ab Igm PX-3028678700 CDM 86787 CPT 302 RC outpatient 185 185 BLUE CROSS BLUE SHIELD WELLMARK SB889 [3081026] BCBS WYOMING [308102603] 175.75 percent of total billed charges 114.7 175.75 Technical (Hospital) Services Varicella Zoster Ab Igm PX-3028678700 CDM 86787 CPT 302 RC outpatient 185 185 CIGNA 62308 [3081051] CIGNA 62308 [308105105] 148 percent of total billed charges 114.7 175.75 Technical (Hospital) Services Varicella Zoster Ab Igm PX-3028678700 CDM 86787 CPT 302 RC outpatient 185 185 CIGNA 62308 [3081051] CIGNA STATE OF WYOMING [308105107] 148 percent of total billed charges 114.7 175.75 Technical (Hospital) Services Varicella Zoster Ab Igm PX-3028678700 CDM 86787 CPT 302 RC outpatient 185 185 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES EPO [308136803] 148 percent of total billed charges 114.7 175.75 Technical (Hospital) Services Varicella Zoster Ab Igm PX-3028678700 CDM 86787 CPT 302 RC outpatient 185 185 MULTIPLAN INC 34080 [3081285] MULTIPLAN INC [308128501] 175.75 percent of total billed charges 114.7 175.75 Technical (Hospital) Services Varicella Zoster Ab Igm PX-3028678700 CDM 86787 CPT 302 RC outpatient 185 185 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES PPO [308136801] 148 percent of total billed charges 114.7 175.75 Technical (Hospital) Services Varicella Zoster Ab Igm PX-3028678700 CDM 86787 CPT 302 RC outpatient 185 185 HEALTHPARTNERS SX009 HEALTHPARTNERS 148 percent of total billed charges 114.7 175.75 Technical (Hospital) Services Varicella Zoster Ab Igm PX-3028678700 CDM 86787 CPT 302 RC outpatient 185 185 UNITED HEALTHCARE (COMMERCIAL) [3081199] UNITED HEALTHCARE 87726 [308119901] 114.7 percent of total billed charges 114.7 175.75 Technical (Hospital) Services Varicella Zoster Ab Igm PX-3028678700 CDM 86787 CPT 302 RC outpatient 185 185 MEDICA (COMMERCIAL) 94265 [3081118] MEDICA CLAIMS [308111801] 166.5 percent of total billed charges 114.7 175.75 Technical (Hospital) Services HC Wch Varicella Zoster Igg PX-3028678704 CDM 86787 CPT 302 RC outpatient 69 69 MULTIPLAN INC 34080 [3081285] MULTIPLAN INC [308128501] 65.55 percent of total billed charges 42.78 65.55 Technical (Hospital) Services HC Wch Varicella Zoster Igg PX-3028678704 CDM 86787 CPT 302 RC outpatient 69 69 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES EPO [308136803] 55.2 percent of total billed charges 42.78 65.55 Technical (Hospital) Services HC Wch Varicella Zoster Igg PX-3028678704 CDM 86787 CPT 302 RC outpatient 69 69 CIGNA 62308 [3081051] CIGNA 62308 [308105105] 55.2 percent of total billed charges 42.78 65.55 Technical (Hospital) Services HC Wch Varicella Zoster Igg PX-3028678704 CDM 86787 CPT 302 RC outpatient 69 69 CIGNA 62308 [3081051] CIGNA STATE OF WYOMING [308105107] 55.2 percent of total billed charges 42.78 65.55 Technical (Hospital) Services HC Wch Varicella Zoster Igg PX-3028678704 CDM 86787 CPT 302 RC outpatient 69 69 BLUE CROSS BLUE SHIELD WELLMARK SB889 [3081026] BCBS WYOMING [308102603] 65.55 percent of total billed charges 42.78 65.55 Technical (Hospital) Services HC Wch Varicella Zoster Igg PX-3028678704 CDM 86787 CPT 302 RC outpatient 69 69 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES HDHP [308136802] 55.2 percent of total billed charges 42.78 65.55 Technical (Hospital) Services HC Wch Varicella Zoster Igg PX-3028678704 CDM 86787 CPT 302 RC outpatient 69 69 UNITED HEALTHCARE (COMMERCIAL) [3081199] UNITED HEALTHCARE 87726 [308119901] 42.78 percent of total billed charges 42.78 65.55 Technical (Hospital) Services HC Wch Varicella Zoster Igg PX-3028678704 CDM 86787 CPT 302 RC outpatient 69 69 HEALTHPARTNERS SX009 HEALTHPARTNERS 55.2 percent of total billed charges 42.78 65.55 Technical (Hospital) Services HC Wch Varicella Zoster Igg PX-3028678704 CDM 86787 CPT 302 RC outpatient 69 69 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES PPO [308136801] 55.2 percent of total billed charges 42.78 65.55 Technical (Hospital) Services HC Wch Varicella Zoster Igg PX-3028678704 CDM 86787 CPT 302 RC outpatient 69 69 MEDICA (COMMERCIAL) 94265 [3081118] MEDICA CLAIMS [308111801] 62.1 percent of total billed charges 42.78 65.55 Technical (Hospital) Services HC Wch Varicella Zoster Igg PX-3028678704 CDM 86787 CPT 302 RC inpatient 69 69 UNITED HEALTHCARE (COMMERCIAL) [3081199] UNITED HEALTHCARE 87726 [308119901] 42.78 percent of total billed charges 42.78 65.55 Technical (Hospital) Services HC Wch Varicella Zoster Igg PX-3028678704 CDM 86787 CPT 302 RC inpatient 69 69 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES PPO [308136801] 54.63 percent of total billed charges 42.78 65.55 Technical (Hospital) Services HC Wch Varicella Zoster Igg PX-3028678704 CDM 86787 CPT 302 RC inpatient 69 69 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES HDHP [308136802] 54.63 percent of total billed charges 42.78 65.55 Technical (Hospital) Services HC Wch Varicella Zoster Igg PX-3028678704 CDM 86787 CPT 302 RC inpatient 69 69 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES EPO [308136803] 54.63 percent of total billed charges 42.78 65.55 Technical (Hospital) Services HC Wch Varicella Zoster Igg PX-3028678704 CDM 86787 CPT 302 RC inpatient 69 69 HEALTHPARTNERS SX009 HEALTHPARTNERS 54.63 percent of total billed charges 42.78 65.55 Technical (Hospital) Services HC Wch Varicella Zoster Igg PX-3028678704 CDM 86787 CPT 302 RC inpatient 69 69 MEDICA (COMMERCIAL) 94265 [3081118] MEDICA CLAIMS [308111801] 62.1 percent of total billed charges 42.78 65.55 Technical (Hospital) Services HC Wch Varicella Zoster Igg PX-3028678704 CDM 86787 CPT 302 RC inpatient 69 69 MULTIPLAN INC 34080 [3081285] MULTIPLAN INC [308128501] 65.55 percent of total billed charges 42.78 65.55 Technical (Hospital) Services HC Wch Varicella Zoster Igg PX-3028678704 CDM 86787 CPT 302 RC inpatient 69 69 CIGNA 62308 [3081051] CIGNA 62308 [308105105] 54.63 percent of total billed charges 42.78 65.55 Technical (Hospital) Services HC Wch Varicella Zoster Igg PX-3028678704 CDM 86787 CPT 302 RC inpatient 69 69 CIGNA 62308 [3081051] CIGNA STATE OF WYOMING [308105107] 54.63 percent of total billed charges 42.78 65.55 Technical (Hospital) Services HC Wch Varicella Zoster Igg PX-3028678704 CDM 86787 CPT 302 RC inpatient 69 69 BLUE CROSS BLUE SHIELD WELLMARK SB889 [3081026] BCBS WYOMING [308102603] 65.55 percent of total billed charges 42.78 65.55 Technical (Hospital) Services Syphilis T Pallidum Ab PX-3028678000 CDM 86780 CPT 302 RC outpatient 120 120 MEDICA (COMMERCIAL) 94265 [3081118] MEDICA CLAIMS [308111801] 108 percent of total billed charges 74.4 114 Technical (Hospital) Services Syphilis T Pallidum Ab PX-3028678000 CDM 86780 CPT 302 RC outpatient 120 120 UNITED HEALTHCARE (COMMERCIAL) [3081199] UNITED HEALTHCARE 87726 [308119901] 74.4 percent of total billed charges 74.4 114 Technical (Hospital) Services Syphilis T Pallidum Ab PX-3028678000 CDM 86780 CPT 302 RC outpatient 120 120 HEALTHPARTNERS SX009 HEALTHPARTNERS 96 percent of total billed charges 74.4 114 Technical (Hospital) Services Syphilis T Pallidum Ab PX-3028678000 CDM 86780 CPT 302 RC outpatient 120 120 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES PPO [308136801] 96 percent of total billed charges 74.4 114 Technical (Hospital) Services Syphilis T Pallidum Ab PX-3028678000 CDM 86780 CPT 302 RC outpatient 120 120 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES HDHP [308136802] 96 percent of total billed charges 74.4 114 Technical (Hospital) Services Syphilis T Pallidum Ab PX-3028678000 CDM 86780 CPT 302 RC outpatient 120 120 BLUE CROSS BLUE SHIELD WELLMARK SB889 [3081026] BCBS WYOMING [308102603] 114 percent of total billed charges 74.4 114 Technical (Hospital) Services Syphilis T Pallidum Ab PX-3028678000 CDM 86780 CPT 302 RC outpatient 120 120 CIGNA 62308 [3081051] CIGNA 62308 [308105105] 96 percent of total billed charges 74.4 114 Technical (Hospital) Services Syphilis T Pallidum Ab PX-3028678000 CDM 86780 CPT 302 RC outpatient 120 120 CIGNA 62308 [3081051] CIGNA STATE OF WYOMING [308105107] 96 percent of total billed charges 74.4 114 Technical (Hospital) Services Syphilis T Pallidum Ab PX-3028678000 CDM 86780 CPT 302 RC outpatient 120 120 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES EPO [308136803] 96 percent of total billed charges 74.4 114 Technical (Hospital) Services Syphilis T Pallidum Ab PX-3028678000 CDM 86780 CPT 302 RC outpatient 120 120 MULTIPLAN INC 34080 [3081285] MULTIPLAN INC [308128501] 114 percent of total billed charges 74.4 114 Technical (Hospital) Services Syphilis T Pallidum Ab PX-3028678000 CDM 86780 CPT 302 RC inpatient 120 120 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES PPO [308136801] 95.02 percent of total billed charges 74.4 114 Technical (Hospital) Services Syphilis T Pallidum Ab PX-3028678000 CDM 86780 CPT 302 RC inpatient 120 120 UNITED HEALTHCARE (COMMERCIAL) [3081199] UNITED HEALTHCARE 87726 [308119901] 74.4 percent of total billed charges 74.4 114 Technical (Hospital) Services Syphilis T Pallidum Ab PX-3028678000 CDM 86780 CPT 302 RC inpatient 120 120 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES HDHP [308136802] 95.02 percent of total billed charges 74.4 114 Technical (Hospital) Services Syphilis T Pallidum Ab PX-3028678000 CDM 86780 CPT 302 RC inpatient 120 120 HEALTHPARTNERS SX009 HEALTHPARTNERS 95.02 percent of total billed charges 74.4 114 Technical (Hospital) Services Syphilis T Pallidum Ab PX-3028678000 CDM 86780 CPT 302 RC inpatient 120 120 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES EPO [308136803] 95.02 percent of total billed charges 74.4 114 Technical (Hospital) Services Syphilis T Pallidum Ab PX-3028678000 CDM 86780 CPT 302 RC inpatient 120 120 BLUE CROSS BLUE SHIELD WELLMARK SB889 [3081026] BCBS WYOMING [308102603] 114 percent of total billed charges 74.4 114 Technical (Hospital) Services Syphilis T Pallidum Ab PX-3028678000 CDM 86780 CPT 302 RC inpatient 120 120 CIGNA 62308 [3081051] CIGNA 62308 [308105105] 95.02 percent of total billed charges 74.4 114 Technical (Hospital) Services Syphilis T Pallidum Ab PX-3028678000 CDM 86780 CPT 302 RC inpatient 120 120 CIGNA 62308 [3081051] CIGNA STATE OF WYOMING [308105107] 95.02 percent of total billed charges 74.4 114 Technical (Hospital) Services Syphilis T Pallidum Ab PX-3028678000 CDM 86780 CPT 302 RC inpatient 120 120 MEDICA (COMMERCIAL) 94265 [3081118] MEDICA CLAIMS [308111801] 108 percent of total billed charges 74.4 114 Technical (Hospital) Services Syphilis T Pallidum Ab PX-3028678000 CDM 86780 CPT 302 RC inpatient 120 120 MULTIPLAN INC 34080 [3081285] MULTIPLAN INC [308128501] 114 percent of total billed charges 74.4 114 Technical (Hospital) Services Ref Toxoplasmosis Igm Antibody PX-3028677801 CDM 86778 CPT 302 RC inpatient 184 184 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES HDHP [308136802] 145.69 percent of total billed charges 114.08 174.8 Technical (Hospital) Services Ref Toxoplasmosis Igm Antibody PX-3028677801 CDM 86778 CPT 302 RC inpatient 184 184 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES PPO [308136801] 145.69 percent of total billed charges 114.08 174.8 Technical (Hospital) Services Ref Toxoplasmosis Igm Antibody PX-3028677801 CDM 86778 CPT 302 RC inpatient 184 184 UNITED HEALTHCARE (COMMERCIAL) [3081199] UNITED HEALTHCARE 87726 [308119901] 114.08 percent of total billed charges 114.08 174.8 Technical (Hospital) Services Ref Toxoplasmosis Igm Antibody PX-3028677801 CDM 86778 CPT 302 RC inpatient 184 184 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES EPO [308136803] 145.69 percent of total billed charges 114.08 174.8 Technical (Hospital) Services Ref Toxoplasmosis Igm Antibody PX-3028677801 CDM 86778 CPT 302 RC inpatient 184 184 HEALTHPARTNERS SX009 HEALTHPARTNERS 145.69 percent of total billed charges 114.08 174.8 Technical (Hospital) Services Ref Toxoplasmosis Igm Antibody PX-3028677801 CDM 86778 CPT 302 RC inpatient 184 184 MEDICA (COMMERCIAL) 94265 [3081118] MEDICA CLAIMS [308111801] 165.6 percent of total billed charges 114.08 174.8 Technical (Hospital) Services Ref Toxoplasmosis Igm Antibody PX-3028677801 CDM 86778 CPT 302 RC inpatient 184 184 MULTIPLAN INC 34080 [3081285] MULTIPLAN INC [308128501] 174.8 percent of total billed charges 114.08 174.8 Technical (Hospital) Services Ref Toxoplasmosis Igm Antibody PX-3028677801 CDM 86778 CPT 302 RC inpatient 184 184 CIGNA 62308 [3081051] CIGNA 62308 [308105105] 145.69 percent of total billed charges 114.08 174.8 Technical (Hospital) Services Ref Toxoplasmosis Igm Antibody PX-3028677801 CDM 86778 CPT 302 RC inpatient 184 184 CIGNA 62308 [3081051] CIGNA STATE OF WYOMING [308105107] 145.69 percent of total billed charges 114.08 174.8 Technical (Hospital) Services Ref Toxoplasmosis Igm Antibody PX-3028677801 CDM 86778 CPT 302 RC inpatient 184 184 BLUE CROSS BLUE SHIELD WELLMARK SB889 [3081026] BCBS WYOMING [308102603] 174.8 percent of total billed charges 114.08 174.8 Technical (Hospital) Services Ref Toxoplasmosis Igm Antibody PX-3028677801 CDM 86778 CPT 302 RC outpatient 184 184 MEDICA (COMMERCIAL) 94265 [3081118] MEDICA CLAIMS [308111801] 165.6 percent of total billed charges 114.08 174.8 Technical (Hospital) Services Ref Toxoplasmosis Igm Antibody PX-3028677801 CDM 86778 CPT 302 RC outpatient 184 184 HEALTHPARTNERS SX009 HEALTHPARTNERS 147.2 percent of total billed charges 114.08 174.8 Technical (Hospital) Services Ref Toxoplasmosis Igm Antibody PX-3028677801 CDM 86778 CPT 302 RC outpatient 184 184 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES PPO [308136801] 147.2 percent of total billed charges 114.08 174.8 Technical (Hospital) Services Ref Toxoplasmosis Igm Antibody PX-3028677801 CDM 86778 CPT 302 RC outpatient 184 184 UNITED HEALTHCARE (COMMERCIAL) [3081199] UNITED HEALTHCARE 87726 [308119901] 114.08 percent of total billed charges 114.08 174.8 Technical (Hospital) Services Ref Toxoplasmosis Igm Antibody PX-3028677801 CDM 86778 CPT 302 RC outpatient 184 184 MULTIPLAN INC 34080 [3081285] MULTIPLAN INC [308128501] 174.8 percent of total billed charges 114.08 174.8 Technical (Hospital) Services Ref Toxoplasmosis Igm Antibody PX-3028677801 CDM 86778 CPT 302 RC outpatient 184 184 CIGNA 62308 [3081051] CIGNA 62308 [308105105] 147.2 percent of total billed charges 114.08 174.8 Technical (Hospital) Services Ref Toxoplasmosis Igm Antibody PX-3028677801 CDM 86778 CPT 302 RC outpatient 184 184 CIGNA 62308 [3081051] CIGNA STATE OF WYOMING [308105107] 147.2 percent of total billed charges 114.08 174.8 Technical (Hospital) Services Ref Toxoplasmosis Igm Antibody PX-3028677801 CDM 86778 CPT 302 RC outpatient 184 184 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES EPO [308136803] 147.2 percent of total billed charges 114.08 174.8 Technical (Hospital) Services Ref Toxoplasmosis Igm Antibody PX-3028677801 CDM 86778 CPT 302 RC outpatient 184 184 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES HDHP [308136802] 147.2 percent of total billed charges 114.08 174.8 Technical (Hospital) Services Ref Toxoplasmosis Igm Antibody PX-3028677801 CDM 86778 CPT 302 RC outpatient 184 184 BLUE CROSS BLUE SHIELD WELLMARK SB889 [3081026] BCBS WYOMING [308102603] 174.8 percent of total billed charges 114.08 174.8 Technical (Hospital) Services Ref Torch Profile Igg Toxoplasma PX-3028677700 CDM 86777 CPT 302 RC inpatient 170 170 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES PPO [308136801] 134.61 percent of total billed charges 105.4 161.5 Technical (Hospital) Services Ref Torch Profile Igg Toxoplasma PX-3028677700 CDM 86777 CPT 302 RC inpatient 170 170 UNITED HEALTHCARE (COMMERCIAL) [3081199] UNITED HEALTHCARE 87726 [308119901] 105.4 percent of total billed charges 105.4 161.5 Technical (Hospital) Services Ref Torch Profile Igg Toxoplasma PX-3028677700 CDM 86777 CPT 302 RC inpatient 170 170 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES HDHP [308136802] 134.61 percent of total billed charges 105.4 161.5 Technical (Hospital) Services Ref Torch Profile Igg Toxoplasma PX-3028677700 CDM 86777 CPT 302 RC inpatient 170 170 MEDICA (COMMERCIAL) 94265 [3081118] MEDICA CLAIMS [308111801] 153 percent of total billed charges 105.4 161.5 Technical (Hospital) Services Ref Torch Profile Igg Toxoplasma PX-3028677700 CDM 86777 CPT 302 RC inpatient 170 170 MULTIPLAN INC 34080 [3081285] MULTIPLAN INC [308128501] 161.5 percent of total billed charges 105.4 161.5 Technical (Hospital) Services Ref Torch Profile Igg Toxoplasma PX-3028677700 CDM 86777 CPT 302 RC inpatient 170 170 BLUE CROSS BLUE SHIELD WELLMARK SB889 [3081026] BCBS WYOMING [308102603] 161.5 percent of total billed charges 105.4 161.5 Technical (Hospital) Services Ref Torch Profile Igg Toxoplasma PX-3028677700 CDM 86777 CPT 302 RC inpatient 170 170 CIGNA 62308 [3081051] CIGNA 62308 [308105105] 134.61 percent of total billed charges 105.4 161.5 Technical (Hospital) Services Ref Torch Profile Igg Toxoplasma PX-3028677700 CDM 86777 CPT 302 RC inpatient 170 170 CIGNA 62308 [3081051] CIGNA STATE OF WYOMING [308105107] 134.61 percent of total billed charges 105.4 161.5 Technical (Hospital) Services Ref Torch Profile Igg Toxoplasma PX-3028677700 CDM 86777 CPT 302 RC inpatient 170 170 HEALTHPARTNERS SX009 HEALTHPARTNERS 134.61 percent of total billed charges 105.4 161.5 Technical (Hospital) Services Ref Torch Profile Igg Toxoplasma PX-3028677700 CDM 86777 CPT 302 RC inpatient 170 170 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES EPO [308136803] 134.61 percent of total billed charges 105.4 161.5 Technical (Hospital) Services Ref Torch Profile Igg Toxoplasma PX-3028677700 CDM 86777 CPT 302 RC outpatient 170 170 BLUE CROSS BLUE SHIELD WELLMARK SB889 [3081026] BCBS WYOMING [308102603] 161.5 percent of total billed charges 105.4 161.5 Technical (Hospital) Services Ref Torch Profile Igg Toxoplasma PX-3028677700 CDM 86777 CPT 302 RC outpatient 170 170 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES HDHP [308136802] 136 percent of total billed charges 105.4 161.5 Technical (Hospital) Services Ref Torch Profile Igg Toxoplasma PX-3028677700 CDM 86777 CPT 302 RC outpatient 170 170 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES EPO [308136803] 136 percent of total billed charges 105.4 161.5 Technical (Hospital) Services Ref Torch Profile Igg Toxoplasma PX-3028677700 CDM 86777 CPT 302 RC outpatient 170 170 CIGNA 62308 [3081051] CIGNA 62308 [308105105] 136 percent of total billed charges 105.4 161.5 Technical (Hospital) Services Ref Torch Profile Igg Toxoplasma PX-3028677700 CDM 86777 CPT 302 RC outpatient 170 170 CIGNA 62308 [3081051] CIGNA STATE OF WYOMING [308105107] 136 percent of total billed charges 105.4 161.5 Technical (Hospital) Services Ref Torch Profile Igg Toxoplasma PX-3028677700 CDM 86777 CPT 302 RC outpatient 170 170 MULTIPLAN INC 34080 [3081285] MULTIPLAN INC [308128501] 161.5 percent of total billed charges 105.4 161.5 Technical (Hospital) Services Ref Torch Profile Igg Toxoplasma PX-3028677700 CDM 86777 CPT 302 RC outpatient 170 170 UNITED HEALTHCARE (COMMERCIAL) [3081199] UNITED HEALTHCARE 87726 [308119901] 105.4 percent of total billed charges 105.4 161.5 Technical (Hospital) Services Ref Torch Profile Igg Toxoplasma PX-3028677700 CDM 86777 CPT 302 RC outpatient 170 170 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES PPO [308136801] 136 percent of total billed charges 105.4 161.5 Technical (Hospital) Services Ref Torch Profile Igg Toxoplasma PX-3028677700 CDM 86777 CPT 302 RC outpatient 170 170 HEALTHPARTNERS SX009 HEALTHPARTNERS 136 percent of total billed charges 105.4 161.5 Technical (Hospital) Services Ref Torch Profile Igg Toxoplasma PX-3028677700 CDM 86777 CPT 302 RC outpatient 170 170 MEDICA (COMMERCIAL) 94265 [3081118] MEDICA CLAIMS [308111801] 153 percent of total billed charges 105.4 161.5 Technical (Hospital) Services Ref Toxoplasmosis Ab Igg PX-3028677701 CDM 86777 CPT 302 RC inpatient 170 170 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES EPO [308136803] 134.61 percent of total billed charges 105.4 161.5 Technical (Hospital) Services Ref Toxoplasmosis Ab Igg PX-3028677701 CDM 86777 CPT 302 RC inpatient 170 170 HEALTHPARTNERS SX009 HEALTHPARTNERS 134.61 percent of total billed charges 105.4 161.5 Technical (Hospital) Services Ref Toxoplasmosis Ab Igg PX-3028677701 CDM 86777 CPT 302 RC inpatient 170 170 MEDICA (COMMERCIAL) 94265 [3081118] MEDICA CLAIMS [308111801] 153 percent of total billed charges 105.4 161.5 Technical (Hospital) Services Ref Toxoplasmosis Ab Igg PX-3028677701 CDM 86777 CPT 302 RC inpatient 170 170 MULTIPLAN INC 34080 [3081285] MULTIPLAN INC [308128501] 161.5 percent of total billed charges 105.4 161.5 Technical (Hospital) Services Ref Toxoplasmosis Ab Igg PX-3028677701 CDM 86777 CPT 302 RC inpatient 170 170 BLUE CROSS BLUE SHIELD WELLMARK SB889 [3081026] BCBS WYOMING [308102603] 161.5 percent of total billed charges 105.4 161.5 Technical (Hospital) Services Ref Toxoplasmosis Ab Igg PX-3028677701 CDM 86777 CPT 302 RC inpatient 170 170 CIGNA 62308 [3081051] CIGNA 62308 [308105105] 134.61 percent of total billed charges 105.4 161.5 Technical (Hospital) Services Ref Toxoplasmosis Ab Igg PX-3028677701 CDM 86777 CPT 302 RC inpatient 170 170 CIGNA 62308 [3081051] CIGNA STATE OF WYOMING [308105107] 134.61 percent of total billed charges 105.4 161.5 Technical (Hospital) Services Ref Toxoplasmosis Ab Igg PX-3028677701 CDM 86777 CPT 302 RC inpatient 170 170 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES HDHP [308136802] 134.61 percent of total billed charges 105.4 161.5 Technical (Hospital) Services Ref Toxoplasmosis Ab Igg PX-3028677701 CDM 86777 CPT 302 RC inpatient 170 170 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES PPO [308136801] 134.61 percent of total billed charges 105.4 161.5 Technical (Hospital) Services Ref Toxoplasmosis Ab Igg PX-3028677701 CDM 86777 CPT 302 RC inpatient 170 170 UNITED HEALTHCARE (COMMERCIAL) [3081199] UNITED HEALTHCARE 87726 [308119901] 105.4 percent of total billed charges 105.4 161.5 Technical (Hospital) Services Ref Toxoplasmosis Ab Igg PX-3028677701 CDM 86777 CPT 302 RC outpatient 170 170 UNITED HEALTHCARE (COMMERCIAL) [3081199] UNITED HEALTHCARE 87726 [308119901] 105.4 percent of total billed charges 105.4 161.5 Technical (Hospital) Services Ref Toxoplasmosis Ab Igg PX-3028677701 CDM 86777 CPT 302 RC outpatient 170 170 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES PPO [308136801] 136 percent of total billed charges 105.4 161.5 Technical (Hospital) Services Ref Toxoplasmosis Ab Igg PX-3028677701 CDM 86777 CPT 302 RC outpatient 170 170 HEALTHPARTNERS SX009 HEALTHPARTNERS 136 percent of total billed charges 105.4 161.5 Technical (Hospital) Services Ref Toxoplasmosis Ab Igg PX-3028677701 CDM 86777 CPT 302 RC outpatient 170 170 MULTIPLAN INC 34080 [3081285] MULTIPLAN INC [308128501] 161.5 percent of total billed charges 105.4 161.5 Technical (Hospital) Services Ref Toxoplasmosis Ab Igg PX-3028677701 CDM 86777 CPT 302 RC outpatient 170 170 CIGNA 62308 [3081051] CIGNA 62308 [308105105] 136 percent of total billed charges 105.4 161.5 Technical (Hospital) Services Ref Toxoplasmosis Ab Igg PX-3028677701 CDM 86777 CPT 302 RC outpatient 170 170 CIGNA 62308 [3081051] CIGNA STATE OF WYOMING [308105107] 136 percent of total billed charges 105.4 161.5 Technical (Hospital) Services Ref Toxoplasmosis Ab Igg PX-3028677701 CDM 86777 CPT 302 RC outpatient 170 170 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES EPO [308136803] 136 percent of total billed charges 105.4 161.5 Technical (Hospital) Services Ref Toxoplasmosis Ab Igg PX-3028677701 CDM 86777 CPT 302 RC outpatient 170 170 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES HDHP [308136802] 136 percent of total billed charges 105.4 161.5 Technical (Hospital) Services Ref Toxoplasmosis Ab Igg PX-3028677701 CDM 86777 CPT 302 RC outpatient 170 170 BLUE CROSS BLUE SHIELD WELLMARK SB889 [3081026] BCBS WYOMING [308102603] 161.5 percent of total billed charges 105.4 161.5 Technical (Hospital) Services Ref Toxoplasmosis Ab Igg PX-3028677701 CDM 86777 CPT 302 RC outpatient 170 170 MEDICA (COMMERCIAL) 94265 [3081118] MEDICA CLAIMS [308111801] 153 percent of total billed charges 105.4 161.5 Technical (Hospital) Services "Ref Sars Coronavirus 2 Igg Ab, S (Mayo)" PX-3028676900 CDM 86769 CPT 302 RC outpatient 119 119 MULTIPLAN INC 34080 [3081285] MULTIPLAN INC [308128501] 113.05 percent of total billed charges 73.78 113.05 Technical (Hospital) Services "Ref Sars Coronavirus 2 Igg Ab, S (Mayo)" PX-3028676900 CDM 86769 CPT 302 RC outpatient 119 119 BLUE CROSS BLUE SHIELD WELLMARK SB889 [3081026] BCBS WYOMING [308102603] 113.05 percent of total billed charges 73.78 113.05 Technical (Hospital) Services "Ref Sars Coronavirus 2 Igg Ab, S (Mayo)" PX-3028676900 CDM 86769 CPT 302 RC outpatient 119 119 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES EPO [308136803] 95.2 percent of total billed charges 73.78 113.05 Technical (Hospital) Services "Ref Sars Coronavirus 2 Igg Ab, S (Mayo)" PX-3028676900 CDM 86769 CPT 302 RC outpatient 119 119 CIGNA 62308 [3081051] CIGNA 62308 [308105105] 95.2 percent of total billed charges 73.78 113.05 Technical (Hospital) Services "Ref Sars Coronavirus 2 Igg Ab, S (Mayo)" PX-3028676900 CDM 86769 CPT 302 RC outpatient 119 119 CIGNA 62308 [3081051] CIGNA STATE OF WYOMING [308105107] 95.2 percent of total billed charges 73.78 113.05 Technical (Hospital) Services "Ref Sars Coronavirus 2 Igg Ab, S (Mayo)" PX-3028676900 CDM 86769 CPT 302 RC outpatient 119 119 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES HDHP [308136802] 95.2 percent of total billed charges 73.78 113.05 Technical (Hospital) Services "Ref Sars Coronavirus 2 Igg Ab, S (Mayo)" PX-3028676900 CDM 86769 CPT 302 RC outpatient 119 119 UNITED HEALTHCARE (COMMERCIAL) [3081199] UNITED HEALTHCARE 87726 [308119901] 73.78 percent of total billed charges 73.78 113.05 Technical (Hospital) Services "Ref Sars Coronavirus 2 Igg Ab, S (Mayo)" PX-3028676900 CDM 86769 CPT 302 RC outpatient 119 119 HEALTHPARTNERS SX009 HEALTHPARTNERS 95.2 percent of total billed charges 73.78 113.05 Technical (Hospital) Services "Ref Sars Coronavirus 2 Igg Ab, S (Mayo)" PX-3028676900 CDM 86769 CPT 302 RC outpatient 119 119 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES PPO [308136801] 95.2 percent of total billed charges 73.78 113.05 Technical (Hospital) Services "Ref Sars Coronavirus 2 Igg Ab, S (Mayo)" PX-3028676900 CDM 86769 CPT 302 RC outpatient 119 119 MEDICA (COMMERCIAL) 94265 [3081118] MEDICA CLAIMS [308111801] 107.1 percent of total billed charges 73.78 113.05 Technical (Hospital) Services "Ref Sars Coronavirus 2 Igg Ab, S (Mayo)" PX-3028676900 CDM 86769 CPT 302 RC inpatient 119 119 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES EPO [308136803] 94.22 percent of total billed charges 73.78 113.05 Technical (Hospital) Services "Ref Sars Coronavirus 2 Igg Ab, S (Mayo)" PX-3028676900 CDM 86769 CPT 302 RC inpatient 119 119 HEALTHPARTNERS SX009 HEALTHPARTNERS 94.22 percent of total billed charges 73.78 113.05 Technical (Hospital) Services "Ref Sars Coronavirus 2 Igg Ab, S (Mayo)" PX-3028676900 CDM 86769 CPT 302 RC inpatient 119 119 MULTIPLAN INC 34080 [3081285] MULTIPLAN INC [308128501] 113.05 percent of total billed charges 73.78 113.05 Technical (Hospital) Services "Ref Sars Coronavirus 2 Igg Ab, S (Mayo)" PX-3028676900 CDM 86769 CPT 302 RC inpatient 119 119 CIGNA 62308 [3081051] CIGNA 62308 [308105105] 94.22 percent of total billed charges 73.78 113.05 Technical (Hospital) Services "Ref Sars Coronavirus 2 Igg Ab, S (Mayo)" PX-3028676900 CDM 86769 CPT 302 RC inpatient 119 119 CIGNA 62308 [3081051] CIGNA STATE OF WYOMING [308105107] 94.22 percent of total billed charges 73.78 113.05 Technical (Hospital) Services "Ref Sars Coronavirus 2 Igg Ab, S (Mayo)" PX-3028676900 CDM 86769 CPT 302 RC inpatient 119 119 BLUE CROSS BLUE SHIELD WELLMARK SB889 [3081026] BCBS WYOMING [308102603] 113.05 percent of total billed charges 73.78 113.05 Technical (Hospital) Services "Ref Sars Coronavirus 2 Igg Ab, S (Mayo)" PX-3028676900 CDM 86769 CPT 302 RC inpatient 119 119 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES PPO [308136801] 94.22 percent of total billed charges 73.78 113.05 Technical (Hospital) Services "Ref Sars Coronavirus 2 Igg Ab, S (Mayo)" PX-3028676900 CDM 86769 CPT 302 RC inpatient 119 119 UNITED HEALTHCARE (COMMERCIAL) [3081199] UNITED HEALTHCARE 87726 [308119901] 73.78 percent of total billed charges 73.78 113.05 Technical (Hospital) Services "Ref Sars Coronavirus 2 Igg Ab, S (Mayo)" PX-3028676900 CDM 86769 CPT 302 RC inpatient 119 119 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES HDHP [308136802] 94.22 percent of total billed charges 73.78 113.05 Technical (Hospital) Services "Ref Sars Coronavirus 2 Igg Ab, S (Mayo)" PX-3028676900 CDM 86769 CPT 302 RC inpatient 119 119 MEDICA (COMMERCIAL) 94265 [3081118] MEDICA CLAIMS [308111801] 107.1 percent of total billed charges 73.78 113.05 Technical (Hospital) Services Antibody: Severe Acute Respiratory Syndrome Coronavirus 2 (Sar-Cov-2) Covid-19 PX-3028676901 CDM 86769 CPT 302 RC inpatient 119 119 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES PPO [308136801] 94.22 percent of total billed charges 73.78 113.05 Technical (Hospital) Services Antibody: Severe Acute Respiratory Syndrome Coronavirus 2 (Sar-Cov-2) Covid-19 PX-3028676901 CDM 86769 CPT 302 RC inpatient 119 119 UNITED HEALTHCARE (COMMERCIAL) [3081199] UNITED HEALTHCARE 87726 [308119901] 73.78 percent of total billed charges 73.78 113.05 Technical (Hospital) Services Antibody: Severe Acute Respiratory Syndrome Coronavirus 2 (Sar-Cov-2) Covid-19 PX-3028676901 CDM 86769 CPT 302 RC inpatient 119 119 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES HDHP [308136802] 94.22 percent of total billed charges 73.78 113.05 Technical (Hospital) Services Antibody: Severe Acute Respiratory Syndrome Coronavirus 2 (Sar-Cov-2) Covid-19 PX-3028676901 CDM 86769 CPT 302 RC inpatient 119 119 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES EPO [308136803] 94.22 percent of total billed charges 73.78 113.05 Technical (Hospital) Services Antibody: Severe Acute Respiratory Syndrome Coronavirus 2 (Sar-Cov-2) Covid-19 PX-3028676901 CDM 86769 CPT 302 RC inpatient 119 119 HEALTHPARTNERS SX009 HEALTHPARTNERS 94.22 percent of total billed charges 73.78 113.05 Technical (Hospital) Services Antibody: Severe Acute Respiratory Syndrome Coronavirus 2 (Sar-Cov-2) Covid-19 PX-3028676901 CDM 86769 CPT 302 RC outpatient 119 119 HEALTHPARTNERS SX009 HEALTHPARTNERS 95.2 percent of total billed charges 73.78 113.05 Technical (Hospital) Services Antibody: Severe Acute Respiratory Syndrome Coronavirus 2 (Sar-Cov-2) Covid-19 PX-3028676901 CDM 86769 CPT 302 RC outpatient 119 119 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES PPO [308136801] 95.2 percent of total billed charges 73.78 113.05 Technical (Hospital) Services Antibody: Severe Acute Respiratory Syndrome Coronavirus 2 (Sar-Cov-2) Covid-19 PX-3028676901 CDM 86769 CPT 302 RC outpatient 119 119 UNITED HEALTHCARE (COMMERCIAL) [3081199] UNITED HEALTHCARE 87726 [308119901] 73.78 percent of total billed charges 73.78 113.05 Technical (Hospital) Services Antibody: Severe Acute Respiratory Syndrome Coronavirus 2 (Sar-Cov-2) Covid-19 PX-3028676901 CDM 86769 CPT 302 RC inpatient 119 119 CIGNA 62308 [3081051] CIGNA 62308 [308105105] 94.22 percent of total billed charges 73.78 113.05 Technical (Hospital) Services Antibody: Severe Acute Respiratory Syndrome Coronavirus 2 (Sar-Cov-2) Covid-19 PX-3028676901 CDM 86769 CPT 302 RC inpatient 119 119 CIGNA 62308 [3081051] CIGNA STATE OF WYOMING [308105107] 94.22 percent of total billed charges 73.78 113.05 Technical (Hospital) Services Antibody: Severe Acute Respiratory Syndrome Coronavirus 2 (Sar-Cov-2) Covid-19 PX-3028676901 CDM 86769 CPT 302 RC inpatient 119 119 BLUE CROSS BLUE SHIELD WELLMARK SB889 [3081026] BCBS WYOMING [308102603] 113.05 percent of total billed charges 73.78 113.05 Technical (Hospital) Services Antibody: Severe Acute Respiratory Syndrome Coronavirus 2 (Sar-Cov-2) Covid-19 PX-3028676901 CDM 86769 CPT 302 RC inpatient 119 119 MULTIPLAN INC 34080 [3081285] MULTIPLAN INC [308128501] 113.05 percent of total billed charges 73.78 113.05 Technical (Hospital) Services Antibody: Severe Acute Respiratory Syndrome Coronavirus 2 (Sar-Cov-2) Covid-19 PX-3028676901 CDM 86769 CPT 302 RC inpatient 119 119 MEDICA (COMMERCIAL) 94265 [3081118] MEDICA CLAIMS [308111801] 107.1 percent of total billed charges 73.78 113.05 Technical (Hospital) Services Antibody: Severe Acute Respiratory Syndrome Coronavirus 2 (Sar-Cov-2) Covid-19 PX-3028676901 CDM 86769 CPT 302 RC outpatient 119 119 BLUE CROSS BLUE SHIELD WELLMARK SB889 [3081026] BCBS WYOMING [308102603] 113.05 percent of total billed charges 73.78 113.05 Technical (Hospital) Services Antibody: Severe Acute Respiratory Syndrome Coronavirus 2 (Sar-Cov-2) Covid-19 PX-3028676901 CDM 86769 CPT 302 RC outpatient 119 119 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES HDHP [308136802] 95.2 percent of total billed charges 73.78 113.05 Technical (Hospital) Services Antibody: Severe Acute Respiratory Syndrome Coronavirus 2 (Sar-Cov-2) Covid-19 PX-3028676901 CDM 86769 CPT 302 RC outpatient 119 119 CIGNA 62308 [3081051] CIGNA 62308 [308105105] 95.2 percent of total billed charges 73.78 113.05 Technical (Hospital) Services Antibody: Severe Acute Respiratory Syndrome Coronavirus 2 (Sar-Cov-2) Covid-19 PX-3028676901 CDM 86769 CPT 302 RC outpatient 119 119 CIGNA 62308 [3081051] CIGNA STATE OF WYOMING [308105107] 95.2 percent of total billed charges 73.78 113.05 Technical (Hospital) Services Antibody: Severe Acute Respiratory Syndrome Coronavirus 2 (Sar-Cov-2) Covid-19 PX-3028676901 CDM 86769 CPT 302 RC outpatient 119 119 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES EPO [308136803] 95.2 percent of total billed charges 73.78 113.05 Technical (Hospital) Services Antibody: Severe Acute Respiratory Syndrome Coronavirus 2 (Sar-Cov-2) Covid-19 PX-3028676901 CDM 86769 CPT 302 RC outpatient 119 119 MULTIPLAN INC 34080 [3081285] MULTIPLAN INC [308128501] 113.05 percent of total billed charges 73.78 113.05 Technical (Hospital) Services Antibody: Severe Acute Respiratory Syndrome Coronavirus 2 (Sar-Cov-2) Covid-19 PX-3028676901 CDM 86769 CPT 302 RC outpatient 119 119 MEDICA (COMMERCIAL) 94265 [3081118] MEDICA CLAIMS [308111801] 107.1 percent of total billed charges 73.78 113.05 Technical (Hospital) Services Rubeola PX-3028676500 CDM 86765 CPT 302 RC outpatient 214 214 HEALTHPARTNERS SX009 HEALTHPARTNERS 171.2 percent of total billed charges 132.68 203.3 Technical (Hospital) Services Rubeola PX-3028676500 CDM 86765 CPT 302 RC outpatient 214 214 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES PPO [308136801] 171.2 percent of total billed charges 132.68 203.3 Technical (Hospital) Services Rubeola PX-3028676500 CDM 86765 CPT 302 RC outpatient 214 214 UNITED HEALTHCARE (COMMERCIAL) [3081199] UNITED HEALTHCARE 87726 [308119901] 132.68 percent of total billed charges 132.68 203.3 Technical (Hospital) Services Rubeola PX-3028676500 CDM 86765 CPT 302 RC outpatient 214 214 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES HDHP [308136802] 171.2 percent of total billed charges 132.68 203.3 Technical (Hospital) Services Rubeola PX-3028676500 CDM 86765 CPT 302 RC outpatient 214 214 BLUE CROSS BLUE SHIELD WELLMARK SB889 [3081026] BCBS WYOMING [308102603] 203.3 percent of total billed charges 132.68 203.3 Technical (Hospital) Services Rubeola PX-3028676500 CDM 86765 CPT 302 RC outpatient 214 214 MULTIPLAN INC 34080 [3081285] MULTIPLAN INC [308128501] 203.3 percent of total billed charges 132.68 203.3 Technical (Hospital) Services Rubeola PX-3028676500 CDM 86765 CPT 302 RC outpatient 214 214 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES EPO [308136803] 171.2 percent of total billed charges 132.68 203.3 Technical (Hospital) Services Rubeola PX-3028676500 CDM 86765 CPT 302 RC outpatient 214 214 CIGNA 62308 [3081051] CIGNA 62308 [308105105] 171.2 percent of total billed charges 132.68 203.3 Technical (Hospital) Services Rubeola PX-3028676500 CDM 86765 CPT 302 RC outpatient 214 214 CIGNA 62308 [3081051] CIGNA STATE OF WYOMING [308105107] 171.2 percent of total billed charges 132.68 203.3 Technical (Hospital) Services Rubeola PX-3028676500 CDM 86765 CPT 302 RC outpatient 214 214 MEDICA (COMMERCIAL) 94265 [3081118] MEDICA CLAIMS [308111801] 192.6 percent of total billed charges 132.68 203.3 Technical (Hospital) Services Rubeola PX-3028676500 CDM 86765 CPT 302 RC inpatient 214 214 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES HDHP [308136802] 169.45 percent of total billed charges 132.68 203.3 Technical (Hospital) Services Rubeola PX-3028676500 CDM 86765 CPT 302 RC inpatient 214 214 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES PPO [308136801] 169.45 percent of total billed charges 132.68 203.3 Technical (Hospital) Services Rubeola PX-3028676500 CDM 86765 CPT 302 RC inpatient 214 214 UNITED HEALTHCARE (COMMERCIAL) [3081199] UNITED HEALTHCARE 87726 [308119901] 132.68 percent of total billed charges 132.68 203.3 Technical (Hospital) Services Rubeola PX-3028676500 CDM 86765 CPT 302 RC inpatient 214 214 HEALTHPARTNERS SX009 HEALTHPARTNERS 169.45 percent of total billed charges 132.68 203.3 Technical (Hospital) Services Rubeola PX-3028676500 CDM 86765 CPT 302 RC inpatient 214 214 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES EPO [308136803] 169.45 percent of total billed charges 132.68 203.3 Technical (Hospital) Services Rubeola PX-3028676500 CDM 86765 CPT 302 RC inpatient 214 214 CIGNA 62308 [3081051] CIGNA STATE OF WYOMING [308105107] 169.45 percent of total billed charges 132.68 203.3 Technical (Hospital) Services Rubeola PX-3028676500 CDM 86765 CPT 302 RC inpatient 214 214 CIGNA 62308 [3081051] CIGNA 62308 [308105105] 169.45 percent of total billed charges 132.68 203.3 Technical (Hospital) Services Rubeola PX-3028676500 CDM 86765 CPT 302 RC inpatient 214 214 BLUE CROSS BLUE SHIELD WELLMARK SB889 [3081026] BCBS WYOMING [308102603] 203.3 percent of total billed charges 132.68 203.3 Technical (Hospital) Services Rubeola PX-3028676500 CDM 86765 CPT 302 RC inpatient 214 214 MULTIPLAN INC 34080 [3081285] MULTIPLAN INC [308128501] 203.3 percent of total billed charges 132.68 203.3 Technical (Hospital) Services Rubeola PX-3028676500 CDM 86765 CPT 302 RC inpatient 214 214 MEDICA (COMMERCIAL) 94265 [3081118] MEDICA CLAIMS [308111801] 192.6 percent of total billed charges 132.68 203.3 Technical (Hospital) Services Rubella PX-3028676200 CDM 86762 CPT 302 RC outpatient 108 108 MEDICA (COMMERCIAL) 94265 [3081118] MEDICA CLAIMS [308111801] 97.2 percent of total billed charges 66.96 102.6 Technical (Hospital) Services Rubella PX-3028676200 CDM 86762 CPT 302 RC outpatient 108 108 UNITED HEALTHCARE (COMMERCIAL) [3081199] UNITED HEALTHCARE 87726 [308119901] 66.96 percent of total billed charges 66.96 102.6 Technical (Hospital) Services Rubella PX-3028676200 CDM 86762 CPT 302 RC outpatient 108 108 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES PPO [308136801] 86.4 percent of total billed charges 66.96 102.6 Technical (Hospital) Services Rubella PX-3028676200 CDM 86762 CPT 302 RC outpatient 108 108 HEALTHPARTNERS SX009 HEALTHPARTNERS 86.4 percent of total billed charges 66.96 102.6 Technical (Hospital) Services Rubella PX-3028676200 CDM 86762 CPT 302 RC outpatient 108 108 BLUE CROSS BLUE SHIELD WELLMARK SB889 [3081026] BCBS WYOMING [308102603] 102.6 percent of total billed charges 66.96 102.6 Technical (Hospital) Services Rubella PX-3028676200 CDM 86762 CPT 302 RC outpatient 108 108 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES HDHP [308136802] 86.4 percent of total billed charges 66.96 102.6 Technical (Hospital) Services Rubella PX-3028676200 CDM 86762 CPT 302 RC outpatient 108 108 CIGNA 62308 [3081051] CIGNA 62308 [308105105] 86.4 percent of total billed charges 66.96 102.6 Technical (Hospital) Services Rubella PX-3028676200 CDM 86762 CPT 302 RC outpatient 108 108 CIGNA 62308 [3081051] CIGNA STATE OF WYOMING [308105107] 86.4 percent of total billed charges 66.96 102.6 Technical (Hospital) Services Rubella PX-3028676200 CDM 86762 CPT 302 RC outpatient 108 108 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES EPO [308136803] 86.4 percent of total billed charges 66.96 102.6 Technical (Hospital) Services Rubella PX-3028676200 CDM 86762 CPT 302 RC outpatient 108 108 MULTIPLAN INC 34080 [3081285] MULTIPLAN INC [308128501] 102.6 percent of total billed charges 66.96 102.6 Technical (Hospital) Services Rubella PX-3028676200 CDM 86762 CPT 302 RC inpatient 108 108 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES HDHP [308136802] 85.51 percent of total billed charges 66.96 102.6 Technical (Hospital) Services Rubella PX-3028676200 CDM 86762 CPT 302 RC inpatient 108 108 UNITED HEALTHCARE (COMMERCIAL) [3081199] UNITED HEALTHCARE 87726 [308119901] 66.96 percent of total billed charges 66.96 102.6 Technical (Hospital) Services Rubella PX-3028676200 CDM 86762 CPT 302 RC inpatient 108 108 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES PPO [308136801] 85.51 percent of total billed charges 66.96 102.6 Technical (Hospital) Services Rubella PX-3028676200 CDM 86762 CPT 302 RC inpatient 108 108 BLUE CROSS BLUE SHIELD WELLMARK SB889 [3081026] BCBS WYOMING [308102603] 102.6 percent of total billed charges 66.96 102.6 Technical (Hospital) Services Rubella PX-3028676200 CDM 86762 CPT 302 RC inpatient 108 108 HEALTHPARTNERS SX009 HEALTHPARTNERS 85.51 percent of total billed charges 66.96 102.6 Technical (Hospital) Services Rubella PX-3028676200 CDM 86762 CPT 302 RC inpatient 108 108 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES EPO [308136803] 85.51 percent of total billed charges 66.96 102.6 Technical (Hospital) Services Rubella PX-3028676200 CDM 86762 CPT 302 RC inpatient 108 108 MEDICA (COMMERCIAL) 94265 [3081118] MEDICA CLAIMS [308111801] 97.2 percent of total billed charges 66.96 102.6 Technical (Hospital) Services Rubella PX-3028676200 CDM 86762 CPT 302 RC inpatient 108 108 MULTIPLAN INC 34080 [3081285] MULTIPLAN INC [308128501] 102.6 percent of total billed charges 66.96 102.6 Technical (Hospital) Services Rubella PX-3028676200 CDM 86762 CPT 302 RC inpatient 108 108 CIGNA 62308 [3081051] CIGNA 62308 [308105105] 85.51 percent of total billed charges 66.96 102.6 Technical (Hospital) Services Rubella PX-3028676200 CDM 86762 CPT 302 RC inpatient 108 108 CIGNA 62308 [3081051] CIGNA STATE OF WYOMING [308105107] 85.51 percent of total billed charges 66.96 102.6 Technical (Hospital) Services Ref Typhus Antibody Igg or Igm PX-3028675701 CDM 86757 CPT 302 RC outpatient 182 182 MULTIPLAN INC 34080 [3081285] MULTIPLAN INC [308128501] 172.9 percent of total billed charges 112.84 172.9 Technical (Hospital) Services Ref Typhus Antibody Igg or Igm PX-3028675701 CDM 86757 CPT 302 RC outpatient 182 182 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES EPO [308136803] 145.6 percent of total billed charges 112.84 172.9 Technical (Hospital) Services Ref Typhus Antibody Igg or Igm PX-3028675701 CDM 86757 CPT 302 RC outpatient 182 182 CIGNA 62308 [3081051] CIGNA 62308 [308105105] 145.6 percent of total billed charges 112.84 172.9 Technical (Hospital) Services Ref Typhus Antibody Igg or Igm PX-3028675701 CDM 86757 CPT 302 RC outpatient 182 182 CIGNA 62308 [3081051] CIGNA STATE OF WYOMING [308105107] 145.6 percent of total billed charges 112.84 172.9 Technical (Hospital) Services Ref Typhus Antibody Igg or Igm PX-3028675701 CDM 86757 CPT 302 RC outpatient 182 182 BLUE CROSS BLUE SHIELD WELLMARK SB889 [3081026] BCBS WYOMING [308102603] 172.9 percent of total billed charges 112.84 172.9 Technical (Hospital) Services Ref Typhus Antibody Igg or Igm PX-3028675701 CDM 86757 CPT 302 RC outpatient 182 182 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES HDHP [308136802] 145.6 percent of total billed charges 112.84 172.9 Technical (Hospital) Services Ref Typhus Antibody Igg or Igm PX-3028675701 CDM 86757 CPT 302 RC outpatient 182 182 UNITED HEALTHCARE (COMMERCIAL) [3081199] UNITED HEALTHCARE 87726 [308119901] 112.84 percent of total billed charges 112.84 172.9 Technical (Hospital) Services Ref Typhus Antibody Igg or Igm PX-3028675701 CDM 86757 CPT 302 RC outpatient 182 182 HEALTHPARTNERS SX009 HEALTHPARTNERS 145.6 percent of total billed charges 112.84 172.9 Technical (Hospital) Services Ref Typhus Antibody Igg or Igm PX-3028675701 CDM 86757 CPT 302 RC outpatient 182 182 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES PPO [308136801] 145.6 percent of total billed charges 112.84 172.9 Technical (Hospital) Services Ref Typhus Antibody Igg or Igm PX-3028675701 CDM 86757 CPT 302 RC outpatient 182 182 MEDICA (COMMERCIAL) 94265 [3081118] MEDICA CLAIMS [308111801] 163.8 percent of total billed charges 112.84 172.9 Technical (Hospital) Services Ref Typhus Antibody Igg or Igm PX-3028675701 CDM 86757 CPT 302 RC inpatient 182 182 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES EPO [308136803] 144.11 percent of total billed charges 112.84 172.9 Technical (Hospital) Services Ref Typhus Antibody Igg or Igm PX-3028675701 CDM 86757 CPT 302 RC inpatient 182 182 HEALTHPARTNERS SX009 HEALTHPARTNERS 144.11 percent of total billed charges 112.84 172.9 Technical (Hospital) Services Ref Typhus Antibody Igg or Igm PX-3028675701 CDM 86757 CPT 302 RC inpatient 182 182 BLUE CROSS BLUE SHIELD WELLMARK SB889 [3081026] BCBS WYOMING [308102603] 172.9 percent of total billed charges 112.84 172.9 Technical (Hospital) Services Ref Typhus Antibody Igg or Igm PX-3028675701 CDM 86757 CPT 302 RC inpatient 182 182 CIGNA 62308 [3081051] CIGNA 62308 [308105105] 144.11 percent of total billed charges 112.84 172.9 Technical (Hospital) Services Ref Typhus Antibody Igg or Igm PX-3028675701 CDM 86757 CPT 302 RC inpatient 182 182 CIGNA 62308 [3081051] CIGNA STATE OF WYOMING [308105107] 144.11 percent of total billed charges 112.84 172.9 Technical (Hospital) Services Ref Typhus Antibody Igg or Igm PX-3028675701 CDM 86757 CPT 302 RC inpatient 182 182 MULTIPLAN INC 34080 [3081285] MULTIPLAN INC [308128501] 172.9 percent of total billed charges 112.84 172.9 Technical (Hospital) Services Ref Typhus Antibody Igg or Igm PX-3028675701 CDM 86757 CPT 302 RC inpatient 182 182 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES PPO [308136801] 144.11 percent of total billed charges 112.84 172.9 Technical (Hospital) Services Ref Typhus Antibody Igg or Igm PX-3028675701 CDM 86757 CPT 302 RC inpatient 182 182 UNITED HEALTHCARE (COMMERCIAL) [3081199] UNITED HEALTHCARE 87726 [308119901] 112.84 percent of total billed charges 112.84 172.9 Technical (Hospital) Services Ref Typhus Antibody Igg or Igm PX-3028675701 CDM 86757 CPT 302 RC inpatient 182 182 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES HDHP [308136802] 144.11 percent of total billed charges 112.84 172.9 Technical (Hospital) Services Ref Typhus Antibody Igg or Igm PX-3028675701 CDM 86757 CPT 302 RC inpatient 182 182 MEDICA (COMMERCIAL) 94265 [3081118] MEDICA CLAIMS [308111801] 163.8 percent of total billed charges 112.84 172.9 Technical (Hospital) Services Ref Parvovirus B19 Ab Igg or Igm PX-3028674701 CDM 86747 CPT 302 RC outpatient 212 212 BLUE CROSS BLUE SHIELD WELLMARK SB889 [3081026] BCBS WYOMING [308102603] 201.4 percent of total billed charges 131.44 201.4 Technical (Hospital) Services Ref Parvovirus B19 Ab Igg or Igm PX-3028674701 CDM 86747 CPT 302 RC outpatient 212 212 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES HDHP [308136802] 169.6 percent of total billed charges 131.44 201.4 Technical (Hospital) Services Ref Parvovirus B19 Ab Igg or Igm PX-3028674701 CDM 86747 CPT 302 RC outpatient 212 212 CIGNA 62308 [3081051] CIGNA 62308 [308105105] 169.6 percent of total billed charges 131.44 201.4 Technical (Hospital) Services Ref Parvovirus B19 Ab Igg or Igm PX-3028674701 CDM 86747 CPT 302 RC outpatient 212 212 CIGNA 62308 [3081051] CIGNA STATE OF WYOMING [308105107] 169.6 percent of total billed charges 131.44 201.4 Technical (Hospital) Services Ref Parvovirus B19 Ab Igg or Igm PX-3028674701 CDM 86747 CPT 302 RC outpatient 212 212 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES EPO [308136803] 169.6 percent of total billed charges 131.44 201.4 Technical (Hospital) Services Ref Parvovirus B19 Ab Igg or Igm PX-3028674701 CDM 86747 CPT 302 RC outpatient 212 212 MULTIPLAN INC 34080 [3081285] MULTIPLAN INC [308128501] 201.4 percent of total billed charges 131.44 201.4 Technical (Hospital) Services Ref Parvovirus B19 Ab Igg or Igm PX-3028674701 CDM 86747 CPT 302 RC outpatient 212 212 HEALTHPARTNERS SX009 HEALTHPARTNERS 169.6 percent of total billed charges 131.44 201.4 Technical (Hospital) Services Ref Parvovirus B19 Ab Igg or Igm PX-3028674701 CDM 86747 CPT 302 RC outpatient 212 212 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES PPO [308136801] 169.6 percent of total billed charges 131.44 201.4 Technical (Hospital) Services Ref Parvovirus B19 Ab Igg or Igm PX-3028674701 CDM 86747 CPT 302 RC outpatient 212 212 UNITED HEALTHCARE (COMMERCIAL) [3081199] UNITED HEALTHCARE 87726 [308119901] 131.44 percent of total billed charges 131.44 201.4 Technical (Hospital) Services Ref Parvovirus B19 Ab Igg or Igm PX-3028674701 CDM 86747 CPT 302 RC outpatient 212 212 MEDICA (COMMERCIAL) 94265 [3081118] MEDICA CLAIMS [308111801] 190.8 percent of total billed charges 131.44 201.4 Technical (Hospital) Services Ref Parvovirus B19 Ab Igg or Igm PX-3028674701 CDM 86747 CPT 302 RC inpatient 212 212 UNITED HEALTHCARE (COMMERCIAL) [3081199] UNITED HEALTHCARE 87726 [308119901] 131.44 percent of total billed charges 131.44 201.4 Technical (Hospital) Services Ref Parvovirus B19 Ab Igg or Igm PX-3028674701 CDM 86747 CPT 302 RC inpatient 212 212 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES PPO [308136801] 167.86 percent of total billed charges 131.44 201.4 Technical (Hospital) Services Ref Parvovirus B19 Ab Igg or Igm PX-3028674701 CDM 86747 CPT 302 RC inpatient 212 212 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES HDHP [308136802] 167.86 percent of total billed charges 131.44 201.4 Technical (Hospital) Services Ref Parvovirus B19 Ab Igg or Igm PX-3028674701 CDM 86747 CPT 302 RC inpatient 212 212 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES EPO [308136803] 167.86 percent of total billed charges 131.44 201.4 Technical (Hospital) Services Ref Parvovirus B19 Ab Igg or Igm PX-3028674701 CDM 86747 CPT 302 RC inpatient 212 212 BLUE CROSS BLUE SHIELD WELLMARK SB889 [3081026] BCBS WYOMING [308102603] 201.4 percent of total billed charges 131.44 201.4 Technical (Hospital) Services Ref Parvovirus B19 Ab Igg or Igm PX-3028674701 CDM 86747 CPT 302 RC inpatient 212 212 HEALTHPARTNERS SX009 HEALTHPARTNERS 167.86 percent of total billed charges 131.44 201.4 Technical (Hospital) Services Ref Parvovirus B19 Ab Igg or Igm PX-3028674701 CDM 86747 CPT 302 RC inpatient 212 212 CIGNA 62308 [3081051] CIGNA 62308 [308105105] 167.86 percent of total billed charges 131.44 201.4 Technical (Hospital) Services Ref Parvovirus B19 Ab Igg or Igm PX-3028674701 CDM 86747 CPT 302 RC inpatient 212 212 CIGNA 62308 [3081051] CIGNA STATE OF WYOMING [308105107] 167.86 percent of total billed charges 131.44 201.4 Technical (Hospital) Services Ref Parvovirus B19 Ab Igg or Igm PX-3028674701 CDM 86747 CPT 302 RC inpatient 212 212 MULTIPLAN INC 34080 [3081285] MULTIPLAN INC [308128501] 201.4 percent of total billed charges 131.44 201.4 Technical (Hospital) Services Ref Parvovirus B19 Ab Igg or Igm PX-3028674701 CDM 86747 CPT 302 RC inpatient 212 212 MEDICA (COMMERCIAL) 94265 [3081118] MEDICA CLAIMS [308111801] 190.8 percent of total billed charges 131.44 201.4 Technical (Hospital) Services Ref Mycoplasma Pneumo Igg or Igm PX-3028673801 CDM 86738 CPT 302 RC outpatient 182 182 MULTIPLAN INC 34080 [3081285] MULTIPLAN INC [308128501] 172.9 percent of total billed charges 112.84 172.9 Technical (Hospital) Services Ref Mycoplasma Pneumo Igg or Igm PX-3028673801 CDM 86738 CPT 302 RC outpatient 182 182 UNITED HEALTHCARE (COMMERCIAL) [3081199] UNITED HEALTHCARE 87726 [308119901] 112.84 percent of total billed charges 112.84 172.9 Technical (Hospital) Services Ref Mycoplasma Pneumo Igg or Igm PX-3028673801 CDM 86738 CPT 302 RC outpatient 182 182 BLUE CROSS BLUE SHIELD WELLMARK SB889 [3081026] BCBS WYOMING [308102603] 172.9 percent of total billed charges 112.84 172.9 Technical (Hospital) Services Ref Mycoplasma Pneumo Igg or Igm PX-3028673801 CDM 86738 CPT 302 RC outpatient 182 182 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES HDHP [308136802] 145.6 percent of total billed charges 112.84 172.9 Technical (Hospital) Services Ref Mycoplasma Pneumo Igg or Igm PX-3028673801 CDM 86738 CPT 302 RC outpatient 182 182 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES PPO [308136801] 145.6 percent of total billed charges 112.84 172.9 Technical (Hospital) Services Ref Mycoplasma Pneumo Igg or Igm PX-3028673801 CDM 86738 CPT 302 RC outpatient 182 182 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES EPO [308136803] 145.6 percent of total billed charges 112.84 172.9 Technical (Hospital) Services Ref Mycoplasma Pneumo Igg or Igm PX-3028673801 CDM 86738 CPT 302 RC outpatient 182 182 HEALTHPARTNERS SX009 HEALTHPARTNERS 145.6 percent of total billed charges 112.84 172.9 Technical (Hospital) Services Ref Mycoplasma Pneumo Igg or Igm PX-3028673801 CDM 86738 CPT 302 RC outpatient 182 182 MEDICA (COMMERCIAL) 94265 [3081118] MEDICA CLAIMS [308111801] 163.8 percent of total billed charges 112.84 172.9 Technical (Hospital) Services Ref Mycoplasma Pneumo Igg or Igm PX-3028673801 CDM 86738 CPT 302 RC outpatient 182 182 CIGNA 62308 [3081051] CIGNA 62308 [308105105] 145.6 percent of total billed charges 112.84 172.9 Technical (Hospital) Services Ref Mycoplasma Pneumo Igg or Igm PX-3028673801 CDM 86738 CPT 302 RC outpatient 182 182 CIGNA 62308 [3081051] CIGNA STATE OF WYOMING [308105107] 145.6 percent of total billed charges 112.84 172.9 Technical (Hospital) Services Ref Mycoplasma Pneumo Igg or Igm PX-3028673801 CDM 86738 CPT 302 RC inpatient 182 182 MEDICA (COMMERCIAL) 94265 [3081118] MEDICA CLAIMS [308111801] 163.8 percent of total billed charges 112.84 172.9 Technical (Hospital) Services Ref Mycoplasma Pneumo Igg or Igm PX-3028673801 CDM 86738 CPT 302 RC inpatient 182 182 MULTIPLAN INC 34080 [3081285] MULTIPLAN INC [308128501] 172.9 percent of total billed charges 112.84 172.9 Technical (Hospital) Services Ref Mycoplasma Pneumo Igg or Igm PX-3028673801 CDM 86738 CPT 302 RC inpatient 182 182 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES HDHP [308136802] 144.11 percent of total billed charges 112.84 172.9 Technical (Hospital) Services Ref Mycoplasma Pneumo Igg or Igm PX-3028673801 CDM 86738 CPT 302 RC inpatient 182 182 HEALTHPARTNERS SX009 HEALTHPARTNERS 144.11 percent of total billed charges 112.84 172.9 Technical (Hospital) Services Ref Mycoplasma Pneumo Igg or Igm PX-3028673801 CDM 86738 CPT 302 RC inpatient 182 182 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES PPO [308136801] 144.11 percent of total billed charges 112.84 172.9 Technical (Hospital) Services Ref Mycoplasma Pneumo Igg or Igm PX-3028673801 CDM 86738 CPT 302 RC inpatient 182 182 BLUE CROSS BLUE SHIELD WELLMARK SB889 [3081026] BCBS WYOMING [308102603] 172.9 percent of total billed charges 112.84 172.9 Technical (Hospital) Services Ref Mycoplasma Pneumo Igg or Igm PX-3028673801 CDM 86738 CPT 302 RC inpatient 182 182 UNITED HEALTHCARE (COMMERCIAL) [3081199] UNITED HEALTHCARE 87726 [308119901] 112.84 percent of total billed charges 112.84 172.9 Technical (Hospital) Services Ref Mycoplasma Pneumo Igg or Igm PX-3028673801 CDM 86738 CPT 302 RC inpatient 182 182 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES EPO [308136803] 144.11 percent of total billed charges 112.84 172.9 Technical (Hospital) Services Ref Mycoplasma Pneumo Igg or Igm PX-3028673801 CDM 86738 CPT 302 RC inpatient 182 182 CIGNA 62308 [3081051] CIGNA 62308 [308105105] 144.11 percent of total billed charges 112.84 172.9 Technical (Hospital) Services Ref Mycoplasma Pneumo Igg or Igm PX-3028673801 CDM 86738 CPT 302 RC inpatient 182 182 CIGNA 62308 [3081051] CIGNA STATE OF WYOMING [308105107] 144.11 percent of total billed charges 112.84 172.9 Technical (Hospital) Services "Ref M. Pneumoniae Ab, Igm, S by Ifa" PX-3028673803 CDM 86738 CPT 302 RC inpatient 197 197 UNITED HEALTHCARE (COMMERCIAL) [3081199] UNITED HEALTHCARE 87726 [308119901] 122.14 percent of total billed charges 122.14 187.15 Technical (Hospital) Services "Ref M. Pneumoniae Ab, Igm, S by Ifa" PX-3028673803 CDM 86738 CPT 302 RC inpatient 197 197 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES PPO [308136801] 155.98 percent of total billed charges 122.14 187.15 Technical (Hospital) Services "Ref M. Pneumoniae Ab, Igm, S by Ifa" PX-3028673803 CDM 86738 CPT 302 RC inpatient 197 197 MEDICA (COMMERCIAL) 94265 [3081118] MEDICA CLAIMS [308111801] 177.3 percent of total billed charges 122.14 187.15 Technical (Hospital) Services "Ref M. Pneumoniae Ab, Igm, S by Ifa" PX-3028673803 CDM 86738 CPT 302 RC inpatient 197 197 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES HDHP [308136802] 155.98 percent of total billed charges 122.14 187.15 Technical (Hospital) Services "Ref M. Pneumoniae Ab, Igm, S by Ifa" PX-3028673803 CDM 86738 CPT 302 RC inpatient 197 197 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES EPO [308136803] 155.98 percent of total billed charges 122.14 187.15 Technical (Hospital) Services "Ref M. Pneumoniae Ab, Igm, S by Ifa" PX-3028673803 CDM 86738 CPT 302 RC inpatient 197 197 HEALTHPARTNERS SX009 HEALTHPARTNERS 155.98 percent of total billed charges 122.14 187.15 Technical (Hospital) Services "Ref M. Pneumoniae Ab, Igm, S by Ifa" PX-3028673803 CDM 86738 CPT 302 RC inpatient 197 197 MULTIPLAN INC 34080 [3081285] MULTIPLAN INC [308128501] 187.15 percent of total billed charges 122.14 187.15 Technical (Hospital) Services "Ref M. Pneumoniae Ab, Igm, S by Ifa" PX-3028673803 CDM 86738 CPT 302 RC inpatient 197 197 BLUE CROSS BLUE SHIELD WELLMARK SB889 [3081026] BCBS WYOMING [308102603] 187.15 percent of total billed charges 122.14 187.15 Technical (Hospital) Services "Ref M. Pneumoniae Ab, Igm, S by Ifa" PX-3028673803 CDM 86738 CPT 302 RC inpatient 197 197 CIGNA 62308 [3081051] CIGNA 62308 [308105105] 155.98 percent of total billed charges 122.14 187.15 Technical (Hospital) Services "Ref M. Pneumoniae Ab, Igm, S by Ifa" PX-3028673803 CDM 86738 CPT 302 RC inpatient 197 197 CIGNA 62308 [3081051] CIGNA STATE OF WYOMING [308105107] 155.98 percent of total billed charges 122.14 187.15 Technical (Hospital) Services "Ref M. Pneumoniae Ab, Igm, S by Ifa" PX-3028673803 CDM 86738 CPT 302 RC outpatient 197 197 BLUE CROSS BLUE SHIELD WELLMARK SB889 [3081026] BCBS WYOMING [308102603] 187.15 percent of total billed charges 122.14 187.15 Technical (Hospital) Services "Ref M. Pneumoniae Ab, Igm, S by Ifa" PX-3028673803 CDM 86738 CPT 302 RC outpatient 197 197 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES HDHP [308136802] 157.6 percent of total billed charges 122.14 187.15 Technical (Hospital) Services "Ref M. Pneumoniae Ab, Igm, S by Ifa" PX-3028673803 CDM 86738 CPT 302 RC outpatient 197 197 MULTIPLAN INC 34080 [3081285] MULTIPLAN INC [308128501] 187.15 percent of total billed charges 122.14 187.15 Technical (Hospital) Services "Ref M. Pneumoniae Ab, Igm, S by Ifa" PX-3028673803 CDM 86738 CPT 302 RC outpatient 197 197 CIGNA 62308 [3081051] CIGNA 62308 [308105105] 157.6 percent of total billed charges 122.14 187.15 Technical (Hospital) Services "Ref M. Pneumoniae Ab, Igm, S by Ifa" PX-3028673803 CDM 86738 CPT 302 RC outpatient 197 197 CIGNA 62308 [3081051] CIGNA STATE OF WYOMING [308105107] 157.6 percent of total billed charges 122.14 187.15 Technical (Hospital) Services "Ref M. Pneumoniae Ab, Igm, S by Ifa" PX-3028673803 CDM 86738 CPT 302 RC outpatient 197 197 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES EPO [308136803] 157.6 percent of total billed charges 122.14 187.15 Technical (Hospital) Services "Ref M. Pneumoniae Ab, Igm, S by Ifa" PX-3028673803 CDM 86738 CPT 302 RC outpatient 197 197 UNITED HEALTHCARE (COMMERCIAL) [3081199] UNITED HEALTHCARE 87726 [308119901] 122.14 percent of total billed charges 122.14 187.15 Technical (Hospital) Services "Ref M. Pneumoniae Ab, Igm, S by Ifa" PX-3028673803 CDM 86738 CPT 302 RC outpatient 197 197 HEALTHPARTNERS SX009 HEALTHPARTNERS 157.6 percent of total billed charges 122.14 187.15 Technical (Hospital) Services "Ref M. Pneumoniae Ab, Igm, S by Ifa" PX-3028673803 CDM 86738 CPT 302 RC outpatient 197 197 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES PPO [308136801] 157.6 percent of total billed charges 122.14 187.15 Technical (Hospital) Services "Ref M. Pneumoniae Ab, Igm, S by Ifa" PX-3028673803 CDM 86738 CPT 302 RC outpatient 197 197 MEDICA (COMMERCIAL) 94265 [3081118] MEDICA CLAIMS [308111801] 177.3 percent of total billed charges 122.14 187.15 Technical (Hospital) Services Mumps PX-3028673500 CDM 86735 CPT 302 RC outpatient 182 182 MEDICA (COMMERCIAL) 94265 [3081118] MEDICA CLAIMS [308111801] 163.8 percent of total billed charges 112.84 172.9 Technical (Hospital) Services Mumps PX-3028673500 CDM 86735 CPT 302 RC outpatient 182 182 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES HDHP [308136802] 145.6 percent of total billed charges 112.84 172.9 Technical (Hospital) Services Mumps PX-3028673500 CDM 86735 CPT 302 RC outpatient 182 182 BLUE CROSS BLUE SHIELD WELLMARK SB889 [3081026] BCBS WYOMING [308102603] 172.9 percent of total billed charges 112.84 172.9 Technical (Hospital) Services Mumps PX-3028673500 CDM 86735 CPT 302 RC outpatient 182 182 CIGNA 62308 [3081051] CIGNA 62308 [308105105] 145.6 percent of total billed charges 112.84 172.9 Technical (Hospital) Services Mumps PX-3028673500 CDM 86735 CPT 302 RC outpatient 182 182 CIGNA 62308 [3081051] CIGNA STATE OF WYOMING [308105107] 145.6 percent of total billed charges 112.84 172.9 Technical (Hospital) Services Mumps PX-3028673500 CDM 86735 CPT 302 RC outpatient 182 182 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES EPO [308136803] 145.6 percent of total billed charges 112.84 172.9 Technical (Hospital) Services Mumps PX-3028673500 CDM 86735 CPT 302 RC outpatient 182 182 MULTIPLAN INC 34080 [3081285] MULTIPLAN INC [308128501] 172.9 percent of total billed charges 112.84 172.9 Technical (Hospital) Services Mumps PX-3028673500 CDM 86735 CPT 302 RC outpatient 182 182 HEALTHPARTNERS SX009 HEALTHPARTNERS 145.6 percent of total billed charges 112.84 172.9 Technical (Hospital) Services Mumps PX-3028673500 CDM 86735 CPT 302 RC outpatient 182 182 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES PPO [308136801] 145.6 percent of total billed charges 112.84 172.9 Technical (Hospital) Services Mumps PX-3028673500 CDM 86735 CPT 302 RC outpatient 182 182 UNITED HEALTHCARE (COMMERCIAL) [3081199] UNITED HEALTHCARE 87726 [308119901] 112.84 percent of total billed charges 112.84 172.9 Technical (Hospital) Services Mumps PX-3028673500 CDM 86735 CPT 302 RC inpatient 182 182 MEDICA (COMMERCIAL) 94265 [3081118] MEDICA CLAIMS [308111801] 163.8 percent of total billed charges 112.84 172.9 Technical (Hospital) Services Mumps PX-3028673500 CDM 86735 CPT 302 RC inpatient 182 182 MULTIPLAN INC 34080 [3081285] MULTIPLAN INC [308128501] 172.9 percent of total billed charges 112.84 172.9 Technical (Hospital) Services Mumps PX-3028673500 CDM 86735 CPT 302 RC inpatient 182 182 CIGNA 62308 [3081051] CIGNA 62308 [308105105] 144.11 percent of total billed charges 112.84 172.9 Technical (Hospital) Services Mumps PX-3028673500 CDM 86735 CPT 302 RC inpatient 182 182 CIGNA 62308 [3081051] CIGNA STATE OF WYOMING [308105107] 144.11 percent of total billed charges 112.84 172.9 Technical (Hospital) Services Mumps PX-3028673500 CDM 86735 CPT 302 RC inpatient 182 182 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES EPO [308136803] 144.11 percent of total billed charges 112.84 172.9 Technical (Hospital) Services Mumps PX-3028673500 CDM 86735 CPT 302 RC inpatient 182 182 BLUE CROSS BLUE SHIELD WELLMARK SB889 [3081026] BCBS WYOMING [308102603] 172.9 percent of total billed charges 112.84 172.9 Technical (Hospital) Services Mumps PX-3028673500 CDM 86735 CPT 302 RC inpatient 182 182 HEALTHPARTNERS SX009 HEALTHPARTNERS 144.11 percent of total billed charges 112.84 172.9 Technical (Hospital) Services Mumps PX-3028673500 CDM 86735 CPT 302 RC inpatient 182 182 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES HDHP [308136802] 144.11 percent of total billed charges 112.84 172.9 Technical (Hospital) Services Mumps PX-3028673500 CDM 86735 CPT 302 RC inpatient 182 182 UNITED HEALTHCARE (COMMERCIAL) [3081199] UNITED HEALTHCARE 87726 [308119901] 112.84 percent of total billed charges 112.84 172.9 Technical (Hospital) Services Mumps PX-3028673500 CDM 86735 CPT 302 RC inpatient 182 182 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES PPO [308136801] 144.11 percent of total billed charges 112.84 172.9 Technical (Hospital) Services Ref Leptospira Antibody PX-3028672000 CDM 86720 CPT 302 RC outpatient 182 182 MEDICA (COMMERCIAL) 94265 [3081118] MEDICA CLAIMS [308111801] 163.8 percent of total billed charges 112.84 172.9 Technical (Hospital) Services Ref Leptospira Antibody PX-3028672000 CDM 86720 CPT 302 RC outpatient 182 182 UNITED HEALTHCARE (COMMERCIAL) [3081199] UNITED HEALTHCARE 87726 [308119901] 112.84 percent of total billed charges 112.84 172.9 Technical (Hospital) Services Ref Leptospira Antibody PX-3028672000 CDM 86720 CPT 302 RC outpatient 182 182 HEALTHPARTNERS SX009 HEALTHPARTNERS 145.6 percent of total billed charges 112.84 172.9 Technical (Hospital) Services Ref Leptospira Antibody PX-3028672000 CDM 86720 CPT 302 RC outpatient 182 182 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES PPO [308136801] 145.6 percent of total billed charges 112.84 172.9 Technical (Hospital) Services Ref Leptospira Antibody PX-3028672000 CDM 86720 CPT 302 RC outpatient 182 182 CIGNA 62308 [3081051] CIGNA 62308 [308105105] 145.6 percent of total billed charges 112.84 172.9 Technical (Hospital) Services Ref Leptospira Antibody PX-3028672000 CDM 86720 CPT 302 RC outpatient 182 182 CIGNA 62308 [3081051] CIGNA STATE OF WYOMING [308105107] 145.6 percent of total billed charges 112.84 172.9 Technical (Hospital) Services Ref Leptospira Antibody PX-3028672000 CDM 86720 CPT 302 RC outpatient 182 182 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES EPO [308136803] 145.6 percent of total billed charges 112.84 172.9 Technical (Hospital) Services Ref Leptospira Antibody PX-3028672000 CDM 86720 CPT 302 RC outpatient 182 182 MULTIPLAN INC 34080 [3081285] MULTIPLAN INC [308128501] 172.9 percent of total billed charges 112.84 172.9 Technical (Hospital) Services Ref Leptospira Antibody PX-3028672000 CDM 86720 CPT 302 RC outpatient 182 182 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES HDHP [308136802] 145.6 percent of total billed charges 112.84 172.9 Technical (Hospital) Services Ref Leptospira Antibody PX-3028672000 CDM 86720 CPT 302 RC outpatient 182 182 BLUE CROSS BLUE SHIELD WELLMARK SB889 [3081026] BCBS WYOMING [308102603] 172.9 percent of total billed charges 112.84 172.9 Technical (Hospital) Services Ref Leptospira Antibody PX-3028672000 CDM 86720 CPT 302 RC inpatient 182 182 HEALTHPARTNERS SX009 HEALTHPARTNERS 144.11 percent of total billed charges 112.84 172.9 Technical (Hospital) Services Ref Leptospira Antibody PX-3028672000 CDM 86720 CPT 302 RC inpatient 182 182 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES EPO [308136803] 144.11 percent of total billed charges 112.84 172.9 Technical (Hospital) Services Ref Leptospira Antibody PX-3028672000 CDM 86720 CPT 302 RC inpatient 182 182 CIGNA 62308 [3081051] CIGNA 62308 [308105105] 144.11 percent of total billed charges 112.84 172.9 Technical (Hospital) Services Ref Leptospira Antibody PX-3028672000 CDM 86720 CPT 302 RC inpatient 182 182 CIGNA 62308 [3081051] CIGNA STATE OF WYOMING [308105107] 144.11 percent of total billed charges 112.84 172.9 Technical (Hospital) Services Ref Leptospira Antibody PX-3028672000 CDM 86720 CPT 302 RC inpatient 182 182 BLUE CROSS BLUE SHIELD WELLMARK SB889 [3081026] BCBS WYOMING [308102603] 172.9 percent of total billed charges 112.84 172.9 Technical (Hospital) Services Ref Leptospira Antibody PX-3028672000 CDM 86720 CPT 302 RC inpatient 182 182 MEDICA (COMMERCIAL) 94265 [3081118] MEDICA CLAIMS [308111801] 163.8 percent of total billed charges 112.84 172.9 Technical (Hospital) Services Ref Leptospira Antibody PX-3028672000 CDM 86720 CPT 302 RC inpatient 182 182 MULTIPLAN INC 34080 [3081285] MULTIPLAN INC [308128501] 172.9 percent of total billed charges 112.84 172.9 Technical (Hospital) Services Ref Leptospira Antibody PX-3028672000 CDM 86720 CPT 302 RC inpatient 182 182 UNITED HEALTHCARE (COMMERCIAL) [3081199] UNITED HEALTHCARE 87726 [308119901] 112.84 percent of total billed charges 112.84 172.9 Technical (Hospital) Services Ref Leptospira Antibody PX-3028672000 CDM 86720 CPT 302 RC inpatient 182 182 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES PPO [308136801] 144.11 percent of total billed charges 112.84 172.9 Technical (Hospital) Services Ref Leptospira Antibody PX-3028672000 CDM 86720 CPT 302 RC inpatient 182 182 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES HDHP [308136802] 144.11 percent of total billed charges 112.84 172.9 Technical (Hospital) Services Ref Legionella Titer PX-3028671300 CDM 86713 CPT 302 RC inpatient 216 216 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES PPO [308136801] 171.03 percent of total billed charges 133.92 205.2 Technical (Hospital) Services Ref Legionella Titer PX-3028671300 CDM 86713 CPT 302 RC inpatient 216 216 UNITED HEALTHCARE (COMMERCIAL) [3081199] UNITED HEALTHCARE 87726 [308119901] 133.92 percent of total billed charges 133.92 205.2 Technical (Hospital) Services Ref Legionella Titer PX-3028671300 CDM 86713 CPT 302 RC inpatient 216 216 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES HDHP [308136802] 171.03 percent of total billed charges 133.92 205.2 Technical (Hospital) Services Ref Legionella Titer PX-3028671300 CDM 86713 CPT 302 RC inpatient 216 216 MULTIPLAN INC 34080 [3081285] MULTIPLAN INC [308128501] 205.2 percent of total billed charges 133.92 205.2 Technical (Hospital) Services Ref Legionella Titer PX-3028671300 CDM 86713 CPT 302 RC inpatient 216 216 MEDICA (COMMERCIAL) 94265 [3081118] MEDICA CLAIMS [308111801] 194.4 percent of total billed charges 133.92 205.2 Technical (Hospital) Services Ref Legionella Titer PX-3028671300 CDM 86713 CPT 302 RC inpatient 216 216 BLUE CROSS BLUE SHIELD WELLMARK SB889 [3081026] BCBS WYOMING [308102603] 205.2 percent of total billed charges 133.92 205.2 Technical (Hospital) Services Ref Legionella Titer PX-3028671300 CDM 86713 CPT 302 RC inpatient 216 216 CIGNA 62308 [3081051] CIGNA 62308 [308105105] 171.03 percent of total billed charges 133.92 205.2 Technical (Hospital) Services Ref Legionella Titer PX-3028671300 CDM 86713 CPT 302 RC inpatient 216 216 CIGNA 62308 [3081051] CIGNA STATE OF WYOMING [308105107] 171.03 percent of total billed charges 133.92 205.2 Technical (Hospital) Services Ref Legionella Titer PX-3028671300 CDM 86713 CPT 302 RC inpatient 216 216 HEALTHPARTNERS SX009 HEALTHPARTNERS 171.03 percent of total billed charges 133.92 205.2 Technical (Hospital) Services Ref Legionella Titer PX-3028671300 CDM 86713 CPT 302 RC inpatient 216 216 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES EPO [308136803] 171.03 percent of total billed charges 133.92 205.2 Technical (Hospital) Services Ref Legionella Titer PX-3028671300 CDM 86713 CPT 302 RC outpatient 216 216 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES PPO [308136801] 172.8 percent of total billed charges 133.92 205.2 Technical (Hospital) Services Ref Legionella Titer PX-3028671300 CDM 86713 CPT 302 RC outpatient 216 216 HEALTHPARTNERS SX009 HEALTHPARTNERS 172.8 percent of total billed charges 133.92 205.2 Technical (Hospital) Services Ref Legionella Titer PX-3028671300 CDM 86713 CPT 302 RC outpatient 216 216 UNITED HEALTHCARE (COMMERCIAL) [3081199] UNITED HEALTHCARE 87726 [308119901] 133.92 percent of total billed charges 133.92 205.2 Technical (Hospital) Services Ref Legionella Titer PX-3028671300 CDM 86713 CPT 302 RC outpatient 216 216 BLUE CROSS BLUE SHIELD WELLMARK SB889 [3081026] BCBS WYOMING [308102603] 205.2 percent of total billed charges 133.92 205.2 Technical (Hospital) Services Ref Legionella Titer PX-3028671300 CDM 86713 CPT 302 RC outpatient 216 216 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES HDHP [308136802] 172.8 percent of total billed charges 133.92 205.2 Technical (Hospital) Services Ref Legionella Titer PX-3028671300 CDM 86713 CPT 302 RC outpatient 216 216 MULTIPLAN INC 34080 [3081285] MULTIPLAN INC [308128501] 205.2 percent of total billed charges 133.92 205.2 Technical (Hospital) Services Ref Legionella Titer PX-3028671300 CDM 86713 CPT 302 RC outpatient 216 216 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES EPO [308136803] 172.8 percent of total billed charges 133.92 205.2 Technical (Hospital) Services Ref Legionella Titer PX-3028671300 CDM 86713 CPT 302 RC outpatient 216 216 CIGNA 62308 [3081051] CIGNA 62308 [308105105] 172.8 percent of total billed charges 133.92 205.2 Technical (Hospital) Services Ref Legionella Titer PX-3028671300 CDM 86713 CPT 302 RC outpatient 216 216 CIGNA 62308 [3081051] CIGNA STATE OF WYOMING [308105107] 172.8 percent of total billed charges 133.92 205.2 Technical (Hospital) Services Ref Legionella Titer PX-3028671300 CDM 86713 CPT 302 RC outpatient 216 216 MEDICA (COMMERCIAL) 94265 [3081118] MEDICA CLAIMS [308111801] 194.4 percent of total billed charges 133.92 205.2 Technical (Hospital) Services Hav Igm PX-3028670900 CDM 86709 CPT 302 RC inpatient 160 160 MEDICA (COMMERCIAL) 94265 [3081118] MEDICA CLAIMS [308111801] 144 percent of total billed charges 99.2 152 Technical (Hospital) Services Hav Igm PX-3028670900 CDM 86709 CPT 302 RC inpatient 160 160 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES HDHP [308136802] 126.69 percent of total billed charges 99.2 152 Technical (Hospital) Services Hav Igm PX-3028670900 CDM 86709 CPT 302 RC inpatient 160 160 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES PPO [308136801] 126.69 percent of total billed charges 99.2 152 Technical (Hospital) Services Hav Igm PX-3028670900 CDM 86709 CPT 302 RC inpatient 160 160 UNITED HEALTHCARE (COMMERCIAL) [3081199] UNITED HEALTHCARE 87726 [308119901] 99.2 percent of total billed charges 99.2 152 Technical (Hospital) Services Hav Igm PX-3028670900 CDM 86709 CPT 302 RC inpatient 160 160 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES EPO [308136803] 126.69 percent of total billed charges 99.2 152 Technical (Hospital) Services Hav Igm PX-3028670900 CDM 86709 CPT 302 RC inpatient 160 160 HEALTHPARTNERS SX009 HEALTHPARTNERS 126.69 percent of total billed charges 99.2 152 Technical (Hospital) Services Hav Igm PX-3028670900 CDM 86709 CPT 302 RC inpatient 160 160 BLUE CROSS BLUE SHIELD WELLMARK SB889 [3081026] BCBS WYOMING [308102603] 152 percent of total billed charges 99.2 152 Technical (Hospital) Services Hav Igm PX-3028670900 CDM 86709 CPT 302 RC inpatient 160 160 CIGNA 62308 [3081051] CIGNA 62308 [308105105] 126.69 percent of total billed charges 99.2 152 Technical (Hospital) Services Hav Igm PX-3028670900 CDM 86709 CPT 302 RC inpatient 160 160 CIGNA 62308 [3081051] CIGNA STATE OF WYOMING [308105107] 126.69 percent of total billed charges 99.2 152 Technical (Hospital) Services Hav Igm PX-3028670900 CDM 86709 CPT 302 RC inpatient 160 160 MULTIPLAN INC 34080 [3081285] MULTIPLAN INC [308128501] 152 percent of total billed charges 99.2 152 Technical (Hospital) Services Hav Igm PX-3028670900 CDM 86709 CPT 302 RC outpatient 160 160 BLUE CROSS BLUE SHIELD WELLMARK SB889 [3081026] BCBS WYOMING [308102603] 152 percent of total billed charges 99.2 152 Technical (Hospital) Services Hav Igm PX-3028670900 CDM 86709 CPT 302 RC outpatient 160 160 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES HDHP [308136802] 128 percent of total billed charges 99.2 152 Technical (Hospital) Services Hav Igm PX-3028670900 CDM 86709 CPT 302 RC outpatient 160 160 MULTIPLAN INC 34080 [3081285] MULTIPLAN INC [308128501] 152 percent of total billed charges 99.2 152 Technical (Hospital) Services Hav Igm PX-3028670900 CDM 86709 CPT 302 RC outpatient 160 160 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES EPO [308136803] 128 percent of total billed charges 99.2 152 Technical (Hospital) Services Hav Igm PX-3028670900 CDM 86709 CPT 302 RC outpatient 160 160 CIGNA 62308 [3081051] CIGNA 62308 [308105105] 128 percent of total billed charges 99.2 152 Technical (Hospital) Services Hav Igm PX-3028670900 CDM 86709 CPT 302 RC outpatient 160 160 CIGNA 62308 [3081051] CIGNA STATE OF WYOMING [308105107] 128 percent of total billed charges 99.2 152 Technical (Hospital) Services Hav Igm PX-3028670900 CDM 86709 CPT 302 RC outpatient 160 160 HEALTHPARTNERS SX009 HEALTHPARTNERS 128 percent of total billed charges 99.2 152 Technical (Hospital) Services Hav Igm PX-3028670900 CDM 86709 CPT 302 RC outpatient 160 160 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES PPO [308136801] 128 percent of total billed charges 99.2 152 Technical (Hospital) Services Hav Igm PX-3028670900 CDM 86709 CPT 302 RC outpatient 160 160 UNITED HEALTHCARE (COMMERCIAL) [3081199] UNITED HEALTHCARE 87726 [308119901] 99.2 percent of total billed charges 99.2 152 Technical (Hospital) Services Hav Igm PX-3028670900 CDM 86709 CPT 302 RC outpatient 160 160 MEDICA (COMMERCIAL) 94265 [3081118] MEDICA CLAIMS [308111801] 144 percent of total billed charges 99.2 152 Technical (Hospital) Services Ref Hep a Antibody Igg PX-3028670800 CDM 86708 CPT 302 RC inpatient 166 166 CIGNA 62308 [3081051] CIGNA 62308 [308105105] 131.44 percent of total billed charges 102.92 157.7 Technical (Hospital) Services Ref Hep a Antibody Igg PX-3028670800 CDM 86708 CPT 302 RC inpatient 166 166 CIGNA 62308 [3081051] CIGNA STATE OF WYOMING [308105107] 131.44 percent of total billed charges 102.92 157.7 Technical (Hospital) Services Ref Hep a Antibody Igg PX-3028670800 CDM 86708 CPT 302 RC inpatient 166 166 MEDICA (COMMERCIAL) 94265 [3081118] MEDICA CLAIMS [308111801] 149.4 percent of total billed charges 102.92 157.7 Technical (Hospital) Services Ref Hep a Antibody Igg PX-3028670800 CDM 86708 CPT 302 RC inpatient 166 166 MULTIPLAN INC 34080 [3081285] MULTIPLAN INC [308128501] 157.7 percent of total billed charges 102.92 157.7 Technical (Hospital) Services Ref Hep a Antibody Igg PX-3028670800 CDM 86708 CPT 302 RC inpatient 166 166 BLUE CROSS BLUE SHIELD WELLMARK SB889 [3081026] BCBS WYOMING [308102603] 157.7 percent of total billed charges 102.92 157.7 Technical (Hospital) Services Ref Hep a Antibody Igg PX-3028670800 CDM 86708 CPT 302 RC inpatient 166 166 HEALTHPARTNERS SX009 HEALTHPARTNERS 131.44 percent of total billed charges 102.92 157.7 Technical (Hospital) Services Ref Hep a Antibody Igg PX-3028670800 CDM 86708 CPT 302 RC inpatient 166 166 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES EPO [308136803] 131.44 percent of total billed charges 102.92 157.7 Technical (Hospital) Services Ref Hep a Antibody Igg PX-3028670800 CDM 86708 CPT 302 RC inpatient 166 166 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES HDHP [308136802] 131.44 percent of total billed charges 102.92 157.7 Technical (Hospital) Services Ref Hep a Antibody Igg PX-3028670800 CDM 86708 CPT 302 RC inpatient 166 166 UNITED HEALTHCARE (COMMERCIAL) [3081199] UNITED HEALTHCARE 87726 [308119901] 102.92 percent of total billed charges 102.92 157.7 Technical (Hospital) Services Ref Hep a Antibody Igg PX-3028670800 CDM 86708 CPT 302 RC inpatient 166 166 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES PPO [308136801] 131.44 percent of total billed charges 102.92 157.7 Technical (Hospital) Services Ref Hep a Antibody Igg PX-3028670800 CDM 86708 CPT 302 RC outpatient 166 166 UNITED HEALTHCARE (COMMERCIAL) [3081199] UNITED HEALTHCARE 87726 [308119901] 102.92 percent of total billed charges 102.92 157.7 Technical (Hospital) Services Ref Hep a Antibody Igg PX-3028670800 CDM 86708 CPT 302 RC outpatient 166 166 HEALTHPARTNERS SX009 HEALTHPARTNERS 132.8 percent of total billed charges 102.92 157.7 Technical (Hospital) Services Ref Hep a Antibody Igg PX-3028670800 CDM 86708 CPT 302 RC outpatient 166 166 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES PPO [308136801] 132.8 percent of total billed charges 102.92 157.7 Technical (Hospital) Services Ref Hep a Antibody Igg PX-3028670800 CDM 86708 CPT 302 RC outpatient 166 166 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES EPO [308136803] 132.8 percent of total billed charges 102.92 157.7 Technical (Hospital) Services Ref Hep a Antibody Igg PX-3028670800 CDM 86708 CPT 302 RC outpatient 166 166 CIGNA 62308 [3081051] CIGNA 62308 [308105105] 132.8 percent of total billed charges 102.92 157.7 Technical (Hospital) Services Ref Hep a Antibody Igg PX-3028670800 CDM 86708 CPT 302 RC outpatient 166 166 CIGNA 62308 [3081051] CIGNA STATE OF WYOMING [308105107] 132.8 percent of total billed charges 102.92 157.7 Technical (Hospital) Services Ref Hep a Antibody Igg PX-3028670800 CDM 86708 CPT 302 RC outpatient 166 166 MULTIPLAN INC 34080 [3081285] MULTIPLAN INC [308128501] 157.7 percent of total billed charges 102.92 157.7 Technical (Hospital) Services Ref Hep a Antibody Igg PX-3028670800 CDM 86708 CPT 302 RC outpatient 166 166 BLUE CROSS BLUE SHIELD WELLMARK SB889 [3081026] BCBS WYOMING [308102603] 157.7 percent of total billed charges 102.92 157.7 Technical (Hospital) Services Ref Hep a Antibody Igg PX-3028670800 CDM 86708 CPT 302 RC outpatient 166 166 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES HDHP [308136802] 132.8 percent of total billed charges 102.92 157.7 Technical (Hospital) Services Ref Hep a Antibody Igg PX-3028670800 CDM 86708 CPT 302 RC outpatient 166 166 MEDICA (COMMERCIAL) 94265 [3081118] MEDICA CLAIMS [308111801] 149.4 percent of total billed charges 102.92 157.7 Technical (Hospital) Services Ref Hepatitis Be Antibody PX-3028670701 CDM 86707 CPT 302 RC inpatient 109 109 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES PPO [308136801] 86.31 percent of total billed charges 67.58 103.55 Technical (Hospital) Services Ref Hepatitis Be Antibody PX-3028670701 CDM 86707 CPT 302 RC inpatient 109 109 UNITED HEALTHCARE (COMMERCIAL) [3081199] UNITED HEALTHCARE 87726 [308119901] 67.58 percent of total billed charges 67.58 103.55 Technical (Hospital) Services Ref Hepatitis Be Antibody PX-3028670701 CDM 86707 CPT 302 RC inpatient 109 109 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES HDHP [308136802] 86.31 percent of total billed charges 67.58 103.55 Technical (Hospital) Services Ref Hepatitis Be Antibody PX-3028670701 CDM 86707 CPT 302 RC inpatient 109 109 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES EPO [308136803] 86.31 percent of total billed charges 67.58 103.55 Technical (Hospital) Services Ref Hepatitis Be Antibody PX-3028670701 CDM 86707 CPT 302 RC inpatient 109 109 HEALTHPARTNERS SX009 HEALTHPARTNERS 86.31 percent of total billed charges 67.58 103.55 Technical (Hospital) Services Ref Hepatitis Be Antibody PX-3028670701 CDM 86707 CPT 302 RC inpatient 109 109 BLUE CROSS BLUE SHIELD WELLMARK SB889 [3081026] BCBS WYOMING [308102603] 103.55 percent of total billed charges 67.58 103.55 Technical (Hospital) Services Ref Hepatitis Be Antibody PX-3028670701 CDM 86707 CPT 302 RC inpatient 109 109 MULTIPLAN INC 34080 [3081285] MULTIPLAN INC [308128501] 103.55 percent of total billed charges 67.58 103.55 Technical (Hospital) Services Ref Hepatitis Be Antibody PX-3028670701 CDM 86707 CPT 302 RC inpatient 109 109 MEDICA (COMMERCIAL) 94265 [3081118] MEDICA CLAIMS [308111801] 98.1 percent of total billed charges 67.58 103.55 Technical (Hospital) Services Ref Hepatitis Be Antibody PX-3028670701 CDM 86707 CPT 302 RC inpatient 109 109 CIGNA 62308 [3081051] CIGNA 62308 [308105105] 86.31 percent of total billed charges 67.58 103.55 Technical (Hospital) Services Ref Hepatitis Be Antibody PX-3028670701 CDM 86707 CPT 302 RC inpatient 109 109 CIGNA 62308 [3081051] CIGNA STATE OF WYOMING [308105107] 86.31 percent of total billed charges 67.58 103.55 Technical (Hospital) Services Ref Hepatitis Be Antibody PX-3028670701 CDM 86707 CPT 302 RC outpatient 109 109 MEDICA (COMMERCIAL) 94265 [3081118] MEDICA CLAIMS [308111801] 98.1 percent of total billed charges 67.58 103.55 Technical (Hospital) Services Ref Hepatitis Be Antibody PX-3028670701 CDM 86707 CPT 302 RC outpatient 109 109 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES HDHP [308136802] 87.2 percent of total billed charges 67.58 103.55 Technical (Hospital) Services Ref Hepatitis Be Antibody PX-3028670701 CDM 86707 CPT 302 RC outpatient 109 109 BLUE CROSS BLUE SHIELD WELLMARK SB889 [3081026] BCBS WYOMING [308102603] 103.55 percent of total billed charges 67.58 103.55 Technical (Hospital) Services Ref Hepatitis Be Antibody PX-3028670701 CDM 86707 CPT 302 RC outpatient 109 109 MULTIPLAN INC 34080 [3081285] MULTIPLAN INC [308128501] 103.55 percent of total billed charges 67.58 103.55 Technical (Hospital) Services Ref Hepatitis Be Antibody PX-3028670701 CDM 86707 CPT 302 RC outpatient 109 109 CIGNA 62308 [3081051] CIGNA 62308 [308105105] 87.2 percent of total billed charges 67.58 103.55 Technical (Hospital) Services Ref Hepatitis Be Antibody PX-3028670701 CDM 86707 CPT 302 RC outpatient 109 109 CIGNA 62308 [3081051] CIGNA STATE OF WYOMING [308105107] 87.2 percent of total billed charges 67.58 103.55 Technical (Hospital) Services Ref Hepatitis Be Antibody PX-3028670701 CDM 86707 CPT 302 RC outpatient 109 109 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES EPO [308136803] 87.2 percent of total billed charges 67.58 103.55 Technical (Hospital) Services Ref Hepatitis Be Antibody PX-3028670701 CDM 86707 CPT 302 RC outpatient 109 109 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES PPO [308136801] 87.2 percent of total billed charges 67.58 103.55 Technical (Hospital) Services Ref Hepatitis Be Antibody PX-3028670701 CDM 86707 CPT 302 RC outpatient 109 109 HEALTHPARTNERS SX009 HEALTHPARTNERS 87.2 percent of total billed charges 67.58 103.55 Technical (Hospital) Services Ref Hepatitis Be Antibody PX-3028670701 CDM 86707 CPT 302 RC outpatient 109 109 UNITED HEALTHCARE (COMMERCIAL) [3081199] UNITED HEALTHCARE 87726 [308119901] 67.58 percent of total billed charges 67.58 103.55 Technical (Hospital) Services Hbs Ab PX-3028670600 CDM 86706 CPT 302 RC outpatient 140 140 UNITED HEALTHCARE (COMMERCIAL) [3081199] UNITED HEALTHCARE 87726 [308119901] 86.8 percent of total billed charges 86.8 133 Technical (Hospital) Services Hbs Ab PX-3028670600 CDM 86706 CPT 302 RC outpatient 140 140 HEALTHPARTNERS SX009 HEALTHPARTNERS 112 percent of total billed charges 86.8 133 Technical (Hospital) Services Hbs Ab PX-3028670600 CDM 86706 CPT 302 RC outpatient 140 140 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES PPO [308136801] 112 percent of total billed charges 86.8 133 Technical (Hospital) Services Hbs Ab PX-3028670600 CDM 86706 CPT 302 RC outpatient 140 140 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES HDHP [308136802] 112 percent of total billed charges 86.8 133 Technical (Hospital) Services Hbs Ab PX-3028670600 CDM 86706 CPT 302 RC outpatient 140 140 BLUE CROSS BLUE SHIELD WELLMARK SB889 [3081026] BCBS WYOMING [308102603] 133 percent of total billed charges 86.8 133 Technical (Hospital) Services Hbs Ab PX-3028670600 CDM 86706 CPT 302 RC outpatient 140 140 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES EPO [308136803] 112 percent of total billed charges 86.8 133 Technical (Hospital) Services Hbs Ab PX-3028670600 CDM 86706 CPT 302 RC outpatient 140 140 CIGNA 62308 [3081051] CIGNA 62308 [308105105] 112 percent of total billed charges 86.8 133 Technical (Hospital) Services Hbs Ab PX-3028670600 CDM 86706 CPT 302 RC outpatient 140 140 CIGNA 62308 [3081051] CIGNA STATE OF WYOMING [308105107] 112 percent of total billed charges 86.8 133 Technical (Hospital) Services Hbs Ab PX-3028670600 CDM 86706 CPT 302 RC outpatient 140 140 MULTIPLAN INC 34080 [3081285] MULTIPLAN INC [308128501] 133 percent of total billed charges 86.8 133 Technical (Hospital) Services Hbs Ab PX-3028670600 CDM 86706 CPT 302 RC outpatient 140 140 MEDICA (COMMERCIAL) 94265 [3081118] MEDICA CLAIMS [308111801] 126 percent of total billed charges 86.8 133 Technical (Hospital) Services Hbs Ab PX-3028670600 CDM 86706 CPT 302 RC inpatient 140 140 UNITED HEALTHCARE (COMMERCIAL) [3081199] UNITED HEALTHCARE 87726 [308119901] 86.8 percent of total billed charges 86.8 133 Technical (Hospital) Services Hbs Ab PX-3028670600 CDM 86706 CPT 302 RC inpatient 140 140 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES PPO [308136801] 110.85 percent of total billed charges 86.8 133 Technical (Hospital) Services Hbs Ab PX-3028670600 CDM 86706 CPT 302 RC inpatient 140 140 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES HDHP [308136802] 110.85 percent of total billed charges 86.8 133 Technical (Hospital) Services Hbs Ab PX-3028670600 CDM 86706 CPT 302 RC inpatient 140 140 BLUE CROSS BLUE SHIELD WELLMARK SB889 [3081026] BCBS WYOMING [308102603] 133 percent of total billed charges 86.8 133 Technical (Hospital) Services Hbs Ab PX-3028670600 CDM 86706 CPT 302 RC inpatient 140 140 HEALTHPARTNERS SX009 HEALTHPARTNERS 110.85 percent of total billed charges 86.8 133 Technical (Hospital) Services Hbs Ab PX-3028670600 CDM 86706 CPT 302 RC inpatient 140 140 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES EPO [308136803] 110.85 percent of total billed charges 86.8 133 Technical (Hospital) Services Hbs Ab PX-3028670600 CDM 86706 CPT 302 RC inpatient 140 140 MEDICA (COMMERCIAL) 94265 [3081118] MEDICA CLAIMS [308111801] 126 percent of total billed charges 86.8 133 Technical (Hospital) Services Hbs Ab PX-3028670600 CDM 86706 CPT 302 RC inpatient 140 140 MULTIPLAN INC 34080 [3081285] MULTIPLAN INC [308128501] 133 percent of total billed charges 86.8 133 Technical (Hospital) Services Hbs Ab PX-3028670600 CDM 86706 CPT 302 RC inpatient 140 140 CIGNA 62308 [3081051] CIGNA 62308 [308105105] 110.85 percent of total billed charges 86.8 133 Technical (Hospital) Services Hbs Ab PX-3028670600 CDM 86706 CPT 302 RC inpatient 140 140 CIGNA 62308 [3081051] CIGNA STATE OF WYOMING [308105107] 110.85 percent of total billed charges 86.8 133 Technical (Hospital) Services Ref Hep B Surface Antibody PX-3028670601 CDM 86706 CPT 302 RC outpatient 140 140 UNITED HEALTHCARE (COMMERCIAL) [3081199] UNITED HEALTHCARE 87726 [308119901] 86.8 percent of total billed charges 86.8 133 Technical (Hospital) Services Ref Hep B Surface Antibody PX-3028670601 CDM 86706 CPT 302 RC outpatient 140 140 HEALTHPARTNERS SX009 HEALTHPARTNERS 112 percent of total billed charges 86.8 133 Technical (Hospital) Services Ref Hep B Surface Antibody PX-3028670601 CDM 86706 CPT 302 RC outpatient 140 140 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES PPO [308136801] 112 percent of total billed charges 86.8 133 Technical (Hospital) Services Ref Hep B Surface Antibody PX-3028670601 CDM 86706 CPT 302 RC outpatient 140 140 BLUE CROSS BLUE SHIELD WELLMARK SB889 [3081026] BCBS WYOMING [308102603] 133 percent of total billed charges 86.8 133 Technical (Hospital) Services Ref Hep B Surface Antibody PX-3028670601 CDM 86706 CPT 302 RC outpatient 140 140 MULTIPLAN INC 34080 [3081285] MULTIPLAN INC [308128501] 133 percent of total billed charges 86.8 133 Technical (Hospital) Services Ref Hep B Surface Antibody PX-3028670601 CDM 86706 CPT 302 RC outpatient 140 140 CIGNA 62308 [3081051] CIGNA 62308 [308105105] 112 percent of total billed charges 86.8 133 Technical (Hospital) Services Ref Hep B Surface Antibody PX-3028670601 CDM 86706 CPT 302 RC outpatient 140 140 CIGNA 62308 [3081051] CIGNA STATE OF WYOMING [308105107] 112 percent of total billed charges 86.8 133 Technical (Hospital) Services Ref Hep B Surface Antibody PX-3028670601 CDM 86706 CPT 302 RC outpatient 140 140 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES EPO [308136803] 112 percent of total billed charges 86.8 133 Technical (Hospital) Services Ref Hep B Surface Antibody PX-3028670601 CDM 86706 CPT 302 RC outpatient 140 140 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES HDHP [308136802] 112 percent of total billed charges 86.8 133 Technical (Hospital) Services Ref Hep B Surface Antibody PX-3028670601 CDM 86706 CPT 302 RC outpatient 140 140 MEDICA (COMMERCIAL) 94265 [3081118] MEDICA CLAIMS [308111801] 126 percent of total billed charges 86.8 133 Technical (Hospital) Services Ref Hep B Surface Antibody PX-3028670601 CDM 86706 CPT 302 RC inpatient 140 140 MULTIPLAN INC 34080 [3081285] MULTIPLAN INC [308128501] 133 percent of total billed charges 86.8 133 Technical (Hospital) Services Ref Hep B Surface Antibody PX-3028670601 CDM 86706 CPT 302 RC inpatient 140 140 MEDICA (COMMERCIAL) 94265 [3081118] MEDICA CLAIMS [308111801] 126 percent of total billed charges 86.8 133 Technical (Hospital) Services Ref Hep B Surface Antibody PX-3028670601 CDM 86706 CPT 302 RC inpatient 140 140 CIGNA 62308 [3081051] CIGNA 62308 [308105105] 110.85 percent of total billed charges 86.8 133 Technical (Hospital) Services Ref Hep B Surface Antibody PX-3028670601 CDM 86706 CPT 302 RC inpatient 140 140 CIGNA 62308 [3081051] CIGNA STATE OF WYOMING [308105107] 110.85 percent of total billed charges 86.8 133 Technical (Hospital) Services Ref Hep B Surface Antibody PX-3028670601 CDM 86706 CPT 302 RC inpatient 140 140 BLUE CROSS BLUE SHIELD WELLMARK SB889 [3081026] BCBS WYOMING [308102603] 133 percent of total billed charges 86.8 133 Technical (Hospital) Services Ref Hep B Surface Antibody PX-3028670601 CDM 86706 CPT 302 RC inpatient 140 140 HEALTHPARTNERS SX009 HEALTHPARTNERS 110.85 percent of total billed charges 86.8 133 Technical (Hospital) Services Ref Hep B Surface Antibody PX-3028670601 CDM 86706 CPT 302 RC inpatient 140 140 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES EPO [308136803] 110.85 percent of total billed charges 86.8 133 Technical (Hospital) Services Ref Hep B Surface Antibody PX-3028670601 CDM 86706 CPT 302 RC inpatient 140 140 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES HDHP [308136802] 110.85 percent of total billed charges 86.8 133 Technical (Hospital) Services Ref Hep B Surface Antibody PX-3028670601 CDM 86706 CPT 302 RC inpatient 140 140 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES PPO [308136801] 110.85 percent of total billed charges 86.8 133 Technical (Hospital) Services Ref Hep B Surface Antibody PX-3028670601 CDM 86706 CPT 302 RC inpatient 140 140 UNITED HEALTHCARE (COMMERCIAL) [3081199] UNITED HEALTHCARE 87726 [308119901] 86.8 percent of total billed charges 86.8 133 Technical (Hospital) Services Hepatitis B Core Anti-Body Igm PX-3028670500 CDM 86705 CPT 302 RC inpatient 170 170 MEDICA (COMMERCIAL) 94265 [3081118] MEDICA CLAIMS [308111801] 153 percent of total billed charges 105.4 161.5 Technical (Hospital) Services Hepatitis B Core Anti-Body Igm PX-3028670500 CDM 86705 CPT 302 RC inpatient 170 170 MULTIPLAN INC 34080 [3081285] MULTIPLAN INC [308128501] 161.5 percent of total billed charges 105.4 161.5 Technical (Hospital) Services Hepatitis B Core Anti-Body Igm PX-3028670500 CDM 86705 CPT 302 RC inpatient 170 170 CIGNA 62308 [3081051] CIGNA 62308 [308105105] 134.61 percent of total billed charges 105.4 161.5 Technical (Hospital) Services Hepatitis B Core Anti-Body Igm PX-3028670500 CDM 86705 CPT 302 RC inpatient 170 170 CIGNA 62308 [3081051] CIGNA STATE OF WYOMING [308105107] 134.61 percent of total billed charges 105.4 161.5 Technical (Hospital) Services Hepatitis B Core Anti-Body Igm PX-3028670500 CDM 86705 CPT 302 RC inpatient 170 170 BLUE CROSS BLUE SHIELD WELLMARK SB889 [3081026] BCBS WYOMING [308102603] 161.5 percent of total billed charges 105.4 161.5 Technical (Hospital) Services Hepatitis B Core Anti-Body Igm PX-3028670500 CDM 86705 CPT 302 RC inpatient 170 170 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES EPO [308136803] 134.61 percent of total billed charges 105.4 161.5 Technical (Hospital) Services Hepatitis B Core Anti-Body Igm PX-3028670500 CDM 86705 CPT 302 RC inpatient 170 170 HEALTHPARTNERS SX009 HEALTHPARTNERS 134.61 percent of total billed charges 105.4 161.5 Technical (Hospital) Services Hepatitis B Core Anti-Body Igm PX-3028670500 CDM 86705 CPT 302 RC inpatient 170 170 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES HDHP [308136802] 134.61 percent of total billed charges 105.4 161.5 Technical (Hospital) Services Hepatitis B Core Anti-Body Igm PX-3028670500 CDM 86705 CPT 302 RC inpatient 170 170 UNITED HEALTHCARE (COMMERCIAL) [3081199] UNITED HEALTHCARE 87726 [308119901] 105.4 percent of total billed charges 105.4 161.5 Technical (Hospital) Services Hepatitis B Core Anti-Body Igm PX-3028670500 CDM 86705 CPT 302 RC inpatient 170 170 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES PPO [308136801] 134.61 percent of total billed charges 105.4 161.5 Technical (Hospital) Services Hepatitis B Core Anti-Body Igm PX-3028670500 CDM 86705 CPT 302 RC outpatient 170 170 MEDICA (COMMERCIAL) 94265 [3081118] MEDICA CLAIMS [308111801] 153 percent of total billed charges 105.4 161.5 Technical (Hospital) Services Hepatitis B Core Anti-Body Igm PX-3028670500 CDM 86705 CPT 302 RC outpatient 170 170 MULTIPLAN INC 34080 [3081285] MULTIPLAN INC [308128501] 161.5 percent of total billed charges 105.4 161.5 Technical (Hospital) Services Hepatitis B Core Anti-Body Igm PX-3028670500 CDM 86705 CPT 302 RC outpatient 170 170 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES EPO [308136803] 136 percent of total billed charges 105.4 161.5 Technical (Hospital) Services Hepatitis B Core Anti-Body Igm PX-3028670500 CDM 86705 CPT 302 RC outpatient 170 170 CIGNA 62308 [3081051] CIGNA 62308 [308105105] 136 percent of total billed charges 105.4 161.5 Technical (Hospital) Services Hepatitis B Core Anti-Body Igm PX-3028670500 CDM 86705 CPT 302 RC outpatient 170 170 CIGNA 62308 [3081051] CIGNA STATE OF WYOMING [308105107] 136 percent of total billed charges 105.4 161.5 Technical (Hospital) Services Hepatitis B Core Anti-Body Igm PX-3028670500 CDM 86705 CPT 302 RC outpatient 170 170 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES HDHP [308136802] 136 percent of total billed charges 105.4 161.5 Technical (Hospital) Services Hepatitis B Core Anti-Body Igm PX-3028670500 CDM 86705 CPT 302 RC outpatient 170 170 BLUE CROSS BLUE SHIELD WELLMARK SB889 [3081026] BCBS WYOMING [308102603] 161.5 percent of total billed charges 105.4 161.5 Technical (Hospital) Services Hepatitis B Core Anti-Body Igm PX-3028670500 CDM 86705 CPT 302 RC outpatient 170 170 HEALTHPARTNERS SX009 HEALTHPARTNERS 136 percent of total billed charges 105.4 161.5 Technical (Hospital) Services Hepatitis B Core Anti-Body Igm PX-3028670500 CDM 86705 CPT 302 RC outpatient 170 170 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES PPO [308136801] 136 percent of total billed charges 105.4 161.5 Technical (Hospital) Services Hepatitis B Core Anti-Body Igm PX-3028670500 CDM 86705 CPT 302 RC outpatient 170 170 UNITED HEALTHCARE (COMMERCIAL) [3081199] UNITED HEALTHCARE 87726 [308119901] 105.4 percent of total billed charges 105.4 161.5 Technical (Hospital) Services Ref Hbc Total Ab PX-3028670400 CDM 86704 CPT 302 RC inpatient 166 166 MULTIPLAN INC 34080 [3081285] MULTIPLAN INC [308128501] 157.7 percent of total billed charges 102.92 157.7 Technical (Hospital) Services Ref Hbc Total Ab PX-3028670400 CDM 86704 CPT 302 RC inpatient 166 166 MEDICA (COMMERCIAL) 94265 [3081118] MEDICA CLAIMS [308111801] 149.4 percent of total billed charges 102.92 157.7 Technical (Hospital) Services Ref Hbc Total Ab PX-3028670400 CDM 86704 CPT 302 RC inpatient 166 166 CIGNA 62308 [3081051] CIGNA 62308 [308105105] 131.44 percent of total billed charges 102.92 157.7 Technical (Hospital) Services Ref Hbc Total Ab PX-3028670400 CDM 86704 CPT 302 RC inpatient 166 166 CIGNA 62308 [3081051] CIGNA STATE OF WYOMING [308105107] 131.44 percent of total billed charges 102.92 157.7 Technical (Hospital) Services Ref Hbc Total Ab PX-3028670400 CDM 86704 CPT 302 RC inpatient 166 166 BLUE CROSS BLUE SHIELD WELLMARK SB889 [3081026] BCBS WYOMING [308102603] 157.7 percent of total billed charges 102.92 157.7 Technical (Hospital) Services Ref Hbc Total Ab PX-3028670400 CDM 86704 CPT 302 RC inpatient 166 166 HEALTHPARTNERS SX009 HEALTHPARTNERS 131.44 percent of total billed charges 102.92 157.7 Technical (Hospital) Services Ref Hbc Total Ab PX-3028670400 CDM 86704 CPT 302 RC inpatient 166 166 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES EPO [308136803] 131.44 percent of total billed charges 102.92 157.7 Technical (Hospital) Services Ref Hbc Total Ab PX-3028670400 CDM 86704 CPT 302 RC inpatient 166 166 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES HDHP [308136802] 131.44 percent of total billed charges 102.92 157.7 Technical (Hospital) Services Ref Hbc Total Ab PX-3028670400 CDM 86704 CPT 302 RC inpatient 166 166 UNITED HEALTHCARE (COMMERCIAL) [3081199] UNITED HEALTHCARE 87726 [308119901] 102.92 percent of total billed charges 102.92 157.7 Technical (Hospital) Services Ref Hbc Total Ab PX-3028670400 CDM 86704 CPT 302 RC inpatient 166 166 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES PPO [308136801] 131.44 percent of total billed charges 102.92 157.7 Technical (Hospital) Services Ref Hbc Total Ab PX-3028670400 CDM 86704 CPT 302 RC outpatient 166 166 MULTIPLAN INC 34080 [3081285] MULTIPLAN INC [308128501] 157.7 percent of total billed charges 102.92 157.7 Technical (Hospital) Services Ref Hbc Total Ab PX-3028670400 CDM 86704 CPT 302 RC outpatient 166 166 CIGNA 62308 [3081051] CIGNA 62308 [308105105] 132.8 percent of total billed charges 102.92 157.7 Technical (Hospital) Services Ref Hbc Total Ab PX-3028670400 CDM 86704 CPT 302 RC outpatient 166 166 CIGNA 62308 [3081051] CIGNA STATE OF WYOMING [308105107] 132.8 percent of total billed charges 102.92 157.7 Technical (Hospital) Services Ref Hbc Total Ab PX-3028670400 CDM 86704 CPT 302 RC outpatient 166 166 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES EPO [308136803] 132.8 percent of total billed charges 102.92 157.7 Technical (Hospital) Services Ref Hbc Total Ab PX-3028670400 CDM 86704 CPT 302 RC outpatient 166 166 BLUE CROSS BLUE SHIELD WELLMARK SB889 [3081026] BCBS WYOMING [308102603] 157.7 percent of total billed charges 102.92 157.7 Technical (Hospital) Services Ref Hbc Total Ab PX-3028670400 CDM 86704 CPT 302 RC outpatient 166 166 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES HDHP [308136802] 132.8 percent of total billed charges 102.92 157.7 Technical (Hospital) Services Ref Hbc Total Ab PX-3028670400 CDM 86704 CPT 302 RC outpatient 166 166 UNITED HEALTHCARE (COMMERCIAL) [3081199] UNITED HEALTHCARE 87726 [308119901] 102.92 percent of total billed charges 102.92 157.7 Technical (Hospital) Services Ref Hbc Total Ab PX-3028670400 CDM 86704 CPT 302 RC outpatient 166 166 MEDICA (COMMERCIAL) 94265 [3081118] MEDICA CLAIMS [308111801] 149.4 percent of total billed charges 102.92 157.7 Technical (Hospital) Services Ref Hbc Total Ab PX-3028670400 CDM 86704 CPT 302 RC outpatient 166 166 HEALTHPARTNERS SX009 HEALTHPARTNERS 132.8 percent of total billed charges 102.92 157.7 Technical (Hospital) Services Ref Hbc Total Ab PX-3028670400 CDM 86704 CPT 302 RC outpatient 166 166 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES PPO [308136801] 132.8 percent of total billed charges 102.92 157.7 Technical (Hospital) Services "Hepatitis B Core Antibody, Total" PX-3028670402 CDM 86704 CPT 302 RC inpatient 118 118 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES PPO [308136801] 93.43 percent of total billed charges 73.16 112.1 Technical (Hospital) Services "Hepatitis B Core Antibody, Total" PX-3028670402 CDM 86704 CPT 302 RC inpatient 118 118 UNITED HEALTHCARE (COMMERCIAL) [3081199] UNITED HEALTHCARE 87726 [308119901] 73.16 percent of total billed charges 73.16 112.1 Technical (Hospital) Services "Hepatitis B Core Antibody, Total" PX-3028670402 CDM 86704 CPT 302 RC inpatient 118 118 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES HDHP [308136802] 93.43 percent of total billed charges 73.16 112.1 Technical (Hospital) Services "Hepatitis B Core Antibody, Total" PX-3028670402 CDM 86704 CPT 302 RC inpatient 118 118 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES EPO [308136803] 93.43 percent of total billed charges 73.16 112.1 Technical (Hospital) Services "Hepatitis B Core Antibody, Total" PX-3028670402 CDM 86704 CPT 302 RC inpatient 118 118 BLUE CROSS BLUE SHIELD WELLMARK SB889 [3081026] BCBS WYOMING [308102603] 112.1 percent of total billed charges 73.16 112.1 Technical (Hospital) Services "Hepatitis B Core Antibody, Total" PX-3028670402 CDM 86704 CPT 302 RC inpatient 118 118 HEALTHPARTNERS SX009 HEALTHPARTNERS 93.43 percent of total billed charges 73.16 112.1 Technical (Hospital) Services "Hepatitis B Core Antibody, Total" PX-3028670402 CDM 86704 CPT 302 RC inpatient 118 118 CIGNA 62308 [3081051] CIGNA 62308 [308105105] 93.43 percent of total billed charges 73.16 112.1 Technical (Hospital) Services "Hepatitis B Core Antibody, Total" PX-3028670402 CDM 86704 CPT 302 RC inpatient 118 118 CIGNA 62308 [3081051] CIGNA STATE OF WYOMING [308105107] 93.43 percent of total billed charges 73.16 112.1 Technical (Hospital) Services "Hepatitis B Core Antibody, Total" PX-3028670402 CDM 86704 CPT 302 RC inpatient 118 118 MULTIPLAN INC 34080 [3081285] MULTIPLAN INC [308128501] 112.1 percent of total billed charges 73.16 112.1 Technical (Hospital) Services "Hepatitis B Core Antibody, Total" PX-3028670402 CDM 86704 CPT 302 RC inpatient 118 118 MEDICA (COMMERCIAL) 94265 [3081118] MEDICA CLAIMS [308111801] 106.2 percent of total billed charges 73.16 112.1 Technical (Hospital) Services "Hepatitis B Core Antibody, Total" PX-3028670402 CDM 86704 CPT 302 RC outpatient 118 118 BLUE CROSS BLUE SHIELD WELLMARK SB889 [3081026] BCBS WYOMING [308102603] 112.1 percent of total billed charges 73.16 112.1 Technical (Hospital) Services "Hepatitis B Core Antibody, Total" PX-3028670402 CDM 86704 CPT 302 RC outpatient 118 118 MULTIPLAN INC 34080 [3081285] MULTIPLAN INC [308128501] 112.1 percent of total billed charges 73.16 112.1 Technical (Hospital) Services "Hepatitis B Core Antibody, Total" PX-3028670402 CDM 86704 CPT 302 RC outpatient 118 118 CIGNA 62308 [3081051] CIGNA 62308 [308105105] 94.4 percent of total billed charges 73.16 112.1 Technical (Hospital) Services "Hepatitis B Core Antibody, Total" PX-3028670402 CDM 86704 CPT 302 RC outpatient 118 118 CIGNA 62308 [3081051] CIGNA STATE OF WYOMING [308105107] 94.4 percent of total billed charges 73.16 112.1 Technical (Hospital) Services "Hepatitis B Core Antibody, Total" PX-3028670402 CDM 86704 CPT 302 RC outpatient 118 118 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES EPO [308136803] 94.4 percent of total billed charges 73.16 112.1 Technical (Hospital) Services "Hepatitis B Core Antibody, Total" PX-3028670402 CDM 86704 CPT 302 RC outpatient 118 118 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES HDHP [308136802] 94.4 percent of total billed charges 73.16 112.1 Technical (Hospital) Services "Hepatitis B Core Antibody, Total" PX-3028670402 CDM 86704 CPT 302 RC outpatient 118 118 UNITED HEALTHCARE (COMMERCIAL) [3081199] UNITED HEALTHCARE 87726 [308119901] 73.16 percent of total billed charges 73.16 112.1 Technical (Hospital) Services "Hepatitis B Core Antibody, Total" PX-3028670402 CDM 86704 CPT 302 RC outpatient 118 118 HEALTHPARTNERS SX009 HEALTHPARTNERS 94.4 percent of total billed charges 73.16 112.1 Technical (Hospital) Services "Hepatitis B Core Antibody, Total" PX-3028670402 CDM 86704 CPT 302 RC outpatient 118 118 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES PPO [308136801] 94.4 percent of total billed charges 73.16 112.1 Technical (Hospital) Services "Hepatitis B Core Antibody, Total" PX-3028670402 CDM 86704 CPT 302 RC outpatient 118 118 MEDICA (COMMERCIAL) 94265 [3081118] MEDICA CLAIMS [308111801] 106.2 percent of total billed charges 73.16 112.1 Technical (Hospital) Services Hiv I & II PX-3028670300 CDM 86703 CPT 302 RC outpatient 182 182 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES HDHP [308136802] 145.6 percent of total billed charges 112.84 172.9 Technical (Hospital) Services Hiv I & II PX-3028670300 CDM 86703 CPT 302 RC outpatient 182 182 BLUE CROSS BLUE SHIELD WELLMARK SB889 [3081026] BCBS WYOMING [308102603] 172.9 percent of total billed charges 112.84 172.9 Technical (Hospital) Services Hiv I & II PX-3028670300 CDM 86703 CPT 302 RC outpatient 182 182 MULTIPLAN INC 34080 [3081285] MULTIPLAN INC [308128501] 172.9 percent of total billed charges 112.84 172.9 Technical (Hospital) Services Hiv I & II PX-3028670300 CDM 86703 CPT 302 RC outpatient 182 182 CIGNA 62308 [3081051] CIGNA 62308 [308105105] 145.6 percent of total billed charges 112.84 172.9 Technical (Hospital) Services Hiv I & II PX-3028670300 CDM 86703 CPT 302 RC outpatient 182 182 CIGNA 62308 [3081051] CIGNA STATE OF WYOMING [308105107] 145.6 percent of total billed charges 112.84 172.9 Technical (Hospital) Services Hiv I & II PX-3028670300 CDM 86703 CPT 302 RC outpatient 182 182 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES EPO [308136803] 145.6 percent of total billed charges 112.84 172.9 Technical (Hospital) Services Hiv I & II PX-3028670300 CDM 86703 CPT 302 RC outpatient 182 182 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES PPO [308136801] 145.6 percent of total billed charges 112.84 172.9 Technical (Hospital) Services Hiv I & II PX-3028670300 CDM 86703 CPT 302 RC outpatient 182 182 HEALTHPARTNERS SX009 HEALTHPARTNERS 145.6 percent of total billed charges 112.84 172.9 Technical (Hospital) Services Hiv I & II PX-3028670300 CDM 86703 CPT 302 RC outpatient 182 182 UNITED HEALTHCARE (COMMERCIAL) [3081199] UNITED HEALTHCARE 87726 [308119901] 112.84 percent of total billed charges 112.84 172.9 Technical (Hospital) Services Hiv I & II PX-3028670300 CDM 86703 CPT 302 RC outpatient 182 182 MEDICA (COMMERCIAL) 94265 [3081118] MEDICA CLAIMS [308111801] 163.8 percent of total billed charges 112.84 172.9 Technical (Hospital) Services Hiv I & II PX-3028670300 CDM 86703 CPT 302 RC inpatient 182 182 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES PPO [308136801] 144.11 percent of total billed charges 112.84 172.9 Technical (Hospital) Services Hiv I & II PX-3028670300 CDM 86703 CPT 302 RC inpatient 182 182 UNITED HEALTHCARE (COMMERCIAL) [3081199] UNITED HEALTHCARE 87726 [308119901] 112.84 percent of total billed charges 112.84 172.9 Technical (Hospital) Services Hiv I & II PX-3028670300 CDM 86703 CPT 302 RC inpatient 182 182 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES HDHP [308136802] 144.11 percent of total billed charges 112.84 172.9 Technical (Hospital) Services Hiv I & II PX-3028670300 CDM 86703 CPT 302 RC inpatient 182 182 BLUE CROSS BLUE SHIELD WELLMARK SB889 [3081026] BCBS WYOMING [308102603] 172.9 percent of total billed charges 112.84 172.9 Technical (Hospital) Services Hiv I & II PX-3028670300 CDM 86703 CPT 302 RC inpatient 182 182 HEALTHPARTNERS SX009 HEALTHPARTNERS 144.11 percent of total billed charges 112.84 172.9 Technical (Hospital) Services Hiv I & II PX-3028670300 CDM 86703 CPT 302 RC inpatient 182 182 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES EPO [308136803] 144.11 percent of total billed charges 112.84 172.9 Technical (Hospital) Services Hiv I & II PX-3028670300 CDM 86703 CPT 302 RC inpatient 182 182 CIGNA 62308 [3081051] CIGNA 62308 [308105105] 144.11 percent of total billed charges 112.84 172.9 Technical (Hospital) Services Hiv I & II PX-3028670300 CDM 86703 CPT 302 RC inpatient 182 182 CIGNA 62308 [3081051] CIGNA STATE OF WYOMING [308105107] 144.11 percent of total billed charges 112.84 172.9 Technical (Hospital) Services Hiv I & II PX-3028670300 CDM 86703 CPT 302 RC inpatient 182 182 MEDICA (COMMERCIAL) 94265 [3081118] MEDICA CLAIMS [308111801] 163.8 percent of total billed charges 112.84 172.9 Technical (Hospital) Services Hiv I & II PX-3028670300 CDM 86703 CPT 302 RC inpatient 182 182 MULTIPLAN INC 34080 [3081285] MULTIPLAN INC [308128501] 172.9 percent of total billed charges 112.84 172.9 Technical (Hospital) Services Ref Hiv 2 Antibody PX-3028670200 CDM 86702 CPT 302 RC outpatient 208 208 BLUE CROSS BLUE SHIELD WELLMARK SB889 [3081026] BCBS WYOMING [308102603] 197.6 percent of total billed charges 128.96 197.6 Technical (Hospital) Services Ref Hiv 2 Antibody PX-3028670200 CDM 86702 CPT 302 RC outpatient 208 208 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES HDHP [308136802] 166.4 percent of total billed charges 128.96 197.6 Technical (Hospital) Services Ref Hiv 2 Antibody PX-3028670200 CDM 86702 CPT 302 RC outpatient 208 208 CIGNA 62308 [3081051] CIGNA 62308 [308105105] 166.4 percent of total billed charges 128.96 197.6 Technical (Hospital) Services Ref Hiv 2 Antibody PX-3028670200 CDM 86702 CPT 302 RC outpatient 208 208 CIGNA 62308 [3081051] CIGNA STATE OF WYOMING [308105107] 166.4 percent of total billed charges 128.96 197.6 Technical (Hospital) Services Ref Hiv 2 Antibody PX-3028670200 CDM 86702 CPT 302 RC outpatient 208 208 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES EPO [308136803] 166.4 percent of total billed charges 128.96 197.6 Technical (Hospital) Services Ref Hiv 2 Antibody PX-3028670200 CDM 86702 CPT 302 RC outpatient 208 208 MULTIPLAN INC 34080 [3081285] MULTIPLAN INC [308128501] 197.6 percent of total billed charges 128.96 197.6 Technical (Hospital) Services Ref Hiv 2 Antibody PX-3028670200 CDM 86702 CPT 302 RC outpatient 208 208 HEALTHPARTNERS SX009 HEALTHPARTNERS 166.4 percent of total billed charges 128.96 197.6 Technical (Hospital) Services Ref Hiv 2 Antibody PX-3028670200 CDM 86702 CPT 302 RC outpatient 208 208 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES PPO [308136801] 166.4 percent of total billed charges 128.96 197.6 Technical (Hospital) Services Ref Hiv 2 Antibody PX-3028670200 CDM 86702 CPT 302 RC outpatient 208 208 UNITED HEALTHCARE (COMMERCIAL) [3081199] UNITED HEALTHCARE 87726 [308119901] 128.96 percent of total billed charges 128.96 197.6 Technical (Hospital) Services Ref Hiv 2 Antibody PX-3028670200 CDM 86702 CPT 302 RC outpatient 208 208 MEDICA (COMMERCIAL) 94265 [3081118] MEDICA CLAIMS [308111801] 187.2 percent of total billed charges 128.96 197.6 Technical (Hospital) Services Ref Hiv 2 Antibody PX-3028670200 CDM 86702 CPT 302 RC inpatient 208 208 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES HDHP [308136802] 164.69 percent of total billed charges 128.96 197.6 Technical (Hospital) Services Ref Hiv 2 Antibody PX-3028670200 CDM 86702 CPT 302 RC inpatient 208 208 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES PPO [308136801] 164.69 percent of total billed charges 128.96 197.6 Technical (Hospital) Services Ref Hiv 2 Antibody PX-3028670200 CDM 86702 CPT 302 RC inpatient 208 208 UNITED HEALTHCARE (COMMERCIAL) [3081199] UNITED HEALTHCARE 87726 [308119901] 128.96 percent of total billed charges 128.96 197.6 Technical (Hospital) Services Ref Hiv 2 Antibody PX-3028670200 CDM 86702 CPT 302 RC inpatient 208 208 CIGNA 62308 [3081051] CIGNA 62308 [308105105] 164.69 percent of total billed charges 128.96 197.6 Technical (Hospital) Services Ref Hiv 2 Antibody PX-3028670200 CDM 86702 CPT 302 RC inpatient 208 208 CIGNA 62308 [3081051] CIGNA STATE OF WYOMING [308105107] 164.69 percent of total billed charges 128.96 197.6 Technical (Hospital) Services Ref Hiv 2 Antibody PX-3028670200 CDM 86702 CPT 302 RC inpatient 208 208 MULTIPLAN INC 34080 [3081285] MULTIPLAN INC [308128501] 197.6 percent of total billed charges 128.96 197.6 Technical (Hospital) Services Ref Hiv 2 Antibody PX-3028670200 CDM 86702 CPT 302 RC inpatient 208 208 MEDICA (COMMERCIAL) 94265 [3081118] MEDICA CLAIMS [308111801] 187.2 percent of total billed charges 128.96 197.6 Technical (Hospital) Services Ref Hiv 2 Antibody PX-3028670200 CDM 86702 CPT 302 RC inpatient 208 208 BLUE CROSS BLUE SHIELD WELLMARK SB889 [3081026] BCBS WYOMING [308102603] 197.6 percent of total billed charges 128.96 197.6 Technical (Hospital) Services Ref Hiv 2 Antibody PX-3028670200 CDM 86702 CPT 302 RC inpatient 208 208 HEALTHPARTNERS SX009 HEALTHPARTNERS 164.69 percent of total billed charges 128.96 197.6 Technical (Hospital) Services Ref Hiv 2 Antibody PX-3028670200 CDM 86702 CPT 302 RC inpatient 208 208 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES EPO [308136803] 164.69 percent of total billed charges 128.96 197.6 Technical (Hospital) Services Hiv2 Ab PX-3028670202 CDM 86702 CPT 302 RC inpatient 225 225 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES EPO [308136803] 178.16 percent of total billed charges 139.5 213.75 Technical (Hospital) Services Hiv2 Ab PX-3028670202 CDM 86702 CPT 302 RC inpatient 225 225 BLUE CROSS BLUE SHIELD WELLMARK SB889 [3081026] BCBS WYOMING [308102603] 213.75 percent of total billed charges 139.5 213.75 Technical (Hospital) Services Hiv2 Ab PX-3028670202 CDM 86702 CPT 302 RC inpatient 225 225 HEALTHPARTNERS SX009 HEALTHPARTNERS 178.16 percent of total billed charges 139.5 213.75 Technical (Hospital) Services Hiv2 Ab PX-3028670202 CDM 86702 CPT 302 RC inpatient 225 225 CIGNA 62308 [3081051] CIGNA 62308 [308105105] 178.16 percent of total billed charges 139.5 213.75 Technical (Hospital) Services Hiv2 Ab PX-3028670202 CDM 86702 CPT 302 RC inpatient 225 225 CIGNA 62308 [3081051] CIGNA STATE OF WYOMING [308105107] 178.16 percent of total billed charges 139.5 213.75 Technical (Hospital) Services Hiv2 Ab PX-3028670202 CDM 86702 CPT 302 RC inpatient 225 225 MEDICA (COMMERCIAL) 94265 [3081118] MEDICA CLAIMS [308111801] 202.5 percent of total billed charges 139.5 213.75 Technical (Hospital) Services Hiv2 Ab PX-3028670202 CDM 86702 CPT 302 RC inpatient 225 225 MULTIPLAN INC 34080 [3081285] MULTIPLAN INC [308128501] 213.75 percent of total billed charges 139.5 213.75 Technical (Hospital) Services Hiv2 Ab PX-3028670202 CDM 86702 CPT 302 RC inpatient 225 225 UNITED HEALTHCARE (COMMERCIAL) [3081199] UNITED HEALTHCARE 87726 [308119901] 139.5 percent of total billed charges 139.5 213.75 Technical (Hospital) Services Hiv2 Ab PX-3028670202 CDM 86702 CPT 302 RC inpatient 225 225 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES PPO [308136801] 178.16 percent of total billed charges 139.5 213.75 Technical (Hospital) Services Hiv2 Ab PX-3028670202 CDM 86702 CPT 302 RC inpatient 225 225 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES HDHP [308136802] 178.16 percent of total billed charges 139.5 213.75 Technical (Hospital) Services Hiv2 Ab PX-3028670202 CDM 86702 CPT 302 RC outpatient 225 225 BLUE CROSS BLUE SHIELD WELLMARK SB889 [3081026] BCBS WYOMING [308102603] 213.75 percent of total billed charges 139.5 213.75 Technical (Hospital) Services Hiv2 Ab PX-3028670202 CDM 86702 CPT 302 RC outpatient 225 225 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES HDHP [308136802] 180 percent of total billed charges 139.5 213.75 Technical (Hospital) Services Hiv2 Ab PX-3028670202 CDM 86702 CPT 302 RC outpatient 225 225 MULTIPLAN INC 34080 [3081285] MULTIPLAN INC [308128501] 213.75 percent of total billed charges 139.5 213.75 Technical (Hospital) Services Hiv2 Ab PX-3028670202 CDM 86702 CPT 302 RC outpatient 225 225 CIGNA 62308 [3081051] CIGNA 62308 [308105105] 180 percent of total billed charges 139.5 213.75 Technical (Hospital) Services Hiv2 Ab PX-3028670202 CDM 86702 CPT 302 RC outpatient 225 225 CIGNA 62308 [3081051] CIGNA STATE OF WYOMING [308105107] 180 percent of total billed charges 139.5 213.75 Technical (Hospital) Services Hiv2 Ab PX-3028670202 CDM 86702 CPT 302 RC outpatient 225 225 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES EPO [308136803] 180 percent of total billed charges 139.5 213.75 Technical (Hospital) Services Hiv2 Ab PX-3028670202 CDM 86702 CPT 302 RC outpatient 225 225 UNITED HEALTHCARE (COMMERCIAL) [3081199] UNITED HEALTHCARE 87726 [308119901] 139.5 percent of total billed charges 139.5 213.75 Technical (Hospital) Services Hiv2 Ab PX-3028670202 CDM 86702 CPT 302 RC outpatient 225 225 HEALTHPARTNERS SX009 HEALTHPARTNERS 180 percent of total billed charges 139.5 213.75 Technical (Hospital) Services Hiv2 Ab PX-3028670202 CDM 86702 CPT 302 RC outpatient 225 225 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES PPO [308136801] 180 percent of total billed charges 139.5 213.75 Technical (Hospital) Services Hiv2 Ab PX-3028670202 CDM 86702 CPT 302 RC outpatient 225 225 MEDICA (COMMERCIAL) 94265 [3081118] MEDICA CLAIMS [308111801] 202.5 percent of total billed charges 139.5 213.75 Technical (Hospital) Services Ref Hiv 1 Antibody PX-3028670100 CDM 86701 CPT 302 RC outpatient 170 170 BLUE CROSS BLUE SHIELD WELLMARK SB889 [3081026] BCBS WYOMING [308102603] 161.5 percent of total billed charges 105.4 161.5 Technical (Hospital) Services Ref Hiv 1 Antibody PX-3028670100 CDM 86701 CPT 302 RC outpatient 170 170 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES HDHP [308136802] 136 percent of total billed charges 105.4 161.5 Technical (Hospital) Services Ref Hiv 1 Antibody PX-3028670100 CDM 86701 CPT 302 RC outpatient 170 170 MULTIPLAN INC 34080 [3081285] MULTIPLAN INC [308128501] 161.5 percent of total billed charges 105.4 161.5 Technical (Hospital) Services Ref Hiv 1 Antibody PX-3028670100 CDM 86701 CPT 302 RC outpatient 170 170 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES EPO [308136803] 136 percent of total billed charges 105.4 161.5 Technical (Hospital) Services Ref Hiv 1 Antibody PX-3028670100 CDM 86701 CPT 302 RC outpatient 170 170 CIGNA 62308 [3081051] CIGNA 62308 [308105105] 136 percent of total billed charges 105.4 161.5 Technical (Hospital) Services Ref Hiv 1 Antibody PX-3028670100 CDM 86701 CPT 302 RC outpatient 170 170 CIGNA 62308 [3081051] CIGNA STATE OF WYOMING [308105107] 136 percent of total billed charges 105.4 161.5 Technical (Hospital) Services Ref Hiv 1 Antibody PX-3028670100 CDM 86701 CPT 302 RC outpatient 170 170 HEALTHPARTNERS SX009 HEALTHPARTNERS 136 percent of total billed charges 105.4 161.5 Technical (Hospital) Services Ref Hiv 1 Antibody PX-3028670100 CDM 86701 CPT 302 RC outpatient 170 170 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES PPO [308136801] 136 percent of total billed charges 105.4 161.5 Technical (Hospital) Services Ref Hiv 1 Antibody PX-3028670100 CDM 86701 CPT 302 RC outpatient 170 170 UNITED HEALTHCARE (COMMERCIAL) [3081199] UNITED HEALTHCARE 87726 [308119901] 105.4 percent of total billed charges 105.4 161.5 Technical (Hospital) Services Ref Hiv 1 Antibody PX-3028670100 CDM 86701 CPT 302 RC outpatient 170 170 MEDICA (COMMERCIAL) 94265 [3081118] MEDICA CLAIMS [308111801] 153 percent of total billed charges 105.4 161.5 Technical (Hospital) Services Ref Hiv 1 Antibody PX-3028670100 CDM 86701 CPT 302 RC inpatient 170 170 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES PPO [308136801] 134.61 percent of total billed charges 105.4 161.5 Technical (Hospital) Services Ref Hiv 1 Antibody PX-3028670100 CDM 86701 CPT 302 RC inpatient 170 170 UNITED HEALTHCARE (COMMERCIAL) [3081199] UNITED HEALTHCARE 87726 [308119901] 105.4 percent of total billed charges 105.4 161.5 Technical (Hospital) Services Ref Hiv 1 Antibody PX-3028670100 CDM 86701 CPT 302 RC inpatient 170 170 MEDICA (COMMERCIAL) 94265 [3081118] MEDICA CLAIMS [308111801] 153 percent of total billed charges 105.4 161.5 Technical (Hospital) Services Ref Hiv 1 Antibody PX-3028670100 CDM 86701 CPT 302 RC inpatient 170 170 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES HDHP [308136802] 134.61 percent of total billed charges 105.4 161.5 Technical (Hospital) Services Ref Hiv 1 Antibody PX-3028670100 CDM 86701 CPT 302 RC inpatient 170 170 HEALTHPARTNERS SX009 HEALTHPARTNERS 134.61 percent of total billed charges 105.4 161.5 Technical (Hospital) Services Ref Hiv 1 Antibody PX-3028670100 CDM 86701 CPT 302 RC inpatient 170 170 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES EPO [308136803] 134.61 percent of total billed charges 105.4 161.5 Technical (Hospital) Services Ref Hiv 1 Antibody PX-3028670100 CDM 86701 CPT 302 RC inpatient 170 170 CIGNA 62308 [3081051] CIGNA 62308 [308105105] 134.61 percent of total billed charges 105.4 161.5 Technical (Hospital) Services Ref Hiv 1 Antibody PX-3028670100 CDM 86701 CPT 302 RC inpatient 170 170 CIGNA 62308 [3081051] CIGNA STATE OF WYOMING [308105107] 134.61 percent of total billed charges 105.4 161.5 Technical (Hospital) Services Ref Hiv 1 Antibody PX-3028670100 CDM 86701 CPT 302 RC inpatient 170 170 BLUE CROSS BLUE SHIELD WELLMARK SB889 [3081026] BCBS WYOMING [308102603] 161.5 percent of total billed charges 105.4 161.5 Technical (Hospital) Services Ref Hiv 1 Antibody PX-3028670100 CDM 86701 CPT 302 RC inpatient 170 170 MULTIPLAN INC 34080 [3081285] MULTIPLAN INC [308128501] 161.5 percent of total billed charges 105.4 161.5 Technical (Hospital) Services Hiv1 Ab PX-3028670104 CDM 86701 CPT 302 RC outpatient 147 147 UNITED HEALTHCARE (COMMERCIAL) [3081199] UNITED HEALTHCARE 87726 [308119901] 91.14 percent of total billed charges 91.14 139.65 Technical (Hospital) Services Hiv1 Ab PX-3028670104 CDM 86701 CPT 302 RC outpatient 147 147 HEALTHPARTNERS SX009 HEALTHPARTNERS 117.6 percent of total billed charges 91.14 139.65 Technical (Hospital) Services Hiv1 Ab PX-3028670104 CDM 86701 CPT 302 RC outpatient 147 147 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES PPO [308136801] 117.6 percent of total billed charges 91.14 139.65 Technical (Hospital) Services Hiv1 Ab PX-3028670104 CDM 86701 CPT 302 RC outpatient 147 147 BLUE CROSS BLUE SHIELD WELLMARK SB889 [3081026] BCBS WYOMING [308102603] 139.65 percent of total billed charges 91.14 139.65 Technical (Hospital) Services Hiv1 Ab PX-3028670104 CDM 86701 CPT 302 RC outpatient 147 147 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES HDHP [308136802] 117.6 percent of total billed charges 91.14 139.65 Technical (Hospital) Services Hiv1 Ab PX-3028670104 CDM 86701 CPT 302 RC outpatient 147 147 MULTIPLAN INC 34080 [3081285] MULTIPLAN INC [308128501] 139.65 percent of total billed charges 91.14 139.65 Technical (Hospital) Services Hiv1 Ab PX-3028670104 CDM 86701 CPT 302 RC outpatient 147 147 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES EPO [308136803] 117.6 percent of total billed charges 91.14 139.65 Technical (Hospital) Services Hiv1 Ab PX-3028670104 CDM 86701 CPT 302 RC outpatient 147 147 CIGNA 62308 [3081051] CIGNA 62308 [308105105] 117.6 percent of total billed charges 91.14 139.65 Technical (Hospital) Services Hiv1 Ab PX-3028670104 CDM 86701 CPT 302 RC outpatient 147 147 CIGNA 62308 [3081051] CIGNA STATE OF WYOMING [308105107] 117.6 percent of total billed charges 91.14 139.65 Technical (Hospital) Services Hiv1 Ab PX-3028670104 CDM 86701 CPT 302 RC outpatient 147 147 MEDICA (COMMERCIAL) 94265 [3081118] MEDICA CLAIMS [308111801] 132.3 percent of total billed charges 91.14 139.65 Technical (Hospital) Services Hiv1 Ab PX-3028670104 CDM 86701 CPT 302 RC inpatient 147 147 HEALTHPARTNERS SX009 HEALTHPARTNERS 116.39 percent of total billed charges 91.14 139.65 Technical (Hospital) Services Hiv1 Ab PX-3028670104 CDM 86701 CPT 302 RC inpatient 147 147 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES EPO [308136803] 116.39 percent of total billed charges 91.14 139.65 Technical (Hospital) Services Hiv1 Ab PX-3028670104 CDM 86701 CPT 302 RC inpatient 147 147 MULTIPLAN INC 34080 [3081285] MULTIPLAN INC [308128501] 139.65 percent of total billed charges 91.14 139.65 Technical (Hospital) Services Hiv1 Ab PX-3028670104 CDM 86701 CPT 302 RC inpatient 147 147 CIGNA 62308 [3081051] CIGNA 62308 [308105105] 116.39 percent of total billed charges 91.14 139.65 Technical (Hospital) Services Hiv1 Ab PX-3028670104 CDM 86701 CPT 302 RC inpatient 147 147 CIGNA 62308 [3081051] CIGNA STATE OF WYOMING [308105107] 116.39 percent of total billed charges 91.14 139.65 Technical (Hospital) Services Hiv1 Ab PX-3028670104 CDM 86701 CPT 302 RC inpatient 147 147 BLUE CROSS BLUE SHIELD WELLMARK SB889 [3081026] BCBS WYOMING [308102603] 139.65 percent of total billed charges 91.14 139.65 Technical (Hospital) Services Hiv1 Ab PX-3028670104 CDM 86701 CPT 302 RC inpatient 147 147 MEDICA (COMMERCIAL) 94265 [3081118] MEDICA CLAIMS [308111801] 132.3 percent of total billed charges 91.14 139.65 Technical (Hospital) Services Hiv1 Ab PX-3028670104 CDM 86701 CPT 302 RC inpatient 147 147 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES HDHP [308136802] 116.39 percent of total billed charges 91.14 139.65 Technical (Hospital) Services Hiv1 Ab PX-3028670104 CDM 86701 CPT 302 RC inpatient 147 147 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES PPO [308136801] 116.39 percent of total billed charges 91.14 139.65 Technical (Hospital) Services Hiv1 Ab PX-3028670104 CDM 86701 CPT 302 RC inpatient 147 147 UNITED HEALTHCARE (COMMERCIAL) [3081199] UNITED HEALTHCARE 87726 [308119901] 91.14 percent of total billed charges 91.14 139.65 Technical (Hospital) Services Herpes Simplex Type 3 PX-3028669600 CDM 86696 CPT 302 RC outpatient 196 196 CIGNA 62308 [3081051] CIGNA 62308 [308105105] 156.8 percent of total billed charges 121.52 186.2 Technical (Hospital) Services Herpes Simplex Type 3 PX-3028669600 CDM 86696 CPT 302 RC outpatient 196 196 CIGNA 62308 [3081051] CIGNA STATE OF WYOMING [308105107] 156.8 percent of total billed charges 121.52 186.2 Technical (Hospital) Services Herpes Simplex Type 3 PX-3028669600 CDM 86696 CPT 302 RC outpatient 196 196 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES EPO [308136803] 156.8 percent of total billed charges 121.52 186.2 Technical (Hospital) Services Herpes Simplex Type 3 PX-3028669600 CDM 86696 CPT 302 RC outpatient 196 196 MULTIPLAN INC 34080 [3081285] MULTIPLAN INC [308128501] 186.2 percent of total billed charges 121.52 186.2 Technical (Hospital) Services Herpes Simplex Type 3 PX-3028669600 CDM 86696 CPT 302 RC outpatient 196 196 BLUE CROSS BLUE SHIELD WELLMARK SB889 [3081026] BCBS WYOMING [308102603] 186.2 percent of total billed charges 121.52 186.2 Technical (Hospital) Services Herpes Simplex Type 3 PX-3028669600 CDM 86696 CPT 302 RC outpatient 196 196 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES HDHP [308136802] 156.8 percent of total billed charges 121.52 186.2 Technical (Hospital) Services Herpes Simplex Type 3 PX-3028669600 CDM 86696 CPT 302 RC outpatient 196 196 UNITED HEALTHCARE (COMMERCIAL) [3081199] UNITED HEALTHCARE 87726 [308119901] 121.52 percent of total billed charges 121.52 186.2 Technical (Hospital) Services Herpes Simplex Type 3 PX-3028669600 CDM 86696 CPT 302 RC outpatient 196 196 HEALTHPARTNERS SX009 HEALTHPARTNERS 156.8 percent of total billed charges 121.52 186.2 Technical (Hospital) Services Herpes Simplex Type 3 PX-3028669600 CDM 86696 CPT 302 RC outpatient 196 196 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES PPO [308136801] 156.8 percent of total billed charges 121.52 186.2 Technical (Hospital) Services Herpes Simplex Type 3 PX-3028669600 CDM 86696 CPT 302 RC outpatient 196 196 MEDICA (COMMERCIAL) 94265 [3081118] MEDICA CLAIMS [308111801] 176.4 percent of total billed charges 121.52 186.2 Technical (Hospital) Services Herpes Simplex Type 3 PX-3028669600 CDM 86696 CPT 302 RC inpatient 196 196 HEALTHPARTNERS SX009 HEALTHPARTNERS 155.19 percent of total billed charges 121.52 186.2 Technical (Hospital) Services Herpes Simplex Type 3 PX-3028669600 CDM 86696 CPT 302 RC inpatient 196 196 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES EPO [308136803] 155.19 percent of total billed charges 121.52 186.2 Technical (Hospital) Services Herpes Simplex Type 3 PX-3028669600 CDM 86696 CPT 302 RC inpatient 196 196 MEDICA (COMMERCIAL) 94265 [3081118] MEDICA CLAIMS [308111801] 176.4 percent of total billed charges 121.52 186.2 Technical (Hospital) Services Herpes Simplex Type 3 PX-3028669600 CDM 86696 CPT 302 RC inpatient 196 196 MULTIPLAN INC 34080 [3081285] MULTIPLAN INC [308128501] 186.2 percent of total billed charges 121.52 186.2 Technical (Hospital) Services Herpes Simplex Type 3 PX-3028669600 CDM 86696 CPT 302 RC inpatient 196 196 CIGNA 62308 [3081051] CIGNA 62308 [308105105] 155.19 percent of total billed charges 121.52 186.2 Technical (Hospital) Services Herpes Simplex Type 3 PX-3028669600 CDM 86696 CPT 302 RC inpatient 196 196 CIGNA 62308 [3081051] CIGNA STATE OF WYOMING [308105107] 155.19 percent of total billed charges 121.52 186.2 Technical (Hospital) Services Herpes Simplex Type 3 PX-3028669600 CDM 86696 CPT 302 RC inpatient 196 196 BLUE CROSS BLUE SHIELD WELLMARK SB889 [3081026] BCBS WYOMING [308102603] 186.2 percent of total billed charges 121.52 186.2 Technical (Hospital) Services Herpes Simplex Type 3 PX-3028669600 CDM 86696 CPT 302 RC inpatient 196 196 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES PPO [308136801] 155.19 percent of total billed charges 121.52 186.2 Technical (Hospital) Services Herpes Simplex Type 3 PX-3028669600 CDM 86696 CPT 302 RC inpatient 196 196 UNITED HEALTHCARE (COMMERCIAL) [3081199] UNITED HEALTHCARE 87726 [308119901] 121.52 percent of total billed charges 121.52 186.2 Technical (Hospital) Services Herpes Simplex Type 3 PX-3028669600 CDM 86696 CPT 302 RC inpatient 196 196 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES HDHP [308136802] 155.19 percent of total billed charges 121.52 186.2 Technical (Hospital) Services Hsv Type 2 Ab Igg PX-3028669604 CDM 86696 CPT 302 RC inpatient 176 176 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES PPO [308136801] 139.36 percent of total billed charges 109.12 167.2 Technical (Hospital) Services Hsv Type 2 Ab Igg PX-3028669604 CDM 86696 CPT 302 RC inpatient 176 176 UNITED HEALTHCARE (COMMERCIAL) [3081199] UNITED HEALTHCARE 87726 [308119901] 109.12 percent of total billed charges 109.12 167.2 Technical (Hospital) Services Hsv Type 2 Ab Igg PX-3028669604 CDM 86696 CPT 302 RC inpatient 176 176 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES HDHP [308136802] 139.36 percent of total billed charges 109.12 167.2 Technical (Hospital) Services Hsv Type 2 Ab Igg PX-3028669604 CDM 86696 CPT 302 RC inpatient 176 176 BLUE CROSS BLUE SHIELD WELLMARK SB889 [3081026] BCBS WYOMING [308102603] 167.2 percent of total billed charges 109.12 167.2 Technical (Hospital) Services Hsv Type 2 Ab Igg PX-3028669604 CDM 86696 CPT 302 RC inpatient 176 176 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES EPO [308136803] 139.36 percent of total billed charges 109.12 167.2 Technical (Hospital) Services Hsv Type 2 Ab Igg PX-3028669604 CDM 86696 CPT 302 RC inpatient 176 176 HEALTHPARTNERS SX009 HEALTHPARTNERS 139.36 percent of total billed charges 109.12 167.2 Technical (Hospital) Services Hsv Type 2 Ab Igg PX-3028669604 CDM 86696 CPT 302 RC inpatient 176 176 MULTIPLAN INC 34080 [3081285] MULTIPLAN INC [308128501] 167.2 percent of total billed charges 109.12 167.2 Technical (Hospital) Services Hsv Type 2 Ab Igg PX-3028669604 CDM 86696 CPT 302 RC inpatient 176 176 MEDICA (COMMERCIAL) 94265 [3081118] MEDICA CLAIMS [308111801] 158.4 percent of total billed charges 109.12 167.2 Technical (Hospital) Services Hsv Type 2 Ab Igg PX-3028669604 CDM 86696 CPT 302 RC inpatient 176 176 CIGNA 62308 [3081051] CIGNA 62308 [308105105] 139.36 percent of total billed charges 109.12 167.2 Technical (Hospital) Services Hsv Type 2 Ab Igg PX-3028669604 CDM 86696 CPT 302 RC inpatient 176 176 CIGNA 62308 [3081051] CIGNA STATE OF WYOMING [308105107] 139.36 percent of total billed charges 109.12 167.2 Technical (Hospital) Services Hsv Type 2 Ab Igg PX-3028669604 CDM 86696 CPT 302 RC outpatient 176 176 MEDICA (COMMERCIAL) 94265 [3081118] MEDICA CLAIMS [308111801] 158.4 percent of total billed charges 109.12 167.2 Technical (Hospital) Services Hsv Type 2 Ab Igg PX-3028669604 CDM 86696 CPT 302 RC outpatient 176 176 HEALTHPARTNERS SX009 HEALTHPARTNERS 140.8 percent of total billed charges 109.12 167.2 Technical (Hospital) Services Hsv Type 2 Ab Igg PX-3028669604 CDM 86696 CPT 302 RC outpatient 176 176 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES PPO [308136801] 140.8 percent of total billed charges 109.12 167.2 Technical (Hospital) Services Hsv Type 2 Ab Igg PX-3028669604 CDM 86696 CPT 302 RC outpatient 176 176 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES EPO [308136803] 140.8 percent of total billed charges 109.12 167.2 Technical (Hospital) Services Hsv Type 2 Ab Igg PX-3028669604 CDM 86696 CPT 302 RC outpatient 176 176 CIGNA 62308 [3081051] CIGNA 62308 [308105105] 140.8 percent of total billed charges 109.12 167.2 Technical (Hospital) Services Hsv Type 2 Ab Igg PX-3028669604 CDM 86696 CPT 302 RC outpatient 176 176 CIGNA 62308 [3081051] CIGNA STATE OF WYOMING [308105107] 140.8 percent of total billed charges 109.12 167.2 Technical (Hospital) Services Hsv Type 2 Ab Igg PX-3028669604 CDM 86696 CPT 302 RC outpatient 176 176 MULTIPLAN INC 34080 [3081285] MULTIPLAN INC [308128501] 167.2 percent of total billed charges 109.12 167.2 Technical (Hospital) Services Hsv Type 2 Ab Igg PX-3028669604 CDM 86696 CPT 302 RC outpatient 176 176 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES HDHP [308136802] 140.8 percent of total billed charges 109.12 167.2 Technical (Hospital) Services Hsv Type 2 Ab Igg PX-3028669604 CDM 86696 CPT 302 RC outpatient 176 176 BLUE CROSS BLUE SHIELD WELLMARK SB889 [3081026] BCBS WYOMING [308102603] 167.2 percent of total billed charges 109.12 167.2 Technical (Hospital) Services Hsv Type 2 Ab Igg PX-3028669604 CDM 86696 CPT 302 RC outpatient 176 176 UNITED HEALTHCARE (COMMERCIAL) [3081199] UNITED HEALTHCARE 87726 [308119901] 109.12 percent of total billed charges 109.12 167.2 Technical (Hospital) Services Ref Herpes Simplex Type 1 PX-3028669500 CDM 86695 CPT 302 RC outpatient 197 197 MEDICA (COMMERCIAL) 94265 [3081118] MEDICA CLAIMS [308111801] 177.3 percent of total billed charges 122.14 187.15 Technical (Hospital) Services Ref Herpes Simplex Type 1 PX-3028669500 CDM 86695 CPT 302 RC outpatient 197 197 UNITED HEALTHCARE (COMMERCIAL) [3081199] UNITED HEALTHCARE 87726 [308119901] 122.14 percent of total billed charges 122.14 187.15 Technical (Hospital) Services Ref Herpes Simplex Type 1 PX-3028669500 CDM 86695 CPT 302 RC outpatient 197 197 HEALTHPARTNERS SX009 HEALTHPARTNERS 157.6 percent of total billed charges 122.14 187.15 Technical (Hospital) Services Ref Herpes Simplex Type 1 PX-3028669500 CDM 86695 CPT 302 RC outpatient 197 197 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES PPO [308136801] 157.6 percent of total billed charges 122.14 187.15 Technical (Hospital) Services Ref Herpes Simplex Type 1 PX-3028669500 CDM 86695 CPT 302 RC outpatient 197 197 CIGNA 62308 [3081051] CIGNA 62308 [308105105] 157.6 percent of total billed charges 122.14 187.15 Technical (Hospital) Services Ref Herpes Simplex Type 1 PX-3028669500 CDM 86695 CPT 302 RC outpatient 197 197 CIGNA 62308 [3081051] CIGNA STATE OF WYOMING [308105107] 157.6 percent of total billed charges 122.14 187.15 Technical (Hospital) Services Ref Herpes Simplex Type 1 PX-3028669500 CDM 86695 CPT 302 RC outpatient 197 197 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES EPO [308136803] 157.6 percent of total billed charges 122.14 187.15 Technical (Hospital) Services Ref Herpes Simplex Type 1 PX-3028669500 CDM 86695 CPT 302 RC outpatient 197 197 MULTIPLAN INC 34080 [3081285] MULTIPLAN INC [308128501] 187.15 percent of total billed charges 122.14 187.15 Technical (Hospital) Services Ref Herpes Simplex Type 1 PX-3028669500 CDM 86695 CPT 302 RC outpatient 197 197 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES HDHP [308136802] 157.6 percent of total billed charges 122.14 187.15 Technical (Hospital) Services Ref Herpes Simplex Type 1 PX-3028669500 CDM 86695 CPT 302 RC outpatient 197 197 BLUE CROSS BLUE SHIELD WELLMARK SB889 [3081026] BCBS WYOMING [308102603] 187.15 percent of total billed charges 122.14 187.15 Technical (Hospital) Services Ref Herpes Simplex Type 1 PX-3028669500 CDM 86695 CPT 302 RC inpatient 197 197 MEDICA (COMMERCIAL) 94265 [3081118] MEDICA CLAIMS [308111801] 177.3 percent of total billed charges 122.14 187.15 Technical (Hospital) Services Ref Herpes Simplex Type 1 PX-3028669500 CDM 86695 CPT 302 RC inpatient 197 197 MULTIPLAN INC 34080 [3081285] MULTIPLAN INC [308128501] 187.15 percent of total billed charges 122.14 187.15 Technical (Hospital) Services Ref Herpes Simplex Type 1 PX-3028669500 CDM 86695 CPT 302 RC inpatient 197 197 CIGNA 62308 [3081051] CIGNA 62308 [308105105] 155.98 percent of total billed charges 122.14 187.15 Technical (Hospital) Services Ref Herpes Simplex Type 1 PX-3028669500 CDM 86695 CPT 302 RC inpatient 197 197 CIGNA 62308 [3081051] CIGNA STATE OF WYOMING [308105107] 155.98 percent of total billed charges 122.14 187.15 Technical (Hospital) Services Ref Herpes Simplex Type 1 PX-3028669500 CDM 86695 CPT 302 RC inpatient 197 197 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES EPO [308136803] 155.98 percent of total billed charges 122.14 187.15 Technical (Hospital) Services Ref Herpes Simplex Type 1 PX-3028669500 CDM 86695 CPT 302 RC inpatient 197 197 BLUE CROSS BLUE SHIELD WELLMARK SB889 [3081026] BCBS WYOMING [308102603] 187.15 percent of total billed charges 122.14 187.15 Technical (Hospital) Services Ref Herpes Simplex Type 1 PX-3028669500 CDM 86695 CPT 302 RC inpatient 197 197 HEALTHPARTNERS SX009 HEALTHPARTNERS 155.98 percent of total billed charges 122.14 187.15 Technical (Hospital) Services Ref Herpes Simplex Type 1 PX-3028669500 CDM 86695 CPT 302 RC inpatient 197 197 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES HDHP [308136802] 155.98 percent of total billed charges 122.14 187.15 Technical (Hospital) Services Ref Herpes Simplex Type 1 PX-3028669500 CDM 86695 CPT 302 RC inpatient 197 197 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES PPO [308136801] 155.98 percent of total billed charges 122.14 187.15 Technical (Hospital) Services Ref Herpes Simplex Type 1 PX-3028669500 CDM 86695 CPT 302 RC inpatient 197 197 UNITED HEALTHCARE (COMMERCIAL) [3081199] UNITED HEALTHCARE 87726 [308119901] 122.14 percent of total billed charges 122.14 187.15 Technical (Hospital) Services Hsv Type 1 Ab Igg PX-3028669504 CDM 86695 CPT 302 RC inpatient 139 139 CIGNA 62308 [3081051] CIGNA 62308 [308105105] 110.06 percent of total billed charges 86.18 132.05 Technical (Hospital) Services Hsv Type 1 Ab Igg PX-3028669504 CDM 86695 CPT 302 RC inpatient 139 139 CIGNA 62308 [3081051] CIGNA STATE OF WYOMING [308105107] 110.06 percent of total billed charges 86.18 132.05 Technical (Hospital) Services Hsv Type 1 Ab Igg PX-3028669504 CDM 86695 CPT 302 RC inpatient 139 139 MEDICA (COMMERCIAL) 94265 [3081118] MEDICA CLAIMS [308111801] 125.1 percent of total billed charges 86.18 132.05 Technical (Hospital) Services Hsv Type 1 Ab Igg PX-3028669504 CDM 86695 CPT 302 RC inpatient 139 139 MULTIPLAN INC 34080 [3081285] MULTIPLAN INC [308128501] 132.05 percent of total billed charges 86.18 132.05 Technical (Hospital) Services Hsv Type 1 Ab Igg PX-3028669504 CDM 86695 CPT 302 RC inpatient 139 139 HEALTHPARTNERS SX009 HEALTHPARTNERS 110.06 percent of total billed charges 86.18 132.05 Technical (Hospital) Services Hsv Type 1 Ab Igg PX-3028669504 CDM 86695 CPT 302 RC inpatient 139 139 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES EPO [308136803] 110.06 percent of total billed charges 86.18 132.05 Technical (Hospital) Services Hsv Type 1 Ab Igg PX-3028669504 CDM 86695 CPT 302 RC inpatient 139 139 BLUE CROSS BLUE SHIELD WELLMARK SB889 [3081026] BCBS WYOMING [308102603] 132.05 percent of total billed charges 86.18 132.05 Technical (Hospital) Services Hsv Type 1 Ab Igg PX-3028669504 CDM 86695 CPT 302 RC inpatient 139 139 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES HDHP [308136802] 110.06 percent of total billed charges 86.18 132.05 Technical (Hospital) Services Hsv Type 1 Ab Igg PX-3028669504 CDM 86695 CPT 302 RC inpatient 139 139 UNITED HEALTHCARE (COMMERCIAL) [3081199] UNITED HEALTHCARE 87726 [308119901] 86.18 percent of total billed charges 86.18 132.05 Technical (Hospital) Services Hsv Type 1 Ab Igg PX-3028669504 CDM 86695 CPT 302 RC inpatient 139 139 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES PPO [308136801] 110.06 percent of total billed charges 86.18 132.05 Technical (Hospital) Services Hsv Type 1 Ab Igg PX-3028669504 CDM 86695 CPT 302 RC outpatient 139 139 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES PPO [308136801] 111.2 percent of total billed charges 86.18 132.05 Technical (Hospital) Services Hsv Type 1 Ab Igg PX-3028669504 CDM 86695 CPT 302 RC outpatient 139 139 HEALTHPARTNERS SX009 HEALTHPARTNERS 111.2 percent of total billed charges 86.18 132.05 Technical (Hospital) Services Hsv Type 1 Ab Igg PX-3028669504 CDM 86695 CPT 302 RC outpatient 139 139 UNITED HEALTHCARE (COMMERCIAL) [3081199] UNITED HEALTHCARE 87726 [308119901] 86.18 percent of total billed charges 86.18 132.05 Technical (Hospital) Services Hsv Type 1 Ab Igg PX-3028669504 CDM 86695 CPT 302 RC outpatient 139 139 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES EPO [308136803] 111.2 percent of total billed charges 86.18 132.05 Technical (Hospital) Services Hsv Type 1 Ab Igg PX-3028669504 CDM 86695 CPT 302 RC outpatient 139 139 CIGNA 62308 [3081051] CIGNA 62308 [308105105] 111.2 percent of total billed charges 86.18 132.05 Technical (Hospital) Services Hsv Type 1 Ab Igg PX-3028669504 CDM 86695 CPT 302 RC outpatient 139 139 CIGNA 62308 [3081051] CIGNA STATE OF WYOMING [308105107] 111.2 percent of total billed charges 86.18 132.05 Technical (Hospital) Services Hsv Type 1 Ab Igg PX-3028669504 CDM 86695 CPT 302 RC outpatient 139 139 MULTIPLAN INC 34080 [3081285] MULTIPLAN INC [308128501] 132.05 percent of total billed charges 86.18 132.05 Technical (Hospital) Services Hsv Type 1 Ab Igg PX-3028669504 CDM 86695 CPT 302 RC outpatient 139 139 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES HDHP [308136802] 111.2 percent of total billed charges 86.18 132.05 Technical (Hospital) Services Hsv Type 1 Ab Igg PX-3028669504 CDM 86695 CPT 302 RC outpatient 139 139 BLUE CROSS BLUE SHIELD WELLMARK SB889 [3081026] BCBS WYOMING [308102603] 132.05 percent of total billed charges 86.18 132.05 Technical (Hospital) Services Hsv Type 1 Ab Igg PX-3028669504 CDM 86695 CPT 302 RC outpatient 139 139 MEDICA (COMMERCIAL) 94265 [3081118] MEDICA CLAIMS [308111801] 125.1 percent of total billed charges 86.18 132.05 Technical (Hospital) Services Ref Hsv Ab Igm S by Eia PX-3028669401 CDM 86694 CPT 302 RC inpatient 196 196 MULTIPLAN INC 34080 [3081285] MULTIPLAN INC [308128501] 186.2 percent of total billed charges 121.52 186.2 Technical (Hospital) Services Ref Hsv Ab Igm S by Eia PX-3028669401 CDM 86694 CPT 302 RC inpatient 196 196 BLUE CROSS BLUE SHIELD WELLMARK SB889 [3081026] BCBS WYOMING [308102603] 186.2 percent of total billed charges 121.52 186.2 Technical (Hospital) Services Ref Hsv Ab Igm S by Eia PX-3028669401 CDM 86694 CPT 302 RC inpatient 196 196 CIGNA 62308 [3081051] CIGNA 62308 [308105105] 155.19 percent of total billed charges 121.52 186.2 Technical (Hospital) Services Ref Hsv Ab Igm S by Eia PX-3028669401 CDM 86694 CPT 302 RC inpatient 196 196 CIGNA 62308 [3081051] CIGNA STATE OF WYOMING [308105107] 155.19 percent of total billed charges 121.52 186.2 Technical (Hospital) Services Ref Hsv Ab Igm S by Eia PX-3028669401 CDM 86694 CPT 302 RC inpatient 196 196 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES EPO [308136803] 155.19 percent of total billed charges 121.52 186.2 Technical (Hospital) Services Ref Hsv Ab Igm S by Eia PX-3028669401 CDM 86694 CPT 302 RC inpatient 196 196 HEALTHPARTNERS SX009 HEALTHPARTNERS 155.19 percent of total billed charges 121.52 186.2 Technical (Hospital) Services Ref Hsv Ab Igm S by Eia PX-3028669401 CDM 86694 CPT 302 RC inpatient 196 196 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES HDHP [308136802] 155.19 percent of total billed charges 121.52 186.2 Technical (Hospital) Services Ref Hsv Ab Igm S by Eia PX-3028669401 CDM 86694 CPT 302 RC inpatient 196 196 MEDICA (COMMERCIAL) 94265 [3081118] MEDICA CLAIMS [308111801] 176.4 percent of total billed charges 121.52 186.2 Technical (Hospital) Services Ref Hsv Ab Igm S by Eia PX-3028669401 CDM 86694 CPT 302 RC inpatient 196 196 UNITED HEALTHCARE (COMMERCIAL) [3081199] UNITED HEALTHCARE 87726 [308119901] 121.52 percent of total billed charges 121.52 186.2 Technical (Hospital) Services Ref Hsv Ab Igm S by Eia PX-3028669401 CDM 86694 CPT 302 RC inpatient 196 196 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES PPO [308136801] 155.19 percent of total billed charges 121.52 186.2 Technical (Hospital) Services Ref Hsv Ab Igm S by Eia PX-3028669401 CDM 86694 CPT 302 RC outpatient 196 196 UNITED HEALTHCARE (COMMERCIAL) [3081199] UNITED HEALTHCARE 87726 [308119901] 121.52 percent of total billed charges 121.52 186.2 Technical (Hospital) Services Ref Hsv Ab Igm S by Eia PX-3028669401 CDM 86694 CPT 302 RC outpatient 196 196 BLUE CROSS BLUE SHIELD WELLMARK SB889 [3081026] BCBS WYOMING [308102603] 186.2 percent of total billed charges 121.52 186.2 Technical (Hospital) Services Ref Hsv Ab Igm S by Eia PX-3028669401 CDM 86694 CPT 302 RC outpatient 196 196 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES HDHP [308136802] 156.8 percent of total billed charges 121.52 186.2 Technical (Hospital) Services Ref Hsv Ab Igm S by Eia PX-3028669401 CDM 86694 CPT 302 RC outpatient 196 196 MULTIPLAN INC 34080 [3081285] MULTIPLAN INC [308128501] 186.2 percent of total billed charges 121.52 186.2 Technical (Hospital) Services Ref Hsv Ab Igm S by Eia PX-3028669401 CDM 86694 CPT 302 RC outpatient 196 196 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES EPO [308136803] 156.8 percent of total billed charges 121.52 186.2 Technical (Hospital) Services Ref Hsv Ab Igm S by Eia PX-3028669401 CDM 86694 CPT 302 RC outpatient 196 196 CIGNA 62308 [3081051] CIGNA 62308 [308105105] 156.8 percent of total billed charges 121.52 186.2 Technical (Hospital) Services Ref Hsv Ab Igm S by Eia PX-3028669401 CDM 86694 CPT 302 RC outpatient 196 196 CIGNA 62308 [3081051] CIGNA STATE OF WYOMING [308105107] 156.8 percent of total billed charges 121.52 186.2 Technical (Hospital) Services Ref Hsv Ab Igm S by Eia PX-3028669401 CDM 86694 CPT 302 RC outpatient 196 196 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES PPO [308136801] 156.8 percent of total billed charges 121.52 186.2 Technical (Hospital) Services Ref Hsv Ab Igm S by Eia PX-3028669401 CDM 86694 CPT 302 RC outpatient 196 196 HEALTHPARTNERS SX009 HEALTHPARTNERS 156.8 percent of total billed charges 121.52 186.2 Technical (Hospital) Services Ref Hsv Ab Igm S by Eia PX-3028669401 CDM 86694 CPT 302 RC outpatient 196 196 MEDICA (COMMERCIAL) 94265 [3081118] MEDICA CLAIMS [308111801] 176.4 percent of total billed charges 121.52 186.2 Technical (Hospital) Services Heliobacter Pylori Ab PX-3028667700 CDM 86677 CPT 302 RC outpatient 231 231 UNITED HEALTHCARE (COMMERCIAL) [3081199] UNITED HEALTHCARE 87726 [308119901] 143.22 percent of total billed charges 143.22 219.45 Technical (Hospital) Services Heliobacter Pylori Ab PX-3028667700 CDM 86677 CPT 302 RC outpatient 231 231 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES PPO [308136801] 184.8 percent of total billed charges 143.22 219.45 Technical (Hospital) Services Heliobacter Pylori Ab PX-3028667700 CDM 86677 CPT 302 RC outpatient 231 231 HEALTHPARTNERS SX009 HEALTHPARTNERS 184.8 percent of total billed charges 143.22 219.45 Technical (Hospital) Services Heliobacter Pylori Ab PX-3028667700 CDM 86677 CPT 302 RC outpatient 231 231 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES HDHP [308136802] 184.8 percent of total billed charges 143.22 219.45 Technical (Hospital) Services Heliobacter Pylori Ab PX-3028667700 CDM 86677 CPT 302 RC outpatient 231 231 BLUE CROSS BLUE SHIELD WELLMARK SB889 [3081026] BCBS WYOMING [308102603] 219.45 percent of total billed charges 143.22 219.45 Technical (Hospital) Services Heliobacter Pylori Ab PX-3028667700 CDM 86677 CPT 302 RC outpatient 231 231 CIGNA 62308 [3081051] CIGNA 62308 [308105105] 184.8 percent of total billed charges 143.22 219.45 Technical (Hospital) Services Heliobacter Pylori Ab PX-3028667700 CDM 86677 CPT 302 RC outpatient 231 231 CIGNA 62308 [3081051] CIGNA STATE OF WYOMING [308105107] 184.8 percent of total billed charges 143.22 219.45 Technical (Hospital) Services Heliobacter Pylori Ab PX-3028667700 CDM 86677 CPT 302 RC outpatient 231 231 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES EPO [308136803] 184.8 percent of total billed charges 143.22 219.45 Technical (Hospital) Services Heliobacter Pylori Ab PX-3028667700 CDM 86677 CPT 302 RC outpatient 231 231 MULTIPLAN INC 34080 [3081285] MULTIPLAN INC [308128501] 219.45 percent of total billed charges 143.22 219.45 Technical (Hospital) Services Heliobacter Pylori Ab PX-3028667700 CDM 86677 CPT 302 RC outpatient 231 231 MEDICA (COMMERCIAL) 94265 [3081118] MEDICA CLAIMS [308111801] 207.9 percent of total billed charges 143.22 219.45 Technical (Hospital) Services Heliobacter Pylori Ab PX-3028667700 CDM 86677 CPT 302 RC inpatient 231 231 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES HDHP [308136802] 182.91 percent of total billed charges 143.22 219.45 Technical (Hospital) Services Heliobacter Pylori Ab PX-3028667700 CDM 86677 CPT 302 RC inpatient 231 231 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES PPO [308136801] 182.91 percent of total billed charges 143.22 219.45 Technical (Hospital) Services Heliobacter Pylori Ab PX-3028667700 CDM 86677 CPT 302 RC inpatient 231 231 UNITED HEALTHCARE (COMMERCIAL) [3081199] UNITED HEALTHCARE 87726 [308119901] 143.22 percent of total billed charges 143.22 219.45 Technical (Hospital) Services Heliobacter Pylori Ab PX-3028667700 CDM 86677 CPT 302 RC inpatient 231 231 CIGNA 62308 [3081051] CIGNA 62308 [308105105] 182.91 percent of total billed charges 143.22 219.45 Technical (Hospital) Services Heliobacter Pylori Ab PX-3028667700 CDM 86677 CPT 302 RC inpatient 231 231 CIGNA 62308 [3081051] CIGNA STATE OF WYOMING [308105107] 182.91 percent of total billed charges 143.22 219.45 Technical (Hospital) Services Heliobacter Pylori Ab PX-3028667700 CDM 86677 CPT 302 RC inpatient 231 231 MULTIPLAN INC 34080 [3081285] MULTIPLAN INC [308128501] 219.45 percent of total billed charges 143.22 219.45 Technical (Hospital) Services Heliobacter Pylori Ab PX-3028667700 CDM 86677 CPT 302 RC inpatient 231 231 MEDICA (COMMERCIAL) 94265 [3081118] MEDICA CLAIMS [308111801] 207.9 percent of total billed charges 143.22 219.45 Technical (Hospital) Services Heliobacter Pylori Ab PX-3028667700 CDM 86677 CPT 302 RC inpatient 231 231 HEALTHPARTNERS SX009 HEALTHPARTNERS 182.91 percent of total billed charges 143.22 219.45 Technical (Hospital) Services Heliobacter Pylori Ab PX-3028667700 CDM 86677 CPT 302 RC inpatient 231 231 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES EPO [308136803] 182.91 percent of total billed charges 143.22 219.45 Technical (Hospital) Services Heliobacter Pylori Ab PX-3028667700 CDM 86677 CPT 302 RC inpatient 231 231 BLUE CROSS BLUE SHIELD WELLMARK SB889 [3081026] BCBS WYOMING [308102603] 219.45 percent of total billed charges 143.22 219.45 Technical (Hospital) Services "Ref F. Tularensis Ab, Igm/Igg Elisa, S(Mayo)" PX-3028666800 CDM 86668 CPT 302 RC outpatient 120 120 MEDICA (COMMERCIAL) 94265 [3081118] MEDICA CLAIMS [308111801] 108 percent of total billed charges 74.4 114 Technical (Hospital) Services "Ref F. Tularensis Ab, Igm/Igg Elisa, S(Mayo)" PX-3028666800 CDM 86668 CPT 302 RC outpatient 120 120 UNITED HEALTHCARE (COMMERCIAL) [3081199] UNITED HEALTHCARE 87726 [308119901] 74.4 percent of total billed charges 74.4 114 Technical (Hospital) Services "Ref F. Tularensis Ab, Igm/Igg Elisa, S(Mayo)" PX-3028666800 CDM 86668 CPT 302 RC outpatient 120 120 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES PPO [308136801] 96 percent of total billed charges 74.4 114 Technical (Hospital) Services "Ref F. Tularensis Ab, Igm/Igg Elisa, S(Mayo)" PX-3028666800 CDM 86668 CPT 302 RC outpatient 120 120 HEALTHPARTNERS SX009 HEALTHPARTNERS 96 percent of total billed charges 74.4 114 Technical (Hospital) Services "Ref F. Tularensis Ab, Igm/Igg Elisa, S(Mayo)" PX-3028666800 CDM 86668 CPT 302 RC outpatient 120 120 BLUE CROSS BLUE SHIELD WELLMARK SB889 [3081026] BCBS WYOMING [308102603] 114 percent of total billed charges 74.4 114 Technical (Hospital) Services "Ref F. Tularensis Ab, Igm/Igg Elisa, S(Mayo)" PX-3028666800 CDM 86668 CPT 302 RC outpatient 120 120 MULTIPLAN INC 34080 [3081285] MULTIPLAN INC [308128501] 114 percent of total billed charges 74.4 114 Technical (Hospital) Services "Ref F. Tularensis Ab, Igm/Igg Elisa, S(Mayo)" PX-3028666800 CDM 86668 CPT 302 RC outpatient 120 120 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES EPO [308136803] 96 percent of total billed charges 74.4 114 Technical (Hospital) Services "Ref F. Tularensis Ab, Igm/Igg Elisa, S(Mayo)" PX-3028666800 CDM 86668 CPT 302 RC outpatient 120 120 CIGNA 62308 [3081051] CIGNA STATE OF WYOMING [308105107] 96 percent of total billed charges 74.4 114 Technical (Hospital) Services "Ref F. Tularensis Ab, Igm/Igg Elisa, S(Mayo)" PX-3028666800 CDM 86668 CPT 302 RC outpatient 120 120 CIGNA 62308 [3081051] CIGNA 62308 [308105105] 96 percent of total billed charges 74.4 114 Technical (Hospital) Services "Ref F. Tularensis Ab, Igm/Igg Elisa, S(Mayo)" PX-3028666800 CDM 86668 CPT 302 RC outpatient 120 120 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES HDHP [308136802] 96 percent of total billed charges 74.4 114 Technical (Hospital) Services "Ref F. Tularensis Ab, Igm/Igg Elisa, S(Mayo)" PX-3028666800 CDM 86668 CPT 302 RC inpatient 120 120 UNITED HEALTHCARE (COMMERCIAL) [3081199] UNITED HEALTHCARE 87726 [308119901] 74.4 percent of total billed charges 74.4 114 Technical (Hospital) Services "Ref F. Tularensis Ab, Igm/Igg Elisa, S(Mayo)" PX-3028666800 CDM 86668 CPT 302 RC inpatient 120 120 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES PPO [308136801] 95.02 percent of total billed charges 74.4 114 Technical (Hospital) Services "Ref F. Tularensis Ab, Igm/Igg Elisa, S(Mayo)" PX-3028666800 CDM 86668 CPT 302 RC inpatient 120 120 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES HDHP [308136802] 95.02 percent of total billed charges 74.4 114 Technical (Hospital) Services "Ref F. Tularensis Ab, Igm/Igg Elisa, S(Mayo)" PX-3028666800 CDM 86668 CPT 302 RC inpatient 120 120 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES EPO [308136803] 95.02 percent of total billed charges 74.4 114 Technical (Hospital) Services "Ref F. Tularensis Ab, Igm/Igg Elisa, S(Mayo)" PX-3028666800 CDM 86668 CPT 302 RC inpatient 120 120 BLUE CROSS BLUE SHIELD WELLMARK SB889 [3081026] BCBS WYOMING [308102603] 114 percent of total billed charges 74.4 114 Technical (Hospital) Services "Ref F. Tularensis Ab, Igm/Igg Elisa, S(Mayo)" PX-3028666800 CDM 86668 CPT 302 RC inpatient 120 120 HEALTHPARTNERS SX009 HEALTHPARTNERS 95.02 percent of total billed charges 74.4 114 Technical (Hospital) Services "Ref F. Tularensis Ab, Igm/Igg Elisa, S(Mayo)" PX-3028666800 CDM 86668 CPT 302 RC inpatient 120 120 CIGNA 62308 [3081051] CIGNA 62308 [308105105] 95.02 percent of total billed charges 74.4 114 Technical (Hospital) Services "Ref F. Tularensis Ab, Igm/Igg Elisa, S(Mayo)" PX-3028666800 CDM 86668 CPT 302 RC inpatient 120 120 CIGNA 62308 [3081051] CIGNA STATE OF WYOMING [308105107] 95.02 percent of total billed charges 74.4 114 Technical (Hospital) Services "Ref F. Tularensis Ab, Igm/Igg Elisa, S(Mayo)" PX-3028666800 CDM 86668 CPT 302 RC inpatient 120 120 MEDICA (COMMERCIAL) 94265 [3081118] MEDICA CLAIMS [308111801] 108 percent of total billed charges 74.4 114 Technical (Hospital) Services "Ref F. Tularensis Ab, Igm/Igg Elisa, S(Mayo)" PX-3028666800 CDM 86668 CPT 302 RC inpatient 120 120 MULTIPLAN INC 34080 [3081285] MULTIPLAN INC [308128501] 114 percent of total billed charges 74.4 114 Technical (Hospital) Services Ref Ebv Ab Bca Igg or Igm PX-3028666501 CDM 86665 CPT 302 RC inpatient 238 238 HEALTHPARTNERS SX009 HEALTHPARTNERS 188.45 percent of total billed charges 147.56 226.1 Technical (Hospital) Services Ref Ebv Ab Bca Igg or Igm PX-3028666501 CDM 86665 CPT 302 RC inpatient 238 238 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES EPO [308136803] 188.45 percent of total billed charges 147.56 226.1 Technical (Hospital) Services Ref Ebv Ab Bca Igg or Igm PX-3028666501 CDM 86665 CPT 302 RC inpatient 238 238 BLUE CROSS BLUE SHIELD WELLMARK SB889 [3081026] BCBS WYOMING [308102603] 226.1 percent of total billed charges 147.56 226.1 Technical (Hospital) Services Ref Ebv Ab Bca Igg or Igm PX-3028666501 CDM 86665 CPT 302 RC inpatient 238 238 CIGNA 62308 [3081051] CIGNA 62308 [308105105] 188.45 percent of total billed charges 147.56 226.1 Technical (Hospital) Services Ref Ebv Ab Bca Igg or Igm PX-3028666501 CDM 86665 CPT 302 RC inpatient 238 238 CIGNA 62308 [3081051] CIGNA STATE OF WYOMING [308105107] 188.45 percent of total billed charges 147.56 226.1 Technical (Hospital) Services Ref Ebv Ab Bca Igg or Igm PX-3028666501 CDM 86665 CPT 302 RC inpatient 238 238 MULTIPLAN INC 34080 [3081285] MULTIPLAN INC [308128501] 226.1 percent of total billed charges 147.56 226.1 Technical (Hospital) Services Ref Ebv Ab Bca Igg or Igm PX-3028666501 CDM 86665 CPT 302 RC inpatient 238 238 MEDICA (COMMERCIAL) 94265 [3081118] MEDICA CLAIMS [308111801] 214.2 percent of total billed charges 147.56 226.1 Technical (Hospital) Services Ref Ebv Ab Bca Igg or Igm PX-3028666501 CDM 86665 CPT 302 RC inpatient 238 238 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES PPO [308136801] 188.45 percent of total billed charges 147.56 226.1 Technical (Hospital) Services Ref Ebv Ab Bca Igg or Igm PX-3028666501 CDM 86665 CPT 302 RC inpatient 238 238 UNITED HEALTHCARE (COMMERCIAL) [3081199] UNITED HEALTHCARE 87726 [308119901] 147.56 percent of total billed charges 147.56 226.1 Technical (Hospital) Services Ref Ebv Ab Bca Igg or Igm PX-3028666501 CDM 86665 CPT 302 RC inpatient 238 238 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES HDHP [308136802] 188.45 percent of total billed charges 147.56 226.1 Technical (Hospital) Services Ref Ebv Ab Bca Igg or Igm PX-3028666501 CDM 86665 CPT 302 RC outpatient 238 238 MEDICA (COMMERCIAL) 94265 [3081118] MEDICA CLAIMS [308111801] 214.2 percent of total billed charges 147.56 226.1 Technical (Hospital) Services Ref Ebv Ab Bca Igg or Igm PX-3028666501 CDM 86665 CPT 302 RC outpatient 238 238 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES HDHP [308136802] 190.4 percent of total billed charges 147.56 226.1 Technical (Hospital) Services Ref Ebv Ab Bca Igg or Igm PX-3028666501 CDM 86665 CPT 302 RC outpatient 238 238 BLUE CROSS BLUE SHIELD WELLMARK SB889 [3081026] BCBS WYOMING [308102603] 226.1 percent of total billed charges 147.56 226.1 Technical (Hospital) Services Ref Ebv Ab Bca Igg or Igm PX-3028666501 CDM 86665 CPT 302 RC outpatient 238 238 CIGNA 62308 [3081051] CIGNA 62308 [308105105] 190.4 percent of total billed charges 147.56 226.1 Technical (Hospital) Services Ref Ebv Ab Bca Igg or Igm PX-3028666501 CDM 86665 CPT 302 RC outpatient 238 238 CIGNA 62308 [3081051] CIGNA STATE OF WYOMING [308105107] 190.4 percent of total billed charges 147.56 226.1 Technical (Hospital) Services Ref Ebv Ab Bca Igg or Igm PX-3028666501 CDM 86665 CPT 302 RC outpatient 238 238 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES EPO [308136803] 190.4 percent of total billed charges 147.56 226.1 Technical (Hospital) Services Ref Ebv Ab Bca Igg or Igm PX-3028666501 CDM 86665 CPT 302 RC outpatient 238 238 MULTIPLAN INC 34080 [3081285] MULTIPLAN INC [308128501] 226.1 percent of total billed charges 147.56 226.1 Technical (Hospital) Services Ref Ebv Ab Bca Igg or Igm PX-3028666501 CDM 86665 CPT 302 RC outpatient 238 238 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES PPO [308136801] 190.4 percent of total billed charges 147.56 226.1 Technical (Hospital) Services Ref Ebv Ab Bca Igg or Igm PX-3028666501 CDM 86665 CPT 302 RC outpatient 238 238 HEALTHPARTNERS SX009 HEALTHPARTNERS 190.4 percent of total billed charges 147.56 226.1 Technical (Hospital) Services Ref Ebv Ab Bca Igg or Igm PX-3028666501 CDM 86665 CPT 302 RC outpatient 238 238 UNITED HEALTHCARE (COMMERCIAL) [3081199] UNITED HEALTHCARE 87726 [308119901] 147.56 percent of total billed charges 147.56 226.1 Technical (Hospital) Services Ref Epstein Barr Anti Ebna PX-3028666401 CDM 86664 CPT 302 RC inpatient 209 209 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES HDHP [308136802] 165.49 percent of total billed charges 129.58 198.55 Technical (Hospital) Services Ref Epstein Barr Anti Ebna PX-3028666401 CDM 86664 CPT 302 RC inpatient 209 209 UNITED HEALTHCARE (COMMERCIAL) [3081199] UNITED HEALTHCARE 87726 [308119901] 129.58 percent of total billed charges 129.58 198.55 Technical (Hospital) Services Ref Epstein Barr Anti Ebna PX-3028666401 CDM 86664 CPT 302 RC inpatient 209 209 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES PPO [308136801] 165.49 percent of total billed charges 129.58 198.55 Technical (Hospital) Services Ref Epstein Barr Anti Ebna PX-3028666401 CDM 86664 CPT 302 RC inpatient 209 209 MEDICA (COMMERCIAL) 94265 [3081118] MEDICA CLAIMS [308111801] 188.1 percent of total billed charges 129.58 198.55 Technical (Hospital) Services Ref Epstein Barr Anti Ebna PX-3028666401 CDM 86664 CPT 302 RC inpatient 209 209 MULTIPLAN INC 34080 [3081285] MULTIPLAN INC [308128501] 198.55 percent of total billed charges 129.58 198.55 Technical (Hospital) Services Ref Epstein Barr Anti Ebna PX-3028666401 CDM 86664 CPT 302 RC inpatient 209 209 CIGNA 62308 [3081051] CIGNA 62308 [308105105] 165.49 percent of total billed charges 129.58 198.55 Technical (Hospital) Services Ref Epstein Barr Anti Ebna PX-3028666401 CDM 86664 CPT 302 RC inpatient 209 209 CIGNA 62308 [3081051] CIGNA STATE OF WYOMING [308105107] 165.49 percent of total billed charges 129.58 198.55 Technical (Hospital) Services Ref Epstein Barr Anti Ebna PX-3028666401 CDM 86664 CPT 302 RC inpatient 209 209 BLUE CROSS BLUE SHIELD WELLMARK SB889 [3081026] BCBS WYOMING [308102603] 198.55 percent of total billed charges 129.58 198.55 Technical (Hospital) Services Ref Epstein Barr Anti Ebna PX-3028666401 CDM 86664 CPT 302 RC inpatient 209 209 HEALTHPARTNERS SX009 HEALTHPARTNERS 165.49 percent of total billed charges 129.58 198.55 Technical (Hospital) Services Ref Epstein Barr Anti Ebna PX-3028666401 CDM 86664 CPT 302 RC inpatient 209 209 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES EPO [308136803] 165.49 percent of total billed charges 129.58 198.55 Technical (Hospital) Services Ref Epstein Barr Anti Ebna PX-3028666401 CDM 86664 CPT 302 RC outpatient 209 209 MEDICA (COMMERCIAL) 94265 [3081118] MEDICA CLAIMS [308111801] 188.1 percent of total billed charges 129.58 198.55 Technical (Hospital) Services Ref Epstein Barr Anti Ebna PX-3028666401 CDM 86664 CPT 302 RC outpatient 209 209 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES HDHP [308136802] 167.2 percent of total billed charges 129.58 198.55 Technical (Hospital) Services Ref Epstein Barr Anti Ebna PX-3028666401 CDM 86664 CPT 302 RC outpatient 209 209 BLUE CROSS BLUE SHIELD WELLMARK SB889 [3081026] BCBS WYOMING [308102603] 198.55 percent of total billed charges 129.58 198.55 Technical (Hospital) Services Ref Epstein Barr Anti Ebna PX-3028666401 CDM 86664 CPT 302 RC outpatient 209 209 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES EPO [308136803] 167.2 percent of total billed charges 129.58 198.55 Technical (Hospital) Services Ref Epstein Barr Anti Ebna PX-3028666401 CDM 86664 CPT 302 RC outpatient 209 209 CIGNA 62308 [3081051] CIGNA 62308 [308105105] 167.2 percent of total billed charges 129.58 198.55 Technical (Hospital) Services Ref Epstein Barr Anti Ebna PX-3028666401 CDM 86664 CPT 302 RC outpatient 209 209 CIGNA 62308 [3081051] CIGNA STATE OF WYOMING [308105107] 167.2 percent of total billed charges 129.58 198.55 Technical (Hospital) Services Ref Epstein Barr Anti Ebna PX-3028666401 CDM 86664 CPT 302 RC outpatient 209 209 MULTIPLAN INC 34080 [3081285] MULTIPLAN INC [308128501] 198.55 percent of total billed charges 129.58 198.55 Technical (Hospital) Services Ref Epstein Barr Anti Ebna PX-3028666401 CDM 86664 CPT 302 RC outpatient 209 209 UNITED HEALTHCARE (COMMERCIAL) [3081199] UNITED HEALTHCARE 87726 [308119901] 129.58 percent of total billed charges 129.58 198.55 Technical (Hospital) Services Ref Epstein Barr Anti Ebna PX-3028666401 CDM 86664 CPT 302 RC outpatient 209 209 HEALTHPARTNERS SX009 HEALTHPARTNERS 167.2 percent of total billed charges 129.58 198.55 Technical (Hospital) Services Ref Epstein Barr Anti Ebna PX-3028666401 CDM 86664 CPT 302 RC outpatient 209 209 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES PPO [308136801] 167.2 percent of total billed charges 129.58 198.55 Technical (Hospital) Services Ref Ebv Ea PX-3008666300 CDM 86663 CPT 300 RC inpatient 209 209 CIGNA 62308 [3081051] CIGNA 62308 [308105105] 165.49 percent of total billed charges 129.58 198.55 Technical (Hospital) Services Ref Ebv Ea PX-3008666300 CDM 86663 CPT 300 RC inpatient 209 209 CIGNA 62308 [3081051] CIGNA STATE OF WYOMING [308105107] 165.49 percent of total billed charges 129.58 198.55 Technical (Hospital) Services Ref Ebv Ea PX-3008666300 CDM 86663 CPT 300 RC inpatient 209 209 BLUE CROSS BLUE SHIELD WELLMARK SB889 [3081026] BCBS WYOMING [308102603] 198.55 percent of total billed charges 129.58 198.55 Technical (Hospital) Services Ref Ebv Ea PX-3008666300 CDM 86663 CPT 300 RC inpatient 209 209 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES HDHP [308136802] 165.49 percent of total billed charges 129.58 198.55 Technical (Hospital) Services Ref Ebv Ea PX-3008666300 CDM 86663 CPT 300 RC inpatient 209 209 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES PPO [308136801] 165.49 percent of total billed charges 129.58 198.55 Technical (Hospital) Services Ref Ebv Ea PX-3008666300 CDM 86663 CPT 300 RC inpatient 209 209 UNITED HEALTHCARE (COMMERCIAL) [3081199] UNITED HEALTHCARE 87726 [308119901] 129.58 percent of total billed charges 129.58 198.55 Technical (Hospital) Services Ref Ebv Ea PX-3008666300 CDM 86663 CPT 300 RC inpatient 209 209 MULTIPLAN INC 34080 [3081285] MULTIPLAN INC [308128501] 198.55 percent of total billed charges 129.58 198.55 Technical (Hospital) Services Ref Ebv Ea PX-3008666300 CDM 86663 CPT 300 RC inpatient 209 209 MEDICA (COMMERCIAL) 94265 [3081118] MEDICA CLAIMS [308111801] 188.1 percent of total billed charges 129.58 198.55 Technical (Hospital) Services Ref Ebv Ea PX-3008666300 CDM 86663 CPT 300 RC inpatient 209 209 HEALTHPARTNERS SX009 HEALTHPARTNERS 165.49 percent of total billed charges 129.58 198.55 Technical (Hospital) Services Ref Ebv Ea PX-3008666300 CDM 86663 CPT 300 RC inpatient 209 209 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES EPO [308136803] 165.49 percent of total billed charges 129.58 198.55 Technical (Hospital) Services Ref Ebv Ea PX-3008666300 CDM 86663 CPT 300 RC outpatient 209 209 UNITED HEALTHCARE (COMMERCIAL) [3081199] UNITED HEALTHCARE 87726 [308119901] 129.58 percent of total billed charges 129.58 198.55 Technical (Hospital) Services Ref Ebv Ea PX-3008666300 CDM 86663 CPT 300 RC outpatient 209 209 HEALTHPARTNERS SX009 HEALTHPARTNERS 167.2 percent of total billed charges 129.58 198.55 Technical (Hospital) Services Ref Ebv Ea PX-3008666300 CDM 86663 CPT 300 RC outpatient 209 209 MULTIPLAN INC 34080 [3081285] MULTIPLAN INC [308128501] 198.55 percent of total billed charges 129.58 198.55 Technical (Hospital) Services Ref Ebv Ea PX-3008666300 CDM 86663 CPT 300 RC outpatient 209 209 BLUE CROSS BLUE SHIELD WELLMARK SB889 [3081026] BCBS WYOMING [308102603] 198.55 percent of total billed charges 129.58 198.55 Technical (Hospital) Services Ref Ebv Ea PX-3008666300 CDM 86663 CPT 300 RC outpatient 209 209 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES HDHP [308136802] 167.2 percent of total billed charges 129.58 198.55 Technical (Hospital) Services Ref Ebv Ea PX-3008666300 CDM 86663 CPT 300 RC outpatient 209 209 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES PPO [308136801] 167.2 percent of total billed charges 129.58 198.55 Technical (Hospital) Services Ref Ebv Ea PX-3008666300 CDM 86663 CPT 300 RC outpatient 209 209 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES EPO [308136803] 167.2 percent of total billed charges 129.58 198.55 Technical (Hospital) Services Ref Ebv Ea PX-3008666300 CDM 86663 CPT 300 RC outpatient 209 209 MEDICA (COMMERCIAL) 94265 [3081118] MEDICA CLAIMS [308111801] 188.1 percent of total billed charges 129.58 198.55 Technical (Hospital) Services Ref Ebv Ea PX-3008666300 CDM 86663 CPT 300 RC outpatient 209 209 CIGNA 62308 [3081051] CIGNA 62308 [308105105] 167.2 percent of total billed charges 129.58 198.55 Technical (Hospital) Services Ref Ebv Ea PX-3008666300 CDM 86663 CPT 300 RC outpatient 209 209 CIGNA 62308 [3081051] CIGNA STATE OF WYOMING [308105107] 167.2 percent of total billed charges 129.58 198.55 Technical (Hospital) Services Ref Echovirus Serotypes Each PX-3028665800 CDM 86658 CPT 302 RC outpatient 437 437 UNITED HEALTHCARE (COMMERCIAL) [3081199] UNITED HEALTHCARE 87726 [308119901] 270.94 percent of total billed charges 270.94 415.15 Technical (Hospital) Services Ref Echovirus Serotypes Each PX-3028665800 CDM 86658 CPT 302 RC outpatient 437 437 HEALTHPARTNERS SX009 HEALTHPARTNERS 349.6 percent of total billed charges 270.94 415.15 Technical (Hospital) Services Ref Echovirus Serotypes Each PX-3028665800 CDM 86658 CPT 302 RC outpatient 437 437 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES PPO [308136801] 349.6 percent of total billed charges 270.94 415.15 Technical (Hospital) Services Ref Echovirus Serotypes Each PX-3028665800 CDM 86658 CPT 302 RC outpatient 437 437 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES HDHP [308136802] 349.6 percent of total billed charges 270.94 415.15 Technical (Hospital) Services Ref Echovirus Serotypes Each PX-3028665800 CDM 86658 CPT 302 RC outpatient 437 437 BLUE CROSS BLUE SHIELD WELLMARK SB889 [3081026] BCBS WYOMING [308102603] 415.15 percent of total billed charges 270.94 415.15 Technical (Hospital) Services Ref Echovirus Serotypes Each PX-3028665800 CDM 86658 CPT 302 RC outpatient 437 437 MULTIPLAN INC 34080 [3081285] MULTIPLAN INC [308128501] 415.15 percent of total billed charges 270.94 415.15 Technical (Hospital) Services Ref Echovirus Serotypes Each PX-3028665800 CDM 86658 CPT 302 RC outpatient 437 437 CIGNA 62308 [3081051] CIGNA 62308 [308105105] 349.6 percent of total billed charges 270.94 415.15 Technical (Hospital) Services Ref Echovirus Serotypes Each PX-3028665800 CDM 86658 CPT 302 RC outpatient 437 437 CIGNA 62308 [3081051] CIGNA STATE OF WYOMING [308105107] 349.6 percent of total billed charges 270.94 415.15 Technical (Hospital) Services Ref Echovirus Serotypes Each PX-3028665800 CDM 86658 CPT 302 RC outpatient 437 437 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES EPO [308136803] 349.6 percent of total billed charges 270.94 415.15 Technical (Hospital) Services Ref Echovirus Serotypes Each PX-3028665800 CDM 86658 CPT 302 RC outpatient 437 437 MEDICA (COMMERCIAL) 94265 [3081118] MEDICA CLAIMS [308111801] 393.3 percent of total billed charges 270.94 415.15 Technical (Hospital) Services Ref Echovirus Serotypes Each PX-3028665800 CDM 86658 CPT 302 RC inpatient 437 437 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES EPO [308136803] 346.02 percent of total billed charges 270.94 415.15 Technical (Hospital) Services Ref Echovirus Serotypes Each PX-3028665800 CDM 86658 CPT 302 RC inpatient 437 437 HEALTHPARTNERS SX009 HEALTHPARTNERS 346.02 percent of total billed charges 270.94 415.15 Technical (Hospital) Services Ref Echovirus Serotypes Each PX-3028665800 CDM 86658 CPT 302 RC inpatient 437 437 BLUE CROSS BLUE SHIELD WELLMARK SB889 [3081026] BCBS WYOMING [308102603] 415.15 percent of total billed charges 270.94 415.15 Technical (Hospital) Services Ref Echovirus Serotypes Each PX-3028665800 CDM 86658 CPT 302 RC inpatient 437 437 CIGNA 62308 [3081051] CIGNA 62308 [308105105] 346.02 percent of total billed charges 270.94 415.15 Technical (Hospital) Services Ref Echovirus Serotypes Each PX-3028665800 CDM 86658 CPT 302 RC inpatient 437 437 CIGNA 62308 [3081051] CIGNA STATE OF WYOMING [308105107] 346.02 percent of total billed charges 270.94 415.15 Technical (Hospital) Services Ref Echovirus Serotypes Each PX-3028665800 CDM 86658 CPT 302 RC inpatient 437 437 MULTIPLAN INC 34080 [3081285] MULTIPLAN INC [308128501] 415.15 percent of total billed charges 270.94 415.15 Technical (Hospital) Services Ref Echovirus Serotypes Each PX-3028665800 CDM 86658 CPT 302 RC inpatient 437 437 MEDICA (COMMERCIAL) 94265 [3081118] MEDICA CLAIMS [308111801] 393.3 percent of total billed charges 270.94 415.15 Technical (Hospital) Services Ref Echovirus Serotypes Each PX-3028665800 CDM 86658 CPT 302 RC inpatient 437 437 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES PPO [308136801] 346.02 percent of total billed charges 270.94 415.15 Technical (Hospital) Services Ref Echovirus Serotypes Each PX-3028665800 CDM 86658 CPT 302 RC inpatient 437 437 UNITED HEALTHCARE (COMMERCIAL) [3081199] UNITED HEALTHCARE 87726 [308119901] 270.94 percent of total billed charges 270.94 415.15 Technical (Hospital) Services Ref Echovirus Serotypes Each PX-3028665800 CDM 86658 CPT 302 RC inpatient 437 437 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES HDHP [308136802] 346.02 percent of total billed charges 270.94 415.15 Technical (Hospital) Services Ref Cmv (Cytomegaloviris) Igm PX-3028664500 CDM 86645 CPT 302 RC inpatient 230 230 BLUE CROSS BLUE SHIELD WELLMARK SB889 [3081026] BCBS WYOMING [308102603] 218.5 percent of total billed charges 142.6 218.5 Technical (Hospital) Services Ref Cmv (Cytomegaloviris) Igm PX-3028664500 CDM 86645 CPT 302 RC inpatient 230 230 HEALTHPARTNERS SX009 HEALTHPARTNERS 182.11 percent of total billed charges 142.6 218.5 Technical (Hospital) Services Ref Cmv (Cytomegaloviris) Igm PX-3028664500 CDM 86645 CPT 302 RC inpatient 230 230 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES EPO [308136803] 182.11 percent of total billed charges 142.6 218.5 Technical (Hospital) Services Ref Cmv (Cytomegaloviris) Igm PX-3028664500 CDM 86645 CPT 302 RC inpatient 230 230 MEDICA (COMMERCIAL) 94265 [3081118] MEDICA CLAIMS [308111801] 207 percent of total billed charges 142.6 218.5 Technical (Hospital) Services Ref Cmv (Cytomegaloviris) Igm PX-3028664500 CDM 86645 CPT 302 RC inpatient 230 230 MULTIPLAN INC 34080 [3081285] MULTIPLAN INC [308128501] 218.5 percent of total billed charges 142.6 218.5 Technical (Hospital) Services Ref Cmv (Cytomegaloviris) Igm PX-3028664500 CDM 86645 CPT 302 RC inpatient 230 230 CIGNA 62308 [3081051] CIGNA 62308 [308105105] 182.11 percent of total billed charges 142.6 218.5 Technical (Hospital) Services Ref Cmv (Cytomegaloviris) Igm PX-3028664500 CDM 86645 CPT 302 RC inpatient 230 230 CIGNA 62308 [3081051] CIGNA STATE OF WYOMING [308105107] 182.11 percent of total billed charges 142.6 218.5 Technical (Hospital) Services Ref Cmv (Cytomegaloviris) Igm PX-3028664500 CDM 86645 CPT 302 RC inpatient 230 230 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES PPO [308136801] 182.11 percent of total billed charges 142.6 218.5 Technical (Hospital) Services Ref Cmv (Cytomegaloviris) Igm PX-3028664500 CDM 86645 CPT 302 RC inpatient 230 230 UNITED HEALTHCARE (COMMERCIAL) [3081199] UNITED HEALTHCARE 87726 [308119901] 142.6 percent of total billed charges 142.6 218.5 Technical (Hospital) Services Ref Cmv (Cytomegaloviris) Igm PX-3028664500 CDM 86645 CPT 302 RC inpatient 230 230 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES HDHP [308136802] 182.11 percent of total billed charges 142.6 218.5 Technical (Hospital) Services Ref Cmv (Cytomegaloviris) Igm PX-3028664500 CDM 86645 CPT 302 RC outpatient 230 230 BLUE CROSS BLUE SHIELD WELLMARK SB889 [3081026] BCBS WYOMING [308102603] 218.5 percent of total billed charges 142.6 218.5 Technical (Hospital) Services Ref Cmv (Cytomegaloviris) Igm PX-3028664500 CDM 86645 CPT 302 RC outpatient 230 230 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES HDHP [308136802] 184 percent of total billed charges 142.6 218.5 Technical (Hospital) Services Ref Cmv (Cytomegaloviris) Igm PX-3028664500 CDM 86645 CPT 302 RC outpatient 230 230 MULTIPLAN INC 34080 [3081285] MULTIPLAN INC [308128501] 218.5 percent of total billed charges 142.6 218.5 Technical (Hospital) Services Ref Cmv (Cytomegaloviris) Igm PX-3028664500 CDM 86645 CPT 302 RC outpatient 230 230 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES EPO [308136803] 184 percent of total billed charges 142.6 218.5 Technical (Hospital) Services Ref Cmv (Cytomegaloviris) Igm PX-3028664500 CDM 86645 CPT 302 RC outpatient 230 230 CIGNA 62308 [3081051] CIGNA 62308 [308105105] 184 percent of total billed charges 142.6 218.5 Technical (Hospital) Services Ref Cmv (Cytomegaloviris) Igm PX-3028664500 CDM 86645 CPT 302 RC outpatient 230 230 CIGNA 62308 [3081051] CIGNA STATE OF WYOMING [308105107] 184 percent of total billed charges 142.6 218.5 Technical (Hospital) Services Ref Cmv (Cytomegaloviris) Igm PX-3028664500 CDM 86645 CPT 302 RC outpatient 230 230 UNITED HEALTHCARE (COMMERCIAL) [3081199] UNITED HEALTHCARE 87726 [308119901] 142.6 percent of total billed charges 142.6 218.5 Technical (Hospital) Services Ref Cmv (Cytomegaloviris) Igm PX-3028664500 CDM 86645 CPT 302 RC outpatient 230 230 MEDICA (COMMERCIAL) 94265 [3081118] MEDICA CLAIMS [308111801] 207 percent of total billed charges 142.6 218.5 Technical (Hospital) Services Ref Cmv (Cytomegaloviris) Igm PX-3028664500 CDM 86645 CPT 302 RC outpatient 230 230 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES PPO [308136801] 184 percent of total billed charges 142.6 218.5 Technical (Hospital) Services Ref Cmv (Cytomegaloviris) Igm PX-3028664500 CDM 86645 CPT 302 RC outpatient 230 230 HEALTHPARTNERS SX009 HEALTHPARTNERS 184 percent of total billed charges 142.6 218.5 Technical (Hospital) Services Ref Cytomegalovirus Ab Igm PX-3028664501 CDM 86645 CPT 302 RC outpatient 166 166 CIGNA 62308 [3081051] CIGNA 62308 [308105105] 132.8 percent of total billed charges 102.92 157.7 Technical (Hospital) Services Ref Cytomegalovirus Ab Igm PX-3028664501 CDM 86645 CPT 302 RC outpatient 166 166 CIGNA 62308 [3081051] CIGNA STATE OF WYOMING [308105107] 132.8 percent of total billed charges 102.92 157.7 Technical (Hospital) Services Ref Cytomegalovirus Ab Igm PX-3028664501 CDM 86645 CPT 302 RC outpatient 166 166 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES EPO [308136803] 132.8 percent of total billed charges 102.92 157.7 Technical (Hospital) Services Ref Cytomegalovirus Ab Igm PX-3028664501 CDM 86645 CPT 302 RC outpatient 166 166 BLUE CROSS BLUE SHIELD WELLMARK SB889 [3081026] BCBS WYOMING [308102603] 157.7 percent of total billed charges 102.92 157.7 Technical (Hospital) Services Ref Cytomegalovirus Ab Igm PX-3028664501 CDM 86645 CPT 302 RC outpatient 166 166 MULTIPLAN INC 34080 [3081285] MULTIPLAN INC [308128501] 157.7 percent of total billed charges 102.92 157.7 Technical (Hospital) Services Ref Cytomegalovirus Ab Igm PX-3028664501 CDM 86645 CPT 302 RC outpatient 166 166 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES HDHP [308136802] 132.8 percent of total billed charges 102.92 157.7 Technical (Hospital) Services Ref Cytomegalovirus Ab Igm PX-3028664501 CDM 86645 CPT 302 RC outpatient 166 166 UNITED HEALTHCARE (COMMERCIAL) [3081199] UNITED HEALTHCARE 87726 [308119901] 102.92 percent of total billed charges 102.92 157.7 Technical (Hospital) Services Ref Cytomegalovirus Ab Igm PX-3028664501 CDM 86645 CPT 302 RC outpatient 166 166 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES PPO [308136801] 132.8 percent of total billed charges 102.92 157.7 Technical (Hospital) Services Ref Cytomegalovirus Ab Igm PX-3028664501 CDM 86645 CPT 302 RC outpatient 166 166 HEALTHPARTNERS SX009 HEALTHPARTNERS 132.8 percent of total billed charges 102.92 157.7 Technical (Hospital) Services Ref Cytomegalovirus Ab Igm PX-3028664501 CDM 86645 CPT 302 RC outpatient 166 166 MEDICA (COMMERCIAL) 94265 [3081118] MEDICA CLAIMS [308111801] 149.4 percent of total billed charges 102.92 157.7 Technical (Hospital) Services Ref Cytomegalovirus Ab Igm PX-3028664501 CDM 86645 CPT 302 RC inpatient 166 166 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES HDHP [308136802] 131.44 percent of total billed charges 102.92 157.7 Technical (Hospital) Services Ref Cytomegalovirus Ab Igm PX-3028664501 CDM 86645 CPT 302 RC inpatient 166 166 MEDICA (COMMERCIAL) 94265 [3081118] MEDICA CLAIMS [308111801] 149.4 percent of total billed charges 102.92 157.7 Technical (Hospital) Services Ref Cytomegalovirus Ab Igm PX-3028664501 CDM 86645 CPT 302 RC inpatient 166 166 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES PPO [308136801] 131.44 percent of total billed charges 102.92 157.7 Technical (Hospital) Services Ref Cytomegalovirus Ab Igm PX-3028664501 CDM 86645 CPT 302 RC inpatient 166 166 UNITED HEALTHCARE (COMMERCIAL) [3081199] UNITED HEALTHCARE 87726 [308119901] 102.92 percent of total billed charges 102.92 157.7 Technical (Hospital) Services Ref Cytomegalovirus Ab Igm PX-3028664501 CDM 86645 CPT 302 RC inpatient 166 166 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES EPO [308136803] 131.44 percent of total billed charges 102.92 157.7 Technical (Hospital) Services Ref Cytomegalovirus Ab Igm PX-3028664501 CDM 86645 CPT 302 RC inpatient 166 166 HEALTHPARTNERS SX009 HEALTHPARTNERS 131.44 percent of total billed charges 102.92 157.7 Technical (Hospital) Services Ref Cytomegalovirus Ab Igm PX-3028664501 CDM 86645 CPT 302 RC inpatient 166 166 BLUE CROSS BLUE SHIELD WELLMARK SB889 [3081026] BCBS WYOMING [308102603] 157.7 percent of total billed charges 102.92 157.7 Technical (Hospital) Services Ref Cytomegalovirus Ab Igm PX-3028664501 CDM 86645 CPT 302 RC inpatient 166 166 MULTIPLAN INC 34080 [3081285] MULTIPLAN INC [308128501] 157.7 percent of total billed charges 102.92 157.7 Technical (Hospital) Services Ref Cytomegalovirus Ab Igm PX-3028664501 CDM 86645 CPT 302 RC inpatient 166 166 CIGNA 62308 [3081051] CIGNA 62308 [308105105] 131.44 percent of total billed charges 102.92 157.7 Technical (Hospital) Services Ref Cytomegalovirus Ab Igm PX-3028664501 CDM 86645 CPT 302 RC inpatient 166 166 CIGNA 62308 [3081051] CIGNA STATE OF WYOMING [308105107] 131.44 percent of total billed charges 102.92 157.7 Technical (Hospital) Services Ref Cytomegalovirus (Cmv) PX-3028664400 CDM 86644 CPT 302 RC inpatient 209 209 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES PPO [308136801] 165.49 percent of total billed charges 129.58 198.55 Technical (Hospital) Services Ref Cytomegalovirus (Cmv) PX-3028664400 CDM 86644 CPT 302 RC inpatient 209 209 UNITED HEALTHCARE (COMMERCIAL) [3081199] UNITED HEALTHCARE 87726 [308119901] 129.58 percent of total billed charges 129.58 198.55 Technical (Hospital) Services Ref Cytomegalovirus (Cmv) PX-3028664400 CDM 86644 CPT 302 RC inpatient 209 209 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES HDHP [308136802] 165.49 percent of total billed charges 129.58 198.55 Technical (Hospital) Services Ref Cytomegalovirus (Cmv) PX-3028664400 CDM 86644 CPT 302 RC inpatient 209 209 HEALTHPARTNERS SX009 HEALTHPARTNERS 165.49 percent of total billed charges 129.58 198.55 Technical (Hospital) Services Ref Cytomegalovirus (Cmv) PX-3028664400 CDM 86644 CPT 302 RC inpatient 209 209 BLUE CROSS BLUE SHIELD WELLMARK SB889 [3081026] BCBS WYOMING [308102603] 198.55 percent of total billed charges 129.58 198.55 Technical (Hospital) Services Ref Cytomegalovirus (Cmv) PX-3028664400 CDM 86644 CPT 302 RC inpatient 209 209 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES EPO [308136803] 165.49 percent of total billed charges 129.58 198.55 Technical (Hospital) Services Ref Cytomegalovirus (Cmv) PX-3028664400 CDM 86644 CPT 302 RC inpatient 209 209 CIGNA 62308 [3081051] CIGNA 62308 [308105105] 165.49 percent of total billed charges 129.58 198.55 Technical (Hospital) Services Ref Cytomegalovirus (Cmv) PX-3028664400 CDM 86644 CPT 302 RC inpatient 209 209 CIGNA 62308 [3081051] CIGNA STATE OF WYOMING [308105107] 165.49 percent of total billed charges 129.58 198.55 Technical (Hospital) Services Ref Cytomegalovirus (Cmv) PX-3028664400 CDM 86644 CPT 302 RC inpatient 209 209 MEDICA (COMMERCIAL) 94265 [3081118] MEDICA CLAIMS [308111801] 188.1 percent of total billed charges 129.58 198.55 Technical (Hospital) Services Ref Cytomegalovirus (Cmv) PX-3028664400 CDM 86644 CPT 302 RC inpatient 209 209 MULTIPLAN INC 34080 [3081285] MULTIPLAN INC [308128501] 198.55 percent of total billed charges 129.58 198.55 Technical (Hospital) Services Ref Cytomegalovirus (Cmv) PX-3028664400 CDM 86644 CPT 302 RC outpatient 209 209 UNITED HEALTHCARE (COMMERCIAL) [3081199] UNITED HEALTHCARE 87726 [308119901] 129.58 percent of total billed charges 129.58 198.55 Technical (Hospital) Services Ref Cytomegalovirus (Cmv) PX-3028664400 CDM 86644 CPT 302 RC outpatient 209 209 HEALTHPARTNERS SX009 HEALTHPARTNERS 167.2 percent of total billed charges 129.58 198.55 Technical (Hospital) Services Ref Cytomegalovirus (Cmv) PX-3028664400 CDM 86644 CPT 302 RC outpatient 209 209 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES PPO [308136801] 167.2 percent of total billed charges 129.58 198.55 Technical (Hospital) Services Ref Cytomegalovirus (Cmv) PX-3028664400 CDM 86644 CPT 302 RC outpatient 209 209 BLUE CROSS BLUE SHIELD WELLMARK SB889 [3081026] BCBS WYOMING [308102603] 198.55 percent of total billed charges 129.58 198.55 Technical (Hospital) Services Ref Cytomegalovirus (Cmv) PX-3028664400 CDM 86644 CPT 302 RC outpatient 209 209 MULTIPLAN INC 34080 [3081285] MULTIPLAN INC [308128501] 198.55 percent of total billed charges 129.58 198.55 Technical (Hospital) Services Ref Cytomegalovirus (Cmv) PX-3028664400 CDM 86644 CPT 302 RC outpatient 209 209 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES EPO [308136803] 167.2 percent of total billed charges 129.58 198.55 Technical (Hospital) Services Ref Cytomegalovirus (Cmv) PX-3028664400 CDM 86644 CPT 302 RC outpatient 209 209 CIGNA 62308 [3081051] CIGNA 62308 [308105105] 167.2 percent of total billed charges 129.58 198.55 Technical (Hospital) Services Ref Cytomegalovirus (Cmv) PX-3028664400 CDM 86644 CPT 302 RC outpatient 209 209 CIGNA 62308 [3081051] CIGNA STATE OF WYOMING [308105107] 167.2 percent of total billed charges 129.58 198.55 Technical (Hospital) Services Ref Cytomegalovirus (Cmv) PX-3028664400 CDM 86644 CPT 302 RC outpatient 209 209 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES HDHP [308136802] 167.2 percent of total billed charges 129.58 198.55 Technical (Hospital) Services Ref Cytomegalovirus (Cmv) PX-3028664400 CDM 86644 CPT 302 RC outpatient 209 209 MEDICA (COMMERCIAL) 94265 [3081118] MEDICA CLAIMS [308111801] 188.1 percent of total billed charges 129.58 198.55 Technical (Hospital) Services Ref Cytomegalovirus Qual PX-3028664404 CDM 86644 CPT 302 RC outpatient 154 154 UNITED HEALTHCARE (COMMERCIAL) [3081199] UNITED HEALTHCARE 87726 [308119901] 95.48 percent of total billed charges 95.48 146.3 Technical (Hospital) Services Ref Cytomegalovirus Qual PX-3028664404 CDM 86644 CPT 302 RC outpatient 154 154 HEALTHPARTNERS SX009 HEALTHPARTNERS 123.2 percent of total billed charges 95.48 146.3 Technical (Hospital) Services Ref Cytomegalovirus Qual PX-3028664404 CDM 86644 CPT 302 RC outpatient 154 154 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES PPO [308136801] 123.2 percent of total billed charges 95.48 146.3 Technical (Hospital) Services Ref Cytomegalovirus Qual PX-3028664404 CDM 86644 CPT 302 RC outpatient 154 154 MULTIPLAN INC 34080 [3081285] MULTIPLAN INC [308128501] 146.3 percent of total billed charges 95.48 146.3 Technical (Hospital) Services Ref Cytomegalovirus Qual PX-3028664404 CDM 86644 CPT 302 RC outpatient 154 154 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES EPO [308136803] 123.2 percent of total billed charges 95.48 146.3 Technical (Hospital) Services Ref Cytomegalovirus Qual PX-3028664404 CDM 86644 CPT 302 RC outpatient 154 154 CIGNA 62308 [3081051] CIGNA 62308 [308105105] 123.2 percent of total billed charges 95.48 146.3 Technical (Hospital) Services Ref Cytomegalovirus Qual PX-3028664404 CDM 86644 CPT 302 RC outpatient 154 154 CIGNA 62308 [3081051] CIGNA STATE OF WYOMING [308105107] 123.2 percent of total billed charges 95.48 146.3 Technical (Hospital) Services Ref Cytomegalovirus Qual PX-3028664404 CDM 86644 CPT 302 RC outpatient 154 154 BLUE CROSS BLUE SHIELD WELLMARK SB889 [3081026] BCBS WYOMING [308102603] 146.3 percent of total billed charges 95.48 146.3 Technical (Hospital) Services Ref Cytomegalovirus Qual PX-3028664404 CDM 86644 CPT 302 RC outpatient 154 154 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES HDHP [308136802] 123.2 percent of total billed charges 95.48 146.3 Technical (Hospital) Services Ref Cytomegalovirus Qual PX-3028664404 CDM 86644 CPT 302 RC outpatient 154 154 MEDICA (COMMERCIAL) 94265 [3081118] MEDICA CLAIMS [308111801] 138.6 percent of total billed charges 95.48 146.3 Technical (Hospital) Services Ref Cytomegalovirus Qual PX-3028664404 CDM 86644 CPT 302 RC inpatient 154 154 HEALTHPARTNERS SX009 HEALTHPARTNERS 121.94 percent of total billed charges 95.48 146.3 Technical (Hospital) Services Ref Cytomegalovirus Qual PX-3028664404 CDM 86644 CPT 302 RC inpatient 154 154 BLUE CROSS BLUE SHIELD WELLMARK SB889 [3081026] BCBS WYOMING [308102603] 146.3 percent of total billed charges 95.48 146.3 Technical (Hospital) Services Ref Cytomegalovirus Qual PX-3028664404 CDM 86644 CPT 302 RC inpatient 154 154 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES EPO [308136803] 121.94 percent of total billed charges 95.48 146.3 Technical (Hospital) Services Ref Cytomegalovirus Qual PX-3028664404 CDM 86644 CPT 302 RC inpatient 154 154 CIGNA 62308 [3081051] CIGNA 62308 [308105105] 121.94 percent of total billed charges 95.48 146.3 Technical (Hospital) Services Ref Cytomegalovirus Qual PX-3028664404 CDM 86644 CPT 302 RC inpatient 154 154 CIGNA 62308 [3081051] CIGNA STATE OF WYOMING [308105107] 121.94 percent of total billed charges 95.48 146.3 Technical (Hospital) Services Ref Cytomegalovirus Qual PX-3028664404 CDM 86644 CPT 302 RC inpatient 154 154 MULTIPLAN INC 34080 [3081285] MULTIPLAN INC [308128501] 146.3 percent of total billed charges 95.48 146.3 Technical (Hospital) Services Ref Cytomegalovirus Qual PX-3028664404 CDM 86644 CPT 302 RC inpatient 154 154 MEDICA (COMMERCIAL) 94265 [3081118] MEDICA CLAIMS [308111801] 138.6 percent of total billed charges 95.48 146.3 Technical (Hospital) Services Ref Cytomegalovirus Qual PX-3028664404 CDM 86644 CPT 302 RC inpatient 154 154 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES PPO [308136801] 121.94 percent of total billed charges 95.48 146.3 Technical (Hospital) Services Ref Cytomegalovirus Qual PX-3028664404 CDM 86644 CPT 302 RC inpatient 154 154 UNITED HEALTHCARE (COMMERCIAL) [3081199] UNITED HEALTHCARE 87726 [308119901] 95.48 percent of total billed charges 95.48 146.3 Technical (Hospital) Services Ref Cytomegalovirus Qual PX-3028664404 CDM 86644 CPT 302 RC inpatient 154 154 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES HDHP [308136802] 121.94 percent of total billed charges 95.48 146.3 Technical (Hospital) Services Ref Q Fever Ab Igg or Igm PX-3028663800 CDM 86638 CPT 302 RC outpatient 204 204 MULTIPLAN INC 34080 [3081285] MULTIPLAN INC [308128501] 193.8 percent of total billed charges 126.48 193.8 Technical (Hospital) Services Ref Q Fever Ab Igg or Igm PX-3028663800 CDM 86638 CPT 302 RC outpatient 204 204 CIGNA 62308 [3081051] CIGNA 62308 [308105105] 163.2 percent of total billed charges 126.48 193.8 Technical (Hospital) Services Ref Q Fever Ab Igg or Igm PX-3028663800 CDM 86638 CPT 302 RC outpatient 204 204 CIGNA 62308 [3081051] CIGNA STATE OF WYOMING [308105107] 163.2 percent of total billed charges 126.48 193.8 Technical (Hospital) Services Ref Q Fever Ab Igg or Igm PX-3028663800 CDM 86638 CPT 302 RC outpatient 204 204 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES EPO [308136803] 163.2 percent of total billed charges 126.48 193.8 Technical (Hospital) Services Ref Q Fever Ab Igg or Igm PX-3028663800 CDM 86638 CPT 302 RC outpatient 204 204 BLUE CROSS BLUE SHIELD WELLMARK SB889 [3081026] BCBS WYOMING [308102603] 193.8 percent of total billed charges 126.48 193.8 Technical (Hospital) Services Ref Q Fever Ab Igg or Igm PX-3028663800 CDM 86638 CPT 302 RC outpatient 204 204 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES HDHP [308136802] 163.2 percent of total billed charges 126.48 193.8 Technical (Hospital) Services Ref Q Fever Ab Igg or Igm PX-3028663800 CDM 86638 CPT 302 RC outpatient 204 204 HEALTHPARTNERS SX009 HEALTHPARTNERS 163.2 percent of total billed charges 126.48 193.8 Technical (Hospital) Services Ref Q Fever Ab Igg or Igm PX-3028663800 CDM 86638 CPT 302 RC outpatient 204 204 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES PPO [308136801] 163.2 percent of total billed charges 126.48 193.8 Technical (Hospital) Services Ref Q Fever Ab Igg or Igm PX-3028663800 CDM 86638 CPT 302 RC outpatient 204 204 UNITED HEALTHCARE (COMMERCIAL) [3081199] UNITED HEALTHCARE 87726 [308119901] 126.48 percent of total billed charges 126.48 193.8 Technical (Hospital) Services Ref Q Fever Ab Igg or Igm PX-3028663800 CDM 86638 CPT 302 RC outpatient 204 204 MEDICA (COMMERCIAL) 94265 [3081118] MEDICA CLAIMS [308111801] 183.6 percent of total billed charges 126.48 193.8 Technical (Hospital) Services Ref Q Fever Ab Igg or Igm PX-3028663800 CDM 86638 CPT 302 RC inpatient 204 204 BLUE CROSS BLUE SHIELD WELLMARK SB889 [3081026] BCBS WYOMING [308102603] 193.8 percent of total billed charges 126.48 193.8 Technical (Hospital) Services Ref Q Fever Ab Igg or Igm PX-3028663800 CDM 86638 CPT 302 RC inpatient 204 204 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES EPO [308136803] 161.53 percent of total billed charges 126.48 193.8 Technical (Hospital) Services Ref Q Fever Ab Igg or Igm PX-3028663800 CDM 86638 CPT 302 RC inpatient 204 204 HEALTHPARTNERS SX009 HEALTHPARTNERS 161.53 percent of total billed charges 126.48 193.8 Technical (Hospital) Services Ref Q Fever Ab Igg or Igm PX-3028663800 CDM 86638 CPT 302 RC inpatient 204 204 MULTIPLAN INC 34080 [3081285] MULTIPLAN INC [308128501] 193.8 percent of total billed charges 126.48 193.8 Technical (Hospital) Services Ref Q Fever Ab Igg or Igm PX-3028663800 CDM 86638 CPT 302 RC inpatient 204 204 CIGNA 62308 [3081051] CIGNA 62308 [308105105] 161.53 percent of total billed charges 126.48 193.8 Technical (Hospital) Services Ref Q Fever Ab Igg or Igm PX-3028663800 CDM 86638 CPT 302 RC inpatient 204 204 CIGNA 62308 [3081051] CIGNA STATE OF WYOMING [308105107] 161.53 percent of total billed charges 126.48 193.8 Technical (Hospital) Services Ref Q Fever Ab Igg or Igm PX-3028663800 CDM 86638 CPT 302 RC inpatient 204 204 UNITED HEALTHCARE (COMMERCIAL) [3081199] UNITED HEALTHCARE 87726 [308119901] 126.48 percent of total billed charges 126.48 193.8 Technical (Hospital) Services Ref Q Fever Ab Igg or Igm PX-3028663800 CDM 86638 CPT 302 RC inpatient 204 204 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES PPO [308136801] 161.53 percent of total billed charges 126.48 193.8 Technical (Hospital) Services Ref Q Fever Ab Igg or Igm PX-3028663800 CDM 86638 CPT 302 RC inpatient 204 204 MEDICA (COMMERCIAL) 94265 [3081118] MEDICA CLAIMS [308111801] 183.6 percent of total billed charges 126.48 193.8 Technical (Hospital) Services Ref Q Fever Ab Igg or Igm PX-3028663800 CDM 86638 CPT 302 RC inpatient 204 204 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES HDHP [308136802] 161.53 percent of total billed charges 126.48 193.8 Technical (Hospital) Services Ref Coccidioides Ab Screen With Reflex PX-3028663500 CDM 86635 CPT 302 RC outpatient 200 200 UNITED HEALTHCARE (COMMERCIAL) [3081199] UNITED HEALTHCARE 87726 [308119901] 124 percent of total billed charges 124 190 Technical (Hospital) Services Ref Coccidioides Ab Screen With Reflex PX-3028663500 CDM 86635 CPT 302 RC outpatient 200 200 HEALTHPARTNERS SX009 HEALTHPARTNERS 160 percent of total billed charges 124 190 Technical (Hospital) Services Ref Coccidioides Ab Screen With Reflex PX-3028663500 CDM 86635 CPT 302 RC outpatient 200 200 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES PPO [308136801] 160 percent of total billed charges 124 190 Technical (Hospital) Services Ref Coccidioides Ab Screen With Reflex PX-3028663500 CDM 86635 CPT 302 RC outpatient 200 200 BLUE CROSS BLUE SHIELD WELLMARK SB889 [3081026] BCBS WYOMING [308102603] 190 percent of total billed charges 124 190 Technical (Hospital) Services Ref Coccidioides Ab Screen With Reflex PX-3028663500 CDM 86635 CPT 302 RC outpatient 200 200 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES HDHP [308136802] 160 percent of total billed charges 124 190 Technical (Hospital) Services Ref Coccidioides Ab Screen With Reflex PX-3028663500 CDM 86635 CPT 302 RC outpatient 200 200 MULTIPLAN INC 34080 [3081285] MULTIPLAN INC [308128501] 190 percent of total billed charges 124 190 Technical (Hospital) Services Ref Coccidioides Ab Screen With Reflex PX-3028663500 CDM 86635 CPT 302 RC outpatient 200 200 CIGNA 62308 [3081051] CIGNA 62308 [308105105] 160 percent of total billed charges 124 190 Technical (Hospital) Services Ref Coccidioides Ab Screen With Reflex PX-3028663500 CDM 86635 CPT 302 RC outpatient 200 200 CIGNA 62308 [3081051] CIGNA STATE OF WYOMING [308105107] 160 percent of total billed charges 124 190 Technical (Hospital) Services Ref Coccidioides Ab Screen With Reflex PX-3028663500 CDM 86635 CPT 302 RC outpatient 200 200 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES EPO [308136803] 160 percent of total billed charges 124 190 Technical (Hospital) Services Ref Coccidioides Ab Screen With Reflex PX-3028663500 CDM 86635 CPT 302 RC outpatient 200 200 MEDICA (COMMERCIAL) 94265 [3081118] MEDICA CLAIMS [308111801] 180 percent of total billed charges 124 190 Technical (Hospital) Services Ref Coccidioides Ab Screen With Reflex PX-3028663500 CDM 86635 CPT 302 RC inpatient 200 200 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES PPO [308136801] 158.36 percent of total billed charges 124 190 Technical (Hospital) Services Ref Coccidioides Ab Screen With Reflex PX-3028663500 CDM 86635 CPT 302 RC inpatient 200 200 UNITED HEALTHCARE (COMMERCIAL) [3081199] UNITED HEALTHCARE 87726 [308119901] 124 percent of total billed charges 124 190 Technical (Hospital) Services Ref Coccidioides Ab Screen With Reflex PX-3028663500 CDM 86635 CPT 302 RC inpatient 200 200 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES HDHP [308136802] 158.36 percent of total billed charges 124 190 Technical (Hospital) Services Ref Coccidioides Ab Screen With Reflex PX-3028663500 CDM 86635 CPT 302 RC inpatient 200 200 CIGNA 62308 [3081051] CIGNA 62308 [308105105] 158.36 percent of total billed charges 124 190 Technical (Hospital) Services Ref Coccidioides Ab Screen With Reflex PX-3028663500 CDM 86635 CPT 302 RC inpatient 200 200 CIGNA 62308 [3081051] CIGNA STATE OF WYOMING [308105107] 158.36 percent of total billed charges 124 190 Technical (Hospital) Services Ref Coccidioides Ab Screen With Reflex PX-3028663500 CDM 86635 CPT 302 RC inpatient 200 200 MEDICA (COMMERCIAL) 94265 [3081118] MEDICA CLAIMS [308111801] 180 percent of total billed charges 124 190 Technical (Hospital) Services Ref Coccidioides Ab Screen With Reflex PX-3028663500 CDM 86635 CPT 302 RC inpatient 200 200 MULTIPLAN INC 34080 [3081285] MULTIPLAN INC [308128501] 190 percent of total billed charges 124 190 Technical (Hospital) Services Ref Coccidioides Ab Screen With Reflex PX-3028663500 CDM 86635 CPT 302 RC inpatient 200 200 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES EPO [308136803] 158.36 percent of total billed charges 124 190 Technical (Hospital) Services Ref Coccidioides Ab Screen With Reflex PX-3028663500 CDM 86635 CPT 302 RC inpatient 200 200 HEALTHPARTNERS SX009 HEALTHPARTNERS 158.36 percent of total billed charges 124 190 Technical (Hospital) Services Ref Coccidioides Ab Screen With Reflex PX-3028663500 CDM 86635 CPT 302 RC inpatient 200 200 BLUE CROSS BLUE SHIELD WELLMARK SB889 [3081026] BCBS WYOMING [308102603] 190 percent of total billed charges 124 190 Technical (Hospital) Services Ref Coccidiodes Igg Igm Cf or ID PX-3028663501 CDM 86635 CPT 302 RC inpatient 108 108 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES HDHP [308136802] 85.51 percent of total billed charges 66.96 102.6 Technical (Hospital) Services Ref Coccidiodes Igg Igm Cf or ID PX-3028663501 CDM 86635 CPT 302 RC inpatient 108 108 UNITED HEALTHCARE (COMMERCIAL) [3081199] UNITED HEALTHCARE 87726 [308119901] 66.96 percent of total billed charges 66.96 102.6 Technical (Hospital) Services Ref Coccidiodes Igg Igm Cf or ID PX-3028663501 CDM 86635 CPT 302 RC inpatient 108 108 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES PPO [308136801] 85.51 percent of total billed charges 66.96 102.6 Technical (Hospital) Services Ref Coccidiodes Igg Igm Cf or ID PX-3028663501 CDM 86635 CPT 302 RC inpatient 108 108 MULTIPLAN INC 34080 [3081285] MULTIPLAN INC [308128501] 102.6 percent of total billed charges 66.96 102.6 Technical (Hospital) Services Ref Coccidiodes Igg Igm Cf or ID PX-3028663501 CDM 86635 CPT 302 RC inpatient 108 108 MEDICA (COMMERCIAL) 94265 [3081118] MEDICA CLAIMS [308111801] 97.2 percent of total billed charges 66.96 102.6 Technical (Hospital) Services Ref Coccidiodes Igg Igm Cf or ID PX-3028663501 CDM 86635 CPT 302 RC inpatient 108 108 CIGNA 62308 [3081051] CIGNA 62308 [308105105] 85.51 percent of total billed charges 66.96 102.6 Technical (Hospital) Services Ref Coccidiodes Igg Igm Cf or ID PX-3028663501 CDM 86635 CPT 302 RC inpatient 108 108 CIGNA 62308 [3081051] CIGNA STATE OF WYOMING [308105107] 85.51 percent of total billed charges 66.96 102.6 Technical (Hospital) Services Ref Coccidiodes Igg Igm Cf or ID PX-3028663501 CDM 86635 CPT 302 RC inpatient 108 108 HEALTHPARTNERS SX009 HEALTHPARTNERS 85.51 percent of total billed charges 66.96 102.6 Technical (Hospital) Services Ref Coccidiodes Igg Igm Cf or ID PX-3028663501 CDM 86635 CPT 302 RC inpatient 108 108 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES EPO [308136803] 85.51 percent of total billed charges 66.96 102.6 Technical (Hospital) Services Ref Coccidiodes Igg Igm Cf or ID PX-3028663501 CDM 86635 CPT 302 RC inpatient 108 108 BLUE CROSS BLUE SHIELD WELLMARK SB889 [3081026] BCBS WYOMING [308102603] 102.6 percent of total billed charges 66.96 102.6 Technical (Hospital) Services Ref Coccidiodes Igg Igm Cf or ID PX-3028663501 CDM 86635 CPT 302 RC outpatient 108 108 BLUE CROSS BLUE SHIELD WELLMARK SB889 [3081026] BCBS WYOMING [308102603] 102.6 percent of total billed charges 66.96 102.6 Technical (Hospital) Services Ref Coccidiodes Igg Igm Cf or ID PX-3028663501 CDM 86635 CPT 302 RC outpatient 108 108 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES HDHP [308136802] 86.4 percent of total billed charges 66.96 102.6 Technical (Hospital) Services Ref Coccidiodes Igg Igm Cf or ID PX-3028663501 CDM 86635 CPT 302 RC outpatient 108 108 MULTIPLAN INC 34080 [3081285] MULTIPLAN INC [308128501] 102.6 percent of total billed charges 66.96 102.6 Technical (Hospital) Services Ref Coccidiodes Igg Igm Cf or ID PX-3028663501 CDM 86635 CPT 302 RC outpatient 108 108 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES EPO [308136803] 86.4 percent of total billed charges 66.96 102.6 Technical (Hospital) Services Ref Coccidiodes Igg Igm Cf or ID PX-3028663501 CDM 86635 CPT 302 RC outpatient 108 108 CIGNA 62308 [3081051] CIGNA 62308 [308105105] 86.4 percent of total billed charges 66.96 102.6 Technical (Hospital) Services Ref Coccidiodes Igg Igm Cf or ID PX-3028663501 CDM 86635 CPT 302 RC outpatient 108 108 CIGNA 62308 [3081051] CIGNA STATE OF WYOMING [308105107] 86.4 percent of total billed charges 66.96 102.6 Technical (Hospital) Services Ref Coccidiodes Igg Igm Cf or ID PX-3028663501 CDM 86635 CPT 302 RC outpatient 108 108 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES PPO [308136801] 86.4 percent of total billed charges 66.96 102.6 Technical (Hospital) Services Ref Coccidiodes Igg Igm Cf or ID PX-3028663501 CDM 86635 CPT 302 RC outpatient 108 108 UNITED HEALTHCARE (COMMERCIAL) [3081199] UNITED HEALTHCARE 87726 [308119901] 66.96 percent of total billed charges 66.96 102.6 Technical (Hospital) Services Ref Coccidiodes Igg Igm Cf or ID PX-3028663501 CDM 86635 CPT 302 RC outpatient 108 108 HEALTHPARTNERS SX009 HEALTHPARTNERS 86.4 percent of total billed charges 66.96 102.6 Technical (Hospital) Services Ref Coccidiodes Igg Igm Cf or ID PX-3028663501 CDM 86635 CPT 302 RC outpatient 108 108 MEDICA (COMMERCIAL) 94265 [3081118] MEDICA CLAIMS [308111801] 97.2 percent of total billed charges 66.96 102.6 Technical (Hospital) Services Ref Chlamydia Igg Each Species PX-3028663200 CDM 86632 CPT 302 RC inpatient 174 174 UNITED HEALTHCARE (COMMERCIAL) [3081199] UNITED HEALTHCARE 87726 [308119901] 107.88 percent of total billed charges 107.88 165.3 Technical (Hospital) Services Ref Chlamydia Igg Each Species PX-3028663200 CDM 86632 CPT 302 RC inpatient 174 174 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES PPO [308136801] 137.77 percent of total billed charges 107.88 165.3 Technical (Hospital) Services Ref Chlamydia Igg Each Species PX-3028663200 CDM 86632 CPT 302 RC inpatient 174 174 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES HDHP [308136802] 137.77 percent of total billed charges 107.88 165.3 Technical (Hospital) Services Ref Chlamydia Igg Each Species PX-3028663200 CDM 86632 CPT 302 RC inpatient 174 174 HEALTHPARTNERS SX009 HEALTHPARTNERS 137.77 percent of total billed charges 107.88 165.3 Technical (Hospital) Services Ref Chlamydia Igg Each Species PX-3028663200 CDM 86632 CPT 302 RC inpatient 174 174 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES EPO [308136803] 137.77 percent of total billed charges 107.88 165.3 Technical (Hospital) Services Ref Chlamydia Igg Each Species PX-3028663200 CDM 86632 CPT 302 RC inpatient 174 174 BLUE CROSS BLUE SHIELD WELLMARK SB889 [3081026] BCBS WYOMING [308102603] 165.3 percent of total billed charges 107.88 165.3 Technical (Hospital) Services Ref Chlamydia Igg Each Species PX-3028663200 CDM 86632 CPT 302 RC inpatient 174 174 MULTIPLAN INC 34080 [3081285] MULTIPLAN INC [308128501] 165.3 percent of total billed charges 107.88 165.3 Technical (Hospital) Services Ref Chlamydia Igg Each Species PX-3028663200 CDM 86632 CPT 302 RC inpatient 174 174 MEDICA (COMMERCIAL) 94265 [3081118] MEDICA CLAIMS [308111801] 156.6 percent of total billed charges 107.88 165.3 Technical (Hospital) Services Ref Chlamydia Igg Each Species PX-3028663200 CDM 86632 CPT 302 RC inpatient 174 174 CIGNA 62308 [3081051] CIGNA 62308 [308105105] 137.77 percent of total billed charges 107.88 165.3 Technical (Hospital) Services Ref Chlamydia Igg Each Species PX-3028663200 CDM 86632 CPT 302 RC inpatient 174 174 CIGNA 62308 [3081051] CIGNA STATE OF WYOMING [308105107] 137.77 percent of total billed charges 107.88 165.3 Technical (Hospital) Services Ref Chlamydia Igg Each Species PX-3028663200 CDM 86632 CPT 302 RC outpatient 174 174 UNITED HEALTHCARE (COMMERCIAL) [3081199] UNITED HEALTHCARE 87726 [308119901] 107.88 percent of total billed charges 107.88 165.3 Technical (Hospital) Services Ref Chlamydia Igg Each Species PX-3028663200 CDM 86632 CPT 302 RC outpatient 174 174 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES PPO [308136801] 139.2 percent of total billed charges 107.88 165.3 Technical (Hospital) Services Ref Chlamydia Igg Each Species PX-3028663200 CDM 86632 CPT 302 RC outpatient 174 174 HEALTHPARTNERS SX009 HEALTHPARTNERS 139.2 percent of total billed charges 107.88 165.3 Technical (Hospital) Services Ref Chlamydia Igg Each Species PX-3028663200 CDM 86632 CPT 302 RC outpatient 174 174 MULTIPLAN INC 34080 [3081285] MULTIPLAN INC [308128501] 165.3 percent of total billed charges 107.88 165.3 Technical (Hospital) Services Ref Chlamydia Igg Each Species PX-3028663200 CDM 86632 CPT 302 RC outpatient 174 174 BLUE CROSS BLUE SHIELD WELLMARK SB889 [3081026] BCBS WYOMING [308102603] 165.3 percent of total billed charges 107.88 165.3 Technical (Hospital) Services Ref Chlamydia Igg Each Species PX-3028663200 CDM 86632 CPT 302 RC outpatient 174 174 CIGNA 62308 [3081051] CIGNA 62308 [308105105] 139.2 percent of total billed charges 107.88 165.3 Technical (Hospital) Services Ref Chlamydia Igg Each Species PX-3028663200 CDM 86632 CPT 302 RC outpatient 174 174 CIGNA 62308 [3081051] CIGNA STATE OF WYOMING [308105107] 139.2 percent of total billed charges 107.88 165.3 Technical (Hospital) Services Ref Chlamydia Igg Each Species PX-3028663200 CDM 86632 CPT 302 RC outpatient 174 174 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES EPO [308136803] 139.2 percent of total billed charges 107.88 165.3 Technical (Hospital) Services Ref Chlamydia Igg Each Species PX-3028663200 CDM 86632 CPT 302 RC outpatient 174 174 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES HDHP [308136802] 139.2 percent of total billed charges 107.88 165.3 Technical (Hospital) Services Ref Chlamydia Igg Each Species PX-3028663200 CDM 86632 CPT 302 RC outpatient 174 174 MEDICA (COMMERCIAL) 94265 [3081118] MEDICA CLAIMS [308111801] 156.6 percent of total billed charges 107.88 165.3 Technical (Hospital) Services Chlamydia Antibody PX-3028663100 CDM 86631 CPT 302 RC outpatient 140 140 MEDICA (COMMERCIAL) 94265 [3081118] MEDICA CLAIMS [308111801] 126 percent of total billed charges 86.8 133 Technical (Hospital) Services Chlamydia Antibody PX-3028663100 CDM 86631 CPT 302 RC outpatient 140 140 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES PPO [308136801] 112 percent of total billed charges 86.8 133 Technical (Hospital) Services Chlamydia Antibody PX-3028663100 CDM 86631 CPT 302 RC outpatient 140 140 HEALTHPARTNERS SX009 HEALTHPARTNERS 112 percent of total billed charges 86.8 133 Technical (Hospital) Services Chlamydia Antibody PX-3028663100 CDM 86631 CPT 302 RC outpatient 140 140 UNITED HEALTHCARE (COMMERCIAL) [3081199] UNITED HEALTHCARE 87726 [308119901] 86.8 percent of total billed charges 86.8 133 Technical (Hospital) Services Chlamydia Antibody PX-3028663100 CDM 86631 CPT 302 RC outpatient 140 140 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES HDHP [308136802] 112 percent of total billed charges 86.8 133 Technical (Hospital) Services Chlamydia Antibody PX-3028663100 CDM 86631 CPT 302 RC outpatient 140 140 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES EPO [308136803] 112 percent of total billed charges 86.8 133 Technical (Hospital) Services Chlamydia Antibody PX-3028663100 CDM 86631 CPT 302 RC outpatient 140 140 CIGNA 62308 [3081051] CIGNA STATE OF WYOMING [308105107] 112 percent of total billed charges 86.8 133 Technical (Hospital) Services Chlamydia Antibody PX-3028663100 CDM 86631 CPT 302 RC outpatient 140 140 CIGNA 62308 [3081051] CIGNA 62308 [308105105] 112 percent of total billed charges 86.8 133 Technical (Hospital) Services Chlamydia Antibody PX-3028663100 CDM 86631 CPT 302 RC outpatient 140 140 BLUE CROSS BLUE SHIELD WELLMARK SB889 [3081026] BCBS WYOMING [308102603] 133 percent of total billed charges 86.8 133 Technical (Hospital) Services Chlamydia Antibody PX-3028663100 CDM 86631 CPT 302 RC outpatient 140 140 MULTIPLAN INC 34080 [3081285] MULTIPLAN INC [308128501] 133 percent of total billed charges 86.8 133 Technical (Hospital) Services Chlamydia Antibody PX-3028663100 CDM 86631 CPT 302 RC inpatient 140 140 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES HDHP [308136802] 110.85 percent of total billed charges 86.8 133 Technical (Hospital) Services Chlamydia Antibody PX-3028663100 CDM 86631 CPT 302 RC inpatient 140 140 MEDICA (COMMERCIAL) 94265 [3081118] MEDICA CLAIMS [308111801] 126 percent of total billed charges 86.8 133 Technical (Hospital) Services Chlamydia Antibody PX-3028663100 CDM 86631 CPT 302 RC inpatient 140 140 UNITED HEALTHCARE (COMMERCIAL) [3081199] UNITED HEALTHCARE 87726 [308119901] 86.8 percent of total billed charges 86.8 133 Technical (Hospital) Services Chlamydia Antibody PX-3028663100 CDM 86631 CPT 302 RC inpatient 140 140 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES PPO [308136801] 110.85 percent of total billed charges 86.8 133 Technical (Hospital) Services Chlamydia Antibody PX-3028663100 CDM 86631 CPT 302 RC inpatient 140 140 CIGNA 62308 [3081051] CIGNA 62308 [308105105] 110.85 percent of total billed charges 86.8 133 Technical (Hospital) Services Chlamydia Antibody PX-3028663100 CDM 86631 CPT 302 RC inpatient 140 140 CIGNA 62308 [3081051] CIGNA STATE OF WYOMING [308105107] 110.85 percent of total billed charges 86.8 133 Technical (Hospital) Services Chlamydia Antibody PX-3028663100 CDM 86631 CPT 302 RC inpatient 140 140 MULTIPLAN INC 34080 [3081285] MULTIPLAN INC [308128501] 133 percent of total billed charges 86.8 133 Technical (Hospital) Services Chlamydia Antibody PX-3028663100 CDM 86631 CPT 302 RC inpatient 140 140 BLUE CROSS BLUE SHIELD WELLMARK SB889 [3081026] BCBS WYOMING [308102603] 133 percent of total billed charges 86.8 133 Technical (Hospital) Services Chlamydia Antibody PX-3028663100 CDM 86631 CPT 302 RC inpatient 140 140 HEALTHPARTNERS SX009 HEALTHPARTNERS 110.85 percent of total billed charges 86.8 133 Technical (Hospital) Services Chlamydia Antibody PX-3028663100 CDM 86631 CPT 302 RC inpatient 140 140 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES EPO [308136803] 110.85 percent of total billed charges 86.8 133 Technical (Hospital) Services Ref Brucella Ab Igg or Igm PX-3028662200 CDM 86622 CPT 302 RC outpatient 135 135 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES HDHP [308136802] 108 percent of total billed charges 83.7 128.25 Technical (Hospital) Services Ref Brucella Ab Igg or Igm PX-3028662200 CDM 86622 CPT 302 RC outpatient 135 135 MULTIPLAN INC 34080 [3081285] MULTIPLAN INC [308128501] 128.25 percent of total billed charges 83.7 128.25 Technical (Hospital) Services Ref Brucella Ab Igg or Igm PX-3028662200 CDM 86622 CPT 302 RC outpatient 135 135 BLUE CROSS BLUE SHIELD WELLMARK SB889 [3081026] BCBS WYOMING [308102603] 128.25 percent of total billed charges 83.7 128.25 Technical (Hospital) Services Ref Brucella Ab Igg or Igm PX-3028662200 CDM 86622 CPT 302 RC outpatient 135 135 CIGNA 62308 [3081051] CIGNA 62308 [308105105] 108 percent of total billed charges 83.7 128.25 Technical (Hospital) Services Ref Brucella Ab Igg or Igm PX-3028662200 CDM 86622 CPT 302 RC outpatient 135 135 CIGNA 62308 [3081051] CIGNA STATE OF WYOMING [308105107] 108 percent of total billed charges 83.7 128.25 Technical (Hospital) Services Ref Brucella Ab Igg or Igm PX-3028662200 CDM 86622 CPT 302 RC outpatient 135 135 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES EPO [308136803] 108 percent of total billed charges 83.7 128.25 Technical (Hospital) Services Ref Brucella Ab Igg or Igm PX-3028662200 CDM 86622 CPT 302 RC outpatient 135 135 HEALTHPARTNERS SX009 HEALTHPARTNERS 108 percent of total billed charges 83.7 128.25 Technical (Hospital) Services Ref Brucella Ab Igg or Igm PX-3028662200 CDM 86622 CPT 302 RC outpatient 135 135 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES PPO [308136801] 108 percent of total billed charges 83.7 128.25 Technical (Hospital) Services Ref Brucella Ab Igg or Igm PX-3028662200 CDM 86622 CPT 302 RC outpatient 135 135 UNITED HEALTHCARE (COMMERCIAL) [3081199] UNITED HEALTHCARE 87726 [308119901] 83.7 percent of total billed charges 83.7 128.25 Technical (Hospital) Services Ref Brucella Ab Igg or Igm PX-3028662200 CDM 86622 CPT 302 RC outpatient 135 135 MEDICA (COMMERCIAL) 94265 [3081118] MEDICA CLAIMS [308111801] 121.5 percent of total billed charges 83.7 128.25 Technical (Hospital) Services Ref Brucella Ab Igg or Igm PX-3028662200 CDM 86622 CPT 302 RC inpatient 135 135 HEALTHPARTNERS SX009 HEALTHPARTNERS 106.89 percent of total billed charges 83.7 128.25 Technical (Hospital) Services Ref Brucella Ab Igg or Igm PX-3028662200 CDM 86622 CPT 302 RC inpatient 135 135 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES EPO [308136803] 106.89 percent of total billed charges 83.7 128.25 Technical (Hospital) Services Ref Brucella Ab Igg or Igm PX-3028662200 CDM 86622 CPT 302 RC inpatient 135 135 MEDICA (COMMERCIAL) 94265 [3081118] MEDICA CLAIMS [308111801] 121.5 percent of total billed charges 83.7 128.25 Technical (Hospital) Services Ref Brucella Ab Igg or Igm PX-3028662200 CDM 86622 CPT 302 RC inpatient 135 135 MULTIPLAN INC 34080 [3081285] MULTIPLAN INC [308128501] 128.25 percent of total billed charges 83.7 128.25 Technical (Hospital) Services Ref Brucella Ab Igg or Igm PX-3028662200 CDM 86622 CPT 302 RC inpatient 135 135 BLUE CROSS BLUE SHIELD WELLMARK SB889 [3081026] BCBS WYOMING [308102603] 128.25 percent of total billed charges 83.7 128.25 Technical (Hospital) Services Ref Brucella Ab Igg or Igm PX-3028662200 CDM 86622 CPT 302 RC inpatient 135 135 CIGNA 62308 [3081051] CIGNA 62308 [308105105] 106.89 percent of total billed charges 83.7 128.25 Technical (Hospital) Services Ref Brucella Ab Igg or Igm PX-3028662200 CDM 86622 CPT 302 RC inpatient 135 135 CIGNA 62308 [3081051] CIGNA STATE OF WYOMING [308105107] 106.89 percent of total billed charges 83.7 128.25 Technical (Hospital) Services Ref Brucella Ab Igg or Igm PX-3028662200 CDM 86622 CPT 302 RC inpatient 135 135 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES HDHP [308136802] 106.89 percent of total billed charges 83.7 128.25 Technical (Hospital) Services Ref Brucella Ab Igg or Igm PX-3028662200 CDM 86622 CPT 302 RC inpatient 135 135 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES PPO [308136801] 106.89 percent of total billed charges 83.7 128.25 Technical (Hospital) Services Ref Brucella Ab Igg or Igm PX-3028662200 CDM 86622 CPT 302 RC inpatient 135 135 UNITED HEALTHCARE (COMMERCIAL) [3081199] UNITED HEALTHCARE 87726 [308119901] 83.7 percent of total billed charges 83.7 128.25 Technical (Hospital) Services Ref Lyme Cns Inefection Igg With Antibody Index Reflex PX-3028661800 CDM 86618 CPT 302 RC inpatient 238 238 HEALTHPARTNERS SX009 HEALTHPARTNERS 188.45 percent of total billed charges 147.56 226.1 Technical (Hospital) Services Ref Lyme Cns Inefection Igg With Antibody Index Reflex PX-3028661800 CDM 86618 CPT 302 RC inpatient 238 238 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES EPO [308136803] 188.45 percent of total billed charges 147.56 226.1 Technical (Hospital) Services Ref Lyme Cns Inefection Igg With Antibody Index Reflex PX-3028661800 CDM 86618 CPT 302 RC inpatient 238 238 BLUE CROSS BLUE SHIELD WELLMARK SB889 [3081026] BCBS WYOMING [308102603] 226.1 percent of total billed charges 147.56 226.1 Technical (Hospital) Services Ref Lyme Cns Inefection Igg With Antibody Index Reflex PX-3028661800 CDM 86618 CPT 302 RC inpatient 238 238 MEDICA (COMMERCIAL) 94265 [3081118] MEDICA CLAIMS [308111801] 214.2 percent of total billed charges 147.56 226.1 Technical (Hospital) Services Ref Lyme Cns Inefection Igg With Antibody Index Reflex PX-3028661800 CDM 86618 CPT 302 RC inpatient 238 238 MULTIPLAN INC 34080 [3081285] MULTIPLAN INC [308128501] 226.1 percent of total billed charges 147.56 226.1 Technical (Hospital) Services Ref Lyme Cns Inefection Igg With Antibody Index Reflex PX-3028661800 CDM 86618 CPT 302 RC inpatient 238 238 CIGNA 62308 [3081051] CIGNA 62308 [308105105] 188.45 percent of total billed charges 147.56 226.1 Technical (Hospital) Services Ref Lyme Cns Inefection Igg With Antibody Index Reflex PX-3028661800 CDM 86618 CPT 302 RC inpatient 238 238 CIGNA 62308 [3081051] CIGNA STATE OF WYOMING [308105107] 188.45 percent of total billed charges 147.56 226.1 Technical (Hospital) Services Ref Lyme Cns Inefection Igg With Antibody Index Reflex PX-3028661800 CDM 86618 CPT 302 RC inpatient 238 238 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES HDHP [308136802] 188.45 percent of total billed charges 147.56 226.1 Technical (Hospital) Services Ref Lyme Cns Inefection Igg With Antibody Index Reflex PX-3028661800 CDM 86618 CPT 302 RC inpatient 238 238 UNITED HEALTHCARE (COMMERCIAL) [3081199] UNITED HEALTHCARE 87726 [308119901] 147.56 percent of total billed charges 147.56 226.1 Technical (Hospital) Services Ref Lyme Cns Inefection Igg With Antibody Index Reflex PX-3028661800 CDM 86618 CPT 302 RC inpatient 238 238 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES PPO [308136801] 188.45 percent of total billed charges 147.56 226.1 Technical (Hospital) Services Ref Lyme Cns Inefection Igg With Antibody Index Reflex PX-3028661800 CDM 86618 CPT 302 RC outpatient 238 238 MEDICA (COMMERCIAL) 94265 [3081118] MEDICA CLAIMS [308111801] 214.2 percent of total billed charges 147.56 226.1 Technical (Hospital) Services Ref Lyme Cns Inefection Igg With Antibody Index Reflex PX-3028661800 CDM 86618 CPT 302 RC outpatient 238 238 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES PPO [308136801] 190.4 percent of total billed charges 147.56 226.1 Technical (Hospital) Services Ref Lyme Cns Inefection Igg With Antibody Index Reflex PX-3028661800 CDM 86618 CPT 302 RC outpatient 238 238 HEALTHPARTNERS SX009 HEALTHPARTNERS 190.4 percent of total billed charges 147.56 226.1 Technical (Hospital) Services Ref Lyme Cns Inefection Igg With Antibody Index Reflex PX-3028661800 CDM 86618 CPT 302 RC outpatient 238 238 BLUE CROSS BLUE SHIELD WELLMARK SB889 [3081026] BCBS WYOMING [308102603] 226.1 percent of total billed charges 147.56 226.1 Technical (Hospital) Services Ref Lyme Cns Inefection Igg With Antibody Index Reflex PX-3028661800 CDM 86618 CPT 302 RC outpatient 238 238 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES HDHP [308136802] 190.4 percent of total billed charges 147.56 226.1 Technical (Hospital) Services Ref Lyme Cns Inefection Igg With Antibody Index Reflex PX-3028661800 CDM 86618 CPT 302 RC outpatient 238 238 CIGNA 62308 [3081051] CIGNA 62308 [308105105] 190.4 percent of total billed charges 147.56 226.1 Technical (Hospital) Services Ref Lyme Cns Inefection Igg With Antibody Index Reflex PX-3028661800 CDM 86618 CPT 302 RC outpatient 238 238 CIGNA 62308 [3081051] CIGNA STATE OF WYOMING [308105107] 190.4 percent of total billed charges 147.56 226.1 Technical (Hospital) Services Ref Lyme Cns Inefection Igg With Antibody Index Reflex PX-3028661800 CDM 86618 CPT 302 RC outpatient 238 238 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES EPO [308136803] 190.4 percent of total billed charges 147.56 226.1 Technical (Hospital) Services Ref Lyme Cns Inefection Igg With Antibody Index Reflex PX-3028661800 CDM 86618 CPT 302 RC outpatient 238 238 MULTIPLAN INC 34080 [3081285] MULTIPLAN INC [308128501] 226.1 percent of total billed charges 147.56 226.1 Technical (Hospital) Services Ref Lyme Cns Inefection Igg With Antibody Index Reflex PX-3028661800 CDM 86618 CPT 302 RC outpatient 238 238 UNITED HEALTHCARE (COMMERCIAL) [3081199] UNITED HEALTHCARE 87726 [308119901] 147.56 percent of total billed charges 147.56 226.1 Technical (Hospital) Services Ref Lyme Disease Serology PX-3028661801 CDM 86618 CPT 302 RC inpatient 238 238 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES PPO [308136801] 188.45 percent of total billed charges 147.56 226.1 Technical (Hospital) Services Ref Lyme Disease Serology PX-3028661801 CDM 86618 CPT 302 RC inpatient 238 238 UNITED HEALTHCARE (COMMERCIAL) [3081199] UNITED HEALTHCARE 87726 [308119901] 147.56 percent of total billed charges 147.56 226.1 Technical (Hospital) Services Ref Lyme Disease Serology PX-3028661801 CDM 86618 CPT 302 RC inpatient 238 238 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES HDHP [308136802] 188.45 percent of total billed charges 147.56 226.1 Technical (Hospital) Services Ref Lyme Disease Serology PX-3028661801 CDM 86618 CPT 302 RC inpatient 238 238 MULTIPLAN INC 34080 [3081285] MULTIPLAN INC [308128501] 226.1 percent of total billed charges 147.56 226.1 Technical (Hospital) Services Ref Lyme Disease Serology PX-3028661801 CDM 86618 CPT 302 RC inpatient 238 238 MEDICA (COMMERCIAL) 94265 [3081118] MEDICA CLAIMS [308111801] 214.2 percent of total billed charges 147.56 226.1 Technical (Hospital) Services Ref Lyme Disease Serology PX-3028661801 CDM 86618 CPT 302 RC inpatient 238 238 CIGNA 62308 [3081051] CIGNA 62308 [308105105] 188.45 percent of total billed charges 147.56 226.1 Technical (Hospital) Services Ref Lyme Disease Serology PX-3028661801 CDM 86618 CPT 302 RC inpatient 238 238 CIGNA 62308 [3081051] CIGNA STATE OF WYOMING [308105107] 188.45 percent of total billed charges 147.56 226.1 Technical (Hospital) Services Ref Lyme Disease Serology PX-3028661801 CDM 86618 CPT 302 RC inpatient 238 238 BLUE CROSS BLUE SHIELD WELLMARK SB889 [3081026] BCBS WYOMING [308102603] 226.1 percent of total billed charges 147.56 226.1 Technical (Hospital) Services Ref Lyme Disease Serology PX-3028661801 CDM 86618 CPT 302 RC inpatient 238 238 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES EPO [308136803] 188.45 percent of total billed charges 147.56 226.1 Technical (Hospital) Services Ref Lyme Disease Serology PX-3028661801 CDM 86618 CPT 302 RC inpatient 238 238 HEALTHPARTNERS SX009 HEALTHPARTNERS 188.45 percent of total billed charges 147.56 226.1 Technical (Hospital) Services Ref Lyme Disease Serology PX-3028661801 CDM 86618 CPT 302 RC outpatient 238 238 MEDICA (COMMERCIAL) 94265 [3081118] MEDICA CLAIMS [308111801] 214.2 percent of total billed charges 147.56 226.1 Technical (Hospital) Services Ref Lyme Disease Serology PX-3028661801 CDM 86618 CPT 302 RC outpatient 238 238 MULTIPLAN INC 34080 [3081285] MULTIPLAN INC [308128501] 226.1 percent of total billed charges 147.56 226.1 Technical (Hospital) Services Ref Lyme Disease Serology PX-3028661801 CDM 86618 CPT 302 RC outpatient 238 238 BLUE CROSS BLUE SHIELD WELLMARK SB889 [3081026] BCBS WYOMING [308102603] 226.1 percent of total billed charges 147.56 226.1 Technical (Hospital) Services Ref Lyme Disease Serology PX-3028661801 CDM 86618 CPT 302 RC outpatient 238 238 CIGNA 62308 [3081051] CIGNA 62308 [308105105] 190.4 percent of total billed charges 147.56 226.1 Technical (Hospital) Services Ref Lyme Disease Serology PX-3028661801 CDM 86618 CPT 302 RC outpatient 238 238 CIGNA 62308 [3081051] CIGNA STATE OF WYOMING [308105107] 190.4 percent of total billed charges 147.56 226.1 Technical (Hospital) Services Ref Lyme Disease Serology PX-3028661801 CDM 86618 CPT 302 RC outpatient 238 238 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES EPO [308136803] 190.4 percent of total billed charges 147.56 226.1 Technical (Hospital) Services Ref Lyme Disease Serology PX-3028661801 CDM 86618 CPT 302 RC outpatient 238 238 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES HDHP [308136802] 190.4 percent of total billed charges 147.56 226.1 Technical (Hospital) Services Ref Lyme Disease Serology PX-3028661801 CDM 86618 CPT 302 RC outpatient 238 238 UNITED HEALTHCARE (COMMERCIAL) [3081199] UNITED HEALTHCARE 87726 [308119901] 147.56 percent of total billed charges 147.56 226.1 Technical (Hospital) Services Ref Lyme Disease Serology PX-3028661801 CDM 86618 CPT 302 RC outpatient 238 238 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES PPO [308136801] 190.4 percent of total billed charges 147.56 226.1 Technical (Hospital) Services Ref Lyme Disease Serology PX-3028661801 CDM 86618 CPT 302 RC outpatient 238 238 HEALTHPARTNERS SX009 HEALTHPARTNERS 190.4 percent of total billed charges 147.56 226.1 Technical (Hospital) Services RPR PX-3028659200 CDM 86592 CPT 302 RC outpatient 65 65 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES HDHP [308136802] 52 percent of total billed charges 40.3 61.75 Technical (Hospital) Services RPR PX-3028659200 CDM 86592 CPT 302 RC outpatient 65 65 CIGNA 62308 [3081051] CIGNA 62308 [308105105] 52 percent of total billed charges 40.3 61.75 Technical (Hospital) Services RPR PX-3028659200 CDM 86592 CPT 302 RC outpatient 65 65 CIGNA 62308 [3081051] CIGNA STATE OF WYOMING [308105107] 52 percent of total billed charges 40.3 61.75 Technical (Hospital) Services RPR PX-3028659200 CDM 86592 CPT 302 RC outpatient 65 65 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES EPO [308136803] 52 percent of total billed charges 40.3 61.75 Technical (Hospital) Services RPR PX-3028659200 CDM 86592 CPT 302 RC outpatient 65 65 MULTIPLAN INC 34080 [3081285] MULTIPLAN INC [308128501] 61.75 percent of total billed charges 40.3 61.75 Technical (Hospital) Services RPR PX-3028659200 CDM 86592 CPT 302 RC outpatient 65 65 BLUE CROSS BLUE SHIELD WELLMARK SB889 [3081026] BCBS WYOMING [308102603] 61.75 percent of total billed charges 40.3 61.75 Technical (Hospital) Services RPR PX-3028659200 CDM 86592 CPT 302 RC outpatient 65 65 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES PPO [308136801] 52 percent of total billed charges 40.3 61.75 Technical (Hospital) Services RPR PX-3028659200 CDM 86592 CPT 302 RC outpatient 65 65 HEALTHPARTNERS SX009 HEALTHPARTNERS 52 percent of total billed charges 40.3 61.75 Technical (Hospital) Services RPR PX-3028659200 CDM 86592 CPT 302 RC outpatient 65 65 UNITED HEALTHCARE (COMMERCIAL) [3081199] UNITED HEALTHCARE 87726 [308119901] 40.3 percent of total billed charges 40.3 61.75 Technical (Hospital) Services RPR PX-3028659200 CDM 86592 CPT 302 RC outpatient 65 65 MEDICA (COMMERCIAL) 94265 [3081118] MEDICA CLAIMS [308111801] 58.5 percent of total billed charges 40.3 61.75 Technical (Hospital) Services RPR PX-3028659200 CDM 86592 CPT 302 RC inpatient 65 65 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES PPO [308136801] 51.47 percent of total billed charges 40.3 61.75 Technical (Hospital) Services RPR PX-3028659200 CDM 86592 CPT 302 RC inpatient 65 65 UNITED HEALTHCARE (COMMERCIAL) [3081199] UNITED HEALTHCARE 87726 [308119901] 40.3 percent of total billed charges 40.3 61.75 Technical (Hospital) Services RPR PX-3028659200 CDM 86592 CPT 302 RC inpatient 65 65 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES HDHP [308136802] 51.47 percent of total billed charges 40.3 61.75 Technical (Hospital) Services RPR PX-3028659200 CDM 86592 CPT 302 RC inpatient 65 65 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES EPO [308136803] 51.47 percent of total billed charges 40.3 61.75 Technical (Hospital) Services RPR PX-3028659200 CDM 86592 CPT 302 RC inpatient 65 65 HEALTHPARTNERS SX009 HEALTHPARTNERS 51.47 percent of total billed charges 40.3 61.75 Technical (Hospital) Services RPR PX-3028659200 CDM 86592 CPT 302 RC inpatient 65 65 BLUE CROSS BLUE SHIELD WELLMARK SB889 [3081026] BCBS WYOMING [308102603] 61.75 percent of total billed charges 40.3 61.75 Technical (Hospital) Services RPR PX-3028659200 CDM 86592 CPT 302 RC inpatient 65 65 CIGNA 62308 [3081051] CIGNA 62308 [308105105] 51.47 percent of total billed charges 40.3 61.75 Technical (Hospital) Services RPR PX-3028659200 CDM 86592 CPT 302 RC inpatient 65 65 CIGNA 62308 [3081051] CIGNA STATE OF WYOMING [308105107] 51.47 percent of total billed charges 40.3 61.75 Technical (Hospital) Services RPR PX-3028659200 CDM 86592 CPT 302 RC inpatient 65 65 MULTIPLAN INC 34080 [3081285] MULTIPLAN INC [308128501] 61.75 percent of total billed charges 40.3 61.75 Technical (Hospital) Services RPR PX-3028659200 CDM 86592 CPT 302 RC inpatient 65 65 MEDICA (COMMERCIAL) 94265 [3081118] MEDICA CLAIMS [308111801] 58.5 percent of total billed charges 40.3 61.75 Technical (Hospital) Services TB Gold PX-3028648100 CDM 86481 CPT 302 RC outpatient 477 477 UNITED HEALTHCARE (COMMERCIAL) [3081199] UNITED HEALTHCARE 87726 [308119901] 295.74 percent of total billed charges 295.74 453.15 Technical (Hospital) Services TB Gold PX-3028648100 CDM 86481 CPT 302 RC outpatient 477 477 HEALTHPARTNERS SX009 HEALTHPARTNERS 381.6 percent of total billed charges 295.74 453.15 Technical (Hospital) Services TB Gold PX-3028648100 CDM 86481 CPT 302 RC outpatient 477 477 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES PPO [308136801] 381.6 percent of total billed charges 295.74 453.15 Technical (Hospital) Services TB Gold PX-3028648100 CDM 86481 CPT 302 RC outpatient 477 477 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES HDHP [308136802] 381.6 percent of total billed charges 295.74 453.15 Technical (Hospital) Services TB Gold PX-3028648100 CDM 86481 CPT 302 RC outpatient 477 477 CIGNA 62308 [3081051] CIGNA 62308 [308105105] 381.6 percent of total billed charges 295.74 453.15 Technical (Hospital) Services TB Gold PX-3028648100 CDM 86481 CPT 302 RC outpatient 477 477 CIGNA 62308 [3081051] CIGNA STATE OF WYOMING [308105107] 381.6 percent of total billed charges 295.74 453.15 Technical (Hospital) Services TB Gold PX-3028648100 CDM 86481 CPT 302 RC outpatient 477 477 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES EPO [308136803] 381.6 percent of total billed charges 295.74 453.15 Technical (Hospital) Services TB Gold PX-3028648100 CDM 86481 CPT 302 RC outpatient 477 477 MULTIPLAN INC 34080 [3081285] MULTIPLAN INC [308128501] 453.15 percent of total billed charges 295.74 453.15 Technical (Hospital) Services TB Gold PX-3028648100 CDM 86481 CPT 302 RC outpatient 477 477 BLUE CROSS BLUE SHIELD WELLMARK SB889 [3081026] BCBS WYOMING [308102603] 453.15 percent of total billed charges 295.74 453.15 Technical (Hospital) Services TB Gold PX-3028648100 CDM 86481 CPT 302 RC outpatient 477 477 MEDICA (COMMERCIAL) 94265 [3081118] MEDICA CLAIMS [308111801] 429.3 percent of total billed charges 295.74 453.15 Technical (Hospital) Services TB Gold PX-3028648100 CDM 86481 CPT 302 RC inpatient 477 477 UNITED HEALTHCARE (COMMERCIAL) [3081199] UNITED HEALTHCARE 87726 [308119901] 295.74 percent of total billed charges 295.74 453.15 Technical (Hospital) Services TB Gold PX-3028648100 CDM 86481 CPT 302 RC inpatient 477 477 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES PPO [308136801] 377.69 percent of total billed charges 295.74 453.15 Technical (Hospital) Services TB Gold PX-3028648100 CDM 86481 CPT 302 RC inpatient 477 477 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES HDHP [308136802] 377.69 percent of total billed charges 295.74 453.15 Technical (Hospital) Services TB Gold PX-3028648100 CDM 86481 CPT 302 RC inpatient 477 477 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES EPO [308136803] 377.69 percent of total billed charges 295.74 453.15 Technical (Hospital) Services TB Gold PX-3028648100 CDM 86481 CPT 302 RC inpatient 477 477 BLUE CROSS BLUE SHIELD WELLMARK SB889 [3081026] BCBS WYOMING [308102603] 453.15 percent of total billed charges 295.74 453.15 Technical (Hospital) Services TB Gold PX-3028648100 CDM 86481 CPT 302 RC inpatient 477 477 HEALTHPARTNERS SX009 HEALTHPARTNERS 377.69 percent of total billed charges 295.74 453.15 Technical (Hospital) Services TB Gold PX-3028648100 CDM 86481 CPT 302 RC inpatient 477 477 MEDICA (COMMERCIAL) 94265 [3081118] MEDICA CLAIMS [308111801] 429.3 percent of total billed charges 295.74 453.15 Technical (Hospital) Services TB Gold PX-3028648100 CDM 86481 CPT 302 RC inpatient 477 477 MULTIPLAN INC 34080 [3081285] MULTIPLAN INC [308128501] 453.15 percent of total billed charges 295.74 453.15 Technical (Hospital) Services TB Gold PX-3028648100 CDM 86481 CPT 302 RC inpatient 477 477 CIGNA 62308 [3081051] CIGNA 62308 [308105105] 377.69 percent of total billed charges 295.74 453.15 Technical (Hospital) Services TB Gold PX-3028648100 CDM 86481 CPT 302 RC inpatient 477 477 CIGNA 62308 [3081051] CIGNA STATE OF WYOMING [308105107] 377.69 percent of total billed charges 295.74 453.15 Technical (Hospital) Services TB Gold PX-3028648000 CDM 86480 CPT 302 RC inpatient 289 289 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES HDHP [308136802] 228.83 percent of total billed charges 179.18 274.55 Technical (Hospital) Services TB Gold PX-3028648000 CDM 86480 CPT 302 RC inpatient 289 289 MEDICA (COMMERCIAL) 94265 [3081118] MEDICA CLAIMS [308111801] 260.1 percent of total billed charges 179.18 274.55 Technical (Hospital) Services TB Gold PX-3028648000 CDM 86480 CPT 302 RC inpatient 289 289 UNITED HEALTHCARE (COMMERCIAL) [3081199] UNITED HEALTHCARE 87726 [308119901] 179.18 percent of total billed charges 179.18 274.55 Technical (Hospital) Services TB Gold PX-3028648000 CDM 86480 CPT 302 RC inpatient 289 289 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES PPO [308136801] 228.83 percent of total billed charges 179.18 274.55 Technical (Hospital) Services TB Gold PX-3028648000 CDM 86480 CPT 302 RC inpatient 289 289 CIGNA 62308 [3081051] CIGNA 62308 [308105105] 228.83 percent of total billed charges 179.18 274.55 Technical (Hospital) Services TB Gold PX-3028648000 CDM 86480 CPT 302 RC inpatient 289 289 CIGNA 62308 [3081051] CIGNA STATE OF WYOMING [308105107] 228.83 percent of total billed charges 179.18 274.55 Technical (Hospital) Services TB Gold PX-3028648000 CDM 86480 CPT 302 RC inpatient 289 289 MULTIPLAN INC 34080 [3081285] MULTIPLAN INC [308128501] 274.55 percent of total billed charges 179.18 274.55 Technical (Hospital) Services TB Gold PX-3028648000 CDM 86480 CPT 302 RC inpatient 289 289 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES EPO [308136803] 228.83 percent of total billed charges 179.18 274.55 Technical (Hospital) Services TB Gold PX-3028648000 CDM 86480 CPT 302 RC inpatient 289 289 HEALTHPARTNERS SX009 HEALTHPARTNERS 228.83 percent of total billed charges 179.18 274.55 Technical (Hospital) Services TB Gold PX-3028648000 CDM 86480 CPT 302 RC inpatient 289 289 BLUE CROSS BLUE SHIELD WELLMARK SB889 [3081026] BCBS WYOMING [308102603] 274.55 percent of total billed charges 179.18 274.55 Technical (Hospital) Services TB Gold PX-3028648000 CDM 86480 CPT 302 RC outpatient 289 289 BLUE CROSS BLUE SHIELD WELLMARK SB889 [3081026] BCBS WYOMING [308102603] 274.55 percent of total billed charges 179.18 274.55 Technical (Hospital) Services TB Gold PX-3028648000 CDM 86480 CPT 302 RC outpatient 289 289 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES HDHP [308136802] 231.2 percent of total billed charges 179.18 274.55 Technical (Hospital) Services TB Gold PX-3028648000 CDM 86480 CPT 302 RC outpatient 289 289 MULTIPLAN INC 34080 [3081285] MULTIPLAN INC [308128501] 274.55 percent of total billed charges 179.18 274.55 Technical (Hospital) Services TB Gold PX-3028648000 CDM 86480 CPT 302 RC outpatient 289 289 CIGNA 62308 [3081051] CIGNA 62308 [308105105] 231.2 percent of total billed charges 179.18 274.55 Technical (Hospital) Services TB Gold PX-3028648000 CDM 86480 CPT 302 RC outpatient 289 289 CIGNA 62308 [3081051] CIGNA STATE OF WYOMING [308105107] 231.2 percent of total billed charges 179.18 274.55 Technical (Hospital) Services TB Gold PX-3028648000 CDM 86480 CPT 302 RC outpatient 289 289 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES EPO [308136803] 231.2 percent of total billed charges 179.18 274.55 Technical (Hospital) Services TB Gold PX-3028648000 CDM 86480 CPT 302 RC outpatient 289 289 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES PPO [308136801] 231.2 percent of total billed charges 179.18 274.55 Technical (Hospital) Services TB Gold PX-3028648000 CDM 86480 CPT 302 RC outpatient 289 289 HEALTHPARTNERS SX009 HEALTHPARTNERS 231.2 percent of total billed charges 179.18 274.55 Technical (Hospital) Services TB Gold PX-3028648000 CDM 86480 CPT 302 RC outpatient 289 289 UNITED HEALTHCARE (COMMERCIAL) [3081199] UNITED HEALTHCARE 87726 [308119901] 179.18 percent of total billed charges 179.18 274.55 Technical (Hospital) Services TB Gold PX-3028648000 CDM 86480 CPT 302 RC outpatient 289 289 MEDICA (COMMERCIAL) 94265 [3081118] MEDICA CLAIMS [308111801] 260.1 percent of total billed charges 179.18 274.55 Technical (Hospital) Services Ra Quan PX-3028643100 CDM 86431 CPT 302 RC outpatient 90 90 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES EPO [308136803] 72 percent of total billed charges 55.8 85.5 Technical (Hospital) Services Ra Quan PX-3028643100 CDM 86431 CPT 302 RC outpatient 90 90 CIGNA 62308 [3081051] CIGNA 62308 [308105105] 72 percent of total billed charges 55.8 85.5 Technical (Hospital) Services Ra Quan PX-3028643100 CDM 86431 CPT 302 RC outpatient 90 90 CIGNA 62308 [3081051] CIGNA STATE OF WYOMING [308105107] 72 percent of total billed charges 55.8 85.5 Technical (Hospital) Services Ra Quan PX-3028643100 CDM 86431 CPT 302 RC outpatient 90 90 MULTIPLAN INC 34080 [3081285] MULTIPLAN INC [308128501] 85.5 percent of total billed charges 55.8 85.5 Technical (Hospital) Services Ra Quan PX-3028643100 CDM 86431 CPT 302 RC outpatient 90 90 BLUE CROSS BLUE SHIELD WELLMARK SB889 [3081026] BCBS WYOMING [308102603] 85.5 percent of total billed charges 55.8 85.5 Technical (Hospital) Services Ra Quan PX-3028643100 CDM 86431 CPT 302 RC outpatient 90 90 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES HDHP [308136802] 72 percent of total billed charges 55.8 85.5 Technical (Hospital) Services Ra Quan PX-3028643100 CDM 86431 CPT 302 RC outpatient 90 90 UNITED HEALTHCARE (COMMERCIAL) [3081199] UNITED HEALTHCARE 87726 [308119901] 55.8 percent of total billed charges 55.8 85.5 Technical (Hospital) Services Ra Quan PX-3028643100 CDM 86431 CPT 302 RC outpatient 90 90 HEALTHPARTNERS SX009 HEALTHPARTNERS 72 percent of total billed charges 55.8 85.5 Technical (Hospital) Services Ra Quan PX-3028643100 CDM 86431 CPT 302 RC outpatient 90 90 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES PPO [308136801] 72 percent of total billed charges 55.8 85.5 Technical (Hospital) Services Ra Quan PX-3028643100 CDM 86431 CPT 302 RC outpatient 90 90 MEDICA (COMMERCIAL) 94265 [3081118] MEDICA CLAIMS [308111801] 81 percent of total billed charges 55.8 85.5 Technical (Hospital) Services Ra Quan PX-3028643100 CDM 86431 CPT 302 RC inpatient 90 90 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES HDHP [308136802] 71.26 percent of total billed charges 55.8 85.5 Technical (Hospital) Services Ra Quan PX-3028643100 CDM 86431 CPT 302 RC inpatient 90 90 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES PPO [308136801] 71.26 percent of total billed charges 55.8 85.5 Technical (Hospital) Services Ra Quan PX-3028643100 CDM 86431 CPT 302 RC inpatient 90 90 UNITED HEALTHCARE (COMMERCIAL) [3081199] UNITED HEALTHCARE 87726 [308119901] 55.8 percent of total billed charges 55.8 85.5 Technical (Hospital) Services Ra Quan PX-3028643100 CDM 86431 CPT 302 RC inpatient 90 90 CIGNA 62308 [3081051] CIGNA 62308 [308105105] 71.26 percent of total billed charges 55.8 85.5 Technical (Hospital) Services Ra Quan PX-3028643100 CDM 86431 CPT 302 RC inpatient 90 90 CIGNA 62308 [3081051] CIGNA STATE OF WYOMING [308105107] 71.26 percent of total billed charges 55.8 85.5 Technical (Hospital) Services Ra Quan PX-3028643100 CDM 86431 CPT 302 RC inpatient 90 90 MEDICA (COMMERCIAL) 94265 [3081118] MEDICA CLAIMS [308111801] 81 percent of total billed charges 55.8 85.5 Technical (Hospital) Services Ra Quan PX-3028643100 CDM 86431 CPT 302 RC inpatient 90 90 MULTIPLAN INC 34080 [3081285] MULTIPLAN INC [308128501] 85.5 percent of total billed charges 55.8 85.5 Technical (Hospital) Services Ra Quan PX-3028643100 CDM 86431 CPT 302 RC inpatient 90 90 BLUE CROSS BLUE SHIELD WELLMARK SB889 [3081026] BCBS WYOMING [308102603] 85.5 percent of total billed charges 55.8 85.5 Technical (Hospital) Services Ra Quan PX-3028643100 CDM 86431 CPT 302 RC inpatient 90 90 HEALTHPARTNERS SX009 HEALTHPARTNERS 71.26 percent of total billed charges 55.8 85.5 Technical (Hospital) Services Ra Quan PX-3028643100 CDM 86431 CPT 302 RC inpatient 90 90 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES EPO [308136803] 71.26 percent of total billed charges 55.8 85.5 Technical (Hospital) Services Ra Qual PX-3028643000 CDM 86430 CPT 302 RC inpatient 87 87 MEDICA (COMMERCIAL) 94265 [3081118] MEDICA CLAIMS [308111801] 78.3 percent of total billed charges 53.94 82.65 Technical (Hospital) Services Ra Qual PX-3028643000 CDM 86430 CPT 302 RC inpatient 87 87 MULTIPLAN INC 34080 [3081285] MULTIPLAN INC [308128501] 82.65 percent of total billed charges 53.94 82.65 Technical (Hospital) Services Ra Qual PX-3028643000 CDM 86430 CPT 302 RC inpatient 87 87 CIGNA 62308 [3081051] CIGNA 62308 [308105105] 68.89 percent of total billed charges 53.94 82.65 Technical (Hospital) Services Ra Qual PX-3028643000 CDM 86430 CPT 302 RC inpatient 87 87 CIGNA 62308 [3081051] CIGNA STATE OF WYOMING [308105107] 68.89 percent of total billed charges 53.94 82.65 Technical (Hospital) Services Ra Qual PX-3028643000 CDM 86430 CPT 302 RC inpatient 87 87 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES EPO [308136803] 68.89 percent of total billed charges 53.94 82.65 Technical (Hospital) Services Ra Qual PX-3028643000 CDM 86430 CPT 302 RC inpatient 87 87 HEALTHPARTNERS SX009 HEALTHPARTNERS 68.89 percent of total billed charges 53.94 82.65 Technical (Hospital) Services Ra Qual PX-3028643000 CDM 86430 CPT 302 RC inpatient 87 87 BLUE CROSS BLUE SHIELD WELLMARK SB889 [3081026] BCBS WYOMING [308102603] 82.65 percent of total billed charges 53.94 82.65 Technical (Hospital) Services Ra Qual PX-3028643000 CDM 86430 CPT 302 RC inpatient 87 87 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES PPO [308136801] 68.89 percent of total billed charges 53.94 82.65 Technical (Hospital) Services Ra Qual PX-3028643000 CDM 86430 CPT 302 RC inpatient 87 87 UNITED HEALTHCARE (COMMERCIAL) [3081199] UNITED HEALTHCARE 87726 [308119901] 53.94 percent of total billed charges 53.94 82.65 Technical (Hospital) Services Ra Qual PX-3028643000 CDM 86430 CPT 302 RC inpatient 87 87 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES HDHP [308136802] 68.89 percent of total billed charges 53.94 82.65 Technical (Hospital) Services Ra Qual PX-3028643000 CDM 86430 CPT 302 RC outpatient 87 87 UNITED HEALTHCARE (COMMERCIAL) [3081199] UNITED HEALTHCARE 87726 [308119901] 53.94 percent of total billed charges 53.94 82.65 Technical (Hospital) Services Ra Qual PX-3028643000 CDM 86430 CPT 302 RC outpatient 87 87 HEALTHPARTNERS SX009 HEALTHPARTNERS 69.6 percent of total billed charges 53.94 82.65 Technical (Hospital) Services Ra Qual PX-3028643000 CDM 86430 CPT 302 RC outpatient 87 87 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES PPO [308136801] 69.6 percent of total billed charges 53.94 82.65 Technical (Hospital) Services Ra Qual PX-3028643000 CDM 86430 CPT 302 RC outpatient 87 87 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES HDHP [308136802] 69.6 percent of total billed charges 53.94 82.65 Technical (Hospital) Services Ra Qual PX-3028643000 CDM 86430 CPT 302 RC outpatient 87 87 BLUE CROSS BLUE SHIELD WELLMARK SB889 [3081026] BCBS WYOMING [308102603] 82.65 percent of total billed charges 53.94 82.65 Technical (Hospital) Services Ra Qual PX-3028643000 CDM 86430 CPT 302 RC outpatient 87 87 MULTIPLAN INC 34080 [3081285] MULTIPLAN INC [308128501] 82.65 percent of total billed charges 53.94 82.65 Technical (Hospital) Services Ra Qual PX-3028643000 CDM 86430 CPT 302 RC outpatient 87 87 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES EPO [308136803] 69.6 percent of total billed charges 53.94 82.65 Technical (Hospital) Services Ra Qual PX-3028643000 CDM 86430 CPT 302 RC outpatient 87 87 CIGNA 62308 [3081051] CIGNA 62308 [308105105] 69.6 percent of total billed charges 53.94 82.65 Technical (Hospital) Services Ra Qual PX-3028643000 CDM 86430 CPT 302 RC outpatient 87 87 CIGNA 62308 [3081051] CIGNA STATE OF WYOMING [308105107] 69.6 percent of total billed charges 53.94 82.65 Technical (Hospital) Services Ra Qual PX-3028643000 CDM 86430 CPT 302 RC outpatient 87 87 MEDICA (COMMERCIAL) 94265 [3081118] MEDICA CLAIMS [308111801] 78.3 percent of total billed charges 53.94 82.65 Technical (Hospital) Services "HC Ref Mitochondrial Ab, M2, S (Mayo)" PX-3028638100 CDM 86381 CPT 302 RC inpatient 173 173 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES EPO [308136803] 136.98 percent of total billed charges 107.26 164.35 Technical (Hospital) Services "HC Ref Mitochondrial Ab, M2, S (Mayo)" PX-3028638100 CDM 86381 CPT 302 RC inpatient 173 173 HEALTHPARTNERS SX009 HEALTHPARTNERS 136.98 percent of total billed charges 107.26 164.35 Technical (Hospital) Services "HC Ref Mitochondrial Ab, M2, S (Mayo)" PX-3028638100 CDM 86381 CPT 302 RC inpatient 173 173 BLUE CROSS BLUE SHIELD WELLMARK SB889 [3081026] BCBS WYOMING [308102603] 164.35 percent of total billed charges 107.26 164.35 Technical (Hospital) Services "HC Ref Mitochondrial Ab, M2, S (Mayo)" PX-3028638100 CDM 86381 CPT 302 RC inpatient 173 173 CIGNA 62308 [3081051] CIGNA 62308 [308105105] 136.98 percent of total billed charges 107.26 164.35 Technical (Hospital) Services "HC Ref Mitochondrial Ab, M2, S (Mayo)" PX-3028638100 CDM 86381 CPT 302 RC inpatient 173 173 CIGNA 62308 [3081051] CIGNA STATE OF WYOMING [308105107] 136.98 percent of total billed charges 107.26 164.35 Technical (Hospital) Services "HC Ref Mitochondrial Ab, M2, S (Mayo)" PX-3028638100 CDM 86381 CPT 302 RC inpatient 173 173 MEDICA (COMMERCIAL) 94265 [3081118] MEDICA CLAIMS [308111801] 155.7 percent of total billed charges 107.26 164.35 Technical (Hospital) Services "HC Ref Mitochondrial Ab, M2, S (Mayo)" PX-3028638100 CDM 86381 CPT 302 RC inpatient 173 173 MULTIPLAN INC 34080 [3081285] MULTIPLAN INC [308128501] 164.35 percent of total billed charges 107.26 164.35 Technical (Hospital) Services "HC Ref Mitochondrial Ab, M2, S (Mayo)" PX-3028638100 CDM 86381 CPT 302 RC inpatient 173 173 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES PPO [308136801] 136.98 percent of total billed charges 107.26 164.35 Technical (Hospital) Services "HC Ref Mitochondrial Ab, M2, S (Mayo)" PX-3028638100 CDM 86381 CPT 302 RC inpatient 173 173 UNITED HEALTHCARE (COMMERCIAL) [3081199] UNITED HEALTHCARE 87726 [308119901] 107.26 percent of total billed charges 107.26 164.35 Technical (Hospital) Services "HC Ref Mitochondrial Ab, M2, S (Mayo)" PX-3028638100 CDM 86381 CPT 302 RC inpatient 173 173 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES HDHP [308136802] 136.98 percent of total billed charges 107.26 164.35 Technical (Hospital) Services "HC Ref Mitochondrial Ab, M2, S (Mayo)" PX-3028638100 CDM 86381 CPT 302 RC outpatient 173 173 UNITED HEALTHCARE (COMMERCIAL) [3081199] UNITED HEALTHCARE 87726 [308119901] 107.26 percent of total billed charges 107.26 164.35 Technical (Hospital) Services "HC Ref Mitochondrial Ab, M2, S (Mayo)" PX-3028638100 CDM 86381 CPT 302 RC outpatient 173 173 HEALTHPARTNERS SX009 HEALTHPARTNERS 138.4 percent of total billed charges 107.26 164.35 Technical (Hospital) Services "HC Ref Mitochondrial Ab, M2, S (Mayo)" PX-3028638100 CDM 86381 CPT 302 RC outpatient 173 173 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES PPO [308136801] 138.4 percent of total billed charges 107.26 164.35 Technical (Hospital) Services "HC Ref Mitochondrial Ab, M2, S (Mayo)" PX-3028638100 CDM 86381 CPT 302 RC outpatient 173 173 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES HDHP [308136802] 138.4 percent of total billed charges 107.26 164.35 Technical (Hospital) Services "HC Ref Mitochondrial Ab, M2, S (Mayo)" PX-3028638100 CDM 86381 CPT 302 RC outpatient 173 173 BLUE CROSS BLUE SHIELD WELLMARK SB889 [3081026] BCBS WYOMING [308102603] 164.35 percent of total billed charges 107.26 164.35 Technical (Hospital) Services "HC Ref Mitochondrial Ab, M2, S (Mayo)" PX-3028638100 CDM 86381 CPT 302 RC outpatient 173 173 MULTIPLAN INC 34080 [3081285] MULTIPLAN INC [308128501] 164.35 percent of total billed charges 107.26 164.35 Technical (Hospital) Services "HC Ref Mitochondrial Ab, M2, S (Mayo)" PX-3028638100 CDM 86381 CPT 302 RC outpatient 173 173 CIGNA 62308 [3081051] CIGNA 62308 [308105105] 138.4 percent of total billed charges 107.26 164.35 Technical (Hospital) Services "HC Ref Mitochondrial Ab, M2, S (Mayo)" PX-3028638100 CDM 86381 CPT 302 RC outpatient 173 173 CIGNA 62308 [3081051] CIGNA STATE OF WYOMING [308105107] 138.4 percent of total billed charges 107.26 164.35 Technical (Hospital) Services "HC Ref Mitochondrial Ab, M2, S (Mayo)" PX-3028638100 CDM 86381 CPT 302 RC outpatient 173 173 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES EPO [308136803] 138.4 percent of total billed charges 107.26 164.35 Technical (Hospital) Services "HC Ref Mitochondrial Ab, M2, S (Mayo)" PX-3028638100 CDM 86381 CPT 302 RC outpatient 173 173 MEDICA (COMMERCIAL) 94265 [3081118] MEDICA CLAIMS [308111801] 155.7 percent of total billed charges 107.26 164.35 Technical (Hospital) Services HC Anti-Mitochondrial M2 Antibody PX-3028638101 CDM 86381 CPT 302 RC inpatient 170 170 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES PPO [308136801] 134.61 percent of total billed charges 105.4 161.5 Technical (Hospital) Services HC Anti-Mitochondrial M2 Antibody PX-3028638101 CDM 86381 CPT 302 RC inpatient 170 170 BLUE CROSS BLUE SHIELD WELLMARK SB889 [3081026] BCBS WYOMING [308102603] 161.5 percent of total billed charges 105.4 161.5 Technical (Hospital) Services HC Anti-Mitochondrial M2 Antibody PX-3028638101 CDM 86381 CPT 302 RC inpatient 170 170 UNITED HEALTHCARE (COMMERCIAL) [3081199] UNITED HEALTHCARE 87726 [308119901] 105.4 percent of total billed charges 105.4 161.5 Technical (Hospital) Services HC Anti-Mitochondrial M2 Antibody PX-3028638101 CDM 86381 CPT 302 RC inpatient 170 170 MULTIPLAN INC 34080 [3081285] MULTIPLAN INC [308128501] 161.5 percent of total billed charges 105.4 161.5 Technical (Hospital) Services HC Anti-Mitochondrial M2 Antibody PX-3028638101 CDM 86381 CPT 302 RC inpatient 170 170 MEDICA (COMMERCIAL) 94265 [3081118] MEDICA CLAIMS [308111801] 153 percent of total billed charges 105.4 161.5 Technical (Hospital) Services HC Anti-Mitochondrial M2 Antibody PX-3028638101 CDM 86381 CPT 302 RC inpatient 170 170 HEALTHPARTNERS SX009 HEALTHPARTNERS 134.61 percent of total billed charges 105.4 161.5 Technical (Hospital) Services HC Anti-Mitochondrial M2 Antibody PX-3028638101 CDM 86381 CPT 302 RC inpatient 170 170 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES HDHP [308136802] 134.61 percent of total billed charges 105.4 161.5 Technical (Hospital) Services HC Anti-Mitochondrial M2 Antibody PX-3028638101 CDM 86381 CPT 302 RC inpatient 170 170 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES EPO [308136803] 134.61 percent of total billed charges 105.4 161.5 Technical (Hospital) Services HC Anti-Mitochondrial M2 Antibody PX-3028638101 CDM 86381 CPT 302 RC inpatient 170 170 CIGNA 62308 [3081051] CIGNA 62308 [308105105] 134.61 percent of total billed charges 105.4 161.5 Technical (Hospital) Services HC Anti-Mitochondrial M2 Antibody PX-3028638101 CDM 86381 CPT 302 RC inpatient 170 170 CIGNA 62308 [3081051] CIGNA STATE OF WYOMING [308105107] 134.61 percent of total billed charges 105.4 161.5 Technical (Hospital) Services HC Anti-Mitochondrial M2 Antibody PX-3028638101 CDM 86381 CPT 302 RC outpatient 170 170 MEDICA (COMMERCIAL) 94265 [3081118] MEDICA CLAIMS [308111801] 153 percent of total billed charges 105.4 161.5 Technical (Hospital) Services HC Anti-Mitochondrial M2 Antibody PX-3028638101 CDM 86381 CPT 302 RC outpatient 170 170 CIGNA 62308 [3081051] CIGNA 62308 [308105105] 136 percent of total billed charges 105.4 161.5 Technical (Hospital) Services HC Anti-Mitochondrial M2 Antibody PX-3028638101 CDM 86381 CPT 302 RC outpatient 170 170 CIGNA 62308 [3081051] CIGNA STATE OF WYOMING [308105107] 136 percent of total billed charges 105.4 161.5 Technical (Hospital) Services HC Anti-Mitochondrial M2 Antibody PX-3028638101 CDM 86381 CPT 302 RC outpatient 170 170 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES EPO [308136803] 136 percent of total billed charges 105.4 161.5 Technical (Hospital) Services HC Anti-Mitochondrial M2 Antibody PX-3028638101 CDM 86381 CPT 302 RC outpatient 170 170 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES PPO [308136801] 136 percent of total billed charges 105.4 161.5 Technical (Hospital) Services HC Anti-Mitochondrial M2 Antibody PX-3028638101 CDM 86381 CPT 302 RC outpatient 170 170 MULTIPLAN INC 34080 [3081285] MULTIPLAN INC [308128501] 161.5 percent of total billed charges 105.4 161.5 Technical (Hospital) Services HC Anti-Mitochondrial M2 Antibody PX-3028638101 CDM 86381 CPT 302 RC outpatient 170 170 UNITED HEALTHCARE (COMMERCIAL) [3081199] UNITED HEALTHCARE 87726 [308119901] 105.4 percent of total billed charges 105.4 161.5 Technical (Hospital) Services HC Anti-Mitochondrial M2 Antibody PX-3028638101 CDM 86381 CPT 302 RC outpatient 170 170 BLUE CROSS BLUE SHIELD WELLMARK SB889 [3081026] BCBS WYOMING [308102603] 161.5 percent of total billed charges 105.4 161.5 Technical (Hospital) Services HC Anti-Mitochondrial M2 Antibody PX-3028638101 CDM 86381 CPT 302 RC outpatient 170 170 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES HDHP [308136802] 136 percent of total billed charges 105.4 161.5 Technical (Hospital) Services HC Anti-Mitochondrial M2 Antibody PX-3028638101 CDM 86381 CPT 302 RC outpatient 170 170 HEALTHPARTNERS SX009 HEALTHPARTNERS 136 percent of total billed charges 105.4 161.5 Technical (Hospital) Services Thyroid Antibodies PX-3028637600 CDM 86376 CPT 302 RC inpatient 183 183 MULTIPLAN INC 34080 [3081285] MULTIPLAN INC [308128501] 173.85 percent of total billed charges 113.46 173.85 Technical (Hospital) Services Thyroid Antibodies PX-3028637600 CDM 86376 CPT 302 RC inpatient 183 183 MEDICA (COMMERCIAL) 94265 [3081118] MEDICA CLAIMS [308111801] 164.7 percent of total billed charges 113.46 173.85 Technical (Hospital) Services Thyroid Antibodies PX-3028637600 CDM 86376 CPT 302 RC inpatient 183 183 CIGNA 62308 [3081051] CIGNA 62308 [308105105] 144.9 percent of total billed charges 113.46 173.85 Technical (Hospital) Services Thyroid Antibodies PX-3028637600 CDM 86376 CPT 302 RC inpatient 183 183 CIGNA 62308 [3081051] CIGNA STATE OF WYOMING [308105107] 144.9 percent of total billed charges 113.46 173.85 Technical (Hospital) Services Thyroid Antibodies PX-3028637600 CDM 86376 CPT 302 RC inpatient 183 183 BLUE CROSS BLUE SHIELD WELLMARK SB889 [3081026] BCBS WYOMING [308102603] 173.85 percent of total billed charges 113.46 173.85 Technical (Hospital) Services Thyroid Antibodies PX-3028637600 CDM 86376 CPT 302 RC inpatient 183 183 HEALTHPARTNERS SX009 HEALTHPARTNERS 144.9 percent of total billed charges 113.46 173.85 Technical (Hospital) Services Thyroid Antibodies PX-3028637600 CDM 86376 CPT 302 RC inpatient 183 183 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES EPO [308136803] 144.9 percent of total billed charges 113.46 173.85 Technical (Hospital) Services Thyroid Antibodies PX-3028637600 CDM 86376 CPT 302 RC inpatient 183 183 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES HDHP [308136802] 144.9 percent of total billed charges 113.46 173.85 Technical (Hospital) Services Thyroid Antibodies PX-3028637600 CDM 86376 CPT 302 RC inpatient 183 183 UNITED HEALTHCARE (COMMERCIAL) [3081199] UNITED HEALTHCARE 87726 [308119901] 113.46 percent of total billed charges 113.46 173.85 Technical (Hospital) Services Thyroid Antibodies PX-3028637600 CDM 86376 CPT 302 RC inpatient 183 183 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES PPO [308136801] 144.9 percent of total billed charges 113.46 173.85 Technical (Hospital) Services Thyroid Antibodies PX-3028637600 CDM 86376 CPT 302 RC outpatient 183 183 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES HDHP [308136802] 146.4 percent of total billed charges 113.46 173.85 Technical (Hospital) Services Thyroid Antibodies PX-3028637600 CDM 86376 CPT 302 RC outpatient 183 183 BLUE CROSS BLUE SHIELD WELLMARK SB889 [3081026] BCBS WYOMING [308102603] 173.85 percent of total billed charges 113.46 173.85 Technical (Hospital) Services Thyroid Antibodies PX-3028637600 CDM 86376 CPT 302 RC outpatient 183 183 MULTIPLAN INC 34080 [3081285] MULTIPLAN INC [308128501] 173.85 percent of total billed charges 113.46 173.85 Technical (Hospital) Services Thyroid Antibodies PX-3028637600 CDM 86376 CPT 302 RC outpatient 183 183 CIGNA 62308 [3081051] CIGNA 62308 [308105105] 146.4 percent of total billed charges 113.46 173.85 Technical (Hospital) Services Thyroid Antibodies PX-3028637600 CDM 86376 CPT 302 RC outpatient 183 183 CIGNA 62308 [3081051] CIGNA STATE OF WYOMING [308105107] 146.4 percent of total billed charges 113.46 173.85 Technical (Hospital) Services Thyroid Antibodies PX-3028637600 CDM 86376 CPT 302 RC outpatient 183 183 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES EPO [308136803] 146.4 percent of total billed charges 113.46 173.85 Technical (Hospital) Services Thyroid Antibodies PX-3028637600 CDM 86376 CPT 302 RC outpatient 183 183 UNITED HEALTHCARE (COMMERCIAL) [3081199] UNITED HEALTHCARE 87726 [308119901] 113.46 percent of total billed charges 113.46 173.85 Technical (Hospital) Services Thyroid Antibodies PX-3028637600 CDM 86376 CPT 302 RC outpatient 183 183 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES PPO [308136801] 146.4 percent of total billed charges 113.46 173.85 Technical (Hospital) Services Thyroid Antibodies PX-3028637600 CDM 86376 CPT 302 RC outpatient 183 183 HEALTHPARTNERS SX009 HEALTHPARTNERS 146.4 percent of total billed charges 113.46 173.85 Technical (Hospital) Services Thyroid Antibodies PX-3028637600 CDM 86376 CPT 302 RC outpatient 183 183 MEDICA (COMMERCIAL) 94265 [3081118] MEDICA CLAIMS [308111801] 164.7 percent of total billed charges 113.46 173.85 Technical (Hospital) Services Ref Liver Kidney Microsomal Antibo PX-3028637601 CDM 86376 CPT 302 RC inpatient 197 197 BLUE CROSS BLUE SHIELD WELLMARK SB889 [3081026] BCBS WYOMING [308102603] 187.15 percent of total billed charges 122.14 187.15 Technical (Hospital) Services Ref Liver Kidney Microsomal Antibo PX-3028637601 CDM 86376 CPT 302 RC inpatient 197 197 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES EPO [308136803] 155.98 percent of total billed charges 122.14 187.15 Technical (Hospital) Services Ref Liver Kidney Microsomal Antibo PX-3028637601 CDM 86376 CPT 302 RC inpatient 197 197 HEALTHPARTNERS SX009 HEALTHPARTNERS 155.98 percent of total billed charges 122.14 187.15 Technical (Hospital) Services Ref Liver Kidney Microsomal Antibo PX-3028637601 CDM 86376 CPT 302 RC inpatient 197 197 MEDICA (COMMERCIAL) 94265 [3081118] MEDICA CLAIMS [308111801] 177.3 percent of total billed charges 122.14 187.15 Technical (Hospital) Services Ref Liver Kidney Microsomal Antibo PX-3028637601 CDM 86376 CPT 302 RC inpatient 197 197 MULTIPLAN INC 34080 [3081285] MULTIPLAN INC [308128501] 187.15 percent of total billed charges 122.14 187.15 Technical (Hospital) Services Ref Liver Kidney Microsomal Antibo PX-3028637601 CDM 86376 CPT 302 RC inpatient 197 197 CIGNA 62308 [3081051] CIGNA 62308 [308105105] 155.98 percent of total billed charges 122.14 187.15 Technical (Hospital) Services Ref Liver Kidney Microsomal Antibo PX-3028637601 CDM 86376 CPT 302 RC inpatient 197 197 CIGNA 62308 [3081051] CIGNA STATE OF WYOMING [308105107] 155.98 percent of total billed charges 122.14 187.15 Technical (Hospital) Services Ref Liver Kidney Microsomal Antibo PX-3028637601 CDM 86376 CPT 302 RC inpatient 197 197 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES HDHP [308136802] 155.98 percent of total billed charges 122.14 187.15 Technical (Hospital) Services Ref Liver Kidney Microsomal Antibo PX-3028637601 CDM 86376 CPT 302 RC inpatient 197 197 UNITED HEALTHCARE (COMMERCIAL) [3081199] UNITED HEALTHCARE 87726 [308119901] 122.14 percent of total billed charges 122.14 187.15 Technical (Hospital) Services Ref Liver Kidney Microsomal Antibo PX-3028637601 CDM 86376 CPT 302 RC inpatient 197 197 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES PPO [308136801] 155.98 percent of total billed charges 122.14 187.15 Technical (Hospital) Services Ref Liver Kidney Microsomal Antibo PX-3028637601 CDM 86376 CPT 302 RC outpatient 197 197 MULTIPLAN INC 34080 [3081285] MULTIPLAN INC [308128501] 187.15 percent of total billed charges 122.14 187.15 Technical (Hospital) Services Ref Liver Kidney Microsomal Antibo PX-3028637601 CDM 86376 CPT 302 RC outpatient 197 197 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES EPO [308136803] 157.6 percent of total billed charges 122.14 187.15 Technical (Hospital) Services Ref Liver Kidney Microsomal Antibo PX-3028637601 CDM 86376 CPT 302 RC outpatient 197 197 CIGNA 62308 [3081051] CIGNA 62308 [308105105] 157.6 percent of total billed charges 122.14 187.15 Technical (Hospital) Services Ref Liver Kidney Microsomal Antibo PX-3028637601 CDM 86376 CPT 302 RC outpatient 197 197 CIGNA 62308 [3081051] CIGNA STATE OF WYOMING [308105107] 157.6 percent of total billed charges 122.14 187.15 Technical (Hospital) Services Ref Liver Kidney Microsomal Antibo PX-3028637601 CDM 86376 CPT 302 RC outpatient 197 197 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES HDHP [308136802] 157.6 percent of total billed charges 122.14 187.15 Technical (Hospital) Services Ref Liver Kidney Microsomal Antibo PX-3028637601 CDM 86376 CPT 302 RC outpatient 197 197 BLUE CROSS BLUE SHIELD WELLMARK SB889 [3081026] BCBS WYOMING [308102603] 187.15 percent of total billed charges 122.14 187.15 Technical (Hospital) Services Ref Liver Kidney Microsomal Antibo PX-3028637601 CDM 86376 CPT 302 RC outpatient 197 197 HEALTHPARTNERS SX009 HEALTHPARTNERS 157.6 percent of total billed charges 122.14 187.15 Technical (Hospital) Services Ref Liver Kidney Microsomal Antibo PX-3028637601 CDM 86376 CPT 302 RC outpatient 197 197 UNITED HEALTHCARE (COMMERCIAL) [3081199] UNITED HEALTHCARE 87726 [308119901] 122.14 percent of total billed charges 122.14 187.15 Technical (Hospital) Services Ref Liver Kidney Microsomal Antibo PX-3028637601 CDM 86376 CPT 302 RC outpatient 197 197 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES PPO [308136801] 157.6 percent of total billed charges 122.14 187.15 Technical (Hospital) Services Ref Liver Kidney Microsomal Antibo PX-3028637601 CDM 86376 CPT 302 RC outpatient 197 197 MEDICA (COMMERCIAL) 94265 [3081118] MEDICA CLAIMS [308111801] 177.3 percent of total billed charges 122.14 187.15 Technical (Hospital) Services "HC Ref Tissue Transglt Ab, Iga, S (Mayo)" PX-3028636400 CDM 86364 CPT 302 RC outpatient 137 137 BLUE CROSS BLUE SHIELD WELLMARK SB889 [3081026] BCBS WYOMING [308102603] 130.15 percent of total billed charges 84.94 130.15 Technical (Hospital) Services "HC Ref Tissue Transglt Ab, Iga, S (Mayo)" PX-3028636400 CDM 86364 CPT 302 RC outpatient 137 137 MULTIPLAN INC 34080 [3081285] MULTIPLAN INC [308128501] 130.15 percent of total billed charges 84.94 130.15 Technical (Hospital) Services "HC Ref Tissue Transglt Ab, Iga, S (Mayo)" PX-3028636400 CDM 86364 CPT 302 RC outpatient 137 137 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES EPO [308136803] 109.6 percent of total billed charges 84.94 130.15 Technical (Hospital) Services "HC Ref Tissue Transglt Ab, Iga, S (Mayo)" PX-3028636400 CDM 86364 CPT 302 RC outpatient 137 137 CIGNA 62308 [3081051] CIGNA 62308 [308105105] 109.6 percent of total billed charges 84.94 130.15 Technical (Hospital) Services "HC Ref Tissue Transglt Ab, Iga, S (Mayo)" PX-3028636400 CDM 86364 CPT 302 RC outpatient 137 137 CIGNA 62308 [3081051] CIGNA STATE OF WYOMING [308105107] 109.6 percent of total billed charges 84.94 130.15 Technical (Hospital) Services "HC Ref Tissue Transglt Ab, Iga, S (Mayo)" PX-3028636400 CDM 86364 CPT 302 RC outpatient 137 137 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES HDHP [308136802] 109.6 percent of total billed charges 84.94 130.15 Technical (Hospital) Services "HC Ref Tissue Transglt Ab, Iga, S (Mayo)" PX-3028636400 CDM 86364 CPT 302 RC outpatient 137 137 UNITED HEALTHCARE (COMMERCIAL) [3081199] UNITED HEALTHCARE 87726 [308119901] 84.94 percent of total billed charges 84.94 130.15 Technical (Hospital) Services "HC Ref Tissue Transglt Ab, Iga, S (Mayo)" PX-3028636400 CDM 86364 CPT 302 RC outpatient 137 137 HEALTHPARTNERS SX009 HEALTHPARTNERS 109.6 percent of total billed charges 84.94 130.15 Technical (Hospital) Services "HC Ref Tissue Transglt Ab, Iga, S (Mayo)" PX-3028636400 CDM 86364 CPT 302 RC outpatient 137 137 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES PPO [308136801] 109.6 percent of total billed charges 84.94 130.15 Technical (Hospital) Services "HC Ref Tissue Transglt Ab, Iga, S (Mayo)" PX-3028636400 CDM 86364 CPT 302 RC outpatient 137 137 MEDICA (COMMERCIAL) 94265 [3081118] MEDICA CLAIMS [308111801] 123.3 percent of total billed charges 84.94 130.15 Technical (Hospital) Services "HC Ref Tissue Transglt Ab, Iga, S (Mayo)" PX-3028636400 CDM 86364 CPT 302 RC inpatient 137 137 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES HDHP [308136802] 108.48 percent of total billed charges 84.94 130.15 Technical (Hospital) Services "HC Ref Tissue Transglt Ab, Iga, S (Mayo)" PX-3028636400 CDM 86364 CPT 302 RC inpatient 137 137 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES PPO [308136801] 108.48 percent of total billed charges 84.94 130.15 Technical (Hospital) Services "HC Ref Tissue Transglt Ab, Iga, S (Mayo)" PX-3028636400 CDM 86364 CPT 302 RC inpatient 137 137 UNITED HEALTHCARE (COMMERCIAL) [3081199] UNITED HEALTHCARE 87726 [308119901] 84.94 percent of total billed charges 84.94 130.15 Technical (Hospital) Services "HC Ref Tissue Transglt Ab, Iga, S (Mayo)" PX-3028636400 CDM 86364 CPT 302 RC inpatient 137 137 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES EPO [308136803] 108.48 percent of total billed charges 84.94 130.15 Technical (Hospital) Services "HC Ref Tissue Transglt Ab, Iga, S (Mayo)" PX-3028636400 CDM 86364 CPT 302 RC inpatient 137 137 BLUE CROSS BLUE SHIELD WELLMARK SB889 [3081026] BCBS WYOMING [308102603] 130.15 percent of total billed charges 84.94 130.15 Technical (Hospital) Services "HC Ref Tissue Transglt Ab, Iga, S (Mayo)" PX-3028636400 CDM 86364 CPT 302 RC inpatient 137 137 HEALTHPARTNERS SX009 HEALTHPARTNERS 108.48 percent of total billed charges 84.94 130.15 Technical (Hospital) Services "HC Ref Tissue Transglt Ab, Iga, S (Mayo)" PX-3028636400 CDM 86364 CPT 302 RC inpatient 137 137 CIGNA 62308 [3081051] CIGNA 62308 [308105105] 108.48 percent of total billed charges 84.94 130.15 Technical (Hospital) Services "HC Ref Tissue Transglt Ab, Iga, S (Mayo)" PX-3028636400 CDM 86364 CPT 302 RC inpatient 137 137 CIGNA 62308 [3081051] CIGNA STATE OF WYOMING [308105107] 108.48 percent of total billed charges 84.94 130.15 Technical (Hospital) Services "HC Ref Tissue Transglt Ab, Iga, S (Mayo)" PX-3028636400 CDM 86364 CPT 302 RC inpatient 137 137 MEDICA (COMMERCIAL) 94265 [3081118] MEDICA CLAIMS [308111801] 123.3 percent of total billed charges 84.94 130.15 Technical (Hospital) Services "HC Ref Tissue Transglt Ab, Iga, S (Mayo)" PX-3028636400 CDM 86364 CPT 302 RC inpatient 137 137 MULTIPLAN INC 34080 [3081285] MULTIPLAN INC [308128501] 130.15 percent of total billed charges 84.94 130.15 Technical (Hospital) Services "HC Ref Tissue Transglt Ab,Igg, S (Mayo)" PX-3028636401 CDM 86364 CPT 302 RC inpatient 137 137 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES HDHP [308136802] 108.48 percent of total billed charges 84.94 130.15 Technical (Hospital) Services "HC Ref Tissue Transglt Ab,Igg, S (Mayo)" PX-3028636401 CDM 86364 CPT 302 RC inpatient 137 137 UNITED HEALTHCARE (COMMERCIAL) [3081199] UNITED HEALTHCARE 87726 [308119901] 84.94 percent of total billed charges 84.94 130.15 Technical (Hospital) Services "HC Ref Tissue Transglt Ab,Igg, S (Mayo)" PX-3028636401 CDM 86364 CPT 302 RC inpatient 137 137 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES PPO [308136801] 108.48 percent of total billed charges 84.94 130.15 Technical (Hospital) Services "HC Ref Tissue Transglt Ab,Igg, S (Mayo)" PX-3028636401 CDM 86364 CPT 302 RC inpatient 137 137 MEDICA (COMMERCIAL) 94265 [3081118] MEDICA CLAIMS [308111801] 123.3 percent of total billed charges 84.94 130.15 Technical (Hospital) Services "HC Ref Tissue Transglt Ab,Igg, S (Mayo)" PX-3028636401 CDM 86364 CPT 302 RC inpatient 137 137 MULTIPLAN INC 34080 [3081285] MULTIPLAN INC [308128501] 130.15 percent of total billed charges 84.94 130.15 Technical (Hospital) Services "HC Ref Tissue Transglt Ab,Igg, S (Mayo)" PX-3028636401 CDM 86364 CPT 302 RC inpatient 137 137 CIGNA 62308 [3081051] CIGNA STATE OF WYOMING [308105107] 108.48 percent of total billed charges 84.94 130.15 Technical (Hospital) Services "HC Ref Tissue Transglt Ab,Igg, S (Mayo)" PX-3028636401 CDM 86364 CPT 302 RC inpatient 137 137 CIGNA 62308 [3081051] CIGNA 62308 [308105105] 108.48 percent of total billed charges 84.94 130.15 Technical (Hospital) Services "HC Ref Tissue Transglt Ab,Igg, S (Mayo)" PX-3028636401 CDM 86364 CPT 302 RC inpatient 137 137 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES EPO [308136803] 108.48 percent of total billed charges 84.94 130.15 Technical (Hospital) Services "HC Ref Tissue Transglt Ab,Igg, S (Mayo)" PX-3028636401 CDM 86364 CPT 302 RC inpatient 137 137 HEALTHPARTNERS SX009 HEALTHPARTNERS 108.48 percent of total billed charges 84.94 130.15 Technical (Hospital) Services "HC Ref Tissue Transglt Ab,Igg, S (Mayo)" PX-3028636401 CDM 86364 CPT 302 RC inpatient 137 137 BLUE CROSS BLUE SHIELD WELLMARK SB889 [3081026] BCBS WYOMING [308102603] 130.15 percent of total billed charges 84.94 130.15 Technical (Hospital) Services "HC Ref Tissue Transglt Ab,Igg, S (Mayo)" PX-3028636401 CDM 86364 CPT 302 RC outpatient 137 137 MEDICA (COMMERCIAL) 94265 [3081118] MEDICA CLAIMS [308111801] 123.3 percent of total billed charges 84.94 130.15 Technical (Hospital) Services "HC Ref Tissue Transglt Ab,Igg, S (Mayo)" PX-3028636401 CDM 86364 CPT 302 RC outpatient 137 137 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES PPO [308136801] 109.6 percent of total billed charges 84.94 130.15 Technical (Hospital) Services "HC Ref Tissue Transglt Ab,Igg, S (Mayo)" PX-3028636401 CDM 86364 CPT 302 RC outpatient 137 137 HEALTHPARTNERS SX009 HEALTHPARTNERS 109.6 percent of total billed charges 84.94 130.15 Technical (Hospital) Services "HC Ref Tissue Transglt Ab,Igg, S (Mayo)" PX-3028636401 CDM 86364 CPT 302 RC outpatient 137 137 UNITED HEALTHCARE (COMMERCIAL) [3081199] UNITED HEALTHCARE 87726 [308119901] 84.94 percent of total billed charges 84.94 130.15 Technical (Hospital) Services "HC Ref Tissue Transglt Ab,Igg, S (Mayo)" PX-3028636401 CDM 86364 CPT 302 RC outpatient 137 137 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES HDHP [308136802] 109.6 percent of total billed charges 84.94 130.15 Technical (Hospital) Services "HC Ref Tissue Transglt Ab,Igg, S (Mayo)" PX-3028636401 CDM 86364 CPT 302 RC outpatient 137 137 CIGNA 62308 [3081051] CIGNA 62308 [308105105] 109.6 percent of total billed charges 84.94 130.15 Technical (Hospital) Services "HC Ref Tissue Transglt Ab,Igg, S (Mayo)" PX-3028636401 CDM 86364 CPT 302 RC outpatient 137 137 CIGNA 62308 [3081051] CIGNA STATE OF WYOMING [308105107] 109.6 percent of total billed charges 84.94 130.15 Technical (Hospital) Services "HC Ref Tissue Transglt Ab,Igg, S (Mayo)" PX-3028636401 CDM 86364 CPT 302 RC outpatient 137 137 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES EPO [308136803] 109.6 percent of total billed charges 84.94 130.15 Technical (Hospital) Services "HC Ref Tissue Transglt Ab,Igg, S (Mayo)" PX-3028636401 CDM 86364 CPT 302 RC outpatient 137 137 MULTIPLAN INC 34080 [3081285] MULTIPLAN INC [308128501] 130.15 percent of total billed charges 84.94 130.15 Technical (Hospital) Services "HC Ref Tissue Transglt Ab,Igg, S (Mayo)" PX-3028636401 CDM 86364 CPT 302 RC outpatient 137 137 BLUE CROSS BLUE SHIELD WELLMARK SB889 [3081026] BCBS WYOMING [308102603] 130.15 percent of total billed charges 84.94 130.15 Technical (Hospital) Services HC Anti-Mitochondrial M2 Ab PX-3028636101 CDM 86361 CPT 302 RC inpatient 186 186 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES HDHP [308136802] 147.27 percent of total billed charges 115.32 176.7 Technical (Hospital) Services HC Anti-Mitochondrial M2 Ab PX-3028636101 CDM 86361 CPT 302 RC inpatient 186 186 UNITED HEALTHCARE (COMMERCIAL) [3081199] UNITED HEALTHCARE 87726 [308119901] 115.32 percent of total billed charges 115.32 176.7 Technical (Hospital) Services HC Anti-Mitochondrial M2 Ab PX-3028636101 CDM 86361 CPT 302 RC inpatient 186 186 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES PPO [308136801] 147.27 percent of total billed charges 115.32 176.7 Technical (Hospital) Services HC Anti-Mitochondrial M2 Ab PX-3028636101 CDM 86361 CPT 302 RC inpatient 186 186 MULTIPLAN INC 34080 [3081285] MULTIPLAN INC [308128501] 176.7 percent of total billed charges 115.32 176.7 Technical (Hospital) Services HC Anti-Mitochondrial M2 Ab PX-3028636101 CDM 86361 CPT 302 RC inpatient 186 186 MEDICA (COMMERCIAL) 94265 [3081118] MEDICA CLAIMS [308111801] 167.4 percent of total billed charges 115.32 176.7 Technical (Hospital) Services HC Anti-Mitochondrial M2 Ab PX-3028636101 CDM 86361 CPT 302 RC inpatient 186 186 CIGNA 62308 [3081051] CIGNA 62308 [308105105] 147.27 percent of total billed charges 115.32 176.7 Technical (Hospital) Services HC Anti-Mitochondrial M2 Ab PX-3028636101 CDM 86361 CPT 302 RC inpatient 186 186 CIGNA 62308 [3081051] CIGNA STATE OF WYOMING [308105107] 147.27 percent of total billed charges 115.32 176.7 Technical (Hospital) Services HC Anti-Mitochondrial M2 Ab PX-3028636101 CDM 86361 CPT 302 RC inpatient 186 186 HEALTHPARTNERS SX009 HEALTHPARTNERS 147.27 percent of total billed charges 115.32 176.7 Technical (Hospital) Services HC Anti-Mitochondrial M2 Ab PX-3028636101 CDM 86361 CPT 302 RC inpatient 186 186 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES EPO [308136803] 147.27 percent of total billed charges 115.32 176.7 Technical (Hospital) Services HC Anti-Mitochondrial M2 Ab PX-3028636101 CDM 86361 CPT 302 RC inpatient 186 186 BLUE CROSS BLUE SHIELD WELLMARK SB889 [3081026] BCBS WYOMING [308102603] 176.7 percent of total billed charges 115.32 176.7 Technical (Hospital) Services HC Anti-Mitochondrial M2 Ab PX-3028636101 CDM 86361 CPT 302 RC outpatient 186 186 BLUE CROSS BLUE SHIELD WELLMARK SB889 [3081026] BCBS WYOMING [308102603] 176.7 percent of total billed charges 115.32 176.7 Technical (Hospital) Services HC Anti-Mitochondrial M2 Ab PX-3028636101 CDM 86361 CPT 302 RC outpatient 186 186 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES HDHP [308136802] 148.8 percent of total billed charges 115.32 176.7 Technical (Hospital) Services HC Anti-Mitochondrial M2 Ab PX-3028636101 CDM 86361 CPT 302 RC outpatient 186 186 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES EPO [308136803] 148.8 percent of total billed charges 115.32 176.7 Technical (Hospital) Services HC Anti-Mitochondrial M2 Ab PX-3028636101 CDM 86361 CPT 302 RC outpatient 186 186 CIGNA 62308 [3081051] CIGNA 62308 [308105105] 148.8 percent of total billed charges 115.32 176.7 Technical (Hospital) Services HC Anti-Mitochondrial M2 Ab PX-3028636101 CDM 86361 CPT 302 RC outpatient 186 186 CIGNA 62308 [3081051] CIGNA STATE OF WYOMING [308105107] 148.8 percent of total billed charges 115.32 176.7 Technical (Hospital) Services HC Anti-Mitochondrial M2 Ab PX-3028636101 CDM 86361 CPT 302 RC outpatient 186 186 MULTIPLAN INC 34080 [3081285] MULTIPLAN INC [308128501] 176.7 percent of total billed charges 115.32 176.7 Technical (Hospital) Services HC Anti-Mitochondrial M2 Ab PX-3028636101 CDM 86361 CPT 302 RC outpatient 186 186 HEALTHPARTNERS SX009 HEALTHPARTNERS 148.8 percent of total billed charges 115.32 176.7 Technical (Hospital) Services HC Anti-Mitochondrial M2 Ab PX-3028636101 CDM 86361 CPT 302 RC outpatient 186 186 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES PPO [308136801] 148.8 percent of total billed charges 115.32 176.7 Technical (Hospital) Services HC Anti-Mitochondrial M2 Ab PX-3028636101 CDM 86361 CPT 302 RC outpatient 186 186 UNITED HEALTHCARE (COMMERCIAL) [3081199] UNITED HEALTHCARE 87726 [308119901] 115.32 percent of total billed charges 115.32 176.7 Technical (Hospital) Services HC Anti-Mitochondrial M2 Ab PX-3028636101 CDM 86361 CPT 302 RC outpatient 186 186 MEDICA (COMMERCIAL) 94265 [3081118] MEDICA CLAIMS [308111801] 167.4 percent of total billed charges 115.32 176.7 Technical (Hospital) Services Ref Absolute Cd4/Cd8 Count for Cd4-Cd3 Profile PX-3028636000 CDM 86360 CPT 302 RC inpatient 119 119 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES HDHP [308136802] 94.22 percent of total billed charges 73.78 113.05 Technical (Hospital) Services Ref Absolute Cd4/Cd8 Count for Cd4-Cd3 Profile PX-3028636000 CDM 86360 CPT 302 RC inpatient 119 119 UNITED HEALTHCARE (COMMERCIAL) [3081199] UNITED HEALTHCARE 87726 [308119901] 73.78 percent of total billed charges 73.78 113.05 Technical (Hospital) Services Ref Absolute Cd4/Cd8 Count for Cd4-Cd3 Profile PX-3028636000 CDM 86360 CPT 302 RC inpatient 119 119 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES PPO [308136801] 94.22 percent of total billed charges 73.78 113.05 Technical (Hospital) Services Ref Absolute Cd4/Cd8 Count for Cd4-Cd3 Profile PX-3028636000 CDM 86360 CPT 302 RC inpatient 119 119 BLUE CROSS BLUE SHIELD WELLMARK SB889 [3081026] BCBS WYOMING [308102603] 113.05 percent of total billed charges 73.78 113.05 Technical (Hospital) Services Ref Absolute Cd4/Cd8 Count for Cd4-Cd3 Profile PX-3028636000 CDM 86360 CPT 302 RC inpatient 119 119 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES EPO [308136803] 94.22 percent of total billed charges 73.78 113.05 Technical (Hospital) Services Ref Absolute Cd4/Cd8 Count for Cd4-Cd3 Profile PX-3028636000 CDM 86360 CPT 302 RC inpatient 119 119 HEALTHPARTNERS SX009 HEALTHPARTNERS 94.22 percent of total billed charges 73.78 113.05 Technical (Hospital) Services Ref Absolute Cd4/Cd8 Count for Cd4-Cd3 Profile PX-3028636000 CDM 86360 CPT 302 RC inpatient 119 119 MEDICA (COMMERCIAL) 94265 [3081118] MEDICA CLAIMS [308111801] 107.1 percent of total billed charges 73.78 113.05 Technical (Hospital) Services Ref Absolute Cd4/Cd8 Count for Cd4-Cd3 Profile PX-3028636000 CDM 86360 CPT 302 RC inpatient 119 119 MULTIPLAN INC 34080 [3081285] MULTIPLAN INC [308128501] 113.05 percent of total billed charges 73.78 113.05 Technical (Hospital) Services Ref Absolute Cd4/Cd8 Count for Cd4-Cd3 Profile PX-3028636000 CDM 86360 CPT 302 RC inpatient 119 119 CIGNA 62308 [3081051] CIGNA 62308 [308105105] 94.22 percent of total billed charges 73.78 113.05 Technical (Hospital) Services Ref Absolute Cd4/Cd8 Count for Cd4-Cd3 Profile PX-3028636000 CDM 86360 CPT 302 RC inpatient 119 119 CIGNA 62308 [3081051] CIGNA STATE OF WYOMING [308105107] 94.22 percent of total billed charges 73.78 113.05 Technical (Hospital) Services Ref Absolute Cd4/Cd8 Count for Cd4-Cd3 Profile PX-3028636000 CDM 86360 CPT 302 RC outpatient 119 119 UNITED HEALTHCARE (COMMERCIAL) [3081199] UNITED HEALTHCARE 87726 [308119901] 73.78 percent of total billed charges 73.78 113.05 Technical (Hospital) Services Ref Absolute Cd4/Cd8 Count for Cd4-Cd3 Profile PX-3028636000 CDM 86360 CPT 302 RC outpatient 119 119 MULTIPLAN INC 34080 [3081285] MULTIPLAN INC [308128501] 113.05 percent of total billed charges 73.78 113.05 Technical (Hospital) Services Ref Absolute Cd4/Cd8 Count for Cd4-Cd3 Profile PX-3028636000 CDM 86360 CPT 302 RC outpatient 119 119 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES EPO [308136803] 95.2 percent of total billed charges 73.78 113.05 Technical (Hospital) Services Ref Absolute Cd4/Cd8 Count for Cd4-Cd3 Profile PX-3028636000 CDM 86360 CPT 302 RC outpatient 119 119 CIGNA 62308 [3081051] CIGNA 62308 [308105105] 95.2 percent of total billed charges 73.78 113.05 Technical (Hospital) Services Ref Absolute Cd4/Cd8 Count for Cd4-Cd3 Profile PX-3028636000 CDM 86360 CPT 302 RC outpatient 119 119 CIGNA 62308 [3081051] CIGNA STATE OF WYOMING [308105107] 95.2 percent of total billed charges 73.78 113.05 Technical (Hospital) Services Ref Absolute Cd4/Cd8 Count for Cd4-Cd3 Profile PX-3028636000 CDM 86360 CPT 302 RC outpatient 119 119 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES HDHP [308136802] 95.2 percent of total billed charges 73.78 113.05 Technical (Hospital) Services Ref Absolute Cd4/Cd8 Count for Cd4-Cd3 Profile PX-3028636000 CDM 86360 CPT 302 RC outpatient 119 119 BLUE CROSS BLUE SHIELD WELLMARK SB889 [3081026] BCBS WYOMING [308102603] 113.05 percent of total billed charges 73.78 113.05 Technical (Hospital) Services Ref Absolute Cd4/Cd8 Count for Cd4-Cd3 Profile PX-3028636000 CDM 86360 CPT 302 RC outpatient 119 119 MEDICA (COMMERCIAL) 94265 [3081118] MEDICA CLAIMS [308111801] 107.1 percent of total billed charges 73.78 113.05 Technical (Hospital) Services Ref Absolute Cd4/Cd8 Count for Cd4-Cd3 Profile PX-3028636000 CDM 86360 CPT 302 RC outpatient 119 119 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES PPO [308136801] 95.2 percent of total billed charges 73.78 113.05 Technical (Hospital) Services Ref Absolute Cd4/Cd8 Count for Cd4-Cd3 Profile PX-3028636000 CDM 86360 CPT 302 RC outpatient 119 119 HEALTHPARTNERS SX009 HEALTHPARTNERS 95.2 percent of total billed charges 73.78 113.05 Technical (Hospital) Services Ref T Cells Total Count for Cd4-Cd3 Profile PX-3028635901 CDM 86359 CPT 302 RC inpatient 119 119 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES PPO [308136801] 94.22 percent of total billed charges 73.78 113.05 Technical (Hospital) Services Ref T Cells Total Count for Cd4-Cd3 Profile PX-3028635901 CDM 86359 CPT 302 RC inpatient 119 119 UNITED HEALTHCARE (COMMERCIAL) [3081199] UNITED HEALTHCARE 87726 [308119901] 73.78 percent of total billed charges 73.78 113.05 Technical (Hospital) Services Ref T Cells Total Count for Cd4-Cd3 Profile PX-3028635901 CDM 86359 CPT 302 RC inpatient 119 119 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES HDHP [308136802] 94.22 percent of total billed charges 73.78 113.05 Technical (Hospital) Services Ref T Cells Total Count for Cd4-Cd3 Profile PX-3028635901 CDM 86359 CPT 302 RC inpatient 119 119 BLUE CROSS BLUE SHIELD WELLMARK SB889 [3081026] BCBS WYOMING [308102603] 113.05 percent of total billed charges 73.78 113.05 Technical (Hospital) Services Ref T Cells Total Count for Cd4-Cd3 Profile PX-3028635901 CDM 86359 CPT 302 RC inpatient 119 119 HEALTHPARTNERS SX009 HEALTHPARTNERS 94.22 percent of total billed charges 73.78 113.05 Technical (Hospital) Services Ref T Cells Total Count for Cd4-Cd3 Profile PX-3028635901 CDM 86359 CPT 302 RC inpatient 119 119 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES EPO [308136803] 94.22 percent of total billed charges 73.78 113.05 Technical (Hospital) Services Ref T Cells Total Count for Cd4-Cd3 Profile PX-3028635901 CDM 86359 CPT 302 RC inpatient 119 119 MEDICA (COMMERCIAL) 94265 [3081118] MEDICA CLAIMS [308111801] 107.1 percent of total billed charges 73.78 113.05 Technical (Hospital) Services Ref T Cells Total Count for Cd4-Cd3 Profile PX-3028635901 CDM 86359 CPT 302 RC inpatient 119 119 MULTIPLAN INC 34080 [3081285] MULTIPLAN INC [308128501] 113.05 percent of total billed charges 73.78 113.05 Technical (Hospital) Services Ref T Cells Total Count for Cd4-Cd3 Profile PX-3028635901 CDM 86359 CPT 302 RC inpatient 119 119 CIGNA 62308 [3081051] CIGNA 62308 [308105105] 94.22 percent of total billed charges 73.78 113.05 Technical (Hospital) Services Ref T Cells Total Count for Cd4-Cd3 Profile PX-3028635901 CDM 86359 CPT 302 RC inpatient 119 119 CIGNA 62308 [3081051] CIGNA STATE OF WYOMING [308105107] 94.22 percent of total billed charges 73.78 113.05 Technical (Hospital) Services Ref T Cells Total Count for Cd4-Cd3 Profile PX-3028635901 CDM 86359 CPT 302 RC outpatient 119 119 BLUE CROSS BLUE SHIELD WELLMARK SB889 [3081026] BCBS WYOMING [308102603] 113.05 percent of total billed charges 73.78 113.05 Technical (Hospital) Services Ref T Cells Total Count for Cd4-Cd3 Profile PX-3028635901 CDM 86359 CPT 302 RC outpatient 119 119 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES HDHP [308136802] 95.2 percent of total billed charges 73.78 113.05 Technical (Hospital) Services Ref T Cells Total Count for Cd4-Cd3 Profile PX-3028635901 CDM 86359 CPT 302 RC outpatient 119 119 MULTIPLAN INC 34080 [3081285] MULTIPLAN INC [308128501] 113.05 percent of total billed charges 73.78 113.05 Technical (Hospital) Services Ref T Cells Total Count for Cd4-Cd3 Profile PX-3028635901 CDM 86359 CPT 302 RC outpatient 119 119 CIGNA 62308 [3081051] CIGNA 62308 [308105105] 95.2 percent of total billed charges 73.78 113.05 Technical (Hospital) Services Ref T Cells Total Count for Cd4-Cd3 Profile PX-3028635901 CDM 86359 CPT 302 RC outpatient 119 119 CIGNA 62308 [3081051] CIGNA STATE OF WYOMING [308105107] 95.2 percent of total billed charges 73.78 113.05 Technical (Hospital) Services Ref T Cells Total Count for Cd4-Cd3 Profile PX-3028635901 CDM 86359 CPT 302 RC outpatient 119 119 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES EPO [308136803] 95.2 percent of total billed charges 73.78 113.05 Technical (Hospital) Services Ref T Cells Total Count for Cd4-Cd3 Profile PX-3028635901 CDM 86359 CPT 302 RC outpatient 119 119 HEALTHPARTNERS SX009 HEALTHPARTNERS 95.2 percent of total billed charges 73.78 113.05 Technical (Hospital) Services Ref T Cells Total Count for Cd4-Cd3 Profile PX-3028635901 CDM 86359 CPT 302 RC outpatient 119 119 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES PPO [308136801] 95.2 percent of total billed charges 73.78 113.05 Technical (Hospital) Services Ref T Cells Total Count for Cd4-Cd3 Profile PX-3028635901 CDM 86359 CPT 302 RC outpatient 119 119 UNITED HEALTHCARE (COMMERCIAL) [3081199] UNITED HEALTHCARE 87726 [308119901] 73.78 percent of total billed charges 73.78 113.05 Technical (Hospital) Services Ref T Cells Total Count for Cd4-Cd3 Profile PX-3028635901 CDM 86359 CPT 302 RC outpatient 119 119 MEDICA (COMMERCIAL) 94265 [3081118] MEDICA CLAIMS [308111801] 107.1 percent of total billed charges 73.78 113.05 Technical (Hospital) Services Ref Natural Killer Cells for T-B Lymphocyte Profile PX-3028635700 CDM 86357 CPT 302 RC inpatient 313 313 UNITED HEALTHCARE (COMMERCIAL) [3081199] UNITED HEALTHCARE 87726 [308119901] 194.06 percent of total billed charges 194.06 297.35 Technical (Hospital) Services Ref Natural Killer Cells for T-B Lymphocyte Profile PX-3028635700 CDM 86357 CPT 302 RC inpatient 313 313 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES PPO [308136801] 247.83 percent of total billed charges 194.06 297.35 Technical (Hospital) Services Ref Natural Killer Cells for T-B Lymphocyte Profile PX-3028635700 CDM 86357 CPT 302 RC inpatient 313 313 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES HDHP [308136802] 247.83 percent of total billed charges 194.06 297.35 Technical (Hospital) Services Ref Natural Killer Cells for T-B Lymphocyte Profile PX-3028635700 CDM 86357 CPT 302 RC inpatient 313 313 MULTIPLAN INC 34080 [3081285] MULTIPLAN INC [308128501] 297.35 percent of total billed charges 194.06 297.35 Technical (Hospital) Services Ref Natural Killer Cells for T-B Lymphocyte Profile PX-3028635700 CDM 86357 CPT 302 RC inpatient 313 313 MEDICA (COMMERCIAL) 94265 [3081118] MEDICA CLAIMS [308111801] 281.7 percent of total billed charges 194.06 297.35 Technical (Hospital) Services Ref Natural Killer Cells for T-B Lymphocyte Profile PX-3028635700 CDM 86357 CPT 302 RC inpatient 313 313 CIGNA 62308 [3081051] CIGNA 62308 [308105105] 247.83 percent of total billed charges 194.06 297.35 Technical (Hospital) Services Ref Natural Killer Cells for T-B Lymphocyte Profile PX-3028635700 CDM 86357 CPT 302 RC inpatient 313 313 CIGNA 62308 [3081051] CIGNA STATE OF WYOMING [308105107] 247.83 percent of total billed charges 194.06 297.35 Technical (Hospital) Services Ref Natural Killer Cells for T-B Lymphocyte Profile PX-3028635700 CDM 86357 CPT 302 RC inpatient 313 313 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES EPO [308136803] 247.83 percent of total billed charges 194.06 297.35 Technical (Hospital) Services Ref Natural Killer Cells for T-B Lymphocyte Profile PX-3028635700 CDM 86357 CPT 302 RC inpatient 313 313 HEALTHPARTNERS SX009 HEALTHPARTNERS 247.83 percent of total billed charges 194.06 297.35 Technical (Hospital) Services Ref Natural Killer Cells for T-B Lymphocyte Profile PX-3028635700 CDM 86357 CPT 302 RC inpatient 313 313 BLUE CROSS BLUE SHIELD WELLMARK SB889 [3081026] BCBS WYOMING [308102603] 297.35 percent of total billed charges 194.06 297.35 Technical (Hospital) Services Ref Natural Killer Cells for T-B Lymphocyte Profile PX-3028635700 CDM 86357 CPT 302 RC outpatient 313 313 CIGNA 62308 [3081051] CIGNA 62308 [308105105] 250.4 percent of total billed charges 194.06 297.35 Technical (Hospital) Services Ref Natural Killer Cells for T-B Lymphocyte Profile PX-3028635700 CDM 86357 CPT 302 RC outpatient 313 313 CIGNA 62308 [3081051] CIGNA STATE OF WYOMING [308105107] 250.4 percent of total billed charges 194.06 297.35 Technical (Hospital) Services Ref Natural Killer Cells for T-B Lymphocyte Profile PX-3028635700 CDM 86357 CPT 302 RC outpatient 313 313 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES EPO [308136803] 250.4 percent of total billed charges 194.06 297.35 Technical (Hospital) Services Ref Natural Killer Cells for T-B Lymphocyte Profile PX-3028635700 CDM 86357 CPT 302 RC outpatient 313 313 BLUE CROSS BLUE SHIELD WELLMARK SB889 [3081026] BCBS WYOMING [308102603] 297.35 percent of total billed charges 194.06 297.35 Technical (Hospital) Services Ref Natural Killer Cells for T-B Lymphocyte Profile PX-3028635700 CDM 86357 CPT 302 RC outpatient 313 313 MULTIPLAN INC 34080 [3081285] MULTIPLAN INC [308128501] 297.35 percent of total billed charges 194.06 297.35 Technical (Hospital) Services Ref Natural Killer Cells for T-B Lymphocyte Profile PX-3028635700 CDM 86357 CPT 302 RC outpatient 313 313 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES HDHP [308136802] 250.4 percent of total billed charges 194.06 297.35 Technical (Hospital) Services Ref Natural Killer Cells for T-B Lymphocyte Profile PX-3028635700 CDM 86357 CPT 302 RC outpatient 313 313 UNITED HEALTHCARE (COMMERCIAL) [3081199] UNITED HEALTHCARE 87726 [308119901] 194.06 percent of total billed charges 194.06 297.35 Technical (Hospital) Services Ref Natural Killer Cells for T-B Lymphocyte Profile PX-3028635700 CDM 86357 CPT 302 RC outpatient 313 313 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES PPO [308136801] 250.4 percent of total billed charges 194.06 297.35 Technical (Hospital) Services Ref Natural Killer Cells for T-B Lymphocyte Profile PX-3028635700 CDM 86357 CPT 302 RC outpatient 313 313 HEALTHPARTNERS SX009 HEALTHPARTNERS 250.4 percent of total billed charges 194.06 297.35 Technical (Hospital) Services Ref Natural Killer Cells for T-B Lymphocyte Profile PX-3028635700 CDM 86357 CPT 302 RC outpatient 313 313 MEDICA (COMMERCIAL) 94265 [3081118] MEDICA CLAIMS [308111801] 281.7 percent of total billed charges 194.06 297.35 Technical (Hospital) Services Ref B-Cells Total Count for T-B Lymphocyte Profile PX-3028635500 CDM 86355 CPT 302 RC inpatient 284 284 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES EPO [308136803] 224.87 percent of total billed charges 176.08 269.8 Technical (Hospital) Services Ref B-Cells Total Count for T-B Lymphocyte Profile PX-3028635500 CDM 86355 CPT 302 RC inpatient 284 284 BLUE CROSS BLUE SHIELD WELLMARK SB889 [3081026] BCBS WYOMING [308102603] 269.8 percent of total billed charges 176.08 269.8 Technical (Hospital) Services Ref B-Cells Total Count for T-B Lymphocyte Profile PX-3028635500 CDM 86355 CPT 302 RC inpatient 284 284 HEALTHPARTNERS SX009 HEALTHPARTNERS 224.87 percent of total billed charges 176.08 269.8 Technical (Hospital) Services Ref B-Cells Total Count for T-B Lymphocyte Profile PX-3028635500 CDM 86355 CPT 302 RC inpatient 284 284 CIGNA 62308 [3081051] CIGNA 62308 [308105105] 224.87 percent of total billed charges 176.08 269.8 Technical (Hospital) Services Ref B-Cells Total Count for T-B Lymphocyte Profile PX-3028635500 CDM 86355 CPT 302 RC inpatient 284 284 CIGNA 62308 [3081051] CIGNA STATE OF WYOMING [308105107] 224.87 percent of total billed charges 176.08 269.8 Technical (Hospital) Services Ref B-Cells Total Count for T-B Lymphocyte Profile PX-3028635500 CDM 86355 CPT 302 RC inpatient 284 284 MULTIPLAN INC 34080 [3081285] MULTIPLAN INC [308128501] 269.8 percent of total billed charges 176.08 269.8 Technical (Hospital) Services Ref B-Cells Total Count for T-B Lymphocyte Profile PX-3028635500 CDM 86355 CPT 302 RC inpatient 284 284 MEDICA (COMMERCIAL) 94265 [3081118] MEDICA CLAIMS [308111801] 255.6 percent of total billed charges 176.08 269.8 Technical (Hospital) Services Ref B-Cells Total Count for T-B Lymphocyte Profile PX-3028635500 CDM 86355 CPT 302 RC inpatient 284 284 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES PPO [308136801] 224.87 percent of total billed charges 176.08 269.8 Technical (Hospital) Services Ref B-Cells Total Count for T-B Lymphocyte Profile PX-3028635500 CDM 86355 CPT 302 RC inpatient 284 284 UNITED HEALTHCARE (COMMERCIAL) [3081199] UNITED HEALTHCARE 87726 [308119901] 176.08 percent of total billed charges 176.08 269.8 Technical (Hospital) Services Ref B-Cells Total Count for T-B Lymphocyte Profile PX-3028635500 CDM 86355 CPT 302 RC inpatient 284 284 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES HDHP [308136802] 224.87 percent of total billed charges 176.08 269.8 Technical (Hospital) Services Ref B-Cells Total Count for T-B Lymphocyte Profile PX-3028635500 CDM 86355 CPT 302 RC outpatient 284 284 UNITED HEALTHCARE (COMMERCIAL) [3081199] UNITED HEALTHCARE 87726 [308119901] 176.08 percent of total billed charges 176.08 269.8 Technical (Hospital) Services Ref B-Cells Total Count for T-B Lymphocyte Profile PX-3028635500 CDM 86355 CPT 302 RC outpatient 284 284 HEALTHPARTNERS SX009 HEALTHPARTNERS 227.2 percent of total billed charges 176.08 269.8 Technical (Hospital) Services Ref B-Cells Total Count for T-B Lymphocyte Profile PX-3028635500 CDM 86355 CPT 302 RC outpatient 284 284 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES PPO [308136801] 227.2 percent of total billed charges 176.08 269.8 Technical (Hospital) Services Ref B-Cells Total Count for T-B Lymphocyte Profile PX-3028635500 CDM 86355 CPT 302 RC outpatient 284 284 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES HDHP [308136802] 227.2 percent of total billed charges 176.08 269.8 Technical (Hospital) Services Ref B-Cells Total Count for T-B Lymphocyte Profile PX-3028635500 CDM 86355 CPT 302 RC outpatient 284 284 CIGNA 62308 [3081051] CIGNA 62308 [308105105] 227.2 percent of total billed charges 176.08 269.8 Technical (Hospital) Services Ref B-Cells Total Count for T-B Lymphocyte Profile PX-3028635500 CDM 86355 CPT 302 RC outpatient 284 284 CIGNA 62308 [3081051] CIGNA STATE OF WYOMING [308105107] 227.2 percent of total billed charges 176.08 269.8 Technical (Hospital) Services Ref B-Cells Total Count for T-B Lymphocyte Profile PX-3028635500 CDM 86355 CPT 302 RC outpatient 284 284 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES EPO [308136803] 227.2 percent of total billed charges 176.08 269.8 Technical (Hospital) Services Ref B-Cells Total Count for T-B Lymphocyte Profile PX-3028635500 CDM 86355 CPT 302 RC outpatient 284 284 MULTIPLAN INC 34080 [3081285] MULTIPLAN INC [308128501] 269.8 percent of total billed charges 176.08 269.8 Technical (Hospital) Services Ref B-Cells Total Count for T-B Lymphocyte Profile PX-3028635500 CDM 86355 CPT 302 RC outpatient 284 284 BLUE CROSS BLUE SHIELD WELLMARK SB889 [3081026] BCBS WYOMING [308102603] 269.8 percent of total billed charges 176.08 269.8 Technical (Hospital) Services Ref B-Cells Total Count for T-B Lymphocyte Profile PX-3028635500 CDM 86355 CPT 302 RC outpatient 284 284 MEDICA (COMMERCIAL) 94265 [3081118] MEDICA CLAIMS [308111801] 255.6 percent of total billed charges 176.08 269.8 Technical (Hospital) Services Ref Islet Cell Antibody PX-3028634100 CDM 86341 CPT 302 RC outpatient 148 148 MULTIPLAN INC 34080 [3081285] MULTIPLAN INC [308128501] 140.6 percent of total billed charges 91.76 140.6 Technical (Hospital) Services Ref Islet Cell Antibody PX-3028634100 CDM 86341 CPT 302 RC outpatient 148 148 BLUE CROSS BLUE SHIELD WELLMARK SB889 [3081026] BCBS WYOMING [308102603] 140.6 percent of total billed charges 91.76 140.6 Technical (Hospital) Services Ref Islet Cell Antibody PX-3028634100 CDM 86341 CPT 302 RC outpatient 148 148 CIGNA 62308 [3081051] CIGNA 62308 [308105105] 118.4 percent of total billed charges 91.76 140.6 Technical (Hospital) Services Ref Islet Cell Antibody PX-3028634100 CDM 86341 CPT 302 RC outpatient 148 148 CIGNA 62308 [3081051] CIGNA STATE OF WYOMING [308105107] 118.4 percent of total billed charges 91.76 140.6 Technical (Hospital) Services Ref Islet Cell Antibody PX-3028634100 CDM 86341 CPT 302 RC outpatient 148 148 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES EPO [308136803] 118.4 percent of total billed charges 91.76 140.6 Technical (Hospital) Services Ref Islet Cell Antibody PX-3028634100 CDM 86341 CPT 302 RC outpatient 148 148 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES HDHP [308136802] 118.4 percent of total billed charges 91.76 140.6 Technical (Hospital) Services Ref Islet Cell Antibody PX-3028634100 CDM 86341 CPT 302 RC outpatient 148 148 UNITED HEALTHCARE (COMMERCIAL) [3081199] UNITED HEALTHCARE 87726 [308119901] 91.76 percent of total billed charges 91.76 140.6 Technical (Hospital) Services Ref Islet Cell Antibody PX-3028634100 CDM 86341 CPT 302 RC outpatient 148 148 HEALTHPARTNERS SX009 HEALTHPARTNERS 118.4 percent of total billed charges 91.76 140.6 Technical (Hospital) Services Ref Islet Cell Antibody PX-3028634100 CDM 86341 CPT 302 RC outpatient 148 148 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES PPO [308136801] 118.4 percent of total billed charges 91.76 140.6 Technical (Hospital) Services Ref Islet Cell Antibody PX-3028634100 CDM 86341 CPT 302 RC outpatient 148 148 MEDICA (COMMERCIAL) 94265 [3081118] MEDICA CLAIMS [308111801] 133.2 percent of total billed charges 91.76 140.6 Technical (Hospital) Services Ref Islet Cell Antibody PX-3028634100 CDM 86341 CPT 302 RC inpatient 148 148 BLUE CROSS BLUE SHIELD WELLMARK SB889 [3081026] BCBS WYOMING [308102603] 140.6 percent of total billed charges 91.76 140.6 Technical (Hospital) Services Ref Islet Cell Antibody PX-3028634100 CDM 86341 CPT 302 RC inpatient 148 148 HEALTHPARTNERS SX009 HEALTHPARTNERS 117.19 percent of total billed charges 91.76 140.6 Technical (Hospital) Services Ref Islet Cell Antibody PX-3028634100 CDM 86341 CPT 302 RC inpatient 148 148 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES EPO [308136803] 117.19 percent of total billed charges 91.76 140.6 Technical (Hospital) Services Ref Islet Cell Antibody PX-3028634100 CDM 86341 CPT 302 RC inpatient 148 148 MULTIPLAN INC 34080 [3081285] MULTIPLAN INC [308128501] 140.6 percent of total billed charges 91.76 140.6 Technical (Hospital) Services Ref Islet Cell Antibody PX-3028634100 CDM 86341 CPT 302 RC inpatient 148 148 MEDICA (COMMERCIAL) 94265 [3081118] MEDICA CLAIMS [308111801] 133.2 percent of total billed charges 91.76 140.6 Technical (Hospital) Services Ref Islet Cell Antibody PX-3028634100 CDM 86341 CPT 302 RC inpatient 148 148 CIGNA 62308 [3081051] CIGNA 62308 [308105105] 117.19 percent of total billed charges 91.76 140.6 Technical (Hospital) Services Ref Islet Cell Antibody PX-3028634100 CDM 86341 CPT 302 RC inpatient 148 148 CIGNA 62308 [3081051] CIGNA STATE OF WYOMING [308105107] 117.19 percent of total billed charges 91.76 140.6 Technical (Hospital) Services Ref Islet Cell Antibody PX-3028634100 CDM 86341 CPT 302 RC inpatient 148 148 UNITED HEALTHCARE (COMMERCIAL) [3081199] UNITED HEALTHCARE 87726 [308119901] 91.76 percent of total billed charges 91.76 140.6 Technical (Hospital) Services Ref Islet Cell Antibody PX-3028634100 CDM 86341 CPT 302 RC inpatient 148 148 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES PPO [308136801] 117.19 percent of total billed charges 91.76 140.6 Technical (Hospital) Services Ref Islet Cell Antibody PX-3028634100 CDM 86341 CPT 302 RC inpatient 148 148 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES HDHP [308136802] 117.19 percent of total billed charges 91.76 140.6 Technical (Hospital) Services Ref Gad65 Ab Assay PX-3028634102 CDM 86341 CPT 302 RC outpatient 148 148 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES HDHP [308136802] 118.4 percent of total billed charges 91.76 140.6 Technical (Hospital) Services Ref Gad65 Ab Assay PX-3028634102 CDM 86341 CPT 302 RC outpatient 148 148 MULTIPLAN INC 34080 [3081285] MULTIPLAN INC [308128501] 140.6 percent of total billed charges 91.76 140.6 Technical (Hospital) Services Ref Gad65 Ab Assay PX-3028634102 CDM 86341 CPT 302 RC outpatient 148 148 BLUE CROSS BLUE SHIELD WELLMARK SB889 [3081026] BCBS WYOMING [308102603] 140.6 percent of total billed charges 91.76 140.6 Technical (Hospital) Services Ref Gad65 Ab Assay PX-3028634102 CDM 86341 CPT 302 RC outpatient 148 148 CIGNA 62308 [3081051] CIGNA 62308 [308105105] 118.4 percent of total billed charges 91.76 140.6 Technical (Hospital) Services Ref Gad65 Ab Assay PX-3028634102 CDM 86341 CPT 302 RC outpatient 148 148 CIGNA 62308 [3081051] CIGNA STATE OF WYOMING [308105107] 118.4 percent of total billed charges 91.76 140.6 Technical (Hospital) Services Ref Gad65 Ab Assay PX-3028634102 CDM 86341 CPT 302 RC outpatient 148 148 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES EPO [308136803] 118.4 percent of total billed charges 91.76 140.6 Technical (Hospital) Services Ref Gad65 Ab Assay PX-3028634102 CDM 86341 CPT 302 RC outpatient 148 148 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES PPO [308136801] 118.4 percent of total billed charges 91.76 140.6 Technical (Hospital) Services Ref Gad65 Ab Assay PX-3028634102 CDM 86341 CPT 302 RC outpatient 148 148 HEALTHPARTNERS SX009 HEALTHPARTNERS 118.4 percent of total billed charges 91.76 140.6 Technical (Hospital) Services Ref Gad65 Ab Assay PX-3028634102 CDM 86341 CPT 302 RC outpatient 148 148 UNITED HEALTHCARE (COMMERCIAL) [3081199] UNITED HEALTHCARE 87726 [308119901] 91.76 percent of total billed charges 91.76 140.6 Technical (Hospital) Services Ref Gad65 Ab Assay PX-3028634102 CDM 86341 CPT 302 RC outpatient 148 148 MEDICA (COMMERCIAL) 94265 [3081118] MEDICA CLAIMS [308111801] 133.2 percent of total billed charges 91.76 140.6 Technical (Hospital) Services Ref Gad65 Ab Assay PX-3028634102 CDM 86341 CPT 302 RC inpatient 148 148 CIGNA 62308 [3081051] CIGNA 62308 [308105105] 117.19 percent of total billed charges 91.76 140.6 Technical (Hospital) Services Ref Gad65 Ab Assay PX-3028634102 CDM 86341 CPT 302 RC inpatient 148 148 CIGNA 62308 [3081051] CIGNA STATE OF WYOMING [308105107] 117.19 percent of total billed charges 91.76 140.6 Technical (Hospital) Services Ref Gad65 Ab Assay PX-3028634102 CDM 86341 CPT 302 RC inpatient 148 148 MULTIPLAN INC 34080 [3081285] MULTIPLAN INC [308128501] 140.6 percent of total billed charges 91.76 140.6 Technical (Hospital) Services Ref Gad65 Ab Assay PX-3028634102 CDM 86341 CPT 302 RC inpatient 148 148 MEDICA (COMMERCIAL) 94265 [3081118] MEDICA CLAIMS [308111801] 133.2 percent of total billed charges 91.76 140.6 Technical (Hospital) Services Ref Gad65 Ab Assay PX-3028634102 CDM 86341 CPT 302 RC inpatient 148 148 HEALTHPARTNERS SX009 HEALTHPARTNERS 117.19 percent of total billed charges 91.76 140.6 Technical (Hospital) Services Ref Gad65 Ab Assay PX-3028634102 CDM 86341 CPT 302 RC inpatient 148 148 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES EPO [308136803] 117.19 percent of total billed charges 91.76 140.6 Technical (Hospital) Services Ref Gad65 Ab Assay PX-3028634102 CDM 86341 CPT 302 RC inpatient 148 148 BLUE CROSS BLUE SHIELD WELLMARK SB889 [3081026] BCBS WYOMING [308102603] 140.6 percent of total billed charges 91.76 140.6 Technical (Hospital) Services Ref Gad65 Ab Assay PX-3028634102 CDM 86341 CPT 302 RC inpatient 148 148 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES HDHP [308136802] 117.19 percent of total billed charges 91.76 140.6 Technical (Hospital) Services Ref Gad65 Ab Assay PX-3028634102 CDM 86341 CPT 302 RC inpatient 148 148 UNITED HEALTHCARE (COMMERCIAL) [3081199] UNITED HEALTHCARE 87726 [308119901] 91.76 percent of total billed charges 91.76 140.6 Technical (Hospital) Services Ref Gad65 Ab Assay PX-3028634102 CDM 86341 CPT 302 RC inpatient 148 148 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES PPO [308136801] 117.19 percent of total billed charges 91.76 140.6 Technical (Hospital) Services Ref Intrinsic Factor Blocking Ab PX-3028634000 CDM 86340 CPT 302 RC outpatient 148 148 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES PPO [308136801] 118.4 percent of total billed charges 91.76 140.6 Technical (Hospital) Services Ref Intrinsic Factor Blocking Ab PX-3028634000 CDM 86340 CPT 302 RC outpatient 148 148 HEALTHPARTNERS SX009 HEALTHPARTNERS 118.4 percent of total billed charges 91.76 140.6 Technical (Hospital) Services Ref Intrinsic Factor Blocking Ab PX-3028634000 CDM 86340 CPT 302 RC outpatient 148 148 UNITED HEALTHCARE (COMMERCIAL) [3081199] UNITED HEALTHCARE 87726 [308119901] 91.76 percent of total billed charges 91.76 140.6 Technical (Hospital) Services Ref Intrinsic Factor Blocking Ab PX-3028634000 CDM 86340 CPT 302 RC outpatient 148 148 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES HDHP [308136802] 118.4 percent of total billed charges 91.76 140.6 Technical (Hospital) Services Ref Intrinsic Factor Blocking Ab PX-3028634000 CDM 86340 CPT 302 RC outpatient 148 148 MULTIPLAN INC 34080 [3081285] MULTIPLAN INC [308128501] 140.6 percent of total billed charges 91.76 140.6 Technical (Hospital) Services Ref Intrinsic Factor Blocking Ab PX-3028634000 CDM 86340 CPT 302 RC outpatient 148 148 BLUE CROSS BLUE SHIELD WELLMARK SB889 [3081026] BCBS WYOMING [308102603] 140.6 percent of total billed charges 91.76 140.6 Technical (Hospital) Services Ref Intrinsic Factor Blocking Ab PX-3028634000 CDM 86340 CPT 302 RC outpatient 148 148 CIGNA 62308 [3081051] CIGNA 62308 [308105105] 118.4 percent of total billed charges 91.76 140.6 Technical (Hospital) Services Ref Intrinsic Factor Blocking Ab PX-3028634000 CDM 86340 CPT 302 RC outpatient 148 148 CIGNA 62308 [3081051] CIGNA STATE OF WYOMING [308105107] 118.4 percent of total billed charges 91.76 140.6 Technical (Hospital) Services Ref Intrinsic Factor Blocking Ab PX-3028634000 CDM 86340 CPT 302 RC outpatient 148 148 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES EPO [308136803] 118.4 percent of total billed charges 91.76 140.6 Technical (Hospital) Services Ref Intrinsic Factor Blocking Ab PX-3028634000 CDM 86340 CPT 302 RC outpatient 148 148 MEDICA (COMMERCIAL) 94265 [3081118] MEDICA CLAIMS [308111801] 133.2 percent of total billed charges 91.76 140.6 Technical (Hospital) Services Ref Intrinsic Factor Blocking Ab PX-3028634000 CDM 86340 CPT 302 RC inpatient 148 148 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES PPO [308136801] 117.19 percent of total billed charges 91.76 140.6 Technical (Hospital) Services Ref Intrinsic Factor Blocking Ab PX-3028634000 CDM 86340 CPT 302 RC inpatient 148 148 UNITED HEALTHCARE (COMMERCIAL) [3081199] UNITED HEALTHCARE 87726 [308119901] 91.76 percent of total billed charges 91.76 140.6 Technical (Hospital) Services Ref Intrinsic Factor Blocking Ab PX-3028634000 CDM 86340 CPT 302 RC inpatient 148 148 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES HDHP [308136802] 117.19 percent of total billed charges 91.76 140.6 Technical (Hospital) Services Ref Intrinsic Factor Blocking Ab PX-3028634000 CDM 86340 CPT 302 RC inpatient 148 148 BLUE CROSS BLUE SHIELD WELLMARK SB889 [3081026] BCBS WYOMING [308102603] 140.6 percent of total billed charges 91.76 140.6 Technical (Hospital) Services Ref Intrinsic Factor Blocking Ab PX-3028634000 CDM 86340 CPT 302 RC inpatient 148 148 HEALTHPARTNERS SX009 HEALTHPARTNERS 117.19 percent of total billed charges 91.76 140.6 Technical (Hospital) Services Ref Intrinsic Factor Blocking Ab PX-3028634000 CDM 86340 CPT 302 RC inpatient 148 148 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES EPO [308136803] 117.19 percent of total billed charges 91.76 140.6 Technical (Hospital) Services Ref Intrinsic Factor Blocking Ab PX-3028634000 CDM 86340 CPT 302 RC inpatient 148 148 MULTIPLAN INC 34080 [3081285] MULTIPLAN INC [308128501] 140.6 percent of total billed charges 91.76 140.6 Technical (Hospital) Services Ref Intrinsic Factor Blocking Ab PX-3028634000 CDM 86340 CPT 302 RC inpatient 148 148 MEDICA (COMMERCIAL) 94265 [3081118] MEDICA CLAIMS [308111801] 133.2 percent of total billed charges 91.76 140.6 Technical (Hospital) Services Ref Intrinsic Factor Blocking Ab PX-3028634000 CDM 86340 CPT 302 RC inpatient 148 148 CIGNA 62308 [3081051] CIGNA 62308 [308105105] 117.19 percent of total billed charges 91.76 140.6 Technical (Hospital) Services Ref Intrinsic Factor Blocking Ab PX-3028634000 CDM 86340 CPT 302 RC inpatient 148 148 CIGNA 62308 [3081051] CIGNA STATE OF WYOMING [308105107] 117.19 percent of total billed charges 91.76 140.6 Technical (Hospital) Services Ref Insulin Antibodies PX-3028633700 CDM 86337 CPT 302 RC inpatient 330 330 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES HDHP [308136802] 261.29 percent of total billed charges 204.6 313.5 Technical (Hospital) Services Ref Insulin Antibodies PX-3028633700 CDM 86337 CPT 302 RC inpatient 330 330 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES PPO [308136801] 261.29 percent of total billed charges 204.6 313.5 Technical (Hospital) Services Ref Insulin Antibodies PX-3028633700 CDM 86337 CPT 302 RC inpatient 330 330 UNITED HEALTHCARE (COMMERCIAL) [3081199] UNITED HEALTHCARE 87726 [308119901] 204.6 percent of total billed charges 204.6 313.5 Technical (Hospital) Services Ref Insulin Antibodies PX-3028633700 CDM 86337 CPT 302 RC inpatient 330 330 MEDICA (COMMERCIAL) 94265 [3081118] MEDICA CLAIMS [308111801] 297 percent of total billed charges 204.6 313.5 Technical (Hospital) Services Ref Insulin Antibodies PX-3028633700 CDM 86337 CPT 302 RC inpatient 330 330 MULTIPLAN INC 34080 [3081285] MULTIPLAN INC [308128501] 313.5 percent of total billed charges 204.6 313.5 Technical (Hospital) Services Ref Insulin Antibodies PX-3028633700 CDM 86337 CPT 302 RC inpatient 330 330 CIGNA 62308 [3081051] CIGNA STATE OF WYOMING [308105107] 261.29 percent of total billed charges 204.6 313.5 Technical (Hospital) Services Ref Insulin Antibodies PX-3028633700 CDM 86337 CPT 302 RC inpatient 330 330 CIGNA 62308 [3081051] CIGNA 62308 [308105105] 261.29 percent of total billed charges 204.6 313.5 Technical (Hospital) Services Ref Insulin Antibodies PX-3028633700 CDM 86337 CPT 302 RC inpatient 330 330 BLUE CROSS BLUE SHIELD WELLMARK SB889 [3081026] BCBS WYOMING [308102603] 313.5 percent of total billed charges 204.6 313.5 Technical (Hospital) Services Ref Insulin Antibodies PX-3028633700 CDM 86337 CPT 302 RC inpatient 330 330 HEALTHPARTNERS SX009 HEALTHPARTNERS 261.29 percent of total billed charges 204.6 313.5 Technical (Hospital) Services Ref Insulin Antibodies PX-3028633700 CDM 86337 CPT 302 RC inpatient 330 330 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES EPO [308136803] 261.29 percent of total billed charges 204.6 313.5 Technical (Hospital) Services Ref Insulin Antibodies PX-3028633700 CDM 86337 CPT 302 RC outpatient 330 330 MEDICA (COMMERCIAL) 94265 [3081118] MEDICA CLAIMS [308111801] 297 percent of total billed charges 204.6 313.5 Technical (Hospital) Services Ref Insulin Antibodies PX-3028633700 CDM 86337 CPT 302 RC outpatient 330 330 MULTIPLAN INC 34080 [3081285] MULTIPLAN INC [308128501] 313.5 percent of total billed charges 204.6 313.5 Technical (Hospital) Services Ref Insulin Antibodies PX-3028633700 CDM 86337 CPT 302 RC outpatient 330 330 CIGNA 62308 [3081051] CIGNA 62308 [308105105] 264 percent of total billed charges 204.6 313.5 Technical (Hospital) Services Ref Insulin Antibodies PX-3028633700 CDM 86337 CPT 302 RC outpatient 330 330 CIGNA 62308 [3081051] CIGNA STATE OF WYOMING [308105107] 264 percent of total billed charges 204.6 313.5 Technical (Hospital) Services Ref Insulin Antibodies PX-3028633700 CDM 86337 CPT 302 RC outpatient 330 330 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES EPO [308136803] 264 percent of total billed charges 204.6 313.5 Technical (Hospital) Services Ref Insulin Antibodies PX-3028633700 CDM 86337 CPT 302 RC outpatient 330 330 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES HDHP [308136802] 264 percent of total billed charges 204.6 313.5 Technical (Hospital) Services Ref Insulin Antibodies PX-3028633700 CDM 86337 CPT 302 RC outpatient 330 330 BLUE CROSS BLUE SHIELD WELLMARK SB889 [3081026] BCBS WYOMING [308102603] 313.5 percent of total billed charges 204.6 313.5 Technical (Hospital) Services Ref Insulin Antibodies PX-3028633700 CDM 86337 CPT 302 RC outpatient 330 330 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES PPO [308136801] 264 percent of total billed charges 204.6 313.5 Technical (Hospital) Services Ref Insulin Antibodies PX-3028633700 CDM 86337 CPT 302 RC outpatient 330 330 HEALTHPARTNERS SX009 HEALTHPARTNERS 264 percent of total billed charges 204.6 313.5 Technical (Hospital) Services Ref Insulin Antibodies PX-3028633700 CDM 86337 CPT 302 RC outpatient 330 330 UNITED HEALTHCARE (COMMERCIAL) [3081199] UNITED HEALTHCARE 87726 [308119901] 204.6 percent of total billed charges 204.6 313.5 Technical (Hospital) Services "Ref Immunofixation, Urine" PX-3028633500 CDM 86335 CPT 302 RC outpatient 284 284 MEDICA (COMMERCIAL) 94265 [3081118] MEDICA CLAIMS [308111801] 255.6 percent of total billed charges 176.08 269.8 Technical (Hospital) Services "Ref Immunofixation, Urine" PX-3028633500 CDM 86335 CPT 302 RC outpatient 284 284 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES EPO [308136803] 227.2 percent of total billed charges 176.08 269.8 Technical (Hospital) Services "Ref Immunofixation, Urine" PX-3028633500 CDM 86335 CPT 302 RC outpatient 284 284 CIGNA 62308 [3081051] CIGNA 62308 [308105105] 227.2 percent of total billed charges 176.08 269.8 Technical (Hospital) Services "Ref Immunofixation, Urine" PX-3028633500 CDM 86335 CPT 302 RC outpatient 284 284 CIGNA 62308 [3081051] CIGNA STATE OF WYOMING [308105107] 227.2 percent of total billed charges 176.08 269.8 Technical (Hospital) Services "Ref Immunofixation, Urine" PX-3028633500 CDM 86335 CPT 302 RC outpatient 284 284 BLUE CROSS BLUE SHIELD WELLMARK SB889 [3081026] BCBS WYOMING [308102603] 269.8 percent of total billed charges 176.08 269.8 Technical (Hospital) Services "Ref Immunofixation, Urine" PX-3028633500 CDM 86335 CPT 302 RC outpatient 284 284 MULTIPLAN INC 34080 [3081285] MULTIPLAN INC [308128501] 269.8 percent of total billed charges 176.08 269.8 Technical (Hospital) Services "Ref Immunofixation, Urine" PX-3028633500 CDM 86335 CPT 302 RC outpatient 284 284 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES HDHP [308136802] 227.2 percent of total billed charges 176.08 269.8 Technical (Hospital) Services "Ref Immunofixation, Urine" PX-3028633500 CDM 86335 CPT 302 RC outpatient 284 284 UNITED HEALTHCARE (COMMERCIAL) [3081199] UNITED HEALTHCARE 87726 [308119901] 176.08 percent of total billed charges 176.08 269.8 Technical (Hospital) Services "Ref Immunofixation, Urine" PX-3028633500 CDM 86335 CPT 302 RC outpatient 284 284 HEALTHPARTNERS SX009 HEALTHPARTNERS 227.2 percent of total billed charges 176.08 269.8 Technical (Hospital) Services "Ref Immunofixation, Urine" PX-3028633500 CDM 86335 CPT 302 RC outpatient 284 284 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES PPO [308136801] 227.2 percent of total billed charges 176.08 269.8 Technical (Hospital) Services "Ref Immunofixation, Urine" PX-3028633500 CDM 86335 CPT 302 RC inpatient 284 284 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES EPO [308136803] 224.87 percent of total billed charges 176.08 269.8 Technical (Hospital) Services "Ref Immunofixation, Urine" PX-3028633500 CDM 86335 CPT 302 RC inpatient 284 284 HEALTHPARTNERS SX009 HEALTHPARTNERS 224.87 percent of total billed charges 176.08 269.8 Technical (Hospital) Services "Ref Immunofixation, Urine" PX-3028633500 CDM 86335 CPT 302 RC inpatient 284 284 BLUE CROSS BLUE SHIELD WELLMARK SB889 [3081026] BCBS WYOMING [308102603] 269.8 percent of total billed charges 176.08 269.8 Technical (Hospital) Services "Ref Immunofixation, Urine" PX-3028633500 CDM 86335 CPT 302 RC inpatient 284 284 MULTIPLAN INC 34080 [3081285] MULTIPLAN INC [308128501] 269.8 percent of total billed charges 176.08 269.8 Technical (Hospital) Services "Ref Immunofixation, Urine" PX-3028633500 CDM 86335 CPT 302 RC inpatient 284 284 CIGNA 62308 [3081051] CIGNA 62308 [308105105] 224.87 percent of total billed charges 176.08 269.8 Technical (Hospital) Services "Ref Immunofixation, Urine" PX-3028633500 CDM 86335 CPT 302 RC inpatient 284 284 CIGNA 62308 [3081051] CIGNA STATE OF WYOMING [308105107] 224.87 percent of total billed charges 176.08 269.8 Technical (Hospital) Services "Ref Immunofixation, Urine" PX-3028633500 CDM 86335 CPT 302 RC inpatient 284 284 UNITED HEALTHCARE (COMMERCIAL) [3081199] UNITED HEALTHCARE 87726 [308119901] 176.08 percent of total billed charges 176.08 269.8 Technical (Hospital) Services "Ref Immunofixation, Urine" PX-3028633500 CDM 86335 CPT 302 RC inpatient 284 284 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES PPO [308136801] 224.87 percent of total billed charges 176.08 269.8 Technical (Hospital) Services "Ref Immunofixation, Urine" PX-3028633500 CDM 86335 CPT 302 RC inpatient 284 284 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES HDHP [308136802] 224.87 percent of total billed charges 176.08 269.8 Technical (Hospital) Services "Ref Immunofixation, Urine" PX-3028633500 CDM 86335 CPT 302 RC inpatient 284 284 MEDICA (COMMERCIAL) 94265 [3081118] MEDICA CLAIMS [308111801] 255.6 percent of total billed charges 176.08 269.8 Technical (Hospital) Services "Ref Immunofixation, Urine Monoclonal" PX-3028633503 CDM 86335 CPT 302 RC inpatient 340 340 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES EPO [308136803] 269.21 percent of total billed charges 210.8 323 Technical (Hospital) Services "Ref Immunofixation, Urine Monoclonal" PX-3028633503 CDM 86335 CPT 302 RC inpatient 340 340 BLUE CROSS BLUE SHIELD WELLMARK SB889 [3081026] BCBS WYOMING [308102603] 323 percent of total billed charges 210.8 323 Technical (Hospital) Services "Ref Immunofixation, Urine Monoclonal" PX-3028633503 CDM 86335 CPT 302 RC inpatient 340 340 HEALTHPARTNERS SX009 HEALTHPARTNERS 269.21 percent of total billed charges 210.8 323 Technical (Hospital) Services "Ref Immunofixation, Urine Monoclonal" PX-3028633503 CDM 86335 CPT 302 RC inpatient 340 340 MULTIPLAN INC 34080 [3081285] MULTIPLAN INC [308128501] 323 percent of total billed charges 210.8 323 Technical (Hospital) Services "Ref Immunofixation, Urine Monoclonal" PX-3028633503 CDM 86335 CPT 302 RC inpatient 340 340 MEDICA (COMMERCIAL) 94265 [3081118] MEDICA CLAIMS [308111801] 306 percent of total billed charges 210.8 323 Technical (Hospital) Services "Ref Immunofixation, Urine Monoclonal" PX-3028633503 CDM 86335 CPT 302 RC inpatient 340 340 CIGNA 62308 [3081051] CIGNA 62308 [308105105] 269.21 percent of total billed charges 210.8 323 Technical (Hospital) Services "Ref Immunofixation, Urine Monoclonal" PX-3028633503 CDM 86335 CPT 302 RC inpatient 340 340 CIGNA 62308 [3081051] CIGNA STATE OF WYOMING [308105107] 269.21 percent of total billed charges 210.8 323 Technical (Hospital) Services "Ref Immunofixation, Urine Monoclonal" PX-3028633503 CDM 86335 CPT 302 RC inpatient 340 340 UNITED HEALTHCARE (COMMERCIAL) [3081199] UNITED HEALTHCARE 87726 [308119901] 210.8 percent of total billed charges 210.8 323 Technical (Hospital) Services "Ref Immunofixation, Urine Monoclonal" PX-3028633503 CDM 86335 CPT 302 RC inpatient 340 340 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES PPO [308136801] 269.21 percent of total billed charges 210.8 323 Technical (Hospital) Services "Ref Immunofixation, Urine Monoclonal" PX-3028633503 CDM 86335 CPT 302 RC inpatient 340 340 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES HDHP [308136802] 269.21 percent of total billed charges 210.8 323 Technical (Hospital) Services "Ref Immunofixation, Urine Monoclonal" PX-3028633503 CDM 86335 CPT 302 RC outpatient 340 340 MEDICA (COMMERCIAL) 94265 [3081118] MEDICA CLAIMS [308111801] 306 percent of total billed charges 210.8 323 Technical (Hospital) Services "Ref Immunofixation, Urine Monoclonal" PX-3028633503 CDM 86335 CPT 302 RC outpatient 340 340 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES HDHP [308136802] 272 percent of total billed charges 210.8 323 Technical (Hospital) Services "Ref Immunofixation, Urine Monoclonal" PX-3028633503 CDM 86335 CPT 302 RC outpatient 340 340 BLUE CROSS BLUE SHIELD WELLMARK SB889 [3081026] BCBS WYOMING [308102603] 323 percent of total billed charges 210.8 323 Technical (Hospital) Services "Ref Immunofixation, Urine Monoclonal" PX-3028633503 CDM 86335 CPT 302 RC outpatient 340 340 CIGNA 62308 [3081051] CIGNA 62308 [308105105] 272 percent of total billed charges 210.8 323 Technical (Hospital) Services "Ref Immunofixation, Urine Monoclonal" PX-3028633503 CDM 86335 CPT 302 RC outpatient 340 340 CIGNA 62308 [3081051] CIGNA STATE OF WYOMING [308105107] 272 percent of total billed charges 210.8 323 Technical (Hospital) Services "Ref Immunofixation, Urine Monoclonal" PX-3028633503 CDM 86335 CPT 302 RC outpatient 340 340 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES EPO [308136803] 272 percent of total billed charges 210.8 323 Technical (Hospital) Services "Ref Immunofixation, Urine Monoclonal" PX-3028633503 CDM 86335 CPT 302 RC outpatient 340 340 MULTIPLAN INC 34080 [3081285] MULTIPLAN INC [308128501] 323 percent of total billed charges 210.8 323 Technical (Hospital) Services "Ref Immunofixation, Urine Monoclonal" PX-3028633503 CDM 86335 CPT 302 RC outpatient 340 340 HEALTHPARTNERS SX009 HEALTHPARTNERS 272 percent of total billed charges 210.8 323 Technical (Hospital) Services "Ref Immunofixation, Urine Monoclonal" PX-3028633503 CDM 86335 CPT 302 RC outpatient 340 340 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES PPO [308136801] 272 percent of total billed charges 210.8 323 Technical (Hospital) Services "Ref Immunofixation, Urine Monoclonal" PX-3028633503 CDM 86335 CPT 302 RC outpatient 340 340 UNITED HEALTHCARE (COMMERCIAL) [3081199] UNITED HEALTHCARE 87726 [308119901] 210.8 percent of total billed charges 210.8 323 Technical (Hospital) Services Ref Immunofixation Electrophoresis PX-3028633400 CDM 86334 CPT 302 RC outpatient 284 284 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES PPO [308136801] 227.2 percent of total billed charges 176.08 269.8 Technical (Hospital) Services Ref Immunofixation Electrophoresis PX-3028633400 CDM 86334 CPT 302 RC outpatient 284 284 HEALTHPARTNERS SX009 HEALTHPARTNERS 227.2 percent of total billed charges 176.08 269.8 Technical (Hospital) Services Ref Immunofixation Electrophoresis PX-3028633400 CDM 86334 CPT 302 RC outpatient 284 284 UNITED HEALTHCARE (COMMERCIAL) [3081199] UNITED HEALTHCARE 87726 [308119901] 176.08 percent of total billed charges 176.08 269.8 Technical (Hospital) Services Ref Immunofixation Electrophoresis PX-3028633400 CDM 86334 CPT 302 RC outpatient 284 284 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES HDHP [308136802] 227.2 percent of total billed charges 176.08 269.8 Technical (Hospital) Services Ref Immunofixation Electrophoresis PX-3028633400 CDM 86334 CPT 302 RC outpatient 284 284 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES EPO [308136803] 227.2 percent of total billed charges 176.08 269.8 Technical (Hospital) Services Ref Immunofixation Electrophoresis PX-3028633400 CDM 86334 CPT 302 RC outpatient 284 284 CIGNA 62308 [3081051] CIGNA 62308 [308105105] 227.2 percent of total billed charges 176.08 269.8 Technical (Hospital) Services Ref Immunofixation Electrophoresis PX-3028633400 CDM 86334 CPT 302 RC outpatient 284 284 CIGNA 62308 [3081051] CIGNA STATE OF WYOMING [308105107] 227.2 percent of total billed charges 176.08 269.8 Technical (Hospital) Services Ref Immunofixation Electrophoresis PX-3028633400 CDM 86334 CPT 302 RC outpatient 284 284 MULTIPLAN INC 34080 [3081285] MULTIPLAN INC [308128501] 269.8 percent of total billed charges 176.08 269.8 Technical (Hospital) Services Ref Immunofixation Electrophoresis PX-3028633400 CDM 86334 CPT 302 RC outpatient 284 284 BLUE CROSS BLUE SHIELD WELLMARK SB889 [3081026] BCBS WYOMING [308102603] 269.8 percent of total billed charges 176.08 269.8 Technical (Hospital) Services Ref Immunofixation Electrophoresis PX-3028633400 CDM 86334 CPT 302 RC outpatient 284 284 MEDICA (COMMERCIAL) 94265 [3081118] MEDICA CLAIMS [308111801] 255.6 percent of total billed charges 176.08 269.8 Technical (Hospital) Services Ref Immunofixation Electrophoresis PX-3028633400 CDM 86334 CPT 302 RC inpatient 284 284 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES EPO [308136803] 224.87 percent of total billed charges 176.08 269.8 Technical (Hospital) Services Ref Immunofixation Electrophoresis PX-3028633400 CDM 86334 CPT 302 RC inpatient 284 284 BLUE CROSS BLUE SHIELD WELLMARK SB889 [3081026] BCBS WYOMING [308102603] 269.8 percent of total billed charges 176.08 269.8 Technical (Hospital) Services Ref Immunofixation Electrophoresis PX-3028633400 CDM 86334 CPT 302 RC inpatient 284 284 HEALTHPARTNERS SX009 HEALTHPARTNERS 224.87 percent of total billed charges 176.08 269.8 Technical (Hospital) Services Ref Immunofixation Electrophoresis PX-3028633400 CDM 86334 CPT 302 RC inpatient 284 284 MULTIPLAN INC 34080 [3081285] MULTIPLAN INC [308128501] 269.8 percent of total billed charges 176.08 269.8 Technical (Hospital) Services Ref Immunofixation Electrophoresis PX-3028633400 CDM 86334 CPT 302 RC inpatient 284 284 MEDICA (COMMERCIAL) 94265 [3081118] MEDICA CLAIMS [308111801] 255.6 percent of total billed charges 176.08 269.8 Technical (Hospital) Services Ref Immunofixation Electrophoresis PX-3028633400 CDM 86334 CPT 302 RC inpatient 284 284 CIGNA 62308 [3081051] CIGNA 62308 [308105105] 224.87 percent of total billed charges 176.08 269.8 Technical (Hospital) Services Ref Immunofixation Electrophoresis PX-3028633400 CDM 86334 CPT 302 RC inpatient 284 284 CIGNA 62308 [3081051] CIGNA STATE OF WYOMING [308105107] 224.87 percent of total billed charges 176.08 269.8 Technical (Hospital) Services Ref Immunofixation Electrophoresis PX-3028633400 CDM 86334 CPT 302 RC inpatient 284 284 UNITED HEALTHCARE (COMMERCIAL) [3081199] UNITED HEALTHCARE 87726 [308119901] 176.08 percent of total billed charges 176.08 269.8 Technical (Hospital) Services Ref Immunofixation Electrophoresis PX-3028633400 CDM 86334 CPT 302 RC inpatient 284 284 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES PPO [308136801] 224.87 percent of total billed charges 176.08 269.8 Technical (Hospital) Services Ref Immunofixation Electrophoresis PX-3028633400 CDM 86334 CPT 302 RC inpatient 284 284 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES HDHP [308136802] 224.87 percent of total billed charges 176.08 269.8 Technical (Hospital) Services Ref Monoclonal Protein Study If PX-3028633401 CDM 86334 CPT 302 RC outpatient 255 255 MEDICA (COMMERCIAL) 94265 [3081118] MEDICA CLAIMS [308111801] 229.5 percent of total billed charges 158.1 242.25 Technical (Hospital) Services Ref Monoclonal Protein Study If PX-3028633401 CDM 86334 CPT 302 RC outpatient 255 255 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES PPO [308136801] 204 percent of total billed charges 158.1 242.25 Technical (Hospital) Services Ref Monoclonal Protein Study If PX-3028633401 CDM 86334 CPT 302 RC outpatient 255 255 UNITED HEALTHCARE (COMMERCIAL) [3081199] UNITED HEALTHCARE 87726 [308119901] 158.1 percent of total billed charges 158.1 242.25 Technical (Hospital) Services Ref Monoclonal Protein Study If PX-3028633401 CDM 86334 CPT 302 RC outpatient 255 255 HEALTHPARTNERS SX009 HEALTHPARTNERS 204 percent of total billed charges 158.1 242.25 Technical (Hospital) Services Ref Monoclonal Protein Study If PX-3028633401 CDM 86334 CPT 302 RC outpatient 255 255 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES HDHP [308136802] 204 percent of total billed charges 158.1 242.25 Technical (Hospital) Services Ref Monoclonal Protein Study If PX-3028633401 CDM 86334 CPT 302 RC outpatient 255 255 MULTIPLAN INC 34080 [3081285] MULTIPLAN INC [308128501] 242.25 percent of total billed charges 158.1 242.25 Technical (Hospital) Services Ref Monoclonal Protein Study If PX-3028633401 CDM 86334 CPT 302 RC outpatient 255 255 BLUE CROSS BLUE SHIELD WELLMARK SB889 [3081026] BCBS WYOMING [308102603] 242.25 percent of total billed charges 158.1 242.25 Technical (Hospital) Services Ref Monoclonal Protein Study If PX-3028633401 CDM 86334 CPT 302 RC outpatient 255 255 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES EPO [308136803] 204 percent of total billed charges 158.1 242.25 Technical (Hospital) Services Ref Monoclonal Protein Study If PX-3028633401 CDM 86334 CPT 302 RC outpatient 255 255 CIGNA 62308 [3081051] CIGNA 62308 [308105105] 204 percent of total billed charges 158.1 242.25 Technical (Hospital) Services Ref Monoclonal Protein Study If PX-3028633401 CDM 86334 CPT 302 RC outpatient 255 255 CIGNA 62308 [3081051] CIGNA STATE OF WYOMING [308105107] 204 percent of total billed charges 158.1 242.25 Technical (Hospital) Services Ref Monoclonal Protein Study If PX-3028633401 CDM 86334 CPT 302 RC inpatient 255 255 HEALTHPARTNERS SX009 HEALTHPARTNERS 201.91 percent of total billed charges 158.1 242.25 Technical (Hospital) Services Ref Monoclonal Protein Study If PX-3028633401 CDM 86334 CPT 302 RC inpatient 255 255 BLUE CROSS BLUE SHIELD WELLMARK SB889 [3081026] BCBS WYOMING [308102603] 242.25 percent of total billed charges 158.1 242.25 Technical (Hospital) Services Ref Monoclonal Protein Study If PX-3028633401 CDM 86334 CPT 302 RC inpatient 255 255 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES EPO [308136803] 201.91 percent of total billed charges 158.1 242.25 Technical (Hospital) Services Ref Monoclonal Protein Study If PX-3028633401 CDM 86334 CPT 302 RC inpatient 255 255 CIGNA 62308 [3081051] CIGNA 62308 [308105105] 201.91 percent of total billed charges 158.1 242.25 Technical (Hospital) Services Ref Monoclonal Protein Study If PX-3028633401 CDM 86334 CPT 302 RC inpatient 255 255 CIGNA 62308 [3081051] CIGNA STATE OF WYOMING [308105107] 201.91 percent of total billed charges 158.1 242.25 Technical (Hospital) Services Ref Monoclonal Protein Study If PX-3028633401 CDM 86334 CPT 302 RC inpatient 255 255 MULTIPLAN INC 34080 [3081285] MULTIPLAN INC [308128501] 242.25 percent of total billed charges 158.1 242.25 Technical (Hospital) Services Ref Monoclonal Protein Study If PX-3028633401 CDM 86334 CPT 302 RC inpatient 255 255 MEDICA (COMMERCIAL) 94265 [3081118] MEDICA CLAIMS [308111801] 229.5 percent of total billed charges 158.1 242.25 Technical (Hospital) Services Ref Monoclonal Protein Study If PX-3028633401 CDM 86334 CPT 302 RC inpatient 255 255 UNITED HEALTHCARE (COMMERCIAL) [3081199] UNITED HEALTHCARE 87726 [308119901] 158.1 percent of total billed charges 158.1 242.25 Technical (Hospital) Services Ref Monoclonal Protein Study If PX-3028633401 CDM 86334 CPT 302 RC inpatient 255 255 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES PPO [308136801] 201.91 percent of total billed charges 158.1 242.25 Technical (Hospital) Services Ref Monoclonal Protein Study If PX-3028633401 CDM 86334 CPT 302 RC inpatient 255 255 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES HDHP [308136802] 201.91 percent of total billed charges 158.1 242.25 Technical (Hospital) Services Ref Immunofixation Serum Only Mayo PX-3028633404 CDM 86334 CPT 302 RC inpatient 280 280 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES EPO [308136803] 221.7 percent of total billed charges 173.6 266 Technical (Hospital) Services Ref Immunofixation Serum Only Mayo PX-3028633404 CDM 86334 CPT 302 RC inpatient 280 280 BLUE CROSS BLUE SHIELD WELLMARK SB889 [3081026] BCBS WYOMING [308102603] 266 percent of total billed charges 173.6 266 Technical (Hospital) Services Ref Immunofixation Serum Only Mayo PX-3028633404 CDM 86334 CPT 302 RC inpatient 280 280 HEALTHPARTNERS SX009 HEALTHPARTNERS 221.7 percent of total billed charges 173.6 266 Technical (Hospital) Services Ref Immunofixation Serum Only Mayo PX-3028633404 CDM 86334 CPT 302 RC inpatient 280 280 MEDICA (COMMERCIAL) 94265 [3081118] MEDICA CLAIMS [308111801] 252 percent of total billed charges 173.6 266 Technical (Hospital) Services Ref Immunofixation Serum Only Mayo PX-3028633404 CDM 86334 CPT 302 RC inpatient 280 280 MULTIPLAN INC 34080 [3081285] MULTIPLAN INC [308128501] 266 percent of total billed charges 173.6 266 Technical (Hospital) Services Ref Immunofixation Serum Only Mayo PX-3028633404 CDM 86334 CPT 302 RC inpatient 280 280 CIGNA 62308 [3081051] CIGNA 62308 [308105105] 221.7 percent of total billed charges 173.6 266 Technical (Hospital) Services Ref Immunofixation Serum Only Mayo PX-3028633404 CDM 86334 CPT 302 RC inpatient 280 280 CIGNA 62308 [3081051] CIGNA STATE OF WYOMING [308105107] 221.7 percent of total billed charges 173.6 266 Technical (Hospital) Services Ref Immunofixation Serum Only Mayo PX-3028633404 CDM 86334 CPT 302 RC inpatient 280 280 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES PPO [308136801] 221.7 percent of total billed charges 173.6 266 Technical (Hospital) Services Ref Immunofixation Serum Only Mayo PX-3028633404 CDM 86334 CPT 302 RC inpatient 280 280 UNITED HEALTHCARE (COMMERCIAL) [3081199] UNITED HEALTHCARE 87726 [308119901] 173.6 percent of total billed charges 173.6 266 Technical (Hospital) Services Ref Immunofixation Serum Only Mayo PX-3028633404 CDM 86334 CPT 302 RC inpatient 280 280 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES HDHP [308136802] 221.7 percent of total billed charges 173.6 266 Technical (Hospital) Services Ref Immunofixation Serum Only Mayo PX-3028633404 CDM 86334 CPT 302 RC outpatient 280 280 UNITED HEALTHCARE (COMMERCIAL) [3081199] UNITED HEALTHCARE 87726 [308119901] 173.6 percent of total billed charges 173.6 266 Technical (Hospital) Services Ref Immunofixation Serum Only Mayo PX-3028633404 CDM 86334 CPT 302 RC outpatient 280 280 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES PPO [308136801] 224 percent of total billed charges 173.6 266 Technical (Hospital) Services Ref Immunofixation Serum Only Mayo PX-3028633404 CDM 86334 CPT 302 RC outpatient 280 280 HEALTHPARTNERS SX009 HEALTHPARTNERS 224 percent of total billed charges 173.6 266 Technical (Hospital) Services Ref Immunofixation Serum Only Mayo PX-3028633404 CDM 86334 CPT 302 RC outpatient 280 280 MULTIPLAN INC 34080 [3081285] MULTIPLAN INC [308128501] 266 percent of total billed charges 173.6 266 Technical (Hospital) Services Ref Immunofixation Serum Only Mayo PX-3028633404 CDM 86334 CPT 302 RC outpatient 280 280 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES EPO [308136803] 224 percent of total billed charges 173.6 266 Technical (Hospital) Services Ref Immunofixation Serum Only Mayo PX-3028633404 CDM 86334 CPT 302 RC outpatient 280 280 CIGNA 62308 [3081051] CIGNA 62308 [308105105] 224 percent of total billed charges 173.6 266 Technical (Hospital) Services Ref Immunofixation Serum Only Mayo PX-3028633404 CDM 86334 CPT 302 RC outpatient 280 280 CIGNA 62308 [3081051] CIGNA STATE OF WYOMING [308105107] 224 percent of total billed charges 173.6 266 Technical (Hospital) Services Ref Immunofixation Serum Only Mayo PX-3028633404 CDM 86334 CPT 302 RC outpatient 280 280 BLUE CROSS BLUE SHIELD WELLMARK SB889 [3081026] BCBS WYOMING [308102603] 266 percent of total billed charges 173.6 266 Technical (Hospital) Services Ref Immunofixation Serum Only Mayo PX-3028633404 CDM 86334 CPT 302 RC outpatient 280 280 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES HDHP [308136802] 224 percent of total billed charges 173.6 266 Technical (Hospital) Services Ref Immunofixation Serum Only Mayo PX-3028633404 CDM 86334 CPT 302 RC outpatient 280 280 MEDICA (COMMERCIAL) 94265 [3081118] MEDICA CLAIMS [308111801] 252 percent of total billed charges 173.6 266 Technical (Hospital) Services Ref Rabies Antibody Elisa PX-3028631701 CDM 86317 CPT 302 RC outpatient 126 126 MEDICA (COMMERCIAL) 94265 [3081118] MEDICA CLAIMS [308111801] 113.4 percent of total billed charges 78.12 119.7 Technical (Hospital) Services Ref Rabies Antibody Elisa PX-3028631701 CDM 86317 CPT 302 RC outpatient 126 126 BLUE CROSS BLUE SHIELD WELLMARK SB889 [3081026] BCBS WYOMING [308102603] 119.7 percent of total billed charges 78.12 119.7 Technical (Hospital) Services Ref Rabies Antibody Elisa PX-3028631701 CDM 86317 CPT 302 RC outpatient 126 126 MULTIPLAN INC 34080 [3081285] MULTIPLAN INC [308128501] 119.7 percent of total billed charges 78.12 119.7 Technical (Hospital) Services Ref Rabies Antibody Elisa PX-3028631701 CDM 86317 CPT 302 RC outpatient 126 126 CIGNA 62308 [3081051] CIGNA 62308 [308105105] 100.8 percent of total billed charges 78.12 119.7 Technical (Hospital) Services Ref Rabies Antibody Elisa PX-3028631701 CDM 86317 CPT 302 RC outpatient 126 126 CIGNA 62308 [3081051] CIGNA STATE OF WYOMING [308105107] 100.8 percent of total billed charges 78.12 119.7 Technical (Hospital) Services Ref Rabies Antibody Elisa PX-3028631701 CDM 86317 CPT 302 RC outpatient 126 126 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES EPO [308136803] 100.8 percent of total billed charges 78.12 119.7 Technical (Hospital) Services Ref Rabies Antibody Elisa PX-3028631701 CDM 86317 CPT 302 RC outpatient 126 126 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES HDHP [308136802] 100.8 percent of total billed charges 78.12 119.7 Technical (Hospital) Services Ref Rabies Antibody Elisa PX-3028631701 CDM 86317 CPT 302 RC outpatient 126 126 UNITED HEALTHCARE (COMMERCIAL) [3081199] UNITED HEALTHCARE 87726 [308119901] 78.12 percent of total billed charges 78.12 119.7 Technical (Hospital) Services Ref Rabies Antibody Elisa PX-3028631701 CDM 86317 CPT 302 RC outpatient 126 126 HEALTHPARTNERS SX009 HEALTHPARTNERS 100.8 percent of total billed charges 78.12 119.7 Technical (Hospital) Services Ref Rabies Antibody Elisa PX-3028631701 CDM 86317 CPT 302 RC outpatient 126 126 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES PPO [308136801] 100.8 percent of total billed charges 78.12 119.7 Technical (Hospital) Services Ref Rabies Antibody Elisa PX-3028631701 CDM 86317 CPT 302 RC inpatient 126 126 MEDICA (COMMERCIAL) 94265 [3081118] MEDICA CLAIMS [308111801] 113.4 percent of total billed charges 78.12 119.7 Technical (Hospital) Services Ref Rabies Antibody Elisa PX-3028631701 CDM 86317 CPT 302 RC inpatient 126 126 MULTIPLAN INC 34080 [3081285] MULTIPLAN INC [308128501] 119.7 percent of total billed charges 78.12 119.7 Technical (Hospital) Services Ref Rabies Antibody Elisa PX-3028631701 CDM 86317 CPT 302 RC inpatient 126 126 CIGNA 62308 [3081051] CIGNA 62308 [308105105] 99.77 percent of total billed charges 78.12 119.7 Technical (Hospital) Services Ref Rabies Antibody Elisa PX-3028631701 CDM 86317 CPT 302 RC inpatient 126 126 CIGNA 62308 [3081051] CIGNA STATE OF WYOMING [308105107] 99.77 percent of total billed charges 78.12 119.7 Technical (Hospital) Services Ref Rabies Antibody Elisa PX-3028631701 CDM 86317 CPT 302 RC inpatient 126 126 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES EPO [308136803] 99.77 percent of total billed charges 78.12 119.7 Technical (Hospital) Services Ref Rabies Antibody Elisa PX-3028631701 CDM 86317 CPT 302 RC inpatient 126 126 BLUE CROSS BLUE SHIELD WELLMARK SB889 [3081026] BCBS WYOMING [308102603] 119.7 percent of total billed charges 78.12 119.7 Technical (Hospital) Services Ref Rabies Antibody Elisa PX-3028631701 CDM 86317 CPT 302 RC inpatient 126 126 HEALTHPARTNERS SX009 HEALTHPARTNERS 99.77 percent of total billed charges 78.12 119.7 Technical (Hospital) Services Ref Rabies Antibody Elisa PX-3028631701 CDM 86317 CPT 302 RC inpatient 126 126 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES PPO [308136801] 99.77 percent of total billed charges 78.12 119.7 Technical (Hospital) Services Ref Rabies Antibody Elisa PX-3028631701 CDM 86317 CPT 302 RC inpatient 126 126 UNITED HEALTHCARE (COMMERCIAL) [3081199] UNITED HEALTHCARE 87726 [308119901] 78.12 percent of total billed charges 78.12 119.7 Technical (Hospital) Services Ref Rabies Antibody Elisa PX-3028631701 CDM 86317 CPT 302 RC inpatient 126 126 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES HDHP [308136802] 99.77 percent of total billed charges 78.12 119.7 Technical (Hospital) Services Ref S Pneumoniae Igg Ea Serotype PX-3028631702 CDM 86317 CPT 302 RC outpatient 58 58 BLUE CROSS BLUE SHIELD WELLMARK SB889 [3081026] BCBS WYOMING [308102603] 55.1 percent of total billed charges 35.96 55.1 Technical (Hospital) Services Ref S Pneumoniae Igg Ea Serotype PX-3028631702 CDM 86317 CPT 302 RC outpatient 58 58 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES HDHP [308136802] 46.4 percent of total billed charges 35.96 55.1 Technical (Hospital) Services Ref S Pneumoniae Igg Ea Serotype PX-3028631702 CDM 86317 CPT 302 RC outpatient 58 58 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES EPO [308136803] 46.4 percent of total billed charges 35.96 55.1 Technical (Hospital) Services Ref S Pneumoniae Igg Ea Serotype PX-3028631702 CDM 86317 CPT 302 RC outpatient 58 58 CIGNA 62308 [3081051] CIGNA 62308 [308105105] 46.4 percent of total billed charges 35.96 55.1 Technical (Hospital) Services Ref S Pneumoniae Igg Ea Serotype PX-3028631702 CDM 86317 CPT 302 RC outpatient 58 58 CIGNA 62308 [3081051] CIGNA STATE OF WYOMING [308105107] 46.4 percent of total billed charges 35.96 55.1 Technical (Hospital) Services Ref S Pneumoniae Igg Ea Serotype PX-3028631702 CDM 86317 CPT 302 RC outpatient 58 58 MULTIPLAN INC 34080 [3081285] MULTIPLAN INC [308128501] 55.1 percent of total billed charges 35.96 55.1 Technical (Hospital) Services Ref S Pneumoniae Igg Ea Serotype PX-3028631702 CDM 86317 CPT 302 RC outpatient 58 58 UNITED HEALTHCARE (COMMERCIAL) [3081199] UNITED HEALTHCARE 87726 [308119901] 35.96 percent of total billed charges 35.96 55.1 Technical (Hospital) Services Ref S Pneumoniae Igg Ea Serotype PX-3028631702 CDM 86317 CPT 302 RC outpatient 58 58 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES PPO [308136801] 46.4 percent of total billed charges 35.96 55.1 Technical (Hospital) Services Ref S Pneumoniae Igg Ea Serotype PX-3028631702 CDM 86317 CPT 302 RC outpatient 58 58 HEALTHPARTNERS SX009 HEALTHPARTNERS 46.4 percent of total billed charges 35.96 55.1 Technical (Hospital) Services Ref S Pneumoniae Igg Ea Serotype PX-3028631702 CDM 86317 CPT 302 RC outpatient 58 58 MEDICA (COMMERCIAL) 94265 [3081118] MEDICA CLAIMS [308111801] 52.2 percent of total billed charges 35.96 55.1 Technical (Hospital) Services Ref S Pneumoniae Igg Ea Serotype PX-3028631702 CDM 86317 CPT 302 RC inpatient 58 58 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES PPO [308136801] 45.92 percent of total billed charges 35.96 55.1 Technical (Hospital) Services Ref S Pneumoniae Igg Ea Serotype PX-3028631702 CDM 86317 CPT 302 RC inpatient 58 58 UNITED HEALTHCARE (COMMERCIAL) [3081199] UNITED HEALTHCARE 87726 [308119901] 35.96 percent of total billed charges 35.96 55.1 Technical (Hospital) Services Ref S Pneumoniae Igg Ea Serotype PX-3028631702 CDM 86317 CPT 302 RC inpatient 58 58 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES HDHP [308136802] 45.92 percent of total billed charges 35.96 55.1 Technical (Hospital) Services Ref S Pneumoniae Igg Ea Serotype PX-3028631702 CDM 86317 CPT 302 RC inpatient 58 58 BLUE CROSS BLUE SHIELD WELLMARK SB889 [3081026] BCBS WYOMING [308102603] 55.1 percent of total billed charges 35.96 55.1 Technical (Hospital) Services Ref S Pneumoniae Igg Ea Serotype PX-3028631702 CDM 86317 CPT 302 RC inpatient 58 58 HEALTHPARTNERS SX009 HEALTHPARTNERS 45.92 percent of total billed charges 35.96 55.1 Technical (Hospital) Services Ref S Pneumoniae Igg Ea Serotype PX-3028631702 CDM 86317 CPT 302 RC inpatient 58 58 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES EPO [308136803] 45.92 percent of total billed charges 35.96 55.1 Technical (Hospital) Services Ref S Pneumoniae Igg Ea Serotype PX-3028631702 CDM 86317 CPT 302 RC inpatient 58 58 MEDICA (COMMERCIAL) 94265 [3081118] MEDICA CLAIMS [308111801] 52.2 percent of total billed charges 35.96 55.1 Technical (Hospital) Services Ref S Pneumoniae Igg Ea Serotype PX-3028631702 CDM 86317 CPT 302 RC inpatient 58 58 MULTIPLAN INC 34080 [3081285] MULTIPLAN INC [308128501] 55.1 percent of total billed charges 35.96 55.1 Technical (Hospital) Services Ref S Pneumoniae Igg Ea Serotype PX-3028631702 CDM 86317 CPT 302 RC inpatient 58 58 CIGNA 62308 [3081051] CIGNA 62308 [308105105] 45.92 percent of total billed charges 35.96 55.1 Technical (Hospital) Services Ref S Pneumoniae Igg Ea Serotype PX-3028631702 CDM 86317 CPT 302 RC inpatient 58 58 CIGNA 62308 [3081051] CIGNA STATE OF WYOMING [308105107] 45.92 percent of total billed charges 35.96 55.1 Technical (Hospital) Services Mono Heterophile Scr PX-3028630800 CDM 86308 CPT 302 RC outpatient 95 95 MEDICA (COMMERCIAL) 94265 [3081118] MEDICA CLAIMS [308111801] 85.5 percent of total billed charges 58.9 90.25 Technical (Hospital) Services Mono Heterophile Scr PX-3028630800 CDM 86308 CPT 302 RC outpatient 95 95 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES HDHP [308136802] 76 percent of total billed charges 58.9 90.25 Technical (Hospital) Services Mono Heterophile Scr PX-3028630800 CDM 86308 CPT 302 RC outpatient 95 95 BLUE CROSS BLUE SHIELD WELLMARK SB889 [3081026] BCBS WYOMING [308102603] 90.25 percent of total billed charges 58.9 90.25 Technical (Hospital) Services Mono Heterophile Scr PX-3028630800 CDM 86308 CPT 302 RC outpatient 95 95 CIGNA 62308 [3081051] CIGNA 62308 [308105105] 76 percent of total billed charges 58.9 90.25 Technical (Hospital) Services Mono Heterophile Scr PX-3028630800 CDM 86308 CPT 302 RC outpatient 95 95 CIGNA 62308 [3081051] CIGNA STATE OF WYOMING [308105107] 76 percent of total billed charges 58.9 90.25 Technical (Hospital) Services Mono Heterophile Scr PX-3028630800 CDM 86308 CPT 302 RC outpatient 95 95 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES EPO [308136803] 76 percent of total billed charges 58.9 90.25 Technical (Hospital) Services Mono Heterophile Scr PX-3028630800 CDM 86308 CPT 302 RC outpatient 95 95 MULTIPLAN INC 34080 [3081285] MULTIPLAN INC [308128501] 90.25 percent of total billed charges 58.9 90.25 Technical (Hospital) Services Mono Heterophile Scr PX-3028630800 CDM 86308 CPT 302 RC outpatient 95 95 UNITED HEALTHCARE (COMMERCIAL) [3081199] UNITED HEALTHCARE 87726 [308119901] 58.9 percent of total billed charges 58.9 90.25 Technical (Hospital) Services Mono Heterophile Scr PX-3028630800 CDM 86308 CPT 302 RC outpatient 95 95 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES PPO [308136801] 76 percent of total billed charges 58.9 90.25 Technical (Hospital) Services Mono Heterophile Scr PX-3028630800 CDM 86308 CPT 302 RC outpatient 95 95 HEALTHPARTNERS SX009 HEALTHPARTNERS 76 percent of total billed charges 58.9 90.25 Technical (Hospital) Services Mono Heterophile Scr PX-3028630800 CDM 86308 CPT 302 RC inpatient 95 95 UNITED HEALTHCARE (COMMERCIAL) [3081199] UNITED HEALTHCARE 87726 [308119901] 58.9 percent of total billed charges 58.9 90.25 Technical (Hospital) Services Mono Heterophile Scr PX-3028630800 CDM 86308 CPT 302 RC inpatient 95 95 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES PPO [308136801] 75.22 percent of total billed charges 58.9 90.25 Technical (Hospital) Services Mono Heterophile Scr PX-3028630800 CDM 86308 CPT 302 RC inpatient 95 95 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES HDHP [308136802] 75.22 percent of total billed charges 58.9 90.25 Technical (Hospital) Services Mono Heterophile Scr PX-3028630800 CDM 86308 CPT 302 RC inpatient 95 95 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES EPO [308136803] 75.22 percent of total billed charges 58.9 90.25 Technical (Hospital) Services Mono Heterophile Scr PX-3028630800 CDM 86308 CPT 302 RC inpatient 95 95 BLUE CROSS BLUE SHIELD WELLMARK SB889 [3081026] BCBS WYOMING [308102603] 90.25 percent of total billed charges 58.9 90.25 Technical (Hospital) Services Mono Heterophile Scr PX-3028630800 CDM 86308 CPT 302 RC inpatient 95 95 HEALTHPARTNERS SX009 HEALTHPARTNERS 75.22 percent of total billed charges 58.9 90.25 Technical (Hospital) Services Mono Heterophile Scr PX-3028630800 CDM 86308 CPT 302 RC inpatient 95 95 CIGNA 62308 [3081051] CIGNA 62308 [308105105] 75.22 percent of total billed charges 58.9 90.25 Technical (Hospital) Services Mono Heterophile Scr PX-3028630800 CDM 86308 CPT 302 RC inpatient 95 95 CIGNA 62308 [3081051] CIGNA STATE OF WYOMING [308105107] 75.22 percent of total billed charges 58.9 90.25 Technical (Hospital) Services Mono Heterophile Scr PX-3028630800 CDM 86308 CPT 302 RC inpatient 95 95 MULTIPLAN INC 34080 [3081285] MULTIPLAN INC [308128501] 90.25 percent of total billed charges 58.9 90.25 Technical (Hospital) Services Mono Heterophile Scr PX-3028630800 CDM 86308 CPT 302 RC inpatient 95 95 MEDICA (COMMERCIAL) 94265 [3081118] MEDICA CLAIMS [308111801] 85.5 percent of total billed charges 58.9 90.25 Technical (Hospital) Services Cancer Antigen 125 PX-3028630400 CDM 86304 CPT 302 RC outpatient 259 259 MEDICA (COMMERCIAL) 94265 [3081118] MEDICA CLAIMS [308111801] 233.1 percent of total billed charges 160.58 246.05 Technical (Hospital) Services Cancer Antigen 125 PX-3028630400 CDM 86304 CPT 302 RC outpatient 259 259 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES HDHP [308136802] 207.2 percent of total billed charges 160.58 246.05 Technical (Hospital) Services Cancer Antigen 125 PX-3028630400 CDM 86304 CPT 302 RC outpatient 259 259 BLUE CROSS BLUE SHIELD WELLMARK SB889 [3081026] BCBS WYOMING [308102603] 246.05 percent of total billed charges 160.58 246.05 Technical (Hospital) Services Cancer Antigen 125 PX-3028630400 CDM 86304 CPT 302 RC outpatient 259 259 CIGNA 62308 [3081051] CIGNA 62308 [308105105] 207.2 percent of total billed charges 160.58 246.05 Technical (Hospital) Services Cancer Antigen 125 PX-3028630400 CDM 86304 CPT 302 RC outpatient 259 259 CIGNA 62308 [3081051] CIGNA STATE OF WYOMING [308105107] 207.2 percent of total billed charges 160.58 246.05 Technical (Hospital) Services Cancer Antigen 125 PX-3028630400 CDM 86304 CPT 302 RC outpatient 259 259 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES EPO [308136803] 207.2 percent of total billed charges 160.58 246.05 Technical (Hospital) Services Cancer Antigen 125 PX-3028630400 CDM 86304 CPT 302 RC outpatient 259 259 MULTIPLAN INC 34080 [3081285] MULTIPLAN INC [308128501] 246.05 percent of total billed charges 160.58 246.05 Technical (Hospital) Services Cancer Antigen 125 PX-3028630400 CDM 86304 CPT 302 RC outpatient 259 259 HEALTHPARTNERS SX009 HEALTHPARTNERS 207.2 percent of total billed charges 160.58 246.05 Technical (Hospital) Services Cancer Antigen 125 PX-3028630400 CDM 86304 CPT 302 RC outpatient 259 259 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES PPO [308136801] 207.2 percent of total billed charges 160.58 246.05 Technical (Hospital) Services Cancer Antigen 125 PX-3028630400 CDM 86304 CPT 302 RC outpatient 259 259 UNITED HEALTHCARE (COMMERCIAL) [3081199] UNITED HEALTHCARE 87726 [308119901] 160.58 percent of total billed charges 160.58 246.05 Technical (Hospital) Services Cancer Antigen 125 PX-3028630400 CDM 86304 CPT 302 RC inpatient 259 259 MULTIPLAN INC 34080 [3081285] MULTIPLAN INC [308128501] 246.05 percent of total billed charges 160.58 246.05 Technical (Hospital) Services Cancer Antigen 125 PX-3028630400 CDM 86304 CPT 302 RC inpatient 259 259 CIGNA 62308 [3081051] CIGNA 62308 [308105105] 205.08 percent of total billed charges 160.58 246.05 Technical (Hospital) Services Cancer Antigen 125 PX-3028630400 CDM 86304 CPT 302 RC inpatient 259 259 CIGNA 62308 [3081051] CIGNA STATE OF WYOMING [308105107] 205.08 percent of total billed charges 160.58 246.05 Technical (Hospital) Services Cancer Antigen 125 PX-3028630400 CDM 86304 CPT 302 RC inpatient 259 259 BLUE CROSS BLUE SHIELD WELLMARK SB889 [3081026] BCBS WYOMING [308102603] 246.05 percent of total billed charges 160.58 246.05 Technical (Hospital) Services Cancer Antigen 125 PX-3028630400 CDM 86304 CPT 302 RC inpatient 259 259 HEALTHPARTNERS SX009 HEALTHPARTNERS 205.08 percent of total billed charges 160.58 246.05 Technical (Hospital) Services Cancer Antigen 125 PX-3028630400 CDM 86304 CPT 302 RC inpatient 259 259 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES EPO [308136803] 205.08 percent of total billed charges 160.58 246.05 Technical (Hospital) Services Cancer Antigen 125 PX-3028630400 CDM 86304 CPT 302 RC inpatient 259 259 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES PPO [308136801] 205.08 percent of total billed charges 160.58 246.05 Technical (Hospital) Services Cancer Antigen 125 PX-3028630400 CDM 86304 CPT 302 RC inpatient 259 259 UNITED HEALTHCARE (COMMERCIAL) [3081199] UNITED HEALTHCARE 87726 [308119901] 160.58 percent of total billed charges 160.58 246.05 Technical (Hospital) Services Cancer Antigen 125 PX-3028630400 CDM 86304 CPT 302 RC inpatient 259 259 MEDICA (COMMERCIAL) 94265 [3081118] MEDICA CLAIMS [308111801] 233.1 percent of total billed charges 160.58 246.05 Technical (Hospital) Services Cancer Antigen 125 PX-3028630400 CDM 86304 CPT 302 RC inpatient 259 259 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES HDHP [308136802] 205.08 percent of total billed charges 160.58 246.05 Technical (Hospital) Services "Ref Immunoassay, Tumor, Ca 19-9" PX-3028630100 CDM 86301 CPT 302 RC inpatient 251 251 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES HDHP [308136802] 198.74 percent of total billed charges 155.62 238.45 Technical (Hospital) Services "Ref Immunoassay, Tumor, Ca 19-9" PX-3028630100 CDM 86301 CPT 302 RC inpatient 251 251 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES PPO [308136801] 198.74 percent of total billed charges 155.62 238.45 Technical (Hospital) Services "Ref Immunoassay, Tumor, Ca 19-9" PX-3028630100 CDM 86301 CPT 302 RC inpatient 251 251 UNITED HEALTHCARE (COMMERCIAL) [3081199] UNITED HEALTHCARE 87726 [308119901] 155.62 percent of total billed charges 155.62 238.45 Technical (Hospital) Services "Ref Immunoassay, Tumor, Ca 19-9" PX-3028630100 CDM 86301 CPT 302 RC inpatient 251 251 CIGNA 62308 [3081051] CIGNA 62308 [308105105] 198.74 percent of total billed charges 155.62 238.45 Technical (Hospital) Services "Ref Immunoassay, Tumor, Ca 19-9" PX-3028630100 CDM 86301 CPT 302 RC inpatient 251 251 CIGNA 62308 [3081051] CIGNA STATE OF WYOMING [308105107] 198.74 percent of total billed charges 155.62 238.45 Technical (Hospital) Services "Ref Immunoassay, Tumor, Ca 19-9" PX-3028630100 CDM 86301 CPT 302 RC inpatient 251 251 MEDICA (COMMERCIAL) 94265 [3081118] MEDICA CLAIMS [308111801] 225.9 percent of total billed charges 155.62 238.45 Technical (Hospital) Services "Ref Immunoassay, Tumor, Ca 19-9" PX-3028630100 CDM 86301 CPT 302 RC inpatient 251 251 MULTIPLAN INC 34080 [3081285] MULTIPLAN INC [308128501] 238.45 percent of total billed charges 155.62 238.45 Technical (Hospital) Services "Ref Immunoassay, Tumor, Ca 19-9" PX-3028630100 CDM 86301 CPT 302 RC inpatient 251 251 HEALTHPARTNERS SX009 HEALTHPARTNERS 198.74 percent of total billed charges 155.62 238.45 Technical (Hospital) Services "Ref Immunoassay, Tumor, Ca 19-9" PX-3028630100 CDM 86301 CPT 302 RC inpatient 251 251 BLUE CROSS BLUE SHIELD WELLMARK SB889 [3081026] BCBS WYOMING [308102603] 238.45 percent of total billed charges 155.62 238.45 Technical (Hospital) Services "Ref Immunoassay, Tumor, Ca 19-9" PX-3028630100 CDM 86301 CPT 302 RC inpatient 251 251 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES EPO [308136803] 198.74 percent of total billed charges 155.62 238.45 Technical (Hospital) Services "Ref Immunoassay, Tumor, Ca 19-9" PX-3028630100 CDM 86301 CPT 302 RC outpatient 251 251 MEDICA (COMMERCIAL) 94265 [3081118] MEDICA CLAIMS [308111801] 225.9 percent of total billed charges 155.62 238.45 Technical (Hospital) Services "Ref Immunoassay, Tumor, Ca 19-9" PX-3028630100 CDM 86301 CPT 302 RC outpatient 251 251 BLUE CROSS BLUE SHIELD WELLMARK SB889 [3081026] BCBS WYOMING [308102603] 238.45 percent of total billed charges 155.62 238.45 Technical (Hospital) Services "Ref Immunoassay, Tumor, Ca 19-9" PX-3028630100 CDM 86301 CPT 302 RC outpatient 251 251 MULTIPLAN INC 34080 [3081285] MULTIPLAN INC [308128501] 238.45 percent of total billed charges 155.62 238.45 Technical (Hospital) Services "Ref Immunoassay, Tumor, Ca 19-9" PX-3028630100 CDM 86301 CPT 302 RC outpatient 251 251 CIGNA 62308 [3081051] CIGNA 62308 [308105105] 200.8 percent of total billed charges 155.62 238.45 Technical (Hospital) Services "Ref Immunoassay, Tumor, Ca 19-9" PX-3028630100 CDM 86301 CPT 302 RC outpatient 251 251 CIGNA 62308 [3081051] CIGNA STATE OF WYOMING [308105107] 200.8 percent of total billed charges 155.62 238.45 Technical (Hospital) Services "Ref Immunoassay, Tumor, Ca 19-9" PX-3028630100 CDM 86301 CPT 302 RC outpatient 251 251 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES EPO [308136803] 200.8 percent of total billed charges 155.62 238.45 Technical (Hospital) Services "Ref Immunoassay, Tumor, Ca 19-9" PX-3028630100 CDM 86301 CPT 302 RC outpatient 251 251 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES HDHP [308136802] 200.8 percent of total billed charges 155.62 238.45 Technical (Hospital) Services "Ref Immunoassay, Tumor, Ca 19-9" PX-3028630100 CDM 86301 CPT 302 RC outpatient 251 251 UNITED HEALTHCARE (COMMERCIAL) [3081199] UNITED HEALTHCARE 87726 [308119901] 155.62 percent of total billed charges 155.62 238.45 Technical (Hospital) Services "Ref Immunoassay, Tumor, Ca 19-9" PX-3028630100 CDM 86301 CPT 302 RC outpatient 251 251 HEALTHPARTNERS SX009 HEALTHPARTNERS 200.8 percent of total billed charges 155.62 238.45 Technical (Hospital) Services "Ref Immunoassay, Tumor, Ca 19-9" PX-3028630100 CDM 86301 CPT 302 RC outpatient 251 251 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES PPO [308136801] 200.8 percent of total billed charges 155.62 238.45 Technical (Hospital) Services Ref Ca Ag 19 9 PX-3028630101 CDM 86301 CPT 302 RC inpatient 174 174 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES PPO [308136801] 137.77 percent of total billed charges 107.88 165.3 Technical (Hospital) Services Ref Ca Ag 19 9 PX-3028630101 CDM 86301 CPT 302 RC inpatient 174 174 UNITED HEALTHCARE (COMMERCIAL) [3081199] UNITED HEALTHCARE 87726 [308119901] 107.88 percent of total billed charges 107.88 165.3 Technical (Hospital) Services Ref Ca Ag 19 9 PX-3028630101 CDM 86301 CPT 302 RC inpatient 174 174 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES HDHP [308136802] 137.77 percent of total billed charges 107.88 165.3 Technical (Hospital) Services Ref Ca Ag 19 9 PX-3028630101 CDM 86301 CPT 302 RC inpatient 174 174 CIGNA 62308 [3081051] CIGNA 62308 [308105105] 137.77 percent of total billed charges 107.88 165.3 Technical (Hospital) Services Ref Ca Ag 19 9 PX-3028630101 CDM 86301 CPT 302 RC inpatient 174 174 CIGNA 62308 [3081051] CIGNA STATE OF WYOMING [308105107] 137.77 percent of total billed charges 107.88 165.3 Technical (Hospital) Services Ref Ca Ag 19 9 PX-3028630101 CDM 86301 CPT 302 RC inpatient 174 174 MULTIPLAN INC 34080 [3081285] MULTIPLAN INC [308128501] 165.3 percent of total billed charges 107.88 165.3 Technical (Hospital) Services Ref Ca Ag 19 9 PX-3028630101 CDM 86301 CPT 302 RC inpatient 174 174 MEDICA (COMMERCIAL) 94265 [3081118] MEDICA CLAIMS [308111801] 156.6 percent of total billed charges 107.88 165.3 Technical (Hospital) Services Ref Ca Ag 19 9 PX-3028630101 CDM 86301 CPT 302 RC inpatient 174 174 HEALTHPARTNERS SX009 HEALTHPARTNERS 137.77 percent of total billed charges 107.88 165.3 Technical (Hospital) Services Ref Ca Ag 19 9 PX-3028630101 CDM 86301 CPT 302 RC inpatient 174 174 BLUE CROSS BLUE SHIELD WELLMARK SB889 [3081026] BCBS WYOMING [308102603] 165.3 percent of total billed charges 107.88 165.3 Technical (Hospital) Services Ref Ca Ag 19 9 PX-3028630101 CDM 86301 CPT 302 RC inpatient 174 174 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES EPO [308136803] 137.77 percent of total billed charges 107.88 165.3 Technical (Hospital) Services Ref Ca Ag 19 9 PX-3028630101 CDM 86301 CPT 302 RC outpatient 174 174 UNITED HEALTHCARE (COMMERCIAL) [3081199] UNITED HEALTHCARE 87726 [308119901] 107.88 percent of total billed charges 107.88 165.3 Technical (Hospital) Services Ref Ca Ag 19 9 PX-3028630101 CDM 86301 CPT 302 RC outpatient 174 174 BLUE CROSS BLUE SHIELD WELLMARK SB889 [3081026] BCBS WYOMING [308102603] 165.3 percent of total billed charges 107.88 165.3 Technical (Hospital) Services Ref Ca Ag 19 9 PX-3028630101 CDM 86301 CPT 302 RC outpatient 174 174 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES HDHP [308136802] 139.2 percent of total billed charges 107.88 165.3 Technical (Hospital) Services Ref Ca Ag 19 9 PX-3028630101 CDM 86301 CPT 302 RC outpatient 174 174 MULTIPLAN INC 34080 [3081285] MULTIPLAN INC [308128501] 165.3 percent of total billed charges 107.88 165.3 Technical (Hospital) Services Ref Ca Ag 19 9 PX-3028630101 CDM 86301 CPT 302 RC outpatient 174 174 CIGNA 62308 [3081051] CIGNA 62308 [308105105] 139.2 percent of total billed charges 107.88 165.3 Technical (Hospital) Services Ref Ca Ag 19 9 PX-3028630101 CDM 86301 CPT 302 RC outpatient 174 174 CIGNA 62308 [3081051] CIGNA STATE OF WYOMING [308105107] 139.2 percent of total billed charges 107.88 165.3 Technical (Hospital) Services Ref Ca Ag 19 9 PX-3028630101 CDM 86301 CPT 302 RC outpatient 174 174 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES EPO [308136803] 139.2 percent of total billed charges 107.88 165.3 Technical (Hospital) Services Ref Ca Ag 19 9 PX-3028630101 CDM 86301 CPT 302 RC outpatient 174 174 MEDICA (COMMERCIAL) 94265 [3081118] MEDICA CLAIMS [308111801] 156.6 percent of total billed charges 107.88 165.3 Technical (Hospital) Services Ref Ca Ag 19 9 PX-3028630101 CDM 86301 CPT 302 RC outpatient 174 174 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES PPO [308136801] 139.2 percent of total billed charges 107.88 165.3 Technical (Hospital) Services Ref Ca Ag 19 9 PX-3028630101 CDM 86301 CPT 302 RC outpatient 174 174 HEALTHPARTNERS SX009 HEALTHPARTNERS 139.2 percent of total billed charges 107.88 165.3 Technical (Hospital) Services "Immunoassay, Tumor, Ca 15-4" PX-3028630000 CDM 86300 CPT 302 RC inpatient 259 259 MULTIPLAN INC 34080 [3081285] MULTIPLAN INC [308128501] 246.05 percent of total billed charges 160.58 246.05 Technical (Hospital) Services "Immunoassay, Tumor, Ca 15-4" PX-3028630000 CDM 86300 CPT 302 RC inpatient 259 259 MEDICA (COMMERCIAL) 94265 [3081118] MEDICA CLAIMS [308111801] 233.1 percent of total billed charges 160.58 246.05 Technical (Hospital) Services "Immunoassay, Tumor, Ca 15-4" PX-3028630000 CDM 86300 CPT 302 RC inpatient 259 259 CIGNA 62308 [3081051] CIGNA 62308 [308105105] 205.08 percent of total billed charges 160.58 246.05 Technical (Hospital) Services "Immunoassay, Tumor, Ca 15-4" PX-3028630000 CDM 86300 CPT 302 RC inpatient 259 259 CIGNA 62308 [3081051] CIGNA STATE OF WYOMING [308105107] 205.08 percent of total billed charges 160.58 246.05 Technical (Hospital) Services "Immunoassay, Tumor, Ca 15-4" PX-3028630000 CDM 86300 CPT 302 RC inpatient 259 259 HEALTHPARTNERS SX009 HEALTHPARTNERS 205.08 percent of total billed charges 160.58 246.05 Technical (Hospital) Services "Immunoassay, Tumor, Ca 15-4" PX-3028630000 CDM 86300 CPT 302 RC inpatient 259 259 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES EPO [308136803] 205.08 percent of total billed charges 160.58 246.05 Technical (Hospital) Services "Immunoassay, Tumor, Ca 15-4" PX-3028630000 CDM 86300 CPT 302 RC inpatient 259 259 BLUE CROSS BLUE SHIELD WELLMARK SB889 [3081026] BCBS WYOMING [308102603] 246.05 percent of total billed charges 160.58 246.05 Technical (Hospital) Services "Immunoassay, Tumor, Ca 15-4" PX-3028630000 CDM 86300 CPT 302 RC inpatient 259 259 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES PPO [308136801] 205.08 percent of total billed charges 160.58 246.05 Technical (Hospital) Services "Immunoassay, Tumor, Ca 15-4" PX-3028630000 CDM 86300 CPT 302 RC inpatient 259 259 UNITED HEALTHCARE (COMMERCIAL) [3081199] UNITED HEALTHCARE 87726 [308119901] 160.58 percent of total billed charges 160.58 246.05 Technical (Hospital) Services "Immunoassay, Tumor, Ca 15-4" PX-3028630000 CDM 86300 CPT 302 RC inpatient 259 259 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES HDHP [308136802] 205.08 percent of total billed charges 160.58 246.05 Technical (Hospital) Services "Immunoassay, Tumor, Ca 15-4" PX-3028630000 CDM 86300 CPT 302 RC outpatient 259 259 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES PPO [308136801] 207.2 percent of total billed charges 160.58 246.05 Technical (Hospital) Services "Immunoassay, Tumor, Ca 15-4" PX-3028630000 CDM 86300 CPT 302 RC outpatient 259 259 UNITED HEALTHCARE (COMMERCIAL) [3081199] UNITED HEALTHCARE 87726 [308119901] 160.58 percent of total billed charges 160.58 246.05 Technical (Hospital) Services "Immunoassay, Tumor, Ca 15-4" PX-3028630000 CDM 86300 CPT 302 RC outpatient 259 259 HEALTHPARTNERS SX009 HEALTHPARTNERS 207.2 percent of total billed charges 160.58 246.05 Technical (Hospital) Services "Immunoassay, Tumor, Ca 15-4" PX-3028630000 CDM 86300 CPT 302 RC outpatient 259 259 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES HDHP [308136802] 207.2 percent of total billed charges 160.58 246.05 Technical (Hospital) Services "Immunoassay, Tumor, Ca 15-4" PX-3028630000 CDM 86300 CPT 302 RC outpatient 259 259 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES EPO [308136803] 207.2 percent of total billed charges 160.58 246.05 Technical (Hospital) Services "Immunoassay, Tumor, Ca 15-4" PX-3028630000 CDM 86300 CPT 302 RC outpatient 259 259 CIGNA 62308 [3081051] CIGNA 62308 [308105105] 207.2 percent of total billed charges 160.58 246.05 Technical (Hospital) Services "Immunoassay, Tumor, Ca 15-4" PX-3028630000 CDM 86300 CPT 302 RC outpatient 259 259 CIGNA 62308 [3081051] CIGNA STATE OF WYOMING [308105107] 207.2 percent of total billed charges 160.58 246.05 Technical (Hospital) Services "Immunoassay, Tumor, Ca 15-4" PX-3028630000 CDM 86300 CPT 302 RC outpatient 259 259 BLUE CROSS BLUE SHIELD WELLMARK SB889 [3081026] BCBS WYOMING [308102603] 246.05 percent of total billed charges 160.58 246.05 Technical (Hospital) Services "Immunoassay, Tumor, Ca 15-4" PX-3028630000 CDM 86300 CPT 302 RC outpatient 259 259 MULTIPLAN INC 34080 [3081285] MULTIPLAN INC [308128501] 246.05 percent of total billed charges 160.58 246.05 Technical (Hospital) Services "Immunoassay, Tumor, Ca 15-4" PX-3028630000 CDM 86300 CPT 302 RC outpatient 259 259 MEDICA (COMMERCIAL) 94265 [3081118] MEDICA CLAIMS [308111801] 233.1 percent of total billed charges 160.58 246.05 Technical (Hospital) Services Ref Ca 27.29 PX-3028630001 CDM 86300 CPT 302 RC inpatient 259 259 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES EPO [308136803] 205.08 percent of total billed charges 160.58 246.05 Technical (Hospital) Services Ref Ca 27.29 PX-3028630001 CDM 86300 CPT 302 RC inpatient 259 259 BLUE CROSS BLUE SHIELD WELLMARK SB889 [3081026] BCBS WYOMING [308102603] 246.05 percent of total billed charges 160.58 246.05 Technical (Hospital) Services Ref Ca 27.29 PX-3028630001 CDM 86300 CPT 302 RC inpatient 259 259 HEALTHPARTNERS SX009 HEALTHPARTNERS 205.08 percent of total billed charges 160.58 246.05 Technical (Hospital) Services Ref Ca 27.29 PX-3028630001 CDM 86300 CPT 302 RC inpatient 259 259 MEDICA (COMMERCIAL) 94265 [3081118] MEDICA CLAIMS [308111801] 233.1 percent of total billed charges 160.58 246.05 Technical (Hospital) Services Ref Ca 27.29 PX-3028630001 CDM 86300 CPT 302 RC inpatient 259 259 MULTIPLAN INC 34080 [3081285] MULTIPLAN INC [308128501] 246.05 percent of total billed charges 160.58 246.05 Technical (Hospital) Services Ref Ca 27.29 PX-3028630001 CDM 86300 CPT 302 RC inpatient 259 259 CIGNA 62308 [3081051] CIGNA 62308 [308105105] 205.08 percent of total billed charges 160.58 246.05 Technical (Hospital) Services Ref Ca 27.29 PX-3028630001 CDM 86300 CPT 302 RC inpatient 259 259 CIGNA 62308 [3081051] CIGNA STATE OF WYOMING [308105107] 205.08 percent of total billed charges 160.58 246.05 Technical (Hospital) Services Ref Ca 27.29 PX-3028630001 CDM 86300 CPT 302 RC inpatient 259 259 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES PPO [308136801] 205.08 percent of total billed charges 160.58 246.05 Technical (Hospital) Services Ref Ca 27.29 PX-3028630001 CDM 86300 CPT 302 RC inpatient 259 259 UNITED HEALTHCARE (COMMERCIAL) [3081199] UNITED HEALTHCARE 87726 [308119901] 160.58 percent of total billed charges 160.58 246.05 Technical (Hospital) Services Ref Ca 27.29 PX-3028630001 CDM 86300 CPT 302 RC inpatient 259 259 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES HDHP [308136802] 205.08 percent of total billed charges 160.58 246.05 Technical (Hospital) Services Ref Ca 27.29 PX-3028630001 CDM 86300 CPT 302 RC outpatient 259 259 UNITED HEALTHCARE (COMMERCIAL) [3081199] UNITED HEALTHCARE 87726 [308119901] 160.58 percent of total billed charges 160.58 246.05 Technical (Hospital) Services Ref Ca 27.29 PX-3028630001 CDM 86300 CPT 302 RC outpatient 259 259 HEALTHPARTNERS SX009 HEALTHPARTNERS 207.2 percent of total billed charges 160.58 246.05 Technical (Hospital) Services Ref Ca 27.29 PX-3028630001 CDM 86300 CPT 302 RC outpatient 259 259 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES PPO [308136801] 207.2 percent of total billed charges 160.58 246.05 Technical (Hospital) Services Ref Ca 27.29 PX-3028630001 CDM 86300 CPT 302 RC outpatient 259 259 MULTIPLAN INC 34080 [3081285] MULTIPLAN INC [308128501] 246.05 percent of total billed charges 160.58 246.05 Technical (Hospital) Services Ref Ca 27.29 PX-3028630001 CDM 86300 CPT 302 RC outpatient 259 259 CIGNA 62308 [3081051] CIGNA STATE OF WYOMING [308105107] 207.2 percent of total billed charges 160.58 246.05 Technical (Hospital) Services Ref Ca 27.29 PX-3028630001 CDM 86300 CPT 302 RC outpatient 259 259 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES EPO [308136803] 207.2 percent of total billed charges 160.58 246.05 Technical (Hospital) Services Ref Ca 27.29 PX-3028630001 CDM 86300 CPT 302 RC outpatient 259 259 CIGNA 62308 [3081051] CIGNA 62308 [308105105] 207.2 percent of total billed charges 160.58 246.05 Technical (Hospital) Services Ref Ca 27.29 PX-3028630001 CDM 86300 CPT 302 RC outpatient 259 259 BLUE CROSS BLUE SHIELD WELLMARK SB889 [3081026] BCBS WYOMING [308102603] 246.05 percent of total billed charges 160.58 246.05 Technical (Hospital) Services Ref Ca 27.29 PX-3028630001 CDM 86300 CPT 302 RC outpatient 259 259 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES HDHP [308136802] 207.2 percent of total billed charges 160.58 246.05 Technical (Hospital) Services Ref Ca 27.29 PX-3028630001 CDM 86300 CPT 302 RC outpatient 259 259 MEDICA (COMMERCIAL) 94265 [3081118] MEDICA CLAIMS [308111801] 233.1 percent of total billed charges 160.58 246.05 Technical (Hospital) Services Ref Cancer Antigen 15-3 PX-3028630002 CDM 86300 CPT 302 RC inpatient 259 259 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES EPO [308136803] 205.08 percent of total billed charges 160.58 246.05 Technical (Hospital) Services Ref Cancer Antigen 15-3 PX-3028630002 CDM 86300 CPT 302 RC inpatient 259 259 BLUE CROSS BLUE SHIELD WELLMARK SB889 [3081026] BCBS WYOMING [308102603] 246.05 percent of total billed charges 160.58 246.05 Technical (Hospital) Services Ref Cancer Antigen 15-3 PX-3028630002 CDM 86300 CPT 302 RC inpatient 259 259 HEALTHPARTNERS SX009 HEALTHPARTNERS 205.08 percent of total billed charges 160.58 246.05 Technical (Hospital) Services Ref Cancer Antigen 15-3 PX-3028630002 CDM 86300 CPT 302 RC inpatient 259 259 MEDICA (COMMERCIAL) 94265 [3081118] MEDICA CLAIMS [308111801] 233.1 percent of total billed charges 160.58 246.05 Technical (Hospital) Services Ref Cancer Antigen 15-3 PX-3028630002 CDM 86300 CPT 302 RC inpatient 259 259 MULTIPLAN INC 34080 [3081285] MULTIPLAN INC [308128501] 246.05 percent of total billed charges 160.58 246.05 Technical (Hospital) Services Ref Cancer Antigen 15-3 PX-3028630002 CDM 86300 CPT 302 RC inpatient 259 259 CIGNA 62308 [3081051] CIGNA 62308 [308105105] 205.08 percent of total billed charges 160.58 246.05 Technical (Hospital) Services Ref Cancer Antigen 15-3 PX-3028630002 CDM 86300 CPT 302 RC inpatient 259 259 CIGNA 62308 [3081051] CIGNA STATE OF WYOMING [308105107] 205.08 percent of total billed charges 160.58 246.05 Technical (Hospital) Services Ref Cancer Antigen 15-3 PX-3028630002 CDM 86300 CPT 302 RC inpatient 259 259 UNITED HEALTHCARE (COMMERCIAL) [3081199] UNITED HEALTHCARE 87726 [308119901] 160.58 percent of total billed charges 160.58 246.05 Technical (Hospital) Services Ref Cancer Antigen 15-3 PX-3028630002 CDM 86300 CPT 302 RC inpatient 259 259 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES PPO [308136801] 205.08 percent of total billed charges 160.58 246.05 Technical (Hospital) Services Ref Cancer Antigen 15-3 PX-3028630002 CDM 86300 CPT 302 RC inpatient 259 259 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES HDHP [308136802] 205.08 percent of total billed charges 160.58 246.05 Technical (Hospital) Services Ref Cancer Antigen 15-3 PX-3028630002 CDM 86300 CPT 302 RC outpatient 259 259 UNITED HEALTHCARE (COMMERCIAL) [3081199] UNITED HEALTHCARE 87726 [308119901] 160.58 percent of total billed charges 160.58 246.05 Technical (Hospital) Services Ref Cancer Antigen 15-3 PX-3028630002 CDM 86300 CPT 302 RC outpatient 259 259 HEALTHPARTNERS SX009 HEALTHPARTNERS 207.2 percent of total billed charges 160.58 246.05 Technical (Hospital) Services Ref Cancer Antigen 15-3 PX-3028630002 CDM 86300 CPT 302 RC outpatient 259 259 MULTIPLAN INC 34080 [3081285] MULTIPLAN INC [308128501] 246.05 percent of total billed charges 160.58 246.05 Technical (Hospital) Services Ref Cancer Antigen 15-3 PX-3028630002 CDM 86300 CPT 302 RC outpatient 259 259 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES EPO [308136803] 207.2 percent of total billed charges 160.58 246.05 Technical (Hospital) Services Ref Cancer Antigen 15-3 PX-3028630002 CDM 86300 CPT 302 RC outpatient 259 259 CIGNA 62308 [3081051] CIGNA 62308 [308105105] 207.2 percent of total billed charges 160.58 246.05 Technical (Hospital) Services Ref Cancer Antigen 15-3 PX-3028630002 CDM 86300 CPT 302 RC outpatient 259 259 CIGNA 62308 [3081051] CIGNA STATE OF WYOMING [308105107] 207.2 percent of total billed charges 160.58 246.05 Technical (Hospital) Services Ref Cancer Antigen 15-3 PX-3028630002 CDM 86300 CPT 302 RC outpatient 259 259 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES HDHP [308136802] 207.2 percent of total billed charges 160.58 246.05 Technical (Hospital) Services Ref Cancer Antigen 15-3 PX-3028630002 CDM 86300 CPT 302 RC outpatient 259 259 BLUE CROSS BLUE SHIELD WELLMARK SB889 [3081026] BCBS WYOMING [308102603] 246.05 percent of total billed charges 160.58 246.05 Technical (Hospital) Services Ref Cancer Antigen 15-3 PX-3028630002 CDM 86300 CPT 302 RC outpatient 259 259 MEDICA (COMMERCIAL) 94265 [3081118] MEDICA CLAIMS [308111801] 233.1 percent of total billed charges 160.58 246.05 Technical (Hospital) Services Ref Cancer Antigen 15-3 PX-3028630002 CDM 86300 CPT 302 RC outpatient 259 259 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES PPO [308136801] 207.2 percent of total billed charges 160.58 246.05 Technical (Hospital) Services Ref Florescent Antibody Titer; Each PX-3028625600 CDM 86256 CPT 302 RC inpatient 165 165 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES PPO [308136801] 130.65 percent of total billed charges 102.3 156.75 Technical (Hospital) Services Ref Florescent Antibody Titer; Each PX-3028625600 CDM 86256 CPT 302 RC inpatient 165 165 UNITED HEALTHCARE (COMMERCIAL) [3081199] UNITED HEALTHCARE 87726 [308119901] 102.3 percent of total billed charges 102.3 156.75 Technical (Hospital) Services Ref Florescent Antibody Titer; Each PX-3028625600 CDM 86256 CPT 302 RC inpatient 165 165 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES HDHP [308136802] 130.65 percent of total billed charges 102.3 156.75 Technical (Hospital) Services Ref Florescent Antibody Titer; Each PX-3028625600 CDM 86256 CPT 302 RC inpatient 165 165 CIGNA 62308 [3081051] CIGNA 62308 [308105105] 130.65 percent of total billed charges 102.3 156.75 Technical (Hospital) Services Ref Florescent Antibody Titer; Each PX-3028625600 CDM 86256 CPT 302 RC inpatient 165 165 CIGNA 62308 [3081051] CIGNA STATE OF WYOMING [308105107] 130.65 percent of total billed charges 102.3 156.75 Technical (Hospital) Services Ref Florescent Antibody Titer; Each PX-3028625600 CDM 86256 CPT 302 RC inpatient 165 165 MULTIPLAN INC 34080 [3081285] MULTIPLAN INC [308128501] 156.75 percent of total billed charges 102.3 156.75 Technical (Hospital) Services Ref Florescent Antibody Titer; Each PX-3028625600 CDM 86256 CPT 302 RC inpatient 165 165 MEDICA (COMMERCIAL) 94265 [3081118] MEDICA CLAIMS [308111801] 148.5 percent of total billed charges 102.3 156.75 Technical (Hospital) Services Ref Florescent Antibody Titer; Each PX-3028625600 CDM 86256 CPT 302 RC inpatient 165 165 HEALTHPARTNERS SX009 HEALTHPARTNERS 130.65 percent of total billed charges 102.3 156.75 Technical (Hospital) Services Ref Florescent Antibody Titer; Each PX-3028625600 CDM 86256 CPT 302 RC inpatient 165 165 BLUE CROSS BLUE SHIELD WELLMARK SB889 [3081026] BCBS WYOMING [308102603] 156.75 percent of total billed charges 102.3 156.75 Technical (Hospital) Services Ref Florescent Antibody Titer; Each PX-3028625600 CDM 86256 CPT 302 RC inpatient 165 165 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES EPO [308136803] 130.65 percent of total billed charges 102.3 156.75 Technical (Hospital) Services Ref Florescent Antibody Titer; Each PX-3028625600 CDM 86256 CPT 302 RC outpatient 165 165 MULTIPLAN INC 34080 [3081285] MULTIPLAN INC [308128501] 156.75 percent of total billed charges 102.3 156.75 Technical (Hospital) Services Ref Florescent Antibody Titer; Each PX-3028625600 CDM 86256 CPT 302 RC outpatient 165 165 CIGNA 62308 [3081051] CIGNA 62308 [308105105] 132 percent of total billed charges 102.3 156.75 Technical (Hospital) Services Ref Florescent Antibody Titer; Each PX-3028625600 CDM 86256 CPT 302 RC outpatient 165 165 CIGNA 62308 [3081051] CIGNA STATE OF WYOMING [308105107] 132 percent of total billed charges 102.3 156.75 Technical (Hospital) Services Ref Florescent Antibody Titer; Each PX-3028625600 CDM 86256 CPT 302 RC outpatient 165 165 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES EPO [308136803] 132 percent of total billed charges 102.3 156.75 Technical (Hospital) Services Ref Florescent Antibody Titer; Each PX-3028625600 CDM 86256 CPT 302 RC outpatient 165 165 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES HDHP [308136802] 132 percent of total billed charges 102.3 156.75 Technical (Hospital) Services Ref Florescent Antibody Titer; Each PX-3028625600 CDM 86256 CPT 302 RC outpatient 165 165 BLUE CROSS BLUE SHIELD WELLMARK SB889 [3081026] BCBS WYOMING [308102603] 156.75 percent of total billed charges 102.3 156.75 Technical (Hospital) Services Ref Florescent Antibody Titer; Each PX-3028625600 CDM 86256 CPT 302 RC outpatient 165 165 UNITED HEALTHCARE (COMMERCIAL) [3081199] UNITED HEALTHCARE 87726 [308119901] 102.3 percent of total billed charges 102.3 156.75 Technical (Hospital) Services Ref Florescent Antibody Titer; Each PX-3028625600 CDM 86256 CPT 302 RC outpatient 165 165 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES PPO [308136801] 132 percent of total billed charges 102.3 156.75 Technical (Hospital) Services Ref Florescent Antibody Titer; Each PX-3028625600 CDM 86256 CPT 302 RC outpatient 165 165 HEALTHPARTNERS SX009 HEALTHPARTNERS 132 percent of total billed charges 102.3 156.75 Technical (Hospital) Services Ref Florescent Antibody Titer; Each PX-3028625600 CDM 86256 CPT 302 RC outpatient 165 165 MEDICA (COMMERCIAL) 94265 [3081118] MEDICA CLAIMS [308111801] 148.5 percent of total billed charges 102.3 156.75 Technical (Hospital) Services Ref Cytoplasmic Neutrophil Ab PX-3028625500 CDM 86255 CPT 302 RC inpatient 174 174 BLUE CROSS BLUE SHIELD WELLMARK SB889 [3081026] BCBS WYOMING [308102603] 165.3 percent of total billed charges 107.88 165.3 Technical (Hospital) Services Ref Cytoplasmic Neutrophil Ab PX-3028625500 CDM 86255 CPT 302 RC inpatient 174 174 HEALTHPARTNERS SX009 HEALTHPARTNERS 137.77 percent of total billed charges 107.88 165.3 Technical (Hospital) Services Ref Cytoplasmic Neutrophil Ab PX-3028625500 CDM 86255 CPT 302 RC inpatient 174 174 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES EPO [308136803] 137.77 percent of total billed charges 107.88 165.3 Technical (Hospital) Services Ref Cytoplasmic Neutrophil Ab PX-3028625500 CDM 86255 CPT 302 RC inpatient 174 174 MULTIPLAN INC 34080 [3081285] MULTIPLAN INC [308128501] 165.3 percent of total billed charges 107.88 165.3 Technical (Hospital) Services Ref Cytoplasmic Neutrophil Ab PX-3028625500 CDM 86255 CPT 302 RC inpatient 174 174 MEDICA (COMMERCIAL) 94265 [3081118] MEDICA CLAIMS [308111801] 156.6 percent of total billed charges 107.88 165.3 Technical (Hospital) Services Ref Cytoplasmic Neutrophil Ab PX-3028625500 CDM 86255 CPT 302 RC inpatient 174 174 CIGNA 62308 [3081051] CIGNA 62308 [308105105] 137.77 percent of total billed charges 107.88 165.3 Technical (Hospital) Services Ref Cytoplasmic Neutrophil Ab PX-3028625500 CDM 86255 CPT 302 RC inpatient 174 174 CIGNA 62308 [3081051] CIGNA STATE OF WYOMING [308105107] 137.77 percent of total billed charges 107.88 165.3 Technical (Hospital) Services Ref Cytoplasmic Neutrophil Ab PX-3028625500 CDM 86255 CPT 302 RC inpatient 174 174 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES PPO [308136801] 137.77 percent of total billed charges 107.88 165.3 Technical (Hospital) Services Ref Cytoplasmic Neutrophil Ab PX-3028625500 CDM 86255 CPT 302 RC inpatient 174 174 UNITED HEALTHCARE (COMMERCIAL) [3081199] UNITED HEALTHCARE 87726 [308119901] 107.88 percent of total billed charges 107.88 165.3 Technical (Hospital) Services Ref Cytoplasmic Neutrophil Ab PX-3028625500 CDM 86255 CPT 302 RC inpatient 174 174 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES HDHP [308136802] 137.77 percent of total billed charges 107.88 165.3 Technical (Hospital) Services Ref Cytoplasmic Neutrophil Ab PX-3028625500 CDM 86255 CPT 302 RC outpatient 174 174 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES HDHP [308136802] 139.2 percent of total billed charges 107.88 165.3 Technical (Hospital) Services Ref Cytoplasmic Neutrophil Ab PX-3028625500 CDM 86255 CPT 302 RC outpatient 174 174 BLUE CROSS BLUE SHIELD WELLMARK SB889 [3081026] BCBS WYOMING [308102603] 165.3 percent of total billed charges 107.88 165.3 Technical (Hospital) Services Ref Cytoplasmic Neutrophil Ab PX-3028625500 CDM 86255 CPT 302 RC outpatient 174 174 MULTIPLAN INC 34080 [3081285] MULTIPLAN INC [308128501] 165.3 percent of total billed charges 107.88 165.3 Technical (Hospital) Services Ref Cytoplasmic Neutrophil Ab PX-3028625500 CDM 86255 CPT 302 RC outpatient 174 174 CIGNA 62308 [3081051] CIGNA 62308 [308105105] 139.2 percent of total billed charges 107.88 165.3 Technical (Hospital) Services Ref Cytoplasmic Neutrophil Ab PX-3028625500 CDM 86255 CPT 302 RC outpatient 174 174 CIGNA 62308 [3081051] CIGNA STATE OF WYOMING [308105107] 139.2 percent of total billed charges 107.88 165.3 Technical (Hospital) Services Ref Cytoplasmic Neutrophil Ab PX-3028625500 CDM 86255 CPT 302 RC outpatient 174 174 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES EPO [308136803] 139.2 percent of total billed charges 107.88 165.3 Technical (Hospital) Services Ref Cytoplasmic Neutrophil Ab PX-3028625500 CDM 86255 CPT 302 RC outpatient 174 174 UNITED HEALTHCARE (COMMERCIAL) [3081199] UNITED HEALTHCARE 87726 [308119901] 107.88 percent of total billed charges 107.88 165.3 Technical (Hospital) Services Ref Cytoplasmic Neutrophil Ab PX-3028625500 CDM 86255 CPT 302 RC outpatient 174 174 HEALTHPARTNERS SX009 HEALTHPARTNERS 139.2 percent of total billed charges 107.88 165.3 Technical (Hospital) Services Ref Cytoplasmic Neutrophil Ab PX-3028625500 CDM 86255 CPT 302 RC outpatient 174 174 MEDICA (COMMERCIAL) 94265 [3081118] MEDICA CLAIMS [308111801] 156.6 percent of total billed charges 107.88 165.3 Technical (Hospital) Services Ref Cytoplasmic Neutrophil Ab PX-3028625500 CDM 86255 CPT 302 RC outpatient 174 174 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES PPO [308136801] 139.2 percent of total billed charges 107.88 165.3 Technical (Hospital) Services Ref Inflammatory Bowel Dis Panel PX-3028625502 CDM 86255 CPT 302 RC outpatient 155 155 MEDICA (COMMERCIAL) 94265 [3081118] MEDICA CLAIMS [308111801] 139.5 percent of total billed charges 96.1 147.25 Technical (Hospital) Services Ref Inflammatory Bowel Dis Panel PX-3028625502 CDM 86255 CPT 302 RC outpatient 155 155 CIGNA 62308 [3081051] CIGNA 62308 [308105105] 124 percent of total billed charges 96.1 147.25 Technical (Hospital) Services Ref Inflammatory Bowel Dis Panel PX-3028625502 CDM 86255 CPT 302 RC outpatient 155 155 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES EPO [308136803] 124 percent of total billed charges 96.1 147.25 Technical (Hospital) Services Ref Inflammatory Bowel Dis Panel PX-3028625502 CDM 86255 CPT 302 RC outpatient 155 155 CIGNA 62308 [3081051] CIGNA STATE OF WYOMING [308105107] 124 percent of total billed charges 96.1 147.25 Technical (Hospital) Services Ref Inflammatory Bowel Dis Panel PX-3028625502 CDM 86255 CPT 302 RC outpatient 155 155 BLUE CROSS BLUE SHIELD WELLMARK SB889 [3081026] BCBS WYOMING [308102603] 147.25 percent of total billed charges 96.1 147.25 Technical (Hospital) Services Ref Inflammatory Bowel Dis Panel PX-3028625502 CDM 86255 CPT 302 RC outpatient 155 155 MULTIPLAN INC 34080 [3081285] MULTIPLAN INC [308128501] 147.25 percent of total billed charges 96.1 147.25 Technical (Hospital) Services Ref Inflammatory Bowel Dis Panel PX-3028625502 CDM 86255 CPT 302 RC outpatient 155 155 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES HDHP [308136802] 124 percent of total billed charges 96.1 147.25 Technical (Hospital) Services Ref Inflammatory Bowel Dis Panel PX-3028625502 CDM 86255 CPT 302 RC outpatient 155 155 UNITED HEALTHCARE (COMMERCIAL) [3081199] UNITED HEALTHCARE 87726 [308119901] 96.1 percent of total billed charges 96.1 147.25 Technical (Hospital) Services Ref Inflammatory Bowel Dis Panel PX-3028625502 CDM 86255 CPT 302 RC outpatient 155 155 HEALTHPARTNERS SX009 HEALTHPARTNERS 124 percent of total billed charges 96.1 147.25 Technical (Hospital) Services Ref Inflammatory Bowel Dis Panel PX-3028625502 CDM 86255 CPT 302 RC outpatient 155 155 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES PPO [308136801] 124 percent of total billed charges 96.1 147.25 Technical (Hospital) Services Ref Inflammatory Bowel Dis Panel PX-3028625502 CDM 86255 CPT 302 RC inpatient 155 155 UNITED HEALTHCARE (COMMERCIAL) [3081199] UNITED HEALTHCARE 87726 [308119901] 96.1 percent of total billed charges 96.1 147.25 Technical (Hospital) Services Ref Inflammatory Bowel Dis Panel PX-3028625502 CDM 86255 CPT 302 RC inpatient 155 155 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES PPO [308136801] 122.73 percent of total billed charges 96.1 147.25 Technical (Hospital) Services Ref Inflammatory Bowel Dis Panel PX-3028625502 CDM 86255 CPT 302 RC inpatient 155 155 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES HDHP [308136802] 122.73 percent of total billed charges 96.1 147.25 Technical (Hospital) Services Ref Inflammatory Bowel Dis Panel PX-3028625502 CDM 86255 CPT 302 RC inpatient 155 155 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES EPO [308136803] 122.73 percent of total billed charges 96.1 147.25 Technical (Hospital) Services Ref Inflammatory Bowel Dis Panel PX-3028625502 CDM 86255 CPT 302 RC inpatient 155 155 HEALTHPARTNERS SX009 HEALTHPARTNERS 122.73 percent of total billed charges 96.1 147.25 Technical (Hospital) Services Ref Inflammatory Bowel Dis Panel PX-3028625502 CDM 86255 CPT 302 RC inpatient 155 155 BLUE CROSS BLUE SHIELD WELLMARK SB889 [3081026] BCBS WYOMING [308102603] 147.25 percent of total billed charges 96.1 147.25 Technical (Hospital) Services Ref Inflammatory Bowel Dis Panel PX-3028625502 CDM 86255 CPT 302 RC inpatient 155 155 MEDICA (COMMERCIAL) 94265 [3081118] MEDICA CLAIMS [308111801] 139.5 percent of total billed charges 96.1 147.25 Technical (Hospital) Services Ref Inflammatory Bowel Dis Panel PX-3028625502 CDM 86255 CPT 302 RC inpatient 155 155 MULTIPLAN INC 34080 [3081285] MULTIPLAN INC [308128501] 147.25 percent of total billed charges 96.1 147.25 Technical (Hospital) Services Ref Inflammatory Bowel Dis Panel PX-3028625502 CDM 86255 CPT 302 RC inpatient 155 155 CIGNA 62308 [3081051] CIGNA 62308 [308105105] 122.73 percent of total billed charges 96.1 147.25 Technical (Hospital) Services Ref Inflammatory Bowel Dis Panel PX-3028625502 CDM 86255 CPT 302 RC inpatient 155 155 CIGNA 62308 [3081051] CIGNA STATE OF WYOMING [308105107] 122.73 percent of total billed charges 96.1 147.25 Technical (Hospital) Services Ref Anti Smooth Muscle Ab PX-3028625503 CDM 86255 CPT 302 RC outpatient 173 173 BLUE CROSS BLUE SHIELD WELLMARK SB889 [3081026] BCBS WYOMING [308102603] 164.35 percent of total billed charges 107.26 164.35 Technical (Hospital) Services Ref Anti Smooth Muscle Ab PX-3028625503 CDM 86255 CPT 302 RC outpatient 173 173 MULTIPLAN INC 34080 [3081285] MULTIPLAN INC [308128501] 164.35 percent of total billed charges 107.26 164.35 Technical (Hospital) Services Ref Anti Smooth Muscle Ab PX-3028625503 CDM 86255 CPT 302 RC outpatient 173 173 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES EPO [308136803] 138.4 percent of total billed charges 107.26 164.35 Technical (Hospital) Services Ref Anti Smooth Muscle Ab PX-3028625503 CDM 86255 CPT 302 RC outpatient 173 173 CIGNA 62308 [3081051] CIGNA 62308 [308105105] 138.4 percent of total billed charges 107.26 164.35 Technical (Hospital) Services Ref Anti Smooth Muscle Ab PX-3028625503 CDM 86255 CPT 302 RC outpatient 173 173 CIGNA 62308 [3081051] CIGNA STATE OF WYOMING [308105107] 138.4 percent of total billed charges 107.26 164.35 Technical (Hospital) Services Ref Anti Smooth Muscle Ab PX-3028625503 CDM 86255 CPT 302 RC outpatient 173 173 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES HDHP [308136802] 138.4 percent of total billed charges 107.26 164.35 Technical (Hospital) Services Ref Anti Smooth Muscle Ab PX-3028625503 CDM 86255 CPT 302 RC outpatient 173 173 UNITED HEALTHCARE (COMMERCIAL) [3081199] UNITED HEALTHCARE 87726 [308119901] 107.26 percent of total billed charges 107.26 164.35 Technical (Hospital) Services Ref Anti Smooth Muscle Ab PX-3028625503 CDM 86255 CPT 302 RC outpatient 173 173 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES PPO [308136801] 138.4 percent of total billed charges 107.26 164.35 Technical (Hospital) Services Ref Anti Smooth Muscle Ab PX-3028625503 CDM 86255 CPT 302 RC outpatient 173 173 HEALTHPARTNERS SX009 HEALTHPARTNERS 138.4 percent of total billed charges 107.26 164.35 Technical (Hospital) Services Ref Anti Smooth Muscle Ab PX-3028625503 CDM 86255 CPT 302 RC outpatient 173 173 MEDICA (COMMERCIAL) 94265 [3081118] MEDICA CLAIMS [308111801] 155.7 percent of total billed charges 107.26 164.35 Technical (Hospital) Services Ref Anti Smooth Muscle Ab PX-3028625503 CDM 86255 CPT 302 RC inpatient 173 173 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES PPO [308136801] 136.98 percent of total billed charges 107.26 164.35 Technical (Hospital) Services Ref Anti Smooth Muscle Ab PX-3028625503 CDM 86255 CPT 302 RC inpatient 173 173 UNITED HEALTHCARE (COMMERCIAL) [3081199] UNITED HEALTHCARE 87726 [308119901] 107.26 percent of total billed charges 107.26 164.35 Technical (Hospital) Services Ref Anti Smooth Muscle Ab PX-3028625503 CDM 86255 CPT 302 RC inpatient 173 173 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES HDHP [308136802] 136.98 percent of total billed charges 107.26 164.35 Technical (Hospital) Services Ref Anti Smooth Muscle Ab PX-3028625503 CDM 86255 CPT 302 RC inpatient 173 173 MEDICA (COMMERCIAL) 94265 [3081118] MEDICA CLAIMS [308111801] 155.7 percent of total billed charges 107.26 164.35 Technical (Hospital) Services Ref Anti Smooth Muscle Ab PX-3028625503 CDM 86255 CPT 302 RC inpatient 173 173 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES EPO [308136803] 136.98 percent of total billed charges 107.26 164.35 Technical (Hospital) Services Ref Anti Smooth Muscle Ab PX-3028625503 CDM 86255 CPT 302 RC inpatient 173 173 BLUE CROSS BLUE SHIELD WELLMARK SB889 [3081026] BCBS WYOMING [308102603] 164.35 percent of total billed charges 107.26 164.35 Technical (Hospital) Services Ref Anti Smooth Muscle Ab PX-3028625503 CDM 86255 CPT 302 RC inpatient 173 173 HEALTHPARTNERS SX009 HEALTHPARTNERS 136.98 percent of total billed charges 107.26 164.35 Technical (Hospital) Services Ref Anti Smooth Muscle Ab PX-3028625503 CDM 86255 CPT 302 RC inpatient 173 173 MULTIPLAN INC 34080 [3081285] MULTIPLAN INC [308128501] 164.35 percent of total billed charges 107.26 164.35 Technical (Hospital) Services Ref Anti Smooth Muscle Ab PX-3028625503 CDM 86255 CPT 302 RC inpatient 173 173 CIGNA 62308 [3081051] CIGNA 62308 [308105105] 136.98 percent of total billed charges 107.26 164.35 Technical (Hospital) Services Ref Anti Smooth Muscle Ab PX-3028625503 CDM 86255 CPT 302 RC inpatient 173 173 CIGNA 62308 [3081051] CIGNA STATE OF WYOMING [308105107] 136.98 percent of total billed charges 107.26 164.35 Technical (Hospital) Services "Ref Paraneoplastic Anti-Neuronal Nuclear, Type 1" PX-3028625512 CDM 86255 CPT 302 RC inpatient 614 614 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES EPO [308136803] 486.17 percent of total billed charges 380.68 583.3 Technical (Hospital) Services "Ref Paraneoplastic Anti-Neuronal Nuclear, Type 1" PX-3028625512 CDM 86255 CPT 302 RC inpatient 614 614 BLUE CROSS BLUE SHIELD WELLMARK SB889 [3081026] BCBS WYOMING [308102603] 583.3 percent of total billed charges 380.68 583.3 Technical (Hospital) Services "Ref Paraneoplastic Anti-Neuronal Nuclear, Type 1" PX-3028625512 CDM 86255 CPT 302 RC inpatient 614 614 HEALTHPARTNERS SX009 HEALTHPARTNERS 486.17 percent of total billed charges 380.68 583.3 Technical (Hospital) Services "Ref Paraneoplastic Anti-Neuronal Nuclear, Type 1" PX-3028625512 CDM 86255 CPT 302 RC inpatient 614 614 CIGNA 62308 [3081051] CIGNA 62308 [308105105] 486.17 percent of total billed charges 380.68 583.3 Technical (Hospital) Services "Ref Paraneoplastic Anti-Neuronal Nuclear, Type 1" PX-3028625512 CDM 86255 CPT 302 RC inpatient 614 614 CIGNA 62308 [3081051] CIGNA STATE OF WYOMING [308105107] 486.17 percent of total billed charges 380.68 583.3 Technical (Hospital) Services "Ref Paraneoplastic Anti-Neuronal Nuclear, Type 1" PX-3028625512 CDM 86255 CPT 302 RC inpatient 614 614 MEDICA (COMMERCIAL) 94265 [3081118] MEDICA CLAIMS [308111801] 552.6 percent of total billed charges 380.68 583.3 Technical (Hospital) Services "Ref Paraneoplastic Anti-Neuronal Nuclear, Type 1" PX-3028625512 CDM 86255 CPT 302 RC inpatient 614 614 MULTIPLAN INC 34080 [3081285] MULTIPLAN INC [308128501] 583.3 percent of total billed charges 380.68 583.3 Technical (Hospital) Services "Ref Paraneoplastic Anti-Neuronal Nuclear, Type 1" PX-3028625512 CDM 86255 CPT 302 RC inpatient 614 614 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES HDHP [308136802] 486.17 percent of total billed charges 380.68 583.3 Technical (Hospital) Services "Ref Paraneoplastic Anti-Neuronal Nuclear, Type 1" PX-3028625512 CDM 86255 CPT 302 RC inpatient 614 614 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES PPO [308136801] 486.17 percent of total billed charges 380.68 583.3 Technical (Hospital) Services "Ref Paraneoplastic Anti-Neuronal Nuclear, Type 1" PX-3028625512 CDM 86255 CPT 302 RC inpatient 614 614 UNITED HEALTHCARE (COMMERCIAL) [3081199] UNITED HEALTHCARE 87726 [308119901] 380.68 percent of total billed charges 380.68 583.3 Technical (Hospital) Services "Ref Paraneoplastic Anti-Neuronal Nuclear, Type 1" PX-3028625512 CDM 86255 CPT 302 RC outpatient 614 614 UNITED HEALTHCARE (COMMERCIAL) [3081199] UNITED HEALTHCARE 87726 [308119901] 380.68 percent of total billed charges 380.68 583.3 Technical (Hospital) Services "Ref Paraneoplastic Anti-Neuronal Nuclear, Type 1" PX-3028625512 CDM 86255 CPT 302 RC outpatient 614 614 HEALTHPARTNERS SX009 HEALTHPARTNERS 491.2 percent of total billed charges 380.68 583.3 Technical (Hospital) Services "Ref Paraneoplastic Anti-Neuronal Nuclear, Type 1" PX-3028625512 CDM 86255 CPT 302 RC outpatient 614 614 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES PPO [308136801] 491.2 percent of total billed charges 380.68 583.3 Technical (Hospital) Services "Ref Paraneoplastic Anti-Neuronal Nuclear, Type 1" PX-3028625512 CDM 86255 CPT 302 RC outpatient 614 614 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES EPO [308136803] 491.2 percent of total billed charges 380.68 583.3 Technical (Hospital) Services "Ref Paraneoplastic Anti-Neuronal Nuclear, Type 1" PX-3028625512 CDM 86255 CPT 302 RC outpatient 614 614 CIGNA 62308 [3081051] CIGNA 62308 [308105105] 491.2 percent of total billed charges 380.68 583.3 Technical (Hospital) Services "Ref Paraneoplastic Anti-Neuronal Nuclear, Type 1" PX-3028625512 CDM 86255 CPT 302 RC outpatient 614 614 CIGNA 62308 [3081051] CIGNA STATE OF WYOMING [308105107] 491.2 percent of total billed charges 380.68 583.3 Technical (Hospital) Services "Ref Paraneoplastic Anti-Neuronal Nuclear, Type 1" PX-3028625512 CDM 86255 CPT 302 RC outpatient 614 614 BLUE CROSS BLUE SHIELD WELLMARK SB889 [3081026] BCBS WYOMING [308102603] 583.3 percent of total billed charges 380.68 583.3 Technical (Hospital) Services "Ref Paraneoplastic Anti-Neuronal Nuclear, Type 1" PX-3028625512 CDM 86255 CPT 302 RC outpatient 614 614 MULTIPLAN INC 34080 [3081285] MULTIPLAN INC [308128501] 583.3 percent of total billed charges 380.68 583.3 Technical (Hospital) Services "Ref Paraneoplastic Anti-Neuronal Nuclear, Type 1" PX-3028625512 CDM 86255 CPT 302 RC outpatient 614 614 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES HDHP [308136802] 491.2 percent of total billed charges 380.68 583.3 Technical (Hospital) Services "Ref Paraneoplastic Anti-Neuronal Nuclear, Type 1" PX-3028625512 CDM 86255 CPT 302 RC outpatient 614 614 MEDICA (COMMERCIAL) 94265 [3081118] MEDICA CLAIMS [308111801] 552.6 percent of total billed charges 380.68 583.3 Technical (Hospital) Services Ref Extractable Nuclear Ag Each Ab PX-3028623500 CDM 86235 CPT 302 RC inpatient 190 190 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES HDHP [308136802] 150.44 percent of total billed charges 117.8 180.5 Technical (Hospital) Services Ref Extractable Nuclear Ag Each Ab PX-3028623500 CDM 86235 CPT 302 RC inpatient 190 190 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES PPO [308136801] 150.44 percent of total billed charges 117.8 180.5 Technical (Hospital) Services Ref Extractable Nuclear Ag Each Ab PX-3028623500 CDM 86235 CPT 302 RC inpatient 190 190 UNITED HEALTHCARE (COMMERCIAL) [3081199] UNITED HEALTHCARE 87726 [308119901] 117.8 percent of total billed charges 117.8 180.5 Technical (Hospital) Services Ref Extractable Nuclear Ag Each Ab PX-3028623500 CDM 86235 CPT 302 RC inpatient 190 190 MEDICA (COMMERCIAL) 94265 [3081118] MEDICA CLAIMS [308111801] 171 percent of total billed charges 117.8 180.5 Technical (Hospital) Services Ref Extractable Nuclear Ag Each Ab PX-3028623500 CDM 86235 CPT 302 RC inpatient 190 190 MULTIPLAN INC 34080 [3081285] MULTIPLAN INC [308128501] 180.5 percent of total billed charges 117.8 180.5 Technical (Hospital) Services Ref Extractable Nuclear Ag Each Ab PX-3028623500 CDM 86235 CPT 302 RC inpatient 190 190 CIGNA 62308 [3081051] CIGNA 62308 [308105105] 150.44 percent of total billed charges 117.8 180.5 Technical (Hospital) Services Ref Extractable Nuclear Ag Each Ab PX-3028623500 CDM 86235 CPT 302 RC inpatient 190 190 CIGNA 62308 [3081051] CIGNA STATE OF WYOMING [308105107] 150.44 percent of total billed charges 117.8 180.5 Technical (Hospital) Services Ref Extractable Nuclear Ag Each Ab PX-3028623500 CDM 86235 CPT 302 RC inpatient 190 190 BLUE CROSS BLUE SHIELD WELLMARK SB889 [3081026] BCBS WYOMING [308102603] 180.5 percent of total billed charges 117.8 180.5 Technical (Hospital) Services Ref Extractable Nuclear Ag Each Ab PX-3028623500 CDM 86235 CPT 302 RC inpatient 190 190 HEALTHPARTNERS SX009 HEALTHPARTNERS 150.44 percent of total billed charges 117.8 180.5 Technical (Hospital) Services Ref Extractable Nuclear Ag Each Ab PX-3028623500 CDM 86235 CPT 302 RC inpatient 190 190 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES EPO [308136803] 150.44 percent of total billed charges 117.8 180.5 Technical (Hospital) Services Ref Extractable Nuclear Ag Each Ab PX-3028623500 CDM 86235 CPT 302 RC outpatient 190 190 MEDICA (COMMERCIAL) 94265 [3081118] MEDICA CLAIMS [308111801] 171 percent of total billed charges 117.8 180.5 Technical (Hospital) Services Ref Extractable Nuclear Ag Each Ab PX-3028623500 CDM 86235 CPT 302 RC outpatient 190 190 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES PPO [308136801] 152 percent of total billed charges 117.8 180.5 Technical (Hospital) Services Ref Extractable Nuclear Ag Each Ab PX-3028623500 CDM 86235 CPT 302 RC outpatient 190 190 HEALTHPARTNERS SX009 HEALTHPARTNERS 152 percent of total billed charges 117.8 180.5 Technical (Hospital) Services Ref Extractable Nuclear Ag Each Ab PX-3028623500 CDM 86235 CPT 302 RC outpatient 190 190 UNITED HEALTHCARE (COMMERCIAL) [3081199] UNITED HEALTHCARE 87726 [308119901] 117.8 percent of total billed charges 117.8 180.5 Technical (Hospital) Services Ref Extractable Nuclear Ag Each Ab PX-3028623500 CDM 86235 CPT 302 RC outpatient 190 190 MULTIPLAN INC 34080 [3081285] MULTIPLAN INC [308128501] 180.5 percent of total billed charges 117.8 180.5 Technical (Hospital) Services Ref Extractable Nuclear Ag Each Ab PX-3028623500 CDM 86235 CPT 302 RC outpatient 190 190 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES EPO [308136803] 152 percent of total billed charges 117.8 180.5 Technical (Hospital) Services Ref Extractable Nuclear Ag Each Ab PX-3028623500 CDM 86235 CPT 302 RC outpatient 190 190 CIGNA 62308 [3081051] CIGNA 62308 [308105105] 152 percent of total billed charges 117.8 180.5 Technical (Hospital) Services Ref Extractable Nuclear Ag Each Ab PX-3028623500 CDM 86235 CPT 302 RC outpatient 190 190 CIGNA 62308 [3081051] CIGNA STATE OF WYOMING [308105107] 152 percent of total billed charges 117.8 180.5 Technical (Hospital) Services Ref Extractable Nuclear Ag Each Ab PX-3028623500 CDM 86235 CPT 302 RC outpatient 190 190 BLUE CROSS BLUE SHIELD WELLMARK SB889 [3081026] BCBS WYOMING [308102603] 180.5 percent of total billed charges 117.8 180.5 Technical (Hospital) Services Ref Extractable Nuclear Ag Each Ab PX-3028623500 CDM 86235 CPT 302 RC outpatient 190 190 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES HDHP [308136802] 152 percent of total billed charges 117.8 180.5 Technical (Hospital) Services Extractable Nuclear Ag Each Ab PX-3028623502 CDM 86235 CPT 302 RC outpatient 190 190 MEDICA (COMMERCIAL) 94265 [3081118] MEDICA CLAIMS [308111801] 171 percent of total billed charges 117.8 180.5 Technical (Hospital) Services Extractable Nuclear Ag Each Ab PX-3028623502 CDM 86235 CPT 302 RC outpatient 190 190 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES PPO [308136801] 152 percent of total billed charges 117.8 180.5 Technical (Hospital) Services Extractable Nuclear Ag Each Ab PX-3028623502 CDM 86235 CPT 302 RC outpatient 190 190 HEALTHPARTNERS SX009 HEALTHPARTNERS 152 percent of total billed charges 117.8 180.5 Technical (Hospital) Services Extractable Nuclear Ag Each Ab PX-3028623502 CDM 86235 CPT 302 RC outpatient 190 190 UNITED HEALTHCARE (COMMERCIAL) [3081199] UNITED HEALTHCARE 87726 [308119901] 117.8 percent of total billed charges 117.8 180.5 Technical (Hospital) Services Extractable Nuclear Ag Each Ab PX-3028623502 CDM 86235 CPT 302 RC outpatient 190 190 CIGNA 62308 [3081051] CIGNA 62308 [308105105] 152 percent of total billed charges 117.8 180.5 Technical (Hospital) Services Extractable Nuclear Ag Each Ab PX-3028623502 CDM 86235 CPT 302 RC outpatient 190 190 CIGNA 62308 [3081051] CIGNA STATE OF WYOMING [308105107] 152 percent of total billed charges 117.8 180.5 Technical (Hospital) Services Extractable Nuclear Ag Each Ab PX-3028623502 CDM 86235 CPT 302 RC outpatient 190 190 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES EPO [308136803] 152 percent of total billed charges 117.8 180.5 Technical (Hospital) Services Extractable Nuclear Ag Each Ab PX-3028623502 CDM 86235 CPT 302 RC outpatient 190 190 MULTIPLAN INC 34080 [3081285] MULTIPLAN INC [308128501] 180.5 percent of total billed charges 117.8 180.5 Technical (Hospital) Services Extractable Nuclear Ag Each Ab PX-3028623502 CDM 86235 CPT 302 RC outpatient 190 190 BLUE CROSS BLUE SHIELD WELLMARK SB889 [3081026] BCBS WYOMING [308102603] 180.5 percent of total billed charges 117.8 180.5 Technical (Hospital) Services Extractable Nuclear Ag Each Ab PX-3028623502 CDM 86235 CPT 302 RC outpatient 190 190 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES HDHP [308136802] 152 percent of total billed charges 117.8 180.5 Technical (Hospital) Services Extractable Nuclear Ag Each Ab PX-3028623502 CDM 86235 CPT 302 RC inpatient 190 190 MEDICA (COMMERCIAL) 94265 [3081118] MEDICA CLAIMS [308111801] 171 percent of total billed charges 117.8 180.5 Technical (Hospital) Services Extractable Nuclear Ag Each Ab PX-3028623502 CDM 86235 CPT 302 RC inpatient 190 190 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES HDHP [308136802] 150.44 percent of total billed charges 117.8 180.5 Technical (Hospital) Services Extractable Nuclear Ag Each Ab PX-3028623502 CDM 86235 CPT 302 RC inpatient 190 190 UNITED HEALTHCARE (COMMERCIAL) [3081199] UNITED HEALTHCARE 87726 [308119901] 117.8 percent of total billed charges 117.8 180.5 Technical (Hospital) Services Extractable Nuclear Ag Each Ab PX-3028623502 CDM 86235 CPT 302 RC inpatient 190 190 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES PPO [308136801] 150.44 percent of total billed charges 117.8 180.5 Technical (Hospital) Services Extractable Nuclear Ag Each Ab PX-3028623502 CDM 86235 CPT 302 RC inpatient 190 190 MULTIPLAN INC 34080 [3081285] MULTIPLAN INC [308128501] 180.5 percent of total billed charges 117.8 180.5 Technical (Hospital) Services Extractable Nuclear Ag Each Ab PX-3028623502 CDM 86235 CPT 302 RC inpatient 190 190 CIGNA 62308 [3081051] CIGNA 62308 [308105105] 150.44 percent of total billed charges 117.8 180.5 Technical (Hospital) Services Extractable Nuclear Ag Each Ab PX-3028623502 CDM 86235 CPT 302 RC inpatient 190 190 CIGNA 62308 [3081051] CIGNA STATE OF WYOMING [308105107] 150.44 percent of total billed charges 117.8 180.5 Technical (Hospital) Services Extractable Nuclear Ag Each Ab PX-3028623502 CDM 86235 CPT 302 RC inpatient 190 190 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES EPO [308136803] 150.44 percent of total billed charges 117.8 180.5 Technical (Hospital) Services Extractable Nuclear Ag Each Ab PX-3028623502 CDM 86235 CPT 302 RC inpatient 190 190 BLUE CROSS BLUE SHIELD WELLMARK SB889 [3081026] BCBS WYOMING [308102603] 180.5 percent of total billed charges 117.8 180.5 Technical (Hospital) Services Extractable Nuclear Ag Each Ab PX-3028623502 CDM 86235 CPT 302 RC inpatient 190 190 HEALTHPARTNERS SX009 HEALTHPARTNERS 150.44 percent of total billed charges 117.8 180.5 Technical (Hospital) Services "Ref Dna Antibody, Native/Double Strand" PX-3028622500 CDM 86225 CPT 302 RC inpatient 214 214 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES HDHP [308136802] 169.45 percent of total billed charges 132.68 203.3 Technical (Hospital) Services "Ref Dna Antibody, Native/Double Strand" PX-3028622500 CDM 86225 CPT 302 RC inpatient 214 214 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES PPO [308136801] 169.45 percent of total billed charges 132.68 203.3 Technical (Hospital) Services "Ref Dna Antibody, Native/Double Strand" PX-3028622500 CDM 86225 CPT 302 RC inpatient 214 214 UNITED HEALTHCARE (COMMERCIAL) [3081199] UNITED HEALTHCARE 87726 [308119901] 132.68 percent of total billed charges 132.68 203.3 Technical (Hospital) Services "Ref Dna Antibody, Native/Double Strand" PX-3028622500 CDM 86225 CPT 302 RC inpatient 214 214 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES EPO [308136803] 169.45 percent of total billed charges 132.68 203.3 Technical (Hospital) Services "Ref Dna Antibody, Native/Double Strand" PX-3028622500 CDM 86225 CPT 302 RC inpatient 214 214 BLUE CROSS BLUE SHIELD WELLMARK SB889 [3081026] BCBS WYOMING [308102603] 203.3 percent of total billed charges 132.68 203.3 Technical (Hospital) Services "Ref Dna Antibody, Native/Double Strand" PX-3028622500 CDM 86225 CPT 302 RC inpatient 214 214 HEALTHPARTNERS SX009 HEALTHPARTNERS 169.45 percent of total billed charges 132.68 203.3 Technical (Hospital) Services "Ref Dna Antibody, Native/Double Strand" PX-3028622500 CDM 86225 CPT 302 RC inpatient 214 214 MEDICA (COMMERCIAL) 94265 [3081118] MEDICA CLAIMS [308111801] 192.6 percent of total billed charges 132.68 203.3 Technical (Hospital) Services "Ref Dna Antibody, Native/Double Strand" PX-3028622500 CDM 86225 CPT 302 RC inpatient 214 214 MULTIPLAN INC 34080 [3081285] MULTIPLAN INC [308128501] 203.3 percent of total billed charges 132.68 203.3 Technical (Hospital) Services "Ref Dna Antibody, Native/Double Strand" PX-3028622500 CDM 86225 CPT 302 RC inpatient 214 214 CIGNA 62308 [3081051] CIGNA 62308 [308105105] 169.45 percent of total billed charges 132.68 203.3 Technical (Hospital) Services "Ref Dna Antibody, Native/Double Strand" PX-3028622500 CDM 86225 CPT 302 RC inpatient 214 214 CIGNA 62308 [3081051] CIGNA STATE OF WYOMING [308105107] 169.45 percent of total billed charges 132.68 203.3 Technical (Hospital) Services "Ref Dna Antibody, Native/Double Strand" PX-3028622500 CDM 86225 CPT 302 RC outpatient 214 214 UNITED HEALTHCARE (COMMERCIAL) [3081199] UNITED HEALTHCARE 87726 [308119901] 132.68 percent of total billed charges 132.68 203.3 Technical (Hospital) Services "Ref Dna Antibody, Native/Double Strand" PX-3028622500 CDM 86225 CPT 302 RC outpatient 214 214 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES PPO [308136801] 171.2 percent of total billed charges 132.68 203.3 Technical (Hospital) Services "Ref Dna Antibody, Native/Double Strand" PX-3028622500 CDM 86225 CPT 302 RC outpatient 214 214 HEALTHPARTNERS SX009 HEALTHPARTNERS 171.2 percent of total billed charges 132.68 203.3 Technical (Hospital) Services "Ref Dna Antibody, Native/Double Strand" PX-3028622500 CDM 86225 CPT 302 RC outpatient 214 214 BLUE CROSS BLUE SHIELD WELLMARK SB889 [3081026] BCBS WYOMING [308102603] 203.3 percent of total billed charges 132.68 203.3 Technical (Hospital) Services "Ref Dna Antibody, Native/Double Strand" PX-3028622500 CDM 86225 CPT 302 RC outpatient 214 214 MULTIPLAN INC 34080 [3081285] MULTIPLAN INC [308128501] 203.3 percent of total billed charges 132.68 203.3 Technical (Hospital) Services "Ref Dna Antibody, Native/Double Strand" PX-3028622500 CDM 86225 CPT 302 RC outpatient 214 214 CIGNA 62308 [3081051] CIGNA 62308 [308105105] 171.2 percent of total billed charges 132.68 203.3 Technical (Hospital) Services "Ref Dna Antibody, Native/Double Strand" PX-3028622500 CDM 86225 CPT 302 RC outpatient 214 214 CIGNA 62308 [3081051] CIGNA STATE OF WYOMING [308105107] 171.2 percent of total billed charges 132.68 203.3 Technical (Hospital) Services "Ref Dna Antibody, Native/Double Strand" PX-3028622500 CDM 86225 CPT 302 RC outpatient 214 214 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES EPO [308136803] 171.2 percent of total billed charges 132.68 203.3 Technical (Hospital) Services "Ref Dna Antibody, Native/Double Strand" PX-3028622500 CDM 86225 CPT 302 RC outpatient 214 214 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES HDHP [308136802] 171.2 percent of total billed charges 132.68 203.3 Technical (Hospital) Services "Ref Dna Antibody, Native/Double Strand" PX-3028622500 CDM 86225 CPT 302 RC outpatient 214 214 MEDICA (COMMERCIAL) 94265 [3081118] MEDICA CLAIMS [308111801] 192.6 percent of total billed charges 132.68 203.3 Technical (Hospital) Services "HC Dna Antibody, Natv/2 Strand" PX-3028622502 CDM 86225 CPT 302 RC inpatient 149 149 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES EPO [308136803] 117.98 percent of total billed charges 92.38 141.55 Technical (Hospital) Services "HC Dna Antibody, Natv/2 Strand" PX-3028622502 CDM 86225 CPT 302 RC inpatient 149 149 HEALTHPARTNERS SX009 HEALTHPARTNERS 117.98 percent of total billed charges 92.38 141.55 Technical (Hospital) Services "HC Dna Antibody, Natv/2 Strand" PX-3028622502 CDM 86225 CPT 302 RC inpatient 149 149 BLUE CROSS BLUE SHIELD WELLMARK SB889 [3081026] BCBS WYOMING [308102603] 141.55 percent of total billed charges 92.38 141.55 Technical (Hospital) Services "HC Dna Antibody, Natv/2 Strand" PX-3028622502 CDM 86225 CPT 302 RC inpatient 149 149 CIGNA 62308 [3081051] CIGNA 62308 [308105105] 117.98 percent of total billed charges 92.38 141.55 Technical (Hospital) Services "HC Dna Antibody, Natv/2 Strand" PX-3028622502 CDM 86225 CPT 302 RC inpatient 149 149 CIGNA 62308 [3081051] CIGNA STATE OF WYOMING [308105107] 117.98 percent of total billed charges 92.38 141.55 Technical (Hospital) Services "HC Dna Antibody, Natv/2 Strand" PX-3028622502 CDM 86225 CPT 302 RC inpatient 149 149 MULTIPLAN INC 34080 [3081285] MULTIPLAN INC [308128501] 141.55 percent of total billed charges 92.38 141.55 Technical (Hospital) Services "HC Dna Antibody, Natv/2 Strand" PX-3028622502 CDM 86225 CPT 302 RC inpatient 149 149 MEDICA (COMMERCIAL) 94265 [3081118] MEDICA CLAIMS [308111801] 134.1 percent of total billed charges 92.38 141.55 Technical (Hospital) Services "HC Dna Antibody, Natv/2 Strand" PX-3028622502 CDM 86225 CPT 302 RC inpatient 149 149 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES PPO [308136801] 117.98 percent of total billed charges 92.38 141.55 Technical (Hospital) Services "HC Dna Antibody, Natv/2 Strand" PX-3028622502 CDM 86225 CPT 302 RC inpatient 149 149 UNITED HEALTHCARE (COMMERCIAL) [3081199] UNITED HEALTHCARE 87726 [308119901] 92.38 percent of total billed charges 92.38 141.55 Technical (Hospital) Services "HC Dna Antibody, Natv/2 Strand" PX-3028622502 CDM 86225 CPT 302 RC inpatient 149 149 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES HDHP [308136802] 117.98 percent of total billed charges 92.38 141.55 Technical (Hospital) Services "HC Dna Antibody, Natv/2 Strand" PX-3028622502 CDM 86225 CPT 302 RC outpatient 149 149 MEDICA (COMMERCIAL) 94265 [3081118] MEDICA CLAIMS [308111801] 134.1 percent of total billed charges 92.38 141.55 Technical (Hospital) Services "HC Dna Antibody, Natv/2 Strand" PX-3028622502 CDM 86225 CPT 302 RC outpatient 149 149 UNITED HEALTHCARE (COMMERCIAL) [3081199] UNITED HEALTHCARE 87726 [308119901] 92.38 percent of total billed charges 92.38 141.55 Technical (Hospital) Services "HC Dna Antibody, Natv/2 Strand" PX-3028622502 CDM 86225 CPT 302 RC outpatient 149 149 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES PPO [308136801] 119.2 percent of total billed charges 92.38 141.55 Technical (Hospital) Services "HC Dna Antibody, Natv/2 Strand" PX-3028622502 CDM 86225 CPT 302 RC outpatient 149 149 HEALTHPARTNERS SX009 HEALTHPARTNERS 119.2 percent of total billed charges 92.38 141.55 Technical (Hospital) Services "HC Dna Antibody, Natv/2 Strand" PX-3028622502 CDM 86225 CPT 302 RC outpatient 149 149 MULTIPLAN INC 34080 [3081285] MULTIPLAN INC [308128501] 141.55 percent of total billed charges 92.38 141.55 Technical (Hospital) Services "HC Dna Antibody, Natv/2 Strand" PX-3028622502 CDM 86225 CPT 302 RC outpatient 149 149 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES EPO [308136803] 119.2 percent of total billed charges 92.38 141.55 Technical (Hospital) Services "HC Dna Antibody, Natv/2 Strand" PX-3028622502 CDM 86225 CPT 302 RC outpatient 149 149 CIGNA 62308 [3081051] CIGNA 62308 [308105105] 119.2 percent of total billed charges 92.38 141.55 Technical (Hospital) Services "HC Dna Antibody, Natv/2 Strand" PX-3028622502 CDM 86225 CPT 302 RC outpatient 149 149 CIGNA 62308 [3081051] CIGNA STATE OF WYOMING [308105107] 119.2 percent of total billed charges 92.38 141.55 Technical (Hospital) Services "HC Dna Antibody, Natv/2 Strand" PX-3028622502 CDM 86225 CPT 302 RC outpatient 149 149 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES HDHP [308136802] 119.2 percent of total billed charges 92.38 141.55 Technical (Hospital) Services "HC Dna Antibody, Natv/2 Strand" PX-3028622502 CDM 86225 CPT 302 RC outpatient 149 149 BLUE CROSS BLUE SHIELD WELLMARK SB889 [3081026] BCBS WYOMING [308102603] 141.55 percent of total billed charges 92.38 141.55 Technical (Hospital) Services Ref Deoxyribonuclease Antibody PX-3028621500 CDM 86215 CPT 302 RC outpatient 216 216 BLUE CROSS BLUE SHIELD WELLMARK SB889 [3081026] BCBS WYOMING [308102603] 205.2 percent of total billed charges 133.92 205.2 Technical (Hospital) Services Ref Deoxyribonuclease Antibody PX-3028621500 CDM 86215 CPT 302 RC outpatient 216 216 MULTIPLAN INC 34080 [3081285] MULTIPLAN INC [308128501] 205.2 percent of total billed charges 133.92 205.2 Technical (Hospital) Services Ref Deoxyribonuclease Antibody PX-3028621500 CDM 86215 CPT 302 RC outpatient 216 216 CIGNA 62308 [3081051] CIGNA 62308 [308105105] 172.8 percent of total billed charges 133.92 205.2 Technical (Hospital) Services Ref Deoxyribonuclease Antibody PX-3028621500 CDM 86215 CPT 302 RC outpatient 216 216 CIGNA 62308 [3081051] CIGNA STATE OF WYOMING [308105107] 172.8 percent of total billed charges 133.92 205.2 Technical (Hospital) Services Ref Deoxyribonuclease Antibody PX-3028621500 CDM 86215 CPT 302 RC outpatient 216 216 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES EPO [308136803] 172.8 percent of total billed charges 133.92 205.2 Technical (Hospital) Services Ref Deoxyribonuclease Antibody PX-3028621500 CDM 86215 CPT 302 RC outpatient 216 216 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES HDHP [308136802] 172.8 percent of total billed charges 133.92 205.2 Technical (Hospital) Services Ref Deoxyribonuclease Antibody PX-3028621500 CDM 86215 CPT 302 RC outpatient 216 216 UNITED HEALTHCARE (COMMERCIAL) [3081199] UNITED HEALTHCARE 87726 [308119901] 133.92 percent of total billed charges 133.92 205.2 Technical (Hospital) Services Ref Deoxyribonuclease Antibody PX-3028621500 CDM 86215 CPT 302 RC outpatient 216 216 HEALTHPARTNERS SX009 HEALTHPARTNERS 172.8 percent of total billed charges 133.92 205.2 Technical (Hospital) Services Ref Deoxyribonuclease Antibody PX-3028621500 CDM 86215 CPT 302 RC outpatient 216 216 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES PPO [308136801] 172.8 percent of total billed charges 133.92 205.2 Technical (Hospital) Services Ref Deoxyribonuclease Antibody PX-3028621500 CDM 86215 CPT 302 RC outpatient 216 216 MEDICA (COMMERCIAL) 94265 [3081118] MEDICA CLAIMS [308111801] 194.4 percent of total billed charges 133.92 205.2 Technical (Hospital) Services Ref Deoxyribonuclease Antibody PX-3028621500 CDM 86215 CPT 302 RC inpatient 216 216 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES PPO [308136801] 171.03 percent of total billed charges 133.92 205.2 Technical (Hospital) Services Ref Deoxyribonuclease Antibody PX-3028621500 CDM 86215 CPT 302 RC inpatient 216 216 UNITED HEALTHCARE (COMMERCIAL) [3081199] UNITED HEALTHCARE 87726 [308119901] 133.92 percent of total billed charges 133.92 205.2 Technical (Hospital) Services Ref Deoxyribonuclease Antibody PX-3028621500 CDM 86215 CPT 302 RC inpatient 216 216 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES HDHP [308136802] 171.03 percent of total billed charges 133.92 205.2 Technical (Hospital) Services Ref Deoxyribonuclease Antibody PX-3028621500 CDM 86215 CPT 302 RC inpatient 216 216 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES EPO [308136803] 171.03 percent of total billed charges 133.92 205.2 Technical (Hospital) Services Ref Deoxyribonuclease Antibody PX-3028621500 CDM 86215 CPT 302 RC inpatient 216 216 HEALTHPARTNERS SX009 HEALTHPARTNERS 171.03 percent of total billed charges 133.92 205.2 Technical (Hospital) Services Ref Deoxyribonuclease Antibody PX-3028621500 CDM 86215 CPT 302 RC inpatient 216 216 BLUE CROSS BLUE SHIELD WELLMARK SB889 [3081026] BCBS WYOMING [308102603] 205.2 percent of total billed charges 133.92 205.2 Technical (Hospital) Services Ref Deoxyribonuclease Antibody PX-3028621500 CDM 86215 CPT 302 RC inpatient 216 216 CIGNA 62308 [3081051] CIGNA 62308 [308105105] 171.03 percent of total billed charges 133.92 205.2 Technical (Hospital) Services Ref Deoxyribonuclease Antibody PX-3028621500 CDM 86215 CPT 302 RC inpatient 216 216 CIGNA 62308 [3081051] CIGNA STATE OF WYOMING [308105107] 171.03 percent of total billed charges 133.92 205.2 Technical (Hospital) Services Ref Deoxyribonuclease Antibody PX-3028621500 CDM 86215 CPT 302 RC inpatient 216 216 MULTIPLAN INC 34080 [3081285] MULTIPLAN INC [308128501] 205.2 percent of total billed charges 133.92 205.2 Technical (Hospital) Services Ref Deoxyribonuclease Antibody PX-3028621500 CDM 86215 CPT 302 RC inpatient 216 216 MEDICA (COMMERCIAL) 94265 [3081118] MEDICA CLAIMS [308111801] 194.4 percent of total billed charges 133.92 205.2 Technical (Hospital) Services Ref Dnase Anti Dnase B PX-3028621501 CDM 86215 CPT 302 RC inpatient 216 216 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES EPO [308136803] 171.03 percent of total billed charges 133.92 205.2 Technical (Hospital) Services Ref Dnase Anti Dnase B PX-3028621501 CDM 86215 CPT 302 RC inpatient 216 216 BLUE CROSS BLUE SHIELD WELLMARK SB889 [3081026] BCBS WYOMING [308102603] 205.2 percent of total billed charges 133.92 205.2 Technical (Hospital) Services Ref Dnase Anti Dnase B PX-3028621501 CDM 86215 CPT 302 RC inpatient 216 216 HEALTHPARTNERS SX009 HEALTHPARTNERS 171.03 percent of total billed charges 133.92 205.2 Technical (Hospital) Services Ref Dnase Anti Dnase B PX-3028621501 CDM 86215 CPT 302 RC inpatient 216 216 CIGNA 62308 [3081051] CIGNA 62308 [308105105] 171.03 percent of total billed charges 133.92 205.2 Technical (Hospital) Services Ref Dnase Anti Dnase B PX-3028621501 CDM 86215 CPT 302 RC inpatient 216 216 CIGNA 62308 [3081051] CIGNA STATE OF WYOMING [308105107] 171.03 percent of total billed charges 133.92 205.2 Technical (Hospital) Services Ref Dnase Anti Dnase B PX-3028621501 CDM 86215 CPT 302 RC inpatient 216 216 MULTIPLAN INC 34080 [3081285] MULTIPLAN INC [308128501] 205.2 percent of total billed charges 133.92 205.2 Technical (Hospital) Services Ref Dnase Anti Dnase B PX-3028621501 CDM 86215 CPT 302 RC inpatient 216 216 MEDICA (COMMERCIAL) 94265 [3081118] MEDICA CLAIMS [308111801] 194.4 percent of total billed charges 133.92 205.2 Technical (Hospital) Services Ref Dnase Anti Dnase B PX-3028621501 CDM 86215 CPT 302 RC inpatient 216 216 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES PPO [308136801] 171.03 percent of total billed charges 133.92 205.2 Technical (Hospital) Services Ref Dnase Anti Dnase B PX-3028621501 CDM 86215 CPT 302 RC inpatient 216 216 UNITED HEALTHCARE (COMMERCIAL) [3081199] UNITED HEALTHCARE 87726 [308119901] 133.92 percent of total billed charges 133.92 205.2 Technical (Hospital) Services Ref Dnase Anti Dnase B PX-3028621501 CDM 86215 CPT 302 RC inpatient 216 216 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES HDHP [308136802] 171.03 percent of total billed charges 133.92 205.2 Technical (Hospital) Services Ref Dnase Anti Dnase B PX-3028621501 CDM 86215 CPT 302 RC outpatient 216 216 MULTIPLAN INC 34080 [3081285] MULTIPLAN INC [308128501] 205.2 percent of total billed charges 133.92 205.2 Technical (Hospital) Services Ref Dnase Anti Dnase B PX-3028621501 CDM 86215 CPT 302 RC outpatient 216 216 BLUE CROSS BLUE SHIELD WELLMARK SB889 [3081026] BCBS WYOMING [308102603] 205.2 percent of total billed charges 133.92 205.2 Technical (Hospital) Services Ref Dnase Anti Dnase B PX-3028621501 CDM 86215 CPT 302 RC outpatient 216 216 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES EPO [308136803] 172.8 percent of total billed charges 133.92 205.2 Technical (Hospital) Services Ref Dnase Anti Dnase B PX-3028621501 CDM 86215 CPT 302 RC outpatient 216 216 CIGNA 62308 [3081051] CIGNA 62308 [308105105] 172.8 percent of total billed charges 133.92 205.2 Technical (Hospital) Services Ref Dnase Anti Dnase B PX-3028621501 CDM 86215 CPT 302 RC outpatient 216 216 CIGNA 62308 [3081051] CIGNA STATE OF WYOMING [308105107] 172.8 percent of total billed charges 133.92 205.2 Technical (Hospital) Services Ref Dnase Anti Dnase B PX-3028621501 CDM 86215 CPT 302 RC outpatient 216 216 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES HDHP [308136802] 172.8 percent of total billed charges 133.92 205.2 Technical (Hospital) Services Ref Dnase Anti Dnase B PX-3028621501 CDM 86215 CPT 302 RC outpatient 216 216 UNITED HEALTHCARE (COMMERCIAL) [3081199] UNITED HEALTHCARE 87726 [308119901] 133.92 percent of total billed charges 133.92 205.2 Technical (Hospital) Services Ref Dnase Anti Dnase B PX-3028621501 CDM 86215 CPT 302 RC outpatient 216 216 HEALTHPARTNERS SX009 HEALTHPARTNERS 172.8 percent of total billed charges 133.92 205.2 Technical (Hospital) Services Ref Dnase Anti Dnase B PX-3028621501 CDM 86215 CPT 302 RC outpatient 216 216 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES PPO [308136801] 172.8 percent of total billed charges 133.92 205.2 Technical (Hospital) Services Ref Dnase Anti Dnase B PX-3028621501 CDM 86215 CPT 302 RC outpatient 216 216 MEDICA (COMMERCIAL) 94265 [3081118] MEDICA CLAIMS [308111801] 194.4 percent of total billed charges 133.92 205.2 Technical (Hospital) Services Ref Cyclic Citrullinated Peptide (CCP) PX-3028620000 CDM 86200 CPT 302 RC outpatient 119 119 MEDICA (COMMERCIAL) 94265 [3081118] MEDICA CLAIMS [308111801] 107.1 percent of total billed charges 73.78 113.05 Technical (Hospital) Services Ref Cyclic Citrullinated Peptide (CCP) PX-3028620000 CDM 86200 CPT 302 RC outpatient 119 119 MULTIPLAN INC 34080 [3081285] MULTIPLAN INC [308128501] 113.05 percent of total billed charges 73.78 113.05 Technical (Hospital) Services Ref Cyclic Citrullinated Peptide (CCP) PX-3028620000 CDM 86200 CPT 302 RC outpatient 119 119 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES EPO [308136803] 95.2 percent of total billed charges 73.78 113.05 Technical (Hospital) Services Ref Cyclic Citrullinated Peptide (CCP) PX-3028620000 CDM 86200 CPT 302 RC outpatient 119 119 CIGNA 62308 [3081051] CIGNA 62308 [308105105] 95.2 percent of total billed charges 73.78 113.05 Technical (Hospital) Services Ref Cyclic Citrullinated Peptide (CCP) PX-3028620000 CDM 86200 CPT 302 RC outpatient 119 119 CIGNA 62308 [3081051] CIGNA STATE OF WYOMING [308105107] 95.2 percent of total billed charges 73.78 113.05 Technical (Hospital) Services Ref Cyclic Citrullinated Peptide (CCP) PX-3028620000 CDM 86200 CPT 302 RC outpatient 119 119 BLUE CROSS BLUE SHIELD WELLMARK SB889 [3081026] BCBS WYOMING [308102603] 113.05 percent of total billed charges 73.78 113.05 Technical (Hospital) Services Ref Cyclic Citrullinated Peptide (CCP) PX-3028620000 CDM 86200 CPT 302 RC outpatient 119 119 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES HDHP [308136802] 95.2 percent of total billed charges 73.78 113.05 Technical (Hospital) Services Ref Cyclic Citrullinated Peptide (CCP) PX-3028620000 CDM 86200 CPT 302 RC outpatient 119 119 UNITED HEALTHCARE (COMMERCIAL) [3081199] UNITED HEALTHCARE 87726 [308119901] 73.78 percent of total billed charges 73.78 113.05 Technical (Hospital) Services Ref Cyclic Citrullinated Peptide (CCP) PX-3028620000 CDM 86200 CPT 302 RC outpatient 119 119 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES PPO [308136801] 95.2 percent of total billed charges 73.78 113.05 Technical (Hospital) Services Ref Cyclic Citrullinated Peptide (CCP) PX-3028620000 CDM 86200 CPT 302 RC outpatient 119 119 HEALTHPARTNERS SX009 HEALTHPARTNERS 95.2 percent of total billed charges 73.78 113.05 Technical (Hospital) Services Ref Cyclic Citrullinated Peptide (CCP) PX-3028620000 CDM 86200 CPT 302 RC inpatient 119 119 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES HDHP [308136802] 94.22 percent of total billed charges 73.78 113.05 Technical (Hospital) Services Ref Cyclic Citrullinated Peptide (CCP) PX-3028620000 CDM 86200 CPT 302 RC inpatient 119 119 UNITED HEALTHCARE (COMMERCIAL) [3081199] UNITED HEALTHCARE 87726 [308119901] 73.78 percent of total billed charges 73.78 113.05 Technical (Hospital) Services Ref Cyclic Citrullinated Peptide (CCP) PX-3028620000 CDM 86200 CPT 302 RC inpatient 119 119 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES PPO [308136801] 94.22 percent of total billed charges 73.78 113.05 Technical (Hospital) Services Ref Cyclic Citrullinated Peptide (CCP) PX-3028620000 CDM 86200 CPT 302 RC inpatient 119 119 MEDICA (COMMERCIAL) 94265 [3081118] MEDICA CLAIMS [308111801] 107.1 percent of total billed charges 73.78 113.05 Technical (Hospital) Services Ref Cyclic Citrullinated Peptide (CCP) PX-3028620000 CDM 86200 CPT 302 RC inpatient 119 119 MULTIPLAN INC 34080 [3081285] MULTIPLAN INC [308128501] 113.05 percent of total billed charges 73.78 113.05 Technical (Hospital) Services Ref Cyclic Citrullinated Peptide (CCP) PX-3028620000 CDM 86200 CPT 302 RC inpatient 119 119 CIGNA 62308 [3081051] CIGNA 62308 [308105105] 94.22 percent of total billed charges 73.78 113.05 Technical (Hospital) Services Ref Cyclic Citrullinated Peptide (CCP) PX-3028620000 CDM 86200 CPT 302 RC inpatient 119 119 CIGNA 62308 [3081051] CIGNA STATE OF WYOMING [308105107] 94.22 percent of total billed charges 73.78 113.05 Technical (Hospital) Services Ref Cyclic Citrullinated Peptide (CCP) PX-3028620000 CDM 86200 CPT 302 RC inpatient 119 119 BLUE CROSS BLUE SHIELD WELLMARK SB889 [3081026] BCBS WYOMING [308102603] 113.05 percent of total billed charges 73.78 113.05 Technical (Hospital) Services Ref Cyclic Citrullinated Peptide (CCP) PX-3028620000 CDM 86200 CPT 302 RC inpatient 119 119 HEALTHPARTNERS SX009 HEALTHPARTNERS 94.22 percent of total billed charges 73.78 113.05 Technical (Hospital) Services Ref Cyclic Citrullinated Peptide (CCP) PX-3028620000 CDM 86200 CPT 302 RC inpatient 119 119 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES EPO [308136803] 94.22 percent of total billed charges 73.78 113.05 Technical (Hospital) Services CCP Antibody PX-3028620002 CDM 86200 CPT 302 RC inpatient 119 119 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES HDHP [308136802] 94.22 percent of total billed charges 73.78 113.05 Technical (Hospital) Services CCP Antibody PX-3028620002 CDM 86200 CPT 302 RC inpatient 119 119 UNITED HEALTHCARE (COMMERCIAL) [3081199] UNITED HEALTHCARE 87726 [308119901] 73.78 percent of total billed charges 73.78 113.05 Technical (Hospital) Services CCP Antibody PX-3028620002 CDM 86200 CPT 302 RC inpatient 119 119 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES PPO [308136801] 94.22 percent of total billed charges 73.78 113.05 Technical (Hospital) Services CCP Antibody PX-3028620002 CDM 86200 CPT 302 RC inpatient 119 119 BLUE CROSS BLUE SHIELD WELLMARK SB889 [3081026] BCBS WYOMING [308102603] 113.05 percent of total billed charges 73.78 113.05 Technical (Hospital) Services CCP Antibody PX-3028620002 CDM 86200 CPT 302 RC inpatient 119 119 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES EPO [308136803] 94.22 percent of total billed charges 73.78 113.05 Technical (Hospital) Services CCP Antibody PX-3028620002 CDM 86200 CPT 302 RC inpatient 119 119 HEALTHPARTNERS SX009 HEALTHPARTNERS 94.22 percent of total billed charges 73.78 113.05 Technical (Hospital) Services CCP Antibody PX-3028620002 CDM 86200 CPT 302 RC inpatient 119 119 MEDICA (COMMERCIAL) 94265 [3081118] MEDICA CLAIMS [308111801] 107.1 percent of total billed charges 73.78 113.05 Technical (Hospital) Services CCP Antibody PX-3028620002 CDM 86200 CPT 302 RC inpatient 119 119 MULTIPLAN INC 34080 [3081285] MULTIPLAN INC [308128501] 113.05 percent of total billed charges 73.78 113.05 Technical (Hospital) Services CCP Antibody PX-3028620002 CDM 86200 CPT 302 RC inpatient 119 119 CIGNA 62308 [3081051] CIGNA 62308 [308105105] 94.22 percent of total billed charges 73.78 113.05 Technical (Hospital) Services CCP Antibody PX-3028620002 CDM 86200 CPT 302 RC inpatient 119 119 CIGNA 62308 [3081051] CIGNA STATE OF WYOMING [308105107] 94.22 percent of total billed charges 73.78 113.05 Technical (Hospital) Services CCP Antibody PX-3028620002 CDM 86200 CPT 302 RC outpatient 119 119 BLUE CROSS BLUE SHIELD WELLMARK SB889 [3081026] BCBS WYOMING [308102603] 113.05 percent of total billed charges 73.78 113.05 Technical (Hospital) Services CCP Antibody PX-3028620002 CDM 86200 CPT 302 RC outpatient 119 119 MULTIPLAN INC 34080 [3081285] MULTIPLAN INC [308128501] 113.05 percent of total billed charges 73.78 113.05 Technical (Hospital) Services CCP Antibody PX-3028620002 CDM 86200 CPT 302 RC outpatient 119 119 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES EPO [308136803] 95.2 percent of total billed charges 73.78 113.05 Technical (Hospital) Services CCP Antibody PX-3028620002 CDM 86200 CPT 302 RC outpatient 119 119 CIGNA 62308 [3081051] CIGNA 62308 [308105105] 95.2 percent of total billed charges 73.78 113.05 Technical (Hospital) Services CCP Antibody PX-3028620002 CDM 86200 CPT 302 RC outpatient 119 119 CIGNA 62308 [3081051] CIGNA STATE OF WYOMING [308105107] 95.2 percent of total billed charges 73.78 113.05 Technical (Hospital) Services CCP Antibody PX-3028620002 CDM 86200 CPT 302 RC outpatient 119 119 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES HDHP [308136802] 95.2 percent of total billed charges 73.78 113.05 Technical (Hospital) Services CCP Antibody PX-3028620002 CDM 86200 CPT 302 RC outpatient 119 119 UNITED HEALTHCARE (COMMERCIAL) [3081199] UNITED HEALTHCARE 87726 [308119901] 73.78 percent of total billed charges 73.78 113.05 Technical (Hospital) Services CCP Antibody PX-3028620002 CDM 86200 CPT 302 RC outpatient 119 119 HEALTHPARTNERS SX009 HEALTHPARTNERS 95.2 percent of total billed charges 73.78 113.05 Technical (Hospital) Services CCP Antibody PX-3028620002 CDM 86200 CPT 302 RC outpatient 119 119 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES PPO [308136801] 95.2 percent of total billed charges 73.78 113.05 Technical (Hospital) Services CCP Antibody PX-3028620002 CDM 86200 CPT 302 RC outpatient 119 119 MEDICA (COMMERCIAL) 94265 [3081118] MEDICA CLAIMS [308111801] 107.1 percent of total billed charges 73.78 113.05 Technical (Hospital) Services Ref Ch 50 Complement PX-3028616200 CDM 86162 CPT 302 RC outpatient 119 119 MEDICA (COMMERCIAL) 94265 [3081118] MEDICA CLAIMS [308111801] 107.1 percent of total billed charges 73.78 113.05 Technical (Hospital) Services Ref Ch 50 Complement PX-3028616200 CDM 86162 CPT 302 RC outpatient 119 119 MULTIPLAN INC 34080 [3081285] MULTIPLAN INC [308128501] 113.05 percent of total billed charges 73.78 113.05 Technical (Hospital) Services Ref Ch 50 Complement PX-3028616200 CDM 86162 CPT 302 RC outpatient 119 119 BLUE CROSS BLUE SHIELD WELLMARK SB889 [3081026] BCBS WYOMING [308102603] 113.05 percent of total billed charges 73.78 113.05 Technical (Hospital) Services Ref Ch 50 Complement PX-3028616200 CDM 86162 CPT 302 RC outpatient 119 119 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES EPO [308136803] 95.2 percent of total billed charges 73.78 113.05 Technical (Hospital) Services Ref Ch 50 Complement PX-3028616200 CDM 86162 CPT 302 RC outpatient 119 119 CIGNA 62308 [3081051] CIGNA 62308 [308105105] 95.2 percent of total billed charges 73.78 113.05 Technical (Hospital) Services Ref Ch 50 Complement PX-3028616200 CDM 86162 CPT 302 RC outpatient 119 119 CIGNA 62308 [3081051] CIGNA STATE OF WYOMING [308105107] 95.2 percent of total billed charges 73.78 113.05 Technical (Hospital) Services Ref Ch 50 Complement PX-3028616200 CDM 86162 CPT 302 RC outpatient 119 119 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES HDHP [308136802] 95.2 percent of total billed charges 73.78 113.05 Technical (Hospital) Services Ref Ch 50 Complement PX-3028616200 CDM 86162 CPT 302 RC outpatient 119 119 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES PPO [308136801] 95.2 percent of total billed charges 73.78 113.05 Technical (Hospital) Services Ref Ch 50 Complement PX-3028616200 CDM 86162 CPT 302 RC outpatient 119 119 HEALTHPARTNERS SX009 HEALTHPARTNERS 95.2 percent of total billed charges 73.78 113.05 Technical (Hospital) Services Ref Ch 50 Complement PX-3028616200 CDM 86162 CPT 302 RC outpatient 119 119 UNITED HEALTHCARE (COMMERCIAL) [3081199] UNITED HEALTHCARE 87726 [308119901] 73.78 percent of total billed charges 73.78 113.05 Technical (Hospital) Services Ref Ch 50 Complement PX-3028616200 CDM 86162 CPT 302 RC inpatient 119 119 CIGNA 62308 [3081051] CIGNA 62308 [308105105] 94.22 percent of total billed charges 73.78 113.05 Technical (Hospital) Services Ref Ch 50 Complement PX-3028616200 CDM 86162 CPT 302 RC inpatient 119 119 CIGNA 62308 [3081051] CIGNA STATE OF WYOMING [308105107] 94.22 percent of total billed charges 73.78 113.05 Technical (Hospital) Services Ref Ch 50 Complement PX-3028616200 CDM 86162 CPT 302 RC inpatient 119 119 MEDICA (COMMERCIAL) 94265 [3081118] MEDICA CLAIMS [308111801] 107.1 percent of total billed charges 73.78 113.05 Technical (Hospital) Services Ref Ch 50 Complement PX-3028616200 CDM 86162 CPT 302 RC inpatient 119 119 MULTIPLAN INC 34080 [3081285] MULTIPLAN INC [308128501] 113.05 percent of total billed charges 73.78 113.05 Technical (Hospital) Services Ref Ch 50 Complement PX-3028616200 CDM 86162 CPT 302 RC inpatient 119 119 BLUE CROSS BLUE SHIELD WELLMARK SB889 [3081026] BCBS WYOMING [308102603] 113.05 percent of total billed charges 73.78 113.05 Technical (Hospital) Services Ref Ch 50 Complement PX-3028616200 CDM 86162 CPT 302 RC inpatient 119 119 HEALTHPARTNERS SX009 HEALTHPARTNERS 94.22 percent of total billed charges 73.78 113.05 Technical (Hospital) Services Ref Ch 50 Complement PX-3028616200 CDM 86162 CPT 302 RC inpatient 119 119 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES EPO [308136803] 94.22 percent of total billed charges 73.78 113.05 Technical (Hospital) Services Ref Ch 50 Complement PX-3028616200 CDM 86162 CPT 302 RC inpatient 119 119 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES HDHP [308136802] 94.22 percent of total billed charges 73.78 113.05 Technical (Hospital) Services Ref Ch 50 Complement PX-3028616200 CDM 86162 CPT 302 RC inpatient 119 119 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES PPO [308136801] 94.22 percent of total billed charges 73.78 113.05 Technical (Hospital) Services Ref Ch 50 Complement PX-3028616200 CDM 86162 CPT 302 RC inpatient 119 119 UNITED HEALTHCARE (COMMERCIAL) [3081199] UNITED HEALTHCARE 87726 [308119901] 73.78 percent of total billed charges 73.78 113.05 Technical (Hospital) Services Ref C1q Complement Functional PX-3028616101 CDM 86161 CPT 302 RC outpatient 200 200 UNITED HEALTHCARE (COMMERCIAL) [3081199] UNITED HEALTHCARE 87726 [308119901] 124 percent of total billed charges 124 190 Technical (Hospital) Services Ref C1q Complement Functional PX-3028616101 CDM 86161 CPT 302 RC outpatient 200 200 HEALTHPARTNERS SX009 HEALTHPARTNERS 160 percent of total billed charges 124 190 Technical (Hospital) Services Ref C1q Complement Functional PX-3028616101 CDM 86161 CPT 302 RC outpatient 200 200 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES PPO [308136801] 160 percent of total billed charges 124 190 Technical (Hospital) Services Ref C1q Complement Functional PX-3028616101 CDM 86161 CPT 302 RC outpatient 200 200 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES HDHP [308136802] 160 percent of total billed charges 124 190 Technical (Hospital) Services Ref C1q Complement Functional PX-3028616101 CDM 86161 CPT 302 RC outpatient 200 200 BLUE CROSS BLUE SHIELD WELLMARK SB889 [3081026] BCBS WYOMING [308102603] 190 percent of total billed charges 124 190 Technical (Hospital) Services Ref C1q Complement Functional PX-3028616101 CDM 86161 CPT 302 RC outpatient 200 200 MULTIPLAN INC 34080 [3081285] MULTIPLAN INC [308128501] 190 percent of total billed charges 124 190 Technical (Hospital) Services Ref C1q Complement Functional PX-3028616101 CDM 86161 CPT 302 RC outpatient 200 200 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES EPO [308136803] 160 percent of total billed charges 124 190 Technical (Hospital) Services Ref C1q Complement Functional PX-3028616101 CDM 86161 CPT 302 RC outpatient 200 200 CIGNA 62308 [3081051] CIGNA 62308 [308105105] 160 percent of total billed charges 124 190 Technical (Hospital) Services Ref C1q Complement Functional PX-3028616101 CDM 86161 CPT 302 RC outpatient 200 200 CIGNA 62308 [3081051] CIGNA STATE OF WYOMING [308105107] 160 percent of total billed charges 124 190 Technical (Hospital) Services Ref C1q Complement Functional PX-3028616101 CDM 86161 CPT 302 RC outpatient 200 200 MEDICA (COMMERCIAL) 94265 [3081118] MEDICA CLAIMS [308111801] 180 percent of total billed charges 124 190 Technical (Hospital) Services Ref C1q Complement Functional PX-3028616101 CDM 86161 CPT 302 RC inpatient 200 200 MULTIPLAN INC 34080 [3081285] MULTIPLAN INC [308128501] 190 percent of total billed charges 124 190 Technical (Hospital) Services Ref C1q Complement Functional PX-3028616101 CDM 86161 CPT 302 RC inpatient 200 200 MEDICA (COMMERCIAL) 94265 [3081118] MEDICA CLAIMS [308111801] 180 percent of total billed charges 124 190 Technical (Hospital) Services Ref C1q Complement Functional PX-3028616101 CDM 86161 CPT 302 RC inpatient 200 200 CIGNA 62308 [3081051] CIGNA 62308 [308105105] 158.36 percent of total billed charges 124 190 Technical (Hospital) Services Ref C1q Complement Functional PX-3028616101 CDM 86161 CPT 302 RC inpatient 200 200 CIGNA 62308 [3081051] CIGNA STATE OF WYOMING [308105107] 158.36 percent of total billed charges 124 190 Technical (Hospital) Services Ref C1q Complement Functional PX-3028616101 CDM 86161 CPT 302 RC inpatient 200 200 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES EPO [308136803] 158.36 percent of total billed charges 124 190 Technical (Hospital) Services Ref C1q Complement Functional PX-3028616101 CDM 86161 CPT 302 RC inpatient 200 200 BLUE CROSS BLUE SHIELD WELLMARK SB889 [3081026] BCBS WYOMING [308102603] 190 percent of total billed charges 124 190 Technical (Hospital) Services Ref C1q Complement Functional PX-3028616101 CDM 86161 CPT 302 RC inpatient 200 200 HEALTHPARTNERS SX009 HEALTHPARTNERS 158.36 percent of total billed charges 124 190 Technical (Hospital) Services Ref C1q Complement Functional PX-3028616101 CDM 86161 CPT 302 RC inpatient 200 200 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES HDHP [308136802] 158.36 percent of total billed charges 124 190 Technical (Hospital) Services Ref C1q Complement Functional PX-3028616101 CDM 86161 CPT 302 RC inpatient 200 200 UNITED HEALTHCARE (COMMERCIAL) [3081199] UNITED HEALTHCARE 87726 [308119901] 124 percent of total billed charges 124 190 Technical (Hospital) Services Ref C1q Complement Functional PX-3028616101 CDM 86161 CPT 302 RC inpatient 200 200 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES PPO [308136801] 158.36 percent of total billed charges 124 190 Technical (Hospital) Services Complement 3 Antigen PX-3028616000 CDM 86160 CPT 302 RC outpatient 204 204 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES EPO [308136803] 163.2 percent of total billed charges 126.48 193.8 Technical (Hospital) Services Complement 3 Antigen PX-3028616000 CDM 86160 CPT 302 RC outpatient 204 204 CIGNA 62308 [3081051] CIGNA STATE OF WYOMING [308105107] 163.2 percent of total billed charges 126.48 193.8 Technical (Hospital) Services Complement 3 Antigen PX-3028616000 CDM 86160 CPT 302 RC outpatient 204 204 CIGNA 62308 [3081051] CIGNA 62308 [308105105] 163.2 percent of total billed charges 126.48 193.8 Technical (Hospital) Services Complement 3 Antigen PX-3028616000 CDM 86160 CPT 302 RC outpatient 204 204 MULTIPLAN INC 34080 [3081285] MULTIPLAN INC [308128501] 193.8 percent of total billed charges 126.48 193.8 Technical (Hospital) Services Complement 3 Antigen PX-3028616000 CDM 86160 CPT 302 RC outpatient 204 204 BLUE CROSS BLUE SHIELD WELLMARK SB889 [3081026] BCBS WYOMING [308102603] 193.8 percent of total billed charges 126.48 193.8 Technical (Hospital) Services Complement 3 Antigen PX-3028616000 CDM 86160 CPT 302 RC outpatient 204 204 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES HDHP [308136802] 163.2 percent of total billed charges 126.48 193.8 Technical (Hospital) Services Complement 3 Antigen PX-3028616000 CDM 86160 CPT 302 RC outpatient 204 204 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES PPO [308136801] 163.2 percent of total billed charges 126.48 193.8 Technical (Hospital) Services Complement 3 Antigen PX-3028616000 CDM 86160 CPT 302 RC outpatient 204 204 UNITED HEALTHCARE (COMMERCIAL) [3081199] UNITED HEALTHCARE 87726 [308119901] 126.48 percent of total billed charges 126.48 193.8 Technical (Hospital) Services Complement 3 Antigen PX-3028616000 CDM 86160 CPT 302 RC outpatient 204 204 HEALTHPARTNERS SX009 HEALTHPARTNERS 163.2 percent of total billed charges 126.48 193.8 Technical (Hospital) Services Complement 3 Antigen PX-3028616000 CDM 86160 CPT 302 RC outpatient 204 204 MEDICA (COMMERCIAL) 94265 [3081118] MEDICA CLAIMS [308111801] 183.6 percent of total billed charges 126.48 193.8 Technical (Hospital) Services Complement 3 Antigen PX-3028616000 CDM 86160 CPT 302 RC inpatient 204 204 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES HDHP [308136802] 161.53 percent of total billed charges 126.48 193.8 Technical (Hospital) Services Complement 3 Antigen PX-3028616000 CDM 86160 CPT 302 RC inpatient 204 204 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES PPO [308136801] 161.53 percent of total billed charges 126.48 193.8 Technical (Hospital) Services Complement 3 Antigen PX-3028616000 CDM 86160 CPT 302 RC inpatient 204 204 UNITED HEALTHCARE (COMMERCIAL) [3081199] UNITED HEALTHCARE 87726 [308119901] 126.48 percent of total billed charges 126.48 193.8 Technical (Hospital) Services Complement 3 Antigen PX-3028616000 CDM 86160 CPT 302 RC inpatient 204 204 HEALTHPARTNERS SX009 HEALTHPARTNERS 161.53 percent of total billed charges 126.48 193.8 Technical (Hospital) Services Complement 3 Antigen PX-3028616000 CDM 86160 CPT 302 RC inpatient 204 204 BLUE CROSS BLUE SHIELD WELLMARK SB889 [3081026] BCBS WYOMING [308102603] 193.8 percent of total billed charges 126.48 193.8 Technical (Hospital) Services Complement 3 Antigen PX-3028616000 CDM 86160 CPT 302 RC inpatient 204 204 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES EPO [308136803] 161.53 percent of total billed charges 126.48 193.8 Technical (Hospital) Services Complement 3 Antigen PX-3028616000 CDM 86160 CPT 302 RC inpatient 204 204 MEDICA (COMMERCIAL) 94265 [3081118] MEDICA CLAIMS [308111801] 183.6 percent of total billed charges 126.48 193.8 Technical (Hospital) Services Complement 3 Antigen PX-3028616000 CDM 86160 CPT 302 RC inpatient 204 204 MULTIPLAN INC 34080 [3081285] MULTIPLAN INC [308128501] 193.8 percent of total billed charges 126.48 193.8 Technical (Hospital) Services Complement 3 Antigen PX-3028616000 CDM 86160 CPT 302 RC inpatient 204 204 CIGNA 62308 [3081051] CIGNA 62308 [308105105] 161.53 percent of total billed charges 126.48 193.8 Technical (Hospital) Services Complement 3 Antigen PX-3028616000 CDM 86160 CPT 302 RC inpatient 204 204 CIGNA 62308 [3081051] CIGNA STATE OF WYOMING [308105107] 161.53 percent of total billed charges 126.48 193.8 Technical (Hospital) Services Complement 4 Antigen PX-3028616004 CDM 86160 CPT 302 RC inpatient 200 200 MULTIPLAN INC 34080 [3081285] MULTIPLAN INC [308128501] 190 percent of total billed charges 124 190 Technical (Hospital) Services Complement 4 Antigen PX-3028616004 CDM 86160 CPT 302 RC inpatient 200 200 MEDICA (COMMERCIAL) 94265 [3081118] MEDICA CLAIMS [308111801] 180 percent of total billed charges 124 190 Technical (Hospital) Services Complement 4 Antigen PX-3028616004 CDM 86160 CPT 302 RC inpatient 200 200 CIGNA 62308 [3081051] CIGNA 62308 [308105105] 158.36 percent of total billed charges 124 190 Technical (Hospital) Services Complement 4 Antigen PX-3028616004 CDM 86160 CPT 302 RC inpatient 200 200 CIGNA 62308 [3081051] CIGNA STATE OF WYOMING [308105107] 158.36 percent of total billed charges 124 190 Technical (Hospital) Services Complement 4 Antigen PX-3028616004 CDM 86160 CPT 302 RC inpatient 200 200 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES EPO [308136803] 158.36 percent of total billed charges 124 190 Technical (Hospital) Services Complement 4 Antigen PX-3028616004 CDM 86160 CPT 302 RC inpatient 200 200 BLUE CROSS BLUE SHIELD WELLMARK SB889 [3081026] BCBS WYOMING [308102603] 190 percent of total billed charges 124 190 Technical (Hospital) Services Complement 4 Antigen PX-3028616004 CDM 86160 CPT 302 RC inpatient 200 200 HEALTHPARTNERS SX009 HEALTHPARTNERS 158.36 percent of total billed charges 124 190 Technical (Hospital) Services Complement 4 Antigen PX-3028616004 CDM 86160 CPT 302 RC inpatient 200 200 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES PPO [308136801] 158.36 percent of total billed charges 124 190 Technical (Hospital) Services Complement 4 Antigen PX-3028616004 CDM 86160 CPT 302 RC inpatient 200 200 UNITED HEALTHCARE (COMMERCIAL) [3081199] UNITED HEALTHCARE 87726 [308119901] 124 percent of total billed charges 124 190 Technical (Hospital) Services Complement 4 Antigen PX-3028616004 CDM 86160 CPT 302 RC inpatient 200 200 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES HDHP [308136802] 158.36 percent of total billed charges 124 190 Technical (Hospital) Services Complement 4 Antigen PX-3028616004 CDM 86160 CPT 302 RC outpatient 200 200 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES HDHP [308136802] 160 percent of total billed charges 124 190 Technical (Hospital) Services Complement 4 Antigen PX-3028616004 CDM 86160 CPT 302 RC outpatient 200 200 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES EPO [308136803] 160 percent of total billed charges 124 190 Technical (Hospital) Services Complement 4 Antigen PX-3028616004 CDM 86160 CPT 302 RC outpatient 200 200 CIGNA 62308 [3081051] CIGNA 62308 [308105105] 160 percent of total billed charges 124 190 Technical (Hospital) Services Complement 4 Antigen PX-3028616004 CDM 86160 CPT 302 RC outpatient 200 200 CIGNA 62308 [3081051] CIGNA STATE OF WYOMING [308105107] 160 percent of total billed charges 124 190 Technical (Hospital) Services Complement 4 Antigen PX-3028616004 CDM 86160 CPT 302 RC outpatient 200 200 BLUE CROSS BLUE SHIELD WELLMARK SB889 [3081026] BCBS WYOMING [308102603] 190 percent of total billed charges 124 190 Technical (Hospital) Services Complement 4 Antigen PX-3028616004 CDM 86160 CPT 302 RC outpatient 200 200 MULTIPLAN INC 34080 [3081285] MULTIPLAN INC [308128501] 190 percent of total billed charges 124 190 Technical (Hospital) Services Complement 4 Antigen PX-3028616004 CDM 86160 CPT 302 RC outpatient 200 200 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES PPO [308136801] 160 percent of total billed charges 124 190 Technical (Hospital) Services Complement 4 Antigen PX-3028616004 CDM 86160 CPT 302 RC outpatient 200 200 HEALTHPARTNERS SX009 HEALTHPARTNERS 160 percent of total billed charges 124 190 Technical (Hospital) Services Complement 4 Antigen PX-3028616004 CDM 86160 CPT 302 RC outpatient 200 200 UNITED HEALTHCARE (COMMERCIAL) [3081199] UNITED HEALTHCARE 87726 [308119901] 124 percent of total billed charges 124 190 Technical (Hospital) Services Complement 4 Antigen PX-3028616004 CDM 86160 CPT 302 RC outpatient 200 200 MEDICA (COMMERCIAL) 94265 [3081118] MEDICA CLAIMS [308111801] 180 percent of total billed charges 124 190 Technical (Hospital) Services Ref Cold Agglutinins Titer PX-3028615700 CDM 86157 CPT 302 RC inpatient 200 200 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES EPO [308136803] 158.36 percent of total billed charges 124 190 Technical (Hospital) Services Ref Cold Agglutinins Titer PX-3028615700 CDM 86157 CPT 302 RC inpatient 200 200 BLUE CROSS BLUE SHIELD WELLMARK SB889 [3081026] BCBS WYOMING [308102603] 190 percent of total billed charges 124 190 Technical (Hospital) Services Ref Cold Agglutinins Titer PX-3028615700 CDM 86157 CPT 302 RC inpatient 200 200 HEALTHPARTNERS SX009 HEALTHPARTNERS 158.36 percent of total billed charges 124 190 Technical (Hospital) Services Ref Cold Agglutinins Titer PX-3028615700 CDM 86157 CPT 302 RC inpatient 200 200 MULTIPLAN INC 34080 [3081285] MULTIPLAN INC [308128501] 190 percent of total billed charges 124 190 Technical (Hospital) Services Ref Cold Agglutinins Titer PX-3028615700 CDM 86157 CPT 302 RC inpatient 200 200 MEDICA (COMMERCIAL) 94265 [3081118] MEDICA CLAIMS [308111801] 180 percent of total billed charges 124 190 Technical (Hospital) Services Ref Cold Agglutinins Titer PX-3028615700 CDM 86157 CPT 302 RC inpatient 200 200 CIGNA 62308 [3081051] CIGNA 62308 [308105105] 158.36 percent of total billed charges 124 190 Technical (Hospital) Services Ref Cold Agglutinins Titer PX-3028615700 CDM 86157 CPT 302 RC inpatient 200 200 CIGNA 62308 [3081051] CIGNA STATE OF WYOMING [308105107] 158.36 percent of total billed charges 124 190 Technical (Hospital) Services Ref Cold Agglutinins Titer PX-3028615700 CDM 86157 CPT 302 RC inpatient 200 200 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES PPO [308136801] 158.36 percent of total billed charges 124 190 Technical (Hospital) Services Ref Cold Agglutinins Titer PX-3028615700 CDM 86157 CPT 302 RC inpatient 200 200 UNITED HEALTHCARE (COMMERCIAL) [3081199] UNITED HEALTHCARE 87726 [308119901] 124 percent of total billed charges 124 190 Technical (Hospital) Services Ref Cold Agglutinins Titer PX-3028615700 CDM 86157 CPT 302 RC inpatient 200 200 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES HDHP [308136802] 158.36 percent of total billed charges 124 190 Technical (Hospital) Services Ref Cold Agglutinins Titer PX-3028615700 CDM 86157 CPT 302 RC outpatient 200 200 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES PPO [308136801] 160 percent of total billed charges 124 190 Technical (Hospital) Services Ref Cold Agglutinins Titer PX-3028615700 CDM 86157 CPT 302 RC outpatient 200 200 MEDICA (COMMERCIAL) 94265 [3081118] MEDICA CLAIMS [308111801] 180 percent of total billed charges 124 190 Technical (Hospital) Services Ref Cold Agglutinins Titer PX-3028615700 CDM 86157 CPT 302 RC outpatient 200 200 UNITED HEALTHCARE (COMMERCIAL) [3081199] UNITED HEALTHCARE 87726 [308119901] 124 percent of total billed charges 124 190 Technical (Hospital) Services Ref Cold Agglutinins Titer PX-3028615700 CDM 86157 CPT 302 RC outpatient 200 200 HEALTHPARTNERS SX009 HEALTHPARTNERS 160 percent of total billed charges 124 190 Technical (Hospital) Services Ref Cold Agglutinins Titer PX-3028615700 CDM 86157 CPT 302 RC outpatient 200 200 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES EPO [308136803] 160 percent of total billed charges 124 190 Technical (Hospital) Services Ref Cold Agglutinins Titer PX-3028615700 CDM 86157 CPT 302 RC outpatient 200 200 CIGNA 62308 [3081051] CIGNA 62308 [308105105] 160 percent of total billed charges 124 190 Technical (Hospital) Services Ref Cold Agglutinins Titer PX-3028615700 CDM 86157 CPT 302 RC outpatient 200 200 CIGNA 62308 [3081051] CIGNA STATE OF WYOMING [308105107] 160 percent of total billed charges 124 190 Technical (Hospital) Services Ref Cold Agglutinins Titer PX-3028615700 CDM 86157 CPT 302 RC outpatient 200 200 MULTIPLAN INC 34080 [3081285] MULTIPLAN INC [308128501] 190 percent of total billed charges 124 190 Technical (Hospital) Services Ref Cold Agglutinins Titer PX-3028615700 CDM 86157 CPT 302 RC outpatient 200 200 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES HDHP [308136802] 160 percent of total billed charges 124 190 Technical (Hospital) Services Ref Cold Agglutinins Titer PX-3028615700 CDM 86157 CPT 302 RC outpatient 200 200 BLUE CROSS BLUE SHIELD WELLMARK SB889 [3081026] BCBS WYOMING [308102603] 190 percent of total billed charges 124 190 Technical (Hospital) Services Ref Phospholipid Ab Iga PX-3018614703 CDM 86147 CPT 302 RC inpatient 119 119 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES HDHP [308136802] 94.22 percent of total billed charges 73.78 113.05 Technical (Hospital) Services Ref Phospholipid Ab Iga PX-3018614703 CDM 86147 CPT 302 RC inpatient 119 119 BLUE CROSS BLUE SHIELD WELLMARK SB889 [3081026] BCBS WYOMING [308102603] 113.05 percent of total billed charges 73.78 113.05 Technical (Hospital) Services Ref Phospholipid Ab Iga PX-3018614703 CDM 86147 CPT 302 RC inpatient 119 119 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES PPO [308136801] 94.22 percent of total billed charges 73.78 113.05 Technical (Hospital) Services Ref Phospholipid Ab Iga PX-3018614703 CDM 86147 CPT 302 RC inpatient 119 119 UNITED HEALTHCARE (COMMERCIAL) [3081199] UNITED HEALTHCARE 87726 [308119901] 73.78 percent of total billed charges 73.78 113.05 Technical (Hospital) Services Ref Phospholipid Ab Iga PX-3018614703 CDM 86147 CPT 302 RC inpatient 119 119 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES EPO [308136803] 94.22 percent of total billed charges 73.78 113.05 Technical (Hospital) Services Ref Phospholipid Ab Iga PX-3018614703 CDM 86147 CPT 302 RC inpatient 119 119 HEALTHPARTNERS SX009 HEALTHPARTNERS 94.22 percent of total billed charges 73.78 113.05 Technical (Hospital) Services Ref Phospholipid Ab Iga PX-3018614703 CDM 86147 CPT 302 RC inpatient 119 119 CIGNA 62308 [3081051] CIGNA 62308 [308105105] 94.22 percent of total billed charges 73.78 113.05 Technical (Hospital) Services Ref Phospholipid Ab Iga PX-3018614703 CDM 86147 CPT 302 RC inpatient 119 119 CIGNA 62308 [3081051] CIGNA STATE OF WYOMING [308105107] 94.22 percent of total billed charges 73.78 113.05 Technical (Hospital) Services Ref Phospholipid Ab Iga PX-3018614703 CDM 86147 CPT 302 RC inpatient 119 119 MEDICA (COMMERCIAL) 94265 [3081118] MEDICA CLAIMS [308111801] 107.1 percent of total billed charges 73.78 113.05 Technical (Hospital) Services Ref Phospholipid Ab Iga PX-3018614703 CDM 86147 CPT 302 RC inpatient 119 119 MULTIPLAN INC 34080 [3081285] MULTIPLAN INC [308128501] 113.05 percent of total billed charges 73.78 113.05 Technical (Hospital) Services Ref Phospholipid Ab Iga PX-3018614703 CDM 86147 CPT 302 RC outpatient 119 119 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES HDHP [308136802] 95.2 percent of total billed charges 73.78 113.05 Technical (Hospital) Services Ref Phospholipid Ab Iga PX-3018614703 CDM 86147 CPT 302 RC outpatient 119 119 MULTIPLAN INC 34080 [3081285] MULTIPLAN INC [308128501] 113.05 percent of total billed charges 73.78 113.05 Technical (Hospital) Services Ref Phospholipid Ab Iga PX-3018614703 CDM 86147 CPT 302 RC outpatient 119 119 BLUE CROSS BLUE SHIELD WELLMARK SB889 [3081026] BCBS WYOMING [308102603] 113.05 percent of total billed charges 73.78 113.05 Technical (Hospital) Services Ref Phospholipid Ab Iga PX-3018614703 CDM 86147 CPT 302 RC outpatient 119 119 CIGNA 62308 [3081051] CIGNA 62308 [308105105] 95.2 percent of total billed charges 73.78 113.05 Technical (Hospital) Services Ref Phospholipid Ab Iga PX-3018614703 CDM 86147 CPT 302 RC outpatient 119 119 CIGNA 62308 [3081051] CIGNA STATE OF WYOMING [308105107] 95.2 percent of total billed charges 73.78 113.05 Technical (Hospital) Services Ref Phospholipid Ab Iga PX-3018614703 CDM 86147 CPT 302 RC outpatient 119 119 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES EPO [308136803] 95.2 percent of total billed charges 73.78 113.05 Technical (Hospital) Services Ref Phospholipid Ab Iga PX-3018614703 CDM 86147 CPT 302 RC outpatient 119 119 HEALTHPARTNERS SX009 HEALTHPARTNERS 95.2 percent of total billed charges 73.78 113.05 Technical (Hospital) Services Ref Phospholipid Ab Iga PX-3018614703 CDM 86147 CPT 302 RC outpatient 119 119 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES PPO [308136801] 95.2 percent of total billed charges 73.78 113.05 Technical (Hospital) Services Ref Phospholipid Ab Iga PX-3018614703 CDM 86147 CPT 302 RC outpatient 119 119 UNITED HEALTHCARE (COMMERCIAL) [3081199] UNITED HEALTHCARE 87726 [308119901] 73.78 percent of total billed charges 73.78 113.05 Technical (Hospital) Services Ref Phospholipid Ab Iga PX-3018614703 CDM 86147 CPT 302 RC outpatient 119 119 MEDICA (COMMERCIAL) 94265 [3081118] MEDICA CLAIMS [308111801] 107.1 percent of total billed charges 73.78 113.05 Technical (Hospital) Services Ref Phospholipid Ab Igm PX-3028614701 CDM 86147 CPT 302 RC outpatient 119 119 MEDICA (COMMERCIAL) 94265 [3081118] MEDICA CLAIMS [308111801] 107.1 percent of total billed charges 73.78 113.05 Technical (Hospital) Services Ref Phospholipid Ab Igm PX-3028614701 CDM 86147 CPT 302 RC outpatient 119 119 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES EPO [308136803] 95.2 percent of total billed charges 73.78 113.05 Technical (Hospital) Services Ref Phospholipid Ab Igm PX-3028614701 CDM 86147 CPT 302 RC outpatient 119 119 CIGNA 62308 [3081051] CIGNA 62308 [308105105] 95.2 percent of total billed charges 73.78 113.05 Technical (Hospital) Services Ref Phospholipid Ab Igm PX-3028614701 CDM 86147 CPT 302 RC outpatient 119 119 CIGNA 62308 [3081051] CIGNA STATE OF WYOMING [308105107] 95.2 percent of total billed charges 73.78 113.05 Technical (Hospital) Services Ref Phospholipid Ab Igm PX-3028614701 CDM 86147 CPT 302 RC outpatient 119 119 BLUE CROSS BLUE SHIELD WELLMARK SB889 [3081026] BCBS WYOMING [308102603] 113.05 percent of total billed charges 73.78 113.05 Technical (Hospital) Services Ref Phospholipid Ab Igm PX-3028614701 CDM 86147 CPT 302 RC outpatient 119 119 MULTIPLAN INC 34080 [3081285] MULTIPLAN INC [308128501] 113.05 percent of total billed charges 73.78 113.05 Technical (Hospital) Services Ref Phospholipid Ab Igm PX-3028614701 CDM 86147 CPT 302 RC outpatient 119 119 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES HDHP [308136802] 95.2 percent of total billed charges 73.78 113.05 Technical (Hospital) Services Ref Phospholipid Ab Igm PX-3028614701 CDM 86147 CPT 302 RC outpatient 119 119 UNITED HEALTHCARE (COMMERCIAL) [3081199] UNITED HEALTHCARE 87726 [308119901] 73.78 percent of total billed charges 73.78 113.05 Technical (Hospital) Services Ref Phospholipid Ab Igm PX-3028614701 CDM 86147 CPT 302 RC outpatient 119 119 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES PPO [308136801] 95.2 percent of total billed charges 73.78 113.05 Technical (Hospital) Services Ref Phospholipid Ab Igm PX-3028614701 CDM 86147 CPT 302 RC outpatient 119 119 HEALTHPARTNERS SX009 HEALTHPARTNERS 95.2 percent of total billed charges 73.78 113.05 Technical (Hospital) Services Ref Phospholipid Ab Igm PX-3028614701 CDM 86147 CPT 302 RC inpatient 119 119 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES HDHP [308136802] 94.22 percent of total billed charges 73.78 113.05 Technical (Hospital) Services Ref Phospholipid Ab Igm PX-3028614701 CDM 86147 CPT 302 RC inpatient 119 119 UNITED HEALTHCARE (COMMERCIAL) [3081199] UNITED HEALTHCARE 87726 [308119901] 73.78 percent of total billed charges 73.78 113.05 Technical (Hospital) Services Ref Phospholipid Ab Igm PX-3028614701 CDM 86147 CPT 302 RC inpatient 119 119 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES PPO [308136801] 94.22 percent of total billed charges 73.78 113.05 Technical (Hospital) Services Ref Phospholipid Ab Igm PX-3028614701 CDM 86147 CPT 302 RC inpatient 119 119 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES EPO [308136803] 94.22 percent of total billed charges 73.78 113.05 Technical (Hospital) Services Ref Phospholipid Ab Igm PX-3028614701 CDM 86147 CPT 302 RC inpatient 119 119 BLUE CROSS BLUE SHIELD WELLMARK SB889 [3081026] BCBS WYOMING [308102603] 113.05 percent of total billed charges 73.78 113.05 Technical (Hospital) Services Ref Phospholipid Ab Igm PX-3028614701 CDM 86147 CPT 302 RC inpatient 119 119 HEALTHPARTNERS SX009 HEALTHPARTNERS 94.22 percent of total billed charges 73.78 113.05 Technical (Hospital) Services Ref Phospholipid Ab Igm PX-3028614701 CDM 86147 CPT 302 RC inpatient 119 119 MULTIPLAN INC 34080 [3081285] MULTIPLAN INC [308128501] 113.05 percent of total billed charges 73.78 113.05 Technical (Hospital) Services Ref Phospholipid Ab Igm PX-3028614701 CDM 86147 CPT 302 RC inpatient 119 119 MEDICA (COMMERCIAL) 94265 [3081118] MEDICA CLAIMS [308111801] 107.1 percent of total billed charges 73.78 113.05 Technical (Hospital) Services Ref Phospholipid Ab Igm PX-3028614701 CDM 86147 CPT 302 RC inpatient 119 119 CIGNA 62308 [3081051] CIGNA 62308 [308105105] 94.22 percent of total billed charges 73.78 113.05 Technical (Hospital) Services Ref Phospholipid Ab Igm PX-3028614701 CDM 86147 CPT 302 RC inpatient 119 119 CIGNA 62308 [3081051] CIGNA STATE OF WYOMING [308105107] 94.22 percent of total billed charges 73.78 113.05 Technical (Hospital) Services Ref Phospholipid Ab Igg PX-3028614702 CDM 86147 CPT 302 RC inpatient 119 119 MULTIPLAN INC 34080 [3081285] MULTIPLAN INC [308128501] 113.05 percent of total billed charges 73.78 113.05 Technical (Hospital) Services Ref Phospholipid Ab Igg PX-3028614702 CDM 86147 CPT 302 RC inpatient 119 119 MEDICA (COMMERCIAL) 94265 [3081118] MEDICA CLAIMS [308111801] 107.1 percent of total billed charges 73.78 113.05 Technical (Hospital) Services Ref Phospholipid Ab Igg PX-3028614702 CDM 86147 CPT 302 RC inpatient 119 119 CIGNA 62308 [3081051] CIGNA 62308 [308105105] 94.22 percent of total billed charges 73.78 113.05 Technical (Hospital) Services Ref Phospholipid Ab Igg PX-3028614702 CDM 86147 CPT 302 RC inpatient 119 119 CIGNA 62308 [3081051] CIGNA STATE OF WYOMING [308105107] 94.22 percent of total billed charges 73.78 113.05 Technical (Hospital) Services Ref Phospholipid Ab Igg PX-3028614702 CDM 86147 CPT 302 RC inpatient 119 119 HEALTHPARTNERS SX009 HEALTHPARTNERS 94.22 percent of total billed charges 73.78 113.05 Technical (Hospital) Services Ref Phospholipid Ab Igg PX-3028614702 CDM 86147 CPT 302 RC inpatient 119 119 BLUE CROSS BLUE SHIELD WELLMARK SB889 [3081026] BCBS WYOMING [308102603] 113.05 percent of total billed charges 73.78 113.05 Technical (Hospital) Services Ref Phospholipid Ab Igg PX-3028614702 CDM 86147 CPT 302 RC inpatient 119 119 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES EPO [308136803] 94.22 percent of total billed charges 73.78 113.05 Technical (Hospital) Services Ref Phospholipid Ab Igg PX-3028614702 CDM 86147 CPT 302 RC inpatient 119 119 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES HDHP [308136802] 94.22 percent of total billed charges 73.78 113.05 Technical (Hospital) Services Ref Phospholipid Ab Igg PX-3028614702 CDM 86147 CPT 302 RC inpatient 119 119 UNITED HEALTHCARE (COMMERCIAL) [3081199] UNITED HEALTHCARE 87726 [308119901] 73.78 percent of total billed charges 73.78 113.05 Technical (Hospital) Services Ref Phospholipid Ab Igg PX-3028614702 CDM 86147 CPT 302 RC inpatient 119 119 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES PPO [308136801] 94.22 percent of total billed charges 73.78 113.05 Technical (Hospital) Services Ref Phospholipid Ab Igg PX-3028614702 CDM 86147 CPT 302 RC outpatient 119 119 MEDICA (COMMERCIAL) 94265 [3081118] MEDICA CLAIMS [308111801] 107.1 percent of total billed charges 73.78 113.05 Technical (Hospital) Services Ref Phospholipid Ab Igg PX-3028614702 CDM 86147 CPT 302 RC outpatient 119 119 BLUE CROSS BLUE SHIELD WELLMARK SB889 [3081026] BCBS WYOMING [308102603] 113.05 percent of total billed charges 73.78 113.05 Technical (Hospital) Services Ref Phospholipid Ab Igg PX-3028614702 CDM 86147 CPT 302 RC outpatient 119 119 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES HDHP [308136802] 95.2 percent of total billed charges 73.78 113.05 Technical (Hospital) Services Ref Phospholipid Ab Igg PX-3028614702 CDM 86147 CPT 302 RC outpatient 119 119 MULTIPLAN INC 34080 [3081285] MULTIPLAN INC [308128501] 113.05 percent of total billed charges 73.78 113.05 Technical (Hospital) Services Ref Phospholipid Ab Igg PX-3028614702 CDM 86147 CPT 302 RC outpatient 119 119 CIGNA 62308 [3081051] CIGNA 62308 [308105105] 95.2 percent of total billed charges 73.78 113.05 Technical (Hospital) Services Ref Phospholipid Ab Igg PX-3028614702 CDM 86147 CPT 302 RC outpatient 119 119 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES EPO [308136803] 95.2 percent of total billed charges 73.78 113.05 Technical (Hospital) Services Ref Phospholipid Ab Igg PX-3028614702 CDM 86147 CPT 302 RC outpatient 119 119 CIGNA 62308 [3081051] CIGNA STATE OF WYOMING [308105107] 95.2 percent of total billed charges 73.78 113.05 Technical (Hospital) Services Ref Phospholipid Ab Igg PX-3028614702 CDM 86147 CPT 302 RC outpatient 119 119 HEALTHPARTNERS SX009 HEALTHPARTNERS 95.2 percent of total billed charges 73.78 113.05 Technical (Hospital) Services Ref Phospholipid Ab Igg PX-3028614702 CDM 86147 CPT 302 RC outpatient 119 119 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES PPO [308136801] 95.2 percent of total billed charges 73.78 113.05 Technical (Hospital) Services Ref Phospholipid Ab Igg PX-3028614702 CDM 86147 CPT 302 RC outpatient 119 119 UNITED HEALTHCARE (COMMERCIAL) [3081199] UNITED HEALTHCARE 87726 [308119901] 73.78 percent of total billed charges 73.78 113.05 Technical (Hospital) Services Glycoprotein Antibody PX-3028614600 CDM 86146 CPT 302 RC outpatient 324 324 MEDICA (COMMERCIAL) 94265 [3081118] MEDICA CLAIMS [308111801] 291.6 percent of total billed charges 200.88 307.8 Technical (Hospital) Services Glycoprotein Antibody PX-3028614600 CDM 86146 CPT 302 RC outpatient 324 324 UNITED HEALTHCARE (COMMERCIAL) [3081199] UNITED HEALTHCARE 87726 [308119901] 200.88 percent of total billed charges 200.88 307.8 Technical (Hospital) Services Glycoprotein Antibody PX-3028614600 CDM 86146 CPT 302 RC outpatient 324 324 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES PPO [308136801] 259.2 percent of total billed charges 200.88 307.8 Technical (Hospital) Services Glycoprotein Antibody PX-3028614600 CDM 86146 CPT 302 RC outpatient 324 324 HEALTHPARTNERS SX009 HEALTHPARTNERS 259.2 percent of total billed charges 200.88 307.8 Technical (Hospital) Services Glycoprotein Antibody PX-3028614600 CDM 86146 CPT 302 RC outpatient 324 324 CIGNA 62308 [3081051] CIGNA 62308 [308105105] 259.2 percent of total billed charges 200.88 307.8 Technical (Hospital) Services Glycoprotein Antibody PX-3028614600 CDM 86146 CPT 302 RC outpatient 324 324 CIGNA 62308 [3081051] CIGNA STATE OF WYOMING [308105107] 259.2 percent of total billed charges 200.88 307.8 Technical (Hospital) Services Glycoprotein Antibody PX-3028614600 CDM 86146 CPT 302 RC outpatient 324 324 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES EPO [308136803] 259.2 percent of total billed charges 200.88 307.8 Technical (Hospital) Services Glycoprotein Antibody PX-3028614600 CDM 86146 CPT 302 RC outpatient 324 324 MULTIPLAN INC 34080 [3081285] MULTIPLAN INC [308128501] 307.8 percent of total billed charges 200.88 307.8 Technical (Hospital) Services Glycoprotein Antibody PX-3028614600 CDM 86146 CPT 302 RC outpatient 324 324 BLUE CROSS BLUE SHIELD WELLMARK SB889 [3081026] BCBS WYOMING [308102603] 307.8 percent of total billed charges 200.88 307.8 Technical (Hospital) Services Glycoprotein Antibody PX-3028614600 CDM 86146 CPT 302 RC outpatient 324 324 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES HDHP [308136802] 259.2 percent of total billed charges 200.88 307.8 Technical (Hospital) Services Glycoprotein Antibody PX-3028614600 CDM 86146 CPT 302 RC inpatient 324 324 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES HDHP [308136802] 256.54 percent of total billed charges 200.88 307.8 Technical (Hospital) Services Glycoprotein Antibody PX-3028614600 CDM 86146 CPT 302 RC inpatient 324 324 BLUE CROSS BLUE SHIELD WELLMARK SB889 [3081026] BCBS WYOMING [308102603] 307.8 percent of total billed charges 200.88 307.8 Technical (Hospital) Services Glycoprotein Antibody PX-3028614600 CDM 86146 CPT 302 RC inpatient 324 324 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES PPO [308136801] 256.54 percent of total billed charges 200.88 307.8 Technical (Hospital) Services Glycoprotein Antibody PX-3028614600 CDM 86146 CPT 302 RC inpatient 324 324 UNITED HEALTHCARE (COMMERCIAL) [3081199] UNITED HEALTHCARE 87726 [308119901] 200.88 percent of total billed charges 200.88 307.8 Technical (Hospital) Services Glycoprotein Antibody PX-3028614600 CDM 86146 CPT 302 RC inpatient 324 324 MULTIPLAN INC 34080 [3081285] MULTIPLAN INC [308128501] 307.8 percent of total billed charges 200.88 307.8 Technical (Hospital) Services Glycoprotein Antibody PX-3028614600 CDM 86146 CPT 302 RC inpatient 324 324 MEDICA (COMMERCIAL) 94265 [3081118] MEDICA CLAIMS [308111801] 291.6 percent of total billed charges 200.88 307.8 Technical (Hospital) Services Glycoprotein Antibody PX-3028614600 CDM 86146 CPT 302 RC inpatient 324 324 CIGNA 62308 [3081051] CIGNA 62308 [308105105] 256.54 percent of total billed charges 200.88 307.8 Technical (Hospital) Services Glycoprotein Antibody PX-3028614600 CDM 86146 CPT 302 RC inpatient 324 324 CIGNA 62308 [3081051] CIGNA STATE OF WYOMING [308105107] 256.54 percent of total billed charges 200.88 307.8 Technical (Hospital) Services Glycoprotein Antibody PX-3028614600 CDM 86146 CPT 302 RC inpatient 324 324 HEALTHPARTNERS SX009 HEALTHPARTNERS 256.54 percent of total billed charges 200.88 307.8 Technical (Hospital) Services Glycoprotein Antibody PX-3028614600 CDM 86146 CPT 302 RC inpatient 324 324 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES EPO [308136803] 256.54 percent of total billed charges 200.88 307.8 Technical (Hospital) Services Ref Beta 2 Gp1 Igg Igm or Iga PX-3028614601 CDM 86146 CPT 302 RC outpatient 160 160 MEDICA (COMMERCIAL) 94265 [3081118] MEDICA CLAIMS [308111801] 144 percent of total billed charges 99.2 152 Technical (Hospital) Services Ref Beta 2 Gp1 Igg Igm or Iga PX-3028614601 CDM 86146 CPT 302 RC outpatient 160 160 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES EPO [308136803] 128 percent of total billed charges 99.2 152 Technical (Hospital) Services Ref Beta 2 Gp1 Igg Igm or Iga PX-3028614601 CDM 86146 CPT 302 RC outpatient 160 160 CIGNA 62308 [3081051] CIGNA 62308 [308105105] 128 percent of total billed charges 99.2 152 Technical (Hospital) Services Ref Beta 2 Gp1 Igg Igm or Iga PX-3028614601 CDM 86146 CPT 302 RC outpatient 160 160 CIGNA 62308 [3081051] CIGNA STATE OF WYOMING [308105107] 128 percent of total billed charges 99.2 152 Technical (Hospital) Services Ref Beta 2 Gp1 Igg Igm or Iga PX-3028614601 CDM 86146 CPT 302 RC outpatient 160 160 BLUE CROSS BLUE SHIELD WELLMARK SB889 [3081026] BCBS WYOMING [308102603] 152 percent of total billed charges 99.2 152 Technical (Hospital) Services Ref Beta 2 Gp1 Igg Igm or Iga PX-3028614601 CDM 86146 CPT 302 RC outpatient 160 160 MULTIPLAN INC 34080 [3081285] MULTIPLAN INC [308128501] 152 percent of total billed charges 99.2 152 Technical (Hospital) Services Ref Beta 2 Gp1 Igg Igm or Iga PX-3028614601 CDM 86146 CPT 302 RC outpatient 160 160 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES HDHP [308136802] 128 percent of total billed charges 99.2 152 Technical (Hospital) Services Ref Beta 2 Gp1 Igg Igm or Iga PX-3028614601 CDM 86146 CPT 302 RC outpatient 160 160 HEALTHPARTNERS SX009 HEALTHPARTNERS 128 percent of total billed charges 99.2 152 Technical (Hospital) Services Ref Beta 2 Gp1 Igg Igm or Iga PX-3028614601 CDM 86146 CPT 302 RC outpatient 160 160 UNITED HEALTHCARE (COMMERCIAL) [3081199] UNITED HEALTHCARE 87726 [308119901] 99.2 percent of total billed charges 99.2 152 Technical (Hospital) Services Ref Beta 2 Gp1 Igg Igm or Iga PX-3028614601 CDM 86146 CPT 302 RC outpatient 160 160 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES PPO [308136801] 128 percent of total billed charges 99.2 152 Technical (Hospital) Services Ref Beta 2 Gp1 Igg Igm or Iga PX-3028614601 CDM 86146 CPT 302 RC inpatient 160 160 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES HDHP [308136802] 126.69 percent of total billed charges 99.2 152 Technical (Hospital) Services Ref Beta 2 Gp1 Igg Igm or Iga PX-3028614601 CDM 86146 CPT 302 RC inpatient 160 160 BLUE CROSS BLUE SHIELD WELLMARK SB889 [3081026] BCBS WYOMING [308102603] 152 percent of total billed charges 99.2 152 Technical (Hospital) Services Ref Beta 2 Gp1 Igg Igm or Iga PX-3028614601 CDM 86146 CPT 302 RC inpatient 160 160 UNITED HEALTHCARE (COMMERCIAL) [3081199] UNITED HEALTHCARE 87726 [308119901] 99.2 percent of total billed charges 99.2 152 Technical (Hospital) Services Ref Beta 2 Gp1 Igg Igm or Iga PX-3028614601 CDM 86146 CPT 302 RC inpatient 160 160 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES PPO [308136801] 126.69 percent of total billed charges 99.2 152 Technical (Hospital) Services Ref Beta 2 Gp1 Igg Igm or Iga PX-3028614601 CDM 86146 CPT 302 RC inpatient 160 160 MEDICA (COMMERCIAL) 94265 [3081118] MEDICA CLAIMS [308111801] 144 percent of total billed charges 99.2 152 Technical (Hospital) Services Ref Beta 2 Gp1 Igg Igm or Iga PX-3028614601 CDM 86146 CPT 302 RC inpatient 160 160 MULTIPLAN INC 34080 [3081285] MULTIPLAN INC [308128501] 152 percent of total billed charges 99.2 152 Technical (Hospital) Services Ref Beta 2 Gp1 Igg Igm or Iga PX-3028614601 CDM 86146 CPT 302 RC inpatient 160 160 CIGNA 62308 [3081051] CIGNA 62308 [308105105] 126.69 percent of total billed charges 99.2 152 Technical (Hospital) Services Ref Beta 2 Gp1 Igg Igm or Iga PX-3028614601 CDM 86146 CPT 302 RC inpatient 160 160 CIGNA 62308 [3081051] CIGNA STATE OF WYOMING [308105107] 126.69 percent of total billed charges 99.2 152 Technical (Hospital) Services Ref Beta 2 Gp1 Igg Igm or Iga PX-3028614601 CDM 86146 CPT 302 RC inpatient 160 160 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES EPO [308136803] 126.69 percent of total billed charges 99.2 152 Technical (Hospital) Services Ref Beta 2 Gp1 Igg Igm or Iga PX-3028614601 CDM 86146 CPT 302 RC inpatient 160 160 HEALTHPARTNERS SX009 HEALTHPARTNERS 126.69 percent of total billed charges 99.2 152 Technical (Hospital) Services Crpq C Reative Protein PX-3028614100 CDM 86141 CPT 302 RC inpatient 129 129 HEALTHPARTNERS SX009 HEALTHPARTNERS 102.14 percent of total billed charges 79.98 122.55 Technical (Hospital) Services Crpq C Reative Protein PX-3028614100 CDM 86141 CPT 302 RC inpatient 129 129 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES EPO [308136803] 102.14 percent of total billed charges 79.98 122.55 Technical (Hospital) Services Crpq C Reative Protein PX-3028614100 CDM 86141 CPT 302 RC inpatient 129 129 MULTIPLAN INC 34080 [3081285] MULTIPLAN INC [308128501] 122.55 percent of total billed charges 79.98 122.55 Technical (Hospital) Services Crpq C Reative Protein PX-3028614100 CDM 86141 CPT 302 RC inpatient 129 129 MEDICA (COMMERCIAL) 94265 [3081118] MEDICA CLAIMS [308111801] 116.1 percent of total billed charges 79.98 122.55 Technical (Hospital) Services Crpq C Reative Protein PX-3028614100 CDM 86141 CPT 302 RC inpatient 129 129 CIGNA 62308 [3081051] CIGNA 62308 [308105105] 102.14 percent of total billed charges 79.98 122.55 Technical (Hospital) Services Crpq C Reative Protein PX-3028614100 CDM 86141 CPT 302 RC inpatient 129 129 CIGNA 62308 [3081051] CIGNA STATE OF WYOMING [308105107] 102.14 percent of total billed charges 79.98 122.55 Technical (Hospital) Services Crpq C Reative Protein PX-3028614100 CDM 86141 CPT 302 RC inpatient 129 129 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES PPO [308136801] 102.14 percent of total billed charges 79.98 122.55 Technical (Hospital) Services Crpq C Reative Protein PX-3028614100 CDM 86141 CPT 302 RC inpatient 129 129 UNITED HEALTHCARE (COMMERCIAL) [3081199] UNITED HEALTHCARE 87726 [308119901] 79.98 percent of total billed charges 79.98 122.55 Technical (Hospital) Services Crpq C Reative Protein PX-3028614100 CDM 86141 CPT 302 RC inpatient 129 129 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES HDHP [308136802] 102.14 percent of total billed charges 79.98 122.55 Technical (Hospital) Services Crpq C Reative Protein PX-3028614100 CDM 86141 CPT 302 RC inpatient 129 129 BLUE CROSS BLUE SHIELD WELLMARK SB889 [3081026] BCBS WYOMING [308102603] 122.55 percent of total billed charges 79.98 122.55 Technical (Hospital) Services Crpq C Reative Protein PX-3028614100 CDM 86141 CPT 302 RC outpatient 129 129 MEDICA (COMMERCIAL) 94265 [3081118] MEDICA CLAIMS [308111801] 116.1 percent of total billed charges 79.98 122.55 Technical (Hospital) Services Crpq C Reative Protein PX-3028614100 CDM 86141 CPT 302 RC outpatient 129 129 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES EPO [308136803] 103.2 percent of total billed charges 79.98 122.55 Technical (Hospital) Services Crpq C Reative Protein PX-3028614100 CDM 86141 CPT 302 RC outpatient 129 129 CIGNA 62308 [3081051] CIGNA 62308 [308105105] 103.2 percent of total billed charges 79.98 122.55 Technical (Hospital) Services Crpq C Reative Protein PX-3028614100 CDM 86141 CPT 302 RC outpatient 129 129 CIGNA 62308 [3081051] CIGNA STATE OF WYOMING [308105107] 103.2 percent of total billed charges 79.98 122.55 Technical (Hospital) Services Crpq C Reative Protein PX-3028614100 CDM 86141 CPT 302 RC outpatient 129 129 MULTIPLAN INC 34080 [3081285] MULTIPLAN INC [308128501] 122.55 percent of total billed charges 79.98 122.55 Technical (Hospital) Services Crpq C Reative Protein PX-3028614100 CDM 86141 CPT 302 RC outpatient 129 129 BLUE CROSS BLUE SHIELD WELLMARK SB889 [3081026] BCBS WYOMING [308102603] 122.55 percent of total billed charges 79.98 122.55 Technical (Hospital) Services Crpq C Reative Protein PX-3028614100 CDM 86141 CPT 302 RC outpatient 129 129 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES HDHP [308136802] 103.2 percent of total billed charges 79.98 122.55 Technical (Hospital) Services Crpq C Reative Protein PX-3028614100 CDM 86141 CPT 302 RC outpatient 129 129 UNITED HEALTHCARE (COMMERCIAL) [3081199] UNITED HEALTHCARE 87726 [308119901] 79.98 percent of total billed charges 79.98 122.55 Technical (Hospital) Services Crpq C Reative Protein PX-3028614100 CDM 86141 CPT 302 RC outpatient 129 129 HEALTHPARTNERS SX009 HEALTHPARTNERS 103.2 percent of total billed charges 79.98 122.55 Technical (Hospital) Services Crpq C Reative Protein PX-3028614100 CDM 86141 CPT 302 RC outpatient 129 129 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES PPO [308136801] 103.2 percent of total billed charges 79.98 122.55 Technical (Hospital) Services C-Ractive Protein Quant PX-3028614000 CDM 86140 CPT 302 RC inpatient 103 103 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES PPO [308136801] 81.56 percent of total billed charges 63.86 97.85 Technical (Hospital) Services C-Ractive Protein Quant PX-3028614000 CDM 86140 CPT 302 RC inpatient 103 103 UNITED HEALTHCARE (COMMERCIAL) [3081199] UNITED HEALTHCARE 87726 [308119901] 63.86 percent of total billed charges 63.86 97.85 Technical (Hospital) Services C-Ractive Protein Quant PX-3028614000 CDM 86140 CPT 302 RC inpatient 103 103 BLUE CROSS BLUE SHIELD WELLMARK SB889 [3081026] BCBS WYOMING [308102603] 97.85 percent of total billed charges 63.86 97.85 Technical (Hospital) Services C-Ractive Protein Quant PX-3028614000 CDM 86140 CPT 302 RC inpatient 103 103 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES HDHP [308136802] 81.56 percent of total billed charges 63.86 97.85 Technical (Hospital) Services C-Ractive Protein Quant PX-3028614000 CDM 86140 CPT 302 RC inpatient 103 103 MULTIPLAN INC 34080 [3081285] MULTIPLAN INC [308128501] 97.85 percent of total billed charges 63.86 97.85 Technical (Hospital) Services C-Ractive Protein Quant PX-3028614000 CDM 86140 CPT 302 RC inpatient 103 103 MEDICA (COMMERCIAL) 94265 [3081118] MEDICA CLAIMS [308111801] 92.7 percent of total billed charges 63.86 97.85 Technical (Hospital) Services C-Ractive Protein Quant PX-3028614000 CDM 86140 CPT 302 RC inpatient 103 103 CIGNA 62308 [3081051] CIGNA 62308 [308105105] 81.56 percent of total billed charges 63.86 97.85 Technical (Hospital) Services C-Ractive Protein Quant PX-3028614000 CDM 86140 CPT 302 RC inpatient 103 103 CIGNA 62308 [3081051] CIGNA STATE OF WYOMING [308105107] 81.56 percent of total billed charges 63.86 97.85 Technical (Hospital) Services C-Ractive Protein Quant PX-3028614000 CDM 86140 CPT 302 RC inpatient 103 103 HEALTHPARTNERS SX009 HEALTHPARTNERS 81.56 percent of total billed charges 63.86 97.85 Technical (Hospital) Services C-Ractive Protein Quant PX-3028614000 CDM 86140 CPT 302 RC inpatient 103 103 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES EPO [308136803] 81.56 percent of total billed charges 63.86 97.85 Technical (Hospital) Services C-Ractive Protein Quant PX-3028614000 CDM 86140 CPT 302 RC outpatient 103 103 MEDICA (COMMERCIAL) 94265 [3081118] MEDICA CLAIMS [308111801] 92.7 percent of total billed charges 63.86 97.85 Technical (Hospital) Services C-Ractive Protein Quant PX-3028614000 CDM 86140 CPT 302 RC outpatient 103 103 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES PPO [308136801] 82.4 percent of total billed charges 63.86 97.85 Technical (Hospital) Services C-Ractive Protein Quant PX-3028614000 CDM 86140 CPT 302 RC outpatient 103 103 BLUE CROSS BLUE SHIELD WELLMARK SB889 [3081026] BCBS WYOMING [308102603] 97.85 percent of total billed charges 63.86 97.85 Technical (Hospital) Services C-Ractive Protein Quant PX-3028614000 CDM 86140 CPT 302 RC outpatient 103 103 MULTIPLAN INC 34080 [3081285] MULTIPLAN INC [308128501] 97.85 percent of total billed charges 63.86 97.85 Technical (Hospital) Services C-Ractive Protein Quant PX-3028614000 CDM 86140 CPT 302 RC outpatient 103 103 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES EPO [308136803] 82.4 percent of total billed charges 63.86 97.85 Technical (Hospital) Services C-Ractive Protein Quant PX-3028614000 CDM 86140 CPT 302 RC outpatient 103 103 CIGNA 62308 [3081051] CIGNA 62308 [308105105] 82.4 percent of total billed charges 63.86 97.85 Technical (Hospital) Services C-Ractive Protein Quant PX-3028614000 CDM 86140 CPT 302 RC outpatient 103 103 CIGNA 62308 [3081051] CIGNA STATE OF WYOMING [308105107] 82.4 percent of total billed charges 63.86 97.85 Technical (Hospital) Services C-Ractive Protein Quant PX-3028614000 CDM 86140 CPT 302 RC outpatient 103 103 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES HDHP [308136802] 82.4 percent of total billed charges 63.86 97.85 Technical (Hospital) Services C-Ractive Protein Quant PX-3028614000 CDM 86140 CPT 302 RC outpatient 103 103 UNITED HEALTHCARE (COMMERCIAL) [3081199] UNITED HEALTHCARE 87726 [308119901] 63.86 percent of total billed charges 63.86 97.85 Technical (Hospital) Services C-Ractive Protein Quant PX-3028614000 CDM 86140 CPT 302 RC outpatient 103 103 HEALTHPARTNERS SX009 HEALTHPARTNERS 82.4 percent of total billed charges 63.86 97.85 Technical (Hospital) Services Antistreptolysin O Screen PX-3028606300 CDM 86063 CPT 302 RC inpatient 103 103 UNITED HEALTHCARE (COMMERCIAL) [3081199] UNITED HEALTHCARE 87726 [308119901] 63.86 percent of total billed charges 63.86 97.85 Technical (Hospital) Services Antistreptolysin O Screen PX-3028606300 CDM 86063 CPT 302 RC inpatient 103 103 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES PPO [308136801] 81.56 percent of total billed charges 63.86 97.85 Technical (Hospital) Services Antistreptolysin O Screen PX-3028606300 CDM 86063 CPT 302 RC inpatient 103 103 BLUE CROSS BLUE SHIELD WELLMARK SB889 [3081026] BCBS WYOMING [308102603] 97.85 percent of total billed charges 63.86 97.85 Technical (Hospital) Services Antistreptolysin O Screen PX-3028606300 CDM 86063 CPT 302 RC inpatient 103 103 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES HDHP [308136802] 81.56 percent of total billed charges 63.86 97.85 Technical (Hospital) Services Antistreptolysin O Screen PX-3028606300 CDM 86063 CPT 302 RC inpatient 103 103 MULTIPLAN INC 34080 [3081285] MULTIPLAN INC [308128501] 97.85 percent of total billed charges 63.86 97.85 Technical (Hospital) Services Antistreptolysin O Screen PX-3028606300 CDM 86063 CPT 302 RC inpatient 103 103 MEDICA (COMMERCIAL) 94265 [3081118] MEDICA CLAIMS [308111801] 92.7 percent of total billed charges 63.86 97.85 Technical (Hospital) Services Antistreptolysin O Screen PX-3028606300 CDM 86063 CPT 302 RC inpatient 103 103 CIGNA 62308 [3081051] CIGNA 62308 [308105105] 81.56 percent of total billed charges 63.86 97.85 Technical (Hospital) Services Antistreptolysin O Screen PX-3028606300 CDM 86063 CPT 302 RC inpatient 103 103 CIGNA 62308 [3081051] CIGNA STATE OF WYOMING [308105107] 81.56 percent of total billed charges 63.86 97.85 Technical (Hospital) Services Antistreptolysin O Screen PX-3028606300 CDM 86063 CPT 302 RC inpatient 103 103 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES EPO [308136803] 81.56 percent of total billed charges 63.86 97.85 Technical (Hospital) Services Antistreptolysin O Screen PX-3028606300 CDM 86063 CPT 302 RC inpatient 103 103 HEALTHPARTNERS SX009 HEALTHPARTNERS 81.56 percent of total billed charges 63.86 97.85 Technical (Hospital) Services Antistreptolysin O Screen PX-3028606300 CDM 86063 CPT 302 RC outpatient 103 103 MEDICA (COMMERCIAL) 94265 [3081118] MEDICA CLAIMS [308111801] 92.7 percent of total billed charges 63.86 97.85 Technical (Hospital) Services Antistreptolysin O Screen PX-3028606300 CDM 86063 CPT 302 RC outpatient 103 103 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES PPO [308136801] 82.4 percent of total billed charges 63.86 97.85 Technical (Hospital) Services Antistreptolysin O Screen PX-3028606300 CDM 86063 CPT 302 RC outpatient 103 103 UNITED HEALTHCARE (COMMERCIAL) [3081199] UNITED HEALTHCARE 87726 [308119901] 63.86 percent of total billed charges 63.86 97.85 Technical (Hospital) Services Antistreptolysin O Screen PX-3028606300 CDM 86063 CPT 302 RC outpatient 103 103 HEALTHPARTNERS SX009 HEALTHPARTNERS 82.4 percent of total billed charges 63.86 97.85 Technical (Hospital) Services Antistreptolysin O Screen PX-3028606300 CDM 86063 CPT 302 RC outpatient 103 103 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES HDHP [308136802] 82.4 percent of total billed charges 63.86 97.85 Technical (Hospital) Services Antistreptolysin O Screen PX-3028606300 CDM 86063 CPT 302 RC outpatient 103 103 MULTIPLAN INC 34080 [3081285] MULTIPLAN INC [308128501] 97.85 percent of total billed charges 63.86 97.85 Technical (Hospital) Services Antistreptolysin O Screen PX-3028606300 CDM 86063 CPT 302 RC outpatient 103 103 BLUE CROSS BLUE SHIELD WELLMARK SB889 [3081026] BCBS WYOMING [308102603] 97.85 percent of total billed charges 63.86 97.85 Technical (Hospital) Services Antistreptolysin O Screen PX-3028606300 CDM 86063 CPT 302 RC outpatient 103 103 CIGNA 62308 [3081051] CIGNA 62308 [308105105] 82.4 percent of total billed charges 63.86 97.85 Technical (Hospital) Services Antistreptolysin O Screen PX-3028606300 CDM 86063 CPT 302 RC outpatient 103 103 CIGNA 62308 [3081051] CIGNA STATE OF WYOMING [308105107] 82.4 percent of total billed charges 63.86 97.85 Technical (Hospital) Services Antistreptolysin O Screen PX-3028606300 CDM 86063 CPT 302 RC outpatient 103 103 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES EPO [308136803] 82.4 percent of total billed charges 63.86 97.85 Technical (Hospital) Services Strepzt PX-3028606000 CDM 86060 CPT 302 RC outpatient 110 110 HEALTHPARTNERS SX009 HEALTHPARTNERS 88 percent of total billed charges 68.2 104.5 Technical (Hospital) Services Strepzt PX-3028606000 CDM 86060 CPT 302 RC outpatient 110 110 UNITED HEALTHCARE (COMMERCIAL) [3081199] UNITED HEALTHCARE 87726 [308119901] 68.2 percent of total billed charges 68.2 104.5 Technical (Hospital) Services Strepzt PX-3028606000 CDM 86060 CPT 302 RC outpatient 110 110 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES PPO [308136801] 88 percent of total billed charges 68.2 104.5 Technical (Hospital) Services Strepzt PX-3028606000 CDM 86060 CPT 302 RC outpatient 110 110 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES HDHP [308136802] 88 percent of total billed charges 68.2 104.5 Technical (Hospital) Services Strepzt PX-3028606000 CDM 86060 CPT 302 RC outpatient 110 110 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES EPO [308136803] 88 percent of total billed charges 68.2 104.5 Technical (Hospital) Services Strepzt PX-3028606000 CDM 86060 CPT 302 RC outpatient 110 110 CIGNA 62308 [3081051] CIGNA 62308 [308105105] 88 percent of total billed charges 68.2 104.5 Technical (Hospital) Services Strepzt PX-3028606000 CDM 86060 CPT 302 RC outpatient 110 110 CIGNA 62308 [3081051] CIGNA STATE OF WYOMING [308105107] 88 percent of total billed charges 68.2 104.5 Technical (Hospital) Services Strepzt PX-3028606000 CDM 86060 CPT 302 RC outpatient 110 110 BLUE CROSS BLUE SHIELD WELLMARK SB889 [3081026] BCBS WYOMING [308102603] 104.5 percent of total billed charges 68.2 104.5 Technical (Hospital) Services Strepzt PX-3028606000 CDM 86060 CPT 302 RC outpatient 110 110 MULTIPLAN INC 34080 [3081285] MULTIPLAN INC [308128501] 104.5 percent of total billed charges 68.2 104.5 Technical (Hospital) Services Strepzt PX-3028606000 CDM 86060 CPT 302 RC outpatient 110 110 MEDICA (COMMERCIAL) 94265 [3081118] MEDICA CLAIMS [308111801] 99 percent of total billed charges 68.2 104.5 Technical (Hospital) Services Strepzt PX-3028606000 CDM 86060 CPT 302 RC inpatient 110 110 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES EPO [308136803] 87.1 percent of total billed charges 68.2 104.5 Technical (Hospital) Services Strepzt PX-3028606000 CDM 86060 CPT 302 RC inpatient 110 110 HEALTHPARTNERS SX009 HEALTHPARTNERS 87.1 percent of total billed charges 68.2 104.5 Technical (Hospital) Services Strepzt PX-3028606000 CDM 86060 CPT 302 RC inpatient 110 110 MEDICA (COMMERCIAL) 94265 [3081118] MEDICA CLAIMS [308111801] 99 percent of total billed charges 68.2 104.5 Technical (Hospital) Services Strepzt PX-3028606000 CDM 86060 CPT 302 RC inpatient 110 110 MULTIPLAN INC 34080 [3081285] MULTIPLAN INC [308128501] 104.5 percent of total billed charges 68.2 104.5 Technical (Hospital) Services Strepzt PX-3028606000 CDM 86060 CPT 302 RC inpatient 110 110 CIGNA 62308 [3081051] CIGNA 62308 [308105105] 87.1 percent of total billed charges 68.2 104.5 Technical (Hospital) Services Strepzt PX-3028606000 CDM 86060 CPT 302 RC inpatient 110 110 CIGNA 62308 [3081051] CIGNA STATE OF WYOMING [308105107] 87.1 percent of total billed charges 68.2 104.5 Technical (Hospital) Services Strepzt PX-3028606000 CDM 86060 CPT 302 RC inpatient 110 110 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES PPO [308136801] 87.1 percent of total billed charges 68.2 104.5 Technical (Hospital) Services Strepzt PX-3028606000 CDM 86060 CPT 302 RC inpatient 110 110 UNITED HEALTHCARE (COMMERCIAL) [3081199] UNITED HEALTHCARE 87726 [308119901] 68.2 percent of total billed charges 68.2 104.5 Technical (Hospital) Services Strepzt PX-3028606000 CDM 86060 CPT 302 RC inpatient 110 110 BLUE CROSS BLUE SHIELD WELLMARK SB889 [3081026] BCBS WYOMING [308102603] 104.5 percent of total billed charges 68.2 104.5 Technical (Hospital) Services Strepzt PX-3028606000 CDM 86060 CPT 302 RC inpatient 110 110 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES HDHP [308136802] 87.1 percent of total billed charges 68.2 104.5 Technical (Hospital) Services Ref Antistrep Labtolysin O Titer PX-3028606003 CDM 86060 CPT 302 RC inpatient 91 91 MEDICA (COMMERCIAL) 94265 [3081118] MEDICA CLAIMS [308111801] 81.9 percent of total billed charges 56.42 86.45 Technical (Hospital) Services Ref Antistrep Labtolysin O Titer PX-3028606003 CDM 86060 CPT 302 RC inpatient 91 91 MULTIPLAN INC 34080 [3081285] MULTIPLAN INC [308128501] 86.45 percent of total billed charges 56.42 86.45 Technical (Hospital) Services Ref Antistrep Labtolysin O Titer PX-3028606003 CDM 86060 CPT 302 RC inpatient 91 91 CIGNA 62308 [3081051] CIGNA 62308 [308105105] 72.05 percent of total billed charges 56.42 86.45 Technical (Hospital) Services Ref Antistrep Labtolysin O Titer PX-3028606003 CDM 86060 CPT 302 RC inpatient 91 91 CIGNA 62308 [3081051] CIGNA STATE OF WYOMING [308105107] 72.05 percent of total billed charges 56.42 86.45 Technical (Hospital) Services Ref Antistrep Labtolysin O Titer PX-3028606003 CDM 86060 CPT 302 RC inpatient 91 91 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES EPO [308136803] 72.05 percent of total billed charges 56.42 86.45 Technical (Hospital) Services Ref Antistrep Labtolysin O Titer PX-3028606003 CDM 86060 CPT 302 RC inpatient 91 91 HEALTHPARTNERS SX009 HEALTHPARTNERS 72.05 percent of total billed charges 56.42 86.45 Technical (Hospital) Services Ref Antistrep Labtolysin O Titer PX-3028606003 CDM 86060 CPT 302 RC inpatient 91 91 UNITED HEALTHCARE (COMMERCIAL) [3081199] UNITED HEALTHCARE 87726 [308119901] 56.42 percent of total billed charges 56.42 86.45 Technical (Hospital) Services Ref Antistrep Labtolysin O Titer PX-3028606003 CDM 86060 CPT 302 RC inpatient 91 91 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES PPO [308136801] 72.05 percent of total billed charges 56.42 86.45 Technical (Hospital) Services Ref Antistrep Labtolysin O Titer PX-3028606003 CDM 86060 CPT 302 RC inpatient 91 91 BLUE CROSS BLUE SHIELD WELLMARK SB889 [3081026] BCBS WYOMING [308102603] 86.45 percent of total billed charges 56.42 86.45 Technical (Hospital) Services Ref Antistrep Labtolysin O Titer PX-3028606003 CDM 86060 CPT 302 RC inpatient 91 91 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES HDHP [308136802] 72.05 percent of total billed charges 56.42 86.45 Technical (Hospital) Services Ref Antistrep Labtolysin O Titer PX-3028606003 CDM 86060 CPT 302 RC outpatient 91 91 MEDICA (COMMERCIAL) 94265 [3081118] MEDICA CLAIMS [308111801] 81.9 percent of total billed charges 56.42 86.45 Technical (Hospital) Services Ref Antistrep Labtolysin O Titer PX-3028606003 CDM 86060 CPT 302 RC outpatient 91 91 UNITED HEALTHCARE (COMMERCIAL) [3081199] UNITED HEALTHCARE 87726 [308119901] 56.42 percent of total billed charges 56.42 86.45 Technical (Hospital) Services Ref Antistrep Labtolysin O Titer PX-3028606003 CDM 86060 CPT 302 RC outpatient 91 91 HEALTHPARTNERS SX009 HEALTHPARTNERS 72.8 percent of total billed charges 56.42 86.45 Technical (Hospital) Services Ref Antistrep Labtolysin O Titer PX-3028606003 CDM 86060 CPT 302 RC outpatient 91 91 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES PPO [308136801] 72.8 percent of total billed charges 56.42 86.45 Technical (Hospital) Services Ref Antistrep Labtolysin O Titer PX-3028606003 CDM 86060 CPT 302 RC outpatient 91 91 CIGNA 62308 [3081051] CIGNA 62308 [308105105] 72.8 percent of total billed charges 56.42 86.45 Technical (Hospital) Services Ref Antistrep Labtolysin O Titer PX-3028606003 CDM 86060 CPT 302 RC outpatient 91 91 CIGNA 62308 [3081051] CIGNA STATE OF WYOMING [308105107] 72.8 percent of total billed charges 56.42 86.45 Technical (Hospital) Services Ref Antistrep Labtolysin O Titer PX-3028606003 CDM 86060 CPT 302 RC outpatient 91 91 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES EPO [308136803] 72.8 percent of total billed charges 56.42 86.45 Technical (Hospital) Services Ref Antistrep Labtolysin O Titer PX-3028606003 CDM 86060 CPT 302 RC outpatient 91 91 MULTIPLAN INC 34080 [3081285] MULTIPLAN INC [308128501] 86.45 percent of total billed charges 56.42 86.45 Technical (Hospital) Services Ref Antistrep Labtolysin O Titer PX-3028606003 CDM 86060 CPT 302 RC outpatient 91 91 BLUE CROSS BLUE SHIELD WELLMARK SB889 [3081026] BCBS WYOMING [308102603] 86.45 percent of total billed charges 56.42 86.45 Technical (Hospital) Services Ref Antistrep Labtolysin O Titer PX-3028606003 CDM 86060 CPT 302 RC outpatient 91 91 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES HDHP [308136802] 72.8 percent of total billed charges 56.42 86.45 Technical (Hospital) Services Fana Titer PX-3028603900 CDM 86039 CPT 302 RC inpatient 160 160 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES HDHP [308136802] 126.69 percent of total billed charges 99.2 152 Technical (Hospital) Services Fana Titer PX-3028603900 CDM 86039 CPT 302 RC inpatient 160 160 BLUE CROSS BLUE SHIELD WELLMARK SB889 [3081026] BCBS WYOMING [308102603] 152 percent of total billed charges 99.2 152 Technical (Hospital) Services Fana Titer PX-3028603900 CDM 86039 CPT 302 RC inpatient 160 160 UNITED HEALTHCARE (COMMERCIAL) [3081199] UNITED HEALTHCARE 87726 [308119901] 99.2 percent of total billed charges 99.2 152 Technical (Hospital) Services Fana Titer PX-3028603900 CDM 86039 CPT 302 RC inpatient 160 160 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES PPO [308136801] 126.69 percent of total billed charges 99.2 152 Technical (Hospital) Services Fana Titer PX-3028603900 CDM 86039 CPT 302 RC inpatient 160 160 CIGNA 62308 [3081051] CIGNA 62308 [308105105] 126.69 percent of total billed charges 99.2 152 Technical (Hospital) Services Fana Titer PX-3028603900 CDM 86039 CPT 302 RC inpatient 160 160 CIGNA 62308 [3081051] CIGNA STATE OF WYOMING [308105107] 126.69 percent of total billed charges 99.2 152 Technical (Hospital) Services Fana Titer PX-3028603900 CDM 86039 CPT 302 RC inpatient 160 160 MULTIPLAN INC 34080 [3081285] MULTIPLAN INC [308128501] 152 percent of total billed charges 99.2 152 Technical (Hospital) Services Fana Titer PX-3028603900 CDM 86039 CPT 302 RC inpatient 160 160 MEDICA (COMMERCIAL) 94265 [3081118] MEDICA CLAIMS [308111801] 144 percent of total billed charges 99.2 152 Technical (Hospital) Services Fana Titer PX-3028603900 CDM 86039 CPT 302 RC inpatient 160 160 HEALTHPARTNERS SX009 HEALTHPARTNERS 126.69 percent of total billed charges 99.2 152 Technical (Hospital) Services Fana Titer PX-3028603900 CDM 86039 CPT 302 RC inpatient 160 160 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES EPO [308136803] 126.69 percent of total billed charges 99.2 152 Technical (Hospital) Services Fana Titer PX-3028603900 CDM 86039 CPT 302 RC outpatient 160 160 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES PPO [308136801] 128 percent of total billed charges 99.2 152 Technical (Hospital) Services Fana Titer PX-3028603900 CDM 86039 CPT 302 RC outpatient 160 160 HEALTHPARTNERS SX009 HEALTHPARTNERS 128 percent of total billed charges 99.2 152 Technical (Hospital) Services Fana Titer PX-3028603900 CDM 86039 CPT 302 RC outpatient 160 160 UNITED HEALTHCARE (COMMERCIAL) [3081199] UNITED HEALTHCARE 87726 [308119901] 99.2 percent of total billed charges 99.2 152 Technical (Hospital) Services Fana Titer PX-3028603900 CDM 86039 CPT 302 RC outpatient 160 160 MULTIPLAN INC 34080 [3081285] MULTIPLAN INC [308128501] 152 percent of total billed charges 99.2 152 Technical (Hospital) Services Fana Titer PX-3028603900 CDM 86039 CPT 302 RC outpatient 160 160 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES EPO [308136803] 128 percent of total billed charges 99.2 152 Technical (Hospital) Services Fana Titer PX-3028603900 CDM 86039 CPT 302 RC outpatient 160 160 CIGNA 62308 [3081051] CIGNA 62308 [308105105] 128 percent of total billed charges 99.2 152 Technical (Hospital) Services Fana Titer PX-3028603900 CDM 86039 CPT 302 RC outpatient 160 160 CIGNA 62308 [3081051] CIGNA STATE OF WYOMING [308105107] 128 percent of total billed charges 99.2 152 Technical (Hospital) Services Fana Titer PX-3028603900 CDM 86039 CPT 302 RC outpatient 160 160 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES HDHP [308136802] 128 percent of total billed charges 99.2 152 Technical (Hospital) Services Fana Titer PX-3028603900 CDM 86039 CPT 302 RC outpatient 160 160 BLUE CROSS BLUE SHIELD WELLMARK SB889 [3081026] BCBS WYOMING [308102603] 152 percent of total billed charges 99.2 152 Technical (Hospital) Services Fana Titer PX-3028603900 CDM 86039 CPT 302 RC outpatient 160 160 MEDICA (COMMERCIAL) 94265 [3081118] MEDICA CLAIMS [308111801] 144 percent of total billed charges 99.2 152 Technical (Hospital) Services "HC Ref Antinuclear Antibodies, Hep-2 Substrate, Igg (Mayo)" PX-3028603902 CDM 86039 CPT 302 RC inpatient 45 45 HEALTHPARTNERS SX009 HEALTHPARTNERS 35.63 percent of total billed charges 27.9 42.75 Technical (Hospital) Services "HC Ref Antinuclear Antibodies, Hep-2 Substrate, Igg (Mayo)" PX-3028603902 CDM 86039 CPT 302 RC inpatient 45 45 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES EPO [308136803] 35.63 percent of total billed charges 27.9 42.75 Technical (Hospital) Services "HC Ref Antinuclear Antibodies, Hep-2 Substrate, Igg (Mayo)" PX-3028603902 CDM 86039 CPT 302 RC inpatient 45 45 CIGNA 62308 [3081051] CIGNA 62308 [308105105] 35.63 percent of total billed charges 27.9 42.75 Technical (Hospital) Services "HC Ref Antinuclear Antibodies, Hep-2 Substrate, Igg (Mayo)" PX-3028603902 CDM 86039 CPT 302 RC inpatient 45 45 CIGNA 62308 [3081051] CIGNA STATE OF WYOMING [308105107] 35.63 percent of total billed charges 27.9 42.75 Technical (Hospital) Services "HC Ref Antinuclear Antibodies, Hep-2 Substrate, Igg (Mayo)" PX-3028603902 CDM 86039 CPT 302 RC inpatient 45 45 MULTIPLAN INC 34080 [3081285] MULTIPLAN INC [308128501] 42.75 percent of total billed charges 27.9 42.75 Technical (Hospital) Services "HC Ref Antinuclear Antibodies, Hep-2 Substrate, Igg (Mayo)" PX-3028603902 CDM 86039 CPT 302 RC inpatient 45 45 MEDICA (COMMERCIAL) 94265 [3081118] MEDICA CLAIMS [308111801] 40.5 percent of total billed charges 27.9 42.75 Technical (Hospital) Services "HC Ref Antinuclear Antibodies, Hep-2 Substrate, Igg (Mayo)" PX-3028603902 CDM 86039 CPT 302 RC inpatient 45 45 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES PPO [308136801] 35.63 percent of total billed charges 27.9 42.75 Technical (Hospital) Services "HC Ref Antinuclear Antibodies, Hep-2 Substrate, Igg (Mayo)" PX-3028603902 CDM 86039 CPT 302 RC inpatient 45 45 UNITED HEALTHCARE (COMMERCIAL) [3081199] UNITED HEALTHCARE 87726 [308119901] 27.9 percent of total billed charges 27.9 42.75 Technical (Hospital) Services "HC Ref Antinuclear Antibodies, Hep-2 Substrate, Igg (Mayo)" PX-3028603902 CDM 86039 CPT 302 RC inpatient 45 45 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES HDHP [308136802] 35.63 percent of total billed charges 27.9 42.75 Technical (Hospital) Services "HC Ref Antinuclear Antibodies, Hep-2 Substrate, Igg (Mayo)" PX-3028603902 CDM 86039 CPT 302 RC inpatient 45 45 BLUE CROSS BLUE SHIELD WELLMARK SB889 [3081026] BCBS WYOMING [308102603] 42.75 percent of total billed charges 27.9 42.75 Technical (Hospital) Services "HC Ref Antinuclear Antibodies, Hep-2 Substrate, Igg (Mayo)" PX-3028603902 CDM 86039 CPT 302 RC outpatient 45 45 UNITED HEALTHCARE (COMMERCIAL) [3081199] UNITED HEALTHCARE 87726 [308119901] 27.9 percent of total billed charges 27.9 42.75 Technical (Hospital) Services "HC Ref Antinuclear Antibodies, Hep-2 Substrate, Igg (Mayo)" PX-3028603902 CDM 86039 CPT 302 RC outpatient 45 45 HEALTHPARTNERS SX009 HEALTHPARTNERS 36 percent of total billed charges 27.9 42.75 Technical (Hospital) Services "HC Ref Antinuclear Antibodies, Hep-2 Substrate, Igg (Mayo)" PX-3028603902 CDM 86039 CPT 302 RC outpatient 45 45 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES PPO [308136801] 36 percent of total billed charges 27.9 42.75 Technical (Hospital) Services "HC Ref Antinuclear Antibodies, Hep-2 Substrate, Igg (Mayo)" PX-3028603902 CDM 86039 CPT 302 RC outpatient 45 45 MULTIPLAN INC 34080 [3081285] MULTIPLAN INC [308128501] 42.75 percent of total billed charges 27.9 42.75 Technical (Hospital) Services "HC Ref Antinuclear Antibodies, Hep-2 Substrate, Igg (Mayo)" PX-3028603902 CDM 86039 CPT 302 RC outpatient 45 45 CIGNA 62308 [3081051] CIGNA 62308 [308105105] 36 percent of total billed charges 27.9 42.75 Technical (Hospital) Services "HC Ref Antinuclear Antibodies, Hep-2 Substrate, Igg (Mayo)" PX-3028603902 CDM 86039 CPT 302 RC outpatient 45 45 CIGNA 62308 [3081051] CIGNA STATE OF WYOMING [308105107] 36 percent of total billed charges 27.9 42.75 Technical (Hospital) Services "HC Ref Antinuclear Antibodies, Hep-2 Substrate, Igg (Mayo)" PX-3028603902 CDM 86039 CPT 302 RC outpatient 45 45 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES EPO [308136803] 36 percent of total billed charges 27.9 42.75 Technical (Hospital) Services "HC Ref Antinuclear Antibodies, Hep-2 Substrate, Igg (Mayo)" PX-3028603902 CDM 86039 CPT 302 RC outpatient 45 45 BLUE CROSS BLUE SHIELD WELLMARK SB889 [3081026] BCBS WYOMING [308102603] 42.75 percent of total billed charges 27.9 42.75 Technical (Hospital) Services "HC Ref Antinuclear Antibodies, Hep-2 Substrate, Igg (Mayo)" PX-3028603902 CDM 86039 CPT 302 RC outpatient 45 45 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES HDHP [308136802] 36 percent of total billed charges 27.9 42.75 Technical (Hospital) Services "HC Ref Antinuclear Antibodies, Hep-2 Substrate, Igg (Mayo)" PX-3028603902 CDM 86039 CPT 302 RC outpatient 45 45 MEDICA (COMMERCIAL) 94265 [3081118] MEDICA CLAIMS [308111801] 40.5 percent of total billed charges 27.9 42.75 Technical (Hospital) Services Anti Nuclear Ab PX-3028603800 CDM 86038 CPT 302 RC outpatient 160 160 HEALTHPARTNERS SX009 HEALTHPARTNERS 128 percent of total billed charges 99.2 152 Technical (Hospital) Services Anti Nuclear Ab PX-3028603800 CDM 86038 CPT 302 RC outpatient 160 160 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES PPO [308136801] 128 percent of total billed charges 99.2 152 Technical (Hospital) Services Anti Nuclear Ab PX-3028603800 CDM 86038 CPT 302 RC outpatient 160 160 UNITED HEALTHCARE (COMMERCIAL) [3081199] UNITED HEALTHCARE 87726 [308119901] 99.2 percent of total billed charges 99.2 152 Technical (Hospital) Services Anti Nuclear Ab PX-3028603800 CDM 86038 CPT 302 RC outpatient 160 160 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES HDHP [308136802] 128 percent of total billed charges 99.2 152 Technical (Hospital) Services Anti Nuclear Ab PX-3028603800 CDM 86038 CPT 302 RC outpatient 160 160 BLUE CROSS BLUE SHIELD WELLMARK SB889 [3081026] BCBS WYOMING [308102603] 152 percent of total billed charges 99.2 152 Technical (Hospital) Services Anti Nuclear Ab PX-3028603800 CDM 86038 CPT 302 RC outpatient 160 160 MULTIPLAN INC 34080 [3081285] MULTIPLAN INC [308128501] 152 percent of total billed charges 99.2 152 Technical (Hospital) Services Anti Nuclear Ab PX-3028603800 CDM 86038 CPT 302 RC outpatient 160 160 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES EPO [308136803] 128 percent of total billed charges 99.2 152 Technical (Hospital) Services Anti Nuclear Ab PX-3028603800 CDM 86038 CPT 302 RC outpatient 160 160 CIGNA 62308 [3081051] CIGNA 62308 [308105105] 128 percent of total billed charges 99.2 152 Technical (Hospital) Services Anti Nuclear Ab PX-3028603800 CDM 86038 CPT 302 RC outpatient 160 160 CIGNA 62308 [3081051] CIGNA STATE OF WYOMING [308105107] 128 percent of total billed charges 99.2 152 Technical (Hospital) Services Anti Nuclear Ab PX-3028603800 CDM 86038 CPT 302 RC outpatient 160 160 MEDICA (COMMERCIAL) 94265 [3081118] MEDICA CLAIMS [308111801] 144 percent of total billed charges 99.2 152 Technical (Hospital) Services Anti Nuclear Ab PX-3028603800 CDM 86038 CPT 302 RC inpatient 160 160 MEDICA (COMMERCIAL) 94265 [3081118] MEDICA CLAIMS [308111801] 144 percent of total billed charges 99.2 152 Technical (Hospital) Services Anti Nuclear Ab PX-3028603800 CDM 86038 CPT 302 RC inpatient 160 160 MULTIPLAN INC 34080 [3081285] MULTIPLAN INC [308128501] 152 percent of total billed charges 99.2 152 Technical (Hospital) Services Anti Nuclear Ab PX-3028603800 CDM 86038 CPT 302 RC inpatient 160 160 CIGNA 62308 [3081051] CIGNA 62308 [308105105] 126.69 percent of total billed charges 99.2 152 Technical (Hospital) Services Anti Nuclear Ab PX-3028603800 CDM 86038 CPT 302 RC inpatient 160 160 CIGNA 62308 [3081051] CIGNA STATE OF WYOMING [308105107] 126.69 percent of total billed charges 99.2 152 Technical (Hospital) Services Anti Nuclear Ab PX-3028603800 CDM 86038 CPT 302 RC inpatient 160 160 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES EPO [308136803] 126.69 percent of total billed charges 99.2 152 Technical (Hospital) Services Anti Nuclear Ab PX-3028603800 CDM 86038 CPT 302 RC inpatient 160 160 HEALTHPARTNERS SX009 HEALTHPARTNERS 126.69 percent of total billed charges 99.2 152 Technical (Hospital) Services Anti Nuclear Ab PX-3028603800 CDM 86038 CPT 302 RC inpatient 160 160 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES PPO [308136801] 126.69 percent of total billed charges 99.2 152 Technical (Hospital) Services Anti Nuclear Ab PX-3028603800 CDM 86038 CPT 302 RC inpatient 160 160 UNITED HEALTHCARE (COMMERCIAL) [3081199] UNITED HEALTHCARE 87726 [308119901] 99.2 percent of total billed charges 99.2 152 Technical (Hospital) Services Anti Nuclear Ab PX-3028603800 CDM 86038 CPT 302 RC inpatient 160 160 BLUE CROSS BLUE SHIELD WELLMARK SB889 [3081026] BCBS WYOMING [308102603] 152 percent of total billed charges 99.2 152 Technical (Hospital) Services Anti Nuclear Ab PX-3028603800 CDM 86038 CPT 302 RC inpatient 160 160 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES HDHP [308136802] 126.69 percent of total billed charges 99.2 152 Technical (Hospital) Services "HC Ana (Antinuclear Antibodies), Screen W or W/O Reflex Mia" PX-3028603807 CDM 86038 CPT 302 RC inpatient 110 110 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES HDHP [308136802] 87.1 percent of total billed charges 68.2 104.5 Technical (Hospital) Services "HC Ana (Antinuclear Antibodies), Screen W or W/O Reflex Mia" PX-3028603807 CDM 86038 CPT 302 RC inpatient 110 110 BLUE CROSS BLUE SHIELD WELLMARK SB889 [3081026] BCBS WYOMING [308102603] 104.5 percent of total billed charges 68.2 104.5 Technical (Hospital) Services "HC Ana (Antinuclear Antibodies), Screen W or W/O Reflex Mia" PX-3028603807 CDM 86038 CPT 302 RC inpatient 110 110 UNITED HEALTHCARE (COMMERCIAL) [3081199] UNITED HEALTHCARE 87726 [308119901] 68.2 percent of total billed charges 68.2 104.5 Technical (Hospital) Services "HC Ana (Antinuclear Antibodies), Screen W or W/O Reflex Mia" PX-3028603807 CDM 86038 CPT 302 RC inpatient 110 110 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES PPO [308136801] 87.1 percent of total billed charges 68.2 104.5 Technical (Hospital) Services "HC Ana (Antinuclear Antibodies), Screen W or W/O Reflex Mia" PX-3028603807 CDM 86038 CPT 302 RC inpatient 110 110 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES EPO [308136803] 87.1 percent of total billed charges 68.2 104.5 Technical (Hospital) Services "HC Ana (Antinuclear Antibodies), Screen W or W/O Reflex Mia" PX-3028603807 CDM 86038 CPT 302 RC inpatient 110 110 HEALTHPARTNERS SX009 HEALTHPARTNERS 87.1 percent of total billed charges 68.2 104.5 Technical (Hospital) Services "HC Ana (Antinuclear Antibodies), Screen W or W/O Reflex Mia" PX-3028603807 CDM 86038 CPT 302 RC inpatient 110 110 MULTIPLAN INC 34080 [3081285] MULTIPLAN INC [308128501] 104.5 percent of total billed charges 68.2 104.5 Technical (Hospital) Services "HC Ana (Antinuclear Antibodies), Screen W or W/O Reflex Mia" PX-3028603807 CDM 86038 CPT 302 RC inpatient 110 110 MEDICA (COMMERCIAL) 94265 [3081118] MEDICA CLAIMS [308111801] 99 percent of total billed charges 68.2 104.5 Technical (Hospital) Services "HC Ana (Antinuclear Antibodies), Screen W or W/O Reflex Mia" PX-3028603807 CDM 86038 CPT 302 RC inpatient 110 110 CIGNA 62308 [3081051] CIGNA 62308 [308105105] 87.1 percent of total billed charges 68.2 104.5 Technical (Hospital) Services "HC Ana (Antinuclear Antibodies), Screen W or W/O Reflex Mia" PX-3028603807 CDM 86038 CPT 302 RC inpatient 110 110 CIGNA 62308 [3081051] CIGNA STATE OF WYOMING [308105107] 87.1 percent of total billed charges 68.2 104.5 Technical (Hospital) Services "HC Ana (Antinuclear Antibodies), Screen W or W/O Reflex Mia" PX-3028603807 CDM 86038 CPT 302 RC outpatient 110 110 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES HDHP [308136802] 88 percent of total billed charges 68.2 104.5 Technical (Hospital) Services "HC Ana (Antinuclear Antibodies), Screen W or W/O Reflex Mia" PX-3028603807 CDM 86038 CPT 302 RC outpatient 110 110 MULTIPLAN INC 34080 [3081285] MULTIPLAN INC [308128501] 104.5 percent of total billed charges 68.2 104.5 Technical (Hospital) Services "HC Ana (Antinuclear Antibodies), Screen W or W/O Reflex Mia" PX-3028603807 CDM 86038 CPT 302 RC outpatient 110 110 BLUE CROSS BLUE SHIELD WELLMARK SB889 [3081026] BCBS WYOMING [308102603] 104.5 percent of total billed charges 68.2 104.5 Technical (Hospital) Services "HC Ana (Antinuclear Antibodies), Screen W or W/O Reflex Mia" PX-3028603807 CDM 86038 CPT 302 RC outpatient 110 110 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES EPO [308136803] 88 percent of total billed charges 68.2 104.5 Technical (Hospital) Services "HC Ana (Antinuclear Antibodies), Screen W or W/O Reflex Mia" PX-3028603807 CDM 86038 CPT 302 RC outpatient 110 110 CIGNA 62308 [3081051] CIGNA 62308 [308105105] 88 percent of total billed charges 68.2 104.5 Technical (Hospital) Services "HC Ana (Antinuclear Antibodies), Screen W or W/O Reflex Mia" PX-3028603807 CDM 86038 CPT 302 RC outpatient 110 110 CIGNA 62308 [3081051] CIGNA STATE OF WYOMING [308105107] 88 percent of total billed charges 68.2 104.5 Technical (Hospital) Services "HC Ana (Antinuclear Antibodies), Screen W or W/O Reflex Mia" PX-3028603807 CDM 86038 CPT 302 RC outpatient 110 110 UNITED HEALTHCARE (COMMERCIAL) [3081199] UNITED HEALTHCARE 87726 [308119901] 68.2 percent of total billed charges 68.2 104.5 Technical (Hospital) Services "HC Ana (Antinuclear Antibodies), Screen W or W/O Reflex Mia" PX-3028603807 CDM 86038 CPT 302 RC outpatient 110 110 HEALTHPARTNERS SX009 HEALTHPARTNERS 88 percent of total billed charges 68.2 104.5 Technical (Hospital) Services "HC Ana (Antinuclear Antibodies), Screen W or W/O Reflex Mia" PX-3028603807 CDM 86038 CPT 302 RC outpatient 110 110 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES PPO [308136801] 88 percent of total billed charges 68.2 104.5 Technical (Hospital) Services "HC Ana (Antinuclear Antibodies), Screen W or W/O Reflex Mia" PX-3028603807 CDM 86038 CPT 302 RC outpatient 110 110 MEDICA (COMMERCIAL) 94265 [3081118] MEDICA CLAIMS [308111801] 99 percent of total billed charges 68.2 104.5 Technical (Hospital) Services Ref Food Panel PX-3028600300 CDM 86003 CPT 302 RC inpatient 51 51 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES HDHP [308136802] 40.38 percent of total billed charges 31.62 48.45 Technical (Hospital) Services Ref Food Panel PX-3028600300 CDM 86003 CPT 302 RC inpatient 51 51 BLUE CROSS BLUE SHIELD WELLMARK SB889 [3081026] BCBS WYOMING [308102603] 48.45 percent of total billed charges 31.62 48.45 Technical (Hospital) Services Ref Food Panel PX-3028600300 CDM 86003 CPT 302 RC inpatient 51 51 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES PPO [308136801] 40.38 percent of total billed charges 31.62 48.45 Technical (Hospital) Services Ref Food Panel PX-3028600300 CDM 86003 CPT 302 RC inpatient 51 51 UNITED HEALTHCARE (COMMERCIAL) [3081199] UNITED HEALTHCARE 87726 [308119901] 31.62 percent of total billed charges 31.62 48.45 Technical (Hospital) Services Ref Food Panel PX-3028600300 CDM 86003 CPT 302 RC inpatient 51 51 CIGNA 62308 [3081051] CIGNA 62308 [308105105] 40.38 percent of total billed charges 31.62 48.45 Technical (Hospital) Services Ref Food Panel PX-3028600300 CDM 86003 CPT 302 RC inpatient 51 51 CIGNA 62308 [3081051] CIGNA STATE OF WYOMING [308105107] 40.38 percent of total billed charges 31.62 48.45 Technical (Hospital) Services Ref Food Panel PX-3028600300 CDM 86003 CPT 302 RC inpatient 51 51 MULTIPLAN INC 34080 [3081285] MULTIPLAN INC [308128501] 48.45 percent of total billed charges 31.62 48.45 Technical (Hospital) Services Ref Food Panel PX-3028600300 CDM 86003 CPT 302 RC inpatient 51 51 MEDICA (COMMERCIAL) 94265 [3081118] MEDICA CLAIMS [308111801] 45.9 percent of total billed charges 31.62 48.45 Technical (Hospital) Services Ref Food Panel PX-3028600300 CDM 86003 CPT 302 RC inpatient 51 51 HEALTHPARTNERS SX009 HEALTHPARTNERS 40.38 percent of total billed charges 31.62 48.45 Technical (Hospital) Services Ref Food Panel PX-3028600300 CDM 86003 CPT 302 RC inpatient 51 51 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES EPO [308136803] 40.38 percent of total billed charges 31.62 48.45 Technical (Hospital) Services Ref Food Panel PX-3028600300 CDM 86003 CPT 302 RC outpatient 51 51 MEDICA (COMMERCIAL) 94265 [3081118] MEDICA CLAIMS [308111801] 45.9 percent of total billed charges 31.62 48.45 Technical (Hospital) Services Ref Food Panel PX-3028600300 CDM 86003 CPT 302 RC outpatient 51 51 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES EPO [308136803] 40.8 percent of total billed charges 31.62 48.45 Technical (Hospital) Services Ref Food Panel PX-3028600300 CDM 86003 CPT 302 RC outpatient 51 51 CIGNA 62308 [3081051] CIGNA 62308 [308105105] 40.8 percent of total billed charges 31.62 48.45 Technical (Hospital) Services Ref Food Panel PX-3028600300 CDM 86003 CPT 302 RC outpatient 51 51 CIGNA 62308 [3081051] CIGNA STATE OF WYOMING [308105107] 40.8 percent of total billed charges 31.62 48.45 Technical (Hospital) Services Ref Food Panel PX-3028600300 CDM 86003 CPT 302 RC outpatient 51 51 BLUE CROSS BLUE SHIELD WELLMARK SB889 [3081026] BCBS WYOMING [308102603] 48.45 percent of total billed charges 31.62 48.45 Technical (Hospital) Services Ref Food Panel PX-3028600300 CDM 86003 CPT 302 RC outpatient 51 51 MULTIPLAN INC 34080 [3081285] MULTIPLAN INC [308128501] 48.45 percent of total billed charges 31.62 48.45 Technical (Hospital) Services Ref Food Panel PX-3028600300 CDM 86003 CPT 302 RC outpatient 51 51 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES HDHP [308136802] 40.8 percent of total billed charges 31.62 48.45 Technical (Hospital) Services Ref Food Panel PX-3028600300 CDM 86003 CPT 302 RC outpatient 51 51 UNITED HEALTHCARE (COMMERCIAL) [3081199] UNITED HEALTHCARE 87726 [308119901] 31.62 percent of total billed charges 31.62 48.45 Technical (Hospital) Services Ref Food Panel PX-3028600300 CDM 86003 CPT 302 RC outpatient 51 51 HEALTHPARTNERS SX009 HEALTHPARTNERS 40.8 percent of total billed charges 31.62 48.45 Technical (Hospital) Services Ref Food Panel PX-3028600300 CDM 86003 CPT 302 RC outpatient 51 51 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES PPO [308136801] 40.8 percent of total billed charges 31.62 48.45 Technical (Hospital) Services Ref Allergen Specific Ige PX-3028600301 CDM 86003 CPT 302 RC inpatient 51 51 UNITED HEALTHCARE (COMMERCIAL) [3081199] UNITED HEALTHCARE 87726 [308119901] 31.62 percent of total billed charges 31.62 48.45 Technical (Hospital) Services Ref Allergen Specific Ige PX-3028600301 CDM 86003 CPT 302 RC inpatient 51 51 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES PPO [308136801] 40.38 percent of total billed charges 31.62 48.45 Technical (Hospital) Services Ref Allergen Specific Ige PX-3028600301 CDM 86003 CPT 302 RC inpatient 51 51 BLUE CROSS BLUE SHIELD WELLMARK SB889 [3081026] BCBS WYOMING [308102603] 48.45 percent of total billed charges 31.62 48.45 Technical (Hospital) Services Ref Allergen Specific Ige PX-3028600301 CDM 86003 CPT 302 RC inpatient 51 51 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES HDHP [308136802] 40.38 percent of total billed charges 31.62 48.45 Technical (Hospital) Services Ref Allergen Specific Ige PX-3028600301 CDM 86003 CPT 302 RC inpatient 51 51 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES EPO [308136803] 40.38 percent of total billed charges 31.62 48.45 Technical (Hospital) Services Ref Allergen Specific Ige PX-3028600301 CDM 86003 CPT 302 RC inpatient 51 51 HEALTHPARTNERS SX009 HEALTHPARTNERS 40.38 percent of total billed charges 31.62 48.45 Technical (Hospital) Services Ref Allergen Specific Ige PX-3028600301 CDM 86003 CPT 302 RC inpatient 51 51 CIGNA 62308 [3081051] CIGNA 62308 [308105105] 40.38 percent of total billed charges 31.62 48.45 Technical (Hospital) Services Ref Allergen Specific Ige PX-3028600301 CDM 86003 CPT 302 RC inpatient 51 51 CIGNA 62308 [3081051] CIGNA STATE OF WYOMING [308105107] 40.38 percent of total billed charges 31.62 48.45 Technical (Hospital) Services Ref Allergen Specific Ige PX-3028600301 CDM 86003 CPT 302 RC inpatient 51 51 MULTIPLAN INC 34080 [3081285] MULTIPLAN INC [308128501] 48.45 percent of total billed charges 31.62 48.45 Technical (Hospital) Services Ref Allergen Specific Ige PX-3028600301 CDM 86003 CPT 302 RC inpatient 51 51 MEDICA (COMMERCIAL) 94265 [3081118] MEDICA CLAIMS [308111801] 45.9 percent of total billed charges 31.62 48.45 Technical (Hospital) Services Ref Allergen Specific Ige PX-3028600301 CDM 86003 CPT 302 RC outpatient 51 51 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES HDHP [308136802] 40.8 percent of total billed charges 31.62 48.45 Technical (Hospital) Services Ref Allergen Specific Ige PX-3028600301 CDM 86003 CPT 302 RC outpatient 51 51 MULTIPLAN INC 34080 [3081285] MULTIPLAN INC [308128501] 48.45 percent of total billed charges 31.62 48.45 Technical (Hospital) Services Ref Allergen Specific Ige PX-3028600301 CDM 86003 CPT 302 RC outpatient 51 51 BLUE CROSS BLUE SHIELD WELLMARK SB889 [3081026] BCBS WYOMING [308102603] 48.45 percent of total billed charges 31.62 48.45 Technical (Hospital) Services Ref Allergen Specific Ige PX-3028600301 CDM 86003 CPT 302 RC outpatient 51 51 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES EPO [308136803] 40.8 percent of total billed charges 31.62 48.45 Technical (Hospital) Services Ref Allergen Specific Ige PX-3028600301 CDM 86003 CPT 302 RC outpatient 51 51 CIGNA 62308 [3081051] CIGNA 62308 [308105105] 40.8 percent of total billed charges 31.62 48.45 Technical (Hospital) Services Ref Allergen Specific Ige PX-3028600301 CDM 86003 CPT 302 RC outpatient 51 51 CIGNA 62308 [3081051] CIGNA STATE OF WYOMING [308105107] 40.8 percent of total billed charges 31.62 48.45 Technical (Hospital) Services Ref Allergen Specific Ige PX-3028600301 CDM 86003 CPT 302 RC outpatient 51 51 UNITED HEALTHCARE (COMMERCIAL) [3081199] UNITED HEALTHCARE 87726 [308119901] 31.62 percent of total billed charges 31.62 48.45 Technical (Hospital) Services Ref Allergen Specific Ige PX-3028600301 CDM 86003 CPT 302 RC outpatient 51 51 HEALTHPARTNERS SX009 HEALTHPARTNERS 40.8 percent of total billed charges 31.62 48.45 Technical (Hospital) Services Ref Allergen Specific Ige PX-3028600301 CDM 86003 CPT 302 RC outpatient 51 51 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES PPO [308136801] 40.8 percent of total billed charges 31.62 48.45 Technical (Hospital) Services Ref Allergen Specific Ige PX-3028600301 CDM 86003 CPT 302 RC outpatient 51 51 MEDICA (COMMERCIAL) 94265 [3081118] MEDICA CLAIMS [308111801] 45.9 percent of total billed charges 31.62 48.45 Technical (Hospital) Services PTT PX-3058573000 CDM 85730 CPT 305 RC inpatient 101 101 MULTIPLAN INC 34080 [3081285] MULTIPLAN INC [308128501] 95.95 percent of total billed charges 62.62 95.95 Technical (Hospital) Services PTT PX-3058573000 CDM 85730 CPT 305 RC inpatient 101 101 CIGNA 62308 [3081051] CIGNA 62308 [308105105] 79.97 percent of total billed charges 62.62 95.95 Technical (Hospital) Services PTT PX-3058573000 CDM 85730 CPT 305 RC inpatient 101 101 CIGNA 62308 [3081051] CIGNA STATE OF WYOMING [308105107] 79.97 percent of total billed charges 62.62 95.95 Technical (Hospital) Services PTT PX-3058573000 CDM 85730 CPT 305 RC inpatient 101 101 BLUE CROSS BLUE SHIELD WELLMARK SB889 [3081026] BCBS WYOMING [308102603] 95.95 percent of total billed charges 62.62 95.95 Technical (Hospital) Services PTT PX-3058573000 CDM 85730 CPT 305 RC inpatient 101 101 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES EPO [308136803] 79.97 percent of total billed charges 62.62 95.95 Technical (Hospital) Services PTT PX-3058573000 CDM 85730 CPT 305 RC inpatient 101 101 HEALTHPARTNERS SX009 HEALTHPARTNERS 79.97 percent of total billed charges 62.62 95.95 Technical (Hospital) Services PTT PX-3058573000 CDM 85730 CPT 305 RC inpatient 101 101 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES PPO [308136801] 79.97 percent of total billed charges 62.62 95.95 Technical (Hospital) Services PTT PX-3058573000 CDM 85730 CPT 305 RC inpatient 101 101 MEDICA (COMMERCIAL) 94265 [3081118] MEDICA CLAIMS [308111801] 90.9 percent of total billed charges 62.62 95.95 Technical (Hospital) Services PTT PX-3058573000 CDM 85730 CPT 305 RC inpatient 101 101 UNITED HEALTHCARE (COMMERCIAL) [3081199] UNITED HEALTHCARE 87726 [308119901] 62.62 percent of total billed charges 62.62 95.95 Technical (Hospital) Services PTT PX-3058573000 CDM 85730 CPT 305 RC inpatient 101 101 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES HDHP [308136802] 79.97 percent of total billed charges 62.62 95.95 Technical (Hospital) Services PTT PX-3058573000 CDM 85730 CPT 305 RC outpatient 101 101 MEDICA (COMMERCIAL) 94265 [3081118] MEDICA CLAIMS [308111801] 90.9 percent of total billed charges 62.62 95.95 Technical (Hospital) Services PTT PX-3058573000 CDM 85730 CPT 305 RC outpatient 101 101 UNITED HEALTHCARE (COMMERCIAL) [3081199] UNITED HEALTHCARE 87726 [308119901] 62.62 percent of total billed charges 62.62 95.95 Technical (Hospital) Services PTT PX-3058573000 CDM 85730 CPT 305 RC outpatient 101 101 HEALTHPARTNERS SX009 HEALTHPARTNERS 80.8 percent of total billed charges 62.62 95.95 Technical (Hospital) Services PTT PX-3058573000 CDM 85730 CPT 305 RC outpatient 101 101 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES PPO [308136801] 80.8 percent of total billed charges 62.62 95.95 Technical (Hospital) Services PTT PX-3058573000 CDM 85730 CPT 305 RC outpatient 101 101 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES HDHP [308136802] 80.8 percent of total billed charges 62.62 95.95 Technical (Hospital) Services PTT PX-3058573000 CDM 85730 CPT 305 RC outpatient 101 101 BLUE CROSS BLUE SHIELD WELLMARK SB889 [3081026] BCBS WYOMING [308102603] 95.95 percent of total billed charges 62.62 95.95 Technical (Hospital) Services PTT PX-3058573000 CDM 85730 CPT 305 RC outpatient 101 101 CIGNA 62308 [3081051] CIGNA 62308 [308105105] 80.8 percent of total billed charges 62.62 95.95 Technical (Hospital) Services PTT PX-3058573000 CDM 85730 CPT 305 RC outpatient 101 101 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES EPO [308136803] 80.8 percent of total billed charges 62.62 95.95 Technical (Hospital) Services PTT PX-3058573000 CDM 85730 CPT 305 RC outpatient 101 101 CIGNA 62308 [3081051] CIGNA STATE OF WYOMING [308105107] 80.8 percent of total billed charges 62.62 95.95 Technical (Hospital) Services PTT PX-3058573000 CDM 85730 CPT 305 RC outpatient 101 101 MULTIPLAN INC 34080 [3081285] MULTIPLAN INC [308128501] 95.95 percent of total billed charges 62.62 95.95 Technical (Hospital) Services "Ref Activated Partial Thrombopla Time, P (Mayo) Aathr Panel" PX-3058573006 CDM 85730 CPT 305 RC inpatient 75 75 CIGNA 62308 [3081051] CIGNA 62308 [308105105] 59.39 percent of total billed charges 46.5 71.25 Technical (Hospital) Services "Ref Activated Partial Thrombopla Time, P (Mayo) Aathr Panel" PX-3058573006 CDM 85730 CPT 305 RC inpatient 75 75 CIGNA 62308 [3081051] CIGNA STATE OF WYOMING [308105107] 59.39 percent of total billed charges 46.5 71.25 Technical (Hospital) Services "Ref Activated Partial Thrombopla Time, P (Mayo) Aathr Panel" PX-3058573006 CDM 85730 CPT 305 RC inpatient 75 75 BLUE CROSS BLUE SHIELD WELLMARK SB889 [3081026] BCBS WYOMING [308102603] 71.25 percent of total billed charges 46.5 71.25 Technical (Hospital) Services "Ref Activated Partial Thrombopla Time, P (Mayo) Aathr Panel" PX-3058573006 CDM 85730 CPT 305 RC inpatient 75 75 MULTIPLAN INC 34080 [3081285] MULTIPLAN INC [308128501] 71.25 percent of total billed charges 46.5 71.25 Technical (Hospital) Services "Ref Activated Partial Thrombopla Time, P (Mayo) Aathr Panel" PX-3058573006 CDM 85730 CPT 305 RC inpatient 75 75 MEDICA (COMMERCIAL) 94265 [3081118] MEDICA CLAIMS [308111801] 67.5 percent of total billed charges 46.5 71.25 Technical (Hospital) Services "Ref Activated Partial Thrombopla Time, P (Mayo) Aathr Panel" PX-3058573006 CDM 85730 CPT 305 RC inpatient 75 75 HEALTHPARTNERS SX009 HEALTHPARTNERS 59.39 percent of total billed charges 46.5 71.25 Technical (Hospital) Services "Ref Activated Partial Thrombopla Time, P (Mayo) Aathr Panel" PX-3058573006 CDM 85730 CPT 305 RC inpatient 75 75 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES EPO [308136803] 59.39 percent of total billed charges 46.5 71.25 Technical (Hospital) Services "Ref Activated Partial Thrombopla Time, P (Mayo) Aathr Panel" PX-3058573006 CDM 85730 CPT 305 RC inpatient 75 75 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES HDHP [308136802] 59.39 percent of total billed charges 46.5 71.25 Technical (Hospital) Services "Ref Activated Partial Thrombopla Time, P (Mayo) Aathr Panel" PX-3058573006 CDM 85730 CPT 305 RC inpatient 75 75 UNITED HEALTHCARE (COMMERCIAL) [3081199] UNITED HEALTHCARE 87726 [308119901] 46.5 percent of total billed charges 46.5 71.25 Technical (Hospital) Services "Ref Activated Partial Thrombopla Time, P (Mayo) Aathr Panel" PX-3058573006 CDM 85730 CPT 305 RC inpatient 75 75 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES PPO [308136801] 59.39 percent of total billed charges 46.5 71.25 Technical (Hospital) Services "Ref Activated Partial Thrombopla Time, P (Mayo) Aathr Panel" PX-3058573006 CDM 85730 CPT 305 RC outpatient 75 75 HEALTHPARTNERS SX009 HEALTHPARTNERS 60 percent of total billed charges 46.5 71.25 Technical (Hospital) Services "Ref Activated Partial Thrombopla Time, P (Mayo) Aathr Panel" PX-3058573006 CDM 85730 CPT 305 RC outpatient 75 75 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES PPO [308136801] 60 percent of total billed charges 46.5 71.25 Technical (Hospital) Services "Ref Activated Partial Thrombopla Time, P (Mayo) Aathr Panel" PX-3058573006 CDM 85730 CPT 305 RC outpatient 75 75 UNITED HEALTHCARE (COMMERCIAL) [3081199] UNITED HEALTHCARE 87726 [308119901] 46.5 percent of total billed charges 46.5 71.25 Technical (Hospital) Services "Ref Activated Partial Thrombopla Time, P (Mayo) Aathr Panel" PX-3058573006 CDM 85730 CPT 305 RC outpatient 75 75 BLUE CROSS BLUE SHIELD WELLMARK SB889 [3081026] BCBS WYOMING [308102603] 71.25 percent of total billed charges 46.5 71.25 Technical (Hospital) Services "Ref Activated Partial Thrombopla Time, P (Mayo) Aathr Panel" PX-3058573006 CDM 85730 CPT 305 RC outpatient 75 75 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES HDHP [308136802] 60 percent of total billed charges 46.5 71.25 Technical (Hospital) Services "Ref Activated Partial Thrombopla Time, P (Mayo) Aathr Panel" PX-3058573006 CDM 85730 CPT 305 RC outpatient 75 75 MULTIPLAN INC 34080 [3081285] MULTIPLAN INC [308128501] 71.25 percent of total billed charges 46.5 71.25 Technical (Hospital) Services "Ref Activated Partial Thrombopla Time, P (Mayo) Aathr Panel" PX-3058573006 CDM 85730 CPT 305 RC outpatient 75 75 CIGNA 62308 [3081051] CIGNA 62308 [308105105] 60 percent of total billed charges 46.5 71.25 Technical (Hospital) Services "Ref Activated Partial Thrombopla Time, P (Mayo) Aathr Panel" PX-3058573006 CDM 85730 CPT 305 RC outpatient 75 75 CIGNA 62308 [3081051] CIGNA STATE OF WYOMING [308105107] 60 percent of total billed charges 46.5 71.25 Technical (Hospital) Services "Ref Activated Partial Thrombopla Time, P (Mayo) Aathr Panel" PX-3058573006 CDM 85730 CPT 305 RC outpatient 75 75 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES EPO [308136803] 60 percent of total billed charges 46.5 71.25 Technical (Hospital) Services "Ref Activated Partial Thrombopla Time, P (Mayo) Aathr Panel" PX-3058573006 CDM 85730 CPT 305 RC outpatient 75 75 MEDICA (COMMERCIAL) 94265 [3081118] MEDICA CLAIMS [308111801] 67.5 percent of total billed charges 46.5 71.25 Technical (Hospital) Services "Ref Activated Partial Thrombopla Time, P (Mayo) Alupp Panel" PX-3058573007 CDM 85730 CPT 305 RC inpatient 122 122 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES PPO [308136801] 96.6 percent of total billed charges 75.64 115.9 Technical (Hospital) Services "Ref Activated Partial Thrombopla Time, P (Mayo) Alupp Panel" PX-3058573007 CDM 85730 CPT 305 RC inpatient 122 122 UNITED HEALTHCARE (COMMERCIAL) [3081199] UNITED HEALTHCARE 87726 [308119901] 75.64 percent of total billed charges 75.64 115.9 Technical (Hospital) Services "Ref Activated Partial Thrombopla Time, P (Mayo) Alupp Panel" PX-3058573007 CDM 85730 CPT 305 RC inpatient 122 122 MEDICA (COMMERCIAL) 94265 [3081118] MEDICA CLAIMS [308111801] 109.8 percent of total billed charges 75.64 115.9 Technical (Hospital) Services "Ref Activated Partial Thrombopla Time, P (Mayo) Alupp Panel" PX-3058573007 CDM 85730 CPT 305 RC inpatient 122 122 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES HDHP [308136802] 96.6 percent of total billed charges 75.64 115.9 Technical (Hospital) Services "Ref Activated Partial Thrombopla Time, P (Mayo) Alupp Panel" PX-3058573007 CDM 85730 CPT 305 RC inpatient 122 122 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES EPO [308136803] 96.6 percent of total billed charges 75.64 115.9 Technical (Hospital) Services "Ref Activated Partial Thrombopla Time, P (Mayo) Alupp Panel" PX-3058573007 CDM 85730 CPT 305 RC inpatient 122 122 HEALTHPARTNERS SX009 HEALTHPARTNERS 96.6 percent of total billed charges 75.64 115.9 Technical (Hospital) Services "Ref Activated Partial Thrombopla Time, P (Mayo) Alupp Panel" PX-3058573007 CDM 85730 CPT 305 RC inpatient 122 122 MULTIPLAN INC 34080 [3081285] MULTIPLAN INC [308128501] 115.9 percent of total billed charges 75.64 115.9 Technical (Hospital) Services "Ref Activated Partial Thrombopla Time, P (Mayo) Alupp Panel" PX-3058573007 CDM 85730 CPT 305 RC inpatient 122 122 BLUE CROSS BLUE SHIELD WELLMARK SB889 [3081026] BCBS WYOMING [308102603] 115.9 percent of total billed charges 75.64 115.9 Technical (Hospital) Services "Ref Activated Partial Thrombopla Time, P (Mayo) Alupp Panel" PX-3058573007 CDM 85730 CPT 305 RC inpatient 122 122 CIGNA 62308 [3081051] CIGNA 62308 [308105105] 96.6 percent of total billed charges 75.64 115.9 Technical (Hospital) Services "Ref Activated Partial Thrombopla Time, P (Mayo) Alupp Panel" PX-3058573007 CDM 85730 CPT 305 RC inpatient 122 122 CIGNA 62308 [3081051] CIGNA STATE OF WYOMING [308105107] 96.6 percent of total billed charges 75.64 115.9 Technical (Hospital) Services "Ref Activated Partial Thrombopla Time, P (Mayo) Alupp Panel" PX-3058573007 CDM 85730 CPT 305 RC outpatient 122 122 MEDICA (COMMERCIAL) 94265 [3081118] MEDICA CLAIMS [308111801] 109.8 percent of total billed charges 75.64 115.9 Technical (Hospital) Services "Ref Activated Partial Thrombopla Time, P (Mayo) Alupp Panel" PX-3058573007 CDM 85730 CPT 305 RC outpatient 122 122 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES EPO [308136803] 97.6 percent of total billed charges 75.64 115.9 Technical (Hospital) Services "Ref Activated Partial Thrombopla Time, P (Mayo) Alupp Panel" PX-3058573007 CDM 85730 CPT 305 RC outpatient 122 122 CIGNA 62308 [3081051] CIGNA 62308 [308105105] 97.6 percent of total billed charges 75.64 115.9 Technical (Hospital) Services "Ref Activated Partial Thrombopla Time, P (Mayo) Alupp Panel" PX-3058573007 CDM 85730 CPT 305 RC outpatient 122 122 CIGNA 62308 [3081051] CIGNA STATE OF WYOMING [308105107] 97.6 percent of total billed charges 75.64 115.9 Technical (Hospital) Services "Ref Activated Partial Thrombopla Time, P (Mayo) Alupp Panel" PX-3058573007 CDM 85730 CPT 305 RC outpatient 122 122 MULTIPLAN INC 34080 [3081285] MULTIPLAN INC [308128501] 115.9 percent of total billed charges 75.64 115.9 Technical (Hospital) Services "Ref Activated Partial Thrombopla Time, P (Mayo) Alupp Panel" PX-3058573007 CDM 85730 CPT 305 RC outpatient 122 122 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES HDHP [308136802] 97.6 percent of total billed charges 75.64 115.9 Technical (Hospital) Services "Ref Activated Partial Thrombopla Time, P (Mayo) Alupp Panel" PX-3058573007 CDM 85730 CPT 305 RC outpatient 122 122 BLUE CROSS BLUE SHIELD WELLMARK SB889 [3081026] BCBS WYOMING [308102603] 115.9 percent of total billed charges 75.64 115.9 Technical (Hospital) Services "Ref Activated Partial Thrombopla Time, P (Mayo) Alupp Panel" PX-3058573007 CDM 85730 CPT 305 RC outpatient 122 122 UNITED HEALTHCARE (COMMERCIAL) [3081199] UNITED HEALTHCARE 87726 [308119901] 75.64 percent of total billed charges 75.64 115.9 Technical (Hospital) Services "Ref Activated Partial Thrombopla Time, P (Mayo) Alupp Panel" PX-3058573007 CDM 85730 CPT 305 RC outpatient 122 122 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES PPO [308136801] 97.6 percent of total billed charges 75.64 115.9 Technical (Hospital) Services "Ref Activated Partial Thrombopla Time, P (Mayo) Alupp Panel" PX-3058573007 CDM 85730 CPT 305 RC outpatient 122 122 HEALTHPARTNERS SX009 HEALTHPARTNERS 97.6 percent of total billed charges 75.64 115.9 Technical (Hospital) Services "Thrombin Time, Plasma" PX-3058567000 CDM 85670 CPT 305 RC outpatient 100 100 UNITED HEALTHCARE (COMMERCIAL) [3081199] UNITED HEALTHCARE 87726 [308119901] 62 percent of total billed charges 62 95 Technical (Hospital) Services "Thrombin Time, Plasma" PX-3058567000 CDM 85670 CPT 305 RC outpatient 100 100 HEALTHPARTNERS SX009 HEALTHPARTNERS 80 percent of total billed charges 62 95 Technical (Hospital) Services "Thrombin Time, Plasma" PX-3058567000 CDM 85670 CPT 305 RC outpatient 100 100 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES PPO [308136801] 80 percent of total billed charges 62 95 Technical (Hospital) Services "Thrombin Time, Plasma" PX-3058567000 CDM 85670 CPT 305 RC outpatient 100 100 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES HDHP [308136802] 80 percent of total billed charges 62 95 Technical (Hospital) Services "Thrombin Time, Plasma" PX-3058567000 CDM 85670 CPT 305 RC outpatient 100 100 BLUE CROSS BLUE SHIELD WELLMARK SB889 [3081026] BCBS WYOMING [308102603] 95 percent of total billed charges 62 95 Technical (Hospital) Services "Thrombin Time, Plasma" PX-3058567000 CDM 85670 CPT 305 RC outpatient 100 100 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES EPO [308136803] 80 percent of total billed charges 62 95 Technical (Hospital) Services "Thrombin Time, Plasma" PX-3058567000 CDM 85670 CPT 305 RC outpatient 100 100 CIGNA 62308 [3081051] CIGNA 62308 [308105105] 80 percent of total billed charges 62 95 Technical (Hospital) Services "Thrombin Time, Plasma" PX-3058567000 CDM 85670 CPT 305 RC outpatient 100 100 CIGNA 62308 [3081051] CIGNA STATE OF WYOMING [308105107] 80 percent of total billed charges 62 95 Technical (Hospital) Services "Thrombin Time, Plasma" PX-3058567000 CDM 85670 CPT 305 RC outpatient 100 100 MULTIPLAN INC 34080 [3081285] MULTIPLAN INC [308128501] 95 percent of total billed charges 62 95 Technical (Hospital) Services "Thrombin Time, Plasma" PX-3058567000 CDM 85670 CPT 305 RC outpatient 100 100 MEDICA (COMMERCIAL) 94265 [3081118] MEDICA CLAIMS [308111801] 90 percent of total billed charges 62 95 Technical (Hospital) Services "Thrombin Time, Plasma" PX-3058567000 CDM 85670 CPT 305 RC inpatient 100 100 MEDICA (COMMERCIAL) 94265 [3081118] MEDICA CLAIMS [308111801] 90 percent of total billed charges 62 95 Technical (Hospital) Services "Thrombin Time, Plasma" PX-3058567000 CDM 85670 CPT 305 RC inpatient 100 100 MULTIPLAN INC 34080 [3081285] MULTIPLAN INC [308128501] 95 percent of total billed charges 62 95 Technical (Hospital) Services "Thrombin Time, Plasma" PX-3058567000 CDM 85670 CPT 305 RC inpatient 100 100 BLUE CROSS BLUE SHIELD WELLMARK SB889 [3081026] BCBS WYOMING [308102603] 95 percent of total billed charges 62 95 Technical (Hospital) Services "Thrombin Time, Plasma" PX-3058567000 CDM 85670 CPT 305 RC inpatient 100 100 CIGNA 62308 [3081051] CIGNA 62308 [308105105] 79.18 percent of total billed charges 62 95 Technical (Hospital) Services "Thrombin Time, Plasma" PX-3058567000 CDM 85670 CPT 305 RC inpatient 100 100 CIGNA 62308 [3081051] CIGNA STATE OF WYOMING [308105107] 79.18 percent of total billed charges 62 95 Technical (Hospital) Services "Thrombin Time, Plasma" PX-3058567000 CDM 85670 CPT 305 RC inpatient 100 100 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES EPO [308136803] 79.18 percent of total billed charges 62 95 Technical (Hospital) Services "Thrombin Time, Plasma" PX-3058567000 CDM 85670 CPT 305 RC inpatient 100 100 HEALTHPARTNERS SX009 HEALTHPARTNERS 79.18 percent of total billed charges 62 95 Technical (Hospital) Services "Thrombin Time, Plasma" PX-3058567000 CDM 85670 CPT 305 RC inpatient 100 100 UNITED HEALTHCARE (COMMERCIAL) [3081199] UNITED HEALTHCARE 87726 [308119901] 62 percent of total billed charges 62 95 Technical (Hospital) Services "Thrombin Time, Plasma" PX-3058567000 CDM 85670 CPT 305 RC inpatient 100 100 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES HDHP [308136802] 79.18 percent of total billed charges 62 95 Technical (Hospital) Services "Thrombin Time, Plasma" PX-3058567000 CDM 85670 CPT 305 RC inpatient 100 100 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES PPO [308136801] 79.18 percent of total billed charges 62 95 Technical (Hospital) Services Ref Thrombin Time Bovine PX-3058567001 CDM 85670 CPT 305 RC outpatient 95 95 MULTIPLAN INC 34080 [3081285] MULTIPLAN INC [308128501] 90.25 percent of total billed charges 58.9 90.25 Technical (Hospital) Services Ref Thrombin Time Bovine PX-3058567001 CDM 85670 CPT 305 RC outpatient 95 95 CIGNA 62308 [3081051] CIGNA 62308 [308105105] 76 percent of total billed charges 58.9 90.25 Technical (Hospital) Services Ref Thrombin Time Bovine PX-3058567001 CDM 85670 CPT 305 RC outpatient 95 95 CIGNA 62308 [3081051] CIGNA STATE OF WYOMING [308105107] 76 percent of total billed charges 58.9 90.25 Technical (Hospital) Services Ref Thrombin Time Bovine PX-3058567001 CDM 85670 CPT 305 RC outpatient 95 95 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES EPO [308136803] 76 percent of total billed charges 58.9 90.25 Technical (Hospital) Services Ref Thrombin Time Bovine PX-3058567001 CDM 85670 CPT 305 RC outpatient 95 95 BLUE CROSS BLUE SHIELD WELLMARK SB889 [3081026] BCBS WYOMING [308102603] 90.25 percent of total billed charges 58.9 90.25 Technical (Hospital) Services Ref Thrombin Time Bovine PX-3058567001 CDM 85670 CPT 305 RC outpatient 95 95 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES HDHP [308136802] 76 percent of total billed charges 58.9 90.25 Technical (Hospital) Services Ref Thrombin Time Bovine PX-3058567001 CDM 85670 CPT 305 RC outpatient 95 95 UNITED HEALTHCARE (COMMERCIAL) [3081199] UNITED HEALTHCARE 87726 [308119901] 58.9 percent of total billed charges 58.9 90.25 Technical (Hospital) Services Ref Thrombin Time Bovine PX-3058567001 CDM 85670 CPT 305 RC outpatient 95 95 HEALTHPARTNERS SX009 HEALTHPARTNERS 76 percent of total billed charges 58.9 90.25 Technical (Hospital) Services Ref Thrombin Time Bovine PX-3058567001 CDM 85670 CPT 305 RC outpatient 95 95 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES PPO [308136801] 76 percent of total billed charges 58.9 90.25 Technical (Hospital) Services Ref Thrombin Time Bovine PX-3058567001 CDM 85670 CPT 305 RC outpatient 95 95 MEDICA (COMMERCIAL) 94265 [3081118] MEDICA CLAIMS [308111801] 85.5 percent of total billed charges 58.9 90.25 Technical (Hospital) Services Ref Thrombin Time Bovine PX-3058567001 CDM 85670 CPT 305 RC inpatient 95 95 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES EPO [308136803] 75.22 percent of total billed charges 58.9 90.25 Technical (Hospital) Services Ref Thrombin Time Bovine PX-3058567001 CDM 85670 CPT 305 RC inpatient 95 95 HEALTHPARTNERS SX009 HEALTHPARTNERS 75.22 percent of total billed charges 58.9 90.25 Technical (Hospital) Services Ref Thrombin Time Bovine PX-3058567001 CDM 85670 CPT 305 RC inpatient 95 95 CIGNA 62308 [3081051] CIGNA 62308 [308105105] 75.22 percent of total billed charges 58.9 90.25 Technical (Hospital) Services Ref Thrombin Time Bovine PX-3058567001 CDM 85670 CPT 305 RC inpatient 95 95 CIGNA 62308 [3081051] CIGNA STATE OF WYOMING [308105107] 75.22 percent of total billed charges 58.9 90.25 Technical (Hospital) Services Ref Thrombin Time Bovine PX-3058567001 CDM 85670 CPT 305 RC inpatient 95 95 BLUE CROSS BLUE SHIELD WELLMARK SB889 [3081026] BCBS WYOMING [308102603] 90.25 percent of total billed charges 58.9 90.25 Technical (Hospital) Services Ref Thrombin Time Bovine PX-3058567001 CDM 85670 CPT 305 RC inpatient 95 95 MULTIPLAN INC 34080 [3081285] MULTIPLAN INC [308128501] 90.25 percent of total billed charges 58.9 90.25 Technical (Hospital) Services Ref Thrombin Time Bovine PX-3058567001 CDM 85670 CPT 305 RC inpatient 95 95 MEDICA (COMMERCIAL) 94265 [3081118] MEDICA CLAIMS [308111801] 85.5 percent of total billed charges 58.9 90.25 Technical (Hospital) Services Ref Thrombin Time Bovine PX-3058567001 CDM 85670 CPT 305 RC inpatient 95 95 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES HDHP [308136802] 75.22 percent of total billed charges 58.9 90.25 Technical (Hospital) Services Ref Thrombin Time Bovine PX-3058567001 CDM 85670 CPT 305 RC inpatient 95 95 UNITED HEALTHCARE (COMMERCIAL) [3081199] UNITED HEALTHCARE 87726 [308119901] 58.9 percent of total billed charges 58.9 90.25 Technical (Hospital) Services Ref Thrombin Time Bovine PX-3058567001 CDM 85670 CPT 305 RC inpatient 95 95 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES PPO [308136801] 75.22 percent of total billed charges 58.9 90.25 Technical (Hospital) Services "Ref Thrombin Time, Plasma (Mayo) Aathr Panel" PX-3058567005 CDM 85670 CPT 305 RC inpatient 195 195 UNITED HEALTHCARE (COMMERCIAL) [3081199] UNITED HEALTHCARE 87726 [308119901] 120.9 percent of total billed charges 120.9 185.25 Technical (Hospital) Services "Ref Thrombin Time, Plasma (Mayo) Aathr Panel" PX-3058567005 CDM 85670 CPT 305 RC inpatient 195 195 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES HDHP [308136802] 154.4 percent of total billed charges 120.9 185.25 Technical (Hospital) Services "Ref Thrombin Time, Plasma (Mayo) Aathr Panel" PX-3058567005 CDM 85670 CPT 305 RC inpatient 195 195 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES PPO [308136801] 154.4 percent of total billed charges 120.9 185.25 Technical (Hospital) Services "Ref Thrombin Time, Plasma (Mayo) Aathr Panel" PX-3058567005 CDM 85670 CPT 305 RC inpatient 195 195 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES EPO [308136803] 154.4 percent of total billed charges 120.9 185.25 Technical (Hospital) Services "Ref Thrombin Time, Plasma (Mayo) Aathr Panel" PX-3058567005 CDM 85670 CPT 305 RC inpatient 195 195 HEALTHPARTNERS SX009 HEALTHPARTNERS 154.4 percent of total billed charges 120.9 185.25 Technical (Hospital) Services "Ref Thrombin Time, Plasma (Mayo) Aathr Panel" PX-3058567005 CDM 85670 CPT 305 RC inpatient 195 195 MULTIPLAN INC 34080 [3081285] MULTIPLAN INC [308128501] 185.25 percent of total billed charges 120.9 185.25 Technical (Hospital) Services "Ref Thrombin Time, Plasma (Mayo) Aathr Panel" PX-3058567005 CDM 85670 CPT 305 RC inpatient 195 195 MEDICA (COMMERCIAL) 94265 [3081118] MEDICA CLAIMS [308111801] 175.5 percent of total billed charges 120.9 185.25 Technical (Hospital) Services "Ref Thrombin Time, Plasma (Mayo) Aathr Panel" PX-3058567005 CDM 85670 CPT 305 RC inpatient 195 195 BLUE CROSS BLUE SHIELD WELLMARK SB889 [3081026] BCBS WYOMING [308102603] 185.25 percent of total billed charges 120.9 185.25 Technical (Hospital) Services "Ref Thrombin Time, Plasma (Mayo) Aathr Panel" PX-3058567005 CDM 85670 CPT 305 RC inpatient 195 195 CIGNA 62308 [3081051] CIGNA 62308 [308105105] 154.4 percent of total billed charges 120.9 185.25 Technical (Hospital) Services "Ref Thrombin Time, Plasma (Mayo) Aathr Panel" PX-3058567005 CDM 85670 CPT 305 RC inpatient 195 195 CIGNA 62308 [3081051] CIGNA STATE OF WYOMING [308105107] 154.4 percent of total billed charges 120.9 185.25 Technical (Hospital) Services "Ref Thrombin Time, Plasma (Mayo) Aathr Panel" PX-3058567005 CDM 85670 CPT 305 RC outpatient 195 195 UNITED HEALTHCARE (COMMERCIAL) [3081199] UNITED HEALTHCARE 87726 [308119901] 120.9 percent of total billed charges 120.9 185.25 Technical (Hospital) Services "Ref Thrombin Time, Plasma (Mayo) Aathr Panel" PX-3058567005 CDM 85670 CPT 305 RC outpatient 195 195 HEALTHPARTNERS SX009 HEALTHPARTNERS 156 percent of total billed charges 120.9 185.25 Technical (Hospital) Services "Ref Thrombin Time, Plasma (Mayo) Aathr Panel" PX-3058567005 CDM 85670 CPT 305 RC outpatient 195 195 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES PPO [308136801] 156 percent of total billed charges 120.9 185.25 Technical (Hospital) Services "Ref Thrombin Time, Plasma (Mayo) Aathr Panel" PX-3058567005 CDM 85670 CPT 305 RC outpatient 195 195 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES HDHP [308136802] 156 percent of total billed charges 120.9 185.25 Technical (Hospital) Services "Ref Thrombin Time, Plasma (Mayo) Aathr Panel" PX-3058567005 CDM 85670 CPT 305 RC outpatient 195 195 BLUE CROSS BLUE SHIELD WELLMARK SB889 [3081026] BCBS WYOMING [308102603] 185.25 percent of total billed charges 120.9 185.25 Technical (Hospital) Services "Ref Thrombin Time, Plasma (Mayo) Aathr Panel" PX-3058567005 CDM 85670 CPT 305 RC outpatient 195 195 MULTIPLAN INC 34080 [3081285] MULTIPLAN INC [308128501] 185.25 percent of total billed charges 120.9 185.25 Technical (Hospital) Services "Ref Thrombin Time, Plasma (Mayo) Aathr Panel" PX-3058567005 CDM 85670 CPT 305 RC outpatient 195 195 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES EPO [308136803] 156 percent of total billed charges 120.9 185.25 Technical (Hospital) Services "Ref Thrombin Time, Plasma (Mayo) Aathr Panel" PX-3058567005 CDM 85670 CPT 305 RC outpatient 195 195 CIGNA 62308 [3081051] CIGNA 62308 [308105105] 156 percent of total billed charges 120.9 185.25 Technical (Hospital) Services "Ref Thrombin Time, Plasma (Mayo) Aathr Panel" PX-3058567005 CDM 85670 CPT 305 RC outpatient 195 195 CIGNA 62308 [3081051] CIGNA STATE OF WYOMING [308105107] 156 percent of total billed charges 120.9 185.25 Technical (Hospital) Services "Ref Thrombin Time, Plasma (Mayo) Aathr Panel" PX-3058567005 CDM 85670 CPT 305 RC outpatient 195 195 MEDICA (COMMERCIAL) 94265 [3081118] MEDICA CLAIMS [308111801] 175.5 percent of total billed charges 120.9 185.25 Technical (Hospital) Services Ref Sickle Cell Test PX-3058566000 CDM 85660 CPT 305 RC inpatient 74 74 BLUE CROSS BLUE SHIELD WELLMARK SB889 [3081026] BCBS WYOMING [308102603] 70.3 percent of total billed charges 45.88 70.3 Technical (Hospital) Services Ref Sickle Cell Test PX-3058566000 CDM 85660 CPT 305 RC inpatient 74 74 CIGNA 62308 [3081051] CIGNA 62308 [308105105] 58.59 percent of total billed charges 45.88 70.3 Technical (Hospital) Services Ref Sickle Cell Test PX-3058566000 CDM 85660 CPT 305 RC inpatient 74 74 CIGNA 62308 [3081051] CIGNA STATE OF WYOMING [308105107] 58.59 percent of total billed charges 45.88 70.3 Technical (Hospital) Services Ref Sickle Cell Test PX-3058566000 CDM 85660 CPT 305 RC inpatient 74 74 MULTIPLAN INC 34080 [3081285] MULTIPLAN INC [308128501] 70.3 percent of total billed charges 45.88 70.3 Technical (Hospital) Services Ref Sickle Cell Test PX-3058566000 CDM 85660 CPT 305 RC inpatient 74 74 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES EPO [308136803] 58.59 percent of total billed charges 45.88 70.3 Technical (Hospital) Services Ref Sickle Cell Test PX-3058566000 CDM 85660 CPT 305 RC inpatient 74 74 HEALTHPARTNERS SX009 HEALTHPARTNERS 58.59 percent of total billed charges 45.88 70.3 Technical (Hospital) Services Ref Sickle Cell Test PX-3058566000 CDM 85660 CPT 305 RC inpatient 74 74 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES HDHP [308136802] 58.59 percent of total billed charges 45.88 70.3 Technical (Hospital) Services Ref Sickle Cell Test PX-3058566000 CDM 85660 CPT 305 RC inpatient 74 74 UNITED HEALTHCARE (COMMERCIAL) [3081199] UNITED HEALTHCARE 87726 [308119901] 45.88 percent of total billed charges 45.88 70.3 Technical (Hospital) Services Ref Sickle Cell Test PX-3058566000 CDM 85660 CPT 305 RC inpatient 74 74 MEDICA (COMMERCIAL) 94265 [3081118] MEDICA CLAIMS [308111801] 66.6 percent of total billed charges 45.88 70.3 Technical (Hospital) Services Ref Sickle Cell Test PX-3058566000 CDM 85660 CPT 305 RC inpatient 74 74 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES PPO [308136801] 58.59 percent of total billed charges 45.88 70.3 Technical (Hospital) Services Ref Sickle Cell Test PX-3058566000 CDM 85660 CPT 305 RC outpatient 74 74 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES EPO [308136803] 59.2 percent of total billed charges 45.88 70.3 Technical (Hospital) Services Ref Sickle Cell Test PX-3058566000 CDM 85660 CPT 305 RC outpatient 74 74 MULTIPLAN INC 34080 [3081285] MULTIPLAN INC [308128501] 70.3 percent of total billed charges 45.88 70.3 Technical (Hospital) Services Ref Sickle Cell Test PX-3058566000 CDM 85660 CPT 305 RC outpatient 74 74 CIGNA 62308 [3081051] CIGNA 62308 [308105105] 59.2 percent of total billed charges 45.88 70.3 Technical (Hospital) Services Ref Sickle Cell Test PX-3058566000 CDM 85660 CPT 305 RC outpatient 74 74 CIGNA 62308 [3081051] CIGNA STATE OF WYOMING [308105107] 59.2 percent of total billed charges 45.88 70.3 Technical (Hospital) Services Ref Sickle Cell Test PX-3058566000 CDM 85660 CPT 305 RC outpatient 74 74 BLUE CROSS BLUE SHIELD WELLMARK SB889 [3081026] BCBS WYOMING [308102603] 70.3 percent of total billed charges 45.88 70.3 Technical (Hospital) Services Ref Sickle Cell Test PX-3058566000 CDM 85660 CPT 305 RC outpatient 74 74 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES HDHP [308136802] 59.2 percent of total billed charges 45.88 70.3 Technical (Hospital) Services Ref Sickle Cell Test PX-3058566000 CDM 85660 CPT 305 RC outpatient 74 74 HEALTHPARTNERS SX009 HEALTHPARTNERS 59.2 percent of total billed charges 45.88 70.3 Technical (Hospital) Services Ref Sickle Cell Test PX-3058566000 CDM 85660 CPT 305 RC outpatient 74 74 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES PPO [308136801] 59.2 percent of total billed charges 45.88 70.3 Technical (Hospital) Services Ref Sickle Cell Test PX-3058566000 CDM 85660 CPT 305 RC outpatient 74 74 UNITED HEALTHCARE (COMMERCIAL) [3081199] UNITED HEALTHCARE 87726 [308119901] 45.88 percent of total billed charges 45.88 70.3 Technical (Hospital) Services Ref Sickle Cell Test PX-3058566000 CDM 85660 CPT 305 RC outpatient 74 74 MEDICA (COMMERCIAL) 94265 [3081118] MEDICA CLAIMS [308111801] 66.6 percent of total billed charges 45.88 70.3 Technical (Hospital) Services Westergren Esr PX-3058565200 CDM 85652 CPT 305 RC outpatient 70 70 MEDICA (COMMERCIAL) 94265 [3081118] MEDICA CLAIMS [308111801] 63 percent of total billed charges 43.4 66.5 Technical (Hospital) Services Westergren Esr PX-3058565200 CDM 85652 CPT 305 RC outpatient 70 70 HEALTHPARTNERS SX009 HEALTHPARTNERS 56 percent of total billed charges 43.4 66.5 Technical (Hospital) Services Westergren Esr PX-3058565200 CDM 85652 CPT 305 RC outpatient 70 70 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES PPO [308136801] 56 percent of total billed charges 43.4 66.5 Technical (Hospital) Services Westergren Esr PX-3058565200 CDM 85652 CPT 305 RC outpatient 70 70 UNITED HEALTHCARE (COMMERCIAL) [3081199] UNITED HEALTHCARE 87726 [308119901] 43.4 percent of total billed charges 43.4 66.5 Technical (Hospital) Services Westergren Esr PX-3058565200 CDM 85652 CPT 305 RC outpatient 70 70 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES HDHP [308136802] 56 percent of total billed charges 43.4 66.5 Technical (Hospital) Services Westergren Esr PX-3058565200 CDM 85652 CPT 305 RC outpatient 70 70 BLUE CROSS BLUE SHIELD WELLMARK SB889 [3081026] BCBS WYOMING [308102603] 66.5 percent of total billed charges 43.4 66.5 Technical (Hospital) Services Westergren Esr PX-3058565200 CDM 85652 CPT 305 RC outpatient 70 70 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES EPO [308136803] 56 percent of total billed charges 43.4 66.5 Technical (Hospital) Services Westergren Esr PX-3058565200 CDM 85652 CPT 305 RC outpatient 70 70 CIGNA 62308 [3081051] CIGNA 62308 [308105105] 56 percent of total billed charges 43.4 66.5 Technical (Hospital) Services Westergren Esr PX-3058565200 CDM 85652 CPT 305 RC outpatient 70 70 CIGNA 62308 [3081051] CIGNA STATE OF WYOMING [308105107] 56 percent of total billed charges 43.4 66.5 Technical (Hospital) Services Westergren Esr PX-3058565200 CDM 85652 CPT 305 RC outpatient 70 70 MULTIPLAN INC 34080 [3081285] MULTIPLAN INC [308128501] 66.5 percent of total billed charges 43.4 66.5 Technical (Hospital) Services Westergren Esr PX-3058565200 CDM 85652 CPT 305 RC inpatient 70 70 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES PPO [308136801] 55.43 percent of total billed charges 43.4 66.5 Technical (Hospital) Services Westergren Esr PX-3058565200 CDM 85652 CPT 305 RC inpatient 70 70 MEDICA (COMMERCIAL) 94265 [3081118] MEDICA CLAIMS [308111801] 63 percent of total billed charges 43.4 66.5 Technical (Hospital) Services Westergren Esr PX-3058565200 CDM 85652 CPT 305 RC inpatient 70 70 UNITED HEALTHCARE (COMMERCIAL) [3081199] UNITED HEALTHCARE 87726 [308119901] 43.4 percent of total billed charges 43.4 66.5 Technical (Hospital) Services Westergren Esr PX-3058565200 CDM 85652 CPT 305 RC inpatient 70 70 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES HDHP [308136802] 55.43 percent of total billed charges 43.4 66.5 Technical (Hospital) Services Westergren Esr PX-3058565200 CDM 85652 CPT 305 RC inpatient 70 70 MULTIPLAN INC 34080 [3081285] MULTIPLAN INC [308128501] 66.5 percent of total billed charges 43.4 66.5 Technical (Hospital) Services Westergren Esr PX-3058565200 CDM 85652 CPT 305 RC inpatient 70 70 BLUE CROSS BLUE SHIELD WELLMARK SB889 [3081026] BCBS WYOMING [308102603] 66.5 percent of total billed charges 43.4 66.5 Technical (Hospital) Services Westergren Esr PX-3058565200 CDM 85652 CPT 305 RC inpatient 70 70 CIGNA 62308 [3081051] CIGNA 62308 [308105105] 55.43 percent of total billed charges 43.4 66.5 Technical (Hospital) Services Westergren Esr PX-3058565200 CDM 85652 CPT 305 RC inpatient 70 70 CIGNA 62308 [3081051] CIGNA STATE OF WYOMING [308105107] 55.43 percent of total billed charges 43.4 66.5 Technical (Hospital) Services Westergren Esr PX-3058565200 CDM 85652 CPT 305 RC inpatient 70 70 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES EPO [308136803] 55.43 percent of total billed charges 43.4 66.5 Technical (Hospital) Services Westergren Esr PX-3058565200 CDM 85652 CPT 305 RC inpatient 70 70 HEALTHPARTNERS SX009 HEALTHPARTNERS 55.43 percent of total billed charges 43.4 66.5 Technical (Hospital) Services Ref Drvvt Mix PX-3058561305 CDM 85613 CPT 305 RC outpatient 184 184 BLUE CROSS BLUE SHIELD WELLMARK SB889 [3081026] BCBS WYOMING [308102603] 174.8 percent of total billed charges 114.08 174.8 Technical (Hospital) Services Ref Drvvt Mix PX-3058561305 CDM 85613 CPT 305 RC outpatient 184 184 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES HDHP [308136802] 147.2 percent of total billed charges 114.08 174.8 Technical (Hospital) Services Ref Drvvt Mix PX-3058561305 CDM 85613 CPT 305 RC outpatient 184 184 MULTIPLAN INC 34080 [3081285] MULTIPLAN INC [308128501] 174.8 percent of total billed charges 114.08 174.8 Technical (Hospital) Services Ref Drvvt Mix PX-3058561305 CDM 85613 CPT 305 RC outpatient 184 184 CIGNA 62308 [3081051] CIGNA 62308 [308105105] 147.2 percent of total billed charges 114.08 174.8 Technical (Hospital) Services Ref Drvvt Mix PX-3058561305 CDM 85613 CPT 305 RC outpatient 184 184 CIGNA 62308 [3081051] CIGNA STATE OF WYOMING [308105107] 147.2 percent of total billed charges 114.08 174.8 Technical (Hospital) Services Ref Drvvt Mix PX-3058561305 CDM 85613 CPT 305 RC outpatient 184 184 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES EPO [308136803] 147.2 percent of total billed charges 114.08 174.8 Technical (Hospital) Services Ref Drvvt Mix PX-3058561305 CDM 85613 CPT 305 RC outpatient 184 184 UNITED HEALTHCARE (COMMERCIAL) [3081199] UNITED HEALTHCARE 87726 [308119901] 114.08 percent of total billed charges 114.08 174.8 Technical (Hospital) Services Ref Drvvt Mix PX-3058561305 CDM 85613 CPT 305 RC outpatient 184 184 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES PPO [308136801] 147.2 percent of total billed charges 114.08 174.8 Technical (Hospital) Services Ref Drvvt Mix PX-3058561305 CDM 85613 CPT 305 RC outpatient 184 184 HEALTHPARTNERS SX009 HEALTHPARTNERS 147.2 percent of total billed charges 114.08 174.8 Technical (Hospital) Services Ref Drvvt Mix PX-3058561305 CDM 85613 CPT 305 RC outpatient 184 184 MEDICA (COMMERCIAL) 94265 [3081118] MEDICA CLAIMS [308111801] 165.6 percent of total billed charges 114.08 174.8 Technical (Hospital) Services Ref Drvvt Mix PX-3058561305 CDM 85613 CPT 305 RC inpatient 184 184 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES PPO [308136801] 145.69 percent of total billed charges 114.08 174.8 Technical (Hospital) Services Ref Drvvt Mix PX-3058561305 CDM 85613 CPT 305 RC inpatient 184 184 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES HDHP [308136802] 145.69 percent of total billed charges 114.08 174.8 Technical (Hospital) Services Ref Drvvt Mix PX-3058561305 CDM 85613 CPT 305 RC inpatient 184 184 UNITED HEALTHCARE (COMMERCIAL) [3081199] UNITED HEALTHCARE 87726 [308119901] 114.08 percent of total billed charges 114.08 174.8 Technical (Hospital) Services Ref Drvvt Mix PX-3058561305 CDM 85613 CPT 305 RC inpatient 184 184 MEDICA (COMMERCIAL) 94265 [3081118] MEDICA CLAIMS [308111801] 165.6 percent of total billed charges 114.08 174.8 Technical (Hospital) Services Ref Drvvt Mix PX-3058561305 CDM 85613 CPT 305 RC inpatient 184 184 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES EPO [308136803] 145.69 percent of total billed charges 114.08 174.8 Technical (Hospital) Services Ref Drvvt Mix PX-3058561305 CDM 85613 CPT 305 RC inpatient 184 184 HEALTHPARTNERS SX009 HEALTHPARTNERS 145.69 percent of total billed charges 114.08 174.8 Technical (Hospital) Services Ref Drvvt Mix PX-3058561305 CDM 85613 CPT 305 RC inpatient 184 184 MULTIPLAN INC 34080 [3081285] MULTIPLAN INC [308128501] 174.8 percent of total billed charges 114.08 174.8 Technical (Hospital) Services Ref Drvvt Mix PX-3058561305 CDM 85613 CPT 305 RC inpatient 184 184 CIGNA 62308 [3081051] CIGNA 62308 [308105105] 145.69 percent of total billed charges 114.08 174.8 Technical (Hospital) Services Ref Drvvt Mix PX-3058561305 CDM 85613 CPT 305 RC inpatient 184 184 CIGNA 62308 [3081051] CIGNA STATE OF WYOMING [308105107] 145.69 percent of total billed charges 114.08 174.8 Technical (Hospital) Services Ref Drvvt Mix PX-3058561305 CDM 85613 CPT 305 RC inpatient 184 184 BLUE CROSS BLUE SHIELD WELLMARK SB889 [3081026] BCBS WYOMING [308102603] 174.8 percent of total billed charges 114.08 174.8 Technical (Hospital) Services Ref Drvvt Confirmation PX-3058561306 CDM 85613 CPT 305 RC inpatient 192 192 UNITED HEALTHCARE (COMMERCIAL) [3081199] UNITED HEALTHCARE 87726 [308119901] 119.04 percent of total billed charges 119.04 182.4 Technical (Hospital) Services Ref Drvvt Confirmation PX-3058561306 CDM 85613 CPT 305 RC inpatient 192 192 MEDICA (COMMERCIAL) 94265 [3081118] MEDICA CLAIMS [308111801] 172.8 percent of total billed charges 119.04 182.4 Technical (Hospital) Services Ref Drvvt Confirmation PX-3058561306 CDM 85613 CPT 305 RC inpatient 192 192 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES HDHP [308136802] 152.03 percent of total billed charges 119.04 182.4 Technical (Hospital) Services Ref Drvvt Confirmation PX-3058561306 CDM 85613 CPT 305 RC inpatient 192 192 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES PPO [308136801] 152.03 percent of total billed charges 119.04 182.4 Technical (Hospital) Services Ref Drvvt Confirmation PX-3058561306 CDM 85613 CPT 305 RC inpatient 192 192 MULTIPLAN INC 34080 [3081285] MULTIPLAN INC [308128501] 182.4 percent of total billed charges 119.04 182.4 Technical (Hospital) Services Ref Drvvt Confirmation PX-3058561306 CDM 85613 CPT 305 RC inpatient 192 192 BLUE CROSS BLUE SHIELD WELLMARK SB889 [3081026] BCBS WYOMING [308102603] 182.4 percent of total billed charges 119.04 182.4 Technical (Hospital) Services Ref Drvvt Confirmation PX-3058561306 CDM 85613 CPT 305 RC inpatient 192 192 CIGNA 62308 [3081051] CIGNA 62308 [308105105] 152.03 percent of total billed charges 119.04 182.4 Technical (Hospital) Services Ref Drvvt Confirmation PX-3058561306 CDM 85613 CPT 305 RC inpatient 192 192 CIGNA 62308 [3081051] CIGNA STATE OF WYOMING [308105107] 152.03 percent of total billed charges 119.04 182.4 Technical (Hospital) Services Ref Drvvt Confirmation PX-3058561306 CDM 85613 CPT 305 RC inpatient 192 192 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES EPO [308136803] 152.03 percent of total billed charges 119.04 182.4 Technical (Hospital) Services Ref Drvvt Confirmation PX-3058561306 CDM 85613 CPT 305 RC inpatient 192 192 HEALTHPARTNERS SX009 HEALTHPARTNERS 152.03 percent of total billed charges 119.04 182.4 Technical (Hospital) Services Ref Drvvt Confirmation PX-3058561306 CDM 85613 CPT 305 RC outpatient 192 192 BLUE CROSS BLUE SHIELD WELLMARK SB889 [3081026] BCBS WYOMING [308102603] 182.4 percent of total billed charges 119.04 182.4 Technical (Hospital) Services Ref Drvvt Confirmation PX-3058561306 CDM 85613 CPT 305 RC outpatient 192 192 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES HDHP [308136802] 153.6 percent of total billed charges 119.04 182.4 Technical (Hospital) Services Ref Drvvt Confirmation PX-3058561306 CDM 85613 CPT 305 RC outpatient 192 192 MULTIPLAN INC 34080 [3081285] MULTIPLAN INC [308128501] 182.4 percent of total billed charges 119.04 182.4 Technical (Hospital) Services Ref Drvvt Confirmation PX-3058561306 CDM 85613 CPT 305 RC outpatient 192 192 CIGNA 62308 [3081051] CIGNA 62308 [308105105] 153.6 percent of total billed charges 119.04 182.4 Technical (Hospital) Services Ref Drvvt Confirmation PX-3058561306 CDM 85613 CPT 305 RC outpatient 192 192 CIGNA 62308 [3081051] CIGNA STATE OF WYOMING [308105107] 153.6 percent of total billed charges 119.04 182.4 Technical (Hospital) Services Ref Drvvt Confirmation PX-3058561306 CDM 85613 CPT 305 RC outpatient 192 192 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES EPO [308136803] 153.6 percent of total billed charges 119.04 182.4 Technical (Hospital) Services Ref Drvvt Confirmation PX-3058561306 CDM 85613 CPT 305 RC outpatient 192 192 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES PPO [308136801] 153.6 percent of total billed charges 119.04 182.4 Technical (Hospital) Services Ref Drvvt Confirmation PX-3058561306 CDM 85613 CPT 305 RC outpatient 192 192 HEALTHPARTNERS SX009 HEALTHPARTNERS 153.6 percent of total billed charges 119.04 182.4 Technical (Hospital) Services Ref Drvvt Confirmation PX-3058561306 CDM 85613 CPT 305 RC outpatient 192 192 UNITED HEALTHCARE (COMMERCIAL) [3081199] UNITED HEALTHCARE 87726 [308119901] 119.04 percent of total billed charges 119.04 182.4 Technical (Hospital) Services Ref Drvvt Confirmation PX-3058561306 CDM 85613 CPT 305 RC outpatient 192 192 MEDICA (COMMERCIAL) 94265 [3081118] MEDICA CLAIMS [308111801] 172.8 percent of total billed charges 119.04 182.4 Technical (Hospital) Services Ref Dilute Russell's Viper Venom Time (Drvvt) PX-3058561307 CDM 85613 CPT 305 RC outpatient 169 169 UNITED HEALTHCARE (COMMERCIAL) [3081199] UNITED HEALTHCARE 87726 [308119901] 104.78 percent of total billed charges 104.78 160.55 Technical (Hospital) Services Ref Dilute Russell's Viper Venom Time (Drvvt) PX-3058561307 CDM 85613 CPT 305 RC outpatient 169 169 HEALTHPARTNERS SX009 HEALTHPARTNERS 135.2 percent of total billed charges 104.78 160.55 Technical (Hospital) Services Ref Dilute Russell's Viper Venom Time (Drvvt) PX-3058561307 CDM 85613 CPT 305 RC outpatient 169 169 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES PPO [308136801] 135.2 percent of total billed charges 104.78 160.55 Technical (Hospital) Services Ref Dilute Russell's Viper Venom Time (Drvvt) PX-3058561307 CDM 85613 CPT 305 RC outpatient 169 169 BLUE CROSS BLUE SHIELD WELLMARK SB889 [3081026] BCBS WYOMING [308102603] 160.55 percent of total billed charges 104.78 160.55 Technical (Hospital) Services Ref Dilute Russell's Viper Venom Time (Drvvt) PX-3058561307 CDM 85613 CPT 305 RC outpatient 169 169 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES HDHP [308136802] 135.2 percent of total billed charges 104.78 160.55 Technical (Hospital) Services Ref Dilute Russell's Viper Venom Time (Drvvt) PX-3058561307 CDM 85613 CPT 305 RC outpatient 169 169 CIGNA 62308 [3081051] CIGNA 62308 [308105105] 135.2 percent of total billed charges 104.78 160.55 Technical (Hospital) Services Ref Dilute Russell's Viper Venom Time (Drvvt) PX-3058561307 CDM 85613 CPT 305 RC outpatient 169 169 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES EPO [308136803] 135.2 percent of total billed charges 104.78 160.55 Technical (Hospital) Services Ref Dilute Russell's Viper Venom Time (Drvvt) PX-3058561307 CDM 85613 CPT 305 RC outpatient 169 169 MULTIPLAN INC 34080 [3081285] MULTIPLAN INC [308128501] 160.55 percent of total billed charges 104.78 160.55 Technical (Hospital) Services Ref Dilute Russell's Viper Venom Time (Drvvt) PX-3058561307 CDM 85613 CPT 305 RC outpatient 169 169 CIGNA 62308 [3081051] CIGNA STATE OF WYOMING [308105107] 135.2 percent of total billed charges 104.78 160.55 Technical (Hospital) Services Ref Dilute Russell's Viper Venom Time (Drvvt) PX-3058561307 CDM 85613 CPT 305 RC outpatient 169 169 MEDICA (COMMERCIAL) 94265 [3081118] MEDICA CLAIMS [308111801] 152.1 percent of total billed charges 104.78 160.55 Technical (Hospital) Services Ref Dilute Russell's Viper Venom Time (Drvvt) PX-3058561307 CDM 85613 CPT 305 RC inpatient 169 169 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES PPO [308136801] 133.81 percent of total billed charges 104.78 160.55 Technical (Hospital) Services Ref Dilute Russell's Viper Venom Time (Drvvt) PX-3058561307 CDM 85613 CPT 305 RC inpatient 169 169 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES HDHP [308136802] 133.81 percent of total billed charges 104.78 160.55 Technical (Hospital) Services Ref Dilute Russell's Viper Venom Time (Drvvt) PX-3058561307 CDM 85613 CPT 305 RC inpatient 169 169 HEALTHPARTNERS SX009 HEALTHPARTNERS 133.81 percent of total billed charges 104.78 160.55 Technical (Hospital) Services Ref Dilute Russell's Viper Venom Time (Drvvt) PX-3058561307 CDM 85613 CPT 305 RC inpatient 169 169 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES EPO [308136803] 133.81 percent of total billed charges 104.78 160.55 Technical (Hospital) Services Ref Dilute Russell's Viper Venom Time (Drvvt) PX-3058561307 CDM 85613 CPT 305 RC inpatient 169 169 MEDICA (COMMERCIAL) 94265 [3081118] MEDICA CLAIMS [308111801] 152.1 percent of total billed charges 104.78 160.55 Technical (Hospital) Services Ref Dilute Russell's Viper Venom Time (Drvvt) PX-3058561307 CDM 85613 CPT 305 RC inpatient 169 169 UNITED HEALTHCARE (COMMERCIAL) [3081199] UNITED HEALTHCARE 87726 [308119901] 104.78 percent of total billed charges 104.78 160.55 Technical (Hospital) Services Ref Dilute Russell's Viper Venom Time (Drvvt) PX-3058561307 CDM 85613 CPT 305 RC inpatient 169 169 MULTIPLAN INC 34080 [3081285] MULTIPLAN INC [308128501] 160.55 percent of total billed charges 104.78 160.55 Technical (Hospital) Services Ref Dilute Russell's Viper Venom Time (Drvvt) PX-3058561307 CDM 85613 CPT 305 RC inpatient 169 169 BLUE CROSS BLUE SHIELD WELLMARK SB889 [3081026] BCBS WYOMING [308102603] 160.55 percent of total billed charges 104.78 160.55 Technical (Hospital) Services Ref Dilute Russell's Viper Venom Time (Drvvt) PX-3058561307 CDM 85613 CPT 305 RC inpatient 169 169 CIGNA 62308 [3081051] CIGNA 62308 [308105105] 133.81 percent of total billed charges 104.78 160.55 Technical (Hospital) Services Ref Dilute Russell's Viper Venom Time (Drvvt) PX-3058561307 CDM 85613 CPT 305 RC inpatient 169 169 CIGNA 62308 [3081051] CIGNA STATE OF WYOMING [308105107] 133.81 percent of total billed charges 104.78 160.55 Technical (Hospital) Services "Ref Dilute Russells Viper Venom Time, P (Mayo) Aathr Panel" PX-3058561309 CDM 85613 CPT 305 RC inpatient 155 155 HEALTHPARTNERS SX009 HEALTHPARTNERS 122.73 percent of total billed charges 96.1 147.25 Technical (Hospital) Services "Ref Dilute Russells Viper Venom Time, P (Mayo) Aathr Panel" PX-3058561309 CDM 85613 CPT 305 RC inpatient 155 155 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES EPO [308136803] 122.73 percent of total billed charges 96.1 147.25 Technical (Hospital) Services "Ref Dilute Russells Viper Venom Time, P (Mayo) Aathr Panel" PX-3058561309 CDM 85613 CPT 305 RC inpatient 155 155 MULTIPLAN INC 34080 [3081285] MULTIPLAN INC [308128501] 147.25 percent of total billed charges 96.1 147.25 Technical (Hospital) Services "Ref Dilute Russells Viper Venom Time, P (Mayo) Aathr Panel" PX-3058561309 CDM 85613 CPT 305 RC inpatient 155 155 BLUE CROSS BLUE SHIELD WELLMARK SB889 [3081026] BCBS WYOMING [308102603] 147.25 percent of total billed charges 96.1 147.25 Technical (Hospital) Services "Ref Dilute Russells Viper Venom Time, P (Mayo) Aathr Panel" PX-3058561309 CDM 85613 CPT 305 RC inpatient 155 155 CIGNA 62308 [3081051] CIGNA 62308 [308105105] 122.73 percent of total billed charges 96.1 147.25 Technical (Hospital) Services "Ref Dilute Russells Viper Venom Time, P (Mayo) Aathr Panel" PX-3058561309 CDM 85613 CPT 305 RC inpatient 155 155 CIGNA 62308 [3081051] CIGNA STATE OF WYOMING [308105107] 122.73 percent of total billed charges 96.1 147.25 Technical (Hospital) Services "Ref Dilute Russells Viper Venom Time, P (Mayo) Aathr Panel" PX-3058561309 CDM 85613 CPT 305 RC inpatient 155 155 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES PPO [308136801] 122.73 percent of total billed charges 96.1 147.25 Technical (Hospital) Services "Ref Dilute Russells Viper Venom Time, P (Mayo) Aathr Panel" PX-3058561309 CDM 85613 CPT 305 RC inpatient 155 155 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES HDHP [308136802] 122.73 percent of total billed charges 96.1 147.25 Technical (Hospital) Services "Ref Dilute Russells Viper Venom Time, P (Mayo) Aathr Panel" PX-3058561309 CDM 85613 CPT 305 RC inpatient 155 155 MEDICA (COMMERCIAL) 94265 [3081118] MEDICA CLAIMS [308111801] 139.5 percent of total billed charges 96.1 147.25 Technical (Hospital) Services "Ref Dilute Russells Viper Venom Time, P (Mayo) Aathr Panel" PX-3058561309 CDM 85613 CPT 305 RC inpatient 155 155 UNITED HEALTHCARE (COMMERCIAL) [3081199] UNITED HEALTHCARE 87726 [308119901] 96.1 percent of total billed charges 96.1 147.25 Technical (Hospital) Services "Ref Dilute Russells Viper Venom Time, P (Mayo) Aathr Panel" PX-3058561309 CDM 85613 CPT 305 RC outpatient 155 155 UNITED HEALTHCARE (COMMERCIAL) [3081199] UNITED HEALTHCARE 87726 [308119901] 96.1 percent of total billed charges 96.1 147.25 Technical (Hospital) Services "Ref Dilute Russells Viper Venom Time, P (Mayo) Aathr Panel" PX-3058561309 CDM 85613 CPT 305 RC outpatient 155 155 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES PPO [308136801] 124 percent of total billed charges 96.1 147.25 Technical (Hospital) Services "Ref Dilute Russells Viper Venom Time, P (Mayo) Aathr Panel" PX-3058561309 CDM 85613 CPT 305 RC outpatient 155 155 HEALTHPARTNERS SX009 HEALTHPARTNERS 124 percent of total billed charges 96.1 147.25 Technical (Hospital) Services "Ref Dilute Russells Viper Venom Time, P (Mayo) Aathr Panel" PX-3058561309 CDM 85613 CPT 305 RC outpatient 155 155 BLUE CROSS BLUE SHIELD WELLMARK SB889 [3081026] BCBS WYOMING [308102603] 147.25 percent of total billed charges 96.1 147.25 Technical (Hospital) Services "Ref Dilute Russells Viper Venom Time, P (Mayo) Aathr Panel" PX-3058561309 CDM 85613 CPT 305 RC outpatient 155 155 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES HDHP [308136802] 124 percent of total billed charges 96.1 147.25 Technical (Hospital) Services "Ref Dilute Russells Viper Venom Time, P (Mayo) Aathr Panel" PX-3058561309 CDM 85613 CPT 305 RC outpatient 155 155 CIGNA 62308 [3081051] CIGNA 62308 [308105105] 124 percent of total billed charges 96.1 147.25 Technical (Hospital) Services "Ref Dilute Russells Viper Venom Time, P (Mayo) Aathr Panel" PX-3058561309 CDM 85613 CPT 305 RC outpatient 155 155 CIGNA 62308 [3081051] CIGNA STATE OF WYOMING [308105107] 124 percent of total billed charges 96.1 147.25 Technical (Hospital) Services "Ref Dilute Russells Viper Venom Time, P (Mayo) Aathr Panel" PX-3058561309 CDM 85613 CPT 305 RC outpatient 155 155 MULTIPLAN INC 34080 [3081285] MULTIPLAN INC [308128501] 147.25 percent of total billed charges 96.1 147.25 Technical (Hospital) Services "Ref Dilute Russells Viper Venom Time, P (Mayo) Aathr Panel" PX-3058561309 CDM 85613 CPT 305 RC outpatient 155 155 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES EPO [308136803] 124 percent of total billed charges 96.1 147.25 Technical (Hospital) Services "Ref Dilute Russells Viper Venom Time, P (Mayo) Aathr Panel" PX-3058561309 CDM 85613 CPT 305 RC outpatient 155 155 MEDICA (COMMERCIAL) 94265 [3081118] MEDICA CLAIMS [308111801] 139.5 percent of total billed charges 96.1 147.25 Technical (Hospital) Services "Ref Dilute Russells Viper Venom Time, P (Mayo) Alupp Panel" PX-3058561310 CDM 85613 CPT 305 RC outpatient 193 193 MEDICA (COMMERCIAL) 94265 [3081118] MEDICA CLAIMS [308111801] 173.7 percent of total billed charges 119.66 183.35 Technical (Hospital) Services "Ref Dilute Russells Viper Venom Time, P (Mayo) Alupp Panel" PX-3058561310 CDM 85613 CPT 305 RC outpatient 193 193 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES PPO [308136801] 154.4 percent of total billed charges 119.66 183.35 Technical (Hospital) Services "Ref Dilute Russells Viper Venom Time, P (Mayo) Alupp Panel" PX-3058561310 CDM 85613 CPT 305 RC outpatient 193 193 HEALTHPARTNERS SX009 HEALTHPARTNERS 154.4 percent of total billed charges 119.66 183.35 Technical (Hospital) Services "Ref Dilute Russells Viper Venom Time, P (Mayo) Alupp Panel" PX-3058561310 CDM 85613 CPT 305 RC outpatient 193 193 UNITED HEALTHCARE (COMMERCIAL) [3081199] UNITED HEALTHCARE 87726 [308119901] 119.66 percent of total billed charges 119.66 183.35 Technical (Hospital) Services "Ref Dilute Russells Viper Venom Time, P (Mayo) Alupp Panel" PX-3058561310 CDM 85613 CPT 305 RC outpatient 193 193 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES HDHP [308136802] 154.4 percent of total billed charges 119.66 183.35 Technical (Hospital) Services "Ref Dilute Russells Viper Venom Time, P (Mayo) Alupp Panel" PX-3058561310 CDM 85613 CPT 305 RC outpatient 193 193 BLUE CROSS BLUE SHIELD WELLMARK SB889 [3081026] BCBS WYOMING [308102603] 183.35 percent of total billed charges 119.66 183.35 Technical (Hospital) Services "Ref Dilute Russells Viper Venom Time, P (Mayo) Alupp Panel" PX-3058561310 CDM 85613 CPT 305 RC outpatient 193 193 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES EPO [308136803] 154.4 percent of total billed charges 119.66 183.35 Technical (Hospital) Services "Ref Dilute Russells Viper Venom Time, P (Mayo) Alupp Panel" PX-3058561310 CDM 85613 CPT 305 RC outpatient 193 193 MULTIPLAN INC 34080 [3081285] MULTIPLAN INC [308128501] 183.35 percent of total billed charges 119.66 183.35 Technical (Hospital) Services "Ref Dilute Russells Viper Venom Time, P (Mayo) Alupp Panel" PX-3058561310 CDM 85613 CPT 305 RC outpatient 193 193 CIGNA 62308 [3081051] CIGNA 62308 [308105105] 154.4 percent of total billed charges 119.66 183.35 Technical (Hospital) Services "Ref Dilute Russells Viper Venom Time, P (Mayo) Alupp Panel" PX-3058561310 CDM 85613 CPT 305 RC outpatient 193 193 CIGNA 62308 [3081051] CIGNA STATE OF WYOMING [308105107] 154.4 percent of total billed charges 119.66 183.35 Technical (Hospital) Services "Ref Dilute Russells Viper Venom Time, P (Mayo) Alupp Panel" PX-3058561310 CDM 85613 CPT 305 RC inpatient 193 193 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES PPO [308136801] 152.82 percent of total billed charges 119.66 183.35 Technical (Hospital) Services "Ref Dilute Russells Viper Venom Time, P (Mayo) Alupp Panel" PX-3058561310 CDM 85613 CPT 305 RC inpatient 193 193 UNITED HEALTHCARE (COMMERCIAL) [3081199] UNITED HEALTHCARE 87726 [308119901] 119.66 percent of total billed charges 119.66 183.35 Technical (Hospital) Services "Ref Dilute Russells Viper Venom Time, P (Mayo) Alupp Panel" PX-3058561310 CDM 85613 CPT 305 RC inpatient 193 193 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES HDHP [308136802] 152.82 percent of total billed charges 119.66 183.35 Technical (Hospital) Services "Ref Dilute Russells Viper Venom Time, P (Mayo) Alupp Panel" PX-3058561310 CDM 85613 CPT 305 RC inpatient 193 193 MEDICA (COMMERCIAL) 94265 [3081118] MEDICA CLAIMS [308111801] 173.7 percent of total billed charges 119.66 183.35 Technical (Hospital) Services "Ref Dilute Russells Viper Venom Time, P (Mayo) Alupp Panel" PX-3058561310 CDM 85613 CPT 305 RC inpatient 193 193 HEALTHPARTNERS SX009 HEALTHPARTNERS 152.82 percent of total billed charges 119.66 183.35 Technical (Hospital) Services "Ref Dilute Russells Viper Venom Time, P (Mayo) Alupp Panel" PX-3058561310 CDM 85613 CPT 305 RC inpatient 193 193 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES EPO [308136803] 152.82 percent of total billed charges 119.66 183.35 Technical (Hospital) Services "Ref Dilute Russells Viper Venom Time, P (Mayo) Alupp Panel" PX-3058561310 CDM 85613 CPT 305 RC inpatient 193 193 BLUE CROSS BLUE SHIELD WELLMARK SB889 [3081026] BCBS WYOMING [308102603] 183.35 percent of total billed charges 119.66 183.35 Technical (Hospital) Services "Ref Dilute Russells Viper Venom Time, P (Mayo) Alupp Panel" PX-3058561310 CDM 85613 CPT 305 RC inpatient 193 193 CIGNA 62308 [3081051] CIGNA STATE OF WYOMING [308105107] 152.82 percent of total billed charges 119.66 183.35 Technical (Hospital) Services "Ref Dilute Russells Viper Venom Time, P (Mayo) Alupp Panel" PX-3058561310 CDM 85613 CPT 305 RC inpatient 193 193 CIGNA 62308 [3081051] CIGNA 62308 [308105105] 152.82 percent of total billed charges 119.66 183.35 Technical (Hospital) Services "Ref Dilute Russells Viper Venom Time, P (Mayo) Alupp Panel" PX-3058561310 CDM 85613 CPT 305 RC inpatient 193 193 MULTIPLAN INC 34080 [3081285] MULTIPLAN INC [308128501] 183.35 percent of total billed charges 119.66 183.35 Technical (Hospital) Services "Ref Prothrombin Time (Pt),P (Mayo) Proct Panel" PX-3058561000 CDM 85610 CPT 305 RC inpatient 82 82 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES EPO [308136803] 64.93 percent of total billed charges 50.84 77.9 Technical (Hospital) Services "Ref Prothrombin Time (Pt),P (Mayo) Proct Panel" PX-3058561000 CDM 85610 CPT 305 RC inpatient 82 82 HEALTHPARTNERS SX009 HEALTHPARTNERS 64.93 percent of total billed charges 50.84 77.9 Technical (Hospital) Services "Ref Prothrombin Time (Pt),P (Mayo) Proct Panel" PX-3058561000 CDM 85610 CPT 305 RC inpatient 82 82 MEDICA (COMMERCIAL) 94265 [3081118] MEDICA CLAIMS [308111801] 73.8 percent of total billed charges 50.84 77.9 Technical (Hospital) Services "Ref Prothrombin Time (Pt),P (Mayo) Proct Panel" PX-3058561000 CDM 85610 CPT 305 RC inpatient 82 82 MULTIPLAN INC 34080 [3081285] MULTIPLAN INC [308128501] 77.9 percent of total billed charges 50.84 77.9 Technical (Hospital) Services "Ref Prothrombin Time (Pt),P (Mayo) Proct Panel" PX-3058561000 CDM 85610 CPT 305 RC inpatient 82 82 CIGNA 62308 [3081051] CIGNA 62308 [308105105] 64.93 percent of total billed charges 50.84 77.9 Technical (Hospital) Services "Ref Prothrombin Time (Pt),P (Mayo) Proct Panel" PX-3058561000 CDM 85610 CPT 305 RC inpatient 82 82 CIGNA 62308 [3081051] CIGNA STATE OF WYOMING [308105107] 64.93 percent of total billed charges 50.84 77.9 Technical (Hospital) Services "Ref Prothrombin Time (Pt),P (Mayo) Proct Panel" PX-3058561000 CDM 85610 CPT 305 RC inpatient 82 82 BLUE CROSS BLUE SHIELD WELLMARK SB889 [3081026] BCBS WYOMING [308102603] 77.9 percent of total billed charges 50.84 77.9 Technical (Hospital) Services "Ref Prothrombin Time (Pt),P (Mayo) Proct Panel" PX-3058561000 CDM 85610 CPT 305 RC inpatient 82 82 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES PPO [308136801] 64.93 percent of total billed charges 50.84 77.9 Technical (Hospital) Services "Ref Prothrombin Time (Pt),P (Mayo) Proct Panel" PX-3058561000 CDM 85610 CPT 305 RC inpatient 82 82 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES HDHP [308136802] 64.93 percent of total billed charges 50.84 77.9 Technical (Hospital) Services "Ref Prothrombin Time (Pt),P (Mayo) Proct Panel" PX-3058561000 CDM 85610 CPT 305 RC inpatient 82 82 UNITED HEALTHCARE (COMMERCIAL) [3081199] UNITED HEALTHCARE 87726 [308119901] 50.84 percent of total billed charges 50.84 77.9 Technical (Hospital) Services "Ref Prothrombin Time (Pt),P (Mayo) Proct Panel" PX-3058561000 CDM 85610 CPT 305 RC outpatient 82 82 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES PPO [308136801] 65.6 percent of total billed charges 50.84 77.9 Technical (Hospital) Services "Ref Prothrombin Time (Pt),P (Mayo) Proct Panel" PX-3058561000 CDM 85610 CPT 305 RC outpatient 82 82 HEALTHPARTNERS SX009 HEALTHPARTNERS 65.6 percent of total billed charges 50.84 77.9 Technical (Hospital) Services "Ref Prothrombin Time (Pt),P (Mayo) Proct Panel" PX-3058561000 CDM 85610 CPT 305 RC outpatient 82 82 UNITED HEALTHCARE (COMMERCIAL) [3081199] UNITED HEALTHCARE 87726 [308119901] 50.84 percent of total billed charges 50.84 77.9 Technical (Hospital) Services "Ref Prothrombin Time (Pt),P (Mayo) Proct Panel" PX-3058561000 CDM 85610 CPT 305 RC outpatient 82 82 BLUE CROSS BLUE SHIELD WELLMARK SB889 [3081026] BCBS WYOMING [308102603] 77.9 percent of total billed charges 50.84 77.9 Technical (Hospital) Services "Ref Prothrombin Time (Pt),P (Mayo) Proct Panel" PX-3058561000 CDM 85610 CPT 305 RC outpatient 82 82 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES HDHP [308136802] 65.6 percent of total billed charges 50.84 77.9 Technical (Hospital) Services "Ref Prothrombin Time (Pt),P (Mayo) Proct Panel" PX-3058561000 CDM 85610 CPT 305 RC outpatient 82 82 MULTIPLAN INC 34080 [3081285] MULTIPLAN INC [308128501] 77.9 percent of total billed charges 50.84 77.9 Technical (Hospital) Services "Ref Prothrombin Time (Pt),P (Mayo) Proct Panel" PX-3058561000 CDM 85610 CPT 305 RC outpatient 82 82 CIGNA 62308 [3081051] CIGNA 62308 [308105105] 65.6 percent of total billed charges 50.84 77.9 Technical (Hospital) Services "Ref Prothrombin Time (Pt),P (Mayo) Proct Panel" PX-3058561000 CDM 85610 CPT 305 RC outpatient 82 82 CIGNA 62308 [3081051] CIGNA STATE OF WYOMING [308105107] 65.6 percent of total billed charges 50.84 77.9 Technical (Hospital) Services "Ref Prothrombin Time (Pt),P (Mayo) Proct Panel" PX-3058561000 CDM 85610 CPT 305 RC outpatient 82 82 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES EPO [308136803] 65.6 percent of total billed charges 50.84 77.9 Technical (Hospital) Services "Ref Prothrombin Time (Pt),P (Mayo) Proct Panel" PX-3058561000 CDM 85610 CPT 305 RC outpatient 82 82 MEDICA (COMMERCIAL) 94265 [3081118] MEDICA CLAIMS [308111801] 73.8 percent of total billed charges 50.84 77.9 Technical (Hospital) Services Protime PX-3058561005 CDM 85610 CPT 305 RC outpatient 88 88 MEDICA (COMMERCIAL) 94265 [3081118] MEDICA CLAIMS [308111801] 79.2 percent of total billed charges 54.56 83.6 Technical (Hospital) Services Protime PX-3058561005 CDM 85610 CPT 305 RC outpatient 88 88 CIGNA 62308 [3081051] CIGNA 62308 [308105105] 70.4 percent of total billed charges 54.56 83.6 Technical (Hospital) Services Protime PX-3058561005 CDM 85610 CPT 305 RC outpatient 88 88 CIGNA 62308 [3081051] CIGNA STATE OF WYOMING [308105107] 70.4 percent of total billed charges 54.56 83.6 Technical (Hospital) Services Protime PX-3058561005 CDM 85610 CPT 305 RC outpatient 88 88 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES EPO [308136803] 70.4 percent of total billed charges 54.56 83.6 Technical (Hospital) Services Protime PX-3058561005 CDM 85610 CPT 305 RC outpatient 88 88 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES PPO [308136801] 70.4 percent of total billed charges 54.56 83.6 Technical (Hospital) Services Protime PX-3058561005 CDM 85610 CPT 305 RC outpatient 88 88 MULTIPLAN INC 34080 [3081285] MULTIPLAN INC [308128501] 83.6 percent of total billed charges 54.56 83.6 Technical (Hospital) Services Protime PX-3058561005 CDM 85610 CPT 305 RC outpatient 88 88 UNITED HEALTHCARE (COMMERCIAL) [3081199] UNITED HEALTHCARE 87726 [308119901] 54.56 percent of total billed charges 54.56 83.6 Technical (Hospital) Services Protime PX-3058561005 CDM 85610 CPT 305 RC outpatient 88 88 BLUE CROSS BLUE SHIELD WELLMARK SB889 [3081026] BCBS WYOMING [308102603] 83.6 percent of total billed charges 54.56 83.6 Technical (Hospital) Services Protime PX-3058561005 CDM 85610 CPT 305 RC outpatient 88 88 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES HDHP [308136802] 70.4 percent of total billed charges 54.56 83.6 Technical (Hospital) Services Protime PX-3058561005 CDM 85610 CPT 305 RC outpatient 88 88 HEALTHPARTNERS SX009 HEALTHPARTNERS 70.4 percent of total billed charges 54.56 83.6 Technical (Hospital) Services Protime PX-3058561005 CDM 85610 CPT 305 RC inpatient 88 88 UNITED HEALTHCARE (COMMERCIAL) [3081199] UNITED HEALTHCARE 87726 [308119901] 54.56 percent of total billed charges 54.56 83.6 Technical (Hospital) Services Protime PX-3058561005 CDM 85610 CPT 305 RC inpatient 88 88 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES PPO [308136801] 69.68 percent of total billed charges 54.56 83.6 Technical (Hospital) Services Protime PX-3058561005 CDM 85610 CPT 305 RC inpatient 88 88 BLUE CROSS BLUE SHIELD WELLMARK SB889 [3081026] BCBS WYOMING [308102603] 83.6 percent of total billed charges 54.56 83.6 Technical (Hospital) Services Protime PX-3058561005 CDM 85610 CPT 305 RC inpatient 88 88 MULTIPLAN INC 34080 [3081285] MULTIPLAN INC [308128501] 83.6 percent of total billed charges 54.56 83.6 Technical (Hospital) Services Protime PX-3058561005 CDM 85610 CPT 305 RC inpatient 88 88 MEDICA (COMMERCIAL) 94265 [3081118] MEDICA CLAIMS [308111801] 79.2 percent of total billed charges 54.56 83.6 Technical (Hospital) Services Protime PX-3058561005 CDM 85610 CPT 305 RC inpatient 88 88 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES HDHP [308136802] 69.68 percent of total billed charges 54.56 83.6 Technical (Hospital) Services Protime PX-3058561005 CDM 85610 CPT 305 RC inpatient 88 88 HEALTHPARTNERS SX009 HEALTHPARTNERS 69.68 percent of total billed charges 54.56 83.6 Technical (Hospital) Services Protime PX-3058561005 CDM 85610 CPT 305 RC inpatient 88 88 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES EPO [308136803] 69.68 percent of total billed charges 54.56 83.6 Technical (Hospital) Services Protime PX-3058561005 CDM 85610 CPT 305 RC inpatient 88 88 CIGNA 62308 [3081051] CIGNA STATE OF WYOMING [308105107] 69.68 percent of total billed charges 54.56 83.6 Technical (Hospital) Services Protime PX-3058561005 CDM 85610 CPT 305 RC inpatient 88 88 CIGNA 62308 [3081051] CIGNA 62308 [308105105] 69.68 percent of total billed charges 54.56 83.6 Technical (Hospital) Services "Ref Prothrombin Time (Pt), P-Aprol" PX-3058561007 CDM 85610 CPT 305 RC outpatient 57 57 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES HDHP [308136802] 45.6 percent of total billed charges 35.34 54.15 Technical (Hospital) Services "Ref Prothrombin Time (Pt), P-Aprol" PX-3058561007 CDM 85610 CPT 305 RC outpatient 57 57 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES EPO [308136803] 45.6 percent of total billed charges 35.34 54.15 Technical (Hospital) Services "Ref Prothrombin Time (Pt), P-Aprol" PX-3058561007 CDM 85610 CPT 305 RC outpatient 57 57 CIGNA 62308 [3081051] CIGNA 62308 [308105105] 45.6 percent of total billed charges 35.34 54.15 Technical (Hospital) Services "Ref Prothrombin Time (Pt), P-Aprol" PX-3058561007 CDM 85610 CPT 305 RC outpatient 57 57 CIGNA 62308 [3081051] CIGNA STATE OF WYOMING [308105107] 45.6 percent of total billed charges 35.34 54.15 Technical (Hospital) Services "Ref Prothrombin Time (Pt), P-Aprol" PX-3058561007 CDM 85610 CPT 305 RC outpatient 57 57 MULTIPLAN INC 34080 [3081285] MULTIPLAN INC [308128501] 54.15 percent of total billed charges 35.34 54.15 Technical (Hospital) Services "Ref Prothrombin Time (Pt), P-Aprol" PX-3058561007 CDM 85610 CPT 305 RC outpatient 57 57 BLUE CROSS BLUE SHIELD WELLMARK SB889 [3081026] BCBS WYOMING [308102603] 54.15 percent of total billed charges 35.34 54.15 Technical (Hospital) Services "Ref Prothrombin Time (Pt), P-Aprol" PX-3058561007 CDM 85610 CPT 305 RC outpatient 57 57 HEALTHPARTNERS SX009 HEALTHPARTNERS 45.6 percent of total billed charges 35.34 54.15 Technical (Hospital) Services "Ref Prothrombin Time (Pt), P-Aprol" PX-3058561007 CDM 85610 CPT 305 RC outpatient 57 57 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES PPO [308136801] 45.6 percent of total billed charges 35.34 54.15 Technical (Hospital) Services "Ref Prothrombin Time (Pt), P-Aprol" PX-3058561007 CDM 85610 CPT 305 RC outpatient 57 57 UNITED HEALTHCARE (COMMERCIAL) [3081199] UNITED HEALTHCARE 87726 [308119901] 35.34 percent of total billed charges 35.34 54.15 Technical (Hospital) Services "Ref Prothrombin Time (Pt), P-Aprol" PX-3058561007 CDM 85610 CPT 305 RC outpatient 57 57 MEDICA (COMMERCIAL) 94265 [3081118] MEDICA CLAIMS [308111801] 51.3 percent of total billed charges 35.34 54.15 Technical (Hospital) Services "Ref Prothrombin Time (Pt), P-Aprol" PX-3058561007 CDM 85610 CPT 305 RC inpatient 57 57 CIGNA 62308 [3081051] CIGNA 62308 [308105105] 45.13 percent of total billed charges 35.34 54.15 Technical (Hospital) Services "Ref Prothrombin Time (Pt), P-Aprol" PX-3058561007 CDM 85610 CPT 305 RC inpatient 57 57 CIGNA 62308 [3081051] CIGNA STATE OF WYOMING [308105107] 45.13 percent of total billed charges 35.34 54.15 Technical (Hospital) Services "Ref Prothrombin Time (Pt), P-Aprol" PX-3058561007 CDM 85610 CPT 305 RC inpatient 57 57 BLUE CROSS BLUE SHIELD WELLMARK SB889 [3081026] BCBS WYOMING [308102603] 54.15 percent of total billed charges 35.34 54.15 Technical (Hospital) Services "Ref Prothrombin Time (Pt), P-Aprol" PX-3058561007 CDM 85610 CPT 305 RC inpatient 57 57 MULTIPLAN INC 34080 [3081285] MULTIPLAN INC [308128501] 54.15 percent of total billed charges 35.34 54.15 Technical (Hospital) Services "Ref Prothrombin Time (Pt), P-Aprol" PX-3058561007 CDM 85610 CPT 305 RC inpatient 57 57 MEDICA (COMMERCIAL) 94265 [3081118] MEDICA CLAIMS [308111801] 51.3 percent of total billed charges 35.34 54.15 Technical (Hospital) Services "Ref Prothrombin Time (Pt), P-Aprol" PX-3058561007 CDM 85610 CPT 305 RC inpatient 57 57 HEALTHPARTNERS SX009 HEALTHPARTNERS 45.13 percent of total billed charges 35.34 54.15 Technical (Hospital) Services "Ref Prothrombin Time (Pt), P-Aprol" PX-3058561007 CDM 85610 CPT 305 RC inpatient 57 57 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES EPO [308136803] 45.13 percent of total billed charges 35.34 54.15 Technical (Hospital) Services "Ref Prothrombin Time (Pt), P-Aprol" PX-3058561007 CDM 85610 CPT 305 RC inpatient 57 57 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES HDHP [308136802] 45.13 percent of total billed charges 35.34 54.15 Technical (Hospital) Services "Ref Prothrombin Time (Pt), P-Aprol" PX-3058561007 CDM 85610 CPT 305 RC inpatient 57 57 UNITED HEALTHCARE (COMMERCIAL) [3081199] UNITED HEALTHCARE 87726 [308119901] 35.34 percent of total billed charges 35.34 54.15 Technical (Hospital) Services "Ref Prothrombin Time (Pt), P-Aprol" PX-3058561007 CDM 85610 CPT 305 RC inpatient 57 57 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES PPO [308136801] 45.13 percent of total billed charges 35.34 54.15 Technical (Hospital) Services "Ref Prothrombin Time (Pt),P Mayo Aathr Panel" PX-3058561008 CDM 85610 CPT 305 RC outpatient 146 146 HEALTHPARTNERS SX009 HEALTHPARTNERS 116.8 percent of total billed charges 90.52 138.7 Technical (Hospital) Services "Ref Prothrombin Time (Pt),P Mayo Aathr Panel" PX-3058561008 CDM 85610 CPT 305 RC outpatient 146 146 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES PPO [308136801] 116.8 percent of total billed charges 90.52 138.7 Technical (Hospital) Services "Ref Prothrombin Time (Pt),P Mayo Aathr Panel" PX-3058561008 CDM 85610 CPT 305 RC outpatient 146 146 UNITED HEALTHCARE (COMMERCIAL) [3081199] UNITED HEALTHCARE 87726 [308119901] 90.52 percent of total billed charges 90.52 138.7 Technical (Hospital) Services "Ref Prothrombin Time (Pt),P Mayo Aathr Panel" PX-3058561008 CDM 85610 CPT 305 RC outpatient 146 146 MULTIPLAN INC 34080 [3081285] MULTIPLAN INC [308128501] 138.7 percent of total billed charges 90.52 138.7 Technical (Hospital) Services "Ref Prothrombin Time (Pt),P Mayo Aathr Panel" PX-3058561008 CDM 85610 CPT 305 RC outpatient 146 146 CIGNA 62308 [3081051] CIGNA 62308 [308105105] 116.8 percent of total billed charges 90.52 138.7 Technical (Hospital) Services "Ref Prothrombin Time (Pt),P Mayo Aathr Panel" PX-3058561008 CDM 85610 CPT 305 RC outpatient 146 146 CIGNA 62308 [3081051] CIGNA STATE OF WYOMING [308105107] 116.8 percent of total billed charges 90.52 138.7 Technical (Hospital) Services "Ref Prothrombin Time (Pt),P Mayo Aathr Panel" PX-3058561008 CDM 85610 CPT 305 RC outpatient 146 146 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES EPO [308136803] 116.8 percent of total billed charges 90.52 138.7 Technical (Hospital) Services "Ref Prothrombin Time (Pt),P Mayo Aathr Panel" PX-3058561008 CDM 85610 CPT 305 RC outpatient 146 146 BLUE CROSS BLUE SHIELD WELLMARK SB889 [3081026] BCBS WYOMING [308102603] 138.7 percent of total billed charges 90.52 138.7 Technical (Hospital) Services "Ref Prothrombin Time (Pt),P Mayo Aathr Panel" PX-3058561008 CDM 85610 CPT 305 RC outpatient 146 146 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES HDHP [308136802] 116.8 percent of total billed charges 90.52 138.7 Technical (Hospital) Services "Ref Prothrombin Time (Pt),P Mayo Aathr Panel" PX-3058561008 CDM 85610 CPT 305 RC outpatient 146 146 MEDICA (COMMERCIAL) 94265 [3081118] MEDICA CLAIMS [308111801] 131.4 percent of total billed charges 90.52 138.7 Technical (Hospital) Services "Ref Prothrombin Time (Pt),P Mayo Aathr Panel" PX-3058561008 CDM 85610 CPT 305 RC inpatient 146 146 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES PPO [308136801] 115.6 percent of total billed charges 90.52 138.7 Technical (Hospital) Services "Ref Prothrombin Time (Pt),P Mayo Aathr Panel" PX-3058561008 CDM 85610 CPT 305 RC inpatient 146 146 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES HDHP [308136802] 115.6 percent of total billed charges 90.52 138.7 Technical (Hospital) Services "Ref Prothrombin Time (Pt),P Mayo Aathr Panel" PX-3058561008 CDM 85610 CPT 305 RC inpatient 146 146 HEALTHPARTNERS SX009 HEALTHPARTNERS 115.6 percent of total billed charges 90.52 138.7 Technical (Hospital) Services "Ref Prothrombin Time (Pt),P Mayo Aathr Panel" PX-3058561008 CDM 85610 CPT 305 RC inpatient 146 146 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES EPO [308136803] 115.6 percent of total billed charges 90.52 138.7 Technical (Hospital) Services "Ref Prothrombin Time (Pt),P Mayo Aathr Panel" PX-3058561008 CDM 85610 CPT 305 RC inpatient 146 146 BLUE CROSS BLUE SHIELD WELLMARK SB889 [3081026] BCBS WYOMING [308102603] 138.7 percent of total billed charges 90.52 138.7 Technical (Hospital) Services "Ref Prothrombin Time (Pt),P Mayo Aathr Panel" PX-3058561008 CDM 85610 CPT 305 RC inpatient 146 146 CIGNA 62308 [3081051] CIGNA 62308 [308105105] 115.6 percent of total billed charges 90.52 138.7 Technical (Hospital) Services "Ref Prothrombin Time (Pt),P Mayo Aathr Panel" PX-3058561008 CDM 85610 CPT 305 RC inpatient 146 146 CIGNA 62308 [3081051] CIGNA STATE OF WYOMING [308105107] 115.6 percent of total billed charges 90.52 138.7 Technical (Hospital) Services "Ref Prothrombin Time (Pt),P Mayo Aathr Panel" PX-3058561008 CDM 85610 CPT 305 RC inpatient 146 146 MULTIPLAN INC 34080 [3081285] MULTIPLAN INC [308128501] 138.7 percent of total billed charges 90.52 138.7 Technical (Hospital) Services "Ref Prothrombin Time (Pt),P Mayo Aathr Panel" PX-3058561008 CDM 85610 CPT 305 RC inpatient 146 146 MEDICA (COMMERCIAL) 94265 [3081118] MEDICA CLAIMS [308111801] 131.4 percent of total billed charges 90.52 138.7 Technical (Hospital) Services "Ref Prothrombin Time (Pt),P Mayo Aathr Panel" PX-3058561008 CDM 85610 CPT 305 RC inpatient 146 146 UNITED HEALTHCARE (COMMERCIAL) [3081199] UNITED HEALTHCARE 87726 [308119901] 90.52 percent of total billed charges 90.52 138.7 Technical (Hospital) Services Plat Func PX-3058557601 CDM 85576 CPT 305 RC outpatient 180 180 MEDICA (COMMERCIAL) 94265 [3081118] MEDICA CLAIMS [308111801] 162 percent of total billed charges 111.6 171 Technical (Hospital) Services Plat Func PX-3058557601 CDM 85576 CPT 305 RC outpatient 180 180 UNITED HEALTHCARE (COMMERCIAL) [3081199] UNITED HEALTHCARE 87726 [308119901] 111.6 percent of total billed charges 111.6 171 Technical (Hospital) Services Plat Func PX-3058557601 CDM 85576 CPT 305 RC outpatient 180 180 HEALTHPARTNERS SX009 HEALTHPARTNERS 144 percent of total billed charges 111.6 171 Technical (Hospital) Services Plat Func PX-3058557601 CDM 85576 CPT 305 RC outpatient 180 180 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES PPO [308136801] 144 percent of total billed charges 111.6 171 Technical (Hospital) Services Plat Func PX-3058557601 CDM 85576 CPT 305 RC outpatient 180 180 CIGNA 62308 [3081051] CIGNA 62308 [308105105] 144 percent of total billed charges 111.6 171 Technical (Hospital) Services Plat Func PX-3058557601 CDM 85576 CPT 305 RC outpatient 180 180 CIGNA 62308 [3081051] CIGNA STATE OF WYOMING [308105107] 144 percent of total billed charges 111.6 171 Technical (Hospital) Services Plat Func PX-3058557601 CDM 85576 CPT 305 RC outpatient 180 180 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES EPO [308136803] 144 percent of total billed charges 111.6 171 Technical (Hospital) Services Plat Func PX-3058557601 CDM 85576 CPT 305 RC outpatient 180 180 MULTIPLAN INC 34080 [3081285] MULTIPLAN INC [308128501] 171 percent of total billed charges 111.6 171 Technical (Hospital) Services Plat Func PX-3058557601 CDM 85576 CPT 305 RC outpatient 180 180 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES HDHP [308136802] 144 percent of total billed charges 111.6 171 Technical (Hospital) Services Plat Func PX-3058557601 CDM 85576 CPT 305 RC outpatient 180 180 BLUE CROSS BLUE SHIELD WELLMARK SB889 [3081026] BCBS WYOMING [308102603] 171 percent of total billed charges 111.6 171 Technical (Hospital) Services Plat Func PX-3058557601 CDM 85576 CPT 305 RC inpatient 180 180 BLUE CROSS BLUE SHIELD WELLMARK SB889 [3081026] BCBS WYOMING [308102603] 171 percent of total billed charges 111.6 171 Technical (Hospital) Services Plat Func PX-3058557601 CDM 85576 CPT 305 RC inpatient 180 180 CIGNA 62308 [3081051] CIGNA 62308 [308105105] 142.52 percent of total billed charges 111.6 171 Technical (Hospital) Services Plat Func PX-3058557601 CDM 85576 CPT 305 RC inpatient 180 180 CIGNA 62308 [3081051] CIGNA STATE OF WYOMING [308105107] 142.52 percent of total billed charges 111.6 171 Technical (Hospital) Services Plat Func PX-3058557601 CDM 85576 CPT 305 RC inpatient 180 180 MULTIPLAN INC 34080 [3081285] MULTIPLAN INC [308128501] 171 percent of total billed charges 111.6 171 Technical (Hospital) Services Plat Func PX-3058557601 CDM 85576 CPT 305 RC inpatient 180 180 HEALTHPARTNERS SX009 HEALTHPARTNERS 142.52 percent of total billed charges 111.6 171 Technical (Hospital) Services Plat Func PX-3058557601 CDM 85576 CPT 305 RC inpatient 180 180 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES EPO [308136803] 142.52 percent of total billed charges 111.6 171 Technical (Hospital) Services Plat Func PX-3058557601 CDM 85576 CPT 305 RC inpatient 180 180 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES HDHP [308136802] 142.52 percent of total billed charges 111.6 171 Technical (Hospital) Services Plat Func PX-3058557601 CDM 85576 CPT 305 RC inpatient 180 180 UNITED HEALTHCARE (COMMERCIAL) [3081199] UNITED HEALTHCARE 87726 [308119901] 111.6 percent of total billed charges 111.6 171 Technical (Hospital) Services Plat Func PX-3058557601 CDM 85576 CPT 305 RC inpatient 180 180 MEDICA (COMMERCIAL) 94265 [3081118] MEDICA CLAIMS [308111801] 162 percent of total billed charges 111.6 171 Technical (Hospital) Services Plat Func PX-3058557601 CDM 85576 CPT 305 RC inpatient 180 180 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES PPO [308136801] 142.52 percent of total billed charges 111.6 171 Technical (Hospital) Services Muramidase PX-3058554900 CDM 85549 CPT 305 RC inpatient 213 213 CIGNA 62308 [3081051] CIGNA 62308 [308105105] 168.65 percent of total billed charges 132.06 202.35 Technical (Hospital) Services Muramidase PX-3058554900 CDM 85549 CPT 305 RC inpatient 213 213 CIGNA 62308 [3081051] CIGNA STATE OF WYOMING [308105107] 168.65 percent of total billed charges 132.06 202.35 Technical (Hospital) Services Muramidase PX-3058554900 CDM 85549 CPT 305 RC inpatient 213 213 BLUE CROSS BLUE SHIELD WELLMARK SB889 [3081026] BCBS WYOMING [308102603] 202.35 percent of total billed charges 132.06 202.35 Technical (Hospital) Services Muramidase PX-3058554900 CDM 85549 CPT 305 RC inpatient 213 213 MULTIPLAN INC 34080 [3081285] MULTIPLAN INC [308128501] 202.35 percent of total billed charges 132.06 202.35 Technical (Hospital) Services Muramidase PX-3058554900 CDM 85549 CPT 305 RC inpatient 213 213 HEALTHPARTNERS SX009 HEALTHPARTNERS 168.65 percent of total billed charges 132.06 202.35 Technical (Hospital) Services Muramidase PX-3058554900 CDM 85549 CPT 305 RC inpatient 213 213 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES EPO [308136803] 168.65 percent of total billed charges 132.06 202.35 Technical (Hospital) Services Muramidase PX-3058554900 CDM 85549 CPT 305 RC inpatient 213 213 MEDICA (COMMERCIAL) 94265 [3081118] MEDICA CLAIMS [308111801] 191.7 percent of total billed charges 132.06 202.35 Technical (Hospital) Services Muramidase PX-3058554900 CDM 85549 CPT 305 RC inpatient 213 213 UNITED HEALTHCARE (COMMERCIAL) [3081199] UNITED HEALTHCARE 87726 [308119901] 132.06 percent of total billed charges 132.06 202.35 Technical (Hospital) Services Muramidase PX-3058554900 CDM 85549 CPT 305 RC inpatient 213 213 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES HDHP [308136802] 168.65 percent of total billed charges 132.06 202.35 Technical (Hospital) Services Muramidase PX-3058554900 CDM 85549 CPT 305 RC inpatient 213 213 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES PPO [308136801] 168.65 percent of total billed charges 132.06 202.35 Technical (Hospital) Services Muramidase PX-3058554900 CDM 85549 CPT 305 RC outpatient 213 213 BLUE CROSS BLUE SHIELD WELLMARK SB889 [3081026] BCBS WYOMING [308102603] 202.35 percent of total billed charges 132.06 202.35 Technical (Hospital) Services Muramidase PX-3058554900 CDM 85549 CPT 305 RC outpatient 213 213 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES HDHP [308136802] 170.4 percent of total billed charges 132.06 202.35 Technical (Hospital) Services Muramidase PX-3058554900 CDM 85549 CPT 305 RC outpatient 213 213 MULTIPLAN INC 34080 [3081285] MULTIPLAN INC [308128501] 202.35 percent of total billed charges 132.06 202.35 Technical (Hospital) Services Muramidase PX-3058554900 CDM 85549 CPT 305 RC outpatient 213 213 CIGNA 62308 [3081051] CIGNA STATE OF WYOMING [308105107] 170.4 percent of total billed charges 132.06 202.35 Technical (Hospital) Services Muramidase PX-3058554900 CDM 85549 CPT 305 RC outpatient 213 213 CIGNA 62308 [3081051] CIGNA 62308 [308105105] 170.4 percent of total billed charges 132.06 202.35 Technical (Hospital) Services Muramidase PX-3058554900 CDM 85549 CPT 305 RC outpatient 213 213 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES EPO [308136803] 170.4 percent of total billed charges 132.06 202.35 Technical (Hospital) Services Muramidase PX-3058554900 CDM 85549 CPT 305 RC outpatient 213 213 HEALTHPARTNERS SX009 HEALTHPARTNERS 170.4 percent of total billed charges 132.06 202.35 Technical (Hospital) Services Muramidase PX-3058554900 CDM 85549 CPT 305 RC outpatient 213 213 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES PPO [308136801] 170.4 percent of total billed charges 132.06 202.35 Technical (Hospital) Services Muramidase PX-3058554900 CDM 85549 CPT 305 RC outpatient 213 213 UNITED HEALTHCARE (COMMERCIAL) [3081199] UNITED HEALTHCARE 87726 [308119901] 132.06 percent of total billed charges 132.06 202.35 Technical (Hospital) Services Muramidase PX-3058554900 CDM 85549 CPT 305 RC outpatient 213 213 MEDICA (COMMERCIAL) 94265 [3081118] MEDICA CLAIMS [308111801] 191.7 percent of total billed charges 132.06 202.35 Technical (Hospital) Services Heparin Anti Xa PX-3058552000 CDM 85520 CPT 305 RC inpatient 217 217 MULTIPLAN INC 34080 [3081285] MULTIPLAN INC [308128501] 206.15 percent of total billed charges 134.54 206.15 Technical (Hospital) Services Heparin Anti Xa PX-3058552000 CDM 85520 CPT 305 RC inpatient 217 217 MEDICA (COMMERCIAL) 94265 [3081118] MEDICA CLAIMS [308111801] 195.3 percent of total billed charges 134.54 206.15 Technical (Hospital) Services Heparin Anti Xa PX-3058552000 CDM 85520 CPT 305 RC inpatient 217 217 BLUE CROSS BLUE SHIELD WELLMARK SB889 [3081026] BCBS WYOMING [308102603] 206.15 percent of total billed charges 134.54 206.15 Technical (Hospital) Services Heparin Anti Xa PX-3058552000 CDM 85520 CPT 305 RC inpatient 217 217 CIGNA 62308 [3081051] CIGNA 62308 [308105105] 171.82 percent of total billed charges 134.54 206.15 Technical (Hospital) Services Heparin Anti Xa PX-3058552000 CDM 85520 CPT 305 RC inpatient 217 217 CIGNA 62308 [3081051] CIGNA STATE OF WYOMING [308105107] 171.82 percent of total billed charges 134.54 206.15 Technical (Hospital) Services Heparin Anti Xa PX-3058552000 CDM 85520 CPT 305 RC inpatient 217 217 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES EPO [308136803] 171.82 percent of total billed charges 134.54 206.15 Technical (Hospital) Services Heparin Anti Xa PX-3058552000 CDM 85520 CPT 305 RC inpatient 217 217 HEALTHPARTNERS SX009 HEALTHPARTNERS 171.82 percent of total billed charges 134.54 206.15 Technical (Hospital) Services Heparin Anti Xa PX-3058552000 CDM 85520 CPT 305 RC inpatient 217 217 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES HDHP [308136802] 171.82 percent of total billed charges 134.54 206.15 Technical (Hospital) Services Heparin Anti Xa PX-3058552000 CDM 85520 CPT 305 RC inpatient 217 217 UNITED HEALTHCARE (COMMERCIAL) [3081199] UNITED HEALTHCARE 87726 [308119901] 134.54 percent of total billed charges 134.54 206.15 Technical (Hospital) Services Heparin Anti Xa PX-3058552000 CDM 85520 CPT 305 RC inpatient 217 217 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES PPO [308136801] 171.82 percent of total billed charges 134.54 206.15 Technical (Hospital) Services Heparin Anti Xa PX-3058552000 CDM 85520 CPT 305 RC outpatient 217 217 UNITED HEALTHCARE (COMMERCIAL) [3081199] UNITED HEALTHCARE 87726 [308119901] 134.54 percent of total billed charges 134.54 206.15 Technical (Hospital) Services Heparin Anti Xa PX-3058552000 CDM 85520 CPT 305 RC outpatient 217 217 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES PPO [308136801] 173.6 percent of total billed charges 134.54 206.15 Technical (Hospital) Services Heparin Anti Xa PX-3058552000 CDM 85520 CPT 305 RC outpatient 217 217 HEALTHPARTNERS SX009 HEALTHPARTNERS 173.6 percent of total billed charges 134.54 206.15 Technical (Hospital) Services Heparin Anti Xa PX-3058552000 CDM 85520 CPT 305 RC outpatient 217 217 BLUE CROSS BLUE SHIELD WELLMARK SB889 [3081026] BCBS WYOMING [308102603] 206.15 percent of total billed charges 134.54 206.15 Technical (Hospital) Services Heparin Anti Xa PX-3058552000 CDM 85520 CPT 305 RC outpatient 217 217 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES HDHP [308136802] 173.6 percent of total billed charges 134.54 206.15 Technical (Hospital) Services Heparin Anti Xa PX-3058552000 CDM 85520 CPT 305 RC outpatient 217 217 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES EPO [308136803] 173.6 percent of total billed charges 134.54 206.15 Technical (Hospital) Services Heparin Anti Xa PX-3058552000 CDM 85520 CPT 305 RC outpatient 217 217 CIGNA 62308 [3081051] CIGNA 62308 [308105105] 173.6 percent of total billed charges 134.54 206.15 Technical (Hospital) Services Heparin Anti Xa PX-3058552000 CDM 85520 CPT 305 RC outpatient 217 217 CIGNA 62308 [3081051] CIGNA STATE OF WYOMING [308105107] 173.6 percent of total billed charges 134.54 206.15 Technical (Hospital) Services Heparin Anti Xa PX-3058552000 CDM 85520 CPT 305 RC outpatient 217 217 MULTIPLAN INC 34080 [3081285] MULTIPLAN INC [308128501] 206.15 percent of total billed charges 134.54 206.15 Technical (Hospital) Services Heparin Anti Xa PX-3058552000 CDM 85520 CPT 305 RC outpatient 217 217 MEDICA (COMMERCIAL) 94265 [3081118] MEDICA CLAIMS [308111801] 195.3 percent of total billed charges 134.54 206.15 Technical (Hospital) Services Fetal Screen PX-3058546100 CDM 85461 CPT 305 RC outpatient 114 114 CIGNA 62308 [3081051] CIGNA 62308 [308105105] 91.2 percent of total billed charges 70.68 108.3 Technical (Hospital) Services Fetal Screen PX-3058546100 CDM 85461 CPT 305 RC outpatient 114 114 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES EPO [308136803] 91.2 percent of total billed charges 70.68 108.3 Technical (Hospital) Services Fetal Screen PX-3058546100 CDM 85461 CPT 305 RC outpatient 114 114 MULTIPLAN INC 34080 [3081285] MULTIPLAN INC [308128501] 108.3 percent of total billed charges 70.68 108.3 Technical (Hospital) Services Fetal Screen PX-3058546100 CDM 85461 CPT 305 RC outpatient 114 114 CIGNA 62308 [3081051] CIGNA STATE OF WYOMING [308105107] 91.2 percent of total billed charges 70.68 108.3 Technical (Hospital) Services Fetal Screen PX-3058546100 CDM 85461 CPT 305 RC outpatient 114 114 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES HDHP [308136802] 91.2 percent of total billed charges 70.68 108.3 Technical (Hospital) Services Fetal Screen PX-3058546100 CDM 85461 CPT 305 RC outpatient 114 114 BLUE CROSS BLUE SHIELD WELLMARK SB889 [3081026] BCBS WYOMING [308102603] 108.3 percent of total billed charges 70.68 108.3 Technical (Hospital) Services Fetal Screen PX-3058546100 CDM 85461 CPT 305 RC outpatient 114 114 UNITED HEALTHCARE (COMMERCIAL) [3081199] UNITED HEALTHCARE 87726 [308119901] 70.68 percent of total billed charges 70.68 108.3 Technical (Hospital) Services Fetal Screen PX-3058546100 CDM 85461 CPT 305 RC outpatient 114 114 HEALTHPARTNERS SX009 HEALTHPARTNERS 91.2 percent of total billed charges 70.68 108.3 Technical (Hospital) Services Fetal Screen PX-3058546100 CDM 85461 CPT 305 RC outpatient 114 114 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES PPO [308136801] 91.2 percent of total billed charges 70.68 108.3 Technical (Hospital) Services Fetal Screen PX-3058546100 CDM 85461 CPT 305 RC outpatient 114 114 MEDICA (COMMERCIAL) 94265 [3081118] MEDICA CLAIMS [308111801] 102.6 percent of total billed charges 70.68 108.3 Technical (Hospital) Services Fetal Screen PX-3058546100 CDM 85461 CPT 305 RC inpatient 114 114 UNITED HEALTHCARE (COMMERCIAL) [3081199] UNITED HEALTHCARE 87726 [308119901] 70.68 percent of total billed charges 70.68 108.3 Technical (Hospital) Services Fetal Screen PX-3058546100 CDM 85461 CPT 305 RC inpatient 114 114 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES HDHP [308136802] 90.27 percent of total billed charges 70.68 108.3 Technical (Hospital) Services Fetal Screen PX-3058546100 CDM 85461 CPT 305 RC inpatient 114 114 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES PPO [308136801] 90.27 percent of total billed charges 70.68 108.3 Technical (Hospital) Services Fetal Screen PX-3058546100 CDM 85461 CPT 305 RC inpatient 114 114 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES EPO [308136803] 90.27 percent of total billed charges 70.68 108.3 Technical (Hospital) Services Fetal Screen PX-3058546100 CDM 85461 CPT 305 RC inpatient 114 114 HEALTHPARTNERS SX009 HEALTHPARTNERS 90.27 percent of total billed charges 70.68 108.3 Technical (Hospital) Services Fetal Screen PX-3058546100 CDM 85461 CPT 305 RC inpatient 114 114 MEDICA (COMMERCIAL) 94265 [3081118] MEDICA CLAIMS [308111801] 102.6 percent of total billed charges 70.68 108.3 Technical (Hospital) Services Fetal Screen PX-3058546100 CDM 85461 CPT 305 RC inpatient 114 114 MULTIPLAN INC 34080 [3081285] MULTIPLAN INC [308128501] 108.3 percent of total billed charges 70.68 108.3 Technical (Hospital) Services Fetal Screen PX-3058546100 CDM 85461 CPT 305 RC inpatient 114 114 BLUE CROSS BLUE SHIELD WELLMARK SB889 [3081026] BCBS WYOMING [308102603] 108.3 percent of total billed charges 70.68 108.3 Technical (Hospital) Services Fetal Screen PX-3058546100 CDM 85461 CPT 305 RC inpatient 114 114 CIGNA 62308 [3081051] CIGNA 62308 [308105105] 90.27 percent of total billed charges 70.68 108.3 Technical (Hospital) Services Fetal Screen PX-3058546100 CDM 85461 CPT 305 RC inpatient 114 114 CIGNA 62308 [3081051] CIGNA STATE OF WYOMING [308105107] 90.27 percent of total billed charges 70.68 108.3 Technical (Hospital) Services Ref Plasminogen Activity PX-3058542000 CDM 85420 CPT 305 RC inpatient 213 213 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES PPO [308136801] 168.65 percent of total billed charges 132.06 202.35 Technical (Hospital) Services Ref Plasminogen Activity PX-3058542000 CDM 85420 CPT 305 RC inpatient 213 213 MEDICA (COMMERCIAL) 94265 [3081118] MEDICA CLAIMS [308111801] 191.7 percent of total billed charges 132.06 202.35 Technical (Hospital) Services Ref Plasminogen Activity PX-3058542000 CDM 85420 CPT 305 RC inpatient 213 213 UNITED HEALTHCARE (COMMERCIAL) [3081199] UNITED HEALTHCARE 87726 [308119901] 132.06 percent of total billed charges 132.06 202.35 Technical (Hospital) Services Ref Plasminogen Activity PX-3058542000 CDM 85420 CPT 305 RC inpatient 213 213 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES HDHP [308136802] 168.65 percent of total billed charges 132.06 202.35 Technical (Hospital) Services Ref Plasminogen Activity PX-3058542000 CDM 85420 CPT 305 RC inpatient 213 213 HEALTHPARTNERS SX009 HEALTHPARTNERS 168.65 percent of total billed charges 132.06 202.35 Technical (Hospital) Services Ref Plasminogen Activity PX-3058542000 CDM 85420 CPT 305 RC inpatient 213 213 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES EPO [308136803] 168.65 percent of total billed charges 132.06 202.35 Technical (Hospital) Services Ref Plasminogen Activity PX-3058542000 CDM 85420 CPT 305 RC inpatient 213 213 MULTIPLAN INC 34080 [3081285] MULTIPLAN INC [308128501] 202.35 percent of total billed charges 132.06 202.35 Technical (Hospital) Services Ref Plasminogen Activity PX-3058542000 CDM 85420 CPT 305 RC inpatient 213 213 BLUE CROSS BLUE SHIELD WELLMARK SB889 [3081026] BCBS WYOMING [308102603] 202.35 percent of total billed charges 132.06 202.35 Technical (Hospital) Services Ref Plasminogen Activity PX-3058542000 CDM 85420 CPT 305 RC inpatient 213 213 CIGNA 62308 [3081051] CIGNA 62308 [308105105] 168.65 percent of total billed charges 132.06 202.35 Technical (Hospital) Services Ref Plasminogen Activity PX-3058542000 CDM 85420 CPT 305 RC inpatient 213 213 CIGNA 62308 [3081051] CIGNA STATE OF WYOMING [308105107] 168.65 percent of total billed charges 132.06 202.35 Technical (Hospital) Services Ref Plasminogen Activity PX-3058542000 CDM 85420 CPT 305 RC outpatient 213 213 UNITED HEALTHCARE (COMMERCIAL) [3081199] UNITED HEALTHCARE 87726 [308119901] 132.06 percent of total billed charges 132.06 202.35 Technical (Hospital) Services Ref Plasminogen Activity PX-3058542000 CDM 85420 CPT 305 RC outpatient 213 213 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES PPO [308136801] 170.4 percent of total billed charges 132.06 202.35 Technical (Hospital) Services Ref Plasminogen Activity PX-3058542000 CDM 85420 CPT 305 RC outpatient 213 213 HEALTHPARTNERS SX009 HEALTHPARTNERS 170.4 percent of total billed charges 132.06 202.35 Technical (Hospital) Services Ref Plasminogen Activity PX-3058542000 CDM 85420 CPT 305 RC outpatient 213 213 BLUE CROSS BLUE SHIELD WELLMARK SB889 [3081026] BCBS WYOMING [308102603] 202.35 percent of total billed charges 132.06 202.35 Technical (Hospital) Services Ref Plasminogen Activity PX-3058542000 CDM 85420 CPT 305 RC outpatient 213 213 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES HDHP [308136802] 170.4 percent of total billed charges 132.06 202.35 Technical (Hospital) Services Ref Plasminogen Activity PX-3058542000 CDM 85420 CPT 305 RC outpatient 213 213 MULTIPLAN INC 34080 [3081285] MULTIPLAN INC [308128501] 202.35 percent of total billed charges 132.06 202.35 Technical (Hospital) Services Ref Plasminogen Activity PX-3058542000 CDM 85420 CPT 305 RC outpatient 213 213 CIGNA 62308 [3081051] CIGNA 62308 [308105105] 170.4 percent of total billed charges 132.06 202.35 Technical (Hospital) Services Ref Plasminogen Activity PX-3058542000 CDM 85420 CPT 305 RC outpatient 213 213 CIGNA 62308 [3081051] CIGNA STATE OF WYOMING [308105107] 170.4 percent of total billed charges 132.06 202.35 Technical (Hospital) Services Ref Plasminogen Activity PX-3058542000 CDM 85420 CPT 305 RC outpatient 213 213 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES EPO [308136803] 170.4 percent of total billed charges 132.06 202.35 Technical (Hospital) Services Ref Plasminogen Activity PX-3058542000 CDM 85420 CPT 305 RC outpatient 213 213 MEDICA (COMMERCIAL) 94265 [3081118] MEDICA CLAIMS [308111801] 191.7 percent of total billed charges 132.06 202.35 Technical (Hospital) Services Ref Plasminogen Activator Inh1 Act PX-3058541500 CDM 85415 CPT 305 RC outpatient 759 759 UNITED HEALTHCARE (COMMERCIAL) [3081199] UNITED HEALTHCARE 87726 [308119901] 470.58 percent of total billed charges 470.58 721.05 Technical (Hospital) Services Ref Plasminogen Activator Inh1 Act PX-3058541500 CDM 85415 CPT 305 RC outpatient 759 759 BLUE CROSS BLUE SHIELD WELLMARK SB889 [3081026] BCBS WYOMING [308102603] 721.05 percent of total billed charges 470.58 721.05 Technical (Hospital) Services Ref Plasminogen Activator Inh1 Act PX-3058541500 CDM 85415 CPT 305 RC outpatient 759 759 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES HDHP [308136802] 607.2 percent of total billed charges 470.58 721.05 Technical (Hospital) Services Ref Plasminogen Activator Inh1 Act PX-3058541500 CDM 85415 CPT 305 RC outpatient 759 759 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES EPO [308136803] 607.2 percent of total billed charges 470.58 721.05 Technical (Hospital) Services Ref Plasminogen Activator Inh1 Act PX-3058541500 CDM 85415 CPT 305 RC outpatient 759 759 CIGNA 62308 [3081051] CIGNA 62308 [308105105] 607.2 percent of total billed charges 470.58 721.05 Technical (Hospital) Services Ref Plasminogen Activator Inh1 Act PX-3058541500 CDM 85415 CPT 305 RC outpatient 759 759 CIGNA 62308 [3081051] CIGNA STATE OF WYOMING [308105107] 607.2 percent of total billed charges 470.58 721.05 Technical (Hospital) Services Ref Plasminogen Activator Inh1 Act PX-3058541500 CDM 85415 CPT 305 RC outpatient 759 759 MULTIPLAN INC 34080 [3081285] MULTIPLAN INC [308128501] 721.05 percent of total billed charges 470.58 721.05 Technical (Hospital) Services Ref Plasminogen Activator Inh1 Act PX-3058541500 CDM 85415 CPT 305 RC outpatient 759 759 MEDICA (COMMERCIAL) 94265 [3081118] MEDICA CLAIMS [308111801] 683.1 percent of total billed charges 470.58 721.05 Technical (Hospital) Services Ref Plasminogen Activator Inh1 Act PX-3058541500 CDM 85415 CPT 305 RC outpatient 759 759 HEALTHPARTNERS SX009 HEALTHPARTNERS 607.2 percent of total billed charges 470.58 721.05 Technical (Hospital) Services Ref Plasminogen Activator Inh1 Act PX-3058541500 CDM 85415 CPT 305 RC outpatient 759 759 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES PPO [308136801] 607.2 percent of total billed charges 470.58 721.05 Technical (Hospital) Services Ref Plasminogen Activator Inh1 Act PX-3058541500 CDM 85415 CPT 305 RC inpatient 759 759 BLUE CROSS BLUE SHIELD WELLMARK SB889 [3081026] BCBS WYOMING [308102603] 721.05 percent of total billed charges 470.58 721.05 Technical (Hospital) Services Ref Plasminogen Activator Inh1 Act PX-3058541500 CDM 85415 CPT 305 RC inpatient 759 759 CIGNA 62308 [3081051] CIGNA 62308 [308105105] 600.98 percent of total billed charges 470.58 721.05 Technical (Hospital) Services Ref Plasminogen Activator Inh1 Act PX-3058541500 CDM 85415 CPT 305 RC inpatient 759 759 CIGNA 62308 [3081051] CIGNA STATE OF WYOMING [308105107] 600.98 percent of total billed charges 470.58 721.05 Technical (Hospital) Services Ref Plasminogen Activator Inh1 Act PX-3058541500 CDM 85415 CPT 305 RC inpatient 759 759 MEDICA (COMMERCIAL) 94265 [3081118] MEDICA CLAIMS [308111801] 683.1 percent of total billed charges 470.58 721.05 Technical (Hospital) Services Ref Plasminogen Activator Inh1 Act PX-3058541500 CDM 85415 CPT 305 RC inpatient 759 759 MULTIPLAN INC 34080 [3081285] MULTIPLAN INC [308128501] 721.05 percent of total billed charges 470.58 721.05 Technical (Hospital) Services Ref Plasminogen Activator Inh1 Act PX-3058541500 CDM 85415 CPT 305 RC inpatient 759 759 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES EPO [308136803] 600.98 percent of total billed charges 470.58 721.05 Technical (Hospital) Services Ref Plasminogen Activator Inh1 Act PX-3058541500 CDM 85415 CPT 305 RC inpatient 759 759 HEALTHPARTNERS SX009 HEALTHPARTNERS 600.98 percent of total billed charges 470.58 721.05 Technical (Hospital) Services Ref Plasminogen Activator Inh1 Act PX-3058541500 CDM 85415 CPT 305 RC inpatient 759 759 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES PPO [308136801] 600.98 percent of total billed charges 470.58 721.05 Technical (Hospital) Services Ref Plasminogen Activator Inh1 Act PX-3058541500 CDM 85415 CPT 305 RC inpatient 759 759 UNITED HEALTHCARE (COMMERCIAL) [3081199] UNITED HEALTHCARE 87726 [308119901] 470.58 percent of total billed charges 470.58 721.05 Technical (Hospital) Services Ref Plasminogen Activator Inh1 Act PX-3058541500 CDM 85415 CPT 305 RC inpatient 759 759 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES HDHP [308136802] 600.98 percent of total billed charges 470.58 721.05 Technical (Hospital) Services Ref Special Coagulation Interpretation (Mayo) Luppr Panel PX-3058539002 CDM 85390 CPT 305 RC outpatient 280 280 MEDICA (COMMERCIAL) 94265 [3081118] MEDICA CLAIMS [308111801] 252 percent of total billed charges 173.6 266 Technical (Hospital) Services Ref Special Coagulation Interpretation (Mayo) Luppr Panel PX-3058539002 CDM 85390 CPT 305 RC outpatient 280 280 CIGNA 62308 [3081051] CIGNA 62308 [308105105] 224 percent of total billed charges 173.6 266 Technical (Hospital) Services Ref Special Coagulation Interpretation (Mayo) Luppr Panel PX-3058539002 CDM 85390 CPT 305 RC outpatient 280 280 CIGNA 62308 [3081051] CIGNA STATE OF WYOMING [308105107] 224 percent of total billed charges 173.6 266 Technical (Hospital) Services Ref Special Coagulation Interpretation (Mayo) Luppr Panel PX-3058539002 CDM 85390 CPT 305 RC outpatient 280 280 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES EPO [308136803] 224 percent of total billed charges 173.6 266 Technical (Hospital) Services Ref Special Coagulation Interpretation (Mayo) Luppr Panel PX-3058539002 CDM 85390 CPT 305 RC outpatient 280 280 MULTIPLAN INC 34080 [3081285] MULTIPLAN INC [308128501] 266 percent of total billed charges 173.6 266 Technical (Hospital) Services Ref Special Coagulation Interpretation (Mayo) Luppr Panel PX-3058539002 CDM 85390 CPT 305 RC outpatient 280 280 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES HDHP [308136802] 224 percent of total billed charges 173.6 266 Technical (Hospital) Services Ref Special Coagulation Interpretation (Mayo) Luppr Panel PX-3058539002 CDM 85390 CPT 305 RC outpatient 280 280 BLUE CROSS BLUE SHIELD WELLMARK SB889 [3081026] BCBS WYOMING [308102603] 266 percent of total billed charges 173.6 266 Technical (Hospital) Services Ref Special Coagulation Interpretation (Mayo) Luppr Panel PX-3058539002 CDM 85390 CPT 305 RC outpatient 280 280 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES PPO [308136801] 224 percent of total billed charges 173.6 266 Technical (Hospital) Services Ref Special Coagulation Interpretation (Mayo) Luppr Panel PX-3058539002 CDM 85390 CPT 305 RC outpatient 280 280 HEALTHPARTNERS SX009 HEALTHPARTNERS 224 percent of total billed charges 173.6 266 Technical (Hospital) Services Ref Special Coagulation Interpretation (Mayo) Luppr Panel PX-3058539002 CDM 85390 CPT 305 RC outpatient 280 280 UNITED HEALTHCARE (COMMERCIAL) [3081199] UNITED HEALTHCARE 87726 [308119901] 173.6 percent of total billed charges 173.6 266 Technical (Hospital) Services Ref Special Coagulation Interpretation (Mayo) Luppr Panel PX-3058539002 CDM 85390 CPT 305 RC inpatient 280 280 BLUE CROSS BLUE SHIELD WELLMARK SB889 [3081026] BCBS WYOMING [308102603] 266 percent of total billed charges 173.6 266 Technical (Hospital) Services Ref Special Coagulation Interpretation (Mayo) Luppr Panel PX-3058539002 CDM 85390 CPT 305 RC inpatient 280 280 CIGNA 62308 [3081051] CIGNA STATE OF WYOMING [308105107] 221.7 percent of total billed charges 173.6 266 Technical (Hospital) Services Ref Special Coagulation Interpretation (Mayo) Luppr Panel PX-3058539002 CDM 85390 CPT 305 RC inpatient 280 280 CIGNA 62308 [3081051] CIGNA 62308 [308105105] 221.7 percent of total billed charges 173.6 266 Technical (Hospital) Services Ref Special Coagulation Interpretation (Mayo) Luppr Panel PX-3058539002 CDM 85390 CPT 305 RC inpatient 280 280 MULTIPLAN INC 34080 [3081285] MULTIPLAN INC [308128501] 266 percent of total billed charges 173.6 266 Technical (Hospital) Services Ref Special Coagulation Interpretation (Mayo) Luppr Panel PX-3058539002 CDM 85390 CPT 305 RC inpatient 280 280 MEDICA (COMMERCIAL) 94265 [3081118] MEDICA CLAIMS [308111801] 252 percent of total billed charges 173.6 266 Technical (Hospital) Services Ref Special Coagulation Interpretation (Mayo) Luppr Panel PX-3058539002 CDM 85390 CPT 305 RC inpatient 280 280 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES EPO [308136803] 221.7 percent of total billed charges 173.6 266 Technical (Hospital) Services Ref Special Coagulation Interpretation (Mayo) Luppr Panel PX-3058539002 CDM 85390 CPT 305 RC inpatient 280 280 HEALTHPARTNERS SX009 HEALTHPARTNERS 221.7 percent of total billed charges 173.6 266 Technical (Hospital) Services Ref Special Coagulation Interpretation (Mayo) Luppr Panel PX-3058539002 CDM 85390 CPT 305 RC inpatient 280 280 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES PPO [308136801] 221.7 percent of total billed charges 173.6 266 Technical (Hospital) Services Ref Special Coagulation Interpretation (Mayo) Luppr Panel PX-3058539002 CDM 85390 CPT 305 RC inpatient 280 280 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES HDHP [308136802] 221.7 percent of total billed charges 173.6 266 Technical (Hospital) Services Ref Special Coagulation Interpretation (Mayo) Luppr Panel PX-3058539002 CDM 85390 CPT 305 RC inpatient 280 280 UNITED HEALTHCARE (COMMERCIAL) [3081199] UNITED HEALTHCARE 87726 [308119901] 173.6 percent of total billed charges 173.6 266 Technical (Hospital) Services "Ref Fibrinolysins,or Coagulopathy Screen,Interp and Report (Mayo) Aathr Panel" PX-3058539005 CDM 85390 CPT 305 RC inpatient 524 524 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES PPO [308136801] 414.9 percent of total billed charges 324.88 497.8 Technical (Hospital) Services "Ref Fibrinolysins,or Coagulopathy Screen,Interp and Report (Mayo) Aathr Panel" PX-3058539005 CDM 85390 CPT 305 RC inpatient 524 524 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES HDHP [308136802] 414.9 percent of total billed charges 324.88 497.8 Technical (Hospital) Services "Ref Fibrinolysins,or Coagulopathy Screen,Interp and Report (Mayo) Aathr Panel" PX-3058539005 CDM 85390 CPT 305 RC inpatient 524 524 UNITED HEALTHCARE (COMMERCIAL) [3081199] UNITED HEALTHCARE 87726 [308119901] 324.88 percent of total billed charges 324.88 497.8 Technical (Hospital) Services "Ref Fibrinolysins,or Coagulopathy Screen,Interp and Report (Mayo) Aathr Panel" PX-3058539005 CDM 85390 CPT 305 RC inpatient 524 524 MEDICA (COMMERCIAL) 94265 [3081118] MEDICA CLAIMS [308111801] 471.6 percent of total billed charges 324.88 497.8 Technical (Hospital) Services "Ref Fibrinolysins,or Coagulopathy Screen,Interp and Report (Mayo) Aathr Panel" PX-3058539005 CDM 85390 CPT 305 RC outpatient 524 524 UNITED HEALTHCARE (COMMERCIAL) [3081199] UNITED HEALTHCARE 87726 [308119901] 324.88 percent of total billed charges 324.88 497.8 Technical (Hospital) Services "Ref Fibrinolysins,or Coagulopathy Screen,Interp and Report (Mayo) Aathr Panel" PX-3058539005 CDM 85390 CPT 305 RC inpatient 524 524 BLUE CROSS BLUE SHIELD WELLMARK SB889 [3081026] BCBS WYOMING [308102603] 497.8 percent of total billed charges 324.88 497.8 Technical (Hospital) Services "Ref Fibrinolysins,or Coagulopathy Screen,Interp and Report (Mayo) Aathr Panel" PX-3058539005 CDM 85390 CPT 305 RC inpatient 524 524 CIGNA 62308 [3081051] CIGNA 62308 [308105105] 414.9 percent of total billed charges 324.88 497.8 Technical (Hospital) Services "Ref Fibrinolysins,or Coagulopathy Screen,Interp and Report (Mayo) Aathr Panel" PX-3058539005 CDM 85390 CPT 305 RC inpatient 524 524 CIGNA 62308 [3081051] CIGNA STATE OF WYOMING [308105107] 414.9 percent of total billed charges 324.88 497.8 Technical (Hospital) Services "Ref Fibrinolysins,or Coagulopathy Screen,Interp and Report (Mayo) Aathr Panel" PX-3058539005 CDM 85390 CPT 305 RC inpatient 524 524 MULTIPLAN INC 34080 [3081285] MULTIPLAN INC [308128501] 497.8 percent of total billed charges 324.88 497.8 Technical (Hospital) Services "Ref Fibrinolysins,or Coagulopathy Screen,Interp and Report (Mayo) Aathr Panel" PX-3058539005 CDM 85390 CPT 305 RC inpatient 524 524 HEALTHPARTNERS SX009 HEALTHPARTNERS 414.9 percent of total billed charges 324.88 497.8 Technical (Hospital) Services "Ref Fibrinolysins,or Coagulopathy Screen,Interp and Report (Mayo) Aathr Panel" PX-3058539005 CDM 85390 CPT 305 RC inpatient 524 524 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES EPO [308136803] 414.9 percent of total billed charges 324.88 497.8 Technical (Hospital) Services "Ref Fibrinolysins,or Coagulopathy Screen,Interp and Report (Mayo) Aathr Panel" PX-3058539005 CDM 85390 CPT 305 RC outpatient 524 524 HEALTHPARTNERS SX009 HEALTHPARTNERS 419.2 percent of total billed charges 324.88 497.8 Technical (Hospital) Services "Ref Fibrinolysins,or Coagulopathy Screen,Interp and Report (Mayo) Aathr Panel" PX-3058539005 CDM 85390 CPT 305 RC outpatient 524 524 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES PPO [308136801] 419.2 percent of total billed charges 324.88 497.8 Technical (Hospital) Services "Ref Fibrinolysins,or Coagulopathy Screen,Interp and Report (Mayo) Aathr Panel" PX-3058539005 CDM 85390 CPT 305 RC outpatient 524 524 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES HDHP [308136802] 419.2 percent of total billed charges 324.88 497.8 Technical (Hospital) Services "Ref Fibrinolysins,or Coagulopathy Screen,Interp and Report (Mayo) Aathr Panel" PX-3058539005 CDM 85390 CPT 305 RC outpatient 524 524 BLUE CROSS BLUE SHIELD WELLMARK SB889 [3081026] BCBS WYOMING [308102603] 497.8 percent of total billed charges 324.88 497.8 Technical (Hospital) Services "Ref Fibrinolysins,or Coagulopathy Screen,Interp and Report (Mayo) Aathr Panel" PX-3058539005 CDM 85390 CPT 305 RC outpatient 524 524 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES EPO [308136803] 419.2 percent of total billed charges 324.88 497.8 Technical (Hospital) Services "Ref Fibrinolysins,or Coagulopathy Screen,Interp and Report (Mayo) Aathr Panel" PX-3058539005 CDM 85390 CPT 305 RC outpatient 524 524 CIGNA 62308 [3081051] CIGNA 62308 [308105105] 419.2 percent of total billed charges 324.88 497.8 Technical (Hospital) Services "Ref Fibrinolysins,or Coagulopathy Screen,Interp and Report (Mayo) Aathr Panel" PX-3058539005 CDM 85390 CPT 305 RC outpatient 524 524 CIGNA 62308 [3081051] CIGNA STATE OF WYOMING [308105107] 419.2 percent of total billed charges 324.88 497.8 Technical (Hospital) Services "Ref Fibrinolysins,or Coagulopathy Screen,Interp and Report (Mayo) Aathr Panel" PX-3058539005 CDM 85390 CPT 305 RC outpatient 524 524 MULTIPLAN INC 34080 [3081285] MULTIPLAN INC [308128501] 497.8 percent of total billed charges 324.88 497.8 Technical (Hospital) Services "Ref Fibrinolysins,or Coagulopathy Screen,Interp and Report (Mayo) Aathr Panel" PX-3058539005 CDM 85390 CPT 305 RC outpatient 524 524 MEDICA (COMMERCIAL) 94265 [3081118] MEDICA CLAIMS [308111801] 471.6 percent of total billed charges 324.88 497.8 Technical (Hospital) Services Fibrinogen PX-3058538400 CDM 85384 CPT 305 RC inpatient 133 133 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES EPO [308136803] 105.31 percent of total billed charges 82.46 126.35 Technical (Hospital) Services Fibrinogen PX-3058538400 CDM 85384 CPT 305 RC inpatient 133 133 HEALTHPARTNERS SX009 HEALTHPARTNERS 105.31 percent of total billed charges 82.46 126.35 Technical (Hospital) Services Fibrinogen PX-3058538400 CDM 85384 CPT 305 RC inpatient 133 133 CIGNA 62308 [3081051] CIGNA 62308 [308105105] 105.31 percent of total billed charges 82.46 126.35 Technical (Hospital) Services Fibrinogen PX-3058538400 CDM 85384 CPT 305 RC inpatient 133 133 CIGNA 62308 [3081051] CIGNA STATE OF WYOMING [308105107] 105.31 percent of total billed charges 82.46 126.35 Technical (Hospital) Services Fibrinogen PX-3058538400 CDM 85384 CPT 305 RC inpatient 133 133 BLUE CROSS BLUE SHIELD WELLMARK SB889 [3081026] BCBS WYOMING [308102603] 126.35 percent of total billed charges 82.46 126.35 Technical (Hospital) Services Fibrinogen PX-3058538400 CDM 85384 CPT 305 RC inpatient 133 133 MULTIPLAN INC 34080 [3081285] MULTIPLAN INC [308128501] 126.35 percent of total billed charges 82.46 126.35 Technical (Hospital) Services Fibrinogen PX-3058538400 CDM 85384 CPT 305 RC inpatient 133 133 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES PPO [308136801] 105.31 percent of total billed charges 82.46 126.35 Technical (Hospital) Services Fibrinogen PX-3058538400 CDM 85384 CPT 305 RC inpatient 133 133 MEDICA (COMMERCIAL) 94265 [3081118] MEDICA CLAIMS [308111801] 119.7 percent of total billed charges 82.46 126.35 Technical (Hospital) Services Fibrinogen PX-3058538400 CDM 85384 CPT 305 RC inpatient 133 133 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES HDHP [308136802] 105.31 percent of total billed charges 82.46 126.35 Technical (Hospital) Services Fibrinogen PX-3058538400 CDM 85384 CPT 305 RC inpatient 133 133 UNITED HEALTHCARE (COMMERCIAL) [3081199] UNITED HEALTHCARE 87726 [308119901] 82.46 percent of total billed charges 82.46 126.35 Technical (Hospital) Services Fibrinogen PX-3058538400 CDM 85384 CPT 305 RC outpatient 133 133 BLUE CROSS BLUE SHIELD WELLMARK SB889 [3081026] BCBS WYOMING [308102603] 126.35 percent of total billed charges 82.46 126.35 Technical (Hospital) Services Fibrinogen PX-3058538400 CDM 85384 CPT 305 RC outpatient 133 133 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES HDHP [308136802] 106.4 percent of total billed charges 82.46 126.35 Technical (Hospital) Services Fibrinogen PX-3058538400 CDM 85384 CPT 305 RC outpatient 133 133 CIGNA 62308 [3081051] CIGNA 62308 [308105105] 106.4 percent of total billed charges 82.46 126.35 Technical (Hospital) Services Fibrinogen PX-3058538400 CDM 85384 CPT 305 RC outpatient 133 133 CIGNA 62308 [3081051] CIGNA STATE OF WYOMING [308105107] 106.4 percent of total billed charges 82.46 126.35 Technical (Hospital) Services Fibrinogen PX-3058538400 CDM 85384 CPT 305 RC outpatient 133 133 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES EPO [308136803] 106.4 percent of total billed charges 82.46 126.35 Technical (Hospital) Services Fibrinogen PX-3058538400 CDM 85384 CPT 305 RC outpatient 133 133 MULTIPLAN INC 34080 [3081285] MULTIPLAN INC [308128501] 126.35 percent of total billed charges 82.46 126.35 Technical (Hospital) Services Fibrinogen PX-3058538400 CDM 85384 CPT 305 RC outpatient 133 133 UNITED HEALTHCARE (COMMERCIAL) [3081199] UNITED HEALTHCARE 87726 [308119901] 82.46 percent of total billed charges 82.46 126.35 Technical (Hospital) Services Fibrinogen PX-3058538400 CDM 85384 CPT 305 RC outpatient 133 133 HEALTHPARTNERS SX009 HEALTHPARTNERS 106.4 percent of total billed charges 82.46 126.35 Technical (Hospital) Services Fibrinogen PX-3058538400 CDM 85384 CPT 305 RC outpatient 133 133 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES PPO [308136801] 106.4 percent of total billed charges 82.46 126.35 Technical (Hospital) Services Fibrinogen PX-3058538400 CDM 85384 CPT 305 RC outpatient 133 133 MEDICA (COMMERCIAL) 94265 [3081118] MEDICA CLAIMS [308111801] 119.7 percent of total billed charges 82.46 126.35 Technical (Hospital) Services "Ref Fibrinogen,P (Mayo) Aathr Panel" PX-3058538404 CDM 85384 CPT 305 RC outpatient 330 330 MEDICA (COMMERCIAL) 94265 [3081118] MEDICA CLAIMS [308111801] 297 percent of total billed charges 204.6 313.5 Technical (Hospital) Services "Ref Fibrinogen,P (Mayo) Aathr Panel" PX-3058538404 CDM 85384 CPT 305 RC outpatient 330 330 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES HDHP [308136802] 264 percent of total billed charges 204.6 313.5 Technical (Hospital) Services "Ref Fibrinogen,P (Mayo) Aathr Panel" PX-3058538404 CDM 85384 CPT 305 RC outpatient 330 330 BLUE CROSS BLUE SHIELD WELLMARK SB889 [3081026] BCBS WYOMING [308102603] 313.5 percent of total billed charges 204.6 313.5 Technical (Hospital) Services "Ref Fibrinogen,P (Mayo) Aathr Panel" PX-3058538404 CDM 85384 CPT 305 RC outpatient 330 330 CIGNA 62308 [3081051] CIGNA 62308 [308105105] 264 percent of total billed charges 204.6 313.5 Technical (Hospital) Services "Ref Fibrinogen,P (Mayo) Aathr Panel" PX-3058538404 CDM 85384 CPT 305 RC outpatient 330 330 CIGNA 62308 [3081051] CIGNA STATE OF WYOMING [308105107] 264 percent of total billed charges 204.6 313.5 Technical (Hospital) Services "Ref Fibrinogen,P (Mayo) Aathr Panel" PX-3058538404 CDM 85384 CPT 305 RC outpatient 330 330 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES EPO [308136803] 264 percent of total billed charges 204.6 313.5 Technical (Hospital) Services "Ref Fibrinogen,P (Mayo) Aathr Panel" PX-3058538404 CDM 85384 CPT 305 RC outpatient 330 330 MULTIPLAN INC 34080 [3081285] MULTIPLAN INC [308128501] 313.5 percent of total billed charges 204.6 313.5 Technical (Hospital) Services "Ref Fibrinogen,P (Mayo) Aathr Panel" PX-3058538404 CDM 85384 CPT 305 RC outpatient 330 330 UNITED HEALTHCARE (COMMERCIAL) [3081199] UNITED HEALTHCARE 87726 [308119901] 204.6 percent of total billed charges 204.6 313.5 Technical (Hospital) Services "Ref Fibrinogen,P (Mayo) Aathr Panel" PX-3058538404 CDM 85384 CPT 305 RC outpatient 330 330 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES PPO [308136801] 264 percent of total billed charges 204.6 313.5 Technical (Hospital) Services "Ref Fibrinogen,P (Mayo) Aathr Panel" PX-3058538404 CDM 85384 CPT 305 RC outpatient 330 330 HEALTHPARTNERS SX009 HEALTHPARTNERS 264 percent of total billed charges 204.6 313.5 Technical (Hospital) Services "Ref Fibrinogen,P (Mayo) Aathr Panel" PX-3058538404 CDM 85384 CPT 305 RC inpatient 330 330 UNITED HEALTHCARE (COMMERCIAL) [3081199] UNITED HEALTHCARE 87726 [308119901] 204.6 percent of total billed charges 204.6 313.5 Technical (Hospital) Services "Ref Fibrinogen,P (Mayo) Aathr Panel" PX-3058538404 CDM 85384 CPT 305 RC inpatient 330 330 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES HDHP [308136802] 261.29 percent of total billed charges 204.6 313.5 Technical (Hospital) Services "Ref Fibrinogen,P (Mayo) Aathr Panel" PX-3058538404 CDM 85384 CPT 305 RC inpatient 330 330 MEDICA (COMMERCIAL) 94265 [3081118] MEDICA CLAIMS [308111801] 297 percent of total billed charges 204.6 313.5 Technical (Hospital) Services "Ref Fibrinogen,P (Mayo) Aathr Panel" PX-3058538404 CDM 85384 CPT 305 RC inpatient 330 330 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES PPO [308136801] 261.29 percent of total billed charges 204.6 313.5 Technical (Hospital) Services "Ref Fibrinogen,P (Mayo) Aathr Panel" PX-3058538404 CDM 85384 CPT 305 RC inpatient 330 330 MULTIPLAN INC 34080 [3081285] MULTIPLAN INC [308128501] 313.5 percent of total billed charges 204.6 313.5 Technical (Hospital) Services "Ref Fibrinogen,P (Mayo) Aathr Panel" PX-3058538404 CDM 85384 CPT 305 RC inpatient 330 330 BLUE CROSS BLUE SHIELD WELLMARK SB889 [3081026] BCBS WYOMING [308102603] 313.5 percent of total billed charges 204.6 313.5 Technical (Hospital) Services "Ref Fibrinogen,P (Mayo) Aathr Panel" PX-3058538404 CDM 85384 CPT 305 RC inpatient 330 330 CIGNA 62308 [3081051] CIGNA 62308 [308105105] 261.29 percent of total billed charges 204.6 313.5 Technical (Hospital) Services "Ref Fibrinogen,P (Mayo) Aathr Panel" PX-3058538404 CDM 85384 CPT 305 RC inpatient 330 330 CIGNA 62308 [3081051] CIGNA STATE OF WYOMING [308105107] 261.29 percent of total billed charges 204.6 313.5 Technical (Hospital) Services "Ref Fibrinogen,P (Mayo) Aathr Panel" PX-3058538404 CDM 85384 CPT 305 RC inpatient 330 330 HEALTHPARTNERS SX009 HEALTHPARTNERS 261.29 percent of total billed charges 204.6 313.5 Technical (Hospital) Services "Ref Fibrinogen,P (Mayo) Aathr Panel" PX-3058538404 CDM 85384 CPT 305 RC inpatient 330 330 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES EPO [308136803] 261.29 percent of total billed charges 204.6 313.5 Technical (Hospital) Services D Dimer PX-3058537900 CDM 85379 CPT 305 RC inpatient 212 212 BLUE CROSS BLUE SHIELD WELLMARK SB889 [3081026] BCBS WYOMING [308102603] 201.4 percent of total billed charges 131.44 201.4 Technical (Hospital) Services D Dimer PX-3058537900 CDM 85379 CPT 305 RC inpatient 212 212 CIGNA 62308 [3081051] CIGNA 62308 [308105105] 167.86 percent of total billed charges 131.44 201.4 Technical (Hospital) Services D Dimer PX-3058537900 CDM 85379 CPT 305 RC inpatient 212 212 CIGNA 62308 [3081051] CIGNA STATE OF WYOMING [308105107] 167.86 percent of total billed charges 131.44 201.4 Technical (Hospital) Services D Dimer PX-3058537900 CDM 85379 CPT 305 RC inpatient 212 212 MEDICA (COMMERCIAL) 94265 [3081118] MEDICA CLAIMS [308111801] 190.8 percent of total billed charges 131.44 201.4 Technical (Hospital) Services D Dimer PX-3058537900 CDM 85379 CPT 305 RC inpatient 212 212 MULTIPLAN INC 34080 [3081285] MULTIPLAN INC [308128501] 201.4 percent of total billed charges 131.44 201.4 Technical (Hospital) Services D Dimer PX-3058537900 CDM 85379 CPT 305 RC inpatient 212 212 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES EPO [308136803] 167.86 percent of total billed charges 131.44 201.4 Technical (Hospital) Services D Dimer PX-3058537900 CDM 85379 CPT 305 RC inpatient 212 212 HEALTHPARTNERS SX009 HEALTHPARTNERS 167.86 percent of total billed charges 131.44 201.4 Technical (Hospital) Services D Dimer PX-3058537900 CDM 85379 CPT 305 RC inpatient 212 212 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES PPO [308136801] 167.86 percent of total billed charges 131.44 201.4 Technical (Hospital) Services D Dimer PX-3058537900 CDM 85379 CPT 305 RC inpatient 212 212 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES HDHP [308136802] 167.86 percent of total billed charges 131.44 201.4 Technical (Hospital) Services D Dimer PX-3058537900 CDM 85379 CPT 305 RC inpatient 212 212 UNITED HEALTHCARE (COMMERCIAL) [3081199] UNITED HEALTHCARE 87726 [308119901] 131.44 percent of total billed charges 131.44 201.4 Technical (Hospital) Services D Dimer PX-3058537900 CDM 85379 CPT 305 RC outpatient 212 212 MEDICA (COMMERCIAL) 94265 [3081118] MEDICA CLAIMS [308111801] 190.8 percent of total billed charges 131.44 201.4 Technical (Hospital) Services D Dimer PX-3058537900 CDM 85379 CPT 305 RC outpatient 212 212 MULTIPLAN INC 34080 [3081285] MULTIPLAN INC [308128501] 201.4 percent of total billed charges 131.44 201.4 Technical (Hospital) Services D Dimer PX-3058537900 CDM 85379 CPT 305 RC outpatient 212 212 BLUE CROSS BLUE SHIELD WELLMARK SB889 [3081026] BCBS WYOMING [308102603] 201.4 percent of total billed charges 131.44 201.4 Technical (Hospital) Services D Dimer PX-3058537900 CDM 85379 CPT 305 RC outpatient 212 212 CIGNA 62308 [3081051] CIGNA STATE OF WYOMING [308105107] 169.6 percent of total billed charges 131.44 201.4 Technical (Hospital) Services D Dimer PX-3058537900 CDM 85379 CPT 305 RC outpatient 212 212 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES EPO [308136803] 169.6 percent of total billed charges 131.44 201.4 Technical (Hospital) Services D Dimer PX-3058537900 CDM 85379 CPT 305 RC outpatient 212 212 CIGNA 62308 [3081051] CIGNA 62308 [308105105] 169.6 percent of total billed charges 131.44 201.4 Technical (Hospital) Services D Dimer PX-3058537900 CDM 85379 CPT 305 RC outpatient 212 212 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES HDHP [308136802] 169.6 percent of total billed charges 131.44 201.4 Technical (Hospital) Services D Dimer PX-3058537900 CDM 85379 CPT 305 RC outpatient 212 212 UNITED HEALTHCARE (COMMERCIAL) [3081199] UNITED HEALTHCARE 87726 [308119901] 131.44 percent of total billed charges 131.44 201.4 Technical (Hospital) Services D Dimer PX-3058537900 CDM 85379 CPT 305 RC outpatient 212 212 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES PPO [308136801] 169.6 percent of total billed charges 131.44 201.4 Technical (Hospital) Services D Dimer PX-3058537900 CDM 85379 CPT 305 RC outpatient 212 212 HEALTHPARTNERS SX009 HEALTHPARTNERS 169.6 percent of total billed charges 131.44 201.4 Technical (Hospital) Services "Ref D-Dimer, P-Aprol" PX-3058537904 CDM 85379 CPT 305 RC outpatient 343 343 CIGNA 62308 [3081051] CIGNA 62308 [308105105] 274.4 percent of total billed charges 212.66 325.85 Technical (Hospital) Services "Ref D-Dimer, P-Aprol" PX-3058537904 CDM 85379 CPT 305 RC outpatient 343 343 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES EPO [308136803] 274.4 percent of total billed charges 212.66 325.85 Technical (Hospital) Services "Ref D-Dimer, P-Aprol" PX-3058537904 CDM 85379 CPT 305 RC outpatient 343 343 CIGNA 62308 [3081051] CIGNA STATE OF WYOMING [308105107] 274.4 percent of total billed charges 212.66 325.85 Technical (Hospital) Services "Ref D-Dimer, P-Aprol" PX-3058537904 CDM 85379 CPT 305 RC outpatient 343 343 MULTIPLAN INC 34080 [3081285] MULTIPLAN INC [308128501] 325.85 percent of total billed charges 212.66 325.85 Technical (Hospital) Services "Ref D-Dimer, P-Aprol" PX-3058537904 CDM 85379 CPT 305 RC outpatient 343 343 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES HDHP [308136802] 274.4 percent of total billed charges 212.66 325.85 Technical (Hospital) Services "Ref D-Dimer, P-Aprol" PX-3058537904 CDM 85379 CPT 305 RC outpatient 343 343 BLUE CROSS BLUE SHIELD WELLMARK SB889 [3081026] BCBS WYOMING [308102603] 325.85 percent of total billed charges 212.66 325.85 Technical (Hospital) Services "Ref D-Dimer, P-Aprol" PX-3058537904 CDM 85379 CPT 305 RC outpatient 343 343 UNITED HEALTHCARE (COMMERCIAL) [3081199] UNITED HEALTHCARE 87726 [308119901] 212.66 percent of total billed charges 212.66 325.85 Technical (Hospital) Services "Ref D-Dimer, P-Aprol" PX-3058537904 CDM 85379 CPT 305 RC outpatient 343 343 HEALTHPARTNERS SX009 HEALTHPARTNERS 274.4 percent of total billed charges 212.66 325.85 Technical (Hospital) Services "Ref D-Dimer, P-Aprol" PX-3058537904 CDM 85379 CPT 305 RC outpatient 343 343 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES PPO [308136801] 274.4 percent of total billed charges 212.66 325.85 Technical (Hospital) Services "Ref D-Dimer, P-Aprol" PX-3058537904 CDM 85379 CPT 305 RC outpatient 343 343 MEDICA (COMMERCIAL) 94265 [3081118] MEDICA CLAIMS [308111801] 308.7 percent of total billed charges 212.66 325.85 Technical (Hospital) Services "Ref D-Dimer, P-Aprol" PX-3058537904 CDM 85379 CPT 305 RC inpatient 343 343 UNITED HEALTHCARE (COMMERCIAL) [3081199] UNITED HEALTHCARE 87726 [308119901] 212.66 percent of total billed charges 212.66 325.85 Technical (Hospital) Services "Ref D-Dimer, P-Aprol" PX-3058537904 CDM 85379 CPT 305 RC inpatient 343 343 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES HDHP [308136802] 271.59 percent of total billed charges 212.66 325.85 Technical (Hospital) Services "Ref D-Dimer, P-Aprol" PX-3058537904 CDM 85379 CPT 305 RC inpatient 343 343 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES PPO [308136801] 271.59 percent of total billed charges 212.66 325.85 Technical (Hospital) Services "Ref D-Dimer, P-Aprol" PX-3058537904 CDM 85379 CPT 305 RC inpatient 343 343 MEDICA (COMMERCIAL) 94265 [3081118] MEDICA CLAIMS [308111801] 308.7 percent of total billed charges 212.66 325.85 Technical (Hospital) Services "Ref D-Dimer, P-Aprol" PX-3058537904 CDM 85379 CPT 305 RC inpatient 343 343 MULTIPLAN INC 34080 [3081285] MULTIPLAN INC [308128501] 325.85 percent of total billed charges 212.66 325.85 Technical (Hospital) Services "Ref D-Dimer, P-Aprol" PX-3058537904 CDM 85379 CPT 305 RC inpatient 343 343 CIGNA 62308 [3081051] CIGNA 62308 [308105105] 271.59 percent of total billed charges 212.66 325.85 Technical (Hospital) Services "Ref D-Dimer, P-Aprol" PX-3058537904 CDM 85379 CPT 305 RC inpatient 343 343 CIGNA 62308 [3081051] CIGNA STATE OF WYOMING [308105107] 271.59 percent of total billed charges 212.66 325.85 Technical (Hospital) Services "Ref D-Dimer, P-Aprol" PX-3058537904 CDM 85379 CPT 305 RC inpatient 343 343 BLUE CROSS BLUE SHIELD WELLMARK SB889 [3081026] BCBS WYOMING [308102603] 325.85 percent of total billed charges 212.66 325.85 Technical (Hospital) Services "Ref D-Dimer, P-Aprol" PX-3058537904 CDM 85379 CPT 305 RC inpatient 343 343 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES EPO [308136803] 271.59 percent of total billed charges 212.66 325.85 Technical (Hospital) Services "Ref D-Dimer, P-Aprol" PX-3058537904 CDM 85379 CPT 305 RC inpatient 343 343 HEALTHPARTNERS SX009 HEALTHPARTNERS 271.59 percent of total billed charges 212.66 325.85 Technical (Hospital) Services Ref Soluble Fibrin Monomer- Thrombo Panel PX-3058536600 CDM 85366 CPT 305 RC outpatient 142 142 UNITED HEALTHCARE (COMMERCIAL) [3081199] UNITED HEALTHCARE 87726 [308119901] 88.04 percent of total billed charges 88.04 134.9 Technical (Hospital) Services Ref Soluble Fibrin Monomer- Thrombo Panel PX-3058536600 CDM 85366 CPT 305 RC outpatient 142 142 HEALTHPARTNERS SX009 HEALTHPARTNERS 113.6 percent of total billed charges 88.04 134.9 Technical (Hospital) Services Ref Soluble Fibrin Monomer- Thrombo Panel PX-3058536600 CDM 85366 CPT 305 RC outpatient 142 142 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES PPO [308136801] 113.6 percent of total billed charges 88.04 134.9 Technical (Hospital) Services Ref Soluble Fibrin Monomer- Thrombo Panel PX-3058536600 CDM 85366 CPT 305 RC outpatient 142 142 BLUE CROSS BLUE SHIELD WELLMARK SB889 [3081026] BCBS WYOMING [308102603] 134.9 percent of total billed charges 88.04 134.9 Technical (Hospital) Services Ref Soluble Fibrin Monomer- Thrombo Panel PX-3058536600 CDM 85366 CPT 305 RC outpatient 142 142 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES HDHP [308136802] 113.6 percent of total billed charges 88.04 134.9 Technical (Hospital) Services Ref Soluble Fibrin Monomer- Thrombo Panel PX-3058536600 CDM 85366 CPT 305 RC outpatient 142 142 MULTIPLAN INC 34080 [3081285] MULTIPLAN INC [308128501] 134.9 percent of total billed charges 88.04 134.9 Technical (Hospital) Services Ref Soluble Fibrin Monomer- Thrombo Panel PX-3058536600 CDM 85366 CPT 305 RC outpatient 142 142 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES EPO [308136803] 113.6 percent of total billed charges 88.04 134.9 Technical (Hospital) Services Ref Soluble Fibrin Monomer- Thrombo Panel PX-3058536600 CDM 85366 CPT 305 RC outpatient 142 142 CIGNA 62308 [3081051] CIGNA 62308 [308105105] 113.6 percent of total billed charges 88.04 134.9 Technical (Hospital) Services Ref Soluble Fibrin Monomer- Thrombo Panel PX-3058536600 CDM 85366 CPT 305 RC outpatient 142 142 CIGNA 62308 [3081051] CIGNA STATE OF WYOMING [308105107] 113.6 percent of total billed charges 88.04 134.9 Technical (Hospital) Services Ref Soluble Fibrin Monomer- Thrombo Panel PX-3058536600 CDM 85366 CPT 305 RC outpatient 142 142 MEDICA (COMMERCIAL) 94265 [3081118] MEDICA CLAIMS [308111801] 127.8 percent of total billed charges 88.04 134.9 Technical (Hospital) Services Ref Soluble Fibrin Monomer- Thrombo Panel PX-3058536600 CDM 85366 CPT 305 RC inpatient 142 142 HEALTHPARTNERS SX009 HEALTHPARTNERS 112.44 percent of total billed charges 88.04 134.9 Technical (Hospital) Services Ref Soluble Fibrin Monomer- Thrombo Panel PX-3058536600 CDM 85366 CPT 305 RC inpatient 142 142 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES EPO [308136803] 112.44 percent of total billed charges 88.04 134.9 Technical (Hospital) Services Ref Soluble Fibrin Monomer- Thrombo Panel PX-3058536600 CDM 85366 CPT 305 RC inpatient 142 142 BLUE CROSS BLUE SHIELD WELLMARK SB889 [3081026] BCBS WYOMING [308102603] 134.9 percent of total billed charges 88.04 134.9 Technical (Hospital) Services Ref Soluble Fibrin Monomer- Thrombo Panel PX-3058536600 CDM 85366 CPT 305 RC inpatient 142 142 CIGNA 62308 [3081051] CIGNA 62308 [308105105] 112.44 percent of total billed charges 88.04 134.9 Technical (Hospital) Services Ref Soluble Fibrin Monomer- Thrombo Panel PX-3058536600 CDM 85366 CPT 305 RC inpatient 142 142 CIGNA 62308 [3081051] CIGNA STATE OF WYOMING [308105107] 112.44 percent of total billed charges 88.04 134.9 Technical (Hospital) Services Ref Soluble Fibrin Monomer- Thrombo Panel PX-3058536600 CDM 85366 CPT 305 RC inpatient 142 142 MULTIPLAN INC 34080 [3081285] MULTIPLAN INC [308128501] 134.9 percent of total billed charges 88.04 134.9 Technical (Hospital) Services Ref Soluble Fibrin Monomer- Thrombo Panel PX-3058536600 CDM 85366 CPT 305 RC inpatient 142 142 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES PPO [308136801] 112.44 percent of total billed charges 88.04 134.9 Technical (Hospital) Services Ref Soluble Fibrin Monomer- Thrombo Panel PX-3058536600 CDM 85366 CPT 305 RC inpatient 142 142 MEDICA (COMMERCIAL) 94265 [3081118] MEDICA CLAIMS [308111801] 127.8 percent of total billed charges 88.04 134.9 Technical (Hospital) Services Ref Soluble Fibrin Monomer- Thrombo Panel PX-3058536600 CDM 85366 CPT 305 RC inpatient 142 142 UNITED HEALTHCARE (COMMERCIAL) [3081199] UNITED HEALTHCARE 87726 [308119901] 88.04 percent of total billed charges 88.04 134.9 Technical (Hospital) Services Ref Soluble Fibrin Monomer- Thrombo Panel PX-3058536600 CDM 85366 CPT 305 RC inpatient 142 142 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES HDHP [308136802] 112.44 percent of total billed charges 88.04 134.9 Technical (Hospital) Services Ref Soluble Fibrin Monomer (Mayo) PX-3058536602 CDM 85366 CPT 305 RC outpatient 372 372 BLUE CROSS BLUE SHIELD WELLMARK SB889 [3081026] BCBS WYOMING [308102603] 353.4 percent of total billed charges 230.64 353.4 Technical (Hospital) Services Ref Soluble Fibrin Monomer (Mayo) PX-3058536602 CDM 85366 CPT 305 RC outpatient 372 372 MULTIPLAN INC 34080 [3081285] MULTIPLAN INC [308128501] 353.4 percent of total billed charges 230.64 353.4 Technical (Hospital) Services Ref Soluble Fibrin Monomer (Mayo) PX-3058536602 CDM 85366 CPT 305 RC outpatient 372 372 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES EPO [308136803] 297.6 percent of total billed charges 230.64 353.4 Technical (Hospital) Services Ref Soluble Fibrin Monomer (Mayo) PX-3058536602 CDM 85366 CPT 305 RC outpatient 372 372 CIGNA 62308 [3081051] CIGNA 62308 [308105105] 297.6 percent of total billed charges 230.64 353.4 Technical (Hospital) Services Ref Soluble Fibrin Monomer (Mayo) PX-3058536602 CDM 85366 CPT 305 RC outpatient 372 372 CIGNA 62308 [3081051] CIGNA STATE OF WYOMING [308105107] 297.6 percent of total billed charges 230.64 353.4 Technical (Hospital) Services Ref Soluble Fibrin Monomer (Mayo) PX-3058536602 CDM 85366 CPT 305 RC outpatient 372 372 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES HDHP [308136802] 297.6 percent of total billed charges 230.64 353.4 Technical (Hospital) Services Ref Soluble Fibrin Monomer (Mayo) PX-3058536602 CDM 85366 CPT 305 RC outpatient 372 372 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES PPO [308136801] 297.6 percent of total billed charges 230.64 353.4 Technical (Hospital) Services Ref Soluble Fibrin Monomer (Mayo) PX-3058536602 CDM 85366 CPT 305 RC outpatient 372 372 HEALTHPARTNERS SX009 HEALTHPARTNERS 297.6 percent of total billed charges 230.64 353.4 Technical (Hospital) Services Ref Soluble Fibrin Monomer (Mayo) PX-3058536602 CDM 85366 CPT 305 RC outpatient 372 372 UNITED HEALTHCARE (COMMERCIAL) [3081199] UNITED HEALTHCARE 87726 [308119901] 230.64 percent of total billed charges 230.64 353.4 Technical (Hospital) Services Ref Soluble Fibrin Monomer (Mayo) PX-3058536602 CDM 85366 CPT 305 RC outpatient 372 372 MEDICA (COMMERCIAL) 94265 [3081118] MEDICA CLAIMS [308111801] 334.8 percent of total billed charges 230.64 353.4 Technical (Hospital) Services Ref Soluble Fibrin Monomer (Mayo) PX-3058536602 CDM 85366 CPT 305 RC inpatient 372 372 BLUE CROSS BLUE SHIELD WELLMARK SB889 [3081026] BCBS WYOMING [308102603] 353.4 percent of total billed charges 230.64 353.4 Technical (Hospital) Services Ref Soluble Fibrin Monomer (Mayo) PX-3058536602 CDM 85366 CPT 305 RC inpatient 372 372 CIGNA 62308 [3081051] CIGNA STATE OF WYOMING [308105107] 294.55 percent of total billed charges 230.64 353.4 Technical (Hospital) Services Ref Soluble Fibrin Monomer (Mayo) PX-3058536602 CDM 85366 CPT 305 RC inpatient 372 372 CIGNA 62308 [3081051] CIGNA 62308 [308105105] 294.55 percent of total billed charges 230.64 353.4 Technical (Hospital) Services Ref Soluble Fibrin Monomer (Mayo) PX-3058536602 CDM 85366 CPT 305 RC inpatient 372 372 MULTIPLAN INC 34080 [3081285] MULTIPLAN INC [308128501] 353.4 percent of total billed charges 230.64 353.4 Technical (Hospital) Services Ref Soluble Fibrin Monomer (Mayo) PX-3058536602 CDM 85366 CPT 305 RC inpatient 372 372 MEDICA (COMMERCIAL) 94265 [3081118] MEDICA CLAIMS [308111801] 334.8 percent of total billed charges 230.64 353.4 Technical (Hospital) Services Ref Soluble Fibrin Monomer (Mayo) PX-3058536602 CDM 85366 CPT 305 RC inpatient 372 372 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES EPO [308136803] 294.55 percent of total billed charges 230.64 353.4 Technical (Hospital) Services Ref Soluble Fibrin Monomer (Mayo) PX-3058536602 CDM 85366 CPT 305 RC inpatient 372 372 HEALTHPARTNERS SX009 HEALTHPARTNERS 294.55 percent of total billed charges 230.64 353.4 Technical (Hospital) Services Ref Soluble Fibrin Monomer (Mayo) PX-3058536602 CDM 85366 CPT 305 RC inpatient 372 372 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES HDHP [308136802] 294.55 percent of total billed charges 230.64 353.4 Technical (Hospital) Services Ref Soluble Fibrin Monomer (Mayo) PX-3058536602 CDM 85366 CPT 305 RC inpatient 372 372 UNITED HEALTHCARE (COMMERCIAL) [3081199] UNITED HEALTHCARE 87726 [308119901] 230.64 percent of total billed charges 230.64 353.4 Technical (Hospital) Services Ref Soluble Fibrin Monomer (Mayo) PX-3058536602 CDM 85366 CPT 305 RC inpatient 372 372 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES PPO [308136801] 294.55 percent of total billed charges 230.64 353.4 Technical (Hospital) Services Ref Assay Activiated Protein C PX-3058530700 CDM 85307 CPT 305 RC inpatient 269 269 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES EPO [308136803] 212.99 percent of total billed charges 166.78 255.55 Technical (Hospital) Services Ref Assay Activiated Protein C PX-3058530700 CDM 85307 CPT 305 RC inpatient 269 269 HEALTHPARTNERS SX009 HEALTHPARTNERS 212.99 percent of total billed charges 166.78 255.55 Technical (Hospital) Services Ref Assay Activiated Protein C PX-3058530700 CDM 85307 CPT 305 RC inpatient 269 269 MEDICA (COMMERCIAL) 94265 [3081118] MEDICA CLAIMS [308111801] 242.1 percent of total billed charges 166.78 255.55 Technical (Hospital) Services Ref Assay Activiated Protein C PX-3058530700 CDM 85307 CPT 305 RC inpatient 269 269 MULTIPLAN INC 34080 [3081285] MULTIPLAN INC [308128501] 255.55 percent of total billed charges 166.78 255.55 Technical (Hospital) Services Ref Assay Activiated Protein C PX-3058530700 CDM 85307 CPT 305 RC inpatient 269 269 CIGNA 62308 [3081051] CIGNA 62308 [308105105] 212.99 percent of total billed charges 166.78 255.55 Technical (Hospital) Services Ref Assay Activiated Protein C PX-3058530700 CDM 85307 CPT 305 RC inpatient 269 269 CIGNA 62308 [3081051] CIGNA STATE OF WYOMING [308105107] 212.99 percent of total billed charges 166.78 255.55 Technical (Hospital) Services Ref Assay Activiated Protein C PX-3058530700 CDM 85307 CPT 305 RC inpatient 269 269 BLUE CROSS BLUE SHIELD WELLMARK SB889 [3081026] BCBS WYOMING [308102603] 255.55 percent of total billed charges 166.78 255.55 Technical (Hospital) Services Ref Assay Activiated Protein C PX-3058530700 CDM 85307 CPT 305 RC inpatient 269 269 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES PPO [308136801] 212.99 percent of total billed charges 166.78 255.55 Technical (Hospital) Services Ref Assay Activiated Protein C PX-3058530700 CDM 85307 CPT 305 RC inpatient 269 269 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES HDHP [308136802] 212.99 percent of total billed charges 166.78 255.55 Technical (Hospital) Services Ref Assay Activiated Protein C PX-3058530700 CDM 85307 CPT 305 RC inpatient 269 269 UNITED HEALTHCARE (COMMERCIAL) [3081199] UNITED HEALTHCARE 87726 [308119901] 166.78 percent of total billed charges 166.78 255.55 Technical (Hospital) Services Ref Assay Activiated Protein C PX-3058530700 CDM 85307 CPT 305 RC outpatient 269 269 UNITED HEALTHCARE (COMMERCIAL) [3081199] UNITED HEALTHCARE 87726 [308119901] 166.78 percent of total billed charges 166.78 255.55 Technical (Hospital) Services Ref Assay Activiated Protein C PX-3058530700 CDM 85307 CPT 305 RC outpatient 269 269 HEALTHPARTNERS SX009 HEALTHPARTNERS 215.2 percent of total billed charges 166.78 255.55 Technical (Hospital) Services Ref Assay Activiated Protein C PX-3058530700 CDM 85307 CPT 305 RC outpatient 269 269 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES PPO [308136801] 215.2 percent of total billed charges 166.78 255.55 Technical (Hospital) Services Ref Assay Activiated Protein C PX-3058530700 CDM 85307 CPT 305 RC outpatient 269 269 BLUE CROSS BLUE SHIELD WELLMARK SB889 [3081026] BCBS WYOMING [308102603] 255.55 percent of total billed charges 166.78 255.55 Technical (Hospital) Services Ref Assay Activiated Protein C PX-3058530700 CDM 85307 CPT 305 RC outpatient 269 269 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES HDHP [308136802] 215.2 percent of total billed charges 166.78 255.55 Technical (Hospital) Services Ref Assay Activiated Protein C PX-3058530700 CDM 85307 CPT 305 RC outpatient 269 269 MULTIPLAN INC 34080 [3081285] MULTIPLAN INC [308128501] 255.55 percent of total billed charges 166.78 255.55 Technical (Hospital) Services Ref Assay Activiated Protein C PX-3058530700 CDM 85307 CPT 305 RC outpatient 269 269 CIGNA 62308 [3081051] CIGNA 62308 [308105105] 215.2 percent of total billed charges 166.78 255.55 Technical (Hospital) Services Ref Assay Activiated Protein C PX-3058530700 CDM 85307 CPT 305 RC outpatient 269 269 CIGNA 62308 [3081051] CIGNA STATE OF WYOMING [308105107] 215.2 percent of total billed charges 166.78 255.55 Technical (Hospital) Services Ref Assay Activiated Protein C PX-3058530700 CDM 85307 CPT 305 RC outpatient 269 269 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES EPO [308136803] 215.2 percent of total billed charges 166.78 255.55 Technical (Hospital) Services Ref Assay Activiated Protein C PX-3058530700 CDM 85307 CPT 305 RC outpatient 269 269 MEDICA (COMMERCIAL) 94265 [3081118] MEDICA CLAIMS [308111801] 242.1 percent of total billed charges 166.78 255.55 Technical (Hospital) Services "Ref Activated Protein Resistance V, P (Mayo) Aathr Panel" PX-3058530703 CDM 85307 CPT 305 RC inpatient 208 208 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES PPO [308136801] 164.69 percent of total billed charges 128.96 197.6 Technical (Hospital) Services "Ref Activated Protein Resistance V, P (Mayo) Aathr Panel" PX-3058530703 CDM 85307 CPT 305 RC inpatient 208 208 UNITED HEALTHCARE (COMMERCIAL) [3081199] UNITED HEALTHCARE 87726 [308119901] 128.96 percent of total billed charges 128.96 197.6 Technical (Hospital) Services "Ref Activated Protein Resistance V, P (Mayo) Aathr Panel" PX-3058530703 CDM 85307 CPT 305 RC inpatient 208 208 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES HDHP [308136802] 164.69 percent of total billed charges 128.96 197.6 Technical (Hospital) Services "Ref Activated Protein Resistance V, P (Mayo) Aathr Panel" PX-3058530703 CDM 85307 CPT 305 RC inpatient 208 208 HEALTHPARTNERS SX009 HEALTHPARTNERS 164.69 percent of total billed charges 128.96 197.6 Technical (Hospital) Services "Ref Activated Protein Resistance V, P (Mayo) Aathr Panel" PX-3058530703 CDM 85307 CPT 305 RC inpatient 208 208 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES EPO [308136803] 164.69 percent of total billed charges 128.96 197.6 Technical (Hospital) Services "Ref Activated Protein Resistance V, P (Mayo) Aathr Panel" PX-3058530703 CDM 85307 CPT 305 RC inpatient 208 208 MEDICA (COMMERCIAL) 94265 [3081118] MEDICA CLAIMS [308111801] 187.2 percent of total billed charges 128.96 197.6 Technical (Hospital) Services "Ref Activated Protein Resistance V, P (Mayo) Aathr Panel" PX-3058530703 CDM 85307 CPT 305 RC inpatient 208 208 MULTIPLAN INC 34080 [3081285] MULTIPLAN INC [308128501] 197.6 percent of total billed charges 128.96 197.6 Technical (Hospital) Services "Ref Activated Protein Resistance V, P (Mayo) Aathr Panel" PX-3058530703 CDM 85307 CPT 305 RC inpatient 208 208 CIGNA 62308 [3081051] CIGNA 62308 [308105105] 164.69 percent of total billed charges 128.96 197.6 Technical (Hospital) Services "Ref Activated Protein Resistance V, P (Mayo) Aathr Panel" PX-3058530703 CDM 85307 CPT 305 RC inpatient 208 208 CIGNA 62308 [3081051] CIGNA STATE OF WYOMING [308105107] 164.69 percent of total billed charges 128.96 197.6 Technical (Hospital) Services "Ref Activated Protein Resistance V, P (Mayo) Aathr Panel" PX-3058530703 CDM 85307 CPT 305 RC inpatient 208 208 BLUE CROSS BLUE SHIELD WELLMARK SB889 [3081026] BCBS WYOMING [308102603] 197.6 percent of total billed charges 128.96 197.6 Technical (Hospital) Services "Ref Activated Protein Resistance V, P (Mayo) Aathr Panel" PX-3058530703 CDM 85307 CPT 305 RC outpatient 208 208 UNITED HEALTHCARE (COMMERCIAL) [3081199] UNITED HEALTHCARE 87726 [308119901] 128.96 percent of total billed charges 128.96 197.6 Technical (Hospital) Services "Ref Activated Protein Resistance V, P (Mayo) Aathr Panel" PX-3058530703 CDM 85307 CPT 305 RC outpatient 208 208 HEALTHPARTNERS SX009 HEALTHPARTNERS 166.4 percent of total billed charges 128.96 197.6 Technical (Hospital) Services "Ref Activated Protein Resistance V, P (Mayo) Aathr Panel" PX-3058530703 CDM 85307 CPT 305 RC outpatient 208 208 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES PPO [308136801] 166.4 percent of total billed charges 128.96 197.6 Technical (Hospital) Services "Ref Activated Protein Resistance V, P (Mayo) Aathr Panel" PX-3058530703 CDM 85307 CPT 305 RC outpatient 208 208 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES HDHP [308136802] 166.4 percent of total billed charges 128.96 197.6 Technical (Hospital) Services "Ref Activated Protein Resistance V, P (Mayo) Aathr Panel" PX-3058530703 CDM 85307 CPT 305 RC outpatient 208 208 BLUE CROSS BLUE SHIELD WELLMARK SB889 [3081026] BCBS WYOMING [308102603] 197.6 percent of total billed charges 128.96 197.6 Technical (Hospital) Services "Ref Activated Protein Resistance V, P (Mayo) Aathr Panel" PX-3058530703 CDM 85307 CPT 305 RC outpatient 208 208 MULTIPLAN INC 34080 [3081285] MULTIPLAN INC [308128501] 197.6 percent of total billed charges 128.96 197.6 Technical (Hospital) Services "Ref Activated Protein Resistance V, P (Mayo) Aathr Panel" PX-3058530703 CDM 85307 CPT 305 RC outpatient 208 208 CIGNA 62308 [3081051] CIGNA 62308 [308105105] 166.4 percent of total billed charges 128.96 197.6 Technical (Hospital) Services "Ref Activated Protein Resistance V, P (Mayo) Aathr Panel" PX-3058530703 CDM 85307 CPT 305 RC outpatient 208 208 CIGNA 62308 [3081051] CIGNA STATE OF WYOMING [308105107] 166.4 percent of total billed charges 128.96 197.6 Technical (Hospital) Services "Ref Activated Protein Resistance V, P (Mayo) Aathr Panel" PX-3058530703 CDM 85307 CPT 305 RC outpatient 208 208 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES EPO [308136803] 166.4 percent of total billed charges 128.96 197.6 Technical (Hospital) Services "Ref Activated Protein Resistance V, P (Mayo) Aathr Panel" PX-3058530703 CDM 85307 CPT 305 RC outpatient 208 208 MEDICA (COMMERCIAL) 94265 [3081118] MEDICA CLAIMS [308111801] 187.2 percent of total billed charges 128.96 197.6 Technical (Hospital) Services Ref Protein S Activity Plasma PX-3058530600 CDM 85306 CPT 305 RC outpatient 180 180 UNITED HEALTHCARE (COMMERCIAL) [3081199] UNITED HEALTHCARE 87726 [308119901] 111.6 percent of total billed charges 111.6 171 Technical (Hospital) Services Ref Protein S Activity Plasma PX-3058530600 CDM 85306 CPT 305 RC outpatient 180 180 HEALTHPARTNERS SX009 HEALTHPARTNERS 144 percent of total billed charges 111.6 171 Technical (Hospital) Services Ref Protein S Activity Plasma PX-3058530600 CDM 85306 CPT 305 RC outpatient 180 180 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES PPO [308136801] 144 percent of total billed charges 111.6 171 Technical (Hospital) Services Ref Protein S Activity Plasma PX-3058530600 CDM 85306 CPT 305 RC outpatient 180 180 MULTIPLAN INC 34080 [3081285] MULTIPLAN INC [308128501] 171 percent of total billed charges 111.6 171 Technical (Hospital) Services Ref Protein S Activity Plasma PX-3058530600 CDM 85306 CPT 305 RC outpatient 180 180 CIGNA 62308 [3081051] CIGNA 62308 [308105105] 144 percent of total billed charges 111.6 171 Technical (Hospital) Services Ref Protein S Activity Plasma PX-3058530600 CDM 85306 CPT 305 RC outpatient 180 180 CIGNA 62308 [3081051] CIGNA STATE OF WYOMING [308105107] 144 percent of total billed charges 111.6 171 Technical (Hospital) Services Ref Protein S Activity Plasma PX-3058530600 CDM 85306 CPT 305 RC outpatient 180 180 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES EPO [308136803] 144 percent of total billed charges 111.6 171 Technical (Hospital) Services Ref Protein S Activity Plasma PX-3058530600 CDM 85306 CPT 305 RC outpatient 180 180 BLUE CROSS BLUE SHIELD WELLMARK SB889 [3081026] BCBS WYOMING [308102603] 171 percent of total billed charges 111.6 171 Technical (Hospital) Services Ref Protein S Activity Plasma PX-3058530600 CDM 85306 CPT 305 RC outpatient 180 180 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES HDHP [308136802] 144 percent of total billed charges 111.6 171 Technical (Hospital) Services Ref Protein S Activity Plasma PX-3058530600 CDM 85306 CPT 305 RC outpatient 180 180 MEDICA (COMMERCIAL) 94265 [3081118] MEDICA CLAIMS [308111801] 162 percent of total billed charges 111.6 171 Technical (Hospital) Services Ref Protein S Activity Plasma PX-3058530600 CDM 85306 CPT 305 RC inpatient 180 180 BLUE CROSS BLUE SHIELD WELLMARK SB889 [3081026] BCBS WYOMING [308102603] 171 percent of total billed charges 111.6 171 Technical (Hospital) Services Ref Protein S Activity Plasma PX-3058530600 CDM 85306 CPT 305 RC inpatient 180 180 CIGNA 62308 [3081051] CIGNA 62308 [308105105] 142.52 percent of total billed charges 111.6 171 Technical (Hospital) Services Ref Protein S Activity Plasma PX-3058530600 CDM 85306 CPT 305 RC inpatient 180 180 CIGNA 62308 [3081051] CIGNA STATE OF WYOMING [308105107] 142.52 percent of total billed charges 111.6 171 Technical (Hospital) Services Ref Protein S Activity Plasma PX-3058530600 CDM 85306 CPT 305 RC inpatient 180 180 MULTIPLAN INC 34080 [3081285] MULTIPLAN INC [308128501] 171 percent of total billed charges 111.6 171 Technical (Hospital) Services Ref Protein S Activity Plasma PX-3058530600 CDM 85306 CPT 305 RC inpatient 180 180 MEDICA (COMMERCIAL) 94265 [3081118] MEDICA CLAIMS [308111801] 162 percent of total billed charges 111.6 171 Technical (Hospital) Services Ref Protein S Activity Plasma PX-3058530600 CDM 85306 CPT 305 RC inpatient 180 180 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES EPO [308136803] 142.52 percent of total billed charges 111.6 171 Technical (Hospital) Services Ref Protein S Activity Plasma PX-3058530600 CDM 85306 CPT 305 RC inpatient 180 180 HEALTHPARTNERS SX009 HEALTHPARTNERS 142.52 percent of total billed charges 111.6 171 Technical (Hospital) Services Ref Protein S Activity Plasma PX-3058530600 CDM 85306 CPT 305 RC inpatient 180 180 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES HDHP [308136802] 142.52 percent of total billed charges 111.6 171 Technical (Hospital) Services Ref Protein S Activity Plasma PX-3058530600 CDM 85306 CPT 305 RC inpatient 180 180 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES PPO [308136801] 142.52 percent of total billed charges 111.6 171 Technical (Hospital) Services Ref Protein S Activity Plasma PX-3058530600 CDM 85306 CPT 305 RC inpatient 180 180 UNITED HEALTHCARE (COMMERCIAL) [3081199] UNITED HEALTHCARE 87726 [308119901] 111.6 percent of total billed charges 111.6 171 Technical (Hospital) Services "Ref Protein S Activity, P (Mayo)" PX-3058530601 CDM 85306 CPT 305 RC outpatient 180 180 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES PPO [308136801] 144 percent of total billed charges 111.6 171 Technical (Hospital) Services "Ref Protein S Activity, P (Mayo)" PX-3058530601 CDM 85306 CPT 305 RC outpatient 180 180 HEALTHPARTNERS SX009 HEALTHPARTNERS 144 percent of total billed charges 111.6 171 Technical (Hospital) Services "Ref Protein S Activity, P (Mayo)" PX-3058530601 CDM 85306 CPT 305 RC outpatient 180 180 UNITED HEALTHCARE (COMMERCIAL) [3081199] UNITED HEALTHCARE 87726 [308119901] 111.6 percent of total billed charges 111.6 171 Technical (Hospital) Services "Ref Protein S Activity, P (Mayo)" PX-3058530601 CDM 85306 CPT 305 RC outpatient 180 180 MULTIPLAN INC 34080 [3081285] MULTIPLAN INC [308128501] 171 percent of total billed charges 111.6 171 Technical (Hospital) Services "Ref Protein S Activity, P (Mayo)" PX-3058530601 CDM 85306 CPT 305 RC inpatient 180 180 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES PPO [308136801] 142.52 percent of total billed charges 111.6 171 Technical (Hospital) Services "Ref Protein S Activity, P (Mayo)" PX-3058530601 CDM 85306 CPT 305 RC inpatient 180 180 UNITED HEALTHCARE (COMMERCIAL) [3081199] UNITED HEALTHCARE 87726 [308119901] 111.6 percent of total billed charges 111.6 171 Technical (Hospital) Services "Ref Protein S Activity, P (Mayo)" PX-3058530601 CDM 85306 CPT 305 RC inpatient 180 180 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES HDHP [308136802] 142.52 percent of total billed charges 111.6 171 Technical (Hospital) Services "Ref Protein S Activity, P (Mayo)" PX-3058530601 CDM 85306 CPT 305 RC inpatient 180 180 HEALTHPARTNERS SX009 HEALTHPARTNERS 142.52 percent of total billed charges 111.6 171 Technical (Hospital) Services "Ref Protein S Activity, P (Mayo)" PX-3058530601 CDM 85306 CPT 305 RC inpatient 180 180 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES EPO [308136803] 142.52 percent of total billed charges 111.6 171 Technical (Hospital) Services "Ref Protein S Activity, P (Mayo)" PX-3058530601 CDM 85306 CPT 305 RC inpatient 180 180 BLUE CROSS BLUE SHIELD WELLMARK SB889 [3081026] BCBS WYOMING [308102603] 171 percent of total billed charges 111.6 171 Technical (Hospital) Services "Ref Protein S Activity, P (Mayo)" PX-3058530601 CDM 85306 CPT 305 RC inpatient 180 180 CIGNA 62308 [3081051] CIGNA 62308 [308105105] 142.52 percent of total billed charges 111.6 171 Technical (Hospital) Services "Ref Protein S Activity, P (Mayo)" PX-3058530601 CDM 85306 CPT 305 RC inpatient 180 180 CIGNA 62308 [3081051] CIGNA STATE OF WYOMING [308105107] 142.52 percent of total billed charges 111.6 171 Technical (Hospital) Services "Ref Protein S Activity, P (Mayo)" PX-3058530601 CDM 85306 CPT 305 RC inpatient 180 180 MEDICA (COMMERCIAL) 94265 [3081118] MEDICA CLAIMS [308111801] 162 percent of total billed charges 111.6 171 Technical (Hospital) Services "Ref Protein S Activity, P (Mayo)" PX-3058530601 CDM 85306 CPT 305 RC inpatient 180 180 MULTIPLAN INC 34080 [3081285] MULTIPLAN INC [308128501] 171 percent of total billed charges 111.6 171 Technical (Hospital) Services "Ref Protein S Activity, P (Mayo)" PX-3058530601 CDM 85306 CPT 305 RC outpatient 180 180 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES EPO [308136803] 144 percent of total billed charges 111.6 171 Technical (Hospital) Services "Ref Protein S Activity, P (Mayo)" PX-3058530601 CDM 85306 CPT 305 RC outpatient 180 180 CIGNA 62308 [3081051] CIGNA 62308 [308105105] 144 percent of total billed charges 111.6 171 Technical (Hospital) Services "Ref Protein S Activity, P (Mayo)" PX-3058530601 CDM 85306 CPT 305 RC outpatient 180 180 CIGNA 62308 [3081051] CIGNA STATE OF WYOMING [308105107] 144 percent of total billed charges 111.6 171 Technical (Hospital) Services "Ref Protein S Activity, P (Mayo)" PX-3058530601 CDM 85306 CPT 305 RC outpatient 180 180 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES HDHP [308136802] 144 percent of total billed charges 111.6 171 Technical (Hospital) Services "Ref Protein S Activity, P (Mayo)" PX-3058530601 CDM 85306 CPT 305 RC outpatient 180 180 BLUE CROSS BLUE SHIELD WELLMARK SB889 [3081026] BCBS WYOMING [308102603] 171 percent of total billed charges 111.6 171 Technical (Hospital) Services "Ref Protein S Activity, P (Mayo)" PX-3058530601 CDM 85306 CPT 305 RC outpatient 180 180 MEDICA (COMMERCIAL) 94265 [3081118] MEDICA CLAIMS [308111801] 162 percent of total billed charges 111.6 171 Technical (Hospital) Services "Ref Protein S Ag, Free, P (Mayo) Aathr Panel" PX-3058530605 CDM 85306 CPT 305 RC inpatient 180 180 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES EPO [308136803] 142.52 percent of total billed charges 111.6 171 Technical (Hospital) Services "Ref Protein S Ag, Free, P (Mayo) Aathr Panel" PX-3058530605 CDM 85306 CPT 305 RC inpatient 180 180 HEALTHPARTNERS SX009 HEALTHPARTNERS 142.52 percent of total billed charges 111.6 171 Technical (Hospital) Services "Ref Protein S Ag, Free, P (Mayo) Aathr Panel" PX-3058530605 CDM 85306 CPT 305 RC inpatient 180 180 MULTIPLAN INC 34080 [3081285] MULTIPLAN INC [308128501] 171 percent of total billed charges 111.6 171 Technical (Hospital) Services "Ref Protein S Ag, Free, P (Mayo) Aathr Panel" PX-3058530605 CDM 85306 CPT 305 RC inpatient 180 180 BLUE CROSS BLUE SHIELD WELLMARK SB889 [3081026] BCBS WYOMING [308102603] 171 percent of total billed charges 111.6 171 Technical (Hospital) Services "Ref Protein S Ag, Free, P (Mayo) Aathr Panel" PX-3058530605 CDM 85306 CPT 305 RC inpatient 180 180 CIGNA 62308 [3081051] CIGNA 62308 [308105105] 142.52 percent of total billed charges 111.6 171 Technical (Hospital) Services "Ref Protein S Ag, Free, P (Mayo) Aathr Panel" PX-3058530605 CDM 85306 CPT 305 RC inpatient 180 180 CIGNA 62308 [3081051] CIGNA STATE OF WYOMING [308105107] 142.52 percent of total billed charges 111.6 171 Technical (Hospital) Services "Ref Protein S Ag, Free, P (Mayo) Aathr Panel" PX-3058530605 CDM 85306 CPT 305 RC inpatient 180 180 UNITED HEALTHCARE (COMMERCIAL) [3081199] UNITED HEALTHCARE 87726 [308119901] 111.6 percent of total billed charges 111.6 171 Technical (Hospital) Services "Ref Protein S Ag, Free, P (Mayo) Aathr Panel" PX-3058530605 CDM 85306 CPT 305 RC inpatient 180 180 MEDICA (COMMERCIAL) 94265 [3081118] MEDICA CLAIMS [308111801] 162 percent of total billed charges 111.6 171 Technical (Hospital) Services "Ref Protein S Ag, Free, P (Mayo) Aathr Panel" PX-3058530605 CDM 85306 CPT 305 RC inpatient 180 180 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES HDHP [308136802] 142.52 percent of total billed charges 111.6 171 Technical (Hospital) Services "Ref Protein S Ag, Free, P (Mayo) Aathr Panel" PX-3058530605 CDM 85306 CPT 305 RC inpatient 180 180 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES PPO [308136801] 142.52 percent of total billed charges 111.6 171 Technical (Hospital) Services "Ref Protein S Ag, Free, P (Mayo) Aathr Panel" PX-3058530605 CDM 85306 CPT 305 RC outpatient 180 180 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES HDHP [308136802] 144 percent of total billed charges 111.6 171 Technical (Hospital) Services "Ref Protein S Ag, Free, P (Mayo) Aathr Panel" PX-3058530605 CDM 85306 CPT 305 RC outpatient 180 180 BLUE CROSS BLUE SHIELD WELLMARK SB889 [3081026] BCBS WYOMING [308102603] 171 percent of total billed charges 111.6 171 Technical (Hospital) Services "Ref Protein S Ag, Free, P (Mayo) Aathr Panel" PX-3058530605 CDM 85306 CPT 305 RC outpatient 180 180 MULTIPLAN INC 34080 [3081285] MULTIPLAN INC [308128501] 171 percent of total billed charges 111.6 171 Technical (Hospital) Services "Ref Protein S Ag, Free, P (Mayo) Aathr Panel" PX-3058530605 CDM 85306 CPT 305 RC outpatient 180 180 CIGNA 62308 [3081051] CIGNA 62308 [308105105] 144 percent of total billed charges 111.6 171 Technical (Hospital) Services "Ref Protein S Ag, Free, P (Mayo) Aathr Panel" PX-3058530605 CDM 85306 CPT 305 RC outpatient 180 180 CIGNA 62308 [3081051] CIGNA STATE OF WYOMING [308105107] 144 percent of total billed charges 111.6 171 Technical (Hospital) Services "Ref Protein S Ag, Free, P (Mayo) Aathr Panel" PX-3058530605 CDM 85306 CPT 305 RC outpatient 180 180 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES EPO [308136803] 144 percent of total billed charges 111.6 171 Technical (Hospital) Services "Ref Protein S Ag, Free, P (Mayo) Aathr Panel" PX-3058530605 CDM 85306 CPT 305 RC outpatient 180 180 UNITED HEALTHCARE (COMMERCIAL) [3081199] UNITED HEALTHCARE 87726 [308119901] 111.6 percent of total billed charges 111.6 171 Technical (Hospital) Services "Ref Protein S Ag, Free, P (Mayo) Aathr Panel" PX-3058530605 CDM 85306 CPT 305 RC outpatient 180 180 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES PPO [308136801] 144 percent of total billed charges 111.6 171 Technical (Hospital) Services "Ref Protein S Ag, Free, P (Mayo) Aathr Panel" PX-3058530605 CDM 85306 CPT 305 RC outpatient 180 180 HEALTHPARTNERS SX009 HEALTHPARTNERS 144 percent of total billed charges 111.6 171 Technical (Hospital) Services "Ref Protein S Ag, Free, P (Mayo) Aathr Panel" PX-3058530605 CDM 85306 CPT 305 RC outpatient 180 180 MEDICA (COMMERCIAL) 94265 [3081118] MEDICA CLAIMS [308111801] 162 percent of total billed charges 111.6 171 Technical (Hospital) Services Ref Protein S Total PX-3058530500 CDM 85305 CPT 305 RC inpatient 298 298 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES PPO [308136801] 235.96 percent of total billed charges 184.76 283.1 Technical (Hospital) Services Ref Protein S Total PX-3058530500 CDM 85305 CPT 305 RC inpatient 298 298 UNITED HEALTHCARE (COMMERCIAL) [3081199] UNITED HEALTHCARE 87726 [308119901] 184.76 percent of total billed charges 184.76 283.1 Technical (Hospital) Services Ref Protein S Total PX-3058530500 CDM 85305 CPT 305 RC inpatient 298 298 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES HDHP [308136802] 235.96 percent of total billed charges 184.76 283.1 Technical (Hospital) Services Ref Protein S Total PX-3058530500 CDM 85305 CPT 305 RC inpatient 298 298 MEDICA (COMMERCIAL) 94265 [3081118] MEDICA CLAIMS [308111801] 268.2 percent of total billed charges 184.76 283.1 Technical (Hospital) Services Ref Protein S Total PX-3058530500 CDM 85305 CPT 305 RC inpatient 298 298 CIGNA 62308 [3081051] CIGNA 62308 [308105105] 235.96 percent of total billed charges 184.76 283.1 Technical (Hospital) Services Ref Protein S Total PX-3058530500 CDM 85305 CPT 305 RC inpatient 298 298 CIGNA 62308 [3081051] CIGNA STATE OF WYOMING [308105107] 235.96 percent of total billed charges 184.76 283.1 Technical (Hospital) Services Ref Protein S Total PX-3058530500 CDM 85305 CPT 305 RC inpatient 298 298 BLUE CROSS BLUE SHIELD WELLMARK SB889 [3081026] BCBS WYOMING [308102603] 283.1 percent of total billed charges 184.76 283.1 Technical (Hospital) Services Ref Protein S Total PX-3058530500 CDM 85305 CPT 305 RC inpatient 298 298 MULTIPLAN INC 34080 [3081285] MULTIPLAN INC [308128501] 283.1 percent of total billed charges 184.76 283.1 Technical (Hospital) Services Ref Protein S Total PX-3058530500 CDM 85305 CPT 305 RC inpatient 298 298 HEALTHPARTNERS SX009 HEALTHPARTNERS 235.96 percent of total billed charges 184.76 283.1 Technical (Hospital) Services Ref Protein S Total PX-3058530500 CDM 85305 CPT 305 RC inpatient 298 298 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES EPO [308136803] 235.96 percent of total billed charges 184.76 283.1 Technical (Hospital) Services Ref Protein S Total PX-3058530500 CDM 85305 CPT 305 RC outpatient 298 298 MULTIPLAN INC 34080 [3081285] MULTIPLAN INC [308128501] 283.1 percent of total billed charges 184.76 283.1 Technical (Hospital) Services Ref Protein S Total PX-3058530500 CDM 85305 CPT 305 RC outpatient 298 298 CIGNA 62308 [3081051] CIGNA 62308 [308105105] 238.4 percent of total billed charges 184.76 283.1 Technical (Hospital) Services Ref Protein S Total PX-3058530500 CDM 85305 CPT 305 RC outpatient 298 298 CIGNA 62308 [3081051] CIGNA STATE OF WYOMING [308105107] 238.4 percent of total billed charges 184.76 283.1 Technical (Hospital) Services Ref Protein S Total PX-3058530500 CDM 85305 CPT 305 RC outpatient 298 298 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES EPO [308136803] 238.4 percent of total billed charges 184.76 283.1 Technical (Hospital) Services Ref Protein S Total PX-3058530500 CDM 85305 CPT 305 RC outpatient 298 298 BLUE CROSS BLUE SHIELD WELLMARK SB889 [3081026] BCBS WYOMING [308102603] 283.1 percent of total billed charges 184.76 283.1 Technical (Hospital) Services Ref Protein S Total PX-3058530500 CDM 85305 CPT 305 RC outpatient 298 298 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES HDHP [308136802] 238.4 percent of total billed charges 184.76 283.1 Technical (Hospital) Services Ref Protein S Total PX-3058530500 CDM 85305 CPT 305 RC outpatient 298 298 UNITED HEALTHCARE (COMMERCIAL) [3081199] UNITED HEALTHCARE 87726 [308119901] 184.76 percent of total billed charges 184.76 283.1 Technical (Hospital) Services Ref Protein S Total PX-3058530500 CDM 85305 CPT 305 RC outpatient 298 298 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES PPO [308136801] 238.4 percent of total billed charges 184.76 283.1 Technical (Hospital) Services Ref Protein S Total PX-3058530500 CDM 85305 CPT 305 RC outpatient 298 298 HEALTHPARTNERS SX009 HEALTHPARTNERS 238.4 percent of total billed charges 184.76 283.1 Technical (Hospital) Services Ref Protein S Total PX-3058530500 CDM 85305 CPT 305 RC outpatient 298 298 MEDICA (COMMERCIAL) 94265 [3081118] MEDICA CLAIMS [308111801] 268.2 percent of total billed charges 184.76 283.1 Technical (Hospital) Services Ref Protein C Functional PX-3058530301 CDM 85303 CPT 305 RC inpatient 307 307 MEDICA (COMMERCIAL) 94265 [3081118] MEDICA CLAIMS [308111801] 276.3 percent of total billed charges 190.34 291.65 Technical (Hospital) Services Ref Protein C Functional PX-3058530301 CDM 85303 CPT 305 RC inpatient 307 307 MULTIPLAN INC 34080 [3081285] MULTIPLAN INC [308128501] 291.65 percent of total billed charges 190.34 291.65 Technical (Hospital) Services Ref Protein C Functional PX-3058530301 CDM 85303 CPT 305 RC inpatient 307 307 CIGNA 62308 [3081051] CIGNA 62308 [308105105] 243.08 percent of total billed charges 190.34 291.65 Technical (Hospital) Services Ref Protein C Functional PX-3058530301 CDM 85303 CPT 305 RC inpatient 307 307 CIGNA 62308 [3081051] CIGNA STATE OF WYOMING [308105107] 243.08 percent of total billed charges 190.34 291.65 Technical (Hospital) Services Ref Protein C Functional PX-3058530301 CDM 85303 CPT 305 RC inpatient 307 307 BLUE CROSS BLUE SHIELD WELLMARK SB889 [3081026] BCBS WYOMING [308102603] 291.65 percent of total billed charges 190.34 291.65 Technical (Hospital) Services Ref Protein C Functional PX-3058530301 CDM 85303 CPT 305 RC inpatient 307 307 HEALTHPARTNERS SX009 HEALTHPARTNERS 243.08 percent of total billed charges 190.34 291.65 Technical (Hospital) Services Ref Protein C Functional PX-3058530301 CDM 85303 CPT 305 RC inpatient 307 307 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES EPO [308136803] 243.08 percent of total billed charges 190.34 291.65 Technical (Hospital) Services Ref Protein C Functional PX-3058530301 CDM 85303 CPT 305 RC inpatient 307 307 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES HDHP [308136802] 243.08 percent of total billed charges 190.34 291.65 Technical (Hospital) Services Ref Protein C Functional PX-3058530301 CDM 85303 CPT 305 RC inpatient 307 307 UNITED HEALTHCARE (COMMERCIAL) [3081199] UNITED HEALTHCARE 87726 [308119901] 190.34 percent of total billed charges 190.34 291.65 Technical (Hospital) Services Ref Protein C Functional PX-3058530301 CDM 85303 CPT 305 RC inpatient 307 307 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES PPO [308136801] 243.08 percent of total billed charges 190.34 291.65 Technical (Hospital) Services Ref Protein C Functional PX-3058530301 CDM 85303 CPT 305 RC outpatient 307 307 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES HDHP [308136802] 245.6 percent of total billed charges 190.34 291.65 Technical (Hospital) Services Ref Protein C Functional PX-3058530301 CDM 85303 CPT 305 RC outpatient 307 307 BLUE CROSS BLUE SHIELD WELLMARK SB889 [3081026] BCBS WYOMING [308102603] 291.65 percent of total billed charges 190.34 291.65 Technical (Hospital) Services Ref Protein C Functional PX-3058530301 CDM 85303 CPT 305 RC outpatient 307 307 MULTIPLAN INC 34080 [3081285] MULTIPLAN INC [308128501] 291.65 percent of total billed charges 190.34 291.65 Technical (Hospital) Services Ref Protein C Functional PX-3058530301 CDM 85303 CPT 305 RC outpatient 307 307 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES EPO [308136803] 245.6 percent of total billed charges 190.34 291.65 Technical (Hospital) Services Ref Protein C Functional PX-3058530301 CDM 85303 CPT 305 RC outpatient 307 307 CIGNA 62308 [3081051] CIGNA 62308 [308105105] 245.6 percent of total billed charges 190.34 291.65 Technical (Hospital) Services Ref Protein C Functional PX-3058530301 CDM 85303 CPT 305 RC outpatient 307 307 CIGNA 62308 [3081051] CIGNA STATE OF WYOMING [308105107] 245.6 percent of total billed charges 190.34 291.65 Technical (Hospital) Services Ref Protein C Functional PX-3058530301 CDM 85303 CPT 305 RC outpatient 307 307 UNITED HEALTHCARE (COMMERCIAL) [3081199] UNITED HEALTHCARE 87726 [308119901] 190.34 percent of total billed charges 190.34 291.65 Technical (Hospital) Services Ref Protein C Functional PX-3058530301 CDM 85303 CPT 305 RC outpatient 307 307 HEALTHPARTNERS SX009 HEALTHPARTNERS 245.6 percent of total billed charges 190.34 291.65 Technical (Hospital) Services Ref Protein C Functional PX-3058530301 CDM 85303 CPT 305 RC outpatient 307 307 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES PPO [308136801] 245.6 percent of total billed charges 190.34 291.65 Technical (Hospital) Services Ref Protein C Functional PX-3058530301 CDM 85303 CPT 305 RC outpatient 307 307 MEDICA (COMMERCIAL) 94265 [3081118] MEDICA CLAIMS [308111801] 276.3 percent of total billed charges 190.34 291.65 Technical (Hospital) Services "Ref Protein C Activity,P (Mayo) Aathr Panel" PX-3058530304 CDM 85303 CPT 305 RC outpatient 280 280 MEDICA (COMMERCIAL) 94265 [3081118] MEDICA CLAIMS [308111801] 252 percent of total billed charges 173.6 266 Technical (Hospital) Services "Ref Protein C Activity,P (Mayo) Aathr Panel" PX-3058530304 CDM 85303 CPT 305 RC outpatient 280 280 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES EPO [308136803] 224 percent of total billed charges 173.6 266 Technical (Hospital) Services "Ref Protein C Activity,P (Mayo) Aathr Panel" PX-3058530304 CDM 85303 CPT 305 RC outpatient 280 280 CIGNA 62308 [3081051] CIGNA 62308 [308105105] 224 percent of total billed charges 173.6 266 Technical (Hospital) Services "Ref Protein C Activity,P (Mayo) Aathr Panel" PX-3058530304 CDM 85303 CPT 305 RC outpatient 280 280 CIGNA 62308 [3081051] CIGNA STATE OF WYOMING [308105107] 224 percent of total billed charges 173.6 266 Technical (Hospital) Services "Ref Protein C Activity,P (Mayo) Aathr Panel" PX-3058530304 CDM 85303 CPT 305 RC outpatient 280 280 MULTIPLAN INC 34080 [3081285] MULTIPLAN INC [308128501] 266 percent of total billed charges 173.6 266 Technical (Hospital) Services "Ref Protein C Activity,P (Mayo) Aathr Panel" PX-3058530304 CDM 85303 CPT 305 RC outpatient 280 280 BLUE CROSS BLUE SHIELD WELLMARK SB889 [3081026] BCBS WYOMING [308102603] 266 percent of total billed charges 173.6 266 Technical (Hospital) Services "Ref Protein C Activity,P (Mayo) Aathr Panel" PX-3058530304 CDM 85303 CPT 305 RC outpatient 280 280 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES HDHP [308136802] 224 percent of total billed charges 173.6 266 Technical (Hospital) Services "Ref Protein C Activity,P (Mayo) Aathr Panel" PX-3058530304 CDM 85303 CPT 305 RC outpatient 280 280 UNITED HEALTHCARE (COMMERCIAL) [3081199] UNITED HEALTHCARE 87726 [308119901] 173.6 percent of total billed charges 173.6 266 Technical (Hospital) Services "Ref Protein C Activity,P (Mayo) Aathr Panel" PX-3058530304 CDM 85303 CPT 305 RC outpatient 280 280 HEALTHPARTNERS SX009 HEALTHPARTNERS 224 percent of total billed charges 173.6 266 Technical (Hospital) Services "Ref Protein C Activity,P (Mayo) Aathr Panel" PX-3058530304 CDM 85303 CPT 305 RC outpatient 280 280 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES PPO [308136801] 224 percent of total billed charges 173.6 266 Technical (Hospital) Services "Ref Protein C Activity,P (Mayo) Aathr Panel" PX-3058530304 CDM 85303 CPT 305 RC inpatient 280 280 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES HDHP [308136802] 221.7 percent of total billed charges 173.6 266 Technical (Hospital) Services "Ref Protein C Activity,P (Mayo) Aathr Panel" PX-3058530304 CDM 85303 CPT 305 RC inpatient 280 280 MEDICA (COMMERCIAL) 94265 [3081118] MEDICA CLAIMS [308111801] 252 percent of total billed charges 173.6 266 Technical (Hospital) Services "Ref Protein C Activity,P (Mayo) Aathr Panel" PX-3058530304 CDM 85303 CPT 305 RC inpatient 280 280 UNITED HEALTHCARE (COMMERCIAL) [3081199] UNITED HEALTHCARE 87726 [308119901] 173.6 percent of total billed charges 173.6 266 Technical (Hospital) Services "Ref Protein C Activity,P (Mayo) Aathr Panel" PX-3058530304 CDM 85303 CPT 305 RC inpatient 280 280 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES PPO [308136801] 221.7 percent of total billed charges 173.6 266 Technical (Hospital) Services "Ref Protein C Activity,P (Mayo) Aathr Panel" PX-3058530304 CDM 85303 CPT 305 RC inpatient 280 280 HEALTHPARTNERS SX009 HEALTHPARTNERS 221.7 percent of total billed charges 173.6 266 Technical (Hospital) Services "Ref Protein C Activity,P (Mayo) Aathr Panel" PX-3058530304 CDM 85303 CPT 305 RC inpatient 280 280 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES EPO [308136803] 221.7 percent of total billed charges 173.6 266 Technical (Hospital) Services "Ref Protein C Activity,P (Mayo) Aathr Panel" PX-3058530304 CDM 85303 CPT 305 RC inpatient 280 280 BLUE CROSS BLUE SHIELD WELLMARK SB889 [3081026] BCBS WYOMING [308102603] 266 percent of total billed charges 173.6 266 Technical (Hospital) Services "Ref Protein C Activity,P (Mayo) Aathr Panel" PX-3058530304 CDM 85303 CPT 305 RC inpatient 280 280 CIGNA 62308 [3081051] CIGNA 62308 [308105105] 221.7 percent of total billed charges 173.6 266 Technical (Hospital) Services "Ref Protein C Activity,P (Mayo) Aathr Panel" PX-3058530304 CDM 85303 CPT 305 RC inpatient 280 280 CIGNA 62308 [3081051] CIGNA STATE OF WYOMING [308105107] 221.7 percent of total billed charges 173.6 266 Technical (Hospital) Services "Ref Protein C Activity,P (Mayo) Aathr Panel" PX-3058530304 CDM 85303 CPT 305 RC inpatient 280 280 MULTIPLAN INC 34080 [3081285] MULTIPLAN INC [308128501] 266 percent of total billed charges 173.6 266 Technical (Hospital) Services Ref Antithrombin III PX-3058530000 CDM 85300 CPT 305 RC inpatient 251 251 UNITED HEALTHCARE (COMMERCIAL) [3081199] UNITED HEALTHCARE 87726 [308119901] 155.62 percent of total billed charges 155.62 238.45 Technical (Hospital) Services Ref Antithrombin III PX-3058530000 CDM 85300 CPT 305 RC inpatient 251 251 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES PPO [308136801] 198.74 percent of total billed charges 155.62 238.45 Technical (Hospital) Services Ref Antithrombin III PX-3058530000 CDM 85300 CPT 305 RC inpatient 251 251 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES HDHP [308136802] 198.74 percent of total billed charges 155.62 238.45 Technical (Hospital) Services Ref Antithrombin III PX-3058530000 CDM 85300 CPT 305 RC inpatient 251 251 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES EPO [308136803] 198.74 percent of total billed charges 155.62 238.45 Technical (Hospital) Services Ref Antithrombin III PX-3058530000 CDM 85300 CPT 305 RC inpatient 251 251 HEALTHPARTNERS SX009 HEALTHPARTNERS 198.74 percent of total billed charges 155.62 238.45 Technical (Hospital) Services Ref Antithrombin III PX-3058530000 CDM 85300 CPT 305 RC inpatient 251 251 MEDICA (COMMERCIAL) 94265 [3081118] MEDICA CLAIMS [308111801] 225.9 percent of total billed charges 155.62 238.45 Technical (Hospital) Services Ref Antithrombin III PX-3058530000 CDM 85300 CPT 305 RC inpatient 251 251 MULTIPLAN INC 34080 [3081285] MULTIPLAN INC [308128501] 238.45 percent of total billed charges 155.62 238.45 Technical (Hospital) Services Ref Antithrombin III PX-3058530000 CDM 85300 CPT 305 RC inpatient 251 251 CIGNA 62308 [3081051] CIGNA 62308 [308105105] 198.74 percent of total billed charges 155.62 238.45 Technical (Hospital) Services Ref Antithrombin III PX-3058530000 CDM 85300 CPT 305 RC inpatient 251 251 CIGNA 62308 [3081051] CIGNA STATE OF WYOMING [308105107] 198.74 percent of total billed charges 155.62 238.45 Technical (Hospital) Services Ref Antithrombin III PX-3058530000 CDM 85300 CPT 305 RC inpatient 251 251 BLUE CROSS BLUE SHIELD WELLMARK SB889 [3081026] BCBS WYOMING [308102603] 238.45 percent of total billed charges 155.62 238.45 Technical (Hospital) Services Ref Antithrombin III PX-3058530000 CDM 85300 CPT 305 RC outpatient 251 251 MEDICA (COMMERCIAL) 94265 [3081118] MEDICA CLAIMS [308111801] 225.9 percent of total billed charges 155.62 238.45 Technical (Hospital) Services Ref Antithrombin III PX-3058530000 CDM 85300 CPT 305 RC outpatient 251 251 UNITED HEALTHCARE (COMMERCIAL) [3081199] UNITED HEALTHCARE 87726 [308119901] 155.62 percent of total billed charges 155.62 238.45 Technical (Hospital) Services Ref Antithrombin III PX-3058530000 CDM 85300 CPT 305 RC outpatient 251 251 HEALTHPARTNERS SX009 HEALTHPARTNERS 200.8 percent of total billed charges 155.62 238.45 Technical (Hospital) Services Ref Antithrombin III PX-3058530000 CDM 85300 CPT 305 RC outpatient 251 251 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES PPO [308136801] 200.8 percent of total billed charges 155.62 238.45 Technical (Hospital) Services Ref Antithrombin III PX-3058530000 CDM 85300 CPT 305 RC outpatient 251 251 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES EPO [308136803] 200.8 percent of total billed charges 155.62 238.45 Technical (Hospital) Services Ref Antithrombin III PX-3058530000 CDM 85300 CPT 305 RC outpatient 251 251 CIGNA 62308 [3081051] CIGNA 62308 [308105105] 200.8 percent of total billed charges 155.62 238.45 Technical (Hospital) Services Ref Antithrombin III PX-3058530000 CDM 85300 CPT 305 RC outpatient 251 251 CIGNA 62308 [3081051] CIGNA STATE OF WYOMING [308105107] 200.8 percent of total billed charges 155.62 238.45 Technical (Hospital) Services Ref Antithrombin III PX-3058530000 CDM 85300 CPT 305 RC outpatient 251 251 MULTIPLAN INC 34080 [3081285] MULTIPLAN INC [308128501] 238.45 percent of total billed charges 155.62 238.45 Technical (Hospital) Services Ref Antithrombin III PX-3058530000 CDM 85300 CPT 305 RC outpatient 251 251 BLUE CROSS BLUE SHIELD WELLMARK SB889 [3081026] BCBS WYOMING [308102603] 238.45 percent of total billed charges 155.62 238.45 Technical (Hospital) Services Ref Antithrombin III PX-3058530000 CDM 85300 CPT 305 RC outpatient 251 251 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES HDHP [308136802] 200.8 percent of total billed charges 155.62 238.45 Technical (Hospital) Services Ref Antithrombin III Activity PX-3058530001 CDM 85300 CPT 305 RC inpatient 327 327 MULTIPLAN INC 34080 [3081285] MULTIPLAN INC [308128501] 310.65 percent of total billed charges 202.74 310.65 Technical (Hospital) Services Ref Antithrombin III Activity PX-3058530001 CDM 85300 CPT 305 RC inpatient 327 327 MEDICA (COMMERCIAL) 94265 [3081118] MEDICA CLAIMS [308111801] 294.3 percent of total billed charges 202.74 310.65 Technical (Hospital) Services Ref Antithrombin III Activity PX-3058530001 CDM 85300 CPT 305 RC inpatient 327 327 CIGNA 62308 [3081051] CIGNA 62308 [308105105] 258.92 percent of total billed charges 202.74 310.65 Technical (Hospital) Services Ref Antithrombin III Activity PX-3058530001 CDM 85300 CPT 305 RC inpatient 327 327 CIGNA 62308 [3081051] CIGNA STATE OF WYOMING [308105107] 258.92 percent of total billed charges 202.74 310.65 Technical (Hospital) Services Ref Antithrombin III Activity PX-3058530001 CDM 85300 CPT 305 RC inpatient 327 327 BLUE CROSS BLUE SHIELD WELLMARK SB889 [3081026] BCBS WYOMING [308102603] 310.65 percent of total billed charges 202.74 310.65 Technical (Hospital) Services Ref Antithrombin III Activity PX-3058530001 CDM 85300 CPT 305 RC inpatient 327 327 HEALTHPARTNERS SX009 HEALTHPARTNERS 258.92 percent of total billed charges 202.74 310.65 Technical (Hospital) Services Ref Antithrombin III Activity PX-3058530001 CDM 85300 CPT 305 RC inpatient 327 327 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES EPO [308136803] 258.92 percent of total billed charges 202.74 310.65 Technical (Hospital) Services Ref Antithrombin III Activity PX-3058530001 CDM 85300 CPT 305 RC inpatient 327 327 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES HDHP [308136802] 258.92 percent of total billed charges 202.74 310.65 Technical (Hospital) Services Ref Antithrombin III Activity PX-3058530001 CDM 85300 CPT 305 RC inpatient 327 327 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES PPO [308136801] 258.92 percent of total billed charges 202.74 310.65 Technical (Hospital) Services Ref Antithrombin III Activity PX-3058530001 CDM 85300 CPT 305 RC inpatient 327 327 UNITED HEALTHCARE (COMMERCIAL) [3081199] UNITED HEALTHCARE 87726 [308119901] 202.74 percent of total billed charges 202.74 310.65 Technical (Hospital) Services Ref Antithrombin III Activity PX-3058530001 CDM 85300 CPT 305 RC outpatient 327 327 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES HDHP [308136802] 261.6 percent of total billed charges 202.74 310.65 Technical (Hospital) Services Ref Antithrombin III Activity PX-3058530001 CDM 85300 CPT 305 RC outpatient 327 327 BLUE CROSS BLUE SHIELD WELLMARK SB889 [3081026] BCBS WYOMING [308102603] 310.65 percent of total billed charges 202.74 310.65 Technical (Hospital) Services Ref Antithrombin III Activity PX-3058530001 CDM 85300 CPT 305 RC outpatient 327 327 MULTIPLAN INC 34080 [3081285] MULTIPLAN INC [308128501] 310.65 percent of total billed charges 202.74 310.65 Technical (Hospital) Services Ref Antithrombin III Activity PX-3058530001 CDM 85300 CPT 305 RC outpatient 327 327 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES EPO [308136803] 261.6 percent of total billed charges 202.74 310.65 Technical (Hospital) Services Ref Antithrombin III Activity PX-3058530001 CDM 85300 CPT 305 RC outpatient 327 327 CIGNA 62308 [3081051] CIGNA 62308 [308105105] 261.6 percent of total billed charges 202.74 310.65 Technical (Hospital) Services Ref Antithrombin III Activity PX-3058530001 CDM 85300 CPT 305 RC outpatient 327 327 CIGNA 62308 [3081051] CIGNA STATE OF WYOMING [308105107] 261.6 percent of total billed charges 202.74 310.65 Technical (Hospital) Services Ref Antithrombin III Activity PX-3058530001 CDM 85300 CPT 305 RC outpatient 327 327 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES PPO [308136801] 261.6 percent of total billed charges 202.74 310.65 Technical (Hospital) Services Ref Antithrombin III Activity PX-3058530001 CDM 85300 CPT 305 RC outpatient 327 327 HEALTHPARTNERS SX009 HEALTHPARTNERS 261.6 percent of total billed charges 202.74 310.65 Technical (Hospital) Services Ref Antithrombin III Activity PX-3058530001 CDM 85300 CPT 305 RC outpatient 327 327 UNITED HEALTHCARE (COMMERCIAL) [3081199] UNITED HEALTHCARE 87726 [308119901] 202.74 percent of total billed charges 202.74 310.65 Technical (Hospital) Services Ref Antithrombin III Activity PX-3058530001 CDM 85300 CPT 305 RC outpatient 327 327 MEDICA (COMMERCIAL) 94265 [3081118] MEDICA CLAIMS [308111801] 294.3 percent of total billed charges 202.74 310.65 Technical (Hospital) Services Ref Thrombo at Activity PX-3058530002 CDM 85300 CPT 305 RC outpatient 326 326 BLUE CROSS BLUE SHIELD WELLMARK SB889 [3081026] BCBS WYOMING [308102603] 309.7 percent of total billed charges 202.12 309.7 Technical (Hospital) Services Ref Thrombo at Activity PX-3058530002 CDM 85300 CPT 305 RC outpatient 326 326 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES HDHP [308136802] 260.8 percent of total billed charges 202.12 309.7 Technical (Hospital) Services Ref Thrombo at Activity PX-3058530002 CDM 85300 CPT 305 RC outpatient 326 326 MULTIPLAN INC 34080 [3081285] MULTIPLAN INC [308128501] 309.7 percent of total billed charges 202.12 309.7 Technical (Hospital) Services Ref Thrombo at Activity PX-3058530002 CDM 85300 CPT 305 RC outpatient 326 326 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES EPO [308136803] 260.8 percent of total billed charges 202.12 309.7 Technical (Hospital) Services Ref Thrombo at Activity PX-3058530002 CDM 85300 CPT 305 RC outpatient 326 326 CIGNA 62308 [3081051] CIGNA 62308 [308105105] 260.8 percent of total billed charges 202.12 309.7 Technical (Hospital) Services Ref Thrombo at Activity PX-3058530002 CDM 85300 CPT 305 RC outpatient 326 326 CIGNA 62308 [3081051] CIGNA STATE OF WYOMING [308105107] 260.8 percent of total billed charges 202.12 309.7 Technical (Hospital) Services Ref Thrombo at Activity PX-3058530002 CDM 85300 CPT 305 RC outpatient 326 326 HEALTHPARTNERS SX009 HEALTHPARTNERS 260.8 percent of total billed charges 202.12 309.7 Technical (Hospital) Services Ref Thrombo at Activity PX-3058530002 CDM 85300 CPT 305 RC outpatient 326 326 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES PPO [308136801] 260.8 percent of total billed charges 202.12 309.7 Technical (Hospital) Services Ref Thrombo at Activity PX-3058530002 CDM 85300 CPT 305 RC outpatient 326 326 UNITED HEALTHCARE (COMMERCIAL) [3081199] UNITED HEALTHCARE 87726 [308119901] 202.12 percent of total billed charges 202.12 309.7 Technical (Hospital) Services Ref Thrombo at Activity PX-3058530002 CDM 85300 CPT 305 RC outpatient 326 326 MEDICA (COMMERCIAL) 94265 [3081118] MEDICA CLAIMS [308111801] 293.4 percent of total billed charges 202.12 309.7 Technical (Hospital) Services Ref Thrombo at Activity PX-3058530002 CDM 85300 CPT 305 RC inpatient 326 326 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES EPO [308136803] 258.13 percent of total billed charges 202.12 309.7 Technical (Hospital) Services Ref Thrombo at Activity PX-3058530002 CDM 85300 CPT 305 RC inpatient 326 326 HEALTHPARTNERS SX009 HEALTHPARTNERS 258.13 percent of total billed charges 202.12 309.7 Technical (Hospital) Services Ref Thrombo at Activity PX-3058530002 CDM 85300 CPT 305 RC inpatient 326 326 MEDICA (COMMERCIAL) 94265 [3081118] MEDICA CLAIMS [308111801] 293.4 percent of total billed charges 202.12 309.7 Technical (Hospital) Services Ref Thrombo at Activity PX-3058530002 CDM 85300 CPT 305 RC inpatient 326 326 MULTIPLAN INC 34080 [3081285] MULTIPLAN INC [308128501] 309.7 percent of total billed charges 202.12 309.7 Technical (Hospital) Services Ref Thrombo at Activity PX-3058530002 CDM 85300 CPT 305 RC inpatient 326 326 BLUE CROSS BLUE SHIELD WELLMARK SB889 [3081026] BCBS WYOMING [308102603] 309.7 percent of total billed charges 202.12 309.7 Technical (Hospital) Services Ref Thrombo at Activity PX-3058530002 CDM 85300 CPT 305 RC inpatient 326 326 CIGNA 62308 [3081051] CIGNA 62308 [308105105] 258.13 percent of total billed charges 202.12 309.7 Technical (Hospital) Services Ref Thrombo at Activity PX-3058530002 CDM 85300 CPT 305 RC inpatient 326 326 CIGNA 62308 [3081051] CIGNA STATE OF WYOMING [308105107] 258.13 percent of total billed charges 202.12 309.7 Technical (Hospital) Services Ref Thrombo at Activity PX-3058530002 CDM 85300 CPT 305 RC inpatient 326 326 UNITED HEALTHCARE (COMMERCIAL) [3081199] UNITED HEALTHCARE 87726 [308119901] 202.12 percent of total billed charges 202.12 309.7 Technical (Hospital) Services Ref Thrombo at Activity PX-3058530002 CDM 85300 CPT 305 RC inpatient 326 326 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES PPO [308136801] 258.13 percent of total billed charges 202.12 309.7 Technical (Hospital) Services Ref Thrombo at Activity PX-3058530002 CDM 85300 CPT 305 RC inpatient 326 326 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES HDHP [308136802] 258.13 percent of total billed charges 202.12 309.7 Technical (Hospital) Services "Ref Coag Factor X Assay, P (Mayo)" PX-3058526000 CDM 85260 CPT 305 RC inpatient 180 180 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES EPO [308136803] 142.52 percent of total billed charges 111.6 171 Technical (Hospital) Services "Ref Coag Factor X Assay, P (Mayo)" PX-3058526000 CDM 85260 CPT 305 RC inpatient 180 180 HEALTHPARTNERS SX009 HEALTHPARTNERS 142.52 percent of total billed charges 111.6 171 Technical (Hospital) Services "Ref Coag Factor X Assay, P (Mayo)" PX-3058526000 CDM 85260 CPT 305 RC inpatient 180 180 MULTIPLAN INC 34080 [3081285] MULTIPLAN INC [308128501] 171 percent of total billed charges 111.6 171 Technical (Hospital) Services "Ref Coag Factor X Assay, P (Mayo)" PX-3058526000 CDM 85260 CPT 305 RC inpatient 180 180 MEDICA (COMMERCIAL) 94265 [3081118] MEDICA CLAIMS [308111801] 162 percent of total billed charges 111.6 171 Technical (Hospital) Services "Ref Coag Factor X Assay, P (Mayo)" PX-3058526000 CDM 85260 CPT 305 RC inpatient 180 180 CIGNA 62308 [3081051] CIGNA 62308 [308105105] 142.52 percent of total billed charges 111.6 171 Technical (Hospital) Services "Ref Coag Factor X Assay, P (Mayo)" PX-3058526000 CDM 85260 CPT 305 RC inpatient 180 180 CIGNA 62308 [3081051] CIGNA STATE OF WYOMING [308105107] 142.52 percent of total billed charges 111.6 171 Technical (Hospital) Services "Ref Coag Factor X Assay, P (Mayo)" PX-3058526000 CDM 85260 CPT 305 RC inpatient 180 180 BLUE CROSS BLUE SHIELD WELLMARK SB889 [3081026] BCBS WYOMING [308102603] 171 percent of total billed charges 111.6 171 Technical (Hospital) Services "Ref Coag Factor X Assay, P (Mayo)" PX-3058526000 CDM 85260 CPT 305 RC inpatient 180 180 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES PPO [308136801] 142.52 percent of total billed charges 111.6 171 Technical (Hospital) Services "Ref Coag Factor X Assay, P (Mayo)" PX-3058526000 CDM 85260 CPT 305 RC inpatient 180 180 UNITED HEALTHCARE (COMMERCIAL) [3081199] UNITED HEALTHCARE 87726 [308119901] 111.6 percent of total billed charges 111.6 171 Technical (Hospital) Services "Ref Coag Factor X Assay, P (Mayo)" PX-3058526000 CDM 85260 CPT 305 RC inpatient 180 180 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES HDHP [308136802] 142.52 percent of total billed charges 111.6 171 Technical (Hospital) Services "Ref Coag Factor X Assay, P (Mayo)" PX-3058526000 CDM 85260 CPT 305 RC outpatient 180 180 BLUE CROSS BLUE SHIELD WELLMARK SB889 [3081026] BCBS WYOMING [308102603] 171 percent of total billed charges 111.6 171 Technical (Hospital) Services "Ref Coag Factor X Assay, P (Mayo)" PX-3058526000 CDM 85260 CPT 305 RC outpatient 180 180 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES HDHP [308136802] 144 percent of total billed charges 111.6 171 Technical (Hospital) Services "Ref Coag Factor X Assay, P (Mayo)" PX-3058526000 CDM 85260 CPT 305 RC outpatient 180 180 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES EPO [308136803] 144 percent of total billed charges 111.6 171 Technical (Hospital) Services "Ref Coag Factor X Assay, P (Mayo)" PX-3058526000 CDM 85260 CPT 305 RC outpatient 180 180 CIGNA 62308 [3081051] CIGNA STATE OF WYOMING [308105107] 144 percent of total billed charges 111.6 171 Technical (Hospital) Services "Ref Coag Factor X Assay, P (Mayo)" PX-3058526000 CDM 85260 CPT 305 RC outpatient 180 180 MULTIPLAN INC 34080 [3081285] MULTIPLAN INC [308128501] 171 percent of total billed charges 111.6 171 Technical (Hospital) Services "Ref Coag Factor X Assay, P (Mayo)" PX-3058526000 CDM 85260 CPT 305 RC outpatient 180 180 CIGNA 62308 [3081051] CIGNA 62308 [308105105] 144 percent of total billed charges 111.6 171 Technical (Hospital) Services "Ref Coag Factor X Assay, P (Mayo)" PX-3058526000 CDM 85260 CPT 305 RC outpatient 180 180 UNITED HEALTHCARE (COMMERCIAL) [3081199] UNITED HEALTHCARE 87726 [308119901] 111.6 percent of total billed charges 111.6 171 Technical (Hospital) Services "Ref Coag Factor X Assay, P (Mayo)" PX-3058526000 CDM 85260 CPT 305 RC outpatient 180 180 MEDICA (COMMERCIAL) 94265 [3081118] MEDICA CLAIMS [308111801] 162 percent of total billed charges 111.6 171 Technical (Hospital) Services "Ref Coag Factor X Assay, P (Mayo)" PX-3058526000 CDM 85260 CPT 305 RC outpatient 180 180 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES PPO [308136801] 144 percent of total billed charges 111.6 171 Technical (Hospital) Services "Ref Coag Factor X Assay, P (Mayo)" PX-3058526000 CDM 85260 CPT 305 RC outpatient 180 180 HEALTHPARTNERS SX009 HEALTHPARTNERS 144 percent of total billed charges 111.6 171 Technical (Hospital) Services Ref Clotting: Factor VIII (Ahg) One Stag PX-3058524000 CDM 85240 CPT 305 RC outpatient 286 286 MEDICA (COMMERCIAL) 94265 [3081118] MEDICA CLAIMS [308111801] 257.4 percent of total billed charges 177.32 271.7 Technical (Hospital) Services Ref Clotting: Factor VIII (Ahg) One Stag PX-3058524000 CDM 85240 CPT 305 RC outpatient 286 286 UNITED HEALTHCARE (COMMERCIAL) [3081199] UNITED HEALTHCARE 87726 [308119901] 177.32 percent of total billed charges 177.32 271.7 Technical (Hospital) Services Ref Clotting: Factor VIII (Ahg) One Stag PX-3058524000 CDM 85240 CPT 305 RC outpatient 286 286 HEALTHPARTNERS SX009 HEALTHPARTNERS 228.8 percent of total billed charges 177.32 271.7 Technical (Hospital) Services Ref Clotting: Factor VIII (Ahg) One Stag PX-3058524000 CDM 85240 CPT 305 RC outpatient 286 286 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES PPO [308136801] 228.8 percent of total billed charges 177.32 271.7 Technical (Hospital) Services Ref Clotting: Factor VIII (Ahg) One Stag PX-3058524000 CDM 85240 CPT 305 RC outpatient 286 286 CIGNA 62308 [3081051] CIGNA 62308 [308105105] 228.8 percent of total billed charges 177.32 271.7 Technical (Hospital) Services Ref Clotting: Factor VIII (Ahg) One Stag PX-3058524000 CDM 85240 CPT 305 RC outpatient 286 286 CIGNA 62308 [3081051] CIGNA STATE OF WYOMING [308105107] 228.8 percent of total billed charges 177.32 271.7 Technical (Hospital) Services Ref Clotting: Factor VIII (Ahg) One Stag PX-3058524000 CDM 85240 CPT 305 RC outpatient 286 286 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES EPO [308136803] 228.8 percent of total billed charges 177.32 271.7 Technical (Hospital) Services Ref Clotting: Factor VIII (Ahg) One Stag PX-3058524000 CDM 85240 CPT 305 RC outpatient 286 286 MULTIPLAN INC 34080 [3081285] MULTIPLAN INC [308128501] 271.7 percent of total billed charges 177.32 271.7 Technical (Hospital) Services Ref Clotting: Factor VIII (Ahg) One Stag PX-3058524000 CDM 85240 CPT 305 RC outpatient 286 286 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES HDHP [308136802] 228.8 percent of total billed charges 177.32 271.7 Technical (Hospital) Services Ref Clotting: Factor VIII (Ahg) One Stag PX-3058524000 CDM 85240 CPT 305 RC outpatient 286 286 BLUE CROSS BLUE SHIELD WELLMARK SB889 [3081026] BCBS WYOMING [308102603] 271.7 percent of total billed charges 177.32 271.7 Technical (Hospital) Services Ref Clotting: Factor VIII (Ahg) One Stag PX-3058524000 CDM 85240 CPT 305 RC inpatient 286 286 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES HDHP [308136802] 226.45 percent of total billed charges 177.32 271.7 Technical (Hospital) Services Ref Clotting: Factor VIII (Ahg) One Stag PX-3058524000 CDM 85240 CPT 305 RC inpatient 286 286 MEDICA (COMMERCIAL) 94265 [3081118] MEDICA CLAIMS [308111801] 257.4 percent of total billed charges 177.32 271.7 Technical (Hospital) Services Ref Clotting: Factor VIII (Ahg) One Stag PX-3058524000 CDM 85240 CPT 305 RC inpatient 286 286 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES PPO [308136801] 226.45 percent of total billed charges 177.32 271.7 Technical (Hospital) Services Ref Clotting: Factor VIII (Ahg) One Stag PX-3058524000 CDM 85240 CPT 305 RC inpatient 286 286 UNITED HEALTHCARE (COMMERCIAL) [3081199] UNITED HEALTHCARE 87726 [308119901] 177.32 percent of total billed charges 177.32 271.7 Technical (Hospital) Services Ref Clotting: Factor VIII (Ahg) One Stag PX-3058524000 CDM 85240 CPT 305 RC inpatient 286 286 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES EPO [308136803] 226.45 percent of total billed charges 177.32 271.7 Technical (Hospital) Services Ref Clotting: Factor VIII (Ahg) One Stag PX-3058524000 CDM 85240 CPT 305 RC inpatient 286 286 HEALTHPARTNERS SX009 HEALTHPARTNERS 226.45 percent of total billed charges 177.32 271.7 Technical (Hospital) Services Ref Clotting: Factor VIII (Ahg) One Stag PX-3058524000 CDM 85240 CPT 305 RC inpatient 286 286 MULTIPLAN INC 34080 [3081285] MULTIPLAN INC [308128501] 271.7 percent of total billed charges 177.32 271.7 Technical (Hospital) Services Ref Clotting: Factor VIII (Ahg) One Stag PX-3058524000 CDM 85240 CPT 305 RC inpatient 286 286 BLUE CROSS BLUE SHIELD WELLMARK SB889 [3081026] BCBS WYOMING [308102603] 271.7 percent of total billed charges 177.32 271.7 Technical (Hospital) Services Ref Clotting: Factor VIII (Ahg) One Stag PX-3058524000 CDM 85240 CPT 305 RC inpatient 286 286 CIGNA 62308 [3081051] CIGNA 62308 [308105105] 226.45 percent of total billed charges 177.32 271.7 Technical (Hospital) Services Ref Clotting: Factor VIII (Ahg) One Stag PX-3058524000 CDM 85240 CPT 305 RC inpatient 286 286 CIGNA 62308 [3081051] CIGNA STATE OF WYOMING [308105107] 226.45 percent of total billed charges 177.32 271.7 Technical (Hospital) Services Ref Blood Clot Factor II Test PX-3058521000 CDM 85210 CPT 305 RC inpatient 139 139 CIGNA 62308 [3081051] CIGNA 62308 [308105105] 110.06 percent of total billed charges 86.18 132.05 Technical (Hospital) Services Ref Blood Clot Factor II Test PX-3058521000 CDM 85210 CPT 305 RC inpatient 139 139 CIGNA 62308 [3081051] CIGNA STATE OF WYOMING [308105107] 110.06 percent of total billed charges 86.18 132.05 Technical (Hospital) Services Ref Blood Clot Factor II Test PX-3058521000 CDM 85210 CPT 305 RC inpatient 139 139 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES EPO [308136803] 110.06 percent of total billed charges 86.18 132.05 Technical (Hospital) Services Ref Blood Clot Factor II Test PX-3058521000 CDM 85210 CPT 305 RC inpatient 139 139 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES PPO [308136801] 110.06 percent of total billed charges 86.18 132.05 Technical (Hospital) Services Ref Blood Clot Factor II Test PX-3058521000 CDM 85210 CPT 305 RC inpatient 139 139 BLUE CROSS BLUE SHIELD WELLMARK SB889 [3081026] BCBS WYOMING [308102603] 132.05 percent of total billed charges 86.18 132.05 Technical (Hospital) Services Ref Blood Clot Factor II Test PX-3058521000 CDM 85210 CPT 305 RC inpatient 139 139 UNITED HEALTHCARE (COMMERCIAL) [3081199] UNITED HEALTHCARE 87726 [308119901] 86.18 percent of total billed charges 86.18 132.05 Technical (Hospital) Services Ref Blood Clot Factor II Test PX-3058521000 CDM 85210 CPT 305 RC inpatient 139 139 HEALTHPARTNERS SX009 HEALTHPARTNERS 110.06 percent of total billed charges 86.18 132.05 Technical (Hospital) Services Ref Blood Clot Factor II Test PX-3058521000 CDM 85210 CPT 305 RC inpatient 139 139 MULTIPLAN INC 34080 [3081285] MULTIPLAN INC [308128501] 132.05 percent of total billed charges 86.18 132.05 Technical (Hospital) Services Ref Blood Clot Factor II Test PX-3058521000 CDM 85210 CPT 305 RC inpatient 139 139 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES HDHP [308136802] 110.06 percent of total billed charges 86.18 132.05 Technical (Hospital) Services Ref Blood Clot Factor II Test PX-3058521000 CDM 85210 CPT 305 RC inpatient 139 139 MEDICA (COMMERCIAL) 94265 [3081118] MEDICA CLAIMS [308111801] 125.1 percent of total billed charges 86.18 132.05 Technical (Hospital) Services Ref Blood Clot Factor II Test PX-3058521000 CDM 85210 CPT 305 RC outpatient 139 139 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES HDHP [308136802] 111.2 percent of total billed charges 86.18 132.05 Technical (Hospital) Services Ref Blood Clot Factor II Test PX-3058521000 CDM 85210 CPT 305 RC outpatient 139 139 BLUE CROSS BLUE SHIELD WELLMARK SB889 [3081026] BCBS WYOMING [308102603] 132.05 percent of total billed charges 86.18 132.05 Technical (Hospital) Services Ref Blood Clot Factor II Test PX-3058521000 CDM 85210 CPT 305 RC outpatient 139 139 UNITED HEALTHCARE (COMMERCIAL) [3081199] UNITED HEALTHCARE 87726 [308119901] 86.18 percent of total billed charges 86.18 132.05 Technical (Hospital) Services Ref Blood Clot Factor II Test PX-3058521000 CDM 85210 CPT 305 RC outpatient 139 139 MULTIPLAN INC 34080 [3081285] MULTIPLAN INC [308128501] 132.05 percent of total billed charges 86.18 132.05 Technical (Hospital) Services Ref Blood Clot Factor II Test PX-3058521000 CDM 85210 CPT 305 RC outpatient 139 139 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES EPO [308136803] 111.2 percent of total billed charges 86.18 132.05 Technical (Hospital) Services Ref Blood Clot Factor II Test PX-3058521000 CDM 85210 CPT 305 RC outpatient 139 139 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES PPO [308136801] 111.2 percent of total billed charges 86.18 132.05 Technical (Hospital) Services Ref Blood Clot Factor II Test PX-3058521000 CDM 85210 CPT 305 RC outpatient 139 139 HEALTHPARTNERS SX009 HEALTHPARTNERS 111.2 percent of total billed charges 86.18 132.05 Technical (Hospital) Services Ref Blood Clot Factor II Test PX-3058521000 CDM 85210 CPT 305 RC outpatient 139 139 CIGNA 62308 [3081051] CIGNA 62308 [308105105] 111.2 percent of total billed charges 86.18 132.05 Technical (Hospital) Services Ref Blood Clot Factor II Test PX-3058521000 CDM 85210 CPT 305 RC outpatient 139 139 CIGNA 62308 [3081051] CIGNA STATE OF WYOMING [308105107] 111.2 percent of total billed charges 86.18 132.05 Technical (Hospital) Services Ref Blood Clot Factor II Test PX-3058521000 CDM 85210 CPT 305 RC outpatient 139 139 MEDICA (COMMERCIAL) 94265 [3081118] MEDICA CLAIMS [308111801] 125.1 percent of total billed charges 86.18 132.05 Technical (Hospital) Services Platelet CT PX-3058504900 CDM 85049 CPT 305 RC inpatient 51 51 HEALTHPARTNERS SX009 HEALTHPARTNERS 40.38 percent of total billed charges 31.62 48.45 Technical (Hospital) Services Platelet CT PX-3058504900 CDM 85049 CPT 305 RC inpatient 51 51 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES EPO [308136803] 40.38 percent of total billed charges 31.62 48.45 Technical (Hospital) Services Platelet CT PX-3058504900 CDM 85049 CPT 305 RC inpatient 51 51 MEDICA (COMMERCIAL) 94265 [3081118] MEDICA CLAIMS [308111801] 45.9 percent of total billed charges 31.62 48.45 Technical (Hospital) Services Platelet CT PX-3058504900 CDM 85049 CPT 305 RC inpatient 51 51 MULTIPLAN INC 34080 [3081285] MULTIPLAN INC [308128501] 48.45 percent of total billed charges 31.62 48.45 Technical (Hospital) Services Platelet CT PX-3058504900 CDM 85049 CPT 305 RC inpatient 51 51 CIGNA 62308 [3081051] CIGNA 62308 [308105105] 40.38 percent of total billed charges 31.62 48.45 Technical (Hospital) Services Platelet CT PX-3058504900 CDM 85049 CPT 305 RC inpatient 51 51 CIGNA 62308 [3081051] CIGNA STATE OF WYOMING [308105107] 40.38 percent of total billed charges 31.62 48.45 Technical (Hospital) Services Platelet CT PX-3058504900 CDM 85049 CPT 305 RC inpatient 51 51 BLUE CROSS BLUE SHIELD WELLMARK SB889 [3081026] BCBS WYOMING [308102603] 48.45 percent of total billed charges 31.62 48.45 Technical (Hospital) Services Platelet CT PX-3058504900 CDM 85049 CPT 305 RC inpatient 51 51 UNITED HEALTHCARE (COMMERCIAL) [3081199] UNITED HEALTHCARE 87726 [308119901] 31.62 percent of total billed charges 31.62 48.45 Technical (Hospital) Services Platelet CT PX-3058504900 CDM 85049 CPT 305 RC inpatient 51 51 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES PPO [308136801] 40.38 percent of total billed charges 31.62 48.45 Technical (Hospital) Services Platelet CT PX-3058504900 CDM 85049 CPT 305 RC inpatient 51 51 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES HDHP [308136802] 40.38 percent of total billed charges 31.62 48.45 Technical (Hospital) Services Platelet CT PX-3058504900 CDM 85049 CPT 305 RC outpatient 51 51 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES HDHP [308136802] 40.8 percent of total billed charges 31.62 48.45 Technical (Hospital) Services Platelet CT PX-3058504900 CDM 85049 CPT 305 RC outpatient 51 51 BLUE CROSS BLUE SHIELD WELLMARK SB889 [3081026] BCBS WYOMING [308102603] 48.45 percent of total billed charges 31.62 48.45 Technical (Hospital) Services Platelet CT PX-3058504900 CDM 85049 CPT 305 RC outpatient 51 51 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES EPO [308136803] 40.8 percent of total billed charges 31.62 48.45 Technical (Hospital) Services Platelet CT PX-3058504900 CDM 85049 CPT 305 RC outpatient 51 51 CIGNA 62308 [3081051] CIGNA 62308 [308105105] 40.8 percent of total billed charges 31.62 48.45 Technical (Hospital) Services Platelet CT PX-3058504900 CDM 85049 CPT 305 RC outpatient 51 51 CIGNA 62308 [3081051] CIGNA STATE OF WYOMING [308105107] 40.8 percent of total billed charges 31.62 48.45 Technical (Hospital) Services Platelet CT PX-3058504900 CDM 85049 CPT 305 RC outpatient 51 51 MULTIPLAN INC 34080 [3081285] MULTIPLAN INC [308128501] 48.45 percent of total billed charges 31.62 48.45 Technical (Hospital) Services Platelet CT PX-3058504900 CDM 85049 CPT 305 RC outpatient 51 51 HEALTHPARTNERS SX009 HEALTHPARTNERS 40.8 percent of total billed charges 31.62 48.45 Technical (Hospital) Services Platelet CT PX-3058504900 CDM 85049 CPT 305 RC outpatient 51 51 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES PPO [308136801] 40.8 percent of total billed charges 31.62 48.45 Technical (Hospital) Services Platelet CT PX-3058504900 CDM 85049 CPT 305 RC outpatient 51 51 UNITED HEALTHCARE (COMMERCIAL) [3081199] UNITED HEALTHCARE 87726 [308119901] 31.62 percent of total billed charges 31.62 48.45 Technical (Hospital) Services Platelet CT PX-3058504900 CDM 85049 CPT 305 RC outpatient 51 51 MEDICA (COMMERCIAL) 94265 [3081118] MEDICA CLAIMS [308111801] 45.9 percent of total billed charges 31.62 48.45 Technical (Hospital) Services Wbc White Blood Count PX-3058504800 CDM 85048 CPT 305 RC inpatient 51 51 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES PPO [308136801] 40.38 percent of total billed charges 31.62 48.45 Technical (Hospital) Services Wbc White Blood Count PX-3058504800 CDM 85048 CPT 305 RC inpatient 51 51 UNITED HEALTHCARE (COMMERCIAL) [3081199] UNITED HEALTHCARE 87726 [308119901] 31.62 percent of total billed charges 31.62 48.45 Technical (Hospital) Services Wbc White Blood Count PX-3058504800 CDM 85048 CPT 305 RC inpatient 51 51 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES HDHP [308136802] 40.38 percent of total billed charges 31.62 48.45 Technical (Hospital) Services Wbc White Blood Count PX-3058504800 CDM 85048 CPT 305 RC inpatient 51 51 MULTIPLAN INC 34080 [3081285] MULTIPLAN INC [308128501] 48.45 percent of total billed charges 31.62 48.45 Technical (Hospital) Services Wbc White Blood Count PX-3058504800 CDM 85048 CPT 305 RC inpatient 51 51 MEDICA (COMMERCIAL) 94265 [3081118] MEDICA CLAIMS [308111801] 45.9 percent of total billed charges 31.62 48.45 Technical (Hospital) Services Wbc White Blood Count PX-3058504800 CDM 85048 CPT 305 RC inpatient 51 51 BLUE CROSS BLUE SHIELD WELLMARK SB889 [3081026] BCBS WYOMING [308102603] 48.45 percent of total billed charges 31.62 48.45 Technical (Hospital) Services Wbc White Blood Count PX-3058504800 CDM 85048 CPT 305 RC inpatient 51 51 CIGNA 62308 [3081051] CIGNA 62308 [308105105] 40.38 percent of total billed charges 31.62 48.45 Technical (Hospital) Services Wbc White Blood Count PX-3058504800 CDM 85048 CPT 305 RC inpatient 51 51 CIGNA 62308 [3081051] CIGNA STATE OF WYOMING [308105107] 40.38 percent of total billed charges 31.62 48.45 Technical (Hospital) Services Wbc White Blood Count PX-3058504800 CDM 85048 CPT 305 RC inpatient 51 51 HEALTHPARTNERS SX009 HEALTHPARTNERS 40.38 percent of total billed charges 31.62 48.45 Technical (Hospital) Services Wbc White Blood Count PX-3058504800 CDM 85048 CPT 305 RC inpatient 51 51 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES EPO [308136803] 40.38 percent of total billed charges 31.62 48.45 Technical (Hospital) Services Wbc White Blood Count PX-3058504800 CDM 85048 CPT 305 RC outpatient 51 51 UNITED HEALTHCARE (COMMERCIAL) [3081199] UNITED HEALTHCARE 87726 [308119901] 31.62 percent of total billed charges 31.62 48.45 Technical (Hospital) Services Wbc White Blood Count PX-3058504800 CDM 85048 CPT 305 RC outpatient 51 51 MULTIPLAN INC 34080 [3081285] MULTIPLAN INC [308128501] 48.45 percent of total billed charges 31.62 48.45 Technical (Hospital) Services Wbc White Blood Count PX-3058504800 CDM 85048 CPT 305 RC outpatient 51 51 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES EPO [308136803] 40.8 percent of total billed charges 31.62 48.45 Technical (Hospital) Services Wbc White Blood Count PX-3058504800 CDM 85048 CPT 305 RC outpatient 51 51 CIGNA 62308 [3081051] CIGNA 62308 [308105105] 40.8 percent of total billed charges 31.62 48.45 Technical (Hospital) Services Wbc White Blood Count PX-3058504800 CDM 85048 CPT 305 RC outpatient 51 51 CIGNA 62308 [3081051] CIGNA STATE OF WYOMING [308105107] 40.8 percent of total billed charges 31.62 48.45 Technical (Hospital) Services Wbc White Blood Count PX-3058504800 CDM 85048 CPT 305 RC outpatient 51 51 BLUE CROSS BLUE SHIELD WELLMARK SB889 [3081026] BCBS WYOMING [308102603] 48.45 percent of total billed charges 31.62 48.45 Technical (Hospital) Services Wbc White Blood Count PX-3058504800 CDM 85048 CPT 305 RC outpatient 51 51 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES HDHP [308136802] 40.8 percent of total billed charges 31.62 48.45 Technical (Hospital) Services Wbc White Blood Count PX-3058504800 CDM 85048 CPT 305 RC outpatient 51 51 MEDICA (COMMERCIAL) 94265 [3081118] MEDICA CLAIMS [308111801] 45.9 percent of total billed charges 31.62 48.45 Technical (Hospital) Services Wbc White Blood Count PX-3058504800 CDM 85048 CPT 305 RC outpatient 51 51 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES PPO [308136801] 40.8 percent of total billed charges 31.62 48.45 Technical (Hospital) Services Wbc White Blood Count PX-3058504800 CDM 85048 CPT 305 RC outpatient 51 51 HEALTHPARTNERS SX009 HEALTHPARTNERS 40.8 percent of total billed charges 31.62 48.45 Technical (Hospital) Services Reticulocyte Count PX-3058504500 CDM 85045 CPT 305 RC inpatient 66 66 BLUE CROSS BLUE SHIELD WELLMARK SB889 [3081026] BCBS WYOMING [308102603] 62.7 percent of total billed charges 40.92 62.7 Technical (Hospital) Services Reticulocyte Count PX-3058504500 CDM 85045 CPT 305 RC inpatient 66 66 CIGNA 62308 [3081051] CIGNA 62308 [308105105] 52.26 percent of total billed charges 40.92 62.7 Technical (Hospital) Services Reticulocyte Count PX-3058504500 CDM 85045 CPT 305 RC inpatient 66 66 CIGNA 62308 [3081051] CIGNA STATE OF WYOMING [308105107] 52.26 percent of total billed charges 40.92 62.7 Technical (Hospital) Services Reticulocyte Count PX-3058504500 CDM 85045 CPT 305 RC inpatient 66 66 MEDICA (COMMERCIAL) 94265 [3081118] MEDICA CLAIMS [308111801] 59.4 percent of total billed charges 40.92 62.7 Technical (Hospital) Services Reticulocyte Count PX-3058504500 CDM 85045 CPT 305 RC inpatient 66 66 MULTIPLAN INC 34080 [3081285] MULTIPLAN INC [308128501] 62.7 percent of total billed charges 40.92 62.7 Technical (Hospital) Services Reticulocyte Count PX-3058504500 CDM 85045 CPT 305 RC inpatient 66 66 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES EPO [308136803] 52.26 percent of total billed charges 40.92 62.7 Technical (Hospital) Services Reticulocyte Count PX-3058504500 CDM 85045 CPT 305 RC inpatient 66 66 HEALTHPARTNERS SX009 HEALTHPARTNERS 52.26 percent of total billed charges 40.92 62.7 Technical (Hospital) Services Reticulocyte Count PX-3058504500 CDM 85045 CPT 305 RC inpatient 66 66 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES PPO [308136801] 52.26 percent of total billed charges 40.92 62.7 Technical (Hospital) Services Reticulocyte Count PX-3058504500 CDM 85045 CPT 305 RC inpatient 66 66 UNITED HEALTHCARE (COMMERCIAL) [3081199] UNITED HEALTHCARE 87726 [308119901] 40.92 percent of total billed charges 40.92 62.7 Technical (Hospital) Services Reticulocyte Count PX-3058504500 CDM 85045 CPT 305 RC inpatient 66 66 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES HDHP [308136802] 52.26 percent of total billed charges 40.92 62.7 Technical (Hospital) Services Reticulocyte Count PX-3058504500 CDM 85045 CPT 305 RC outpatient 66 66 HEALTHPARTNERS SX009 HEALTHPARTNERS 52.8 percent of total billed charges 40.92 62.7 Technical (Hospital) Services Reticulocyte Count PX-3058504500 CDM 85045 CPT 305 RC outpatient 66 66 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES PPO [308136801] 52.8 percent of total billed charges 40.92 62.7 Technical (Hospital) Services Reticulocyte Count PX-3058504500 CDM 85045 CPT 305 RC outpatient 66 66 UNITED HEALTHCARE (COMMERCIAL) [3081199] UNITED HEALTHCARE 87726 [308119901] 40.92 percent of total billed charges 40.92 62.7 Technical (Hospital) Services Reticulocyte Count PX-3058504500 CDM 85045 CPT 305 RC outpatient 66 66 BLUE CROSS BLUE SHIELD WELLMARK SB889 [3081026] BCBS WYOMING [308102603] 62.7 percent of total billed charges 40.92 62.7 Technical (Hospital) Services Reticulocyte Count PX-3058504500 CDM 85045 CPT 305 RC outpatient 66 66 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES HDHP [308136802] 52.8 percent of total billed charges 40.92 62.7 Technical (Hospital) Services Reticulocyte Count PX-3058504500 CDM 85045 CPT 305 RC outpatient 66 66 CIGNA 62308 [3081051] CIGNA 62308 [308105105] 52.8 percent of total billed charges 40.92 62.7 Technical (Hospital) Services Reticulocyte Count PX-3058504500 CDM 85045 CPT 305 RC outpatient 66 66 CIGNA 62308 [3081051] CIGNA STATE OF WYOMING [308105107] 52.8 percent of total billed charges 40.92 62.7 Technical (Hospital) Services Reticulocyte Count PX-3058504500 CDM 85045 CPT 305 RC outpatient 66 66 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES EPO [308136803] 52.8 percent of total billed charges 40.92 62.7 Technical (Hospital) Services Reticulocyte Count PX-3058504500 CDM 85045 CPT 305 RC outpatient 66 66 MULTIPLAN INC 34080 [3081285] MULTIPLAN INC [308128501] 62.7 percent of total billed charges 40.92 62.7 Technical (Hospital) Services Reticulocyte Count PX-3058504500 CDM 85045 CPT 305 RC outpatient 66 66 MEDICA (COMMERCIAL) 94265 [3081118] MEDICA CLAIMS [308111801] 59.4 percent of total billed charges 40.92 62.7 Technical (Hospital) Services Complete Bl Count Automated PX-3058502700 CDM 85027 CPT 305 RC inpatient 99 99 MULTIPLAN INC 34080 [3081285] MULTIPLAN INC [308128501] 94.05 percent of total billed charges 61.38 94.05 Technical (Hospital) Services Complete Bl Count Automated PX-3058502700 CDM 85027 CPT 305 RC inpatient 99 99 CIGNA 62308 [3081051] CIGNA 62308 [308105105] 78.39 percent of total billed charges 61.38 94.05 Technical (Hospital) Services Complete Bl Count Automated PX-3058502700 CDM 85027 CPT 305 RC inpatient 99 99 CIGNA 62308 [3081051] CIGNA STATE OF WYOMING [308105107] 78.39 percent of total billed charges 61.38 94.05 Technical (Hospital) Services Complete Bl Count Automated PX-3058502700 CDM 85027 CPT 305 RC inpatient 99 99 BLUE CROSS BLUE SHIELD WELLMARK SB889 [3081026] BCBS WYOMING [308102603] 94.05 percent of total billed charges 61.38 94.05 Technical (Hospital) Services Complete Bl Count Automated PX-3058502700 CDM 85027 CPT 305 RC inpatient 99 99 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES EPO [308136803] 78.39 percent of total billed charges 61.38 94.05 Technical (Hospital) Services Complete Bl Count Automated PX-3058502700 CDM 85027 CPT 305 RC inpatient 99 99 HEALTHPARTNERS SX009 HEALTHPARTNERS 78.39 percent of total billed charges 61.38 94.05 Technical (Hospital) Services Complete Bl Count Automated PX-3058502700 CDM 85027 CPT 305 RC inpatient 99 99 MEDICA (COMMERCIAL) 94265 [3081118] MEDICA CLAIMS [308111801] 89.1 percent of total billed charges 61.38 94.05 Technical (Hospital) Services Complete Bl Count Automated PX-3058502700 CDM 85027 CPT 305 RC inpatient 99 99 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES HDHP [308136802] 78.39 percent of total billed charges 61.38 94.05 Technical (Hospital) Services Complete Bl Count Automated PX-3058502700 CDM 85027 CPT 305 RC inpatient 99 99 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES PPO [308136801] 78.39 percent of total billed charges 61.38 94.05 Technical (Hospital) Services Complete Bl Count Automated PX-3058502700 CDM 85027 CPT 305 RC inpatient 99 99 UNITED HEALTHCARE (COMMERCIAL) [3081199] UNITED HEALTHCARE 87726 [308119901] 61.38 percent of total billed charges 61.38 94.05 Technical (Hospital) Services Complete Bl Count Automated PX-3058502700 CDM 85027 CPT 305 RC outpatient 99 99 HEALTHPARTNERS SX009 HEALTHPARTNERS 79.2 percent of total billed charges 61.38 94.05 Technical (Hospital) Services Complete Bl Count Automated PX-3058502700 CDM 85027 CPT 305 RC outpatient 99 99 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES PPO [308136801] 79.2 percent of total billed charges 61.38 94.05 Technical (Hospital) Services Complete Bl Count Automated PX-3058502700 CDM 85027 CPT 305 RC outpatient 99 99 UNITED HEALTHCARE (COMMERCIAL) [3081199] UNITED HEALTHCARE 87726 [308119901] 61.38 percent of total billed charges 61.38 94.05 Technical (Hospital) Services Complete Bl Count Automated PX-3058502700 CDM 85027 CPT 305 RC outpatient 99 99 MULTIPLAN INC 34080 [3081285] MULTIPLAN INC [308128501] 94.05 percent of total billed charges 61.38 94.05 Technical (Hospital) Services Complete Bl Count Automated PX-3058502700 CDM 85027 CPT 305 RC outpatient 99 99 CIGNA 62308 [3081051] CIGNA 62308 [308105105] 79.2 percent of total billed charges 61.38 94.05 Technical (Hospital) Services Complete Bl Count Automated PX-3058502700 CDM 85027 CPT 305 RC outpatient 99 99 CIGNA 62308 [3081051] CIGNA STATE OF WYOMING [308105107] 79.2 percent of total billed charges 61.38 94.05 Technical (Hospital) Services Complete Bl Count Automated PX-3058502700 CDM 85027 CPT 305 RC outpatient 99 99 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES EPO [308136803] 79.2 percent of total billed charges 61.38 94.05 Technical (Hospital) Services Complete Bl Count Automated PX-3058502700 CDM 85027 CPT 305 RC outpatient 99 99 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES HDHP [308136802] 79.2 percent of total billed charges 61.38 94.05 Technical (Hospital) Services Complete Bl Count Automated PX-3058502700 CDM 85027 CPT 305 RC outpatient 99 99 BLUE CROSS BLUE SHIELD WELLMARK SB889 [3081026] BCBS WYOMING [308102603] 94.05 percent of total billed charges 61.38 94.05 Technical (Hospital) Services Complete Bl Count Automated PX-3058502700 CDM 85027 CPT 305 RC outpatient 99 99 MEDICA (COMMERCIAL) 94265 [3081118] MEDICA CLAIMS [308111801] 89.1 percent of total billed charges 61.38 94.05 Technical (Hospital) Services Complete Bl Count W Diff Auto PX-3058502500 CDM 85025 CPT 305 RC inpatient 133 133 UNITED HEALTHCARE (COMMERCIAL) [3081199] UNITED HEALTHCARE 87726 [308119901] 82.46 percent of total billed charges 82.46 126.35 Technical (Hospital) Services Complete Bl Count W Diff Auto PX-3058502500 CDM 85025 CPT 305 RC inpatient 133 133 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES PPO [308136801] 105.31 percent of total billed charges 82.46 126.35 Technical (Hospital) Services Complete Bl Count W Diff Auto PX-3058502500 CDM 85025 CPT 305 RC inpatient 133 133 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES HDHP [308136802] 105.31 percent of total billed charges 82.46 126.35 Technical (Hospital) Services Complete Bl Count W Diff Auto PX-3058502500 CDM 85025 CPT 305 RC inpatient 133 133 MEDICA (COMMERCIAL) 94265 [3081118] MEDICA CLAIMS [308111801] 119.7 percent of total billed charges 82.46 126.35 Technical (Hospital) Services Complete Bl Count W Diff Auto PX-3058502500 CDM 85025 CPT 305 RC inpatient 133 133 HEALTHPARTNERS SX009 HEALTHPARTNERS 105.31 percent of total billed charges 82.46 126.35 Technical (Hospital) Services Complete Bl Count W Diff Auto PX-3058502500 CDM 85025 CPT 305 RC inpatient 133 133 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES EPO [308136803] 105.31 percent of total billed charges 82.46 126.35 Technical (Hospital) Services Complete Bl Count W Diff Auto PX-3058502500 CDM 85025 CPT 305 RC inpatient 133 133 BLUE CROSS BLUE SHIELD WELLMARK SB889 [3081026] BCBS WYOMING [308102603] 126.35 percent of total billed charges 82.46 126.35 Technical (Hospital) Services Complete Bl Count W Diff Auto PX-3058502500 CDM 85025 CPT 305 RC inpatient 133 133 CIGNA 62308 [3081051] CIGNA 62308 [308105105] 105.31 percent of total billed charges 82.46 126.35 Technical (Hospital) Services Complete Bl Count W Diff Auto PX-3058502500 CDM 85025 CPT 305 RC inpatient 133 133 CIGNA 62308 [3081051] CIGNA STATE OF WYOMING [308105107] 105.31 percent of total billed charges 82.46 126.35 Technical (Hospital) Services Complete Bl Count W Diff Auto PX-3058502500 CDM 85025 CPT 305 RC inpatient 133 133 MULTIPLAN INC 34080 [3081285] MULTIPLAN INC [308128501] 126.35 percent of total billed charges 82.46 126.35 Technical (Hospital) Services Complete Bl Count W Diff Auto PX-3058502500 CDM 85025 CPT 305 RC outpatient 133 133 UNITED HEALTHCARE (COMMERCIAL) [3081199] UNITED HEALTHCARE 87726 [308119901] 82.46 percent of total billed charges 82.46 126.35 Technical (Hospital) Services Complete Bl Count W Diff Auto PX-3058502500 CDM 85025 CPT 305 RC outpatient 133 133 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES PPO [308136801] 106.4 percent of total billed charges 82.46 126.35 Technical (Hospital) Services Complete Bl Count W Diff Auto PX-3058502500 CDM 85025 CPT 305 RC outpatient 133 133 HEALTHPARTNERS SX009 HEALTHPARTNERS 106.4 percent of total billed charges 82.46 126.35 Technical (Hospital) Services Complete Bl Count W Diff Auto PX-3058502500 CDM 85025 CPT 305 RC outpatient 133 133 BLUE CROSS BLUE SHIELD WELLMARK SB889 [3081026] BCBS WYOMING [308102603] 126.35 percent of total billed charges 82.46 126.35 Technical (Hospital) Services Complete Bl Count W Diff Auto PX-3058502500 CDM 85025 CPT 305 RC outpatient 133 133 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES HDHP [308136802] 106.4 percent of total billed charges 82.46 126.35 Technical (Hospital) Services Complete Bl Count W Diff Auto PX-3058502500 CDM 85025 CPT 305 RC outpatient 133 133 MULTIPLAN INC 34080 [3081285] MULTIPLAN INC [308128501] 126.35 percent of total billed charges 82.46 126.35 Technical (Hospital) Services Complete Bl Count W Diff Auto PX-3058502500 CDM 85025 CPT 305 RC outpatient 133 133 CIGNA 62308 [3081051] CIGNA STATE OF WYOMING [308105107] 106.4 percent of total billed charges 82.46 126.35 Technical (Hospital) Services Complete Bl Count W Diff Auto PX-3058502500 CDM 85025 CPT 305 RC outpatient 133 133 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES EPO [308136803] 106.4 percent of total billed charges 82.46 126.35 Technical (Hospital) Services Complete Bl Count W Diff Auto PX-3058502500 CDM 85025 CPT 305 RC outpatient 133 133 CIGNA 62308 [3081051] CIGNA 62308 [308105105] 106.4 percent of total billed charges 82.46 126.35 Technical (Hospital) Services Complete Bl Count W Diff Auto PX-3058502500 CDM 85025 CPT 305 RC outpatient 133 133 MEDICA (COMMERCIAL) 94265 [3081118] MEDICA CLAIMS [308111801] 119.7 percent of total billed charges 82.46 126.35 Technical (Hospital) Services PR Complete Bl Count W Diff Auto PX-8502500 CDM 85025 CPT 305 RC outpatient 133 133 MEDICA (COMMERCIAL) 94265 [3081118] MEDICA CLAIMS [308111801] 119.7 percent of total billed charges 82.46 126.35 Technical (Hospital) Services PR Complete Bl Count W Diff Auto PX-8502500 CDM 85025 CPT 305 RC outpatient 133 133 UNITED HEALTHCARE (COMMERCIAL) [3081199] UNITED HEALTHCARE 87726 [308119901] 82.46 percent of total billed charges 82.46 126.35 Technical (Hospital) Services PR Complete Bl Count W Diff Auto PX-8502500 CDM 85025 CPT 305 RC outpatient 133 133 HEALTHPARTNERS SX009 HEALTHPARTNERS 106.4 percent of total billed charges 82.46 126.35 Technical (Hospital) Services PR Complete Bl Count W Diff Auto PX-8502500 CDM 85025 CPT 305 RC outpatient 133 133 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES PPO [308136801] 106.4 percent of total billed charges 82.46 126.35 Technical (Hospital) Services PR Complete Bl Count W Diff Auto PX-8502500 CDM 85025 CPT 305 RC outpatient 133 133 MULTIPLAN INC 34080 [3081285] MULTIPLAN INC [308128501] 126.35 percent of total billed charges 82.46 126.35 Technical (Hospital) Services PR Complete Bl Count W Diff Auto PX-8502500 CDM 85025 CPT 305 RC outpatient 133 133 CIGNA 62308 [3081051] CIGNA 62308 [308105105] 106.4 percent of total billed charges 82.46 126.35 Technical (Hospital) Services PR Complete Bl Count W Diff Auto PX-8502500 CDM 85025 CPT 305 RC outpatient 133 133 CIGNA 62308 [3081051] CIGNA STATE OF WYOMING [308105107] 106.4 percent of total billed charges 82.46 126.35 Technical (Hospital) Services PR Complete Bl Count W Diff Auto PX-8502500 CDM 85025 CPT 305 RC outpatient 133 133 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES EPO [308136803] 106.4 percent of total billed charges 82.46 126.35 Technical (Hospital) Services PR Complete Bl Count W Diff Auto PX-8502500 CDM 85025 CPT 305 RC outpatient 133 133 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES HDHP [308136802] 106.4 percent of total billed charges 82.46 126.35 Technical (Hospital) Services PR Complete Bl Count W Diff Auto PX-8502500 CDM 85025 CPT 305 RC outpatient 133 133 BLUE CROSS BLUE SHIELD WELLMARK SB889 [3081026] BCBS WYOMING [308102603] 126.35 percent of total billed charges 82.46 126.35 Technical (Hospital) Services PR Complete Bl Count W Diff Auto PX-8502500 CDM 85025 CPT 305 RC inpatient 133 133 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES EPO [308136803] 105.31 percent of total billed charges 82.46 126.35 Technical (Hospital) Services PR Complete Bl Count W Diff Auto PX-8502500 CDM 85025 CPT 305 RC inpatient 133 133 HEALTHPARTNERS SX009 HEALTHPARTNERS 105.31 percent of total billed charges 82.46 126.35 Technical (Hospital) Services PR Complete Bl Count W Diff Auto PX-8502500 CDM 85025 CPT 305 RC inpatient 133 133 BLUE CROSS BLUE SHIELD WELLMARK SB889 [3081026] BCBS WYOMING [308102603] 126.35 percent of total billed charges 82.46 126.35 Technical (Hospital) Services PR Complete Bl Count W Diff Auto PX-8502500 CDM 85025 CPT 305 RC inpatient 133 133 CIGNA 62308 [3081051] CIGNA 62308 [308105105] 105.31 percent of total billed charges 82.46 126.35 Technical (Hospital) Services PR Complete Bl Count W Diff Auto PX-8502500 CDM 85025 CPT 305 RC inpatient 133 133 CIGNA 62308 [3081051] CIGNA STATE OF WYOMING [308105107] 105.31 percent of total billed charges 82.46 126.35 Technical (Hospital) Services PR Complete Bl Count W Diff Auto PX-8502500 CDM 85025 CPT 305 RC inpatient 133 133 MULTIPLAN INC 34080 [3081285] MULTIPLAN INC [308128501] 126.35 percent of total billed charges 82.46 126.35 Technical (Hospital) Services PR Complete Bl Count W Diff Auto PX-8502500 CDM 85025 CPT 305 RC inpatient 133 133 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES PPO [308136801] 105.31 percent of total billed charges 82.46 126.35 Technical (Hospital) Services PR Complete Bl Count W Diff Auto PX-8502500 CDM 85025 CPT 305 RC inpatient 133 133 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES HDHP [308136802] 105.31 percent of total billed charges 82.46 126.35 Technical (Hospital) Services PR Complete Bl Count W Diff Auto PX-8502500 CDM 85025 CPT 305 RC inpatient 133 133 UNITED HEALTHCARE (COMMERCIAL) [3081199] UNITED HEALTHCARE 87726 [308119901] 82.46 percent of total billed charges 82.46 126.35 Technical (Hospital) Services PR Complete Bl Count W Diff Auto PX-8502500 CDM 85025 CPT 305 RC inpatient 133 133 MEDICA (COMMERCIAL) 94265 [3081118] MEDICA CLAIMS [308111801] 119.7 percent of total billed charges 82.46 126.35 Technical (Hospital) Services Hemoglobin PX-3058501800 CDM 85018 CPT 305 RC inpatient 48 48 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES PPO [308136801] 38.01 percent of total billed charges 29.76 45.6 Technical (Hospital) Services Hemoglobin PX-3058501800 CDM 85018 CPT 305 RC inpatient 48 48 UNITED HEALTHCARE (COMMERCIAL) [3081199] UNITED HEALTHCARE 87726 [308119901] 29.76 percent of total billed charges 29.76 45.6 Technical (Hospital) Services Hemoglobin PX-3058501800 CDM 85018 CPT 305 RC inpatient 48 48 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES HDHP [308136802] 38.01 percent of total billed charges 29.76 45.6 Technical (Hospital) Services Hemoglobin PX-3058501800 CDM 85018 CPT 305 RC inpatient 48 48 BLUE CROSS BLUE SHIELD WELLMARK SB889 [3081026] BCBS WYOMING [308102603] 45.6 percent of total billed charges 29.76 45.6 Technical (Hospital) Services Hemoglobin PX-3058501800 CDM 85018 CPT 305 RC inpatient 48 48 CIGNA 62308 [3081051] CIGNA 62308 [308105105] 38.01 percent of total billed charges 29.76 45.6 Technical (Hospital) Services Hemoglobin PX-3058501800 CDM 85018 CPT 305 RC inpatient 48 48 CIGNA 62308 [3081051] CIGNA STATE OF WYOMING [308105107] 38.01 percent of total billed charges 29.76 45.6 Technical (Hospital) Services Hemoglobin PX-3058501800 CDM 85018 CPT 305 RC inpatient 48 48 MEDICA (COMMERCIAL) 94265 [3081118] MEDICA CLAIMS [308111801] 43.2 percent of total billed charges 29.76 45.6 Technical (Hospital) Services Hemoglobin PX-3058501800 CDM 85018 CPT 305 RC inpatient 48 48 MULTIPLAN INC 34080 [3081285] MULTIPLAN INC [308128501] 45.6 percent of total billed charges 29.76 45.6 Technical (Hospital) Services Hemoglobin PX-3058501800 CDM 85018 CPT 305 RC inpatient 48 48 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES EPO [308136803] 38.01 percent of total billed charges 29.76 45.6 Technical (Hospital) Services Hemoglobin PX-3058501800 CDM 85018 CPT 305 RC inpatient 48 48 HEALTHPARTNERS SX009 HEALTHPARTNERS 38.01 percent of total billed charges 29.76 45.6 Technical (Hospital) Services Hemoglobin PX-3058501800 CDM 85018 CPT 305 RC outpatient 48 48 MEDICA (COMMERCIAL) 94265 [3081118] MEDICA CLAIMS [308111801] 43.2 percent of total billed charges 29.76 45.6 Technical (Hospital) Services Hemoglobin PX-3058501800 CDM 85018 CPT 305 RC outpatient 48 48 MULTIPLAN INC 34080 [3081285] MULTIPLAN INC [308128501] 45.6 percent of total billed charges 29.76 45.6 Technical (Hospital) Services Hemoglobin PX-3058501800 CDM 85018 CPT 305 RC outpatient 48 48 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES EPO [308136803] 38.4 percent of total billed charges 29.76 45.6 Technical (Hospital) Services Hemoglobin PX-3058501800 CDM 85018 CPT 305 RC outpatient 48 48 CIGNA 62308 [3081051] CIGNA 62308 [308105105] 38.4 percent of total billed charges 29.76 45.6 Technical (Hospital) Services Hemoglobin PX-3058501800 CDM 85018 CPT 305 RC outpatient 48 48 CIGNA 62308 [3081051] CIGNA STATE OF WYOMING [308105107] 38.4 percent of total billed charges 29.76 45.6 Technical (Hospital) Services Hemoglobin PX-3058501800 CDM 85018 CPT 305 RC outpatient 48 48 BLUE CROSS BLUE SHIELD WELLMARK SB889 [3081026] BCBS WYOMING [308102603] 45.6 percent of total billed charges 29.76 45.6 Technical (Hospital) Services Hemoglobin PX-3058501800 CDM 85018 CPT 305 RC outpatient 48 48 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES HDHP [308136802] 38.4 percent of total billed charges 29.76 45.6 Technical (Hospital) Services Hemoglobin PX-3058501800 CDM 85018 CPT 305 RC outpatient 48 48 HEALTHPARTNERS SX009 HEALTHPARTNERS 38.4 percent of total billed charges 29.76 45.6 Technical (Hospital) Services Hemoglobin PX-3058501800 CDM 85018 CPT 305 RC outpatient 48 48 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES PPO [308136801] 38.4 percent of total billed charges 29.76 45.6 Technical (Hospital) Services Hemoglobin PX-3058501800 CDM 85018 CPT 305 RC outpatient 48 48 UNITED HEALTHCARE (COMMERCIAL) [3081199] UNITED HEALTHCARE 87726 [308119901] 29.76 percent of total billed charges 29.76 45.6 Technical (Hospital) Services Hematocrit PX-3058501400 CDM 85014 CPT 305 RC inpatient 48 48 UNITED HEALTHCARE (COMMERCIAL) [3081199] UNITED HEALTHCARE 87726 [308119901] 29.76 percent of total billed charges 29.76 45.6 Technical (Hospital) Services Hematocrit PX-3058501400 CDM 85014 CPT 305 RC inpatient 48 48 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES PPO [308136801] 38.01 percent of total billed charges 29.76 45.6 Technical (Hospital) Services Hematocrit PX-3058501400 CDM 85014 CPT 305 RC inpatient 48 48 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES HDHP [308136802] 38.01 percent of total billed charges 29.76 45.6 Technical (Hospital) Services Hematocrit PX-3058501400 CDM 85014 CPT 305 RC inpatient 48 48 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES EPO [308136803] 38.01 percent of total billed charges 29.76 45.6 Technical (Hospital) Services Hematocrit PX-3058501400 CDM 85014 CPT 305 RC inpatient 48 48 HEALTHPARTNERS SX009 HEALTHPARTNERS 38.01 percent of total billed charges 29.76 45.6 Technical (Hospital) Services Hematocrit PX-3058501400 CDM 85014 CPT 305 RC inpatient 48 48 BLUE CROSS BLUE SHIELD WELLMARK SB889 [3081026] BCBS WYOMING [308102603] 45.6 percent of total billed charges 29.76 45.6 Technical (Hospital) Services Hematocrit PX-3058501400 CDM 85014 CPT 305 RC inpatient 48 48 CIGNA 62308 [3081051] CIGNA 62308 [308105105] 38.01 percent of total billed charges 29.76 45.6 Technical (Hospital) Services Hematocrit PX-3058501400 CDM 85014 CPT 305 RC inpatient 48 48 CIGNA 62308 [3081051] CIGNA STATE OF WYOMING [308105107] 38.01 percent of total billed charges 29.76 45.6 Technical (Hospital) Services Hematocrit PX-3058501400 CDM 85014 CPT 305 RC inpatient 48 48 MULTIPLAN INC 34080 [3081285] MULTIPLAN INC [308128501] 45.6 percent of total billed charges 29.76 45.6 Technical (Hospital) Services Hematocrit PX-3058501400 CDM 85014 CPT 305 RC inpatient 48 48 MEDICA (COMMERCIAL) 94265 [3081118] MEDICA CLAIMS [308111801] 43.2 percent of total billed charges 29.76 45.6 Technical (Hospital) Services Hematocrit PX-3058501400 CDM 85014 CPT 305 RC outpatient 48 48 BLUE CROSS BLUE SHIELD WELLMARK SB889 [3081026] BCBS WYOMING [308102603] 45.6 percent of total billed charges 29.76 45.6 Technical (Hospital) Services Hematocrit PX-3058501400 CDM 85014 CPT 305 RC outpatient 48 48 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES HDHP [308136802] 38.4 percent of total billed charges 29.76 45.6 Technical (Hospital) Services Hematocrit PX-3058501400 CDM 85014 CPT 305 RC outpatient 48 48 CIGNA 62308 [3081051] CIGNA 62308 [308105105] 38.4 percent of total billed charges 29.76 45.6 Technical (Hospital) Services Hematocrit PX-3058501400 CDM 85014 CPT 305 RC outpatient 48 48 CIGNA 62308 [3081051] CIGNA STATE OF WYOMING [308105107] 38.4 percent of total billed charges 29.76 45.6 Technical (Hospital) Services Hematocrit PX-3058501400 CDM 85014 CPT 305 RC outpatient 48 48 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES EPO [308136803] 38.4 percent of total billed charges 29.76 45.6 Technical (Hospital) Services Hematocrit PX-3058501400 CDM 85014 CPT 305 RC outpatient 48 48 MULTIPLAN INC 34080 [3081285] MULTIPLAN INC [308128501] 45.6 percent of total billed charges 29.76 45.6 Technical (Hospital) Services Hematocrit PX-3058501400 CDM 85014 CPT 305 RC outpatient 48 48 UNITED HEALTHCARE (COMMERCIAL) [3081199] UNITED HEALTHCARE 87726 [308119901] 29.76 percent of total billed charges 29.76 45.6 Technical (Hospital) Services Hematocrit PX-3058501400 CDM 85014 CPT 305 RC outpatient 48 48 HEALTHPARTNERS SX009 HEALTHPARTNERS 38.4 percent of total billed charges 29.76 45.6 Technical (Hospital) Services Hematocrit PX-3058501400 CDM 85014 CPT 305 RC outpatient 48 48 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES PPO [308136801] 38.4 percent of total billed charges 29.76 45.6 Technical (Hospital) Services Hematocrit PX-3058501400 CDM 85014 CPT 305 RC outpatient 48 48 MEDICA (COMMERCIAL) 94265 [3081118] MEDICA CLAIMS [308111801] 43.2 percent of total billed charges 29.76 45.6 Technical (Hospital) Services Bl Count W Manual Diff Wbc CT PX-3058500700 CDM 85007 CPT 305 RC inpatient 54 54 UNITED HEALTHCARE (COMMERCIAL) [3081199] UNITED HEALTHCARE 87726 [308119901] 33.48 percent of total billed charges 33.48 51.3 Technical (Hospital) Services Bl Count W Manual Diff Wbc CT PX-3058500700 CDM 85007 CPT 305 RC inpatient 54 54 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES PPO [308136801] 42.76 percent of total billed charges 33.48 51.3 Technical (Hospital) Services Bl Count W Manual Diff Wbc CT PX-3058500700 CDM 85007 CPT 305 RC inpatient 54 54 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES HDHP [308136802] 42.76 percent of total billed charges 33.48 51.3 Technical (Hospital) Services Bl Count W Manual Diff Wbc CT PX-3058500700 CDM 85007 CPT 305 RC inpatient 54 54 MULTIPLAN INC 34080 [3081285] MULTIPLAN INC [308128501] 51.3 percent of total billed charges 33.48 51.3 Technical (Hospital) Services Bl Count W Manual Diff Wbc CT PX-3058500700 CDM 85007 CPT 305 RC inpatient 54 54 MEDICA (COMMERCIAL) 94265 [3081118] MEDICA CLAIMS [308111801] 48.6 percent of total billed charges 33.48 51.3 Technical (Hospital) Services Bl Count W Manual Diff Wbc CT PX-3058500700 CDM 85007 CPT 305 RC inpatient 54 54 CIGNA 62308 [3081051] CIGNA 62308 [308105105] 42.76 percent of total billed charges 33.48 51.3 Technical (Hospital) Services Bl Count W Manual Diff Wbc CT PX-3058500700 CDM 85007 CPT 305 RC inpatient 54 54 CIGNA 62308 [3081051] CIGNA STATE OF WYOMING [308105107] 42.76 percent of total billed charges 33.48 51.3 Technical (Hospital) Services Bl Count W Manual Diff Wbc CT PX-3058500700 CDM 85007 CPT 305 RC inpatient 54 54 BLUE CROSS BLUE SHIELD WELLMARK SB889 [3081026] BCBS WYOMING [308102603] 51.3 percent of total billed charges 33.48 51.3 Technical (Hospital) Services Bl Count W Manual Diff Wbc CT PX-3058500700 CDM 85007 CPT 305 RC inpatient 54 54 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES EPO [308136803] 42.76 percent of total billed charges 33.48 51.3 Technical (Hospital) Services Bl Count W Manual Diff Wbc CT PX-3058500700 CDM 85007 CPT 305 RC inpatient 54 54 HEALTHPARTNERS SX009 HEALTHPARTNERS 42.76 percent of total billed charges 33.48 51.3 Technical (Hospital) Services Bl Count W Manual Diff Wbc CT PX-3058500700 CDM 85007 CPT 305 RC outpatient 54 54 MEDICA (COMMERCIAL) 94265 [3081118] MEDICA CLAIMS [308111801] 48.6 percent of total billed charges 33.48 51.3 Technical (Hospital) Services Bl Count W Manual Diff Wbc CT PX-3058500700 CDM 85007 CPT 305 RC outpatient 54 54 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES HDHP [308136802] 43.2 percent of total billed charges 33.48 51.3 Technical (Hospital) Services Bl Count W Manual Diff Wbc CT PX-3058500700 CDM 85007 CPT 305 RC outpatient 54 54 BLUE CROSS BLUE SHIELD WELLMARK SB889 [3081026] BCBS WYOMING [308102603] 51.3 percent of total billed charges 33.48 51.3 Technical (Hospital) Services Bl Count W Manual Diff Wbc CT PX-3058500700 CDM 85007 CPT 305 RC outpatient 54 54 CIGNA 62308 [3081051] CIGNA 62308 [308105105] 43.2 percent of total billed charges 33.48 51.3 Technical (Hospital) Services Bl Count W Manual Diff Wbc CT PX-3058500700 CDM 85007 CPT 305 RC outpatient 54 54 CIGNA 62308 [3081051] CIGNA STATE OF WYOMING [308105107] 43.2 percent of total billed charges 33.48 51.3 Technical (Hospital) Services Bl Count W Manual Diff Wbc CT PX-3058500700 CDM 85007 CPT 305 RC outpatient 54 54 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES EPO [308136803] 43.2 percent of total billed charges 33.48 51.3 Technical (Hospital) Services Bl Count W Manual Diff Wbc CT PX-3058500700 CDM 85007 CPT 305 RC outpatient 54 54 MULTIPLAN INC 34080 [3081285] MULTIPLAN INC [308128501] 51.3 percent of total billed charges 33.48 51.3 Technical (Hospital) Services Bl Count W Manual Diff Wbc CT PX-3058500700 CDM 85007 CPT 305 RC outpatient 54 54 UNITED HEALTHCARE (COMMERCIAL) [3081199] UNITED HEALTHCARE 87726 [308119901] 33.48 percent of total billed charges 33.48 51.3 Technical (Hospital) Services Bl Count W Manual Diff Wbc CT PX-3058500700 CDM 85007 CPT 305 RC outpatient 54 54 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES PPO [308136801] 43.2 percent of total billed charges 33.48 51.3 Technical (Hospital) Services Bl Count W Manual Diff Wbc CT PX-3058500700 CDM 85007 CPT 305 RC outpatient 54 54 HEALTHPARTNERS SX009 HEALTHPARTNERS 43.2 percent of total billed charges 33.48 51.3 Technical (Hospital) Services Automated Differential Wbc Cnt PX-3058500400 CDM 85004 CPT 305 RC outpatient 29 29 UNITED HEALTHCARE (COMMERCIAL) [3081199] UNITED HEALTHCARE 87726 [308119901] 17.98 percent of total billed charges 17.98 27.55 Technical (Hospital) Services Automated Differential Wbc Cnt PX-3058500400 CDM 85004 CPT 305 RC outpatient 29 29 MULTIPLAN INC 34080 [3081285] MULTIPLAN INC [308128501] 27.55 percent of total billed charges 17.98 27.55 Technical (Hospital) Services Automated Differential Wbc Cnt PX-3058500400 CDM 85004 CPT 305 RC outpatient 29 29 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES EPO [308136803] 23.2 percent of total billed charges 17.98 27.55 Technical (Hospital) Services Automated Differential Wbc Cnt PX-3058500400 CDM 85004 CPT 305 RC outpatient 29 29 CIGNA 62308 [3081051] CIGNA 62308 [308105105] 23.2 percent of total billed charges 17.98 27.55 Technical (Hospital) Services Automated Differential Wbc Cnt PX-3058500400 CDM 85004 CPT 305 RC outpatient 29 29 CIGNA 62308 [3081051] CIGNA STATE OF WYOMING [308105107] 23.2 percent of total billed charges 17.98 27.55 Technical (Hospital) Services Automated Differential Wbc Cnt PX-3058500400 CDM 85004 CPT 305 RC outpatient 29 29 BLUE CROSS BLUE SHIELD WELLMARK SB889 [3081026] BCBS WYOMING [308102603] 27.55 percent of total billed charges 17.98 27.55 Technical (Hospital) Services Automated Differential Wbc Cnt PX-3058500400 CDM 85004 CPT 305 RC outpatient 29 29 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES HDHP [308136802] 23.2 percent of total billed charges 17.98 27.55 Technical (Hospital) Services Automated Differential Wbc Cnt PX-3058500400 CDM 85004 CPT 305 RC outpatient 29 29 HEALTHPARTNERS SX009 HEALTHPARTNERS 23.2 percent of total billed charges 17.98 27.55 Technical (Hospital) Services Automated Differential Wbc Cnt PX-3058500400 CDM 85004 CPT 305 RC outpatient 29 29 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES PPO [308136801] 23.2 percent of total billed charges 17.98 27.55 Technical (Hospital) Services Automated Differential Wbc Cnt PX-3058500400 CDM 85004 CPT 305 RC outpatient 29 29 MEDICA (COMMERCIAL) 94265 [3081118] MEDICA CLAIMS [308111801] 26.1 percent of total billed charges 17.98 27.55 Technical (Hospital) Services Automated Differential Wbc Cnt PX-3058500400 CDM 85004 CPT 305 RC inpatient 29 29 UNITED HEALTHCARE (COMMERCIAL) [3081199] UNITED HEALTHCARE 87726 [308119901] 17.98 percent of total billed charges 17.98 27.55 Technical (Hospital) Services Automated Differential Wbc Cnt PX-3058500400 CDM 85004 CPT 305 RC inpatient 29 29 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES PPO [308136801] 22.96 percent of total billed charges 17.98 27.55 Technical (Hospital) Services Automated Differential Wbc Cnt PX-3058500400 CDM 85004 CPT 305 RC inpatient 29 29 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES HDHP [308136802] 22.96 percent of total billed charges 17.98 27.55 Technical (Hospital) Services Automated Differential Wbc Cnt PX-3058500400 CDM 85004 CPT 305 RC inpatient 29 29 CIGNA 62308 [3081051] CIGNA 62308 [308105105] 22.96 percent of total billed charges 17.98 27.55 Technical (Hospital) Services Automated Differential Wbc Cnt PX-3058500400 CDM 85004 CPT 305 RC inpatient 29 29 CIGNA 62308 [3081051] CIGNA STATE OF WYOMING [308105107] 22.96 percent of total billed charges 17.98 27.55 Technical (Hospital) Services Automated Differential Wbc Cnt PX-3058500400 CDM 85004 CPT 305 RC inpatient 29 29 BLUE CROSS BLUE SHIELD WELLMARK SB889 [3081026] BCBS WYOMING [308102603] 27.55 percent of total billed charges 17.98 27.55 Technical (Hospital) Services Automated Differential Wbc Cnt PX-3058500400 CDM 85004 CPT 305 RC inpatient 29 29 MEDICA (COMMERCIAL) 94265 [3081118] MEDICA CLAIMS [308111801] 26.1 percent of total billed charges 17.98 27.55 Technical (Hospital) Services Automated Differential Wbc Cnt PX-3058500400 CDM 85004 CPT 305 RC inpatient 29 29 MULTIPLAN INC 34080 [3081285] MULTIPLAN INC [308128501] 27.55 percent of total billed charges 17.98 27.55 Technical (Hospital) Services Automated Differential Wbc Cnt PX-3058500400 CDM 85004 CPT 305 RC inpatient 29 29 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES EPO [308136803] 22.96 percent of total billed charges 17.98 27.55 Technical (Hospital) Services Automated Differential Wbc Cnt PX-3058500400 CDM 85004 CPT 305 RC inpatient 29 29 HEALTHPARTNERS SX009 HEALTHPARTNERS 22.96 percent of total billed charges 17.98 27.55 Technical (Hospital) Services Ref Osmolality Stool PX-3018499900 CDM 84999 CPT 301 RC inpatient 48 48 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES EPO [308136803] 38.01 percent of total billed charges 29.76 45.6 Technical (Hospital) Services Ref Osmolality Stool PX-3018499900 CDM 84999 CPT 301 RC inpatient 48 48 HEALTHPARTNERS SX009 HEALTHPARTNERS 38.01 percent of total billed charges 29.76 45.6 Technical (Hospital) Services Ref Osmolality Stool PX-3018499900 CDM 84999 CPT 301 RC inpatient 48 48 MULTIPLAN INC 34080 [3081285] MULTIPLAN INC [308128501] 45.6 percent of total billed charges 29.76 45.6 Technical (Hospital) Services Ref Osmolality Stool PX-3018499900 CDM 84999 CPT 301 RC inpatient 48 48 MEDICA (COMMERCIAL) 94265 [3081118] MEDICA CLAIMS [308111801] 43.2 percent of total billed charges 29.76 45.6 Technical (Hospital) Services Ref Osmolality Stool PX-3018499900 CDM 84999 CPT 301 RC inpatient 48 48 CIGNA 62308 [3081051] CIGNA STATE OF WYOMING [308105107] 38.01 percent of total billed charges 29.76 45.6 Technical (Hospital) Services Ref Osmolality Stool PX-3018499900 CDM 84999 CPT 301 RC inpatient 48 48 CIGNA 62308 [3081051] CIGNA 62308 [308105105] 38.01 percent of total billed charges 29.76 45.6 Technical (Hospital) Services Ref Osmolality Stool PX-3018499900 CDM 84999 CPT 301 RC inpatient 48 48 BLUE CROSS BLUE SHIELD WELLMARK SB889 [3081026] BCBS WYOMING [308102603] 45.6 percent of total billed charges 29.76 45.6 Technical (Hospital) Services Ref Osmolality Stool PX-3018499900 CDM 84999 CPT 301 RC inpatient 48 48 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES HDHP [308136802] 38.01 percent of total billed charges 29.76 45.6 Technical (Hospital) Services Ref Osmolality Stool PX-3018499900 CDM 84999 CPT 301 RC inpatient 48 48 UNITED HEALTHCARE (COMMERCIAL) [3081199] UNITED HEALTHCARE 87726 [308119901] 29.76 percent of total billed charges 29.76 45.6 Technical (Hospital) Services Ref Osmolality Stool PX-3018499900 CDM 84999 CPT 301 RC inpatient 48 48 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES PPO [308136801] 38.01 percent of total billed charges 29.76 45.6 Technical (Hospital) Services Ref Osmolality Stool PX-3018499900 CDM 84999 CPT 301 RC outpatient 48 48 MEDICA (COMMERCIAL) 94265 [3081118] MEDICA CLAIMS [308111801] 43.2 percent of total billed charges 29.76 45.6 Technical (Hospital) Services Ref Osmolality Stool PX-3018499900 CDM 84999 CPT 301 RC outpatient 48 48 UNITED HEALTHCARE (COMMERCIAL) [3081199] UNITED HEALTHCARE 87726 [308119901] 29.76 percent of total billed charges 29.76 45.6 Technical (Hospital) Services Ref Osmolality Stool PX-3018499900 CDM 84999 CPT 301 RC outpatient 48 48 HEALTHPARTNERS SX009 HEALTHPARTNERS 38.4 percent of total billed charges 29.76 45.6 Technical (Hospital) Services Ref Osmolality Stool PX-3018499900 CDM 84999 CPT 301 RC outpatient 48 48 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES PPO [308136801] 38.4 percent of total billed charges 29.76 45.6 Technical (Hospital) Services Ref Osmolality Stool PX-3018499900 CDM 84999 CPT 301 RC outpatient 48 48 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES HDHP [308136802] 38.4 percent of total billed charges 29.76 45.6 Technical (Hospital) Services Ref Osmolality Stool PX-3018499900 CDM 84999 CPT 301 RC outpatient 48 48 BLUE CROSS BLUE SHIELD WELLMARK SB889 [3081026] BCBS WYOMING [308102603] 45.6 percent of total billed charges 29.76 45.6 Technical (Hospital) Services Ref Osmolality Stool PX-3018499900 CDM 84999 CPT 301 RC outpatient 48 48 MULTIPLAN INC 34080 [3081285] MULTIPLAN INC [308128501] 45.6 percent of total billed charges 29.76 45.6 Technical (Hospital) Services Ref Osmolality Stool PX-3018499900 CDM 84999 CPT 301 RC outpatient 48 48 CIGNA 62308 [3081051] CIGNA 62308 [308105105] 38.4 percent of total billed charges 29.76 45.6 Technical (Hospital) Services Ref Osmolality Stool PX-3018499900 CDM 84999 CPT 301 RC outpatient 48 48 CIGNA 62308 [3081051] CIGNA STATE OF WYOMING [308105107] 38.4 percent of total billed charges 29.76 45.6 Technical (Hospital) Services Ref Osmolality Stool PX-3018499900 CDM 84999 CPT 301 RC outpatient 48 48 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES EPO [308136803] 38.4 percent of total billed charges 29.76 45.6 Technical (Hospital) Services Hcg Qual Preg Test PX-3018470300 CDM 84703 CPT 301 RC outpatient 127 127 MEDICA (COMMERCIAL) 94265 [3081118] MEDICA CLAIMS [308111801] 114.3 percent of total billed charges 78.74 120.65 Technical (Hospital) Services Hcg Qual Preg Test PX-3018470300 CDM 84703 CPT 301 RC outpatient 127 127 BLUE CROSS BLUE SHIELD WELLMARK SB889 [3081026] BCBS WYOMING [308102603] 120.65 percent of total billed charges 78.74 120.65 Technical (Hospital) Services Hcg Qual Preg Test PX-3018470300 CDM 84703 CPT 301 RC outpatient 127 127 MULTIPLAN INC 34080 [3081285] MULTIPLAN INC [308128501] 120.65 percent of total billed charges 78.74 120.65 Technical (Hospital) Services Hcg Qual Preg Test PX-3018470300 CDM 84703 CPT 301 RC outpatient 127 127 CIGNA 62308 [3081051] CIGNA 62308 [308105105] 101.6 percent of total billed charges 78.74 120.65 Technical (Hospital) Services Hcg Qual Preg Test PX-3018470300 CDM 84703 CPT 301 RC outpatient 127 127 CIGNA 62308 [3081051] CIGNA STATE OF WYOMING [308105107] 101.6 percent of total billed charges 78.74 120.65 Technical (Hospital) Services Hcg Qual Preg Test PX-3018470300 CDM 84703 CPT 301 RC outpatient 127 127 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES EPO [308136803] 101.6 percent of total billed charges 78.74 120.65 Technical (Hospital) Services Hcg Qual Preg Test PX-3018470300 CDM 84703 CPT 301 RC outpatient 127 127 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES HDHP [308136802] 101.6 percent of total billed charges 78.74 120.65 Technical (Hospital) Services Hcg Qual Preg Test PX-3018470300 CDM 84703 CPT 301 RC outpatient 127 127 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES PPO [308136801] 101.6 percent of total billed charges 78.74 120.65 Technical (Hospital) Services Hcg Qual Preg Test PX-3018470300 CDM 84703 CPT 301 RC outpatient 127 127 HEALTHPARTNERS SX009 HEALTHPARTNERS 101.6 percent of total billed charges 78.74 120.65 Technical (Hospital) Services Hcg Qual Preg Test PX-3018470300 CDM 84703 CPT 301 RC outpatient 127 127 UNITED HEALTHCARE (COMMERCIAL) [3081199] UNITED HEALTHCARE 87726 [308119901] 78.74 percent of total billed charges 78.74 120.65 Technical (Hospital) Services Hcg Qual Preg Test PX-3018470300 CDM 84703 CPT 301 RC inpatient 127 127 CIGNA 62308 [3081051] CIGNA 62308 [308105105] 100.56 percent of total billed charges 78.74 120.65 Technical (Hospital) Services Hcg Qual Preg Test PX-3018470300 CDM 84703 CPT 301 RC inpatient 127 127 CIGNA 62308 [3081051] CIGNA STATE OF WYOMING [308105107] 100.56 percent of total billed charges 78.74 120.65 Technical (Hospital) Services Hcg Qual Preg Test PX-3018470300 CDM 84703 CPT 301 RC inpatient 127 127 MEDICA (COMMERCIAL) 94265 [3081118] MEDICA CLAIMS [308111801] 114.3 percent of total billed charges 78.74 120.65 Technical (Hospital) Services Hcg Qual Preg Test PX-3018470300 CDM 84703 CPT 301 RC inpatient 127 127 MULTIPLAN INC 34080 [3081285] MULTIPLAN INC [308128501] 120.65 percent of total billed charges 78.74 120.65 Technical (Hospital) Services Hcg Qual Preg Test PX-3018470300 CDM 84703 CPT 301 RC inpatient 127 127 HEALTHPARTNERS SX009 HEALTHPARTNERS 100.56 percent of total billed charges 78.74 120.65 Technical (Hospital) Services Hcg Qual Preg Test PX-3018470300 CDM 84703 CPT 301 RC inpatient 127 127 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES EPO [308136803] 100.56 percent of total billed charges 78.74 120.65 Technical (Hospital) Services Hcg Qual Preg Test PX-3018470300 CDM 84703 CPT 301 RC inpatient 127 127 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES PPO [308136801] 100.56 percent of total billed charges 78.74 120.65 Technical (Hospital) Services Hcg Qual Preg Test PX-3018470300 CDM 84703 CPT 301 RC inpatient 127 127 UNITED HEALTHCARE (COMMERCIAL) [3081199] UNITED HEALTHCARE 87726 [308119901] 78.74 percent of total billed charges 78.74 120.65 Technical (Hospital) Services Hcg Qual Preg Test PX-3018470300 CDM 84703 CPT 301 RC inpatient 127 127 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES HDHP [308136802] 100.56 percent of total billed charges 78.74 120.65 Technical (Hospital) Services Hcg Qual Preg Test PX-3018470300 CDM 84703 CPT 301 RC inpatient 127 127 BLUE CROSS BLUE SHIELD WELLMARK SB889 [3081026] BCBS WYOMING [308102603] 120.65 percent of total billed charges 78.74 120.65 Technical (Hospital) Services Hcg Quant Preg Test PX-3018470200 CDM 84702 CPT 301 RC outpatient 210 210 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES PPO [308136801] 168 percent of total billed charges 130.2 199.5 Technical (Hospital) Services Hcg Quant Preg Test PX-3018470200 CDM 84702 CPT 301 RC outpatient 210 210 HEALTHPARTNERS SX009 HEALTHPARTNERS 168 percent of total billed charges 130.2 199.5 Technical (Hospital) Services Hcg Quant Preg Test PX-3018470200 CDM 84702 CPT 301 RC outpatient 210 210 UNITED HEALTHCARE (COMMERCIAL) [3081199] UNITED HEALTHCARE 87726 [308119901] 130.2 percent of total billed charges 130.2 199.5 Technical (Hospital) Services Hcg Quant Preg Test PX-3018470200 CDM 84702 CPT 301 RC outpatient 210 210 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES HDHP [308136802] 168 percent of total billed charges 130.2 199.5 Technical (Hospital) Services Hcg Quant Preg Test PX-3018470200 CDM 84702 CPT 301 RC outpatient 210 210 BLUE CROSS BLUE SHIELD WELLMARK SB889 [3081026] BCBS WYOMING [308102603] 199.5 percent of total billed charges 130.2 199.5 Technical (Hospital) Services Hcg Quant Preg Test PX-3018470200 CDM 84702 CPT 301 RC outpatient 210 210 MULTIPLAN INC 34080 [3081285] MULTIPLAN INC [308128501] 199.5 percent of total billed charges 130.2 199.5 Technical (Hospital) Services Hcg Quant Preg Test PX-3018470200 CDM 84702 CPT 301 RC outpatient 210 210 CIGNA 62308 [3081051] CIGNA 62308 [308105105] 168 percent of total billed charges 130.2 199.5 Technical (Hospital) Services Hcg Quant Preg Test PX-3018470200 CDM 84702 CPT 301 RC outpatient 210 210 CIGNA 62308 [3081051] CIGNA STATE OF WYOMING [308105107] 168 percent of total billed charges 130.2 199.5 Technical (Hospital) Services Hcg Quant Preg Test PX-3018470200 CDM 84702 CPT 301 RC outpatient 210 210 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES EPO [308136803] 168 percent of total billed charges 130.2 199.5 Technical (Hospital) Services Hcg Quant Preg Test PX-3018470200 CDM 84702 CPT 301 RC outpatient 210 210 MEDICA (COMMERCIAL) 94265 [3081118] MEDICA CLAIMS [308111801] 189 percent of total billed charges 130.2 199.5 Technical (Hospital) Services Hcg Quant Preg Test PX-3018470200 CDM 84702 CPT 301 RC inpatient 210 210 UNITED HEALTHCARE (COMMERCIAL) [3081199] UNITED HEALTHCARE 87726 [308119901] 130.2 percent of total billed charges 130.2 199.5 Technical (Hospital) Services Hcg Quant Preg Test PX-3018470200 CDM 84702 CPT 301 RC inpatient 210 210 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES PPO [308136801] 166.28 percent of total billed charges 130.2 199.5 Technical (Hospital) Services Hcg Quant Preg Test PX-3018470200 CDM 84702 CPT 301 RC inpatient 210 210 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES HDHP [308136802] 166.28 percent of total billed charges 130.2 199.5 Technical (Hospital) Services Hcg Quant Preg Test PX-3018470200 CDM 84702 CPT 301 RC inpatient 210 210 BLUE CROSS BLUE SHIELD WELLMARK SB889 [3081026] BCBS WYOMING [308102603] 199.5 percent of total billed charges 130.2 199.5 Technical (Hospital) Services Hcg Quant Preg Test PX-3018470200 CDM 84702 CPT 301 RC inpatient 210 210 CIGNA 62308 [3081051] CIGNA 62308 [308105105] 166.28 percent of total billed charges 130.2 199.5 Technical (Hospital) Services Hcg Quant Preg Test PX-3018470200 CDM 84702 CPT 301 RC inpatient 210 210 CIGNA 62308 [3081051] CIGNA STATE OF WYOMING [308105107] 166.28 percent of total billed charges 130.2 199.5 Technical (Hospital) Services Hcg Quant Preg Test PX-3018470200 CDM 84702 CPT 301 RC inpatient 210 210 MEDICA (COMMERCIAL) 94265 [3081118] MEDICA CLAIMS [308111801] 189 percent of total billed charges 130.2 199.5 Technical (Hospital) Services Hcg Quant Preg Test PX-3018470200 CDM 84702 CPT 301 RC inpatient 210 210 MULTIPLAN INC 34080 [3081285] MULTIPLAN INC [308128501] 199.5 percent of total billed charges 130.2 199.5 Technical (Hospital) Services Hcg Quant Preg Test PX-3018470200 CDM 84702 CPT 301 RC inpatient 210 210 HEALTHPARTNERS SX009 HEALTHPARTNERS 166.28 percent of total billed charges 130.2 199.5 Technical (Hospital) Services Hcg Quant Preg Test PX-3018470200 CDM 84702 CPT 301 RC inpatient 210 210 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES EPO [308136803] 166.28 percent of total billed charges 130.2 199.5 Technical (Hospital) Services Ref Bhcg CSF PX-3018470201 CDM 84702 CPT 301 RC inpatient 170 170 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES EPO [308136803] 134.61 percent of total billed charges 105.4 161.5 Technical (Hospital) Services Ref Bhcg CSF PX-3018470201 CDM 84702 CPT 301 RC inpatient 170 170 HEALTHPARTNERS SX009 HEALTHPARTNERS 134.61 percent of total billed charges 105.4 161.5 Technical (Hospital) Services Ref Bhcg CSF PX-3018470201 CDM 84702 CPT 301 RC inpatient 170 170 MEDICA (COMMERCIAL) 94265 [3081118] MEDICA CLAIMS [308111801] 153 percent of total billed charges 105.4 161.5 Technical (Hospital) Services Ref Bhcg CSF PX-3018470201 CDM 84702 CPT 301 RC inpatient 170 170 MULTIPLAN INC 34080 [3081285] MULTIPLAN INC [308128501] 161.5 percent of total billed charges 105.4 161.5 Technical (Hospital) Services Ref Bhcg CSF PX-3018470201 CDM 84702 CPT 301 RC inpatient 170 170 CIGNA 62308 [3081051] CIGNA 62308 [308105105] 134.61 percent of total billed charges 105.4 161.5 Technical (Hospital) Services Ref Bhcg CSF PX-3018470201 CDM 84702 CPT 301 RC inpatient 170 170 CIGNA 62308 [3081051] CIGNA STATE OF WYOMING [308105107] 134.61 percent of total billed charges 105.4 161.5 Technical (Hospital) Services Ref Bhcg CSF PX-3018470201 CDM 84702 CPT 301 RC inpatient 170 170 BLUE CROSS BLUE SHIELD WELLMARK SB889 [3081026] BCBS WYOMING [308102603] 161.5 percent of total billed charges 105.4 161.5 Technical (Hospital) Services Ref Bhcg CSF PX-3018470201 CDM 84702 CPT 301 RC inpatient 170 170 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES HDHP [308136802] 134.61 percent of total billed charges 105.4 161.5 Technical (Hospital) Services Ref Bhcg CSF PX-3018470201 CDM 84702 CPT 301 RC inpatient 170 170 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES PPO [308136801] 134.61 percent of total billed charges 105.4 161.5 Technical (Hospital) Services Ref Bhcg CSF PX-3018470201 CDM 84702 CPT 301 RC inpatient 170 170 UNITED HEALTHCARE (COMMERCIAL) [3081199] UNITED HEALTHCARE 87726 [308119901] 105.4 percent of total billed charges 105.4 161.5 Technical (Hospital) Services Ref Bhcg CSF PX-3018470201 CDM 84702 CPT 301 RC outpatient 170 170 MULTIPLAN INC 34080 [3081285] MULTIPLAN INC [308128501] 161.5 percent of total billed charges 105.4 161.5 Technical (Hospital) Services Ref Bhcg CSF PX-3018470201 CDM 84702 CPT 301 RC outpatient 170 170 BLUE CROSS BLUE SHIELD WELLMARK SB889 [3081026] BCBS WYOMING [308102603] 161.5 percent of total billed charges 105.4 161.5 Technical (Hospital) Services Ref Bhcg CSF PX-3018470201 CDM 84702 CPT 301 RC outpatient 170 170 CIGNA 62308 [3081051] CIGNA 62308 [308105105] 136 percent of total billed charges 105.4 161.5 Technical (Hospital) Services Ref Bhcg CSF PX-3018470201 CDM 84702 CPT 301 RC outpatient 170 170 CIGNA 62308 [3081051] CIGNA STATE OF WYOMING [308105107] 136 percent of total billed charges 105.4 161.5 Technical (Hospital) Services Ref Bhcg CSF PX-3018470201 CDM 84702 CPT 301 RC outpatient 170 170 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES EPO [308136803] 136 percent of total billed charges 105.4 161.5 Technical (Hospital) Services Ref Bhcg CSF PX-3018470201 CDM 84702 CPT 301 RC outpatient 170 170 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES HDHP [308136802] 136 percent of total billed charges 105.4 161.5 Technical (Hospital) Services Ref Bhcg CSF PX-3018470201 CDM 84702 CPT 301 RC outpatient 170 170 UNITED HEALTHCARE (COMMERCIAL) [3081199] UNITED HEALTHCARE 87726 [308119901] 105.4 percent of total billed charges 105.4 161.5 Technical (Hospital) Services Ref Bhcg CSF PX-3018470201 CDM 84702 CPT 301 RC outpatient 170 170 HEALTHPARTNERS SX009 HEALTHPARTNERS 136 percent of total billed charges 105.4 161.5 Technical (Hospital) Services Ref Bhcg CSF PX-3018470201 CDM 84702 CPT 301 RC outpatient 170 170 MEDICA (COMMERCIAL) 94265 [3081118] MEDICA CLAIMS [308111801] 153 percent of total billed charges 105.4 161.5 Technical (Hospital) Services Ref Bhcg CSF PX-3018470201 CDM 84702 CPT 301 RC outpatient 170 170 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES PPO [308136801] 136 percent of total billed charges 105.4 161.5 Technical (Hospital) Services Ref C Peptide PX-3018468100 CDM 84681 CPT 301 RC outpatient 119 119 MEDICA (COMMERCIAL) 94265 [3081118] MEDICA CLAIMS [308111801] 107.1 percent of total billed charges 73.78 113.05 Technical (Hospital) Services Ref C Peptide PX-3018468100 CDM 84681 CPT 301 RC outpatient 119 119 UNITED HEALTHCARE (COMMERCIAL) [3081199] UNITED HEALTHCARE 87726 [308119901] 73.78 percent of total billed charges 73.78 113.05 Technical (Hospital) Services Ref C Peptide PX-3018468100 CDM 84681 CPT 301 RC outpatient 119 119 HEALTHPARTNERS SX009 HEALTHPARTNERS 95.2 percent of total billed charges 73.78 113.05 Technical (Hospital) Services Ref C Peptide PX-3018468100 CDM 84681 CPT 301 RC outpatient 119 119 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES PPO [308136801] 95.2 percent of total billed charges 73.78 113.05 Technical (Hospital) Services Ref C Peptide PX-3018468100 CDM 84681 CPT 301 RC outpatient 119 119 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES HDHP [308136802] 95.2 percent of total billed charges 73.78 113.05 Technical (Hospital) Services Ref C Peptide PX-3018468100 CDM 84681 CPT 301 RC outpatient 119 119 BLUE CROSS BLUE SHIELD WELLMARK SB889 [3081026] BCBS WYOMING [308102603] 113.05 percent of total billed charges 73.78 113.05 Technical (Hospital) Services Ref C Peptide PX-3018468100 CDM 84681 CPT 301 RC outpatient 119 119 MULTIPLAN INC 34080 [3081285] MULTIPLAN INC [308128501] 113.05 percent of total billed charges 73.78 113.05 Technical (Hospital) Services Ref C Peptide PX-3018468100 CDM 84681 CPT 301 RC outpatient 119 119 CIGNA 62308 [3081051] CIGNA 62308 [308105105] 95.2 percent of total billed charges 73.78 113.05 Technical (Hospital) Services Ref C Peptide PX-3018468100 CDM 84681 CPT 301 RC outpatient 119 119 CIGNA 62308 [3081051] CIGNA STATE OF WYOMING [308105107] 95.2 percent of total billed charges 73.78 113.05 Technical (Hospital) Services Ref C Peptide PX-3018468100 CDM 84681 CPT 301 RC outpatient 119 119 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES EPO [308136803] 95.2 percent of total billed charges 73.78 113.05 Technical (Hospital) Services Ref C Peptide PX-3018468100 CDM 84681 CPT 301 RC inpatient 119 119 HEALTHPARTNERS SX009 HEALTHPARTNERS 94.22 percent of total billed charges 73.78 113.05 Technical (Hospital) Services Ref C Peptide PX-3018468100 CDM 84681 CPT 301 RC inpatient 119 119 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES EPO [308136803] 94.22 percent of total billed charges 73.78 113.05 Technical (Hospital) Services Ref C Peptide PX-3018468100 CDM 84681 CPT 301 RC inpatient 119 119 CIGNA 62308 [3081051] CIGNA 62308 [308105105] 94.22 percent of total billed charges 73.78 113.05 Technical (Hospital) Services Ref C Peptide PX-3018468100 CDM 84681 CPT 301 RC inpatient 119 119 CIGNA 62308 [3081051] CIGNA STATE OF WYOMING [308105107] 94.22 percent of total billed charges 73.78 113.05 Technical (Hospital) Services Ref C Peptide PX-3018468100 CDM 84681 CPT 301 RC inpatient 119 119 MULTIPLAN INC 34080 [3081285] MULTIPLAN INC [308128501] 113.05 percent of total billed charges 73.78 113.05 Technical (Hospital) Services Ref C Peptide PX-3018468100 CDM 84681 CPT 301 RC inpatient 119 119 MEDICA (COMMERCIAL) 94265 [3081118] MEDICA CLAIMS [308111801] 107.1 percent of total billed charges 73.78 113.05 Technical (Hospital) Services Ref C Peptide PX-3018468100 CDM 84681 CPT 301 RC inpatient 119 119 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES PPO [308136801] 94.22 percent of total billed charges 73.78 113.05 Technical (Hospital) Services Ref C Peptide PX-3018468100 CDM 84681 CPT 301 RC inpatient 119 119 UNITED HEALTHCARE (COMMERCIAL) [3081199] UNITED HEALTHCARE 87726 [308119901] 73.78 percent of total billed charges 73.78 113.05 Technical (Hospital) Services Ref C Peptide PX-3018468100 CDM 84681 CPT 301 RC inpatient 119 119 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES HDHP [308136802] 94.22 percent of total billed charges 73.78 113.05 Technical (Hospital) Services Ref C Peptide PX-3018468100 CDM 84681 CPT 301 RC inpatient 119 119 BLUE CROSS BLUE SHIELD WELLMARK SB889 [3081026] BCBS WYOMING [308102603] 113.05 percent of total billed charges 73.78 113.05 Technical (Hospital) Services Ref C Peptide PX-3018468101 CDM 84681 CPT 301 RC inpatient 119 119 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES PPO [308136801] 94.22 percent of total billed charges 73.78 113.05 Technical (Hospital) Services Ref C Peptide PX-3018468101 CDM 84681 CPT 301 RC inpatient 119 119 UNITED HEALTHCARE (COMMERCIAL) [3081199] UNITED HEALTHCARE 87726 [308119901] 73.78 percent of total billed charges 73.78 113.05 Technical (Hospital) Services Ref C Peptide PX-3018468101 CDM 84681 CPT 301 RC inpatient 119 119 BLUE CROSS BLUE SHIELD WELLMARK SB889 [3081026] BCBS WYOMING [308102603] 113.05 percent of total billed charges 73.78 113.05 Technical (Hospital) Services Ref C Peptide PX-3018468101 CDM 84681 CPT 301 RC inpatient 119 119 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES HDHP [308136802] 94.22 percent of total billed charges 73.78 113.05 Technical (Hospital) Services Ref C Peptide PX-3018468101 CDM 84681 CPT 301 RC inpatient 119 119 HEALTHPARTNERS SX009 HEALTHPARTNERS 94.22 percent of total billed charges 73.78 113.05 Technical (Hospital) Services Ref C Peptide PX-3018468101 CDM 84681 CPT 301 RC inpatient 119 119 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES EPO [308136803] 94.22 percent of total billed charges 73.78 113.05 Technical (Hospital) Services Ref C Peptide PX-3018468101 CDM 84681 CPT 301 RC inpatient 119 119 CIGNA 62308 [3081051] CIGNA 62308 [308105105] 94.22 percent of total billed charges 73.78 113.05 Technical (Hospital) Services Ref C Peptide PX-3018468101 CDM 84681 CPT 301 RC inpatient 119 119 CIGNA 62308 [3081051] CIGNA STATE OF WYOMING [308105107] 94.22 percent of total billed charges 73.78 113.05 Technical (Hospital) Services Ref C Peptide PX-3018468101 CDM 84681 CPT 301 RC inpatient 119 119 MULTIPLAN INC 34080 [3081285] MULTIPLAN INC [308128501] 113.05 percent of total billed charges 73.78 113.05 Technical (Hospital) Services Ref C Peptide PX-3018468101 CDM 84681 CPT 301 RC inpatient 119 119 MEDICA (COMMERCIAL) 94265 [3081118] MEDICA CLAIMS [308111801] 107.1 percent of total billed charges 73.78 113.05 Technical (Hospital) Services Ref C Peptide PX-3018468101 CDM 84681 CPT 301 RC outpatient 119 119 MEDICA (COMMERCIAL) 94265 [3081118] MEDICA CLAIMS [308111801] 107.1 percent of total billed charges 73.78 113.05 Technical (Hospital) Services Ref C Peptide PX-3018468101 CDM 84681 CPT 301 RC outpatient 119 119 UNITED HEALTHCARE (COMMERCIAL) [3081199] UNITED HEALTHCARE 87726 [308119901] 73.78 percent of total billed charges 73.78 113.05 Technical (Hospital) Services Ref C Peptide PX-3018468101 CDM 84681 CPT 301 RC outpatient 119 119 HEALTHPARTNERS SX009 HEALTHPARTNERS 95.2 percent of total billed charges 73.78 113.05 Technical (Hospital) Services Ref C Peptide PX-3018468101 CDM 84681 CPT 301 RC outpatient 119 119 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES PPO [308136801] 95.2 percent of total billed charges 73.78 113.05 Technical (Hospital) Services Ref C Peptide PX-3018468101 CDM 84681 CPT 301 RC outpatient 119 119 MULTIPLAN INC 34080 [3081285] MULTIPLAN INC [308128501] 113.05 percent of total billed charges 73.78 113.05 Technical (Hospital) Services Ref C Peptide PX-3018468101 CDM 84681 CPT 301 RC outpatient 119 119 BLUE CROSS BLUE SHIELD WELLMARK SB889 [3081026] BCBS WYOMING [308102603] 113.05 percent of total billed charges 73.78 113.05 Technical (Hospital) Services Ref C Peptide PX-3018468101 CDM 84681 CPT 301 RC outpatient 119 119 CIGNA 62308 [3081051] CIGNA 62308 [308105105] 95.2 percent of total billed charges 73.78 113.05 Technical (Hospital) Services Ref C Peptide PX-3018468101 CDM 84681 CPT 301 RC outpatient 119 119 CIGNA 62308 [3081051] CIGNA STATE OF WYOMING [308105107] 95.2 percent of total billed charges 73.78 113.05 Technical (Hospital) Services Ref C Peptide PX-3018468101 CDM 84681 CPT 301 RC outpatient 119 119 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES EPO [308136803] 95.2 percent of total billed charges 73.78 113.05 Technical (Hospital) Services Ref C Peptide PX-3018468101 CDM 84681 CPT 301 RC outpatient 119 119 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES HDHP [308136802] 95.2 percent of total billed charges 73.78 113.05 Technical (Hospital) Services Ref Zinc Serum PX-3018463001 CDM 84630 CPT 301 RC outpatient 119 119 MEDICA (COMMERCIAL) 94265 [3081118] MEDICA CLAIMS [308111801] 107.1 percent of total billed charges 73.78 113.05 Technical (Hospital) Services Ref Zinc Serum PX-3018463001 CDM 84630 CPT 301 RC outpatient 119 119 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES EPO [308136803] 95.2 percent of total billed charges 73.78 113.05 Technical (Hospital) Services Ref Zinc Serum PX-3018463001 CDM 84630 CPT 301 RC outpatient 119 119 CIGNA 62308 [3081051] CIGNA 62308 [308105105] 95.2 percent of total billed charges 73.78 113.05 Technical (Hospital) Services Ref Zinc Serum PX-3018463001 CDM 84630 CPT 301 RC outpatient 119 119 CIGNA 62308 [3081051] CIGNA STATE OF WYOMING [308105107] 95.2 percent of total billed charges 73.78 113.05 Technical (Hospital) Services Ref Zinc Serum PX-3018463001 CDM 84630 CPT 301 RC outpatient 119 119 MULTIPLAN INC 34080 [3081285] MULTIPLAN INC [308128501] 113.05 percent of total billed charges 73.78 113.05 Technical (Hospital) Services Ref Zinc Serum PX-3018463001 CDM 84630 CPT 301 RC outpatient 119 119 BLUE CROSS BLUE SHIELD WELLMARK SB889 [3081026] BCBS WYOMING [308102603] 113.05 percent of total billed charges 73.78 113.05 Technical (Hospital) Services Ref Zinc Serum PX-3018463001 CDM 84630 CPT 301 RC outpatient 119 119 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES HDHP [308136802] 95.2 percent of total billed charges 73.78 113.05 Technical (Hospital) Services Ref Zinc Serum PX-3018463001 CDM 84630 CPT 301 RC outpatient 119 119 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES PPO [308136801] 95.2 percent of total billed charges 73.78 113.05 Technical (Hospital) Services Ref Zinc Serum PX-3018463001 CDM 84630 CPT 301 RC outpatient 119 119 HEALTHPARTNERS SX009 HEALTHPARTNERS 95.2 percent of total billed charges 73.78 113.05 Technical (Hospital) Services Ref Zinc Serum PX-3018463001 CDM 84630 CPT 301 RC outpatient 119 119 UNITED HEALTHCARE (COMMERCIAL) [3081199] UNITED HEALTHCARE 87726 [308119901] 73.78 percent of total billed charges 73.78 113.05 Technical (Hospital) Services Ref Zinc Serum PX-3018463001 CDM 84630 CPT 301 RC inpatient 119 119 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES PPO [308136801] 94.22 percent of total billed charges 73.78 113.05 Technical (Hospital) Services Ref Zinc Serum PX-3018463001 CDM 84630 CPT 301 RC inpatient 119 119 UNITED HEALTHCARE (COMMERCIAL) [3081199] UNITED HEALTHCARE 87726 [308119901] 73.78 percent of total billed charges 73.78 113.05 Technical (Hospital) Services Ref Zinc Serum PX-3018463001 CDM 84630 CPT 301 RC inpatient 119 119 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES HDHP [308136802] 94.22 percent of total billed charges 73.78 113.05 Technical (Hospital) Services Ref Zinc Serum PX-3018463001 CDM 84630 CPT 301 RC inpatient 119 119 BLUE CROSS BLUE SHIELD WELLMARK SB889 [3081026] BCBS WYOMING [308102603] 113.05 percent of total billed charges 73.78 113.05 Technical (Hospital) Services Ref Zinc Serum PX-3018463001 CDM 84630 CPT 301 RC inpatient 119 119 HEALTHPARTNERS SX009 HEALTHPARTNERS 94.22 percent of total billed charges 73.78 113.05 Technical (Hospital) Services Ref Zinc Serum PX-3018463001 CDM 84630 CPT 301 RC inpatient 119 119 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES EPO [308136803] 94.22 percent of total billed charges 73.78 113.05 Technical (Hospital) Services Ref Zinc Serum PX-3018463001 CDM 84630 CPT 301 RC inpatient 119 119 CIGNA 62308 [3081051] CIGNA 62308 [308105105] 94.22 percent of total billed charges 73.78 113.05 Technical (Hospital) Services Ref Zinc Serum PX-3018463001 CDM 84630 CPT 301 RC inpatient 119 119 CIGNA 62308 [3081051] CIGNA STATE OF WYOMING [308105107] 94.22 percent of total billed charges 73.78 113.05 Technical (Hospital) Services Ref Zinc Serum PX-3018463001 CDM 84630 CPT 301 RC inpatient 119 119 MEDICA (COMMERCIAL) 94265 [3081118] MEDICA CLAIMS [308111801] 107.1 percent of total billed charges 73.78 113.05 Technical (Hospital) Services Ref Zinc Serum PX-3018463001 CDM 84630 CPT 301 RC inpatient 119 119 MULTIPLAN INC 34080 [3081285] MULTIPLAN INC [308128501] 113.05 percent of total billed charges 73.78 113.05 Technical (Hospital) Services Ref Vitamin K1 PX-3018459701 CDM 84597 CPT 301 RC outpatient 268 268 BLUE CROSS BLUE SHIELD WELLMARK SB889 [3081026] BCBS WYOMING [308102603] 254.6 percent of total billed charges 166.16 254.6 Technical (Hospital) Services Ref Vitamin K1 PX-3018459701 CDM 84597 CPT 301 RC outpatient 268 268 MULTIPLAN INC 34080 [3081285] MULTIPLAN INC [308128501] 254.6 percent of total billed charges 166.16 254.6 Technical (Hospital) Services Ref Vitamin K1 PX-3018459701 CDM 84597 CPT 301 RC outpatient 268 268 CIGNA 62308 [3081051] CIGNA 62308 [308105105] 214.4 percent of total billed charges 166.16 254.6 Technical (Hospital) Services Ref Vitamin K1 PX-3018459701 CDM 84597 CPT 301 RC outpatient 268 268 CIGNA 62308 [3081051] CIGNA STATE OF WYOMING [308105107] 214.4 percent of total billed charges 166.16 254.6 Technical (Hospital) Services Ref Vitamin K1 PX-3018459701 CDM 84597 CPT 301 RC outpatient 268 268 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES EPO [308136803] 214.4 percent of total billed charges 166.16 254.6 Technical (Hospital) Services Ref Vitamin K1 PX-3018459701 CDM 84597 CPT 301 RC outpatient 268 268 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES HDHP [308136802] 214.4 percent of total billed charges 166.16 254.6 Technical (Hospital) Services Ref Vitamin K1 PX-3018459701 CDM 84597 CPT 301 RC outpatient 268 268 UNITED HEALTHCARE (COMMERCIAL) [3081199] UNITED HEALTHCARE 87726 [308119901] 166.16 percent of total billed charges 166.16 254.6 Technical (Hospital) Services Ref Vitamin K1 PX-3018459701 CDM 84597 CPT 301 RC outpatient 268 268 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES PPO [308136801] 214.4 percent of total billed charges 166.16 254.6 Technical (Hospital) Services Ref Vitamin K1 PX-3018459701 CDM 84597 CPT 301 RC outpatient 268 268 HEALTHPARTNERS SX009 HEALTHPARTNERS 214.4 percent of total billed charges 166.16 254.6 Technical (Hospital) Services Ref Vitamin K1 PX-3018459701 CDM 84597 CPT 301 RC outpatient 268 268 MEDICA (COMMERCIAL) 94265 [3081118] MEDICA CLAIMS [308111801] 241.2 percent of total billed charges 166.16 254.6 Technical (Hospital) Services Ref Vitamin K1 PX-3018459701 CDM 84597 CPT 301 RC inpatient 268 268 BLUE CROSS BLUE SHIELD WELLMARK SB889 [3081026] BCBS WYOMING [308102603] 254.6 percent of total billed charges 166.16 254.6 Technical (Hospital) Services Ref Vitamin K1 PX-3018459701 CDM 84597 CPT 301 RC inpatient 268 268 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES HDHP [308136802] 212.2 percent of total billed charges 166.16 254.6 Technical (Hospital) Services Ref Vitamin K1 PX-3018459701 CDM 84597 CPT 301 RC inpatient 268 268 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES PPO [308136801] 212.2 percent of total billed charges 166.16 254.6 Technical (Hospital) Services Ref Vitamin K1 PX-3018459701 CDM 84597 CPT 301 RC inpatient 268 268 UNITED HEALTHCARE (COMMERCIAL) [3081199] UNITED HEALTHCARE 87726 [308119901] 166.16 percent of total billed charges 166.16 254.6 Technical (Hospital) Services Ref Vitamin K1 PX-3018459701 CDM 84597 CPT 301 RC inpatient 268 268 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES EPO [308136803] 212.2 percent of total billed charges 166.16 254.6 Technical (Hospital) Services Ref Vitamin K1 PX-3018459701 CDM 84597 CPT 301 RC inpatient 268 268 HEALTHPARTNERS SX009 HEALTHPARTNERS 212.2 percent of total billed charges 166.16 254.6 Technical (Hospital) Services Ref Vitamin K1 PX-3018459701 CDM 84597 CPT 301 RC inpatient 268 268 MULTIPLAN INC 34080 [3081285] MULTIPLAN INC [308128501] 254.6 percent of total billed charges 166.16 254.6 Technical (Hospital) Services Ref Vitamin K1 PX-3018459701 CDM 84597 CPT 301 RC inpatient 268 268 MEDICA (COMMERCIAL) 94265 [3081118] MEDICA CLAIMS [308111801] 241.2 percent of total billed charges 166.16 254.6 Technical (Hospital) Services Ref Vitamin K1 PX-3018459701 CDM 84597 CPT 301 RC inpatient 268 268 CIGNA 62308 [3081051] CIGNA 62308 [308105105] 212.2 percent of total billed charges 166.16 254.6 Technical (Hospital) Services Ref Vitamin K1 PX-3018459701 CDM 84597 CPT 301 RC inpatient 268 268 CIGNA 62308 [3081051] CIGNA STATE OF WYOMING [308105107] 212.2 percent of total billed charges 166.16 254.6 Technical (Hospital) Services Ref Vitamin a Serum PX-3018459000 CDM 84590 CPT 301 RC inpatient 119 119 UNITED HEALTHCARE (COMMERCIAL) [3081199] UNITED HEALTHCARE 87726 [308119901] 73.78 percent of total billed charges 73.78 113.05 Technical (Hospital) Services Ref Vitamin a Serum PX-3018459000 CDM 84590 CPT 301 RC inpatient 119 119 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES PPO [308136801] 94.22 percent of total billed charges 73.78 113.05 Technical (Hospital) Services Ref Vitamin a Serum PX-3018459000 CDM 84590 CPT 301 RC inpatient 119 119 BLUE CROSS BLUE SHIELD WELLMARK SB889 [3081026] BCBS WYOMING [308102603] 113.05 percent of total billed charges 73.78 113.05 Technical (Hospital) Services Ref Vitamin a Serum PX-3018459000 CDM 84590 CPT 301 RC inpatient 119 119 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES HDHP [308136802] 94.22 percent of total billed charges 73.78 113.05 Technical (Hospital) Services Ref Vitamin a Serum PX-3018459000 CDM 84590 CPT 301 RC inpatient 119 119 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES EPO [308136803] 94.22 percent of total billed charges 73.78 113.05 Technical (Hospital) Services Ref Vitamin a Serum PX-3018459000 CDM 84590 CPT 301 RC inpatient 119 119 HEALTHPARTNERS SX009 HEALTHPARTNERS 94.22 percent of total billed charges 73.78 113.05 Technical (Hospital) Services Ref Vitamin a Serum PX-3018459000 CDM 84590 CPT 301 RC inpatient 119 119 MEDICA (COMMERCIAL) 94265 [3081118] MEDICA CLAIMS [308111801] 107.1 percent of total billed charges 73.78 113.05 Technical (Hospital) Services Ref Vitamin a Serum PX-3018459000 CDM 84590 CPT 301 RC inpatient 119 119 MULTIPLAN INC 34080 [3081285] MULTIPLAN INC [308128501] 113.05 percent of total billed charges 73.78 113.05 Technical (Hospital) Services Ref Vitamin a Serum PX-3018459000 CDM 84590 CPT 301 RC inpatient 119 119 CIGNA 62308 [3081051] CIGNA 62308 [308105105] 94.22 percent of total billed charges 73.78 113.05 Technical (Hospital) Services Ref Vitamin a Serum PX-3018459000 CDM 84590 CPT 301 RC inpatient 119 119 CIGNA 62308 [3081051] CIGNA STATE OF WYOMING [308105107] 94.22 percent of total billed charges 73.78 113.05 Technical (Hospital) Services Ref Vitamin a Serum PX-3018459000 CDM 84590 CPT 301 RC outpatient 119 119 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES PPO [308136801] 95.2 percent of total billed charges 73.78 113.05 Technical (Hospital) Services Ref Vitamin a Serum PX-3018459000 CDM 84590 CPT 301 RC outpatient 119 119 HEALTHPARTNERS SX009 HEALTHPARTNERS 95.2 percent of total billed charges 73.78 113.05 Technical (Hospital) Services Ref Vitamin a Serum PX-3018459000 CDM 84590 CPT 301 RC outpatient 119 119 UNITED HEALTHCARE (COMMERCIAL) [3081199] UNITED HEALTHCARE 87726 [308119901] 73.78 percent of total billed charges 73.78 113.05 Technical (Hospital) Services Ref Vitamin a Serum PX-3018459000 CDM 84590 CPT 301 RC outpatient 119 119 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES HDHP [308136802] 95.2 percent of total billed charges 73.78 113.05 Technical (Hospital) Services Ref Vitamin a Serum PX-3018459000 CDM 84590 CPT 301 RC outpatient 119 119 MULTIPLAN INC 34080 [3081285] MULTIPLAN INC [308128501] 113.05 percent of total billed charges 73.78 113.05 Technical (Hospital) Services Ref Vitamin a Serum PX-3018459000 CDM 84590 CPT 301 RC outpatient 119 119 BLUE CROSS BLUE SHIELD WELLMARK SB889 [3081026] BCBS WYOMING [308102603] 113.05 percent of total billed charges 73.78 113.05 Technical (Hospital) Services Ref Vitamin a Serum PX-3018459000 CDM 84590 CPT 301 RC outpatient 119 119 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES EPO [308136803] 95.2 percent of total billed charges 73.78 113.05 Technical (Hospital) Services Ref Vitamin a Serum PX-3018459000 CDM 84590 CPT 301 RC outpatient 119 119 CIGNA 62308 [3081051] CIGNA 62308 [308105105] 95.2 percent of total billed charges 73.78 113.05 Technical (Hospital) Services Ref Vitamin a Serum PX-3018459000 CDM 84590 CPT 301 RC outpatient 119 119 CIGNA 62308 [3081051] CIGNA STATE OF WYOMING [308105107] 95.2 percent of total billed charges 73.78 113.05 Technical (Hospital) Services Ref Vitamin a Serum PX-3018459000 CDM 84590 CPT 301 RC outpatient 119 119 MEDICA (COMMERCIAL) 94265 [3081118] MEDICA CLAIMS [308111801] 107.1 percent of total billed charges 73.78 113.05 Technical (Hospital) Services Ref Arginine Vasopressin PX-3018458800 CDM 84588 CPT 301 RC outpatient 459 459 MEDICA (COMMERCIAL) 94265 [3081118] MEDICA CLAIMS [308111801] 413.1 percent of total billed charges 284.58 436.05 Technical (Hospital) Services Ref Arginine Vasopressin PX-3018458800 CDM 84588 CPT 301 RC outpatient 459 459 UNITED HEALTHCARE (COMMERCIAL) [3081199] UNITED HEALTHCARE 87726 [308119901] 284.58 percent of total billed charges 284.58 436.05 Technical (Hospital) Services Ref Arginine Vasopressin PX-3018458800 CDM 84588 CPT 301 RC outpatient 459 459 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES PPO [308136801] 367.2 percent of total billed charges 284.58 436.05 Technical (Hospital) Services Ref Arginine Vasopressin PX-3018458800 CDM 84588 CPT 301 RC outpatient 459 459 HEALTHPARTNERS SX009 HEALTHPARTNERS 367.2 percent of total billed charges 284.58 436.05 Technical (Hospital) Services Ref Arginine Vasopressin PX-3018458800 CDM 84588 CPT 301 RC outpatient 459 459 CIGNA 62308 [3081051] CIGNA 62308 [308105105] 367.2 percent of total billed charges 284.58 436.05 Technical (Hospital) Services Ref Arginine Vasopressin PX-3018458800 CDM 84588 CPT 301 RC outpatient 459 459 CIGNA 62308 [3081051] CIGNA STATE OF WYOMING [308105107] 367.2 percent of total billed charges 284.58 436.05 Technical (Hospital) Services Ref Arginine Vasopressin PX-3018458800 CDM 84588 CPT 301 RC outpatient 459 459 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES EPO [308136803] 367.2 percent of total billed charges 284.58 436.05 Technical (Hospital) Services Ref Arginine Vasopressin PX-3018458800 CDM 84588 CPT 301 RC outpatient 459 459 MULTIPLAN INC 34080 [3081285] MULTIPLAN INC [308128501] 436.05 percent of total billed charges 284.58 436.05 Technical (Hospital) Services Ref Arginine Vasopressin PX-3018458800 CDM 84588 CPT 301 RC outpatient 459 459 BLUE CROSS BLUE SHIELD WELLMARK SB889 [3081026] BCBS WYOMING [308102603] 436.05 percent of total billed charges 284.58 436.05 Technical (Hospital) Services Ref Arginine Vasopressin PX-3018458800 CDM 84588 CPT 301 RC outpatient 459 459 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES HDHP [308136802] 367.2 percent of total billed charges 284.58 436.05 Technical (Hospital) Services Ref Arginine Vasopressin PX-3018458800 CDM 84588 CPT 301 RC inpatient 459 459 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES HDHP [308136802] 363.44 percent of total billed charges 284.58 436.05 Technical (Hospital) Services Ref Arginine Vasopressin PX-3018458800 CDM 84588 CPT 301 RC inpatient 459 459 BLUE CROSS BLUE SHIELD WELLMARK SB889 [3081026] BCBS WYOMING [308102603] 436.05 percent of total billed charges 284.58 436.05 Technical (Hospital) Services Ref Arginine Vasopressin PX-3018458800 CDM 84588 CPT 301 RC inpatient 459 459 UNITED HEALTHCARE (COMMERCIAL) [3081199] UNITED HEALTHCARE 87726 [308119901] 284.58 percent of total billed charges 284.58 436.05 Technical (Hospital) Services Ref Arginine Vasopressin PX-3018458800 CDM 84588 CPT 301 RC inpatient 459 459 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES PPO [308136801] 363.44 percent of total billed charges 284.58 436.05 Technical (Hospital) Services Ref Arginine Vasopressin PX-3018458800 CDM 84588 CPT 301 RC inpatient 459 459 HEALTHPARTNERS SX009 HEALTHPARTNERS 363.44 percent of total billed charges 284.58 436.05 Technical (Hospital) Services Ref Arginine Vasopressin PX-3018458800 CDM 84588 CPT 301 RC inpatient 459 459 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES EPO [308136803] 363.44 percent of total billed charges 284.58 436.05 Technical (Hospital) Services Ref Arginine Vasopressin PX-3018458800 CDM 84588 CPT 301 RC inpatient 459 459 CIGNA 62308 [3081051] CIGNA 62308 [308105105] 363.44 percent of total billed charges 284.58 436.05 Technical (Hospital) Services Ref Arginine Vasopressin PX-3018458800 CDM 84588 CPT 301 RC inpatient 459 459 CIGNA 62308 [3081051] CIGNA STATE OF WYOMING [308105107] 363.44 percent of total billed charges 284.58 436.05 Technical (Hospital) Services Ref Arginine Vasopressin PX-3018458800 CDM 84588 CPT 301 RC inpatient 459 459 MULTIPLAN INC 34080 [3081285] MULTIPLAN INC [308128501] 436.05 percent of total billed charges 284.58 436.05 Technical (Hospital) Services Ref Arginine Vasopressin PX-3018458800 CDM 84588 CPT 301 RC inpatient 459 459 MEDICA (COMMERCIAL) 94265 [3081118] MEDICA CLAIMS [308111801] 413.1 percent of total billed charges 284.58 436.05 Technical (Hospital) Services Ref Vanillymandelic Ac PX-3018458500 CDM 84585 CPT 301 RC outpatient 247 247 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES PPO [308136801] 197.6 percent of total billed charges 153.14 234.65 Technical (Hospital) Services Ref Vanillymandelic Ac PX-3018458500 CDM 84585 CPT 301 RC outpatient 247 247 HEALTHPARTNERS SX009 HEALTHPARTNERS 197.6 percent of total billed charges 153.14 234.65 Technical (Hospital) Services Ref Vanillymandelic Ac PX-3018458500 CDM 84585 CPT 301 RC outpatient 247 247 UNITED HEALTHCARE (COMMERCIAL) [3081199] UNITED HEALTHCARE 87726 [308119901] 153.14 percent of total billed charges 153.14 234.65 Technical (Hospital) Services Ref Vanillymandelic Ac PX-3018458500 CDM 84585 CPT 301 RC outpatient 247 247 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES HDHP [308136802] 197.6 percent of total billed charges 153.14 234.65 Technical (Hospital) Services Ref Vanillymandelic Ac PX-3018458500 CDM 84585 CPT 301 RC outpatient 247 247 BLUE CROSS BLUE SHIELD WELLMARK SB889 [3081026] BCBS WYOMING [308102603] 234.65 percent of total billed charges 153.14 234.65 Technical (Hospital) Services Ref Vanillymandelic Ac PX-3018458500 CDM 84585 CPT 301 RC outpatient 247 247 MULTIPLAN INC 34080 [3081285] MULTIPLAN INC [308128501] 234.65 percent of total billed charges 153.14 234.65 Technical (Hospital) Services Ref Vanillymandelic Ac PX-3018458500 CDM 84585 CPT 301 RC outpatient 247 247 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES EPO [308136803] 197.6 percent of total billed charges 153.14 234.65 Technical (Hospital) Services Ref Vanillymandelic Ac PX-3018458500 CDM 84585 CPT 301 RC outpatient 247 247 CIGNA 62308 [3081051] CIGNA 62308 [308105105] 197.6 percent of total billed charges 153.14 234.65 Technical (Hospital) Services Ref Vanillymandelic Ac PX-3018458500 CDM 84585 CPT 301 RC outpatient 247 247 CIGNA 62308 [3081051] CIGNA STATE OF WYOMING [308105107] 197.6 percent of total billed charges 153.14 234.65 Technical (Hospital) Services Ref Vanillymandelic Ac PX-3018458500 CDM 84585 CPT 301 RC outpatient 247 247 MEDICA (COMMERCIAL) 94265 [3081118] MEDICA CLAIMS [308111801] 222.3 percent of total billed charges 153.14 234.65 Technical (Hospital) Services Ref Vanillymandelic Ac PX-3018458500 CDM 84585 CPT 301 RC inpatient 247 247 BLUE CROSS BLUE SHIELD WELLMARK SB889 [3081026] BCBS WYOMING [308102603] 234.65 percent of total billed charges 153.14 234.65 Technical (Hospital) Services Ref Vanillymandelic Ac PX-3018458500 CDM 84585 CPT 301 RC inpatient 247 247 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES HDHP [308136802] 195.57 percent of total billed charges 153.14 234.65 Technical (Hospital) Services Ref Vanillymandelic Ac PX-3018458500 CDM 84585 CPT 301 RC inpatient 247 247 UNITED HEALTHCARE (COMMERCIAL) [3081199] UNITED HEALTHCARE 87726 [308119901] 153.14 percent of total billed charges 153.14 234.65 Technical (Hospital) Services Ref Vanillymandelic Ac PX-3018458500 CDM 84585 CPT 301 RC inpatient 247 247 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES PPO [308136801] 195.57 percent of total billed charges 153.14 234.65 Technical (Hospital) Services Ref Vanillymandelic Ac PX-3018458500 CDM 84585 CPT 301 RC inpatient 247 247 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES EPO [308136803] 195.57 percent of total billed charges 153.14 234.65 Technical (Hospital) Services Ref Vanillymandelic Ac PX-3018458500 CDM 84585 CPT 301 RC inpatient 247 247 HEALTHPARTNERS SX009 HEALTHPARTNERS 195.57 percent of total billed charges 153.14 234.65 Technical (Hospital) Services Ref Vanillymandelic Ac PX-3018458500 CDM 84585 CPT 301 RC inpatient 247 247 MEDICA (COMMERCIAL) 94265 [3081118] MEDICA CLAIMS [308111801] 222.3 percent of total billed charges 153.14 234.65 Technical (Hospital) Services Ref Vanillymandelic Ac PX-3018458500 CDM 84585 CPT 301 RC inpatient 247 247 MULTIPLAN INC 34080 [3081285] MULTIPLAN INC [308128501] 234.65 percent of total billed charges 153.14 234.65 Technical (Hospital) Services Ref Vanillymandelic Ac PX-3018458500 CDM 84585 CPT 301 RC inpatient 247 247 CIGNA 62308 [3081051] CIGNA 62308 [308105105] 195.57 percent of total billed charges 153.14 234.65 Technical (Hospital) Services Ref Vanillymandelic Ac PX-3018458500 CDM 84585 CPT 301 RC inpatient 247 247 CIGNA 62308 [3081051] CIGNA STATE OF WYOMING [308105107] 195.57 percent of total billed charges 153.14 234.65 Technical (Hospital) Services Assay of Urine/Uric Acid PX-3018456000 CDM 84560 CPT 301 RC inpatient 88 88 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES EPO [308136803] 69.68 percent of total billed charges 54.56 83.6 Technical (Hospital) Services Assay of Urine/Uric Acid PX-3018456000 CDM 84560 CPT 301 RC inpatient 88 88 HEALTHPARTNERS SX009 HEALTHPARTNERS 69.68 percent of total billed charges 54.56 83.6 Technical (Hospital) Services Assay of Urine/Uric Acid PX-3018456000 CDM 84560 CPT 301 RC inpatient 88 88 CIGNA 62308 [3081051] CIGNA 62308 [308105105] 69.68 percent of total billed charges 54.56 83.6 Technical (Hospital) Services Assay of Urine/Uric Acid PX-3018456000 CDM 84560 CPT 301 RC inpatient 88 88 CIGNA 62308 [3081051] CIGNA STATE OF WYOMING [308105107] 69.68 percent of total billed charges 54.56 83.6 Technical (Hospital) Services Assay of Urine/Uric Acid PX-3018456000 CDM 84560 CPT 301 RC inpatient 88 88 MULTIPLAN INC 34080 [3081285] MULTIPLAN INC [308128501] 83.6 percent of total billed charges 54.56 83.6 Technical (Hospital) Services Assay of Urine/Uric Acid PX-3018456000 CDM 84560 CPT 301 RC inpatient 88 88 MEDICA (COMMERCIAL) 94265 [3081118] MEDICA CLAIMS [308111801] 79.2 percent of total billed charges 54.56 83.6 Technical (Hospital) Services Assay of Urine/Uric Acid PX-3018456000 CDM 84560 CPT 301 RC inpatient 88 88 UNITED HEALTHCARE (COMMERCIAL) [3081199] UNITED HEALTHCARE 87726 [308119901] 54.56 percent of total billed charges 54.56 83.6 Technical (Hospital) Services Assay of Urine/Uric Acid PX-3018456000 CDM 84560 CPT 301 RC inpatient 88 88 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES PPO [308136801] 69.68 percent of total billed charges 54.56 83.6 Technical (Hospital) Services Assay of Urine/Uric Acid PX-3018456000 CDM 84560 CPT 301 RC inpatient 88 88 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES HDHP [308136802] 69.68 percent of total billed charges 54.56 83.6 Technical (Hospital) Services Assay of Urine/Uric Acid PX-3018456000 CDM 84560 CPT 301 RC inpatient 88 88 BLUE CROSS BLUE SHIELD WELLMARK SB889 [3081026] BCBS WYOMING [308102603] 83.6 percent of total billed charges 54.56 83.6 Technical (Hospital) Services Assay of Urine/Uric Acid PX-3018456000 CDM 84560 CPT 301 RC outpatient 88 88 UNITED HEALTHCARE (COMMERCIAL) [3081199] UNITED HEALTHCARE 87726 [308119901] 54.56 percent of total billed charges 54.56 83.6 Technical (Hospital) Services Assay of Urine/Uric Acid PX-3018456000 CDM 84560 CPT 301 RC outpatient 88 88 HEALTHPARTNERS SX009 HEALTHPARTNERS 70.4 percent of total billed charges 54.56 83.6 Technical (Hospital) Services Assay of Urine/Uric Acid PX-3018456000 CDM 84560 CPT 301 RC outpatient 88 88 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES PPO [308136801] 70.4 percent of total billed charges 54.56 83.6 Technical (Hospital) Services Assay of Urine/Uric Acid PX-3018456000 CDM 84560 CPT 301 RC outpatient 88 88 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES HDHP [308136802] 70.4 percent of total billed charges 54.56 83.6 Technical (Hospital) Services Assay of Urine/Uric Acid PX-3018456000 CDM 84560 CPT 301 RC outpatient 88 88 BLUE CROSS BLUE SHIELD WELLMARK SB889 [3081026] BCBS WYOMING [308102603] 83.6 percent of total billed charges 54.56 83.6 Technical (Hospital) Services Assay of Urine/Uric Acid PX-3018456000 CDM 84560 CPT 301 RC outpatient 88 88 MULTIPLAN INC 34080 [3081285] MULTIPLAN INC [308128501] 83.6 percent of total billed charges 54.56 83.6 Technical (Hospital) Services Assay of Urine/Uric Acid PX-3018456000 CDM 84560 CPT 301 RC outpatient 88 88 CIGNA 62308 [3081051] CIGNA 62308 [308105105] 70.4 percent of total billed charges 54.56 83.6 Technical (Hospital) Services Assay of Urine/Uric Acid PX-3018456000 CDM 84560 CPT 301 RC outpatient 88 88 CIGNA 62308 [3081051] CIGNA STATE OF WYOMING [308105107] 70.4 percent of total billed charges 54.56 83.6 Technical (Hospital) Services Assay of Urine/Uric Acid PX-3018456000 CDM 84560 CPT 301 RC outpatient 88 88 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES EPO [308136803] 70.4 percent of total billed charges 54.56 83.6 Technical (Hospital) Services Assay of Urine/Uric Acid PX-3018456000 CDM 84560 CPT 301 RC outpatient 88 88 MEDICA (COMMERCIAL) 94265 [3081118] MEDICA CLAIMS [308111801] 79.2 percent of total billed charges 54.56 83.6 Technical (Hospital) Services Uric Acid Blood PX-3018455000 CDM 84550 CPT 301 RC outpatient 97 97 MEDICA (COMMERCIAL) 94265 [3081118] MEDICA CLAIMS [308111801] 87.3 percent of total billed charges 60.14 92.15 Technical (Hospital) Services Uric Acid Blood PX-3018455000 CDM 84550 CPT 301 RC outpatient 97 97 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES PPO [308136801] 77.6 percent of total billed charges 60.14 92.15 Technical (Hospital) Services Uric Acid Blood PX-3018455000 CDM 84550 CPT 301 RC outpatient 97 97 HEALTHPARTNERS SX009 HEALTHPARTNERS 77.6 percent of total billed charges 60.14 92.15 Technical (Hospital) Services Uric Acid Blood PX-3018455000 CDM 84550 CPT 301 RC outpatient 97 97 UNITED HEALTHCARE (COMMERCIAL) [3081199] UNITED HEALTHCARE 87726 [308119901] 60.14 percent of total billed charges 60.14 92.15 Technical (Hospital) Services Uric Acid Blood PX-3018455000 CDM 84550 CPT 301 RC outpatient 97 97 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES HDHP [308136802] 77.6 percent of total billed charges 60.14 92.15 Technical (Hospital) Services Uric Acid Blood PX-3018455000 CDM 84550 CPT 301 RC outpatient 97 97 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES EPO [308136803] 77.6 percent of total billed charges 60.14 92.15 Technical (Hospital) Services Uric Acid Blood PX-3018455000 CDM 84550 CPT 301 RC outpatient 97 97 CIGNA 62308 [3081051] CIGNA 62308 [308105105] 77.6 percent of total billed charges 60.14 92.15 Technical (Hospital) Services Uric Acid Blood PX-3018455000 CDM 84550 CPT 301 RC outpatient 97 97 CIGNA 62308 [3081051] CIGNA STATE OF WYOMING [308105107] 77.6 percent of total billed charges 60.14 92.15 Technical (Hospital) Services Uric Acid Blood PX-3018455000 CDM 84550 CPT 301 RC outpatient 97 97 MULTIPLAN INC 34080 [3081285] MULTIPLAN INC [308128501] 92.15 percent of total billed charges 60.14 92.15 Technical (Hospital) Services Uric Acid Blood PX-3018455000 CDM 84550 CPT 301 RC outpatient 97 97 BLUE CROSS BLUE SHIELD WELLMARK SB889 [3081026] BCBS WYOMING [308102603] 92.15 percent of total billed charges 60.14 92.15 Technical (Hospital) Services Uric Acid Blood PX-3018455000 CDM 84550 CPT 301 RC inpatient 97 97 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES PPO [308136801] 76.8 percent of total billed charges 60.14 92.15 Technical (Hospital) Services Uric Acid Blood PX-3018455000 CDM 84550 CPT 301 RC inpatient 97 97 UNITED HEALTHCARE (COMMERCIAL) [3081199] UNITED HEALTHCARE 87726 [308119901] 60.14 percent of total billed charges 60.14 92.15 Technical (Hospital) Services Uric Acid Blood PX-3018455000 CDM 84550 CPT 301 RC inpatient 97 97 BLUE CROSS BLUE SHIELD WELLMARK SB889 [3081026] BCBS WYOMING [308102603] 92.15 percent of total billed charges 60.14 92.15 Technical (Hospital) Services Uric Acid Blood PX-3018455000 CDM 84550 CPT 301 RC inpatient 97 97 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES HDHP [308136802] 76.8 percent of total billed charges 60.14 92.15 Technical (Hospital) Services Uric Acid Blood PX-3018455000 CDM 84550 CPT 301 RC inpatient 97 97 CIGNA 62308 [3081051] CIGNA 62308 [308105105] 76.8 percent of total billed charges 60.14 92.15 Technical (Hospital) Services Uric Acid Blood PX-3018455000 CDM 84550 CPT 301 RC inpatient 97 97 CIGNA 62308 [3081051] CIGNA STATE OF WYOMING [308105107] 76.8 percent of total billed charges 60.14 92.15 Technical (Hospital) Services Uric Acid Blood PX-3018455000 CDM 84550 CPT 301 RC inpatient 97 97 MEDICA (COMMERCIAL) 94265 [3081118] MEDICA CLAIMS [308111801] 87.3 percent of total billed charges 60.14 92.15 Technical (Hospital) Services Uric Acid Blood PX-3018455000 CDM 84550 CPT 301 RC inpatient 97 97 MULTIPLAN INC 34080 [3081285] MULTIPLAN INC [308128501] 92.15 percent of total billed charges 60.14 92.15 Technical (Hospital) Services Uric Acid Blood PX-3018455000 CDM 84550 CPT 301 RC inpatient 97 97 HEALTHPARTNERS SX009 HEALTHPARTNERS 76.8 percent of total billed charges 60.14 92.15 Technical (Hospital) Services Uric Acid Blood PX-3018455000 CDM 84550 CPT 301 RC inpatient 97 97 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES EPO [308136803] 76.8 percent of total billed charges 60.14 92.15 Technical (Hospital) Services Urea N Urine PX-3018454000 CDM 84540 CPT 301 RC inpatient 90 90 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES HDHP [308136802] 71.26 percent of total billed charges 55.8 85.5 Technical (Hospital) Services Urea N Urine PX-3018454000 CDM 84540 CPT 301 RC inpatient 90 90 BLUE CROSS BLUE SHIELD WELLMARK SB889 [3081026] BCBS WYOMING [308102603] 85.5 percent of total billed charges 55.8 85.5 Technical (Hospital) Services Urea N Urine PX-3018454000 CDM 84540 CPT 301 RC inpatient 90 90 UNITED HEALTHCARE (COMMERCIAL) [3081199] UNITED HEALTHCARE 87726 [308119901] 55.8 percent of total billed charges 55.8 85.5 Technical (Hospital) Services Urea N Urine PX-3018454000 CDM 84540 CPT 301 RC inpatient 90 90 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES PPO [308136801] 71.26 percent of total billed charges 55.8 85.5 Technical (Hospital) Services Urea N Urine PX-3018454000 CDM 84540 CPT 301 RC inpatient 90 90 MULTIPLAN INC 34080 [3081285] MULTIPLAN INC [308128501] 85.5 percent of total billed charges 55.8 85.5 Technical (Hospital) Services Urea N Urine PX-3018454000 CDM 84540 CPT 301 RC inpatient 90 90 MEDICA (COMMERCIAL) 94265 [3081118] MEDICA CLAIMS [308111801] 81 percent of total billed charges 55.8 85.5 Technical (Hospital) Services Urea N Urine PX-3018454000 CDM 84540 CPT 301 RC inpatient 90 90 CIGNA 62308 [3081051] CIGNA 62308 [308105105] 71.26 percent of total billed charges 55.8 85.5 Technical (Hospital) Services Urea N Urine PX-3018454000 CDM 84540 CPT 301 RC inpatient 90 90 CIGNA 62308 [3081051] CIGNA STATE OF WYOMING [308105107] 71.26 percent of total billed charges 55.8 85.5 Technical (Hospital) Services Urea N Urine PX-3018454000 CDM 84540 CPT 301 RC inpatient 90 90 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES EPO [308136803] 71.26 percent of total billed charges 55.8 85.5 Technical (Hospital) Services Urea N Urine PX-3018454000 CDM 84540 CPT 301 RC inpatient 90 90 HEALTHPARTNERS SX009 HEALTHPARTNERS 71.26 percent of total billed charges 55.8 85.5 Technical (Hospital) Services Urea N Urine PX-3018454000 CDM 84540 CPT 301 RC outpatient 90 90 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES HDHP [308136802] 72 percent of total billed charges 55.8 85.5 Technical (Hospital) Services Urea N Urine PX-3018454000 CDM 84540 CPT 301 RC outpatient 90 90 BLUE CROSS BLUE SHIELD WELLMARK SB889 [3081026] BCBS WYOMING [308102603] 85.5 percent of total billed charges 55.8 85.5 Technical (Hospital) Services Urea N Urine PX-3018454000 CDM 84540 CPT 301 RC outpatient 90 90 MULTIPLAN INC 34080 [3081285] MULTIPLAN INC [308128501] 85.5 percent of total billed charges 55.8 85.5 Technical (Hospital) Services Urea N Urine PX-3018454000 CDM 84540 CPT 301 RC outpatient 90 90 CIGNA 62308 [3081051] CIGNA 62308 [308105105] 72 percent of total billed charges 55.8 85.5 Technical (Hospital) Services Urea N Urine PX-3018454000 CDM 84540 CPT 301 RC outpatient 90 90 CIGNA 62308 [3081051] CIGNA STATE OF WYOMING [308105107] 72 percent of total billed charges 55.8 85.5 Technical (Hospital) Services Urea N Urine PX-3018454000 CDM 84540 CPT 301 RC outpatient 90 90 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES EPO [308136803] 72 percent of total billed charges 55.8 85.5 Technical (Hospital) Services Urea N Urine PX-3018454000 CDM 84540 CPT 301 RC outpatient 90 90 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES PPO [308136801] 72 percent of total billed charges 55.8 85.5 Technical (Hospital) Services Urea N Urine PX-3018454000 CDM 84540 CPT 301 RC outpatient 90 90 HEALTHPARTNERS SX009 HEALTHPARTNERS 72 percent of total billed charges 55.8 85.5 Technical (Hospital) Services Urea N Urine PX-3018454000 CDM 84540 CPT 301 RC outpatient 90 90 UNITED HEALTHCARE (COMMERCIAL) [3081199] UNITED HEALTHCARE 87726 [308119901] 55.8 percent of total billed charges 55.8 85.5 Technical (Hospital) Services Urea N Urine PX-3018454000 CDM 84540 CPT 301 RC outpatient 90 90 MEDICA (COMMERCIAL) 94265 [3081118] MEDICA CLAIMS [308111801] 81 percent of total billed charges 55.8 85.5 Technical (Hospital) Services BUN PX-3018452000 CDM 84520 CPT 301 RC inpatient 88 88 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES PPO [308136801] 69.68 percent of total billed charges 54.56 83.6 Technical (Hospital) Services BUN PX-3018452000 CDM 84520 CPT 301 RC inpatient 88 88 UNITED HEALTHCARE (COMMERCIAL) [3081199] UNITED HEALTHCARE 87726 [308119901] 54.56 percent of total billed charges 54.56 83.6 Technical (Hospital) Services BUN PX-3018452000 CDM 84520 CPT 301 RC inpatient 88 88 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES HDHP [308136802] 69.68 percent of total billed charges 54.56 83.6 Technical (Hospital) Services BUN PX-3018452000 CDM 84520 CPT 301 RC inpatient 88 88 BLUE CROSS BLUE SHIELD WELLMARK SB889 [3081026] BCBS WYOMING [308102603] 83.6 percent of total billed charges 54.56 83.6 Technical (Hospital) Services BUN PX-3018452000 CDM 84520 CPT 301 RC inpatient 88 88 MEDICA (COMMERCIAL) 94265 [3081118] MEDICA CLAIMS [308111801] 79.2 percent of total billed charges 54.56 83.6 Technical (Hospital) Services BUN PX-3018452000 CDM 84520 CPT 301 RC inpatient 88 88 MULTIPLAN INC 34080 [3081285] MULTIPLAN INC [308128501] 83.6 percent of total billed charges 54.56 83.6 Technical (Hospital) Services BUN PX-3018452000 CDM 84520 CPT 301 RC inpatient 88 88 CIGNA 62308 [3081051] CIGNA 62308 [308105105] 69.68 percent of total billed charges 54.56 83.6 Technical (Hospital) Services BUN PX-3018452000 CDM 84520 CPT 301 RC inpatient 88 88 CIGNA 62308 [3081051] CIGNA STATE OF WYOMING [308105107] 69.68 percent of total billed charges 54.56 83.6 Technical (Hospital) Services BUN PX-3018452000 CDM 84520 CPT 301 RC inpatient 88 88 HEALTHPARTNERS SX009 HEALTHPARTNERS 69.68 percent of total billed charges 54.56 83.6 Technical (Hospital) Services BUN PX-3018452000 CDM 84520 CPT 301 RC inpatient 88 88 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES EPO [308136803] 69.68 percent of total billed charges 54.56 83.6 Technical (Hospital) Services BUN PX-3018452000 CDM 84520 CPT 301 RC outpatient 88 88 MULTIPLAN INC 34080 [3081285] MULTIPLAN INC [308128501] 83.6 percent of total billed charges 54.56 83.6 Technical (Hospital) Services BUN PX-3018452000 CDM 84520 CPT 301 RC outpatient 88 88 BLUE CROSS BLUE SHIELD WELLMARK SB889 [3081026] BCBS WYOMING [308102603] 83.6 percent of total billed charges 54.56 83.6 Technical (Hospital) Services BUN PX-3018452000 CDM 84520 CPT 301 RC outpatient 88 88 CIGNA 62308 [3081051] CIGNA 62308 [308105105] 70.4 percent of total billed charges 54.56 83.6 Technical (Hospital) Services BUN PX-3018452000 CDM 84520 CPT 301 RC outpatient 88 88 CIGNA 62308 [3081051] CIGNA STATE OF WYOMING [308105107] 70.4 percent of total billed charges 54.56 83.6 Technical (Hospital) Services BUN PX-3018452000 CDM 84520 CPT 301 RC outpatient 88 88 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES EPO [308136803] 70.4 percent of total billed charges 54.56 83.6 Technical (Hospital) Services BUN PX-3018452000 CDM 84520 CPT 301 RC outpatient 88 88 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES HDHP [308136802] 70.4 percent of total billed charges 54.56 83.6 Technical (Hospital) Services BUN PX-3018452000 CDM 84520 CPT 301 RC outpatient 88 88 UNITED HEALTHCARE (COMMERCIAL) [3081199] UNITED HEALTHCARE 87726 [308119901] 54.56 percent of total billed charges 54.56 83.6 Technical (Hospital) Services BUN PX-3018452000 CDM 84520 CPT 301 RC outpatient 88 88 HEALTHPARTNERS SX009 HEALTHPARTNERS 70.4 percent of total billed charges 54.56 83.6 Technical (Hospital) Services BUN PX-3018452000 CDM 84520 CPT 301 RC outpatient 88 88 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES PPO [308136801] 70.4 percent of total billed charges 54.56 83.6 Technical (Hospital) Services BUN PX-3018452000 CDM 84520 CPT 301 RC outpatient 88 88 MEDICA (COMMERCIAL) 94265 [3081118] MEDICA CLAIMS [308111801] 79.2 percent of total billed charges 54.56 83.6 Technical (Hospital) Services "Ref Tyrosine, P (Mayo)" PX-3018451000 CDM 84510 CPT 301 RC inpatient 216 216 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES PPO [308136801] 171.03 percent of total billed charges 133.92 205.2 Technical (Hospital) Services "Ref Tyrosine, P (Mayo)" PX-3018451000 CDM 84510 CPT 301 RC inpatient 216 216 UNITED HEALTHCARE (COMMERCIAL) [3081199] UNITED HEALTHCARE 87726 [308119901] 133.92 percent of total billed charges 133.92 205.2 Technical (Hospital) Services "Ref Tyrosine, P (Mayo)" PX-3018451000 CDM 84510 CPT 301 RC inpatient 216 216 BLUE CROSS BLUE SHIELD WELLMARK SB889 [3081026] BCBS WYOMING [308102603] 205.2 percent of total billed charges 133.92 205.2 Technical (Hospital) Services "Ref Tyrosine, P (Mayo)" PX-3018451000 CDM 84510 CPT 301 RC inpatient 216 216 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES HDHP [308136802] 171.03 percent of total billed charges 133.92 205.2 Technical (Hospital) Services "Ref Tyrosine, P (Mayo)" PX-3018451000 CDM 84510 CPT 301 RC inpatient 216 216 HEALTHPARTNERS SX009 HEALTHPARTNERS 171.03 percent of total billed charges 133.92 205.2 Technical (Hospital) Services "Ref Tyrosine, P (Mayo)" PX-3018451000 CDM 84510 CPT 301 RC inpatient 216 216 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES EPO [308136803] 171.03 percent of total billed charges 133.92 205.2 Technical (Hospital) Services "Ref Tyrosine, P (Mayo)" PX-3018451000 CDM 84510 CPT 301 RC inpatient 216 216 CIGNA 62308 [3081051] CIGNA 62308 [308105105] 171.03 percent of total billed charges 133.92 205.2 Technical (Hospital) Services "Ref Tyrosine, P (Mayo)" PX-3018451000 CDM 84510 CPT 301 RC inpatient 216 216 CIGNA 62308 [3081051] CIGNA STATE OF WYOMING [308105107] 171.03 percent of total billed charges 133.92 205.2 Technical (Hospital) Services "Ref Tyrosine, P (Mayo)" PX-3018451000 CDM 84510 CPT 301 RC inpatient 216 216 MEDICA (COMMERCIAL) 94265 [3081118] MEDICA CLAIMS [308111801] 194.4 percent of total billed charges 133.92 205.2 Technical (Hospital) Services "Ref Tyrosine, P (Mayo)" PX-3018451000 CDM 84510 CPT 301 RC inpatient 216 216 MULTIPLAN INC 34080 [3081285] MULTIPLAN INC [308128501] 205.2 percent of total billed charges 133.92 205.2 Technical (Hospital) Services "Ref Tyrosine, P (Mayo)" PX-3018451000 CDM 84510 CPT 301 RC outpatient 216 216 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES HDHP [308136802] 172.8 percent of total billed charges 133.92 205.2 Technical (Hospital) Services "Ref Tyrosine, P (Mayo)" PX-3018451000 CDM 84510 CPT 301 RC outpatient 216 216 CIGNA 62308 [3081051] CIGNA 62308 [308105105] 172.8 percent of total billed charges 133.92 205.2 Technical (Hospital) Services "Ref Tyrosine, P (Mayo)" PX-3018451000 CDM 84510 CPT 301 RC outpatient 216 216 CIGNA 62308 [3081051] CIGNA STATE OF WYOMING [308105107] 172.8 percent of total billed charges 133.92 205.2 Technical (Hospital) Services "Ref Tyrosine, P (Mayo)" PX-3018451000 CDM 84510 CPT 301 RC outpatient 216 216 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES EPO [308136803] 172.8 percent of total billed charges 133.92 205.2 Technical (Hospital) Services "Ref Tyrosine, P (Mayo)" PX-3018451000 CDM 84510 CPT 301 RC outpatient 216 216 MULTIPLAN INC 34080 [3081285] MULTIPLAN INC [308128501] 205.2 percent of total billed charges 133.92 205.2 Technical (Hospital) Services "Ref Tyrosine, P (Mayo)" PX-3018451000 CDM 84510 CPT 301 RC outpatient 216 216 BLUE CROSS BLUE SHIELD WELLMARK SB889 [3081026] BCBS WYOMING [308102603] 205.2 percent of total billed charges 133.92 205.2 Technical (Hospital) Services "Ref Tyrosine, P (Mayo)" PX-3018451000 CDM 84510 CPT 301 RC outpatient 216 216 HEALTHPARTNERS SX009 HEALTHPARTNERS 172.8 percent of total billed charges 133.92 205.2 Technical (Hospital) Services "Ref Tyrosine, P (Mayo)" PX-3018451000 CDM 84510 CPT 301 RC outpatient 216 216 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES PPO [308136801] 172.8 percent of total billed charges 133.92 205.2 Technical (Hospital) Services "Ref Tyrosine, P (Mayo)" PX-3018451000 CDM 84510 CPT 301 RC outpatient 216 216 UNITED HEALTHCARE (COMMERCIAL) [3081199] UNITED HEALTHCARE 87726 [308119901] 133.92 percent of total billed charges 133.92 205.2 Technical (Hospital) Services "Ref Tyrosine, P (Mayo)" PX-3018451000 CDM 84510 CPT 301 RC outpatient 216 216 MEDICA (COMMERCIAL) 94265 [3081118] MEDICA CLAIMS [308111801] 194.4 percent of total billed charges 133.92 205.2 Technical (Hospital) Services Troponin I PX-3018448400 CDM 84484 CPT 301 RC inpatient 133 133 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES PPO [308136801] 105.31 percent of total billed charges 82.46 126.35 Technical (Hospital) Services Troponin I PX-3018448400 CDM 84484 CPT 301 RC inpatient 133 133 UNITED HEALTHCARE (COMMERCIAL) [3081199] UNITED HEALTHCARE 87726 [308119901] 82.46 percent of total billed charges 82.46 126.35 Technical (Hospital) Services Troponin I PX-3018448400 CDM 84484 CPT 301 RC inpatient 133 133 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES HDHP [308136802] 105.31 percent of total billed charges 82.46 126.35 Technical (Hospital) Services Troponin I PX-3018448400 CDM 84484 CPT 301 RC inpatient 133 133 BLUE CROSS BLUE SHIELD WELLMARK SB889 [3081026] BCBS WYOMING [308102603] 126.35 percent of total billed charges 82.46 126.35 Technical (Hospital) Services Troponin I PX-3018448400 CDM 84484 CPT 301 RC inpatient 133 133 CIGNA 62308 [3081051] CIGNA 62308 [308105105] 105.31 percent of total billed charges 82.46 126.35 Technical (Hospital) Services Troponin I PX-3018448400 CDM 84484 CPT 301 RC inpatient 133 133 CIGNA 62308 [3081051] CIGNA STATE OF WYOMING [308105107] 105.31 percent of total billed charges 82.46 126.35 Technical (Hospital) Services Troponin I PX-3018448400 CDM 84484 CPT 301 RC inpatient 133 133 MEDICA (COMMERCIAL) 94265 [3081118] MEDICA CLAIMS [308111801] 119.7 percent of total billed charges 82.46 126.35 Technical (Hospital) Services Troponin I PX-3018448400 CDM 84484 CPT 301 RC inpatient 133 133 MULTIPLAN INC 34080 [3081285] MULTIPLAN INC [308128501] 126.35 percent of total billed charges 82.46 126.35 Technical (Hospital) Services Troponin I PX-3018448400 CDM 84484 CPT 301 RC inpatient 133 133 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES EPO [308136803] 105.31 percent of total billed charges 82.46 126.35 Technical (Hospital) Services Troponin I PX-3018448400 CDM 84484 CPT 301 RC inpatient 133 133 HEALTHPARTNERS SX009 HEALTHPARTNERS 105.31 percent of total billed charges 82.46 126.35 Technical (Hospital) Services Troponin I PX-3018448400 CDM 84484 CPT 301 RC outpatient 133 133 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES HDHP [308136802] 106.4 percent of total billed charges 82.46 126.35 Technical (Hospital) Services Troponin I PX-3018448400 CDM 84484 CPT 301 RC outpatient 133 133 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES EPO [308136803] 106.4 percent of total billed charges 82.46 126.35 Technical (Hospital) Services Troponin I PX-3018448400 CDM 84484 CPT 301 RC outpatient 133 133 CIGNA 62308 [3081051] CIGNA 62308 [308105105] 106.4 percent of total billed charges 82.46 126.35 Technical (Hospital) Services Troponin I PX-3018448400 CDM 84484 CPT 301 RC outpatient 133 133 CIGNA 62308 [3081051] CIGNA STATE OF WYOMING [308105107] 106.4 percent of total billed charges 82.46 126.35 Technical (Hospital) Services Troponin I PX-3018448400 CDM 84484 CPT 301 RC outpatient 133 133 MULTIPLAN INC 34080 [3081285] MULTIPLAN INC [308128501] 126.35 percent of total billed charges 82.46 126.35 Technical (Hospital) Services Troponin I PX-3018448400 CDM 84484 CPT 301 RC outpatient 133 133 BLUE CROSS BLUE SHIELD WELLMARK SB889 [3081026] BCBS WYOMING [308102603] 126.35 percent of total billed charges 82.46 126.35 Technical (Hospital) Services Troponin I PX-3018448400 CDM 84484 CPT 301 RC outpatient 133 133 HEALTHPARTNERS SX009 HEALTHPARTNERS 106.4 percent of total billed charges 82.46 126.35 Technical (Hospital) Services Troponin I PX-3018448400 CDM 84484 CPT 301 RC outpatient 133 133 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES PPO [308136801] 106.4 percent of total billed charges 82.46 126.35 Technical (Hospital) Services Troponin I PX-3018448400 CDM 84484 CPT 301 RC outpatient 133 133 UNITED HEALTHCARE (COMMERCIAL) [3081199] UNITED HEALTHCARE 87726 [308119901] 82.46 percent of total billed charges 82.46 126.35 Technical (Hospital) Services Troponin I PX-3018448400 CDM 84484 CPT 301 RC outpatient 133 133 MEDICA (COMMERCIAL) 94265 [3081118] MEDICA CLAIMS [308111801] 119.7 percent of total billed charges 82.46 126.35 Technical (Hospital) Services Ref T3 Teiodothyronine Reverse PX-3018448200 CDM 84482 CPT 301 RC inpatient 258 258 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES PPO [308136801] 204.28 percent of total billed charges 159.96 245.1 Technical (Hospital) Services Ref T3 Teiodothyronine Reverse PX-3018448200 CDM 84482 CPT 301 RC inpatient 258 258 UNITED HEALTHCARE (COMMERCIAL) [3081199] UNITED HEALTHCARE 87726 [308119901] 159.96 percent of total billed charges 159.96 245.1 Technical (Hospital) Services Ref T3 Teiodothyronine Reverse PX-3018448200 CDM 84482 CPT 301 RC inpatient 258 258 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES HDHP [308136802] 204.28 percent of total billed charges 159.96 245.1 Technical (Hospital) Services Ref T3 Teiodothyronine Reverse PX-3018448200 CDM 84482 CPT 301 RC inpatient 258 258 BLUE CROSS BLUE SHIELD WELLMARK SB889 [3081026] BCBS WYOMING [308102603] 245.1 percent of total billed charges 159.96 245.1 Technical (Hospital) Services Ref T3 Teiodothyronine Reverse PX-3018448200 CDM 84482 CPT 301 RC inpatient 258 258 HEALTHPARTNERS SX009 HEALTHPARTNERS 204.28 percent of total billed charges 159.96 245.1 Technical (Hospital) Services Ref T3 Teiodothyronine Reverse PX-3018448200 CDM 84482 CPT 301 RC inpatient 258 258 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES EPO [308136803] 204.28 percent of total billed charges 159.96 245.1 Technical (Hospital) Services Ref T3 Teiodothyronine Reverse PX-3018448200 CDM 84482 CPT 301 RC inpatient 258 258 MULTIPLAN INC 34080 [3081285] MULTIPLAN INC [308128501] 245.1 percent of total billed charges 159.96 245.1 Technical (Hospital) Services Ref T3 Teiodothyronine Reverse PX-3018448200 CDM 84482 CPT 301 RC inpatient 258 258 MEDICA (COMMERCIAL) 94265 [3081118] MEDICA CLAIMS [308111801] 232.2 percent of total billed charges 159.96 245.1 Technical (Hospital) Services Ref T3 Teiodothyronine Reverse PX-3018448200 CDM 84482 CPT 301 RC inpatient 258 258 CIGNA 62308 [3081051] CIGNA 62308 [308105105] 204.28 percent of total billed charges 159.96 245.1 Technical (Hospital) Services Ref T3 Teiodothyronine Reverse PX-3018448200 CDM 84482 CPT 301 RC inpatient 258 258 CIGNA 62308 [3081051] CIGNA STATE OF WYOMING [308105107] 204.28 percent of total billed charges 159.96 245.1 Technical (Hospital) Services Ref T3 Teiodothyronine Reverse PX-3018448200 CDM 84482 CPT 301 RC outpatient 258 258 MEDICA (COMMERCIAL) 94265 [3081118] MEDICA CLAIMS [308111801] 232.2 percent of total billed charges 159.96 245.1 Technical (Hospital) Services Ref T3 Teiodothyronine Reverse PX-3018448200 CDM 84482 CPT 301 RC outpatient 258 258 HEALTHPARTNERS SX009 HEALTHPARTNERS 206.4 percent of total billed charges 159.96 245.1 Technical (Hospital) Services Ref T3 Teiodothyronine Reverse PX-3018448200 CDM 84482 CPT 301 RC outpatient 258 258 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES PPO [308136801] 206.4 percent of total billed charges 159.96 245.1 Technical (Hospital) Services Ref T3 Teiodothyronine Reverse PX-3018448200 CDM 84482 CPT 301 RC outpatient 258 258 UNITED HEALTHCARE (COMMERCIAL) [3081199] UNITED HEALTHCARE 87726 [308119901] 159.96 percent of total billed charges 159.96 245.1 Technical (Hospital) Services Ref T3 Teiodothyronine Reverse PX-3018448200 CDM 84482 CPT 301 RC outpatient 258 258 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES EPO [308136803] 206.4 percent of total billed charges 159.96 245.1 Technical (Hospital) Services Ref T3 Teiodothyronine Reverse PX-3018448200 CDM 84482 CPT 301 RC outpatient 258 258 CIGNA 62308 [3081051] CIGNA 62308 [308105105] 206.4 percent of total billed charges 159.96 245.1 Technical (Hospital) Services Ref T3 Teiodothyronine Reverse PX-3018448200 CDM 84482 CPT 301 RC outpatient 258 258 CIGNA 62308 [3081051] CIGNA STATE OF WYOMING [308105107] 206.4 percent of total billed charges 159.96 245.1 Technical (Hospital) Services Ref T3 Teiodothyronine Reverse PX-3018448200 CDM 84482 CPT 301 RC outpatient 258 258 BLUE CROSS BLUE SHIELD WELLMARK SB889 [3081026] BCBS WYOMING [308102603] 245.1 percent of total billed charges 159.96 245.1 Technical (Hospital) Services Ref T3 Teiodothyronine Reverse PX-3018448200 CDM 84482 CPT 301 RC outpatient 258 258 MULTIPLAN INC 34080 [3081285] MULTIPLAN INC [308128501] 245.1 percent of total billed charges 159.96 245.1 Technical (Hospital) Services Ref T3 Teiodothyronine Reverse PX-3018448200 CDM 84482 CPT 301 RC outpatient 258 258 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES HDHP [308136802] 206.4 percent of total billed charges 159.96 245.1 Technical (Hospital) Services Ref T3 Triiodothyronine Reverse PX-3018448201 CDM 84482 CPT 301 RC outpatient 360 360 MEDICA (COMMERCIAL) 94265 [3081118] MEDICA CLAIMS [308111801] 324 percent of total billed charges 223.2 342 Technical (Hospital) Services Ref T3 Triiodothyronine Reverse PX-3018448201 CDM 84482 CPT 301 RC outpatient 360 360 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES EPO [308136803] 288 percent of total billed charges 223.2 342 Technical (Hospital) Services Ref T3 Triiodothyronine Reverse PX-3018448201 CDM 84482 CPT 301 RC outpatient 360 360 CIGNA 62308 [3081051] CIGNA 62308 [308105105] 288 percent of total billed charges 223.2 342 Technical (Hospital) Services Ref T3 Triiodothyronine Reverse PX-3018448201 CDM 84482 CPT 301 RC outpatient 360 360 CIGNA 62308 [3081051] CIGNA STATE OF WYOMING [308105107] 288 percent of total billed charges 223.2 342 Technical (Hospital) Services Ref T3 Triiodothyronine Reverse PX-3018448201 CDM 84482 CPT 301 RC outpatient 360 360 BLUE CROSS BLUE SHIELD WELLMARK SB889 [3081026] BCBS WYOMING [308102603] 342 percent of total billed charges 223.2 342 Technical (Hospital) Services Ref T3 Triiodothyronine Reverse PX-3018448201 CDM 84482 CPT 301 RC outpatient 360 360 MULTIPLAN INC 34080 [3081285] MULTIPLAN INC [308128501] 342 percent of total billed charges 223.2 342 Technical (Hospital) Services Ref T3 Triiodothyronine Reverse PX-3018448201 CDM 84482 CPT 301 RC outpatient 360 360 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES HDHP [308136802] 288 percent of total billed charges 223.2 342 Technical (Hospital) Services Ref T3 Triiodothyronine Reverse PX-3018448201 CDM 84482 CPT 301 RC outpatient 360 360 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES PPO [308136801] 288 percent of total billed charges 223.2 342 Technical (Hospital) Services Ref T3 Triiodothyronine Reverse PX-3018448201 CDM 84482 CPT 301 RC outpatient 360 360 HEALTHPARTNERS SX009 HEALTHPARTNERS 288 percent of total billed charges 223.2 342 Technical (Hospital) Services Ref T3 Triiodothyronine Reverse PX-3018448201 CDM 84482 CPT 301 RC outpatient 360 360 UNITED HEALTHCARE (COMMERCIAL) [3081199] UNITED HEALTHCARE 87726 [308119901] 223.2 percent of total billed charges 223.2 342 Technical (Hospital) Services Ref T3 Triiodothyronine Reverse PX-3018448201 CDM 84482 CPT 301 RC inpatient 360 360 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES EPO [308136803] 285.05 percent of total billed charges 223.2 342 Technical (Hospital) Services Ref T3 Triiodothyronine Reverse PX-3018448201 CDM 84482 CPT 301 RC inpatient 360 360 HEALTHPARTNERS SX009 HEALTHPARTNERS 285.05 percent of total billed charges 223.2 342 Technical (Hospital) Services Ref T3 Triiodothyronine Reverse PX-3018448201 CDM 84482 CPT 301 RC inpatient 360 360 CIGNA 62308 [3081051] CIGNA 62308 [308105105] 285.05 percent of total billed charges 223.2 342 Technical (Hospital) Services Ref T3 Triiodothyronine Reverse PX-3018448201 CDM 84482 CPT 301 RC inpatient 360 360 CIGNA 62308 [3081051] CIGNA STATE OF WYOMING [308105107] 285.05 percent of total billed charges 223.2 342 Technical (Hospital) Services Ref T3 Triiodothyronine Reverse PX-3018448201 CDM 84482 CPT 301 RC inpatient 360 360 MULTIPLAN INC 34080 [3081285] MULTIPLAN INC [308128501] 342 percent of total billed charges 223.2 342 Technical (Hospital) Services Ref T3 Triiodothyronine Reverse PX-3018448201 CDM 84482 CPT 301 RC inpatient 360 360 MEDICA (COMMERCIAL) 94265 [3081118] MEDICA CLAIMS [308111801] 324 percent of total billed charges 223.2 342 Technical (Hospital) Services Ref T3 Triiodothyronine Reverse PX-3018448201 CDM 84482 CPT 301 RC inpatient 360 360 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES PPO [308136801] 285.05 percent of total billed charges 223.2 342 Technical (Hospital) Services Ref T3 Triiodothyronine Reverse PX-3018448201 CDM 84482 CPT 301 RC inpatient 360 360 UNITED HEALTHCARE (COMMERCIAL) [3081199] UNITED HEALTHCARE 87726 [308119901] 223.2 percent of total billed charges 223.2 342 Technical (Hospital) Services Ref T3 Triiodothyronine Reverse PX-3018448201 CDM 84482 CPT 301 RC inpatient 360 360 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES HDHP [308136802] 285.05 percent of total billed charges 223.2 342 Technical (Hospital) Services Ref T3 Triiodothyronine Reverse PX-3018448201 CDM 84482 CPT 301 RC inpatient 360 360 BLUE CROSS BLUE SHIELD WELLMARK SB889 [3081026] BCBS WYOMING [308102603] 342 percent of total billed charges 223.2 342 Technical (Hospital) Services T3 Triiodothyronine Free PX-3018448100 CDM 84481 CPT 301 RC inpatient 274 274 CIGNA 62308 [3081051] CIGNA 62308 [308105105] 216.95 percent of total billed charges 169.88 260.3 Technical (Hospital) Services T3 Triiodothyronine Free PX-3018448100 CDM 84481 CPT 301 RC inpatient 274 274 CIGNA 62308 [3081051] CIGNA STATE OF WYOMING [308105107] 216.95 percent of total billed charges 169.88 260.3 Technical (Hospital) Services T3 Triiodothyronine Free PX-3018448100 CDM 84481 CPT 301 RC inpatient 274 274 MEDICA (COMMERCIAL) 94265 [3081118] MEDICA CLAIMS [308111801] 246.6 percent of total billed charges 169.88 260.3 Technical (Hospital) Services T3 Triiodothyronine Free PX-3018448100 CDM 84481 CPT 301 RC inpatient 274 274 MULTIPLAN INC 34080 [3081285] MULTIPLAN INC [308128501] 260.3 percent of total billed charges 169.88 260.3 Technical (Hospital) Services T3 Triiodothyronine Free PX-3018448100 CDM 84481 CPT 301 RC inpatient 274 274 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES EPO [308136803] 216.95 percent of total billed charges 169.88 260.3 Technical (Hospital) Services T3 Triiodothyronine Free PX-3018448100 CDM 84481 CPT 301 RC inpatient 274 274 HEALTHPARTNERS SX009 HEALTHPARTNERS 216.95 percent of total billed charges 169.88 260.3 Technical (Hospital) Services T3 Triiodothyronine Free PX-3018448100 CDM 84481 CPT 301 RC inpatient 274 274 UNITED HEALTHCARE (COMMERCIAL) [3081199] UNITED HEALTHCARE 87726 [308119901] 169.88 percent of total billed charges 169.88 260.3 Technical (Hospital) Services T3 Triiodothyronine Free PX-3018448100 CDM 84481 CPT 301 RC inpatient 274 274 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES PPO [308136801] 216.95 percent of total billed charges 169.88 260.3 Technical (Hospital) Services T3 Triiodothyronine Free PX-3018448100 CDM 84481 CPT 301 RC inpatient 274 274 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES HDHP [308136802] 216.95 percent of total billed charges 169.88 260.3 Technical (Hospital) Services T3 Triiodothyronine Free PX-3018448100 CDM 84481 CPT 301 RC inpatient 274 274 BLUE CROSS BLUE SHIELD WELLMARK SB889 [3081026] BCBS WYOMING [308102603] 260.3 percent of total billed charges 169.88 260.3 Technical (Hospital) Services T3 Triiodothyronine Free PX-3018448100 CDM 84481 CPT 301 RC outpatient 274 274 BLUE CROSS BLUE SHIELD WELLMARK SB889 [3081026] BCBS WYOMING [308102603] 260.3 percent of total billed charges 169.88 260.3 Technical (Hospital) Services T3 Triiodothyronine Free PX-3018448100 CDM 84481 CPT 301 RC outpatient 274 274 MULTIPLAN INC 34080 [3081285] MULTIPLAN INC [308128501] 260.3 percent of total billed charges 169.88 260.3 Technical (Hospital) Services T3 Triiodothyronine Free PX-3018448100 CDM 84481 CPT 301 RC outpatient 274 274 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES EPO [308136803] 219.2 percent of total billed charges 169.88 260.3 Technical (Hospital) Services T3 Triiodothyronine Free PX-3018448100 CDM 84481 CPT 301 RC outpatient 274 274 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES HDHP [308136802] 219.2 percent of total billed charges 169.88 260.3 Technical (Hospital) Services T3 Triiodothyronine Free PX-3018448100 CDM 84481 CPT 301 RC outpatient 274 274 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES PPO [308136801] 219.2 percent of total billed charges 169.88 260.3 Technical (Hospital) Services T3 Triiodothyronine Free PX-3018448100 CDM 84481 CPT 301 RC outpatient 274 274 HEALTHPARTNERS SX009 HEALTHPARTNERS 219.2 percent of total billed charges 169.88 260.3 Technical (Hospital) Services T3 Triiodothyronine Free PX-3018448100 CDM 84481 CPT 301 RC outpatient 274 274 UNITED HEALTHCARE (COMMERCIAL) [3081199] UNITED HEALTHCARE 87726 [308119901] 169.88 percent of total billed charges 169.88 260.3 Technical (Hospital) Services T3 Triiodothyronine Free PX-3018448100 CDM 84481 CPT 301 RC outpatient 274 274 MEDICA (COMMERCIAL) 94265 [3081118] MEDICA CLAIMS [308111801] 246.6 percent of total billed charges 169.88 260.3 Technical (Hospital) Services T3 Triiodothyronine Free PX-3018448100 CDM 84481 CPT 301 RC outpatient 274 274 CIGNA 62308 [3081051] CIGNA 62308 [308105105] 219.2 percent of total billed charges 169.88 260.3 Technical (Hospital) Services T3 Triiodothyronine Free PX-3018448100 CDM 84481 CPT 301 RC outpatient 274 274 CIGNA 62308 [3081051] CIGNA STATE OF WYOMING [308105107] 219.2 percent of total billed charges 169.88 260.3 Technical (Hospital) Services Ref T-3 Triiodothyronine Total PX-3018448001 CDM 84480 CPT 301 RC outpatient 119 119 UNITED HEALTHCARE (COMMERCIAL) [3081199] UNITED HEALTHCARE 87726 [308119901] 73.78 percent of total billed charges 73.78 113.05 Technical (Hospital) Services Ref T-3 Triiodothyronine Total PX-3018448001 CDM 84480 CPT 301 RC outpatient 119 119 HEALTHPARTNERS SX009 HEALTHPARTNERS 95.2 percent of total billed charges 73.78 113.05 Technical (Hospital) Services Ref T-3 Triiodothyronine Total PX-3018448001 CDM 84480 CPT 301 RC outpatient 119 119 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES PPO [308136801] 95.2 percent of total billed charges 73.78 113.05 Technical (Hospital) Services Ref T-3 Triiodothyronine Total PX-3018448001 CDM 84480 CPT 301 RC outpatient 119 119 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES HDHP [308136802] 95.2 percent of total billed charges 73.78 113.05 Technical (Hospital) Services Ref T-3 Triiodothyronine Total PX-3018448001 CDM 84480 CPT 301 RC outpatient 119 119 MULTIPLAN INC 34080 [3081285] MULTIPLAN INC [308128501] 113.05 percent of total billed charges 73.78 113.05 Technical (Hospital) Services Ref T-3 Triiodothyronine Total PX-3018448001 CDM 84480 CPT 301 RC outpatient 119 119 BLUE CROSS BLUE SHIELD WELLMARK SB889 [3081026] BCBS WYOMING [308102603] 113.05 percent of total billed charges 73.78 113.05 Technical (Hospital) Services Ref T-3 Triiodothyronine Total PX-3018448001 CDM 84480 CPT 301 RC outpatient 119 119 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES EPO [308136803] 95.2 percent of total billed charges 73.78 113.05 Technical (Hospital) Services Ref T-3 Triiodothyronine Total PX-3018448001 CDM 84480 CPT 301 RC outpatient 119 119 CIGNA 62308 [3081051] CIGNA 62308 [308105105] 95.2 percent of total billed charges 73.78 113.05 Technical (Hospital) Services Ref T-3 Triiodothyronine Total PX-3018448001 CDM 84480 CPT 301 RC outpatient 119 119 CIGNA 62308 [3081051] CIGNA STATE OF WYOMING [308105107] 95.2 percent of total billed charges 73.78 113.05 Technical (Hospital) Services Ref T-3 Triiodothyronine Total PX-3018448001 CDM 84480 CPT 301 RC outpatient 119 119 MEDICA (COMMERCIAL) 94265 [3081118] MEDICA CLAIMS [308111801] 107.1 percent of total billed charges 73.78 113.05 Technical (Hospital) Services Ref T-3 Triiodothyronine Total PX-3018448001 CDM 84480 CPT 301 RC inpatient 119 119 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES PPO [308136801] 94.22 percent of total billed charges 73.78 113.05 Technical (Hospital) Services Ref T-3 Triiodothyronine Total PX-3018448001 CDM 84480 CPT 301 RC inpatient 119 119 UNITED HEALTHCARE (COMMERCIAL) [3081199] UNITED HEALTHCARE 87726 [308119901] 73.78 percent of total billed charges 73.78 113.05 Technical (Hospital) Services Ref T-3 Triiodothyronine Total PX-3018448001 CDM 84480 CPT 301 RC inpatient 119 119 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES HDHP [308136802] 94.22 percent of total billed charges 73.78 113.05 Technical (Hospital) Services Ref T-3 Triiodothyronine Total PX-3018448001 CDM 84480 CPT 301 RC inpatient 119 119 BLUE CROSS BLUE SHIELD WELLMARK SB889 [3081026] BCBS WYOMING [308102603] 113.05 percent of total billed charges 73.78 113.05 Technical (Hospital) Services Ref T-3 Triiodothyronine Total PX-3018448001 CDM 84480 CPT 301 RC inpatient 119 119 HEALTHPARTNERS SX009 HEALTHPARTNERS 94.22 percent of total billed charges 73.78 113.05 Technical (Hospital) Services Ref T-3 Triiodothyronine Total PX-3018448001 CDM 84480 CPT 301 RC inpatient 119 119 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES EPO [308136803] 94.22 percent of total billed charges 73.78 113.05 Technical (Hospital) Services Ref T-3 Triiodothyronine Total PX-3018448001 CDM 84480 CPT 301 RC inpatient 119 119 MEDICA (COMMERCIAL) 94265 [3081118] MEDICA CLAIMS [308111801] 107.1 percent of total billed charges 73.78 113.05 Technical (Hospital) Services Ref T-3 Triiodothyronine Total PX-3018448001 CDM 84480 CPT 301 RC inpatient 119 119 MULTIPLAN INC 34080 [3081285] MULTIPLAN INC [308128501] 113.05 percent of total billed charges 73.78 113.05 Technical (Hospital) Services Ref T-3 Triiodothyronine Total PX-3018448001 CDM 84480 CPT 301 RC inpatient 119 119 CIGNA 62308 [3081051] CIGNA 62308 [308105105] 94.22 percent of total billed charges 73.78 113.05 Technical (Hospital) Services Ref T-3 Triiodothyronine Total PX-3018448001 CDM 84480 CPT 301 RC inpatient 119 119 CIGNA 62308 [3081051] CIGNA STATE OF WYOMING [308105107] 94.22 percent of total billed charges 73.78 113.05 Technical (Hospital) Services T3 Uptake PX-3018447900 CDM 84479 CPT 301 RC outpatient 95 95 UNITED HEALTHCARE (COMMERCIAL) [3081199] UNITED HEALTHCARE 87726 [308119901] 58.9 percent of total billed charges 58.9 90.25 Technical (Hospital) Services T3 Uptake PX-3018447900 CDM 84479 CPT 301 RC outpatient 95 95 HEALTHPARTNERS SX009 HEALTHPARTNERS 76 percent of total billed charges 58.9 90.25 Technical (Hospital) Services T3 Uptake PX-3018447900 CDM 84479 CPT 301 RC outpatient 95 95 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES PPO [308136801] 76 percent of total billed charges 58.9 90.25 Technical (Hospital) Services T3 Uptake PX-3018447900 CDM 84479 CPT 301 RC outpatient 95 95 BLUE CROSS BLUE SHIELD WELLMARK SB889 [3081026] BCBS WYOMING [308102603] 90.25 percent of total billed charges 58.9 90.25 Technical (Hospital) Services T3 Uptake PX-3018447900 CDM 84479 CPT 301 RC outpatient 95 95 MULTIPLAN INC 34080 [3081285] MULTIPLAN INC [308128501] 90.25 percent of total billed charges 58.9 90.25 Technical (Hospital) Services T3 Uptake PX-3018447900 CDM 84479 CPT 301 RC outpatient 95 95 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES EPO [308136803] 76 percent of total billed charges 58.9 90.25 Technical (Hospital) Services T3 Uptake PX-3018447900 CDM 84479 CPT 301 RC outpatient 95 95 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES HDHP [308136802] 76 percent of total billed charges 58.9 90.25 Technical (Hospital) Services T3 Uptake PX-3018447900 CDM 84479 CPT 301 RC outpatient 95 95 MEDICA (COMMERCIAL) 94265 [3081118] MEDICA CLAIMS [308111801] 85.5 percent of total billed charges 58.9 90.25 Technical (Hospital) Services T3 Uptake PX-3018447900 CDM 84479 CPT 301 RC outpatient 95 95 CIGNA 62308 [3081051] CIGNA 62308 [308105105] 76 percent of total billed charges 58.9 90.25 Technical (Hospital) Services T3 Uptake PX-3018447900 CDM 84479 CPT 301 RC outpatient 95 95 CIGNA 62308 [3081051] CIGNA STATE OF WYOMING [308105107] 76 percent of total billed charges 58.9 90.25 Technical (Hospital) Services T3 Uptake PX-3018447900 CDM 84479 CPT 301 RC inpatient 95 95 HEALTHPARTNERS SX009 HEALTHPARTNERS 75.22 percent of total billed charges 58.9 90.25 Technical (Hospital) Services T3 Uptake PX-3018447900 CDM 84479 CPT 301 RC inpatient 95 95 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES EPO [308136803] 75.22 percent of total billed charges 58.9 90.25 Technical (Hospital) Services T3 Uptake PX-3018447900 CDM 84479 CPT 301 RC inpatient 95 95 MEDICA (COMMERCIAL) 94265 [3081118] MEDICA CLAIMS [308111801] 85.5 percent of total billed charges 58.9 90.25 Technical (Hospital) Services T3 Uptake PX-3018447900 CDM 84479 CPT 301 RC inpatient 95 95 MULTIPLAN INC 34080 [3081285] MULTIPLAN INC [308128501] 90.25 percent of total billed charges 58.9 90.25 Technical (Hospital) Services T3 Uptake PX-3018447900 CDM 84479 CPT 301 RC inpatient 95 95 CIGNA 62308 [3081051] CIGNA 62308 [308105105] 75.22 percent of total billed charges 58.9 90.25 Technical (Hospital) Services T3 Uptake PX-3018447900 CDM 84479 CPT 301 RC inpatient 95 95 CIGNA 62308 [3081051] CIGNA STATE OF WYOMING [308105107] 75.22 percent of total billed charges 58.9 90.25 Technical (Hospital) Services T3 Uptake PX-3018447900 CDM 84479 CPT 301 RC inpatient 95 95 BLUE CROSS BLUE SHIELD WELLMARK SB889 [3081026] BCBS WYOMING [308102603] 90.25 percent of total billed charges 58.9 90.25 Technical (Hospital) Services T3 Uptake PX-3018447900 CDM 84479 CPT 301 RC inpatient 95 95 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES PPO [308136801] 75.22 percent of total billed charges 58.9 90.25 Technical (Hospital) Services T3 Uptake PX-3018447900 CDM 84479 CPT 301 RC inpatient 95 95 UNITED HEALTHCARE (COMMERCIAL) [3081199] UNITED HEALTHCARE 87726 [308119901] 58.9 percent of total billed charges 58.9 90.25 Technical (Hospital) Services T3 Uptake PX-3018447900 CDM 84479 CPT 301 RC inpatient 95 95 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES HDHP [308136802] 75.22 percent of total billed charges 58.9 90.25 Technical (Hospital) Services Vap Cholesterol Triglycerides PX-3018447800 CDM 84478 CPT 301 RC inpatient 61 61 CIGNA 62308 [3081051] CIGNA 62308 [308105105] 48.3 percent of total billed charges 37.82 57.95 Technical (Hospital) Services Vap Cholesterol Triglycerides PX-3018447800 CDM 84478 CPT 301 RC inpatient 61 61 CIGNA 62308 [3081051] CIGNA STATE OF WYOMING [308105107] 48.3 percent of total billed charges 37.82 57.95 Technical (Hospital) Services Vap Cholesterol Triglycerides PX-3018447800 CDM 84478 CPT 301 RC inpatient 61 61 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES EPO [308136803] 48.3 percent of total billed charges 37.82 57.95 Technical (Hospital) Services Vap Cholesterol Triglycerides PX-3018447800 CDM 84478 CPT 301 RC inpatient 61 61 MULTIPLAN INC 34080 [3081285] MULTIPLAN INC [308128501] 57.95 percent of total billed charges 37.82 57.95 Technical (Hospital) Services Vap Cholesterol Triglycerides PX-3018447800 CDM 84478 CPT 301 RC inpatient 61 61 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES HDHP [308136802] 48.3 percent of total billed charges 37.82 57.95 Technical (Hospital) Services Vap Cholesterol Triglycerides PX-3018447800 CDM 84478 CPT 301 RC inpatient 61 61 MEDICA (COMMERCIAL) 94265 [3081118] MEDICA CLAIMS [308111801] 54.9 percent of total billed charges 37.82 57.95 Technical (Hospital) Services Vap Cholesterol Triglycerides PX-3018447800 CDM 84478 CPT 301 RC inpatient 61 61 HEALTHPARTNERS SX009 HEALTHPARTNERS 48.3 percent of total billed charges 37.82 57.95 Technical (Hospital) Services Vap Cholesterol Triglycerides PX-3018447800 CDM 84478 CPT 301 RC inpatient 61 61 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES PPO [308136801] 48.3 percent of total billed charges 37.82 57.95 Technical (Hospital) Services Vap Cholesterol Triglycerides PX-3018447800 CDM 84478 CPT 301 RC inpatient 61 61 BLUE CROSS BLUE SHIELD WELLMARK SB889 [3081026] BCBS WYOMING [308102603] 57.95 percent of total billed charges 37.82 57.95 Technical (Hospital) Services Vap Cholesterol Triglycerides PX-3018447800 CDM 84478 CPT 301 RC inpatient 61 61 UNITED HEALTHCARE (COMMERCIAL) [3081199] UNITED HEALTHCARE 87726 [308119901] 37.82 percent of total billed charges 37.82 57.95 Technical (Hospital) Services Vap Cholesterol Triglycerides PX-3018447800 CDM 84478 CPT 301 RC outpatient 61 61 MEDICA (COMMERCIAL) 94265 [3081118] MEDICA CLAIMS [308111801] 54.9 percent of total billed charges 37.82 57.95 Technical (Hospital) Services Vap Cholesterol Triglycerides PX-3018447800 CDM 84478 CPT 301 RC outpatient 61 61 CIGNA 62308 [3081051] CIGNA 62308 [308105105] 48.8 percent of total billed charges 37.82 57.95 Technical (Hospital) Services Vap Cholesterol Triglycerides PX-3018447800 CDM 84478 CPT 301 RC outpatient 61 61 CIGNA 62308 [3081051] CIGNA STATE OF WYOMING [308105107] 48.8 percent of total billed charges 37.82 57.95 Technical (Hospital) Services Vap Cholesterol Triglycerides PX-3018447800 CDM 84478 CPT 301 RC outpatient 61 61 HEALTHPARTNERS SX009 HEALTHPARTNERS 48.8 percent of total billed charges 37.82 57.95 Technical (Hospital) Services Vap Cholesterol Triglycerides PX-3018447800 CDM 84478 CPT 301 RC outpatient 61 61 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES EPO [308136803] 48.8 percent of total billed charges 37.82 57.95 Technical (Hospital) Services Vap Cholesterol Triglycerides PX-3018447800 CDM 84478 CPT 301 RC outpatient 61 61 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES PPO [308136801] 48.8 percent of total billed charges 37.82 57.95 Technical (Hospital) Services Vap Cholesterol Triglycerides PX-3018447800 CDM 84478 CPT 301 RC outpatient 61 61 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES HDHP [308136802] 48.8 percent of total billed charges 37.82 57.95 Technical (Hospital) Services Vap Cholesterol Triglycerides PX-3018447800 CDM 84478 CPT 301 RC outpatient 61 61 UNITED HEALTHCARE (COMMERCIAL) [3081199] UNITED HEALTHCARE 87726 [308119901] 37.82 percent of total billed charges 37.82 57.95 Technical (Hospital) Services Vap Cholesterol Triglycerides PX-3018447800 CDM 84478 CPT 301 RC outpatient 61 61 BLUE CROSS BLUE SHIELD WELLMARK SB889 [3081026] BCBS WYOMING [308102603] 57.95 percent of total billed charges 37.82 57.95 Technical (Hospital) Services Vap Cholesterol Triglycerides PX-3018447800 CDM 84478 CPT 301 RC outpatient 61 61 MULTIPLAN INC 34080 [3081285] MULTIPLAN INC [308128501] 57.95 percent of total billed charges 37.82 57.95 Technical (Hospital) Services Triglycerides PX-3018447803 CDM 84478 CPT 301 RC outpatient 61 61 MEDICA (COMMERCIAL) 94265 [3081118] MEDICA CLAIMS [308111801] 54.9 percent of total billed charges 37.82 57.95 Technical (Hospital) Services Triglycerides PX-3018447803 CDM 84478 CPT 301 RC outpatient 61 61 CIGNA 62308 [3081051] CIGNA 62308 [308105105] 48.8 percent of total billed charges 37.82 57.95 Technical (Hospital) Services Triglycerides PX-3018447803 CDM 84478 CPT 301 RC outpatient 61 61 CIGNA 62308 [3081051] CIGNA STATE OF WYOMING [308105107] 48.8 percent of total billed charges 37.82 57.95 Technical (Hospital) Services Triglycerides PX-3018447803 CDM 84478 CPT 301 RC outpatient 61 61 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES EPO [308136803] 48.8 percent of total billed charges 37.82 57.95 Technical (Hospital) Services Triglycerides PX-3018447803 CDM 84478 CPT 301 RC outpatient 61 61 MULTIPLAN INC 34080 [3081285] MULTIPLAN INC [308128501] 57.95 percent of total billed charges 37.82 57.95 Technical (Hospital) Services Triglycerides PX-3018447803 CDM 84478 CPT 301 RC outpatient 61 61 BLUE CROSS BLUE SHIELD WELLMARK SB889 [3081026] BCBS WYOMING [308102603] 57.95 percent of total billed charges 37.82 57.95 Technical (Hospital) Services Triglycerides PX-3018447803 CDM 84478 CPT 301 RC outpatient 61 61 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES HDHP [308136802] 48.8 percent of total billed charges 37.82 57.95 Technical (Hospital) Services Triglycerides PX-3018447803 CDM 84478 CPT 301 RC outpatient 61 61 UNITED HEALTHCARE (COMMERCIAL) [3081199] UNITED HEALTHCARE 87726 [308119901] 37.82 percent of total billed charges 37.82 57.95 Technical (Hospital) Services Triglycerides PX-3018447803 CDM 84478 CPT 301 RC outpatient 61 61 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES PPO [308136801] 48.8 percent of total billed charges 37.82 57.95 Technical (Hospital) Services Triglycerides PX-3018447803 CDM 84478 CPT 301 RC outpatient 61 61 HEALTHPARTNERS SX009 HEALTHPARTNERS 48.8 percent of total billed charges 37.82 57.95 Technical (Hospital) Services Triglycerides PX-3018447803 CDM 84478 CPT 301 RC inpatient 61 61 UNITED HEALTHCARE (COMMERCIAL) [3081199] UNITED HEALTHCARE 87726 [308119901] 37.82 percent of total billed charges 37.82 57.95 Technical (Hospital) Services Triglycerides PX-3018447803 CDM 84478 CPT 301 RC inpatient 61 61 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES PPO [308136801] 48.3 percent of total billed charges 37.82 57.95 Technical (Hospital) Services Triglycerides PX-3018447803 CDM 84478 CPT 301 RC inpatient 61 61 BLUE CROSS BLUE SHIELD WELLMARK SB889 [3081026] BCBS WYOMING [308102603] 57.95 percent of total billed charges 37.82 57.95 Technical (Hospital) Services Triglycerides PX-3018447803 CDM 84478 CPT 301 RC inpatient 61 61 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES HDHP [308136802] 48.3 percent of total billed charges 37.82 57.95 Technical (Hospital) Services Triglycerides PX-3018447803 CDM 84478 CPT 301 RC inpatient 61 61 CIGNA 62308 [3081051] CIGNA 62308 [308105105] 48.3 percent of total billed charges 37.82 57.95 Technical (Hospital) Services Triglycerides PX-3018447803 CDM 84478 CPT 301 RC inpatient 61 61 CIGNA 62308 [3081051] CIGNA STATE OF WYOMING [308105107] 48.3 percent of total billed charges 37.82 57.95 Technical (Hospital) Services Triglycerides PX-3018447803 CDM 84478 CPT 301 RC inpatient 61 61 MULTIPLAN INC 34080 [3081285] MULTIPLAN INC [308128501] 57.95 percent of total billed charges 37.82 57.95 Technical (Hospital) Services Triglycerides PX-3018447803 CDM 84478 CPT 301 RC inpatient 61 61 MEDICA (COMMERCIAL) 94265 [3081118] MEDICA CLAIMS [308111801] 54.9 percent of total billed charges 37.82 57.95 Technical (Hospital) Services Triglycerides PX-3018447803 CDM 84478 CPT 301 RC inpatient 61 61 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES EPO [308136803] 48.3 percent of total billed charges 37.82 57.95 Technical (Hospital) Services Triglycerides PX-3018447803 CDM 84478 CPT 301 RC inpatient 61 61 HEALTHPARTNERS SX009 HEALTHPARTNERS 48.3 percent of total billed charges 37.82 57.95 Technical (Hospital) Services Ref Transferrin PX-3018446600 CDM 84466 CPT 301 RC outpatient 196 196 MEDICA (COMMERCIAL) 94265 [3081118] MEDICA CLAIMS [308111801] 176.4 percent of total billed charges 121.52 186.2 Technical (Hospital) Services Ref Transferrin PX-3018446600 CDM 84466 CPT 301 RC outpatient 196 196 CIGNA 62308 [3081051] CIGNA 62308 [308105105] 156.8 percent of total billed charges 121.52 186.2 Technical (Hospital) Services Ref Transferrin PX-3018446600 CDM 84466 CPT 301 RC outpatient 196 196 CIGNA 62308 [3081051] CIGNA STATE OF WYOMING [308105107] 156.8 percent of total billed charges 121.52 186.2 Technical (Hospital) Services Ref Transferrin PX-3018446600 CDM 84466 CPT 301 RC outpatient 196 196 MULTIPLAN INC 34080 [3081285] MULTIPLAN INC [308128501] 186.2 percent of total billed charges 121.52 186.2 Technical (Hospital) Services Ref Transferrin PX-3018446600 CDM 84466 CPT 301 RC outpatient 196 196 BLUE CROSS BLUE SHIELD WELLMARK SB889 [3081026] BCBS WYOMING [308102603] 186.2 percent of total billed charges 121.52 186.2 Technical (Hospital) Services Ref Transferrin PX-3018446600 CDM 84466 CPT 301 RC outpatient 196 196 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES EPO [308136803] 156.8 percent of total billed charges 121.52 186.2 Technical (Hospital) Services Ref Transferrin PX-3018446600 CDM 84466 CPT 301 RC outpatient 196 196 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES HDHP [308136802] 156.8 percent of total billed charges 121.52 186.2 Technical (Hospital) Services Ref Transferrin PX-3018446600 CDM 84466 CPT 301 RC outpatient 196 196 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES PPO [308136801] 156.8 percent of total billed charges 121.52 186.2 Technical (Hospital) Services Ref Transferrin PX-3018446600 CDM 84466 CPT 301 RC outpatient 196 196 HEALTHPARTNERS SX009 HEALTHPARTNERS 156.8 percent of total billed charges 121.52 186.2 Technical (Hospital) Services Ref Transferrin PX-3018446600 CDM 84466 CPT 301 RC outpatient 196 196 UNITED HEALTHCARE (COMMERCIAL) [3081199] UNITED HEALTHCARE 87726 [308119901] 121.52 percent of total billed charges 121.52 186.2 Technical (Hospital) Services Ref Transferrin PX-3018446600 CDM 84466 CPT 301 RC inpatient 196 196 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES HDHP [308136802] 155.19 percent of total billed charges 121.52 186.2 Technical (Hospital) Services Ref Transferrin PX-3018446600 CDM 84466 CPT 301 RC inpatient 196 196 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES PPO [308136801] 155.19 percent of total billed charges 121.52 186.2 Technical (Hospital) Services Ref Transferrin PX-3018446600 CDM 84466 CPT 301 RC inpatient 196 196 UNITED HEALTHCARE (COMMERCIAL) [3081199] UNITED HEALTHCARE 87726 [308119901] 121.52 percent of total billed charges 121.52 186.2 Technical (Hospital) Services Ref Transferrin PX-3018446600 CDM 84466 CPT 301 RC inpatient 196 196 BLUE CROSS BLUE SHIELD WELLMARK SB889 [3081026] BCBS WYOMING [308102603] 186.2 percent of total billed charges 121.52 186.2 Technical (Hospital) Services Ref Transferrin PX-3018446600 CDM 84466 CPT 301 RC inpatient 196 196 CIGNA 62308 [3081051] CIGNA 62308 [308105105] 155.19 percent of total billed charges 121.52 186.2 Technical (Hospital) Services Ref Transferrin PX-3018446600 CDM 84466 CPT 301 RC inpatient 196 196 CIGNA 62308 [3081051] CIGNA STATE OF WYOMING [308105107] 155.19 percent of total billed charges 121.52 186.2 Technical (Hospital) Services Ref Transferrin PX-3018446600 CDM 84466 CPT 301 RC inpatient 196 196 MULTIPLAN INC 34080 [3081285] MULTIPLAN INC [308128501] 186.2 percent of total billed charges 121.52 186.2 Technical (Hospital) Services Ref Transferrin PX-3018446600 CDM 84466 CPT 301 RC inpatient 196 196 MEDICA (COMMERCIAL) 94265 [3081118] MEDICA CLAIMS [308111801] 176.4 percent of total billed charges 121.52 186.2 Technical (Hospital) Services Ref Transferrin PX-3018446600 CDM 84466 CPT 301 RC inpatient 196 196 HEALTHPARTNERS SX009 HEALTHPARTNERS 155.19 percent of total billed charges 121.52 186.2 Technical (Hospital) Services Ref Transferrin PX-3018446600 CDM 84466 CPT 301 RC inpatient 196 196 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES EPO [308136803] 155.19 percent of total billed charges 121.52 186.2 Technical (Hospital) Services Ref Transferrin PX-3018446601 CDM 84466 CPT 301 RC inpatient 185 185 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES HDHP [308136802] 146.48 percent of total billed charges 114.7 175.75 Technical (Hospital) Services Ref Transferrin PX-3018446601 CDM 84466 CPT 301 RC inpatient 185 185 BLUE CROSS BLUE SHIELD WELLMARK SB889 [3081026] BCBS WYOMING [308102603] 175.75 percent of total billed charges 114.7 175.75 Technical (Hospital) Services Ref Transferrin PX-3018446601 CDM 84466 CPT 301 RC inpatient 185 185 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES PPO [308136801] 146.48 percent of total billed charges 114.7 175.75 Technical (Hospital) Services Ref Transferrin PX-3018446601 CDM 84466 CPT 301 RC inpatient 185 185 UNITED HEALTHCARE (COMMERCIAL) [3081199] UNITED HEALTHCARE 87726 [308119901] 114.7 percent of total billed charges 114.7 175.75 Technical (Hospital) Services Ref Transferrin PX-3018446601 CDM 84466 CPT 301 RC inpatient 185 185 HEALTHPARTNERS SX009 HEALTHPARTNERS 146.48 percent of total billed charges 114.7 175.75 Technical (Hospital) Services Ref Transferrin PX-3018446601 CDM 84466 CPT 301 RC inpatient 185 185 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES EPO [308136803] 146.48 percent of total billed charges 114.7 175.75 Technical (Hospital) Services Ref Transferrin PX-3018446601 CDM 84466 CPT 301 RC inpatient 185 185 CIGNA 62308 [3081051] CIGNA STATE OF WYOMING [308105107] 146.48 percent of total billed charges 114.7 175.75 Technical (Hospital) Services Ref Transferrin PX-3018446601 CDM 84466 CPT 301 RC inpatient 185 185 CIGNA 62308 [3081051] CIGNA 62308 [308105105] 146.48 percent of total billed charges 114.7 175.75 Technical (Hospital) Services Ref Transferrin PX-3018446601 CDM 84466 CPT 301 RC inpatient 185 185 MULTIPLAN INC 34080 [3081285] MULTIPLAN INC [308128501] 175.75 percent of total billed charges 114.7 175.75 Technical (Hospital) Services Ref Transferrin PX-3018446601 CDM 84466 CPT 301 RC inpatient 185 185 MEDICA (COMMERCIAL) 94265 [3081118] MEDICA CLAIMS [308111801] 166.5 percent of total billed charges 114.7 175.75 Technical (Hospital) Services Ref Transferrin PX-3018446601 CDM 84466 CPT 301 RC outpatient 185 185 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES HDHP [308136802] 148 percent of total billed charges 114.7 175.75 Technical (Hospital) Services Ref Transferrin PX-3018446601 CDM 84466 CPT 301 RC outpatient 185 185 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES EPO [308136803] 148 percent of total billed charges 114.7 175.75 Technical (Hospital) Services Ref Transferrin PX-3018446601 CDM 84466 CPT 301 RC outpatient 185 185 BLUE CROSS BLUE SHIELD WELLMARK SB889 [3081026] BCBS WYOMING [308102603] 175.75 percent of total billed charges 114.7 175.75 Technical (Hospital) Services Ref Transferrin PX-3018446601 CDM 84466 CPT 301 RC outpatient 185 185 MULTIPLAN INC 34080 [3081285] MULTIPLAN INC [308128501] 175.75 percent of total billed charges 114.7 175.75 Technical (Hospital) Services Ref Transferrin PX-3018446601 CDM 84466 CPT 301 RC outpatient 185 185 HEALTHPARTNERS SX009 HEALTHPARTNERS 148 percent of total billed charges 114.7 175.75 Technical (Hospital) Services Ref Transferrin PX-3018446601 CDM 84466 CPT 301 RC outpatient 185 185 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES PPO [308136801] 148 percent of total billed charges 114.7 175.75 Technical (Hospital) Services Ref Transferrin PX-3018446601 CDM 84466 CPT 301 RC outpatient 185 185 UNITED HEALTHCARE (COMMERCIAL) [3081199] UNITED HEALTHCARE 87726 [308119901] 114.7 percent of total billed charges 114.7 175.75 Technical (Hospital) Services Ref Transferrin PX-3018446601 CDM 84466 CPT 301 RC outpatient 185 185 MEDICA (COMMERCIAL) 94265 [3081118] MEDICA CLAIMS [308111801] 166.5 percent of total billed charges 114.7 175.75 Technical (Hospital) Services Ref Transferrin PX-3018446601 CDM 84466 CPT 301 RC outpatient 185 185 CIGNA 62308 [3081051] CIGNA 62308 [308105105] 148 percent of total billed charges 114.7 175.75 Technical (Hospital) Services Ref Transferrin PX-3018446601 CDM 84466 CPT 301 RC outpatient 185 185 CIGNA 62308 [3081051] CIGNA STATE OF WYOMING [308105107] 148 percent of total billed charges 114.7 175.75 Technical (Hospital) Services Sgpt Alt PX-3018446000 CDM 84460 CPT 301 RC inpatient 2 2 HEALTHPARTNERS SX009 HEALTHPARTNERS 1.58 percent of total billed charges 1.24 1.9 Technical (Hospital) Services Sgpt Alt PX-3018446000 CDM 84460 CPT 301 RC inpatient 2 2 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES EPO [308136803] 1.58 percent of total billed charges 1.24 1.9 Technical (Hospital) Services Sgpt Alt PX-3018446000 CDM 84460 CPT 301 RC inpatient 2 2 MEDICA (COMMERCIAL) 94265 [3081118] MEDICA CLAIMS [308111801] 1.8 percent of total billed charges 1.24 1.9 Technical (Hospital) Services Sgpt Alt PX-3018446000 CDM 84460 CPT 301 RC inpatient 2 2 MULTIPLAN INC 34080 [3081285] MULTIPLAN INC [308128501] 1.9 percent of total billed charges 1.24 1.9 Technical (Hospital) Services Sgpt Alt PX-3018446000 CDM 84460 CPT 301 RC inpatient 2 2 CIGNA 62308 [3081051] CIGNA 62308 [308105105] 1.58 percent of total billed charges 1.24 1.9 Technical (Hospital) Services Sgpt Alt PX-3018446000 CDM 84460 CPT 301 RC inpatient 2 2 CIGNA 62308 [3081051] CIGNA STATE OF WYOMING [308105107] 1.58 percent of total billed charges 1.24 1.9 Technical (Hospital) Services Sgpt Alt PX-3018446000 CDM 84460 CPT 301 RC inpatient 2 2 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES PPO [308136801] 1.58 percent of total billed charges 1.24 1.9 Technical (Hospital) Services Sgpt Alt PX-3018446000 CDM 84460 CPT 301 RC inpatient 2 2 UNITED HEALTHCARE (COMMERCIAL) [3081199] UNITED HEALTHCARE 87726 [308119901] 1.24 percent of total billed charges 1.24 1.9 Technical (Hospital) Services Sgpt Alt PX-3018446000 CDM 84460 CPT 301 RC inpatient 2 2 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES HDHP [308136802] 1.58 percent of total billed charges 1.24 1.9 Technical (Hospital) Services Sgpt Alt PX-3018446000 CDM 84460 CPT 301 RC inpatient 2 2 BLUE CROSS BLUE SHIELD WELLMARK SB889 [3081026] BCBS WYOMING [308102603] 1.9 percent of total billed charges 1.24 1.9 Technical (Hospital) Services Sgpt Alt PX-3018446000 CDM 84460 CPT 301 RC outpatient 2 2 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES HDHP [308136802] 1.6 percent of total billed charges 1.24 1.9 Technical (Hospital) Services Sgpt Alt PX-3018446000 CDM 84460 CPT 301 RC outpatient 2 2 MULTIPLAN INC 34080 [3081285] MULTIPLAN INC [308128501] 1.9 percent of total billed charges 1.24 1.9 Technical (Hospital) Services Sgpt Alt PX-3018446000 CDM 84460 CPT 301 RC outpatient 2 2 BLUE CROSS BLUE SHIELD WELLMARK SB889 [3081026] BCBS WYOMING [308102603] 1.9 percent of total billed charges 1.24 1.9 Technical (Hospital) Services Sgpt Alt PX-3018446000 CDM 84460 CPT 301 RC outpatient 2 2 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES EPO [308136803] 1.6 percent of total billed charges 1.24 1.9 Technical (Hospital) Services Sgpt Alt PX-3018446000 CDM 84460 CPT 301 RC outpatient 2 2 HEALTHPARTNERS SX009 HEALTHPARTNERS 1.6 percent of total billed charges 1.24 1.9 Technical (Hospital) Services Sgpt Alt PX-3018446000 CDM 84460 CPT 301 RC outpatient 2 2 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES PPO [308136801] 1.6 percent of total billed charges 1.24 1.9 Technical (Hospital) Services Sgpt Alt PX-3018446000 CDM 84460 CPT 301 RC outpatient 2 2 UNITED HEALTHCARE (COMMERCIAL) [3081199] UNITED HEALTHCARE 87726 [308119901] 1.24 percent of total billed charges 1.24 1.9 Technical (Hospital) Services Sgpt Alt PX-3018446000 CDM 84460 CPT 301 RC outpatient 2 2 MEDICA (COMMERCIAL) 94265 [3081118] MEDICA CLAIMS [308111801] 1.8 percent of total billed charges 1.24 1.9 Technical (Hospital) Services Sgpt Alt PX-3018446000 CDM 84460 CPT 301 RC outpatient 2 2 CIGNA 62308 [3081051] CIGNA 62308 [308105105] 1.6 percent of total billed charges 1.24 1.9 Technical (Hospital) Services Sgpt Alt PX-3018446000 CDM 84460 CPT 301 RC outpatient 2 2 CIGNA 62308 [3081051] CIGNA STATE OF WYOMING [308105107] 1.6 percent of total billed charges 1.24 1.9 Technical (Hospital) Services Sgot Ast PX-3018445000 CDM 84450 CPT 301 RC outpatient 80 80 UNITED HEALTHCARE (COMMERCIAL) [3081199] UNITED HEALTHCARE 87726 [308119901] 49.6 percent of total billed charges 49.6 76 Technical (Hospital) Services Sgot Ast PX-3018445000 CDM 84450 CPT 301 RC outpatient 80 80 HEALTHPARTNERS SX009 HEALTHPARTNERS 64 percent of total billed charges 49.6 76 Technical (Hospital) Services Sgot Ast PX-3018445000 CDM 84450 CPT 301 RC outpatient 80 80 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES PPO [308136801] 64 percent of total billed charges 49.6 76 Technical (Hospital) Services Sgot Ast PX-3018445000 CDM 84450 CPT 301 RC outpatient 80 80 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES HDHP [308136802] 64 percent of total billed charges 49.6 76 Technical (Hospital) Services Sgot Ast PX-3018445000 CDM 84450 CPT 301 RC outpatient 80 80 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES EPO [308136803] 64 percent of total billed charges 49.6 76 Technical (Hospital) Services Sgot Ast PX-3018445000 CDM 84450 CPT 301 RC outpatient 80 80 MULTIPLAN INC 34080 [3081285] MULTIPLAN INC [308128501] 76 percent of total billed charges 49.6 76 Technical (Hospital) Services Sgot Ast PX-3018445000 CDM 84450 CPT 301 RC outpatient 80 80 BLUE CROSS BLUE SHIELD WELLMARK SB889 [3081026] BCBS WYOMING [308102603] 76 percent of total billed charges 49.6 76 Technical (Hospital) Services Sgot Ast PX-3018445000 CDM 84450 CPT 301 RC outpatient 80 80 MEDICA (COMMERCIAL) 94265 [3081118] MEDICA CLAIMS [308111801] 72 percent of total billed charges 49.6 76 Technical (Hospital) Services Sgot Ast PX-3018445000 CDM 84450 CPT 301 RC outpatient 80 80 CIGNA 62308 [3081051] CIGNA 62308 [308105105] 64 percent of total billed charges 49.6 76 Technical (Hospital) Services Sgot Ast PX-3018445000 CDM 84450 CPT 301 RC outpatient 80 80 CIGNA 62308 [3081051] CIGNA STATE OF WYOMING [308105107] 64 percent of total billed charges 49.6 76 Technical (Hospital) Services Sgot Ast PX-3018445000 CDM 84450 CPT 301 RC inpatient 80 80 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES HDHP [308136802] 63.34 percent of total billed charges 49.6 76 Technical (Hospital) Services Sgot Ast PX-3018445000 CDM 84450 CPT 301 RC inpatient 80 80 BLUE CROSS BLUE SHIELD WELLMARK SB889 [3081026] BCBS WYOMING [308102603] 76 percent of total billed charges 49.6 76 Technical (Hospital) Services Sgot Ast PX-3018445000 CDM 84450 CPT 301 RC inpatient 80 80 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES PPO [308136801] 63.34 percent of total billed charges 49.6 76 Technical (Hospital) Services Sgot Ast PX-3018445000 CDM 84450 CPT 301 RC inpatient 80 80 UNITED HEALTHCARE (COMMERCIAL) [3081199] UNITED HEALTHCARE 87726 [308119901] 49.6 percent of total billed charges 49.6 76 Technical (Hospital) Services Sgot Ast PX-3018445000 CDM 84450 CPT 301 RC inpatient 80 80 MEDICA (COMMERCIAL) 94265 [3081118] MEDICA CLAIMS [308111801] 72 percent of total billed charges 49.6 76 Technical (Hospital) Services Sgot Ast PX-3018445000 CDM 84450 CPT 301 RC inpatient 80 80 MULTIPLAN INC 34080 [3081285] MULTIPLAN INC [308128501] 76 percent of total billed charges 49.6 76 Technical (Hospital) Services Sgot Ast PX-3018445000 CDM 84450 CPT 301 RC inpatient 80 80 CIGNA 62308 [3081051] CIGNA STATE OF WYOMING [308105107] 63.34 percent of total billed charges 49.6 76 Technical (Hospital) Services Sgot Ast PX-3018445000 CDM 84450 CPT 301 RC inpatient 80 80 CIGNA 62308 [3081051] CIGNA 62308 [308105105] 63.34 percent of total billed charges 49.6 76 Technical (Hospital) Services Sgot Ast PX-3018445000 CDM 84450 CPT 301 RC inpatient 80 80 HEALTHPARTNERS SX009 HEALTHPARTNERS 63.34 percent of total billed charges 49.6 76 Technical (Hospital) Services Sgot Ast PX-3018445000 CDM 84450 CPT 301 RC inpatient 80 80 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES EPO [308136803] 63.34 percent of total billed charges 49.6 76 Technical (Hospital) Services Ref Vitamin E (Todopherol Alpha) PX-3018444600 CDM 84446 CPT 301 RC outpatient 166 166 UNITED HEALTHCARE (COMMERCIAL) [3081199] UNITED HEALTHCARE 87726 [308119901] 102.92 percent of total billed charges 102.92 157.7 Technical (Hospital) Services Ref Vitamin E (Todopherol Alpha) PX-3018444600 CDM 84446 CPT 301 RC outpatient 166 166 HEALTHPARTNERS SX009 HEALTHPARTNERS 132.8 percent of total billed charges 102.92 157.7 Technical (Hospital) Services Ref Vitamin E (Todopherol Alpha) PX-3018444600 CDM 84446 CPT 301 RC outpatient 166 166 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES PPO [308136801] 132.8 percent of total billed charges 102.92 157.7 Technical (Hospital) Services Ref Vitamin E (Todopherol Alpha) PX-3018444600 CDM 84446 CPT 301 RC outpatient 166 166 BLUE CROSS BLUE SHIELD WELLMARK SB889 [3081026] BCBS WYOMING [308102603] 157.7 percent of total billed charges 102.92 157.7 Technical (Hospital) Services Ref Vitamin E (Todopherol Alpha) PX-3018444600 CDM 84446 CPT 301 RC outpatient 166 166 MULTIPLAN INC 34080 [3081285] MULTIPLAN INC [308128501] 157.7 percent of total billed charges 102.92 157.7 Technical (Hospital) Services Ref Vitamin E (Todopherol Alpha) PX-3018444600 CDM 84446 CPT 301 RC outpatient 166 166 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES HDHP [308136802] 132.8 percent of total billed charges 102.92 157.7 Technical (Hospital) Services Ref Vitamin E (Todopherol Alpha) PX-3018444600 CDM 84446 CPT 301 RC outpatient 166 166 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES EPO [308136803] 132.8 percent of total billed charges 102.92 157.7 Technical (Hospital) Services Ref Vitamin E (Todopherol Alpha) PX-3018444600 CDM 84446 CPT 301 RC outpatient 166 166 CIGNA 62308 [3081051] CIGNA 62308 [308105105] 132.8 percent of total billed charges 102.92 157.7 Technical (Hospital) Services Ref Vitamin E (Todopherol Alpha) PX-3018444600 CDM 84446 CPT 301 RC outpatient 166 166 CIGNA 62308 [3081051] CIGNA STATE OF WYOMING [308105107] 132.8 percent of total billed charges 102.92 157.7 Technical (Hospital) Services Ref Vitamin E (Todopherol Alpha) PX-3018444600 CDM 84446 CPT 301 RC outpatient 166 166 MEDICA (COMMERCIAL) 94265 [3081118] MEDICA CLAIMS [308111801] 149.4 percent of total billed charges 102.92 157.7 Technical (Hospital) Services Ref Vitamin E (Todopherol Alpha) PX-3018444600 CDM 84446 CPT 301 RC inpatient 166 166 CIGNA 62308 [3081051] CIGNA 62308 [308105105] 131.44 percent of total billed charges 102.92 157.7 Technical (Hospital) Services Ref Vitamin E (Todopherol Alpha) PX-3018444600 CDM 84446 CPT 301 RC inpatient 166 166 CIGNA 62308 [3081051] CIGNA STATE OF WYOMING [308105107] 131.44 percent of total billed charges 102.92 157.7 Technical (Hospital) Services Ref Vitamin E (Todopherol Alpha) PX-3018444600 CDM 84446 CPT 301 RC inpatient 166 166 MULTIPLAN INC 34080 [3081285] MULTIPLAN INC [308128501] 157.7 percent of total billed charges 102.92 157.7 Technical (Hospital) Services Ref Vitamin E (Todopherol Alpha) PX-3018444600 CDM 84446 CPT 301 RC inpatient 166 166 MEDICA (COMMERCIAL) 94265 [3081118] MEDICA CLAIMS [308111801] 149.4 percent of total billed charges 102.92 157.7 Technical (Hospital) Services Ref Vitamin E (Todopherol Alpha) PX-3018444600 CDM 84446 CPT 301 RC inpatient 166 166 HEALTHPARTNERS SX009 HEALTHPARTNERS 131.44 percent of total billed charges 102.92 157.7 Technical (Hospital) Services Ref Vitamin E (Todopherol Alpha) PX-3018444600 CDM 84446 CPT 301 RC inpatient 166 166 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES EPO [308136803] 131.44 percent of total billed charges 102.92 157.7 Technical (Hospital) Services Ref Vitamin E (Todopherol Alpha) PX-3018444600 CDM 84446 CPT 301 RC inpatient 166 166 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES PPO [308136801] 131.44 percent of total billed charges 102.92 157.7 Technical (Hospital) Services Ref Vitamin E (Todopherol Alpha) PX-3018444600 CDM 84446 CPT 301 RC inpatient 166 166 UNITED HEALTHCARE (COMMERCIAL) [3081199] UNITED HEALTHCARE 87726 [308119901] 102.92 percent of total billed charges 102.92 157.7 Technical (Hospital) Services Ref Vitamin E (Todopherol Alpha) PX-3018444600 CDM 84446 CPT 301 RC inpatient 166 166 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES HDHP [308136802] 131.44 percent of total billed charges 102.92 157.7 Technical (Hospital) Services Ref Vitamin E (Todopherol Alpha) PX-3018444600 CDM 84446 CPT 301 RC inpatient 166 166 BLUE CROSS BLUE SHIELD WELLMARK SB889 [3081026] BCBS WYOMING [308102603] 157.7 percent of total billed charges 102.92 157.7 Technical (Hospital) Services Ref Vitamin E PX-3018444601 CDM 84446 CPT 301 RC inpatient 166 166 CIGNA 62308 [3081051] CIGNA 62308 [308105105] 131.44 percent of total billed charges 102.92 157.7 Technical (Hospital) Services Ref Vitamin E PX-3018444601 CDM 84446 CPT 301 RC inpatient 166 166 CIGNA 62308 [3081051] CIGNA STATE OF WYOMING [308105107] 131.44 percent of total billed charges 102.92 157.7 Technical (Hospital) Services Ref Vitamin E PX-3018444601 CDM 84446 CPT 301 RC inpatient 166 166 MULTIPLAN INC 34080 [3081285] MULTIPLAN INC [308128501] 157.7 percent of total billed charges 102.92 157.7 Technical (Hospital) Services Ref Vitamin E PX-3018444601 CDM 84446 CPT 301 RC inpatient 166 166 MEDICA (COMMERCIAL) 94265 [3081118] MEDICA CLAIMS [308111801] 149.4 percent of total billed charges 102.92 157.7 Technical (Hospital) Services Ref Vitamin E PX-3018444601 CDM 84446 CPT 301 RC inpatient 166 166 HEALTHPARTNERS SX009 HEALTHPARTNERS 131.44 percent of total billed charges 102.92 157.7 Technical (Hospital) Services Ref Vitamin E PX-3018444601 CDM 84446 CPT 301 RC inpatient 166 166 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES EPO [308136803] 131.44 percent of total billed charges 102.92 157.7 Technical (Hospital) Services Ref Vitamin E PX-3018444601 CDM 84446 CPT 301 RC inpatient 166 166 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES HDHP [308136802] 131.44 percent of total billed charges 102.92 157.7 Technical (Hospital) Services Ref Vitamin E PX-3018444601 CDM 84446 CPT 301 RC inpatient 166 166 BLUE CROSS BLUE SHIELD WELLMARK SB889 [3081026] BCBS WYOMING [308102603] 157.7 percent of total billed charges 102.92 157.7 Technical (Hospital) Services Ref Vitamin E PX-3018444601 CDM 84446 CPT 301 RC inpatient 166 166 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES PPO [308136801] 131.44 percent of total billed charges 102.92 157.7 Technical (Hospital) Services Ref Vitamin E PX-3018444601 CDM 84446 CPT 301 RC inpatient 166 166 UNITED HEALTHCARE (COMMERCIAL) [3081199] UNITED HEALTHCARE 87726 [308119901] 102.92 percent of total billed charges 102.92 157.7 Technical (Hospital) Services Ref Vitamin E PX-3018444601 CDM 84446 CPT 301 RC outpatient 166 166 BLUE CROSS BLUE SHIELD WELLMARK SB889 [3081026] BCBS WYOMING [308102603] 157.7 percent of total billed charges 102.92 157.7 Technical (Hospital) Services Ref Vitamin E PX-3018444601 CDM 84446 CPT 301 RC outpatient 166 166 MULTIPLAN INC 34080 [3081285] MULTIPLAN INC [308128501] 157.7 percent of total billed charges 102.92 157.7 Technical (Hospital) Services Ref Vitamin E PX-3018444601 CDM 84446 CPT 301 RC outpatient 166 166 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES EPO [308136803] 132.8 percent of total billed charges 102.92 157.7 Technical (Hospital) Services Ref Vitamin E PX-3018444601 CDM 84446 CPT 301 RC outpatient 166 166 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES HDHP [308136802] 132.8 percent of total billed charges 102.92 157.7 Technical (Hospital) Services Ref Vitamin E PX-3018444601 CDM 84446 CPT 301 RC outpatient 166 166 HEALTHPARTNERS SX009 HEALTHPARTNERS 132.8 percent of total billed charges 102.92 157.7 Technical (Hospital) Services Ref Vitamin E PX-3018444601 CDM 84446 CPT 301 RC outpatient 166 166 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES PPO [308136801] 132.8 percent of total billed charges 102.92 157.7 Technical (Hospital) Services Ref Vitamin E PX-3018444601 CDM 84446 CPT 301 RC outpatient 166 166 UNITED HEALTHCARE (COMMERCIAL) [3081199] UNITED HEALTHCARE 87726 [308119901] 102.92 percent of total billed charges 102.92 157.7 Technical (Hospital) Services Ref Vitamin E PX-3018444601 CDM 84446 CPT 301 RC outpatient 166 166 MEDICA (COMMERCIAL) 94265 [3081118] MEDICA CLAIMS [308111801] 149.4 percent of total billed charges 102.92 157.7 Technical (Hospital) Services Ref Vitamin E PX-3018444601 CDM 84446 CPT 301 RC outpatient 166 166 CIGNA 62308 [3081051] CIGNA 62308 [308105105] 132.8 percent of total billed charges 102.92 157.7 Technical (Hospital) Services Ref Vitamin E PX-3018444601 CDM 84446 CPT 301 RC outpatient 166 166 CIGNA 62308 [3081051] CIGNA STATE OF WYOMING [308105107] 132.8 percent of total billed charges 102.92 157.7 Technical (Hospital) Services Ref Thyroid Stimulating Immune Globulins PX-3018444500 CDM 84445 CPT 301 RC inpatient 327 327 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES PPO [308136801] 258.92 percent of total billed charges 202.74 310.65 Technical (Hospital) Services Ref Thyroid Stimulating Immune Globulins PX-3018444500 CDM 84445 CPT 301 RC inpatient 327 327 UNITED HEALTHCARE (COMMERCIAL) [3081199] UNITED HEALTHCARE 87726 [308119901] 202.74 percent of total billed charges 202.74 310.65 Technical (Hospital) Services Ref Thyroid Stimulating Immune Globulins PX-3018444500 CDM 84445 CPT 301 RC inpatient 327 327 BLUE CROSS BLUE SHIELD WELLMARK SB889 [3081026] BCBS WYOMING [308102603] 310.65 percent of total billed charges 202.74 310.65 Technical (Hospital) Services Ref Thyroid Stimulating Immune Globulins PX-3018444500 CDM 84445 CPT 301 RC inpatient 327 327 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES HDHP [308136802] 258.92 percent of total billed charges 202.74 310.65 Technical (Hospital) Services Ref Thyroid Stimulating Immune Globulins PX-3018444500 CDM 84445 CPT 301 RC inpatient 327 327 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES EPO [308136803] 258.92 percent of total billed charges 202.74 310.65 Technical (Hospital) Services Ref Thyroid Stimulating Immune Globulins PX-3018444500 CDM 84445 CPT 301 RC inpatient 327 327 HEALTHPARTNERS SX009 HEALTHPARTNERS 258.92 percent of total billed charges 202.74 310.65 Technical (Hospital) Services Ref Thyroid Stimulating Immune Globulins PX-3018444500 CDM 84445 CPT 301 RC inpatient 327 327 MEDICA (COMMERCIAL) 94265 [3081118] MEDICA CLAIMS [308111801] 294.3 percent of total billed charges 202.74 310.65 Technical (Hospital) Services Ref Thyroid Stimulating Immune Globulins PX-3018444500 CDM 84445 CPT 301 RC inpatient 327 327 MULTIPLAN INC 34080 [3081285] MULTIPLAN INC [308128501] 310.65 percent of total billed charges 202.74 310.65 Technical (Hospital) Services Ref Thyroid Stimulating Immune Globulins PX-3018444500 CDM 84445 CPT 301 RC inpatient 327 327 CIGNA 62308 [3081051] CIGNA 62308 [308105105] 258.92 percent of total billed charges 202.74 310.65 Technical (Hospital) Services Ref Thyroid Stimulating Immune Globulins PX-3018444500 CDM 84445 CPT 301 RC inpatient 327 327 CIGNA 62308 [3081051] CIGNA STATE OF WYOMING [308105107] 258.92 percent of total billed charges 202.74 310.65 Technical (Hospital) Services Ref Thyroid Stimulating Immune Globulins PX-3018444500 CDM 84445 CPT 301 RC outpatient 327 327 CIGNA 62308 [3081051] CIGNA 62308 [308105105] 261.6 percent of total billed charges 202.74 310.65 Technical (Hospital) Services Ref Thyroid Stimulating Immune Globulins PX-3018444500 CDM 84445 CPT 301 RC outpatient 327 327 CIGNA 62308 [3081051] CIGNA STATE OF WYOMING [308105107] 261.6 percent of total billed charges 202.74 310.65 Technical (Hospital) Services Ref Thyroid Stimulating Immune Globulins PX-3018444500 CDM 84445 CPT 301 RC outpatient 327 327 MEDICA (COMMERCIAL) 94265 [3081118] MEDICA CLAIMS [308111801] 294.3 percent of total billed charges 202.74 310.65 Technical (Hospital) Services Ref Thyroid Stimulating Immune Globulins PX-3018444500 CDM 84445 CPT 301 RC outpatient 327 327 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES PPO [308136801] 261.6 percent of total billed charges 202.74 310.65 Technical (Hospital) Services Ref Thyroid Stimulating Immune Globulins PX-3018444500 CDM 84445 CPT 301 RC outpatient 327 327 HEALTHPARTNERS SX009 HEALTHPARTNERS 261.6 percent of total billed charges 202.74 310.65 Technical (Hospital) Services Ref Thyroid Stimulating Immune Globulins PX-3018444500 CDM 84445 CPT 301 RC outpatient 327 327 UNITED HEALTHCARE (COMMERCIAL) [3081199] UNITED HEALTHCARE 87726 [308119901] 202.74 percent of total billed charges 202.74 310.65 Technical (Hospital) Services Ref Thyroid Stimulating Immune Globulins PX-3018444500 CDM 84445 CPT 301 RC outpatient 327 327 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES EPO [308136803] 261.6 percent of total billed charges 202.74 310.65 Technical (Hospital) Services Ref Thyroid Stimulating Immune Globulins PX-3018444500 CDM 84445 CPT 301 RC outpatient 327 327 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES HDHP [308136802] 261.6 percent of total billed charges 202.74 310.65 Technical (Hospital) Services Ref Thyroid Stimulating Immune Globulins PX-3018444500 CDM 84445 CPT 301 RC outpatient 327 327 MULTIPLAN INC 34080 [3081285] MULTIPLAN INC [308128501] 310.65 percent of total billed charges 202.74 310.65 Technical (Hospital) Services Ref Thyroid Stimulating Immune Globulins PX-3018444500 CDM 84445 CPT 301 RC outpatient 327 327 BLUE CROSS BLUE SHIELD WELLMARK SB889 [3081026] BCBS WYOMING [308102603] 310.65 percent of total billed charges 202.74 310.65 Technical (Hospital) Services Ref Thyroid Stimulating Immunoglob PX-3018444501 CDM 84445 CPT 301 RC outpatient 629 629 CIGNA 62308 [3081051] CIGNA 62308 [308105105] 503.2 percent of total billed charges 389.98 597.55 Technical (Hospital) Services Ref Thyroid Stimulating Immunoglob PX-3018444501 CDM 84445 CPT 301 RC outpatient 629 629 CIGNA 62308 [3081051] CIGNA STATE OF WYOMING [308105107] 503.2 percent of total billed charges 389.98 597.55 Technical (Hospital) Services Ref Thyroid Stimulating Immunoglob PX-3018444501 CDM 84445 CPT 301 RC outpatient 629 629 MEDICA (COMMERCIAL) 94265 [3081118] MEDICA CLAIMS [308111801] 566.1 percent of total billed charges 389.98 597.55 Technical (Hospital) Services Ref Thyroid Stimulating Immunoglob PX-3018444501 CDM 84445 CPT 301 RC outpatient 629 629 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES EPO [308136803] 503.2 percent of total billed charges 389.98 597.55 Technical (Hospital) Services Ref Thyroid Stimulating Immunoglob PX-3018444501 CDM 84445 CPT 301 RC outpatient 629 629 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES HDHP [308136802] 503.2 percent of total billed charges 389.98 597.55 Technical (Hospital) Services Ref Thyroid Stimulating Immunoglob PX-3018444501 CDM 84445 CPT 301 RC outpatient 629 629 MULTIPLAN INC 34080 [3081285] MULTIPLAN INC [308128501] 597.55 percent of total billed charges 389.98 597.55 Technical (Hospital) Services Ref Thyroid Stimulating Immunoglob PX-3018444501 CDM 84445 CPT 301 RC outpatient 629 629 BLUE CROSS BLUE SHIELD WELLMARK SB889 [3081026] BCBS WYOMING [308102603] 597.55 percent of total billed charges 389.98 597.55 Technical (Hospital) Services Ref Thyroid Stimulating Immunoglob PX-3018444501 CDM 84445 CPT 301 RC outpatient 629 629 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES PPO [308136801] 503.2 percent of total billed charges 389.98 597.55 Technical (Hospital) Services Ref Thyroid Stimulating Immunoglob PX-3018444501 CDM 84445 CPT 301 RC outpatient 629 629 HEALTHPARTNERS SX009 HEALTHPARTNERS 503.2 percent of total billed charges 389.98 597.55 Technical (Hospital) Services Ref Thyroid Stimulating Immunoglob PX-3018444501 CDM 84445 CPT 301 RC outpatient 629 629 UNITED HEALTHCARE (COMMERCIAL) [3081199] UNITED HEALTHCARE 87726 [308119901] 389.98 percent of total billed charges 389.98 597.55 Technical (Hospital) Services Ref Thyroid Stimulating Immunoglob PX-3018444501 CDM 84445 CPT 301 RC inpatient 629 629 CIGNA 62308 [3081051] CIGNA 62308 [308105105] 498.04 percent of total billed charges 389.98 597.55 Technical (Hospital) Services Ref Thyroid Stimulating Immunoglob PX-3018444501 CDM 84445 CPT 301 RC inpatient 629 629 CIGNA 62308 [3081051] CIGNA STATE OF WYOMING [308105107] 498.04 percent of total billed charges 389.98 597.55 Technical (Hospital) Services Ref Thyroid Stimulating Immunoglob PX-3018444501 CDM 84445 CPT 301 RC inpatient 629 629 MULTIPLAN INC 34080 [3081285] MULTIPLAN INC [308128501] 597.55 percent of total billed charges 389.98 597.55 Technical (Hospital) Services Ref Thyroid Stimulating Immunoglob PX-3018444501 CDM 84445 CPT 301 RC inpatient 629 629 MEDICA (COMMERCIAL) 94265 [3081118] MEDICA CLAIMS [308111801] 566.1 percent of total billed charges 389.98 597.55 Technical (Hospital) Services Ref Thyroid Stimulating Immunoglob PX-3018444501 CDM 84445 CPT 301 RC inpatient 629 629 HEALTHPARTNERS SX009 HEALTHPARTNERS 498.04 percent of total billed charges 389.98 597.55 Technical (Hospital) Services Ref Thyroid Stimulating Immunoglob PX-3018444501 CDM 84445 CPT 301 RC inpatient 629 629 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES EPO [308136803] 498.04 percent of total billed charges 389.98 597.55 Technical (Hospital) Services Ref Thyroid Stimulating Immunoglob PX-3018444501 CDM 84445 CPT 301 RC inpatient 629 629 BLUE CROSS BLUE SHIELD WELLMARK SB889 [3081026] BCBS WYOMING [308102603] 597.55 percent of total billed charges 389.98 597.55 Technical (Hospital) Services Ref Thyroid Stimulating Immunoglob PX-3018444501 CDM 84445 CPT 301 RC inpatient 629 629 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES HDHP [308136802] 498.04 percent of total billed charges 389.98 597.55 Technical (Hospital) Services Ref Thyroid Stimulating Immunoglob PX-3018444501 CDM 84445 CPT 301 RC inpatient 629 629 UNITED HEALTHCARE (COMMERCIAL) [3081199] UNITED HEALTHCARE 87726 [308119901] 389.98 percent of total billed charges 389.98 597.55 Technical (Hospital) Services Ref Thyroid Stimulating Immunoglob PX-3018444501 CDM 84445 CPT 301 RC inpatient 629 629 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES PPO [308136801] 498.04 percent of total billed charges 389.98 597.55 Technical (Hospital) Services TSH PX-3018444300 CDM 84443 CPT 301 RC outpatient 209 209 HEALTHPARTNERS SX009 HEALTHPARTNERS 167.2 percent of total billed charges 129.58 198.55 Technical (Hospital) Services TSH PX-3018444300 CDM 84443 CPT 301 RC outpatient 209 209 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES HDHP [308136802] 167.2 percent of total billed charges 129.58 198.55 Technical (Hospital) Services TSH PX-3018444300 CDM 84443 CPT 301 RC outpatient 209 209 MULTIPLAN INC 34080 [3081285] MULTIPLAN INC [308128501] 198.55 percent of total billed charges 129.58 198.55 Technical (Hospital) Services TSH PX-3018444300 CDM 84443 CPT 301 RC outpatient 209 209 BLUE CROSS BLUE SHIELD WELLMARK SB889 [3081026] BCBS WYOMING [308102603] 198.55 percent of total billed charges 129.58 198.55 Technical (Hospital) Services TSH PX-3018444300 CDM 84443 CPT 301 RC outpatient 209 209 UNITED HEALTHCARE (COMMERCIAL) [3081199] UNITED HEALTHCARE 87726 [308119901] 129.58 percent of total billed charges 129.58 198.55 Technical (Hospital) Services TSH PX-3018444300 CDM 84443 CPT 301 RC outpatient 209 209 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES EPO [308136803] 167.2 percent of total billed charges 129.58 198.55 Technical (Hospital) Services TSH PX-3018444300 CDM 84443 CPT 301 RC outpatient 209 209 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES PPO [308136801] 167.2 percent of total billed charges 129.58 198.55 Technical (Hospital) Services TSH PX-3018444300 CDM 84443 CPT 301 RC outpatient 209 209 CIGNA 62308 [3081051] CIGNA 62308 [308105105] 167.2 percent of total billed charges 129.58 198.55 Technical (Hospital) Services TSH PX-3018444300 CDM 84443 CPT 301 RC outpatient 209 209 CIGNA 62308 [3081051] CIGNA STATE OF WYOMING [308105107] 167.2 percent of total billed charges 129.58 198.55 Technical (Hospital) Services TSH PX-3018444300 CDM 84443 CPT 301 RC outpatient 209 209 MEDICA (COMMERCIAL) 94265 [3081118] MEDICA CLAIMS [308111801] 188.1 percent of total billed charges 129.58 198.55 Technical (Hospital) Services TSH PX-3018444300 CDM 84443 CPT 301 RC inpatient 209 209 CIGNA 62308 [3081051] CIGNA 62308 [308105105] 165.49 percent of total billed charges 129.58 198.55 Technical (Hospital) Services TSH PX-3018444300 CDM 84443 CPT 301 RC inpatient 209 209 CIGNA 62308 [3081051] CIGNA STATE OF WYOMING [308105107] 165.49 percent of total billed charges 129.58 198.55 Technical (Hospital) Services TSH PX-3018444300 CDM 84443 CPT 301 RC inpatient 209 209 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES EPO [308136803] 165.49 percent of total billed charges 129.58 198.55 Technical (Hospital) Services TSH PX-3018444300 CDM 84443 CPT 301 RC inpatient 209 209 HEALTHPARTNERS SX009 HEALTHPARTNERS 165.49 percent of total billed charges 129.58 198.55 Technical (Hospital) Services TSH PX-3018444300 CDM 84443 CPT 301 RC inpatient 209 209 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES HDHP [308136802] 165.49 percent of total billed charges 129.58 198.55 Technical (Hospital) Services TSH PX-3018444300 CDM 84443 CPT 301 RC inpatient 209 209 MEDICA (COMMERCIAL) 94265 [3081118] MEDICA CLAIMS [308111801] 188.1 percent of total billed charges 129.58 198.55 Technical (Hospital) Services TSH PX-3018444300 CDM 84443 CPT 301 RC inpatient 209 209 MULTIPLAN INC 34080 [3081285] MULTIPLAN INC [308128501] 198.55 percent of total billed charges 129.58 198.55 Technical (Hospital) Services TSH PX-3018444300 CDM 84443 CPT 301 RC inpatient 209 209 UNITED HEALTHCARE (COMMERCIAL) [3081199] UNITED HEALTHCARE 87726 [308119901] 129.58 percent of total billed charges 129.58 198.55 Technical (Hospital) Services TSH PX-3018444300 CDM 84443 CPT 301 RC inpatient 209 209 BLUE CROSS BLUE SHIELD WELLMARK SB889 [3081026] BCBS WYOMING [308102603] 198.55 percent of total billed charges 129.58 198.55 Technical (Hospital) Services TSH PX-3018444300 CDM 84443 CPT 301 RC inpatient 209 209 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES PPO [308136801] 165.49 percent of total billed charges 129.58 198.55 Technical (Hospital) Services Ref Tsh PX-3018444301 CDM 84443 CPT 301 RC inpatient 214 214 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES EPO [308136803] 169.45 percent of total billed charges 132.68 203.3 Technical (Hospital) Services Ref Tsh PX-3018444301 CDM 84443 CPT 301 RC inpatient 214 214 HEALTHPARTNERS SX009 HEALTHPARTNERS 169.45 percent of total billed charges 132.68 203.3 Technical (Hospital) Services Ref Tsh PX-3018444301 CDM 84443 CPT 301 RC inpatient 214 214 MEDICA (COMMERCIAL) 94265 [3081118] MEDICA CLAIMS [308111801] 192.6 percent of total billed charges 132.68 203.3 Technical (Hospital) Services Ref Tsh PX-3018444301 CDM 84443 CPT 301 RC inpatient 214 214 MULTIPLAN INC 34080 [3081285] MULTIPLAN INC [308128501] 203.3 percent of total billed charges 132.68 203.3 Technical (Hospital) Services Ref Tsh PX-3018444301 CDM 84443 CPT 301 RC inpatient 214 214 CIGNA 62308 [3081051] CIGNA 62308 [308105105] 169.45 percent of total billed charges 132.68 203.3 Technical (Hospital) Services Ref Tsh PX-3018444301 CDM 84443 CPT 301 RC inpatient 214 214 CIGNA 62308 [3081051] CIGNA STATE OF WYOMING [308105107] 169.45 percent of total billed charges 132.68 203.3 Technical (Hospital) Services Ref Tsh PX-3018444301 CDM 84443 CPT 301 RC inpatient 214 214 BLUE CROSS BLUE SHIELD WELLMARK SB889 [3081026] BCBS WYOMING [308102603] 203.3 percent of total billed charges 132.68 203.3 Technical (Hospital) Services Ref Tsh PX-3018444301 CDM 84443 CPT 301 RC inpatient 214 214 UNITED HEALTHCARE (COMMERCIAL) [3081199] UNITED HEALTHCARE 87726 [308119901] 132.68 percent of total billed charges 132.68 203.3 Technical (Hospital) Services Ref Tsh PX-3018444301 CDM 84443 CPT 301 RC inpatient 214 214 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES PPO [308136801] 169.45 percent of total billed charges 132.68 203.3 Technical (Hospital) Services Ref Tsh PX-3018444301 CDM 84443 CPT 301 RC inpatient 214 214 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES HDHP [308136802] 169.45 percent of total billed charges 132.68 203.3 Technical (Hospital) Services Ref Tsh PX-3018444301 CDM 84443 CPT 301 RC outpatient 214 214 UNITED HEALTHCARE (COMMERCIAL) [3081199] UNITED HEALTHCARE 87726 [308119901] 132.68 percent of total billed charges 132.68 203.3 Technical (Hospital) Services Ref Tsh PX-3018444301 CDM 84443 CPT 301 RC outpatient 214 214 HEALTHPARTNERS SX009 HEALTHPARTNERS 171.2 percent of total billed charges 132.68 203.3 Technical (Hospital) Services Ref Tsh PX-3018444301 CDM 84443 CPT 301 RC outpatient 214 214 BLUE CROSS BLUE SHIELD WELLMARK SB889 [3081026] BCBS WYOMING [308102603] 203.3 percent of total billed charges 132.68 203.3 Technical (Hospital) Services Ref Tsh PX-3018444301 CDM 84443 CPT 301 RC outpatient 214 214 MULTIPLAN INC 34080 [3081285] MULTIPLAN INC [308128501] 203.3 percent of total billed charges 132.68 203.3 Technical (Hospital) Services Ref Tsh PX-3018444301 CDM 84443 CPT 301 RC outpatient 214 214 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES HDHP [308136802] 171.2 percent of total billed charges 132.68 203.3 Technical (Hospital) Services Ref Tsh PX-3018444301 CDM 84443 CPT 301 RC outpatient 214 214 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES EPO [308136803] 171.2 percent of total billed charges 132.68 203.3 Technical (Hospital) Services Ref Tsh PX-3018444301 CDM 84443 CPT 301 RC outpatient 214 214 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES PPO [308136801] 171.2 percent of total billed charges 132.68 203.3 Technical (Hospital) Services Ref Tsh PX-3018444301 CDM 84443 CPT 301 RC outpatient 214 214 MEDICA (COMMERCIAL) 94265 [3081118] MEDICA CLAIMS [308111801] 192.6 percent of total billed charges 132.68 203.3 Technical (Hospital) Services Ref Tsh PX-3018444301 CDM 84443 CPT 301 RC outpatient 214 214 CIGNA 62308 [3081051] CIGNA 62308 [308105105] 171.2 percent of total billed charges 132.68 203.3 Technical (Hospital) Services Ref Tsh PX-3018444301 CDM 84443 CPT 301 RC outpatient 214 214 CIGNA 62308 [3081051] CIGNA STATE OF WYOMING [308105107] 171.2 percent of total billed charges 132.68 203.3 Technical (Hospital) Services Free T 4 PX-3018443900 CDM 84439 CPT 301 RC outpatient 145 145 UNITED HEALTHCARE (COMMERCIAL) [3081199] UNITED HEALTHCARE 87726 [308119901] 89.9 percent of total billed charges 89.9 137.75 Technical (Hospital) Services Free T 4 PX-3018443900 CDM 84439 CPT 301 RC outpatient 145 145 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES PPO [308136801] 116 percent of total billed charges 89.9 137.75 Technical (Hospital) Services Free T 4 PX-3018443900 CDM 84439 CPT 301 RC outpatient 145 145 HEALTHPARTNERS SX009 HEALTHPARTNERS 116 percent of total billed charges 89.9 137.75 Technical (Hospital) Services Free T 4 PX-3018443900 CDM 84439 CPT 301 RC outpatient 145 145 BLUE CROSS BLUE SHIELD WELLMARK SB889 [3081026] BCBS WYOMING [308102603] 137.75 percent of total billed charges 89.9 137.75 Technical (Hospital) Services Free T 4 PX-3018443900 CDM 84439 CPT 301 RC outpatient 145 145 MULTIPLAN INC 34080 [3081285] MULTIPLAN INC [308128501] 137.75 percent of total billed charges 89.9 137.75 Technical (Hospital) Services Free T 4 PX-3018443900 CDM 84439 CPT 301 RC outpatient 145 145 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES EPO [308136803] 116 percent of total billed charges 89.9 137.75 Technical (Hospital) Services Free T 4 PX-3018443900 CDM 84439 CPT 301 RC outpatient 145 145 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES HDHP [308136802] 116 percent of total billed charges 89.9 137.75 Technical (Hospital) Services Free T 4 PX-3018443900 CDM 84439 CPT 301 RC outpatient 145 145 MEDICA (COMMERCIAL) 94265 [3081118] MEDICA CLAIMS [308111801] 130.5 percent of total billed charges 89.9 137.75 Technical (Hospital) Services Free T 4 PX-3018443900 CDM 84439 CPT 301 RC outpatient 145 145 CIGNA 62308 [3081051] CIGNA 62308 [308105105] 116 percent of total billed charges 89.9 137.75 Technical (Hospital) Services Free T 4 PX-3018443900 CDM 84439 CPT 301 RC outpatient 145 145 CIGNA 62308 [3081051] CIGNA STATE OF WYOMING [308105107] 116 percent of total billed charges 89.9 137.75 Technical (Hospital) Services Free T 4 PX-3018443900 CDM 84439 CPT 301 RC inpatient 145 145 CIGNA 62308 [3081051] CIGNA 62308 [308105105] 114.81 percent of total billed charges 89.9 137.75 Technical (Hospital) Services Free T 4 PX-3018443900 CDM 84439 CPT 301 RC inpatient 145 145 CIGNA 62308 [3081051] CIGNA STATE OF WYOMING [308105107] 114.81 percent of total billed charges 89.9 137.75 Technical (Hospital) Services Free T 4 PX-3018443900 CDM 84439 CPT 301 RC inpatient 145 145 MULTIPLAN INC 34080 [3081285] MULTIPLAN INC [308128501] 137.75 percent of total billed charges 89.9 137.75 Technical (Hospital) Services Free T 4 PX-3018443900 CDM 84439 CPT 301 RC inpatient 145 145 MEDICA (COMMERCIAL) 94265 [3081118] MEDICA CLAIMS [308111801] 130.5 percent of total billed charges 89.9 137.75 Technical (Hospital) Services Free T 4 PX-3018443900 CDM 84439 CPT 301 RC inpatient 145 145 HEALTHPARTNERS SX009 HEALTHPARTNERS 114.81 percent of total billed charges 89.9 137.75 Technical (Hospital) Services Free T 4 PX-3018443900 CDM 84439 CPT 301 RC inpatient 145 145 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES EPO [308136803] 114.81 percent of total billed charges 89.9 137.75 Technical (Hospital) Services Free T 4 PX-3018443900 CDM 84439 CPT 301 RC inpatient 145 145 BLUE CROSS BLUE SHIELD WELLMARK SB889 [3081026] BCBS WYOMING [308102603] 137.75 percent of total billed charges 89.9 137.75 Technical (Hospital) Services Free T 4 PX-3018443900 CDM 84439 CPT 301 RC inpatient 145 145 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES HDHP [308136802] 114.81 percent of total billed charges 89.9 137.75 Technical (Hospital) Services Free T 4 PX-3018443900 CDM 84439 CPT 301 RC inpatient 145 145 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES PPO [308136801] 114.81 percent of total billed charges 89.9 137.75 Technical (Hospital) Services Free T 4 PX-3018443900 CDM 84439 CPT 301 RC inpatient 145 145 UNITED HEALTHCARE (COMMERCIAL) [3081199] UNITED HEALTHCARE 87726 [308119901] 89.9 percent of total billed charges 89.9 137.75 Technical (Hospital) Services "Assay, True Thyroxine" PX-3018443600 CDM 84436 CPT 301 RC inpatient 84 84 BLUE CROSS BLUE SHIELD WELLMARK SB889 [3081026] BCBS WYOMING [308102603] 79.8 percent of total billed charges 52.08 79.8 Technical (Hospital) Services "Assay, True Thyroxine" PX-3018443600 CDM 84436 CPT 301 RC inpatient 84 84 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES HDHP [308136802] 66.51 percent of total billed charges 52.08 79.8 Technical (Hospital) Services "Assay, True Thyroxine" PX-3018443600 CDM 84436 CPT 301 RC inpatient 84 84 UNITED HEALTHCARE (COMMERCIAL) [3081199] UNITED HEALTHCARE 87726 [308119901] 52.08 percent of total billed charges 52.08 79.8 Technical (Hospital) Services "Assay, True Thyroxine" PX-3018443600 CDM 84436 CPT 301 RC inpatient 84 84 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES PPO [308136801] 66.51 percent of total billed charges 52.08 79.8 Technical (Hospital) Services "Assay, True Thyroxine" PX-3018443600 CDM 84436 CPT 301 RC inpatient 84 84 MEDICA (COMMERCIAL) 94265 [3081118] MEDICA CLAIMS [308111801] 75.6 percent of total billed charges 52.08 79.8 Technical (Hospital) Services "Assay, True Thyroxine" PX-3018443600 CDM 84436 CPT 301 RC inpatient 84 84 MULTIPLAN INC 34080 [3081285] MULTIPLAN INC [308128501] 79.8 percent of total billed charges 52.08 79.8 Technical (Hospital) Services "Assay, True Thyroxine" PX-3018443600 CDM 84436 CPT 301 RC inpatient 84 84 CIGNA 62308 [3081051] CIGNA 62308 [308105105] 66.51 percent of total billed charges 52.08 79.8 Technical (Hospital) Services "Assay, True Thyroxine" PX-3018443600 CDM 84436 CPT 301 RC inpatient 84 84 CIGNA 62308 [3081051] CIGNA STATE OF WYOMING [308105107] 66.51 percent of total billed charges 52.08 79.8 Technical (Hospital) Services "Assay, True Thyroxine" PX-3018443600 CDM 84436 CPT 301 RC inpatient 84 84 HEALTHPARTNERS SX009 HEALTHPARTNERS 66.51 percent of total billed charges 52.08 79.8 Technical (Hospital) Services "Assay, True Thyroxine" PX-3018443600 CDM 84436 CPT 301 RC inpatient 84 84 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES EPO [308136803] 66.51 percent of total billed charges 52.08 79.8 Technical (Hospital) Services "Assay, True Thyroxine" PX-3018443600 CDM 84436 CPT 301 RC outpatient 84 84 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES PPO [308136801] 67.2 percent of total billed charges 52.08 79.8 Technical (Hospital) Services "Assay, True Thyroxine" PX-3018443600 CDM 84436 CPT 301 RC outpatient 84 84 HEALTHPARTNERS SX009 HEALTHPARTNERS 67.2 percent of total billed charges 52.08 79.8 Technical (Hospital) Services "Assay, True Thyroxine" PX-3018443600 CDM 84436 CPT 301 RC outpatient 84 84 UNITED HEALTHCARE (COMMERCIAL) [3081199] UNITED HEALTHCARE 87726 [308119901] 52.08 percent of total billed charges 52.08 79.8 Technical (Hospital) Services "Assay, True Thyroxine" PX-3018443600 CDM 84436 CPT 301 RC outpatient 84 84 BLUE CROSS BLUE SHIELD WELLMARK SB889 [3081026] BCBS WYOMING [308102603] 79.8 percent of total billed charges 52.08 79.8 Technical (Hospital) Services "Assay, True Thyroxine" PX-3018443600 CDM 84436 CPT 301 RC outpatient 84 84 MULTIPLAN INC 34080 [3081285] MULTIPLAN INC [308128501] 79.8 percent of total billed charges 52.08 79.8 Technical (Hospital) Services "Assay, True Thyroxine" PX-3018443600 CDM 84436 CPT 301 RC outpatient 84 84 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES HDHP [308136802] 67.2 percent of total billed charges 52.08 79.8 Technical (Hospital) Services "Assay, True Thyroxine" PX-3018443600 CDM 84436 CPT 301 RC outpatient 84 84 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES EPO [308136803] 67.2 percent of total billed charges 52.08 79.8 Technical (Hospital) Services "Assay, True Thyroxine" PX-3018443600 CDM 84436 CPT 301 RC outpatient 84 84 CIGNA 62308 [3081051] CIGNA 62308 [308105105] 67.2 percent of total billed charges 52.08 79.8 Technical (Hospital) Services "Assay, True Thyroxine" PX-3018443600 CDM 84436 CPT 301 RC outpatient 84 84 CIGNA 62308 [3081051] CIGNA STATE OF WYOMING [308105107] 67.2 percent of total billed charges 52.08 79.8 Technical (Hospital) Services "Assay, True Thyroxine" PX-3018443600 CDM 84436 CPT 301 RC outpatient 84 84 MEDICA (COMMERCIAL) 94265 [3081118] MEDICA CLAIMS [308111801] 75.6 percent of total billed charges 52.08 79.8 Technical (Hospital) Services Ref Thyroglobulin Tumor Marker PX-3018443200 CDM 84432 CPT 301 RC outpatient 148 148 MEDICA (COMMERCIAL) 94265 [3081118] MEDICA CLAIMS [308111801] 133.2 percent of total billed charges 91.76 140.6 Technical (Hospital) Services Ref Thyroglobulin Tumor Marker PX-3018443200 CDM 84432 CPT 301 RC outpatient 148 148 CIGNA 62308 [3081051] CIGNA 62308 [308105105] 118.4 percent of total billed charges 91.76 140.6 Technical (Hospital) Services Ref Thyroglobulin Tumor Marker PX-3018443200 CDM 84432 CPT 301 RC outpatient 148 148 CIGNA 62308 [3081051] CIGNA STATE OF WYOMING [308105107] 118.4 percent of total billed charges 91.76 140.6 Technical (Hospital) Services Ref Thyroglobulin Tumor Marker PX-3018443200 CDM 84432 CPT 301 RC outpatient 148 148 HEALTHPARTNERS SX009 HEALTHPARTNERS 118.4 percent of total billed charges 91.76 140.6 Technical (Hospital) Services Ref Thyroglobulin Tumor Marker PX-3018443200 CDM 84432 CPT 301 RC outpatient 148 148 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES PPO [308136801] 118.4 percent of total billed charges 91.76 140.6 Technical (Hospital) Services Ref Thyroglobulin Tumor Marker PX-3018443200 CDM 84432 CPT 301 RC outpatient 148 148 UNITED HEALTHCARE (COMMERCIAL) [3081199] UNITED HEALTHCARE 87726 [308119901] 91.76 percent of total billed charges 91.76 140.6 Technical (Hospital) Services Ref Thyroglobulin Tumor Marker PX-3018443200 CDM 84432 CPT 301 RC outpatient 148 148 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES EPO [308136803] 118.4 percent of total billed charges 91.76 140.6 Technical (Hospital) Services Ref Thyroglobulin Tumor Marker PX-3018443200 CDM 84432 CPT 301 RC outpatient 148 148 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES HDHP [308136802] 118.4 percent of total billed charges 91.76 140.6 Technical (Hospital) Services Ref Thyroglobulin Tumor Marker PX-3018443200 CDM 84432 CPT 301 RC outpatient 148 148 MULTIPLAN INC 34080 [3081285] MULTIPLAN INC [308128501] 140.6 percent of total billed charges 91.76 140.6 Technical (Hospital) Services Ref Thyroglobulin Tumor Marker PX-3018443200 CDM 84432 CPT 301 RC outpatient 148 148 BLUE CROSS BLUE SHIELD WELLMARK SB889 [3081026] BCBS WYOMING [308102603] 140.6 percent of total billed charges 91.76 140.6 Technical (Hospital) Services Ref Thyroglobulin Tumor Marker PX-3018443200 CDM 84432 CPT 301 RC inpatient 148 148 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES PPO [308136801] 117.19 percent of total billed charges 91.76 140.6 Technical (Hospital) Services Ref Thyroglobulin Tumor Marker PX-3018443200 CDM 84432 CPT 301 RC inpatient 148 148 UNITED HEALTHCARE (COMMERCIAL) [3081199] UNITED HEALTHCARE 87726 [308119901] 91.76 percent of total billed charges 91.76 140.6 Technical (Hospital) Services Ref Thyroglobulin Tumor Marker PX-3018443200 CDM 84432 CPT 301 RC inpatient 148 148 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES HDHP [308136802] 117.19 percent of total billed charges 91.76 140.6 Technical (Hospital) Services Ref Thyroglobulin Tumor Marker PX-3018443200 CDM 84432 CPT 301 RC inpatient 148 148 BLUE CROSS BLUE SHIELD WELLMARK SB889 [3081026] BCBS WYOMING [308102603] 140.6 percent of total billed charges 91.76 140.6 Technical (Hospital) Services Ref Thyroglobulin Tumor Marker PX-3018443200 CDM 84432 CPT 301 RC inpatient 148 148 MEDICA (COMMERCIAL) 94265 [3081118] MEDICA CLAIMS [308111801] 133.2 percent of total billed charges 91.76 140.6 Technical (Hospital) Services Ref Thyroglobulin Tumor Marker PX-3018443200 CDM 84432 CPT 301 RC inpatient 148 148 MULTIPLAN INC 34080 [3081285] MULTIPLAN INC [308128501] 140.6 percent of total billed charges 91.76 140.6 Technical (Hospital) Services Ref Thyroglobulin Tumor Marker PX-3018443200 CDM 84432 CPT 301 RC inpatient 148 148 CIGNA 62308 [3081051] CIGNA 62308 [308105105] 117.19 percent of total billed charges 91.76 140.6 Technical (Hospital) Services Ref Thyroglobulin Tumor Marker PX-3018443200 CDM 84432 CPT 301 RC inpatient 148 148 CIGNA 62308 [3081051] CIGNA STATE OF WYOMING [308105107] 117.19 percent of total billed charges 91.76 140.6 Technical (Hospital) Services Ref Thyroglobulin Tumor Marker PX-3018443200 CDM 84432 CPT 301 RC inpatient 148 148 HEALTHPARTNERS SX009 HEALTHPARTNERS 117.19 percent of total billed charges 91.76 140.6 Technical (Hospital) Services Ref Thyroglobulin Tumor Marker PX-3018443200 CDM 84432 CPT 301 RC inpatient 148 148 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES EPO [308136803] 117.19 percent of total billed charges 91.76 140.6 Technical (Hospital) Services Ref Thyroglobulin Tumor Marker PX-3018443201 CDM 84432 CPT 301 RC inpatient 148 148 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES PPO [308136801] 117.19 percent of total billed charges 91.76 140.6 Technical (Hospital) Services Ref Thyroglobulin Tumor Marker PX-3018443201 CDM 84432 CPT 301 RC inpatient 148 148 UNITED HEALTHCARE (COMMERCIAL) [3081199] UNITED HEALTHCARE 87726 [308119901] 91.76 percent of total billed charges 91.76 140.6 Technical (Hospital) Services Ref Thyroglobulin Tumor Marker PX-3018443201 CDM 84432 CPT 301 RC inpatient 148 148 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES HDHP [308136802] 117.19 percent of total billed charges 91.76 140.6 Technical (Hospital) Services Ref Thyroglobulin Tumor Marker PX-3018443201 CDM 84432 CPT 301 RC inpatient 148 148 BLUE CROSS BLUE SHIELD WELLMARK SB889 [3081026] BCBS WYOMING [308102603] 140.6 percent of total billed charges 91.76 140.6 Technical (Hospital) Services Ref Thyroglobulin Tumor Marker PX-3018443201 CDM 84432 CPT 301 RC inpatient 148 148 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES EPO [308136803] 117.19 percent of total billed charges 91.76 140.6 Technical (Hospital) Services Ref Thyroglobulin Tumor Marker PX-3018443201 CDM 84432 CPT 301 RC inpatient 148 148 HEALTHPARTNERS SX009 HEALTHPARTNERS 117.19 percent of total billed charges 91.76 140.6 Technical (Hospital) Services Ref Thyroglobulin Tumor Marker PX-3018443201 CDM 84432 CPT 301 RC inpatient 148 148 MULTIPLAN INC 34080 [3081285] MULTIPLAN INC [308128501] 140.6 percent of total billed charges 91.76 140.6 Technical (Hospital) Services Ref Thyroglobulin Tumor Marker PX-3018443201 CDM 84432 CPT 301 RC inpatient 148 148 MEDICA (COMMERCIAL) 94265 [3081118] MEDICA CLAIMS [308111801] 133.2 percent of total billed charges 91.76 140.6 Technical (Hospital) Services Ref Thyroglobulin Tumor Marker PX-3018443201 CDM 84432 CPT 301 RC inpatient 148 148 CIGNA 62308 [3081051] CIGNA 62308 [308105105] 117.19 percent of total billed charges 91.76 140.6 Technical (Hospital) Services Ref Thyroglobulin Tumor Marker PX-3018443201 CDM 84432 CPT 301 RC inpatient 148 148 CIGNA 62308 [3081051] CIGNA STATE OF WYOMING [308105107] 117.19 percent of total billed charges 91.76 140.6 Technical (Hospital) Services Ref Thyroglobulin Tumor Marker PX-3018443201 CDM 84432 CPT 301 RC outpatient 148 148 BLUE CROSS BLUE SHIELD WELLMARK SB889 [3081026] BCBS WYOMING [308102603] 140.6 percent of total billed charges 91.76 140.6 Technical (Hospital) Services Ref Thyroglobulin Tumor Marker PX-3018443201 CDM 84432 CPT 301 RC outpatient 148 148 MULTIPLAN INC 34080 [3081285] MULTIPLAN INC [308128501] 140.6 percent of total billed charges 91.76 140.6 Technical (Hospital) Services Ref Thyroglobulin Tumor Marker PX-3018443201 CDM 84432 CPT 301 RC outpatient 148 148 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES HDHP [308136802] 118.4 percent of total billed charges 91.76 140.6 Technical (Hospital) Services Ref Thyroglobulin Tumor Marker PX-3018443201 CDM 84432 CPT 301 RC outpatient 148 148 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES EPO [308136803] 118.4 percent of total billed charges 91.76 140.6 Technical (Hospital) Services Ref Thyroglobulin Tumor Marker PX-3018443201 CDM 84432 CPT 301 RC outpatient 148 148 UNITED HEALTHCARE (COMMERCIAL) [3081199] UNITED HEALTHCARE 87726 [308119901] 91.76 percent of total billed charges 91.76 140.6 Technical (Hospital) Services Ref Thyroglobulin Tumor Marker PX-3018443201 CDM 84432 CPT 301 RC outpatient 148 148 HEALTHPARTNERS SX009 HEALTHPARTNERS 118.4 percent of total billed charges 91.76 140.6 Technical (Hospital) Services Ref Thyroglobulin Tumor Marker PX-3018443201 CDM 84432 CPT 301 RC outpatient 148 148 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES PPO [308136801] 118.4 percent of total billed charges 91.76 140.6 Technical (Hospital) Services Ref Thyroglobulin Tumor Marker PX-3018443201 CDM 84432 CPT 301 RC outpatient 148 148 MEDICA (COMMERCIAL) 94265 [3081118] MEDICA CLAIMS [308111801] 133.2 percent of total billed charges 91.76 140.6 Technical (Hospital) Services Ref Thyroglobulin Tumor Marker PX-3018443201 CDM 84432 CPT 301 RC outpatient 148 148 CIGNA 62308 [3081051] CIGNA 62308 [308105105] 118.4 percent of total billed charges 91.76 140.6 Technical (Hospital) Services Ref Thyroglobulin Tumor Marker PX-3018443201 CDM 84432 CPT 301 RC outpatient 148 148 CIGNA 62308 [3081051] CIGNA STATE OF WYOMING [308105107] 118.4 percent of total billed charges 91.76 140.6 Technical (Hospital) Services Ref Thiamine PX-3018442500 CDM 84425 CPT 301 RC outpatient 148 148 CIGNA 62308 [3081051] CIGNA 62308 [308105105] 118.4 percent of total billed charges 91.76 140.6 Technical (Hospital) Services Ref Thiamine PX-3018442500 CDM 84425 CPT 301 RC outpatient 148 148 CIGNA 62308 [3081051] CIGNA STATE OF WYOMING [308105107] 118.4 percent of total billed charges 91.76 140.6 Technical (Hospital) Services Ref Thiamine PX-3018442500 CDM 84425 CPT 301 RC outpatient 148 148 MEDICA (COMMERCIAL) 94265 [3081118] MEDICA CLAIMS [308111801] 133.2 percent of total billed charges 91.76 140.6 Technical (Hospital) Services Ref Thiamine PX-3018442500 CDM 84425 CPT 301 RC outpatient 148 148 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES HDHP [308136802] 118.4 percent of total billed charges 91.76 140.6 Technical (Hospital) Services Ref Thiamine PX-3018442500 CDM 84425 CPT 301 RC outpatient 148 148 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES EPO [308136803] 118.4 percent of total billed charges 91.76 140.6 Technical (Hospital) Services Ref Thiamine PX-3018442500 CDM 84425 CPT 301 RC outpatient 148 148 BLUE CROSS BLUE SHIELD WELLMARK SB889 [3081026] BCBS WYOMING [308102603] 140.6 percent of total billed charges 91.76 140.6 Technical (Hospital) Services Ref Thiamine PX-3018442500 CDM 84425 CPT 301 RC outpatient 148 148 MULTIPLAN INC 34080 [3081285] MULTIPLAN INC [308128501] 140.6 percent of total billed charges 91.76 140.6 Technical (Hospital) Services Ref Thiamine PX-3018442500 CDM 84425 CPT 301 RC outpatient 148 148 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES PPO [308136801] 118.4 percent of total billed charges 91.76 140.6 Technical (Hospital) Services Ref Thiamine PX-3018442500 CDM 84425 CPT 301 RC outpatient 148 148 HEALTHPARTNERS SX009 HEALTHPARTNERS 118.4 percent of total billed charges 91.76 140.6 Technical (Hospital) Services Ref Thiamine PX-3018442500 CDM 84425 CPT 301 RC outpatient 148 148 UNITED HEALTHCARE (COMMERCIAL) [3081199] UNITED HEALTHCARE 87726 [308119901] 91.76 percent of total billed charges 91.76 140.6 Technical (Hospital) Services Ref Thiamine PX-3018442500 CDM 84425 CPT 301 RC inpatient 148 148 CIGNA 62308 [3081051] CIGNA 62308 [308105105] 117.19 percent of total billed charges 91.76 140.6 Technical (Hospital) Services Ref Thiamine PX-3018442500 CDM 84425 CPT 301 RC inpatient 148 148 CIGNA 62308 [3081051] CIGNA STATE OF WYOMING [308105107] 117.19 percent of total billed charges 91.76 140.6 Technical (Hospital) Services Ref Thiamine PX-3018442500 CDM 84425 CPT 301 RC inpatient 148 148 MULTIPLAN INC 34080 [3081285] MULTIPLAN INC [308128501] 140.6 percent of total billed charges 91.76 140.6 Technical (Hospital) Services Ref Thiamine PX-3018442500 CDM 84425 CPT 301 RC inpatient 148 148 MEDICA (COMMERCIAL) 94265 [3081118] MEDICA CLAIMS [308111801] 133.2 percent of total billed charges 91.76 140.6 Technical (Hospital) Services Ref Thiamine PX-3018442500 CDM 84425 CPT 301 RC inpatient 148 148 HEALTHPARTNERS SX009 HEALTHPARTNERS 117.19 percent of total billed charges 91.76 140.6 Technical (Hospital) Services Ref Thiamine PX-3018442500 CDM 84425 CPT 301 RC inpatient 148 148 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES EPO [308136803] 117.19 percent of total billed charges 91.76 140.6 Technical (Hospital) Services Ref Thiamine PX-3018442500 CDM 84425 CPT 301 RC inpatient 148 148 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES HDHP [308136802] 117.19 percent of total billed charges 91.76 140.6 Technical (Hospital) Services Ref Thiamine PX-3018442500 CDM 84425 CPT 301 RC inpatient 148 148 BLUE CROSS BLUE SHIELD WELLMARK SB889 [3081026] BCBS WYOMING [308102603] 140.6 percent of total billed charges 91.76 140.6 Technical (Hospital) Services Ref Thiamine PX-3018442500 CDM 84425 CPT 301 RC inpatient 148 148 UNITED HEALTHCARE (COMMERCIAL) [3081199] UNITED HEALTHCARE 87726 [308119901] 91.76 percent of total billed charges 91.76 140.6 Technical (Hospital) Services Ref Thiamine PX-3018442500 CDM 84425 CPT 301 RC inpatient 148 148 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES PPO [308136801] 117.19 percent of total billed charges 91.76 140.6 Technical (Hospital) Services Ref Thiamine PX-3018442501 CDM 84425 CPT 301 RC outpatient 148 148 CIGNA 62308 [3081051] CIGNA 62308 [308105105] 118.4 percent of total billed charges 91.76 140.6 Technical (Hospital) Services Ref Thiamine PX-3018442501 CDM 84425 CPT 301 RC outpatient 148 148 CIGNA 62308 [3081051] CIGNA STATE OF WYOMING [308105107] 118.4 percent of total billed charges 91.76 140.6 Technical (Hospital) Services Ref Thiamine PX-3018442501 CDM 84425 CPT 301 RC outpatient 148 148 MEDICA (COMMERCIAL) 94265 [3081118] MEDICA CLAIMS [308111801] 133.2 percent of total billed charges 91.76 140.6 Technical (Hospital) Services Ref Thiamine PX-3018442501 CDM 84425 CPT 301 RC outpatient 148 148 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES PPO [308136801] 118.4 percent of total billed charges 91.76 140.6 Technical (Hospital) Services Ref Thiamine PX-3018442501 CDM 84425 CPT 301 RC outpatient 148 148 HEALTHPARTNERS SX009 HEALTHPARTNERS 118.4 percent of total billed charges 91.76 140.6 Technical (Hospital) Services Ref Thiamine PX-3018442501 CDM 84425 CPT 301 RC outpatient 148 148 UNITED HEALTHCARE (COMMERCIAL) [3081199] UNITED HEALTHCARE 87726 [308119901] 91.76 percent of total billed charges 91.76 140.6 Technical (Hospital) Services Ref Thiamine PX-3018442501 CDM 84425 CPT 301 RC outpatient 148 148 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES HDHP [308136802] 118.4 percent of total billed charges 91.76 140.6 Technical (Hospital) Services Ref Thiamine PX-3018442501 CDM 84425 CPT 301 RC outpatient 148 148 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES EPO [308136803] 118.4 percent of total billed charges 91.76 140.6 Technical (Hospital) Services Ref Thiamine PX-3018442501 CDM 84425 CPT 301 RC outpatient 148 148 BLUE CROSS BLUE SHIELD WELLMARK SB889 [3081026] BCBS WYOMING [308102603] 140.6 percent of total billed charges 91.76 140.6 Technical (Hospital) Services Ref Thiamine PX-3018442501 CDM 84425 CPT 301 RC outpatient 148 148 MULTIPLAN INC 34080 [3081285] MULTIPLAN INC [308128501] 140.6 percent of total billed charges 91.76 140.6 Technical (Hospital) Services Ref Thiamine PX-3018442501 CDM 84425 CPT 301 RC inpatient 148 148 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES PPO [308136801] 117.19 percent of total billed charges 91.76 140.6 Technical (Hospital) Services Ref Thiamine PX-3018442501 CDM 84425 CPT 301 RC inpatient 148 148 UNITED HEALTHCARE (COMMERCIAL) [3081199] UNITED HEALTHCARE 87726 [308119901] 91.76 percent of total billed charges 91.76 140.6 Technical (Hospital) Services Ref Thiamine PX-3018442501 CDM 84425 CPT 301 RC inpatient 148 148 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES HDHP [308136802] 117.19 percent of total billed charges 91.76 140.6 Technical (Hospital) Services Ref Thiamine PX-3018442501 CDM 84425 CPT 301 RC inpatient 148 148 BLUE CROSS BLUE SHIELD WELLMARK SB889 [3081026] BCBS WYOMING [308102603] 140.6 percent of total billed charges 91.76 140.6 Technical (Hospital) Services Ref Thiamine PX-3018442501 CDM 84425 CPT 301 RC inpatient 148 148 HEALTHPARTNERS SX009 HEALTHPARTNERS 117.19 percent of total billed charges 91.76 140.6 Technical (Hospital) Services Ref Thiamine PX-3018442501 CDM 84425 CPT 301 RC inpatient 148 148 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES EPO [308136803] 117.19 percent of total billed charges 91.76 140.6 Technical (Hospital) Services Ref Thiamine PX-3018442501 CDM 84425 CPT 301 RC inpatient 148 148 MEDICA (COMMERCIAL) 94265 [3081118] MEDICA CLAIMS [308111801] 133.2 percent of total billed charges 91.76 140.6 Technical (Hospital) Services Ref Thiamine PX-3018442501 CDM 84425 CPT 301 RC inpatient 148 148 MULTIPLAN INC 34080 [3081285] MULTIPLAN INC [308128501] 140.6 percent of total billed charges 91.76 140.6 Technical (Hospital) Services Ref Thiamine PX-3018442501 CDM 84425 CPT 301 RC inpatient 148 148 CIGNA 62308 [3081051] CIGNA 62308 [308105105] 117.19 percent of total billed charges 91.76 140.6 Technical (Hospital) Services Ref Thiamine PX-3018442501 CDM 84425 CPT 301 RC inpatient 148 148 CIGNA 62308 [3081051] CIGNA STATE OF WYOMING [308105107] 117.19 percent of total billed charges 91.76 140.6 Technical (Hospital) Services "Ref Testosterone Bioavailable for Mayo Total, Bio, Free" PX-3018441000 CDM 84410 CPT 301 RC outpatient 289 289 MULTIPLAN INC 34080 [3081285] MULTIPLAN INC [308128501] 274.55 percent of total billed charges 179.18 274.55 Technical (Hospital) Services "Ref Testosterone Bioavailable for Mayo Total, Bio, Free" PX-3018441000 CDM 84410 CPT 301 RC outpatient 289 289 BLUE CROSS BLUE SHIELD WELLMARK SB889 [3081026] BCBS WYOMING [308102603] 274.55 percent of total billed charges 179.18 274.55 Technical (Hospital) Services "Ref Testosterone Bioavailable for Mayo Total, Bio, Free" PX-3018441000 CDM 84410 CPT 301 RC outpatient 289 289 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES EPO [308136803] 231.2 percent of total billed charges 179.18 274.55 Technical (Hospital) Services "Ref Testosterone Bioavailable for Mayo Total, Bio, Free" PX-3018441000 CDM 84410 CPT 301 RC outpatient 289 289 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES HDHP [308136802] 231.2 percent of total billed charges 179.18 274.55 Technical (Hospital) Services "Ref Testosterone Bioavailable for Mayo Total, Bio, Free" PX-3018441000 CDM 84410 CPT 301 RC outpatient 289 289 UNITED HEALTHCARE (COMMERCIAL) [3081199] UNITED HEALTHCARE 87726 [308119901] 179.18 percent of total billed charges 179.18 274.55 Technical (Hospital) Services "Ref Testosterone Bioavailable for Mayo Total, Bio, Free" PX-3018441000 CDM 84410 CPT 301 RC outpatient 289 289 HEALTHPARTNERS SX009 HEALTHPARTNERS 231.2 percent of total billed charges 179.18 274.55 Technical (Hospital) Services "Ref Testosterone Bioavailable for Mayo Total, Bio, Free" PX-3018441000 CDM 84410 CPT 301 RC outpatient 289 289 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES PPO [308136801] 231.2 percent of total billed charges 179.18 274.55 Technical (Hospital) Services "Ref Testosterone Bioavailable for Mayo Total, Bio, Free" PX-3018441000 CDM 84410 CPT 301 RC outpatient 289 289 MEDICA (COMMERCIAL) 94265 [3081118] MEDICA CLAIMS [308111801] 260.1 percent of total billed charges 179.18 274.55 Technical (Hospital) Services "Ref Testosterone Bioavailable for Mayo Total, Bio, Free" PX-3018441000 CDM 84410 CPT 301 RC outpatient 289 289 CIGNA 62308 [3081051] CIGNA 62308 [308105105] 231.2 percent of total billed charges 179.18 274.55 Technical (Hospital) Services "Ref Testosterone Bioavailable for Mayo Total, Bio, Free" PX-3018441000 CDM 84410 CPT 301 RC outpatient 289 289 CIGNA 62308 [3081051] CIGNA STATE OF WYOMING [308105107] 231.2 percent of total billed charges 179.18 274.55 Technical (Hospital) Services "Ref Testosterone Bioavailable for Mayo Total, Bio, Free" PX-3018441000 CDM 84410 CPT 301 RC inpatient 289 289 CIGNA 62308 [3081051] CIGNA 62308 [308105105] 228.83 percent of total billed charges 179.18 274.55 Technical (Hospital) Services "Ref Testosterone Bioavailable for Mayo Total, Bio, Free" PX-3018441000 CDM 84410 CPT 301 RC inpatient 289 289 CIGNA 62308 [3081051] CIGNA STATE OF WYOMING [308105107] 228.83 percent of total billed charges 179.18 274.55 Technical (Hospital) Services "Ref Testosterone Bioavailable for Mayo Total, Bio, Free" PX-3018441000 CDM 84410 CPT 301 RC inpatient 289 289 MULTIPLAN INC 34080 [3081285] MULTIPLAN INC [308128501] 274.55 percent of total billed charges 179.18 274.55 Technical (Hospital) Services "Ref Testosterone Bioavailable for Mayo Total, Bio, Free" PX-3018441000 CDM 84410 CPT 301 RC inpatient 289 289 MEDICA (COMMERCIAL) 94265 [3081118] MEDICA CLAIMS [308111801] 260.1 percent of total billed charges 179.18 274.55 Technical (Hospital) Services "Ref Testosterone Bioavailable for Mayo Total, Bio, Free" PX-3018441000 CDM 84410 CPT 301 RC inpatient 289 289 HEALTHPARTNERS SX009 HEALTHPARTNERS 228.83 percent of total billed charges 179.18 274.55 Technical (Hospital) Services "Ref Testosterone Bioavailable for Mayo Total, Bio, Free" PX-3018441000 CDM 84410 CPT 301 RC inpatient 289 289 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES EPO [308136803] 228.83 percent of total billed charges 179.18 274.55 Technical (Hospital) Services "Ref Testosterone Bioavailable for Mayo Total, Bio, Free" PX-3018441000 CDM 84410 CPT 301 RC inpatient 289 289 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES HDHP [308136802] 228.83 percent of total billed charges 179.18 274.55 Technical (Hospital) Services "Ref Testosterone Bioavailable for Mayo Total, Bio, Free" PX-3018441000 CDM 84410 CPT 301 RC inpatient 289 289 BLUE CROSS BLUE SHIELD WELLMARK SB889 [3081026] BCBS WYOMING [308102603] 274.55 percent of total billed charges 179.18 274.55 Technical (Hospital) Services "Ref Testosterone Bioavailable for Mayo Total, Bio, Free" PX-3018441000 CDM 84410 CPT 301 RC inpatient 289 289 UNITED HEALTHCARE (COMMERCIAL) [3081199] UNITED HEALTHCARE 87726 [308119901] 179.18 percent of total billed charges 179.18 274.55 Technical (Hospital) Services "Ref Testosterone Bioavailable for Mayo Total, Bio, Free" PX-3018441000 CDM 84410 CPT 301 RC inpatient 289 289 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES PPO [308136801] 228.83 percent of total billed charges 179.18 274.55 Technical (Hospital) Services Testosterone Total PX-3018440300 CDM 84403 CPT 301 RC inpatient 232 232 MULTIPLAN INC 34080 [3081285] MULTIPLAN INC [308128501] 220.4 percent of total billed charges 143.84 220.4 Technical (Hospital) Services Testosterone Total PX-3018440300 CDM 84403 CPT 301 RC inpatient 232 232 MEDICA (COMMERCIAL) 94265 [3081118] MEDICA CLAIMS [308111801] 208.8 percent of total billed charges 143.84 220.4 Technical (Hospital) Services Testosterone Total PX-3018440300 CDM 84403 CPT 301 RC inpatient 232 232 CIGNA 62308 [3081051] CIGNA 62308 [308105105] 183.7 percent of total billed charges 143.84 220.4 Technical (Hospital) Services Testosterone Total PX-3018440300 CDM 84403 CPT 301 RC inpatient 232 232 CIGNA 62308 [3081051] CIGNA STATE OF WYOMING [308105107] 183.7 percent of total billed charges 143.84 220.4 Technical (Hospital) Services Testosterone Total PX-3018440300 CDM 84403 CPT 301 RC inpatient 232 232 HEALTHPARTNERS SX009 HEALTHPARTNERS 183.7 percent of total billed charges 143.84 220.4 Technical (Hospital) Services Testosterone Total PX-3018440300 CDM 84403 CPT 301 RC inpatient 232 232 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES EPO [308136803] 183.7 percent of total billed charges 143.84 220.4 Technical (Hospital) Services Testosterone Total PX-3018440300 CDM 84403 CPT 301 RC inpatient 232 232 UNITED HEALTHCARE (COMMERCIAL) [3081199] UNITED HEALTHCARE 87726 [308119901] 143.84 percent of total billed charges 143.84 220.4 Technical (Hospital) Services Testosterone Total PX-3018440300 CDM 84403 CPT 301 RC inpatient 232 232 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES PPO [308136801] 183.7 percent of total billed charges 143.84 220.4 Technical (Hospital) Services Testosterone Total PX-3018440300 CDM 84403 CPT 301 RC inpatient 232 232 BLUE CROSS BLUE SHIELD WELLMARK SB889 [3081026] BCBS WYOMING [308102603] 220.4 percent of total billed charges 143.84 220.4 Technical (Hospital) Services Testosterone Total PX-3018440300 CDM 84403 CPT 301 RC inpatient 232 232 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES HDHP [308136802] 183.7 percent of total billed charges 143.84 220.4 Technical (Hospital) Services Testosterone Total PX-3018440300 CDM 84403 CPT 301 RC outpatient 232 232 UNITED HEALTHCARE (COMMERCIAL) [3081199] UNITED HEALTHCARE 87726 [308119901] 143.84 percent of total billed charges 143.84 220.4 Technical (Hospital) Services Testosterone Total PX-3018440300 CDM 84403 CPT 301 RC outpatient 232 232 HEALTHPARTNERS SX009 HEALTHPARTNERS 185.6 percent of total billed charges 143.84 220.4 Technical (Hospital) Services Testosterone Total PX-3018440300 CDM 84403 CPT 301 RC outpatient 232 232 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES PPO [308136801] 185.6 percent of total billed charges 143.84 220.4 Technical (Hospital) Services Testosterone Total PX-3018440300 CDM 84403 CPT 301 RC outpatient 232 232 BLUE CROSS BLUE SHIELD WELLMARK SB889 [3081026] BCBS WYOMING [308102603] 220.4 percent of total billed charges 143.84 220.4 Technical (Hospital) Services Testosterone Total PX-3018440300 CDM 84403 CPT 301 RC outpatient 232 232 MULTIPLAN INC 34080 [3081285] MULTIPLAN INC [308128501] 220.4 percent of total billed charges 143.84 220.4 Technical (Hospital) Services Testosterone Total PX-3018440300 CDM 84403 CPT 301 RC outpatient 232 232 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES EPO [308136803] 185.6 percent of total billed charges 143.84 220.4 Technical (Hospital) Services Testosterone Total PX-3018440300 CDM 84403 CPT 301 RC outpatient 232 232 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES HDHP [308136802] 185.6 percent of total billed charges 143.84 220.4 Technical (Hospital) Services Testosterone Total PX-3018440300 CDM 84403 CPT 301 RC outpatient 232 232 MEDICA (COMMERCIAL) 94265 [3081118] MEDICA CLAIMS [308111801] 208.8 percent of total billed charges 143.84 220.4 Technical (Hospital) Services Testosterone Total PX-3018440300 CDM 84403 CPT 301 RC outpatient 232 232 CIGNA 62308 [3081051] CIGNA 62308 [308105105] 185.6 percent of total billed charges 143.84 220.4 Technical (Hospital) Services Testosterone Total PX-3018440300 CDM 84403 CPT 301 RC outpatient 232 232 CIGNA 62308 [3081051] CIGNA STATE OF WYOMING [308105107] 185.6 percent of total billed charges 143.84 220.4 Technical (Hospital) Services "Ref Testosterone Total, for Mayo Total and Free" PX-3018440301 CDM 84403 CPT 301 RC inpatient 232 232 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES HDHP [308136802] 183.7 percent of total billed charges 143.84 220.4 Technical (Hospital) Services "Ref Testosterone Total, for Mayo Total and Free" PX-3018440301 CDM 84403 CPT 301 RC inpatient 232 232 UNITED HEALTHCARE (COMMERCIAL) [3081199] UNITED HEALTHCARE 87726 [308119901] 143.84 percent of total billed charges 143.84 220.4 Technical (Hospital) Services "Ref Testosterone Total, for Mayo Total and Free" PX-3018440301 CDM 84403 CPT 301 RC inpatient 232 232 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES PPO [308136801] 183.7 percent of total billed charges 143.84 220.4 Technical (Hospital) Services "Ref Testosterone Total, for Mayo Total and Free" PX-3018440301 CDM 84403 CPT 301 RC inpatient 232 232 BLUE CROSS BLUE SHIELD WELLMARK SB889 [3081026] BCBS WYOMING [308102603] 220.4 percent of total billed charges 143.84 220.4 Technical (Hospital) Services "Ref Testosterone Total, for Mayo Total and Free" PX-3018440301 CDM 84403 CPT 301 RC inpatient 232 232 MEDICA (COMMERCIAL) 94265 [3081118] MEDICA CLAIMS [308111801] 208.8 percent of total billed charges 143.84 220.4 Technical (Hospital) Services "Ref Testosterone Total, for Mayo Total and Free" PX-3018440301 CDM 84403 CPT 301 RC inpatient 232 232 MULTIPLAN INC 34080 [3081285] MULTIPLAN INC [308128501] 220.4 percent of total billed charges 143.84 220.4 Technical (Hospital) Services "Ref Testosterone Total, for Mayo Total and Free" PX-3018440301 CDM 84403 CPT 301 RC inpatient 232 232 CIGNA 62308 [3081051] CIGNA 62308 [308105105] 183.7 percent of total billed charges 143.84 220.4 Technical (Hospital) Services "Ref Testosterone Total, for Mayo Total and Free" PX-3018440301 CDM 84403 CPT 301 RC inpatient 232 232 CIGNA 62308 [3081051] CIGNA STATE OF WYOMING [308105107] 183.7 percent of total billed charges 143.84 220.4 Technical (Hospital) Services "Ref Testosterone Total, for Mayo Total and Free" PX-3018440301 CDM 84403 CPT 301 RC inpatient 232 232 HEALTHPARTNERS SX009 HEALTHPARTNERS 183.7 percent of total billed charges 143.84 220.4 Technical (Hospital) Services "Ref Testosterone Total, for Mayo Total and Free" PX-3018440301 CDM 84403 CPT 301 RC inpatient 232 232 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES EPO [308136803] 183.7 percent of total billed charges 143.84 220.4 Technical (Hospital) Services "Ref Testosterone Total, for Mayo Total and Free" PX-3018440301 CDM 84403 CPT 301 RC outpatient 232 232 UNITED HEALTHCARE (COMMERCIAL) [3081199] UNITED HEALTHCARE 87726 [308119901] 143.84 percent of total billed charges 143.84 220.4 Technical (Hospital) Services "Ref Testosterone Total, for Mayo Total and Free" PX-3018440301 CDM 84403 CPT 301 RC outpatient 232 232 HEALTHPARTNERS SX009 HEALTHPARTNERS 185.6 percent of total billed charges 143.84 220.4 Technical (Hospital) Services "Ref Testosterone Total, for Mayo Total and Free" PX-3018440301 CDM 84403 CPT 301 RC outpatient 232 232 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES PPO [308136801] 185.6 percent of total billed charges 143.84 220.4 Technical (Hospital) Services "Ref Testosterone Total, for Mayo Total and Free" PX-3018440301 CDM 84403 CPT 301 RC outpatient 232 232 BLUE CROSS BLUE SHIELD WELLMARK SB889 [3081026] BCBS WYOMING [308102603] 220.4 percent of total billed charges 143.84 220.4 Technical (Hospital) Services "Ref Testosterone Total, for Mayo Total and Free" PX-3018440301 CDM 84403 CPT 301 RC outpatient 232 232 MULTIPLAN INC 34080 [3081285] MULTIPLAN INC [308128501] 220.4 percent of total billed charges 143.84 220.4 Technical (Hospital) Services "Ref Testosterone Total, for Mayo Total and Free" PX-3018440301 CDM 84403 CPT 301 RC outpatient 232 232 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES EPO [308136803] 185.6 percent of total billed charges 143.84 220.4 Technical (Hospital) Services "Ref Testosterone Total, for Mayo Total and Free" PX-3018440301 CDM 84403 CPT 301 RC outpatient 232 232 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES HDHP [308136802] 185.6 percent of total billed charges 143.84 220.4 Technical (Hospital) Services "Ref Testosterone Total, for Mayo Total and Free" PX-3018440301 CDM 84403 CPT 301 RC outpatient 232 232 MEDICA (COMMERCIAL) 94265 [3081118] MEDICA CLAIMS [308111801] 208.8 percent of total billed charges 143.84 220.4 Technical (Hospital) Services "Ref Testosterone Total, for Mayo Total and Free" PX-3018440301 CDM 84403 CPT 301 RC outpatient 232 232 CIGNA 62308 [3081051] CIGNA 62308 [308105105] 185.6 percent of total billed charges 143.84 220.4 Technical (Hospital) Services "Ref Testosterone Total, for Mayo Total and Free" PX-3018440301 CDM 84403 CPT 301 RC outpatient 232 232 CIGNA 62308 [3081051] CIGNA STATE OF WYOMING [308105107] 185.6 percent of total billed charges 143.84 220.4 Technical (Hospital) Services "Ref Testosterone, Total for Mayo Total, Bio, and Free" PX-3018440302 CDM 84403 CPT 301 RC outpatient 224 224 MULTIPLAN INC 34080 [3081285] MULTIPLAN INC [308128501] 212.8 percent of total billed charges 138.88 212.8 Technical (Hospital) Services "Ref Testosterone, Total for Mayo Total, Bio, and Free" PX-3018440302 CDM 84403 CPT 301 RC outpatient 224 224 BLUE CROSS BLUE SHIELD WELLMARK SB889 [3081026] BCBS WYOMING [308102603] 212.8 percent of total billed charges 138.88 212.8 Technical (Hospital) Services "Ref Testosterone, Total for Mayo Total, Bio, and Free" PX-3018440302 CDM 84403 CPT 301 RC outpatient 224 224 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES EPO [308136803] 179.2 percent of total billed charges 138.88 212.8 Technical (Hospital) Services "Ref Testosterone, Total for Mayo Total, Bio, and Free" PX-3018440302 CDM 84403 CPT 301 RC outpatient 224 224 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES HDHP [308136802] 179.2 percent of total billed charges 138.88 212.8 Technical (Hospital) Services "Ref Testosterone, Total for Mayo Total, Bio, and Free" PX-3018440302 CDM 84403 CPT 301 RC outpatient 224 224 UNITED HEALTHCARE (COMMERCIAL) [3081199] UNITED HEALTHCARE 87726 [308119901] 138.88 percent of total billed charges 138.88 212.8 Technical (Hospital) Services "Ref Testosterone, Total for Mayo Total, Bio, and Free" PX-3018440302 CDM 84403 CPT 301 RC outpatient 224 224 HEALTHPARTNERS SX009 HEALTHPARTNERS 179.2 percent of total billed charges 138.88 212.8 Technical (Hospital) Services "Ref Testosterone, Total for Mayo Total, Bio, and Free" PX-3018440302 CDM 84403 CPT 301 RC outpatient 224 224 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES PPO [308136801] 179.2 percent of total billed charges 138.88 212.8 Technical (Hospital) Services "Ref Testosterone, Total for Mayo Total, Bio, and Free" PX-3018440302 CDM 84403 CPT 301 RC outpatient 224 224 MEDICA (COMMERCIAL) 94265 [3081118] MEDICA CLAIMS [308111801] 201.6 percent of total billed charges 138.88 212.8 Technical (Hospital) Services "Ref Testosterone, Total for Mayo Total, Bio, and Free" PX-3018440302 CDM 84403 CPT 301 RC outpatient 224 224 CIGNA 62308 [3081051] CIGNA 62308 [308105105] 179.2 percent of total billed charges 138.88 212.8 Technical (Hospital) Services "Ref Testosterone, Total for Mayo Total, Bio, and Free" PX-3018440302 CDM 84403 CPT 301 RC outpatient 224 224 CIGNA 62308 [3081051] CIGNA STATE OF WYOMING [308105107] 179.2 percent of total billed charges 138.88 212.8 Technical (Hospital) Services "Ref Testosterone, Total for Mayo Total, Bio, and Free" PX-3018440302 CDM 84403 CPT 301 RC inpatient 224 224 CIGNA 62308 [3081051] CIGNA 62308 [308105105] 177.36 percent of total billed charges 138.88 212.8 Technical (Hospital) Services "Ref Testosterone, Total for Mayo Total, Bio, and Free" PX-3018440302 CDM 84403 CPT 301 RC inpatient 224 224 CIGNA 62308 [3081051] CIGNA STATE OF WYOMING [308105107] 177.36 percent of total billed charges 138.88 212.8 Technical (Hospital) Services "Ref Testosterone, Total for Mayo Total, Bio, and Free" PX-3018440302 CDM 84403 CPT 301 RC inpatient 224 224 MULTIPLAN INC 34080 [3081285] MULTIPLAN INC [308128501] 212.8 percent of total billed charges 138.88 212.8 Technical (Hospital) Services "Ref Testosterone, Total for Mayo Total, Bio, and Free" PX-3018440302 CDM 84403 CPT 301 RC inpatient 224 224 MEDICA (COMMERCIAL) 94265 [3081118] MEDICA CLAIMS [308111801] 201.6 percent of total billed charges 138.88 212.8 Technical (Hospital) Services "Ref Testosterone, Total for Mayo Total, Bio, and Free" PX-3018440302 CDM 84403 CPT 301 RC inpatient 224 224 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES EPO [308136803] 177.36 percent of total billed charges 138.88 212.8 Technical (Hospital) Services "Ref Testosterone, Total for Mayo Total, Bio, and Free" PX-3018440302 CDM 84403 CPT 301 RC inpatient 224 224 HEALTHPARTNERS SX009 HEALTHPARTNERS 177.36 percent of total billed charges 138.88 212.8 Technical (Hospital) Services "Ref Testosterone, Total for Mayo Total, Bio, and Free" PX-3018440302 CDM 84403 CPT 301 RC inpatient 224 224 BLUE CROSS BLUE SHIELD WELLMARK SB889 [3081026] BCBS WYOMING [308102603] 212.8 percent of total billed charges 138.88 212.8 Technical (Hospital) Services "Ref Testosterone, Total for Mayo Total, Bio, and Free" PX-3018440302 CDM 84403 CPT 301 RC inpatient 224 224 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES HDHP [308136802] 177.36 percent of total billed charges 138.88 212.8 Technical (Hospital) Services "Ref Testosterone, Total for Mayo Total, Bio, and Free" PX-3018440302 CDM 84403 CPT 301 RC inpatient 224 224 UNITED HEALTHCARE (COMMERCIAL) [3081199] UNITED HEALTHCARE 87726 [308119901] 138.88 percent of total billed charges 138.88 212.8 Technical (Hospital) Services "Ref Testosterone, Total for Mayo Total, Bio, and Free" PX-3018440302 CDM 84403 CPT 301 RC inpatient 224 224 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES PPO [308136801] 177.36 percent of total billed charges 138.88 212.8 Technical (Hospital) Services "Ref Testosterone, Free for Mayo Total and Free" PX-3018440200 CDM 84402 CPT 301 RC inpatient 119 119 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES EPO [308136803] 94.22 percent of total billed charges 73.78 113.05 Technical (Hospital) Services "Ref Testosterone, Free for Mayo Total and Free" PX-3018440200 CDM 84402 CPT 301 RC inpatient 119 119 HEALTHPARTNERS SX009 HEALTHPARTNERS 94.22 percent of total billed charges 73.78 113.05 Technical (Hospital) Services "Ref Testosterone, Free for Mayo Total and Free" PX-3018440200 CDM 84402 CPT 301 RC inpatient 119 119 CIGNA 62308 [3081051] CIGNA 62308 [308105105] 94.22 percent of total billed charges 73.78 113.05 Technical (Hospital) Services "Ref Testosterone, Free for Mayo Total and Free" PX-3018440200 CDM 84402 CPT 301 RC inpatient 119 119 CIGNA 62308 [3081051] CIGNA STATE OF WYOMING [308105107] 94.22 percent of total billed charges 73.78 113.05 Technical (Hospital) Services "Ref Testosterone, Free for Mayo Total and Free" PX-3018440200 CDM 84402 CPT 301 RC inpatient 119 119 MULTIPLAN INC 34080 [3081285] MULTIPLAN INC [308128501] 113.05 percent of total billed charges 73.78 113.05 Technical (Hospital) Services "Ref Testosterone, Free for Mayo Total and Free" PX-3018440200 CDM 84402 CPT 301 RC inpatient 119 119 MEDICA (COMMERCIAL) 94265 [3081118] MEDICA CLAIMS [308111801] 107.1 percent of total billed charges 73.78 113.05 Technical (Hospital) Services "Ref Testosterone, Free for Mayo Total and Free" PX-3018440200 CDM 84402 CPT 301 RC inpatient 119 119 UNITED HEALTHCARE (COMMERCIAL) [3081199] UNITED HEALTHCARE 87726 [308119901] 73.78 percent of total billed charges 73.78 113.05 Technical (Hospital) Services "Ref Testosterone, Free for Mayo Total and Free" PX-3018440200 CDM 84402 CPT 301 RC inpatient 119 119 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES PPO [308136801] 94.22 percent of total billed charges 73.78 113.05 Technical (Hospital) Services "Ref Testosterone, Free for Mayo Total and Free" PX-3018440200 CDM 84402 CPT 301 RC inpatient 119 119 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES HDHP [308136802] 94.22 percent of total billed charges 73.78 113.05 Technical (Hospital) Services "Ref Testosterone, Free for Mayo Total and Free" PX-3018440200 CDM 84402 CPT 301 RC inpatient 119 119 BLUE CROSS BLUE SHIELD WELLMARK SB889 [3081026] BCBS WYOMING [308102603] 113.05 percent of total billed charges 73.78 113.05 Technical (Hospital) Services "Ref Testosterone, Free for Mayo Total and Free" PX-3018440200 CDM 84402 CPT 301 RC outpatient 119 119 UNITED HEALTHCARE (COMMERCIAL) [3081199] UNITED HEALTHCARE 87726 [308119901] 73.78 percent of total billed charges 73.78 113.05 Technical (Hospital) Services "Ref Testosterone, Free for Mayo Total and Free" PX-3018440200 CDM 84402 CPT 301 RC outpatient 119 119 HEALTHPARTNERS SX009 HEALTHPARTNERS 95.2 percent of total billed charges 73.78 113.05 Technical (Hospital) Services "Ref Testosterone, Free for Mayo Total and Free" PX-3018440200 CDM 84402 CPT 301 RC outpatient 119 119 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES PPO [308136801] 95.2 percent of total billed charges 73.78 113.05 Technical (Hospital) Services "Ref Testosterone, Free for Mayo Total and Free" PX-3018440200 CDM 84402 CPT 301 RC outpatient 119 119 MULTIPLAN INC 34080 [3081285] MULTIPLAN INC [308128501] 113.05 percent of total billed charges 73.78 113.05 Technical (Hospital) Services "Ref Testosterone, Free for Mayo Total and Free" PX-3018440200 CDM 84402 CPT 301 RC outpatient 119 119 BLUE CROSS BLUE SHIELD WELLMARK SB889 [3081026] BCBS WYOMING [308102603] 113.05 percent of total billed charges 73.78 113.05 Technical (Hospital) Services "Ref Testosterone, Free for Mayo Total and Free" PX-3018440200 CDM 84402 CPT 301 RC outpatient 119 119 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES EPO [308136803] 95.2 percent of total billed charges 73.78 113.05 Technical (Hospital) Services "Ref Testosterone, Free for Mayo Total and Free" PX-3018440200 CDM 84402 CPT 301 RC outpatient 119 119 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES HDHP [308136802] 95.2 percent of total billed charges 73.78 113.05 Technical (Hospital) Services "Ref Testosterone, Free for Mayo Total and Free" PX-3018440200 CDM 84402 CPT 301 RC outpatient 119 119 MEDICA (COMMERCIAL) 94265 [3081118] MEDICA CLAIMS [308111801] 107.1 percent of total billed charges 73.78 113.05 Technical (Hospital) Services "Ref Testosterone, Free for Mayo Total and Free" PX-3018440200 CDM 84402 CPT 301 RC outpatient 119 119 CIGNA 62308 [3081051] CIGNA 62308 [308105105] 95.2 percent of total billed charges 73.78 113.05 Technical (Hospital) Services "Ref Testosterone, Free for Mayo Total and Free" PX-3018440200 CDM 84402 CPT 301 RC outpatient 119 119 CIGNA 62308 [3081051] CIGNA STATE OF WYOMING [308105107] 95.2 percent of total billed charges 73.78 113.05 Technical (Hospital) Services "Ref Testosterone Free for Mayo Total, Bio, Free" PX-3018440202 CDM 84402 CPT 301 RC outpatient 119 119 CIGNA 62308 [3081051] CIGNA 62308 [308105105] 95.2 percent of total billed charges 73.78 113.05 Technical (Hospital) Services "Ref Testosterone Free for Mayo Total, Bio, Free" PX-3018440202 CDM 84402 CPT 301 RC outpatient 119 119 CIGNA 62308 [3081051] CIGNA STATE OF WYOMING [308105107] 95.2 percent of total billed charges 73.78 113.05 Technical (Hospital) Services "Ref Testosterone Free for Mayo Total, Bio, Free" PX-3018440202 CDM 84402 CPT 301 RC outpatient 119 119 MEDICA (COMMERCIAL) 94265 [3081118] MEDICA CLAIMS [308111801] 107.1 percent of total billed charges 73.78 113.05 Technical (Hospital) Services "Ref Testosterone Free for Mayo Total, Bio, Free" PX-3018440202 CDM 84402 CPT 301 RC outpatient 119 119 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES PPO [308136801] 95.2 percent of total billed charges 73.78 113.05 Technical (Hospital) Services "Ref Testosterone Free for Mayo Total, Bio, Free" PX-3018440202 CDM 84402 CPT 301 RC outpatient 119 119 HEALTHPARTNERS SX009 HEALTHPARTNERS 95.2 percent of total billed charges 73.78 113.05 Technical (Hospital) Services "Ref Testosterone Free for Mayo Total, Bio, Free" PX-3018440202 CDM 84402 CPT 301 RC outpatient 119 119 UNITED HEALTHCARE (COMMERCIAL) [3081199] UNITED HEALTHCARE 87726 [308119901] 73.78 percent of total billed charges 73.78 113.05 Technical (Hospital) Services "Ref Testosterone Free for Mayo Total, Bio, Free" PX-3018440202 CDM 84402 CPT 301 RC outpatient 119 119 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES HDHP [308136802] 95.2 percent of total billed charges 73.78 113.05 Technical (Hospital) Services "Ref Testosterone Free for Mayo Total, Bio, Free" PX-3018440202 CDM 84402 CPT 301 RC outpatient 119 119 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES EPO [308136803] 95.2 percent of total billed charges 73.78 113.05 Technical (Hospital) Services "Ref Testosterone Free for Mayo Total, Bio, Free" PX-3018440202 CDM 84402 CPT 301 RC outpatient 119 119 BLUE CROSS BLUE SHIELD WELLMARK SB889 [3081026] BCBS WYOMING [308102603] 113.05 percent of total billed charges 73.78 113.05 Technical (Hospital) Services "Ref Testosterone Free for Mayo Total, Bio, Free" PX-3018440202 CDM 84402 CPT 301 RC outpatient 119 119 MULTIPLAN INC 34080 [3081285] MULTIPLAN INC [308128501] 113.05 percent of total billed charges 73.78 113.05 Technical (Hospital) Services "Ref Testosterone Free for Mayo Total, Bio, Free" PX-3018440202 CDM 84402 CPT 301 RC inpatient 119 119 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES PPO [308136801] 94.22 percent of total billed charges 73.78 113.05 Technical (Hospital) Services "Ref Testosterone Free for Mayo Total, Bio, Free" PX-3018440202 CDM 84402 CPT 301 RC inpatient 119 119 UNITED HEALTHCARE (COMMERCIAL) [3081199] UNITED HEALTHCARE 87726 [308119901] 73.78 percent of total billed charges 73.78 113.05 Technical (Hospital) Services "Ref Testosterone Free for Mayo Total, Bio, Free" PX-3018440202 CDM 84402 CPT 301 RC inpatient 119 119 BLUE CROSS BLUE SHIELD WELLMARK SB889 [3081026] BCBS WYOMING [308102603] 113.05 percent of total billed charges 73.78 113.05 Technical (Hospital) Services "Ref Testosterone Free for Mayo Total, Bio, Free" PX-3018440202 CDM 84402 CPT 301 RC inpatient 119 119 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES HDHP [308136802] 94.22 percent of total billed charges 73.78 113.05 Technical (Hospital) Services "Ref Testosterone Free for Mayo Total, Bio, Free" PX-3018440202 CDM 84402 CPT 301 RC inpatient 119 119 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES EPO [308136803] 94.22 percent of total billed charges 73.78 113.05 Technical (Hospital) Services "Ref Testosterone Free for Mayo Total, Bio, Free" PX-3018440202 CDM 84402 CPT 301 RC inpatient 119 119 HEALTHPARTNERS SX009 HEALTHPARTNERS 94.22 percent of total billed charges 73.78 113.05 Technical (Hospital) Services "Ref Testosterone Free for Mayo Total, Bio, Free" PX-3018440202 CDM 84402 CPT 301 RC inpatient 119 119 MULTIPLAN INC 34080 [3081285] MULTIPLAN INC [308128501] 113.05 percent of total billed charges 73.78 113.05 Technical (Hospital) Services "Ref Testosterone Free for Mayo Total, Bio, Free" PX-3018440202 CDM 84402 CPT 301 RC inpatient 119 119 MEDICA (COMMERCIAL) 94265 [3081118] MEDICA CLAIMS [308111801] 107.1 percent of total billed charges 73.78 113.05 Technical (Hospital) Services "Ref Testosterone Free for Mayo Total, Bio, Free" PX-3018440202 CDM 84402 CPT 301 RC inpatient 119 119 CIGNA 62308 [3081051] CIGNA 62308 [308105105] 94.22 percent of total billed charges 73.78 113.05 Technical (Hospital) Services "Ref Testosterone Free for Mayo Total, Bio, Free" PX-3018440202 CDM 84402 CPT 301 RC inpatient 119 119 CIGNA 62308 [3081051] CIGNA STATE OF WYOMING [308105107] 94.22 percent of total billed charges 73.78 113.05 Technical (Hospital) Services Specific Gravity Except Urine PX-3018431500 CDM 84315 CPT 301 RC outpatient 40 40 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES EPO [308136803] 32 percent of total billed charges 24.8 38 Technical (Hospital) Services Specific Gravity Except Urine PX-3018431500 CDM 84315 CPT 301 RC outpatient 40 40 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES HDHP [308136802] 32 percent of total billed charges 24.8 38 Technical (Hospital) Services Specific Gravity Except Urine PX-3018431500 CDM 84315 CPT 301 RC outpatient 40 40 BLUE CROSS BLUE SHIELD WELLMARK SB889 [3081026] BCBS WYOMING [308102603] 38 percent of total billed charges 24.8 38 Technical (Hospital) Services Specific Gravity Except Urine PX-3018431500 CDM 84315 CPT 301 RC outpatient 40 40 MULTIPLAN INC 34080 [3081285] MULTIPLAN INC [308128501] 38 percent of total billed charges 24.8 38 Technical (Hospital) Services Specific Gravity Except Urine PX-3018431500 CDM 84315 CPT 301 RC outpatient 40 40 UNITED HEALTHCARE (COMMERCIAL) [3081199] UNITED HEALTHCARE 87726 [308119901] 24.8 percent of total billed charges 24.8 38 Technical (Hospital) Services Specific Gravity Except Urine PX-3018431500 CDM 84315 CPT 301 RC outpatient 40 40 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES PPO [308136801] 32 percent of total billed charges 24.8 38 Technical (Hospital) Services Specific Gravity Except Urine PX-3018431500 CDM 84315 CPT 301 RC outpatient 40 40 HEALTHPARTNERS SX009 HEALTHPARTNERS 32 percent of total billed charges 24.8 38 Technical (Hospital) Services Specific Gravity Except Urine PX-3018431500 CDM 84315 CPT 301 RC outpatient 40 40 MEDICA (COMMERCIAL) 94265 [3081118] MEDICA CLAIMS [308111801] 36 percent of total billed charges 24.8 38 Technical (Hospital) Services Specific Gravity Except Urine PX-3018431500 CDM 84315 CPT 301 RC outpatient 40 40 CIGNA 62308 [3081051] CIGNA 62308 [308105105] 32 percent of total billed charges 24.8 38 Technical (Hospital) Services Specific Gravity Except Urine PX-3018431500 CDM 84315 CPT 301 RC outpatient 40 40 CIGNA 62308 [3081051] CIGNA STATE OF WYOMING [308105107] 32 percent of total billed charges 24.8 38 Technical (Hospital) Services Specific Gravity Except Urine PX-3018431500 CDM 84315 CPT 301 RC inpatient 40 40 BLUE CROSS BLUE SHIELD WELLMARK SB889 [3081026] BCBS WYOMING [308102603] 38 percent of total billed charges 24.8 38 Technical (Hospital) Services Specific Gravity Except Urine PX-3018431500 CDM 84315 CPT 301 RC inpatient 40 40 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES HDHP [308136802] 31.67 percent of total billed charges 24.8 38 Technical (Hospital) Services Specific Gravity Except Urine PX-3018431500 CDM 84315 CPT 301 RC inpatient 40 40 UNITED HEALTHCARE (COMMERCIAL) [3081199] UNITED HEALTHCARE 87726 [308119901] 24.8 percent of total billed charges 24.8 38 Technical (Hospital) Services Specific Gravity Except Urine PX-3018431500 CDM 84315 CPT 301 RC inpatient 40 40 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES PPO [308136801] 31.67 percent of total billed charges 24.8 38 Technical (Hospital) Services Specific Gravity Except Urine PX-3018431500 CDM 84315 CPT 301 RC inpatient 40 40 MULTIPLAN INC 34080 [3081285] MULTIPLAN INC [308128501] 38 percent of total billed charges 24.8 38 Technical (Hospital) Services Specific Gravity Except Urine PX-3018431500 CDM 84315 CPT 301 RC inpatient 40 40 MEDICA (COMMERCIAL) 94265 [3081118] MEDICA CLAIMS [308111801] 36 percent of total billed charges 24.8 38 Technical (Hospital) Services Specific Gravity Except Urine PX-3018431500 CDM 84315 CPT 301 RC inpatient 40 40 CIGNA 62308 [3081051] CIGNA 62308 [308105105] 31.67 percent of total billed charges 24.8 38 Technical (Hospital) Services Specific Gravity Except Urine PX-3018431500 CDM 84315 CPT 301 RC inpatient 40 40 CIGNA 62308 [3081051] CIGNA STATE OF WYOMING [308105107] 31.67 percent of total billed charges 24.8 38 Technical (Hospital) Services Specific Gravity Except Urine PX-3018431500 CDM 84315 CPT 301 RC inpatient 40 40 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES EPO [308136803] 31.67 percent of total billed charges 24.8 38 Technical (Hospital) Services Specific Gravity Except Urine PX-3018431500 CDM 84315 CPT 301 RC inpatient 40 40 HEALTHPARTNERS SX009 HEALTHPARTNERS 31.67 percent of total billed charges 24.8 38 Technical (Hospital) Services Ref Assay of Somatomedin PX-3018430500 CDM 84305 CPT 301 RC inpatient 378 378 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES HDHP [308136802] 299.3 percent of total billed charges 234.36 359.1 Technical (Hospital) Services Ref Assay of Somatomedin PX-3018430500 CDM 84305 CPT 301 RC inpatient 378 378 BLUE CROSS BLUE SHIELD WELLMARK SB889 [3081026] BCBS WYOMING [308102603] 359.1 percent of total billed charges 234.36 359.1 Technical (Hospital) Services Ref Assay of Somatomedin PX-3018430500 CDM 84305 CPT 301 RC inpatient 378 378 UNITED HEALTHCARE (COMMERCIAL) [3081199] UNITED HEALTHCARE 87726 [308119901] 234.36 percent of total billed charges 234.36 359.1 Technical (Hospital) Services Ref Assay of Somatomedin PX-3018430500 CDM 84305 CPT 301 RC inpatient 378 378 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES PPO [308136801] 299.3 percent of total billed charges 234.36 359.1 Technical (Hospital) Services Ref Assay of Somatomedin PX-3018430500 CDM 84305 CPT 301 RC inpatient 378 378 MULTIPLAN INC 34080 [3081285] MULTIPLAN INC [308128501] 359.1 percent of total billed charges 234.36 359.1 Technical (Hospital) Services Ref Assay of Somatomedin PX-3018430500 CDM 84305 CPT 301 RC inpatient 378 378 MEDICA (COMMERCIAL) 94265 [3081118] MEDICA CLAIMS [308111801] 340.2 percent of total billed charges 234.36 359.1 Technical (Hospital) Services Ref Assay of Somatomedin PX-3018430500 CDM 84305 CPT 301 RC inpatient 378 378 CIGNA 62308 [3081051] CIGNA 62308 [308105105] 299.3 percent of total billed charges 234.36 359.1 Technical (Hospital) Services Ref Assay of Somatomedin PX-3018430500 CDM 84305 CPT 301 RC inpatient 378 378 CIGNA 62308 [3081051] CIGNA STATE OF WYOMING [308105107] 299.3 percent of total billed charges 234.36 359.1 Technical (Hospital) Services Ref Assay of Somatomedin PX-3018430500 CDM 84305 CPT 301 RC inpatient 378 378 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES EPO [308136803] 299.3 percent of total billed charges 234.36 359.1 Technical (Hospital) Services Ref Assay of Somatomedin PX-3018430500 CDM 84305 CPT 301 RC inpatient 378 378 HEALTHPARTNERS SX009 HEALTHPARTNERS 299.3 percent of total billed charges 234.36 359.1 Technical (Hospital) Services Ref Assay of Somatomedin PX-3018430500 CDM 84305 CPT 301 RC outpatient 378 378 MEDICA (COMMERCIAL) 94265 [3081118] MEDICA CLAIMS [308111801] 340.2 percent of total billed charges 234.36 359.1 Technical (Hospital) Services Ref Assay of Somatomedin PX-3018430500 CDM 84305 CPT 301 RC outpatient 378 378 CIGNA 62308 [3081051] CIGNA 62308 [308105105] 302.4 percent of total billed charges 234.36 359.1 Technical (Hospital) Services Ref Assay of Somatomedin PX-3018430500 CDM 84305 CPT 301 RC outpatient 378 378 CIGNA 62308 [3081051] CIGNA STATE OF WYOMING [308105107] 302.4 percent of total billed charges 234.36 359.1 Technical (Hospital) Services Ref Assay of Somatomedin PX-3018430500 CDM 84305 CPT 301 RC outpatient 378 378 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES EPO [308136803] 302.4 percent of total billed charges 234.36 359.1 Technical (Hospital) Services Ref Assay of Somatomedin PX-3018430500 CDM 84305 CPT 301 RC outpatient 378 378 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES HDHP [308136802] 302.4 percent of total billed charges 234.36 359.1 Technical (Hospital) Services Ref Assay of Somatomedin PX-3018430500 CDM 84305 CPT 301 RC outpatient 378 378 MULTIPLAN INC 34080 [3081285] MULTIPLAN INC [308128501] 359.1 percent of total billed charges 234.36 359.1 Technical (Hospital) Services Ref Assay of Somatomedin PX-3018430500 CDM 84305 CPT 301 RC outpatient 378 378 BLUE CROSS BLUE SHIELD WELLMARK SB889 [3081026] BCBS WYOMING [308102603] 359.1 percent of total billed charges 234.36 359.1 Technical (Hospital) Services Ref Assay of Somatomedin PX-3018430500 CDM 84305 CPT 301 RC outpatient 378 378 UNITED HEALTHCARE (COMMERCIAL) [3081199] UNITED HEALTHCARE 87726 [308119901] 234.36 percent of total billed charges 234.36 359.1 Technical (Hospital) Services Ref Assay of Somatomedin PX-3018430500 CDM 84305 CPT 301 RC outpatient 378 378 HEALTHPARTNERS SX009 HEALTHPARTNERS 302.4 percent of total billed charges 234.36 359.1 Technical (Hospital) Services Ref Assay of Somatomedin PX-3018430500 CDM 84305 CPT 301 RC outpatient 378 378 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES PPO [308136801] 302.4 percent of total billed charges 234.36 359.1 Technical (Hospital) Services Ref Insulin Like Growth Factor I PX-3018430501 CDM 84305 CPT 301 RC inpatient 244 244 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES HDHP [308136802] 193.2 percent of total billed charges 151.28 231.8 Technical (Hospital) Services Ref Insulin Like Growth Factor I PX-3018430501 CDM 84305 CPT 301 RC inpatient 244 244 BLUE CROSS BLUE SHIELD WELLMARK SB889 [3081026] BCBS WYOMING [308102603] 231.8 percent of total billed charges 151.28 231.8 Technical (Hospital) Services Ref Insulin Like Growth Factor I PX-3018430501 CDM 84305 CPT 301 RC inpatient 244 244 UNITED HEALTHCARE (COMMERCIAL) [3081199] UNITED HEALTHCARE 87726 [308119901] 151.28 percent of total billed charges 151.28 231.8 Technical (Hospital) Services Ref Insulin Like Growth Factor I PX-3018430501 CDM 84305 CPT 301 RC inpatient 244 244 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES PPO [308136801] 193.2 percent of total billed charges 151.28 231.8 Technical (Hospital) Services Ref Insulin Like Growth Factor I PX-3018430501 CDM 84305 CPT 301 RC inpatient 244 244 CIGNA 62308 [3081051] CIGNA 62308 [308105105] 193.2 percent of total billed charges 151.28 231.8 Technical (Hospital) Services Ref Insulin Like Growth Factor I PX-3018430501 CDM 84305 CPT 301 RC inpatient 244 244 CIGNA 62308 [3081051] CIGNA STATE OF WYOMING [308105107] 193.2 percent of total billed charges 151.28 231.8 Technical (Hospital) Services Ref Insulin Like Growth Factor I PX-3018430501 CDM 84305 CPT 301 RC inpatient 244 244 MULTIPLAN INC 34080 [3081285] MULTIPLAN INC [308128501] 231.8 percent of total billed charges 151.28 231.8 Technical (Hospital) Services Ref Insulin Like Growth Factor I PX-3018430501 CDM 84305 CPT 301 RC inpatient 244 244 MEDICA (COMMERCIAL) 94265 [3081118] MEDICA CLAIMS [308111801] 219.6 percent of total billed charges 151.28 231.8 Technical (Hospital) Services Ref Insulin Like Growth Factor I PX-3018430501 CDM 84305 CPT 301 RC inpatient 244 244 HEALTHPARTNERS SX009 HEALTHPARTNERS 193.2 percent of total billed charges 151.28 231.8 Technical (Hospital) Services Ref Insulin Like Growth Factor I PX-3018430501 CDM 84305 CPT 301 RC inpatient 244 244 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES EPO [308136803] 193.2 percent of total billed charges 151.28 231.8 Technical (Hospital) Services Ref Insulin Like Growth Factor I PX-3018430501 CDM 84305 CPT 301 RC outpatient 244 244 UNITED HEALTHCARE (COMMERCIAL) [3081199] UNITED HEALTHCARE 87726 [308119901] 151.28 percent of total billed charges 151.28 231.8 Technical (Hospital) Services Ref Insulin Like Growth Factor I PX-3018430501 CDM 84305 CPT 301 RC outpatient 244 244 HEALTHPARTNERS SX009 HEALTHPARTNERS 195.2 percent of total billed charges 151.28 231.8 Technical (Hospital) Services Ref Insulin Like Growth Factor I PX-3018430501 CDM 84305 CPT 301 RC outpatient 244 244 BLUE CROSS BLUE SHIELD WELLMARK SB889 [3081026] BCBS WYOMING [308102603] 231.8 percent of total billed charges 151.28 231.8 Technical (Hospital) Services Ref Insulin Like Growth Factor I PX-3018430501 CDM 84305 CPT 301 RC outpatient 244 244 MULTIPLAN INC 34080 [3081285] MULTIPLAN INC [308128501] 231.8 percent of total billed charges 151.28 231.8 Technical (Hospital) Services Ref Insulin Like Growth Factor I PX-3018430501 CDM 84305 CPT 301 RC outpatient 244 244 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES EPO [308136803] 195.2 percent of total billed charges 151.28 231.8 Technical (Hospital) Services Ref Insulin Like Growth Factor I PX-3018430501 CDM 84305 CPT 301 RC outpatient 244 244 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES HDHP [308136802] 195.2 percent of total billed charges 151.28 231.8 Technical (Hospital) Services Ref Insulin Like Growth Factor I PX-3018430501 CDM 84305 CPT 301 RC outpatient 244 244 MEDICA (COMMERCIAL) 94265 [3081118] MEDICA CLAIMS [308111801] 219.6 percent of total billed charges 151.28 231.8 Technical (Hospital) Services Ref Insulin Like Growth Factor I PX-3018430501 CDM 84305 CPT 301 RC outpatient 244 244 CIGNA 62308 [3081051] CIGNA 62308 [308105105] 195.2 percent of total billed charges 151.28 231.8 Technical (Hospital) Services Ref Insulin Like Growth Factor I PX-3018430501 CDM 84305 CPT 301 RC outpatient 244 244 CIGNA 62308 [3081051] CIGNA STATE OF WYOMING [308105107] 195.2 percent of total billed charges 151.28 231.8 Technical (Hospital) Services Ref Insulin Like Growth Factor I PX-3018430501 CDM 84305 CPT 301 RC outpatient 244 244 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES PPO [308136801] 195.2 percent of total billed charges 151.28 231.8 Technical (Hospital) Services Sodium Other Source PX-3018430200 CDM 84302 CPT 301 RC outpatient 63 63 UNITED HEALTHCARE (COMMERCIAL) [3081199] UNITED HEALTHCARE 87726 [308119901] 39.06 percent of total billed charges 39.06 59.85 Technical (Hospital) Services Sodium Other Source PX-3018430200 CDM 84302 CPT 301 RC outpatient 63 63 HEALTHPARTNERS SX009 HEALTHPARTNERS 50.4 percent of total billed charges 39.06 59.85 Technical (Hospital) Services Sodium Other Source PX-3018430200 CDM 84302 CPT 301 RC outpatient 63 63 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES PPO [308136801] 50.4 percent of total billed charges 39.06 59.85 Technical (Hospital) Services Sodium Other Source PX-3018430200 CDM 84302 CPT 301 RC outpatient 63 63 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES HDHP [308136802] 50.4 percent of total billed charges 39.06 59.85 Technical (Hospital) Services Sodium Other Source PX-3018430200 CDM 84302 CPT 301 RC outpatient 63 63 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES EPO [308136803] 50.4 percent of total billed charges 39.06 59.85 Technical (Hospital) Services Sodium Other Source PX-3018430200 CDM 84302 CPT 301 RC outpatient 63 63 MULTIPLAN INC 34080 [3081285] MULTIPLAN INC [308128501] 59.85 percent of total billed charges 39.06 59.85 Technical (Hospital) Services Sodium Other Source PX-3018430200 CDM 84302 CPT 301 RC outpatient 63 63 BLUE CROSS BLUE SHIELD WELLMARK SB889 [3081026] BCBS WYOMING [308102603] 59.85 percent of total billed charges 39.06 59.85 Technical (Hospital) Services Sodium Other Source PX-3018430200 CDM 84302 CPT 301 RC outpatient 63 63 MEDICA (COMMERCIAL) 94265 [3081118] MEDICA CLAIMS [308111801] 56.7 percent of total billed charges 39.06 59.85 Technical (Hospital) Services Sodium Other Source PX-3018430200 CDM 84302 CPT 301 RC outpatient 63 63 CIGNA 62308 [3081051] CIGNA 62308 [308105105] 50.4 percent of total billed charges 39.06 59.85 Technical (Hospital) Services Sodium Other Source PX-3018430200 CDM 84302 CPT 301 RC outpatient 63 63 CIGNA 62308 [3081051] CIGNA STATE OF WYOMING [308105107] 50.4 percent of total billed charges 39.06 59.85 Technical (Hospital) Services Sodium Other Source PX-3018430200 CDM 84302 CPT 301 RC inpatient 63 63 UNITED HEALTHCARE (COMMERCIAL) [3081199] UNITED HEALTHCARE 87726 [308119901] 39.06 percent of total billed charges 39.06 59.85 Technical (Hospital) Services Sodium Other Source PX-3018430200 CDM 84302 CPT 301 RC inpatient 63 63 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES PPO [308136801] 49.88 percent of total billed charges 39.06 59.85 Technical (Hospital) Services Sodium Other Source PX-3018430200 CDM 84302 CPT 301 RC inpatient 63 63 BLUE CROSS BLUE SHIELD WELLMARK SB889 [3081026] BCBS WYOMING [308102603] 59.85 percent of total billed charges 39.06 59.85 Technical (Hospital) Services Sodium Other Source PX-3018430200 CDM 84302 CPT 301 RC inpatient 63 63 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES HDHP [308136802] 49.88 percent of total billed charges 39.06 59.85 Technical (Hospital) Services Sodium Other Source PX-3018430200 CDM 84302 CPT 301 RC inpatient 63 63 HEALTHPARTNERS SX009 HEALTHPARTNERS 49.88 percent of total billed charges 39.06 59.85 Technical (Hospital) Services Sodium Other Source PX-3018430200 CDM 84302 CPT 301 RC inpatient 63 63 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES EPO [308136803] 49.88 percent of total billed charges 39.06 59.85 Technical (Hospital) Services Sodium Other Source PX-3018430200 CDM 84302 CPT 301 RC inpatient 63 63 MULTIPLAN INC 34080 [3081285] MULTIPLAN INC [308128501] 59.85 percent of total billed charges 39.06 59.85 Technical (Hospital) Services Sodium Other Source PX-3018430200 CDM 84302 CPT 301 RC inpatient 63 63 MEDICA (COMMERCIAL) 94265 [3081118] MEDICA CLAIMS [308111801] 56.7 percent of total billed charges 39.06 59.85 Technical (Hospital) Services Sodium Other Source PX-3018430200 CDM 84302 CPT 301 RC inpatient 63 63 CIGNA 62308 [3081051] CIGNA 62308 [308105105] 49.88 percent of total billed charges 39.06 59.85 Technical (Hospital) Services Sodium Other Source PX-3018430200 CDM 84302 CPT 301 RC inpatient 63 63 CIGNA 62308 [3081051] CIGNA STATE OF WYOMING [308105107] 49.88 percent of total billed charges 39.06 59.85 Technical (Hospital) Services Sodium Urine PX-3018430000 CDM 84300 CPT 301 RC outpatient 62 62 UNITED HEALTHCARE (COMMERCIAL) [3081199] UNITED HEALTHCARE 87726 [308119901] 38.44 percent of total billed charges 38.44 58.9 Technical (Hospital) Services Sodium Urine PX-3018430000 CDM 84300 CPT 301 RC outpatient 62 62 HEALTHPARTNERS SX009 HEALTHPARTNERS 49.6 percent of total billed charges 38.44 58.9 Technical (Hospital) Services Sodium Urine PX-3018430000 CDM 84300 CPT 301 RC outpatient 62 62 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES PPO [308136801] 49.6 percent of total billed charges 38.44 58.9 Technical (Hospital) Services Sodium Urine PX-3018430000 CDM 84300 CPT 301 RC outpatient 62 62 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES HDHP [308136802] 49.6 percent of total billed charges 38.44 58.9 Technical (Hospital) Services Sodium Urine PX-3018430000 CDM 84300 CPT 301 RC outpatient 62 62 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES EPO [308136803] 49.6 percent of total billed charges 38.44 58.9 Technical (Hospital) Services Sodium Urine PX-3018430000 CDM 84300 CPT 301 RC outpatient 62 62 BLUE CROSS BLUE SHIELD WELLMARK SB889 [3081026] BCBS WYOMING [308102603] 58.9 percent of total billed charges 38.44 58.9 Technical (Hospital) Services Sodium Urine PX-3018430000 CDM 84300 CPT 301 RC outpatient 62 62 MULTIPLAN INC 34080 [3081285] MULTIPLAN INC [308128501] 58.9 percent of total billed charges 38.44 58.9 Technical (Hospital) Services Sodium Urine PX-3018430000 CDM 84300 CPT 301 RC outpatient 62 62 MEDICA (COMMERCIAL) 94265 [3081118] MEDICA CLAIMS [308111801] 55.8 percent of total billed charges 38.44 58.9 Technical (Hospital) Services Sodium Urine PX-3018430000 CDM 84300 CPT 301 RC outpatient 62 62 CIGNA 62308 [3081051] CIGNA 62308 [308105105] 49.6 percent of total billed charges 38.44 58.9 Technical (Hospital) Services Sodium Urine PX-3018430000 CDM 84300 CPT 301 RC outpatient 62 62 CIGNA 62308 [3081051] CIGNA STATE OF WYOMING [308105107] 49.6 percent of total billed charges 38.44 58.9 Technical (Hospital) Services Sodium Urine PX-3018430000 CDM 84300 CPT 301 RC inpatient 62 62 MULTIPLAN INC 34080 [3081285] MULTIPLAN INC [308128501] 58.9 percent of total billed charges 38.44 58.9 Technical (Hospital) Services Sodium Urine PX-3018430000 CDM 84300 CPT 301 RC inpatient 62 62 MEDICA (COMMERCIAL) 94265 [3081118] MEDICA CLAIMS [308111801] 55.8 percent of total billed charges 38.44 58.9 Technical (Hospital) Services Sodium Urine PX-3018430000 CDM 84300 CPT 301 RC inpatient 62 62 CIGNA 62308 [3081051] CIGNA 62308 [308105105] 49.09 percent of total billed charges 38.44 58.9 Technical (Hospital) Services Sodium Urine PX-3018430000 CDM 84300 CPT 301 RC inpatient 62 62 CIGNA 62308 [3081051] CIGNA STATE OF WYOMING [308105107] 49.09 percent of total billed charges 38.44 58.9 Technical (Hospital) Services Sodium Urine PX-3018430000 CDM 84300 CPT 301 RC inpatient 62 62 HEALTHPARTNERS SX009 HEALTHPARTNERS 49.09 percent of total billed charges 38.44 58.9 Technical (Hospital) Services Sodium Urine PX-3018430000 CDM 84300 CPT 301 RC inpatient 62 62 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES EPO [308136803] 49.09 percent of total billed charges 38.44 58.9 Technical (Hospital) Services Sodium Urine PX-3018430000 CDM 84300 CPT 301 RC inpatient 62 62 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES HDHP [308136802] 49.09 percent of total billed charges 38.44 58.9 Technical (Hospital) Services Sodium Urine PX-3018430000 CDM 84300 CPT 301 RC inpatient 62 62 BLUE CROSS BLUE SHIELD WELLMARK SB889 [3081026] BCBS WYOMING [308102603] 58.9 percent of total billed charges 38.44 58.9 Technical (Hospital) Services Sodium Urine PX-3018430000 CDM 84300 CPT 301 RC inpatient 62 62 UNITED HEALTHCARE (COMMERCIAL) [3081199] UNITED HEALTHCARE 87726 [308119901] 38.44 percent of total billed charges 38.44 58.9 Technical (Hospital) Services Sodium Urine PX-3018430000 CDM 84300 CPT 301 RC inpatient 62 62 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES PPO [308136801] 49.09 percent of total billed charges 38.44 58.9 Technical (Hospital) Services Sodium Serum Plasma Wb PX-3018429500 CDM 84295 CPT 301 RC outpatient 63 63 BLUE CROSS BLUE SHIELD WELLMARK SB889 [3081026] BCBS WYOMING [308102603] 59.85 percent of total billed charges 39.06 59.85 Technical (Hospital) Services Sodium Serum Plasma Wb PX-3018429500 CDM 84295 CPT 301 RC outpatient 63 63 MULTIPLAN INC 34080 [3081285] MULTIPLAN INC [308128501] 59.85 percent of total billed charges 39.06 59.85 Technical (Hospital) Services Sodium Serum Plasma Wb PX-3018429500 CDM 84295 CPT 301 RC outpatient 63 63 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES HDHP [308136802] 50.4 percent of total billed charges 39.06 59.85 Technical (Hospital) Services Sodium Serum Plasma Wb PX-3018429500 CDM 84295 CPT 301 RC outpatient 63 63 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES EPO [308136803] 50.4 percent of total billed charges 39.06 59.85 Technical (Hospital) Services Sodium Serum Plasma Wb PX-3018429500 CDM 84295 CPT 301 RC outpatient 63 63 UNITED HEALTHCARE (COMMERCIAL) [3081199] UNITED HEALTHCARE 87726 [308119901] 39.06 percent of total billed charges 39.06 59.85 Technical (Hospital) Services Sodium Serum Plasma Wb PX-3018429500 CDM 84295 CPT 301 RC outpatient 63 63 HEALTHPARTNERS SX009 HEALTHPARTNERS 50.4 percent of total billed charges 39.06 59.85 Technical (Hospital) Services Sodium Serum Plasma Wb PX-3018429500 CDM 84295 CPT 301 RC outpatient 63 63 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES PPO [308136801] 50.4 percent of total billed charges 39.06 59.85 Technical (Hospital) Services Sodium Serum Plasma Wb PX-3018429500 CDM 84295 CPT 301 RC outpatient 63 63 MEDICA (COMMERCIAL) 94265 [3081118] MEDICA CLAIMS [308111801] 56.7 percent of total billed charges 39.06 59.85 Technical (Hospital) Services Sodium Serum Plasma Wb PX-3018429500 CDM 84295 CPT 301 RC outpatient 63 63 CIGNA 62308 [3081051] CIGNA 62308 [308105105] 50.4 percent of total billed charges 39.06 59.85 Technical (Hospital) Services Sodium Serum Plasma Wb PX-3018429500 CDM 84295 CPT 301 RC outpatient 63 63 CIGNA 62308 [3081051] CIGNA STATE OF WYOMING [308105107] 50.4 percent of total billed charges 39.06 59.85 Technical (Hospital) Services Sodium Serum Plasma Wb PX-3018429500 CDM 84295 CPT 301 RC inpatient 63 63 MEDICA (COMMERCIAL) 94265 [3081118] MEDICA CLAIMS [308111801] 56.7 percent of total billed charges 39.06 59.85 Technical (Hospital) Services Sodium Serum Plasma Wb PX-3018429500 CDM 84295 CPT 301 RC inpatient 63 63 MULTIPLAN INC 34080 [3081285] MULTIPLAN INC [308128501] 59.85 percent of total billed charges 39.06 59.85 Technical (Hospital) Services Sodium Serum Plasma Wb PX-3018429500 CDM 84295 CPT 301 RC inpatient 63 63 CIGNA 62308 [3081051] CIGNA 62308 [308105105] 49.88 percent of total billed charges 39.06 59.85 Technical (Hospital) Services Sodium Serum Plasma Wb PX-3018429500 CDM 84295 CPT 301 RC inpatient 63 63 CIGNA 62308 [3081051] CIGNA STATE OF WYOMING [308105107] 49.88 percent of total billed charges 39.06 59.85 Technical (Hospital) Services Sodium Serum Plasma Wb PX-3018429500 CDM 84295 CPT 301 RC inpatient 63 63 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES EPO [308136803] 49.88 percent of total billed charges 39.06 59.85 Technical (Hospital) Services Sodium Serum Plasma Wb PX-3018429500 CDM 84295 CPT 301 RC inpatient 63 63 HEALTHPARTNERS SX009 HEALTHPARTNERS 49.88 percent of total billed charges 39.06 59.85 Technical (Hospital) Services Sodium Serum Plasma Wb PX-3018429500 CDM 84295 CPT 301 RC inpatient 63 63 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES HDHP [308136802] 49.88 percent of total billed charges 39.06 59.85 Technical (Hospital) Services Sodium Serum Plasma Wb PX-3018429500 CDM 84295 CPT 301 RC inpatient 63 63 BLUE CROSS BLUE SHIELD WELLMARK SB889 [3081026] BCBS WYOMING [308102603] 59.85 percent of total billed charges 39.06 59.85 Technical (Hospital) Services Sodium Serum Plasma Wb PX-3018429500 CDM 84295 CPT 301 RC inpatient 63 63 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES PPO [308136801] 49.88 percent of total billed charges 39.06 59.85 Technical (Hospital) Services Sodium Serum Plasma Wb PX-3018429500 CDM 84295 CPT 301 RC inpatient 63 63 UNITED HEALTHCARE (COMMERCIAL) [3081199] UNITED HEALTHCARE 87726 [308119901] 39.06 percent of total billed charges 39.06 59.85 Technical (Hospital) Services Ref Sex Hormone Binding Globulin PX-3018427000 CDM 84270 CPT 301 RC inpatient 251 251 BLUE CROSS BLUE SHIELD WELLMARK SB889 [3081026] BCBS WYOMING [308102603] 238.45 percent of total billed charges 155.62 238.45 Technical (Hospital) Services Ref Sex Hormone Binding Globulin PX-3018427000 CDM 84270 CPT 301 RC inpatient 251 251 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES HDHP [308136802] 198.74 percent of total billed charges 155.62 238.45 Technical (Hospital) Services Ref Sex Hormone Binding Globulin PX-3018427000 CDM 84270 CPT 301 RC inpatient 251 251 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES PPO [308136801] 198.74 percent of total billed charges 155.62 238.45 Technical (Hospital) Services Ref Sex Hormone Binding Globulin PX-3018427000 CDM 84270 CPT 301 RC inpatient 251 251 UNITED HEALTHCARE (COMMERCIAL) [3081199] UNITED HEALTHCARE 87726 [308119901] 155.62 percent of total billed charges 155.62 238.45 Technical (Hospital) Services Ref Sex Hormone Binding Globulin PX-3018427000 CDM 84270 CPT 301 RC inpatient 251 251 HEALTHPARTNERS SX009 HEALTHPARTNERS 198.74 percent of total billed charges 155.62 238.45 Technical (Hospital) Services Ref Sex Hormone Binding Globulin PX-3018427000 CDM 84270 CPT 301 RC inpatient 251 251 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES EPO [308136803] 198.74 percent of total billed charges 155.62 238.45 Technical (Hospital) Services Ref Sex Hormone Binding Globulin PX-3018427000 CDM 84270 CPT 301 RC inpatient 251 251 MEDICA (COMMERCIAL) 94265 [3081118] MEDICA CLAIMS [308111801] 225.9 percent of total billed charges 155.62 238.45 Technical (Hospital) Services Ref Sex Hormone Binding Globulin PX-3018427000 CDM 84270 CPT 301 RC inpatient 251 251 MULTIPLAN INC 34080 [3081285] MULTIPLAN INC [308128501] 238.45 percent of total billed charges 155.62 238.45 Technical (Hospital) Services Ref Sex Hormone Binding Globulin PX-3018427000 CDM 84270 CPT 301 RC inpatient 251 251 CIGNA 62308 [3081051] CIGNA 62308 [308105105] 198.74 percent of total billed charges 155.62 238.45 Technical (Hospital) Services Ref Sex Hormone Binding Globulin PX-3018427000 CDM 84270 CPT 301 RC inpatient 251 251 CIGNA 62308 [3081051] CIGNA STATE OF WYOMING [308105107] 198.74 percent of total billed charges 155.62 238.45 Technical (Hospital) Services Ref Sex Hormone Binding Globulin PX-3018427000 CDM 84270 CPT 301 RC outpatient 251 251 MEDICA (COMMERCIAL) 94265 [3081118] MEDICA CLAIMS [308111801] 225.9 percent of total billed charges 155.62 238.45 Technical (Hospital) Services Ref Sex Hormone Binding Globulin PX-3018427000 CDM 84270 CPT 301 RC outpatient 251 251 CIGNA 62308 [3081051] CIGNA 62308 [308105105] 200.8 percent of total billed charges 155.62 238.45 Technical (Hospital) Services Ref Sex Hormone Binding Globulin PX-3018427000 CDM 84270 CPT 301 RC outpatient 251 251 CIGNA 62308 [3081051] CIGNA STATE OF WYOMING [308105107] 200.8 percent of total billed charges 155.62 238.45 Technical (Hospital) Services Ref Sex Hormone Binding Globulin PX-3018427000 CDM 84270 CPT 301 RC outpatient 251 251 HEALTHPARTNERS SX009 HEALTHPARTNERS 200.8 percent of total billed charges 155.62 238.45 Technical (Hospital) Services Ref Sex Hormone Binding Globulin PX-3018427000 CDM 84270 CPT 301 RC outpatient 251 251 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES PPO [308136801] 200.8 percent of total billed charges 155.62 238.45 Technical (Hospital) Services Ref Sex Hormone Binding Globulin PX-3018427000 CDM 84270 CPT 301 RC outpatient 251 251 UNITED HEALTHCARE (COMMERCIAL) [3081199] UNITED HEALTHCARE 87726 [308119901] 155.62 percent of total billed charges 155.62 238.45 Technical (Hospital) Services Ref Sex Hormone Binding Globulin PX-3018427000 CDM 84270 CPT 301 RC outpatient 251 251 BLUE CROSS BLUE SHIELD WELLMARK SB889 [3081026] BCBS WYOMING [308102603] 238.45 percent of total billed charges 155.62 238.45 Technical (Hospital) Services Ref Sex Hormone Binding Globulin PX-3018427000 CDM 84270 CPT 301 RC outpatient 251 251 MULTIPLAN INC 34080 [3081285] MULTIPLAN INC [308128501] 238.45 percent of total billed charges 155.62 238.45 Technical (Hospital) Services Ref Sex Hormone Binding Globulin PX-3018427000 CDM 84270 CPT 301 RC outpatient 251 251 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES EPO [308136803] 200.8 percent of total billed charges 155.62 238.45 Technical (Hospital) Services Ref Sex Hormone Binding Globulin PX-3018427000 CDM 84270 CPT 301 RC outpatient 251 251 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES HDHP [308136802] 200.8 percent of total billed charges 155.62 238.45 Technical (Hospital) Services Ref Selenium PX-3018425500 CDM 84255 CPT 301 RC outpatient 211 211 UNITED HEALTHCARE (COMMERCIAL) [3081199] UNITED HEALTHCARE 87726 [308119901] 130.82 percent of total billed charges 130.82 200.45 Technical (Hospital) Services Ref Selenium PX-3018425500 CDM 84255 CPT 301 RC outpatient 211 211 HEALTHPARTNERS SX009 HEALTHPARTNERS 168.8 percent of total billed charges 130.82 200.45 Technical (Hospital) Services Ref Selenium PX-3018425500 CDM 84255 CPT 301 RC outpatient 211 211 BLUE CROSS BLUE SHIELD WELLMARK SB889 [3081026] BCBS WYOMING [308102603] 200.45 percent of total billed charges 130.82 200.45 Technical (Hospital) Services Ref Selenium PX-3018425500 CDM 84255 CPT 301 RC outpatient 211 211 MULTIPLAN INC 34080 [3081285] MULTIPLAN INC [308128501] 200.45 percent of total billed charges 130.82 200.45 Technical (Hospital) Services Ref Selenium PX-3018425500 CDM 84255 CPT 301 RC outpatient 211 211 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES HDHP [308136802] 168.8 percent of total billed charges 130.82 200.45 Technical (Hospital) Services Ref Selenium PX-3018425500 CDM 84255 CPT 301 RC outpatient 211 211 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES EPO [308136803] 168.8 percent of total billed charges 130.82 200.45 Technical (Hospital) Services Ref Selenium PX-3018425500 CDM 84255 CPT 301 RC outpatient 211 211 MEDICA (COMMERCIAL) 94265 [3081118] MEDICA CLAIMS [308111801] 189.9 percent of total billed charges 130.82 200.45 Technical (Hospital) Services Ref Selenium PX-3018425500 CDM 84255 CPT 301 RC outpatient 211 211 CIGNA 62308 [3081051] CIGNA 62308 [308105105] 168.8 percent of total billed charges 130.82 200.45 Technical (Hospital) Services Ref Selenium PX-3018425500 CDM 84255 CPT 301 RC outpatient 211 211 CIGNA 62308 [3081051] CIGNA STATE OF WYOMING [308105107] 168.8 percent of total billed charges 130.82 200.45 Technical (Hospital) Services Ref Selenium PX-3018425500 CDM 84255 CPT 301 RC outpatient 211 211 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES PPO [308136801] 168.8 percent of total billed charges 130.82 200.45 Technical (Hospital) Services Ref Selenium PX-3018425500 CDM 84255 CPT 301 RC inpatient 211 211 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES HDHP [308136802] 167.07 percent of total billed charges 130.82 200.45 Technical (Hospital) Services Ref Selenium PX-3018425500 CDM 84255 CPT 301 RC inpatient 211 211 BLUE CROSS BLUE SHIELD WELLMARK SB889 [3081026] BCBS WYOMING [308102603] 200.45 percent of total billed charges 130.82 200.45 Technical (Hospital) Services Ref Selenium PX-3018425500 CDM 84255 CPT 301 RC inpatient 211 211 UNITED HEALTHCARE (COMMERCIAL) [3081199] UNITED HEALTHCARE 87726 [308119901] 130.82 percent of total billed charges 130.82 200.45 Technical (Hospital) Services Ref Selenium PX-3018425500 CDM 84255 CPT 301 RC inpatient 211 211 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES PPO [308136801] 167.07 percent of total billed charges 130.82 200.45 Technical (Hospital) Services Ref Selenium PX-3018425500 CDM 84255 CPT 301 RC inpatient 211 211 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES EPO [308136803] 167.07 percent of total billed charges 130.82 200.45 Technical (Hospital) Services Ref Selenium PX-3018425500 CDM 84255 CPT 301 RC inpatient 211 211 HEALTHPARTNERS SX009 HEALTHPARTNERS 167.07 percent of total billed charges 130.82 200.45 Technical (Hospital) Services Ref Selenium PX-3018425500 CDM 84255 CPT 301 RC inpatient 211 211 MEDICA (COMMERCIAL) 94265 [3081118] MEDICA CLAIMS [308111801] 189.9 percent of total billed charges 130.82 200.45 Technical (Hospital) Services Ref Selenium PX-3018425500 CDM 84255 CPT 301 RC inpatient 211 211 MULTIPLAN INC 34080 [3081285] MULTIPLAN INC [308128501] 200.45 percent of total billed charges 130.82 200.45 Technical (Hospital) Services Ref Selenium PX-3018425500 CDM 84255 CPT 301 RC inpatient 211 211 CIGNA 62308 [3081051] CIGNA 62308 [308105105] 167.07 percent of total billed charges 130.82 200.45 Technical (Hospital) Services Ref Selenium PX-3018425500 CDM 84255 CPT 301 RC inpatient 211 211 CIGNA 62308 [3081051] CIGNA STATE OF WYOMING [308105107] 167.07 percent of total billed charges 130.82 200.45 Technical (Hospital) Services Ref Renin Activity PX-3018424400 CDM 84244 CPT 301 RC inpatient 298 298 CIGNA 62308 [3081051] CIGNA 62308 [308105105] 235.96 percent of total billed charges 184.76 283.1 Technical (Hospital) Services Ref Renin Activity PX-3018424400 CDM 84244 CPT 301 RC inpatient 298 298 CIGNA 62308 [3081051] CIGNA STATE OF WYOMING [308105107] 235.96 percent of total billed charges 184.76 283.1 Technical (Hospital) Services Ref Renin Activity PX-3018424400 CDM 84244 CPT 301 RC inpatient 298 298 MULTIPLAN INC 34080 [3081285] MULTIPLAN INC [308128501] 283.1 percent of total billed charges 184.76 283.1 Technical (Hospital) Services Ref Renin Activity PX-3018424400 CDM 84244 CPT 301 RC inpatient 298 298 MEDICA (COMMERCIAL) 94265 [3081118] MEDICA CLAIMS [308111801] 268.2 percent of total billed charges 184.76 283.1 Technical (Hospital) Services Ref Renin Activity PX-3018424400 CDM 84244 CPT 301 RC inpatient 298 298 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES EPO [308136803] 235.96 percent of total billed charges 184.76 283.1 Technical (Hospital) Services Ref Renin Activity PX-3018424400 CDM 84244 CPT 301 RC inpatient 298 298 HEALTHPARTNERS SX009 HEALTHPARTNERS 235.96 percent of total billed charges 184.76 283.1 Technical (Hospital) Services Ref Renin Activity PX-3018424400 CDM 84244 CPT 301 RC inpatient 298 298 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES PPO [308136801] 235.96 percent of total billed charges 184.76 283.1 Technical (Hospital) Services Ref Renin Activity PX-3018424400 CDM 84244 CPT 301 RC inpatient 298 298 UNITED HEALTHCARE (COMMERCIAL) [3081199] UNITED HEALTHCARE 87726 [308119901] 184.76 percent of total billed charges 184.76 283.1 Technical (Hospital) Services Ref Renin Activity PX-3018424400 CDM 84244 CPT 301 RC inpatient 298 298 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES HDHP [308136802] 235.96 percent of total billed charges 184.76 283.1 Technical (Hospital) Services Ref Renin Activity PX-3018424400 CDM 84244 CPT 301 RC inpatient 298 298 BLUE CROSS BLUE SHIELD WELLMARK SB889 [3081026] BCBS WYOMING [308102603] 283.1 percent of total billed charges 184.76 283.1 Technical (Hospital) Services Ref Renin Activity PX-3018424400 CDM 84244 CPT 301 RC outpatient 298 298 MEDICA (COMMERCIAL) 94265 [3081118] MEDICA CLAIMS [308111801] 268.2 percent of total billed charges 184.76 283.1 Technical (Hospital) Services Ref Renin Activity PX-3018424400 CDM 84244 CPT 301 RC outpatient 298 298 CIGNA 62308 [3081051] CIGNA 62308 [308105105] 238.4 percent of total billed charges 184.76 283.1 Technical (Hospital) Services Ref Renin Activity PX-3018424400 CDM 84244 CPT 301 RC outpatient 298 298 CIGNA 62308 [3081051] CIGNA STATE OF WYOMING [308105107] 238.4 percent of total billed charges 184.76 283.1 Technical (Hospital) Services Ref Renin Activity PX-3018424400 CDM 84244 CPT 301 RC outpatient 298 298 MULTIPLAN INC 34080 [3081285] MULTIPLAN INC [308128501] 283.1 percent of total billed charges 184.76 283.1 Technical (Hospital) Services Ref Renin Activity PX-3018424400 CDM 84244 CPT 301 RC outpatient 298 298 BLUE CROSS BLUE SHIELD WELLMARK SB889 [3081026] BCBS WYOMING [308102603] 283.1 percent of total billed charges 184.76 283.1 Technical (Hospital) Services Ref Renin Activity PX-3018424400 CDM 84244 CPT 301 RC outpatient 298 298 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES HDHP [308136802] 238.4 percent of total billed charges 184.76 283.1 Technical (Hospital) Services Ref Renin Activity PX-3018424400 CDM 84244 CPT 301 RC outpatient 298 298 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES EPO [308136803] 238.4 percent of total billed charges 184.76 283.1 Technical (Hospital) Services Ref Renin Activity PX-3018424400 CDM 84244 CPT 301 RC outpatient 298 298 HEALTHPARTNERS SX009 HEALTHPARTNERS 238.4 percent of total billed charges 184.76 283.1 Technical (Hospital) Services Ref Renin Activity PX-3018424400 CDM 84244 CPT 301 RC outpatient 298 298 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES PPO [308136801] 238.4 percent of total billed charges 184.76 283.1 Technical (Hospital) Services Ref Renin Activity PX-3018424400 CDM 84244 CPT 301 RC outpatient 298 298 UNITED HEALTHCARE (COMMERCIAL) [3081199] UNITED HEALTHCARE 87726 [308119901] 184.76 percent of total billed charges 184.76 283.1 Technical (Hospital) Services Ref Renin Activity PX-3018424401 CDM 84244 CPT 301 RC inpatient 298 298 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES PPO [308136801] 235.96 percent of total billed charges 184.76 283.1 Technical (Hospital) Services Ref Renin Activity PX-3018424401 CDM 84244 CPT 301 RC inpatient 298 298 UNITED HEALTHCARE (COMMERCIAL) [3081199] UNITED HEALTHCARE 87726 [308119901] 184.76 percent of total billed charges 184.76 283.1 Technical (Hospital) Services Ref Renin Activity PX-3018424401 CDM 84244 CPT 301 RC inpatient 298 298 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES HDHP [308136802] 235.96 percent of total billed charges 184.76 283.1 Technical (Hospital) Services Ref Renin Activity PX-3018424401 CDM 84244 CPT 301 RC inpatient 298 298 BLUE CROSS BLUE SHIELD WELLMARK SB889 [3081026] BCBS WYOMING [308102603] 283.1 percent of total billed charges 184.76 283.1 Technical (Hospital) Services Ref Renin Activity PX-3018424401 CDM 84244 CPT 301 RC inpatient 298 298 HEALTHPARTNERS SX009 HEALTHPARTNERS 235.96 percent of total billed charges 184.76 283.1 Technical (Hospital) Services Ref Renin Activity PX-3018424401 CDM 84244 CPT 301 RC inpatient 298 298 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES EPO [308136803] 235.96 percent of total billed charges 184.76 283.1 Technical (Hospital) Services Ref Renin Activity PX-3018424401 CDM 84244 CPT 301 RC inpatient 298 298 CIGNA 62308 [3081051] CIGNA 62308 [308105105] 235.96 percent of total billed charges 184.76 283.1 Technical (Hospital) Services Ref Renin Activity PX-3018424401 CDM 84244 CPT 301 RC inpatient 298 298 CIGNA 62308 [3081051] CIGNA STATE OF WYOMING [308105107] 235.96 percent of total billed charges 184.76 283.1 Technical (Hospital) Services Ref Renin Activity PX-3018424401 CDM 84244 CPT 301 RC inpatient 298 298 MEDICA (COMMERCIAL) 94265 [3081118] MEDICA CLAIMS [308111801] 268.2 percent of total billed charges 184.76 283.1 Technical (Hospital) Services Ref Renin Activity PX-3018424401 CDM 84244 CPT 301 RC inpatient 298 298 MULTIPLAN INC 34080 [3081285] MULTIPLAN INC [308128501] 283.1 percent of total billed charges 184.76 283.1 Technical (Hospital) Services Ref Renin Activity PX-3018424401 CDM 84244 CPT 301 RC outpatient 298 298 MEDICA (COMMERCIAL) 94265 [3081118] MEDICA CLAIMS [308111801] 268.2 percent of total billed charges 184.76 283.1 Technical (Hospital) Services Ref Renin Activity PX-3018424401 CDM 84244 CPT 301 RC outpatient 298 298 CIGNA 62308 [3081051] CIGNA 62308 [308105105] 238.4 percent of total billed charges 184.76 283.1 Technical (Hospital) Services Ref Renin Activity PX-3018424401 CDM 84244 CPT 301 RC outpatient 298 298 CIGNA 62308 [3081051] CIGNA STATE OF WYOMING [308105107] 238.4 percent of total billed charges 184.76 283.1 Technical (Hospital) Services Ref Renin Activity PX-3018424401 CDM 84244 CPT 301 RC outpatient 298 298 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES HDHP [308136802] 238.4 percent of total billed charges 184.76 283.1 Technical (Hospital) Services Ref Renin Activity PX-3018424401 CDM 84244 CPT 301 RC outpatient 298 298 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES EPO [308136803] 238.4 percent of total billed charges 184.76 283.1 Technical (Hospital) Services Ref Renin Activity PX-3018424401 CDM 84244 CPT 301 RC outpatient 298 298 MULTIPLAN INC 34080 [3081285] MULTIPLAN INC [308128501] 283.1 percent of total billed charges 184.76 283.1 Technical (Hospital) Services Ref Renin Activity PX-3018424401 CDM 84244 CPT 301 RC outpatient 298 298 BLUE CROSS BLUE SHIELD WELLMARK SB889 [3081026] BCBS WYOMING [308102603] 283.1 percent of total billed charges 184.76 283.1 Technical (Hospital) Services Ref Renin Activity PX-3018424401 CDM 84244 CPT 301 RC outpatient 298 298 HEALTHPARTNERS SX009 HEALTHPARTNERS 238.4 percent of total billed charges 184.76 283.1 Technical (Hospital) Services Ref Renin Activity PX-3018424401 CDM 84244 CPT 301 RC outpatient 298 298 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES PPO [308136801] 238.4 percent of total billed charges 184.76 283.1 Technical (Hospital) Services Ref Renin Activity PX-3018424401 CDM 84244 CPT 301 RC outpatient 298 298 UNITED HEALTHCARE (COMMERCIAL) [3081199] UNITED HEALTHCARE 87726 [308119901] 184.76 percent of total billed charges 184.76 283.1 Technical (Hospital) Services Ref Protein Electrphorsis Urine Monoclonal PX-3018416601 CDM 84166 CPT 301 RC inpatient 210 210 MEDICA (COMMERCIAL) 94265 [3081118] MEDICA CLAIMS [308111801] 189 percent of total billed charges 130.2 199.5 Technical (Hospital) Services Ref Protein Electrphorsis Urine Monoclonal PX-3018416601 CDM 84166 CPT 301 RC inpatient 210 210 MULTIPLAN INC 34080 [3081285] MULTIPLAN INC [308128501] 199.5 percent of total billed charges 130.2 199.5 Technical (Hospital) Services Ref Protein Electrphorsis Urine Monoclonal PX-3018416601 CDM 84166 CPT 301 RC inpatient 210 210 CIGNA 62308 [3081051] CIGNA 62308 [308105105] 166.28 percent of total billed charges 130.2 199.5 Technical (Hospital) Services Ref Protein Electrphorsis Urine Monoclonal PX-3018416601 CDM 84166 CPT 301 RC inpatient 210 210 CIGNA 62308 [3081051] CIGNA STATE OF WYOMING [308105107] 166.28 percent of total billed charges 130.2 199.5 Technical (Hospital) Services Ref Protein Electrphorsis Urine Monoclonal PX-3018416601 CDM 84166 CPT 301 RC inpatient 210 210 HEALTHPARTNERS SX009 HEALTHPARTNERS 166.28 percent of total billed charges 130.2 199.5 Technical (Hospital) Services Ref Protein Electrphorsis Urine Monoclonal PX-3018416601 CDM 84166 CPT 301 RC inpatient 210 210 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES EPO [308136803] 166.28 percent of total billed charges 130.2 199.5 Technical (Hospital) Services Ref Protein Electrphorsis Urine Monoclonal PX-3018416601 CDM 84166 CPT 301 RC inpatient 210 210 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES PPO [308136801] 166.28 percent of total billed charges 130.2 199.5 Technical (Hospital) Services Ref Protein Electrphorsis Urine Monoclonal PX-3018416601 CDM 84166 CPT 301 RC inpatient 210 210 UNITED HEALTHCARE (COMMERCIAL) [3081199] UNITED HEALTHCARE 87726 [308119901] 130.2 percent of total billed charges 130.2 199.5 Technical (Hospital) Services Ref Protein Electrphorsis Urine Monoclonal PX-3018416601 CDM 84166 CPT 301 RC inpatient 210 210 BLUE CROSS BLUE SHIELD WELLMARK SB889 [3081026] BCBS WYOMING [308102603] 199.5 percent of total billed charges 130.2 199.5 Technical (Hospital) Services Ref Protein Electrphorsis Urine Monoclonal PX-3018416601 CDM 84166 CPT 301 RC inpatient 210 210 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES HDHP [308136802] 166.28 percent of total billed charges 130.2 199.5 Technical (Hospital) Services Ref Protein Electrphorsis Urine Monoclonal PX-3018416601 CDM 84166 CPT 301 RC outpatient 210 210 UNITED HEALTHCARE (COMMERCIAL) [3081199] UNITED HEALTHCARE 87726 [308119901] 130.2 percent of total billed charges 130.2 199.5 Technical (Hospital) Services Ref Protein Electrphorsis Urine Monoclonal PX-3018416601 CDM 84166 CPT 301 RC outpatient 210 210 HEALTHPARTNERS SX009 HEALTHPARTNERS 168 percent of total billed charges 130.2 199.5 Technical (Hospital) Services Ref Protein Electrphorsis Urine Monoclonal PX-3018416601 CDM 84166 CPT 301 RC outpatient 210 210 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES PPO [308136801] 168 percent of total billed charges 130.2 199.5 Technical (Hospital) Services Ref Protein Electrphorsis Urine Monoclonal PX-3018416601 CDM 84166 CPT 301 RC outpatient 210 210 BLUE CROSS BLUE SHIELD WELLMARK SB889 [3081026] BCBS WYOMING [308102603] 199.5 percent of total billed charges 130.2 199.5 Technical (Hospital) Services Ref Protein Electrphorsis Urine Monoclonal PX-3018416601 CDM 84166 CPT 301 RC outpatient 210 210 MULTIPLAN INC 34080 [3081285] MULTIPLAN INC [308128501] 199.5 percent of total billed charges 130.2 199.5 Technical (Hospital) Services Ref Protein Electrphorsis Urine Monoclonal PX-3018416601 CDM 84166 CPT 301 RC outpatient 210 210 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES EPO [308136803] 168 percent of total billed charges 130.2 199.5 Technical (Hospital) Services Ref Protein Electrphorsis Urine Monoclonal PX-3018416601 CDM 84166 CPT 301 RC outpatient 210 210 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES HDHP [308136802] 168 percent of total billed charges 130.2 199.5 Technical (Hospital) Services Ref Protein Electrphorsis Urine Monoclonal PX-3018416601 CDM 84166 CPT 301 RC outpatient 210 210 CIGNA 62308 [3081051] CIGNA 62308 [308105105] 168 percent of total billed charges 130.2 199.5 Technical (Hospital) Services Ref Protein Electrphorsis Urine Monoclonal PX-3018416601 CDM 84166 CPT 301 RC outpatient 210 210 CIGNA 62308 [3081051] CIGNA STATE OF WYOMING [308105107] 168 percent of total billed charges 130.2 199.5 Technical (Hospital) Services Ref Protein Electrphorsis Urine Monoclonal PX-3018416601 CDM 84166 CPT 301 RC outpatient 210 210 MEDICA (COMMERCIAL) 94265 [3081118] MEDICA CLAIMS [308111801] 189 percent of total billed charges 130.2 199.5 Technical (Hospital) Services Ref Protein Electrphorsis Urine PX-3018416602 CDM 84166 CPT 301 RC inpatient 165 165 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES PPO [308136801] 130.65 percent of total billed charges 102.3 156.75 Technical (Hospital) Services Ref Protein Electrphorsis Urine PX-3018416602 CDM 84166 CPT 301 RC inpatient 165 165 UNITED HEALTHCARE (COMMERCIAL) [3081199] UNITED HEALTHCARE 87726 [308119901] 102.3 percent of total billed charges 102.3 156.75 Technical (Hospital) Services Ref Protein Electrphorsis Urine PX-3018416602 CDM 84166 CPT 301 RC inpatient 165 165 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES HDHP [308136802] 130.65 percent of total billed charges 102.3 156.75 Technical (Hospital) Services Ref Protein Electrphorsis Urine PX-3018416602 CDM 84166 CPT 301 RC inpatient 165 165 BLUE CROSS BLUE SHIELD WELLMARK SB889 [3081026] BCBS WYOMING [308102603] 156.75 percent of total billed charges 102.3 156.75 Technical (Hospital) Services Ref Protein Electrphorsis Urine PX-3018416602 CDM 84166 CPT 301 RC inpatient 165 165 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES EPO [308136803] 130.65 percent of total billed charges 102.3 156.75 Technical (Hospital) Services Ref Protein Electrphorsis Urine PX-3018416602 CDM 84166 CPT 301 RC inpatient 165 165 HEALTHPARTNERS SX009 HEALTHPARTNERS 130.65 percent of total billed charges 102.3 156.75 Technical (Hospital) Services Ref Protein Electrphorsis Urine PX-3018416602 CDM 84166 CPT 301 RC inpatient 165 165 MEDICA (COMMERCIAL) 94265 [3081118] MEDICA CLAIMS [308111801] 148.5 percent of total billed charges 102.3 156.75 Technical (Hospital) Services Ref Protein Electrphorsis Urine PX-3018416602 CDM 84166 CPT 301 RC inpatient 165 165 MULTIPLAN INC 34080 [3081285] MULTIPLAN INC [308128501] 156.75 percent of total billed charges 102.3 156.75 Technical (Hospital) Services Ref Protein Electrphorsis Urine PX-3018416602 CDM 84166 CPT 301 RC inpatient 165 165 CIGNA 62308 [3081051] CIGNA 62308 [308105105] 130.65 percent of total billed charges 102.3 156.75 Technical (Hospital) Services Ref Protein Electrphorsis Urine PX-3018416602 CDM 84166 CPT 301 RC inpatient 165 165 CIGNA 62308 [3081051] CIGNA STATE OF WYOMING [308105107] 130.65 percent of total billed charges 102.3 156.75 Technical (Hospital) Services Ref Protein Electrphorsis Urine PX-3018416602 CDM 84166 CPT 301 RC outpatient 165 165 MEDICA (COMMERCIAL) 94265 [3081118] MEDICA CLAIMS [308111801] 148.5 percent of total billed charges 102.3 156.75 Technical (Hospital) Services Ref Protein Electrphorsis Urine PX-3018416602 CDM 84166 CPT 301 RC outpatient 165 165 CIGNA 62308 [3081051] CIGNA 62308 [308105105] 132 percent of total billed charges 102.3 156.75 Technical (Hospital) Services Ref Protein Electrphorsis Urine PX-3018416602 CDM 84166 CPT 301 RC outpatient 165 165 CIGNA 62308 [3081051] CIGNA STATE OF WYOMING [308105107] 132 percent of total billed charges 102.3 156.75 Technical (Hospital) Services Ref Protein Electrphorsis Urine PX-3018416602 CDM 84166 CPT 301 RC outpatient 165 165 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES HDHP [308136802] 132 percent of total billed charges 102.3 156.75 Technical (Hospital) Services Ref Protein Electrphorsis Urine PX-3018416602 CDM 84166 CPT 301 RC outpatient 165 165 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES EPO [308136803] 132 percent of total billed charges 102.3 156.75 Technical (Hospital) Services Ref Protein Electrphorsis Urine PX-3018416602 CDM 84166 CPT 301 RC outpatient 165 165 MULTIPLAN INC 34080 [3081285] MULTIPLAN INC [308128501] 156.75 percent of total billed charges 102.3 156.75 Technical (Hospital) Services Ref Protein Electrphorsis Urine PX-3018416602 CDM 84166 CPT 301 RC outpatient 165 165 BLUE CROSS BLUE SHIELD WELLMARK SB889 [3081026] BCBS WYOMING [308102603] 156.75 percent of total billed charges 102.3 156.75 Technical (Hospital) Services Ref Protein Electrphorsis Urine PX-3018416602 CDM 84166 CPT 301 RC outpatient 165 165 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES PPO [308136801] 132 percent of total billed charges 102.3 156.75 Technical (Hospital) Services Ref Protein Electrphorsis Urine PX-3018416602 CDM 84166 CPT 301 RC outpatient 165 165 HEALTHPARTNERS SX009 HEALTHPARTNERS 132 percent of total billed charges 102.3 156.75 Technical (Hospital) Services Ref Protein Electrphorsis Urine PX-3018416602 CDM 84166 CPT 301 RC outpatient 165 165 UNITED HEALTHCARE (COMMERCIAL) [3081199] UNITED HEALTHCARE 87726 [308119901] 102.3 percent of total billed charges 102.3 156.75 Technical (Hospital) Services Ref Monoclonal Protein Study Elp PX-3018416501 CDM 84165 CPT 301 RC outpatient 100 100 CIGNA 62308 [3081051] CIGNA 62308 [308105105] 80 percent of total billed charges 62 95 Technical (Hospital) Services Ref Monoclonal Protein Study Elp PX-3018416501 CDM 84165 CPT 301 RC outpatient 100 100 CIGNA 62308 [3081051] CIGNA STATE OF WYOMING [308105107] 80 percent of total billed charges 62 95 Technical (Hospital) Services Ref Monoclonal Protein Study Elp PX-3018416501 CDM 84165 CPT 301 RC outpatient 100 100 MEDICA (COMMERCIAL) 94265 [3081118] MEDICA CLAIMS [308111801] 90 percent of total billed charges 62 95 Technical (Hospital) Services Ref Monoclonal Protein Study Elp PX-3018416501 CDM 84165 CPT 301 RC outpatient 100 100 MULTIPLAN INC 34080 [3081285] MULTIPLAN INC [308128501] 95 percent of total billed charges 62 95 Technical (Hospital) Services Ref Monoclonal Protein Study Elp PX-3018416501 CDM 84165 CPT 301 RC outpatient 100 100 BLUE CROSS BLUE SHIELD WELLMARK SB889 [3081026] BCBS WYOMING [308102603] 95 percent of total billed charges 62 95 Technical (Hospital) Services Ref Monoclonal Protein Study Elp PX-3018416501 CDM 84165 CPT 301 RC outpatient 100 100 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES HDHP [308136802] 80 percent of total billed charges 62 95 Technical (Hospital) Services Ref Monoclonal Protein Study Elp PX-3018416501 CDM 84165 CPT 301 RC outpatient 100 100 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES EPO [308136803] 80 percent of total billed charges 62 95 Technical (Hospital) Services Ref Monoclonal Protein Study Elp PX-3018416501 CDM 84165 CPT 301 RC outpatient 100 100 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES PPO [308136801] 80 percent of total billed charges 62 95 Technical (Hospital) Services Ref Monoclonal Protein Study Elp PX-3018416501 CDM 84165 CPT 301 RC outpatient 100 100 HEALTHPARTNERS SX009 HEALTHPARTNERS 80 percent of total billed charges 62 95 Technical (Hospital) Services Ref Monoclonal Protein Study Elp PX-3018416501 CDM 84165 CPT 301 RC outpatient 100 100 UNITED HEALTHCARE (COMMERCIAL) [3081199] UNITED HEALTHCARE 87726 [308119901] 62 percent of total billed charges 62 95 Technical (Hospital) Services Ref Monoclonal Protein Study Elp PX-3018416501 CDM 84165 CPT 301 RC inpatient 100 100 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES HDHP [308136802] 79.18 percent of total billed charges 62 95 Technical (Hospital) Services Ref Monoclonal Protein Study Elp PX-3018416501 CDM 84165 CPT 301 RC inpatient 100 100 BLUE CROSS BLUE SHIELD WELLMARK SB889 [3081026] BCBS WYOMING [308102603] 95 percent of total billed charges 62 95 Technical (Hospital) Services Ref Monoclonal Protein Study Elp PX-3018416501 CDM 84165 CPT 301 RC inpatient 100 100 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES PPO [308136801] 79.18 percent of total billed charges 62 95 Technical (Hospital) Services Ref Monoclonal Protein Study Elp PX-3018416501 CDM 84165 CPT 301 RC inpatient 100 100 UNITED HEALTHCARE (COMMERCIAL) [3081199] UNITED HEALTHCARE 87726 [308119901] 62 percent of total billed charges 62 95 Technical (Hospital) Services Ref Monoclonal Protein Study Elp PX-3018416501 CDM 84165 CPT 301 RC inpatient 100 100 MEDICA (COMMERCIAL) 94265 [3081118] MEDICA CLAIMS [308111801] 90 percent of total billed charges 62 95 Technical (Hospital) Services Ref Monoclonal Protein Study Elp PX-3018416501 CDM 84165 CPT 301 RC inpatient 100 100 MULTIPLAN INC 34080 [3081285] MULTIPLAN INC [308128501] 95 percent of total billed charges 62 95 Technical (Hospital) Services Ref Monoclonal Protein Study Elp PX-3018416501 CDM 84165 CPT 301 RC inpatient 100 100 CIGNA 62308 [3081051] CIGNA 62308 [308105105] 79.18 percent of total billed charges 62 95 Technical (Hospital) Services Ref Monoclonal Protein Study Elp PX-3018416501 CDM 84165 CPT 301 RC inpatient 100 100 CIGNA 62308 [3081051] CIGNA STATE OF WYOMING [308105107] 79.18 percent of total billed charges 62 95 Technical (Hospital) Services Ref Monoclonal Protein Study Elp PX-3018416501 CDM 84165 CPT 301 RC inpatient 100 100 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES EPO [308136803] 79.18 percent of total billed charges 62 95 Technical (Hospital) Services Ref Monoclonal Protein Study Elp PX-3018416501 CDM 84165 CPT 301 RC inpatient 100 100 HEALTHPARTNERS SX009 HEALTHPARTNERS 79.18 percent of total billed charges 62 95 Technical (Hospital) Services "Ref Protein Study, Serum Elp Mayo" PX-3018416502 CDM 84165 CPT 301 RC outpatient 156 156 MEDICA (COMMERCIAL) 94265 [3081118] MEDICA CLAIMS [308111801] 140.4 percent of total billed charges 96.72 148.2 Technical (Hospital) Services "Ref Protein Study, Serum Elp Mayo" PX-3018416502 CDM 84165 CPT 301 RC outpatient 156 156 CIGNA 62308 [3081051] CIGNA 62308 [308105105] 124.8 percent of total billed charges 96.72 148.2 Technical (Hospital) Services "Ref Protein Study, Serum Elp Mayo" PX-3018416502 CDM 84165 CPT 301 RC outpatient 156 156 CIGNA 62308 [3081051] CIGNA STATE OF WYOMING [308105107] 124.8 percent of total billed charges 96.72 148.2 Technical (Hospital) Services "Ref Protein Study, Serum Elp Mayo" PX-3018416502 CDM 84165 CPT 301 RC outpatient 156 156 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES EPO [308136803] 124.8 percent of total billed charges 96.72 148.2 Technical (Hospital) Services "Ref Protein Study, Serum Elp Mayo" PX-3018416502 CDM 84165 CPT 301 RC outpatient 156 156 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES HDHP [308136802] 124.8 percent of total billed charges 96.72 148.2 Technical (Hospital) Services "Ref Protein Study, Serum Elp Mayo" PX-3018416502 CDM 84165 CPT 301 RC outpatient 156 156 MULTIPLAN INC 34080 [3081285] MULTIPLAN INC [308128501] 148.2 percent of total billed charges 96.72 148.2 Technical (Hospital) Services "Ref Protein Study, Serum Elp Mayo" PX-3018416502 CDM 84165 CPT 301 RC outpatient 156 156 BLUE CROSS BLUE SHIELD WELLMARK SB889 [3081026] BCBS WYOMING [308102603] 148.2 percent of total billed charges 96.72 148.2 Technical (Hospital) Services "Ref Protein Study, Serum Elp Mayo" PX-3018416502 CDM 84165 CPT 301 RC outpatient 156 156 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES PPO [308136801] 124.8 percent of total billed charges 96.72 148.2 Technical (Hospital) Services "Ref Protein Study, Serum Elp Mayo" PX-3018416502 CDM 84165 CPT 301 RC outpatient 156 156 HEALTHPARTNERS SX009 HEALTHPARTNERS 124.8 percent of total billed charges 96.72 148.2 Technical (Hospital) Services "Ref Protein Study, Serum Elp Mayo" PX-3018416502 CDM 84165 CPT 301 RC outpatient 156 156 UNITED HEALTHCARE (COMMERCIAL) [3081199] UNITED HEALTHCARE 87726 [308119901] 96.72 percent of total billed charges 96.72 148.2 Technical (Hospital) Services "Ref Protein Study, Serum Elp Mayo" PX-3018416502 CDM 84165 CPT 301 RC inpatient 156 156 BLUE CROSS BLUE SHIELD WELLMARK SB889 [3081026] BCBS WYOMING [308102603] 148.2 percent of total billed charges 96.72 148.2 Technical (Hospital) Services "Ref Protein Study, Serum Elp Mayo" PX-3018416502 CDM 84165 CPT 301 RC inpatient 156 156 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES HDHP [308136802] 123.52 percent of total billed charges 96.72 148.2 Technical (Hospital) Services "Ref Protein Study, Serum Elp Mayo" PX-3018416502 CDM 84165 CPT 301 RC inpatient 156 156 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES PPO [308136801] 123.52 percent of total billed charges 96.72 148.2 Technical (Hospital) Services "Ref Protein Study, Serum Elp Mayo" PX-3018416502 CDM 84165 CPT 301 RC inpatient 156 156 UNITED HEALTHCARE (COMMERCIAL) [3081199] UNITED HEALTHCARE 87726 [308119901] 96.72 percent of total billed charges 96.72 148.2 Technical (Hospital) Services "Ref Protein Study, Serum Elp Mayo" PX-3018416502 CDM 84165 CPT 301 RC inpatient 156 156 HEALTHPARTNERS SX009 HEALTHPARTNERS 123.52 percent of total billed charges 96.72 148.2 Technical (Hospital) Services "Ref Protein Study, Serum Elp Mayo" PX-3018416502 CDM 84165 CPT 301 RC inpatient 156 156 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES EPO [308136803] 123.52 percent of total billed charges 96.72 148.2 Technical (Hospital) Services "Ref Protein Study, Serum Elp Mayo" PX-3018416502 CDM 84165 CPT 301 RC inpatient 156 156 CIGNA 62308 [3081051] CIGNA 62308 [308105105] 123.52 percent of total billed charges 96.72 148.2 Technical (Hospital) Services "Ref Protein Study, Serum Elp Mayo" PX-3018416502 CDM 84165 CPT 301 RC inpatient 156 156 CIGNA 62308 [3081051] CIGNA STATE OF WYOMING [308105107] 123.52 percent of total billed charges 96.72 148.2 Technical (Hospital) Services "Ref Protein Study, Serum Elp Mayo" PX-3018416502 CDM 84165 CPT 301 RC inpatient 156 156 MULTIPLAN INC 34080 [3081285] MULTIPLAN INC [308128501] 148.2 percent of total billed charges 96.72 148.2 Technical (Hospital) Services "Ref Protein Study, Serum Elp Mayo" PX-3018416502 CDM 84165 CPT 301 RC inpatient 156 156 MEDICA (COMMERCIAL) 94265 [3081118] MEDICA CLAIMS [308111801] 140.4 percent of total billed charges 96.72 148.2 Technical (Hospital) Services "HC Ref Protein Electrophoresis, Serum(Mayo) Spep Spe" PX-3018416504 CDM 84165 CPT 301 RC inpatient 33 33 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES HDHP [308136802] 26.13 percent of total billed charges 20.46 31.35 Technical (Hospital) Services "HC Ref Protein Electrophoresis, Serum(Mayo) Spep Spe" PX-3018416504 CDM 84165 CPT 301 RC inpatient 33 33 BLUE CROSS BLUE SHIELD WELLMARK SB889 [3081026] BCBS WYOMING [308102603] 31.35 percent of total billed charges 20.46 31.35 Technical (Hospital) Services "HC Ref Protein Electrophoresis, Serum(Mayo) Spep Spe" PX-3018416504 CDM 84165 CPT 301 RC inpatient 33 33 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES PPO [308136801] 26.13 percent of total billed charges 20.46 31.35 Technical (Hospital) Services "HC Ref Protein Electrophoresis, Serum(Mayo) Spep Spe" PX-3018416504 CDM 84165 CPT 301 RC inpatient 33 33 UNITED HEALTHCARE (COMMERCIAL) [3081199] UNITED HEALTHCARE 87726 [308119901] 20.46 percent of total billed charges 20.46 31.35 Technical (Hospital) Services "HC Ref Protein Electrophoresis, Serum(Mayo) Spep Spe" PX-3018416504 CDM 84165 CPT 301 RC inpatient 33 33 MEDICA (COMMERCIAL) 94265 [3081118] MEDICA CLAIMS [308111801] 29.7 percent of total billed charges 20.46 31.35 Technical (Hospital) Services "HC Ref Protein Electrophoresis, Serum(Mayo) Spep Spe" PX-3018416504 CDM 84165 CPT 301 RC inpatient 33 33 MULTIPLAN INC 34080 [3081285] MULTIPLAN INC [308128501] 31.35 percent of total billed charges 20.46 31.35 Technical (Hospital) Services "HC Ref Protein Electrophoresis, Serum(Mayo) Spep Spe" PX-3018416504 CDM 84165 CPT 301 RC inpatient 33 33 CIGNA 62308 [3081051] CIGNA 62308 [308105105] 26.13 percent of total billed charges 20.46 31.35 Technical (Hospital) Services "HC Ref Protein Electrophoresis, Serum(Mayo) Spep Spe" PX-3018416504 CDM 84165 CPT 301 RC inpatient 33 33 CIGNA 62308 [3081051] CIGNA STATE OF WYOMING [308105107] 26.13 percent of total billed charges 20.46 31.35 Technical (Hospital) Services "HC Ref Protein Electrophoresis, Serum(Mayo) Spep Spe" PX-3018416504 CDM 84165 CPT 301 RC inpatient 33 33 HEALTHPARTNERS SX009 HEALTHPARTNERS 26.13 percent of total billed charges 20.46 31.35 Technical (Hospital) Services "HC Ref Protein Electrophoresis, Serum(Mayo) Spep Spe" PX-3018416504 CDM 84165 CPT 301 RC inpatient 33 33 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES EPO [308136803] 26.13 percent of total billed charges 20.46 31.35 Technical (Hospital) Services "HC Ref Protein Electrophoresis, Serum(Mayo) Spep Spe" PX-3018416504 CDM 84165 CPT 301 RC outpatient 33 33 CIGNA 62308 [3081051] CIGNA 62308 [308105105] 26.4 percent of total billed charges 20.46 31.35 Technical (Hospital) Services "HC Ref Protein Electrophoresis, Serum(Mayo) Spep Spe" PX-3018416504 CDM 84165 CPT 301 RC outpatient 33 33 CIGNA 62308 [3081051] CIGNA STATE OF WYOMING [308105107] 26.4 percent of total billed charges 20.46 31.35 Technical (Hospital) Services "HC Ref Protein Electrophoresis, Serum(Mayo) Spep Spe" PX-3018416504 CDM 84165 CPT 301 RC outpatient 33 33 MEDICA (COMMERCIAL) 94265 [3081118] MEDICA CLAIMS [308111801] 29.7 percent of total billed charges 20.46 31.35 Technical (Hospital) Services "HC Ref Protein Electrophoresis, Serum(Mayo) Spep Spe" PX-3018416504 CDM 84165 CPT 301 RC outpatient 33 33 BLUE CROSS BLUE SHIELD WELLMARK SB889 [3081026] BCBS WYOMING [308102603] 31.35 percent of total billed charges 20.46 31.35 Technical (Hospital) Services "HC Ref Protein Electrophoresis, Serum(Mayo) Spep Spe" PX-3018416504 CDM 84165 CPT 301 RC outpatient 33 33 MULTIPLAN INC 34080 [3081285] MULTIPLAN INC [308128501] 31.35 percent of total billed charges 20.46 31.35 Technical (Hospital) Services "HC Ref Protein Electrophoresis, Serum(Mayo) Spep Spe" PX-3018416504 CDM 84165 CPT 301 RC outpatient 33 33 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES HDHP [308136802] 26.4 percent of total billed charges 20.46 31.35 Technical (Hospital) Services "HC Ref Protein Electrophoresis, Serum(Mayo) Spep Spe" PX-3018416504 CDM 84165 CPT 301 RC outpatient 33 33 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES EPO [308136803] 26.4 percent of total billed charges 20.46 31.35 Technical (Hospital) Services "HC Ref Protein Electrophoresis, Serum(Mayo) Spep Spe" PX-3018416504 CDM 84165 CPT 301 RC outpatient 33 33 UNITED HEALTHCARE (COMMERCIAL) [3081199] UNITED HEALTHCARE 87726 [308119901] 20.46 percent of total billed charges 20.46 31.35 Technical (Hospital) Services "HC Ref Protein Electrophoresis, Serum(Mayo) Spep Spe" PX-3018416504 CDM 84165 CPT 301 RC outpatient 33 33 HEALTHPARTNERS SX009 HEALTHPARTNERS 26.4 percent of total billed charges 20.46 31.35 Technical (Hospital) Services "HC Ref Protein Electrophoresis, Serum(Mayo) Spep Spe" PX-3018416504 CDM 84165 CPT 301 RC outpatient 33 33 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES PPO [308136801] 26.4 percent of total billed charges 20.46 31.35 Technical (Hospital) Services "Assay, Protein, Other Source, Total" PX-3018415700 CDM 84157 CPT 301 RC outpatient 95 95 MEDICA (COMMERCIAL) 94265 [3081118] MEDICA CLAIMS [308111801] 85.5 percent of total billed charges 58.9 90.25 Technical (Hospital) Services "Assay, Protein, Other Source, Total" PX-3018415700 CDM 84157 CPT 301 RC outpatient 95 95 CIGNA 62308 [3081051] CIGNA 62308 [308105105] 76 percent of total billed charges 58.9 90.25 Technical (Hospital) Services "Assay, Protein, Other Source, Total" PX-3018415700 CDM 84157 CPT 301 RC outpatient 95 95 CIGNA 62308 [3081051] CIGNA STATE OF WYOMING [308105107] 76 percent of total billed charges 58.9 90.25 Technical (Hospital) Services "Assay, Protein, Other Source, Total" PX-3018415700 CDM 84157 CPT 301 RC outpatient 95 95 BLUE CROSS BLUE SHIELD WELLMARK SB889 [3081026] BCBS WYOMING [308102603] 90.25 percent of total billed charges 58.9 90.25 Technical (Hospital) Services "Assay, Protein, Other Source, Total" PX-3018415700 CDM 84157 CPT 301 RC outpatient 95 95 MULTIPLAN INC 34080 [3081285] MULTIPLAN INC [308128501] 90.25 percent of total billed charges 58.9 90.25 Technical (Hospital) Services "Assay, Protein, Other Source, Total" PX-3018415700 CDM 84157 CPT 301 RC outpatient 95 95 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES HDHP [308136802] 76 percent of total billed charges 58.9 90.25 Technical (Hospital) Services "Assay, Protein, Other Source, Total" PX-3018415700 CDM 84157 CPT 301 RC outpatient 95 95 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES EPO [308136803] 76 percent of total billed charges 58.9 90.25 Technical (Hospital) Services "Assay, Protein, Other Source, Total" PX-3018415700 CDM 84157 CPT 301 RC outpatient 95 95 UNITED HEALTHCARE (COMMERCIAL) [3081199] UNITED HEALTHCARE 87726 [308119901] 58.9 percent of total billed charges 58.9 90.25 Technical (Hospital) Services "Assay, Protein, Other Source, Total" PX-3018415700 CDM 84157 CPT 301 RC outpatient 95 95 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES PPO [308136801] 76 percent of total billed charges 58.9 90.25 Technical (Hospital) Services "Assay, Protein, Other Source, Total" PX-3018415700 CDM 84157 CPT 301 RC outpatient 95 95 HEALTHPARTNERS SX009 HEALTHPARTNERS 76 percent of total billed charges 58.9 90.25 Technical (Hospital) Services "Assay, Protein, Other Source, Total" PX-3018415700 CDM 84157 CPT 301 RC inpatient 95 95 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES EPO [308136803] 75.22 percent of total billed charges 58.9 90.25 Technical (Hospital) Services "Assay, Protein, Other Source, Total" PX-3018415700 CDM 84157 CPT 301 RC inpatient 95 95 HEALTHPARTNERS SX009 HEALTHPARTNERS 75.22 percent of total billed charges 58.9 90.25 Technical (Hospital) Services "Assay, Protein, Other Source, Total" PX-3018415700 CDM 84157 CPT 301 RC inpatient 95 95 CIGNA 62308 [3081051] CIGNA 62308 [308105105] 75.22 percent of total billed charges 58.9 90.25 Technical (Hospital) Services "Assay, Protein, Other Source, Total" PX-3018415700 CDM 84157 CPT 301 RC inpatient 95 95 CIGNA 62308 [3081051] CIGNA STATE OF WYOMING [308105107] 75.22 percent of total billed charges 58.9 90.25 Technical (Hospital) Services "Assay, Protein, Other Source, Total" PX-3018415700 CDM 84157 CPT 301 RC inpatient 95 95 MULTIPLAN INC 34080 [3081285] MULTIPLAN INC [308128501] 90.25 percent of total billed charges 58.9 90.25 Technical (Hospital) Services "Assay, Protein, Other Source, Total" PX-3018415700 CDM 84157 CPT 301 RC inpatient 95 95 MEDICA (COMMERCIAL) 94265 [3081118] MEDICA CLAIMS [308111801] 85.5 percent of total billed charges 58.9 90.25 Technical (Hospital) Services "Assay, Protein, Other Source, Total" PX-3018415700 CDM 84157 CPT 301 RC inpatient 95 95 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES PPO [308136801] 75.22 percent of total billed charges 58.9 90.25 Technical (Hospital) Services "Assay, Protein, Other Source, Total" PX-3018415700 CDM 84157 CPT 301 RC inpatient 95 95 UNITED HEALTHCARE (COMMERCIAL) [3081199] UNITED HEALTHCARE 87726 [308119901] 58.9 percent of total billed charges 58.9 90.25 Technical (Hospital) Services "Assay, Protein, Other Source, Total" PX-3018415700 CDM 84157 CPT 301 RC inpatient 95 95 BLUE CROSS BLUE SHIELD WELLMARK SB889 [3081026] BCBS WYOMING [308102603] 90.25 percent of total billed charges 58.9 90.25 Technical (Hospital) Services "Assay, Protein, Other Source, Total" PX-3018415700 CDM 84157 CPT 301 RC inpatient 95 95 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES HDHP [308136802] 75.22 percent of total billed charges 58.9 90.25 Technical (Hospital) Services Protein-Quant Urine PX-3018415600 CDM 84156 CPT 301 RC inpatient 86 86 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES PPO [308136801] 68.09 percent of total billed charges 53.32 81.7 Technical (Hospital) Services Protein-Quant Urine PX-3018415600 CDM 84156 CPT 301 RC inpatient 86 86 UNITED HEALTHCARE (COMMERCIAL) [3081199] UNITED HEALTHCARE 87726 [308119901] 53.32 percent of total billed charges 53.32 81.7 Technical (Hospital) Services Protein-Quant Urine PX-3018415600 CDM 84156 CPT 301 RC inpatient 86 86 BLUE CROSS BLUE SHIELD WELLMARK SB889 [3081026] BCBS WYOMING [308102603] 81.7 percent of total billed charges 53.32 81.7 Technical (Hospital) Services Protein-Quant Urine PX-3018415600 CDM 84156 CPT 301 RC inpatient 86 86 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES HDHP [308136802] 68.09 percent of total billed charges 53.32 81.7 Technical (Hospital) Services Protein-Quant Urine PX-3018415600 CDM 84156 CPT 301 RC inpatient 86 86 CIGNA 62308 [3081051] CIGNA 62308 [308105105] 68.09 percent of total billed charges 53.32 81.7 Technical (Hospital) Services Protein-Quant Urine PX-3018415600 CDM 84156 CPT 301 RC inpatient 86 86 CIGNA 62308 [3081051] CIGNA STATE OF WYOMING [308105107] 68.09 percent of total billed charges 53.32 81.7 Technical (Hospital) Services Protein-Quant Urine PX-3018415600 CDM 84156 CPT 301 RC inpatient 86 86 MEDICA (COMMERCIAL) 94265 [3081118] MEDICA CLAIMS [308111801] 77.4 percent of total billed charges 53.32 81.7 Technical (Hospital) Services Protein-Quant Urine PX-3018415600 CDM 84156 CPT 301 RC inpatient 86 86 MULTIPLAN INC 34080 [3081285] MULTIPLAN INC [308128501] 81.7 percent of total billed charges 53.32 81.7 Technical (Hospital) Services Protein-Quant Urine PX-3018415600 CDM 84156 CPT 301 RC inpatient 86 86 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES EPO [308136803] 68.09 percent of total billed charges 53.32 81.7 Technical (Hospital) Services Protein-Quant Urine PX-3018415600 CDM 84156 CPT 301 RC inpatient 86 86 HEALTHPARTNERS SX009 HEALTHPARTNERS 68.09 percent of total billed charges 53.32 81.7 Technical (Hospital) Services Protein-Quant Urine PX-3018415600 CDM 84156 CPT 301 RC outpatient 86 86 MEDICA (COMMERCIAL) 94265 [3081118] MEDICA CLAIMS [308111801] 77.4 percent of total billed charges 53.32 81.7 Technical (Hospital) Services Protein-Quant Urine PX-3018415600 CDM 84156 CPT 301 RC outpatient 86 86 CIGNA 62308 [3081051] CIGNA 62308 [308105105] 68.8 percent of total billed charges 53.32 81.7 Technical (Hospital) Services Protein-Quant Urine PX-3018415600 CDM 84156 CPT 301 RC outpatient 86 86 CIGNA 62308 [3081051] CIGNA STATE OF WYOMING [308105107] 68.8 percent of total billed charges 53.32 81.7 Technical (Hospital) Services Protein-Quant Urine PX-3018415600 CDM 84156 CPT 301 RC outpatient 86 86 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES HDHP [308136802] 68.8 percent of total billed charges 53.32 81.7 Technical (Hospital) Services Protein-Quant Urine PX-3018415600 CDM 84156 CPT 301 RC outpatient 86 86 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES EPO [308136803] 68.8 percent of total billed charges 53.32 81.7 Technical (Hospital) Services Protein-Quant Urine PX-3018415600 CDM 84156 CPT 301 RC outpatient 86 86 BLUE CROSS BLUE SHIELD WELLMARK SB889 [3081026] BCBS WYOMING [308102603] 81.7 percent of total billed charges 53.32 81.7 Technical (Hospital) Services Protein-Quant Urine PX-3018415600 CDM 84156 CPT 301 RC outpatient 86 86 MULTIPLAN INC 34080 [3081285] MULTIPLAN INC [308128501] 81.7 percent of total billed charges 53.32 81.7 Technical (Hospital) Services Protein-Quant Urine PX-3018415600 CDM 84156 CPT 301 RC outpatient 86 86 UNITED HEALTHCARE (COMMERCIAL) [3081199] UNITED HEALTHCARE 87726 [308119901] 53.32 percent of total billed charges 53.32 81.7 Technical (Hospital) Services Protein-Quant Urine PX-3018415600 CDM 84156 CPT 301 RC outpatient 86 86 HEALTHPARTNERS SX009 HEALTHPARTNERS 68.8 percent of total billed charges 53.32 81.7 Technical (Hospital) Services Protein-Quant Urine PX-3018415600 CDM 84156 CPT 301 RC outpatient 86 86 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES PPO [308136801] 68.8 percent of total billed charges 53.32 81.7 Technical (Hospital) Services "Ref Protein, Total, Urine Monoclonal" PX-3018415601 CDM 84156 CPT 301 RC inpatient 60 60 UNITED HEALTHCARE (COMMERCIAL) [3081199] UNITED HEALTHCARE 87726 [308119901] 37.2 percent of total billed charges 37.2 57 Technical (Hospital) Services "Ref Protein, Total, Urine Monoclonal" PX-3018415601 CDM 84156 CPT 301 RC inpatient 60 60 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES PPO [308136801] 47.51 percent of total billed charges 37.2 57 Technical (Hospital) Services "Ref Protein, Total, Urine Monoclonal" PX-3018415601 CDM 84156 CPT 301 RC inpatient 60 60 BLUE CROSS BLUE SHIELD WELLMARK SB889 [3081026] BCBS WYOMING [308102603] 57 percent of total billed charges 37.2 57 Technical (Hospital) Services "Ref Protein, Total, Urine Monoclonal" PX-3018415601 CDM 84156 CPT 301 RC inpatient 60 60 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES HDHP [308136802] 47.51 percent of total billed charges 37.2 57 Technical (Hospital) Services "Ref Protein, Total, Urine Monoclonal" PX-3018415601 CDM 84156 CPT 301 RC inpatient 60 60 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES EPO [308136803] 47.51 percent of total billed charges 37.2 57 Technical (Hospital) Services "Ref Protein, Total, Urine Monoclonal" PX-3018415601 CDM 84156 CPT 301 RC inpatient 60 60 HEALTHPARTNERS SX009 HEALTHPARTNERS 47.51 percent of total billed charges 37.2 57 Technical (Hospital) Services "Ref Protein, Total, Urine Monoclonal" PX-3018415601 CDM 84156 CPT 301 RC inpatient 60 60 CIGNA 62308 [3081051] CIGNA 62308 [308105105] 47.51 percent of total billed charges 37.2 57 Technical (Hospital) Services "Ref Protein, Total, Urine Monoclonal" PX-3018415601 CDM 84156 CPT 301 RC inpatient 60 60 CIGNA 62308 [3081051] CIGNA STATE OF WYOMING [308105107] 47.51 percent of total billed charges 37.2 57 Technical (Hospital) Services "Ref Protein, Total, Urine Monoclonal" PX-3018415601 CDM 84156 CPT 301 RC inpatient 60 60 MULTIPLAN INC 34080 [3081285] MULTIPLAN INC [308128501] 57 percent of total billed charges 37.2 57 Technical (Hospital) Services "Ref Protein, Total, Urine Monoclonal" PX-3018415601 CDM 84156 CPT 301 RC inpatient 60 60 MEDICA (COMMERCIAL) 94265 [3081118] MEDICA CLAIMS [308111801] 54 percent of total billed charges 37.2 57 Technical (Hospital) Services "Ref Protein, Total, Urine Monoclonal" PX-3018415601 CDM 84156 CPT 301 RC outpatient 60 60 BLUE CROSS BLUE SHIELD WELLMARK SB889 [3081026] BCBS WYOMING [308102603] 57 percent of total billed charges 37.2 57 Technical (Hospital) Services "Ref Protein, Total, Urine Monoclonal" PX-3018415601 CDM 84156 CPT 301 RC outpatient 60 60 MULTIPLAN INC 34080 [3081285] MULTIPLAN INC [308128501] 57 percent of total billed charges 37.2 57 Technical (Hospital) Services "Ref Protein, Total, Urine Monoclonal" PX-3018415601 CDM 84156 CPT 301 RC outpatient 60 60 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES EPO [308136803] 48 percent of total billed charges 37.2 57 Technical (Hospital) Services "Ref Protein, Total, Urine Monoclonal" PX-3018415601 CDM 84156 CPT 301 RC outpatient 60 60 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES HDHP [308136802] 48 percent of total billed charges 37.2 57 Technical (Hospital) Services "Ref Protein, Total, Urine Monoclonal" PX-3018415601 CDM 84156 CPT 301 RC outpatient 60 60 UNITED HEALTHCARE (COMMERCIAL) [3081199] UNITED HEALTHCARE 87726 [308119901] 37.2 percent of total billed charges 37.2 57 Technical (Hospital) Services "Ref Protein, Total, Urine Monoclonal" PX-3018415601 CDM 84156 CPT 301 RC outpatient 60 60 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES PPO [308136801] 48 percent of total billed charges 37.2 57 Technical (Hospital) Services "Ref Protein, Total, Urine Monoclonal" PX-3018415601 CDM 84156 CPT 301 RC outpatient 60 60 HEALTHPARTNERS SX009 HEALTHPARTNERS 48 percent of total billed charges 37.2 57 Technical (Hospital) Services "Ref Protein, Total, Urine Monoclonal" PX-3018415601 CDM 84156 CPT 301 RC outpatient 60 60 MEDICA (COMMERCIAL) 94265 [3081118] MEDICA CLAIMS [308111801] 54 percent of total billed charges 37.2 57 Technical (Hospital) Services "Ref Protein, Total, Urine Monoclonal" PX-3018415601 CDM 84156 CPT 301 RC outpatient 60 60 CIGNA 62308 [3081051] CIGNA 62308 [308105105] 48 percent of total billed charges 37.2 57 Technical (Hospital) Services "Ref Protein, Total, Urine Monoclonal" PX-3018415601 CDM 84156 CPT 301 RC outpatient 60 60 CIGNA 62308 [3081051] CIGNA STATE OF WYOMING [308105107] 48 percent of total billed charges 37.2 57 Technical (Hospital) Services "Ref Protein, Total, Urine" PX-3018415602 CDM 84156 CPT 301 RC outpatient 86 86 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES HDHP [308136802] 68.8 percent of total billed charges 53.32 81.7 Technical (Hospital) Services "Ref Protein, Total, Urine" PX-3018415602 CDM 84156 CPT 301 RC outpatient 86 86 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES EPO [308136803] 68.8 percent of total billed charges 53.32 81.7 Technical (Hospital) Services "Ref Protein, Total, Urine" PX-3018415602 CDM 84156 CPT 301 RC outpatient 86 86 BLUE CROSS BLUE SHIELD WELLMARK SB889 [3081026] BCBS WYOMING [308102603] 81.7 percent of total billed charges 53.32 81.7 Technical (Hospital) Services "Ref Protein, Total, Urine" PX-3018415602 CDM 84156 CPT 301 RC outpatient 86 86 MULTIPLAN INC 34080 [3081285] MULTIPLAN INC [308128501] 81.7 percent of total billed charges 53.32 81.7 Technical (Hospital) Services "Ref Protein, Total, Urine" PX-3018415602 CDM 84156 CPT 301 RC outpatient 86 86 UNITED HEALTHCARE (COMMERCIAL) [3081199] UNITED HEALTHCARE 87726 [308119901] 53.32 percent of total billed charges 53.32 81.7 Technical (Hospital) Services "Ref Protein, Total, Urine" PX-3018415602 CDM 84156 CPT 301 RC outpatient 86 86 HEALTHPARTNERS SX009 HEALTHPARTNERS 68.8 percent of total billed charges 53.32 81.7 Technical (Hospital) Services "Ref Protein, Total, Urine" PX-3018415602 CDM 84156 CPT 301 RC outpatient 86 86 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES PPO [308136801] 68.8 percent of total billed charges 53.32 81.7 Technical (Hospital) Services "Ref Protein, Total, Urine" PX-3018415602 CDM 84156 CPT 301 RC outpatient 86 86 CIGNA 62308 [3081051] CIGNA 62308 [308105105] 68.8 percent of total billed charges 53.32 81.7 Technical (Hospital) Services "Ref Protein, Total, Urine" PX-3018415602 CDM 84156 CPT 301 RC outpatient 86 86 CIGNA 62308 [3081051] CIGNA STATE OF WYOMING [308105107] 68.8 percent of total billed charges 53.32 81.7 Technical (Hospital) Services "Ref Protein, Total, Urine" PX-3018415602 CDM 84156 CPT 301 RC outpatient 86 86 MEDICA (COMMERCIAL) 94265 [3081118] MEDICA CLAIMS [308111801] 77.4 percent of total billed charges 53.32 81.7 Technical (Hospital) Services "Ref Protein, Total, Urine" PX-3018415602 CDM 84156 CPT 301 RC inpatient 86 86 BLUE CROSS BLUE SHIELD WELLMARK SB889 [3081026] BCBS WYOMING [308102603] 81.7 percent of total billed charges 53.32 81.7 Technical (Hospital) Services "Ref Protein, Total, Urine" PX-3018415602 CDM 84156 CPT 301 RC inpatient 86 86 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES HDHP [308136802] 68.09 percent of total billed charges 53.32 81.7 Technical (Hospital) Services "Ref Protein, Total, Urine" PX-3018415602 CDM 84156 CPT 301 RC inpatient 86 86 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES PPO [308136801] 68.09 percent of total billed charges 53.32 81.7 Technical (Hospital) Services "Ref Protein, Total, Urine" PX-3018415602 CDM 84156 CPT 301 RC inpatient 86 86 UNITED HEALTHCARE (COMMERCIAL) [3081199] UNITED HEALTHCARE 87726 [308119901] 53.32 percent of total billed charges 53.32 81.7 Technical (Hospital) Services "Ref Protein, Total, Urine" PX-3018415602 CDM 84156 CPT 301 RC inpatient 86 86 HEALTHPARTNERS SX009 HEALTHPARTNERS 68.09 percent of total billed charges 53.32 81.7 Technical (Hospital) Services "Ref Protein, Total, Urine" PX-3018415602 CDM 84156 CPT 301 RC inpatient 86 86 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES EPO [308136803] 68.09 percent of total billed charges 53.32 81.7 Technical (Hospital) Services "Ref Protein, Total, Urine" PX-3018415602 CDM 84156 CPT 301 RC inpatient 86 86 CIGNA 62308 [3081051] CIGNA 62308 [308105105] 68.09 percent of total billed charges 53.32 81.7 Technical (Hospital) Services "Ref Protein, Total, Urine" PX-3018415602 CDM 84156 CPT 301 RC inpatient 86 86 CIGNA 62308 [3081051] CIGNA STATE OF WYOMING [308105107] 68.09 percent of total billed charges 53.32 81.7 Technical (Hospital) Services "Ref Protein, Total, Urine" PX-3018415602 CDM 84156 CPT 301 RC inpatient 86 86 MULTIPLAN INC 34080 [3081285] MULTIPLAN INC [308128501] 81.7 percent of total billed charges 53.32 81.7 Technical (Hospital) Services "Ref Protein, Total, Urine" PX-3018415602 CDM 84156 CPT 301 RC inpatient 86 86 MEDICA (COMMERCIAL) 94265 [3081118] MEDICA CLAIMS [308111801] 77.4 percent of total billed charges 53.32 81.7 Technical (Hospital) Services Ref Protein (Rptu) Urine PX-3018415603 CDM 84156 CPT 301 RC outpatient 65 65 BLUE CROSS BLUE SHIELD WELLMARK SB889 [3081026] BCBS WYOMING [308102603] 61.75 percent of total billed charges 40.3 61.75 Technical (Hospital) Services Ref Protein (Rptu) Urine PX-3018415603 CDM 84156 CPT 301 RC outpatient 65 65 MULTIPLAN INC 34080 [3081285] MULTIPLAN INC [308128501] 61.75 percent of total billed charges 40.3 61.75 Technical (Hospital) Services Ref Protein (Rptu) Urine PX-3018415603 CDM 84156 CPT 301 RC outpatient 65 65 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES EPO [308136803] 52 percent of total billed charges 40.3 61.75 Technical (Hospital) Services Ref Protein (Rptu) Urine PX-3018415603 CDM 84156 CPT 301 RC outpatient 65 65 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES HDHP [308136802] 52 percent of total billed charges 40.3 61.75 Technical (Hospital) Services Ref Protein (Rptu) Urine PX-3018415603 CDM 84156 CPT 301 RC outpatient 65 65 HEALTHPARTNERS SX009 HEALTHPARTNERS 52 percent of total billed charges 40.3 61.75 Technical (Hospital) Services Ref Protein (Rptu) Urine PX-3018415603 CDM 84156 CPT 301 RC outpatient 65 65 UNITED HEALTHCARE (COMMERCIAL) [3081199] UNITED HEALTHCARE 87726 [308119901] 40.3 percent of total billed charges 40.3 61.75 Technical (Hospital) Services Ref Protein (Rptu) Urine PX-3018415603 CDM 84156 CPT 301 RC outpatient 65 65 CIGNA 62308 [3081051] CIGNA 62308 [308105105] 52 percent of total billed charges 40.3 61.75 Technical (Hospital) Services Ref Protein (Rptu) Urine PX-3018415603 CDM 84156 CPT 301 RC outpatient 65 65 CIGNA 62308 [3081051] CIGNA STATE OF WYOMING [308105107] 52 percent of total billed charges 40.3 61.75 Technical (Hospital) Services Ref Protein (Rptu) Urine PX-3018415603 CDM 84156 CPT 301 RC outpatient 65 65 MEDICA (COMMERCIAL) 94265 [3081118] MEDICA CLAIMS [308111801] 58.5 percent of total billed charges 40.3 61.75 Technical (Hospital) Services Ref Protein (Rptu) Urine PX-3018415603 CDM 84156 CPT 301 RC outpatient 65 65 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES PPO [308136801] 52 percent of total billed charges 40.3 61.75 Technical (Hospital) Services Ref Protein (Rptu) Urine PX-3018415603 CDM 84156 CPT 301 RC inpatient 65 65 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES PPO [308136801] 51.47 percent of total billed charges 40.3 61.75 Technical (Hospital) Services Ref Protein (Rptu) Urine PX-3018415603 CDM 84156 CPT 301 RC inpatient 65 65 UNITED HEALTHCARE (COMMERCIAL) [3081199] UNITED HEALTHCARE 87726 [308119901] 40.3 percent of total billed charges 40.3 61.75 Technical (Hospital) Services Ref Protein (Rptu) Urine PX-3018415603 CDM 84156 CPT 301 RC inpatient 65 65 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES HDHP [308136802] 51.47 percent of total billed charges 40.3 61.75 Technical (Hospital) Services Ref Protein (Rptu) Urine PX-3018415603 CDM 84156 CPT 301 RC inpatient 65 65 BLUE CROSS BLUE SHIELD WELLMARK SB889 [3081026] BCBS WYOMING [308102603] 61.75 percent of total billed charges 40.3 61.75 Technical (Hospital) Services Ref Protein (Rptu) Urine PX-3018415603 CDM 84156 CPT 301 RC inpatient 65 65 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES EPO [308136803] 51.47 percent of total billed charges 40.3 61.75 Technical (Hospital) Services Ref Protein (Rptu) Urine PX-3018415603 CDM 84156 CPT 301 RC inpatient 65 65 HEALTHPARTNERS SX009 HEALTHPARTNERS 51.47 percent of total billed charges 40.3 61.75 Technical (Hospital) Services Ref Protein (Rptu) Urine PX-3018415603 CDM 84156 CPT 301 RC inpatient 65 65 MULTIPLAN INC 34080 [3081285] MULTIPLAN INC [308128501] 61.75 percent of total billed charges 40.3 61.75 Technical (Hospital) Services Ref Protein (Rptu) Urine PX-3018415603 CDM 84156 CPT 301 RC inpatient 65 65 MEDICA (COMMERCIAL) 94265 [3081118] MEDICA CLAIMS [308111801] 58.5 percent of total billed charges 40.3 61.75 Technical (Hospital) Services Ref Protein (Rptu) Urine PX-3018415603 CDM 84156 CPT 301 RC inpatient 65 65 CIGNA 62308 [3081051] CIGNA STATE OF WYOMING [308105107] 51.47 percent of total billed charges 40.3 61.75 Technical (Hospital) Services Ref Protein (Rptu) Urine PX-3018415603 CDM 84156 CPT 301 RC inpatient 65 65 CIGNA 62308 [3081051] CIGNA 62308 [308105105] 51.47 percent of total billed charges 40.3 61.75 Technical (Hospital) Services Total Protein Serum Plasma Wb PX-3018415500 CDM 84155 CPT 301 RC inpatient 153 153 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES EPO [308136803] 121.15 percent of total billed charges 94.86 145.35 Technical (Hospital) Services Total Protein Serum Plasma Wb PX-3018415500 CDM 84155 CPT 301 RC inpatient 153 153 HEALTHPARTNERS SX009 HEALTHPARTNERS 121.15 percent of total billed charges 94.86 145.35 Technical (Hospital) Services Total Protein Serum Plasma Wb PX-3018415500 CDM 84155 CPT 301 RC inpatient 153 153 MEDICA (COMMERCIAL) 94265 [3081118] MEDICA CLAIMS [308111801] 137.7 percent of total billed charges 94.86 145.35 Technical (Hospital) Services Total Protein Serum Plasma Wb PX-3018415500 CDM 84155 CPT 301 RC inpatient 153 153 MULTIPLAN INC 34080 [3081285] MULTIPLAN INC [308128501] 145.35 percent of total billed charges 94.86 145.35 Technical (Hospital) Services Total Protein Serum Plasma Wb PX-3018415500 CDM 84155 CPT 301 RC inpatient 153 153 CIGNA 62308 [3081051] CIGNA 62308 [308105105] 121.15 percent of total billed charges 94.86 145.35 Technical (Hospital) Services Total Protein Serum Plasma Wb PX-3018415500 CDM 84155 CPT 301 RC inpatient 153 153 CIGNA 62308 [3081051] CIGNA STATE OF WYOMING [308105107] 121.15 percent of total billed charges 94.86 145.35 Technical (Hospital) Services Total Protein Serum Plasma Wb PX-3018415500 CDM 84155 CPT 301 RC inpatient 153 153 BLUE CROSS BLUE SHIELD WELLMARK SB889 [3081026] BCBS WYOMING [308102603] 145.35 percent of total billed charges 94.86 145.35 Technical (Hospital) Services Total Protein Serum Plasma Wb PX-3018415500 CDM 84155 CPT 301 RC inpatient 153 153 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES HDHP [308136802] 121.15 percent of total billed charges 94.86 145.35 Technical (Hospital) Services Total Protein Serum Plasma Wb PX-3018415500 CDM 84155 CPT 301 RC inpatient 153 153 UNITED HEALTHCARE (COMMERCIAL) [3081199] UNITED HEALTHCARE 87726 [308119901] 94.86 percent of total billed charges 94.86 145.35 Technical (Hospital) Services Total Protein Serum Plasma Wb PX-3018415500 CDM 84155 CPT 301 RC inpatient 153 153 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES PPO [308136801] 121.15 percent of total billed charges 94.86 145.35 Technical (Hospital) Services Total Protein Serum Plasma Wb PX-3018415500 CDM 84155 CPT 301 RC outpatient 153 153 HEALTHPARTNERS SX009 HEALTHPARTNERS 122.4 percent of total billed charges 94.86 145.35 Technical (Hospital) Services Total Protein Serum Plasma Wb PX-3018415500 CDM 84155 CPT 301 RC outpatient 153 153 UNITED HEALTHCARE (COMMERCIAL) [3081199] UNITED HEALTHCARE 87726 [308119901] 94.86 percent of total billed charges 94.86 145.35 Technical (Hospital) Services Total Protein Serum Plasma Wb PX-3018415500 CDM 84155 CPT 301 RC outpatient 153 153 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES EPO [308136803] 122.4 percent of total billed charges 94.86 145.35 Technical (Hospital) Services Total Protein Serum Plasma Wb PX-3018415500 CDM 84155 CPT 301 RC outpatient 153 153 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES HDHP [308136802] 122.4 percent of total billed charges 94.86 145.35 Technical (Hospital) Services Total Protein Serum Plasma Wb PX-3018415500 CDM 84155 CPT 301 RC outpatient 153 153 BLUE CROSS BLUE SHIELD WELLMARK SB889 [3081026] BCBS WYOMING [308102603] 145.35 percent of total billed charges 94.86 145.35 Technical (Hospital) Services Total Protein Serum Plasma Wb PX-3018415500 CDM 84155 CPT 301 RC outpatient 153 153 MULTIPLAN INC 34080 [3081285] MULTIPLAN INC [308128501] 145.35 percent of total billed charges 94.86 145.35 Technical (Hospital) Services Total Protein Serum Plasma Wb PX-3018415500 CDM 84155 CPT 301 RC outpatient 153 153 MEDICA (COMMERCIAL) 94265 [3081118] MEDICA CLAIMS [308111801] 137.7 percent of total billed charges 94.86 145.35 Technical (Hospital) Services Total Protein Serum Plasma Wb PX-3018415500 CDM 84155 CPT 301 RC outpatient 153 153 CIGNA 62308 [3081051] CIGNA 62308 [308105105] 122.4 percent of total billed charges 94.86 145.35 Technical (Hospital) Services Total Protein Serum Plasma Wb PX-3018415500 CDM 84155 CPT 301 RC outpatient 153 153 CIGNA 62308 [3081051] CIGNA STATE OF WYOMING [308105107] 122.4 percent of total billed charges 94.86 145.35 Technical (Hospital) Services Total Protein Serum Plasma Wb PX-3018415500 CDM 84155 CPT 301 RC outpatient 153 153 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES PPO [308136801] 122.4 percent of total billed charges 94.86 145.35 Technical (Hospital) Services Ref Monoclonal Protein Study Tp PX-3018415501 CDM 84155 CPT 301 RC inpatient 33 33 UNITED HEALTHCARE (COMMERCIAL) [3081199] UNITED HEALTHCARE 87726 [308119901] 20.46 percent of total billed charges 20.46 31.35 Technical (Hospital) Services Ref Monoclonal Protein Study Tp PX-3018415501 CDM 84155 CPT 301 RC inpatient 33 33 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES PPO [308136801] 26.13 percent of total billed charges 20.46 31.35 Technical (Hospital) Services Ref Monoclonal Protein Study Tp PX-3018415501 CDM 84155 CPT 301 RC inpatient 33 33 BLUE CROSS BLUE SHIELD WELLMARK SB889 [3081026] BCBS WYOMING [308102603] 31.35 percent of total billed charges 20.46 31.35 Technical (Hospital) Services Ref Monoclonal Protein Study Tp PX-3018415501 CDM 84155 CPT 301 RC inpatient 33 33 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES HDHP [308136802] 26.13 percent of total billed charges 20.46 31.35 Technical (Hospital) Services Ref Monoclonal Protein Study Tp PX-3018415501 CDM 84155 CPT 301 RC inpatient 33 33 HEALTHPARTNERS SX009 HEALTHPARTNERS 26.13 percent of total billed charges 20.46 31.35 Technical (Hospital) Services Ref Monoclonal Protein Study Tp PX-3018415501 CDM 84155 CPT 301 RC inpatient 33 33 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES EPO [308136803] 26.13 percent of total billed charges 20.46 31.35 Technical (Hospital) Services Ref Monoclonal Protein Study Tp PX-3018415501 CDM 84155 CPT 301 RC inpatient 33 33 MEDICA (COMMERCIAL) 94265 [3081118] MEDICA CLAIMS [308111801] 29.7 percent of total billed charges 20.46 31.35 Technical (Hospital) Services Ref Monoclonal Protein Study Tp PX-3018415501 CDM 84155 CPT 301 RC inpatient 33 33 MULTIPLAN INC 34080 [3081285] MULTIPLAN INC [308128501] 31.35 percent of total billed charges 20.46 31.35 Technical (Hospital) Services Ref Monoclonal Protein Study Tp PX-3018415501 CDM 84155 CPT 301 RC inpatient 33 33 CIGNA 62308 [3081051] CIGNA 62308 [308105105] 26.13 percent of total billed charges 20.46 31.35 Technical (Hospital) Services Ref Monoclonal Protein Study Tp PX-3018415501 CDM 84155 CPT 301 RC inpatient 33 33 CIGNA 62308 [3081051] CIGNA STATE OF WYOMING [308105107] 26.13 percent of total billed charges 20.46 31.35 Technical (Hospital) Services Ref Monoclonal Protein Study Tp PX-3018415501 CDM 84155 CPT 301 RC outpatient 33 33 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES HDHP [308136802] 26.4 percent of total billed charges 20.46 31.35 Technical (Hospital) Services Ref Monoclonal Protein Study Tp PX-3018415501 CDM 84155 CPT 301 RC outpatient 33 33 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES EPO [308136803] 26.4 percent of total billed charges 20.46 31.35 Technical (Hospital) Services Ref Monoclonal Protein Study Tp PX-3018415501 CDM 84155 CPT 301 RC outpatient 33 33 BLUE CROSS BLUE SHIELD WELLMARK SB889 [3081026] BCBS WYOMING [308102603] 31.35 percent of total billed charges 20.46 31.35 Technical (Hospital) Services Ref Monoclonal Protein Study Tp PX-3018415501 CDM 84155 CPT 301 RC outpatient 33 33 MULTIPLAN INC 34080 [3081285] MULTIPLAN INC [308128501] 31.35 percent of total billed charges 20.46 31.35 Technical (Hospital) Services Ref Monoclonal Protein Study Tp PX-3018415501 CDM 84155 CPT 301 RC outpatient 33 33 HEALTHPARTNERS SX009 HEALTHPARTNERS 26.4 percent of total billed charges 20.46 31.35 Technical (Hospital) Services Ref Monoclonal Protein Study Tp PX-3018415501 CDM 84155 CPT 301 RC outpatient 33 33 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES PPO [308136801] 26.4 percent of total billed charges 20.46 31.35 Technical (Hospital) Services Ref Monoclonal Protein Study Tp PX-3018415501 CDM 84155 CPT 301 RC outpatient 33 33 UNITED HEALTHCARE (COMMERCIAL) [3081199] UNITED HEALTHCARE 87726 [308119901] 20.46 percent of total billed charges 20.46 31.35 Technical (Hospital) Services Ref Monoclonal Protein Study Tp PX-3018415501 CDM 84155 CPT 301 RC outpatient 33 33 MEDICA (COMMERCIAL) 94265 [3081118] MEDICA CLAIMS [308111801] 29.7 percent of total billed charges 20.46 31.35 Technical (Hospital) Services Ref Monoclonal Protein Study Tp PX-3018415501 CDM 84155 CPT 301 RC outpatient 33 33 CIGNA 62308 [3081051] CIGNA 62308 [308105105] 26.4 percent of total billed charges 20.46 31.35 Technical (Hospital) Services Ref Monoclonal Protein Study Tp PX-3018415501 CDM 84155 CPT 301 RC outpatient 33 33 CIGNA 62308 [3081051] CIGNA STATE OF WYOMING [308105107] 26.4 percent of total billed charges 20.46 31.35 Technical (Hospital) Services "Ref Protein Study, Serum Tp Mayo" PX-3018415502 CDM 84155 CPT 301 RC outpatient 153 153 MEDICA (COMMERCIAL) 94265 [3081118] MEDICA CLAIMS [308111801] 137.7 percent of total billed charges 94.86 145.35 Technical (Hospital) Services "Ref Protein Study, Serum Tp Mayo" PX-3018415502 CDM 84155 CPT 301 RC outpatient 153 153 CIGNA 62308 [3081051] CIGNA 62308 [308105105] 122.4 percent of total billed charges 94.86 145.35 Technical (Hospital) Services "Ref Protein Study, Serum Tp Mayo" PX-3018415502 CDM 84155 CPT 301 RC outpatient 153 153 CIGNA 62308 [3081051] CIGNA STATE OF WYOMING [308105107] 122.4 percent of total billed charges 94.86 145.35 Technical (Hospital) Services "Ref Protein Study, Serum Tp Mayo" PX-3018415502 CDM 84155 CPT 301 RC outpatient 153 153 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES EPO [308136803] 122.4 percent of total billed charges 94.86 145.35 Technical (Hospital) Services "Ref Protein Study, Serum Tp Mayo" PX-3018415502 CDM 84155 CPT 301 RC outpatient 153 153 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES HDHP [308136802] 122.4 percent of total billed charges 94.86 145.35 Technical (Hospital) Services "Ref Protein Study, Serum Tp Mayo" PX-3018415502 CDM 84155 CPT 301 RC outpatient 153 153 MULTIPLAN INC 34080 [3081285] MULTIPLAN INC [308128501] 145.35 percent of total billed charges 94.86 145.35 Technical (Hospital) Services "Ref Protein Study, Serum Tp Mayo" PX-3018415502 CDM 84155 CPT 301 RC outpatient 153 153 BLUE CROSS BLUE SHIELD WELLMARK SB889 [3081026] BCBS WYOMING [308102603] 145.35 percent of total billed charges 94.86 145.35 Technical (Hospital) Services "Ref Protein Study, Serum Tp Mayo" PX-3018415502 CDM 84155 CPT 301 RC outpatient 153 153 HEALTHPARTNERS SX009 HEALTHPARTNERS 122.4 percent of total billed charges 94.86 145.35 Technical (Hospital) Services "Ref Protein Study, Serum Tp Mayo" PX-3018415502 CDM 84155 CPT 301 RC outpatient 153 153 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES PPO [308136801] 122.4 percent of total billed charges 94.86 145.35 Technical (Hospital) Services "Ref Protein Study, Serum Tp Mayo" PX-3018415502 CDM 84155 CPT 301 RC outpatient 153 153 UNITED HEALTHCARE (COMMERCIAL) [3081199] UNITED HEALTHCARE 87726 [308119901] 94.86 percent of total billed charges 94.86 145.35 Technical (Hospital) Services "Ref Protein Study, Serum Tp Mayo" PX-3018415502 CDM 84155 CPT 301 RC inpatient 153 153 MEDICA (COMMERCIAL) 94265 [3081118] MEDICA CLAIMS [308111801] 137.7 percent of total billed charges 94.86 145.35 Technical (Hospital) Services "Ref Protein Study, Serum Tp Mayo" PX-3018415502 CDM 84155 CPT 301 RC inpatient 153 153 MULTIPLAN INC 34080 [3081285] MULTIPLAN INC [308128501] 145.35 percent of total billed charges 94.86 145.35 Technical (Hospital) Services "Ref Protein Study, Serum Tp Mayo" PX-3018415502 CDM 84155 CPT 301 RC inpatient 153 153 CIGNA 62308 [3081051] CIGNA 62308 [308105105] 121.15 percent of total billed charges 94.86 145.35 Technical (Hospital) Services "Ref Protein Study, Serum Tp Mayo" PX-3018415502 CDM 84155 CPT 301 RC inpatient 153 153 CIGNA 62308 [3081051] CIGNA STATE OF WYOMING [308105107] 121.15 percent of total billed charges 94.86 145.35 Technical (Hospital) Services "Ref Protein Study, Serum Tp Mayo" PX-3018415502 CDM 84155 CPT 301 RC inpatient 153 153 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES EPO [308136803] 121.15 percent of total billed charges 94.86 145.35 Technical (Hospital) Services "Ref Protein Study, Serum Tp Mayo" PX-3018415502 CDM 84155 CPT 301 RC inpatient 153 153 HEALTHPARTNERS SX009 HEALTHPARTNERS 121.15 percent of total billed charges 94.86 145.35 Technical (Hospital) Services "Ref Protein Study, Serum Tp Mayo" PX-3018415502 CDM 84155 CPT 301 RC inpatient 153 153 UNITED HEALTHCARE (COMMERCIAL) [3081199] UNITED HEALTHCARE 87726 [308119901] 94.86 percent of total billed charges 94.86 145.35 Technical (Hospital) Services "Ref Protein Study, Serum Tp Mayo" PX-3018415502 CDM 84155 CPT 301 RC inpatient 153 153 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES PPO [308136801] 121.15 percent of total billed charges 94.86 145.35 Technical (Hospital) Services "Ref Protein Study, Serum Tp Mayo" PX-3018415502 CDM 84155 CPT 301 RC inpatient 153 153 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES HDHP [308136802] 121.15 percent of total billed charges 94.86 145.35 Technical (Hospital) Services "Ref Protein Study, Serum Tp Mayo" PX-3018415502 CDM 84155 CPT 301 RC inpatient 153 153 BLUE CROSS BLUE SHIELD WELLMARK SB889 [3081026] BCBS WYOMING [308102603] 145.35 percent of total billed charges 94.86 145.35 Technical (Hospital) Services "HC Ref Protein Electrophoresis, Serum(Mayo) Spep Tpe" PX-3018415503 CDM 84155 CPT 301 RC inpatient 33 33 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES PPO [308136801] 26.13 percent of total billed charges 20.46 31.35 Technical (Hospital) Services "HC Ref Protein Electrophoresis, Serum(Mayo) Spep Tpe" PX-3018415503 CDM 84155 CPT 301 RC inpatient 33 33 UNITED HEALTHCARE (COMMERCIAL) [3081199] UNITED HEALTHCARE 87726 [308119901] 20.46 percent of total billed charges 20.46 31.35 Technical (Hospital) Services "HC Ref Protein Electrophoresis, Serum(Mayo) Spep Tpe" PX-3018415503 CDM 84155 CPT 301 RC inpatient 33 33 BLUE CROSS BLUE SHIELD WELLMARK SB889 [3081026] BCBS WYOMING [308102603] 31.35 percent of total billed charges 20.46 31.35 Technical (Hospital) Services "HC Ref Protein Electrophoresis, Serum(Mayo) Spep Tpe" PX-3018415503 CDM 84155 CPT 301 RC inpatient 33 33 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES HDHP [308136802] 26.13 percent of total billed charges 20.46 31.35 Technical (Hospital) Services "HC Ref Protein Electrophoresis, Serum(Mayo) Spep Tpe" PX-3018415503 CDM 84155 CPT 301 RC inpatient 33 33 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES EPO [308136803] 26.13 percent of total billed charges 20.46 31.35 Technical (Hospital) Services "HC Ref Protein Electrophoresis, Serum(Mayo) Spep Tpe" PX-3018415503 CDM 84155 CPT 301 RC inpatient 33 33 HEALTHPARTNERS SX009 HEALTHPARTNERS 26.13 percent of total billed charges 20.46 31.35 Technical (Hospital) Services "HC Ref Protein Electrophoresis, Serum(Mayo) Spep Tpe" PX-3018415503 CDM 84155 CPT 301 RC inpatient 33 33 MEDICA (COMMERCIAL) 94265 [3081118] MEDICA CLAIMS [308111801] 29.7 percent of total billed charges 20.46 31.35 Technical (Hospital) Services "HC Ref Protein Electrophoresis, Serum(Mayo) Spep Tpe" PX-3018415503 CDM 84155 CPT 301 RC inpatient 33 33 MULTIPLAN INC 34080 [3081285] MULTIPLAN INC [308128501] 31.35 percent of total billed charges 20.46 31.35 Technical (Hospital) Services "HC Ref Protein Electrophoresis, Serum(Mayo) Spep Tpe" PX-3018415503 CDM 84155 CPT 301 RC inpatient 33 33 CIGNA 62308 [3081051] CIGNA 62308 [308105105] 26.13 percent of total billed charges 20.46 31.35 Technical (Hospital) Services "HC Ref Protein Electrophoresis, Serum(Mayo) Spep Tpe" PX-3018415503 CDM 84155 CPT 301 RC inpatient 33 33 CIGNA 62308 [3081051] CIGNA STATE OF WYOMING [308105107] 26.13 percent of total billed charges 20.46 31.35 Technical (Hospital) Services "HC Ref Protein Electrophoresis, Serum(Mayo) Spep Tpe" PX-3018415503 CDM 84155 CPT 301 RC outpatient 33 33 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES PPO [308136801] 26.4 percent of total billed charges 20.46 31.35 Technical (Hospital) Services "HC Ref Protein Electrophoresis, Serum(Mayo) Spep Tpe" PX-3018415503 CDM 84155 CPT 301 RC outpatient 33 33 MEDICA (COMMERCIAL) 94265 [3081118] MEDICA CLAIMS [308111801] 29.7 percent of total billed charges 20.46 31.35 Technical (Hospital) Services "HC Ref Protein Electrophoresis, Serum(Mayo) Spep Tpe" PX-3018415503 CDM 84155 CPT 301 RC outpatient 33 33 CIGNA 62308 [3081051] CIGNA 62308 [308105105] 26.4 percent of total billed charges 20.46 31.35 Technical (Hospital) Services "HC Ref Protein Electrophoresis, Serum(Mayo) Spep Tpe" PX-3018415503 CDM 84155 CPT 301 RC outpatient 33 33 CIGNA 62308 [3081051] CIGNA STATE OF WYOMING [308105107] 26.4 percent of total billed charges 20.46 31.35 Technical (Hospital) Services "HC Ref Protein Electrophoresis, Serum(Mayo) Spep Tpe" PX-3018415503 CDM 84155 CPT 301 RC outpatient 33 33 HEALTHPARTNERS SX009 HEALTHPARTNERS 26.4 percent of total billed charges 20.46 31.35 Technical (Hospital) Services "HC Ref Protein Electrophoresis, Serum(Mayo) Spep Tpe" PX-3018415503 CDM 84155 CPT 301 RC outpatient 33 33 UNITED HEALTHCARE (COMMERCIAL) [3081199] UNITED HEALTHCARE 87726 [308119901] 20.46 percent of total billed charges 20.46 31.35 Technical (Hospital) Services "HC Ref Protein Electrophoresis, Serum(Mayo) Spep Tpe" PX-3018415503 CDM 84155 CPT 301 RC outpatient 33 33 MULTIPLAN INC 34080 [3081285] MULTIPLAN INC [308128501] 31.35 percent of total billed charges 20.46 31.35 Technical (Hospital) Services "HC Ref Protein Electrophoresis, Serum(Mayo) Spep Tpe" PX-3018415503 CDM 84155 CPT 301 RC outpatient 33 33 BLUE CROSS BLUE SHIELD WELLMARK SB889 [3081026] BCBS WYOMING [308102603] 31.35 percent of total billed charges 20.46 31.35 Technical (Hospital) Services "HC Ref Protein Electrophoresis, Serum(Mayo) Spep Tpe" PX-3018415503 CDM 84155 CPT 301 RC outpatient 33 33 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES EPO [308136803] 26.4 percent of total billed charges 20.46 31.35 Technical (Hospital) Services "HC Ref Protein Electrophoresis, Serum(Mayo) Spep Tpe" PX-3018415503 CDM 84155 CPT 301 RC outpatient 33 33 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES HDHP [308136802] 26.4 percent of total billed charges 20.46 31.35 Technical (Hospital) Services Ref Prostate Specific Antigen (Psa-Free) PX-3018415400 CDM 84154 CPT 301 RC outpatient 172 172 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES PPO [308136801] 137.6 percent of total billed charges 106.64 163.4 Technical (Hospital) Services Ref Prostate Specific Antigen (Psa-Free) PX-3018415400 CDM 84154 CPT 301 RC outpatient 172 172 HEALTHPARTNERS SX009 HEALTHPARTNERS 137.6 percent of total billed charges 106.64 163.4 Technical (Hospital) Services Ref Prostate Specific Antigen (Psa-Free) PX-3018415400 CDM 84154 CPT 301 RC outpatient 172 172 UNITED HEALTHCARE (COMMERCIAL) [3081199] UNITED HEALTHCARE 87726 [308119901] 106.64 percent of total billed charges 106.64 163.4 Technical (Hospital) Services Ref Prostate Specific Antigen (Psa-Free) PX-3018415400 CDM 84154 CPT 301 RC outpatient 172 172 MULTIPLAN INC 34080 [3081285] MULTIPLAN INC [308128501] 163.4 percent of total billed charges 106.64 163.4 Technical (Hospital) Services Ref Prostate Specific Antigen (Psa-Free) PX-3018415400 CDM 84154 CPT 301 RC outpatient 172 172 BLUE CROSS BLUE SHIELD WELLMARK SB889 [3081026] BCBS WYOMING [308102603] 163.4 percent of total billed charges 106.64 163.4 Technical (Hospital) Services Ref Prostate Specific Antigen (Psa-Free) PX-3018415400 CDM 84154 CPT 301 RC outpatient 172 172 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES EPO [308136803] 137.6 percent of total billed charges 106.64 163.4 Technical (Hospital) Services Ref Prostate Specific Antigen (Psa-Free) PX-3018415400 CDM 84154 CPT 301 RC outpatient 172 172 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES HDHP [308136802] 137.6 percent of total billed charges 106.64 163.4 Technical (Hospital) Services Ref Prostate Specific Antigen (Psa-Free) PX-3018415400 CDM 84154 CPT 301 RC outpatient 172 172 MEDICA (COMMERCIAL) 94265 [3081118] MEDICA CLAIMS [308111801] 154.8 percent of total billed charges 106.64 163.4 Technical (Hospital) Services Ref Prostate Specific Antigen (Psa-Free) PX-3018415400 CDM 84154 CPT 301 RC outpatient 172 172 CIGNA 62308 [3081051] CIGNA 62308 [308105105] 137.6 percent of total billed charges 106.64 163.4 Technical (Hospital) Services Ref Prostate Specific Antigen (Psa-Free) PX-3018415400 CDM 84154 CPT 301 RC outpatient 172 172 CIGNA 62308 [3081051] CIGNA STATE OF WYOMING [308105107] 137.6 percent of total billed charges 106.64 163.4 Technical (Hospital) Services Ref Prostate Specific Antigen (Psa-Free) PX-3018415400 CDM 84154 CPT 301 RC inpatient 172 172 BLUE CROSS BLUE SHIELD WELLMARK SB889 [3081026] BCBS WYOMING [308102603] 163.4 percent of total billed charges 106.64 163.4 Technical (Hospital) Services Ref Prostate Specific Antigen (Psa-Free) PX-3018415400 CDM 84154 CPT 301 RC inpatient 172 172 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES HDHP [308136802] 136.19 percent of total billed charges 106.64 163.4 Technical (Hospital) Services Ref Prostate Specific Antigen (Psa-Free) PX-3018415400 CDM 84154 CPT 301 RC inpatient 172 172 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES PPO [308136801] 136.19 percent of total billed charges 106.64 163.4 Technical (Hospital) Services Ref Prostate Specific Antigen (Psa-Free) PX-3018415400 CDM 84154 CPT 301 RC inpatient 172 172 UNITED HEALTHCARE (COMMERCIAL) [3081199] UNITED HEALTHCARE 87726 [308119901] 106.64 percent of total billed charges 106.64 163.4 Technical (Hospital) Services Ref Prostate Specific Antigen (Psa-Free) PX-3018415400 CDM 84154 CPT 301 RC inpatient 172 172 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES EPO [308136803] 136.19 percent of total billed charges 106.64 163.4 Technical (Hospital) Services Ref Prostate Specific Antigen (Psa-Free) PX-3018415400 CDM 84154 CPT 301 RC inpatient 172 172 HEALTHPARTNERS SX009 HEALTHPARTNERS 136.19 percent of total billed charges 106.64 163.4 Technical (Hospital) Services Ref Prostate Specific Antigen (Psa-Free) PX-3018415400 CDM 84154 CPT 301 RC inpatient 172 172 MULTIPLAN INC 34080 [3081285] MULTIPLAN INC [308128501] 163.4 percent of total billed charges 106.64 163.4 Technical (Hospital) Services Ref Prostate Specific Antigen (Psa-Free) PX-3018415400 CDM 84154 CPT 301 RC inpatient 172 172 MEDICA (COMMERCIAL) 94265 [3081118] MEDICA CLAIMS [308111801] 154.8 percent of total billed charges 106.64 163.4 Technical (Hospital) Services Ref Prostate Specific Antigen (Psa-Free) PX-3018415400 CDM 84154 CPT 301 RC inpatient 172 172 CIGNA 62308 [3081051] CIGNA 62308 [308105105] 136.19 percent of total billed charges 106.64 163.4 Technical (Hospital) Services Ref Prostate Specific Antigen (Psa-Free) PX-3018415400 CDM 84154 CPT 301 RC inpatient 172 172 CIGNA 62308 [3081051] CIGNA STATE OF WYOMING [308105107] 136.19 percent of total billed charges 106.64 163.4 Technical (Hospital) Services Ref Psa Free PX-3018415401 CDM 84154 CPT 301 RC inpatient 172 172 CIGNA 62308 [3081051] CIGNA 62308 [308105105] 136.19 percent of total billed charges 106.64 163.4 Technical (Hospital) Services Ref Psa Free PX-3018415401 CDM 84154 CPT 301 RC inpatient 172 172 CIGNA 62308 [3081051] CIGNA STATE OF WYOMING [308105107] 136.19 percent of total billed charges 106.64 163.4 Technical (Hospital) Services Ref Psa Free PX-3018415401 CDM 84154 CPT 301 RC inpatient 172 172 MULTIPLAN INC 34080 [3081285] MULTIPLAN INC [308128501] 163.4 percent of total billed charges 106.64 163.4 Technical (Hospital) Services Ref Psa Free PX-3018415401 CDM 84154 CPT 301 RC inpatient 172 172 MEDICA (COMMERCIAL) 94265 [3081118] MEDICA CLAIMS [308111801] 154.8 percent of total billed charges 106.64 163.4 Technical (Hospital) Services Ref Psa Free PX-3018415401 CDM 84154 CPT 301 RC inpatient 172 172 HEALTHPARTNERS SX009 HEALTHPARTNERS 136.19 percent of total billed charges 106.64 163.4 Technical (Hospital) Services Ref Psa Free PX-3018415401 CDM 84154 CPT 301 RC inpatient 172 172 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES EPO [308136803] 136.19 percent of total billed charges 106.64 163.4 Technical (Hospital) Services Ref Psa Free PX-3018415401 CDM 84154 CPT 301 RC inpatient 172 172 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES PPO [308136801] 136.19 percent of total billed charges 106.64 163.4 Technical (Hospital) Services Ref Psa Free PX-3018415401 CDM 84154 CPT 301 RC inpatient 172 172 UNITED HEALTHCARE (COMMERCIAL) [3081199] UNITED HEALTHCARE 87726 [308119901] 106.64 percent of total billed charges 106.64 163.4 Technical (Hospital) Services Ref Psa Free PX-3018415401 CDM 84154 CPT 301 RC inpatient 172 172 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES HDHP [308136802] 136.19 percent of total billed charges 106.64 163.4 Technical (Hospital) Services Ref Psa Free PX-3018415401 CDM 84154 CPT 301 RC inpatient 172 172 BLUE CROSS BLUE SHIELD WELLMARK SB889 [3081026] BCBS WYOMING [308102603] 163.4 percent of total billed charges 106.64 163.4 Technical (Hospital) Services Ref Psa Free PX-3018415401 CDM 84154 CPT 301 RC outpatient 172 172 MULTIPLAN INC 34080 [3081285] MULTIPLAN INC [308128501] 163.4 percent of total billed charges 106.64 163.4 Technical (Hospital) Services Ref Psa Free PX-3018415401 CDM 84154 CPT 301 RC outpatient 172 172 BLUE CROSS BLUE SHIELD WELLMARK SB889 [3081026] BCBS WYOMING [308102603] 163.4 percent of total billed charges 106.64 163.4 Technical (Hospital) Services Ref Psa Free PX-3018415401 CDM 84154 CPT 301 RC outpatient 172 172 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES EPO [308136803] 137.6 percent of total billed charges 106.64 163.4 Technical (Hospital) Services Ref Psa Free PX-3018415401 CDM 84154 CPT 301 RC outpatient 172 172 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES HDHP [308136802] 137.6 percent of total billed charges 106.64 163.4 Technical (Hospital) Services Ref Psa Free PX-3018415401 CDM 84154 CPT 301 RC outpatient 172 172 HEALTHPARTNERS SX009 HEALTHPARTNERS 137.6 percent of total billed charges 106.64 163.4 Technical (Hospital) Services Ref Psa Free PX-3018415401 CDM 84154 CPT 301 RC outpatient 172 172 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES PPO [308136801] 137.6 percent of total billed charges 106.64 163.4 Technical (Hospital) Services Ref Psa Free PX-3018415401 CDM 84154 CPT 301 RC outpatient 172 172 UNITED HEALTHCARE (COMMERCIAL) [3081199] UNITED HEALTHCARE 87726 [308119901] 106.64 percent of total billed charges 106.64 163.4 Technical (Hospital) Services Ref Psa Free PX-3018415401 CDM 84154 CPT 301 RC outpatient 172 172 CIGNA 62308 [3081051] CIGNA 62308 [308105105] 137.6 percent of total billed charges 106.64 163.4 Technical (Hospital) Services Ref Psa Free PX-3018415401 CDM 84154 CPT 301 RC outpatient 172 172 CIGNA 62308 [3081051] CIGNA STATE OF WYOMING [308105107] 137.6 percent of total billed charges 106.64 163.4 Technical (Hospital) Services Ref Psa Free PX-3018415401 CDM 84154 CPT 301 RC outpatient 172 172 MEDICA (COMMERCIAL) 94265 [3081118] MEDICA CLAIMS [308111801] 154.8 percent of total billed charges 106.64 163.4 Technical (Hospital) Services HC Psa Free PX-3018415402 CDM 84154 CPT 301 RC inpatient 103 103 CIGNA 62308 [3081051] CIGNA 62308 [308105105] 81.56 percent of total billed charges 63.86 97.85 Technical (Hospital) Services HC Psa Free PX-3018415402 CDM 84154 CPT 301 RC inpatient 103 103 CIGNA 62308 [3081051] CIGNA STATE OF WYOMING [308105107] 81.56 percent of total billed charges 63.86 97.85 Technical (Hospital) Services HC Psa Free PX-3018415402 CDM 84154 CPT 301 RC inpatient 103 103 MULTIPLAN INC 34080 [3081285] MULTIPLAN INC [308128501] 97.85 percent of total billed charges 63.86 97.85 Technical (Hospital) Services HC Psa Free PX-3018415402 CDM 84154 CPT 301 RC inpatient 103 103 MEDICA (COMMERCIAL) 94265 [3081118] MEDICA CLAIMS [308111801] 92.7 percent of total billed charges 63.86 97.85 Technical (Hospital) Services HC Psa Free PX-3018415402 CDM 84154 CPT 301 RC inpatient 103 103 HEALTHPARTNERS SX009 HEALTHPARTNERS 81.56 percent of total billed charges 63.86 97.85 Technical (Hospital) Services HC Psa Free PX-3018415402 CDM 84154 CPT 301 RC inpatient 103 103 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES EPO [308136803] 81.56 percent of total billed charges 63.86 97.85 Technical (Hospital) Services HC Psa Free PX-3018415402 CDM 84154 CPT 301 RC inpatient 103 103 UNITED HEALTHCARE (COMMERCIAL) [3081199] UNITED HEALTHCARE 87726 [308119901] 63.86 percent of total billed charges 63.86 97.85 Technical (Hospital) Services HC Psa Free PX-3018415402 CDM 84154 CPT 301 RC inpatient 103 103 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES PPO [308136801] 81.56 percent of total billed charges 63.86 97.85 Technical (Hospital) Services HC Psa Free PX-3018415402 CDM 84154 CPT 301 RC inpatient 103 103 BLUE CROSS BLUE SHIELD WELLMARK SB889 [3081026] BCBS WYOMING [308102603] 97.85 percent of total billed charges 63.86 97.85 Technical (Hospital) Services HC Psa Free PX-3018415402 CDM 84154 CPT 301 RC inpatient 103 103 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES HDHP [308136802] 81.56 percent of total billed charges 63.86 97.85 Technical (Hospital) Services HC Psa Free PX-3018415402 CDM 84154 CPT 301 RC outpatient 103 103 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES HDHP [308136802] 82.4 percent of total billed charges 63.86 97.85 Technical (Hospital) Services HC Psa Free PX-3018415402 CDM 84154 CPT 301 RC outpatient 103 103 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES EPO [308136803] 82.4 percent of total billed charges 63.86 97.85 Technical (Hospital) Services HC Psa Free PX-3018415402 CDM 84154 CPT 301 RC outpatient 103 103 BLUE CROSS BLUE SHIELD WELLMARK SB889 [3081026] BCBS WYOMING [308102603] 97.85 percent of total billed charges 63.86 97.85 Technical (Hospital) Services HC Psa Free PX-3018415402 CDM 84154 CPT 301 RC outpatient 103 103 MULTIPLAN INC 34080 [3081285] MULTIPLAN INC [308128501] 97.85 percent of total billed charges 63.86 97.85 Technical (Hospital) Services HC Psa Free PX-3018415402 CDM 84154 CPT 301 RC outpatient 103 103 UNITED HEALTHCARE (COMMERCIAL) [3081199] UNITED HEALTHCARE 87726 [308119901] 63.86 percent of total billed charges 63.86 97.85 Technical (Hospital) Services HC Psa Free PX-3018415402 CDM 84154 CPT 301 RC outpatient 103 103 HEALTHPARTNERS SX009 HEALTHPARTNERS 82.4 percent of total billed charges 63.86 97.85 Technical (Hospital) Services HC Psa Free PX-3018415402 CDM 84154 CPT 301 RC outpatient 103 103 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES PPO [308136801] 82.4 percent of total billed charges 63.86 97.85 Technical (Hospital) Services HC Psa Free PX-3018415402 CDM 84154 CPT 301 RC outpatient 103 103 MEDICA (COMMERCIAL) 94265 [3081118] MEDICA CLAIMS [308111801] 92.7 percent of total billed charges 63.86 97.85 Technical (Hospital) Services HC Psa Free PX-3018415402 CDM 84154 CPT 301 RC outpatient 103 103 CIGNA 62308 [3081051] CIGNA 62308 [308105105] 82.4 percent of total billed charges 63.86 97.85 Technical (Hospital) Services HC Psa Free PX-3018415402 CDM 84154 CPT 301 RC outpatient 103 103 CIGNA 62308 [3081051] CIGNA STATE OF WYOMING [308105107] 82.4 percent of total billed charges 63.86 97.85 Technical (Hospital) Services Psa Diagnostic PX-3018415300 CDM 84153 CPT 301 RC outpatient 209 209 CIGNA 62308 [3081051] CIGNA 62308 [308105105] 167.2 percent of total billed charges 129.58 198.55 Technical (Hospital) Services Psa Diagnostic PX-3018415300 CDM 84153 CPT 301 RC outpatient 209 209 CIGNA 62308 [3081051] CIGNA STATE OF WYOMING [308105107] 167.2 percent of total billed charges 129.58 198.55 Technical (Hospital) Services Psa Diagnostic PX-3018415300 CDM 84153 CPT 301 RC outpatient 209 209 BLUE CROSS BLUE SHIELD WELLMARK SB889 [3081026] BCBS WYOMING [308102603] 198.55 percent of total billed charges 129.58 198.55 Technical (Hospital) Services Psa Diagnostic PX-3018415300 CDM 84153 CPT 301 RC outpatient 209 209 UNITED HEALTHCARE (COMMERCIAL) [3081199] UNITED HEALTHCARE 87726 [308119901] 129.58 percent of total billed charges 129.58 198.55 Technical (Hospital) Services Psa Diagnostic PX-3018415300 CDM 84153 CPT 301 RC outpatient 209 209 MULTIPLAN INC 34080 [3081285] MULTIPLAN INC [308128501] 198.55 percent of total billed charges 129.58 198.55 Technical (Hospital) Services Psa Diagnostic PX-3018415300 CDM 84153 CPT 301 RC outpatient 209 209 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES HDHP [308136802] 167.2 percent of total billed charges 129.58 198.55 Technical (Hospital) Services Psa Diagnostic PX-3018415300 CDM 84153 CPT 301 RC outpatient 209 209 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES PPO [308136801] 167.2 percent of total billed charges 129.58 198.55 Technical (Hospital) Services Psa Diagnostic PX-3018415300 CDM 84153 CPT 301 RC outpatient 209 209 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES EPO [308136803] 167.2 percent of total billed charges 129.58 198.55 Technical (Hospital) Services Psa Diagnostic PX-3018415300 CDM 84153 CPT 301 RC outpatient 209 209 HEALTHPARTNERS SX009 HEALTHPARTNERS 167.2 percent of total billed charges 129.58 198.55 Technical (Hospital) Services Psa Diagnostic PX-3018415300 CDM 84153 CPT 301 RC outpatient 209 209 MEDICA (COMMERCIAL) 94265 [3081118] MEDICA CLAIMS [308111801] 188.1 percent of total billed charges 129.58 198.55 Technical (Hospital) Services Psa Diagnostic PX-3018415300 CDM 84153 CPT 301 RC inpatient 209 209 HEALTHPARTNERS SX009 HEALTHPARTNERS 165.49 percent of total billed charges 129.58 198.55 Technical (Hospital) Services Psa Diagnostic PX-3018415300 CDM 84153 CPT 301 RC inpatient 209 209 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES HDHP [308136802] 165.49 percent of total billed charges 129.58 198.55 Technical (Hospital) Services Psa Diagnostic PX-3018415300 CDM 84153 CPT 301 RC inpatient 209 209 MULTIPLAN INC 34080 [3081285] MULTIPLAN INC [308128501] 198.55 percent of total billed charges 129.58 198.55 Technical (Hospital) Services Psa Diagnostic PX-3018415300 CDM 84153 CPT 301 RC inpatient 209 209 MEDICA (COMMERCIAL) 94265 [3081118] MEDICA CLAIMS [308111801] 188.1 percent of total billed charges 129.58 198.55 Technical (Hospital) Services Psa Diagnostic PX-3018415300 CDM 84153 CPT 301 RC inpatient 209 209 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES PPO [308136801] 165.49 percent of total billed charges 129.58 198.55 Technical (Hospital) Services Psa Diagnostic PX-3018415300 CDM 84153 CPT 301 RC inpatient 209 209 BLUE CROSS BLUE SHIELD WELLMARK SB889 [3081026] BCBS WYOMING [308102603] 198.55 percent of total billed charges 129.58 198.55 Technical (Hospital) Services Psa Diagnostic PX-3018415300 CDM 84153 CPT 301 RC inpatient 209 209 UNITED HEALTHCARE (COMMERCIAL) [3081199] UNITED HEALTHCARE 87726 [308119901] 129.58 percent of total billed charges 129.58 198.55 Technical (Hospital) Services Psa Diagnostic PX-3018415300 CDM 84153 CPT 301 RC inpatient 209 209 CIGNA 62308 [3081051] CIGNA 62308 [308105105] 165.49 percent of total billed charges 129.58 198.55 Technical (Hospital) Services Psa Diagnostic PX-3018415300 CDM 84153 CPT 301 RC inpatient 209 209 CIGNA 62308 [3081051] CIGNA STATE OF WYOMING [308105107] 165.49 percent of total billed charges 129.58 198.55 Technical (Hospital) Services Psa Diagnostic PX-3018415300 CDM 84153 CPT 301 RC inpatient 209 209 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES EPO [308136803] 165.49 percent of total billed charges 129.58 198.55 Technical (Hospital) Services Ref Psa Total PX-3018415301 CDM 84153 CPT 301 RC inpatient 209 209 HEALTHPARTNERS SX009 HEALTHPARTNERS 165.49 percent of total billed charges 129.58 198.55 Technical (Hospital) Services Ref Psa Total PX-3018415301 CDM 84153 CPT 301 RC inpatient 209 209 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES EPO [308136803] 165.49 percent of total billed charges 129.58 198.55 Technical (Hospital) Services Ref Psa Total PX-3018415301 CDM 84153 CPT 301 RC inpatient 209 209 CIGNA 62308 [3081051] CIGNA 62308 [308105105] 165.49 percent of total billed charges 129.58 198.55 Technical (Hospital) Services Ref Psa Total PX-3018415301 CDM 84153 CPT 301 RC inpatient 209 209 CIGNA 62308 [3081051] CIGNA STATE OF WYOMING [308105107] 165.49 percent of total billed charges 129.58 198.55 Technical (Hospital) Services Ref Psa Total PX-3018415301 CDM 84153 CPT 301 RC inpatient 209 209 MEDICA (COMMERCIAL) 94265 [3081118] MEDICA CLAIMS [308111801] 188.1 percent of total billed charges 129.58 198.55 Technical (Hospital) Services Ref Psa Total PX-3018415301 CDM 84153 CPT 301 RC inpatient 209 209 MULTIPLAN INC 34080 [3081285] MULTIPLAN INC [308128501] 198.55 percent of total billed charges 129.58 198.55 Technical (Hospital) Services Ref Psa Total PX-3018415301 CDM 84153 CPT 301 RC inpatient 209 209 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES PPO [308136801] 165.49 percent of total billed charges 129.58 198.55 Technical (Hospital) Services Ref Psa Total PX-3018415301 CDM 84153 CPT 301 RC inpatient 209 209 UNITED HEALTHCARE (COMMERCIAL) [3081199] UNITED HEALTHCARE 87726 [308119901] 129.58 percent of total billed charges 129.58 198.55 Technical (Hospital) Services Ref Psa Total PX-3018415301 CDM 84153 CPT 301 RC inpatient 209 209 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES HDHP [308136802] 165.49 percent of total billed charges 129.58 198.55 Technical (Hospital) Services Ref Psa Total PX-3018415301 CDM 84153 CPT 301 RC inpatient 209 209 BLUE CROSS BLUE SHIELD WELLMARK SB889 [3081026] BCBS WYOMING [308102603] 198.55 percent of total billed charges 129.58 198.55 Technical (Hospital) Services Ref Psa Total PX-3018415301 CDM 84153 CPT 301 RC outpatient 209 209 MEDICA (COMMERCIAL) 94265 [3081118] MEDICA CLAIMS [308111801] 188.1 percent of total billed charges 129.58 198.55 Technical (Hospital) Services Ref Psa Total PX-3018415301 CDM 84153 CPT 301 RC outpatient 209 209 CIGNA 62308 [3081051] CIGNA 62308 [308105105] 167.2 percent of total billed charges 129.58 198.55 Technical (Hospital) Services Ref Psa Total PX-3018415301 CDM 84153 CPT 301 RC outpatient 209 209 CIGNA 62308 [3081051] CIGNA STATE OF WYOMING [308105107] 167.2 percent of total billed charges 129.58 198.55 Technical (Hospital) Services Ref Psa Total PX-3018415301 CDM 84153 CPT 301 RC outpatient 209 209 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES EPO [308136803] 167.2 percent of total billed charges 129.58 198.55 Technical (Hospital) Services Ref Psa Total PX-3018415301 CDM 84153 CPT 301 RC outpatient 209 209 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES HDHP [308136802] 167.2 percent of total billed charges 129.58 198.55 Technical (Hospital) Services Ref Psa Total PX-3018415301 CDM 84153 CPT 301 RC outpatient 209 209 BLUE CROSS BLUE SHIELD WELLMARK SB889 [3081026] BCBS WYOMING [308102603] 198.55 percent of total billed charges 129.58 198.55 Technical (Hospital) Services Ref Psa Total PX-3018415301 CDM 84153 CPT 301 RC outpatient 209 209 MULTIPLAN INC 34080 [3081285] MULTIPLAN INC [308128501] 198.55 percent of total billed charges 129.58 198.55 Technical (Hospital) Services Ref Psa Total PX-3018415301 CDM 84153 CPT 301 RC outpatient 209 209 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES PPO [308136801] 167.2 percent of total billed charges 129.58 198.55 Technical (Hospital) Services Ref Psa Total PX-3018415301 CDM 84153 CPT 301 RC outpatient 209 209 HEALTHPARTNERS SX009 HEALTHPARTNERS 167.2 percent of total billed charges 129.58 198.55 Technical (Hospital) Services Ref Psa Total PX-3018415301 CDM 84153 CPT 301 RC outpatient 209 209 UNITED HEALTHCARE (COMMERCIAL) [3081199] UNITED HEALTHCARE 87726 [308119901] 129.58 percent of total billed charges 129.58 198.55 Technical (Hospital) Services "Ref Assay, Psa, Total" PX-3018415302 CDM 84153 CPT 301 RC inpatient 176 176 HEALTHPARTNERS SX009 HEALTHPARTNERS 139.36 percent of total billed charges 109.12 167.2 Technical (Hospital) Services "Ref Assay, Psa, Total" PX-3018415302 CDM 84153 CPT 301 RC inpatient 176 176 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES EPO [308136803] 139.36 percent of total billed charges 109.12 167.2 Technical (Hospital) Services "Ref Assay, Psa, Total" PX-3018415302 CDM 84153 CPT 301 RC inpatient 176 176 CIGNA 62308 [3081051] CIGNA 62308 [308105105] 139.36 percent of total billed charges 109.12 167.2 Technical (Hospital) Services "Ref Assay, Psa, Total" PX-3018415302 CDM 84153 CPT 301 RC inpatient 176 176 CIGNA 62308 [3081051] CIGNA STATE OF WYOMING [308105107] 139.36 percent of total billed charges 109.12 167.2 Technical (Hospital) Services "Ref Assay, Psa, Total" PX-3018415302 CDM 84153 CPT 301 RC inpatient 176 176 MEDICA (COMMERCIAL) 94265 [3081118] MEDICA CLAIMS [308111801] 158.4 percent of total billed charges 109.12 167.2 Technical (Hospital) Services "Ref Assay, Psa, Total" PX-3018415302 CDM 84153 CPT 301 RC inpatient 176 176 MULTIPLAN INC 34080 [3081285] MULTIPLAN INC [308128501] 167.2 percent of total billed charges 109.12 167.2 Technical (Hospital) Services "Ref Assay, Psa, Total" PX-3018415302 CDM 84153 CPT 301 RC inpatient 176 176 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES PPO [308136801] 139.36 percent of total billed charges 109.12 167.2 Technical (Hospital) Services "Ref Assay, Psa, Total" PX-3018415302 CDM 84153 CPT 301 RC inpatient 176 176 UNITED HEALTHCARE (COMMERCIAL) [3081199] UNITED HEALTHCARE 87726 [308119901] 109.12 percent of total billed charges 109.12 167.2 Technical (Hospital) Services "Ref Assay, Psa, Total" PX-3018415302 CDM 84153 CPT 301 RC inpatient 176 176 BLUE CROSS BLUE SHIELD WELLMARK SB889 [3081026] BCBS WYOMING [308102603] 167.2 percent of total billed charges 109.12 167.2 Technical (Hospital) Services "Ref Assay, Psa, Total" PX-3018415302 CDM 84153 CPT 301 RC inpatient 176 176 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES HDHP [308136802] 139.36 percent of total billed charges 109.12 167.2 Technical (Hospital) Services "Ref Assay, Psa, Total" PX-3018415302 CDM 84153 CPT 301 RC outpatient 176 176 CIGNA 62308 [3081051] CIGNA 62308 [308105105] 140.8 percent of total billed charges 109.12 167.2 Technical (Hospital) Services "Ref Assay, Psa, Total" PX-3018415302 CDM 84153 CPT 301 RC outpatient 176 176 CIGNA 62308 [3081051] CIGNA STATE OF WYOMING [308105107] 140.8 percent of total billed charges 109.12 167.2 Technical (Hospital) Services "Ref Assay, Psa, Total" PX-3018415302 CDM 84153 CPT 301 RC outpatient 176 176 MEDICA (COMMERCIAL) 94265 [3081118] MEDICA CLAIMS [308111801] 158.4 percent of total billed charges 109.12 167.2 Technical (Hospital) Services "Ref Assay, Psa, Total" PX-3018415302 CDM 84153 CPT 301 RC outpatient 176 176 HEALTHPARTNERS SX009 HEALTHPARTNERS 140.8 percent of total billed charges 109.12 167.2 Technical (Hospital) Services "Ref Assay, Psa, Total" PX-3018415302 CDM 84153 CPT 301 RC outpatient 176 176 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES PPO [308136801] 140.8 percent of total billed charges 109.12 167.2 Technical (Hospital) Services "Ref Assay, Psa, Total" PX-3018415302 CDM 84153 CPT 301 RC outpatient 176 176 UNITED HEALTHCARE (COMMERCIAL) [3081199] UNITED HEALTHCARE 87726 [308119901] 109.12 percent of total billed charges 109.12 167.2 Technical (Hospital) Services "Ref Assay, Psa, Total" PX-3018415302 CDM 84153 CPT 301 RC outpatient 176 176 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES HDHP [308136802] 140.8 percent of total billed charges 109.12 167.2 Technical (Hospital) Services "Ref Assay, Psa, Total" PX-3018415302 CDM 84153 CPT 301 RC outpatient 176 176 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES EPO [308136803] 140.8 percent of total billed charges 109.12 167.2 Technical (Hospital) Services "Ref Assay, Psa, Total" PX-3018415302 CDM 84153 CPT 301 RC outpatient 176 176 MULTIPLAN INC 34080 [3081285] MULTIPLAN INC [308128501] 167.2 percent of total billed charges 109.12 167.2 Technical (Hospital) Services "Ref Assay, Psa, Total" PX-3018415302 CDM 84153 CPT 301 RC outpatient 176 176 BLUE CROSS BLUE SHIELD WELLMARK SB889 [3081026] BCBS WYOMING [308102603] 167.2 percent of total billed charges 109.12 167.2 Technical (Hospital) Services Psa Screening PX-3018415303 CDM 84153 CPT 301 RC outpatient 209 209 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES EPO [308136803] 167.2 percent of total billed charges 129.58 198.55 Technical (Hospital) Services Psa Screening PX-3018415303 CDM 84153 CPT 301 RC outpatient 209 209 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES HDHP [308136802] 167.2 percent of total billed charges 129.58 198.55 Technical (Hospital) Services Psa Screening PX-3018415303 CDM 84153 CPT 301 RC outpatient 209 209 MULTIPLAN INC 34080 [3081285] MULTIPLAN INC [308128501] 198.55 percent of total billed charges 129.58 198.55 Technical (Hospital) Services Psa Screening PX-3018415303 CDM 84153 CPT 301 RC outpatient 209 209 BLUE CROSS BLUE SHIELD WELLMARK SB889 [3081026] BCBS WYOMING [308102603] 198.55 percent of total billed charges 129.58 198.55 Technical (Hospital) Services Psa Screening PX-3018415303 CDM 84153 CPT 301 RC outpatient 209 209 UNITED HEALTHCARE (COMMERCIAL) [3081199] UNITED HEALTHCARE 87726 [308119901] 129.58 percent of total billed charges 129.58 198.55 Technical (Hospital) Services Psa Screening PX-3018415303 CDM 84153 CPT 301 RC outpatient 209 209 HEALTHPARTNERS SX009 HEALTHPARTNERS 167.2 percent of total billed charges 129.58 198.55 Technical (Hospital) Services Psa Screening PX-3018415303 CDM 84153 CPT 301 RC outpatient 209 209 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES PPO [308136801] 167.2 percent of total billed charges 129.58 198.55 Technical (Hospital) Services Psa Screening PX-3018415303 CDM 84153 CPT 301 RC outpatient 209 209 MEDICA (COMMERCIAL) 94265 [3081118] MEDICA CLAIMS [308111801] 188.1 percent of total billed charges 129.58 198.55 Technical (Hospital) Services Psa Screening PX-3018415303 CDM 84153 CPT 301 RC outpatient 209 209 CIGNA 62308 [3081051] CIGNA 62308 [308105105] 167.2 percent of total billed charges 129.58 198.55 Technical (Hospital) Services Psa Screening PX-3018415303 CDM 84153 CPT 301 RC outpatient 209 209 CIGNA 62308 [3081051] CIGNA STATE OF WYOMING [308105107] 167.2 percent of total billed charges 129.58 198.55 Technical (Hospital) Services Psa Screening PX-3018415303 CDM 84153 CPT 301 RC inpatient 209 209 UNITED HEALTHCARE (COMMERCIAL) [3081199] UNITED HEALTHCARE 87726 [308119901] 129.58 percent of total billed charges 129.58 198.55 Technical (Hospital) Services Psa Screening PX-3018415303 CDM 84153 CPT 301 RC inpatient 209 209 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES PPO [308136801] 165.49 percent of total billed charges 129.58 198.55 Technical (Hospital) Services Psa Screening PX-3018415303 CDM 84153 CPT 301 RC inpatient 209 209 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES HDHP [308136802] 165.49 percent of total billed charges 129.58 198.55 Technical (Hospital) Services Psa Screening PX-3018415303 CDM 84153 CPT 301 RC inpatient 209 209 BLUE CROSS BLUE SHIELD WELLMARK SB889 [3081026] BCBS WYOMING [308102603] 198.55 percent of total billed charges 129.58 198.55 Technical (Hospital) Services Psa Screening PX-3018415303 CDM 84153 CPT 301 RC inpatient 209 209 HEALTHPARTNERS SX009 HEALTHPARTNERS 165.49 percent of total billed charges 129.58 198.55 Technical (Hospital) Services Psa Screening PX-3018415303 CDM 84153 CPT 301 RC inpatient 209 209 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES EPO [308136803] 165.49 percent of total billed charges 129.58 198.55 Technical (Hospital) Services Psa Screening PX-3018415303 CDM 84153 CPT 301 RC inpatient 209 209 CIGNA 62308 [3081051] CIGNA 62308 [308105105] 165.49 percent of total billed charges 129.58 198.55 Technical (Hospital) Services Psa Screening PX-3018415303 CDM 84153 CPT 301 RC inpatient 209 209 CIGNA 62308 [3081051] CIGNA STATE OF WYOMING [308105107] 165.49 percent of total billed charges 129.58 198.55 Technical (Hospital) Services Psa Screening PX-3018415303 CDM 84153 CPT 301 RC inpatient 209 209 MEDICA (COMMERCIAL) 94265 [3081118] MEDICA CLAIMS [308111801] 188.1 percent of total billed charges 129.58 198.55 Technical (Hospital) Services Psa Screening PX-3018415303 CDM 84153 CPT 301 RC inpatient 209 209 MULTIPLAN INC 34080 [3081285] MULTIPLAN INC [308128501] 198.55 percent of total billed charges 129.58 198.55 Technical (Hospital) Services Prolactin PX-3018414600 CDM 84146 CPT 301 RC outpatient 216 216 MEDICA (COMMERCIAL) 94265 [3081118] MEDICA CLAIMS [308111801] 194.4 percent of total billed charges 133.92 205.2 Technical (Hospital) Services Prolactin PX-3018414600 CDM 84146 CPT 301 RC outpatient 216 216 CIGNA 62308 [3081051] CIGNA 62308 [308105105] 172.8 percent of total billed charges 133.92 205.2 Technical (Hospital) Services Prolactin PX-3018414600 CDM 84146 CPT 301 RC outpatient 216 216 CIGNA 62308 [3081051] CIGNA STATE OF WYOMING [308105107] 172.8 percent of total billed charges 133.92 205.2 Technical (Hospital) Services Prolactin PX-3018414600 CDM 84146 CPT 301 RC outpatient 216 216 UNITED HEALTHCARE (COMMERCIAL) [3081199] UNITED HEALTHCARE 87726 [308119901] 133.92 percent of total billed charges 133.92 205.2 Technical (Hospital) Services Prolactin PX-3018414600 CDM 84146 CPT 301 RC outpatient 216 216 HEALTHPARTNERS SX009 HEALTHPARTNERS 172.8 percent of total billed charges 133.92 205.2 Technical (Hospital) Services Prolactin PX-3018414600 CDM 84146 CPT 301 RC outpatient 216 216 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES PPO [308136801] 172.8 percent of total billed charges 133.92 205.2 Technical (Hospital) Services Prolactin PX-3018414600 CDM 84146 CPT 301 RC outpatient 216 216 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES HDHP [308136802] 172.8 percent of total billed charges 133.92 205.2 Technical (Hospital) Services Prolactin PX-3018414600 CDM 84146 CPT 301 RC outpatient 216 216 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES EPO [308136803] 172.8 percent of total billed charges 133.92 205.2 Technical (Hospital) Services Prolactin PX-3018414600 CDM 84146 CPT 301 RC outpatient 216 216 BLUE CROSS BLUE SHIELD WELLMARK SB889 [3081026] BCBS WYOMING [308102603] 205.2 percent of total billed charges 133.92 205.2 Technical (Hospital) Services Prolactin PX-3018414600 CDM 84146 CPT 301 RC outpatient 216 216 MULTIPLAN INC 34080 [3081285] MULTIPLAN INC [308128501] 205.2 percent of total billed charges 133.92 205.2 Technical (Hospital) Services Prolactin PX-3018414600 CDM 84146 CPT 301 RC inpatient 216 216 UNITED HEALTHCARE (COMMERCIAL) [3081199] UNITED HEALTHCARE 87726 [308119901] 133.92 percent of total billed charges 133.92 205.2 Technical (Hospital) Services Prolactin PX-3018414600 CDM 84146 CPT 301 RC inpatient 216 216 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES PPO [308136801] 171.03 percent of total billed charges 133.92 205.2 Technical (Hospital) Services Prolactin PX-3018414600 CDM 84146 CPT 301 RC inpatient 216 216 BLUE CROSS BLUE SHIELD WELLMARK SB889 [3081026] BCBS WYOMING [308102603] 205.2 percent of total billed charges 133.92 205.2 Technical (Hospital) Services Prolactin PX-3018414600 CDM 84146 CPT 301 RC inpatient 216 216 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES HDHP [308136802] 171.03 percent of total billed charges 133.92 205.2 Technical (Hospital) Services Prolactin PX-3018414600 CDM 84146 CPT 301 RC inpatient 216 216 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES EPO [308136803] 171.03 percent of total billed charges 133.92 205.2 Technical (Hospital) Services Prolactin PX-3018414600 CDM 84146 CPT 301 RC inpatient 216 216 HEALTHPARTNERS SX009 HEALTHPARTNERS 171.03 percent of total billed charges 133.92 205.2 Technical (Hospital) Services Prolactin PX-3018414600 CDM 84146 CPT 301 RC inpatient 216 216 MEDICA (COMMERCIAL) 94265 [3081118] MEDICA CLAIMS [308111801] 194.4 percent of total billed charges 133.92 205.2 Technical (Hospital) Services Prolactin PX-3018414600 CDM 84146 CPT 301 RC inpatient 216 216 MULTIPLAN INC 34080 [3081285] MULTIPLAN INC [308128501] 205.2 percent of total billed charges 133.92 205.2 Technical (Hospital) Services Prolactin PX-3018414600 CDM 84146 CPT 301 RC inpatient 216 216 CIGNA 62308 [3081051] CIGNA 62308 [308105105] 171.03 percent of total billed charges 133.92 205.2 Technical (Hospital) Services Prolactin PX-3018414600 CDM 84146 CPT 301 RC inpatient 216 216 CIGNA 62308 [3081051] CIGNA STATE OF WYOMING [308105107] 171.03 percent of total billed charges 133.92 205.2 Technical (Hospital) Services Procalcitonin PX-3018414500 CDM 84145 CPT 301 RC inpatient 309 309 BLUE CROSS BLUE SHIELD WELLMARK SB889 [3081026] BCBS WYOMING [308102603] 293.55 percent of total billed charges 191.58 293.55 Technical (Hospital) Services Procalcitonin PX-3018414500 CDM 84145 CPT 301 RC inpatient 309 309 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES HDHP [308136802] 244.67 percent of total billed charges 191.58 293.55 Technical (Hospital) Services Procalcitonin PX-3018414500 CDM 84145 CPT 301 RC inpatient 309 309 UNITED HEALTHCARE (COMMERCIAL) [3081199] UNITED HEALTHCARE 87726 [308119901] 191.58 percent of total billed charges 191.58 293.55 Technical (Hospital) Services Procalcitonin PX-3018414500 CDM 84145 CPT 301 RC outpatient 309 309 CIGNA 62308 [3081051] CIGNA 62308 [308105105] 247.2 percent of total billed charges 191.58 293.55 Technical (Hospital) Services Procalcitonin PX-3018414500 CDM 84145 CPT 301 RC outpatient 309 309 CIGNA 62308 [3081051] CIGNA STATE OF WYOMING [308105107] 247.2 percent of total billed charges 191.58 293.55 Technical (Hospital) Services Procalcitonin PX-3018414500 CDM 84145 CPT 301 RC outpatient 309 309 MEDICA (COMMERCIAL) 94265 [3081118] MEDICA CLAIMS [308111801] 278.1 percent of total billed charges 191.58 293.55 Technical (Hospital) Services Procalcitonin PX-3018414500 CDM 84145 CPT 301 RC outpatient 309 309 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES EPO [308136803] 247.2 percent of total billed charges 191.58 293.55 Technical (Hospital) Services Procalcitonin PX-3018414500 CDM 84145 CPT 301 RC outpatient 309 309 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES HDHP [308136802] 247.2 percent of total billed charges 191.58 293.55 Technical (Hospital) Services Procalcitonin PX-3018414500 CDM 84145 CPT 301 RC inpatient 309 309 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES PPO [308136801] 244.67 percent of total billed charges 191.58 293.55 Technical (Hospital) Services Procalcitonin PX-3018414500 CDM 84145 CPT 301 RC inpatient 309 309 MULTIPLAN INC 34080 [3081285] MULTIPLAN INC [308128501] 293.55 percent of total billed charges 191.58 293.55 Technical (Hospital) Services Procalcitonin PX-3018414500 CDM 84145 CPT 301 RC inpatient 309 309 MEDICA (COMMERCIAL) 94265 [3081118] MEDICA CLAIMS [308111801] 278.1 percent of total billed charges 191.58 293.55 Technical (Hospital) Services Procalcitonin PX-3018414500 CDM 84145 CPT 301 RC inpatient 309 309 CIGNA 62308 [3081051] CIGNA 62308 [308105105] 244.67 percent of total billed charges 191.58 293.55 Technical (Hospital) Services Procalcitonin PX-3018414500 CDM 84145 CPT 301 RC inpatient 309 309 CIGNA 62308 [3081051] CIGNA STATE OF WYOMING [308105107] 244.67 percent of total billed charges 191.58 293.55 Technical (Hospital) Services Procalcitonin PX-3018414500 CDM 84145 CPT 301 RC inpatient 309 309 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES EPO [308136803] 244.67 percent of total billed charges 191.58 293.55 Technical (Hospital) Services Procalcitonin PX-3018414500 CDM 84145 CPT 301 RC inpatient 309 309 HEALTHPARTNERS SX009 HEALTHPARTNERS 244.67 percent of total billed charges 191.58 293.55 Technical (Hospital) Services Procalcitonin PX-3018414500 CDM 84145 CPT 301 RC outpatient 309 309 BLUE CROSS BLUE SHIELD WELLMARK SB889 [3081026] BCBS WYOMING [308102603] 293.55 percent of total billed charges 191.58 293.55 Technical (Hospital) Services Procalcitonin PX-3018414500 CDM 84145 CPT 301 RC outpatient 309 309 MULTIPLAN INC 34080 [3081285] MULTIPLAN INC [308128501] 293.55 percent of total billed charges 191.58 293.55 Technical (Hospital) Services Procalcitonin PX-3018414500 CDM 84145 CPT 301 RC outpatient 309 309 HEALTHPARTNERS SX009 HEALTHPARTNERS 247.2 percent of total billed charges 191.58 293.55 Technical (Hospital) Services Procalcitonin PX-3018414500 CDM 84145 CPT 301 RC outpatient 309 309 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES PPO [308136801] 247.2 percent of total billed charges 191.58 293.55 Technical (Hospital) Services Procalcitonin PX-3018414500 CDM 84145 CPT 301 RC outpatient 309 309 UNITED HEALTHCARE (COMMERCIAL) [3081199] UNITED HEALTHCARE 87726 [308119901] 191.58 percent of total billed charges 191.58 293.55 Technical (Hospital) Services Progesterone PX-3018414400 CDM 84144 CPT 301 RC outpatient 270 270 UNITED HEALTHCARE (COMMERCIAL) [3081199] UNITED HEALTHCARE 87726 [308119901] 167.4 percent of total billed charges 167.4 256.5 Technical (Hospital) Services Progesterone PX-3018414400 CDM 84144 CPT 301 RC outpatient 270 270 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES PPO [308136801] 216 percent of total billed charges 167.4 256.5 Technical (Hospital) Services Progesterone PX-3018414400 CDM 84144 CPT 301 RC outpatient 270 270 HEALTHPARTNERS SX009 HEALTHPARTNERS 216 percent of total billed charges 167.4 256.5 Technical (Hospital) Services Progesterone PX-3018414400 CDM 84144 CPT 301 RC outpatient 270 270 MULTIPLAN INC 34080 [3081285] MULTIPLAN INC [308128501] 256.5 percent of total billed charges 167.4 256.5 Technical (Hospital) Services Progesterone PX-3018414400 CDM 84144 CPT 301 RC outpatient 270 270 BLUE CROSS BLUE SHIELD WELLMARK SB889 [3081026] BCBS WYOMING [308102603] 256.5 percent of total billed charges 167.4 256.5 Technical (Hospital) Services Progesterone PX-3018414400 CDM 84144 CPT 301 RC outpatient 270 270 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES HDHP [308136802] 216 percent of total billed charges 167.4 256.5 Technical (Hospital) Services Progesterone PX-3018414400 CDM 84144 CPT 301 RC outpatient 270 270 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES EPO [308136803] 216 percent of total billed charges 167.4 256.5 Technical (Hospital) Services Progesterone PX-3018414400 CDM 84144 CPT 301 RC outpatient 270 270 CIGNA 62308 [3081051] CIGNA 62308 [308105105] 216 percent of total billed charges 167.4 256.5 Technical (Hospital) Services Progesterone PX-3018414400 CDM 84144 CPT 301 RC outpatient 270 270 CIGNA 62308 [3081051] CIGNA STATE OF WYOMING [308105107] 216 percent of total billed charges 167.4 256.5 Technical (Hospital) Services Progesterone PX-3018414400 CDM 84144 CPT 301 RC outpatient 270 270 MEDICA (COMMERCIAL) 94265 [3081118] MEDICA CLAIMS [308111801] 243 percent of total billed charges 167.4 256.5 Technical (Hospital) Services Progesterone PX-3018414400 CDM 84144 CPT 301 RC inpatient 270 270 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES PPO [308136801] 213.79 percent of total billed charges 167.4 256.5 Technical (Hospital) Services Progesterone PX-3018414400 CDM 84144 CPT 301 RC inpatient 270 270 UNITED HEALTHCARE (COMMERCIAL) [3081199] UNITED HEALTHCARE 87726 [308119901] 167.4 percent of total billed charges 167.4 256.5 Technical (Hospital) Services Progesterone PX-3018414400 CDM 84144 CPT 301 RC inpatient 270 270 BLUE CROSS BLUE SHIELD WELLMARK SB889 [3081026] BCBS WYOMING [308102603] 256.5 percent of total billed charges 167.4 256.5 Technical (Hospital) Services Progesterone PX-3018414400 CDM 84144 CPT 301 RC inpatient 270 270 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES HDHP [308136802] 213.79 percent of total billed charges 167.4 256.5 Technical (Hospital) Services Progesterone PX-3018414400 CDM 84144 CPT 301 RC inpatient 270 270 CIGNA 62308 [3081051] CIGNA 62308 [308105105] 213.79 percent of total billed charges 167.4 256.5 Technical (Hospital) Services Progesterone PX-3018414400 CDM 84144 CPT 301 RC inpatient 270 270 CIGNA 62308 [3081051] CIGNA STATE OF WYOMING [308105107] 213.79 percent of total billed charges 167.4 256.5 Technical (Hospital) Services Progesterone PX-3018414400 CDM 84144 CPT 301 RC inpatient 270 270 MEDICA (COMMERCIAL) 94265 [3081118] MEDICA CLAIMS [308111801] 243 percent of total billed charges 167.4 256.5 Technical (Hospital) Services Progesterone PX-3018414400 CDM 84144 CPT 301 RC inpatient 270 270 MULTIPLAN INC 34080 [3081285] MULTIPLAN INC [308128501] 256.5 percent of total billed charges 167.4 256.5 Technical (Hospital) Services Progesterone PX-3018414400 CDM 84144 CPT 301 RC inpatient 270 270 HEALTHPARTNERS SX009 HEALTHPARTNERS 213.79 percent of total billed charges 167.4 256.5 Technical (Hospital) Services Progesterone PX-3018414400 CDM 84144 CPT 301 RC inpatient 270 270 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES EPO [308136803] 213.79 percent of total billed charges 167.4 256.5 Technical (Hospital) Services Ref Pregnenolone PX-3018414000 CDM 84140 CPT 301 RC outpatient 185 185 HEALTHPARTNERS SX009 HEALTHPARTNERS 148 percent of total billed charges 114.7 175.75 Technical (Hospital) Services Ref Pregnenolone PX-3018414000 CDM 84140 CPT 301 RC outpatient 185 185 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES PPO [308136801] 148 percent of total billed charges 114.7 175.75 Technical (Hospital) Services Ref Pregnenolone PX-3018414000 CDM 84140 CPT 301 RC outpatient 185 185 UNITED HEALTHCARE (COMMERCIAL) [3081199] UNITED HEALTHCARE 87726 [308119901] 114.7 percent of total billed charges 114.7 175.75 Technical (Hospital) Services Ref Pregnenolone PX-3018414000 CDM 84140 CPT 301 RC outpatient 185 185 BLUE CROSS BLUE SHIELD WELLMARK SB889 [3081026] BCBS WYOMING [308102603] 175.75 percent of total billed charges 114.7 175.75 Technical (Hospital) Services Ref Pregnenolone PX-3018414000 CDM 84140 CPT 301 RC outpatient 185 185 MULTIPLAN INC 34080 [3081285] MULTIPLAN INC [308128501] 175.75 percent of total billed charges 114.7 175.75 Technical (Hospital) Services Ref Pregnenolone PX-3018414000 CDM 84140 CPT 301 RC outpatient 185 185 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES HDHP [308136802] 148 percent of total billed charges 114.7 175.75 Technical (Hospital) Services Ref Pregnenolone PX-3018414000 CDM 84140 CPT 301 RC outpatient 185 185 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES EPO [308136803] 148 percent of total billed charges 114.7 175.75 Technical (Hospital) Services Ref Pregnenolone PX-3018414000 CDM 84140 CPT 301 RC outpatient 185 185 MEDICA (COMMERCIAL) 94265 [3081118] MEDICA CLAIMS [308111801] 166.5 percent of total billed charges 114.7 175.75 Technical (Hospital) Services Ref Pregnenolone PX-3018414000 CDM 84140 CPT 301 RC outpatient 185 185 CIGNA 62308 [3081051] CIGNA 62308 [308105105] 148 percent of total billed charges 114.7 175.75 Technical (Hospital) Services Ref Pregnenolone PX-3018414000 CDM 84140 CPT 301 RC outpatient 185 185 CIGNA 62308 [3081051] CIGNA STATE OF WYOMING [308105107] 148 percent of total billed charges 114.7 175.75 Technical (Hospital) Services Ref Pregnenolone PX-3018414000 CDM 84140 CPT 301 RC inpatient 185 185 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES EPO [308136803] 146.48 percent of total billed charges 114.7 175.75 Technical (Hospital) Services Ref Pregnenolone PX-3018414000 CDM 84140 CPT 301 RC inpatient 185 185 HEALTHPARTNERS SX009 HEALTHPARTNERS 146.48 percent of total billed charges 114.7 175.75 Technical (Hospital) Services Ref Pregnenolone PX-3018414000 CDM 84140 CPT 301 RC inpatient 185 185 MULTIPLAN INC 34080 [3081285] MULTIPLAN INC [308128501] 175.75 percent of total billed charges 114.7 175.75 Technical (Hospital) Services Ref Pregnenolone PX-3018414000 CDM 84140 CPT 301 RC inpatient 185 185 MEDICA (COMMERCIAL) 94265 [3081118] MEDICA CLAIMS [308111801] 166.5 percent of total billed charges 114.7 175.75 Technical (Hospital) Services Ref Pregnenolone PX-3018414000 CDM 84140 CPT 301 RC inpatient 185 185 CIGNA 62308 [3081051] CIGNA 62308 [308105105] 146.48 percent of total billed charges 114.7 175.75 Technical (Hospital) Services Ref Pregnenolone PX-3018414000 CDM 84140 CPT 301 RC inpatient 185 185 CIGNA 62308 [3081051] CIGNA STATE OF WYOMING [308105107] 146.48 percent of total billed charges 114.7 175.75 Technical (Hospital) Services Ref Pregnenolone PX-3018414000 CDM 84140 CPT 301 RC inpatient 185 185 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES PPO [308136801] 146.48 percent of total billed charges 114.7 175.75 Technical (Hospital) Services Ref Pregnenolone PX-3018414000 CDM 84140 CPT 301 RC inpatient 185 185 UNITED HEALTHCARE (COMMERCIAL) [3081199] UNITED HEALTHCARE 87726 [308119901] 114.7 percent of total billed charges 114.7 175.75 Technical (Hospital) Services Ref Pregnenolone PX-3018414000 CDM 84140 CPT 301 RC inpatient 185 185 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES HDHP [308136802] 146.48 percent of total billed charges 114.7 175.75 Technical (Hospital) Services Ref Pregnenolone PX-3018414000 CDM 84140 CPT 301 RC inpatient 185 185 BLUE CROSS BLUE SHIELD WELLMARK SB889 [3081026] BCBS WYOMING [308102603] 175.75 percent of total billed charges 114.7 175.75 Technical (Hospital) Services Prealbumin PX-3018413400 CDM 84134 CPT 301 RC inpatient 153 153 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES HDHP [308136802] 121.15 percent of total billed charges 94.86 145.35 Technical (Hospital) Services Prealbumin PX-3018413400 CDM 84134 CPT 301 RC inpatient 153 153 BLUE CROSS BLUE SHIELD WELLMARK SB889 [3081026] BCBS WYOMING [308102603] 145.35 percent of total billed charges 94.86 145.35 Technical (Hospital) Services Prealbumin PX-3018413400 CDM 84134 CPT 301 RC inpatient 153 153 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES PPO [308136801] 121.15 percent of total billed charges 94.86 145.35 Technical (Hospital) Services Prealbumin PX-3018413400 CDM 84134 CPT 301 RC inpatient 153 153 UNITED HEALTHCARE (COMMERCIAL) [3081199] UNITED HEALTHCARE 87726 [308119901] 94.86 percent of total billed charges 94.86 145.35 Technical (Hospital) Services Prealbumin PX-3018413400 CDM 84134 CPT 301 RC inpatient 153 153 MULTIPLAN INC 34080 [3081285] MULTIPLAN INC [308128501] 145.35 percent of total billed charges 94.86 145.35 Technical (Hospital) Services Prealbumin PX-3018413400 CDM 84134 CPT 301 RC inpatient 153 153 MEDICA (COMMERCIAL) 94265 [3081118] MEDICA CLAIMS [308111801] 137.7 percent of total billed charges 94.86 145.35 Technical (Hospital) Services Prealbumin PX-3018413400 CDM 84134 CPT 301 RC inpatient 153 153 CIGNA 62308 [3081051] CIGNA 62308 [308105105] 121.15 percent of total billed charges 94.86 145.35 Technical (Hospital) Services Prealbumin PX-3018413400 CDM 84134 CPT 301 RC inpatient 153 153 CIGNA 62308 [3081051] CIGNA STATE OF WYOMING [308105107] 121.15 percent of total billed charges 94.86 145.35 Technical (Hospital) Services Prealbumin PX-3018413400 CDM 84134 CPT 301 RC inpatient 153 153 HEALTHPARTNERS SX009 HEALTHPARTNERS 121.15 percent of total billed charges 94.86 145.35 Technical (Hospital) Services Prealbumin PX-3018413400 CDM 84134 CPT 301 RC inpatient 153 153 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES EPO [308136803] 121.15 percent of total billed charges 94.86 145.35 Technical (Hospital) Services Prealbumin PX-3018413400 CDM 84134 CPT 301 RC outpatient 153 153 MEDICA (COMMERCIAL) 94265 [3081118] MEDICA CLAIMS [308111801] 137.7 percent of total billed charges 94.86 145.35 Technical (Hospital) Services Prealbumin PX-3018413400 CDM 84134 CPT 301 RC outpatient 153 153 CIGNA 62308 [3081051] CIGNA 62308 [308105105] 122.4 percent of total billed charges 94.86 145.35 Technical (Hospital) Services Prealbumin PX-3018413400 CDM 84134 CPT 301 RC outpatient 153 153 CIGNA 62308 [3081051] CIGNA STATE OF WYOMING [308105107] 122.4 percent of total billed charges 94.86 145.35 Technical (Hospital) Services Prealbumin PX-3018413400 CDM 84134 CPT 301 RC outpatient 153 153 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES PPO [308136801] 122.4 percent of total billed charges 94.86 145.35 Technical (Hospital) Services Prealbumin PX-3018413400 CDM 84134 CPT 301 RC outpatient 153 153 HEALTHPARTNERS SX009 HEALTHPARTNERS 122.4 percent of total billed charges 94.86 145.35 Technical (Hospital) Services Prealbumin PX-3018413400 CDM 84134 CPT 301 RC outpatient 153 153 UNITED HEALTHCARE (COMMERCIAL) [3081199] UNITED HEALTHCARE 87726 [308119901] 94.86 percent of total billed charges 94.86 145.35 Technical (Hospital) Services Prealbumin PX-3018413400 CDM 84134 CPT 301 RC outpatient 153 153 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES EPO [308136803] 122.4 percent of total billed charges 94.86 145.35 Technical (Hospital) Services Prealbumin PX-3018413400 CDM 84134 CPT 301 RC outpatient 153 153 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES HDHP [308136802] 122.4 percent of total billed charges 94.86 145.35 Technical (Hospital) Services Prealbumin PX-3018413400 CDM 84134 CPT 301 RC outpatient 153 153 BLUE CROSS BLUE SHIELD WELLMARK SB889 [3081026] BCBS WYOMING [308102603] 145.35 percent of total billed charges 94.86 145.35 Technical (Hospital) Services Prealbumin PX-3018413400 CDM 84134 CPT 301 RC outpatient 153 153 MULTIPLAN INC 34080 [3081285] MULTIPLAN INC [308128501] 145.35 percent of total billed charges 94.86 145.35 Technical (Hospital) Services Potassium Urine PX-3018413300 CDM 84133 CPT 301 RC outpatient 63 63 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES HDHP [308136802] 50.4 percent of total billed charges 39.06 59.85 Technical (Hospital) Services Potassium Urine PX-3018413300 CDM 84133 CPT 301 RC outpatient 63 63 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES EPO [308136803] 50.4 percent of total billed charges 39.06 59.85 Technical (Hospital) Services Potassium Urine PX-3018413300 CDM 84133 CPT 301 RC outpatient 63 63 MULTIPLAN INC 34080 [3081285] MULTIPLAN INC [308128501] 59.85 percent of total billed charges 39.06 59.85 Technical (Hospital) Services Potassium Urine PX-3018413300 CDM 84133 CPT 301 RC outpatient 63 63 BLUE CROSS BLUE SHIELD WELLMARK SB889 [3081026] BCBS WYOMING [308102603] 59.85 percent of total billed charges 39.06 59.85 Technical (Hospital) Services Potassium Urine PX-3018413300 CDM 84133 CPT 301 RC outpatient 63 63 UNITED HEALTHCARE (COMMERCIAL) [3081199] UNITED HEALTHCARE 87726 [308119901] 39.06 percent of total billed charges 39.06 59.85 Technical (Hospital) Services Potassium Urine PX-3018413300 CDM 84133 CPT 301 RC outpatient 63 63 HEALTHPARTNERS SX009 HEALTHPARTNERS 50.4 percent of total billed charges 39.06 59.85 Technical (Hospital) Services Potassium Urine PX-3018413300 CDM 84133 CPT 301 RC outpatient 63 63 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES PPO [308136801] 50.4 percent of total billed charges 39.06 59.85 Technical (Hospital) Services Potassium Urine PX-3018413300 CDM 84133 CPT 301 RC outpatient 63 63 MEDICA (COMMERCIAL) 94265 [3081118] MEDICA CLAIMS [308111801] 56.7 percent of total billed charges 39.06 59.85 Technical (Hospital) Services Potassium Urine PX-3018413300 CDM 84133 CPT 301 RC outpatient 63 63 CIGNA 62308 [3081051] CIGNA 62308 [308105105] 50.4 percent of total billed charges 39.06 59.85 Technical (Hospital) Services Potassium Urine PX-3018413300 CDM 84133 CPT 301 RC outpatient 63 63 CIGNA 62308 [3081051] CIGNA STATE OF WYOMING [308105107] 50.4 percent of total billed charges 39.06 59.85 Technical (Hospital) Services Potassium Urine PX-3018413300 CDM 84133 CPT 301 RC inpatient 63 63 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES PPO [308136801] 49.88 percent of total billed charges 39.06 59.85 Technical (Hospital) Services Potassium Urine PX-3018413300 CDM 84133 CPT 301 RC inpatient 63 63 UNITED HEALTHCARE (COMMERCIAL) [3081199] UNITED HEALTHCARE 87726 [308119901] 39.06 percent of total billed charges 39.06 59.85 Technical (Hospital) Services Potassium Urine PX-3018413300 CDM 84133 CPT 301 RC inpatient 63 63 BLUE CROSS BLUE SHIELD WELLMARK SB889 [3081026] BCBS WYOMING [308102603] 59.85 percent of total billed charges 39.06 59.85 Technical (Hospital) Services Potassium Urine PX-3018413300 CDM 84133 CPT 301 RC inpatient 63 63 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES HDHP [308136802] 49.88 percent of total billed charges 39.06 59.85 Technical (Hospital) Services Potassium Urine PX-3018413300 CDM 84133 CPT 301 RC inpatient 63 63 MEDICA (COMMERCIAL) 94265 [3081118] MEDICA CLAIMS [308111801] 56.7 percent of total billed charges 39.06 59.85 Technical (Hospital) Services Potassium Urine PX-3018413300 CDM 84133 CPT 301 RC inpatient 63 63 MULTIPLAN INC 34080 [3081285] MULTIPLAN INC [308128501] 59.85 percent of total billed charges 39.06 59.85 Technical (Hospital) Services Potassium Urine PX-3018413300 CDM 84133 CPT 301 RC inpatient 63 63 CIGNA 62308 [3081051] CIGNA 62308 [308105105] 49.88 percent of total billed charges 39.06 59.85 Technical (Hospital) Services Potassium Urine PX-3018413300 CDM 84133 CPT 301 RC inpatient 63 63 CIGNA 62308 [3081051] CIGNA STATE OF WYOMING [308105107] 49.88 percent of total billed charges 39.06 59.85 Technical (Hospital) Services Potassium Urine PX-3018413300 CDM 84133 CPT 301 RC inpatient 63 63 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES EPO [308136803] 49.88 percent of total billed charges 39.06 59.85 Technical (Hospital) Services Potassium Urine PX-3018413300 CDM 84133 CPT 301 RC inpatient 63 63 HEALTHPARTNERS SX009 HEALTHPARTNERS 49.88 percent of total billed charges 39.06 59.85 Technical (Hospital) Services Potassium Serum Plasma Wb PX-3018413200 CDM 84132 CPT 301 RC inpatient 95 95 HEALTHPARTNERS SX009 HEALTHPARTNERS 75.22 percent of total billed charges 58.9 90.25 Technical (Hospital) Services Potassium Serum Plasma Wb PX-3018413200 CDM 84132 CPT 301 RC inpatient 95 95 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES EPO [308136803] 75.22 percent of total billed charges 58.9 90.25 Technical (Hospital) Services Potassium Serum Plasma Wb PX-3018413200 CDM 84132 CPT 301 RC inpatient 95 95 CIGNA 62308 [3081051] CIGNA 62308 [308105105] 75.22 percent of total billed charges 58.9 90.25 Technical (Hospital) Services Potassium Serum Plasma Wb PX-3018413200 CDM 84132 CPT 301 RC inpatient 95 95 CIGNA 62308 [3081051] CIGNA STATE OF WYOMING [308105107] 75.22 percent of total billed charges 58.9 90.25 Technical (Hospital) Services Potassium Serum Plasma Wb PX-3018413200 CDM 84132 CPT 301 RC inpatient 95 95 MEDICA (COMMERCIAL) 94265 [3081118] MEDICA CLAIMS [308111801] 85.5 percent of total billed charges 58.9 90.25 Technical (Hospital) Services Potassium Serum Plasma Wb PX-3018413200 CDM 84132 CPT 301 RC inpatient 95 95 MULTIPLAN INC 34080 [3081285] MULTIPLAN INC [308128501] 90.25 percent of total billed charges 58.9 90.25 Technical (Hospital) Services Potassium Serum Plasma Wb PX-3018413200 CDM 84132 CPT 301 RC inpatient 95 95 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES HDHP [308136802] 75.22 percent of total billed charges 58.9 90.25 Technical (Hospital) Services Potassium Serum Plasma Wb PX-3018413200 CDM 84132 CPT 301 RC inpatient 95 95 BLUE CROSS BLUE SHIELD WELLMARK SB889 [3081026] BCBS WYOMING [308102603] 90.25 percent of total billed charges 58.9 90.25 Technical (Hospital) Services Potassium Serum Plasma Wb PX-3018413200 CDM 84132 CPT 301 RC inpatient 95 95 UNITED HEALTHCARE (COMMERCIAL) [3081199] UNITED HEALTHCARE 87726 [308119901] 58.9 percent of total billed charges 58.9 90.25 Technical (Hospital) Services Potassium Serum Plasma Wb PX-3018413200 CDM 84132 CPT 301 RC inpatient 95 95 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES PPO [308136801] 75.22 percent of total billed charges 58.9 90.25 Technical (Hospital) Services Potassium Serum Plasma Wb PX-3018413200 CDM 84132 CPT 301 RC outpatient 95 95 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES HDHP [308136802] 76 percent of total billed charges 58.9 90.25 Technical (Hospital) Services Potassium Serum Plasma Wb PX-3018413200 CDM 84132 CPT 301 RC outpatient 95 95 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES EPO [308136803] 76 percent of total billed charges 58.9 90.25 Technical (Hospital) Services Potassium Serum Plasma Wb PX-3018413200 CDM 84132 CPT 301 RC outpatient 95 95 BLUE CROSS BLUE SHIELD WELLMARK SB889 [3081026] BCBS WYOMING [308102603] 90.25 percent of total billed charges 58.9 90.25 Technical (Hospital) Services Potassium Serum Plasma Wb PX-3018413200 CDM 84132 CPT 301 RC outpatient 95 95 MULTIPLAN INC 34080 [3081285] MULTIPLAN INC [308128501] 90.25 percent of total billed charges 58.9 90.25 Technical (Hospital) Services Potassium Serum Plasma Wb PX-3018413200 CDM 84132 CPT 301 RC outpatient 95 95 UNITED HEALTHCARE (COMMERCIAL) [3081199] UNITED HEALTHCARE 87726 [308119901] 58.9 percent of total billed charges 58.9 90.25 Technical (Hospital) Services Potassium Serum Plasma Wb PX-3018413200 CDM 84132 CPT 301 RC outpatient 95 95 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES PPO [308136801] 76 percent of total billed charges 58.9 90.25 Technical (Hospital) Services Potassium Serum Plasma Wb PX-3018413200 CDM 84132 CPT 301 RC outpatient 95 95 HEALTHPARTNERS SX009 HEALTHPARTNERS 76 percent of total billed charges 58.9 90.25 Technical (Hospital) Services Potassium Serum Plasma Wb PX-3018413200 CDM 84132 CPT 301 RC outpatient 95 95 MEDICA (COMMERCIAL) 94265 [3081118] MEDICA CLAIMS [308111801] 85.5 percent of total billed charges 58.9 90.25 Technical (Hospital) Services Potassium Serum Plasma Wb PX-3018413200 CDM 84132 CPT 301 RC outpatient 95 95 CIGNA 62308 [3081051] CIGNA 62308 [308105105] 76 percent of total billed charges 58.9 90.25 Technical (Hospital) Services Potassium Serum Plasma Wb PX-3018413200 CDM 84132 CPT 301 RC outpatient 95 95 CIGNA 62308 [3081051] CIGNA STATE OF WYOMING [308105107] 76 percent of total billed charges 58.9 90.25 Technical (Hospital) Services Ref Porphyrins Qn U PX-3018412001 CDM 84120 CPT 301 RC inpatient 214 214 CIGNA 62308 [3081051] CIGNA 62308 [308105105] 169.45 percent of total billed charges 132.68 203.3 Technical (Hospital) Services Ref Porphyrins Qn U PX-3018412001 CDM 84120 CPT 301 RC inpatient 214 214 CIGNA 62308 [3081051] CIGNA STATE OF WYOMING [308105107] 169.45 percent of total billed charges 132.68 203.3 Technical (Hospital) Services Ref Porphyrins Qn U PX-3018412001 CDM 84120 CPT 301 RC inpatient 214 214 MULTIPLAN INC 34080 [3081285] MULTIPLAN INC [308128501] 203.3 percent of total billed charges 132.68 203.3 Technical (Hospital) Services Ref Porphyrins Qn U PX-3018412001 CDM 84120 CPT 301 RC inpatient 214 214 MEDICA (COMMERCIAL) 94265 [3081118] MEDICA CLAIMS [308111801] 192.6 percent of total billed charges 132.68 203.3 Technical (Hospital) Services Ref Porphyrins Qn U PX-3018412001 CDM 84120 CPT 301 RC inpatient 214 214 HEALTHPARTNERS SX009 HEALTHPARTNERS 169.45 percent of total billed charges 132.68 203.3 Technical (Hospital) Services Ref Porphyrins Qn U PX-3018412001 CDM 84120 CPT 301 RC inpatient 214 214 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES EPO [308136803] 169.45 percent of total billed charges 132.68 203.3 Technical (Hospital) Services Ref Porphyrins Qn U PX-3018412001 CDM 84120 CPT 301 RC inpatient 214 214 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES HDHP [308136802] 169.45 percent of total billed charges 132.68 203.3 Technical (Hospital) Services Ref Porphyrins Qn U PX-3018412001 CDM 84120 CPT 301 RC inpatient 214 214 BLUE CROSS BLUE SHIELD WELLMARK SB889 [3081026] BCBS WYOMING [308102603] 203.3 percent of total billed charges 132.68 203.3 Technical (Hospital) Services Ref Porphyrins Qn U PX-3018412001 CDM 84120 CPT 301 RC inpatient 214 214 UNITED HEALTHCARE (COMMERCIAL) [3081199] UNITED HEALTHCARE 87726 [308119901] 132.68 percent of total billed charges 132.68 203.3 Technical (Hospital) Services Ref Porphyrins Qn U PX-3018412001 CDM 84120 CPT 301 RC inpatient 214 214 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES PPO [308136801] 169.45 percent of total billed charges 132.68 203.3 Technical (Hospital) Services Ref Porphyrins Qn U PX-3018412001 CDM 84120 CPT 301 RC outpatient 214 214 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES PPO [308136801] 171.2 percent of total billed charges 132.68 203.3 Technical (Hospital) Services Ref Porphyrins Qn U PX-3018412001 CDM 84120 CPT 301 RC outpatient 214 214 MEDICA (COMMERCIAL) 94265 [3081118] MEDICA CLAIMS [308111801] 192.6 percent of total billed charges 132.68 203.3 Technical (Hospital) Services Ref Porphyrins Qn U PX-3018412001 CDM 84120 CPT 301 RC outpatient 214 214 CIGNA 62308 [3081051] CIGNA 62308 [308105105] 171.2 percent of total billed charges 132.68 203.3 Technical (Hospital) Services Ref Porphyrins Qn U PX-3018412001 CDM 84120 CPT 301 RC outpatient 214 214 CIGNA 62308 [3081051] CIGNA STATE OF WYOMING [308105107] 171.2 percent of total billed charges 132.68 203.3 Technical (Hospital) Services Ref Porphyrins Qn U PX-3018412001 CDM 84120 CPT 301 RC outpatient 214 214 MULTIPLAN INC 34080 [3081285] MULTIPLAN INC [308128501] 203.3 percent of total billed charges 132.68 203.3 Technical (Hospital) Services Ref Porphyrins Qn U PX-3018412001 CDM 84120 CPT 301 RC outpatient 214 214 BLUE CROSS BLUE SHIELD WELLMARK SB889 [3081026] BCBS WYOMING [308102603] 203.3 percent of total billed charges 132.68 203.3 Technical (Hospital) Services Ref Porphyrins Qn U PX-3018412001 CDM 84120 CPT 301 RC outpatient 214 214 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES HDHP [308136802] 171.2 percent of total billed charges 132.68 203.3 Technical (Hospital) Services Ref Porphyrins Qn U PX-3018412001 CDM 84120 CPT 301 RC outpatient 214 214 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES EPO [308136803] 171.2 percent of total billed charges 132.68 203.3 Technical (Hospital) Services Ref Porphyrins Qn U PX-3018412001 CDM 84120 CPT 301 RC outpatient 214 214 HEALTHPARTNERS SX009 HEALTHPARTNERS 171.2 percent of total billed charges 132.68 203.3 Technical (Hospital) Services Ref Porphyrins Qn U PX-3018412001 CDM 84120 CPT 301 RC outpatient 214 214 UNITED HEALTHCARE (COMMERCIAL) [3081199] UNITED HEALTHCARE 87726 [308119901] 132.68 percent of total billed charges 132.68 203.3 Technical (Hospital) Services Assay of Porphoblinogen PX-3018411000 CDM 84110 CPT 301 RC outpatient 126 126 MEDICA (COMMERCIAL) 94265 [3081118] MEDICA CLAIMS [308111801] 113.4 percent of total billed charges 78.12 119.7 Technical (Hospital) Services Assay of Porphoblinogen PX-3018411000 CDM 84110 CPT 301 RC outpatient 126 126 CIGNA 62308 [3081051] CIGNA 62308 [308105105] 100.8 percent of total billed charges 78.12 119.7 Technical (Hospital) Services Assay of Porphoblinogen PX-3018411000 CDM 84110 CPT 301 RC outpatient 126 126 CIGNA 62308 [3081051] CIGNA STATE OF WYOMING [308105107] 100.8 percent of total billed charges 78.12 119.7 Technical (Hospital) Services Assay of Porphoblinogen PX-3018411000 CDM 84110 CPT 301 RC outpatient 126 126 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES EPO [308136803] 100.8 percent of total billed charges 78.12 119.7 Technical (Hospital) Services Assay of Porphoblinogen PX-3018411000 CDM 84110 CPT 301 RC outpatient 126 126 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES HDHP [308136802] 100.8 percent of total billed charges 78.12 119.7 Technical (Hospital) Services Assay of Porphoblinogen PX-3018411000 CDM 84110 CPT 301 RC outpatient 126 126 BLUE CROSS BLUE SHIELD WELLMARK SB889 [3081026] BCBS WYOMING [308102603] 119.7 percent of total billed charges 78.12 119.7 Technical (Hospital) Services Assay of Porphoblinogen PX-3018411000 CDM 84110 CPT 301 RC outpatient 126 126 MULTIPLAN INC 34080 [3081285] MULTIPLAN INC [308128501] 119.7 percent of total billed charges 78.12 119.7 Technical (Hospital) Services Assay of Porphoblinogen PX-3018411000 CDM 84110 CPT 301 RC outpatient 126 126 HEALTHPARTNERS SX009 HEALTHPARTNERS 100.8 percent of total billed charges 78.12 119.7 Technical (Hospital) Services Assay of Porphoblinogen PX-3018411000 CDM 84110 CPT 301 RC outpatient 126 126 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES PPO [308136801] 100.8 percent of total billed charges 78.12 119.7 Technical (Hospital) Services Assay of Porphoblinogen PX-3018411000 CDM 84110 CPT 301 RC outpatient 126 126 UNITED HEALTHCARE (COMMERCIAL) [3081199] UNITED HEALTHCARE 87726 [308119901] 78.12 percent of total billed charges 78.12 119.7 Technical (Hospital) Services Assay of Porphoblinogen PX-3018411000 CDM 84110 CPT 301 RC inpatient 126 126 BLUE CROSS BLUE SHIELD WELLMARK SB889 [3081026] BCBS WYOMING [308102603] 119.7 percent of total billed charges 78.12 119.7 Technical (Hospital) Services Assay of Porphoblinogen PX-3018411000 CDM 84110 CPT 301 RC inpatient 126 126 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES HDHP [308136802] 99.77 percent of total billed charges 78.12 119.7 Technical (Hospital) Services Assay of Porphoblinogen PX-3018411000 CDM 84110 CPT 301 RC inpatient 126 126 UNITED HEALTHCARE (COMMERCIAL) [3081199] UNITED HEALTHCARE 87726 [308119901] 78.12 percent of total billed charges 78.12 119.7 Technical (Hospital) Services Assay of Porphoblinogen PX-3018411000 CDM 84110 CPT 301 RC inpatient 126 126 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES PPO [308136801] 99.77 percent of total billed charges 78.12 119.7 Technical (Hospital) Services Assay of Porphoblinogen PX-3018411000 CDM 84110 CPT 301 RC inpatient 126 126 MULTIPLAN INC 34080 [3081285] MULTIPLAN INC [308128501] 119.7 percent of total billed charges 78.12 119.7 Technical (Hospital) Services Assay of Porphoblinogen PX-3018411000 CDM 84110 CPT 301 RC inpatient 126 126 MEDICA (COMMERCIAL) 94265 [3081118] MEDICA CLAIMS [308111801] 113.4 percent of total billed charges 78.12 119.7 Technical (Hospital) Services Assay of Porphoblinogen PX-3018411000 CDM 84110 CPT 301 RC inpatient 126 126 CIGNA 62308 [3081051] CIGNA 62308 [308105105] 99.77 percent of total billed charges 78.12 119.7 Technical (Hospital) Services Assay of Porphoblinogen PX-3018411000 CDM 84110 CPT 301 RC inpatient 126 126 CIGNA 62308 [3081051] CIGNA STATE OF WYOMING [308105107] 99.77 percent of total billed charges 78.12 119.7 Technical (Hospital) Services Assay of Porphoblinogen PX-3018411000 CDM 84110 CPT 301 RC inpatient 126 126 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES EPO [308136803] 99.77 percent of total billed charges 78.12 119.7 Technical (Hospital) Services Assay of Porphoblinogen PX-3018411000 CDM 84110 CPT 301 RC inpatient 126 126 HEALTHPARTNERS SX009 HEALTHPARTNERS 99.77 percent of total billed charges 78.12 119.7 Technical (Hospital) Services Phos Urine PX-3018410500 CDM 84105 CPT 301 RC inpatient 69 69 UNITED HEALTHCARE (COMMERCIAL) [3081199] UNITED HEALTHCARE 87726 [308119901] 42.78 percent of total billed charges 42.78 65.55 Technical (Hospital) Services Phos Urine PX-3018410500 CDM 84105 CPT 301 RC inpatient 69 69 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES PPO [308136801] 54.63 percent of total billed charges 42.78 65.55 Technical (Hospital) Services Phos Urine PX-3018410500 CDM 84105 CPT 301 RC inpatient 69 69 BLUE CROSS BLUE SHIELD WELLMARK SB889 [3081026] BCBS WYOMING [308102603] 65.55 percent of total billed charges 42.78 65.55 Technical (Hospital) Services Phos Urine PX-3018410500 CDM 84105 CPT 301 RC inpatient 69 69 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES HDHP [308136802] 54.63 percent of total billed charges 42.78 65.55 Technical (Hospital) Services Phos Urine PX-3018410500 CDM 84105 CPT 301 RC inpatient 69 69 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES EPO [308136803] 54.63 percent of total billed charges 42.78 65.55 Technical (Hospital) Services Phos Urine PX-3018410500 CDM 84105 CPT 301 RC inpatient 69 69 HEALTHPARTNERS SX009 HEALTHPARTNERS 54.63 percent of total billed charges 42.78 65.55 Technical (Hospital) Services Phos Urine PX-3018410500 CDM 84105 CPT 301 RC inpatient 69 69 CIGNA 62308 [3081051] CIGNA 62308 [308105105] 54.63 percent of total billed charges 42.78 65.55 Technical (Hospital) Services Phos Urine PX-3018410500 CDM 84105 CPT 301 RC inpatient 69 69 CIGNA 62308 [3081051] CIGNA STATE OF WYOMING [308105107] 54.63 percent of total billed charges 42.78 65.55 Technical (Hospital) Services Phos Urine PX-3018410500 CDM 84105 CPT 301 RC inpatient 69 69 MULTIPLAN INC 34080 [3081285] MULTIPLAN INC [308128501] 65.55 percent of total billed charges 42.78 65.55 Technical (Hospital) Services Phos Urine PX-3018410500 CDM 84105 CPT 301 RC inpatient 69 69 MEDICA (COMMERCIAL) 94265 [3081118] MEDICA CLAIMS [308111801] 62.1 percent of total billed charges 42.78 65.55 Technical (Hospital) Services Phos Urine PX-3018410500 CDM 84105 CPT 301 RC outpatient 69 69 MEDICA (COMMERCIAL) 94265 [3081118] MEDICA CLAIMS [308111801] 62.1 percent of total billed charges 42.78 65.55 Technical (Hospital) Services Phos Urine PX-3018410500 CDM 84105 CPT 301 RC outpatient 69 69 CIGNA 62308 [3081051] CIGNA 62308 [308105105] 55.2 percent of total billed charges 42.78 65.55 Technical (Hospital) Services Phos Urine PX-3018410500 CDM 84105 CPT 301 RC outpatient 69 69 CIGNA 62308 [3081051] CIGNA STATE OF WYOMING [308105107] 55.2 percent of total billed charges 42.78 65.55 Technical (Hospital) Services Phos Urine PX-3018410500 CDM 84105 CPT 301 RC outpatient 69 69 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES PPO [308136801] 55.2 percent of total billed charges 42.78 65.55 Technical (Hospital) Services Phos Urine PX-3018410500 CDM 84105 CPT 301 RC outpatient 69 69 HEALTHPARTNERS SX009 HEALTHPARTNERS 55.2 percent of total billed charges 42.78 65.55 Technical (Hospital) Services Phos Urine PX-3018410500 CDM 84105 CPT 301 RC outpatient 69 69 UNITED HEALTHCARE (COMMERCIAL) [3081199] UNITED HEALTHCARE 87726 [308119901] 42.78 percent of total billed charges 42.78 65.55 Technical (Hospital) Services Phos Urine PX-3018410500 CDM 84105 CPT 301 RC outpatient 69 69 BLUE CROSS BLUE SHIELD WELLMARK SB889 [3081026] BCBS WYOMING [308102603] 65.55 percent of total billed charges 42.78 65.55 Technical (Hospital) Services Phos Urine PX-3018410500 CDM 84105 CPT 301 RC outpatient 69 69 MULTIPLAN INC 34080 [3081285] MULTIPLAN INC [308128501] 65.55 percent of total billed charges 42.78 65.55 Technical (Hospital) Services Phos Urine PX-3018410500 CDM 84105 CPT 301 RC outpatient 69 69 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES HDHP [308136802] 55.2 percent of total billed charges 42.78 65.55 Technical (Hospital) Services Phos Urine PX-3018410500 CDM 84105 CPT 301 RC outpatient 69 69 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES EPO [308136803] 55.2 percent of total billed charges 42.78 65.55 Technical (Hospital) Services Phosphorus PX-3018410000 CDM 84100 CPT 301 RC outpatient 62 62 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES EPO [308136803] 49.6 percent of total billed charges 38.44 58.9 Technical (Hospital) Services Phosphorus PX-3018410000 CDM 84100 CPT 301 RC outpatient 62 62 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES HDHP [308136802] 49.6 percent of total billed charges 38.44 58.9 Technical (Hospital) Services Phosphorus PX-3018410000 CDM 84100 CPT 301 RC outpatient 62 62 BLUE CROSS BLUE SHIELD WELLMARK SB889 [3081026] BCBS WYOMING [308102603] 58.9 percent of total billed charges 38.44 58.9 Technical (Hospital) Services Phosphorus PX-3018410000 CDM 84100 CPT 301 RC outpatient 62 62 MULTIPLAN INC 34080 [3081285] MULTIPLAN INC [308128501] 58.9 percent of total billed charges 38.44 58.9 Technical (Hospital) Services Phosphorus PX-3018410000 CDM 84100 CPT 301 RC outpatient 62 62 UNITED HEALTHCARE (COMMERCIAL) [3081199] UNITED HEALTHCARE 87726 [308119901] 38.44 percent of total billed charges 38.44 58.9 Technical (Hospital) Services Phosphorus PX-3018410000 CDM 84100 CPT 301 RC outpatient 62 62 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES PPO [308136801] 49.6 percent of total billed charges 38.44 58.9 Technical (Hospital) Services Phosphorus PX-3018410000 CDM 84100 CPT 301 RC outpatient 62 62 HEALTHPARTNERS SX009 HEALTHPARTNERS 49.6 percent of total billed charges 38.44 58.9 Technical (Hospital) Services Phosphorus PX-3018410000 CDM 84100 CPT 301 RC outpatient 62 62 CIGNA 62308 [3081051] CIGNA 62308 [308105105] 49.6 percent of total billed charges 38.44 58.9 Technical (Hospital) Services Phosphorus PX-3018410000 CDM 84100 CPT 301 RC outpatient 62 62 CIGNA 62308 [3081051] CIGNA STATE OF WYOMING [308105107] 49.6 percent of total billed charges 38.44 58.9 Technical (Hospital) Services Phosphorus PX-3018410000 CDM 84100 CPT 301 RC outpatient 62 62 MEDICA (COMMERCIAL) 94265 [3081118] MEDICA CLAIMS [308111801] 55.8 percent of total billed charges 38.44 58.9 Technical (Hospital) Services Phosphorus PX-3018410000 CDM 84100 CPT 301 RC inpatient 62 62 BLUE CROSS BLUE SHIELD WELLMARK SB889 [3081026] BCBS WYOMING [308102603] 58.9 percent of total billed charges 38.44 58.9 Technical (Hospital) Services Phosphorus PX-3018410000 CDM 84100 CPT 301 RC inpatient 62 62 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES HDHP [308136802] 49.09 percent of total billed charges 38.44 58.9 Technical (Hospital) Services Phosphorus PX-3018410000 CDM 84100 CPT 301 RC inpatient 62 62 UNITED HEALTHCARE (COMMERCIAL) [3081199] UNITED HEALTHCARE 87726 [308119901] 38.44 percent of total billed charges 38.44 58.9 Technical (Hospital) Services Phosphorus PX-3018410000 CDM 84100 CPT 301 RC inpatient 62 62 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES PPO [308136801] 49.09 percent of total billed charges 38.44 58.9 Technical (Hospital) Services Phosphorus PX-3018410000 CDM 84100 CPT 301 RC inpatient 62 62 CIGNA 62308 [3081051] CIGNA 62308 [308105105] 49.09 percent of total billed charges 38.44 58.9 Technical (Hospital) Services Phosphorus PX-3018410000 CDM 84100 CPT 301 RC inpatient 62 62 CIGNA 62308 [3081051] CIGNA STATE OF WYOMING [308105107] 49.09 percent of total billed charges 38.44 58.9 Technical (Hospital) Services Phosphorus PX-3018410000 CDM 84100 CPT 301 RC inpatient 62 62 MEDICA (COMMERCIAL) 94265 [3081118] MEDICA CLAIMS [308111801] 55.8 percent of total billed charges 38.44 58.9 Technical (Hospital) Services Phosphorus PX-3018410000 CDM 84100 CPT 301 RC inpatient 62 62 MULTIPLAN INC 34080 [3081285] MULTIPLAN INC [308128501] 58.9 percent of total billed charges 38.44 58.9 Technical (Hospital) Services Phosphorus PX-3018410000 CDM 84100 CPT 301 RC inpatient 62 62 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES EPO [308136803] 49.09 percent of total billed charges 38.44 58.9 Technical (Hospital) Services Phosphorus PX-3018410000 CDM 84100 CPT 301 RC inpatient 62 62 HEALTHPARTNERS SX009 HEALTHPARTNERS 49.09 percent of total billed charges 38.44 58.9 Technical (Hospital) Services Ref Alk Phosphatase Isoenzyme PX-3018408000 CDM 84080 CPT 301 RC outpatient 186 186 MULTIPLAN INC 34080 [3081285] MULTIPLAN INC [308128501] 176.7 percent of total billed charges 115.32 176.7 Technical (Hospital) Services Ref Alk Phosphatase Isoenzyme PX-3018408000 CDM 84080 CPT 301 RC outpatient 186 186 BLUE CROSS BLUE SHIELD WELLMARK SB889 [3081026] BCBS WYOMING [308102603] 176.7 percent of total billed charges 115.32 176.7 Technical (Hospital) Services Ref Alk Phosphatase Isoenzyme PX-3018408000 CDM 84080 CPT 301 RC outpatient 186 186 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES EPO [308136803] 148.8 percent of total billed charges 115.32 176.7 Technical (Hospital) Services Ref Alk Phosphatase Isoenzyme PX-3018408000 CDM 84080 CPT 301 RC outpatient 186 186 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES HDHP [308136802] 148.8 percent of total billed charges 115.32 176.7 Technical (Hospital) Services Ref Alk Phosphatase Isoenzyme PX-3018408000 CDM 84080 CPT 301 RC outpatient 186 186 UNITED HEALTHCARE (COMMERCIAL) [3081199] UNITED HEALTHCARE 87726 [308119901] 115.32 percent of total billed charges 115.32 176.7 Technical (Hospital) Services Ref Alk Phosphatase Isoenzyme PX-3018408000 CDM 84080 CPT 301 RC outpatient 186 186 HEALTHPARTNERS SX009 HEALTHPARTNERS 148.8 percent of total billed charges 115.32 176.7 Technical (Hospital) Services Ref Alk Phosphatase Isoenzyme PX-3018408000 CDM 84080 CPT 301 RC outpatient 186 186 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES PPO [308136801] 148.8 percent of total billed charges 115.32 176.7 Technical (Hospital) Services Ref Alk Phosphatase Isoenzyme PX-3018408000 CDM 84080 CPT 301 RC outpatient 186 186 MEDICA (COMMERCIAL) 94265 [3081118] MEDICA CLAIMS [308111801] 167.4 percent of total billed charges 115.32 176.7 Technical (Hospital) Services Ref Alk Phosphatase Isoenzyme PX-3018408000 CDM 84080 CPT 301 RC outpatient 186 186 CIGNA 62308 [3081051] CIGNA 62308 [308105105] 148.8 percent of total billed charges 115.32 176.7 Technical (Hospital) Services Ref Alk Phosphatase Isoenzyme PX-3018408000 CDM 84080 CPT 301 RC outpatient 186 186 CIGNA 62308 [3081051] CIGNA STATE OF WYOMING [308105107] 148.8 percent of total billed charges 115.32 176.7 Technical (Hospital) Services Ref Alk Phosphatase Isoenzyme PX-3018408000 CDM 84080 CPT 301 RC inpatient 186 186 HEALTHPARTNERS SX009 HEALTHPARTNERS 147.27 percent of total billed charges 115.32 176.7 Technical (Hospital) Services Ref Alk Phosphatase Isoenzyme PX-3018408000 CDM 84080 CPT 301 RC inpatient 186 186 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES EPO [308136803] 147.27 percent of total billed charges 115.32 176.7 Technical (Hospital) Services Ref Alk Phosphatase Isoenzyme PX-3018408000 CDM 84080 CPT 301 RC inpatient 186 186 MULTIPLAN INC 34080 [3081285] MULTIPLAN INC [308128501] 176.7 percent of total billed charges 115.32 176.7 Technical (Hospital) Services Ref Alk Phosphatase Isoenzyme PX-3018408000 CDM 84080 CPT 301 RC inpatient 186 186 MEDICA (COMMERCIAL) 94265 [3081118] MEDICA CLAIMS [308111801] 167.4 percent of total billed charges 115.32 176.7 Technical (Hospital) Services Ref Alk Phosphatase Isoenzyme PX-3018408000 CDM 84080 CPT 301 RC inpatient 186 186 CIGNA 62308 [3081051] CIGNA 62308 [308105105] 147.27 percent of total billed charges 115.32 176.7 Technical (Hospital) Services Ref Alk Phosphatase Isoenzyme PX-3018408000 CDM 84080 CPT 301 RC inpatient 186 186 CIGNA 62308 [3081051] CIGNA STATE OF WYOMING [308105107] 147.27 percent of total billed charges 115.32 176.7 Technical (Hospital) Services Ref Alk Phosphatase Isoenzyme PX-3018408000 CDM 84080 CPT 301 RC inpatient 186 186 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES PPO [308136801] 147.27 percent of total billed charges 115.32 176.7 Technical (Hospital) Services Ref Alk Phosphatase Isoenzyme PX-3018408000 CDM 84080 CPT 301 RC inpatient 186 186 UNITED HEALTHCARE (COMMERCIAL) [3081199] UNITED HEALTHCARE 87726 [308119901] 115.32 percent of total billed charges 115.32 176.7 Technical (Hospital) Services Ref Alk Phosphatase Isoenzyme PX-3018408000 CDM 84080 CPT 301 RC inpatient 186 186 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES HDHP [308136802] 147.27 percent of total billed charges 115.32 176.7 Technical (Hospital) Services Ref Alk Phosphatase Isoenzyme PX-3018408000 CDM 84080 CPT 301 RC inpatient 186 186 BLUE CROSS BLUE SHIELD WELLMARK SB889 [3081026] BCBS WYOMING [308102603] 176.7 percent of total billed charges 115.32 176.7 Technical (Hospital) Services Alk Phosphotase PX-3018407500 CDM 84075 CPT 301 RC inpatient 53 53 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES EPO [308136803] 41.97 percent of total billed charges 32.86 50.35 Technical (Hospital) Services Alk Phosphotase PX-3018407500 CDM 84075 CPT 301 RC inpatient 53 53 HEALTHPARTNERS SX009 HEALTHPARTNERS 41.97 percent of total billed charges 32.86 50.35 Technical (Hospital) Services Alk Phosphotase PX-3018407500 CDM 84075 CPT 301 RC inpatient 53 53 MULTIPLAN INC 34080 [3081285] MULTIPLAN INC [308128501] 50.35 percent of total billed charges 32.86 50.35 Technical (Hospital) Services Alk Phosphotase PX-3018407500 CDM 84075 CPT 301 RC inpatient 53 53 MEDICA (COMMERCIAL) 94265 [3081118] MEDICA CLAIMS [308111801] 47.7 percent of total billed charges 32.86 50.35 Technical (Hospital) Services Alk Phosphotase PX-3018407500 CDM 84075 CPT 301 RC inpatient 53 53 CIGNA 62308 [3081051] CIGNA 62308 [308105105] 41.97 percent of total billed charges 32.86 50.35 Technical (Hospital) Services Alk Phosphotase PX-3018407500 CDM 84075 CPT 301 RC inpatient 53 53 CIGNA 62308 [3081051] CIGNA STATE OF WYOMING [308105107] 41.97 percent of total billed charges 32.86 50.35 Technical (Hospital) Services Alk Phosphotase PX-3018407500 CDM 84075 CPT 301 RC inpatient 53 53 BLUE CROSS BLUE SHIELD WELLMARK SB889 [3081026] BCBS WYOMING [308102603] 50.35 percent of total billed charges 32.86 50.35 Technical (Hospital) Services Alk Phosphotase PX-3018407500 CDM 84075 CPT 301 RC inpatient 53 53 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES HDHP [308136802] 41.97 percent of total billed charges 32.86 50.35 Technical (Hospital) Services Alk Phosphotase PX-3018407500 CDM 84075 CPT 301 RC inpatient 53 53 UNITED HEALTHCARE (COMMERCIAL) [3081199] UNITED HEALTHCARE 87726 [308119901] 32.86 percent of total billed charges 32.86 50.35 Technical (Hospital) Services Alk Phosphotase PX-3018407500 CDM 84075 CPT 301 RC inpatient 53 53 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES PPO [308136801] 41.97 percent of total billed charges 32.86 50.35 Technical (Hospital) Services Alk Phosphotase PX-3018407500 CDM 84075 CPT 301 RC outpatient 53 53 MEDICA (COMMERCIAL) 94265 [3081118] MEDICA CLAIMS [308111801] 47.7 percent of total billed charges 32.86 50.35 Technical (Hospital) Services Alk Phosphotase PX-3018407500 CDM 84075 CPT 301 RC outpatient 53 53 CIGNA 62308 [3081051] CIGNA 62308 [308105105] 42.4 percent of total billed charges 32.86 50.35 Technical (Hospital) Services Alk Phosphotase PX-3018407500 CDM 84075 CPT 301 RC outpatient 53 53 CIGNA 62308 [3081051] CIGNA STATE OF WYOMING [308105107] 42.4 percent of total billed charges 32.86 50.35 Technical (Hospital) Services Alk Phosphotase PX-3018407500 CDM 84075 CPT 301 RC outpatient 53 53 HEALTHPARTNERS SX009 HEALTHPARTNERS 42.4 percent of total billed charges 32.86 50.35 Technical (Hospital) Services Alk Phosphotase PX-3018407500 CDM 84075 CPT 301 RC outpatient 53 53 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES PPO [308136801] 42.4 percent of total billed charges 32.86 50.35 Technical (Hospital) Services Alk Phosphotase PX-3018407500 CDM 84075 CPT 301 RC outpatient 53 53 UNITED HEALTHCARE (COMMERCIAL) [3081199] UNITED HEALTHCARE 87726 [308119901] 32.86 percent of total billed charges 32.86 50.35 Technical (Hospital) Services Alk Phosphotase PX-3018407500 CDM 84075 CPT 301 RC outpatient 53 53 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES EPO [308136803] 42.4 percent of total billed charges 32.86 50.35 Technical (Hospital) Services Alk Phosphotase PX-3018407500 CDM 84075 CPT 301 RC outpatient 53 53 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES HDHP [308136802] 42.4 percent of total billed charges 32.86 50.35 Technical (Hospital) Services Alk Phosphotase PX-3018407500 CDM 84075 CPT 301 RC outpatient 53 53 MULTIPLAN INC 34080 [3081285] MULTIPLAN INC [308128501] 50.35 percent of total billed charges 32.86 50.35 Technical (Hospital) Services Alk Phosphotase PX-3018407500 CDM 84075 CPT 301 RC outpatient 53 53 BLUE CROSS BLUE SHIELD WELLMARK SB889 [3081026] BCBS WYOMING [308102603] 50.35 percent of total billed charges 32.86 50.35 Technical (Hospital) Services Ref Alk Ptase Total PX-3018407501 CDM 84075 CPT 301 RC outpatient 62 62 MULTIPLAN INC 34080 [3081285] MULTIPLAN INC [308128501] 58.9 percent of total billed charges 38.44 58.9 Technical (Hospital) Services Ref Alk Ptase Total PX-3018407501 CDM 84075 CPT 301 RC outpatient 62 62 BLUE CROSS BLUE SHIELD WELLMARK SB889 [3081026] BCBS WYOMING [308102603] 58.9 percent of total billed charges 38.44 58.9 Technical (Hospital) Services Ref Alk Ptase Total PX-3018407501 CDM 84075 CPT 301 RC outpatient 62 62 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES HDHP [308136802] 49.6 percent of total billed charges 38.44 58.9 Technical (Hospital) Services Ref Alk Ptase Total PX-3018407501 CDM 84075 CPT 301 RC outpatient 62 62 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES EPO [308136803] 49.6 percent of total billed charges 38.44 58.9 Technical (Hospital) Services Ref Alk Ptase Total PX-3018407501 CDM 84075 CPT 301 RC outpatient 62 62 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES PPO [308136801] 49.6 percent of total billed charges 38.44 58.9 Technical (Hospital) Services Ref Alk Ptase Total PX-3018407501 CDM 84075 CPT 301 RC outpatient 62 62 HEALTHPARTNERS SX009 HEALTHPARTNERS 49.6 percent of total billed charges 38.44 58.9 Technical (Hospital) Services Ref Alk Ptase Total PX-3018407501 CDM 84075 CPT 301 RC outpatient 62 62 UNITED HEALTHCARE (COMMERCIAL) [3081199] UNITED HEALTHCARE 87726 [308119901] 38.44 percent of total billed charges 38.44 58.9 Technical (Hospital) Services Ref Alk Ptase Total PX-3018407501 CDM 84075 CPT 301 RC outpatient 62 62 MEDICA (COMMERCIAL) 94265 [3081118] MEDICA CLAIMS [308111801] 55.8 percent of total billed charges 38.44 58.9 Technical (Hospital) Services Ref Alk Ptase Total PX-3018407501 CDM 84075 CPT 301 RC outpatient 62 62 CIGNA 62308 [3081051] CIGNA 62308 [308105105] 49.6 percent of total billed charges 38.44 58.9 Technical (Hospital) Services Ref Alk Ptase Total PX-3018407501 CDM 84075 CPT 301 RC outpatient 62 62 CIGNA 62308 [3081051] CIGNA STATE OF WYOMING [308105107] 49.6 percent of total billed charges 38.44 58.9 Technical (Hospital) Services Ref Alk Ptase Total PX-3018407501 CDM 84075 CPT 301 RC inpatient 62 62 BLUE CROSS BLUE SHIELD WELLMARK SB889 [3081026] BCBS WYOMING [308102603] 58.9 percent of total billed charges 38.44 58.9 Technical (Hospital) Services Ref Alk Ptase Total PX-3018407501 CDM 84075 CPT 301 RC inpatient 62 62 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES HDHP [308136802] 49.09 percent of total billed charges 38.44 58.9 Technical (Hospital) Services Ref Alk Ptase Total PX-3018407501 CDM 84075 CPT 301 RC inpatient 62 62 UNITED HEALTHCARE (COMMERCIAL) [3081199] UNITED HEALTHCARE 87726 [308119901] 38.44 percent of total billed charges 38.44 58.9 Technical (Hospital) Services Ref Alk Ptase Total PX-3018407501 CDM 84075 CPT 301 RC inpatient 62 62 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES PPO [308136801] 49.09 percent of total billed charges 38.44 58.9 Technical (Hospital) Services Ref Alk Ptase Total PX-3018407501 CDM 84075 CPT 301 RC inpatient 62 62 CIGNA 62308 [3081051] CIGNA 62308 [308105105] 49.09 percent of total billed charges 38.44 58.9 Technical (Hospital) Services Ref Alk Ptase Total PX-3018407501 CDM 84075 CPT 301 RC inpatient 62 62 CIGNA 62308 [3081051] CIGNA STATE OF WYOMING [308105107] 49.09 percent of total billed charges 38.44 58.9 Technical (Hospital) Services Ref Alk Ptase Total PX-3018407501 CDM 84075 CPT 301 RC inpatient 62 62 MEDICA (COMMERCIAL) 94265 [3081118] MEDICA CLAIMS [308111801] 55.8 percent of total billed charges 38.44 58.9 Technical (Hospital) Services Ref Alk Ptase Total PX-3018407501 CDM 84075 CPT 301 RC inpatient 62 62 MULTIPLAN INC 34080 [3081285] MULTIPLAN INC [308128501] 58.9 percent of total billed charges 38.44 58.9 Technical (Hospital) Services Ref Alk Ptase Total PX-3018407501 CDM 84075 CPT 301 RC inpatient 62 62 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES EPO [308136803] 49.09 percent of total billed charges 38.44 58.9 Technical (Hospital) Services Ref Alk Ptase Total PX-3018407501 CDM 84075 CPT 301 RC inpatient 62 62 HEALTHPARTNERS SX009 HEALTHPARTNERS 49.09 percent of total billed charges 38.44 58.9 Technical (Hospital) Services "Ref Phenylalanine, P (Mayo)" PX-3018403000 CDM 84030 CPT 301 RC inpatient 61 61 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES EPO [308136803] 48.3 percent of total billed charges 37.82 57.95 Technical (Hospital) Services "Ref Phenylalanine, P (Mayo)" PX-3018403000 CDM 84030 CPT 301 RC inpatient 61 61 HEALTHPARTNERS SX009 HEALTHPARTNERS 48.3 percent of total billed charges 37.82 57.95 Technical (Hospital) Services "Ref Phenylalanine, P (Mayo)" PX-3018403000 CDM 84030 CPT 301 RC inpatient 61 61 MEDICA (COMMERCIAL) 94265 [3081118] MEDICA CLAIMS [308111801] 54.9 percent of total billed charges 37.82 57.95 Technical (Hospital) Services "Ref Phenylalanine, P (Mayo)" PX-3018403000 CDM 84030 CPT 301 RC inpatient 61 61 MULTIPLAN INC 34080 [3081285] MULTIPLAN INC [308128501] 57.95 percent of total billed charges 37.82 57.95 Technical (Hospital) Services "Ref Phenylalanine, P (Mayo)" PX-3018403000 CDM 84030 CPT 301 RC inpatient 61 61 CIGNA 62308 [3081051] CIGNA 62308 [308105105] 48.3 percent of total billed charges 37.82 57.95 Technical (Hospital) Services "Ref Phenylalanine, P (Mayo)" PX-3018403000 CDM 84030 CPT 301 RC inpatient 61 61 CIGNA 62308 [3081051] CIGNA STATE OF WYOMING [308105107] 48.3 percent of total billed charges 37.82 57.95 Technical (Hospital) Services "Ref Phenylalanine, P (Mayo)" PX-3018403000 CDM 84030 CPT 301 RC inpatient 61 61 BLUE CROSS BLUE SHIELD WELLMARK SB889 [3081026] BCBS WYOMING [308102603] 57.95 percent of total billed charges 37.82 57.95 Technical (Hospital) Services "Ref Phenylalanine, P (Mayo)" PX-3018403000 CDM 84030 CPT 301 RC inpatient 61 61 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES HDHP [308136802] 48.3 percent of total billed charges 37.82 57.95 Technical (Hospital) Services "Ref Phenylalanine, P (Mayo)" PX-3018403000 CDM 84030 CPT 301 RC inpatient 61 61 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES PPO [308136801] 48.3 percent of total billed charges 37.82 57.95 Technical (Hospital) Services "Ref Phenylalanine, P (Mayo)" PX-3018403000 CDM 84030 CPT 301 RC inpatient 61 61 UNITED HEALTHCARE (COMMERCIAL) [3081199] UNITED HEALTHCARE 87726 [308119901] 37.82 percent of total billed charges 37.82 57.95 Technical (Hospital) Services "Ref Phenylalanine, P (Mayo)" PX-3018403000 CDM 84030 CPT 301 RC outpatient 61 61 UNITED HEALTHCARE (COMMERCIAL) [3081199] UNITED HEALTHCARE 87726 [308119901] 37.82 percent of total billed charges 37.82 57.95 Technical (Hospital) Services "Ref Phenylalanine, P (Mayo)" PX-3018403000 CDM 84030 CPT 301 RC outpatient 61 61 HEALTHPARTNERS SX009 HEALTHPARTNERS 48.8 percent of total billed charges 37.82 57.95 Technical (Hospital) Services "Ref Phenylalanine, P (Mayo)" PX-3018403000 CDM 84030 CPT 301 RC outpatient 61 61 BLUE CROSS BLUE SHIELD WELLMARK SB889 [3081026] BCBS WYOMING [308102603] 57.95 percent of total billed charges 37.82 57.95 Technical (Hospital) Services "Ref Phenylalanine, P (Mayo)" PX-3018403000 CDM 84030 CPT 301 RC outpatient 61 61 MULTIPLAN INC 34080 [3081285] MULTIPLAN INC [308128501] 57.95 percent of total billed charges 37.82 57.95 Technical (Hospital) Services "Ref Phenylalanine, P (Mayo)" PX-3018403000 CDM 84030 CPT 301 RC outpatient 61 61 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES EPO [308136803] 48.8 percent of total billed charges 37.82 57.95 Technical (Hospital) Services "Ref Phenylalanine, P (Mayo)" PX-3018403000 CDM 84030 CPT 301 RC outpatient 61 61 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES HDHP [308136802] 48.8 percent of total billed charges 37.82 57.95 Technical (Hospital) Services "Ref Phenylalanine, P (Mayo)" PX-3018403000 CDM 84030 CPT 301 RC outpatient 61 61 MEDICA (COMMERCIAL) 94265 [3081118] MEDICA CLAIMS [308111801] 54.9 percent of total billed charges 37.82 57.95 Technical (Hospital) Services "Ref Phenylalanine, P (Mayo)" PX-3018403000 CDM 84030 CPT 301 RC outpatient 61 61 CIGNA 62308 [3081051] CIGNA 62308 [308105105] 48.8 percent of total billed charges 37.82 57.95 Technical (Hospital) Services "Ref Phenylalanine, P (Mayo)" PX-3018403000 CDM 84030 CPT 301 RC outpatient 61 61 CIGNA 62308 [3081051] CIGNA STATE OF WYOMING [308105107] 48.8 percent of total billed charges 37.82 57.95 Technical (Hospital) Services "Ref Phenylalanine, P (Mayo)" PX-3018403000 CDM 84030 CPT 301 RC outpatient 61 61 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES PPO [308136801] 48.8 percent of total billed charges 37.82 57.95 Technical (Hospital) Services Assay for Calprotectin Fecal PX-3018399300 CDM 83993 CPT 301 RC inpatient 377 377 BLUE CROSS BLUE SHIELD WELLMARK SB889 [3081026] BCBS WYOMING [308102603] 358.15 percent of total billed charges 233.74 358.15 Technical (Hospital) Services Assay for Calprotectin Fecal PX-3018399300 CDM 83993 CPT 301 RC inpatient 377 377 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES HDHP [308136802] 298.51 percent of total billed charges 233.74 358.15 Technical (Hospital) Services Assay for Calprotectin Fecal PX-3018399300 CDM 83993 CPT 301 RC inpatient 377 377 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES PPO [308136801] 298.51 percent of total billed charges 233.74 358.15 Technical (Hospital) Services Assay for Calprotectin Fecal PX-3018399300 CDM 83993 CPT 301 RC inpatient 377 377 UNITED HEALTHCARE (COMMERCIAL) [3081199] UNITED HEALTHCARE 87726 [308119901] 233.74 percent of total billed charges 233.74 358.15 Technical (Hospital) Services Assay for Calprotectin Fecal PX-3018399300 CDM 83993 CPT 301 RC inpatient 377 377 MEDICA (COMMERCIAL) 94265 [3081118] MEDICA CLAIMS [308111801] 339.3 percent of total billed charges 233.74 358.15 Technical (Hospital) Services Assay for Calprotectin Fecal PX-3018399300 CDM 83993 CPT 301 RC inpatient 377 377 MULTIPLAN INC 34080 [3081285] MULTIPLAN INC [308128501] 358.15 percent of total billed charges 233.74 358.15 Technical (Hospital) Services Assay for Calprotectin Fecal PX-3018399300 CDM 83993 CPT 301 RC inpatient 377 377 CIGNA 62308 [3081051] CIGNA 62308 [308105105] 298.51 percent of total billed charges 233.74 358.15 Technical (Hospital) Services Assay for Calprotectin Fecal PX-3018399300 CDM 83993 CPT 301 RC inpatient 377 377 CIGNA 62308 [3081051] CIGNA STATE OF WYOMING [308105107] 298.51 percent of total billed charges 233.74 358.15 Technical (Hospital) Services Assay for Calprotectin Fecal PX-3018399300 CDM 83993 CPT 301 RC inpatient 377 377 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES EPO [308136803] 298.51 percent of total billed charges 233.74 358.15 Technical (Hospital) Services Assay for Calprotectin Fecal PX-3018399300 CDM 83993 CPT 301 RC inpatient 377 377 HEALTHPARTNERS SX009 HEALTHPARTNERS 298.51 percent of total billed charges 233.74 358.15 Technical (Hospital) Services Assay for Calprotectin Fecal PX-3018399300 CDM 83993 CPT 301 RC outpatient 377 377 MEDICA (COMMERCIAL) 94265 [3081118] MEDICA CLAIMS [308111801] 339.3 percent of total billed charges 233.74 358.15 Technical (Hospital) Services Assay for Calprotectin Fecal PX-3018399300 CDM 83993 CPT 301 RC outpatient 377 377 CIGNA 62308 [3081051] CIGNA 62308 [308105105] 301.6 percent of total billed charges 233.74 358.15 Technical (Hospital) Services Assay for Calprotectin Fecal PX-3018399300 CDM 83993 CPT 301 RC outpatient 377 377 CIGNA 62308 [3081051] CIGNA STATE OF WYOMING [308105107] 301.6 percent of total billed charges 233.74 358.15 Technical (Hospital) Services Assay for Calprotectin Fecal PX-3018399300 CDM 83993 CPT 301 RC outpatient 377 377 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES EPO [308136803] 301.6 percent of total billed charges 233.74 358.15 Technical (Hospital) Services Assay for Calprotectin Fecal PX-3018399300 CDM 83993 CPT 301 RC outpatient 377 377 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES HDHP [308136802] 301.6 percent of total billed charges 233.74 358.15 Technical (Hospital) Services Assay for Calprotectin Fecal PX-3018399300 CDM 83993 CPT 301 RC outpatient 377 377 MULTIPLAN INC 34080 [3081285] MULTIPLAN INC [308128501] 358.15 percent of total billed charges 233.74 358.15 Technical (Hospital) Services Assay for Calprotectin Fecal PX-3018399300 CDM 83993 CPT 301 RC outpatient 377 377 BLUE CROSS BLUE SHIELD WELLMARK SB889 [3081026] BCBS WYOMING [308102603] 358.15 percent of total billed charges 233.74 358.15 Technical (Hospital) Services Assay for Calprotectin Fecal PX-3018399300 CDM 83993 CPT 301 RC outpatient 377 377 UNITED HEALTHCARE (COMMERCIAL) [3081199] UNITED HEALTHCARE 87726 [308119901] 233.74 percent of total billed charges 233.74 358.15 Technical (Hospital) Services Assay for Calprotectin Fecal PX-3018399300 CDM 83993 CPT 301 RC outpatient 377 377 HEALTHPARTNERS SX009 HEALTHPARTNERS 301.6 percent of total billed charges 233.74 358.15 Technical (Hospital) Services Assay for Calprotectin Fecal PX-3018399300 CDM 83993 CPT 301 RC outpatient 377 377 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES PPO [308136801] 301.6 percent of total billed charges 233.74 358.15 Technical (Hospital) Services "Ref Calprotectin, F" PX-3018399301 CDM 83993 CPT 301 RC inpatient 298 298 HEALTHPARTNERS SX009 HEALTHPARTNERS 235.96 percent of total billed charges 184.76 283.1 Technical (Hospital) Services "Ref Calprotectin, F" PX-3018399301 CDM 83993 CPT 301 RC inpatient 298 298 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES EPO [308136803] 235.96 percent of total billed charges 184.76 283.1 Technical (Hospital) Services "Ref Calprotectin, F" PX-3018399301 CDM 83993 CPT 301 RC inpatient 298 298 MEDICA (COMMERCIAL) 94265 [3081118] MEDICA CLAIMS [308111801] 268.2 percent of total billed charges 184.76 283.1 Technical (Hospital) Services "Ref Calprotectin, F" PX-3018399301 CDM 83993 CPT 301 RC inpatient 298 298 MULTIPLAN INC 34080 [3081285] MULTIPLAN INC [308128501] 283.1 percent of total billed charges 184.76 283.1 Technical (Hospital) Services "Ref Calprotectin, F" PX-3018399301 CDM 83993 CPT 301 RC inpatient 298 298 CIGNA 62308 [3081051] CIGNA 62308 [308105105] 235.96 percent of total billed charges 184.76 283.1 Technical (Hospital) Services "Ref Calprotectin, F" PX-3018399301 CDM 83993 CPT 301 RC inpatient 298 298 CIGNA 62308 [3081051] CIGNA STATE OF WYOMING [308105107] 235.96 percent of total billed charges 184.76 283.1 Technical (Hospital) Services "Ref Calprotectin, F" PX-3018399301 CDM 83993 CPT 301 RC inpatient 298 298 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES HDHP [308136802] 235.96 percent of total billed charges 184.76 283.1 Technical (Hospital) Services "Ref Calprotectin, F" PX-3018399301 CDM 83993 CPT 301 RC inpatient 298 298 BLUE CROSS BLUE SHIELD WELLMARK SB889 [3081026] BCBS WYOMING [308102603] 283.1 percent of total billed charges 184.76 283.1 Technical (Hospital) Services "Ref Calprotectin, F" PX-3018399301 CDM 83993 CPT 301 RC inpatient 298 298 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES PPO [308136801] 235.96 percent of total billed charges 184.76 283.1 Technical (Hospital) Services "Ref Calprotectin, F" PX-3018399301 CDM 83993 CPT 301 RC inpatient 298 298 UNITED HEALTHCARE (COMMERCIAL) [3081199] UNITED HEALTHCARE 87726 [308119901] 184.76 percent of total billed charges 184.76 283.1 Technical (Hospital) Services "Ref Calprotectin, F" PX-3018399301 CDM 83993 CPT 301 RC outpatient 298 298 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES EPO [308136803] 238.4 percent of total billed charges 184.76 283.1 Technical (Hospital) Services "Ref Calprotectin, F" PX-3018399301 CDM 83993 CPT 301 RC outpatient 298 298 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES HDHP [308136802] 238.4 percent of total billed charges 184.76 283.1 Technical (Hospital) Services "Ref Calprotectin, F" PX-3018399301 CDM 83993 CPT 301 RC outpatient 298 298 BLUE CROSS BLUE SHIELD WELLMARK SB889 [3081026] BCBS WYOMING [308102603] 283.1 percent of total billed charges 184.76 283.1 Technical (Hospital) Services "Ref Calprotectin, F" PX-3018399301 CDM 83993 CPT 301 RC outpatient 298 298 MULTIPLAN INC 34080 [3081285] MULTIPLAN INC [308128501] 283.1 percent of total billed charges 184.76 283.1 Technical (Hospital) Services "Ref Calprotectin, F" PX-3018399301 CDM 83993 CPT 301 RC outpatient 298 298 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES PPO [308136801] 238.4 percent of total billed charges 184.76 283.1 Technical (Hospital) Services "Ref Calprotectin, F" PX-3018399301 CDM 83993 CPT 301 RC outpatient 298 298 HEALTHPARTNERS SX009 HEALTHPARTNERS 238.4 percent of total billed charges 184.76 283.1 Technical (Hospital) Services "Ref Calprotectin, F" PX-3018399301 CDM 83993 CPT 301 RC outpatient 298 298 UNITED HEALTHCARE (COMMERCIAL) [3081199] UNITED HEALTHCARE 87726 [308119901] 184.76 percent of total billed charges 184.76 283.1 Technical (Hospital) Services "Ref Calprotectin, F" PX-3018399301 CDM 83993 CPT 301 RC outpatient 298 298 MEDICA (COMMERCIAL) 94265 [3081118] MEDICA CLAIMS [308111801] 268.2 percent of total billed charges 184.76 283.1 Technical (Hospital) Services "Ref Calprotectin, F" PX-3018399301 CDM 83993 CPT 301 RC outpatient 298 298 CIGNA 62308 [3081051] CIGNA 62308 [308105105] 238.4 percent of total billed charges 184.76 283.1 Technical (Hospital) Services "Ref Calprotectin, F" PX-3018399301 CDM 83993 CPT 301 RC outpatient 298 298 CIGNA 62308 [3081051] CIGNA STATE OF WYOMING [308105107] 238.4 percent of total billed charges 184.76 283.1 Technical (Hospital) Services HC Calprotectin Fecal Stool PX-3018399302 CDM 83993 CPT 301 RC inpatient 252 252 BLUE CROSS BLUE SHIELD WELLMARK SB889 [3081026] BCBS WYOMING [308102603] 239.4 percent of total billed charges 156.24 239.4 Technical (Hospital) Services HC Calprotectin Fecal Stool PX-3018399302 CDM 83993 CPT 301 RC inpatient 252 252 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES HDHP [308136802] 199.53 percent of total billed charges 156.24 239.4 Technical (Hospital) Services HC Calprotectin Fecal Stool PX-3018399302 CDM 83993 CPT 301 RC inpatient 252 252 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES PPO [308136801] 199.53 percent of total billed charges 156.24 239.4 Technical (Hospital) Services HC Calprotectin Fecal Stool PX-3018399302 CDM 83993 CPT 301 RC inpatient 252 252 UNITED HEALTHCARE (COMMERCIAL) [3081199] UNITED HEALTHCARE 87726 [308119901] 156.24 percent of total billed charges 156.24 239.4 Technical (Hospital) Services HC Calprotectin Fecal Stool PX-3018399302 CDM 83993 CPT 301 RC inpatient 252 252 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES EPO [308136803] 199.53 percent of total billed charges 156.24 239.4 Technical (Hospital) Services HC Calprotectin Fecal Stool PX-3018399302 CDM 83993 CPT 301 RC inpatient 252 252 HEALTHPARTNERS SX009 HEALTHPARTNERS 199.53 percent of total billed charges 156.24 239.4 Technical (Hospital) Services HC Calprotectin Fecal Stool PX-3018399302 CDM 83993 CPT 301 RC inpatient 252 252 CIGNA 62308 [3081051] CIGNA 62308 [308105105] 199.53 percent of total billed charges 156.24 239.4 Technical (Hospital) Services HC Calprotectin Fecal Stool PX-3018399302 CDM 83993 CPT 301 RC inpatient 252 252 CIGNA 62308 [3081051] CIGNA STATE OF WYOMING [308105107] 199.53 percent of total billed charges 156.24 239.4 Technical (Hospital) Services HC Calprotectin Fecal Stool PX-3018399302 CDM 83993 CPT 301 RC inpatient 252 252 MULTIPLAN INC 34080 [3081285] MULTIPLAN INC [308128501] 239.4 percent of total billed charges 156.24 239.4 Technical (Hospital) Services HC Calprotectin Fecal Stool PX-3018399302 CDM 83993 CPT 301 RC inpatient 252 252 MEDICA (COMMERCIAL) 94265 [3081118] MEDICA CLAIMS [308111801] 226.8 percent of total billed charges 156.24 239.4 Technical (Hospital) Services HC Calprotectin Fecal Stool PX-3018399302 CDM 83993 CPT 301 RC outpatient 252 252 BLUE CROSS BLUE SHIELD WELLMARK SB889 [3081026] BCBS WYOMING [308102603] 239.4 percent of total billed charges 156.24 239.4 Technical (Hospital) Services HC Calprotectin Fecal Stool PX-3018399302 CDM 83993 CPT 301 RC outpatient 252 252 MULTIPLAN INC 34080 [3081285] MULTIPLAN INC [308128501] 239.4 percent of total billed charges 156.24 239.4 Technical (Hospital) Services HC Calprotectin Fecal Stool PX-3018399302 CDM 83993 CPT 301 RC outpatient 252 252 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES HDHP [308136802] 201.6 percent of total billed charges 156.24 239.4 Technical (Hospital) Services HC Calprotectin Fecal Stool PX-3018399302 CDM 83993 CPT 301 RC outpatient 252 252 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES EPO [308136803] 201.6 percent of total billed charges 156.24 239.4 Technical (Hospital) Services HC Calprotectin Fecal Stool PX-3018399302 CDM 83993 CPT 301 RC outpatient 252 252 HEALTHPARTNERS SX009 HEALTHPARTNERS 201.6 percent of total billed charges 156.24 239.4 Technical (Hospital) Services HC Calprotectin Fecal Stool PX-3018399302 CDM 83993 CPT 301 RC outpatient 252 252 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES PPO [308136801] 201.6 percent of total billed charges 156.24 239.4 Technical (Hospital) Services HC Calprotectin Fecal Stool PX-3018399302 CDM 83993 CPT 301 RC outpatient 252 252 UNITED HEALTHCARE (COMMERCIAL) [3081199] UNITED HEALTHCARE 87726 [308119901] 156.24 percent of total billed charges 156.24 239.4 Technical (Hospital) Services HC Calprotectin Fecal Stool PX-3018399302 CDM 83993 CPT 301 RC outpatient 252 252 CIGNA 62308 [3081051] CIGNA 62308 [308105105] 201.6 percent of total billed charges 156.24 239.4 Technical (Hospital) Services HC Calprotectin Fecal Stool PX-3018399302 CDM 83993 CPT 301 RC outpatient 252 252 CIGNA 62308 [3081051] CIGNA STATE OF WYOMING [308105107] 201.6 percent of total billed charges 156.24 239.4 Technical (Hospital) Services HC Calprotectin Fecal Stool PX-3018399302 CDM 83993 CPT 301 RC outpatient 252 252 MEDICA (COMMERCIAL) 94265 [3081118] MEDICA CLAIMS [308111801] 226.8 percent of total billed charges 156.24 239.4 Technical (Hospital) Services Ph-Body Fluid (P-Metric) PX-3018398600 CDM 83986 CPT 301 RC inpatient 77 77 UNITED HEALTHCARE (COMMERCIAL) [3081199] UNITED HEALTHCARE 87726 [308119901] 47.74 percent of total billed charges 47.74 73.15 Technical (Hospital) Services Ph-Body Fluid (P-Metric) PX-3018398600 CDM 83986 CPT 301 RC inpatient 77 77 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES PPO [308136801] 60.97 percent of total billed charges 47.74 73.15 Technical (Hospital) Services Ph-Body Fluid (P-Metric) PX-3018398600 CDM 83986 CPT 301 RC inpatient 77 77 BLUE CROSS BLUE SHIELD WELLMARK SB889 [3081026] BCBS WYOMING [308102603] 73.15 percent of total billed charges 47.74 73.15 Technical (Hospital) Services Ph-Body Fluid (P-Metric) PX-3018398600 CDM 83986 CPT 301 RC inpatient 77 77 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES HDHP [308136802] 60.97 percent of total billed charges 47.74 73.15 Technical (Hospital) Services Ph-Body Fluid (P-Metric) PX-3018398600 CDM 83986 CPT 301 RC inpatient 77 77 MEDICA (COMMERCIAL) 94265 [3081118] MEDICA CLAIMS [308111801] 69.3 percent of total billed charges 47.74 73.15 Technical (Hospital) Services Ph-Body Fluid (P-Metric) PX-3018398600 CDM 83986 CPT 301 RC inpatient 77 77 MULTIPLAN INC 34080 [3081285] MULTIPLAN INC [308128501] 73.15 percent of total billed charges 47.74 73.15 Technical (Hospital) Services Ph-Body Fluid (P-Metric) PX-3018398600 CDM 83986 CPT 301 RC inpatient 77 77 CIGNA 62308 [3081051] CIGNA 62308 [308105105] 60.97 percent of total billed charges 47.74 73.15 Technical (Hospital) Services Ph-Body Fluid (P-Metric) PX-3018398600 CDM 83986 CPT 301 RC inpatient 77 77 CIGNA 62308 [3081051] CIGNA STATE OF WYOMING [308105107] 60.97 percent of total billed charges 47.74 73.15 Technical (Hospital) Services Ph-Body Fluid (P-Metric) PX-3018398600 CDM 83986 CPT 301 RC inpatient 77 77 HEALTHPARTNERS SX009 HEALTHPARTNERS 60.97 percent of total billed charges 47.74 73.15 Technical (Hospital) Services Ph-Body Fluid (P-Metric) PX-3018398600 CDM 83986 CPT 301 RC inpatient 77 77 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES EPO [308136803] 60.97 percent of total billed charges 47.74 73.15 Technical (Hospital) Services Ph-Body Fluid (P-Metric) PX-3018398600 CDM 83986 CPT 301 RC outpatient 77 77 UNITED HEALTHCARE (COMMERCIAL) [3081199] UNITED HEALTHCARE 87726 [308119901] 47.74 percent of total billed charges 47.74 73.15 Technical (Hospital) Services Ph-Body Fluid (P-Metric) PX-3018398600 CDM 83986 CPT 301 RC outpatient 77 77 HEALTHPARTNERS SX009 HEALTHPARTNERS 61.6 percent of total billed charges 47.74 73.15 Technical (Hospital) Services Ph-Body Fluid (P-Metric) PX-3018398600 CDM 83986 CPT 301 RC outpatient 77 77 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES HDHP [308136802] 61.6 percent of total billed charges 47.74 73.15 Technical (Hospital) Services Ph-Body Fluid (P-Metric) PX-3018398600 CDM 83986 CPT 301 RC outpatient 77 77 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES EPO [308136803] 61.6 percent of total billed charges 47.74 73.15 Technical (Hospital) Services Ph-Body Fluid (P-Metric) PX-3018398600 CDM 83986 CPT 301 RC outpatient 77 77 MULTIPLAN INC 34080 [3081285] MULTIPLAN INC [308128501] 73.15 percent of total billed charges 47.74 73.15 Technical (Hospital) Services Ph-Body Fluid (P-Metric) PX-3018398600 CDM 83986 CPT 301 RC outpatient 77 77 BLUE CROSS BLUE SHIELD WELLMARK SB889 [3081026] BCBS WYOMING [308102603] 73.15 percent of total billed charges 47.74 73.15 Technical (Hospital) Services Ph-Body Fluid (P-Metric) PX-3018398600 CDM 83986 CPT 301 RC outpatient 77 77 MEDICA (COMMERCIAL) 94265 [3081118] MEDICA CLAIMS [308111801] 69.3 percent of total billed charges 47.74 73.15 Technical (Hospital) Services Ph-Body Fluid (P-Metric) PX-3018398600 CDM 83986 CPT 301 RC outpatient 77 77 CIGNA 62308 [3081051] CIGNA 62308 [308105105] 61.6 percent of total billed charges 47.74 73.15 Technical (Hospital) Services Ph-Body Fluid (P-Metric) PX-3018398600 CDM 83986 CPT 301 RC outpatient 77 77 CIGNA 62308 [3081051] CIGNA STATE OF WYOMING [308105107] 61.6 percent of total billed charges 47.74 73.15 Technical (Hospital) Services Ph-Body Fluid (P-Metric) PX-3018398600 CDM 83986 CPT 301 RC outpatient 77 77 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES PPO [308136801] 61.6 percent of total billed charges 47.74 73.15 Technical (Hospital) Services "Assay, Parathormone" PX-3018397000 CDM 83970 CPT 301 RC inpatient 238 238 CIGNA 62308 [3081051] CIGNA 62308 [308105105] 188.45 percent of total billed charges 147.56 226.1 Technical (Hospital) Services "Assay, Parathormone" PX-3018397000 CDM 83970 CPT 301 RC inpatient 238 238 CIGNA 62308 [3081051] CIGNA STATE OF WYOMING [308105107] 188.45 percent of total billed charges 147.56 226.1 Technical (Hospital) Services "Assay, Parathormone" PX-3018397000 CDM 83970 CPT 301 RC inpatient 238 238 MULTIPLAN INC 34080 [3081285] MULTIPLAN INC [308128501] 226.1 percent of total billed charges 147.56 226.1 Technical (Hospital) Services "Assay, Parathormone" PX-3018397000 CDM 83970 CPT 301 RC inpatient 238 238 MEDICA (COMMERCIAL) 94265 [3081118] MEDICA CLAIMS [308111801] 214.2 percent of total billed charges 147.56 226.1 Technical (Hospital) Services "Assay, Parathormone" PX-3018397000 CDM 83970 CPT 301 RC inpatient 238 238 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES EPO [308136803] 188.45 percent of total billed charges 147.56 226.1 Technical (Hospital) Services "Assay, Parathormone" PX-3018397000 CDM 83970 CPT 301 RC inpatient 238 238 HEALTHPARTNERS SX009 HEALTHPARTNERS 188.45 percent of total billed charges 147.56 226.1 Technical (Hospital) Services "Assay, Parathormone" PX-3018397000 CDM 83970 CPT 301 RC inpatient 238 238 BLUE CROSS BLUE SHIELD WELLMARK SB889 [3081026] BCBS WYOMING [308102603] 226.1 percent of total billed charges 147.56 226.1 Technical (Hospital) Services "Assay, Parathormone" PX-3018397000 CDM 83970 CPT 301 RC inpatient 238 238 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES HDHP [308136802] 188.45 percent of total billed charges 147.56 226.1 Technical (Hospital) Services "Assay, Parathormone" PX-3018397000 CDM 83970 CPT 301 RC inpatient 238 238 UNITED HEALTHCARE (COMMERCIAL) [3081199] UNITED HEALTHCARE 87726 [308119901] 147.56 percent of total billed charges 147.56 226.1 Technical (Hospital) Services "Assay, Parathormone" PX-3018397000 CDM 83970 CPT 301 RC inpatient 238 238 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES PPO [308136801] 188.45 percent of total billed charges 147.56 226.1 Technical (Hospital) Services "Assay, Parathormone" PX-3018397000 CDM 83970 CPT 301 RC outpatient 238 238 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES PPO [308136801] 190.4 percent of total billed charges 147.56 226.1 Technical (Hospital) Services "Assay, Parathormone" PX-3018397000 CDM 83970 CPT 301 RC outpatient 238 238 MEDICA (COMMERCIAL) 94265 [3081118] MEDICA CLAIMS [308111801] 214.2 percent of total billed charges 147.56 226.1 Technical (Hospital) Services "Assay, Parathormone" PX-3018397000 CDM 83970 CPT 301 RC outpatient 238 238 CIGNA 62308 [3081051] CIGNA 62308 [308105105] 190.4 percent of total billed charges 147.56 226.1 Technical (Hospital) Services "Assay, Parathormone" PX-3018397000 CDM 83970 CPT 301 RC outpatient 238 238 CIGNA 62308 [3081051] CIGNA STATE OF WYOMING [308105107] 190.4 percent of total billed charges 147.56 226.1 Technical (Hospital) Services "Assay, Parathormone" PX-3018397000 CDM 83970 CPT 301 RC outpatient 238 238 UNITED HEALTHCARE (COMMERCIAL) [3081199] UNITED HEALTHCARE 87726 [308119901] 147.56 percent of total billed charges 147.56 226.1 Technical (Hospital) Services "Assay, Parathormone" PX-3018397000 CDM 83970 CPT 301 RC outpatient 238 238 HEALTHPARTNERS SX009 HEALTHPARTNERS 190.4 percent of total billed charges 147.56 226.1 Technical (Hospital) Services "Assay, Parathormone" PX-3018397000 CDM 83970 CPT 301 RC outpatient 238 238 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES EPO [308136803] 190.4 percent of total billed charges 147.56 226.1 Technical (Hospital) Services "Assay, Parathormone" PX-3018397000 CDM 83970 CPT 301 RC outpatient 238 238 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES HDHP [308136802] 190.4 percent of total billed charges 147.56 226.1 Technical (Hospital) Services "Assay, Parathormone" PX-3018397000 CDM 83970 CPT 301 RC outpatient 238 238 BLUE CROSS BLUE SHIELD WELLMARK SB889 [3081026] BCBS WYOMING [308102603] 226.1 percent of total billed charges 147.56 226.1 Technical (Hospital) Services "Assay, Parathormone" PX-3018397000 CDM 83970 CPT 301 RC outpatient 238 238 MULTIPLAN INC 34080 [3081285] MULTIPLAN INC [308128501] 226.1 percent of total billed charges 147.56 226.1 Technical (Hospital) Services Ref Oxalate Urine (Sat 24) PX-3018394500 CDM 83945 CPT 301 RC inpatient 144 144 HEALTHPARTNERS SX009 HEALTHPARTNERS 114.02 percent of total billed charges 89.28 136.8 Technical (Hospital) Services Ref Oxalate Urine (Sat 24) PX-3018394500 CDM 83945 CPT 301 RC inpatient 144 144 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES EPO [308136803] 114.02 percent of total billed charges 89.28 136.8 Technical (Hospital) Services Ref Oxalate Urine (Sat 24) PX-3018394500 CDM 83945 CPT 301 RC inpatient 144 144 CIGNA 62308 [3081051] CIGNA 62308 [308105105] 114.02 percent of total billed charges 89.28 136.8 Technical (Hospital) Services Ref Oxalate Urine (Sat 24) PX-3018394500 CDM 83945 CPT 301 RC inpatient 144 144 CIGNA 62308 [3081051] CIGNA STATE OF WYOMING [308105107] 114.02 percent of total billed charges 89.28 136.8 Technical (Hospital) Services Ref Oxalate Urine (Sat 24) PX-3018394500 CDM 83945 CPT 301 RC inpatient 144 144 MULTIPLAN INC 34080 [3081285] MULTIPLAN INC [308128501] 136.8 percent of total billed charges 89.28 136.8 Technical (Hospital) Services Ref Oxalate Urine (Sat 24) PX-3018394500 CDM 83945 CPT 301 RC inpatient 144 144 MEDICA (COMMERCIAL) 94265 [3081118] MEDICA CLAIMS [308111801] 129.6 percent of total billed charges 89.28 136.8 Technical (Hospital) Services Ref Oxalate Urine (Sat 24) PX-3018394500 CDM 83945 CPT 301 RC inpatient 144 144 UNITED HEALTHCARE (COMMERCIAL) [3081199] UNITED HEALTHCARE 87726 [308119901] 89.28 percent of total billed charges 89.28 136.8 Technical (Hospital) Services Ref Oxalate Urine (Sat 24) PX-3018394500 CDM 83945 CPT 301 RC inpatient 144 144 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES PPO [308136801] 114.02 percent of total billed charges 89.28 136.8 Technical (Hospital) Services Ref Oxalate Urine (Sat 24) PX-3018394500 CDM 83945 CPT 301 RC inpatient 144 144 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES HDHP [308136802] 114.02 percent of total billed charges 89.28 136.8 Technical (Hospital) Services Ref Oxalate Urine (Sat 24) PX-3018394500 CDM 83945 CPT 301 RC inpatient 144 144 BLUE CROSS BLUE SHIELD WELLMARK SB889 [3081026] BCBS WYOMING [308102603] 136.8 percent of total billed charges 89.28 136.8 Technical (Hospital) Services Ref Oxalate Urine (Sat 24) PX-3018394500 CDM 83945 CPT 301 RC outpatient 144 144 MEDICA (COMMERCIAL) 94265 [3081118] MEDICA CLAIMS [308111801] 129.6 percent of total billed charges 89.28 136.8 Technical (Hospital) Services Ref Oxalate Urine (Sat 24) PX-3018394500 CDM 83945 CPT 301 RC outpatient 144 144 CIGNA 62308 [3081051] CIGNA 62308 [308105105] 115.2 percent of total billed charges 89.28 136.8 Technical (Hospital) Services Ref Oxalate Urine (Sat 24) PX-3018394500 CDM 83945 CPT 301 RC outpatient 144 144 CIGNA 62308 [3081051] CIGNA STATE OF WYOMING [308105107] 115.2 percent of total billed charges 89.28 136.8 Technical (Hospital) Services Ref Oxalate Urine (Sat 24) PX-3018394500 CDM 83945 CPT 301 RC outpatient 144 144 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES EPO [308136803] 115.2 percent of total billed charges 89.28 136.8 Technical (Hospital) Services Ref Oxalate Urine (Sat 24) PX-3018394500 CDM 83945 CPT 301 RC outpatient 144 144 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES HDHP [308136802] 115.2 percent of total billed charges 89.28 136.8 Technical (Hospital) Services Ref Oxalate Urine (Sat 24) PX-3018394500 CDM 83945 CPT 301 RC outpatient 144 144 BLUE CROSS BLUE SHIELD WELLMARK SB889 [3081026] BCBS WYOMING [308102603] 136.8 percent of total billed charges 89.28 136.8 Technical (Hospital) Services Ref Oxalate Urine (Sat 24) PX-3018394500 CDM 83945 CPT 301 RC outpatient 144 144 MULTIPLAN INC 34080 [3081285] MULTIPLAN INC [308128501] 136.8 percent of total billed charges 89.28 136.8 Technical (Hospital) Services Ref Oxalate Urine (Sat 24) PX-3018394500 CDM 83945 CPT 301 RC outpatient 144 144 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES PPO [308136801] 115.2 percent of total billed charges 89.28 136.8 Technical (Hospital) Services Ref Oxalate Urine (Sat 24) PX-3018394500 CDM 83945 CPT 301 RC outpatient 144 144 HEALTHPARTNERS SX009 HEALTHPARTNERS 115.2 percent of total billed charges 89.28 136.8 Technical (Hospital) Services Ref Oxalate Urine (Sat 24) PX-3018394500 CDM 83945 CPT 301 RC outpatient 144 144 UNITED HEALTHCARE (COMMERCIAL) [3081199] UNITED HEALTHCARE 87726 [308119901] 89.28 percent of total billed charges 89.28 136.8 Technical (Hospital) Services Ref Oxalate Urine PX-3018394501 CDM 83945 CPT 301 RC outpatient 148 148 UNITED HEALTHCARE (COMMERCIAL) [3081199] UNITED HEALTHCARE 87726 [308119901] 91.76 percent of total billed charges 91.76 140.6 Technical (Hospital) Services Ref Oxalate Urine PX-3018394501 CDM 83945 CPT 301 RC outpatient 148 148 HEALTHPARTNERS SX009 HEALTHPARTNERS 118.4 percent of total billed charges 91.76 140.6 Technical (Hospital) Services Ref Oxalate Urine PX-3018394501 CDM 83945 CPT 301 RC outpatient 148 148 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES PPO [308136801] 118.4 percent of total billed charges 91.76 140.6 Technical (Hospital) Services Ref Oxalate Urine PX-3018394501 CDM 83945 CPT 301 RC outpatient 148 148 MULTIPLAN INC 34080 [3081285] MULTIPLAN INC [308128501] 140.6 percent of total billed charges 91.76 140.6 Technical (Hospital) Services Ref Oxalate Urine PX-3018394501 CDM 83945 CPT 301 RC outpatient 148 148 BLUE CROSS BLUE SHIELD WELLMARK SB889 [3081026] BCBS WYOMING [308102603] 140.6 percent of total billed charges 91.76 140.6 Technical (Hospital) Services Ref Oxalate Urine PX-3018394501 CDM 83945 CPT 301 RC outpatient 148 148 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES HDHP [308136802] 118.4 percent of total billed charges 91.76 140.6 Technical (Hospital) Services Ref Oxalate Urine PX-3018394501 CDM 83945 CPT 301 RC outpatient 148 148 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES EPO [308136803] 118.4 percent of total billed charges 91.76 140.6 Technical (Hospital) Services Ref Oxalate Urine PX-3018394501 CDM 83945 CPT 301 RC outpatient 148 148 CIGNA 62308 [3081051] CIGNA 62308 [308105105] 118.4 percent of total billed charges 91.76 140.6 Technical (Hospital) Services Ref Oxalate Urine PX-3018394501 CDM 83945 CPT 301 RC outpatient 148 148 CIGNA 62308 [3081051] CIGNA STATE OF WYOMING [308105107] 118.4 percent of total billed charges 91.76 140.6 Technical (Hospital) Services Ref Oxalate Urine PX-3018394501 CDM 83945 CPT 301 RC outpatient 148 148 MEDICA (COMMERCIAL) 94265 [3081118] MEDICA CLAIMS [308111801] 133.2 percent of total billed charges 91.76 140.6 Technical (Hospital) Services Ref Oxalate Urine PX-3018394501 CDM 83945 CPT 301 RC inpatient 148 148 MULTIPLAN INC 34080 [3081285] MULTIPLAN INC [308128501] 140.6 percent of total billed charges 91.76 140.6 Technical (Hospital) Services Ref Oxalate Urine PX-3018394501 CDM 83945 CPT 301 RC inpatient 148 148 MEDICA (COMMERCIAL) 94265 [3081118] MEDICA CLAIMS [308111801] 133.2 percent of total billed charges 91.76 140.6 Technical (Hospital) Services Ref Oxalate Urine PX-3018394501 CDM 83945 CPT 301 RC inpatient 148 148 CIGNA 62308 [3081051] CIGNA 62308 [308105105] 117.19 percent of total billed charges 91.76 140.6 Technical (Hospital) Services Ref Oxalate Urine PX-3018394501 CDM 83945 CPT 301 RC inpatient 148 148 CIGNA 62308 [3081051] CIGNA STATE OF WYOMING [308105107] 117.19 percent of total billed charges 91.76 140.6 Technical (Hospital) Services Ref Oxalate Urine PX-3018394501 CDM 83945 CPT 301 RC inpatient 148 148 HEALTHPARTNERS SX009 HEALTHPARTNERS 117.19 percent of total billed charges 91.76 140.6 Technical (Hospital) Services Ref Oxalate Urine PX-3018394501 CDM 83945 CPT 301 RC inpatient 148 148 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES EPO [308136803] 117.19 percent of total billed charges 91.76 140.6 Technical (Hospital) Services Ref Oxalate Urine PX-3018394501 CDM 83945 CPT 301 RC inpatient 148 148 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES HDHP [308136802] 117.19 percent of total billed charges 91.76 140.6 Technical (Hospital) Services Ref Oxalate Urine PX-3018394501 CDM 83945 CPT 301 RC inpatient 148 148 BLUE CROSS BLUE SHIELD WELLMARK SB889 [3081026] BCBS WYOMING [308102603] 140.6 percent of total billed charges 91.76 140.6 Technical (Hospital) Services Ref Oxalate Urine PX-3018394501 CDM 83945 CPT 301 RC inpatient 148 148 UNITED HEALTHCARE (COMMERCIAL) [3081199] UNITED HEALTHCARE 87726 [308119901] 91.76 percent of total billed charges 91.76 140.6 Technical (Hospital) Services Ref Oxalate Urine PX-3018394501 CDM 83945 CPT 301 RC inpatient 148 148 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES PPO [308136801] 117.19 percent of total billed charges 91.76 140.6 Technical (Hospital) Services Osmolarity Urine PX-3018393500 CDM 83935 CPT 301 RC inpatient 108 108 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES EPO [308136803] 85.51 percent of total billed charges 66.96 102.6 Technical (Hospital) Services Osmolarity Urine PX-3018393500 CDM 83935 CPT 301 RC inpatient 108 108 HEALTHPARTNERS SX009 HEALTHPARTNERS 85.51 percent of total billed charges 66.96 102.6 Technical (Hospital) Services Osmolarity Urine PX-3018393500 CDM 83935 CPT 301 RC inpatient 108 108 CIGNA 62308 [3081051] CIGNA 62308 [308105105] 85.51 percent of total billed charges 66.96 102.6 Technical (Hospital) Services Osmolarity Urine PX-3018393500 CDM 83935 CPT 301 RC inpatient 108 108 CIGNA 62308 [3081051] CIGNA STATE OF WYOMING [308105107] 85.51 percent of total billed charges 66.96 102.6 Technical (Hospital) Services Osmolarity Urine PX-3018393500 CDM 83935 CPT 301 RC inpatient 108 108 MULTIPLAN INC 34080 [3081285] MULTIPLAN INC [308128501] 102.6 percent of total billed charges 66.96 102.6 Technical (Hospital) Services Osmolarity Urine PX-3018393500 CDM 83935 CPT 301 RC inpatient 108 108 MEDICA (COMMERCIAL) 94265 [3081118] MEDICA CLAIMS [308111801] 97.2 percent of total billed charges 66.96 102.6 Technical (Hospital) Services Osmolarity Urine PX-3018393500 CDM 83935 CPT 301 RC inpatient 108 108 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES HDHP [308136802] 85.51 percent of total billed charges 66.96 102.6 Technical (Hospital) Services Osmolarity Urine PX-3018393500 CDM 83935 CPT 301 RC inpatient 108 108 BLUE CROSS BLUE SHIELD WELLMARK SB889 [3081026] BCBS WYOMING [308102603] 102.6 percent of total billed charges 66.96 102.6 Technical (Hospital) Services Osmolarity Urine PX-3018393500 CDM 83935 CPT 301 RC inpatient 108 108 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES PPO [308136801] 85.51 percent of total billed charges 66.96 102.6 Technical (Hospital) Services Osmolarity Urine PX-3018393500 CDM 83935 CPT 301 RC inpatient 108 108 UNITED HEALTHCARE (COMMERCIAL) [3081199] UNITED HEALTHCARE 87726 [308119901] 66.96 percent of total billed charges 66.96 102.6 Technical (Hospital) Services Osmolarity Urine PX-3018393500 CDM 83935 CPT 301 RC outpatient 108 108 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES PPO [308136801] 86.4 percent of total billed charges 66.96 102.6 Technical (Hospital) Services Osmolarity Urine PX-3018393500 CDM 83935 CPT 301 RC outpatient 108 108 MEDICA (COMMERCIAL) 94265 [3081118] MEDICA CLAIMS [308111801] 97.2 percent of total billed charges 66.96 102.6 Technical (Hospital) Services Osmolarity Urine PX-3018393500 CDM 83935 CPT 301 RC outpatient 108 108 CIGNA 62308 [3081051] CIGNA 62308 [308105105] 86.4 percent of total billed charges 66.96 102.6 Technical (Hospital) Services Osmolarity Urine PX-3018393500 CDM 83935 CPT 301 RC outpatient 108 108 CIGNA 62308 [3081051] CIGNA STATE OF WYOMING [308105107] 86.4 percent of total billed charges 66.96 102.6 Technical (Hospital) Services Osmolarity Urine PX-3018393500 CDM 83935 CPT 301 RC outpatient 108 108 BLUE CROSS BLUE SHIELD WELLMARK SB889 [3081026] BCBS WYOMING [308102603] 102.6 percent of total billed charges 66.96 102.6 Technical (Hospital) Services Osmolarity Urine PX-3018393500 CDM 83935 CPT 301 RC outpatient 108 108 MULTIPLAN INC 34080 [3081285] MULTIPLAN INC [308128501] 102.6 percent of total billed charges 66.96 102.6 Technical (Hospital) Services Osmolarity Urine PX-3018393500 CDM 83935 CPT 301 RC outpatient 108 108 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES EPO [308136803] 86.4 percent of total billed charges 66.96 102.6 Technical (Hospital) Services Osmolarity Urine PX-3018393500 CDM 83935 CPT 301 RC outpatient 108 108 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES HDHP [308136802] 86.4 percent of total billed charges 66.96 102.6 Technical (Hospital) Services Osmolarity Urine PX-3018393500 CDM 83935 CPT 301 RC outpatient 108 108 HEALTHPARTNERS SX009 HEALTHPARTNERS 86.4 percent of total billed charges 66.96 102.6 Technical (Hospital) Services Osmolarity Urine PX-3018393500 CDM 83935 CPT 301 RC outpatient 108 108 UNITED HEALTHCARE (COMMERCIAL) [3081199] UNITED HEALTHCARE 87726 [308119901] 66.96 percent of total billed charges 66.96 102.6 Technical (Hospital) Services Osmolarity Serum PX-3018393000 CDM 83930 CPT 301 RC inpatient 82 82 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES HDHP [308136802] 64.93 percent of total billed charges 50.84 77.9 Technical (Hospital) Services Osmolarity Serum PX-3018393000 CDM 83930 CPT 301 RC inpatient 82 82 BLUE CROSS BLUE SHIELD WELLMARK SB889 [3081026] BCBS WYOMING [308102603] 77.9 percent of total billed charges 50.84 77.9 Technical (Hospital) Services Osmolarity Serum PX-3018393000 CDM 83930 CPT 301 RC inpatient 82 82 UNITED HEALTHCARE (COMMERCIAL) [3081199] UNITED HEALTHCARE 87726 [308119901] 50.84 percent of total billed charges 50.84 77.9 Technical (Hospital) Services Osmolarity Serum PX-3018393000 CDM 83930 CPT 301 RC inpatient 82 82 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES PPO [308136801] 64.93 percent of total billed charges 50.84 77.9 Technical (Hospital) Services Osmolarity Serum PX-3018393000 CDM 83930 CPT 301 RC inpatient 82 82 CIGNA 62308 [3081051] CIGNA 62308 [308105105] 64.93 percent of total billed charges 50.84 77.9 Technical (Hospital) Services Osmolarity Serum PX-3018393000 CDM 83930 CPT 301 RC inpatient 82 82 CIGNA 62308 [3081051] CIGNA STATE OF WYOMING [308105107] 64.93 percent of total billed charges 50.84 77.9 Technical (Hospital) Services Osmolarity Serum PX-3018393000 CDM 83930 CPT 301 RC inpatient 82 82 MEDICA (COMMERCIAL) 94265 [3081118] MEDICA CLAIMS [308111801] 73.8 percent of total billed charges 50.84 77.9 Technical (Hospital) Services Osmolarity Serum PX-3018393000 CDM 83930 CPT 301 RC inpatient 82 82 MULTIPLAN INC 34080 [3081285] MULTIPLAN INC [308128501] 77.9 percent of total billed charges 50.84 77.9 Technical (Hospital) Services Osmolarity Serum PX-3018393000 CDM 83930 CPT 301 RC inpatient 82 82 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES EPO [308136803] 64.93 percent of total billed charges 50.84 77.9 Technical (Hospital) Services Osmolarity Serum PX-3018393000 CDM 83930 CPT 301 RC inpatient 82 82 HEALTHPARTNERS SX009 HEALTHPARTNERS 64.93 percent of total billed charges 50.84 77.9 Technical (Hospital) Services Osmolarity Serum PX-3018393000 CDM 83930 CPT 301 RC outpatient 82 82 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES EPO [308136803] 65.6 percent of total billed charges 50.84 77.9 Technical (Hospital) Services Osmolarity Serum PX-3018393000 CDM 83930 CPT 301 RC outpatient 82 82 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES HDHP [308136802] 65.6 percent of total billed charges 50.84 77.9 Technical (Hospital) Services Osmolarity Serum PX-3018393000 CDM 83930 CPT 301 RC outpatient 82 82 MULTIPLAN INC 34080 [3081285] MULTIPLAN INC [308128501] 77.9 percent of total billed charges 50.84 77.9 Technical (Hospital) Services Osmolarity Serum PX-3018393000 CDM 83930 CPT 301 RC outpatient 82 82 BLUE CROSS BLUE SHIELD WELLMARK SB889 [3081026] BCBS WYOMING [308102603] 77.9 percent of total billed charges 50.84 77.9 Technical (Hospital) Services Osmolarity Serum PX-3018393000 CDM 83930 CPT 301 RC outpatient 82 82 UNITED HEALTHCARE (COMMERCIAL) [3081199] UNITED HEALTHCARE 87726 [308119901] 50.84 percent of total billed charges 50.84 77.9 Technical (Hospital) Services Osmolarity Serum PX-3018393000 CDM 83930 CPT 301 RC outpatient 82 82 HEALTHPARTNERS SX009 HEALTHPARTNERS 65.6 percent of total billed charges 50.84 77.9 Technical (Hospital) Services Osmolarity Serum PX-3018393000 CDM 83930 CPT 301 RC outpatient 82 82 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES PPO [308136801] 65.6 percent of total billed charges 50.84 77.9 Technical (Hospital) Services Osmolarity Serum PX-3018393000 CDM 83930 CPT 301 RC outpatient 82 82 MEDICA (COMMERCIAL) 94265 [3081118] MEDICA CLAIMS [308111801] 73.8 percent of total billed charges 50.84 77.9 Technical (Hospital) Services Osmolarity Serum PX-3018393000 CDM 83930 CPT 301 RC outpatient 82 82 CIGNA 62308 [3081051] CIGNA 62308 [308105105] 65.6 percent of total billed charges 50.84 77.9 Technical (Hospital) Services Osmolarity Serum PX-3018393000 CDM 83930 CPT 301 RC outpatient 82 82 CIGNA 62308 [3081051] CIGNA STATE OF WYOMING [308105107] 65.6 percent of total billed charges 50.84 77.9 Technical (Hospital) Services Ref Methylmalonic Acid Serum PX-3018392100 CDM 83921 CPT 301 RC inpatient 197 197 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES PPO [308136801] 155.98 percent of total billed charges 122.14 187.15 Technical (Hospital) Services Ref Methylmalonic Acid Serum PX-3018392100 CDM 83921 CPT 301 RC inpatient 197 197 UNITED HEALTHCARE (COMMERCIAL) [3081199] UNITED HEALTHCARE 87726 [308119901] 122.14 percent of total billed charges 122.14 187.15 Technical (Hospital) Services Ref Methylmalonic Acid Serum PX-3018392100 CDM 83921 CPT 301 RC inpatient 197 197 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES HDHP [308136802] 155.98 percent of total billed charges 122.14 187.15 Technical (Hospital) Services Ref Methylmalonic Acid Serum PX-3018392100 CDM 83921 CPT 301 RC inpatient 197 197 BLUE CROSS BLUE SHIELD WELLMARK SB889 [3081026] BCBS WYOMING [308102603] 187.15 percent of total billed charges 122.14 187.15 Technical (Hospital) Services Ref Methylmalonic Acid Serum PX-3018392100 CDM 83921 CPT 301 RC inpatient 197 197 CIGNA 62308 [3081051] CIGNA 62308 [308105105] 155.98 percent of total billed charges 122.14 187.15 Technical (Hospital) Services Ref Methylmalonic Acid Serum PX-3018392100 CDM 83921 CPT 301 RC inpatient 197 197 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES EPO [308136803] 155.98 percent of total billed charges 122.14 187.15 Technical (Hospital) Services Ref Methylmalonic Acid Serum PX-3018392100 CDM 83921 CPT 301 RC inpatient 197 197 HEALTHPARTNERS SX009 HEALTHPARTNERS 155.98 percent of total billed charges 122.14 187.15 Technical (Hospital) Services Ref Methylmalonic Acid Serum PX-3018392100 CDM 83921 CPT 301 RC inpatient 197 197 MEDICA (COMMERCIAL) 94265 [3081118] MEDICA CLAIMS [308111801] 177.3 percent of total billed charges 122.14 187.15 Technical (Hospital) Services Ref Methylmalonic Acid Serum PX-3018392100 CDM 83921 CPT 301 RC inpatient 197 197 MULTIPLAN INC 34080 [3081285] MULTIPLAN INC [308128501] 187.15 percent of total billed charges 122.14 187.15 Technical (Hospital) Services Ref Methylmalonic Acid Serum PX-3018392100 CDM 83921 CPT 301 RC inpatient 197 197 CIGNA 62308 [3081051] CIGNA STATE OF WYOMING [308105107] 155.98 percent of total billed charges 122.14 187.15 Technical (Hospital) Services Ref Methylmalonic Acid Serum PX-3018392100 CDM 83921 CPT 301 RC outpatient 197 197 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES PPO [308136801] 157.6 percent of total billed charges 122.14 187.15 Technical (Hospital) Services Ref Methylmalonic Acid Serum PX-3018392100 CDM 83921 CPT 301 RC outpatient 197 197 BLUE CROSS BLUE SHIELD WELLMARK SB889 [3081026] BCBS WYOMING [308102603] 187.15 percent of total billed charges 122.14 187.15 Technical (Hospital) Services Ref Methylmalonic Acid Serum PX-3018392100 CDM 83921 CPT 301 RC outpatient 197 197 MULTIPLAN INC 34080 [3081285] MULTIPLAN INC [308128501] 187.15 percent of total billed charges 122.14 187.15 Technical (Hospital) Services Ref Methylmalonic Acid Serum PX-3018392100 CDM 83921 CPT 301 RC outpatient 197 197 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES EPO [308136803] 157.6 percent of total billed charges 122.14 187.15 Technical (Hospital) Services Ref Methylmalonic Acid Serum PX-3018392100 CDM 83921 CPT 301 RC outpatient 197 197 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES HDHP [308136802] 157.6 percent of total billed charges 122.14 187.15 Technical (Hospital) Services Ref Methylmalonic Acid Serum PX-3018392100 CDM 83921 CPT 301 RC outpatient 197 197 UNITED HEALTHCARE (COMMERCIAL) [3081199] UNITED HEALTHCARE 87726 [308119901] 122.14 percent of total billed charges 122.14 187.15 Technical (Hospital) Services Ref Methylmalonic Acid Serum PX-3018392100 CDM 83921 CPT 301 RC outpatient 197 197 HEALTHPARTNERS SX009 HEALTHPARTNERS 157.6 percent of total billed charges 122.14 187.15 Technical (Hospital) Services Ref Methylmalonic Acid Serum PX-3018392100 CDM 83921 CPT 301 RC outpatient 197 197 MEDICA (COMMERCIAL) 94265 [3081118] MEDICA CLAIMS [308111801] 177.3 percent of total billed charges 122.14 187.15 Technical (Hospital) Services Ref Methylmalonic Acid Serum PX-3018392100 CDM 83921 CPT 301 RC outpatient 197 197 CIGNA 62308 [3081051] CIGNA 62308 [308105105] 157.6 percent of total billed charges 122.14 187.15 Technical (Hospital) Services Ref Methylmalonic Acid Serum PX-3018392100 CDM 83921 CPT 301 RC outpatient 197 197 CIGNA 62308 [3081051] CIGNA STATE OF WYOMING [308105107] 157.6 percent of total billed charges 122.14 187.15 Technical (Hospital) Services Ref Immunoglobulin Light Ch PX-3018388301 CDM 83883 CPT 301 RC outpatient 183 183 UNITED HEALTHCARE (COMMERCIAL) [3081199] UNITED HEALTHCARE 87726 [308119901] 113.46 percent of total billed charges 113.46 173.85 Technical (Hospital) Services Ref Immunoglobulin Light Ch PX-3018388301 CDM 83883 CPT 301 RC outpatient 183 183 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES PPO [308136801] 146.4 percent of total billed charges 113.46 173.85 Technical (Hospital) Services Ref Immunoglobulin Light Ch PX-3018388301 CDM 83883 CPT 301 RC outpatient 183 183 HEALTHPARTNERS SX009 HEALTHPARTNERS 146.4 percent of total billed charges 113.46 173.85 Technical (Hospital) Services Ref Immunoglobulin Light Ch PX-3018388301 CDM 83883 CPT 301 RC outpatient 183 183 BLUE CROSS BLUE SHIELD WELLMARK SB889 [3081026] BCBS WYOMING [308102603] 173.85 percent of total billed charges 113.46 173.85 Technical (Hospital) Services Ref Immunoglobulin Light Ch PX-3018388301 CDM 83883 CPT 301 RC outpatient 183 183 MULTIPLAN INC 34080 [3081285] MULTIPLAN INC [308128501] 173.85 percent of total billed charges 113.46 173.85 Technical (Hospital) Services Ref Immunoglobulin Light Ch PX-3018388301 CDM 83883 CPT 301 RC outpatient 183 183 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES HDHP [308136802] 146.4 percent of total billed charges 113.46 173.85 Technical (Hospital) Services Ref Immunoglobulin Light Ch PX-3018388301 CDM 83883 CPT 301 RC outpatient 183 183 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES EPO [308136803] 146.4 percent of total billed charges 113.46 173.85 Technical (Hospital) Services Ref Immunoglobulin Light Ch PX-3018388301 CDM 83883 CPT 301 RC outpatient 183 183 MEDICA (COMMERCIAL) 94265 [3081118] MEDICA CLAIMS [308111801] 164.7 percent of total billed charges 113.46 173.85 Technical (Hospital) Services Ref Immunoglobulin Light Ch PX-3018388301 CDM 83883 CPT 301 RC outpatient 183 183 CIGNA 62308 [3081051] CIGNA 62308 [308105105] 146.4 percent of total billed charges 113.46 173.85 Technical (Hospital) Services Ref Immunoglobulin Light Ch PX-3018388301 CDM 83883 CPT 301 RC outpatient 183 183 CIGNA 62308 [3081051] CIGNA STATE OF WYOMING [308105107] 146.4 percent of total billed charges 113.46 173.85 Technical (Hospital) Services Ref Immunoglobulin Light Ch PX-3018388301 CDM 83883 CPT 301 RC inpatient 183 183 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES HDHP [308136802] 144.9 percent of total billed charges 113.46 173.85 Technical (Hospital) Services Ref Immunoglobulin Light Ch PX-3018388301 CDM 83883 CPT 301 RC inpatient 183 183 BLUE CROSS BLUE SHIELD WELLMARK SB889 [3081026] BCBS WYOMING [308102603] 173.85 percent of total billed charges 113.46 173.85 Technical (Hospital) Services Ref Immunoglobulin Light Ch PX-3018388301 CDM 83883 CPT 301 RC inpatient 183 183 UNITED HEALTHCARE (COMMERCIAL) [3081199] UNITED HEALTHCARE 87726 [308119901] 113.46 percent of total billed charges 113.46 173.85 Technical (Hospital) Services Ref Immunoglobulin Light Ch PX-3018388301 CDM 83883 CPT 301 RC inpatient 183 183 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES PPO [308136801] 144.9 percent of total billed charges 113.46 173.85 Technical (Hospital) Services Ref Immunoglobulin Light Ch PX-3018388301 CDM 83883 CPT 301 RC inpatient 183 183 CIGNA 62308 [3081051] CIGNA 62308 [308105105] 144.9 percent of total billed charges 113.46 173.85 Technical (Hospital) Services Ref Immunoglobulin Light Ch PX-3018388301 CDM 83883 CPT 301 RC inpatient 183 183 CIGNA 62308 [3081051] CIGNA STATE OF WYOMING [308105107] 144.9 percent of total billed charges 113.46 173.85 Technical (Hospital) Services Ref Immunoglobulin Light Ch PX-3018388301 CDM 83883 CPT 301 RC inpatient 183 183 MEDICA (COMMERCIAL) 94265 [3081118] MEDICA CLAIMS [308111801] 164.7 percent of total billed charges 113.46 173.85 Technical (Hospital) Services Ref Immunoglobulin Light Ch PX-3018388301 CDM 83883 CPT 301 RC inpatient 183 183 MULTIPLAN INC 34080 [3081285] MULTIPLAN INC [308128501] 173.85 percent of total billed charges 113.46 173.85 Technical (Hospital) Services Ref Immunoglobulin Light Ch PX-3018388301 CDM 83883 CPT 301 RC inpatient 183 183 HEALTHPARTNERS SX009 HEALTHPARTNERS 144.9 percent of total billed charges 113.46 173.85 Technical (Hospital) Services Ref Immunoglobulin Light Ch PX-3018388301 CDM 83883 CPT 301 RC inpatient 183 183 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES EPO [308136803] 144.9 percent of total billed charges 113.46 173.85 Technical (Hospital) Services Ref Igg Total Light Chains U PX-3018388302 CDM 83883 CPT 301 RC inpatient 210 210 HEALTHPARTNERS SX009 HEALTHPARTNERS 166.28 percent of total billed charges 130.2 199.5 Technical (Hospital) Services Ref Igg Total Light Chains U PX-3018388302 CDM 83883 CPT 301 RC inpatient 210 210 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES EPO [308136803] 166.28 percent of total billed charges 130.2 199.5 Technical (Hospital) Services Ref Igg Total Light Chains U PX-3018388302 CDM 83883 CPT 301 RC inpatient 210 210 CIGNA 62308 [3081051] CIGNA 62308 [308105105] 166.28 percent of total billed charges 130.2 199.5 Technical (Hospital) Services Ref Igg Total Light Chains U PX-3018388302 CDM 83883 CPT 301 RC inpatient 210 210 CIGNA 62308 [3081051] CIGNA STATE OF WYOMING [308105107] 166.28 percent of total billed charges 130.2 199.5 Technical (Hospital) Services Ref Igg Total Light Chains U PX-3018388302 CDM 83883 CPT 301 RC inpatient 210 210 MEDICA (COMMERCIAL) 94265 [3081118] MEDICA CLAIMS [308111801] 189 percent of total billed charges 130.2 199.5 Technical (Hospital) Services Ref Igg Total Light Chains U PX-3018388302 CDM 83883 CPT 301 RC inpatient 210 210 MULTIPLAN INC 34080 [3081285] MULTIPLAN INC [308128501] 199.5 percent of total billed charges 130.2 199.5 Technical (Hospital) Services Ref Igg Total Light Chains U PX-3018388302 CDM 83883 CPT 301 RC inpatient 210 210 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES PPO [308136801] 166.28 percent of total billed charges 130.2 199.5 Technical (Hospital) Services Ref Igg Total Light Chains U PX-3018388302 CDM 83883 CPT 301 RC inpatient 210 210 UNITED HEALTHCARE (COMMERCIAL) [3081199] UNITED HEALTHCARE 87726 [308119901] 130.2 percent of total billed charges 130.2 199.5 Technical (Hospital) Services Ref Igg Total Light Chains U PX-3018388302 CDM 83883 CPT 301 RC inpatient 210 210 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES HDHP [308136802] 166.28 percent of total billed charges 130.2 199.5 Technical (Hospital) Services Ref Igg Total Light Chains U PX-3018388302 CDM 83883 CPT 301 RC inpatient 210 210 BLUE CROSS BLUE SHIELD WELLMARK SB889 [3081026] BCBS WYOMING [308102603] 199.5 percent of total billed charges 130.2 199.5 Technical (Hospital) Services Ref Igg Total Light Chains U PX-3018388302 CDM 83883 CPT 301 RC outpatient 210 210 HEALTHPARTNERS SX009 HEALTHPARTNERS 168 percent of total billed charges 130.2 199.5 Technical (Hospital) Services Ref Igg Total Light Chains U PX-3018388302 CDM 83883 CPT 301 RC outpatient 210 210 UNITED HEALTHCARE (COMMERCIAL) [3081199] UNITED HEALTHCARE 87726 [308119901] 130.2 percent of total billed charges 130.2 199.5 Technical (Hospital) Services Ref Igg Total Light Chains U PX-3018388302 CDM 83883 CPT 301 RC outpatient 210 210 MULTIPLAN INC 34080 [3081285] MULTIPLAN INC [308128501] 199.5 percent of total billed charges 130.2 199.5 Technical (Hospital) Services Ref Igg Total Light Chains U PX-3018388302 CDM 83883 CPT 301 RC outpatient 210 210 BLUE CROSS BLUE SHIELD WELLMARK SB889 [3081026] BCBS WYOMING [308102603] 199.5 percent of total billed charges 130.2 199.5 Technical (Hospital) Services Ref Igg Total Light Chains U PX-3018388302 CDM 83883 CPT 301 RC outpatient 210 210 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES HDHP [308136802] 168 percent of total billed charges 130.2 199.5 Technical (Hospital) Services Ref Igg Total Light Chains U PX-3018388302 CDM 83883 CPT 301 RC outpatient 210 210 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES EPO [308136803] 168 percent of total billed charges 130.2 199.5 Technical (Hospital) Services Ref Igg Total Light Chains U PX-3018388302 CDM 83883 CPT 301 RC outpatient 210 210 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES PPO [308136801] 168 percent of total billed charges 130.2 199.5 Technical (Hospital) Services Ref Igg Total Light Chains U PX-3018388302 CDM 83883 CPT 301 RC outpatient 210 210 CIGNA 62308 [3081051] CIGNA 62308 [308105105] 168 percent of total billed charges 130.2 199.5 Technical (Hospital) Services Ref Igg Total Light Chains U PX-3018388302 CDM 83883 CPT 301 RC outpatient 210 210 CIGNA 62308 [3081051] CIGNA STATE OF WYOMING [308105107] 168 percent of total billed charges 130.2 199.5 Technical (Hospital) Services Ref Igg Total Light Chains U PX-3018388302 CDM 83883 CPT 301 RC outpatient 210 210 MEDICA (COMMERCIAL) 94265 [3081118] MEDICA CLAIMS [308111801] 189 percent of total billed charges 130.2 199.5 Technical (Hospital) Services Bnp B-Type Natriuetic Peptide PX-3018388000 CDM 83880 CPT 301 RC inpatient 383 383 CIGNA 62308 [3081051] CIGNA 62308 [308105105] 303.26 percent of total billed charges 237.46 363.85 Technical (Hospital) Services Bnp B-Type Natriuetic Peptide PX-3018388000 CDM 83880 CPT 301 RC inpatient 383 383 CIGNA 62308 [3081051] CIGNA STATE OF WYOMING [308105107] 303.26 percent of total billed charges 237.46 363.85 Technical (Hospital) Services Bnp B-Type Natriuetic Peptide PX-3018388000 CDM 83880 CPT 301 RC inpatient 383 383 MULTIPLAN INC 34080 [3081285] MULTIPLAN INC [308128501] 363.85 percent of total billed charges 237.46 363.85 Technical (Hospital) Services Bnp B-Type Natriuetic Peptide PX-3018388000 CDM 83880 CPT 301 RC inpatient 383 383 MEDICA (COMMERCIAL) 94265 [3081118] MEDICA CLAIMS [308111801] 344.7 percent of total billed charges 237.46 363.85 Technical (Hospital) Services Bnp B-Type Natriuetic Peptide PX-3018388000 CDM 83880 CPT 301 RC inpatient 383 383 HEALTHPARTNERS SX009 HEALTHPARTNERS 303.26 percent of total billed charges 237.46 363.85 Technical (Hospital) Services Bnp B-Type Natriuetic Peptide PX-3018388000 CDM 83880 CPT 301 RC inpatient 383 383 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES EPO [308136803] 303.26 percent of total billed charges 237.46 363.85 Technical (Hospital) Services Bnp B-Type Natriuetic Peptide PX-3018388000 CDM 83880 CPT 301 RC inpatient 383 383 BLUE CROSS BLUE SHIELD WELLMARK SB889 [3081026] BCBS WYOMING [308102603] 363.85 percent of total billed charges 237.46 363.85 Technical (Hospital) Services Bnp B-Type Natriuetic Peptide PX-3018388000 CDM 83880 CPT 301 RC inpatient 383 383 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES HDHP [308136802] 303.26 percent of total billed charges 237.46 363.85 Technical (Hospital) Services Bnp B-Type Natriuetic Peptide PX-3018388000 CDM 83880 CPT 301 RC inpatient 383 383 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES PPO [308136801] 303.26 percent of total billed charges 237.46 363.85 Technical (Hospital) Services Bnp B-Type Natriuetic Peptide PX-3018388000 CDM 83880 CPT 301 RC inpatient 383 383 UNITED HEALTHCARE (COMMERCIAL) [3081199] UNITED HEALTHCARE 87726 [308119901] 237.46 percent of total billed charges 237.46 363.85 Technical (Hospital) Services Bnp B-Type Natriuetic Peptide PX-3018388000 CDM 83880 CPT 301 RC outpatient 383 383 MEDICA (COMMERCIAL) 94265 [3081118] MEDICA CLAIMS [308111801] 344.7 percent of total billed charges 237.46 363.85 Technical (Hospital) Services Bnp B-Type Natriuetic Peptide PX-3018388000 CDM 83880 CPT 301 RC outpatient 383 383 CIGNA 62308 [3081051] CIGNA 62308 [308105105] 306.4 percent of total billed charges 237.46 363.85 Technical (Hospital) Services Bnp B-Type Natriuetic Peptide PX-3018388000 CDM 83880 CPT 301 RC outpatient 383 383 CIGNA 62308 [3081051] CIGNA STATE OF WYOMING [308105107] 306.4 percent of total billed charges 237.46 363.85 Technical (Hospital) Services Bnp B-Type Natriuetic Peptide PX-3018388000 CDM 83880 CPT 301 RC outpatient 383 383 UNITED HEALTHCARE (COMMERCIAL) [3081199] UNITED HEALTHCARE 87726 [308119901] 237.46 percent of total billed charges 237.46 363.85 Technical (Hospital) Services Bnp B-Type Natriuetic Peptide PX-3018388000 CDM 83880 CPT 301 RC outpatient 383 383 HEALTHPARTNERS SX009 HEALTHPARTNERS 306.4 percent of total billed charges 237.46 363.85 Technical (Hospital) Services Bnp B-Type Natriuetic Peptide PX-3018388000 CDM 83880 CPT 301 RC outpatient 383 383 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES EPO [308136803] 306.4 percent of total billed charges 237.46 363.85 Technical (Hospital) Services Bnp B-Type Natriuetic Peptide PX-3018388000 CDM 83880 CPT 301 RC outpatient 383 383 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES HDHP [308136802] 306.4 percent of total billed charges 237.46 363.85 Technical (Hospital) Services Bnp B-Type Natriuetic Peptide PX-3018388000 CDM 83880 CPT 301 RC outpatient 383 383 BLUE CROSS BLUE SHIELD WELLMARK SB889 [3081026] BCBS WYOMING [308102603] 363.85 percent of total billed charges 237.46 363.85 Technical (Hospital) Services Bnp B-Type Natriuetic Peptide PX-3018388000 CDM 83880 CPT 301 RC outpatient 383 383 MULTIPLAN INC 34080 [3081285] MULTIPLAN INC [308128501] 363.85 percent of total billed charges 237.46 363.85 Technical (Hospital) Services Bnp B-Type Natriuetic Peptide PX-3018388000 CDM 83880 CPT 301 RC outpatient 383 383 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES PPO [308136801] 306.4 percent of total billed charges 237.46 363.85 Technical (Hospital) Services Myoglobin PX-3018387400 CDM 83874 CPT 301 RC inpatient 188 188 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES HDHP [308136802] 148.86 percent of total billed charges 116.56 178.6 Technical (Hospital) Services Myoglobin PX-3018387400 CDM 83874 CPT 301 RC inpatient 188 188 BLUE CROSS BLUE SHIELD WELLMARK SB889 [3081026] BCBS WYOMING [308102603] 178.6 percent of total billed charges 116.56 178.6 Technical (Hospital) Services Myoglobin PX-3018387400 CDM 83874 CPT 301 RC inpatient 188 188 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES PPO [308136801] 148.86 percent of total billed charges 116.56 178.6 Technical (Hospital) Services Myoglobin PX-3018387400 CDM 83874 CPT 301 RC inpatient 188 188 UNITED HEALTHCARE (COMMERCIAL) [3081199] UNITED HEALTHCARE 87726 [308119901] 116.56 percent of total billed charges 116.56 178.6 Technical (Hospital) Services Myoglobin PX-3018387400 CDM 83874 CPT 301 RC inpatient 188 188 MULTIPLAN INC 34080 [3081285] MULTIPLAN INC [308128501] 178.6 percent of total billed charges 116.56 178.6 Technical (Hospital) Services Myoglobin PX-3018387400 CDM 83874 CPT 301 RC inpatient 188 188 MEDICA (COMMERCIAL) 94265 [3081118] MEDICA CLAIMS [308111801] 169.2 percent of total billed charges 116.56 178.6 Technical (Hospital) Services Myoglobin PX-3018387400 CDM 83874 CPT 301 RC inpatient 188 188 CIGNA 62308 [3081051] CIGNA 62308 [308105105] 148.86 percent of total billed charges 116.56 178.6 Technical (Hospital) Services Myoglobin PX-3018387400 CDM 83874 CPT 301 RC inpatient 188 188 CIGNA 62308 [3081051] CIGNA STATE OF WYOMING [308105107] 148.86 percent of total billed charges 116.56 178.6 Technical (Hospital) Services Myoglobin PX-3018387400 CDM 83874 CPT 301 RC inpatient 188 188 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES EPO [308136803] 148.86 percent of total billed charges 116.56 178.6 Technical (Hospital) Services Myoglobin PX-3018387400 CDM 83874 CPT 301 RC inpatient 188 188 HEALTHPARTNERS SX009 HEALTHPARTNERS 148.86 percent of total billed charges 116.56 178.6 Technical (Hospital) Services Myoglobin PX-3018387400 CDM 83874 CPT 301 RC outpatient 188 188 MEDICA (COMMERCIAL) 94265 [3081118] MEDICA CLAIMS [308111801] 169.2 percent of total billed charges 116.56 178.6 Technical (Hospital) Services Myoglobin PX-3018387400 CDM 83874 CPT 301 RC outpatient 188 188 CIGNA 62308 [3081051] CIGNA 62308 [308105105] 150.4 percent of total billed charges 116.56 178.6 Technical (Hospital) Services Myoglobin PX-3018387400 CDM 83874 CPT 301 RC outpatient 188 188 CIGNA 62308 [3081051] CIGNA STATE OF WYOMING [308105107] 150.4 percent of total billed charges 116.56 178.6 Technical (Hospital) Services Myoglobin PX-3018387400 CDM 83874 CPT 301 RC outpatient 188 188 HEALTHPARTNERS SX009 HEALTHPARTNERS 150.4 percent of total billed charges 116.56 178.6 Technical (Hospital) Services Myoglobin PX-3018387400 CDM 83874 CPT 301 RC outpatient 188 188 UNITED HEALTHCARE (COMMERCIAL) [3081199] UNITED HEALTHCARE 87726 [308119901] 116.56 percent of total billed charges 116.56 178.6 Technical (Hospital) Services Myoglobin PX-3018387400 CDM 83874 CPT 301 RC outpatient 188 188 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES EPO [308136803] 150.4 percent of total billed charges 116.56 178.6 Technical (Hospital) Services Myoglobin PX-3018387400 CDM 83874 CPT 301 RC outpatient 188 188 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES HDHP [308136802] 150.4 percent of total billed charges 116.56 178.6 Technical (Hospital) Services Myoglobin PX-3018387400 CDM 83874 CPT 301 RC outpatient 188 188 BLUE CROSS BLUE SHIELD WELLMARK SB889 [3081026] BCBS WYOMING [308102603] 178.6 percent of total billed charges 116.56 178.6 Technical (Hospital) Services Myoglobin PX-3018387400 CDM 83874 CPT 301 RC outpatient 188 188 MULTIPLAN INC 34080 [3081285] MULTIPLAN INC [308128501] 178.6 percent of total billed charges 116.56 178.6 Technical (Hospital) Services Myoglobin PX-3018387400 CDM 83874 CPT 301 RC outpatient 188 188 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES PPO [308136801] 150.4 percent of total billed charges 116.56 178.6 Technical (Hospital) Services Ref Metaneprines PX-3018383500 CDM 83835 CPT 301 RC inpatient 180 180 MULTIPLAN INC 34080 [3081285] MULTIPLAN INC [308128501] 171 percent of total billed charges 111.6 171 Technical (Hospital) Services Ref Metaneprines PX-3018383500 CDM 83835 CPT 301 RC inpatient 180 180 MEDICA (COMMERCIAL) 94265 [3081118] MEDICA CLAIMS [308111801] 162 percent of total billed charges 111.6 171 Technical (Hospital) Services Ref Metaneprines PX-3018383500 CDM 83835 CPT 301 RC inpatient 180 180 CIGNA 62308 [3081051] CIGNA 62308 [308105105] 142.52 percent of total billed charges 111.6 171 Technical (Hospital) Services Ref Metaneprines PX-3018383500 CDM 83835 CPT 301 RC inpatient 180 180 CIGNA 62308 [3081051] CIGNA STATE OF WYOMING [308105107] 142.52 percent of total billed charges 111.6 171 Technical (Hospital) Services Ref Metaneprines PX-3018383500 CDM 83835 CPT 301 RC inpatient 180 180 HEALTHPARTNERS SX009 HEALTHPARTNERS 142.52 percent of total billed charges 111.6 171 Technical (Hospital) Services Ref Metaneprines PX-3018383500 CDM 83835 CPT 301 RC inpatient 180 180 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES EPO [308136803] 142.52 percent of total billed charges 111.6 171 Technical (Hospital) Services Ref Metaneprines PX-3018383500 CDM 83835 CPT 301 RC inpatient 180 180 BLUE CROSS BLUE SHIELD WELLMARK SB889 [3081026] BCBS WYOMING [308102603] 171 percent of total billed charges 111.6 171 Technical (Hospital) Services Ref Metaneprines PX-3018383500 CDM 83835 CPT 301 RC inpatient 180 180 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES HDHP [308136802] 142.52 percent of total billed charges 111.6 171 Technical (Hospital) Services Ref Metaneprines PX-3018383500 CDM 83835 CPT 301 RC inpatient 180 180 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES PPO [308136801] 142.52 percent of total billed charges 111.6 171 Technical (Hospital) Services Ref Metaneprines PX-3018383500 CDM 83835 CPT 301 RC inpatient 180 180 UNITED HEALTHCARE (COMMERCIAL) [3081199] UNITED HEALTHCARE 87726 [308119901] 111.6 percent of total billed charges 111.6 171 Technical (Hospital) Services Ref Metaneprines PX-3018383500 CDM 83835 CPT 301 RC outpatient 180 180 BLUE CROSS BLUE SHIELD WELLMARK SB889 [3081026] BCBS WYOMING [308102603] 171 percent of total billed charges 111.6 171 Technical (Hospital) Services Ref Metaneprines PX-3018383500 CDM 83835 CPT 301 RC outpatient 180 180 MULTIPLAN INC 34080 [3081285] MULTIPLAN INC [308128501] 171 percent of total billed charges 111.6 171 Technical (Hospital) Services Ref Metaneprines PX-3018383500 CDM 83835 CPT 301 RC outpatient 180 180 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES HDHP [308136802] 144 percent of total billed charges 111.6 171 Technical (Hospital) Services Ref Metaneprines PX-3018383500 CDM 83835 CPT 301 RC outpatient 180 180 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES EPO [308136803] 144 percent of total billed charges 111.6 171 Technical (Hospital) Services Ref Metaneprines PX-3018383500 CDM 83835 CPT 301 RC outpatient 180 180 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES PPO [308136801] 144 percent of total billed charges 111.6 171 Technical (Hospital) Services Ref Metaneprines PX-3018383500 CDM 83835 CPT 301 RC outpatient 180 180 HEALTHPARTNERS SX009 HEALTHPARTNERS 144 percent of total billed charges 111.6 171 Technical (Hospital) Services Ref Metaneprines PX-3018383500 CDM 83835 CPT 301 RC outpatient 180 180 UNITED HEALTHCARE (COMMERCIAL) [3081199] UNITED HEALTHCARE 87726 [308119901] 111.6 percent of total billed charges 111.6 171 Technical (Hospital) Services Ref Metaneprines PX-3018383500 CDM 83835 CPT 301 RC outpatient 180 180 MEDICA (COMMERCIAL) 94265 [3081118] MEDICA CLAIMS [308111801] 162 percent of total billed charges 111.6 171 Technical (Hospital) Services Ref Metaneprines PX-3018383500 CDM 83835 CPT 301 RC outpatient 180 180 CIGNA 62308 [3081051] CIGNA 62308 [308105105] 144 percent of total billed charges 111.6 171 Technical (Hospital) Services Ref Metaneprines PX-3018383500 CDM 83835 CPT 301 RC outpatient 180 180 CIGNA 62308 [3081051] CIGNA STATE OF WYOMING [308105107] 144 percent of total billed charges 111.6 171 Technical (Hospital) Services Ref Metanephrines PX-3018383501 CDM 83835 CPT 301 RC inpatient 180 180 UNITED HEALTHCARE (COMMERCIAL) [3081199] UNITED HEALTHCARE 87726 [308119901] 111.6 percent of total billed charges 111.6 171 Technical (Hospital) Services Ref Metanephrines PX-3018383501 CDM 83835 CPT 301 RC inpatient 180 180 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES PPO [308136801] 142.52 percent of total billed charges 111.6 171 Technical (Hospital) Services Ref Metanephrines PX-3018383501 CDM 83835 CPT 301 RC inpatient 180 180 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES HDHP [308136802] 142.52 percent of total billed charges 111.6 171 Technical (Hospital) Services Ref Metanephrines PX-3018383501 CDM 83835 CPT 301 RC inpatient 180 180 BLUE CROSS BLUE SHIELD WELLMARK SB889 [3081026] BCBS WYOMING [308102603] 171 percent of total billed charges 111.6 171 Technical (Hospital) Services Ref Metanephrines PX-3018383501 CDM 83835 CPT 301 RC inpatient 180 180 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES EPO [308136803] 142.52 percent of total billed charges 111.6 171 Technical (Hospital) Services Ref Metanephrines PX-3018383501 CDM 83835 CPT 301 RC inpatient 180 180 HEALTHPARTNERS SX009 HEALTHPARTNERS 142.52 percent of total billed charges 111.6 171 Technical (Hospital) Services Ref Metanephrines PX-3018383501 CDM 83835 CPT 301 RC inpatient 180 180 CIGNA 62308 [3081051] CIGNA 62308 [308105105] 142.52 percent of total billed charges 111.6 171 Technical (Hospital) Services Ref Metanephrines PX-3018383501 CDM 83835 CPT 301 RC inpatient 180 180 CIGNA 62308 [3081051] CIGNA STATE OF WYOMING [308105107] 142.52 percent of total billed charges 111.6 171 Technical (Hospital) Services Ref Metanephrines PX-3018383501 CDM 83835 CPT 301 RC inpatient 180 180 MULTIPLAN INC 34080 [3081285] MULTIPLAN INC [308128501] 171 percent of total billed charges 111.6 171 Technical (Hospital) Services Ref Metanephrines PX-3018383501 CDM 83835 CPT 301 RC inpatient 180 180 MEDICA (COMMERCIAL) 94265 [3081118] MEDICA CLAIMS [308111801] 162 percent of total billed charges 111.6 171 Technical (Hospital) Services Ref Metanephrines PX-3018383501 CDM 83835 CPT 301 RC outpatient 180 180 CIGNA 62308 [3081051] CIGNA 62308 [308105105] 144 percent of total billed charges 111.6 171 Technical (Hospital) Services Ref Metanephrines PX-3018383501 CDM 83835 CPT 301 RC outpatient 180 180 CIGNA 62308 [3081051] CIGNA STATE OF WYOMING [308105107] 144 percent of total billed charges 111.6 171 Technical (Hospital) Services Ref Metanephrines PX-3018383501 CDM 83835 CPT 301 RC outpatient 180 180 MEDICA (COMMERCIAL) 94265 [3081118] MEDICA CLAIMS [308111801] 162 percent of total billed charges 111.6 171 Technical (Hospital) Services Ref Metanephrines PX-3018383501 CDM 83835 CPT 301 RC outpatient 180 180 UNITED HEALTHCARE (COMMERCIAL) [3081199] UNITED HEALTHCARE 87726 [308119901] 111.6 percent of total billed charges 111.6 171 Technical (Hospital) Services Ref Metanephrines PX-3018383501 CDM 83835 CPT 301 RC outpatient 180 180 HEALTHPARTNERS SX009 HEALTHPARTNERS 144 percent of total billed charges 111.6 171 Technical (Hospital) Services Ref Metanephrines PX-3018383501 CDM 83835 CPT 301 RC outpatient 180 180 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES PPO [308136801] 144 percent of total billed charges 111.6 171 Technical (Hospital) Services Ref Metanephrines PX-3018383501 CDM 83835 CPT 301 RC outpatient 180 180 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES EPO [308136803] 144 percent of total billed charges 111.6 171 Technical (Hospital) Services Ref Metanephrines PX-3018383501 CDM 83835 CPT 301 RC outpatient 180 180 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES HDHP [308136802] 144 percent of total billed charges 111.6 171 Technical (Hospital) Services Ref Metanephrines PX-3018383501 CDM 83835 CPT 301 RC outpatient 180 180 MULTIPLAN INC 34080 [3081285] MULTIPLAN INC [308128501] 171 percent of total billed charges 111.6 171 Technical (Hospital) Services Ref Metanephrines PX-3018383501 CDM 83835 CPT 301 RC outpatient 180 180 BLUE CROSS BLUE SHIELD WELLMARK SB889 [3081026] BCBS WYOMING [308102603] 171 percent of total billed charges 111.6 171 Technical (Hospital) Services Ref Metanephrines Fraction 24 Hr PX-3018383502 CDM 83835 CPT 301 RC inpatient 180 180 HEALTHPARTNERS SX009 HEALTHPARTNERS 142.52 percent of total billed charges 111.6 171 Technical (Hospital) Services Ref Metanephrines Fraction 24 Hr PX-3018383502 CDM 83835 CPT 301 RC inpatient 180 180 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES EPO [308136803] 142.52 percent of total billed charges 111.6 171 Technical (Hospital) Services Ref Metanephrines Fraction 24 Hr PX-3018383502 CDM 83835 CPT 301 RC inpatient 180 180 CIGNA 62308 [3081051] CIGNA 62308 [308105105] 142.52 percent of total billed charges 111.6 171 Technical (Hospital) Services Ref Metanephrines Fraction 24 Hr PX-3018383502 CDM 83835 CPT 301 RC inpatient 180 180 CIGNA 62308 [3081051] CIGNA STATE OF WYOMING [308105107] 142.52 percent of total billed charges 111.6 171 Technical (Hospital) Services Ref Metanephrines Fraction 24 Hr PX-3018383502 CDM 83835 CPT 301 RC inpatient 180 180 MULTIPLAN INC 34080 [3081285] MULTIPLAN INC [308128501] 171 percent of total billed charges 111.6 171 Technical (Hospital) Services Ref Metanephrines Fraction 24 Hr PX-3018383502 CDM 83835 CPT 301 RC inpatient 180 180 MEDICA (COMMERCIAL) 94265 [3081118] MEDICA CLAIMS [308111801] 162 percent of total billed charges 111.6 171 Technical (Hospital) Services Ref Metanephrines Fraction 24 Hr PX-3018383502 CDM 83835 CPT 301 RC inpatient 180 180 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES HDHP [308136802] 142.52 percent of total billed charges 111.6 171 Technical (Hospital) Services Ref Metanephrines Fraction 24 Hr PX-3018383502 CDM 83835 CPT 301 RC inpatient 180 180 BLUE CROSS BLUE SHIELD WELLMARK SB889 [3081026] BCBS WYOMING [308102603] 171 percent of total billed charges 111.6 171 Technical (Hospital) Services Ref Metanephrines Fraction 24 Hr PX-3018383502 CDM 83835 CPT 301 RC inpatient 180 180 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES PPO [308136801] 142.52 percent of total billed charges 111.6 171 Technical (Hospital) Services Ref Metanephrines Fraction 24 Hr PX-3018383502 CDM 83835 CPT 301 RC inpatient 180 180 UNITED HEALTHCARE (COMMERCIAL) [3081199] UNITED HEALTHCARE 87726 [308119901] 111.6 percent of total billed charges 111.6 171 Technical (Hospital) Services Ref Metanephrines Fraction 24 Hr PX-3018383502 CDM 83835 CPT 301 RC outpatient 180 180 HEALTHPARTNERS SX009 HEALTHPARTNERS 144 percent of total billed charges 111.6 171 Technical (Hospital) Services Ref Metanephrines Fraction 24 Hr PX-3018383502 CDM 83835 CPT 301 RC outpatient 180 180 UNITED HEALTHCARE (COMMERCIAL) [3081199] UNITED HEALTHCARE 87726 [308119901] 111.6 percent of total billed charges 111.6 171 Technical (Hospital) Services Ref Metanephrines Fraction 24 Hr PX-3018383502 CDM 83835 CPT 301 RC outpatient 180 180 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES EPO [308136803] 144 percent of total billed charges 111.6 171 Technical (Hospital) Services Ref Metanephrines Fraction 24 Hr PX-3018383502 CDM 83835 CPT 301 RC outpatient 180 180 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES HDHP [308136802] 144 percent of total billed charges 111.6 171 Technical (Hospital) Services Ref Metanephrines Fraction 24 Hr PX-3018383502 CDM 83835 CPT 301 RC outpatient 180 180 BLUE CROSS BLUE SHIELD WELLMARK SB889 [3081026] BCBS WYOMING [308102603] 171 percent of total billed charges 111.6 171 Technical (Hospital) Services Ref Metanephrines Fraction 24 Hr PX-3018383502 CDM 83835 CPT 301 RC outpatient 180 180 MULTIPLAN INC 34080 [3081285] MULTIPLAN INC [308128501] 171 percent of total billed charges 111.6 171 Technical (Hospital) Services Ref Metanephrines Fraction 24 Hr PX-3018383502 CDM 83835 CPT 301 RC outpatient 180 180 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES PPO [308136801] 144 percent of total billed charges 111.6 171 Technical (Hospital) Services Ref Metanephrines Fraction 24 Hr PX-3018383502 CDM 83835 CPT 301 RC outpatient 180 180 CIGNA 62308 [3081051] CIGNA 62308 [308105105] 144 percent of total billed charges 111.6 171 Technical (Hospital) Services Ref Metanephrines Fraction 24 Hr PX-3018383502 CDM 83835 CPT 301 RC outpatient 180 180 CIGNA 62308 [3081051] CIGNA STATE OF WYOMING [308105107] 144 percent of total billed charges 111.6 171 Technical (Hospital) Services Ref Metanephrines Fraction 24 Hr PX-3018383502 CDM 83835 CPT 301 RC outpatient 180 180 MEDICA (COMMERCIAL) 94265 [3081118] MEDICA CLAIMS [308111801] 162 percent of total billed charges 111.6 171 Technical (Hospital) Services "Ref Mercury, 24 Hour, Urine" PX-3018382500 CDM 83825 CPT 301 RC inpatient 213 213 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES PPO [308136801] 168.65 percent of total billed charges 132.06 202.35 Technical (Hospital) Services "Ref Mercury, 24 Hour, Urine" PX-3018382500 CDM 83825 CPT 301 RC inpatient 213 213 UNITED HEALTHCARE (COMMERCIAL) [3081199] UNITED HEALTHCARE 87726 [308119901] 132.06 percent of total billed charges 132.06 202.35 Technical (Hospital) Services "Ref Mercury, 24 Hour, Urine" PX-3018382500 CDM 83825 CPT 301 RC inpatient 213 213 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES HDHP [308136802] 168.65 percent of total billed charges 132.06 202.35 Technical (Hospital) Services "Ref Mercury, 24 Hour, Urine" PX-3018382500 CDM 83825 CPT 301 RC inpatient 213 213 BLUE CROSS BLUE SHIELD WELLMARK SB889 [3081026] BCBS WYOMING [308102603] 202.35 percent of total billed charges 132.06 202.35 Technical (Hospital) Services "Ref Mercury, 24 Hour, Urine" PX-3018382500 CDM 83825 CPT 301 RC inpatient 213 213 HEALTHPARTNERS SX009 HEALTHPARTNERS 168.65 percent of total billed charges 132.06 202.35 Technical (Hospital) Services "Ref Mercury, 24 Hour, Urine" PX-3018382500 CDM 83825 CPT 301 RC inpatient 213 213 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES EPO [308136803] 168.65 percent of total billed charges 132.06 202.35 Technical (Hospital) Services "Ref Mercury, 24 Hour, Urine" PX-3018382500 CDM 83825 CPT 301 RC inpatient 213 213 MULTIPLAN INC 34080 [3081285] MULTIPLAN INC [308128501] 202.35 percent of total billed charges 132.06 202.35 Technical (Hospital) Services "Ref Mercury, 24 Hour, Urine" PX-3018382500 CDM 83825 CPT 301 RC inpatient 213 213 MEDICA (COMMERCIAL) 94265 [3081118] MEDICA CLAIMS [308111801] 191.7 percent of total billed charges 132.06 202.35 Technical (Hospital) Services "Ref Mercury, 24 Hour, Urine" PX-3018382500 CDM 83825 CPT 301 RC inpatient 213 213 CIGNA 62308 [3081051] CIGNA 62308 [308105105] 168.65 percent of total billed charges 132.06 202.35 Technical (Hospital) Services "Ref Mercury, 24 Hour, Urine" PX-3018382500 CDM 83825 CPT 301 RC inpatient 213 213 CIGNA 62308 [3081051] CIGNA STATE OF WYOMING [308105107] 168.65 percent of total billed charges 132.06 202.35 Technical (Hospital) Services "Ref Mercury, 24 Hour, Urine" PX-3018382500 CDM 83825 CPT 301 RC outpatient 213 213 BLUE CROSS BLUE SHIELD WELLMARK SB889 [3081026] BCBS WYOMING [308102603] 202.35 percent of total billed charges 132.06 202.35 Technical (Hospital) Services "Ref Mercury, 24 Hour, Urine" PX-3018382500 CDM 83825 CPT 301 RC outpatient 213 213 MULTIPLAN INC 34080 [3081285] MULTIPLAN INC [308128501] 202.35 percent of total billed charges 132.06 202.35 Technical (Hospital) Services "Ref Mercury, 24 Hour, Urine" PX-3018382500 CDM 83825 CPT 301 RC outpatient 213 213 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES HDHP [308136802] 170.4 percent of total billed charges 132.06 202.35 Technical (Hospital) Services "Ref Mercury, 24 Hour, Urine" PX-3018382500 CDM 83825 CPT 301 RC outpatient 213 213 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES EPO [308136803] 170.4 percent of total billed charges 132.06 202.35 Technical (Hospital) Services "Ref Mercury, 24 Hour, Urine" PX-3018382500 CDM 83825 CPT 301 RC outpatient 213 213 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES PPO [308136801] 170.4 percent of total billed charges 132.06 202.35 Technical (Hospital) Services "Ref Mercury, 24 Hour, Urine" PX-3018382500 CDM 83825 CPT 301 RC outpatient 213 213 HEALTHPARTNERS SX009 HEALTHPARTNERS 170.4 percent of total billed charges 132.06 202.35 Technical (Hospital) Services "Ref Mercury, 24 Hour, Urine" PX-3018382500 CDM 83825 CPT 301 RC outpatient 213 213 UNITED HEALTHCARE (COMMERCIAL) [3081199] UNITED HEALTHCARE 87726 [308119901] 132.06 percent of total billed charges 132.06 202.35 Technical (Hospital) Services "Ref Mercury, 24 Hour, Urine" PX-3018382500 CDM 83825 CPT 301 RC outpatient 213 213 MEDICA (COMMERCIAL) 94265 [3081118] MEDICA CLAIMS [308111801] 191.7 percent of total billed charges 132.06 202.35 Technical (Hospital) Services "Ref Mercury, 24 Hour, Urine" PX-3018382500 CDM 83825 CPT 301 RC outpatient 213 213 CIGNA 62308 [3081051] CIGNA 62308 [308105105] 170.4 percent of total billed charges 132.06 202.35 Technical (Hospital) Services "Ref Mercury, 24 Hour, Urine" PX-3018382500 CDM 83825 CPT 301 RC outpatient 213 213 CIGNA 62308 [3081051] CIGNA STATE OF WYOMING [308105107] 170.4 percent of total billed charges 132.06 202.35 Technical (Hospital) Services Ref Amino Acid Acylcarnitine Scrn PX-3018378901 CDM 83789 CPT 301 RC inpatient 170 170 HEALTHPARTNERS SX009 HEALTHPARTNERS 134.61 percent of total billed charges 105.4 161.5 Technical (Hospital) Services Ref Amino Acid Acylcarnitine Scrn PX-3018378901 CDM 83789 CPT 301 RC inpatient 170 170 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES EPO [308136803] 134.61 percent of total billed charges 105.4 161.5 Technical (Hospital) Services Ref Amino Acid Acylcarnitine Scrn PX-3018378901 CDM 83789 CPT 301 RC inpatient 170 170 CIGNA 62308 [3081051] CIGNA 62308 [308105105] 134.61 percent of total billed charges 105.4 161.5 Technical (Hospital) Services Ref Amino Acid Acylcarnitine Scrn PX-3018378901 CDM 83789 CPT 301 RC inpatient 170 170 CIGNA 62308 [3081051] CIGNA STATE OF WYOMING [308105107] 134.61 percent of total billed charges 105.4 161.5 Technical (Hospital) Services Ref Amino Acid Acylcarnitine Scrn PX-3018378901 CDM 83789 CPT 301 RC inpatient 170 170 MEDICA (COMMERCIAL) 94265 [3081118] MEDICA CLAIMS [308111801] 153 percent of total billed charges 105.4 161.5 Technical (Hospital) Services Ref Amino Acid Acylcarnitine Scrn PX-3018378901 CDM 83789 CPT 301 RC inpatient 170 170 MULTIPLAN INC 34080 [3081285] MULTIPLAN INC [308128501] 161.5 percent of total billed charges 105.4 161.5 Technical (Hospital) Services Ref Amino Acid Acylcarnitine Scrn PX-3018378901 CDM 83789 CPT 301 RC inpatient 170 170 UNITED HEALTHCARE (COMMERCIAL) [3081199] UNITED HEALTHCARE 87726 [308119901] 105.4 percent of total billed charges 105.4 161.5 Technical (Hospital) Services Ref Amino Acid Acylcarnitine Scrn PX-3018378901 CDM 83789 CPT 301 RC inpatient 170 170 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES PPO [308136801] 134.61 percent of total billed charges 105.4 161.5 Technical (Hospital) Services Ref Amino Acid Acylcarnitine Scrn PX-3018378901 CDM 83789 CPT 301 RC inpatient 170 170 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES HDHP [308136802] 134.61 percent of total billed charges 105.4 161.5 Technical (Hospital) Services Ref Amino Acid Acylcarnitine Scrn PX-3018378901 CDM 83789 CPT 301 RC inpatient 170 170 BLUE CROSS BLUE SHIELD WELLMARK SB889 [3081026] BCBS WYOMING [308102603] 161.5 percent of total billed charges 105.4 161.5 Technical (Hospital) Services Ref Amino Acid Acylcarnitine Scrn PX-3018378901 CDM 83789 CPT 301 RC outpatient 170 170 UNITED HEALTHCARE (COMMERCIAL) [3081199] UNITED HEALTHCARE 87726 [308119901] 105.4 percent of total billed charges 105.4 161.5 Technical (Hospital) Services Ref Amino Acid Acylcarnitine Scrn PX-3018378901 CDM 83789 CPT 301 RC outpatient 170 170 HEALTHPARTNERS SX009 HEALTHPARTNERS 136 percent of total billed charges 105.4 161.5 Technical (Hospital) Services Ref Amino Acid Acylcarnitine Scrn PX-3018378901 CDM 83789 CPT 301 RC outpatient 170 170 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES PPO [308136801] 136 percent of total billed charges 105.4 161.5 Technical (Hospital) Services Ref Amino Acid Acylcarnitine Scrn PX-3018378901 CDM 83789 CPT 301 RC outpatient 170 170 BLUE CROSS BLUE SHIELD WELLMARK SB889 [3081026] BCBS WYOMING [308102603] 161.5 percent of total billed charges 105.4 161.5 Technical (Hospital) Services Ref Amino Acid Acylcarnitine Scrn PX-3018378901 CDM 83789 CPT 301 RC outpatient 170 170 MULTIPLAN INC 34080 [3081285] MULTIPLAN INC [308128501] 161.5 percent of total billed charges 105.4 161.5 Technical (Hospital) Services Ref Amino Acid Acylcarnitine Scrn PX-3018378901 CDM 83789 CPT 301 RC outpatient 170 170 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES EPO [308136803] 136 percent of total billed charges 105.4 161.5 Technical (Hospital) Services Ref Amino Acid Acylcarnitine Scrn PX-3018378901 CDM 83789 CPT 301 RC outpatient 170 170 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES HDHP [308136802] 136 percent of total billed charges 105.4 161.5 Technical (Hospital) Services Ref Amino Acid Acylcarnitine Scrn PX-3018378901 CDM 83789 CPT 301 RC outpatient 170 170 MEDICA (COMMERCIAL) 94265 [3081118] MEDICA CLAIMS [308111801] 153 percent of total billed charges 105.4 161.5 Technical (Hospital) Services Ref Amino Acid Acylcarnitine Scrn PX-3018378901 CDM 83789 CPT 301 RC outpatient 170 170 CIGNA 62308 [3081051] CIGNA 62308 [308105105] 136 percent of total billed charges 105.4 161.5 Technical (Hospital) Services Ref Amino Acid Acylcarnitine Scrn PX-3018378901 CDM 83789 CPT 301 RC outpatient 170 170 CIGNA 62308 [3081051] CIGNA STATE OF WYOMING [308105107] 136 percent of total billed charges 105.4 161.5 Technical (Hospital) Services Magnesium PX-3018373500 CDM 83735 CPT 301 RC outpatient 84 84 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES HDHP [308136802] 67.2 percent of total billed charges 52.08 79.8 Technical (Hospital) Services Magnesium PX-3018373500 CDM 83735 CPT 301 RC outpatient 84 84 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES EPO [308136803] 67.2 percent of total billed charges 52.08 79.8 Technical (Hospital) Services Magnesium PX-3018373500 CDM 83735 CPT 301 RC outpatient 84 84 MULTIPLAN INC 34080 [3081285] MULTIPLAN INC [308128501] 79.8 percent of total billed charges 52.08 79.8 Technical (Hospital) Services Magnesium PX-3018373500 CDM 83735 CPT 301 RC outpatient 84 84 BLUE CROSS BLUE SHIELD WELLMARK SB889 [3081026] BCBS WYOMING [308102603] 79.8 percent of total billed charges 52.08 79.8 Technical (Hospital) Services Magnesium PX-3018373500 CDM 83735 CPT 301 RC outpatient 84 84 HEALTHPARTNERS SX009 HEALTHPARTNERS 67.2 percent of total billed charges 52.08 79.8 Technical (Hospital) Services Magnesium PX-3018373500 CDM 83735 CPT 301 RC outpatient 84 84 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES PPO [308136801] 67.2 percent of total billed charges 52.08 79.8 Technical (Hospital) Services Magnesium PX-3018373500 CDM 83735 CPT 301 RC outpatient 84 84 UNITED HEALTHCARE (COMMERCIAL) [3081199] UNITED HEALTHCARE 87726 [308119901] 52.08 percent of total billed charges 52.08 79.8 Technical (Hospital) Services Magnesium PX-3018373500 CDM 83735 CPT 301 RC outpatient 84 84 MEDICA (COMMERCIAL) 94265 [3081118] MEDICA CLAIMS [308111801] 75.6 percent of total billed charges 52.08 79.8 Technical (Hospital) Services Magnesium PX-3018373500 CDM 83735 CPT 301 RC outpatient 84 84 CIGNA 62308 [3081051] CIGNA 62308 [308105105] 67.2 percent of total billed charges 52.08 79.8 Technical (Hospital) Services Magnesium PX-3018373500 CDM 83735 CPT 301 RC outpatient 84 84 CIGNA 62308 [3081051] CIGNA STATE OF WYOMING [308105107] 67.2 percent of total billed charges 52.08 79.8 Technical (Hospital) Services Magnesium PX-3018373500 CDM 83735 CPT 301 RC inpatient 84 84 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES PPO [308136801] 66.51 percent of total billed charges 52.08 79.8 Technical (Hospital) Services Magnesium PX-3018373500 CDM 83735 CPT 301 RC inpatient 84 84 UNITED HEALTHCARE (COMMERCIAL) [3081199] UNITED HEALTHCARE 87726 [308119901] 52.08 percent of total billed charges 52.08 79.8 Technical (Hospital) Services Magnesium PX-3018373500 CDM 83735 CPT 301 RC inpatient 84 84 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES HDHP [308136802] 66.51 percent of total billed charges 52.08 79.8 Technical (Hospital) Services Magnesium PX-3018373500 CDM 83735 CPT 301 RC inpatient 84 84 BLUE CROSS BLUE SHIELD WELLMARK SB889 [3081026] BCBS WYOMING [308102603] 79.8 percent of total billed charges 52.08 79.8 Technical (Hospital) Services Magnesium PX-3018373500 CDM 83735 CPT 301 RC inpatient 84 84 HEALTHPARTNERS SX009 HEALTHPARTNERS 66.51 percent of total billed charges 52.08 79.8 Technical (Hospital) Services Magnesium PX-3018373500 CDM 83735 CPT 301 RC inpatient 84 84 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES EPO [308136803] 66.51 percent of total billed charges 52.08 79.8 Technical (Hospital) Services Magnesium PX-3018373500 CDM 83735 CPT 301 RC inpatient 84 84 CIGNA 62308 [3081051] CIGNA 62308 [308105105] 66.51 percent of total billed charges 52.08 79.8 Technical (Hospital) Services Magnesium PX-3018373500 CDM 83735 CPT 301 RC inpatient 84 84 CIGNA 62308 [3081051] CIGNA STATE OF WYOMING [308105107] 66.51 percent of total billed charges 52.08 79.8 Technical (Hospital) Services Magnesium PX-3018373500 CDM 83735 CPT 301 RC inpatient 84 84 MULTIPLAN INC 34080 [3081285] MULTIPLAN INC [308128501] 79.8 percent of total billed charges 52.08 79.8 Technical (Hospital) Services Magnesium PX-3018373500 CDM 83735 CPT 301 RC inpatient 84 84 MEDICA (COMMERCIAL) 94265 [3081118] MEDICA CLAIMS [308111801] 75.6 percent of total billed charges 52.08 79.8 Technical (Hospital) Services Direct Ldl Cholesterol PX-3018372100 CDM 83721 CPT 301 RC inpatient 105 105 UNITED HEALTHCARE (COMMERCIAL) [3081199] UNITED HEALTHCARE 87726 [308119901] 65.1 percent of total billed charges 65.1 99.75 Technical (Hospital) Services Direct Ldl Cholesterol PX-3018372100 CDM 83721 CPT 301 RC inpatient 105 105 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES PPO [308136801] 83.14 percent of total billed charges 65.1 99.75 Technical (Hospital) Services Direct Ldl Cholesterol PX-3018372100 CDM 83721 CPT 301 RC inpatient 105 105 BLUE CROSS BLUE SHIELD WELLMARK SB889 [3081026] BCBS WYOMING [308102603] 99.75 percent of total billed charges 65.1 99.75 Technical (Hospital) Services Direct Ldl Cholesterol PX-3018372100 CDM 83721 CPT 301 RC inpatient 105 105 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES HDHP [308136802] 83.14 percent of total billed charges 65.1 99.75 Technical (Hospital) Services Direct Ldl Cholesterol PX-3018372100 CDM 83721 CPT 301 RC inpatient 105 105 CIGNA 62308 [3081051] CIGNA 62308 [308105105] 83.14 percent of total billed charges 65.1 99.75 Technical (Hospital) Services Direct Ldl Cholesterol PX-3018372100 CDM 83721 CPT 301 RC inpatient 105 105 CIGNA 62308 [3081051] CIGNA STATE OF WYOMING [308105107] 83.14 percent of total billed charges 65.1 99.75 Technical (Hospital) Services Direct Ldl Cholesterol PX-3018372100 CDM 83721 CPT 301 RC inpatient 105 105 MULTIPLAN INC 34080 [3081285] MULTIPLAN INC [308128501] 99.75 percent of total billed charges 65.1 99.75 Technical (Hospital) Services Direct Ldl Cholesterol PX-3018372100 CDM 83721 CPT 301 RC inpatient 105 105 MEDICA (COMMERCIAL) 94265 [3081118] MEDICA CLAIMS [308111801] 94.5 percent of total billed charges 65.1 99.75 Technical (Hospital) Services Direct Ldl Cholesterol PX-3018372100 CDM 83721 CPT 301 RC inpatient 105 105 HEALTHPARTNERS SX009 HEALTHPARTNERS 83.14 percent of total billed charges 65.1 99.75 Technical (Hospital) Services Direct Ldl Cholesterol PX-3018372100 CDM 83721 CPT 301 RC inpatient 105 105 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES EPO [308136803] 83.14 percent of total billed charges 65.1 99.75 Technical (Hospital) Services Direct Ldl Cholesterol PX-3018372100 CDM 83721 CPT 301 RC outpatient 105 105 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES EPO [308136803] 84 percent of total billed charges 65.1 99.75 Technical (Hospital) Services Direct Ldl Cholesterol PX-3018372100 CDM 83721 CPT 301 RC outpatient 105 105 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES HDHP [308136802] 84 percent of total billed charges 65.1 99.75 Technical (Hospital) Services Direct Ldl Cholesterol PX-3018372100 CDM 83721 CPT 301 RC outpatient 105 105 MULTIPLAN INC 34080 [3081285] MULTIPLAN INC [308128501] 99.75 percent of total billed charges 65.1 99.75 Technical (Hospital) Services Direct Ldl Cholesterol PX-3018372100 CDM 83721 CPT 301 RC outpatient 105 105 BLUE CROSS BLUE SHIELD WELLMARK SB889 [3081026] BCBS WYOMING [308102603] 99.75 percent of total billed charges 65.1 99.75 Technical (Hospital) Services Direct Ldl Cholesterol PX-3018372100 CDM 83721 CPT 301 RC outpatient 105 105 HEALTHPARTNERS SX009 HEALTHPARTNERS 84 percent of total billed charges 65.1 99.75 Technical (Hospital) Services Direct Ldl Cholesterol PX-3018372100 CDM 83721 CPT 301 RC outpatient 105 105 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES PPO [308136801] 84 percent of total billed charges 65.1 99.75 Technical (Hospital) Services Direct Ldl Cholesterol PX-3018372100 CDM 83721 CPT 301 RC outpatient 105 105 UNITED HEALTHCARE (COMMERCIAL) [3081199] UNITED HEALTHCARE 87726 [308119901] 65.1 percent of total billed charges 65.1 99.75 Technical (Hospital) Services Direct Ldl Cholesterol PX-3018372100 CDM 83721 CPT 301 RC outpatient 105 105 MEDICA (COMMERCIAL) 94265 [3081118] MEDICA CLAIMS [308111801] 94.5 percent of total billed charges 65.1 99.75 Technical (Hospital) Services Direct Ldl Cholesterol PX-3018372100 CDM 83721 CPT 301 RC outpatient 105 105 CIGNA 62308 [3081051] CIGNA 62308 [308105105] 84 percent of total billed charges 65.1 99.75 Technical (Hospital) Services Direct Ldl Cholesterol PX-3018372100 CDM 83721 CPT 301 RC outpatient 105 105 CIGNA 62308 [3081051] CIGNA STATE OF WYOMING [308105107] 84 percent of total billed charges 65.1 99.75 Technical (Hospital) Services Hdl High Dens Lipoprotein PX-3018371800 CDM 83718 CPT 301 RC outpatient 102 102 BLUE CROSS BLUE SHIELD WELLMARK SB889 [3081026] BCBS WYOMING [308102603] 96.9 percent of total billed charges 63.24 96.9 Technical (Hospital) Services Hdl High Dens Lipoprotein PX-3018371800 CDM 83718 CPT 301 RC outpatient 102 102 MULTIPLAN INC 34080 [3081285] MULTIPLAN INC [308128501] 96.9 percent of total billed charges 63.24 96.9 Technical (Hospital) Services Hdl High Dens Lipoprotein PX-3018371800 CDM 83718 CPT 301 RC outpatient 102 102 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES EPO [308136803] 81.6 percent of total billed charges 63.24 96.9 Technical (Hospital) Services Hdl High Dens Lipoprotein PX-3018371800 CDM 83718 CPT 301 RC outpatient 102 102 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES HDHP [308136802] 81.6 percent of total billed charges 63.24 96.9 Technical (Hospital) Services Hdl High Dens Lipoprotein PX-3018371800 CDM 83718 CPT 301 RC outpatient 102 102 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES PPO [308136801] 81.6 percent of total billed charges 63.24 96.9 Technical (Hospital) Services Hdl High Dens Lipoprotein PX-3018371800 CDM 83718 CPT 301 RC outpatient 102 102 HEALTHPARTNERS SX009 HEALTHPARTNERS 81.6 percent of total billed charges 63.24 96.9 Technical (Hospital) Services Hdl High Dens Lipoprotein PX-3018371800 CDM 83718 CPT 301 RC outpatient 102 102 UNITED HEALTHCARE (COMMERCIAL) [3081199] UNITED HEALTHCARE 87726 [308119901] 63.24 percent of total billed charges 63.24 96.9 Technical (Hospital) Services Hdl High Dens Lipoprotein PX-3018371800 CDM 83718 CPT 301 RC outpatient 102 102 CIGNA 62308 [3081051] CIGNA 62308 [308105105] 81.6 percent of total billed charges 63.24 96.9 Technical (Hospital) Services Hdl High Dens Lipoprotein PX-3018371800 CDM 83718 CPT 301 RC outpatient 102 102 CIGNA 62308 [3081051] CIGNA STATE OF WYOMING [308105107] 81.6 percent of total billed charges 63.24 96.9 Technical (Hospital) Services Hdl High Dens Lipoprotein PX-3018371800 CDM 83718 CPT 301 RC outpatient 102 102 MEDICA (COMMERCIAL) 94265 [3081118] MEDICA CLAIMS [308111801] 91.8 percent of total billed charges 63.24 96.9 Technical (Hospital) Services Hdl High Dens Lipoprotein PX-3018371800 CDM 83718 CPT 301 RC inpatient 102 102 HEALTHPARTNERS SX009 HEALTHPARTNERS 80.76 percent of total billed charges 63.24 96.9 Technical (Hospital) Services Hdl High Dens Lipoprotein PX-3018371800 CDM 83718 CPT 301 RC inpatient 102 102 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES EPO [308136803] 80.76 percent of total billed charges 63.24 96.9 Technical (Hospital) Services Hdl High Dens Lipoprotein PX-3018371800 CDM 83718 CPT 301 RC inpatient 102 102 CIGNA 62308 [3081051] CIGNA 62308 [308105105] 80.76 percent of total billed charges 63.24 96.9 Technical (Hospital) Services Hdl High Dens Lipoprotein PX-3018371800 CDM 83718 CPT 301 RC inpatient 102 102 CIGNA 62308 [3081051] CIGNA STATE OF WYOMING [308105107] 80.76 percent of total billed charges 63.24 96.9 Technical (Hospital) Services Hdl High Dens Lipoprotein PX-3018371800 CDM 83718 CPT 301 RC inpatient 102 102 MULTIPLAN INC 34080 [3081285] MULTIPLAN INC [308128501] 96.9 percent of total billed charges 63.24 96.9 Technical (Hospital) Services Hdl High Dens Lipoprotein PX-3018371800 CDM 83718 CPT 301 RC inpatient 102 102 MEDICA (COMMERCIAL) 94265 [3081118] MEDICA CLAIMS [308111801] 91.8 percent of total billed charges 63.24 96.9 Technical (Hospital) Services Hdl High Dens Lipoprotein PX-3018371800 CDM 83718 CPT 301 RC inpatient 102 102 BLUE CROSS BLUE SHIELD WELLMARK SB889 [3081026] BCBS WYOMING [308102603] 96.9 percent of total billed charges 63.24 96.9 Technical (Hospital) Services Hdl High Dens Lipoprotein PX-3018371800 CDM 83718 CPT 301 RC inpatient 102 102 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES HDHP [308136802] 80.76 percent of total billed charges 63.24 96.9 Technical (Hospital) Services Hdl High Dens Lipoprotein PX-3018371800 CDM 83718 CPT 301 RC inpatient 102 102 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES PPO [308136801] 80.76 percent of total billed charges 63.24 96.9 Technical (Hospital) Services Hdl High Dens Lipoprotein PX-3018371800 CDM 83718 CPT 301 RC inpatient 102 102 UNITED HEALTHCARE (COMMERCIAL) [3081199] UNITED HEALTHCARE 87726 [308119901] 63.24 percent of total billed charges 63.24 96.9 Technical (Hospital) Services Ref Lp(a) Cholesterol Serum PX-3018370001 CDM 83700 CPT 301 RC outpatient 253 253 HEALTHPARTNERS SX009 HEALTHPARTNERS 202.4 percent of total billed charges 156.86 240.35 Technical (Hospital) Services Ref Lp(a) Cholesterol Serum PX-3018370001 CDM 83700 CPT 301 RC outpatient 253 253 UNITED HEALTHCARE (COMMERCIAL) [3081199] UNITED HEALTHCARE 87726 [308119901] 156.86 percent of total billed charges 156.86 240.35 Technical (Hospital) Services Ref Lp(a) Cholesterol Serum PX-3018370001 CDM 83700 CPT 301 RC outpatient 253 253 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES PPO [308136801] 202.4 percent of total billed charges 156.86 240.35 Technical (Hospital) Services Ref Lp(a) Cholesterol Serum PX-3018370001 CDM 83700 CPT 301 RC outpatient 253 253 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES EPO [308136803] 202.4 percent of total billed charges 156.86 240.35 Technical (Hospital) Services Ref Lp(a) Cholesterol Serum PX-3018370001 CDM 83700 CPT 301 RC outpatient 253 253 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES HDHP [308136802] 202.4 percent of total billed charges 156.86 240.35 Technical (Hospital) Services Ref Lp(a) Cholesterol Serum PX-3018370001 CDM 83700 CPT 301 RC outpatient 253 253 MULTIPLAN INC 34080 [3081285] MULTIPLAN INC [308128501] 240.35 percent of total billed charges 156.86 240.35 Technical (Hospital) Services Ref Lp(a) Cholesterol Serum PX-3018370001 CDM 83700 CPT 301 RC outpatient 253 253 BLUE CROSS BLUE SHIELD WELLMARK SB889 [3081026] BCBS WYOMING [308102603] 240.35 percent of total billed charges 156.86 240.35 Technical (Hospital) Services Ref Lp(a) Cholesterol Serum PX-3018370001 CDM 83700 CPT 301 RC outpatient 253 253 MEDICA (COMMERCIAL) 94265 [3081118] MEDICA CLAIMS [308111801] 227.7 percent of total billed charges 156.86 240.35 Technical (Hospital) Services Ref Lp(a) Cholesterol Serum PX-3018370001 CDM 83700 CPT 301 RC outpatient 253 253 CIGNA 62308 [3081051] CIGNA 62308 [308105105] 202.4 percent of total billed charges 156.86 240.35 Technical (Hospital) Services Ref Lp(a) Cholesterol Serum PX-3018370001 CDM 83700 CPT 301 RC outpatient 253 253 CIGNA 62308 [3081051] CIGNA STATE OF WYOMING [308105107] 202.4 percent of total billed charges 156.86 240.35 Technical (Hospital) Services Ref Lp(a) Cholesterol Serum PX-3018370001 CDM 83700 CPT 301 RC inpatient 253 253 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES HDHP [308136802] 200.33 percent of total billed charges 156.86 240.35 Technical (Hospital) Services Ref Lp(a) Cholesterol Serum PX-3018370001 CDM 83700 CPT 301 RC inpatient 253 253 BLUE CROSS BLUE SHIELD WELLMARK SB889 [3081026] BCBS WYOMING [308102603] 240.35 percent of total billed charges 156.86 240.35 Technical (Hospital) Services Ref Lp(a) Cholesterol Serum PX-3018370001 CDM 83700 CPT 301 RC inpatient 253 253 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES PPO [308136801] 200.33 percent of total billed charges 156.86 240.35 Technical (Hospital) Services Ref Lp(a) Cholesterol Serum PX-3018370001 CDM 83700 CPT 301 RC inpatient 253 253 UNITED HEALTHCARE (COMMERCIAL) [3081199] UNITED HEALTHCARE 87726 [308119901] 156.86 percent of total billed charges 156.86 240.35 Technical (Hospital) Services Ref Lp(a) Cholesterol Serum PX-3018370001 CDM 83700 CPT 301 RC inpatient 253 253 MULTIPLAN INC 34080 [3081285] MULTIPLAN INC [308128501] 240.35 percent of total billed charges 156.86 240.35 Technical (Hospital) Services Ref Lp(a) Cholesterol Serum PX-3018370001 CDM 83700 CPT 301 RC inpatient 253 253 MEDICA (COMMERCIAL) 94265 [3081118] MEDICA CLAIMS [308111801] 227.7 percent of total billed charges 156.86 240.35 Technical (Hospital) Services Ref Lp(a) Cholesterol Serum PX-3018370001 CDM 83700 CPT 301 RC inpatient 253 253 CIGNA 62308 [3081051] CIGNA 62308 [308105105] 200.33 percent of total billed charges 156.86 240.35 Technical (Hospital) Services Ref Lp(a) Cholesterol Serum PX-3018370001 CDM 83700 CPT 301 RC inpatient 253 253 CIGNA 62308 [3081051] CIGNA STATE OF WYOMING [308105107] 200.33 percent of total billed charges 156.86 240.35 Technical (Hospital) Services Ref Lp(a) Cholesterol Serum PX-3018370001 CDM 83700 CPT 301 RC inpatient 253 253 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES EPO [308136803] 200.33 percent of total billed charges 156.86 240.35 Technical (Hospital) Services Ref Lp(a) Cholesterol Serum PX-3018370001 CDM 83700 CPT 301 RC inpatient 253 253 HEALTHPARTNERS SX009 HEALTHPARTNERS 200.33 percent of total billed charges 156.86 240.35 Technical (Hospital) Services Ref Lipoprotein a Serum PX-3018369500 CDM 83695 CPT 301 RC inpatient 238 238 UNITED HEALTHCARE (COMMERCIAL) [3081199] UNITED HEALTHCARE 87726 [308119901] 147.56 percent of total billed charges 147.56 226.1 Technical (Hospital) Services Ref Lipoprotein a Serum PX-3018369500 CDM 83695 CPT 301 RC inpatient 238 238 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES PPO [308136801] 188.45 percent of total billed charges 147.56 226.1 Technical (Hospital) Services Ref Lipoprotein a Serum PX-3018369500 CDM 83695 CPT 301 RC inpatient 238 238 BLUE CROSS BLUE SHIELD WELLMARK SB889 [3081026] BCBS WYOMING [308102603] 226.1 percent of total billed charges 147.56 226.1 Technical (Hospital) Services Ref Lipoprotein a Serum PX-3018369500 CDM 83695 CPT 301 RC inpatient 238 238 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES HDHP [308136802] 188.45 percent of total billed charges 147.56 226.1 Technical (Hospital) Services Ref Lipoprotein a Serum PX-3018369500 CDM 83695 CPT 301 RC inpatient 238 238 CIGNA 62308 [3081051] CIGNA 62308 [308105105] 188.45 percent of total billed charges 147.56 226.1 Technical (Hospital) Services Ref Lipoprotein a Serum PX-3018369500 CDM 83695 CPT 301 RC inpatient 238 238 CIGNA 62308 [3081051] CIGNA STATE OF WYOMING [308105107] 188.45 percent of total billed charges 147.56 226.1 Technical (Hospital) Services Ref Lipoprotein a Serum PX-3018369500 CDM 83695 CPT 301 RC inpatient 238 238 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES EPO [308136803] 188.45 percent of total billed charges 147.56 226.1 Technical (Hospital) Services Ref Lipoprotein a Serum PX-3018369500 CDM 83695 CPT 301 RC inpatient 238 238 HEALTHPARTNERS SX009 HEALTHPARTNERS 188.45 percent of total billed charges 147.56 226.1 Technical (Hospital) Services Ref Lipoprotein a Serum PX-3018369500 CDM 83695 CPT 301 RC inpatient 238 238 MULTIPLAN INC 34080 [3081285] MULTIPLAN INC [308128501] 226.1 percent of total billed charges 147.56 226.1 Technical (Hospital) Services Ref Lipoprotein a Serum PX-3018369500 CDM 83695 CPT 301 RC inpatient 238 238 MEDICA (COMMERCIAL) 94265 [3081118] MEDICA CLAIMS [308111801] 214.2 percent of total billed charges 147.56 226.1 Technical (Hospital) Services Ref Lipoprotein a Serum PX-3018369500 CDM 83695 CPT 301 RC outpatient 238 238 HEALTHPARTNERS SX009 HEALTHPARTNERS 190.4 percent of total billed charges 147.56 226.1 Technical (Hospital) Services Ref Lipoprotein a Serum PX-3018369500 CDM 83695 CPT 301 RC outpatient 238 238 UNITED HEALTHCARE (COMMERCIAL) [3081199] UNITED HEALTHCARE 87726 [308119901] 147.56 percent of total billed charges 147.56 226.1 Technical (Hospital) Services Ref Lipoprotein a Serum PX-3018369500 CDM 83695 CPT 301 RC outpatient 238 238 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES PPO [308136801] 190.4 percent of total billed charges 147.56 226.1 Technical (Hospital) Services Ref Lipoprotein a Serum PX-3018369500 CDM 83695 CPT 301 RC outpatient 238 238 BLUE CROSS BLUE SHIELD WELLMARK SB889 [3081026] BCBS WYOMING [308102603] 226.1 percent of total billed charges 147.56 226.1 Technical (Hospital) Services Ref Lipoprotein a Serum PX-3018369500 CDM 83695 CPT 301 RC outpatient 238 238 MULTIPLAN INC 34080 [3081285] MULTIPLAN INC [308128501] 226.1 percent of total billed charges 147.56 226.1 Technical (Hospital) Services Ref Lipoprotein a Serum PX-3018369500 CDM 83695 CPT 301 RC outpatient 238 238 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES HDHP [308136802] 190.4 percent of total billed charges 147.56 226.1 Technical (Hospital) Services Ref Lipoprotein a Serum PX-3018369500 CDM 83695 CPT 301 RC outpatient 238 238 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES EPO [308136803] 190.4 percent of total billed charges 147.56 226.1 Technical (Hospital) Services Ref Lipoprotein a Serum PX-3018369500 CDM 83695 CPT 301 RC outpatient 238 238 MEDICA (COMMERCIAL) 94265 [3081118] MEDICA CLAIMS [308111801] 214.2 percent of total billed charges 147.56 226.1 Technical (Hospital) Services Ref Lipoprotein a Serum PX-3018369500 CDM 83695 CPT 301 RC outpatient 238 238 CIGNA 62308 [3081051] CIGNA 62308 [308105105] 190.4 percent of total billed charges 147.56 226.1 Technical (Hospital) Services Ref Lipoprotein a Serum PX-3018369500 CDM 83695 CPT 301 RC outpatient 238 238 CIGNA 62308 [3081051] CIGNA STATE OF WYOMING [308105107] 190.4 percent of total billed charges 147.56 226.1 Technical (Hospital) Services Lipase PX-3018369000 CDM 83690 CPT 301 RC outpatient 120 120 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES PPO [308136801] 96 percent of total billed charges 74.4 114 Technical (Hospital) Services Lipase PX-3018369000 CDM 83690 CPT 301 RC outpatient 120 120 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES EPO [308136803] 96 percent of total billed charges 74.4 114 Technical (Hospital) Services Lipase PX-3018369000 CDM 83690 CPT 301 RC outpatient 120 120 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES HDHP [308136802] 96 percent of total billed charges 74.4 114 Technical (Hospital) Services Lipase PX-3018369000 CDM 83690 CPT 301 RC outpatient 120 120 MULTIPLAN INC 34080 [3081285] MULTIPLAN INC [308128501] 114 percent of total billed charges 74.4 114 Technical (Hospital) Services Lipase PX-3018369000 CDM 83690 CPT 301 RC outpatient 120 120 BLUE CROSS BLUE SHIELD WELLMARK SB889 [3081026] BCBS WYOMING [308102603] 114 percent of total billed charges 74.4 114 Technical (Hospital) Services Lipase PX-3018369000 CDM 83690 CPT 301 RC outpatient 120 120 HEALTHPARTNERS SX009 HEALTHPARTNERS 96 percent of total billed charges 74.4 114 Technical (Hospital) Services Lipase PX-3018369000 CDM 83690 CPT 301 RC outpatient 120 120 UNITED HEALTHCARE (COMMERCIAL) [3081199] UNITED HEALTHCARE 87726 [308119901] 74.4 percent of total billed charges 74.4 114 Technical (Hospital) Services Lipase PX-3018369000 CDM 83690 CPT 301 RC outpatient 120 120 MEDICA (COMMERCIAL) 94265 [3081118] MEDICA CLAIMS [308111801] 108 percent of total billed charges 74.4 114 Technical (Hospital) Services Lipase PX-3018369000 CDM 83690 CPT 301 RC outpatient 120 120 CIGNA 62308 [3081051] CIGNA 62308 [308105105] 96 percent of total billed charges 74.4 114 Technical (Hospital) Services Lipase PX-3018369000 CDM 83690 CPT 301 RC outpatient 120 120 CIGNA 62308 [3081051] CIGNA STATE OF WYOMING [308105107] 96 percent of total billed charges 74.4 114 Technical (Hospital) Services Lipase PX-3018369000 CDM 83690 CPT 301 RC inpatient 120 120 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES PPO [308136801] 95.02 percent of total billed charges 74.4 114 Technical (Hospital) Services Lipase PX-3018369000 CDM 83690 CPT 301 RC inpatient 120 120 UNITED HEALTHCARE (COMMERCIAL) [3081199] UNITED HEALTHCARE 87726 [308119901] 74.4 percent of total billed charges 74.4 114 Technical (Hospital) Services Lipase PX-3018369000 CDM 83690 CPT 301 RC inpatient 120 120 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES HDHP [308136802] 95.02 percent of total billed charges 74.4 114 Technical (Hospital) Services Lipase PX-3018369000 CDM 83690 CPT 301 RC inpatient 120 120 BLUE CROSS BLUE SHIELD WELLMARK SB889 [3081026] BCBS WYOMING [308102603] 114 percent of total billed charges 74.4 114 Technical (Hospital) Services Lipase PX-3018369000 CDM 83690 CPT 301 RC inpatient 120 120 MULTIPLAN INC 34080 [3081285] MULTIPLAN INC [308128501] 114 percent of total billed charges 74.4 114 Technical (Hospital) Services Lipase PX-3018369000 CDM 83690 CPT 301 RC inpatient 120 120 MEDICA (COMMERCIAL) 94265 [3081118] MEDICA CLAIMS [308111801] 108 percent of total billed charges 74.4 114 Technical (Hospital) Services Lipase PX-3018369000 CDM 83690 CPT 301 RC inpatient 120 120 CIGNA 62308 [3081051] CIGNA 62308 [308105105] 95.02 percent of total billed charges 74.4 114 Technical (Hospital) Services Lipase PX-3018369000 CDM 83690 CPT 301 RC inpatient 120 120 CIGNA 62308 [3081051] CIGNA STATE OF WYOMING [308105107] 95.02 percent of total billed charges 74.4 114 Technical (Hospital) Services Lipase PX-3018369000 CDM 83690 CPT 301 RC inpatient 120 120 HEALTHPARTNERS SX009 HEALTHPARTNERS 95.02 percent of total billed charges 74.4 114 Technical (Hospital) Services Lipase PX-3018369000 CDM 83690 CPT 301 RC inpatient 120 120 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES EPO [308136803] 95.02 percent of total billed charges 74.4 114 Technical (Hospital) Services Heavy Metal Lead Wb PX-3018365500 CDM 83655 CPT 301 RC inpatient 133 133 BLUE CROSS BLUE SHIELD WELLMARK SB889 [3081026] BCBS WYOMING [308102603] 126.35 percent of total billed charges 82.46 126.35 Technical (Hospital) Services Heavy Metal Lead Wb PX-3018365500 CDM 83655 CPT 301 RC inpatient 133 133 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES HDHP [308136802] 105.31 percent of total billed charges 82.46 126.35 Technical (Hospital) Services Heavy Metal Lead Wb PX-3018365500 CDM 83655 CPT 301 RC inpatient 133 133 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES PPO [308136801] 105.31 percent of total billed charges 82.46 126.35 Technical (Hospital) Services Heavy Metal Lead Wb PX-3018365500 CDM 83655 CPT 301 RC inpatient 133 133 UNITED HEALTHCARE (COMMERCIAL) [3081199] UNITED HEALTHCARE 87726 [308119901] 82.46 percent of total billed charges 82.46 126.35 Technical (Hospital) Services Heavy Metal Lead Wb PX-3018365500 CDM 83655 CPT 301 RC inpatient 133 133 HEALTHPARTNERS SX009 HEALTHPARTNERS 105.31 percent of total billed charges 82.46 126.35 Technical (Hospital) Services Heavy Metal Lead Wb PX-3018365500 CDM 83655 CPT 301 RC inpatient 133 133 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES EPO [308136803] 105.31 percent of total billed charges 82.46 126.35 Technical (Hospital) Services Heavy Metal Lead Wb PX-3018365500 CDM 83655 CPT 301 RC inpatient 133 133 MEDICA (COMMERCIAL) 94265 [3081118] MEDICA CLAIMS [308111801] 119.7 percent of total billed charges 82.46 126.35 Technical (Hospital) Services Heavy Metal Lead Wb PX-3018365500 CDM 83655 CPT 301 RC inpatient 133 133 MULTIPLAN INC 34080 [3081285] MULTIPLAN INC [308128501] 126.35 percent of total billed charges 82.46 126.35 Technical (Hospital) Services Heavy Metal Lead Wb PX-3018365500 CDM 83655 CPT 301 RC inpatient 133 133 CIGNA 62308 [3081051] CIGNA 62308 [308105105] 105.31 percent of total billed charges 82.46 126.35 Technical (Hospital) Services Heavy Metal Lead Wb PX-3018365500 CDM 83655 CPT 301 RC inpatient 133 133 CIGNA 62308 [3081051] CIGNA STATE OF WYOMING [308105107] 105.31 percent of total billed charges 82.46 126.35 Technical (Hospital) Services Heavy Metal Lead Wb PX-3018365500 CDM 83655 CPT 301 RC outpatient 133 133 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES PPO [308136801] 106.4 percent of total billed charges 82.46 126.35 Technical (Hospital) Services Heavy Metal Lead Wb PX-3018365500 CDM 83655 CPT 301 RC outpatient 133 133 MULTIPLAN INC 34080 [3081285] MULTIPLAN INC [308128501] 126.35 percent of total billed charges 82.46 126.35 Technical (Hospital) Services Heavy Metal Lead Wb PX-3018365500 CDM 83655 CPT 301 RC outpatient 133 133 BLUE CROSS BLUE SHIELD WELLMARK SB889 [3081026] BCBS WYOMING [308102603] 126.35 percent of total billed charges 82.46 126.35 Technical (Hospital) Services Heavy Metal Lead Wb PX-3018365500 CDM 83655 CPT 301 RC outpatient 133 133 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES EPO [308136803] 106.4 percent of total billed charges 82.46 126.35 Technical (Hospital) Services Heavy Metal Lead Wb PX-3018365500 CDM 83655 CPT 301 RC outpatient 133 133 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES HDHP [308136802] 106.4 percent of total billed charges 82.46 126.35 Technical (Hospital) Services Heavy Metal Lead Wb PX-3018365500 CDM 83655 CPT 301 RC outpatient 133 133 HEALTHPARTNERS SX009 HEALTHPARTNERS 106.4 percent of total billed charges 82.46 126.35 Technical (Hospital) Services Heavy Metal Lead Wb PX-3018365500 CDM 83655 CPT 301 RC outpatient 133 133 UNITED HEALTHCARE (COMMERCIAL) [3081199] UNITED HEALTHCARE 87726 [308119901] 82.46 percent of total billed charges 82.46 126.35 Technical (Hospital) Services Heavy Metal Lead Wb PX-3018365500 CDM 83655 CPT 301 RC outpatient 133 133 MEDICA (COMMERCIAL) 94265 [3081118] MEDICA CLAIMS [308111801] 119.7 percent of total billed charges 82.46 126.35 Technical (Hospital) Services Heavy Metal Lead Wb PX-3018365500 CDM 83655 CPT 301 RC outpatient 133 133 CIGNA 62308 [3081051] CIGNA 62308 [308105105] 106.4 percent of total billed charges 82.46 126.35 Technical (Hospital) Services Heavy Metal Lead Wb PX-3018365500 CDM 83655 CPT 301 RC outpatient 133 133 CIGNA 62308 [3081051] CIGNA STATE OF WYOMING [308105107] 106.4 percent of total billed charges 82.46 126.35 Technical (Hospital) Services Ref Heavy Metals Scrn UR Lead PX-3018365502 CDM 83655 CPT 301 RC outpatient 129 129 UNITED HEALTHCARE (COMMERCIAL) [3081199] UNITED HEALTHCARE 87726 [308119901] 79.98 percent of total billed charges 79.98 122.55 Technical (Hospital) Services Ref Heavy Metals Scrn UR Lead PX-3018365502 CDM 83655 CPT 301 RC outpatient 129 129 HEALTHPARTNERS SX009 HEALTHPARTNERS 103.2 percent of total billed charges 79.98 122.55 Technical (Hospital) Services Ref Heavy Metals Scrn UR Lead PX-3018365502 CDM 83655 CPT 301 RC outpatient 129 129 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES PPO [308136801] 103.2 percent of total billed charges 79.98 122.55 Technical (Hospital) Services Ref Heavy Metals Scrn UR Lead PX-3018365502 CDM 83655 CPT 301 RC outpatient 129 129 BLUE CROSS BLUE SHIELD WELLMARK SB889 [3081026] BCBS WYOMING [308102603] 122.55 percent of total billed charges 79.98 122.55 Technical (Hospital) Services Ref Heavy Metals Scrn UR Lead PX-3018365502 CDM 83655 CPT 301 RC outpatient 129 129 MULTIPLAN INC 34080 [3081285] MULTIPLAN INC [308128501] 122.55 percent of total billed charges 79.98 122.55 Technical (Hospital) Services Ref Heavy Metals Scrn UR Lead PX-3018365502 CDM 83655 CPT 301 RC outpatient 129 129 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES HDHP [308136802] 103.2 percent of total billed charges 79.98 122.55 Technical (Hospital) Services Ref Heavy Metals Scrn UR Lead PX-3018365502 CDM 83655 CPT 301 RC outpatient 129 129 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES EPO [308136803] 103.2 percent of total billed charges 79.98 122.55 Technical (Hospital) Services Ref Heavy Metals Scrn UR Lead PX-3018365502 CDM 83655 CPT 301 RC outpatient 129 129 MEDICA (COMMERCIAL) 94265 [3081118] MEDICA CLAIMS [308111801] 116.1 percent of total billed charges 79.98 122.55 Technical (Hospital) Services Ref Heavy Metals Scrn UR Lead PX-3018365502 CDM 83655 CPT 301 RC outpatient 129 129 CIGNA 62308 [3081051] CIGNA 62308 [308105105] 103.2 percent of total billed charges 79.98 122.55 Technical (Hospital) Services Ref Heavy Metals Scrn UR Lead PX-3018365502 CDM 83655 CPT 301 RC outpatient 129 129 CIGNA 62308 [3081051] CIGNA STATE OF WYOMING [308105107] 103.2 percent of total billed charges 79.98 122.55 Technical (Hospital) Services Ref Heavy Metals Scrn UR Lead PX-3018365502 CDM 83655 CPT 301 RC inpatient 129 129 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES PPO [308136801] 102.14 percent of total billed charges 79.98 122.55 Technical (Hospital) Services Ref Heavy Metals Scrn UR Lead PX-3018365502 CDM 83655 CPT 301 RC inpatient 129 129 UNITED HEALTHCARE (COMMERCIAL) [3081199] UNITED HEALTHCARE 87726 [308119901] 79.98 percent of total billed charges 79.98 122.55 Technical (Hospital) Services Ref Heavy Metals Scrn UR Lead PX-3018365502 CDM 83655 CPT 301 RC inpatient 129 129 BLUE CROSS BLUE SHIELD WELLMARK SB889 [3081026] BCBS WYOMING [308102603] 122.55 percent of total billed charges 79.98 122.55 Technical (Hospital) Services Ref Heavy Metals Scrn UR Lead PX-3018365502 CDM 83655 CPT 301 RC inpatient 129 129 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES HDHP [308136802] 102.14 percent of total billed charges 79.98 122.55 Technical (Hospital) Services Ref Heavy Metals Scrn UR Lead PX-3018365502 CDM 83655 CPT 301 RC inpatient 129 129 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES EPO [308136803] 102.14 percent of total billed charges 79.98 122.55 Technical (Hospital) Services Ref Heavy Metals Scrn UR Lead PX-3018365502 CDM 83655 CPT 301 RC inpatient 129 129 HEALTHPARTNERS SX009 HEALTHPARTNERS 102.14 percent of total billed charges 79.98 122.55 Technical (Hospital) Services Ref Heavy Metals Scrn UR Lead PX-3018365502 CDM 83655 CPT 301 RC inpatient 129 129 CIGNA 62308 [3081051] CIGNA 62308 [308105105] 102.14 percent of total billed charges 79.98 122.55 Technical (Hospital) Services Ref Heavy Metals Scrn UR Lead PX-3018365502 CDM 83655 CPT 301 RC inpatient 129 129 CIGNA 62308 [3081051] CIGNA STATE OF WYOMING [308105107] 102.14 percent of total billed charges 79.98 122.55 Technical (Hospital) Services Ref Heavy Metals Scrn UR Lead PX-3018365502 CDM 83655 CPT 301 RC inpatient 129 129 MULTIPLAN INC 34080 [3081285] MULTIPLAN INC [308128501] 122.55 percent of total billed charges 79.98 122.55 Technical (Hospital) Services Ref Heavy Metals Scrn UR Lead PX-3018365502 CDM 83655 CPT 301 RC inpatient 129 129 MEDICA (COMMERCIAL) 94265 [3081118] MEDICA CLAIMS [308111801] 116.1 percent of total billed charges 79.98 122.55 Technical (Hospital) Services Ref Ldh Isoenzymes S PX-3018362501 CDM 83625 CPT 301 RC outpatient 153 153 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES PPO [308136801] 122.4 percent of total billed charges 94.86 145.35 Technical (Hospital) Services Ref Ldh Isoenzymes S PX-3018362501 CDM 83625 CPT 301 RC outpatient 153 153 MULTIPLAN INC 34080 [3081285] MULTIPLAN INC [308128501] 145.35 percent of total billed charges 94.86 145.35 Technical (Hospital) Services Ref Ldh Isoenzymes S PX-3018362501 CDM 83625 CPT 301 RC outpatient 153 153 BLUE CROSS BLUE SHIELD WELLMARK SB889 [3081026] BCBS WYOMING [308102603] 145.35 percent of total billed charges 94.86 145.35 Technical (Hospital) Services Ref Ldh Isoenzymes S PX-3018362501 CDM 83625 CPT 301 RC outpatient 153 153 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES EPO [308136803] 122.4 percent of total billed charges 94.86 145.35 Technical (Hospital) Services Ref Ldh Isoenzymes S PX-3018362501 CDM 83625 CPT 301 RC outpatient 153 153 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES HDHP [308136802] 122.4 percent of total billed charges 94.86 145.35 Technical (Hospital) Services Ref Ldh Isoenzymes S PX-3018362501 CDM 83625 CPT 301 RC outpatient 153 153 UNITED HEALTHCARE (COMMERCIAL) [3081199] UNITED HEALTHCARE 87726 [308119901] 94.86 percent of total billed charges 94.86 145.35 Technical (Hospital) Services Ref Ldh Isoenzymes S PX-3018362501 CDM 83625 CPT 301 RC outpatient 153 153 HEALTHPARTNERS SX009 HEALTHPARTNERS 122.4 percent of total billed charges 94.86 145.35 Technical (Hospital) Services Ref Ldh Isoenzymes S PX-3018362501 CDM 83625 CPT 301 RC outpatient 153 153 MEDICA (COMMERCIAL) 94265 [3081118] MEDICA CLAIMS [308111801] 137.7 percent of total billed charges 94.86 145.35 Technical (Hospital) Services Ref Ldh Isoenzymes S PX-3018362501 CDM 83625 CPT 301 RC outpatient 153 153 CIGNA 62308 [3081051] CIGNA 62308 [308105105] 122.4 percent of total billed charges 94.86 145.35 Technical (Hospital) Services Ref Ldh Isoenzymes S PX-3018362501 CDM 83625 CPT 301 RC outpatient 153 153 CIGNA 62308 [3081051] CIGNA STATE OF WYOMING [308105107] 122.4 percent of total billed charges 94.86 145.35 Technical (Hospital) Services Ref Ldh Isoenzymes S PX-3018362501 CDM 83625 CPT 301 RC inpatient 153 153 MEDICA (COMMERCIAL) 94265 [3081118] MEDICA CLAIMS [308111801] 137.7 percent of total billed charges 94.86 145.35 Technical (Hospital) Services Ref Ldh Isoenzymes S PX-3018362501 CDM 83625 CPT 301 RC inpatient 153 153 MULTIPLAN INC 34080 [3081285] MULTIPLAN INC [308128501] 145.35 percent of total billed charges 94.86 145.35 Technical (Hospital) Services Ref Ldh Isoenzymes S PX-3018362501 CDM 83625 CPT 301 RC inpatient 153 153 HEALTHPARTNERS SX009 HEALTHPARTNERS 121.15 percent of total billed charges 94.86 145.35 Technical (Hospital) Services Ref Ldh Isoenzymes S PX-3018362501 CDM 83625 CPT 301 RC inpatient 153 153 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES EPO [308136803] 121.15 percent of total billed charges 94.86 145.35 Technical (Hospital) Services Ref Ldh Isoenzymes S PX-3018362501 CDM 83625 CPT 301 RC inpatient 153 153 CIGNA 62308 [3081051] CIGNA 62308 [308105105] 121.15 percent of total billed charges 94.86 145.35 Technical (Hospital) Services Ref Ldh Isoenzymes S PX-3018362501 CDM 83625 CPT 301 RC inpatient 153 153 CIGNA 62308 [3081051] CIGNA STATE OF WYOMING [308105107] 121.15 percent of total billed charges 94.86 145.35 Technical (Hospital) Services Ref Ldh Isoenzymes S PX-3018362501 CDM 83625 CPT 301 RC inpatient 153 153 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES HDHP [308136802] 121.15 percent of total billed charges 94.86 145.35 Technical (Hospital) Services Ref Ldh Isoenzymes S PX-3018362501 CDM 83625 CPT 301 RC inpatient 153 153 BLUE CROSS BLUE SHIELD WELLMARK SB889 [3081026] BCBS WYOMING [308102603] 145.35 percent of total billed charges 94.86 145.35 Technical (Hospital) Services Ref Ldh Isoenzymes S PX-3018362501 CDM 83625 CPT 301 RC inpatient 153 153 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES PPO [308136801] 121.15 percent of total billed charges 94.86 145.35 Technical (Hospital) Services Ref Ldh Isoenzymes S PX-3018362501 CDM 83625 CPT 301 RC inpatient 153 153 UNITED HEALTHCARE (COMMERCIAL) [3081199] UNITED HEALTHCARE 87726 [308119901] 94.86 percent of total billed charges 94.86 145.35 Technical (Hospital) Services LDH PX-3018361500 CDM 83615 CPT 301 RC inpatient 61 61 CIGNA 62308 [3081051] CIGNA 62308 [308105105] 48.3 percent of total billed charges 37.82 57.95 Technical (Hospital) Services LDH PX-3018361500 CDM 83615 CPT 301 RC inpatient 61 61 CIGNA 62308 [3081051] CIGNA STATE OF WYOMING [308105107] 48.3 percent of total billed charges 37.82 57.95 Technical (Hospital) Services LDH PX-3018361500 CDM 83615 CPT 301 RC inpatient 61 61 MULTIPLAN INC 34080 [3081285] MULTIPLAN INC [308128501] 57.95 percent of total billed charges 37.82 57.95 Technical (Hospital) Services LDH PX-3018361500 CDM 83615 CPT 301 RC inpatient 61 61 MEDICA (COMMERCIAL) 94265 [3081118] MEDICA CLAIMS [308111801] 54.9 percent of total billed charges 37.82 57.95 Technical (Hospital) Services LDH PX-3018361500 CDM 83615 CPT 301 RC inpatient 61 61 HEALTHPARTNERS SX009 HEALTHPARTNERS 48.3 percent of total billed charges 37.82 57.95 Technical (Hospital) Services LDH PX-3018361500 CDM 83615 CPT 301 RC inpatient 61 61 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES EPO [308136803] 48.3 percent of total billed charges 37.82 57.95 Technical (Hospital) Services LDH PX-3018361500 CDM 83615 CPT 301 RC inpatient 61 61 UNITED HEALTHCARE (COMMERCIAL) [3081199] UNITED HEALTHCARE 87726 [308119901] 37.82 percent of total billed charges 37.82 57.95 Technical (Hospital) Services LDH PX-3018361500 CDM 83615 CPT 301 RC inpatient 61 61 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES PPO [308136801] 48.3 percent of total billed charges 37.82 57.95 Technical (Hospital) Services LDH PX-3018361500 CDM 83615 CPT 301 RC inpatient 61 61 BLUE CROSS BLUE SHIELD WELLMARK SB889 [3081026] BCBS WYOMING [308102603] 57.95 percent of total billed charges 37.82 57.95 Technical (Hospital) Services LDH PX-3018361500 CDM 83615 CPT 301 RC inpatient 61 61 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES HDHP [308136802] 48.3 percent of total billed charges 37.82 57.95 Technical (Hospital) Services LDH PX-3018361500 CDM 83615 CPT 301 RC outpatient 61 61 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES PPO [308136801] 48.8 percent of total billed charges 37.82 57.95 Technical (Hospital) Services LDH PX-3018361500 CDM 83615 CPT 301 RC outpatient 61 61 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES EPO [308136803] 48.8 percent of total billed charges 37.82 57.95 Technical (Hospital) Services LDH PX-3018361500 CDM 83615 CPT 301 RC outpatient 61 61 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES HDHP [308136802] 48.8 percent of total billed charges 37.82 57.95 Technical (Hospital) Services LDH PX-3018361500 CDM 83615 CPT 301 RC outpatient 61 61 MULTIPLAN INC 34080 [3081285] MULTIPLAN INC [308128501] 57.95 percent of total billed charges 37.82 57.95 Technical (Hospital) Services LDH PX-3018361500 CDM 83615 CPT 301 RC outpatient 61 61 BLUE CROSS BLUE SHIELD WELLMARK SB889 [3081026] BCBS WYOMING [308102603] 57.95 percent of total billed charges 37.82 57.95 Technical (Hospital) Services LDH PX-3018361500 CDM 83615 CPT 301 RC outpatient 61 61 HEALTHPARTNERS SX009 HEALTHPARTNERS 48.8 percent of total billed charges 37.82 57.95 Technical (Hospital) Services LDH PX-3018361500 CDM 83615 CPT 301 RC outpatient 61 61 UNITED HEALTHCARE (COMMERCIAL) [3081199] UNITED HEALTHCARE 87726 [308119901] 37.82 percent of total billed charges 37.82 57.95 Technical (Hospital) Services LDH PX-3018361500 CDM 83615 CPT 301 RC outpatient 61 61 MEDICA (COMMERCIAL) 94265 [3081118] MEDICA CLAIMS [308111801] 54.9 percent of total billed charges 37.82 57.95 Technical (Hospital) Services LDH PX-3018361500 CDM 83615 CPT 301 RC outpatient 61 61 CIGNA 62308 [3081051] CIGNA 62308 [308105105] 48.8 percent of total billed charges 37.82 57.95 Technical (Hospital) Services LDH PX-3018361500 CDM 83615 CPT 301 RC outpatient 61 61 CIGNA 62308 [3081051] CIGNA STATE OF WYOMING [308105107] 48.8 percent of total billed charges 37.82 57.95 Technical (Hospital) Services Ref Ldh Total PX-3018361501 CDM 83615 CPT 301 RC inpatient 63 63 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES EPO [308136803] 49.88 percent of total billed charges 39.06 59.85 Technical (Hospital) Services Ref Ldh Total PX-3018361501 CDM 83615 CPT 301 RC inpatient 63 63 HEALTHPARTNERS SX009 HEALTHPARTNERS 49.88 percent of total billed charges 39.06 59.85 Technical (Hospital) Services Ref Ldh Total PX-3018361501 CDM 83615 CPT 301 RC inpatient 63 63 MEDICA (COMMERCIAL) 94265 [3081118] MEDICA CLAIMS [308111801] 56.7 percent of total billed charges 39.06 59.85 Technical (Hospital) Services Ref Ldh Total PX-3018361501 CDM 83615 CPT 301 RC inpatient 63 63 MULTIPLAN INC 34080 [3081285] MULTIPLAN INC [308128501] 59.85 percent of total billed charges 39.06 59.85 Technical (Hospital) Services Ref Ldh Total PX-3018361501 CDM 83615 CPT 301 RC inpatient 63 63 CIGNA 62308 [3081051] CIGNA 62308 [308105105] 49.88 percent of total billed charges 39.06 59.85 Technical (Hospital) Services Ref Ldh Total PX-3018361501 CDM 83615 CPT 301 RC inpatient 63 63 CIGNA 62308 [3081051] CIGNA STATE OF WYOMING [308105107] 49.88 percent of total billed charges 39.06 59.85 Technical (Hospital) Services Ref Ldh Total PX-3018361501 CDM 83615 CPT 301 RC inpatient 63 63 BLUE CROSS BLUE SHIELD WELLMARK SB889 [3081026] BCBS WYOMING [308102603] 59.85 percent of total billed charges 39.06 59.85 Technical (Hospital) Services Ref Ldh Total PX-3018361501 CDM 83615 CPT 301 RC inpatient 63 63 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES HDHP [308136802] 49.88 percent of total billed charges 39.06 59.85 Technical (Hospital) Services Ref Ldh Total PX-3018361501 CDM 83615 CPT 301 RC inpatient 63 63 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES PPO [308136801] 49.88 percent of total billed charges 39.06 59.85 Technical (Hospital) Services Ref Ldh Total PX-3018361501 CDM 83615 CPT 301 RC inpatient 63 63 UNITED HEALTHCARE (COMMERCIAL) [3081199] UNITED HEALTHCARE 87726 [308119901] 39.06 percent of total billed charges 39.06 59.85 Technical (Hospital) Services Ref Ldh Total PX-3018361501 CDM 83615 CPT 301 RC outpatient 63 63 HEALTHPARTNERS SX009 HEALTHPARTNERS 50.4 percent of total billed charges 39.06 59.85 Technical (Hospital) Services Ref Ldh Total PX-3018361501 CDM 83615 CPT 301 RC outpatient 63 63 UNITED HEALTHCARE (COMMERCIAL) [3081199] UNITED HEALTHCARE 87726 [308119901] 39.06 percent of total billed charges 39.06 59.85 Technical (Hospital) Services Ref Ldh Total PX-3018361501 CDM 83615 CPT 301 RC outpatient 63 63 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES PPO [308136801] 50.4 percent of total billed charges 39.06 59.85 Technical (Hospital) Services Ref Ldh Total PX-3018361501 CDM 83615 CPT 301 RC outpatient 63 63 BLUE CROSS BLUE SHIELD WELLMARK SB889 [3081026] BCBS WYOMING [308102603] 59.85 percent of total billed charges 39.06 59.85 Technical (Hospital) Services Ref Ldh Total PX-3018361501 CDM 83615 CPT 301 RC outpatient 63 63 MULTIPLAN INC 34080 [3081285] MULTIPLAN INC [308128501] 59.85 percent of total billed charges 39.06 59.85 Technical (Hospital) Services Ref Ldh Total PX-3018361501 CDM 83615 CPT 301 RC outpatient 63 63 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES HDHP [308136802] 50.4 percent of total billed charges 39.06 59.85 Technical (Hospital) Services Ref Ldh Total PX-3018361501 CDM 83615 CPT 301 RC outpatient 63 63 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES EPO [308136803] 50.4 percent of total billed charges 39.06 59.85 Technical (Hospital) Services Ref Ldh Total PX-3018361501 CDM 83615 CPT 301 RC outpatient 63 63 CIGNA 62308 [3081051] CIGNA 62308 [308105105] 50.4 percent of total billed charges 39.06 59.85 Technical (Hospital) Services Ref Ldh Total PX-3018361501 CDM 83615 CPT 301 RC outpatient 63 63 CIGNA 62308 [3081051] CIGNA STATE OF WYOMING [308105107] 50.4 percent of total billed charges 39.06 59.85 Technical (Hospital) Services Ref Ldh Total PX-3018361501 CDM 83615 CPT 301 RC outpatient 63 63 MEDICA (COMMERCIAL) 94265 [3081118] MEDICA CLAIMS [308111801] 56.7 percent of total billed charges 39.06 59.85 Technical (Hospital) Services Lactic Acid PX-3018360500 CDM 83605 CPT 301 RC inpatient 160 160 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES HDHP [308136802] 126.69 percent of total billed charges 99.2 152 Technical (Hospital) Services Lactic Acid PX-3018360500 CDM 83605 CPT 301 RC inpatient 160 160 BLUE CROSS BLUE SHIELD WELLMARK SB889 [3081026] BCBS WYOMING [308102603] 152 percent of total billed charges 99.2 152 Technical (Hospital) Services Lactic Acid PX-3018360500 CDM 83605 CPT 301 RC inpatient 160 160 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES PPO [308136801] 126.69 percent of total billed charges 99.2 152 Technical (Hospital) Services Lactic Acid PX-3018360500 CDM 83605 CPT 301 RC inpatient 160 160 UNITED HEALTHCARE (COMMERCIAL) [3081199] UNITED HEALTHCARE 87726 [308119901] 99.2 percent of total billed charges 99.2 152 Technical (Hospital) Services Lactic Acid PX-3018360500 CDM 83605 CPT 301 RC inpatient 160 160 CIGNA 62308 [3081051] CIGNA 62308 [308105105] 126.69 percent of total billed charges 99.2 152 Technical (Hospital) Services Lactic Acid PX-3018360500 CDM 83605 CPT 301 RC inpatient 160 160 CIGNA 62308 [3081051] CIGNA STATE OF WYOMING [308105107] 126.69 percent of total billed charges 99.2 152 Technical (Hospital) Services Lactic Acid PX-3018360500 CDM 83605 CPT 301 RC inpatient 160 160 MEDICA (COMMERCIAL) 94265 [3081118] MEDICA CLAIMS [308111801] 144 percent of total billed charges 99.2 152 Technical (Hospital) Services Lactic Acid PX-3018360500 CDM 83605 CPT 301 RC inpatient 160 160 MULTIPLAN INC 34080 [3081285] MULTIPLAN INC [308128501] 152 percent of total billed charges 99.2 152 Technical (Hospital) Services Lactic Acid PX-3018360500 CDM 83605 CPT 301 RC inpatient 160 160 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES EPO [308136803] 126.69 percent of total billed charges 99.2 152 Technical (Hospital) Services Lactic Acid PX-3018360500 CDM 83605 CPT 301 RC inpatient 160 160 HEALTHPARTNERS SX009 HEALTHPARTNERS 126.69 percent of total billed charges 99.2 152 Technical (Hospital) Services Lactic Acid PX-3018360500 CDM 83605 CPT 301 RC outpatient 160 160 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES EPO [308136803] 128 percent of total billed charges 99.2 152 Technical (Hospital) Services Lactic Acid PX-3018360500 CDM 83605 CPT 301 RC outpatient 160 160 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES HDHP [308136802] 128 percent of total billed charges 99.2 152 Technical (Hospital) Services Lactic Acid PX-3018360500 CDM 83605 CPT 301 RC outpatient 160 160 BLUE CROSS BLUE SHIELD WELLMARK SB889 [3081026] BCBS WYOMING [308102603] 152 percent of total billed charges 99.2 152 Technical (Hospital) Services Lactic Acid PX-3018360500 CDM 83605 CPT 301 RC outpatient 160 160 MULTIPLAN INC 34080 [3081285] MULTIPLAN INC [308128501] 152 percent of total billed charges 99.2 152 Technical (Hospital) Services Lactic Acid PX-3018360500 CDM 83605 CPT 301 RC outpatient 160 160 UNITED HEALTHCARE (COMMERCIAL) [3081199] UNITED HEALTHCARE 87726 [308119901] 99.2 percent of total billed charges 99.2 152 Technical (Hospital) Services Lactic Acid PX-3018360500 CDM 83605 CPT 301 RC outpatient 160 160 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES PPO [308136801] 128 percent of total billed charges 99.2 152 Technical (Hospital) Services Lactic Acid PX-3018360500 CDM 83605 CPT 301 RC outpatient 160 160 HEALTHPARTNERS SX009 HEALTHPARTNERS 128 percent of total billed charges 99.2 152 Technical (Hospital) Services Lactic Acid PX-3018360500 CDM 83605 CPT 301 RC outpatient 160 160 MEDICA (COMMERCIAL) 94265 [3081118] MEDICA CLAIMS [308111801] 144 percent of total billed charges 99.2 152 Technical (Hospital) Services Lactic Acid PX-3018360500 CDM 83605 CPT 301 RC outpatient 160 160 CIGNA 62308 [3081051] CIGNA 62308 [308105105] 128 percent of total billed charges 99.2 152 Technical (Hospital) Services Lactic Acid PX-3018360500 CDM 83605 CPT 301 RC outpatient 160 160 CIGNA 62308 [3081051] CIGNA STATE OF WYOMING [308105107] 128 percent of total billed charges 99.2 152 Technical (Hospital) Services Iron Bind Serum PX-3018355000 CDM 83550 CPT 301 RC outpatient 90 90 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES PPO [308136801] 72 percent of total billed charges 55.8 85.5 Technical (Hospital) Services Iron Bind Serum PX-3018355000 CDM 83550 CPT 301 RC outpatient 90 90 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES HDHP [308136802] 72 percent of total billed charges 55.8 85.5 Technical (Hospital) Services Iron Bind Serum PX-3018355000 CDM 83550 CPT 301 RC outpatient 90 90 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES EPO [308136803] 72 percent of total billed charges 55.8 85.5 Technical (Hospital) Services Iron Bind Serum PX-3018355000 CDM 83550 CPT 301 RC outpatient 90 90 MULTIPLAN INC 34080 [3081285] MULTIPLAN INC [308128501] 85.5 percent of total billed charges 55.8 85.5 Technical (Hospital) Services Iron Bind Serum PX-3018355000 CDM 83550 CPT 301 RC outpatient 90 90 BLUE CROSS BLUE SHIELD WELLMARK SB889 [3081026] BCBS WYOMING [308102603] 85.5 percent of total billed charges 55.8 85.5 Technical (Hospital) Services Iron Bind Serum PX-3018355000 CDM 83550 CPT 301 RC outpatient 90 90 UNITED HEALTHCARE (COMMERCIAL) [3081199] UNITED HEALTHCARE 87726 [308119901] 55.8 percent of total billed charges 55.8 85.5 Technical (Hospital) Services Iron Bind Serum PX-3018355000 CDM 83550 CPT 301 RC outpatient 90 90 HEALTHPARTNERS SX009 HEALTHPARTNERS 72 percent of total billed charges 55.8 85.5 Technical (Hospital) Services Iron Bind Serum PX-3018355000 CDM 83550 CPT 301 RC outpatient 90 90 MEDICA (COMMERCIAL) 94265 [3081118] MEDICA CLAIMS [308111801] 81 percent of total billed charges 55.8 85.5 Technical (Hospital) Services Iron Bind Serum PX-3018355000 CDM 83550 CPT 301 RC outpatient 90 90 CIGNA 62308 [3081051] CIGNA 62308 [308105105] 72 percent of total billed charges 55.8 85.5 Technical (Hospital) Services Iron Bind Serum PX-3018355000 CDM 83550 CPT 301 RC outpatient 90 90 CIGNA 62308 [3081051] CIGNA STATE OF WYOMING [308105107] 72 percent of total billed charges 55.8 85.5 Technical (Hospital) Services Iron Bind Serum PX-3018355000 CDM 83550 CPT 301 RC inpatient 90 90 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES PPO [308136801] 71.26 percent of total billed charges 55.8 85.5 Technical (Hospital) Services Iron Bind Serum PX-3018355000 CDM 83550 CPT 301 RC inpatient 90 90 UNITED HEALTHCARE (COMMERCIAL) [3081199] UNITED HEALTHCARE 87726 [308119901] 55.8 percent of total billed charges 55.8 85.5 Technical (Hospital) Services Iron Bind Serum PX-3018355000 CDM 83550 CPT 301 RC inpatient 90 90 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES HDHP [308136802] 71.26 percent of total billed charges 55.8 85.5 Technical (Hospital) Services Iron Bind Serum PX-3018355000 CDM 83550 CPT 301 RC inpatient 90 90 BLUE CROSS BLUE SHIELD WELLMARK SB889 [3081026] BCBS WYOMING [308102603] 85.5 percent of total billed charges 55.8 85.5 Technical (Hospital) Services Iron Bind Serum PX-3018355000 CDM 83550 CPT 301 RC inpatient 90 90 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES EPO [308136803] 71.26 percent of total billed charges 55.8 85.5 Technical (Hospital) Services Iron Bind Serum PX-3018355000 CDM 83550 CPT 301 RC inpatient 90 90 HEALTHPARTNERS SX009 HEALTHPARTNERS 71.26 percent of total billed charges 55.8 85.5 Technical (Hospital) Services Iron Bind Serum PX-3018355000 CDM 83550 CPT 301 RC inpatient 90 90 CIGNA 62308 [3081051] CIGNA STATE OF WYOMING [308105107] 71.26 percent of total billed charges 55.8 85.5 Technical (Hospital) Services Iron Bind Serum PX-3018355000 CDM 83550 CPT 301 RC inpatient 90 90 CIGNA 62308 [3081051] CIGNA 62308 [308105105] 71.26 percent of total billed charges 55.8 85.5 Technical (Hospital) Services Iron Bind Serum PX-3018355000 CDM 83550 CPT 301 RC inpatient 90 90 MULTIPLAN INC 34080 [3081285] MULTIPLAN INC [308128501] 85.5 percent of total billed charges 55.8 85.5 Technical (Hospital) Services Iron Bind Serum PX-3018355000 CDM 83550 CPT 301 RC inpatient 90 90 MEDICA (COMMERCIAL) 94265 [3081118] MEDICA CLAIMS [308111801] 81 percent of total billed charges 55.8 85.5 Technical (Hospital) Services Iron Serum PX-3018354000 CDM 83540 CPT 301 RC outpatient 70 70 CIGNA 62308 [3081051] CIGNA 62308 [308105105] 56 percent of total billed charges 43.4 66.5 Technical (Hospital) Services Iron Serum PX-3018354000 CDM 83540 CPT 301 RC outpatient 70 70 CIGNA 62308 [3081051] CIGNA STATE OF WYOMING [308105107] 56 percent of total billed charges 43.4 66.5 Technical (Hospital) Services Iron Serum PX-3018354000 CDM 83540 CPT 301 RC outpatient 70 70 MEDICA (COMMERCIAL) 94265 [3081118] MEDICA CLAIMS [308111801] 63 percent of total billed charges 43.4 66.5 Technical (Hospital) Services Iron Serum PX-3018354000 CDM 83540 CPT 301 RC outpatient 70 70 HEALTHPARTNERS SX009 HEALTHPARTNERS 56 percent of total billed charges 43.4 66.5 Technical (Hospital) Services Iron Serum PX-3018354000 CDM 83540 CPT 301 RC outpatient 70 70 UNITED HEALTHCARE (COMMERCIAL) [3081199] UNITED HEALTHCARE 87726 [308119901] 43.4 percent of total billed charges 43.4 66.5 Technical (Hospital) Services Iron Serum PX-3018354000 CDM 83540 CPT 301 RC outpatient 70 70 BLUE CROSS BLUE SHIELD WELLMARK SB889 [3081026] BCBS WYOMING [308102603] 66.5 percent of total billed charges 43.4 66.5 Technical (Hospital) Services Iron Serum PX-3018354000 CDM 83540 CPT 301 RC outpatient 70 70 MULTIPLAN INC 34080 [3081285] MULTIPLAN INC [308128501] 66.5 percent of total billed charges 43.4 66.5 Technical (Hospital) Services Iron Serum PX-3018354000 CDM 83540 CPT 301 RC outpatient 70 70 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES EPO [308136803] 56 percent of total billed charges 43.4 66.5 Technical (Hospital) Services Iron Serum PX-3018354000 CDM 83540 CPT 301 RC outpatient 70 70 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES HDHP [308136802] 56 percent of total billed charges 43.4 66.5 Technical (Hospital) Services Iron Serum PX-3018354000 CDM 83540 CPT 301 RC outpatient 70 70 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES PPO [308136801] 56 percent of total billed charges 43.4 66.5 Technical (Hospital) Services Iron Serum PX-3018354000 CDM 83540 CPT 301 RC inpatient 70 70 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES EPO [308136803] 55.43 percent of total billed charges 43.4 66.5 Technical (Hospital) Services Iron Serum PX-3018354000 CDM 83540 CPT 301 RC inpatient 70 70 HEALTHPARTNERS SX009 HEALTHPARTNERS 55.43 percent of total billed charges 43.4 66.5 Technical (Hospital) Services Iron Serum PX-3018354000 CDM 83540 CPT 301 RC inpatient 70 70 MULTIPLAN INC 34080 [3081285] MULTIPLAN INC [308128501] 66.5 percent of total billed charges 43.4 66.5 Technical (Hospital) Services Iron Serum PX-3018354000 CDM 83540 CPT 301 RC inpatient 70 70 MEDICA (COMMERCIAL) 94265 [3081118] MEDICA CLAIMS [308111801] 63 percent of total billed charges 43.4 66.5 Technical (Hospital) Services Iron Serum PX-3018354000 CDM 83540 CPT 301 RC inpatient 70 70 CIGNA 62308 [3081051] CIGNA 62308 [308105105] 55.43 percent of total billed charges 43.4 66.5 Technical (Hospital) Services Iron Serum PX-3018354000 CDM 83540 CPT 301 RC inpatient 70 70 CIGNA 62308 [3081051] CIGNA STATE OF WYOMING [308105107] 55.43 percent of total billed charges 43.4 66.5 Technical (Hospital) Services Iron Serum PX-3018354000 CDM 83540 CPT 301 RC inpatient 70 70 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES HDHP [308136802] 55.43 percent of total billed charges 43.4 66.5 Technical (Hospital) Services Iron Serum PX-3018354000 CDM 83540 CPT 301 RC inpatient 70 70 BLUE CROSS BLUE SHIELD WELLMARK SB889 [3081026] BCBS WYOMING [308102603] 66.5 percent of total billed charges 43.4 66.5 Technical (Hospital) Services Iron Serum PX-3018354000 CDM 83540 CPT 301 RC inpatient 70 70 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES PPO [308136801] 55.43 percent of total billed charges 43.4 66.5 Technical (Hospital) Services Iron Serum PX-3018354000 CDM 83540 CPT 301 RC inpatient 70 70 UNITED HEALTHCARE (COMMERCIAL) [3081199] UNITED HEALTHCARE 87726 [308119901] 43.4 percent of total billed charges 43.4 66.5 Technical (Hospital) Services Ref Free Insulin PX-3018352700 CDM 83527 CPT 301 RC outpatient 237 237 HEALTHPARTNERS SX009 HEALTHPARTNERS 189.6 percent of total billed charges 146.94 225.15 Technical (Hospital) Services Ref Free Insulin PX-3018352700 CDM 83527 CPT 301 RC outpatient 237 237 UNITED HEALTHCARE (COMMERCIAL) [3081199] UNITED HEALTHCARE 87726 [308119901] 146.94 percent of total billed charges 146.94 225.15 Technical (Hospital) Services Ref Free Insulin PX-3018352700 CDM 83527 CPT 301 RC outpatient 237 237 MULTIPLAN INC 34080 [3081285] MULTIPLAN INC [308128501] 225.15 percent of total billed charges 146.94 225.15 Technical (Hospital) Services Ref Free Insulin PX-3018352700 CDM 83527 CPT 301 RC outpatient 237 237 BLUE CROSS BLUE SHIELD WELLMARK SB889 [3081026] BCBS WYOMING [308102603] 225.15 percent of total billed charges 146.94 225.15 Technical (Hospital) Services Ref Free Insulin PX-3018352700 CDM 83527 CPT 301 RC outpatient 237 237 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES EPO [308136803] 189.6 percent of total billed charges 146.94 225.15 Technical (Hospital) Services Ref Free Insulin PX-3018352700 CDM 83527 CPT 301 RC outpatient 237 237 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES HDHP [308136802] 189.6 percent of total billed charges 146.94 225.15 Technical (Hospital) Services Ref Free Insulin PX-3018352700 CDM 83527 CPT 301 RC outpatient 237 237 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES PPO [308136801] 189.6 percent of total billed charges 146.94 225.15 Technical (Hospital) Services Ref Free Insulin PX-3018352700 CDM 83527 CPT 301 RC outpatient 237 237 CIGNA 62308 [3081051] CIGNA 62308 [308105105] 189.6 percent of total billed charges 146.94 225.15 Technical (Hospital) Services Ref Free Insulin PX-3018352700 CDM 83527 CPT 301 RC outpatient 237 237 CIGNA 62308 [3081051] CIGNA STATE OF WYOMING [308105107] 189.6 percent of total billed charges 146.94 225.15 Technical (Hospital) Services Ref Free Insulin PX-3018352700 CDM 83527 CPT 301 RC outpatient 237 237 MEDICA (COMMERCIAL) 94265 [3081118] MEDICA CLAIMS [308111801] 213.3 percent of total billed charges 146.94 225.15 Technical (Hospital) Services Ref Free Insulin PX-3018352700 CDM 83527 CPT 301 RC inpatient 237 237 UNITED HEALTHCARE (COMMERCIAL) [3081199] UNITED HEALTHCARE 87726 [308119901] 146.94 percent of total billed charges 146.94 225.15 Technical (Hospital) Services Ref Free Insulin PX-3018352700 CDM 83527 CPT 301 RC inpatient 237 237 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES PPO [308136801] 187.66 percent of total billed charges 146.94 225.15 Technical (Hospital) Services Ref Free Insulin PX-3018352700 CDM 83527 CPT 301 RC inpatient 237 237 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES HDHP [308136802] 187.66 percent of total billed charges 146.94 225.15 Technical (Hospital) Services Ref Free Insulin PX-3018352700 CDM 83527 CPT 301 RC inpatient 237 237 BLUE CROSS BLUE SHIELD WELLMARK SB889 [3081026] BCBS WYOMING [308102603] 225.15 percent of total billed charges 146.94 225.15 Technical (Hospital) Services Ref Free Insulin PX-3018352700 CDM 83527 CPT 301 RC inpatient 237 237 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES EPO [308136803] 187.66 percent of total billed charges 146.94 225.15 Technical (Hospital) Services Ref Free Insulin PX-3018352700 CDM 83527 CPT 301 RC inpatient 237 237 HEALTHPARTNERS SX009 HEALTHPARTNERS 187.66 percent of total billed charges 146.94 225.15 Technical (Hospital) Services Ref Free Insulin PX-3018352700 CDM 83527 CPT 301 RC inpatient 237 237 MULTIPLAN INC 34080 [3081285] MULTIPLAN INC [308128501] 225.15 percent of total billed charges 146.94 225.15 Technical (Hospital) Services Ref Free Insulin PX-3018352700 CDM 83527 CPT 301 RC inpatient 237 237 MEDICA (COMMERCIAL) 94265 [3081118] MEDICA CLAIMS [308111801] 213.3 percent of total billed charges 146.94 225.15 Technical (Hospital) Services Ref Free Insulin PX-3018352700 CDM 83527 CPT 301 RC inpatient 237 237 CIGNA 62308 [3081051] CIGNA 62308 [308105105] 187.66 percent of total billed charges 146.94 225.15 Technical (Hospital) Services Ref Free Insulin PX-3018352700 CDM 83527 CPT 301 RC inpatient 237 237 CIGNA 62308 [3081051] CIGNA STATE OF WYOMING [308105107] 187.66 percent of total billed charges 146.94 225.15 Technical (Hospital) Services Ref Insulin PX-3018352500 CDM 83525 CPT 301 RC outpatient 204 204 UNITED HEALTHCARE (COMMERCIAL) [3081199] UNITED HEALTHCARE 87726 [308119901] 126.48 percent of total billed charges 126.48 193.8 Technical (Hospital) Services Ref Insulin PX-3018352500 CDM 83525 CPT 301 RC outpatient 204 204 HEALTHPARTNERS SX009 HEALTHPARTNERS 163.2 percent of total billed charges 126.48 193.8 Technical (Hospital) Services Ref Insulin PX-3018352500 CDM 83525 CPT 301 RC outpatient 204 204 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES PPO [308136801] 163.2 percent of total billed charges 126.48 193.8 Technical (Hospital) Services Ref Insulin PX-3018352500 CDM 83525 CPT 301 RC outpatient 204 204 MULTIPLAN INC 34080 [3081285] MULTIPLAN INC [308128501] 193.8 percent of total billed charges 126.48 193.8 Technical (Hospital) Services Ref Insulin PX-3018352500 CDM 83525 CPT 301 RC outpatient 204 204 BLUE CROSS BLUE SHIELD WELLMARK SB889 [3081026] BCBS WYOMING [308102603] 193.8 percent of total billed charges 126.48 193.8 Technical (Hospital) Services Ref Insulin PX-3018352500 CDM 83525 CPT 301 RC outpatient 204 204 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES EPO [308136803] 163.2 percent of total billed charges 126.48 193.8 Technical (Hospital) Services Ref Insulin PX-3018352500 CDM 83525 CPT 301 RC outpatient 204 204 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES HDHP [308136802] 163.2 percent of total billed charges 126.48 193.8 Technical (Hospital) Services Ref Insulin PX-3018352500 CDM 83525 CPT 301 RC outpatient 204 204 MEDICA (COMMERCIAL) 94265 [3081118] MEDICA CLAIMS [308111801] 183.6 percent of total billed charges 126.48 193.8 Technical (Hospital) Services Ref Insulin PX-3018352500 CDM 83525 CPT 301 RC outpatient 204 204 CIGNA 62308 [3081051] CIGNA 62308 [308105105] 163.2 percent of total billed charges 126.48 193.8 Technical (Hospital) Services Ref Insulin PX-3018352500 CDM 83525 CPT 301 RC outpatient 204 204 CIGNA 62308 [3081051] CIGNA STATE OF WYOMING [308105107] 163.2 percent of total billed charges 126.48 193.8 Technical (Hospital) Services Ref Insulin PX-3018352500 CDM 83525 CPT 301 RC inpatient 204 204 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES HDHP [308136802] 161.53 percent of total billed charges 126.48 193.8 Technical (Hospital) Services Ref Insulin PX-3018352500 CDM 83525 CPT 301 RC inpatient 204 204 BLUE CROSS BLUE SHIELD WELLMARK SB889 [3081026] BCBS WYOMING [308102603] 193.8 percent of total billed charges 126.48 193.8 Technical (Hospital) Services Ref Insulin PX-3018352500 CDM 83525 CPT 301 RC inpatient 204 204 UNITED HEALTHCARE (COMMERCIAL) [3081199] UNITED HEALTHCARE 87726 [308119901] 126.48 percent of total billed charges 126.48 193.8 Technical (Hospital) Services Ref Insulin PX-3018352500 CDM 83525 CPT 301 RC inpatient 204 204 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES PPO [308136801] 161.53 percent of total billed charges 126.48 193.8 Technical (Hospital) Services Ref Insulin PX-3018352500 CDM 83525 CPT 301 RC inpatient 204 204 MULTIPLAN INC 34080 [3081285] MULTIPLAN INC [308128501] 193.8 percent of total billed charges 126.48 193.8 Technical (Hospital) Services Ref Insulin PX-3018352500 CDM 83525 CPT 301 RC inpatient 204 204 MEDICA (COMMERCIAL) 94265 [3081118] MEDICA CLAIMS [308111801] 183.6 percent of total billed charges 126.48 193.8 Technical (Hospital) Services Ref Insulin PX-3018352500 CDM 83525 CPT 301 RC inpatient 204 204 HEALTHPARTNERS SX009 HEALTHPARTNERS 161.53 percent of total billed charges 126.48 193.8 Technical (Hospital) Services Ref Insulin PX-3018352500 CDM 83525 CPT 301 RC inpatient 204 204 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES EPO [308136803] 161.53 percent of total billed charges 126.48 193.8 Technical (Hospital) Services Ref Insulin PX-3018352500 CDM 83525 CPT 301 RC inpatient 204 204 CIGNA 62308 [3081051] CIGNA 62308 [308105105] 161.53 percent of total billed charges 126.48 193.8 Technical (Hospital) Services Ref Insulin PX-3018352500 CDM 83525 CPT 301 RC inpatient 204 204 CIGNA 62308 [3081051] CIGNA STATE OF WYOMING [308105107] 161.53 percent of total billed charges 126.48 193.8 Technical (Hospital) Services Ref Glomerular Basemnt Membrane Ab PX-3018352000 CDM 83520 CPT 301 RC outpatient 183 183 MEDICA (COMMERCIAL) 94265 [3081118] MEDICA CLAIMS [308111801] 164.7 percent of total billed charges 113.46 173.85 Technical (Hospital) Services Ref Glomerular Basemnt Membrane Ab PX-3018352000 CDM 83520 CPT 301 RC outpatient 183 183 CIGNA 62308 [3081051] CIGNA 62308 [308105105] 146.4 percent of total billed charges 113.46 173.85 Technical (Hospital) Services Ref Glomerular Basemnt Membrane Ab PX-3018352000 CDM 83520 CPT 301 RC outpatient 183 183 CIGNA 62308 [3081051] CIGNA STATE OF WYOMING [308105107] 146.4 percent of total billed charges 113.46 173.85 Technical (Hospital) Services Ref Glomerular Basemnt Membrane Ab PX-3018352000 CDM 83520 CPT 301 RC outpatient 183 183 UNITED HEALTHCARE (COMMERCIAL) [3081199] UNITED HEALTHCARE 87726 [308119901] 113.46 percent of total billed charges 113.46 173.85 Technical (Hospital) Services Ref Glomerular Basemnt Membrane Ab PX-3018352000 CDM 83520 CPT 301 RC outpatient 183 183 HEALTHPARTNERS SX009 HEALTHPARTNERS 146.4 percent of total billed charges 113.46 173.85 Technical (Hospital) Services Ref Glomerular Basemnt Membrane Ab PX-3018352000 CDM 83520 CPT 301 RC outpatient 183 183 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES PPO [308136801] 146.4 percent of total billed charges 113.46 173.85 Technical (Hospital) Services Ref Glomerular Basemnt Membrane Ab PX-3018352000 CDM 83520 CPT 301 RC outpatient 183 183 MULTIPLAN INC 34080 [3081285] MULTIPLAN INC [308128501] 173.85 percent of total billed charges 113.46 173.85 Technical (Hospital) Services Ref Glomerular Basemnt Membrane Ab PX-3018352000 CDM 83520 CPT 301 RC outpatient 183 183 BLUE CROSS BLUE SHIELD WELLMARK SB889 [3081026] BCBS WYOMING [308102603] 173.85 percent of total billed charges 113.46 173.85 Technical (Hospital) Services Ref Glomerular Basemnt Membrane Ab PX-3018352000 CDM 83520 CPT 301 RC outpatient 183 183 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES EPO [308136803] 146.4 percent of total billed charges 113.46 173.85 Technical (Hospital) Services Ref Glomerular Basemnt Membrane Ab PX-3018352000 CDM 83520 CPT 301 RC outpatient 183 183 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES HDHP [308136802] 146.4 percent of total billed charges 113.46 173.85 Technical (Hospital) Services Ref Glomerular Basemnt Membrane Ab PX-3018352000 CDM 83520 CPT 301 RC inpatient 183 183 MEDICA (COMMERCIAL) 94265 [3081118] MEDICA CLAIMS [308111801] 164.7 percent of total billed charges 113.46 173.85 Technical (Hospital) Services Ref Glomerular Basemnt Membrane Ab PX-3018352000 CDM 83520 CPT 301 RC inpatient 183 183 MULTIPLAN INC 34080 [3081285] MULTIPLAN INC [308128501] 173.85 percent of total billed charges 113.46 173.85 Technical (Hospital) Services Ref Glomerular Basemnt Membrane Ab PX-3018352000 CDM 83520 CPT 301 RC inpatient 183 183 CIGNA 62308 [3081051] CIGNA 62308 [308105105] 144.9 percent of total billed charges 113.46 173.85 Technical (Hospital) Services Ref Glomerular Basemnt Membrane Ab PX-3018352000 CDM 83520 CPT 301 RC inpatient 183 183 CIGNA 62308 [3081051] CIGNA STATE OF WYOMING [308105107] 144.9 percent of total billed charges 113.46 173.85 Technical (Hospital) Services Ref Glomerular Basemnt Membrane Ab PX-3018352000 CDM 83520 CPT 301 RC inpatient 183 183 HEALTHPARTNERS SX009 HEALTHPARTNERS 144.9 percent of total billed charges 113.46 173.85 Technical (Hospital) Services Ref Glomerular Basemnt Membrane Ab PX-3018352000 CDM 83520 CPT 301 RC inpatient 183 183 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES EPO [308136803] 144.9 percent of total billed charges 113.46 173.85 Technical (Hospital) Services Ref Glomerular Basemnt Membrane Ab PX-3018352000 CDM 83520 CPT 301 RC inpatient 183 183 BLUE CROSS BLUE SHIELD WELLMARK SB889 [3081026] BCBS WYOMING [308102603] 173.85 percent of total billed charges 113.46 173.85 Technical (Hospital) Services Ref Glomerular Basemnt Membrane Ab PX-3018352000 CDM 83520 CPT 301 RC inpatient 183 183 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES HDHP [308136802] 144.9 percent of total billed charges 113.46 173.85 Technical (Hospital) Services Ref Glomerular Basemnt Membrane Ab PX-3018352000 CDM 83520 CPT 301 RC inpatient 183 183 UNITED HEALTHCARE (COMMERCIAL) [3081199] UNITED HEALTHCARE 87726 [308119901] 113.46 percent of total billed charges 113.46 173.85 Technical (Hospital) Services Ref Glomerular Basemnt Membrane Ab PX-3018352000 CDM 83520 CPT 301 RC inpatient 183 183 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES PPO [308136801] 144.9 percent of total billed charges 113.46 173.85 Technical (Hospital) Services Ref Ibd Saccharomyces Igg or Iga PX-3018352003 CDM 83520 CPT 301 RC outpatient 182 182 CIGNA 62308 [3081051] CIGNA 62308 [308105105] 145.6 percent of total billed charges 112.84 172.9 Technical (Hospital) Services Ref Ibd Saccharomyces Igg or Iga PX-3018352003 CDM 83520 CPT 301 RC outpatient 182 182 CIGNA 62308 [3081051] CIGNA STATE OF WYOMING [308105107] 145.6 percent of total billed charges 112.84 172.9 Technical (Hospital) Services Ref Ibd Saccharomyces Igg or Iga PX-3018352003 CDM 83520 CPT 301 RC outpatient 182 182 MEDICA (COMMERCIAL) 94265 [3081118] MEDICA CLAIMS [308111801] 163.8 percent of total billed charges 112.84 172.9 Technical (Hospital) Services Ref Ibd Saccharomyces Igg or Iga PX-3018352003 CDM 83520 CPT 301 RC outpatient 182 182 UNITED HEALTHCARE (COMMERCIAL) [3081199] UNITED HEALTHCARE 87726 [308119901] 112.84 percent of total billed charges 112.84 172.9 Technical (Hospital) Services Ref Ibd Saccharomyces Igg or Iga PX-3018352003 CDM 83520 CPT 301 RC outpatient 182 182 HEALTHPARTNERS SX009 HEALTHPARTNERS 145.6 percent of total billed charges 112.84 172.9 Technical (Hospital) Services Ref Ibd Saccharomyces Igg or Iga PX-3018352003 CDM 83520 CPT 301 RC outpatient 182 182 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES PPO [308136801] 145.6 percent of total billed charges 112.84 172.9 Technical (Hospital) Services Ref Ibd Saccharomyces Igg or Iga PX-3018352003 CDM 83520 CPT 301 RC outpatient 182 182 BLUE CROSS BLUE SHIELD WELLMARK SB889 [3081026] BCBS WYOMING [308102603] 172.9 percent of total billed charges 112.84 172.9 Technical (Hospital) Services Ref Ibd Saccharomyces Igg or Iga PX-3018352003 CDM 83520 CPT 301 RC outpatient 182 182 MULTIPLAN INC 34080 [3081285] MULTIPLAN INC [308128501] 172.9 percent of total billed charges 112.84 172.9 Technical (Hospital) Services Ref Ibd Saccharomyces Igg or Iga PX-3018352003 CDM 83520 CPT 301 RC outpatient 182 182 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES EPO [308136803] 145.6 percent of total billed charges 112.84 172.9 Technical (Hospital) Services Ref Ibd Saccharomyces Igg or Iga PX-3018352003 CDM 83520 CPT 301 RC outpatient 182 182 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES HDHP [308136802] 145.6 percent of total billed charges 112.84 172.9 Technical (Hospital) Services Ref Ibd Saccharomyces Igg or Iga PX-3018352003 CDM 83520 CPT 301 RC inpatient 182 182 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES HDHP [308136802] 144.11 percent of total billed charges 112.84 172.9 Technical (Hospital) Services Ref Ibd Saccharomyces Igg or Iga PX-3018352003 CDM 83520 CPT 301 RC inpatient 182 182 BLUE CROSS BLUE SHIELD WELLMARK SB889 [3081026] BCBS WYOMING [308102603] 172.9 percent of total billed charges 112.84 172.9 Technical (Hospital) Services Ref Ibd Saccharomyces Igg or Iga PX-3018352003 CDM 83520 CPT 301 RC inpatient 182 182 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES PPO [308136801] 144.11 percent of total billed charges 112.84 172.9 Technical (Hospital) Services Ref Ibd Saccharomyces Igg or Iga PX-3018352003 CDM 83520 CPT 301 RC inpatient 182 182 UNITED HEALTHCARE (COMMERCIAL) [3081199] UNITED HEALTHCARE 87726 [308119901] 112.84 percent of total billed charges 112.84 172.9 Technical (Hospital) Services Ref Ibd Saccharomyces Igg or Iga PX-3018352003 CDM 83520 CPT 301 RC inpatient 182 182 MEDICA (COMMERCIAL) 94265 [3081118] MEDICA CLAIMS [308111801] 163.8 percent of total billed charges 112.84 172.9 Technical (Hospital) Services Ref Ibd Saccharomyces Igg or Iga PX-3018352003 CDM 83520 CPT 301 RC inpatient 182 182 MULTIPLAN INC 34080 [3081285] MULTIPLAN INC [308128501] 172.9 percent of total billed charges 112.84 172.9 Technical (Hospital) Services Ref Ibd Saccharomyces Igg or Iga PX-3018352003 CDM 83520 CPT 301 RC inpatient 182 182 CIGNA 62308 [3081051] CIGNA 62308 [308105105] 144.11 percent of total billed charges 112.84 172.9 Technical (Hospital) Services Ref Ibd Saccharomyces Igg or Iga PX-3018352003 CDM 83520 CPT 301 RC inpatient 182 182 CIGNA 62308 [3081051] CIGNA STATE OF WYOMING [308105107] 144.11 percent of total billed charges 112.84 172.9 Technical (Hospital) Services Ref Ibd Saccharomyces Igg or Iga PX-3018352003 CDM 83520 CPT 301 RC inpatient 182 182 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES EPO [308136803] 144.11 percent of total billed charges 112.84 172.9 Technical (Hospital) Services Ref Ibd Saccharomyces Igg or Iga PX-3018352003 CDM 83520 CPT 301 RC inpatient 182 182 HEALTHPARTNERS SX009 HEALTHPARTNERS 144.11 percent of total billed charges 112.84 172.9 Technical (Hospital) Services Ref Igfbp 3 PX-3018352004 CDM 83520 CPT 301 RC outpatient 54 54 CIGNA 62308 [3081051] CIGNA 62308 [308105105] 43.2 percent of total billed charges 33.48 51.3 Technical (Hospital) Services Ref Igfbp 3 PX-3018352004 CDM 83520 CPT 301 RC outpatient 54 54 CIGNA 62308 [3081051] CIGNA STATE OF WYOMING [308105107] 43.2 percent of total billed charges 33.48 51.3 Technical (Hospital) Services Ref Igfbp 3 PX-3018352004 CDM 83520 CPT 301 RC outpatient 54 54 MEDICA (COMMERCIAL) 94265 [3081118] MEDICA CLAIMS [308111801] 48.6 percent of total billed charges 33.48 51.3 Technical (Hospital) Services Ref Igfbp 3 PX-3018352004 CDM 83520 CPT 301 RC outpatient 54 54 BLUE CROSS BLUE SHIELD WELLMARK SB889 [3081026] BCBS WYOMING [308102603] 51.3 percent of total billed charges 33.48 51.3 Technical (Hospital) Services Ref Igfbp 3 PX-3018352004 CDM 83520 CPT 301 RC outpatient 54 54 UNITED HEALTHCARE (COMMERCIAL) [3081199] UNITED HEALTHCARE 87726 [308119901] 33.48 percent of total billed charges 33.48 51.3 Technical (Hospital) Services Ref Igfbp 3 PX-3018352004 CDM 83520 CPT 301 RC outpatient 54 54 MULTIPLAN INC 34080 [3081285] MULTIPLAN INC [308128501] 51.3 percent of total billed charges 33.48 51.3 Technical (Hospital) Services Ref Igfbp 3 PX-3018352004 CDM 83520 CPT 301 RC outpatient 54 54 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES HDHP [308136802] 43.2 percent of total billed charges 33.48 51.3 Technical (Hospital) Services Ref Igfbp 3 PX-3018352004 CDM 83520 CPT 301 RC outpatient 54 54 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES PPO [308136801] 43.2 percent of total billed charges 33.48 51.3 Technical (Hospital) Services Ref Igfbp 3 PX-3018352004 CDM 83520 CPT 301 RC outpatient 54 54 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES EPO [308136803] 43.2 percent of total billed charges 33.48 51.3 Technical (Hospital) Services Ref Igfbp 3 PX-3018352004 CDM 83520 CPT 301 RC outpatient 54 54 HEALTHPARTNERS SX009 HEALTHPARTNERS 43.2 percent of total billed charges 33.48 51.3 Technical (Hospital) Services Ref Igfbp 3 PX-3018352004 CDM 83520 CPT 301 RC inpatient 54 54 BLUE CROSS BLUE SHIELD WELLMARK SB889 [3081026] BCBS WYOMING [308102603] 51.3 percent of total billed charges 33.48 51.3 Technical (Hospital) Services Ref Igfbp 3 PX-3018352004 CDM 83520 CPT 301 RC inpatient 54 54 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES PPO [308136801] 42.76 percent of total billed charges 33.48 51.3 Technical (Hospital) Services Ref Igfbp 3 PX-3018352004 CDM 83520 CPT 301 RC inpatient 54 54 UNITED HEALTHCARE (COMMERCIAL) [3081199] UNITED HEALTHCARE 87726 [308119901] 33.48 percent of total billed charges 33.48 51.3 Technical (Hospital) Services Ref Igfbp 3 PX-3018352004 CDM 83520 CPT 301 RC inpatient 54 54 HEALTHPARTNERS SX009 HEALTHPARTNERS 42.76 percent of total billed charges 33.48 51.3 Technical (Hospital) Services Ref Igfbp 3 PX-3018352004 CDM 83520 CPT 301 RC inpatient 54 54 MULTIPLAN INC 34080 [3081285] MULTIPLAN INC [308128501] 51.3 percent of total billed charges 33.48 51.3 Technical (Hospital) Services Ref Igfbp 3 PX-3018352004 CDM 83520 CPT 301 RC inpatient 54 54 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES HDHP [308136802] 42.76 percent of total billed charges 33.48 51.3 Technical (Hospital) Services Ref Igfbp 3 PX-3018352004 CDM 83520 CPT 301 RC inpatient 54 54 MEDICA (COMMERCIAL) 94265 [3081118] MEDICA CLAIMS [308111801] 48.6 percent of total billed charges 33.48 51.3 Technical (Hospital) Services Ref Igfbp 3 PX-3018352004 CDM 83520 CPT 301 RC inpatient 54 54 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES EPO [308136803] 42.76 percent of total billed charges 33.48 51.3 Technical (Hospital) Services Ref Igfbp 3 PX-3018352004 CDM 83520 CPT 301 RC inpatient 54 54 CIGNA 62308 [3081051] CIGNA 62308 [308105105] 42.76 percent of total billed charges 33.48 51.3 Technical (Hospital) Services Ref Igfbp 3 PX-3018352004 CDM 83520 CPT 301 RC inpatient 54 54 CIGNA 62308 [3081051] CIGNA STATE OF WYOMING [308105107] 42.76 percent of total billed charges 33.48 51.3 Technical (Hospital) Services Ref Mg Eval Striational Ab PX-3018352005 CDM 83520 CPT 301 RC inpatient 180 180 MULTIPLAN INC 34080 [3081285] MULTIPLAN INC [308128501] 171 percent of total billed charges 111.6 171 Technical (Hospital) Services Ref Mg Eval Striational Ab PX-3018352005 CDM 83520 CPT 301 RC inpatient 180 180 MEDICA (COMMERCIAL) 94265 [3081118] MEDICA CLAIMS [308111801] 162 percent of total billed charges 111.6 171 Technical (Hospital) Services Ref Mg Eval Striational Ab PX-3018352005 CDM 83520 CPT 301 RC inpatient 180 180 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES EPO [308136803] 142.52 percent of total billed charges 111.6 171 Technical (Hospital) Services Ref Mg Eval Striational Ab PX-3018352005 CDM 83520 CPT 301 RC inpatient 180 180 HEALTHPARTNERS SX009 HEALTHPARTNERS 142.52 percent of total billed charges 111.6 171 Technical (Hospital) Services Ref Mg Eval Striational Ab PX-3018352005 CDM 83520 CPT 301 RC inpatient 180 180 CIGNA 62308 [3081051] CIGNA 62308 [308105105] 142.52 percent of total billed charges 111.6 171 Technical (Hospital) Services Ref Mg Eval Striational Ab PX-3018352005 CDM 83520 CPT 301 RC inpatient 180 180 CIGNA 62308 [3081051] CIGNA STATE OF WYOMING [308105107] 142.52 percent of total billed charges 111.6 171 Technical (Hospital) Services Ref Mg Eval Striational Ab PX-3018352005 CDM 83520 CPT 301 RC inpatient 180 180 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES HDHP [308136802] 142.52 percent of total billed charges 111.6 171 Technical (Hospital) Services Ref Mg Eval Striational Ab PX-3018352005 CDM 83520 CPT 301 RC inpatient 180 180 BLUE CROSS BLUE SHIELD WELLMARK SB889 [3081026] BCBS WYOMING [308102603] 171 percent of total billed charges 111.6 171 Technical (Hospital) Services Ref Mg Eval Striational Ab PX-3018352005 CDM 83520 CPT 301 RC inpatient 180 180 UNITED HEALTHCARE (COMMERCIAL) [3081199] UNITED HEALTHCARE 87726 [308119901] 111.6 percent of total billed charges 111.6 171 Technical (Hospital) Services Ref Mg Eval Striational Ab PX-3018352005 CDM 83520 CPT 301 RC inpatient 180 180 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES PPO [308136801] 142.52 percent of total billed charges 111.6 171 Technical (Hospital) Services Ref Mg Eval Striational Ab PX-3018352005 CDM 83520 CPT 301 RC outpatient 180 180 CIGNA 62308 [3081051] CIGNA 62308 [308105105] 144 percent of total billed charges 111.6 171 Technical (Hospital) Services Ref Mg Eval Striational Ab PX-3018352005 CDM 83520 CPT 301 RC outpatient 180 180 CIGNA 62308 [3081051] CIGNA STATE OF WYOMING [308105107] 144 percent of total billed charges 111.6 171 Technical (Hospital) Services Ref Mg Eval Striational Ab PX-3018352005 CDM 83520 CPT 301 RC outpatient 180 180 MEDICA (COMMERCIAL) 94265 [3081118] MEDICA CLAIMS [308111801] 162 percent of total billed charges 111.6 171 Technical (Hospital) Services Ref Mg Eval Striational Ab PX-3018352005 CDM 83520 CPT 301 RC outpatient 180 180 UNITED HEALTHCARE (COMMERCIAL) [3081199] UNITED HEALTHCARE 87726 [308119901] 111.6 percent of total billed charges 111.6 171 Technical (Hospital) Services Ref Mg Eval Striational Ab PX-3018352005 CDM 83520 CPT 301 RC outpatient 180 180 HEALTHPARTNERS SX009 HEALTHPARTNERS 144 percent of total billed charges 111.6 171 Technical (Hospital) Services Ref Mg Eval Striational Ab PX-3018352005 CDM 83520 CPT 301 RC outpatient 180 180 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES PPO [308136801] 144 percent of total billed charges 111.6 171 Technical (Hospital) Services Ref Mg Eval Striational Ab PX-3018352005 CDM 83520 CPT 301 RC outpatient 180 180 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES EPO [308136803] 144 percent of total billed charges 111.6 171 Technical (Hospital) Services Ref Mg Eval Striational Ab PX-3018352005 CDM 83520 CPT 301 RC outpatient 180 180 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES HDHP [308136802] 144 percent of total billed charges 111.6 171 Technical (Hospital) Services Ref Mg Eval Striational Ab PX-3018352005 CDM 83520 CPT 301 RC outpatient 180 180 MULTIPLAN INC 34080 [3081285] MULTIPLAN INC [308128501] 171 percent of total billed charges 111.6 171 Technical (Hospital) Services Ref Mg Eval Striational Ab PX-3018352005 CDM 83520 CPT 301 RC outpatient 180 180 BLUE CROSS BLUE SHIELD WELLMARK SB889 [3081026] BCBS WYOMING [308102603] 171 percent of total billed charges 111.6 171 Technical (Hospital) Services Ref Tryptase PX-3018352009 CDM 83520 CPT 301 RC inpatient 198 198 CIGNA 62308 [3081051] CIGNA 62308 [308105105] 156.78 percent of total billed charges 122.76 188.1 Technical (Hospital) Services Ref Tryptase PX-3018352009 CDM 83520 CPT 301 RC inpatient 198 198 CIGNA 62308 [3081051] CIGNA STATE OF WYOMING [308105107] 156.78 percent of total billed charges 122.76 188.1 Technical (Hospital) Services Ref Tryptase PX-3018352009 CDM 83520 CPT 301 RC inpatient 198 198 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES EPO [308136803] 156.78 percent of total billed charges 122.76 188.1 Technical (Hospital) Services Ref Tryptase PX-3018352009 CDM 83520 CPT 301 RC inpatient 198 198 HEALTHPARTNERS SX009 HEALTHPARTNERS 156.78 percent of total billed charges 122.76 188.1 Technical (Hospital) Services Ref Tryptase PX-3018352009 CDM 83520 CPT 301 RC inpatient 198 198 MEDICA (COMMERCIAL) 94265 [3081118] MEDICA CLAIMS [308111801] 178.2 percent of total billed charges 122.76 188.1 Technical (Hospital) Services Ref Tryptase PX-3018352009 CDM 83520 CPT 301 RC inpatient 198 198 MULTIPLAN INC 34080 [3081285] MULTIPLAN INC [308128501] 188.1 percent of total billed charges 122.76 188.1 Technical (Hospital) Services Ref Tryptase PX-3018352009 CDM 83520 CPT 301 RC inpatient 198 198 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES PPO [308136801] 156.78 percent of total billed charges 122.76 188.1 Technical (Hospital) Services Ref Tryptase PX-3018352009 CDM 83520 CPT 301 RC inpatient 198 198 UNITED HEALTHCARE (COMMERCIAL) [3081199] UNITED HEALTHCARE 87726 [308119901] 122.76 percent of total billed charges 122.76 188.1 Technical (Hospital) Services Ref Tryptase PX-3018352009 CDM 83520 CPT 301 RC inpatient 198 198 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES HDHP [308136802] 156.78 percent of total billed charges 122.76 188.1 Technical (Hospital) Services Ref Tryptase PX-3018352009 CDM 83520 CPT 301 RC inpatient 198 198 BLUE CROSS BLUE SHIELD WELLMARK SB889 [3081026] BCBS WYOMING [308102603] 188.1 percent of total billed charges 122.76 188.1 Technical (Hospital) Services Ref Tryptase PX-3018352009 CDM 83520 CPT 301 RC outpatient 198 198 CIGNA 62308 [3081051] CIGNA 62308 [308105105] 158.4 percent of total billed charges 122.76 188.1 Technical (Hospital) Services Ref Tryptase PX-3018352009 CDM 83520 CPT 301 RC outpatient 198 198 CIGNA 62308 [3081051] CIGNA STATE OF WYOMING [308105107] 158.4 percent of total billed charges 122.76 188.1 Technical (Hospital) Services Ref Tryptase PX-3018352009 CDM 83520 CPT 301 RC outpatient 198 198 MEDICA (COMMERCIAL) 94265 [3081118] MEDICA CLAIMS [308111801] 178.2 percent of total billed charges 122.76 188.1 Technical (Hospital) Services Ref Tryptase PX-3018352009 CDM 83520 CPT 301 RC outpatient 198 198 UNITED HEALTHCARE (COMMERCIAL) [3081199] UNITED HEALTHCARE 87726 [308119901] 122.76 percent of total billed charges 122.76 188.1 Technical (Hospital) Services Ref Tryptase PX-3018352009 CDM 83520 CPT 301 RC outpatient 198 198 HEALTHPARTNERS SX009 HEALTHPARTNERS 158.4 percent of total billed charges 122.76 188.1 Technical (Hospital) Services Ref Tryptase PX-3018352009 CDM 83520 CPT 301 RC outpatient 198 198 MULTIPLAN INC 34080 [3081285] MULTIPLAN INC [308128501] 188.1 percent of total billed charges 122.76 188.1 Technical (Hospital) Services Ref Tryptase PX-3018352009 CDM 83520 CPT 301 RC outpatient 198 198 BLUE CROSS BLUE SHIELD WELLMARK SB889 [3081026] BCBS WYOMING [308102603] 188.1 percent of total billed charges 122.76 188.1 Technical (Hospital) Services Ref Tryptase PX-3018352009 CDM 83520 CPT 301 RC outpatient 198 198 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES EPO [308136803] 158.4 percent of total billed charges 122.76 188.1 Technical (Hospital) Services Ref Tryptase PX-3018352009 CDM 83520 CPT 301 RC outpatient 198 198 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES HDHP [308136802] 158.4 percent of total billed charges 122.76 188.1 Technical (Hospital) Services Ref Tryptase PX-3018352009 CDM 83520 CPT 301 RC outpatient 198 198 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES PPO [308136801] 158.4 percent of total billed charges 122.76 188.1 Technical (Hospital) Services Ref Antimullerian Hormone Serum PX-3018352010 CDM 83520 CPT 301 RC outpatient 212 212 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES PPO [308136801] 169.6 percent of total billed charges 131.44 201.4 Technical (Hospital) Services Ref Antimullerian Hormone Serum PX-3018352010 CDM 83520 CPT 301 RC outpatient 212 212 MULTIPLAN INC 34080 [3081285] MULTIPLAN INC [308128501] 201.4 percent of total billed charges 131.44 201.4 Technical (Hospital) Services Ref Antimullerian Hormone Serum PX-3018352010 CDM 83520 CPT 301 RC outpatient 212 212 BLUE CROSS BLUE SHIELD WELLMARK SB889 [3081026] BCBS WYOMING [308102603] 201.4 percent of total billed charges 131.44 201.4 Technical (Hospital) Services Ref Antimullerian Hormone Serum PX-3018352010 CDM 83520 CPT 301 RC outpatient 212 212 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES EPO [308136803] 169.6 percent of total billed charges 131.44 201.4 Technical (Hospital) Services Ref Antimullerian Hormone Serum PX-3018352010 CDM 83520 CPT 301 RC outpatient 212 212 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES HDHP [308136802] 169.6 percent of total billed charges 131.44 201.4 Technical (Hospital) Services Ref Antimullerian Hormone Serum PX-3018352010 CDM 83520 CPT 301 RC outpatient 212 212 UNITED HEALTHCARE (COMMERCIAL) [3081199] UNITED HEALTHCARE 87726 [308119901] 131.44 percent of total billed charges 131.44 201.4 Technical (Hospital) Services Ref Antimullerian Hormone Serum PX-3018352010 CDM 83520 CPT 301 RC outpatient 212 212 HEALTHPARTNERS SX009 HEALTHPARTNERS 169.6 percent of total billed charges 131.44 201.4 Technical (Hospital) Services Ref Antimullerian Hormone Serum PX-3018352010 CDM 83520 CPT 301 RC outpatient 212 212 CIGNA 62308 [3081051] CIGNA 62308 [308105105] 169.6 percent of total billed charges 131.44 201.4 Technical (Hospital) Services Ref Antimullerian Hormone Serum PX-3018352010 CDM 83520 CPT 301 RC outpatient 212 212 CIGNA 62308 [3081051] CIGNA STATE OF WYOMING [308105107] 169.6 percent of total billed charges 131.44 201.4 Technical (Hospital) Services Ref Antimullerian Hormone Serum PX-3018352010 CDM 83520 CPT 301 RC outpatient 212 212 MEDICA (COMMERCIAL) 94265 [3081118] MEDICA CLAIMS [308111801] 190.8 percent of total billed charges 131.44 201.4 Technical (Hospital) Services Ref Antimullerian Hormone Serum PX-3018352010 CDM 83520 CPT 301 RC inpatient 212 212 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES PPO [308136801] 167.86 percent of total billed charges 131.44 201.4 Technical (Hospital) Services Ref Antimullerian Hormone Serum PX-3018352010 CDM 83520 CPT 301 RC inpatient 212 212 UNITED HEALTHCARE (COMMERCIAL) [3081199] UNITED HEALTHCARE 87726 [308119901] 131.44 percent of total billed charges 131.44 201.4 Technical (Hospital) Services Ref Antimullerian Hormone Serum PX-3018352010 CDM 83520 CPT 301 RC inpatient 212 212 BLUE CROSS BLUE SHIELD WELLMARK SB889 [3081026] BCBS WYOMING [308102603] 201.4 percent of total billed charges 131.44 201.4 Technical (Hospital) Services Ref Antimullerian Hormone Serum PX-3018352010 CDM 83520 CPT 301 RC inpatient 212 212 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES HDHP [308136802] 167.86 percent of total billed charges 131.44 201.4 Technical (Hospital) Services Ref Antimullerian Hormone Serum PX-3018352010 CDM 83520 CPT 301 RC inpatient 212 212 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES EPO [308136803] 167.86 percent of total billed charges 131.44 201.4 Technical (Hospital) Services Ref Antimullerian Hormone Serum PX-3018352010 CDM 83520 CPT 301 RC inpatient 212 212 HEALTHPARTNERS SX009 HEALTHPARTNERS 167.86 percent of total billed charges 131.44 201.4 Technical (Hospital) Services Ref Antimullerian Hormone Serum PX-3018352010 CDM 83520 CPT 301 RC inpatient 212 212 MULTIPLAN INC 34080 [3081285] MULTIPLAN INC [308128501] 201.4 percent of total billed charges 131.44 201.4 Technical (Hospital) Services Ref Antimullerian Hormone Serum PX-3018352010 CDM 83520 CPT 301 RC inpatient 212 212 MEDICA (COMMERCIAL) 94265 [3081118] MEDICA CLAIMS [308111801] 190.8 percent of total billed charges 131.44 201.4 Technical (Hospital) Services Ref Antimullerian Hormone Serum PX-3018352010 CDM 83520 CPT 301 RC inpatient 212 212 CIGNA 62308 [3081051] CIGNA 62308 [308105105] 167.86 percent of total billed charges 131.44 201.4 Technical (Hospital) Services Ref Antimullerian Hormone Serum PX-3018352010 CDM 83520 CPT 301 RC inpatient 212 212 CIGNA 62308 [3081051] CIGNA STATE OF WYOMING [308105107] 167.86 percent of total billed charges 131.44 201.4 Technical (Hospital) Services Ref Thyrotropin Receptor Ab PX-3018352011 CDM 83520 CPT 301 RC inpatient 54 54 HEALTHPARTNERS SX009 HEALTHPARTNERS 42.76 percent of total billed charges 33.48 51.3 Technical (Hospital) Services Ref Thyrotropin Receptor Ab PX-3018352011 CDM 83520 CPT 301 RC inpatient 54 54 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES EPO [308136803] 42.76 percent of total billed charges 33.48 51.3 Technical (Hospital) Services Ref Thyrotropin Receptor Ab PX-3018352011 CDM 83520 CPT 301 RC inpatient 54 54 CIGNA 62308 [3081051] CIGNA 62308 [308105105] 42.76 percent of total billed charges 33.48 51.3 Technical (Hospital) Services Ref Thyrotropin Receptor Ab PX-3018352011 CDM 83520 CPT 301 RC inpatient 54 54 CIGNA 62308 [3081051] CIGNA STATE OF WYOMING [308105107] 42.76 percent of total billed charges 33.48 51.3 Technical (Hospital) Services Ref Thyrotropin Receptor Ab PX-3018352011 CDM 83520 CPT 301 RC inpatient 54 54 MULTIPLAN INC 34080 [3081285] MULTIPLAN INC [308128501] 51.3 percent of total billed charges 33.48 51.3 Technical (Hospital) Services Ref Thyrotropin Receptor Ab PX-3018352011 CDM 83520 CPT 301 RC inpatient 54 54 MEDICA (COMMERCIAL) 94265 [3081118] MEDICA CLAIMS [308111801] 48.6 percent of total billed charges 33.48 51.3 Technical (Hospital) Services Ref Thyrotropin Receptor Ab PX-3018352011 CDM 83520 CPT 301 RC inpatient 54 54 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES HDHP [308136802] 42.76 percent of total billed charges 33.48 51.3 Technical (Hospital) Services Ref Thyrotropin Receptor Ab PX-3018352011 CDM 83520 CPT 301 RC inpatient 54 54 BLUE CROSS BLUE SHIELD WELLMARK SB889 [3081026] BCBS WYOMING [308102603] 51.3 percent of total billed charges 33.48 51.3 Technical (Hospital) Services Ref Thyrotropin Receptor Ab PX-3018352011 CDM 83520 CPT 301 RC inpatient 54 54 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES PPO [308136801] 42.76 percent of total billed charges 33.48 51.3 Technical (Hospital) Services Ref Thyrotropin Receptor Ab PX-3018352011 CDM 83520 CPT 301 RC inpatient 54 54 UNITED HEALTHCARE (COMMERCIAL) [3081199] UNITED HEALTHCARE 87726 [308119901] 33.48 percent of total billed charges 33.48 51.3 Technical (Hospital) Services Ref Thyrotropin Receptor Ab PX-3018352011 CDM 83520 CPT 301 RC outpatient 54 54 MULTIPLAN INC 34080 [3081285] MULTIPLAN INC [308128501] 51.3 percent of total billed charges 33.48 51.3 Technical (Hospital) Services Ref Thyrotropin Receptor Ab PX-3018352011 CDM 83520 CPT 301 RC outpatient 54 54 BLUE CROSS BLUE SHIELD WELLMARK SB889 [3081026] BCBS WYOMING [308102603] 51.3 percent of total billed charges 33.48 51.3 Technical (Hospital) Services Ref Thyrotropin Receptor Ab PX-3018352011 CDM 83520 CPT 301 RC outpatient 54 54 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES HDHP [308136802] 43.2 percent of total billed charges 33.48 51.3 Technical (Hospital) Services Ref Thyrotropin Receptor Ab PX-3018352011 CDM 83520 CPT 301 RC outpatient 54 54 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES EPO [308136803] 43.2 percent of total billed charges 33.48 51.3 Technical (Hospital) Services Ref Thyrotropin Receptor Ab PX-3018352011 CDM 83520 CPT 301 RC outpatient 54 54 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES PPO [308136801] 43.2 percent of total billed charges 33.48 51.3 Technical (Hospital) Services Ref Thyrotropin Receptor Ab PX-3018352011 CDM 83520 CPT 301 RC outpatient 54 54 UNITED HEALTHCARE (COMMERCIAL) [3081199] UNITED HEALTHCARE 87726 [308119901] 33.48 percent of total billed charges 33.48 51.3 Technical (Hospital) Services Ref Thyrotropin Receptor Ab PX-3018352011 CDM 83520 CPT 301 RC outpatient 54 54 HEALTHPARTNERS SX009 HEALTHPARTNERS 43.2 percent of total billed charges 33.48 51.3 Technical (Hospital) Services Ref Thyrotropin Receptor Ab PX-3018352011 CDM 83520 CPT 301 RC outpatient 54 54 MEDICA (COMMERCIAL) 94265 [3081118] MEDICA CLAIMS [308111801] 48.6 percent of total billed charges 33.48 51.3 Technical (Hospital) Services Ref Thyrotropin Receptor Ab PX-3018352011 CDM 83520 CPT 301 RC outpatient 54 54 CIGNA 62308 [3081051] CIGNA 62308 [308105105] 43.2 percent of total billed charges 33.48 51.3 Technical (Hospital) Services Ref Thyrotropin Receptor Ab PX-3018352011 CDM 83520 CPT 301 RC outpatient 54 54 CIGNA 62308 [3081051] CIGNA STATE OF WYOMING [308105107] 43.2 percent of total billed charges 33.48 51.3 Technical (Hospital) Services Paraneoplastic Striational Ab PX-3018352013 CDM 83520 CPT 301 RC inpatient 182 182 UNITED HEALTHCARE (COMMERCIAL) [3081199] UNITED HEALTHCARE 87726 [308119901] 112.84 percent of total billed charges 112.84 172.9 Technical (Hospital) Services Paraneoplastic Striational Ab PX-3018352013 CDM 83520 CPT 301 RC inpatient 182 182 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES PPO [308136801] 144.11 percent of total billed charges 112.84 172.9 Technical (Hospital) Services Paraneoplastic Striational Ab PX-3018352013 CDM 83520 CPT 301 RC inpatient 182 182 BLUE CROSS BLUE SHIELD WELLMARK SB889 [3081026] BCBS WYOMING [308102603] 172.9 percent of total billed charges 112.84 172.9 Technical (Hospital) Services Paraneoplastic Striational Ab PX-3018352013 CDM 83520 CPT 301 RC inpatient 182 182 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES HDHP [308136802] 144.11 percent of total billed charges 112.84 172.9 Technical (Hospital) Services Paraneoplastic Striational Ab PX-3018352013 CDM 83520 CPT 301 RC inpatient 182 182 MEDICA (COMMERCIAL) 94265 [3081118] MEDICA CLAIMS [308111801] 163.8 percent of total billed charges 112.84 172.9 Technical (Hospital) Services Paraneoplastic Striational Ab PX-3018352013 CDM 83520 CPT 301 RC inpatient 182 182 MULTIPLAN INC 34080 [3081285] MULTIPLAN INC [308128501] 172.9 percent of total billed charges 112.84 172.9 Technical (Hospital) Services Paraneoplastic Striational Ab PX-3018352013 CDM 83520 CPT 301 RC inpatient 182 182 CIGNA 62308 [3081051] CIGNA 62308 [308105105] 144.11 percent of total billed charges 112.84 172.9 Technical (Hospital) Services Paraneoplastic Striational Ab PX-3018352013 CDM 83520 CPT 301 RC inpatient 182 182 CIGNA 62308 [3081051] CIGNA STATE OF WYOMING [308105107] 144.11 percent of total billed charges 112.84 172.9 Technical (Hospital) Services Paraneoplastic Striational Ab PX-3018352013 CDM 83520 CPT 301 RC inpatient 182 182 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES EPO [308136803] 144.11 percent of total billed charges 112.84 172.9 Technical (Hospital) Services Paraneoplastic Striational Ab PX-3018352013 CDM 83520 CPT 301 RC inpatient 182 182 HEALTHPARTNERS SX009 HEALTHPARTNERS 144.11 percent of total billed charges 112.84 172.9 Technical (Hospital) Services Paraneoplastic Striational Ab PX-3018352013 CDM 83520 CPT 301 RC outpatient 182 182 HEALTHPARTNERS SX009 HEALTHPARTNERS 145.6 percent of total billed charges 112.84 172.9 Technical (Hospital) Services Paraneoplastic Striational Ab PX-3018352013 CDM 83520 CPT 301 RC outpatient 182 182 UNITED HEALTHCARE (COMMERCIAL) [3081199] UNITED HEALTHCARE 87726 [308119901] 112.84 percent of total billed charges 112.84 172.9 Technical (Hospital) Services Paraneoplastic Striational Ab PX-3018352013 CDM 83520 CPT 301 RC outpatient 182 182 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES PPO [308136801] 145.6 percent of total billed charges 112.84 172.9 Technical (Hospital) Services Paraneoplastic Striational Ab PX-3018352013 CDM 83520 CPT 301 RC outpatient 182 182 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES HDHP [308136802] 145.6 percent of total billed charges 112.84 172.9 Technical (Hospital) Services Paraneoplastic Striational Ab PX-3018352013 CDM 83520 CPT 301 RC outpatient 182 182 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES EPO [308136803] 145.6 percent of total billed charges 112.84 172.9 Technical (Hospital) Services Paraneoplastic Striational Ab PX-3018352013 CDM 83520 CPT 301 RC outpatient 182 182 BLUE CROSS BLUE SHIELD WELLMARK SB889 [3081026] BCBS WYOMING [308102603] 172.9 percent of total billed charges 112.84 172.9 Technical (Hospital) Services Paraneoplastic Striational Ab PX-3018352013 CDM 83520 CPT 301 RC outpatient 182 182 MULTIPLAN INC 34080 [3081285] MULTIPLAN INC [308128501] 172.9 percent of total billed charges 112.84 172.9 Technical (Hospital) Services Paraneoplastic Striational Ab PX-3018352013 CDM 83520 CPT 301 RC outpatient 182 182 MEDICA (COMMERCIAL) 94265 [3081118] MEDICA CLAIMS [308111801] 163.8 percent of total billed charges 112.84 172.9 Technical (Hospital) Services Paraneoplastic Striational Ab PX-3018352013 CDM 83520 CPT 301 RC outpatient 182 182 CIGNA 62308 [3081051] CIGNA 62308 [308105105] 145.6 percent of total billed charges 112.84 172.9 Technical (Hospital) Services Paraneoplastic Striational Ab PX-3018352013 CDM 83520 CPT 301 RC outpatient 182 182 CIGNA 62308 [3081051] CIGNA STATE OF WYOMING [308105107] 145.6 percent of total billed charges 112.84 172.9 Technical (Hospital) Services HC Ref Immunoglobulin Free Lt Chains Serum(Mayo) PX-3018352020 CDM 83520 CPT 301 RC inpatient 180 180 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES HDHP [308136802] 142.52 percent of total billed charges 111.6 171 Technical (Hospital) Services HC Ref Immunoglobulin Free Lt Chains Serum(Mayo) PX-3018352020 CDM 83520 CPT 301 RC inpatient 180 180 BLUE CROSS BLUE SHIELD WELLMARK SB889 [3081026] BCBS WYOMING [308102603] 171 percent of total billed charges 111.6 171 Technical (Hospital) Services HC Ref Immunoglobulin Free Lt Chains Serum(Mayo) PX-3018352020 CDM 83520 CPT 301 RC inpatient 180 180 UNITED HEALTHCARE (COMMERCIAL) [3081199] UNITED HEALTHCARE 87726 [308119901] 111.6 percent of total billed charges 111.6 171 Technical (Hospital) Services HC Ref Immunoglobulin Free Lt Chains Serum(Mayo) PX-3018352020 CDM 83520 CPT 301 RC inpatient 180 180 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES PPO [308136801] 142.52 percent of total billed charges 111.6 171 Technical (Hospital) Services HC Ref Immunoglobulin Free Lt Chains Serum(Mayo) PX-3018352020 CDM 83520 CPT 301 RC inpatient 180 180 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES EPO [308136803] 142.52 percent of total billed charges 111.6 171 Technical (Hospital) Services HC Ref Immunoglobulin Free Lt Chains Serum(Mayo) PX-3018352020 CDM 83520 CPT 301 RC inpatient 180 180 HEALTHPARTNERS SX009 HEALTHPARTNERS 142.52 percent of total billed charges 111.6 171 Technical (Hospital) Services HC Ref Immunoglobulin Free Lt Chains Serum(Mayo) PX-3018352020 CDM 83520 CPT 301 RC inpatient 180 180 CIGNA 62308 [3081051] CIGNA 62308 [308105105] 142.52 percent of total billed charges 111.6 171 Technical (Hospital) Services HC Ref Immunoglobulin Free Lt Chains Serum(Mayo) PX-3018352020 CDM 83520 CPT 301 RC inpatient 180 180 CIGNA 62308 [3081051] CIGNA STATE OF WYOMING [308105107] 142.52 percent of total billed charges 111.6 171 Technical (Hospital) Services HC Ref Immunoglobulin Free Lt Chains Serum(Mayo) PX-3018352020 CDM 83520 CPT 301 RC inpatient 180 180 MULTIPLAN INC 34080 [3081285] MULTIPLAN INC [308128501] 171 percent of total billed charges 111.6 171 Technical (Hospital) Services HC Ref Immunoglobulin Free Lt Chains Serum(Mayo) PX-3018352020 CDM 83520 CPT 301 RC inpatient 180 180 MEDICA (COMMERCIAL) 94265 [3081118] MEDICA CLAIMS [308111801] 162 percent of total billed charges 111.6 171 Technical (Hospital) Services HC Ref Immunoglobulin Free Lt Chains Serum(Mayo) PX-3018352020 CDM 83520 CPT 301 RC outpatient 180 180 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES HDHP [308136802] 144 percent of total billed charges 111.6 171 Technical (Hospital) Services HC Ref Immunoglobulin Free Lt Chains Serum(Mayo) PX-3018352020 CDM 83520 CPT 301 RC outpatient 180 180 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES EPO [308136803] 144 percent of total billed charges 111.6 171 Technical (Hospital) Services HC Ref Immunoglobulin Free Lt Chains Serum(Mayo) PX-3018352020 CDM 83520 CPT 301 RC outpatient 180 180 MULTIPLAN INC 34080 [3081285] MULTIPLAN INC [308128501] 171 percent of total billed charges 111.6 171 Technical (Hospital) Services HC Ref Immunoglobulin Free Lt Chains Serum(Mayo) PX-3018352020 CDM 83520 CPT 301 RC outpatient 180 180 BLUE CROSS BLUE SHIELD WELLMARK SB889 [3081026] BCBS WYOMING [308102603] 171 percent of total billed charges 111.6 171 Technical (Hospital) Services HC Ref Immunoglobulin Free Lt Chains Serum(Mayo) PX-3018352020 CDM 83520 CPT 301 RC outpatient 180 180 HEALTHPARTNERS SX009 HEALTHPARTNERS 144 percent of total billed charges 111.6 171 Technical (Hospital) Services HC Ref Immunoglobulin Free Lt Chains Serum(Mayo) PX-3018352020 CDM 83520 CPT 301 RC outpatient 180 180 UNITED HEALTHCARE (COMMERCIAL) [3081199] UNITED HEALTHCARE 87726 [308119901] 111.6 percent of total billed charges 111.6 171 Technical (Hospital) Services HC Ref Immunoglobulin Free Lt Chains Serum(Mayo) PX-3018352020 CDM 83520 CPT 301 RC outpatient 180 180 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES PPO [308136801] 144 percent of total billed charges 111.6 171 Technical (Hospital) Services HC Ref Immunoglobulin Free Lt Chains Serum(Mayo) PX-3018352020 CDM 83520 CPT 301 RC outpatient 180 180 MEDICA (COMMERCIAL) 94265 [3081118] MEDICA CLAIMS [308111801] 162 percent of total billed charges 111.6 171 Technical (Hospital) Services HC Ref Immunoglobulin Free Lt Chains Serum(Mayo) PX-3018352020 CDM 83520 CPT 301 RC outpatient 180 180 CIGNA 62308 [3081051] CIGNA 62308 [308105105] 144 percent of total billed charges 111.6 171 Technical (Hospital) Services HC Ref Immunoglobulin Free Lt Chains Serum(Mayo) PX-3018352020 CDM 83520 CPT 301 RC outpatient 180 180 CIGNA 62308 [3081051] CIGNA STATE OF WYOMING [308105107] 144 percent of total billed charges 111.6 171 Technical (Hospital) Services Ref Paraneoplastic (V-G) K+ Chnl PX-3018351900 CDM 83519 CPT 301 RC outpatient 240 240 BLUE CROSS BLUE SHIELD WELLMARK SB889 [3081026] BCBS WYOMING [308102603] 228 percent of total billed charges 148.8 228 Technical (Hospital) Services Ref Paraneoplastic (V-G) K+ Chnl PX-3018351900 CDM 83519 CPT 301 RC outpatient 240 240 MULTIPLAN INC 34080 [3081285] MULTIPLAN INC [308128501] 228 percent of total billed charges 148.8 228 Technical (Hospital) Services Ref Paraneoplastic (V-G) K+ Chnl PX-3018351900 CDM 83519 CPT 301 RC outpatient 240 240 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES HDHP [308136802] 192 percent of total billed charges 148.8 228 Technical (Hospital) Services Ref Paraneoplastic (V-G) K+ Chnl PX-3018351900 CDM 83519 CPT 301 RC outpatient 240 240 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES EPO [308136803] 192 percent of total billed charges 148.8 228 Technical (Hospital) Services Ref Paraneoplastic (V-G) K+ Chnl PX-3018351900 CDM 83519 CPT 301 RC outpatient 240 240 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES PPO [308136801] 192 percent of total billed charges 148.8 228 Technical (Hospital) Services Ref Paraneoplastic (V-G) K+ Chnl PX-3018351900 CDM 83519 CPT 301 RC outpatient 240 240 UNITED HEALTHCARE (COMMERCIAL) [3081199] UNITED HEALTHCARE 87726 [308119901] 148.8 percent of total billed charges 148.8 228 Technical (Hospital) Services Ref Paraneoplastic (V-G) K+ Chnl PX-3018351900 CDM 83519 CPT 301 RC outpatient 240 240 HEALTHPARTNERS SX009 HEALTHPARTNERS 192 percent of total billed charges 148.8 228 Technical (Hospital) Services Ref Paraneoplastic (V-G) K+ Chnl PX-3018351900 CDM 83519 CPT 301 RC outpatient 240 240 CIGNA 62308 [3081051] CIGNA 62308 [308105105] 192 percent of total billed charges 148.8 228 Technical (Hospital) Services Ref Paraneoplastic (V-G) K+ Chnl PX-3018351900 CDM 83519 CPT 301 RC outpatient 240 240 CIGNA 62308 [3081051] CIGNA STATE OF WYOMING [308105107] 192 percent of total billed charges 148.8 228 Technical (Hospital) Services Ref Paraneoplastic (V-G) K+ Chnl PX-3018351900 CDM 83519 CPT 301 RC outpatient 240 240 MEDICA (COMMERCIAL) 94265 [3081118] MEDICA CLAIMS [308111801] 216 percent of total billed charges 148.8 228 Technical (Hospital) Services Ref Paraneoplastic (V-G) K+ Chnl PX-3018351900 CDM 83519 CPT 301 RC inpatient 240 240 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES HDHP [308136802] 190.03 percent of total billed charges 148.8 228 Technical (Hospital) Services Ref Paraneoplastic (V-G) K+ Chnl PX-3018351900 CDM 83519 CPT 301 RC inpatient 240 240 BLUE CROSS BLUE SHIELD WELLMARK SB889 [3081026] BCBS WYOMING [308102603] 228 percent of total billed charges 148.8 228 Technical (Hospital) Services Ref Paraneoplastic (V-G) K+ Chnl PX-3018351900 CDM 83519 CPT 301 RC inpatient 240 240 UNITED HEALTHCARE (COMMERCIAL) [3081199] UNITED HEALTHCARE 87726 [308119901] 148.8 percent of total billed charges 148.8 228 Technical (Hospital) Services Ref Paraneoplastic (V-G) K+ Chnl PX-3018351900 CDM 83519 CPT 301 RC inpatient 240 240 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES PPO [308136801] 190.03 percent of total billed charges 148.8 228 Technical (Hospital) Services Ref Paraneoplastic (V-G) K+ Chnl PX-3018351900 CDM 83519 CPT 301 RC inpatient 240 240 MULTIPLAN INC 34080 [3081285] MULTIPLAN INC [308128501] 228 percent of total billed charges 148.8 228 Technical (Hospital) Services Ref Paraneoplastic (V-G) K+ Chnl PX-3018351900 CDM 83519 CPT 301 RC inpatient 240 240 MEDICA (COMMERCIAL) 94265 [3081118] MEDICA CLAIMS [308111801] 216 percent of total billed charges 148.8 228 Technical (Hospital) Services Ref Paraneoplastic (V-G) K+ Chnl PX-3018351900 CDM 83519 CPT 301 RC inpatient 240 240 CIGNA 62308 [3081051] CIGNA 62308 [308105105] 190.03 percent of total billed charges 148.8 228 Technical (Hospital) Services Ref Paraneoplastic (V-G) K+ Chnl PX-3018351900 CDM 83519 CPT 301 RC inpatient 240 240 CIGNA 62308 [3081051] CIGNA STATE OF WYOMING [308105107] 190.03 percent of total billed charges 148.8 228 Technical (Hospital) Services Ref Paraneoplastic (V-G) K+ Chnl PX-3018351900 CDM 83519 CPT 301 RC inpatient 240 240 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES EPO [308136803] 190.03 percent of total billed charges 148.8 228 Technical (Hospital) Services Ref Paraneoplastic (V-G) K+ Chnl PX-3018351900 CDM 83519 CPT 301 RC inpatient 240 240 HEALTHPARTNERS SX009 HEALTHPARTNERS 190.03 percent of total billed charges 148.8 228 Technical (Hospital) Services Ref Ach Receptor Muscle Binding PX-3018351904 CDM 83519 CPT 301 RC outpatient 198 198 CIGNA 62308 [3081051] CIGNA 62308 [308105105] 158.4 percent of total billed charges 122.76 188.1 Technical (Hospital) Services Ref Ach Receptor Muscle Binding PX-3018351904 CDM 83519 CPT 301 RC outpatient 198 198 CIGNA 62308 [3081051] CIGNA STATE OF WYOMING [308105107] 158.4 percent of total billed charges 122.76 188.1 Technical (Hospital) Services Ref Ach Receptor Muscle Binding PX-3018351904 CDM 83519 CPT 301 RC outpatient 198 198 MEDICA (COMMERCIAL) 94265 [3081118] MEDICA CLAIMS [308111801] 178.2 percent of total billed charges 122.76 188.1 Technical (Hospital) Services Ref Ach Receptor Muscle Binding PX-3018351904 CDM 83519 CPT 301 RC outpatient 198 198 HEALTHPARTNERS SX009 HEALTHPARTNERS 158.4 percent of total billed charges 122.76 188.1 Technical (Hospital) Services Ref Ach Receptor Muscle Binding PX-3018351904 CDM 83519 CPT 301 RC outpatient 198 198 UNITED HEALTHCARE (COMMERCIAL) [3081199] UNITED HEALTHCARE 87726 [308119901] 122.76 percent of total billed charges 122.76 188.1 Technical (Hospital) Services Ref Ach Receptor Muscle Binding PX-3018351904 CDM 83519 CPT 301 RC outpatient 198 198 BLUE CROSS BLUE SHIELD WELLMARK SB889 [3081026] BCBS WYOMING [308102603] 188.1 percent of total billed charges 122.76 188.1 Technical (Hospital) Services Ref Ach Receptor Muscle Binding PX-3018351904 CDM 83519 CPT 301 RC outpatient 198 198 MULTIPLAN INC 34080 [3081285] MULTIPLAN INC [308128501] 188.1 percent of total billed charges 122.76 188.1 Technical (Hospital) Services Ref Ach Receptor Muscle Binding PX-3018351904 CDM 83519 CPT 301 RC outpatient 198 198 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES EPO [308136803] 158.4 percent of total billed charges 122.76 188.1 Technical (Hospital) Services Ref Ach Receptor Muscle Binding PX-3018351904 CDM 83519 CPT 301 RC outpatient 198 198 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES HDHP [308136802] 158.4 percent of total billed charges 122.76 188.1 Technical (Hospital) Services Ref Ach Receptor Muscle Binding PX-3018351904 CDM 83519 CPT 301 RC outpatient 198 198 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES PPO [308136801] 158.4 percent of total billed charges 122.76 188.1 Technical (Hospital) Services Ref Ach Receptor Muscle Binding PX-3018351904 CDM 83519 CPT 301 RC inpatient 198 198 MEDICA (COMMERCIAL) 94265 [3081118] MEDICA CLAIMS [308111801] 178.2 percent of total billed charges 122.76 188.1 Technical (Hospital) Services Ref Ach Receptor Muscle Binding PX-3018351904 CDM 83519 CPT 301 RC inpatient 198 198 MULTIPLAN INC 34080 [3081285] MULTIPLAN INC [308128501] 188.1 percent of total billed charges 122.76 188.1 Technical (Hospital) Services Ref Ach Receptor Muscle Binding PX-3018351904 CDM 83519 CPT 301 RC inpatient 198 198 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES EPO [308136803] 156.78 percent of total billed charges 122.76 188.1 Technical (Hospital) Services Ref Ach Receptor Muscle Binding PX-3018351904 CDM 83519 CPT 301 RC inpatient 198 198 HEALTHPARTNERS SX009 HEALTHPARTNERS 156.78 percent of total billed charges 122.76 188.1 Technical (Hospital) Services Ref Ach Receptor Muscle Binding PX-3018351904 CDM 83519 CPT 301 RC inpatient 198 198 CIGNA 62308 [3081051] CIGNA 62308 [308105105] 156.78 percent of total billed charges 122.76 188.1 Technical (Hospital) Services Ref Ach Receptor Muscle Binding PX-3018351904 CDM 83519 CPT 301 RC inpatient 198 198 CIGNA 62308 [3081051] CIGNA STATE OF WYOMING [308105107] 156.78 percent of total billed charges 122.76 188.1 Technical (Hospital) Services Ref Ach Receptor Muscle Binding PX-3018351904 CDM 83519 CPT 301 RC inpatient 198 198 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES PPO [308136801] 156.78 percent of total billed charges 122.76 188.1 Technical (Hospital) Services Ref Ach Receptor Muscle Binding PX-3018351904 CDM 83519 CPT 301 RC inpatient 198 198 UNITED HEALTHCARE (COMMERCIAL) [3081199] UNITED HEALTHCARE 87726 [308119901] 122.76 percent of total billed charges 122.76 188.1 Technical (Hospital) Services Ref Ach Receptor Muscle Binding PX-3018351904 CDM 83519 CPT 301 RC inpatient 198 198 BLUE CROSS BLUE SHIELD WELLMARK SB889 [3081026] BCBS WYOMING [308102603] 188.1 percent of total billed charges 122.76 188.1 Technical (Hospital) Services Ref Ach Receptor Muscle Binding PX-3018351904 CDM 83519 CPT 301 RC inpatient 198 198 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES HDHP [308136802] 156.78 percent of total billed charges 122.76 188.1 Technical (Hospital) Services Ref Mg Eval Ach Receptor Binding PX-3018351906 CDM 83519 CPT 301 RC outpatient 271 271 MEDICA (COMMERCIAL) 94265 [3081118] MEDICA CLAIMS [308111801] 243.9 percent of total billed charges 168.02 257.45 Technical (Hospital) Services Ref Mg Eval Ach Receptor Binding PX-3018351906 CDM 83519 CPT 301 RC outpatient 271 271 CIGNA 62308 [3081051] CIGNA 62308 [308105105] 216.8 percent of total billed charges 168.02 257.45 Technical (Hospital) Services Ref Mg Eval Ach Receptor Binding PX-3018351906 CDM 83519 CPT 301 RC outpatient 271 271 CIGNA 62308 [3081051] CIGNA STATE OF WYOMING [308105107] 216.8 percent of total billed charges 168.02 257.45 Technical (Hospital) Services Ref Mg Eval Ach Receptor Binding PX-3018351906 CDM 83519 CPT 301 RC outpatient 271 271 BLUE CROSS BLUE SHIELD WELLMARK SB889 [3081026] BCBS WYOMING [308102603] 257.45 percent of total billed charges 168.02 257.45 Technical (Hospital) Services Ref Mg Eval Ach Receptor Binding PX-3018351906 CDM 83519 CPT 301 RC outpatient 271 271 MULTIPLAN INC 34080 [3081285] MULTIPLAN INC [308128501] 257.45 percent of total billed charges 168.02 257.45 Technical (Hospital) Services Ref Mg Eval Ach Receptor Binding PX-3018351906 CDM 83519 CPT 301 RC outpatient 271 271 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES HDHP [308136802] 216.8 percent of total billed charges 168.02 257.45 Technical (Hospital) Services Ref Mg Eval Ach Receptor Binding PX-3018351906 CDM 83519 CPT 301 RC outpatient 271 271 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES EPO [308136803] 216.8 percent of total billed charges 168.02 257.45 Technical (Hospital) Services Ref Mg Eval Ach Receptor Binding PX-3018351906 CDM 83519 CPT 301 RC outpatient 271 271 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES PPO [308136801] 216.8 percent of total billed charges 168.02 257.45 Technical (Hospital) Services Ref Mg Eval Ach Receptor Binding PX-3018351906 CDM 83519 CPT 301 RC outpatient 271 271 UNITED HEALTHCARE (COMMERCIAL) [3081199] UNITED HEALTHCARE 87726 [308119901] 168.02 percent of total billed charges 168.02 257.45 Technical (Hospital) Services Ref Mg Eval Ach Receptor Binding PX-3018351906 CDM 83519 CPT 301 RC outpatient 271 271 HEALTHPARTNERS SX009 HEALTHPARTNERS 216.8 percent of total billed charges 168.02 257.45 Technical (Hospital) Services Ref Mg Eval Ach Receptor Binding PX-3018351906 CDM 83519 CPT 301 RC inpatient 271 271 UNITED HEALTHCARE (COMMERCIAL) [3081199] UNITED HEALTHCARE 87726 [308119901] 168.02 percent of total billed charges 168.02 257.45 Technical (Hospital) Services Ref Mg Eval Ach Receptor Binding PX-3018351906 CDM 83519 CPT 301 RC inpatient 271 271 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES PPO [308136801] 214.58 percent of total billed charges 168.02 257.45 Technical (Hospital) Services Ref Mg Eval Ach Receptor Binding PX-3018351906 CDM 83519 CPT 301 RC inpatient 271 271 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES HDHP [308136802] 214.58 percent of total billed charges 168.02 257.45 Technical (Hospital) Services Ref Mg Eval Ach Receptor Binding PX-3018351906 CDM 83519 CPT 301 RC inpatient 271 271 BLUE CROSS BLUE SHIELD WELLMARK SB889 [3081026] BCBS WYOMING [308102603] 257.45 percent of total billed charges 168.02 257.45 Technical (Hospital) Services Ref Mg Eval Ach Receptor Binding PX-3018351906 CDM 83519 CPT 301 RC inpatient 271 271 HEALTHPARTNERS SX009 HEALTHPARTNERS 214.58 percent of total billed charges 168.02 257.45 Technical (Hospital) Services Ref Mg Eval Ach Receptor Binding PX-3018351906 CDM 83519 CPT 301 RC inpatient 271 271 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES EPO [308136803] 214.58 percent of total billed charges 168.02 257.45 Technical (Hospital) Services Ref Mg Eval Ach Receptor Binding PX-3018351906 CDM 83519 CPT 301 RC inpatient 271 271 CIGNA 62308 [3081051] CIGNA 62308 [308105105] 214.58 percent of total billed charges 168.02 257.45 Technical (Hospital) Services Ref Mg Eval Ach Receptor Binding PX-3018351906 CDM 83519 CPT 301 RC inpatient 271 271 CIGNA 62308 [3081051] CIGNA STATE OF WYOMING [308105107] 214.58 percent of total billed charges 168.02 257.45 Technical (Hospital) Services Ref Mg Eval Ach Receptor Binding PX-3018351906 CDM 83519 CPT 301 RC inpatient 271 271 MEDICA (COMMERCIAL) 94265 [3081118] MEDICA CLAIMS [308111801] 243.9 percent of total billed charges 168.02 257.45 Technical (Hospital) Services Ref Mg Eval Ach Receptor Binding PX-3018351906 CDM 83519 CPT 301 RC inpatient 271 271 MULTIPLAN INC 34080 [3081285] MULTIPLAN INC [308128501] 257.45 percent of total billed charges 168.02 257.45 Technical (Hospital) Services Ref Mg Eval Ach Receptor Modulatin PX-3018351907 CDM 83519 CPT 301 RC outpatient 271 271 HEALTHPARTNERS SX009 HEALTHPARTNERS 216.8 percent of total billed charges 168.02 257.45 Technical (Hospital) Services Ref Mg Eval Ach Receptor Modulatin PX-3018351907 CDM 83519 CPT 301 RC outpatient 271 271 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES PPO [308136801] 216.8 percent of total billed charges 168.02 257.45 Technical (Hospital) Services Ref Mg Eval Ach Receptor Modulatin PX-3018351907 CDM 83519 CPT 301 RC outpatient 271 271 UNITED HEALTHCARE (COMMERCIAL) [3081199] UNITED HEALTHCARE 87726 [308119901] 168.02 percent of total billed charges 168.02 257.45 Technical (Hospital) Services Ref Mg Eval Ach Receptor Modulatin PX-3018351907 CDM 83519 CPT 301 RC outpatient 271 271 BLUE CROSS BLUE SHIELD WELLMARK SB889 [3081026] BCBS WYOMING [308102603] 257.45 percent of total billed charges 168.02 257.45 Technical (Hospital) Services Ref Mg Eval Ach Receptor Modulatin PX-3018351907 CDM 83519 CPT 301 RC outpatient 271 271 MULTIPLAN INC 34080 [3081285] MULTIPLAN INC [308128501] 257.45 percent of total billed charges 168.02 257.45 Technical (Hospital) Services Ref Mg Eval Ach Receptor Modulatin PX-3018351907 CDM 83519 CPT 301 RC outpatient 271 271 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES HDHP [308136802] 216.8 percent of total billed charges 168.02 257.45 Technical (Hospital) Services Ref Mg Eval Ach Receptor Modulatin PX-3018351907 CDM 83519 CPT 301 RC outpatient 271 271 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES EPO [308136803] 216.8 percent of total billed charges 168.02 257.45 Technical (Hospital) Services Ref Mg Eval Ach Receptor Modulatin PX-3018351907 CDM 83519 CPT 301 RC outpatient 271 271 MEDICA (COMMERCIAL) 94265 [3081118] MEDICA CLAIMS [308111801] 243.9 percent of total billed charges 168.02 257.45 Technical (Hospital) Services Ref Mg Eval Ach Receptor Modulatin PX-3018351907 CDM 83519 CPT 301 RC outpatient 271 271 CIGNA 62308 [3081051] CIGNA 62308 [308105105] 216.8 percent of total billed charges 168.02 257.45 Technical (Hospital) Services Ref Mg Eval Ach Receptor Modulatin PX-3018351907 CDM 83519 CPT 301 RC outpatient 271 271 CIGNA 62308 [3081051] CIGNA STATE OF WYOMING [308105107] 216.8 percent of total billed charges 168.02 257.45 Technical (Hospital) Services Ref Mg Eval Ach Receptor Modulatin PX-3018351907 CDM 83519 CPT 301 RC inpatient 271 271 CIGNA 62308 [3081051] CIGNA 62308 [308105105] 214.58 percent of total billed charges 168.02 257.45 Technical (Hospital) Services Ref Mg Eval Ach Receptor Modulatin PX-3018351907 CDM 83519 CPT 301 RC inpatient 271 271 CIGNA 62308 [3081051] CIGNA STATE OF WYOMING [308105107] 214.58 percent of total billed charges 168.02 257.45 Technical (Hospital) Services Ref Mg Eval Ach Receptor Modulatin PX-3018351907 CDM 83519 CPT 301 RC inpatient 271 271 MEDICA (COMMERCIAL) 94265 [3081118] MEDICA CLAIMS [308111801] 243.9 percent of total billed charges 168.02 257.45 Technical (Hospital) Services Ref Mg Eval Ach Receptor Modulatin PX-3018351907 CDM 83519 CPT 301 RC inpatient 271 271 MULTIPLAN INC 34080 [3081285] MULTIPLAN INC [308128501] 257.45 percent of total billed charges 168.02 257.45 Technical (Hospital) Services Ref Mg Eval Ach Receptor Modulatin PX-3018351907 CDM 83519 CPT 301 RC inpatient 271 271 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES EPO [308136803] 214.58 percent of total billed charges 168.02 257.45 Technical (Hospital) Services Ref Mg Eval Ach Receptor Modulatin PX-3018351907 CDM 83519 CPT 301 RC inpatient 271 271 HEALTHPARTNERS SX009 HEALTHPARTNERS 214.58 percent of total billed charges 168.02 257.45 Technical (Hospital) Services Ref Mg Eval Ach Receptor Modulatin PX-3018351907 CDM 83519 CPT 301 RC inpatient 271 271 BLUE CROSS BLUE SHIELD WELLMARK SB889 [3081026] BCBS WYOMING [308102603] 257.45 percent of total billed charges 168.02 257.45 Technical (Hospital) Services Ref Mg Eval Ach Receptor Modulatin PX-3018351907 CDM 83519 CPT 301 RC inpatient 271 271 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES HDHP [308136802] 214.58 percent of total billed charges 168.02 257.45 Technical (Hospital) Services Ref Mg Eval Ach Receptor Modulatin PX-3018351907 CDM 83519 CPT 301 RC inpatient 271 271 UNITED HEALTHCARE (COMMERCIAL) [3081199] UNITED HEALTHCARE 87726 [308119901] 168.02 percent of total billed charges 168.02 257.45 Technical (Hospital) Services Ref Mg Eval Ach Receptor Modulatin PX-3018351907 CDM 83519 CPT 301 RC inpatient 271 271 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES PPO [308136801] 214.58 percent of total billed charges 168.02 257.45 Technical (Hospital) Services Ref Paraneoplastic Ach Ganglionic PX-3018351909 CDM 83519 CPT 301 RC outpatient 378 378 MEDICA (COMMERCIAL) 94265 [3081118] MEDICA CLAIMS [308111801] 340.2 percent of total billed charges 234.36 359.1 Technical (Hospital) Services Ref Paraneoplastic Ach Ganglionic PX-3018351909 CDM 83519 CPT 301 RC outpatient 378 378 CIGNA 62308 [3081051] CIGNA 62308 [308105105] 302.4 percent of total billed charges 234.36 359.1 Technical (Hospital) Services Ref Paraneoplastic Ach Ganglionic PX-3018351909 CDM 83519 CPT 301 RC outpatient 378 378 CIGNA 62308 [3081051] CIGNA STATE OF WYOMING [308105107] 302.4 percent of total billed charges 234.36 359.1 Technical (Hospital) Services Ref Paraneoplastic Ach Ganglionic PX-3018351909 CDM 83519 CPT 301 RC outpatient 378 378 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES PPO [308136801] 302.4 percent of total billed charges 234.36 359.1 Technical (Hospital) Services Ref Paraneoplastic Ach Ganglionic PX-3018351909 CDM 83519 CPT 301 RC outpatient 378 378 MULTIPLAN INC 34080 [3081285] MULTIPLAN INC [308128501] 359.1 percent of total billed charges 234.36 359.1 Technical (Hospital) Services Ref Paraneoplastic Ach Ganglionic PX-3018351909 CDM 83519 CPT 301 RC outpatient 378 378 BLUE CROSS BLUE SHIELD WELLMARK SB889 [3081026] BCBS WYOMING [308102603] 359.1 percent of total billed charges 234.36 359.1 Technical (Hospital) Services Ref Paraneoplastic Ach Ganglionic PX-3018351909 CDM 83519 CPT 301 RC outpatient 378 378 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES HDHP [308136802] 302.4 percent of total billed charges 234.36 359.1 Technical (Hospital) Services Ref Paraneoplastic Ach Ganglionic PX-3018351909 CDM 83519 CPT 301 RC outpatient 378 378 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES EPO [308136803] 302.4 percent of total billed charges 234.36 359.1 Technical (Hospital) Services Ref Paraneoplastic Ach Ganglionic PX-3018351909 CDM 83519 CPT 301 RC outpatient 378 378 HEALTHPARTNERS SX009 HEALTHPARTNERS 302.4 percent of total billed charges 234.36 359.1 Technical (Hospital) Services Ref Paraneoplastic Ach Ganglionic PX-3018351909 CDM 83519 CPT 301 RC outpatient 378 378 UNITED HEALTHCARE (COMMERCIAL) [3081199] UNITED HEALTHCARE 87726 [308119901] 234.36 percent of total billed charges 234.36 359.1 Technical (Hospital) Services Ref Paraneoplastic Ach Ganglionic PX-3018351909 CDM 83519 CPT 301 RC inpatient 378 378 HEALTHPARTNERS SX009 HEALTHPARTNERS 299.3 percent of total billed charges 234.36 359.1 Technical (Hospital) Services Ref Paraneoplastic Ach Ganglionic PX-3018351909 CDM 83519 CPT 301 RC inpatient 378 378 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES EPO [308136803] 299.3 percent of total billed charges 234.36 359.1 Technical (Hospital) Services Ref Paraneoplastic Ach Ganglionic PX-3018351909 CDM 83519 CPT 301 RC inpatient 378 378 CIGNA 62308 [3081051] CIGNA 62308 [308105105] 299.3 percent of total billed charges 234.36 359.1 Technical (Hospital) Services Ref Paraneoplastic Ach Ganglionic PX-3018351909 CDM 83519 CPT 301 RC inpatient 378 378 CIGNA 62308 [3081051] CIGNA STATE OF WYOMING [308105107] 299.3 percent of total billed charges 234.36 359.1 Technical (Hospital) Services Ref Paraneoplastic Ach Ganglionic PX-3018351909 CDM 83519 CPT 301 RC inpatient 378 378 MEDICA (COMMERCIAL) 94265 [3081118] MEDICA CLAIMS [308111801] 340.2 percent of total billed charges 234.36 359.1 Technical (Hospital) Services Ref Paraneoplastic Ach Ganglionic PX-3018351909 CDM 83519 CPT 301 RC inpatient 378 378 MULTIPLAN INC 34080 [3081285] MULTIPLAN INC [308128501] 359.1 percent of total billed charges 234.36 359.1 Technical (Hospital) Services Ref Paraneoplastic Ach Ganglionic PX-3018351909 CDM 83519 CPT 301 RC inpatient 378 378 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES PPO [308136801] 299.3 percent of total billed charges 234.36 359.1 Technical (Hospital) Services Ref Paraneoplastic Ach Ganglionic PX-3018351909 CDM 83519 CPT 301 RC inpatient 378 378 UNITED HEALTHCARE (COMMERCIAL) [3081199] UNITED HEALTHCARE 87726 [308119901] 234.36 percent of total billed charges 234.36 359.1 Technical (Hospital) Services Ref Paraneoplastic Ach Ganglionic PX-3018351909 CDM 83519 CPT 301 RC inpatient 378 378 BLUE CROSS BLUE SHIELD WELLMARK SB889 [3081026] BCBS WYOMING [308102603] 359.1 percent of total billed charges 234.36 359.1 Technical (Hospital) Services Ref Paraneoplastic Ach Ganglionic PX-3018351909 CDM 83519 CPT 301 RC inpatient 378 378 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES HDHP [308136802] 299.3 percent of total billed charges 234.36 359.1 Technical (Hospital) Services Ref Musk Autoanitbody PX-3018351914 CDM 83519 CPT 301 RC outpatient 1022 1022 CIGNA 62308 [3081051] CIGNA 62308 [308105105] 817.6 percent of total billed charges 633.64 970.9 Technical (Hospital) Services Ref Musk Autoanitbody PX-3018351914 CDM 83519 CPT 301 RC outpatient 1022 1022 CIGNA 62308 [3081051] CIGNA STATE OF WYOMING [308105107] 817.6 percent of total billed charges 633.64 970.9 Technical (Hospital) Services Ref Musk Autoanitbody PX-3018351914 CDM 83519 CPT 301 RC outpatient 1022 1022 MEDICA (COMMERCIAL) 94265 [3081118] MEDICA CLAIMS [308111801] 919.8 percent of total billed charges 633.64 970.9 Technical (Hospital) Services Ref Musk Autoanitbody PX-3018351914 CDM 83519 CPT 301 RC outpatient 1022 1022 UNITED HEALTHCARE (COMMERCIAL) [3081199] UNITED HEALTHCARE 87726 [308119901] 633.64 percent of total billed charges 633.64 970.9 Technical (Hospital) Services Ref Musk Autoanitbody PX-3018351914 CDM 83519 CPT 301 RC outpatient 1022 1022 HEALTHPARTNERS SX009 HEALTHPARTNERS 817.6 percent of total billed charges 633.64 970.9 Technical (Hospital) Services Ref Musk Autoanitbody PX-3018351914 CDM 83519 CPT 301 RC outpatient 1022 1022 BLUE CROSS BLUE SHIELD WELLMARK SB889 [3081026] BCBS WYOMING [308102603] 970.9 percent of total billed charges 633.64 970.9 Technical (Hospital) Services Ref Musk Autoanitbody PX-3018351914 CDM 83519 CPT 301 RC outpatient 1022 1022 MULTIPLAN INC 34080 [3081285] MULTIPLAN INC [308128501] 970.9 percent of total billed charges 633.64 970.9 Technical (Hospital) Services Ref Musk Autoanitbody PX-3018351914 CDM 83519 CPT 301 RC outpatient 1022 1022 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES EPO [308136803] 817.6 percent of total billed charges 633.64 970.9 Technical (Hospital) Services Ref Musk Autoanitbody PX-3018351914 CDM 83519 CPT 301 RC outpatient 1022 1022 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES HDHP [308136802] 817.6 percent of total billed charges 633.64 970.9 Technical (Hospital) Services Ref Musk Autoanitbody PX-3018351914 CDM 83519 CPT 301 RC outpatient 1022 1022 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES PPO [308136801] 817.6 percent of total billed charges 633.64 970.9 Technical (Hospital) Services Ref Musk Autoanitbody PX-3018351914 CDM 83519 CPT 301 RC inpatient 1022 1022 UNITED HEALTHCARE (COMMERCIAL) [3081199] UNITED HEALTHCARE 87726 [308119901] 633.64 percent of total billed charges 633.64 970.9 Technical (Hospital) Services Ref Musk Autoanitbody PX-3018351914 CDM 83519 CPT 301 RC inpatient 1022 1022 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES PPO [308136801] 809.22 percent of total billed charges 633.64 970.9 Technical (Hospital) Services Ref Musk Autoanitbody PX-3018351914 CDM 83519 CPT 301 RC inpatient 1022 1022 BLUE CROSS BLUE SHIELD WELLMARK SB889 [3081026] BCBS WYOMING [308102603] 970.9 percent of total billed charges 633.64 970.9 Technical (Hospital) Services Ref Musk Autoanitbody PX-3018351914 CDM 83519 CPT 301 RC inpatient 1022 1022 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES HDHP [308136802] 809.22 percent of total billed charges 633.64 970.9 Technical (Hospital) Services Ref Musk Autoanitbody PX-3018351914 CDM 83519 CPT 301 RC inpatient 1022 1022 CIGNA 62308 [3081051] CIGNA 62308 [308105105] 809.22 percent of total billed charges 633.64 970.9 Technical (Hospital) Services Ref Musk Autoanitbody PX-3018351914 CDM 83519 CPT 301 RC inpatient 1022 1022 CIGNA 62308 [3081051] CIGNA STATE OF WYOMING [308105107] 809.22 percent of total billed charges 633.64 970.9 Technical (Hospital) Services Ref Musk Autoanitbody PX-3018351914 CDM 83519 CPT 301 RC inpatient 1022 1022 MEDICA (COMMERCIAL) 94265 [3081118] MEDICA CLAIMS [308111801] 919.8 percent of total billed charges 633.64 970.9 Technical (Hospital) Services Ref Musk Autoanitbody PX-3018351914 CDM 83519 CPT 301 RC inpatient 1022 1022 MULTIPLAN INC 34080 [3081285] MULTIPLAN INC [308128501] 970.9 percent of total billed charges 633.64 970.9 Technical (Hospital) Services Ref Musk Autoanitbody PX-3018351914 CDM 83519 CPT 301 RC inpatient 1022 1022 HEALTHPARTNERS SX009 HEALTHPARTNERS 809.22 percent of total billed charges 633.64 970.9 Technical (Hospital) Services Ref Musk Autoanitbody PX-3018351914 CDM 83519 CPT 301 RC inpatient 1022 1022 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES EPO [308136803] 809.22 percent of total billed charges 633.64 970.9 Technical (Hospital) Services Ref Gliadin Ab or Igg or Igm PX-3018351600 CDM 83516 CPT 301 RC outpatient 161 161 MEDICA (COMMERCIAL) 94265 [3081118] MEDICA CLAIMS [308111801] 144.9 percent of total billed charges 99.82 152.95 Technical (Hospital) Services Ref Gliadin Ab or Igg or Igm PX-3018351600 CDM 83516 CPT 301 RC outpatient 161 161 CIGNA 62308 [3081051] CIGNA 62308 [308105105] 128.8 percent of total billed charges 99.82 152.95 Technical (Hospital) Services Ref Gliadin Ab or Igg or Igm PX-3018351600 CDM 83516 CPT 301 RC outpatient 161 161 CIGNA 62308 [3081051] CIGNA STATE OF WYOMING [308105107] 128.8 percent of total billed charges 99.82 152.95 Technical (Hospital) Services Ref Gliadin Ab or Igg or Igm PX-3018351600 CDM 83516 CPT 301 RC outpatient 161 161 HEALTHPARTNERS SX009 HEALTHPARTNERS 128.8 percent of total billed charges 99.82 152.95 Technical (Hospital) Services Ref Gliadin Ab or Igg or Igm PX-3018351600 CDM 83516 CPT 301 RC outpatient 161 161 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES PPO [308136801] 128.8 percent of total billed charges 99.82 152.95 Technical (Hospital) Services Ref Gliadin Ab or Igg or Igm PX-3018351600 CDM 83516 CPT 301 RC outpatient 161 161 UNITED HEALTHCARE (COMMERCIAL) [3081199] UNITED HEALTHCARE 87726 [308119901] 99.82 percent of total billed charges 99.82 152.95 Technical (Hospital) Services Ref Gliadin Ab or Igg or Igm PX-3018351600 CDM 83516 CPT 301 RC outpatient 161 161 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES HDHP [308136802] 128.8 percent of total billed charges 99.82 152.95 Technical (Hospital) Services Ref Gliadin Ab or Igg or Igm PX-3018351600 CDM 83516 CPT 301 RC outpatient 161 161 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES EPO [308136803] 128.8 percent of total billed charges 99.82 152.95 Technical (Hospital) Services Ref Gliadin Ab or Igg or Igm PX-3018351600 CDM 83516 CPT 301 RC outpatient 161 161 MULTIPLAN INC 34080 [3081285] MULTIPLAN INC [308128501] 152.95 percent of total billed charges 99.82 152.95 Technical (Hospital) Services Ref Gliadin Ab or Igg or Igm PX-3018351600 CDM 83516 CPT 301 RC outpatient 161 161 BLUE CROSS BLUE SHIELD WELLMARK SB889 [3081026] BCBS WYOMING [308102603] 152.95 percent of total billed charges 99.82 152.95 Technical (Hospital) Services Ref Gliadin Ab or Igg or Igm PX-3018351600 CDM 83516 CPT 301 RC inpatient 161 161 UNITED HEALTHCARE (COMMERCIAL) [3081199] UNITED HEALTHCARE 87726 [308119901] 99.82 percent of total billed charges 99.82 152.95 Technical (Hospital) Services Ref Gliadin Ab or Igg or Igm PX-3018351600 CDM 83516 CPT 301 RC inpatient 161 161 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES PPO [308136801] 127.48 percent of total billed charges 99.82 152.95 Technical (Hospital) Services Ref Gliadin Ab or Igg or Igm PX-3018351600 CDM 83516 CPT 301 RC inpatient 161 161 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES HDHP [308136802] 127.48 percent of total billed charges 99.82 152.95 Technical (Hospital) Services Ref Gliadin Ab or Igg or Igm PX-3018351600 CDM 83516 CPT 301 RC inpatient 161 161 BLUE CROSS BLUE SHIELD WELLMARK SB889 [3081026] BCBS WYOMING [308102603] 152.95 percent of total billed charges 99.82 152.95 Technical (Hospital) Services Ref Gliadin Ab or Igg or Igm PX-3018351600 CDM 83516 CPT 301 RC inpatient 161 161 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES EPO [308136803] 127.48 percent of total billed charges 99.82 152.95 Technical (Hospital) Services Ref Gliadin Ab or Igg or Igm PX-3018351600 CDM 83516 CPT 301 RC inpatient 161 161 HEALTHPARTNERS SX009 HEALTHPARTNERS 127.48 percent of total billed charges 99.82 152.95 Technical (Hospital) Services Ref Gliadin Ab or Igg or Igm PX-3018351600 CDM 83516 CPT 301 RC inpatient 161 161 CIGNA 62308 [3081051] CIGNA 62308 [308105105] 127.48 percent of total billed charges 99.82 152.95 Technical (Hospital) Services Ref Gliadin Ab or Igg or Igm PX-3018351600 CDM 83516 CPT 301 RC inpatient 161 161 CIGNA 62308 [3081051] CIGNA STATE OF WYOMING [308105107] 127.48 percent of total billed charges 99.82 152.95 Technical (Hospital) Services Ref Gliadin Ab or Igg or Igm PX-3018351600 CDM 83516 CPT 301 RC inpatient 161 161 MEDICA (COMMERCIAL) 94265 [3081118] MEDICA CLAIMS [308111801] 144.9 percent of total billed charges 99.82 152.95 Technical (Hospital) Services Ref Gliadin Ab or Igg or Igm PX-3018351600 CDM 83516 CPT 301 RC inpatient 161 161 MULTIPLAN INC 34080 [3081285] MULTIPLAN INC [308128501] 152.95 percent of total billed charges 99.82 152.95 Technical (Hospital) Services Ref Cystic Fibrosis PX-3018351601 CDM 83516 CPT 301 RC inpatient 166 166 HEALTHPARTNERS SX009 HEALTHPARTNERS 131.44 percent of total billed charges 102.92 157.7 Technical (Hospital) Services Ref Cystic Fibrosis PX-3018351601 CDM 83516 CPT 301 RC inpatient 166 166 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES EPO [308136803] 131.44 percent of total billed charges 102.92 157.7 Technical (Hospital) Services Ref Cystic Fibrosis PX-3018351601 CDM 83516 CPT 301 RC inpatient 166 166 CIGNA 62308 [3081051] CIGNA 62308 [308105105] 131.44 percent of total billed charges 102.92 157.7 Technical (Hospital) Services Ref Cystic Fibrosis PX-3018351601 CDM 83516 CPT 301 RC inpatient 166 166 CIGNA 62308 [3081051] CIGNA STATE OF WYOMING [308105107] 131.44 percent of total billed charges 102.92 157.7 Technical (Hospital) Services Ref Cystic Fibrosis PX-3018351601 CDM 83516 CPT 301 RC inpatient 166 166 MEDICA (COMMERCIAL) 94265 [3081118] MEDICA CLAIMS [308111801] 149.4 percent of total billed charges 102.92 157.7 Technical (Hospital) Services Ref Cystic Fibrosis PX-3018351601 CDM 83516 CPT 301 RC inpatient 166 166 MULTIPLAN INC 34080 [3081285] MULTIPLAN INC [308128501] 157.7 percent of total billed charges 102.92 157.7 Technical (Hospital) Services Ref Cystic Fibrosis PX-3018351601 CDM 83516 CPT 301 RC inpatient 166 166 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES PPO [308136801] 131.44 percent of total billed charges 102.92 157.7 Technical (Hospital) Services Ref Cystic Fibrosis PX-3018351601 CDM 83516 CPT 301 RC inpatient 166 166 UNITED HEALTHCARE (COMMERCIAL) [3081199] UNITED HEALTHCARE 87726 [308119901] 102.92 percent of total billed charges 102.92 157.7 Technical (Hospital) Services Ref Cystic Fibrosis PX-3018351601 CDM 83516 CPT 301 RC inpatient 166 166 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES HDHP [308136802] 131.44 percent of total billed charges 102.92 157.7 Technical (Hospital) Services Ref Cystic Fibrosis PX-3018351601 CDM 83516 CPT 301 RC inpatient 166 166 BLUE CROSS BLUE SHIELD WELLMARK SB889 [3081026] BCBS WYOMING [308102603] 157.7 percent of total billed charges 102.92 157.7 Technical (Hospital) Services Ref Cystic Fibrosis PX-3018351601 CDM 83516 CPT 301 RC outpatient 166 166 MEDICA (COMMERCIAL) 94265 [3081118] MEDICA CLAIMS [308111801] 149.4 percent of total billed charges 102.92 157.7 Technical (Hospital) Services Ref Cystic Fibrosis PX-3018351601 CDM 83516 CPT 301 RC outpatient 166 166 CIGNA 62308 [3081051] CIGNA 62308 [308105105] 132.8 percent of total billed charges 102.92 157.7 Technical (Hospital) Services Ref Cystic Fibrosis PX-3018351601 CDM 83516 CPT 301 RC outpatient 166 166 CIGNA 62308 [3081051] CIGNA STATE OF WYOMING [308105107] 132.8 percent of total billed charges 102.92 157.7 Technical (Hospital) Services Ref Cystic Fibrosis PX-3018351601 CDM 83516 CPT 301 RC outpatient 166 166 HEALTHPARTNERS SX009 HEALTHPARTNERS 132.8 percent of total billed charges 102.92 157.7 Technical (Hospital) Services Ref Cystic Fibrosis PX-3018351601 CDM 83516 CPT 301 RC outpatient 166 166 UNITED HEALTHCARE (COMMERCIAL) [3081199] UNITED HEALTHCARE 87726 [308119901] 102.92 percent of total billed charges 102.92 157.7 Technical (Hospital) Services Ref Cystic Fibrosis PX-3018351601 CDM 83516 CPT 301 RC outpatient 166 166 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES PPO [308136801] 132.8 percent of total billed charges 102.92 157.7 Technical (Hospital) Services Ref Cystic Fibrosis PX-3018351601 CDM 83516 CPT 301 RC outpatient 166 166 BLUE CROSS BLUE SHIELD WELLMARK SB889 [3081026] BCBS WYOMING [308102603] 157.7 percent of total billed charges 102.92 157.7 Technical (Hospital) Services Ref Cystic Fibrosis PX-3018351601 CDM 83516 CPT 301 RC outpatient 166 166 MULTIPLAN INC 34080 [3081285] MULTIPLAN INC [308128501] 157.7 percent of total billed charges 102.92 157.7 Technical (Hospital) Services Ref Cystic Fibrosis PX-3018351601 CDM 83516 CPT 301 RC outpatient 166 166 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES HDHP [308136802] 132.8 percent of total billed charges 102.92 157.7 Technical (Hospital) Services Ref Cystic Fibrosis PX-3018351601 CDM 83516 CPT 301 RC outpatient 166 166 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES EPO [308136803] 132.8 percent of total billed charges 102.92 157.7 Technical (Hospital) Services Ref Pr3 PX-3018351602 CDM 83516 CPT 301 RC inpatient 160 160 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES PPO [308136801] 126.69 percent of total billed charges 99.2 152 Technical (Hospital) Services Ref Pr3 PX-3018351602 CDM 83516 CPT 301 RC inpatient 160 160 UNITED HEALTHCARE (COMMERCIAL) [3081199] UNITED HEALTHCARE 87726 [308119901] 99.2 percent of total billed charges 99.2 152 Technical (Hospital) Services Ref Pr3 PX-3018351602 CDM 83516 CPT 301 RC inpatient 160 160 BLUE CROSS BLUE SHIELD WELLMARK SB889 [3081026] BCBS WYOMING [308102603] 152 percent of total billed charges 99.2 152 Technical (Hospital) Services Ref Pr3 PX-3018351602 CDM 83516 CPT 301 RC inpatient 160 160 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES HDHP [308136802] 126.69 percent of total billed charges 99.2 152 Technical (Hospital) Services Ref Pr3 PX-3018351602 CDM 83516 CPT 301 RC inpatient 160 160 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES EPO [308136803] 126.69 percent of total billed charges 99.2 152 Technical (Hospital) Services Ref Pr3 PX-3018351602 CDM 83516 CPT 301 RC inpatient 160 160 HEALTHPARTNERS SX009 HEALTHPARTNERS 126.69 percent of total billed charges 99.2 152 Technical (Hospital) Services Ref Pr3 PX-3018351602 CDM 83516 CPT 301 RC inpatient 160 160 CIGNA 62308 [3081051] CIGNA 62308 [308105105] 126.69 percent of total billed charges 99.2 152 Technical (Hospital) Services Ref Pr3 PX-3018351602 CDM 83516 CPT 301 RC inpatient 160 160 CIGNA 62308 [3081051] CIGNA STATE OF WYOMING [308105107] 126.69 percent of total billed charges 99.2 152 Technical (Hospital) Services Ref Pr3 PX-3018351602 CDM 83516 CPT 301 RC inpatient 160 160 MEDICA (COMMERCIAL) 94265 [3081118] MEDICA CLAIMS [308111801] 144 percent of total billed charges 99.2 152 Technical (Hospital) Services Ref Pr3 PX-3018351602 CDM 83516 CPT 301 RC inpatient 160 160 MULTIPLAN INC 34080 [3081285] MULTIPLAN INC [308128501] 152 percent of total billed charges 99.2 152 Technical (Hospital) Services Ref Pr3 PX-3018351602 CDM 83516 CPT 301 RC outpatient 160 160 HEALTHPARTNERS SX009 HEALTHPARTNERS 128 percent of total billed charges 99.2 152 Technical (Hospital) Services Ref Pr3 PX-3018351602 CDM 83516 CPT 301 RC outpatient 160 160 UNITED HEALTHCARE (COMMERCIAL) [3081199] UNITED HEALTHCARE 87726 [308119901] 99.2 percent of total billed charges 99.2 152 Technical (Hospital) Services Ref Pr3 PX-3018351602 CDM 83516 CPT 301 RC outpatient 160 160 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES EPO [308136803] 128 percent of total billed charges 99.2 152 Technical (Hospital) Services Ref Pr3 PX-3018351602 CDM 83516 CPT 301 RC outpatient 160 160 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES HDHP [308136802] 128 percent of total billed charges 99.2 152 Technical (Hospital) Services Ref Pr3 PX-3018351602 CDM 83516 CPT 301 RC outpatient 160 160 BLUE CROSS BLUE SHIELD WELLMARK SB889 [3081026] BCBS WYOMING [308102603] 152 percent of total billed charges 99.2 152 Technical (Hospital) Services Ref Pr3 PX-3018351602 CDM 83516 CPT 301 RC outpatient 160 160 MULTIPLAN INC 34080 [3081285] MULTIPLAN INC [308128501] 152 percent of total billed charges 99.2 152 Technical (Hospital) Services Ref Pr3 PX-3018351602 CDM 83516 CPT 301 RC outpatient 160 160 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES PPO [308136801] 128 percent of total billed charges 99.2 152 Technical (Hospital) Services Ref Pr3 PX-3018351602 CDM 83516 CPT 301 RC outpatient 160 160 MEDICA (COMMERCIAL) 94265 [3081118] MEDICA CLAIMS [308111801] 144 percent of total billed charges 99.2 152 Technical (Hospital) Services Ref Pr3 PX-3018351602 CDM 83516 CPT 301 RC outpatient 160 160 CIGNA 62308 [3081051] CIGNA 62308 [308105105] 128 percent of total billed charges 99.2 152 Technical (Hospital) Services Ref Pr3 PX-3018351602 CDM 83516 CPT 301 RC outpatient 160 160 CIGNA 62308 [3081051] CIGNA STATE OF WYOMING [308105107] 128 percent of total billed charges 99.2 152 Technical (Hospital) Services Ref Mpo PX-3018351603 CDM 83516 CPT 301 RC inpatient 160 160 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES PPO [308136801] 126.69 percent of total billed charges 99.2 152 Technical (Hospital) Services Ref Mpo PX-3018351603 CDM 83516 CPT 301 RC inpatient 160 160 UNITED HEALTHCARE (COMMERCIAL) [3081199] UNITED HEALTHCARE 87726 [308119901] 99.2 percent of total billed charges 99.2 152 Technical (Hospital) Services Ref Mpo PX-3018351603 CDM 83516 CPT 301 RC inpatient 160 160 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES HDHP [308136802] 126.69 percent of total billed charges 99.2 152 Technical (Hospital) Services Ref Mpo PX-3018351603 CDM 83516 CPT 301 RC inpatient 160 160 BLUE CROSS BLUE SHIELD WELLMARK SB889 [3081026] BCBS WYOMING [308102603] 152 percent of total billed charges 99.2 152 Technical (Hospital) Services Ref Mpo PX-3018351603 CDM 83516 CPT 301 RC inpatient 160 160 MEDICA (COMMERCIAL) 94265 [3081118] MEDICA CLAIMS [308111801] 144 percent of total billed charges 99.2 152 Technical (Hospital) Services Ref Mpo PX-3018351603 CDM 83516 CPT 301 RC inpatient 160 160 MULTIPLAN INC 34080 [3081285] MULTIPLAN INC [308128501] 152 percent of total billed charges 99.2 152 Technical (Hospital) Services Ref Mpo PX-3018351603 CDM 83516 CPT 301 RC inpatient 160 160 CIGNA 62308 [3081051] CIGNA 62308 [308105105] 126.69 percent of total billed charges 99.2 152 Technical (Hospital) Services Ref Mpo PX-3018351603 CDM 83516 CPT 301 RC inpatient 160 160 CIGNA 62308 [3081051] CIGNA STATE OF WYOMING [308105107] 126.69 percent of total billed charges 99.2 152 Technical (Hospital) Services Ref Mpo PX-3018351603 CDM 83516 CPT 301 RC inpatient 160 160 HEALTHPARTNERS SX009 HEALTHPARTNERS 126.69 percent of total billed charges 99.2 152 Technical (Hospital) Services Ref Mpo PX-3018351603 CDM 83516 CPT 301 RC inpatient 160 160 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES EPO [308136803] 126.69 percent of total billed charges 99.2 152 Technical (Hospital) Services Ref Mpo PX-3018351603 CDM 83516 CPT 301 RC outpatient 160 160 UNITED HEALTHCARE (COMMERCIAL) [3081199] UNITED HEALTHCARE 87726 [308119901] 99.2 percent of total billed charges 99.2 152 Technical (Hospital) Services Ref Mpo PX-3018351603 CDM 83516 CPT 301 RC outpatient 160 160 HEALTHPARTNERS SX009 HEALTHPARTNERS 128 percent of total billed charges 99.2 152 Technical (Hospital) Services Ref Mpo PX-3018351603 CDM 83516 CPT 301 RC outpatient 160 160 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES HDHP [308136802] 128 percent of total billed charges 99.2 152 Technical (Hospital) Services Ref Mpo PX-3018351603 CDM 83516 CPT 301 RC outpatient 160 160 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES EPO [308136803] 128 percent of total billed charges 99.2 152 Technical (Hospital) Services Ref Mpo PX-3018351603 CDM 83516 CPT 301 RC outpatient 160 160 MULTIPLAN INC 34080 [3081285] MULTIPLAN INC [308128501] 152 percent of total billed charges 99.2 152 Technical (Hospital) Services Ref Mpo PX-3018351603 CDM 83516 CPT 301 RC outpatient 160 160 BLUE CROSS BLUE SHIELD WELLMARK SB889 [3081026] BCBS WYOMING [308102603] 152 percent of total billed charges 99.2 152 Technical (Hospital) Services Ref Mpo PX-3018351603 CDM 83516 CPT 301 RC outpatient 160 160 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES PPO [308136801] 128 percent of total billed charges 99.2 152 Technical (Hospital) Services Ref Mpo PX-3018351603 CDM 83516 CPT 301 RC outpatient 160 160 MEDICA (COMMERCIAL) 94265 [3081118] MEDICA CLAIMS [308111801] 144 percent of total billed charges 99.2 152 Technical (Hospital) Services Ref Mpo PX-3018351603 CDM 83516 CPT 301 RC outpatient 160 160 CIGNA 62308 [3081051] CIGNA 62308 [308105105] 128 percent of total billed charges 99.2 152 Technical (Hospital) Services Ref Mpo PX-3018351603 CDM 83516 CPT 301 RC outpatient 160 160 CIGNA 62308 [3081051] CIGNA STATE OF WYOMING [308105107] 128 percent of total billed charges 99.2 152 Technical (Hospital) Services Ref Gliadin Deaminated Igg or Iga PX-3018351604 CDM 83516 CPT 301 RC outpatient 194 194 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES PPO [308136801] 155.2 percent of total billed charges 120.28 184.3 Technical (Hospital) Services Ref Gliadin Deaminated Igg or Iga PX-3018351604 CDM 83516 CPT 301 RC outpatient 194 194 BLUE CROSS BLUE SHIELD WELLMARK SB889 [3081026] BCBS WYOMING [308102603] 184.3 percent of total billed charges 120.28 184.3 Technical (Hospital) Services Ref Gliadin Deaminated Igg or Iga PX-3018351604 CDM 83516 CPT 301 RC outpatient 194 194 MULTIPLAN INC 34080 [3081285] MULTIPLAN INC [308128501] 184.3 percent of total billed charges 120.28 184.3 Technical (Hospital) Services Ref Gliadin Deaminated Igg or Iga PX-3018351604 CDM 83516 CPT 301 RC outpatient 194 194 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES EPO [308136803] 155.2 percent of total billed charges 120.28 184.3 Technical (Hospital) Services Ref Gliadin Deaminated Igg or Iga PX-3018351604 CDM 83516 CPT 301 RC outpatient 194 194 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES HDHP [308136802] 155.2 percent of total billed charges 120.28 184.3 Technical (Hospital) Services Ref Gliadin Deaminated Igg or Iga PX-3018351604 CDM 83516 CPT 301 RC outpatient 194 194 UNITED HEALTHCARE (COMMERCIAL) [3081199] UNITED HEALTHCARE 87726 [308119901] 120.28 percent of total billed charges 120.28 184.3 Technical (Hospital) Services Ref Gliadin Deaminated Igg or Iga PX-3018351604 CDM 83516 CPT 301 RC outpatient 194 194 HEALTHPARTNERS SX009 HEALTHPARTNERS 155.2 percent of total billed charges 120.28 184.3 Technical (Hospital) Services Ref Gliadin Deaminated Igg or Iga PX-3018351604 CDM 83516 CPT 301 RC outpatient 194 194 MEDICA (COMMERCIAL) 94265 [3081118] MEDICA CLAIMS [308111801] 174.6 percent of total billed charges 120.28 184.3 Technical (Hospital) Services Ref Gliadin Deaminated Igg or Iga PX-3018351604 CDM 83516 CPT 301 RC outpatient 194 194 CIGNA 62308 [3081051] CIGNA 62308 [308105105] 155.2 percent of total billed charges 120.28 184.3 Technical (Hospital) Services Ref Gliadin Deaminated Igg or Iga PX-3018351604 CDM 83516 CPT 301 RC outpatient 194 194 CIGNA 62308 [3081051] CIGNA STATE OF WYOMING [308105107] 155.2 percent of total billed charges 120.28 184.3 Technical (Hospital) Services Ref Gliadin Deaminated Igg or Iga PX-3018351604 CDM 83516 CPT 301 RC inpatient 194 194 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES HDHP [308136802] 153.61 percent of total billed charges 120.28 184.3 Technical (Hospital) Services Ref Gliadin Deaminated Igg or Iga PX-3018351604 CDM 83516 CPT 301 RC inpatient 194 194 BLUE CROSS BLUE SHIELD WELLMARK SB889 [3081026] BCBS WYOMING [308102603] 184.3 percent of total billed charges 120.28 184.3 Technical (Hospital) Services Ref Gliadin Deaminated Igg or Iga PX-3018351604 CDM 83516 CPT 301 RC inpatient 194 194 UNITED HEALTHCARE (COMMERCIAL) [3081199] UNITED HEALTHCARE 87726 [308119901] 120.28 percent of total billed charges 120.28 184.3 Technical (Hospital) Services Ref Gliadin Deaminated Igg or Iga PX-3018351604 CDM 83516 CPT 301 RC inpatient 194 194 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES PPO [308136801] 153.61 percent of total billed charges 120.28 184.3 Technical (Hospital) Services Ref Gliadin Deaminated Igg or Iga PX-3018351604 CDM 83516 CPT 301 RC inpatient 194 194 HEALTHPARTNERS SX009 HEALTHPARTNERS 153.61 percent of total billed charges 120.28 184.3 Technical (Hospital) Services Ref Gliadin Deaminated Igg or Iga PX-3018351604 CDM 83516 CPT 301 RC inpatient 194 194 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES EPO [308136803] 153.61 percent of total billed charges 120.28 184.3 Technical (Hospital) Services Ref Gliadin Deaminated Igg or Iga PX-3018351604 CDM 83516 CPT 301 RC inpatient 194 194 MEDICA (COMMERCIAL) 94265 [3081118] MEDICA CLAIMS [308111801] 174.6 percent of total billed charges 120.28 184.3 Technical (Hospital) Services Ref Gliadin Deaminated Igg or Iga PX-3018351604 CDM 83516 CPT 301 RC inpatient 194 194 MULTIPLAN INC 34080 [3081285] MULTIPLAN INC [308128501] 184.3 percent of total billed charges 120.28 184.3 Technical (Hospital) Services Ref Gliadin Deaminated Igg or Iga PX-3018351604 CDM 83516 CPT 301 RC inpatient 194 194 CIGNA 62308 [3081051] CIGNA 62308 [308105105] 153.61 percent of total billed charges 120.28 184.3 Technical (Hospital) Services Ref Gliadin Deaminated Igg or Iga PX-3018351604 CDM 83516 CPT 301 RC inpatient 194 194 CIGNA 62308 [3081051] CIGNA STATE OF WYOMING [308105107] 153.61 percent of total billed charges 120.28 184.3 Technical (Hospital) Services Ref Mitochondiral Ab M2 PX-3018351605 CDM 83516 CPT 301 RC inpatient 161 161 MULTIPLAN INC 34080 [3081285] MULTIPLAN INC [308128501] 152.95 percent of total billed charges 99.82 152.95 Technical (Hospital) Services Ref Mitochondiral Ab M2 PX-3018351605 CDM 83516 CPT 301 RC inpatient 161 161 MEDICA (COMMERCIAL) 94265 [3081118] MEDICA CLAIMS [308111801] 144.9 percent of total billed charges 99.82 152.95 Technical (Hospital) Services Ref Mitochondiral Ab M2 PX-3018351605 CDM 83516 CPT 301 RC inpatient 161 161 CIGNA 62308 [3081051] CIGNA 62308 [308105105] 127.48 percent of total billed charges 99.82 152.95 Technical (Hospital) Services Ref Mitochondiral Ab M2 PX-3018351605 CDM 83516 CPT 301 RC inpatient 161 161 CIGNA 62308 [3081051] CIGNA STATE OF WYOMING [308105107] 127.48 percent of total billed charges 99.82 152.95 Technical (Hospital) Services Ref Mitochondiral Ab M2 PX-3018351605 CDM 83516 CPT 301 RC inpatient 161 161 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES EPO [308136803] 127.48 percent of total billed charges 99.82 152.95 Technical (Hospital) Services Ref Mitochondiral Ab M2 PX-3018351605 CDM 83516 CPT 301 RC inpatient 161 161 HEALTHPARTNERS SX009 HEALTHPARTNERS 127.48 percent of total billed charges 99.82 152.95 Technical (Hospital) Services Ref Mitochondiral Ab M2 PX-3018351605 CDM 83516 CPT 301 RC inpatient 161 161 BLUE CROSS BLUE SHIELD WELLMARK SB889 [3081026] BCBS WYOMING [308102603] 152.95 percent of total billed charges 99.82 152.95 Technical (Hospital) Services Ref Mitochondiral Ab M2 PX-3018351605 CDM 83516 CPT 301 RC inpatient 161 161 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES HDHP [308136802] 127.48 percent of total billed charges 99.82 152.95 Technical (Hospital) Services Ref Mitochondiral Ab M2 PX-3018351605 CDM 83516 CPT 301 RC inpatient 161 161 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES PPO [308136801] 127.48 percent of total billed charges 99.82 152.95 Technical (Hospital) Services Ref Mitochondiral Ab M2 PX-3018351605 CDM 83516 CPT 301 RC inpatient 161 161 UNITED HEALTHCARE (COMMERCIAL) [3081199] UNITED HEALTHCARE 87726 [308119901] 99.82 percent of total billed charges 99.82 152.95 Technical (Hospital) Services Ref Mitochondiral Ab M2 PX-3018351605 CDM 83516 CPT 301 RC outpatient 161 161 BLUE CROSS BLUE SHIELD WELLMARK SB889 [3081026] BCBS WYOMING [308102603] 152.95 percent of total billed charges 99.82 152.95 Technical (Hospital) Services Ref Mitochondiral Ab M2 PX-3018351605 CDM 83516 CPT 301 RC outpatient 161 161 MULTIPLAN INC 34080 [3081285] MULTIPLAN INC [308128501] 152.95 percent of total billed charges 99.82 152.95 Technical (Hospital) Services Ref Mitochondiral Ab M2 PX-3018351605 CDM 83516 CPT 301 RC outpatient 161 161 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES HDHP [308136802] 128.8 percent of total billed charges 99.82 152.95 Technical (Hospital) Services Ref Mitochondiral Ab M2 PX-3018351605 CDM 83516 CPT 301 RC outpatient 161 161 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES EPO [308136803] 128.8 percent of total billed charges 99.82 152.95 Technical (Hospital) Services Ref Mitochondiral Ab M2 PX-3018351605 CDM 83516 CPT 301 RC outpatient 161 161 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES PPO [308136801] 128.8 percent of total billed charges 99.82 152.95 Technical (Hospital) Services Ref Mitochondiral Ab M2 PX-3018351605 CDM 83516 CPT 301 RC outpatient 161 161 HEALTHPARTNERS SX009 HEALTHPARTNERS 128.8 percent of total billed charges 99.82 152.95 Technical (Hospital) Services Ref Mitochondiral Ab M2 PX-3018351605 CDM 83516 CPT 301 RC outpatient 161 161 UNITED HEALTHCARE (COMMERCIAL) [3081199] UNITED HEALTHCARE 87726 [308119901] 99.82 percent of total billed charges 99.82 152.95 Technical (Hospital) Services Ref Mitochondiral Ab M2 PX-3018351605 CDM 83516 CPT 301 RC outpatient 161 161 MEDICA (COMMERCIAL) 94265 [3081118] MEDICA CLAIMS [308111801] 144.9 percent of total billed charges 99.82 152.95 Technical (Hospital) Services Ref Mitochondiral Ab M2 PX-3018351605 CDM 83516 CPT 301 RC outpatient 161 161 CIGNA 62308 [3081051] CIGNA 62308 [308105105] 128.8 percent of total billed charges 99.82 152.95 Technical (Hospital) Services Ref Mitochondiral Ab M2 PX-3018351605 CDM 83516 CPT 301 RC outpatient 161 161 CIGNA 62308 [3081051] CIGNA STATE OF WYOMING [308105107] 128.8 percent of total billed charges 99.82 152.95 Technical (Hospital) Services Ref Parietal Cell Ab Igg PX-3018351607 CDM 83516 CPT 301 RC inpatient 180 180 MEDICA (COMMERCIAL) 94265 [3081118] MEDICA CLAIMS [308111801] 162 percent of total billed charges 111.6 171 Technical (Hospital) Services Ref Parietal Cell Ab Igg PX-3018351607 CDM 83516 CPT 301 RC inpatient 180 180 MULTIPLAN INC 34080 [3081285] MULTIPLAN INC [308128501] 171 percent of total billed charges 111.6 171 Technical (Hospital) Services Ref Parietal Cell Ab Igg PX-3018351607 CDM 83516 CPT 301 RC inpatient 180 180 CIGNA 62308 [3081051] CIGNA STATE OF WYOMING [308105107] 142.52 percent of total billed charges 111.6 171 Technical (Hospital) Services Ref Parietal Cell Ab Igg PX-3018351607 CDM 83516 CPT 301 RC inpatient 180 180 CIGNA 62308 [3081051] CIGNA 62308 [308105105] 142.52 percent of total billed charges 111.6 171 Technical (Hospital) Services Ref Parietal Cell Ab Igg PX-3018351607 CDM 83516 CPT 301 RC inpatient 180 180 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES EPO [308136803] 142.52 percent of total billed charges 111.6 171 Technical (Hospital) Services Ref Parietal Cell Ab Igg PX-3018351607 CDM 83516 CPT 301 RC inpatient 180 180 HEALTHPARTNERS SX009 HEALTHPARTNERS 142.52 percent of total billed charges 111.6 171 Technical (Hospital) Services Ref Parietal Cell Ab Igg PX-3018351607 CDM 83516 CPT 301 RC inpatient 180 180 UNITED HEALTHCARE (COMMERCIAL) [3081199] UNITED HEALTHCARE 87726 [308119901] 111.6 percent of total billed charges 111.6 171 Technical (Hospital) Services Ref Parietal Cell Ab Igg PX-3018351607 CDM 83516 CPT 301 RC inpatient 180 180 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES PPO [308136801] 142.52 percent of total billed charges 111.6 171 Technical (Hospital) Services Ref Parietal Cell Ab Igg PX-3018351607 CDM 83516 CPT 301 RC inpatient 180 180 BLUE CROSS BLUE SHIELD WELLMARK SB889 [3081026] BCBS WYOMING [308102603] 171 percent of total billed charges 111.6 171 Technical (Hospital) Services Ref Parietal Cell Ab Igg PX-3018351607 CDM 83516 CPT 301 RC inpatient 180 180 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES HDHP [308136802] 142.52 percent of total billed charges 111.6 171 Technical (Hospital) Services Ref Parietal Cell Ab Igg PX-3018351607 CDM 83516 CPT 301 RC outpatient 180 180 MEDICA (COMMERCIAL) 94265 [3081118] MEDICA CLAIMS [308111801] 162 percent of total billed charges 111.6 171 Technical (Hospital) Services Ref Parietal Cell Ab Igg PX-3018351607 CDM 83516 CPT 301 RC outpatient 180 180 CIGNA 62308 [3081051] CIGNA 62308 [308105105] 144 percent of total billed charges 111.6 171 Technical (Hospital) Services Ref Parietal Cell Ab Igg PX-3018351607 CDM 83516 CPT 301 RC outpatient 180 180 CIGNA 62308 [3081051] CIGNA STATE OF WYOMING [308105107] 144 percent of total billed charges 111.6 171 Technical (Hospital) Services Ref Parietal Cell Ab Igg PX-3018351607 CDM 83516 CPT 301 RC outpatient 180 180 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES EPO [308136803] 144 percent of total billed charges 111.6 171 Technical (Hospital) Services Ref Parietal Cell Ab Igg PX-3018351607 CDM 83516 CPT 301 RC outpatient 180 180 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES HDHP [308136802] 144 percent of total billed charges 111.6 171 Technical (Hospital) Services Ref Parietal Cell Ab Igg PX-3018351607 CDM 83516 CPT 301 RC outpatient 180 180 MULTIPLAN INC 34080 [3081285] MULTIPLAN INC [308128501] 171 percent of total billed charges 111.6 171 Technical (Hospital) Services Ref Parietal Cell Ab Igg PX-3018351607 CDM 83516 CPT 301 RC outpatient 180 180 BLUE CROSS BLUE SHIELD WELLMARK SB889 [3081026] BCBS WYOMING [308102603] 171 percent of total billed charges 111.6 171 Technical (Hospital) Services Ref Parietal Cell Ab Igg PX-3018351607 CDM 83516 CPT 301 RC outpatient 180 180 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES PPO [308136801] 144 percent of total billed charges 111.6 171 Technical (Hospital) Services Ref Parietal Cell Ab Igg PX-3018351607 CDM 83516 CPT 301 RC outpatient 180 180 HEALTHPARTNERS SX009 HEALTHPARTNERS 144 percent of total billed charges 111.6 171 Technical (Hospital) Services Ref Parietal Cell Ab Igg PX-3018351607 CDM 83516 CPT 301 RC outpatient 180 180 UNITED HEALTHCARE (COMMERCIAL) [3081199] UNITED HEALTHCARE 87726 [308119901] 111.6 percent of total billed charges 111.6 171 Technical (Hospital) Services Ref Tissue Transglutaminase Ab Igg or Iga PX-3018351609 CDM 83516 CPT 301 RC inpatient 160 160 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES EPO [308136803] 126.69 percent of total billed charges 99.2 152 Technical (Hospital) Services Ref Tissue Transglutaminase Ab Igg or Iga PX-3018351609 CDM 83516 CPT 301 RC inpatient 160 160 HEALTHPARTNERS SX009 HEALTHPARTNERS 126.69 percent of total billed charges 99.2 152 Technical (Hospital) Services Ref Tissue Transglutaminase Ab Igg or Iga PX-3018351609 CDM 83516 CPT 301 RC inpatient 160 160 CIGNA 62308 [3081051] CIGNA 62308 [308105105] 126.69 percent of total billed charges 99.2 152 Technical (Hospital) Services Ref Tissue Transglutaminase Ab Igg or Iga PX-3018351609 CDM 83516 CPT 301 RC inpatient 160 160 CIGNA 62308 [3081051] CIGNA STATE OF WYOMING [308105107] 126.69 percent of total billed charges 99.2 152 Technical (Hospital) Services Ref Tissue Transglutaminase Ab Igg or Iga PX-3018351609 CDM 83516 CPT 301 RC inpatient 160 160 MULTIPLAN INC 34080 [3081285] MULTIPLAN INC [308128501] 152 percent of total billed charges 99.2 152 Technical (Hospital) Services Ref Tissue Transglutaminase Ab Igg or Iga PX-3018351609 CDM 83516 CPT 301 RC inpatient 160 160 MEDICA (COMMERCIAL) 94265 [3081118] MEDICA CLAIMS [308111801] 144 percent of total billed charges 99.2 152 Technical (Hospital) Services Ref Tissue Transglutaminase Ab Igg or Iga PX-3018351609 CDM 83516 CPT 301 RC inpatient 160 160 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES PPO [308136801] 126.69 percent of total billed charges 99.2 152 Technical (Hospital) Services Ref Tissue Transglutaminase Ab Igg or Iga PX-3018351609 CDM 83516 CPT 301 RC inpatient 160 160 UNITED HEALTHCARE (COMMERCIAL) [3081199] UNITED HEALTHCARE 87726 [308119901] 99.2 percent of total billed charges 99.2 152 Technical (Hospital) Services Ref Tissue Transglutaminase Ab Igg or Iga PX-3018351609 CDM 83516 CPT 301 RC inpatient 160 160 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES HDHP [308136802] 126.69 percent of total billed charges 99.2 152 Technical (Hospital) Services Ref Tissue Transglutaminase Ab Igg or Iga PX-3018351609 CDM 83516 CPT 301 RC inpatient 160 160 BLUE CROSS BLUE SHIELD WELLMARK SB889 [3081026] BCBS WYOMING [308102603] 152 percent of total billed charges 99.2 152 Technical (Hospital) Services Ref Tissue Transglutaminase Ab Igg or Iga PX-3018351609 CDM 83516 CPT 301 RC outpatient 160 160 UNITED HEALTHCARE (COMMERCIAL) [3081199] UNITED HEALTHCARE 87726 [308119901] 99.2 percent of total billed charges 99.2 152 Technical (Hospital) Services Ref Tissue Transglutaminase Ab Igg or Iga PX-3018351609 CDM 83516 CPT 301 RC outpatient 160 160 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES PPO [308136801] 128 percent of total billed charges 99.2 152 Technical (Hospital) Services Ref Tissue Transglutaminase Ab Igg or Iga PX-3018351609 CDM 83516 CPT 301 RC outpatient 160 160 HEALTHPARTNERS SX009 HEALTHPARTNERS 128 percent of total billed charges 99.2 152 Technical (Hospital) Services Ref Tissue Transglutaminase Ab Igg or Iga PX-3018351609 CDM 83516 CPT 301 RC outpatient 160 160 MULTIPLAN INC 34080 [3081285] MULTIPLAN INC [308128501] 152 percent of total billed charges 99.2 152 Technical (Hospital) Services Ref Tissue Transglutaminase Ab Igg or Iga PX-3018351609 CDM 83516 CPT 301 RC outpatient 160 160 BLUE CROSS BLUE SHIELD WELLMARK SB889 [3081026] BCBS WYOMING [308102603] 152 percent of total billed charges 99.2 152 Technical (Hospital) Services Ref Tissue Transglutaminase Ab Igg or Iga PX-3018351609 CDM 83516 CPT 301 RC outpatient 160 160 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES EPO [308136803] 128 percent of total billed charges 99.2 152 Technical (Hospital) Services Ref Tissue Transglutaminase Ab Igg or Iga PX-3018351609 CDM 83516 CPT 301 RC outpatient 160 160 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES HDHP [308136802] 128 percent of total billed charges 99.2 152 Technical (Hospital) Services Ref Tissue Transglutaminase Ab Igg or Iga PX-3018351609 CDM 83516 CPT 301 RC outpatient 160 160 MEDICA (COMMERCIAL) 94265 [3081118] MEDICA CLAIMS [308111801] 144 percent of total billed charges 99.2 152 Technical (Hospital) Services Ref Tissue Transglutaminase Ab Igg or Iga PX-3018351609 CDM 83516 CPT 301 RC outpatient 160 160 CIGNA 62308 [3081051] CIGNA 62308 [308105105] 128 percent of total billed charges 99.2 152 Technical (Hospital) Services Ref Tissue Transglutaminase Ab Igg or Iga PX-3018351609 CDM 83516 CPT 301 RC outpatient 160 160 CIGNA 62308 [3081051] CIGNA STATE OF WYOMING [308105107] 128 percent of total billed charges 99.2 152 Technical (Hospital) Services Ref Anti Glomerular Basement Membr(Mayo) PX-3018351617 CDM 83516 CPT 301 RC inpatient 180 180 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES HDHP [308136802] 142.52 percent of total billed charges 111.6 171 Technical (Hospital) Services Ref Anti Glomerular Basement Membr(Mayo) PX-3018351617 CDM 83516 CPT 301 RC inpatient 180 180 BLUE CROSS BLUE SHIELD WELLMARK SB889 [3081026] BCBS WYOMING [308102603] 171 percent of total billed charges 111.6 171 Technical (Hospital) Services Ref Anti Glomerular Basement Membr(Mayo) PX-3018351617 CDM 83516 CPT 301 RC inpatient 180 180 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES PPO [308136801] 142.52 percent of total billed charges 111.6 171 Technical (Hospital) Services Ref Anti Glomerular Basement Membr(Mayo) PX-3018351617 CDM 83516 CPT 301 RC inpatient 180 180 UNITED HEALTHCARE (COMMERCIAL) [3081199] UNITED HEALTHCARE 87726 [308119901] 111.6 percent of total billed charges 111.6 171 Technical (Hospital) Services Ref Anti Glomerular Basement Membr(Mayo) PX-3018351617 CDM 83516 CPT 301 RC inpatient 180 180 HEALTHPARTNERS SX009 HEALTHPARTNERS 142.52 percent of total billed charges 111.6 171 Technical (Hospital) Services Ref Anti Glomerular Basement Membr(Mayo) PX-3018351617 CDM 83516 CPT 301 RC inpatient 180 180 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES EPO [308136803] 142.52 percent of total billed charges 111.6 171 Technical (Hospital) Services Ref Anti Glomerular Basement Membr(Mayo) PX-3018351617 CDM 83516 CPT 301 RC inpatient 180 180 CIGNA 62308 [3081051] CIGNA 62308 [308105105] 142.52 percent of total billed charges 111.6 171 Technical (Hospital) Services Ref Anti Glomerular Basement Membr(Mayo) PX-3018351617 CDM 83516 CPT 301 RC inpatient 180 180 CIGNA 62308 [3081051] CIGNA STATE OF WYOMING [308105107] 142.52 percent of total billed charges 111.6 171 Technical (Hospital) Services Ref Anti Glomerular Basement Membr(Mayo) PX-3018351617 CDM 83516 CPT 301 RC inpatient 180 180 MEDICA (COMMERCIAL) 94265 [3081118] MEDICA CLAIMS [308111801] 162 percent of total billed charges 111.6 171 Technical (Hospital) Services Ref Anti Glomerular Basement Membr(Mayo) PX-3018351617 CDM 83516 CPT 301 RC inpatient 180 180 MULTIPLAN INC 34080 [3081285] MULTIPLAN INC [308128501] 171 percent of total billed charges 111.6 171 Technical (Hospital) Services Ref Anti Glomerular Basement Membr(Mayo) PX-3018351617 CDM 83516 CPT 301 RC outpatient 180 180 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES PPO [308136801] 144 percent of total billed charges 111.6 171 Technical (Hospital) Services Ref Anti Glomerular Basement Membr(Mayo) PX-3018351617 CDM 83516 CPT 301 RC outpatient 180 180 BLUE CROSS BLUE SHIELD WELLMARK SB889 [3081026] BCBS WYOMING [308102603] 171 percent of total billed charges 111.6 171 Technical (Hospital) Services Ref Anti Glomerular Basement Membr(Mayo) PX-3018351617 CDM 83516 CPT 301 RC outpatient 180 180 MULTIPLAN INC 34080 [3081285] MULTIPLAN INC [308128501] 171 percent of total billed charges 111.6 171 Technical (Hospital) Services Ref Anti Glomerular Basement Membr(Mayo) PX-3018351617 CDM 83516 CPT 301 RC outpatient 180 180 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES EPO [308136803] 144 percent of total billed charges 111.6 171 Technical (Hospital) Services Ref Anti Glomerular Basement Membr(Mayo) PX-3018351617 CDM 83516 CPT 301 RC outpatient 180 180 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES HDHP [308136802] 144 percent of total billed charges 111.6 171 Technical (Hospital) Services Ref Anti Glomerular Basement Membr(Mayo) PX-3018351617 CDM 83516 CPT 301 RC outpatient 180 180 HEALTHPARTNERS SX009 HEALTHPARTNERS 144 percent of total billed charges 111.6 171 Technical (Hospital) Services Ref Anti Glomerular Basement Membr(Mayo) PX-3018351617 CDM 83516 CPT 301 RC outpatient 180 180 UNITED HEALTHCARE (COMMERCIAL) [3081199] UNITED HEALTHCARE 87726 [308119901] 111.6 percent of total billed charges 111.6 171 Technical (Hospital) Services Ref Anti Glomerular Basement Membr(Mayo) PX-3018351617 CDM 83516 CPT 301 RC outpatient 180 180 MEDICA (COMMERCIAL) 94265 [3081118] MEDICA CLAIMS [308111801] 162 percent of total billed charges 111.6 171 Technical (Hospital) Services Ref Anti Glomerular Basement Membr(Mayo) PX-3018351617 CDM 83516 CPT 301 RC outpatient 180 180 CIGNA 62308 [3081051] CIGNA 62308 [308105105] 144 percent of total billed charges 111.6 171 Technical (Hospital) Services Ref Anti Glomerular Basement Membr(Mayo) PX-3018351617 CDM 83516 CPT 301 RC outpatient 180 180 CIGNA 62308 [3081051] CIGNA STATE OF WYOMING [308105107] 144 percent of total billed charges 111.6 171 Technical (Hospital) Services "HC Tissue Transglutaminase, Iga" PX-3018351626 CDM 83516 CPT 301 RC inpatient 194 194 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES HDHP [308136802] 153.61 percent of total billed charges 120.28 184.3 Technical (Hospital) Services "HC Tissue Transglutaminase, Iga" PX-3018351626 CDM 83516 CPT 301 RC inpatient 194 194 HEALTHPARTNERS SX009 HEALTHPARTNERS 153.61 percent of total billed charges 120.28 184.3 Technical (Hospital) Services "HC Tissue Transglutaminase, Iga" PX-3018351626 CDM 83516 CPT 301 RC inpatient 194 194 MEDICA (COMMERCIAL) 94265 [3081118] MEDICA CLAIMS [308111801] 174.6 percent of total billed charges 120.28 184.3 Technical (Hospital) Services "HC Tissue Transglutaminase, Iga" PX-3018351626 CDM 83516 CPT 301 RC inpatient 194 194 MULTIPLAN INC 34080 [3081285] MULTIPLAN INC [308128501] 184.3 percent of total billed charges 120.28 184.3 Technical (Hospital) Services "HC Tissue Transglutaminase, Iga" PX-3018351626 CDM 83516 CPT 301 RC inpatient 194 194 UNITED HEALTHCARE (COMMERCIAL) [3081199] UNITED HEALTHCARE 87726 [308119901] 120.28 percent of total billed charges 120.28 184.3 Technical (Hospital) Services "HC Tissue Transglutaminase, Iga" PX-3018351626 CDM 83516 CPT 301 RC inpatient 194 194 BLUE CROSS BLUE SHIELD WELLMARK SB889 [3081026] BCBS WYOMING [308102603] 184.3 percent of total billed charges 120.28 184.3 Technical (Hospital) Services "HC Tissue Transglutaminase, Iga" PX-3018351626 CDM 83516 CPT 301 RC inpatient 194 194 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES PPO [308136801] 153.61 percent of total billed charges 120.28 184.3 Technical (Hospital) Services "HC Tissue Transglutaminase, Iga" PX-3018351626 CDM 83516 CPT 301 RC inpatient 194 194 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES EPO [308136803] 153.61 percent of total billed charges 120.28 184.3 Technical (Hospital) Services "HC Tissue Transglutaminase, Iga" PX-3018351626 CDM 83516 CPT 301 RC inpatient 194 194 CIGNA 62308 [3081051] CIGNA 62308 [308105105] 153.61 percent of total billed charges 120.28 184.3 Technical (Hospital) Services "HC Tissue Transglutaminase, Iga" PX-3018351626 CDM 83516 CPT 301 RC inpatient 194 194 CIGNA 62308 [3081051] CIGNA STATE OF WYOMING [308105107] 153.61 percent of total billed charges 120.28 184.3 Technical (Hospital) Services "HC Tissue Transglutaminase, Iga" PX-3018351626 CDM 83516 CPT 301 RC outpatient 194 194 MULTIPLAN INC 34080 [3081285] MULTIPLAN INC [308128501] 184.3 percent of total billed charges 120.28 184.3 Technical (Hospital) Services "HC Tissue Transglutaminase, Iga" PX-3018351626 CDM 83516 CPT 301 RC outpatient 194 194 UNITED HEALTHCARE (COMMERCIAL) [3081199] UNITED HEALTHCARE 87726 [308119901] 120.28 percent of total billed charges 120.28 184.3 Technical (Hospital) Services "HC Tissue Transglutaminase, Iga" PX-3018351626 CDM 83516 CPT 301 RC outpatient 194 194 BLUE CROSS BLUE SHIELD WELLMARK SB889 [3081026] BCBS WYOMING [308102603] 184.3 percent of total billed charges 120.28 184.3 Technical (Hospital) Services "HC Tissue Transglutaminase, Iga" PX-3018351626 CDM 83516 CPT 301 RC outpatient 194 194 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES HDHP [308136802] 155.2 percent of total billed charges 120.28 184.3 Technical (Hospital) Services "HC Tissue Transglutaminase, Iga" PX-3018351626 CDM 83516 CPT 301 RC outpatient 194 194 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES PPO [308136801] 155.2 percent of total billed charges 120.28 184.3 Technical (Hospital) Services "HC Tissue Transglutaminase, Iga" PX-3018351626 CDM 83516 CPT 301 RC outpatient 194 194 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES EPO [308136803] 155.2 percent of total billed charges 120.28 184.3 Technical (Hospital) Services "HC Tissue Transglutaminase, Iga" PX-3018351626 CDM 83516 CPT 301 RC outpatient 194 194 MEDICA (COMMERCIAL) 94265 [3081118] MEDICA CLAIMS [308111801] 174.6 percent of total billed charges 120.28 184.3 Technical (Hospital) Services "HC Tissue Transglutaminase, Iga" PX-3018351626 CDM 83516 CPT 301 RC outpatient 194 194 HEALTHPARTNERS SX009 HEALTHPARTNERS 155.2 percent of total billed charges 120.28 184.3 Technical (Hospital) Services "HC Tissue Transglutaminase, Iga" PX-3018351626 CDM 83516 CPT 301 RC outpatient 194 194 CIGNA 62308 [3081051] CIGNA 62308 [308105105] 155.2 percent of total billed charges 120.28 184.3 Technical (Hospital) Services "HC Tissue Transglutaminase, Iga" PX-3018351626 CDM 83516 CPT 301 RC outpatient 194 194 CIGNA 62308 [3081051] CIGNA STATE OF WYOMING [308105107] 155.2 percent of total billed charges 120.28 184.3 Technical (Hospital) Services "HC Tissue Transglutaminase, Igg" PX-3018351627 CDM 83516 CPT 301 RC inpatient 194 194 MEDICA (COMMERCIAL) 94265 [3081118] MEDICA CLAIMS [308111801] 174.6 percent of total billed charges 120.28 184.3 Technical (Hospital) Services "HC Tissue Transglutaminase, Igg" PX-3018351627 CDM 83516 CPT 301 RC inpatient 194 194 MULTIPLAN INC 34080 [3081285] MULTIPLAN INC [308128501] 184.3 percent of total billed charges 120.28 184.3 Technical (Hospital) Services "HC Tissue Transglutaminase, Igg" PX-3018351627 CDM 83516 CPT 301 RC inpatient 194 194 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES HDHP [308136802] 153.61 percent of total billed charges 120.28 184.3 Technical (Hospital) Services "HC Tissue Transglutaminase, Igg" PX-3018351627 CDM 83516 CPT 301 RC inpatient 194 194 HEALTHPARTNERS SX009 HEALTHPARTNERS 153.61 percent of total billed charges 120.28 184.3 Technical (Hospital) Services "HC Tissue Transglutaminase, Igg" PX-3018351627 CDM 83516 CPT 301 RC inpatient 194 194 BLUE CROSS BLUE SHIELD WELLMARK SB889 [3081026] BCBS WYOMING [308102603] 184.3 percent of total billed charges 120.28 184.3 Technical (Hospital) Services "HC Tissue Transglutaminase, Igg" PX-3018351627 CDM 83516 CPT 301 RC inpatient 194 194 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES PPO [308136801] 153.61 percent of total billed charges 120.28 184.3 Technical (Hospital) Services "HC Tissue Transglutaminase, Igg" PX-3018351627 CDM 83516 CPT 301 RC inpatient 194 194 UNITED HEALTHCARE (COMMERCIAL) [3081199] UNITED HEALTHCARE 87726 [308119901] 120.28 percent of total billed charges 120.28 184.3 Technical (Hospital) Services "HC Tissue Transglutaminase, Igg" PX-3018351627 CDM 83516 CPT 301 RC inpatient 194 194 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES EPO [308136803] 153.61 percent of total billed charges 120.28 184.3 Technical (Hospital) Services "HC Tissue Transglutaminase, Igg" PX-3018351627 CDM 83516 CPT 301 RC inpatient 194 194 CIGNA 62308 [3081051] CIGNA 62308 [308105105] 153.61 percent of total billed charges 120.28 184.3 Technical (Hospital) Services "HC Tissue Transglutaminase, Igg" PX-3018351627 CDM 83516 CPT 301 RC inpatient 194 194 CIGNA 62308 [3081051] CIGNA STATE OF WYOMING [308105107] 153.61 percent of total billed charges 120.28 184.3 Technical (Hospital) Services "HC Tissue Transglutaminase, Igg" PX-3018351627 CDM 83516 CPT 301 RC outpatient 194 194 HEALTHPARTNERS SX009 HEALTHPARTNERS 155.2 percent of total billed charges 120.28 184.3 Technical (Hospital) Services "HC Tissue Transglutaminase, Igg" PX-3018351627 CDM 83516 CPT 301 RC outpatient 194 194 UNITED HEALTHCARE (COMMERCIAL) [3081199] UNITED HEALTHCARE 87726 [308119901] 120.28 percent of total billed charges 120.28 184.3 Technical (Hospital) Services "HC Tissue Transglutaminase, Igg" PX-3018351627 CDM 83516 CPT 301 RC outpatient 194 194 BLUE CROSS BLUE SHIELD WELLMARK SB889 [3081026] BCBS WYOMING [308102603] 184.3 percent of total billed charges 120.28 184.3 Technical (Hospital) Services "HC Tissue Transglutaminase, Igg" PX-3018351627 CDM 83516 CPT 301 RC outpatient 194 194 MULTIPLAN INC 34080 [3081285] MULTIPLAN INC [308128501] 184.3 percent of total billed charges 120.28 184.3 Technical (Hospital) Services "HC Tissue Transglutaminase, Igg" PX-3018351627 CDM 83516 CPT 301 RC outpatient 194 194 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES HDHP [308136802] 155.2 percent of total billed charges 120.28 184.3 Technical (Hospital) Services "HC Tissue Transglutaminase, Igg" PX-3018351627 CDM 83516 CPT 301 RC outpatient 194 194 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES EPO [308136803] 155.2 percent of total billed charges 120.28 184.3 Technical (Hospital) Services "HC Tissue Transglutaminase, Igg" PX-3018351627 CDM 83516 CPT 301 RC outpatient 194 194 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES PPO [308136801] 155.2 percent of total billed charges 120.28 184.3 Technical (Hospital) Services "HC Tissue Transglutaminase, Igg" PX-3018351627 CDM 83516 CPT 301 RC outpatient 194 194 CIGNA 62308 [3081051] CIGNA 62308 [308105105] 155.2 percent of total billed charges 120.28 184.3 Technical (Hospital) Services "HC Tissue Transglutaminase, Igg" PX-3018351627 CDM 83516 CPT 301 RC outpatient 194 194 CIGNA 62308 [3081051] CIGNA STATE OF WYOMING [308105107] 155.2 percent of total billed charges 120.28 184.3 Technical (Hospital) Services "HC Tissue Transglutaminase, Igg" PX-3018351627 CDM 83516 CPT 301 RC outpatient 194 194 MEDICA (COMMERCIAL) 94265 [3081118] MEDICA CLAIMS [308111801] 174.6 percent of total billed charges 120.28 184.3 Technical (Hospital) Services Ref 18 Hydroxyprogesterone PX-3018349800 CDM 83498 CPT 301 RC inpatient 289 289 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES PPO [308136801] 228.83 percent of total billed charges 179.18 274.55 Technical (Hospital) Services Ref 18 Hydroxyprogesterone PX-3018349800 CDM 83498 CPT 301 RC inpatient 289 289 UNITED HEALTHCARE (COMMERCIAL) [3081199] UNITED HEALTHCARE 87726 [308119901] 179.18 percent of total billed charges 179.18 274.55 Technical (Hospital) Services Ref 18 Hydroxyprogesterone PX-3018349800 CDM 83498 CPT 301 RC inpatient 289 289 BLUE CROSS BLUE SHIELD WELLMARK SB889 [3081026] BCBS WYOMING [308102603] 274.55 percent of total billed charges 179.18 274.55 Technical (Hospital) Services Ref 18 Hydroxyprogesterone PX-3018349800 CDM 83498 CPT 301 RC inpatient 289 289 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES HDHP [308136802] 228.83 percent of total billed charges 179.18 274.55 Technical (Hospital) Services Ref 18 Hydroxyprogesterone PX-3018349800 CDM 83498 CPT 301 RC inpatient 289 289 HEALTHPARTNERS SX009 HEALTHPARTNERS 228.83 percent of total billed charges 179.18 274.55 Technical (Hospital) Services Ref 18 Hydroxyprogesterone PX-3018349800 CDM 83498 CPT 301 RC inpatient 289 289 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES EPO [308136803] 228.83 percent of total billed charges 179.18 274.55 Technical (Hospital) Services Ref 18 Hydroxyprogesterone PX-3018349800 CDM 83498 CPT 301 RC inpatient 289 289 MEDICA (COMMERCIAL) 94265 [3081118] MEDICA CLAIMS [308111801] 260.1 percent of total billed charges 179.18 274.55 Technical (Hospital) Services Ref 18 Hydroxyprogesterone PX-3018349800 CDM 83498 CPT 301 RC inpatient 289 289 MULTIPLAN INC 34080 [3081285] MULTIPLAN INC [308128501] 274.55 percent of total billed charges 179.18 274.55 Technical (Hospital) Services Ref 18 Hydroxyprogesterone PX-3018349800 CDM 83498 CPT 301 RC inpatient 289 289 CIGNA 62308 [3081051] CIGNA 62308 [308105105] 228.83 percent of total billed charges 179.18 274.55 Technical (Hospital) Services Ref 18 Hydroxyprogesterone PX-3018349800 CDM 83498 CPT 301 RC inpatient 289 289 CIGNA 62308 [3081051] CIGNA STATE OF WYOMING [308105107] 228.83 percent of total billed charges 179.18 274.55 Technical (Hospital) Services Ref 18 Hydroxyprogesterone PX-3018349800 CDM 83498 CPT 301 RC outpatient 289 289 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES PPO [308136801] 231.2 percent of total billed charges 179.18 274.55 Technical (Hospital) Services Ref 18 Hydroxyprogesterone PX-3018349800 CDM 83498 CPT 301 RC outpatient 289 289 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES HDHP [308136802] 231.2 percent of total billed charges 179.18 274.55 Technical (Hospital) Services Ref 18 Hydroxyprogesterone PX-3018349800 CDM 83498 CPT 301 RC outpatient 289 289 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES EPO [308136803] 231.2 percent of total billed charges 179.18 274.55 Technical (Hospital) Services Ref 18 Hydroxyprogesterone PX-3018349800 CDM 83498 CPT 301 RC outpatient 289 289 BLUE CROSS BLUE SHIELD WELLMARK SB889 [3081026] BCBS WYOMING [308102603] 274.55 percent of total billed charges 179.18 274.55 Technical (Hospital) Services Ref 18 Hydroxyprogesterone PX-3018349800 CDM 83498 CPT 301 RC outpatient 289 289 MULTIPLAN INC 34080 [3081285] MULTIPLAN INC [308128501] 274.55 percent of total billed charges 179.18 274.55 Technical (Hospital) Services Ref 18 Hydroxyprogesterone PX-3018349800 CDM 83498 CPT 301 RC outpatient 289 289 HEALTHPARTNERS SX009 HEALTHPARTNERS 231.2 percent of total billed charges 179.18 274.55 Technical (Hospital) Services Ref 18 Hydroxyprogesterone PX-3018349800 CDM 83498 CPT 301 RC outpatient 289 289 UNITED HEALTHCARE (COMMERCIAL) [3081199] UNITED HEALTHCARE 87726 [308119901] 179.18 percent of total billed charges 179.18 274.55 Technical (Hospital) Services Ref 18 Hydroxyprogesterone PX-3018349800 CDM 83498 CPT 301 RC outpatient 289 289 CIGNA 62308 [3081051] CIGNA 62308 [308105105] 231.2 percent of total billed charges 179.18 274.55 Technical (Hospital) Services Ref 18 Hydroxyprogesterone PX-3018349800 CDM 83498 CPT 301 RC outpatient 289 289 CIGNA 62308 [3081051] CIGNA STATE OF WYOMING [308105107] 231.2 percent of total billed charges 179.18 274.55 Technical (Hospital) Services Ref 18 Hydroxyprogesterone PX-3018349800 CDM 83498 CPT 301 RC outpatient 289 289 MEDICA (COMMERCIAL) 94265 [3081118] MEDICA CLAIMS [308111801] 260.1 percent of total billed charges 179.18 274.55 Technical (Hospital) Services Ref 17 Hydroxyprogesterone PX-3018349801 CDM 83498 CPT 301 RC outpatient 289 289 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES PPO [308136801] 231.2 percent of total billed charges 179.18 274.55 Technical (Hospital) Services Ref 17 Hydroxyprogesterone PX-3018349801 CDM 83498 CPT 301 RC outpatient 289 289 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES HDHP [308136802] 231.2 percent of total billed charges 179.18 274.55 Technical (Hospital) Services Ref 17 Hydroxyprogesterone PX-3018349801 CDM 83498 CPT 301 RC outpatient 289 289 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES EPO [308136803] 231.2 percent of total billed charges 179.18 274.55 Technical (Hospital) Services Ref 17 Hydroxyprogesterone PX-3018349801 CDM 83498 CPT 301 RC outpatient 289 289 MULTIPLAN INC 34080 [3081285] MULTIPLAN INC [308128501] 274.55 percent of total billed charges 179.18 274.55 Technical (Hospital) Services Ref 17 Hydroxyprogesterone PX-3018349801 CDM 83498 CPT 301 RC outpatient 289 289 BLUE CROSS BLUE SHIELD WELLMARK SB889 [3081026] BCBS WYOMING [308102603] 274.55 percent of total billed charges 179.18 274.55 Technical (Hospital) Services Ref 17 Hydroxyprogesterone PX-3018349801 CDM 83498 CPT 301 RC outpatient 289 289 UNITED HEALTHCARE (COMMERCIAL) [3081199] UNITED HEALTHCARE 87726 [308119901] 179.18 percent of total billed charges 179.18 274.55 Technical (Hospital) Services Ref 17 Hydroxyprogesterone PX-3018349801 CDM 83498 CPT 301 RC outpatient 289 289 HEALTHPARTNERS SX009 HEALTHPARTNERS 231.2 percent of total billed charges 179.18 274.55 Technical (Hospital) Services Ref 17 Hydroxyprogesterone PX-3018349801 CDM 83498 CPT 301 RC outpatient 289 289 MEDICA (COMMERCIAL) 94265 [3081118] MEDICA CLAIMS [308111801] 260.1 percent of total billed charges 179.18 274.55 Technical (Hospital) Services Ref 17 Hydroxyprogesterone PX-3018349801 CDM 83498 CPT 301 RC outpatient 289 289 CIGNA 62308 [3081051] CIGNA 62308 [308105105] 231.2 percent of total billed charges 179.18 274.55 Technical (Hospital) Services Ref 17 Hydroxyprogesterone PX-3018349801 CDM 83498 CPT 301 RC outpatient 289 289 CIGNA 62308 [3081051] CIGNA STATE OF WYOMING [308105107] 231.2 percent of total billed charges 179.18 274.55 Technical (Hospital) Services Ref 17 Hydroxyprogesterone PX-3018349801 CDM 83498 CPT 301 RC inpatient 289 289 MULTIPLAN INC 34080 [3081285] MULTIPLAN INC [308128501] 274.55 percent of total billed charges 179.18 274.55 Technical (Hospital) Services Ref 17 Hydroxyprogesterone PX-3018349801 CDM 83498 CPT 301 RC inpatient 289 289 MEDICA (COMMERCIAL) 94265 [3081118] MEDICA CLAIMS [308111801] 260.1 percent of total billed charges 179.18 274.55 Technical (Hospital) Services Ref 17 Hydroxyprogesterone PX-3018349801 CDM 83498 CPT 301 RC inpatient 289 289 CIGNA 62308 [3081051] CIGNA 62308 [308105105] 228.83 percent of total billed charges 179.18 274.55 Technical (Hospital) Services Ref 17 Hydroxyprogesterone PX-3018349801 CDM 83498 CPT 301 RC inpatient 289 289 CIGNA 62308 [3081051] CIGNA STATE OF WYOMING [308105107] 228.83 percent of total billed charges 179.18 274.55 Technical (Hospital) Services Ref 17 Hydroxyprogesterone PX-3018349801 CDM 83498 CPT 301 RC inpatient 289 289 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES EPO [308136803] 228.83 percent of total billed charges 179.18 274.55 Technical (Hospital) Services Ref 17 Hydroxyprogesterone PX-3018349801 CDM 83498 CPT 301 RC inpatient 289 289 HEALTHPARTNERS SX009 HEALTHPARTNERS 228.83 percent of total billed charges 179.18 274.55 Technical (Hospital) Services Ref 17 Hydroxyprogesterone PX-3018349801 CDM 83498 CPT 301 RC inpatient 289 289 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES PPO [308136801] 228.83 percent of total billed charges 179.18 274.55 Technical (Hospital) Services Ref 17 Hydroxyprogesterone PX-3018349801 CDM 83498 CPT 301 RC inpatient 289 289 UNITED HEALTHCARE (COMMERCIAL) [3081199] UNITED HEALTHCARE 87726 [308119901] 179.18 percent of total billed charges 179.18 274.55 Technical (Hospital) Services Ref 17 Hydroxyprogesterone PX-3018349801 CDM 83498 CPT 301 RC inpatient 289 289 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES HDHP [308136802] 228.83 percent of total billed charges 179.18 274.55 Technical (Hospital) Services Ref 17 Hydroxyprogesterone PX-3018349801 CDM 83498 CPT 301 RC inpatient 289 289 BLUE CROSS BLUE SHIELD WELLMARK SB889 [3081026] BCBS WYOMING [308102603] 274.55 percent of total billed charges 179.18 274.55 Technical (Hospital) Services Ref CAH PX-3018349802 CDM 83498 CPT 301 RC outpatient 289 289 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES PPO [308136801] 231.2 percent of total billed charges 179.18 274.55 Technical (Hospital) Services Ref CAH PX-3018349802 CDM 83498 CPT 301 RC outpatient 289 289 BLUE CROSS BLUE SHIELD WELLMARK SB889 [3081026] BCBS WYOMING [308102603] 274.55 percent of total billed charges 179.18 274.55 Technical (Hospital) Services Ref CAH PX-3018349802 CDM 83498 CPT 301 RC outpatient 289 289 MULTIPLAN INC 34080 [3081285] MULTIPLAN INC [308128501] 274.55 percent of total billed charges 179.18 274.55 Technical (Hospital) Services Ref CAH PX-3018349802 CDM 83498 CPT 301 RC outpatient 289 289 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES HDHP [308136802] 231.2 percent of total billed charges 179.18 274.55 Technical (Hospital) Services Ref CAH PX-3018349802 CDM 83498 CPT 301 RC outpatient 289 289 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES EPO [308136803] 231.2 percent of total billed charges 179.18 274.55 Technical (Hospital) Services Ref CAH PX-3018349802 CDM 83498 CPT 301 RC outpatient 289 289 UNITED HEALTHCARE (COMMERCIAL) [3081199] UNITED HEALTHCARE 87726 [308119901] 179.18 percent of total billed charges 179.18 274.55 Technical (Hospital) Services Ref CAH PX-3018349802 CDM 83498 CPT 301 RC outpatient 289 289 HEALTHPARTNERS SX009 HEALTHPARTNERS 231.2 percent of total billed charges 179.18 274.55 Technical (Hospital) Services Ref CAH PX-3018349802 CDM 83498 CPT 301 RC outpatient 289 289 MEDICA (COMMERCIAL) 94265 [3081118] MEDICA CLAIMS [308111801] 260.1 percent of total billed charges 179.18 274.55 Technical (Hospital) Services Ref CAH PX-3018349802 CDM 83498 CPT 301 RC outpatient 289 289 CIGNA 62308 [3081051] CIGNA 62308 [308105105] 231.2 percent of total billed charges 179.18 274.55 Technical (Hospital) Services Ref CAH PX-3018349802 CDM 83498 CPT 301 RC outpatient 289 289 CIGNA 62308 [3081051] CIGNA STATE OF WYOMING [308105107] 231.2 percent of total billed charges 179.18 274.55 Technical (Hospital) Services Ref CAH PX-3018349802 CDM 83498 CPT 301 RC inpatient 289 289 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES EPO [308136803] 228.83 percent of total billed charges 179.18 274.55 Technical (Hospital) Services Ref CAH PX-3018349802 CDM 83498 CPT 301 RC inpatient 289 289 HEALTHPARTNERS SX009 HEALTHPARTNERS 228.83 percent of total billed charges 179.18 274.55 Technical (Hospital) Services Ref CAH PX-3018349802 CDM 83498 CPT 301 RC inpatient 289 289 CIGNA 62308 [3081051] CIGNA 62308 [308105105] 228.83 percent of total billed charges 179.18 274.55 Technical (Hospital) Services Ref CAH PX-3018349802 CDM 83498 CPT 301 RC inpatient 289 289 CIGNA 62308 [3081051] CIGNA STATE OF WYOMING [308105107] 228.83 percent of total billed charges 179.18 274.55 Technical (Hospital) Services Ref CAH PX-3018349802 CDM 83498 CPT 301 RC inpatient 289 289 MEDICA (COMMERCIAL) 94265 [3081118] MEDICA CLAIMS [308111801] 260.1 percent of total billed charges 179.18 274.55 Technical (Hospital) Services Ref CAH PX-3018349802 CDM 83498 CPT 301 RC inpatient 289 289 MULTIPLAN INC 34080 [3081285] MULTIPLAN INC [308128501] 274.55 percent of total billed charges 179.18 274.55 Technical (Hospital) Services Ref CAH PX-3018349802 CDM 83498 CPT 301 RC inpatient 289 289 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES PPO [308136801] 228.83 percent of total billed charges 179.18 274.55 Technical (Hospital) Services Ref CAH PX-3018349802 CDM 83498 CPT 301 RC inpatient 289 289 UNITED HEALTHCARE (COMMERCIAL) [3081199] UNITED HEALTHCARE 87726 [308119901] 179.18 percent of total billed charges 179.18 274.55 Technical (Hospital) Services Ref CAH PX-3018349802 CDM 83498 CPT 301 RC inpatient 289 289 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES HDHP [308136802] 228.83 percent of total billed charges 179.18 274.55 Technical (Hospital) Services Ref CAH PX-3018349802 CDM 83498 CPT 301 RC inpatient 289 289 BLUE CROSS BLUE SHIELD WELLMARK SB889 [3081026] BCBS WYOMING [308102603] 274.55 percent of total billed charges 179.18 274.55 Technical (Hospital) Services Ref Quant 5hiaa PX-3018349700 CDM 83497 CPT 301 RC inpatient 211 211 UNITED HEALTHCARE (COMMERCIAL) [3081199] UNITED HEALTHCARE 87726 [308119901] 130.82 percent of total billed charges 130.82 200.45 Technical (Hospital) Services Ref Quant 5hiaa PX-3018349700 CDM 83497 CPT 301 RC inpatient 211 211 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES PPO [308136801] 167.07 percent of total billed charges 130.82 200.45 Technical (Hospital) Services Ref Quant 5hiaa PX-3018349700 CDM 83497 CPT 301 RC inpatient 211 211 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES HDHP [308136802] 167.07 percent of total billed charges 130.82 200.45 Technical (Hospital) Services Ref Quant 5hiaa PX-3018349700 CDM 83497 CPT 301 RC inpatient 211 211 BLUE CROSS BLUE SHIELD WELLMARK SB889 [3081026] BCBS WYOMING [308102603] 200.45 percent of total billed charges 130.82 200.45 Technical (Hospital) Services Ref Quant 5hiaa PX-3018349700 CDM 83497 CPT 301 RC inpatient 211 211 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES EPO [308136803] 167.07 percent of total billed charges 130.82 200.45 Technical (Hospital) Services Ref Quant 5hiaa PX-3018349700 CDM 83497 CPT 301 RC inpatient 211 211 HEALTHPARTNERS SX009 HEALTHPARTNERS 167.07 percent of total billed charges 130.82 200.45 Technical (Hospital) Services Ref Quant 5hiaa PX-3018349700 CDM 83497 CPT 301 RC inpatient 211 211 MULTIPLAN INC 34080 [3081285] MULTIPLAN INC [308128501] 200.45 percent of total billed charges 130.82 200.45 Technical (Hospital) Services Ref Quant 5hiaa PX-3018349700 CDM 83497 CPT 301 RC inpatient 211 211 MEDICA (COMMERCIAL) 94265 [3081118] MEDICA CLAIMS [308111801] 189.9 percent of total billed charges 130.82 200.45 Technical (Hospital) Services Ref Quant 5hiaa PX-3018349700 CDM 83497 CPT 301 RC inpatient 211 211 CIGNA 62308 [3081051] CIGNA 62308 [308105105] 167.07 percent of total billed charges 130.82 200.45 Technical (Hospital) Services Ref Quant 5hiaa PX-3018349700 CDM 83497 CPT 301 RC inpatient 211 211 CIGNA 62308 [3081051] CIGNA STATE OF WYOMING [308105107] 167.07 percent of total billed charges 130.82 200.45 Technical (Hospital) Services Ref Quant 5hiaa PX-3018349700 CDM 83497 CPT 301 RC outpatient 211 211 MEDICA (COMMERCIAL) 94265 [3081118] MEDICA CLAIMS [308111801] 189.9 percent of total billed charges 130.82 200.45 Technical (Hospital) Services Ref Quant 5hiaa PX-3018349700 CDM 83497 CPT 301 RC outpatient 211 211 CIGNA 62308 [3081051] CIGNA 62308 [308105105] 168.8 percent of total billed charges 130.82 200.45 Technical (Hospital) Services Ref Quant 5hiaa PX-3018349700 CDM 83497 CPT 301 RC outpatient 211 211 CIGNA 62308 [3081051] CIGNA STATE OF WYOMING [308105107] 168.8 percent of total billed charges 130.82 200.45 Technical (Hospital) Services Ref Quant 5hiaa PX-3018349700 CDM 83497 CPT 301 RC outpatient 211 211 UNITED HEALTHCARE (COMMERCIAL) [3081199] UNITED HEALTHCARE 87726 [308119901] 130.82 percent of total billed charges 130.82 200.45 Technical (Hospital) Services Ref Quant 5hiaa PX-3018349700 CDM 83497 CPT 301 RC outpatient 211 211 HEALTHPARTNERS SX009 HEALTHPARTNERS 168.8 percent of total billed charges 130.82 200.45 Technical (Hospital) Services Ref Quant 5hiaa PX-3018349700 CDM 83497 CPT 301 RC outpatient 211 211 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES HDHP [308136802] 168.8 percent of total billed charges 130.82 200.45 Technical (Hospital) Services Ref Quant 5hiaa PX-3018349700 CDM 83497 CPT 301 RC outpatient 211 211 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES EPO [308136803] 168.8 percent of total billed charges 130.82 200.45 Technical (Hospital) Services Ref Quant 5hiaa PX-3018349700 CDM 83497 CPT 301 RC outpatient 211 211 MULTIPLAN INC 34080 [3081285] MULTIPLAN INC [308128501] 200.45 percent of total billed charges 130.82 200.45 Technical (Hospital) Services Ref Quant 5hiaa PX-3018349700 CDM 83497 CPT 301 RC outpatient 211 211 BLUE CROSS BLUE SHIELD WELLMARK SB889 [3081026] BCBS WYOMING [308102603] 200.45 percent of total billed charges 130.82 200.45 Technical (Hospital) Services Ref Quant 5hiaa PX-3018349700 CDM 83497 CPT 301 RC outpatient 211 211 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES PPO [308136801] 168.8 percent of total billed charges 130.82 200.45 Technical (Hospital) Services Ref Homocysteine Total Serum PX-3018309003 CDM 83090 CPT 301 RC inpatient 257 257 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES EPO [308136803] 203.49 percent of total billed charges 159.34 244.15 Technical (Hospital) Services Ref Homocysteine Total Serum PX-3018309003 CDM 83090 CPT 301 RC inpatient 257 257 HEALTHPARTNERS SX009 HEALTHPARTNERS 203.49 percent of total billed charges 159.34 244.15 Technical (Hospital) Services Ref Homocysteine Total Serum PX-3018309003 CDM 83090 CPT 301 RC inpatient 257 257 MEDICA (COMMERCIAL) 94265 [3081118] MEDICA CLAIMS [308111801] 231.3 percent of total billed charges 159.34 244.15 Technical (Hospital) Services Ref Homocysteine Total Serum PX-3018309003 CDM 83090 CPT 301 RC inpatient 257 257 MULTIPLAN INC 34080 [3081285] MULTIPLAN INC [308128501] 244.15 percent of total billed charges 159.34 244.15 Technical (Hospital) Services Ref Homocysteine Total Serum PX-3018309003 CDM 83090 CPT 301 RC inpatient 257 257 CIGNA 62308 [3081051] CIGNA 62308 [308105105] 203.49 percent of total billed charges 159.34 244.15 Technical (Hospital) Services Ref Homocysteine Total Serum PX-3018309003 CDM 83090 CPT 301 RC inpatient 257 257 CIGNA 62308 [3081051] CIGNA STATE OF WYOMING [308105107] 203.49 percent of total billed charges 159.34 244.15 Technical (Hospital) Services Ref Homocysteine Total Serum PX-3018309003 CDM 83090 CPT 301 RC inpatient 257 257 UNITED HEALTHCARE (COMMERCIAL) [3081199] UNITED HEALTHCARE 87726 [308119901] 159.34 percent of total billed charges 159.34 244.15 Technical (Hospital) Services Ref Homocysteine Total Serum PX-3018309003 CDM 83090 CPT 301 RC inpatient 257 257 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES PPO [308136801] 203.49 percent of total billed charges 159.34 244.15 Technical (Hospital) Services Ref Homocysteine Total Serum PX-3018309003 CDM 83090 CPT 301 RC inpatient 257 257 BLUE CROSS BLUE SHIELD WELLMARK SB889 [3081026] BCBS WYOMING [308102603] 244.15 percent of total billed charges 159.34 244.15 Technical (Hospital) Services Ref Homocysteine Total Serum PX-3018309003 CDM 83090 CPT 301 RC inpatient 257 257 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES HDHP [308136802] 203.49 percent of total billed charges 159.34 244.15 Technical (Hospital) Services Ref Homocysteine Total Serum PX-3018309003 CDM 83090 CPT 301 RC outpatient 257 257 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES PPO [308136801] 205.6 percent of total billed charges 159.34 244.15 Technical (Hospital) Services Ref Homocysteine Total Serum PX-3018309003 CDM 83090 CPT 301 RC outpatient 257 257 UNITED HEALTHCARE (COMMERCIAL) [3081199] UNITED HEALTHCARE 87726 [308119901] 159.34 percent of total billed charges 159.34 244.15 Technical (Hospital) Services Ref Homocysteine Total Serum PX-3018309003 CDM 83090 CPT 301 RC outpatient 257 257 HEALTHPARTNERS SX009 HEALTHPARTNERS 205.6 percent of total billed charges 159.34 244.15 Technical (Hospital) Services Ref Homocysteine Total Serum PX-3018309003 CDM 83090 CPT 301 RC outpatient 257 257 MULTIPLAN INC 34080 [3081285] MULTIPLAN INC [308128501] 244.15 percent of total billed charges 159.34 244.15 Technical (Hospital) Services Ref Homocysteine Total Serum PX-3018309003 CDM 83090 CPT 301 RC outpatient 257 257 BLUE CROSS BLUE SHIELD WELLMARK SB889 [3081026] BCBS WYOMING [308102603] 244.15 percent of total billed charges 159.34 244.15 Technical (Hospital) Services Ref Homocysteine Total Serum PX-3018309003 CDM 83090 CPT 301 RC outpatient 257 257 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES HDHP [308136802] 205.6 percent of total billed charges 159.34 244.15 Technical (Hospital) Services Ref Homocysteine Total Serum PX-3018309003 CDM 83090 CPT 301 RC outpatient 257 257 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES EPO [308136803] 205.6 percent of total billed charges 159.34 244.15 Technical (Hospital) Services Ref Homocysteine Total Serum PX-3018309003 CDM 83090 CPT 301 RC outpatient 257 257 MEDICA (COMMERCIAL) 94265 [3081118] MEDICA CLAIMS [308111801] 231.3 percent of total billed charges 159.34 244.15 Technical (Hospital) Services Ref Homocysteine Total Serum PX-3018309003 CDM 83090 CPT 301 RC outpatient 257 257 CIGNA 62308 [3081051] CIGNA 62308 [308105105] 205.6 percent of total billed charges 159.34 244.15 Technical (Hospital) Services Ref Homocysteine Total Serum PX-3018309003 CDM 83090 CPT 301 RC outpatient 257 257 CIGNA 62308 [3081051] CIGNA STATE OF WYOMING [308105107] 205.6 percent of total billed charges 159.34 244.15 Technical (Hospital) Services Ref Hemosiderin U PX-3018307000 CDM 83070 CPT 301 RC outpatient 61 61 CIGNA 62308 [3081051] CIGNA 62308 [308105105] 48.8 percent of total billed charges 37.82 57.95 Technical (Hospital) Services Ref Hemosiderin U PX-3018307000 CDM 83070 CPT 301 RC outpatient 61 61 CIGNA 62308 [3081051] CIGNA STATE OF WYOMING [308105107] 48.8 percent of total billed charges 37.82 57.95 Technical (Hospital) Services Ref Hemosiderin U PX-3018307000 CDM 83070 CPT 301 RC outpatient 61 61 MEDICA (COMMERCIAL) 94265 [3081118] MEDICA CLAIMS [308111801] 54.9 percent of total billed charges 37.82 57.95 Technical (Hospital) Services Ref Hemosiderin U PX-3018307000 CDM 83070 CPT 301 RC outpatient 61 61 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES HDHP [308136802] 48.8 percent of total billed charges 37.82 57.95 Technical (Hospital) Services Ref Hemosiderin U PX-3018307000 CDM 83070 CPT 301 RC outpatient 61 61 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES EPO [308136803] 48.8 percent of total billed charges 37.82 57.95 Technical (Hospital) Services Ref Hemosiderin U PX-3018307000 CDM 83070 CPT 301 RC outpatient 61 61 BLUE CROSS BLUE SHIELD WELLMARK SB889 [3081026] BCBS WYOMING [308102603] 57.95 percent of total billed charges 37.82 57.95 Technical (Hospital) Services Ref Hemosiderin U PX-3018307000 CDM 83070 CPT 301 RC outpatient 61 61 MULTIPLAN INC 34080 [3081285] MULTIPLAN INC [308128501] 57.95 percent of total billed charges 37.82 57.95 Technical (Hospital) Services Ref Hemosiderin U PX-3018307000 CDM 83070 CPT 301 RC outpatient 61 61 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES PPO [308136801] 48.8 percent of total billed charges 37.82 57.95 Technical (Hospital) Services Ref Hemosiderin U PX-3018307000 CDM 83070 CPT 301 RC outpatient 61 61 HEALTHPARTNERS SX009 HEALTHPARTNERS 48.8 percent of total billed charges 37.82 57.95 Technical (Hospital) Services Ref Hemosiderin U PX-3018307000 CDM 83070 CPT 301 RC outpatient 61 61 UNITED HEALTHCARE (COMMERCIAL) [3081199] UNITED HEALTHCARE 87726 [308119901] 37.82 percent of total billed charges 37.82 57.95 Technical (Hospital) Services Ref Hemosiderin U PX-3018307000 CDM 83070 CPT 301 RC inpatient 61 61 MULTIPLAN INC 34080 [3081285] MULTIPLAN INC [308128501] 57.95 percent of total billed charges 37.82 57.95 Technical (Hospital) Services Ref Hemosiderin U PX-3018307000 CDM 83070 CPT 301 RC inpatient 61 61 MEDICA (COMMERCIAL) 94265 [3081118] MEDICA CLAIMS [308111801] 54.9 percent of total billed charges 37.82 57.95 Technical (Hospital) Services Ref Hemosiderin U PX-3018307000 CDM 83070 CPT 301 RC inpatient 61 61 CIGNA 62308 [3081051] CIGNA 62308 [308105105] 48.3 percent of total billed charges 37.82 57.95 Technical (Hospital) Services Ref Hemosiderin U PX-3018307000 CDM 83070 CPT 301 RC inpatient 61 61 CIGNA 62308 [3081051] CIGNA STATE OF WYOMING [308105107] 48.3 percent of total billed charges 37.82 57.95 Technical (Hospital) Services Ref Hemosiderin U PX-3018307000 CDM 83070 CPT 301 RC inpatient 61 61 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES EPO [308136803] 48.3 percent of total billed charges 37.82 57.95 Technical (Hospital) Services Ref Hemosiderin U PX-3018307000 CDM 83070 CPT 301 RC inpatient 61 61 HEALTHPARTNERS SX009 HEALTHPARTNERS 48.3 percent of total billed charges 37.82 57.95 Technical (Hospital) Services Ref Hemosiderin U PX-3018307000 CDM 83070 CPT 301 RC inpatient 61 61 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES HDHP [308136802] 48.3 percent of total billed charges 37.82 57.95 Technical (Hospital) Services Ref Hemosiderin U PX-3018307000 CDM 83070 CPT 301 RC inpatient 61 61 BLUE CROSS BLUE SHIELD WELLMARK SB889 [3081026] BCBS WYOMING [308102603] 57.95 percent of total billed charges 37.82 57.95 Technical (Hospital) Services Ref Hemosiderin U PX-3018307000 CDM 83070 CPT 301 RC inpatient 61 61 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES PPO [308136801] 48.3 percent of total billed charges 37.82 57.95 Technical (Hospital) Services Ref Hemosiderin U PX-3018307000 CDM 83070 CPT 301 RC inpatient 61 61 UNITED HEALTHCARE (COMMERCIAL) [3081199] UNITED HEALTHCARE 87726 [308119901] 37.82 percent of total billed charges 37.82 57.95 Technical (Hospital) Services Hemoglobin A1c PX-3018303600 CDM 83036 CPT 301 RC outpatient 114 114 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES HDHP [308136802] 91.2 percent of total billed charges 70.68 108.3 Technical (Hospital) Services Hemoglobin A1c PX-3018303600 CDM 83036 CPT 301 RC outpatient 114 114 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES EPO [308136803] 91.2 percent of total billed charges 70.68 108.3 Technical (Hospital) Services Hemoglobin A1c PX-3018303600 CDM 83036 CPT 301 RC outpatient 114 114 BLUE CROSS BLUE SHIELD WELLMARK SB889 [3081026] BCBS WYOMING [308102603] 108.3 percent of total billed charges 70.68 108.3 Technical (Hospital) Services Hemoglobin A1c PX-3018303600 CDM 83036 CPT 301 RC outpatient 114 114 MULTIPLAN INC 34080 [3081285] MULTIPLAN INC [308128501] 108.3 percent of total billed charges 70.68 108.3 Technical (Hospital) Services Hemoglobin A1c PX-3018303600 CDM 83036 CPT 301 RC outpatient 114 114 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES PPO [308136801] 91.2 percent of total billed charges 70.68 108.3 Technical (Hospital) Services Hemoglobin A1c PX-3018303600 CDM 83036 CPT 301 RC outpatient 114 114 HEALTHPARTNERS SX009 HEALTHPARTNERS 91.2 percent of total billed charges 70.68 108.3 Technical (Hospital) Services Hemoglobin A1c PX-3018303600 CDM 83036 CPT 301 RC outpatient 114 114 UNITED HEALTHCARE (COMMERCIAL) [3081199] UNITED HEALTHCARE 87726 [308119901] 70.68 percent of total billed charges 70.68 108.3 Technical (Hospital) Services Hemoglobin A1c PX-3018303600 CDM 83036 CPT 301 RC outpatient 114 114 MEDICA (COMMERCIAL) 94265 [3081118] MEDICA CLAIMS [308111801] 102.6 percent of total billed charges 70.68 108.3 Technical (Hospital) Services Hemoglobin A1c PX-3018303600 CDM 83036 CPT 301 RC outpatient 114 114 CIGNA 62308 [3081051] CIGNA 62308 [308105105] 91.2 percent of total billed charges 70.68 108.3 Technical (Hospital) Services Hemoglobin A1c PX-3018303600 CDM 83036 CPT 301 RC outpatient 114 114 CIGNA 62308 [3081051] CIGNA STATE OF WYOMING [308105107] 91.2 percent of total billed charges 70.68 108.3 Technical (Hospital) Services Hemoglobin A1c PX-3018303600 CDM 83036 CPT 301 RC inpatient 114 114 UNITED HEALTHCARE (COMMERCIAL) [3081199] UNITED HEALTHCARE 87726 [308119901] 70.68 percent of total billed charges 70.68 108.3 Technical (Hospital) Services Hemoglobin A1c PX-3018303600 CDM 83036 CPT 301 RC inpatient 114 114 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES PPO [308136801] 90.27 percent of total billed charges 70.68 108.3 Technical (Hospital) Services Hemoglobin A1c PX-3018303600 CDM 83036 CPT 301 RC inpatient 114 114 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES HDHP [308136802] 90.27 percent of total billed charges 70.68 108.3 Technical (Hospital) Services Hemoglobin A1c PX-3018303600 CDM 83036 CPT 301 RC inpatient 114 114 BLUE CROSS BLUE SHIELD WELLMARK SB889 [3081026] BCBS WYOMING [308102603] 108.3 percent of total billed charges 70.68 108.3 Technical (Hospital) Services Hemoglobin A1c PX-3018303600 CDM 83036 CPT 301 RC inpatient 114 114 MEDICA (COMMERCIAL) 94265 [3081118] MEDICA CLAIMS [308111801] 102.6 percent of total billed charges 70.68 108.3 Technical (Hospital) Services Hemoglobin A1c PX-3018303600 CDM 83036 CPT 301 RC inpatient 114 114 MULTIPLAN INC 34080 [3081285] MULTIPLAN INC [308128501] 108.3 percent of total billed charges 70.68 108.3 Technical (Hospital) Services Hemoglobin A1c PX-3018303600 CDM 83036 CPT 301 RC inpatient 114 114 CIGNA 62308 [3081051] CIGNA 62308 [308105105] 90.27 percent of total billed charges 70.68 108.3 Technical (Hospital) Services Hemoglobin A1c PX-3018303600 CDM 83036 CPT 301 RC inpatient 114 114 CIGNA 62308 [3081051] CIGNA STATE OF WYOMING [308105107] 90.27 percent of total billed charges 70.68 108.3 Technical (Hospital) Services Hemoglobin A1c PX-3018303600 CDM 83036 CPT 301 RC inpatient 114 114 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES EPO [308136803] 90.27 percent of total billed charges 70.68 108.3 Technical (Hospital) Services Hemoglobin A1c PX-3018303600 CDM 83036 CPT 301 RC inpatient 114 114 HEALTHPARTNERS SX009 HEALTHPARTNERS 90.27 percent of total billed charges 70.68 108.3 Technical (Hospital) Services Ref Hemoglobin A2 & F PX-3018302101 CDM 83021 CPT 301 RC inpatient 207 207 UNITED HEALTHCARE (COMMERCIAL) [3081199] UNITED HEALTHCARE 87726 [308119901] 128.34 percent of total billed charges 128.34 196.65 Technical (Hospital) Services Ref Hemoglobin A2 & F PX-3018302101 CDM 83021 CPT 301 RC inpatient 207 207 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES PPO [308136801] 163.9 percent of total billed charges 128.34 196.65 Technical (Hospital) Services Ref Hemoglobin A2 & F PX-3018302101 CDM 83021 CPT 301 RC inpatient 207 207 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES HDHP [308136802] 163.9 percent of total billed charges 128.34 196.65 Technical (Hospital) Services Ref Hemoglobin A2 & F PX-3018302101 CDM 83021 CPT 301 RC inpatient 207 207 BLUE CROSS BLUE SHIELD WELLMARK SB889 [3081026] BCBS WYOMING [308102603] 196.65 percent of total billed charges 128.34 196.65 Technical (Hospital) Services Ref Hemoglobin A2 & F PX-3018302101 CDM 83021 CPT 301 RC inpatient 207 207 HEALTHPARTNERS SX009 HEALTHPARTNERS 163.9 percent of total billed charges 128.34 196.65 Technical (Hospital) Services Ref Hemoglobin A2 & F PX-3018302101 CDM 83021 CPT 301 RC inpatient 207 207 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES EPO [308136803] 163.9 percent of total billed charges 128.34 196.65 Technical (Hospital) Services Ref Hemoglobin A2 & F PX-3018302101 CDM 83021 CPT 301 RC inpatient 207 207 MULTIPLAN INC 34080 [3081285] MULTIPLAN INC [308128501] 196.65 percent of total billed charges 128.34 196.65 Technical (Hospital) Services Ref Hemoglobin A2 & F PX-3018302101 CDM 83021 CPT 301 RC inpatient 207 207 MEDICA (COMMERCIAL) 94265 [3081118] MEDICA CLAIMS [308111801] 186.3 percent of total billed charges 128.34 196.65 Technical (Hospital) Services Ref Hemoglobin A2 & F PX-3018302101 CDM 83021 CPT 301 RC inpatient 207 207 CIGNA 62308 [3081051] CIGNA 62308 [308105105] 163.9 percent of total billed charges 128.34 196.65 Technical (Hospital) Services Ref Hemoglobin A2 & F PX-3018302101 CDM 83021 CPT 301 RC inpatient 207 207 CIGNA 62308 [3081051] CIGNA STATE OF WYOMING [308105107] 163.9 percent of total billed charges 128.34 196.65 Technical (Hospital) Services Ref Hemoglobin A2 & F PX-3018302101 CDM 83021 CPT 301 RC outpatient 207 207 MEDICA (COMMERCIAL) 94265 [3081118] MEDICA CLAIMS [308111801] 186.3 percent of total billed charges 128.34 196.65 Technical (Hospital) Services Ref Hemoglobin A2 & F PX-3018302101 CDM 83021 CPT 301 RC outpatient 207 207 CIGNA 62308 [3081051] CIGNA 62308 [308105105] 165.6 percent of total billed charges 128.34 196.65 Technical (Hospital) Services Ref Hemoglobin A2 & F PX-3018302101 CDM 83021 CPT 301 RC outpatient 207 207 CIGNA 62308 [3081051] CIGNA STATE OF WYOMING [308105107] 165.6 percent of total billed charges 128.34 196.65 Technical (Hospital) Services Ref Hemoglobin A2 & F PX-3018302101 CDM 83021 CPT 301 RC outpatient 207 207 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES PPO [308136801] 165.6 percent of total billed charges 128.34 196.65 Technical (Hospital) Services Ref Hemoglobin A2 & F PX-3018302101 CDM 83021 CPT 301 RC outpatient 207 207 MULTIPLAN INC 34080 [3081285] MULTIPLAN INC [308128501] 196.65 percent of total billed charges 128.34 196.65 Technical (Hospital) Services Ref Hemoglobin A2 & F PX-3018302101 CDM 83021 CPT 301 RC outpatient 207 207 BLUE CROSS BLUE SHIELD WELLMARK SB889 [3081026] BCBS WYOMING [308102603] 196.65 percent of total billed charges 128.34 196.65 Technical (Hospital) Services Ref Hemoglobin A2 & F PX-3018302101 CDM 83021 CPT 301 RC outpatient 207 207 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES EPO [308136803] 165.6 percent of total billed charges 128.34 196.65 Technical (Hospital) Services Ref Hemoglobin A2 & F PX-3018302101 CDM 83021 CPT 301 RC outpatient 207 207 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES HDHP [308136802] 165.6 percent of total billed charges 128.34 196.65 Technical (Hospital) Services Ref Hemoglobin A2 & F PX-3018302101 CDM 83021 CPT 301 RC outpatient 207 207 UNITED HEALTHCARE (COMMERCIAL) [3081199] UNITED HEALTHCARE 87726 [308119901] 128.34 percent of total billed charges 128.34 196.65 Technical (Hospital) Services Ref Hemoglobin A2 & F PX-3018302101 CDM 83021 CPT 301 RC outpatient 207 207 HEALTHPARTNERS SX009 HEALTHPARTNERS 165.6 percent of total billed charges 128.34 196.65 Technical (Hospital) Services Ref Hemoglobin A2 & F - Thalassemia & Hemo Eval PX-3018302102 CDM 83021 CPT 301 RC inpatient 452 452 UNITED HEALTHCARE (COMMERCIAL) [3081199] UNITED HEALTHCARE 87726 [308119901] 280.24 percent of total billed charges 280.24 429.4 Technical (Hospital) Services Ref Hemoglobin A2 & F - Thalassemia & Hemo Eval PX-3018302102 CDM 83021 CPT 301 RC inpatient 452 452 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES PPO [308136801] 357.89 percent of total billed charges 280.24 429.4 Technical (Hospital) Services Ref Hemoglobin A2 & F - Thalassemia & Hemo Eval PX-3018302102 CDM 83021 CPT 301 RC inpatient 452 452 BLUE CROSS BLUE SHIELD WELLMARK SB889 [3081026] BCBS WYOMING [308102603] 429.4 percent of total billed charges 280.24 429.4 Technical (Hospital) Services Ref Hemoglobin A2 & F - Thalassemia & Hemo Eval PX-3018302102 CDM 83021 CPT 301 RC inpatient 452 452 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES HDHP [308136802] 357.89 percent of total billed charges 280.24 429.4 Technical (Hospital) Services Ref Hemoglobin A2 & F - Thalassemia & Hemo Eval PX-3018302102 CDM 83021 CPT 301 RC inpatient 452 452 HEALTHPARTNERS SX009 HEALTHPARTNERS 357.89 percent of total billed charges 280.24 429.4 Technical (Hospital) Services Ref Hemoglobin A2 & F - Thalassemia & Hemo Eval PX-3018302102 CDM 83021 CPT 301 RC inpatient 452 452 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES EPO [308136803] 357.89 percent of total billed charges 280.24 429.4 Technical (Hospital) Services Ref Hemoglobin A2 & F - Thalassemia & Hemo Eval PX-3018302102 CDM 83021 CPT 301 RC inpatient 452 452 CIGNA 62308 [3081051] CIGNA 62308 [308105105] 357.89 percent of total billed charges 280.24 429.4 Technical (Hospital) Services Ref Hemoglobin A2 & F - Thalassemia & Hemo Eval PX-3018302102 CDM 83021 CPT 301 RC inpatient 452 452 CIGNA 62308 [3081051] CIGNA STATE OF WYOMING [308105107] 357.89 percent of total billed charges 280.24 429.4 Technical (Hospital) Services Ref Hemoglobin A2 & F - Thalassemia & Hemo Eval PX-3018302102 CDM 83021 CPT 301 RC inpatient 452 452 MULTIPLAN INC 34080 [3081285] MULTIPLAN INC [308128501] 429.4 percent of total billed charges 280.24 429.4 Technical (Hospital) Services Ref Hemoglobin A2 & F - Thalassemia & Hemo Eval PX-3018302102 CDM 83021 CPT 301 RC inpatient 452 452 MEDICA (COMMERCIAL) 94265 [3081118] MEDICA CLAIMS [308111801] 406.8 percent of total billed charges 280.24 429.4 Technical (Hospital) Services Ref Hemoglobin A2 & F - Thalassemia & Hemo Eval PX-3018302102 CDM 83021 CPT 301 RC outpatient 452 452 UNITED HEALTHCARE (COMMERCIAL) [3081199] UNITED HEALTHCARE 87726 [308119901] 280.24 percent of total billed charges 280.24 429.4 Technical (Hospital) Services Ref Hemoglobin A2 & F - Thalassemia & Hemo Eval PX-3018302102 CDM 83021 CPT 301 RC outpatient 452 452 HEALTHPARTNERS SX009 HEALTHPARTNERS 361.6 percent of total billed charges 280.24 429.4 Technical (Hospital) Services Ref Hemoglobin A2 & F - Thalassemia & Hemo Eval PX-3018302102 CDM 83021 CPT 301 RC outpatient 452 452 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES HDHP [308136802] 361.6 percent of total billed charges 280.24 429.4 Technical (Hospital) Services Ref Hemoglobin A2 & F - Thalassemia & Hemo Eval PX-3018302102 CDM 83021 CPT 301 RC outpatient 452 452 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES EPO [308136803] 361.6 percent of total billed charges 280.24 429.4 Technical (Hospital) Services Ref Hemoglobin A2 & F - Thalassemia & Hemo Eval PX-3018302102 CDM 83021 CPT 301 RC outpatient 452 452 BLUE CROSS BLUE SHIELD WELLMARK SB889 [3081026] BCBS WYOMING [308102603] 429.4 percent of total billed charges 280.24 429.4 Technical (Hospital) Services Ref Hemoglobin A2 & F - Thalassemia & Hemo Eval PX-3018302102 CDM 83021 CPT 301 RC outpatient 452 452 MULTIPLAN INC 34080 [3081285] MULTIPLAN INC [308128501] 429.4 percent of total billed charges 280.24 429.4 Technical (Hospital) Services Ref Hemoglobin A2 & F - Thalassemia & Hemo Eval PX-3018302102 CDM 83021 CPT 301 RC outpatient 452 452 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES PPO [308136801] 361.6 percent of total billed charges 280.24 429.4 Technical (Hospital) Services Ref Hemoglobin A2 & F - Thalassemia & Hemo Eval PX-3018302102 CDM 83021 CPT 301 RC outpatient 452 452 MEDICA (COMMERCIAL) 94265 [3081118] MEDICA CLAIMS [308111801] 406.8 percent of total billed charges 280.24 429.4 Technical (Hospital) Services Ref Hemoglobin A2 & F - Thalassemia & Hemo Eval PX-3018302102 CDM 83021 CPT 301 RC outpatient 452 452 CIGNA 62308 [3081051] CIGNA 62308 [308105105] 361.6 percent of total billed charges 280.24 429.4 Technical (Hospital) Services Ref Hemoglobin A2 & F - Thalassemia & Hemo Eval PX-3018302102 CDM 83021 CPT 301 RC outpatient 452 452 CIGNA 62308 [3081051] CIGNA STATE OF WYOMING [308105107] 361.6 percent of total billed charges 280.24 429.4 Technical (Hospital) Services Ref Hemoglobin Electrophoresis (Hgb E) PX-3018302000 CDM 83020 CPT 301 RC outpatient 158 158 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES PPO [308136801] 126.4 percent of total billed charges 97.96 150.1 Technical (Hospital) Services Ref Hemoglobin Electrophoresis (Hgb E) PX-3018302000 CDM 83020 CPT 301 RC outpatient 158 158 BLUE CROSS BLUE SHIELD WELLMARK SB889 [3081026] BCBS WYOMING [308102603] 150.1 percent of total billed charges 97.96 150.1 Technical (Hospital) Services Ref Hemoglobin Electrophoresis (Hgb E) PX-3018302000 CDM 83020 CPT 301 RC outpatient 158 158 MULTIPLAN INC 34080 [3081285] MULTIPLAN INC [308128501] 150.1 percent of total billed charges 97.96 150.1 Technical (Hospital) Services Ref Hemoglobin Electrophoresis (Hgb E) PX-3018302000 CDM 83020 CPT 301 RC outpatient 158 158 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES HDHP [308136802] 126.4 percent of total billed charges 97.96 150.1 Technical (Hospital) Services Ref Hemoglobin Electrophoresis (Hgb E) PX-3018302000 CDM 83020 CPT 301 RC outpatient 158 158 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES EPO [308136803] 126.4 percent of total billed charges 97.96 150.1 Technical (Hospital) Services Ref Hemoglobin Electrophoresis (Hgb E) PX-3018302000 CDM 83020 CPT 301 RC outpatient 158 158 UNITED HEALTHCARE (COMMERCIAL) [3081199] UNITED HEALTHCARE 87726 [308119901] 97.96 percent of total billed charges 97.96 150.1 Technical (Hospital) Services Ref Hemoglobin Electrophoresis (Hgb E) PX-3018302000 CDM 83020 CPT 301 RC outpatient 158 158 HEALTHPARTNERS SX009 HEALTHPARTNERS 126.4 percent of total billed charges 97.96 150.1 Technical (Hospital) Services Ref Hemoglobin Electrophoresis (Hgb E) PX-3018302000 CDM 83020 CPT 301 RC outpatient 158 158 CIGNA 62308 [3081051] CIGNA 62308 [308105105] 126.4 percent of total billed charges 97.96 150.1 Technical (Hospital) Services Ref Hemoglobin Electrophoresis (Hgb E) PX-3018302000 CDM 83020 CPT 301 RC outpatient 158 158 CIGNA 62308 [3081051] CIGNA STATE OF WYOMING [308105107] 126.4 percent of total billed charges 97.96 150.1 Technical (Hospital) Services Ref Hemoglobin Electrophoresis (Hgb E) PX-3018302000 CDM 83020 CPT 301 RC outpatient 158 158 MEDICA (COMMERCIAL) 94265 [3081118] MEDICA CLAIMS [308111801] 142.2 percent of total billed charges 97.96 150.1 Technical (Hospital) Services Ref Hemoglobin Electrophoresis (Hgb E) PX-3018302000 CDM 83020 CPT 301 RC inpatient 158 158 UNITED HEALTHCARE (COMMERCIAL) [3081199] UNITED HEALTHCARE 87726 [308119901] 97.96 percent of total billed charges 97.96 150.1 Technical (Hospital) Services Ref Hemoglobin Electrophoresis (Hgb E) PX-3018302000 CDM 83020 CPT 301 RC inpatient 158 158 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES PPO [308136801] 125.1 percent of total billed charges 97.96 150.1 Technical (Hospital) Services Ref Hemoglobin Electrophoresis (Hgb E) PX-3018302000 CDM 83020 CPT 301 RC inpatient 158 158 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES HDHP [308136802] 125.1 percent of total billed charges 97.96 150.1 Technical (Hospital) Services Ref Hemoglobin Electrophoresis (Hgb E) PX-3018302000 CDM 83020 CPT 301 RC inpatient 158 158 BLUE CROSS BLUE SHIELD WELLMARK SB889 [3081026] BCBS WYOMING [308102603] 150.1 percent of total billed charges 97.96 150.1 Technical (Hospital) Services Ref Hemoglobin Electrophoresis (Hgb E) PX-3018302000 CDM 83020 CPT 301 RC inpatient 158 158 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES EPO [308136803] 125.1 percent of total billed charges 97.96 150.1 Technical (Hospital) Services Ref Hemoglobin Electrophoresis (Hgb E) PX-3018302000 CDM 83020 CPT 301 RC inpatient 158 158 HEALTHPARTNERS SX009 HEALTHPARTNERS 125.1 percent of total billed charges 97.96 150.1 Technical (Hospital) Services Ref Hemoglobin Electrophoresis (Hgb E) PX-3018302000 CDM 83020 CPT 301 RC inpatient 158 158 MULTIPLAN INC 34080 [3081285] MULTIPLAN INC [308128501] 150.1 percent of total billed charges 97.96 150.1 Technical (Hospital) Services Ref Hemoglobin Electrophoresis (Hgb E) PX-3018302000 CDM 83020 CPT 301 RC inpatient 158 158 MEDICA (COMMERCIAL) 94265 [3081118] MEDICA CLAIMS [308111801] 142.2 percent of total billed charges 97.96 150.1 Technical (Hospital) Services Ref Hemoglobin Electrophoresis (Hgb E) PX-3018302000 CDM 83020 CPT 301 RC inpatient 158 158 CIGNA 62308 [3081051] CIGNA 62308 [308105105] 125.1 percent of total billed charges 97.96 150.1 Technical (Hospital) Services Ref Hemoglobin Electrophoresis (Hgb E) PX-3018302000 CDM 83020 CPT 301 RC inpatient 158 158 CIGNA 62308 [3081051] CIGNA STATE OF WYOMING [308105107] 125.1 percent of total billed charges 97.96 150.1 Technical (Hospital) Services Ref Hemoglobin Elp B PX-3018302001 CDM 83020 CPT 301 RC outpatient 894 894 MEDICA (COMMERCIAL) 94265 [3081118] MEDICA CLAIMS [308111801] 804.6 percent of total billed charges 554.28 849.3 Technical (Hospital) Services Ref Hemoglobin Elp B PX-3018302001 CDM 83020 CPT 301 RC outpatient 894 894 CIGNA 62308 [3081051] CIGNA 62308 [308105105] 715.2 percent of total billed charges 554.28 849.3 Technical (Hospital) Services Ref Hemoglobin Elp B PX-3018302001 CDM 83020 CPT 301 RC outpatient 894 894 CIGNA 62308 [3081051] CIGNA STATE OF WYOMING [308105107] 715.2 percent of total billed charges 554.28 849.3 Technical (Hospital) Services Ref Hemoglobin Elp B PX-3018302001 CDM 83020 CPT 301 RC outpatient 894 894 HEALTHPARTNERS SX009 HEALTHPARTNERS 715.2 percent of total billed charges 554.28 849.3 Technical (Hospital) Services Ref Hemoglobin Elp B PX-3018302001 CDM 83020 CPT 301 RC outpatient 894 894 UNITED HEALTHCARE (COMMERCIAL) [3081199] UNITED HEALTHCARE 87726 [308119901] 554.28 percent of total billed charges 554.28 849.3 Technical (Hospital) Services Ref Hemoglobin Elp B PX-3018302001 CDM 83020 CPT 301 RC outpatient 894 894 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES EPO [308136803] 715.2 percent of total billed charges 554.28 849.3 Technical (Hospital) Services Ref Hemoglobin Elp B PX-3018302001 CDM 83020 CPT 301 RC outpatient 894 894 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES HDHP [308136802] 715.2 percent of total billed charges 554.28 849.3 Technical (Hospital) Services Ref Hemoglobin Elp B PX-3018302001 CDM 83020 CPT 301 RC outpatient 894 894 MULTIPLAN INC 34080 [3081285] MULTIPLAN INC [308128501] 849.3 percent of total billed charges 554.28 849.3 Technical (Hospital) Services Ref Hemoglobin Elp B PX-3018302001 CDM 83020 CPT 301 RC outpatient 894 894 BLUE CROSS BLUE SHIELD WELLMARK SB889 [3081026] BCBS WYOMING [308102603] 849.3 percent of total billed charges 554.28 849.3 Technical (Hospital) Services Ref Hemoglobin Elp B PX-3018302001 CDM 83020 CPT 301 RC outpatient 894 894 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES PPO [308136801] 715.2 percent of total billed charges 554.28 849.3 Technical (Hospital) Services Ref Hemoglobin Elp B PX-3018302001 CDM 83020 CPT 301 RC inpatient 894 894 UNITED HEALTHCARE (COMMERCIAL) [3081199] UNITED HEALTHCARE 87726 [308119901] 554.28 percent of total billed charges 554.28 849.3 Technical (Hospital) Services Ref Hemoglobin Elp B PX-3018302001 CDM 83020 CPT 301 RC inpatient 894 894 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES PPO [308136801] 707.87 percent of total billed charges 554.28 849.3 Technical (Hospital) Services Ref Hemoglobin Elp B PX-3018302001 CDM 83020 CPT 301 RC inpatient 894 894 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES HDHP [308136802] 707.87 percent of total billed charges 554.28 849.3 Technical (Hospital) Services Ref Hemoglobin Elp B PX-3018302001 CDM 83020 CPT 301 RC inpatient 894 894 BLUE CROSS BLUE SHIELD WELLMARK SB889 [3081026] BCBS WYOMING [308102603] 849.3 percent of total billed charges 554.28 849.3 Technical (Hospital) Services Ref Hemoglobin Elp B PX-3018302001 CDM 83020 CPT 301 RC inpatient 894 894 HEALTHPARTNERS SX009 HEALTHPARTNERS 707.87 percent of total billed charges 554.28 849.3 Technical (Hospital) Services Ref Hemoglobin Elp B PX-3018302001 CDM 83020 CPT 301 RC inpatient 894 894 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES EPO [308136803] 707.87 percent of total billed charges 554.28 849.3 Technical (Hospital) Services Ref Hemoglobin Elp B PX-3018302001 CDM 83020 CPT 301 RC inpatient 894 894 CIGNA 62308 [3081051] CIGNA 62308 [308105105] 707.87 percent of total billed charges 554.28 849.3 Technical (Hospital) Services Ref Hemoglobin Elp B PX-3018302001 CDM 83020 CPT 301 RC inpatient 894 894 CIGNA 62308 [3081051] CIGNA STATE OF WYOMING [308105107] 707.87 percent of total billed charges 554.28 849.3 Technical (Hospital) Services Ref Hemoglobin Elp B PX-3018302001 CDM 83020 CPT 301 RC inpatient 894 894 MEDICA (COMMERCIAL) 94265 [3081118] MEDICA CLAIMS [308111801] 804.6 percent of total billed charges 554.28 849.3 Technical (Hospital) Services Ref Hemoglobin Elp B PX-3018302001 CDM 83020 CPT 301 RC inpatient 894 894 MULTIPLAN INC 34080 [3081285] MULTIPLAN INC [308128501] 849.3 percent of total billed charges 554.28 849.3 Technical (Hospital) Services Ref Hemoglobin Elp B - Thalassemia & Hemo Eval PX-3018302002 CDM 83020 CPT 301 RC inpatient 894 894 UNITED HEALTHCARE (COMMERCIAL) [3081199] UNITED HEALTHCARE 87726 [308119901] 554.28 percent of total billed charges 554.28 849.3 Technical (Hospital) Services Ref Hemoglobin Elp B - Thalassemia & Hemo Eval PX-3018302002 CDM 83020 CPT 301 RC inpatient 894 894 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES PPO [308136801] 707.87 percent of total billed charges 554.28 849.3 Technical (Hospital) Services Ref Hemoglobin Elp B - Thalassemia & Hemo Eval PX-3018302002 CDM 83020 CPT 301 RC inpatient 894 894 BLUE CROSS BLUE SHIELD WELLMARK SB889 [3081026] BCBS WYOMING [308102603] 849.3 percent of total billed charges 554.28 849.3 Technical (Hospital) Services Ref Hemoglobin Elp B - Thalassemia & Hemo Eval PX-3018302002 CDM 83020 CPT 301 RC inpatient 894 894 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES HDHP [308136802] 707.87 percent of total billed charges 554.28 849.3 Technical (Hospital) Services Ref Hemoglobin Elp B - Thalassemia & Hemo Eval PX-3018302002 CDM 83020 CPT 301 RC inpatient 894 894 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES EPO [308136803] 707.87 percent of total billed charges 554.28 849.3 Technical (Hospital) Services Ref Hemoglobin Elp B - Thalassemia & Hemo Eval PX-3018302002 CDM 83020 CPT 301 RC inpatient 894 894 HEALTHPARTNERS SX009 HEALTHPARTNERS 707.87 percent of total billed charges 554.28 849.3 Technical (Hospital) Services Ref Hemoglobin Elp B - Thalassemia & Hemo Eval PX-3018302002 CDM 83020 CPT 301 RC inpatient 894 894 MEDICA (COMMERCIAL) 94265 [3081118] MEDICA CLAIMS [308111801] 804.6 percent of total billed charges 554.28 849.3 Technical (Hospital) Services Ref Hemoglobin Elp B - Thalassemia & Hemo Eval PX-3018302002 CDM 83020 CPT 301 RC inpatient 894 894 MULTIPLAN INC 34080 [3081285] MULTIPLAN INC [308128501] 849.3 percent of total billed charges 554.28 849.3 Technical (Hospital) Services Ref Hemoglobin Elp B - Thalassemia & Hemo Eval PX-3018302002 CDM 83020 CPT 301 RC inpatient 894 894 CIGNA 62308 [3081051] CIGNA 62308 [308105105] 707.87 percent of total billed charges 554.28 849.3 Technical (Hospital) Services Ref Hemoglobin Elp B - Thalassemia & Hemo Eval PX-3018302002 CDM 83020 CPT 301 RC inpatient 894 894 CIGNA 62308 [3081051] CIGNA STATE OF WYOMING [308105107] 707.87 percent of total billed charges 554.28 849.3 Technical (Hospital) Services Ref Hemoglobin Elp B - Thalassemia & Hemo Eval PX-3018302002 CDM 83020 CPT 301 RC outpatient 894 894 MEDICA (COMMERCIAL) 94265 [3081118] MEDICA CLAIMS [308111801] 804.6 percent of total billed charges 554.28 849.3 Technical (Hospital) Services Ref Hemoglobin Elp B - Thalassemia & Hemo Eval PX-3018302002 CDM 83020 CPT 301 RC outpatient 894 894 CIGNA 62308 [3081051] CIGNA 62308 [308105105] 715.2 percent of total billed charges 554.28 849.3 Technical (Hospital) Services Ref Hemoglobin Elp B - Thalassemia & Hemo Eval PX-3018302002 CDM 83020 CPT 301 RC outpatient 894 894 CIGNA 62308 [3081051] CIGNA STATE OF WYOMING [308105107] 715.2 percent of total billed charges 554.28 849.3 Technical (Hospital) Services Ref Hemoglobin Elp B - Thalassemia & Hemo Eval PX-3018302002 CDM 83020 CPT 301 RC outpatient 894 894 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES PPO [308136801] 715.2 percent of total billed charges 554.28 849.3 Technical (Hospital) Services Ref Hemoglobin Elp B - Thalassemia & Hemo Eval PX-3018302002 CDM 83020 CPT 301 RC outpatient 894 894 MULTIPLAN INC 34080 [3081285] MULTIPLAN INC [308128501] 849.3 percent of total billed charges 554.28 849.3 Technical (Hospital) Services Ref Hemoglobin Elp B - Thalassemia & Hemo Eval PX-3018302002 CDM 83020 CPT 301 RC outpatient 894 894 BLUE CROSS BLUE SHIELD WELLMARK SB889 [3081026] BCBS WYOMING [308102603] 849.3 percent of total billed charges 554.28 849.3 Technical (Hospital) Services Ref Hemoglobin Elp B - Thalassemia & Hemo Eval PX-3018302002 CDM 83020 CPT 301 RC outpatient 894 894 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES EPO [308136803] 715.2 percent of total billed charges 554.28 849.3 Technical (Hospital) Services Ref Hemoglobin Elp B - Thalassemia & Hemo Eval PX-3018302002 CDM 83020 CPT 301 RC outpatient 894 894 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES HDHP [308136802] 715.2 percent of total billed charges 554.28 849.3 Technical (Hospital) Services Ref Hemoglobin Elp B - Thalassemia & Hemo Eval PX-3018302002 CDM 83020 CPT 301 RC outpatient 894 894 HEALTHPARTNERS SX009 HEALTHPARTNERS 715.2 percent of total billed charges 554.28 849.3 Technical (Hospital) Services Ref Hemoglobin Elp B - Thalassemia & Hemo Eval PX-3018302002 CDM 83020 CPT 301 RC outpatient 894 894 UNITED HEALTHCARE (COMMERCIAL) [3081199] UNITED HEALTHCARE 87726 [308119901] 554.28 percent of total billed charges 554.28 849.3 Technical (Hospital) Services "Quantitative Screen, Metals" PX-3018301800 CDM 83018 CPT 301 RC inpatient 245 245 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES HDHP [308136802] 193.99 percent of total billed charges 151.9 232.75 Technical (Hospital) Services "Quantitative Screen, Metals" PX-3018301800 CDM 83018 CPT 301 RC inpatient 245 245 BLUE CROSS BLUE SHIELD WELLMARK SB889 [3081026] BCBS WYOMING [308102603] 232.75 percent of total billed charges 151.9 232.75 Technical (Hospital) Services "Quantitative Screen, Metals" PX-3018301800 CDM 83018 CPT 301 RC inpatient 245 245 UNITED HEALTHCARE (COMMERCIAL) [3081199] UNITED HEALTHCARE 87726 [308119901] 151.9 percent of total billed charges 151.9 232.75 Technical (Hospital) Services "Quantitative Screen, Metals" PX-3018301800 CDM 83018 CPT 301 RC inpatient 245 245 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES PPO [308136801] 193.99 percent of total billed charges 151.9 232.75 Technical (Hospital) Services "Quantitative Screen, Metals" PX-3018301800 CDM 83018 CPT 301 RC inpatient 245 245 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES EPO [308136803] 193.99 percent of total billed charges 151.9 232.75 Technical (Hospital) Services "Quantitative Screen, Metals" PX-3018301800 CDM 83018 CPT 301 RC inpatient 245 245 HEALTHPARTNERS SX009 HEALTHPARTNERS 193.99 percent of total billed charges 151.9 232.75 Technical (Hospital) Services "Quantitative Screen, Metals" PX-3018301800 CDM 83018 CPT 301 RC inpatient 245 245 CIGNA 62308 [3081051] CIGNA 62308 [308105105] 193.99 percent of total billed charges 151.9 232.75 Technical (Hospital) Services "Quantitative Screen, Metals" PX-3018301800 CDM 83018 CPT 301 RC inpatient 245 245 CIGNA 62308 [3081051] CIGNA STATE OF WYOMING [308105107] 193.99 percent of total billed charges 151.9 232.75 Technical (Hospital) Services "Quantitative Screen, Metals" PX-3018301800 CDM 83018 CPT 301 RC inpatient 245 245 MEDICA (COMMERCIAL) 94265 [3081118] MEDICA CLAIMS [308111801] 220.5 percent of total billed charges 151.9 232.75 Technical (Hospital) Services "Quantitative Screen, Metals" PX-3018301800 CDM 83018 CPT 301 RC inpatient 245 245 MULTIPLAN INC 34080 [3081285] MULTIPLAN INC [308128501] 232.75 percent of total billed charges 151.9 232.75 Technical (Hospital) Services "Quantitative Screen, Metals" PX-3018301800 CDM 83018 CPT 301 RC outpatient 245 245 MULTIPLAN INC 34080 [3081285] MULTIPLAN INC [308128501] 232.75 percent of total billed charges 151.9 232.75 Technical (Hospital) Services "Quantitative Screen, Metals" PX-3018301800 CDM 83018 CPT 301 RC outpatient 245 245 BLUE CROSS BLUE SHIELD WELLMARK SB889 [3081026] BCBS WYOMING [308102603] 232.75 percent of total billed charges 151.9 232.75 Technical (Hospital) Services "Quantitative Screen, Metals" PX-3018301800 CDM 83018 CPT 301 RC outpatient 245 245 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES EPO [308136803] 196 percent of total billed charges 151.9 232.75 Technical (Hospital) Services "Quantitative Screen, Metals" PX-3018301800 CDM 83018 CPT 301 RC outpatient 245 245 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES HDHP [308136802] 196 percent of total billed charges 151.9 232.75 Technical (Hospital) Services "Quantitative Screen, Metals" PX-3018301800 CDM 83018 CPT 301 RC outpatient 245 245 HEALTHPARTNERS SX009 HEALTHPARTNERS 196 percent of total billed charges 151.9 232.75 Technical (Hospital) Services "Quantitative Screen, Metals" PX-3018301800 CDM 83018 CPT 301 RC outpatient 245 245 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES PPO [308136801] 196 percent of total billed charges 151.9 232.75 Technical (Hospital) Services "Quantitative Screen, Metals" PX-3018301800 CDM 83018 CPT 301 RC outpatient 245 245 UNITED HEALTHCARE (COMMERCIAL) [3081199] UNITED HEALTHCARE 87726 [308119901] 151.9 percent of total billed charges 151.9 232.75 Technical (Hospital) Services "Quantitative Screen, Metals" PX-3018301800 CDM 83018 CPT 301 RC outpatient 245 245 MEDICA (COMMERCIAL) 94265 [3081118] MEDICA CLAIMS [308111801] 220.5 percent of total billed charges 151.9 232.75 Technical (Hospital) Services "Quantitative Screen, Metals" PX-3018301800 CDM 83018 CPT 301 RC outpatient 245 245 CIGNA 62308 [3081051] CIGNA 62308 [308105105] 196 percent of total billed charges 151.9 232.75 Technical (Hospital) Services "Quantitative Screen, Metals" PX-3018301800 CDM 83018 CPT 301 RC outpatient 245 245 CIGNA 62308 [3081051] CIGNA STATE OF WYOMING [308105107] 196 percent of total billed charges 151.9 232.75 Technical (Hospital) Services Ref Haptoglobin PX-3018301000 CDM 83010 CPT 301 RC outpatient 156 156 UNITED HEALTHCARE (COMMERCIAL) [3081199] UNITED HEALTHCARE 87726 [308119901] 96.72 percent of total billed charges 96.72 148.2 Technical (Hospital) Services Ref Haptoglobin PX-3018301000 CDM 83010 CPT 301 RC outpatient 156 156 HEALTHPARTNERS SX009 HEALTHPARTNERS 124.8 percent of total billed charges 96.72 148.2 Technical (Hospital) Services Ref Haptoglobin PX-3018301000 CDM 83010 CPT 301 RC outpatient 156 156 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES PPO [308136801] 124.8 percent of total billed charges 96.72 148.2 Technical (Hospital) Services Ref Haptoglobin PX-3018301000 CDM 83010 CPT 301 RC outpatient 156 156 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES HDHP [308136802] 124.8 percent of total billed charges 96.72 148.2 Technical (Hospital) Services Ref Haptoglobin PX-3018301000 CDM 83010 CPT 301 RC outpatient 156 156 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES EPO [308136803] 124.8 percent of total billed charges 96.72 148.2 Technical (Hospital) Services Ref Haptoglobin PX-3018301000 CDM 83010 CPT 301 RC outpatient 156 156 BLUE CROSS BLUE SHIELD WELLMARK SB889 [3081026] BCBS WYOMING [308102603] 148.2 percent of total billed charges 96.72 148.2 Technical (Hospital) Services Ref Haptoglobin PX-3018301000 CDM 83010 CPT 301 RC outpatient 156 156 MULTIPLAN INC 34080 [3081285] MULTIPLAN INC [308128501] 148.2 percent of total billed charges 96.72 148.2 Technical (Hospital) Services Ref Haptoglobin PX-3018301000 CDM 83010 CPT 301 RC outpatient 156 156 CIGNA 62308 [3081051] CIGNA 62308 [308105105] 124.8 percent of total billed charges 96.72 148.2 Technical (Hospital) Services Ref Haptoglobin PX-3018301000 CDM 83010 CPT 301 RC outpatient 156 156 CIGNA 62308 [3081051] CIGNA STATE OF WYOMING [308105107] 124.8 percent of total billed charges 96.72 148.2 Technical (Hospital) Services Ref Haptoglobin PX-3018301000 CDM 83010 CPT 301 RC outpatient 156 156 MEDICA (COMMERCIAL) 94265 [3081118] MEDICA CLAIMS [308111801] 140.4 percent of total billed charges 96.72 148.2 Technical (Hospital) Services Ref Haptoglobin PX-3018301000 CDM 83010 CPT 301 RC inpatient 156 156 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES PPO [308136801] 123.52 percent of total billed charges 96.72 148.2 Technical (Hospital) Services Ref Haptoglobin PX-3018301000 CDM 83010 CPT 301 RC inpatient 156 156 UNITED HEALTHCARE (COMMERCIAL) [3081199] UNITED HEALTHCARE 87726 [308119901] 96.72 percent of total billed charges 96.72 148.2 Technical (Hospital) Services Ref Haptoglobin PX-3018301000 CDM 83010 CPT 301 RC inpatient 156 156 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES HDHP [308136802] 123.52 percent of total billed charges 96.72 148.2 Technical (Hospital) Services Ref Haptoglobin PX-3018301000 CDM 83010 CPT 301 RC inpatient 156 156 BLUE CROSS BLUE SHIELD WELLMARK SB889 [3081026] BCBS WYOMING [308102603] 148.2 percent of total billed charges 96.72 148.2 Technical (Hospital) Services Ref Haptoglobin PX-3018301000 CDM 83010 CPT 301 RC inpatient 156 156 HEALTHPARTNERS SX009 HEALTHPARTNERS 123.52 percent of total billed charges 96.72 148.2 Technical (Hospital) Services Ref Haptoglobin PX-3018301000 CDM 83010 CPT 301 RC inpatient 156 156 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES EPO [308136803] 123.52 percent of total billed charges 96.72 148.2 Technical (Hospital) Services Ref Haptoglobin PX-3018301000 CDM 83010 CPT 301 RC inpatient 156 156 CIGNA 62308 [3081051] CIGNA STATE OF WYOMING [308105107] 123.52 percent of total billed charges 96.72 148.2 Technical (Hospital) Services Ref Haptoglobin PX-3018301000 CDM 83010 CPT 301 RC inpatient 156 156 CIGNA 62308 [3081051] CIGNA 62308 [308105105] 123.52 percent of total billed charges 96.72 148.2 Technical (Hospital) Services Ref Haptoglobin PX-3018301000 CDM 83010 CPT 301 RC inpatient 156 156 MULTIPLAN INC 34080 [3081285] MULTIPLAN INC [308128501] 148.2 percent of total billed charges 96.72 148.2 Technical (Hospital) Services Ref Haptoglobin PX-3018301000 CDM 83010 CPT 301 RC inpatient 156 156 MEDICA (COMMERCIAL) 94265 [3081118] MEDICA CLAIMS [308111801] 140.4 percent of total billed charges 96.72 148.2 Technical (Hospital) Services HC Haptoglobin PX-3018301002 CDM 83010 CPT 301 RC outpatient 131 131 MULTIPLAN INC 34080 [3081285] MULTIPLAN INC [308128501] 124.45 percent of total billed charges 81.22 124.45 Technical (Hospital) Services HC Haptoglobin PX-3018301002 CDM 83010 CPT 301 RC outpatient 131 131 BLUE CROSS BLUE SHIELD WELLMARK SB889 [3081026] BCBS WYOMING [308102603] 124.45 percent of total billed charges 81.22 124.45 Technical (Hospital) Services HC Haptoglobin PX-3018301002 CDM 83010 CPT 301 RC outpatient 131 131 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES EPO [308136803] 104.8 percent of total billed charges 81.22 124.45 Technical (Hospital) Services HC Haptoglobin PX-3018301002 CDM 83010 CPT 301 RC outpatient 131 131 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES HDHP [308136802] 104.8 percent of total billed charges 81.22 124.45 Technical (Hospital) Services HC Haptoglobin PX-3018301002 CDM 83010 CPT 301 RC outpatient 131 131 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES PPO [308136801] 104.8 percent of total billed charges 81.22 124.45 Technical (Hospital) Services HC Haptoglobin PX-3018301002 CDM 83010 CPT 301 RC outpatient 131 131 HEALTHPARTNERS SX009 HEALTHPARTNERS 104.8 percent of total billed charges 81.22 124.45 Technical (Hospital) Services HC Haptoglobin PX-3018301002 CDM 83010 CPT 301 RC outpatient 131 131 UNITED HEALTHCARE (COMMERCIAL) [3081199] UNITED HEALTHCARE 87726 [308119901] 81.22 percent of total billed charges 81.22 124.45 Technical (Hospital) Services HC Haptoglobin PX-3018301002 CDM 83010 CPT 301 RC outpatient 131 131 MEDICA (COMMERCIAL) 94265 [3081118] MEDICA CLAIMS [308111801] 117.9 percent of total billed charges 81.22 124.45 Technical (Hospital) Services HC Haptoglobin PX-3018301002 CDM 83010 CPT 301 RC outpatient 131 131 CIGNA 62308 [3081051] CIGNA 62308 [308105105] 104.8 percent of total billed charges 81.22 124.45 Technical (Hospital) Services HC Haptoglobin PX-3018301002 CDM 83010 CPT 301 RC outpatient 131 131 CIGNA 62308 [3081051] CIGNA STATE OF WYOMING [308105107] 104.8 percent of total billed charges 81.22 124.45 Technical (Hospital) Services HC Haptoglobin PX-3018301002 CDM 83010 CPT 301 RC inpatient 131 131 CIGNA 62308 [3081051] CIGNA 62308 [308105105] 103.73 percent of total billed charges 81.22 124.45 Technical (Hospital) Services HC Haptoglobin PX-3018301002 CDM 83010 CPT 301 RC inpatient 131 131 CIGNA 62308 [3081051] CIGNA STATE OF WYOMING [308105107] 103.73 percent of total billed charges 81.22 124.45 Technical (Hospital) Services HC Haptoglobin PX-3018301002 CDM 83010 CPT 301 RC inpatient 131 131 MULTIPLAN INC 34080 [3081285] MULTIPLAN INC [308128501] 124.45 percent of total billed charges 81.22 124.45 Technical (Hospital) Services HC Haptoglobin PX-3018301002 CDM 83010 CPT 301 RC inpatient 131 131 MEDICA (COMMERCIAL) 94265 [3081118] MEDICA CLAIMS [308111801] 117.9 percent of total billed charges 81.22 124.45 Technical (Hospital) Services HC Haptoglobin PX-3018301002 CDM 83010 CPT 301 RC inpatient 131 131 HEALTHPARTNERS SX009 HEALTHPARTNERS 103.73 percent of total billed charges 81.22 124.45 Technical (Hospital) Services HC Haptoglobin PX-3018301002 CDM 83010 CPT 301 RC inpatient 131 131 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES EPO [308136803] 103.73 percent of total billed charges 81.22 124.45 Technical (Hospital) Services HC Haptoglobin PX-3018301002 CDM 83010 CPT 301 RC inpatient 131 131 UNITED HEALTHCARE (COMMERCIAL) [3081199] UNITED HEALTHCARE 87726 [308119901] 81.22 percent of total billed charges 81.22 124.45 Technical (Hospital) Services HC Haptoglobin PX-3018301002 CDM 83010 CPT 301 RC inpatient 131 131 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES PPO [308136801] 103.73 percent of total billed charges 81.22 124.45 Technical (Hospital) Services HC Haptoglobin PX-3018301002 CDM 83010 CPT 301 RC inpatient 131 131 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES HDHP [308136802] 103.73 percent of total billed charges 81.22 124.45 Technical (Hospital) Services HC Haptoglobin PX-3018301002 CDM 83010 CPT 301 RC inpatient 131 131 BLUE CROSS BLUE SHIELD WELLMARK SB889 [3081026] BCBS WYOMING [308102603] 124.45 percent of total billed charges 81.22 124.45 Technical (Hospital) Services Ref Luteinzine Hormone (Lh) PX-3018300200 CDM 83002 CPT 301 RC inpatient 204 204 CIGNA 62308 [3081051] CIGNA 62308 [308105105] 161.53 percent of total billed charges 126.48 193.8 Technical (Hospital) Services Ref Luteinzine Hormone (Lh) PX-3018300200 CDM 83002 CPT 301 RC inpatient 204 204 CIGNA 62308 [3081051] CIGNA STATE OF WYOMING [308105107] 161.53 percent of total billed charges 126.48 193.8 Technical (Hospital) Services Ref Luteinzine Hormone (Lh) PX-3018300200 CDM 83002 CPT 301 RC inpatient 204 204 HEALTHPARTNERS SX009 HEALTHPARTNERS 161.53 percent of total billed charges 126.48 193.8 Technical (Hospital) Services Ref Luteinzine Hormone (Lh) PX-3018300200 CDM 83002 CPT 301 RC inpatient 204 204 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES EPO [308136803] 161.53 percent of total billed charges 126.48 193.8 Technical (Hospital) Services Ref Luteinzine Hormone (Lh) PX-3018300200 CDM 83002 CPT 301 RC inpatient 204 204 MEDICA (COMMERCIAL) 94265 [3081118] MEDICA CLAIMS [308111801] 183.6 percent of total billed charges 126.48 193.8 Technical (Hospital) Services Ref Luteinzine Hormone (Lh) PX-3018300200 CDM 83002 CPT 301 RC inpatient 204 204 MULTIPLAN INC 34080 [3081285] MULTIPLAN INC [308128501] 193.8 percent of total billed charges 126.48 193.8 Technical (Hospital) Services Ref Luteinzine Hormone (Lh) PX-3018300200 CDM 83002 CPT 301 RC inpatient 204 204 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES HDHP [308136802] 161.53 percent of total billed charges 126.48 193.8 Technical (Hospital) Services Ref Luteinzine Hormone (Lh) PX-3018300200 CDM 83002 CPT 301 RC inpatient 204 204 BLUE CROSS BLUE SHIELD WELLMARK SB889 [3081026] BCBS WYOMING [308102603] 193.8 percent of total billed charges 126.48 193.8 Technical (Hospital) Services Ref Luteinzine Hormone (Lh) PX-3018300200 CDM 83002 CPT 301 RC inpatient 204 204 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES PPO [308136801] 161.53 percent of total billed charges 126.48 193.8 Technical (Hospital) Services Ref Luteinzine Hormone (Lh) PX-3018300200 CDM 83002 CPT 301 RC inpatient 204 204 UNITED HEALTHCARE (COMMERCIAL) [3081199] UNITED HEALTHCARE 87726 [308119901] 126.48 percent of total billed charges 126.48 193.8 Technical (Hospital) Services Ref Luteinzine Hormone (Lh) PX-3018300200 CDM 83002 CPT 301 RC outpatient 204 204 HEALTHPARTNERS SX009 HEALTHPARTNERS 163.2 percent of total billed charges 126.48 193.8 Technical (Hospital) Services Ref Luteinzine Hormone (Lh) PX-3018300200 CDM 83002 CPT 301 RC outpatient 204 204 UNITED HEALTHCARE (COMMERCIAL) [3081199] UNITED HEALTHCARE 87726 [308119901] 126.48 percent of total billed charges 126.48 193.8 Technical (Hospital) Services Ref Luteinzine Hormone (Lh) PX-3018300200 CDM 83002 CPT 301 RC outpatient 204 204 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES PPO [308136801] 163.2 percent of total billed charges 126.48 193.8 Technical (Hospital) Services Ref Luteinzine Hormone (Lh) PX-3018300200 CDM 83002 CPT 301 RC outpatient 204 204 BLUE CROSS BLUE SHIELD WELLMARK SB889 [3081026] BCBS WYOMING [308102603] 193.8 percent of total billed charges 126.48 193.8 Technical (Hospital) Services Ref Luteinzine Hormone (Lh) PX-3018300200 CDM 83002 CPT 301 RC outpatient 204 204 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES HDHP [308136802] 163.2 percent of total billed charges 126.48 193.8 Technical (Hospital) Services Ref Luteinzine Hormone (Lh) PX-3018300200 CDM 83002 CPT 301 RC outpatient 204 204 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES EPO [308136803] 163.2 percent of total billed charges 126.48 193.8 Technical (Hospital) Services Ref Luteinzine Hormone (Lh) PX-3018300200 CDM 83002 CPT 301 RC outpatient 204 204 MULTIPLAN INC 34080 [3081285] MULTIPLAN INC [308128501] 193.8 percent of total billed charges 126.48 193.8 Technical (Hospital) Services Ref Luteinzine Hormone (Lh) PX-3018300200 CDM 83002 CPT 301 RC outpatient 204 204 MEDICA (COMMERCIAL) 94265 [3081118] MEDICA CLAIMS [308111801] 183.6 percent of total billed charges 126.48 193.8 Technical (Hospital) Services Ref Luteinzine Hormone (Lh) PX-3018300200 CDM 83002 CPT 301 RC outpatient 204 204 CIGNA 62308 [3081051] CIGNA 62308 [308105105] 163.2 percent of total billed charges 126.48 193.8 Technical (Hospital) Services Ref Luteinzine Hormone (Lh) PX-3018300200 CDM 83002 CPT 301 RC outpatient 204 204 CIGNA 62308 [3081051] CIGNA STATE OF WYOMING [308105107] 163.2 percent of total billed charges 126.48 193.8 Technical (Hospital) Services Luteinizing Hormone PX-3018300201 CDM 83002 CPT 301 RC outpatient 204 204 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES PPO [308136801] 163.2 percent of total billed charges 126.48 193.8 Technical (Hospital) Services Luteinizing Hormone PX-3018300201 CDM 83002 CPT 301 RC outpatient 204 204 BLUE CROSS BLUE SHIELD WELLMARK SB889 [3081026] BCBS WYOMING [308102603] 193.8 percent of total billed charges 126.48 193.8 Technical (Hospital) Services Luteinizing Hormone PX-3018300201 CDM 83002 CPT 301 RC outpatient 204 204 MULTIPLAN INC 34080 [3081285] MULTIPLAN INC [308128501] 193.8 percent of total billed charges 126.48 193.8 Technical (Hospital) Services Luteinizing Hormone PX-3018300201 CDM 83002 CPT 301 RC outpatient 204 204 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES HDHP [308136802] 163.2 percent of total billed charges 126.48 193.8 Technical (Hospital) Services Luteinizing Hormone PX-3018300201 CDM 83002 CPT 301 RC outpatient 204 204 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES EPO [308136803] 163.2 percent of total billed charges 126.48 193.8 Technical (Hospital) Services Luteinizing Hormone PX-3018300201 CDM 83002 CPT 301 RC outpatient 204 204 UNITED HEALTHCARE (COMMERCIAL) [3081199] UNITED HEALTHCARE 87726 [308119901] 126.48 percent of total billed charges 126.48 193.8 Technical (Hospital) Services Luteinizing Hormone PX-3018300201 CDM 83002 CPT 301 RC outpatient 204 204 HEALTHPARTNERS SX009 HEALTHPARTNERS 163.2 percent of total billed charges 126.48 193.8 Technical (Hospital) Services Luteinizing Hormone PX-3018300201 CDM 83002 CPT 301 RC outpatient 204 204 CIGNA 62308 [3081051] CIGNA 62308 [308105105] 163.2 percent of total billed charges 126.48 193.8 Technical (Hospital) Services Luteinizing Hormone PX-3018300201 CDM 83002 CPT 301 RC outpatient 204 204 CIGNA 62308 [3081051] CIGNA STATE OF WYOMING [308105107] 163.2 percent of total billed charges 126.48 193.8 Technical (Hospital) Services Luteinizing Hormone PX-3018300201 CDM 83002 CPT 301 RC outpatient 204 204 MEDICA (COMMERCIAL) 94265 [3081118] MEDICA CLAIMS [308111801] 183.6 percent of total billed charges 126.48 193.8 Technical (Hospital) Services Luteinizing Hormone PX-3018300201 CDM 83002 CPT 301 RC inpatient 204 204 BLUE CROSS BLUE SHIELD WELLMARK SB889 [3081026] BCBS WYOMING [308102603] 193.8 percent of total billed charges 126.48 193.8 Technical (Hospital) Services Luteinizing Hormone PX-3018300201 CDM 83002 CPT 301 RC inpatient 204 204 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES HDHP [308136802] 161.53 percent of total billed charges 126.48 193.8 Technical (Hospital) Services Luteinizing Hormone PX-3018300201 CDM 83002 CPT 301 RC inpatient 204 204 UNITED HEALTHCARE (COMMERCIAL) [3081199] UNITED HEALTHCARE 87726 [308119901] 126.48 percent of total billed charges 126.48 193.8 Technical (Hospital) Services Luteinizing Hormone PX-3018300201 CDM 83002 CPT 301 RC inpatient 204 204 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES PPO [308136801] 161.53 percent of total billed charges 126.48 193.8 Technical (Hospital) Services Luteinizing Hormone PX-3018300201 CDM 83002 CPT 301 RC inpatient 204 204 MEDICA (COMMERCIAL) 94265 [3081118] MEDICA CLAIMS [308111801] 183.6 percent of total billed charges 126.48 193.8 Technical (Hospital) Services Luteinizing Hormone PX-3018300201 CDM 83002 CPT 301 RC inpatient 204 204 MULTIPLAN INC 34080 [3081285] MULTIPLAN INC [308128501] 193.8 percent of total billed charges 126.48 193.8 Technical (Hospital) Services Luteinizing Hormone PX-3018300201 CDM 83002 CPT 301 RC inpatient 204 204 CIGNA 62308 [3081051] CIGNA 62308 [308105105] 161.53 percent of total billed charges 126.48 193.8 Technical (Hospital) Services Luteinizing Hormone PX-3018300201 CDM 83002 CPT 301 RC inpatient 204 204 CIGNA 62308 [3081051] CIGNA STATE OF WYOMING [308105107] 161.53 percent of total billed charges 126.48 193.8 Technical (Hospital) Services Luteinizing Hormone PX-3018300201 CDM 83002 CPT 301 RC inpatient 204 204 HEALTHPARTNERS SX009 HEALTHPARTNERS 161.53 percent of total billed charges 126.48 193.8 Technical (Hospital) Services Luteinizing Hormone PX-3018300201 CDM 83002 CPT 301 RC inpatient 204 204 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES EPO [308136803] 161.53 percent of total billed charges 126.48 193.8 Technical (Hospital) Services FSH PX-3018300100 CDM 83001 CPT 301 RC inpatient 197 197 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES HDHP [308136802] 155.98 percent of total billed charges 122.14 187.15 Technical (Hospital) Services FSH PX-3018300100 CDM 83001 CPT 301 RC inpatient 197 197 BLUE CROSS BLUE SHIELD WELLMARK SB889 [3081026] BCBS WYOMING [308102603] 187.15 percent of total billed charges 122.14 187.15 Technical (Hospital) Services FSH PX-3018300100 CDM 83001 CPT 301 RC inpatient 197 197 UNITED HEALTHCARE (COMMERCIAL) [3081199] UNITED HEALTHCARE 87726 [308119901] 122.14 percent of total billed charges 122.14 187.15 Technical (Hospital) Services FSH PX-3018300100 CDM 83001 CPT 301 RC inpatient 197 197 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES PPO [308136801] 155.98 percent of total billed charges 122.14 187.15 Technical (Hospital) Services FSH PX-3018300100 CDM 83001 CPT 301 RC inpatient 197 197 MULTIPLAN INC 34080 [3081285] MULTIPLAN INC [308128501] 187.15 percent of total billed charges 122.14 187.15 Technical (Hospital) Services FSH PX-3018300100 CDM 83001 CPT 301 RC inpatient 197 197 MEDICA (COMMERCIAL) 94265 [3081118] MEDICA CLAIMS [308111801] 177.3 percent of total billed charges 122.14 187.15 Technical (Hospital) Services FSH PX-3018300100 CDM 83001 CPT 301 RC inpatient 197 197 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES EPO [308136803] 155.98 percent of total billed charges 122.14 187.15 Technical (Hospital) Services FSH PX-3018300100 CDM 83001 CPT 301 RC inpatient 197 197 HEALTHPARTNERS SX009 HEALTHPARTNERS 155.98 percent of total billed charges 122.14 187.15 Technical (Hospital) Services FSH PX-3018300100 CDM 83001 CPT 301 RC inpatient 197 197 CIGNA 62308 [3081051] CIGNA 62308 [308105105] 155.98 percent of total billed charges 122.14 187.15 Technical (Hospital) Services FSH PX-3018300100 CDM 83001 CPT 301 RC inpatient 197 197 CIGNA 62308 [3081051] CIGNA STATE OF WYOMING [308105107] 155.98 percent of total billed charges 122.14 187.15 Technical (Hospital) Services FSH PX-3018300100 CDM 83001 CPT 301 RC outpatient 197 197 CIGNA 62308 [3081051] CIGNA 62308 [308105105] 157.6 percent of total billed charges 122.14 187.15 Technical (Hospital) Services FSH PX-3018300100 CDM 83001 CPT 301 RC outpatient 197 197 CIGNA 62308 [3081051] CIGNA STATE OF WYOMING [308105107] 157.6 percent of total billed charges 122.14 187.15 Technical (Hospital) Services FSH PX-3018300100 CDM 83001 CPT 301 RC outpatient 197 197 MEDICA (COMMERCIAL) 94265 [3081118] MEDICA CLAIMS [308111801] 177.3 percent of total billed charges 122.14 187.15 Technical (Hospital) Services FSH PX-3018300100 CDM 83001 CPT 301 RC outpatient 197 197 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES PPO [308136801] 157.6 percent of total billed charges 122.14 187.15 Technical (Hospital) Services FSH PX-3018300100 CDM 83001 CPT 301 RC outpatient 197 197 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES EPO [308136803] 157.6 percent of total billed charges 122.14 187.15 Technical (Hospital) Services FSH PX-3018300100 CDM 83001 CPT 301 RC outpatient 197 197 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES HDHP [308136802] 157.6 percent of total billed charges 122.14 187.15 Technical (Hospital) Services FSH PX-3018300100 CDM 83001 CPT 301 RC outpatient 197 197 BLUE CROSS BLUE SHIELD WELLMARK SB889 [3081026] BCBS WYOMING [308102603] 187.15 percent of total billed charges 122.14 187.15 Technical (Hospital) Services FSH PX-3018300100 CDM 83001 CPT 301 RC outpatient 197 197 MULTIPLAN INC 34080 [3081285] MULTIPLAN INC [308128501] 187.15 percent of total billed charges 122.14 187.15 Technical (Hospital) Services FSH PX-3018300100 CDM 83001 CPT 301 RC outpatient 197 197 HEALTHPARTNERS SX009 HEALTHPARTNERS 157.6 percent of total billed charges 122.14 187.15 Technical (Hospital) Services FSH PX-3018300100 CDM 83001 CPT 301 RC outpatient 197 197 UNITED HEALTHCARE (COMMERCIAL) [3081199] UNITED HEALTHCARE 87726 [308119901] 122.14 percent of total billed charges 122.14 187.15 Technical (Hospital) Services Ref Fructosamine PX-3018298500 CDM 82985 CPT 301 RC inpatient 81 81 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES EPO [308136803] 64.14 percent of total billed charges 50.22 76.95 Technical (Hospital) Services Ref Fructosamine PX-3018298500 CDM 82985 CPT 301 RC inpatient 81 81 HEALTHPARTNERS SX009 HEALTHPARTNERS 64.14 percent of total billed charges 50.22 76.95 Technical (Hospital) Services Ref Fructosamine PX-3018298500 CDM 82985 CPT 301 RC inpatient 81 81 MULTIPLAN INC 34080 [3081285] MULTIPLAN INC [308128501] 76.95 percent of total billed charges 50.22 76.95 Technical (Hospital) Services Ref Fructosamine PX-3018298500 CDM 82985 CPT 301 RC inpatient 81 81 MEDICA (COMMERCIAL) 94265 [3081118] MEDICA CLAIMS [308111801] 72.9 percent of total billed charges 50.22 76.95 Technical (Hospital) Services Ref Fructosamine PX-3018298500 CDM 82985 CPT 301 RC inpatient 81 81 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES PPO [308136801] 64.14 percent of total billed charges 50.22 76.95 Technical (Hospital) Services Ref Fructosamine PX-3018298500 CDM 82985 CPT 301 RC inpatient 81 81 UNITED HEALTHCARE (COMMERCIAL) [3081199] UNITED HEALTHCARE 87726 [308119901] 50.22 percent of total billed charges 50.22 76.95 Technical (Hospital) Services Ref Fructosamine PX-3018298500 CDM 82985 CPT 301 RC inpatient 81 81 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES HDHP [308136802] 64.14 percent of total billed charges 50.22 76.95 Technical (Hospital) Services Ref Fructosamine PX-3018298500 CDM 82985 CPT 301 RC inpatient 81 81 BLUE CROSS BLUE SHIELD WELLMARK SB889 [3081026] BCBS WYOMING [308102603] 76.95 percent of total billed charges 50.22 76.95 Technical (Hospital) Services Ref Fructosamine PX-3018298500 CDM 82985 CPT 301 RC inpatient 81 81 CIGNA 62308 [3081051] CIGNA 62308 [308105105] 64.14 percent of total billed charges 50.22 76.95 Technical (Hospital) Services Ref Fructosamine PX-3018298500 CDM 82985 CPT 301 RC inpatient 81 81 CIGNA 62308 [3081051] CIGNA STATE OF WYOMING [308105107] 64.14 percent of total billed charges 50.22 76.95 Technical (Hospital) Services Ref Fructosamine PX-3018298500 CDM 82985 CPT 301 RC outpatient 81 81 MEDICA (COMMERCIAL) 94265 [3081118] MEDICA CLAIMS [308111801] 72.9 percent of total billed charges 50.22 76.95 Technical (Hospital) Services Ref Fructosamine PX-3018298500 CDM 82985 CPT 301 RC outpatient 81 81 CIGNA 62308 [3081051] CIGNA 62308 [308105105] 64.8 percent of total billed charges 50.22 76.95 Technical (Hospital) Services Ref Fructosamine PX-3018298500 CDM 82985 CPT 301 RC outpatient 81 81 CIGNA 62308 [3081051] CIGNA STATE OF WYOMING [308105107] 64.8 percent of total billed charges 50.22 76.95 Technical (Hospital) Services Ref Fructosamine PX-3018298500 CDM 82985 CPT 301 RC outpatient 81 81 UNITED HEALTHCARE (COMMERCIAL) [3081199] UNITED HEALTHCARE 87726 [308119901] 50.22 percent of total billed charges 50.22 76.95 Technical (Hospital) Services Ref Fructosamine PX-3018298500 CDM 82985 CPT 301 RC outpatient 81 81 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES PPO [308136801] 64.8 percent of total billed charges 50.22 76.95 Technical (Hospital) Services Ref Fructosamine PX-3018298500 CDM 82985 CPT 301 RC outpatient 81 81 HEALTHPARTNERS SX009 HEALTHPARTNERS 64.8 percent of total billed charges 50.22 76.95 Technical (Hospital) Services Ref Fructosamine PX-3018298500 CDM 82985 CPT 301 RC outpatient 81 81 MULTIPLAN INC 34080 [3081285] MULTIPLAN INC [308128501] 76.95 percent of total billed charges 50.22 76.95 Technical (Hospital) Services Ref Fructosamine PX-3018298500 CDM 82985 CPT 301 RC outpatient 81 81 BLUE CROSS BLUE SHIELD WELLMARK SB889 [3081026] BCBS WYOMING [308102603] 76.95 percent of total billed charges 50.22 76.95 Technical (Hospital) Services Ref Fructosamine PX-3018298500 CDM 82985 CPT 301 RC outpatient 81 81 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES EPO [308136803] 64.8 percent of total billed charges 50.22 76.95 Technical (Hospital) Services Ref Fructosamine PX-3018298500 CDM 82985 CPT 301 RC outpatient 81 81 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES HDHP [308136802] 64.8 percent of total billed charges 50.22 76.95 Technical (Hospital) Services Gamma Gt (Gtt) PX-3018297700 CDM 82977 CPT 301 RC inpatient 123 123 CIGNA 62308 [3081051] CIGNA 62308 [308105105] 97.39 percent of total billed charges 76.26 116.85 Technical (Hospital) Services Gamma Gt (Gtt) PX-3018297700 CDM 82977 CPT 301 RC inpatient 123 123 CIGNA 62308 [3081051] CIGNA STATE OF WYOMING [308105107] 97.39 percent of total billed charges 76.26 116.85 Technical (Hospital) Services Gamma Gt (Gtt) PX-3018297700 CDM 82977 CPT 301 RC inpatient 123 123 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES EPO [308136803] 97.39 percent of total billed charges 76.26 116.85 Technical (Hospital) Services Gamma Gt (Gtt) PX-3018297700 CDM 82977 CPT 301 RC inpatient 123 123 HEALTHPARTNERS SX009 HEALTHPARTNERS 97.39 percent of total billed charges 76.26 116.85 Technical (Hospital) Services Gamma Gt (Gtt) PX-3018297700 CDM 82977 CPT 301 RC inpatient 123 123 MEDICA (COMMERCIAL) 94265 [3081118] MEDICA CLAIMS [308111801] 110.7 percent of total billed charges 76.26 116.85 Technical (Hospital) Services Gamma Gt (Gtt) PX-3018297700 CDM 82977 CPT 301 RC inpatient 123 123 MULTIPLAN INC 34080 [3081285] MULTIPLAN INC [308128501] 116.85 percent of total billed charges 76.26 116.85 Technical (Hospital) Services Gamma Gt (Gtt) PX-3018297700 CDM 82977 CPT 301 RC inpatient 123 123 UNITED HEALTHCARE (COMMERCIAL) [3081199] UNITED HEALTHCARE 87726 [308119901] 76.26 percent of total billed charges 76.26 116.85 Technical (Hospital) Services Gamma Gt (Gtt) PX-3018297700 CDM 82977 CPT 301 RC inpatient 123 123 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES PPO [308136801] 97.39 percent of total billed charges 76.26 116.85 Technical (Hospital) Services Gamma Gt (Gtt) PX-3018297700 CDM 82977 CPT 301 RC inpatient 123 123 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES HDHP [308136802] 97.39 percent of total billed charges 76.26 116.85 Technical (Hospital) Services Gamma Gt (Gtt) PX-3018297700 CDM 82977 CPT 301 RC inpatient 123 123 BLUE CROSS BLUE SHIELD WELLMARK SB889 [3081026] BCBS WYOMING [308102603] 116.85 percent of total billed charges 76.26 116.85 Technical (Hospital) Services Gamma Gt (Gtt) PX-3018297700 CDM 82977 CPT 301 RC outpatient 123 123 MEDICA (COMMERCIAL) 94265 [3081118] MEDICA CLAIMS [308111801] 110.7 percent of total billed charges 76.26 116.85 Technical (Hospital) Services Gamma Gt (Gtt) PX-3018297700 CDM 82977 CPT 301 RC outpatient 123 123 CIGNA 62308 [3081051] CIGNA 62308 [308105105] 98.4 percent of total billed charges 76.26 116.85 Technical (Hospital) Services Gamma Gt (Gtt) PX-3018297700 CDM 82977 CPT 301 RC outpatient 123 123 CIGNA 62308 [3081051] CIGNA STATE OF WYOMING [308105107] 98.4 percent of total billed charges 76.26 116.85 Technical (Hospital) Services Gamma Gt (Gtt) PX-3018297700 CDM 82977 CPT 301 RC outpatient 123 123 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES PPO [308136801] 98.4 percent of total billed charges 76.26 116.85 Technical (Hospital) Services Gamma Gt (Gtt) PX-3018297700 CDM 82977 CPT 301 RC outpatient 123 123 MULTIPLAN INC 34080 [3081285] MULTIPLAN INC [308128501] 116.85 percent of total billed charges 76.26 116.85 Technical (Hospital) Services Gamma Gt (Gtt) PX-3018297700 CDM 82977 CPT 301 RC outpatient 123 123 BLUE CROSS BLUE SHIELD WELLMARK SB889 [3081026] BCBS WYOMING [308102603] 116.85 percent of total billed charges 76.26 116.85 Technical (Hospital) Services Gamma Gt (Gtt) PX-3018297700 CDM 82977 CPT 301 RC outpatient 123 123 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES EPO [308136803] 98.4 percent of total billed charges 76.26 116.85 Technical (Hospital) Services Gamma Gt (Gtt) PX-3018297700 CDM 82977 CPT 301 RC outpatient 123 123 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES HDHP [308136802] 98.4 percent of total billed charges 76.26 116.85 Technical (Hospital) Services Gamma Gt (Gtt) PX-3018297700 CDM 82977 CPT 301 RC outpatient 123 123 HEALTHPARTNERS SX009 HEALTHPARTNERS 98.4 percent of total billed charges 76.26 116.85 Technical (Hospital) Services Gamma Gt (Gtt) PX-3018297700 CDM 82977 CPT 301 RC outpatient 123 123 UNITED HEALTHCARE (COMMERCIAL) [3081199] UNITED HEALTHCARE 87726 [308119901] 76.26 percent of total billed charges 76.26 116.85 Technical (Hospital) Services Ref G 6 Pd Qn Rc PX-3018295500 CDM 82955 CPT 301 RC outpatient 156 156 MEDICA (COMMERCIAL) 94265 [3081118] MEDICA CLAIMS [308111801] 140.4 percent of total billed charges 96.72 148.2 Technical (Hospital) Services Ref G 6 Pd Qn Rc PX-3018295500 CDM 82955 CPT 301 RC outpatient 156 156 CIGNA 62308 [3081051] CIGNA 62308 [308105105] 124.8 percent of total billed charges 96.72 148.2 Technical (Hospital) Services Ref G 6 Pd Qn Rc PX-3018295500 CDM 82955 CPT 301 RC outpatient 156 156 CIGNA 62308 [3081051] CIGNA STATE OF WYOMING [308105107] 124.8 percent of total billed charges 96.72 148.2 Technical (Hospital) Services Ref G 6 Pd Qn Rc PX-3018295500 CDM 82955 CPT 301 RC outpatient 156 156 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES PPO [308136801] 124.8 percent of total billed charges 96.72 148.2 Technical (Hospital) Services Ref G 6 Pd Qn Rc PX-3018295500 CDM 82955 CPT 301 RC outpatient 156 156 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES HDHP [308136802] 124.8 percent of total billed charges 96.72 148.2 Technical (Hospital) Services Ref G 6 Pd Qn Rc PX-3018295500 CDM 82955 CPT 301 RC outpatient 156 156 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES EPO [308136803] 124.8 percent of total billed charges 96.72 148.2 Technical (Hospital) Services Ref G 6 Pd Qn Rc PX-3018295500 CDM 82955 CPT 301 RC outpatient 156 156 MULTIPLAN INC 34080 [3081285] MULTIPLAN INC [308128501] 148.2 percent of total billed charges 96.72 148.2 Technical (Hospital) Services Ref G 6 Pd Qn Rc PX-3018295500 CDM 82955 CPT 301 RC outpatient 156 156 BLUE CROSS BLUE SHIELD WELLMARK SB889 [3081026] BCBS WYOMING [308102603] 148.2 percent of total billed charges 96.72 148.2 Technical (Hospital) Services Ref G 6 Pd Qn Rc PX-3018295500 CDM 82955 CPT 301 RC outpatient 156 156 UNITED HEALTHCARE (COMMERCIAL) [3081199] UNITED HEALTHCARE 87726 [308119901] 96.72 percent of total billed charges 96.72 148.2 Technical (Hospital) Services Ref G 6 Pd Qn Rc PX-3018295500 CDM 82955 CPT 301 RC outpatient 156 156 HEALTHPARTNERS SX009 HEALTHPARTNERS 124.8 percent of total billed charges 96.72 148.2 Technical (Hospital) Services Ref G 6 Pd Qn Rc PX-3018295500 CDM 82955 CPT 301 RC inpatient 156 156 CIGNA 62308 [3081051] CIGNA 62308 [308105105] 123.52 percent of total billed charges 96.72 148.2 Technical (Hospital) Services Ref G 6 Pd Qn Rc PX-3018295500 CDM 82955 CPT 301 RC inpatient 156 156 CIGNA 62308 [3081051] CIGNA STATE OF WYOMING [308105107] 123.52 percent of total billed charges 96.72 148.2 Technical (Hospital) Services Ref G 6 Pd Qn Rc PX-3018295500 CDM 82955 CPT 301 RC inpatient 156 156 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES PPO [308136801] 123.52 percent of total billed charges 96.72 148.2 Technical (Hospital) Services Ref G 6 Pd Qn Rc PX-3018295500 CDM 82955 CPT 301 RC inpatient 156 156 UNITED HEALTHCARE (COMMERCIAL) [3081199] UNITED HEALTHCARE 87726 [308119901] 96.72 percent of total billed charges 96.72 148.2 Technical (Hospital) Services Ref G 6 Pd Qn Rc PX-3018295500 CDM 82955 CPT 301 RC inpatient 156 156 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES HDHP [308136802] 123.52 percent of total billed charges 96.72 148.2 Technical (Hospital) Services Ref G 6 Pd Qn Rc PX-3018295500 CDM 82955 CPT 301 RC inpatient 156 156 BLUE CROSS BLUE SHIELD WELLMARK SB889 [3081026] BCBS WYOMING [308102603] 148.2 percent of total billed charges 96.72 148.2 Technical (Hospital) Services Ref G 6 Pd Qn Rc PX-3018295500 CDM 82955 CPT 301 RC inpatient 156 156 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES EPO [308136803] 123.52 percent of total billed charges 96.72 148.2 Technical (Hospital) Services Ref G 6 Pd Qn Rc PX-3018295500 CDM 82955 CPT 301 RC inpatient 156 156 HEALTHPARTNERS SX009 HEALTHPARTNERS 123.52 percent of total billed charges 96.72 148.2 Technical (Hospital) Services Ref G 6 Pd Qn Rc PX-3018295500 CDM 82955 CPT 301 RC inpatient 156 156 MULTIPLAN INC 34080 [3081285] MULTIPLAN INC [308128501] 148.2 percent of total billed charges 96.72 148.2 Technical (Hospital) Services Ref G 6 Pd Qn Rc PX-3018295500 CDM 82955 CPT 301 RC inpatient 156 156 MEDICA (COMMERCIAL) 94265 [3081118] MEDICA CLAIMS [308111801] 140.4 percent of total billed charges 96.72 148.2 Technical (Hospital) Services Gluc Tolerance Addl >3 Spec PX-3018295200 CDM 82952 CPT 301 RC inpatient 63 63 CIGNA 62308 [3081051] CIGNA 62308 [308105105] 49.88 percent of total billed charges 39.06 59.85 Technical (Hospital) Services Gluc Tolerance Addl >3 Spec PX-3018295200 CDM 82952 CPT 301 RC inpatient 63 63 CIGNA 62308 [3081051] CIGNA STATE OF WYOMING [308105107] 49.88 percent of total billed charges 39.06 59.85 Technical (Hospital) Services Gluc Tolerance Addl >3 Spec PX-3018295200 CDM 82952 CPT 301 RC inpatient 63 63 MEDICA (COMMERCIAL) 94265 [3081118] MEDICA CLAIMS [308111801] 56.7 percent of total billed charges 39.06 59.85 Technical (Hospital) Services Gluc Tolerance Addl >3 Spec PX-3018295200 CDM 82952 CPT 301 RC inpatient 63 63 MULTIPLAN INC 34080 [3081285] MULTIPLAN INC [308128501] 59.85 percent of total billed charges 39.06 59.85 Technical (Hospital) Services Gluc Tolerance Addl >3 Spec PX-3018295200 CDM 82952 CPT 301 RC inpatient 63 63 HEALTHPARTNERS SX009 HEALTHPARTNERS 49.88 percent of total billed charges 39.06 59.85 Technical (Hospital) Services Gluc Tolerance Addl >3 Spec PX-3018295200 CDM 82952 CPT 301 RC inpatient 63 63 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES EPO [308136803] 49.88 percent of total billed charges 39.06 59.85 Technical (Hospital) Services Gluc Tolerance Addl >3 Spec PX-3018295200 CDM 82952 CPT 301 RC inpatient 63 63 UNITED HEALTHCARE (COMMERCIAL) [3081199] UNITED HEALTHCARE 87726 [308119901] 39.06 percent of total billed charges 39.06 59.85 Technical (Hospital) Services Gluc Tolerance Addl >3 Spec PX-3018295200 CDM 82952 CPT 301 RC inpatient 63 63 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES PPO [308136801] 49.88 percent of total billed charges 39.06 59.85 Technical (Hospital) Services Gluc Tolerance Addl >3 Spec PX-3018295200 CDM 82952 CPT 301 RC inpatient 63 63 BLUE CROSS BLUE SHIELD WELLMARK SB889 [3081026] BCBS WYOMING [308102603] 59.85 percent of total billed charges 39.06 59.85 Technical (Hospital) Services Gluc Tolerance Addl >3 Spec PX-3018295200 CDM 82952 CPT 301 RC inpatient 63 63 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES HDHP [308136802] 49.88 percent of total billed charges 39.06 59.85 Technical (Hospital) Services Gluc Tolerance Addl >3 Spec PX-3018295200 CDM 82952 CPT 301 RC outpatient 63 63 MEDICA (COMMERCIAL) 94265 [3081118] MEDICA CLAIMS [308111801] 56.7 percent of total billed charges 39.06 59.85 Technical (Hospital) Services Gluc Tolerance Addl >3 Spec PX-3018295200 CDM 82952 CPT 301 RC outpatient 63 63 CIGNA 62308 [3081051] CIGNA 62308 [308105105] 50.4 percent of total billed charges 39.06 59.85 Technical (Hospital) Services Gluc Tolerance Addl >3 Spec PX-3018295200 CDM 82952 CPT 301 RC outpatient 63 63 CIGNA 62308 [3081051] CIGNA STATE OF WYOMING [308105107] 50.4 percent of total billed charges 39.06 59.85 Technical (Hospital) Services Gluc Tolerance Addl >3 Spec PX-3018295200 CDM 82952 CPT 301 RC outpatient 63 63 HEALTHPARTNERS SX009 HEALTHPARTNERS 50.4 percent of total billed charges 39.06 59.85 Technical (Hospital) Services Gluc Tolerance Addl >3 Spec PX-3018295200 CDM 82952 CPT 301 RC outpatient 63 63 UNITED HEALTHCARE (COMMERCIAL) [3081199] UNITED HEALTHCARE 87726 [308119901] 39.06 percent of total billed charges 39.06 59.85 Technical (Hospital) Services Gluc Tolerance Addl >3 Spec PX-3018295200 CDM 82952 CPT 301 RC outpatient 63 63 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES PPO [308136801] 50.4 percent of total billed charges 39.06 59.85 Technical (Hospital) Services Gluc Tolerance Addl >3 Spec PX-3018295200 CDM 82952 CPT 301 RC outpatient 63 63 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES HDHP [308136802] 50.4 percent of total billed charges 39.06 59.85 Technical (Hospital) Services Gluc Tolerance Addl >3 Spec PX-3018295200 CDM 82952 CPT 301 RC outpatient 63 63 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES EPO [308136803] 50.4 percent of total billed charges 39.06 59.85 Technical (Hospital) Services Gluc Tolerance Addl >3 Spec PX-3018295200 CDM 82952 CPT 301 RC outpatient 63 63 BLUE CROSS BLUE SHIELD WELLMARK SB889 [3081026] BCBS WYOMING [308102603] 59.85 percent of total billed charges 39.06 59.85 Technical (Hospital) Services Gluc Tolerance Addl >3 Spec PX-3018295200 CDM 82952 CPT 301 RC outpatient 63 63 MULTIPLAN INC 34080 [3081285] MULTIPLAN INC [308128501] 59.85 percent of total billed charges 39.06 59.85 Technical (Hospital) Services Gtt 3 3hr Glucose Tolerance PX-3018295100 CDM 82951 CPT 301 RC outpatient 152 152 MEDICA (COMMERCIAL) 94265 [3081118] MEDICA CLAIMS [308111801] 136.8 percent of total billed charges 94.24 144.4 Technical (Hospital) Services Gtt 3 3hr Glucose Tolerance PX-3018295100 CDM 82951 CPT 301 RC outpatient 152 152 CIGNA 62308 [3081051] CIGNA 62308 [308105105] 121.6 percent of total billed charges 94.24 144.4 Technical (Hospital) Services Gtt 3 3hr Glucose Tolerance PX-3018295100 CDM 82951 CPT 301 RC outpatient 152 152 CIGNA 62308 [3081051] CIGNA STATE OF WYOMING [308105107] 121.6 percent of total billed charges 94.24 144.4 Technical (Hospital) Services Gtt 3 3hr Glucose Tolerance PX-3018295100 CDM 82951 CPT 301 RC outpatient 152 152 BLUE CROSS BLUE SHIELD WELLMARK SB889 [3081026] BCBS WYOMING [308102603] 144.4 percent of total billed charges 94.24 144.4 Technical (Hospital) Services Gtt 3 3hr Glucose Tolerance PX-3018295100 CDM 82951 CPT 301 RC outpatient 152 152 MULTIPLAN INC 34080 [3081285] MULTIPLAN INC [308128501] 144.4 percent of total billed charges 94.24 144.4 Technical (Hospital) Services Gtt 3 3hr Glucose Tolerance PX-3018295100 CDM 82951 CPT 301 RC outpatient 152 152 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES EPO [308136803] 121.6 percent of total billed charges 94.24 144.4 Technical (Hospital) Services Gtt 3 3hr Glucose Tolerance PX-3018295100 CDM 82951 CPT 301 RC outpatient 152 152 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES HDHP [308136802] 121.6 percent of total billed charges 94.24 144.4 Technical (Hospital) Services Gtt 3 3hr Glucose Tolerance PX-3018295100 CDM 82951 CPT 301 RC outpatient 152 152 HEALTHPARTNERS SX009 HEALTHPARTNERS 121.6 percent of total billed charges 94.24 144.4 Technical (Hospital) Services Gtt 3 3hr Glucose Tolerance PX-3018295100 CDM 82951 CPT 301 RC outpatient 152 152 UNITED HEALTHCARE (COMMERCIAL) [3081199] UNITED HEALTHCARE 87726 [308119901] 94.24 percent of total billed charges 94.24 144.4 Technical (Hospital) Services Gtt 3 3hr Glucose Tolerance PX-3018295100 CDM 82951 CPT 301 RC outpatient 152 152 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES PPO [308136801] 121.6 percent of total billed charges 94.24 144.4 Technical (Hospital) Services Gtt 3 3hr Glucose Tolerance PX-3018295100 CDM 82951 CPT 301 RC inpatient 152 152 CIGNA 62308 [3081051] CIGNA 62308 [308105105] 120.35 percent of total billed charges 94.24 144.4 Technical (Hospital) Services Gtt 3 3hr Glucose Tolerance PX-3018295100 CDM 82951 CPT 301 RC inpatient 152 152 CIGNA 62308 [3081051] CIGNA STATE OF WYOMING [308105107] 120.35 percent of total billed charges 94.24 144.4 Technical (Hospital) Services Gtt 3 3hr Glucose Tolerance PX-3018295100 CDM 82951 CPT 301 RC inpatient 152 152 MULTIPLAN INC 34080 [3081285] MULTIPLAN INC [308128501] 144.4 percent of total billed charges 94.24 144.4 Technical (Hospital) Services Gtt 3 3hr Glucose Tolerance PX-3018295100 CDM 82951 CPT 301 RC inpatient 152 152 MEDICA (COMMERCIAL) 94265 [3081118] MEDICA CLAIMS [308111801] 136.8 percent of total billed charges 94.24 144.4 Technical (Hospital) Services Gtt 3 3hr Glucose Tolerance PX-3018295100 CDM 82951 CPT 301 RC inpatient 152 152 HEALTHPARTNERS SX009 HEALTHPARTNERS 120.35 percent of total billed charges 94.24 144.4 Technical (Hospital) Services Gtt 3 3hr Glucose Tolerance PX-3018295100 CDM 82951 CPT 301 RC inpatient 152 152 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES EPO [308136803] 120.35 percent of total billed charges 94.24 144.4 Technical (Hospital) Services Gtt 3 3hr Glucose Tolerance PX-3018295100 CDM 82951 CPT 301 RC inpatient 152 152 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES PPO [308136801] 120.35 percent of total billed charges 94.24 144.4 Technical (Hospital) Services Gtt 3 3hr Glucose Tolerance PX-3018295100 CDM 82951 CPT 301 RC inpatient 152 152 UNITED HEALTHCARE (COMMERCIAL) [3081199] UNITED HEALTHCARE 87726 [308119901] 94.24 percent of total billed charges 94.24 144.4 Technical (Hospital) Services Gtt 3 3hr Glucose Tolerance PX-3018295100 CDM 82951 CPT 301 RC inpatient 152 152 BLUE CROSS BLUE SHIELD WELLMARK SB889 [3081026] BCBS WYOMING [308102603] 144.4 percent of total billed charges 94.24 144.4 Technical (Hospital) Services Gtt 3 3hr Glucose Tolerance PX-3018295100 CDM 82951 CPT 301 RC inpatient 152 152 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES HDHP [308136802] 120.35 percent of total billed charges 94.24 144.4 Technical (Hospital) Services Glucose Tolerance OB PX-3018295000 CDM 82950 CPT 301 RC outpatient 69 69 MEDICA (COMMERCIAL) 94265 [3081118] MEDICA CLAIMS [308111801] 62.1 percent of total billed charges 42.78 65.55 Technical (Hospital) Services Glucose Tolerance OB PX-3018295000 CDM 82950 CPT 301 RC outpatient 69 69 CIGNA 62308 [3081051] CIGNA 62308 [308105105] 55.2 percent of total billed charges 42.78 65.55 Technical (Hospital) Services Glucose Tolerance OB PX-3018295000 CDM 82950 CPT 301 RC outpatient 69 69 CIGNA 62308 [3081051] CIGNA STATE OF WYOMING [308105107] 55.2 percent of total billed charges 42.78 65.55 Technical (Hospital) Services Glucose Tolerance OB PX-3018295000 CDM 82950 CPT 301 RC outpatient 69 69 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES HDHP [308136802] 55.2 percent of total billed charges 42.78 65.55 Technical (Hospital) Services Glucose Tolerance OB PX-3018295000 CDM 82950 CPT 301 RC outpatient 69 69 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES EPO [308136803] 55.2 percent of total billed charges 42.78 65.55 Technical (Hospital) Services Glucose Tolerance OB PX-3018295000 CDM 82950 CPT 301 RC outpatient 69 69 MULTIPLAN INC 34080 [3081285] MULTIPLAN INC [308128501] 65.55 percent of total billed charges 42.78 65.55 Technical (Hospital) Services Glucose Tolerance OB PX-3018295000 CDM 82950 CPT 301 RC outpatient 69 69 BLUE CROSS BLUE SHIELD WELLMARK SB889 [3081026] BCBS WYOMING [308102603] 65.55 percent of total billed charges 42.78 65.55 Technical (Hospital) Services Glucose Tolerance OB PX-3018295000 CDM 82950 CPT 301 RC outpatient 69 69 HEALTHPARTNERS SX009 HEALTHPARTNERS 55.2 percent of total billed charges 42.78 65.55 Technical (Hospital) Services Glucose Tolerance OB PX-3018295000 CDM 82950 CPT 301 RC outpatient 69 69 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES PPO [308136801] 55.2 percent of total billed charges 42.78 65.55 Technical (Hospital) Services Glucose Tolerance OB PX-3018295000 CDM 82950 CPT 301 RC outpatient 69 69 UNITED HEALTHCARE (COMMERCIAL) [3081199] UNITED HEALTHCARE 87726 [308119901] 42.78 percent of total billed charges 42.78 65.55 Technical (Hospital) Services Glucose Tolerance OB PX-3018295000 CDM 82950 CPT 301 RC inpatient 69 69 CIGNA 62308 [3081051] CIGNA 62308 [308105105] 54.63 percent of total billed charges 42.78 65.55 Technical (Hospital) Services Glucose Tolerance OB PX-3018295000 CDM 82950 CPT 301 RC inpatient 69 69 CIGNA 62308 [3081051] CIGNA STATE OF WYOMING [308105107] 54.63 percent of total billed charges 42.78 65.55 Technical (Hospital) Services Glucose Tolerance OB PX-3018295000 CDM 82950 CPT 301 RC inpatient 69 69 MEDICA (COMMERCIAL) 94265 [3081118] MEDICA CLAIMS [308111801] 62.1 percent of total billed charges 42.78 65.55 Technical (Hospital) Services Glucose Tolerance OB PX-3018295000 CDM 82950 CPT 301 RC inpatient 69 69 MULTIPLAN INC 34080 [3081285] MULTIPLAN INC [308128501] 65.55 percent of total billed charges 42.78 65.55 Technical (Hospital) Services Glucose Tolerance OB PX-3018295000 CDM 82950 CPT 301 RC inpatient 69 69 HEALTHPARTNERS SX009 HEALTHPARTNERS 54.63 percent of total billed charges 42.78 65.55 Technical (Hospital) Services Glucose Tolerance OB PX-3018295000 CDM 82950 CPT 301 RC inpatient 69 69 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES EPO [308136803] 54.63 percent of total billed charges 42.78 65.55 Technical (Hospital) Services Glucose Tolerance OB PX-3018295000 CDM 82950 CPT 301 RC inpatient 69 69 BLUE CROSS BLUE SHIELD WELLMARK SB889 [3081026] BCBS WYOMING [308102603] 65.55 percent of total billed charges 42.78 65.55 Technical (Hospital) Services Glucose Tolerance OB PX-3018295000 CDM 82950 CPT 301 RC inpatient 69 69 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES HDHP [308136802] 54.63 percent of total billed charges 42.78 65.55 Technical (Hospital) Services Glucose Tolerance OB PX-3018295000 CDM 82950 CPT 301 RC inpatient 69 69 UNITED HEALTHCARE (COMMERCIAL) [3081199] UNITED HEALTHCARE 87726 [308119901] 42.78 percent of total billed charges 42.78 65.55 Technical (Hospital) Services Glucose Tolerance OB PX-3018295000 CDM 82950 CPT 301 RC inpatient 69 69 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES PPO [308136801] 54.63 percent of total billed charges 42.78 65.55 Technical (Hospital) Services Glucose PX-3018294700 CDM 82947 CPT 301 RC inpatient 91 91 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES PPO [308136801] 72.05 percent of total billed charges 56.42 86.45 Technical (Hospital) Services Glucose PX-3018294700 CDM 82947 CPT 301 RC inpatient 91 91 UNITED HEALTHCARE (COMMERCIAL) [3081199] UNITED HEALTHCARE 87726 [308119901] 56.42 percent of total billed charges 56.42 86.45 Technical (Hospital) Services Glucose PX-3018294700 CDM 82947 CPT 301 RC inpatient 91 91 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES HDHP [308136802] 72.05 percent of total billed charges 56.42 86.45 Technical (Hospital) Services Glucose PX-3018294700 CDM 82947 CPT 301 RC inpatient 91 91 BLUE CROSS BLUE SHIELD WELLMARK SB889 [3081026] BCBS WYOMING [308102603] 86.45 percent of total billed charges 56.42 86.45 Technical (Hospital) Services Glucose PX-3018294700 CDM 82947 CPT 301 RC inpatient 91 91 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES EPO [308136803] 72.05 percent of total billed charges 56.42 86.45 Technical (Hospital) Services Glucose PX-3018294700 CDM 82947 CPT 301 RC inpatient 91 91 HEALTHPARTNERS SX009 HEALTHPARTNERS 72.05 percent of total billed charges 56.42 86.45 Technical (Hospital) Services Glucose PX-3018294700 CDM 82947 CPT 301 RC inpatient 91 91 MULTIPLAN INC 34080 [3081285] MULTIPLAN INC [308128501] 86.45 percent of total billed charges 56.42 86.45 Technical (Hospital) Services Glucose PX-3018294700 CDM 82947 CPT 301 RC inpatient 91 91 MEDICA (COMMERCIAL) 94265 [3081118] MEDICA CLAIMS [308111801] 81.9 percent of total billed charges 56.42 86.45 Technical (Hospital) Services Glucose PX-3018294700 CDM 82947 CPT 301 RC inpatient 91 91 CIGNA 62308 [3081051] CIGNA 62308 [308105105] 72.05 percent of total billed charges 56.42 86.45 Technical (Hospital) Services Glucose PX-3018294700 CDM 82947 CPT 301 RC inpatient 91 91 CIGNA 62308 [3081051] CIGNA STATE OF WYOMING [308105107] 72.05 percent of total billed charges 56.42 86.45 Technical (Hospital) Services Glucose PX-3018294700 CDM 82947 CPT 301 RC outpatient 91 91 MEDICA (COMMERCIAL) 94265 [3081118] MEDICA CLAIMS [308111801] 81.9 percent of total billed charges 56.42 86.45 Technical (Hospital) Services Glucose PX-3018294700 CDM 82947 CPT 301 RC outpatient 91 91 CIGNA 62308 [3081051] CIGNA 62308 [308105105] 72.8 percent of total billed charges 56.42 86.45 Technical (Hospital) Services Glucose PX-3018294700 CDM 82947 CPT 301 RC outpatient 91 91 CIGNA 62308 [3081051] CIGNA STATE OF WYOMING [308105107] 72.8 percent of total billed charges 56.42 86.45 Technical (Hospital) Services Glucose PX-3018294700 CDM 82947 CPT 301 RC outpatient 91 91 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES PPO [308136801] 72.8 percent of total billed charges 56.42 86.45 Technical (Hospital) Services Glucose PX-3018294700 CDM 82947 CPT 301 RC outpatient 91 91 MULTIPLAN INC 34080 [3081285] MULTIPLAN INC [308128501] 86.45 percent of total billed charges 56.42 86.45 Technical (Hospital) Services Glucose PX-3018294700 CDM 82947 CPT 301 RC outpatient 91 91 BLUE CROSS BLUE SHIELD WELLMARK SB889 [3081026] BCBS WYOMING [308102603] 86.45 percent of total billed charges 56.42 86.45 Technical (Hospital) Services Glucose PX-3018294700 CDM 82947 CPT 301 RC outpatient 91 91 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES HDHP [308136802] 72.8 percent of total billed charges 56.42 86.45 Technical (Hospital) Services Glucose PX-3018294700 CDM 82947 CPT 301 RC outpatient 91 91 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES EPO [308136803] 72.8 percent of total billed charges 56.42 86.45 Technical (Hospital) Services Glucose PX-3018294700 CDM 82947 CPT 301 RC outpatient 91 91 UNITED HEALTHCARE (COMMERCIAL) [3081199] UNITED HEALTHCARE 87726 [308119901] 56.42 percent of total billed charges 56.42 86.45 Technical (Hospital) Services Glucose PX-3018294700 CDM 82947 CPT 301 RC outpatient 91 91 HEALTHPARTNERS SX009 HEALTHPARTNERS 72.8 percent of total billed charges 56.42 86.45 Technical (Hospital) Services Glucometer Strip Waived PX-3018294701 CDM 82947 CPT 301 RC inpatient 0.01 0.01 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES PPO [308136801] 0.01 percent of total billed charges 0.01 0.01 Technical (Hospital) Services Glucometer Strip Waived PX-3018294701 CDM 82947 CPT 301 RC inpatient 0.01 0.01 BLUE CROSS BLUE SHIELD WELLMARK SB889 [3081026] BCBS WYOMING [308102603] 0.01 percent of total billed charges 0.01 0.01 Technical (Hospital) Services Glucometer Strip Waived PX-3018294701 CDM 82947 CPT 301 RC inpatient 0.01 0.01 UNITED HEALTHCARE (COMMERCIAL) [3081199] UNITED HEALTHCARE 87726 [308119901] 0.01 percent of total billed charges 0.01 0.01 Technical (Hospital) Services Glucometer Strip Waived PX-3018294701 CDM 82947 CPT 301 RC inpatient 0.01 0.01 HEALTHPARTNERS SX009 HEALTHPARTNERS 0.01 percent of total billed charges 0.01 0.01 Technical (Hospital) Services Glucometer Strip Waived PX-3018294701 CDM 82947 CPT 301 RC inpatient 0.01 0.01 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES HDHP [308136802] 0.01 percent of total billed charges 0.01 0.01 Technical (Hospital) Services Glucometer Strip Waived PX-3018294701 CDM 82947 CPT 301 RC inpatient 0.01 0.01 MULTIPLAN INC 34080 [3081285] MULTIPLAN INC [308128501] 0.01 percent of total billed charges 0.01 0.01 Technical (Hospital) Services Glucometer Strip Waived PX-3018294701 CDM 82947 CPT 301 RC inpatient 0.01 0.01 MEDICA (COMMERCIAL) 94265 [3081118] MEDICA CLAIMS [308111801] 0.01 percent of total billed charges 0.01 0.01 Technical (Hospital) Services Glucometer Strip Waived PX-3018294701 CDM 82947 CPT 301 RC inpatient 0.01 0.01 CIGNA 62308 [3081051] CIGNA 62308 [308105105] 0.01 percent of total billed charges 0.01 0.01 Technical (Hospital) Services Glucometer Strip Waived PX-3018294701 CDM 82947 CPT 301 RC inpatient 0.01 0.01 CIGNA 62308 [3081051] CIGNA STATE OF WYOMING [308105107] 0.01 percent of total billed charges 0.01 0.01 Technical (Hospital) Services Glucometer Strip Waived PX-3018294701 CDM 82947 CPT 301 RC inpatient 0.01 0.01 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES EPO [308136803] 0.01 percent of total billed charges 0.01 0.01 Technical (Hospital) Services Glucometer Strip Waived PX-3018294701 CDM 82947 CPT 301 RC outpatient 0.01 0.01 HEALTHPARTNERS SX009 HEALTHPARTNERS 0.01 percent of total billed charges 0.01 0.01 Technical (Hospital) Services Glucometer Strip Waived PX-3018294701 CDM 82947 CPT 301 RC outpatient 0.01 0.01 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES HDHP [308136802] 0.01 percent of total billed charges 0.01 0.01 Technical (Hospital) Services Glucometer Strip Waived PX-3018294701 CDM 82947 CPT 301 RC outpatient 0.01 0.01 UNITED HEALTHCARE (COMMERCIAL) [3081199] UNITED HEALTHCARE 87726 [308119901] 0.01 percent of total billed charges 0.01 0.01 Technical (Hospital) Services Glucometer Strip Waived PX-3018294701 CDM 82947 CPT 301 RC outpatient 0.01 0.01 BLUE CROSS BLUE SHIELD WELLMARK SB889 [3081026] BCBS WYOMING [308102603] 0.01 percent of total billed charges 0.01 0.01 Technical (Hospital) Services Glucometer Strip Waived PX-3018294701 CDM 82947 CPT 301 RC outpatient 0.01 0.01 MULTIPLAN INC 34080 [3081285] MULTIPLAN INC [308128501] 0.01 percent of total billed charges 0.01 0.01 Technical (Hospital) Services Glucometer Strip Waived PX-3018294701 CDM 82947 CPT 301 RC outpatient 0.01 0.01 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES EPO [308136803] 0.01 percent of total billed charges 0.01 0.01 Technical (Hospital) Services Glucometer Strip Waived PX-3018294701 CDM 82947 CPT 301 RC outpatient 0.01 0.01 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES PPO [308136801] 0.01 percent of total billed charges 0.01 0.01 Technical (Hospital) Services Glucometer Strip Waived PX-3018294701 CDM 82947 CPT 301 RC outpatient 0.01 0.01 MEDICA (COMMERCIAL) 94265 [3081118] MEDICA CLAIMS [308111801] 0.01 percent of total billed charges 0.01 0.01 Technical (Hospital) Services Glucometer Strip Waived PX-3018294701 CDM 82947 CPT 301 RC outpatient 0.01 0.01 CIGNA 62308 [3081051] CIGNA 62308 [308105105] 0.01 percent of total billed charges 0.01 0.01 Technical (Hospital) Services Glucometer Strip Waived PX-3018294701 CDM 82947 CPT 301 RC outpatient 0.01 0.01 CIGNA 62308 [3081051] CIGNA STATE OF WYOMING [308105107] 0.01 percent of total billed charges 0.01 0.01 Technical (Hospital) Services Glucose CSF or Body Fluid PX-3018294500 CDM 82945 CPT 301 RC outpatient 174 174 MEDICA (COMMERCIAL) 94265 [3081118] MEDICA CLAIMS [308111801] 156.6 percent of total billed charges 107.88 165.3 Technical (Hospital) Services Glucose CSF or Body Fluid PX-3018294500 CDM 82945 CPT 301 RC outpatient 174 174 CIGNA 62308 [3081051] CIGNA 62308 [308105105] 139.2 percent of total billed charges 107.88 165.3 Technical (Hospital) Services Glucose CSF or Body Fluid PX-3018294500 CDM 82945 CPT 301 RC outpatient 174 174 CIGNA 62308 [3081051] CIGNA STATE OF WYOMING [308105107] 139.2 percent of total billed charges 107.88 165.3 Technical (Hospital) Services Glucose CSF or Body Fluid PX-3018294500 CDM 82945 CPT 301 RC outpatient 174 174 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES PPO [308136801] 139.2 percent of total billed charges 107.88 165.3 Technical (Hospital) Services Glucose CSF or Body Fluid PX-3018294500 CDM 82945 CPT 301 RC outpatient 174 174 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES EPO [308136803] 139.2 percent of total billed charges 107.88 165.3 Technical (Hospital) Services Glucose CSF or Body Fluid PX-3018294500 CDM 82945 CPT 301 RC outpatient 174 174 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES HDHP [308136802] 139.2 percent of total billed charges 107.88 165.3 Technical (Hospital) Services Glucose CSF or Body Fluid PX-3018294500 CDM 82945 CPT 301 RC outpatient 174 174 BLUE CROSS BLUE SHIELD WELLMARK SB889 [3081026] BCBS WYOMING [308102603] 165.3 percent of total billed charges 107.88 165.3 Technical (Hospital) Services Glucose CSF or Body Fluid PX-3018294500 CDM 82945 CPT 301 RC outpatient 174 174 MULTIPLAN INC 34080 [3081285] MULTIPLAN INC [308128501] 165.3 percent of total billed charges 107.88 165.3 Technical (Hospital) Services Glucose CSF or Body Fluid PX-3018294500 CDM 82945 CPT 301 RC outpatient 174 174 HEALTHPARTNERS SX009 HEALTHPARTNERS 139.2 percent of total billed charges 107.88 165.3 Technical (Hospital) Services Glucose CSF or Body Fluid PX-3018294500 CDM 82945 CPT 301 RC outpatient 174 174 UNITED HEALTHCARE (COMMERCIAL) [3081199] UNITED HEALTHCARE 87726 [308119901] 107.88 percent of total billed charges 107.88 165.3 Technical (Hospital) Services Glucose CSF or Body Fluid PX-3018294500 CDM 82945 CPT 301 RC inpatient 174 174 UNITED HEALTHCARE (COMMERCIAL) [3081199] UNITED HEALTHCARE 87726 [308119901] 107.88 percent of total billed charges 107.88 165.3 Technical (Hospital) Services Glucose CSF or Body Fluid PX-3018294500 CDM 82945 CPT 301 RC inpatient 174 174 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES PPO [308136801] 137.77 percent of total billed charges 107.88 165.3 Technical (Hospital) Services Glucose CSF or Body Fluid PX-3018294500 CDM 82945 CPT 301 RC inpatient 174 174 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES HDHP [308136802] 137.77 percent of total billed charges 107.88 165.3 Technical (Hospital) Services Glucose CSF or Body Fluid PX-3018294500 CDM 82945 CPT 301 RC inpatient 174 174 BLUE CROSS BLUE SHIELD WELLMARK SB889 [3081026] BCBS WYOMING [308102603] 165.3 percent of total billed charges 107.88 165.3 Technical (Hospital) Services Glucose CSF or Body Fluid PX-3018294500 CDM 82945 CPT 301 RC inpatient 174 174 MULTIPLAN INC 34080 [3081285] MULTIPLAN INC [308128501] 165.3 percent of total billed charges 107.88 165.3 Technical (Hospital) Services Glucose CSF or Body Fluid PX-3018294500 CDM 82945 CPT 301 RC inpatient 174 174 MEDICA (COMMERCIAL) 94265 [3081118] MEDICA CLAIMS [308111801] 156.6 percent of total billed charges 107.88 165.3 Technical (Hospital) Services Glucose CSF or Body Fluid PX-3018294500 CDM 82945 CPT 301 RC inpatient 174 174 HEALTHPARTNERS SX009 HEALTHPARTNERS 137.77 percent of total billed charges 107.88 165.3 Technical (Hospital) Services Glucose CSF or Body Fluid PX-3018294500 CDM 82945 CPT 301 RC inpatient 174 174 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES EPO [308136803] 137.77 percent of total billed charges 107.88 165.3 Technical (Hospital) Services Glucose CSF or Body Fluid PX-3018294500 CDM 82945 CPT 301 RC inpatient 174 174 CIGNA 62308 [3081051] CIGNA 62308 [308105105] 137.77 percent of total billed charges 107.88 165.3 Technical (Hospital) Services Glucose CSF or Body Fluid PX-3018294500 CDM 82945 CPT 301 RC inpatient 174 174 CIGNA 62308 [3081051] CIGNA STATE OF WYOMING [308105107] 137.77 percent of total billed charges 107.88 165.3 Technical (Hospital) Services Ref Gastrin PX-3018294100 CDM 82941 CPT 301 RC inpatient 190 190 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES PPO [308136801] 150.44 percent of total billed charges 117.8 180.5 Technical (Hospital) Services Ref Gastrin PX-3018294100 CDM 82941 CPT 301 RC inpatient 190 190 UNITED HEALTHCARE (COMMERCIAL) [3081199] UNITED HEALTHCARE 87726 [308119901] 117.8 percent of total billed charges 117.8 180.5 Technical (Hospital) Services Ref Gastrin PX-3018294100 CDM 82941 CPT 301 RC inpatient 190 190 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES HDHP [308136802] 150.44 percent of total billed charges 117.8 180.5 Technical (Hospital) Services Ref Gastrin PX-3018294100 CDM 82941 CPT 301 RC inpatient 190 190 BLUE CROSS BLUE SHIELD WELLMARK SB889 [3081026] BCBS WYOMING [308102603] 180.5 percent of total billed charges 117.8 180.5 Technical (Hospital) Services Ref Gastrin PX-3018294100 CDM 82941 CPT 301 RC inpatient 190 190 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES EPO [308136803] 150.44 percent of total billed charges 117.8 180.5 Technical (Hospital) Services Ref Gastrin PX-3018294100 CDM 82941 CPT 301 RC inpatient 190 190 HEALTHPARTNERS SX009 HEALTHPARTNERS 150.44 percent of total billed charges 117.8 180.5 Technical (Hospital) Services Ref Gastrin PX-3018294100 CDM 82941 CPT 301 RC inpatient 190 190 MEDICA (COMMERCIAL) 94265 [3081118] MEDICA CLAIMS [308111801] 171 percent of total billed charges 117.8 180.5 Technical (Hospital) Services Ref Gastrin PX-3018294100 CDM 82941 CPT 301 RC inpatient 190 190 MULTIPLAN INC 34080 [3081285] MULTIPLAN INC [308128501] 180.5 percent of total billed charges 117.8 180.5 Technical (Hospital) Services Ref Gastrin PX-3018294100 CDM 82941 CPT 301 RC inpatient 190 190 CIGNA 62308 [3081051] CIGNA 62308 [308105105] 150.44 percent of total billed charges 117.8 180.5 Technical (Hospital) Services Ref Gastrin PX-3018294100 CDM 82941 CPT 301 RC inpatient 190 190 CIGNA 62308 [3081051] CIGNA STATE OF WYOMING [308105107] 150.44 percent of total billed charges 117.8 180.5 Technical (Hospital) Services Ref Gastrin PX-3018294100 CDM 82941 CPT 301 RC outpatient 190 190 HEALTHPARTNERS SX009 HEALTHPARTNERS 152 percent of total billed charges 117.8 180.5 Technical (Hospital) Services Ref Gastrin PX-3018294100 CDM 82941 CPT 301 RC outpatient 190 190 UNITED HEALTHCARE (COMMERCIAL) [3081199] UNITED HEALTHCARE 87726 [308119901] 117.8 percent of total billed charges 117.8 180.5 Technical (Hospital) Services Ref Gastrin PX-3018294100 CDM 82941 CPT 301 RC outpatient 190 190 MULTIPLAN INC 34080 [3081285] MULTIPLAN INC [308128501] 180.5 percent of total billed charges 117.8 180.5 Technical (Hospital) Services Ref Gastrin PX-3018294100 CDM 82941 CPT 301 RC outpatient 190 190 BLUE CROSS BLUE SHIELD WELLMARK SB889 [3081026] BCBS WYOMING [308102603] 180.5 percent of total billed charges 117.8 180.5 Technical (Hospital) Services Ref Gastrin PX-3018294100 CDM 82941 CPT 301 RC outpatient 190 190 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES EPO [308136803] 152 percent of total billed charges 117.8 180.5 Technical (Hospital) Services Ref Gastrin PX-3018294100 CDM 82941 CPT 301 RC outpatient 190 190 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES HDHP [308136802] 152 percent of total billed charges 117.8 180.5 Technical (Hospital) Services Ref Gastrin PX-3018294100 CDM 82941 CPT 301 RC outpatient 190 190 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES PPO [308136801] 152 percent of total billed charges 117.8 180.5 Technical (Hospital) Services Ref Gastrin PX-3018294100 CDM 82941 CPT 301 RC outpatient 190 190 MEDICA (COMMERCIAL) 94265 [3081118] MEDICA CLAIMS [308111801] 171 percent of total billed charges 117.8 180.5 Technical (Hospital) Services Ref Gastrin PX-3018294100 CDM 82941 CPT 301 RC outpatient 190 190 CIGNA 62308 [3081051] CIGNA 62308 [308105105] 152 percent of total billed charges 117.8 180.5 Technical (Hospital) Services Ref Gastrin PX-3018294100 CDM 82941 CPT 301 RC outpatient 190 190 CIGNA 62308 [3081051] CIGNA STATE OF WYOMING [308105107] 152 percent of total billed charges 117.8 180.5 Technical (Hospital) Services Bl Gas W 02 Sat Measure Rt PX-3018280500 CDM 82805 CPT 301 RC inpatient 278 278 BLUE CROSS BLUE SHIELD WELLMARK SB889 [3081026] BCBS WYOMING [308102603] 264.1 percent of total billed charges 172.36 264.1 Technical (Hospital) Services Bl Gas W 02 Sat Measure Rt PX-3018280500 CDM 82805 CPT 301 RC inpatient 278 278 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES HDHP [308136802] 220.12 percent of total billed charges 172.36 264.1 Technical (Hospital) Services Bl Gas W 02 Sat Measure Rt PX-3018280500 CDM 82805 CPT 301 RC inpatient 278 278 UNITED HEALTHCARE (COMMERCIAL) [3081199] UNITED HEALTHCARE 87726 [308119901] 172.36 percent of total billed charges 172.36 264.1 Technical (Hospital) Services Bl Gas W 02 Sat Measure Rt PX-3018280500 CDM 82805 CPT 301 RC inpatient 278 278 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES PPO [308136801] 220.12 percent of total billed charges 172.36 264.1 Technical (Hospital) Services Bl Gas W 02 Sat Measure Rt PX-3018280500 CDM 82805 CPT 301 RC inpatient 278 278 MEDICA (COMMERCIAL) 94265 [3081118] MEDICA CLAIMS [308111801] 250.2 percent of total billed charges 172.36 264.1 Technical (Hospital) Services Bl Gas W 02 Sat Measure Rt PX-3018280500 CDM 82805 CPT 301 RC inpatient 278 278 MULTIPLAN INC 34080 [3081285] MULTIPLAN INC [308128501] 264.1 percent of total billed charges 172.36 264.1 Technical (Hospital) Services Bl Gas W 02 Sat Measure Rt PX-3018280500 CDM 82805 CPT 301 RC inpatient 278 278 HEALTHPARTNERS SX009 HEALTHPARTNERS 220.12 percent of total billed charges 172.36 264.1 Technical (Hospital) Services Bl Gas W 02 Sat Measure Rt PX-3018280500 CDM 82805 CPT 301 RC inpatient 278 278 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES EPO [308136803] 220.12 percent of total billed charges 172.36 264.1 Technical (Hospital) Services Bl Gas W 02 Sat Measure Rt PX-3018280500 CDM 82805 CPT 301 RC inpatient 278 278 CIGNA 62308 [3081051] CIGNA 62308 [308105105] 220.12 percent of total billed charges 172.36 264.1 Technical (Hospital) Services Bl Gas W 02 Sat Measure Rt PX-3018280500 CDM 82805 CPT 301 RC inpatient 278 278 CIGNA 62308 [3081051] CIGNA STATE OF WYOMING [308105107] 220.12 percent of total billed charges 172.36 264.1 Technical (Hospital) Services Bl Gas W 02 Sat Measure Rt PX-3018280500 CDM 82805 CPT 301 RC outpatient 278 278 MEDICA (COMMERCIAL) 94265 [3081118] MEDICA CLAIMS [308111801] 250.2 percent of total billed charges 172.36 264.1 Technical (Hospital) Services Bl Gas W 02 Sat Measure Rt PX-3018280500 CDM 82805 CPT 301 RC outpatient 278 278 CIGNA 62308 [3081051] CIGNA 62308 [308105105] 222.4 percent of total billed charges 172.36 264.1 Technical (Hospital) Services Bl Gas W 02 Sat Measure Rt PX-3018280500 CDM 82805 CPT 301 RC outpatient 278 278 CIGNA 62308 [3081051] CIGNA STATE OF WYOMING [308105107] 222.4 percent of total billed charges 172.36 264.1 Technical (Hospital) Services Bl Gas W 02 Sat Measure Rt PX-3018280500 CDM 82805 CPT 301 RC outpatient 278 278 BLUE CROSS BLUE SHIELD WELLMARK SB889 [3081026] BCBS WYOMING [308102603] 264.1 percent of total billed charges 172.36 264.1 Technical (Hospital) Services Bl Gas W 02 Sat Measure Rt PX-3018280500 CDM 82805 CPT 301 RC outpatient 278 278 MULTIPLAN INC 34080 [3081285] MULTIPLAN INC [308128501] 264.1 percent of total billed charges 172.36 264.1 Technical (Hospital) Services Bl Gas W 02 Sat Measure Rt PX-3018280500 CDM 82805 CPT 301 RC outpatient 278 278 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES HDHP [308136802] 222.4 percent of total billed charges 172.36 264.1 Technical (Hospital) Services Bl Gas W 02 Sat Measure Rt PX-3018280500 CDM 82805 CPT 301 RC outpatient 278 278 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES EPO [308136803] 222.4 percent of total billed charges 172.36 264.1 Technical (Hospital) Services Bl Gas W 02 Sat Measure Rt PX-3018280500 CDM 82805 CPT 301 RC outpatient 278 278 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES PPO [308136801] 222.4 percent of total billed charges 172.36 264.1 Technical (Hospital) Services Bl Gas W 02 Sat Measure Rt PX-3018280500 CDM 82805 CPT 301 RC outpatient 278 278 HEALTHPARTNERS SX009 HEALTHPARTNERS 222.4 percent of total billed charges 172.36 264.1 Technical (Hospital) Services Bl Gas W 02 Sat Measure Rt PX-3018280500 CDM 82805 CPT 301 RC outpatient 278 278 UNITED HEALTHCARE (COMMERCIAL) [3081199] UNITED HEALTHCARE 87726 [308119901] 172.36 percent of total billed charges 172.36 264.1 Technical (Hospital) Services Bl Gas W O2 Sat Calculated Lab PX-3018280300 CDM 82803 CPT 301 RC inpatient 278 278 HEALTHPARTNERS SX009 HEALTHPARTNERS 220.12 percent of total billed charges 172.36 264.1 Technical (Hospital) Services Bl Gas W O2 Sat Calculated Lab PX-3018280300 CDM 82803 CPT 301 RC inpatient 278 278 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES EPO [308136803] 220.12 percent of total billed charges 172.36 264.1 Technical (Hospital) Services Bl Gas W O2 Sat Calculated Lab PX-3018280300 CDM 82803 CPT 301 RC inpatient 278 278 MULTIPLAN INC 34080 [3081285] MULTIPLAN INC [308128501] 264.1 percent of total billed charges 172.36 264.1 Technical (Hospital) Services Bl Gas W O2 Sat Calculated Lab PX-3018280300 CDM 82803 CPT 301 RC inpatient 278 278 MEDICA (COMMERCIAL) 94265 [3081118] MEDICA CLAIMS [308111801] 250.2 percent of total billed charges 172.36 264.1 Technical (Hospital) Services Bl Gas W O2 Sat Calculated Lab PX-3018280300 CDM 82803 CPT 301 RC inpatient 278 278 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES HDHP [308136802] 220.12 percent of total billed charges 172.36 264.1 Technical (Hospital) Services Bl Gas W O2 Sat Calculated Lab PX-3018280300 CDM 82803 CPT 301 RC inpatient 278 278 BLUE CROSS BLUE SHIELD WELLMARK SB889 [3081026] BCBS WYOMING [308102603] 264.1 percent of total billed charges 172.36 264.1 Technical (Hospital) Services Bl Gas W O2 Sat Calculated Lab PX-3018280300 CDM 82803 CPT 301 RC inpatient 278 278 UNITED HEALTHCARE (COMMERCIAL) [3081199] UNITED HEALTHCARE 87726 [308119901] 172.36 percent of total billed charges 172.36 264.1 Technical (Hospital) Services Bl Gas W O2 Sat Calculated Lab PX-3018280300 CDM 82803 CPT 301 RC inpatient 278 278 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES PPO [308136801] 220.12 percent of total billed charges 172.36 264.1 Technical (Hospital) Services Bl Gas W O2 Sat Calculated Lab PX-3018280300 CDM 82803 CPT 301 RC inpatient 278 278 CIGNA 62308 [3081051] CIGNA 62308 [308105105] 220.12 percent of total billed charges 172.36 264.1 Technical (Hospital) Services Bl Gas W O2 Sat Calculated Lab PX-3018280300 CDM 82803 CPT 301 RC inpatient 278 278 CIGNA 62308 [3081051] CIGNA STATE OF WYOMING [308105107] 220.12 percent of total billed charges 172.36 264.1 Technical (Hospital) Services Bl Gas W O2 Sat Calculated Lab PX-3018280300 CDM 82803 CPT 301 RC outpatient 278 278 HEALTHPARTNERS SX009 HEALTHPARTNERS 222.4 percent of total billed charges 172.36 264.1 Technical (Hospital) Services Bl Gas W O2 Sat Calculated Lab PX-3018280300 CDM 82803 CPT 301 RC outpatient 278 278 UNITED HEALTHCARE (COMMERCIAL) [3081199] UNITED HEALTHCARE 87726 [308119901] 172.36 percent of total billed charges 172.36 264.1 Technical (Hospital) Services Bl Gas W O2 Sat Calculated Lab PX-3018280300 CDM 82803 CPT 301 RC outpatient 278 278 MULTIPLAN INC 34080 [3081285] MULTIPLAN INC [308128501] 264.1 percent of total billed charges 172.36 264.1 Technical (Hospital) Services Bl Gas W O2 Sat Calculated Lab PX-3018280300 CDM 82803 CPT 301 RC outpatient 278 278 BLUE CROSS BLUE SHIELD WELLMARK SB889 [3081026] BCBS WYOMING [308102603] 264.1 percent of total billed charges 172.36 264.1 Technical (Hospital) Services Bl Gas W O2 Sat Calculated Lab PX-3018280300 CDM 82803 CPT 301 RC outpatient 278 278 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES EPO [308136803] 222.4 percent of total billed charges 172.36 264.1 Technical (Hospital) Services Bl Gas W O2 Sat Calculated Lab PX-3018280300 CDM 82803 CPT 301 RC outpatient 278 278 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES HDHP [308136802] 222.4 percent of total billed charges 172.36 264.1 Technical (Hospital) Services Bl Gas W O2 Sat Calculated Lab PX-3018280300 CDM 82803 CPT 301 RC outpatient 278 278 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES PPO [308136801] 222.4 percent of total billed charges 172.36 264.1 Technical (Hospital) Services Bl Gas W O2 Sat Calculated Lab PX-3018280300 CDM 82803 CPT 301 RC outpatient 278 278 CIGNA 62308 [3081051] CIGNA 62308 [308105105] 222.4 percent of total billed charges 172.36 264.1 Technical (Hospital) Services Bl Gas W O2 Sat Calculated Lab PX-3018280300 CDM 82803 CPT 301 RC outpatient 278 278 CIGNA 62308 [3081051] CIGNA STATE OF WYOMING [308105107] 222.4 percent of total billed charges 172.36 264.1 Technical (Hospital) Services Bl Gas W O2 Sat Calculated Lab PX-3018280300 CDM 82803 CPT 301 RC outpatient 278 278 MEDICA (COMMERCIAL) 94265 [3081118] MEDICA CLAIMS [308111801] 250.2 percent of total billed charges 172.36 264.1 Technical (Hospital) Services Ref Igg Subclasses Each PX-3018278700 CDM 82787 CPT 301 RC outpatient 180 180 HEALTHPARTNERS SX009 HEALTHPARTNERS 144 percent of total billed charges 111.6 171 Technical (Hospital) Services Ref Igg Subclasses Each PX-3018278700 CDM 82787 CPT 301 RC outpatient 180 180 UNITED HEALTHCARE (COMMERCIAL) [3081199] UNITED HEALTHCARE 87726 [308119901] 111.6 percent of total billed charges 111.6 171 Technical (Hospital) Services Ref Igg Subclasses Each PX-3018278700 CDM 82787 CPT 301 RC outpatient 180 180 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES HDHP [308136802] 144 percent of total billed charges 111.6 171 Technical (Hospital) Services Ref Igg Subclasses Each PX-3018278700 CDM 82787 CPT 301 RC outpatient 180 180 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES EPO [308136803] 144 percent of total billed charges 111.6 171 Technical (Hospital) Services Ref Igg Subclasses Each PX-3018278700 CDM 82787 CPT 301 RC outpatient 180 180 BLUE CROSS BLUE SHIELD WELLMARK SB889 [3081026] BCBS WYOMING [308102603] 171 percent of total billed charges 111.6 171 Technical (Hospital) Services Ref Igg Subclasses Each PX-3018278700 CDM 82787 CPT 301 RC outpatient 180 180 MULTIPLAN INC 34080 [3081285] MULTIPLAN INC [308128501] 171 percent of total billed charges 111.6 171 Technical (Hospital) Services Ref Igg Subclasses Each PX-3018278700 CDM 82787 CPT 301 RC outpatient 180 180 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES PPO [308136801] 144 percent of total billed charges 111.6 171 Technical (Hospital) Services Ref Igg Subclasses Each PX-3018278700 CDM 82787 CPT 301 RC outpatient 180 180 CIGNA 62308 [3081051] CIGNA 62308 [308105105] 144 percent of total billed charges 111.6 171 Technical (Hospital) Services Ref Igg Subclasses Each PX-3018278700 CDM 82787 CPT 301 RC outpatient 180 180 CIGNA 62308 [3081051] CIGNA STATE OF WYOMING [308105107] 144 percent of total billed charges 111.6 171 Technical (Hospital) Services Ref Igg Subclasses Each PX-3018278700 CDM 82787 CPT 301 RC outpatient 180 180 MEDICA (COMMERCIAL) 94265 [3081118] MEDICA CLAIMS [308111801] 162 percent of total billed charges 111.6 171 Technical (Hospital) Services Ref Igg Subclasses Each PX-3018278700 CDM 82787 CPT 301 RC inpatient 180 180 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES HDHP [308136802] 142.52 percent of total billed charges 111.6 171 Technical (Hospital) Services Ref Igg Subclasses Each PX-3018278700 CDM 82787 CPT 301 RC inpatient 180 180 BLUE CROSS BLUE SHIELD WELLMARK SB889 [3081026] BCBS WYOMING [308102603] 171 percent of total billed charges 111.6 171 Technical (Hospital) Services Ref Igg Subclasses Each PX-3018278700 CDM 82787 CPT 301 RC inpatient 180 180 UNITED HEALTHCARE (COMMERCIAL) [3081199] UNITED HEALTHCARE 87726 [308119901] 111.6 percent of total billed charges 111.6 171 Technical (Hospital) Services Ref Igg Subclasses Each PX-3018278700 CDM 82787 CPT 301 RC inpatient 180 180 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES PPO [308136801] 142.52 percent of total billed charges 111.6 171 Technical (Hospital) Services Ref Igg Subclasses Each PX-3018278700 CDM 82787 CPT 301 RC inpatient 180 180 MULTIPLAN INC 34080 [3081285] MULTIPLAN INC [308128501] 171 percent of total billed charges 111.6 171 Technical (Hospital) Services Ref Igg Subclasses Each PX-3018278700 CDM 82787 CPT 301 RC inpatient 180 180 MEDICA (COMMERCIAL) 94265 [3081118] MEDICA CLAIMS [308111801] 162 percent of total billed charges 111.6 171 Technical (Hospital) Services Ref Igg Subclasses Each PX-3018278700 CDM 82787 CPT 301 RC inpatient 180 180 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES EPO [308136803] 142.52 percent of total billed charges 111.6 171 Technical (Hospital) Services Ref Igg Subclasses Each PX-3018278700 CDM 82787 CPT 301 RC inpatient 180 180 HEALTHPARTNERS SX009 HEALTHPARTNERS 142.52 percent of total billed charges 111.6 171 Technical (Hospital) Services Ref Igg Subclasses Each PX-3018278700 CDM 82787 CPT 301 RC inpatient 180 180 CIGNA 62308 [3081051] CIGNA 62308 [308105105] 142.52 percent of total billed charges 111.6 171 Technical (Hospital) Services Ref Igg Subclasses Each PX-3018278700 CDM 82787 CPT 301 RC inpatient 180 180 CIGNA 62308 [3081051] CIGNA STATE OF WYOMING [308105107] 142.52 percent of total billed charges 111.6 171 Technical (Hospital) Services Ref Immuglobulin E PX-3018278500 CDM 82785 CPT 301 RC inpatient 133 133 BLUE CROSS BLUE SHIELD WELLMARK SB889 [3081026] BCBS WYOMING [308102603] 126.35 percent of total billed charges 82.46 126.35 Technical (Hospital) Services Ref Immuglobulin E PX-3018278500 CDM 82785 CPT 301 RC inpatient 133 133 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES HDHP [308136802] 105.31 percent of total billed charges 82.46 126.35 Technical (Hospital) Services Ref Immuglobulin E PX-3018278500 CDM 82785 CPT 301 RC inpatient 133 133 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES PPO [308136801] 105.31 percent of total billed charges 82.46 126.35 Technical (Hospital) Services Ref Immuglobulin E PX-3018278500 CDM 82785 CPT 301 RC inpatient 133 133 UNITED HEALTHCARE (COMMERCIAL) [3081199] UNITED HEALTHCARE 87726 [308119901] 82.46 percent of total billed charges 82.46 126.35 Technical (Hospital) Services Ref Immuglobulin E PX-3018278500 CDM 82785 CPT 301 RC inpatient 133 133 MULTIPLAN INC 34080 [3081285] MULTIPLAN INC [308128501] 126.35 percent of total billed charges 82.46 126.35 Technical (Hospital) Services Ref Immuglobulin E PX-3018278500 CDM 82785 CPT 301 RC inpatient 133 133 MEDICA (COMMERCIAL) 94265 [3081118] MEDICA CLAIMS [308111801] 119.7 percent of total billed charges 82.46 126.35 Technical (Hospital) Services Ref Immuglobulin E PX-3018278500 CDM 82785 CPT 301 RC inpatient 133 133 HEALTHPARTNERS SX009 HEALTHPARTNERS 105.31 percent of total billed charges 82.46 126.35 Technical (Hospital) Services Ref Immuglobulin E PX-3018278500 CDM 82785 CPT 301 RC inpatient 133 133 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES EPO [308136803] 105.31 percent of total billed charges 82.46 126.35 Technical (Hospital) Services Ref Immuglobulin E PX-3018278500 CDM 82785 CPT 301 RC inpatient 133 133 CIGNA 62308 [3081051] CIGNA 62308 [308105105] 105.31 percent of total billed charges 82.46 126.35 Technical (Hospital) Services Ref Immuglobulin E PX-3018278500 CDM 82785 CPT 301 RC inpatient 133 133 CIGNA 62308 [3081051] CIGNA STATE OF WYOMING [308105107] 105.31 percent of total billed charges 82.46 126.35 Technical (Hospital) Services Ref Immuglobulin E PX-3018278500 CDM 82785 CPT 301 RC outpatient 133 133 MEDICA (COMMERCIAL) 94265 [3081118] MEDICA CLAIMS [308111801] 119.7 percent of total billed charges 82.46 126.35 Technical (Hospital) Services Ref Immuglobulin E PX-3018278500 CDM 82785 CPT 301 RC outpatient 133 133 CIGNA 62308 [3081051] CIGNA 62308 [308105105] 106.4 percent of total billed charges 82.46 126.35 Technical (Hospital) Services Ref Immuglobulin E PX-3018278500 CDM 82785 CPT 301 RC outpatient 133 133 CIGNA 62308 [3081051] CIGNA STATE OF WYOMING [308105107] 106.4 percent of total billed charges 82.46 126.35 Technical (Hospital) Services Ref Immuglobulin E PX-3018278500 CDM 82785 CPT 301 RC outpatient 133 133 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES PPO [308136801] 106.4 percent of total billed charges 82.46 126.35 Technical (Hospital) Services Ref Immuglobulin E PX-3018278500 CDM 82785 CPT 301 RC outpatient 133 133 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES HDHP [308136802] 106.4 percent of total billed charges 82.46 126.35 Technical (Hospital) Services Ref Immuglobulin E PX-3018278500 CDM 82785 CPT 301 RC outpatient 133 133 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES EPO [308136803] 106.4 percent of total billed charges 82.46 126.35 Technical (Hospital) Services Ref Immuglobulin E PX-3018278500 CDM 82785 CPT 301 RC outpatient 133 133 BLUE CROSS BLUE SHIELD WELLMARK SB889 [3081026] BCBS WYOMING [308102603] 126.35 percent of total billed charges 82.46 126.35 Technical (Hospital) Services Ref Immuglobulin E PX-3018278500 CDM 82785 CPT 301 RC outpatient 133 133 MULTIPLAN INC 34080 [3081285] MULTIPLAN INC [308128501] 126.35 percent of total billed charges 82.46 126.35 Technical (Hospital) Services Ref Immuglobulin E PX-3018278500 CDM 82785 CPT 301 RC outpatient 133 133 HEALTHPARTNERS SX009 HEALTHPARTNERS 106.4 percent of total billed charges 82.46 126.35 Technical (Hospital) Services Ref Immuglobulin E PX-3018278500 CDM 82785 CPT 301 RC outpatient 133 133 UNITED HEALTHCARE (COMMERCIAL) [3081199] UNITED HEALTHCARE 87726 [308119901] 82.46 percent of total billed charges 82.46 126.35 Technical (Hospital) Services Ref Celiac Dis Serlgy Cascade Iga PX-3018278400 CDM 82784 CPT 301 RC outpatient 132 132 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES PPO [308136801] 105.6 percent of total billed charges 81.84 125.4 Technical (Hospital) Services Ref Celiac Dis Serlgy Cascade Iga PX-3018278400 CDM 82784 CPT 301 RC outpatient 132 132 BLUE CROSS BLUE SHIELD WELLMARK SB889 [3081026] BCBS WYOMING [308102603] 125.4 percent of total billed charges 81.84 125.4 Technical (Hospital) Services Ref Celiac Dis Serlgy Cascade Iga PX-3018278400 CDM 82784 CPT 301 RC outpatient 132 132 MULTIPLAN INC 34080 [3081285] MULTIPLAN INC [308128501] 125.4 percent of total billed charges 81.84 125.4 Technical (Hospital) Services Ref Celiac Dis Serlgy Cascade Iga PX-3018278400 CDM 82784 CPT 301 RC outpatient 132 132 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES EPO [308136803] 105.6 percent of total billed charges 81.84 125.4 Technical (Hospital) Services Ref Celiac Dis Serlgy Cascade Iga PX-3018278400 CDM 82784 CPT 301 RC outpatient 132 132 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES HDHP [308136802] 105.6 percent of total billed charges 81.84 125.4 Technical (Hospital) Services Ref Celiac Dis Serlgy Cascade Iga PX-3018278400 CDM 82784 CPT 301 RC outpatient 132 132 UNITED HEALTHCARE (COMMERCIAL) [3081199] UNITED HEALTHCARE 87726 [308119901] 81.84 percent of total billed charges 81.84 125.4 Technical (Hospital) Services Ref Celiac Dis Serlgy Cascade Iga PX-3018278400 CDM 82784 CPT 301 RC outpatient 132 132 HEALTHPARTNERS SX009 HEALTHPARTNERS 105.6 percent of total billed charges 81.84 125.4 Technical (Hospital) Services Ref Celiac Dis Serlgy Cascade Iga PX-3018278400 CDM 82784 CPT 301 RC outpatient 132 132 MEDICA (COMMERCIAL) 94265 [3081118] MEDICA CLAIMS [308111801] 118.8 percent of total billed charges 81.84 125.4 Technical (Hospital) Services Ref Celiac Dis Serlgy Cascade Iga PX-3018278400 CDM 82784 CPT 301 RC outpatient 132 132 CIGNA 62308 [3081051] CIGNA 62308 [308105105] 105.6 percent of total billed charges 81.84 125.4 Technical (Hospital) Services Ref Celiac Dis Serlgy Cascade Iga PX-3018278400 CDM 82784 CPT 301 RC outpatient 132 132 CIGNA 62308 [3081051] CIGNA STATE OF WYOMING [308105107] 105.6 percent of total billed charges 81.84 125.4 Technical (Hospital) Services Ref Celiac Dis Serlgy Cascade Iga PX-3018278400 CDM 82784 CPT 301 RC inpatient 132 132 BLUE CROSS BLUE SHIELD WELLMARK SB889 [3081026] BCBS WYOMING [308102603] 125.4 percent of total billed charges 81.84 125.4 Technical (Hospital) Services Ref Celiac Dis Serlgy Cascade Iga PX-3018278400 CDM 82784 CPT 301 RC inpatient 132 132 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES HDHP [308136802] 104.52 percent of total billed charges 81.84 125.4 Technical (Hospital) Services Ref Celiac Dis Serlgy Cascade Iga PX-3018278400 CDM 82784 CPT 301 RC inpatient 132 132 UNITED HEALTHCARE (COMMERCIAL) [3081199] UNITED HEALTHCARE 87726 [308119901] 81.84 percent of total billed charges 81.84 125.4 Technical (Hospital) Services Ref Celiac Dis Serlgy Cascade Iga PX-3018278400 CDM 82784 CPT 301 RC inpatient 132 132 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES PPO [308136801] 104.52 percent of total billed charges 81.84 125.4 Technical (Hospital) Services Ref Celiac Dis Serlgy Cascade Iga PX-3018278400 CDM 82784 CPT 301 RC inpatient 132 132 MULTIPLAN INC 34080 [3081285] MULTIPLAN INC [308128501] 125.4 percent of total billed charges 81.84 125.4 Technical (Hospital) Services Ref Celiac Dis Serlgy Cascade Iga PX-3018278400 CDM 82784 CPT 301 RC inpatient 132 132 MEDICA (COMMERCIAL) 94265 [3081118] MEDICA CLAIMS [308111801] 118.8 percent of total billed charges 81.84 125.4 Technical (Hospital) Services Ref Celiac Dis Serlgy Cascade Iga PX-3018278400 CDM 82784 CPT 301 RC inpatient 132 132 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES EPO [308136803] 104.52 percent of total billed charges 81.84 125.4 Technical (Hospital) Services Ref Celiac Dis Serlgy Cascade Iga PX-3018278400 CDM 82784 CPT 301 RC inpatient 132 132 HEALTHPARTNERS SX009 HEALTHPARTNERS 104.52 percent of total billed charges 81.84 125.4 Technical (Hospital) Services Ref Celiac Dis Serlgy Cascade Iga PX-3018278400 CDM 82784 CPT 301 RC inpatient 132 132 CIGNA 62308 [3081051] CIGNA 62308 [308105105] 104.52 percent of total billed charges 81.84 125.4 Technical (Hospital) Services Ref Celiac Dis Serlgy Cascade Iga PX-3018278400 CDM 82784 CPT 301 RC inpatient 132 132 CIGNA 62308 [3081051] CIGNA STATE OF WYOMING [308105107] 104.52 percent of total billed charges 81.84 125.4 Technical (Hospital) Services Ref Gammaglob Immunglob Igg Total PX-3018278402 CDM 82784 CPT 301 RC inpatient 87 87 MULTIPLAN INC 34080 [3081285] MULTIPLAN INC [308128501] 82.65 percent of total billed charges 53.94 82.65 Technical (Hospital) Services Ref Gammaglob Immunglob Igg Total PX-3018278402 CDM 82784 CPT 301 RC inpatient 87 87 MEDICA (COMMERCIAL) 94265 [3081118] MEDICA CLAIMS [308111801] 78.3 percent of total billed charges 53.94 82.65 Technical (Hospital) Services Ref Gammaglob Immunglob Igg Total PX-3018278402 CDM 82784 CPT 301 RC inpatient 87 87 HEALTHPARTNERS SX009 HEALTHPARTNERS 68.89 percent of total billed charges 53.94 82.65 Technical (Hospital) Services Ref Gammaglob Immunglob Igg Total PX-3018278402 CDM 82784 CPT 301 RC inpatient 87 87 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES EPO [308136803] 68.89 percent of total billed charges 53.94 82.65 Technical (Hospital) Services Ref Gammaglob Immunglob Igg Total PX-3018278402 CDM 82784 CPT 301 RC inpatient 87 87 BLUE CROSS BLUE SHIELD WELLMARK SB889 [3081026] BCBS WYOMING [308102603] 82.65 percent of total billed charges 53.94 82.65 Technical (Hospital) Services Ref Gammaglob Immunglob Igg Total PX-3018278402 CDM 82784 CPT 301 RC inpatient 87 87 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES HDHP [308136802] 68.89 percent of total billed charges 53.94 82.65 Technical (Hospital) Services Ref Gammaglob Immunglob Igg Total PX-3018278402 CDM 82784 CPT 301 RC inpatient 87 87 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES PPO [308136801] 68.89 percent of total billed charges 53.94 82.65 Technical (Hospital) Services Ref Gammaglob Immunglob Igg Total PX-3018278402 CDM 82784 CPT 301 RC inpatient 87 87 UNITED HEALTHCARE (COMMERCIAL) [3081199] UNITED HEALTHCARE 87726 [308119901] 53.94 percent of total billed charges 53.94 82.65 Technical (Hospital) Services Ref Gammaglob Immunglob Igg Total PX-3018278402 CDM 82784 CPT 301 RC inpatient 87 87 CIGNA 62308 [3081051] CIGNA 62308 [308105105] 68.89 percent of total billed charges 53.94 82.65 Technical (Hospital) Services Ref Gammaglob Immunglob Igg Total PX-3018278402 CDM 82784 CPT 301 RC inpatient 87 87 CIGNA 62308 [3081051] CIGNA STATE OF WYOMING [308105107] 68.89 percent of total billed charges 53.94 82.65 Technical (Hospital) Services Ref Gammaglob Immunglob Igg Total PX-3018278402 CDM 82784 CPT 301 RC outpatient 87 87 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES HDHP [308136802] 69.6 percent of total billed charges 53.94 82.65 Technical (Hospital) Services Ref Gammaglob Immunglob Igg Total PX-3018278402 CDM 82784 CPT 301 RC outpatient 87 87 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES EPO [308136803] 69.6 percent of total billed charges 53.94 82.65 Technical (Hospital) Services Ref Gammaglob Immunglob Igg Total PX-3018278402 CDM 82784 CPT 301 RC outpatient 87 87 BLUE CROSS BLUE SHIELD WELLMARK SB889 [3081026] BCBS WYOMING [308102603] 82.65 percent of total billed charges 53.94 82.65 Technical (Hospital) Services Ref Gammaglob Immunglob Igg Total PX-3018278402 CDM 82784 CPT 301 RC outpatient 87 87 MULTIPLAN INC 34080 [3081285] MULTIPLAN INC [308128501] 82.65 percent of total billed charges 53.94 82.65 Technical (Hospital) Services Ref Gammaglob Immunglob Igg Total PX-3018278402 CDM 82784 CPT 301 RC outpatient 87 87 HEALTHPARTNERS SX009 HEALTHPARTNERS 69.6 percent of total billed charges 53.94 82.65 Technical (Hospital) Services Ref Gammaglob Immunglob Igg Total PX-3018278402 CDM 82784 CPT 301 RC outpatient 87 87 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES PPO [308136801] 69.6 percent of total billed charges 53.94 82.65 Technical (Hospital) Services Ref Gammaglob Immunglob Igg Total PX-3018278402 CDM 82784 CPT 301 RC outpatient 87 87 UNITED HEALTHCARE (COMMERCIAL) [3081199] UNITED HEALTHCARE 87726 [308119901] 53.94 percent of total billed charges 53.94 82.65 Technical (Hospital) Services Ref Gammaglob Immunglob Igg Total PX-3018278402 CDM 82784 CPT 301 RC outpatient 87 87 CIGNA 62308 [3081051] CIGNA 62308 [308105105] 69.6 percent of total billed charges 53.94 82.65 Technical (Hospital) Services Ref Gammaglob Immunglob Igg Total PX-3018278402 CDM 82784 CPT 301 RC outpatient 87 87 CIGNA 62308 [3081051] CIGNA STATE OF WYOMING [308105107] 69.6 percent of total billed charges 53.94 82.65 Technical (Hospital) Services Ref Gammaglob Immunglob Igg Total PX-3018278402 CDM 82784 CPT 301 RC outpatient 87 87 MEDICA (COMMERCIAL) 94265 [3081118] MEDICA CLAIMS [308111801] 78.3 percent of total billed charges 53.94 82.65 Technical (Hospital) Services Ref Celiac Dis Serlgy Cascade Iga PX-3018278404 CDM 82784 CPT 301 RC outpatient 132 132 MEDICA (COMMERCIAL) 94265 [3081118] MEDICA CLAIMS [308111801] 118.8 percent of total billed charges 81.84 125.4 Technical (Hospital) Services Ref Celiac Dis Serlgy Cascade Iga PX-3018278404 CDM 82784 CPT 301 RC outpatient 132 132 CIGNA 62308 [3081051] CIGNA 62308 [308105105] 105.6 percent of total billed charges 81.84 125.4 Technical (Hospital) Services Ref Celiac Dis Serlgy Cascade Iga PX-3018278404 CDM 82784 CPT 301 RC outpatient 132 132 CIGNA 62308 [3081051] CIGNA STATE OF WYOMING [308105107] 105.6 percent of total billed charges 81.84 125.4 Technical (Hospital) Services Ref Celiac Dis Serlgy Cascade Iga PX-3018278404 CDM 82784 CPT 301 RC outpatient 132 132 BLUE CROSS BLUE SHIELD WELLMARK SB889 [3081026] BCBS WYOMING [308102603] 125.4 percent of total billed charges 81.84 125.4 Technical (Hospital) Services Ref Celiac Dis Serlgy Cascade Iga PX-3018278404 CDM 82784 CPT 301 RC outpatient 132 132 MULTIPLAN INC 34080 [3081285] MULTIPLAN INC [308128501] 125.4 percent of total billed charges 81.84 125.4 Technical (Hospital) Services Ref Celiac Dis Serlgy Cascade Iga PX-3018278404 CDM 82784 CPT 301 RC outpatient 132 132 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES EPO [308136803] 105.6 percent of total billed charges 81.84 125.4 Technical (Hospital) Services Ref Celiac Dis Serlgy Cascade Iga PX-3018278404 CDM 82784 CPT 301 RC outpatient 132 132 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES HDHP [308136802] 105.6 percent of total billed charges 81.84 125.4 Technical (Hospital) Services Ref Celiac Dis Serlgy Cascade Iga PX-3018278404 CDM 82784 CPT 301 RC outpatient 132 132 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES PPO [308136801] 105.6 percent of total billed charges 81.84 125.4 Technical (Hospital) Services Ref Celiac Dis Serlgy Cascade Iga PX-3018278404 CDM 82784 CPT 301 RC outpatient 132 132 HEALTHPARTNERS SX009 HEALTHPARTNERS 105.6 percent of total billed charges 81.84 125.4 Technical (Hospital) Services Ref Celiac Dis Serlgy Cascade Iga PX-3018278404 CDM 82784 CPT 301 RC outpatient 132 132 UNITED HEALTHCARE (COMMERCIAL) [3081199] UNITED HEALTHCARE 87726 [308119901] 81.84 percent of total billed charges 81.84 125.4 Technical (Hospital) Services Ref Celiac Dis Serlgy Cascade Iga PX-3018278404 CDM 82784 CPT 301 RC inpatient 132 132 CIGNA 62308 [3081051] CIGNA 62308 [308105105] 104.52 percent of total billed charges 81.84 125.4 Technical (Hospital) Services Ref Celiac Dis Serlgy Cascade Iga PX-3018278404 CDM 82784 CPT 301 RC inpatient 132 132 CIGNA 62308 [3081051] CIGNA STATE OF WYOMING [308105107] 104.52 percent of total billed charges 81.84 125.4 Technical (Hospital) Services Ref Celiac Dis Serlgy Cascade Iga PX-3018278404 CDM 82784 CPT 301 RC inpatient 132 132 HEALTHPARTNERS SX009 HEALTHPARTNERS 104.52 percent of total billed charges 81.84 125.4 Technical (Hospital) Services Ref Celiac Dis Serlgy Cascade Iga PX-3018278404 CDM 82784 CPT 301 RC inpatient 132 132 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES EPO [308136803] 104.52 percent of total billed charges 81.84 125.4 Technical (Hospital) Services Ref Celiac Dis Serlgy Cascade Iga PX-3018278404 CDM 82784 CPT 301 RC inpatient 132 132 MEDICA (COMMERCIAL) 94265 [3081118] MEDICA CLAIMS [308111801] 118.8 percent of total billed charges 81.84 125.4 Technical (Hospital) Services Ref Celiac Dis Serlgy Cascade Iga PX-3018278404 CDM 82784 CPT 301 RC inpatient 132 132 MULTIPLAN INC 34080 [3081285] MULTIPLAN INC [308128501] 125.4 percent of total billed charges 81.84 125.4 Technical (Hospital) Services Ref Celiac Dis Serlgy Cascade Iga PX-3018278404 CDM 82784 CPT 301 RC inpatient 132 132 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES PPO [308136801] 104.52 percent of total billed charges 81.84 125.4 Technical (Hospital) Services Ref Celiac Dis Serlgy Cascade Iga PX-3018278404 CDM 82784 CPT 301 RC inpatient 132 132 UNITED HEALTHCARE (COMMERCIAL) [3081199] UNITED HEALTHCARE 87726 [308119901] 81.84 percent of total billed charges 81.84 125.4 Technical (Hospital) Services Ref Celiac Dis Serlgy Cascade Iga PX-3018278404 CDM 82784 CPT 301 RC inpatient 132 132 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES HDHP [308136802] 104.52 percent of total billed charges 81.84 125.4 Technical (Hospital) Services Ref Celiac Dis Serlgy Cascade Iga PX-3018278404 CDM 82784 CPT 301 RC inpatient 132 132 BLUE CROSS BLUE SHIELD WELLMARK SB889 [3081026] BCBS WYOMING [308102603] 125.4 percent of total billed charges 81.84 125.4 Technical (Hospital) Services Gammaglob Immunoglobulin Each PX-3018278406 CDM 82784 CPT 301 RC inpatient 132 132 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES PPO [308136801] 104.52 percent of total billed charges 81.84 125.4 Technical (Hospital) Services Gammaglob Immunoglobulin Each PX-3018278406 CDM 82784 CPT 301 RC inpatient 132 132 UNITED HEALTHCARE (COMMERCIAL) [3081199] UNITED HEALTHCARE 87726 [308119901] 81.84 percent of total billed charges 81.84 125.4 Technical (Hospital) Services Gammaglob Immunoglobulin Each PX-3018278406 CDM 82784 CPT 301 RC inpatient 132 132 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES HDHP [308136802] 104.52 percent of total billed charges 81.84 125.4 Technical (Hospital) Services Gammaglob Immunoglobulin Each PX-3018278406 CDM 82784 CPT 301 RC inpatient 132 132 BLUE CROSS BLUE SHIELD WELLMARK SB889 [3081026] BCBS WYOMING [308102603] 125.4 percent of total billed charges 81.84 125.4 Technical (Hospital) Services Gammaglob Immunoglobulin Each PX-3018278406 CDM 82784 CPT 301 RC inpatient 132 132 MEDICA (COMMERCIAL) 94265 [3081118] MEDICA CLAIMS [308111801] 118.8 percent of total billed charges 81.84 125.4 Technical (Hospital) Services Gammaglob Immunoglobulin Each PX-3018278406 CDM 82784 CPT 301 RC inpatient 132 132 MULTIPLAN INC 34080 [3081285] MULTIPLAN INC [308128501] 125.4 percent of total billed charges 81.84 125.4 Technical (Hospital) Services Gammaglob Immunoglobulin Each PX-3018278406 CDM 82784 CPT 301 RC inpatient 132 132 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES EPO [308136803] 104.52 percent of total billed charges 81.84 125.4 Technical (Hospital) Services Gammaglob Immunoglobulin Each PX-3018278406 CDM 82784 CPT 301 RC inpatient 132 132 HEALTHPARTNERS SX009 HEALTHPARTNERS 104.52 percent of total billed charges 81.84 125.4 Technical (Hospital) Services Gammaglob Immunoglobulin Each PX-3018278406 CDM 82784 CPT 301 RC inpatient 132 132 CIGNA 62308 [3081051] CIGNA 62308 [308105105] 104.52 percent of total billed charges 81.84 125.4 Technical (Hospital) Services Gammaglob Immunoglobulin Each PX-3018278406 CDM 82784 CPT 301 RC inpatient 132 132 CIGNA 62308 [3081051] CIGNA STATE OF WYOMING [308105107] 104.52 percent of total billed charges 81.84 125.4 Technical (Hospital) Services Gammaglob Immunoglobulin Each PX-3018278406 CDM 82784 CPT 301 RC outpatient 132 132 MEDICA (COMMERCIAL) 94265 [3081118] MEDICA CLAIMS [308111801] 118.8 percent of total billed charges 81.84 125.4 Technical (Hospital) Services Gammaglob Immunoglobulin Each PX-3018278406 CDM 82784 CPT 301 RC outpatient 132 132 CIGNA 62308 [3081051] CIGNA 62308 [308105105] 105.6 percent of total billed charges 81.84 125.4 Technical (Hospital) Services Gammaglob Immunoglobulin Each PX-3018278406 CDM 82784 CPT 301 RC outpatient 132 132 CIGNA 62308 [3081051] CIGNA STATE OF WYOMING [308105107] 105.6 percent of total billed charges 81.84 125.4 Technical (Hospital) Services Gammaglob Immunoglobulin Each PX-3018278406 CDM 82784 CPT 301 RC outpatient 132 132 MULTIPLAN INC 34080 [3081285] MULTIPLAN INC [308128501] 125.4 percent of total billed charges 81.84 125.4 Technical (Hospital) Services Gammaglob Immunoglobulin Each PX-3018278406 CDM 82784 CPT 301 RC outpatient 132 132 BLUE CROSS BLUE SHIELD WELLMARK SB889 [3081026] BCBS WYOMING [308102603] 125.4 percent of total billed charges 81.84 125.4 Technical (Hospital) Services Gammaglob Immunoglobulin Each PX-3018278406 CDM 82784 CPT 301 RC outpatient 132 132 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES HDHP [308136802] 105.6 percent of total billed charges 81.84 125.4 Technical (Hospital) Services Gammaglob Immunoglobulin Each PX-3018278406 CDM 82784 CPT 301 RC outpatient 132 132 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES EPO [308136803] 105.6 percent of total billed charges 81.84 125.4 Technical (Hospital) Services Gammaglob Immunoglobulin Each PX-3018278406 CDM 82784 CPT 301 RC outpatient 132 132 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES PPO [308136801] 105.6 percent of total billed charges 81.84 125.4 Technical (Hospital) Services Gammaglob Immunoglobulin Each PX-3018278406 CDM 82784 CPT 301 RC outpatient 132 132 UNITED HEALTHCARE (COMMERCIAL) [3081199] UNITED HEALTHCARE 87726 [308119901] 81.84 percent of total billed charges 81.84 125.4 Technical (Hospital) Services Gammaglob Immunoglobulin Each PX-3018278406 CDM 82784 CPT 301 RC outpatient 132 132 HEALTHPARTNERS SX009 HEALTHPARTNERS 105.6 percent of total billed charges 81.84 125.4 Technical (Hospital) Services Ref Galactosemia Screen PX-3018277600 CDM 82776 CPT 301 RC outpatient 34 34 MULTIPLAN INC 34080 [3081285] MULTIPLAN INC [308128501] 32.3 percent of total billed charges 21.08 32.3 Technical (Hospital) Services Ref Galactosemia Screen PX-3018277600 CDM 82776 CPT 301 RC outpatient 34 34 BLUE CROSS BLUE SHIELD WELLMARK SB889 [3081026] BCBS WYOMING [308102603] 32.3 percent of total billed charges 21.08 32.3 Technical (Hospital) Services Ref Galactosemia Screen PX-3018277600 CDM 82776 CPT 301 RC outpatient 34 34 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES EPO [308136803] 27.2 percent of total billed charges 21.08 32.3 Technical (Hospital) Services Ref Galactosemia Screen PX-3018277600 CDM 82776 CPT 301 RC outpatient 34 34 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES HDHP [308136802] 27.2 percent of total billed charges 21.08 32.3 Technical (Hospital) Services Ref Galactosemia Screen PX-3018277600 CDM 82776 CPT 301 RC outpatient 34 34 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES PPO [308136801] 27.2 percent of total billed charges 21.08 32.3 Technical (Hospital) Services Ref Galactosemia Screen PX-3018277600 CDM 82776 CPT 301 RC outpatient 34 34 UNITED HEALTHCARE (COMMERCIAL) [3081199] UNITED HEALTHCARE 87726 [308119901] 21.08 percent of total billed charges 21.08 32.3 Technical (Hospital) Services Ref Galactosemia Screen PX-3018277600 CDM 82776 CPT 301 RC outpatient 34 34 HEALTHPARTNERS SX009 HEALTHPARTNERS 27.2 percent of total billed charges 21.08 32.3 Technical (Hospital) Services Ref Galactosemia Screen PX-3018277600 CDM 82776 CPT 301 RC outpatient 34 34 CIGNA 62308 [3081051] CIGNA 62308 [308105105] 27.2 percent of total billed charges 21.08 32.3 Technical (Hospital) Services Ref Galactosemia Screen PX-3018277600 CDM 82776 CPT 301 RC outpatient 34 34 CIGNA 62308 [3081051] CIGNA STATE OF WYOMING [308105107] 27.2 percent of total billed charges 21.08 32.3 Technical (Hospital) Services Ref Galactosemia Screen PX-3018277600 CDM 82776 CPT 301 RC outpatient 34 34 MEDICA (COMMERCIAL) 94265 [3081118] MEDICA CLAIMS [308111801] 30.6 percent of total billed charges 21.08 32.3 Technical (Hospital) Services Ref Galactosemia Screen PX-3018277600 CDM 82776 CPT 301 RC inpatient 34 34 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES EPO [308136803] 26.92 percent of total billed charges 21.08 32.3 Technical (Hospital) Services Ref Galactosemia Screen PX-3018277600 CDM 82776 CPT 301 RC inpatient 34 34 HEALTHPARTNERS SX009 HEALTHPARTNERS 26.92 percent of total billed charges 21.08 32.3 Technical (Hospital) Services Ref Galactosemia Screen PX-3018277600 CDM 82776 CPT 301 RC inpatient 34 34 MULTIPLAN INC 34080 [3081285] MULTIPLAN INC [308128501] 32.3 percent of total billed charges 21.08 32.3 Technical (Hospital) Services Ref Galactosemia Screen PX-3018277600 CDM 82776 CPT 301 RC inpatient 34 34 MEDICA (COMMERCIAL) 94265 [3081118] MEDICA CLAIMS [308111801] 30.6 percent of total billed charges 21.08 32.3 Technical (Hospital) Services Ref Galactosemia Screen PX-3018277600 CDM 82776 CPT 301 RC inpatient 34 34 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES PPO [308136801] 26.92 percent of total billed charges 21.08 32.3 Technical (Hospital) Services Ref Galactosemia Screen PX-3018277600 CDM 82776 CPT 301 RC inpatient 34 34 UNITED HEALTHCARE (COMMERCIAL) [3081199] UNITED HEALTHCARE 87726 [308119901] 21.08 percent of total billed charges 21.08 32.3 Technical (Hospital) Services Ref Galactosemia Screen PX-3018277600 CDM 82776 CPT 301 RC inpatient 34 34 BLUE CROSS BLUE SHIELD WELLMARK SB889 [3081026] BCBS WYOMING [308102603] 32.3 percent of total billed charges 21.08 32.3 Technical (Hospital) Services Ref Galactosemia Screen PX-3018277600 CDM 82776 CPT 301 RC inpatient 34 34 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES HDHP [308136802] 26.92 percent of total billed charges 21.08 32.3 Technical (Hospital) Services Ref Galactosemia Screen PX-3018277600 CDM 82776 CPT 301 RC inpatient 34 34 CIGNA 62308 [3081051] CIGNA 62308 [308105105] 26.92 percent of total billed charges 21.08 32.3 Technical (Hospital) Services Ref Galactosemia Screen PX-3018277600 CDM 82776 CPT 301 RC inpatient 34 34 CIGNA 62308 [3081051] CIGNA STATE OF WYOMING [308105107] 26.92 percent of total billed charges 21.08 32.3 Technical (Hospital) Services Folate Serum PX-3018274600 CDM 82746 CPT 301 RC outpatient 195 195 MEDICA (COMMERCIAL) 94265 [3081118] MEDICA CLAIMS [308111801] 175.5 percent of total billed charges 120.9 185.25 Technical (Hospital) Services Folate Serum PX-3018274600 CDM 82746 CPT 301 RC outpatient 195 195 CIGNA 62308 [3081051] CIGNA 62308 [308105105] 156 percent of total billed charges 120.9 185.25 Technical (Hospital) Services Folate Serum PX-3018274600 CDM 82746 CPT 301 RC outpatient 195 195 CIGNA 62308 [3081051] CIGNA STATE OF WYOMING [308105107] 156 percent of total billed charges 120.9 185.25 Technical (Hospital) Services Folate Serum PX-3018274600 CDM 82746 CPT 301 RC outpatient 195 195 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES PPO [308136801] 156 percent of total billed charges 120.9 185.25 Technical (Hospital) Services Folate Serum PX-3018274600 CDM 82746 CPT 301 RC outpatient 195 195 MULTIPLAN INC 34080 [3081285] MULTIPLAN INC [308128501] 185.25 percent of total billed charges 120.9 185.25 Technical (Hospital) Services Folate Serum PX-3018274600 CDM 82746 CPT 301 RC outpatient 195 195 BLUE CROSS BLUE SHIELD WELLMARK SB889 [3081026] BCBS WYOMING [308102603] 185.25 percent of total billed charges 120.9 185.25 Technical (Hospital) Services Folate Serum PX-3018274600 CDM 82746 CPT 301 RC outpatient 195 195 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES EPO [308136803] 156 percent of total billed charges 120.9 185.25 Technical (Hospital) Services Folate Serum PX-3018274600 CDM 82746 CPT 301 RC outpatient 195 195 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES HDHP [308136802] 156 percent of total billed charges 120.9 185.25 Technical (Hospital) Services Folate Serum PX-3018274600 CDM 82746 CPT 301 RC outpatient 195 195 UNITED HEALTHCARE (COMMERCIAL) [3081199] UNITED HEALTHCARE 87726 [308119901] 120.9 percent of total billed charges 120.9 185.25 Technical (Hospital) Services Folate Serum PX-3018274600 CDM 82746 CPT 301 RC outpatient 195 195 HEALTHPARTNERS SX009 HEALTHPARTNERS 156 percent of total billed charges 120.9 185.25 Technical (Hospital) Services Folate Serum PX-3018274600 CDM 82746 CPT 301 RC inpatient 195 195 CIGNA 62308 [3081051] CIGNA 62308 [308105105] 154.4 percent of total billed charges 120.9 185.25 Technical (Hospital) Services Folate Serum PX-3018274600 CDM 82746 CPT 301 RC inpatient 195 195 CIGNA 62308 [3081051] CIGNA STATE OF WYOMING [308105107] 154.4 percent of total billed charges 120.9 185.25 Technical (Hospital) Services Folate Serum PX-3018274600 CDM 82746 CPT 301 RC inpatient 195 195 UNITED HEALTHCARE (COMMERCIAL) [3081199] UNITED HEALTHCARE 87726 [308119901] 120.9 percent of total billed charges 120.9 185.25 Technical (Hospital) Services Folate Serum PX-3018274600 CDM 82746 CPT 301 RC inpatient 195 195 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES PPO [308136801] 154.4 percent of total billed charges 120.9 185.25 Technical (Hospital) Services Folate Serum PX-3018274600 CDM 82746 CPT 301 RC inpatient 195 195 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES HDHP [308136802] 154.4 percent of total billed charges 120.9 185.25 Technical (Hospital) Services Folate Serum PX-3018274600 CDM 82746 CPT 301 RC inpatient 195 195 BLUE CROSS BLUE SHIELD WELLMARK SB889 [3081026] BCBS WYOMING [308102603] 185.25 percent of total billed charges 120.9 185.25 Technical (Hospital) Services Folate Serum PX-3018274600 CDM 82746 CPT 301 RC inpatient 195 195 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES EPO [308136803] 154.4 percent of total billed charges 120.9 185.25 Technical (Hospital) Services Folate Serum PX-3018274600 CDM 82746 CPT 301 RC inpatient 195 195 HEALTHPARTNERS SX009 HEALTHPARTNERS 154.4 percent of total billed charges 120.9 185.25 Technical (Hospital) Services Folate Serum PX-3018274600 CDM 82746 CPT 301 RC inpatient 195 195 MEDICA (COMMERCIAL) 94265 [3081118] MEDICA CLAIMS [308111801] 175.5 percent of total billed charges 120.9 185.25 Technical (Hospital) Services Folate Serum PX-3018274600 CDM 82746 CPT 301 RC inpatient 195 195 MULTIPLAN INC 34080 [3081285] MULTIPLAN INC [308128501] 185.25 percent of total billed charges 120.9 185.25 Technical (Hospital) Services Ferritin PX-3018272800 CDM 82728 CPT 301 RC outpatient 176 176 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES HDHP [308136802] 140.8 percent of total billed charges 109.12 167.2 Technical (Hospital) Services Ferritin PX-3018272800 CDM 82728 CPT 301 RC outpatient 176 176 MULTIPLAN INC 34080 [3081285] MULTIPLAN INC [308128501] 167.2 percent of total billed charges 109.12 167.2 Technical (Hospital) Services Ferritin PX-3018272800 CDM 82728 CPT 301 RC outpatient 176 176 BLUE CROSS BLUE SHIELD WELLMARK SB889 [3081026] BCBS WYOMING [308102603] 167.2 percent of total billed charges 109.12 167.2 Technical (Hospital) Services Ferritin PX-3018272800 CDM 82728 CPT 301 RC outpatient 176 176 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES EPO [308136803] 140.8 percent of total billed charges 109.12 167.2 Technical (Hospital) Services Ferritin PX-3018272800 CDM 82728 CPT 301 RC outpatient 176 176 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES PPO [308136801] 140.8 percent of total billed charges 109.12 167.2 Technical (Hospital) Services Ferritin PX-3018272800 CDM 82728 CPT 301 RC outpatient 176 176 UNITED HEALTHCARE (COMMERCIAL) [3081199] UNITED HEALTHCARE 87726 [308119901] 109.12 percent of total billed charges 109.12 167.2 Technical (Hospital) Services Ferritin PX-3018272800 CDM 82728 CPT 301 RC outpatient 176 176 HEALTHPARTNERS SX009 HEALTHPARTNERS 140.8 percent of total billed charges 109.12 167.2 Technical (Hospital) Services Ferritin PX-3018272800 CDM 82728 CPT 301 RC outpatient 176 176 CIGNA 62308 [3081051] CIGNA 62308 [308105105] 140.8 percent of total billed charges 109.12 167.2 Technical (Hospital) Services Ferritin PX-3018272800 CDM 82728 CPT 301 RC outpatient 176 176 CIGNA 62308 [3081051] CIGNA STATE OF WYOMING [308105107] 140.8 percent of total billed charges 109.12 167.2 Technical (Hospital) Services Ferritin PX-3018272800 CDM 82728 CPT 301 RC outpatient 176 176 MEDICA (COMMERCIAL) 94265 [3081118] MEDICA CLAIMS [308111801] 158.4 percent of total billed charges 109.12 167.2 Technical (Hospital) Services Ferritin PX-3018272800 CDM 82728 CPT 301 RC inpatient 176 176 CIGNA 62308 [3081051] CIGNA 62308 [308105105] 139.36 percent of total billed charges 109.12 167.2 Technical (Hospital) Services Ferritin PX-3018272800 CDM 82728 CPT 301 RC inpatient 176 176 CIGNA 62308 [3081051] CIGNA STATE OF WYOMING [308105107] 139.36 percent of total billed charges 109.12 167.2 Technical (Hospital) Services Ferritin PX-3018272800 CDM 82728 CPT 301 RC inpatient 176 176 MULTIPLAN INC 34080 [3081285] MULTIPLAN INC [308128501] 167.2 percent of total billed charges 109.12 167.2 Technical (Hospital) Services Ferritin PX-3018272800 CDM 82728 CPT 301 RC inpatient 176 176 MEDICA (COMMERCIAL) 94265 [3081118] MEDICA CLAIMS [308111801] 158.4 percent of total billed charges 109.12 167.2 Technical (Hospital) Services Ferritin PX-3018272800 CDM 82728 CPT 301 RC inpatient 176 176 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES EPO [308136803] 139.36 percent of total billed charges 109.12 167.2 Technical (Hospital) Services Ferritin PX-3018272800 CDM 82728 CPT 301 RC inpatient 176 176 HEALTHPARTNERS SX009 HEALTHPARTNERS 139.36 percent of total billed charges 109.12 167.2 Technical (Hospital) Services Ferritin PX-3018272800 CDM 82728 CPT 301 RC inpatient 176 176 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES HDHP [308136802] 139.36 percent of total billed charges 109.12 167.2 Technical (Hospital) Services Ferritin PX-3018272800 CDM 82728 CPT 301 RC inpatient 176 176 BLUE CROSS BLUE SHIELD WELLMARK SB889 [3081026] BCBS WYOMING [308102603] 167.2 percent of total billed charges 109.12 167.2 Technical (Hospital) Services Ferritin PX-3018272800 CDM 82728 CPT 301 RC inpatient 176 176 UNITED HEALTHCARE (COMMERCIAL) [3081199] UNITED HEALTHCARE 87726 [308119901] 109.12 percent of total billed charges 109.12 167.2 Technical (Hospital) Services Ferritin PX-3018272800 CDM 82728 CPT 301 RC inpatient 176 176 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES PPO [308136801] 139.36 percent of total billed charges 109.12 167.2 Technical (Hospital) Services Ref Ferritin Serum PX-3018272801 CDM 82728 CPT 301 RC inpatient 340 340 CIGNA 62308 [3081051] CIGNA 62308 [308105105] 269.21 percent of total billed charges 210.8 323 Technical (Hospital) Services Ref Ferritin Serum PX-3018272801 CDM 82728 CPT 301 RC inpatient 340 340 CIGNA 62308 [3081051] CIGNA STATE OF WYOMING [308105107] 269.21 percent of total billed charges 210.8 323 Technical (Hospital) Services Ref Ferritin Serum PX-3018272801 CDM 82728 CPT 301 RC inpatient 340 340 UNITED HEALTHCARE (COMMERCIAL) [3081199] UNITED HEALTHCARE 87726 [308119901] 210.8 percent of total billed charges 210.8 323 Technical (Hospital) Services Ref Ferritin Serum PX-3018272801 CDM 82728 CPT 301 RC inpatient 340 340 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES PPO [308136801] 269.21 percent of total billed charges 210.8 323 Technical (Hospital) Services Ref Ferritin Serum PX-3018272801 CDM 82728 CPT 301 RC inpatient 340 340 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES HDHP [308136802] 269.21 percent of total billed charges 210.8 323 Technical (Hospital) Services Ref Ferritin Serum PX-3018272801 CDM 82728 CPT 301 RC inpatient 340 340 BLUE CROSS BLUE SHIELD WELLMARK SB889 [3081026] BCBS WYOMING [308102603] 323 percent of total billed charges 210.8 323 Technical (Hospital) Services Ref Ferritin Serum PX-3018272801 CDM 82728 CPT 301 RC inpatient 340 340 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES EPO [308136803] 269.21 percent of total billed charges 210.8 323 Technical (Hospital) Services Ref Ferritin Serum PX-3018272801 CDM 82728 CPT 301 RC inpatient 340 340 HEALTHPARTNERS SX009 HEALTHPARTNERS 269.21 percent of total billed charges 210.8 323 Technical (Hospital) Services Ref Ferritin Serum PX-3018272801 CDM 82728 CPT 301 RC inpatient 340 340 MEDICA (COMMERCIAL) 94265 [3081118] MEDICA CLAIMS [308111801] 306 percent of total billed charges 210.8 323 Technical (Hospital) Services Ref Ferritin Serum PX-3018272801 CDM 82728 CPT 301 RC inpatient 340 340 MULTIPLAN INC 34080 [3081285] MULTIPLAN INC [308128501] 323 percent of total billed charges 210.8 323 Technical (Hospital) Services Ref Ferritin Serum PX-3018272801 CDM 82728 CPT 301 RC outpatient 340 340 HEALTHPARTNERS SX009 HEALTHPARTNERS 272 percent of total billed charges 210.8 323 Technical (Hospital) Services Ref Ferritin Serum PX-3018272801 CDM 82728 CPT 301 RC outpatient 340 340 UNITED HEALTHCARE (COMMERCIAL) [3081199] UNITED HEALTHCARE 87726 [308119901] 210.8 percent of total billed charges 210.8 323 Technical (Hospital) Services Ref Ferritin Serum PX-3018272801 CDM 82728 CPT 301 RC outpatient 340 340 MULTIPLAN INC 34080 [3081285] MULTIPLAN INC [308128501] 323 percent of total billed charges 210.8 323 Technical (Hospital) Services Ref Ferritin Serum PX-3018272801 CDM 82728 CPT 301 RC outpatient 340 340 BLUE CROSS BLUE SHIELD WELLMARK SB889 [3081026] BCBS WYOMING [308102603] 323 percent of total billed charges 210.8 323 Technical (Hospital) Services Ref Ferritin Serum PX-3018272801 CDM 82728 CPT 301 RC outpatient 340 340 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES EPO [308136803] 272 percent of total billed charges 210.8 323 Technical (Hospital) Services Ref Ferritin Serum PX-3018272801 CDM 82728 CPT 301 RC outpatient 340 340 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES HDHP [308136802] 272 percent of total billed charges 210.8 323 Technical (Hospital) Services Ref Ferritin Serum PX-3018272801 CDM 82728 CPT 301 RC outpatient 340 340 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES PPO [308136801] 272 percent of total billed charges 210.8 323 Technical (Hospital) Services Ref Ferritin Serum PX-3018272801 CDM 82728 CPT 301 RC outpatient 340 340 MEDICA (COMMERCIAL) 94265 [3081118] MEDICA CLAIMS [308111801] 306 percent of total billed charges 210.8 323 Technical (Hospital) Services Ref Ferritin Serum PX-3018272801 CDM 82728 CPT 301 RC outpatient 340 340 CIGNA 62308 [3081051] CIGNA 62308 [308105105] 272 percent of total billed charges 210.8 323 Technical (Hospital) Services Ref Ferritin Serum PX-3018272801 CDM 82728 CPT 301 RC outpatient 340 340 CIGNA 62308 [3081051] CIGNA STATE OF WYOMING [308105107] 272 percent of total billed charges 210.8 323 Technical (Hospital) Services Ref Fecal Fat Quant PX-3018271000 CDM 82710 CPT 301 RC inpatient 232 232 UNITED HEALTHCARE (COMMERCIAL) [3081199] UNITED HEALTHCARE 87726 [308119901] 143.84 percent of total billed charges 143.84 220.4 Technical (Hospital) Services Ref Fecal Fat Quant PX-3018271000 CDM 82710 CPT 301 RC inpatient 232 232 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES PPO [308136801] 183.7 percent of total billed charges 143.84 220.4 Technical (Hospital) Services Ref Fecal Fat Quant PX-3018271000 CDM 82710 CPT 301 RC inpatient 232 232 BLUE CROSS BLUE SHIELD WELLMARK SB889 [3081026] BCBS WYOMING [308102603] 220.4 percent of total billed charges 143.84 220.4 Technical (Hospital) Services Ref Fecal Fat Quant PX-3018271000 CDM 82710 CPT 301 RC inpatient 232 232 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES EPO [308136803] 183.7 percent of total billed charges 143.84 220.4 Technical (Hospital) Services Ref Fecal Fat Quant PX-3018271000 CDM 82710 CPT 301 RC inpatient 232 232 HEALTHPARTNERS SX009 HEALTHPARTNERS 183.7 percent of total billed charges 143.84 220.4 Technical (Hospital) Services Ref Fecal Fat Quant PX-3018271000 CDM 82710 CPT 301 RC inpatient 232 232 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES HDHP [308136802] 183.7 percent of total billed charges 143.84 220.4 Technical (Hospital) Services Ref Fecal Fat Quant PX-3018271000 CDM 82710 CPT 301 RC inpatient 232 232 MULTIPLAN INC 34080 [3081285] MULTIPLAN INC [308128501] 220.4 percent of total billed charges 143.84 220.4 Technical (Hospital) Services Ref Fecal Fat Quant PX-3018271000 CDM 82710 CPT 301 RC inpatient 232 232 MEDICA (COMMERCIAL) 94265 [3081118] MEDICA CLAIMS [308111801] 208.8 percent of total billed charges 143.84 220.4 Technical (Hospital) Services Ref Fecal Fat Quant PX-3018271000 CDM 82710 CPT 301 RC inpatient 232 232 CIGNA 62308 [3081051] CIGNA 62308 [308105105] 183.7 percent of total billed charges 143.84 220.4 Technical (Hospital) Services Ref Fecal Fat Quant PX-3018271000 CDM 82710 CPT 301 RC inpatient 232 232 CIGNA 62308 [3081051] CIGNA STATE OF WYOMING [308105107] 183.7 percent of total billed charges 143.84 220.4 Technical (Hospital) Services Ref Fecal Fat Quant PX-3018271000 CDM 82710 CPT 301 RC outpatient 232 232 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES HDHP [308136802] 185.6 percent of total billed charges 143.84 220.4 Technical (Hospital) Services Ref Fecal Fat Quant PX-3018271000 CDM 82710 CPT 301 RC outpatient 232 232 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES EPO [308136803] 185.6 percent of total billed charges 143.84 220.4 Technical (Hospital) Services Ref Fecal Fat Quant PX-3018271000 CDM 82710 CPT 301 RC outpatient 232 232 BLUE CROSS BLUE SHIELD WELLMARK SB889 [3081026] BCBS WYOMING [308102603] 220.4 percent of total billed charges 143.84 220.4 Technical (Hospital) Services Ref Fecal Fat Quant PX-3018271000 CDM 82710 CPT 301 RC outpatient 232 232 MULTIPLAN INC 34080 [3081285] MULTIPLAN INC [308128501] 220.4 percent of total billed charges 143.84 220.4 Technical (Hospital) Services Ref Fecal Fat Quant PX-3018271000 CDM 82710 CPT 301 RC outpatient 232 232 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES PPO [308136801] 185.6 percent of total billed charges 143.84 220.4 Technical (Hospital) Services Ref Fecal Fat Quant PX-3018271000 CDM 82710 CPT 301 RC outpatient 232 232 HEALTHPARTNERS SX009 HEALTHPARTNERS 185.6 percent of total billed charges 143.84 220.4 Technical (Hospital) Services Ref Fecal Fat Quant PX-3018271000 CDM 82710 CPT 301 RC outpatient 232 232 UNITED HEALTHCARE (COMMERCIAL) [3081199] UNITED HEALTHCARE 87726 [308119901] 143.84 percent of total billed charges 143.84 220.4 Technical (Hospital) Services Ref Fecal Fat Quant PX-3018271000 CDM 82710 CPT 301 RC outpatient 232 232 MEDICA (COMMERCIAL) 94265 [3081118] MEDICA CLAIMS [308111801] 208.8 percent of total billed charges 143.84 220.4 Technical (Hospital) Services Ref Fecal Fat Quant PX-3018271000 CDM 82710 CPT 301 RC outpatient 232 232 CIGNA 62308 [3081051] CIGNA 62308 [308105105] 185.6 percent of total billed charges 143.84 220.4 Technical (Hospital) Services Ref Fecal Fat Quant PX-3018271000 CDM 82710 CPT 301 RC outpatient 232 232 CIGNA 62308 [3081051] CIGNA STATE OF WYOMING [308105107] 185.6 percent of total billed charges 143.84 220.4 Technical (Hospital) Services Ref Ethylene Glycol PX-3018032003 CDM 82693 CPT 301 RC outpatient 230 230 MEDICA (COMMERCIAL) 94265 [3081118] MEDICA CLAIMS [308111801] 207 percent of total billed charges 142.6 218.5 Technical (Hospital) Services Ref Ethylene Glycol PX-3018032003 CDM 82693 CPT 301 RC outpatient 230 230 CIGNA 62308 [3081051] CIGNA 62308 [308105105] 184 percent of total billed charges 142.6 218.5 Technical (Hospital) Services Ref Ethylene Glycol PX-3018032003 CDM 82693 CPT 301 RC outpatient 230 230 CIGNA 62308 [3081051] CIGNA STATE OF WYOMING [308105107] 184 percent of total billed charges 142.6 218.5 Technical (Hospital) Services Ref Ethylene Glycol PX-3018032003 CDM 82693 CPT 301 RC outpatient 230 230 HEALTHPARTNERS SX009 HEALTHPARTNERS 184 percent of total billed charges 142.6 218.5 Technical (Hospital) Services Ref Ethylene Glycol PX-3018032003 CDM 82693 CPT 301 RC outpatient 230 230 UNITED HEALTHCARE (COMMERCIAL) [3081199] UNITED HEALTHCARE 87726 [308119901] 142.6 percent of total billed charges 142.6 218.5 Technical (Hospital) Services Ref Ethylene Glycol PX-3018032003 CDM 82693 CPT 301 RC outpatient 230 230 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES EPO [308136803] 184 percent of total billed charges 142.6 218.5 Technical (Hospital) Services Ref Ethylene Glycol PX-3018032003 CDM 82693 CPT 301 RC outpatient 230 230 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES PPO [308136801] 184 percent of total billed charges 142.6 218.5 Technical (Hospital) Services Ref Ethylene Glycol PX-3018032003 CDM 82693 CPT 301 RC outpatient 230 230 BLUE CROSS BLUE SHIELD WELLMARK SB889 [3081026] BCBS WYOMING [308102603] 218.5 percent of total billed charges 142.6 218.5 Technical (Hospital) Services Ref Ethylene Glycol PX-3018032003 CDM 82693 CPT 301 RC outpatient 230 230 MULTIPLAN INC 34080 [3081285] MULTIPLAN INC [308128501] 218.5 percent of total billed charges 142.6 218.5 Technical (Hospital) Services Ref Ethylene Glycol PX-3018032003 CDM 82693 CPT 301 RC outpatient 230 230 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES HDHP [308136802] 184 percent of total billed charges 142.6 218.5 Technical (Hospital) Services Ref Ethylene Glycol PX-3018032003 CDM 82693 CPT 301 RC inpatient 230 230 MEDICA (COMMERCIAL) 94265 [3081118] MEDICA CLAIMS [308111801] 207 percent of total billed charges 142.6 218.5 Technical (Hospital) Services Ref Ethylene Glycol PX-3018032003 CDM 82693 CPT 301 RC inpatient 230 230 MULTIPLAN INC 34080 [3081285] MULTIPLAN INC [308128501] 218.5 percent of total billed charges 142.6 218.5 Technical (Hospital) Services Ref Ethylene Glycol PX-3018032003 CDM 82693 CPT 301 RC inpatient 230 230 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES EPO [308136803] 182.11 percent of total billed charges 142.6 218.5 Technical (Hospital) Services Ref Ethylene Glycol PX-3018032003 CDM 82693 CPT 301 RC inpatient 230 230 HEALTHPARTNERS SX009 HEALTHPARTNERS 182.11 percent of total billed charges 142.6 218.5 Technical (Hospital) Services Ref Ethylene Glycol PX-3018032003 CDM 82693 CPT 301 RC inpatient 230 230 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES HDHP [308136802] 182.11 percent of total billed charges 142.6 218.5 Technical (Hospital) Services Ref Ethylene Glycol PX-3018032003 CDM 82693 CPT 301 RC inpatient 230 230 BLUE CROSS BLUE SHIELD WELLMARK SB889 [3081026] BCBS WYOMING [308102603] 218.5 percent of total billed charges 142.6 218.5 Technical (Hospital) Services Ref Ethylene Glycol PX-3018032003 CDM 82693 CPT 301 RC inpatient 230 230 UNITED HEALTHCARE (COMMERCIAL) [3081199] UNITED HEALTHCARE 87726 [308119901] 142.6 percent of total billed charges 142.6 218.5 Technical (Hospital) Services Ref Ethylene Glycol PX-3018032003 CDM 82693 CPT 301 RC inpatient 230 230 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES PPO [308136801] 182.11 percent of total billed charges 142.6 218.5 Technical (Hospital) Services Ref Ethylene Glycol PX-3018032003 CDM 82693 CPT 301 RC inpatient 230 230 CIGNA 62308 [3081051] CIGNA 62308 [308105105] 182.11 percent of total billed charges 142.6 218.5 Technical (Hospital) Services Ref Ethylene Glycol PX-3018032003 CDM 82693 CPT 301 RC inpatient 230 230 CIGNA 62308 [3081051] CIGNA STATE OF WYOMING [308105107] 182.11 percent of total billed charges 142.6 218.5 Technical (Hospital) Services Ref Assay of Estrone PX-3018267900 CDM 82679 CPT 301 RC inpatient 286 286 CIGNA 62308 [3081051] CIGNA 62308 [308105105] 226.45 percent of total billed charges 177.32 271.7 Technical (Hospital) Services Ref Assay of Estrone PX-3018267900 CDM 82679 CPT 301 RC inpatient 286 286 CIGNA 62308 [3081051] CIGNA STATE OF WYOMING [308105107] 226.45 percent of total billed charges 177.32 271.7 Technical (Hospital) Services Ref Assay of Estrone PX-3018267900 CDM 82679 CPT 301 RC inpatient 286 286 UNITED HEALTHCARE (COMMERCIAL) [3081199] UNITED HEALTHCARE 87726 [308119901] 177.32 percent of total billed charges 177.32 271.7 Technical (Hospital) Services Ref Assay of Estrone PX-3018267900 CDM 82679 CPT 301 RC inpatient 286 286 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES PPO [308136801] 226.45 percent of total billed charges 177.32 271.7 Technical (Hospital) Services Ref Assay of Estrone PX-3018267900 CDM 82679 CPT 301 RC inpatient 286 286 BLUE CROSS BLUE SHIELD WELLMARK SB889 [3081026] BCBS WYOMING [308102603] 271.7 percent of total billed charges 177.32 271.7 Technical (Hospital) Services Ref Assay of Estrone PX-3018267900 CDM 82679 CPT 301 RC inpatient 286 286 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES HDHP [308136802] 226.45 percent of total billed charges 177.32 271.7 Technical (Hospital) Services Ref Assay of Estrone PX-3018267900 CDM 82679 CPT 301 RC inpatient 286 286 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES EPO [308136803] 226.45 percent of total billed charges 177.32 271.7 Technical (Hospital) Services Ref Assay of Estrone PX-3018267900 CDM 82679 CPT 301 RC inpatient 286 286 HEALTHPARTNERS SX009 HEALTHPARTNERS 226.45 percent of total billed charges 177.32 271.7 Technical (Hospital) Services Ref Assay of Estrone PX-3018267900 CDM 82679 CPT 301 RC inpatient 286 286 MEDICA (COMMERCIAL) 94265 [3081118] MEDICA CLAIMS [308111801] 257.4 percent of total billed charges 177.32 271.7 Technical (Hospital) Services Ref Assay of Estrone PX-3018267900 CDM 82679 CPT 301 RC inpatient 286 286 MULTIPLAN INC 34080 [3081285] MULTIPLAN INC [308128501] 271.7 percent of total billed charges 177.32 271.7 Technical (Hospital) Services Ref Assay of Estrone PX-3018267900 CDM 82679 CPT 301 RC outpatient 286 286 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES PPO [308136801] 228.8 percent of total billed charges 177.32 271.7 Technical (Hospital) Services Ref Assay of Estrone PX-3018267900 CDM 82679 CPT 301 RC outpatient 286 286 MULTIPLAN INC 34080 [3081285] MULTIPLAN INC [308128501] 271.7 percent of total billed charges 177.32 271.7 Technical (Hospital) Services Ref Assay of Estrone PX-3018267900 CDM 82679 CPT 301 RC outpatient 286 286 BLUE CROSS BLUE SHIELD WELLMARK SB889 [3081026] BCBS WYOMING [308102603] 271.7 percent of total billed charges 177.32 271.7 Technical (Hospital) Services Ref Assay of Estrone PX-3018267900 CDM 82679 CPT 301 RC outpatient 286 286 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES EPO [308136803] 228.8 percent of total billed charges 177.32 271.7 Technical (Hospital) Services Ref Assay of Estrone PX-3018267900 CDM 82679 CPT 301 RC outpatient 286 286 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES HDHP [308136802] 228.8 percent of total billed charges 177.32 271.7 Technical (Hospital) Services Ref Assay of Estrone PX-3018267900 CDM 82679 CPT 301 RC outpatient 286 286 UNITED HEALTHCARE (COMMERCIAL) [3081199] UNITED HEALTHCARE 87726 [308119901] 177.32 percent of total billed charges 177.32 271.7 Technical (Hospital) Services Ref Assay of Estrone PX-3018267900 CDM 82679 CPT 301 RC outpatient 286 286 HEALTHPARTNERS SX009 HEALTHPARTNERS 228.8 percent of total billed charges 177.32 271.7 Technical (Hospital) Services Ref Assay of Estrone PX-3018267900 CDM 82679 CPT 301 RC outpatient 286 286 MEDICA (COMMERCIAL) 94265 [3081118] MEDICA CLAIMS [308111801] 257.4 percent of total billed charges 177.32 271.7 Technical (Hospital) Services Ref Assay of Estrone PX-3018267900 CDM 82679 CPT 301 RC outpatient 286 286 CIGNA 62308 [3081051] CIGNA 62308 [308105105] 228.8 percent of total billed charges 177.32 271.7 Technical (Hospital) Services Ref Assay of Estrone PX-3018267900 CDM 82679 CPT 301 RC outpatient 286 286 CIGNA 62308 [3081051] CIGNA STATE OF WYOMING [308105107] 228.8 percent of total billed charges 177.32 271.7 Technical (Hospital) Services Ref Quad Scrn Estriol PX-3018267700 CDM 82677 CPT 301 RC outpatient 208 208 HEALTHPARTNERS SX009 HEALTHPARTNERS 166.4 percent of total billed charges 128.96 197.6 Technical (Hospital) Services Ref Quad Scrn Estriol PX-3018267700 CDM 82677 CPT 301 RC outpatient 208 208 UNITED HEALTHCARE (COMMERCIAL) [3081199] UNITED HEALTHCARE 87726 [308119901] 128.96 percent of total billed charges 128.96 197.6 Technical (Hospital) Services Ref Quad Scrn Estriol PX-3018267700 CDM 82677 CPT 301 RC outpatient 208 208 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES HDHP [308136802] 166.4 percent of total billed charges 128.96 197.6 Technical (Hospital) Services Ref Quad Scrn Estriol PX-3018267700 CDM 82677 CPT 301 RC outpatient 208 208 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES EPO [308136803] 166.4 percent of total billed charges 128.96 197.6 Technical (Hospital) Services Ref Quad Scrn Estriol PX-3018267700 CDM 82677 CPT 301 RC outpatient 208 208 BLUE CROSS BLUE SHIELD WELLMARK SB889 [3081026] BCBS WYOMING [308102603] 197.6 percent of total billed charges 128.96 197.6 Technical (Hospital) Services Ref Quad Scrn Estriol PX-3018267700 CDM 82677 CPT 301 RC outpatient 208 208 MULTIPLAN INC 34080 [3081285] MULTIPLAN INC [308128501] 197.6 percent of total billed charges 128.96 197.6 Technical (Hospital) Services Ref Quad Scrn Estriol PX-3018267700 CDM 82677 CPT 301 RC outpatient 208 208 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES PPO [308136801] 166.4 percent of total billed charges 128.96 197.6 Technical (Hospital) Services Ref Quad Scrn Estriol PX-3018267700 CDM 82677 CPT 301 RC outpatient 208 208 CIGNA 62308 [3081051] CIGNA 62308 [308105105] 166.4 percent of total billed charges 128.96 197.6 Technical (Hospital) Services Ref Quad Scrn Estriol PX-3018267700 CDM 82677 CPT 301 RC outpatient 208 208 CIGNA 62308 [3081051] CIGNA STATE OF WYOMING [308105107] 166.4 percent of total billed charges 128.96 197.6 Technical (Hospital) Services Ref Quad Scrn Estriol PX-3018267700 CDM 82677 CPT 301 RC outpatient 208 208 MEDICA (COMMERCIAL) 94265 [3081118] MEDICA CLAIMS [308111801] 187.2 percent of total billed charges 128.96 197.6 Technical (Hospital) Services Ref Quad Scrn Estriol PX-3018267700 CDM 82677 CPT 301 RC inpatient 208 208 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES HDHP [308136802] 164.69 percent of total billed charges 128.96 197.6 Technical (Hospital) Services Ref Quad Scrn Estriol PX-3018267700 CDM 82677 CPT 301 RC inpatient 208 208 BLUE CROSS BLUE SHIELD WELLMARK SB889 [3081026] BCBS WYOMING [308102603] 197.6 percent of total billed charges 128.96 197.6 Technical (Hospital) Services Ref Quad Scrn Estriol PX-3018267700 CDM 82677 CPT 301 RC inpatient 208 208 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES PPO [308136801] 164.69 percent of total billed charges 128.96 197.6 Technical (Hospital) Services Ref Quad Scrn Estriol PX-3018267700 CDM 82677 CPT 301 RC inpatient 208 208 UNITED HEALTHCARE (COMMERCIAL) [3081199] UNITED HEALTHCARE 87726 [308119901] 128.96 percent of total billed charges 128.96 197.6 Technical (Hospital) Services Ref Quad Scrn Estriol PX-3018267700 CDM 82677 CPT 301 RC inpatient 208 208 MEDICA (COMMERCIAL) 94265 [3081118] MEDICA CLAIMS [308111801] 187.2 percent of total billed charges 128.96 197.6 Technical (Hospital) Services Ref Quad Scrn Estriol PX-3018267700 CDM 82677 CPT 301 RC inpatient 208 208 MULTIPLAN INC 34080 [3081285] MULTIPLAN INC [308128501] 197.6 percent of total billed charges 128.96 197.6 Technical (Hospital) Services Ref Quad Scrn Estriol PX-3018267700 CDM 82677 CPT 301 RC inpatient 208 208 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES EPO [308136803] 164.69 percent of total billed charges 128.96 197.6 Technical (Hospital) Services Ref Quad Scrn Estriol PX-3018267700 CDM 82677 CPT 301 RC inpatient 208 208 HEALTHPARTNERS SX009 HEALTHPARTNERS 164.69 percent of total billed charges 128.96 197.6 Technical (Hospital) Services Ref Quad Scrn Estriol PX-3018267700 CDM 82677 CPT 301 RC inpatient 208 208 CIGNA 62308 [3081051] CIGNA 62308 [308105105] 164.69 percent of total billed charges 128.96 197.6 Technical (Hospital) Services Ref Quad Scrn Estriol PX-3018267700 CDM 82677 CPT 301 RC inpatient 208 208 CIGNA 62308 [3081051] CIGNA STATE OF WYOMING [308105107] 164.69 percent of total billed charges 128.96 197.6 Technical (Hospital) Services "Ref Estrogens, Fractionated" PX-3018267100 CDM 82671 CPT 301 RC inpatient 309 309 HEALTHPARTNERS SX009 HEALTHPARTNERS 244.67 percent of total billed charges 191.58 293.55 Technical (Hospital) Services "Ref Estrogens, Fractionated" PX-3018267100 CDM 82671 CPT 301 RC inpatient 309 309 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES EPO [308136803] 244.67 percent of total billed charges 191.58 293.55 Technical (Hospital) Services "Ref Estrogens, Fractionated" PX-3018267100 CDM 82671 CPT 301 RC inpatient 309 309 MEDICA (COMMERCIAL) 94265 [3081118] MEDICA CLAIMS [308111801] 278.1 percent of total billed charges 191.58 293.55 Technical (Hospital) Services "Ref Estrogens, Fractionated" PX-3018267100 CDM 82671 CPT 301 RC inpatient 309 309 MULTIPLAN INC 34080 [3081285] MULTIPLAN INC [308128501] 293.55 percent of total billed charges 191.58 293.55 Technical (Hospital) Services "Ref Estrogens, Fractionated" PX-3018267100 CDM 82671 CPT 301 RC inpatient 309 309 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES PPO [308136801] 244.67 percent of total billed charges 191.58 293.55 Technical (Hospital) Services "Ref Estrogens, Fractionated" PX-3018267100 CDM 82671 CPT 301 RC inpatient 309 309 UNITED HEALTHCARE (COMMERCIAL) [3081199] UNITED HEALTHCARE 87726 [308119901] 191.58 percent of total billed charges 191.58 293.55 Technical (Hospital) Services "Ref Estrogens, Fractionated" PX-3018267100 CDM 82671 CPT 301 RC inpatient 309 309 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES HDHP [308136802] 244.67 percent of total billed charges 191.58 293.55 Technical (Hospital) Services "Ref Estrogens, Fractionated" PX-3018267100 CDM 82671 CPT 301 RC inpatient 309 309 BLUE CROSS BLUE SHIELD WELLMARK SB889 [3081026] BCBS WYOMING [308102603] 293.55 percent of total billed charges 191.58 293.55 Technical (Hospital) Services "Ref Estrogens, Fractionated" PX-3018267100 CDM 82671 CPT 301 RC inpatient 309 309 CIGNA 62308 [3081051] CIGNA 62308 [308105105] 244.67 percent of total billed charges 191.58 293.55 Technical (Hospital) Services "Ref Estrogens, Fractionated" PX-3018267100 CDM 82671 CPT 301 RC inpatient 309 309 CIGNA 62308 [3081051] CIGNA STATE OF WYOMING [308105107] 244.67 percent of total billed charges 191.58 293.55 Technical (Hospital) Services "Ref Estrogens, Fractionated" PX-3018267100 CDM 82671 CPT 301 RC outpatient 309 309 MULTIPLAN INC 34080 [3081285] MULTIPLAN INC [308128501] 293.55 percent of total billed charges 191.58 293.55 Technical (Hospital) Services "Ref Estrogens, Fractionated" PX-3018267100 CDM 82671 CPT 301 RC outpatient 309 309 BLUE CROSS BLUE SHIELD WELLMARK SB889 [3081026] BCBS WYOMING [308102603] 293.55 percent of total billed charges 191.58 293.55 Technical (Hospital) Services "Ref Estrogens, Fractionated" PX-3018267100 CDM 82671 CPT 301 RC outpatient 309 309 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES EPO [308136803] 247.2 percent of total billed charges 191.58 293.55 Technical (Hospital) Services "Ref Estrogens, Fractionated" PX-3018267100 CDM 82671 CPT 301 RC outpatient 309 309 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES HDHP [308136802] 247.2 percent of total billed charges 191.58 293.55 Technical (Hospital) Services "Ref Estrogens, Fractionated" PX-3018267100 CDM 82671 CPT 301 RC outpatient 309 309 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES PPO [308136801] 247.2 percent of total billed charges 191.58 293.55 Technical (Hospital) Services "Ref Estrogens, Fractionated" PX-3018267100 CDM 82671 CPT 301 RC outpatient 309 309 HEALTHPARTNERS SX009 HEALTHPARTNERS 247.2 percent of total billed charges 191.58 293.55 Technical (Hospital) Services "Ref Estrogens, Fractionated" PX-3018267100 CDM 82671 CPT 301 RC outpatient 309 309 UNITED HEALTHCARE (COMMERCIAL) [3081199] UNITED HEALTHCARE 87726 [308119901] 191.58 percent of total billed charges 191.58 293.55 Technical (Hospital) Services "Ref Estrogens, Fractionated" PX-3018267100 CDM 82671 CPT 301 RC outpatient 309 309 MEDICA (COMMERCIAL) 94265 [3081118] MEDICA CLAIMS [308111801] 278.1 percent of total billed charges 191.58 293.55 Technical (Hospital) Services "Ref Estrogens, Fractionated" PX-3018267100 CDM 82671 CPT 301 RC outpatient 309 309 CIGNA 62308 [3081051] CIGNA 62308 [308105105] 247.2 percent of total billed charges 191.58 293.55 Technical (Hospital) Services "Ref Estrogens, Fractionated" PX-3018267100 CDM 82671 CPT 301 RC outpatient 309 309 CIGNA 62308 [3081051] CIGNA STATE OF WYOMING [308105107] 247.2 percent of total billed charges 191.58 293.55 Technical (Hospital) Services Estradiol PX-3018267000 CDM 82670 CPT 301 RC outpatient 223 223 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES HDHP [308136802] 178.4 percent of total billed charges 138.26 211.85 Technical (Hospital) Services Estradiol PX-3018267000 CDM 82670 CPT 301 RC outpatient 223 223 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES EPO [308136803] 178.4 percent of total billed charges 138.26 211.85 Technical (Hospital) Services Estradiol PX-3018267000 CDM 82670 CPT 301 RC outpatient 223 223 BLUE CROSS BLUE SHIELD WELLMARK SB889 [3081026] BCBS WYOMING [308102603] 211.85 percent of total billed charges 138.26 211.85 Technical (Hospital) Services Estradiol PX-3018267000 CDM 82670 CPT 301 RC outpatient 223 223 MULTIPLAN INC 34080 [3081285] MULTIPLAN INC [308128501] 211.85 percent of total billed charges 138.26 211.85 Technical (Hospital) Services Estradiol PX-3018267000 CDM 82670 CPT 301 RC outpatient 223 223 HEALTHPARTNERS SX009 HEALTHPARTNERS 178.4 percent of total billed charges 138.26 211.85 Technical (Hospital) Services Estradiol PX-3018267000 CDM 82670 CPT 301 RC outpatient 223 223 UNITED HEALTHCARE (COMMERCIAL) [3081199] UNITED HEALTHCARE 87726 [308119901] 138.26 percent of total billed charges 138.26 211.85 Technical (Hospital) Services Estradiol PX-3018267000 CDM 82670 CPT 301 RC outpatient 223 223 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES PPO [308136801] 178.4 percent of total billed charges 138.26 211.85 Technical (Hospital) Services Estradiol PX-3018267000 CDM 82670 CPT 301 RC outpatient 223 223 MEDICA (COMMERCIAL) 94265 [3081118] MEDICA CLAIMS [308111801] 200.7 percent of total billed charges 138.26 211.85 Technical (Hospital) Services Estradiol PX-3018267000 CDM 82670 CPT 301 RC outpatient 223 223 CIGNA 62308 [3081051] CIGNA 62308 [308105105] 178.4 percent of total billed charges 138.26 211.85 Technical (Hospital) Services Estradiol PX-3018267000 CDM 82670 CPT 301 RC outpatient 223 223 CIGNA 62308 [3081051] CIGNA STATE OF WYOMING [308105107] 178.4 percent of total billed charges 138.26 211.85 Technical (Hospital) Services Estradiol PX-3018267000 CDM 82670 CPT 301 RC inpatient 223 223 CIGNA 62308 [3081051] CIGNA 62308 [308105105] 176.57 percent of total billed charges 138.26 211.85 Technical (Hospital) Services Estradiol PX-3018267000 CDM 82670 CPT 301 RC inpatient 223 223 CIGNA 62308 [3081051] CIGNA STATE OF WYOMING [308105107] 176.57 percent of total billed charges 138.26 211.85 Technical (Hospital) Services Estradiol PX-3018267000 CDM 82670 CPT 301 RC inpatient 223 223 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES HDHP [308136802] 176.57 percent of total billed charges 138.26 211.85 Technical (Hospital) Services Estradiol PX-3018267000 CDM 82670 CPT 301 RC inpatient 223 223 BLUE CROSS BLUE SHIELD WELLMARK SB889 [3081026] BCBS WYOMING [308102603] 211.85 percent of total billed charges 138.26 211.85 Technical (Hospital) Services Estradiol PX-3018267000 CDM 82670 CPT 301 RC inpatient 223 223 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES PPO [308136801] 176.57 percent of total billed charges 138.26 211.85 Technical (Hospital) Services Estradiol PX-3018267000 CDM 82670 CPT 301 RC inpatient 223 223 UNITED HEALTHCARE (COMMERCIAL) [3081199] UNITED HEALTHCARE 87726 [308119901] 138.26 percent of total billed charges 138.26 211.85 Technical (Hospital) Services Estradiol PX-3018267000 CDM 82670 CPT 301 RC inpatient 223 223 MULTIPLAN INC 34080 [3081285] MULTIPLAN INC [308128501] 211.85 percent of total billed charges 138.26 211.85 Technical (Hospital) Services Estradiol PX-3018267000 CDM 82670 CPT 301 RC inpatient 223 223 MEDICA (COMMERCIAL) 94265 [3081118] MEDICA CLAIMS [308111801] 200.7 percent of total billed charges 138.26 211.85 Technical (Hospital) Services Estradiol PX-3018267000 CDM 82670 CPT 301 RC inpatient 223 223 HEALTHPARTNERS SX009 HEALTHPARTNERS 176.57 percent of total billed charges 138.26 211.85 Technical (Hospital) Services Estradiol PX-3018267000 CDM 82670 CPT 301 RC inpatient 223 223 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES EPO [308136803] 176.57 percent of total billed charges 138.26 211.85 Technical (Hospital) Services Ref Erythropoietin PX-3018266800 CDM 82668 CPT 301 RC outpatient 119 119 MEDICA (COMMERCIAL) 94265 [3081118] MEDICA CLAIMS [308111801] 107.1 percent of total billed charges 73.78 113.05 Technical (Hospital) Services Ref Erythropoietin PX-3018266800 CDM 82668 CPT 301 RC outpatient 119 119 CIGNA 62308 [3081051] CIGNA 62308 [308105105] 95.2 percent of total billed charges 73.78 113.05 Technical (Hospital) Services Ref Erythropoietin PX-3018266800 CDM 82668 CPT 301 RC outpatient 119 119 CIGNA 62308 [3081051] CIGNA STATE OF WYOMING [308105107] 95.2 percent of total billed charges 73.78 113.05 Technical (Hospital) Services Ref Erythropoietin PX-3018266800 CDM 82668 CPT 301 RC outpatient 119 119 MULTIPLAN INC 34080 [3081285] MULTIPLAN INC [308128501] 113.05 percent of total billed charges 73.78 113.05 Technical (Hospital) Services Ref Erythropoietin PX-3018266800 CDM 82668 CPT 301 RC outpatient 119 119 BLUE CROSS BLUE SHIELD WELLMARK SB889 [3081026] BCBS WYOMING [308102603] 113.05 percent of total billed charges 73.78 113.05 Technical (Hospital) Services Ref Erythropoietin PX-3018266800 CDM 82668 CPT 301 RC outpatient 119 119 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES EPO [308136803] 95.2 percent of total billed charges 73.78 113.05 Technical (Hospital) Services Ref Erythropoietin PX-3018266800 CDM 82668 CPT 301 RC outpatient 119 119 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES HDHP [308136802] 95.2 percent of total billed charges 73.78 113.05 Technical (Hospital) Services Ref Erythropoietin PX-3018266800 CDM 82668 CPT 301 RC outpatient 119 119 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES PPO [308136801] 95.2 percent of total billed charges 73.78 113.05 Technical (Hospital) Services Ref Erythropoietin PX-3018266800 CDM 82668 CPT 301 RC outpatient 119 119 HEALTHPARTNERS SX009 HEALTHPARTNERS 95.2 percent of total billed charges 73.78 113.05 Technical (Hospital) Services Ref Erythropoietin PX-3018266800 CDM 82668 CPT 301 RC outpatient 119 119 UNITED HEALTHCARE (COMMERCIAL) [3081199] UNITED HEALTHCARE 87726 [308119901] 73.78 percent of total billed charges 73.78 113.05 Technical (Hospital) Services Ref Erythropoietin PX-3018266800 CDM 82668 CPT 301 RC inpatient 119 119 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES EPO [308136803] 94.22 percent of total billed charges 73.78 113.05 Technical (Hospital) Services Ref Erythropoietin PX-3018266800 CDM 82668 CPT 301 RC inpatient 119 119 HEALTHPARTNERS SX009 HEALTHPARTNERS 94.22 percent of total billed charges 73.78 113.05 Technical (Hospital) Services Ref Erythropoietin PX-3018266800 CDM 82668 CPT 301 RC inpatient 119 119 MEDICA (COMMERCIAL) 94265 [3081118] MEDICA CLAIMS [308111801] 107.1 percent of total billed charges 73.78 113.05 Technical (Hospital) Services Ref Erythropoietin PX-3018266800 CDM 82668 CPT 301 RC inpatient 119 119 MULTIPLAN INC 34080 [3081285] MULTIPLAN INC [308128501] 113.05 percent of total billed charges 73.78 113.05 Technical (Hospital) Services Ref Erythropoietin PX-3018266800 CDM 82668 CPT 301 RC inpatient 119 119 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES PPO [308136801] 94.22 percent of total billed charges 73.78 113.05 Technical (Hospital) Services Ref Erythropoietin PX-3018266800 CDM 82668 CPT 301 RC inpatient 119 119 UNITED HEALTHCARE (COMMERCIAL) [3081199] UNITED HEALTHCARE 87726 [308119901] 73.78 percent of total billed charges 73.78 113.05 Technical (Hospital) Services Ref Erythropoietin PX-3018266800 CDM 82668 CPT 301 RC inpatient 119 119 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES HDHP [308136802] 94.22 percent of total billed charges 73.78 113.05 Technical (Hospital) Services Ref Erythropoietin PX-3018266800 CDM 82668 CPT 301 RC inpatient 119 119 BLUE CROSS BLUE SHIELD WELLMARK SB889 [3081026] BCBS WYOMING [308102603] 113.05 percent of total billed charges 73.78 113.05 Technical (Hospital) Services Ref Erythropoietin PX-3018266800 CDM 82668 CPT 301 RC inpatient 119 119 CIGNA 62308 [3081051] CIGNA 62308 [308105105] 94.22 percent of total billed charges 73.78 113.05 Technical (Hospital) Services Ref Erythropoietin PX-3018266800 CDM 82668 CPT 301 RC inpatient 119 119 CIGNA 62308 [3081051] CIGNA STATE OF WYOMING [308105107] 94.22 percent of total billed charges 73.78 113.05 Technical (Hospital) Services "Ref Tpmt Activity, RBC" PX-3018265701 CDM 82657 CPT 301 RC inpatient 540 540 MEDICA (COMMERCIAL) 94265 [3081118] MEDICA CLAIMS [308111801] 486 percent of total billed charges 334.8 513 Technical (Hospital) Services "Ref Tpmt Activity, RBC" PX-3018265701 CDM 82657 CPT 301 RC inpatient 540 540 MULTIPLAN INC 34080 [3081285] MULTIPLAN INC [308128501] 513 percent of total billed charges 334.8 513 Technical (Hospital) Services "Ref Tpmt Activity, RBC" PX-3018265701 CDM 82657 CPT 301 RC inpatient 540 540 HEALTHPARTNERS SX009 HEALTHPARTNERS 427.57 percent of total billed charges 334.8 513 Technical (Hospital) Services "Ref Tpmt Activity, RBC" PX-3018265701 CDM 82657 CPT 301 RC inpatient 540 540 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES EPO [308136803] 427.57 percent of total billed charges 334.8 513 Technical (Hospital) Services "Ref Tpmt Activity, RBC" PX-3018265701 CDM 82657 CPT 301 RC inpatient 540 540 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES PPO [308136801] 427.57 percent of total billed charges 334.8 513 Technical (Hospital) Services "Ref Tpmt Activity, RBC" PX-3018265701 CDM 82657 CPT 301 RC inpatient 540 540 UNITED HEALTHCARE (COMMERCIAL) [3081199] UNITED HEALTHCARE 87726 [308119901] 334.8 percent of total billed charges 334.8 513 Technical (Hospital) Services "Ref Tpmt Activity, RBC" PX-3018265701 CDM 82657 CPT 301 RC inpatient 540 540 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES HDHP [308136802] 427.57 percent of total billed charges 334.8 513 Technical (Hospital) Services "Ref Tpmt Activity, RBC" PX-3018265701 CDM 82657 CPT 301 RC inpatient 540 540 BLUE CROSS BLUE SHIELD WELLMARK SB889 [3081026] BCBS WYOMING [308102603] 513 percent of total billed charges 334.8 513 Technical (Hospital) Services "Ref Tpmt Activity, RBC" PX-3018265701 CDM 82657 CPT 301 RC inpatient 540 540 CIGNA 62308 [3081051] CIGNA STATE OF WYOMING [308105107] 427.57 percent of total billed charges 334.8 513 Technical (Hospital) Services "Ref Tpmt Activity, RBC" PX-3018265701 CDM 82657 CPT 301 RC inpatient 540 540 CIGNA 62308 [3081051] CIGNA 62308 [308105105] 427.57 percent of total billed charges 334.8 513 Technical (Hospital) Services "Ref Tpmt Activity, RBC" PX-3018265701 CDM 82657 CPT 301 RC outpatient 540 540 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES PPO [308136801] 432 percent of total billed charges 334.8 513 Technical (Hospital) Services "Ref Tpmt Activity, RBC" PX-3018265701 CDM 82657 CPT 301 RC outpatient 540 540 UNITED HEALTHCARE (COMMERCIAL) [3081199] UNITED HEALTHCARE 87726 [308119901] 334.8 percent of total billed charges 334.8 513 Technical (Hospital) Services "Ref Tpmt Activity, RBC" PX-3018265701 CDM 82657 CPT 301 RC outpatient 540 540 HEALTHPARTNERS SX009 HEALTHPARTNERS 432 percent of total billed charges 334.8 513 Technical (Hospital) Services "Ref Tpmt Activity, RBC" PX-3018265701 CDM 82657 CPT 301 RC outpatient 540 540 BLUE CROSS BLUE SHIELD WELLMARK SB889 [3081026] BCBS WYOMING [308102603] 513 percent of total billed charges 334.8 513 Technical (Hospital) Services "Ref Tpmt Activity, RBC" PX-3018265701 CDM 82657 CPT 301 RC outpatient 540 540 MULTIPLAN INC 34080 [3081285] MULTIPLAN INC [308128501] 513 percent of total billed charges 334.8 513 Technical (Hospital) Services "Ref Tpmt Activity, RBC" PX-3018265701 CDM 82657 CPT 301 RC outpatient 540 540 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES EPO [308136803] 432 percent of total billed charges 334.8 513 Technical (Hospital) Services "Ref Tpmt Activity, RBC" PX-3018265701 CDM 82657 CPT 301 RC outpatient 540 540 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES HDHP [308136802] 432 percent of total billed charges 334.8 513 Technical (Hospital) Services "Ref Tpmt Activity, RBC" PX-3018265701 CDM 82657 CPT 301 RC outpatient 540 540 MEDICA (COMMERCIAL) 94265 [3081118] MEDICA CLAIMS [308111801] 486 percent of total billed charges 334.8 513 Technical (Hospital) Services "Ref Tpmt Activity, RBC" PX-3018265701 CDM 82657 CPT 301 RC outpatient 540 540 CIGNA 62308 [3081051] CIGNA 62308 [308105105] 432 percent of total billed charges 334.8 513 Technical (Hospital) Services "Ref Tpmt Activity, RBC" PX-3018265701 CDM 82657 CPT 301 RC outpatient 540 540 CIGNA 62308 [3081051] CIGNA STATE OF WYOMING [308105107] 432 percent of total billed charges 334.8 513 Technical (Hospital) Services Ref Pancreatic Elastase Fecal PX-3018265601 CDM 82656 CPT 301 RC outpatient 180 180 HEALTHPARTNERS SX009 HEALTHPARTNERS 144 percent of total billed charges 111.6 171 Technical (Hospital) Services Ref Pancreatic Elastase Fecal PX-3018265601 CDM 82656 CPT 301 RC outpatient 180 180 UNITED HEALTHCARE (COMMERCIAL) [3081199] UNITED HEALTHCARE 87726 [308119901] 111.6 percent of total billed charges 111.6 171 Technical (Hospital) Services Ref Pancreatic Elastase Fecal PX-3018265601 CDM 82656 CPT 301 RC outpatient 180 180 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES PPO [308136801] 144 percent of total billed charges 111.6 171 Technical (Hospital) Services Ref Pancreatic Elastase Fecal PX-3018265601 CDM 82656 CPT 301 RC outpatient 180 180 MULTIPLAN INC 34080 [3081285] MULTIPLAN INC [308128501] 171 percent of total billed charges 111.6 171 Technical (Hospital) Services Ref Pancreatic Elastase Fecal PX-3018265601 CDM 82656 CPT 301 RC outpatient 180 180 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES HDHP [308136802] 144 percent of total billed charges 111.6 171 Technical (Hospital) Services Ref Pancreatic Elastase Fecal PX-3018265601 CDM 82656 CPT 301 RC outpatient 180 180 BLUE CROSS BLUE SHIELD WELLMARK SB889 [3081026] BCBS WYOMING [308102603] 171 percent of total billed charges 111.6 171 Technical (Hospital) Services Ref Pancreatic Elastase Fecal PX-3018265601 CDM 82656 CPT 301 RC outpatient 180 180 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES EPO [308136803] 144 percent of total billed charges 111.6 171 Technical (Hospital) Services Ref Pancreatic Elastase Fecal PX-3018265601 CDM 82656 CPT 301 RC outpatient 180 180 MEDICA (COMMERCIAL) 94265 [3081118] MEDICA CLAIMS [308111801] 162 percent of total billed charges 111.6 171 Technical (Hospital) Services Ref Pancreatic Elastase Fecal PX-3018265601 CDM 82656 CPT 301 RC outpatient 180 180 CIGNA 62308 [3081051] CIGNA 62308 [308105105] 144 percent of total billed charges 111.6 171 Technical (Hospital) Services Ref Pancreatic Elastase Fecal PX-3018265601 CDM 82656 CPT 301 RC outpatient 180 180 CIGNA 62308 [3081051] CIGNA STATE OF WYOMING [308105107] 144 percent of total billed charges 111.6 171 Technical (Hospital) Services Ref Pancreatic Elastase Fecal PX-3018265601 CDM 82656 CPT 301 RC inpatient 180 180 BLUE CROSS BLUE SHIELD WELLMARK SB889 [3081026] BCBS WYOMING [308102603] 171 percent of total billed charges 111.6 171 Technical (Hospital) Services Ref Pancreatic Elastase Fecal PX-3018265601 CDM 82656 CPT 301 RC inpatient 180 180 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES HDHP [308136802] 142.52 percent of total billed charges 111.6 171 Technical (Hospital) Services Ref Pancreatic Elastase Fecal PX-3018265601 CDM 82656 CPT 301 RC inpatient 180 180 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES PPO [308136801] 142.52 percent of total billed charges 111.6 171 Technical (Hospital) Services Ref Pancreatic Elastase Fecal PX-3018265601 CDM 82656 CPT 301 RC inpatient 180 180 UNITED HEALTHCARE (COMMERCIAL) [3081199] UNITED HEALTHCARE 87726 [308119901] 111.6 percent of total billed charges 111.6 171 Technical (Hospital) Services Ref Pancreatic Elastase Fecal PX-3018265601 CDM 82656 CPT 301 RC inpatient 180 180 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES EPO [308136803] 142.52 percent of total billed charges 111.6 171 Technical (Hospital) Services Ref Pancreatic Elastase Fecal PX-3018265601 CDM 82656 CPT 301 RC inpatient 180 180 HEALTHPARTNERS SX009 HEALTHPARTNERS 142.52 percent of total billed charges 111.6 171 Technical (Hospital) Services Ref Pancreatic Elastase Fecal PX-3018265601 CDM 82656 CPT 301 RC inpatient 180 180 MULTIPLAN INC 34080 [3081285] MULTIPLAN INC [308128501] 171 percent of total billed charges 111.6 171 Technical (Hospital) Services Ref Pancreatic Elastase Fecal PX-3018265601 CDM 82656 CPT 301 RC inpatient 180 180 MEDICA (COMMERCIAL) 94265 [3081118] MEDICA CLAIMS [308111801] 162 percent of total billed charges 111.6 171 Technical (Hospital) Services Ref Pancreatic Elastase Fecal PX-3018265601 CDM 82656 CPT 301 RC inpatient 180 180 CIGNA 62308 [3081051] CIGNA 62308 [308105105] 142.52 percent of total billed charges 111.6 171 Technical (Hospital) Services Ref Pancreatic Elastase Fecal PX-3018265601 CDM 82656 CPT 301 RC inpatient 180 180 CIGNA 62308 [3081051] CIGNA STATE OF WYOMING [308105107] 142.52 percent of total billed charges 111.6 171 Technical (Hospital) Services "HC Ref Pancreatic Elastase, F (Mayo)" PX-3018265300 CDM 82653 CPT 301 RC inpatient 175 175 CIGNA 62308 [3081051] CIGNA 62308 [308105105] 138.57 percent of total billed charges 108.5 166.25 Technical (Hospital) Services "HC Ref Pancreatic Elastase, F (Mayo)" PX-3018265300 CDM 82653 CPT 301 RC inpatient 175 175 CIGNA 62308 [3081051] CIGNA STATE OF WYOMING [308105107] 138.57 percent of total billed charges 108.5 166.25 Technical (Hospital) Services "HC Ref Pancreatic Elastase, F (Mayo)" PX-3018265300 CDM 82653 CPT 301 RC inpatient 175 175 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES EPO [308136803] 138.57 percent of total billed charges 108.5 166.25 Technical (Hospital) Services "HC Ref Pancreatic Elastase, F (Mayo)" PX-3018265300 CDM 82653 CPT 301 RC inpatient 175 175 HEALTHPARTNERS SX009 HEALTHPARTNERS 138.57 percent of total billed charges 108.5 166.25 Technical (Hospital) Services "HC Ref Pancreatic Elastase, F (Mayo)" PX-3018265300 CDM 82653 CPT 301 RC inpatient 175 175 MEDICA (COMMERCIAL) 94265 [3081118] MEDICA CLAIMS [308111801] 157.5 percent of total billed charges 108.5 166.25 Technical (Hospital) Services "HC Ref Pancreatic Elastase, F (Mayo)" PX-3018265300 CDM 82653 CPT 301 RC inpatient 175 175 MULTIPLAN INC 34080 [3081285] MULTIPLAN INC [308128501] 166.25 percent of total billed charges 108.5 166.25 Technical (Hospital) Services "HC Ref Pancreatic Elastase, F (Mayo)" PX-3018265300 CDM 82653 CPT 301 RC inpatient 175 175 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES HDHP [308136802] 138.57 percent of total billed charges 108.5 166.25 Technical (Hospital) Services "HC Ref Pancreatic Elastase, F (Mayo)" PX-3018265300 CDM 82653 CPT 301 RC inpatient 175 175 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES PPO [308136801] 138.57 percent of total billed charges 108.5 166.25 Technical (Hospital) Services "HC Ref Pancreatic Elastase, F (Mayo)" PX-3018265300 CDM 82653 CPT 301 RC inpatient 175 175 UNITED HEALTHCARE (COMMERCIAL) [3081199] UNITED HEALTHCARE 87726 [308119901] 108.5 percent of total billed charges 108.5 166.25 Technical (Hospital) Services "HC Ref Pancreatic Elastase, F (Mayo)" PX-3018265300 CDM 82653 CPT 301 RC inpatient 175 175 BLUE CROSS BLUE SHIELD WELLMARK SB889 [3081026] BCBS WYOMING [308102603] 166.25 percent of total billed charges 108.5 166.25 Technical (Hospital) Services "HC Ref Pancreatic Elastase, F (Mayo)" PX-3018265300 CDM 82653 CPT 301 RC outpatient 175 175 HEALTHPARTNERS SX009 HEALTHPARTNERS 140 percent of total billed charges 108.5 166.25 Technical (Hospital) Services "HC Ref Pancreatic Elastase, F (Mayo)" PX-3018265300 CDM 82653 CPT 301 RC outpatient 175 175 UNITED HEALTHCARE (COMMERCIAL) [3081199] UNITED HEALTHCARE 87726 [308119901] 108.5 percent of total billed charges 108.5 166.25 Technical (Hospital) Services "HC Ref Pancreatic Elastase, F (Mayo)" PX-3018265300 CDM 82653 CPT 301 RC outpatient 175 175 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES HDHP [308136802] 140 percent of total billed charges 108.5 166.25 Technical (Hospital) Services "HC Ref Pancreatic Elastase, F (Mayo)" PX-3018265300 CDM 82653 CPT 301 RC outpatient 175 175 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES EPO [308136803] 140 percent of total billed charges 108.5 166.25 Technical (Hospital) Services "HC Ref Pancreatic Elastase, F (Mayo)" PX-3018265300 CDM 82653 CPT 301 RC outpatient 175 175 BLUE CROSS BLUE SHIELD WELLMARK SB889 [3081026] BCBS WYOMING [308102603] 166.25 percent of total billed charges 108.5 166.25 Technical (Hospital) Services "HC Ref Pancreatic Elastase, F (Mayo)" PX-3018265300 CDM 82653 CPT 301 RC outpatient 175 175 MULTIPLAN INC 34080 [3081285] MULTIPLAN INC [308128501] 166.25 percent of total billed charges 108.5 166.25 Technical (Hospital) Services "HC Ref Pancreatic Elastase, F (Mayo)" PX-3018265300 CDM 82653 CPT 301 RC outpatient 175 175 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES PPO [308136801] 140 percent of total billed charges 108.5 166.25 Technical (Hospital) Services "HC Ref Pancreatic Elastase, F (Mayo)" PX-3018265300 CDM 82653 CPT 301 RC outpatient 175 175 MEDICA (COMMERCIAL) 94265 [3081118] MEDICA CLAIMS [308111801] 157.5 percent of total billed charges 108.5 166.25 Technical (Hospital) Services "HC Ref Pancreatic Elastase, F (Mayo)" PX-3018265300 CDM 82653 CPT 301 RC outpatient 175 175 CIGNA 62308 [3081051] CIGNA 62308 [308105105] 140 percent of total billed charges 108.5 166.25 Technical (Hospital) Services "HC Ref Pancreatic Elastase, F (Mayo)" PX-3018265300 CDM 82653 CPT 301 RC outpatient 175 175 CIGNA 62308 [3081051] CIGNA STATE OF WYOMING [308105107] 140 percent of total billed charges 108.5 166.25 Technical (Hospital) Services Ref Vit D1 25 Dihydroxy W Frac PX-3018265200 CDM 82652 CPT 301 RC outpatient 119 119 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES PPO [308136801] 95.2 percent of total billed charges 73.78 113.05 Technical (Hospital) Services Ref Vit D1 25 Dihydroxy W Frac PX-3018265200 CDM 82652 CPT 301 RC outpatient 119 119 MULTIPLAN INC 34080 [3081285] MULTIPLAN INC [308128501] 113.05 percent of total billed charges 73.78 113.05 Technical (Hospital) Services Ref Vit D1 25 Dihydroxy W Frac PX-3018265200 CDM 82652 CPT 301 RC outpatient 119 119 BLUE CROSS BLUE SHIELD WELLMARK SB889 [3081026] BCBS WYOMING [308102603] 113.05 percent of total billed charges 73.78 113.05 Technical (Hospital) Services Ref Vit D1 25 Dihydroxy W Frac PX-3018265200 CDM 82652 CPT 301 RC outpatient 119 119 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES EPO [308136803] 95.2 percent of total billed charges 73.78 113.05 Technical (Hospital) Services Ref Vit D1 25 Dihydroxy W Frac PX-3018265200 CDM 82652 CPT 301 RC outpatient 119 119 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES HDHP [308136802] 95.2 percent of total billed charges 73.78 113.05 Technical (Hospital) Services Ref Vit D1 25 Dihydroxy W Frac PX-3018265200 CDM 82652 CPT 301 RC outpatient 119 119 HEALTHPARTNERS SX009 HEALTHPARTNERS 95.2 percent of total billed charges 73.78 113.05 Technical (Hospital) Services Ref Vit D1 25 Dihydroxy W Frac PX-3018265200 CDM 82652 CPT 301 RC outpatient 119 119 UNITED HEALTHCARE (COMMERCIAL) [3081199] UNITED HEALTHCARE 87726 [308119901] 73.78 percent of total billed charges 73.78 113.05 Technical (Hospital) Services Ref Vit D1 25 Dihydroxy W Frac PX-3018265200 CDM 82652 CPT 301 RC outpatient 119 119 MEDICA (COMMERCIAL) 94265 [3081118] MEDICA CLAIMS [308111801] 107.1 percent of total billed charges 73.78 113.05 Technical (Hospital) Services Ref Vit D1 25 Dihydroxy W Frac PX-3018265200 CDM 82652 CPT 301 RC outpatient 119 119 CIGNA 62308 [3081051] CIGNA 62308 [308105105] 95.2 percent of total billed charges 73.78 113.05 Technical (Hospital) Services Ref Vit D1 25 Dihydroxy W Frac PX-3018265200 CDM 82652 CPT 301 RC outpatient 119 119 CIGNA 62308 [3081051] CIGNA STATE OF WYOMING [308105107] 95.2 percent of total billed charges 73.78 113.05 Technical (Hospital) Services Ref Vit D1 25 Dihydroxy W Frac PX-3018265200 CDM 82652 CPT 301 RC inpatient 119 119 MULTIPLAN INC 34080 [3081285] MULTIPLAN INC [308128501] 113.05 percent of total billed charges 73.78 113.05 Technical (Hospital) Services Ref Vit D1 25 Dihydroxy W Frac PX-3018265200 CDM 82652 CPT 301 RC inpatient 119 119 MEDICA (COMMERCIAL) 94265 [3081118] MEDICA CLAIMS [308111801] 107.1 percent of total billed charges 73.78 113.05 Technical (Hospital) Services Ref Vit D1 25 Dihydroxy W Frac PX-3018265200 CDM 82652 CPT 301 RC inpatient 119 119 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES EPO [308136803] 94.22 percent of total billed charges 73.78 113.05 Technical (Hospital) Services Ref Vit D1 25 Dihydroxy W Frac PX-3018265200 CDM 82652 CPT 301 RC inpatient 119 119 HEALTHPARTNERS SX009 HEALTHPARTNERS 94.22 percent of total billed charges 73.78 113.05 Technical (Hospital) Services Ref Vit D1 25 Dihydroxy W Frac PX-3018265200 CDM 82652 CPT 301 RC inpatient 119 119 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES PPO [308136801] 94.22 percent of total billed charges 73.78 113.05 Technical (Hospital) Services Ref Vit D1 25 Dihydroxy W Frac PX-3018265200 CDM 82652 CPT 301 RC inpatient 119 119 UNITED HEALTHCARE (COMMERCIAL) [3081199] UNITED HEALTHCARE 87726 [308119901] 73.78 percent of total billed charges 73.78 113.05 Technical (Hospital) Services Ref Vit D1 25 Dihydroxy W Frac PX-3018265200 CDM 82652 CPT 301 RC inpatient 119 119 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES HDHP [308136802] 94.22 percent of total billed charges 73.78 113.05 Technical (Hospital) Services Ref Vit D1 25 Dihydroxy W Frac PX-3018265200 CDM 82652 CPT 301 RC inpatient 119 119 BLUE CROSS BLUE SHIELD WELLMARK SB889 [3081026] BCBS WYOMING [308102603] 113.05 percent of total billed charges 73.78 113.05 Technical (Hospital) Services Ref Vit D1 25 Dihydroxy W Frac PX-3018265200 CDM 82652 CPT 301 RC inpatient 119 119 CIGNA 62308 [3081051] CIGNA 62308 [308105105] 94.22 percent of total billed charges 73.78 113.05 Technical (Hospital) Services Ref Vit D1 25 Dihydroxy W Frac PX-3018265200 CDM 82652 CPT 301 RC inpatient 119 119 CIGNA 62308 [3081051] CIGNA STATE OF WYOMING [308105107] 94.22 percent of total billed charges 73.78 113.05 Technical (Hospital) Services Ref Vit D1 25 Dihydroxy W Frac PX-3018265201 CDM 82652 CPT 301 RC outpatient 119 119 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES PPO [308136801] 95.2 percent of total billed charges 73.78 113.05 Technical (Hospital) Services Ref Vit D1 25 Dihydroxy W Frac PX-3018265201 CDM 82652 CPT 301 RC outpatient 119 119 BLUE CROSS BLUE SHIELD WELLMARK SB889 [3081026] BCBS WYOMING [308102603] 113.05 percent of total billed charges 73.78 113.05 Technical (Hospital) Services Ref Vit D1 25 Dihydroxy W Frac PX-3018265201 CDM 82652 CPT 301 RC outpatient 119 119 MULTIPLAN INC 34080 [3081285] MULTIPLAN INC [308128501] 113.05 percent of total billed charges 73.78 113.05 Technical (Hospital) Services Ref Vit D1 25 Dihydroxy W Frac PX-3018265201 CDM 82652 CPT 301 RC outpatient 119 119 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES EPO [308136803] 95.2 percent of total billed charges 73.78 113.05 Technical (Hospital) Services Ref Vit D1 25 Dihydroxy W Frac PX-3018265201 CDM 82652 CPT 301 RC outpatient 119 119 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES HDHP [308136802] 95.2 percent of total billed charges 73.78 113.05 Technical (Hospital) Services Ref Vit D1 25 Dihydroxy W Frac PX-3018265201 CDM 82652 CPT 301 RC outpatient 119 119 UNITED HEALTHCARE (COMMERCIAL) [3081199] UNITED HEALTHCARE 87726 [308119901] 73.78 percent of total billed charges 73.78 113.05 Technical (Hospital) Services Ref Vit D1 25 Dihydroxy W Frac PX-3018265201 CDM 82652 CPT 301 RC outpatient 119 119 HEALTHPARTNERS SX009 HEALTHPARTNERS 95.2 percent of total billed charges 73.78 113.05 Technical (Hospital) Services Ref Vit D1 25 Dihydroxy W Frac PX-3018265201 CDM 82652 CPT 301 RC outpatient 119 119 MEDICA (COMMERCIAL) 94265 [3081118] MEDICA CLAIMS [308111801] 107.1 percent of total billed charges 73.78 113.05 Technical (Hospital) Services Ref Vit D1 25 Dihydroxy W Frac PX-3018265201 CDM 82652 CPT 301 RC outpatient 119 119 CIGNA 62308 [3081051] CIGNA 62308 [308105105] 95.2 percent of total billed charges 73.78 113.05 Technical (Hospital) Services Ref Vit D1 25 Dihydroxy W Frac PX-3018265201 CDM 82652 CPT 301 RC outpatient 119 119 CIGNA 62308 [3081051] CIGNA STATE OF WYOMING [308105107] 95.2 percent of total billed charges 73.78 113.05 Technical (Hospital) Services Ref Vit D1 25 Dihydroxy W Frac PX-3018265201 CDM 82652 CPT 301 RC inpatient 119 119 CIGNA 62308 [3081051] CIGNA 62308 [308105105] 94.22 percent of total billed charges 73.78 113.05 Technical (Hospital) Services Ref Vit D1 25 Dihydroxy W Frac PX-3018265201 CDM 82652 CPT 301 RC inpatient 119 119 CIGNA 62308 [3081051] CIGNA STATE OF WYOMING [308105107] 94.22 percent of total billed charges 73.78 113.05 Technical (Hospital) Services Ref Vit D1 25 Dihydroxy W Frac PX-3018265201 CDM 82652 CPT 301 RC inpatient 119 119 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES HDHP [308136802] 94.22 percent of total billed charges 73.78 113.05 Technical (Hospital) Services Ref Vit D1 25 Dihydroxy W Frac PX-3018265201 CDM 82652 CPT 301 RC inpatient 119 119 BLUE CROSS BLUE SHIELD WELLMARK SB889 [3081026] BCBS WYOMING [308102603] 113.05 percent of total billed charges 73.78 113.05 Technical (Hospital) Services Ref Vit D1 25 Dihydroxy W Frac PX-3018265201 CDM 82652 CPT 301 RC inpatient 119 119 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES PPO [308136801] 94.22 percent of total billed charges 73.78 113.05 Technical (Hospital) Services Ref Vit D1 25 Dihydroxy W Frac PX-3018265201 CDM 82652 CPT 301 RC inpatient 119 119 UNITED HEALTHCARE (COMMERCIAL) [3081199] UNITED HEALTHCARE 87726 [308119901] 73.78 percent of total billed charges 73.78 113.05 Technical (Hospital) Services Ref Vit D1 25 Dihydroxy W Frac PX-3018265201 CDM 82652 CPT 301 RC inpatient 119 119 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES EPO [308136803] 94.22 percent of total billed charges 73.78 113.05 Technical (Hospital) Services Ref Vit D1 25 Dihydroxy W Frac PX-3018265201 CDM 82652 CPT 301 RC inpatient 119 119 HEALTHPARTNERS SX009 HEALTHPARTNERS 94.22 percent of total billed charges 73.78 113.05 Technical (Hospital) Services Ref Vit D1 25 Dihydroxy W Frac PX-3018265201 CDM 82652 CPT 301 RC inpatient 119 119 MULTIPLAN INC 34080 [3081285] MULTIPLAN INC [308128501] 113.05 percent of total billed charges 73.78 113.05 Technical (Hospital) Services Ref Vit D1 25 Dihydroxy W Frac PX-3018265201 CDM 82652 CPT 301 RC inpatient 119 119 MEDICA (COMMERCIAL) 94265 [3081118] MEDICA CLAIMS [308111801] 107.1 percent of total billed charges 73.78 113.05 Technical (Hospital) Services Ref Dhea Sulfate PX-3018262700 CDM 82627 CPT 301 RC inpatient 286 286 UNITED HEALTHCARE (COMMERCIAL) [3081199] UNITED HEALTHCARE 87726 [308119901] 177.32 percent of total billed charges 177.32 271.7 Technical (Hospital) Services Ref Dhea Sulfate PX-3018262700 CDM 82627 CPT 301 RC inpatient 286 286 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES PPO [308136801] 226.45 percent of total billed charges 177.32 271.7 Technical (Hospital) Services Ref Dhea Sulfate PX-3018262700 CDM 82627 CPT 301 RC inpatient 286 286 BLUE CROSS BLUE SHIELD WELLMARK SB889 [3081026] BCBS WYOMING [308102603] 271.7 percent of total billed charges 177.32 271.7 Technical (Hospital) Services Ref Dhea Sulfate PX-3018262700 CDM 82627 CPT 301 RC inpatient 286 286 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES HDHP [308136802] 226.45 percent of total billed charges 177.32 271.7 Technical (Hospital) Services Ref Dhea Sulfate PX-3018262700 CDM 82627 CPT 301 RC inpatient 286 286 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES EPO [308136803] 226.45 percent of total billed charges 177.32 271.7 Technical (Hospital) Services Ref Dhea Sulfate PX-3018262700 CDM 82627 CPT 301 RC inpatient 286 286 HEALTHPARTNERS SX009 HEALTHPARTNERS 226.45 percent of total billed charges 177.32 271.7 Technical (Hospital) Services Ref Dhea Sulfate PX-3018262700 CDM 82627 CPT 301 RC inpatient 286 286 MEDICA (COMMERCIAL) 94265 [3081118] MEDICA CLAIMS [308111801] 257.4 percent of total billed charges 177.32 271.7 Technical (Hospital) Services Ref Dhea Sulfate PX-3018262700 CDM 82627 CPT 301 RC inpatient 286 286 MULTIPLAN INC 34080 [3081285] MULTIPLAN INC [308128501] 271.7 percent of total billed charges 177.32 271.7 Technical (Hospital) Services Ref Dhea Sulfate PX-3018262700 CDM 82627 CPT 301 RC inpatient 286 286 CIGNA 62308 [3081051] CIGNA 62308 [308105105] 226.45 percent of total billed charges 177.32 271.7 Technical (Hospital) Services Ref Dhea Sulfate PX-3018262700 CDM 82627 CPT 301 RC inpatient 286 286 CIGNA 62308 [3081051] CIGNA STATE OF WYOMING [308105107] 226.45 percent of total billed charges 177.32 271.7 Technical (Hospital) Services Ref Dhea Sulfate PX-3018262700 CDM 82627 CPT 301 RC outpatient 286 286 MEDICA (COMMERCIAL) 94265 [3081118] MEDICA CLAIMS [308111801] 257.4 percent of total billed charges 177.32 271.7 Technical (Hospital) Services Ref Dhea Sulfate PX-3018262700 CDM 82627 CPT 301 RC outpatient 286 286 CIGNA 62308 [3081051] CIGNA 62308 [308105105] 228.8 percent of total billed charges 177.32 271.7 Technical (Hospital) Services Ref Dhea Sulfate PX-3018262700 CDM 82627 CPT 301 RC outpatient 286 286 CIGNA 62308 [3081051] CIGNA STATE OF WYOMING [308105107] 228.8 percent of total billed charges 177.32 271.7 Technical (Hospital) Services Ref Dhea Sulfate PX-3018262700 CDM 82627 CPT 301 RC outpatient 286 286 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES HDHP [308136802] 228.8 percent of total billed charges 177.32 271.7 Technical (Hospital) Services Ref Dhea Sulfate PX-3018262700 CDM 82627 CPT 301 RC outpatient 286 286 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES EPO [308136803] 228.8 percent of total billed charges 177.32 271.7 Technical (Hospital) Services Ref Dhea Sulfate PX-3018262700 CDM 82627 CPT 301 RC outpatient 286 286 BLUE CROSS BLUE SHIELD WELLMARK SB889 [3081026] BCBS WYOMING [308102603] 271.7 percent of total billed charges 177.32 271.7 Technical (Hospital) Services Ref Dhea Sulfate PX-3018262700 CDM 82627 CPT 301 RC outpatient 286 286 MULTIPLAN INC 34080 [3081285] MULTIPLAN INC [308128501] 271.7 percent of total billed charges 177.32 271.7 Technical (Hospital) Services Ref Dhea Sulfate PX-3018262700 CDM 82627 CPT 301 RC outpatient 286 286 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES PPO [308136801] 228.8 percent of total billed charges 177.32 271.7 Technical (Hospital) Services Ref Dhea Sulfate PX-3018262700 CDM 82627 CPT 301 RC outpatient 286 286 HEALTHPARTNERS SX009 HEALTHPARTNERS 228.8 percent of total billed charges 177.32 271.7 Technical (Hospital) Services Ref Dhea Sulfate PX-3018262700 CDM 82627 CPT 301 RC outpatient 286 286 UNITED HEALTHCARE (COMMERCIAL) [3081199] UNITED HEALTHCARE 87726 [308119901] 177.32 percent of total billed charges 177.32 271.7 Technical (Hospital) Services Ref Dhea PX-3018262601 CDM 82626 CPT 301 RC outpatient 303 303 MEDICA (COMMERCIAL) 94265 [3081118] MEDICA CLAIMS [308111801] 272.7 percent of total billed charges 187.86 287.85 Technical (Hospital) Services Ref Dhea PX-3018262601 CDM 82626 CPT 301 RC outpatient 303 303 CIGNA 62308 [3081051] CIGNA 62308 [308105105] 242.4 percent of total billed charges 187.86 287.85 Technical (Hospital) Services Ref Dhea PX-3018262601 CDM 82626 CPT 301 RC outpatient 303 303 CIGNA 62308 [3081051] CIGNA STATE OF WYOMING [308105107] 242.4 percent of total billed charges 187.86 287.85 Technical (Hospital) Services Ref Dhea PX-3018262601 CDM 82626 CPT 301 RC outpatient 303 303 BLUE CROSS BLUE SHIELD WELLMARK SB889 [3081026] BCBS WYOMING [308102603] 287.85 percent of total billed charges 187.86 287.85 Technical (Hospital) Services Ref Dhea PX-3018262601 CDM 82626 CPT 301 RC outpatient 303 303 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES EPO [308136803] 242.4 percent of total billed charges 187.86 287.85 Technical (Hospital) Services Ref Dhea PX-3018262601 CDM 82626 CPT 301 RC outpatient 303 303 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES HDHP [308136802] 242.4 percent of total billed charges 187.86 287.85 Technical (Hospital) Services Ref Dhea PX-3018262601 CDM 82626 CPT 301 RC outpatient 303 303 MULTIPLAN INC 34080 [3081285] MULTIPLAN INC [308128501] 287.85 percent of total billed charges 187.86 287.85 Technical (Hospital) Services Ref Dhea PX-3018262601 CDM 82626 CPT 301 RC outpatient 303 303 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES PPO [308136801] 242.4 percent of total billed charges 187.86 287.85 Technical (Hospital) Services Ref Dhea PX-3018262601 CDM 82626 CPT 301 RC outpatient 303 303 UNITED HEALTHCARE (COMMERCIAL) [3081199] UNITED HEALTHCARE 87726 [308119901] 187.86 percent of total billed charges 187.86 287.85 Technical (Hospital) Services Ref Dhea PX-3018262601 CDM 82626 CPT 301 RC outpatient 303 303 HEALTHPARTNERS SX009 HEALTHPARTNERS 242.4 percent of total billed charges 187.86 287.85 Technical (Hospital) Services Ref Dhea PX-3018262601 CDM 82626 CPT 301 RC inpatient 303 303 HEALTHPARTNERS SX009 HEALTHPARTNERS 239.92 percent of total billed charges 187.86 287.85 Technical (Hospital) Services Ref Dhea PX-3018262601 CDM 82626 CPT 301 RC inpatient 303 303 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES EPO [308136803] 239.92 percent of total billed charges 187.86 287.85 Technical (Hospital) Services Ref Dhea PX-3018262601 CDM 82626 CPT 301 RC inpatient 303 303 MEDICA (COMMERCIAL) 94265 [3081118] MEDICA CLAIMS [308111801] 272.7 percent of total billed charges 187.86 287.85 Technical (Hospital) Services Ref Dhea PX-3018262601 CDM 82626 CPT 301 RC inpatient 303 303 MULTIPLAN INC 34080 [3081285] MULTIPLAN INC [308128501] 287.85 percent of total billed charges 187.86 287.85 Technical (Hospital) Services Ref Dhea PX-3018262601 CDM 82626 CPT 301 RC inpatient 303 303 UNITED HEALTHCARE (COMMERCIAL) [3081199] UNITED HEALTHCARE 87726 [308119901] 187.86 percent of total billed charges 187.86 287.85 Technical (Hospital) Services Ref Dhea PX-3018262601 CDM 82626 CPT 301 RC inpatient 303 303 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES PPO [308136801] 239.92 percent of total billed charges 187.86 287.85 Technical (Hospital) Services Ref Dhea PX-3018262601 CDM 82626 CPT 301 RC inpatient 303 303 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES HDHP [308136802] 239.92 percent of total billed charges 187.86 287.85 Technical (Hospital) Services Ref Dhea PX-3018262601 CDM 82626 CPT 301 RC inpatient 303 303 BLUE CROSS BLUE SHIELD WELLMARK SB889 [3081026] BCBS WYOMING [308102603] 287.85 percent of total billed charges 187.86 287.85 Technical (Hospital) Services Ref Dhea PX-3018262601 CDM 82626 CPT 301 RC inpatient 303 303 CIGNA 62308 [3081051] CIGNA 62308 [308105105] 239.92 percent of total billed charges 187.86 287.85 Technical (Hospital) Services Ref Dhea PX-3018262601 CDM 82626 CPT 301 RC inpatient 303 303 CIGNA 62308 [3081051] CIGNA STATE OF WYOMING [308105107] 239.92 percent of total billed charges 187.86 287.85 Technical (Hospital) Services Ref Cystatin C With Estimated Gfr(Mayo) PX-3018261000 CDM 82610 CPT 301 RC inpatient 203 203 HEALTHPARTNERS SX009 HEALTHPARTNERS 160.74 percent of total billed charges 125.86 192.85 Technical (Hospital) Services Ref Cystatin C With Estimated Gfr(Mayo) PX-3018261000 CDM 82610 CPT 301 RC inpatient 203 203 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES EPO [308136803] 160.74 percent of total billed charges 125.86 192.85 Technical (Hospital) Services Ref Cystatin C With Estimated Gfr(Mayo) PX-3018261000 CDM 82610 CPT 301 RC inpatient 203 203 MULTIPLAN INC 34080 [3081285] MULTIPLAN INC [308128501] 192.85 percent of total billed charges 125.86 192.85 Technical (Hospital) Services Ref Cystatin C With Estimated Gfr(Mayo) PX-3018261000 CDM 82610 CPT 301 RC inpatient 203 203 MEDICA (COMMERCIAL) 94265 [3081118] MEDICA CLAIMS [308111801] 182.7 percent of total billed charges 125.86 192.85 Technical (Hospital) Services Ref Cystatin C With Estimated Gfr(Mayo) PX-3018261000 CDM 82610 CPT 301 RC inpatient 203 203 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES HDHP [308136802] 160.74 percent of total billed charges 125.86 192.85 Technical (Hospital) Services Ref Cystatin C With Estimated Gfr(Mayo) PX-3018261000 CDM 82610 CPT 301 RC inpatient 203 203 BLUE CROSS BLUE SHIELD WELLMARK SB889 [3081026] BCBS WYOMING [308102603] 192.85 percent of total billed charges 125.86 192.85 Technical (Hospital) Services Ref Cystatin C With Estimated Gfr(Mayo) PX-3018261000 CDM 82610 CPT 301 RC inpatient 203 203 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES PPO [308136801] 160.74 percent of total billed charges 125.86 192.85 Technical (Hospital) Services Ref Cystatin C With Estimated Gfr(Mayo) PX-3018261000 CDM 82610 CPT 301 RC inpatient 203 203 UNITED HEALTHCARE (COMMERCIAL) [3081199] UNITED HEALTHCARE 87726 [308119901] 125.86 percent of total billed charges 125.86 192.85 Technical (Hospital) Services Ref Cystatin C With Estimated Gfr(Mayo) PX-3018261000 CDM 82610 CPT 301 RC inpatient 203 203 CIGNA 62308 [3081051] CIGNA 62308 [308105105] 160.74 percent of total billed charges 125.86 192.85 Technical (Hospital) Services Ref Cystatin C With Estimated Gfr(Mayo) PX-3018261000 CDM 82610 CPT 301 RC inpatient 203 203 CIGNA 62308 [3081051] CIGNA STATE OF WYOMING [308105107] 160.74 percent of total billed charges 125.86 192.85 Technical (Hospital) Services Ref Cystatin C With Estimated Gfr(Mayo) PX-3018261000 CDM 82610 CPT 301 RC outpatient 203 203 MEDICA (COMMERCIAL) 94265 [3081118] MEDICA CLAIMS [308111801] 182.7 percent of total billed charges 125.86 192.85 Technical (Hospital) Services Ref Cystatin C With Estimated Gfr(Mayo) PX-3018261000 CDM 82610 CPT 301 RC outpatient 203 203 CIGNA 62308 [3081051] CIGNA 62308 [308105105] 162.4 percent of total billed charges 125.86 192.85 Technical (Hospital) Services Ref Cystatin C With Estimated Gfr(Mayo) PX-3018261000 CDM 82610 CPT 301 RC outpatient 203 203 CIGNA 62308 [3081051] CIGNA STATE OF WYOMING [308105107] 162.4 percent of total billed charges 125.86 192.85 Technical (Hospital) Services Ref Cystatin C With Estimated Gfr(Mayo) PX-3018261000 CDM 82610 CPT 301 RC outpatient 203 203 HEALTHPARTNERS SX009 HEALTHPARTNERS 162.4 percent of total billed charges 125.86 192.85 Technical (Hospital) Services Ref Cystatin C With Estimated Gfr(Mayo) PX-3018261000 CDM 82610 CPT 301 RC outpatient 203 203 UNITED HEALTHCARE (COMMERCIAL) [3081199] UNITED HEALTHCARE 87726 [308119901] 125.86 percent of total billed charges 125.86 192.85 Technical (Hospital) Services Ref Cystatin C With Estimated Gfr(Mayo) PX-3018261000 CDM 82610 CPT 301 RC outpatient 203 203 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES EPO [308136803] 162.4 percent of total billed charges 125.86 192.85 Technical (Hospital) Services Ref Cystatin C With Estimated Gfr(Mayo) PX-3018261000 CDM 82610 CPT 301 RC outpatient 203 203 BLUE CROSS BLUE SHIELD WELLMARK SB889 [3081026] BCBS WYOMING [308102603] 192.85 percent of total billed charges 125.86 192.85 Technical (Hospital) Services Ref Cystatin C With Estimated Gfr(Mayo) PX-3018261000 CDM 82610 CPT 301 RC outpatient 203 203 MULTIPLAN INC 34080 [3081285] MULTIPLAN INC [308128501] 192.85 percent of total billed charges 125.86 192.85 Technical (Hospital) Services Ref Cystatin C With Estimated Gfr(Mayo) PX-3018261000 CDM 82610 CPT 301 RC outpatient 203 203 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES HDHP [308136802] 162.4 percent of total billed charges 125.86 192.85 Technical (Hospital) Services Ref Cystatin C With Estimated Gfr(Mayo) PX-3018261000 CDM 82610 CPT 301 RC outpatient 203 203 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES PPO [308136801] 162.4 percent of total billed charges 125.86 192.85 Technical (Hospital) Services Vit B12 Serum PX-3018260700 CDM 82607 CPT 301 RC inpatient 193 193 CIGNA 62308 [3081051] CIGNA 62308 [308105105] 152.82 percent of total billed charges 119.66 183.35 Technical (Hospital) Services Vit B12 Serum PX-3018260700 CDM 82607 CPT 301 RC inpatient 193 193 CIGNA 62308 [3081051] CIGNA STATE OF WYOMING [308105107] 152.82 percent of total billed charges 119.66 183.35 Technical (Hospital) Services Vit B12 Serum PX-3018260700 CDM 82607 CPT 301 RC inpatient 193 193 BLUE CROSS BLUE SHIELD WELLMARK SB889 [3081026] BCBS WYOMING [308102603] 183.35 percent of total billed charges 119.66 183.35 Technical (Hospital) Services Vit B12 Serum PX-3018260700 CDM 82607 CPT 301 RC inpatient 193 193 UNITED HEALTHCARE (COMMERCIAL) [3081199] UNITED HEALTHCARE 87726 [308119901] 119.66 percent of total billed charges 119.66 183.35 Technical (Hospital) Services Vit B12 Serum PX-3018260700 CDM 82607 CPT 301 RC inpatient 193 193 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES PPO [308136801] 152.82 percent of total billed charges 119.66 183.35 Technical (Hospital) Services Vit B12 Serum PX-3018260700 CDM 82607 CPT 301 RC inpatient 193 193 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES HDHP [308136802] 152.82 percent of total billed charges 119.66 183.35 Technical (Hospital) Services Vit B12 Serum PX-3018260700 CDM 82607 CPT 301 RC inpatient 193 193 MULTIPLAN INC 34080 [3081285] MULTIPLAN INC [308128501] 183.35 percent of total billed charges 119.66 183.35 Technical (Hospital) Services Vit B12 Serum PX-3018260700 CDM 82607 CPT 301 RC inpatient 193 193 MEDICA (COMMERCIAL) 94265 [3081118] MEDICA CLAIMS [308111801] 173.7 percent of total billed charges 119.66 183.35 Technical (Hospital) Services Vit B12 Serum PX-3018260700 CDM 82607 CPT 301 RC inpatient 193 193 HEALTHPARTNERS SX009 HEALTHPARTNERS 152.82 percent of total billed charges 119.66 183.35 Technical (Hospital) Services Vit B12 Serum PX-3018260700 CDM 82607 CPT 301 RC inpatient 193 193 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES EPO [308136803] 152.82 percent of total billed charges 119.66 183.35 Technical (Hospital) Services Vit B12 Serum PX-3018260700 CDM 82607 CPT 301 RC outpatient 193 193 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES PPO [308136801] 154.4 percent of total billed charges 119.66 183.35 Technical (Hospital) Services Vit B12 Serum PX-3018260700 CDM 82607 CPT 301 RC outpatient 193 193 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES HDHP [308136802] 154.4 percent of total billed charges 119.66 183.35 Technical (Hospital) Services Vit B12 Serum PX-3018260700 CDM 82607 CPT 301 RC outpatient 193 193 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES EPO [308136803] 154.4 percent of total billed charges 119.66 183.35 Technical (Hospital) Services Vit B12 Serum PX-3018260700 CDM 82607 CPT 301 RC outpatient 193 193 BLUE CROSS BLUE SHIELD WELLMARK SB889 [3081026] BCBS WYOMING [308102603] 183.35 percent of total billed charges 119.66 183.35 Technical (Hospital) Services Vit B12 Serum PX-3018260700 CDM 82607 CPT 301 RC outpatient 193 193 MULTIPLAN INC 34080 [3081285] MULTIPLAN INC [308128501] 183.35 percent of total billed charges 119.66 183.35 Technical (Hospital) Services Vit B12 Serum PX-3018260700 CDM 82607 CPT 301 RC outpatient 193 193 HEALTHPARTNERS SX009 HEALTHPARTNERS 154.4 percent of total billed charges 119.66 183.35 Technical (Hospital) Services Vit B12 Serum PX-3018260700 CDM 82607 CPT 301 RC outpatient 193 193 UNITED HEALTHCARE (COMMERCIAL) [3081199] UNITED HEALTHCARE 87726 [308119901] 119.66 percent of total billed charges 119.66 183.35 Technical (Hospital) Services Vit B12 Serum PX-3018260700 CDM 82607 CPT 301 RC outpatient 193 193 CIGNA 62308 [3081051] CIGNA 62308 [308105105] 154.4 percent of total billed charges 119.66 183.35 Technical (Hospital) Services Vit B12 Serum PX-3018260700 CDM 82607 CPT 301 RC outpatient 193 193 CIGNA 62308 [3081051] CIGNA STATE OF WYOMING [308105107] 154.4 percent of total billed charges 119.66 183.35 Technical (Hospital) Services Vit B12 Serum PX-3018260700 CDM 82607 CPT 301 RC outpatient 193 193 MEDICA (COMMERCIAL) 94265 [3081118] MEDICA CLAIMS [308111801] 173.7 percent of total billed charges 119.66 183.35 Technical (Hospital) Services "Ref Cryo Panel, Serum and Plasma(Mayo)" PX-3018259500 CDM 82595 CPT 301 RC outpatient 95 95 CIGNA 62308 [3081051] CIGNA 62308 [308105105] 76 percent of total billed charges 58.9 90.25 Technical (Hospital) Services "Ref Cryo Panel, Serum and Plasma(Mayo)" PX-3018259500 CDM 82595 CPT 301 RC outpatient 95 95 CIGNA 62308 [3081051] CIGNA STATE OF WYOMING [308105107] 76 percent of total billed charges 58.9 90.25 Technical (Hospital) Services "Ref Cryo Panel, Serum and Plasma(Mayo)" PX-3018259500 CDM 82595 CPT 301 RC outpatient 95 95 MEDICA (COMMERCIAL) 94265 [3081118] MEDICA CLAIMS [308111801] 85.5 percent of total billed charges 58.9 90.25 Technical (Hospital) Services "Ref Cryo Panel, Serum and Plasma(Mayo)" PX-3018259500 CDM 82595 CPT 301 RC outpatient 95 95 HEALTHPARTNERS SX009 HEALTHPARTNERS 76 percent of total billed charges 58.9 90.25 Technical (Hospital) Services "Ref Cryo Panel, Serum and Plasma(Mayo)" PX-3018259500 CDM 82595 CPT 301 RC outpatient 95 95 UNITED HEALTHCARE (COMMERCIAL) [3081199] UNITED HEALTHCARE 87726 [308119901] 58.9 percent of total billed charges 58.9 90.25 Technical (Hospital) Services "Ref Cryo Panel, Serum and Plasma(Mayo)" PX-3018259500 CDM 82595 CPT 301 RC outpatient 95 95 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES HDHP [308136802] 76 percent of total billed charges 58.9 90.25 Technical (Hospital) Services "Ref Cryo Panel, Serum and Plasma(Mayo)" PX-3018259500 CDM 82595 CPT 301 RC outpatient 95 95 BLUE CROSS BLUE SHIELD WELLMARK SB889 [3081026] BCBS WYOMING [308102603] 90.25 percent of total billed charges 58.9 90.25 Technical (Hospital) Services "Ref Cryo Panel, Serum and Plasma(Mayo)" PX-3018259500 CDM 82595 CPT 301 RC outpatient 95 95 MULTIPLAN INC 34080 [3081285] MULTIPLAN INC [308128501] 90.25 percent of total billed charges 58.9 90.25 Technical (Hospital) Services "Ref Cryo Panel, Serum and Plasma(Mayo)" PX-3018259500 CDM 82595 CPT 301 RC outpatient 95 95 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES EPO [308136803] 76 percent of total billed charges 58.9 90.25 Technical (Hospital) Services "Ref Cryo Panel, Serum and Plasma(Mayo)" PX-3018259500 CDM 82595 CPT 301 RC outpatient 95 95 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES PPO [308136801] 76 percent of total billed charges 58.9 90.25 Technical (Hospital) Services "Ref Cryo Panel, Serum and Plasma(Mayo)" PX-3018259500 CDM 82595 CPT 301 RC inpatient 95 95 MULTIPLAN INC 34080 [3081285] MULTIPLAN INC [308128501] 90.25 percent of total billed charges 58.9 90.25 Technical (Hospital) Services "Ref Cryo Panel, Serum and Plasma(Mayo)" PX-3018259500 CDM 82595 CPT 301 RC inpatient 95 95 MEDICA (COMMERCIAL) 94265 [3081118] MEDICA CLAIMS [308111801] 85.5 percent of total billed charges 58.9 90.25 Technical (Hospital) Services "Ref Cryo Panel, Serum and Plasma(Mayo)" PX-3018259500 CDM 82595 CPT 301 RC inpatient 95 95 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES EPO [308136803] 75.22 percent of total billed charges 58.9 90.25 Technical (Hospital) Services "Ref Cryo Panel, Serum and Plasma(Mayo)" PX-3018259500 CDM 82595 CPT 301 RC inpatient 95 95 HEALTHPARTNERS SX009 HEALTHPARTNERS 75.22 percent of total billed charges 58.9 90.25 Technical (Hospital) Services "Ref Cryo Panel, Serum and Plasma(Mayo)" PX-3018259500 CDM 82595 CPT 301 RC inpatient 95 95 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES PPO [308136801] 75.22 percent of total billed charges 58.9 90.25 Technical (Hospital) Services "Ref Cryo Panel, Serum and Plasma(Mayo)" PX-3018259500 CDM 82595 CPT 301 RC inpatient 95 95 UNITED HEALTHCARE (COMMERCIAL) [3081199] UNITED HEALTHCARE 87726 [308119901] 58.9 percent of total billed charges 58.9 90.25 Technical (Hospital) Services "Ref Cryo Panel, Serum and Plasma(Mayo)" PX-3018259500 CDM 82595 CPT 301 RC inpatient 95 95 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES HDHP [308136802] 75.22 percent of total billed charges 58.9 90.25 Technical (Hospital) Services "Ref Cryo Panel, Serum and Plasma(Mayo)" PX-3018259500 CDM 82595 CPT 301 RC inpatient 95 95 BLUE CROSS BLUE SHIELD WELLMARK SB889 [3081026] BCBS WYOMING [308102603] 90.25 percent of total billed charges 58.9 90.25 Technical (Hospital) Services "Ref Cryo Panel, Serum and Plasma(Mayo)" PX-3018259500 CDM 82595 CPT 301 RC inpatient 95 95 CIGNA 62308 [3081051] CIGNA 62308 [308105105] 75.22 percent of total billed charges 58.9 90.25 Technical (Hospital) Services "Ref Cryo Panel, Serum and Plasma(Mayo)" PX-3018259500 CDM 82595 CPT 301 RC inpatient 95 95 CIGNA 62308 [3081051] CIGNA STATE OF WYOMING [308105107] 75.22 percent of total billed charges 58.9 90.25 Technical (Hospital) Services Ref Cryoglobulin S&P PX-3018259501 CDM 82595 CPT 301 RC outpatient 210 210 MULTIPLAN INC 34080 [3081285] MULTIPLAN INC [308128501] 199.5 percent of total billed charges 130.2 199.5 Technical (Hospital) Services Ref Cryoglobulin S&P PX-3018259501 CDM 82595 CPT 301 RC outpatient 210 210 BLUE CROSS BLUE SHIELD WELLMARK SB889 [3081026] BCBS WYOMING [308102603] 199.5 percent of total billed charges 130.2 199.5 Technical (Hospital) Services Ref Cryoglobulin S&P PX-3018259501 CDM 82595 CPT 301 RC outpatient 210 210 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES EPO [308136803] 168 percent of total billed charges 130.2 199.5 Technical (Hospital) Services Ref Cryoglobulin S&P PX-3018259501 CDM 82595 CPT 301 RC outpatient 210 210 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES HDHP [308136802] 168 percent of total billed charges 130.2 199.5 Technical (Hospital) Services Ref Cryoglobulin S&P PX-3018259501 CDM 82595 CPT 301 RC outpatient 210 210 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES PPO [308136801] 168 percent of total billed charges 130.2 199.5 Technical (Hospital) Services Ref Cryoglobulin S&P PX-3018259501 CDM 82595 CPT 301 RC outpatient 210 210 HEALTHPARTNERS SX009 HEALTHPARTNERS 168 percent of total billed charges 130.2 199.5 Technical (Hospital) Services Ref Cryoglobulin S&P PX-3018259501 CDM 82595 CPT 301 RC outpatient 210 210 UNITED HEALTHCARE (COMMERCIAL) [3081199] UNITED HEALTHCARE 87726 [308119901] 130.2 percent of total billed charges 130.2 199.5 Technical (Hospital) Services Ref Cryoglobulin S&P PX-3018259501 CDM 82595 CPT 301 RC outpatient 210 210 CIGNA 62308 [3081051] CIGNA 62308 [308105105] 168 percent of total billed charges 130.2 199.5 Technical (Hospital) Services Ref Cryoglobulin S&P PX-3018259501 CDM 82595 CPT 301 RC outpatient 210 210 CIGNA 62308 [3081051] CIGNA STATE OF WYOMING [308105107] 168 percent of total billed charges 130.2 199.5 Technical (Hospital) Services Ref Cryoglobulin S&P PX-3018259501 CDM 82595 CPT 301 RC outpatient 210 210 MEDICA (COMMERCIAL) 94265 [3081118] MEDICA CLAIMS [308111801] 189 percent of total billed charges 130.2 199.5 Technical (Hospital) Services Ref Cryoglobulin S&P PX-3018259501 CDM 82595 CPT 301 RC inpatient 210 210 CIGNA 62308 [3081051] CIGNA 62308 [308105105] 166.28 percent of total billed charges 130.2 199.5 Technical (Hospital) Services Ref Cryoglobulin S&P PX-3018259501 CDM 82595 CPT 301 RC inpatient 210 210 CIGNA 62308 [3081051] CIGNA STATE OF WYOMING [308105107] 166.28 percent of total billed charges 130.2 199.5 Technical (Hospital) Services Ref Cryoglobulin S&P PX-3018259501 CDM 82595 CPT 301 RC inpatient 210 210 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES EPO [308136803] 166.28 percent of total billed charges 130.2 199.5 Technical (Hospital) Services Ref Cryoglobulin S&P PX-3018259501 CDM 82595 CPT 301 RC inpatient 210 210 HEALTHPARTNERS SX009 HEALTHPARTNERS 166.28 percent of total billed charges 130.2 199.5 Technical (Hospital) Services Ref Cryoglobulin S&P PX-3018259501 CDM 82595 CPT 301 RC inpatient 210 210 MULTIPLAN INC 34080 [3081285] MULTIPLAN INC [308128501] 199.5 percent of total billed charges 130.2 199.5 Technical (Hospital) Services Ref Cryoglobulin S&P PX-3018259501 CDM 82595 CPT 301 RC inpatient 210 210 MEDICA (COMMERCIAL) 94265 [3081118] MEDICA CLAIMS [308111801] 189 percent of total billed charges 130.2 199.5 Technical (Hospital) Services Ref Cryoglobulin S&P PX-3018259501 CDM 82595 CPT 301 RC inpatient 210 210 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES PPO [308136801] 166.28 percent of total billed charges 130.2 199.5 Technical (Hospital) Services Ref Cryoglobulin S&P PX-3018259501 CDM 82595 CPT 301 RC inpatient 210 210 UNITED HEALTHCARE (COMMERCIAL) [3081199] UNITED HEALTHCARE 87726 [308119901] 130.2 percent of total billed charges 130.2 199.5 Technical (Hospital) Services Ref Cryoglobulin S&P PX-3018259501 CDM 82595 CPT 301 RC inpatient 210 210 BLUE CROSS BLUE SHIELD WELLMARK SB889 [3081026] BCBS WYOMING [308102603] 199.5 percent of total billed charges 130.2 199.5 Technical (Hospital) Services Ref Cryoglobulin S&P PX-3018259501 CDM 82595 CPT 301 RC inpatient 210 210 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES HDHP [308136802] 166.28 percent of total billed charges 130.2 199.5 Technical (Hospital) Services Ref Cryog Cryofibrengogen PX-3018258500 CDM 82585 CPT 301 RC inpatient 102 102 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES HDHP [308136802] 80.76 percent of total billed charges 63.24 96.9 Technical (Hospital) Services Ref Cryog Cryofibrengogen PX-3018258500 CDM 82585 CPT 301 RC inpatient 102 102 BLUE CROSS BLUE SHIELD WELLMARK SB889 [3081026] BCBS WYOMING [308102603] 96.9 percent of total billed charges 63.24 96.9 Technical (Hospital) Services Ref Cryog Cryofibrengogen PX-3018258500 CDM 82585 CPT 301 RC inpatient 102 102 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES PPO [308136801] 80.76 percent of total billed charges 63.24 96.9 Technical (Hospital) Services Ref Cryog Cryofibrengogen PX-3018258500 CDM 82585 CPT 301 RC inpatient 102 102 UNITED HEALTHCARE (COMMERCIAL) [3081199] UNITED HEALTHCARE 87726 [308119901] 63.24 percent of total billed charges 63.24 96.9 Technical (Hospital) Services Ref Cryog Cryofibrengogen PX-3018258500 CDM 82585 CPT 301 RC inpatient 102 102 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES EPO [308136803] 80.76 percent of total billed charges 63.24 96.9 Technical (Hospital) Services Ref Cryog Cryofibrengogen PX-3018258500 CDM 82585 CPT 301 RC inpatient 102 102 HEALTHPARTNERS SX009 HEALTHPARTNERS 80.76 percent of total billed charges 63.24 96.9 Technical (Hospital) Services Ref Cryog Cryofibrengogen PX-3018258500 CDM 82585 CPT 301 RC inpatient 102 102 MULTIPLAN INC 34080 [3081285] MULTIPLAN INC [308128501] 96.9 percent of total billed charges 63.24 96.9 Technical (Hospital) Services Ref Cryog Cryofibrengogen PX-3018258500 CDM 82585 CPT 301 RC inpatient 102 102 MEDICA (COMMERCIAL) 94265 [3081118] MEDICA CLAIMS [308111801] 91.8 percent of total billed charges 63.24 96.9 Technical (Hospital) Services Ref Cryog Cryofibrengogen PX-3018258500 CDM 82585 CPT 301 RC inpatient 102 102 CIGNA 62308 [3081051] CIGNA 62308 [308105105] 80.76 percent of total billed charges 63.24 96.9 Technical (Hospital) Services Ref Cryog Cryofibrengogen PX-3018258500 CDM 82585 CPT 301 RC inpatient 102 102 CIGNA 62308 [3081051] CIGNA STATE OF WYOMING [308105107] 80.76 percent of total billed charges 63.24 96.9 Technical (Hospital) Services Ref Cryog Cryofibrengogen PX-3018258500 CDM 82585 CPT 301 RC outpatient 102 102 MEDICA (COMMERCIAL) 94265 [3081118] MEDICA CLAIMS [308111801] 91.8 percent of total billed charges 63.24 96.9 Technical (Hospital) Services Ref Cryog Cryofibrengogen PX-3018258500 CDM 82585 CPT 301 RC outpatient 102 102 CIGNA 62308 [3081051] CIGNA 62308 [308105105] 81.6 percent of total billed charges 63.24 96.9 Technical (Hospital) Services Ref Cryog Cryofibrengogen PX-3018258500 CDM 82585 CPT 301 RC outpatient 102 102 CIGNA 62308 [3081051] CIGNA STATE OF WYOMING [308105107] 81.6 percent of total billed charges 63.24 96.9 Technical (Hospital) Services Ref Cryog Cryofibrengogen PX-3018258500 CDM 82585 CPT 301 RC outpatient 102 102 UNITED HEALTHCARE (COMMERCIAL) [3081199] UNITED HEALTHCARE 87726 [308119901] 63.24 percent of total billed charges 63.24 96.9 Technical (Hospital) Services Ref Cryog Cryofibrengogen PX-3018258500 CDM 82585 CPT 301 RC outpatient 102 102 HEALTHPARTNERS SX009 HEALTHPARTNERS 81.6 percent of total billed charges 63.24 96.9 Technical (Hospital) Services Ref Cryog Cryofibrengogen PX-3018258500 CDM 82585 CPT 301 RC outpatient 102 102 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES PPO [308136801] 81.6 percent of total billed charges 63.24 96.9 Technical (Hospital) Services Ref Cryog Cryofibrengogen PX-3018258500 CDM 82585 CPT 301 RC outpatient 102 102 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES HDHP [308136802] 81.6 percent of total billed charges 63.24 96.9 Technical (Hospital) Services Ref Cryog Cryofibrengogen PX-3018258500 CDM 82585 CPT 301 RC outpatient 102 102 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES EPO [308136803] 81.6 percent of total billed charges 63.24 96.9 Technical (Hospital) Services Ref Cryog Cryofibrengogen PX-3018258500 CDM 82585 CPT 301 RC outpatient 102 102 BLUE CROSS BLUE SHIELD WELLMARK SB889 [3081026] BCBS WYOMING [308102603] 96.9 percent of total billed charges 63.24 96.9 Technical (Hospital) Services Ref Cryog Cryofibrengogen PX-3018258500 CDM 82585 CPT 301 RC outpatient 102 102 MULTIPLAN INC 34080 [3081285] MULTIPLAN INC [308128501] 96.9 percent of total billed charges 63.24 96.9 Technical (Hospital) Services Creat Clearance PX-3018257500 CDM 82575 CPT 301 RC inpatient 143 143 MEDICA (COMMERCIAL) 94265 [3081118] MEDICA CLAIMS [308111801] 128.7 percent of total billed charges 88.66 135.85 Technical (Hospital) Services Creat Clearance PX-3018257500 CDM 82575 CPT 301 RC inpatient 143 143 MULTIPLAN INC 34080 [3081285] MULTIPLAN INC [308128501] 135.85 percent of total billed charges 88.66 135.85 Technical (Hospital) Services Creat Clearance PX-3018257500 CDM 82575 CPT 301 RC inpatient 143 143 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES HDHP [308136802] 113.23 percent of total billed charges 88.66 135.85 Technical (Hospital) Services Creat Clearance PX-3018257500 CDM 82575 CPT 301 RC inpatient 143 143 HEALTHPARTNERS SX009 HEALTHPARTNERS 113.23 percent of total billed charges 88.66 135.85 Technical (Hospital) Services Creat Clearance PX-3018257500 CDM 82575 CPT 301 RC inpatient 143 143 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES EPO [308136803] 113.23 percent of total billed charges 88.66 135.85 Technical (Hospital) Services Creat Clearance PX-3018257500 CDM 82575 CPT 301 RC inpatient 143 143 BLUE CROSS BLUE SHIELD WELLMARK SB889 [3081026] BCBS WYOMING [308102603] 135.85 percent of total billed charges 88.66 135.85 Technical (Hospital) Services Creat Clearance PX-3018257500 CDM 82575 CPT 301 RC inpatient 143 143 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES PPO [308136801] 113.23 percent of total billed charges 88.66 135.85 Technical (Hospital) Services Creat Clearance PX-3018257500 CDM 82575 CPT 301 RC inpatient 143 143 UNITED HEALTHCARE (COMMERCIAL) [3081199] UNITED HEALTHCARE 87726 [308119901] 88.66 percent of total billed charges 88.66 135.85 Technical (Hospital) Services Creat Clearance PX-3018257500 CDM 82575 CPT 301 RC inpatient 143 143 CIGNA 62308 [3081051] CIGNA 62308 [308105105] 113.23 percent of total billed charges 88.66 135.85 Technical (Hospital) Services Creat Clearance PX-3018257500 CDM 82575 CPT 301 RC inpatient 143 143 CIGNA 62308 [3081051] CIGNA STATE OF WYOMING [308105107] 113.23 percent of total billed charges 88.66 135.85 Technical (Hospital) Services Creat Clearance PX-3018257500 CDM 82575 CPT 301 RC outpatient 143 143 MEDICA (COMMERCIAL) 94265 [3081118] MEDICA CLAIMS [308111801] 128.7 percent of total billed charges 88.66 135.85 Technical (Hospital) Services Creat Clearance PX-3018257500 CDM 82575 CPT 301 RC outpatient 143 143 CIGNA 62308 [3081051] CIGNA 62308 [308105105] 114.4 percent of total billed charges 88.66 135.85 Technical (Hospital) Services Creat Clearance PX-3018257500 CDM 82575 CPT 301 RC outpatient 143 143 CIGNA 62308 [3081051] CIGNA STATE OF WYOMING [308105107] 114.4 percent of total billed charges 88.66 135.85 Technical (Hospital) Services Creat Clearance PX-3018257500 CDM 82575 CPT 301 RC outpatient 143 143 HEALTHPARTNERS SX009 HEALTHPARTNERS 114.4 percent of total billed charges 88.66 135.85 Technical (Hospital) Services Creat Clearance PX-3018257500 CDM 82575 CPT 301 RC outpatient 143 143 UNITED HEALTHCARE (COMMERCIAL) [3081199] UNITED HEALTHCARE 87726 [308119901] 88.66 percent of total billed charges 88.66 135.85 Technical (Hospital) Services Creat Clearance PX-3018257500 CDM 82575 CPT 301 RC outpatient 143 143 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES PPO [308136801] 114.4 percent of total billed charges 88.66 135.85 Technical (Hospital) Services Creat Clearance PX-3018257500 CDM 82575 CPT 301 RC outpatient 143 143 MULTIPLAN INC 34080 [3081285] MULTIPLAN INC [308128501] 135.85 percent of total billed charges 88.66 135.85 Technical (Hospital) Services Creat Clearance PX-3018257500 CDM 82575 CPT 301 RC outpatient 143 143 BLUE CROSS BLUE SHIELD WELLMARK SB889 [3081026] BCBS WYOMING [308102603] 135.85 percent of total billed charges 88.66 135.85 Technical (Hospital) Services Creat Clearance PX-3018257500 CDM 82575 CPT 301 RC outpatient 143 143 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES EPO [308136803] 114.4 percent of total billed charges 88.66 135.85 Technical (Hospital) Services Creat Clearance PX-3018257500 CDM 82575 CPT 301 RC outpatient 143 143 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES HDHP [308136802] 114.4 percent of total billed charges 88.66 135.85 Technical (Hospital) Services Creatinine Body Fluid PX-3018257000 CDM 82570 CPT 301 RC outpatient 110 110 MEDICA (COMMERCIAL) 94265 [3081118] MEDICA CLAIMS [308111801] 99 percent of total billed charges 68.2 104.5 Technical (Hospital) Services Creatinine Body Fluid PX-3018257000 CDM 82570 CPT 301 RC outpatient 110 110 CIGNA 62308 [3081051] CIGNA 62308 [308105105] 88 percent of total billed charges 68.2 104.5 Technical (Hospital) Services Creatinine Body Fluid PX-3018257000 CDM 82570 CPT 301 RC outpatient 110 110 CIGNA 62308 [3081051] CIGNA STATE OF WYOMING [308105107] 88 percent of total billed charges 68.2 104.5 Technical (Hospital) Services Creatinine Body Fluid PX-3018257000 CDM 82570 CPT 301 RC outpatient 110 110 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES PPO [308136801] 88 percent of total billed charges 68.2 104.5 Technical (Hospital) Services Creatinine Body Fluid PX-3018257000 CDM 82570 CPT 301 RC outpatient 110 110 UNITED HEALTHCARE (COMMERCIAL) [3081199] UNITED HEALTHCARE 87726 [308119901] 68.2 percent of total billed charges 68.2 104.5 Technical (Hospital) Services Creatinine Body Fluid PX-3018257000 CDM 82570 CPT 301 RC outpatient 110 110 HEALTHPARTNERS SX009 HEALTHPARTNERS 88 percent of total billed charges 68.2 104.5 Technical (Hospital) Services Creatinine Body Fluid PX-3018257000 CDM 82570 CPT 301 RC outpatient 110 110 BLUE CROSS BLUE SHIELD WELLMARK SB889 [3081026] BCBS WYOMING [308102603] 104.5 percent of total billed charges 68.2 104.5 Technical (Hospital) Services Creatinine Body Fluid PX-3018257000 CDM 82570 CPT 301 RC outpatient 110 110 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES EPO [308136803] 88 percent of total billed charges 68.2 104.5 Technical (Hospital) Services Creatinine Body Fluid PX-3018257000 CDM 82570 CPT 301 RC outpatient 110 110 MULTIPLAN INC 34080 [3081285] MULTIPLAN INC [308128501] 104.5 percent of total billed charges 68.2 104.5 Technical (Hospital) Services Creatinine Body Fluid PX-3018257000 CDM 82570 CPT 301 RC outpatient 110 110 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES HDHP [308136802] 88 percent of total billed charges 68.2 104.5 Technical (Hospital) Services Creatinine Body Fluid PX-3018257000 CDM 82570 CPT 301 RC inpatient 110 110 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES EPO [308136803] 87.1 percent of total billed charges 68.2 104.5 Technical (Hospital) Services Creatinine Body Fluid PX-3018257000 CDM 82570 CPT 301 RC inpatient 110 110 HEALTHPARTNERS SX009 HEALTHPARTNERS 87.1 percent of total billed charges 68.2 104.5 Technical (Hospital) Services Creatinine Body Fluid PX-3018257000 CDM 82570 CPT 301 RC inpatient 110 110 MULTIPLAN INC 34080 [3081285] MULTIPLAN INC [308128501] 104.5 percent of total billed charges 68.2 104.5 Technical (Hospital) Services Creatinine Body Fluid PX-3018257000 CDM 82570 CPT 301 RC inpatient 110 110 MEDICA (COMMERCIAL) 94265 [3081118] MEDICA CLAIMS [308111801] 99 percent of total billed charges 68.2 104.5 Technical (Hospital) Services Creatinine Body Fluid PX-3018257000 CDM 82570 CPT 301 RC inpatient 110 110 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES HDHP [308136802] 87.1 percent of total billed charges 68.2 104.5 Technical (Hospital) Services Creatinine Body Fluid PX-3018257000 CDM 82570 CPT 301 RC inpatient 110 110 BLUE CROSS BLUE SHIELD WELLMARK SB889 [3081026] BCBS WYOMING [308102603] 104.5 percent of total billed charges 68.2 104.5 Technical (Hospital) Services Creatinine Body Fluid PX-3018257000 CDM 82570 CPT 301 RC inpatient 110 110 UNITED HEALTHCARE (COMMERCIAL) [3081199] UNITED HEALTHCARE 87726 [308119901] 68.2 percent of total billed charges 68.2 104.5 Technical (Hospital) Services Creatinine Body Fluid PX-3018257000 CDM 82570 CPT 301 RC inpatient 110 110 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES PPO [308136801] 87.1 percent of total billed charges 68.2 104.5 Technical (Hospital) Services Creatinine Body Fluid PX-3018257000 CDM 82570 CPT 301 RC inpatient 110 110 CIGNA 62308 [3081051] CIGNA 62308 [308105105] 87.1 percent of total billed charges 68.2 104.5 Technical (Hospital) Services Creatinine Body Fluid PX-3018257000 CDM 82570 CPT 301 RC inpatient 110 110 CIGNA 62308 [3081051] CIGNA STATE OF WYOMING [308105107] 87.1 percent of total billed charges 68.2 104.5 Technical (Hospital) Services Ref Creatinine Other Source PX-3018257001 CDM 82570 CPT 301 RC inpatient 110 110 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES HDHP [308136802] 87.1 percent of total billed charges 68.2 104.5 Technical (Hospital) Services Ref Creatinine Other Source PX-3018257001 CDM 82570 CPT 301 RC inpatient 110 110 BLUE CROSS BLUE SHIELD WELLMARK SB889 [3081026] BCBS WYOMING [308102603] 104.5 percent of total billed charges 68.2 104.5 Technical (Hospital) Services Ref Creatinine Other Source PX-3018257001 CDM 82570 CPT 301 RC inpatient 110 110 UNITED HEALTHCARE (COMMERCIAL) [3081199] UNITED HEALTHCARE 87726 [308119901] 68.2 percent of total billed charges 68.2 104.5 Technical (Hospital) Services Ref Creatinine Other Source PX-3018257001 CDM 82570 CPT 301 RC inpatient 110 110 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES PPO [308136801] 87.1 percent of total billed charges 68.2 104.5 Technical (Hospital) Services Ref Creatinine Other Source PX-3018257001 CDM 82570 CPT 301 RC inpatient 110 110 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES EPO [308136803] 87.1 percent of total billed charges 68.2 104.5 Technical (Hospital) Services Ref Creatinine Other Source PX-3018257001 CDM 82570 CPT 301 RC inpatient 110 110 HEALTHPARTNERS SX009 HEALTHPARTNERS 87.1 percent of total billed charges 68.2 104.5 Technical (Hospital) Services Ref Creatinine Other Source PX-3018257001 CDM 82570 CPT 301 RC inpatient 110 110 MEDICA (COMMERCIAL) 94265 [3081118] MEDICA CLAIMS [308111801] 99 percent of total billed charges 68.2 104.5 Technical (Hospital) Services Ref Creatinine Other Source PX-3018257001 CDM 82570 CPT 301 RC inpatient 110 110 MULTIPLAN INC 34080 [3081285] MULTIPLAN INC [308128501] 104.5 percent of total billed charges 68.2 104.5 Technical (Hospital) Services Ref Creatinine Other Source PX-3018257001 CDM 82570 CPT 301 RC inpatient 110 110 CIGNA 62308 [3081051] CIGNA 62308 [308105105] 87.1 percent of total billed charges 68.2 104.5 Technical (Hospital) Services Ref Creatinine Other Source PX-3018257001 CDM 82570 CPT 301 RC inpatient 110 110 CIGNA 62308 [3081051] CIGNA STATE OF WYOMING [308105107] 87.1 percent of total billed charges 68.2 104.5 Technical (Hospital) Services Ref Creatinine Other Source PX-3018257001 CDM 82570 CPT 301 RC outpatient 110 110 MEDICA (COMMERCIAL) 94265 [3081118] MEDICA CLAIMS [308111801] 99 percent of total billed charges 68.2 104.5 Technical (Hospital) Services Ref Creatinine Other Source PX-3018257001 CDM 82570 CPT 301 RC outpatient 110 110 CIGNA 62308 [3081051] CIGNA 62308 [308105105] 88 percent of total billed charges 68.2 104.5 Technical (Hospital) Services Ref Creatinine Other Source PX-3018257001 CDM 82570 CPT 301 RC outpatient 110 110 CIGNA 62308 [3081051] CIGNA STATE OF WYOMING [308105107] 88 percent of total billed charges 68.2 104.5 Technical (Hospital) Services Ref Creatinine Other Source PX-3018257001 CDM 82570 CPT 301 RC outpatient 110 110 BLUE CROSS BLUE SHIELD WELLMARK SB889 [3081026] BCBS WYOMING [308102603] 104.5 percent of total billed charges 68.2 104.5 Technical (Hospital) Services Ref Creatinine Other Source PX-3018257001 CDM 82570 CPT 301 RC outpatient 110 110 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES EPO [308136803] 88 percent of total billed charges 68.2 104.5 Technical (Hospital) Services Ref Creatinine Other Source PX-3018257001 CDM 82570 CPT 301 RC outpatient 110 110 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES HDHP [308136802] 88 percent of total billed charges 68.2 104.5 Technical (Hospital) Services Ref Creatinine Other Source PX-3018257001 CDM 82570 CPT 301 RC outpatient 110 110 MULTIPLAN INC 34080 [3081285] MULTIPLAN INC [308128501] 104.5 percent of total billed charges 68.2 104.5 Technical (Hospital) Services Ref Creatinine Other Source PX-3018257001 CDM 82570 CPT 301 RC outpatient 110 110 HEALTHPARTNERS SX009 HEALTHPARTNERS 88 percent of total billed charges 68.2 104.5 Technical (Hospital) Services Ref Creatinine Other Source PX-3018257001 CDM 82570 CPT 301 RC outpatient 110 110 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES PPO [308136801] 88 percent of total billed charges 68.2 104.5 Technical (Hospital) Services Ref Creatinine Other Source PX-3018257001 CDM 82570 CPT 301 RC outpatient 110 110 UNITED HEALTHCARE (COMMERCIAL) [3081199] UNITED HEALTHCARE 87726 [308119901] 68.2 percent of total billed charges 68.2 104.5 Technical (Hospital) Services Ref Creatine (Rptu) Urine PX-3018257003 CDM 82570 CPT 301 RC outpatient 84 84 MEDICA (COMMERCIAL) 94265 [3081118] MEDICA CLAIMS [308111801] 75.6 percent of total billed charges 52.08 79.8 Technical (Hospital) Services Ref Creatine (Rptu) Urine PX-3018257003 CDM 82570 CPT 301 RC outpatient 84 84 CIGNA 62308 [3081051] CIGNA 62308 [308105105] 67.2 percent of total billed charges 52.08 79.8 Technical (Hospital) Services Ref Creatine (Rptu) Urine PX-3018257003 CDM 82570 CPT 301 RC outpatient 84 84 CIGNA 62308 [3081051] CIGNA STATE OF WYOMING [308105107] 67.2 percent of total billed charges 52.08 79.8 Technical (Hospital) Services Ref Creatine (Rptu) Urine PX-3018257003 CDM 82570 CPT 301 RC outpatient 84 84 BLUE CROSS BLUE SHIELD WELLMARK SB889 [3081026] BCBS WYOMING [308102603] 79.8 percent of total billed charges 52.08 79.8 Technical (Hospital) Services Ref Creatine (Rptu) Urine PX-3018257003 CDM 82570 CPT 301 RC outpatient 84 84 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES EPO [308136803] 67.2 percent of total billed charges 52.08 79.8 Technical (Hospital) Services Ref Creatine (Rptu) Urine PX-3018257003 CDM 82570 CPT 301 RC outpatient 84 84 MULTIPLAN INC 34080 [3081285] MULTIPLAN INC [308128501] 79.8 percent of total billed charges 52.08 79.8 Technical (Hospital) Services Ref Creatine (Rptu) Urine PX-3018257003 CDM 82570 CPT 301 RC outpatient 84 84 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES HDHP [308136802] 67.2 percent of total billed charges 52.08 79.8 Technical (Hospital) Services Ref Creatine (Rptu) Urine PX-3018257003 CDM 82570 CPT 301 RC outpatient 84 84 HEALTHPARTNERS SX009 HEALTHPARTNERS 67.2 percent of total billed charges 52.08 79.8 Technical (Hospital) Services Ref Creatine (Rptu) Urine PX-3018257003 CDM 82570 CPT 301 RC outpatient 84 84 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES PPO [308136801] 67.2 percent of total billed charges 52.08 79.8 Technical (Hospital) Services Ref Creatine (Rptu) Urine PX-3018257003 CDM 82570 CPT 301 RC outpatient 84 84 UNITED HEALTHCARE (COMMERCIAL) [3081199] UNITED HEALTHCARE 87726 [308119901] 52.08 percent of total billed charges 52.08 79.8 Technical (Hospital) Services Ref Creatine (Rptu) Urine PX-3018257003 CDM 82570 CPT 301 RC inpatient 84 84 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES HDHP [308136802] 66.51 percent of total billed charges 52.08 79.8 Technical (Hospital) Services Ref Creatine (Rptu) Urine PX-3018257003 CDM 82570 CPT 301 RC inpatient 84 84 BLUE CROSS BLUE SHIELD WELLMARK SB889 [3081026] BCBS WYOMING [308102603] 79.8 percent of total billed charges 52.08 79.8 Technical (Hospital) Services Ref Creatine (Rptu) Urine PX-3018257003 CDM 82570 CPT 301 RC inpatient 84 84 UNITED HEALTHCARE (COMMERCIAL) [3081199] UNITED HEALTHCARE 87726 [308119901] 52.08 percent of total billed charges 52.08 79.8 Technical (Hospital) Services Ref Creatine (Rptu) Urine PX-3018257003 CDM 82570 CPT 301 RC inpatient 84 84 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES PPO [308136801] 66.51 percent of total billed charges 52.08 79.8 Technical (Hospital) Services Ref Creatine (Rptu) Urine PX-3018257003 CDM 82570 CPT 301 RC inpatient 84 84 MEDICA (COMMERCIAL) 94265 [3081118] MEDICA CLAIMS [308111801] 75.6 percent of total billed charges 52.08 79.8 Technical (Hospital) Services Ref Creatine (Rptu) Urine PX-3018257003 CDM 82570 CPT 301 RC inpatient 84 84 MULTIPLAN INC 34080 [3081285] MULTIPLAN INC [308128501] 79.8 percent of total billed charges 52.08 79.8 Technical (Hospital) Services Ref Creatine (Rptu) Urine PX-3018257003 CDM 82570 CPT 301 RC inpatient 84 84 HEALTHPARTNERS SX009 HEALTHPARTNERS 66.51 percent of total billed charges 52.08 79.8 Technical (Hospital) Services Ref Creatine (Rptu) Urine PX-3018257003 CDM 82570 CPT 301 RC inpatient 84 84 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES EPO [308136803] 66.51 percent of total billed charges 52.08 79.8 Technical (Hospital) Services Ref Creatine (Rptu) Urine PX-3018257003 CDM 82570 CPT 301 RC inpatient 84 84 CIGNA 62308 [3081051] CIGNA 62308 [308105105] 66.51 percent of total billed charges 52.08 79.8 Technical (Hospital) Services Ref Creatine (Rptu) Urine PX-3018257003 CDM 82570 CPT 301 RC inpatient 84 84 CIGNA 62308 [3081051] CIGNA STATE OF WYOMING [308105107] 66.51 percent of total billed charges 52.08 79.8 Technical (Hospital) Services Creatinine Serum PX-3018256500 CDM 82565 CPT 301 RC inpatient 101 101 CIGNA 62308 [3081051] CIGNA 62308 [308105105] 79.97 percent of total billed charges 62.62 95.95 Technical (Hospital) Services Creatinine Serum PX-3018256500 CDM 82565 CPT 301 RC inpatient 101 101 CIGNA 62308 [3081051] CIGNA STATE OF WYOMING [308105107] 79.97 percent of total billed charges 62.62 95.95 Technical (Hospital) Services Creatinine Serum PX-3018256500 CDM 82565 CPT 301 RC inpatient 101 101 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES PPO [308136801] 79.97 percent of total billed charges 62.62 95.95 Technical (Hospital) Services Creatinine Serum PX-3018256500 CDM 82565 CPT 301 RC inpatient 101 101 UNITED HEALTHCARE (COMMERCIAL) [3081199] UNITED HEALTHCARE 87726 [308119901] 62.62 percent of total billed charges 62.62 95.95 Technical (Hospital) Services Creatinine Serum PX-3018256500 CDM 82565 CPT 301 RC inpatient 101 101 BLUE CROSS BLUE SHIELD WELLMARK SB889 [3081026] BCBS WYOMING [308102603] 95.95 percent of total billed charges 62.62 95.95 Technical (Hospital) Services Creatinine Serum PX-3018256500 CDM 82565 CPT 301 RC inpatient 101 101 HEALTHPARTNERS SX009 HEALTHPARTNERS 79.97 percent of total billed charges 62.62 95.95 Technical (Hospital) Services Creatinine Serum PX-3018256500 CDM 82565 CPT 301 RC inpatient 101 101 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES EPO [308136803] 79.97 percent of total billed charges 62.62 95.95 Technical (Hospital) Services Creatinine Serum PX-3018256500 CDM 82565 CPT 301 RC inpatient 101 101 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES HDHP [308136802] 79.97 percent of total billed charges 62.62 95.95 Technical (Hospital) Services Creatinine Serum PX-3018256500 CDM 82565 CPT 301 RC inpatient 101 101 MULTIPLAN INC 34080 [3081285] MULTIPLAN INC [308128501] 95.95 percent of total billed charges 62.62 95.95 Technical (Hospital) Services Creatinine Serum PX-3018256500 CDM 82565 CPT 301 RC inpatient 101 101 MEDICA (COMMERCIAL) 94265 [3081118] MEDICA CLAIMS [308111801] 90.9 percent of total billed charges 62.62 95.95 Technical (Hospital) Services Creatinine Serum PX-3018256500 CDM 82565 CPT 301 RC outpatient 101 101 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES PPO [308136801] 80.8 percent of total billed charges 62.62 95.95 Technical (Hospital) Services Creatinine Serum PX-3018256500 CDM 82565 CPT 301 RC outpatient 101 101 UNITED HEALTHCARE (COMMERCIAL) [3081199] UNITED HEALTHCARE 87726 [308119901] 62.62 percent of total billed charges 62.62 95.95 Technical (Hospital) Services Creatinine Serum PX-3018256500 CDM 82565 CPT 301 RC outpatient 101 101 HEALTHPARTNERS SX009 HEALTHPARTNERS 80.8 percent of total billed charges 62.62 95.95 Technical (Hospital) Services Creatinine Serum PX-3018256500 CDM 82565 CPT 301 RC outpatient 101 101 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES HDHP [308136802] 80.8 percent of total billed charges 62.62 95.95 Technical (Hospital) Services Creatinine Serum PX-3018256500 CDM 82565 CPT 301 RC outpatient 101 101 MULTIPLAN INC 34080 [3081285] MULTIPLAN INC [308128501] 95.95 percent of total billed charges 62.62 95.95 Technical (Hospital) Services Creatinine Serum PX-3018256500 CDM 82565 CPT 301 RC outpatient 101 101 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES EPO [308136803] 80.8 percent of total billed charges 62.62 95.95 Technical (Hospital) Services Creatinine Serum PX-3018256500 CDM 82565 CPT 301 RC outpatient 101 101 BLUE CROSS BLUE SHIELD WELLMARK SB889 [3081026] BCBS WYOMING [308102603] 95.95 percent of total billed charges 62.62 95.95 Technical (Hospital) Services Creatinine Serum PX-3018256500 CDM 82565 CPT 301 RC outpatient 101 101 CIGNA 62308 [3081051] CIGNA 62308 [308105105] 80.8 percent of total billed charges 62.62 95.95 Technical (Hospital) Services Creatinine Serum PX-3018256500 CDM 82565 CPT 301 RC outpatient 101 101 CIGNA 62308 [3081051] CIGNA STATE OF WYOMING [308105107] 80.8 percent of total billed charges 62.62 95.95 Technical (Hospital) Services Creatinine Serum PX-3018256500 CDM 82565 CPT 301 RC outpatient 101 101 MEDICA (COMMERCIAL) 94265 [3081118] MEDICA CLAIMS [308111801] 90.9 percent of total billed charges 62.62 95.95 Technical (Hospital) Services Mb Fraction PX-3018255300 CDM 82553 CPT 301 RC outpatient 103 103 CIGNA 62308 [3081051] CIGNA 62308 [308105105] 82.4 percent of total billed charges 63.86 97.85 Technical (Hospital) Services Mb Fraction PX-3018255300 CDM 82553 CPT 301 RC outpatient 103 103 CIGNA 62308 [3081051] CIGNA STATE OF WYOMING [308105107] 82.4 percent of total billed charges 63.86 97.85 Technical (Hospital) Services Mb Fraction PX-3018255300 CDM 82553 CPT 301 RC outpatient 103 103 MEDICA (COMMERCIAL) 94265 [3081118] MEDICA CLAIMS [308111801] 92.7 percent of total billed charges 63.86 97.85 Technical (Hospital) Services Mb Fraction PX-3018255300 CDM 82553 CPT 301 RC outpatient 103 103 UNITED HEALTHCARE (COMMERCIAL) [3081199] UNITED HEALTHCARE 87726 [308119901] 63.86 percent of total billed charges 63.86 97.85 Technical (Hospital) Services Mb Fraction PX-3018255300 CDM 82553 CPT 301 RC outpatient 103 103 HEALTHPARTNERS SX009 HEALTHPARTNERS 82.4 percent of total billed charges 63.86 97.85 Technical (Hospital) Services Mb Fraction PX-3018255300 CDM 82553 CPT 301 RC outpatient 103 103 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES EPO [308136803] 82.4 percent of total billed charges 63.86 97.85 Technical (Hospital) Services Mb Fraction PX-3018255300 CDM 82553 CPT 301 RC outpatient 103 103 MULTIPLAN INC 34080 [3081285] MULTIPLAN INC [308128501] 97.85 percent of total billed charges 63.86 97.85 Technical (Hospital) Services Mb Fraction PX-3018255300 CDM 82553 CPT 301 RC outpatient 103 103 BLUE CROSS BLUE SHIELD WELLMARK SB889 [3081026] BCBS WYOMING [308102603] 97.85 percent of total billed charges 63.86 97.85 Technical (Hospital) Services Mb Fraction PX-3018255300 CDM 82553 CPT 301 RC outpatient 103 103 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES HDHP [308136802] 82.4 percent of total billed charges 63.86 97.85 Technical (Hospital) Services Mb Fraction PX-3018255300 CDM 82553 CPT 301 RC outpatient 103 103 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES PPO [308136801] 82.4 percent of total billed charges 63.86 97.85 Technical (Hospital) Services Mb Fraction PX-3018255300 CDM 82553 CPT 301 RC inpatient 103 103 MULTIPLAN INC 34080 [3081285] MULTIPLAN INC [308128501] 97.85 percent of total billed charges 63.86 97.85 Technical (Hospital) Services Mb Fraction PX-3018255300 CDM 82553 CPT 301 RC inpatient 103 103 MEDICA (COMMERCIAL) 94265 [3081118] MEDICA CLAIMS [308111801] 92.7 percent of total billed charges 63.86 97.85 Technical (Hospital) Services Mb Fraction PX-3018255300 CDM 82553 CPT 301 RC inpatient 103 103 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES EPO [308136803] 81.56 percent of total billed charges 63.86 97.85 Technical (Hospital) Services Mb Fraction PX-3018255300 CDM 82553 CPT 301 RC inpatient 103 103 HEALTHPARTNERS SX009 HEALTHPARTNERS 81.56 percent of total billed charges 63.86 97.85 Technical (Hospital) Services Mb Fraction PX-3018255300 CDM 82553 CPT 301 RC inpatient 103 103 BLUE CROSS BLUE SHIELD WELLMARK SB889 [3081026] BCBS WYOMING [308102603] 97.85 percent of total billed charges 63.86 97.85 Technical (Hospital) Services Mb Fraction PX-3018255300 CDM 82553 CPT 301 RC inpatient 103 103 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES HDHP [308136802] 81.56 percent of total billed charges 63.86 97.85 Technical (Hospital) Services Mb Fraction PX-3018255300 CDM 82553 CPT 301 RC inpatient 103 103 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES PPO [308136801] 81.56 percent of total billed charges 63.86 97.85 Technical (Hospital) Services Mb Fraction PX-3018255300 CDM 82553 CPT 301 RC inpatient 103 103 UNITED HEALTHCARE (COMMERCIAL) [3081199] UNITED HEALTHCARE 87726 [308119901] 63.86 percent of total billed charges 63.86 97.85 Technical (Hospital) Services Mb Fraction PX-3018255300 CDM 82553 CPT 301 RC inpatient 103 103 CIGNA 62308 [3081051] CIGNA 62308 [308105105] 81.56 percent of total billed charges 63.86 97.85 Technical (Hospital) Services Mb Fraction PX-3018255300 CDM 82553 CPT 301 RC inpatient 103 103 CIGNA 62308 [3081051] CIGNA STATE OF WYOMING [308105107] 81.56 percent of total billed charges 63.86 97.85 Technical (Hospital) Services Cpk Total PX-3018255000 CDM 82550 CPT 301 RC inpatient 211 211 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES EPO [308136803] 167.07 percent of total billed charges 130.82 200.45 Technical (Hospital) Services Cpk Total PX-3018255000 CDM 82550 CPT 301 RC inpatient 211 211 HEALTHPARTNERS SX009 HEALTHPARTNERS 167.07 percent of total billed charges 130.82 200.45 Technical (Hospital) Services Cpk Total PX-3018255000 CDM 82550 CPT 301 RC inpatient 211 211 MULTIPLAN INC 34080 [3081285] MULTIPLAN INC [308128501] 200.45 percent of total billed charges 130.82 200.45 Technical (Hospital) Services Cpk Total PX-3018255000 CDM 82550 CPT 301 RC inpatient 211 211 MEDICA (COMMERCIAL) 94265 [3081118] MEDICA CLAIMS [308111801] 189.9 percent of total billed charges 130.82 200.45 Technical (Hospital) Services Cpk Total PX-3018255000 CDM 82550 CPT 301 RC inpatient 211 211 UNITED HEALTHCARE (COMMERCIAL) [3081199] UNITED HEALTHCARE 87726 [308119901] 130.82 percent of total billed charges 130.82 200.45 Technical (Hospital) Services Cpk Total PX-3018255000 CDM 82550 CPT 301 RC inpatient 211 211 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES PPO [308136801] 167.07 percent of total billed charges 130.82 200.45 Technical (Hospital) Services Cpk Total PX-3018255000 CDM 82550 CPT 301 RC inpatient 211 211 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES HDHP [308136802] 167.07 percent of total billed charges 130.82 200.45 Technical (Hospital) Services Cpk Total PX-3018255000 CDM 82550 CPT 301 RC inpatient 211 211 BLUE CROSS BLUE SHIELD WELLMARK SB889 [3081026] BCBS WYOMING [308102603] 200.45 percent of total billed charges 130.82 200.45 Technical (Hospital) Services Cpk Total PX-3018255000 CDM 82550 CPT 301 RC inpatient 211 211 CIGNA 62308 [3081051] CIGNA 62308 [308105105] 167.07 percent of total billed charges 130.82 200.45 Technical (Hospital) Services Cpk Total PX-3018255000 CDM 82550 CPT 301 RC inpatient 211 211 CIGNA 62308 [3081051] CIGNA STATE OF WYOMING [308105107] 167.07 percent of total billed charges 130.82 200.45 Technical (Hospital) Services Cpk Total PX-3018255000 CDM 82550 CPT 301 RC outpatient 211 211 CIGNA 62308 [3081051] CIGNA STATE OF WYOMING [308105107] 168.8 percent of total billed charges 130.82 200.45 Technical (Hospital) Services Cpk Total PX-3018255000 CDM 82550 CPT 301 RC outpatient 211 211 CIGNA 62308 [3081051] CIGNA 62308 [308105105] 168.8 percent of total billed charges 130.82 200.45 Technical (Hospital) Services Cpk Total PX-3018255000 CDM 82550 CPT 301 RC outpatient 211 211 MEDICA (COMMERCIAL) 94265 [3081118] MEDICA CLAIMS [308111801] 189.9 percent of total billed charges 130.82 200.45 Technical (Hospital) Services Cpk Total PX-3018255000 CDM 82550 CPT 301 RC outpatient 211 211 HEALTHPARTNERS SX009 HEALTHPARTNERS 168.8 percent of total billed charges 130.82 200.45 Technical (Hospital) Services Cpk Total PX-3018255000 CDM 82550 CPT 301 RC outpatient 211 211 UNITED HEALTHCARE (COMMERCIAL) [3081199] UNITED HEALTHCARE 87726 [308119901] 130.82 percent of total billed charges 130.82 200.45 Technical (Hospital) Services Cpk Total PX-3018255000 CDM 82550 CPT 301 RC outpatient 211 211 BLUE CROSS BLUE SHIELD WELLMARK SB889 [3081026] BCBS WYOMING [308102603] 200.45 percent of total billed charges 130.82 200.45 Technical (Hospital) Services Cpk Total PX-3018255000 CDM 82550 CPT 301 RC outpatient 211 211 MULTIPLAN INC 34080 [3081285] MULTIPLAN INC [308128501] 200.45 percent of total billed charges 130.82 200.45 Technical (Hospital) Services Cpk Total PX-3018255000 CDM 82550 CPT 301 RC outpatient 211 211 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES EPO [308136803] 168.8 percent of total billed charges 130.82 200.45 Technical (Hospital) Services Cpk Total PX-3018255000 CDM 82550 CPT 301 RC outpatient 211 211 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES HDHP [308136802] 168.8 percent of total billed charges 130.82 200.45 Technical (Hospital) Services Cpk Total PX-3018255000 CDM 82550 CPT 301 RC outpatient 211 211 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES PPO [308136801] 168.8 percent of total billed charges 130.82 200.45 Technical (Hospital) Services Ref Cortisol Urine Lc-Ms/Ms PX-3018254200 CDM 82542 CPT 301 RC outpatient 198 198 CIGNA 62308 [3081051] CIGNA 62308 [308105105] 158.4 percent of total billed charges 122.76 188.1 Technical (Hospital) Services Ref Cortisol Urine Lc-Ms/Ms PX-3018254200 CDM 82542 CPT 301 RC outpatient 198 198 CIGNA 62308 [3081051] CIGNA STATE OF WYOMING [308105107] 158.4 percent of total billed charges 122.76 188.1 Technical (Hospital) Services Ref Cortisol Urine Lc-Ms/Ms PX-3018254200 CDM 82542 CPT 301 RC outpatient 198 198 MEDICA (COMMERCIAL) 94265 [3081118] MEDICA CLAIMS [308111801] 178.2 percent of total billed charges 122.76 188.1 Technical (Hospital) Services Ref Cortisol Urine Lc-Ms/Ms PX-3018254200 CDM 82542 CPT 301 RC outpatient 198 198 HEALTHPARTNERS SX009 HEALTHPARTNERS 158.4 percent of total billed charges 122.76 188.1 Technical (Hospital) Services Ref Cortisol Urine Lc-Ms/Ms PX-3018254200 CDM 82542 CPT 301 RC outpatient 198 198 UNITED HEALTHCARE (COMMERCIAL) [3081199] UNITED HEALTHCARE 87726 [308119901] 122.76 percent of total billed charges 122.76 188.1 Technical (Hospital) Services Ref Cortisol Urine Lc-Ms/Ms PX-3018254200 CDM 82542 CPT 301 RC outpatient 198 198 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES HDHP [308136802] 158.4 percent of total billed charges 122.76 188.1 Technical (Hospital) Services Ref Cortisol Urine Lc-Ms/Ms PX-3018254200 CDM 82542 CPT 301 RC outpatient 198 198 BLUE CROSS BLUE SHIELD WELLMARK SB889 [3081026] BCBS WYOMING [308102603] 188.1 percent of total billed charges 122.76 188.1 Technical (Hospital) Services Ref Cortisol Urine Lc-Ms/Ms PX-3018254200 CDM 82542 CPT 301 RC outpatient 198 198 MULTIPLAN INC 34080 [3081285] MULTIPLAN INC [308128501] 188.1 percent of total billed charges 122.76 188.1 Technical (Hospital) Services Ref Cortisol Urine Lc-Ms/Ms PX-3018254200 CDM 82542 CPT 301 RC outpatient 198 198 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES EPO [308136803] 158.4 percent of total billed charges 122.76 188.1 Technical (Hospital) Services Ref Cortisol Urine Lc-Ms/Ms PX-3018254200 CDM 82542 CPT 301 RC outpatient 198 198 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES PPO [308136801] 158.4 percent of total billed charges 122.76 188.1 Technical (Hospital) Services Ref Cortisol Urine Lc-Ms/Ms PX-3018254200 CDM 82542 CPT 301 RC inpatient 198 198 CIGNA 62308 [3081051] CIGNA 62308 [308105105] 156.78 percent of total billed charges 122.76 188.1 Technical (Hospital) Services Ref Cortisol Urine Lc-Ms/Ms PX-3018254200 CDM 82542 CPT 301 RC inpatient 198 198 CIGNA 62308 [3081051] CIGNA STATE OF WYOMING [308105107] 156.78 percent of total billed charges 122.76 188.1 Technical (Hospital) Services Ref Cortisol Urine Lc-Ms/Ms PX-3018254200 CDM 82542 CPT 301 RC inpatient 198 198 BLUE CROSS BLUE SHIELD WELLMARK SB889 [3081026] BCBS WYOMING [308102603] 188.1 percent of total billed charges 122.76 188.1 Technical (Hospital) Services Ref Cortisol Urine Lc-Ms/Ms PX-3018254200 CDM 82542 CPT 301 RC inpatient 198 198 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES HDHP [308136802] 156.78 percent of total billed charges 122.76 188.1 Technical (Hospital) Services Ref Cortisol Urine Lc-Ms/Ms PX-3018254200 CDM 82542 CPT 301 RC inpatient 198 198 UNITED HEALTHCARE (COMMERCIAL) [3081199] UNITED HEALTHCARE 87726 [308119901] 122.76 percent of total billed charges 122.76 188.1 Technical (Hospital) Services Ref Cortisol Urine Lc-Ms/Ms PX-3018254200 CDM 82542 CPT 301 RC inpatient 198 198 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES PPO [308136801] 156.78 percent of total billed charges 122.76 188.1 Technical (Hospital) Services Ref Cortisol Urine Lc-Ms/Ms PX-3018254200 CDM 82542 CPT 301 RC inpatient 198 198 HEALTHPARTNERS SX009 HEALTHPARTNERS 156.78 percent of total billed charges 122.76 188.1 Technical (Hospital) Services Ref Cortisol Urine Lc-Ms/Ms PX-3018254200 CDM 82542 CPT 301 RC inpatient 198 198 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES EPO [308136803] 156.78 percent of total billed charges 122.76 188.1 Technical (Hospital) Services Ref Cortisol Urine Lc-Ms/Ms PX-3018254200 CDM 82542 CPT 301 RC inpatient 198 198 MULTIPLAN INC 34080 [3081285] MULTIPLAN INC [308128501] 188.1 percent of total billed charges 122.76 188.1 Technical (Hospital) Services Ref Cortisol Urine Lc-Ms/Ms PX-3018254200 CDM 82542 CPT 301 RC inpatient 198 198 MEDICA (COMMERCIAL) 94265 [3081118] MEDICA CLAIMS [308111801] 178.2 percent of total billed charges 122.76 188.1 Technical (Hospital) Services Ref Prometh Thiopurine Metab PX-3018254216 CDM 82542 CPT 301 RC inpatient 539 539 CIGNA 62308 [3081051] CIGNA 62308 [308105105] 426.78 percent of total billed charges 334.18 512.05 Technical (Hospital) Services Ref Prometh Thiopurine Metab PX-3018254216 CDM 82542 CPT 301 RC inpatient 539 539 CIGNA 62308 [3081051] CIGNA STATE OF WYOMING [308105107] 426.78 percent of total billed charges 334.18 512.05 Technical (Hospital) Services Ref Prometh Thiopurine Metab PX-3018254216 CDM 82542 CPT 301 RC inpatient 539 539 HEALTHPARTNERS SX009 HEALTHPARTNERS 426.78 percent of total billed charges 334.18 512.05 Technical (Hospital) Services Ref Prometh Thiopurine Metab PX-3018254216 CDM 82542 CPT 301 RC inpatient 539 539 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES EPO [308136803] 426.78 percent of total billed charges 334.18 512.05 Technical (Hospital) Services Ref Prometh Thiopurine Metab PX-3018254216 CDM 82542 CPT 301 RC inpatient 539 539 MULTIPLAN INC 34080 [3081285] MULTIPLAN INC [308128501] 512.05 percent of total billed charges 334.18 512.05 Technical (Hospital) Services Ref Prometh Thiopurine Metab PX-3018254216 CDM 82542 CPT 301 RC inpatient 539 539 MEDICA (COMMERCIAL) 94265 [3081118] MEDICA CLAIMS [308111801] 485.1 percent of total billed charges 334.18 512.05 Technical (Hospital) Services Ref Prometh Thiopurine Metab PX-3018254216 CDM 82542 CPT 301 RC inpatient 539 539 BLUE CROSS BLUE SHIELD WELLMARK SB889 [3081026] BCBS WYOMING [308102603] 512.05 percent of total billed charges 334.18 512.05 Technical (Hospital) Services Ref Prometh Thiopurine Metab PX-3018254216 CDM 82542 CPT 301 RC inpatient 539 539 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES HDHP [308136802] 426.78 percent of total billed charges 334.18 512.05 Technical (Hospital) Services Ref Prometh Thiopurine Metab PX-3018254216 CDM 82542 CPT 301 RC inpatient 539 539 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES PPO [308136801] 426.78 percent of total billed charges 334.18 512.05 Technical (Hospital) Services Ref Prometh Thiopurine Metab PX-3018254216 CDM 82542 CPT 301 RC inpatient 539 539 UNITED HEALTHCARE (COMMERCIAL) [3081199] UNITED HEALTHCARE 87726 [308119901] 334.18 percent of total billed charges 334.18 512.05 Technical (Hospital) Services Ref Prometh Thiopurine Metab PX-3018254216 CDM 82542 CPT 301 RC outpatient 539 539 MEDICA (COMMERCIAL) 94265 [3081118] MEDICA CLAIMS [308111801] 485.1 percent of total billed charges 334.18 512.05 Technical (Hospital) Services Ref Prometh Thiopurine Metab PX-3018254216 CDM 82542 CPT 301 RC outpatient 539 539 CIGNA 62308 [3081051] CIGNA 62308 [308105105] 431.2 percent of total billed charges 334.18 512.05 Technical (Hospital) Services Ref Prometh Thiopurine Metab PX-3018254216 CDM 82542 CPT 301 RC outpatient 539 539 CIGNA 62308 [3081051] CIGNA STATE OF WYOMING [308105107] 431.2 percent of total billed charges 334.18 512.05 Technical (Hospital) Services Ref Prometh Thiopurine Metab PX-3018254216 CDM 82542 CPT 301 RC outpatient 539 539 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES PPO [308136801] 431.2 percent of total billed charges 334.18 512.05 Technical (Hospital) Services Ref Prometh Thiopurine Metab PX-3018254216 CDM 82542 CPT 301 RC outpatient 539 539 MULTIPLAN INC 34080 [3081285] MULTIPLAN INC [308128501] 512.05 percent of total billed charges 334.18 512.05 Technical (Hospital) Services Ref Prometh Thiopurine Metab PX-3018254216 CDM 82542 CPT 301 RC outpatient 539 539 BLUE CROSS BLUE SHIELD WELLMARK SB889 [3081026] BCBS WYOMING [308102603] 512.05 percent of total billed charges 334.18 512.05 Technical (Hospital) Services Ref Prometh Thiopurine Metab PX-3018254216 CDM 82542 CPT 301 RC outpatient 539 539 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES EPO [308136803] 431.2 percent of total billed charges 334.18 512.05 Technical (Hospital) Services Ref Prometh Thiopurine Metab PX-3018254216 CDM 82542 CPT 301 RC outpatient 539 539 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES HDHP [308136802] 431.2 percent of total billed charges 334.18 512.05 Technical (Hospital) Services Ref Prometh Thiopurine Metab PX-3018254216 CDM 82542 CPT 301 RC outpatient 539 539 UNITED HEALTHCARE (COMMERCIAL) [3081199] UNITED HEALTHCARE 87726 [308119901] 334.18 percent of total billed charges 334.18 512.05 Technical (Hospital) Services Ref Prometh Thiopurine Metab PX-3018254216 CDM 82542 CPT 301 RC outpatient 539 539 HEALTHPARTNERS SX009 HEALTHPARTNERS 431.2 percent of total billed charges 334.18 512.05 Technical (Hospital) Services Ref Pyridoxic Acid PX-3018254217 CDM 82542 CPT 301 RC outpatient 198 198 UNITED HEALTHCARE (COMMERCIAL) [3081199] UNITED HEALTHCARE 87726 [308119901] 122.76 percent of total billed charges 122.76 188.1 Technical (Hospital) Services Ref Pyridoxic Acid PX-3018254217 CDM 82542 CPT 301 RC outpatient 198 198 HEALTHPARTNERS SX009 HEALTHPARTNERS 158.4 percent of total billed charges 122.76 188.1 Technical (Hospital) Services Ref Pyridoxic Acid PX-3018254217 CDM 82542 CPT 301 RC outpatient 198 198 MULTIPLAN INC 34080 [3081285] MULTIPLAN INC [308128501] 188.1 percent of total billed charges 122.76 188.1 Technical (Hospital) Services Ref Pyridoxic Acid PX-3018254217 CDM 82542 CPT 301 RC outpatient 198 198 BLUE CROSS BLUE SHIELD WELLMARK SB889 [3081026] BCBS WYOMING [308102603] 188.1 percent of total billed charges 122.76 188.1 Technical (Hospital) Services Ref Pyridoxic Acid PX-3018254217 CDM 82542 CPT 301 RC outpatient 198 198 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES EPO [308136803] 158.4 percent of total billed charges 122.76 188.1 Technical (Hospital) Services Ref Pyridoxic Acid PX-3018254217 CDM 82542 CPT 301 RC outpatient 198 198 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES HDHP [308136802] 158.4 percent of total billed charges 122.76 188.1 Technical (Hospital) Services Ref Pyridoxic Acid PX-3018254217 CDM 82542 CPT 301 RC outpatient 198 198 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES PPO [308136801] 158.4 percent of total billed charges 122.76 188.1 Technical (Hospital) Services Ref Pyridoxic Acid PX-3018254217 CDM 82542 CPT 301 RC outpatient 198 198 CIGNA 62308 [3081051] CIGNA 62308 [308105105] 158.4 percent of total billed charges 122.76 188.1 Technical (Hospital) Services Ref Pyridoxic Acid PX-3018254217 CDM 82542 CPT 301 RC outpatient 198 198 CIGNA 62308 [3081051] CIGNA STATE OF WYOMING [308105107] 158.4 percent of total billed charges 122.76 188.1 Technical (Hospital) Services Ref Pyridoxic Acid PX-3018254217 CDM 82542 CPT 301 RC outpatient 198 198 MEDICA (COMMERCIAL) 94265 [3081118] MEDICA CLAIMS [308111801] 178.2 percent of total billed charges 122.76 188.1 Technical (Hospital) Services Ref Pyridoxic Acid PX-3018254217 CDM 82542 CPT 301 RC inpatient 198 198 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES HDHP [308136802] 156.78 percent of total billed charges 122.76 188.1 Technical (Hospital) Services Ref Pyridoxic Acid PX-3018254217 CDM 82542 CPT 301 RC inpatient 198 198 BLUE CROSS BLUE SHIELD WELLMARK SB889 [3081026] BCBS WYOMING [308102603] 188.1 percent of total billed charges 122.76 188.1 Technical (Hospital) Services Ref Pyridoxic Acid PX-3018254217 CDM 82542 CPT 301 RC inpatient 198 198 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES PPO [308136801] 156.78 percent of total billed charges 122.76 188.1 Technical (Hospital) Services Ref Pyridoxic Acid PX-3018254217 CDM 82542 CPT 301 RC inpatient 198 198 UNITED HEALTHCARE (COMMERCIAL) [3081199] UNITED HEALTHCARE 87726 [308119901] 122.76 percent of total billed charges 122.76 188.1 Technical (Hospital) Services Ref Pyridoxic Acid PX-3018254217 CDM 82542 CPT 301 RC inpatient 198 198 HEALTHPARTNERS SX009 HEALTHPARTNERS 156.78 percent of total billed charges 122.76 188.1 Technical (Hospital) Services Ref Pyridoxic Acid PX-3018254217 CDM 82542 CPT 301 RC inpatient 198 198 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES EPO [308136803] 156.78 percent of total billed charges 122.76 188.1 Technical (Hospital) Services Ref Pyridoxic Acid PX-3018254217 CDM 82542 CPT 301 RC inpatient 198 198 MEDICA (COMMERCIAL) 94265 [3081118] MEDICA CLAIMS [308111801] 178.2 percent of total billed charges 122.76 188.1 Technical (Hospital) Services Ref Pyridoxic Acid PX-3018254217 CDM 82542 CPT 301 RC inpatient 198 198 MULTIPLAN INC 34080 [3081285] MULTIPLAN INC [308128501] 188.1 percent of total billed charges 122.76 188.1 Technical (Hospital) Services Ref Pyridoxic Acid PX-3018254217 CDM 82542 CPT 301 RC inpatient 198 198 CIGNA 62308 [3081051] CIGNA 62308 [308105105] 156.78 percent of total billed charges 122.76 188.1 Technical (Hospital) Services Ref Pyridoxic Acid PX-3018254217 CDM 82542 CPT 301 RC inpatient 198 198 CIGNA 62308 [3081051] CIGNA STATE OF WYOMING [308105107] 156.78 percent of total billed charges 122.76 188.1 Technical (Hospital) Services Cortisol Single PX-3018253300 CDM 82533 CPT 301 RC outpatient 214 214 MEDICA (COMMERCIAL) 94265 [3081118] MEDICA CLAIMS [308111801] 192.6 percent of total billed charges 132.68 203.3 Technical (Hospital) Services Cortisol Single PX-3018253300 CDM 82533 CPT 301 RC outpatient 214 214 CIGNA 62308 [3081051] CIGNA 62308 [308105105] 171.2 percent of total billed charges 132.68 203.3 Technical (Hospital) Services Cortisol Single PX-3018253300 CDM 82533 CPT 301 RC outpatient 214 214 CIGNA 62308 [3081051] CIGNA STATE OF WYOMING [308105107] 171.2 percent of total billed charges 132.68 203.3 Technical (Hospital) Services Cortisol Single PX-3018253300 CDM 82533 CPT 301 RC outpatient 214 214 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES PPO [308136801] 171.2 percent of total billed charges 132.68 203.3 Technical (Hospital) Services Cortisol Single PX-3018253300 CDM 82533 CPT 301 RC outpatient 214 214 UNITED HEALTHCARE (COMMERCIAL) [3081199] UNITED HEALTHCARE 87726 [308119901] 132.68 percent of total billed charges 132.68 203.3 Technical (Hospital) Services Cortisol Single PX-3018253300 CDM 82533 CPT 301 RC outpatient 214 214 HEALTHPARTNERS SX009 HEALTHPARTNERS 171.2 percent of total billed charges 132.68 203.3 Technical (Hospital) Services Cortisol Single PX-3018253300 CDM 82533 CPT 301 RC outpatient 214 214 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES EPO [308136803] 171.2 percent of total billed charges 132.68 203.3 Technical (Hospital) Services Cortisol Single PX-3018253300 CDM 82533 CPT 301 RC outpatient 214 214 BLUE CROSS BLUE SHIELD WELLMARK SB889 [3081026] BCBS WYOMING [308102603] 203.3 percent of total billed charges 132.68 203.3 Technical (Hospital) Services Cortisol Single PX-3018253300 CDM 82533 CPT 301 RC outpatient 214 214 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES HDHP [308136802] 171.2 percent of total billed charges 132.68 203.3 Technical (Hospital) Services Cortisol Single PX-3018253300 CDM 82533 CPT 301 RC outpatient 214 214 MULTIPLAN INC 34080 [3081285] MULTIPLAN INC [308128501] 203.3 percent of total billed charges 132.68 203.3 Technical (Hospital) Services Cortisol Single PX-3018253300 CDM 82533 CPT 301 RC inpatient 214 214 CIGNA 62308 [3081051] CIGNA 62308 [308105105] 169.45 percent of total billed charges 132.68 203.3 Technical (Hospital) Services Cortisol Single PX-3018253300 CDM 82533 CPT 301 RC inpatient 214 214 CIGNA 62308 [3081051] CIGNA STATE OF WYOMING [308105107] 169.45 percent of total billed charges 132.68 203.3 Technical (Hospital) Services Cortisol Single PX-3018253300 CDM 82533 CPT 301 RC inpatient 214 214 UNITED HEALTHCARE (COMMERCIAL) [3081199] UNITED HEALTHCARE 87726 [308119901] 132.68 percent of total billed charges 132.68 203.3 Technical (Hospital) Services Cortisol Single PX-3018253300 CDM 82533 CPT 301 RC inpatient 214 214 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES PPO [308136801] 169.45 percent of total billed charges 132.68 203.3 Technical (Hospital) Services Cortisol Single PX-3018253300 CDM 82533 CPT 301 RC inpatient 214 214 BLUE CROSS BLUE SHIELD WELLMARK SB889 [3081026] BCBS WYOMING [308102603] 203.3 percent of total billed charges 132.68 203.3 Technical (Hospital) Services Cortisol Single PX-3018253300 CDM 82533 CPT 301 RC inpatient 214 214 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES EPO [308136803] 169.45 percent of total billed charges 132.68 203.3 Technical (Hospital) Services Cortisol Single PX-3018253300 CDM 82533 CPT 301 RC inpatient 214 214 HEALTHPARTNERS SX009 HEALTHPARTNERS 169.45 percent of total billed charges 132.68 203.3 Technical (Hospital) Services Cortisol Single PX-3018253300 CDM 82533 CPT 301 RC inpatient 214 214 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES HDHP [308136802] 169.45 percent of total billed charges 132.68 203.3 Technical (Hospital) Services Cortisol Single PX-3018253300 CDM 82533 CPT 301 RC inpatient 214 214 MULTIPLAN INC 34080 [3081285] MULTIPLAN INC [308128501] 203.3 percent of total billed charges 132.68 203.3 Technical (Hospital) Services Cortisol Single PX-3018253300 CDM 82533 CPT 301 RC inpatient 214 214 MEDICA (COMMERCIAL) 94265 [3081118] MEDICA CLAIMS [308111801] 192.6 percent of total billed charges 132.68 203.3 Technical (Hospital) Services Ref Cortisol Saliva PX-3018253301 CDM 82533 CPT 301 RC inpatient 193 193 CIGNA 62308 [3081051] CIGNA 62308 [308105105] 152.82 percent of total billed charges 119.66 183.35 Technical (Hospital) Services Ref Cortisol Saliva PX-3018253301 CDM 82533 CPT 301 RC inpatient 193 193 CIGNA 62308 [3081051] CIGNA STATE OF WYOMING [308105107] 152.82 percent of total billed charges 119.66 183.35 Technical (Hospital) Services Ref Cortisol Saliva PX-3018253301 CDM 82533 CPT 301 RC inpatient 193 193 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES HDHP [308136802] 152.82 percent of total billed charges 119.66 183.35 Technical (Hospital) Services Ref Cortisol Saliva PX-3018253301 CDM 82533 CPT 301 RC inpatient 193 193 BLUE CROSS BLUE SHIELD WELLMARK SB889 [3081026] BCBS WYOMING [308102603] 183.35 percent of total billed charges 119.66 183.35 Technical (Hospital) Services Ref Cortisol Saliva PX-3018253301 CDM 82533 CPT 301 RC inpatient 193 193 UNITED HEALTHCARE (COMMERCIAL) [3081199] UNITED HEALTHCARE 87726 [308119901] 119.66 percent of total billed charges 119.66 183.35 Technical (Hospital) Services Ref Cortisol Saliva PX-3018253301 CDM 82533 CPT 301 RC inpatient 193 193 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES PPO [308136801] 152.82 percent of total billed charges 119.66 183.35 Technical (Hospital) Services Ref Cortisol Saliva PX-3018253301 CDM 82533 CPT 301 RC inpatient 193 193 MEDICA (COMMERCIAL) 94265 [3081118] MEDICA CLAIMS [308111801] 173.7 percent of total billed charges 119.66 183.35 Technical (Hospital) Services Ref Cortisol Saliva PX-3018253301 CDM 82533 CPT 301 RC inpatient 193 193 MULTIPLAN INC 34080 [3081285] MULTIPLAN INC [308128501] 183.35 percent of total billed charges 119.66 183.35 Technical (Hospital) Services Ref Cortisol Saliva PX-3018253301 CDM 82533 CPT 301 RC inpatient 193 193 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES EPO [308136803] 152.82 percent of total billed charges 119.66 183.35 Technical (Hospital) Services Ref Cortisol Saliva PX-3018253301 CDM 82533 CPT 301 RC inpatient 193 193 HEALTHPARTNERS SX009 HEALTHPARTNERS 152.82 percent of total billed charges 119.66 183.35 Technical (Hospital) Services Ref Cortisol Saliva PX-3018253301 CDM 82533 CPT 301 RC outpatient 193 193 BLUE CROSS BLUE SHIELD WELLMARK SB889 [3081026] BCBS WYOMING [308102603] 183.35 percent of total billed charges 119.66 183.35 Technical (Hospital) Services Ref Cortisol Saliva PX-3018253301 CDM 82533 CPT 301 RC outpatient 193 193 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES EPO [308136803] 154.4 percent of total billed charges 119.66 183.35 Technical (Hospital) Services Ref Cortisol Saliva PX-3018253301 CDM 82533 CPT 301 RC outpatient 193 193 MULTIPLAN INC 34080 [3081285] MULTIPLAN INC [308128501] 183.35 percent of total billed charges 119.66 183.35 Technical (Hospital) Services Ref Cortisol Saliva PX-3018253301 CDM 82533 CPT 301 RC outpatient 193 193 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES HDHP [308136802] 154.4 percent of total billed charges 119.66 183.35 Technical (Hospital) Services Ref Cortisol Saliva PX-3018253301 CDM 82533 CPT 301 RC outpatient 193 193 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES PPO [308136801] 154.4 percent of total billed charges 119.66 183.35 Technical (Hospital) Services Ref Cortisol Saliva PX-3018253301 CDM 82533 CPT 301 RC outpatient 193 193 HEALTHPARTNERS SX009 HEALTHPARTNERS 154.4 percent of total billed charges 119.66 183.35 Technical (Hospital) Services Ref Cortisol Saliva PX-3018253301 CDM 82533 CPT 301 RC outpatient 193 193 UNITED HEALTHCARE (COMMERCIAL) [3081199] UNITED HEALTHCARE 87726 [308119901] 119.66 percent of total billed charges 119.66 183.35 Technical (Hospital) Services Ref Cortisol Saliva PX-3018253301 CDM 82533 CPT 301 RC outpatient 193 193 CIGNA 62308 [3081051] CIGNA 62308 [308105105] 154.4 percent of total billed charges 119.66 183.35 Technical (Hospital) Services Ref Cortisol Saliva PX-3018253301 CDM 82533 CPT 301 RC outpatient 193 193 CIGNA 62308 [3081051] CIGNA STATE OF WYOMING [308105107] 154.4 percent of total billed charges 119.66 183.35 Technical (Hospital) Services Ref Cortisol Saliva PX-3018253301 CDM 82533 CPT 301 RC outpatient 193 193 MEDICA (COMMERCIAL) 94265 [3081118] MEDICA CLAIMS [308111801] 173.7 percent of total billed charges 119.66 183.35 Technical (Hospital) Services "Cortisol, Free, Urine" PX-3018253000 CDM 82530 CPT 301 RC inpatient 251 251 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES EPO [308136803] 198.74 percent of total billed charges 155.62 238.45 Technical (Hospital) Services "Cortisol, Free, Urine" PX-3018253000 CDM 82530 CPT 301 RC inpatient 251 251 HEALTHPARTNERS SX009 HEALTHPARTNERS 198.74 percent of total billed charges 155.62 238.45 Technical (Hospital) Services "Cortisol, Free, Urine" PX-3018253000 CDM 82530 CPT 301 RC inpatient 251 251 MULTIPLAN INC 34080 [3081285] MULTIPLAN INC [308128501] 238.45 percent of total billed charges 155.62 238.45 Technical (Hospital) Services "Cortisol, Free, Urine" PX-3018253000 CDM 82530 CPT 301 RC inpatient 251 251 MEDICA (COMMERCIAL) 94265 [3081118] MEDICA CLAIMS [308111801] 225.9 percent of total billed charges 155.62 238.45 Technical (Hospital) Services "Cortisol, Free, Urine" PX-3018253000 CDM 82530 CPT 301 RC inpatient 251 251 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES HDHP [308136802] 198.74 percent of total billed charges 155.62 238.45 Technical (Hospital) Services "Cortisol, Free, Urine" PX-3018253000 CDM 82530 CPT 301 RC inpatient 251 251 BLUE CROSS BLUE SHIELD WELLMARK SB889 [3081026] BCBS WYOMING [308102603] 238.45 percent of total billed charges 155.62 238.45 Technical (Hospital) Services "Cortisol, Free, Urine" PX-3018253000 CDM 82530 CPT 301 RC inpatient 251 251 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES PPO [308136801] 198.74 percent of total billed charges 155.62 238.45 Technical (Hospital) Services "Cortisol, Free, Urine" PX-3018253000 CDM 82530 CPT 301 RC inpatient 251 251 UNITED HEALTHCARE (COMMERCIAL) [3081199] UNITED HEALTHCARE 87726 [308119901] 155.62 percent of total billed charges 155.62 238.45 Technical (Hospital) Services "Cortisol, Free, Urine" PX-3018253000 CDM 82530 CPT 301 RC inpatient 251 251 CIGNA 62308 [3081051] CIGNA 62308 [308105105] 198.74 percent of total billed charges 155.62 238.45 Technical (Hospital) Services "Cortisol, Free, Urine" PX-3018253000 CDM 82530 CPT 301 RC inpatient 251 251 CIGNA 62308 [3081051] CIGNA STATE OF WYOMING [308105107] 198.74 percent of total billed charges 155.62 238.45 Technical (Hospital) Services "Cortisol, Free, Urine" PX-3018253000 CDM 82530 CPT 301 RC outpatient 251 251 MEDICA (COMMERCIAL) 94265 [3081118] MEDICA CLAIMS [308111801] 225.9 percent of total billed charges 155.62 238.45 Technical (Hospital) Services "Cortisol, Free, Urine" PX-3018253000 CDM 82530 CPT 301 RC outpatient 251 251 CIGNA 62308 [3081051] CIGNA 62308 [308105105] 200.8 percent of total billed charges 155.62 238.45 Technical (Hospital) Services "Cortisol, Free, Urine" PX-3018253000 CDM 82530 CPT 301 RC outpatient 251 251 CIGNA 62308 [3081051] CIGNA STATE OF WYOMING [308105107] 200.8 percent of total billed charges 155.62 238.45 Technical (Hospital) Services "Cortisol, Free, Urine" PX-3018253000 CDM 82530 CPT 301 RC outpatient 251 251 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES PPO [308136801] 200.8 percent of total billed charges 155.62 238.45 Technical (Hospital) Services "Cortisol, Free, Urine" PX-3018253000 CDM 82530 CPT 301 RC outpatient 251 251 BLUE CROSS BLUE SHIELD WELLMARK SB889 [3081026] BCBS WYOMING [308102603] 238.45 percent of total billed charges 155.62 238.45 Technical (Hospital) Services "Cortisol, Free, Urine" PX-3018253000 CDM 82530 CPT 301 RC outpatient 251 251 MULTIPLAN INC 34080 [3081285] MULTIPLAN INC [308128501] 238.45 percent of total billed charges 155.62 238.45 Technical (Hospital) Services "Cortisol, Free, Urine" PX-3018253000 CDM 82530 CPT 301 RC outpatient 251 251 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES EPO [308136803] 200.8 percent of total billed charges 155.62 238.45 Technical (Hospital) Services "Cortisol, Free, Urine" PX-3018253000 CDM 82530 CPT 301 RC outpatient 251 251 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES HDHP [308136802] 200.8 percent of total billed charges 155.62 238.45 Technical (Hospital) Services "Cortisol, Free, Urine" PX-3018253000 CDM 82530 CPT 301 RC outpatient 251 251 HEALTHPARTNERS SX009 HEALTHPARTNERS 200.8 percent of total billed charges 155.62 238.45 Technical (Hospital) Services "Cortisol, Free, Urine" PX-3018253000 CDM 82530 CPT 301 RC outpatient 251 251 UNITED HEALTHCARE (COMMERCIAL) [3081199] UNITED HEALTHCARE 87726 [308119901] 155.62 percent of total billed charges 155.62 238.45 Technical (Hospital) Services Ref Cortisol Free Urine PX-3018253002 CDM 82530 CPT 301 RC outpatient 251 251 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES HDHP [308136802] 200.8 percent of total billed charges 155.62 238.45 Technical (Hospital) Services Ref Cortisol Free Urine PX-3018253002 CDM 82530 CPT 301 RC outpatient 251 251 MULTIPLAN INC 34080 [3081285] MULTIPLAN INC [308128501] 238.45 percent of total billed charges 155.62 238.45 Technical (Hospital) Services Ref Cortisol Free Urine PX-3018253002 CDM 82530 CPT 301 RC outpatient 251 251 BLUE CROSS BLUE SHIELD WELLMARK SB889 [3081026] BCBS WYOMING [308102603] 238.45 percent of total billed charges 155.62 238.45 Technical (Hospital) Services Ref Cortisol Free Urine PX-3018253002 CDM 82530 CPT 301 RC outpatient 251 251 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES EPO [308136803] 200.8 percent of total billed charges 155.62 238.45 Technical (Hospital) Services Ref Cortisol Free Urine PX-3018253002 CDM 82530 CPT 301 RC outpatient 251 251 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES PPO [308136801] 200.8 percent of total billed charges 155.62 238.45 Technical (Hospital) Services Ref Cortisol Free Urine PX-3018253002 CDM 82530 CPT 301 RC outpatient 251 251 HEALTHPARTNERS SX009 HEALTHPARTNERS 200.8 percent of total billed charges 155.62 238.45 Technical (Hospital) Services Ref Cortisol Free Urine PX-3018253002 CDM 82530 CPT 301 RC outpatient 251 251 UNITED HEALTHCARE (COMMERCIAL) [3081199] UNITED HEALTHCARE 87726 [308119901] 155.62 percent of total billed charges 155.62 238.45 Technical (Hospital) Services Ref Cortisol Free Urine PX-3018253002 CDM 82530 CPT 301 RC outpatient 251 251 CIGNA 62308 [3081051] CIGNA 62308 [308105105] 200.8 percent of total billed charges 155.62 238.45 Technical (Hospital) Services Ref Cortisol Free Urine PX-3018253002 CDM 82530 CPT 301 RC outpatient 251 251 CIGNA 62308 [3081051] CIGNA STATE OF WYOMING [308105107] 200.8 percent of total billed charges 155.62 238.45 Technical (Hospital) Services Ref Cortisol Free Urine PX-3018253002 CDM 82530 CPT 301 RC outpatient 251 251 MEDICA (COMMERCIAL) 94265 [3081118] MEDICA CLAIMS [308111801] 225.9 percent of total billed charges 155.62 238.45 Technical (Hospital) Services Ref Cortisol Free Urine PX-3018253002 CDM 82530 CPT 301 RC inpatient 251 251 MEDICA (COMMERCIAL) 94265 [3081118] MEDICA CLAIMS [308111801] 225.9 percent of total billed charges 155.62 238.45 Technical (Hospital) Services Ref Cortisol Free Urine PX-3018253002 CDM 82530 CPT 301 RC inpatient 251 251 MULTIPLAN INC 34080 [3081285] MULTIPLAN INC [308128501] 238.45 percent of total billed charges 155.62 238.45 Technical (Hospital) Services Ref Cortisol Free Urine PX-3018253002 CDM 82530 CPT 301 RC inpatient 251 251 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES EPO [308136803] 198.74 percent of total billed charges 155.62 238.45 Technical (Hospital) Services Ref Cortisol Free Urine PX-3018253002 CDM 82530 CPT 301 RC inpatient 251 251 HEALTHPARTNERS SX009 HEALTHPARTNERS 198.74 percent of total billed charges 155.62 238.45 Technical (Hospital) Services Ref Cortisol Free Urine PX-3018253002 CDM 82530 CPT 301 RC inpatient 251 251 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES PPO [308136801] 198.74 percent of total billed charges 155.62 238.45 Technical (Hospital) Services Ref Cortisol Free Urine PX-3018253002 CDM 82530 CPT 301 RC inpatient 251 251 UNITED HEALTHCARE (COMMERCIAL) [3081199] UNITED HEALTHCARE 87726 [308119901] 155.62 percent of total billed charges 155.62 238.45 Technical (Hospital) Services Ref Cortisol Free Urine PX-3018253002 CDM 82530 CPT 301 RC inpatient 251 251 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES HDHP [308136802] 198.74 percent of total billed charges 155.62 238.45 Technical (Hospital) Services Ref Cortisol Free Urine PX-3018253002 CDM 82530 CPT 301 RC inpatient 251 251 BLUE CROSS BLUE SHIELD WELLMARK SB889 [3081026] BCBS WYOMING [308102603] 238.45 percent of total billed charges 155.62 238.45 Technical (Hospital) Services Ref Cortisol Free Urine PX-3018253002 CDM 82530 CPT 301 RC inpatient 251 251 CIGNA 62308 [3081051] CIGNA 62308 [308105105] 198.74 percent of total billed charges 155.62 238.45 Technical (Hospital) Services Ref Cortisol Free Urine PX-3018253002 CDM 82530 CPT 301 RC inpatient 251 251 CIGNA 62308 [3081051] CIGNA STATE OF WYOMING [308105107] 198.74 percent of total billed charges 155.62 238.45 Technical (Hospital) Services "Ref Cortisol, Free" PX-3018253005 CDM 82530 CPT 301 RC inpatient 232 232 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES HDHP [308136802] 183.7 percent of total billed charges 143.84 220.4 Technical (Hospital) Services "Ref Cortisol, Free" PX-3018253005 CDM 82530 CPT 301 RC inpatient 232 232 BLUE CROSS BLUE SHIELD WELLMARK SB889 [3081026] BCBS WYOMING [308102603] 220.4 percent of total billed charges 143.84 220.4 Technical (Hospital) Services "Ref Cortisol, Free" PX-3018253005 CDM 82530 CPT 301 RC inpatient 232 232 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES PPO [308136801] 183.7 percent of total billed charges 143.84 220.4 Technical (Hospital) Services "Ref Cortisol, Free" PX-3018253005 CDM 82530 CPT 301 RC inpatient 232 232 UNITED HEALTHCARE (COMMERCIAL) [3081199] UNITED HEALTHCARE 87726 [308119901] 143.84 percent of total billed charges 143.84 220.4 Technical (Hospital) Services "Ref Cortisol, Free" PX-3018253005 CDM 82530 CPT 301 RC inpatient 232 232 MULTIPLAN INC 34080 [3081285] MULTIPLAN INC [308128501] 220.4 percent of total billed charges 143.84 220.4 Technical (Hospital) Services "Ref Cortisol, Free" PX-3018253005 CDM 82530 CPT 301 RC inpatient 232 232 MEDICA (COMMERCIAL) 94265 [3081118] MEDICA CLAIMS [308111801] 208.8 percent of total billed charges 143.84 220.4 Technical (Hospital) Services "Ref Cortisol, Free" PX-3018253005 CDM 82530 CPT 301 RC inpatient 232 232 HEALTHPARTNERS SX009 HEALTHPARTNERS 183.7 percent of total billed charges 143.84 220.4 Technical (Hospital) Services "Ref Cortisol, Free" PX-3018253005 CDM 82530 CPT 301 RC inpatient 232 232 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES EPO [308136803] 183.7 percent of total billed charges 143.84 220.4 Technical (Hospital) Services "Ref Cortisol, Free" PX-3018253005 CDM 82530 CPT 301 RC inpatient 232 232 CIGNA 62308 [3081051] CIGNA 62308 [308105105] 183.7 percent of total billed charges 143.84 220.4 Technical (Hospital) Services "Ref Cortisol, Free" PX-3018253005 CDM 82530 CPT 301 RC inpatient 232 232 CIGNA 62308 [3081051] CIGNA STATE OF WYOMING [308105107] 183.7 percent of total billed charges 143.84 220.4 Technical (Hospital) Services "Ref Cortisol, Free" PX-3018253005 CDM 82530 CPT 301 RC outpatient 232 232 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES PPO [308136801] 185.6 percent of total billed charges 143.84 220.4 Technical (Hospital) Services "Ref Cortisol, Free" PX-3018253005 CDM 82530 CPT 301 RC outpatient 232 232 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES EPO [308136803] 185.6 percent of total billed charges 143.84 220.4 Technical (Hospital) Services "Ref Cortisol, Free" PX-3018253005 CDM 82530 CPT 301 RC outpatient 232 232 MULTIPLAN INC 34080 [3081285] MULTIPLAN INC [308128501] 220.4 percent of total billed charges 143.84 220.4 Technical (Hospital) Services "Ref Cortisol, Free" PX-3018253005 CDM 82530 CPT 301 RC outpatient 232 232 BLUE CROSS BLUE SHIELD WELLMARK SB889 [3081026] BCBS WYOMING [308102603] 220.4 percent of total billed charges 143.84 220.4 Technical (Hospital) Services "Ref Cortisol, Free" PX-3018253005 CDM 82530 CPT 301 RC outpatient 232 232 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES HDHP [308136802] 185.6 percent of total billed charges 143.84 220.4 Technical (Hospital) Services "Ref Cortisol, Free" PX-3018253005 CDM 82530 CPT 301 RC outpatient 232 232 UNITED HEALTHCARE (COMMERCIAL) [3081199] UNITED HEALTHCARE 87726 [308119901] 143.84 percent of total billed charges 143.84 220.4 Technical (Hospital) Services "Ref Cortisol, Free" PX-3018253005 CDM 82530 CPT 301 RC outpatient 232 232 HEALTHPARTNERS SX009 HEALTHPARTNERS 185.6 percent of total billed charges 143.84 220.4 Technical (Hospital) Services "Ref Cortisol, Free" PX-3018253005 CDM 82530 CPT 301 RC outpatient 232 232 MEDICA (COMMERCIAL) 94265 [3081118] MEDICA CLAIMS [308111801] 208.8 percent of total billed charges 143.84 220.4 Technical (Hospital) Services "Ref Cortisol, Free" PX-3018253005 CDM 82530 CPT 301 RC outpatient 232 232 CIGNA 62308 [3081051] CIGNA 62308 [308105105] 185.6 percent of total billed charges 143.84 220.4 Technical (Hospital) Services "Ref Cortisol, Free" PX-3018253005 CDM 82530 CPT 301 RC outpatient 232 232 CIGNA 62308 [3081051] CIGNA STATE OF WYOMING [308105107] 185.6 percent of total billed charges 143.84 220.4 Technical (Hospital) Services Ref Copper Urine PX-3018252500 CDM 82525 CPT 301 RC inpatient 161 161 CIGNA 62308 [3081051] CIGNA 62308 [308105105] 127.48 percent of total billed charges 99.82 152.95 Technical (Hospital) Services Ref Copper Urine PX-3018252500 CDM 82525 CPT 301 RC inpatient 161 161 CIGNA 62308 [3081051] CIGNA STATE OF WYOMING [308105107] 127.48 percent of total billed charges 99.82 152.95 Technical (Hospital) Services Ref Copper Urine PX-3018252500 CDM 82525 CPT 301 RC inpatient 161 161 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES PPO [308136801] 127.48 percent of total billed charges 99.82 152.95 Technical (Hospital) Services Ref Copper Urine PX-3018252500 CDM 82525 CPT 301 RC inpatient 161 161 UNITED HEALTHCARE (COMMERCIAL) [3081199] UNITED HEALTHCARE 87726 [308119901] 99.82 percent of total billed charges 99.82 152.95 Technical (Hospital) Services Ref Copper Urine PX-3018252500 CDM 82525 CPT 301 RC inpatient 161 161 BLUE CROSS BLUE SHIELD WELLMARK SB889 [3081026] BCBS WYOMING [308102603] 152.95 percent of total billed charges 99.82 152.95 Technical (Hospital) Services Ref Copper Urine PX-3018252500 CDM 82525 CPT 301 RC inpatient 161 161 HEALTHPARTNERS SX009 HEALTHPARTNERS 127.48 percent of total billed charges 99.82 152.95 Technical (Hospital) Services Ref Copper Urine PX-3018252500 CDM 82525 CPT 301 RC inpatient 161 161 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES EPO [308136803] 127.48 percent of total billed charges 99.82 152.95 Technical (Hospital) Services Ref Copper Urine PX-3018252500 CDM 82525 CPT 301 RC inpatient 161 161 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES HDHP [308136802] 127.48 percent of total billed charges 99.82 152.95 Technical (Hospital) Services Ref Copper Urine PX-3018252500 CDM 82525 CPT 301 RC inpatient 161 161 MULTIPLAN INC 34080 [3081285] MULTIPLAN INC [308128501] 152.95 percent of total billed charges 99.82 152.95 Technical (Hospital) Services Ref Copper Urine PX-3018252500 CDM 82525 CPT 301 RC inpatient 161 161 MEDICA (COMMERCIAL) 94265 [3081118] MEDICA CLAIMS [308111801] 144.9 percent of total billed charges 99.82 152.95 Technical (Hospital) Services Ref Copper Urine PX-3018252500 CDM 82525 CPT 301 RC outpatient 161 161 MULTIPLAN INC 34080 [3081285] MULTIPLAN INC [308128501] 152.95 percent of total billed charges 99.82 152.95 Technical (Hospital) Services Ref Copper Urine PX-3018252500 CDM 82525 CPT 301 RC outpatient 161 161 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES HDHP [308136802] 128.8 percent of total billed charges 99.82 152.95 Technical (Hospital) Services Ref Copper Urine PX-3018252500 CDM 82525 CPT 301 RC outpatient 161 161 BLUE CROSS BLUE SHIELD WELLMARK SB889 [3081026] BCBS WYOMING [308102603] 152.95 percent of total billed charges 99.82 152.95 Technical (Hospital) Services Ref Copper Urine PX-3018252500 CDM 82525 CPT 301 RC outpatient 161 161 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES EPO [308136803] 128.8 percent of total billed charges 99.82 152.95 Technical (Hospital) Services Ref Copper Urine PX-3018252500 CDM 82525 CPT 301 RC outpatient 161 161 HEALTHPARTNERS SX009 HEALTHPARTNERS 128.8 percent of total billed charges 99.82 152.95 Technical (Hospital) Services Ref Copper Urine PX-3018252500 CDM 82525 CPT 301 RC outpatient 161 161 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES PPO [308136801] 128.8 percent of total billed charges 99.82 152.95 Technical (Hospital) Services Ref Copper Urine PX-3018252500 CDM 82525 CPT 301 RC outpatient 161 161 UNITED HEALTHCARE (COMMERCIAL) [3081199] UNITED HEALTHCARE 87726 [308119901] 99.82 percent of total billed charges 99.82 152.95 Technical (Hospital) Services Ref Copper Urine PX-3018252500 CDM 82525 CPT 301 RC outpatient 161 161 MEDICA (COMMERCIAL) 94265 [3081118] MEDICA CLAIMS [308111801] 144.9 percent of total billed charges 99.82 152.95 Technical (Hospital) Services Ref Copper Urine PX-3018252500 CDM 82525 CPT 301 RC outpatient 161 161 CIGNA 62308 [3081051] CIGNA 62308 [308105105] 128.8 percent of total billed charges 99.82 152.95 Technical (Hospital) Services Ref Copper Urine PX-3018252500 CDM 82525 CPT 301 RC outpatient 161 161 CIGNA 62308 [3081051] CIGNA STATE OF WYOMING [308105107] 128.8 percent of total billed charges 99.82 152.95 Technical (Hospital) Services Ref Copper Serum PX-3018252501 CDM 82525 CPT 301 RC inpatient 161 161 HEALTHPARTNERS SX009 HEALTHPARTNERS 127.48 percent of total billed charges 99.82 152.95 Technical (Hospital) Services Ref Copper Serum PX-3018252501 CDM 82525 CPT 301 RC inpatient 161 161 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES EPO [308136803] 127.48 percent of total billed charges 99.82 152.95 Technical (Hospital) Services Ref Copper Serum PX-3018252501 CDM 82525 CPT 301 RC inpatient 161 161 MEDICA (COMMERCIAL) 94265 [3081118] MEDICA CLAIMS [308111801] 144.9 percent of total billed charges 99.82 152.95 Technical (Hospital) Services Ref Copper Serum PX-3018252501 CDM 82525 CPT 301 RC inpatient 161 161 MULTIPLAN INC 34080 [3081285] MULTIPLAN INC [308128501] 152.95 percent of total billed charges 99.82 152.95 Technical (Hospital) Services Ref Copper Serum PX-3018252501 CDM 82525 CPT 301 RC inpatient 161 161 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES HDHP [308136802] 127.48 percent of total billed charges 99.82 152.95 Technical (Hospital) Services Ref Copper Serum PX-3018252501 CDM 82525 CPT 301 RC inpatient 161 161 BLUE CROSS BLUE SHIELD WELLMARK SB889 [3081026] BCBS WYOMING [308102603] 152.95 percent of total billed charges 99.82 152.95 Technical (Hospital) Services Ref Copper Serum PX-3018252501 CDM 82525 CPT 301 RC inpatient 161 161 UNITED HEALTHCARE (COMMERCIAL) [3081199] UNITED HEALTHCARE 87726 [308119901] 99.82 percent of total billed charges 99.82 152.95 Technical (Hospital) Services Ref Copper Serum PX-3018252501 CDM 82525 CPT 301 RC inpatient 161 161 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES PPO [308136801] 127.48 percent of total billed charges 99.82 152.95 Technical (Hospital) Services Ref Copper Serum PX-3018252501 CDM 82525 CPT 301 RC inpatient 161 161 CIGNA 62308 [3081051] CIGNA 62308 [308105105] 127.48 percent of total billed charges 99.82 152.95 Technical (Hospital) Services Ref Copper Serum PX-3018252501 CDM 82525 CPT 301 RC inpatient 161 161 CIGNA 62308 [3081051] CIGNA STATE OF WYOMING [308105107] 127.48 percent of total billed charges 99.82 152.95 Technical (Hospital) Services Ref Copper Serum PX-3018252501 CDM 82525 CPT 301 RC outpatient 161 161 MEDICA (COMMERCIAL) 94265 [3081118] MEDICA CLAIMS [308111801] 144.9 percent of total billed charges 99.82 152.95 Technical (Hospital) Services Ref Copper Serum PX-3018252501 CDM 82525 CPT 301 RC outpatient 161 161 CIGNA 62308 [3081051] CIGNA 62308 [308105105] 128.8 percent of total billed charges 99.82 152.95 Technical (Hospital) Services Ref Copper Serum PX-3018252501 CDM 82525 CPT 301 RC outpatient 161 161 CIGNA 62308 [3081051] CIGNA STATE OF WYOMING [308105107] 128.8 percent of total billed charges 99.82 152.95 Technical (Hospital) Services Ref Copper Serum PX-3018252501 CDM 82525 CPT 301 RC outpatient 161 161 HEALTHPARTNERS SX009 HEALTHPARTNERS 128.8 percent of total billed charges 99.82 152.95 Technical (Hospital) Services Ref Copper Serum PX-3018252501 CDM 82525 CPT 301 RC outpatient 161 161 UNITED HEALTHCARE (COMMERCIAL) [3081199] UNITED HEALTHCARE 87726 [308119901] 99.82 percent of total billed charges 99.82 152.95 Technical (Hospital) Services Ref Copper Serum PX-3018252501 CDM 82525 CPT 301 RC outpatient 161 161 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES PPO [308136801] 128.8 percent of total billed charges 99.82 152.95 Technical (Hospital) Services Ref Copper Serum PX-3018252501 CDM 82525 CPT 301 RC outpatient 161 161 BLUE CROSS BLUE SHIELD WELLMARK SB889 [3081026] BCBS WYOMING [308102603] 152.95 percent of total billed charges 99.82 152.95 Technical (Hospital) Services Ref Copper Serum PX-3018252501 CDM 82525 CPT 301 RC outpatient 161 161 MULTIPLAN INC 34080 [3081285] MULTIPLAN INC [308128501] 152.95 percent of total billed charges 99.82 152.95 Technical (Hospital) Services Ref Copper Serum PX-3018252501 CDM 82525 CPT 301 RC outpatient 161 161 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES EPO [308136803] 128.8 percent of total billed charges 99.82 152.95 Technical (Hospital) Services Ref Copper Serum PX-3018252501 CDM 82525 CPT 301 RC outpatient 161 161 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES HDHP [308136802] 128.8 percent of total billed charges 99.82 152.95 Technical (Hospital) Services Ref Ntx Telopeptide U PX-3018252301 CDM 82523 CPT 301 RC outpatient 216 216 MEDICA (COMMERCIAL) 94265 [3081118] MEDICA CLAIMS [308111801] 194.4 percent of total billed charges 133.92 205.2 Technical (Hospital) Services Ref Ntx Telopeptide U PX-3018252301 CDM 82523 CPT 301 RC outpatient 216 216 CIGNA 62308 [3081051] CIGNA 62308 [308105105] 172.8 percent of total billed charges 133.92 205.2 Technical (Hospital) Services Ref Ntx Telopeptide U PX-3018252301 CDM 82523 CPT 301 RC outpatient 216 216 CIGNA 62308 [3081051] CIGNA STATE OF WYOMING [308105107] 172.8 percent of total billed charges 133.92 205.2 Technical (Hospital) Services Ref Ntx Telopeptide U PX-3018252301 CDM 82523 CPT 301 RC outpatient 216 216 HEALTHPARTNERS SX009 HEALTHPARTNERS 172.8 percent of total billed charges 133.92 205.2 Technical (Hospital) Services Ref Ntx Telopeptide U PX-3018252301 CDM 82523 CPT 301 RC outpatient 216 216 UNITED HEALTHCARE (COMMERCIAL) [3081199] UNITED HEALTHCARE 87726 [308119901] 133.92 percent of total billed charges 133.92 205.2 Technical (Hospital) Services Ref Ntx Telopeptide U PX-3018252301 CDM 82523 CPT 301 RC outpatient 216 216 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES HDHP [308136802] 172.8 percent of total billed charges 133.92 205.2 Technical (Hospital) Services Ref Ntx Telopeptide U PX-3018252301 CDM 82523 CPT 301 RC outpatient 216 216 BLUE CROSS BLUE SHIELD WELLMARK SB889 [3081026] BCBS WYOMING [308102603] 205.2 percent of total billed charges 133.92 205.2 Technical (Hospital) Services Ref Ntx Telopeptide U PX-3018252301 CDM 82523 CPT 301 RC outpatient 216 216 MULTIPLAN INC 34080 [3081285] MULTIPLAN INC [308128501] 205.2 percent of total billed charges 133.92 205.2 Technical (Hospital) Services Ref Ntx Telopeptide U PX-3018252301 CDM 82523 CPT 301 RC outpatient 216 216 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES EPO [308136803] 172.8 percent of total billed charges 133.92 205.2 Technical (Hospital) Services Ref Ntx Telopeptide U PX-3018252301 CDM 82523 CPT 301 RC outpatient 216 216 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES PPO [308136801] 172.8 percent of total billed charges 133.92 205.2 Technical (Hospital) Services Ref Ntx Telopeptide U PX-3018252301 CDM 82523 CPT 301 RC inpatient 216 216 CIGNA 62308 [3081051] CIGNA 62308 [308105105] 171.03 percent of total billed charges 133.92 205.2 Technical (Hospital) Services Ref Ntx Telopeptide U PX-3018252301 CDM 82523 CPT 301 RC inpatient 216 216 CIGNA 62308 [3081051] CIGNA STATE OF WYOMING [308105107] 171.03 percent of total billed charges 133.92 205.2 Technical (Hospital) Services Ref Ntx Telopeptide U PX-3018252301 CDM 82523 CPT 301 RC inpatient 216 216 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES PPO [308136801] 171.03 percent of total billed charges 133.92 205.2 Technical (Hospital) Services Ref Ntx Telopeptide U PX-3018252301 CDM 82523 CPT 301 RC inpatient 216 216 UNITED HEALTHCARE (COMMERCIAL) [3081199] UNITED HEALTHCARE 87726 [308119901] 133.92 percent of total billed charges 133.92 205.2 Technical (Hospital) Services Ref Ntx Telopeptide U PX-3018252301 CDM 82523 CPT 301 RC inpatient 216 216 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES HDHP [308136802] 171.03 percent of total billed charges 133.92 205.2 Technical (Hospital) Services Ref Ntx Telopeptide U PX-3018252301 CDM 82523 CPT 301 RC inpatient 216 216 BLUE CROSS BLUE SHIELD WELLMARK SB889 [3081026] BCBS WYOMING [308102603] 205.2 percent of total billed charges 133.92 205.2 Technical (Hospital) Services Ref Ntx Telopeptide U PX-3018252301 CDM 82523 CPT 301 RC inpatient 216 216 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES EPO [308136803] 171.03 percent of total billed charges 133.92 205.2 Technical (Hospital) Services Ref Ntx Telopeptide U PX-3018252301 CDM 82523 CPT 301 RC inpatient 216 216 HEALTHPARTNERS SX009 HEALTHPARTNERS 171.03 percent of total billed charges 133.92 205.2 Technical (Hospital) Services Ref Ntx Telopeptide U PX-3018252301 CDM 82523 CPT 301 RC inpatient 216 216 MULTIPLAN INC 34080 [3081285] MULTIPLAN INC [308128501] 205.2 percent of total billed charges 133.92 205.2 Technical (Hospital) Services Ref Ntx Telopeptide U PX-3018252301 CDM 82523 CPT 301 RC inpatient 216 216 MEDICA (COMMERCIAL) 94265 [3081118] MEDICA CLAIMS [308111801] 194.4 percent of total billed charges 133.92 205.2 Technical (Hospital) Services Ref Ntx Serum PX-3018252302 CDM 82523 CPT 301 RC inpatient 272 272 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES PPO [308136801] 215.37 percent of total billed charges 168.64 258.4 Technical (Hospital) Services Ref Ntx Serum PX-3018252302 CDM 82523 CPT 301 RC inpatient 272 272 UNITED HEALTHCARE (COMMERCIAL) [3081199] UNITED HEALTHCARE 87726 [308119901] 168.64 percent of total billed charges 168.64 258.4 Technical (Hospital) Services Ref Ntx Serum PX-3018252302 CDM 82523 CPT 301 RC inpatient 272 272 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES HDHP [308136802] 215.37 percent of total billed charges 168.64 258.4 Technical (Hospital) Services Ref Ntx Serum PX-3018252302 CDM 82523 CPT 301 RC inpatient 272 272 BLUE CROSS BLUE SHIELD WELLMARK SB889 [3081026] BCBS WYOMING [308102603] 258.4 percent of total billed charges 168.64 258.4 Technical (Hospital) Services Ref Ntx Serum PX-3018252302 CDM 82523 CPT 301 RC inpatient 272 272 MULTIPLAN INC 34080 [3081285] MULTIPLAN INC [308128501] 258.4 percent of total billed charges 168.64 258.4 Technical (Hospital) Services Ref Ntx Serum PX-3018252302 CDM 82523 CPT 301 RC inpatient 272 272 MEDICA (COMMERCIAL) 94265 [3081118] MEDICA CLAIMS [308111801] 244.8 percent of total billed charges 168.64 258.4 Technical (Hospital) Services Ref Ntx Serum PX-3018252302 CDM 82523 CPT 301 RC inpatient 272 272 HEALTHPARTNERS SX009 HEALTHPARTNERS 215.37 percent of total billed charges 168.64 258.4 Technical (Hospital) Services Ref Ntx Serum PX-3018252302 CDM 82523 CPT 301 RC inpatient 272 272 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES EPO [308136803] 215.37 percent of total billed charges 168.64 258.4 Technical (Hospital) Services Ref Ntx Serum PX-3018252302 CDM 82523 CPT 301 RC inpatient 272 272 CIGNA 62308 [3081051] CIGNA STATE OF WYOMING [308105107] 215.37 percent of total billed charges 168.64 258.4 Technical (Hospital) Services Ref Ntx Serum PX-3018252302 CDM 82523 CPT 301 RC inpatient 272 272 CIGNA 62308 [3081051] CIGNA 62308 [308105105] 215.37 percent of total billed charges 168.64 258.4 Technical (Hospital) Services Ref Ntx Serum PX-3018252302 CDM 82523 CPT 301 RC outpatient 272 272 CIGNA 62308 [3081051] CIGNA 62308 [308105105] 217.6 percent of total billed charges 168.64 258.4 Technical (Hospital) Services Ref Ntx Serum PX-3018252302 CDM 82523 CPT 301 RC outpatient 272 272 CIGNA 62308 [3081051] CIGNA STATE OF WYOMING [308105107] 217.6 percent of total billed charges 168.64 258.4 Technical (Hospital) Services Ref Ntx Serum PX-3018252302 CDM 82523 CPT 301 RC outpatient 272 272 MEDICA (COMMERCIAL) 94265 [3081118] MEDICA CLAIMS [308111801] 244.8 percent of total billed charges 168.64 258.4 Technical (Hospital) Services Ref Ntx Serum PX-3018252302 CDM 82523 CPT 301 RC outpatient 272 272 HEALTHPARTNERS SX009 HEALTHPARTNERS 217.6 percent of total billed charges 168.64 258.4 Technical (Hospital) Services Ref Ntx Serum PX-3018252302 CDM 82523 CPT 301 RC outpatient 272 272 UNITED HEALTHCARE (COMMERCIAL) [3081199] UNITED HEALTHCARE 87726 [308119901] 168.64 percent of total billed charges 168.64 258.4 Technical (Hospital) Services Ref Ntx Serum PX-3018252302 CDM 82523 CPT 301 RC outpatient 272 272 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES PPO [308136801] 217.6 percent of total billed charges 168.64 258.4 Technical (Hospital) Services Ref Ntx Serum PX-3018252302 CDM 82523 CPT 301 RC outpatient 272 272 MULTIPLAN INC 34080 [3081285] MULTIPLAN INC [308128501] 258.4 percent of total billed charges 168.64 258.4 Technical (Hospital) Services Ref Ntx Serum PX-3018252302 CDM 82523 CPT 301 RC outpatient 272 272 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES HDHP [308136802] 217.6 percent of total billed charges 168.64 258.4 Technical (Hospital) Services Ref Ntx Serum PX-3018252302 CDM 82523 CPT 301 RC outpatient 272 272 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES EPO [308136803] 217.6 percent of total billed charges 168.64 258.4 Technical (Hospital) Services Ref Ntx Serum PX-3018252302 CDM 82523 CPT 301 RC outpatient 272 272 BLUE CROSS BLUE SHIELD WELLMARK SB889 [3081026] BCBS WYOMING [308102603] 258.4 percent of total billed charges 168.64 258.4 Technical (Hospital) Services "Ref Beta-Crosslaps (Beta-Ctx), Serum(Mayo)" PX-3018252303 CDM 82523 CPT 301 RC inpatient 252 252 BLUE CROSS BLUE SHIELD WELLMARK SB889 [3081026] BCBS WYOMING [308102603] 239.4 percent of total billed charges 156.24 239.4 Technical (Hospital) Services "Ref Beta-Crosslaps (Beta-Ctx), Serum(Mayo)" PX-3018252303 CDM 82523 CPT 301 RC inpatient 252 252 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES HDHP [308136802] 199.53 percent of total billed charges 156.24 239.4 Technical (Hospital) Services "Ref Beta-Crosslaps (Beta-Ctx), Serum(Mayo)" PX-3018252303 CDM 82523 CPT 301 RC inpatient 252 252 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES PPO [308136801] 199.53 percent of total billed charges 156.24 239.4 Technical (Hospital) Services "Ref Beta-Crosslaps (Beta-Ctx), Serum(Mayo)" PX-3018252303 CDM 82523 CPT 301 RC inpatient 252 252 UNITED HEALTHCARE (COMMERCIAL) [3081199] UNITED HEALTHCARE 87726 [308119901] 156.24 percent of total billed charges 156.24 239.4 Technical (Hospital) Services "Ref Beta-Crosslaps (Beta-Ctx), Serum(Mayo)" PX-3018252303 CDM 82523 CPT 301 RC inpatient 252 252 MEDICA (COMMERCIAL) 94265 [3081118] MEDICA CLAIMS [308111801] 226.8 percent of total billed charges 156.24 239.4 Technical (Hospital) Services "Ref Beta-Crosslaps (Beta-Ctx), Serum(Mayo)" PX-3018252303 CDM 82523 CPT 301 RC inpatient 252 252 MULTIPLAN INC 34080 [3081285] MULTIPLAN INC [308128501] 239.4 percent of total billed charges 156.24 239.4 Technical (Hospital) Services "Ref Beta-Crosslaps (Beta-Ctx), Serum(Mayo)" PX-3018252303 CDM 82523 CPT 301 RC inpatient 252 252 HEALTHPARTNERS SX009 HEALTHPARTNERS 199.53 percent of total billed charges 156.24 239.4 Technical (Hospital) Services "Ref Beta-Crosslaps (Beta-Ctx), Serum(Mayo)" PX-3018252303 CDM 82523 CPT 301 RC inpatient 252 252 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES EPO [308136803] 199.53 percent of total billed charges 156.24 239.4 Technical (Hospital) Services "Ref Beta-Crosslaps (Beta-Ctx), Serum(Mayo)" PX-3018252303 CDM 82523 CPT 301 RC inpatient 252 252 CIGNA 62308 [3081051] CIGNA 62308 [308105105] 199.53 percent of total billed charges 156.24 239.4 Technical (Hospital) Services "Ref Beta-Crosslaps (Beta-Ctx), Serum(Mayo)" PX-3018252303 CDM 82523 CPT 301 RC inpatient 252 252 CIGNA 62308 [3081051] CIGNA STATE OF WYOMING [308105107] 199.53 percent of total billed charges 156.24 239.4 Technical (Hospital) Services "Ref Beta-Crosslaps (Beta-Ctx), Serum(Mayo)" PX-3018252303 CDM 82523 CPT 301 RC outpatient 252 252 MEDICA (COMMERCIAL) 94265 [3081118] MEDICA CLAIMS [308111801] 226.8 percent of total billed charges 156.24 239.4 Technical (Hospital) Services "Ref Beta-Crosslaps (Beta-Ctx), Serum(Mayo)" PX-3018252303 CDM 82523 CPT 301 RC outpatient 252 252 CIGNA 62308 [3081051] CIGNA 62308 [308105105] 201.6 percent of total billed charges 156.24 239.4 Technical (Hospital) Services "Ref Beta-Crosslaps (Beta-Ctx), Serum(Mayo)" PX-3018252303 CDM 82523 CPT 301 RC outpatient 252 252 CIGNA 62308 [3081051] CIGNA STATE OF WYOMING [308105107] 201.6 percent of total billed charges 156.24 239.4 Technical (Hospital) Services "Ref Beta-Crosslaps (Beta-Ctx), Serum(Mayo)" PX-3018252303 CDM 82523 CPT 301 RC outpatient 252 252 BLUE CROSS BLUE SHIELD WELLMARK SB889 [3081026] BCBS WYOMING [308102603] 239.4 percent of total billed charges 156.24 239.4 Technical (Hospital) Services "Ref Beta-Crosslaps (Beta-Ctx), Serum(Mayo)" PX-3018252303 CDM 82523 CPT 301 RC outpatient 252 252 MULTIPLAN INC 34080 [3081285] MULTIPLAN INC [308128501] 239.4 percent of total billed charges 156.24 239.4 Technical (Hospital) Services "Ref Beta-Crosslaps (Beta-Ctx), Serum(Mayo)" PX-3018252303 CDM 82523 CPT 301 RC outpatient 252 252 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES EPO [308136803] 201.6 percent of total billed charges 156.24 239.4 Technical (Hospital) Services "Ref Beta-Crosslaps (Beta-Ctx), Serum(Mayo)" PX-3018252303 CDM 82523 CPT 301 RC outpatient 252 252 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES HDHP [308136802] 201.6 percent of total billed charges 156.24 239.4 Technical (Hospital) Services "Ref Beta-Crosslaps (Beta-Ctx), Serum(Mayo)" PX-3018252303 CDM 82523 CPT 301 RC outpatient 252 252 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES PPO [308136801] 201.6 percent of total billed charges 156.24 239.4 Technical (Hospital) Services "Ref Beta-Crosslaps (Beta-Ctx), Serum(Mayo)" PX-3018252303 CDM 82523 CPT 301 RC outpatient 252 252 HEALTHPARTNERS SX009 HEALTHPARTNERS 201.6 percent of total billed charges 156.24 239.4 Technical (Hospital) Services "Ref Beta-Crosslaps (Beta-Ctx), Serum(Mayo)" PX-3018252303 CDM 82523 CPT 301 RC outpatient 252 252 UNITED HEALTHCARE (COMMERCIAL) [3081199] UNITED HEALTHCARE 87726 [308119901] 156.24 percent of total billed charges 156.24 239.4 Technical (Hospital) Services Ref Citrate Excretion (Sat 24) PX-3018250700 CDM 82507 CPT 301 RC inpatient 352 352 CIGNA 62308 [3081051] CIGNA 62308 [308105105] 278.71 percent of total billed charges 218.24 334.4 Technical (Hospital) Services Ref Citrate Excretion (Sat 24) PX-3018250700 CDM 82507 CPT 301 RC inpatient 352 352 CIGNA 62308 [3081051] CIGNA STATE OF WYOMING [308105107] 278.71 percent of total billed charges 218.24 334.4 Technical (Hospital) Services Ref Citrate Excretion (Sat 24) PX-3018250700 CDM 82507 CPT 301 RC inpatient 352 352 HEALTHPARTNERS SX009 HEALTHPARTNERS 278.71 percent of total billed charges 218.24 334.4 Technical (Hospital) Services Ref Citrate Excretion (Sat 24) PX-3018250700 CDM 82507 CPT 301 RC inpatient 352 352 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES EPO [308136803] 278.71 percent of total billed charges 218.24 334.4 Technical (Hospital) Services Ref Citrate Excretion (Sat 24) PX-3018250700 CDM 82507 CPT 301 RC inpatient 352 352 MULTIPLAN INC 34080 [3081285] MULTIPLAN INC [308128501] 334.4 percent of total billed charges 218.24 334.4 Technical (Hospital) Services Ref Citrate Excretion (Sat 24) PX-3018250700 CDM 82507 CPT 301 RC inpatient 352 352 MEDICA (COMMERCIAL) 94265 [3081118] MEDICA CLAIMS [308111801] 316.8 percent of total billed charges 218.24 334.4 Technical (Hospital) Services Ref Citrate Excretion (Sat 24) PX-3018250700 CDM 82507 CPT 301 RC inpatient 352 352 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES PPO [308136801] 278.71 percent of total billed charges 218.24 334.4 Technical (Hospital) Services Ref Citrate Excretion (Sat 24) PX-3018250700 CDM 82507 CPT 301 RC inpatient 352 352 UNITED HEALTHCARE (COMMERCIAL) [3081199] UNITED HEALTHCARE 87726 [308119901] 218.24 percent of total billed charges 218.24 334.4 Technical (Hospital) Services Ref Citrate Excretion (Sat 24) PX-3018250700 CDM 82507 CPT 301 RC inpatient 352 352 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES HDHP [308136802] 278.71 percent of total billed charges 218.24 334.4 Technical (Hospital) Services Ref Citrate Excretion (Sat 24) PX-3018250700 CDM 82507 CPT 301 RC inpatient 352 352 BLUE CROSS BLUE SHIELD WELLMARK SB889 [3081026] BCBS WYOMING [308102603] 334.4 percent of total billed charges 218.24 334.4 Technical (Hospital) Services Ref Citrate Excretion (Sat 24) PX-3018250700 CDM 82507 CPT 301 RC outpatient 352 352 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES PPO [308136801] 281.6 percent of total billed charges 218.24 334.4 Technical (Hospital) Services Ref Citrate Excretion (Sat 24) PX-3018250700 CDM 82507 CPT 301 RC outpatient 352 352 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES HDHP [308136802] 281.6 percent of total billed charges 218.24 334.4 Technical (Hospital) Services Ref Citrate Excretion (Sat 24) PX-3018250700 CDM 82507 CPT 301 RC outpatient 352 352 BLUE CROSS BLUE SHIELD WELLMARK SB889 [3081026] BCBS WYOMING [308102603] 334.4 percent of total billed charges 218.24 334.4 Technical (Hospital) Services Ref Citrate Excretion (Sat 24) PX-3018250700 CDM 82507 CPT 301 RC outpatient 352 352 MULTIPLAN INC 34080 [3081285] MULTIPLAN INC [308128501] 334.4 percent of total billed charges 218.24 334.4 Technical (Hospital) Services Ref Citrate Excretion (Sat 24) PX-3018250700 CDM 82507 CPT 301 RC outpatient 352 352 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES EPO [308136803] 281.6 percent of total billed charges 218.24 334.4 Technical (Hospital) Services Ref Citrate Excretion (Sat 24) PX-3018250700 CDM 82507 CPT 301 RC outpatient 352 352 HEALTHPARTNERS SX009 HEALTHPARTNERS 281.6 percent of total billed charges 218.24 334.4 Technical (Hospital) Services Ref Citrate Excretion (Sat 24) PX-3018250700 CDM 82507 CPT 301 RC outpatient 352 352 UNITED HEALTHCARE (COMMERCIAL) [3081199] UNITED HEALTHCARE 87726 [308119901] 218.24 percent of total billed charges 218.24 334.4 Technical (Hospital) Services Ref Citrate Excretion (Sat 24) PX-3018250700 CDM 82507 CPT 301 RC outpatient 352 352 CIGNA 62308 [3081051] CIGNA 62308 [308105105] 281.6 percent of total billed charges 218.24 334.4 Technical (Hospital) Services Ref Citrate Excretion (Sat 24) PX-3018250700 CDM 82507 CPT 301 RC outpatient 352 352 CIGNA 62308 [3081051] CIGNA STATE OF WYOMING [308105107] 281.6 percent of total billed charges 218.24 334.4 Technical (Hospital) Services Ref Citrate Excretion (Sat 24) PX-3018250700 CDM 82507 CPT 301 RC outpatient 352 352 MEDICA (COMMERCIAL) 94265 [3081118] MEDICA CLAIMS [308111801] 316.8 percent of total billed charges 218.24 334.4 Technical (Hospital) Services Ref Citrate Excretion PX-3018250701 CDM 82507 CPT 301 RC outpatient 360 360 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES PPO [308136801] 288 percent of total billed charges 223.2 342 Technical (Hospital) Services Ref Citrate Excretion PX-3018250701 CDM 82507 CPT 301 RC outpatient 360 360 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES HDHP [308136802] 288 percent of total billed charges 223.2 342 Technical (Hospital) Services Ref Citrate Excretion PX-3018250701 CDM 82507 CPT 301 RC outpatient 360 360 MULTIPLAN INC 34080 [3081285] MULTIPLAN INC [308128501] 342 percent of total billed charges 223.2 342 Technical (Hospital) Services Ref Citrate Excretion PX-3018250701 CDM 82507 CPT 301 RC outpatient 360 360 BLUE CROSS BLUE SHIELD WELLMARK SB889 [3081026] BCBS WYOMING [308102603] 342 percent of total billed charges 223.2 342 Technical (Hospital) Services Ref Citrate Excretion PX-3018250701 CDM 82507 CPT 301 RC outpatient 360 360 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES EPO [308136803] 288 percent of total billed charges 223.2 342 Technical (Hospital) Services Ref Citrate Excretion PX-3018250701 CDM 82507 CPT 301 RC outpatient 360 360 UNITED HEALTHCARE (COMMERCIAL) [3081199] UNITED HEALTHCARE 87726 [308119901] 223.2 percent of total billed charges 223.2 342 Technical (Hospital) Services Ref Citrate Excretion PX-3018250701 CDM 82507 CPT 301 RC outpatient 360 360 HEALTHPARTNERS SX009 HEALTHPARTNERS 288 percent of total billed charges 223.2 342 Technical (Hospital) Services Ref Citrate Excretion PX-3018250701 CDM 82507 CPT 301 RC outpatient 360 360 MEDICA (COMMERCIAL) 94265 [3081118] MEDICA CLAIMS [308111801] 324 percent of total billed charges 223.2 342 Technical (Hospital) Services Ref Citrate Excretion PX-3018250701 CDM 82507 CPT 301 RC outpatient 360 360 CIGNA 62308 [3081051] CIGNA 62308 [308105105] 288 percent of total billed charges 223.2 342 Technical (Hospital) Services Ref Citrate Excretion PX-3018250701 CDM 82507 CPT 301 RC outpatient 360 360 CIGNA 62308 [3081051] CIGNA STATE OF WYOMING [308105107] 288 percent of total billed charges 223.2 342 Technical (Hospital) Services Ref Citrate Excretion PX-3018250701 CDM 82507 CPT 301 RC inpatient 360 360 CIGNA 62308 [3081051] CIGNA 62308 [308105105] 285.05 percent of total billed charges 223.2 342 Technical (Hospital) Services Ref Citrate Excretion PX-3018250701 CDM 82507 CPT 301 RC inpatient 360 360 CIGNA 62308 [3081051] CIGNA STATE OF WYOMING [308105107] 285.05 percent of total billed charges 223.2 342 Technical (Hospital) Services Ref Citrate Excretion PX-3018250701 CDM 82507 CPT 301 RC inpatient 360 360 MEDICA (COMMERCIAL) 94265 [3081118] MEDICA CLAIMS [308111801] 324 percent of total billed charges 223.2 342 Technical (Hospital) Services Ref Citrate Excretion PX-3018250701 CDM 82507 CPT 301 RC inpatient 360 360 MULTIPLAN INC 34080 [3081285] MULTIPLAN INC [308128501] 342 percent of total billed charges 223.2 342 Technical (Hospital) Services Ref Citrate Excretion PX-3018250701 CDM 82507 CPT 301 RC inpatient 360 360 HEALTHPARTNERS SX009 HEALTHPARTNERS 285.05 percent of total billed charges 223.2 342 Technical (Hospital) Services Ref Citrate Excretion PX-3018250701 CDM 82507 CPT 301 RC inpatient 360 360 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES EPO [308136803] 285.05 percent of total billed charges 223.2 342 Technical (Hospital) Services Ref Citrate Excretion PX-3018250701 CDM 82507 CPT 301 RC inpatient 360 360 UNITED HEALTHCARE (COMMERCIAL) [3081199] UNITED HEALTHCARE 87726 [308119901] 223.2 percent of total billed charges 223.2 342 Technical (Hospital) Services Ref Citrate Excretion PX-3018250701 CDM 82507 CPT 301 RC inpatient 360 360 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES PPO [308136801] 285.05 percent of total billed charges 223.2 342 Technical (Hospital) Services Ref Citrate Excretion PX-3018250701 CDM 82507 CPT 301 RC inpatient 360 360 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES HDHP [308136802] 285.05 percent of total billed charges 223.2 342 Technical (Hospital) Services Ref Citrate Excretion PX-3018250701 CDM 82507 CPT 301 RC inpatient 360 360 BLUE CROSS BLUE SHIELD WELLMARK SB889 [3081026] BCBS WYOMING [308102603] 342 percent of total billed charges 223.2 342 Technical (Hospital) Services Ref Chromium PX-3018249500 CDM 82495 CPT 301 RC inpatient 290 290 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES PPO [308136801] 229.62 percent of total billed charges 179.8 275.5 Technical (Hospital) Services Ref Chromium PX-3018249500 CDM 82495 CPT 301 RC inpatient 290 290 UNITED HEALTHCARE (COMMERCIAL) [3081199] UNITED HEALTHCARE 87726 [308119901] 179.8 percent of total billed charges 179.8 275.5 Technical (Hospital) Services Ref Chromium PX-3018249500 CDM 82495 CPT 301 RC inpatient 290 290 BLUE CROSS BLUE SHIELD WELLMARK SB889 [3081026] BCBS WYOMING [308102603] 275.5 percent of total billed charges 179.8 275.5 Technical (Hospital) Services Ref Chromium PX-3018249500 CDM 82495 CPT 301 RC inpatient 290 290 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES HDHP [308136802] 229.62 percent of total billed charges 179.8 275.5 Technical (Hospital) Services Ref Chromium PX-3018249500 CDM 82495 CPT 301 RC inpatient 290 290 HEALTHPARTNERS SX009 HEALTHPARTNERS 229.62 percent of total billed charges 179.8 275.5 Technical (Hospital) Services Ref Chromium PX-3018249500 CDM 82495 CPT 301 RC inpatient 290 290 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES EPO [308136803] 229.62 percent of total billed charges 179.8 275.5 Technical (Hospital) Services Ref Chromium PX-3018249500 CDM 82495 CPT 301 RC inpatient 290 290 MEDICA (COMMERCIAL) 94265 [3081118] MEDICA CLAIMS [308111801] 261 percent of total billed charges 179.8 275.5 Technical (Hospital) Services Ref Chromium PX-3018249500 CDM 82495 CPT 301 RC inpatient 290 290 MULTIPLAN INC 34080 [3081285] MULTIPLAN INC [308128501] 275.5 percent of total billed charges 179.8 275.5 Technical (Hospital) Services Ref Chromium PX-3018249500 CDM 82495 CPT 301 RC inpatient 290 290 CIGNA 62308 [3081051] CIGNA 62308 [308105105] 229.62 percent of total billed charges 179.8 275.5 Technical (Hospital) Services Ref Chromium PX-3018249500 CDM 82495 CPT 301 RC inpatient 290 290 CIGNA 62308 [3081051] CIGNA STATE OF WYOMING [308105107] 229.62 percent of total billed charges 179.8 275.5 Technical (Hospital) Services Ref Chromium PX-3018249500 CDM 82495 CPT 301 RC outpatient 290 290 MEDICA (COMMERCIAL) 94265 [3081118] MEDICA CLAIMS [308111801] 261 percent of total billed charges 179.8 275.5 Technical (Hospital) Services Ref Chromium PX-3018249500 CDM 82495 CPT 301 RC outpatient 290 290 CIGNA 62308 [3081051] CIGNA 62308 [308105105] 232 percent of total billed charges 179.8 275.5 Technical (Hospital) Services Ref Chromium PX-3018249500 CDM 82495 CPT 301 RC outpatient 290 290 CIGNA 62308 [3081051] CIGNA STATE OF WYOMING [308105107] 232 percent of total billed charges 179.8 275.5 Technical (Hospital) Services Ref Chromium PX-3018249500 CDM 82495 CPT 301 RC outpatient 290 290 BLUE CROSS BLUE SHIELD WELLMARK SB889 [3081026] BCBS WYOMING [308102603] 275.5 percent of total billed charges 179.8 275.5 Technical (Hospital) Services Ref Chromium PX-3018249500 CDM 82495 CPT 301 RC outpatient 290 290 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES EPO [308136803] 232 percent of total billed charges 179.8 275.5 Technical (Hospital) Services Ref Chromium PX-3018249500 CDM 82495 CPT 301 RC outpatient 290 290 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES HDHP [308136802] 232 percent of total billed charges 179.8 275.5 Technical (Hospital) Services Ref Chromium PX-3018249500 CDM 82495 CPT 301 RC outpatient 290 290 MULTIPLAN INC 34080 [3081285] MULTIPLAN INC [308128501] 275.5 percent of total billed charges 179.8 275.5 Technical (Hospital) Services Ref Chromium PX-3018249500 CDM 82495 CPT 301 RC outpatient 290 290 HEALTHPARTNERS SX009 HEALTHPARTNERS 232 percent of total billed charges 179.8 275.5 Technical (Hospital) Services Ref Chromium PX-3018249500 CDM 82495 CPT 301 RC outpatient 290 290 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES PPO [308136801] 232 percent of total billed charges 179.8 275.5 Technical (Hospital) Services Ref Chromium PX-3018249500 CDM 82495 CPT 301 RC outpatient 290 290 UNITED HEALTHCARE (COMMERCIAL) [3081199] UNITED HEALTHCARE 87726 [308119901] 179.8 percent of total billed charges 179.8 275.5 Technical (Hospital) Services Cholesterol PX-3018246500 CDM 82465 CPT 301 RC outpatient 63 63 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES PPO [308136801] 50.4 percent of total billed charges 39.06 59.85 Technical (Hospital) Services Cholesterol PX-3018246500 CDM 82465 CPT 301 RC outpatient 63 63 UNITED HEALTHCARE (COMMERCIAL) [3081199] UNITED HEALTHCARE 87726 [308119901] 39.06 percent of total billed charges 39.06 59.85 Technical (Hospital) Services Cholesterol PX-3018246500 CDM 82465 CPT 301 RC outpatient 63 63 HEALTHPARTNERS SX009 HEALTHPARTNERS 50.4 percent of total billed charges 39.06 59.85 Technical (Hospital) Services Cholesterol PX-3018246500 CDM 82465 CPT 301 RC outpatient 63 63 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES EPO [308136803] 50.4 percent of total billed charges 39.06 59.85 Technical (Hospital) Services Cholesterol PX-3018246500 CDM 82465 CPT 301 RC outpatient 63 63 BLUE CROSS BLUE SHIELD WELLMARK SB889 [3081026] BCBS WYOMING [308102603] 59.85 percent of total billed charges 39.06 59.85 Technical (Hospital) Services Cholesterol PX-3018246500 CDM 82465 CPT 301 RC outpatient 63 63 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES HDHP [308136802] 50.4 percent of total billed charges 39.06 59.85 Technical (Hospital) Services Cholesterol PX-3018246500 CDM 82465 CPT 301 RC outpatient 63 63 MULTIPLAN INC 34080 [3081285] MULTIPLAN INC [308128501] 59.85 percent of total billed charges 39.06 59.85 Technical (Hospital) Services Cholesterol PX-3018246500 CDM 82465 CPT 301 RC outpatient 63 63 MEDICA (COMMERCIAL) 94265 [3081118] MEDICA CLAIMS [308111801] 56.7 percent of total billed charges 39.06 59.85 Technical (Hospital) Services Cholesterol PX-3018246500 CDM 82465 CPT 301 RC outpatient 63 63 CIGNA 62308 [3081051] CIGNA 62308 [308105105] 50.4 percent of total billed charges 39.06 59.85 Technical (Hospital) Services Cholesterol PX-3018246500 CDM 82465 CPT 301 RC outpatient 63 63 CIGNA 62308 [3081051] CIGNA STATE OF WYOMING [308105107] 50.4 percent of total billed charges 39.06 59.85 Technical (Hospital) Services Cholesterol PX-3018246500 CDM 82465 CPT 301 RC inpatient 63 63 CIGNA 62308 [3081051] CIGNA 62308 [308105105] 49.88 percent of total billed charges 39.06 59.85 Technical (Hospital) Services Cholesterol PX-3018246500 CDM 82465 CPT 301 RC inpatient 63 63 CIGNA 62308 [3081051] CIGNA STATE OF WYOMING [308105107] 49.88 percent of total billed charges 39.06 59.85 Technical (Hospital) Services Cholesterol PX-3018246500 CDM 82465 CPT 301 RC inpatient 63 63 MEDICA (COMMERCIAL) 94265 [3081118] MEDICA CLAIMS [308111801] 56.7 percent of total billed charges 39.06 59.85 Technical (Hospital) Services Cholesterol PX-3018246500 CDM 82465 CPT 301 RC inpatient 63 63 MULTIPLAN INC 34080 [3081285] MULTIPLAN INC [308128501] 59.85 percent of total billed charges 39.06 59.85 Technical (Hospital) Services Cholesterol PX-3018246500 CDM 82465 CPT 301 RC inpatient 63 63 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES EPO [308136803] 49.88 percent of total billed charges 39.06 59.85 Technical (Hospital) Services Cholesterol PX-3018246500 CDM 82465 CPT 301 RC inpatient 63 63 HEALTHPARTNERS SX009 HEALTHPARTNERS 49.88 percent of total billed charges 39.06 59.85 Technical (Hospital) Services Cholesterol PX-3018246500 CDM 82465 CPT 301 RC inpatient 63 63 BLUE CROSS BLUE SHIELD WELLMARK SB889 [3081026] BCBS WYOMING [308102603] 59.85 percent of total billed charges 39.06 59.85 Technical (Hospital) Services Cholesterol PX-3018246500 CDM 82465 CPT 301 RC inpatient 63 63 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES HDHP [308136802] 49.88 percent of total billed charges 39.06 59.85 Technical (Hospital) Services Cholesterol PX-3018246500 CDM 82465 CPT 301 RC inpatient 63 63 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES PPO [308136801] 49.88 percent of total billed charges 39.06 59.85 Technical (Hospital) Services Cholesterol PX-3018246500 CDM 82465 CPT 301 RC inpatient 63 63 UNITED HEALTHCARE (COMMERCIAL) [3081199] UNITED HEALTHCARE 87726 [308119901] 39.06 percent of total billed charges 39.06 59.85 Technical (Hospital) Services Chloride CSF Body Fluid Urine PX-3018243800 CDM 82438 CPT 301 RC inpatient 95 95 CIGNA 62308 [3081051] CIGNA 62308 [308105105] 75.22 percent of total billed charges 58.9 90.25 Technical (Hospital) Services Chloride CSF Body Fluid Urine PX-3018243800 CDM 82438 CPT 301 RC inpatient 95 95 CIGNA 62308 [3081051] CIGNA STATE OF WYOMING [308105107] 75.22 percent of total billed charges 58.9 90.25 Technical (Hospital) Services Chloride CSF Body Fluid Urine PX-3018243800 CDM 82438 CPT 301 RC inpatient 95 95 BLUE CROSS BLUE SHIELD WELLMARK SB889 [3081026] BCBS WYOMING [308102603] 90.25 percent of total billed charges 58.9 90.25 Technical (Hospital) Services Chloride CSF Body Fluid Urine PX-3018243800 CDM 82438 CPT 301 RC inpatient 95 95 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES PPO [308136801] 75.22 percent of total billed charges 58.9 90.25 Technical (Hospital) Services Chloride CSF Body Fluid Urine PX-3018243800 CDM 82438 CPT 301 RC inpatient 95 95 UNITED HEALTHCARE (COMMERCIAL) [3081199] UNITED HEALTHCARE 87726 [308119901] 58.9 percent of total billed charges 58.9 90.25 Technical (Hospital) Services Chloride CSF Body Fluid Urine PX-3018243800 CDM 82438 CPT 301 RC inpatient 95 95 MEDICA (COMMERCIAL) 94265 [3081118] MEDICA CLAIMS [308111801] 85.5 percent of total billed charges 58.9 90.25 Technical (Hospital) Services Chloride CSF Body Fluid Urine PX-3018243800 CDM 82438 CPT 301 RC inpatient 95 95 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES HDHP [308136802] 75.22 percent of total billed charges 58.9 90.25 Technical (Hospital) Services Chloride CSF Body Fluid Urine PX-3018243800 CDM 82438 CPT 301 RC inpatient 95 95 MULTIPLAN INC 34080 [3081285] MULTIPLAN INC [308128501] 90.25 percent of total billed charges 58.9 90.25 Technical (Hospital) Services Chloride CSF Body Fluid Urine PX-3018243800 CDM 82438 CPT 301 RC inpatient 95 95 HEALTHPARTNERS SX009 HEALTHPARTNERS 75.22 percent of total billed charges 58.9 90.25 Technical (Hospital) Services Chloride CSF Body Fluid Urine PX-3018243800 CDM 82438 CPT 301 RC inpatient 95 95 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES EPO [308136803] 75.22 percent of total billed charges 58.9 90.25 Technical (Hospital) Services Chloride CSF Body Fluid Urine PX-3018243800 CDM 82438 CPT 301 RC outpatient 95 95 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES HDHP [308136802] 76 percent of total billed charges 58.9 90.25 Technical (Hospital) Services Chloride CSF Body Fluid Urine PX-3018243800 CDM 82438 CPT 301 RC outpatient 95 95 BLUE CROSS BLUE SHIELD WELLMARK SB889 [3081026] BCBS WYOMING [308102603] 90.25 percent of total billed charges 58.9 90.25 Technical (Hospital) Services Chloride CSF Body Fluid Urine PX-3018243800 CDM 82438 CPT 301 RC outpatient 95 95 MULTIPLAN INC 34080 [3081285] MULTIPLAN INC [308128501] 90.25 percent of total billed charges 58.9 90.25 Technical (Hospital) Services Chloride CSF Body Fluid Urine PX-3018243800 CDM 82438 CPT 301 RC outpatient 95 95 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES EPO [308136803] 76 percent of total billed charges 58.9 90.25 Technical (Hospital) Services Chloride CSF Body Fluid Urine PX-3018243800 CDM 82438 CPT 301 RC outpatient 95 95 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES PPO [308136801] 76 percent of total billed charges 58.9 90.25 Technical (Hospital) Services Chloride CSF Body Fluid Urine PX-3018243800 CDM 82438 CPT 301 RC outpatient 95 95 HEALTHPARTNERS SX009 HEALTHPARTNERS 76 percent of total billed charges 58.9 90.25 Technical (Hospital) Services Chloride CSF Body Fluid Urine PX-3018243800 CDM 82438 CPT 301 RC outpatient 95 95 UNITED HEALTHCARE (COMMERCIAL) [3081199] UNITED HEALTHCARE 87726 [308119901] 58.9 percent of total billed charges 58.9 90.25 Technical (Hospital) Services Chloride CSF Body Fluid Urine PX-3018243800 CDM 82438 CPT 301 RC outpatient 95 95 CIGNA 62308 [3081051] CIGNA STATE OF WYOMING [308105107] 76 percent of total billed charges 58.9 90.25 Technical (Hospital) Services Chloride CSF Body Fluid Urine PX-3018243800 CDM 82438 CPT 301 RC outpatient 95 95 CIGNA 62308 [3081051] CIGNA 62308 [308105105] 76 percent of total billed charges 58.9 90.25 Technical (Hospital) Services Chloride CSF Body Fluid Urine PX-3018243800 CDM 82438 CPT 301 RC outpatient 95 95 MEDICA (COMMERCIAL) 94265 [3081118] MEDICA CLAIMS [308111801] 85.5 percent of total billed charges 58.9 90.25 Technical (Hospital) Services Chloride Urine PX-3018243600 CDM 82436 CPT 301 RC inpatient 61 61 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES EPO [308136803] 48.3 percent of total billed charges 37.82 57.95 Technical (Hospital) Services Chloride Urine PX-3018243600 CDM 82436 CPT 301 RC inpatient 61 61 HEALTHPARTNERS SX009 HEALTHPARTNERS 48.3 percent of total billed charges 37.82 57.95 Technical (Hospital) Services Chloride Urine PX-3018243600 CDM 82436 CPT 301 RC inpatient 61 61 MULTIPLAN INC 34080 [3081285] MULTIPLAN INC [308128501] 57.95 percent of total billed charges 37.82 57.95 Technical (Hospital) Services Chloride Urine PX-3018243600 CDM 82436 CPT 301 RC inpatient 61 61 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES HDHP [308136802] 48.3 percent of total billed charges 37.82 57.95 Technical (Hospital) Services Chloride Urine PX-3018243600 CDM 82436 CPT 301 RC inpatient 61 61 MEDICA (COMMERCIAL) 94265 [3081118] MEDICA CLAIMS [308111801] 54.9 percent of total billed charges 37.82 57.95 Technical (Hospital) Services Chloride Urine PX-3018243600 CDM 82436 CPT 301 RC inpatient 61 61 UNITED HEALTHCARE (COMMERCIAL) [3081199] UNITED HEALTHCARE 87726 [308119901] 37.82 percent of total billed charges 37.82 57.95 Technical (Hospital) Services Chloride Urine PX-3018243600 CDM 82436 CPT 301 RC inpatient 61 61 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES PPO [308136801] 48.3 percent of total billed charges 37.82 57.95 Technical (Hospital) Services Chloride Urine PX-3018243600 CDM 82436 CPT 301 RC inpatient 61 61 BLUE CROSS BLUE SHIELD WELLMARK SB889 [3081026] BCBS WYOMING [308102603] 57.95 percent of total billed charges 37.82 57.95 Technical (Hospital) Services Chloride Urine PX-3018243600 CDM 82436 CPT 301 RC inpatient 61 61 CIGNA 62308 [3081051] CIGNA 62308 [308105105] 48.3 percent of total billed charges 37.82 57.95 Technical (Hospital) Services Chloride Urine PX-3018243600 CDM 82436 CPT 301 RC inpatient 61 61 CIGNA 62308 [3081051] CIGNA STATE OF WYOMING [308105107] 48.3 percent of total billed charges 37.82 57.95 Technical (Hospital) Services Chloride Urine PX-3018243600 CDM 82436 CPT 301 RC outpatient 61 61 MEDICA (COMMERCIAL) 94265 [3081118] MEDICA CLAIMS [308111801] 54.9 percent of total billed charges 37.82 57.95 Technical (Hospital) Services Chloride Urine PX-3018243600 CDM 82436 CPT 301 RC outpatient 61 61 CIGNA 62308 [3081051] CIGNA 62308 [308105105] 48.8 percent of total billed charges 37.82 57.95 Technical (Hospital) Services Chloride Urine PX-3018243600 CDM 82436 CPT 301 RC outpatient 61 61 CIGNA 62308 [3081051] CIGNA STATE OF WYOMING [308105107] 48.8 percent of total billed charges 37.82 57.95 Technical (Hospital) Services Chloride Urine PX-3018243600 CDM 82436 CPT 301 RC outpatient 61 61 UNITED HEALTHCARE (COMMERCIAL) [3081199] UNITED HEALTHCARE 87726 [308119901] 37.82 percent of total billed charges 37.82 57.95 Technical (Hospital) Services Chloride Urine PX-3018243600 CDM 82436 CPT 301 RC outpatient 61 61 HEALTHPARTNERS SX009 HEALTHPARTNERS 48.8 percent of total billed charges 37.82 57.95 Technical (Hospital) Services Chloride Urine PX-3018243600 CDM 82436 CPT 301 RC outpatient 61 61 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES PPO [308136801] 48.8 percent of total billed charges 37.82 57.95 Technical (Hospital) Services Chloride Urine PX-3018243600 CDM 82436 CPT 301 RC outpatient 61 61 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES EPO [308136803] 48.8 percent of total billed charges 37.82 57.95 Technical (Hospital) Services Chloride Urine PX-3018243600 CDM 82436 CPT 301 RC outpatient 61 61 MULTIPLAN INC 34080 [3081285] MULTIPLAN INC [308128501] 57.95 percent of total billed charges 37.82 57.95 Technical (Hospital) Services Chloride Urine PX-3018243600 CDM 82436 CPT 301 RC outpatient 61 61 BLUE CROSS BLUE SHIELD WELLMARK SB889 [3081026] BCBS WYOMING [308102603] 57.95 percent of total billed charges 37.82 57.95 Technical (Hospital) Services Chloride Urine PX-3018243600 CDM 82436 CPT 301 RC outpatient 61 61 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES HDHP [308136802] 48.8 percent of total billed charges 37.82 57.95 Technical (Hospital) Services "Chloride, Serum" PX-3018243500 CDM 82435 CPT 301 RC outpatient 63 63 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES PPO [308136801] 50.4 percent of total billed charges 39.06 59.85 Technical (Hospital) Services "Chloride, Serum" PX-3018243500 CDM 82435 CPT 301 RC outpatient 63 63 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES EPO [308136803] 50.4 percent of total billed charges 39.06 59.85 Technical (Hospital) Services "Chloride, Serum" PX-3018243500 CDM 82435 CPT 301 RC outpatient 63 63 BLUE CROSS BLUE SHIELD WELLMARK SB889 [3081026] BCBS WYOMING [308102603] 59.85 percent of total billed charges 39.06 59.85 Technical (Hospital) Services "Chloride, Serum" PX-3018243500 CDM 82435 CPT 301 RC outpatient 63 63 MULTIPLAN INC 34080 [3081285] MULTIPLAN INC [308128501] 59.85 percent of total billed charges 39.06 59.85 Technical (Hospital) Services "Chloride, Serum" PX-3018243500 CDM 82435 CPT 301 RC outpatient 63 63 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES HDHP [308136802] 50.4 percent of total billed charges 39.06 59.85 Technical (Hospital) Services "Chloride, Serum" PX-3018243500 CDM 82435 CPT 301 RC outpatient 63 63 HEALTHPARTNERS SX009 HEALTHPARTNERS 50.4 percent of total billed charges 39.06 59.85 Technical (Hospital) Services "Chloride, Serum" PX-3018243500 CDM 82435 CPT 301 RC outpatient 63 63 UNITED HEALTHCARE (COMMERCIAL) [3081199] UNITED HEALTHCARE 87726 [308119901] 39.06 percent of total billed charges 39.06 59.85 Technical (Hospital) Services "Chloride, Serum" PX-3018243500 CDM 82435 CPT 301 RC outpatient 63 63 MEDICA (COMMERCIAL) 94265 [3081118] MEDICA CLAIMS [308111801] 56.7 percent of total billed charges 39.06 59.85 Technical (Hospital) Services "Chloride, Serum" PX-3018243500 CDM 82435 CPT 301 RC outpatient 63 63 CIGNA 62308 [3081051] CIGNA 62308 [308105105] 50.4 percent of total billed charges 39.06 59.85 Technical (Hospital) Services "Chloride, Serum" PX-3018243500 CDM 82435 CPT 301 RC outpatient 63 63 CIGNA 62308 [3081051] CIGNA STATE OF WYOMING [308105107] 50.4 percent of total billed charges 39.06 59.85 Technical (Hospital) Services "Chloride, Serum" PX-3018243500 CDM 82435 CPT 301 RC inpatient 63 63 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES EPO [308136803] 49.88 percent of total billed charges 39.06 59.85 Technical (Hospital) Services "Chloride, Serum" PX-3018243500 CDM 82435 CPT 301 RC inpatient 63 63 HEALTHPARTNERS SX009 HEALTHPARTNERS 49.88 percent of total billed charges 39.06 59.85 Technical (Hospital) Services "Chloride, Serum" PX-3018243500 CDM 82435 CPT 301 RC inpatient 63 63 MULTIPLAN INC 34080 [3081285] MULTIPLAN INC [308128501] 59.85 percent of total billed charges 39.06 59.85 Technical (Hospital) Services "Chloride, Serum" PX-3018243500 CDM 82435 CPT 301 RC inpatient 63 63 MEDICA (COMMERCIAL) 94265 [3081118] MEDICA CLAIMS [308111801] 56.7 percent of total billed charges 39.06 59.85 Technical (Hospital) Services "Chloride, Serum" PX-3018243500 CDM 82435 CPT 301 RC inpatient 63 63 UNITED HEALTHCARE (COMMERCIAL) [3081199] UNITED HEALTHCARE 87726 [308119901] 39.06 percent of total billed charges 39.06 59.85 Technical (Hospital) Services "Chloride, Serum" PX-3018243500 CDM 82435 CPT 301 RC inpatient 63 63 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES PPO [308136801] 49.88 percent of total billed charges 39.06 59.85 Technical (Hospital) Services "Chloride, Serum" PX-3018243500 CDM 82435 CPT 301 RC inpatient 63 63 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES HDHP [308136802] 49.88 percent of total billed charges 39.06 59.85 Technical (Hospital) Services "Chloride, Serum" PX-3018243500 CDM 82435 CPT 301 RC inpatient 63 63 BLUE CROSS BLUE SHIELD WELLMARK SB889 [3081026] BCBS WYOMING [308102603] 59.85 percent of total billed charges 39.06 59.85 Technical (Hospital) Services "Chloride, Serum" PX-3018243500 CDM 82435 CPT 301 RC inpatient 63 63 CIGNA 62308 [3081051] CIGNA 62308 [308105105] 49.88 percent of total billed charges 39.06 59.85 Technical (Hospital) Services "Chloride, Serum" PX-3018243500 CDM 82435 CPT 301 RC inpatient 63 63 CIGNA 62308 [3081051] CIGNA STATE OF WYOMING [308105107] 49.88 percent of total billed charges 39.06 59.85 Technical (Hospital) Services Ref Pth Related Peptide PX-3018239700 CDM 82397 CPT 301 RC inpatient 227 227 CIGNA 62308 [3081051] CIGNA 62308 [308105105] 179.74 percent of total billed charges 140.74 215.65 Technical (Hospital) Services Ref Pth Related Peptide PX-3018239700 CDM 82397 CPT 301 RC inpatient 227 227 CIGNA 62308 [3081051] CIGNA STATE OF WYOMING [308105107] 179.74 percent of total billed charges 140.74 215.65 Technical (Hospital) Services Ref Pth Related Peptide PX-3018239700 CDM 82397 CPT 301 RC inpatient 227 227 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES PPO [308136801] 179.74 percent of total billed charges 140.74 215.65 Technical (Hospital) Services Ref Pth Related Peptide PX-3018239700 CDM 82397 CPT 301 RC inpatient 227 227 UNITED HEALTHCARE (COMMERCIAL) [3081199] UNITED HEALTHCARE 87726 [308119901] 140.74 percent of total billed charges 140.74 215.65 Technical (Hospital) Services Ref Pth Related Peptide PX-3018239700 CDM 82397 CPT 301 RC inpatient 227 227 BLUE CROSS BLUE SHIELD WELLMARK SB889 [3081026] BCBS WYOMING [308102603] 215.65 percent of total billed charges 140.74 215.65 Technical (Hospital) Services Ref Pth Related Peptide PX-3018239700 CDM 82397 CPT 301 RC inpatient 227 227 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES HDHP [308136802] 179.74 percent of total billed charges 140.74 215.65 Technical (Hospital) Services Ref Pth Related Peptide PX-3018239700 CDM 82397 CPT 301 RC inpatient 227 227 HEALTHPARTNERS SX009 HEALTHPARTNERS 179.74 percent of total billed charges 140.74 215.65 Technical (Hospital) Services Ref Pth Related Peptide PX-3018239700 CDM 82397 CPT 301 RC inpatient 227 227 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES EPO [308136803] 179.74 percent of total billed charges 140.74 215.65 Technical (Hospital) Services Ref Pth Related Peptide PX-3018239700 CDM 82397 CPT 301 RC inpatient 227 227 MEDICA (COMMERCIAL) 94265 [3081118] MEDICA CLAIMS [308111801] 204.3 percent of total billed charges 140.74 215.65 Technical (Hospital) Services Ref Pth Related Peptide PX-3018239700 CDM 82397 CPT 301 RC inpatient 227 227 MULTIPLAN INC 34080 [3081285] MULTIPLAN INC [308128501] 215.65 percent of total billed charges 140.74 215.65 Technical (Hospital) Services Ref Pth Related Peptide PX-3018239700 CDM 82397 CPT 301 RC outpatient 227 227 UNITED HEALTHCARE (COMMERCIAL) [3081199] UNITED HEALTHCARE 87726 [308119901] 140.74 percent of total billed charges 140.74 215.65 Technical (Hospital) Services Ref Pth Related Peptide PX-3018239700 CDM 82397 CPT 301 RC outpatient 227 227 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES PPO [308136801] 181.6 percent of total billed charges 140.74 215.65 Technical (Hospital) Services Ref Pth Related Peptide PX-3018239700 CDM 82397 CPT 301 RC outpatient 227 227 HEALTHPARTNERS SX009 HEALTHPARTNERS 181.6 percent of total billed charges 140.74 215.65 Technical (Hospital) Services Ref Pth Related Peptide PX-3018239700 CDM 82397 CPT 301 RC outpatient 227 227 BLUE CROSS BLUE SHIELD WELLMARK SB889 [3081026] BCBS WYOMING [308102603] 215.65 percent of total billed charges 140.74 215.65 Technical (Hospital) Services Ref Pth Related Peptide PX-3018239700 CDM 82397 CPT 301 RC outpatient 227 227 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES EPO [308136803] 181.6 percent of total billed charges 140.74 215.65 Technical (Hospital) Services Ref Pth Related Peptide PX-3018239700 CDM 82397 CPT 301 RC outpatient 227 227 MULTIPLAN INC 34080 [3081285] MULTIPLAN INC [308128501] 215.65 percent of total billed charges 140.74 215.65 Technical (Hospital) Services Ref Pth Related Peptide PX-3018239700 CDM 82397 CPT 301 RC outpatient 227 227 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES HDHP [308136802] 181.6 percent of total billed charges 140.74 215.65 Technical (Hospital) Services Ref Pth Related Peptide PX-3018239700 CDM 82397 CPT 301 RC outpatient 227 227 CIGNA 62308 [3081051] CIGNA 62308 [308105105] 181.6 percent of total billed charges 140.74 215.65 Technical (Hospital) Services Ref Pth Related Peptide PX-3018239700 CDM 82397 CPT 301 RC outpatient 227 227 CIGNA 62308 [3081051] CIGNA STATE OF WYOMING [308105107] 181.6 percent of total billed charges 140.74 215.65 Technical (Hospital) Services Ref Pth Related Peptide PX-3018239700 CDM 82397 CPT 301 RC outpatient 227 227 MEDICA (COMMERCIAL) 94265 [3081118] MEDICA CLAIMS [308111801] 204.3 percent of total billed charges 140.74 215.65 Technical (Hospital) Services Ref Infliximab Ab PX-3018239702 CDM 82397 CPT 301 RC inpatient 182 182 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES PPO [308136801] 144.11 percent of total billed charges 112.84 172.9 Technical (Hospital) Services Ref Infliximab Ab PX-3018239702 CDM 82397 CPT 301 RC inpatient 182 182 UNITED HEALTHCARE (COMMERCIAL) [3081199] UNITED HEALTHCARE 87726 [308119901] 112.84 percent of total billed charges 112.84 172.9 Technical (Hospital) Services Ref Infliximab Ab PX-3018239702 CDM 82397 CPT 301 RC inpatient 182 182 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES HDHP [308136802] 144.11 percent of total billed charges 112.84 172.9 Technical (Hospital) Services Ref Infliximab Ab PX-3018239702 CDM 82397 CPT 301 RC inpatient 182 182 BLUE CROSS BLUE SHIELD WELLMARK SB889 [3081026] BCBS WYOMING [308102603] 172.9 percent of total billed charges 112.84 172.9 Technical (Hospital) Services Ref Infliximab Ab PX-3018239702 CDM 82397 CPT 301 RC inpatient 182 182 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES EPO [308136803] 144.11 percent of total billed charges 112.84 172.9 Technical (Hospital) Services Ref Infliximab Ab PX-3018239702 CDM 82397 CPT 301 RC inpatient 182 182 HEALTHPARTNERS SX009 HEALTHPARTNERS 144.11 percent of total billed charges 112.84 172.9 Technical (Hospital) Services Ref Infliximab Ab PX-3018239702 CDM 82397 CPT 301 RC inpatient 182 182 MULTIPLAN INC 34080 [3081285] MULTIPLAN INC [308128501] 172.9 percent of total billed charges 112.84 172.9 Technical (Hospital) Services Ref Infliximab Ab PX-3018239702 CDM 82397 CPT 301 RC inpatient 182 182 MEDICA (COMMERCIAL) 94265 [3081118] MEDICA CLAIMS [308111801] 163.8 percent of total billed charges 112.84 172.9 Technical (Hospital) Services Ref Infliximab Ab PX-3018239702 CDM 82397 CPT 301 RC inpatient 182 182 CIGNA 62308 [3081051] CIGNA 62308 [308105105] 144.11 percent of total billed charges 112.84 172.9 Technical (Hospital) Services Ref Infliximab Ab PX-3018239702 CDM 82397 CPT 301 RC inpatient 182 182 CIGNA 62308 [3081051] CIGNA STATE OF WYOMING [308105107] 144.11 percent of total billed charges 112.84 172.9 Technical (Hospital) Services Ref Infliximab Ab PX-3018239702 CDM 82397 CPT 301 RC outpatient 182 182 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES PPO [308136801] 145.6 percent of total billed charges 112.84 172.9 Technical (Hospital) Services Ref Infliximab Ab PX-3018239702 CDM 82397 CPT 301 RC outpatient 182 182 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES HDHP [308136802] 145.6 percent of total billed charges 112.84 172.9 Technical (Hospital) Services Ref Infliximab Ab PX-3018239702 CDM 82397 CPT 301 RC outpatient 182 182 BLUE CROSS BLUE SHIELD WELLMARK SB889 [3081026] BCBS WYOMING [308102603] 172.9 percent of total billed charges 112.84 172.9 Technical (Hospital) Services Ref Infliximab Ab PX-3018239702 CDM 82397 CPT 301 RC outpatient 182 182 MULTIPLAN INC 34080 [3081285] MULTIPLAN INC [308128501] 172.9 percent of total billed charges 112.84 172.9 Technical (Hospital) Services Ref Infliximab Ab PX-3018239702 CDM 82397 CPT 301 RC outpatient 182 182 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES EPO [308136803] 145.6 percent of total billed charges 112.84 172.9 Technical (Hospital) Services Ref Infliximab Ab PX-3018239702 CDM 82397 CPT 301 RC outpatient 182 182 UNITED HEALTHCARE (COMMERCIAL) [3081199] UNITED HEALTHCARE 87726 [308119901] 112.84 percent of total billed charges 112.84 172.9 Technical (Hospital) Services Ref Infliximab Ab PX-3018239702 CDM 82397 CPT 301 RC outpatient 182 182 HEALTHPARTNERS SX009 HEALTHPARTNERS 145.6 percent of total billed charges 112.84 172.9 Technical (Hospital) Services Ref Infliximab Ab PX-3018239702 CDM 82397 CPT 301 RC outpatient 182 182 MEDICA (COMMERCIAL) 94265 [3081118] MEDICA CLAIMS [308111801] 163.8 percent of total billed charges 112.84 172.9 Technical (Hospital) Services Ref Infliximab Ab PX-3018239702 CDM 82397 CPT 301 RC outpatient 182 182 CIGNA 62308 [3081051] CIGNA 62308 [308105105] 145.6 percent of total billed charges 112.84 172.9 Technical (Hospital) Services Ref Infliximab Ab PX-3018239702 CDM 82397 CPT 301 RC outpatient 182 182 CIGNA 62308 [3081051] CIGNA STATE OF WYOMING [308105107] 145.6 percent of total billed charges 112.84 172.9 Technical (Hospital) Services Ref Ceruloplasmin PX-3018239000 CDM 82390 CPT 301 RC inpatient 161 161 UNITED HEALTHCARE (COMMERCIAL) [3081199] UNITED HEALTHCARE 87726 [308119901] 99.82 percent of total billed charges 99.82 152.95 Technical (Hospital) Services Ref Ceruloplasmin PX-3018239000 CDM 82390 CPT 301 RC inpatient 161 161 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES PPO [308136801] 127.48 percent of total billed charges 99.82 152.95 Technical (Hospital) Services Ref Ceruloplasmin PX-3018239000 CDM 82390 CPT 301 RC inpatient 161 161 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES HDHP [308136802] 127.48 percent of total billed charges 99.82 152.95 Technical (Hospital) Services Ref Ceruloplasmin PX-3018239000 CDM 82390 CPT 301 RC inpatient 161 161 BLUE CROSS BLUE SHIELD WELLMARK SB889 [3081026] BCBS WYOMING [308102603] 152.95 percent of total billed charges 99.82 152.95 Technical (Hospital) Services Ref Ceruloplasmin PX-3018239000 CDM 82390 CPT 301 RC inpatient 161 161 MULTIPLAN INC 34080 [3081285] MULTIPLAN INC [308128501] 152.95 percent of total billed charges 99.82 152.95 Technical (Hospital) Services Ref Ceruloplasmin PX-3018239000 CDM 82390 CPT 301 RC inpatient 161 161 MEDICA (COMMERCIAL) 94265 [3081118] MEDICA CLAIMS [308111801] 144.9 percent of total billed charges 99.82 152.95 Technical (Hospital) Services Ref Ceruloplasmin PX-3018239000 CDM 82390 CPT 301 RC inpatient 161 161 HEALTHPARTNERS SX009 HEALTHPARTNERS 127.48 percent of total billed charges 99.82 152.95 Technical (Hospital) Services Ref Ceruloplasmin PX-3018239000 CDM 82390 CPT 301 RC inpatient 161 161 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES EPO [308136803] 127.48 percent of total billed charges 99.82 152.95 Technical (Hospital) Services Ref Ceruloplasmin PX-3018239000 CDM 82390 CPT 301 RC inpatient 161 161 CIGNA 62308 [3081051] CIGNA 62308 [308105105] 127.48 percent of total billed charges 99.82 152.95 Technical (Hospital) Services Ref Ceruloplasmin PX-3018239000 CDM 82390 CPT 301 RC inpatient 161 161 CIGNA 62308 [3081051] CIGNA STATE OF WYOMING [308105107] 127.48 percent of total billed charges 99.82 152.95 Technical (Hospital) Services Ref Ceruloplasmin PX-3018239000 CDM 82390 CPT 301 RC outpatient 161 161 UNITED HEALTHCARE (COMMERCIAL) [3081199] UNITED HEALTHCARE 87726 [308119901] 99.82 percent of total billed charges 99.82 152.95 Technical (Hospital) Services Ref Ceruloplasmin PX-3018239000 CDM 82390 CPT 301 RC outpatient 161 161 HEALTHPARTNERS SX009 HEALTHPARTNERS 128.8 percent of total billed charges 99.82 152.95 Technical (Hospital) Services Ref Ceruloplasmin PX-3018239000 CDM 82390 CPT 301 RC outpatient 161 161 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES PPO [308136801] 128.8 percent of total billed charges 99.82 152.95 Technical (Hospital) Services Ref Ceruloplasmin PX-3018239000 CDM 82390 CPT 301 RC outpatient 161 161 MULTIPLAN INC 34080 [3081285] MULTIPLAN INC [308128501] 152.95 percent of total billed charges 99.82 152.95 Technical (Hospital) Services Ref Ceruloplasmin PX-3018239000 CDM 82390 CPT 301 RC outpatient 161 161 BLUE CROSS BLUE SHIELD WELLMARK SB889 [3081026] BCBS WYOMING [308102603] 152.95 percent of total billed charges 99.82 152.95 Technical (Hospital) Services Ref Ceruloplasmin PX-3018239000 CDM 82390 CPT 301 RC outpatient 161 161 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES EPO [308136803] 128.8 percent of total billed charges 99.82 152.95 Technical (Hospital) Services Ref Ceruloplasmin PX-3018239000 CDM 82390 CPT 301 RC outpatient 161 161 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES HDHP [308136802] 128.8 percent of total billed charges 99.82 152.95 Technical (Hospital) Services Ref Ceruloplasmin PX-3018239000 CDM 82390 CPT 301 RC outpatient 161 161 MEDICA (COMMERCIAL) 94265 [3081118] MEDICA CLAIMS [308111801] 144.9 percent of total billed charges 99.82 152.95 Technical (Hospital) Services Ref Ceruloplasmin PX-3018239000 CDM 82390 CPT 301 RC outpatient 161 161 CIGNA 62308 [3081051] CIGNA 62308 [308105105] 128.8 percent of total billed charges 99.82 152.95 Technical (Hospital) Services Ref Ceruloplasmin PX-3018239000 CDM 82390 CPT 301 RC outpatient 161 161 CIGNA 62308 [3081051] CIGNA STATE OF WYOMING [308105107] 128.8 percent of total billed charges 99.82 152.95 Technical (Hospital) Services "Assay, Three Catecholamines" PX-3018238400 CDM 82384 CPT 301 RC outpatient 180 180 CIGNA 62308 [3081051] CIGNA 62308 [308105105] 144 percent of total billed charges 111.6 171 Technical (Hospital) Services "Assay, Three Catecholamines" PX-3018238400 CDM 82384 CPT 301 RC outpatient 180 180 CIGNA 62308 [3081051] CIGNA STATE OF WYOMING [308105107] 144 percent of total billed charges 111.6 171 Technical (Hospital) Services "Assay, Three Catecholamines" PX-3018238400 CDM 82384 CPT 301 RC outpatient 180 180 MEDICA (COMMERCIAL) 94265 [3081118] MEDICA CLAIMS [308111801] 162 percent of total billed charges 111.6 171 Technical (Hospital) Services "Assay, Three Catecholamines" PX-3018238400 CDM 82384 CPT 301 RC outpatient 180 180 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES PPO [308136801] 144 percent of total billed charges 111.6 171 Technical (Hospital) Services "Assay, Three Catecholamines" PX-3018238400 CDM 82384 CPT 301 RC outpatient 180 180 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES EPO [308136803] 144 percent of total billed charges 111.6 171 Technical (Hospital) Services "Assay, Three Catecholamines" PX-3018238400 CDM 82384 CPT 301 RC outpatient 180 180 BLUE CROSS BLUE SHIELD WELLMARK SB889 [3081026] BCBS WYOMING [308102603] 171 percent of total billed charges 111.6 171 Technical (Hospital) Services "Assay, Three Catecholamines" PX-3018238400 CDM 82384 CPT 301 RC outpatient 180 180 MULTIPLAN INC 34080 [3081285] MULTIPLAN INC [308128501] 171 percent of total billed charges 111.6 171 Technical (Hospital) Services "Assay, Three Catecholamines" PX-3018238400 CDM 82384 CPT 301 RC outpatient 180 180 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES HDHP [308136802] 144 percent of total billed charges 111.6 171 Technical (Hospital) Services "Assay, Three Catecholamines" PX-3018238400 CDM 82384 CPT 301 RC outpatient 180 180 UNITED HEALTHCARE (COMMERCIAL) [3081199] UNITED HEALTHCARE 87726 [308119901] 111.6 percent of total billed charges 111.6 171 Technical (Hospital) Services "Assay, Three Catecholamines" PX-3018238400 CDM 82384 CPT 301 RC outpatient 180 180 HEALTHPARTNERS SX009 HEALTHPARTNERS 144 percent of total billed charges 111.6 171 Technical (Hospital) Services "Assay, Three Catecholamines" PX-3018238400 CDM 82384 CPT 301 RC inpatient 180 180 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES HDHP [308136802] 142.52 percent of total billed charges 111.6 171 Technical (Hospital) Services "Assay, Three Catecholamines" PX-3018238400 CDM 82384 CPT 301 RC inpatient 180 180 BLUE CROSS BLUE SHIELD WELLMARK SB889 [3081026] BCBS WYOMING [308102603] 171 percent of total billed charges 111.6 171 Technical (Hospital) Services "Assay, Three Catecholamines" PX-3018238400 CDM 82384 CPT 301 RC inpatient 180 180 UNITED HEALTHCARE (COMMERCIAL) [3081199] UNITED HEALTHCARE 87726 [308119901] 111.6 percent of total billed charges 111.6 171 Technical (Hospital) Services "Assay, Three Catecholamines" PX-3018238400 CDM 82384 CPT 301 RC inpatient 180 180 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES PPO [308136801] 142.52 percent of total billed charges 111.6 171 Technical (Hospital) Services "Assay, Three Catecholamines" PX-3018238400 CDM 82384 CPT 301 RC inpatient 180 180 MULTIPLAN INC 34080 [3081285] MULTIPLAN INC [308128501] 171 percent of total billed charges 111.6 171 Technical (Hospital) Services "Assay, Three Catecholamines" PX-3018238400 CDM 82384 CPT 301 RC inpatient 180 180 MEDICA (COMMERCIAL) 94265 [3081118] MEDICA CLAIMS [308111801] 162 percent of total billed charges 111.6 171 Technical (Hospital) Services "Assay, Three Catecholamines" PX-3018238400 CDM 82384 CPT 301 RC inpatient 180 180 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES EPO [308136803] 142.52 percent of total billed charges 111.6 171 Technical (Hospital) Services "Assay, Three Catecholamines" PX-3018238400 CDM 82384 CPT 301 RC inpatient 180 180 HEALTHPARTNERS SX009 HEALTHPARTNERS 142.52 percent of total billed charges 111.6 171 Technical (Hospital) Services "Assay, Three Catecholamines" PX-3018238400 CDM 82384 CPT 301 RC inpatient 180 180 CIGNA 62308 [3081051] CIGNA 62308 [308105105] 142.52 percent of total billed charges 111.6 171 Technical (Hospital) Services "Assay, Three Catecholamines" PX-3018238400 CDM 82384 CPT 301 RC inpatient 180 180 CIGNA 62308 [3081051] CIGNA STATE OF WYOMING [308105107] 142.52 percent of total billed charges 111.6 171 Technical (Hospital) Services Ref Catecholamine Fract Free Urine PX-3018238402 CDM 82384 CPT 301 RC outpatient 180 180 CIGNA 62308 [3081051] CIGNA 62308 [308105105] 144 percent of total billed charges 111.6 171 Technical (Hospital) Services Ref Catecholamine Fract Free Urine PX-3018238402 CDM 82384 CPT 301 RC outpatient 180 180 CIGNA 62308 [3081051] CIGNA STATE OF WYOMING [308105107] 144 percent of total billed charges 111.6 171 Technical (Hospital) Services Ref Catecholamine Fract Free Urine PX-3018238402 CDM 82384 CPT 301 RC outpatient 180 180 MEDICA (COMMERCIAL) 94265 [3081118] MEDICA CLAIMS [308111801] 162 percent of total billed charges 111.6 171 Technical (Hospital) Services Ref Catecholamine Fract Free Urine PX-3018238402 CDM 82384 CPT 301 RC outpatient 180 180 HEALTHPARTNERS SX009 HEALTHPARTNERS 144 percent of total billed charges 111.6 171 Technical (Hospital) Services Ref Catecholamine Fract Free Urine PX-3018238402 CDM 82384 CPT 301 RC outpatient 180 180 UNITED HEALTHCARE (COMMERCIAL) [3081199] UNITED HEALTHCARE 87726 [308119901] 111.6 percent of total billed charges 111.6 171 Technical (Hospital) Services Ref Catecholamine Fract Free Urine PX-3018238402 CDM 82384 CPT 301 RC outpatient 180 180 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES EPO [308136803] 144 percent of total billed charges 111.6 171 Technical (Hospital) Services Ref Catecholamine Fract Free Urine PX-3018238402 CDM 82384 CPT 301 RC outpatient 180 180 BLUE CROSS BLUE SHIELD WELLMARK SB889 [3081026] BCBS WYOMING [308102603] 171 percent of total billed charges 111.6 171 Technical (Hospital) Services Ref Catecholamine Fract Free Urine PX-3018238402 CDM 82384 CPT 301 RC outpatient 180 180 MULTIPLAN INC 34080 [3081285] MULTIPLAN INC [308128501] 171 percent of total billed charges 111.6 171 Technical (Hospital) Services Ref Catecholamine Fract Free Urine PX-3018238402 CDM 82384 CPT 301 RC outpatient 180 180 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES HDHP [308136802] 144 percent of total billed charges 111.6 171 Technical (Hospital) Services Ref Catecholamine Fract Free Urine PX-3018238402 CDM 82384 CPT 301 RC outpatient 180 180 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES PPO [308136801] 144 percent of total billed charges 111.6 171 Technical (Hospital) Services Ref Catecholamine Fract Free Urine PX-3018238402 CDM 82384 CPT 301 RC inpatient 180 180 CIGNA 62308 [3081051] CIGNA 62308 [308105105] 142.52 percent of total billed charges 111.6 171 Technical (Hospital) Services Ref Catecholamine Fract Free Urine PX-3018238402 CDM 82384 CPT 301 RC inpatient 180 180 CIGNA 62308 [3081051] CIGNA STATE OF WYOMING [308105107] 142.52 percent of total billed charges 111.6 171 Technical (Hospital) Services Ref Catecholamine Fract Free Urine PX-3018238402 CDM 82384 CPT 301 RC inpatient 180 180 HEALTHPARTNERS SX009 HEALTHPARTNERS 142.52 percent of total billed charges 111.6 171 Technical (Hospital) Services Ref Catecholamine Fract Free Urine PX-3018238402 CDM 82384 CPT 301 RC inpatient 180 180 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES EPO [308136803] 142.52 percent of total billed charges 111.6 171 Technical (Hospital) Services Ref Catecholamine Fract Free Urine PX-3018238402 CDM 82384 CPT 301 RC inpatient 180 180 MULTIPLAN INC 34080 [3081285] MULTIPLAN INC [308128501] 171 percent of total billed charges 111.6 171 Technical (Hospital) Services Ref Catecholamine Fract Free Urine PX-3018238402 CDM 82384 CPT 301 RC inpatient 180 180 MEDICA (COMMERCIAL) 94265 [3081118] MEDICA CLAIMS [308111801] 162 percent of total billed charges 111.6 171 Technical (Hospital) Services Ref Catecholamine Fract Free Urine PX-3018238402 CDM 82384 CPT 301 RC inpatient 180 180 UNITED HEALTHCARE (COMMERCIAL) [3081199] UNITED HEALTHCARE 87726 [308119901] 111.6 percent of total billed charges 111.6 171 Technical (Hospital) Services Ref Catecholamine Fract Free Urine PX-3018238402 CDM 82384 CPT 301 RC inpatient 180 180 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES PPO [308136801] 142.52 percent of total billed charges 111.6 171 Technical (Hospital) Services Ref Catecholamine Fract Free Urine PX-3018238402 CDM 82384 CPT 301 RC inpatient 180 180 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES HDHP [308136802] 142.52 percent of total billed charges 111.6 171 Technical (Hospital) Services Ref Catecholamine Fract Free Urine PX-3018238402 CDM 82384 CPT 301 RC inpatient 180 180 BLUE CROSS BLUE SHIELD WELLMARK SB889 [3081026] BCBS WYOMING [308102603] 171 percent of total billed charges 111.6 171 Technical (Hospital) Services Ref Carnitine P S PX-3018237900 CDM 82379 CPT 301 RC inpatient 112 112 CIGNA 62308 [3081051] CIGNA 62308 [308105105] 88.68 percent of total billed charges 69.44 106.4 Technical (Hospital) Services Ref Carnitine P S PX-3018237900 CDM 82379 CPT 301 RC inpatient 112 112 CIGNA 62308 [3081051] CIGNA STATE OF WYOMING [308105107] 88.68 percent of total billed charges 69.44 106.4 Technical (Hospital) Services Ref Carnitine P S PX-3018237900 CDM 82379 CPT 301 RC inpatient 112 112 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES EPO [308136803] 88.68 percent of total billed charges 69.44 106.4 Technical (Hospital) Services Ref Carnitine P S PX-3018237900 CDM 82379 CPT 301 RC inpatient 112 112 HEALTHPARTNERS SX009 HEALTHPARTNERS 88.68 percent of total billed charges 69.44 106.4 Technical (Hospital) Services Ref Carnitine P S PX-3018237900 CDM 82379 CPT 301 RC inpatient 112 112 MULTIPLAN INC 34080 [3081285] MULTIPLAN INC [308128501] 106.4 percent of total billed charges 69.44 106.4 Technical (Hospital) Services Ref Carnitine P S PX-3018237900 CDM 82379 CPT 301 RC inpatient 112 112 MEDICA (COMMERCIAL) 94265 [3081118] MEDICA CLAIMS [308111801] 100.8 percent of total billed charges 69.44 106.4 Technical (Hospital) Services Ref Carnitine P S PX-3018237900 CDM 82379 CPT 301 RC inpatient 112 112 UNITED HEALTHCARE (COMMERCIAL) [3081199] UNITED HEALTHCARE 87726 [308119901] 69.44 percent of total billed charges 69.44 106.4 Technical (Hospital) Services Ref Carnitine P S PX-3018237900 CDM 82379 CPT 301 RC inpatient 112 112 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES PPO [308136801] 88.68 percent of total billed charges 69.44 106.4 Technical (Hospital) Services Ref Carnitine P S PX-3018237900 CDM 82379 CPT 301 RC inpatient 112 112 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES HDHP [308136802] 88.68 percent of total billed charges 69.44 106.4 Technical (Hospital) Services Ref Carnitine P S PX-3018237900 CDM 82379 CPT 301 RC inpatient 112 112 BLUE CROSS BLUE SHIELD WELLMARK SB889 [3081026] BCBS WYOMING [308102603] 106.4 percent of total billed charges 69.44 106.4 Technical (Hospital) Services Ref Carnitine P S PX-3018237900 CDM 82379 CPT 301 RC outpatient 112 112 UNITED HEALTHCARE (COMMERCIAL) [3081199] UNITED HEALTHCARE 87726 [308119901] 69.44 percent of total billed charges 69.44 106.4 Technical (Hospital) Services Ref Carnitine P S PX-3018237900 CDM 82379 CPT 301 RC outpatient 112 112 HEALTHPARTNERS SX009 HEALTHPARTNERS 89.6 percent of total billed charges 69.44 106.4 Technical (Hospital) Services Ref Carnitine P S PX-3018237900 CDM 82379 CPT 301 RC outpatient 112 112 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES PPO [308136801] 89.6 percent of total billed charges 69.44 106.4 Technical (Hospital) Services Ref Carnitine P S PX-3018237900 CDM 82379 CPT 301 RC outpatient 112 112 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES HDHP [308136802] 89.6 percent of total billed charges 69.44 106.4 Technical (Hospital) Services Ref Carnitine P S PX-3018237900 CDM 82379 CPT 301 RC outpatient 112 112 BLUE CROSS BLUE SHIELD WELLMARK SB889 [3081026] BCBS WYOMING [308102603] 106.4 percent of total billed charges 69.44 106.4 Technical (Hospital) Services Ref Carnitine P S PX-3018237900 CDM 82379 CPT 301 RC outpatient 112 112 MULTIPLAN INC 34080 [3081285] MULTIPLAN INC [308128501] 106.4 percent of total billed charges 69.44 106.4 Technical (Hospital) Services Ref Carnitine P S PX-3018237900 CDM 82379 CPT 301 RC outpatient 112 112 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES EPO [308136803] 89.6 percent of total billed charges 69.44 106.4 Technical (Hospital) Services Ref Carnitine P S PX-3018237900 CDM 82379 CPT 301 RC outpatient 112 112 CIGNA 62308 [3081051] CIGNA 62308 [308105105] 89.6 percent of total billed charges 69.44 106.4 Technical (Hospital) Services Ref Carnitine P S PX-3018237900 CDM 82379 CPT 301 RC outpatient 112 112 CIGNA 62308 [3081051] CIGNA STATE OF WYOMING [308105107] 89.6 percent of total billed charges 69.44 106.4 Technical (Hospital) Services Ref Carnitine P S PX-3018237900 CDM 82379 CPT 301 RC outpatient 112 112 MEDICA (COMMERCIAL) 94265 [3081118] MEDICA CLAIMS [308111801] 100.8 percent of total billed charges 69.44 106.4 Technical (Hospital) Services Carcinoembryonic Antigen PX-3018237800 CDM 82378 CPT 301 RC inpatient 256 256 MEDICA (COMMERCIAL) 94265 [3081118] MEDICA CLAIMS [308111801] 230.4 percent of total billed charges 158.72 243.2 Technical (Hospital) Services Carcinoembryonic Antigen PX-3018237800 CDM 82378 CPT 301 RC inpatient 256 256 MULTIPLAN INC 34080 [3081285] MULTIPLAN INC [308128501] 243.2 percent of total billed charges 158.72 243.2 Technical (Hospital) Services Carcinoembryonic Antigen PX-3018237800 CDM 82378 CPT 301 RC inpatient 256 256 HEALTHPARTNERS SX009 HEALTHPARTNERS 202.7 percent of total billed charges 158.72 243.2 Technical (Hospital) Services Carcinoembryonic Antigen PX-3018237800 CDM 82378 CPT 301 RC inpatient 256 256 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES EPO [308136803] 202.7 percent of total billed charges 158.72 243.2 Technical (Hospital) Services Carcinoembryonic Antigen PX-3018237800 CDM 82378 CPT 301 RC inpatient 256 256 BLUE CROSS BLUE SHIELD WELLMARK SB889 [3081026] BCBS WYOMING [308102603] 243.2 percent of total billed charges 158.72 243.2 Technical (Hospital) Services Carcinoembryonic Antigen PX-3018237800 CDM 82378 CPT 301 RC inpatient 256 256 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES HDHP [308136802] 202.7 percent of total billed charges 158.72 243.2 Technical (Hospital) Services Carcinoembryonic Antigen PX-3018237800 CDM 82378 CPT 301 RC inpatient 256 256 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES PPO [308136801] 202.7 percent of total billed charges 158.72 243.2 Technical (Hospital) Services Carcinoembryonic Antigen PX-3018237800 CDM 82378 CPT 301 RC inpatient 256 256 UNITED HEALTHCARE (COMMERCIAL) [3081199] UNITED HEALTHCARE 87726 [308119901] 158.72 percent of total billed charges 158.72 243.2 Technical (Hospital) Services Carcinoembryonic Antigen PX-3018237800 CDM 82378 CPT 301 RC inpatient 256 256 CIGNA 62308 [3081051] CIGNA 62308 [308105105] 202.7 percent of total billed charges 158.72 243.2 Technical (Hospital) Services Carcinoembryonic Antigen PX-3018237800 CDM 82378 CPT 301 RC inpatient 256 256 CIGNA 62308 [3081051] CIGNA STATE OF WYOMING [308105107] 202.7 percent of total billed charges 158.72 243.2 Technical (Hospital) Services Carcinoembryonic Antigen PX-3018237800 CDM 82378 CPT 301 RC outpatient 256 256 CIGNA 62308 [3081051] CIGNA 62308 [308105105] 204.8 percent of total billed charges 158.72 243.2 Technical (Hospital) Services Carcinoembryonic Antigen PX-3018237800 CDM 82378 CPT 301 RC outpatient 256 256 CIGNA 62308 [3081051] CIGNA STATE OF WYOMING [308105107] 204.8 percent of total billed charges 158.72 243.2 Technical (Hospital) Services Carcinoembryonic Antigen PX-3018237800 CDM 82378 CPT 301 RC outpatient 256 256 MEDICA (COMMERCIAL) 94265 [3081118] MEDICA CLAIMS [308111801] 230.4 percent of total billed charges 158.72 243.2 Technical (Hospital) Services Carcinoembryonic Antigen PX-3018237800 CDM 82378 CPT 301 RC outpatient 256 256 HEALTHPARTNERS SX009 HEALTHPARTNERS 204.8 percent of total billed charges 158.72 243.2 Technical (Hospital) Services Carcinoembryonic Antigen PX-3018237800 CDM 82378 CPT 301 RC outpatient 256 256 UNITED HEALTHCARE (COMMERCIAL) [3081199] UNITED HEALTHCARE 87726 [308119901] 158.72 percent of total billed charges 158.72 243.2 Technical (Hospital) Services Carcinoembryonic Antigen PX-3018237800 CDM 82378 CPT 301 RC outpatient 256 256 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES HDHP [308136802] 204.8 percent of total billed charges 158.72 243.2 Technical (Hospital) Services Carcinoembryonic Antigen PX-3018237800 CDM 82378 CPT 301 RC outpatient 256 256 MULTIPLAN INC 34080 [3081285] MULTIPLAN INC [308128501] 243.2 percent of total billed charges 158.72 243.2 Technical (Hospital) Services Carcinoembryonic Antigen PX-3018237800 CDM 82378 CPT 301 RC outpatient 256 256 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES EPO [308136803] 204.8 percent of total billed charges 158.72 243.2 Technical (Hospital) Services Carcinoembryonic Antigen PX-3018237800 CDM 82378 CPT 301 RC outpatient 256 256 BLUE CROSS BLUE SHIELD WELLMARK SB889 [3081026] BCBS WYOMING [308102603] 243.2 percent of total billed charges 158.72 243.2 Technical (Hospital) Services Carcinoembryonic Antigen PX-3018237800 CDM 82378 CPT 301 RC outpatient 256 256 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES PPO [308136801] 204.8 percent of total billed charges 158.72 243.2 Technical (Hospital) Services Carboxyhemoglobin Quant PX-3018237501 CDM 82375 CPT 301 RC inpatient 153 153 CIGNA 62308 [3081051] CIGNA 62308 [308105105] 121.15 percent of total billed charges 94.86 145.35 Technical (Hospital) Services Carboxyhemoglobin Quant PX-3018237501 CDM 82375 CPT 301 RC inpatient 153 153 CIGNA 62308 [3081051] CIGNA STATE OF WYOMING [308105107] 121.15 percent of total billed charges 94.86 145.35 Technical (Hospital) Services Carboxyhemoglobin Quant PX-3018237501 CDM 82375 CPT 301 RC inpatient 153 153 MULTIPLAN INC 34080 [3081285] MULTIPLAN INC [308128501] 145.35 percent of total billed charges 94.86 145.35 Technical (Hospital) Services Carboxyhemoglobin Quant PX-3018237501 CDM 82375 CPT 301 RC inpatient 153 153 MEDICA (COMMERCIAL) 94265 [3081118] MEDICA CLAIMS [308111801] 137.7 percent of total billed charges 94.86 145.35 Technical (Hospital) Services Carboxyhemoglobin Quant PX-3018237501 CDM 82375 CPT 301 RC inpatient 153 153 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES EPO [308136803] 121.15 percent of total billed charges 94.86 145.35 Technical (Hospital) Services Carboxyhemoglobin Quant PX-3018237501 CDM 82375 CPT 301 RC inpatient 153 153 HEALTHPARTNERS SX009 HEALTHPARTNERS 121.15 percent of total billed charges 94.86 145.35 Technical (Hospital) Services Carboxyhemoglobin Quant PX-3018237501 CDM 82375 CPT 301 RC inpatient 153 153 BLUE CROSS BLUE SHIELD WELLMARK SB889 [3081026] BCBS WYOMING [308102603] 145.35 percent of total billed charges 94.86 145.35 Technical (Hospital) Services Carboxyhemoglobin Quant PX-3018237501 CDM 82375 CPT 301 RC inpatient 153 153 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES HDHP [308136802] 121.15 percent of total billed charges 94.86 145.35 Technical (Hospital) Services Carboxyhemoglobin Quant PX-3018237501 CDM 82375 CPT 301 RC inpatient 153 153 UNITED HEALTHCARE (COMMERCIAL) [3081199] UNITED HEALTHCARE 87726 [308119901] 94.86 percent of total billed charges 94.86 145.35 Technical (Hospital) Services Carboxyhemoglobin Quant PX-3018237501 CDM 82375 CPT 301 RC inpatient 153 153 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES PPO [308136801] 121.15 percent of total billed charges 94.86 145.35 Technical (Hospital) Services Carboxyhemoglobin Quant PX-3018237501 CDM 82375 CPT 301 RC outpatient 153 153 MEDICA (COMMERCIAL) 94265 [3081118] MEDICA CLAIMS [308111801] 137.7 percent of total billed charges 94.86 145.35 Technical (Hospital) Services Carboxyhemoglobin Quant PX-3018237501 CDM 82375 CPT 301 RC outpatient 153 153 CIGNA 62308 [3081051] CIGNA 62308 [308105105] 122.4 percent of total billed charges 94.86 145.35 Technical (Hospital) Services Carboxyhemoglobin Quant PX-3018237501 CDM 82375 CPT 301 RC outpatient 153 153 CIGNA 62308 [3081051] CIGNA STATE OF WYOMING [308105107] 122.4 percent of total billed charges 94.86 145.35 Technical (Hospital) Services Carboxyhemoglobin Quant PX-3018237501 CDM 82375 CPT 301 RC outpatient 153 153 BLUE CROSS BLUE SHIELD WELLMARK SB889 [3081026] BCBS WYOMING [308102603] 145.35 percent of total billed charges 94.86 145.35 Technical (Hospital) Services Carboxyhemoglobin Quant PX-3018237501 CDM 82375 CPT 301 RC outpatient 153 153 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES EPO [308136803] 122.4 percent of total billed charges 94.86 145.35 Technical (Hospital) Services Carboxyhemoglobin Quant PX-3018237501 CDM 82375 CPT 301 RC outpatient 153 153 MULTIPLAN INC 34080 [3081285] MULTIPLAN INC [308128501] 145.35 percent of total billed charges 94.86 145.35 Technical (Hospital) Services Carboxyhemoglobin Quant PX-3018237501 CDM 82375 CPT 301 RC outpatient 153 153 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES HDHP [308136802] 122.4 percent of total billed charges 94.86 145.35 Technical (Hospital) Services Carboxyhemoglobin Quant PX-3018237501 CDM 82375 CPT 301 RC outpatient 153 153 HEALTHPARTNERS SX009 HEALTHPARTNERS 122.4 percent of total billed charges 94.86 145.35 Technical (Hospital) Services Carboxyhemoglobin Quant PX-3018237501 CDM 82375 CPT 301 RC outpatient 153 153 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES PPO [308136801] 122.4 percent of total billed charges 94.86 145.35 Technical (Hospital) Services Carboxyhemoglobin Quant PX-3018237501 CDM 82375 CPT 301 RC outpatient 153 153 UNITED HEALTHCARE (COMMERCIAL) [3081199] UNITED HEALTHCARE 87726 [308119901] 94.86 percent of total billed charges 94.86 145.35 Technical (Hospital) Services Carbon Dioxide Bicarb PX-3018237400 CDM 82374 CPT 301 RC outpatient 61 61 UNITED HEALTHCARE (COMMERCIAL) [3081199] UNITED HEALTHCARE 87726 [308119901] 37.82 percent of total billed charges 37.82 57.95 Technical (Hospital) Services Carbon Dioxide Bicarb PX-3018237400 CDM 82374 CPT 301 RC outpatient 61 61 HEALTHPARTNERS SX009 HEALTHPARTNERS 48.8 percent of total billed charges 37.82 57.95 Technical (Hospital) Services Carbon Dioxide Bicarb PX-3018237400 CDM 82374 CPT 301 RC outpatient 61 61 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES HDHP [308136802] 48.8 percent of total billed charges 37.82 57.95 Technical (Hospital) Services Carbon Dioxide Bicarb PX-3018237400 CDM 82374 CPT 301 RC outpatient 61 61 BLUE CROSS BLUE SHIELD WELLMARK SB889 [3081026] BCBS WYOMING [308102603] 57.95 percent of total billed charges 37.82 57.95 Technical (Hospital) Services Carbon Dioxide Bicarb PX-3018237400 CDM 82374 CPT 301 RC outpatient 61 61 MULTIPLAN INC 34080 [3081285] MULTIPLAN INC [308128501] 57.95 percent of total billed charges 37.82 57.95 Technical (Hospital) Services Carbon Dioxide Bicarb PX-3018237400 CDM 82374 CPT 301 RC outpatient 61 61 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES EPO [308136803] 48.8 percent of total billed charges 37.82 57.95 Technical (Hospital) Services Carbon Dioxide Bicarb PX-3018237400 CDM 82374 CPT 301 RC outpatient 61 61 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES PPO [308136801] 48.8 percent of total billed charges 37.82 57.95 Technical (Hospital) Services Carbon Dioxide Bicarb PX-3018237400 CDM 82374 CPT 301 RC outpatient 61 61 MEDICA (COMMERCIAL) 94265 [3081118] MEDICA CLAIMS [308111801] 54.9 percent of total billed charges 37.82 57.95 Technical (Hospital) Services Carbon Dioxide Bicarb PX-3018237400 CDM 82374 CPT 301 RC outpatient 61 61 CIGNA 62308 [3081051] CIGNA 62308 [308105105] 48.8 percent of total billed charges 37.82 57.95 Technical (Hospital) Services Carbon Dioxide Bicarb PX-3018237400 CDM 82374 CPT 301 RC outpatient 61 61 CIGNA 62308 [3081051] CIGNA STATE OF WYOMING [308105107] 48.8 percent of total billed charges 37.82 57.95 Technical (Hospital) Services Carbon Dioxide Bicarb PX-3018237400 CDM 82374 CPT 301 RC inpatient 61 61 MULTIPLAN INC 34080 [3081285] MULTIPLAN INC [308128501] 57.95 percent of total billed charges 37.82 57.95 Technical (Hospital) Services Carbon Dioxide Bicarb PX-3018237400 CDM 82374 CPT 301 RC inpatient 61 61 MEDICA (COMMERCIAL) 94265 [3081118] MEDICA CLAIMS [308111801] 54.9 percent of total billed charges 37.82 57.95 Technical (Hospital) Services Carbon Dioxide Bicarb PX-3018237400 CDM 82374 CPT 301 RC inpatient 61 61 HEALTHPARTNERS SX009 HEALTHPARTNERS 48.3 percent of total billed charges 37.82 57.95 Technical (Hospital) Services Carbon Dioxide Bicarb PX-3018237400 CDM 82374 CPT 301 RC inpatient 61 61 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES EPO [308136803] 48.3 percent of total billed charges 37.82 57.95 Technical (Hospital) Services Carbon Dioxide Bicarb PX-3018237400 CDM 82374 CPT 301 RC inpatient 61 61 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES PPO [308136801] 48.3 percent of total billed charges 37.82 57.95 Technical (Hospital) Services Carbon Dioxide Bicarb PX-3018237400 CDM 82374 CPT 301 RC inpatient 61 61 UNITED HEALTHCARE (COMMERCIAL) [3081199] UNITED HEALTHCARE 87726 [308119901] 37.82 percent of total billed charges 37.82 57.95 Technical (Hospital) Services Carbon Dioxide Bicarb PX-3018237400 CDM 82374 CPT 301 RC inpatient 61 61 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES HDHP [308136802] 48.3 percent of total billed charges 37.82 57.95 Technical (Hospital) Services Carbon Dioxide Bicarb PX-3018237400 CDM 82374 CPT 301 RC inpatient 61 61 BLUE CROSS BLUE SHIELD WELLMARK SB889 [3081026] BCBS WYOMING [308102603] 57.95 percent of total billed charges 37.82 57.95 Technical (Hospital) Services Carbon Dioxide Bicarb PX-3018237400 CDM 82374 CPT 301 RC inpatient 61 61 CIGNA 62308 [3081051] CIGNA 62308 [308105105] 48.3 percent of total billed charges 37.82 57.95 Technical (Hospital) Services Carbon Dioxide Bicarb PX-3018237400 CDM 82374 CPT 301 RC inpatient 61 61 CIGNA 62308 [3081051] CIGNA STATE OF WYOMING [308105107] 48.3 percent of total billed charges 37.82 57.95 Technical (Hospital) Services Ref Calculus Qual Anal Infrd Spect PX-3018236501 CDM 82365 CPT 301 RC inpatient 151 151 CIGNA 62308 [3081051] CIGNA 62308 [308105105] 119.56 percent of total billed charges 93.62 143.45 Technical (Hospital) Services Ref Calculus Qual Anal Infrd Spect PX-3018236501 CDM 82365 CPT 301 RC inpatient 151 151 CIGNA 62308 [3081051] CIGNA STATE OF WYOMING [308105107] 119.56 percent of total billed charges 93.62 143.45 Technical (Hospital) Services Ref Calculus Qual Anal Infrd Spect PX-3018236501 CDM 82365 CPT 301 RC inpatient 151 151 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES PPO [308136801] 119.56 percent of total billed charges 93.62 143.45 Technical (Hospital) Services Ref Calculus Qual Anal Infrd Spect PX-3018236501 CDM 82365 CPT 301 RC inpatient 151 151 UNITED HEALTHCARE (COMMERCIAL) [3081199] UNITED HEALTHCARE 87726 [308119901] 93.62 percent of total billed charges 93.62 143.45 Technical (Hospital) Services Ref Calculus Qual Anal Infrd Spect PX-3018236501 CDM 82365 CPT 301 RC inpatient 151 151 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES HDHP [308136802] 119.56 percent of total billed charges 93.62 143.45 Technical (Hospital) Services Ref Calculus Qual Anal Infrd Spect PX-3018236501 CDM 82365 CPT 301 RC inpatient 151 151 BLUE CROSS BLUE SHIELD WELLMARK SB889 [3081026] BCBS WYOMING [308102603] 143.45 percent of total billed charges 93.62 143.45 Technical (Hospital) Services Ref Calculus Qual Anal Infrd Spect PX-3018236501 CDM 82365 CPT 301 RC inpatient 151 151 HEALTHPARTNERS SX009 HEALTHPARTNERS 119.56 percent of total billed charges 93.62 143.45 Technical (Hospital) Services Ref Calculus Qual Anal Infrd Spect PX-3018236501 CDM 82365 CPT 301 RC inpatient 151 151 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES EPO [308136803] 119.56 percent of total billed charges 93.62 143.45 Technical (Hospital) Services Ref Calculus Qual Anal Infrd Spect PX-3018236501 CDM 82365 CPT 301 RC inpatient 151 151 MULTIPLAN INC 34080 [3081285] MULTIPLAN INC [308128501] 143.45 percent of total billed charges 93.62 143.45 Technical (Hospital) Services Ref Calculus Qual Anal Infrd Spect PX-3018236501 CDM 82365 CPT 301 RC inpatient 151 151 MEDICA (COMMERCIAL) 94265 [3081118] MEDICA CLAIMS [308111801] 135.9 percent of total billed charges 93.62 143.45 Technical (Hospital) Services Ref Calculus Qual Anal Infrd Spect PX-3018236501 CDM 82365 CPT 301 RC outpatient 151 151 UNITED HEALTHCARE (COMMERCIAL) [3081199] UNITED HEALTHCARE 87726 [308119901] 93.62 percent of total billed charges 93.62 143.45 Technical (Hospital) Services Ref Calculus Qual Anal Infrd Spect PX-3018236501 CDM 82365 CPT 301 RC outpatient 151 151 HEALTHPARTNERS SX009 HEALTHPARTNERS 120.8 percent of total billed charges 93.62 143.45 Technical (Hospital) Services Ref Calculus Qual Anal Infrd Spect PX-3018236501 CDM 82365 CPT 301 RC outpatient 151 151 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES PPO [308136801] 120.8 percent of total billed charges 93.62 143.45 Technical (Hospital) Services Ref Calculus Qual Anal Infrd Spect PX-3018236501 CDM 82365 CPT 301 RC outpatient 151 151 MULTIPLAN INC 34080 [3081285] MULTIPLAN INC [308128501] 143.45 percent of total billed charges 93.62 143.45 Technical (Hospital) Services Ref Calculus Qual Anal Infrd Spect PX-3018236501 CDM 82365 CPT 301 RC outpatient 151 151 BLUE CROSS BLUE SHIELD WELLMARK SB889 [3081026] BCBS WYOMING [308102603] 143.45 percent of total billed charges 93.62 143.45 Technical (Hospital) Services Ref Calculus Qual Anal Infrd Spect PX-3018236501 CDM 82365 CPT 301 RC outpatient 151 151 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES EPO [308136803] 120.8 percent of total billed charges 93.62 143.45 Technical (Hospital) Services Ref Calculus Qual Anal Infrd Spect PX-3018236501 CDM 82365 CPT 301 RC outpatient 151 151 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES HDHP [308136802] 120.8 percent of total billed charges 93.62 143.45 Technical (Hospital) Services Ref Calculus Qual Anal Infrd Spect PX-3018236501 CDM 82365 CPT 301 RC outpatient 151 151 CIGNA 62308 [3081051] CIGNA 62308 [308105105] 120.8 percent of total billed charges 93.62 143.45 Technical (Hospital) Services Ref Calculus Qual Anal Infrd Spect PX-3018236501 CDM 82365 CPT 301 RC outpatient 151 151 CIGNA 62308 [3081051] CIGNA STATE OF WYOMING [308105107] 120.8 percent of total billed charges 93.62 143.45 Technical (Hospital) Services Ref Calculus Qual Anal Infrd Spect PX-3018236501 CDM 82365 CPT 301 RC outpatient 151 151 MEDICA (COMMERCIAL) 94265 [3081118] MEDICA CLAIMS [308111801] 135.9 percent of total billed charges 93.62 143.45 Technical (Hospital) Services Ref 24 Hr Urine Calcium PX-3018234000 CDM 82340 CPT 301 RC inpatient 81 81 MULTIPLAN INC 34080 [3081285] MULTIPLAN INC [308128501] 76.95 percent of total billed charges 50.22 76.95 Technical (Hospital) Services Ref 24 Hr Urine Calcium PX-3018234000 CDM 82340 CPT 301 RC inpatient 81 81 MEDICA (COMMERCIAL) 94265 [3081118] MEDICA CLAIMS [308111801] 72.9 percent of total billed charges 50.22 76.95 Technical (Hospital) Services Ref 24 Hr Urine Calcium PX-3018234000 CDM 82340 CPT 301 RC inpatient 81 81 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES EPO [308136803] 64.14 percent of total billed charges 50.22 76.95 Technical (Hospital) Services Ref 24 Hr Urine Calcium PX-3018234000 CDM 82340 CPT 301 RC inpatient 81 81 HEALTHPARTNERS SX009 HEALTHPARTNERS 64.14 percent of total billed charges 50.22 76.95 Technical (Hospital) Services Ref 24 Hr Urine Calcium PX-3018234000 CDM 82340 CPT 301 RC inpatient 81 81 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES HDHP [308136802] 64.14 percent of total billed charges 50.22 76.95 Technical (Hospital) Services Ref 24 Hr Urine Calcium PX-3018234000 CDM 82340 CPT 301 RC inpatient 81 81 BLUE CROSS BLUE SHIELD WELLMARK SB889 [3081026] BCBS WYOMING [308102603] 76.95 percent of total billed charges 50.22 76.95 Technical (Hospital) Services Ref 24 Hr Urine Calcium PX-3018234000 CDM 82340 CPT 301 RC inpatient 81 81 UNITED HEALTHCARE (COMMERCIAL) [3081199] UNITED HEALTHCARE 87726 [308119901] 50.22 percent of total billed charges 50.22 76.95 Technical (Hospital) Services Ref 24 Hr Urine Calcium PX-3018234000 CDM 82340 CPT 301 RC inpatient 81 81 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES PPO [308136801] 64.14 percent of total billed charges 50.22 76.95 Technical (Hospital) Services Ref 24 Hr Urine Calcium PX-3018234000 CDM 82340 CPT 301 RC inpatient 81 81 CIGNA 62308 [3081051] CIGNA 62308 [308105105] 64.14 percent of total billed charges 50.22 76.95 Technical (Hospital) Services Ref 24 Hr Urine Calcium PX-3018234000 CDM 82340 CPT 301 RC inpatient 81 81 CIGNA 62308 [3081051] CIGNA STATE OF WYOMING [308105107] 64.14 percent of total billed charges 50.22 76.95 Technical (Hospital) Services Ref 24 Hr Urine Calcium PX-3018234000 CDM 82340 CPT 301 RC outpatient 81 81 MEDICA (COMMERCIAL) 94265 [3081118] MEDICA CLAIMS [308111801] 72.9 percent of total billed charges 50.22 76.95 Technical (Hospital) Services Ref 24 Hr Urine Calcium PX-3018234000 CDM 82340 CPT 301 RC outpatient 81 81 CIGNA 62308 [3081051] CIGNA 62308 [308105105] 64.8 percent of total billed charges 50.22 76.95 Technical (Hospital) Services Ref 24 Hr Urine Calcium PX-3018234000 CDM 82340 CPT 301 RC outpatient 81 81 CIGNA 62308 [3081051] CIGNA STATE OF WYOMING [308105107] 64.8 percent of total billed charges 50.22 76.95 Technical (Hospital) Services Ref 24 Hr Urine Calcium PX-3018234000 CDM 82340 CPT 301 RC outpatient 81 81 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES PPO [308136801] 64.8 percent of total billed charges 50.22 76.95 Technical (Hospital) Services Ref 24 Hr Urine Calcium PX-3018234000 CDM 82340 CPT 301 RC outpatient 81 81 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES EPO [308136803] 64.8 percent of total billed charges 50.22 76.95 Technical (Hospital) Services Ref 24 Hr Urine Calcium PX-3018234000 CDM 82340 CPT 301 RC outpatient 81 81 BLUE CROSS BLUE SHIELD WELLMARK SB889 [3081026] BCBS WYOMING [308102603] 76.95 percent of total billed charges 50.22 76.95 Technical (Hospital) Services Ref 24 Hr Urine Calcium PX-3018234000 CDM 82340 CPT 301 RC outpatient 81 81 MULTIPLAN INC 34080 [3081285] MULTIPLAN INC [308128501] 76.95 percent of total billed charges 50.22 76.95 Technical (Hospital) Services Ref 24 Hr Urine Calcium PX-3018234000 CDM 82340 CPT 301 RC outpatient 81 81 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES HDHP [308136802] 64.8 percent of total billed charges 50.22 76.95 Technical (Hospital) Services Ref 24 Hr Urine Calcium PX-3018234000 CDM 82340 CPT 301 RC outpatient 81 81 HEALTHPARTNERS SX009 HEALTHPARTNERS 64.8 percent of total billed charges 50.22 76.95 Technical (Hospital) Services Ref 24 Hr Urine Calcium PX-3018234000 CDM 82340 CPT 301 RC outpatient 81 81 UNITED HEALTHCARE (COMMERCIAL) [3081199] UNITED HEALTHCARE 87726 [308119901] 50.22 percent of total billed charges 50.22 76.95 Technical (Hospital) Services Calcium Ionized Assay PX-3018233000 CDM 82330 CPT 301 RC outpatient 166 166 MEDICA (COMMERCIAL) 94265 [3081118] MEDICA CLAIMS [308111801] 149.4 percent of total billed charges 102.92 157.7 Technical (Hospital) Services Calcium Ionized Assay PX-3018233000 CDM 82330 CPT 301 RC outpatient 166 166 CIGNA 62308 [3081051] CIGNA 62308 [308105105] 132.8 percent of total billed charges 102.92 157.7 Technical (Hospital) Services Calcium Ionized Assay PX-3018233000 CDM 82330 CPT 301 RC outpatient 166 166 CIGNA 62308 [3081051] CIGNA STATE OF WYOMING [308105107] 132.8 percent of total billed charges 102.92 157.7 Technical (Hospital) Services Calcium Ionized Assay PX-3018233000 CDM 82330 CPT 301 RC outpatient 166 166 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES PPO [308136801] 132.8 percent of total billed charges 102.92 157.7 Technical (Hospital) Services Calcium Ionized Assay PX-3018233000 CDM 82330 CPT 301 RC outpatient 166 166 BLUE CROSS BLUE SHIELD WELLMARK SB889 [3081026] BCBS WYOMING [308102603] 157.7 percent of total billed charges 102.92 157.7 Technical (Hospital) Services Calcium Ionized Assay PX-3018233000 CDM 82330 CPT 301 RC outpatient 166 166 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES EPO [308136803] 132.8 percent of total billed charges 102.92 157.7 Technical (Hospital) Services Calcium Ionized Assay PX-3018233000 CDM 82330 CPT 301 RC outpatient 166 166 MULTIPLAN INC 34080 [3081285] MULTIPLAN INC [308128501] 157.7 percent of total billed charges 102.92 157.7 Technical (Hospital) Services Calcium Ionized Assay PX-3018233000 CDM 82330 CPT 301 RC outpatient 166 166 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES HDHP [308136802] 132.8 percent of total billed charges 102.92 157.7 Technical (Hospital) Services Calcium Ionized Assay PX-3018233000 CDM 82330 CPT 301 RC outpatient 166 166 UNITED HEALTHCARE (COMMERCIAL) [3081199] UNITED HEALTHCARE 87726 [308119901] 102.92 percent of total billed charges 102.92 157.7 Technical (Hospital) Services Calcium Ionized Assay PX-3018233000 CDM 82330 CPT 301 RC outpatient 166 166 HEALTHPARTNERS SX009 HEALTHPARTNERS 132.8 percent of total billed charges 102.92 157.7 Technical (Hospital) Services Calcium Ionized Assay PX-3018233000 CDM 82330 CPT 301 RC inpatient 166 166 BLUE CROSS BLUE SHIELD WELLMARK SB889 [3081026] BCBS WYOMING [308102603] 157.7 percent of total billed charges 102.92 157.7 Technical (Hospital) Services Calcium Ionized Assay PX-3018233000 CDM 82330 CPT 301 RC inpatient 166 166 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES HDHP [308136802] 131.44 percent of total billed charges 102.92 157.7 Technical (Hospital) Services Calcium Ionized Assay PX-3018233000 CDM 82330 CPT 301 RC inpatient 166 166 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES PPO [308136801] 131.44 percent of total billed charges 102.92 157.7 Technical (Hospital) Services Calcium Ionized Assay PX-3018233000 CDM 82330 CPT 301 RC inpatient 166 166 UNITED HEALTHCARE (COMMERCIAL) [3081199] UNITED HEALTHCARE 87726 [308119901] 102.92 percent of total billed charges 102.92 157.7 Technical (Hospital) Services Calcium Ionized Assay PX-3018233000 CDM 82330 CPT 301 RC inpatient 166 166 MULTIPLAN INC 34080 [3081285] MULTIPLAN INC [308128501] 157.7 percent of total billed charges 102.92 157.7 Technical (Hospital) Services Calcium Ionized Assay PX-3018233000 CDM 82330 CPT 301 RC inpatient 166 166 MEDICA (COMMERCIAL) 94265 [3081118] MEDICA CLAIMS [308111801] 149.4 percent of total billed charges 102.92 157.7 Technical (Hospital) Services Calcium Ionized Assay PX-3018233000 CDM 82330 CPT 301 RC inpatient 166 166 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES EPO [308136803] 131.44 percent of total billed charges 102.92 157.7 Technical (Hospital) Services Calcium Ionized Assay PX-3018233000 CDM 82330 CPT 301 RC inpatient 166 166 HEALTHPARTNERS SX009 HEALTHPARTNERS 131.44 percent of total billed charges 102.92 157.7 Technical (Hospital) Services Calcium Ionized Assay PX-3018233000 CDM 82330 CPT 301 RC inpatient 166 166 CIGNA 62308 [3081051] CIGNA 62308 [308105105] 131.44 percent of total billed charges 102.92 157.7 Technical (Hospital) Services Calcium Ionized Assay PX-3018233000 CDM 82330 CPT 301 RC inpatient 166 166 CIGNA 62308 [3081051] CIGNA STATE OF WYOMING [308105107] 131.44 percent of total billed charges 102.92 157.7 Technical (Hospital) Services Ref Calcuim Ionized Serum PX-3018233001 CDM 82330 CPT 301 RC inpatient 166 166 MEDICA (COMMERCIAL) 94265 [3081118] MEDICA CLAIMS [308111801] 149.4 percent of total billed charges 102.92 157.7 Technical (Hospital) Services Ref Calcuim Ionized Serum PX-3018233001 CDM 82330 CPT 301 RC inpatient 166 166 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES HDHP [308136802] 131.44 percent of total billed charges 102.92 157.7 Technical (Hospital) Services Ref Calcuim Ionized Serum PX-3018233001 CDM 82330 CPT 301 RC inpatient 166 166 MULTIPLAN INC 34080 [3081285] MULTIPLAN INC [308128501] 157.7 percent of total billed charges 102.92 157.7 Technical (Hospital) Services Ref Calcuim Ionized Serum PX-3018233001 CDM 82330 CPT 301 RC inpatient 166 166 HEALTHPARTNERS SX009 HEALTHPARTNERS 131.44 percent of total billed charges 102.92 157.7 Technical (Hospital) Services Ref Calcuim Ionized Serum PX-3018233001 CDM 82330 CPT 301 RC inpatient 166 166 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES EPO [308136803] 131.44 percent of total billed charges 102.92 157.7 Technical (Hospital) Services Ref Calcuim Ionized Serum PX-3018233001 CDM 82330 CPT 301 RC inpatient 166 166 BLUE CROSS BLUE SHIELD WELLMARK SB889 [3081026] BCBS WYOMING [308102603] 157.7 percent of total billed charges 102.92 157.7 Technical (Hospital) Services Ref Calcuim Ionized Serum PX-3018233001 CDM 82330 CPT 301 RC inpatient 166 166 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES PPO [308136801] 131.44 percent of total billed charges 102.92 157.7 Technical (Hospital) Services Ref Calcuim Ionized Serum PX-3018233001 CDM 82330 CPT 301 RC inpatient 166 166 UNITED HEALTHCARE (COMMERCIAL) [3081199] UNITED HEALTHCARE 87726 [308119901] 102.92 percent of total billed charges 102.92 157.7 Technical (Hospital) Services Ref Calcuim Ionized Serum PX-3018233001 CDM 82330 CPT 301 RC inpatient 166 166 CIGNA 62308 [3081051] CIGNA 62308 [308105105] 131.44 percent of total billed charges 102.92 157.7 Technical (Hospital) Services Ref Calcuim Ionized Serum PX-3018233001 CDM 82330 CPT 301 RC inpatient 166 166 CIGNA 62308 [3081051] CIGNA STATE OF WYOMING [308105107] 131.44 percent of total billed charges 102.92 157.7 Technical (Hospital) Services Ref Calcuim Ionized Serum PX-3018233001 CDM 82330 CPT 301 RC outpatient 166 166 CIGNA 62308 [3081051] CIGNA 62308 [308105105] 132.8 percent of total billed charges 102.92 157.7 Technical (Hospital) Services Ref Calcuim Ionized Serum PX-3018233001 CDM 82330 CPT 301 RC outpatient 166 166 CIGNA 62308 [3081051] CIGNA STATE OF WYOMING [308105107] 132.8 percent of total billed charges 102.92 157.7 Technical (Hospital) Services Ref Calcuim Ionized Serum PX-3018233001 CDM 82330 CPT 301 RC outpatient 166 166 MEDICA (COMMERCIAL) 94265 [3081118] MEDICA CLAIMS [308111801] 149.4 percent of total billed charges 102.92 157.7 Technical (Hospital) Services Ref Calcuim Ionized Serum PX-3018233001 CDM 82330 CPT 301 RC outpatient 166 166 HEALTHPARTNERS SX009 HEALTHPARTNERS 132.8 percent of total billed charges 102.92 157.7 Technical (Hospital) Services Ref Calcuim Ionized Serum PX-3018233001 CDM 82330 CPT 301 RC outpatient 166 166 UNITED HEALTHCARE (COMMERCIAL) [3081199] UNITED HEALTHCARE 87726 [308119901] 102.92 percent of total billed charges 102.92 157.7 Technical (Hospital) Services Ref Calcuim Ionized Serum PX-3018233001 CDM 82330 CPT 301 RC outpatient 166 166 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES EPO [308136803] 132.8 percent of total billed charges 102.92 157.7 Technical (Hospital) Services Ref Calcuim Ionized Serum PX-3018233001 CDM 82330 CPT 301 RC outpatient 166 166 MULTIPLAN INC 34080 [3081285] MULTIPLAN INC [308128501] 157.7 percent of total billed charges 102.92 157.7 Technical (Hospital) Services Ref Calcuim Ionized Serum PX-3018233001 CDM 82330 CPT 301 RC outpatient 166 166 BLUE CROSS BLUE SHIELD WELLMARK SB889 [3081026] BCBS WYOMING [308102603] 157.7 percent of total billed charges 102.92 157.7 Technical (Hospital) Services Ref Calcuim Ionized Serum PX-3018233001 CDM 82330 CPT 301 RC outpatient 166 166 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES HDHP [308136802] 132.8 percent of total billed charges 102.92 157.7 Technical (Hospital) Services Ref Calcuim Ionized Serum PX-3018233001 CDM 82330 CPT 301 RC outpatient 166 166 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES PPO [308136801] 132.8 percent of total billed charges 102.92 157.7 Technical (Hospital) Services Calcium Total Serum PX-3018231000 CDM 82310 CPT 301 RC outpatient 72 72 UNITED HEALTHCARE (COMMERCIAL) [3081199] UNITED HEALTHCARE 87726 [308119901] 44.64 percent of total billed charges 44.64 68.4 Technical (Hospital) Services Calcium Total Serum PX-3018231000 CDM 82310 CPT 301 RC outpatient 72 72 HEALTHPARTNERS SX009 HEALTHPARTNERS 57.6 percent of total billed charges 44.64 68.4 Technical (Hospital) Services Calcium Total Serum PX-3018231000 CDM 82310 CPT 301 RC outpatient 72 72 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES HDHP [308136802] 57.6 percent of total billed charges 44.64 68.4 Technical (Hospital) Services Calcium Total Serum PX-3018231000 CDM 82310 CPT 301 RC outpatient 72 72 BLUE CROSS BLUE SHIELD WELLMARK SB889 [3081026] BCBS WYOMING [308102603] 68.4 percent of total billed charges 44.64 68.4 Technical (Hospital) Services Calcium Total Serum PX-3018231000 CDM 82310 CPT 301 RC outpatient 72 72 MULTIPLAN INC 34080 [3081285] MULTIPLAN INC [308128501] 68.4 percent of total billed charges 44.64 68.4 Technical (Hospital) Services Calcium Total Serum PX-3018231000 CDM 82310 CPT 301 RC outpatient 72 72 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES EPO [308136803] 57.6 percent of total billed charges 44.64 68.4 Technical (Hospital) Services Calcium Total Serum PX-3018231000 CDM 82310 CPT 301 RC outpatient 72 72 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES PPO [308136801] 57.6 percent of total billed charges 44.64 68.4 Technical (Hospital) Services Calcium Total Serum PX-3018231000 CDM 82310 CPT 301 RC outpatient 72 72 MEDICA (COMMERCIAL) 94265 [3081118] MEDICA CLAIMS [308111801] 64.8 percent of total billed charges 44.64 68.4 Technical (Hospital) Services Calcium Total Serum PX-3018231000 CDM 82310 CPT 301 RC outpatient 72 72 CIGNA 62308 [3081051] CIGNA 62308 [308105105] 57.6 percent of total billed charges 44.64 68.4 Technical (Hospital) Services Calcium Total Serum PX-3018231000 CDM 82310 CPT 301 RC outpatient 72 72 CIGNA 62308 [3081051] CIGNA STATE OF WYOMING [308105107] 57.6 percent of total billed charges 44.64 68.4 Technical (Hospital) Services Calcium Total Serum PX-3018231000 CDM 82310 CPT 301 RC inpatient 72 72 CIGNA 62308 [3081051] CIGNA 62308 [308105105] 57.01 percent of total billed charges 44.64 68.4 Technical (Hospital) Services Calcium Total Serum PX-3018231000 CDM 82310 CPT 301 RC inpatient 72 72 CIGNA 62308 [3081051] CIGNA STATE OF WYOMING [308105107] 57.01 percent of total billed charges 44.64 68.4 Technical (Hospital) Services Calcium Total Serum PX-3018231000 CDM 82310 CPT 301 RC inpatient 72 72 HEALTHPARTNERS SX009 HEALTHPARTNERS 57.01 percent of total billed charges 44.64 68.4 Technical (Hospital) Services Calcium Total Serum PX-3018231000 CDM 82310 CPT 301 RC inpatient 72 72 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES EPO [308136803] 57.01 percent of total billed charges 44.64 68.4 Technical (Hospital) Services Calcium Total Serum PX-3018231000 CDM 82310 CPT 301 RC inpatient 72 72 MULTIPLAN INC 34080 [3081285] MULTIPLAN INC [308128501] 68.4 percent of total billed charges 44.64 68.4 Technical (Hospital) Services Calcium Total Serum PX-3018231000 CDM 82310 CPT 301 RC inpatient 72 72 MEDICA (COMMERCIAL) 94265 [3081118] MEDICA CLAIMS [308111801] 64.8 percent of total billed charges 44.64 68.4 Technical (Hospital) Services Calcium Total Serum PX-3018231000 CDM 82310 CPT 301 RC inpatient 72 72 UNITED HEALTHCARE (COMMERCIAL) [3081199] UNITED HEALTHCARE 87726 [308119901] 44.64 percent of total billed charges 44.64 68.4 Technical (Hospital) Services Calcium Total Serum PX-3018231000 CDM 82310 CPT 301 RC inpatient 72 72 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES PPO [308136801] 57.01 percent of total billed charges 44.64 68.4 Technical (Hospital) Services Calcium Total Serum PX-3018231000 CDM 82310 CPT 301 RC inpatient 72 72 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES HDHP [308136802] 57.01 percent of total billed charges 44.64 68.4 Technical (Hospital) Services Calcium Total Serum PX-3018231000 CDM 82310 CPT 301 RC inpatient 72 72 BLUE CROSS BLUE SHIELD WELLMARK SB889 [3081026] BCBS WYOMING [308102603] 68.4 percent of total billed charges 44.64 68.4 Technical (Hospital) Services "Ref Calcium, Urine, Random(Mayo)" PX-3018231003 CDM 82310 CPT 301 RC outpatient 45 45 UNITED HEALTHCARE (COMMERCIAL) [3081199] UNITED HEALTHCARE 87726 [308119901] 27.9 percent of total billed charges 27.9 42.75 Technical (Hospital) Services "Ref Calcium, Urine, Random(Mayo)" PX-3018231003 CDM 82310 CPT 301 RC outpatient 45 45 HEALTHPARTNERS SX009 HEALTHPARTNERS 36 percent of total billed charges 27.9 42.75 Technical (Hospital) Services "Ref Calcium, Urine, Random(Mayo)" PX-3018231003 CDM 82310 CPT 301 RC outpatient 45 45 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES PPO [308136801] 36 percent of total billed charges 27.9 42.75 Technical (Hospital) Services "Ref Calcium, Urine, Random(Mayo)" PX-3018231003 CDM 82310 CPT 301 RC outpatient 45 45 MULTIPLAN INC 34080 [3081285] MULTIPLAN INC [308128501] 42.75 percent of total billed charges 27.9 42.75 Technical (Hospital) Services "Ref Calcium, Urine, Random(Mayo)" PX-3018231003 CDM 82310 CPT 301 RC outpatient 45 45 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES HDHP [308136802] 36 percent of total billed charges 27.9 42.75 Technical (Hospital) Services "Ref Calcium, Urine, Random(Mayo)" PX-3018231003 CDM 82310 CPT 301 RC outpatient 45 45 BLUE CROSS BLUE SHIELD WELLMARK SB889 [3081026] BCBS WYOMING [308102603] 42.75 percent of total billed charges 27.9 42.75 Technical (Hospital) Services "Ref Calcium, Urine, Random(Mayo)" PX-3018231003 CDM 82310 CPT 301 RC outpatient 45 45 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES EPO [308136803] 36 percent of total billed charges 27.9 42.75 Technical (Hospital) Services "Ref Calcium, Urine, Random(Mayo)" PX-3018231003 CDM 82310 CPT 301 RC outpatient 45 45 CIGNA 62308 [3081051] CIGNA 62308 [308105105] 36 percent of total billed charges 27.9 42.75 Technical (Hospital) Services "Ref Calcium, Urine, Random(Mayo)" PX-3018231003 CDM 82310 CPT 301 RC outpatient 45 45 CIGNA 62308 [3081051] CIGNA STATE OF WYOMING [308105107] 36 percent of total billed charges 27.9 42.75 Technical (Hospital) Services "Ref Calcium, Urine, Random(Mayo)" PX-3018231003 CDM 82310 CPT 301 RC outpatient 45 45 MEDICA (COMMERCIAL) 94265 [3081118] MEDICA CLAIMS [308111801] 40.5 percent of total billed charges 27.9 42.75 Technical (Hospital) Services "Ref Calcium, Urine, Random(Mayo)" PX-3018231003 CDM 82310 CPT 301 RC inpatient 45 45 BLUE CROSS BLUE SHIELD WELLMARK SB889 [3081026] BCBS WYOMING [308102603] 42.75 percent of total billed charges 27.9 42.75 Technical (Hospital) Services "Ref Calcium, Urine, Random(Mayo)" PX-3018231003 CDM 82310 CPT 301 RC inpatient 45 45 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES HDHP [308136802] 35.63 percent of total billed charges 27.9 42.75 Technical (Hospital) Services "Ref Calcium, Urine, Random(Mayo)" PX-3018231003 CDM 82310 CPT 301 RC inpatient 45 45 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES PPO [308136801] 35.63 percent of total billed charges 27.9 42.75 Technical (Hospital) Services "Ref Calcium, Urine, Random(Mayo)" PX-3018231003 CDM 82310 CPT 301 RC inpatient 45 45 UNITED HEALTHCARE (COMMERCIAL) [3081199] UNITED HEALTHCARE 87726 [308119901] 27.9 percent of total billed charges 27.9 42.75 Technical (Hospital) Services "Ref Calcium, Urine, Random(Mayo)" PX-3018231003 CDM 82310 CPT 301 RC inpatient 45 45 MULTIPLAN INC 34080 [3081285] MULTIPLAN INC [308128501] 42.75 percent of total billed charges 27.9 42.75 Technical (Hospital) Services "Ref Calcium, Urine, Random(Mayo)" PX-3018231003 CDM 82310 CPT 301 RC inpatient 45 45 MEDICA (COMMERCIAL) 94265 [3081118] MEDICA CLAIMS [308111801] 40.5 percent of total billed charges 27.9 42.75 Technical (Hospital) Services "Ref Calcium, Urine, Random(Mayo)" PX-3018231003 CDM 82310 CPT 301 RC inpatient 45 45 HEALTHPARTNERS SX009 HEALTHPARTNERS 35.63 percent of total billed charges 27.9 42.75 Technical (Hospital) Services "Ref Calcium, Urine, Random(Mayo)" PX-3018231003 CDM 82310 CPT 301 RC inpatient 45 45 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES EPO [308136803] 35.63 percent of total billed charges 27.9 42.75 Technical (Hospital) Services "Ref Calcium, Urine, Random(Mayo)" PX-3018231003 CDM 82310 CPT 301 RC inpatient 45 45 CIGNA 62308 [3081051] CIGNA 62308 [308105105] 35.63 percent of total billed charges 27.9 42.75 Technical (Hospital) Services "Ref Calcium, Urine, Random(Mayo)" PX-3018231003 CDM 82310 CPT 301 RC inpatient 45 45 CIGNA 62308 [3081051] CIGNA STATE OF WYOMING [308105107] 35.63 percent of total billed charges 27.9 42.75 Technical (Hospital) Services Ref Calcitonin PX-3018230800 CDM 82308 CPT 301 RC outpatient 343 343 MEDICA (COMMERCIAL) 94265 [3081118] MEDICA CLAIMS [308111801] 308.7 percent of total billed charges 212.66 325.85 Technical (Hospital) Services Ref Calcitonin PX-3018230800 CDM 82308 CPT 301 RC outpatient 343 343 CIGNA 62308 [3081051] CIGNA 62308 [308105105] 274.4 percent of total billed charges 212.66 325.85 Technical (Hospital) Services Ref Calcitonin PX-3018230800 CDM 82308 CPT 301 RC outpatient 343 343 CIGNA 62308 [3081051] CIGNA STATE OF WYOMING [308105107] 274.4 percent of total billed charges 212.66 325.85 Technical (Hospital) Services Ref Calcitonin PX-3018230800 CDM 82308 CPT 301 RC outpatient 343 343 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES HDHP [308136802] 274.4 percent of total billed charges 212.66 325.85 Technical (Hospital) Services Ref Calcitonin PX-3018230800 CDM 82308 CPT 301 RC outpatient 343 343 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES EPO [308136803] 274.4 percent of total billed charges 212.66 325.85 Technical (Hospital) Services Ref Calcitonin PX-3018230800 CDM 82308 CPT 301 RC outpatient 343 343 BLUE CROSS BLUE SHIELD WELLMARK SB889 [3081026] BCBS WYOMING [308102603] 325.85 percent of total billed charges 212.66 325.85 Technical (Hospital) Services Ref Calcitonin PX-3018230800 CDM 82308 CPT 301 RC outpatient 343 343 MULTIPLAN INC 34080 [3081285] MULTIPLAN INC [308128501] 325.85 percent of total billed charges 212.66 325.85 Technical (Hospital) Services Ref Calcitonin PX-3018230800 CDM 82308 CPT 301 RC outpatient 343 343 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES PPO [308136801] 274.4 percent of total billed charges 212.66 325.85 Technical (Hospital) Services Ref Calcitonin PX-3018230800 CDM 82308 CPT 301 RC outpatient 343 343 HEALTHPARTNERS SX009 HEALTHPARTNERS 274.4 percent of total billed charges 212.66 325.85 Technical (Hospital) Services Ref Calcitonin PX-3018230800 CDM 82308 CPT 301 RC outpatient 343 343 UNITED HEALTHCARE (COMMERCIAL) [3081199] UNITED HEALTHCARE 87726 [308119901] 212.66 percent of total billed charges 212.66 325.85 Technical (Hospital) Services Ref Calcitonin PX-3018230800 CDM 82308 CPT 301 RC inpatient 343 343 CIGNA 62308 [3081051] CIGNA 62308 [308105105] 271.59 percent of total billed charges 212.66 325.85 Technical (Hospital) Services Ref Calcitonin PX-3018230800 CDM 82308 CPT 301 RC inpatient 343 343 CIGNA 62308 [3081051] CIGNA STATE OF WYOMING [308105107] 271.59 percent of total billed charges 212.66 325.85 Technical (Hospital) Services Ref Calcitonin PX-3018230800 CDM 82308 CPT 301 RC inpatient 343 343 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES EPO [308136803] 271.59 percent of total billed charges 212.66 325.85 Technical (Hospital) Services Ref Calcitonin PX-3018230800 CDM 82308 CPT 301 RC inpatient 343 343 HEALTHPARTNERS SX009 HEALTHPARTNERS 271.59 percent of total billed charges 212.66 325.85 Technical (Hospital) Services Ref Calcitonin PX-3018230800 CDM 82308 CPT 301 RC inpatient 343 343 MULTIPLAN INC 34080 [3081285] MULTIPLAN INC [308128501] 325.85 percent of total billed charges 212.66 325.85 Technical (Hospital) Services Ref Calcitonin PX-3018230800 CDM 82308 CPT 301 RC inpatient 343 343 MEDICA (COMMERCIAL) 94265 [3081118] MEDICA CLAIMS [308111801] 308.7 percent of total billed charges 212.66 325.85 Technical (Hospital) Services Ref Calcitonin PX-3018230800 CDM 82308 CPT 301 RC inpatient 343 343 UNITED HEALTHCARE (COMMERCIAL) [3081199] UNITED HEALTHCARE 87726 [308119901] 212.66 percent of total billed charges 212.66 325.85 Technical (Hospital) Services Ref Calcitonin PX-3018230800 CDM 82308 CPT 301 RC inpatient 343 343 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES PPO [308136801] 271.59 percent of total billed charges 212.66 325.85 Technical (Hospital) Services Ref Calcitonin PX-3018230800 CDM 82308 CPT 301 RC inpatient 343 343 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES HDHP [308136802] 271.59 percent of total billed charges 212.66 325.85 Technical (Hospital) Services Ref Calcitonin PX-3018230800 CDM 82308 CPT 301 RC inpatient 343 343 BLUE CROSS BLUE SHIELD WELLMARK SB889 [3081026] BCBS WYOMING [308102603] 325.85 percent of total billed charges 212.66 325.85 Technical (Hospital) Services Vit D 25 Hydroxy W Fractions PX-3018230600 CDM 82306 CPT 301 RC outpatient 379 379 CIGNA 62308 [3081051] CIGNA 62308 [308105105] 303.2 percent of total billed charges 234.98 360.05 Technical (Hospital) Services Vit D 25 Hydroxy W Fractions PX-3018230600 CDM 82306 CPT 301 RC outpatient 379 379 CIGNA 62308 [3081051] CIGNA STATE OF WYOMING [308105107] 303.2 percent of total billed charges 234.98 360.05 Technical (Hospital) Services Vit D 25 Hydroxy W Fractions PX-3018230600 CDM 82306 CPT 301 RC outpatient 379 379 MEDICA (COMMERCIAL) 94265 [3081118] MEDICA CLAIMS [308111801] 341.1 percent of total billed charges 234.98 360.05 Technical (Hospital) Services Vit D 25 Hydroxy W Fractions PX-3018230600 CDM 82306 CPT 301 RC outpatient 379 379 HEALTHPARTNERS SX009 HEALTHPARTNERS 303.2 percent of total billed charges 234.98 360.05 Technical (Hospital) Services Vit D 25 Hydroxy W Fractions PX-3018230600 CDM 82306 CPT 301 RC outpatient 379 379 UNITED HEALTHCARE (COMMERCIAL) [3081199] UNITED HEALTHCARE 87726 [308119901] 234.98 percent of total billed charges 234.98 360.05 Technical (Hospital) Services Vit D 25 Hydroxy W Fractions PX-3018230600 CDM 82306 CPT 301 RC outpatient 379 379 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES HDHP [308136802] 303.2 percent of total billed charges 234.98 360.05 Technical (Hospital) Services Vit D 25 Hydroxy W Fractions PX-3018230600 CDM 82306 CPT 301 RC outpatient 379 379 BLUE CROSS BLUE SHIELD WELLMARK SB889 [3081026] BCBS WYOMING [308102603] 360.05 percent of total billed charges 234.98 360.05 Technical (Hospital) Services Vit D 25 Hydroxy W Fractions PX-3018230600 CDM 82306 CPT 301 RC outpatient 379 379 MULTIPLAN INC 34080 [3081285] MULTIPLAN INC [308128501] 360.05 percent of total billed charges 234.98 360.05 Technical (Hospital) Services Vit D 25 Hydroxy W Fractions PX-3018230600 CDM 82306 CPT 301 RC outpatient 379 379 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES EPO [308136803] 303.2 percent of total billed charges 234.98 360.05 Technical (Hospital) Services Vit D 25 Hydroxy W Fractions PX-3018230600 CDM 82306 CPT 301 RC outpatient 379 379 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES PPO [308136801] 303.2 percent of total billed charges 234.98 360.05 Technical (Hospital) Services Vit D 25 Hydroxy W Fractions PX-3018230600 CDM 82306 CPT 301 RC inpatient 379 379 CIGNA 62308 [3081051] CIGNA 62308 [308105105] 300.09 percent of total billed charges 234.98 360.05 Technical (Hospital) Services Vit D 25 Hydroxy W Fractions PX-3018230600 CDM 82306 CPT 301 RC inpatient 379 379 CIGNA 62308 [3081051] CIGNA STATE OF WYOMING [308105107] 300.09 percent of total billed charges 234.98 360.05 Technical (Hospital) Services Vit D 25 Hydroxy W Fractions PX-3018230600 CDM 82306 CPT 301 RC inpatient 379 379 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES PPO [308136801] 300.09 percent of total billed charges 234.98 360.05 Technical (Hospital) Services Vit D 25 Hydroxy W Fractions PX-3018230600 CDM 82306 CPT 301 RC inpatient 379 379 UNITED HEALTHCARE (COMMERCIAL) [3081199] UNITED HEALTHCARE 87726 [308119901] 234.98 percent of total billed charges 234.98 360.05 Technical (Hospital) Services Vit D 25 Hydroxy W Fractions PX-3018230600 CDM 82306 CPT 301 RC inpatient 379 379 BLUE CROSS BLUE SHIELD WELLMARK SB889 [3081026] BCBS WYOMING [308102603] 360.05 percent of total billed charges 234.98 360.05 Technical (Hospital) Services Vit D 25 Hydroxy W Fractions PX-3018230600 CDM 82306 CPT 301 RC inpatient 379 379 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES HDHP [308136802] 300.09 percent of total billed charges 234.98 360.05 Technical (Hospital) Services Vit D 25 Hydroxy W Fractions PX-3018230600 CDM 82306 CPT 301 RC inpatient 379 379 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES EPO [308136803] 300.09 percent of total billed charges 234.98 360.05 Technical (Hospital) Services Vit D 25 Hydroxy W Fractions PX-3018230600 CDM 82306 CPT 301 RC inpatient 379 379 HEALTHPARTNERS SX009 HEALTHPARTNERS 300.09 percent of total billed charges 234.98 360.05 Technical (Hospital) Services Vit D 25 Hydroxy W Fractions PX-3018230600 CDM 82306 CPT 301 RC inpatient 379 379 MEDICA (COMMERCIAL) 94265 [3081118] MEDICA CLAIMS [308111801] 341.1 percent of total billed charges 234.98 360.05 Technical (Hospital) Services Vit D 25 Hydroxy W Fractions PX-3018230600 CDM 82306 CPT 301 RC inpatient 379 379 MULTIPLAN INC 34080 [3081285] MULTIPLAN INC [308128501] 360.05 percent of total billed charges 234.98 360.05 Technical (Hospital) Services Ref Vit D 25 Hydroxy W Fractions PX-3018230601 CDM 82306 CPT 301 RC inpatient 379 379 MEDICA (COMMERCIAL) 94265 [3081118] MEDICA CLAIMS [308111801] 341.1 percent of total billed charges 234.98 360.05 Technical (Hospital) Services Ref Vit D 25 Hydroxy W Fractions PX-3018230601 CDM 82306 CPT 301 RC inpatient 379 379 MULTIPLAN INC 34080 [3081285] MULTIPLAN INC [308128501] 360.05 percent of total billed charges 234.98 360.05 Technical (Hospital) Services Ref Vit D 25 Hydroxy W Fractions PX-3018230601 CDM 82306 CPT 301 RC inpatient 379 379 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES EPO [308136803] 300.09 percent of total billed charges 234.98 360.05 Technical (Hospital) Services Ref Vit D 25 Hydroxy W Fractions PX-3018230601 CDM 82306 CPT 301 RC inpatient 379 379 HEALTHPARTNERS SX009 HEALTHPARTNERS 300.09 percent of total billed charges 234.98 360.05 Technical (Hospital) Services Ref Vit D 25 Hydroxy W Fractions PX-3018230601 CDM 82306 CPT 301 RC inpatient 379 379 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES HDHP [308136802] 300.09 percent of total billed charges 234.98 360.05 Technical (Hospital) Services Ref Vit D 25 Hydroxy W Fractions PX-3018230601 CDM 82306 CPT 301 RC inpatient 379 379 BLUE CROSS BLUE SHIELD WELLMARK SB889 [3081026] BCBS WYOMING [308102603] 360.05 percent of total billed charges 234.98 360.05 Technical (Hospital) Services Ref Vit D 25 Hydroxy W Fractions PX-3018230601 CDM 82306 CPT 301 RC inpatient 379 379 UNITED HEALTHCARE (COMMERCIAL) [3081199] UNITED HEALTHCARE 87726 [308119901] 234.98 percent of total billed charges 234.98 360.05 Technical (Hospital) Services Ref Vit D 25 Hydroxy W Fractions PX-3018230601 CDM 82306 CPT 301 RC inpatient 379 379 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES PPO [308136801] 300.09 percent of total billed charges 234.98 360.05 Technical (Hospital) Services Ref Vit D 25 Hydroxy W Fractions PX-3018230601 CDM 82306 CPT 301 RC inpatient 379 379 CIGNA 62308 [3081051] CIGNA 62308 [308105105] 300.09 percent of total billed charges 234.98 360.05 Technical (Hospital) Services Ref Vit D 25 Hydroxy W Fractions PX-3018230601 CDM 82306 CPT 301 RC inpatient 379 379 CIGNA 62308 [3081051] CIGNA STATE OF WYOMING [308105107] 300.09 percent of total billed charges 234.98 360.05 Technical (Hospital) Services Ref Vit D 25 Hydroxy W Fractions PX-3018230601 CDM 82306 CPT 301 RC outpatient 379 379 CIGNA 62308 [3081051] CIGNA 62308 [308105105] 303.2 percent of total billed charges 234.98 360.05 Technical (Hospital) Services Ref Vit D 25 Hydroxy W Fractions PX-3018230601 CDM 82306 CPT 301 RC outpatient 379 379 CIGNA 62308 [3081051] CIGNA STATE OF WYOMING [308105107] 303.2 percent of total billed charges 234.98 360.05 Technical (Hospital) Services Ref Vit D 25 Hydroxy W Fractions PX-3018230601 CDM 82306 CPT 301 RC outpatient 379 379 MEDICA (COMMERCIAL) 94265 [3081118] MEDICA CLAIMS [308111801] 341.1 percent of total billed charges 234.98 360.05 Technical (Hospital) Services Ref Vit D 25 Hydroxy W Fractions PX-3018230601 CDM 82306 CPT 301 RC outpatient 379 379 HEALTHPARTNERS SX009 HEALTHPARTNERS 303.2 percent of total billed charges 234.98 360.05 Technical (Hospital) Services Ref Vit D 25 Hydroxy W Fractions PX-3018230601 CDM 82306 CPT 301 RC outpatient 379 379 UNITED HEALTHCARE (COMMERCIAL) [3081199] UNITED HEALTHCARE 87726 [308119901] 234.98 percent of total billed charges 234.98 360.05 Technical (Hospital) Services Ref Vit D 25 Hydroxy W Fractions PX-3018230601 CDM 82306 CPT 301 RC outpatient 379 379 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES HDHP [308136802] 303.2 percent of total billed charges 234.98 360.05 Technical (Hospital) Services Ref Vit D 25 Hydroxy W Fractions PX-3018230601 CDM 82306 CPT 301 RC outpatient 379 379 MULTIPLAN INC 34080 [3081285] MULTIPLAN INC [308128501] 360.05 percent of total billed charges 234.98 360.05 Technical (Hospital) Services Ref Vit D 25 Hydroxy W Fractions PX-3018230601 CDM 82306 CPT 301 RC outpatient 379 379 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES EPO [308136803] 303.2 percent of total billed charges 234.98 360.05 Technical (Hospital) Services Ref Vit D 25 Hydroxy W Fractions PX-3018230601 CDM 82306 CPT 301 RC outpatient 379 379 BLUE CROSS BLUE SHIELD WELLMARK SB889 [3081026] BCBS WYOMING [308102603] 360.05 percent of total billed charges 234.98 360.05 Technical (Hospital) Services Ref Vit D 25 Hydroxy W Fractions PX-3018230601 CDM 82306 CPT 301 RC outpatient 379 379 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES PPO [308136801] 303.2 percent of total billed charges 234.98 360.05 Technical (Hospital) Services Ref Heavy Metals Scrn UR Cadmium PX-3018230001 CDM 82300 CPT 301 RC inpatient 155 155 UNITED HEALTHCARE (COMMERCIAL) [3081199] UNITED HEALTHCARE 87726 [308119901] 96.1 percent of total billed charges 96.1 147.25 Technical (Hospital) Services Ref Heavy Metals Scrn UR Cadmium PX-3018230001 CDM 82300 CPT 301 RC inpatient 155 155 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES PPO [308136801] 122.73 percent of total billed charges 96.1 147.25 Technical (Hospital) Services Ref Heavy Metals Scrn UR Cadmium PX-3018230001 CDM 82300 CPT 301 RC inpatient 155 155 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES HDHP [308136802] 122.73 percent of total billed charges 96.1 147.25 Technical (Hospital) Services Ref Heavy Metals Scrn UR Cadmium PX-3018230001 CDM 82300 CPT 301 RC inpatient 155 155 BLUE CROSS BLUE SHIELD WELLMARK SB889 [3081026] BCBS WYOMING [308102603] 147.25 percent of total billed charges 96.1 147.25 Technical (Hospital) Services Ref Heavy Metals Scrn UR Cadmium PX-3018230001 CDM 82300 CPT 301 RC inpatient 155 155 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES EPO [308136803] 122.73 percent of total billed charges 96.1 147.25 Technical (Hospital) Services Ref Heavy Metals Scrn UR Cadmium PX-3018230001 CDM 82300 CPT 301 RC inpatient 155 155 HEALTHPARTNERS SX009 HEALTHPARTNERS 122.73 percent of total billed charges 96.1 147.25 Technical (Hospital) Services Ref Heavy Metals Scrn UR Cadmium PX-3018230001 CDM 82300 CPT 301 RC inpatient 155 155 MULTIPLAN INC 34080 [3081285] MULTIPLAN INC [308128501] 147.25 percent of total billed charges 96.1 147.25 Technical (Hospital) Services Ref Heavy Metals Scrn UR Cadmium PX-3018230001 CDM 82300 CPT 301 RC inpatient 155 155 MEDICA (COMMERCIAL) 94265 [3081118] MEDICA CLAIMS [308111801] 139.5 percent of total billed charges 96.1 147.25 Technical (Hospital) Services Ref Heavy Metals Scrn UR Cadmium PX-3018230001 CDM 82300 CPT 301 RC inpatient 155 155 CIGNA 62308 [3081051] CIGNA 62308 [308105105] 122.73 percent of total billed charges 96.1 147.25 Technical (Hospital) Services Ref Heavy Metals Scrn UR Cadmium PX-3018230001 CDM 82300 CPT 301 RC inpatient 155 155 CIGNA 62308 [3081051] CIGNA STATE OF WYOMING [308105107] 122.73 percent of total billed charges 96.1 147.25 Technical (Hospital) Services Ref Heavy Metals Scrn UR Cadmium PX-3018230001 CDM 82300 CPT 301 RC outpatient 155 155 MEDICA (COMMERCIAL) 94265 [3081118] MEDICA CLAIMS [308111801] 139.5 percent of total billed charges 96.1 147.25 Technical (Hospital) Services Ref Heavy Metals Scrn UR Cadmium PX-3018230001 CDM 82300 CPT 301 RC outpatient 155 155 CIGNA 62308 [3081051] CIGNA 62308 [308105105] 124 percent of total billed charges 96.1 147.25 Technical (Hospital) Services Ref Heavy Metals Scrn UR Cadmium PX-3018230001 CDM 82300 CPT 301 RC outpatient 155 155 CIGNA 62308 [3081051] CIGNA STATE OF WYOMING [308105107] 124 percent of total billed charges 96.1 147.25 Technical (Hospital) Services Ref Heavy Metals Scrn UR Cadmium PX-3018230001 CDM 82300 CPT 301 RC outpatient 155 155 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES PPO [308136801] 124 percent of total billed charges 96.1 147.25 Technical (Hospital) Services Ref Heavy Metals Scrn UR Cadmium PX-3018230001 CDM 82300 CPT 301 RC outpatient 155 155 BLUE CROSS BLUE SHIELD WELLMARK SB889 [3081026] BCBS WYOMING [308102603] 147.25 percent of total billed charges 96.1 147.25 Technical (Hospital) Services Ref Heavy Metals Scrn UR Cadmium PX-3018230001 CDM 82300 CPT 301 RC outpatient 155 155 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES EPO [308136803] 124 percent of total billed charges 96.1 147.25 Technical (Hospital) Services Ref Heavy Metals Scrn UR Cadmium PX-3018230001 CDM 82300 CPT 301 RC outpatient 155 155 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES HDHP [308136802] 124 percent of total billed charges 96.1 147.25 Technical (Hospital) Services Ref Heavy Metals Scrn UR Cadmium PX-3018230001 CDM 82300 CPT 301 RC outpatient 155 155 MULTIPLAN INC 34080 [3081285] MULTIPLAN INC [308128501] 147.25 percent of total billed charges 96.1 147.25 Technical (Hospital) Services Ref Heavy Metals Scrn UR Cadmium PX-3018230001 CDM 82300 CPT 301 RC outpatient 155 155 HEALTHPARTNERS SX009 HEALTHPARTNERS 124 percent of total billed charges 96.1 147.25 Technical (Hospital) Services Ref Heavy Metals Scrn UR Cadmium PX-3018230001 CDM 82300 CPT 301 RC outpatient 155 155 UNITED HEALTHCARE (COMMERCIAL) [3081199] UNITED HEALTHCARE 87726 [308119901] 96.1 percent of total billed charges 96.1 147.25 Technical (Hospital) Services Fecal Occ Bl Test Ifob Diag PX-3018227400 CDM 82274 CPT 301 RC outpatient 127 127 CIGNA 62308 [3081051] CIGNA 62308 [308105105] 101.6 percent of total billed charges 78.74 120.65 Technical (Hospital) Services Fecal Occ Bl Test Ifob Diag PX-3018227400 CDM 82274 CPT 301 RC outpatient 127 127 CIGNA 62308 [3081051] CIGNA STATE OF WYOMING [308105107] 101.6 percent of total billed charges 78.74 120.65 Technical (Hospital) Services Fecal Occ Bl Test Ifob Diag PX-3018227400 CDM 82274 CPT 301 RC outpatient 127 127 MEDICA (COMMERCIAL) 94265 [3081118] MEDICA CLAIMS [308111801] 114.3 percent of total billed charges 78.74 120.65 Technical (Hospital) Services Fecal Occ Bl Test Ifob Diag PX-3018227400 CDM 82274 CPT 301 RC outpatient 127 127 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES PPO [308136801] 101.6 percent of total billed charges 78.74 120.65 Technical (Hospital) Services Fecal Occ Bl Test Ifob Diag PX-3018227400 CDM 82274 CPT 301 RC outpatient 127 127 UNITED HEALTHCARE (COMMERCIAL) [3081199] UNITED HEALTHCARE 87726 [308119901] 78.74 percent of total billed charges 78.74 120.65 Technical (Hospital) Services Fecal Occ Bl Test Ifob Diag PX-3018227400 CDM 82274 CPT 301 RC outpatient 127 127 HEALTHPARTNERS SX009 HEALTHPARTNERS 101.6 percent of total billed charges 78.74 120.65 Technical (Hospital) Services Fecal Occ Bl Test Ifob Diag PX-3018227400 CDM 82274 CPT 301 RC outpatient 127 127 MULTIPLAN INC 34080 [3081285] MULTIPLAN INC [308128501] 120.65 percent of total billed charges 78.74 120.65 Technical (Hospital) Services Fecal Occ Bl Test Ifob Diag PX-3018227400 CDM 82274 CPT 301 RC outpatient 127 127 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES HDHP [308136802] 101.6 percent of total billed charges 78.74 120.65 Technical (Hospital) Services Fecal Occ Bl Test Ifob Diag PX-3018227400 CDM 82274 CPT 301 RC outpatient 127 127 BLUE CROSS BLUE SHIELD WELLMARK SB889 [3081026] BCBS WYOMING [308102603] 120.65 percent of total billed charges 78.74 120.65 Technical (Hospital) Services Fecal Occ Bl Test Ifob Diag PX-3018227400 CDM 82274 CPT 301 RC outpatient 127 127 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES EPO [308136803] 101.6 percent of total billed charges 78.74 120.65 Technical (Hospital) Services Fecal Occ Bl Test Ifob Diag PX-3018227400 CDM 82274 CPT 301 RC inpatient 127 127 CIGNA 62308 [3081051] CIGNA 62308 [308105105] 100.56 percent of total billed charges 78.74 120.65 Technical (Hospital) Services Fecal Occ Bl Test Ifob Diag PX-3018227400 CDM 82274 CPT 301 RC inpatient 127 127 CIGNA 62308 [3081051] CIGNA STATE OF WYOMING [308105107] 100.56 percent of total billed charges 78.74 120.65 Technical (Hospital) Services Fecal Occ Bl Test Ifob Diag PX-3018227400 CDM 82274 CPT 301 RC inpatient 127 127 MEDICA (COMMERCIAL) 94265 [3081118] MEDICA CLAIMS [308111801] 114.3 percent of total billed charges 78.74 120.65 Technical (Hospital) Services Fecal Occ Bl Test Ifob Diag PX-3018227400 CDM 82274 CPT 301 RC inpatient 127 127 MULTIPLAN INC 34080 [3081285] MULTIPLAN INC [308128501] 120.65 percent of total billed charges 78.74 120.65 Technical (Hospital) Services Fecal Occ Bl Test Ifob Diag PX-3018227400 CDM 82274 CPT 301 RC inpatient 127 127 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES EPO [308136803] 100.56 percent of total billed charges 78.74 120.65 Technical (Hospital) Services Fecal Occ Bl Test Ifob Diag PX-3018227400 CDM 82274 CPT 301 RC inpatient 127 127 HEALTHPARTNERS SX009 HEALTHPARTNERS 100.56 percent of total billed charges 78.74 120.65 Technical (Hospital) Services Fecal Occ Bl Test Ifob Diag PX-3018227400 CDM 82274 CPT 301 RC inpatient 127 127 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES HDHP [308136802] 100.56 percent of total billed charges 78.74 120.65 Technical (Hospital) Services Fecal Occ Bl Test Ifob Diag PX-3018227400 CDM 82274 CPT 301 RC inpatient 127 127 BLUE CROSS BLUE SHIELD WELLMARK SB889 [3081026] BCBS WYOMING [308102603] 120.65 percent of total billed charges 78.74 120.65 Technical (Hospital) Services Fecal Occ Bl Test Ifob Diag PX-3018227400 CDM 82274 CPT 301 RC inpatient 127 127 UNITED HEALTHCARE (COMMERCIAL) [3081199] UNITED HEALTHCARE 87726 [308119901] 78.74 percent of total billed charges 78.74 120.65 Technical (Hospital) Services Fecal Occ Bl Test Ifob Diag PX-3018227400 CDM 82274 CPT 301 RC inpatient 127 127 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES PPO [308136801] 100.56 percent of total billed charges 78.74 120.65 Technical (Hospital) Services Fecal Occult Bl Test Ifob Scrn PX-3018227401 CDM 82274 CPT 301 RC inpatient 131 131 MEDICA (COMMERCIAL) 94265 [3081118] MEDICA CLAIMS [308111801] 117.9 percent of total billed charges 81.22 124.45 Technical (Hospital) Services Fecal Occult Bl Test Ifob Scrn PX-3018227401 CDM 82274 CPT 301 RC inpatient 131 131 MULTIPLAN INC 34080 [3081285] MULTIPLAN INC [308128501] 124.45 percent of total billed charges 81.22 124.45 Technical (Hospital) Services Fecal Occult Bl Test Ifob Scrn PX-3018227401 CDM 82274 CPT 301 RC inpatient 131 131 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES EPO [308136803] 103.73 percent of total billed charges 81.22 124.45 Technical (Hospital) Services Fecal Occult Bl Test Ifob Scrn PX-3018227401 CDM 82274 CPT 301 RC inpatient 131 131 HEALTHPARTNERS SX009 HEALTHPARTNERS 103.73 percent of total billed charges 81.22 124.45 Technical (Hospital) Services Fecal Occult Bl Test Ifob Scrn PX-3018227401 CDM 82274 CPT 301 RC inpatient 131 131 BLUE CROSS BLUE SHIELD WELLMARK SB889 [3081026] BCBS WYOMING [308102603] 124.45 percent of total billed charges 81.22 124.45 Technical (Hospital) Services Fecal Occult Bl Test Ifob Scrn PX-3018227401 CDM 82274 CPT 301 RC inpatient 131 131 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES HDHP [308136802] 103.73 percent of total billed charges 81.22 124.45 Technical (Hospital) Services Fecal Occult Bl Test Ifob Scrn PX-3018227401 CDM 82274 CPT 301 RC inpatient 131 131 UNITED HEALTHCARE (COMMERCIAL) [3081199] UNITED HEALTHCARE 87726 [308119901] 81.22 percent of total billed charges 81.22 124.45 Technical (Hospital) Services Fecal Occult Bl Test Ifob Scrn PX-3018227401 CDM 82274 CPT 301 RC inpatient 131 131 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES PPO [308136801] 103.73 percent of total billed charges 81.22 124.45 Technical (Hospital) Services Fecal Occult Bl Test Ifob Scrn PX-3018227401 CDM 82274 CPT 301 RC inpatient 131 131 CIGNA 62308 [3081051] CIGNA 62308 [308105105] 103.73 percent of total billed charges 81.22 124.45 Technical (Hospital) Services Fecal Occult Bl Test Ifob Scrn PX-3018227401 CDM 82274 CPT 301 RC inpatient 131 131 CIGNA 62308 [3081051] CIGNA STATE OF WYOMING [308105107] 103.73 percent of total billed charges 81.22 124.45 Technical (Hospital) Services Fecal Occult Bl Test Ifob Scrn PX-3018227401 CDM 82274 CPT 301 RC outpatient 131 131 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES EPO [308136803] 104.8 percent of total billed charges 81.22 124.45 Technical (Hospital) Services Fecal Occult Bl Test Ifob Scrn PX-3018227401 CDM 82274 CPT 301 RC outpatient 131 131 BLUE CROSS BLUE SHIELD WELLMARK SB889 [3081026] BCBS WYOMING [308102603] 124.45 percent of total billed charges 81.22 124.45 Technical (Hospital) Services Fecal Occult Bl Test Ifob Scrn PX-3018227401 CDM 82274 CPT 301 RC outpatient 131 131 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES HDHP [308136802] 104.8 percent of total billed charges 81.22 124.45 Technical (Hospital) Services Fecal Occult Bl Test Ifob Scrn PX-3018227401 CDM 82274 CPT 301 RC outpatient 131 131 MULTIPLAN INC 34080 [3081285] MULTIPLAN INC [308128501] 124.45 percent of total billed charges 81.22 124.45 Technical (Hospital) Services Fecal Occult Bl Test Ifob Scrn PX-3018227401 CDM 82274 CPT 301 RC outpatient 131 131 HEALTHPARTNERS SX009 HEALTHPARTNERS 104.8 percent of total billed charges 81.22 124.45 Technical (Hospital) Services Fecal Occult Bl Test Ifob Scrn PX-3018227401 CDM 82274 CPT 301 RC outpatient 131 131 UNITED HEALTHCARE (COMMERCIAL) [3081199] UNITED HEALTHCARE 87726 [308119901] 81.22 percent of total billed charges 81.22 124.45 Technical (Hospital) Services Fecal Occult Bl Test Ifob Scrn PX-3018227401 CDM 82274 CPT 301 RC outpatient 131 131 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES PPO [308136801] 104.8 percent of total billed charges 81.22 124.45 Technical (Hospital) Services Fecal Occult Bl Test Ifob Scrn PX-3018227401 CDM 82274 CPT 301 RC outpatient 131 131 MEDICA (COMMERCIAL) 94265 [3081118] MEDICA CLAIMS [308111801] 117.9 percent of total billed charges 81.22 124.45 Technical (Hospital) Services Fecal Occult Bl Test Ifob Scrn PX-3018227401 CDM 82274 CPT 301 RC outpatient 131 131 CIGNA 62308 [3081051] CIGNA 62308 [308105105] 104.8 percent of total billed charges 81.22 124.45 Technical (Hospital) Services Fecal Occult Bl Test Ifob Scrn PX-3018227401 CDM 82274 CPT 301 RC outpatient 131 131 CIGNA 62308 [3081051] CIGNA STATE OF WYOMING [308105107] 104.8 percent of total billed charges 81.22 124.45 Technical (Hospital) Services Occult Blood Feces Waived PX-3018227200 CDM 82272 CPT 301 RC inpatient 69 69 CIGNA 62308 [3081051] CIGNA 62308 [308105105] 54.63 percent of total billed charges 42.78 65.55 Technical (Hospital) Services Occult Blood Feces Waived PX-3018227200 CDM 82272 CPT 301 RC inpatient 69 69 CIGNA 62308 [3081051] CIGNA STATE OF WYOMING [308105107] 54.63 percent of total billed charges 42.78 65.55 Technical (Hospital) Services Occult Blood Feces Waived PX-3018227200 CDM 82272 CPT 301 RC inpatient 69 69 BLUE CROSS BLUE SHIELD WELLMARK SB889 [3081026] BCBS WYOMING [308102603] 65.55 percent of total billed charges 42.78 65.55 Technical (Hospital) Services Occult Blood Feces Waived PX-3018227200 CDM 82272 CPT 301 RC inpatient 69 69 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES PPO [308136801] 54.63 percent of total billed charges 42.78 65.55 Technical (Hospital) Services Occult Blood Feces Waived PX-3018227200 CDM 82272 CPT 301 RC inpatient 69 69 UNITED HEALTHCARE (COMMERCIAL) [3081199] UNITED HEALTHCARE 87726 [308119901] 42.78 percent of total billed charges 42.78 65.55 Technical (Hospital) Services Occult Blood Feces Waived PX-3018227200 CDM 82272 CPT 301 RC inpatient 69 69 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES EPO [308136803] 54.63 percent of total billed charges 42.78 65.55 Technical (Hospital) Services Occult Blood Feces Waived PX-3018227200 CDM 82272 CPT 301 RC inpatient 69 69 HEALTHPARTNERS SX009 HEALTHPARTNERS 54.63 percent of total billed charges 42.78 65.55 Technical (Hospital) Services Occult Blood Feces Waived PX-3018227200 CDM 82272 CPT 301 RC inpatient 69 69 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES HDHP [308136802] 54.63 percent of total billed charges 42.78 65.55 Technical (Hospital) Services Occult Blood Feces Waived PX-3018227200 CDM 82272 CPT 301 RC inpatient 69 69 MULTIPLAN INC 34080 [3081285] MULTIPLAN INC [308128501] 65.55 percent of total billed charges 42.78 65.55 Technical (Hospital) Services Occult Blood Feces Waived PX-3018227200 CDM 82272 CPT 301 RC inpatient 69 69 MEDICA (COMMERCIAL) 94265 [3081118] MEDICA CLAIMS [308111801] 62.1 percent of total billed charges 42.78 65.55 Technical (Hospital) Services Occult Blood Feces Waived PX-3018227200 CDM 82272 CPT 301 RC outpatient 69 69 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES PPO [308136801] 55.2 percent of total billed charges 42.78 65.55 Technical (Hospital) Services Occult Blood Feces Waived PX-3018227200 CDM 82272 CPT 301 RC outpatient 69 69 MULTIPLAN INC 34080 [3081285] MULTIPLAN INC [308128501] 65.55 percent of total billed charges 42.78 65.55 Technical (Hospital) Services Occult Blood Feces Waived PX-3018227200 CDM 82272 CPT 301 RC outpatient 69 69 BLUE CROSS BLUE SHIELD WELLMARK SB889 [3081026] BCBS WYOMING [308102603] 65.55 percent of total billed charges 42.78 65.55 Technical (Hospital) Services Occult Blood Feces Waived PX-3018227200 CDM 82272 CPT 301 RC outpatient 69 69 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES EPO [308136803] 55.2 percent of total billed charges 42.78 65.55 Technical (Hospital) Services Occult Blood Feces Waived PX-3018227200 CDM 82272 CPT 301 RC outpatient 69 69 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES HDHP [308136802] 55.2 percent of total billed charges 42.78 65.55 Technical (Hospital) Services Occult Blood Feces Waived PX-3018227200 CDM 82272 CPT 301 RC outpatient 69 69 HEALTHPARTNERS SX009 HEALTHPARTNERS 55.2 percent of total billed charges 42.78 65.55 Technical (Hospital) Services Occult Blood Feces Waived PX-3018227200 CDM 82272 CPT 301 RC outpatient 69 69 UNITED HEALTHCARE (COMMERCIAL) [3081199] UNITED HEALTHCARE 87726 [308119901] 42.78 percent of total billed charges 42.78 65.55 Technical (Hospital) Services Occult Blood Feces Waived PX-3018227200 CDM 82272 CPT 301 RC outpatient 69 69 CIGNA 62308 [3081051] CIGNA 62308 [308105105] 55.2 percent of total billed charges 42.78 65.55 Technical (Hospital) Services Occult Blood Feces Waived PX-3018227200 CDM 82272 CPT 301 RC outpatient 69 69 CIGNA 62308 [3081051] CIGNA STATE OF WYOMING [308105107] 55.2 percent of total billed charges 42.78 65.55 Technical (Hospital) Services Occult Blood Feces Waived PX-3018227200 CDM 82272 CPT 301 RC outpatient 69 69 MEDICA (COMMERCIAL) 94265 [3081118] MEDICA CLAIMS [308111801] 62.1 percent of total billed charges 42.78 65.55 Technical (Hospital) Services Fecal Occult Blood Nonmedicare PX-3018227000 CDM 82270 CPT 301 RC outpatient 40 40 CIGNA 62308 [3081051] CIGNA 62308 [308105105] 32 percent of total billed charges 24.8 38 Technical (Hospital) Services Fecal Occult Blood Nonmedicare PX-3018227000 CDM 82270 CPT 301 RC outpatient 40 40 CIGNA 62308 [3081051] CIGNA STATE OF WYOMING [308105107] 32 percent of total billed charges 24.8 38 Technical (Hospital) Services Fecal Occult Blood Nonmedicare PX-3018227000 CDM 82270 CPT 301 RC outpatient 40 40 MEDICA (COMMERCIAL) 94265 [3081118] MEDICA CLAIMS [308111801] 36 percent of total billed charges 24.8 38 Technical (Hospital) Services Fecal Occult Blood Nonmedicare PX-3018227000 CDM 82270 CPT 301 RC outpatient 40 40 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES PPO [308136801] 32 percent of total billed charges 24.8 38 Technical (Hospital) Services Fecal Occult Blood Nonmedicare PX-3018227000 CDM 82270 CPT 301 RC outpatient 40 40 UNITED HEALTHCARE (COMMERCIAL) [3081199] UNITED HEALTHCARE 87726 [308119901] 24.8 percent of total billed charges 24.8 38 Technical (Hospital) Services Fecal Occult Blood Nonmedicare PX-3018227000 CDM 82270 CPT 301 RC outpatient 40 40 HEALTHPARTNERS SX009 HEALTHPARTNERS 32 percent of total billed charges 24.8 38 Technical (Hospital) Services Fecal Occult Blood Nonmedicare PX-3018227000 CDM 82270 CPT 301 RC outpatient 40 40 MULTIPLAN INC 34080 [3081285] MULTIPLAN INC [308128501] 38 percent of total billed charges 24.8 38 Technical (Hospital) Services Fecal Occult Blood Nonmedicare PX-3018227000 CDM 82270 CPT 301 RC inpatient 40 40 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES PPO [308136801] 31.67 percent of total billed charges 24.8 38 Technical (Hospital) Services Fecal Occult Blood Nonmedicare PX-3018227000 CDM 82270 CPT 301 RC inpatient 40 40 UNITED HEALTHCARE (COMMERCIAL) [3081199] UNITED HEALTHCARE 87726 [308119901] 24.8 percent of total billed charges 24.8 38 Technical (Hospital) Services Fecal Occult Blood Nonmedicare PX-3018227000 CDM 82270 CPT 301 RC inpatient 40 40 BLUE CROSS BLUE SHIELD WELLMARK SB889 [3081026] BCBS WYOMING [308102603] 38 percent of total billed charges 24.8 38 Technical (Hospital) Services Fecal Occult Blood Nonmedicare PX-3018227000 CDM 82270 CPT 301 RC inpatient 40 40 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES HDHP [308136802] 31.67 percent of total billed charges 24.8 38 Technical (Hospital) Services Fecal Occult Blood Nonmedicare PX-3018227000 CDM 82270 CPT 301 RC outpatient 40 40 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES HDHP [308136802] 32 percent of total billed charges 24.8 38 Technical (Hospital) Services Fecal Occult Blood Nonmedicare PX-3018227000 CDM 82270 CPT 301 RC outpatient 40 40 BLUE CROSS BLUE SHIELD WELLMARK SB889 [3081026] BCBS WYOMING [308102603] 38 percent of total billed charges 24.8 38 Technical (Hospital) Services Fecal Occult Blood Nonmedicare PX-3018227000 CDM 82270 CPT 301 RC outpatient 40 40 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES EPO [308136803] 32 percent of total billed charges 24.8 38 Technical (Hospital) Services Fecal Occult Blood Nonmedicare PX-3018227000 CDM 82270 CPT 301 RC inpatient 40 40 HEALTHPARTNERS SX009 HEALTHPARTNERS 31.67 percent of total billed charges 24.8 38 Technical (Hospital) Services Fecal Occult Blood Nonmedicare PX-3018227000 CDM 82270 CPT 301 RC inpatient 40 40 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES EPO [308136803] 31.67 percent of total billed charges 24.8 38 Technical (Hospital) Services Fecal Occult Blood Nonmedicare PX-3018227000 CDM 82270 CPT 301 RC inpatient 40 40 MULTIPLAN INC 34080 [3081285] MULTIPLAN INC [308128501] 38 percent of total billed charges 24.8 38 Technical (Hospital) Services Fecal Occult Blood Nonmedicare PX-3018227000 CDM 82270 CPT 301 RC inpatient 40 40 MEDICA (COMMERCIAL) 94265 [3081118] MEDICA CLAIMS [308111801] 36 percent of total billed charges 24.8 38 Technical (Hospital) Services Fecal Occult Blood Nonmedicare PX-3018227000 CDM 82270 CPT 301 RC inpatient 40 40 CIGNA 62308 [3081051] CIGNA 62308 [308105105] 31.67 percent of total billed charges 24.8 38 Technical (Hospital) Services Fecal Occult Blood Nonmedicare PX-3018227000 CDM 82270 CPT 301 RC inpatient 40 40 CIGNA 62308 [3081051] CIGNA STATE OF WYOMING [308105107] 31.67 percent of total billed charges 24.8 38 Technical (Hospital) Services "Blood, Occult: Feces Screening 1-3" PX-3018227001 CDM 82270 CPT 301 RC outpatient 26 26 CIGNA 62308 [3081051] CIGNA 62308 [308105105] 20.8 percent of total billed charges 16.12 24.7 Technical (Hospital) Services "Blood, Occult: Feces Screening 1-3" PX-3018227001 CDM 82270 CPT 301 RC outpatient 26 26 CIGNA 62308 [3081051] CIGNA STATE OF WYOMING [308105107] 20.8 percent of total billed charges 16.12 24.7 Technical (Hospital) Services "Blood, Occult: Feces Screening 1-3" PX-3018227001 CDM 82270 CPT 301 RC outpatient 26 26 MEDICA (COMMERCIAL) 94265 [3081118] MEDICA CLAIMS [308111801] 23.4 percent of total billed charges 16.12 24.7 Technical (Hospital) Services "Blood, Occult: Feces Screening 1-3" PX-3018227001 CDM 82270 CPT 301 RC outpatient 26 26 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES HDHP [308136802] 20.8 percent of total billed charges 16.12 24.7 Technical (Hospital) Services "Blood, Occult: Feces Screening 1-3" PX-3018227001 CDM 82270 CPT 301 RC outpatient 26 26 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES EPO [308136803] 20.8 percent of total billed charges 16.12 24.7 Technical (Hospital) Services "Blood, Occult: Feces Screening 1-3" PX-3018227001 CDM 82270 CPT 301 RC outpatient 26 26 BLUE CROSS BLUE SHIELD WELLMARK SB889 [3081026] BCBS WYOMING [308102603] 24.7 percent of total billed charges 16.12 24.7 Technical (Hospital) Services "Blood, Occult: Feces Screening 1-3" PX-3018227001 CDM 82270 CPT 301 RC outpatient 26 26 MULTIPLAN INC 34080 [3081285] MULTIPLAN INC [308128501] 24.7 percent of total billed charges 16.12 24.7 Technical (Hospital) Services "Blood, Occult: Feces Screening 1-3" PX-3018227001 CDM 82270 CPT 301 RC outpatient 26 26 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES PPO [308136801] 20.8 percent of total billed charges 16.12 24.7 Technical (Hospital) Services "Blood, Occult: Feces Screening 1-3" PX-3018227001 CDM 82270 CPT 301 RC outpatient 26 26 HEALTHPARTNERS SX009 HEALTHPARTNERS 20.8 percent of total billed charges 16.12 24.7 Technical (Hospital) Services "Blood, Occult: Feces Screening 1-3" PX-3018227001 CDM 82270 CPT 301 RC outpatient 26 26 UNITED HEALTHCARE (COMMERCIAL) [3081199] UNITED HEALTHCARE 87726 [308119901] 16.12 percent of total billed charges 16.12 24.7 Technical (Hospital) Services "Blood, Occult: Feces Screening 1-3" PX-3018227001 CDM 82270 CPT 301 RC inpatient 26 26 BLUE CROSS BLUE SHIELD WELLMARK SB889 [3081026] BCBS WYOMING [308102603] 24.7 percent of total billed charges 16.12 24.7 Technical (Hospital) Services "Blood, Occult: Feces Screening 1-3" PX-3018227001 CDM 82270 CPT 301 RC inpatient 26 26 MULTIPLAN INC 34080 [3081285] MULTIPLAN INC [308128501] 24.7 percent of total billed charges 16.12 24.7 Technical (Hospital) Services "Blood, Occult: Feces Screening 1-3" PX-3018227001 CDM 82270 CPT 301 RC inpatient 26 26 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES HDHP [308136802] 20.59 percent of total billed charges 16.12 24.7 Technical (Hospital) Services "Blood, Occult: Feces Screening 1-3" PX-3018227001 CDM 82270 CPT 301 RC inpatient 26 26 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES PPO [308136801] 20.59 percent of total billed charges 16.12 24.7 Technical (Hospital) Services "Blood, Occult: Feces Screening 1-3" PX-3018227001 CDM 82270 CPT 301 RC inpatient 26 26 UNITED HEALTHCARE (COMMERCIAL) [3081199] UNITED HEALTHCARE 87726 [308119901] 16.12 percent of total billed charges 16.12 24.7 Technical (Hospital) Services "Blood, Occult: Feces Screening 1-3" PX-3018227001 CDM 82270 CPT 301 RC inpatient 26 26 MEDICA (COMMERCIAL) 94265 [3081118] MEDICA CLAIMS [308111801] 23.4 percent of total billed charges 16.12 24.7 Technical (Hospital) Services "Blood, Occult: Feces Screening 1-3" PX-3018227001 CDM 82270 CPT 301 RC inpatient 26 26 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES EPO [308136803] 20.59 percent of total billed charges 16.12 24.7 Technical (Hospital) Services "Blood, Occult: Feces Screening 1-3" PX-3018227001 CDM 82270 CPT 301 RC inpatient 26 26 HEALTHPARTNERS SX009 HEALTHPARTNERS 20.59 percent of total billed charges 16.12 24.7 Technical (Hospital) Services "Blood, Occult: Feces Screening 1-3" PX-3018227001 CDM 82270 CPT 301 RC inpatient 26 26 CIGNA 62308 [3081051] CIGNA 62308 [308105105] 20.59 percent of total billed charges 16.12 24.7 Technical (Hospital) Services "Blood, Occult: Feces Screening 1-3" PX-3018227001 CDM 82270 CPT 301 RC inpatient 26 26 CIGNA 62308 [3081051] CIGNA STATE OF WYOMING [308105107] 20.59 percent of total billed charges 16.12 24.7 Technical (Hospital) Services Ref Biotinidase Deficiency Screen PX-3018226100 CDM 82261 CPT 301 RC inpatient 34 34 HEALTHPARTNERS SX009 HEALTHPARTNERS 26.92 percent of total billed charges 21.08 32.3 Technical (Hospital) Services Ref Biotinidase Deficiency Screen PX-3018226100 CDM 82261 CPT 301 RC inpatient 34 34 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES EPO [308136803] 26.92 percent of total billed charges 21.08 32.3 Technical (Hospital) Services Ref Biotinidase Deficiency Screen PX-3018226100 CDM 82261 CPT 301 RC inpatient 34 34 MEDICA (COMMERCIAL) 94265 [3081118] MEDICA CLAIMS [308111801] 30.6 percent of total billed charges 21.08 32.3 Technical (Hospital) Services Ref Biotinidase Deficiency Screen PX-3018226100 CDM 82261 CPT 301 RC inpatient 34 34 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES HDHP [308136802] 26.92 percent of total billed charges 21.08 32.3 Technical (Hospital) Services Ref Biotinidase Deficiency Screen PX-3018226100 CDM 82261 CPT 301 RC inpatient 34 34 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES PPO [308136801] 26.92 percent of total billed charges 21.08 32.3 Technical (Hospital) Services Ref Biotinidase Deficiency Screen PX-3018226100 CDM 82261 CPT 301 RC inpatient 34 34 UNITED HEALTHCARE (COMMERCIAL) [3081199] UNITED HEALTHCARE 87726 [308119901] 21.08 percent of total billed charges 21.08 32.3 Technical (Hospital) Services Ref Biotinidase Deficiency Screen PX-3018226100 CDM 82261 CPT 301 RC inpatient 34 34 BLUE CROSS BLUE SHIELD WELLMARK SB889 [3081026] BCBS WYOMING [308102603] 32.3 percent of total billed charges 21.08 32.3 Technical (Hospital) Services Ref Biotinidase Deficiency Screen PX-3018226100 CDM 82261 CPT 301 RC inpatient 34 34 MULTIPLAN INC 34080 [3081285] MULTIPLAN INC [308128501] 32.3 percent of total billed charges 21.08 32.3 Technical (Hospital) Services Ref Biotinidase Deficiency Screen PX-3018226100 CDM 82261 CPT 301 RC inpatient 34 34 CIGNA 62308 [3081051] CIGNA 62308 [308105105] 26.92 percent of total billed charges 21.08 32.3 Technical (Hospital) Services Ref Biotinidase Deficiency Screen PX-3018226100 CDM 82261 CPT 301 RC inpatient 34 34 CIGNA 62308 [3081051] CIGNA STATE OF WYOMING [308105107] 26.92 percent of total billed charges 21.08 32.3 Technical (Hospital) Services Ref Biotinidase Deficiency Screen PX-3018226100 CDM 82261 CPT 301 RC outpatient 34 34 MEDICA (COMMERCIAL) 94265 [3081118] MEDICA CLAIMS [308111801] 30.6 percent of total billed charges 21.08 32.3 Technical (Hospital) Services Ref Biotinidase Deficiency Screen PX-3018226100 CDM 82261 CPT 301 RC outpatient 34 34 CIGNA 62308 [3081051] CIGNA 62308 [308105105] 27.2 percent of total billed charges 21.08 32.3 Technical (Hospital) Services Ref Biotinidase Deficiency Screen PX-3018226100 CDM 82261 CPT 301 RC outpatient 34 34 CIGNA 62308 [3081051] CIGNA STATE OF WYOMING [308105107] 27.2 percent of total billed charges 21.08 32.3 Technical (Hospital) Services Ref Biotinidase Deficiency Screen PX-3018226100 CDM 82261 CPT 301 RC outpatient 34 34 UNITED HEALTHCARE (COMMERCIAL) [3081199] UNITED HEALTHCARE 87726 [308119901] 21.08 percent of total billed charges 21.08 32.3 Technical (Hospital) Services Ref Biotinidase Deficiency Screen PX-3018226100 CDM 82261 CPT 301 RC outpatient 34 34 HEALTHPARTNERS SX009 HEALTHPARTNERS 27.2 percent of total billed charges 21.08 32.3 Technical (Hospital) Services Ref Biotinidase Deficiency Screen PX-3018226100 CDM 82261 CPT 301 RC outpatient 34 34 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES PPO [308136801] 27.2 percent of total billed charges 21.08 32.3 Technical (Hospital) Services Ref Biotinidase Deficiency Screen PX-3018226100 CDM 82261 CPT 301 RC outpatient 34 34 BLUE CROSS BLUE SHIELD WELLMARK SB889 [3081026] BCBS WYOMING [308102603] 32.3 percent of total billed charges 21.08 32.3 Technical (Hospital) Services Ref Biotinidase Deficiency Screen PX-3018226100 CDM 82261 CPT 301 RC outpatient 34 34 MULTIPLAN INC 34080 [3081285] MULTIPLAN INC [308128501] 32.3 percent of total billed charges 21.08 32.3 Technical (Hospital) Services Ref Biotinidase Deficiency Screen PX-3018226100 CDM 82261 CPT 301 RC outpatient 34 34 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES EPO [308136803] 27.2 percent of total billed charges 21.08 32.3 Technical (Hospital) Services Ref Biotinidase Deficiency Screen PX-3018226100 CDM 82261 CPT 301 RC outpatient 34 34 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES HDHP [308136802] 27.2 percent of total billed charges 21.08 32.3 Technical (Hospital) Services Conjugated Bilirubin PX-3018224800 CDM 82248 CPT 301 RC outpatient 50 50 MULTIPLAN INC 34080 [3081285] MULTIPLAN INC [308128501] 47.5 percent of total billed charges 31 47.5 Technical (Hospital) Services Conjugated Bilirubin PX-3018224800 CDM 82248 CPT 301 RC outpatient 50 50 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES HDHP [308136802] 40 percent of total billed charges 31 47.5 Technical (Hospital) Services Conjugated Bilirubin PX-3018224800 CDM 82248 CPT 301 RC outpatient 50 50 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES EPO [308136803] 40 percent of total billed charges 31 47.5 Technical (Hospital) Services Conjugated Bilirubin PX-3018224800 CDM 82248 CPT 301 RC outpatient 50 50 BLUE CROSS BLUE SHIELD WELLMARK SB889 [3081026] BCBS WYOMING [308102603] 47.5 percent of total billed charges 31 47.5 Technical (Hospital) Services Conjugated Bilirubin PX-3018224800 CDM 82248 CPT 301 RC outpatient 50 50 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES PPO [308136801] 40 percent of total billed charges 31 47.5 Technical (Hospital) Services Conjugated Bilirubin PX-3018224800 CDM 82248 CPT 301 RC outpatient 50 50 UNITED HEALTHCARE (COMMERCIAL) [3081199] UNITED HEALTHCARE 87726 [308119901] 31 percent of total billed charges 31 47.5 Technical (Hospital) Services Conjugated Bilirubin PX-3018224800 CDM 82248 CPT 301 RC outpatient 50 50 HEALTHPARTNERS SX009 HEALTHPARTNERS 40 percent of total billed charges 31 47.5 Technical (Hospital) Services Conjugated Bilirubin PX-3018224800 CDM 82248 CPT 301 RC outpatient 50 50 MEDICA (COMMERCIAL) 94265 [3081118] MEDICA CLAIMS [308111801] 45 percent of total billed charges 31 47.5 Technical (Hospital) Services Conjugated Bilirubin PX-3018224800 CDM 82248 CPT 301 RC outpatient 50 50 CIGNA 62308 [3081051] CIGNA 62308 [308105105] 40 percent of total billed charges 31 47.5 Technical (Hospital) Services Conjugated Bilirubin PX-3018224800 CDM 82248 CPT 301 RC outpatient 50 50 CIGNA 62308 [3081051] CIGNA STATE OF WYOMING [308105107] 40 percent of total billed charges 31 47.5 Technical (Hospital) Services Conjugated Bilirubin PX-3018224800 CDM 82248 CPT 301 RC inpatient 50 50 CIGNA 62308 [3081051] CIGNA 62308 [308105105] 39.59 percent of total billed charges 31 47.5 Technical (Hospital) Services Conjugated Bilirubin PX-3018224800 CDM 82248 CPT 301 RC inpatient 50 50 CIGNA 62308 [3081051] CIGNA STATE OF WYOMING [308105107] 39.59 percent of total billed charges 31 47.5 Technical (Hospital) Services Conjugated Bilirubin PX-3018224800 CDM 82248 CPT 301 RC inpatient 50 50 HEALTHPARTNERS SX009 HEALTHPARTNERS 39.59 percent of total billed charges 31 47.5 Technical (Hospital) Services Conjugated Bilirubin PX-3018224800 CDM 82248 CPT 301 RC inpatient 50 50 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES EPO [308136803] 39.59 percent of total billed charges 31 47.5 Technical (Hospital) Services Conjugated Bilirubin PX-3018224800 CDM 82248 CPT 301 RC inpatient 50 50 MEDICA (COMMERCIAL) 94265 [3081118] MEDICA CLAIMS [308111801] 45 percent of total billed charges 31 47.5 Technical (Hospital) Services Conjugated Bilirubin PX-3018224800 CDM 82248 CPT 301 RC inpatient 50 50 UNITED HEALTHCARE (COMMERCIAL) [3081199] UNITED HEALTHCARE 87726 [308119901] 31 percent of total billed charges 31 47.5 Technical (Hospital) Services Conjugated Bilirubin PX-3018224800 CDM 82248 CPT 301 RC inpatient 50 50 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES PPO [308136801] 39.59 percent of total billed charges 31 47.5 Technical (Hospital) Services Conjugated Bilirubin PX-3018224800 CDM 82248 CPT 301 RC inpatient 50 50 BLUE CROSS BLUE SHIELD WELLMARK SB889 [3081026] BCBS WYOMING [308102603] 47.5 percent of total billed charges 31 47.5 Technical (Hospital) Services Conjugated Bilirubin PX-3018224800 CDM 82248 CPT 301 RC inpatient 50 50 MULTIPLAN INC 34080 [3081285] MULTIPLAN INC [308128501] 47.5 percent of total billed charges 31 47.5 Technical (Hospital) Services Conjugated Bilirubin PX-3018224800 CDM 82248 CPT 301 RC inpatient 50 50 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES HDHP [308136802] 39.59 percent of total billed charges 31 47.5 Technical (Hospital) Services Bilirubin Total PX-3018224700 CDM 82247 CPT 301 RC outpatient 66 66 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES PPO [308136801] 52.8 percent of total billed charges 40.92 62.7 Technical (Hospital) Services Bilirubin Total PX-3018224700 CDM 82247 CPT 301 RC outpatient 66 66 UNITED HEALTHCARE (COMMERCIAL) [3081199] UNITED HEALTHCARE 87726 [308119901] 40.92 percent of total billed charges 40.92 62.7 Technical (Hospital) Services Bilirubin Total PX-3018224700 CDM 82247 CPT 301 RC outpatient 66 66 HEALTHPARTNERS SX009 HEALTHPARTNERS 52.8 percent of total billed charges 40.92 62.7 Technical (Hospital) Services Bilirubin Total PX-3018224700 CDM 82247 CPT 301 RC outpatient 66 66 BLUE CROSS BLUE SHIELD WELLMARK SB889 [3081026] BCBS WYOMING [308102603] 62.7 percent of total billed charges 40.92 62.7 Technical (Hospital) Services Bilirubin Total PX-3018224700 CDM 82247 CPT 301 RC outpatient 66 66 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES EPO [308136803] 52.8 percent of total billed charges 40.92 62.7 Technical (Hospital) Services Bilirubin Total PX-3018224700 CDM 82247 CPT 301 RC outpatient 66 66 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES HDHP [308136802] 52.8 percent of total billed charges 40.92 62.7 Technical (Hospital) Services Bilirubin Total PX-3018224700 CDM 82247 CPT 301 RC outpatient 66 66 MULTIPLAN INC 34080 [3081285] MULTIPLAN INC [308128501] 62.7 percent of total billed charges 40.92 62.7 Technical (Hospital) Services Bilirubin Total PX-3018224700 CDM 82247 CPT 301 RC outpatient 66 66 MEDICA (COMMERCIAL) 94265 [3081118] MEDICA CLAIMS [308111801] 59.4 percent of total billed charges 40.92 62.7 Technical (Hospital) Services Bilirubin Total PX-3018224700 CDM 82247 CPT 301 RC inpatient 66 66 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES PPO [308136801] 52.26 percent of total billed charges 40.92 62.7 Technical (Hospital) Services Bilirubin Total PX-3018224700 CDM 82247 CPT 301 RC inpatient 66 66 UNITED HEALTHCARE (COMMERCIAL) [3081199] UNITED HEALTHCARE 87726 [308119901] 40.92 percent of total billed charges 40.92 62.7 Technical (Hospital) Services Bilirubin Total PX-3018224700 CDM 82247 CPT 301 RC inpatient 66 66 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES HDHP [308136802] 52.26 percent of total billed charges 40.92 62.7 Technical (Hospital) Services Bilirubin Total PX-3018224700 CDM 82247 CPT 301 RC inpatient 66 66 MULTIPLAN INC 34080 [3081285] MULTIPLAN INC [308128501] 62.7 percent of total billed charges 40.92 62.7 Technical (Hospital) Services Bilirubin Total PX-3018224700 CDM 82247 CPT 301 RC outpatient 66 66 CIGNA 62308 [3081051] CIGNA 62308 [308105105] 52.8 percent of total billed charges 40.92 62.7 Technical (Hospital) Services Bilirubin Total PX-3018224700 CDM 82247 CPT 301 RC outpatient 66 66 CIGNA 62308 [3081051] CIGNA STATE OF WYOMING [308105107] 52.8 percent of total billed charges 40.92 62.7 Technical (Hospital) Services Bilirubin Total PX-3018224700 CDM 82247 CPT 301 RC inpatient 66 66 BLUE CROSS BLUE SHIELD WELLMARK SB889 [3081026] BCBS WYOMING [308102603] 62.7 percent of total billed charges 40.92 62.7 Technical (Hospital) Services Bilirubin Total PX-3018224700 CDM 82247 CPT 301 RC inpatient 66 66 HEALTHPARTNERS SX009 HEALTHPARTNERS 52.26 percent of total billed charges 40.92 62.7 Technical (Hospital) Services Bilirubin Total PX-3018224700 CDM 82247 CPT 301 RC inpatient 66 66 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES EPO [308136803] 52.26 percent of total billed charges 40.92 62.7 Technical (Hospital) Services Bilirubin Total PX-3018224700 CDM 82247 CPT 301 RC inpatient 66 66 MEDICA (COMMERCIAL) 94265 [3081118] MEDICA CLAIMS [308111801] 59.4 percent of total billed charges 40.92 62.7 Technical (Hospital) Services Bilirubin Total PX-3018224700 CDM 82247 CPT 301 RC inpatient 66 66 CIGNA 62308 [3081051] CIGNA 62308 [308105105] 52.26 percent of total billed charges 40.92 62.7 Technical (Hospital) Services Bilirubin Total PX-3018224700 CDM 82247 CPT 301 RC inpatient 66 66 CIGNA 62308 [3081051] CIGNA STATE OF WYOMING [308105107] 52.26 percent of total billed charges 40.92 62.7 Technical (Hospital) Services Ref Beta 2 Microglobulin Urine PX-3018223200 CDM 82232 CPT 301 RC outpatient 244 244 MEDICA (COMMERCIAL) 94265 [3081118] MEDICA CLAIMS [308111801] 219.6 percent of total billed charges 151.28 231.8 Technical (Hospital) Services Ref Beta 2 Microglobulin Urine PX-3018223200 CDM 82232 CPT 301 RC outpatient 244 244 CIGNA 62308 [3081051] CIGNA 62308 [308105105] 195.2 percent of total billed charges 151.28 231.8 Technical (Hospital) Services Ref Beta 2 Microglobulin Urine PX-3018223200 CDM 82232 CPT 301 RC outpatient 244 244 CIGNA 62308 [3081051] CIGNA STATE OF WYOMING [308105107] 195.2 percent of total billed charges 151.28 231.8 Technical (Hospital) Services Ref Beta 2 Microglobulin Urine PX-3018223200 CDM 82232 CPT 301 RC outpatient 244 244 MULTIPLAN INC 34080 [3081285] MULTIPLAN INC [308128501] 231.8 percent of total billed charges 151.28 231.8 Technical (Hospital) Services Ref Beta 2 Microglobulin Urine PX-3018223200 CDM 82232 CPT 301 RC outpatient 244 244 BLUE CROSS BLUE SHIELD WELLMARK SB889 [3081026] BCBS WYOMING [308102603] 231.8 percent of total billed charges 151.28 231.8 Technical (Hospital) Services Ref Beta 2 Microglobulin Urine PX-3018223200 CDM 82232 CPT 301 RC outpatient 244 244 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES EPO [308136803] 195.2 percent of total billed charges 151.28 231.8 Technical (Hospital) Services Ref Beta 2 Microglobulin Urine PX-3018223200 CDM 82232 CPT 301 RC outpatient 244 244 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES HDHP [308136802] 195.2 percent of total billed charges 151.28 231.8 Technical (Hospital) Services Ref Beta 2 Microglobulin Urine PX-3018223200 CDM 82232 CPT 301 RC outpatient 244 244 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES PPO [308136801] 195.2 percent of total billed charges 151.28 231.8 Technical (Hospital) Services Ref Beta 2 Microglobulin Urine PX-3018223200 CDM 82232 CPT 301 RC outpatient 244 244 UNITED HEALTHCARE (COMMERCIAL) [3081199] UNITED HEALTHCARE 87726 [308119901] 151.28 percent of total billed charges 151.28 231.8 Technical (Hospital) Services Ref Beta 2 Microglobulin Urine PX-3018223200 CDM 82232 CPT 301 RC outpatient 244 244 HEALTHPARTNERS SX009 HEALTHPARTNERS 195.2 percent of total billed charges 151.28 231.8 Technical (Hospital) Services Ref Beta 2 Microglobulin Urine PX-3018223200 CDM 82232 CPT 301 RC inpatient 244 244 CIGNA 62308 [3081051] CIGNA 62308 [308105105] 193.2 percent of total billed charges 151.28 231.8 Technical (Hospital) Services Ref Beta 2 Microglobulin Urine PX-3018223200 CDM 82232 CPT 301 RC inpatient 244 244 CIGNA 62308 [3081051] CIGNA STATE OF WYOMING [308105107] 193.2 percent of total billed charges 151.28 231.8 Technical (Hospital) Services Ref Beta 2 Microglobulin Urine PX-3018223200 CDM 82232 CPT 301 RC inpatient 244 244 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES PPO [308136801] 193.2 percent of total billed charges 151.28 231.8 Technical (Hospital) Services Ref Beta 2 Microglobulin Urine PX-3018223200 CDM 82232 CPT 301 RC inpatient 244 244 UNITED HEALTHCARE (COMMERCIAL) [3081199] UNITED HEALTHCARE 87726 [308119901] 151.28 percent of total billed charges 151.28 231.8 Technical (Hospital) Services Ref Beta 2 Microglobulin Urine PX-3018223200 CDM 82232 CPT 301 RC inpatient 244 244 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES HDHP [308136802] 193.2 percent of total billed charges 151.28 231.8 Technical (Hospital) Services Ref Beta 2 Microglobulin Urine PX-3018223200 CDM 82232 CPT 301 RC inpatient 244 244 BLUE CROSS BLUE SHIELD WELLMARK SB889 [3081026] BCBS WYOMING [308102603] 231.8 percent of total billed charges 151.28 231.8 Technical (Hospital) Services Ref Beta 2 Microglobulin Urine PX-3018223200 CDM 82232 CPT 301 RC inpatient 244 244 MULTIPLAN INC 34080 [3081285] MULTIPLAN INC [308128501] 231.8 percent of total billed charges 151.28 231.8 Technical (Hospital) Services Ref Beta 2 Microglobulin Urine PX-3018223200 CDM 82232 CPT 301 RC inpatient 244 244 HEALTHPARTNERS SX009 HEALTHPARTNERS 193.2 percent of total billed charges 151.28 231.8 Technical (Hospital) Services Ref Beta 2 Microglobulin Urine PX-3018223200 CDM 82232 CPT 301 RC inpatient 244 244 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES EPO [308136803] 193.2 percent of total billed charges 151.28 231.8 Technical (Hospital) Services Ref Beta 2 Microglobulin Urine PX-3018223200 CDM 82232 CPT 301 RC inpatient 244 244 MEDICA (COMMERCIAL) 94265 [3081118] MEDICA CLAIMS [308111801] 219.6 percent of total billed charges 151.28 231.8 Technical (Hospital) Services "Ref Beta 2 Microglobulin, Serum" PX-3018223201 CDM 82232 CPT 301 RC inpatient 194 194 CIGNA 62308 [3081051] CIGNA 62308 [308105105] 153.61 percent of total billed charges 120.28 184.3 Technical (Hospital) Services "Ref Beta 2 Microglobulin, Serum" PX-3018223201 CDM 82232 CPT 301 RC inpatient 194 194 CIGNA 62308 [3081051] CIGNA STATE OF WYOMING [308105107] 153.61 percent of total billed charges 120.28 184.3 Technical (Hospital) Services "Ref Beta 2 Microglobulin, Serum" PX-3018223201 CDM 82232 CPT 301 RC inpatient 194 194 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES EPO [308136803] 153.61 percent of total billed charges 120.28 184.3 Technical (Hospital) Services "Ref Beta 2 Microglobulin, Serum" PX-3018223201 CDM 82232 CPT 301 RC inpatient 194 194 HEALTHPARTNERS SX009 HEALTHPARTNERS 153.61 percent of total billed charges 120.28 184.3 Technical (Hospital) Services "Ref Beta 2 Microglobulin, Serum" PX-3018223201 CDM 82232 CPT 301 RC inpatient 194 194 MEDICA (COMMERCIAL) 94265 [3081118] MEDICA CLAIMS [308111801] 174.6 percent of total billed charges 120.28 184.3 Technical (Hospital) Services "Ref Beta 2 Microglobulin, Serum" PX-3018223201 CDM 82232 CPT 301 RC inpatient 194 194 UNITED HEALTHCARE (COMMERCIAL) [3081199] UNITED HEALTHCARE 87726 [308119901] 120.28 percent of total billed charges 120.28 184.3 Technical (Hospital) Services "Ref Beta 2 Microglobulin, Serum" PX-3018223201 CDM 82232 CPT 301 RC inpatient 194 194 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES PPO [308136801] 153.61 percent of total billed charges 120.28 184.3 Technical (Hospital) Services "Ref Beta 2 Microglobulin, Serum" PX-3018223201 CDM 82232 CPT 301 RC inpatient 194 194 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES HDHP [308136802] 153.61 percent of total billed charges 120.28 184.3 Technical (Hospital) Services "Ref Beta 2 Microglobulin, Serum" PX-3018223201 CDM 82232 CPT 301 RC inpatient 194 194 MULTIPLAN INC 34080 [3081285] MULTIPLAN INC [308128501] 184.3 percent of total billed charges 120.28 184.3 Technical (Hospital) Services "Ref Beta 2 Microglobulin, Serum" PX-3018223201 CDM 82232 CPT 301 RC inpatient 194 194 BLUE CROSS BLUE SHIELD WELLMARK SB889 [3081026] BCBS WYOMING [308102603] 184.3 percent of total billed charges 120.28 184.3 Technical (Hospital) Services "Ref Beta 2 Microglobulin, Serum" PX-3018223201 CDM 82232 CPT 301 RC outpatient 194 194 HEALTHPARTNERS SX009 HEALTHPARTNERS 155.2 percent of total billed charges 120.28 184.3 Technical (Hospital) Services "Ref Beta 2 Microglobulin, Serum" PX-3018223201 CDM 82232 CPT 301 RC outpatient 194 194 UNITED HEALTHCARE (COMMERCIAL) [3081199] UNITED HEALTHCARE 87726 [308119901] 120.28 percent of total billed charges 120.28 184.3 Technical (Hospital) Services "Ref Beta 2 Microglobulin, Serum" PX-3018223201 CDM 82232 CPT 301 RC outpatient 194 194 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES PPO [308136801] 155.2 percent of total billed charges 120.28 184.3 Technical (Hospital) Services "Ref Beta 2 Microglobulin, Serum" PX-3018223201 CDM 82232 CPT 301 RC outpatient 194 194 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES HDHP [308136802] 155.2 percent of total billed charges 120.28 184.3 Technical (Hospital) Services "Ref Beta 2 Microglobulin, Serum" PX-3018223201 CDM 82232 CPT 301 RC outpatient 194 194 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES EPO [308136803] 155.2 percent of total billed charges 120.28 184.3 Technical (Hospital) Services "Ref Beta 2 Microglobulin, Serum" PX-3018223201 CDM 82232 CPT 301 RC outpatient 194 194 BLUE CROSS BLUE SHIELD WELLMARK SB889 [3081026] BCBS WYOMING [308102603] 184.3 percent of total billed charges 120.28 184.3 Technical (Hospital) Services "Ref Beta 2 Microglobulin, Serum" PX-3018223201 CDM 82232 CPT 301 RC outpatient 194 194 MULTIPLAN INC 34080 [3081285] MULTIPLAN INC [308128501] 184.3 percent of total billed charges 120.28 184.3 Technical (Hospital) Services "Ref Beta 2 Microglobulin, Serum" PX-3018223201 CDM 82232 CPT 301 RC outpatient 194 194 CIGNA 62308 [3081051] CIGNA 62308 [308105105] 155.2 percent of total billed charges 120.28 184.3 Technical (Hospital) Services "Ref Beta 2 Microglobulin, Serum" PX-3018223201 CDM 82232 CPT 301 RC outpatient 194 194 CIGNA 62308 [3081051] CIGNA STATE OF WYOMING [308105107] 155.2 percent of total billed charges 120.28 184.3 Technical (Hospital) Services "Ref Beta 2 Microglobulin, Serum" PX-3018223201 CDM 82232 CPT 301 RC outpatient 194 194 MEDICA (COMMERCIAL) 94265 [3081118] MEDICA CLAIMS [308111801] 174.6 percent of total billed charges 120.28 184.3 Technical (Hospital) Services Ref Vitamin C PX-3018218000 CDM 82180 CPT 301 RC inpatient 329 329 CIGNA 62308 [3081051] CIGNA 62308 [308105105] 260.5 percent of total billed charges 203.98 312.55 Technical (Hospital) Services Ref Vitamin C PX-3018218000 CDM 82180 CPT 301 RC inpatient 329 329 CIGNA 62308 [3081051] CIGNA STATE OF WYOMING [308105107] 260.5 percent of total billed charges 203.98 312.55 Technical (Hospital) Services Ref Vitamin C PX-3018218000 CDM 82180 CPT 301 RC inpatient 329 329 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES PPO [308136801] 260.5 percent of total billed charges 203.98 312.55 Technical (Hospital) Services Ref Vitamin C PX-3018218000 CDM 82180 CPT 301 RC inpatient 329 329 UNITED HEALTHCARE (COMMERCIAL) [3081199] UNITED HEALTHCARE 87726 [308119901] 203.98 percent of total billed charges 203.98 312.55 Technical (Hospital) Services Ref Vitamin C PX-3018218000 CDM 82180 CPT 301 RC inpatient 329 329 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES HDHP [308136802] 260.5 percent of total billed charges 203.98 312.55 Technical (Hospital) Services Ref Vitamin C PX-3018218000 CDM 82180 CPT 301 RC inpatient 329 329 MULTIPLAN INC 34080 [3081285] MULTIPLAN INC [308128501] 312.55 percent of total billed charges 203.98 312.55 Technical (Hospital) Services Ref Vitamin C PX-3018218000 CDM 82180 CPT 301 RC inpatient 329 329 BLUE CROSS BLUE SHIELD WELLMARK SB889 [3081026] BCBS WYOMING [308102603] 312.55 percent of total billed charges 203.98 312.55 Technical (Hospital) Services Ref Vitamin C PX-3018218000 CDM 82180 CPT 301 RC inpatient 329 329 HEALTHPARTNERS SX009 HEALTHPARTNERS 260.5 percent of total billed charges 203.98 312.55 Technical (Hospital) Services Ref Vitamin C PX-3018218000 CDM 82180 CPT 301 RC inpatient 329 329 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES EPO [308136803] 260.5 percent of total billed charges 203.98 312.55 Technical (Hospital) Services Ref Vitamin C PX-3018218000 CDM 82180 CPT 301 RC inpatient 329 329 MEDICA (COMMERCIAL) 94265 [3081118] MEDICA CLAIMS [308111801] 296.1 percent of total billed charges 203.98 312.55 Technical (Hospital) Services Ref Vitamin C PX-3018218000 CDM 82180 CPT 301 RC outpatient 329 329 MEDICA (COMMERCIAL) 94265 [3081118] MEDICA CLAIMS [308111801] 296.1 percent of total billed charges 203.98 312.55 Technical (Hospital) Services Ref Vitamin C PX-3018218000 CDM 82180 CPT 301 RC outpatient 329 329 CIGNA 62308 [3081051] CIGNA 62308 [308105105] 263.2 percent of total billed charges 203.98 312.55 Technical (Hospital) Services Ref Vitamin C PX-3018218000 CDM 82180 CPT 301 RC outpatient 329 329 CIGNA 62308 [3081051] CIGNA STATE OF WYOMING [308105107] 263.2 percent of total billed charges 203.98 312.55 Technical (Hospital) Services Ref Vitamin C PX-3018218000 CDM 82180 CPT 301 RC outpatient 329 329 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES HDHP [308136802] 263.2 percent of total billed charges 203.98 312.55 Technical (Hospital) Services Ref Vitamin C PX-3018218000 CDM 82180 CPT 301 RC outpatient 329 329 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES EPO [308136803] 263.2 percent of total billed charges 203.98 312.55 Technical (Hospital) Services Ref Vitamin C PX-3018218000 CDM 82180 CPT 301 RC outpatient 329 329 BLUE CROSS BLUE SHIELD WELLMARK SB889 [3081026] BCBS WYOMING [308102603] 312.55 percent of total billed charges 203.98 312.55 Technical (Hospital) Services Ref Vitamin C PX-3018218000 CDM 82180 CPT 301 RC outpatient 329 329 MULTIPLAN INC 34080 [3081285] MULTIPLAN INC [308128501] 312.55 percent of total billed charges 203.98 312.55 Technical (Hospital) Services Ref Vitamin C PX-3018218000 CDM 82180 CPT 301 RC outpatient 329 329 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES PPO [308136801] 263.2 percent of total billed charges 203.98 312.55 Technical (Hospital) Services Ref Vitamin C PX-3018218000 CDM 82180 CPT 301 RC outpatient 329 329 HEALTHPARTNERS SX009 HEALTHPARTNERS 263.2 percent of total billed charges 203.98 312.55 Technical (Hospital) Services Ref Vitamin C PX-3018218000 CDM 82180 CPT 301 RC outpatient 329 329 UNITED HEALTHCARE (COMMERCIAL) [3081199] UNITED HEALTHCARE 87726 [308119901] 203.98 percent of total billed charges 203.98 312.55 Technical (Hospital) Services "Ref Heavy Metal Screen Arsenic, 24 Hour" PX-3018217500 CDM 82175 CPT 301 RC inpatient 183 183 MEDICA (COMMERCIAL) 94265 [3081118] MEDICA CLAIMS [308111801] 164.7 percent of total billed charges 113.46 173.85 Technical (Hospital) Services "Ref Heavy Metal Screen Arsenic, 24 Hour" PX-3018217500 CDM 82175 CPT 301 RC inpatient 183 183 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES HDHP [308136802] 144.9 percent of total billed charges 113.46 173.85 Technical (Hospital) Services "Ref Heavy Metal Screen Arsenic, 24 Hour" PX-3018217500 CDM 82175 CPT 301 RC inpatient 183 183 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES EPO [308136803] 144.9 percent of total billed charges 113.46 173.85 Technical (Hospital) Services "Ref Heavy Metal Screen Arsenic, 24 Hour" PX-3018217500 CDM 82175 CPT 301 RC inpatient 183 183 HEALTHPARTNERS SX009 HEALTHPARTNERS 144.9 percent of total billed charges 113.46 173.85 Technical (Hospital) Services "Ref Heavy Metal Screen Arsenic, 24 Hour" PX-3018217500 CDM 82175 CPT 301 RC inpatient 183 183 MULTIPLAN INC 34080 [3081285] MULTIPLAN INC [308128501] 173.85 percent of total billed charges 113.46 173.85 Technical (Hospital) Services "Ref Heavy Metal Screen Arsenic, 24 Hour" PX-3018217500 CDM 82175 CPT 301 RC inpatient 183 183 BLUE CROSS BLUE SHIELD WELLMARK SB889 [3081026] BCBS WYOMING [308102603] 173.85 percent of total billed charges 113.46 173.85 Technical (Hospital) Services "Ref Heavy Metal Screen Arsenic, 24 Hour" PX-3018217500 CDM 82175 CPT 301 RC inpatient 183 183 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES PPO [308136801] 144.9 percent of total billed charges 113.46 173.85 Technical (Hospital) Services "Ref Heavy Metal Screen Arsenic, 24 Hour" PX-3018217500 CDM 82175 CPT 301 RC inpatient 183 183 UNITED HEALTHCARE (COMMERCIAL) [3081199] UNITED HEALTHCARE 87726 [308119901] 113.46 percent of total billed charges 113.46 173.85 Technical (Hospital) Services "Ref Heavy Metal Screen Arsenic, 24 Hour" PX-3018217500 CDM 82175 CPT 301 RC inpatient 183 183 CIGNA 62308 [3081051] CIGNA 62308 [308105105] 144.9 percent of total billed charges 113.46 173.85 Technical (Hospital) Services "Ref Heavy Metal Screen Arsenic, 24 Hour" PX-3018217500 CDM 82175 CPT 301 RC inpatient 183 183 CIGNA 62308 [3081051] CIGNA STATE OF WYOMING [308105107] 144.9 percent of total billed charges 113.46 173.85 Technical (Hospital) Services "Ref Heavy Metal Screen Arsenic, 24 Hour" PX-3018217500 CDM 82175 CPT 301 RC outpatient 183 183 UNITED HEALTHCARE (COMMERCIAL) [3081199] UNITED HEALTHCARE 87726 [308119901] 113.46 percent of total billed charges 113.46 173.85 Technical (Hospital) Services "Ref Heavy Metal Screen Arsenic, 24 Hour" PX-3018217500 CDM 82175 CPT 301 RC outpatient 183 183 HEALTHPARTNERS SX009 HEALTHPARTNERS 146.4 percent of total billed charges 113.46 173.85 Technical (Hospital) Services "Ref Heavy Metal Screen Arsenic, 24 Hour" PX-3018217500 CDM 82175 CPT 301 RC outpatient 183 183 MULTIPLAN INC 34080 [3081285] MULTIPLAN INC [308128501] 173.85 percent of total billed charges 113.46 173.85 Technical (Hospital) Services "Ref Heavy Metal Screen Arsenic, 24 Hour" PX-3018217500 CDM 82175 CPT 301 RC outpatient 183 183 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES HDHP [308136802] 146.4 percent of total billed charges 113.46 173.85 Technical (Hospital) Services "Ref Heavy Metal Screen Arsenic, 24 Hour" PX-3018217500 CDM 82175 CPT 301 RC outpatient 183 183 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES EPO [308136803] 146.4 percent of total billed charges 113.46 173.85 Technical (Hospital) Services "Ref Heavy Metal Screen Arsenic, 24 Hour" PX-3018217500 CDM 82175 CPT 301 RC outpatient 183 183 BLUE CROSS BLUE SHIELD WELLMARK SB889 [3081026] BCBS WYOMING [308102603] 173.85 percent of total billed charges 113.46 173.85 Technical (Hospital) Services "Ref Heavy Metal Screen Arsenic, 24 Hour" PX-3018217500 CDM 82175 CPT 301 RC outpatient 183 183 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES PPO [308136801] 146.4 percent of total billed charges 113.46 173.85 Technical (Hospital) Services "Ref Heavy Metal Screen Arsenic, 24 Hour" PX-3018217500 CDM 82175 CPT 301 RC outpatient 183 183 CIGNA 62308 [3081051] CIGNA 62308 [308105105] 146.4 percent of total billed charges 113.46 173.85 Technical (Hospital) Services "Ref Heavy Metal Screen Arsenic, 24 Hour" PX-3018217500 CDM 82175 CPT 301 RC outpatient 183 183 CIGNA 62308 [3081051] CIGNA STATE OF WYOMING [308105107] 146.4 percent of total billed charges 113.46 173.85 Technical (Hospital) Services "Ref Heavy Metal Screen Arsenic, 24 Hour" PX-3018217500 CDM 82175 CPT 301 RC outpatient 183 183 MEDICA (COMMERCIAL) 94265 [3081118] MEDICA CLAIMS [308111801] 164.7 percent of total billed charges 113.46 173.85 Technical (Hospital) Services "Ref Arsenic, 24 Hour, Urine" PX-3018217501 CDM 82175 CPT 301 RC inpatient 183 183 HEALTHPARTNERS SX009 HEALTHPARTNERS 144.9 percent of total billed charges 113.46 173.85 Technical (Hospital) Services "Ref Arsenic, 24 Hour, Urine" PX-3018217501 CDM 82175 CPT 301 RC inpatient 183 183 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES EPO [308136803] 144.9 percent of total billed charges 113.46 173.85 Technical (Hospital) Services "Ref Arsenic, 24 Hour, Urine" PX-3018217501 CDM 82175 CPT 301 RC inpatient 183 183 MEDICA (COMMERCIAL) 94265 [3081118] MEDICA CLAIMS [308111801] 164.7 percent of total billed charges 113.46 173.85 Technical (Hospital) Services "Ref Arsenic, 24 Hour, Urine" PX-3018217501 CDM 82175 CPT 301 RC inpatient 183 183 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES PPO [308136801] 144.9 percent of total billed charges 113.46 173.85 Technical (Hospital) Services "Ref Arsenic, 24 Hour, Urine" PX-3018217501 CDM 82175 CPT 301 RC inpatient 183 183 UNITED HEALTHCARE (COMMERCIAL) [3081199] UNITED HEALTHCARE 87726 [308119901] 113.46 percent of total billed charges 113.46 173.85 Technical (Hospital) Services "Ref Arsenic, 24 Hour, Urine" PX-3018217501 CDM 82175 CPT 301 RC inpatient 183 183 BLUE CROSS BLUE SHIELD WELLMARK SB889 [3081026] BCBS WYOMING [308102603] 173.85 percent of total billed charges 113.46 173.85 Technical (Hospital) Services "Ref Arsenic, 24 Hour, Urine" PX-3018217501 CDM 82175 CPT 301 RC inpatient 183 183 MULTIPLAN INC 34080 [3081285] MULTIPLAN INC [308128501] 173.85 percent of total billed charges 113.46 173.85 Technical (Hospital) Services "Ref Arsenic, 24 Hour, Urine" PX-3018217501 CDM 82175 CPT 301 RC inpatient 183 183 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES HDHP [308136802] 144.9 percent of total billed charges 113.46 173.85 Technical (Hospital) Services "Ref Arsenic, 24 Hour, Urine" PX-3018217501 CDM 82175 CPT 301 RC inpatient 183 183 CIGNA 62308 [3081051] CIGNA 62308 [308105105] 144.9 percent of total billed charges 113.46 173.85 Technical (Hospital) Services "Ref Arsenic, 24 Hour, Urine" PX-3018217501 CDM 82175 CPT 301 RC inpatient 183 183 CIGNA 62308 [3081051] CIGNA STATE OF WYOMING [308105107] 144.9 percent of total billed charges 113.46 173.85 Technical (Hospital) Services "Ref Arsenic, 24 Hour, Urine" PX-3018217501 CDM 82175 CPT 301 RC outpatient 183 183 UNITED HEALTHCARE (COMMERCIAL) [3081199] UNITED HEALTHCARE 87726 [308119901] 113.46 percent of total billed charges 113.46 173.85 Technical (Hospital) Services "Ref Arsenic, 24 Hour, Urine" PX-3018217501 CDM 82175 CPT 301 RC outpatient 183 183 HEALTHPARTNERS SX009 HEALTHPARTNERS 146.4 percent of total billed charges 113.46 173.85 Technical (Hospital) Services "Ref Arsenic, 24 Hour, Urine" PX-3018217501 CDM 82175 CPT 301 RC outpatient 183 183 BLUE CROSS BLUE SHIELD WELLMARK SB889 [3081026] BCBS WYOMING [308102603] 173.85 percent of total billed charges 113.46 173.85 Technical (Hospital) Services "Ref Arsenic, 24 Hour, Urine" PX-3018217501 CDM 82175 CPT 301 RC outpatient 183 183 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES EPO [308136803] 146.4 percent of total billed charges 113.46 173.85 Technical (Hospital) Services "Ref Arsenic, 24 Hour, Urine" PX-3018217501 CDM 82175 CPT 301 RC outpatient 183 183 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES HDHP [308136802] 146.4 percent of total billed charges 113.46 173.85 Technical (Hospital) Services "Ref Arsenic, 24 Hour, Urine" PX-3018217501 CDM 82175 CPT 301 RC outpatient 183 183 MULTIPLAN INC 34080 [3081285] MULTIPLAN INC [308128501] 173.85 percent of total billed charges 113.46 173.85 Technical (Hospital) Services "Ref Arsenic, 24 Hour, Urine" PX-3018217501 CDM 82175 CPT 301 RC outpatient 183 183 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES PPO [308136801] 146.4 percent of total billed charges 113.46 173.85 Technical (Hospital) Services "Ref Arsenic, 24 Hour, Urine" PX-3018217501 CDM 82175 CPT 301 RC outpatient 183 183 MEDICA (COMMERCIAL) 94265 [3081118] MEDICA CLAIMS [308111801] 164.7 percent of total billed charges 113.46 173.85 Technical (Hospital) Services "Ref Arsenic, 24 Hour, Urine" PX-3018217501 CDM 82175 CPT 301 RC outpatient 183 183 CIGNA 62308 [3081051] CIGNA 62308 [308105105] 146.4 percent of total billed charges 113.46 173.85 Technical (Hospital) Services "Ref Arsenic, 24 Hour, Urine" PX-3018217501 CDM 82175 CPT 301 RC outpatient 183 183 CIGNA 62308 [3081051] CIGNA STATE OF WYOMING [308105107] 146.4 percent of total billed charges 113.46 173.85 Technical (Hospital) Services Ref Apolipoprotein A1 PX-3018217200 CDM 82172 CPT 301 RC outpatient 119 119 MEDICA (COMMERCIAL) 94265 [3081118] MEDICA CLAIMS [308111801] 107.1 percent of total billed charges 73.78 113.05 Technical (Hospital) Services Ref Apolipoprotein A1 PX-3018217200 CDM 82172 CPT 301 RC outpatient 119 119 CIGNA 62308 [3081051] CIGNA 62308 [308105105] 95.2 percent of total billed charges 73.78 113.05 Technical (Hospital) Services Ref Apolipoprotein A1 PX-3018217200 CDM 82172 CPT 301 RC outpatient 119 119 CIGNA 62308 [3081051] CIGNA STATE OF WYOMING [308105107] 95.2 percent of total billed charges 73.78 113.05 Technical (Hospital) Services Ref Apolipoprotein A1 PX-3018217200 CDM 82172 CPT 301 RC outpatient 119 119 BLUE CROSS BLUE SHIELD WELLMARK SB889 [3081026] BCBS WYOMING [308102603] 113.05 percent of total billed charges 73.78 113.05 Technical (Hospital) Services Ref Apolipoprotein A1 PX-3018217200 CDM 82172 CPT 301 RC outpatient 119 119 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES EPO [308136803] 95.2 percent of total billed charges 73.78 113.05 Technical (Hospital) Services Ref Apolipoprotein A1 PX-3018217200 CDM 82172 CPT 301 RC outpatient 119 119 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES HDHP [308136802] 95.2 percent of total billed charges 73.78 113.05 Technical (Hospital) Services Ref Apolipoprotein A1 PX-3018217200 CDM 82172 CPT 301 RC outpatient 119 119 MULTIPLAN INC 34080 [3081285] MULTIPLAN INC [308128501] 113.05 percent of total billed charges 73.78 113.05 Technical (Hospital) Services Ref Apolipoprotein A1 PX-3018217200 CDM 82172 CPT 301 RC outpatient 119 119 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES PPO [308136801] 95.2 percent of total billed charges 73.78 113.05 Technical (Hospital) Services Ref Apolipoprotein A1 PX-3018217200 CDM 82172 CPT 301 RC outpatient 119 119 HEALTHPARTNERS SX009 HEALTHPARTNERS 95.2 percent of total billed charges 73.78 113.05 Technical (Hospital) Services Ref Apolipoprotein A1 PX-3018217200 CDM 82172 CPT 301 RC outpatient 119 119 UNITED HEALTHCARE (COMMERCIAL) [3081199] UNITED HEALTHCARE 87726 [308119901] 73.78 percent of total billed charges 73.78 113.05 Technical (Hospital) Services Ref Apolipoprotein A1 PX-3018217200 CDM 82172 CPT 301 RC inpatient 119 119 MEDICA (COMMERCIAL) 94265 [3081118] MEDICA CLAIMS [308111801] 107.1 percent of total billed charges 73.78 113.05 Technical (Hospital) Services Ref Apolipoprotein A1 PX-3018217200 CDM 82172 CPT 301 RC inpatient 119 119 HEALTHPARTNERS SX009 HEALTHPARTNERS 94.22 percent of total billed charges 73.78 113.05 Technical (Hospital) Services Ref Apolipoprotein A1 PX-3018217200 CDM 82172 CPT 301 RC inpatient 119 119 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES EPO [308136803] 94.22 percent of total billed charges 73.78 113.05 Technical (Hospital) Services Ref Apolipoprotein A1 PX-3018217200 CDM 82172 CPT 301 RC inpatient 119 119 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES HDHP [308136802] 94.22 percent of total billed charges 73.78 113.05 Technical (Hospital) Services Ref Apolipoprotein A1 PX-3018217200 CDM 82172 CPT 301 RC inpatient 119 119 BLUE CROSS BLUE SHIELD WELLMARK SB889 [3081026] BCBS WYOMING [308102603] 113.05 percent of total billed charges 73.78 113.05 Technical (Hospital) Services Ref Apolipoprotein A1 PX-3018217200 CDM 82172 CPT 301 RC inpatient 119 119 MULTIPLAN INC 34080 [3081285] MULTIPLAN INC [308128501] 113.05 percent of total billed charges 73.78 113.05 Technical (Hospital) Services Ref Apolipoprotein A1 PX-3018217200 CDM 82172 CPT 301 RC inpatient 119 119 UNITED HEALTHCARE (COMMERCIAL) [3081199] UNITED HEALTHCARE 87726 [308119901] 73.78 percent of total billed charges 73.78 113.05 Technical (Hospital) Services Ref Apolipoprotein A1 PX-3018217200 CDM 82172 CPT 301 RC inpatient 119 119 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES PPO [308136801] 94.22 percent of total billed charges 73.78 113.05 Technical (Hospital) Services Ref Apolipoprotein A1 PX-3018217200 CDM 82172 CPT 301 RC inpatient 119 119 CIGNA 62308 [3081051] CIGNA 62308 [308105105] 94.22 percent of total billed charges 73.78 113.05 Technical (Hospital) Services Ref Apolipoprotein A1 PX-3018217200 CDM 82172 CPT 301 RC inpatient 119 119 CIGNA 62308 [3081051] CIGNA STATE OF WYOMING [308105107] 94.22 percent of total billed charges 73.78 113.05 Technical (Hospital) Services Ref Apolipoprotein B for Apoab PX-3018217204 CDM 82172 CPT 301 RC inpatient 100 100 MEDICA (COMMERCIAL) 94265 [3081118] MEDICA CLAIMS [308111801] 90 percent of total billed charges 62 95 Technical (Hospital) Services Ref Apolipoprotein B for Apoab PX-3018217204 CDM 82172 CPT 301 RC inpatient 100 100 HEALTHPARTNERS SX009 HEALTHPARTNERS 79.18 percent of total billed charges 62 95 Technical (Hospital) Services Ref Apolipoprotein B for Apoab PX-3018217204 CDM 82172 CPT 301 RC inpatient 100 100 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES EPO [308136803] 79.18 percent of total billed charges 62 95 Technical (Hospital) Services Ref Apolipoprotein B for Apoab PX-3018217204 CDM 82172 CPT 301 RC inpatient 100 100 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES HDHP [308136802] 79.18 percent of total billed charges 62 95 Technical (Hospital) Services Ref Apolipoprotein B for Apoab PX-3018217204 CDM 82172 CPT 301 RC inpatient 100 100 BLUE CROSS BLUE SHIELD WELLMARK SB889 [3081026] BCBS WYOMING [308102603] 95 percent of total billed charges 62 95 Technical (Hospital) Services Ref Apolipoprotein B for Apoab PX-3018217204 CDM 82172 CPT 301 RC inpatient 100 100 MULTIPLAN INC 34080 [3081285] MULTIPLAN INC [308128501] 95 percent of total billed charges 62 95 Technical (Hospital) Services Ref Apolipoprotein B for Apoab PX-3018217204 CDM 82172 CPT 301 RC inpatient 100 100 UNITED HEALTHCARE (COMMERCIAL) [3081199] UNITED HEALTHCARE 87726 [308119901] 62 percent of total billed charges 62 95 Technical (Hospital) Services Ref Apolipoprotein B for Apoab PX-3018217204 CDM 82172 CPT 301 RC inpatient 100 100 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES PPO [308136801] 79.18 percent of total billed charges 62 95 Technical (Hospital) Services Ref Apolipoprotein B for Apoab PX-3018217204 CDM 82172 CPT 301 RC inpatient 100 100 CIGNA 62308 [3081051] CIGNA 62308 [308105105] 79.18 percent of total billed charges 62 95 Technical (Hospital) Services Ref Apolipoprotein B for Apoab PX-3018217204 CDM 82172 CPT 301 RC inpatient 100 100 CIGNA 62308 [3081051] CIGNA STATE OF WYOMING [308105107] 79.18 percent of total billed charges 62 95 Technical (Hospital) Services Ref Apolipoprotein B for Apoab PX-3018217204 CDM 82172 CPT 301 RC outpatient 100 100 CIGNA 62308 [3081051] CIGNA 62308 [308105105] 80 percent of total billed charges 62 95 Technical (Hospital) Services Ref Apolipoprotein B for Apoab PX-3018217204 CDM 82172 CPT 301 RC outpatient 100 100 CIGNA 62308 [3081051] CIGNA STATE OF WYOMING [308105107] 80 percent of total billed charges 62 95 Technical (Hospital) Services Ref Apolipoprotein B for Apoab PX-3018217204 CDM 82172 CPT 301 RC outpatient 100 100 MEDICA (COMMERCIAL) 94265 [3081118] MEDICA CLAIMS [308111801] 90 percent of total billed charges 62 95 Technical (Hospital) Services Ref Apolipoprotein B for Apoab PX-3018217204 CDM 82172 CPT 301 RC outpatient 100 100 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES PPO [308136801] 80 percent of total billed charges 62 95 Technical (Hospital) Services Ref Apolipoprotein B for Apoab PX-3018217204 CDM 82172 CPT 301 RC outpatient 100 100 MULTIPLAN INC 34080 [3081285] MULTIPLAN INC [308128501] 95 percent of total billed charges 62 95 Technical (Hospital) Services Ref Apolipoprotein B for Apoab PX-3018217204 CDM 82172 CPT 301 RC outpatient 100 100 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES HDHP [308136802] 80 percent of total billed charges 62 95 Technical (Hospital) Services Ref Apolipoprotein B for Apoab PX-3018217204 CDM 82172 CPT 301 RC outpatient 100 100 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES EPO [308136803] 80 percent of total billed charges 62 95 Technical (Hospital) Services Ref Apolipoprotein B for Apoab PX-3018217204 CDM 82172 CPT 301 RC outpatient 100 100 BLUE CROSS BLUE SHIELD WELLMARK SB889 [3081026] BCBS WYOMING [308102603] 95 percent of total billed charges 62 95 Technical (Hospital) Services Ref Apolipoprotein B for Apoab PX-3018217204 CDM 82172 CPT 301 RC outpatient 100 100 HEALTHPARTNERS SX009 HEALTHPARTNERS 80 percent of total billed charges 62 95 Technical (Hospital) Services Ref Apolipoprotein B for Apoab PX-3018217204 CDM 82172 CPT 301 RC outpatient 100 100 UNITED HEALTHCARE (COMMERCIAL) [3081199] UNITED HEALTHCARE 87726 [308119901] 62 percent of total billed charges 62 95 Technical (Hospital) Services Ref Angiotensin I-Converting Enzyme CSF PX-3018216400 CDM 82164 CPT 301 RC outpatient 183 183 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES PPO [308136801] 146.4 percent of total billed charges 113.46 173.85 Technical (Hospital) Services Ref Angiotensin I-Converting Enzyme CSF PX-3018216400 CDM 82164 CPT 301 RC outpatient 183 183 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES HDHP [308136802] 146.4 percent of total billed charges 113.46 173.85 Technical (Hospital) Services Ref Angiotensin I-Converting Enzyme CSF PX-3018216400 CDM 82164 CPT 301 RC outpatient 183 183 MULTIPLAN INC 34080 [3081285] MULTIPLAN INC [308128501] 173.85 percent of total billed charges 113.46 173.85 Technical (Hospital) Services Ref Angiotensin I-Converting Enzyme CSF PX-3018216400 CDM 82164 CPT 301 RC outpatient 183 183 BLUE CROSS BLUE SHIELD WELLMARK SB889 [3081026] BCBS WYOMING [308102603] 173.85 percent of total billed charges 113.46 173.85 Technical (Hospital) Services Ref Angiotensin I-Converting Enzyme CSF PX-3018216400 CDM 82164 CPT 301 RC outpatient 183 183 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES EPO [308136803] 146.4 percent of total billed charges 113.46 173.85 Technical (Hospital) Services Ref Angiotensin I-Converting Enzyme CSF PX-3018216400 CDM 82164 CPT 301 RC outpatient 183 183 UNITED HEALTHCARE (COMMERCIAL) [3081199] UNITED HEALTHCARE 87726 [308119901] 113.46 percent of total billed charges 113.46 173.85 Technical (Hospital) Services Ref Angiotensin I-Converting Enzyme CSF PX-3018216400 CDM 82164 CPT 301 RC outpatient 183 183 HEALTHPARTNERS SX009 HEALTHPARTNERS 146.4 percent of total billed charges 113.46 173.85 Technical (Hospital) Services Ref Angiotensin I-Converting Enzyme CSF PX-3018216400 CDM 82164 CPT 301 RC outpatient 183 183 MEDICA (COMMERCIAL) 94265 [3081118] MEDICA CLAIMS [308111801] 164.7 percent of total billed charges 113.46 173.85 Technical (Hospital) Services Ref Angiotensin I-Converting Enzyme CSF PX-3018216400 CDM 82164 CPT 301 RC outpatient 183 183 CIGNA 62308 [3081051] CIGNA 62308 [308105105] 146.4 percent of total billed charges 113.46 173.85 Technical (Hospital) Services Ref Angiotensin I-Converting Enzyme CSF PX-3018216400 CDM 82164 CPT 301 RC outpatient 183 183 CIGNA 62308 [3081051] CIGNA STATE OF WYOMING [308105107] 146.4 percent of total billed charges 113.46 173.85 Technical (Hospital) Services Ref Angiotensin I-Converting Enzyme CSF PX-3018216400 CDM 82164 CPT 301 RC inpatient 183 183 MULTIPLAN INC 34080 [3081285] MULTIPLAN INC [308128501] 173.85 percent of total billed charges 113.46 173.85 Technical (Hospital) Services Ref Angiotensin I-Converting Enzyme CSF PX-3018216400 CDM 82164 CPT 301 RC inpatient 183 183 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES HDHP [308136802] 144.9 percent of total billed charges 113.46 173.85 Technical (Hospital) Services Ref Angiotensin I-Converting Enzyme CSF PX-3018216400 CDM 82164 CPT 301 RC inpatient 183 183 BLUE CROSS BLUE SHIELD WELLMARK SB889 [3081026] BCBS WYOMING [308102603] 173.85 percent of total billed charges 113.46 173.85 Technical (Hospital) Services Ref Angiotensin I-Converting Enzyme CSF PX-3018216400 CDM 82164 CPT 301 RC inpatient 183 183 UNITED HEALTHCARE (COMMERCIAL) [3081199] UNITED HEALTHCARE 87726 [308119901] 113.46 percent of total billed charges 113.46 173.85 Technical (Hospital) Services Ref Angiotensin I-Converting Enzyme CSF PX-3018216400 CDM 82164 CPT 301 RC inpatient 183 183 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES PPO [308136801] 144.9 percent of total billed charges 113.46 173.85 Technical (Hospital) Services Ref Angiotensin I-Converting Enzyme CSF PX-3018216400 CDM 82164 CPT 301 RC inpatient 183 183 MEDICA (COMMERCIAL) 94265 [3081118] MEDICA CLAIMS [308111801] 164.7 percent of total billed charges 113.46 173.85 Technical (Hospital) Services Ref Angiotensin I-Converting Enzyme CSF PX-3018216400 CDM 82164 CPT 301 RC inpatient 183 183 HEALTHPARTNERS SX009 HEALTHPARTNERS 144.9 percent of total billed charges 113.46 173.85 Technical (Hospital) Services Ref Angiotensin I-Converting Enzyme CSF PX-3018216400 CDM 82164 CPT 301 RC inpatient 183 183 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES EPO [308136803] 144.9 percent of total billed charges 113.46 173.85 Technical (Hospital) Services Ref Angiotensin I-Converting Enzyme CSF PX-3018216400 CDM 82164 CPT 301 RC inpatient 183 183 CIGNA 62308 [3081051] CIGNA 62308 [308105105] 144.9 percent of total billed charges 113.46 173.85 Technical (Hospital) Services Ref Angiotensin I-Converting Enzyme CSF PX-3018216400 CDM 82164 CPT 301 RC inpatient 183 183 CIGNA 62308 [3081051] CIGNA STATE OF WYOMING [308105107] 144.9 percent of total billed charges 113.46 173.85 Technical (Hospital) Services Ref Angiotensin Conv Enzyme PX-3018216401 CDM 82164 CPT 301 RC inpatient 183 183 CIGNA 62308 [3081051] CIGNA 62308 [308105105] 144.9 percent of total billed charges 113.46 173.85 Technical (Hospital) Services Ref Angiotensin Conv Enzyme PX-3018216401 CDM 82164 CPT 301 RC inpatient 183 183 CIGNA 62308 [3081051] CIGNA STATE OF WYOMING [308105107] 144.9 percent of total billed charges 113.46 173.85 Technical (Hospital) Services Ref Angiotensin Conv Enzyme PX-3018216401 CDM 82164 CPT 301 RC inpatient 183 183 MEDICA (COMMERCIAL) 94265 [3081118] MEDICA CLAIMS [308111801] 164.7 percent of total billed charges 113.46 173.85 Technical (Hospital) Services Ref Angiotensin Conv Enzyme PX-3018216401 CDM 82164 CPT 301 RC inpatient 183 183 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES EPO [308136803] 144.9 percent of total billed charges 113.46 173.85 Technical (Hospital) Services Ref Angiotensin Conv Enzyme PX-3018216401 CDM 82164 CPT 301 RC inpatient 183 183 HEALTHPARTNERS SX009 HEALTHPARTNERS 144.9 percent of total billed charges 113.46 173.85 Technical (Hospital) Services Ref Angiotensin Conv Enzyme PX-3018216401 CDM 82164 CPT 301 RC inpatient 183 183 BLUE CROSS BLUE SHIELD WELLMARK SB889 [3081026] BCBS WYOMING [308102603] 173.85 percent of total billed charges 113.46 173.85 Technical (Hospital) Services Ref Angiotensin Conv Enzyme PX-3018216401 CDM 82164 CPT 301 RC inpatient 183 183 MULTIPLAN INC 34080 [3081285] MULTIPLAN INC [308128501] 173.85 percent of total billed charges 113.46 173.85 Technical (Hospital) Services Ref Angiotensin Conv Enzyme PX-3018216401 CDM 82164 CPT 301 RC inpatient 183 183 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES HDHP [308136802] 144.9 percent of total billed charges 113.46 173.85 Technical (Hospital) Services Ref Angiotensin Conv Enzyme PX-3018216401 CDM 82164 CPT 301 RC inpatient 183 183 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES PPO [308136801] 144.9 percent of total billed charges 113.46 173.85 Technical (Hospital) Services Ref Angiotensin Conv Enzyme PX-3018216401 CDM 82164 CPT 301 RC inpatient 183 183 UNITED HEALTHCARE (COMMERCIAL) [3081199] UNITED HEALTHCARE 87726 [308119901] 113.46 percent of total billed charges 113.46 173.85 Technical (Hospital) Services Ref Angiotensin Conv Enzyme PX-3018216401 CDM 82164 CPT 301 RC outpatient 183 183 UNITED HEALTHCARE (COMMERCIAL) [3081199] UNITED HEALTHCARE 87726 [308119901] 113.46 percent of total billed charges 113.46 173.85 Technical (Hospital) Services Ref Angiotensin Conv Enzyme PX-3018216401 CDM 82164 CPT 301 RC outpatient 183 183 HEALTHPARTNERS SX009 HEALTHPARTNERS 146.4 percent of total billed charges 113.46 173.85 Technical (Hospital) Services Ref Angiotensin Conv Enzyme PX-3018216401 CDM 82164 CPT 301 RC outpatient 183 183 BLUE CROSS BLUE SHIELD WELLMARK SB889 [3081026] BCBS WYOMING [308102603] 173.85 percent of total billed charges 113.46 173.85 Technical (Hospital) Services Ref Angiotensin Conv Enzyme PX-3018216401 CDM 82164 CPT 301 RC outpatient 183 183 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES EPO [308136803] 146.4 percent of total billed charges 113.46 173.85 Technical (Hospital) Services Ref Angiotensin Conv Enzyme PX-3018216401 CDM 82164 CPT 301 RC outpatient 183 183 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES HDHP [308136802] 146.4 percent of total billed charges 113.46 173.85 Technical (Hospital) Services Ref Angiotensin Conv Enzyme PX-3018216401 CDM 82164 CPT 301 RC outpatient 183 183 MULTIPLAN INC 34080 [3081285] MULTIPLAN INC [308128501] 173.85 percent of total billed charges 113.46 173.85 Technical (Hospital) Services Ref Angiotensin Conv Enzyme PX-3018216401 CDM 82164 CPT 301 RC outpatient 183 183 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES PPO [308136801] 146.4 percent of total billed charges 113.46 173.85 Technical (Hospital) Services Ref Angiotensin Conv Enzyme PX-3018216401 CDM 82164 CPT 301 RC outpatient 183 183 MEDICA (COMMERCIAL) 94265 [3081118] MEDICA CLAIMS [308111801] 164.7 percent of total billed charges 113.46 173.85 Technical (Hospital) Services Ref Angiotensin Conv Enzyme PX-3018216401 CDM 82164 CPT 301 RC outpatient 183 183 CIGNA 62308 [3081051] CIGNA 62308 [308105105] 146.4 percent of total billed charges 113.46 173.85 Technical (Hospital) Services Ref Angiotensin Conv Enzyme PX-3018216401 CDM 82164 CPT 301 RC outpatient 183 183 CIGNA 62308 [3081051] CIGNA STATE OF WYOMING [308105107] 146.4 percent of total billed charges 113.46 173.85 Technical (Hospital) Services Ref Androstenedione S PX-3018215700 CDM 82157 CPT 301 RC inpatient 225 225 CIGNA 62308 [3081051] CIGNA 62308 [308105105] 178.16 percent of total billed charges 139.5 213.75 Technical (Hospital) Services Ref Androstenedione S PX-3018215700 CDM 82157 CPT 301 RC inpatient 225 225 CIGNA 62308 [3081051] CIGNA STATE OF WYOMING [308105107] 178.16 percent of total billed charges 139.5 213.75 Technical (Hospital) Services Ref Androstenedione S PX-3018215700 CDM 82157 CPT 301 RC inpatient 225 225 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES PPO [308136801] 178.16 percent of total billed charges 139.5 213.75 Technical (Hospital) Services Ref Androstenedione S PX-3018215700 CDM 82157 CPT 301 RC inpatient 225 225 UNITED HEALTHCARE (COMMERCIAL) [3081199] UNITED HEALTHCARE 87726 [308119901] 139.5 percent of total billed charges 139.5 213.75 Technical (Hospital) Services Ref Androstenedione S PX-3018215700 CDM 82157 CPT 301 RC inpatient 225 225 BLUE CROSS BLUE SHIELD WELLMARK SB889 [3081026] BCBS WYOMING [308102603] 213.75 percent of total billed charges 139.5 213.75 Technical (Hospital) Services Ref Androstenedione S PX-3018215700 CDM 82157 CPT 301 RC inpatient 225 225 MULTIPLAN INC 34080 [3081285] MULTIPLAN INC [308128501] 213.75 percent of total billed charges 139.5 213.75 Technical (Hospital) Services Ref Androstenedione S PX-3018215700 CDM 82157 CPT 301 RC inpatient 225 225 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES EPO [308136803] 178.16 percent of total billed charges 139.5 213.75 Technical (Hospital) Services Ref Androstenedione S PX-3018215700 CDM 82157 CPT 301 RC inpatient 225 225 HEALTHPARTNERS SX009 HEALTHPARTNERS 178.16 percent of total billed charges 139.5 213.75 Technical (Hospital) Services Ref Androstenedione S PX-3018215700 CDM 82157 CPT 301 RC inpatient 225 225 MEDICA (COMMERCIAL) 94265 [3081118] MEDICA CLAIMS [308111801] 202.5 percent of total billed charges 139.5 213.75 Technical (Hospital) Services Ref Androstenedione S PX-3018215700 CDM 82157 CPT 301 RC inpatient 225 225 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES HDHP [308136802] 178.16 percent of total billed charges 139.5 213.75 Technical (Hospital) Services Ref Androstenedione S PX-3018215700 CDM 82157 CPT 301 RC outpatient 225 225 UNITED HEALTHCARE (COMMERCIAL) [3081199] UNITED HEALTHCARE 87726 [308119901] 139.5 percent of total billed charges 139.5 213.75 Technical (Hospital) Services Ref Androstenedione S PX-3018215700 CDM 82157 CPT 301 RC outpatient 225 225 HEALTHPARTNERS SX009 HEALTHPARTNERS 180 percent of total billed charges 139.5 213.75 Technical (Hospital) Services Ref Androstenedione S PX-3018215700 CDM 82157 CPT 301 RC outpatient 225 225 MULTIPLAN INC 34080 [3081285] MULTIPLAN INC [308128501] 213.75 percent of total billed charges 139.5 213.75 Technical (Hospital) Services Ref Androstenedione S PX-3018215700 CDM 82157 CPT 301 RC outpatient 225 225 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES HDHP [308136802] 180 percent of total billed charges 139.5 213.75 Technical (Hospital) Services Ref Androstenedione S PX-3018215700 CDM 82157 CPT 301 RC outpatient 225 225 BLUE CROSS BLUE SHIELD WELLMARK SB889 [3081026] BCBS WYOMING [308102603] 213.75 percent of total billed charges 139.5 213.75 Technical (Hospital) Services Ref Androstenedione S PX-3018215700 CDM 82157 CPT 301 RC outpatient 225 225 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES EPO [308136803] 180 percent of total billed charges 139.5 213.75 Technical (Hospital) Services Ref Androstenedione S PX-3018215700 CDM 82157 CPT 301 RC outpatient 225 225 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES PPO [308136801] 180 percent of total billed charges 139.5 213.75 Technical (Hospital) Services Ref Androstenedione S PX-3018215700 CDM 82157 CPT 301 RC outpatient 225 225 CIGNA 62308 [3081051] CIGNA 62308 [308105105] 180 percent of total billed charges 139.5 213.75 Technical (Hospital) Services Ref Androstenedione S PX-3018215700 CDM 82157 CPT 301 RC outpatient 225 225 CIGNA 62308 [3081051] CIGNA STATE OF WYOMING [308105107] 180 percent of total billed charges 139.5 213.75 Technical (Hospital) Services Ref Androstenedione S PX-3018215700 CDM 82157 CPT 301 RC outpatient 225 225 MEDICA (COMMERCIAL) 94265 [3081118] MEDICA CLAIMS [308111801] 202.5 percent of total billed charges 139.5 213.75 Technical (Hospital) Services Amylase Serum PX-3018215000 CDM 82150 CPT 301 RC inpatient 119 119 CIGNA 62308 [3081051] CIGNA 62308 [308105105] 94.22 percent of total billed charges 73.78 113.05 Technical (Hospital) Services Amylase Serum PX-3018215000 CDM 82150 CPT 301 RC inpatient 119 119 CIGNA 62308 [3081051] CIGNA STATE OF WYOMING [308105107] 94.22 percent of total billed charges 73.78 113.05 Technical (Hospital) Services Amylase Serum PX-3018215000 CDM 82150 CPT 301 RC inpatient 119 119 HEALTHPARTNERS SX009 HEALTHPARTNERS 94.22 percent of total billed charges 73.78 113.05 Technical (Hospital) Services Amylase Serum PX-3018215000 CDM 82150 CPT 301 RC inpatient 119 119 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES EPO [308136803] 94.22 percent of total billed charges 73.78 113.05 Technical (Hospital) Services Amylase Serum PX-3018215000 CDM 82150 CPT 301 RC inpatient 119 119 MEDICA (COMMERCIAL) 94265 [3081118] MEDICA CLAIMS [308111801] 107.1 percent of total billed charges 73.78 113.05 Technical (Hospital) Services Amylase Serum PX-3018215000 CDM 82150 CPT 301 RC inpatient 119 119 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES HDHP [308136802] 94.22 percent of total billed charges 73.78 113.05 Technical (Hospital) Services Amylase Serum PX-3018215000 CDM 82150 CPT 301 RC inpatient 119 119 MULTIPLAN INC 34080 [3081285] MULTIPLAN INC [308128501] 113.05 percent of total billed charges 73.78 113.05 Technical (Hospital) Services Amylase Serum PX-3018215000 CDM 82150 CPT 301 RC inpatient 119 119 BLUE CROSS BLUE SHIELD WELLMARK SB889 [3081026] BCBS WYOMING [308102603] 113.05 percent of total billed charges 73.78 113.05 Technical (Hospital) Services Amylase Serum PX-3018215000 CDM 82150 CPT 301 RC inpatient 119 119 UNITED HEALTHCARE (COMMERCIAL) [3081199] UNITED HEALTHCARE 87726 [308119901] 73.78 percent of total billed charges 73.78 113.05 Technical (Hospital) Services Amylase Serum PX-3018215000 CDM 82150 CPT 301 RC inpatient 119 119 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES PPO [308136801] 94.22 percent of total billed charges 73.78 113.05 Technical (Hospital) Services Amylase Serum PX-3018215000 CDM 82150 CPT 301 RC outpatient 119 119 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES EPO [308136803] 95.2 percent of total billed charges 73.78 113.05 Technical (Hospital) Services Amylase Serum PX-3018215000 CDM 82150 CPT 301 RC outpatient 119 119 BLUE CROSS BLUE SHIELD WELLMARK SB889 [3081026] BCBS WYOMING [308102603] 113.05 percent of total billed charges 73.78 113.05 Technical (Hospital) Services Amylase Serum PX-3018215000 CDM 82150 CPT 301 RC outpatient 119 119 MULTIPLAN INC 34080 [3081285] MULTIPLAN INC [308128501] 113.05 percent of total billed charges 73.78 113.05 Technical (Hospital) Services Amylase Serum PX-3018215000 CDM 82150 CPT 301 RC outpatient 119 119 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES HDHP [308136802] 95.2 percent of total billed charges 73.78 113.05 Technical (Hospital) Services Amylase Serum PX-3018215000 CDM 82150 CPT 301 RC outpatient 119 119 HEALTHPARTNERS SX009 HEALTHPARTNERS 95.2 percent of total billed charges 73.78 113.05 Technical (Hospital) Services Amylase Serum PX-3018215000 CDM 82150 CPT 301 RC outpatient 119 119 UNITED HEALTHCARE (COMMERCIAL) [3081199] UNITED HEALTHCARE 87726 [308119901] 73.78 percent of total billed charges 73.78 113.05 Technical (Hospital) Services Amylase Serum PX-3018215000 CDM 82150 CPT 301 RC outpatient 119 119 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES PPO [308136801] 95.2 percent of total billed charges 73.78 113.05 Technical (Hospital) Services Amylase Serum PX-3018215000 CDM 82150 CPT 301 RC outpatient 119 119 MEDICA (COMMERCIAL) 94265 [3081118] MEDICA CLAIMS [308111801] 107.1 percent of total billed charges 73.78 113.05 Technical (Hospital) Services Amylase Serum PX-3018215000 CDM 82150 CPT 301 RC outpatient 119 119 CIGNA 62308 [3081051] CIGNA 62308 [308105105] 95.2 percent of total billed charges 73.78 113.05 Technical (Hospital) Services Amylase Serum PX-3018215000 CDM 82150 CPT 301 RC outpatient 119 119 CIGNA 62308 [3081051] CIGNA STATE OF WYOMING [308105107] 95.2 percent of total billed charges 73.78 113.05 Technical (Hospital) Services Ammonia PX-3018214000 CDM 82140 CPT 301 RC inpatient 126 126 CIGNA 62308 [3081051] CIGNA 62308 [308105105] 99.77 percent of total billed charges 78.12 119.7 Technical (Hospital) Services Ammonia PX-3018214000 CDM 82140 CPT 301 RC inpatient 126 126 CIGNA 62308 [3081051] CIGNA STATE OF WYOMING [308105107] 99.77 percent of total billed charges 78.12 119.7 Technical (Hospital) Services Ammonia PX-3018214000 CDM 82140 CPT 301 RC inpatient 126 126 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES HDHP [308136802] 99.77 percent of total billed charges 78.12 119.7 Technical (Hospital) Services Ammonia PX-3018214000 CDM 82140 CPT 301 RC inpatient 126 126 MEDICA (COMMERCIAL) 94265 [3081118] MEDICA CLAIMS [308111801] 113.4 percent of total billed charges 78.12 119.7 Technical (Hospital) Services Ammonia PX-3018214000 CDM 82140 CPT 301 RC inpatient 126 126 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES EPO [308136803] 99.77 percent of total billed charges 78.12 119.7 Technical (Hospital) Services Ammonia PX-3018214000 CDM 82140 CPT 301 RC inpatient 126 126 HEALTHPARTNERS SX009 HEALTHPARTNERS 99.77 percent of total billed charges 78.12 119.7 Technical (Hospital) Services Ammonia PX-3018214000 CDM 82140 CPT 301 RC inpatient 126 126 BLUE CROSS BLUE SHIELD WELLMARK SB889 [3081026] BCBS WYOMING [308102603] 119.7 percent of total billed charges 78.12 119.7 Technical (Hospital) Services Ammonia PX-3018214000 CDM 82140 CPT 301 RC inpatient 126 126 MULTIPLAN INC 34080 [3081285] MULTIPLAN INC [308128501] 119.7 percent of total billed charges 78.12 119.7 Technical (Hospital) Services Ammonia PX-3018214000 CDM 82140 CPT 301 RC inpatient 126 126 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES PPO [308136801] 99.77 percent of total billed charges 78.12 119.7 Technical (Hospital) Services Ammonia PX-3018214000 CDM 82140 CPT 301 RC inpatient 126 126 UNITED HEALTHCARE (COMMERCIAL) [3081199] UNITED HEALTHCARE 87726 [308119901] 78.12 percent of total billed charges 78.12 119.7 Technical (Hospital) Services Ammonia PX-3018214000 CDM 82140 CPT 301 RC outpatient 126 126 UNITED HEALTHCARE (COMMERCIAL) [3081199] UNITED HEALTHCARE 87726 [308119901] 78.12 percent of total billed charges 78.12 119.7 Technical (Hospital) Services Ammonia PX-3018214000 CDM 82140 CPT 301 RC outpatient 126 126 HEALTHPARTNERS SX009 HEALTHPARTNERS 100.8 percent of total billed charges 78.12 119.7 Technical (Hospital) Services Ammonia PX-3018214000 CDM 82140 CPT 301 RC outpatient 126 126 BLUE CROSS BLUE SHIELD WELLMARK SB889 [3081026] BCBS WYOMING [308102603] 119.7 percent of total billed charges 78.12 119.7 Technical (Hospital) Services Ammonia PX-3018214000 CDM 82140 CPT 301 RC outpatient 126 126 MULTIPLAN INC 34080 [3081285] MULTIPLAN INC [308128501] 119.7 percent of total billed charges 78.12 119.7 Technical (Hospital) Services Ammonia PX-3018214000 CDM 82140 CPT 301 RC outpatient 126 126 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES HDHP [308136802] 100.8 percent of total billed charges 78.12 119.7 Technical (Hospital) Services Ammonia PX-3018214000 CDM 82140 CPT 301 RC outpatient 126 126 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES PPO [308136801] 100.8 percent of total billed charges 78.12 119.7 Technical (Hospital) Services Ammonia PX-3018214000 CDM 82140 CPT 301 RC outpatient 126 126 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES EPO [308136803] 100.8 percent of total billed charges 78.12 119.7 Technical (Hospital) Services Ammonia PX-3018214000 CDM 82140 CPT 301 RC outpatient 126 126 CIGNA 62308 [3081051] CIGNA 62308 [308105105] 100.8 percent of total billed charges 78.12 119.7 Technical (Hospital) Services Ammonia PX-3018214000 CDM 82140 CPT 301 RC outpatient 126 126 CIGNA 62308 [3081051] CIGNA STATE OF WYOMING [308105107] 100.8 percent of total billed charges 78.12 119.7 Technical (Hospital) Services Ammonia PX-3018214000 CDM 82140 CPT 301 RC outpatient 126 126 MEDICA (COMMERCIAL) 94265 [3081118] MEDICA CLAIMS [308111801] 113.4 percent of total billed charges 78.12 119.7 Technical (Hospital) Services "HC Ref Ammonia, Plasma (Mayo)" PX-3018214003 CDM 82140 CPT 301 RC inpatient 284 284 CIGNA 62308 [3081051] CIGNA 62308 [308105105] 224.87 percent of total billed charges 176.08 269.8 Technical (Hospital) Services "HC Ref Ammonia, Plasma (Mayo)" PX-3018214003 CDM 82140 CPT 301 RC inpatient 284 284 CIGNA 62308 [3081051] CIGNA STATE OF WYOMING [308105107] 224.87 percent of total billed charges 176.08 269.8 Technical (Hospital) Services "HC Ref Ammonia, Plasma (Mayo)" PX-3018214003 CDM 82140 CPT 301 RC inpatient 284 284 MULTIPLAN INC 34080 [3081285] MULTIPLAN INC [308128501] 269.8 percent of total billed charges 176.08 269.8 Technical (Hospital) Services "HC Ref Ammonia, Plasma (Mayo)" PX-3018214003 CDM 82140 CPT 301 RC inpatient 284 284 BLUE CROSS BLUE SHIELD WELLMARK SB889 [3081026] BCBS WYOMING [308102603] 269.8 percent of total billed charges 176.08 269.8 Technical (Hospital) Services "HC Ref Ammonia, Plasma (Mayo)" PX-3018214003 CDM 82140 CPT 301 RC inpatient 284 284 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES PPO [308136801] 224.87 percent of total billed charges 176.08 269.8 Technical (Hospital) Services "HC Ref Ammonia, Plasma (Mayo)" PX-3018214003 CDM 82140 CPT 301 RC inpatient 284 284 UNITED HEALTHCARE (COMMERCIAL) [3081199] UNITED HEALTHCARE 87726 [308119901] 176.08 percent of total billed charges 176.08 269.8 Technical (Hospital) Services "HC Ref Ammonia, Plasma (Mayo)" PX-3018214003 CDM 82140 CPT 301 RC inpatient 284 284 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES HDHP [308136802] 224.87 percent of total billed charges 176.08 269.8 Technical (Hospital) Services "HC Ref Ammonia, Plasma (Mayo)" PX-3018214003 CDM 82140 CPT 301 RC inpatient 284 284 MEDICA (COMMERCIAL) 94265 [3081118] MEDICA CLAIMS [308111801] 255.6 percent of total billed charges 176.08 269.8 Technical (Hospital) Services "HC Ref Ammonia, Plasma (Mayo)" PX-3018214003 CDM 82140 CPT 301 RC inpatient 284 284 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES EPO [308136803] 224.87 percent of total billed charges 176.08 269.8 Technical (Hospital) Services "HC Ref Ammonia, Plasma (Mayo)" PX-3018214003 CDM 82140 CPT 301 RC inpatient 284 284 HEALTHPARTNERS SX009 HEALTHPARTNERS 224.87 percent of total billed charges 176.08 269.8 Technical (Hospital) Services "HC Ref Ammonia, Plasma (Mayo)" PX-3018214003 CDM 82140 CPT 301 RC outpatient 284 284 UNITED HEALTHCARE (COMMERCIAL) [3081199] UNITED HEALTHCARE 87726 [308119901] 176.08 percent of total billed charges 176.08 269.8 Technical (Hospital) Services "HC Ref Ammonia, Plasma (Mayo)" PX-3018214003 CDM 82140 CPT 301 RC outpatient 284 284 HEALTHPARTNERS SX009 HEALTHPARTNERS 227.2 percent of total billed charges 176.08 269.8 Technical (Hospital) Services "HC Ref Ammonia, Plasma (Mayo)" PX-3018214003 CDM 82140 CPT 301 RC outpatient 284 284 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES PPO [308136801] 227.2 percent of total billed charges 176.08 269.8 Technical (Hospital) Services "HC Ref Ammonia, Plasma (Mayo)" PX-3018214003 CDM 82140 CPT 301 RC outpatient 284 284 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES HDHP [308136802] 227.2 percent of total billed charges 176.08 269.8 Technical (Hospital) Services "HC Ref Ammonia, Plasma (Mayo)" PX-3018214003 CDM 82140 CPT 301 RC outpatient 284 284 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES EPO [308136803] 227.2 percent of total billed charges 176.08 269.8 Technical (Hospital) Services "HC Ref Ammonia, Plasma (Mayo)" PX-3018214003 CDM 82140 CPT 301 RC outpatient 284 284 BLUE CROSS BLUE SHIELD WELLMARK SB889 [3081026] BCBS WYOMING [308102603] 269.8 percent of total billed charges 176.08 269.8 Technical (Hospital) Services "HC Ref Ammonia, Plasma (Mayo)" PX-3018214003 CDM 82140 CPT 301 RC outpatient 284 284 MULTIPLAN INC 34080 [3081285] MULTIPLAN INC [308128501] 269.8 percent of total billed charges 176.08 269.8 Technical (Hospital) Services "HC Ref Ammonia, Plasma (Mayo)" PX-3018214003 CDM 82140 CPT 301 RC outpatient 284 284 MEDICA (COMMERCIAL) 94265 [3081118] MEDICA CLAIMS [308111801] 255.6 percent of total billed charges 176.08 269.8 Technical (Hospital) Services "HC Ref Ammonia, Plasma (Mayo)" PX-3018214003 CDM 82140 CPT 301 RC outpatient 284 284 CIGNA 62308 [3081051] CIGNA 62308 [308105105] 227.2 percent of total billed charges 176.08 269.8 Technical (Hospital) Services "HC Ref Ammonia, Plasma (Mayo)" PX-3018214003 CDM 82140 CPT 301 RC outpatient 284 284 CIGNA 62308 [3081051] CIGNA STATE OF WYOMING [308105107] 227.2 percent of total billed charges 176.08 269.8 Technical (Hospital) Services Ref Aminolevulinic Acid Ala U PX-3018213500 CDM 82135 CPT 301 RC inpatient 158 158 MEDICA (COMMERCIAL) 94265 [3081118] MEDICA CLAIMS [308111801] 142.2 percent of total billed charges 97.96 150.1 Technical (Hospital) Services Ref Aminolevulinic Acid Ala U PX-3018213500 CDM 82135 CPT 301 RC inpatient 158 158 HEALTHPARTNERS SX009 HEALTHPARTNERS 125.1 percent of total billed charges 97.96 150.1 Technical (Hospital) Services Ref Aminolevulinic Acid Ala U PX-3018213500 CDM 82135 CPT 301 RC inpatient 158 158 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES EPO [308136803] 125.1 percent of total billed charges 97.96 150.1 Technical (Hospital) Services Ref Aminolevulinic Acid Ala U PX-3018213500 CDM 82135 CPT 301 RC inpatient 158 158 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES HDHP [308136802] 125.1 percent of total billed charges 97.96 150.1 Technical (Hospital) Services Ref Aminolevulinic Acid Ala U PX-3018213500 CDM 82135 CPT 301 RC inpatient 158 158 MULTIPLAN INC 34080 [3081285] MULTIPLAN INC [308128501] 150.1 percent of total billed charges 97.96 150.1 Technical (Hospital) Services Ref Aminolevulinic Acid Ala U PX-3018213500 CDM 82135 CPT 301 RC inpatient 158 158 BLUE CROSS BLUE SHIELD WELLMARK SB889 [3081026] BCBS WYOMING [308102603] 150.1 percent of total billed charges 97.96 150.1 Technical (Hospital) Services Ref Aminolevulinic Acid Ala U PX-3018213500 CDM 82135 CPT 301 RC inpatient 158 158 UNITED HEALTHCARE (COMMERCIAL) [3081199] UNITED HEALTHCARE 87726 [308119901] 97.96 percent of total billed charges 97.96 150.1 Technical (Hospital) Services Ref Aminolevulinic Acid Ala U PX-3018213500 CDM 82135 CPT 301 RC inpatient 158 158 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES PPO [308136801] 125.1 percent of total billed charges 97.96 150.1 Technical (Hospital) Services Ref Aminolevulinic Acid Ala U PX-3018213500 CDM 82135 CPT 301 RC inpatient 158 158 CIGNA 62308 [3081051] CIGNA 62308 [308105105] 125.1 percent of total billed charges 97.96 150.1 Technical (Hospital) Services Ref Aminolevulinic Acid Ala U PX-3018213500 CDM 82135 CPT 301 RC inpatient 158 158 CIGNA 62308 [3081051] CIGNA STATE OF WYOMING [308105107] 125.1 percent of total billed charges 97.96 150.1 Technical (Hospital) Services Ref Aminolevulinic Acid Ala U PX-3018213500 CDM 82135 CPT 301 RC outpatient 158 158 MEDICA (COMMERCIAL) 94265 [3081118] MEDICA CLAIMS [308111801] 142.2 percent of total billed charges 97.96 150.1 Technical (Hospital) Services Ref Aminolevulinic Acid Ala U PX-3018213500 CDM 82135 CPT 301 RC outpatient 158 158 CIGNA 62308 [3081051] CIGNA 62308 [308105105] 126.4 percent of total billed charges 97.96 150.1 Technical (Hospital) Services Ref Aminolevulinic Acid Ala U PX-3018213500 CDM 82135 CPT 301 RC outpatient 158 158 CIGNA 62308 [3081051] CIGNA STATE OF WYOMING [308105107] 126.4 percent of total billed charges 97.96 150.1 Technical (Hospital) Services Ref Aminolevulinic Acid Ala U PX-3018213500 CDM 82135 CPT 301 RC outpatient 158 158 HEALTHPARTNERS SX009 HEALTHPARTNERS 126.4 percent of total billed charges 97.96 150.1 Technical (Hospital) Services Ref Aminolevulinic Acid Ala U PX-3018213500 CDM 82135 CPT 301 RC outpatient 158 158 UNITED HEALTHCARE (COMMERCIAL) [3081199] UNITED HEALTHCARE 87726 [308119901] 97.96 percent of total billed charges 97.96 150.1 Technical (Hospital) Services Ref Aminolevulinic Acid Ala U PX-3018213500 CDM 82135 CPT 301 RC outpatient 158 158 BLUE CROSS BLUE SHIELD WELLMARK SB889 [3081026] BCBS WYOMING [308102603] 150.1 percent of total billed charges 97.96 150.1 Technical (Hospital) Services Ref Aminolevulinic Acid Ala U PX-3018213500 CDM 82135 CPT 301 RC outpatient 158 158 MULTIPLAN INC 34080 [3081285] MULTIPLAN INC [308128501] 150.1 percent of total billed charges 97.96 150.1 Technical (Hospital) Services Ref Aminolevulinic Acid Ala U PX-3018213500 CDM 82135 CPT 301 RC outpatient 158 158 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES HDHP [308136802] 126.4 percent of total billed charges 97.96 150.1 Technical (Hospital) Services Ref Aminolevulinic Acid Ala U PX-3018213500 CDM 82135 CPT 301 RC outpatient 158 158 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES PPO [308136801] 126.4 percent of total billed charges 97.96 150.1 Technical (Hospital) Services Ref Aminolevulinic Acid Ala U PX-3018213500 CDM 82135 CPT 301 RC outpatient 158 158 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES EPO [308136803] 126.4 percent of total billed charges 97.96 150.1 Technical (Hospital) Services Ref Alpha-Fetoprotein: Serum PX-3018210500 CDM 82105 CPT 301 RC inpatient 162 162 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES HDHP [308136802] 128.27 percent of total billed charges 100.44 153.9 Technical (Hospital) Services Ref Alpha-Fetoprotein: Serum PX-3018210500 CDM 82105 CPT 301 RC inpatient 162 162 MEDICA (COMMERCIAL) 94265 [3081118] MEDICA CLAIMS [308111801] 145.8 percent of total billed charges 100.44 153.9 Technical (Hospital) Services Ref Alpha-Fetoprotein: Serum PX-3018210500 CDM 82105 CPT 301 RC inpatient 162 162 HEALTHPARTNERS SX009 HEALTHPARTNERS 128.27 percent of total billed charges 100.44 153.9 Technical (Hospital) Services Ref Alpha-Fetoprotein: Serum PX-3018210500 CDM 82105 CPT 301 RC inpatient 162 162 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES EPO [308136803] 128.27 percent of total billed charges 100.44 153.9 Technical (Hospital) Services Ref Alpha-Fetoprotein: Serum PX-3018210500 CDM 82105 CPT 301 RC inpatient 162 162 MULTIPLAN INC 34080 [3081285] MULTIPLAN INC [308128501] 153.9 percent of total billed charges 100.44 153.9 Technical (Hospital) Services Ref Alpha-Fetoprotein: Serum PX-3018210500 CDM 82105 CPT 301 RC inpatient 162 162 BLUE CROSS BLUE SHIELD WELLMARK SB889 [3081026] BCBS WYOMING [308102603] 153.9 percent of total billed charges 100.44 153.9 Technical (Hospital) Services Ref Alpha-Fetoprotein: Serum PX-3018210500 CDM 82105 CPT 301 RC inpatient 162 162 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES PPO [308136801] 128.27 percent of total billed charges 100.44 153.9 Technical (Hospital) Services Ref Alpha-Fetoprotein: Serum PX-3018210500 CDM 82105 CPT 301 RC inpatient 162 162 UNITED HEALTHCARE (COMMERCIAL) [3081199] UNITED HEALTHCARE 87726 [308119901] 100.44 percent of total billed charges 100.44 153.9 Technical (Hospital) Services Ref Alpha-Fetoprotein: Serum PX-3018210500 CDM 82105 CPT 301 RC inpatient 162 162 CIGNA 62308 [3081051] CIGNA 62308 [308105105] 128.27 percent of total billed charges 100.44 153.9 Technical (Hospital) Services Ref Alpha-Fetoprotein: Serum PX-3018210500 CDM 82105 CPT 301 RC inpatient 162 162 CIGNA 62308 [3081051] CIGNA STATE OF WYOMING [308105107] 128.27 percent of total billed charges 100.44 153.9 Technical (Hospital) Services Ref Alpha-Fetoprotein: Serum PX-3018210500 CDM 82105 CPT 301 RC outpatient 162 162 MEDICA (COMMERCIAL) 94265 [3081118] MEDICA CLAIMS [308111801] 145.8 percent of total billed charges 100.44 153.9 Technical (Hospital) Services Ref Alpha-Fetoprotein: Serum PX-3018210500 CDM 82105 CPT 301 RC outpatient 162 162 CIGNA 62308 [3081051] CIGNA 62308 [308105105] 129.6 percent of total billed charges 100.44 153.9 Technical (Hospital) Services Ref Alpha-Fetoprotein: Serum PX-3018210500 CDM 82105 CPT 301 RC outpatient 162 162 CIGNA 62308 [3081051] CIGNA STATE OF WYOMING [308105107] 129.6 percent of total billed charges 100.44 153.9 Technical (Hospital) Services Ref Alpha-Fetoprotein: Serum PX-3018210500 CDM 82105 CPT 301 RC outpatient 162 162 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES PPO [308136801] 129.6 percent of total billed charges 100.44 153.9 Technical (Hospital) Services Ref Alpha-Fetoprotein: Serum PX-3018210500 CDM 82105 CPT 301 RC outpatient 162 162 BLUE CROSS BLUE SHIELD WELLMARK SB889 [3081026] BCBS WYOMING [308102603] 153.9 percent of total billed charges 100.44 153.9 Technical (Hospital) Services Ref Alpha-Fetoprotein: Serum PX-3018210500 CDM 82105 CPT 301 RC outpatient 162 162 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES HDHP [308136802] 129.6 percent of total billed charges 100.44 153.9 Technical (Hospital) Services Ref Alpha-Fetoprotein: Serum PX-3018210500 CDM 82105 CPT 301 RC outpatient 162 162 MULTIPLAN INC 34080 [3081285] MULTIPLAN INC [308128501] 153.9 percent of total billed charges 100.44 153.9 Technical (Hospital) Services Ref Alpha-Fetoprotein: Serum PX-3018210500 CDM 82105 CPT 301 RC outpatient 162 162 HEALTHPARTNERS SX009 HEALTHPARTNERS 129.6 percent of total billed charges 100.44 153.9 Technical (Hospital) Services Ref Alpha-Fetoprotein: Serum PX-3018210500 CDM 82105 CPT 301 RC outpatient 162 162 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES EPO [308136803] 129.6 percent of total billed charges 100.44 153.9 Technical (Hospital) Services Ref Alpha-Fetoprotein: Serum PX-3018210500 CDM 82105 CPT 301 RC outpatient 162 162 UNITED HEALTHCARE (COMMERCIAL) [3081199] UNITED HEALTHCARE 87726 [308119901] 100.44 percent of total billed charges 100.44 153.9 Technical (Hospital) Services Afp Tumor Marker PX-3018210502 CDM 82105 CPT 301 RC outpatient 162 162 MEDICA (COMMERCIAL) 94265 [3081118] MEDICA CLAIMS [308111801] 145.8 percent of total billed charges 100.44 153.9 Technical (Hospital) Services Afp Tumor Marker PX-3018210502 CDM 82105 CPT 301 RC outpatient 162 162 CIGNA 62308 [3081051] CIGNA 62308 [308105105] 129.6 percent of total billed charges 100.44 153.9 Technical (Hospital) Services Afp Tumor Marker PX-3018210502 CDM 82105 CPT 301 RC outpatient 162 162 CIGNA 62308 [3081051] CIGNA STATE OF WYOMING [308105107] 129.6 percent of total billed charges 100.44 153.9 Technical (Hospital) Services Afp Tumor Marker PX-3018210502 CDM 82105 CPT 301 RC outpatient 162 162 UNITED HEALTHCARE (COMMERCIAL) [3081199] UNITED HEALTHCARE 87726 [308119901] 100.44 percent of total billed charges 100.44 153.9 Technical (Hospital) Services Afp Tumor Marker PX-3018210502 CDM 82105 CPT 301 RC outpatient 162 162 HEALTHPARTNERS SX009 HEALTHPARTNERS 129.6 percent of total billed charges 100.44 153.9 Technical (Hospital) Services Afp Tumor Marker PX-3018210502 CDM 82105 CPT 301 RC outpatient 162 162 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES EPO [308136803] 129.6 percent of total billed charges 100.44 153.9 Technical (Hospital) Services Afp Tumor Marker PX-3018210502 CDM 82105 CPT 301 RC outpatient 162 162 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES PPO [308136801] 129.6 percent of total billed charges 100.44 153.9 Technical (Hospital) Services Afp Tumor Marker PX-3018210502 CDM 82105 CPT 301 RC outpatient 162 162 BLUE CROSS BLUE SHIELD WELLMARK SB889 [3081026] BCBS WYOMING [308102603] 153.9 percent of total billed charges 100.44 153.9 Technical (Hospital) Services Afp Tumor Marker PX-3018210502 CDM 82105 CPT 301 RC outpatient 162 162 MULTIPLAN INC 34080 [3081285] MULTIPLAN INC [308128501] 153.9 percent of total billed charges 100.44 153.9 Technical (Hospital) Services Afp Tumor Marker PX-3018210502 CDM 82105 CPT 301 RC outpatient 162 162 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES HDHP [308136802] 129.6 percent of total billed charges 100.44 153.9 Technical (Hospital) Services Afp Tumor Marker PX-3018210502 CDM 82105 CPT 301 RC inpatient 162 162 UNITED HEALTHCARE (COMMERCIAL) [3081199] UNITED HEALTHCARE 87726 [308119901] 100.44 percent of total billed charges 100.44 153.9 Technical (Hospital) Services Afp Tumor Marker PX-3018210502 CDM 82105 CPT 301 RC inpatient 162 162 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES PPO [308136801] 128.27 percent of total billed charges 100.44 153.9 Technical (Hospital) Services Afp Tumor Marker PX-3018210502 CDM 82105 CPT 301 RC inpatient 162 162 MULTIPLAN INC 34080 [3081285] MULTIPLAN INC [308128501] 153.9 percent of total billed charges 100.44 153.9 Technical (Hospital) Services Afp Tumor Marker PX-3018210502 CDM 82105 CPT 301 RC inpatient 162 162 BLUE CROSS BLUE SHIELD WELLMARK SB889 [3081026] BCBS WYOMING [308102603] 153.9 percent of total billed charges 100.44 153.9 Technical (Hospital) Services Afp Tumor Marker PX-3018210502 CDM 82105 CPT 301 RC inpatient 162 162 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES HDHP [308136802] 128.27 percent of total billed charges 100.44 153.9 Technical (Hospital) Services Afp Tumor Marker PX-3018210502 CDM 82105 CPT 301 RC inpatient 162 162 MEDICA (COMMERCIAL) 94265 [3081118] MEDICA CLAIMS [308111801] 145.8 percent of total billed charges 100.44 153.9 Technical (Hospital) Services Afp Tumor Marker PX-3018210502 CDM 82105 CPT 301 RC inpatient 162 162 HEALTHPARTNERS SX009 HEALTHPARTNERS 128.27 percent of total billed charges 100.44 153.9 Technical (Hospital) Services Afp Tumor Marker PX-3018210502 CDM 82105 CPT 301 RC inpatient 162 162 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES EPO [308136803] 128.27 percent of total billed charges 100.44 153.9 Technical (Hospital) Services Afp Tumor Marker PX-3018210502 CDM 82105 CPT 301 RC inpatient 162 162 CIGNA 62308 [3081051] CIGNA 62308 [308105105] 128.27 percent of total billed charges 100.44 153.9 Technical (Hospital) Services Afp Tumor Marker PX-3018210502 CDM 82105 CPT 301 RC inpatient 162 162 CIGNA 62308 [3081051] CIGNA STATE OF WYOMING [308105107] 128.27 percent of total billed charges 100.44 153.9 Technical (Hospital) Services Ref A1at Phenotype PX-3018210400 CDM 82104 CPT 301 RC inpatient 211 211 MEDICA (COMMERCIAL) 94265 [3081118] MEDICA CLAIMS [308111801] 189.9 percent of total billed charges 130.82 200.45 Technical (Hospital) Services Ref A1at Phenotype PX-3018210400 CDM 82104 CPT 301 RC inpatient 211 211 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES HDHP [308136802] 167.07 percent of total billed charges 130.82 200.45 Technical (Hospital) Services Ref A1at Phenotype PX-3018210400 CDM 82104 CPT 301 RC inpatient 211 211 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES EPO [308136803] 167.07 percent of total billed charges 130.82 200.45 Technical (Hospital) Services Ref A1at Phenotype PX-3018210400 CDM 82104 CPT 301 RC inpatient 211 211 HEALTHPARTNERS SX009 HEALTHPARTNERS 167.07 percent of total billed charges 130.82 200.45 Technical (Hospital) Services Ref A1at Phenotype PX-3018210400 CDM 82104 CPT 301 RC inpatient 211 211 MULTIPLAN INC 34080 [3081285] MULTIPLAN INC [308128501] 200.45 percent of total billed charges 130.82 200.45 Technical (Hospital) Services Ref A1at Phenotype PX-3018210400 CDM 82104 CPT 301 RC inpatient 211 211 BLUE CROSS BLUE SHIELD WELLMARK SB889 [3081026] BCBS WYOMING [308102603] 200.45 percent of total billed charges 130.82 200.45 Technical (Hospital) Services Ref A1at Phenotype PX-3018210400 CDM 82104 CPT 301 RC inpatient 211 211 UNITED HEALTHCARE (COMMERCIAL) [3081199] UNITED HEALTHCARE 87726 [308119901] 130.82 percent of total billed charges 130.82 200.45 Technical (Hospital) Services Ref A1at Phenotype PX-3018210400 CDM 82104 CPT 301 RC inpatient 211 211 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES PPO [308136801] 167.07 percent of total billed charges 130.82 200.45 Technical (Hospital) Services Ref A1at Phenotype PX-3018210400 CDM 82104 CPT 301 RC inpatient 211 211 CIGNA 62308 [3081051] CIGNA 62308 [308105105] 167.07 percent of total billed charges 130.82 200.45 Technical (Hospital) Services Ref A1at Phenotype PX-3018210400 CDM 82104 CPT 301 RC inpatient 211 211 CIGNA 62308 [3081051] CIGNA STATE OF WYOMING [308105107] 167.07 percent of total billed charges 130.82 200.45 Technical (Hospital) Services Ref A1at Phenotype PX-3018210400 CDM 82104 CPT 301 RC outpatient 211 211 CIGNA 62308 [3081051] CIGNA 62308 [308105105] 168.8 percent of total billed charges 130.82 200.45 Technical (Hospital) Services Ref A1at Phenotype PX-3018210400 CDM 82104 CPT 301 RC outpatient 211 211 CIGNA 62308 [3081051] CIGNA STATE OF WYOMING [308105107] 168.8 percent of total billed charges 130.82 200.45 Technical (Hospital) Services Ref A1at Phenotype PX-3018210400 CDM 82104 CPT 301 RC outpatient 211 211 MEDICA (COMMERCIAL) 94265 [3081118] MEDICA CLAIMS [308111801] 189.9 percent of total billed charges 130.82 200.45 Technical (Hospital) Services Ref A1at Phenotype PX-3018210400 CDM 82104 CPT 301 RC outpatient 211 211 BLUE CROSS BLUE SHIELD WELLMARK SB889 [3081026] BCBS WYOMING [308102603] 200.45 percent of total billed charges 130.82 200.45 Technical (Hospital) Services Ref A1at Phenotype PX-3018210400 CDM 82104 CPT 301 RC outpatient 211 211 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES HDHP [308136802] 168.8 percent of total billed charges 130.82 200.45 Technical (Hospital) Services Ref A1at Phenotype PX-3018210400 CDM 82104 CPT 301 RC outpatient 211 211 MULTIPLAN INC 34080 [3081285] MULTIPLAN INC [308128501] 200.45 percent of total billed charges 130.82 200.45 Technical (Hospital) Services Ref A1at Phenotype PX-3018210400 CDM 82104 CPT 301 RC outpatient 211 211 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES PPO [308136801] 168.8 percent of total billed charges 130.82 200.45 Technical (Hospital) Services Ref A1at Phenotype PX-3018210400 CDM 82104 CPT 301 RC outpatient 211 211 HEALTHPARTNERS SX009 HEALTHPARTNERS 168.8 percent of total billed charges 130.82 200.45 Technical (Hospital) Services Ref A1at Phenotype PX-3018210400 CDM 82104 CPT 301 RC outpatient 211 211 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES EPO [308136803] 168.8 percent of total billed charges 130.82 200.45 Technical (Hospital) Services Ref A1at Phenotype PX-3018210400 CDM 82104 CPT 301 RC outpatient 211 211 UNITED HEALTHCARE (COMMERCIAL) [3081199] UNITED HEALTHCARE 87726 [308119901] 130.82 percent of total billed charges 130.82 200.45 Technical (Hospital) Services Ref Alpha 1 Antitrypsin PX-3018210300 CDM 82103 CPT 301 RC outpatient 180 180 CIGNA 62308 [3081051] CIGNA 62308 [308105105] 144 percent of total billed charges 111.6 171 Technical (Hospital) Services Ref Alpha 1 Antitrypsin PX-3018210300 CDM 82103 CPT 301 RC outpatient 180 180 CIGNA 62308 [3081051] CIGNA STATE OF WYOMING [308105107] 144 percent of total billed charges 111.6 171 Technical (Hospital) Services Ref Alpha 1 Antitrypsin PX-3018210300 CDM 82103 CPT 301 RC outpatient 180 180 MEDICA (COMMERCIAL) 94265 [3081118] MEDICA CLAIMS [308111801] 162 percent of total billed charges 111.6 171 Technical (Hospital) Services Ref Alpha 1 Antitrypsin PX-3018210300 CDM 82103 CPT 301 RC outpatient 180 180 HEALTHPARTNERS SX009 HEALTHPARTNERS 144 percent of total billed charges 111.6 171 Technical (Hospital) Services Ref Alpha 1 Antitrypsin PX-3018210300 CDM 82103 CPT 301 RC outpatient 180 180 UNITED HEALTHCARE (COMMERCIAL) [3081199] UNITED HEALTHCARE 87726 [308119901] 111.6 percent of total billed charges 111.6 171 Technical (Hospital) Services Ref Alpha 1 Antitrypsin PX-3018210300 CDM 82103 CPT 301 RC outpatient 180 180 BLUE CROSS BLUE SHIELD WELLMARK SB889 [3081026] BCBS WYOMING [308102603] 171 percent of total billed charges 111.6 171 Technical (Hospital) Services Ref Alpha 1 Antitrypsin PX-3018210300 CDM 82103 CPT 301 RC outpatient 180 180 MULTIPLAN INC 34080 [3081285] MULTIPLAN INC [308128501] 171 percent of total billed charges 111.6 171 Technical (Hospital) Services Ref Alpha 1 Antitrypsin PX-3018210300 CDM 82103 CPT 301 RC outpatient 180 180 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES HDHP [308136802] 144 percent of total billed charges 111.6 171 Technical (Hospital) Services Ref Alpha 1 Antitrypsin PX-3018210300 CDM 82103 CPT 301 RC outpatient 180 180 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES PPO [308136801] 144 percent of total billed charges 111.6 171 Technical (Hospital) Services Ref Alpha 1 Antitrypsin PX-3018210300 CDM 82103 CPT 301 RC outpatient 180 180 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES EPO [308136803] 144 percent of total billed charges 111.6 171 Technical (Hospital) Services Ref Alpha 1 Antitrypsin PX-3018210300 CDM 82103 CPT 301 RC inpatient 180 180 CIGNA 62308 [3081051] CIGNA 62308 [308105105] 142.52 percent of total billed charges 111.6 171 Technical (Hospital) Services Ref Alpha 1 Antitrypsin PX-3018210300 CDM 82103 CPT 301 RC inpatient 180 180 CIGNA 62308 [3081051] CIGNA STATE OF WYOMING [308105107] 142.52 percent of total billed charges 111.6 171 Technical (Hospital) Services Ref Alpha 1 Antitrypsin PX-3018210300 CDM 82103 CPT 301 RC inpatient 180 180 BLUE CROSS BLUE SHIELD WELLMARK SB889 [3081026] BCBS WYOMING [308102603] 171 percent of total billed charges 111.6 171 Technical (Hospital) Services Ref Alpha 1 Antitrypsin PX-3018210300 CDM 82103 CPT 301 RC inpatient 180 180 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES HDHP [308136802] 142.52 percent of total billed charges 111.6 171 Technical (Hospital) Services Ref Alpha 1 Antitrypsin PX-3018210300 CDM 82103 CPT 301 RC inpatient 180 180 MULTIPLAN INC 34080 [3081285] MULTIPLAN INC [308128501] 171 percent of total billed charges 111.6 171 Technical (Hospital) Services Ref Alpha 1 Antitrypsin PX-3018210300 CDM 82103 CPT 301 RC inpatient 180 180 UNITED HEALTHCARE (COMMERCIAL) [3081199] UNITED HEALTHCARE 87726 [308119901] 111.6 percent of total billed charges 111.6 171 Technical (Hospital) Services Ref Alpha 1 Antitrypsin PX-3018210300 CDM 82103 CPT 301 RC inpatient 180 180 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES PPO [308136801] 142.52 percent of total billed charges 111.6 171 Technical (Hospital) Services Ref Alpha 1 Antitrypsin PX-3018210300 CDM 82103 CPT 301 RC inpatient 180 180 MEDICA (COMMERCIAL) 94265 [3081118] MEDICA CLAIMS [308111801] 162 percent of total billed charges 111.6 171 Technical (Hospital) Services Ref Alpha 1 Antitrypsin PX-3018210300 CDM 82103 CPT 301 RC inpatient 180 180 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES EPO [308136803] 142.52 percent of total billed charges 111.6 171 Technical (Hospital) Services Ref Alpha 1 Antitrypsin PX-3018210300 CDM 82103 CPT 301 RC inpatient 180 180 HEALTHPARTNERS SX009 HEALTHPARTNERS 142.52 percent of total billed charges 111.6 171 Technical (Hospital) Services Ref Aldosterone Urine PX-3018208801 CDM 82088 CPT 301 RC inpatient 238 238 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES HDHP [308136802] 188.45 percent of total billed charges 147.56 226.1 Technical (Hospital) Services Ref Aldosterone Urine PX-3018208801 CDM 82088 CPT 301 RC inpatient 238 238 MEDICA (COMMERCIAL) 94265 [3081118] MEDICA CLAIMS [308111801] 214.2 percent of total billed charges 147.56 226.1 Technical (Hospital) Services Ref Aldosterone Urine PX-3018208801 CDM 82088 CPT 301 RC inpatient 238 238 HEALTHPARTNERS SX009 HEALTHPARTNERS 188.45 percent of total billed charges 147.56 226.1 Technical (Hospital) Services Ref Aldosterone Urine PX-3018208801 CDM 82088 CPT 301 RC inpatient 238 238 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES EPO [308136803] 188.45 percent of total billed charges 147.56 226.1 Technical (Hospital) Services Ref Aldosterone Urine PX-3018208801 CDM 82088 CPT 301 RC inpatient 238 238 MULTIPLAN INC 34080 [3081285] MULTIPLAN INC [308128501] 226.1 percent of total billed charges 147.56 226.1 Technical (Hospital) Services Ref Aldosterone Urine PX-3018208801 CDM 82088 CPT 301 RC inpatient 238 238 BLUE CROSS BLUE SHIELD WELLMARK SB889 [3081026] BCBS WYOMING [308102603] 226.1 percent of total billed charges 147.56 226.1 Technical (Hospital) Services Ref Aldosterone Urine PX-3018208801 CDM 82088 CPT 301 RC inpatient 238 238 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES PPO [308136801] 188.45 percent of total billed charges 147.56 226.1 Technical (Hospital) Services Ref Aldosterone Urine PX-3018208801 CDM 82088 CPT 301 RC inpatient 238 238 UNITED HEALTHCARE (COMMERCIAL) [3081199] UNITED HEALTHCARE 87726 [308119901] 147.56 percent of total billed charges 147.56 226.1 Technical (Hospital) Services Ref Aldosterone Urine PX-3018208801 CDM 82088 CPT 301 RC inpatient 238 238 CIGNA 62308 [3081051] CIGNA STATE OF WYOMING [308105107] 188.45 percent of total billed charges 147.56 226.1 Technical (Hospital) Services Ref Aldosterone Urine PX-3018208801 CDM 82088 CPT 301 RC inpatient 238 238 CIGNA 62308 [3081051] CIGNA 62308 [308105105] 188.45 percent of total billed charges 147.56 226.1 Technical (Hospital) Services Ref Aldosterone Urine PX-3018208801 CDM 82088 CPT 301 RC outpatient 238 238 UNITED HEALTHCARE (COMMERCIAL) [3081199] UNITED HEALTHCARE 87726 [308119901] 147.56 percent of total billed charges 147.56 226.1 Technical (Hospital) Services Ref Aldosterone Urine PX-3018208801 CDM 82088 CPT 301 RC outpatient 238 238 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES EPO [308136803] 190.4 percent of total billed charges 147.56 226.1 Technical (Hospital) Services Ref Aldosterone Urine PX-3018208801 CDM 82088 CPT 301 RC outpatient 238 238 HEALTHPARTNERS SX009 HEALTHPARTNERS 190.4 percent of total billed charges 147.56 226.1 Technical (Hospital) Services Ref Aldosterone Urine PX-3018208801 CDM 82088 CPT 301 RC outpatient 238 238 MULTIPLAN INC 34080 [3081285] MULTIPLAN INC [308128501] 226.1 percent of total billed charges 147.56 226.1 Technical (Hospital) Services Ref Aldosterone Urine PX-3018208801 CDM 82088 CPT 301 RC outpatient 238 238 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES HDHP [308136802] 190.4 percent of total billed charges 147.56 226.1 Technical (Hospital) Services Ref Aldosterone Urine PX-3018208801 CDM 82088 CPT 301 RC outpatient 238 238 BLUE CROSS BLUE SHIELD WELLMARK SB889 [3081026] BCBS WYOMING [308102603] 226.1 percent of total billed charges 147.56 226.1 Technical (Hospital) Services Ref Aldosterone Urine PX-3018208801 CDM 82088 CPT 301 RC outpatient 238 238 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES PPO [308136801] 190.4 percent of total billed charges 147.56 226.1 Technical (Hospital) Services Ref Aldosterone Urine PX-3018208801 CDM 82088 CPT 301 RC outpatient 238 238 CIGNA 62308 [3081051] CIGNA 62308 [308105105] 190.4 percent of total billed charges 147.56 226.1 Technical (Hospital) Services Ref Aldosterone Urine PX-3018208801 CDM 82088 CPT 301 RC outpatient 238 238 CIGNA 62308 [3081051] CIGNA STATE OF WYOMING [308105107] 190.4 percent of total billed charges 147.56 226.1 Technical (Hospital) Services Ref Aldosterone Urine PX-3018208801 CDM 82088 CPT 301 RC outpatient 238 238 MEDICA (COMMERCIAL) 94265 [3081118] MEDICA CLAIMS [308111801] 214.2 percent of total billed charges 147.56 226.1 Technical (Hospital) Services Ref Aldosterone Serum PX-3018208802 CDM 82088 CPT 301 RC inpatient 364 364 MEDICA (COMMERCIAL) 94265 [3081118] MEDICA CLAIMS [308111801] 327.6 percent of total billed charges 225.68 345.8 Technical (Hospital) Services Ref Aldosterone Serum PX-3018208802 CDM 82088 CPT 301 RC inpatient 364 364 HEALTHPARTNERS SX009 HEALTHPARTNERS 288.22 percent of total billed charges 225.68 345.8 Technical (Hospital) Services Ref Aldosterone Serum PX-3018208802 CDM 82088 CPT 301 RC inpatient 364 364 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES EPO [308136803] 288.22 percent of total billed charges 225.68 345.8 Technical (Hospital) Services Ref Aldosterone Serum PX-3018208802 CDM 82088 CPT 301 RC inpatient 364 364 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES HDHP [308136802] 288.22 percent of total billed charges 225.68 345.8 Technical (Hospital) Services Ref Aldosterone Serum PX-3018208802 CDM 82088 CPT 301 RC inpatient 364 364 BLUE CROSS BLUE SHIELD WELLMARK SB889 [3081026] BCBS WYOMING [308102603] 345.8 percent of total billed charges 225.68 345.8 Technical (Hospital) Services Ref Aldosterone Serum PX-3018208802 CDM 82088 CPT 301 RC inpatient 364 364 MULTIPLAN INC 34080 [3081285] MULTIPLAN INC [308128501] 345.8 percent of total billed charges 225.68 345.8 Technical (Hospital) Services Ref Aldosterone Serum PX-3018208802 CDM 82088 CPT 301 RC inpatient 364 364 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES PPO [308136801] 288.22 percent of total billed charges 225.68 345.8 Technical (Hospital) Services Ref Aldosterone Serum PX-3018208802 CDM 82088 CPT 301 RC inpatient 364 364 UNITED HEALTHCARE (COMMERCIAL) [3081199] UNITED HEALTHCARE 87726 [308119901] 225.68 percent of total billed charges 225.68 345.8 Technical (Hospital) Services Ref Aldosterone Serum PX-3018208802 CDM 82088 CPT 301 RC inpatient 364 364 CIGNA 62308 [3081051] CIGNA 62308 [308105105] 288.22 percent of total billed charges 225.68 345.8 Technical (Hospital) Services Ref Aldosterone Serum PX-3018208802 CDM 82088 CPT 301 RC inpatient 364 364 CIGNA 62308 [3081051] CIGNA STATE OF WYOMING [308105107] 288.22 percent of total billed charges 225.68 345.8 Technical (Hospital) Services Ref Aldosterone Serum PX-3018208802 CDM 82088 CPT 301 RC outpatient 364 364 MULTIPLAN INC 34080 [3081285] MULTIPLAN INC [308128501] 345.8 percent of total billed charges 225.68 345.8 Technical (Hospital) Services Ref Aldosterone Serum PX-3018208802 CDM 82088 CPT 301 RC outpatient 364 364 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES HDHP [308136802] 291.2 percent of total billed charges 225.68 345.8 Technical (Hospital) Services Ref Aldosterone Serum PX-3018208802 CDM 82088 CPT 301 RC outpatient 364 364 BLUE CROSS BLUE SHIELD WELLMARK SB889 [3081026] BCBS WYOMING [308102603] 345.8 percent of total billed charges 225.68 345.8 Technical (Hospital) Services Ref Aldosterone Serum PX-3018208802 CDM 82088 CPT 301 RC outpatient 364 364 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES PPO [308136801] 291.2 percent of total billed charges 225.68 345.8 Technical (Hospital) Services Ref Aldosterone Serum PX-3018208802 CDM 82088 CPT 301 RC outpatient 364 364 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES EPO [308136803] 291.2 percent of total billed charges 225.68 345.8 Technical (Hospital) Services Ref Aldosterone Serum PX-3018208802 CDM 82088 CPT 301 RC outpatient 364 364 UNITED HEALTHCARE (COMMERCIAL) [3081199] UNITED HEALTHCARE 87726 [308119901] 225.68 percent of total billed charges 225.68 345.8 Technical (Hospital) Services Ref Aldosterone Serum PX-3018208802 CDM 82088 CPT 301 RC outpatient 364 364 HEALTHPARTNERS SX009 HEALTHPARTNERS 291.2 percent of total billed charges 225.68 345.8 Technical (Hospital) Services Ref Aldosterone Serum PX-3018208802 CDM 82088 CPT 301 RC outpatient 364 364 MEDICA (COMMERCIAL) 94265 [3081118] MEDICA CLAIMS [308111801] 327.6 percent of total billed charges 225.68 345.8 Technical (Hospital) Services Ref Aldosterone Serum PX-3018208802 CDM 82088 CPT 301 RC outpatient 364 364 CIGNA 62308 [3081051] CIGNA 62308 [308105105] 291.2 percent of total billed charges 225.68 345.8 Technical (Hospital) Services Ref Aldosterone Serum PX-3018208802 CDM 82088 CPT 301 RC outpatient 364 364 CIGNA 62308 [3081051] CIGNA STATE OF WYOMING [308105107] 291.2 percent of total billed charges 225.68 345.8 Technical (Hospital) Services Ref Aldolase PX-3018208501 CDM 82085 CPT 301 RC inpatient 100 100 CIGNA 62308 [3081051] CIGNA 62308 [308105105] 79.18 percent of total billed charges 62 95 Technical (Hospital) Services Ref Aldolase PX-3018208501 CDM 82085 CPT 301 RC inpatient 100 100 CIGNA 62308 [3081051] CIGNA STATE OF WYOMING [308105107] 79.18 percent of total billed charges 62 95 Technical (Hospital) Services Ref Aldolase PX-3018208501 CDM 82085 CPT 301 RC inpatient 100 100 UNITED HEALTHCARE (COMMERCIAL) [3081199] UNITED HEALTHCARE 87726 [308119901] 62 percent of total billed charges 62 95 Technical (Hospital) Services Ref Aldolase PX-3018208501 CDM 82085 CPT 301 RC inpatient 100 100 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES PPO [308136801] 79.18 percent of total billed charges 62 95 Technical (Hospital) Services Ref Aldolase PX-3018208501 CDM 82085 CPT 301 RC inpatient 100 100 MULTIPLAN INC 34080 [3081285] MULTIPLAN INC [308128501] 95 percent of total billed charges 62 95 Technical (Hospital) Services Ref Aldolase PX-3018208501 CDM 82085 CPT 301 RC inpatient 100 100 BLUE CROSS BLUE SHIELD WELLMARK SB889 [3081026] BCBS WYOMING [308102603] 95 percent of total billed charges 62 95 Technical (Hospital) Services Ref Aldolase PX-3018208501 CDM 82085 CPT 301 RC inpatient 100 100 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES HDHP [308136802] 79.18 percent of total billed charges 62 95 Technical (Hospital) Services Ref Aldolase PX-3018208501 CDM 82085 CPT 301 RC inpatient 100 100 HEALTHPARTNERS SX009 HEALTHPARTNERS 79.18 percent of total billed charges 62 95 Technical (Hospital) Services Ref Aldolase PX-3018208501 CDM 82085 CPT 301 RC inpatient 100 100 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES EPO [308136803] 79.18 percent of total billed charges 62 95 Technical (Hospital) Services Ref Aldolase PX-3018208501 CDM 82085 CPT 301 RC inpatient 100 100 MEDICA (COMMERCIAL) 94265 [3081118] MEDICA CLAIMS [308111801] 90 percent of total billed charges 62 95 Technical (Hospital) Services Ref Aldolase PX-3018208501 CDM 82085 CPT 301 RC outpatient 100 100 CIGNA 62308 [3081051] CIGNA 62308 [308105105] 80 percent of total billed charges 62 95 Technical (Hospital) Services Ref Aldolase PX-3018208501 CDM 82085 CPT 301 RC outpatient 100 100 CIGNA 62308 [3081051] CIGNA STATE OF WYOMING [308105107] 80 percent of total billed charges 62 95 Technical (Hospital) Services Ref Aldolase PX-3018208501 CDM 82085 CPT 301 RC outpatient 100 100 MEDICA (COMMERCIAL) 94265 [3081118] MEDICA CLAIMS [308111801] 90 percent of total billed charges 62 95 Technical (Hospital) Services Ref Aldolase PX-3018208501 CDM 82085 CPT 301 RC outpatient 100 100 HEALTHPARTNERS SX009 HEALTHPARTNERS 80 percent of total billed charges 62 95 Technical (Hospital) Services Ref Aldolase PX-3018208501 CDM 82085 CPT 301 RC outpatient 100 100 UNITED HEALTHCARE (COMMERCIAL) [3081199] UNITED HEALTHCARE 87726 [308119901] 62 percent of total billed charges 62 95 Technical (Hospital) Services Ref Aldolase PX-3018208501 CDM 82085 CPT 301 RC outpatient 100 100 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES HDHP [308136802] 80 percent of total billed charges 62 95 Technical (Hospital) Services Ref Aldolase PX-3018208501 CDM 82085 CPT 301 RC outpatient 100 100 BLUE CROSS BLUE SHIELD WELLMARK SB889 [3081026] BCBS WYOMING [308102603] 95 percent of total billed charges 62 95 Technical (Hospital) Services Ref Aldolase PX-3018208501 CDM 82085 CPT 301 RC outpatient 100 100 MULTIPLAN INC 34080 [3081285] MULTIPLAN INC [308128501] 95 percent of total billed charges 62 95 Technical (Hospital) Services Ref Aldolase PX-3018208501 CDM 82085 CPT 301 RC outpatient 100 100 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES EPO [308136803] 80 percent of total billed charges 62 95 Technical (Hospital) Services Ref Aldolase PX-3018208501 CDM 82085 CPT 301 RC outpatient 100 100 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES PPO [308136801] 80 percent of total billed charges 62 95 Technical (Hospital) Services Assay of Alcohol (Ethanol) Spec Xcp UR&Breath Ia PX-3018207700 CDM 82077 CPT 301 RC outpatient 183 183 UNITED HEALTHCARE (COMMERCIAL) [3081199] UNITED HEALTHCARE 87726 [308119901] 113.46 percent of total billed charges 113.46 173.85 Technical (Hospital) Services Assay of Alcohol (Ethanol) Spec Xcp UR&Breath Ia PX-3018207700 CDM 82077 CPT 301 RC outpatient 183 183 HEALTHPARTNERS SX009 HEALTHPARTNERS 146.4 percent of total billed charges 113.46 173.85 Technical (Hospital) Services Assay of Alcohol (Ethanol) Spec Xcp UR&Breath Ia PX-3018207700 CDM 82077 CPT 301 RC outpatient 183 183 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES EPO [308136803] 146.4 percent of total billed charges 113.46 173.85 Technical (Hospital) Services Assay of Alcohol (Ethanol) Spec Xcp UR&Breath Ia PX-3018207700 CDM 82077 CPT 301 RC outpatient 183 183 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES PPO [308136801] 146.4 percent of total billed charges 113.46 173.85 Technical (Hospital) Services Assay of Alcohol (Ethanol) Spec Xcp UR&Breath Ia PX-3018207700 CDM 82077 CPT 301 RC outpatient 183 183 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES HDHP [308136802] 146.4 percent of total billed charges 113.46 173.85 Technical (Hospital) Services Assay of Alcohol (Ethanol) Spec Xcp UR&Breath Ia PX-3018207700 CDM 82077 CPT 301 RC outpatient 183 183 BLUE CROSS BLUE SHIELD WELLMARK SB889 [3081026] BCBS WYOMING [308102603] 173.85 percent of total billed charges 113.46 173.85 Technical (Hospital) Services Assay of Alcohol (Ethanol) Spec Xcp UR&Breath Ia PX-3018207700 CDM 82077 CPT 301 RC outpatient 183 183 MULTIPLAN INC 34080 [3081285] MULTIPLAN INC [308128501] 173.85 percent of total billed charges 113.46 173.85 Technical (Hospital) Services Assay of Alcohol (Ethanol) Spec Xcp UR&Breath Ia PX-3018207700 CDM 82077 CPT 301 RC outpatient 183 183 CIGNA 62308 [3081051] CIGNA 62308 [308105105] 146.4 percent of total billed charges 113.46 173.85 Technical (Hospital) Services Assay of Alcohol (Ethanol) Spec Xcp UR&Breath Ia PX-3018207700 CDM 82077 CPT 301 RC outpatient 183 183 CIGNA 62308 [3081051] CIGNA STATE OF WYOMING [308105107] 146.4 percent of total billed charges 113.46 173.85 Technical (Hospital) Services Assay of Alcohol (Ethanol) Spec Xcp UR&Breath Ia PX-3018207700 CDM 82077 CPT 301 RC outpatient 183 183 MEDICA (COMMERCIAL) 94265 [3081118] MEDICA CLAIMS [308111801] 164.7 percent of total billed charges 113.46 173.85 Technical (Hospital) Services Assay of Alcohol (Ethanol) Spec Xcp UR&Breath Ia PX-3018207700 CDM 82077 CPT 301 RC inpatient 183 183 HEALTHPARTNERS SX009 HEALTHPARTNERS 144.9 percent of total billed charges 113.46 173.85 Technical (Hospital) Services Assay of Alcohol (Ethanol) Spec Xcp UR&Breath Ia PX-3018207700 CDM 82077 CPT 301 RC inpatient 183 183 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES EPO [308136803] 144.9 percent of total billed charges 113.46 173.85 Technical (Hospital) Services Assay of Alcohol (Ethanol) Spec Xcp UR&Breath Ia PX-3018207700 CDM 82077 CPT 301 RC inpatient 183 183 MEDICA (COMMERCIAL) 94265 [3081118] MEDICA CLAIMS [308111801] 164.7 percent of total billed charges 113.46 173.85 Technical (Hospital) Services Assay of Alcohol (Ethanol) Spec Xcp UR&Breath Ia PX-3018207700 CDM 82077 CPT 301 RC inpatient 183 183 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES PPO [308136801] 144.9 percent of total billed charges 113.46 173.85 Technical (Hospital) Services Assay of Alcohol (Ethanol) Spec Xcp UR&Breath Ia PX-3018207700 CDM 82077 CPT 301 RC inpatient 183 183 UNITED HEALTHCARE (COMMERCIAL) [3081199] UNITED HEALTHCARE 87726 [308119901] 113.46 percent of total billed charges 113.46 173.85 Technical (Hospital) Services Assay of Alcohol (Ethanol) Spec Xcp UR&Breath Ia PX-3018207700 CDM 82077 CPT 301 RC inpatient 183 183 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES HDHP [308136802] 144.9 percent of total billed charges 113.46 173.85 Technical (Hospital) Services Assay of Alcohol (Ethanol) Spec Xcp UR&Breath Ia PX-3018207700 CDM 82077 CPT 301 RC inpatient 183 183 BLUE CROSS BLUE SHIELD WELLMARK SB889 [3081026] BCBS WYOMING [308102603] 173.85 percent of total billed charges 113.46 173.85 Technical (Hospital) Services Assay of Alcohol (Ethanol) Spec Xcp UR&Breath Ia PX-3018207700 CDM 82077 CPT 301 RC inpatient 183 183 MULTIPLAN INC 34080 [3081285] MULTIPLAN INC [308128501] 173.85 percent of total billed charges 113.46 173.85 Technical (Hospital) Services Assay of Alcohol (Ethanol) Spec Xcp UR&Breath Ia PX-3018207700 CDM 82077 CPT 301 RC inpatient 183 183 CIGNA 62308 [3081051] CIGNA 62308 [308105105] 144.9 percent of total billed charges 113.46 173.85 Technical (Hospital) Services Assay of Alcohol (Ethanol) Spec Xcp UR&Breath Ia PX-3018207700 CDM 82077 CPT 301 RC inpatient 183 183 CIGNA 62308 [3081051] CIGNA STATE OF WYOMING [308105107] 144.9 percent of total billed charges 113.46 173.85 Technical (Hospital) Services Assay of Breath Ethanol PX-3018207500 CDM 82075 CPT 301 RC inpatient 80 80 UNITED HEALTHCARE (COMMERCIAL) [3081199] UNITED HEALTHCARE 87726 [308119901] 49.6 percent of total billed charges 49.6 76 Technical (Hospital) Services Assay of Breath Ethanol PX-3018207500 CDM 82075 CPT 301 RC inpatient 80 80 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES PPO [308136801] 63.34 percent of total billed charges 49.6 76 Technical (Hospital) Services Assay of Breath Ethanol PX-3018207500 CDM 82075 CPT 301 RC inpatient 80 80 BLUE CROSS BLUE SHIELD WELLMARK SB889 [3081026] BCBS WYOMING [308102603] 76 percent of total billed charges 49.6 76 Technical (Hospital) Services Assay of Breath Ethanol PX-3018207500 CDM 82075 CPT 301 RC inpatient 80 80 MULTIPLAN INC 34080 [3081285] MULTIPLAN INC [308128501] 76 percent of total billed charges 49.6 76 Technical (Hospital) Services Assay of Breath Ethanol PX-3018207500 CDM 82075 CPT 301 RC inpatient 80 80 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES HDHP [308136802] 63.34 percent of total billed charges 49.6 76 Technical (Hospital) Services Assay of Breath Ethanol PX-3018207500 CDM 82075 CPT 301 RC inpatient 80 80 MEDICA (COMMERCIAL) 94265 [3081118] MEDICA CLAIMS [308111801] 72 percent of total billed charges 49.6 76 Technical (Hospital) Services Assay of Breath Ethanol PX-3018207500 CDM 82075 CPT 301 RC inpatient 80 80 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES EPO [308136803] 63.34 percent of total billed charges 49.6 76 Technical (Hospital) Services Assay of Breath Ethanol PX-3018207500 CDM 82075 CPT 301 RC inpatient 80 80 HEALTHPARTNERS SX009 HEALTHPARTNERS 63.34 percent of total billed charges 49.6 76 Technical (Hospital) Services Assay of Breath Ethanol PX-3018207500 CDM 82075 CPT 301 RC inpatient 80 80 CIGNA 62308 [3081051] CIGNA 62308 [308105105] 63.34 percent of total billed charges 49.6 76 Technical (Hospital) Services Assay of Breath Ethanol PX-3018207500 CDM 82075 CPT 301 RC inpatient 80 80 CIGNA 62308 [3081051] CIGNA STATE OF WYOMING [308105107] 63.34 percent of total billed charges 49.6 76 Technical (Hospital) Services Assay of Breath Ethanol PX-3018207500 CDM 82075 CPT 301 RC outpatient 80 80 MEDICA (COMMERCIAL) 94265 [3081118] MEDICA CLAIMS [308111801] 72 percent of total billed charges 49.6 76 Technical (Hospital) Services Assay of Breath Ethanol PX-3018207500 CDM 82075 CPT 301 RC outpatient 80 80 CIGNA 62308 [3081051] CIGNA 62308 [308105105] 64 percent of total billed charges 49.6 76 Technical (Hospital) Services Assay of Breath Ethanol PX-3018207500 CDM 82075 CPT 301 RC outpatient 80 80 CIGNA 62308 [3081051] CIGNA STATE OF WYOMING [308105107] 64 percent of total billed charges 49.6 76 Technical (Hospital) Services Assay of Breath Ethanol PX-3018207500 CDM 82075 CPT 301 RC outpatient 80 80 BLUE CROSS BLUE SHIELD WELLMARK SB889 [3081026] BCBS WYOMING [308102603] 76 percent of total billed charges 49.6 76 Technical (Hospital) Services Assay of Breath Ethanol PX-3018207500 CDM 82075 CPT 301 RC outpatient 80 80 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES HDHP [308136802] 64 percent of total billed charges 49.6 76 Technical (Hospital) Services Assay of Breath Ethanol PX-3018207500 CDM 82075 CPT 301 RC outpatient 80 80 MULTIPLAN INC 34080 [3081285] MULTIPLAN INC [308128501] 76 percent of total billed charges 49.6 76 Technical (Hospital) Services Assay of Breath Ethanol PX-3018207500 CDM 82075 CPT 301 RC outpatient 80 80 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES PPO [308136801] 64 percent of total billed charges 49.6 76 Technical (Hospital) Services Assay of Breath Ethanol PX-3018207500 CDM 82075 CPT 301 RC outpatient 80 80 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES EPO [308136803] 64 percent of total billed charges 49.6 76 Technical (Hospital) Services Assay of Breath Ethanol PX-3018207500 CDM 82075 CPT 301 RC outpatient 80 80 UNITED HEALTHCARE (COMMERCIAL) [3081199] UNITED HEALTHCARE 87726 [308119901] 49.6 percent of total billed charges 49.6 76 Technical (Hospital) Services Assay of Breath Ethanol PX-3018207500 CDM 82075 CPT 301 RC outpatient 80 80 HEALTHPARTNERS SX009 HEALTHPARTNERS 64 percent of total billed charges 49.6 76 Technical (Hospital) Services Workplace Breath Alcohol Test (Bat) PX-3078207501 CDM 82075 CPT 307 RC inpatient 58 58 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES EPO [308136803] 45.92 percent of total billed charges 35.96 55.1 Technical (Hospital) Services Workplace Breath Alcohol Test (Bat) PX-3078207501 CDM 82075 CPT 307 RC inpatient 58 58 HEALTHPARTNERS SX009 HEALTHPARTNERS 45.92 percent of total billed charges 35.96 55.1 Technical (Hospital) Services Workplace Breath Alcohol Test (Bat) PX-3078207501 CDM 82075 CPT 307 RC inpatient 58 58 CIGNA 62308 [3081051] CIGNA 62308 [308105105] 45.92 percent of total billed charges 35.96 55.1 Technical (Hospital) Services Workplace Breath Alcohol Test (Bat) PX-3078207501 CDM 82075 CPT 307 RC inpatient 58 58 CIGNA 62308 [3081051] CIGNA STATE OF WYOMING [308105107] 45.92 percent of total billed charges 35.96 55.1 Technical (Hospital) Services Workplace Breath Alcohol Test (Bat) PX-3078207501 CDM 82075 CPT 307 RC inpatient 58 58 BLUE CROSS BLUE SHIELD WELLMARK SB889 [3081026] BCBS WYOMING [308102603] 55.1 percent of total billed charges 35.96 55.1 Technical (Hospital) Services Workplace Breath Alcohol Test (Bat) PX-3078207501 CDM 82075 CPT 307 RC inpatient 58 58 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES PPO [308136801] 45.92 percent of total billed charges 35.96 55.1 Technical (Hospital) Services Workplace Breath Alcohol Test (Bat) PX-3078207501 CDM 82075 CPT 307 RC inpatient 58 58 MULTIPLAN INC 34080 [3081285] MULTIPLAN INC [308128501] 55.1 percent of total billed charges 35.96 55.1 Technical (Hospital) Services Workplace Breath Alcohol Test (Bat) PX-3078207501 CDM 82075 CPT 307 RC inpatient 58 58 MEDICA (COMMERCIAL) 94265 [3081118] MEDICA CLAIMS [308111801] 52.2 percent of total billed charges 35.96 55.1 Technical (Hospital) Services Workplace Breath Alcohol Test (Bat) PX-3078207501 CDM 82075 CPT 307 RC inpatient 58 58 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES HDHP [308136802] 45.92 percent of total billed charges 35.96 55.1 Technical (Hospital) Services Workplace Breath Alcohol Test (Bat) PX-3078207501 CDM 82075 CPT 307 RC inpatient 58 58 UNITED HEALTHCARE (COMMERCIAL) [3081199] UNITED HEALTHCARE 87726 [308119901] 35.96 percent of total billed charges 35.96 55.1 Technical (Hospital) Services Workplace Breath Alcohol Test (Bat) PX-3078207501 CDM 82075 CPT 307 RC outpatient 58 58 HEALTHPARTNERS SX009 HEALTHPARTNERS 46.4 percent of total billed charges 35.96 55.1 Technical (Hospital) Services Workplace Breath Alcohol Test (Bat) PX-3078207501 CDM 82075 CPT 307 RC outpatient 58 58 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES PPO [308136801] 46.4 percent of total billed charges 35.96 55.1 Technical (Hospital) Services Workplace Breath Alcohol Test (Bat) PX-3078207501 CDM 82075 CPT 307 RC outpatient 58 58 UNITED HEALTHCARE (COMMERCIAL) [3081199] UNITED HEALTHCARE 87726 [308119901] 35.96 percent of total billed charges 35.96 55.1 Technical (Hospital) Services Workplace Breath Alcohol Test (Bat) PX-3078207501 CDM 82075 CPT 307 RC outpatient 58 58 BLUE CROSS BLUE SHIELD WELLMARK SB889 [3081026] BCBS WYOMING [308102603] 55.1 percent of total billed charges 35.96 55.1 Technical (Hospital) Services Workplace Breath Alcohol Test (Bat) PX-3078207501 CDM 82075 CPT 307 RC outpatient 58 58 MULTIPLAN INC 34080 [3081285] MULTIPLAN INC [308128501] 55.1 percent of total billed charges 35.96 55.1 Technical (Hospital) Services Workplace Breath Alcohol Test (Bat) PX-3078207501 CDM 82075 CPT 307 RC outpatient 58 58 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES HDHP [308136802] 46.4 percent of total billed charges 35.96 55.1 Technical (Hospital) Services Workplace Breath Alcohol Test (Bat) PX-3078207501 CDM 82075 CPT 307 RC outpatient 58 58 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES EPO [308136803] 46.4 percent of total billed charges 35.96 55.1 Technical (Hospital) Services Workplace Breath Alcohol Test (Bat) PX-3078207501 CDM 82075 CPT 307 RC outpatient 58 58 CIGNA 62308 [3081051] CIGNA 62308 [308105105] 46.4 percent of total billed charges 35.96 55.1 Technical (Hospital) Services Workplace Breath Alcohol Test (Bat) PX-3078207501 CDM 82075 CPT 307 RC outpatient 58 58 CIGNA 62308 [3081051] CIGNA STATE OF WYOMING [308105107] 46.4 percent of total billed charges 35.96 55.1 Technical (Hospital) Services Workplace Breath Alcohol Test (Bat) PX-3078207501 CDM 82075 CPT 307 RC outpatient 58 58 MEDICA (COMMERCIAL) 94265 [3081118] MEDICA CLAIMS [308111801] 52.2 percent of total billed charges 35.96 55.1 Technical (Hospital) Services Microalbumin Qual PX-3018204400 CDM 82044 CPT 301 RC inpatient 42 42 MEDICA (COMMERCIAL) 94265 [3081118] MEDICA CLAIMS [308111801] 37.8 percent of total billed charges 26.04 39.9 Technical (Hospital) Services Microalbumin Qual PX-3018204400 CDM 82044 CPT 301 RC inpatient 42 42 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES EPO [308136803] 33.26 percent of total billed charges 26.04 39.9 Technical (Hospital) Services Microalbumin Qual PX-3018204400 CDM 82044 CPT 301 RC inpatient 42 42 HEALTHPARTNERS SX009 HEALTHPARTNERS 33.26 percent of total billed charges 26.04 39.9 Technical (Hospital) Services Microalbumin Qual PX-3018204400 CDM 82044 CPT 301 RC inpatient 42 42 BLUE CROSS BLUE SHIELD WELLMARK SB889 [3081026] BCBS WYOMING [308102603] 39.9 percent of total billed charges 26.04 39.9 Technical (Hospital) Services Microalbumin Qual PX-3018204400 CDM 82044 CPT 301 RC inpatient 42 42 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES HDHP [308136802] 33.26 percent of total billed charges 26.04 39.9 Technical (Hospital) Services Microalbumin Qual PX-3018204400 CDM 82044 CPT 301 RC inpatient 42 42 MULTIPLAN INC 34080 [3081285] MULTIPLAN INC [308128501] 39.9 percent of total billed charges 26.04 39.9 Technical (Hospital) Services Microalbumin Qual PX-3018204400 CDM 82044 CPT 301 RC inpatient 42 42 UNITED HEALTHCARE (COMMERCIAL) [3081199] UNITED HEALTHCARE 87726 [308119901] 26.04 percent of total billed charges 26.04 39.9 Technical (Hospital) Services Microalbumin Qual PX-3018204400 CDM 82044 CPT 301 RC inpatient 42 42 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES PPO [308136801] 33.26 percent of total billed charges 26.04 39.9 Technical (Hospital) Services Microalbumin Qual PX-3018204400 CDM 82044 CPT 301 RC inpatient 42 42 CIGNA 62308 [3081051] CIGNA 62308 [308105105] 33.26 percent of total billed charges 26.04 39.9 Technical (Hospital) Services Microalbumin Qual PX-3018204400 CDM 82044 CPT 301 RC inpatient 42 42 CIGNA 62308 [3081051] CIGNA STATE OF WYOMING [308105107] 33.26 percent of total billed charges 26.04 39.9 Technical (Hospital) Services Microalbumin Qual PX-3018204400 CDM 82044 CPT 301 RC outpatient 42 42 HEALTHPARTNERS SX009 HEALTHPARTNERS 33.6 percent of total billed charges 26.04 39.9 Technical (Hospital) Services Microalbumin Qual PX-3018204400 CDM 82044 CPT 301 RC outpatient 42 42 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES EPO [308136803] 33.6 percent of total billed charges 26.04 39.9 Technical (Hospital) Services Microalbumin Qual PX-3018204400 CDM 82044 CPT 301 RC outpatient 42 42 UNITED HEALTHCARE (COMMERCIAL) [3081199] UNITED HEALTHCARE 87726 [308119901] 26.04 percent of total billed charges 26.04 39.9 Technical (Hospital) Services Microalbumin Qual PX-3018204400 CDM 82044 CPT 301 RC outpatient 42 42 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES PPO [308136801] 33.6 percent of total billed charges 26.04 39.9 Technical (Hospital) Services Microalbumin Qual PX-3018204400 CDM 82044 CPT 301 RC outpatient 42 42 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES HDHP [308136802] 33.6 percent of total billed charges 26.04 39.9 Technical (Hospital) Services Microalbumin Qual PX-3018204400 CDM 82044 CPT 301 RC outpatient 42 42 MULTIPLAN INC 34080 [3081285] MULTIPLAN INC [308128501] 39.9 percent of total billed charges 26.04 39.9 Technical (Hospital) Services Microalbumin Qual PX-3018204400 CDM 82044 CPT 301 RC outpatient 42 42 BLUE CROSS BLUE SHIELD WELLMARK SB889 [3081026] BCBS WYOMING [308102603] 39.9 percent of total billed charges 26.04 39.9 Technical (Hospital) Services Microalbumin Qual PX-3018204400 CDM 82044 CPT 301 RC outpatient 42 42 MEDICA (COMMERCIAL) 94265 [3081118] MEDICA CLAIMS [308111801] 37.8 percent of total billed charges 26.04 39.9 Technical (Hospital) Services Microalbumin Qual PX-3018204400 CDM 82044 CPT 301 RC outpatient 42 42 CIGNA 62308 [3081051] CIGNA 62308 [308105105] 33.6 percent of total billed charges 26.04 39.9 Technical (Hospital) Services Microalbumin Qual PX-3018204400 CDM 82044 CPT 301 RC outpatient 42 42 CIGNA 62308 [3081051] CIGNA STATE OF WYOMING [308105107] 33.6 percent of total billed charges 26.04 39.9 Technical (Hospital) Services Urine Microalbumin Quantitativ PX-3018204300 CDM 82043 CPT 301 RC inpatient 128 128 HEALTHPARTNERS SX009 HEALTHPARTNERS 101.35 percent of total billed charges 79.36 121.6 Technical (Hospital) Services Urine Microalbumin Quantitativ PX-3018204300 CDM 82043 CPT 301 RC inpatient 128 128 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES EPO [308136803] 101.35 percent of total billed charges 79.36 121.6 Technical (Hospital) Services Urine Microalbumin Quantitativ PX-3018204300 CDM 82043 CPT 301 RC inpatient 128 128 MEDICA (COMMERCIAL) 94265 [3081118] MEDICA CLAIMS [308111801] 115.2 percent of total billed charges 79.36 121.6 Technical (Hospital) Services Urine Microalbumin Quantitativ PX-3018204300 CDM 82043 CPT 301 RC inpatient 128 128 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES HDHP [308136802] 101.35 percent of total billed charges 79.36 121.6 Technical (Hospital) Services Urine Microalbumin Quantitativ PX-3018204300 CDM 82043 CPT 301 RC inpatient 128 128 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES PPO [308136801] 101.35 percent of total billed charges 79.36 121.6 Technical (Hospital) Services Urine Microalbumin Quantitativ PX-3018204300 CDM 82043 CPT 301 RC inpatient 128 128 UNITED HEALTHCARE (COMMERCIAL) [3081199] UNITED HEALTHCARE 87726 [308119901] 79.36 percent of total billed charges 79.36 121.6 Technical (Hospital) Services Urine Microalbumin Quantitativ PX-3018204300 CDM 82043 CPT 301 RC inpatient 128 128 MULTIPLAN INC 34080 [3081285] MULTIPLAN INC [308128501] 121.6 percent of total billed charges 79.36 121.6 Technical (Hospital) Services Urine Microalbumin Quantitativ PX-3018204300 CDM 82043 CPT 301 RC inpatient 128 128 BLUE CROSS BLUE SHIELD WELLMARK SB889 [3081026] BCBS WYOMING [308102603] 121.6 percent of total billed charges 79.36 121.6 Technical (Hospital) Services Urine Microalbumin Quantitativ PX-3018204300 CDM 82043 CPT 301 RC inpatient 128 128 CIGNA 62308 [3081051] CIGNA 62308 [308105105] 101.35 percent of total billed charges 79.36 121.6 Technical (Hospital) Services Urine Microalbumin Quantitativ PX-3018204300 CDM 82043 CPT 301 RC inpatient 128 128 CIGNA 62308 [3081051] CIGNA STATE OF WYOMING [308105107] 101.35 percent of total billed charges 79.36 121.6 Technical (Hospital) Services Urine Microalbumin Quantitativ PX-3018204300 CDM 82043 CPT 301 RC outpatient 128 128 MEDICA (COMMERCIAL) 94265 [3081118] MEDICA CLAIMS [308111801] 115.2 percent of total billed charges 79.36 121.6 Technical (Hospital) Services Urine Microalbumin Quantitativ PX-3018204300 CDM 82043 CPT 301 RC outpatient 128 128 CIGNA 62308 [3081051] CIGNA 62308 [308105105] 102.4 percent of total billed charges 79.36 121.6 Technical (Hospital) Services Urine Microalbumin Quantitativ PX-3018204300 CDM 82043 CPT 301 RC outpatient 128 128 CIGNA 62308 [3081051] CIGNA STATE OF WYOMING [308105107] 102.4 percent of total billed charges 79.36 121.6 Technical (Hospital) Services Urine Microalbumin Quantitativ PX-3018204300 CDM 82043 CPT 301 RC outpatient 128 128 HEALTHPARTNERS SX009 HEALTHPARTNERS 102.4 percent of total billed charges 79.36 121.6 Technical (Hospital) Services Urine Microalbumin Quantitativ PX-3018204300 CDM 82043 CPT 301 RC outpatient 128 128 UNITED HEALTHCARE (COMMERCIAL) [3081199] UNITED HEALTHCARE 87726 [308119901] 79.36 percent of total billed charges 79.36 121.6 Technical (Hospital) Services Urine Microalbumin Quantitativ PX-3018204300 CDM 82043 CPT 301 RC outpatient 128 128 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES EPO [308136803] 102.4 percent of total billed charges 79.36 121.6 Technical (Hospital) Services Urine Microalbumin Quantitativ PX-3018204300 CDM 82043 CPT 301 RC outpatient 128 128 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES PPO [308136801] 102.4 percent of total billed charges 79.36 121.6 Technical (Hospital) Services Urine Microalbumin Quantitativ PX-3018204300 CDM 82043 CPT 301 RC outpatient 128 128 BLUE CROSS BLUE SHIELD WELLMARK SB889 [3081026] BCBS WYOMING [308102603] 121.6 percent of total billed charges 79.36 121.6 Technical (Hospital) Services Urine Microalbumin Quantitativ PX-3018204300 CDM 82043 CPT 301 RC outpatient 128 128 MULTIPLAN INC 34080 [3081285] MULTIPLAN INC [308128501] 121.6 percent of total billed charges 79.36 121.6 Technical (Hospital) Services Urine Microalbumin Quantitativ PX-3018204300 CDM 82043 CPT 301 RC outpatient 128 128 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES HDHP [308136802] 102.4 percent of total billed charges 79.36 121.6 Technical (Hospital) Services Albumin Body Fluid PX-3018204200 CDM 82042 CPT 301 RC inpatient 61 61 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES EPO [308136803] 48.3 percent of total billed charges 37.82 57.95 Technical (Hospital) Services Albumin Body Fluid PX-3018204200 CDM 82042 CPT 301 RC inpatient 61 61 HEALTHPARTNERS SX009 HEALTHPARTNERS 48.3 percent of total billed charges 37.82 57.95 Technical (Hospital) Services Albumin Body Fluid PX-3018204200 CDM 82042 CPT 301 RC inpatient 61 61 MEDICA (COMMERCIAL) 94265 [3081118] MEDICA CLAIMS [308111801] 54.9 percent of total billed charges 37.82 57.95 Technical (Hospital) Services Albumin Body Fluid PX-3018204200 CDM 82042 CPT 301 RC inpatient 61 61 BLUE CROSS BLUE SHIELD WELLMARK SB889 [3081026] BCBS WYOMING [308102603] 57.95 percent of total billed charges 37.82 57.95 Technical (Hospital) Services Albumin Body Fluid PX-3018204200 CDM 82042 CPT 301 RC inpatient 61 61 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES HDHP [308136802] 48.3 percent of total billed charges 37.82 57.95 Technical (Hospital) Services Albumin Body Fluid PX-3018204200 CDM 82042 CPT 301 RC inpatient 61 61 MULTIPLAN INC 34080 [3081285] MULTIPLAN INC [308128501] 57.95 percent of total billed charges 37.82 57.95 Technical (Hospital) Services Albumin Body Fluid PX-3018204200 CDM 82042 CPT 301 RC inpatient 61 61 UNITED HEALTHCARE (COMMERCIAL) [3081199] UNITED HEALTHCARE 87726 [308119901] 37.82 percent of total billed charges 37.82 57.95 Technical (Hospital) Services Albumin Body Fluid PX-3018204200 CDM 82042 CPT 301 RC inpatient 61 61 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES PPO [308136801] 48.3 percent of total billed charges 37.82 57.95 Technical (Hospital) Services Albumin Body Fluid PX-3018204200 CDM 82042 CPT 301 RC inpatient 61 61 CIGNA 62308 [3081051] CIGNA 62308 [308105105] 48.3 percent of total billed charges 37.82 57.95 Technical (Hospital) Services Albumin Body Fluid PX-3018204200 CDM 82042 CPT 301 RC inpatient 61 61 CIGNA 62308 [3081051] CIGNA STATE OF WYOMING [308105107] 48.3 percent of total billed charges 37.82 57.95 Technical (Hospital) Services Albumin Body Fluid PX-3018204200 CDM 82042 CPT 301 RC outpatient 61 61 HEALTHPARTNERS SX009 HEALTHPARTNERS 48.8 percent of total billed charges 37.82 57.95 Technical (Hospital) Services Albumin Body Fluid PX-3018204200 CDM 82042 CPT 301 RC outpatient 61 61 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES EPO [308136803] 48.8 percent of total billed charges 37.82 57.95 Technical (Hospital) Services Albumin Body Fluid PX-3018204200 CDM 82042 CPT 301 RC outpatient 61 61 UNITED HEALTHCARE (COMMERCIAL) [3081199] UNITED HEALTHCARE 87726 [308119901] 37.82 percent of total billed charges 37.82 57.95 Technical (Hospital) Services Albumin Body Fluid PX-3018204200 CDM 82042 CPT 301 RC outpatient 61 61 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES PPO [308136801] 48.8 percent of total billed charges 37.82 57.95 Technical (Hospital) Services Albumin Body Fluid PX-3018204200 CDM 82042 CPT 301 RC outpatient 61 61 BLUE CROSS BLUE SHIELD WELLMARK SB889 [3081026] BCBS WYOMING [308102603] 57.95 percent of total billed charges 37.82 57.95 Technical (Hospital) Services Albumin Body Fluid PX-3018204200 CDM 82042 CPT 301 RC outpatient 61 61 MULTIPLAN INC 34080 [3081285] MULTIPLAN INC [308128501] 57.95 percent of total billed charges 37.82 57.95 Technical (Hospital) Services Albumin Body Fluid PX-3018204200 CDM 82042 CPT 301 RC outpatient 61 61 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES HDHP [308136802] 48.8 percent of total billed charges 37.82 57.95 Technical (Hospital) Services Albumin Body Fluid PX-3018204200 CDM 82042 CPT 301 RC outpatient 61 61 CIGNA 62308 [3081051] CIGNA 62308 [308105105] 48.8 percent of total billed charges 37.82 57.95 Technical (Hospital) Services Albumin Body Fluid PX-3018204200 CDM 82042 CPT 301 RC outpatient 61 61 CIGNA 62308 [3081051] CIGNA STATE OF WYOMING [308105107] 48.8 percent of total billed charges 37.82 57.95 Technical (Hospital) Services Albumin Body Fluid PX-3018204200 CDM 82042 CPT 301 RC outpatient 61 61 MEDICA (COMMERCIAL) 94265 [3081118] MEDICA CLAIMS [308111801] 54.9 percent of total billed charges 37.82 57.95 Technical (Hospital) Services Albumin Serum Plasma Wh Blood PX-3018204000 CDM 82040 CPT 301 RC inpatient 50 50 CIGNA 62308 [3081051] CIGNA 62308 [308105105] 39.59 percent of total billed charges 31 47.5 Technical (Hospital) Services Albumin Serum Plasma Wh Blood PX-3018204000 CDM 82040 CPT 301 RC inpatient 50 50 CIGNA 62308 [3081051] CIGNA STATE OF WYOMING [308105107] 39.59 percent of total billed charges 31 47.5 Technical (Hospital) Services Albumin Serum Plasma Wh Blood PX-3018204000 CDM 82040 CPT 301 RC inpatient 50 50 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES PPO [308136801] 39.59 percent of total billed charges 31 47.5 Technical (Hospital) Services Albumin Serum Plasma Wh Blood PX-3018204000 CDM 82040 CPT 301 RC inpatient 50 50 UNITED HEALTHCARE (COMMERCIAL) [3081199] UNITED HEALTHCARE 87726 [308119901] 31 percent of total billed charges 31 47.5 Technical (Hospital) Services Albumin Serum Plasma Wh Blood PX-3018204000 CDM 82040 CPT 301 RC inpatient 50 50 MULTIPLAN INC 34080 [3081285] MULTIPLAN INC [308128501] 47.5 percent of total billed charges 31 47.5 Technical (Hospital) Services Albumin Serum Plasma Wh Blood PX-3018204000 CDM 82040 CPT 301 RC inpatient 50 50 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES HDHP [308136802] 39.59 percent of total billed charges 31 47.5 Technical (Hospital) Services Albumin Serum Plasma Wh Blood PX-3018204000 CDM 82040 CPT 301 RC inpatient 50 50 BLUE CROSS BLUE SHIELD WELLMARK SB889 [3081026] BCBS WYOMING [308102603] 47.5 percent of total billed charges 31 47.5 Technical (Hospital) Services Albumin Serum Plasma Wh Blood PX-3018204000 CDM 82040 CPT 301 RC inpatient 50 50 MEDICA (COMMERCIAL) 94265 [3081118] MEDICA CLAIMS [308111801] 45 percent of total billed charges 31 47.5 Technical (Hospital) Services Albumin Serum Plasma Wh Blood PX-3018204000 CDM 82040 CPT 301 RC inpatient 50 50 HEALTHPARTNERS SX009 HEALTHPARTNERS 39.59 percent of total billed charges 31 47.5 Technical (Hospital) Services Albumin Serum Plasma Wh Blood PX-3018204000 CDM 82040 CPT 301 RC inpatient 50 50 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES EPO [308136803] 39.59 percent of total billed charges 31 47.5 Technical (Hospital) Services Albumin Serum Plasma Wh Blood PX-3018204000 CDM 82040 CPT 301 RC outpatient 50 50 MEDICA (COMMERCIAL) 94265 [3081118] MEDICA CLAIMS [308111801] 45 percent of total billed charges 31 47.5 Technical (Hospital) Services Albumin Serum Plasma Wh Blood PX-3018204000 CDM 82040 CPT 301 RC outpatient 50 50 CIGNA 62308 [3081051] CIGNA 62308 [308105105] 40 percent of total billed charges 31 47.5 Technical (Hospital) Services Albumin Serum Plasma Wh Blood PX-3018204000 CDM 82040 CPT 301 RC outpatient 50 50 CIGNA 62308 [3081051] CIGNA STATE OF WYOMING [308105107] 40 percent of total billed charges 31 47.5 Technical (Hospital) Services Albumin Serum Plasma Wh Blood PX-3018204000 CDM 82040 CPT 301 RC outpatient 50 50 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES HDHP [308136802] 40 percent of total billed charges 31 47.5 Technical (Hospital) Services Albumin Serum Plasma Wh Blood PX-3018204000 CDM 82040 CPT 301 RC outpatient 50 50 MULTIPLAN INC 34080 [3081285] MULTIPLAN INC [308128501] 47.5 percent of total billed charges 31 47.5 Technical (Hospital) Services Albumin Serum Plasma Wh Blood PX-3018204000 CDM 82040 CPT 301 RC outpatient 50 50 BLUE CROSS BLUE SHIELD WELLMARK SB889 [3081026] BCBS WYOMING [308102603] 47.5 percent of total billed charges 31 47.5 Technical (Hospital) Services Albumin Serum Plasma Wh Blood PX-3018204000 CDM 82040 CPT 301 RC outpatient 50 50 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES PPO [308136801] 40 percent of total billed charges 31 47.5 Technical (Hospital) Services Albumin Serum Plasma Wh Blood PX-3018204000 CDM 82040 CPT 301 RC outpatient 50 50 UNITED HEALTHCARE (COMMERCIAL) [3081199] UNITED HEALTHCARE 87726 [308119901] 31 percent of total billed charges 31 47.5 Technical (Hospital) Services Albumin Serum Plasma Wh Blood PX-3018204000 CDM 82040 CPT 301 RC outpatient 50 50 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES EPO [308136803] 40 percent of total billed charges 31 47.5 Technical (Hospital) Services Albumin Serum Plasma Wh Blood PX-3018204000 CDM 82040 CPT 301 RC outpatient 50 50 HEALTHPARTNERS SX009 HEALTHPARTNERS 40 percent of total billed charges 31 47.5 Technical (Hospital) Services ACTH PX-3018202400 CDM 82024 CPT 301 RC inpatient 119 119 CIGNA 62308 [3081051] CIGNA 62308 [308105105] 94.22 percent of total billed charges 73.78 113.05 Technical (Hospital) Services ACTH PX-3018202400 CDM 82024 CPT 301 RC inpatient 119 119 CIGNA 62308 [3081051] CIGNA STATE OF WYOMING [308105107] 94.22 percent of total billed charges 73.78 113.05 Technical (Hospital) Services ACTH PX-3018202400 CDM 82024 CPT 301 RC inpatient 119 119 MULTIPLAN INC 34080 [3081285] MULTIPLAN INC [308128501] 113.05 percent of total billed charges 73.78 113.05 Technical (Hospital) Services ACTH PX-3018202400 CDM 82024 CPT 301 RC inpatient 119 119 BLUE CROSS BLUE SHIELD WELLMARK SB889 [3081026] BCBS WYOMING [308102603] 113.05 percent of total billed charges 73.78 113.05 Technical (Hospital) Services ACTH PX-3018202400 CDM 82024 CPT 301 RC inpatient 119 119 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES HDHP [308136802] 94.22 percent of total billed charges 73.78 113.05 Technical (Hospital) Services ACTH PX-3018202400 CDM 82024 CPT 301 RC inpatient 119 119 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES PPO [308136801] 94.22 percent of total billed charges 73.78 113.05 Technical (Hospital) Services ACTH PX-3018202400 CDM 82024 CPT 301 RC inpatient 119 119 UNITED HEALTHCARE (COMMERCIAL) [3081199] UNITED HEALTHCARE 87726 [308119901] 73.78 percent of total billed charges 73.78 113.05 Technical (Hospital) Services ACTH PX-3018202400 CDM 82024 CPT 301 RC inpatient 119 119 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES EPO [308136803] 94.22 percent of total billed charges 73.78 113.05 Technical (Hospital) Services ACTH PX-3018202400 CDM 82024 CPT 301 RC inpatient 119 119 HEALTHPARTNERS SX009 HEALTHPARTNERS 94.22 percent of total billed charges 73.78 113.05 Technical (Hospital) Services ACTH PX-3018202400 CDM 82024 CPT 301 RC inpatient 119 119 MEDICA (COMMERCIAL) 94265 [3081118] MEDICA CLAIMS [308111801] 107.1 percent of total billed charges 73.78 113.05 Technical (Hospital) Services ACTH PX-3018202400 CDM 82024 CPT 301 RC outpatient 119 119 CIGNA 62308 [3081051] CIGNA 62308 [308105105] 95.2 percent of total billed charges 73.78 113.05 Technical (Hospital) Services ACTH PX-3018202400 CDM 82024 CPT 301 RC outpatient 119 119 CIGNA 62308 [3081051] CIGNA STATE OF WYOMING [308105107] 95.2 percent of total billed charges 73.78 113.05 Technical (Hospital) Services ACTH PX-3018202400 CDM 82024 CPT 301 RC outpatient 119 119 MEDICA (COMMERCIAL) 94265 [3081118] MEDICA CLAIMS [308111801] 107.1 percent of total billed charges 73.78 113.05 Technical (Hospital) Services ACTH PX-3018202400 CDM 82024 CPT 301 RC outpatient 119 119 UNITED HEALTHCARE (COMMERCIAL) [3081199] UNITED HEALTHCARE 87726 [308119901] 73.78 percent of total billed charges 73.78 113.05 Technical (Hospital) Services ACTH PX-3018202400 CDM 82024 CPT 301 RC outpatient 119 119 HEALTHPARTNERS SX009 HEALTHPARTNERS 95.2 percent of total billed charges 73.78 113.05 Technical (Hospital) Services ACTH PX-3018202400 CDM 82024 CPT 301 RC outpatient 119 119 MULTIPLAN INC 34080 [3081285] MULTIPLAN INC [308128501] 113.05 percent of total billed charges 73.78 113.05 Technical (Hospital) Services ACTH PX-3018202400 CDM 82024 CPT 301 RC outpatient 119 119 BLUE CROSS BLUE SHIELD WELLMARK SB889 [3081026] BCBS WYOMING [308102603] 113.05 percent of total billed charges 73.78 113.05 Technical (Hospital) Services ACTH PX-3018202400 CDM 82024 CPT 301 RC outpatient 119 119 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES HDHP [308136802] 95.2 percent of total billed charges 73.78 113.05 Technical (Hospital) Services ACTH PX-3018202400 CDM 82024 CPT 301 RC outpatient 119 119 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES PPO [308136801] 95.2 percent of total billed charges 73.78 113.05 Technical (Hospital) Services ACTH PX-3018202400 CDM 82024 CPT 301 RC outpatient 119 119 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES EPO [308136803] 95.2 percent of total billed charges 73.78 113.05 Technical (Hospital) Services Ref Acth PX-3018202401 CDM 82024 CPT 301 RC outpatient 119 119 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES EPO [308136803] 95.2 percent of total billed charges 73.78 113.05 Technical (Hospital) Services Ref Acth PX-3018202401 CDM 82024 CPT 301 RC outpatient 119 119 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES PPO [308136801] 95.2 percent of total billed charges 73.78 113.05 Technical (Hospital) Services Ref Acth PX-3018202401 CDM 82024 CPT 301 RC outpatient 119 119 MULTIPLAN INC 34080 [3081285] MULTIPLAN INC [308128501] 113.05 percent of total billed charges 73.78 113.05 Technical (Hospital) Services Ref Acth PX-3018202401 CDM 82024 CPT 301 RC outpatient 119 119 BLUE CROSS BLUE SHIELD WELLMARK SB889 [3081026] BCBS WYOMING [308102603] 113.05 percent of total billed charges 73.78 113.05 Technical (Hospital) Services Ref Acth PX-3018202401 CDM 82024 CPT 301 RC outpatient 119 119 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES HDHP [308136802] 95.2 percent of total billed charges 73.78 113.05 Technical (Hospital) Services Ref Acth PX-3018202401 CDM 82024 CPT 301 RC outpatient 119 119 UNITED HEALTHCARE (COMMERCIAL) [3081199] UNITED HEALTHCARE 87726 [308119901] 73.78 percent of total billed charges 73.78 113.05 Technical (Hospital) Services Ref Acth PX-3018202401 CDM 82024 CPT 301 RC outpatient 119 119 HEALTHPARTNERS SX009 HEALTHPARTNERS 95.2 percent of total billed charges 73.78 113.05 Technical (Hospital) Services Ref Acth PX-3018202401 CDM 82024 CPT 301 RC outpatient 119 119 MEDICA (COMMERCIAL) 94265 [3081118] MEDICA CLAIMS [308111801] 107.1 percent of total billed charges 73.78 113.05 Technical (Hospital) Services Ref Acth PX-3018202401 CDM 82024 CPT 301 RC outpatient 119 119 CIGNA 62308 [3081051] CIGNA 62308 [308105105] 95.2 percent of total billed charges 73.78 113.05 Technical (Hospital) Services Ref Acth PX-3018202401 CDM 82024 CPT 301 RC outpatient 119 119 CIGNA 62308 [3081051] CIGNA STATE OF WYOMING [308105107] 95.2 percent of total billed charges 73.78 113.05 Technical (Hospital) Services Ref Acth PX-3018202401 CDM 82024 CPT 301 RC inpatient 119 119 CIGNA 62308 [3081051] CIGNA 62308 [308105105] 94.22 percent of total billed charges 73.78 113.05 Technical (Hospital) Services Ref Acth PX-3018202401 CDM 82024 CPT 301 RC inpatient 119 119 CIGNA 62308 [3081051] CIGNA STATE OF WYOMING [308105107] 94.22 percent of total billed charges 73.78 113.05 Technical (Hospital) Services Ref Acth PX-3018202401 CDM 82024 CPT 301 RC inpatient 119 119 MULTIPLAN INC 34080 [3081285] MULTIPLAN INC [308128501] 113.05 percent of total billed charges 73.78 113.05 Technical (Hospital) Services Ref Acth PX-3018202401 CDM 82024 CPT 301 RC inpatient 119 119 BLUE CROSS BLUE SHIELD WELLMARK SB889 [3081026] BCBS WYOMING [308102603] 113.05 percent of total billed charges 73.78 113.05 Technical (Hospital) Services Ref Acth PX-3018202401 CDM 82024 CPT 301 RC inpatient 119 119 UNITED HEALTHCARE (COMMERCIAL) [3081199] UNITED HEALTHCARE 87726 [308119901] 73.78 percent of total billed charges 73.78 113.05 Technical (Hospital) Services Ref Acth PX-3018202401 CDM 82024 CPT 301 RC inpatient 119 119 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES PPO [308136801] 94.22 percent of total billed charges 73.78 113.05 Technical (Hospital) Services Ref Acth PX-3018202401 CDM 82024 CPT 301 RC inpatient 119 119 HEALTHPARTNERS SX009 HEALTHPARTNERS 94.22 percent of total billed charges 73.78 113.05 Technical (Hospital) Services Ref Acth PX-3018202401 CDM 82024 CPT 301 RC inpatient 119 119 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES EPO [308136803] 94.22 percent of total billed charges 73.78 113.05 Technical (Hospital) Services Ref Acth PX-3018202401 CDM 82024 CPT 301 RC inpatient 119 119 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES HDHP [308136802] 94.22 percent of total billed charges 73.78 113.05 Technical (Hospital) Services Ref Acth PX-3018202401 CDM 82024 CPT 301 RC inpatient 119 119 MEDICA (COMMERCIAL) 94265 [3081118] MEDICA CLAIMS [308111801] 107.1 percent of total billed charges 73.78 113.05 Technical (Hospital) Services Ketone PX-3018201000 CDM 82010 CPT 301 RC inpatient 131 131 CIGNA 62308 [3081051] CIGNA 62308 [308105105] 103.73 percent of total billed charges 81.22 124.45 Technical (Hospital) Services Ketone PX-3018201000 CDM 82010 CPT 301 RC inpatient 131 131 CIGNA 62308 [3081051] CIGNA STATE OF WYOMING [308105107] 103.73 percent of total billed charges 81.22 124.45 Technical (Hospital) Services Ketone PX-3018201000 CDM 82010 CPT 301 RC inpatient 131 131 MULTIPLAN INC 34080 [3081285] MULTIPLAN INC [308128501] 124.45 percent of total billed charges 81.22 124.45 Technical (Hospital) Services Ketone PX-3018201000 CDM 82010 CPT 301 RC inpatient 131 131 BLUE CROSS BLUE SHIELD WELLMARK SB889 [3081026] BCBS WYOMING [308102603] 124.45 percent of total billed charges 81.22 124.45 Technical (Hospital) Services Ketone PX-3018201000 CDM 82010 CPT 301 RC inpatient 131 131 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES HDHP [308136802] 103.73 percent of total billed charges 81.22 124.45 Technical (Hospital) Services Ketone PX-3018201000 CDM 82010 CPT 301 RC inpatient 131 131 UNITED HEALTHCARE (COMMERCIAL) [3081199] UNITED HEALTHCARE 87726 [308119901] 81.22 percent of total billed charges 81.22 124.45 Technical (Hospital) Services Ketone PX-3018201000 CDM 82010 CPT 301 RC inpatient 131 131 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES PPO [308136801] 103.73 percent of total billed charges 81.22 124.45 Technical (Hospital) Services Ketone PX-3018201000 CDM 82010 CPT 301 RC inpatient 131 131 HEALTHPARTNERS SX009 HEALTHPARTNERS 103.73 percent of total billed charges 81.22 124.45 Technical (Hospital) Services Ketone PX-3018201000 CDM 82010 CPT 301 RC inpatient 131 131 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES EPO [308136803] 103.73 percent of total billed charges 81.22 124.45 Technical (Hospital) Services Ketone PX-3018201000 CDM 82010 CPT 301 RC inpatient 131 131 MEDICA (COMMERCIAL) 94265 [3081118] MEDICA CLAIMS [308111801] 117.9 percent of total billed charges 81.22 124.45 Technical (Hospital) Services Ketone PX-3018201000 CDM 82010 CPT 301 RC outpatient 131 131 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES PPO [308136801] 104.8 percent of total billed charges 81.22 124.45 Technical (Hospital) Services Ketone PX-3018201000 CDM 82010 CPT 301 RC outpatient 131 131 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES EPO [308136803] 104.8 percent of total billed charges 81.22 124.45 Technical (Hospital) Services Ketone PX-3018201000 CDM 82010 CPT 301 RC outpatient 131 131 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES HDHP [308136802] 104.8 percent of total billed charges 81.22 124.45 Technical (Hospital) Services Ketone PX-3018201000 CDM 82010 CPT 301 RC outpatient 131 131 MULTIPLAN INC 34080 [3081285] MULTIPLAN INC [308128501] 124.45 percent of total billed charges 81.22 124.45 Technical (Hospital) Services Ketone PX-3018201000 CDM 82010 CPT 301 RC outpatient 131 131 BLUE CROSS BLUE SHIELD WELLMARK SB889 [3081026] BCBS WYOMING [308102603] 124.45 percent of total billed charges 81.22 124.45 Technical (Hospital) Services Ketone PX-3018201000 CDM 82010 CPT 301 RC outpatient 131 131 HEALTHPARTNERS SX009 HEALTHPARTNERS 104.8 percent of total billed charges 81.22 124.45 Technical (Hospital) Services Ketone PX-3018201000 CDM 82010 CPT 301 RC outpatient 131 131 UNITED HEALTHCARE (COMMERCIAL) [3081199] UNITED HEALTHCARE 87726 [308119901] 81.22 percent of total billed charges 81.22 124.45 Technical (Hospital) Services Ketone PX-3018201000 CDM 82010 CPT 301 RC outpatient 131 131 MEDICA (COMMERCIAL) 94265 [3081118] MEDICA CLAIMS [308111801] 117.9 percent of total billed charges 81.22 124.45 Technical (Hospital) Services Ketone PX-3018201000 CDM 82010 CPT 301 RC outpatient 131 131 CIGNA 62308 [3081051] CIGNA 62308 [308105105] 104.8 percent of total billed charges 81.22 124.45 Technical (Hospital) Services Ketone PX-3018201000 CDM 82010 CPT 301 RC outpatient 131 131 CIGNA 62308 [3081051] CIGNA STATE OF WYOMING [308105107] 104.8 percent of total billed charges 81.22 124.45 Technical (Hospital) Services "Fibrotest-Actitest, S(Mayo)" PX-3108159600 CDM 81596 CPT 310 RC outpatient 509 509 MEDICA (COMMERCIAL) 94265 [3081118] MEDICA CLAIMS [308111801] 458.1 percent of total billed charges 315.58 483.55 Technical (Hospital) Services "Fibrotest-Actitest, S(Mayo)" PX-3108159600 CDM 81596 CPT 310 RC outpatient 509 509 UNITED HEALTHCARE (COMMERCIAL) [3081199] UNITED HEALTHCARE 87726 [308119901] 315.58 percent of total billed charges 315.58 483.55 Technical (Hospital) Services "Fibrotest-Actitest, S(Mayo)" PX-3108159600 CDM 81596 CPT 310 RC outpatient 509 509 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES PPO [308136801] 407.2 percent of total billed charges 315.58 483.55 Technical (Hospital) Services "Fibrotest-Actitest, S(Mayo)" PX-3108159600 CDM 81596 CPT 310 RC outpatient 509 509 HEALTHPARTNERS SX009 HEALTHPARTNERS 407.2 percent of total billed charges 315.58 483.55 Technical (Hospital) Services "Fibrotest-Actitest, S(Mayo)" PX-3108159600 CDM 81596 CPT 310 RC outpatient 509 509 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES EPO [308136803] 407.2 percent of total billed charges 315.58 483.55 Technical (Hospital) Services "Fibrotest-Actitest, S(Mayo)" PX-3108159600 CDM 81596 CPT 310 RC outpatient 509 509 MULTIPLAN INC 34080 [3081285] MULTIPLAN INC [308128501] 483.55 percent of total billed charges 315.58 483.55 Technical (Hospital) Services "Fibrotest-Actitest, S(Mayo)" PX-3108159600 CDM 81596 CPT 310 RC outpatient 509 509 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES HDHP [308136802] 407.2 percent of total billed charges 315.58 483.55 Technical (Hospital) Services "Fibrotest-Actitest, S(Mayo)" PX-3108159600 CDM 81596 CPT 310 RC outpatient 509 509 CIGNA 62308 [3081051] CIGNA 62308 [308105105] 407.2 percent of total billed charges 315.58 483.55 Technical (Hospital) Services "Fibrotest-Actitest, S(Mayo)" PX-3108159600 CDM 81596 CPT 310 RC outpatient 509 509 CIGNA 62308 [3081051] CIGNA STATE OF WYOMING [308105107] 407.2 percent of total billed charges 315.58 483.55 Technical (Hospital) Services "Fibrotest-Actitest, S(Mayo)" PX-3108159600 CDM 81596 CPT 310 RC outpatient 509 509 BLUE CROSS BLUE SHIELD WELLMARK SB889 [3081026] BCBS WYOMING [308102603] 483.55 percent of total billed charges 315.58 483.55 Technical (Hospital) Services "Fibrotest-Actitest, S(Mayo)" PX-3108159600 CDM 81596 CPT 310 RC inpatient 509 509 BLUE CROSS BLUE SHIELD WELLMARK SB889 [3081026] BCBS WYOMING [308102603] 483.55 percent of total billed charges 315.58 483.55 Technical (Hospital) Services "Fibrotest-Actitest, S(Mayo)" PX-3108159600 CDM 81596 CPT 310 RC inpatient 509 509 CIGNA 62308 [3081051] CIGNA 62308 [308105105] 403.03 percent of total billed charges 315.58 483.55 Technical (Hospital) Services "Fibrotest-Actitest, S(Mayo)" PX-3108159600 CDM 81596 CPT 310 RC inpatient 509 509 CIGNA 62308 [3081051] CIGNA STATE OF WYOMING [308105107] 403.03 percent of total billed charges 315.58 483.55 Technical (Hospital) Services "Fibrotest-Actitest, S(Mayo)" PX-3108159600 CDM 81596 CPT 310 RC inpatient 509 509 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES EPO [308136803] 403.03 percent of total billed charges 315.58 483.55 Technical (Hospital) Services "Fibrotest-Actitest, S(Mayo)" PX-3108159600 CDM 81596 CPT 310 RC inpatient 509 509 HEALTHPARTNERS SX009 HEALTHPARTNERS 403.03 percent of total billed charges 315.58 483.55 Technical (Hospital) Services "Fibrotest-Actitest, S(Mayo)" PX-3108159600 CDM 81596 CPT 310 RC inpatient 509 509 MEDICA (COMMERCIAL) 94265 [3081118] MEDICA CLAIMS [308111801] 458.1 percent of total billed charges 315.58 483.55 Technical (Hospital) Services "Fibrotest-Actitest, S(Mayo)" PX-3108159600 CDM 81596 CPT 310 RC inpatient 509 509 UNITED HEALTHCARE (COMMERCIAL) [3081199] UNITED HEALTHCARE 87726 [308119901] 315.58 percent of total billed charges 315.58 483.55 Technical (Hospital) Services "Fibrotest-Actitest, S(Mayo)" PX-3108159600 CDM 81596 CPT 310 RC inpatient 509 509 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES HDHP [308136802] 403.03 percent of total billed charges 315.58 483.55 Technical (Hospital) Services "Fibrotest-Actitest, S(Mayo)" PX-3108159600 CDM 81596 CPT 310 RC inpatient 509 509 MULTIPLAN INC 34080 [3081285] MULTIPLAN INC [308128501] 483.55 percent of total billed charges 315.58 483.55 Technical (Hospital) Services "Fibrotest-Actitest, S(Mayo)" PX-3108159600 CDM 81596 CPT 310 RC inpatient 509 509 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES PPO [308136801] 403.03 percent of total billed charges 315.58 483.55 Technical (Hospital) Services Ref Severe Combine Immunodef PX-3108147900 CDM 81479 CPT 310 RC inpatient 812 812 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES PPO [308136801] 642.94 percent of total billed charges 503.44 771.4 Technical (Hospital) Services Ref Severe Combine Immunodef PX-3108147900 CDM 81479 CPT 310 RC inpatient 812 812 MULTIPLAN INC 34080 [3081285] MULTIPLAN INC [308128501] 771.4 percent of total billed charges 503.44 771.4 Technical (Hospital) Services Ref Severe Combine Immunodef PX-3108147900 CDM 81479 CPT 310 RC inpatient 812 812 MEDICA (COMMERCIAL) 94265 [3081118] MEDICA CLAIMS [308111801] 730.8 percent of total billed charges 503.44 771.4 Technical (Hospital) Services Ref Severe Combine Immunodef PX-3108147900 CDM 81479 CPT 310 RC inpatient 812 812 UNITED HEALTHCARE (COMMERCIAL) [3081199] UNITED HEALTHCARE 87726 [308119901] 503.44 percent of total billed charges 503.44 771.4 Technical (Hospital) Services Ref Severe Combine Immunodef PX-3108147900 CDM 81479 CPT 310 RC inpatient 812 812 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES HDHP [308136802] 642.94 percent of total billed charges 503.44 771.4 Technical (Hospital) Services Ref Severe Combine Immunodef PX-3108147900 CDM 81479 CPT 310 RC inpatient 812 812 HEALTHPARTNERS SX009 HEALTHPARTNERS 642.94 percent of total billed charges 503.44 771.4 Technical (Hospital) Services Ref Severe Combine Immunodef PX-3108147900 CDM 81479 CPT 310 RC inpatient 812 812 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES EPO [308136803] 642.94 percent of total billed charges 503.44 771.4 Technical (Hospital) Services Ref Severe Combine Immunodef PX-3108147900 CDM 81479 CPT 310 RC inpatient 812 812 CIGNA 62308 [3081051] CIGNA 62308 [308105105] 642.94 percent of total billed charges 503.44 771.4 Technical (Hospital) Services Ref Severe Combine Immunodef PX-3108147900 CDM 81479 CPT 310 RC inpatient 812 812 CIGNA 62308 [3081051] CIGNA STATE OF WYOMING [308105107] 642.94 percent of total billed charges 503.44 771.4 Technical (Hospital) Services Ref Severe Combine Immunodef PX-3108147900 CDM 81479 CPT 310 RC inpatient 812 812 BLUE CROSS BLUE SHIELD WELLMARK SB889 [3081026] BCBS WYOMING [308102603] 771.4 percent of total billed charges 503.44 771.4 Technical (Hospital) Services Ref Severe Combine Immunodef PX-3108147900 CDM 81479 CPT 310 RC outpatient 812 812 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES HDHP [308136802] 649.6 percent of total billed charges 503.44 771.4 Technical (Hospital) Services Ref Severe Combine Immunodef PX-3108147900 CDM 81479 CPT 310 RC outpatient 812 812 MULTIPLAN INC 34080 [3081285] MULTIPLAN INC [308128501] 771.4 percent of total billed charges 503.44 771.4 Technical (Hospital) Services Ref Severe Combine Immunodef PX-3108147900 CDM 81479 CPT 310 RC outpatient 812 812 CIGNA 62308 [3081051] CIGNA 62308 [308105105] 649.6 percent of total billed charges 503.44 771.4 Technical (Hospital) Services Ref Severe Combine Immunodef PX-3108147900 CDM 81479 CPT 310 RC outpatient 812 812 CIGNA 62308 [3081051] CIGNA STATE OF WYOMING [308105107] 649.6 percent of total billed charges 503.44 771.4 Technical (Hospital) Services Ref Severe Combine Immunodef PX-3108147900 CDM 81479 CPT 310 RC outpatient 812 812 BLUE CROSS BLUE SHIELD WELLMARK SB889 [3081026] BCBS WYOMING [308102603] 771.4 percent of total billed charges 503.44 771.4 Technical (Hospital) Services Ref Severe Combine Immunodef PX-3108147900 CDM 81479 CPT 310 RC outpatient 812 812 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES EPO [308136803] 649.6 percent of total billed charges 503.44 771.4 Technical (Hospital) Services Ref Severe Combine Immunodef PX-3108147900 CDM 81479 CPT 310 RC outpatient 812 812 HEALTHPARTNERS SX009 HEALTHPARTNERS 649.6 percent of total billed charges 503.44 771.4 Technical (Hospital) Services Ref Severe Combine Immunodef PX-3108147900 CDM 81479 CPT 310 RC outpatient 812 812 UNITED HEALTHCARE (COMMERCIAL) [3081199] UNITED HEALTHCARE 87726 [308119901] 503.44 percent of total billed charges 503.44 771.4 Technical (Hospital) Services Ref Severe Combine Immunodef PX-3108147900 CDM 81479 CPT 310 RC outpatient 812 812 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES PPO [308136801] 649.6 percent of total billed charges 503.44 771.4 Technical (Hospital) Services Ref Severe Combine Immunodef PX-3108147900 CDM 81479 CPT 310 RC outpatient 812 812 MEDICA (COMMERCIAL) 94265 [3081118] MEDICA CLAIMS [308111801] 730.8 percent of total billed charges 503.44 771.4 Technical (Hospital) Services Ref Molecular Path Proc Level 4 PX-3108140300 CDM 81403 CPT 310 RC inpatient 1205 1205 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES PPO [308136801] 954.12 percent of total billed charges 747.1 1144.75 Technical (Hospital) Services Ref Molecular Path Proc Level 4 PX-3108140300 CDM 81403 CPT 310 RC inpatient 1205 1205 MEDICA (COMMERCIAL) 94265 [3081118] MEDICA CLAIMS [308111801] 1084.5 percent of total billed charges 747.1 1144.75 Technical (Hospital) Services Ref Molecular Path Proc Level 4 PX-3108140300 CDM 81403 CPT 310 RC inpatient 1205 1205 UNITED HEALTHCARE (COMMERCIAL) [3081199] UNITED HEALTHCARE 87726 [308119901] 747.1 percent of total billed charges 747.1 1144.75 Technical (Hospital) Services Ref Molecular Path Proc Level 4 PX-3108140300 CDM 81403 CPT 310 RC inpatient 1205 1205 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES HDHP [308136802] 954.12 percent of total billed charges 747.1 1144.75 Technical (Hospital) Services Ref Molecular Path Proc Level 4 PX-3108140300 CDM 81403 CPT 310 RC inpatient 1205 1205 MULTIPLAN INC 34080 [3081285] MULTIPLAN INC [308128501] 1144.75 percent of total billed charges 747.1 1144.75 Technical (Hospital) Services Ref Molecular Path Proc Level 4 PX-3108140300 CDM 81403 CPT 310 RC inpatient 1205 1205 HEALTHPARTNERS SX009 HEALTHPARTNERS 954.12 percent of total billed charges 747.1 1144.75 Technical (Hospital) Services Ref Molecular Path Proc Level 4 PX-3108140300 CDM 81403 CPT 310 RC inpatient 1205 1205 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES EPO [308136803] 954.12 percent of total billed charges 747.1 1144.75 Technical (Hospital) Services Ref Molecular Path Proc Level 4 PX-3108140300 CDM 81403 CPT 310 RC inpatient 1205 1205 BLUE CROSS BLUE SHIELD WELLMARK SB889 [3081026] BCBS WYOMING [308102603] 1144.75 percent of total billed charges 747.1 1144.75 Technical (Hospital) Services Ref Molecular Path Proc Level 4 PX-3108140300 CDM 81403 CPT 310 RC inpatient 1205 1205 CIGNA 62308 [3081051] CIGNA 62308 [308105105] 954.12 percent of total billed charges 747.1 1144.75 Technical (Hospital) Services Ref Molecular Path Proc Level 4 PX-3108140300 CDM 81403 CPT 310 RC inpatient 1205 1205 CIGNA 62308 [3081051] CIGNA STATE OF WYOMING [308105107] 954.12 percent of total billed charges 747.1 1144.75 Technical (Hospital) Services Ref Molecular Path Proc Level 4 PX-3108140300 CDM 81403 CPT 310 RC outpatient 1205 1205 UNITED HEALTHCARE (COMMERCIAL) [3081199] UNITED HEALTHCARE 87726 [308119901] 747.1 percent of total billed charges 747.1 1144.75 Technical (Hospital) Services Ref Molecular Path Proc Level 4 PX-3108140300 CDM 81403 CPT 310 RC outpatient 1205 1205 HEALTHPARTNERS SX009 HEALTHPARTNERS 964 percent of total billed charges 747.1 1144.75 Technical (Hospital) Services Ref Molecular Path Proc Level 4 PX-3108140300 CDM 81403 CPT 310 RC outpatient 1205 1205 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES PPO [308136801] 964 percent of total billed charges 747.1 1144.75 Technical (Hospital) Services Ref Molecular Path Proc Level 4 PX-3108140300 CDM 81403 CPT 310 RC outpatient 1205 1205 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES EPO [308136803] 964 percent of total billed charges 747.1 1144.75 Technical (Hospital) Services Ref Molecular Path Proc Level 4 PX-3108140300 CDM 81403 CPT 310 RC outpatient 1205 1205 CIGNA 62308 [3081051] CIGNA 62308 [308105105] 964 percent of total billed charges 747.1 1144.75 Technical (Hospital) Services Ref Molecular Path Proc Level 4 PX-3108140300 CDM 81403 CPT 310 RC outpatient 1205 1205 CIGNA 62308 [3081051] CIGNA STATE OF WYOMING [308105107] 964 percent of total billed charges 747.1 1144.75 Technical (Hospital) Services Ref Molecular Path Proc Level 4 PX-3108140300 CDM 81403 CPT 310 RC outpatient 1205 1205 MULTIPLAN INC 34080 [3081285] MULTIPLAN INC [308128501] 1144.75 percent of total billed charges 747.1 1144.75 Technical (Hospital) Services Ref Molecular Path Proc Level 4 PX-3108140300 CDM 81403 CPT 310 RC outpatient 1205 1205 BLUE CROSS BLUE SHIELD WELLMARK SB889 [3081026] BCBS WYOMING [308102603] 1144.75 percent of total billed charges 747.1 1144.75 Technical (Hospital) Services Ref Molecular Path Proc Level 4 PX-3108140300 CDM 81403 CPT 310 RC outpatient 1205 1205 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES HDHP [308136802] 964 percent of total billed charges 747.1 1144.75 Technical (Hospital) Services Ref Molecular Path Proc Level 4 PX-3108140300 CDM 81403 CPT 310 RC outpatient 1205 1205 MEDICA (COMMERCIAL) 94265 [3081118] MEDICA CLAIMS [308111801] 1084.5 percent of total billed charges 747.1 1144.75 Technical (Hospital) Services Tpmt Genotype PX-3108140100 CDM 81401 CPT 310 RC outpatient 834 834 MEDICA (COMMERCIAL) 94265 [3081118] MEDICA CLAIMS [308111801] 750.6 percent of total billed charges 517.08 792.3 Technical (Hospital) Services Tpmt Genotype PX-3108140100 CDM 81401 CPT 310 RC outpatient 834 834 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES HDHP [308136802] 667.2 percent of total billed charges 517.08 792.3 Technical (Hospital) Services Tpmt Genotype PX-3108140100 CDM 81401 CPT 310 RC outpatient 834 834 CIGNA 62308 [3081051] CIGNA STATE OF WYOMING [308105107] 667.2 percent of total billed charges 517.08 792.3 Technical (Hospital) Services Tpmt Genotype PX-3108140100 CDM 81401 CPT 310 RC outpatient 834 834 MULTIPLAN INC 34080 [3081285] MULTIPLAN INC [308128501] 792.3 percent of total billed charges 517.08 792.3 Technical (Hospital) Services Tpmt Genotype PX-3108140100 CDM 81401 CPT 310 RC outpatient 834 834 BLUE CROSS BLUE SHIELD WELLMARK SB889 [3081026] BCBS WYOMING [308102603] 792.3 percent of total billed charges 517.08 792.3 Technical (Hospital) Services Tpmt Genotype PX-3108140100 CDM 81401 CPT 310 RC outpatient 834 834 CIGNA 62308 [3081051] CIGNA 62308 [308105105] 667.2 percent of total billed charges 517.08 792.3 Technical (Hospital) Services Tpmt Genotype PX-3108140100 CDM 81401 CPT 310 RC outpatient 834 834 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES EPO [308136803] 667.2 percent of total billed charges 517.08 792.3 Technical (Hospital) Services Tpmt Genotype PX-3108140100 CDM 81401 CPT 310 RC outpatient 834 834 UNITED HEALTHCARE (COMMERCIAL) [3081199] UNITED HEALTHCARE 87726 [308119901] 517.08 percent of total billed charges 517.08 792.3 Technical (Hospital) Services Tpmt Genotype PX-3108140100 CDM 81401 CPT 310 RC outpatient 834 834 HEALTHPARTNERS SX009 HEALTHPARTNERS 667.2 percent of total billed charges 517.08 792.3 Technical (Hospital) Services Tpmt Genotype PX-3108140100 CDM 81401 CPT 310 RC outpatient 834 834 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES PPO [308136801] 667.2 percent of total billed charges 517.08 792.3 Technical (Hospital) Services Tpmt Genotype PX-3108140100 CDM 81401 CPT 310 RC inpatient 834 834 BLUE CROSS BLUE SHIELD WELLMARK SB889 [3081026] BCBS WYOMING [308102603] 792.3 percent of total billed charges 517.08 792.3 Technical (Hospital) Services Tpmt Genotype PX-3108140100 CDM 81401 CPT 310 RC inpatient 834 834 CIGNA 62308 [3081051] CIGNA 62308 [308105105] 660.36 percent of total billed charges 517.08 792.3 Technical (Hospital) Services Tpmt Genotype PX-3108140100 CDM 81401 CPT 310 RC inpatient 834 834 CIGNA 62308 [3081051] CIGNA STATE OF WYOMING [308105107] 660.36 percent of total billed charges 517.08 792.3 Technical (Hospital) Services Tpmt Genotype PX-3108140100 CDM 81401 CPT 310 RC inpatient 834 834 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES EPO [308136803] 660.36 percent of total billed charges 517.08 792.3 Technical (Hospital) Services Tpmt Genotype PX-3108140100 CDM 81401 CPT 310 RC inpatient 834 834 HEALTHPARTNERS SX009 HEALTHPARTNERS 660.36 percent of total billed charges 517.08 792.3 Technical (Hospital) Services Tpmt Genotype PX-3108140100 CDM 81401 CPT 310 RC inpatient 834 834 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES PPO [308136801] 660.36 percent of total billed charges 517.08 792.3 Technical (Hospital) Services Tpmt Genotype PX-3108140100 CDM 81401 CPT 310 RC inpatient 834 834 UNITED HEALTHCARE (COMMERCIAL) [3081199] UNITED HEALTHCARE 87726 [308119901] 517.08 percent of total billed charges 517.08 792.3 Technical (Hospital) Services Tpmt Genotype PX-3108140100 CDM 81401 CPT 310 RC inpatient 834 834 MEDICA (COMMERCIAL) 94265 [3081118] MEDICA CLAIMS [308111801] 750.6 percent of total billed charges 517.08 792.3 Technical (Hospital) Services Tpmt Genotype PX-3108140100 CDM 81401 CPT 310 RC inpatient 834 834 MULTIPLAN INC 34080 [3081285] MULTIPLAN INC [308128501] 792.3 percent of total billed charges 517.08 792.3 Technical (Hospital) Services Tpmt Genotype PX-3108140100 CDM 81401 CPT 310 RC inpatient 834 834 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES HDHP [308136802] 660.36 percent of total billed charges 517.08 792.3 Technical (Hospital) Services Ref Cdcomp Hla-Dq Typing PX-3108137601 CDM 81376 CPT 310 RC outpatient 520 520 MEDICA (COMMERCIAL) 94265 [3081118] MEDICA CLAIMS [308111801] 468 percent of total billed charges 322.4 494 Technical (Hospital) Services Ref Cdcomp Hla-Dq Typing PX-3108137601 CDM 81376 CPT 310 RC outpatient 520 520 MULTIPLAN INC 34080 [3081285] MULTIPLAN INC [308128501] 494 percent of total billed charges 322.4 494 Technical (Hospital) Services Ref Cdcomp Hla-Dq Typing PX-3108137601 CDM 81376 CPT 310 RC outpatient 520 520 BLUE CROSS BLUE SHIELD WELLMARK SB889 [3081026] BCBS WYOMING [308102603] 494 percent of total billed charges 322.4 494 Technical (Hospital) Services Ref Cdcomp Hla-Dq Typing PX-3108137601 CDM 81376 CPT 310 RC outpatient 520 520 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES EPO [308136803] 416 percent of total billed charges 322.4 494 Technical (Hospital) Services Ref Cdcomp Hla-Dq Typing PX-3108137601 CDM 81376 CPT 310 RC outpatient 520 520 CIGNA 62308 [3081051] CIGNA 62308 [308105105] 416 percent of total billed charges 322.4 494 Technical (Hospital) Services Ref Cdcomp Hla-Dq Typing PX-3108137601 CDM 81376 CPT 310 RC outpatient 520 520 CIGNA 62308 [3081051] CIGNA STATE OF WYOMING [308105107] 416 percent of total billed charges 322.4 494 Technical (Hospital) Services Ref Cdcomp Hla-Dq Typing PX-3108137601 CDM 81376 CPT 310 RC outpatient 520 520 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES HDHP [308136802] 416 percent of total billed charges 322.4 494 Technical (Hospital) Services Ref Cdcomp Hla-Dq Typing PX-3108137601 CDM 81376 CPT 310 RC outpatient 520 520 UNITED HEALTHCARE (COMMERCIAL) [3081199] UNITED HEALTHCARE 87726 [308119901] 322.4 percent of total billed charges 322.4 494 Technical (Hospital) Services Ref Cdcomp Hla-Dq Typing PX-3108137601 CDM 81376 CPT 310 RC outpatient 520 520 HEALTHPARTNERS SX009 HEALTHPARTNERS 416 percent of total billed charges 322.4 494 Technical (Hospital) Services Ref Cdcomp Hla-Dq Typing PX-3108137601 CDM 81376 CPT 310 RC outpatient 520 520 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES PPO [308136801] 416 percent of total billed charges 322.4 494 Technical (Hospital) Services Ref Cdcomp Hla-Dq Typing PX-3108137601 CDM 81376 CPT 310 RC inpatient 520 520 CIGNA 62308 [3081051] CIGNA 62308 [308105105] 411.74 percent of total billed charges 322.4 494 Technical (Hospital) Services Ref Cdcomp Hla-Dq Typing PX-3108137601 CDM 81376 CPT 310 RC inpatient 520 520 CIGNA 62308 [3081051] CIGNA STATE OF WYOMING [308105107] 411.74 percent of total billed charges 322.4 494 Technical (Hospital) Services Ref Cdcomp Hla-Dq Typing PX-3108137601 CDM 81376 CPT 310 RC inpatient 520 520 BLUE CROSS BLUE SHIELD WELLMARK SB889 [3081026] BCBS WYOMING [308102603] 494 percent of total billed charges 322.4 494 Technical (Hospital) Services Ref Cdcomp Hla-Dq Typing PX-3108137601 CDM 81376 CPT 310 RC inpatient 520 520 HEALTHPARTNERS SX009 HEALTHPARTNERS 411.74 percent of total billed charges 322.4 494 Technical (Hospital) Services Ref Cdcomp Hla-Dq Typing PX-3108137601 CDM 81376 CPT 310 RC inpatient 520 520 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES EPO [308136803] 411.74 percent of total billed charges 322.4 494 Technical (Hospital) Services Ref Cdcomp Hla-Dq Typing PX-3108137601 CDM 81376 CPT 310 RC inpatient 520 520 MEDICA (COMMERCIAL) 94265 [3081118] MEDICA CLAIMS [308111801] 468 percent of total billed charges 322.4 494 Technical (Hospital) Services Ref Cdcomp Hla-Dq Typing PX-3108137601 CDM 81376 CPT 310 RC inpatient 520 520 UNITED HEALTHCARE (COMMERCIAL) [3081199] UNITED HEALTHCARE 87726 [308119901] 322.4 percent of total billed charges 322.4 494 Technical (Hospital) Services Ref Cdcomp Hla-Dq Typing PX-3108137601 CDM 81376 CPT 310 RC inpatient 520 520 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES HDHP [308136802] 411.74 percent of total billed charges 322.4 494 Technical (Hospital) Services Ref Cdcomp Hla-Dq Typing PX-3108137601 CDM 81376 CPT 310 RC inpatient 520 520 MULTIPLAN INC 34080 [3081285] MULTIPLAN INC [308128501] 494 percent of total billed charges 322.4 494 Technical (Hospital) Services Ref Cdcomp Hla-Dq Typing PX-3108137601 CDM 81376 CPT 310 RC inpatient 520 520 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES PPO [308136801] 411.74 percent of total billed charges 322.4 494 Technical (Hospital) Services Ref Celiac Disease Gluten-Free Cascade PX-3108137602 CDM 81376 CPT 310 RC inpatient 520 520 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES PPO [308136801] 411.74 percent of total billed charges 322.4 494 Technical (Hospital) Services Ref Celiac Disease Gluten-Free Cascade PX-3108137602 CDM 81376 CPT 310 RC inpatient 520 520 MULTIPLAN INC 34080 [3081285] MULTIPLAN INC [308128501] 494 percent of total billed charges 322.4 494 Technical (Hospital) Services Ref Celiac Disease Gluten-Free Cascade PX-3108137602 CDM 81376 CPT 310 RC inpatient 520 520 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES HDHP [308136802] 411.74 percent of total billed charges 322.4 494 Technical (Hospital) Services Ref Celiac Disease Gluten-Free Cascade PX-3108137602 CDM 81376 CPT 310 RC inpatient 520 520 UNITED HEALTHCARE (COMMERCIAL) [3081199] UNITED HEALTHCARE 87726 [308119901] 322.4 percent of total billed charges 322.4 494 Technical (Hospital) Services Ref Celiac Disease Gluten-Free Cascade PX-3108137602 CDM 81376 CPT 310 RC inpatient 520 520 MEDICA (COMMERCIAL) 94265 [3081118] MEDICA CLAIMS [308111801] 468 percent of total billed charges 322.4 494 Technical (Hospital) Services Ref Celiac Disease Gluten-Free Cascade PX-3108137602 CDM 81376 CPT 310 RC inpatient 520 520 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES EPO [308136803] 411.74 percent of total billed charges 322.4 494 Technical (Hospital) Services Ref Celiac Disease Gluten-Free Cascade PX-3108137602 CDM 81376 CPT 310 RC inpatient 520 520 HEALTHPARTNERS SX009 HEALTHPARTNERS 411.74 percent of total billed charges 322.4 494 Technical (Hospital) Services Ref Celiac Disease Gluten-Free Cascade PX-3108137602 CDM 81376 CPT 310 RC inpatient 520 520 BLUE CROSS BLUE SHIELD WELLMARK SB889 [3081026] BCBS WYOMING [308102603] 494 percent of total billed charges 322.4 494 Technical (Hospital) Services Ref Celiac Disease Gluten-Free Cascade PX-3108137602 CDM 81376 CPT 310 RC inpatient 520 520 CIGNA 62308 [3081051] CIGNA 62308 [308105105] 411.74 percent of total billed charges 322.4 494 Technical (Hospital) Services Ref Celiac Disease Gluten-Free Cascade PX-3108137602 CDM 81376 CPT 310 RC inpatient 520 520 CIGNA 62308 [3081051] CIGNA STATE OF WYOMING [308105107] 411.74 percent of total billed charges 322.4 494 Technical (Hospital) Services Ref Celiac Disease Gluten-Free Cascade PX-3108137602 CDM 81376 CPT 310 RC outpatient 520 520 MEDICA (COMMERCIAL) 94265 [3081118] MEDICA CLAIMS [308111801] 468 percent of total billed charges 322.4 494 Technical (Hospital) Services Ref Celiac Disease Gluten-Free Cascade PX-3108137602 CDM 81376 CPT 310 RC outpatient 520 520 UNITED HEALTHCARE (COMMERCIAL) [3081199] UNITED HEALTHCARE 87726 [308119901] 322.4 percent of total billed charges 322.4 494 Technical (Hospital) Services Ref Celiac Disease Gluten-Free Cascade PX-3108137602 CDM 81376 CPT 310 RC outpatient 520 520 HEALTHPARTNERS SX009 HEALTHPARTNERS 416 percent of total billed charges 322.4 494 Technical (Hospital) Services Ref Celiac Disease Gluten-Free Cascade PX-3108137602 CDM 81376 CPT 310 RC outpatient 520 520 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES PPO [308136801] 416 percent of total billed charges 322.4 494 Technical (Hospital) Services Ref Celiac Disease Gluten-Free Cascade PX-3108137602 CDM 81376 CPT 310 RC outpatient 520 520 MULTIPLAN INC 34080 [3081285] MULTIPLAN INC [308128501] 494 percent of total billed charges 322.4 494 Technical (Hospital) Services Ref Celiac Disease Gluten-Free Cascade PX-3108137602 CDM 81376 CPT 310 RC outpatient 520 520 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES EPO [308136803] 416 percent of total billed charges 322.4 494 Technical (Hospital) Services Ref Celiac Disease Gluten-Free Cascade PX-3108137602 CDM 81376 CPT 310 RC outpatient 520 520 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES HDHP [308136802] 416 percent of total billed charges 322.4 494 Technical (Hospital) Services Ref Celiac Disease Gluten-Free Cascade PX-3108137602 CDM 81376 CPT 310 RC outpatient 520 520 BLUE CROSS BLUE SHIELD WELLMARK SB889 [3081026] BCBS WYOMING [308102603] 494 percent of total billed charges 322.4 494 Technical (Hospital) Services Ref Celiac Disease Gluten-Free Cascade PX-3108137602 CDM 81376 CPT 310 RC outpatient 520 520 CIGNA 62308 [3081051] CIGNA 62308 [308105105] 416 percent of total billed charges 322.4 494 Technical (Hospital) Services Ref Celiac Disease Gluten-Free Cascade PX-3108137602 CDM 81376 CPT 310 RC outpatient 520 520 CIGNA 62308 [3081051] CIGNA STATE OF WYOMING [308105107] 416 percent of total billed charges 322.4 494 Technical (Hospital) Services Ref Hla Dr-Dq Disassoc Typing Lowres(Mayo) PX-3108137501 CDM 81375 CPT 310 RC inpatient 520 520 HEALTHPARTNERS SX009 HEALTHPARTNERS 411.74 percent of total billed charges 322.4 494 Technical (Hospital) Services Ref Hla Dr-Dq Disassoc Typing Lowres(Mayo) PX-3108137501 CDM 81375 CPT 310 RC inpatient 520 520 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES EPO [308136803] 411.74 percent of total billed charges 322.4 494 Technical (Hospital) Services Ref Hla Dr-Dq Disassoc Typing Lowres(Mayo) PX-3108137501 CDM 81375 CPT 310 RC inpatient 520 520 CIGNA 62308 [3081051] CIGNA 62308 [308105105] 411.74 percent of total billed charges 322.4 494 Technical (Hospital) Services Ref Hla Dr-Dq Disassoc Typing Lowres(Mayo) PX-3108137501 CDM 81375 CPT 310 RC inpatient 520 520 CIGNA 62308 [3081051] CIGNA STATE OF WYOMING [308105107] 411.74 percent of total billed charges 322.4 494 Technical (Hospital) Services Ref Hla Dr-Dq Disassoc Typing Lowres(Mayo) PX-3108137501 CDM 81375 CPT 310 RC inpatient 520 520 BLUE CROSS BLUE SHIELD WELLMARK SB889 [3081026] BCBS WYOMING [308102603] 494 percent of total billed charges 322.4 494 Technical (Hospital) Services Ref Hla Dr-Dq Disassoc Typing Lowres(Mayo) PX-3108137501 CDM 81375 CPT 310 RC inpatient 520 520 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES PPO [308136801] 411.74 percent of total billed charges 322.4 494 Technical (Hospital) Services Ref Hla Dr-Dq Disassoc Typing Lowres(Mayo) PX-3108137501 CDM 81375 CPT 310 RC inpatient 520 520 UNITED HEALTHCARE (COMMERCIAL) [3081199] UNITED HEALTHCARE 87726 [308119901] 322.4 percent of total billed charges 322.4 494 Technical (Hospital) Services Ref Hla Dr-Dq Disassoc Typing Lowres(Mayo) PX-3108137501 CDM 81375 CPT 310 RC inpatient 520 520 MEDICA (COMMERCIAL) 94265 [3081118] MEDICA CLAIMS [308111801] 468 percent of total billed charges 322.4 494 Technical (Hospital) Services Ref Hla Dr-Dq Disassoc Typing Lowres(Mayo) PX-3108137501 CDM 81375 CPT 310 RC inpatient 520 520 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES HDHP [308136802] 411.74 percent of total billed charges 322.4 494 Technical (Hospital) Services Ref Hla Dr-Dq Disassoc Typing Lowres(Mayo) PX-3108137501 CDM 81375 CPT 310 RC inpatient 520 520 MULTIPLAN INC 34080 [3081285] MULTIPLAN INC [308128501] 494 percent of total billed charges 322.4 494 Technical (Hospital) Services Ref Hla Dr-Dq Disassoc Typing Lowres(Mayo) PX-3108137501 CDM 81375 CPT 310 RC outpatient 520 520 CIGNA 62308 [3081051] CIGNA 62308 [308105105] 416 percent of total billed charges 322.4 494 Technical (Hospital) Services Ref Hla Dr-Dq Disassoc Typing Lowres(Mayo) PX-3108137501 CDM 81375 CPT 310 RC outpatient 520 520 CIGNA 62308 [3081051] CIGNA STATE OF WYOMING [308105107] 416 percent of total billed charges 322.4 494 Technical (Hospital) Services Ref Hla Dr-Dq Disassoc Typing Lowres(Mayo) PX-3108137501 CDM 81375 CPT 310 RC outpatient 520 520 MULTIPLAN INC 34080 [3081285] MULTIPLAN INC [308128501] 494 percent of total billed charges 322.4 494 Technical (Hospital) Services Ref Hla Dr-Dq Disassoc Typing Lowres(Mayo) PX-3108137501 CDM 81375 CPT 310 RC outpatient 520 520 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES EPO [308136803] 416 percent of total billed charges 322.4 494 Technical (Hospital) Services Ref Hla Dr-Dq Disassoc Typing Lowres(Mayo) PX-3108137501 CDM 81375 CPT 310 RC outpatient 520 520 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES HDHP [308136802] 416 percent of total billed charges 322.4 494 Technical (Hospital) Services Ref Hla Dr-Dq Disassoc Typing Lowres(Mayo) PX-3108137501 CDM 81375 CPT 310 RC outpatient 520 520 BLUE CROSS BLUE SHIELD WELLMARK SB889 [3081026] BCBS WYOMING [308102603] 494 percent of total billed charges 322.4 494 Technical (Hospital) Services Ref Hla Dr-Dq Disassoc Typing Lowres(Mayo) PX-3108137501 CDM 81375 CPT 310 RC outpatient 520 520 UNITED HEALTHCARE (COMMERCIAL) [3081199] UNITED HEALTHCARE 87726 [308119901] 322.4 percent of total billed charges 322.4 494 Technical (Hospital) Services Ref Hla Dr-Dq Disassoc Typing Lowres(Mayo) PX-3108137501 CDM 81375 CPT 310 RC outpatient 520 520 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES PPO [308136801] 416 percent of total billed charges 322.4 494 Technical (Hospital) Services Ref Hla Dr-Dq Disassoc Typing Lowres(Mayo) PX-3108137501 CDM 81375 CPT 310 RC outpatient 520 520 HEALTHPARTNERS SX009 HEALTHPARTNERS 416 percent of total billed charges 322.4 494 Technical (Hospital) Services Ref Hla Dr-Dq Disassoc Typing Lowres(Mayo) PX-3108137501 CDM 81375 CPT 310 RC outpatient 520 520 MEDICA (COMMERCIAL) 94265 [3081118] MEDICA CLAIMS [308111801] 468 percent of total billed charges 322.4 494 Technical (Hospital) Services Ref Jak2 Gene Anal P.Val617phe Vrn PX-3108127000 CDM 81270 CPT 310 RC inpatient 912 912 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES EPO [308136803] 722.12 percent of total billed charges 565.44 866.4 Technical (Hospital) Services Ref Jak2 Gene Anal P.Val617phe Vrn PX-3108127000 CDM 81270 CPT 310 RC inpatient 912 912 HEALTHPARTNERS SX009 HEALTHPARTNERS 722.12 percent of total billed charges 565.44 866.4 Technical (Hospital) Services Ref Jak2 Gene Anal P.Val617phe Vrn PX-3108127000 CDM 81270 CPT 310 RC inpatient 912 912 BLUE CROSS BLUE SHIELD WELLMARK SB889 [3081026] BCBS WYOMING [308102603] 866.4 percent of total billed charges 565.44 866.4 Technical (Hospital) Services Ref Jak2 Gene Anal P.Val617phe Vrn PX-3108127000 CDM 81270 CPT 310 RC inpatient 912 912 CIGNA 62308 [3081051] CIGNA 62308 [308105105] 722.12 percent of total billed charges 565.44 866.4 Technical (Hospital) Services Ref Jak2 Gene Anal P.Val617phe Vrn PX-3108127000 CDM 81270 CPT 310 RC inpatient 912 912 CIGNA 62308 [3081051] CIGNA STATE OF WYOMING [308105107] 722.12 percent of total billed charges 565.44 866.4 Technical (Hospital) Services Ref Jak2 Gene Anal P.Val617phe Vrn PX-3108127000 CDM 81270 CPT 310 RC inpatient 912 912 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES PPO [308136801] 722.12 percent of total billed charges 565.44 866.4 Technical (Hospital) Services Ref Jak2 Gene Anal P.Val617phe Vrn PX-3108127000 CDM 81270 CPT 310 RC inpatient 912 912 UNITED HEALTHCARE (COMMERCIAL) [3081199] UNITED HEALTHCARE 87726 [308119901] 565.44 percent of total billed charges 565.44 866.4 Technical (Hospital) Services Ref Jak2 Gene Anal P.Val617phe Vrn PX-3108127000 CDM 81270 CPT 310 RC inpatient 912 912 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES HDHP [308136802] 722.12 percent of total billed charges 565.44 866.4 Technical (Hospital) Services Ref Jak2 Gene Anal P.Val617phe Vrn PX-3108127000 CDM 81270 CPT 310 RC inpatient 912 912 MEDICA (COMMERCIAL) 94265 [3081118] MEDICA CLAIMS [308111801] 820.8 percent of total billed charges 565.44 866.4 Technical (Hospital) Services Ref Jak2 Gene Anal P.Val617phe Vrn PX-3108127000 CDM 81270 CPT 310 RC inpatient 912 912 MULTIPLAN INC 34080 [3081285] MULTIPLAN INC [308128501] 866.4 percent of total billed charges 565.44 866.4 Technical (Hospital) Services Ref Jak2 Gene Anal P.Val617phe Vrn PX-3108127000 CDM 81270 CPT 310 RC outpatient 912 912 MEDICA (COMMERCIAL) 94265 [3081118] MEDICA CLAIMS [308111801] 820.8 percent of total billed charges 565.44 866.4 Technical (Hospital) Services Ref Jak2 Gene Anal P.Val617phe Vrn PX-3108127000 CDM 81270 CPT 310 RC outpatient 912 912 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES EPO [308136803] 729.6 percent of total billed charges 565.44 866.4 Technical (Hospital) Services Ref Jak2 Gene Anal P.Val617phe Vrn PX-3108127000 CDM 81270 CPT 310 RC outpatient 912 912 CIGNA 62308 [3081051] CIGNA 62308 [308105105] 729.6 percent of total billed charges 565.44 866.4 Technical (Hospital) Services Ref Jak2 Gene Anal P.Val617phe Vrn PX-3108127000 CDM 81270 CPT 310 RC outpatient 912 912 CIGNA 62308 [3081051] CIGNA STATE OF WYOMING [308105107] 729.6 percent of total billed charges 565.44 866.4 Technical (Hospital) Services Ref Jak2 Gene Anal P.Val617phe Vrn PX-3108127000 CDM 81270 CPT 310 RC outpatient 912 912 MULTIPLAN INC 34080 [3081285] MULTIPLAN INC [308128501] 866.4 percent of total billed charges 565.44 866.4 Technical (Hospital) Services Ref Jak2 Gene Anal P.Val617phe Vrn PX-3108127000 CDM 81270 CPT 310 RC outpatient 912 912 BLUE CROSS BLUE SHIELD WELLMARK SB889 [3081026] BCBS WYOMING [308102603] 866.4 percent of total billed charges 565.44 866.4 Technical (Hospital) Services Ref Jak2 Gene Anal P.Val617phe Vrn PX-3108127000 CDM 81270 CPT 310 RC outpatient 912 912 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES HDHP [308136802] 729.6 percent of total billed charges 565.44 866.4 Technical (Hospital) Services Ref Jak2 Gene Anal P.Val617phe Vrn PX-3108127000 CDM 81270 CPT 310 RC outpatient 912 912 UNITED HEALTHCARE (COMMERCIAL) [3081199] UNITED HEALTHCARE 87726 [308119901] 565.44 percent of total billed charges 565.44 866.4 Technical (Hospital) Services Ref Jak2 Gene Anal P.Val617phe Vrn PX-3108127000 CDM 81270 CPT 310 RC outpatient 912 912 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES PPO [308136801] 729.6 percent of total billed charges 565.44 866.4 Technical (Hospital) Services Ref Jak2 Gene Anal P.Val617phe Vrn PX-3108127000 CDM 81270 CPT 310 RC outpatient 912 912 HEALTHPARTNERS SX009 HEALTHPARTNERS 729.6 percent of total billed charges 565.44 866.4 Technical (Hospital) Services Ref Hfe Gene Analysis Common Vrnts PX-3108125600 CDM 81256 CPT 310 RC outpatient 637 637 UNITED HEALTHCARE (COMMERCIAL) [3081199] UNITED HEALTHCARE 87726 [308119901] 394.94 percent of total billed charges 394.94 605.15 Technical (Hospital) Services Ref Hfe Gene Analysis Common Vrnts PX-3108125600 CDM 81256 CPT 310 RC outpatient 637 637 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES PPO [308136801] 509.6 percent of total billed charges 394.94 605.15 Technical (Hospital) Services Ref Hfe Gene Analysis Common Vrnts PX-3108125600 CDM 81256 CPT 310 RC outpatient 637 637 HEALTHPARTNERS SX009 HEALTHPARTNERS 509.6 percent of total billed charges 394.94 605.15 Technical (Hospital) Services Ref Hfe Gene Analysis Common Vrnts PX-3108125600 CDM 81256 CPT 310 RC outpatient 637 637 CIGNA 62308 [3081051] CIGNA 62308 [308105105] 509.6 percent of total billed charges 394.94 605.15 Technical (Hospital) Services Ref Hfe Gene Analysis Common Vrnts PX-3108125600 CDM 81256 CPT 310 RC outpatient 637 637 CIGNA 62308 [3081051] CIGNA STATE OF WYOMING [308105107] 509.6 percent of total billed charges 394.94 605.15 Technical (Hospital) Services Ref Hfe Gene Analysis Common Vrnts PX-3108125600 CDM 81256 CPT 310 RC outpatient 637 637 BLUE CROSS BLUE SHIELD WELLMARK SB889 [3081026] BCBS WYOMING [308102603] 605.15 percent of total billed charges 394.94 605.15 Technical (Hospital) Services Ref Hfe Gene Analysis Common Vrnts PX-3108125600 CDM 81256 CPT 310 RC outpatient 637 637 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES HDHP [308136802] 509.6 percent of total billed charges 394.94 605.15 Technical (Hospital) Services Ref Hfe Gene Analysis Common Vrnts PX-3108125600 CDM 81256 CPT 310 RC outpatient 637 637 MULTIPLAN INC 34080 [3081285] MULTIPLAN INC [308128501] 605.15 percent of total billed charges 394.94 605.15 Technical (Hospital) Services Ref Hfe Gene Analysis Common Vrnts PX-3108125600 CDM 81256 CPT 310 RC outpatient 637 637 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES EPO [308136803] 509.6 percent of total billed charges 394.94 605.15 Technical (Hospital) Services Ref Hfe Gene Analysis Common Vrnts PX-3108125600 CDM 81256 CPT 310 RC outpatient 637 637 MEDICA (COMMERCIAL) 94265 [3081118] MEDICA CLAIMS [308111801] 573.3 percent of total billed charges 394.94 605.15 Technical (Hospital) Services Ref Hfe Gene Analysis Common Vrnts PX-3108125600 CDM 81256 CPT 310 RC inpatient 637 637 BLUE CROSS BLUE SHIELD WELLMARK SB889 [3081026] BCBS WYOMING [308102603] 605.15 percent of total billed charges 394.94 605.15 Technical (Hospital) Services Ref Hfe Gene Analysis Common Vrnts PX-3108125600 CDM 81256 CPT 310 RC inpatient 637 637 CIGNA 62308 [3081051] CIGNA STATE OF WYOMING [308105107] 504.38 percent of total billed charges 394.94 605.15 Technical (Hospital) Services Ref Hfe Gene Analysis Common Vrnts PX-3108125600 CDM 81256 CPT 310 RC inpatient 637 637 CIGNA 62308 [3081051] CIGNA 62308 [308105105] 504.38 percent of total billed charges 394.94 605.15 Technical (Hospital) Services Ref Hfe Gene Analysis Common Vrnts PX-3108125600 CDM 81256 CPT 310 RC inpatient 637 637 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES EPO [308136803] 504.38 percent of total billed charges 394.94 605.15 Technical (Hospital) Services Ref Hfe Gene Analysis Common Vrnts PX-3108125600 CDM 81256 CPT 310 RC inpatient 637 637 HEALTHPARTNERS SX009 HEALTHPARTNERS 504.38 percent of total billed charges 394.94 605.15 Technical (Hospital) Services Ref Hfe Gene Analysis Common Vrnts PX-3108125600 CDM 81256 CPT 310 RC inpatient 637 637 MULTIPLAN INC 34080 [3081285] MULTIPLAN INC [308128501] 605.15 percent of total billed charges 394.94 605.15 Technical (Hospital) Services Ref Hfe Gene Analysis Common Vrnts PX-3108125600 CDM 81256 CPT 310 RC inpatient 637 637 MEDICA (COMMERCIAL) 94265 [3081118] MEDICA CLAIMS [308111801] 573.3 percent of total billed charges 394.94 605.15 Technical (Hospital) Services Ref Hfe Gene Analysis Common Vrnts PX-3108125600 CDM 81256 CPT 310 RC inpatient 637 637 UNITED HEALTHCARE (COMMERCIAL) [3081199] UNITED HEALTHCARE 87726 [308119901] 394.94 percent of total billed charges 394.94 605.15 Technical (Hospital) Services Ref Hfe Gene Analysis Common Vrnts PX-3108125600 CDM 81256 CPT 310 RC inpatient 637 637 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES HDHP [308136802] 504.38 percent of total billed charges 394.94 605.15 Technical (Hospital) Services Ref Hfe Gene Analysis Common Vrnts PX-3108125600 CDM 81256 CPT 310 RC inpatient 637 637 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES PPO [308136801] 504.38 percent of total billed charges 394.94 605.15 Technical (Hospital) Services "Ref F5 Gene Analysis, Leiden Variant" PX-3108124100 CDM 81241 CPT 310 RC inpatient 257 257 HEALTHPARTNERS SX009 HEALTHPARTNERS 203.49 percent of total billed charges 159.34 244.15 Technical (Hospital) Services "Ref F5 Gene Analysis, Leiden Variant" PX-3108124100 CDM 81241 CPT 310 RC inpatient 257 257 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES EPO [308136803] 203.49 percent of total billed charges 159.34 244.15 Technical (Hospital) Services "Ref F5 Gene Analysis, Leiden Variant" PX-3108124100 CDM 81241 CPT 310 RC inpatient 257 257 CIGNA 62308 [3081051] CIGNA 62308 [308105105] 203.49 percent of total billed charges 159.34 244.15 Technical (Hospital) Services "Ref F5 Gene Analysis, Leiden Variant" PX-3108124100 CDM 81241 CPT 310 RC inpatient 257 257 CIGNA 62308 [3081051] CIGNA STATE OF WYOMING [308105107] 203.49 percent of total billed charges 159.34 244.15 Technical (Hospital) Services "Ref F5 Gene Analysis, Leiden Variant" PX-3108124100 CDM 81241 CPT 310 RC inpatient 257 257 BLUE CROSS BLUE SHIELD WELLMARK SB889 [3081026] BCBS WYOMING [308102603] 244.15 percent of total billed charges 159.34 244.15 Technical (Hospital) Services "Ref F5 Gene Analysis, Leiden Variant" PX-3108124100 CDM 81241 CPT 310 RC inpatient 257 257 MEDICA (COMMERCIAL) 94265 [3081118] MEDICA CLAIMS [308111801] 231.3 percent of total billed charges 159.34 244.15 Technical (Hospital) Services "Ref F5 Gene Analysis, Leiden Variant" PX-3108124100 CDM 81241 CPT 310 RC inpatient 257 257 UNITED HEALTHCARE (COMMERCIAL) [3081199] UNITED HEALTHCARE 87726 [308119901] 159.34 percent of total billed charges 159.34 244.15 Technical (Hospital) Services "Ref F5 Gene Analysis, Leiden Variant" PX-3108124100 CDM 81241 CPT 310 RC inpatient 257 257 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES HDHP [308136802] 203.49 percent of total billed charges 159.34 244.15 Technical (Hospital) Services "Ref F5 Gene Analysis, Leiden Variant" PX-3108124100 CDM 81241 CPT 310 RC inpatient 257 257 MULTIPLAN INC 34080 [3081285] MULTIPLAN INC [308128501] 244.15 percent of total billed charges 159.34 244.15 Technical (Hospital) Services "Ref F5 Gene Analysis, Leiden Variant" PX-3108124100 CDM 81241 CPT 310 RC inpatient 257 257 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES PPO [308136801] 203.49 percent of total billed charges 159.34 244.15 Technical (Hospital) Services "Ref F5 Gene Analysis, Leiden Variant" PX-3108124100 CDM 81241 CPT 310 RC outpatient 257 257 CIGNA 62308 [3081051] CIGNA STATE OF WYOMING [308105107] 205.6 percent of total billed charges 159.34 244.15 Technical (Hospital) Services "Ref F5 Gene Analysis, Leiden Variant" PX-3108124100 CDM 81241 CPT 310 RC outpatient 257 257 BLUE CROSS BLUE SHIELD WELLMARK SB889 [3081026] BCBS WYOMING [308102603] 244.15 percent of total billed charges 159.34 244.15 Technical (Hospital) Services "Ref F5 Gene Analysis, Leiden Variant" PX-3108124100 CDM 81241 CPT 310 RC outpatient 257 257 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES HDHP [308136802] 205.6 percent of total billed charges 159.34 244.15 Technical (Hospital) Services "Ref F5 Gene Analysis, Leiden Variant" PX-3108124100 CDM 81241 CPT 310 RC outpatient 257 257 MULTIPLAN INC 34080 [3081285] MULTIPLAN INC [308128501] 244.15 percent of total billed charges 159.34 244.15 Technical (Hospital) Services "Ref F5 Gene Analysis, Leiden Variant" PX-3108124100 CDM 81241 CPT 310 RC outpatient 257 257 CIGNA 62308 [3081051] CIGNA 62308 [308105105] 205.6 percent of total billed charges 159.34 244.15 Technical (Hospital) Services "Ref F5 Gene Analysis, Leiden Variant" PX-3108124100 CDM 81241 CPT 310 RC outpatient 257 257 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES EPO [308136803] 205.6 percent of total billed charges 159.34 244.15 Technical (Hospital) Services "Ref F5 Gene Analysis, Leiden Variant" PX-3108124100 CDM 81241 CPT 310 RC outpatient 257 257 UNITED HEALTHCARE (COMMERCIAL) [3081199] UNITED HEALTHCARE 87726 [308119901] 159.34 percent of total billed charges 159.34 244.15 Technical (Hospital) Services "Ref F5 Gene Analysis, Leiden Variant" PX-3108124100 CDM 81241 CPT 310 RC outpatient 257 257 HEALTHPARTNERS SX009 HEALTHPARTNERS 205.6 percent of total billed charges 159.34 244.15 Technical (Hospital) Services "Ref F5 Gene Analysis, Leiden Variant" PX-3108124100 CDM 81241 CPT 310 RC outpatient 257 257 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES PPO [308136801] 205.6 percent of total billed charges 159.34 244.15 Technical (Hospital) Services "Ref F5 Gene Analysis, Leiden Variant" PX-3108124100 CDM 81241 CPT 310 RC outpatient 257 257 MEDICA (COMMERCIAL) 94265 [3081118] MEDICA CLAIMS [308111801] 231.3 percent of total billed charges 159.34 244.15 Technical (Hospital) Services "Ref Factor V Leiden (R506q) Mutation, B (Mayo)" PX-3108124101 CDM 81241 CPT 310 RC inpatient 450 450 BLUE CROSS BLUE SHIELD WELLMARK SB889 [3081026] BCBS WYOMING [308102603] 427.5 percent of total billed charges 279 427.5 Technical (Hospital) Services "Ref Factor V Leiden (R506q) Mutation, B (Mayo)" PX-3108124101 CDM 81241 CPT 310 RC inpatient 450 450 CIGNA 62308 [3081051] CIGNA 62308 [308105105] 356.31 percent of total billed charges 279 427.5 Technical (Hospital) Services "Ref Factor V Leiden (R506q) Mutation, B (Mayo)" PX-3108124101 CDM 81241 CPT 310 RC inpatient 450 450 CIGNA 62308 [3081051] CIGNA STATE OF WYOMING [308105107] 356.31 percent of total billed charges 279 427.5 Technical (Hospital) Services "Ref Factor V Leiden (R506q) Mutation, B (Mayo)" PX-3108124101 CDM 81241 CPT 310 RC inpatient 450 450 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES EPO [308136803] 356.31 percent of total billed charges 279 427.5 Technical (Hospital) Services "Ref Factor V Leiden (R506q) Mutation, B (Mayo)" PX-3108124101 CDM 81241 CPT 310 RC inpatient 450 450 HEALTHPARTNERS SX009 HEALTHPARTNERS 356.31 percent of total billed charges 279 427.5 Technical (Hospital) Services "Ref Factor V Leiden (R506q) Mutation, B (Mayo)" PX-3108124101 CDM 81241 CPT 310 RC inpatient 450 450 MEDICA (COMMERCIAL) 94265 [3081118] MEDICA CLAIMS [308111801] 405 percent of total billed charges 279 427.5 Technical (Hospital) Services "Ref Factor V Leiden (R506q) Mutation, B (Mayo)" PX-3108124101 CDM 81241 CPT 310 RC inpatient 450 450 UNITED HEALTHCARE (COMMERCIAL) [3081199] UNITED HEALTHCARE 87726 [308119901] 279 percent of total billed charges 279 427.5 Technical (Hospital) Services "Ref Factor V Leiden (R506q) Mutation, B (Mayo)" PX-3108124101 CDM 81241 CPT 310 RC inpatient 450 450 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES HDHP [308136802] 356.31 percent of total billed charges 279 427.5 Technical (Hospital) Services "Ref Factor V Leiden (R506q) Mutation, B (Mayo)" PX-3108124101 CDM 81241 CPT 310 RC inpatient 450 450 MULTIPLAN INC 34080 [3081285] MULTIPLAN INC [308128501] 427.5 percent of total billed charges 279 427.5 Technical (Hospital) Services "Ref Factor V Leiden (R506q) Mutation, B (Mayo)" PX-3108124101 CDM 81241 CPT 310 RC inpatient 450 450 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES PPO [308136801] 356.31 percent of total billed charges 279 427.5 Technical (Hospital) Services "Ref Factor V Leiden (R506q) Mutation, B (Mayo)" PX-3108124101 CDM 81241 CPT 310 RC outpatient 450 450 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES EPO [308136803] 360 percent of total billed charges 279 427.5 Technical (Hospital) Services "Ref Factor V Leiden (R506q) Mutation, B (Mayo)" PX-3108124101 CDM 81241 CPT 310 RC outpatient 450 450 MULTIPLAN INC 34080 [3081285] MULTIPLAN INC [308128501] 427.5 percent of total billed charges 279 427.5 Technical (Hospital) Services "Ref Factor V Leiden (R506q) Mutation, B (Mayo)" PX-3108124101 CDM 81241 CPT 310 RC outpatient 450 450 CIGNA 62308 [3081051] CIGNA 62308 [308105105] 360 percent of total billed charges 279 427.5 Technical (Hospital) Services "Ref Factor V Leiden (R506q) Mutation, B (Mayo)" PX-3108124101 CDM 81241 CPT 310 RC outpatient 450 450 CIGNA 62308 [3081051] CIGNA STATE OF WYOMING [308105107] 360 percent of total billed charges 279 427.5 Technical (Hospital) Services "Ref Factor V Leiden (R506q) Mutation, B (Mayo)" PX-3108124101 CDM 81241 CPT 310 RC outpatient 450 450 BLUE CROSS BLUE SHIELD WELLMARK SB889 [3081026] BCBS WYOMING [308102603] 427.5 percent of total billed charges 279 427.5 Technical (Hospital) Services "Ref Factor V Leiden (R506q) Mutation, B (Mayo)" PX-3108124101 CDM 81241 CPT 310 RC outpatient 450 450 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES HDHP [308136802] 360 percent of total billed charges 279 427.5 Technical (Hospital) Services "Ref Factor V Leiden (R506q) Mutation, B (Mayo)" PX-3108124101 CDM 81241 CPT 310 RC outpatient 450 450 UNITED HEALTHCARE (COMMERCIAL) [3081199] UNITED HEALTHCARE 87726 [308119901] 279 percent of total billed charges 279 427.5 Technical (Hospital) Services "Ref Factor V Leiden (R506q) Mutation, B (Mayo)" PX-3108124101 CDM 81241 CPT 310 RC outpatient 450 450 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES PPO [308136801] 360 percent of total billed charges 279 427.5 Technical (Hospital) Services "Ref Factor V Leiden (R506q) Mutation, B (Mayo)" PX-3108124101 CDM 81241 CPT 310 RC outpatient 450 450 HEALTHPARTNERS SX009 HEALTHPARTNERS 360 percent of total billed charges 279 427.5 Technical (Hospital) Services "Ref Factor V Leiden (R506q) Mutation, B (Mayo)" PX-3108124101 CDM 81241 CPT 310 RC outpatient 450 450 MEDICA (COMMERCIAL) 94265 [3081118] MEDICA CLAIMS [308111801] 405 percent of total billed charges 279 427.5 Technical (Hospital) Services "Ref Prothrombin G20210a Mutation,B" PX-3108124000 CDM 81240 CPT 310 RC inpatient 734 734 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES PPO [308136801] 581.18 percent of total billed charges 455.08 697.3 Technical (Hospital) Services "Ref Prothrombin G20210a Mutation,B" PX-3108124000 CDM 81240 CPT 310 RC inpatient 734 734 MULTIPLAN INC 34080 [3081285] MULTIPLAN INC [308128501] 697.3 percent of total billed charges 455.08 697.3 Technical (Hospital) Services "Ref Prothrombin G20210a Mutation,B" PX-3108124000 CDM 81240 CPT 310 RC inpatient 734 734 MEDICA (COMMERCIAL) 94265 [3081118] MEDICA CLAIMS [308111801] 660.6 percent of total billed charges 455.08 697.3 Technical (Hospital) Services "Ref Prothrombin G20210a Mutation,B" PX-3108124000 CDM 81240 CPT 310 RC inpatient 734 734 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES HDHP [308136802] 581.18 percent of total billed charges 455.08 697.3 Technical (Hospital) Services "Ref Prothrombin G20210a Mutation,B" PX-3108124000 CDM 81240 CPT 310 RC inpatient 734 734 UNITED HEALTHCARE (COMMERCIAL) [3081199] UNITED HEALTHCARE 87726 [308119901] 455.08 percent of total billed charges 455.08 697.3 Technical (Hospital) Services "Ref Prothrombin G20210a Mutation,B" PX-3108124000 CDM 81240 CPT 310 RC inpatient 734 734 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES EPO [308136803] 581.18 percent of total billed charges 455.08 697.3 Technical (Hospital) Services "Ref Prothrombin G20210a Mutation,B" PX-3108124000 CDM 81240 CPT 310 RC inpatient 734 734 HEALTHPARTNERS SX009 HEALTHPARTNERS 581.18 percent of total billed charges 455.08 697.3 Technical (Hospital) Services "Ref Prothrombin G20210a Mutation,B" PX-3108124000 CDM 81240 CPT 310 RC inpatient 734 734 BLUE CROSS BLUE SHIELD WELLMARK SB889 [3081026] BCBS WYOMING [308102603] 697.3 percent of total billed charges 455.08 697.3 Technical (Hospital) Services "Ref Prothrombin G20210a Mutation,B" PX-3108124000 CDM 81240 CPT 310 RC inpatient 734 734 CIGNA 62308 [3081051] CIGNA 62308 [308105105] 581.18 percent of total billed charges 455.08 697.3 Technical (Hospital) Services "Ref Prothrombin G20210a Mutation,B" PX-3108124000 CDM 81240 CPT 310 RC inpatient 734 734 CIGNA 62308 [3081051] CIGNA STATE OF WYOMING [308105107] 581.18 percent of total billed charges 455.08 697.3 Technical (Hospital) Services "Ref Prothrombin G20210a Mutation,B" PX-3108124000 CDM 81240 CPT 310 RC outpatient 734 734 UNITED HEALTHCARE (COMMERCIAL) [3081199] UNITED HEALTHCARE 87726 [308119901] 455.08 percent of total billed charges 455.08 697.3 Technical (Hospital) Services "Ref Prothrombin G20210a Mutation,B" PX-3108124000 CDM 81240 CPT 310 RC outpatient 734 734 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES EPO [308136803] 587.2 percent of total billed charges 455.08 697.3 Technical (Hospital) Services "Ref Prothrombin G20210a Mutation,B" PX-3108124000 CDM 81240 CPT 310 RC outpatient 734 734 MULTIPLAN INC 34080 [3081285] MULTIPLAN INC [308128501] 697.3 percent of total billed charges 455.08 697.3 Technical (Hospital) Services "Ref Prothrombin G20210a Mutation,B" PX-3108124000 CDM 81240 CPT 310 RC outpatient 734 734 CIGNA 62308 [3081051] CIGNA 62308 [308105105] 587.2 percent of total billed charges 455.08 697.3 Technical (Hospital) Services "Ref Prothrombin G20210a Mutation,B" PX-3108124000 CDM 81240 CPT 310 RC outpatient 734 734 CIGNA 62308 [3081051] CIGNA STATE OF WYOMING [308105107] 587.2 percent of total billed charges 455.08 697.3 Technical (Hospital) Services "Ref Prothrombin G20210a Mutation,B" PX-3108124000 CDM 81240 CPT 310 RC outpatient 734 734 BLUE CROSS BLUE SHIELD WELLMARK SB889 [3081026] BCBS WYOMING [308102603] 697.3 percent of total billed charges 455.08 697.3 Technical (Hospital) Services "Ref Prothrombin G20210a Mutation,B" PX-3108124000 CDM 81240 CPT 310 RC outpatient 734 734 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES HDHP [308136802] 587.2 percent of total billed charges 455.08 697.3 Technical (Hospital) Services "Ref Prothrombin G20210a Mutation,B" PX-3108124000 CDM 81240 CPT 310 RC outpatient 734 734 HEALTHPARTNERS SX009 HEALTHPARTNERS 587.2 percent of total billed charges 455.08 697.3 Technical (Hospital) Services "Ref Prothrombin G20210a Mutation,B" PX-3108124000 CDM 81240 CPT 310 RC outpatient 734 734 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES PPO [308136801] 587.2 percent of total billed charges 455.08 697.3 Technical (Hospital) Services "Ref Prothrombin G20210a Mutation,B" PX-3108124000 CDM 81240 CPT 310 RC outpatient 734 734 MEDICA (COMMERCIAL) 94265 [3081118] MEDICA CLAIMS [308111801] 660.6 percent of total billed charges 455.08 697.3 Technical (Hospital) Services "Ref Prothrombin G20210a Mutation,B Aathr Panel" PX-3108124002 CDM 81240 CPT 310 RC inpatient 349 349 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES PPO [308136801] 276.34 percent of total billed charges 216.38 331.55 Technical (Hospital) Services "Ref Prothrombin G20210a Mutation,B Aathr Panel" PX-3108124002 CDM 81240 CPT 310 RC inpatient 349 349 UNITED HEALTHCARE (COMMERCIAL) [3081199] UNITED HEALTHCARE 87726 [308119901] 216.38 percent of total billed charges 216.38 331.55 Technical (Hospital) Services "Ref Prothrombin G20210a Mutation,B Aathr Panel" PX-3108124002 CDM 81240 CPT 310 RC inpatient 349 349 MEDICA (COMMERCIAL) 94265 [3081118] MEDICA CLAIMS [308111801] 314.1 percent of total billed charges 216.38 331.55 Technical (Hospital) Services "Ref Prothrombin G20210a Mutation,B Aathr Panel" PX-3108124002 CDM 81240 CPT 310 RC inpatient 349 349 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES HDHP [308136802] 276.34 percent of total billed charges 216.38 331.55 Technical (Hospital) Services "Ref Prothrombin G20210a Mutation,B Aathr Panel" PX-3108124002 CDM 81240 CPT 310 RC inpatient 349 349 MULTIPLAN INC 34080 [3081285] MULTIPLAN INC [308128501] 331.55 percent of total billed charges 216.38 331.55 Technical (Hospital) Services "Ref Prothrombin G20210a Mutation,B Aathr Panel" PX-3108124002 CDM 81240 CPT 310 RC inpatient 349 349 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES EPO [308136803] 276.34 percent of total billed charges 216.38 331.55 Technical (Hospital) Services "Ref Prothrombin G20210a Mutation,B Aathr Panel" PX-3108124002 CDM 81240 CPT 310 RC inpatient 349 349 HEALTHPARTNERS SX009 HEALTHPARTNERS 276.34 percent of total billed charges 216.38 331.55 Technical (Hospital) Services "Ref Prothrombin G20210a Mutation,B Aathr Panel" PX-3108124002 CDM 81240 CPT 310 RC inpatient 349 349 BLUE CROSS BLUE SHIELD WELLMARK SB889 [3081026] BCBS WYOMING [308102603] 331.55 percent of total billed charges 216.38 331.55 Technical (Hospital) Services "Ref Prothrombin G20210a Mutation,B Aathr Panel" PX-3108124002 CDM 81240 CPT 310 RC inpatient 349 349 CIGNA 62308 [3081051] CIGNA 62308 [308105105] 276.34 percent of total billed charges 216.38 331.55 Technical (Hospital) Services "Ref Prothrombin G20210a Mutation,B Aathr Panel" PX-3108124002 CDM 81240 CPT 310 RC inpatient 349 349 CIGNA 62308 [3081051] CIGNA STATE OF WYOMING [308105107] 276.34 percent of total billed charges 216.38 331.55 Technical (Hospital) Services "Ref Prothrombin G20210a Mutation,B Aathr Panel" PX-3108124002 CDM 81240 CPT 310 RC outpatient 349 349 HEALTHPARTNERS SX009 HEALTHPARTNERS 279.2 percent of total billed charges 216.38 331.55 Technical (Hospital) Services "Ref Prothrombin G20210a Mutation,B Aathr Panel" PX-3108124002 CDM 81240 CPT 310 RC outpatient 349 349 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES PPO [308136801] 279.2 percent of total billed charges 216.38 331.55 Technical (Hospital) Services "Ref Prothrombin G20210a Mutation,B Aathr Panel" PX-3108124002 CDM 81240 CPT 310 RC outpatient 349 349 UNITED HEALTHCARE (COMMERCIAL) [3081199] UNITED HEALTHCARE 87726 [308119901] 216.38 percent of total billed charges 216.38 331.55 Technical (Hospital) Services "Ref Prothrombin G20210a Mutation,B Aathr Panel" PX-3108124002 CDM 81240 CPT 310 RC outpatient 349 349 BLUE CROSS BLUE SHIELD WELLMARK SB889 [3081026] BCBS WYOMING [308102603] 331.55 percent of total billed charges 216.38 331.55 Technical (Hospital) Services "Ref Prothrombin G20210a Mutation,B Aathr Panel" PX-3108124002 CDM 81240 CPT 310 RC outpatient 349 349 CIGNA 62308 [3081051] CIGNA 62308 [308105105] 279.2 percent of total billed charges 216.38 331.55 Technical (Hospital) Services "Ref Prothrombin G20210a Mutation,B Aathr Panel" PX-3108124002 CDM 81240 CPT 310 RC outpatient 349 349 CIGNA 62308 [3081051] CIGNA STATE OF WYOMING [308105107] 279.2 percent of total billed charges 216.38 331.55 Technical (Hospital) Services "Ref Prothrombin G20210a Mutation,B Aathr Panel" PX-3108124002 CDM 81240 CPT 310 RC outpatient 349 349 MULTIPLAN INC 34080 [3081285] MULTIPLAN INC [308128501] 331.55 percent of total billed charges 216.38 331.55 Technical (Hospital) Services "Ref Prothrombin G20210a Mutation,B Aathr Panel" PX-3108124002 CDM 81240 CPT 310 RC outpatient 349 349 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES HDHP [308136802] 279.2 percent of total billed charges 216.38 331.55 Technical (Hospital) Services "Ref Prothrombin G20210a Mutation,B Aathr Panel" PX-3108124002 CDM 81240 CPT 310 RC outpatient 349 349 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES EPO [308136803] 279.2 percent of total billed charges 216.38 331.55 Technical (Hospital) Services "Ref Prothrombin G20210a Mutation,B Aathr Panel" PX-3108124002 CDM 81240 CPT 310 RC outpatient 349 349 MEDICA (COMMERCIAL) 94265 [3081118] MEDICA CLAIMS [308111801] 314.1 percent of total billed charges 216.38 331.55 Technical (Hospital) Services "Ref Mpn, Calr Gene Mutation" PX-3108121900 CDM 81219 CPT 310 RC inpatient 867 867 BLUE CROSS BLUE SHIELD WELLMARK SB889 [3081026] BCBS WYOMING [308102603] 823.65 percent of total billed charges 537.54 823.65 Technical (Hospital) Services "Ref Mpn, Calr Gene Mutation" PX-3108121900 CDM 81219 CPT 310 RC inpatient 867 867 CIGNA 62308 [3081051] CIGNA 62308 [308105105] 686.49 percent of total billed charges 537.54 823.65 Technical (Hospital) Services "Ref Mpn, Calr Gene Mutation" PX-3108121900 CDM 81219 CPT 310 RC inpatient 867 867 CIGNA 62308 [3081051] CIGNA STATE OF WYOMING [308105107] 686.49 percent of total billed charges 537.54 823.65 Technical (Hospital) Services "Ref Mpn, Calr Gene Mutation" PX-3108121900 CDM 81219 CPT 310 RC inpatient 867 867 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES EPO [308136803] 686.49 percent of total billed charges 537.54 823.65 Technical (Hospital) Services "Ref Mpn, Calr Gene Mutation" PX-3108121900 CDM 81219 CPT 310 RC inpatient 867 867 HEALTHPARTNERS SX009 HEALTHPARTNERS 686.49 percent of total billed charges 537.54 823.65 Technical (Hospital) Services "Ref Mpn, Calr Gene Mutation" PX-3108121900 CDM 81219 CPT 310 RC inpatient 867 867 MEDICA (COMMERCIAL) 94265 [3081118] MEDICA CLAIMS [308111801] 780.3 percent of total billed charges 537.54 823.65 Technical (Hospital) Services "Ref Mpn, Calr Gene Mutation" PX-3108121900 CDM 81219 CPT 310 RC inpatient 867 867 UNITED HEALTHCARE (COMMERCIAL) [3081199] UNITED HEALTHCARE 87726 [308119901] 537.54 percent of total billed charges 537.54 823.65 Technical (Hospital) Services "Ref Mpn, Calr Gene Mutation" PX-3108121900 CDM 81219 CPT 310 RC inpatient 867 867 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES HDHP [308136802] 686.49 percent of total billed charges 537.54 823.65 Technical (Hospital) Services "Ref Mpn, Calr Gene Mutation" PX-3108121900 CDM 81219 CPT 310 RC inpatient 867 867 MULTIPLAN INC 34080 [3081285] MULTIPLAN INC [308128501] 823.65 percent of total billed charges 537.54 823.65 Technical (Hospital) Services "Ref Mpn, Calr Gene Mutation" PX-3108121900 CDM 81219 CPT 310 RC inpatient 867 867 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES PPO [308136801] 686.49 percent of total billed charges 537.54 823.65 Technical (Hospital) Services "Ref Mpn, Calr Gene Mutation" PX-3108121900 CDM 81219 CPT 310 RC outpatient 867 867 MEDICA (COMMERCIAL) 94265 [3081118] MEDICA CLAIMS [308111801] 780.3 percent of total billed charges 537.54 823.65 Technical (Hospital) Services "Ref Mpn, Calr Gene Mutation" PX-3108121900 CDM 81219 CPT 310 RC outpatient 867 867 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES PPO [308136801] 693.6 percent of total billed charges 537.54 823.65 Technical (Hospital) Services "Ref Mpn, Calr Gene Mutation" PX-3108121900 CDM 81219 CPT 310 RC outpatient 867 867 HEALTHPARTNERS SX009 HEALTHPARTNERS 693.6 percent of total billed charges 537.54 823.65 Technical (Hospital) Services "Ref Mpn, Calr Gene Mutation" PX-3108121900 CDM 81219 CPT 310 RC outpatient 867 867 CIGNA 62308 [3081051] CIGNA 62308 [308105105] 693.6 percent of total billed charges 537.54 823.65 Technical (Hospital) Services "Ref Mpn, Calr Gene Mutation" PX-3108121900 CDM 81219 CPT 310 RC outpatient 867 867 CIGNA 62308 [3081051] CIGNA STATE OF WYOMING [308105107] 693.6 percent of total billed charges 537.54 823.65 Technical (Hospital) Services "Ref Mpn, Calr Gene Mutation" PX-3108121900 CDM 81219 CPT 310 RC outpatient 867 867 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES EPO [308136803] 693.6 percent of total billed charges 537.54 823.65 Technical (Hospital) Services "Ref Mpn, Calr Gene Mutation" PX-3108121900 CDM 81219 CPT 310 RC outpatient 867 867 MULTIPLAN INC 34080 [3081285] MULTIPLAN INC [308128501] 823.65 percent of total billed charges 537.54 823.65 Technical (Hospital) Services "Ref Mpn, Calr Gene Mutation" PX-3108121900 CDM 81219 CPT 310 RC outpatient 867 867 BLUE CROSS BLUE SHIELD WELLMARK SB889 [3081026] BCBS WYOMING [308102603] 823.65 percent of total billed charges 537.54 823.65 Technical (Hospital) Services "Ref Mpn, Calr Gene Mutation" PX-3108121900 CDM 81219 CPT 310 RC outpatient 867 867 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES HDHP [308136802] 693.6 percent of total billed charges 537.54 823.65 Technical (Hospital) Services "Ref Mpn, Calr Gene Mutation" PX-3108121900 CDM 81219 CPT 310 RC outpatient 867 867 UNITED HEALTHCARE (COMMERCIAL) [3081199] UNITED HEALTHCARE 87726 [308119901] 537.54 percent of total billed charges 537.54 823.65 Technical (Hospital) Services Ref Bcr Abl1 Major Brkpt Qual Quan PX-3108120601 CDM 81206 CPT 310 RC inpatient 1966 1966 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES PPO [308136801] 1556.68 percent of total billed charges 1218.92 1867.7 Technical (Hospital) Services Ref Bcr Abl1 Major Brkpt Qual Quan PX-3108120601 CDM 81206 CPT 310 RC inpatient 1966 1966 MULTIPLAN INC 34080 [3081285] MULTIPLAN INC [308128501] 1867.7 percent of total billed charges 1218.92 1867.7 Technical (Hospital) Services Ref Bcr Abl1 Major Brkpt Qual Quan PX-3108120601 CDM 81206 CPT 310 RC inpatient 1966 1966 UNITED HEALTHCARE (COMMERCIAL) [3081199] UNITED HEALTHCARE 87726 [308119901] 1218.92 percent of total billed charges 1218.92 1867.7 Technical (Hospital) Services Ref Bcr Abl1 Major Brkpt Qual Quan PX-3108120601 CDM 81206 CPT 310 RC inpatient 1966 1966 MEDICA (COMMERCIAL) 94265 [3081118] MEDICA CLAIMS [308111801] 1769.4 percent of total billed charges 1218.92 1867.7 Technical (Hospital) Services Ref Bcr Abl1 Major Brkpt Qual Quan PX-3108120601 CDM 81206 CPT 310 RC inpatient 1966 1966 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES HDHP [308136802] 1556.68 percent of total billed charges 1218.92 1867.7 Technical (Hospital) Services Ref Bcr Abl1 Major Brkpt Qual Quan PX-3108120601 CDM 81206 CPT 310 RC inpatient 1966 1966 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES EPO [308136803] 1556.68 percent of total billed charges 1218.92 1867.7 Technical (Hospital) Services Ref Bcr Abl1 Major Brkpt Qual Quan PX-3108120601 CDM 81206 CPT 310 RC inpatient 1966 1966 HEALTHPARTNERS SX009 HEALTHPARTNERS 1556.68 percent of total billed charges 1218.92 1867.7 Technical (Hospital) Services Ref Bcr Abl1 Major Brkpt Qual Quan PX-3108120601 CDM 81206 CPT 310 RC inpatient 1966 1966 CIGNA 62308 [3081051] CIGNA 62308 [308105105] 1556.68 percent of total billed charges 1218.92 1867.7 Technical (Hospital) Services Ref Bcr Abl1 Major Brkpt Qual Quan PX-3108120601 CDM 81206 CPT 310 RC inpatient 1966 1966 CIGNA 62308 [3081051] CIGNA STATE OF WYOMING [308105107] 1556.68 percent of total billed charges 1218.92 1867.7 Technical (Hospital) Services Ref Bcr Abl1 Major Brkpt Qual Quan PX-3108120601 CDM 81206 CPT 310 RC inpatient 1966 1966 BLUE CROSS BLUE SHIELD WELLMARK SB889 [3081026] BCBS WYOMING [308102603] 1867.7 percent of total billed charges 1218.92 1867.7 Technical (Hospital) Services Ref Bcr Abl1 Major Brkpt Qual Quan PX-3108120601 CDM 81206 CPT 310 RC outpatient 1966 1966 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES HDHP [308136802] 1572.8 percent of total billed charges 1218.92 1867.7 Technical (Hospital) Services Ref Bcr Abl1 Major Brkpt Qual Quan PX-3108120601 CDM 81206 CPT 310 RC outpatient 1966 1966 MULTIPLAN INC 34080 [3081285] MULTIPLAN INC [308128501] 1867.7 percent of total billed charges 1218.92 1867.7 Technical (Hospital) Services Ref Bcr Abl1 Major Brkpt Qual Quan PX-3108120601 CDM 81206 CPT 310 RC outpatient 1966 1966 BLUE CROSS BLUE SHIELD WELLMARK SB889 [3081026] BCBS WYOMING [308102603] 1867.7 percent of total billed charges 1218.92 1867.7 Technical (Hospital) Services Ref Bcr Abl1 Major Brkpt Qual Quan PX-3108120601 CDM 81206 CPT 310 RC outpatient 1966 1966 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES EPO [308136803] 1572.8 percent of total billed charges 1218.92 1867.7 Technical (Hospital) Services Ref Bcr Abl1 Major Brkpt Qual Quan PX-3108120601 CDM 81206 CPT 310 RC outpatient 1966 1966 CIGNA 62308 [3081051] CIGNA 62308 [308105105] 1572.8 percent of total billed charges 1218.92 1867.7 Technical (Hospital) Services Ref Bcr Abl1 Major Brkpt Qual Quan PX-3108120601 CDM 81206 CPT 310 RC outpatient 1966 1966 CIGNA 62308 [3081051] CIGNA STATE OF WYOMING [308105107] 1572.8 percent of total billed charges 1218.92 1867.7 Technical (Hospital) Services Ref Bcr Abl1 Major Brkpt Qual Quan PX-3108120601 CDM 81206 CPT 310 RC outpatient 1966 1966 UNITED HEALTHCARE (COMMERCIAL) [3081199] UNITED HEALTHCARE 87726 [308119901] 1218.92 percent of total billed charges 1218.92 1867.7 Technical (Hospital) Services Ref Bcr Abl1 Major Brkpt Qual Quan PX-3108120601 CDM 81206 CPT 310 RC outpatient 1966 1966 HEALTHPARTNERS SX009 HEALTHPARTNERS 1572.8 percent of total billed charges 1218.92 1867.7 Technical (Hospital) Services Ref Bcr Abl1 Major Brkpt Qual Quan PX-3108120601 CDM 81206 CPT 310 RC outpatient 1966 1966 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES PPO [308136801] 1572.8 percent of total billed charges 1218.92 1867.7 Technical (Hospital) Services Ref Bcr Abl1 Major Brkpt Qual Quan PX-3108120601 CDM 81206 CPT 310 RC outpatient 1966 1966 MEDICA (COMMERCIAL) 94265 [3081118] MEDICA CLAIMS [308111801] 1769.4 percent of total billed charges 1218.92 1867.7 Technical (Hospital) Services Ref Brca1/Brca2 Full Gene Analysis PX-3108116200 CDM 81162 CPT 310 RC outpatient 5291 5291 MEDICA (COMMERCIAL) 94265 [3081118] MEDICA CLAIMS [308111801] 4761.9 percent of total billed charges 3280.42 5026.45 Technical (Hospital) Services Ref Brca1/Brca2 Full Gene Analysis PX-3108116200 CDM 81162 CPT 310 RC outpatient 5291 5291 CIGNA 62308 [3081051] CIGNA 62308 [308105105] 4232.8 percent of total billed charges 3280.42 5026.45 Technical (Hospital) Services Ref Brca1/Brca2 Full Gene Analysis PX-3108116200 CDM 81162 CPT 310 RC outpatient 5291 5291 CIGNA 62308 [3081051] CIGNA STATE OF WYOMING [308105107] 4232.8 percent of total billed charges 3280.42 5026.45 Technical (Hospital) Services Ref Brca1/Brca2 Full Gene Analysis PX-3108116200 CDM 81162 CPT 310 RC outpatient 5291 5291 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES EPO [308136803] 4232.8 percent of total billed charges 3280.42 5026.45 Technical (Hospital) Services Ref Brca1/Brca2 Full Gene Analysis PX-3108116200 CDM 81162 CPT 310 RC outpatient 5291 5291 BLUE CROSS BLUE SHIELD WELLMARK SB889 [3081026] BCBS WYOMING [308102603] 5026.45 percent of total billed charges 3280.42 5026.45 Technical (Hospital) Services Ref Brca1/Brca2 Full Gene Analysis PX-3108116200 CDM 81162 CPT 310 RC outpatient 5291 5291 MULTIPLAN INC 34080 [3081285] MULTIPLAN INC [308128501] 5026.45 percent of total billed charges 3280.42 5026.45 Technical (Hospital) Services Ref Brca1/Brca2 Full Gene Analysis PX-3108116200 CDM 81162 CPT 310 RC outpatient 5291 5291 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES HDHP [308136802] 4232.8 percent of total billed charges 3280.42 5026.45 Technical (Hospital) Services Ref Brca1/Brca2 Full Gene Analysis PX-3108116200 CDM 81162 CPT 310 RC outpatient 5291 5291 UNITED HEALTHCARE (COMMERCIAL) [3081199] UNITED HEALTHCARE 87726 [308119901] 3280.42 percent of total billed charges 3280.42 5026.45 Technical (Hospital) Services Ref Brca1/Brca2 Full Gene Analysis PX-3108116200 CDM 81162 CPT 310 RC outpatient 5291 5291 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES PPO [308136801] 4232.8 percent of total billed charges 3280.42 5026.45 Technical (Hospital) Services Ref Brca1/Brca2 Full Gene Analysis PX-3108116200 CDM 81162 CPT 310 RC outpatient 5291 5291 HEALTHPARTNERS SX009 HEALTHPARTNERS 4232.8 percent of total billed charges 3280.42 5026.45 Technical (Hospital) Services Ref Brca1/Brca2 Full Gene Analysis PX-3108116200 CDM 81162 CPT 310 RC inpatient 5291 5291 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES PPO [308136801] 4189.41 percent of total billed charges 3280.42 5026.45 Technical (Hospital) Services Ref Brca1/Brca2 Full Gene Analysis PX-3108116200 CDM 81162 CPT 310 RC inpatient 5291 5291 MEDICA (COMMERCIAL) 94265 [3081118] MEDICA CLAIMS [308111801] 4761.9 percent of total billed charges 3280.42 5026.45 Technical (Hospital) Services Ref Brca1/Brca2 Full Gene Analysis PX-3108116200 CDM 81162 CPT 310 RC inpatient 5291 5291 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES HDHP [308136802] 4189.41 percent of total billed charges 3280.42 5026.45 Technical (Hospital) Services Ref Brca1/Brca2 Full Gene Analysis PX-3108116200 CDM 81162 CPT 310 RC inpatient 5291 5291 UNITED HEALTHCARE (COMMERCIAL) [3081199] UNITED HEALTHCARE 87726 [308119901] 3280.42 percent of total billed charges 3280.42 5026.45 Technical (Hospital) Services Ref Brca1/Brca2 Full Gene Analysis PX-3108116200 CDM 81162 CPT 310 RC inpatient 5291 5291 MULTIPLAN INC 34080 [3081285] MULTIPLAN INC [308128501] 5026.45 percent of total billed charges 3280.42 5026.45 Technical (Hospital) Services Ref Brca1/Brca2 Full Gene Analysis PX-3108116200 CDM 81162 CPT 310 RC inpatient 5291 5291 BLUE CROSS BLUE SHIELD WELLMARK SB889 [3081026] BCBS WYOMING [308102603] 5026.45 percent of total billed charges 3280.42 5026.45 Technical (Hospital) Services Ref Brca1/Brca2 Full Gene Analysis PX-3108116200 CDM 81162 CPT 310 RC inpatient 5291 5291 CIGNA 62308 [3081051] CIGNA 62308 [308105105] 4189.41 percent of total billed charges 3280.42 5026.45 Technical (Hospital) Services Ref Brca1/Brca2 Full Gene Analysis PX-3108116200 CDM 81162 CPT 310 RC inpatient 5291 5291 CIGNA 62308 [3081051] CIGNA STATE OF WYOMING [308105107] 4189.41 percent of total billed charges 3280.42 5026.45 Technical (Hospital) Services Ref Brca1/Brca2 Full Gene Analysis PX-3108116200 CDM 81162 CPT 310 RC inpatient 5291 5291 HEALTHPARTNERS SX009 HEALTHPARTNERS 4189.41 percent of total billed charges 3280.42 5026.45 Technical (Hospital) Services Ref Brca1/Brca2 Full Gene Analysis PX-3108116200 CDM 81162 CPT 310 RC inpatient 5291 5291 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES EPO [308136803] 4189.41 percent of total billed charges 3280.42 5026.45 Technical (Hospital) Services Drug Screen Collection Only PX-3078109900 CDM 81099 CPT 307 RC outpatient 55 55 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES EPO [308136803] 44 percent of total billed charges 34.1 52.25 Technical (Hospital) Services Drug Screen Collection Only PX-3078109900 CDM 81099 CPT 307 RC outpatient 55 55 CIGNA 62308 [3081051] CIGNA 62308 [308105105] 44 percent of total billed charges 34.1 52.25 Technical (Hospital) Services Drug Screen Collection Only PX-3078109900 CDM 81099 CPT 307 RC outpatient 55 55 CIGNA 62308 [3081051] CIGNA STATE OF WYOMING [308105107] 44 percent of total billed charges 34.1 52.25 Technical (Hospital) Services Drug Screen Collection Only PX-3078109900 CDM 81099 CPT 307 RC outpatient 55 55 BLUE CROSS BLUE SHIELD WELLMARK SB889 [3081026] BCBS WYOMING [308102603] 52.25 percent of total billed charges 34.1 52.25 Technical (Hospital) Services Drug Screen Collection Only PX-3078109900 CDM 81099 CPT 307 RC outpatient 55 55 MULTIPLAN INC 34080 [3081285] MULTIPLAN INC [308128501] 52.25 percent of total billed charges 34.1 52.25 Technical (Hospital) Services Drug Screen Collection Only PX-3078109900 CDM 81099 CPT 307 RC outpatient 55 55 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES HDHP [308136802] 44 percent of total billed charges 34.1 52.25 Technical (Hospital) Services Drug Screen Collection Only PX-3078109900 CDM 81099 CPT 307 RC outpatient 55 55 UNITED HEALTHCARE (COMMERCIAL) [3081199] UNITED HEALTHCARE 87726 [308119901] 34.1 percent of total billed charges 34.1 52.25 Technical (Hospital) Services Drug Screen Collection Only PX-3078109900 CDM 81099 CPT 307 RC outpatient 55 55 MEDICA (COMMERCIAL) 94265 [3081118] MEDICA CLAIMS [308111801] 49.5 percent of total billed charges 34.1 52.25 Technical (Hospital) Services Drug Screen Collection Only PX-3078109900 CDM 81099 CPT 307 RC outpatient 55 55 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES PPO [308136801] 44 percent of total billed charges 34.1 52.25 Technical (Hospital) Services Drug Screen Collection Only PX-3078109900 CDM 81099 CPT 307 RC outpatient 55 55 HEALTHPARTNERS SX009 HEALTHPARTNERS 44 percent of total billed charges 34.1 52.25 Technical (Hospital) Services Drug Screen Collection Only PX-3078109900 CDM 81099 CPT 307 RC inpatient 55 55 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES PPO [308136801] 43.55 percent of total billed charges 34.1 52.25 Technical (Hospital) Services Drug Screen Collection Only PX-3078109900 CDM 81099 CPT 307 RC inpatient 55 55 MEDICA (COMMERCIAL) 94265 [3081118] MEDICA CLAIMS [308111801] 49.5 percent of total billed charges 34.1 52.25 Technical (Hospital) Services Drug Screen Collection Only PX-3078109900 CDM 81099 CPT 307 RC inpatient 55 55 UNITED HEALTHCARE (COMMERCIAL) [3081199] UNITED HEALTHCARE 87726 [308119901] 34.1 percent of total billed charges 34.1 52.25 Technical (Hospital) Services Drug Screen Collection Only PX-3078109900 CDM 81099 CPT 307 RC inpatient 55 55 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES HDHP [308136802] 43.55 percent of total billed charges 34.1 52.25 Technical (Hospital) Services Drug Screen Collection Only PX-3078109900 CDM 81099 CPT 307 RC inpatient 55 55 MULTIPLAN INC 34080 [3081285] MULTIPLAN INC [308128501] 52.25 percent of total billed charges 34.1 52.25 Technical (Hospital) Services Drug Screen Collection Only PX-3078109900 CDM 81099 CPT 307 RC inpatient 55 55 HEALTHPARTNERS SX009 HEALTHPARTNERS 43.55 percent of total billed charges 34.1 52.25 Technical (Hospital) Services Drug Screen Collection Only PX-3078109900 CDM 81099 CPT 307 RC inpatient 55 55 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES EPO [308136803] 43.55 percent of total billed charges 34.1 52.25 Technical (Hospital) Services Drug Screen Collection Only PX-3078109900 CDM 81099 CPT 307 RC inpatient 55 55 BLUE CROSS BLUE SHIELD WELLMARK SB889 [3081026] BCBS WYOMING [308102603] 52.25 percent of total billed charges 34.1 52.25 Technical (Hospital) Services Drug Screen Collection Only PX-3078109900 CDM 81099 CPT 307 RC inpatient 55 55 CIGNA 62308 [3081051] CIGNA 62308 [308105105] 43.55 percent of total billed charges 34.1 52.25 Technical (Hospital) Services Drug Screen Collection Only PX-3078109900 CDM 81099 CPT 307 RC inpatient 55 55 CIGNA 62308 [3081051] CIGNA STATE OF WYOMING [308105107] 43.55 percent of total billed charges 34.1 52.25 Technical (Hospital) Services Hcg Urine Waived PX-3078102500 CDM 81025 CPT 307 RC outpatient 104 104 BLUE CROSS BLUE SHIELD WELLMARK SB889 [3081026] BCBS WYOMING [308102603] 98.8 percent of total billed charges 64.48 98.8 Technical (Hospital) Services Hcg Urine Waived PX-3078102500 CDM 81025 CPT 307 RC outpatient 104 104 UNITED HEALTHCARE (COMMERCIAL) [3081199] UNITED HEALTHCARE 87726 [308119901] 64.48 percent of total billed charges 64.48 98.8 Technical (Hospital) Services Hcg Urine Waived PX-3078102500 CDM 81025 CPT 307 RC outpatient 104 104 MULTIPLAN INC 34080 [3081285] MULTIPLAN INC [308128501] 98.8 percent of total billed charges 64.48 98.8 Technical (Hospital) Services Hcg Urine Waived PX-3078102500 CDM 81025 CPT 307 RC outpatient 104 104 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES HDHP [308136802] 83.2 percent of total billed charges 64.48 98.8 Technical (Hospital) Services Hcg Urine Waived PX-3078102500 CDM 81025 CPT 307 RC outpatient 104 104 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES EPO [308136803] 83.2 percent of total billed charges 64.48 98.8 Technical (Hospital) Services Hcg Urine Waived PX-3078102500 CDM 81025 CPT 307 RC outpatient 104 104 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES PPO [308136801] 83.2 percent of total billed charges 64.48 98.8 Technical (Hospital) Services Hcg Urine Waived PX-3078102500 CDM 81025 CPT 307 RC outpatient 104 104 HEALTHPARTNERS SX009 HEALTHPARTNERS 83.2 percent of total billed charges 64.48 98.8 Technical (Hospital) Services Hcg Urine Waived PX-3078102500 CDM 81025 CPT 307 RC outpatient 104 104 CIGNA 62308 [3081051] CIGNA 62308 [308105105] 83.2 percent of total billed charges 64.48 98.8 Technical (Hospital) Services Hcg Urine Waived PX-3078102500 CDM 81025 CPT 307 RC outpatient 104 104 CIGNA 62308 [3081051] CIGNA STATE OF WYOMING [308105107] 83.2 percent of total billed charges 64.48 98.8 Technical (Hospital) Services Hcg Urine Waived PX-3078102500 CDM 81025 CPT 307 RC outpatient 104 104 MEDICA (COMMERCIAL) 94265 [3081118] MEDICA CLAIMS [308111801] 93.6 percent of total billed charges 64.48 98.8 Technical (Hospital) Services Hcg Urine Waived PX-3078102500 CDM 81025 CPT 307 RC inpatient 104 104 CIGNA 62308 [3081051] CIGNA 62308 [308105105] 82.35 percent of total billed charges 64.48 98.8 Technical (Hospital) Services Hcg Urine Waived PX-3078102500 CDM 81025 CPT 307 RC inpatient 104 104 CIGNA 62308 [3081051] CIGNA STATE OF WYOMING [308105107] 82.35 percent of total billed charges 64.48 98.8 Technical (Hospital) Services Hcg Urine Waived PX-3078102500 CDM 81025 CPT 307 RC inpatient 104 104 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES EPO [308136803] 82.35 percent of total billed charges 64.48 98.8 Technical (Hospital) Services Hcg Urine Waived PX-3078102500 CDM 81025 CPT 307 RC inpatient 104 104 UNITED HEALTHCARE (COMMERCIAL) [3081199] UNITED HEALTHCARE 87726 [308119901] 64.48 percent of total billed charges 64.48 98.8 Technical (Hospital) Services Hcg Urine Waived PX-3078102500 CDM 81025 CPT 307 RC inpatient 104 104 BLUE CROSS BLUE SHIELD WELLMARK SB889 [3081026] BCBS WYOMING [308102603] 98.8 percent of total billed charges 64.48 98.8 Technical (Hospital) Services Hcg Urine Waived PX-3078102500 CDM 81025 CPT 307 RC inpatient 104 104 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES PPO [308136801] 82.35 percent of total billed charges 64.48 98.8 Technical (Hospital) Services Hcg Urine Waived PX-3078102500 CDM 81025 CPT 307 RC inpatient 104 104 MULTIPLAN INC 34080 [3081285] MULTIPLAN INC [308128501] 98.8 percent of total billed charges 64.48 98.8 Technical (Hospital) Services Hcg Urine Waived PX-3078102500 CDM 81025 CPT 307 RC inpatient 104 104 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES HDHP [308136802] 82.35 percent of total billed charges 64.48 98.8 Technical (Hospital) Services Hcg Urine Waived PX-3078102500 CDM 81025 CPT 307 RC inpatient 104 104 MEDICA (COMMERCIAL) 94265 [3081118] MEDICA CLAIMS [308111801] 93.6 percent of total billed charges 64.48 98.8 Technical (Hospital) Services Hcg Urine Waived PX-3078102500 CDM 81025 CPT 307 RC inpatient 104 104 HEALTHPARTNERS SX009 HEALTHPARTNERS 82.35 percent of total billed charges 64.48 98.8 Technical (Hospital) Services Hcg Urine PX-3078102501 CDM 81025 CPT 307 RC inpatient 104 104 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES PPO [308136801] 82.35 percent of total billed charges 64.48 98.8 Technical (Hospital) Services Hcg Urine PX-3078102501 CDM 81025 CPT 307 RC inpatient 104 104 UNITED HEALTHCARE (COMMERCIAL) [3081199] UNITED HEALTHCARE 87726 [308119901] 64.48 percent of total billed charges 64.48 98.8 Technical (Hospital) Services Hcg Urine PX-3078102501 CDM 81025 CPT 307 RC inpatient 104 104 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES HDHP [308136802] 82.35 percent of total billed charges 64.48 98.8 Technical (Hospital) Services Hcg Urine PX-3078102501 CDM 81025 CPT 307 RC inpatient 104 104 MEDICA (COMMERCIAL) 94265 [3081118] MEDICA CLAIMS [308111801] 93.6 percent of total billed charges 64.48 98.8 Technical (Hospital) Services Hcg Urine PX-3078102501 CDM 81025 CPT 307 RC inpatient 104 104 MULTIPLAN INC 34080 [3081285] MULTIPLAN INC [308128501] 98.8 percent of total billed charges 64.48 98.8 Technical (Hospital) Services Hcg Urine PX-3078102501 CDM 81025 CPT 307 RC inpatient 104 104 CIGNA 62308 [3081051] CIGNA 62308 [308105105] 82.35 percent of total billed charges 64.48 98.8 Technical (Hospital) Services Hcg Urine PX-3078102501 CDM 81025 CPT 307 RC inpatient 104 104 CIGNA 62308 [3081051] CIGNA STATE OF WYOMING [308105107] 82.35 percent of total billed charges 64.48 98.8 Technical (Hospital) Services Hcg Urine PX-3078102501 CDM 81025 CPT 307 RC inpatient 104 104 BLUE CROSS BLUE SHIELD WELLMARK SB889 [3081026] BCBS WYOMING [308102603] 98.8 percent of total billed charges 64.48 98.8 Technical (Hospital) Services Hcg Urine PX-3078102501 CDM 81025 CPT 307 RC inpatient 104 104 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES EPO [308136803] 82.35 percent of total billed charges 64.48 98.8 Technical (Hospital) Services Hcg Urine PX-3078102501 CDM 81025 CPT 307 RC inpatient 104 104 HEALTHPARTNERS SX009 HEALTHPARTNERS 82.35 percent of total billed charges 64.48 98.8 Technical (Hospital) Services Hcg Urine PX-3078102501 CDM 81025 CPT 307 RC outpatient 104 104 BLUE CROSS BLUE SHIELD WELLMARK SB889 [3081026] BCBS WYOMING [308102603] 98.8 percent of total billed charges 64.48 98.8 Technical (Hospital) Services Hcg Urine PX-3078102501 CDM 81025 CPT 307 RC outpatient 104 104 MULTIPLAN INC 34080 [3081285] MULTIPLAN INC [308128501] 98.8 percent of total billed charges 64.48 98.8 Technical (Hospital) Services Hcg Urine PX-3078102501 CDM 81025 CPT 307 RC outpatient 104 104 CIGNA 62308 [3081051] CIGNA 62308 [308105105] 83.2 percent of total billed charges 64.48 98.8 Technical (Hospital) Services Hcg Urine PX-3078102501 CDM 81025 CPT 307 RC outpatient 104 104 CIGNA 62308 [3081051] CIGNA STATE OF WYOMING [308105107] 83.2 percent of total billed charges 64.48 98.8 Technical (Hospital) Services Hcg Urine PX-3078102501 CDM 81025 CPT 307 RC outpatient 104 104 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES EPO [308136803] 83.2 percent of total billed charges 64.48 98.8 Technical (Hospital) Services Hcg Urine PX-3078102501 CDM 81025 CPT 307 RC outpatient 104 104 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES HDHP [308136802] 83.2 percent of total billed charges 64.48 98.8 Technical (Hospital) Services Hcg Urine PX-3078102501 CDM 81025 CPT 307 RC outpatient 104 104 UNITED HEALTHCARE (COMMERCIAL) [3081199] UNITED HEALTHCARE 87726 [308119901] 64.48 percent of total billed charges 64.48 98.8 Technical (Hospital) Services Hcg Urine PX-3078102501 CDM 81025 CPT 307 RC outpatient 104 104 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES PPO [308136801] 83.2 percent of total billed charges 64.48 98.8 Technical (Hospital) Services Hcg Urine PX-3078102501 CDM 81025 CPT 307 RC outpatient 104 104 HEALTHPARTNERS SX009 HEALTHPARTNERS 83.2 percent of total billed charges 64.48 98.8 Technical (Hospital) Services Hcg Urine PX-3078102501 CDM 81025 CPT 307 RC outpatient 104 104 MEDICA (COMMERCIAL) 94265 [3081118] MEDICA CLAIMS [308111801] 93.6 percent of total billed charges 64.48 98.8 Technical (Hospital) Services Urine Microscopic Only PX-3078101500 CDM 81015 CPT 307 RC outpatient 37 37 MEDICA (COMMERCIAL) 94265 [3081118] MEDICA CLAIMS [308111801] 33.3 percent of total billed charges 22.94 35.15 Technical (Hospital) Services Urine Microscopic Only PX-3078101500 CDM 81015 CPT 307 RC outpatient 37 37 UNITED HEALTHCARE (COMMERCIAL) [3081199] UNITED HEALTHCARE 87726 [308119901] 22.94 percent of total billed charges 22.94 35.15 Technical (Hospital) Services Urine Microscopic Only PX-3078101500 CDM 81015 CPT 307 RC outpatient 37 37 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES PPO [308136801] 29.6 percent of total billed charges 22.94 35.15 Technical (Hospital) Services Urine Microscopic Only PX-3078101500 CDM 81015 CPT 307 RC outpatient 37 37 HEALTHPARTNERS SX009 HEALTHPARTNERS 29.6 percent of total billed charges 22.94 35.15 Technical (Hospital) Services Urine Microscopic Only PX-3078101500 CDM 81015 CPT 307 RC outpatient 37 37 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES EPO [308136803] 29.6 percent of total billed charges 22.94 35.15 Technical (Hospital) Services Urine Microscopic Only PX-3078101500 CDM 81015 CPT 307 RC outpatient 37 37 MULTIPLAN INC 34080 [3081285] MULTIPLAN INC [308128501] 35.15 percent of total billed charges 22.94 35.15 Technical (Hospital) Services Urine Microscopic Only PX-3078101500 CDM 81015 CPT 307 RC outpatient 37 37 CIGNA 62308 [3081051] CIGNA 62308 [308105105] 29.6 percent of total billed charges 22.94 35.15 Technical (Hospital) Services Urine Microscopic Only PX-3078101500 CDM 81015 CPT 307 RC outpatient 37 37 CIGNA 62308 [3081051] CIGNA STATE OF WYOMING [308105107] 29.6 percent of total billed charges 22.94 35.15 Technical (Hospital) Services Urine Microscopic Only PX-3078101500 CDM 81015 CPT 307 RC outpatient 37 37 BLUE CROSS BLUE SHIELD WELLMARK SB889 [3081026] BCBS WYOMING [308102603] 35.15 percent of total billed charges 22.94 35.15 Technical (Hospital) Services Urine Microscopic Only PX-3078101500 CDM 81015 CPT 307 RC outpatient 37 37 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES HDHP [308136802] 29.6 percent of total billed charges 22.94 35.15 Technical (Hospital) Services Urine Microscopic Only PX-3078101500 CDM 81015 CPT 307 RC inpatient 37 37 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES EPO [308136803] 29.3 percent of total billed charges 22.94 35.15 Technical (Hospital) Services Urine Microscopic Only PX-3078101500 CDM 81015 CPT 307 RC inpatient 37 37 HEALTHPARTNERS SX009 HEALTHPARTNERS 29.3 percent of total billed charges 22.94 35.15 Technical (Hospital) Services Urine Microscopic Only PX-3078101500 CDM 81015 CPT 307 RC inpatient 37 37 BLUE CROSS BLUE SHIELD WELLMARK SB889 [3081026] BCBS WYOMING [308102603] 35.15 percent of total billed charges 22.94 35.15 Technical (Hospital) Services Urine Microscopic Only PX-3078101500 CDM 81015 CPT 307 RC inpatient 37 37 CIGNA 62308 [3081051] CIGNA 62308 [308105105] 29.3 percent of total billed charges 22.94 35.15 Technical (Hospital) Services Urine Microscopic Only PX-3078101500 CDM 81015 CPT 307 RC inpatient 37 37 CIGNA 62308 [3081051] CIGNA STATE OF WYOMING [308105107] 29.3 percent of total billed charges 22.94 35.15 Technical (Hospital) Services Urine Microscopic Only PX-3078101500 CDM 81015 CPT 307 RC inpatient 37 37 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES PPO [308136801] 29.3 percent of total billed charges 22.94 35.15 Technical (Hospital) Services Urine Microscopic Only PX-3078101500 CDM 81015 CPT 307 RC inpatient 37 37 UNITED HEALTHCARE (COMMERCIAL) [3081199] UNITED HEALTHCARE 87726 [308119901] 22.94 percent of total billed charges 22.94 35.15 Technical (Hospital) Services Urine Microscopic Only PX-3078101500 CDM 81015 CPT 307 RC inpatient 37 37 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES HDHP [308136802] 29.3 percent of total billed charges 22.94 35.15 Technical (Hospital) Services Urine Microscopic Only PX-3078101500 CDM 81015 CPT 307 RC inpatient 37 37 MEDICA (COMMERCIAL) 94265 [3081118] MEDICA CLAIMS [308111801] 33.3 percent of total billed charges 22.94 35.15 Technical (Hospital) Services Urine Microscopic Only PX-3078101500 CDM 81015 CPT 307 RC inpatient 37 37 MULTIPLAN INC 34080 [3081285] MULTIPLAN INC [308128501] 35.15 percent of total billed charges 22.94 35.15 Technical (Hospital) Services Urine Auto WO Micro Waived PX-3078100300 CDM 81003 CPT 307 RC inpatient 37 37 HEALTHPARTNERS SX009 HEALTHPARTNERS 29.3 percent of total billed charges 22.94 35.15 Technical (Hospital) Services Urine Auto WO Micro Waived PX-3078100300 CDM 81003 CPT 307 RC inpatient 37 37 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES HDHP [308136802] 29.3 percent of total billed charges 22.94 35.15 Technical (Hospital) Services Urine Auto WO Micro Waived PX-3078100300 CDM 81003 CPT 307 RC inpatient 37 37 MEDICA (COMMERCIAL) 94265 [3081118] MEDICA CLAIMS [308111801] 33.3 percent of total billed charges 22.94 35.15 Technical (Hospital) Services Urine Auto WO Micro Waived PX-3078100300 CDM 81003 CPT 307 RC inpatient 37 37 MULTIPLAN INC 34080 [3081285] MULTIPLAN INC [308128501] 35.15 percent of total billed charges 22.94 35.15 Technical (Hospital) Services Urine Auto WO Micro Waived PX-3078100300 CDM 81003 CPT 307 RC inpatient 37 37 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES PPO [308136801] 29.3 percent of total billed charges 22.94 35.15 Technical (Hospital) Services Urine Auto WO Micro Waived PX-3078100300 CDM 81003 CPT 307 RC inpatient 37 37 BLUE CROSS BLUE SHIELD WELLMARK SB889 [3081026] BCBS WYOMING [308102603] 35.15 percent of total billed charges 22.94 35.15 Technical (Hospital) Services Urine Auto WO Micro Waived PX-3078100300 CDM 81003 CPT 307 RC inpatient 37 37 UNITED HEALTHCARE (COMMERCIAL) [3081199] UNITED HEALTHCARE 87726 [308119901] 22.94 percent of total billed charges 22.94 35.15 Technical (Hospital) Services Urine Auto WO Micro Waived PX-3078100300 CDM 81003 CPT 307 RC inpatient 37 37 CIGNA 62308 [3081051] CIGNA 62308 [308105105] 29.3 percent of total billed charges 22.94 35.15 Technical (Hospital) Services Urine Auto WO Micro Waived PX-3078100300 CDM 81003 CPT 307 RC inpatient 37 37 CIGNA 62308 [3081051] CIGNA STATE OF WYOMING [308105107] 29.3 percent of total billed charges 22.94 35.15 Technical (Hospital) Services Urine Auto WO Micro Waived PX-3078100300 CDM 81003 CPT 307 RC inpatient 37 37 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES EPO [308136803] 29.3 percent of total billed charges 22.94 35.15 Technical (Hospital) Services Urine Auto WO Micro Waived PX-3078100300 CDM 81003 CPT 307 RC outpatient 37 37 MULTIPLAN INC 34080 [3081285] MULTIPLAN INC [308128501] 35.15 percent of total billed charges 22.94 35.15 Technical (Hospital) Services Urine Auto WO Micro Waived PX-3078100300 CDM 81003 CPT 307 RC outpatient 37 37 BLUE CROSS BLUE SHIELD WELLMARK SB889 [3081026] BCBS WYOMING [308102603] 35.15 percent of total billed charges 22.94 35.15 Technical (Hospital) Services Urine Auto WO Micro Waived PX-3078100300 CDM 81003 CPT 307 RC outpatient 37 37 UNITED HEALTHCARE (COMMERCIAL) [3081199] UNITED HEALTHCARE 87726 [308119901] 22.94 percent of total billed charges 22.94 35.15 Technical (Hospital) Services Urine Auto WO Micro Waived PX-3078100300 CDM 81003 CPT 307 RC outpatient 37 37 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES HDHP [308136802] 29.6 percent of total billed charges 22.94 35.15 Technical (Hospital) Services Urine Auto WO Micro Waived PX-3078100300 CDM 81003 CPT 307 RC outpatient 37 37 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES PPO [308136801] 29.6 percent of total billed charges 22.94 35.15 Technical (Hospital) Services Urine Auto WO Micro Waived PX-3078100300 CDM 81003 CPT 307 RC outpatient 37 37 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES EPO [308136803] 29.6 percent of total billed charges 22.94 35.15 Technical (Hospital) Services Urine Auto WO Micro Waived PX-3078100300 CDM 81003 CPT 307 RC outpatient 37 37 HEALTHPARTNERS SX009 HEALTHPARTNERS 29.6 percent of total billed charges 22.94 35.15 Technical (Hospital) Services Urine Auto WO Micro Waived PX-3078100300 CDM 81003 CPT 307 RC outpatient 37 37 MEDICA (COMMERCIAL) 94265 [3081118] MEDICA CLAIMS [308111801] 33.3 percent of total billed charges 22.94 35.15 Technical (Hospital) Services Urine Auto WO Micro Waived PX-3078100300 CDM 81003 CPT 307 RC outpatient 37 37 CIGNA 62308 [3081051] CIGNA 62308 [308105105] 29.6 percent of total billed charges 22.94 35.15 Technical (Hospital) Services Urine Auto WO Micro Waived PX-3078100300 CDM 81003 CPT 307 RC outpatient 37 37 CIGNA 62308 [3081051] CIGNA STATE OF WYOMING [308105107] 29.6 percent of total billed charges 22.94 35.15 Technical (Hospital) Services Urine Auto WO Micro PX-3078100301 CDM 81003 CPT 307 RC inpatient 37 37 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES EPO [308136803] 29.3 percent of total billed charges 22.94 35.15 Technical (Hospital) Services Urine Auto WO Micro PX-3078100301 CDM 81003 CPT 307 RC inpatient 37 37 HEALTHPARTNERS SX009 HEALTHPARTNERS 29.3 percent of total billed charges 22.94 35.15 Technical (Hospital) Services Urine Auto WO Micro PX-3078100301 CDM 81003 CPT 307 RC inpatient 37 37 BLUE CROSS BLUE SHIELD WELLMARK SB889 [3081026] BCBS WYOMING [308102603] 35.15 percent of total billed charges 22.94 35.15 Technical (Hospital) Services Urine Auto WO Micro PX-3078100301 CDM 81003 CPT 307 RC inpatient 37 37 CIGNA 62308 [3081051] CIGNA 62308 [308105105] 29.3 percent of total billed charges 22.94 35.15 Technical (Hospital) Services Urine Auto WO Micro PX-3078100301 CDM 81003 CPT 307 RC inpatient 37 37 CIGNA 62308 [3081051] CIGNA STATE OF WYOMING [308105107] 29.3 percent of total billed charges 22.94 35.15 Technical (Hospital) Services Urine Auto WO Micro PX-3078100301 CDM 81003 CPT 307 RC inpatient 37 37 MEDICA (COMMERCIAL) 94265 [3081118] MEDICA CLAIMS [308111801] 33.3 percent of total billed charges 22.94 35.15 Technical (Hospital) Services Urine Auto WO Micro PX-3078100301 CDM 81003 CPT 307 RC inpatient 37 37 UNITED HEALTHCARE (COMMERCIAL) [3081199] UNITED HEALTHCARE 87726 [308119901] 22.94 percent of total billed charges 22.94 35.15 Technical (Hospital) Services Urine Auto WO Micro PX-3078100301 CDM 81003 CPT 307 RC inpatient 37 37 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES HDHP [308136802] 29.3 percent of total billed charges 22.94 35.15 Technical (Hospital) Services Urine Auto WO Micro PX-3078100301 CDM 81003 CPT 307 RC inpatient 37 37 MULTIPLAN INC 34080 [3081285] MULTIPLAN INC [308128501] 35.15 percent of total billed charges 22.94 35.15 Technical (Hospital) Services Urine Auto WO Micro PX-3078100301 CDM 81003 CPT 307 RC inpatient 37 37 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES PPO [308136801] 29.3 percent of total billed charges 22.94 35.15 Technical (Hospital) Services Urine Auto WO Micro PX-3078100301 CDM 81003 CPT 307 RC outpatient 37 37 BLUE CROSS BLUE SHIELD WELLMARK SB889 [3081026] BCBS WYOMING [308102603] 35.15 percent of total billed charges 22.94 35.15 Technical (Hospital) Services Urine Auto WO Micro PX-3078100301 CDM 81003 CPT 307 RC outpatient 37 37 MULTIPLAN INC 34080 [3081285] MULTIPLAN INC [308128501] 35.15 percent of total billed charges 22.94 35.15 Technical (Hospital) Services Urine Auto WO Micro PX-3078100301 CDM 81003 CPT 307 RC outpatient 37 37 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES HDHP [308136802] 29.6 percent of total billed charges 22.94 35.15 Technical (Hospital) Services Urine Auto WO Micro PX-3078100301 CDM 81003 CPT 307 RC outpatient 37 37 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES EPO [308136803] 29.6 percent of total billed charges 22.94 35.15 Technical (Hospital) Services Urine Auto WO Micro PX-3078100301 CDM 81003 CPT 307 RC outpatient 37 37 CIGNA 62308 [3081051] CIGNA 62308 [308105105] 29.6 percent of total billed charges 22.94 35.15 Technical (Hospital) Services Urine Auto WO Micro PX-3078100301 CDM 81003 CPT 307 RC outpatient 37 37 CIGNA 62308 [3081051] CIGNA STATE OF WYOMING [308105107] 29.6 percent of total billed charges 22.94 35.15 Technical (Hospital) Services Urine Auto WO Micro PX-3078100301 CDM 81003 CPT 307 RC outpatient 37 37 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES PPO [308136801] 29.6 percent of total billed charges 22.94 35.15 Technical (Hospital) Services Urine Auto WO Micro PX-3078100301 CDM 81003 CPT 307 RC outpatient 37 37 HEALTHPARTNERS SX009 HEALTHPARTNERS 29.6 percent of total billed charges 22.94 35.15 Technical (Hospital) Services Urine Auto WO Micro PX-3078100301 CDM 81003 CPT 307 RC outpatient 37 37 UNITED HEALTHCARE (COMMERCIAL) [3081199] UNITED HEALTHCARE 87726 [308119901] 22.94 percent of total billed charges 22.94 35.15 Technical (Hospital) Services Urine Auto WO Micro PX-3078100301 CDM 81003 CPT 307 RC outpatient 37 37 MEDICA (COMMERCIAL) 94265 [3081118] MEDICA CLAIMS [308111801] 33.3 percent of total billed charges 22.94 35.15 Technical (Hospital) Services Urine Dip POC PX-3078100200 CDM 81002 CPT 307 RC outpatient 37 37 UNITED HEALTHCARE (COMMERCIAL) [3081199] UNITED HEALTHCARE 87726 [308119901] 22.94 percent of total billed charges 22.94 35.15 Technical (Hospital) Services Urine Dip POC PX-3078100200 CDM 81002 CPT 307 RC outpatient 37 37 HEALTHPARTNERS SX009 HEALTHPARTNERS 29.6 percent of total billed charges 22.94 35.15 Technical (Hospital) Services Urine Dip POC PX-3078100200 CDM 81002 CPT 307 RC outpatient 37 37 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES PPO [308136801] 29.6 percent of total billed charges 22.94 35.15 Technical (Hospital) Services Urine Dip POC PX-3078100200 CDM 81002 CPT 307 RC outpatient 37 37 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES HDHP [308136802] 29.6 percent of total billed charges 22.94 35.15 Technical (Hospital) Services Urine Dip POC PX-3078100200 CDM 81002 CPT 307 RC outpatient 37 37 BLUE CROSS BLUE SHIELD WELLMARK SB889 [3081026] BCBS WYOMING [308102603] 35.15 percent of total billed charges 22.94 35.15 Technical (Hospital) Services Urine Dip POC PX-3078100200 CDM 81002 CPT 307 RC outpatient 37 37 MULTIPLAN INC 34080 [3081285] MULTIPLAN INC [308128501] 35.15 percent of total billed charges 22.94 35.15 Technical (Hospital) Services Urine Dip POC PX-3078100200 CDM 81002 CPT 307 RC outpatient 37 37 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES EPO [308136803] 29.6 percent of total billed charges 22.94 35.15 Technical (Hospital) Services Urine Dip POC PX-3078100200 CDM 81002 CPT 307 RC outpatient 37 37 CIGNA 62308 [3081051] CIGNA 62308 [308105105] 29.6 percent of total billed charges 22.94 35.15 Technical (Hospital) Services Urine Dip POC PX-3078100200 CDM 81002 CPT 307 RC outpatient 37 37 CIGNA 62308 [3081051] CIGNA STATE OF WYOMING [308105107] 29.6 percent of total billed charges 22.94 35.15 Technical (Hospital) Services Urine Dip POC PX-3078100200 CDM 81002 CPT 307 RC outpatient 37 37 MEDICA (COMMERCIAL) 94265 [3081118] MEDICA CLAIMS [308111801] 33.3 percent of total billed charges 22.94 35.15 Technical (Hospital) Services Urine Dip POC PX-3078100200 CDM 81002 CPT 307 RC inpatient 37 37 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES PPO [308136801] 29.3 percent of total billed charges 22.94 35.15 Technical (Hospital) Services Urine Dip POC PX-3078100200 CDM 81002 CPT 307 RC inpatient 37 37 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES EPO [308136803] 29.3 percent of total billed charges 22.94 35.15 Technical (Hospital) Services Urine Dip POC PX-3078100200 CDM 81002 CPT 307 RC inpatient 37 37 HEALTHPARTNERS SX009 HEALTHPARTNERS 29.3 percent of total billed charges 22.94 35.15 Technical (Hospital) Services Urine Dip POC PX-3078100200 CDM 81002 CPT 307 RC inpatient 37 37 BLUE CROSS BLUE SHIELD WELLMARK SB889 [3081026] BCBS WYOMING [308102603] 35.15 percent of total billed charges 22.94 35.15 Technical (Hospital) Services Urine Dip POC PX-3078100200 CDM 81002 CPT 307 RC inpatient 37 37 CIGNA 62308 [3081051] CIGNA 62308 [308105105] 29.3 percent of total billed charges 22.94 35.15 Technical (Hospital) Services Urine Dip POC PX-3078100200 CDM 81002 CPT 307 RC inpatient 37 37 CIGNA 62308 [3081051] CIGNA STATE OF WYOMING [308105107] 29.3 percent of total billed charges 22.94 35.15 Technical (Hospital) Services Urine Dip POC PX-3078100200 CDM 81002 CPT 307 RC inpatient 37 37 MULTIPLAN INC 34080 [3081285] MULTIPLAN INC [308128501] 35.15 percent of total billed charges 22.94 35.15 Technical (Hospital) Services Urine Dip POC PX-3078100200 CDM 81002 CPT 307 RC inpatient 37 37 MEDICA (COMMERCIAL) 94265 [3081118] MEDICA CLAIMS [308111801] 33.3 percent of total billed charges 22.94 35.15 Technical (Hospital) Services Urine Dip POC PX-3078100200 CDM 81002 CPT 307 RC inpatient 37 37 UNITED HEALTHCARE (COMMERCIAL) [3081199] UNITED HEALTHCARE 87726 [308119901] 22.94 percent of total billed charges 22.94 35.15 Technical (Hospital) Services Urine Dip POC PX-3078100200 CDM 81002 CPT 307 RC inpatient 37 37 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES HDHP [308136802] 29.3 percent of total billed charges 22.94 35.15 Technical (Hospital) Services Urine Auto With Micro PX-3078100100 CDM 81001 CPT 307 RC inpatient 80 80 CIGNA 62308 [3081051] CIGNA 62308 [308105105] 63.34 percent of total billed charges 49.6 76 Technical (Hospital) Services Urine Auto With Micro PX-3078100100 CDM 81001 CPT 307 RC inpatient 80 80 CIGNA 62308 [3081051] CIGNA STATE OF WYOMING [308105107] 63.34 percent of total billed charges 49.6 76 Technical (Hospital) Services Urine Auto With Micro PX-3078100100 CDM 81001 CPT 307 RC inpatient 80 80 BLUE CROSS BLUE SHIELD WELLMARK SB889 [3081026] BCBS WYOMING [308102603] 76 percent of total billed charges 49.6 76 Technical (Hospital) Services Urine Auto With Micro PX-3078100100 CDM 81001 CPT 307 RC inpatient 80 80 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES EPO [308136803] 63.34 percent of total billed charges 49.6 76 Technical (Hospital) Services Urine Auto With Micro PX-3078100100 CDM 81001 CPT 307 RC inpatient 80 80 HEALTHPARTNERS SX009 HEALTHPARTNERS 63.34 percent of total billed charges 49.6 76 Technical (Hospital) Services Urine Auto With Micro PX-3078100100 CDM 81001 CPT 307 RC inpatient 80 80 MULTIPLAN INC 34080 [3081285] MULTIPLAN INC [308128501] 76 percent of total billed charges 49.6 76 Technical (Hospital) Services Urine Auto With Micro PX-3078100100 CDM 81001 CPT 307 RC inpatient 80 80 MEDICA (COMMERCIAL) 94265 [3081118] MEDICA CLAIMS [308111801] 72 percent of total billed charges 49.6 76 Technical (Hospital) Services Urine Auto With Micro PX-3078100100 CDM 81001 CPT 307 RC inpatient 80 80 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES HDHP [308136802] 63.34 percent of total billed charges 49.6 76 Technical (Hospital) Services Urine Auto With Micro PX-3078100100 CDM 81001 CPT 307 RC inpatient 80 80 UNITED HEALTHCARE (COMMERCIAL) [3081199] UNITED HEALTHCARE 87726 [308119901] 49.6 percent of total billed charges 49.6 76 Technical (Hospital) Services Urine Auto With Micro PX-3078100100 CDM 81001 CPT 307 RC inpatient 80 80 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES PPO [308136801] 63.34 percent of total billed charges 49.6 76 Technical (Hospital) Services Urine Auto With Micro PX-3078100100 CDM 81001 CPT 307 RC outpatient 80 80 UNITED HEALTHCARE (COMMERCIAL) [3081199] UNITED HEALTHCARE 87726 [308119901] 49.6 percent of total billed charges 49.6 76 Technical (Hospital) Services Urine Auto With Micro PX-3078100100 CDM 81001 CPT 307 RC outpatient 80 80 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES HDHP [308136802] 64 percent of total billed charges 49.6 76 Technical (Hospital) Services Urine Auto With Micro PX-3078100100 CDM 81001 CPT 307 RC outpatient 80 80 MULTIPLAN INC 34080 [3081285] MULTIPLAN INC [308128501] 76 percent of total billed charges 49.6 76 Technical (Hospital) Services Urine Auto With Micro PX-3078100100 CDM 81001 CPT 307 RC outpatient 80 80 BLUE CROSS BLUE SHIELD WELLMARK SB889 [3081026] BCBS WYOMING [308102603] 76 percent of total billed charges 49.6 76 Technical (Hospital) Services Urine Auto With Micro PX-3078100100 CDM 81001 CPT 307 RC outpatient 80 80 CIGNA 62308 [3081051] CIGNA 62308 [308105105] 64 percent of total billed charges 49.6 76 Technical (Hospital) Services Urine Auto With Micro PX-3078100100 CDM 81001 CPT 307 RC outpatient 80 80 CIGNA 62308 [3081051] CIGNA STATE OF WYOMING [308105107] 64 percent of total billed charges 49.6 76 Technical (Hospital) Services Urine Auto With Micro PX-3078100100 CDM 81001 CPT 307 RC outpatient 80 80 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES EPO [308136803] 64 percent of total billed charges 49.6 76 Technical (Hospital) Services Urine Auto With Micro PX-3078100100 CDM 81001 CPT 307 RC outpatient 80 80 MEDICA (COMMERCIAL) 94265 [3081118] MEDICA CLAIMS [308111801] 72 percent of total billed charges 49.6 76 Technical (Hospital) Services Urine Auto With Micro PX-3078100100 CDM 81001 CPT 307 RC outpatient 80 80 HEALTHPARTNERS SX009 HEALTHPARTNERS 64 percent of total billed charges 49.6 76 Technical (Hospital) Services Urine Auto With Micro PX-3078100100 CDM 81001 CPT 307 RC outpatient 80 80 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES PPO [308136801] 64 percent of total billed charges 49.6 76 Technical (Hospital) Services Urine Dip W Micro08012012 PX-3078100000 CDM 81000 CPT 307 RC inpatient 80 80 MEDICA (COMMERCIAL) 94265 [3081118] MEDICA CLAIMS [308111801] 72 percent of total billed charges 49.6 76 Technical (Hospital) Services Urine Dip W Micro08012012 PX-3078100000 CDM 81000 CPT 307 RC inpatient 80 80 UNITED HEALTHCARE (COMMERCIAL) [3081199] UNITED HEALTHCARE 87726 [308119901] 49.6 percent of total billed charges 49.6 76 Technical (Hospital) Services Urine Dip W Micro08012012 PX-3078100000 CDM 81000 CPT 307 RC inpatient 80 80 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES HDHP [308136802] 63.34 percent of total billed charges 49.6 76 Technical (Hospital) Services Urine Dip W Micro08012012 PX-3078100000 CDM 81000 CPT 307 RC inpatient 80 80 MULTIPLAN INC 34080 [3081285] MULTIPLAN INC [308128501] 76 percent of total billed charges 49.6 76 Technical (Hospital) Services Urine Dip W Micro08012012 PX-3078100000 CDM 81000 CPT 307 RC inpatient 80 80 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES PPO [308136801] 63.34 percent of total billed charges 49.6 76 Technical (Hospital) Services Urine Dip W Micro08012012 PX-3078100000 CDM 81000 CPT 307 RC inpatient 80 80 CIGNA 62308 [3081051] CIGNA 62308 [308105105] 63.34 percent of total billed charges 49.6 76 Technical (Hospital) Services Urine Dip W Micro08012012 PX-3078100000 CDM 81000 CPT 307 RC inpatient 80 80 CIGNA 62308 [3081051] CIGNA STATE OF WYOMING [308105107] 63.34 percent of total billed charges 49.6 76 Technical (Hospital) Services Urine Dip W Micro08012012 PX-3078100000 CDM 81000 CPT 307 RC inpatient 80 80 BLUE CROSS BLUE SHIELD WELLMARK SB889 [3081026] BCBS WYOMING [308102603] 76 percent of total billed charges 49.6 76 Technical (Hospital) Services Urine Dip W Micro08012012 PX-3078100000 CDM 81000 CPT 307 RC inpatient 80 80 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES EPO [308136803] 63.34 percent of total billed charges 49.6 76 Technical (Hospital) Services Urine Dip W Micro08012012 PX-3078100000 CDM 81000 CPT 307 RC inpatient 80 80 HEALTHPARTNERS SX009 HEALTHPARTNERS 63.34 percent of total billed charges 49.6 76 Technical (Hospital) Services Urine Dip W Micro08012012 PX-3078100000 CDM 81000 CPT 307 RC outpatient 80 80 MEDICA (COMMERCIAL) 94265 [3081118] MEDICA CLAIMS [308111801] 72 percent of total billed charges 49.6 76 Technical (Hospital) Services Urine Dip W Micro08012012 PX-3078100000 CDM 81000 CPT 307 RC outpatient 80 80 UNITED HEALTHCARE (COMMERCIAL) [3081199] UNITED HEALTHCARE 87726 [308119901] 49.6 percent of total billed charges 49.6 76 Technical (Hospital) Services Urine Dip W Micro08012012 PX-3078100000 CDM 81000 CPT 307 RC outpatient 80 80 HEALTHPARTNERS SX009 HEALTHPARTNERS 64 percent of total billed charges 49.6 76 Technical (Hospital) Services Urine Dip W Micro08012012 PX-3078100000 CDM 81000 CPT 307 RC outpatient 80 80 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES PPO [308136801] 64 percent of total billed charges 49.6 76 Technical (Hospital) Services Urine Dip W Micro08012012 PX-3078100000 CDM 81000 CPT 307 RC outpatient 80 80 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES HDHP [308136802] 64 percent of total billed charges 49.6 76 Technical (Hospital) Services Urine Dip W Micro08012012 PX-3078100000 CDM 81000 CPT 307 RC outpatient 80 80 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES EPO [308136803] 64 percent of total billed charges 49.6 76 Technical (Hospital) Services Urine Dip W Micro08012012 PX-3078100000 CDM 81000 CPT 307 RC outpatient 80 80 CIGNA 62308 [3081051] CIGNA 62308 [308105105] 64 percent of total billed charges 49.6 76 Technical (Hospital) Services Urine Dip W Micro08012012 PX-3078100000 CDM 81000 CPT 307 RC outpatient 80 80 CIGNA 62308 [3081051] CIGNA STATE OF WYOMING [308105107] 64 percent of total billed charges 49.6 76 Technical (Hospital) Services Urine Dip W Micro08012012 PX-3078100000 CDM 81000 CPT 307 RC outpatient 80 80 MULTIPLAN INC 34080 [3081285] MULTIPLAN INC [308128501] 76 percent of total billed charges 49.6 76 Technical (Hospital) Services Urine Dip W Micro08012012 PX-3078100000 CDM 81000 CPT 307 RC outpatient 80 80 BLUE CROSS BLUE SHIELD WELLMARK SB889 [3081026] BCBS WYOMING [308102603] 76 percent of total billed charges 49.6 76 Technical (Hospital) Services Acth Stimulation PX-3018040000 CDM 80400 CPT 301 RC inpatient 154 154 MEDICA (COMMERCIAL) 94265 [3081118] MEDICA CLAIMS [308111801] 138.6 percent of total billed charges 95.48 146.3 Technical (Hospital) Services Acth Stimulation PX-3018040000 CDM 80400 CPT 301 RC inpatient 154 154 HEALTHPARTNERS SX009 HEALTHPARTNERS 121.94 percent of total billed charges 95.48 146.3 Technical (Hospital) Services Acth Stimulation PX-3018040000 CDM 80400 CPT 301 RC inpatient 154 154 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES HDHP [308136802] 121.94 percent of total billed charges 95.48 146.3 Technical (Hospital) Services Acth Stimulation PX-3018040000 CDM 80400 CPT 301 RC inpatient 154 154 UNITED HEALTHCARE (COMMERCIAL) [3081199] UNITED HEALTHCARE 87726 [308119901] 95.48 percent of total billed charges 95.48 146.3 Technical (Hospital) Services Acth Stimulation PX-3018040000 CDM 80400 CPT 301 RC inpatient 154 154 BLUE CROSS BLUE SHIELD WELLMARK SB889 [3081026] BCBS WYOMING [308102603] 146.3 percent of total billed charges 95.48 146.3 Technical (Hospital) Services Acth Stimulation PX-3018040000 CDM 80400 CPT 301 RC inpatient 154 154 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES PPO [308136801] 121.94 percent of total billed charges 95.48 146.3 Technical (Hospital) Services Acth Stimulation PX-3018040000 CDM 80400 CPT 301 RC inpatient 154 154 MULTIPLAN INC 34080 [3081285] MULTIPLAN INC [308128501] 146.3 percent of total billed charges 95.48 146.3 Technical (Hospital) Services Acth Stimulation PX-3018040000 CDM 80400 CPT 301 RC inpatient 154 154 CIGNA 62308 [3081051] CIGNA 62308 [308105105] 121.94 percent of total billed charges 95.48 146.3 Technical (Hospital) Services Acth Stimulation PX-3018040000 CDM 80400 CPT 301 RC inpatient 154 154 CIGNA 62308 [3081051] CIGNA STATE OF WYOMING [308105107] 121.94 percent of total billed charges 95.48 146.3 Technical (Hospital) Services Acth Stimulation PX-3018040000 CDM 80400 CPT 301 RC inpatient 154 154 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES EPO [308136803] 121.94 percent of total billed charges 95.48 146.3 Technical (Hospital) Services Acth Stimulation PX-3018040000 CDM 80400 CPT 301 RC outpatient 154 154 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES PPO [308136801] 123.2 percent of total billed charges 95.48 146.3 Technical (Hospital) Services Acth Stimulation PX-3018040000 CDM 80400 CPT 301 RC outpatient 154 154 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES EPO [308136803] 123.2 percent of total billed charges 95.48 146.3 Technical (Hospital) Services Acth Stimulation PX-3018040000 CDM 80400 CPT 301 RC outpatient 154 154 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES HDHP [308136802] 123.2 percent of total billed charges 95.48 146.3 Technical (Hospital) Services Acth Stimulation PX-3018040000 CDM 80400 CPT 301 RC outpatient 154 154 UNITED HEALTHCARE (COMMERCIAL) [3081199] UNITED HEALTHCARE 87726 [308119901] 95.48 percent of total billed charges 95.48 146.3 Technical (Hospital) Services Acth Stimulation PX-3018040000 CDM 80400 CPT 301 RC outpatient 154 154 BLUE CROSS BLUE SHIELD WELLMARK SB889 [3081026] BCBS WYOMING [308102603] 146.3 percent of total billed charges 95.48 146.3 Technical (Hospital) Services Acth Stimulation PX-3018040000 CDM 80400 CPT 301 RC outpatient 154 154 MULTIPLAN INC 34080 [3081285] MULTIPLAN INC [308128501] 146.3 percent of total billed charges 95.48 146.3 Technical (Hospital) Services Acth Stimulation PX-3018040000 CDM 80400 CPT 301 RC outpatient 154 154 HEALTHPARTNERS SX009 HEALTHPARTNERS 123.2 percent of total billed charges 95.48 146.3 Technical (Hospital) Services Acth Stimulation PX-3018040000 CDM 80400 CPT 301 RC outpatient 154 154 MEDICA (COMMERCIAL) 94265 [3081118] MEDICA CLAIMS [308111801] 138.6 percent of total billed charges 95.48 146.3 Technical (Hospital) Services Acth Stimulation PX-3018040000 CDM 80400 CPT 301 RC outpatient 154 154 CIGNA 62308 [3081051] CIGNA 62308 [308105105] 123.2 percent of total billed charges 95.48 146.3 Technical (Hospital) Services Acth Stimulation PX-3018040000 CDM 80400 CPT 301 RC outpatient 154 154 CIGNA 62308 [3081051] CIGNA STATE OF WYOMING [308105107] 123.2 percent of total billed charges 95.48 146.3 Technical (Hospital) Services Ref Drug Subs Not Spec 7 More Pm U PX-3018037700 CDM 80377 CPT 301 RC inpatient 181 181 HEALTHPARTNERS SX009 HEALTHPARTNERS 143.32 percent of total billed charges 112.22 171.95 Technical (Hospital) Services Ref Drug Subs Not Spec 7 More Pm U PX-3018037700 CDM 80377 CPT 301 RC inpatient 181 181 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES EPO [308136803] 143.32 percent of total billed charges 112.22 171.95 Technical (Hospital) Services Ref Drug Subs Not Spec 7 More Pm U PX-3018037700 CDM 80377 CPT 301 RC inpatient 181 181 MEDICA (COMMERCIAL) 94265 [3081118] MEDICA CLAIMS [308111801] 162.9 percent of total billed charges 112.22 171.95 Technical (Hospital) Services Ref Drug Subs Not Spec 7 More Pm U PX-3018037700 CDM 80377 CPT 301 RC inpatient 181 181 UNITED HEALTHCARE (COMMERCIAL) [3081199] UNITED HEALTHCARE 87726 [308119901] 112.22 percent of total billed charges 112.22 171.95 Technical (Hospital) Services Ref Drug Subs Not Spec 7 More Pm U PX-3018037700 CDM 80377 CPT 301 RC inpatient 181 181 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES PPO [308136801] 143.32 percent of total billed charges 112.22 171.95 Technical (Hospital) Services Ref Drug Subs Not Spec 7 More Pm U PX-3018037700 CDM 80377 CPT 301 RC inpatient 181 181 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES HDHP [308136802] 143.32 percent of total billed charges 112.22 171.95 Technical (Hospital) Services Ref Drug Subs Not Spec 7 More Pm U PX-3018037700 CDM 80377 CPT 301 RC inpatient 181 181 MULTIPLAN INC 34080 [3081285] MULTIPLAN INC [308128501] 171.95 percent of total billed charges 112.22 171.95 Technical (Hospital) Services Ref Drug Subs Not Spec 7 More Pm U PX-3018037700 CDM 80377 CPT 301 RC inpatient 181 181 BLUE CROSS BLUE SHIELD WELLMARK SB889 [3081026] BCBS WYOMING [308102603] 171.95 percent of total billed charges 112.22 171.95 Technical (Hospital) Services Ref Drug Subs Not Spec 7 More Pm U PX-3018037700 CDM 80377 CPT 301 RC inpatient 181 181 CIGNA 62308 [3081051] CIGNA 62308 [308105105] 143.32 percent of total billed charges 112.22 171.95 Technical (Hospital) Services Ref Drug Subs Not Spec 7 More Pm U PX-3018037700 CDM 80377 CPT 301 RC inpatient 181 181 CIGNA 62308 [3081051] CIGNA STATE OF WYOMING [308105107] 143.32 percent of total billed charges 112.22 171.95 Technical (Hospital) Services Ref Drug Subs Not Spec 7 More Pm U PX-3018037700 CDM 80377 CPT 301 RC outpatient 181 181 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES PPO [308136801] 144.8 percent of total billed charges 112.22 171.95 Technical (Hospital) Services Ref Drug Subs Not Spec 7 More Pm U PX-3018037700 CDM 80377 CPT 301 RC outpatient 181 181 MULTIPLAN INC 34080 [3081285] MULTIPLAN INC [308128501] 171.95 percent of total billed charges 112.22 171.95 Technical (Hospital) Services Ref Drug Subs Not Spec 7 More Pm U PX-3018037700 CDM 80377 CPT 301 RC outpatient 181 181 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES HDHP [308136802] 144.8 percent of total billed charges 112.22 171.95 Technical (Hospital) Services Ref Drug Subs Not Spec 7 More Pm U PX-3018037700 CDM 80377 CPT 301 RC outpatient 181 181 BLUE CROSS BLUE SHIELD WELLMARK SB889 [3081026] BCBS WYOMING [308102603] 171.95 percent of total billed charges 112.22 171.95 Technical (Hospital) Services Ref Drug Subs Not Spec 7 More Pm U PX-3018037700 CDM 80377 CPT 301 RC outpatient 181 181 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES EPO [308136803] 144.8 percent of total billed charges 112.22 171.95 Technical (Hospital) Services Ref Drug Subs Not Spec 7 More Pm U PX-3018037700 CDM 80377 CPT 301 RC outpatient 181 181 UNITED HEALTHCARE (COMMERCIAL) [3081199] UNITED HEALTHCARE 87726 [308119901] 112.22 percent of total billed charges 112.22 171.95 Technical (Hospital) Services Ref Drug Subs Not Spec 7 More Pm U PX-3018037700 CDM 80377 CPT 301 RC outpatient 181 181 HEALTHPARTNERS SX009 HEALTHPARTNERS 144.8 percent of total billed charges 112.22 171.95 Technical (Hospital) Services Ref Drug Subs Not Spec 7 More Pm U PX-3018037700 CDM 80377 CPT 301 RC outpatient 181 181 CIGNA 62308 [3081051] CIGNA 62308 [308105105] 144.8 percent of total billed charges 112.22 171.95 Technical (Hospital) Services Ref Drug Subs Not Spec 7 More Pm U PX-3018037700 CDM 80377 CPT 301 RC outpatient 181 181 CIGNA 62308 [3081051] CIGNA STATE OF WYOMING [308105107] 144.8 percent of total billed charges 112.22 171.95 Technical (Hospital) Services Ref Drug Subs Not Spec 7 More Pm U PX-3018037700 CDM 80377 CPT 301 RC outpatient 181 181 MEDICA (COMMERCIAL) 94265 [3081118] MEDICA CLAIMS [308111801] 162.9 percent of total billed charges 112.22 171.95 Technical (Hospital) Services Ref Digitoxin Serum Plasma PX-3018037501 CDM 80375 CPT 301 RC inpatient 198 198 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES HDHP [308136802] 156.78 percent of total billed charges 122.76 188.1 Technical (Hospital) Services Ref Digitoxin Serum Plasma PX-3018037501 CDM 80375 CPT 301 RC inpatient 198 198 MULTIPLAN INC 34080 [3081285] MULTIPLAN INC [308128501] 188.1 percent of total billed charges 122.76 188.1 Technical (Hospital) Services Ref Digitoxin Serum Plasma PX-3018037501 CDM 80375 CPT 301 RC inpatient 198 198 BLUE CROSS BLUE SHIELD WELLMARK SB889 [3081026] BCBS WYOMING [308102603] 188.1 percent of total billed charges 122.76 188.1 Technical (Hospital) Services Ref Digitoxin Serum Plasma PX-3018037501 CDM 80375 CPT 301 RC inpatient 198 198 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES PPO [308136801] 156.78 percent of total billed charges 122.76 188.1 Technical (Hospital) Services Ref Digitoxin Serum Plasma PX-3018037501 CDM 80375 CPT 301 RC inpatient 198 198 UNITED HEALTHCARE (COMMERCIAL) [3081199] UNITED HEALTHCARE 87726 [308119901] 122.76 percent of total billed charges 122.76 188.1 Technical (Hospital) Services Ref Digitoxin Serum Plasma PX-3018037501 CDM 80375 CPT 301 RC inpatient 198 198 MEDICA (COMMERCIAL) 94265 [3081118] MEDICA CLAIMS [308111801] 178.2 percent of total billed charges 122.76 188.1 Technical (Hospital) Services Ref Digitoxin Serum Plasma PX-3018037501 CDM 80375 CPT 301 RC inpatient 198 198 HEALTHPARTNERS SX009 HEALTHPARTNERS 156.78 percent of total billed charges 122.76 188.1 Technical (Hospital) Services Ref Digitoxin Serum Plasma PX-3018037501 CDM 80375 CPT 301 RC inpatient 198 198 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES EPO [308136803] 156.78 percent of total billed charges 122.76 188.1 Technical (Hospital) Services Ref Digitoxin Serum Plasma PX-3018037501 CDM 80375 CPT 301 RC inpatient 198 198 CIGNA 62308 [3081051] CIGNA 62308 [308105105] 156.78 percent of total billed charges 122.76 188.1 Technical (Hospital) Services Ref Digitoxin Serum Plasma PX-3018037501 CDM 80375 CPT 301 RC inpatient 198 198 CIGNA 62308 [3081051] CIGNA STATE OF WYOMING [308105107] 156.78 percent of total billed charges 122.76 188.1 Technical (Hospital) Services Ref Digitoxin Serum Plasma PX-3018037501 CDM 80375 CPT 301 RC outpatient 198 198 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES PPO [308136801] 158.4 percent of total billed charges 122.76 188.1 Technical (Hospital) Services Ref Digitoxin Serum Plasma PX-3018037501 CDM 80375 CPT 301 RC outpatient 198 198 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES EPO [308136803] 158.4 percent of total billed charges 122.76 188.1 Technical (Hospital) Services Ref Digitoxin Serum Plasma PX-3018037501 CDM 80375 CPT 301 RC outpatient 198 198 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES HDHP [308136802] 158.4 percent of total billed charges 122.76 188.1 Technical (Hospital) Services Ref Digitoxin Serum Plasma PX-3018037501 CDM 80375 CPT 301 RC outpatient 198 198 BLUE CROSS BLUE SHIELD WELLMARK SB889 [3081026] BCBS WYOMING [308102603] 188.1 percent of total billed charges 122.76 188.1 Technical (Hospital) Services Ref Digitoxin Serum Plasma PX-3018037501 CDM 80375 CPT 301 RC outpatient 198 198 MULTIPLAN INC 34080 [3081285] MULTIPLAN INC [308128501] 188.1 percent of total billed charges 122.76 188.1 Technical (Hospital) Services Ref Digitoxin Serum Plasma PX-3018037501 CDM 80375 CPT 301 RC outpatient 198 198 UNITED HEALTHCARE (COMMERCIAL) [3081199] UNITED HEALTHCARE 87726 [308119901] 122.76 percent of total billed charges 122.76 188.1 Technical (Hospital) Services Ref Digitoxin Serum Plasma PX-3018037501 CDM 80375 CPT 301 RC outpatient 198 198 HEALTHPARTNERS SX009 HEALTHPARTNERS 158.4 percent of total billed charges 122.76 188.1 Technical (Hospital) Services Ref Digitoxin Serum Plasma PX-3018037501 CDM 80375 CPT 301 RC outpatient 198 198 CIGNA 62308 [3081051] CIGNA 62308 [308105105] 158.4 percent of total billed charges 122.76 188.1 Technical (Hospital) Services Ref Digitoxin Serum Plasma PX-3018037501 CDM 80375 CPT 301 RC outpatient 198 198 CIGNA 62308 [3081051] CIGNA STATE OF WYOMING [308105107] 158.4 percent of total billed charges 122.76 188.1 Technical (Hospital) Services Ref Digitoxin Serum Plasma PX-3018037501 CDM 80375 CPT 301 RC outpatient 198 198 MEDICA (COMMERCIAL) 94265 [3081118] MEDICA CLAIMS [308111801] 178.2 percent of total billed charges 122.76 188.1 Technical (Hospital) Services Ref Oxycodone Conf PX-3018036500 CDM 80365 CPT 301 RC inpatient 99 99 HEALTHPARTNERS SX009 HEALTHPARTNERS 78.39 percent of total billed charges 61.38 94.05 Technical (Hospital) Services Ref Oxycodone Conf PX-3018036500 CDM 80365 CPT 301 RC inpatient 99 99 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES EPO [308136803] 78.39 percent of total billed charges 61.38 94.05 Technical (Hospital) Services Ref Oxycodone Conf PX-3018036500 CDM 80365 CPT 301 RC inpatient 99 99 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES HDHP [308136802] 78.39 percent of total billed charges 61.38 94.05 Technical (Hospital) Services Ref Oxycodone Conf PX-3018036500 CDM 80365 CPT 301 RC inpatient 99 99 MEDICA (COMMERCIAL) 94265 [3081118] MEDICA CLAIMS [308111801] 89.1 percent of total billed charges 61.38 94.05 Technical (Hospital) Services Ref Oxycodone Conf PX-3018036500 CDM 80365 CPT 301 RC inpatient 99 99 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES PPO [308136801] 78.39 percent of total billed charges 61.38 94.05 Technical (Hospital) Services Ref Oxycodone Conf PX-3018036500 CDM 80365 CPT 301 RC inpatient 99 99 UNITED HEALTHCARE (COMMERCIAL) [3081199] UNITED HEALTHCARE 87726 [308119901] 61.38 percent of total billed charges 61.38 94.05 Technical (Hospital) Services Ref Oxycodone Conf PX-3018036500 CDM 80365 CPT 301 RC inpatient 99 99 MULTIPLAN INC 34080 [3081285] MULTIPLAN INC [308128501] 94.05 percent of total billed charges 61.38 94.05 Technical (Hospital) Services Ref Oxycodone Conf PX-3018036500 CDM 80365 CPT 301 RC inpatient 99 99 BLUE CROSS BLUE SHIELD WELLMARK SB889 [3081026] BCBS WYOMING [308102603] 94.05 percent of total billed charges 61.38 94.05 Technical (Hospital) Services Ref Oxycodone Conf PX-3018036500 CDM 80365 CPT 301 RC inpatient 99 99 CIGNA 62308 [3081051] CIGNA 62308 [308105105] 78.39 percent of total billed charges 61.38 94.05 Technical (Hospital) Services Ref Oxycodone Conf PX-3018036500 CDM 80365 CPT 301 RC inpatient 99 99 CIGNA 62308 [3081051] CIGNA STATE OF WYOMING [308105107] 78.39 percent of total billed charges 61.38 94.05 Technical (Hospital) Services Ref Oxycodone Conf PX-3018036500 CDM 80365 CPT 301 RC outpatient 99 99 CIGNA 62308 [3081051] CIGNA 62308 [308105105] 79.2 percent of total billed charges 61.38 94.05 Technical (Hospital) Services Ref Oxycodone Conf PX-3018036500 CDM 80365 CPT 301 RC outpatient 99 99 CIGNA 62308 [3081051] CIGNA STATE OF WYOMING [308105107] 79.2 percent of total billed charges 61.38 94.05 Technical (Hospital) Services Ref Oxycodone Conf PX-3018036500 CDM 80365 CPT 301 RC outpatient 99 99 MEDICA (COMMERCIAL) 94265 [3081118] MEDICA CLAIMS [308111801] 89.1 percent of total billed charges 61.38 94.05 Technical (Hospital) Services Ref Oxycodone Conf PX-3018036500 CDM 80365 CPT 301 RC outpatient 99 99 HEALTHPARTNERS SX009 HEALTHPARTNERS 79.2 percent of total billed charges 61.38 94.05 Technical (Hospital) Services Ref Oxycodone Conf PX-3018036500 CDM 80365 CPT 301 RC outpatient 99 99 UNITED HEALTHCARE (COMMERCIAL) [3081199] UNITED HEALTHCARE 87726 [308119901] 61.38 percent of total billed charges 61.38 94.05 Technical (Hospital) Services Ref Oxycodone Conf PX-3018036500 CDM 80365 CPT 301 RC outpatient 99 99 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES EPO [308136803] 79.2 percent of total billed charges 61.38 94.05 Technical (Hospital) Services Ref Oxycodone Conf PX-3018036500 CDM 80365 CPT 301 RC outpatient 99 99 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES PPO [308136801] 79.2 percent of total billed charges 61.38 94.05 Technical (Hospital) Services Ref Oxycodone Conf PX-3018036500 CDM 80365 CPT 301 RC outpatient 99 99 BLUE CROSS BLUE SHIELD WELLMARK SB889 [3081026] BCBS WYOMING [308102603] 94.05 percent of total billed charges 61.38 94.05 Technical (Hospital) Services Ref Oxycodone Conf PX-3018036500 CDM 80365 CPT 301 RC outpatient 99 99 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES HDHP [308136802] 79.2 percent of total billed charges 61.38 94.05 Technical (Hospital) Services Ref Oxycodone Conf PX-3018036500 CDM 80365 CPT 301 RC outpatient 99 99 MULTIPLAN INC 34080 [3081285] MULTIPLAN INC [308128501] 94.05 percent of total billed charges 61.38 94.05 Technical (Hospital) Services Ref Opiates 1 or More PX-3018036100 CDM 80361 CPT 301 RC outpatient 171 171 BLUE CROSS BLUE SHIELD WELLMARK SB889 [3081026] BCBS WYOMING [308102603] 162.45 percent of total billed charges 106.02 162.45 Technical (Hospital) Services Ref Opiates 1 or More PX-3018036100 CDM 80361 CPT 301 RC outpatient 171 171 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES HDHP [308136802] 136.8 percent of total billed charges 106.02 162.45 Technical (Hospital) Services Ref Opiates 1 or More PX-3018036100 CDM 80361 CPT 301 RC outpatient 171 171 MULTIPLAN INC 34080 [3081285] MULTIPLAN INC [308128501] 162.45 percent of total billed charges 106.02 162.45 Technical (Hospital) Services Ref Opiates 1 or More PX-3018036100 CDM 80361 CPT 301 RC outpatient 171 171 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES PPO [308136801] 136.8 percent of total billed charges 106.02 162.45 Technical (Hospital) Services Ref Opiates 1 or More PX-3018036100 CDM 80361 CPT 301 RC outpatient 171 171 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES EPO [308136803] 136.8 percent of total billed charges 106.02 162.45 Technical (Hospital) Services Ref Opiates 1 or More PX-3018036100 CDM 80361 CPT 301 RC outpatient 171 171 UNITED HEALTHCARE (COMMERCIAL) [3081199] UNITED HEALTHCARE 87726 [308119901] 106.02 percent of total billed charges 106.02 162.45 Technical (Hospital) Services Ref Opiates 1 or More PX-3018036100 CDM 80361 CPT 301 RC outpatient 171 171 HEALTHPARTNERS SX009 HEALTHPARTNERS 136.8 percent of total billed charges 106.02 162.45 Technical (Hospital) Services Ref Opiates 1 or More PX-3018036100 CDM 80361 CPT 301 RC outpatient 171 171 MEDICA (COMMERCIAL) 94265 [3081118] MEDICA CLAIMS [308111801] 153.9 percent of total billed charges 106.02 162.45 Technical (Hospital) Services Ref Opiates 1 or More PX-3018036100 CDM 80361 CPT 301 RC outpatient 171 171 CIGNA 62308 [3081051] CIGNA 62308 [308105105] 136.8 percent of total billed charges 106.02 162.45 Technical (Hospital) Services Ref Opiates 1 or More PX-3018036100 CDM 80361 CPT 301 RC outpatient 171 171 CIGNA 62308 [3081051] CIGNA STATE OF WYOMING [308105107] 136.8 percent of total billed charges 106.02 162.45 Technical (Hospital) Services Ref Opiates 1 or More PX-3018036100 CDM 80361 CPT 301 RC inpatient 171 171 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES HDHP [308136802] 135.4 percent of total billed charges 106.02 162.45 Technical (Hospital) Services Ref Opiates 1 or More PX-3018036100 CDM 80361 CPT 301 RC inpatient 171 171 BLUE CROSS BLUE SHIELD WELLMARK SB889 [3081026] BCBS WYOMING [308102603] 162.45 percent of total billed charges 106.02 162.45 Technical (Hospital) Services Ref Opiates 1 or More PX-3018036100 CDM 80361 CPT 301 RC inpatient 171 171 MULTIPLAN INC 34080 [3081285] MULTIPLAN INC [308128501] 162.45 percent of total billed charges 106.02 162.45 Technical (Hospital) Services Ref Opiates 1 or More PX-3018036100 CDM 80361 CPT 301 RC inpatient 171 171 UNITED HEALTHCARE (COMMERCIAL) [3081199] UNITED HEALTHCARE 87726 [308119901] 106.02 percent of total billed charges 106.02 162.45 Technical (Hospital) Services Ref Opiates 1 or More PX-3018036100 CDM 80361 CPT 301 RC inpatient 171 171 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES PPO [308136801] 135.4 percent of total billed charges 106.02 162.45 Technical (Hospital) Services Ref Opiates 1 or More PX-3018036100 CDM 80361 CPT 301 RC inpatient 171 171 HEALTHPARTNERS SX009 HEALTHPARTNERS 135.4 percent of total billed charges 106.02 162.45 Technical (Hospital) Services Ref Opiates 1 or More PX-3018036100 CDM 80361 CPT 301 RC inpatient 171 171 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES EPO [308136803] 135.4 percent of total billed charges 106.02 162.45 Technical (Hospital) Services Ref Opiates 1 or More PX-3018036100 CDM 80361 CPT 301 RC inpatient 171 171 MEDICA (COMMERCIAL) 94265 [3081118] MEDICA CLAIMS [308111801] 153.9 percent of total billed charges 106.02 162.45 Technical (Hospital) Services Ref Opiates 1 or More PX-3018036100 CDM 80361 CPT 301 RC inpatient 171 171 CIGNA 62308 [3081051] CIGNA 62308 [308105105] 135.4 percent of total billed charges 106.02 162.45 Technical (Hospital) Services Ref Opiates 1 or More PX-3018036100 CDM 80361 CPT 301 RC inpatient 171 171 CIGNA 62308 [3081051] CIGNA STATE OF WYOMING [308105107] 135.4 percent of total billed charges 106.02 162.45 Technical (Hospital) Services Ref Heroine Metabolite Conf PX-3018035600 CDM 80356 CPT 301 RC inpatient 133 133 MEDICA (COMMERCIAL) 94265 [3081118] MEDICA CLAIMS [308111801] 119.7 percent of total billed charges 82.46 126.35 Technical (Hospital) Services Ref Heroine Metabolite Conf PX-3018035600 CDM 80356 CPT 301 RC inpatient 133 133 HEALTHPARTNERS SX009 HEALTHPARTNERS 105.31 percent of total billed charges 82.46 126.35 Technical (Hospital) Services Ref Heroine Metabolite Conf PX-3018035600 CDM 80356 CPT 301 RC inpatient 133 133 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES EPO [308136803] 105.31 percent of total billed charges 82.46 126.35 Technical (Hospital) Services Ref Heroine Metabolite Conf PX-3018035600 CDM 80356 CPT 301 RC inpatient 133 133 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES HDHP [308136802] 105.31 percent of total billed charges 82.46 126.35 Technical (Hospital) Services Ref Heroine Metabolite Conf PX-3018035600 CDM 80356 CPT 301 RC inpatient 133 133 MULTIPLAN INC 34080 [3081285] MULTIPLAN INC [308128501] 126.35 percent of total billed charges 82.46 126.35 Technical (Hospital) Services Ref Heroine Metabolite Conf PX-3018035600 CDM 80356 CPT 301 RC inpatient 133 133 BLUE CROSS BLUE SHIELD WELLMARK SB889 [3081026] BCBS WYOMING [308102603] 126.35 percent of total billed charges 82.46 126.35 Technical (Hospital) Services Ref Heroine Metabolite Conf PX-3018035600 CDM 80356 CPT 301 RC inpatient 133 133 UNITED HEALTHCARE (COMMERCIAL) [3081199] UNITED HEALTHCARE 87726 [308119901] 82.46 percent of total billed charges 82.46 126.35 Technical (Hospital) Services Ref Heroine Metabolite Conf PX-3018035600 CDM 80356 CPT 301 RC inpatient 133 133 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES PPO [308136801] 105.31 percent of total billed charges 82.46 126.35 Technical (Hospital) Services Ref Heroine Metabolite Conf PX-3018035600 CDM 80356 CPT 301 RC inpatient 133 133 CIGNA 62308 [3081051] CIGNA STATE OF WYOMING [308105107] 105.31 percent of total billed charges 82.46 126.35 Technical (Hospital) Services Ref Heroine Metabolite Conf PX-3018035600 CDM 80356 CPT 301 RC inpatient 133 133 CIGNA 62308 [3081051] CIGNA 62308 [308105105] 105.31 percent of total billed charges 82.46 126.35 Technical (Hospital) Services Ref Heroine Metabolite Conf PX-3018035600 CDM 80356 CPT 301 RC outpatient 133 133 CIGNA 62308 [3081051] CIGNA 62308 [308105105] 106.4 percent of total billed charges 82.46 126.35 Technical (Hospital) Services Ref Heroine Metabolite Conf PX-3018035600 CDM 80356 CPT 301 RC outpatient 133 133 CIGNA 62308 [3081051] CIGNA STATE OF WYOMING [308105107] 106.4 percent of total billed charges 82.46 126.35 Technical (Hospital) Services Ref Heroine Metabolite Conf PX-3018035600 CDM 80356 CPT 301 RC outpatient 133 133 MEDICA (COMMERCIAL) 94265 [3081118] MEDICA CLAIMS [308111801] 119.7 percent of total billed charges 82.46 126.35 Technical (Hospital) Services Ref Heroine Metabolite Conf PX-3018035600 CDM 80356 CPT 301 RC outpatient 133 133 UNITED HEALTHCARE (COMMERCIAL) [3081199] UNITED HEALTHCARE 87726 [308119901] 82.46 percent of total billed charges 82.46 126.35 Technical (Hospital) Services Ref Heroine Metabolite Conf PX-3018035600 CDM 80356 CPT 301 RC outpatient 133 133 HEALTHPARTNERS SX009 HEALTHPARTNERS 106.4 percent of total billed charges 82.46 126.35 Technical (Hospital) Services Ref Heroine Metabolite Conf PX-3018035600 CDM 80356 CPT 301 RC outpatient 133 133 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES HDHP [308136802] 106.4 percent of total billed charges 82.46 126.35 Technical (Hospital) Services Ref Heroine Metabolite Conf PX-3018035600 CDM 80356 CPT 301 RC outpatient 133 133 BLUE CROSS BLUE SHIELD WELLMARK SB889 [3081026] BCBS WYOMING [308102603] 126.35 percent of total billed charges 82.46 126.35 Technical (Hospital) Services Ref Heroine Metabolite Conf PX-3018035600 CDM 80356 CPT 301 RC outpatient 133 133 MULTIPLAN INC 34080 [3081285] MULTIPLAN INC [308128501] 126.35 percent of total billed charges 82.46 126.35 Technical (Hospital) Services Ref Heroine Metabolite Conf PX-3018035600 CDM 80356 CPT 301 RC outpatient 133 133 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES EPO [308136803] 106.4 percent of total billed charges 82.46 126.35 Technical (Hospital) Services Ref Heroine Metabolite Conf PX-3018035600 CDM 80356 CPT 301 RC outpatient 133 133 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES PPO [308136801] 106.4 percent of total billed charges 82.46 126.35 Technical (Hospital) Services Ref Cannabinoids Natural Conf PX-3018034900 CDM 80349 CPT 301 RC inpatient 200 200 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES HDHP [308136802] 158.36 percent of total billed charges 124 190 Technical (Hospital) Services Ref Cannabinoids Natural Conf PX-3018034900 CDM 80349 CPT 301 RC inpatient 200 200 MEDICA (COMMERCIAL) 94265 [3081118] MEDICA CLAIMS [308111801] 180 percent of total billed charges 124 190 Technical (Hospital) Services Ref Cannabinoids Natural Conf PX-3018034900 CDM 80349 CPT 301 RC inpatient 200 200 HEALTHPARTNERS SX009 HEALTHPARTNERS 158.36 percent of total billed charges 124 190 Technical (Hospital) Services Ref Cannabinoids Natural Conf PX-3018034900 CDM 80349 CPT 301 RC inpatient 200 200 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES EPO [308136803] 158.36 percent of total billed charges 124 190 Technical (Hospital) Services Ref Cannabinoids Natural Conf PX-3018034900 CDM 80349 CPT 301 RC inpatient 200 200 MULTIPLAN INC 34080 [3081285] MULTIPLAN INC [308128501] 190 percent of total billed charges 124 190 Technical (Hospital) Services Ref Cannabinoids Natural Conf PX-3018034900 CDM 80349 CPT 301 RC inpatient 200 200 BLUE CROSS BLUE SHIELD WELLMARK SB889 [3081026] BCBS WYOMING [308102603] 190 percent of total billed charges 124 190 Technical (Hospital) Services Ref Cannabinoids Natural Conf PX-3018034900 CDM 80349 CPT 301 RC inpatient 200 200 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES PPO [308136801] 158.36 percent of total billed charges 124 190 Technical (Hospital) Services Ref Cannabinoids Natural Conf PX-3018034900 CDM 80349 CPT 301 RC inpatient 200 200 UNITED HEALTHCARE (COMMERCIAL) [3081199] UNITED HEALTHCARE 87726 [308119901] 124 percent of total billed charges 124 190 Technical (Hospital) Services Ref Cannabinoids Natural Conf PX-3018034900 CDM 80349 CPT 301 RC inpatient 200 200 CIGNA 62308 [3081051] CIGNA 62308 [308105105] 158.36 percent of total billed charges 124 190 Technical (Hospital) Services Ref Cannabinoids Natural Conf PX-3018034900 CDM 80349 CPT 301 RC inpatient 200 200 CIGNA 62308 [3081051] CIGNA STATE OF WYOMING [308105107] 158.36 percent of total billed charges 124 190 Technical (Hospital) Services Ref Cannabinoids Natural Conf PX-3018034900 CDM 80349 CPT 301 RC outpatient 200 200 MEDICA (COMMERCIAL) 94265 [3081118] MEDICA CLAIMS [308111801] 180 percent of total billed charges 124 190 Technical (Hospital) Services Ref Cannabinoids Natural Conf PX-3018034900 CDM 80349 CPT 301 RC outpatient 200 200 CIGNA 62308 [3081051] CIGNA 62308 [308105105] 160 percent of total billed charges 124 190 Technical (Hospital) Services Ref Cannabinoids Natural Conf PX-3018034900 CDM 80349 CPT 301 RC outpatient 200 200 CIGNA 62308 [3081051] CIGNA STATE OF WYOMING [308105107] 160 percent of total billed charges 124 190 Technical (Hospital) Services Ref Cannabinoids Natural Conf PX-3018034900 CDM 80349 CPT 301 RC outpatient 200 200 BLUE CROSS BLUE SHIELD WELLMARK SB889 [3081026] BCBS WYOMING [308102603] 190 percent of total billed charges 124 190 Technical (Hospital) Services Ref Cannabinoids Natural Conf PX-3018034900 CDM 80349 CPT 301 RC outpatient 200 200 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES HDHP [308136802] 160 percent of total billed charges 124 190 Technical (Hospital) Services Ref Cannabinoids Natural Conf PX-3018034900 CDM 80349 CPT 301 RC outpatient 200 200 MULTIPLAN INC 34080 [3081285] MULTIPLAN INC [308128501] 190 percent of total billed charges 124 190 Technical (Hospital) Services Ref Cannabinoids Natural Conf PX-3018034900 CDM 80349 CPT 301 RC outpatient 200 200 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES PPO [308136801] 160 percent of total billed charges 124 190 Technical (Hospital) Services Ref Cannabinoids Natural Conf PX-3018034900 CDM 80349 CPT 301 RC outpatient 200 200 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES EPO [308136803] 160 percent of total billed charges 124 190 Technical (Hospital) Services Ref Cannabinoids Natural Conf PX-3018034900 CDM 80349 CPT 301 RC outpatient 200 200 UNITED HEALTHCARE (COMMERCIAL) [3081199] UNITED HEALTHCARE 87726 [308119901] 124 percent of total billed charges 124 190 Technical (Hospital) Services Ref Cannabinoids Natural Conf PX-3018034900 CDM 80349 CPT 301 RC outpatient 200 200 HEALTHPARTNERS SX009 HEALTHPARTNERS 160 percent of total billed charges 124 190 Technical (Hospital) Services Ref Benzodiazepine Conf Urine PX-3018034600 CDM 80346 CPT 301 RC inpatient 368 368 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES HDHP [308136802] 291.38 percent of total billed charges 228.16 349.6 Technical (Hospital) Services Ref Benzodiazepine Conf Urine PX-3018034600 CDM 80346 CPT 301 RC inpatient 368 368 MULTIPLAN INC 34080 [3081285] MULTIPLAN INC [308128501] 349.6 percent of total billed charges 228.16 349.6 Technical (Hospital) Services Ref Benzodiazepine Conf Urine PX-3018034600 CDM 80346 CPT 301 RC inpatient 368 368 BLUE CROSS BLUE SHIELD WELLMARK SB889 [3081026] BCBS WYOMING [308102603] 349.6 percent of total billed charges 228.16 349.6 Technical (Hospital) Services Ref Benzodiazepine Conf Urine PX-3018034600 CDM 80346 CPT 301 RC inpatient 368 368 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES PPO [308136801] 291.38 percent of total billed charges 228.16 349.6 Technical (Hospital) Services Ref Benzodiazepine Conf Urine PX-3018034600 CDM 80346 CPT 301 RC inpatient 368 368 UNITED HEALTHCARE (COMMERCIAL) [3081199] UNITED HEALTHCARE 87726 [308119901] 228.16 percent of total billed charges 228.16 349.6 Technical (Hospital) Services Ref Benzodiazepine Conf Urine PX-3018034600 CDM 80346 CPT 301 RC inpatient 368 368 MEDICA (COMMERCIAL) 94265 [3081118] MEDICA CLAIMS [308111801] 331.2 percent of total billed charges 228.16 349.6 Technical (Hospital) Services Ref Benzodiazepine Conf Urine PX-3018034600 CDM 80346 CPT 301 RC inpatient 368 368 HEALTHPARTNERS SX009 HEALTHPARTNERS 291.38 percent of total billed charges 228.16 349.6 Technical (Hospital) Services Ref Benzodiazepine Conf Urine PX-3018034600 CDM 80346 CPT 301 RC inpatient 368 368 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES EPO [308136803] 291.38 percent of total billed charges 228.16 349.6 Technical (Hospital) Services Ref Benzodiazepine Conf Urine PX-3018034600 CDM 80346 CPT 301 RC inpatient 368 368 CIGNA 62308 [3081051] CIGNA 62308 [308105105] 291.38 percent of total billed charges 228.16 349.6 Technical (Hospital) Services Ref Benzodiazepine Conf Urine PX-3018034600 CDM 80346 CPT 301 RC inpatient 368 368 CIGNA 62308 [3081051] CIGNA STATE OF WYOMING [308105107] 291.38 percent of total billed charges 228.16 349.6 Technical (Hospital) Services Ref Benzodiazepine Conf Urine PX-3018034600 CDM 80346 CPT 301 RC outpatient 368 368 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES PPO [308136801] 294.4 percent of total billed charges 228.16 349.6 Technical (Hospital) Services Ref Benzodiazepine Conf Urine PX-3018034600 CDM 80346 CPT 301 RC outpatient 368 368 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES EPO [308136803] 294.4 percent of total billed charges 228.16 349.6 Technical (Hospital) Services Ref Benzodiazepine Conf Urine PX-3018034600 CDM 80346 CPT 301 RC outpatient 368 368 BLUE CROSS BLUE SHIELD WELLMARK SB889 [3081026] BCBS WYOMING [308102603] 349.6 percent of total billed charges 228.16 349.6 Technical (Hospital) Services Ref Benzodiazepine Conf Urine PX-3018034600 CDM 80346 CPT 301 RC outpatient 368 368 MULTIPLAN INC 34080 [3081285] MULTIPLAN INC [308128501] 349.6 percent of total billed charges 228.16 349.6 Technical (Hospital) Services Ref Benzodiazepine Conf Urine PX-3018034600 CDM 80346 CPT 301 RC outpatient 368 368 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES HDHP [308136802] 294.4 percent of total billed charges 228.16 349.6 Technical (Hospital) Services Ref Benzodiazepine Conf Urine PX-3018034600 CDM 80346 CPT 301 RC outpatient 368 368 HEALTHPARTNERS SX009 HEALTHPARTNERS 294.4 percent of total billed charges 228.16 349.6 Technical (Hospital) Services Ref Benzodiazepine Conf Urine PX-3018034600 CDM 80346 CPT 301 RC outpatient 368 368 UNITED HEALTHCARE (COMMERCIAL) [3081199] UNITED HEALTHCARE 87726 [308119901] 228.16 percent of total billed charges 228.16 349.6 Technical (Hospital) Services Ref Benzodiazepine Conf Urine PX-3018034600 CDM 80346 CPT 301 RC outpatient 368 368 CIGNA 62308 [3081051] CIGNA 62308 [308105105] 294.4 percent of total billed charges 228.16 349.6 Technical (Hospital) Services Ref Benzodiazepine Conf Urine PX-3018034600 CDM 80346 CPT 301 RC outpatient 368 368 CIGNA 62308 [3081051] CIGNA STATE OF WYOMING [308105107] 294.4 percent of total billed charges 228.16 349.6 Technical (Hospital) Services Ref Benzodiazepine Conf Urine PX-3018034600 CDM 80346 CPT 301 RC outpatient 368 368 MEDICA (COMMERCIAL) 94265 [3081118] MEDICA CLAIMS [308111801] 331.2 percent of total billed charges 228.16 349.6 Technical (Hospital) Services Ref Antidpressnt Not Spec Pm Urine PX-3018033800 CDM 80338 CPT 301 RC outpatient 131 131 CIGNA 62308 [3081051] CIGNA 62308 [308105105] 104.8 percent of total billed charges 81.22 124.45 Technical (Hospital) Services Ref Antidpressnt Not Spec Pm Urine PX-3018033800 CDM 80338 CPT 301 RC outpatient 131 131 CIGNA 62308 [3081051] CIGNA STATE OF WYOMING [308105107] 104.8 percent of total billed charges 81.22 124.45 Technical (Hospital) Services Ref Antidpressnt Not Spec Pm Urine PX-3018033800 CDM 80338 CPT 301 RC outpatient 131 131 MEDICA (COMMERCIAL) 94265 [3081118] MEDICA CLAIMS [308111801] 117.9 percent of total billed charges 81.22 124.45 Technical (Hospital) Services Ref Antidpressnt Not Spec Pm Urine PX-3018033800 CDM 80338 CPT 301 RC outpatient 131 131 UNITED HEALTHCARE (COMMERCIAL) [3081199] UNITED HEALTHCARE 87726 [308119901] 81.22 percent of total billed charges 81.22 124.45 Technical (Hospital) Services Ref Antidpressnt Not Spec Pm Urine PX-3018033800 CDM 80338 CPT 301 RC outpatient 131 131 HEALTHPARTNERS SX009 HEALTHPARTNERS 104.8 percent of total billed charges 81.22 124.45 Technical (Hospital) Services Ref Antidpressnt Not Spec Pm Urine PX-3018033800 CDM 80338 CPT 301 RC outpatient 131 131 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES HDHP [308136802] 104.8 percent of total billed charges 81.22 124.45 Technical (Hospital) Services Ref Antidpressnt Not Spec Pm Urine PX-3018033800 CDM 80338 CPT 301 RC outpatient 131 131 BLUE CROSS BLUE SHIELD WELLMARK SB889 [3081026] BCBS WYOMING [308102603] 124.45 percent of total billed charges 81.22 124.45 Technical (Hospital) Services Ref Antidpressnt Not Spec Pm Urine PX-3018033800 CDM 80338 CPT 301 RC outpatient 131 131 MULTIPLAN INC 34080 [3081285] MULTIPLAN INC [308128501] 124.45 percent of total billed charges 81.22 124.45 Technical (Hospital) Services Ref Antidpressnt Not Spec Pm Urine PX-3018033800 CDM 80338 CPT 301 RC outpatient 131 131 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES EPO [308136803] 104.8 percent of total billed charges 81.22 124.45 Technical (Hospital) Services Ref Antidpressnt Not Spec Pm Urine PX-3018033800 CDM 80338 CPT 301 RC outpatient 131 131 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES PPO [308136801] 104.8 percent of total billed charges 81.22 124.45 Technical (Hospital) Services Ref Antidpressnt Not Spec Pm Urine PX-3018033800 CDM 80338 CPT 301 RC inpatient 131 131 MEDICA (COMMERCIAL) 94265 [3081118] MEDICA CLAIMS [308111801] 117.9 percent of total billed charges 81.22 124.45 Technical (Hospital) Services Ref Antidpressnt Not Spec Pm Urine PX-3018033800 CDM 80338 CPT 301 RC inpatient 131 131 HEALTHPARTNERS SX009 HEALTHPARTNERS 103.73 percent of total billed charges 81.22 124.45 Technical (Hospital) Services Ref Antidpressnt Not Spec Pm Urine PX-3018033800 CDM 80338 CPT 301 RC inpatient 131 131 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES EPO [308136803] 103.73 percent of total billed charges 81.22 124.45 Technical (Hospital) Services Ref Antidpressnt Not Spec Pm Urine PX-3018033800 CDM 80338 CPT 301 RC inpatient 131 131 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES HDHP [308136802] 103.73 percent of total billed charges 81.22 124.45 Technical (Hospital) Services Ref Antidpressnt Not Spec Pm Urine PX-3018033800 CDM 80338 CPT 301 RC inpatient 131 131 BLUE CROSS BLUE SHIELD WELLMARK SB889 [3081026] BCBS WYOMING [308102603] 124.45 percent of total billed charges 81.22 124.45 Technical (Hospital) Services Ref Antidpressnt Not Spec Pm Urine PX-3018033800 CDM 80338 CPT 301 RC inpatient 131 131 MULTIPLAN INC 34080 [3081285] MULTIPLAN INC [308128501] 124.45 percent of total billed charges 81.22 124.45 Technical (Hospital) Services Ref Antidpressnt Not Spec Pm Urine PX-3018033800 CDM 80338 CPT 301 RC inpatient 131 131 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES PPO [308136801] 103.73 percent of total billed charges 81.22 124.45 Technical (Hospital) Services Ref Antidpressnt Not Spec Pm Urine PX-3018033800 CDM 80338 CPT 301 RC inpatient 131 131 UNITED HEALTHCARE (COMMERCIAL) [3081199] UNITED HEALTHCARE 87726 [308119901] 81.22 percent of total billed charges 81.22 124.45 Technical (Hospital) Services Ref Antidpressnt Not Spec Pm Urine PX-3018033800 CDM 80338 CPT 301 RC inpatient 131 131 CIGNA 62308 [3081051] CIGNA STATE OF WYOMING [308105107] 103.73 percent of total billed charges 81.22 124.45 Technical (Hospital) Services Ref Antidpressnt Not Spec Pm Urine PX-3018033800 CDM 80338 CPT 301 RC inpatient 131 131 CIGNA 62308 [3081051] CIGNA 62308 [308105105] 103.73 percent of total billed charges 81.22 124.45 Technical (Hospital) Services Salicylates PX-3018032900 CDM 80329 CPT 301 RC inpatient 253 253 MEDICA (COMMERCIAL) 94265 [3081118] MEDICA CLAIMS [308111801] 227.7 percent of total billed charges 156.86 240.35 Technical (Hospital) Services Salicylates PX-3018032900 CDM 80329 CPT 301 RC inpatient 253 253 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES EPO [308136803] 200.33 percent of total billed charges 156.86 240.35 Technical (Hospital) Services Salicylates PX-3018032900 CDM 80329 CPT 301 RC inpatient 253 253 HEALTHPARTNERS SX009 HEALTHPARTNERS 200.33 percent of total billed charges 156.86 240.35 Technical (Hospital) Services Salicylates PX-3018032900 CDM 80329 CPT 301 RC inpatient 253 253 UNITED HEALTHCARE (COMMERCIAL) [3081199] UNITED HEALTHCARE 87726 [308119901] 156.86 percent of total billed charges 156.86 240.35 Technical (Hospital) Services Salicylates PX-3018032900 CDM 80329 CPT 301 RC inpatient 253 253 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES PPO [308136801] 200.33 percent of total billed charges 156.86 240.35 Technical (Hospital) Services Salicylates PX-3018032900 CDM 80329 CPT 301 RC inpatient 253 253 MULTIPLAN INC 34080 [3081285] MULTIPLAN INC [308128501] 240.35 percent of total billed charges 156.86 240.35 Technical (Hospital) Services Salicylates PX-3018032900 CDM 80329 CPT 301 RC inpatient 253 253 BLUE CROSS BLUE SHIELD WELLMARK SB889 [3081026] BCBS WYOMING [308102603] 240.35 percent of total billed charges 156.86 240.35 Technical (Hospital) Services Salicylates PX-3018032900 CDM 80329 CPT 301 RC inpatient 253 253 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES HDHP [308136802] 200.33 percent of total billed charges 156.86 240.35 Technical (Hospital) Services Salicylates PX-3018032900 CDM 80329 CPT 301 RC inpatient 253 253 CIGNA 62308 [3081051] CIGNA 62308 [308105105] 200.33 percent of total billed charges 156.86 240.35 Technical (Hospital) Services Salicylates PX-3018032900 CDM 80329 CPT 301 RC inpatient 253 253 CIGNA 62308 [3081051] CIGNA STATE OF WYOMING [308105107] 200.33 percent of total billed charges 156.86 240.35 Technical (Hospital) Services Salicylates PX-3018032900 CDM 80329 CPT 301 RC outpatient 253 253 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES PPO [308136801] 202.4 percent of total billed charges 156.86 240.35 Technical (Hospital) Services Salicylates PX-3018032900 CDM 80329 CPT 301 RC outpatient 253 253 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES EPO [308136803] 202.4 percent of total billed charges 156.86 240.35 Technical (Hospital) Services Salicylates PX-3018032900 CDM 80329 CPT 301 RC outpatient 253 253 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES HDHP [308136802] 202.4 percent of total billed charges 156.86 240.35 Technical (Hospital) Services Salicylates PX-3018032900 CDM 80329 CPT 301 RC outpatient 253 253 MULTIPLAN INC 34080 [3081285] MULTIPLAN INC [308128501] 240.35 percent of total billed charges 156.86 240.35 Technical (Hospital) Services Salicylates PX-3018032900 CDM 80329 CPT 301 RC outpatient 253 253 BLUE CROSS BLUE SHIELD WELLMARK SB889 [3081026] BCBS WYOMING [308102603] 240.35 percent of total billed charges 156.86 240.35 Technical (Hospital) Services Salicylates PX-3018032900 CDM 80329 CPT 301 RC outpatient 253 253 UNITED HEALTHCARE (COMMERCIAL) [3081199] UNITED HEALTHCARE 87726 [308119901] 156.86 percent of total billed charges 156.86 240.35 Technical (Hospital) Services Salicylates PX-3018032900 CDM 80329 CPT 301 RC outpatient 253 253 HEALTHPARTNERS SX009 HEALTHPARTNERS 202.4 percent of total billed charges 156.86 240.35 Technical (Hospital) Services Salicylates PX-3018032900 CDM 80329 CPT 301 RC outpatient 253 253 MEDICA (COMMERCIAL) 94265 [3081118] MEDICA CLAIMS [308111801] 227.7 percent of total billed charges 156.86 240.35 Technical (Hospital) Services Salicylates PX-3018032900 CDM 80329 CPT 301 RC outpatient 253 253 CIGNA 62308 [3081051] CIGNA 62308 [308105105] 202.4 percent of total billed charges 156.86 240.35 Technical (Hospital) Services Salicylates PX-3018032900 CDM 80329 CPT 301 RC outpatient 253 253 CIGNA 62308 [3081051] CIGNA STATE OF WYOMING [308105107] 202.4 percent of total billed charges 156.86 240.35 Technical (Hospital) Services Acetaminophen PX-3018032901 CDM 80329 CPT 301 RC outpatient 253 253 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES HDHP [308136802] 202.4 percent of total billed charges 156.86 240.35 Technical (Hospital) Services Acetaminophen PX-3018032901 CDM 80329 CPT 301 RC outpatient 253 253 BLUE CROSS BLUE SHIELD WELLMARK SB889 [3081026] BCBS WYOMING [308102603] 240.35 percent of total billed charges 156.86 240.35 Technical (Hospital) Services Acetaminophen PX-3018032901 CDM 80329 CPT 301 RC outpatient 253 253 MULTIPLAN INC 34080 [3081285] MULTIPLAN INC [308128501] 240.35 percent of total billed charges 156.86 240.35 Technical (Hospital) Services Acetaminophen PX-3018032901 CDM 80329 CPT 301 RC outpatient 253 253 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES PPO [308136801] 202.4 percent of total billed charges 156.86 240.35 Technical (Hospital) Services Acetaminophen PX-3018032901 CDM 80329 CPT 301 RC outpatient 253 253 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES EPO [308136803] 202.4 percent of total billed charges 156.86 240.35 Technical (Hospital) Services Acetaminophen PX-3018032901 CDM 80329 CPT 301 RC outpatient 253 253 UNITED HEALTHCARE (COMMERCIAL) [3081199] UNITED HEALTHCARE 87726 [308119901] 156.86 percent of total billed charges 156.86 240.35 Technical (Hospital) Services Acetaminophen PX-3018032901 CDM 80329 CPT 301 RC outpatient 253 253 HEALTHPARTNERS SX009 HEALTHPARTNERS 202.4 percent of total billed charges 156.86 240.35 Technical (Hospital) Services Acetaminophen PX-3018032901 CDM 80329 CPT 301 RC outpatient 253 253 MEDICA (COMMERCIAL) 94265 [3081118] MEDICA CLAIMS [308111801] 227.7 percent of total billed charges 156.86 240.35 Technical (Hospital) Services Acetaminophen PX-3018032901 CDM 80329 CPT 301 RC outpatient 253 253 CIGNA 62308 [3081051] CIGNA 62308 [308105105] 202.4 percent of total billed charges 156.86 240.35 Technical (Hospital) Services Acetaminophen PX-3018032901 CDM 80329 CPT 301 RC outpatient 253 253 CIGNA 62308 [3081051] CIGNA STATE OF WYOMING [308105107] 202.4 percent of total billed charges 156.86 240.35 Technical (Hospital) Services Acetaminophen PX-3018032901 CDM 80329 CPT 301 RC inpatient 253 253 CIGNA 62308 [3081051] CIGNA 62308 [308105105] 200.33 percent of total billed charges 156.86 240.35 Technical (Hospital) Services Acetaminophen PX-3018032901 CDM 80329 CPT 301 RC inpatient 253 253 CIGNA 62308 [3081051] CIGNA STATE OF WYOMING [308105107] 200.33 percent of total billed charges 156.86 240.35 Technical (Hospital) Services Acetaminophen PX-3018032901 CDM 80329 CPT 301 RC inpatient 253 253 MULTIPLAN INC 34080 [3081285] MULTIPLAN INC [308128501] 240.35 percent of total billed charges 156.86 240.35 Technical (Hospital) Services Acetaminophen PX-3018032901 CDM 80329 CPT 301 RC inpatient 253 253 BLUE CROSS BLUE SHIELD WELLMARK SB889 [3081026] BCBS WYOMING [308102603] 240.35 percent of total billed charges 156.86 240.35 Technical (Hospital) Services Acetaminophen PX-3018032901 CDM 80329 CPT 301 RC inpatient 253 253 UNITED HEALTHCARE (COMMERCIAL) [3081199] UNITED HEALTHCARE 87726 [308119901] 156.86 percent of total billed charges 156.86 240.35 Technical (Hospital) Services Acetaminophen PX-3018032901 CDM 80329 CPT 301 RC inpatient 253 253 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES PPO [308136801] 200.33 percent of total billed charges 156.86 240.35 Technical (Hospital) Services Acetaminophen PX-3018032901 CDM 80329 CPT 301 RC inpatient 253 253 HEALTHPARTNERS SX009 HEALTHPARTNERS 200.33 percent of total billed charges 156.86 240.35 Technical (Hospital) Services Acetaminophen PX-3018032901 CDM 80329 CPT 301 RC inpatient 253 253 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES EPO [308136803] 200.33 percent of total billed charges 156.86 240.35 Technical (Hospital) Services Acetaminophen PX-3018032901 CDM 80329 CPT 301 RC inpatient 253 253 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES HDHP [308136802] 200.33 percent of total billed charges 156.86 240.35 Technical (Hospital) Services Acetaminophen PX-3018032901 CDM 80329 CPT 301 RC inpatient 253 253 MEDICA (COMMERCIAL) 94265 [3081118] MEDICA CLAIMS [308111801] 227.7 percent of total billed charges 156.86 240.35 Technical (Hospital) Services Ref Nicotine and Metabolites PX-3018032300 CDM 80323 CPT 301 RC inpatient 266 266 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES HDHP [308136802] 210.62 percent of total billed charges 164.92 252.7 Technical (Hospital) Services Ref Nicotine and Metabolites PX-3018032300 CDM 80323 CPT 301 RC inpatient 266 266 MULTIPLAN INC 34080 [3081285] MULTIPLAN INC [308128501] 252.7 percent of total billed charges 164.92 252.7 Technical (Hospital) Services Ref Nicotine and Metabolites PX-3018032300 CDM 80323 CPT 301 RC inpatient 266 266 BLUE CROSS BLUE SHIELD WELLMARK SB889 [3081026] BCBS WYOMING [308102603] 252.7 percent of total billed charges 164.92 252.7 Technical (Hospital) Services Ref Nicotine and Metabolites PX-3018032300 CDM 80323 CPT 301 RC inpatient 266 266 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES PPO [308136801] 210.62 percent of total billed charges 164.92 252.7 Technical (Hospital) Services Ref Nicotine and Metabolites PX-3018032300 CDM 80323 CPT 301 RC inpatient 266 266 UNITED HEALTHCARE (COMMERCIAL) [3081199] UNITED HEALTHCARE 87726 [308119901] 164.92 percent of total billed charges 164.92 252.7 Technical (Hospital) Services Ref Nicotine and Metabolites PX-3018032300 CDM 80323 CPT 301 RC inpatient 266 266 HEALTHPARTNERS SX009 HEALTHPARTNERS 210.62 percent of total billed charges 164.92 252.7 Technical (Hospital) Services Ref Nicotine and Metabolites PX-3018032300 CDM 80323 CPT 301 RC inpatient 266 266 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES EPO [308136803] 210.62 percent of total billed charges 164.92 252.7 Technical (Hospital) Services Ref Nicotine and Metabolites PX-3018032300 CDM 80323 CPT 301 RC inpatient 266 266 MEDICA (COMMERCIAL) 94265 [3081118] MEDICA CLAIMS [308111801] 239.4 percent of total billed charges 164.92 252.7 Technical (Hospital) Services Ref Nicotine and Metabolites PX-3018032300 CDM 80323 CPT 301 RC inpatient 266 266 CIGNA 62308 [3081051] CIGNA 62308 [308105105] 210.62 percent of total billed charges 164.92 252.7 Technical (Hospital) Services Ref Nicotine and Metabolites PX-3018032300 CDM 80323 CPT 301 RC inpatient 266 266 CIGNA 62308 [3081051] CIGNA STATE OF WYOMING [308105107] 210.62 percent of total billed charges 164.92 252.7 Technical (Hospital) Services Ref Nicotine and Metabolites PX-3018032300 CDM 80323 CPT 301 RC outpatient 266 266 MEDICA (COMMERCIAL) 94265 [3081118] MEDICA CLAIMS [308111801] 239.4 percent of total billed charges 164.92 252.7 Technical (Hospital) Services Ref Nicotine and Metabolites PX-3018032300 CDM 80323 CPT 301 RC outpatient 266 266 CIGNA 62308 [3081051] CIGNA 62308 [308105105] 212.8 percent of total billed charges 164.92 252.7 Technical (Hospital) Services Ref Nicotine and Metabolites PX-3018032300 CDM 80323 CPT 301 RC outpatient 266 266 CIGNA 62308 [3081051] CIGNA STATE OF WYOMING [308105107] 212.8 percent of total billed charges 164.92 252.7 Technical (Hospital) Services Ref Nicotine and Metabolites PX-3018032300 CDM 80323 CPT 301 RC outpatient 266 266 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES PPO [308136801] 212.8 percent of total billed charges 164.92 252.7 Technical (Hospital) Services Ref Nicotine and Metabolites PX-3018032300 CDM 80323 CPT 301 RC outpatient 266 266 BLUE CROSS BLUE SHIELD WELLMARK SB889 [3081026] BCBS WYOMING [308102603] 252.7 percent of total billed charges 164.92 252.7 Technical (Hospital) Services Ref Nicotine and Metabolites PX-3018032300 CDM 80323 CPT 301 RC outpatient 266 266 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES HDHP [308136802] 212.8 percent of total billed charges 164.92 252.7 Technical (Hospital) Services Ref Nicotine and Metabolites PX-3018032300 CDM 80323 CPT 301 RC outpatient 266 266 MULTIPLAN INC 34080 [3081285] MULTIPLAN INC [308128501] 252.7 percent of total billed charges 164.92 252.7 Technical (Hospital) Services Ref Nicotine and Metabolites PX-3018032300 CDM 80323 CPT 301 RC outpatient 266 266 HEALTHPARTNERS SX009 HEALTHPARTNERS 212.8 percent of total billed charges 164.92 252.7 Technical (Hospital) Services Ref Nicotine and Metabolites PX-3018032300 CDM 80323 CPT 301 RC outpatient 266 266 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES EPO [308136803] 212.8 percent of total billed charges 164.92 252.7 Technical (Hospital) Services Ref Nicotine and Metabolites PX-3018032300 CDM 80323 CPT 301 RC outpatient 266 266 UNITED HEALTHCARE (COMMERCIAL) [3081199] UNITED HEALTHCARE 87726 [308119901] 164.92 percent of total billed charges 164.92 252.7 Technical (Hospital) Services Alcohol PX-3018032000 CDM 80320 CPT 301 RC inpatient 183 183 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES EPO [308136803] 144.9 percent of total billed charges 113.46 173.85 Technical (Hospital) Services Alcohol PX-3018032000 CDM 80320 CPT 301 RC inpatient 183 183 HEALTHPARTNERS SX009 HEALTHPARTNERS 144.9 percent of total billed charges 113.46 173.85 Technical (Hospital) Services Alcohol PX-3018032000 CDM 80320 CPT 301 RC inpatient 183 183 MEDICA (COMMERCIAL) 94265 [3081118] MEDICA CLAIMS [308111801] 164.7 percent of total billed charges 113.46 173.85 Technical (Hospital) Services Alcohol PX-3018032000 CDM 80320 CPT 301 RC inpatient 183 183 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES HDHP [308136802] 144.9 percent of total billed charges 113.46 173.85 Technical (Hospital) Services Alcohol PX-3018032000 CDM 80320 CPT 301 RC inpatient 183 183 BLUE CROSS BLUE SHIELD WELLMARK SB889 [3081026] BCBS WYOMING [308102603] 173.85 percent of total billed charges 113.46 173.85 Technical (Hospital) Services Alcohol PX-3018032000 CDM 80320 CPT 301 RC inpatient 183 183 MULTIPLAN INC 34080 [3081285] MULTIPLAN INC [308128501] 173.85 percent of total billed charges 113.46 173.85 Technical (Hospital) Services Alcohol PX-3018032000 CDM 80320 CPT 301 RC inpatient 183 183 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES PPO [308136801] 144.9 percent of total billed charges 113.46 173.85 Technical (Hospital) Services Alcohol PX-3018032000 CDM 80320 CPT 301 RC inpatient 183 183 UNITED HEALTHCARE (COMMERCIAL) [3081199] UNITED HEALTHCARE 87726 [308119901] 113.46 percent of total billed charges 113.46 173.85 Technical (Hospital) Services Alcohol PX-3018032000 CDM 80320 CPT 301 RC inpatient 183 183 CIGNA 62308 [3081051] CIGNA 62308 [308105105] 144.9 percent of total billed charges 113.46 173.85 Technical (Hospital) Services Alcohol PX-3018032000 CDM 80320 CPT 301 RC inpatient 183 183 CIGNA 62308 [3081051] CIGNA STATE OF WYOMING [308105107] 144.9 percent of total billed charges 113.46 173.85 Technical (Hospital) Services Alcohol PX-3018032000 CDM 80320 CPT 301 RC outpatient 183 183 CIGNA 62308 [3081051] CIGNA 62308 [308105105] 146.4 percent of total billed charges 113.46 173.85 Technical (Hospital) Services Alcohol PX-3018032000 CDM 80320 CPT 301 RC outpatient 183 183 CIGNA 62308 [3081051] CIGNA STATE OF WYOMING [308105107] 146.4 percent of total billed charges 113.46 173.85 Technical (Hospital) Services Alcohol PX-3018032000 CDM 80320 CPT 301 RC outpatient 183 183 MEDICA (COMMERCIAL) 94265 [3081118] MEDICA CLAIMS [308111801] 164.7 percent of total billed charges 113.46 173.85 Technical (Hospital) Services Alcohol PX-3018032000 CDM 80320 CPT 301 RC outpatient 183 183 UNITED HEALTHCARE (COMMERCIAL) [3081199] UNITED HEALTHCARE 87726 [308119901] 113.46 percent of total billed charges 113.46 173.85 Technical (Hospital) Services Alcohol PX-3018032000 CDM 80320 CPT 301 RC outpatient 183 183 HEALTHPARTNERS SX009 HEALTHPARTNERS 146.4 percent of total billed charges 113.46 173.85 Technical (Hospital) Services Alcohol PX-3018032000 CDM 80320 CPT 301 RC outpatient 183 183 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES EPO [308136803] 146.4 percent of total billed charges 113.46 173.85 Technical (Hospital) Services Alcohol PX-3018032000 CDM 80320 CPT 301 RC outpatient 183 183 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES PPO [308136801] 146.4 percent of total billed charges 113.46 173.85 Technical (Hospital) Services Alcohol PX-3018032000 CDM 80320 CPT 301 RC outpatient 183 183 BLUE CROSS BLUE SHIELD WELLMARK SB889 [3081026] BCBS WYOMING [308102603] 173.85 percent of total billed charges 113.46 173.85 Technical (Hospital) Services Alcohol PX-3018032000 CDM 80320 CPT 301 RC outpatient 183 183 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES HDHP [308136802] 146.4 percent of total billed charges 113.46 173.85 Technical (Hospital) Services Alcohol PX-3018032000 CDM 80320 CPT 301 RC outpatient 183 183 MULTIPLAN INC 34080 [3081285] MULTIPLAN INC [308128501] 173.85 percent of total billed charges 113.46 173.85 Technical (Hospital) Services Ref Hypoglycemic Agent Scrn PX-3018030700 CDM 80307 CPT 301 RC inpatient 253 253 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES EPO [308136803] 200.33 percent of total billed charges 156.86 240.35 Technical (Hospital) Services Ref Hypoglycemic Agent Scrn PX-3018030700 CDM 80307 CPT 301 RC inpatient 253 253 HEALTHPARTNERS SX009 HEALTHPARTNERS 200.33 percent of total billed charges 156.86 240.35 Technical (Hospital) Services Ref Hypoglycemic Agent Scrn PX-3018030700 CDM 80307 CPT 301 RC inpatient 253 253 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES HDHP [308136802] 200.33 percent of total billed charges 156.86 240.35 Technical (Hospital) Services Ref Hypoglycemic Agent Scrn PX-3018030700 CDM 80307 CPT 301 RC inpatient 253 253 MEDICA (COMMERCIAL) 94265 [3081118] MEDICA CLAIMS [308111801] 227.7 percent of total billed charges 156.86 240.35 Technical (Hospital) Services Ref Hypoglycemic Agent Scrn PX-3018030700 CDM 80307 CPT 301 RC inpatient 253 253 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES PPO [308136801] 200.33 percent of total billed charges 156.86 240.35 Technical (Hospital) Services Ref Hypoglycemic Agent Scrn PX-3018030700 CDM 80307 CPT 301 RC inpatient 253 253 UNITED HEALTHCARE (COMMERCIAL) [3081199] UNITED HEALTHCARE 87726 [308119901] 156.86 percent of total billed charges 156.86 240.35 Technical (Hospital) Services Ref Hypoglycemic Agent Scrn PX-3018030700 CDM 80307 CPT 301 RC inpatient 253 253 MULTIPLAN INC 34080 [3081285] MULTIPLAN INC [308128501] 240.35 percent of total billed charges 156.86 240.35 Technical (Hospital) Services Ref Hypoglycemic Agent Scrn PX-3018030700 CDM 80307 CPT 301 RC inpatient 253 253 BLUE CROSS BLUE SHIELD WELLMARK SB889 [3081026] BCBS WYOMING [308102603] 240.35 percent of total billed charges 156.86 240.35 Technical (Hospital) Services Ref Hypoglycemic Agent Scrn PX-3018030700 CDM 80307 CPT 301 RC inpatient 253 253 CIGNA 62308 [3081051] CIGNA 62308 [308105105] 200.33 percent of total billed charges 156.86 240.35 Technical (Hospital) Services Ref Hypoglycemic Agent Scrn PX-3018030700 CDM 80307 CPT 301 RC inpatient 253 253 CIGNA 62308 [3081051] CIGNA STATE OF WYOMING [308105107] 200.33 percent of total billed charges 156.86 240.35 Technical (Hospital) Services Ref Hypoglycemic Agent Scrn PX-3018030700 CDM 80307 CPT 301 RC outpatient 253 253 CIGNA 62308 [3081051] CIGNA 62308 [308105105] 202.4 percent of total billed charges 156.86 240.35 Technical (Hospital) Services Ref Hypoglycemic Agent Scrn PX-3018030700 CDM 80307 CPT 301 RC outpatient 253 253 CIGNA 62308 [3081051] CIGNA STATE OF WYOMING [308105107] 202.4 percent of total billed charges 156.86 240.35 Technical (Hospital) Services Ref Hypoglycemic Agent Scrn PX-3018030700 CDM 80307 CPT 301 RC outpatient 253 253 MEDICA (COMMERCIAL) 94265 [3081118] MEDICA CLAIMS [308111801] 227.7 percent of total billed charges 156.86 240.35 Technical (Hospital) Services Ref Hypoglycemic Agent Scrn PX-3018030700 CDM 80307 CPT 301 RC outpatient 253 253 BLUE CROSS BLUE SHIELD WELLMARK SB889 [3081026] BCBS WYOMING [308102603] 240.35 percent of total billed charges 156.86 240.35 Technical (Hospital) Services Ref Hypoglycemic Agent Scrn PX-3018030700 CDM 80307 CPT 301 RC outpatient 253 253 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES HDHP [308136802] 202.4 percent of total billed charges 156.86 240.35 Technical (Hospital) Services Ref Hypoglycemic Agent Scrn PX-3018030700 CDM 80307 CPT 301 RC outpatient 253 253 MULTIPLAN INC 34080 [3081285] MULTIPLAN INC [308128501] 240.35 percent of total billed charges 156.86 240.35 Technical (Hospital) Services Ref Hypoglycemic Agent Scrn PX-3018030700 CDM 80307 CPT 301 RC outpatient 253 253 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES PPO [308136801] 202.4 percent of total billed charges 156.86 240.35 Technical (Hospital) Services Ref Hypoglycemic Agent Scrn PX-3018030700 CDM 80307 CPT 301 RC outpatient 253 253 HEALTHPARTNERS SX009 HEALTHPARTNERS 202.4 percent of total billed charges 156.86 240.35 Technical (Hospital) Services Ref Hypoglycemic Agent Scrn PX-3018030700 CDM 80307 CPT 301 RC outpatient 253 253 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES EPO [308136803] 202.4 percent of total billed charges 156.86 240.35 Technical (Hospital) Services Ref Hypoglycemic Agent Scrn PX-3018030700 CDM 80307 CPT 301 RC outpatient 253 253 UNITED HEALTHCARE (COMMERCIAL) [3081199] UNITED HEALTHCARE 87726 [308119901] 156.86 percent of total billed charges 156.86 240.35 Technical (Hospital) Services "Ref Buprenorphine Screen and Confirmation, Urine" PX-3018030707 CDM 80307 CPT 301 RC outpatient 529 529 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES EPO [308136803] 423.2 percent of total billed charges 327.98 502.55 Technical (Hospital) Services "Ref Buprenorphine Screen and Confirmation, Urine" PX-3018030707 CDM 80307 CPT 301 RC outpatient 529 529 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES PPO [308136801] 423.2 percent of total billed charges 327.98 502.55 Technical (Hospital) Services "Ref Buprenorphine Screen and Confirmation, Urine" PX-3018030707 CDM 80307 CPT 301 RC outpatient 529 529 BLUE CROSS BLUE SHIELD WELLMARK SB889 [3081026] BCBS WYOMING [308102603] 502.55 percent of total billed charges 327.98 502.55 Technical (Hospital) Services "Ref Buprenorphine Screen and Confirmation, Urine" PX-3018030707 CDM 80307 CPT 301 RC outpatient 529 529 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES HDHP [308136802] 423.2 percent of total billed charges 327.98 502.55 Technical (Hospital) Services "Ref Buprenorphine Screen and Confirmation, Urine" PX-3018030707 CDM 80307 CPT 301 RC outpatient 529 529 MULTIPLAN INC 34080 [3081285] MULTIPLAN INC [308128501] 502.55 percent of total billed charges 327.98 502.55 Technical (Hospital) Services "Ref Buprenorphine Screen and Confirmation, Urine" PX-3018030707 CDM 80307 CPT 301 RC outpatient 529 529 UNITED HEALTHCARE (COMMERCIAL) [3081199] UNITED HEALTHCARE 87726 [308119901] 327.98 percent of total billed charges 327.98 502.55 Technical (Hospital) Services "Ref Buprenorphine Screen and Confirmation, Urine" PX-3018030707 CDM 80307 CPT 301 RC outpatient 529 529 HEALTHPARTNERS SX009 HEALTHPARTNERS 423.2 percent of total billed charges 327.98 502.55 Technical (Hospital) Services "Ref Buprenorphine Screen and Confirmation, Urine" PX-3018030707 CDM 80307 CPT 301 RC outpatient 529 529 CIGNA 62308 [3081051] CIGNA 62308 [308105105] 423.2 percent of total billed charges 327.98 502.55 Technical (Hospital) Services "Ref Buprenorphine Screen and Confirmation, Urine" PX-3018030707 CDM 80307 CPT 301 RC outpatient 529 529 CIGNA 62308 [3081051] CIGNA STATE OF WYOMING [308105107] 423.2 percent of total billed charges 327.98 502.55 Technical (Hospital) Services "Ref Buprenorphine Screen and Confirmation, Urine" PX-3018030707 CDM 80307 CPT 301 RC outpatient 529 529 MEDICA (COMMERCIAL) 94265 [3081118] MEDICA CLAIMS [308111801] 476.1 percent of total billed charges 327.98 502.55 Technical (Hospital) Services "Ref Buprenorphine Screen and Confirmation, Urine" PX-3018030707 CDM 80307 CPT 301 RC inpatient 529 529 CIGNA 62308 [3081051] CIGNA 62308 [308105105] 418.86 percent of total billed charges 327.98 502.55 Technical (Hospital) Services "Ref Buprenorphine Screen and Confirmation, Urine" PX-3018030707 CDM 80307 CPT 301 RC inpatient 529 529 CIGNA 62308 [3081051] CIGNA STATE OF WYOMING [308105107] 418.86 percent of total billed charges 327.98 502.55 Technical (Hospital) Services "Ref Buprenorphine Screen and Confirmation, Urine" PX-3018030707 CDM 80307 CPT 301 RC inpatient 529 529 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES PPO [308136801] 418.86 percent of total billed charges 327.98 502.55 Technical (Hospital) Services "Ref Buprenorphine Screen and Confirmation, Urine" PX-3018030707 CDM 80307 CPT 301 RC inpatient 529 529 UNITED HEALTHCARE (COMMERCIAL) [3081199] UNITED HEALTHCARE 87726 [308119901] 327.98 percent of total billed charges 327.98 502.55 Technical (Hospital) Services "Ref Buprenorphine Screen and Confirmation, Urine" PX-3018030707 CDM 80307 CPT 301 RC inpatient 529 529 BLUE CROSS BLUE SHIELD WELLMARK SB889 [3081026] BCBS WYOMING [308102603] 502.55 percent of total billed charges 327.98 502.55 Technical (Hospital) Services "Ref Buprenorphine Screen and Confirmation, Urine" PX-3018030707 CDM 80307 CPT 301 RC inpatient 529 529 MULTIPLAN INC 34080 [3081285] MULTIPLAN INC [308128501] 502.55 percent of total billed charges 327.98 502.55 Technical (Hospital) Services "Ref Buprenorphine Screen and Confirmation, Urine" PX-3018030707 CDM 80307 CPT 301 RC inpatient 529 529 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES HDHP [308136802] 418.86 percent of total billed charges 327.98 502.55 Technical (Hospital) Services "Ref Buprenorphine Screen and Confirmation, Urine" PX-3018030707 CDM 80307 CPT 301 RC inpatient 529 529 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES EPO [308136803] 418.86 percent of total billed charges 327.98 502.55 Technical (Hospital) Services "Ref Buprenorphine Screen and Confirmation, Urine" PX-3018030707 CDM 80307 CPT 301 RC inpatient 529 529 HEALTHPARTNERS SX009 HEALTHPARTNERS 418.86 percent of total billed charges 327.98 502.55 Technical (Hospital) Services "Ref Buprenorphine Screen and Confirmation, Urine" PX-3018030707 CDM 80307 CPT 301 RC inpatient 529 529 MEDICA (COMMERCIAL) 94265 [3081118] MEDICA CLAIMS [308111801] 476.1 percent of total billed charges 327.98 502.55 Technical (Hospital) Services Urine Drug Screen PX-3018030600 CDM 80306 CPT 301 RC inpatient 295 295 HEALTHPARTNERS SX009 HEALTHPARTNERS 233.58 percent of total billed charges 182.9 280.25 Technical (Hospital) Services Urine Drug Screen PX-3018030600 CDM 80306 CPT 301 RC inpatient 295 295 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES EPO [308136803] 233.58 percent of total billed charges 182.9 280.25 Technical (Hospital) Services Urine Drug Screen PX-3018030600 CDM 80306 CPT 301 RC inpatient 295 295 MEDICA (COMMERCIAL) 94265 [3081118] MEDICA CLAIMS [308111801] 265.5 percent of total billed charges 182.9 280.25 Technical (Hospital) Services Urine Drug Screen PX-3018030600 CDM 80306 CPT 301 RC inpatient 295 295 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES HDHP [308136802] 233.58 percent of total billed charges 182.9 280.25 Technical (Hospital) Services Urine Drug Screen PX-3018030600 CDM 80306 CPT 301 RC inpatient 295 295 UNITED HEALTHCARE (COMMERCIAL) [3081199] UNITED HEALTHCARE 87726 [308119901] 182.9 percent of total billed charges 182.9 280.25 Technical (Hospital) Services Urine Drug Screen PX-3018030600 CDM 80306 CPT 301 RC inpatient 295 295 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES PPO [308136801] 233.58 percent of total billed charges 182.9 280.25 Technical (Hospital) Services Urine Drug Screen PX-3018030600 CDM 80306 CPT 301 RC inpatient 295 295 MULTIPLAN INC 34080 [3081285] MULTIPLAN INC [308128501] 280.25 percent of total billed charges 182.9 280.25 Technical (Hospital) Services Urine Drug Screen PX-3018030600 CDM 80306 CPT 301 RC inpatient 295 295 BLUE CROSS BLUE SHIELD WELLMARK SB889 [3081026] BCBS WYOMING [308102603] 280.25 percent of total billed charges 182.9 280.25 Technical (Hospital) Services Urine Drug Screen PX-3018030600 CDM 80306 CPT 301 RC inpatient 295 295 CIGNA 62308 [3081051] CIGNA 62308 [308105105] 233.58 percent of total billed charges 182.9 280.25 Technical (Hospital) Services Urine Drug Screen PX-3018030600 CDM 80306 CPT 301 RC inpatient 295 295 CIGNA 62308 [3081051] CIGNA STATE OF WYOMING [308105107] 233.58 percent of total billed charges 182.9 280.25 Technical (Hospital) Services Urine Drug Screen PX-3018030600 CDM 80306 CPT 301 RC outpatient 295 295 CIGNA 62308 [3081051] CIGNA 62308 [308105105] 236 percent of total billed charges 182.9 280.25 Technical (Hospital) Services Urine Drug Screen PX-3018030600 CDM 80306 CPT 301 RC outpatient 295 295 CIGNA 62308 [3081051] CIGNA STATE OF WYOMING [308105107] 236 percent of total billed charges 182.9 280.25 Technical (Hospital) Services Urine Drug Screen PX-3018030600 CDM 80306 CPT 301 RC outpatient 295 295 MEDICA (COMMERCIAL) 94265 [3081118] MEDICA CLAIMS [308111801] 265.5 percent of total billed charges 182.9 280.25 Technical (Hospital) Services Urine Drug Screen PX-3018030600 CDM 80306 CPT 301 RC outpatient 295 295 HEALTHPARTNERS SX009 HEALTHPARTNERS 236 percent of total billed charges 182.9 280.25 Technical (Hospital) Services Urine Drug Screen PX-3018030600 CDM 80306 CPT 301 RC outpatient 295 295 UNITED HEALTHCARE (COMMERCIAL) [3081199] UNITED HEALTHCARE 87726 [308119901] 182.9 percent of total billed charges 182.9 280.25 Technical (Hospital) Services Urine Drug Screen PX-3018030600 CDM 80306 CPT 301 RC outpatient 295 295 BLUE CROSS BLUE SHIELD WELLMARK SB889 [3081026] BCBS WYOMING [308102603] 280.25 percent of total billed charges 182.9 280.25 Technical (Hospital) Services Urine Drug Screen PX-3018030600 CDM 80306 CPT 301 RC outpatient 295 295 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES HDHP [308136802] 236 percent of total billed charges 182.9 280.25 Technical (Hospital) Services Urine Drug Screen PX-3018030600 CDM 80306 CPT 301 RC outpatient 295 295 MULTIPLAN INC 34080 [3081285] MULTIPLAN INC [308128501] 280.25 percent of total billed charges 182.9 280.25 Technical (Hospital) Services Urine Drug Screen PX-3018030600 CDM 80306 CPT 301 RC outpatient 295 295 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES EPO [308136803] 236 percent of total billed charges 182.9 280.25 Technical (Hospital) Services Urine Drug Screen PX-3018030600 CDM 80306 CPT 301 RC outpatient 295 295 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES PPO [308136801] 236 percent of total billed charges 182.9 280.25 Technical (Hospital) Services Workplace Urine Non-Dot Drug Screen (With Mro) PX-3078030602 CDM 80306 CPT 307 RC inpatient 50 50 BLUE CROSS BLUE SHIELD WELLMARK SB889 [3081026] BCBS WYOMING [308102603] 47.5 percent of total billed charges 31 47.5 Technical (Hospital) Services Workplace Urine Non-Dot Drug Screen (With Mro) PX-3078030602 CDM 80306 CPT 307 RC inpatient 50 50 CIGNA 62308 [3081051] CIGNA 62308 [308105105] 39.59 percent of total billed charges 31 47.5 Technical (Hospital) Services Workplace Urine Non-Dot Drug Screen (With Mro) PX-3078030602 CDM 80306 CPT 307 RC inpatient 50 50 CIGNA 62308 [3081051] CIGNA STATE OF WYOMING [308105107] 39.59 percent of total billed charges 31 47.5 Technical (Hospital) Services Workplace Urine Non-Dot Drug Screen (With Mro) PX-3078030602 CDM 80306 CPT 307 RC inpatient 50 50 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES EPO [308136803] 39.59 percent of total billed charges 31 47.5 Technical (Hospital) Services Workplace Urine Non-Dot Drug Screen (With Mro) PX-3078030602 CDM 80306 CPT 307 RC inpatient 50 50 HEALTHPARTNERS SX009 HEALTHPARTNERS 39.59 percent of total billed charges 31 47.5 Technical (Hospital) Services Workplace Urine Non-Dot Drug Screen (With Mro) PX-3078030602 CDM 80306 CPT 307 RC inpatient 50 50 MEDICA (COMMERCIAL) 94265 [3081118] MEDICA CLAIMS [308111801] 45 percent of total billed charges 31 47.5 Technical (Hospital) Services Workplace Urine Non-Dot Drug Screen (With Mro) PX-3078030602 CDM 80306 CPT 307 RC inpatient 50 50 UNITED HEALTHCARE (COMMERCIAL) [3081199] UNITED HEALTHCARE 87726 [308119901] 31 percent of total billed charges 31 47.5 Technical (Hospital) Services Workplace Urine Non-Dot Drug Screen (With Mro) PX-3078030602 CDM 80306 CPT 307 RC inpatient 50 50 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES HDHP [308136802] 39.59 percent of total billed charges 31 47.5 Technical (Hospital) Services Workplace Urine Non-Dot Drug Screen (With Mro) PX-3078030602 CDM 80306 CPT 307 RC inpatient 50 50 MULTIPLAN INC 34080 [3081285] MULTIPLAN INC [308128501] 47.5 percent of total billed charges 31 47.5 Technical (Hospital) Services Workplace Urine Non-Dot Drug Screen (With Mro) PX-3078030602 CDM 80306 CPT 307 RC inpatient 50 50 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES PPO [308136801] 39.59 percent of total billed charges 31 47.5 Technical (Hospital) Services Workplace Urine Non-Dot Drug Screen (With Mro) PX-3078030602 CDM 80306 CPT 307 RC outpatient 50 50 MEDICA (COMMERCIAL) 94265 [3081118] MEDICA CLAIMS [308111801] 45 percent of total billed charges 31 47.5 Technical (Hospital) Services Workplace Urine Non-Dot Drug Screen (With Mro) PX-3078030602 CDM 80306 CPT 307 RC outpatient 50 50 HEALTHPARTNERS SX009 HEALTHPARTNERS 40 percent of total billed charges 31 47.5 Technical (Hospital) Services Workplace Urine Non-Dot Drug Screen (With Mro) PX-3078030602 CDM 80306 CPT 307 RC outpatient 50 50 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES PPO [308136801] 40 percent of total billed charges 31 47.5 Technical (Hospital) Services Workplace Urine Non-Dot Drug Screen (With Mro) PX-3078030602 CDM 80306 CPT 307 RC outpatient 50 50 UNITED HEALTHCARE (COMMERCIAL) [3081199] UNITED HEALTHCARE 87726 [308119901] 31 percent of total billed charges 31 47.5 Technical (Hospital) Services Workplace Urine Non-Dot Drug Screen (With Mro) PX-3078030602 CDM 80306 CPT 307 RC outpatient 50 50 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES EPO [308136803] 40 percent of total billed charges 31 47.5 Technical (Hospital) Services Workplace Urine Non-Dot Drug Screen (With Mro) PX-3078030602 CDM 80306 CPT 307 RC outpatient 50 50 CIGNA 62308 [3081051] CIGNA 62308 [308105105] 40 percent of total billed charges 31 47.5 Technical (Hospital) Services Workplace Urine Non-Dot Drug Screen (With Mro) PX-3078030602 CDM 80306 CPT 307 RC outpatient 50 50 CIGNA 62308 [3081051] CIGNA STATE OF WYOMING [308105107] 40 percent of total billed charges 31 47.5 Technical (Hospital) Services Workplace Urine Non-Dot Drug Screen (With Mro) PX-3078030602 CDM 80306 CPT 307 RC outpatient 50 50 BLUE CROSS BLUE SHIELD WELLMARK SB889 [3081026] BCBS WYOMING [308102603] 47.5 percent of total billed charges 31 47.5 Technical (Hospital) Services Workplace Urine Non-Dot Drug Screen (With Mro) PX-3078030602 CDM 80306 CPT 307 RC outpatient 50 50 MULTIPLAN INC 34080 [3081285] MULTIPLAN INC [308128501] 47.5 percent of total billed charges 31 47.5 Technical (Hospital) Services Workplace Urine Non-Dot Drug Screen (With Mro) PX-3078030602 CDM 80306 CPT 307 RC outpatient 50 50 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES HDHP [308136802] 40 percent of total billed charges 31 47.5 Technical (Hospital) Services Workplace Urine Dot Drug Screen (With Mro) PX-3078030603 CDM 80306 CPT 307 RC inpatient 50 50 BLUE CROSS BLUE SHIELD WELLMARK SB889 [3081026] BCBS WYOMING [308102603] 47.5 percent of total billed charges 31 47.5 Technical (Hospital) Services Workplace Urine Dot Drug Screen (With Mro) PX-3078030603 CDM 80306 CPT 307 RC inpatient 50 50 CIGNA 62308 [3081051] CIGNA 62308 [308105105] 39.59 percent of total billed charges 31 47.5 Technical (Hospital) Services Workplace Urine Dot Drug Screen (With Mro) PX-3078030603 CDM 80306 CPT 307 RC inpatient 50 50 CIGNA 62308 [3081051] CIGNA STATE OF WYOMING [308105107] 39.59 percent of total billed charges 31 47.5 Technical (Hospital) Services Workplace Urine Dot Drug Screen (With Mro) PX-3078030603 CDM 80306 CPT 307 RC inpatient 50 50 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES EPO [308136803] 39.59 percent of total billed charges 31 47.5 Technical (Hospital) Services Workplace Urine Dot Drug Screen (With Mro) PX-3078030603 CDM 80306 CPT 307 RC inpatient 50 50 HEALTHPARTNERS SX009 HEALTHPARTNERS 39.59 percent of total billed charges 31 47.5 Technical (Hospital) Services Workplace Urine Dot Drug Screen (With Mro) PX-3078030603 CDM 80306 CPT 307 RC inpatient 50 50 MULTIPLAN INC 34080 [3081285] MULTIPLAN INC [308128501] 47.5 percent of total billed charges 31 47.5 Technical (Hospital) Services Workplace Urine Dot Drug Screen (With Mro) PX-3078030603 CDM 80306 CPT 307 RC inpatient 50 50 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES HDHP [308136802] 39.59 percent of total billed charges 31 47.5 Technical (Hospital) Services Workplace Urine Dot Drug Screen (With Mro) PX-3078030603 CDM 80306 CPT 307 RC inpatient 50 50 UNITED HEALTHCARE (COMMERCIAL) [3081199] UNITED HEALTHCARE 87726 [308119901] 31 percent of total billed charges 31 47.5 Technical (Hospital) Services Workplace Urine Dot Drug Screen (With Mro) PX-3078030603 CDM 80306 CPT 307 RC inpatient 50 50 MEDICA (COMMERCIAL) 94265 [3081118] MEDICA CLAIMS [308111801] 45 percent of total billed charges 31 47.5 Technical (Hospital) Services Workplace Urine Dot Drug Screen (With Mro) PX-3078030603 CDM 80306 CPT 307 RC inpatient 50 50 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES PPO [308136801] 39.59 percent of total billed charges 31 47.5 Technical (Hospital) Services Workplace Urine Dot Drug Screen (With Mro) PX-3078030603 CDM 80306 CPT 307 RC outpatient 50 50 UNITED HEALTHCARE (COMMERCIAL) [3081199] UNITED HEALTHCARE 87726 [308119901] 31 percent of total billed charges 31 47.5 Technical (Hospital) Services Workplace Urine Dot Drug Screen (With Mro) PX-3078030603 CDM 80306 CPT 307 RC outpatient 50 50 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES PPO [308136801] 40 percent of total billed charges 31 47.5 Technical (Hospital) Services Workplace Urine Dot Drug Screen (With Mro) PX-3078030603 CDM 80306 CPT 307 RC outpatient 50 50 HEALTHPARTNERS SX009 HEALTHPARTNERS 40 percent of total billed charges 31 47.5 Technical (Hospital) Services Workplace Urine Dot Drug Screen (With Mro) PX-3078030603 CDM 80306 CPT 307 RC outpatient 50 50 BLUE CROSS BLUE SHIELD WELLMARK SB889 [3081026] BCBS WYOMING [308102603] 47.5 percent of total billed charges 31 47.5 Technical (Hospital) Services Workplace Urine Dot Drug Screen (With Mro) PX-3078030603 CDM 80306 CPT 307 RC outpatient 50 50 CIGNA 62308 [3081051] CIGNA 62308 [308105105] 40 percent of total billed charges 31 47.5 Technical (Hospital) Services Workplace Urine Dot Drug Screen (With Mro) PX-3078030603 CDM 80306 CPT 307 RC outpatient 50 50 CIGNA 62308 [3081051] CIGNA STATE OF WYOMING [308105107] 40 percent of total billed charges 31 47.5 Technical (Hospital) Services Workplace Urine Dot Drug Screen (With Mro) PX-3078030603 CDM 80306 CPT 307 RC outpatient 50 50 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES HDHP [308136802] 40 percent of total billed charges 31 47.5 Technical (Hospital) Services Workplace Urine Dot Drug Screen (With Mro) PX-3078030603 CDM 80306 CPT 307 RC outpatient 50 50 MULTIPLAN INC 34080 [3081285] MULTIPLAN INC [308128501] 47.5 percent of total billed charges 31 47.5 Technical (Hospital) Services Workplace Urine Dot Drug Screen (With Mro) PX-3078030603 CDM 80306 CPT 307 RC outpatient 50 50 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES EPO [308136803] 40 percent of total billed charges 31 47.5 Technical (Hospital) Services Workplace Urine Dot Drug Screen (With Mro) PX-3078030603 CDM 80306 CPT 307 RC outpatient 50 50 MEDICA (COMMERCIAL) 94265 [3081118] MEDICA CLAIMS [308111801] 45 percent of total billed charges 31 47.5 Technical (Hospital) Services Ref Flecainide PX-3018029900 CDM 80299 CPT 301 RC inpatient 298 298 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES EPO [308136803] 235.96 percent of total billed charges 184.76 283.1 Technical (Hospital) Services Ref Flecainide PX-3018029900 CDM 80299 CPT 301 RC inpatient 298 298 CIGNA 62308 [3081051] CIGNA 62308 [308105105] 235.96 percent of total billed charges 184.76 283.1 Technical (Hospital) Services Ref Flecainide PX-3018029900 CDM 80299 CPT 301 RC inpatient 298 298 CIGNA 62308 [3081051] CIGNA STATE OF WYOMING [308105107] 235.96 percent of total billed charges 184.76 283.1 Technical (Hospital) Services Ref Flecainide PX-3018029900 CDM 80299 CPT 301 RC inpatient 298 298 MEDICA (COMMERCIAL) 94265 [3081118] MEDICA CLAIMS [308111801] 268.2 percent of total billed charges 184.76 283.1 Technical (Hospital) Services Ref Flecainide PX-3018029900 CDM 80299 CPT 301 RC inpatient 298 298 HEALTHPARTNERS SX009 HEALTHPARTNERS 235.96 percent of total billed charges 184.76 283.1 Technical (Hospital) Services Ref Flecainide PX-3018029900 CDM 80299 CPT 301 RC inpatient 298 298 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES HDHP [308136802] 235.96 percent of total billed charges 184.76 283.1 Technical (Hospital) Services Ref Flecainide PX-3018029900 CDM 80299 CPT 301 RC inpatient 298 298 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES PPO [308136801] 235.96 percent of total billed charges 184.76 283.1 Technical (Hospital) Services Ref Flecainide PX-3018029900 CDM 80299 CPT 301 RC inpatient 298 298 MULTIPLAN INC 34080 [3081285] MULTIPLAN INC [308128501] 283.1 percent of total billed charges 184.76 283.1 Technical (Hospital) Services Ref Flecainide PX-3018029900 CDM 80299 CPT 301 RC inpatient 298 298 BLUE CROSS BLUE SHIELD WELLMARK SB889 [3081026] BCBS WYOMING [308102603] 283.1 percent of total billed charges 184.76 283.1 Technical (Hospital) Services Ref Flecainide PX-3018029900 CDM 80299 CPT 301 RC inpatient 298 298 UNITED HEALTHCARE (COMMERCIAL) [3081199] UNITED HEALTHCARE 87726 [308119901] 184.76 percent of total billed charges 184.76 283.1 Technical (Hospital) Services Ref Flecainide PX-3018029900 CDM 80299 CPT 301 RC outpatient 298 298 CIGNA 62308 [3081051] CIGNA 62308 [308105105] 238.4 percent of total billed charges 184.76 283.1 Technical (Hospital) Services Ref Flecainide PX-3018029900 CDM 80299 CPT 301 RC outpatient 298 298 CIGNA 62308 [3081051] CIGNA STATE OF WYOMING [308105107] 238.4 percent of total billed charges 184.76 283.1 Technical (Hospital) Services Ref Flecainide PX-3018029900 CDM 80299 CPT 301 RC outpatient 298 298 MEDICA (COMMERCIAL) 94265 [3081118] MEDICA CLAIMS [308111801] 268.2 percent of total billed charges 184.76 283.1 Technical (Hospital) Services Ref Flecainide PX-3018029900 CDM 80299 CPT 301 RC outpatient 298 298 HEALTHPARTNERS SX009 HEALTHPARTNERS 238.4 percent of total billed charges 184.76 283.1 Technical (Hospital) Services Ref Flecainide PX-3018029900 CDM 80299 CPT 301 RC outpatient 298 298 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES EPO [308136803] 238.4 percent of total billed charges 184.76 283.1 Technical (Hospital) Services Ref Flecainide PX-3018029900 CDM 80299 CPT 301 RC outpatient 298 298 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES PPO [308136801] 238.4 percent of total billed charges 184.76 283.1 Technical (Hospital) Services Ref Flecainide PX-3018029900 CDM 80299 CPT 301 RC outpatient 298 298 MULTIPLAN INC 34080 [3081285] MULTIPLAN INC [308128501] 283.1 percent of total billed charges 184.76 283.1 Technical (Hospital) Services Ref Flecainide PX-3018029900 CDM 80299 CPT 301 RC outpatient 298 298 BLUE CROSS BLUE SHIELD WELLMARK SB889 [3081026] BCBS WYOMING [308102603] 283.1 percent of total billed charges 184.76 283.1 Technical (Hospital) Services Ref Flecainide PX-3018029900 CDM 80299 CPT 301 RC outpatient 298 298 UNITED HEALTHCARE (COMMERCIAL) [3081199] UNITED HEALTHCARE 87726 [308119901] 184.76 percent of total billed charges 184.76 283.1 Technical (Hospital) Services Ref Flecainide PX-3018029900 CDM 80299 CPT 301 RC outpatient 298 298 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES HDHP [308136802] 238.4 percent of total billed charges 184.76 283.1 Technical (Hospital) Services Ref Amiodarone P S PX-3018029901 CDM 80299 CPT 301 RC outpatient 298 298 CIGNA 62308 [3081051] CIGNA STATE OF WYOMING [308105107] 238.4 percent of total billed charges 184.76 283.1 Technical (Hospital) Services Ref Amiodarone P S PX-3018029901 CDM 80299 CPT 301 RC outpatient 298 298 CIGNA 62308 [3081051] CIGNA 62308 [308105105] 238.4 percent of total billed charges 184.76 283.1 Technical (Hospital) Services Ref Amiodarone P S PX-3018029901 CDM 80299 CPT 301 RC outpatient 298 298 MEDICA (COMMERCIAL) 94265 [3081118] MEDICA CLAIMS [308111801] 268.2 percent of total billed charges 184.76 283.1 Technical (Hospital) Services Ref Amiodarone P S PX-3018029901 CDM 80299 CPT 301 RC outpatient 298 298 HEALTHPARTNERS SX009 HEALTHPARTNERS 238.4 percent of total billed charges 184.76 283.1 Technical (Hospital) Services Ref Amiodarone P S PX-3018029901 CDM 80299 CPT 301 RC outpatient 298 298 UNITED HEALTHCARE (COMMERCIAL) [3081199] UNITED HEALTHCARE 87726 [308119901] 184.76 percent of total billed charges 184.76 283.1 Technical (Hospital) Services Ref Amiodarone P S PX-3018029901 CDM 80299 CPT 301 RC outpatient 298 298 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES EPO [308136803] 238.4 percent of total billed charges 184.76 283.1 Technical (Hospital) Services Ref Amiodarone P S PX-3018029901 CDM 80299 CPT 301 RC outpatient 298 298 BLUE CROSS BLUE SHIELD WELLMARK SB889 [3081026] BCBS WYOMING [308102603] 283.1 percent of total billed charges 184.76 283.1 Technical (Hospital) Services Ref Amiodarone P S PX-3018029901 CDM 80299 CPT 301 RC outpatient 298 298 MULTIPLAN INC 34080 [3081285] MULTIPLAN INC [308128501] 283.1 percent of total billed charges 184.76 283.1 Technical (Hospital) Services Ref Amiodarone P S PX-3018029901 CDM 80299 CPT 301 RC outpatient 298 298 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES HDHP [308136802] 238.4 percent of total billed charges 184.76 283.1 Technical (Hospital) Services Ref Amiodarone P S PX-3018029901 CDM 80299 CPT 301 RC outpatient 298 298 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES PPO [308136801] 238.4 percent of total billed charges 184.76 283.1 Technical (Hospital) Services Ref Amiodarone P S PX-3018029901 CDM 80299 CPT 301 RC inpatient 298 298 CIGNA 62308 [3081051] CIGNA 62308 [308105105] 235.96 percent of total billed charges 184.76 283.1 Technical (Hospital) Services Ref Amiodarone P S PX-3018029901 CDM 80299 CPT 301 RC inpatient 298 298 CIGNA 62308 [3081051] CIGNA STATE OF WYOMING [308105107] 235.96 percent of total billed charges 184.76 283.1 Technical (Hospital) Services Ref Amiodarone P S PX-3018029901 CDM 80299 CPT 301 RC inpatient 298 298 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES EPO [308136803] 235.96 percent of total billed charges 184.76 283.1 Technical (Hospital) Services Ref Amiodarone P S PX-3018029901 CDM 80299 CPT 301 RC inpatient 298 298 HEALTHPARTNERS SX009 HEALTHPARTNERS 235.96 percent of total billed charges 184.76 283.1 Technical (Hospital) Services Ref Amiodarone P S PX-3018029901 CDM 80299 CPT 301 RC inpatient 298 298 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES HDHP [308136802] 235.96 percent of total billed charges 184.76 283.1 Technical (Hospital) Services Ref Amiodarone P S PX-3018029901 CDM 80299 CPT 301 RC inpatient 298 298 MEDICA (COMMERCIAL) 94265 [3081118] MEDICA CLAIMS [308111801] 268.2 percent of total billed charges 184.76 283.1 Technical (Hospital) Services Ref Amiodarone P S PX-3018029901 CDM 80299 CPT 301 RC inpatient 298 298 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES PPO [308136801] 235.96 percent of total billed charges 184.76 283.1 Technical (Hospital) Services Ref Amiodarone P S PX-3018029901 CDM 80299 CPT 301 RC inpatient 298 298 UNITED HEALTHCARE (COMMERCIAL) [3081199] UNITED HEALTHCARE 87726 [308119901] 184.76 percent of total billed charges 184.76 283.1 Technical (Hospital) Services Ref Amiodarone P S PX-3018029901 CDM 80299 CPT 301 RC inpatient 298 298 MULTIPLAN INC 34080 [3081285] MULTIPLAN INC [308128501] 283.1 percent of total billed charges 184.76 283.1 Technical (Hospital) Services Ref Amiodarone P S PX-3018029901 CDM 80299 CPT 301 RC inpatient 298 298 BLUE CROSS BLUE SHIELD WELLMARK SB889 [3081026] BCBS WYOMING [308102603] 283.1 percent of total billed charges 184.76 283.1 Technical (Hospital) Services Ref Carbamazepine 10 11 Epoxide PX-3018029902 CDM 80299 CPT 301 RC outpatient 298 298 HEALTHPARTNERS SX009 HEALTHPARTNERS 238.4 percent of total billed charges 184.76 283.1 Technical (Hospital) Services Ref Carbamazepine 10 11 Epoxide PX-3018029902 CDM 80299 CPT 301 RC outpatient 298 298 UNITED HEALTHCARE (COMMERCIAL) [3081199] UNITED HEALTHCARE 87726 [308119901] 184.76 percent of total billed charges 184.76 283.1 Technical (Hospital) Services Ref Carbamazepine 10 11 Epoxide PX-3018029902 CDM 80299 CPT 301 RC outpatient 298 298 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES EPO [308136803] 238.4 percent of total billed charges 184.76 283.1 Technical (Hospital) Services Ref Carbamazepine 10 11 Epoxide PX-3018029902 CDM 80299 CPT 301 RC outpatient 298 298 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES PPO [308136801] 238.4 percent of total billed charges 184.76 283.1 Technical (Hospital) Services Ref Carbamazepine 10 11 Epoxide PX-3018029902 CDM 80299 CPT 301 RC outpatient 298 298 BLUE CROSS BLUE SHIELD WELLMARK SB889 [3081026] BCBS WYOMING [308102603] 283.1 percent of total billed charges 184.76 283.1 Technical (Hospital) Services Ref Carbamazepine 10 11 Epoxide PX-3018029902 CDM 80299 CPT 301 RC outpatient 298 298 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES HDHP [308136802] 238.4 percent of total billed charges 184.76 283.1 Technical (Hospital) Services Ref Carbamazepine 10 11 Epoxide PX-3018029902 CDM 80299 CPT 301 RC outpatient 298 298 MULTIPLAN INC 34080 [3081285] MULTIPLAN INC [308128501] 283.1 percent of total billed charges 184.76 283.1 Technical (Hospital) Services Ref Carbamazepine 10 11 Epoxide PX-3018029902 CDM 80299 CPT 301 RC outpatient 298 298 MEDICA (COMMERCIAL) 94265 [3081118] MEDICA CLAIMS [308111801] 268.2 percent of total billed charges 184.76 283.1 Technical (Hospital) Services Ref Carbamazepine 10 11 Epoxide PX-3018029902 CDM 80299 CPT 301 RC outpatient 298 298 CIGNA 62308 [3081051] CIGNA 62308 [308105105] 238.4 percent of total billed charges 184.76 283.1 Technical (Hospital) Services Ref Carbamazepine 10 11 Epoxide PX-3018029902 CDM 80299 CPT 301 RC outpatient 298 298 CIGNA 62308 [3081051] CIGNA STATE OF WYOMING [308105107] 238.4 percent of total billed charges 184.76 283.1 Technical (Hospital) Services Ref Carbamazepine 10 11 Epoxide PX-3018029902 CDM 80299 CPT 301 RC inpatient 298 298 BLUE CROSS BLUE SHIELD WELLMARK SB889 [3081026] BCBS WYOMING [308102603] 283.1 percent of total billed charges 184.76 283.1 Technical (Hospital) Services Ref Carbamazepine 10 11 Epoxide PX-3018029902 CDM 80299 CPT 301 RC inpatient 298 298 MULTIPLAN INC 34080 [3081285] MULTIPLAN INC [308128501] 283.1 percent of total billed charges 184.76 283.1 Technical (Hospital) Services Ref Carbamazepine 10 11 Epoxide PX-3018029902 CDM 80299 CPT 301 RC inpatient 298 298 UNITED HEALTHCARE (COMMERCIAL) [3081199] UNITED HEALTHCARE 87726 [308119901] 184.76 percent of total billed charges 184.76 283.1 Technical (Hospital) Services Ref Carbamazepine 10 11 Epoxide PX-3018029902 CDM 80299 CPT 301 RC inpatient 298 298 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES PPO [308136801] 235.96 percent of total billed charges 184.76 283.1 Technical (Hospital) Services Ref Carbamazepine 10 11 Epoxide PX-3018029902 CDM 80299 CPT 301 RC inpatient 298 298 MEDICA (COMMERCIAL) 94265 [3081118] MEDICA CLAIMS [308111801] 268.2 percent of total billed charges 184.76 283.1 Technical (Hospital) Services Ref Carbamazepine 10 11 Epoxide PX-3018029902 CDM 80299 CPT 301 RC inpatient 298 298 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES HDHP [308136802] 235.96 percent of total billed charges 184.76 283.1 Technical (Hospital) Services Ref Carbamazepine 10 11 Epoxide PX-3018029902 CDM 80299 CPT 301 RC inpatient 298 298 HEALTHPARTNERS SX009 HEALTHPARTNERS 235.96 percent of total billed charges 184.76 283.1 Technical (Hospital) Services Ref Carbamazepine 10 11 Epoxide PX-3018029902 CDM 80299 CPT 301 RC inpatient 298 298 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES EPO [308136803] 235.96 percent of total billed charges 184.76 283.1 Technical (Hospital) Services Ref Carbamazepine 10 11 Epoxide PX-3018029902 CDM 80299 CPT 301 RC inpatient 298 298 CIGNA 62308 [3081051] CIGNA 62308 [308105105] 235.96 percent of total billed charges 184.76 283.1 Technical (Hospital) Services Ref Carbamazepine 10 11 Epoxide PX-3018029902 CDM 80299 CPT 301 RC inpatient 298 298 CIGNA 62308 [3081051] CIGNA STATE OF WYOMING [308105107] 235.96 percent of total billed charges 184.76 283.1 Technical (Hospital) Services Ref Mexiletine PX-3018029903 CDM 80299 CPT 301 RC inpatient 298 298 CIGNA 62308 [3081051] CIGNA 62308 [308105105] 235.96 percent of total billed charges 184.76 283.1 Technical (Hospital) Services Ref Mexiletine PX-3018029903 CDM 80299 CPT 301 RC inpatient 298 298 CIGNA 62308 [3081051] CIGNA STATE OF WYOMING [308105107] 235.96 percent of total billed charges 184.76 283.1 Technical (Hospital) Services Ref Mexiletine PX-3018029903 CDM 80299 CPT 301 RC inpatient 298 298 BLUE CROSS BLUE SHIELD WELLMARK SB889 [3081026] BCBS WYOMING [308102603] 283.1 percent of total billed charges 184.76 283.1 Technical (Hospital) Services Ref Mexiletine PX-3018029903 CDM 80299 CPT 301 RC inpatient 298 298 MULTIPLAN INC 34080 [3081285] MULTIPLAN INC [308128501] 283.1 percent of total billed charges 184.76 283.1 Technical (Hospital) Services Ref Mexiletine PX-3018029903 CDM 80299 CPT 301 RC inpatient 298 298 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES HDHP [308136802] 235.96 percent of total billed charges 184.76 283.1 Technical (Hospital) Services Ref Mexiletine PX-3018029903 CDM 80299 CPT 301 RC inpatient 298 298 UNITED HEALTHCARE (COMMERCIAL) [3081199] UNITED HEALTHCARE 87726 [308119901] 184.76 percent of total billed charges 184.76 283.1 Technical (Hospital) Services Ref Mexiletine PX-3018029903 CDM 80299 CPT 301 RC inpatient 298 298 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES PPO [308136801] 235.96 percent of total billed charges 184.76 283.1 Technical (Hospital) Services Ref Mexiletine PX-3018029903 CDM 80299 CPT 301 RC inpatient 298 298 MEDICA (COMMERCIAL) 94265 [3081118] MEDICA CLAIMS [308111801] 268.2 percent of total billed charges 184.76 283.1 Technical (Hospital) Services Ref Mexiletine PX-3018029903 CDM 80299 CPT 301 RC inpatient 298 298 HEALTHPARTNERS SX009 HEALTHPARTNERS 235.96 percent of total billed charges 184.76 283.1 Technical (Hospital) Services Ref Mexiletine PX-3018029903 CDM 80299 CPT 301 RC inpatient 298 298 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES EPO [308136803] 235.96 percent of total billed charges 184.76 283.1 Technical (Hospital) Services Ref Mexiletine PX-3018029903 CDM 80299 CPT 301 RC outpatient 298 298 MULTIPLAN INC 34080 [3081285] MULTIPLAN INC [308128501] 283.1 percent of total billed charges 184.76 283.1 Technical (Hospital) Services Ref Mexiletine PX-3018029903 CDM 80299 CPT 301 RC outpatient 298 298 BLUE CROSS BLUE SHIELD WELLMARK SB889 [3081026] BCBS WYOMING [308102603] 283.1 percent of total billed charges 184.76 283.1 Technical (Hospital) Services Ref Mexiletine PX-3018029903 CDM 80299 CPT 301 RC outpatient 298 298 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES HDHP [308136802] 238.4 percent of total billed charges 184.76 283.1 Technical (Hospital) Services Ref Mexiletine PX-3018029903 CDM 80299 CPT 301 RC outpatient 298 298 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES PPO [308136801] 238.4 percent of total billed charges 184.76 283.1 Technical (Hospital) Services Ref Mexiletine PX-3018029903 CDM 80299 CPT 301 RC outpatient 298 298 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES EPO [308136803] 238.4 percent of total billed charges 184.76 283.1 Technical (Hospital) Services Ref Mexiletine PX-3018029903 CDM 80299 CPT 301 RC outpatient 298 298 UNITED HEALTHCARE (COMMERCIAL) [3081199] UNITED HEALTHCARE 87726 [308119901] 184.76 percent of total billed charges 184.76 283.1 Technical (Hospital) Services Ref Mexiletine PX-3018029903 CDM 80299 CPT 301 RC outpatient 298 298 HEALTHPARTNERS SX009 HEALTHPARTNERS 238.4 percent of total billed charges 184.76 283.1 Technical (Hospital) Services Ref Mexiletine PX-3018029903 CDM 80299 CPT 301 RC outpatient 298 298 MEDICA (COMMERCIAL) 94265 [3081118] MEDICA CLAIMS [308111801] 268.2 percent of total billed charges 184.76 283.1 Technical (Hospital) Services Ref Mexiletine PX-3018029903 CDM 80299 CPT 301 RC outpatient 298 298 CIGNA 62308 [3081051] CIGNA 62308 [308105105] 238.4 percent of total billed charges 184.76 283.1 Technical (Hospital) Services Ref Mexiletine PX-3018029903 CDM 80299 CPT 301 RC outpatient 298 298 CIGNA 62308 [3081051] CIGNA STATE OF WYOMING [308105107] 238.4 percent of total billed charges 184.76 283.1 Technical (Hospital) Services Ref Warfarin Coumadin PX-3018029904 CDM 80299 CPT 301 RC inpatient 298 298 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES HDHP [308136802] 235.96 percent of total billed charges 184.76 283.1 Technical (Hospital) Services Ref Warfarin Coumadin PX-3018029904 CDM 80299 CPT 301 RC inpatient 298 298 BLUE CROSS BLUE SHIELD WELLMARK SB889 [3081026] BCBS WYOMING [308102603] 283.1 percent of total billed charges 184.76 283.1 Technical (Hospital) Services Ref Warfarin Coumadin PX-3018029904 CDM 80299 CPT 301 RC inpatient 298 298 MULTIPLAN INC 34080 [3081285] MULTIPLAN INC [308128501] 283.1 percent of total billed charges 184.76 283.1 Technical (Hospital) Services Ref Warfarin Coumadin PX-3018029904 CDM 80299 CPT 301 RC inpatient 298 298 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES PPO [308136801] 235.96 percent of total billed charges 184.76 283.1 Technical (Hospital) Services Ref Warfarin Coumadin PX-3018029904 CDM 80299 CPT 301 RC inpatient 298 298 UNITED HEALTHCARE (COMMERCIAL) [3081199] UNITED HEALTHCARE 87726 [308119901] 184.76 percent of total billed charges 184.76 283.1 Technical (Hospital) Services Ref Warfarin Coumadin PX-3018029904 CDM 80299 CPT 301 RC inpatient 298 298 MEDICA (COMMERCIAL) 94265 [3081118] MEDICA CLAIMS [308111801] 268.2 percent of total billed charges 184.76 283.1 Technical (Hospital) Services Ref Warfarin Coumadin PX-3018029904 CDM 80299 CPT 301 RC inpatient 298 298 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES EPO [308136803] 235.96 percent of total billed charges 184.76 283.1 Technical (Hospital) Services Ref Warfarin Coumadin PX-3018029904 CDM 80299 CPT 301 RC inpatient 298 298 HEALTHPARTNERS SX009 HEALTHPARTNERS 235.96 percent of total billed charges 184.76 283.1 Technical (Hospital) Services Ref Warfarin Coumadin PX-3018029904 CDM 80299 CPT 301 RC inpatient 298 298 CIGNA 62308 [3081051] CIGNA 62308 [308105105] 235.96 percent of total billed charges 184.76 283.1 Technical (Hospital) Services Ref Warfarin Coumadin PX-3018029904 CDM 80299 CPT 301 RC inpatient 298 298 CIGNA 62308 [3081051] CIGNA STATE OF WYOMING [308105107] 235.96 percent of total billed charges 184.76 283.1 Technical (Hospital) Services Ref Warfarin Coumadin PX-3018029904 CDM 80299 CPT 301 RC outpatient 298 298 CIGNA 62308 [3081051] CIGNA 62308 [308105105] 238.4 percent of total billed charges 184.76 283.1 Technical (Hospital) Services Ref Warfarin Coumadin PX-3018029904 CDM 80299 CPT 301 RC outpatient 298 298 CIGNA 62308 [3081051] CIGNA STATE OF WYOMING [308105107] 238.4 percent of total billed charges 184.76 283.1 Technical (Hospital) Services Ref Warfarin Coumadin PX-3018029904 CDM 80299 CPT 301 RC outpatient 298 298 MEDICA (COMMERCIAL) 94265 [3081118] MEDICA CLAIMS [308111801] 268.2 percent of total billed charges 184.76 283.1 Technical (Hospital) Services Ref Warfarin Coumadin PX-3018029904 CDM 80299 CPT 301 RC outpatient 298 298 BLUE CROSS BLUE SHIELD WELLMARK SB889 [3081026] BCBS WYOMING [308102603] 283.1 percent of total billed charges 184.76 283.1 Technical (Hospital) Services Ref Warfarin Coumadin PX-3018029904 CDM 80299 CPT 301 RC outpatient 298 298 MULTIPLAN INC 34080 [3081285] MULTIPLAN INC [308128501] 283.1 percent of total billed charges 184.76 283.1 Technical (Hospital) Services Ref Warfarin Coumadin PX-3018029904 CDM 80299 CPT 301 RC outpatient 298 298 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES HDHP [308136802] 238.4 percent of total billed charges 184.76 283.1 Technical (Hospital) Services Ref Warfarin Coumadin PX-3018029904 CDM 80299 CPT 301 RC outpatient 298 298 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES PPO [308136801] 238.4 percent of total billed charges 184.76 283.1 Technical (Hospital) Services Ref Warfarin Coumadin PX-3018029904 CDM 80299 CPT 301 RC outpatient 298 298 HEALTHPARTNERS SX009 HEALTHPARTNERS 238.4 percent of total billed charges 184.76 283.1 Technical (Hospital) Services Ref Warfarin Coumadin PX-3018029904 CDM 80299 CPT 301 RC outpatient 298 298 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES EPO [308136803] 238.4 percent of total billed charges 184.76 283.1 Technical (Hospital) Services Ref Warfarin Coumadin PX-3018029904 CDM 80299 CPT 301 RC outpatient 298 298 UNITED HEALTHCARE (COMMERCIAL) [3081199] UNITED HEALTHCARE 87726 [308119901] 184.76 percent of total billed charges 184.76 283.1 Technical (Hospital) Services Ref Flecainide PX-3018029905 CDM 80299 CPT 301 RC outpatient 298 298 MULTIPLAN INC 34080 [3081285] MULTIPLAN INC [308128501] 283.1 percent of total billed charges 184.76 283.1 Technical (Hospital) Services Ref Flecainide PX-3018029905 CDM 80299 CPT 301 RC outpatient 298 298 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES HDHP [308136802] 238.4 percent of total billed charges 184.76 283.1 Technical (Hospital) Services Ref Flecainide PX-3018029905 CDM 80299 CPT 301 RC outpatient 298 298 BLUE CROSS BLUE SHIELD WELLMARK SB889 [3081026] BCBS WYOMING [308102603] 283.1 percent of total billed charges 184.76 283.1 Technical (Hospital) Services Ref Flecainide PX-3018029905 CDM 80299 CPT 301 RC outpatient 298 298 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES PPO [308136801] 238.4 percent of total billed charges 184.76 283.1 Technical (Hospital) Services Ref Flecainide PX-3018029905 CDM 80299 CPT 301 RC outpatient 298 298 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES EPO [308136803] 238.4 percent of total billed charges 184.76 283.1 Technical (Hospital) Services Ref Flecainide PX-3018029905 CDM 80299 CPT 301 RC outpatient 298 298 HEALTHPARTNERS SX009 HEALTHPARTNERS 238.4 percent of total billed charges 184.76 283.1 Technical (Hospital) Services Ref Flecainide PX-3018029905 CDM 80299 CPT 301 RC outpatient 298 298 UNITED HEALTHCARE (COMMERCIAL) [3081199] UNITED HEALTHCARE 87726 [308119901] 184.76 percent of total billed charges 184.76 283.1 Technical (Hospital) Services Ref Flecainide PX-3018029905 CDM 80299 CPT 301 RC outpatient 298 298 MEDICA (COMMERCIAL) 94265 [3081118] MEDICA CLAIMS [308111801] 268.2 percent of total billed charges 184.76 283.1 Technical (Hospital) Services Ref Flecainide PX-3018029905 CDM 80299 CPT 301 RC outpatient 298 298 CIGNA 62308 [3081051] CIGNA 62308 [308105105] 238.4 percent of total billed charges 184.76 283.1 Technical (Hospital) Services Ref Flecainide PX-3018029905 CDM 80299 CPT 301 RC outpatient 298 298 CIGNA 62308 [3081051] CIGNA STATE OF WYOMING [308105107] 238.4 percent of total billed charges 184.76 283.1 Technical (Hospital) Services Ref Flecainide PX-3018029905 CDM 80299 CPT 301 RC inpatient 298 298 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES PPO [308136801] 235.96 percent of total billed charges 184.76 283.1 Technical (Hospital) Services Ref Flecainide PX-3018029905 CDM 80299 CPT 301 RC inpatient 298 298 UNITED HEALTHCARE (COMMERCIAL) [3081199] UNITED HEALTHCARE 87726 [308119901] 184.76 percent of total billed charges 184.76 283.1 Technical (Hospital) Services Ref Flecainide PX-3018029905 CDM 80299 CPT 301 RC inpatient 298 298 MULTIPLAN INC 34080 [3081285] MULTIPLAN INC [308128501] 283.1 percent of total billed charges 184.76 283.1 Technical (Hospital) Services Ref Flecainide PX-3018029905 CDM 80299 CPT 301 RC inpatient 298 298 BLUE CROSS BLUE SHIELD WELLMARK SB889 [3081026] BCBS WYOMING [308102603] 283.1 percent of total billed charges 184.76 283.1 Technical (Hospital) Services Ref Flecainide PX-3018029905 CDM 80299 CPT 301 RC inpatient 298 298 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES EPO [308136803] 235.96 percent of total billed charges 184.76 283.1 Technical (Hospital) Services Ref Flecainide PX-3018029905 CDM 80299 CPT 301 RC inpatient 298 298 HEALTHPARTNERS SX009 HEALTHPARTNERS 235.96 percent of total billed charges 184.76 283.1 Technical (Hospital) Services Ref Flecainide PX-3018029905 CDM 80299 CPT 301 RC inpatient 298 298 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES HDHP [308136802] 235.96 percent of total billed charges 184.76 283.1 Technical (Hospital) Services Ref Flecainide PX-3018029905 CDM 80299 CPT 301 RC inpatient 298 298 MEDICA (COMMERCIAL) 94265 [3081118] MEDICA CLAIMS [308111801] 268.2 percent of total billed charges 184.76 283.1 Technical (Hospital) Services Ref Flecainide PX-3018029905 CDM 80299 CPT 301 RC inpatient 298 298 CIGNA 62308 [3081051] CIGNA 62308 [308105105] 235.96 percent of total billed charges 184.76 283.1 Technical (Hospital) Services Ref Flecainide PX-3018029905 CDM 80299 CPT 301 RC inpatient 298 298 CIGNA 62308 [3081051] CIGNA STATE OF WYOMING [308105107] 235.96 percent of total billed charges 184.76 283.1 Technical (Hospital) Services Ref Infliximab PX-3018029906 CDM 80299 CPT 301 RC outpatient 298 298 CIGNA 62308 [3081051] CIGNA 62308 [308105105] 238.4 percent of total billed charges 184.76 283.1 Technical (Hospital) Services Ref Infliximab PX-3018029906 CDM 80299 CPT 301 RC outpatient 298 298 CIGNA 62308 [3081051] CIGNA STATE OF WYOMING [308105107] 238.4 percent of total billed charges 184.76 283.1 Technical (Hospital) Services Ref Infliximab PX-3018029906 CDM 80299 CPT 301 RC outpatient 298 298 MEDICA (COMMERCIAL) 94265 [3081118] MEDICA CLAIMS [308111801] 268.2 percent of total billed charges 184.76 283.1 Technical (Hospital) Services Ref Infliximab PX-3018029906 CDM 80299 CPT 301 RC outpatient 298 298 BLUE CROSS BLUE SHIELD WELLMARK SB889 [3081026] BCBS WYOMING [308102603] 283.1 percent of total billed charges 184.76 283.1 Technical (Hospital) Services Ref Infliximab PX-3018029906 CDM 80299 CPT 301 RC outpatient 298 298 MULTIPLAN INC 34080 [3081285] MULTIPLAN INC [308128501] 283.1 percent of total billed charges 184.76 283.1 Technical (Hospital) Services Ref Infliximab PX-3018029906 CDM 80299 CPT 301 RC outpatient 298 298 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES HDHP [308136802] 238.4 percent of total billed charges 184.76 283.1 Technical (Hospital) Services Ref Infliximab PX-3018029906 CDM 80299 CPT 301 RC outpatient 298 298 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES PPO [308136801] 238.4 percent of total billed charges 184.76 283.1 Technical (Hospital) Services Ref Infliximab PX-3018029906 CDM 80299 CPT 301 RC outpatient 298 298 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES EPO [308136803] 238.4 percent of total billed charges 184.76 283.1 Technical (Hospital) Services Ref Infliximab PX-3018029906 CDM 80299 CPT 301 RC outpatient 298 298 UNITED HEALTHCARE (COMMERCIAL) [3081199] UNITED HEALTHCARE 87726 [308119901] 184.76 percent of total billed charges 184.76 283.1 Technical (Hospital) Services Ref Infliximab PX-3018029906 CDM 80299 CPT 301 RC outpatient 298 298 HEALTHPARTNERS SX009 HEALTHPARTNERS 238.4 percent of total billed charges 184.76 283.1 Technical (Hospital) Services Ref Infliximab PX-3018029906 CDM 80299 CPT 301 RC inpatient 298 298 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES EPO [308136803] 235.96 percent of total billed charges 184.76 283.1 Technical (Hospital) Services Ref Infliximab PX-3018029906 CDM 80299 CPT 301 RC inpatient 298 298 HEALTHPARTNERS SX009 HEALTHPARTNERS 235.96 percent of total billed charges 184.76 283.1 Technical (Hospital) Services Ref Infliximab PX-3018029906 CDM 80299 CPT 301 RC inpatient 298 298 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES HDHP [308136802] 235.96 percent of total billed charges 184.76 283.1 Technical (Hospital) Services Ref Infliximab PX-3018029906 CDM 80299 CPT 301 RC inpatient 298 298 MEDICA (COMMERCIAL) 94265 [3081118] MEDICA CLAIMS [308111801] 268.2 percent of total billed charges 184.76 283.1 Technical (Hospital) Services Ref Infliximab PX-3018029906 CDM 80299 CPT 301 RC inpatient 298 298 UNITED HEALTHCARE (COMMERCIAL) [3081199] UNITED HEALTHCARE 87726 [308119901] 184.76 percent of total billed charges 184.76 283.1 Technical (Hospital) Services Ref Infliximab PX-3018029906 CDM 80299 CPT 301 RC inpatient 298 298 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES PPO [308136801] 235.96 percent of total billed charges 184.76 283.1 Technical (Hospital) Services Ref Infliximab PX-3018029906 CDM 80299 CPT 301 RC inpatient 298 298 MULTIPLAN INC 34080 [3081285] MULTIPLAN INC [308128501] 283.1 percent of total billed charges 184.76 283.1 Technical (Hospital) Services Ref Infliximab PX-3018029906 CDM 80299 CPT 301 RC inpatient 298 298 BLUE CROSS BLUE SHIELD WELLMARK SB889 [3081026] BCBS WYOMING [308102603] 283.1 percent of total billed charges 184.76 283.1 Technical (Hospital) Services Ref Infliximab PX-3018029906 CDM 80299 CPT 301 RC inpatient 298 298 CIGNA 62308 [3081051] CIGNA 62308 [308105105] 235.96 percent of total billed charges 184.76 283.1 Technical (Hospital) Services Ref Infliximab PX-3018029906 CDM 80299 CPT 301 RC inpatient 298 298 CIGNA 62308 [3081051] CIGNA STATE OF WYOMING [308105107] 235.96 percent of total billed charges 184.76 283.1 Technical (Hospital) Services Ref Methotrexate PX-3018029907 CDM 80299 CPT 301 RC inpatient 298 298 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES PPO [308136801] 235.96 percent of total billed charges 184.76 283.1 Technical (Hospital) Services Ref Methotrexate PX-3018029907 CDM 80299 CPT 301 RC inpatient 298 298 UNITED HEALTHCARE (COMMERCIAL) [3081199] UNITED HEALTHCARE 87726 [308119901] 184.76 percent of total billed charges 184.76 283.1 Technical (Hospital) Services Ref Methotrexate PX-3018029907 CDM 80299 CPT 301 RC inpatient 298 298 MULTIPLAN INC 34080 [3081285] MULTIPLAN INC [308128501] 283.1 percent of total billed charges 184.76 283.1 Technical (Hospital) Services Ref Methotrexate PX-3018029907 CDM 80299 CPT 301 RC inpatient 298 298 BLUE CROSS BLUE SHIELD WELLMARK SB889 [3081026] BCBS WYOMING [308102603] 283.1 percent of total billed charges 184.76 283.1 Technical (Hospital) Services Ref Methotrexate PX-3018029907 CDM 80299 CPT 301 RC inpatient 298 298 MEDICA (COMMERCIAL) 94265 [3081118] MEDICA CLAIMS [308111801] 268.2 percent of total billed charges 184.76 283.1 Technical (Hospital) Services Ref Methotrexate PX-3018029907 CDM 80299 CPT 301 RC inpatient 298 298 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES HDHP [308136802] 235.96 percent of total billed charges 184.76 283.1 Technical (Hospital) Services Ref Methotrexate PX-3018029907 CDM 80299 CPT 301 RC inpatient 298 298 HEALTHPARTNERS SX009 HEALTHPARTNERS 235.96 percent of total billed charges 184.76 283.1 Technical (Hospital) Services Ref Methotrexate PX-3018029907 CDM 80299 CPT 301 RC inpatient 298 298 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES EPO [308136803] 235.96 percent of total billed charges 184.76 283.1 Technical (Hospital) Services Ref Methotrexate PX-3018029907 CDM 80299 CPT 301 RC inpatient 298 298 CIGNA 62308 [3081051] CIGNA 62308 [308105105] 235.96 percent of total billed charges 184.76 283.1 Technical (Hospital) Services Ref Methotrexate PX-3018029907 CDM 80299 CPT 301 RC inpatient 298 298 CIGNA 62308 [3081051] CIGNA STATE OF WYOMING [308105107] 235.96 percent of total billed charges 184.76 283.1 Technical (Hospital) Services Ref Methotrexate PX-3018029907 CDM 80299 CPT 301 RC outpatient 298 298 MULTIPLAN INC 34080 [3081285] MULTIPLAN INC [308128501] 283.1 percent of total billed charges 184.76 283.1 Technical (Hospital) Services Ref Methotrexate PX-3018029907 CDM 80299 CPT 301 RC outpatient 298 298 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES HDHP [308136802] 238.4 percent of total billed charges 184.76 283.1 Technical (Hospital) Services Ref Methotrexate PX-3018029907 CDM 80299 CPT 301 RC outpatient 298 298 BLUE CROSS BLUE SHIELD WELLMARK SB889 [3081026] BCBS WYOMING [308102603] 283.1 percent of total billed charges 184.76 283.1 Technical (Hospital) Services Ref Methotrexate PX-3018029907 CDM 80299 CPT 301 RC outpatient 298 298 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES EPO [308136803] 238.4 percent of total billed charges 184.76 283.1 Technical (Hospital) Services Ref Methotrexate PX-3018029907 CDM 80299 CPT 301 RC outpatient 298 298 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES PPO [308136801] 238.4 percent of total billed charges 184.76 283.1 Technical (Hospital) Services Ref Methotrexate PX-3018029907 CDM 80299 CPT 301 RC outpatient 298 298 UNITED HEALTHCARE (COMMERCIAL) [3081199] UNITED HEALTHCARE 87726 [308119901] 184.76 percent of total billed charges 184.76 283.1 Technical (Hospital) Services Ref Methotrexate PX-3018029907 CDM 80299 CPT 301 RC outpatient 298 298 HEALTHPARTNERS SX009 HEALTHPARTNERS 238.4 percent of total billed charges 184.76 283.1 Technical (Hospital) Services Ref Methotrexate PX-3018029907 CDM 80299 CPT 301 RC outpatient 298 298 MEDICA (COMMERCIAL) 94265 [3081118] MEDICA CLAIMS [308111801] 268.2 percent of total billed charges 184.76 283.1 Technical (Hospital) Services Ref Methotrexate PX-3018029907 CDM 80299 CPT 301 RC outpatient 298 298 CIGNA 62308 [3081051] CIGNA 62308 [308105105] 238.4 percent of total billed charges 184.76 283.1 Technical (Hospital) Services Ref Methotrexate PX-3018029907 CDM 80299 CPT 301 RC outpatient 298 298 CIGNA 62308 [3081051] CIGNA STATE OF WYOMING [308105107] 238.4 percent of total billed charges 184.76 283.1 Technical (Hospital) Services Ref Felbamate Level PX-3018029911 CDM 80299 CPT 301 RC inpatient 298 298 CIGNA 62308 [3081051] CIGNA 62308 [308105105] 235.96 percent of total billed charges 184.76 283.1 Technical (Hospital) Services Ref Felbamate Level PX-3018029911 CDM 80299 CPT 301 RC inpatient 298 298 CIGNA 62308 [3081051] CIGNA STATE OF WYOMING [308105107] 235.96 percent of total billed charges 184.76 283.1 Technical (Hospital) Services Ref Felbamate Level PX-3018029911 CDM 80299 CPT 301 RC inpatient 298 298 MEDICA (COMMERCIAL) 94265 [3081118] MEDICA CLAIMS [308111801] 268.2 percent of total billed charges 184.76 283.1 Technical (Hospital) Services Ref Felbamate Level PX-3018029911 CDM 80299 CPT 301 RC inpatient 298 298 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES HDHP [308136802] 235.96 percent of total billed charges 184.76 283.1 Technical (Hospital) Services Ref Felbamate Level PX-3018029911 CDM 80299 CPT 301 RC inpatient 298 298 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES EPO [308136803] 235.96 percent of total billed charges 184.76 283.1 Technical (Hospital) Services Ref Felbamate Level PX-3018029911 CDM 80299 CPT 301 RC inpatient 298 298 HEALTHPARTNERS SX009 HEALTHPARTNERS 235.96 percent of total billed charges 184.76 283.1 Technical (Hospital) Services Ref Felbamate Level PX-3018029911 CDM 80299 CPT 301 RC inpatient 298 298 BLUE CROSS BLUE SHIELD WELLMARK SB889 [3081026] BCBS WYOMING [308102603] 283.1 percent of total billed charges 184.76 283.1 Technical (Hospital) Services Ref Felbamate Level PX-3018029911 CDM 80299 CPT 301 RC inpatient 298 298 MULTIPLAN INC 34080 [3081285] MULTIPLAN INC [308128501] 283.1 percent of total billed charges 184.76 283.1 Technical (Hospital) Services Ref Felbamate Level PX-3018029911 CDM 80299 CPT 301 RC inpatient 298 298 UNITED HEALTHCARE (COMMERCIAL) [3081199] UNITED HEALTHCARE 87726 [308119901] 184.76 percent of total billed charges 184.76 283.1 Technical (Hospital) Services Ref Felbamate Level PX-3018029911 CDM 80299 CPT 301 RC inpatient 298 298 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES PPO [308136801] 235.96 percent of total billed charges 184.76 283.1 Technical (Hospital) Services Ref Felbamate Level PX-3018029911 CDM 80299 CPT 301 RC outpatient 298 298 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES HDHP [308136802] 238.4 percent of total billed charges 184.76 283.1 Technical (Hospital) Services Ref Felbamate Level PX-3018029911 CDM 80299 CPT 301 RC outpatient 298 298 MULTIPLAN INC 34080 [3081285] MULTIPLAN INC [308128501] 283.1 percent of total billed charges 184.76 283.1 Technical (Hospital) Services Ref Felbamate Level PX-3018029911 CDM 80299 CPT 301 RC outpatient 298 298 BLUE CROSS BLUE SHIELD WELLMARK SB889 [3081026] BCBS WYOMING [308102603] 283.1 percent of total billed charges 184.76 283.1 Technical (Hospital) Services Ref Felbamate Level PX-3018029911 CDM 80299 CPT 301 RC outpatient 298 298 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES PPO [308136801] 238.4 percent of total billed charges 184.76 283.1 Technical (Hospital) Services Ref Felbamate Level PX-3018029911 CDM 80299 CPT 301 RC outpatient 298 298 HEALTHPARTNERS SX009 HEALTHPARTNERS 238.4 percent of total billed charges 184.76 283.1 Technical (Hospital) Services Ref Felbamate Level PX-3018029911 CDM 80299 CPT 301 RC outpatient 298 298 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES EPO [308136803] 238.4 percent of total billed charges 184.76 283.1 Technical (Hospital) Services Ref Felbamate Level PX-3018029911 CDM 80299 CPT 301 RC outpatient 298 298 UNITED HEALTHCARE (COMMERCIAL) [3081199] UNITED HEALTHCARE 87726 [308119901] 184.76 percent of total billed charges 184.76 283.1 Technical (Hospital) Services Ref Felbamate Level PX-3018029911 CDM 80299 CPT 301 RC outpatient 298 298 MEDICA (COMMERCIAL) 94265 [3081118] MEDICA CLAIMS [308111801] 268.2 percent of total billed charges 184.76 283.1 Technical (Hospital) Services Ref Felbamate Level PX-3018029911 CDM 80299 CPT 301 RC outpatient 298 298 CIGNA 62308 [3081051] CIGNA 62308 [308105105] 238.4 percent of total billed charges 184.76 283.1 Technical (Hospital) Services Ref Felbamate Level PX-3018029911 CDM 80299 CPT 301 RC outpatient 298 298 CIGNA 62308 [3081051] CIGNA STATE OF WYOMING [308105107] 238.4 percent of total billed charges 184.76 283.1 Technical (Hospital) Services Ref Adalimumab and Ab PX-3018029925 CDM 80299 CPT 301 RC inpatient 298 298 MEDICA (COMMERCIAL) 94265 [3081118] MEDICA CLAIMS [308111801] 268.2 percent of total billed charges 184.76 283.1 Technical (Hospital) Services Ref Adalimumab and Ab PX-3018029925 CDM 80299 CPT 301 RC inpatient 298 298 HEALTHPARTNERS SX009 HEALTHPARTNERS 235.96 percent of total billed charges 184.76 283.1 Technical (Hospital) Services Ref Adalimumab and Ab PX-3018029925 CDM 80299 CPT 301 RC inpatient 298 298 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES EPO [308136803] 235.96 percent of total billed charges 184.76 283.1 Technical (Hospital) Services Ref Adalimumab and Ab PX-3018029925 CDM 80299 CPT 301 RC inpatient 298 298 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES HDHP [308136802] 235.96 percent of total billed charges 184.76 283.1 Technical (Hospital) Services Ref Adalimumab and Ab PX-3018029925 CDM 80299 CPT 301 RC inpatient 298 298 BLUE CROSS BLUE SHIELD WELLMARK SB889 [3081026] BCBS WYOMING [308102603] 283.1 percent of total billed charges 184.76 283.1 Technical (Hospital) Services Ref Adalimumab and Ab PX-3018029925 CDM 80299 CPT 301 RC inpatient 298 298 MULTIPLAN INC 34080 [3081285] MULTIPLAN INC [308128501] 283.1 percent of total billed charges 184.76 283.1 Technical (Hospital) Services Ref Adalimumab and Ab PX-3018029925 CDM 80299 CPT 301 RC inpatient 298 298 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES PPO [308136801] 235.96 percent of total billed charges 184.76 283.1 Technical (Hospital) Services Ref Adalimumab and Ab PX-3018029925 CDM 80299 CPT 301 RC inpatient 298 298 UNITED HEALTHCARE (COMMERCIAL) [3081199] UNITED HEALTHCARE 87726 [308119901] 184.76 percent of total billed charges 184.76 283.1 Technical (Hospital) Services Ref Adalimumab and Ab PX-3018029925 CDM 80299 CPT 301 RC inpatient 298 298 CIGNA 62308 [3081051] CIGNA 62308 [308105105] 235.96 percent of total billed charges 184.76 283.1 Technical (Hospital) Services Ref Adalimumab and Ab PX-3018029925 CDM 80299 CPT 301 RC inpatient 298 298 CIGNA 62308 [3081051] CIGNA STATE OF WYOMING [308105107] 235.96 percent of total billed charges 184.76 283.1 Technical (Hospital) Services Ref Adalimumab and Ab PX-3018029925 CDM 80299 CPT 301 RC outpatient 298 298 MEDICA (COMMERCIAL) 94265 [3081118] MEDICA CLAIMS [308111801] 268.2 percent of total billed charges 184.76 283.1 Technical (Hospital) Services Ref Adalimumab and Ab PX-3018029925 CDM 80299 CPT 301 RC outpatient 298 298 CIGNA 62308 [3081051] CIGNA 62308 [308105105] 238.4 percent of total billed charges 184.76 283.1 Technical (Hospital) Services Ref Adalimumab and Ab PX-3018029925 CDM 80299 CPT 301 RC outpatient 298 298 CIGNA 62308 [3081051] CIGNA STATE OF WYOMING [308105107] 238.4 percent of total billed charges 184.76 283.1 Technical (Hospital) Services Ref Adalimumab and Ab PX-3018029925 CDM 80299 CPT 301 RC outpatient 298 298 MULTIPLAN INC 34080 [3081285] MULTIPLAN INC [308128501] 283.1 percent of total billed charges 184.76 283.1 Technical (Hospital) Services Ref Adalimumab and Ab PX-3018029925 CDM 80299 CPT 301 RC outpatient 298 298 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES HDHP [308136802] 238.4 percent of total billed charges 184.76 283.1 Technical (Hospital) Services Ref Adalimumab and Ab PX-3018029925 CDM 80299 CPT 301 RC outpatient 298 298 BLUE CROSS BLUE SHIELD WELLMARK SB889 [3081026] BCBS WYOMING [308102603] 283.1 percent of total billed charges 184.76 283.1 Technical (Hospital) Services Ref Adalimumab and Ab PX-3018029925 CDM 80299 CPT 301 RC outpatient 298 298 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES PPO [308136801] 238.4 percent of total billed charges 184.76 283.1 Technical (Hospital) Services Ref Adalimumab and Ab PX-3018029925 CDM 80299 CPT 301 RC outpatient 298 298 HEALTHPARTNERS SX009 HEALTHPARTNERS 238.4 percent of total billed charges 184.76 283.1 Technical (Hospital) Services Ref Adalimumab and Ab PX-3018029925 CDM 80299 CPT 301 RC outpatient 298 298 UNITED HEALTHCARE (COMMERCIAL) [3081199] UNITED HEALTHCARE 87726 [308119901] 184.76 percent of total billed charges 184.76 283.1 Technical (Hospital) Services Ref Adalimumab and Ab PX-3018029925 CDM 80299 CPT 301 RC outpatient 298 298 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES EPO [308136803] 238.4 percent of total billed charges 184.76 283.1 Technical (Hospital) Services Ref Lacosamide PX-3018029926 CDM 80299 CPT 301 RC inpatient 298 298 CIGNA 62308 [3081051] CIGNA 62308 [308105105] 235.96 percent of total billed charges 184.76 283.1 Technical (Hospital) Services Ref Lacosamide PX-3018029926 CDM 80299 CPT 301 RC inpatient 298 298 CIGNA 62308 [3081051] CIGNA STATE OF WYOMING [308105107] 235.96 percent of total billed charges 184.76 283.1 Technical (Hospital) Services Ref Lacosamide PX-3018029926 CDM 80299 CPT 301 RC inpatient 298 298 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES EPO [308136803] 235.96 percent of total billed charges 184.76 283.1 Technical (Hospital) Services Ref Lacosamide PX-3018029926 CDM 80299 CPT 301 RC inpatient 298 298 HEALTHPARTNERS SX009 HEALTHPARTNERS 235.96 percent of total billed charges 184.76 283.1 Technical (Hospital) Services Ref Lacosamide PX-3018029926 CDM 80299 CPT 301 RC inpatient 298 298 MEDICA (COMMERCIAL) 94265 [3081118] MEDICA CLAIMS [308111801] 268.2 percent of total billed charges 184.76 283.1 Technical (Hospital) Services Ref Lacosamide PX-3018029926 CDM 80299 CPT 301 RC inpatient 298 298 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES HDHP [308136802] 235.96 percent of total billed charges 184.76 283.1 Technical (Hospital) Services Ref Lacosamide PX-3018029926 CDM 80299 CPT 301 RC inpatient 298 298 MULTIPLAN INC 34080 [3081285] MULTIPLAN INC [308128501] 283.1 percent of total billed charges 184.76 283.1 Technical (Hospital) Services Ref Lacosamide PX-3018029926 CDM 80299 CPT 301 RC inpatient 298 298 BLUE CROSS BLUE SHIELD WELLMARK SB889 [3081026] BCBS WYOMING [308102603] 283.1 percent of total billed charges 184.76 283.1 Technical (Hospital) Services Ref Lacosamide PX-3018029926 CDM 80299 CPT 301 RC inpatient 298 298 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES PPO [308136801] 235.96 percent of total billed charges 184.76 283.1 Technical (Hospital) Services Ref Lacosamide PX-3018029926 CDM 80299 CPT 301 RC inpatient 298 298 UNITED HEALTHCARE (COMMERCIAL) [3081199] UNITED HEALTHCARE 87726 [308119901] 184.76 percent of total billed charges 184.76 283.1 Technical (Hospital) Services Ref Lacosamide PX-3018029926 CDM 80299 CPT 301 RC outpatient 298 298 UNITED HEALTHCARE (COMMERCIAL) [3081199] UNITED HEALTHCARE 87726 [308119901] 184.76 percent of total billed charges 184.76 283.1 Technical (Hospital) Services Ref Lacosamide PX-3018029926 CDM 80299 CPT 301 RC outpatient 298 298 HEALTHPARTNERS SX009 HEALTHPARTNERS 238.4 percent of total billed charges 184.76 283.1 Technical (Hospital) Services Ref Lacosamide PX-3018029926 CDM 80299 CPT 301 RC outpatient 298 298 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES EPO [308136803] 238.4 percent of total billed charges 184.76 283.1 Technical (Hospital) Services Ref Lacosamide PX-3018029926 CDM 80299 CPT 301 RC outpatient 298 298 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES PPO [308136801] 238.4 percent of total billed charges 184.76 283.1 Technical (Hospital) Services Ref Lacosamide PX-3018029926 CDM 80299 CPT 301 RC outpatient 298 298 MULTIPLAN INC 34080 [3081285] MULTIPLAN INC [308128501] 283.1 percent of total billed charges 184.76 283.1 Technical (Hospital) Services Ref Lacosamide PX-3018029926 CDM 80299 CPT 301 RC outpatient 298 298 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES HDHP [308136802] 238.4 percent of total billed charges 184.76 283.1 Technical (Hospital) Services Ref Lacosamide PX-3018029926 CDM 80299 CPT 301 RC outpatient 298 298 BLUE CROSS BLUE SHIELD WELLMARK SB889 [3081026] BCBS WYOMING [308102603] 283.1 percent of total billed charges 184.76 283.1 Technical (Hospital) Services Ref Lacosamide PX-3018029926 CDM 80299 CPT 301 RC outpatient 298 298 CIGNA 62308 [3081051] CIGNA 62308 [308105105] 238.4 percent of total billed charges 184.76 283.1 Technical (Hospital) Services Ref Lacosamide PX-3018029926 CDM 80299 CPT 301 RC outpatient 298 298 CIGNA 62308 [3081051] CIGNA STATE OF WYOMING [308105107] 238.4 percent of total billed charges 184.76 283.1 Technical (Hospital) Services Ref Lacosamide PX-3018029926 CDM 80299 CPT 301 RC outpatient 298 298 MEDICA (COMMERCIAL) 94265 [3081118] MEDICA CLAIMS [308111801] 268.2 percent of total billed charges 184.76 283.1 Technical (Hospital) Services Ref Adalimumab Quantitation With Reflex to Antibody PX-3018029927 CDM 80299 CPT 301 RC inpatient 298 298 CIGNA 62308 [3081051] CIGNA 62308 [308105105] 235.96 percent of total billed charges 184.76 283.1 Technical (Hospital) Services Ref Adalimumab Quantitation With Reflex to Antibody PX-3018029927 CDM 80299 CPT 301 RC inpatient 298 298 CIGNA 62308 [3081051] CIGNA STATE OF WYOMING [308105107] 235.96 percent of total billed charges 184.76 283.1 Technical (Hospital) Services Ref Adalimumab Quantitation With Reflex to Antibody PX-3018029927 CDM 80299 CPT 301 RC inpatient 298 298 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES EPO [308136803] 235.96 percent of total billed charges 184.76 283.1 Technical (Hospital) Services Ref Adalimumab Quantitation With Reflex to Antibody PX-3018029927 CDM 80299 CPT 301 RC inpatient 298 298 HEALTHPARTNERS SX009 HEALTHPARTNERS 235.96 percent of total billed charges 184.76 283.1 Technical (Hospital) Services Ref Adalimumab Quantitation With Reflex to Antibody PX-3018029927 CDM 80299 CPT 301 RC inpatient 298 298 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES HDHP [308136802] 235.96 percent of total billed charges 184.76 283.1 Technical (Hospital) Services Ref Adalimumab Quantitation With Reflex to Antibody PX-3018029927 CDM 80299 CPT 301 RC inpatient 298 298 MEDICA (COMMERCIAL) 94265 [3081118] MEDICA CLAIMS [308111801] 268.2 percent of total billed charges 184.76 283.1 Technical (Hospital) Services Ref Adalimumab Quantitation With Reflex to Antibody PX-3018029927 CDM 80299 CPT 301 RC inpatient 298 298 UNITED HEALTHCARE (COMMERCIAL) [3081199] UNITED HEALTHCARE 87726 [308119901] 184.76 percent of total billed charges 184.76 283.1 Technical (Hospital) Services Ref Adalimumab Quantitation With Reflex to Antibody PX-3018029927 CDM 80299 CPT 301 RC inpatient 298 298 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES PPO [308136801] 235.96 percent of total billed charges 184.76 283.1 Technical (Hospital) Services Ref Adalimumab Quantitation With Reflex to Antibody PX-3018029927 CDM 80299 CPT 301 RC inpatient 298 298 MULTIPLAN INC 34080 [3081285] MULTIPLAN INC [308128501] 283.1 percent of total billed charges 184.76 283.1 Technical (Hospital) Services Ref Adalimumab Quantitation With Reflex to Antibody PX-3018029927 CDM 80299 CPT 301 RC inpatient 298 298 BLUE CROSS BLUE SHIELD WELLMARK SB889 [3081026] BCBS WYOMING [308102603] 283.1 percent of total billed charges 184.76 283.1 Technical (Hospital) Services Ref Adalimumab Quantitation With Reflex to Antibody PX-3018029927 CDM 80299 CPT 301 RC outpatient 298 298 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES EPO [308136803] 238.4 percent of total billed charges 184.76 283.1 Technical (Hospital) Services Ref Adalimumab Quantitation With Reflex to Antibody PX-3018029927 CDM 80299 CPT 301 RC outpatient 298 298 UNITED HEALTHCARE (COMMERCIAL) [3081199] UNITED HEALTHCARE 87726 [308119901] 184.76 percent of total billed charges 184.76 283.1 Technical (Hospital) Services Ref Adalimumab Quantitation With Reflex to Antibody PX-3018029927 CDM 80299 CPT 301 RC outpatient 298 298 HEALTHPARTNERS SX009 HEALTHPARTNERS 238.4 percent of total billed charges 184.76 283.1 Technical (Hospital) Services Ref Adalimumab Quantitation With Reflex to Antibody PX-3018029927 CDM 80299 CPT 301 RC outpatient 298 298 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES PPO [308136801] 238.4 percent of total billed charges 184.76 283.1 Technical (Hospital) Services Ref Adalimumab Quantitation With Reflex to Antibody PX-3018029927 CDM 80299 CPT 301 RC outpatient 298 298 BLUE CROSS BLUE SHIELD WELLMARK SB889 [3081026] BCBS WYOMING [308102603] 283.1 percent of total billed charges 184.76 283.1 Technical (Hospital) Services Ref Adalimumab Quantitation With Reflex to Antibody PX-3018029927 CDM 80299 CPT 301 RC outpatient 298 298 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES HDHP [308136802] 238.4 percent of total billed charges 184.76 283.1 Technical (Hospital) Services Ref Adalimumab Quantitation With Reflex to Antibody PX-3018029927 CDM 80299 CPT 301 RC outpatient 298 298 MULTIPLAN INC 34080 [3081285] MULTIPLAN INC [308128501] 283.1 percent of total billed charges 184.76 283.1 Technical (Hospital) Services Ref Adalimumab Quantitation With Reflex to Antibody PX-3018029927 CDM 80299 CPT 301 RC outpatient 298 298 CIGNA 62308 [3081051] CIGNA 62308 [308105105] 238.4 percent of total billed charges 184.76 283.1 Technical (Hospital) Services Ref Adalimumab Quantitation With Reflex to Antibody PX-3018029927 CDM 80299 CPT 301 RC outpatient 298 298 CIGNA 62308 [3081051] CIGNA STATE OF WYOMING [308105107] 238.4 percent of total billed charges 184.76 283.1 Technical (Hospital) Services Ref Adalimumab Quantitation With Reflex to Antibody PX-3018029927 CDM 80299 CPT 301 RC outpatient 298 298 MEDICA (COMMERCIAL) 94265 [3081118] MEDICA CLAIMS [308111801] 268.2 percent of total billed charges 184.76 283.1 Technical (Hospital) Services Ref Lacosamide(Mayo) PX-3018023500 CDM 80235 CPT 301 RC outpatient 193 193 HEALTHPARTNERS SX009 HEALTHPARTNERS 154.4 percent of total billed charges 119.66 183.35 Technical (Hospital) Services Ref Lacosamide(Mayo) PX-3018023500 CDM 80235 CPT 301 RC outpatient 193 193 UNITED HEALTHCARE (COMMERCIAL) [3081199] UNITED HEALTHCARE 87726 [308119901] 119.66 percent of total billed charges 119.66 183.35 Technical (Hospital) Services Ref Lacosamide(Mayo) PX-3018023500 CDM 80235 CPT 301 RC outpatient 193 193 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES EPO [308136803] 154.4 percent of total billed charges 119.66 183.35 Technical (Hospital) Services Ref Lacosamide(Mayo) PX-3018023500 CDM 80235 CPT 301 RC outpatient 193 193 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES PPO [308136801] 154.4 percent of total billed charges 119.66 183.35 Technical (Hospital) Services Ref Lacosamide(Mayo) PX-3018023500 CDM 80235 CPT 301 RC outpatient 193 193 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES HDHP [308136802] 154.4 percent of total billed charges 119.66 183.35 Technical (Hospital) Services Ref Lacosamide(Mayo) PX-3018023500 CDM 80235 CPT 301 RC outpatient 193 193 MULTIPLAN INC 34080 [3081285] MULTIPLAN INC [308128501] 183.35 percent of total billed charges 119.66 183.35 Technical (Hospital) Services Ref Lacosamide(Mayo) PX-3018023500 CDM 80235 CPT 301 RC outpatient 193 193 BLUE CROSS BLUE SHIELD WELLMARK SB889 [3081026] BCBS WYOMING [308102603] 183.35 percent of total billed charges 119.66 183.35 Technical (Hospital) Services Ref Lacosamide(Mayo) PX-3018023500 CDM 80235 CPT 301 RC outpatient 193 193 MEDICA (COMMERCIAL) 94265 [3081118] MEDICA CLAIMS [308111801] 173.7 percent of total billed charges 119.66 183.35 Technical (Hospital) Services Ref Lacosamide(Mayo) PX-3018023500 CDM 80235 CPT 301 RC outpatient 193 193 CIGNA 62308 [3081051] CIGNA 62308 [308105105] 154.4 percent of total billed charges 119.66 183.35 Technical (Hospital) Services Ref Lacosamide(Mayo) PX-3018023500 CDM 80235 CPT 301 RC outpatient 193 193 CIGNA 62308 [3081051] CIGNA STATE OF WYOMING [308105107] 154.4 percent of total billed charges 119.66 183.35 Technical (Hospital) Services Ref Lacosamide(Mayo) PX-3018023500 CDM 80235 CPT 301 RC inpatient 193 193 CIGNA 62308 [3081051] CIGNA 62308 [308105105] 152.82 percent of total billed charges 119.66 183.35 Technical (Hospital) Services Ref Lacosamide(Mayo) PX-3018023500 CDM 80235 CPT 301 RC inpatient 193 193 CIGNA 62308 [3081051] CIGNA STATE OF WYOMING [308105107] 152.82 percent of total billed charges 119.66 183.35 Technical (Hospital) Services Ref Lacosamide(Mayo) PX-3018023500 CDM 80235 CPT 301 RC inpatient 193 193 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES PPO [308136801] 152.82 percent of total billed charges 119.66 183.35 Technical (Hospital) Services Ref Lacosamide(Mayo) PX-3018023500 CDM 80235 CPT 301 RC inpatient 193 193 UNITED HEALTHCARE (COMMERCIAL) [3081199] UNITED HEALTHCARE 87726 [308119901] 119.66 percent of total billed charges 119.66 183.35 Technical (Hospital) Services Ref Lacosamide(Mayo) PX-3018023500 CDM 80235 CPT 301 RC inpatient 193 193 MULTIPLAN INC 34080 [3081285] MULTIPLAN INC [308128501] 183.35 percent of total billed charges 119.66 183.35 Technical (Hospital) Services Ref Lacosamide(Mayo) PX-3018023500 CDM 80235 CPT 301 RC inpatient 193 193 BLUE CROSS BLUE SHIELD WELLMARK SB889 [3081026] BCBS WYOMING [308102603] 183.35 percent of total billed charges 119.66 183.35 Technical (Hospital) Services Ref Lacosamide(Mayo) PX-3018023500 CDM 80235 CPT 301 RC inpatient 193 193 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES HDHP [308136802] 152.82 percent of total billed charges 119.66 183.35 Technical (Hospital) Services Ref Lacosamide(Mayo) PX-3018023500 CDM 80235 CPT 301 RC inpatient 193 193 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES EPO [308136803] 152.82 percent of total billed charges 119.66 183.35 Technical (Hospital) Services Ref Lacosamide(Mayo) PX-3018023500 CDM 80235 CPT 301 RC inpatient 193 193 HEALTHPARTNERS SX009 HEALTHPARTNERS 152.82 percent of total billed charges 119.66 183.35 Technical (Hospital) Services Ref Lacosamide(Mayo) PX-3018023500 CDM 80235 CPT 301 RC inpatient 193 193 MEDICA (COMMERCIAL) 94265 [3081118] MEDICA CLAIMS [308111801] 173.7 percent of total billed charges 119.66 183.35 Technical (Hospital) Services "HC Ref Hydroxychloroquine, S (Mayo)" PX-3018022000 CDM 80220 CPT 301 RC inpatient 212 212 CIGNA 62308 [3081051] CIGNA 62308 [308105105] 167.86 percent of total billed charges 131.44 201.4 Technical (Hospital) Services "HC Ref Hydroxychloroquine, S (Mayo)" PX-3018022000 CDM 80220 CPT 301 RC inpatient 212 212 CIGNA 62308 [3081051] CIGNA STATE OF WYOMING [308105107] 167.86 percent of total billed charges 131.44 201.4 Technical (Hospital) Services "HC Ref Hydroxychloroquine, S (Mayo)" PX-3018022000 CDM 80220 CPT 301 RC inpatient 212 212 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES PPO [308136801] 167.86 percent of total billed charges 131.44 201.4 Technical (Hospital) Services "HC Ref Hydroxychloroquine, S (Mayo)" PX-3018022000 CDM 80220 CPT 301 RC inpatient 212 212 UNITED HEALTHCARE (COMMERCIAL) [3081199] UNITED HEALTHCARE 87726 [308119901] 131.44 percent of total billed charges 131.44 201.4 Technical (Hospital) Services "HC Ref Hydroxychloroquine, S (Mayo)" PX-3018022000 CDM 80220 CPT 301 RC inpatient 212 212 MULTIPLAN INC 34080 [3081285] MULTIPLAN INC [308128501] 201.4 percent of total billed charges 131.44 201.4 Technical (Hospital) Services "HC Ref Hydroxychloroquine, S (Mayo)" PX-3018022000 CDM 80220 CPT 301 RC inpatient 212 212 BLUE CROSS BLUE SHIELD WELLMARK SB889 [3081026] BCBS WYOMING [308102603] 201.4 percent of total billed charges 131.44 201.4 Technical (Hospital) Services "HC Ref Hydroxychloroquine, S (Mayo)" PX-3018022000 CDM 80220 CPT 301 RC inpatient 212 212 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES HDHP [308136802] 167.86 percent of total billed charges 131.44 201.4 Technical (Hospital) Services "HC Ref Hydroxychloroquine, S (Mayo)" PX-3018022000 CDM 80220 CPT 301 RC inpatient 212 212 HEALTHPARTNERS SX009 HEALTHPARTNERS 167.86 percent of total billed charges 131.44 201.4 Technical (Hospital) Services "HC Ref Hydroxychloroquine, S (Mayo)" PX-3018022000 CDM 80220 CPT 301 RC inpatient 212 212 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES EPO [308136803] 167.86 percent of total billed charges 131.44 201.4 Technical (Hospital) Services "HC Ref Hydroxychloroquine, S (Mayo)" PX-3018022000 CDM 80220 CPT 301 RC inpatient 212 212 MEDICA (COMMERCIAL) 94265 [3081118] MEDICA CLAIMS [308111801] 190.8 percent of total billed charges 131.44 201.4 Technical (Hospital) Services "HC Ref Hydroxychloroquine, S (Mayo)" PX-3018022000 CDM 80220 CPT 301 RC outpatient 212 212 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES PPO [308136801] 169.6 percent of total billed charges 131.44 201.4 Technical (Hospital) Services "HC Ref Hydroxychloroquine, S (Mayo)" PX-3018022000 CDM 80220 CPT 301 RC outpatient 212 212 BLUE CROSS BLUE SHIELD WELLMARK SB889 [3081026] BCBS WYOMING [308102603] 201.4 percent of total billed charges 131.44 201.4 Technical (Hospital) Services "HC Ref Hydroxychloroquine, S (Mayo)" PX-3018022000 CDM 80220 CPT 301 RC outpatient 212 212 MULTIPLAN INC 34080 [3081285] MULTIPLAN INC [308128501] 201.4 percent of total billed charges 131.44 201.4 Technical (Hospital) Services "HC Ref Hydroxychloroquine, S (Mayo)" PX-3018022000 CDM 80220 CPT 301 RC outpatient 212 212 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES HDHP [308136802] 169.6 percent of total billed charges 131.44 201.4 Technical (Hospital) Services "HC Ref Hydroxychloroquine, S (Mayo)" PX-3018022000 CDM 80220 CPT 301 RC outpatient 212 212 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES EPO [308136803] 169.6 percent of total billed charges 131.44 201.4 Technical (Hospital) Services "HC Ref Hydroxychloroquine, S (Mayo)" PX-3018022000 CDM 80220 CPT 301 RC outpatient 212 212 UNITED HEALTHCARE (COMMERCIAL) [3081199] UNITED HEALTHCARE 87726 [308119901] 131.44 percent of total billed charges 131.44 201.4 Technical (Hospital) Services "HC Ref Hydroxychloroquine, S (Mayo)" PX-3018022000 CDM 80220 CPT 301 RC outpatient 212 212 HEALTHPARTNERS SX009 HEALTHPARTNERS 169.6 percent of total billed charges 131.44 201.4 Technical (Hospital) Services "HC Ref Hydroxychloroquine, S (Mayo)" PX-3018022000 CDM 80220 CPT 301 RC outpatient 212 212 CIGNA 62308 [3081051] CIGNA 62308 [308105105] 169.6 percent of total billed charges 131.44 201.4 Technical (Hospital) Services "HC Ref Hydroxychloroquine, S (Mayo)" PX-3018022000 CDM 80220 CPT 301 RC outpatient 212 212 CIGNA 62308 [3081051] CIGNA STATE OF WYOMING [308105107] 169.6 percent of total billed charges 131.44 201.4 Technical (Hospital) Services "HC Ref Hydroxychloroquine, S (Mayo)" PX-3018022000 CDM 80220 CPT 301 RC outpatient 212 212 MEDICA (COMMERCIAL) 94265 [3081118] MEDICA CLAIMS [308111801] 190.8 percent of total billed charges 131.44 201.4 Technical (Hospital) Services Ref Zonisamide PX-3018020300 CDM 80203 CPT 301 RC inpatient 89 89 CIGNA 62308 [3081051] CIGNA 62308 [308105105] 70.47 percent of total billed charges 55.18 84.55 Technical (Hospital) Services Ref Zonisamide PX-3018020300 CDM 80203 CPT 301 RC inpatient 89 89 CIGNA 62308 [3081051] CIGNA STATE OF WYOMING [308105107] 70.47 percent of total billed charges 55.18 84.55 Technical (Hospital) Services Ref Zonisamide PX-3018020300 CDM 80203 CPT 301 RC inpatient 89 89 MULTIPLAN INC 34080 [3081285] MULTIPLAN INC [308128501] 84.55 percent of total billed charges 55.18 84.55 Technical (Hospital) Services Ref Zonisamide PX-3018020300 CDM 80203 CPT 301 RC inpatient 89 89 BLUE CROSS BLUE SHIELD WELLMARK SB889 [3081026] BCBS WYOMING [308102603] 84.55 percent of total billed charges 55.18 84.55 Technical (Hospital) Services Ref Zonisamide PX-3018020300 CDM 80203 CPT 301 RC inpatient 89 89 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES HDHP [308136802] 70.47 percent of total billed charges 55.18 84.55 Technical (Hospital) Services Ref Zonisamide PX-3018020300 CDM 80203 CPT 301 RC inpatient 89 89 UNITED HEALTHCARE (COMMERCIAL) [3081199] UNITED HEALTHCARE 87726 [308119901] 55.18 percent of total billed charges 55.18 84.55 Technical (Hospital) Services Ref Zonisamide PX-3018020300 CDM 80203 CPT 301 RC inpatient 89 89 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES PPO [308136801] 70.47 percent of total billed charges 55.18 84.55 Technical (Hospital) Services Ref Zonisamide PX-3018020300 CDM 80203 CPT 301 RC inpatient 89 89 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES EPO [308136803] 70.47 percent of total billed charges 55.18 84.55 Technical (Hospital) Services Ref Zonisamide PX-3018020300 CDM 80203 CPT 301 RC inpatient 89 89 HEALTHPARTNERS SX009 HEALTHPARTNERS 70.47 percent of total billed charges 55.18 84.55 Technical (Hospital) Services Ref Zonisamide PX-3018020300 CDM 80203 CPT 301 RC inpatient 89 89 MEDICA (COMMERCIAL) 94265 [3081118] MEDICA CLAIMS [308111801] 80.1 percent of total billed charges 55.18 84.55 Technical (Hospital) Services Ref Zonisamide PX-3018020300 CDM 80203 CPT 301 RC outpatient 89 89 UNITED HEALTHCARE (COMMERCIAL) [3081199] UNITED HEALTHCARE 87726 [308119901] 55.18 percent of total billed charges 55.18 84.55 Technical (Hospital) Services Ref Zonisamide PX-3018020300 CDM 80203 CPT 301 RC outpatient 89 89 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES EPO [308136803] 71.2 percent of total billed charges 55.18 84.55 Technical (Hospital) Services Ref Zonisamide PX-3018020300 CDM 80203 CPT 301 RC outpatient 89 89 HEALTHPARTNERS SX009 HEALTHPARTNERS 71.2 percent of total billed charges 55.18 84.55 Technical (Hospital) Services Ref Zonisamide PX-3018020300 CDM 80203 CPT 301 RC outpatient 89 89 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES PPO [308136801] 71.2 percent of total billed charges 55.18 84.55 Technical (Hospital) Services Ref Zonisamide PX-3018020300 CDM 80203 CPT 301 RC outpatient 89 89 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES HDHP [308136802] 71.2 percent of total billed charges 55.18 84.55 Technical (Hospital) Services Ref Zonisamide PX-3018020300 CDM 80203 CPT 301 RC outpatient 89 89 MULTIPLAN INC 34080 [3081285] MULTIPLAN INC [308128501] 84.55 percent of total billed charges 55.18 84.55 Technical (Hospital) Services Ref Zonisamide PX-3018020300 CDM 80203 CPT 301 RC outpatient 89 89 BLUE CROSS BLUE SHIELD WELLMARK SB889 [3081026] BCBS WYOMING [308102603] 84.55 percent of total billed charges 55.18 84.55 Technical (Hospital) Services Ref Zonisamide PX-3018020300 CDM 80203 CPT 301 RC outpatient 89 89 MEDICA (COMMERCIAL) 94265 [3081118] MEDICA CLAIMS [308111801] 80.1 percent of total billed charges 55.18 84.55 Technical (Hospital) Services Ref Zonisamide PX-3018020300 CDM 80203 CPT 301 RC outpatient 89 89 CIGNA 62308 [3081051] CIGNA 62308 [308105105] 71.2 percent of total billed charges 55.18 84.55 Technical (Hospital) Services Ref Zonisamide PX-3018020300 CDM 80203 CPT 301 RC outpatient 89 89 CIGNA 62308 [3081051] CIGNA STATE OF WYOMING [308105107] 71.2 percent of total billed charges 55.18 84.55 Technical (Hospital) Services Vancomycin PX-3018020200 CDM 80202 CPT 301 RC outpatient 152 152 MEDICA (COMMERCIAL) 94265 [3081118] MEDICA CLAIMS [308111801] 136.8 percent of total billed charges 94.24 144.4 Technical (Hospital) Services Vancomycin PX-3018020200 CDM 80202 CPT 301 RC outpatient 152 152 CIGNA 62308 [3081051] CIGNA 62308 [308105105] 121.6 percent of total billed charges 94.24 144.4 Technical (Hospital) Services Vancomycin PX-3018020200 CDM 80202 CPT 301 RC outpatient 152 152 CIGNA 62308 [3081051] CIGNA STATE OF WYOMING [308105107] 121.6 percent of total billed charges 94.24 144.4 Technical (Hospital) Services Vancomycin PX-3018020200 CDM 80202 CPT 301 RC outpatient 152 152 HEALTHPARTNERS SX009 HEALTHPARTNERS 121.6 percent of total billed charges 94.24 144.4 Technical (Hospital) Services Vancomycin PX-3018020200 CDM 80202 CPT 301 RC outpatient 152 152 BLUE CROSS BLUE SHIELD WELLMARK SB889 [3081026] BCBS WYOMING [308102603] 144.4 percent of total billed charges 94.24 144.4 Technical (Hospital) Services Vancomycin PX-3018020200 CDM 80202 CPT 301 RC outpatient 152 152 MULTIPLAN INC 34080 [3081285] MULTIPLAN INC [308128501] 144.4 percent of total billed charges 94.24 144.4 Technical (Hospital) Services Vancomycin PX-3018020200 CDM 80202 CPT 301 RC outpatient 152 152 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES HDHP [308136802] 121.6 percent of total billed charges 94.24 144.4 Technical (Hospital) Services Vancomycin PX-3018020200 CDM 80202 CPT 301 RC outpatient 152 152 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES EPO [308136803] 121.6 percent of total billed charges 94.24 144.4 Technical (Hospital) Services Vancomycin PX-3018020200 CDM 80202 CPT 301 RC outpatient 152 152 UNITED HEALTHCARE (COMMERCIAL) [3081199] UNITED HEALTHCARE 87726 [308119901] 94.24 percent of total billed charges 94.24 144.4 Technical (Hospital) Services Vancomycin PX-3018020200 CDM 80202 CPT 301 RC outpatient 152 152 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES PPO [308136801] 121.6 percent of total billed charges 94.24 144.4 Technical (Hospital) Services Vancomycin PX-3018020200 CDM 80202 CPT 301 RC inpatient 152 152 CIGNA 62308 [3081051] CIGNA 62308 [308105105] 120.35 percent of total billed charges 94.24 144.4 Technical (Hospital) Services Vancomycin PX-3018020200 CDM 80202 CPT 301 RC inpatient 152 152 CIGNA 62308 [3081051] CIGNA STATE OF WYOMING [308105107] 120.35 percent of total billed charges 94.24 144.4 Technical (Hospital) Services Vancomycin PX-3018020200 CDM 80202 CPT 301 RC inpatient 152 152 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES EPO [308136803] 120.35 percent of total billed charges 94.24 144.4 Technical (Hospital) Services Vancomycin PX-3018020200 CDM 80202 CPT 301 RC inpatient 152 152 HEALTHPARTNERS SX009 HEALTHPARTNERS 120.35 percent of total billed charges 94.24 144.4 Technical (Hospital) Services Vancomycin PX-3018020200 CDM 80202 CPT 301 RC inpatient 152 152 MEDICA (COMMERCIAL) 94265 [3081118] MEDICA CLAIMS [308111801] 136.8 percent of total billed charges 94.24 144.4 Technical (Hospital) Services Vancomycin PX-3018020200 CDM 80202 CPT 301 RC inpatient 152 152 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES PPO [308136801] 120.35 percent of total billed charges 94.24 144.4 Technical (Hospital) Services Vancomycin PX-3018020200 CDM 80202 CPT 301 RC inpatient 152 152 UNITED HEALTHCARE (COMMERCIAL) [3081199] UNITED HEALTHCARE 87726 [308119901] 94.24 percent of total billed charges 94.24 144.4 Technical (Hospital) Services Vancomycin PX-3018020200 CDM 80202 CPT 301 RC inpatient 152 152 MULTIPLAN INC 34080 [3081285] MULTIPLAN INC [308128501] 144.4 percent of total billed charges 94.24 144.4 Technical (Hospital) Services Vancomycin PX-3018020200 CDM 80202 CPT 301 RC inpatient 152 152 BLUE CROSS BLUE SHIELD WELLMARK SB889 [3081026] BCBS WYOMING [308102603] 144.4 percent of total billed charges 94.24 144.4 Technical (Hospital) Services Vancomycin PX-3018020200 CDM 80202 CPT 301 RC inpatient 152 152 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES HDHP [308136802] 120.35 percent of total billed charges 94.24 144.4 Technical (Hospital) Services Ref Topiramate PX-3018020101 CDM 80201 CPT 301 RC outpatient 143 143 HEALTHPARTNERS SX009 HEALTHPARTNERS 114.4 percent of total billed charges 88.66 135.85 Technical (Hospital) Services Ref Topiramate PX-3018020101 CDM 80201 CPT 301 RC outpatient 143 143 UNITED HEALTHCARE (COMMERCIAL) [3081199] UNITED HEALTHCARE 87726 [308119901] 88.66 percent of total billed charges 88.66 135.85 Technical (Hospital) Services Ref Topiramate PX-3018020101 CDM 80201 CPT 301 RC outpatient 143 143 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES PPO [308136801] 114.4 percent of total billed charges 88.66 135.85 Technical (Hospital) Services Ref Topiramate PX-3018020101 CDM 80201 CPT 301 RC outpatient 143 143 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES EPO [308136803] 114.4 percent of total billed charges 88.66 135.85 Technical (Hospital) Services Ref Topiramate PX-3018020101 CDM 80201 CPT 301 RC outpatient 143 143 BLUE CROSS BLUE SHIELD WELLMARK SB889 [3081026] BCBS WYOMING [308102603] 135.85 percent of total billed charges 88.66 135.85 Technical (Hospital) Services Ref Topiramate PX-3018020101 CDM 80201 CPT 301 RC outpatient 143 143 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES HDHP [308136802] 114.4 percent of total billed charges 88.66 135.85 Technical (Hospital) Services Ref Topiramate PX-3018020101 CDM 80201 CPT 301 RC outpatient 143 143 MULTIPLAN INC 34080 [3081285] MULTIPLAN INC [308128501] 135.85 percent of total billed charges 88.66 135.85 Technical (Hospital) Services Ref Topiramate PX-3018020101 CDM 80201 CPT 301 RC outpatient 143 143 CIGNA 62308 [3081051] CIGNA 62308 [308105105] 114.4 percent of total billed charges 88.66 135.85 Technical (Hospital) Services Ref Topiramate PX-3018020101 CDM 80201 CPT 301 RC outpatient 143 143 CIGNA 62308 [3081051] CIGNA STATE OF WYOMING [308105107] 114.4 percent of total billed charges 88.66 135.85 Technical (Hospital) Services Ref Topiramate PX-3018020101 CDM 80201 CPT 301 RC outpatient 143 143 MEDICA (COMMERCIAL) 94265 [3081118] MEDICA CLAIMS [308111801] 128.7 percent of total billed charges 88.66 135.85 Technical (Hospital) Services Ref Topiramate PX-3018020101 CDM 80201 CPT 301 RC inpatient 143 143 CIGNA 62308 [3081051] CIGNA 62308 [308105105] 113.23 percent of total billed charges 88.66 135.85 Technical (Hospital) Services Ref Topiramate PX-3018020101 CDM 80201 CPT 301 RC inpatient 143 143 CIGNA 62308 [3081051] CIGNA STATE OF WYOMING [308105107] 113.23 percent of total billed charges 88.66 135.85 Technical (Hospital) Services Ref Topiramate PX-3018020101 CDM 80201 CPT 301 RC inpatient 143 143 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES EPO [308136803] 113.23 percent of total billed charges 88.66 135.85 Technical (Hospital) Services Ref Topiramate PX-3018020101 CDM 80201 CPT 301 RC inpatient 143 143 HEALTHPARTNERS SX009 HEALTHPARTNERS 113.23 percent of total billed charges 88.66 135.85 Technical (Hospital) Services Ref Topiramate PX-3018020101 CDM 80201 CPT 301 RC inpatient 143 143 MEDICA (COMMERCIAL) 94265 [3081118] MEDICA CLAIMS [308111801] 128.7 percent of total billed charges 88.66 135.85 Technical (Hospital) Services Ref Topiramate PX-3018020101 CDM 80201 CPT 301 RC inpatient 143 143 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES PPO [308136801] 113.23 percent of total billed charges 88.66 135.85 Technical (Hospital) Services Ref Topiramate PX-3018020101 CDM 80201 CPT 301 RC inpatient 143 143 UNITED HEALTHCARE (COMMERCIAL) [3081199] UNITED HEALTHCARE 87726 [308119901] 88.66 percent of total billed charges 88.66 135.85 Technical (Hospital) Services Ref Topiramate PX-3018020101 CDM 80201 CPT 301 RC inpatient 143 143 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES HDHP [308136802] 113.23 percent of total billed charges 88.66 135.85 Technical (Hospital) Services Ref Topiramate PX-3018020101 CDM 80201 CPT 301 RC inpatient 143 143 MULTIPLAN INC 34080 [3081285] MULTIPLAN INC [308128501] 135.85 percent of total billed charges 88.66 135.85 Technical (Hospital) Services Ref Topiramate PX-3018020101 CDM 80201 CPT 301 RC inpatient 143 143 BLUE CROSS BLUE SHIELD WELLMARK SB889 [3081026] BCBS WYOMING [308102603] 135.85 percent of total billed charges 88.66 135.85 Technical (Hospital) Services Tobramycin PX-3018020000 CDM 80200 CPT 301 RC inpatient 169 169 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES EPO [308136803] 133.81 percent of total billed charges 104.78 160.55 Technical (Hospital) Services Tobramycin PX-3018020000 CDM 80200 CPT 301 RC inpatient 169 169 HEALTHPARTNERS SX009 HEALTHPARTNERS 133.81 percent of total billed charges 104.78 160.55 Technical (Hospital) Services Tobramycin PX-3018020000 CDM 80200 CPT 301 RC inpatient 169 169 MEDICA (COMMERCIAL) 94265 [3081118] MEDICA CLAIMS [308111801] 152.1 percent of total billed charges 104.78 160.55 Technical (Hospital) Services Tobramycin PX-3018020000 CDM 80200 CPT 301 RC inpatient 169 169 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES HDHP [308136802] 133.81 percent of total billed charges 104.78 160.55 Technical (Hospital) Services Tobramycin PX-3018020000 CDM 80200 CPT 301 RC inpatient 169 169 BLUE CROSS BLUE SHIELD WELLMARK SB889 [3081026] BCBS WYOMING [308102603] 160.55 percent of total billed charges 104.78 160.55 Technical (Hospital) Services Tobramycin PX-3018020000 CDM 80200 CPT 301 RC inpatient 169 169 MULTIPLAN INC 34080 [3081285] MULTIPLAN INC [308128501] 160.55 percent of total billed charges 104.78 160.55 Technical (Hospital) Services Tobramycin PX-3018020000 CDM 80200 CPT 301 RC inpatient 169 169 UNITED HEALTHCARE (COMMERCIAL) [3081199] UNITED HEALTHCARE 87726 [308119901] 104.78 percent of total billed charges 104.78 160.55 Technical (Hospital) Services Tobramycin PX-3018020000 CDM 80200 CPT 301 RC inpatient 169 169 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES PPO [308136801] 133.81 percent of total billed charges 104.78 160.55 Technical (Hospital) Services Tobramycin PX-3018020000 CDM 80200 CPT 301 RC inpatient 169 169 CIGNA 62308 [3081051] CIGNA 62308 [308105105] 133.81 percent of total billed charges 104.78 160.55 Technical (Hospital) Services Tobramycin PX-3018020000 CDM 80200 CPT 301 RC inpatient 169 169 CIGNA 62308 [3081051] CIGNA STATE OF WYOMING [308105107] 133.81 percent of total billed charges 104.78 160.55 Technical (Hospital) Services Tobramycin PX-3018020000 CDM 80200 CPT 301 RC outpatient 169 169 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES EPO [308136803] 135.2 percent of total billed charges 104.78 160.55 Technical (Hospital) Services Tobramycin PX-3018020000 CDM 80200 CPT 301 RC outpatient 169 169 UNITED HEALTHCARE (COMMERCIAL) [3081199] UNITED HEALTHCARE 87726 [308119901] 104.78 percent of total billed charges 104.78 160.55 Technical (Hospital) Services Tobramycin PX-3018020000 CDM 80200 CPT 301 RC outpatient 169 169 HEALTHPARTNERS SX009 HEALTHPARTNERS 135.2 percent of total billed charges 104.78 160.55 Technical (Hospital) Services Tobramycin PX-3018020000 CDM 80200 CPT 301 RC outpatient 169 169 BLUE CROSS BLUE SHIELD WELLMARK SB889 [3081026] BCBS WYOMING [308102603] 160.55 percent of total billed charges 104.78 160.55 Technical (Hospital) Services Tobramycin PX-3018020000 CDM 80200 CPT 301 RC outpatient 169 169 MULTIPLAN INC 34080 [3081285] MULTIPLAN INC [308128501] 160.55 percent of total billed charges 104.78 160.55 Technical (Hospital) Services Tobramycin PX-3018020000 CDM 80200 CPT 301 RC outpatient 169 169 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES HDHP [308136802] 135.2 percent of total billed charges 104.78 160.55 Technical (Hospital) Services Tobramycin PX-3018020000 CDM 80200 CPT 301 RC outpatient 169 169 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES PPO [308136801] 135.2 percent of total billed charges 104.78 160.55 Technical (Hospital) Services Tobramycin PX-3018020000 CDM 80200 CPT 301 RC outpatient 169 169 CIGNA 62308 [3081051] CIGNA 62308 [308105105] 135.2 percent of total billed charges 104.78 160.55 Technical (Hospital) Services Tobramycin PX-3018020000 CDM 80200 CPT 301 RC outpatient 169 169 CIGNA 62308 [3081051] CIGNA STATE OF WYOMING [308105107] 135.2 percent of total billed charges 104.78 160.55 Technical (Hospital) Services Tobramycin PX-3018020000 CDM 80200 CPT 301 RC outpatient 169 169 MEDICA (COMMERCIAL) 94265 [3081118] MEDICA CLAIMS [308111801] 152.1 percent of total billed charges 104.78 160.55 Technical (Hospital) Services Theophylline PX-3018019800 CDM 80198 CPT 301 RC outpatient 160 160 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES HDHP [308136802] 128 percent of total billed charges 99.2 152 Technical (Hospital) Services Theophylline PX-3018019800 CDM 80198 CPT 301 RC outpatient 160 160 BLUE CROSS BLUE SHIELD WELLMARK SB889 [3081026] BCBS WYOMING [308102603] 152 percent of total billed charges 99.2 152 Technical (Hospital) Services Theophylline PX-3018019800 CDM 80198 CPT 301 RC outpatient 160 160 MULTIPLAN INC 34080 [3081285] MULTIPLAN INC [308128501] 152 percent of total billed charges 99.2 152 Technical (Hospital) Services Theophylline PX-3018019800 CDM 80198 CPT 301 RC outpatient 160 160 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES PPO [308136801] 128 percent of total billed charges 99.2 152 Technical (Hospital) Services Theophylline PX-3018019800 CDM 80198 CPT 301 RC outpatient 160 160 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES EPO [308136803] 128 percent of total billed charges 99.2 152 Technical (Hospital) Services Theophylline PX-3018019800 CDM 80198 CPT 301 RC outpatient 160 160 HEALTHPARTNERS SX009 HEALTHPARTNERS 128 percent of total billed charges 99.2 152 Technical (Hospital) Services Theophylline PX-3018019800 CDM 80198 CPT 301 RC outpatient 160 160 UNITED HEALTHCARE (COMMERCIAL) [3081199] UNITED HEALTHCARE 87726 [308119901] 99.2 percent of total billed charges 99.2 152 Technical (Hospital) Services Theophylline PX-3018019800 CDM 80198 CPT 301 RC outpatient 160 160 CIGNA 62308 [3081051] CIGNA 62308 [308105105] 128 percent of total billed charges 99.2 152 Technical (Hospital) Services Theophylline PX-3018019800 CDM 80198 CPT 301 RC outpatient 160 160 CIGNA 62308 [3081051] CIGNA STATE OF WYOMING [308105107] 128 percent of total billed charges 99.2 152 Technical (Hospital) Services Theophylline PX-3018019800 CDM 80198 CPT 301 RC outpatient 160 160 MEDICA (COMMERCIAL) 94265 [3081118] MEDICA CLAIMS [308111801] 144 percent of total billed charges 99.2 152 Technical (Hospital) Services Theophylline PX-3018019800 CDM 80198 CPT 301 RC inpatient 160 160 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES HDHP [308136802] 126.69 percent of total billed charges 99.2 152 Technical (Hospital) Services Theophylline PX-3018019800 CDM 80198 CPT 301 RC inpatient 160 160 BLUE CROSS BLUE SHIELD WELLMARK SB889 [3081026] BCBS WYOMING [308102603] 152 percent of total billed charges 99.2 152 Technical (Hospital) Services Theophylline PX-3018019800 CDM 80198 CPT 301 RC inpatient 160 160 MULTIPLAN INC 34080 [3081285] MULTIPLAN INC [308128501] 152 percent of total billed charges 99.2 152 Technical (Hospital) Services Theophylline PX-3018019800 CDM 80198 CPT 301 RC inpatient 160 160 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES PPO [308136801] 126.69 percent of total billed charges 99.2 152 Technical (Hospital) Services Theophylline PX-3018019800 CDM 80198 CPT 301 RC inpatient 160 160 UNITED HEALTHCARE (COMMERCIAL) [3081199] UNITED HEALTHCARE 87726 [308119901] 99.2 percent of total billed charges 99.2 152 Technical (Hospital) Services Theophylline PX-3018019800 CDM 80198 CPT 301 RC inpatient 160 160 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES EPO [308136803] 126.69 percent of total billed charges 99.2 152 Technical (Hospital) Services Theophylline PX-3018019800 CDM 80198 CPT 301 RC inpatient 160 160 HEALTHPARTNERS SX009 HEALTHPARTNERS 126.69 percent of total billed charges 99.2 152 Technical (Hospital) Services Theophylline PX-3018019800 CDM 80198 CPT 301 RC inpatient 160 160 MEDICA (COMMERCIAL) 94265 [3081118] MEDICA CLAIMS [308111801] 144 percent of total billed charges 99.2 152 Technical (Hospital) Services Theophylline PX-3018019800 CDM 80198 CPT 301 RC inpatient 160 160 CIGNA 62308 [3081051] CIGNA 62308 [308105105] 126.69 percent of total billed charges 99.2 152 Technical (Hospital) Services Theophylline PX-3018019800 CDM 80198 CPT 301 RC inpatient 160 160 CIGNA 62308 [3081051] CIGNA STATE OF WYOMING [308105107] 126.69 percent of total billed charges 99.2 152 Technical (Hospital) Services Ref Tacrolimus Fk506 PX-3018019701 CDM 80197 CPT 301 RC inpatient 210 210 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES HDHP [308136802] 166.28 percent of total billed charges 130.2 199.5 Technical (Hospital) Services Ref Tacrolimus Fk506 PX-3018019701 CDM 80197 CPT 301 RC inpatient 210 210 MULTIPLAN INC 34080 [3081285] MULTIPLAN INC [308128501] 199.5 percent of total billed charges 130.2 199.5 Technical (Hospital) Services Ref Tacrolimus Fk506 PX-3018019701 CDM 80197 CPT 301 RC inpatient 210 210 BLUE CROSS BLUE SHIELD WELLMARK SB889 [3081026] BCBS WYOMING [308102603] 199.5 percent of total billed charges 130.2 199.5 Technical (Hospital) Services Ref Tacrolimus Fk506 PX-3018019701 CDM 80197 CPT 301 RC inpatient 210 210 UNITED HEALTHCARE (COMMERCIAL) [3081199] UNITED HEALTHCARE 87726 [308119901] 130.2 percent of total billed charges 130.2 199.5 Technical (Hospital) Services Ref Tacrolimus Fk506 PX-3018019701 CDM 80197 CPT 301 RC inpatient 210 210 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES PPO [308136801] 166.28 percent of total billed charges 130.2 199.5 Technical (Hospital) Services Ref Tacrolimus Fk506 PX-3018019701 CDM 80197 CPT 301 RC inpatient 210 210 MEDICA (COMMERCIAL) 94265 [3081118] MEDICA CLAIMS [308111801] 189 percent of total billed charges 130.2 199.5 Technical (Hospital) Services Ref Tacrolimus Fk506 PX-3018019701 CDM 80197 CPT 301 RC inpatient 210 210 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES EPO [308136803] 166.28 percent of total billed charges 130.2 199.5 Technical (Hospital) Services Ref Tacrolimus Fk506 PX-3018019701 CDM 80197 CPT 301 RC inpatient 210 210 HEALTHPARTNERS SX009 HEALTHPARTNERS 166.28 percent of total billed charges 130.2 199.5 Technical (Hospital) Services Ref Tacrolimus Fk506 PX-3018019701 CDM 80197 CPT 301 RC inpatient 210 210 CIGNA 62308 [3081051] CIGNA 62308 [308105105] 166.28 percent of total billed charges 130.2 199.5 Technical (Hospital) Services Ref Tacrolimus Fk506 PX-3018019701 CDM 80197 CPT 301 RC inpatient 210 210 CIGNA 62308 [3081051] CIGNA STATE OF WYOMING [308105107] 166.28 percent of total billed charges 130.2 199.5 Technical (Hospital) Services Ref Tacrolimus Fk506 PX-3018019701 CDM 80197 CPT 301 RC outpatient 210 210 CIGNA 62308 [3081051] CIGNA 62308 [308105105] 168 percent of total billed charges 130.2 199.5 Technical (Hospital) Services Ref Tacrolimus Fk506 PX-3018019701 CDM 80197 CPT 301 RC outpatient 210 210 CIGNA 62308 [3081051] CIGNA STATE OF WYOMING [308105107] 168 percent of total billed charges 130.2 199.5 Technical (Hospital) Services Ref Tacrolimus Fk506 PX-3018019701 CDM 80197 CPT 301 RC outpatient 210 210 MEDICA (COMMERCIAL) 94265 [3081118] MEDICA CLAIMS [308111801] 189 percent of total billed charges 130.2 199.5 Technical (Hospital) Services Ref Tacrolimus Fk506 PX-3018019701 CDM 80197 CPT 301 RC outpatient 210 210 BLUE CROSS BLUE SHIELD WELLMARK SB889 [3081026] BCBS WYOMING [308102603] 199.5 percent of total billed charges 130.2 199.5 Technical (Hospital) Services Ref Tacrolimus Fk506 PX-3018019701 CDM 80197 CPT 301 RC outpatient 210 210 MULTIPLAN INC 34080 [3081285] MULTIPLAN INC [308128501] 199.5 percent of total billed charges 130.2 199.5 Technical (Hospital) Services Ref Tacrolimus Fk506 PX-3018019701 CDM 80197 CPT 301 RC outpatient 210 210 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES HDHP [308136802] 168 percent of total billed charges 130.2 199.5 Technical (Hospital) Services Ref Tacrolimus Fk506 PX-3018019701 CDM 80197 CPT 301 RC outpatient 210 210 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES PPO [308136801] 168 percent of total billed charges 130.2 199.5 Technical (Hospital) Services Ref Tacrolimus Fk506 PX-3018019701 CDM 80197 CPT 301 RC outpatient 210 210 HEALTHPARTNERS SX009 HEALTHPARTNERS 168 percent of total billed charges 130.2 199.5 Technical (Hospital) Services Ref Tacrolimus Fk506 PX-3018019701 CDM 80197 CPT 301 RC outpatient 210 210 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES EPO [308136803] 168 percent of total billed charges 130.2 199.5 Technical (Hospital) Services Ref Tacrolimus Fk506 PX-3018019701 CDM 80197 CPT 301 RC outpatient 210 210 UNITED HEALTHCARE (COMMERCIAL) [3081199] UNITED HEALTHCARE 87726 [308119901] 130.2 percent of total billed charges 130.2 199.5 Technical (Hospital) Services Ref Sirolimus Rapamune PX-3018019500 CDM 80195 CPT 301 RC outpatient 183 183 CIGNA 62308 [3081051] CIGNA 62308 [308105105] 146.4 percent of total billed charges 113.46 173.85 Technical (Hospital) Services Ref Sirolimus Rapamune PX-3018019500 CDM 80195 CPT 301 RC outpatient 183 183 CIGNA 62308 [3081051] CIGNA STATE OF WYOMING [308105107] 146.4 percent of total billed charges 113.46 173.85 Technical (Hospital) Services Ref Sirolimus Rapamune PX-3018019500 CDM 80195 CPT 301 RC outpatient 183 183 MEDICA (COMMERCIAL) 94265 [3081118] MEDICA CLAIMS [308111801] 164.7 percent of total billed charges 113.46 173.85 Technical (Hospital) Services Ref Sirolimus Rapamune PX-3018019500 CDM 80195 CPT 301 RC outpatient 183 183 HEALTHPARTNERS SX009 HEALTHPARTNERS 146.4 percent of total billed charges 113.46 173.85 Technical (Hospital) Services Ref Sirolimus Rapamune PX-3018019500 CDM 80195 CPT 301 RC outpatient 183 183 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES HDHP [308136802] 146.4 percent of total billed charges 113.46 173.85 Technical (Hospital) Services Ref Sirolimus Rapamune PX-3018019500 CDM 80195 CPT 301 RC outpatient 183 183 BLUE CROSS BLUE SHIELD WELLMARK SB889 [3081026] BCBS WYOMING [308102603] 173.85 percent of total billed charges 113.46 173.85 Technical (Hospital) Services Ref Sirolimus Rapamune PX-3018019500 CDM 80195 CPT 301 RC outpatient 183 183 MULTIPLAN INC 34080 [3081285] MULTIPLAN INC [308128501] 173.85 percent of total billed charges 113.46 173.85 Technical (Hospital) Services Ref Sirolimus Rapamune PX-3018019500 CDM 80195 CPT 301 RC outpatient 183 183 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES PPO [308136801] 146.4 percent of total billed charges 113.46 173.85 Technical (Hospital) Services Ref Sirolimus Rapamune PX-3018019500 CDM 80195 CPT 301 RC outpatient 183 183 UNITED HEALTHCARE (COMMERCIAL) [3081199] UNITED HEALTHCARE 87726 [308119901] 113.46 percent of total billed charges 113.46 173.85 Technical (Hospital) Services Ref Sirolimus Rapamune PX-3018019500 CDM 80195 CPT 301 RC outpatient 183 183 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES EPO [308136803] 146.4 percent of total billed charges 113.46 173.85 Technical (Hospital) Services Ref Sirolimus Rapamune PX-3018019500 CDM 80195 CPT 301 RC inpatient 183 183 BLUE CROSS BLUE SHIELD WELLMARK SB889 [3081026] BCBS WYOMING [308102603] 173.85 percent of total billed charges 113.46 173.85 Technical (Hospital) Services Ref Sirolimus Rapamune PX-3018019500 CDM 80195 CPT 301 RC inpatient 183 183 MULTIPLAN INC 34080 [3081285] MULTIPLAN INC [308128501] 173.85 percent of total billed charges 113.46 173.85 Technical (Hospital) Services Ref Sirolimus Rapamune PX-3018019500 CDM 80195 CPT 301 RC inpatient 183 183 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES PPO [308136801] 144.9 percent of total billed charges 113.46 173.85 Technical (Hospital) Services Ref Sirolimus Rapamune PX-3018019500 CDM 80195 CPT 301 RC inpatient 183 183 UNITED HEALTHCARE (COMMERCIAL) [3081199] UNITED HEALTHCARE 87726 [308119901] 113.46 percent of total billed charges 113.46 173.85 Technical (Hospital) Services Ref Sirolimus Rapamune PX-3018019500 CDM 80195 CPT 301 RC inpatient 183 183 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES HDHP [308136802] 144.9 percent of total billed charges 113.46 173.85 Technical (Hospital) Services Ref Sirolimus Rapamune PX-3018019500 CDM 80195 CPT 301 RC inpatient 183 183 MEDICA (COMMERCIAL) 94265 [3081118] MEDICA CLAIMS [308111801] 164.7 percent of total billed charges 113.46 173.85 Technical (Hospital) Services Ref Sirolimus Rapamune PX-3018019500 CDM 80195 CPT 301 RC inpatient 183 183 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES EPO [308136803] 144.9 percent of total billed charges 113.46 173.85 Technical (Hospital) Services Ref Sirolimus Rapamune PX-3018019500 CDM 80195 CPT 301 RC inpatient 183 183 HEALTHPARTNERS SX009 HEALTHPARTNERS 144.9 percent of total billed charges 113.46 173.85 Technical (Hospital) Services Ref Sirolimus Rapamune PX-3018019500 CDM 80195 CPT 301 RC inpatient 183 183 CIGNA 62308 [3081051] CIGNA 62308 [308105105] 144.9 percent of total billed charges 113.46 173.85 Technical (Hospital) Services Ref Sirolimus Rapamune PX-3018019500 CDM 80195 CPT 301 RC inpatient 183 183 CIGNA 62308 [3081051] CIGNA STATE OF WYOMING [308105107] 144.9 percent of total billed charges 113.46 173.85 Technical (Hospital) Services Ref Quinidine PX-3018019400 CDM 80194 CPT 301 RC inpatient 172 172 MEDICA (COMMERCIAL) 94265 [3081118] MEDICA CLAIMS [308111801] 154.8 percent of total billed charges 106.64 163.4 Technical (Hospital) Services Ref Quinidine PX-3018019400 CDM 80194 CPT 301 RC inpatient 172 172 HEALTHPARTNERS SX009 HEALTHPARTNERS 136.19 percent of total billed charges 106.64 163.4 Technical (Hospital) Services Ref Quinidine PX-3018019400 CDM 80194 CPT 301 RC inpatient 172 172 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES EPO [308136803] 136.19 percent of total billed charges 106.64 163.4 Technical (Hospital) Services Ref Quinidine PX-3018019400 CDM 80194 CPT 301 RC inpatient 172 172 MULTIPLAN INC 34080 [3081285] MULTIPLAN INC [308128501] 163.4 percent of total billed charges 106.64 163.4 Technical (Hospital) Services Ref Quinidine PX-3018019400 CDM 80194 CPT 301 RC inpatient 172 172 BLUE CROSS BLUE SHIELD WELLMARK SB889 [3081026] BCBS WYOMING [308102603] 163.4 percent of total billed charges 106.64 163.4 Technical (Hospital) Services Ref Quinidine PX-3018019400 CDM 80194 CPT 301 RC inpatient 172 172 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES HDHP [308136802] 136.19 percent of total billed charges 106.64 163.4 Technical (Hospital) Services Ref Quinidine PX-3018019400 CDM 80194 CPT 301 RC inpatient 172 172 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES PPO [308136801] 136.19 percent of total billed charges 106.64 163.4 Technical (Hospital) Services Ref Quinidine PX-3018019400 CDM 80194 CPT 301 RC inpatient 172 172 UNITED HEALTHCARE (COMMERCIAL) [3081199] UNITED HEALTHCARE 87726 [308119901] 106.64 percent of total billed charges 106.64 163.4 Technical (Hospital) Services Ref Quinidine PX-3018019400 CDM 80194 CPT 301 RC inpatient 172 172 CIGNA 62308 [3081051] CIGNA 62308 [308105105] 136.19 percent of total billed charges 106.64 163.4 Technical (Hospital) Services Ref Quinidine PX-3018019400 CDM 80194 CPT 301 RC inpatient 172 172 CIGNA 62308 [3081051] CIGNA STATE OF WYOMING [308105107] 136.19 percent of total billed charges 106.64 163.4 Technical (Hospital) Services Ref Quinidine PX-3018019400 CDM 80194 CPT 301 RC outpatient 172 172 MEDICA (COMMERCIAL) 94265 [3081118] MEDICA CLAIMS [308111801] 154.8 percent of total billed charges 106.64 163.4 Technical (Hospital) Services Ref Quinidine PX-3018019400 CDM 80194 CPT 301 RC outpatient 172 172 CIGNA 62308 [3081051] CIGNA 62308 [308105105] 137.6 percent of total billed charges 106.64 163.4 Technical (Hospital) Services Ref Quinidine PX-3018019400 CDM 80194 CPT 301 RC outpatient 172 172 CIGNA 62308 [3081051] CIGNA STATE OF WYOMING [308105107] 137.6 percent of total billed charges 106.64 163.4 Technical (Hospital) Services Ref Quinidine PX-3018019400 CDM 80194 CPT 301 RC outpatient 172 172 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES EPO [308136803] 137.6 percent of total billed charges 106.64 163.4 Technical (Hospital) Services Ref Quinidine PX-3018019400 CDM 80194 CPT 301 RC outpatient 172 172 UNITED HEALTHCARE (COMMERCIAL) [3081199] UNITED HEALTHCARE 87726 [308119901] 106.64 percent of total billed charges 106.64 163.4 Technical (Hospital) Services Ref Quinidine PX-3018019400 CDM 80194 CPT 301 RC outpatient 172 172 HEALTHPARTNERS SX009 HEALTHPARTNERS 137.6 percent of total billed charges 106.64 163.4 Technical (Hospital) Services Ref Quinidine PX-3018019400 CDM 80194 CPT 301 RC outpatient 172 172 BLUE CROSS BLUE SHIELD WELLMARK SB889 [3081026] BCBS WYOMING [308102603] 163.4 percent of total billed charges 106.64 163.4 Technical (Hospital) Services Ref Quinidine PX-3018019400 CDM 80194 CPT 301 RC outpatient 172 172 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES HDHP [308136802] 137.6 percent of total billed charges 106.64 163.4 Technical (Hospital) Services Ref Quinidine PX-3018019400 CDM 80194 CPT 301 RC outpatient 172 172 MULTIPLAN INC 34080 [3081285] MULTIPLAN INC [308128501] 163.4 percent of total billed charges 106.64 163.4 Technical (Hospital) Services Ref Quinidine PX-3018019400 CDM 80194 CPT 301 RC outpatient 172 172 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES PPO [308136801] 137.6 percent of total billed charges 106.64 163.4 Technical (Hospital) Services Ref Assay of Primidone PX-3018018800 CDM 80188 CPT 301 RC inpatient 188 188 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES PPO [308136801] 148.86 percent of total billed charges 116.56 178.6 Technical (Hospital) Services Ref Assay of Primidone PX-3018018800 CDM 80188 CPT 301 RC inpatient 188 188 UNITED HEALTHCARE (COMMERCIAL) [3081199] UNITED HEALTHCARE 87726 [308119901] 116.56 percent of total billed charges 116.56 178.6 Technical (Hospital) Services Ref Assay of Primidone PX-3018018800 CDM 80188 CPT 301 RC inpatient 188 188 MULTIPLAN INC 34080 [3081285] MULTIPLAN INC [308128501] 178.6 percent of total billed charges 116.56 178.6 Technical (Hospital) Services Ref Assay of Primidone PX-3018018800 CDM 80188 CPT 301 RC inpatient 188 188 BLUE CROSS BLUE SHIELD WELLMARK SB889 [3081026] BCBS WYOMING [308102603] 178.6 percent of total billed charges 116.56 178.6 Technical (Hospital) Services Ref Assay of Primidone PX-3018018800 CDM 80188 CPT 301 RC inpatient 188 188 HEALTHPARTNERS SX009 HEALTHPARTNERS 148.86 percent of total billed charges 116.56 178.6 Technical (Hospital) Services Ref Assay of Primidone PX-3018018800 CDM 80188 CPT 301 RC inpatient 188 188 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES EPO [308136803] 148.86 percent of total billed charges 116.56 178.6 Technical (Hospital) Services Ref Assay of Primidone PX-3018018800 CDM 80188 CPT 301 RC inpatient 188 188 MEDICA (COMMERCIAL) 94265 [3081118] MEDICA CLAIMS [308111801] 169.2 percent of total billed charges 116.56 178.6 Technical (Hospital) Services Ref Assay of Primidone PX-3018018800 CDM 80188 CPT 301 RC inpatient 188 188 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES HDHP [308136802] 148.86 percent of total billed charges 116.56 178.6 Technical (Hospital) Services Ref Assay of Primidone PX-3018018800 CDM 80188 CPT 301 RC inpatient 188 188 CIGNA 62308 [3081051] CIGNA 62308 [308105105] 148.86 percent of total billed charges 116.56 178.6 Technical (Hospital) Services Ref Assay of Primidone PX-3018018800 CDM 80188 CPT 301 RC inpatient 188 188 CIGNA 62308 [3081051] CIGNA STATE OF WYOMING [308105107] 148.86 percent of total billed charges 116.56 178.6 Technical (Hospital) Services Ref Assay of Primidone PX-3018018800 CDM 80188 CPT 301 RC outpatient 188 188 CIGNA 62308 [3081051] CIGNA 62308 [308105105] 150.4 percent of total billed charges 116.56 178.6 Technical (Hospital) Services Ref Assay of Primidone PX-3018018800 CDM 80188 CPT 301 RC outpatient 188 188 CIGNA 62308 [3081051] CIGNA STATE OF WYOMING [308105107] 150.4 percent of total billed charges 116.56 178.6 Technical (Hospital) Services Ref Assay of Primidone PX-3018018800 CDM 80188 CPT 301 RC outpatient 188 188 MEDICA (COMMERCIAL) 94265 [3081118] MEDICA CLAIMS [308111801] 169.2 percent of total billed charges 116.56 178.6 Technical (Hospital) Services Ref Assay of Primidone PX-3018018800 CDM 80188 CPT 301 RC outpatient 188 188 HEALTHPARTNERS SX009 HEALTHPARTNERS 150.4 percent of total billed charges 116.56 178.6 Technical (Hospital) Services Ref Assay of Primidone PX-3018018800 CDM 80188 CPT 301 RC outpatient 188 188 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES EPO [308136803] 150.4 percent of total billed charges 116.56 178.6 Technical (Hospital) Services Ref Assay of Primidone PX-3018018800 CDM 80188 CPT 301 RC outpatient 188 188 UNITED HEALTHCARE (COMMERCIAL) [3081199] UNITED HEALTHCARE 87726 [308119901] 116.56 percent of total billed charges 116.56 178.6 Technical (Hospital) Services Ref Assay of Primidone PX-3018018800 CDM 80188 CPT 301 RC outpatient 188 188 BLUE CROSS BLUE SHIELD WELLMARK SB889 [3081026] BCBS WYOMING [308102603] 178.6 percent of total billed charges 116.56 178.6 Technical (Hospital) Services Ref Assay of Primidone PX-3018018800 CDM 80188 CPT 301 RC outpatient 188 188 MULTIPLAN INC 34080 [3081285] MULTIPLAN INC [308128501] 178.6 percent of total billed charges 116.56 178.6 Technical (Hospital) Services Ref Assay of Primidone PX-3018018800 CDM 80188 CPT 301 RC outpatient 188 188 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES HDHP [308136802] 150.4 percent of total billed charges 116.56 178.6 Technical (Hospital) Services Ref Assay of Primidone PX-3018018800 CDM 80188 CPT 301 RC outpatient 188 188 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES PPO [308136801] 150.4 percent of total billed charges 116.56 178.6 Technical (Hospital) Services Ref Phenytoin Dilantin Free PX-3018018600 CDM 80186 CPT 301 RC inpatient 161 161 UNITED HEALTHCARE (COMMERCIAL) [3081199] UNITED HEALTHCARE 87726 [308119901] 99.82 percent of total billed charges 99.82 152.95 Technical (Hospital) Services Ref Phenytoin Dilantin Free PX-3018018600 CDM 80186 CPT 301 RC inpatient 161 161 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES PPO [308136801] 127.48 percent of total billed charges 99.82 152.95 Technical (Hospital) Services Ref Phenytoin Dilantin Free PX-3018018600 CDM 80186 CPT 301 RC inpatient 161 161 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES HDHP [308136802] 127.48 percent of total billed charges 99.82 152.95 Technical (Hospital) Services Ref Phenytoin Dilantin Free PX-3018018600 CDM 80186 CPT 301 RC inpatient 161 161 BLUE CROSS BLUE SHIELD WELLMARK SB889 [3081026] BCBS WYOMING [308102603] 152.95 percent of total billed charges 99.82 152.95 Technical (Hospital) Services Ref Phenytoin Dilantin Free PX-3018018600 CDM 80186 CPT 301 RC inpatient 161 161 MULTIPLAN INC 34080 [3081285] MULTIPLAN INC [308128501] 152.95 percent of total billed charges 99.82 152.95 Technical (Hospital) Services Ref Phenytoin Dilantin Free PX-3018018600 CDM 80186 CPT 301 RC inpatient 161 161 MEDICA (COMMERCIAL) 94265 [3081118] MEDICA CLAIMS [308111801] 144.9 percent of total billed charges 99.82 152.95 Technical (Hospital) Services Ref Phenytoin Dilantin Free PX-3018018600 CDM 80186 CPT 301 RC inpatient 161 161 HEALTHPARTNERS SX009 HEALTHPARTNERS 127.48 percent of total billed charges 99.82 152.95 Technical (Hospital) Services Ref Phenytoin Dilantin Free PX-3018018600 CDM 80186 CPT 301 RC inpatient 161 161 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES EPO [308136803] 127.48 percent of total billed charges 99.82 152.95 Technical (Hospital) Services Ref Phenytoin Dilantin Free PX-3018018600 CDM 80186 CPT 301 RC inpatient 161 161 CIGNA 62308 [3081051] CIGNA 62308 [308105105] 127.48 percent of total billed charges 99.82 152.95 Technical (Hospital) Services Ref Phenytoin Dilantin Free PX-3018018600 CDM 80186 CPT 301 RC inpatient 161 161 CIGNA 62308 [3081051] CIGNA STATE OF WYOMING [308105107] 127.48 percent of total billed charges 99.82 152.95 Technical (Hospital) Services Ref Phenytoin Dilantin Free PX-3018018600 CDM 80186 CPT 301 RC outpatient 161 161 CIGNA 62308 [3081051] CIGNA 62308 [308105105] 128.8 percent of total billed charges 99.82 152.95 Technical (Hospital) Services Ref Phenytoin Dilantin Free PX-3018018600 CDM 80186 CPT 301 RC outpatient 161 161 CIGNA 62308 [3081051] CIGNA STATE OF WYOMING [308105107] 128.8 percent of total billed charges 99.82 152.95 Technical (Hospital) Services Ref Phenytoin Dilantin Free PX-3018018600 CDM 80186 CPT 301 RC outpatient 161 161 MEDICA (COMMERCIAL) 94265 [3081118] MEDICA CLAIMS [308111801] 144.9 percent of total billed charges 99.82 152.95 Technical (Hospital) Services Ref Phenytoin Dilantin Free PX-3018018600 CDM 80186 CPT 301 RC outpatient 161 161 UNITED HEALTHCARE (COMMERCIAL) [3081199] UNITED HEALTHCARE 87726 [308119901] 99.82 percent of total billed charges 99.82 152.95 Technical (Hospital) Services Ref Phenytoin Dilantin Free PX-3018018600 CDM 80186 CPT 301 RC outpatient 161 161 HEALTHPARTNERS SX009 HEALTHPARTNERS 128.8 percent of total billed charges 99.82 152.95 Technical (Hospital) Services Ref Phenytoin Dilantin Free PX-3018018600 CDM 80186 CPT 301 RC outpatient 161 161 BLUE CROSS BLUE SHIELD WELLMARK SB889 [3081026] BCBS WYOMING [308102603] 152.95 percent of total billed charges 99.82 152.95 Technical (Hospital) Services Ref Phenytoin Dilantin Free PX-3018018600 CDM 80186 CPT 301 RC outpatient 161 161 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES HDHP [308136802] 128.8 percent of total billed charges 99.82 152.95 Technical (Hospital) Services Ref Phenytoin Dilantin Free PX-3018018600 CDM 80186 CPT 301 RC outpatient 161 161 MULTIPLAN INC 34080 [3081285] MULTIPLAN INC [308128501] 152.95 percent of total billed charges 99.82 152.95 Technical (Hospital) Services Ref Phenytoin Dilantin Free PX-3018018600 CDM 80186 CPT 301 RC outpatient 161 161 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES EPO [308136803] 128.8 percent of total billed charges 99.82 152.95 Technical (Hospital) Services Ref Phenytoin Dilantin Free PX-3018018600 CDM 80186 CPT 301 RC outpatient 161 161 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES PPO [308136801] 128.8 percent of total billed charges 99.82 152.95 Technical (Hospital) Services Ref Phenytoin Free PX-3018018601 CDM 80186 CPT 301 RC inpatient 205 205 CIGNA 62308 [3081051] CIGNA 62308 [308105105] 162.32 percent of total billed charges 127.1 194.75 Technical (Hospital) Services Ref Phenytoin Free PX-3018018601 CDM 80186 CPT 301 RC inpatient 205 205 CIGNA 62308 [3081051] CIGNA STATE OF WYOMING [308105107] 162.32 percent of total billed charges 127.1 194.75 Technical (Hospital) Services Ref Phenytoin Free PX-3018018601 CDM 80186 CPT 301 RC inpatient 205 205 MEDICA (COMMERCIAL) 94265 [3081118] MEDICA CLAIMS [308111801] 184.5 percent of total billed charges 127.1 194.75 Technical (Hospital) Services Ref Phenytoin Free PX-3018018601 CDM 80186 CPT 301 RC inpatient 205 205 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES HDHP [308136802] 162.32 percent of total billed charges 127.1 194.75 Technical (Hospital) Services Ref Phenytoin Free PX-3018018601 CDM 80186 CPT 301 RC inpatient 205 205 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES EPO [308136803] 162.32 percent of total billed charges 127.1 194.75 Technical (Hospital) Services Ref Phenytoin Free PX-3018018601 CDM 80186 CPT 301 RC inpatient 205 205 HEALTHPARTNERS SX009 HEALTHPARTNERS 162.32 percent of total billed charges 127.1 194.75 Technical (Hospital) Services Ref Phenytoin Free PX-3018018601 CDM 80186 CPT 301 RC inpatient 205 205 MULTIPLAN INC 34080 [3081285] MULTIPLAN INC [308128501] 194.75 percent of total billed charges 127.1 194.75 Technical (Hospital) Services Ref Phenytoin Free PX-3018018601 CDM 80186 CPT 301 RC inpatient 205 205 BLUE CROSS BLUE SHIELD WELLMARK SB889 [3081026] BCBS WYOMING [308102603] 194.75 percent of total billed charges 127.1 194.75 Technical (Hospital) Services Ref Phenytoin Free PX-3018018601 CDM 80186 CPT 301 RC inpatient 205 205 UNITED HEALTHCARE (COMMERCIAL) [3081199] UNITED HEALTHCARE 87726 [308119901] 127.1 percent of total billed charges 127.1 194.75 Technical (Hospital) Services Ref Phenytoin Free PX-3018018601 CDM 80186 CPT 301 RC inpatient 205 205 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES PPO [308136801] 162.32 percent of total billed charges 127.1 194.75 Technical (Hospital) Services Ref Phenytoin Free PX-3018018601 CDM 80186 CPT 301 RC outpatient 205 205 MEDICA (COMMERCIAL) 94265 [3081118] MEDICA CLAIMS [308111801] 184.5 percent of total billed charges 127.1 194.75 Technical (Hospital) Services Ref Phenytoin Free PX-3018018601 CDM 80186 CPT 301 RC outpatient 205 205 CIGNA 62308 [3081051] CIGNA 62308 [308105105] 164 percent of total billed charges 127.1 194.75 Technical (Hospital) Services Ref Phenytoin Free PX-3018018601 CDM 80186 CPT 301 RC outpatient 205 205 CIGNA 62308 [3081051] CIGNA STATE OF WYOMING [308105107] 164 percent of total billed charges 127.1 194.75 Technical (Hospital) Services Ref Phenytoin Free PX-3018018601 CDM 80186 CPT 301 RC outpatient 205 205 BLUE CROSS BLUE SHIELD WELLMARK SB889 [3081026] BCBS WYOMING [308102603] 194.75 percent of total billed charges 127.1 194.75 Technical (Hospital) Services Ref Phenytoin Free PX-3018018601 CDM 80186 CPT 301 RC outpatient 205 205 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES HDHP [308136802] 164 percent of total billed charges 127.1 194.75 Technical (Hospital) Services Ref Phenytoin Free PX-3018018601 CDM 80186 CPT 301 RC outpatient 205 205 MULTIPLAN INC 34080 [3081285] MULTIPLAN INC [308128501] 194.75 percent of total billed charges 127.1 194.75 Technical (Hospital) Services Ref Phenytoin Free PX-3018018601 CDM 80186 CPT 301 RC outpatient 205 205 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES PPO [308136801] 164 percent of total billed charges 127.1 194.75 Technical (Hospital) Services Ref Phenytoin Free PX-3018018601 CDM 80186 CPT 301 RC outpatient 205 205 HEALTHPARTNERS SX009 HEALTHPARTNERS 164 percent of total billed charges 127.1 194.75 Technical (Hospital) Services Ref Phenytoin Free PX-3018018601 CDM 80186 CPT 301 RC outpatient 205 205 UNITED HEALTHCARE (COMMERCIAL) [3081199] UNITED HEALTHCARE 87726 [308119901] 127.1 percent of total billed charges 127.1 194.75 Technical (Hospital) Services Ref Phenytoin Free PX-3018018601 CDM 80186 CPT 301 RC outpatient 205 205 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES EPO [308136803] 164 percent of total billed charges 127.1 194.75 Technical (Hospital) Services Phenytoin PX-3018018500 CDM 80185 CPT 301 RC outpatient 152 152 CIGNA 62308 [3081051] CIGNA 62308 [308105105] 121.6 percent of total billed charges 94.24 144.4 Technical (Hospital) Services Phenytoin PX-3018018500 CDM 80185 CPT 301 RC outpatient 152 152 CIGNA 62308 [3081051] CIGNA STATE OF WYOMING [308105107] 121.6 percent of total billed charges 94.24 144.4 Technical (Hospital) Services Phenytoin PX-3018018500 CDM 80185 CPT 301 RC outpatient 152 152 MEDICA (COMMERCIAL) 94265 [3081118] MEDICA CLAIMS [308111801] 136.8 percent of total billed charges 94.24 144.4 Technical (Hospital) Services Phenytoin PX-3018018500 CDM 80185 CPT 301 RC outpatient 152 152 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES EPO [308136803] 121.6 percent of total billed charges 94.24 144.4 Technical (Hospital) Services Phenytoin PX-3018018500 CDM 80185 CPT 301 RC outpatient 152 152 UNITED HEALTHCARE (COMMERCIAL) [3081199] UNITED HEALTHCARE 87726 [308119901] 94.24 percent of total billed charges 94.24 144.4 Technical (Hospital) Services Phenytoin PX-3018018500 CDM 80185 CPT 301 RC outpatient 152 152 HEALTHPARTNERS SX009 HEALTHPARTNERS 121.6 percent of total billed charges 94.24 144.4 Technical (Hospital) Services Phenytoin PX-3018018500 CDM 80185 CPT 301 RC outpatient 152 152 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES PPO [308136801] 121.6 percent of total billed charges 94.24 144.4 Technical (Hospital) Services Phenytoin PX-3018018500 CDM 80185 CPT 301 RC outpatient 152 152 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES HDHP [308136802] 121.6 percent of total billed charges 94.24 144.4 Technical (Hospital) Services Phenytoin PX-3018018500 CDM 80185 CPT 301 RC outpatient 152 152 MULTIPLAN INC 34080 [3081285] MULTIPLAN INC [308128501] 144.4 percent of total billed charges 94.24 144.4 Technical (Hospital) Services Phenytoin PX-3018018500 CDM 80185 CPT 301 RC outpatient 152 152 BLUE CROSS BLUE SHIELD WELLMARK SB889 [3081026] BCBS WYOMING [308102603] 144.4 percent of total billed charges 94.24 144.4 Technical (Hospital) Services Phenytoin PX-3018018500 CDM 80185 CPT 301 RC inpatient 152 152 MEDICA (COMMERCIAL) 94265 [3081118] MEDICA CLAIMS [308111801] 136.8 percent of total billed charges 94.24 144.4 Technical (Hospital) Services Phenytoin PX-3018018500 CDM 80185 CPT 301 RC inpatient 152 152 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES HDHP [308136802] 120.35 percent of total billed charges 94.24 144.4 Technical (Hospital) Services Phenytoin PX-3018018500 CDM 80185 CPT 301 RC inpatient 152 152 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES EPO [308136803] 120.35 percent of total billed charges 94.24 144.4 Technical (Hospital) Services Phenytoin PX-3018018500 CDM 80185 CPT 301 RC inpatient 152 152 HEALTHPARTNERS SX009 HEALTHPARTNERS 120.35 percent of total billed charges 94.24 144.4 Technical (Hospital) Services Phenytoin PX-3018018500 CDM 80185 CPT 301 RC inpatient 152 152 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES PPO [308136801] 120.35 percent of total billed charges 94.24 144.4 Technical (Hospital) Services Phenytoin PX-3018018500 CDM 80185 CPT 301 RC inpatient 152 152 UNITED HEALTHCARE (COMMERCIAL) [3081199] UNITED HEALTHCARE 87726 [308119901] 94.24 percent of total billed charges 94.24 144.4 Technical (Hospital) Services Phenytoin PX-3018018500 CDM 80185 CPT 301 RC inpatient 152 152 MULTIPLAN INC 34080 [3081285] MULTIPLAN INC [308128501] 144.4 percent of total billed charges 94.24 144.4 Technical (Hospital) Services Phenytoin PX-3018018500 CDM 80185 CPT 301 RC inpatient 152 152 BLUE CROSS BLUE SHIELD WELLMARK SB889 [3081026] BCBS WYOMING [308102603] 144.4 percent of total billed charges 94.24 144.4 Technical (Hospital) Services Phenytoin PX-3018018500 CDM 80185 CPT 301 RC inpatient 152 152 CIGNA 62308 [3081051] CIGNA 62308 [308105105] 120.35 percent of total billed charges 94.24 144.4 Technical (Hospital) Services Phenytoin PX-3018018500 CDM 80185 CPT 301 RC inpatient 152 152 CIGNA 62308 [3081051] CIGNA STATE OF WYOMING [308105107] 120.35 percent of total billed charges 94.24 144.4 Technical (Hospital) Services Ref Phenytoin Total PX-3018018501 CDM 80185 CPT 301 RC inpatient 140 140 MULTIPLAN INC 34080 [3081285] MULTIPLAN INC [308128501] 133 percent of total billed charges 86.8 133 Technical (Hospital) Services Ref Phenytoin Total PX-3018018501 CDM 80185 CPT 301 RC inpatient 140 140 BLUE CROSS BLUE SHIELD WELLMARK SB889 [3081026] BCBS WYOMING [308102603] 133 percent of total billed charges 86.8 133 Technical (Hospital) Services Ref Phenytoin Total PX-3018018501 CDM 80185 CPT 301 RC inpatient 140 140 UNITED HEALTHCARE (COMMERCIAL) [3081199] UNITED HEALTHCARE 87726 [308119901] 86.8 percent of total billed charges 86.8 133 Technical (Hospital) Services Ref Phenytoin Total PX-3018018501 CDM 80185 CPT 301 RC inpatient 140 140 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES PPO [308136801] 110.85 percent of total billed charges 86.8 133 Technical (Hospital) Services Ref Phenytoin Total PX-3018018501 CDM 80185 CPT 301 RC inpatient 140 140 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES HDHP [308136802] 110.85 percent of total billed charges 86.8 133 Technical (Hospital) Services Ref Phenytoin Total PX-3018018501 CDM 80185 CPT 301 RC inpatient 140 140 MEDICA (COMMERCIAL) 94265 [3081118] MEDICA CLAIMS [308111801] 126 percent of total billed charges 86.8 133 Technical (Hospital) Services Ref Phenytoin Total PX-3018018501 CDM 80185 CPT 301 RC inpatient 140 140 HEALTHPARTNERS SX009 HEALTHPARTNERS 110.85 percent of total billed charges 86.8 133 Technical (Hospital) Services Ref Phenytoin Total PX-3018018501 CDM 80185 CPT 301 RC inpatient 140 140 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES EPO [308136803] 110.85 percent of total billed charges 86.8 133 Technical (Hospital) Services Ref Phenytoin Total PX-3018018501 CDM 80185 CPT 301 RC inpatient 140 140 CIGNA 62308 [3081051] CIGNA 62308 [308105105] 110.85 percent of total billed charges 86.8 133 Technical (Hospital) Services Ref Phenytoin Total PX-3018018501 CDM 80185 CPT 301 RC inpatient 140 140 CIGNA 62308 [3081051] CIGNA STATE OF WYOMING [308105107] 110.85 percent of total billed charges 86.8 133 Technical (Hospital) Services Ref Phenytoin Total PX-3018018501 CDM 80185 CPT 301 RC outpatient 140 140 UNITED HEALTHCARE (COMMERCIAL) [3081199] UNITED HEALTHCARE 87726 [308119901] 86.8 percent of total billed charges 86.8 133 Technical (Hospital) Services Ref Phenytoin Total PX-3018018501 CDM 80185 CPT 301 RC outpatient 140 140 HEALTHPARTNERS SX009 HEALTHPARTNERS 112 percent of total billed charges 86.8 133 Technical (Hospital) Services Ref Phenytoin Total PX-3018018501 CDM 80185 CPT 301 RC outpatient 140 140 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES PPO [308136801] 112 percent of total billed charges 86.8 133 Technical (Hospital) Services Ref Phenytoin Total PX-3018018501 CDM 80185 CPT 301 RC outpatient 140 140 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES EPO [308136803] 112 percent of total billed charges 86.8 133 Technical (Hospital) Services Ref Phenytoin Total PX-3018018501 CDM 80185 CPT 301 RC outpatient 140 140 BLUE CROSS BLUE SHIELD WELLMARK SB889 [3081026] BCBS WYOMING [308102603] 133 percent of total billed charges 86.8 133 Technical (Hospital) Services Ref Phenytoin Total PX-3018018501 CDM 80185 CPT 301 RC outpatient 140 140 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES HDHP [308136802] 112 percent of total billed charges 86.8 133 Technical (Hospital) Services Ref Phenytoin Total PX-3018018501 CDM 80185 CPT 301 RC outpatient 140 140 MULTIPLAN INC 34080 [3081285] MULTIPLAN INC [308128501] 133 percent of total billed charges 86.8 133 Technical (Hospital) Services Ref Phenytoin Total PX-3018018501 CDM 80185 CPT 301 RC outpatient 140 140 MEDICA (COMMERCIAL) 94265 [3081118] MEDICA CLAIMS [308111801] 126 percent of total billed charges 86.8 133 Technical (Hospital) Services Ref Phenytoin Total PX-3018018501 CDM 80185 CPT 301 RC outpatient 140 140 CIGNA 62308 [3081051] CIGNA 62308 [308105105] 112 percent of total billed charges 86.8 133 Technical (Hospital) Services Ref Phenytoin Total PX-3018018501 CDM 80185 CPT 301 RC outpatient 140 140 CIGNA 62308 [3081051] CIGNA STATE OF WYOMING [308105107] 112 percent of total billed charges 86.8 133 Technical (Hospital) Services Phenobarb PX-3018018400 CDM 80184 CPT 301 RC inpatient 95 95 MEDICA (COMMERCIAL) 94265 [3081118] MEDICA CLAIMS [308111801] 85.5 percent of total billed charges 58.9 90.25 Technical (Hospital) Services Phenobarb PX-3018018400 CDM 80184 CPT 301 RC inpatient 95 95 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES EPO [308136803] 75.22 percent of total billed charges 58.9 90.25 Technical (Hospital) Services Phenobarb PX-3018018400 CDM 80184 CPT 301 RC inpatient 95 95 HEALTHPARTNERS SX009 HEALTHPARTNERS 75.22 percent of total billed charges 58.9 90.25 Technical (Hospital) Services Phenobarb PX-3018018400 CDM 80184 CPT 301 RC inpatient 95 95 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES HDHP [308136802] 75.22 percent of total billed charges 58.9 90.25 Technical (Hospital) Services Phenobarb PX-3018018400 CDM 80184 CPT 301 RC inpatient 95 95 BLUE CROSS BLUE SHIELD WELLMARK SB889 [3081026] BCBS WYOMING [308102603] 90.25 percent of total billed charges 58.9 90.25 Technical (Hospital) Services Phenobarb PX-3018018400 CDM 80184 CPT 301 RC inpatient 95 95 MULTIPLAN INC 34080 [3081285] MULTIPLAN INC [308128501] 90.25 percent of total billed charges 58.9 90.25 Technical (Hospital) Services Phenobarb PX-3018018400 CDM 80184 CPT 301 RC inpatient 95 95 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES PPO [308136801] 75.22 percent of total billed charges 58.9 90.25 Technical (Hospital) Services Phenobarb PX-3018018400 CDM 80184 CPT 301 RC inpatient 95 95 UNITED HEALTHCARE (COMMERCIAL) [3081199] UNITED HEALTHCARE 87726 [308119901] 58.9 percent of total billed charges 58.9 90.25 Technical (Hospital) Services Phenobarb PX-3018018400 CDM 80184 CPT 301 RC inpatient 95 95 CIGNA 62308 [3081051] CIGNA 62308 [308105105] 75.22 percent of total billed charges 58.9 90.25 Technical (Hospital) Services Phenobarb PX-3018018400 CDM 80184 CPT 301 RC inpatient 95 95 CIGNA 62308 [3081051] CIGNA STATE OF WYOMING [308105107] 75.22 percent of total billed charges 58.9 90.25 Technical (Hospital) Services Phenobarb PX-3018018400 CDM 80184 CPT 301 RC outpatient 95 95 CIGNA 62308 [3081051] CIGNA 62308 [308105105] 76 percent of total billed charges 58.9 90.25 Technical (Hospital) Services Phenobarb PX-3018018400 CDM 80184 CPT 301 RC outpatient 95 95 CIGNA 62308 [3081051] CIGNA STATE OF WYOMING [308105107] 76 percent of total billed charges 58.9 90.25 Technical (Hospital) Services Phenobarb PX-3018018400 CDM 80184 CPT 301 RC outpatient 95 95 MEDICA (COMMERCIAL) 94265 [3081118] MEDICA CLAIMS [308111801] 85.5 percent of total billed charges 58.9 90.25 Technical (Hospital) Services Phenobarb PX-3018018400 CDM 80184 CPT 301 RC outpatient 95 95 UNITED HEALTHCARE (COMMERCIAL) [3081199] UNITED HEALTHCARE 87726 [308119901] 58.9 percent of total billed charges 58.9 90.25 Technical (Hospital) Services Phenobarb PX-3018018400 CDM 80184 CPT 301 RC outpatient 95 95 HEALTHPARTNERS SX009 HEALTHPARTNERS 76 percent of total billed charges 58.9 90.25 Technical (Hospital) Services Phenobarb PX-3018018400 CDM 80184 CPT 301 RC outpatient 95 95 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES PPO [308136801] 76 percent of total billed charges 58.9 90.25 Technical (Hospital) Services Phenobarb PX-3018018400 CDM 80184 CPT 301 RC outpatient 95 95 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES EPO [308136803] 76 percent of total billed charges 58.9 90.25 Technical (Hospital) Services Phenobarb PX-3018018400 CDM 80184 CPT 301 RC outpatient 95 95 BLUE CROSS BLUE SHIELD WELLMARK SB889 [3081026] BCBS WYOMING [308102603] 90.25 percent of total billed charges 58.9 90.25 Technical (Hospital) Services Phenobarb PX-3018018400 CDM 80184 CPT 301 RC outpatient 95 95 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES HDHP [308136802] 76 percent of total billed charges 58.9 90.25 Technical (Hospital) Services Phenobarb PX-3018018400 CDM 80184 CPT 301 RC outpatient 95 95 MULTIPLAN INC 34080 [3081285] MULTIPLAN INC [308128501] 90.25 percent of total billed charges 58.9 90.25 Technical (Hospital) Services Ref Oxcarbazepine Metabolite (Mhc) PX-3018018300 CDM 80183 CPT 301 RC outpatient 195 195 MEDICA (COMMERCIAL) 94265 [3081118] MEDICA CLAIMS [308111801] 175.5 percent of total billed charges 120.9 185.25 Technical (Hospital) Services Ref Oxcarbazepine Metabolite (Mhc) PX-3018018300 CDM 80183 CPT 301 RC outpatient 195 195 CIGNA 62308 [3081051] CIGNA 62308 [308105105] 156 percent of total billed charges 120.9 185.25 Technical (Hospital) Services Ref Oxcarbazepine Metabolite (Mhc) PX-3018018300 CDM 80183 CPT 301 RC outpatient 195 195 CIGNA 62308 [3081051] CIGNA STATE OF WYOMING [308105107] 156 percent of total billed charges 120.9 185.25 Technical (Hospital) Services Ref Oxcarbazepine Metabolite (Mhc) PX-3018018300 CDM 80183 CPT 301 RC outpatient 195 195 BLUE CROSS BLUE SHIELD WELLMARK SB889 [3081026] BCBS WYOMING [308102603] 185.25 percent of total billed charges 120.9 185.25 Technical (Hospital) Services Ref Oxcarbazepine Metabolite (Mhc) PX-3018018300 CDM 80183 CPT 301 RC outpatient 195 195 MULTIPLAN INC 34080 [3081285] MULTIPLAN INC [308128501] 185.25 percent of total billed charges 120.9 185.25 Technical (Hospital) Services Ref Oxcarbazepine Metabolite (Mhc) PX-3018018300 CDM 80183 CPT 301 RC outpatient 195 195 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES HDHP [308136802] 156 percent of total billed charges 120.9 185.25 Technical (Hospital) Services Ref Oxcarbazepine Metabolite (Mhc) PX-3018018300 CDM 80183 CPT 301 RC outpatient 195 195 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES PPO [308136801] 156 percent of total billed charges 120.9 185.25 Technical (Hospital) Services Ref Oxcarbazepine Metabolite (Mhc) PX-3018018300 CDM 80183 CPT 301 RC outpatient 195 195 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES EPO [308136803] 156 percent of total billed charges 120.9 185.25 Technical (Hospital) Services Ref Oxcarbazepine Metabolite (Mhc) PX-3018018300 CDM 80183 CPT 301 RC outpatient 195 195 UNITED HEALTHCARE (COMMERCIAL) [3081199] UNITED HEALTHCARE 87726 [308119901] 120.9 percent of total billed charges 120.9 185.25 Technical (Hospital) Services Ref Oxcarbazepine Metabolite (Mhc) PX-3018018300 CDM 80183 CPT 301 RC outpatient 195 195 HEALTHPARTNERS SX009 HEALTHPARTNERS 156 percent of total billed charges 120.9 185.25 Technical (Hospital) Services Ref Oxcarbazepine Metabolite (Mhc) PX-3018018300 CDM 80183 CPT 301 RC inpatient 195 195 HEALTHPARTNERS SX009 HEALTHPARTNERS 154.4 percent of total billed charges 120.9 185.25 Technical (Hospital) Services Ref Oxcarbazepine Metabolite (Mhc) PX-3018018300 CDM 80183 CPT 301 RC inpatient 195 195 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES EPO [308136803] 154.4 percent of total billed charges 120.9 185.25 Technical (Hospital) Services Ref Oxcarbazepine Metabolite (Mhc) PX-3018018300 CDM 80183 CPT 301 RC inpatient 195 195 MEDICA (COMMERCIAL) 94265 [3081118] MEDICA CLAIMS [308111801] 175.5 percent of total billed charges 120.9 185.25 Technical (Hospital) Services Ref Oxcarbazepine Metabolite (Mhc) PX-3018018300 CDM 80183 CPT 301 RC inpatient 195 195 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES PPO [308136801] 154.4 percent of total billed charges 120.9 185.25 Technical (Hospital) Services Ref Oxcarbazepine Metabolite (Mhc) PX-3018018300 CDM 80183 CPT 301 RC inpatient 195 195 UNITED HEALTHCARE (COMMERCIAL) [3081199] UNITED HEALTHCARE 87726 [308119901] 120.9 percent of total billed charges 120.9 185.25 Technical (Hospital) Services Ref Oxcarbazepine Metabolite (Mhc) PX-3018018300 CDM 80183 CPT 301 RC inpatient 195 195 BLUE CROSS BLUE SHIELD WELLMARK SB889 [3081026] BCBS WYOMING [308102603] 185.25 percent of total billed charges 120.9 185.25 Technical (Hospital) Services Ref Oxcarbazepine Metabolite (Mhc) PX-3018018300 CDM 80183 CPT 301 RC inpatient 195 195 MULTIPLAN INC 34080 [3081285] MULTIPLAN INC [308128501] 185.25 percent of total billed charges 120.9 185.25 Technical (Hospital) Services Ref Oxcarbazepine Metabolite (Mhc) PX-3018018300 CDM 80183 CPT 301 RC inpatient 195 195 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES HDHP [308136802] 154.4 percent of total billed charges 120.9 185.25 Technical (Hospital) Services Ref Oxcarbazepine Metabolite (Mhc) PX-3018018300 CDM 80183 CPT 301 RC inpatient 195 195 CIGNA 62308 [3081051] CIGNA 62308 [308105105] 154.4 percent of total billed charges 120.9 185.25 Technical (Hospital) Services Ref Oxcarbazepine Metabolite (Mhc) PX-3018018300 CDM 80183 CPT 301 RC inpatient 195 195 CIGNA 62308 [3081051] CIGNA STATE OF WYOMING [308105107] 154.4 percent of total billed charges 120.9 185.25 Technical (Hospital) Services Ref Oxcarbazepine Metabolite Mhc PX-3018018301 CDM 80183 CPT 301 RC outpatient 175 175 MEDICA (COMMERCIAL) 94265 [3081118] MEDICA CLAIMS [308111801] 157.5 percent of total billed charges 108.5 166.25 Technical (Hospital) Services Ref Oxcarbazepine Metabolite Mhc PX-3018018301 CDM 80183 CPT 301 RC outpatient 175 175 CIGNA 62308 [3081051] CIGNA 62308 [308105105] 140 percent of total billed charges 108.5 166.25 Technical (Hospital) Services Ref Oxcarbazepine Metabolite Mhc PX-3018018301 CDM 80183 CPT 301 RC outpatient 175 175 CIGNA 62308 [3081051] CIGNA STATE OF WYOMING [308105107] 140 percent of total billed charges 108.5 166.25 Technical (Hospital) Services Ref Oxcarbazepine Metabolite Mhc PX-3018018301 CDM 80183 CPT 301 RC outpatient 175 175 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES PPO [308136801] 140 percent of total billed charges 108.5 166.25 Technical (Hospital) Services Ref Oxcarbazepine Metabolite Mhc PX-3018018301 CDM 80183 CPT 301 RC outpatient 175 175 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES EPO [308136803] 140 percent of total billed charges 108.5 166.25 Technical (Hospital) Services Ref Oxcarbazepine Metabolite Mhc PX-3018018301 CDM 80183 CPT 301 RC outpatient 175 175 BLUE CROSS BLUE SHIELD WELLMARK SB889 [3081026] BCBS WYOMING [308102603] 166.25 percent of total billed charges 108.5 166.25 Technical (Hospital) Services Ref Oxcarbazepine Metabolite Mhc PX-3018018301 CDM 80183 CPT 301 RC outpatient 175 175 MULTIPLAN INC 34080 [3081285] MULTIPLAN INC [308128501] 166.25 percent of total billed charges 108.5 166.25 Technical (Hospital) Services Ref Oxcarbazepine Metabolite Mhc PX-3018018301 CDM 80183 CPT 301 RC outpatient 175 175 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES HDHP [308136802] 140 percent of total billed charges 108.5 166.25 Technical (Hospital) Services Ref Oxcarbazepine Metabolite Mhc PX-3018018301 CDM 80183 CPT 301 RC outpatient 175 175 UNITED HEALTHCARE (COMMERCIAL) [3081199] UNITED HEALTHCARE 87726 [308119901] 108.5 percent of total billed charges 108.5 166.25 Technical (Hospital) Services Ref Oxcarbazepine Metabolite Mhc PX-3018018301 CDM 80183 CPT 301 RC outpatient 175 175 HEALTHPARTNERS SX009 HEALTHPARTNERS 140 percent of total billed charges 108.5 166.25 Technical (Hospital) Services Ref Oxcarbazepine Metabolite Mhc PX-3018018301 CDM 80183 CPT 301 RC inpatient 175 175 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES HDHP [308136802] 138.57 percent of total billed charges 108.5 166.25 Technical (Hospital) Services Ref Oxcarbazepine Metabolite Mhc PX-3018018301 CDM 80183 CPT 301 RC inpatient 175 175 MULTIPLAN INC 34080 [3081285] MULTIPLAN INC [308128501] 166.25 percent of total billed charges 108.5 166.25 Technical (Hospital) Services Ref Oxcarbazepine Metabolite Mhc PX-3018018301 CDM 80183 CPT 301 RC inpatient 175 175 BLUE CROSS BLUE SHIELD WELLMARK SB889 [3081026] BCBS WYOMING [308102603] 166.25 percent of total billed charges 108.5 166.25 Technical (Hospital) Services Ref Oxcarbazepine Metabolite Mhc PX-3018018301 CDM 80183 CPT 301 RC inpatient 175 175 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES PPO [308136801] 138.57 percent of total billed charges 108.5 166.25 Technical (Hospital) Services Ref Oxcarbazepine Metabolite Mhc PX-3018018301 CDM 80183 CPT 301 RC inpatient 175 175 UNITED HEALTHCARE (COMMERCIAL) [3081199] UNITED HEALTHCARE 87726 [308119901] 108.5 percent of total billed charges 108.5 166.25 Technical (Hospital) Services Ref Oxcarbazepine Metabolite Mhc PX-3018018301 CDM 80183 CPT 301 RC inpatient 175 175 HEALTHPARTNERS SX009 HEALTHPARTNERS 138.57 percent of total billed charges 108.5 166.25 Technical (Hospital) Services Ref Oxcarbazepine Metabolite Mhc PX-3018018301 CDM 80183 CPT 301 RC inpatient 175 175 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES EPO [308136803] 138.57 percent of total billed charges 108.5 166.25 Technical (Hospital) Services Ref Oxcarbazepine Metabolite Mhc PX-3018018301 CDM 80183 CPT 301 RC inpatient 175 175 MEDICA (COMMERCIAL) 94265 [3081118] MEDICA CLAIMS [308111801] 157.5 percent of total billed charges 108.5 166.25 Technical (Hospital) Services Ref Oxcarbazepine Metabolite Mhc PX-3018018301 CDM 80183 CPT 301 RC inpatient 175 175 CIGNA 62308 [3081051] CIGNA 62308 [308105105] 138.57 percent of total billed charges 108.5 166.25 Technical (Hospital) Services Ref Oxcarbazepine Metabolite Mhc PX-3018018301 CDM 80183 CPT 301 RC inpatient 175 175 CIGNA 62308 [3081051] CIGNA STATE OF WYOMING [308105107] 138.57 percent of total billed charges 108.5 166.25 Technical (Hospital) Services Drug Assay Salicylate PX-3018017900 CDM 80179 CPT 301 RC outpatient 253 253 HEALTHPARTNERS SX009 HEALTHPARTNERS 202.4 percent of total billed charges 156.86 240.35 Technical (Hospital) Services Drug Assay Salicylate PX-3018017900 CDM 80179 CPT 301 RC outpatient 253 253 UNITED HEALTHCARE (COMMERCIAL) [3081199] UNITED HEALTHCARE 87726 [308119901] 156.86 percent of total billed charges 156.86 240.35 Technical (Hospital) Services Drug Assay Salicylate PX-3018017900 CDM 80179 CPT 301 RC outpatient 253 253 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES PPO [308136801] 202.4 percent of total billed charges 156.86 240.35 Technical (Hospital) Services Drug Assay Salicylate PX-3018017900 CDM 80179 CPT 301 RC outpatient 253 253 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES EPO [308136803] 202.4 percent of total billed charges 156.86 240.35 Technical (Hospital) Services Drug Assay Salicylate PX-3018017900 CDM 80179 CPT 301 RC outpatient 253 253 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES HDHP [308136802] 202.4 percent of total billed charges 156.86 240.35 Technical (Hospital) Services Drug Assay Salicylate PX-3018017900 CDM 80179 CPT 301 RC outpatient 253 253 MULTIPLAN INC 34080 [3081285] MULTIPLAN INC [308128501] 240.35 percent of total billed charges 156.86 240.35 Technical (Hospital) Services Drug Assay Salicylate PX-3018017900 CDM 80179 CPT 301 RC outpatient 253 253 BLUE CROSS BLUE SHIELD WELLMARK SB889 [3081026] BCBS WYOMING [308102603] 240.35 percent of total billed charges 156.86 240.35 Technical (Hospital) Services Drug Assay Salicylate PX-3018017900 CDM 80179 CPT 301 RC outpatient 253 253 MEDICA (COMMERCIAL) 94265 [3081118] MEDICA CLAIMS [308111801] 227.7 percent of total billed charges 156.86 240.35 Technical (Hospital) Services Drug Assay Salicylate PX-3018017900 CDM 80179 CPT 301 RC outpatient 253 253 CIGNA 62308 [3081051] CIGNA 62308 [308105105] 202.4 percent of total billed charges 156.86 240.35 Technical (Hospital) Services Drug Assay Salicylate PX-3018017900 CDM 80179 CPT 301 RC outpatient 253 253 CIGNA 62308 [3081051] CIGNA STATE OF WYOMING [308105107] 202.4 percent of total billed charges 156.86 240.35 Technical (Hospital) Services Drug Assay Salicylate PX-3018017900 CDM 80179 CPT 301 RC inpatient 253 253 CIGNA 62308 [3081051] CIGNA 62308 [308105105] 200.33 percent of total billed charges 156.86 240.35 Technical (Hospital) Services Drug Assay Salicylate PX-3018017900 CDM 80179 CPT 301 RC inpatient 253 253 CIGNA 62308 [3081051] CIGNA STATE OF WYOMING [308105107] 200.33 percent of total billed charges 156.86 240.35 Technical (Hospital) Services Drug Assay Salicylate PX-3018017900 CDM 80179 CPT 301 RC inpatient 253 253 BLUE CROSS BLUE SHIELD WELLMARK SB889 [3081026] BCBS WYOMING [308102603] 240.35 percent of total billed charges 156.86 240.35 Technical (Hospital) Services Drug Assay Salicylate PX-3018017900 CDM 80179 CPT 301 RC inpatient 253 253 MULTIPLAN INC 34080 [3081285] MULTIPLAN INC [308128501] 240.35 percent of total billed charges 156.86 240.35 Technical (Hospital) Services Drug Assay Salicylate PX-3018017900 CDM 80179 CPT 301 RC inpatient 253 253 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES HDHP [308136802] 200.33 percent of total billed charges 156.86 240.35 Technical (Hospital) Services Drug Assay Salicylate PX-3018017900 CDM 80179 CPT 301 RC inpatient 253 253 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES PPO [308136801] 200.33 percent of total billed charges 156.86 240.35 Technical (Hospital) Services Drug Assay Salicylate PX-3018017900 CDM 80179 CPT 301 RC inpatient 253 253 UNITED HEALTHCARE (COMMERCIAL) [3081199] UNITED HEALTHCARE 87726 [308119901] 156.86 percent of total billed charges 156.86 240.35 Technical (Hospital) Services Drug Assay Salicylate PX-3018017900 CDM 80179 CPT 301 RC inpatient 253 253 MEDICA (COMMERCIAL) 94265 [3081118] MEDICA CLAIMS [308111801] 227.7 percent of total billed charges 156.86 240.35 Technical (Hospital) Services Drug Assay Salicylate PX-3018017900 CDM 80179 CPT 301 RC inpatient 253 253 HEALTHPARTNERS SX009 HEALTHPARTNERS 200.33 percent of total billed charges 156.86 240.35 Technical (Hospital) Services Drug Assay Salicylate PX-3018017900 CDM 80179 CPT 301 RC inpatient 253 253 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES EPO [308136803] 200.33 percent of total billed charges 156.86 240.35 Technical (Hospital) Services Lithium PX-3018017800 CDM 80178 CPT 301 RC inpatient 133 133 BLUE CROSS BLUE SHIELD WELLMARK SB889 [3081026] BCBS WYOMING [308102603] 126.35 percent of total billed charges 82.46 126.35 Technical (Hospital) Services Lithium PX-3018017800 CDM 80178 CPT 301 RC inpatient 133 133 MULTIPLAN INC 34080 [3081285] MULTIPLAN INC [308128501] 126.35 percent of total billed charges 82.46 126.35 Technical (Hospital) Services Lithium PX-3018017800 CDM 80178 CPT 301 RC inpatient 133 133 UNITED HEALTHCARE (COMMERCIAL) [3081199] UNITED HEALTHCARE 87726 [308119901] 82.46 percent of total billed charges 82.46 126.35 Technical (Hospital) Services Lithium PX-3018017800 CDM 80178 CPT 301 RC inpatient 133 133 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES PPO [308136801] 105.31 percent of total billed charges 82.46 126.35 Technical (Hospital) Services Lithium PX-3018017800 CDM 80178 CPT 301 RC inpatient 133 133 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES EPO [308136803] 105.31 percent of total billed charges 82.46 126.35 Technical (Hospital) Services Lithium PX-3018017800 CDM 80178 CPT 301 RC inpatient 133 133 HEALTHPARTNERS SX009 HEALTHPARTNERS 105.31 percent of total billed charges 82.46 126.35 Technical (Hospital) Services Lithium PX-3018017800 CDM 80178 CPT 301 RC inpatient 133 133 MEDICA (COMMERCIAL) 94265 [3081118] MEDICA CLAIMS [308111801] 119.7 percent of total billed charges 82.46 126.35 Technical (Hospital) Services Lithium PX-3018017800 CDM 80178 CPT 301 RC inpatient 133 133 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES HDHP [308136802] 105.31 percent of total billed charges 82.46 126.35 Technical (Hospital) Services Lithium PX-3018017800 CDM 80178 CPT 301 RC inpatient 133 133 CIGNA 62308 [3081051] CIGNA 62308 [308105105] 105.31 percent of total billed charges 82.46 126.35 Technical (Hospital) Services Lithium PX-3018017800 CDM 80178 CPT 301 RC inpatient 133 133 CIGNA 62308 [3081051] CIGNA STATE OF WYOMING [308105107] 105.31 percent of total billed charges 82.46 126.35 Technical (Hospital) Services Lithium PX-3018017800 CDM 80178 CPT 301 RC outpatient 133 133 CIGNA 62308 [3081051] CIGNA 62308 [308105105] 106.4 percent of total billed charges 82.46 126.35 Technical (Hospital) Services Lithium PX-3018017800 CDM 80178 CPT 301 RC outpatient 133 133 CIGNA 62308 [3081051] CIGNA STATE OF WYOMING [308105107] 106.4 percent of total billed charges 82.46 126.35 Technical (Hospital) Services Lithium PX-3018017800 CDM 80178 CPT 301 RC outpatient 133 133 MEDICA (COMMERCIAL) 94265 [3081118] MEDICA CLAIMS [308111801] 119.7 percent of total billed charges 82.46 126.35 Technical (Hospital) Services Lithium PX-3018017800 CDM 80178 CPT 301 RC outpatient 133 133 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES EPO [308136803] 106.4 percent of total billed charges 82.46 126.35 Technical (Hospital) Services Lithium PX-3018017800 CDM 80178 CPT 301 RC outpatient 133 133 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES PPO [308136801] 106.4 percent of total billed charges 82.46 126.35 Technical (Hospital) Services Lithium PX-3018017800 CDM 80178 CPT 301 RC outpatient 133 133 BLUE CROSS BLUE SHIELD WELLMARK SB889 [3081026] BCBS WYOMING [308102603] 126.35 percent of total billed charges 82.46 126.35 Technical (Hospital) Services Lithium PX-3018017800 CDM 80178 CPT 301 RC outpatient 133 133 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES HDHP [308136802] 106.4 percent of total billed charges 82.46 126.35 Technical (Hospital) Services Lithium PX-3018017800 CDM 80178 CPT 301 RC outpatient 133 133 MULTIPLAN INC 34080 [3081285] MULTIPLAN INC [308128501] 126.35 percent of total billed charges 82.46 126.35 Technical (Hospital) Services Lithium PX-3018017800 CDM 80178 CPT 301 RC outpatient 133 133 UNITED HEALTHCARE (COMMERCIAL) [3081199] UNITED HEALTHCARE 87726 [308119901] 82.46 percent of total billed charges 82.46 126.35 Technical (Hospital) Services Lithium PX-3018017800 CDM 80178 CPT 301 RC outpatient 133 133 HEALTHPARTNERS SX009 HEALTHPARTNERS 106.4 percent of total billed charges 82.46 126.35 Technical (Hospital) Services Levetiracetam Keppra PX-3018017700 CDM 80177 CPT 301 RC inpatient 204 204 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES EPO [308136803] 161.53 percent of total billed charges 126.48 193.8 Technical (Hospital) Services Levetiracetam Keppra PX-3018017700 CDM 80177 CPT 301 RC inpatient 204 204 HEALTHPARTNERS SX009 HEALTHPARTNERS 161.53 percent of total billed charges 126.48 193.8 Technical (Hospital) Services Levetiracetam Keppra PX-3018017700 CDM 80177 CPT 301 RC inpatient 204 204 MEDICA (COMMERCIAL) 94265 [3081118] MEDICA CLAIMS [308111801] 183.6 percent of total billed charges 126.48 193.8 Technical (Hospital) Services Levetiracetam Keppra PX-3018017700 CDM 80177 CPT 301 RC inpatient 204 204 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES HDHP [308136802] 161.53 percent of total billed charges 126.48 193.8 Technical (Hospital) Services Levetiracetam Keppra PX-3018017700 CDM 80177 CPT 301 RC inpatient 204 204 UNITED HEALTHCARE (COMMERCIAL) [3081199] UNITED HEALTHCARE 87726 [308119901] 126.48 percent of total billed charges 126.48 193.8 Technical (Hospital) Services Levetiracetam Keppra PX-3018017700 CDM 80177 CPT 301 RC inpatient 204 204 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES PPO [308136801] 161.53 percent of total billed charges 126.48 193.8 Technical (Hospital) Services Levetiracetam Keppra PX-3018017700 CDM 80177 CPT 301 RC inpatient 204 204 MULTIPLAN INC 34080 [3081285] MULTIPLAN INC [308128501] 193.8 percent of total billed charges 126.48 193.8 Technical (Hospital) Services Levetiracetam Keppra PX-3018017700 CDM 80177 CPT 301 RC inpatient 204 204 BLUE CROSS BLUE SHIELD WELLMARK SB889 [3081026] BCBS WYOMING [308102603] 193.8 percent of total billed charges 126.48 193.8 Technical (Hospital) Services Levetiracetam Keppra PX-3018017700 CDM 80177 CPT 301 RC inpatient 204 204 CIGNA 62308 [3081051] CIGNA 62308 [308105105] 161.53 percent of total billed charges 126.48 193.8 Technical (Hospital) Services Levetiracetam Keppra PX-3018017700 CDM 80177 CPT 301 RC inpatient 204 204 CIGNA 62308 [3081051] CIGNA STATE OF WYOMING [308105107] 161.53 percent of total billed charges 126.48 193.8 Technical (Hospital) Services Levetiracetam Keppra PX-3018017700 CDM 80177 CPT 301 RC outpatient 204 204 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES PPO [308136801] 163.2 percent of total billed charges 126.48 193.8 Technical (Hospital) Services Levetiracetam Keppra PX-3018017700 CDM 80177 CPT 301 RC outpatient 204 204 BLUE CROSS BLUE SHIELD WELLMARK SB889 [3081026] BCBS WYOMING [308102603] 193.8 percent of total billed charges 126.48 193.8 Technical (Hospital) Services Levetiracetam Keppra PX-3018017700 CDM 80177 CPT 301 RC outpatient 204 204 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES HDHP [308136802] 163.2 percent of total billed charges 126.48 193.8 Technical (Hospital) Services Levetiracetam Keppra PX-3018017700 CDM 80177 CPT 301 RC outpatient 204 204 MULTIPLAN INC 34080 [3081285] MULTIPLAN INC [308128501] 193.8 percent of total billed charges 126.48 193.8 Technical (Hospital) Services Levetiracetam Keppra PX-3018017700 CDM 80177 CPT 301 RC outpatient 204 204 HEALTHPARTNERS SX009 HEALTHPARTNERS 163.2 percent of total billed charges 126.48 193.8 Technical (Hospital) Services Levetiracetam Keppra PX-3018017700 CDM 80177 CPT 301 RC outpatient 204 204 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES EPO [308136803] 163.2 percent of total billed charges 126.48 193.8 Technical (Hospital) Services Levetiracetam Keppra PX-3018017700 CDM 80177 CPT 301 RC outpatient 204 204 UNITED HEALTHCARE (COMMERCIAL) [3081199] UNITED HEALTHCARE 87726 [308119901] 126.48 percent of total billed charges 126.48 193.8 Technical (Hospital) Services Levetiracetam Keppra PX-3018017700 CDM 80177 CPT 301 RC outpatient 204 204 CIGNA 62308 [3081051] CIGNA STATE OF WYOMING [308105107] 163.2 percent of total billed charges 126.48 193.8 Technical (Hospital) Services Levetiracetam Keppra PX-3018017700 CDM 80177 CPT 301 RC outpatient 204 204 CIGNA 62308 [3081051] CIGNA 62308 [308105105] 163.2 percent of total billed charges 126.48 193.8 Technical (Hospital) Services Levetiracetam Keppra PX-3018017700 CDM 80177 CPT 301 RC outpatient 204 204 MEDICA (COMMERCIAL) 94265 [3081118] MEDICA CLAIMS [308111801] 183.6 percent of total billed charges 126.48 193.8 Technical (Hospital) Services Lamotrigine Lamictal PX-3018017500 CDM 80175 CPT 301 RC outpatient 190 190 BLUE CROSS BLUE SHIELD WELLMARK SB889 [3081026] BCBS WYOMING [308102603] 180.5 percent of total billed charges 117.8 180.5 Technical (Hospital) Services Lamotrigine Lamictal PX-3018017500 CDM 80175 CPT 301 RC outpatient 190 190 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES HDHP [308136802] 152 percent of total billed charges 117.8 180.5 Technical (Hospital) Services Lamotrigine Lamictal PX-3018017500 CDM 80175 CPT 301 RC outpatient 190 190 MULTIPLAN INC 34080 [3081285] MULTIPLAN INC [308128501] 180.5 percent of total billed charges 117.8 180.5 Technical (Hospital) Services Lamotrigine Lamictal PX-3018017500 CDM 80175 CPT 301 RC outpatient 190 190 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES EPO [308136803] 152 percent of total billed charges 117.8 180.5 Technical (Hospital) Services Lamotrigine Lamictal PX-3018017500 CDM 80175 CPT 301 RC outpatient 190 190 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES PPO [308136801] 152 percent of total billed charges 117.8 180.5 Technical (Hospital) Services Lamotrigine Lamictal PX-3018017500 CDM 80175 CPT 301 RC outpatient 190 190 UNITED HEALTHCARE (COMMERCIAL) [3081199] UNITED HEALTHCARE 87726 [308119901] 117.8 percent of total billed charges 117.8 180.5 Technical (Hospital) Services Lamotrigine Lamictal PX-3018017500 CDM 80175 CPT 301 RC outpatient 190 190 HEALTHPARTNERS SX009 HEALTHPARTNERS 152 percent of total billed charges 117.8 180.5 Technical (Hospital) Services Lamotrigine Lamictal PX-3018017500 CDM 80175 CPT 301 RC outpatient 190 190 MEDICA (COMMERCIAL) 94265 [3081118] MEDICA CLAIMS [308111801] 171 percent of total billed charges 117.8 180.5 Technical (Hospital) Services Lamotrigine Lamictal PX-3018017500 CDM 80175 CPT 301 RC outpatient 190 190 CIGNA 62308 [3081051] CIGNA 62308 [308105105] 152 percent of total billed charges 117.8 180.5 Technical (Hospital) Services Lamotrigine Lamictal PX-3018017500 CDM 80175 CPT 301 RC outpatient 190 190 CIGNA 62308 [3081051] CIGNA STATE OF WYOMING [308105107] 152 percent of total billed charges 117.8 180.5 Technical (Hospital) Services Lamotrigine Lamictal PX-3018017500 CDM 80175 CPT 301 RC inpatient 190 190 MEDICA (COMMERCIAL) 94265 [3081118] MEDICA CLAIMS [308111801] 171 percent of total billed charges 117.8 180.5 Technical (Hospital) Services Lamotrigine Lamictal PX-3018017500 CDM 80175 CPT 301 RC inpatient 190 190 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES HDHP [308136802] 150.44 percent of total billed charges 117.8 180.5 Technical (Hospital) Services Lamotrigine Lamictal PX-3018017500 CDM 80175 CPT 301 RC inpatient 190 190 HEALTHPARTNERS SX009 HEALTHPARTNERS 150.44 percent of total billed charges 117.8 180.5 Technical (Hospital) Services Lamotrigine Lamictal PX-3018017500 CDM 80175 CPT 301 RC inpatient 190 190 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES EPO [308136803] 150.44 percent of total billed charges 117.8 180.5 Technical (Hospital) Services Lamotrigine Lamictal PX-3018017500 CDM 80175 CPT 301 RC inpatient 190 190 UNITED HEALTHCARE (COMMERCIAL) [3081199] UNITED HEALTHCARE 87726 [308119901] 117.8 percent of total billed charges 117.8 180.5 Technical (Hospital) Services Lamotrigine Lamictal PX-3018017500 CDM 80175 CPT 301 RC inpatient 190 190 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES PPO [308136801] 150.44 percent of total billed charges 117.8 180.5 Technical (Hospital) Services Lamotrigine Lamictal PX-3018017500 CDM 80175 CPT 301 RC inpatient 190 190 MULTIPLAN INC 34080 [3081285] MULTIPLAN INC [308128501] 180.5 percent of total billed charges 117.8 180.5 Technical (Hospital) Services Lamotrigine Lamictal PX-3018017500 CDM 80175 CPT 301 RC inpatient 190 190 BLUE CROSS BLUE SHIELD WELLMARK SB889 [3081026] BCBS WYOMING [308102603] 180.5 percent of total billed charges 117.8 180.5 Technical (Hospital) Services Lamotrigine Lamictal PX-3018017500 CDM 80175 CPT 301 RC inpatient 190 190 CIGNA 62308 [3081051] CIGNA 62308 [308105105] 150.44 percent of total billed charges 117.8 180.5 Technical (Hospital) Services Lamotrigine Lamictal PX-3018017500 CDM 80175 CPT 301 RC inpatient 190 190 CIGNA 62308 [3081051] CIGNA STATE OF WYOMING [308105107] 150.44 percent of total billed charges 117.8 180.5 Technical (Hospital) Services Ref Drug Screen Quantitative Gabop PX-3018017100 CDM 80171 CPT 301 RC outpatient 228 228 CIGNA 62308 [3081051] CIGNA 62308 [308105105] 182.4 percent of total billed charges 141.36 216.6 Technical (Hospital) Services Ref Drug Screen Quantitative Gabop PX-3018017100 CDM 80171 CPT 301 RC outpatient 228 228 CIGNA 62308 [3081051] CIGNA STATE OF WYOMING [308105107] 182.4 percent of total billed charges 141.36 216.6 Technical (Hospital) Services Ref Drug Screen Quantitative Gabop PX-3018017100 CDM 80171 CPT 301 RC outpatient 228 228 MEDICA (COMMERCIAL) 94265 [3081118] MEDICA CLAIMS [308111801] 205.2 percent of total billed charges 141.36 216.6 Technical (Hospital) Services Ref Drug Screen Quantitative Gabop PX-3018017100 CDM 80171 CPT 301 RC outpatient 228 228 BLUE CROSS BLUE SHIELD WELLMARK SB889 [3081026] BCBS WYOMING [308102603] 216.6 percent of total billed charges 141.36 216.6 Technical (Hospital) Services Ref Drug Screen Quantitative Gabop PX-3018017100 CDM 80171 CPT 301 RC outpatient 228 228 MULTIPLAN INC 34080 [3081285] MULTIPLAN INC [308128501] 216.6 percent of total billed charges 141.36 216.6 Technical (Hospital) Services Ref Drug Screen Quantitative Gabop PX-3018017100 CDM 80171 CPT 301 RC outpatient 228 228 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES HDHP [308136802] 182.4 percent of total billed charges 141.36 216.6 Technical (Hospital) Services Ref Drug Screen Quantitative Gabop PX-3018017100 CDM 80171 CPT 301 RC outpatient 228 228 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES PPO [308136801] 182.4 percent of total billed charges 141.36 216.6 Technical (Hospital) Services Ref Drug Screen Quantitative Gabop PX-3018017100 CDM 80171 CPT 301 RC outpatient 228 228 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES EPO [308136803] 182.4 percent of total billed charges 141.36 216.6 Technical (Hospital) Services Ref Drug Screen Quantitative Gabop PX-3018017100 CDM 80171 CPT 301 RC outpatient 228 228 HEALTHPARTNERS SX009 HEALTHPARTNERS 182.4 percent of total billed charges 141.36 216.6 Technical (Hospital) Services Ref Drug Screen Quantitative Gabop PX-3018017100 CDM 80171 CPT 301 RC outpatient 228 228 UNITED HEALTHCARE (COMMERCIAL) [3081199] UNITED HEALTHCARE 87726 [308119901] 141.36 percent of total billed charges 141.36 216.6 Technical (Hospital) Services Ref Drug Screen Quantitative Gabop PX-3018017100 CDM 80171 CPT 301 RC inpatient 228 228 CIGNA 62308 [3081051] CIGNA 62308 [308105105] 180.53 percent of total billed charges 141.36 216.6 Technical (Hospital) Services Ref Drug Screen Quantitative Gabop PX-3018017100 CDM 80171 CPT 301 RC inpatient 228 228 CIGNA 62308 [3081051] CIGNA STATE OF WYOMING [308105107] 180.53 percent of total billed charges 141.36 216.6 Technical (Hospital) Services Ref Drug Screen Quantitative Gabop PX-3018017100 CDM 80171 CPT 301 RC inpatient 228 228 MULTIPLAN INC 34080 [3081285] MULTIPLAN INC [308128501] 216.6 percent of total billed charges 141.36 216.6 Technical (Hospital) Services Ref Drug Screen Quantitative Gabop PX-3018017100 CDM 80171 CPT 301 RC inpatient 228 228 BLUE CROSS BLUE SHIELD WELLMARK SB889 [3081026] BCBS WYOMING [308102603] 216.6 percent of total billed charges 141.36 216.6 Technical (Hospital) Services Ref Drug Screen Quantitative Gabop PX-3018017100 CDM 80171 CPT 301 RC inpatient 228 228 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES HDHP [308136802] 180.53 percent of total billed charges 141.36 216.6 Technical (Hospital) Services Ref Drug Screen Quantitative Gabop PX-3018017100 CDM 80171 CPT 301 RC inpatient 228 228 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES PPO [308136801] 180.53 percent of total billed charges 141.36 216.6 Technical (Hospital) Services Ref Drug Screen Quantitative Gabop PX-3018017100 CDM 80171 CPT 301 RC inpatient 228 228 UNITED HEALTHCARE (COMMERCIAL) [3081199] UNITED HEALTHCARE 87726 [308119901] 141.36 percent of total billed charges 141.36 216.6 Technical (Hospital) Services Ref Drug Screen Quantitative Gabop PX-3018017100 CDM 80171 CPT 301 RC inpatient 228 228 MEDICA (COMMERCIAL) 94265 [3081118] MEDICA CLAIMS [308111801] 205.2 percent of total billed charges 141.36 216.6 Technical (Hospital) Services Ref Drug Screen Quantitative Gabop PX-3018017100 CDM 80171 CPT 301 RC inpatient 228 228 HEALTHPARTNERS SX009 HEALTHPARTNERS 180.53 percent of total billed charges 141.36 216.6 Technical (Hospital) Services Ref Drug Screen Quantitative Gabop PX-3018017100 CDM 80171 CPT 301 RC inpatient 228 228 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES EPO [308136803] 180.53 percent of total billed charges 141.36 216.6 Technical (Hospital) Services Gentamicin PX-3018017000 CDM 80170 CPT 301 RC inpatient 186 186 CIGNA 62308 [3081051] CIGNA 62308 [308105105] 147.27 percent of total billed charges 115.32 176.7 Technical (Hospital) Services Gentamicin PX-3018017000 CDM 80170 CPT 301 RC inpatient 186 186 CIGNA 62308 [3081051] CIGNA STATE OF WYOMING [308105107] 147.27 percent of total billed charges 115.32 176.7 Technical (Hospital) Services Gentamicin PX-3018017000 CDM 80170 CPT 301 RC inpatient 186 186 MULTIPLAN INC 34080 [3081285] MULTIPLAN INC [308128501] 176.7 percent of total billed charges 115.32 176.7 Technical (Hospital) Services Gentamicin PX-3018017000 CDM 80170 CPT 301 RC inpatient 186 186 BLUE CROSS BLUE SHIELD WELLMARK SB889 [3081026] BCBS WYOMING [308102603] 176.7 percent of total billed charges 115.32 176.7 Technical (Hospital) Services Gentamicin PX-3018017000 CDM 80170 CPT 301 RC inpatient 186 186 UNITED HEALTHCARE (COMMERCIAL) [3081199] UNITED HEALTHCARE 87726 [308119901] 115.32 percent of total billed charges 115.32 176.7 Technical (Hospital) Services Gentamicin PX-3018017000 CDM 80170 CPT 301 RC inpatient 186 186 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES PPO [308136801] 147.27 percent of total billed charges 115.32 176.7 Technical (Hospital) Services Gentamicin PX-3018017000 CDM 80170 CPT 301 RC inpatient 186 186 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES HDHP [308136802] 147.27 percent of total billed charges 115.32 176.7 Technical (Hospital) Services Gentamicin PX-3018017000 CDM 80170 CPT 301 RC inpatient 186 186 MEDICA (COMMERCIAL) 94265 [3081118] MEDICA CLAIMS [308111801] 167.4 percent of total billed charges 115.32 176.7 Technical (Hospital) Services Gentamicin PX-3018017000 CDM 80170 CPT 301 RC inpatient 186 186 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES EPO [308136803] 147.27 percent of total billed charges 115.32 176.7 Technical (Hospital) Services Gentamicin PX-3018017000 CDM 80170 CPT 301 RC inpatient 186 186 HEALTHPARTNERS SX009 HEALTHPARTNERS 147.27 percent of total billed charges 115.32 176.7 Technical (Hospital) Services Gentamicin PX-3018017000 CDM 80170 CPT 301 RC outpatient 186 186 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES EPO [308136803] 148.8 percent of total billed charges 115.32 176.7 Technical (Hospital) Services Gentamicin PX-3018017000 CDM 80170 CPT 301 RC outpatient 186 186 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES PPO [308136801] 148.8 percent of total billed charges 115.32 176.7 Technical (Hospital) Services Gentamicin PX-3018017000 CDM 80170 CPT 301 RC outpatient 186 186 MULTIPLAN INC 34080 [3081285] MULTIPLAN INC [308128501] 176.7 percent of total billed charges 115.32 176.7 Technical (Hospital) Services Gentamicin PX-3018017000 CDM 80170 CPT 301 RC outpatient 186 186 BLUE CROSS BLUE SHIELD WELLMARK SB889 [3081026] BCBS WYOMING [308102603] 176.7 percent of total billed charges 115.32 176.7 Technical (Hospital) Services Gentamicin PX-3018017000 CDM 80170 CPT 301 RC outpatient 186 186 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES HDHP [308136802] 148.8 percent of total billed charges 115.32 176.7 Technical (Hospital) Services Gentamicin PX-3018017000 CDM 80170 CPT 301 RC outpatient 186 186 HEALTHPARTNERS SX009 HEALTHPARTNERS 148.8 percent of total billed charges 115.32 176.7 Technical (Hospital) Services Gentamicin PX-3018017000 CDM 80170 CPT 301 RC outpatient 186 186 UNITED HEALTHCARE (COMMERCIAL) [3081199] UNITED HEALTHCARE 87726 [308119901] 115.32 percent of total billed charges 115.32 176.7 Technical (Hospital) Services Gentamicin PX-3018017000 CDM 80170 CPT 301 RC outpatient 186 186 MEDICA (COMMERCIAL) 94265 [3081118] MEDICA CLAIMS [308111801] 167.4 percent of total billed charges 115.32 176.7 Technical (Hospital) Services Gentamicin PX-3018017000 CDM 80170 CPT 301 RC outpatient 186 186 CIGNA 62308 [3081051] CIGNA 62308 [308105105] 148.8 percent of total billed charges 115.32 176.7 Technical (Hospital) Services Gentamicin PX-3018017000 CDM 80170 CPT 301 RC outpatient 186 186 CIGNA 62308 [3081051] CIGNA STATE OF WYOMING [308105107] 148.8 percent of total billed charges 115.32 176.7 Technical (Hospital) Services Ref Ethosuximide PX-3018016800 CDM 80168 CPT 301 RC outpatient 185 185 CIGNA 62308 [3081051] CIGNA 62308 [308105105] 148 percent of total billed charges 114.7 175.75 Technical (Hospital) Services Ref Ethosuximide PX-3018016800 CDM 80168 CPT 301 RC outpatient 185 185 CIGNA 62308 [3081051] CIGNA STATE OF WYOMING [308105107] 148 percent of total billed charges 114.7 175.75 Technical (Hospital) Services Ref Ethosuximide PX-3018016800 CDM 80168 CPT 301 RC outpatient 185 185 MEDICA (COMMERCIAL) 94265 [3081118] MEDICA CLAIMS [308111801] 166.5 percent of total billed charges 114.7 175.75 Technical (Hospital) Services Ref Ethosuximide PX-3018016800 CDM 80168 CPT 301 RC outpatient 185 185 HEALTHPARTNERS SX009 HEALTHPARTNERS 148 percent of total billed charges 114.7 175.75 Technical (Hospital) Services Ref Ethosuximide PX-3018016800 CDM 80168 CPT 301 RC outpatient 185 185 BLUE CROSS BLUE SHIELD WELLMARK SB889 [3081026] BCBS WYOMING [308102603] 175.75 percent of total billed charges 114.7 175.75 Technical (Hospital) Services Ref Ethosuximide PX-3018016800 CDM 80168 CPT 301 RC outpatient 185 185 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES HDHP [308136802] 148 percent of total billed charges 114.7 175.75 Technical (Hospital) Services Ref Ethosuximide PX-3018016800 CDM 80168 CPT 301 RC outpatient 185 185 MULTIPLAN INC 34080 [3081285] MULTIPLAN INC [308128501] 175.75 percent of total billed charges 114.7 175.75 Technical (Hospital) Services Ref Ethosuximide PX-3018016800 CDM 80168 CPT 301 RC outpatient 185 185 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES PPO [308136801] 148 percent of total billed charges 114.7 175.75 Technical (Hospital) Services Ref Ethosuximide PX-3018016800 CDM 80168 CPT 301 RC outpatient 185 185 UNITED HEALTHCARE (COMMERCIAL) [3081199] UNITED HEALTHCARE 87726 [308119901] 114.7 percent of total billed charges 114.7 175.75 Technical (Hospital) Services Ref Ethosuximide PX-3018016800 CDM 80168 CPT 301 RC outpatient 185 185 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES EPO [308136803] 148 percent of total billed charges 114.7 175.75 Technical (Hospital) Services Ref Ethosuximide PX-3018016800 CDM 80168 CPT 301 RC inpatient 185 185 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES PPO [308136801] 146.48 percent of total billed charges 114.7 175.75 Technical (Hospital) Services Ref Ethosuximide PX-3018016800 CDM 80168 CPT 301 RC inpatient 185 185 UNITED HEALTHCARE (COMMERCIAL) [3081199] UNITED HEALTHCARE 87726 [308119901] 114.7 percent of total billed charges 114.7 175.75 Technical (Hospital) Services Ref Ethosuximide PX-3018016800 CDM 80168 CPT 301 RC inpatient 185 185 MULTIPLAN INC 34080 [3081285] MULTIPLAN INC [308128501] 175.75 percent of total billed charges 114.7 175.75 Technical (Hospital) Services Ref Ethosuximide PX-3018016800 CDM 80168 CPT 301 RC inpatient 185 185 BLUE CROSS BLUE SHIELD WELLMARK SB889 [3081026] BCBS WYOMING [308102603] 175.75 percent of total billed charges 114.7 175.75 Technical (Hospital) Services Ref Ethosuximide PX-3018016800 CDM 80168 CPT 301 RC inpatient 185 185 HEALTHPARTNERS SX009 HEALTHPARTNERS 146.48 percent of total billed charges 114.7 175.75 Technical (Hospital) Services Ref Ethosuximide PX-3018016800 CDM 80168 CPT 301 RC inpatient 185 185 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES EPO [308136803] 146.48 percent of total billed charges 114.7 175.75 Technical (Hospital) Services Ref Ethosuximide PX-3018016800 CDM 80168 CPT 301 RC inpatient 185 185 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES HDHP [308136802] 146.48 percent of total billed charges 114.7 175.75 Technical (Hospital) Services Ref Ethosuximide PX-3018016800 CDM 80168 CPT 301 RC inpatient 185 185 MEDICA (COMMERCIAL) 94265 [3081118] MEDICA CLAIMS [308111801] 166.5 percent of total billed charges 114.7 175.75 Technical (Hospital) Services Ref Ethosuximide PX-3018016800 CDM 80168 CPT 301 RC inpatient 185 185 CIGNA 62308 [3081051] CIGNA 62308 [308105105] 146.48 percent of total billed charges 114.7 175.75 Technical (Hospital) Services Ref Ethosuximide PX-3018016800 CDM 80168 CPT 301 RC inpatient 185 185 CIGNA 62308 [3081051] CIGNA STATE OF WYOMING [308105107] 146.48 percent of total billed charges 114.7 175.75 Technical (Hospital) Services Valproic Acid Total PX-3018016400 CDM 80164 CPT 301 RC outpatient 188 188 HEALTHPARTNERS SX009 HEALTHPARTNERS 150.4 percent of total billed charges 116.56 178.6 Technical (Hospital) Services Valproic Acid Total PX-3018016400 CDM 80164 CPT 301 RC outpatient 188 188 UNITED HEALTHCARE (COMMERCIAL) [3081199] UNITED HEALTHCARE 87726 [308119901] 116.56 percent of total billed charges 116.56 178.6 Technical (Hospital) Services Valproic Acid Total PX-3018016400 CDM 80164 CPT 301 RC outpatient 188 188 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES EPO [308136803] 150.4 percent of total billed charges 116.56 178.6 Technical (Hospital) Services Valproic Acid Total PX-3018016400 CDM 80164 CPT 301 RC outpatient 188 188 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES PPO [308136801] 150.4 percent of total billed charges 116.56 178.6 Technical (Hospital) Services Valproic Acid Total PX-3018016400 CDM 80164 CPT 301 RC outpatient 188 188 BLUE CROSS BLUE SHIELD WELLMARK SB889 [3081026] BCBS WYOMING [308102603] 178.6 percent of total billed charges 116.56 178.6 Technical (Hospital) Services Valproic Acid Total PX-3018016400 CDM 80164 CPT 301 RC outpatient 188 188 MULTIPLAN INC 34080 [3081285] MULTIPLAN INC [308128501] 178.6 percent of total billed charges 116.56 178.6 Technical (Hospital) Services Valproic Acid Total PX-3018016400 CDM 80164 CPT 301 RC outpatient 188 188 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES HDHP [308136802] 150.4 percent of total billed charges 116.56 178.6 Technical (Hospital) Services Valproic Acid Total PX-3018016400 CDM 80164 CPT 301 RC outpatient 188 188 MEDICA (COMMERCIAL) 94265 [3081118] MEDICA CLAIMS [308111801] 169.2 percent of total billed charges 116.56 178.6 Technical (Hospital) Services Valproic Acid Total PX-3018016400 CDM 80164 CPT 301 RC outpatient 188 188 CIGNA 62308 [3081051] CIGNA 62308 [308105105] 150.4 percent of total billed charges 116.56 178.6 Technical (Hospital) Services Valproic Acid Total PX-3018016400 CDM 80164 CPT 301 RC outpatient 188 188 CIGNA 62308 [3081051] CIGNA STATE OF WYOMING [308105107] 150.4 percent of total billed charges 116.56 178.6 Technical (Hospital) Services Valproic Acid Total PX-3018016400 CDM 80164 CPT 301 RC inpatient 188 188 CIGNA 62308 [3081051] CIGNA 62308 [308105105] 148.86 percent of total billed charges 116.56 178.6 Technical (Hospital) Services Valproic Acid Total PX-3018016400 CDM 80164 CPT 301 RC inpatient 188 188 CIGNA 62308 [3081051] CIGNA STATE OF WYOMING [308105107] 148.86 percent of total billed charges 116.56 178.6 Technical (Hospital) Services Valproic Acid Total PX-3018016400 CDM 80164 CPT 301 RC inpatient 188 188 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES EPO [308136803] 148.86 percent of total billed charges 116.56 178.6 Technical (Hospital) Services Valproic Acid Total PX-3018016400 CDM 80164 CPT 301 RC inpatient 188 188 HEALTHPARTNERS SX009 HEALTHPARTNERS 148.86 percent of total billed charges 116.56 178.6 Technical (Hospital) Services Valproic Acid Total PX-3018016400 CDM 80164 CPT 301 RC inpatient 188 188 MEDICA (COMMERCIAL) 94265 [3081118] MEDICA CLAIMS [308111801] 169.2 percent of total billed charges 116.56 178.6 Technical (Hospital) Services Valproic Acid Total PX-3018016400 CDM 80164 CPT 301 RC inpatient 188 188 UNITED HEALTHCARE (COMMERCIAL) [3081199] UNITED HEALTHCARE 87726 [308119901] 116.56 percent of total billed charges 116.56 178.6 Technical (Hospital) Services Valproic Acid Total PX-3018016400 CDM 80164 CPT 301 RC inpatient 188 188 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES PPO [308136801] 148.86 percent of total billed charges 116.56 178.6 Technical (Hospital) Services Valproic Acid Total PX-3018016400 CDM 80164 CPT 301 RC inpatient 188 188 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES HDHP [308136802] 148.86 percent of total billed charges 116.56 178.6 Technical (Hospital) Services Valproic Acid Total PX-3018016400 CDM 80164 CPT 301 RC inpatient 188 188 MULTIPLAN INC 34080 [3081285] MULTIPLAN INC [308128501] 178.6 percent of total billed charges 116.56 178.6 Technical (Hospital) Services Valproic Acid Total PX-3018016400 CDM 80164 CPT 301 RC inpatient 188 188 BLUE CROSS BLUE SHIELD WELLMARK SB889 [3081026] BCBS WYOMING [308102603] 178.6 percent of total billed charges 116.56 178.6 Technical (Hospital) Services Digoxin Total PX-3018016200 CDM 80162 CPT 301 RC outpatient 159 159 MEDICA (COMMERCIAL) 94265 [3081118] MEDICA CLAIMS [308111801] 143.1 percent of total billed charges 98.58 151.05 Technical (Hospital) Services Digoxin Total PX-3018016200 CDM 80162 CPT 301 RC outpatient 159 159 CIGNA 62308 [3081051] CIGNA 62308 [308105105] 127.2 percent of total billed charges 98.58 151.05 Technical (Hospital) Services Digoxin Total PX-3018016200 CDM 80162 CPT 301 RC outpatient 159 159 CIGNA 62308 [3081051] CIGNA STATE OF WYOMING [308105107] 127.2 percent of total billed charges 98.58 151.05 Technical (Hospital) Services Digoxin Total PX-3018016200 CDM 80162 CPT 301 RC outpatient 159 159 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES EPO [308136803] 127.2 percent of total billed charges 98.58 151.05 Technical (Hospital) Services Digoxin Total PX-3018016200 CDM 80162 CPT 301 RC outpatient 159 159 UNITED HEALTHCARE (COMMERCIAL) [3081199] UNITED HEALTHCARE 87726 [308119901] 98.58 percent of total billed charges 98.58 151.05 Technical (Hospital) Services Digoxin Total PX-3018016200 CDM 80162 CPT 301 RC outpatient 159 159 HEALTHPARTNERS SX009 HEALTHPARTNERS 127.2 percent of total billed charges 98.58 151.05 Technical (Hospital) Services Digoxin Total PX-3018016200 CDM 80162 CPT 301 RC outpatient 159 159 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES PPO [308136801] 127.2 percent of total billed charges 98.58 151.05 Technical (Hospital) Services Digoxin Total PX-3018016200 CDM 80162 CPT 301 RC outpatient 159 159 BLUE CROSS BLUE SHIELD WELLMARK SB889 [3081026] BCBS WYOMING [308102603] 151.05 percent of total billed charges 98.58 151.05 Technical (Hospital) Services Digoxin Total PX-3018016200 CDM 80162 CPT 301 RC outpatient 159 159 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES HDHP [308136802] 127.2 percent of total billed charges 98.58 151.05 Technical (Hospital) Services Digoxin Total PX-3018016200 CDM 80162 CPT 301 RC outpatient 159 159 MULTIPLAN INC 34080 [3081285] MULTIPLAN INC [308128501] 151.05 percent of total billed charges 98.58 151.05 Technical (Hospital) Services Digoxin Total PX-3018016200 CDM 80162 CPT 301 RC inpatient 159 159 BLUE CROSS BLUE SHIELD WELLMARK SB889 [3081026] BCBS WYOMING [308102603] 151.05 percent of total billed charges 98.58 151.05 Technical (Hospital) Services Digoxin Total PX-3018016200 CDM 80162 CPT 301 RC inpatient 159 159 MULTIPLAN INC 34080 [3081285] MULTIPLAN INC [308128501] 151.05 percent of total billed charges 98.58 151.05 Technical (Hospital) Services Digoxin Total PX-3018016200 CDM 80162 CPT 301 RC inpatient 159 159 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES PPO [308136801] 125.9 percent of total billed charges 98.58 151.05 Technical (Hospital) Services Digoxin Total PX-3018016200 CDM 80162 CPT 301 RC inpatient 159 159 UNITED HEALTHCARE (COMMERCIAL) [3081199] UNITED HEALTHCARE 87726 [308119901] 98.58 percent of total billed charges 98.58 151.05 Technical (Hospital) Services Digoxin Total PX-3018016200 CDM 80162 CPT 301 RC inpatient 159 159 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES HDHP [308136802] 125.9 percent of total billed charges 98.58 151.05 Technical (Hospital) Services Digoxin Total PX-3018016200 CDM 80162 CPT 301 RC inpatient 159 159 MEDICA (COMMERCIAL) 94265 [3081118] MEDICA CLAIMS [308111801] 143.1 percent of total billed charges 98.58 151.05 Technical (Hospital) Services Digoxin Total PX-3018016200 CDM 80162 CPT 301 RC inpatient 159 159 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES EPO [308136803] 125.9 percent of total billed charges 98.58 151.05 Technical (Hospital) Services Digoxin Total PX-3018016200 CDM 80162 CPT 301 RC inpatient 159 159 HEALTHPARTNERS SX009 HEALTHPARTNERS 125.9 percent of total billed charges 98.58 151.05 Technical (Hospital) Services Digoxin Total PX-3018016200 CDM 80162 CPT 301 RC inpatient 159 159 CIGNA 62308 [3081051] CIGNA 62308 [308105105] 125.9 percent of total billed charges 98.58 151.05 Technical (Hospital) Services Digoxin Total PX-3018016200 CDM 80162 CPT 301 RC inpatient 159 159 CIGNA 62308 [3081051] CIGNA STATE OF WYOMING [308105107] 125.9 percent of total billed charges 98.58 151.05 Technical (Hospital) Services Cyclosporine PX-3018015800 CDM 80158 CPT 301 RC inpatient 173 173 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES PPO [308136801] 136.98 percent of total billed charges 107.26 164.35 Technical (Hospital) Services Cyclosporine PX-3018015800 CDM 80158 CPT 301 RC inpatient 173 173 UNITED HEALTHCARE (COMMERCIAL) [3081199] UNITED HEALTHCARE 87726 [308119901] 107.26 percent of total billed charges 107.26 164.35 Technical (Hospital) Services Cyclosporine PX-3018015800 CDM 80158 CPT 301 RC inpatient 173 173 BLUE CROSS BLUE SHIELD WELLMARK SB889 [3081026] BCBS WYOMING [308102603] 164.35 percent of total billed charges 107.26 164.35 Technical (Hospital) Services Cyclosporine PX-3018015800 CDM 80158 CPT 301 RC inpatient 173 173 MULTIPLAN INC 34080 [3081285] MULTIPLAN INC [308128501] 164.35 percent of total billed charges 107.26 164.35 Technical (Hospital) Services Cyclosporine PX-3018015800 CDM 80158 CPT 301 RC inpatient 173 173 MEDICA (COMMERCIAL) 94265 [3081118] MEDICA CLAIMS [308111801] 155.7 percent of total billed charges 107.26 164.35 Technical (Hospital) Services Cyclosporine PX-3018015800 CDM 80158 CPT 301 RC inpatient 173 173 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES HDHP [308136802] 136.98 percent of total billed charges 107.26 164.35 Technical (Hospital) Services Cyclosporine PX-3018015800 CDM 80158 CPT 301 RC inpatient 173 173 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES EPO [308136803] 136.98 percent of total billed charges 107.26 164.35 Technical (Hospital) Services Cyclosporine PX-3018015800 CDM 80158 CPT 301 RC inpatient 173 173 HEALTHPARTNERS SX009 HEALTHPARTNERS 136.98 percent of total billed charges 107.26 164.35 Technical (Hospital) Services Cyclosporine PX-3018015800 CDM 80158 CPT 301 RC inpatient 173 173 CIGNA 62308 [3081051] CIGNA 62308 [308105105] 136.98 percent of total billed charges 107.26 164.35 Technical (Hospital) Services Cyclosporine PX-3018015800 CDM 80158 CPT 301 RC inpatient 173 173 CIGNA 62308 [3081051] CIGNA STATE OF WYOMING [308105107] 136.98 percent of total billed charges 107.26 164.35 Technical (Hospital) Services Cyclosporine PX-3018015800 CDM 80158 CPT 301 RC outpatient 173 173 CIGNA 62308 [3081051] CIGNA 62308 [308105105] 138.4 percent of total billed charges 107.26 164.35 Technical (Hospital) Services Cyclosporine PX-3018015800 CDM 80158 CPT 301 RC outpatient 173 173 CIGNA 62308 [3081051] CIGNA STATE OF WYOMING [308105107] 138.4 percent of total billed charges 107.26 164.35 Technical (Hospital) Services Cyclosporine PX-3018015800 CDM 80158 CPT 301 RC outpatient 173 173 MEDICA (COMMERCIAL) 94265 [3081118] MEDICA CLAIMS [308111801] 155.7 percent of total billed charges 107.26 164.35 Technical (Hospital) Services Cyclosporine PX-3018015800 CDM 80158 CPT 301 RC outpatient 173 173 BLUE CROSS BLUE SHIELD WELLMARK SB889 [3081026] BCBS WYOMING [308102603] 164.35 percent of total billed charges 107.26 164.35 Technical (Hospital) Services Cyclosporine PX-3018015800 CDM 80158 CPT 301 RC outpatient 173 173 MULTIPLAN INC 34080 [3081285] MULTIPLAN INC [308128501] 164.35 percent of total billed charges 107.26 164.35 Technical (Hospital) Services Cyclosporine PX-3018015800 CDM 80158 CPT 301 RC outpatient 173 173 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES HDHP [308136802] 138.4 percent of total billed charges 107.26 164.35 Technical (Hospital) Services Cyclosporine PX-3018015800 CDM 80158 CPT 301 RC outpatient 173 173 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES PPO [308136801] 138.4 percent of total billed charges 107.26 164.35 Technical (Hospital) Services Cyclosporine PX-3018015800 CDM 80158 CPT 301 RC outpatient 173 173 HEALTHPARTNERS SX009 HEALTHPARTNERS 138.4 percent of total billed charges 107.26 164.35 Technical (Hospital) Services Cyclosporine PX-3018015800 CDM 80158 CPT 301 RC outpatient 173 173 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES EPO [308136803] 138.4 percent of total billed charges 107.26 164.35 Technical (Hospital) Services Cyclosporine PX-3018015800 CDM 80158 CPT 301 RC outpatient 173 173 UNITED HEALTHCARE (COMMERCIAL) [3081199] UNITED HEALTHCARE 87726 [308119901] 107.26 percent of total billed charges 107.26 164.35 Technical (Hospital) Services Carbamazepine PX-3018015600 CDM 80156 CPT 301 RC outpatient 158 158 CIGNA 62308 [3081051] CIGNA 62308 [308105105] 126.4 percent of total billed charges 97.96 150.1 Technical (Hospital) Services Carbamazepine PX-3018015600 CDM 80156 CPT 301 RC outpatient 158 158 CIGNA 62308 [3081051] CIGNA STATE OF WYOMING [308105107] 126.4 percent of total billed charges 97.96 150.1 Technical (Hospital) Services Carbamazepine PX-3018015600 CDM 80156 CPT 301 RC outpatient 158 158 MEDICA (COMMERCIAL) 94265 [3081118] MEDICA CLAIMS [308111801] 142.2 percent of total billed charges 97.96 150.1 Technical (Hospital) Services Carbamazepine PX-3018015600 CDM 80156 CPT 301 RC outpatient 158 158 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES EPO [308136803] 126.4 percent of total billed charges 97.96 150.1 Technical (Hospital) Services Carbamazepine PX-3018015600 CDM 80156 CPT 301 RC outpatient 158 158 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES PPO [308136801] 126.4 percent of total billed charges 97.96 150.1 Technical (Hospital) Services Carbamazepine PX-3018015600 CDM 80156 CPT 301 RC outpatient 158 158 BLUE CROSS BLUE SHIELD WELLMARK SB889 [3081026] BCBS WYOMING [308102603] 150.1 percent of total billed charges 97.96 150.1 Technical (Hospital) Services Carbamazepine PX-3018015600 CDM 80156 CPT 301 RC outpatient 158 158 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES HDHP [308136802] 126.4 percent of total billed charges 97.96 150.1 Technical (Hospital) Services Carbamazepine PX-3018015600 CDM 80156 CPT 301 RC outpatient 158 158 MULTIPLAN INC 34080 [3081285] MULTIPLAN INC [308128501] 150.1 percent of total billed charges 97.96 150.1 Technical (Hospital) Services Carbamazepine PX-3018015600 CDM 80156 CPT 301 RC outpatient 158 158 UNITED HEALTHCARE (COMMERCIAL) [3081199] UNITED HEALTHCARE 87726 [308119901] 97.96 percent of total billed charges 97.96 150.1 Technical (Hospital) Services Carbamazepine PX-3018015600 CDM 80156 CPT 301 RC outpatient 158 158 HEALTHPARTNERS SX009 HEALTHPARTNERS 126.4 percent of total billed charges 97.96 150.1 Technical (Hospital) Services Carbamazepine PX-3018015600 CDM 80156 CPT 301 RC inpatient 158 158 CIGNA 62308 [3081051] CIGNA 62308 [308105105] 125.1 percent of total billed charges 97.96 150.1 Technical (Hospital) Services Carbamazepine PX-3018015600 CDM 80156 CPT 301 RC inpatient 158 158 CIGNA 62308 [3081051] CIGNA STATE OF WYOMING [308105107] 125.1 percent of total billed charges 97.96 150.1 Technical (Hospital) Services Carbamazepine PX-3018015600 CDM 80156 CPT 301 RC inpatient 158 158 HEALTHPARTNERS SX009 HEALTHPARTNERS 125.1 percent of total billed charges 97.96 150.1 Technical (Hospital) Services Carbamazepine PX-3018015600 CDM 80156 CPT 301 RC inpatient 158 158 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES EPO [308136803] 125.1 percent of total billed charges 97.96 150.1 Technical (Hospital) Services Carbamazepine PX-3018015600 CDM 80156 CPT 301 RC inpatient 158 158 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES HDHP [308136802] 125.1 percent of total billed charges 97.96 150.1 Technical (Hospital) Services Carbamazepine PX-3018015600 CDM 80156 CPT 301 RC inpatient 158 158 MEDICA (COMMERCIAL) 94265 [3081118] MEDICA CLAIMS [308111801] 142.2 percent of total billed charges 97.96 150.1 Technical (Hospital) Services Carbamazepine PX-3018015600 CDM 80156 CPT 301 RC inpatient 158 158 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES PPO [308136801] 125.1 percent of total billed charges 97.96 150.1 Technical (Hospital) Services Carbamazepine PX-3018015600 CDM 80156 CPT 301 RC inpatient 158 158 UNITED HEALTHCARE (COMMERCIAL) [3081199] UNITED HEALTHCARE 87726 [308119901] 97.96 percent of total billed charges 97.96 150.1 Technical (Hospital) Services Carbamazepine PX-3018015600 CDM 80156 CPT 301 RC inpatient 158 158 BLUE CROSS BLUE SHIELD WELLMARK SB889 [3081026] BCBS WYOMING [308102603] 150.1 percent of total billed charges 97.96 150.1 Technical (Hospital) Services Carbamazepine PX-3018015600 CDM 80156 CPT 301 RC inpatient 158 158 MULTIPLAN INC 34080 [3081285] MULTIPLAN INC [308128501] 150.1 percent of total billed charges 97.96 150.1 Technical (Hospital) Services Drug Assay Acetaminophen PX-3018014300 CDM 80143 CPT 301 RC outpatient 253 253 CIGNA 62308 [3081051] CIGNA 62308 [308105105] 202.4 percent of total billed charges 156.86 240.35 Technical (Hospital) Services Drug Assay Acetaminophen PX-3018014300 CDM 80143 CPT 301 RC outpatient 253 253 CIGNA 62308 [3081051] CIGNA STATE OF WYOMING [308105107] 202.4 percent of total billed charges 156.86 240.35 Technical (Hospital) Services Drug Assay Acetaminophen PX-3018014300 CDM 80143 CPT 301 RC outpatient 253 253 MEDICA (COMMERCIAL) 94265 [3081118] MEDICA CLAIMS [308111801] 227.7 percent of total billed charges 156.86 240.35 Technical (Hospital) Services Drug Assay Acetaminophen PX-3018014300 CDM 80143 CPT 301 RC outpatient 253 253 MULTIPLAN INC 34080 [3081285] MULTIPLAN INC [308128501] 240.35 percent of total billed charges 156.86 240.35 Technical (Hospital) Services Drug Assay Acetaminophen PX-3018014300 CDM 80143 CPT 301 RC outpatient 253 253 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES HDHP [308136802] 202.4 percent of total billed charges 156.86 240.35 Technical (Hospital) Services Drug Assay Acetaminophen PX-3018014300 CDM 80143 CPT 301 RC outpatient 253 253 BLUE CROSS BLUE SHIELD WELLMARK SB889 [3081026] BCBS WYOMING [308102603] 240.35 percent of total billed charges 156.86 240.35 Technical (Hospital) Services Drug Assay Acetaminophen PX-3018014300 CDM 80143 CPT 301 RC outpatient 253 253 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES PPO [308136801] 202.4 percent of total billed charges 156.86 240.35 Technical (Hospital) Services Drug Assay Acetaminophen PX-3018014300 CDM 80143 CPT 301 RC outpatient 253 253 UNITED HEALTHCARE (COMMERCIAL) [3081199] UNITED HEALTHCARE 87726 [308119901] 156.86 percent of total billed charges 156.86 240.35 Technical (Hospital) Services Drug Assay Acetaminophen PX-3018014300 CDM 80143 CPT 301 RC outpatient 253 253 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES EPO [308136803] 202.4 percent of total billed charges 156.86 240.35 Technical (Hospital) Services Drug Assay Acetaminophen PX-3018014300 CDM 80143 CPT 301 RC outpatient 253 253 HEALTHPARTNERS SX009 HEALTHPARTNERS 202.4 percent of total billed charges 156.86 240.35 Technical (Hospital) Services Drug Assay Acetaminophen PX-3018014300 CDM 80143 CPT 301 RC inpatient 253 253 MEDICA (COMMERCIAL) 94265 [3081118] MEDICA CLAIMS [308111801] 227.7 percent of total billed charges 156.86 240.35 Technical (Hospital) Services Drug Assay Acetaminophen PX-3018014300 CDM 80143 CPT 301 RC inpatient 253 253 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES EPO [308136803] 200.33 percent of total billed charges 156.86 240.35 Technical (Hospital) Services Drug Assay Acetaminophen PX-3018014300 CDM 80143 CPT 301 RC inpatient 253 253 HEALTHPARTNERS SX009 HEALTHPARTNERS 200.33 percent of total billed charges 156.86 240.35 Technical (Hospital) Services Drug Assay Acetaminophen PX-3018014300 CDM 80143 CPT 301 RC inpatient 253 253 MULTIPLAN INC 34080 [3081285] MULTIPLAN INC [308128501] 240.35 percent of total billed charges 156.86 240.35 Technical (Hospital) Services Drug Assay Acetaminophen PX-3018014300 CDM 80143 CPT 301 RC inpatient 253 253 BLUE CROSS BLUE SHIELD WELLMARK SB889 [3081026] BCBS WYOMING [308102603] 240.35 percent of total billed charges 156.86 240.35 Technical (Hospital) Services Drug Assay Acetaminophen PX-3018014300 CDM 80143 CPT 301 RC inpatient 253 253 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES HDHP [308136802] 200.33 percent of total billed charges 156.86 240.35 Technical (Hospital) Services Drug Assay Acetaminophen PX-3018014300 CDM 80143 CPT 301 RC inpatient 253 253 UNITED HEALTHCARE (COMMERCIAL) [3081199] UNITED HEALTHCARE 87726 [308119901] 156.86 percent of total billed charges 156.86 240.35 Technical (Hospital) Services Drug Assay Acetaminophen PX-3018014300 CDM 80143 CPT 301 RC inpatient 253 253 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES PPO [308136801] 200.33 percent of total billed charges 156.86 240.35 Technical (Hospital) Services Drug Assay Acetaminophen PX-3018014300 CDM 80143 CPT 301 RC inpatient 253 253 CIGNA 62308 [3081051] CIGNA 62308 [308105105] 200.33 percent of total billed charges 156.86 240.35 Technical (Hospital) Services Drug Assay Acetaminophen PX-3018014300 CDM 80143 CPT 301 RC inpatient 253 253 CIGNA 62308 [3081051] CIGNA STATE OF WYOMING [308105107] 200.33 percent of total billed charges 156.86 240.35 Technical (Hospital) Services Hepatic Function Panel PX-3018007600 CDM 80076 CPT 301 RC inpatient 144 144 HEALTHPARTNERS SX009 HEALTHPARTNERS 114.02 percent of total billed charges 89.28 136.8 Technical (Hospital) Services Hepatic Function Panel PX-3018007600 CDM 80076 CPT 301 RC inpatient 144 144 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES EPO [308136803] 114.02 percent of total billed charges 89.28 136.8 Technical (Hospital) Services Hepatic Function Panel PX-3018007600 CDM 80076 CPT 301 RC inpatient 144 144 MEDICA (COMMERCIAL) 94265 [3081118] MEDICA CLAIMS [308111801] 129.6 percent of total billed charges 89.28 136.8 Technical (Hospital) Services Hepatic Function Panel PX-3018007600 CDM 80076 CPT 301 RC inpatient 144 144 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES HDHP [308136802] 114.02 percent of total billed charges 89.28 136.8 Technical (Hospital) Services Hepatic Function Panel PX-3018007600 CDM 80076 CPT 301 RC inpatient 144 144 MULTIPLAN INC 34080 [3081285] MULTIPLAN INC [308128501] 136.8 percent of total billed charges 89.28 136.8 Technical (Hospital) Services Hepatic Function Panel PX-3018007600 CDM 80076 CPT 301 RC inpatient 144 144 BLUE CROSS BLUE SHIELD WELLMARK SB889 [3081026] BCBS WYOMING [308102603] 136.8 percent of total billed charges 89.28 136.8 Technical (Hospital) Services Hepatic Function Panel PX-3018007600 CDM 80076 CPT 301 RC inpatient 144 144 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES PPO [308136801] 114.02 percent of total billed charges 89.28 136.8 Technical (Hospital) Services Hepatic Function Panel PX-3018007600 CDM 80076 CPT 301 RC inpatient 144 144 UNITED HEALTHCARE (COMMERCIAL) [3081199] UNITED HEALTHCARE 87726 [308119901] 89.28 percent of total billed charges 89.28 136.8 Technical (Hospital) Services Hepatic Function Panel PX-3018007600 CDM 80076 CPT 301 RC inpatient 144 144 CIGNA 62308 [3081051] CIGNA 62308 [308105105] 114.02 percent of total billed charges 89.28 136.8 Technical (Hospital) Services Hepatic Function Panel PX-3018007600 CDM 80076 CPT 301 RC inpatient 144 144 CIGNA 62308 [3081051] CIGNA STATE OF WYOMING [308105107] 114.02 percent of total billed charges 89.28 136.8 Technical (Hospital) Services Hepatic Function Panel PX-3018007600 CDM 80076 CPT 301 RC outpatient 144 144 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES PPO [308136801] 115.2 percent of total billed charges 89.28 136.8 Technical (Hospital) Services Hepatic Function Panel PX-3018007600 CDM 80076 CPT 301 RC outpatient 144 144 BLUE CROSS BLUE SHIELD WELLMARK SB889 [3081026] BCBS WYOMING [308102603] 136.8 percent of total billed charges 89.28 136.8 Technical (Hospital) Services Hepatic Function Panel PX-3018007600 CDM 80076 CPT 301 RC outpatient 144 144 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES HDHP [308136802] 115.2 percent of total billed charges 89.28 136.8 Technical (Hospital) Services Hepatic Function Panel PX-3018007600 CDM 80076 CPT 301 RC outpatient 144 144 MULTIPLAN INC 34080 [3081285] MULTIPLAN INC [308128501] 136.8 percent of total billed charges 89.28 136.8 Technical (Hospital) Services Hepatic Function Panel PX-3018007600 CDM 80076 CPT 301 RC outpatient 144 144 UNITED HEALTHCARE (COMMERCIAL) [3081199] UNITED HEALTHCARE 87726 [308119901] 89.28 percent of total billed charges 89.28 136.8 Technical (Hospital) Services Hepatic Function Panel PX-3018007600 CDM 80076 CPT 301 RC outpatient 144 144 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES EPO [308136803] 115.2 percent of total billed charges 89.28 136.8 Technical (Hospital) Services Hepatic Function Panel PX-3018007600 CDM 80076 CPT 301 RC outpatient 144 144 HEALTHPARTNERS SX009 HEALTHPARTNERS 115.2 percent of total billed charges 89.28 136.8 Technical (Hospital) Services Hepatic Function Panel PX-3018007600 CDM 80076 CPT 301 RC outpatient 144 144 MEDICA (COMMERCIAL) 94265 [3081118] MEDICA CLAIMS [308111801] 129.6 percent of total billed charges 89.28 136.8 Technical (Hospital) Services Hepatic Function Panel PX-3018007600 CDM 80076 CPT 301 RC outpatient 144 144 CIGNA 62308 [3081051] CIGNA 62308 [308105105] 115.2 percent of total billed charges 89.28 136.8 Technical (Hospital) Services Hepatic Function Panel PX-3018007600 CDM 80076 CPT 301 RC outpatient 144 144 CIGNA 62308 [3081051] CIGNA STATE OF WYOMING [308105107] 115.2 percent of total billed charges 89.28 136.8 Technical (Hospital) Services Hepatitis Acute Panel PX-3018007400 CDM 80074 CPT 301 RC outpatient 462 462 HEALTHPARTNERS SX009 HEALTHPARTNERS 369.6 percent of total billed charges 286.44 438.9 Technical (Hospital) Services Hepatitis Acute Panel PX-3018007400 CDM 80074 CPT 301 RC outpatient 462 462 MULTIPLAN INC 34080 [3081285] MULTIPLAN INC [308128501] 438.9 percent of total billed charges 286.44 438.9 Technical (Hospital) Services Hepatitis Acute Panel PX-3018007400 CDM 80074 CPT 301 RC outpatient 462 462 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES HDHP [308136802] 369.6 percent of total billed charges 286.44 438.9 Technical (Hospital) Services Hepatitis Acute Panel PX-3018007400 CDM 80074 CPT 301 RC outpatient 462 462 BLUE CROSS BLUE SHIELD WELLMARK SB889 [3081026] BCBS WYOMING [308102603] 438.9 percent of total billed charges 286.44 438.9 Technical (Hospital) Services Hepatitis Acute Panel PX-3018007400 CDM 80074 CPT 301 RC outpatient 462 462 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES PPO [308136801] 369.6 percent of total billed charges 286.44 438.9 Technical (Hospital) Services Hepatitis Acute Panel PX-3018007400 CDM 80074 CPT 301 RC outpatient 462 462 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES EPO [308136803] 369.6 percent of total billed charges 286.44 438.9 Technical (Hospital) Services Hepatitis Acute Panel PX-3018007400 CDM 80074 CPT 301 RC outpatient 462 462 UNITED HEALTHCARE (COMMERCIAL) [3081199] UNITED HEALTHCARE 87726 [308119901] 286.44 percent of total billed charges 286.44 438.9 Technical (Hospital) Services Hepatitis Acute Panel PX-3018007400 CDM 80074 CPT 301 RC outpatient 462 462 CIGNA 62308 [3081051] CIGNA 62308 [308105105] 369.6 percent of total billed charges 286.44 438.9 Technical (Hospital) Services Hepatitis Acute Panel PX-3018007400 CDM 80074 CPT 301 RC outpatient 462 462 CIGNA 62308 [3081051] CIGNA STATE OF WYOMING [308105107] 369.6 percent of total billed charges 286.44 438.9 Technical (Hospital) Services Hepatitis Acute Panel PX-3018007400 CDM 80074 CPT 301 RC outpatient 462 462 MEDICA (COMMERCIAL) 94265 [3081118] MEDICA CLAIMS [308111801] 415.8 percent of total billed charges 286.44 438.9 Technical (Hospital) Services Hepatitis Acute Panel PX-3018007400 CDM 80074 CPT 301 RC inpatient 462 462 CIGNA 62308 [3081051] CIGNA 62308 [308105105] 365.81 percent of total billed charges 286.44 438.9 Technical (Hospital) Services Hepatitis Acute Panel PX-3018007400 CDM 80074 CPT 301 RC inpatient 462 462 CIGNA 62308 [3081051] CIGNA STATE OF WYOMING [308105107] 365.81 percent of total billed charges 286.44 438.9 Technical (Hospital) Services Hepatitis Acute Panel PX-3018007400 CDM 80074 CPT 301 RC inpatient 462 462 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES PPO [308136801] 365.81 percent of total billed charges 286.44 438.9 Technical (Hospital) Services Hepatitis Acute Panel PX-3018007400 CDM 80074 CPT 301 RC inpatient 462 462 UNITED HEALTHCARE (COMMERCIAL) [3081199] UNITED HEALTHCARE 87726 [308119901] 286.44 percent of total billed charges 286.44 438.9 Technical (Hospital) Services Hepatitis Acute Panel PX-3018007400 CDM 80074 CPT 301 RC inpatient 462 462 MULTIPLAN INC 34080 [3081285] MULTIPLAN INC [308128501] 438.9 percent of total billed charges 286.44 438.9 Technical (Hospital) Services Hepatitis Acute Panel PX-3018007400 CDM 80074 CPT 301 RC inpatient 462 462 BLUE CROSS BLUE SHIELD WELLMARK SB889 [3081026] BCBS WYOMING [308102603] 438.9 percent of total billed charges 286.44 438.9 Technical (Hospital) Services Hepatitis Acute Panel PX-3018007400 CDM 80074 CPT 301 RC inpatient 462 462 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES HDHP [308136802] 365.81 percent of total billed charges 286.44 438.9 Technical (Hospital) Services Hepatitis Acute Panel PX-3018007400 CDM 80074 CPT 301 RC inpatient 462 462 MEDICA (COMMERCIAL) 94265 [3081118] MEDICA CLAIMS [308111801] 415.8 percent of total billed charges 286.44 438.9 Technical (Hospital) Services Hepatitis Acute Panel PX-3018007400 CDM 80074 CPT 301 RC inpatient 462 462 HEALTHPARTNERS SX009 HEALTHPARTNERS 365.81 percent of total billed charges 286.44 438.9 Technical (Hospital) Services Hepatitis Acute Panel PX-3018007400 CDM 80074 CPT 301 RC inpatient 462 462 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES EPO [308136803] 365.81 percent of total billed charges 286.44 438.9 Technical (Hospital) Services Renal Function Panel PX-3018006900 CDM 80069 CPT 301 RC outpatient 156 156 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES PPO [308136801] 124.8 percent of total billed charges 96.72 148.2 Technical (Hospital) Services Renal Function Panel PX-3018006900 CDM 80069 CPT 301 RC outpatient 156 156 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES EPO [308136803] 124.8 percent of total billed charges 96.72 148.2 Technical (Hospital) Services Renal Function Panel PX-3018006900 CDM 80069 CPT 301 RC outpatient 156 156 BLUE CROSS BLUE SHIELD WELLMARK SB889 [3081026] BCBS WYOMING [308102603] 148.2 percent of total billed charges 96.72 148.2 Technical (Hospital) Services Renal Function Panel PX-3018006900 CDM 80069 CPT 301 RC outpatient 156 156 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES HDHP [308136802] 124.8 percent of total billed charges 96.72 148.2 Technical (Hospital) Services Renal Function Panel PX-3018006900 CDM 80069 CPT 301 RC outpatient 156 156 MULTIPLAN INC 34080 [3081285] MULTIPLAN INC [308128501] 148.2 percent of total billed charges 96.72 148.2 Technical (Hospital) Services Renal Function Panel PX-3018006900 CDM 80069 CPT 301 RC outpatient 156 156 UNITED HEALTHCARE (COMMERCIAL) [3081199] UNITED HEALTHCARE 87726 [308119901] 96.72 percent of total billed charges 96.72 148.2 Technical (Hospital) Services Renal Function Panel PX-3018006900 CDM 80069 CPT 301 RC outpatient 156 156 HEALTHPARTNERS SX009 HEALTHPARTNERS 124.8 percent of total billed charges 96.72 148.2 Technical (Hospital) Services Renal Function Panel PX-3018006900 CDM 80069 CPT 301 RC outpatient 156 156 MEDICA (COMMERCIAL) 94265 [3081118] MEDICA CLAIMS [308111801] 140.4 percent of total billed charges 96.72 148.2 Technical (Hospital) Services Renal Function Panel PX-3018006900 CDM 80069 CPT 301 RC outpatient 156 156 CIGNA 62308 [3081051] CIGNA 62308 [308105105] 124.8 percent of total billed charges 96.72 148.2 Technical (Hospital) Services Renal Function Panel PX-3018006900 CDM 80069 CPT 301 RC outpatient 156 156 CIGNA 62308 [3081051] CIGNA STATE OF WYOMING [308105107] 124.8 percent of total billed charges 96.72 148.2 Technical (Hospital) Services Renal Function Panel PX-3018006900 CDM 80069 CPT 301 RC inpatient 156 156 BLUE CROSS BLUE SHIELD WELLMARK SB889 [3081026] BCBS WYOMING [308102603] 148.2 percent of total billed charges 96.72 148.2 Technical (Hospital) Services Renal Function Panel PX-3018006900 CDM 80069 CPT 301 RC inpatient 156 156 MULTIPLAN INC 34080 [3081285] MULTIPLAN INC [308128501] 148.2 percent of total billed charges 96.72 148.2 Technical (Hospital) Services Renal Function Panel PX-3018006900 CDM 80069 CPT 301 RC inpatient 156 156 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES PPO [308136801] 123.52 percent of total billed charges 96.72 148.2 Technical (Hospital) Services Renal Function Panel PX-3018006900 CDM 80069 CPT 301 RC inpatient 156 156 UNITED HEALTHCARE (COMMERCIAL) [3081199] UNITED HEALTHCARE 87726 [308119901] 96.72 percent of total billed charges 96.72 148.2 Technical (Hospital) Services Renal Function Panel PX-3018006900 CDM 80069 CPT 301 RC inpatient 156 156 HEALTHPARTNERS SX009 HEALTHPARTNERS 123.52 percent of total billed charges 96.72 148.2 Technical (Hospital) Services Renal Function Panel PX-3018006900 CDM 80069 CPT 301 RC inpatient 156 156 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES EPO [308136803] 123.52 percent of total billed charges 96.72 148.2 Technical (Hospital) Services Renal Function Panel PX-3018006900 CDM 80069 CPT 301 RC inpatient 156 156 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES HDHP [308136802] 123.52 percent of total billed charges 96.72 148.2 Technical (Hospital) Services Renal Function Panel PX-3018006900 CDM 80069 CPT 301 RC inpatient 156 156 MEDICA (COMMERCIAL) 94265 [3081118] MEDICA CLAIMS [308111801] 140.4 percent of total billed charges 96.72 148.2 Technical (Hospital) Services Renal Function Panel PX-3018006900 CDM 80069 CPT 301 RC inpatient 156 156 CIGNA 62308 [3081051] CIGNA 62308 [308105105] 123.52 percent of total billed charges 96.72 148.2 Technical (Hospital) Services Renal Function Panel PX-3018006900 CDM 80069 CPT 301 RC inpatient 156 156 CIGNA 62308 [3081051] CIGNA STATE OF WYOMING [308105107] 123.52 percent of total billed charges 96.72 148.2 Technical (Hospital) Services Lipid Panel Chol Tgl Ldl Hdl PX-3018006100 CDM 80061 CPT 301 RC outpatient 165 165 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES PPO [308136801] 132 percent of total billed charges 102.3 156.75 Technical (Hospital) Services Lipid Panel Chol Tgl Ldl Hdl PX-3018006100 CDM 80061 CPT 301 RC outpatient 165 165 BLUE CROSS BLUE SHIELD WELLMARK SB889 [3081026] BCBS WYOMING [308102603] 156.75 percent of total billed charges 102.3 156.75 Technical (Hospital) Services Lipid Panel Chol Tgl Ldl Hdl PX-3018006100 CDM 80061 CPT 301 RC outpatient 165 165 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES HDHP [308136802] 132 percent of total billed charges 102.3 156.75 Technical (Hospital) Services Lipid Panel Chol Tgl Ldl Hdl PX-3018006100 CDM 80061 CPT 301 RC outpatient 165 165 MULTIPLAN INC 34080 [3081285] MULTIPLAN INC [308128501] 156.75 percent of total billed charges 102.3 156.75 Technical (Hospital) Services Lipid Panel Chol Tgl Ldl Hdl PX-3018006100 CDM 80061 CPT 301 RC outpatient 165 165 UNITED HEALTHCARE (COMMERCIAL) [3081199] UNITED HEALTHCARE 87726 [308119901] 102.3 percent of total billed charges 102.3 156.75 Technical (Hospital) Services Lipid Panel Chol Tgl Ldl Hdl PX-3018006100 CDM 80061 CPT 301 RC outpatient 165 165 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES EPO [308136803] 132 percent of total billed charges 102.3 156.75 Technical (Hospital) Services Lipid Panel Chol Tgl Ldl Hdl PX-3018006100 CDM 80061 CPT 301 RC outpatient 165 165 HEALTHPARTNERS SX009 HEALTHPARTNERS 132 percent of total billed charges 102.3 156.75 Technical (Hospital) Services Lipid Panel Chol Tgl Ldl Hdl PX-3018006100 CDM 80061 CPT 301 RC outpatient 165 165 MEDICA (COMMERCIAL) 94265 [3081118] MEDICA CLAIMS [308111801] 148.5 percent of total billed charges 102.3 156.75 Technical (Hospital) Services Lipid Panel Chol Tgl Ldl Hdl PX-3018006100 CDM 80061 CPT 301 RC outpatient 165 165 CIGNA 62308 [3081051] CIGNA 62308 [308105105] 132 percent of total billed charges 102.3 156.75 Technical (Hospital) Services Lipid Panel Chol Tgl Ldl Hdl PX-3018006100 CDM 80061 CPT 301 RC outpatient 165 165 CIGNA 62308 [3081051] CIGNA STATE OF WYOMING [308105107] 132 percent of total billed charges 102.3 156.75 Technical (Hospital) Services Lipid Panel Chol Tgl Ldl Hdl PX-3018006100 CDM 80061 CPT 301 RC inpatient 165 165 UNITED HEALTHCARE (COMMERCIAL) [3081199] UNITED HEALTHCARE 87726 [308119901] 102.3 percent of total billed charges 102.3 156.75 Technical (Hospital) Services Lipid Panel Chol Tgl Ldl Hdl PX-3018006100 CDM 80061 CPT 301 RC inpatient 165 165 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES PPO [308136801] 130.65 percent of total billed charges 102.3 156.75 Technical (Hospital) Services Lipid Panel Chol Tgl Ldl Hdl PX-3018006100 CDM 80061 CPT 301 RC inpatient 165 165 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES HDHP [308136802] 130.65 percent of total billed charges 102.3 156.75 Technical (Hospital) Services Lipid Panel Chol Tgl Ldl Hdl PX-3018006100 CDM 80061 CPT 301 RC inpatient 165 165 BLUE CROSS BLUE SHIELD WELLMARK SB889 [3081026] BCBS WYOMING [308102603] 156.75 percent of total billed charges 102.3 156.75 Technical (Hospital) Services Lipid Panel Chol Tgl Ldl Hdl PX-3018006100 CDM 80061 CPT 301 RC inpatient 165 165 MULTIPLAN INC 34080 [3081285] MULTIPLAN INC [308128501] 156.75 percent of total billed charges 102.3 156.75 Technical (Hospital) Services Lipid Panel Chol Tgl Ldl Hdl PX-3018006100 CDM 80061 CPT 301 RC inpatient 165 165 MEDICA (COMMERCIAL) 94265 [3081118] MEDICA CLAIMS [308111801] 148.5 percent of total billed charges 102.3 156.75 Technical (Hospital) Services Lipid Panel Chol Tgl Ldl Hdl PX-3018006100 CDM 80061 CPT 301 RC inpatient 165 165 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES EPO [308136803] 130.65 percent of total billed charges 102.3 156.75 Technical (Hospital) Services Lipid Panel Chol Tgl Ldl Hdl PX-3018006100 CDM 80061 CPT 301 RC inpatient 165 165 HEALTHPARTNERS SX009 HEALTHPARTNERS 130.65 percent of total billed charges 102.3 156.75 Technical (Hospital) Services Lipid Panel Chol Tgl Ldl Hdl PX-3018006100 CDM 80061 CPT 301 RC inpatient 165 165 CIGNA 62308 [3081051] CIGNA 62308 [308105105] 130.65 percent of total billed charges 102.3 156.75 Technical (Hospital) Services Lipid Panel Chol Tgl Ldl Hdl PX-3018006100 CDM 80061 CPT 301 RC inpatient 165 165 CIGNA 62308 [3081051] CIGNA STATE OF WYOMING [308105107] 130.65 percent of total billed charges 102.3 156.75 Technical (Hospital) Services OB Panel PX-3018005500 CDM 80055 CPT 301 RC inpatient 411 411 MEDICA (COMMERCIAL) 94265 [3081118] MEDICA CLAIMS [308111801] 369.9 percent of total billed charges 254.82 390.45 Technical (Hospital) Services OB Panel PX-3018005500 CDM 80055 CPT 301 RC inpatient 411 411 HEALTHPARTNERS SX009 HEALTHPARTNERS 325.43 percent of total billed charges 254.82 390.45 Technical (Hospital) Services OB Panel PX-3018005500 CDM 80055 CPT 301 RC inpatient 411 411 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES EPO [308136803] 325.43 percent of total billed charges 254.82 390.45 Technical (Hospital) Services OB Panel PX-3018005500 CDM 80055 CPT 301 RC inpatient 411 411 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES PPO [308136801] 325.43 percent of total billed charges 254.82 390.45 Technical (Hospital) Services OB Panel PX-3018005500 CDM 80055 CPT 301 RC inpatient 411 411 UNITED HEALTHCARE (COMMERCIAL) [3081199] UNITED HEALTHCARE 87726 [308119901] 254.82 percent of total billed charges 254.82 390.45 Technical (Hospital) Services OB Panel PX-3018005500 CDM 80055 CPT 301 RC inpatient 411 411 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES HDHP [308136802] 325.43 percent of total billed charges 254.82 390.45 Technical (Hospital) Services OB Panel PX-3018005500 CDM 80055 CPT 301 RC inpatient 411 411 MULTIPLAN INC 34080 [3081285] MULTIPLAN INC [308128501] 390.45 percent of total billed charges 254.82 390.45 Technical (Hospital) Services OB Panel PX-3018005500 CDM 80055 CPT 301 RC inpatient 411 411 BLUE CROSS BLUE SHIELD WELLMARK SB889 [3081026] BCBS WYOMING [308102603] 390.45 percent of total billed charges 254.82 390.45 Technical (Hospital) Services OB Panel PX-3018005500 CDM 80055 CPT 301 RC inpatient 411 411 CIGNA 62308 [3081051] CIGNA 62308 [308105105] 325.43 percent of total billed charges 254.82 390.45 Technical (Hospital) Services OB Panel PX-3018005500 CDM 80055 CPT 301 RC inpatient 411 411 CIGNA 62308 [3081051] CIGNA STATE OF WYOMING [308105107] 325.43 percent of total billed charges 254.82 390.45 Technical (Hospital) Services OB Panel PX-3018005500 CDM 80055 CPT 301 RC outpatient 411 411 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES HDHP [308136802] 328.8 percent of total billed charges 254.82 390.45 Technical (Hospital) Services OB Panel PX-3018005500 CDM 80055 CPT 301 RC outpatient 411 411 MULTIPLAN INC 34080 [3081285] MULTIPLAN INC [308128501] 390.45 percent of total billed charges 254.82 390.45 Technical (Hospital) Services OB Panel PX-3018005500 CDM 80055 CPT 301 RC outpatient 411 411 BLUE CROSS BLUE SHIELD WELLMARK SB889 [3081026] BCBS WYOMING [308102603] 390.45 percent of total billed charges 254.82 390.45 Technical (Hospital) Services OB Panel PX-3018005500 CDM 80055 CPT 301 RC outpatient 411 411 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES EPO [308136803] 328.8 percent of total billed charges 254.82 390.45 Technical (Hospital) Services OB Panel PX-3018005500 CDM 80055 CPT 301 RC outpatient 411 411 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES PPO [308136801] 328.8 percent of total billed charges 254.82 390.45 Technical (Hospital) Services OB Panel PX-3018005500 CDM 80055 CPT 301 RC outpatient 411 411 HEALTHPARTNERS SX009 HEALTHPARTNERS 328.8 percent of total billed charges 254.82 390.45 Technical (Hospital) Services OB Panel PX-3018005500 CDM 80055 CPT 301 RC outpatient 411 411 UNITED HEALTHCARE (COMMERCIAL) [3081199] UNITED HEALTHCARE 87726 [308119901] 254.82 percent of total billed charges 254.82 390.45 Technical (Hospital) Services OB Panel PX-3018005500 CDM 80055 CPT 301 RC outpatient 411 411 MEDICA (COMMERCIAL) 94265 [3081118] MEDICA CLAIMS [308111801] 369.9 percent of total billed charges 254.82 390.45 Technical (Hospital) Services OB Panel PX-3018005500 CDM 80055 CPT 301 RC outpatient 411 411 CIGNA 62308 [3081051] CIGNA STATE OF WYOMING [308105107] 328.8 percent of total billed charges 254.82 390.45 Technical (Hospital) Services OB Panel PX-3018005500 CDM 80055 CPT 301 RC outpatient 411 411 CIGNA 62308 [3081051] CIGNA 62308 [308105105] 328.8 percent of total billed charges 254.82 390.45 Technical (Hospital) Services Cmp Comprehensive Metabolic PX-3018005300 CDM 80053 CPT 301 RC inpatient 195 195 MEDICA (COMMERCIAL) 94265 [3081118] MEDICA CLAIMS [308111801] 175.5 percent of total billed charges 120.9 185.25 Technical (Hospital) Services Cmp Comprehensive Metabolic PX-3018005300 CDM 80053 CPT 301 RC inpatient 195 195 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES EPO [308136803] 154.4 percent of total billed charges 120.9 185.25 Technical (Hospital) Services Cmp Comprehensive Metabolic PX-3018005300 CDM 80053 CPT 301 RC inpatient 195 195 HEALTHPARTNERS SX009 HEALTHPARTNERS 154.4 percent of total billed charges 120.9 185.25 Technical (Hospital) Services Cmp Comprehensive Metabolic PX-3018005300 CDM 80053 CPT 301 RC inpatient 195 195 MULTIPLAN INC 34080 [3081285] MULTIPLAN INC [308128501] 185.25 percent of total billed charges 120.9 185.25 Technical (Hospital) Services Cmp Comprehensive Metabolic PX-3018005300 CDM 80053 CPT 301 RC inpatient 195 195 BLUE CROSS BLUE SHIELD WELLMARK SB889 [3081026] BCBS WYOMING [308102603] 185.25 percent of total billed charges 120.9 185.25 Technical (Hospital) Services Cmp Comprehensive Metabolic PX-3018005300 CDM 80053 CPT 301 RC inpatient 195 195 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES HDHP [308136802] 154.4 percent of total billed charges 120.9 185.25 Technical (Hospital) Services Cmp Comprehensive Metabolic PX-3018005300 CDM 80053 CPT 301 RC inpatient 195 195 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES PPO [308136801] 154.4 percent of total billed charges 120.9 185.25 Technical (Hospital) Services Cmp Comprehensive Metabolic PX-3018005300 CDM 80053 CPT 301 RC inpatient 195 195 UNITED HEALTHCARE (COMMERCIAL) [3081199] UNITED HEALTHCARE 87726 [308119901] 120.9 percent of total billed charges 120.9 185.25 Technical (Hospital) Services Cmp Comprehensive Metabolic PX-3018005300 CDM 80053 CPT 301 RC inpatient 195 195 CIGNA 62308 [3081051] CIGNA 62308 [308105105] 154.4 percent of total billed charges 120.9 185.25 Technical (Hospital) Services Cmp Comprehensive Metabolic PX-3018005300 CDM 80053 CPT 301 RC inpatient 195 195 CIGNA 62308 [3081051] CIGNA STATE OF WYOMING [308105107] 154.4 percent of total billed charges 120.9 185.25 Technical (Hospital) Services Cmp Comprehensive Metabolic PX-3018005300 CDM 80053 CPT 301 RC outpatient 195 195 MULTIPLAN INC 34080 [3081285] MULTIPLAN INC [308128501] 185.25 percent of total billed charges 120.9 185.25 Technical (Hospital) Services Cmp Comprehensive Metabolic PX-3018005300 CDM 80053 CPT 301 RC outpatient 195 195 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES HDHP [308136802] 156 percent of total billed charges 120.9 185.25 Technical (Hospital) Services Cmp Comprehensive Metabolic PX-3018005300 CDM 80053 CPT 301 RC outpatient 195 195 BLUE CROSS BLUE SHIELD WELLMARK SB889 [3081026] BCBS WYOMING [308102603] 185.25 percent of total billed charges 120.9 185.25 Technical (Hospital) Services Cmp Comprehensive Metabolic PX-3018005300 CDM 80053 CPT 301 RC outpatient 195 195 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES PPO [308136801] 156 percent of total billed charges 120.9 185.25 Technical (Hospital) Services Cmp Comprehensive Metabolic PX-3018005300 CDM 80053 CPT 301 RC outpatient 195 195 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES EPO [308136803] 156 percent of total billed charges 120.9 185.25 Technical (Hospital) Services Cmp Comprehensive Metabolic PX-3018005300 CDM 80053 CPT 301 RC outpatient 195 195 HEALTHPARTNERS SX009 HEALTHPARTNERS 156 percent of total billed charges 120.9 185.25 Technical (Hospital) Services Cmp Comprehensive Metabolic PX-3018005300 CDM 80053 CPT 301 RC outpatient 195 195 UNITED HEALTHCARE (COMMERCIAL) [3081199] UNITED HEALTHCARE 87726 [308119901] 120.9 percent of total billed charges 120.9 185.25 Technical (Hospital) Services Cmp Comprehensive Metabolic PX-3018005300 CDM 80053 CPT 301 RC outpatient 195 195 CIGNA 62308 [3081051] CIGNA 62308 [308105105] 156 percent of total billed charges 120.9 185.25 Technical (Hospital) Services Cmp Comprehensive Metabolic PX-3018005300 CDM 80053 CPT 301 RC outpatient 195 195 CIGNA 62308 [3081051] CIGNA STATE OF WYOMING [308105107] 156 percent of total billed charges 120.9 185.25 Technical (Hospital) Services Cmp Comprehensive Metabolic PX-3018005300 CDM 80053 CPT 301 RC outpatient 195 195 MEDICA (COMMERCIAL) 94265 [3081118] MEDICA CLAIMS [308111801] 175.5 percent of total billed charges 120.9 185.25 Technical (Hospital) Services Electrolyte Panel PX-3018005100 CDM 80051 CPT 301 RC inpatient 103 103 MULTIPLAN INC 34080 [3081285] MULTIPLAN INC [308128501] 97.85 percent of total billed charges 63.86 97.85 Technical (Hospital) Services Electrolyte Panel PX-3018005100 CDM 80051 CPT 301 RC inpatient 103 103 BLUE CROSS BLUE SHIELD WELLMARK SB889 [3081026] BCBS WYOMING [308102603] 97.85 percent of total billed charges 63.86 97.85 Technical (Hospital) Services Electrolyte Panel PX-3018005100 CDM 80051 CPT 301 RC inpatient 103 103 UNITED HEALTHCARE (COMMERCIAL) [3081199] UNITED HEALTHCARE 87726 [308119901] 63.86 percent of total billed charges 63.86 97.85 Technical (Hospital) Services Electrolyte Panel PX-3018005100 CDM 80051 CPT 301 RC inpatient 103 103 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES PPO [308136801] 81.56 percent of total billed charges 63.86 97.85 Technical (Hospital) Services Electrolyte Panel PX-3018005100 CDM 80051 CPT 301 RC inpatient 103 103 HEALTHPARTNERS SX009 HEALTHPARTNERS 81.56 percent of total billed charges 63.86 97.85 Technical (Hospital) Services Electrolyte Panel PX-3018005100 CDM 80051 CPT 301 RC inpatient 103 103 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES EPO [308136803] 81.56 percent of total billed charges 63.86 97.85 Technical (Hospital) Services Electrolyte Panel PX-3018005100 CDM 80051 CPT 301 RC inpatient 103 103 MEDICA (COMMERCIAL) 94265 [3081118] MEDICA CLAIMS [308111801] 92.7 percent of total billed charges 63.86 97.85 Technical (Hospital) Services Electrolyte Panel PX-3018005100 CDM 80051 CPT 301 RC inpatient 103 103 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES HDHP [308136802] 81.56 percent of total billed charges 63.86 97.85 Technical (Hospital) Services Electrolyte Panel PX-3018005100 CDM 80051 CPT 301 RC inpatient 103 103 CIGNA 62308 [3081051] CIGNA 62308 [308105105] 81.56 percent of total billed charges 63.86 97.85 Technical (Hospital) Services Electrolyte Panel PX-3018005100 CDM 80051 CPT 301 RC inpatient 103 103 CIGNA 62308 [3081051] CIGNA STATE OF WYOMING [308105107] 81.56 percent of total billed charges 63.86 97.85 Technical (Hospital) Services Electrolyte Panel PX-3018005100 CDM 80051 CPT 301 RC outpatient 103 103 MEDICA (COMMERCIAL) 94265 [3081118] MEDICA CLAIMS [308111801] 92.7 percent of total billed charges 63.86 97.85 Technical (Hospital) Services Electrolyte Panel PX-3018005100 CDM 80051 CPT 301 RC outpatient 103 103 CIGNA 62308 [3081051] CIGNA 62308 [308105105] 82.4 percent of total billed charges 63.86 97.85 Technical (Hospital) Services Electrolyte Panel PX-3018005100 CDM 80051 CPT 301 RC outpatient 103 103 CIGNA 62308 [3081051] CIGNA STATE OF WYOMING [308105107] 82.4 percent of total billed charges 63.86 97.85 Technical (Hospital) Services Electrolyte Panel PX-3018005100 CDM 80051 CPT 301 RC outpatient 103 103 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES EPO [308136803] 82.4 percent of total billed charges 63.86 97.85 Technical (Hospital) Services Electrolyte Panel PX-3018005100 CDM 80051 CPT 301 RC outpatient 103 103 UNITED HEALTHCARE (COMMERCIAL) [3081199] UNITED HEALTHCARE 87726 [308119901] 63.86 percent of total billed charges 63.86 97.85 Technical (Hospital) Services Electrolyte Panel PX-3018005100 CDM 80051 CPT 301 RC outpatient 103 103 HEALTHPARTNERS SX009 HEALTHPARTNERS 82.4 percent of total billed charges 63.86 97.85 Technical (Hospital) Services Electrolyte Panel PX-3018005100 CDM 80051 CPT 301 RC outpatient 103 103 BLUE CROSS BLUE SHIELD WELLMARK SB889 [3081026] BCBS WYOMING [308102603] 97.85 percent of total billed charges 63.86 97.85 Technical (Hospital) Services Electrolyte Panel PX-3018005100 CDM 80051 CPT 301 RC outpatient 103 103 MULTIPLAN INC 34080 [3081285] MULTIPLAN INC [308128501] 97.85 percent of total billed charges 63.86 97.85 Technical (Hospital) Services Electrolyte Panel PX-3018005100 CDM 80051 CPT 301 RC outpatient 103 103 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES HDHP [308136802] 82.4 percent of total billed charges 63.86 97.85 Technical (Hospital) Services Electrolyte Panel PX-3018005100 CDM 80051 CPT 301 RC outpatient 103 103 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES PPO [308136801] 82.4 percent of total billed charges 63.86 97.85 Technical (Hospital) Services Bmp W Total Calcium Panel PX-3018004800 CDM 80048 CPT 301 RC outpatient 165 165 MEDICA (COMMERCIAL) 94265 [3081118] MEDICA CLAIMS [308111801] 148.5 percent of total billed charges 102.3 156.75 Technical (Hospital) Services Bmp W Total Calcium Panel PX-3018004800 CDM 80048 CPT 301 RC outpatient 165 165 CIGNA 62308 [3081051] CIGNA 62308 [308105105] 132 percent of total billed charges 102.3 156.75 Technical (Hospital) Services Bmp W Total Calcium Panel PX-3018004800 CDM 80048 CPT 301 RC outpatient 165 165 CIGNA 62308 [3081051] CIGNA STATE OF WYOMING [308105107] 132 percent of total billed charges 102.3 156.75 Technical (Hospital) Services Bmp W Total Calcium Panel PX-3018004800 CDM 80048 CPT 301 RC outpatient 165 165 HEALTHPARTNERS SX009 HEALTHPARTNERS 132 percent of total billed charges 102.3 156.75 Technical (Hospital) Services Bmp W Total Calcium Panel PX-3018004800 CDM 80048 CPT 301 RC outpatient 165 165 UNITED HEALTHCARE (COMMERCIAL) [3081199] UNITED HEALTHCARE 87726 [308119901] 102.3 percent of total billed charges 102.3 156.75 Technical (Hospital) Services Bmp W Total Calcium Panel PX-3018004800 CDM 80048 CPT 301 RC outpatient 165 165 BLUE CROSS BLUE SHIELD WELLMARK SB889 [3081026] BCBS WYOMING [308102603] 156.75 percent of total billed charges 102.3 156.75 Technical (Hospital) Services Bmp W Total Calcium Panel PX-3018004800 CDM 80048 CPT 301 RC outpatient 165 165 MULTIPLAN INC 34080 [3081285] MULTIPLAN INC [308128501] 156.75 percent of total billed charges 102.3 156.75 Technical (Hospital) Services Bmp W Total Calcium Panel PX-3018004800 CDM 80048 CPT 301 RC outpatient 165 165 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES HDHP [308136802] 132 percent of total billed charges 102.3 156.75 Technical (Hospital) Services Bmp W Total Calcium Panel PX-3018004800 CDM 80048 CPT 301 RC outpatient 165 165 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES EPO [308136803] 132 percent of total billed charges 102.3 156.75 Technical (Hospital) Services Bmp W Total Calcium Panel PX-3018004800 CDM 80048 CPT 301 RC outpatient 165 165 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES PPO [308136801] 132 percent of total billed charges 102.3 156.75 Technical (Hospital) Services Bmp W Total Calcium Panel PX-3018004800 CDM 80048 CPT 301 RC inpatient 165 165 MEDICA (COMMERCIAL) 94265 [3081118] MEDICA CLAIMS [308111801] 148.5 percent of total billed charges 102.3 156.75 Technical (Hospital) Services Bmp W Total Calcium Panel PX-3018004800 CDM 80048 CPT 301 RC inpatient 165 165 HEALTHPARTNERS SX009 HEALTHPARTNERS 130.65 percent of total billed charges 102.3 156.75 Technical (Hospital) Services Bmp W Total Calcium Panel PX-3018004800 CDM 80048 CPT 301 RC inpatient 165 165 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES HDHP [308136802] 130.65 percent of total billed charges 102.3 156.75 Technical (Hospital) Services Bmp W Total Calcium Panel PX-3018004800 CDM 80048 CPT 301 RC inpatient 165 165 UNITED HEALTHCARE (COMMERCIAL) [3081199] UNITED HEALTHCARE 87726 [308119901] 102.3 percent of total billed charges 102.3 156.75 Technical (Hospital) Services Bmp W Total Calcium Panel PX-3018004800 CDM 80048 CPT 301 RC inpatient 165 165 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES PPO [308136801] 130.65 percent of total billed charges 102.3 156.75 Technical (Hospital) Services Bmp W Total Calcium Panel PX-3018004800 CDM 80048 CPT 301 RC inpatient 165 165 MULTIPLAN INC 34080 [3081285] MULTIPLAN INC [308128501] 156.75 percent of total billed charges 102.3 156.75 Technical (Hospital) Services Bmp W Total Calcium Panel PX-3018004800 CDM 80048 CPT 301 RC inpatient 165 165 BLUE CROSS BLUE SHIELD WELLMARK SB889 [3081026] BCBS WYOMING [308102603] 156.75 percent of total billed charges 102.3 156.75 Technical (Hospital) Services Bmp W Total Calcium Panel PX-3018004800 CDM 80048 CPT 301 RC inpatient 165 165 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES EPO [308136803] 130.65 percent of total billed charges 102.3 156.75 Technical (Hospital) Services Bmp W Total Calcium Panel PX-3018004800 CDM 80048 CPT 301 RC inpatient 165 165 CIGNA 62308 [3081051] CIGNA 62308 [308105105] 130.65 percent of total billed charges 102.3 156.75 Technical (Hospital) Services Bmp W Total Calcium Panel PX-3018004800 CDM 80048 CPT 301 RC inpatient 165 165 CIGNA 62308 [3081051] CIGNA STATE OF WYOMING [308105107] 130.65 percent of total billed charges 102.3 156.75 Technical (Hospital) Services Pulmonary Perfusion Imaging Particulate PX-3417858000 CDM 78580 CPT 341 RC inpatient 1547 1547 CIGNA 62308 [3081051] CIGNA 62308 [308105105] 1224.91 percent of total billed charges 959.14 1469.65 Technical (Hospital) Services Pulmonary Perfusion Imaging Particulate PX-3417858000 CDM 78580 CPT 341 RC inpatient 1547 1547 CIGNA 62308 [3081051] CIGNA STATE OF WYOMING [308105107] 1224.91 percent of total billed charges 959.14 1469.65 Technical (Hospital) Services Pulmonary Perfusion Imaging Particulate PX-3417858000 CDM 78580 CPT 341 RC inpatient 1547 1547 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES EPO [308136803] 1224.91 percent of total billed charges 959.14 1469.65 Technical (Hospital) Services Pulmonary Perfusion Imaging Particulate PX-3417858000 CDM 78580 CPT 341 RC inpatient 1547 1547 HEALTHPARTNERS SX009 HEALTHPARTNERS 1224.91 percent of total billed charges 959.14 1469.65 Technical (Hospital) Services Pulmonary Perfusion Imaging Particulate PX-3417858000 CDM 78580 CPT 341 RC inpatient 1547 1547 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES HDHP [308136802] 1224.91 percent of total billed charges 959.14 1469.65 Technical (Hospital) Services Pulmonary Perfusion Imaging Particulate PX-3417858000 CDM 78580 CPT 341 RC inpatient 1547 1547 MEDICA (COMMERCIAL) 94265 [3081118] MEDICA CLAIMS [308111801] 1392.3 percent of total billed charges 959.14 1469.65 Technical (Hospital) Services Pulmonary Perfusion Imaging Particulate PX-3417858000 CDM 78580 CPT 341 RC inpatient 1547 1547 UNITED HEALTHCARE (COMMERCIAL) [3081199] UNITED HEALTHCARE 87726 [308119901] 959.14 percent of total billed charges 959.14 1469.65 Technical (Hospital) Services Pulmonary Perfusion Imaging Particulate PX-3417858000 CDM 78580 CPT 341 RC inpatient 1547 1547 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES PPO [308136801] 1224.91 percent of total billed charges 959.14 1469.65 Technical (Hospital) Services Pulmonary Perfusion Imaging Particulate PX-3417858000 CDM 78580 CPT 341 RC inpatient 1547 1547 BLUE CROSS BLUE SHIELD WELLMARK SB889 [3081026] BCBS WYOMING [308102603] 1469.65 percent of total billed charges 959.14 1469.65 Technical (Hospital) Services Pulmonary Perfusion Imaging Particulate PX-3417858000 CDM 78580 CPT 341 RC inpatient 1547 1547 MULTIPLAN INC 34080 [3081285] MULTIPLAN INC [308128501] 1469.65 percent of total billed charges 959.14 1469.65 Technical (Hospital) Services Pulmonary Perfusion Imaging Particulate PX-3417858000 CDM 78580 CPT 341 RC outpatient 1547 1547 CIGNA 62308 [3081051] CIGNA 62308 [308105105] 1237.6 percent of total billed charges 959.14 1469.65 Technical (Hospital) Services Pulmonary Perfusion Imaging Particulate PX-3417858000 CDM 78580 CPT 341 RC outpatient 1547 1547 CIGNA 62308 [3081051] CIGNA STATE OF WYOMING [308105107] 1237.6 percent of total billed charges 959.14 1469.65 Technical (Hospital) Services Pulmonary Perfusion Imaging Particulate PX-3417858000 CDM 78580 CPT 341 RC outpatient 1547 1547 MEDICA (COMMERCIAL) 94265 [3081118] MEDICA CLAIMS [308111801] 1392.3 percent of total billed charges 959.14 1469.65 Technical (Hospital) Services Pulmonary Perfusion Imaging Particulate PX-3417858000 CDM 78580 CPT 341 RC outpatient 1547 1547 HEALTHPARTNERS SX009 HEALTHPARTNERS 1237.6 percent of total billed charges 959.14 1469.65 Technical (Hospital) Services Pulmonary Perfusion Imaging Particulate PX-3417858000 CDM 78580 CPT 341 RC outpatient 1547 1547 BLUE CROSS BLUE SHIELD WELLMARK SB889 [3081026] BCBS WYOMING [308102603] 1469.65 percent of total billed charges 959.14 1469.65 Technical (Hospital) Services Pulmonary Perfusion Imaging Particulate PX-3417858000 CDM 78580 CPT 341 RC outpatient 1547 1547 MULTIPLAN INC 34080 [3081285] MULTIPLAN INC [308128501] 1469.65 percent of total billed charges 959.14 1469.65 Technical (Hospital) Services Pulmonary Perfusion Imaging Particulate PX-3417858000 CDM 78580 CPT 341 RC outpatient 1547 1547 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES HDHP [308136802] 1237.6 percent of total billed charges 959.14 1469.65 Technical (Hospital) Services Pulmonary Perfusion Imaging Particulate PX-3417858000 CDM 78580 CPT 341 RC outpatient 1547 1547 UNITED HEALTHCARE (COMMERCIAL) [3081199] UNITED HEALTHCARE 87726 [308119901] 959.14 percent of total billed charges 959.14 1469.65 Technical (Hospital) Services Pulmonary Perfusion Imaging Particulate PX-3417858000 CDM 78580 CPT 341 RC outpatient 1547 1547 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES EPO [308136803] 1237.6 percent of total billed charges 959.14 1469.65 Technical (Hospital) Services Pulmonary Perfusion Imaging Particulate PX-3417858000 CDM 78580 CPT 341 RC outpatient 1547 1547 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES PPO [308136801] 1237.6 percent of total billed charges 959.14 1469.65 Technical (Hospital) Services DXA Bone Density Study 1/> Sites Axial Skel PX-3207708000 CDM 77080 CPT 320 RC inpatient 694 694 CIGNA 62308 [3081051] CIGNA 62308 [308105105] 549.51 percent of total billed charges 430.28 659.3 Technical (Hospital) Services DXA Bone Density Study 1/> Sites Axial Skel PX-3207708000 CDM 77080 CPT 320 RC inpatient 694 694 CIGNA 62308 [3081051] CIGNA STATE OF WYOMING [308105107] 549.51 percent of total billed charges 430.28 659.3 Technical (Hospital) Services DXA Bone Density Study 1/> Sites Axial Skel PX-3207708000 CDM 77080 CPT 320 RC inpatient 694 694 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES EPO [308136803] 549.51 percent of total billed charges 430.28 659.3 Technical (Hospital) Services DXA Bone Density Study 1/> Sites Axial Skel PX-3207708000 CDM 77080 CPT 320 RC inpatient 694 694 BLUE CROSS BLUE SHIELD WELLMARK SB889 [3081026] BCBS WYOMING [308102603] 659.3 percent of total billed charges 430.28 659.3 Technical (Hospital) Services DXA Bone Density Study 1/> Sites Axial Skel PX-3207708000 CDM 77080 CPT 320 RC inpatient 694 694 MULTIPLAN INC 34080 [3081285] MULTIPLAN INC [308128501] 659.3 percent of total billed charges 430.28 659.3 Technical (Hospital) Services DXA Bone Density Study 1/> Sites Axial Skel PX-3207708000 CDM 77080 CPT 320 RC inpatient 694 694 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES PPO [308136801] 549.51 percent of total billed charges 430.28 659.3 Technical (Hospital) Services DXA Bone Density Study 1/> Sites Axial Skel PX-3207708000 CDM 77080 CPT 320 RC inpatient 694 694 UNITED HEALTHCARE (COMMERCIAL) [3081199] UNITED HEALTHCARE 87726 [308119901] 430.28 percent of total billed charges 430.28 659.3 Technical (Hospital) Services DXA Bone Density Study 1/> Sites Axial Skel PX-3207708000 CDM 77080 CPT 320 RC inpatient 694 694 HEALTHPARTNERS SX009 HEALTHPARTNERS 549.51 percent of total billed charges 430.28 659.3 Technical (Hospital) Services DXA Bone Density Study 1/> Sites Axial Skel PX-3207708000 CDM 77080 CPT 320 RC inpatient 694 694 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES HDHP [308136802] 549.51 percent of total billed charges 430.28 659.3 Technical (Hospital) Services DXA Bone Density Study 1/> Sites Axial Skel PX-3207708000 CDM 77080 CPT 320 RC inpatient 694 694 MEDICA (COMMERCIAL) 94265 [3081118] MEDICA CLAIMS [308111801] 624.6 percent of total billed charges 430.28 659.3 Technical (Hospital) Services DXA Bone Density Study 1/> Sites Axial Skel PX-3207708000 CDM 77080 CPT 320 RC outpatient 694 694 UNITED HEALTHCARE (COMMERCIAL) [3081199] UNITED HEALTHCARE 87726 [308119901] 430.28 percent of total billed charges 430.28 659.3 Technical (Hospital) Services DXA Bone Density Study 1/> Sites Axial Skel PX-3207708000 CDM 77080 CPT 320 RC outpatient 694 694 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES PPO [308136801] 555.2 percent of total billed charges 430.28 659.3 Technical (Hospital) Services DXA Bone Density Study 1/> Sites Axial Skel PX-3207708000 CDM 77080 CPT 320 RC outpatient 694 694 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES EPO [308136803] 555.2 percent of total billed charges 430.28 659.3 Technical (Hospital) Services DXA Bone Density Study 1/> Sites Axial Skel PX-3207708000 CDM 77080 CPT 320 RC outpatient 694 694 BLUE CROSS BLUE SHIELD WELLMARK SB889 [3081026] BCBS WYOMING [308102603] 659.3 percent of total billed charges 430.28 659.3 Technical (Hospital) Services DXA Bone Density Study 1/> Sites Axial Skel PX-3207708000 CDM 77080 CPT 320 RC outpatient 694 694 MULTIPLAN INC 34080 [3081285] MULTIPLAN INC [308128501] 659.3 percent of total billed charges 430.28 659.3 Technical (Hospital) Services DXA Bone Density Study 1/> Sites Axial Skel PX-3207708000 CDM 77080 CPT 320 RC outpatient 694 694 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES HDHP [308136802] 555.2 percent of total billed charges 430.28 659.3 Technical (Hospital) Services DXA Bone Density Study 1/> Sites Axial Skel PX-3207708000 CDM 77080 CPT 320 RC outpatient 694 694 HEALTHPARTNERS SX009 HEALTHPARTNERS 555.2 percent of total billed charges 430.28 659.3 Technical (Hospital) Services DXA Bone Density Study 1/> Sites Axial Skel PX-3207708000 CDM 77080 CPT 320 RC outpatient 694 694 MEDICA (COMMERCIAL) 94265 [3081118] MEDICA CLAIMS [308111801] 624.6 percent of total billed charges 430.28 659.3 Technical (Hospital) Services DXA Bone Density Study 1/> Sites Axial Skel PX-3207708000 CDM 77080 CPT 320 RC outpatient 694 694 CIGNA 62308 [3081051] CIGNA 62308 [308105105] 555.2 percent of total billed charges 430.28 659.3 Technical (Hospital) Services DXA Bone Density Study 1/> Sites Axial Skel PX-3207708000 CDM 77080 CPT 320 RC outpatient 694 694 CIGNA 62308 [3081051] CIGNA STATE OF WYOMING [308105107] 555.2 percent of total billed charges 430.28 659.3 Technical (Hospital) Services Radiologic Examination Osseous Survey Infant PX-3207707600 CDM 77076 CPT 320 RC outpatient 289 289 CIGNA 62308 [3081051] CIGNA 62308 [308105105] 231.2 percent of total billed charges 179.18 274.55 Technical (Hospital) Services Radiologic Examination Osseous Survey Infant PX-3207707600 CDM 77076 CPT 320 RC outpatient 289 289 CIGNA 62308 [3081051] CIGNA STATE OF WYOMING [308105107] 231.2 percent of total billed charges 179.18 274.55 Technical (Hospital) Services Radiologic Examination Osseous Survey Infant PX-3207707600 CDM 77076 CPT 320 RC outpatient 289 289 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES HDHP [308136802] 231.2 percent of total billed charges 179.18 274.55 Technical (Hospital) Services Radiologic Examination Osseous Survey Infant PX-3207707600 CDM 77076 CPT 320 RC outpatient 289 289 MULTIPLAN INC 34080 [3081285] MULTIPLAN INC [308128501] 274.55 percent of total billed charges 179.18 274.55 Technical (Hospital) Services Radiologic Examination Osseous Survey Infant PX-3207707600 CDM 77076 CPT 320 RC outpatient 289 289 BLUE CROSS BLUE SHIELD WELLMARK SB889 [3081026] BCBS WYOMING [308102603] 274.55 percent of total billed charges 179.18 274.55 Technical (Hospital) Services Radiologic Examination Osseous Survey Infant PX-3207707600 CDM 77076 CPT 320 RC outpatient 289 289 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES PPO [308136801] 231.2 percent of total billed charges 179.18 274.55 Technical (Hospital) Services Radiologic Examination Osseous Survey Infant PX-3207707600 CDM 77076 CPT 320 RC outpatient 289 289 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES EPO [308136803] 231.2 percent of total billed charges 179.18 274.55 Technical (Hospital) Services Radiologic Examination Osseous Survey Infant PX-3207707600 CDM 77076 CPT 320 RC outpatient 289 289 UNITED HEALTHCARE (COMMERCIAL) [3081199] UNITED HEALTHCARE 87726 [308119901] 179.18 percent of total billed charges 179.18 274.55 Technical (Hospital) Services Radiologic Examination Osseous Survey Infant PX-3207707600 CDM 77076 CPT 320 RC outpatient 289 289 MEDICA (COMMERCIAL) 94265 [3081118] MEDICA CLAIMS [308111801] 260.1 percent of total billed charges 179.18 274.55 Technical (Hospital) Services Radiologic Examination Osseous Survey Infant PX-3207707600 CDM 77076 CPT 320 RC outpatient 289 289 HEALTHPARTNERS SX009 HEALTHPARTNERS 231.2 percent of total billed charges 179.18 274.55 Technical (Hospital) Services Radiologic Examination Osseous Survey Infant PX-3207707600 CDM 77076 CPT 320 RC inpatient 289 289 UNITED HEALTHCARE (COMMERCIAL) [3081199] UNITED HEALTHCARE 87726 [308119901] 179.18 percent of total billed charges 179.18 274.55 Technical (Hospital) Services Radiologic Examination Osseous Survey Infant PX-3207707600 CDM 77076 CPT 320 RC inpatient 289 289 BLUE CROSS BLUE SHIELD WELLMARK SB889 [3081026] BCBS WYOMING [308102603] 274.55 percent of total billed charges 179.18 274.55 Technical (Hospital) Services Radiologic Examination Osseous Survey Infant PX-3207707600 CDM 77076 CPT 320 RC inpatient 289 289 MULTIPLAN INC 34080 [3081285] MULTIPLAN INC [308128501] 274.55 percent of total billed charges 179.18 274.55 Technical (Hospital) Services Radiologic Examination Osseous Survey Infant PX-3207707600 CDM 77076 CPT 320 RC inpatient 289 289 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES PPO [308136801] 228.83 percent of total billed charges 179.18 274.55 Technical (Hospital) Services Radiologic Examination Osseous Survey Infant PX-3207707600 CDM 77076 CPT 320 RC inpatient 289 289 MEDICA (COMMERCIAL) 94265 [3081118] MEDICA CLAIMS [308111801] 260.1 percent of total billed charges 179.18 274.55 Technical (Hospital) Services Radiologic Examination Osseous Survey Infant PX-3207707600 CDM 77076 CPT 320 RC inpatient 289 289 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES HDHP [308136802] 228.83 percent of total billed charges 179.18 274.55 Technical (Hospital) Services Radiologic Examination Osseous Survey Infant PX-3207707600 CDM 77076 CPT 320 RC inpatient 289 289 HEALTHPARTNERS SX009 HEALTHPARTNERS 228.83 percent of total billed charges 179.18 274.55 Technical (Hospital) Services Radiologic Examination Osseous Survey Infant PX-3207707600 CDM 77076 CPT 320 RC inpatient 289 289 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES EPO [308136803] 228.83 percent of total billed charges 179.18 274.55 Technical (Hospital) Services Radiologic Examination Osseous Survey Infant PX-3207707600 CDM 77076 CPT 320 RC inpatient 289 289 CIGNA 62308 [3081051] CIGNA 62308 [308105105] 228.83 percent of total billed charges 179.18 274.55 Technical (Hospital) Services Radiologic Examination Osseous Survey Infant PX-3207707600 CDM 77076 CPT 320 RC inpatient 289 289 CIGNA 62308 [3081051] CIGNA STATE OF WYOMING [308105107] 228.83 percent of total billed charges 179.18 274.55 Technical (Hospital) Services Radiologic Examination Osseous Survey Compl PX-3207707500 CDM 77075 CPT 320 RC outpatient 457 457 MEDICA (COMMERCIAL) 94265 [3081118] MEDICA CLAIMS [308111801] 411.3 percent of total billed charges 283.34 434.15 Technical (Hospital) Services Radiologic Examination Osseous Survey Compl PX-3207707500 CDM 77075 CPT 320 RC outpatient 457 457 CIGNA 62308 [3081051] CIGNA 62308 [308105105] 365.6 percent of total billed charges 283.34 434.15 Technical (Hospital) Services Radiologic Examination Osseous Survey Compl PX-3207707500 CDM 77075 CPT 320 RC outpatient 457 457 CIGNA 62308 [3081051] CIGNA STATE OF WYOMING [308105107] 365.6 percent of total billed charges 283.34 434.15 Technical (Hospital) Services Radiologic Examination Osseous Survey Compl PX-3207707500 CDM 77075 CPT 320 RC outpatient 457 457 HEALTHPARTNERS SX009 HEALTHPARTNERS 365.6 percent of total billed charges 283.34 434.15 Technical (Hospital) Services Radiologic Examination Osseous Survey Compl PX-3207707500 CDM 77075 CPT 320 RC outpatient 457 457 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES HDHP [308136802] 365.6 percent of total billed charges 283.34 434.15 Technical (Hospital) Services Radiologic Examination Osseous Survey Compl PX-3207707500 CDM 77075 CPT 320 RC outpatient 457 457 BLUE CROSS BLUE SHIELD WELLMARK SB889 [3081026] BCBS WYOMING [308102603] 434.15 percent of total billed charges 283.34 434.15 Technical (Hospital) Services Radiologic Examination Osseous Survey Compl PX-3207707500 CDM 77075 CPT 320 RC outpatient 457 457 MULTIPLAN INC 34080 [3081285] MULTIPLAN INC [308128501] 434.15 percent of total billed charges 283.34 434.15 Technical (Hospital) Services Radiologic Examination Osseous Survey Compl PX-3207707500 CDM 77075 CPT 320 RC outpatient 457 457 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES EPO [308136803] 365.6 percent of total billed charges 283.34 434.15 Technical (Hospital) Services Radiologic Examination Osseous Survey Compl PX-3207707500 CDM 77075 CPT 320 RC outpatient 457 457 UNITED HEALTHCARE (COMMERCIAL) [3081199] UNITED HEALTHCARE 87726 [308119901] 283.34 percent of total billed charges 283.34 434.15 Technical (Hospital) Services Radiologic Examination Osseous Survey Compl PX-3207707500 CDM 77075 CPT 320 RC outpatient 457 457 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES PPO [308136801] 365.6 percent of total billed charges 283.34 434.15 Technical (Hospital) Services Radiologic Examination Osseous Survey Compl PX-3207707500 CDM 77075 CPT 320 RC inpatient 457 457 CIGNA 62308 [3081051] CIGNA 62308 [308105105] 361.85 percent of total billed charges 283.34 434.15 Technical (Hospital) Services Radiologic Examination Osseous Survey Compl PX-3207707500 CDM 77075 CPT 320 RC inpatient 457 457 CIGNA 62308 [3081051] CIGNA STATE OF WYOMING [308105107] 361.85 percent of total billed charges 283.34 434.15 Technical (Hospital) Services Radiologic Examination Osseous Survey Compl PX-3207707500 CDM 77075 CPT 320 RC inpatient 457 457 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES EPO [308136803] 361.85 percent of total billed charges 283.34 434.15 Technical (Hospital) Services Radiologic Examination Osseous Survey Compl PX-3207707500 CDM 77075 CPT 320 RC inpatient 457 457 HEALTHPARTNERS SX009 HEALTHPARTNERS 361.85 percent of total billed charges 283.34 434.15 Technical (Hospital) Services Radiologic Examination Osseous Survey Compl PX-3207707500 CDM 77075 CPT 320 RC inpatient 457 457 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES HDHP [308136802] 361.85 percent of total billed charges 283.34 434.15 Technical (Hospital) Services Radiologic Examination Osseous Survey Compl PX-3207707500 CDM 77075 CPT 320 RC inpatient 457 457 MEDICA (COMMERCIAL) 94265 [3081118] MEDICA CLAIMS [308111801] 411.3 percent of total billed charges 283.34 434.15 Technical (Hospital) Services Radiologic Examination Osseous Survey Compl PX-3207707500 CDM 77075 CPT 320 RC inpatient 457 457 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES PPO [308136801] 361.85 percent of total billed charges 283.34 434.15 Technical (Hospital) Services Radiologic Examination Osseous Survey Compl PX-3207707500 CDM 77075 CPT 320 RC inpatient 457 457 MULTIPLAN INC 34080 [3081285] MULTIPLAN INC [308128501] 434.15 percent of total billed charges 283.34 434.15 Technical (Hospital) Services Radiologic Examination Osseous Survey Compl PX-3207707500 CDM 77075 CPT 320 RC inpatient 457 457 BLUE CROSS BLUE SHIELD WELLMARK SB889 [3081026] BCBS WYOMING [308102603] 434.15 percent of total billed charges 283.34 434.15 Technical (Hospital) Services Radiologic Examination Osseous Survey Compl PX-3207707500 CDM 77075 CPT 320 RC inpatient 457 457 UNITED HEALTHCARE (COMMERCIAL) [3081199] UNITED HEALTHCARE 87726 [308119901] 283.34 percent of total billed charges 283.34 434.15 Technical (Hospital) Services Radiologic Examination Osseous Survey Limited PX-3207707400 CDM 77074 CPT 320 RC inpatient 456 456 CIGNA 62308 [3081051] CIGNA 62308 [308105105] 361.06 percent of total billed charges 282.72 433.2 Technical (Hospital) Services Radiologic Examination Osseous Survey Limited PX-3207707400 CDM 77074 CPT 320 RC inpatient 456 456 CIGNA 62308 [3081051] CIGNA STATE OF WYOMING [308105107] 361.06 percent of total billed charges 282.72 433.2 Technical (Hospital) Services Radiologic Examination Osseous Survey Limited PX-3207707400 CDM 77074 CPT 320 RC inpatient 456 456 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES EPO [308136803] 361.06 percent of total billed charges 282.72 433.2 Technical (Hospital) Services Radiologic Examination Osseous Survey Limited PX-3207707400 CDM 77074 CPT 320 RC inpatient 456 456 HEALTHPARTNERS SX009 HEALTHPARTNERS 361.06 percent of total billed charges 282.72 433.2 Technical (Hospital) Services Radiologic Examination Osseous Survey Limited PX-3207707400 CDM 77074 CPT 320 RC inpatient 456 456 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES HDHP [308136802] 361.06 percent of total billed charges 282.72 433.2 Technical (Hospital) Services Radiologic Examination Osseous Survey Limited PX-3207707400 CDM 77074 CPT 320 RC inpatient 456 456 MEDICA (COMMERCIAL) 94265 [3081118] MEDICA CLAIMS [308111801] 410.4 percent of total billed charges 282.72 433.2 Technical (Hospital) Services Radiologic Examination Osseous Survey Limited PX-3207707400 CDM 77074 CPT 320 RC inpatient 456 456 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES PPO [308136801] 361.06 percent of total billed charges 282.72 433.2 Technical (Hospital) Services Radiologic Examination Osseous Survey Limited PX-3207707400 CDM 77074 CPT 320 RC inpatient 456 456 MULTIPLAN INC 34080 [3081285] MULTIPLAN INC [308128501] 433.2 percent of total billed charges 282.72 433.2 Technical (Hospital) Services Radiologic Examination Osseous Survey Limited PX-3207707400 CDM 77074 CPT 320 RC inpatient 456 456 BLUE CROSS BLUE SHIELD WELLMARK SB889 [3081026] BCBS WYOMING [308102603] 433.2 percent of total billed charges 282.72 433.2 Technical (Hospital) Services Radiologic Examination Osseous Survey Limited PX-3207707400 CDM 77074 CPT 320 RC inpatient 456 456 UNITED HEALTHCARE (COMMERCIAL) [3081199] UNITED HEALTHCARE 87726 [308119901] 282.72 percent of total billed charges 282.72 433.2 Technical (Hospital) Services Radiologic Examination Osseous Survey Limited PX-3207707400 CDM 77074 CPT 320 RC outpatient 456 456 HEALTHPARTNERS SX009 HEALTHPARTNERS 364.8 percent of total billed charges 282.72 433.2 Technical (Hospital) Services Radiologic Examination Osseous Survey Limited PX-3207707400 CDM 77074 CPT 320 RC outpatient 456 456 UNITED HEALTHCARE (COMMERCIAL) [3081199] UNITED HEALTHCARE 87726 [308119901] 282.72 percent of total billed charges 282.72 433.2 Technical (Hospital) Services Radiologic Examination Osseous Survey Limited PX-3207707400 CDM 77074 CPT 320 RC outpatient 456 456 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES EPO [308136803] 364.8 percent of total billed charges 282.72 433.2 Technical (Hospital) Services Radiologic Examination Osseous Survey Limited PX-3207707400 CDM 77074 CPT 320 RC outpatient 456 456 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES PPO [308136801] 364.8 percent of total billed charges 282.72 433.2 Technical (Hospital) Services Radiologic Examination Osseous Survey Limited PX-3207707400 CDM 77074 CPT 320 RC outpatient 456 456 BLUE CROSS BLUE SHIELD WELLMARK SB889 [3081026] BCBS WYOMING [308102603] 433.2 percent of total billed charges 282.72 433.2 Technical (Hospital) Services Radiologic Examination Osseous Survey Limited PX-3207707400 CDM 77074 CPT 320 RC outpatient 456 456 MULTIPLAN INC 34080 [3081285] MULTIPLAN INC [308128501] 433.2 percent of total billed charges 282.72 433.2 Technical (Hospital) Services Radiologic Examination Osseous Survey Limited PX-3207707400 CDM 77074 CPT 320 RC outpatient 456 456 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES HDHP [308136802] 364.8 percent of total billed charges 282.72 433.2 Technical (Hospital) Services Radiologic Examination Osseous Survey Limited PX-3207707400 CDM 77074 CPT 320 RC outpatient 456 456 MEDICA (COMMERCIAL) 94265 [3081118] MEDICA CLAIMS [308111801] 410.4 percent of total billed charges 282.72 433.2 Technical (Hospital) Services Radiologic Examination Osseous Survey Limited PX-3207707400 CDM 77074 CPT 320 RC outpatient 456 456 CIGNA 62308 [3081051] CIGNA 62308 [308105105] 364.8 percent of total billed charges 282.72 433.2 Technical (Hospital) Services Radiologic Examination Osseous Survey Limited PX-3207707400 CDM 77074 CPT 320 RC outpatient 456 456 CIGNA 62308 [3081051] CIGNA STATE OF WYOMING [308105107] 364.8 percent of total billed charges 282.72 433.2 Technical (Hospital) Services Bone Length Studies PX-3207707300 CDM 77073 CPT 320 RC inpatient 278 278 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES EPO [308136803] 220.12 percent of total billed charges 172.36 264.1 Technical (Hospital) Services Bone Length Studies PX-3207707300 CDM 77073 CPT 320 RC inpatient 278 278 CIGNA 62308 [3081051] CIGNA 62308 [308105105] 220.12 percent of total billed charges 172.36 264.1 Technical (Hospital) Services Bone Length Studies PX-3207707300 CDM 77073 CPT 320 RC inpatient 278 278 CIGNA 62308 [3081051] CIGNA STATE OF WYOMING [308105107] 220.12 percent of total billed charges 172.36 264.1 Technical (Hospital) Services Bone Length Studies PX-3207707300 CDM 77073 CPT 320 RC inpatient 278 278 HEALTHPARTNERS SX009 HEALTHPARTNERS 220.12 percent of total billed charges 172.36 264.1 Technical (Hospital) Services Bone Length Studies PX-3207707300 CDM 77073 CPT 320 RC inpatient 278 278 MEDICA (COMMERCIAL) 94265 [3081118] MEDICA CLAIMS [308111801] 250.2 percent of total billed charges 172.36 264.1 Technical (Hospital) Services Bone Length Studies PX-3207707300 CDM 77073 CPT 320 RC inpatient 278 278 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES HDHP [308136802] 220.12 percent of total billed charges 172.36 264.1 Technical (Hospital) Services Bone Length Studies PX-3207707300 CDM 77073 CPT 320 RC inpatient 278 278 UNITED HEALTHCARE (COMMERCIAL) [3081199] UNITED HEALTHCARE 87726 [308119901] 172.36 percent of total billed charges 172.36 264.1 Technical (Hospital) Services Bone Length Studies PX-3207707300 CDM 77073 CPT 320 RC inpatient 278 278 BLUE CROSS BLUE SHIELD WELLMARK SB889 [3081026] BCBS WYOMING [308102603] 264.1 percent of total billed charges 172.36 264.1 Technical (Hospital) Services Bone Length Studies PX-3207707300 CDM 77073 CPT 320 RC inpatient 278 278 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES PPO [308136801] 220.12 percent of total billed charges 172.36 264.1 Technical (Hospital) Services Bone Length Studies PX-3207707300 CDM 77073 CPT 320 RC inpatient 278 278 MULTIPLAN INC 34080 [3081285] MULTIPLAN INC [308128501] 264.1 percent of total billed charges 172.36 264.1 Technical (Hospital) Services Bone Length Studies PX-3207707300 CDM 77073 CPT 320 RC outpatient 278 278 MEDICA (COMMERCIAL) 94265 [3081118] MEDICA CLAIMS [308111801] 250.2 percent of total billed charges 172.36 264.1 Technical (Hospital) Services Bone Length Studies PX-3207707300 CDM 77073 CPT 320 RC outpatient 278 278 CIGNA 62308 [3081051] CIGNA 62308 [308105105] 222.4 percent of total billed charges 172.36 264.1 Technical (Hospital) Services Bone Length Studies PX-3207707300 CDM 77073 CPT 320 RC outpatient 278 278 CIGNA 62308 [3081051] CIGNA STATE OF WYOMING [308105107] 222.4 percent of total billed charges 172.36 264.1 Technical (Hospital) Services Bone Length Studies PX-3207707300 CDM 77073 CPT 320 RC outpatient 278 278 HEALTHPARTNERS SX009 HEALTHPARTNERS 222.4 percent of total billed charges 172.36 264.1 Technical (Hospital) Services Bone Length Studies PX-3207707300 CDM 77073 CPT 320 RC outpatient 278 278 MULTIPLAN INC 34080 [3081285] MULTIPLAN INC [308128501] 264.1 percent of total billed charges 172.36 264.1 Technical (Hospital) Services Bone Length Studies PX-3207707300 CDM 77073 CPT 320 RC outpatient 278 278 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES HDHP [308136802] 222.4 percent of total billed charges 172.36 264.1 Technical (Hospital) Services Bone Length Studies PX-3207707300 CDM 77073 CPT 320 RC outpatient 278 278 BLUE CROSS BLUE SHIELD WELLMARK SB889 [3081026] BCBS WYOMING [308102603] 264.1 percent of total billed charges 172.36 264.1 Technical (Hospital) Services Bone Length Studies PX-3207707300 CDM 77073 CPT 320 RC outpatient 278 278 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES PPO [308136801] 222.4 percent of total billed charges 172.36 264.1 Technical (Hospital) Services Bone Length Studies PX-3207707300 CDM 77073 CPT 320 RC outpatient 278 278 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES EPO [308136803] 222.4 percent of total billed charges 172.36 264.1 Technical (Hospital) Services Bone Length Studies PX-3207707300 CDM 77073 CPT 320 RC outpatient 278 278 UNITED HEALTHCARE (COMMERCIAL) [3081199] UNITED HEALTHCARE 87726 [308119901] 172.36 percent of total billed charges 172.36 264.1 Technical (Hospital) Services Bone Age Studies PX-3207707200 CDM 77072 CPT 320 RC inpatient 278 278 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES PPO [308136801] 220.12 percent of total billed charges 172.36 264.1 Technical (Hospital) Services Bone Age Studies PX-3207707200 CDM 77072 CPT 320 RC inpatient 278 278 BLUE CROSS BLUE SHIELD WELLMARK SB889 [3081026] BCBS WYOMING [308102603] 264.1 percent of total billed charges 172.36 264.1 Technical (Hospital) Services Bone Age Studies PX-3207707200 CDM 77072 CPT 320 RC inpatient 278 278 MULTIPLAN INC 34080 [3081285] MULTIPLAN INC [308128501] 264.1 percent of total billed charges 172.36 264.1 Technical (Hospital) Services Bone Age Studies PX-3207707200 CDM 77072 CPT 320 RC inpatient 278 278 UNITED HEALTHCARE (COMMERCIAL) [3081199] UNITED HEALTHCARE 87726 [308119901] 172.36 percent of total billed charges 172.36 264.1 Technical (Hospital) Services Bone Age Studies PX-3207707200 CDM 77072 CPT 320 RC inpatient 278 278 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES HDHP [308136802] 220.12 percent of total billed charges 172.36 264.1 Technical (Hospital) Services Bone Age Studies PX-3207707200 CDM 77072 CPT 320 RC inpatient 278 278 MEDICA (COMMERCIAL) 94265 [3081118] MEDICA CLAIMS [308111801] 250.2 percent of total billed charges 172.36 264.1 Technical (Hospital) Services Bone Age Studies PX-3207707200 CDM 77072 CPT 320 RC inpatient 278 278 HEALTHPARTNERS SX009 HEALTHPARTNERS 220.12 percent of total billed charges 172.36 264.1 Technical (Hospital) Services Bone Age Studies PX-3207707200 CDM 77072 CPT 320 RC inpatient 278 278 CIGNA 62308 [3081051] CIGNA 62308 [308105105] 220.12 percent of total billed charges 172.36 264.1 Technical (Hospital) Services Bone Age Studies PX-3207707200 CDM 77072 CPT 320 RC inpatient 278 278 CIGNA 62308 [3081051] CIGNA STATE OF WYOMING [308105107] 220.12 percent of total billed charges 172.36 264.1 Technical (Hospital) Services Bone Age Studies PX-3207707200 CDM 77072 CPT 320 RC inpatient 278 278 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES EPO [308136803] 220.12 percent of total billed charges 172.36 264.1 Technical (Hospital) Services Bone Age Studies PX-3207707200 CDM 77072 CPT 320 RC outpatient 278 278 UNITED HEALTHCARE (COMMERCIAL) [3081199] UNITED HEALTHCARE 87726 [308119901] 172.36 percent of total billed charges 172.36 264.1 Technical (Hospital) Services Bone Age Studies PX-3207707200 CDM 77072 CPT 320 RC outpatient 278 278 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES EPO [308136803] 222.4 percent of total billed charges 172.36 264.1 Technical (Hospital) Services Bone Age Studies PX-3207707200 CDM 77072 CPT 320 RC outpatient 278 278 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES PPO [308136801] 222.4 percent of total billed charges 172.36 264.1 Technical (Hospital) Services Bone Age Studies PX-3207707200 CDM 77072 CPT 320 RC outpatient 278 278 BLUE CROSS BLUE SHIELD WELLMARK SB889 [3081026] BCBS WYOMING [308102603] 264.1 percent of total billed charges 172.36 264.1 Technical (Hospital) Services Bone Age Studies PX-3207707200 CDM 77072 CPT 320 RC outpatient 278 278 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES HDHP [308136802] 222.4 percent of total billed charges 172.36 264.1 Technical (Hospital) Services Bone Age Studies PX-3207707200 CDM 77072 CPT 320 RC outpatient 278 278 MULTIPLAN INC 34080 [3081285] MULTIPLAN INC [308128501] 264.1 percent of total billed charges 172.36 264.1 Technical (Hospital) Services Bone Age Studies PX-3207707200 CDM 77072 CPT 320 RC outpatient 278 278 HEALTHPARTNERS SX009 HEALTHPARTNERS 222.4 percent of total billed charges 172.36 264.1 Technical (Hospital) Services Bone Age Studies PX-3207707200 CDM 77072 CPT 320 RC outpatient 278 278 CIGNA 62308 [3081051] CIGNA STATE OF WYOMING [308105107] 222.4 percent of total billed charges 172.36 264.1 Technical (Hospital) Services Bone Age Studies PX-3207707200 CDM 77072 CPT 320 RC outpatient 278 278 CIGNA 62308 [3081051] CIGNA 62308 [308105105] 222.4 percent of total billed charges 172.36 264.1 Technical (Hospital) Services Bone Age Studies PX-3207707200 CDM 77072 CPT 320 RC outpatient 278 278 MEDICA (COMMERCIAL) 94265 [3081118] MEDICA CLAIMS [308111801] 250.2 percent of total billed charges 172.36 264.1 Technical (Hospital) Services Screening Mammography Bi 2-View Breast Inc Cad PX-4037706700 CDM 77067 CPT 403 RC outpatient 650 650 CIGNA 62308 [3081051] CIGNA 62308 [308105105] 520 percent of total billed charges 403 617.5 Technical (Hospital) Services Screening Mammography Bi 2-View Breast Inc Cad PX-4037706700 CDM 77067 CPT 403 RC outpatient 650 650 CIGNA 62308 [3081051] CIGNA STATE OF WYOMING [308105107] 520 percent of total billed charges 403 617.5 Technical (Hospital) Services Screening Mammography Bi 2-View Breast Inc Cad PX-4037706700 CDM 77067 CPT 403 RC outpatient 650 650 MEDICA (COMMERCIAL) 94265 [3081118] MEDICA CLAIMS [308111801] 585 percent of total billed charges 403 617.5 Technical (Hospital) Services Screening Mammography Bi 2-View Breast Inc Cad PX-4037706700 CDM 77067 CPT 403 RC outpatient 650 650 HEALTHPARTNERS SX009 HEALTHPARTNERS 520 percent of total billed charges 403 617.5 Technical (Hospital) Services Screening Mammography Bi 2-View Breast Inc Cad PX-4037706700 CDM 77067 CPT 403 RC outpatient 650 650 UNITED HEALTHCARE (COMMERCIAL) [3081199] UNITED HEALTHCARE 87726 [308119901] 403 percent of total billed charges 403 617.5 Technical (Hospital) Services Screening Mammography Bi 2-View Breast Inc Cad PX-4037706700 CDM 77067 CPT 403 RC outpatient 650 650 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES EPO [308136803] 520 percent of total billed charges 403 617.5 Technical (Hospital) Services Screening Mammography Bi 2-View Breast Inc Cad PX-4037706700 CDM 77067 CPT 403 RC outpatient 650 650 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES PPO [308136801] 520 percent of total billed charges 403 617.5 Technical (Hospital) Services Screening Mammography Bi 2-View Breast Inc Cad PX-4037706700 CDM 77067 CPT 403 RC outpatient 650 650 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES HDHP [308136802] 520 percent of total billed charges 403 617.5 Technical (Hospital) Services Screening Mammography Bi 2-View Breast Inc Cad PX-4037706700 CDM 77067 CPT 403 RC outpatient 650 650 MULTIPLAN INC 34080 [3081285] MULTIPLAN INC [308128501] 617.5 percent of total billed charges 403 617.5 Technical (Hospital) Services Screening Mammography Bi 2-View Breast Inc Cad PX-4037706700 CDM 77067 CPT 403 RC outpatient 650 650 BLUE CROSS BLUE SHIELD WELLMARK SB889 [3081026] BCBS WYOMING [308102603] 617.5 percent of total billed charges 403 617.5 Technical (Hospital) Services Screening Mammography Bi 2-View Breast Inc Cad PX-4037706700 CDM 77067 CPT 403 RC inpatient 650 650 CIGNA 62308 [3081051] CIGNA 62308 [308105105] 514.67 percent of total billed charges 403 617.5 Technical (Hospital) Services Screening Mammography Bi 2-View Breast Inc Cad PX-4037706700 CDM 77067 CPT 403 RC inpatient 650 650 CIGNA 62308 [3081051] CIGNA STATE OF WYOMING [308105107] 514.67 percent of total billed charges 403 617.5 Technical (Hospital) Services Screening Mammography Bi 2-View Breast Inc Cad PX-4037706700 CDM 77067 CPT 403 RC inpatient 650 650 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES EPO [308136803] 514.67 percent of total billed charges 403 617.5 Technical (Hospital) Services Screening Mammography Bi 2-View Breast Inc Cad PX-4037706700 CDM 77067 CPT 403 RC inpatient 650 650 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES PPO [308136801] 514.67 percent of total billed charges 403 617.5 Technical (Hospital) Services Screening Mammography Bi 2-View Breast Inc Cad PX-4037706700 CDM 77067 CPT 403 RC inpatient 650 650 UNITED HEALTHCARE (COMMERCIAL) [3081199] UNITED HEALTHCARE 87726 [308119901] 403 percent of total billed charges 403 617.5 Technical (Hospital) Services Screening Mammography Bi 2-View Breast Inc Cad PX-4037706700 CDM 77067 CPT 403 RC inpatient 650 650 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES HDHP [308136802] 514.67 percent of total billed charges 403 617.5 Technical (Hospital) Services Screening Mammography Bi 2-View Breast Inc Cad PX-4037706700 CDM 77067 CPT 403 RC inpatient 650 650 BLUE CROSS BLUE SHIELD WELLMARK SB889 [3081026] BCBS WYOMING [308102603] 617.5 percent of total billed charges 403 617.5 Technical (Hospital) Services Screening Mammography Bi 2-View Breast Inc Cad PX-4037706700 CDM 77067 CPT 403 RC inpatient 650 650 MULTIPLAN INC 34080 [3081285] MULTIPLAN INC [308128501] 617.5 percent of total billed charges 403 617.5 Technical (Hospital) Services Screening Mammography Bi 2-View Breast Inc Cad PX-4037706700 CDM 77067 CPT 403 RC inpatient 650 650 MEDICA (COMMERCIAL) 94265 [3081118] MEDICA CLAIMS [308111801] 585 percent of total billed charges 403 617.5 Technical (Hospital) Services Screening Mammography Bi 2-View Breast Inc Cad PX-4037706700 CDM 77067 CPT 403 RC inpatient 650 650 HEALTHPARTNERS SX009 HEALTHPARTNERS 514.67 percent of total billed charges 403 617.5 Technical (Hospital) Services Screening Digital Breast Tomosynthesis Bi PX-4037706300 CDM 77063 CPT 403 RC inpatient 238 238 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES EPO [308136803] 188.45 percent of total billed charges 147.56 226.1 Technical (Hospital) Services Screening Digital Breast Tomosynthesis Bi PX-4037706300 CDM 77063 CPT 403 RC inpatient 238 238 CIGNA 62308 [3081051] CIGNA 62308 [308105105] 188.45 percent of total billed charges 147.56 226.1 Technical (Hospital) Services Screening Digital Breast Tomosynthesis Bi PX-4037706300 CDM 77063 CPT 403 RC inpatient 238 238 CIGNA 62308 [3081051] CIGNA STATE OF WYOMING [308105107] 188.45 percent of total billed charges 147.56 226.1 Technical (Hospital) Services Screening Digital Breast Tomosynthesis Bi PX-4037706300 CDM 77063 CPT 403 RC inpatient 238 238 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES HDHP [308136802] 188.45 percent of total billed charges 147.56 226.1 Technical (Hospital) Services Screening Digital Breast Tomosynthesis Bi PX-4037706300 CDM 77063 CPT 403 RC inpatient 238 238 MEDICA (COMMERCIAL) 94265 [3081118] MEDICA CLAIMS [308111801] 214.2 percent of total billed charges 147.56 226.1 Technical (Hospital) Services Screening Digital Breast Tomosynthesis Bi PX-4037706300 CDM 77063 CPT 403 RC inpatient 238 238 HEALTHPARTNERS SX009 HEALTHPARTNERS 188.45 percent of total billed charges 147.56 226.1 Technical (Hospital) Services Screening Digital Breast Tomosynthesis Bi PX-4037706300 CDM 77063 CPT 403 RC inpatient 238 238 UNITED HEALTHCARE (COMMERCIAL) [3081199] UNITED HEALTHCARE 87726 [308119901] 147.56 percent of total billed charges 147.56 226.1 Technical (Hospital) Services Screening Digital Breast Tomosynthesis Bi PX-4037706300 CDM 77063 CPT 403 RC inpatient 238 238 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES PPO [308136801] 188.45 percent of total billed charges 147.56 226.1 Technical (Hospital) Services Screening Digital Breast Tomosynthesis Bi PX-4037706300 CDM 77063 CPT 403 RC inpatient 238 238 MULTIPLAN INC 34080 [3081285] MULTIPLAN INC [308128501] 226.1 percent of total billed charges 147.56 226.1 Technical (Hospital) Services Screening Digital Breast Tomosynthesis Bi PX-4037706300 CDM 77063 CPT 403 RC inpatient 238 238 BLUE CROSS BLUE SHIELD WELLMARK SB889 [3081026] BCBS WYOMING [308102603] 226.1 percent of total billed charges 147.56 226.1 Technical (Hospital) Services Screening Digital Breast Tomosynthesis Bi PX-4037706300 CDM 77063 CPT 403 RC outpatient 238 238 CIGNA 62308 [3081051] CIGNA 62308 [308105105] 190.4 percent of total billed charges 147.56 226.1 Technical (Hospital) Services Screening Digital Breast Tomosynthesis Bi PX-4037706300 CDM 77063 CPT 403 RC outpatient 238 238 CIGNA 62308 [3081051] CIGNA STATE OF WYOMING [308105107] 190.4 percent of total billed charges 147.56 226.1 Technical (Hospital) Services Screening Digital Breast Tomosynthesis Bi PX-4037706300 CDM 77063 CPT 403 RC outpatient 238 238 HEALTHPARTNERS SX009 HEALTHPARTNERS 190.4 percent of total billed charges 147.56 226.1 Technical (Hospital) Services Screening Digital Breast Tomosynthesis Bi PX-4037706300 CDM 77063 CPT 403 RC outpatient 238 238 UNITED HEALTHCARE (COMMERCIAL) [3081199] UNITED HEALTHCARE 87726 [308119901] 147.56 percent of total billed charges 147.56 226.1 Technical (Hospital) Services Screening Digital Breast Tomosynthesis Bi PX-4037706300 CDM 77063 CPT 403 RC outpatient 238 238 MEDICA (COMMERCIAL) 94265 [3081118] MEDICA CLAIMS [308111801] 214.2 percent of total billed charges 147.56 226.1 Technical (Hospital) Services Screening Digital Breast Tomosynthesis Bi PX-4037706300 CDM 77063 CPT 403 RC outpatient 238 238 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES PPO [308136801] 190.4 percent of total billed charges 147.56 226.1 Technical (Hospital) Services Screening Digital Breast Tomosynthesis Bi PX-4037706300 CDM 77063 CPT 403 RC outpatient 238 238 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES EPO [308136803] 190.4 percent of total billed charges 147.56 226.1 Technical (Hospital) Services Screening Digital Breast Tomosynthesis Bi PX-4037706300 CDM 77063 CPT 403 RC outpatient 238 238 MULTIPLAN INC 34080 [3081285] MULTIPLAN INC [308128501] 226.1 percent of total billed charges 147.56 226.1 Technical (Hospital) Services Screening Digital Breast Tomosynthesis Bi PX-4037706300 CDM 77063 CPT 403 RC outpatient 238 238 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES HDHP [308136802] 190.4 percent of total billed charges 147.56 226.1 Technical (Hospital) Services Screening Digital Breast Tomosynthesis Bi PX-4037706300 CDM 77063 CPT 403 RC outpatient 238 238 BLUE CROSS BLUE SHIELD WELLMARK SB889 [3081026] BCBS WYOMING [308102603] 226.1 percent of total billed charges 147.56 226.1 Technical (Hospital) Services US Guidance Needle Placement Img S&I PX-4027694200 CDM 76942 CPT 402 RC inpatient 1246 1246 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES EPO [308136803] 986.58 percent of total billed charges 772.52 1183.7 Technical (Hospital) Services US Guidance Needle Placement Img S&I PX-4027694200 CDM 76942 CPT 402 RC inpatient 1246 1246 CIGNA 62308 [3081051] CIGNA 62308 [308105105] 986.58 percent of total billed charges 772.52 1183.7 Technical (Hospital) Services US Guidance Needle Placement Img S&I PX-4027694200 CDM 76942 CPT 402 RC inpatient 1246 1246 CIGNA 62308 [3081051] CIGNA STATE OF WYOMING [308105107] 986.58 percent of total billed charges 772.52 1183.7 Technical (Hospital) Services US Guidance Needle Placement Img S&I PX-4027694200 CDM 76942 CPT 402 RC inpatient 1246 1246 BLUE CROSS BLUE SHIELD WELLMARK SB889 [3081026] BCBS WYOMING [308102603] 1183.7 percent of total billed charges 772.52 1183.7 Technical (Hospital) Services US Guidance Needle Placement Img S&I PX-4027694200 CDM 76942 CPT 402 RC inpatient 1246 1246 MULTIPLAN INC 34080 [3081285] MULTIPLAN INC [308128501] 1183.7 percent of total billed charges 772.52 1183.7 Technical (Hospital) Services US Guidance Needle Placement Img S&I PX-4027694200 CDM 76942 CPT 402 RC inpatient 1246 1246 UNITED HEALTHCARE (COMMERCIAL) [3081199] UNITED HEALTHCARE 87726 [308119901] 772.52 percent of total billed charges 772.52 1183.7 Technical (Hospital) Services US Guidance Needle Placement Img S&I PX-4027694200 CDM 76942 CPT 402 RC inpatient 1246 1246 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES PPO [308136801] 986.58 percent of total billed charges 772.52 1183.7 Technical (Hospital) Services US Guidance Needle Placement Img S&I PX-4027694200 CDM 76942 CPT 402 RC inpatient 1246 1246 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES HDHP [308136802] 986.58 percent of total billed charges 772.52 1183.7 Technical (Hospital) Services US Guidance Needle Placement Img S&I PX-4027694200 CDM 76942 CPT 402 RC inpatient 1246 1246 MEDICA (COMMERCIAL) 94265 [3081118] MEDICA CLAIMS [308111801] 1121.4 percent of total billed charges 772.52 1183.7 Technical (Hospital) Services US Guidance Needle Placement Img S&I PX-4027694200 CDM 76942 CPT 402 RC inpatient 1246 1246 HEALTHPARTNERS SX009 HEALTHPARTNERS 986.58 percent of total billed charges 772.52 1183.7 Technical (Hospital) Services US Guidance Needle Placement Img S&I PX-4027694200 CDM 76942 CPT 402 RC outpatient 1246 1246 BLUE CROSS BLUE SHIELD WELLMARK SB889 [3081026] BCBS WYOMING [308102603] 1183.7 percent of total billed charges 772.52 1183.7 Technical (Hospital) Services US Guidance Needle Placement Img S&I PX-4027694200 CDM 76942 CPT 402 RC outpatient 1246 1246 MULTIPLAN INC 34080 [3081285] MULTIPLAN INC [308128501] 1183.7 percent of total billed charges 772.52 1183.7 Technical (Hospital) Services US Guidance Needle Placement Img S&I PX-4027694200 CDM 76942 CPT 402 RC outpatient 1246 1246 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES HDHP [308136802] 996.8 percent of total billed charges 772.52 1183.7 Technical (Hospital) Services US Guidance Needle Placement Img S&I PX-4027694200 CDM 76942 CPT 402 RC outpatient 1246 1246 UNITED HEALTHCARE (COMMERCIAL) [3081199] UNITED HEALTHCARE 87726 [308119901] 772.52 percent of total billed charges 772.52 1183.7 Technical (Hospital) Services US Guidance Needle Placement Img S&I PX-4027694200 CDM 76942 CPT 402 RC outpatient 1246 1246 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES PPO [308136801] 996.8 percent of total billed charges 772.52 1183.7 Technical (Hospital) Services US Guidance Needle Placement Img S&I PX-4027694200 CDM 76942 CPT 402 RC outpatient 1246 1246 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES EPO [308136803] 996.8 percent of total billed charges 772.52 1183.7 Technical (Hospital) Services US Guidance Needle Placement Img S&I PX-4027694200 CDM 76942 CPT 402 RC outpatient 1246 1246 MEDICA (COMMERCIAL) 94265 [3081118] MEDICA CLAIMS [308111801] 1121.4 percent of total billed charges 772.52 1183.7 Technical (Hospital) Services US Guidance Needle Placement Img S&I PX-4027694200 CDM 76942 CPT 402 RC outpatient 1246 1246 HEALTHPARTNERS SX009 HEALTHPARTNERS 996.8 percent of total billed charges 772.52 1183.7 Technical (Hospital) Services US Guidance Needle Placement Img S&I PX-4027694200 CDM 76942 CPT 402 RC outpatient 1246 1246 CIGNA 62308 [3081051] CIGNA 62308 [308105105] 996.8 percent of total billed charges 772.52 1183.7 Technical (Hospital) Services US Guidance Needle Placement Img S&I PX-4027694200 CDM 76942 CPT 402 RC outpatient 1246 1246 CIGNA 62308 [3081051] CIGNA STATE OF WYOMING [308105107] 996.8 percent of total billed charges 772.52 1183.7 Technical (Hospital) Services US Extremity Non-Vasc Real-Time Img Lmtd PX-4027688200 CDM 76882 CPT 402 RC outpatient 417 417 BLUE CROSS BLUE SHIELD WELLMARK SB889 [3081026] BCBS WYOMING [308102603] 396.15 percent of total billed charges 258.54 396.15 Technical (Hospital) Services US Extremity Non-Vasc Real-Time Img Lmtd PX-4027688200 CDM 76882 CPT 402 RC outpatient 417 417 MULTIPLAN INC 34080 [3081285] MULTIPLAN INC [308128501] 396.15 percent of total billed charges 258.54 396.15 Technical (Hospital) Services US Extremity Non-Vasc Real-Time Img Lmtd PX-4027688200 CDM 76882 CPT 402 RC outpatient 417 417 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES HDHP [308136802] 333.6 percent of total billed charges 258.54 396.15 Technical (Hospital) Services US Extremity Non-Vasc Real-Time Img Lmtd PX-4027688200 CDM 76882 CPT 402 RC outpatient 417 417 UNITED HEALTHCARE (COMMERCIAL) [3081199] UNITED HEALTHCARE 87726 [308119901] 258.54 percent of total billed charges 258.54 396.15 Technical (Hospital) Services US Extremity Non-Vasc Real-Time Img Lmtd PX-4027688200 CDM 76882 CPT 402 RC outpatient 417 417 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES EPO [308136803] 333.6 percent of total billed charges 258.54 396.15 Technical (Hospital) Services US Extremity Non-Vasc Real-Time Img Lmtd PX-4027688200 CDM 76882 CPT 402 RC outpatient 417 417 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES PPO [308136801] 333.6 percent of total billed charges 258.54 396.15 Technical (Hospital) Services US Extremity Non-Vasc Real-Time Img Lmtd PX-4027688200 CDM 76882 CPT 402 RC outpatient 417 417 MEDICA (COMMERCIAL) 94265 [3081118] MEDICA CLAIMS [308111801] 375.3 percent of total billed charges 258.54 396.15 Technical (Hospital) Services US Extremity Non-Vasc Real-Time Img Lmtd PX-4027688200 CDM 76882 CPT 402 RC outpatient 417 417 HEALTHPARTNERS SX009 HEALTHPARTNERS 333.6 percent of total billed charges 258.54 396.15 Technical (Hospital) Services US Extremity Non-Vasc Real-Time Img Lmtd PX-4027688200 CDM 76882 CPT 402 RC outpatient 417 417 CIGNA 62308 [3081051] CIGNA 62308 [308105105] 333.6 percent of total billed charges 258.54 396.15 Technical (Hospital) Services US Extremity Non-Vasc Real-Time Img Lmtd PX-4027688200 CDM 76882 CPT 402 RC outpatient 417 417 CIGNA 62308 [3081051] CIGNA STATE OF WYOMING [308105107] 333.6 percent of total billed charges 258.54 396.15 Technical (Hospital) Services US Extremity Non-Vasc Real-Time Img Lmtd PX-4027688200 CDM 76882 CPT 402 RC inpatient 417 417 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES HDHP [308136802] 330.18 percent of total billed charges 258.54 396.15 Technical (Hospital) Services US Extremity Non-Vasc Real-Time Img Lmtd PX-4027688200 CDM 76882 CPT 402 RC inpatient 417 417 MULTIPLAN INC 34080 [3081285] MULTIPLAN INC [308128501] 396.15 percent of total billed charges 258.54 396.15 Technical (Hospital) Services US Extremity Non-Vasc Real-Time Img Lmtd PX-4027688200 CDM 76882 CPT 402 RC inpatient 417 417 BLUE CROSS BLUE SHIELD WELLMARK SB889 [3081026] BCBS WYOMING [308102603] 396.15 percent of total billed charges 258.54 396.15 Technical (Hospital) Services US Extremity Non-Vasc Real-Time Img Lmtd PX-4027688200 CDM 76882 CPT 402 RC inpatient 417 417 UNITED HEALTHCARE (COMMERCIAL) [3081199] UNITED HEALTHCARE 87726 [308119901] 258.54 percent of total billed charges 258.54 396.15 Technical (Hospital) Services US Extremity Non-Vasc Real-Time Img Lmtd PX-4027688200 CDM 76882 CPT 402 RC inpatient 417 417 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES PPO [308136801] 330.18 percent of total billed charges 258.54 396.15 Technical (Hospital) Services US Extremity Non-Vasc Real-Time Img Lmtd PX-4027688200 CDM 76882 CPT 402 RC inpatient 417 417 MEDICA (COMMERCIAL) 94265 [3081118] MEDICA CLAIMS [308111801] 375.3 percent of total billed charges 258.54 396.15 Technical (Hospital) Services US Extremity Non-Vasc Real-Time Img Lmtd PX-4027688200 CDM 76882 CPT 402 RC inpatient 417 417 HEALTHPARTNERS SX009 HEALTHPARTNERS 330.18 percent of total billed charges 258.54 396.15 Technical (Hospital) Services US Extremity Non-Vasc Real-Time Img Lmtd PX-4027688200 CDM 76882 CPT 402 RC inpatient 417 417 CIGNA 62308 [3081051] CIGNA 62308 [308105105] 330.18 percent of total billed charges 258.54 396.15 Technical (Hospital) Services US Extremity Non-Vasc Real-Time Img Lmtd PX-4027688200 CDM 76882 CPT 402 RC inpatient 417 417 CIGNA 62308 [3081051] CIGNA STATE OF WYOMING [308105107] 330.18 percent of total billed charges 258.54 396.15 Technical (Hospital) Services US Extremity Non-Vasc Real-Time Img Lmtd PX-4027688200 CDM 76882 CPT 402 RC inpatient 417 417 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES EPO [308136803] 330.18 percent of total billed charges 258.54 396.15 Technical (Hospital) Services US Xtr Non-Vasc Complete PX-4027688100 CDM 76881 CPT 402 RC outpatient 477 477 CIGNA 62308 [3081051] CIGNA 62308 [308105105] 381.6 percent of total billed charges 295.74 453.15 Technical (Hospital) Services US Xtr Non-Vasc Complete PX-4027688100 CDM 76881 CPT 402 RC outpatient 477 477 CIGNA 62308 [3081051] CIGNA STATE OF WYOMING [308105107] 381.6 percent of total billed charges 295.74 453.15 Technical (Hospital) Services US Xtr Non-Vasc Complete PX-4027688100 CDM 76881 CPT 402 RC outpatient 477 477 HEALTHPARTNERS SX009 HEALTHPARTNERS 381.6 percent of total billed charges 295.74 453.15 Technical (Hospital) Services US Xtr Non-Vasc Complete PX-4027688100 CDM 76881 CPT 402 RC outpatient 477 477 MEDICA (COMMERCIAL) 94265 [3081118] MEDICA CLAIMS [308111801] 429.3 percent of total billed charges 295.74 453.15 Technical (Hospital) Services US Xtr Non-Vasc Complete PX-4027688100 CDM 76881 CPT 402 RC outpatient 477 477 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES EPO [308136803] 381.6 percent of total billed charges 295.74 453.15 Technical (Hospital) Services US Xtr Non-Vasc Complete PX-4027688100 CDM 76881 CPT 402 RC outpatient 477 477 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES PPO [308136801] 381.6 percent of total billed charges 295.74 453.15 Technical (Hospital) Services US Xtr Non-Vasc Complete PX-4027688100 CDM 76881 CPT 402 RC outpatient 477 477 UNITED HEALTHCARE (COMMERCIAL) [3081199] UNITED HEALTHCARE 87726 [308119901] 295.74 percent of total billed charges 295.74 453.15 Technical (Hospital) Services US Xtr Non-Vasc Complete PX-4027688100 CDM 76881 CPT 402 RC outpatient 477 477 MULTIPLAN INC 34080 [3081285] MULTIPLAN INC [308128501] 453.15 percent of total billed charges 295.74 453.15 Technical (Hospital) Services US Xtr Non-Vasc Complete PX-4027688100 CDM 76881 CPT 402 RC outpatient 477 477 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES HDHP [308136802] 381.6 percent of total billed charges 295.74 453.15 Technical (Hospital) Services US Xtr Non-Vasc Complete PX-4027688100 CDM 76881 CPT 402 RC outpatient 477 477 BLUE CROSS BLUE SHIELD WELLMARK SB889 [3081026] BCBS WYOMING [308102603] 453.15 percent of total billed charges 295.74 453.15 Technical (Hospital) Services US Xtr Non-Vasc Complete PX-4027688100 CDM 76881 CPT 402 RC inpatient 477 477 CIGNA 62308 [3081051] CIGNA 62308 [308105105] 377.69 percent of total billed charges 295.74 453.15 Technical (Hospital) Services US Xtr Non-Vasc Complete PX-4027688100 CDM 76881 CPT 402 RC inpatient 477 477 CIGNA 62308 [3081051] CIGNA STATE OF WYOMING [308105107] 377.69 percent of total billed charges 295.74 453.15 Technical (Hospital) Services US Xtr Non-Vasc Complete PX-4027688100 CDM 76881 CPT 402 RC inpatient 477 477 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES EPO [308136803] 377.69 percent of total billed charges 295.74 453.15 Technical (Hospital) Services US Xtr Non-Vasc Complete PX-4027688100 CDM 76881 CPT 402 RC inpatient 477 477 MULTIPLAN INC 34080 [3081285] MULTIPLAN INC [308128501] 453.15 percent of total billed charges 295.74 453.15 Technical (Hospital) Services US Xtr Non-Vasc Complete PX-4027688100 CDM 76881 CPT 402 RC inpatient 477 477 BLUE CROSS BLUE SHIELD WELLMARK SB889 [3081026] BCBS WYOMING [308102603] 453.15 percent of total billed charges 295.74 453.15 Technical (Hospital) Services US Xtr Non-Vasc Complete PX-4027688100 CDM 76881 CPT 402 RC inpatient 477 477 UNITED HEALTHCARE (COMMERCIAL) [3081199] UNITED HEALTHCARE 87726 [308119901] 295.74 percent of total billed charges 295.74 453.15 Technical (Hospital) Services US Xtr Non-Vasc Complete PX-4027688100 CDM 76881 CPT 402 RC inpatient 477 477 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES PPO [308136801] 377.69 percent of total billed charges 295.74 453.15 Technical (Hospital) Services US Xtr Non-Vasc Complete PX-4027688100 CDM 76881 CPT 402 RC inpatient 477 477 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES HDHP [308136802] 377.69 percent of total billed charges 295.74 453.15 Technical (Hospital) Services US Xtr Non-Vasc Complete PX-4027688100 CDM 76881 CPT 402 RC inpatient 477 477 MEDICA (COMMERCIAL) 94265 [3081118] MEDICA CLAIMS [308111801] 429.3 percent of total billed charges 295.74 453.15 Technical (Hospital) Services US Xtr Non-Vasc Complete PX-4027688100 CDM 76881 CPT 402 RC inpatient 477 477 HEALTHPARTNERS SX009 HEALTHPARTNERS 377.69 percent of total billed charges 295.74 453.15 Technical (Hospital) Services US Scrotum & Contents PX-4027687000 CDM 76870 CPT 402 RC inpatient 827 827 HEALTHPARTNERS SX009 HEALTHPARTNERS 654.82 percent of total billed charges 512.74 785.65 Technical (Hospital) Services US Scrotum & Contents PX-4027687000 CDM 76870 CPT 402 RC inpatient 827 827 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES HDHP [308136802] 654.82 percent of total billed charges 512.74 785.65 Technical (Hospital) Services US Scrotum & Contents PX-4027687000 CDM 76870 CPT 402 RC inpatient 827 827 MEDICA (COMMERCIAL) 94265 [3081118] MEDICA CLAIMS [308111801] 744.3 percent of total billed charges 512.74 785.65 Technical (Hospital) Services US Scrotum & Contents PX-4027687000 CDM 76870 CPT 402 RC inpatient 827 827 MULTIPLAN INC 34080 [3081285] MULTIPLAN INC [308128501] 785.65 percent of total billed charges 512.74 785.65 Technical (Hospital) Services US Scrotum & Contents PX-4027687000 CDM 76870 CPT 402 RC inpatient 827 827 BLUE CROSS BLUE SHIELD WELLMARK SB889 [3081026] BCBS WYOMING [308102603] 785.65 percent of total billed charges 512.74 785.65 Technical (Hospital) Services US Scrotum & Contents PX-4027687000 CDM 76870 CPT 402 RC inpatient 827 827 UNITED HEALTHCARE (COMMERCIAL) [3081199] UNITED HEALTHCARE 87726 [308119901] 512.74 percent of total billed charges 512.74 785.65 Technical (Hospital) Services US Scrotum & Contents PX-4027687000 CDM 76870 CPT 402 RC inpatient 827 827 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES PPO [308136801] 654.82 percent of total billed charges 512.74 785.65 Technical (Hospital) Services US Scrotum & Contents PX-4027687000 CDM 76870 CPT 402 RC inpatient 827 827 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES EPO [308136803] 654.82 percent of total billed charges 512.74 785.65 Technical (Hospital) Services US Scrotum & Contents PX-4027687000 CDM 76870 CPT 402 RC inpatient 827 827 CIGNA 62308 [3081051] CIGNA 62308 [308105105] 654.82 percent of total billed charges 512.74 785.65 Technical (Hospital) Services US Scrotum & Contents PX-4027687000 CDM 76870 CPT 402 RC inpatient 827 827 CIGNA 62308 [3081051] CIGNA STATE OF WYOMING [308105107] 654.82 percent of total billed charges 512.74 785.65 Technical (Hospital) Services US Scrotum & Contents PX-4027687000 CDM 76870 CPT 402 RC outpatient 827 827 MULTIPLAN INC 34080 [3081285] MULTIPLAN INC [308128501] 785.65 percent of total billed charges 512.74 785.65 Technical (Hospital) Services US Scrotum & Contents PX-4027687000 CDM 76870 CPT 402 RC outpatient 827 827 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES HDHP [308136802] 661.6 percent of total billed charges 512.74 785.65 Technical (Hospital) Services US Scrotum & Contents PX-4027687000 CDM 76870 CPT 402 RC outpatient 827 827 BLUE CROSS BLUE SHIELD WELLMARK SB889 [3081026] BCBS WYOMING [308102603] 785.65 percent of total billed charges 512.74 785.65 Technical (Hospital) Services US Scrotum & Contents PX-4027687000 CDM 76870 CPT 402 RC outpatient 827 827 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES EPO [308136803] 661.6 percent of total billed charges 512.74 785.65 Technical (Hospital) Services US Scrotum & Contents PX-4027687000 CDM 76870 CPT 402 RC outpatient 827 827 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES PPO [308136801] 661.6 percent of total billed charges 512.74 785.65 Technical (Hospital) Services US Scrotum & Contents PX-4027687000 CDM 76870 CPT 402 RC outpatient 827 827 UNITED HEALTHCARE (COMMERCIAL) [3081199] UNITED HEALTHCARE 87726 [308119901] 512.74 percent of total billed charges 512.74 785.65 Technical (Hospital) Services US Scrotum & Contents PX-4027687000 CDM 76870 CPT 402 RC outpatient 827 827 HEALTHPARTNERS SX009 HEALTHPARTNERS 661.6 percent of total billed charges 512.74 785.65 Technical (Hospital) Services US Scrotum & Contents PX-4027687000 CDM 76870 CPT 402 RC outpatient 827 827 CIGNA 62308 [3081051] CIGNA 62308 [308105105] 661.6 percent of total billed charges 512.74 785.65 Technical (Hospital) Services US Scrotum & Contents PX-4027687000 CDM 76870 CPT 402 RC outpatient 827 827 CIGNA 62308 [3081051] CIGNA STATE OF WYOMING [308105107] 661.6 percent of total billed charges 512.74 785.65 Technical (Hospital) Services US Scrotum & Contents PX-4027687000 CDM 76870 CPT 402 RC outpatient 827 827 MEDICA (COMMERCIAL) 94265 [3081118] MEDICA CLAIMS [308111801] 744.3 percent of total billed charges 512.74 785.65 Technical (Hospital) Services US Pelvic Nonobstetric Image Dcmtn Limited/F/U PX-4027685700 CDM 76857 CPT 402 RC outpatient 542 542 BLUE CROSS BLUE SHIELD WELLMARK SB889 [3081026] BCBS WYOMING [308102603] 514.9 percent of total billed charges 336.04 514.9 Technical (Hospital) Services US Pelvic Nonobstetric Image Dcmtn Limited/F/U PX-4027685700 CDM 76857 CPT 402 RC outpatient 542 542 MULTIPLAN INC 34080 [3081285] MULTIPLAN INC [308128501] 514.9 percent of total billed charges 336.04 514.9 Technical (Hospital) Services US Pelvic Nonobstetric Image Dcmtn Limited/F/U PX-4027685700 CDM 76857 CPT 402 RC outpatient 542 542 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES HDHP [308136802] 433.6 percent of total billed charges 336.04 514.9 Technical (Hospital) Services US Pelvic Nonobstetric Image Dcmtn Limited/F/U PX-4027685700 CDM 76857 CPT 402 RC outpatient 542 542 UNITED HEALTHCARE (COMMERCIAL) [3081199] UNITED HEALTHCARE 87726 [308119901] 336.04 percent of total billed charges 336.04 514.9 Technical (Hospital) Services US Pelvic Nonobstetric Image Dcmtn Limited/F/U PX-4027685700 CDM 76857 CPT 402 RC outpatient 542 542 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES EPO [308136803] 433.6 percent of total billed charges 336.04 514.9 Technical (Hospital) Services US Pelvic Nonobstetric Image Dcmtn Limited/F/U PX-4027685700 CDM 76857 CPT 402 RC outpatient 542 542 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES PPO [308136801] 433.6 percent of total billed charges 336.04 514.9 Technical (Hospital) Services US Pelvic Nonobstetric Image Dcmtn Limited/F/U PX-4027685700 CDM 76857 CPT 402 RC outpatient 542 542 MEDICA (COMMERCIAL) 94265 [3081118] MEDICA CLAIMS [308111801] 487.8 percent of total billed charges 336.04 514.9 Technical (Hospital) Services US Pelvic Nonobstetric Image Dcmtn Limited/F/U PX-4027685700 CDM 76857 CPT 402 RC outpatient 542 542 HEALTHPARTNERS SX009 HEALTHPARTNERS 433.6 percent of total billed charges 336.04 514.9 Technical (Hospital) Services US Pelvic Nonobstetric Image Dcmtn Limited/F/U PX-4027685700 CDM 76857 CPT 402 RC outpatient 542 542 CIGNA 62308 [3081051] CIGNA 62308 [308105105] 433.6 percent of total billed charges 336.04 514.9 Technical (Hospital) Services US Pelvic Nonobstetric Image Dcmtn Limited/F/U PX-4027685700 CDM 76857 CPT 402 RC outpatient 542 542 CIGNA 62308 [3081051] CIGNA STATE OF WYOMING [308105107] 433.6 percent of total billed charges 336.04 514.9 Technical (Hospital) Services US Pelvic Nonobstetric Image Dcmtn Limited/F/U PX-4027685700 CDM 76857 CPT 402 RC inpatient 542 542 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES EPO [308136803] 429.16 percent of total billed charges 336.04 514.9 Technical (Hospital) Services US Pelvic Nonobstetric Image Dcmtn Limited/F/U PX-4027685700 CDM 76857 CPT 402 RC inpatient 542 542 CIGNA 62308 [3081051] CIGNA 62308 [308105105] 429.16 percent of total billed charges 336.04 514.9 Technical (Hospital) Services US Pelvic Nonobstetric Image Dcmtn Limited/F/U PX-4027685700 CDM 76857 CPT 402 RC inpatient 542 542 CIGNA 62308 [3081051] CIGNA STATE OF WYOMING [308105107] 429.16 percent of total billed charges 336.04 514.9 Technical (Hospital) Services US Pelvic Nonobstetric Image Dcmtn Limited/F/U PX-4027685700 CDM 76857 CPT 402 RC inpatient 542 542 HEALTHPARTNERS SX009 HEALTHPARTNERS 429.16 percent of total billed charges 336.04 514.9 Technical (Hospital) Services US Pelvic Nonobstetric Image Dcmtn Limited/F/U PX-4027685700 CDM 76857 CPT 402 RC inpatient 542 542 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES HDHP [308136802] 429.16 percent of total billed charges 336.04 514.9 Technical (Hospital) Services US Pelvic Nonobstetric Image Dcmtn Limited/F/U PX-4027685700 CDM 76857 CPT 402 RC inpatient 542 542 MEDICA (COMMERCIAL) 94265 [3081118] MEDICA CLAIMS [308111801] 487.8 percent of total billed charges 336.04 514.9 Technical (Hospital) Services US Pelvic Nonobstetric Image Dcmtn Limited/F/U PX-4027685700 CDM 76857 CPT 402 RC inpatient 542 542 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES PPO [308136801] 429.16 percent of total billed charges 336.04 514.9 Technical (Hospital) Services US Pelvic Nonobstetric Image Dcmtn Limited/F/U PX-4027685700 CDM 76857 CPT 402 RC inpatient 542 542 UNITED HEALTHCARE (COMMERCIAL) [3081199] UNITED HEALTHCARE 87726 [308119901] 336.04 percent of total billed charges 336.04 514.9 Technical (Hospital) Services US Pelvic Nonobstetric Image Dcmtn Limited/F/U PX-4027685700 CDM 76857 CPT 402 RC inpatient 542 542 BLUE CROSS BLUE SHIELD WELLMARK SB889 [3081026] BCBS WYOMING [308102603] 514.9 percent of total billed charges 336.04 514.9 Technical (Hospital) Services US Pelvic Nonobstetric Image Dcmtn Limited/F/U PX-4027685700 CDM 76857 CPT 402 RC inpatient 542 542 MULTIPLAN INC 34080 [3081285] MULTIPLAN INC [308128501] 514.9 percent of total billed charges 336.04 514.9 Technical (Hospital) Services US Pelvic Nonobstetric Real-Time Image Complete PX-4027685600 CDM 76856 CPT 402 RC outpatient 1092 1092 CIGNA 62308 [3081051] CIGNA 62308 [308105105] 873.6 percent of total billed charges 677.04 1037.4 Technical (Hospital) Services US Pelvic Nonobstetric Real-Time Image Complete PX-4027685600 CDM 76856 CPT 402 RC outpatient 1092 1092 CIGNA 62308 [3081051] CIGNA STATE OF WYOMING [308105107] 873.6 percent of total billed charges 677.04 1037.4 Technical (Hospital) Services US Pelvic Nonobstetric Real-Time Image Complete PX-4027685600 CDM 76856 CPT 402 RC outpatient 1092 1092 MEDICA (COMMERCIAL) 94265 [3081118] MEDICA CLAIMS [308111801] 982.8 percent of total billed charges 677.04 1037.4 Technical (Hospital) Services US Pelvic Nonobstetric Real-Time Image Complete PX-4027685600 CDM 76856 CPT 402 RC outpatient 1092 1092 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES HDHP [308136802] 873.6 percent of total billed charges 677.04 1037.4 Technical (Hospital) Services US Pelvic Nonobstetric Real-Time Image Complete PX-4027685600 CDM 76856 CPT 402 RC outpatient 1092 1092 MULTIPLAN INC 34080 [3081285] MULTIPLAN INC [308128501] 1037.4 percent of total billed charges 677.04 1037.4 Technical (Hospital) Services US Pelvic Nonobstetric Real-Time Image Complete PX-4027685600 CDM 76856 CPT 402 RC outpatient 1092 1092 BLUE CROSS BLUE SHIELD WELLMARK SB889 [3081026] BCBS WYOMING [308102603] 1037.4 percent of total billed charges 677.04 1037.4 Technical (Hospital) Services US Pelvic Nonobstetric Real-Time Image Complete PX-4027685600 CDM 76856 CPT 402 RC outpatient 1092 1092 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES PPO [308136801] 873.6 percent of total billed charges 677.04 1037.4 Technical (Hospital) Services US Pelvic Nonobstetric Real-Time Image Complete PX-4027685600 CDM 76856 CPT 402 RC outpatient 1092 1092 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES EPO [308136803] 873.6 percent of total billed charges 677.04 1037.4 Technical (Hospital) Services US Pelvic Nonobstetric Real-Time Image Complete PX-4027685600 CDM 76856 CPT 402 RC outpatient 1092 1092 UNITED HEALTHCARE (COMMERCIAL) [3081199] UNITED HEALTHCARE 87726 [308119901] 677.04 percent of total billed charges 677.04 1037.4 Technical (Hospital) Services US Pelvic Nonobstetric Real-Time Image Complete PX-4027685600 CDM 76856 CPT 402 RC outpatient 1092 1092 HEALTHPARTNERS SX009 HEALTHPARTNERS 873.6 percent of total billed charges 677.04 1037.4 Technical (Hospital) Services US Pelvic Nonobstetric Real-Time Image Complete PX-4027685600 CDM 76856 CPT 402 RC inpatient 1092 1092 BLUE CROSS BLUE SHIELD WELLMARK SB889 [3081026] BCBS WYOMING [308102603] 1037.4 percent of total billed charges 677.04 1037.4 Technical (Hospital) Services US Pelvic Nonobstetric Real-Time Image Complete PX-4027685600 CDM 76856 CPT 402 RC inpatient 1092 1092 MULTIPLAN INC 34080 [3081285] MULTIPLAN INC [308128501] 1037.4 percent of total billed charges 677.04 1037.4 Technical (Hospital) Services US Pelvic Nonobstetric Real-Time Image Complete PX-4027685600 CDM 76856 CPT 402 RC inpatient 1092 1092 UNITED HEALTHCARE (COMMERCIAL) [3081199] UNITED HEALTHCARE 87726 [308119901] 677.04 percent of total billed charges 677.04 1037.4 Technical (Hospital) Services US Pelvic Nonobstetric Real-Time Image Complete PX-4027685600 CDM 76856 CPT 402 RC inpatient 1092 1092 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES PPO [308136801] 864.65 percent of total billed charges 677.04 1037.4 Technical (Hospital) Services US Pelvic Nonobstetric Real-Time Image Complete PX-4027685600 CDM 76856 CPT 402 RC inpatient 1092 1092 HEALTHPARTNERS SX009 HEALTHPARTNERS 864.65 percent of total billed charges 677.04 1037.4 Technical (Hospital) Services US Pelvic Nonobstetric Real-Time Image Complete PX-4027685600 CDM 76856 CPT 402 RC inpatient 1092 1092 MEDICA (COMMERCIAL) 94265 [3081118] MEDICA CLAIMS [308111801] 982.8 percent of total billed charges 677.04 1037.4 Technical (Hospital) Services US Pelvic Nonobstetric Real-Time Image Complete PX-4027685600 CDM 76856 CPT 402 RC inpatient 1092 1092 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES HDHP [308136802] 864.65 percent of total billed charges 677.04 1037.4 Technical (Hospital) Services US Pelvic Nonobstetric Real-Time Image Complete PX-4027685600 CDM 76856 CPT 402 RC inpatient 1092 1092 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES EPO [308136803] 864.65 percent of total billed charges 677.04 1037.4 Technical (Hospital) Services US Pelvic Nonobstetric Real-Time Image Complete PX-4027685600 CDM 76856 CPT 402 RC inpatient 1092 1092 CIGNA 62308 [3081051] CIGNA 62308 [308105105] 864.65 percent of total billed charges 677.04 1037.4 Technical (Hospital) Services US Pelvic Nonobstetric Real-Time Image Complete PX-4027685600 CDM 76856 CPT 402 RC inpatient 1092 1092 CIGNA 62308 [3081051] CIGNA STATE OF WYOMING [308105107] 864.65 percent of total billed charges 677.04 1037.4 Technical (Hospital) Services US Transvaginal PX-4027683000 CDM 76830 CPT 402 RC inpatient 595 595 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES EPO [308136803] 471.12 percent of total billed charges 368.9 565.25 Technical (Hospital) Services US Transvaginal PX-4027683000 CDM 76830 CPT 402 RC inpatient 595 595 CIGNA 62308 [3081051] CIGNA 62308 [308105105] 471.12 percent of total billed charges 368.9 565.25 Technical (Hospital) Services US Transvaginal PX-4027683000 CDM 76830 CPT 402 RC inpatient 595 595 CIGNA 62308 [3081051] CIGNA STATE OF WYOMING [308105107] 471.12 percent of total billed charges 368.9 565.25 Technical (Hospital) Services US Transvaginal PX-4027683000 CDM 76830 CPT 402 RC inpatient 595 595 HEALTHPARTNERS SX009 HEALTHPARTNERS 471.12 percent of total billed charges 368.9 565.25 Technical (Hospital) Services US Transvaginal PX-4027683000 CDM 76830 CPT 402 RC inpatient 595 595 MEDICA (COMMERCIAL) 94265 [3081118] MEDICA CLAIMS [308111801] 535.5 percent of total billed charges 368.9 565.25 Technical (Hospital) Services US Transvaginal PX-4027683000 CDM 76830 CPT 402 RC inpatient 595 595 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES HDHP [308136802] 471.12 percent of total billed charges 368.9 565.25 Technical (Hospital) Services US Transvaginal PX-4027683000 CDM 76830 CPT 402 RC inpatient 595 595 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES PPO [308136801] 471.12 percent of total billed charges 368.9 565.25 Technical (Hospital) Services US Transvaginal PX-4027683000 CDM 76830 CPT 402 RC inpatient 595 595 UNITED HEALTHCARE (COMMERCIAL) [3081199] UNITED HEALTHCARE 87726 [308119901] 368.9 percent of total billed charges 368.9 565.25 Technical (Hospital) Services US Transvaginal PX-4027683000 CDM 76830 CPT 402 RC inpatient 595 595 BLUE CROSS BLUE SHIELD WELLMARK SB889 [3081026] BCBS WYOMING [308102603] 565.25 percent of total billed charges 368.9 565.25 Technical (Hospital) Services US Transvaginal PX-4027683000 CDM 76830 CPT 402 RC inpatient 595 595 MULTIPLAN INC 34080 [3081285] MULTIPLAN INC [308128501] 565.25 percent of total billed charges 368.9 565.25 Technical (Hospital) Services US Transvaginal PX-4027683000 CDM 76830 CPT 402 RC outpatient 595 595 MEDICA (COMMERCIAL) 94265 [3081118] MEDICA CLAIMS [308111801] 535.5 percent of total billed charges 368.9 565.25 Technical (Hospital) Services US Transvaginal PX-4027683000 CDM 76830 CPT 402 RC outpatient 595 595 CIGNA 62308 [3081051] CIGNA 62308 [308105105] 476 percent of total billed charges 368.9 565.25 Technical (Hospital) Services US Transvaginal PX-4027683000 CDM 76830 CPT 402 RC outpatient 595 595 CIGNA 62308 [3081051] CIGNA STATE OF WYOMING [308105107] 476 percent of total billed charges 368.9 565.25 Technical (Hospital) Services US Transvaginal PX-4027683000 CDM 76830 CPT 402 RC outpatient 595 595 HEALTHPARTNERS SX009 HEALTHPARTNERS 476 percent of total billed charges 368.9 565.25 Technical (Hospital) Services US Transvaginal PX-4027683000 CDM 76830 CPT 402 RC outpatient 595 595 UNITED HEALTHCARE (COMMERCIAL) [3081199] UNITED HEALTHCARE 87726 [308119901] 368.9 percent of total billed charges 368.9 565.25 Technical (Hospital) Services US Transvaginal PX-4027683000 CDM 76830 CPT 402 RC outpatient 595 595 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES PPO [308136801] 476 percent of total billed charges 368.9 565.25 Technical (Hospital) Services US Transvaginal PX-4027683000 CDM 76830 CPT 402 RC outpatient 595 595 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES EPO [308136803] 476 percent of total billed charges 368.9 565.25 Technical (Hospital) Services US Transvaginal PX-4027683000 CDM 76830 CPT 402 RC outpatient 595 595 BLUE CROSS BLUE SHIELD WELLMARK SB889 [3081026] BCBS WYOMING [308102603] 565.25 percent of total billed charges 368.9 565.25 Technical (Hospital) Services US Transvaginal PX-4027683000 CDM 76830 CPT 402 RC outpatient 595 595 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES HDHP [308136802] 476 percent of total billed charges 368.9 565.25 Technical (Hospital) Services US Transvaginal PX-4027683000 CDM 76830 CPT 402 RC outpatient 595 595 MULTIPLAN INC 34080 [3081285] MULTIPLAN INC [308128501] 565.25 percent of total billed charges 368.9 565.25 Technical (Hospital) Services Fetal Biophysical Profile W/O Non-Stress Testing PX-4027681900 CDM 76819 CPT 402 RC inpatient 725 725 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES EPO [308136803] 574.06 percent of total billed charges 449.5 688.75 Technical (Hospital) Services Fetal Biophysical Profile W/O Non-Stress Testing PX-4027681900 CDM 76819 CPT 402 RC inpatient 725 725 CIGNA 62308 [3081051] CIGNA 62308 [308105105] 574.06 percent of total billed charges 449.5 688.75 Technical (Hospital) Services Fetal Biophysical Profile W/O Non-Stress Testing PX-4027681900 CDM 76819 CPT 402 RC inpatient 725 725 CIGNA 62308 [3081051] CIGNA STATE OF WYOMING [308105107] 574.06 percent of total billed charges 449.5 688.75 Technical (Hospital) Services Fetal Biophysical Profile W/O Non-Stress Testing PX-4027681900 CDM 76819 CPT 402 RC inpatient 725 725 MULTIPLAN INC 34080 [3081285] MULTIPLAN INC [308128501] 688.75 percent of total billed charges 449.5 688.75 Technical (Hospital) Services Fetal Biophysical Profile W/O Non-Stress Testing PX-4027681900 CDM 76819 CPT 402 RC inpatient 725 725 BLUE CROSS BLUE SHIELD WELLMARK SB889 [3081026] BCBS WYOMING [308102603] 688.75 percent of total billed charges 449.5 688.75 Technical (Hospital) Services Fetal Biophysical Profile W/O Non-Stress Testing PX-4027681900 CDM 76819 CPT 402 RC inpatient 725 725 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES HDHP [308136802] 574.06 percent of total billed charges 449.5 688.75 Technical (Hospital) Services Fetal Biophysical Profile W/O Non-Stress Testing PX-4027681900 CDM 76819 CPT 402 RC inpatient 725 725 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES PPO [308136801] 574.06 percent of total billed charges 449.5 688.75 Technical (Hospital) Services Fetal Biophysical Profile W/O Non-Stress Testing PX-4027681900 CDM 76819 CPT 402 RC inpatient 725 725 UNITED HEALTHCARE (COMMERCIAL) [3081199] UNITED HEALTHCARE 87726 [308119901] 449.5 percent of total billed charges 449.5 688.75 Technical (Hospital) Services Fetal Biophysical Profile W/O Non-Stress Testing PX-4027681900 CDM 76819 CPT 402 RC inpatient 725 725 MEDICA (COMMERCIAL) 94265 [3081118] MEDICA CLAIMS [308111801] 652.5 percent of total billed charges 449.5 688.75 Technical (Hospital) Services Fetal Biophysical Profile W/O Non-Stress Testing PX-4027681900 CDM 76819 CPT 402 RC inpatient 725 725 HEALTHPARTNERS SX009 HEALTHPARTNERS 574.06 percent of total billed charges 449.5 688.75 Technical (Hospital) Services Fetal Biophysical Profile W/O Non-Stress Testing PX-4027681900 CDM 76819 CPT 402 RC outpatient 725 725 CIGNA 62308 [3081051] CIGNA 62308 [308105105] 580 percent of total billed charges 449.5 688.75 Technical (Hospital) Services Fetal Biophysical Profile W/O Non-Stress Testing PX-4027681900 CDM 76819 CPT 402 RC outpatient 725 725 CIGNA 62308 [3081051] CIGNA STATE OF WYOMING [308105107] 580 percent of total billed charges 449.5 688.75 Technical (Hospital) Services Fetal Biophysical Profile W/O Non-Stress Testing PX-4027681900 CDM 76819 CPT 402 RC outpatient 725 725 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES EPO [308136803] 580 percent of total billed charges 449.5 688.75 Technical (Hospital) Services Fetal Biophysical Profile W/O Non-Stress Testing PX-4027681900 CDM 76819 CPT 402 RC outpatient 725 725 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES PPO [308136801] 580 percent of total billed charges 449.5 688.75 Technical (Hospital) Services Fetal Biophysical Profile W/O Non-Stress Testing PX-4027681900 CDM 76819 CPT 402 RC outpatient 725 725 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES HDHP [308136802] 580 percent of total billed charges 449.5 688.75 Technical (Hospital) Services Fetal Biophysical Profile W/O Non-Stress Testing PX-4027681900 CDM 76819 CPT 402 RC outpatient 725 725 MULTIPLAN INC 34080 [3081285] MULTIPLAN INC [308128501] 688.75 percent of total billed charges 449.5 688.75 Technical (Hospital) Services Fetal Biophysical Profile W/O Non-Stress Testing PX-4027681900 CDM 76819 CPT 402 RC outpatient 725 725 BLUE CROSS BLUE SHIELD WELLMARK SB889 [3081026] BCBS WYOMING [308102603] 688.75 percent of total billed charges 449.5 688.75 Technical (Hospital) Services Fetal Biophysical Profile W/O Non-Stress Testing PX-4027681900 CDM 76819 CPT 402 RC outpatient 725 725 MEDICA (COMMERCIAL) 94265 [3081118] MEDICA CLAIMS [308111801] 652.5 percent of total billed charges 449.5 688.75 Technical (Hospital) Services Fetal Biophysical Profile W/O Non-Stress Testing PX-4027681900 CDM 76819 CPT 402 RC outpatient 725 725 HEALTHPARTNERS SX009 HEALTHPARTNERS 580 percent of total billed charges 449.5 688.75 Technical (Hospital) Services Fetal Biophysical Profile W/O Non-Stress Testing PX-4027681900 CDM 76819 CPT 402 RC outpatient 725 725 UNITED HEALTHCARE (COMMERCIAL) [3081199] UNITED HEALTHCARE 87726 [308119901] 449.5 percent of total billed charges 449.5 688.75 Technical (Hospital) Services Fetal Biophysical Profile W/O Non-Stress Testing PX-4027681800 CDM 76818 CPT 402 RC inpatient 748 748 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES EPO [308136803] 592.27 percent of total billed charges 463.76 710.6 Technical (Hospital) Services Fetal Biophysical Profile W/O Non-Stress Testing PX-4027681800 CDM 76818 CPT 402 RC inpatient 748 748 CIGNA 62308 [3081051] CIGNA 62308 [308105105] 592.27 percent of total billed charges 463.76 710.6 Technical (Hospital) Services Fetal Biophysical Profile W/O Non-Stress Testing PX-4027681800 CDM 76818 CPT 402 RC inpatient 748 748 CIGNA 62308 [3081051] CIGNA STATE OF WYOMING [308105107] 592.27 percent of total billed charges 463.76 710.6 Technical (Hospital) Services Fetal Biophysical Profile W/O Non-Stress Testing PX-4027681800 CDM 76818 CPT 402 RC inpatient 748 748 UNITED HEALTHCARE (COMMERCIAL) [3081199] UNITED HEALTHCARE 87726 [308119901] 463.76 percent of total billed charges 463.76 710.6 Technical (Hospital) Services Fetal Biophysical Profile W/O Non-Stress Testing PX-4027681800 CDM 76818 CPT 402 RC inpatient 748 748 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES PPO [308136801] 592.27 percent of total billed charges 463.76 710.6 Technical (Hospital) Services Fetal Biophysical Profile W/O Non-Stress Testing PX-4027681800 CDM 76818 CPT 402 RC inpatient 748 748 MULTIPLAN INC 34080 [3081285] MULTIPLAN INC [308128501] 710.6 percent of total billed charges 463.76 710.6 Technical (Hospital) Services Fetal Biophysical Profile W/O Non-Stress Testing PX-4027681800 CDM 76818 CPT 402 RC inpatient 748 748 BLUE CROSS BLUE SHIELD WELLMARK SB889 [3081026] BCBS WYOMING [308102603] 710.6 percent of total billed charges 463.76 710.6 Technical (Hospital) Services Fetal Biophysical Profile W/O Non-Stress Testing PX-4027681800 CDM 76818 CPT 402 RC inpatient 748 748 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES HDHP [308136802] 592.27 percent of total billed charges 463.76 710.6 Technical (Hospital) Services Fetal Biophysical Profile W/O Non-Stress Testing PX-4027681800 CDM 76818 CPT 402 RC inpatient 748 748 MEDICA (COMMERCIAL) 94265 [3081118] MEDICA CLAIMS [308111801] 673.2 percent of total billed charges 463.76 710.6 Technical (Hospital) Services Fetal Biophysical Profile W/O Non-Stress Testing PX-4027681800 CDM 76818 CPT 402 RC inpatient 748 748 HEALTHPARTNERS SX009 HEALTHPARTNERS 592.27 percent of total billed charges 463.76 710.6 Technical (Hospital) Services Fetal Biophysical Profile W/O Non-Stress Testing PX-4027681800 CDM 76818 CPT 402 RC outpatient 748 748 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES PPO [308136801] 598.4 percent of total billed charges 463.76 710.6 Technical (Hospital) Services Fetal Biophysical Profile W/O Non-Stress Testing PX-4027681800 CDM 76818 CPT 402 RC outpatient 748 748 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES EPO [308136803] 598.4 percent of total billed charges 463.76 710.6 Technical (Hospital) Services Fetal Biophysical Profile W/O Non-Stress Testing PX-4027681800 CDM 76818 CPT 402 RC outpatient 748 748 BLUE CROSS BLUE SHIELD WELLMARK SB889 [3081026] BCBS WYOMING [308102603] 710.6 percent of total billed charges 463.76 710.6 Technical (Hospital) Services Fetal Biophysical Profile W/O Non-Stress Testing PX-4027681800 CDM 76818 CPT 402 RC outpatient 748 748 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES HDHP [308136802] 598.4 percent of total billed charges 463.76 710.6 Technical (Hospital) Services Fetal Biophysical Profile W/O Non-Stress Testing PX-4027681800 CDM 76818 CPT 402 RC outpatient 748 748 MULTIPLAN INC 34080 [3081285] MULTIPLAN INC [308128501] 710.6 percent of total billed charges 463.76 710.6 Technical (Hospital) Services Fetal Biophysical Profile W/O Non-Stress Testing PX-4027681800 CDM 76818 CPT 402 RC outpatient 748 748 HEALTHPARTNERS SX009 HEALTHPARTNERS 598.4 percent of total billed charges 463.76 710.6 Technical (Hospital) Services Fetal Biophysical Profile W/O Non-Stress Testing PX-4027681800 CDM 76818 CPT 402 RC outpatient 748 748 UNITED HEALTHCARE (COMMERCIAL) [3081199] UNITED HEALTHCARE 87726 [308119901] 463.76 percent of total billed charges 463.76 710.6 Technical (Hospital) Services Fetal Biophysical Profile W/O Non-Stress Testing PX-4027681800 CDM 76818 CPT 402 RC outpatient 748 748 MEDICA (COMMERCIAL) 94265 [3081118] MEDICA CLAIMS [308111801] 673.2 percent of total billed charges 463.76 710.6 Technical (Hospital) Services Fetal Biophysical Profile W/O Non-Stress Testing PX-4027681800 CDM 76818 CPT 402 RC outpatient 748 748 CIGNA 62308 [3081051] CIGNA 62308 [308105105] 598.4 percent of total billed charges 463.76 710.6 Technical (Hospital) Services Fetal Biophysical Profile W/O Non-Stress Testing PX-4027681800 CDM 76818 CPT 402 RC outpatient 748 748 CIGNA 62308 [3081051] CIGNA STATE OF WYOMING [308105107] 598.4 percent of total billed charges 463.76 710.6 Technical (Hospital) Services US Preg Uterus Real Time W/Image Dcmtn Transvag PX-4027681700 CDM 76817 CPT 402 RC inpatient 641 641 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES EPO [308136803] 507.54 percent of total billed charges 397.42 608.95 Technical (Hospital) Services US Preg Uterus Real Time W/Image Dcmtn Transvag PX-4027681700 CDM 76817 CPT 402 RC inpatient 641 641 CIGNA 62308 [3081051] CIGNA 62308 [308105105] 507.54 percent of total billed charges 397.42 608.95 Technical (Hospital) Services US Preg Uterus Real Time W/Image Dcmtn Transvag PX-4027681700 CDM 76817 CPT 402 RC inpatient 641 641 CIGNA 62308 [3081051] CIGNA STATE OF WYOMING [308105107] 507.54 percent of total billed charges 397.42 608.95 Technical (Hospital) Services US Preg Uterus Real Time W/Image Dcmtn Transvag PX-4027681700 CDM 76817 CPT 402 RC inpatient 641 641 BLUE CROSS BLUE SHIELD WELLMARK SB889 [3081026] BCBS WYOMING [308102603] 608.95 percent of total billed charges 397.42 608.95 Technical (Hospital) Services US Preg Uterus Real Time W/Image Dcmtn Transvag PX-4027681700 CDM 76817 CPT 402 RC inpatient 641 641 MULTIPLAN INC 34080 [3081285] MULTIPLAN INC [308128501] 608.95 percent of total billed charges 397.42 608.95 Technical (Hospital) Services US Preg Uterus Real Time W/Image Dcmtn Transvag PX-4027681700 CDM 76817 CPT 402 RC inpatient 641 641 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES PPO [308136801] 507.54 percent of total billed charges 397.42 608.95 Technical (Hospital) Services US Preg Uterus Real Time W/Image Dcmtn Transvag PX-4027681700 CDM 76817 CPT 402 RC inpatient 641 641 UNITED HEALTHCARE (COMMERCIAL) [3081199] UNITED HEALTHCARE 87726 [308119901] 397.42 percent of total billed charges 397.42 608.95 Technical (Hospital) Services US Preg Uterus Real Time W/Image Dcmtn Transvag PX-4027681700 CDM 76817 CPT 402 RC inpatient 641 641 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES HDHP [308136802] 507.54 percent of total billed charges 397.42 608.95 Technical (Hospital) Services US Preg Uterus Real Time W/Image Dcmtn Transvag PX-4027681700 CDM 76817 CPT 402 RC inpatient 641 641 MEDICA (COMMERCIAL) 94265 [3081118] MEDICA CLAIMS [308111801] 576.9 percent of total billed charges 397.42 608.95 Technical (Hospital) Services US Preg Uterus Real Time W/Image Dcmtn Transvag PX-4027681700 CDM 76817 CPT 402 RC inpatient 641 641 HEALTHPARTNERS SX009 HEALTHPARTNERS 507.54 percent of total billed charges 397.42 608.95 Technical (Hospital) Services US Preg Uterus Real Time W/Image Dcmtn Transvag PX-4027681700 CDM 76817 CPT 402 RC outpatient 641 641 CIGNA 62308 [3081051] CIGNA 62308 [308105105] 512.8 percent of total billed charges 397.42 608.95 Technical (Hospital) Services US Preg Uterus Real Time W/Image Dcmtn Transvag PX-4027681700 CDM 76817 CPT 402 RC outpatient 641 641 CIGNA 62308 [3081051] CIGNA STATE OF WYOMING [308105107] 512.8 percent of total billed charges 397.42 608.95 Technical (Hospital) Services US Preg Uterus Real Time W/Image Dcmtn Transvag PX-4027681700 CDM 76817 CPT 402 RC outpatient 641 641 MEDICA (COMMERCIAL) 94265 [3081118] MEDICA CLAIMS [308111801] 576.9 percent of total billed charges 397.42 608.95 Technical (Hospital) Services US Preg Uterus Real Time W/Image Dcmtn Transvag PX-4027681700 CDM 76817 CPT 402 RC outpatient 641 641 BLUE CROSS BLUE SHIELD WELLMARK SB889 [3081026] BCBS WYOMING [308102603] 608.95 percent of total billed charges 397.42 608.95 Technical (Hospital) Services US Preg Uterus Real Time W/Image Dcmtn Transvag PX-4027681700 CDM 76817 CPT 402 RC outpatient 641 641 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES HDHP [308136802] 512.8 percent of total billed charges 397.42 608.95 Technical (Hospital) Services US Preg Uterus Real Time W/Image Dcmtn Transvag PX-4027681700 CDM 76817 CPT 402 RC outpatient 641 641 MULTIPLAN INC 34080 [3081285] MULTIPLAN INC [308128501] 608.95 percent of total billed charges 397.42 608.95 Technical (Hospital) Services US Preg Uterus Real Time W/Image Dcmtn Transvag PX-4027681700 CDM 76817 CPT 402 RC outpatient 641 641 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES PPO [308136801] 512.8 percent of total billed charges 397.42 608.95 Technical (Hospital) Services US Preg Uterus Real Time W/Image Dcmtn Transvag PX-4027681700 CDM 76817 CPT 402 RC outpatient 641 641 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES EPO [308136803] 512.8 percent of total billed charges 397.42 608.95 Technical (Hospital) Services US Preg Uterus Real Time W/Image Dcmtn Transvag PX-4027681700 CDM 76817 CPT 402 RC outpatient 641 641 HEALTHPARTNERS SX009 HEALTHPARTNERS 512.8 percent of total billed charges 397.42 608.95 Technical (Hospital) Services US Preg Uterus Real Time W/Image Dcmtn Transvag PX-4027681700 CDM 76817 CPT 402 RC outpatient 641 641 UNITED HEALTHCARE (COMMERCIAL) [3081199] UNITED HEALTHCARE 87726 [308119901] 397.42 percent of total billed charges 397.42 608.95 Technical (Hospital) Services US Preg Uterus Real Time F/U Trnsabdl per Fetus PX-4027681600 CDM 76816 CPT 402 RC outpatient 494 494 CIGNA 62308 [3081051] CIGNA 62308 [308105105] 395.2 percent of total billed charges 306.28 469.3 Technical (Hospital) Services US Preg Uterus Real Time F/U Trnsabdl per Fetus PX-4027681600 CDM 76816 CPT 402 RC outpatient 494 494 CIGNA 62308 [3081051] CIGNA STATE OF WYOMING [308105107] 395.2 percent of total billed charges 306.28 469.3 Technical (Hospital) Services US Preg Uterus Real Time F/U Trnsabdl per Fetus PX-4027681600 CDM 76816 CPT 402 RC outpatient 494 494 MEDICA (COMMERCIAL) 94265 [3081118] MEDICA CLAIMS [308111801] 444.6 percent of total billed charges 306.28 469.3 Technical (Hospital) Services US Preg Uterus Real Time F/U Trnsabdl per Fetus PX-4027681600 CDM 76816 CPT 402 RC outpatient 494 494 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES HDHP [308136802] 395.2 percent of total billed charges 306.28 469.3 Technical (Hospital) Services US Preg Uterus Real Time F/U Trnsabdl per Fetus PX-4027681600 CDM 76816 CPT 402 RC outpatient 494 494 MULTIPLAN INC 34080 [3081285] MULTIPLAN INC [308128501] 469.3 percent of total billed charges 306.28 469.3 Technical (Hospital) Services US Preg Uterus Real Time F/U Trnsabdl per Fetus PX-4027681600 CDM 76816 CPT 402 RC outpatient 494 494 BLUE CROSS BLUE SHIELD WELLMARK SB889 [3081026] BCBS WYOMING [308102603] 469.3 percent of total billed charges 306.28 469.3 Technical (Hospital) Services US Preg Uterus Real Time F/U Trnsabdl per Fetus PX-4027681600 CDM 76816 CPT 402 RC outpatient 494 494 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES PPO [308136801] 395.2 percent of total billed charges 306.28 469.3 Technical (Hospital) Services US Preg Uterus Real Time F/U Trnsabdl per Fetus PX-4027681600 CDM 76816 CPT 402 RC outpatient 494 494 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES EPO [308136803] 395.2 percent of total billed charges 306.28 469.3 Technical (Hospital) Services US Preg Uterus Real Time F/U Trnsabdl per Fetus PX-4027681600 CDM 76816 CPT 402 RC outpatient 494 494 UNITED HEALTHCARE (COMMERCIAL) [3081199] UNITED HEALTHCARE 87726 [308119901] 306.28 percent of total billed charges 306.28 469.3 Technical (Hospital) Services US Preg Uterus Real Time F/U Trnsabdl per Fetus PX-4027681600 CDM 76816 CPT 402 RC outpatient 494 494 HEALTHPARTNERS SX009 HEALTHPARTNERS 395.2 percent of total billed charges 306.28 469.3 Technical (Hospital) Services US Preg Uterus Real Time F/U Trnsabdl per Fetus PX-4027681600 CDM 76816 CPT 402 RC inpatient 494 494 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES HDHP [308136802] 391.15 percent of total billed charges 306.28 469.3 Technical (Hospital) Services US Preg Uterus Real Time F/U Trnsabdl per Fetus PX-4027681600 CDM 76816 CPT 402 RC inpatient 494 494 MULTIPLAN INC 34080 [3081285] MULTIPLAN INC [308128501] 469.3 percent of total billed charges 306.28 469.3 Technical (Hospital) Services US Preg Uterus Real Time F/U Trnsabdl per Fetus PX-4027681600 CDM 76816 CPT 402 RC inpatient 494 494 BLUE CROSS BLUE SHIELD WELLMARK SB889 [3081026] BCBS WYOMING [308102603] 469.3 percent of total billed charges 306.28 469.3 Technical (Hospital) Services US Preg Uterus Real Time F/U Trnsabdl per Fetus PX-4027681600 CDM 76816 CPT 402 RC inpatient 494 494 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES PPO [308136801] 391.15 percent of total billed charges 306.28 469.3 Technical (Hospital) Services US Preg Uterus Real Time F/U Trnsabdl per Fetus PX-4027681600 CDM 76816 CPT 402 RC inpatient 494 494 UNITED HEALTHCARE (COMMERCIAL) [3081199] UNITED HEALTHCARE 87726 [308119901] 306.28 percent of total billed charges 306.28 469.3 Technical (Hospital) Services US Preg Uterus Real Time F/U Trnsabdl per Fetus PX-4027681600 CDM 76816 CPT 402 RC inpatient 494 494 MEDICA (COMMERCIAL) 94265 [3081118] MEDICA CLAIMS [308111801] 444.6 percent of total billed charges 306.28 469.3 Technical (Hospital) Services US Preg Uterus Real Time F/U Trnsabdl per Fetus PX-4027681600 CDM 76816 CPT 402 RC inpatient 494 494 HEALTHPARTNERS SX009 HEALTHPARTNERS 391.15 percent of total billed charges 306.28 469.3 Technical (Hospital) Services US Preg Uterus Real Time F/U Trnsabdl per Fetus PX-4027681600 CDM 76816 CPT 402 RC inpatient 494 494 CIGNA 62308 [3081051] CIGNA 62308 [308105105] 391.15 percent of total billed charges 306.28 469.3 Technical (Hospital) Services US Preg Uterus Real Time F/U Trnsabdl per Fetus PX-4027681600 CDM 76816 CPT 402 RC inpatient 494 494 CIGNA 62308 [3081051] CIGNA STATE OF WYOMING [308105107] 391.15 percent of total billed charges 306.28 469.3 Technical (Hospital) Services US Preg Uterus Real Time F/U Trnsabdl per Fetus PX-4027681600 CDM 76816 CPT 402 RC inpatient 494 494 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES EPO [308136803] 391.15 percent of total billed charges 306.28 469.3 Technical (Hospital) Services US Pregnant Uterus Limited 1/> Fetuses PX-4027681500 CDM 76815 CPT 402 RC outpatient 551 551 BLUE CROSS BLUE SHIELD WELLMARK SB889 [3081026] BCBS WYOMING [308102603] 523.45 percent of total billed charges 341.62 523.45 Technical (Hospital) Services US Pregnant Uterus Limited 1/> Fetuses PX-4027681500 CDM 76815 CPT 402 RC outpatient 551 551 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES HDHP [308136802] 440.8 percent of total billed charges 341.62 523.45 Technical (Hospital) Services US Pregnant Uterus Limited 1/> Fetuses PX-4027681500 CDM 76815 CPT 402 RC outpatient 551 551 MULTIPLAN INC 34080 [3081285] MULTIPLAN INC [308128501] 523.45 percent of total billed charges 341.62 523.45 Technical (Hospital) Services US Pregnant Uterus Limited 1/> Fetuses PX-4027681500 CDM 76815 CPT 402 RC outpatient 551 551 UNITED HEALTHCARE (COMMERCIAL) [3081199] UNITED HEALTHCARE 87726 [308119901] 341.62 percent of total billed charges 341.62 523.45 Technical (Hospital) Services US Pregnant Uterus Limited 1/> Fetuses PX-4027681500 CDM 76815 CPT 402 RC outpatient 551 551 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES PPO [308136801] 440.8 percent of total billed charges 341.62 523.45 Technical (Hospital) Services US Pregnant Uterus Limited 1/> Fetuses PX-4027681500 CDM 76815 CPT 402 RC outpatient 551 551 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES EPO [308136803] 440.8 percent of total billed charges 341.62 523.45 Technical (Hospital) Services US Pregnant Uterus Limited 1/> Fetuses PX-4027681500 CDM 76815 CPT 402 RC outpatient 551 551 MEDICA (COMMERCIAL) 94265 [3081118] MEDICA CLAIMS [308111801] 495.9 percent of total billed charges 341.62 523.45 Technical (Hospital) Services US Pregnant Uterus Limited 1/> Fetuses PX-4027681500 CDM 76815 CPT 402 RC outpatient 551 551 HEALTHPARTNERS SX009 HEALTHPARTNERS 440.8 percent of total billed charges 341.62 523.45 Technical (Hospital) Services US Pregnant Uterus Limited 1/> Fetuses PX-4027681500 CDM 76815 CPT 402 RC outpatient 551 551 CIGNA 62308 [3081051] CIGNA 62308 [308105105] 440.8 percent of total billed charges 341.62 523.45 Technical (Hospital) Services US Pregnant Uterus Limited 1/> Fetuses PX-4027681500 CDM 76815 CPT 402 RC outpatient 551 551 CIGNA 62308 [3081051] CIGNA STATE OF WYOMING [308105107] 440.8 percent of total billed charges 341.62 523.45 Technical (Hospital) Services US Pregnant Uterus Limited 1/> Fetuses PX-4027681500 CDM 76815 CPT 402 RC inpatient 551 551 CIGNA 62308 [3081051] CIGNA 62308 [308105105] 436.28 percent of total billed charges 341.62 523.45 Technical (Hospital) Services US Pregnant Uterus Limited 1/> Fetuses PX-4027681500 CDM 76815 CPT 402 RC inpatient 551 551 CIGNA 62308 [3081051] CIGNA STATE OF WYOMING [308105107] 436.28 percent of total billed charges 341.62 523.45 Technical (Hospital) Services US Pregnant Uterus Limited 1/> Fetuses PX-4027681500 CDM 76815 CPT 402 RC inpatient 551 551 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES EPO [308136803] 436.28 percent of total billed charges 341.62 523.45 Technical (Hospital) Services US Pregnant Uterus Limited 1/> Fetuses PX-4027681500 CDM 76815 CPT 402 RC inpatient 551 551 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES HDHP [308136802] 436.28 percent of total billed charges 341.62 523.45 Technical (Hospital) Services US Pregnant Uterus Limited 1/> Fetuses PX-4027681500 CDM 76815 CPT 402 RC inpatient 551 551 MEDICA (COMMERCIAL) 94265 [3081118] MEDICA CLAIMS [308111801] 495.9 percent of total billed charges 341.62 523.45 Technical (Hospital) Services US Pregnant Uterus Limited 1/> Fetuses PX-4027681500 CDM 76815 CPT 402 RC inpatient 551 551 HEALTHPARTNERS SX009 HEALTHPARTNERS 436.28 percent of total billed charges 341.62 523.45 Technical (Hospital) Services US Pregnant Uterus Limited 1/> Fetuses PX-4027681500 CDM 76815 CPT 402 RC inpatient 551 551 UNITED HEALTHCARE (COMMERCIAL) [3081199] UNITED HEALTHCARE 87726 [308119901] 341.62 percent of total billed charges 341.62 523.45 Technical (Hospital) Services US Pregnant Uterus Limited 1/> Fetuses PX-4027681500 CDM 76815 CPT 402 RC inpatient 551 551 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES PPO [308136801] 436.28 percent of total billed charges 341.62 523.45 Technical (Hospital) Services US Pregnant Uterus Limited 1/> Fetuses PX-4027681500 CDM 76815 CPT 402 RC inpatient 551 551 MULTIPLAN INC 34080 [3081285] MULTIPLAN INC [308128501] 523.45 percent of total billed charges 341.62 523.45 Technical (Hospital) Services US Pregnant Uterus Limited 1/> Fetuses PX-4027681500 CDM 76815 CPT 402 RC inpatient 551 551 BLUE CROSS BLUE SHIELD WELLMARK SB889 [3081026] BCBS WYOMING [308102603] 523.45 percent of total billed charges 341.62 523.45 Technical (Hospital) Services US Preg Uterus > 1st Trimester Abdl Ea Gestatio PX-4027681000 CDM 76810 CPT 402 RC inpatient 429 429 CIGNA 62308 [3081051] CIGNA 62308 [308105105] 339.68 percent of total billed charges 265.98 407.55 Technical (Hospital) Services US Preg Uterus > 1st Trimester Abdl Ea Gestatio PX-4027681000 CDM 76810 CPT 402 RC inpatient 429 429 CIGNA 62308 [3081051] CIGNA STATE OF WYOMING [308105107] 339.68 percent of total billed charges 265.98 407.55 Technical (Hospital) Services US Preg Uterus > 1st Trimester Abdl Ea Gestatio PX-4027681000 CDM 76810 CPT 402 RC inpatient 429 429 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES EPO [308136803] 339.68 percent of total billed charges 265.98 407.55 Technical (Hospital) Services US Preg Uterus > 1st Trimester Abdl Ea Gestatio PX-4027681000 CDM 76810 CPT 402 RC inpatient 429 429 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES HDHP [308136802] 339.68 percent of total billed charges 265.98 407.55 Technical (Hospital) Services US Preg Uterus > 1st Trimester Abdl Ea Gestatio PX-4027681000 CDM 76810 CPT 402 RC inpatient 429 429 MEDICA (COMMERCIAL) 94265 [3081118] MEDICA CLAIMS [308111801] 386.1 percent of total billed charges 265.98 407.55 Technical (Hospital) Services US Preg Uterus > 1st Trimester Abdl Ea Gestatio PX-4027681000 CDM 76810 CPT 402 RC inpatient 429 429 HEALTHPARTNERS SX009 HEALTHPARTNERS 339.68 percent of total billed charges 265.98 407.55 Technical (Hospital) Services US Preg Uterus > 1st Trimester Abdl Ea Gestatio PX-4027681000 CDM 76810 CPT 402 RC inpatient 429 429 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES PPO [308136801] 339.68 percent of total billed charges 265.98 407.55 Technical (Hospital) Services US Preg Uterus > 1st Trimester Abdl Ea Gestatio PX-4027681000 CDM 76810 CPT 402 RC inpatient 429 429 UNITED HEALTHCARE (COMMERCIAL) [3081199] UNITED HEALTHCARE 87726 [308119901] 265.98 percent of total billed charges 265.98 407.55 Technical (Hospital) Services US Preg Uterus > 1st Trimester Abdl Ea Gestatio PX-4027681000 CDM 76810 CPT 402 RC inpatient 429 429 MULTIPLAN INC 34080 [3081285] MULTIPLAN INC [308128501] 407.55 percent of total billed charges 265.98 407.55 Technical (Hospital) Services US Preg Uterus > 1st Trimester Abdl Ea Gestatio PX-4027681000 CDM 76810 CPT 402 RC inpatient 429 429 BLUE CROSS BLUE SHIELD WELLMARK SB889 [3081026] BCBS WYOMING [308102603] 407.55 percent of total billed charges 265.98 407.55 Technical (Hospital) Services US Preg Uterus > 1st Trimester Abdl Ea Gestatio PX-4027681000 CDM 76810 CPT 402 RC outpatient 429 429 CIGNA 62308 [3081051] CIGNA 62308 [308105105] 343.2 percent of total billed charges 265.98 407.55 Technical (Hospital) Services US Preg Uterus > 1st Trimester Abdl Ea Gestatio PX-4027681000 CDM 76810 CPT 402 RC outpatient 429 429 CIGNA 62308 [3081051] CIGNA STATE OF WYOMING [308105107] 343.2 percent of total billed charges 265.98 407.55 Technical (Hospital) Services US Preg Uterus > 1st Trimester Abdl Ea Gestatio PX-4027681000 CDM 76810 CPT 402 RC outpatient 429 429 MEDICA (COMMERCIAL) 94265 [3081118] MEDICA CLAIMS [308111801] 386.1 percent of total billed charges 265.98 407.55 Technical (Hospital) Services US Preg Uterus > 1st Trimester Abdl Ea Gestatio PX-4027681000 CDM 76810 CPT 402 RC outpatient 429 429 BLUE CROSS BLUE SHIELD WELLMARK SB889 [3081026] BCBS WYOMING [308102603] 407.55 percent of total billed charges 265.98 407.55 Technical (Hospital) Services US Preg Uterus > 1st Trimester Abdl Ea Gestatio PX-4027681000 CDM 76810 CPT 402 RC outpatient 429 429 MULTIPLAN INC 34080 [3081285] MULTIPLAN INC [308128501] 407.55 percent of total billed charges 265.98 407.55 Technical (Hospital) Services US Preg Uterus > 1st Trimester Abdl Ea Gestatio PX-4027681000 CDM 76810 CPT 402 RC outpatient 429 429 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES HDHP [308136802] 343.2 percent of total billed charges 265.98 407.55 Technical (Hospital) Services US Preg Uterus > 1st Trimester Abdl Ea Gestatio PX-4027681000 CDM 76810 CPT 402 RC outpatient 429 429 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES EPO [308136803] 343.2 percent of total billed charges 265.98 407.55 Technical (Hospital) Services US Preg Uterus > 1st Trimester Abdl Ea Gestatio PX-4027681000 CDM 76810 CPT 402 RC outpatient 429 429 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES PPO [308136801] 343.2 percent of total billed charges 265.98 407.55 Technical (Hospital) Services US Preg Uterus > 1st Trimester Abdl Ea Gestatio PX-4027681000 CDM 76810 CPT 402 RC outpatient 429 429 HEALTHPARTNERS SX009 HEALTHPARTNERS 343.2 percent of total billed charges 265.98 407.55 Technical (Hospital) Services US Preg Uterus > 1st Trimester Abdl Ea Gestatio PX-4027681000 CDM 76810 CPT 402 RC outpatient 429 429 UNITED HEALTHCARE (COMMERCIAL) [3081199] UNITED HEALTHCARE 87726 [308119901] 265.98 percent of total billed charges 265.98 407.55 Technical (Hospital) Services US Preg Uterus After 1st Trimest 1/1st Gestation PX-4027680500 CDM 76805 CPT 402 RC inpatient 755 755 BLUE CROSS BLUE SHIELD WELLMARK SB889 [3081026] BCBS WYOMING [308102603] 717.25 percent of total billed charges 468.1 717.25 Technical (Hospital) Services US Preg Uterus After 1st Trimest 1/1st Gestation PX-4027680500 CDM 76805 CPT 402 RC inpatient 755 755 MULTIPLAN INC 34080 [3081285] MULTIPLAN INC [308128501] 717.25 percent of total billed charges 468.1 717.25 Technical (Hospital) Services US Preg Uterus After 1st Trimest 1/1st Gestation PX-4027680500 CDM 76805 CPT 402 RC inpatient 755 755 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES PPO [308136801] 597.81 percent of total billed charges 468.1 717.25 Technical (Hospital) Services US Preg Uterus After 1st Trimest 1/1st Gestation PX-4027680500 CDM 76805 CPT 402 RC inpatient 755 755 UNITED HEALTHCARE (COMMERCIAL) [3081199] UNITED HEALTHCARE 87726 [308119901] 468.1 percent of total billed charges 468.1 717.25 Technical (Hospital) Services US Preg Uterus After 1st Trimest 1/1st Gestation PX-4027680500 CDM 76805 CPT 402 RC inpatient 755 755 MEDICA (COMMERCIAL) 94265 [3081118] MEDICA CLAIMS [308111801] 679.5 percent of total billed charges 468.1 717.25 Technical (Hospital) Services US Preg Uterus After 1st Trimest 1/1st Gestation PX-4027680500 CDM 76805 CPT 402 RC inpatient 755 755 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES HDHP [308136802] 597.81 percent of total billed charges 468.1 717.25 Technical (Hospital) Services US Preg Uterus After 1st Trimest 1/1st Gestation PX-4027680500 CDM 76805 CPT 402 RC inpatient 755 755 HEALTHPARTNERS SX009 HEALTHPARTNERS 597.81 percent of total billed charges 468.1 717.25 Technical (Hospital) Services US Preg Uterus After 1st Trimest 1/1st Gestation PX-4027680500 CDM 76805 CPT 402 RC inpatient 755 755 CIGNA 62308 [3081051] CIGNA 62308 [308105105] 597.81 percent of total billed charges 468.1 717.25 Technical (Hospital) Services US Preg Uterus After 1st Trimest 1/1st Gestation PX-4027680500 CDM 76805 CPT 402 RC inpatient 755 755 CIGNA 62308 [3081051] CIGNA STATE OF WYOMING [308105107] 597.81 percent of total billed charges 468.1 717.25 Technical (Hospital) Services US Preg Uterus After 1st Trimest 1/1st Gestation PX-4027680500 CDM 76805 CPT 402 RC inpatient 755 755 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES EPO [308136803] 597.81 percent of total billed charges 468.1 717.25 Technical (Hospital) Services US Preg Uterus After 1st Trimest 1/1st Gestation PX-4027680500 CDM 76805 CPT 402 RC outpatient 755 755 HEALTHPARTNERS SX009 HEALTHPARTNERS 604 percent of total billed charges 468.1 717.25 Technical (Hospital) Services US Preg Uterus After 1st Trimest 1/1st Gestation PX-4027680500 CDM 76805 CPT 402 RC outpatient 755 755 UNITED HEALTHCARE (COMMERCIAL) [3081199] UNITED HEALTHCARE 87726 [308119901] 468.1 percent of total billed charges 468.1 717.25 Technical (Hospital) Services US Preg Uterus After 1st Trimest 1/1st Gestation PX-4027680500 CDM 76805 CPT 402 RC outpatient 755 755 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES EPO [308136803] 604 percent of total billed charges 468.1 717.25 Technical (Hospital) Services US Preg Uterus After 1st Trimest 1/1st Gestation PX-4027680500 CDM 76805 CPT 402 RC outpatient 755 755 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES PPO [308136801] 604 percent of total billed charges 468.1 717.25 Technical (Hospital) Services US Preg Uterus After 1st Trimest 1/1st Gestation PX-4027680500 CDM 76805 CPT 402 RC outpatient 755 755 BLUE CROSS BLUE SHIELD WELLMARK SB889 [3081026] BCBS WYOMING [308102603] 717.25 percent of total billed charges 468.1 717.25 Technical (Hospital) Services US Preg Uterus After 1st Trimest 1/1st Gestation PX-4027680500 CDM 76805 CPT 402 RC outpatient 755 755 MULTIPLAN INC 34080 [3081285] MULTIPLAN INC [308128501] 717.25 percent of total billed charges 468.1 717.25 Technical (Hospital) Services US Preg Uterus After 1st Trimest 1/1st Gestation PX-4027680500 CDM 76805 CPT 402 RC outpatient 755 755 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES HDHP [308136802] 604 percent of total billed charges 468.1 717.25 Technical (Hospital) Services US Preg Uterus After 1st Trimest 1/1st Gestation PX-4027680500 CDM 76805 CPT 402 RC outpatient 755 755 MEDICA (COMMERCIAL) 94265 [3081118] MEDICA CLAIMS [308111801] 679.5 percent of total billed charges 468.1 717.25 Technical (Hospital) Services US Preg Uterus After 1st Trimest 1/1st Gestation PX-4027680500 CDM 76805 CPT 402 RC outpatient 755 755 CIGNA 62308 [3081051] CIGNA 62308 [308105105] 604 percent of total billed charges 468.1 717.25 Technical (Hospital) Services US Preg Uterus After 1st Trimest 1/1st Gestation PX-4027680500 CDM 76805 CPT 402 RC outpatient 755 755 CIGNA 62308 [3081051] CIGNA STATE OF WYOMING [308105107] 604 percent of total billed charges 468.1 717.25 Technical (Hospital) Services US Pregnant Uterus 14 Wk Transabdl 1/1st Gestat PX-4027680100 CDM 76801 CPT 402 RC outpatient 755 755 UNITED HEALTHCARE (COMMERCIAL) [3081199] UNITED HEALTHCARE 87726 [308119901] 468.1 percent of total billed charges 468.1 717.25 Technical (Hospital) Services US Pregnant Uterus 14 Wk Transabdl 1/1st Gestat PX-4027680100 CDM 76801 CPT 402 RC outpatient 755 755 HEALTHPARTNERS SX009 HEALTHPARTNERS 604 percent of total billed charges 468.1 717.25 Technical (Hospital) Services US Pregnant Uterus 14 Wk Transabdl 1/1st Gestat PX-4027680100 CDM 76801 CPT 402 RC outpatient 755 755 MEDICA (COMMERCIAL) 94265 [3081118] MEDICA CLAIMS [308111801] 679.5 percent of total billed charges 468.1 717.25 Technical (Hospital) Services US Pregnant Uterus 14 Wk Transabdl 1/1st Gestat PX-4027680100 CDM 76801 CPT 402 RC outpatient 755 755 BLUE CROSS BLUE SHIELD WELLMARK SB889 [3081026] BCBS WYOMING [308102603] 717.25 percent of total billed charges 468.1 717.25 Technical (Hospital) Services US Pregnant Uterus 14 Wk Transabdl 1/1st Gestat PX-4027680100 CDM 76801 CPT 402 RC outpatient 755 755 MULTIPLAN INC 34080 [3081285] MULTIPLAN INC [308128501] 717.25 percent of total billed charges 468.1 717.25 Technical (Hospital) Services US Pregnant Uterus 14 Wk Transabdl 1/1st Gestat PX-4027680100 CDM 76801 CPT 402 RC outpatient 755 755 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES HDHP [308136802] 604 percent of total billed charges 468.1 717.25 Technical (Hospital) Services US Pregnant Uterus 14 Wk Transabdl 1/1st Gestat PX-4027680100 CDM 76801 CPT 402 RC outpatient 755 755 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES EPO [308136803] 604 percent of total billed charges 468.1 717.25 Technical (Hospital) Services US Pregnant Uterus 14 Wk Transabdl 1/1st Gestat PX-4027680100 CDM 76801 CPT 402 RC outpatient 755 755 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES PPO [308136801] 604 percent of total billed charges 468.1 717.25 Technical (Hospital) Services US Pregnant Uterus 14 Wk Transabdl 1/1st Gestat PX-4027680100 CDM 76801 CPT 402 RC outpatient 755 755 CIGNA 62308 [3081051] CIGNA 62308 [308105105] 604 percent of total billed charges 468.1 717.25 Technical (Hospital) Services US Pregnant Uterus 14 Wk Transabdl 1/1st Gestat PX-4027680100 CDM 76801 CPT 402 RC outpatient 755 755 CIGNA 62308 [3081051] CIGNA STATE OF WYOMING [308105107] 604 percent of total billed charges 468.1 717.25 Technical (Hospital) Services US Pregnant Uterus 14 Wk Transabdl 1/1st Gestat PX-4027680100 CDM 76801 CPT 402 RC inpatient 755 755 HEALTHPARTNERS SX009 HEALTHPARTNERS 597.81 percent of total billed charges 468.1 717.25 Technical (Hospital) Services US Pregnant Uterus 14 Wk Transabdl 1/1st Gestat PX-4027680100 CDM 76801 CPT 402 RC inpatient 755 755 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES HDHP [308136802] 597.81 percent of total billed charges 468.1 717.25 Technical (Hospital) Services US Pregnant Uterus 14 Wk Transabdl 1/1st Gestat PX-4027680100 CDM 76801 CPT 402 RC inpatient 755 755 MEDICA (COMMERCIAL) 94265 [3081118] MEDICA CLAIMS [308111801] 679.5 percent of total billed charges 468.1 717.25 Technical (Hospital) Services US Pregnant Uterus 14 Wk Transabdl 1/1st Gestat PX-4027680100 CDM 76801 CPT 402 RC inpatient 755 755 MULTIPLAN INC 34080 [3081285] MULTIPLAN INC [308128501] 717.25 percent of total billed charges 468.1 717.25 Technical (Hospital) Services US Pregnant Uterus 14 Wk Transabdl 1/1st Gestat PX-4027680100 CDM 76801 CPT 402 RC inpatient 755 755 BLUE CROSS BLUE SHIELD WELLMARK SB889 [3081026] BCBS WYOMING [308102603] 717.25 percent of total billed charges 468.1 717.25 Technical (Hospital) Services US Pregnant Uterus 14 Wk Transabdl 1/1st Gestat PX-4027680100 CDM 76801 CPT 402 RC inpatient 755 755 UNITED HEALTHCARE (COMMERCIAL) [3081199] UNITED HEALTHCARE 87726 [308119901] 468.1 percent of total billed charges 468.1 717.25 Technical (Hospital) Services US Pregnant Uterus 14 Wk Transabdl 1/1st Gestat PX-4027680100 CDM 76801 CPT 402 RC inpatient 755 755 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES PPO [308136801] 597.81 percent of total billed charges 468.1 717.25 Technical (Hospital) Services US Pregnant Uterus 14 Wk Transabdl 1/1st Gestat PX-4027680100 CDM 76801 CPT 402 RC inpatient 755 755 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES EPO [308136803] 597.81 percent of total billed charges 468.1 717.25 Technical (Hospital) Services US Pregnant Uterus 14 Wk Transabdl 1/1st Gestat PX-4027680100 CDM 76801 CPT 402 RC inpatient 755 755 CIGNA 62308 [3081051] CIGNA 62308 [308105105] 597.81 percent of total billed charges 468.1 717.25 Technical (Hospital) Services US Pregnant Uterus 14 Wk Transabdl 1/1st Gestat PX-4027680100 CDM 76801 CPT 402 RC inpatient 755 755 CIGNA 62308 [3081051] CIGNA STATE OF WYOMING [308105107] 597.81 percent of total billed charges 468.1 717.25 Technical (Hospital) Services US Retroperitoneal Real Time W/Image Limited PX-4027677500 CDM 76775 CPT 402 RC inpatient 551 551 MULTIPLAN INC 34080 [3081285] MULTIPLAN INC [308128501] 523.45 percent of total billed charges 341.62 523.45 Technical (Hospital) Services US Retroperitoneal Real Time W/Image Limited PX-4027677500 CDM 76775 CPT 402 RC inpatient 551 551 BLUE CROSS BLUE SHIELD WELLMARK SB889 [3081026] BCBS WYOMING [308102603] 523.45 percent of total billed charges 341.62 523.45 Technical (Hospital) Services US Retroperitoneal Real Time W/Image Limited PX-4027677500 CDM 76775 CPT 402 RC inpatient 551 551 UNITED HEALTHCARE (COMMERCIAL) [3081199] UNITED HEALTHCARE 87726 [308119901] 341.62 percent of total billed charges 341.62 523.45 Technical (Hospital) Services US Retroperitoneal Real Time W/Image Limited PX-4027677500 CDM 76775 CPT 402 RC inpatient 551 551 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES PPO [308136801] 436.28 percent of total billed charges 341.62 523.45 Technical (Hospital) Services US Retroperitoneal Real Time W/Image Limited PX-4027677500 CDM 76775 CPT 402 RC inpatient 551 551 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES HDHP [308136802] 436.28 percent of total billed charges 341.62 523.45 Technical (Hospital) Services US Retroperitoneal Real Time W/Image Limited PX-4027677500 CDM 76775 CPT 402 RC inpatient 551 551 MEDICA (COMMERCIAL) 94265 [3081118] MEDICA CLAIMS [308111801] 495.9 percent of total billed charges 341.62 523.45 Technical (Hospital) Services US Retroperitoneal Real Time W/Image Limited PX-4027677500 CDM 76775 CPT 402 RC inpatient 551 551 HEALTHPARTNERS SX009 HEALTHPARTNERS 436.28 percent of total billed charges 341.62 523.45 Technical (Hospital) Services US Retroperitoneal Real Time W/Image Limited PX-4027677500 CDM 76775 CPT 402 RC inpatient 551 551 CIGNA 62308 [3081051] CIGNA 62308 [308105105] 436.28 percent of total billed charges 341.62 523.45 Technical (Hospital) Services US Retroperitoneal Real Time W/Image Limited PX-4027677500 CDM 76775 CPT 402 RC inpatient 551 551 CIGNA 62308 [3081051] CIGNA STATE OF WYOMING [308105107] 436.28 percent of total billed charges 341.62 523.45 Technical (Hospital) Services US Retroperitoneal Real Time W/Image Limited PX-4027677500 CDM 76775 CPT 402 RC inpatient 551 551 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES EPO [308136803] 436.28 percent of total billed charges 341.62 523.45 Technical (Hospital) Services US Retroperitoneal Real Time W/Image Limited PX-4027677500 CDM 76775 CPT 402 RC outpatient 551 551 CIGNA 62308 [3081051] CIGNA 62308 [308105105] 440.8 percent of total billed charges 341.62 523.45 Technical (Hospital) Services US Retroperitoneal Real Time W/Image Limited PX-4027677500 CDM 76775 CPT 402 RC outpatient 551 551 CIGNA 62308 [3081051] CIGNA STATE OF WYOMING [308105107] 440.8 percent of total billed charges 341.62 523.45 Technical (Hospital) Services US Retroperitoneal Real Time W/Image Limited PX-4027677500 CDM 76775 CPT 402 RC outpatient 551 551 MEDICA (COMMERCIAL) 94265 [3081118] MEDICA CLAIMS [308111801] 495.9 percent of total billed charges 341.62 523.45 Technical (Hospital) Services US Retroperitoneal Real Time W/Image Limited PX-4027677500 CDM 76775 CPT 402 RC outpatient 551 551 BLUE CROSS BLUE SHIELD WELLMARK SB889 [3081026] BCBS WYOMING [308102603] 523.45 percent of total billed charges 341.62 523.45 Technical (Hospital) Services US Retroperitoneal Real Time W/Image Limited PX-4027677500 CDM 76775 CPT 402 RC outpatient 551 551 MULTIPLAN INC 34080 [3081285] MULTIPLAN INC [308128501] 523.45 percent of total billed charges 341.62 523.45 Technical (Hospital) Services US Retroperitoneal Real Time W/Image Limited PX-4027677500 CDM 76775 CPT 402 RC outpatient 551 551 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES HDHP [308136802] 440.8 percent of total billed charges 341.62 523.45 Technical (Hospital) Services US Retroperitoneal Real Time W/Image Limited PX-4027677500 CDM 76775 CPT 402 RC outpatient 551 551 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES EPO [308136803] 440.8 percent of total billed charges 341.62 523.45 Technical (Hospital) Services US Retroperitoneal Real Time W/Image Limited PX-4027677500 CDM 76775 CPT 402 RC outpatient 551 551 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES PPO [308136801] 440.8 percent of total billed charges 341.62 523.45 Technical (Hospital) Services US Retroperitoneal Real Time W/Image Limited PX-4027677500 CDM 76775 CPT 402 RC outpatient 551 551 UNITED HEALTHCARE (COMMERCIAL) [3081199] UNITED HEALTHCARE 87726 [308119901] 341.62 percent of total billed charges 341.62 523.45 Technical (Hospital) Services US Retroperitoneal Real Time W/Image Limited PX-4027677500 CDM 76775 CPT 402 RC outpatient 551 551 HEALTHPARTNERS SX009 HEALTHPARTNERS 440.8 percent of total billed charges 341.62 523.45 Technical (Hospital) Services US Retroperitoneal Real Time W/Image Complete PX-4027677000 CDM 76770 CPT 402 RC outpatient 595 595 UNITED HEALTHCARE (COMMERCIAL) [3081199] UNITED HEALTHCARE 87726 [308119901] 368.9 percent of total billed charges 368.9 565.25 Technical (Hospital) Services US Retroperitoneal Real Time W/Image Complete PX-4027677000 CDM 76770 CPT 402 RC outpatient 595 595 HEALTHPARTNERS SX009 HEALTHPARTNERS 476 percent of total billed charges 368.9 565.25 Technical (Hospital) Services US Retroperitoneal Real Time W/Image Complete PX-4027677000 CDM 76770 CPT 402 RC outpatient 595 595 MEDICA (COMMERCIAL) 94265 [3081118] MEDICA CLAIMS [308111801] 535.5 percent of total billed charges 368.9 565.25 Technical (Hospital) Services US Retroperitoneal Real Time W/Image Complete PX-4027677000 CDM 76770 CPT 402 RC outpatient 595 595 BLUE CROSS BLUE SHIELD WELLMARK SB889 [3081026] BCBS WYOMING [308102603] 565.25 percent of total billed charges 368.9 565.25 Technical (Hospital) Services US Retroperitoneal Real Time W/Image Complete PX-4027677000 CDM 76770 CPT 402 RC outpatient 595 595 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES HDHP [308136802] 476 percent of total billed charges 368.9 565.25 Technical (Hospital) Services US Retroperitoneal Real Time W/Image Complete PX-4027677000 CDM 76770 CPT 402 RC outpatient 595 595 MULTIPLAN INC 34080 [3081285] MULTIPLAN INC [308128501] 565.25 percent of total billed charges 368.9 565.25 Technical (Hospital) Services US Retroperitoneal Real Time W/Image Complete PX-4027677000 CDM 76770 CPT 402 RC outpatient 595 595 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES PPO [308136801] 476 percent of total billed charges 368.9 565.25 Technical (Hospital) Services US Retroperitoneal Real Time W/Image Complete PX-4027677000 CDM 76770 CPT 402 RC outpatient 595 595 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES EPO [308136803] 476 percent of total billed charges 368.9 565.25 Technical (Hospital) Services US Retroperitoneal Real Time W/Image Complete PX-4027677000 CDM 76770 CPT 402 RC outpatient 595 595 CIGNA 62308 [3081051] CIGNA 62308 [308105105] 476 percent of total billed charges 368.9 565.25 Technical (Hospital) Services US Retroperitoneal Real Time W/Image Complete PX-4027677000 CDM 76770 CPT 402 RC outpatient 595 595 CIGNA 62308 [3081051] CIGNA STATE OF WYOMING [308105107] 476 percent of total billed charges 368.9 565.25 Technical (Hospital) Services US Retroperitoneal Real Time W/Image Complete PX-4027677000 CDM 76770 CPT 402 RC inpatient 595 595 CIGNA 62308 [3081051] CIGNA STATE OF WYOMING [308105107] 471.12 percent of total billed charges 368.9 565.25 Technical (Hospital) Services US Retroperitoneal Real Time W/Image Complete PX-4027677000 CDM 76770 CPT 402 RC inpatient 595 595 CIGNA 62308 [3081051] CIGNA 62308 [308105105] 471.12 percent of total billed charges 368.9 565.25 Technical (Hospital) Services US Retroperitoneal Real Time W/Image Complete PX-4027677000 CDM 76770 CPT 402 RC inpatient 595 595 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES EPO [308136803] 471.12 percent of total billed charges 368.9 565.25 Technical (Hospital) Services US Retroperitoneal Real Time W/Image Complete PX-4027677000 CDM 76770 CPT 402 RC inpatient 595 595 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES PPO [308136801] 471.12 percent of total billed charges 368.9 565.25 Technical (Hospital) Services US Retroperitoneal Real Time W/Image Complete PX-4027677000 CDM 76770 CPT 402 RC inpatient 595 595 UNITED HEALTHCARE (COMMERCIAL) [3081199] UNITED HEALTHCARE 87726 [308119901] 368.9 percent of total billed charges 368.9 565.25 Technical (Hospital) Services US Retroperitoneal Real Time W/Image Complete PX-4027677000 CDM 76770 CPT 402 RC inpatient 595 595 BLUE CROSS BLUE SHIELD WELLMARK SB889 [3081026] BCBS WYOMING [308102603] 565.25 percent of total billed charges 368.9 565.25 Technical (Hospital) Services US Retroperitoneal Real Time W/Image Complete PX-4027677000 CDM 76770 CPT 402 RC inpatient 595 595 MULTIPLAN INC 34080 [3081285] MULTIPLAN INC [308128501] 565.25 percent of total billed charges 368.9 565.25 Technical (Hospital) Services US Retroperitoneal Real Time W/Image Complete PX-4027677000 CDM 76770 CPT 402 RC inpatient 595 595 MEDICA (COMMERCIAL) 94265 [3081118] MEDICA CLAIMS [308111801] 535.5 percent of total billed charges 368.9 565.25 Technical (Hospital) Services US Retroperitoneal Real Time W/Image Complete PX-4027677000 CDM 76770 CPT 402 RC inpatient 595 595 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES HDHP [308136802] 471.12 percent of total billed charges 368.9 565.25 Technical (Hospital) Services US Retroperitoneal Real Time W/Image Complete PX-4027677000 CDM 76770 CPT 402 RC inpatient 595 595 HEALTHPARTNERS SX009 HEALTHPARTNERS 471.12 percent of total billed charges 368.9 565.25 Technical (Hospital) Services US Abdominal Aorta Real Time Screen Study Aaa PX-4027670600 CDM 76706 CPT 402 RC outpatient 413 413 UNITED HEALTHCARE (COMMERCIAL) [3081199] UNITED HEALTHCARE 87726 [308119901] 256.06 percent of total billed charges 256.06 392.35 Technical (Hospital) Services US Abdominal Aorta Real Time Screen Study Aaa PX-4027670600 CDM 76706 CPT 402 RC outpatient 413 413 HEALTHPARTNERS SX009 HEALTHPARTNERS 330.4 percent of total billed charges 256.06 392.35 Technical (Hospital) Services US Abdominal Aorta Real Time Screen Study Aaa PX-4027670600 CDM 76706 CPT 402 RC outpatient 413 413 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES EPO [308136803] 330.4 percent of total billed charges 256.06 392.35 Technical (Hospital) Services US Abdominal Aorta Real Time Screen Study Aaa PX-4027670600 CDM 76706 CPT 402 RC outpatient 413 413 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES PPO [308136801] 330.4 percent of total billed charges 256.06 392.35 Technical (Hospital) Services US Abdominal Aorta Real Time Screen Study Aaa PX-4027670600 CDM 76706 CPT 402 RC outpatient 413 413 MULTIPLAN INC 34080 [3081285] MULTIPLAN INC [308128501] 392.35 percent of total billed charges 256.06 392.35 Technical (Hospital) Services US Abdominal Aorta Real Time Screen Study Aaa PX-4027670600 CDM 76706 CPT 402 RC outpatient 413 413 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES HDHP [308136802] 330.4 percent of total billed charges 256.06 392.35 Technical (Hospital) Services US Abdominal Aorta Real Time Screen Study Aaa PX-4027670600 CDM 76706 CPT 402 RC outpatient 413 413 BLUE CROSS BLUE SHIELD WELLMARK SB889 [3081026] BCBS WYOMING [308102603] 392.35 percent of total billed charges 256.06 392.35 Technical (Hospital) Services US Abdominal Aorta Real Time Screen Study Aaa PX-4027670600 CDM 76706 CPT 402 RC outpatient 413 413 MEDICA (COMMERCIAL) 94265 [3081118] MEDICA CLAIMS [308111801] 371.7 percent of total billed charges 256.06 392.35 Technical (Hospital) Services US Abdominal Aorta Real Time Screen Study Aaa PX-4027670600 CDM 76706 CPT 402 RC outpatient 413 413 CIGNA 62308 [3081051] CIGNA 62308 [308105105] 330.4 percent of total billed charges 256.06 392.35 Technical (Hospital) Services US Abdominal Aorta Real Time Screen Study Aaa PX-4027670600 CDM 76706 CPT 402 RC outpatient 413 413 CIGNA 62308 [3081051] CIGNA STATE OF WYOMING [308105107] 330.4 percent of total billed charges 256.06 392.35 Technical (Hospital) Services US Abdominal Aorta Real Time Screen Study Aaa PX-4027670600 CDM 76706 CPT 402 RC inpatient 413 413 CIGNA 62308 [3081051] CIGNA 62308 [308105105] 327.01 percent of total billed charges 256.06 392.35 Technical (Hospital) Services US Abdominal Aorta Real Time Screen Study Aaa PX-4027670600 CDM 76706 CPT 402 RC inpatient 413 413 CIGNA 62308 [3081051] CIGNA STATE OF WYOMING [308105107] 327.01 percent of total billed charges 256.06 392.35 Technical (Hospital) Services US Abdominal Aorta Real Time Screen Study Aaa PX-4027670600 CDM 76706 CPT 402 RC inpatient 413 413 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES EPO [308136803] 327.01 percent of total billed charges 256.06 392.35 Technical (Hospital) Services US Abdominal Aorta Real Time Screen Study Aaa PX-4027670600 CDM 76706 CPT 402 RC inpatient 413 413 MULTIPLAN INC 34080 [3081285] MULTIPLAN INC [308128501] 392.35 percent of total billed charges 256.06 392.35 Technical (Hospital) Services US Abdominal Aorta Real Time Screen Study Aaa PX-4027670600 CDM 76706 CPT 402 RC inpatient 413 413 BLUE CROSS BLUE SHIELD WELLMARK SB889 [3081026] BCBS WYOMING [308102603] 392.35 percent of total billed charges 256.06 392.35 Technical (Hospital) Services US Abdominal Aorta Real Time Screen Study Aaa PX-4027670600 CDM 76706 CPT 402 RC inpatient 413 413 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES PPO [308136801] 327.01 percent of total billed charges 256.06 392.35 Technical (Hospital) Services US Abdominal Aorta Real Time Screen Study Aaa PX-4027670600 CDM 76706 CPT 402 RC inpatient 413 413 UNITED HEALTHCARE (COMMERCIAL) [3081199] UNITED HEALTHCARE 87726 [308119901] 256.06 percent of total billed charges 256.06 392.35 Technical (Hospital) Services US Abdominal Aorta Real Time Screen Study Aaa PX-4027670600 CDM 76706 CPT 402 RC inpatient 413 413 MEDICA (COMMERCIAL) 94265 [3081118] MEDICA CLAIMS [308111801] 371.7 percent of total billed charges 256.06 392.35 Technical (Hospital) Services US Abdominal Aorta Real Time Screen Study Aaa PX-4027670600 CDM 76706 CPT 402 RC inpatient 413 413 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES HDHP [308136802] 327.01 percent of total billed charges 256.06 392.35 Technical (Hospital) Services US Abdominal Aorta Real Time Screen Study Aaa PX-4027670600 CDM 76706 CPT 402 RC inpatient 413 413 HEALTHPARTNERS SX009 HEALTHPARTNERS 327.01 percent of total billed charges 256.06 392.35 Technical (Hospital) Services US Abdominal Real Time W/Image Limited PX-4027670500 CDM 76705 CPT 402 RC inpatient 714 714 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES EPO [308136803] 565.35 percent of total billed charges 442.68 678.3 Technical (Hospital) Services US Abdominal Real Time W/Image Limited PX-4027670500 CDM 76705 CPT 402 RC inpatient 714 714 CIGNA 62308 [3081051] CIGNA 62308 [308105105] 565.35 percent of total billed charges 442.68 678.3 Technical (Hospital) Services US Abdominal Real Time W/Image Limited PX-4027670500 CDM 76705 CPT 402 RC inpatient 714 714 CIGNA 62308 [3081051] CIGNA STATE OF WYOMING [308105107] 565.35 percent of total billed charges 442.68 678.3 Technical (Hospital) Services US Abdominal Real Time W/Image Limited PX-4027670500 CDM 76705 CPT 402 RC inpatient 714 714 BLUE CROSS BLUE SHIELD WELLMARK SB889 [3081026] BCBS WYOMING [308102603] 678.3 percent of total billed charges 442.68 678.3 Technical (Hospital) Services US Abdominal Real Time W/Image Limited PX-4027670500 CDM 76705 CPT 402 RC inpatient 714 714 MULTIPLAN INC 34080 [3081285] MULTIPLAN INC [308128501] 678.3 percent of total billed charges 442.68 678.3 Technical (Hospital) Services US Abdominal Real Time W/Image Limited PX-4027670500 CDM 76705 CPT 402 RC inpatient 714 714 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES PPO [308136801] 565.35 percent of total billed charges 442.68 678.3 Technical (Hospital) Services US Abdominal Real Time W/Image Limited PX-4027670500 CDM 76705 CPT 402 RC inpatient 714 714 UNITED HEALTHCARE (COMMERCIAL) [3081199] UNITED HEALTHCARE 87726 [308119901] 442.68 percent of total billed charges 442.68 678.3 Technical (Hospital) Services US Abdominal Real Time W/Image Limited PX-4027670500 CDM 76705 CPT 402 RC inpatient 714 714 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES HDHP [308136802] 565.35 percent of total billed charges 442.68 678.3 Technical (Hospital) Services US Abdominal Real Time W/Image Limited PX-4027670500 CDM 76705 CPT 402 RC inpatient 714 714 MEDICA (COMMERCIAL) 94265 [3081118] MEDICA CLAIMS [308111801] 642.6 percent of total billed charges 442.68 678.3 Technical (Hospital) Services US Abdominal Real Time W/Image Limited PX-4027670500 CDM 76705 CPT 402 RC inpatient 714 714 HEALTHPARTNERS SX009 HEALTHPARTNERS 565.35 percent of total billed charges 442.68 678.3 Technical (Hospital) Services US Abdominal Real Time W/Image Limited PX-4027670500 CDM 76705 CPT 402 RC outpatient 714 714 MEDICA (COMMERCIAL) 94265 [3081118] MEDICA CLAIMS [308111801] 642.6 percent of total billed charges 442.68 678.3 Technical (Hospital) Services US Abdominal Real Time W/Image Limited PX-4027670500 CDM 76705 CPT 402 RC outpatient 714 714 CIGNA 62308 [3081051] CIGNA 62308 [308105105] 571.2 percent of total billed charges 442.68 678.3 Technical (Hospital) Services US Abdominal Real Time W/Image Limited PX-4027670500 CDM 76705 CPT 402 RC outpatient 714 714 CIGNA 62308 [3081051] CIGNA STATE OF WYOMING [308105107] 571.2 percent of total billed charges 442.68 678.3 Technical (Hospital) Services US Abdominal Real Time W/Image Limited PX-4027670500 CDM 76705 CPT 402 RC outpatient 714 714 HEALTHPARTNERS SX009 HEALTHPARTNERS 571.2 percent of total billed charges 442.68 678.3 Technical (Hospital) Services US Abdominal Real Time W/Image Limited PX-4027670500 CDM 76705 CPT 402 RC outpatient 714 714 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES EPO [308136803] 571.2 percent of total billed charges 442.68 678.3 Technical (Hospital) Services US Abdominal Real Time W/Image Limited PX-4027670500 CDM 76705 CPT 402 RC outpatient 714 714 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES PPO [308136801] 571.2 percent of total billed charges 442.68 678.3 Technical (Hospital) Services US Abdominal Real Time W/Image Limited PX-4027670500 CDM 76705 CPT 402 RC outpatient 714 714 UNITED HEALTHCARE (COMMERCIAL) [3081199] UNITED HEALTHCARE 87726 [308119901] 442.68 percent of total billed charges 442.68 678.3 Technical (Hospital) Services US Abdominal Real Time W/Image Limited PX-4027670500 CDM 76705 CPT 402 RC outpatient 714 714 BLUE CROSS BLUE SHIELD WELLMARK SB889 [3081026] BCBS WYOMING [308102603] 678.3 percent of total billed charges 442.68 678.3 Technical (Hospital) Services US Abdominal Real Time W/Image Limited PX-4027670500 CDM 76705 CPT 402 RC outpatient 714 714 MULTIPLAN INC 34080 [3081285] MULTIPLAN INC [308128501] 678.3 percent of total billed charges 442.68 678.3 Technical (Hospital) Services US Abdominal Real Time W/Image Limited PX-4027670500 CDM 76705 CPT 402 RC outpatient 714 714 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES HDHP [308136802] 571.2 percent of total billed charges 442.68 678.3 Technical (Hospital) Services US Abdominal Real Time W/Image Documentation PX-4027670000 CDM 76700 CPT 402 RC outpatient 1072 1072 MULTIPLAN INC 34080 [3081285] MULTIPLAN INC [308128501] 1018.4 percent of total billed charges 664.64 1018.4 Technical (Hospital) Services US Abdominal Real Time W/Image Documentation PX-4027670000 CDM 76700 CPT 402 RC outpatient 1072 1072 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES HDHP [308136802] 857.6 percent of total billed charges 664.64 1018.4 Technical (Hospital) Services US Abdominal Real Time W/Image Documentation PX-4027670000 CDM 76700 CPT 402 RC outpatient 1072 1072 BLUE CROSS BLUE SHIELD WELLMARK SB889 [3081026] BCBS WYOMING [308102603] 1018.4 percent of total billed charges 664.64 1018.4 Technical (Hospital) Services US Abdominal Real Time W/Image Documentation PX-4027670000 CDM 76700 CPT 402 RC outpatient 1072 1072 UNITED HEALTHCARE (COMMERCIAL) [3081199] UNITED HEALTHCARE 87726 [308119901] 664.64 percent of total billed charges 664.64 1018.4 Technical (Hospital) Services US Abdominal Real Time W/Image Documentation PX-4027670000 CDM 76700 CPT 402 RC outpatient 1072 1072 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES EPO [308136803] 857.6 percent of total billed charges 664.64 1018.4 Technical (Hospital) Services US Abdominal Real Time W/Image Documentation PX-4027670000 CDM 76700 CPT 402 RC outpatient 1072 1072 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES PPO [308136801] 857.6 percent of total billed charges 664.64 1018.4 Technical (Hospital) Services US Abdominal Real Time W/Image Documentation PX-4027670000 CDM 76700 CPT 402 RC outpatient 1072 1072 MEDICA (COMMERCIAL) 94265 [3081118] MEDICA CLAIMS [308111801] 964.8 percent of total billed charges 664.64 1018.4 Technical (Hospital) Services US Abdominal Real Time W/Image Documentation PX-4027670000 CDM 76700 CPT 402 RC outpatient 1072 1072 HEALTHPARTNERS SX009 HEALTHPARTNERS 857.6 percent of total billed charges 664.64 1018.4 Technical (Hospital) Services US Abdominal Real Time W/Image Documentation PX-4027670000 CDM 76700 CPT 402 RC outpatient 1072 1072 CIGNA 62308 [3081051] CIGNA 62308 [308105105] 857.6 percent of total billed charges 664.64 1018.4 Technical (Hospital) Services US Abdominal Real Time W/Image Documentation PX-4027670000 CDM 76700 CPT 402 RC outpatient 1072 1072 CIGNA 62308 [3081051] CIGNA STATE OF WYOMING [308105107] 857.6 percent of total billed charges 664.64 1018.4 Technical (Hospital) Services US Abdominal Real Time W/Image Documentation PX-4027670000 CDM 76700 CPT 402 RC inpatient 1072 1072 CIGNA 62308 [3081051] CIGNA 62308 [308105105] 848.81 percent of total billed charges 664.64 1018.4 Technical (Hospital) Services US Abdominal Real Time W/Image Documentation PX-4027670000 CDM 76700 CPT 402 RC inpatient 1072 1072 CIGNA 62308 [3081051] CIGNA STATE OF WYOMING [308105107] 848.81 percent of total billed charges 664.64 1018.4 Technical (Hospital) Services US Abdominal Real Time W/Image Documentation PX-4027670000 CDM 76700 CPT 402 RC inpatient 1072 1072 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES EPO [308136803] 848.81 percent of total billed charges 664.64 1018.4 Technical (Hospital) Services US Abdominal Real Time W/Image Documentation PX-4027670000 CDM 76700 CPT 402 RC inpatient 1072 1072 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES HDHP [308136802] 848.81 percent of total billed charges 664.64 1018.4 Technical (Hospital) Services US Abdominal Real Time W/Image Documentation PX-4027670000 CDM 76700 CPT 402 RC inpatient 1072 1072 MEDICA (COMMERCIAL) 94265 [3081118] MEDICA CLAIMS [308111801] 964.8 percent of total billed charges 664.64 1018.4 Technical (Hospital) Services US Abdominal Real Time W/Image Documentation PX-4027670000 CDM 76700 CPT 402 RC inpatient 1072 1072 HEALTHPARTNERS SX009 HEALTHPARTNERS 848.81 percent of total billed charges 664.64 1018.4 Technical (Hospital) Services US Abdominal Real Time W/Image Documentation PX-4027670000 CDM 76700 CPT 402 RC inpatient 1072 1072 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES PPO [308136801] 848.81 percent of total billed charges 664.64 1018.4 Technical (Hospital) Services US Abdominal Real Time W/Image Documentation PX-4027670000 CDM 76700 CPT 402 RC inpatient 1072 1072 UNITED HEALTHCARE (COMMERCIAL) [3081199] UNITED HEALTHCARE 87726 [308119901] 664.64 percent of total billed charges 664.64 1018.4 Technical (Hospital) Services US Abdominal Real Time W/Image Documentation PX-4027670000 CDM 76700 CPT 402 RC inpatient 1072 1072 MULTIPLAN INC 34080 [3081285] MULTIPLAN INC [308128501] 1018.4 percent of total billed charges 664.64 1018.4 Technical (Hospital) Services US Abdominal Real Time W/Image Documentation PX-4027670000 CDM 76700 CPT 402 RC inpatient 1072 1072 BLUE CROSS BLUE SHIELD WELLMARK SB889 [3081026] BCBS WYOMING [308102603] 1018.4 percent of total billed charges 664.64 1018.4 Technical (Hospital) Services US Chest Real Time W/Image Documentation PX-4027660400 CDM 76604 CPT 402 RC inpatient 533 533 BLUE CROSS BLUE SHIELD WELLMARK SB889 [3081026] BCBS WYOMING [308102603] 506.35 percent of total billed charges 330.46 506.35 Technical (Hospital) Services US Chest Real Time W/Image Documentation PX-4027660400 CDM 76604 CPT 402 RC inpatient 533 533 MULTIPLAN INC 34080 [3081285] MULTIPLAN INC [308128501] 506.35 percent of total billed charges 330.46 506.35 Technical (Hospital) Services US Chest Real Time W/Image Documentation PX-4027660400 CDM 76604 CPT 402 RC inpatient 533 533 UNITED HEALTHCARE (COMMERCIAL) [3081199] UNITED HEALTHCARE 87726 [308119901] 330.46 percent of total billed charges 330.46 506.35 Technical (Hospital) Services US Chest Real Time W/Image Documentation PX-4027660400 CDM 76604 CPT 402 RC inpatient 533 533 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES PPO [308136801] 422.03 percent of total billed charges 330.46 506.35 Technical (Hospital) Services US Chest Real Time W/Image Documentation PX-4027660400 CDM 76604 CPT 402 RC inpatient 533 533 MEDICA (COMMERCIAL) 94265 [3081118] MEDICA CLAIMS [308111801] 479.7 percent of total billed charges 330.46 506.35 Technical (Hospital) Services US Chest Real Time W/Image Documentation PX-4027660400 CDM 76604 CPT 402 RC inpatient 533 533 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES HDHP [308136802] 422.03 percent of total billed charges 330.46 506.35 Technical (Hospital) Services US Chest Real Time W/Image Documentation PX-4027660400 CDM 76604 CPT 402 RC inpatient 533 533 HEALTHPARTNERS SX009 HEALTHPARTNERS 422.03 percent of total billed charges 330.46 506.35 Technical (Hospital) Services US Chest Real Time W/Image Documentation PX-4027660400 CDM 76604 CPT 402 RC inpatient 533 533 CIGNA 62308 [3081051] CIGNA 62308 [308105105] 422.03 percent of total billed charges 330.46 506.35 Technical (Hospital) Services US Chest Real Time W/Image Documentation PX-4027660400 CDM 76604 CPT 402 RC inpatient 533 533 CIGNA 62308 [3081051] CIGNA STATE OF WYOMING [308105107] 422.03 percent of total billed charges 330.46 506.35 Technical (Hospital) Services US Chest Real Time W/Image Documentation PX-4027660400 CDM 76604 CPT 402 RC inpatient 533 533 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES EPO [308136803] 422.03 percent of total billed charges 330.46 506.35 Technical (Hospital) Services US Chest Real Time W/Image Documentation PX-4027660400 CDM 76604 CPT 402 RC outpatient 533 533 CIGNA 62308 [3081051] CIGNA 62308 [308105105] 426.4 percent of total billed charges 330.46 506.35 Technical (Hospital) Services US Chest Real Time W/Image Documentation PX-4027660400 CDM 76604 CPT 402 RC outpatient 533 533 CIGNA 62308 [3081051] CIGNA STATE OF WYOMING [308105107] 426.4 percent of total billed charges 330.46 506.35 Technical (Hospital) Services US Chest Real Time W/Image Documentation PX-4027660400 CDM 76604 CPT 402 RC outpatient 533 533 MEDICA (COMMERCIAL) 94265 [3081118] MEDICA CLAIMS [308111801] 479.7 percent of total billed charges 330.46 506.35 Technical (Hospital) Services US Chest Real Time W/Image Documentation PX-4027660400 CDM 76604 CPT 402 RC outpatient 533 533 BLUE CROSS BLUE SHIELD WELLMARK SB889 [3081026] BCBS WYOMING [308102603] 506.35 percent of total billed charges 330.46 506.35 Technical (Hospital) Services US Chest Real Time W/Image Documentation PX-4027660400 CDM 76604 CPT 402 RC outpatient 533 533 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES HDHP [308136802] 426.4 percent of total billed charges 330.46 506.35 Technical (Hospital) Services US Chest Real Time W/Image Documentation PX-4027660400 CDM 76604 CPT 402 RC outpatient 533 533 MULTIPLAN INC 34080 [3081285] MULTIPLAN INC [308128501] 506.35 percent of total billed charges 330.46 506.35 Technical (Hospital) Services US Chest Real Time W/Image Documentation PX-4027660400 CDM 76604 CPT 402 RC outpatient 533 533 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES PPO [308136801] 426.4 percent of total billed charges 330.46 506.35 Technical (Hospital) Services US Chest Real Time W/Image Documentation PX-4027660400 CDM 76604 CPT 402 RC outpatient 533 533 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES EPO [308136803] 426.4 percent of total billed charges 330.46 506.35 Technical (Hospital) Services US Chest Real Time W/Image Documentation PX-4027660400 CDM 76604 CPT 402 RC outpatient 533 533 HEALTHPARTNERS SX009 HEALTHPARTNERS 426.4 percent of total billed charges 330.46 506.35 Technical (Hospital) Services US Chest Real Time W/Image Documentation PX-4027660400 CDM 76604 CPT 402 RC outpatient 533 533 UNITED HEALTHCARE (COMMERCIAL) [3081199] UNITED HEALTHCARE 87726 [308119901] 330.46 percent of total billed charges 330.46 506.35 Technical (Hospital) Services US Soft Tissue Head & Neck Real Time Imge Docm PX-4027653600 CDM 76536 CPT 402 RC inpatient 548 548 MULTIPLAN INC 34080 [3081285] MULTIPLAN INC [308128501] 520.6 percent of total billed charges 339.76 520.6 Technical (Hospital) Services US Soft Tissue Head & Neck Real Time Imge Docm PX-4027653600 CDM 76536 CPT 402 RC inpatient 548 548 BLUE CROSS BLUE SHIELD WELLMARK SB889 [3081026] BCBS WYOMING [308102603] 520.6 percent of total billed charges 339.76 520.6 Technical (Hospital) Services US Soft Tissue Head & Neck Real Time Imge Docm PX-4027653600 CDM 76536 CPT 402 RC inpatient 548 548 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES PPO [308136801] 433.91 percent of total billed charges 339.76 520.6 Technical (Hospital) Services US Soft Tissue Head & Neck Real Time Imge Docm PX-4027653600 CDM 76536 CPT 402 RC inpatient 548 548 UNITED HEALTHCARE (COMMERCIAL) [3081199] UNITED HEALTHCARE 87726 [308119901] 339.76 percent of total billed charges 339.76 520.6 Technical (Hospital) Services US Soft Tissue Head & Neck Real Time Imge Docm PX-4027653600 CDM 76536 CPT 402 RC inpatient 548 548 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES HDHP [308136802] 433.91 percent of total billed charges 339.76 520.6 Technical (Hospital) Services US Soft Tissue Head & Neck Real Time Imge Docm PX-4027653600 CDM 76536 CPT 402 RC inpatient 548 548 MEDICA (COMMERCIAL) 94265 [3081118] MEDICA CLAIMS [308111801] 493.2 percent of total billed charges 339.76 520.6 Technical (Hospital) Services US Soft Tissue Head & Neck Real Time Imge Docm PX-4027653600 CDM 76536 CPT 402 RC inpatient 548 548 HEALTHPARTNERS SX009 HEALTHPARTNERS 433.91 percent of total billed charges 339.76 520.6 Technical (Hospital) Services US Soft Tissue Head & Neck Real Time Imge Docm PX-4027653600 CDM 76536 CPT 402 RC inpatient 548 548 CIGNA 62308 [3081051] CIGNA 62308 [308105105] 433.91 percent of total billed charges 339.76 520.6 Technical (Hospital) Services US Soft Tissue Head & Neck Real Time Imge Docm PX-4027653600 CDM 76536 CPT 402 RC inpatient 548 548 CIGNA 62308 [3081051] CIGNA STATE OF WYOMING [308105107] 433.91 percent of total billed charges 339.76 520.6 Technical (Hospital) Services US Soft Tissue Head & Neck Real Time Imge Docm PX-4027653600 CDM 76536 CPT 402 RC inpatient 548 548 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES EPO [308136803] 433.91 percent of total billed charges 339.76 520.6 Technical (Hospital) Services US Soft Tissue Head & Neck Real Time Imge Docm PX-4027653600 CDM 76536 CPT 402 RC outpatient 548 548 CIGNA 62308 [3081051] CIGNA 62308 [308105105] 438.4 percent of total billed charges 339.76 520.6 Technical (Hospital) Services US Soft Tissue Head & Neck Real Time Imge Docm PX-4027653600 CDM 76536 CPT 402 RC outpatient 548 548 CIGNA 62308 [3081051] CIGNA STATE OF WYOMING [308105107] 438.4 percent of total billed charges 339.76 520.6 Technical (Hospital) Services US Soft Tissue Head & Neck Real Time Imge Docm PX-4027653600 CDM 76536 CPT 402 RC outpatient 548 548 MEDICA (COMMERCIAL) 94265 [3081118] MEDICA CLAIMS [308111801] 493.2 percent of total billed charges 339.76 520.6 Technical (Hospital) Services US Soft Tissue Head & Neck Real Time Imge Docm PX-4027653600 CDM 76536 CPT 402 RC outpatient 548 548 BLUE CROSS BLUE SHIELD WELLMARK SB889 [3081026] BCBS WYOMING [308102603] 520.6 percent of total billed charges 339.76 520.6 Technical (Hospital) Services US Soft Tissue Head & Neck Real Time Imge Docm PX-4027653600 CDM 76536 CPT 402 RC outpatient 548 548 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES HDHP [308136802] 438.4 percent of total billed charges 339.76 520.6 Technical (Hospital) Services US Soft Tissue Head & Neck Real Time Imge Docm PX-4027653600 CDM 76536 CPT 402 RC outpatient 548 548 MULTIPLAN INC 34080 [3081285] MULTIPLAN INC [308128501] 520.6 percent of total billed charges 339.76 520.6 Technical (Hospital) Services US Soft Tissue Head & Neck Real Time Imge Docm PX-4027653600 CDM 76536 CPT 402 RC outpatient 548 548 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES PPO [308136801] 438.4 percent of total billed charges 339.76 520.6 Technical (Hospital) Services US Soft Tissue Head & Neck Real Time Imge Docm PX-4027653600 CDM 76536 CPT 402 RC outpatient 548 548 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES EPO [308136803] 438.4 percent of total billed charges 339.76 520.6 Technical (Hospital) Services US Soft Tissue Head & Neck Real Time Imge Docm PX-4027653600 CDM 76536 CPT 402 RC outpatient 548 548 HEALTHPARTNERS SX009 HEALTHPARTNERS 438.4 percent of total billed charges 339.76 520.6 Technical (Hospital) Services US Soft Tissue Head & Neck Real Time Imge Docm PX-4027653600 CDM 76536 CPT 402 RC outpatient 548 548 UNITED HEALTHCARE (COMMERCIAL) [3081199] UNITED HEALTHCARE 87726 [308119901] 339.76 percent of total billed charges 339.76 520.6 Technical (Hospital) Services CT Limited/Localized Follow Up Study PX-3507638000 CDM 76380 CPT 350 RC inpatient 785 785 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES EPO [308136803] 621.56 percent of total billed charges 486.7 745.75 Technical (Hospital) Services CT Limited/Localized Follow Up Study PX-3507638000 CDM 76380 CPT 350 RC inpatient 785 785 CIGNA 62308 [3081051] CIGNA 62308 [308105105] 621.56 percent of total billed charges 486.7 745.75 Technical (Hospital) Services CT Limited/Localized Follow Up Study PX-3507638000 CDM 76380 CPT 350 RC inpatient 785 785 CIGNA 62308 [3081051] CIGNA STATE OF WYOMING [308105107] 621.56 percent of total billed charges 486.7 745.75 Technical (Hospital) Services CT Limited/Localized Follow Up Study PX-3507638000 CDM 76380 CPT 350 RC inpatient 785 785 UNITED HEALTHCARE (COMMERCIAL) [3081199] UNITED HEALTHCARE 87726 [308119901] 486.7 percent of total billed charges 486.7 745.75 Technical (Hospital) Services CT Limited/Localized Follow Up Study PX-3507638000 CDM 76380 CPT 350 RC inpatient 785 785 BLUE CROSS BLUE SHIELD WELLMARK SB889 [3081026] BCBS WYOMING [308102603] 745.75 percent of total billed charges 486.7 745.75 Technical (Hospital) Services CT Limited/Localized Follow Up Study PX-3507638000 CDM 76380 CPT 350 RC inpatient 785 785 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES PPO [308136801] 621.56 percent of total billed charges 486.7 745.75 Technical (Hospital) Services CT Limited/Localized Follow Up Study PX-3507638000 CDM 76380 CPT 350 RC inpatient 785 785 MULTIPLAN INC 34080 [3081285] MULTIPLAN INC [308128501] 745.75 percent of total billed charges 486.7 745.75 Technical (Hospital) Services CT Limited/Localized Follow Up Study PX-3507638000 CDM 76380 CPT 350 RC inpatient 785 785 HEALTHPARTNERS SX009 HEALTHPARTNERS 621.56 percent of total billed charges 486.7 745.75 Technical (Hospital) Services CT Limited/Localized Follow Up Study PX-3507638000 CDM 76380 CPT 350 RC inpatient 785 785 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES HDHP [308136802] 621.56 percent of total billed charges 486.7 745.75 Technical (Hospital) Services CT Limited/Localized Follow Up Study PX-3507638000 CDM 76380 CPT 350 RC inpatient 785 785 MEDICA (COMMERCIAL) 94265 [3081118] MEDICA CLAIMS [308111801] 706.5 percent of total billed charges 486.7 745.75 Technical (Hospital) Services CT Limited/Localized Follow Up Study PX-3507638000 CDM 76380 CPT 350 RC outpatient 785 785 UNITED HEALTHCARE (COMMERCIAL) [3081199] UNITED HEALTHCARE 87726 [308119901] 486.7 percent of total billed charges 486.7 745.75 Technical (Hospital) Services CT Limited/Localized Follow Up Study PX-3507638000 CDM 76380 CPT 350 RC outpatient 785 785 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES EPO [308136803] 628 percent of total billed charges 486.7 745.75 Technical (Hospital) Services CT Limited/Localized Follow Up Study PX-3507638000 CDM 76380 CPT 350 RC outpatient 785 785 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES PPO [308136801] 628 percent of total billed charges 486.7 745.75 Technical (Hospital) Services CT Limited/Localized Follow Up Study PX-3507638000 CDM 76380 CPT 350 RC outpatient 785 785 BLUE CROSS BLUE SHIELD WELLMARK SB889 [3081026] BCBS WYOMING [308102603] 745.75 percent of total billed charges 486.7 745.75 Technical (Hospital) Services CT Limited/Localized Follow Up Study PX-3507638000 CDM 76380 CPT 350 RC outpatient 785 785 MULTIPLAN INC 34080 [3081285] MULTIPLAN INC [308128501] 745.75 percent of total billed charges 486.7 745.75 Technical (Hospital) Services CT Limited/Localized Follow Up Study PX-3507638000 CDM 76380 CPT 350 RC outpatient 785 785 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES HDHP [308136802] 628 percent of total billed charges 486.7 745.75 Technical (Hospital) Services CT Limited/Localized Follow Up Study PX-3507638000 CDM 76380 CPT 350 RC outpatient 785 785 HEALTHPARTNERS SX009 HEALTHPARTNERS 628 percent of total billed charges 486.7 745.75 Technical (Hospital) Services CT Limited/Localized Follow Up Study PX-3507638000 CDM 76380 CPT 350 RC outpatient 785 785 MEDICA (COMMERCIAL) 94265 [3081118] MEDICA CLAIMS [308111801] 706.5 percent of total billed charges 486.7 745.75 Technical (Hospital) Services CT Limited/Localized Follow Up Study PX-3507638000 CDM 76380 CPT 350 RC outpatient 785 785 CIGNA 62308 [3081051] CIGNA 62308 [308105105] 628 percent of total billed charges 486.7 745.75 Technical (Hospital) Services CT Limited/Localized Follow Up Study PX-3507638000 CDM 76380 CPT 350 RC outpatient 785 785 CIGNA 62308 [3081051] CIGNA STATE OF WYOMING [308105107] 628 percent of total billed charges 486.7 745.75 Technical (Hospital) Services Radex From Nose Rectum Foreign Body 1 View Chld PX-3207601000 CDM 76010 CPT 320 RC inpatient 166 166 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES EPO [308136803] 131.44 percent of total billed charges 102.92 157.7 Technical (Hospital) Services Radex From Nose Rectum Foreign Body 1 View Chld PX-3207601000 CDM 76010 CPT 320 RC inpatient 166 166 CIGNA 62308 [3081051] CIGNA 62308 [308105105] 131.44 percent of total billed charges 102.92 157.7 Technical (Hospital) Services Radex From Nose Rectum Foreign Body 1 View Chld PX-3207601000 CDM 76010 CPT 320 RC inpatient 166 166 CIGNA 62308 [3081051] CIGNA STATE OF WYOMING [308105107] 131.44 percent of total billed charges 102.92 157.7 Technical (Hospital) Services Radex From Nose Rectum Foreign Body 1 View Chld PX-3207601000 CDM 76010 CPT 320 RC inpatient 166 166 UNITED HEALTHCARE (COMMERCIAL) [3081199] UNITED HEALTHCARE 87726 [308119901] 102.92 percent of total billed charges 102.92 157.7 Technical (Hospital) Services Radex From Nose Rectum Foreign Body 1 View Chld PX-3207601000 CDM 76010 CPT 320 RC inpatient 166 166 BLUE CROSS BLUE SHIELD WELLMARK SB889 [3081026] BCBS WYOMING [308102603] 157.7 percent of total billed charges 102.92 157.7 Technical (Hospital) Services Radex From Nose Rectum Foreign Body 1 View Chld PX-3207601000 CDM 76010 CPT 320 RC inpatient 166 166 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES PPO [308136801] 131.44 percent of total billed charges 102.92 157.7 Technical (Hospital) Services Radex From Nose Rectum Foreign Body 1 View Chld PX-3207601000 CDM 76010 CPT 320 RC inpatient 166 166 MULTIPLAN INC 34080 [3081285] MULTIPLAN INC [308128501] 157.7 percent of total billed charges 102.92 157.7 Technical (Hospital) Services Radex From Nose Rectum Foreign Body 1 View Chld PX-3207601000 CDM 76010 CPT 320 RC inpatient 166 166 HEALTHPARTNERS SX009 HEALTHPARTNERS 131.44 percent of total billed charges 102.92 157.7 Technical (Hospital) Services Radex From Nose Rectum Foreign Body 1 View Chld PX-3207601000 CDM 76010 CPT 320 RC inpatient 166 166 MEDICA (COMMERCIAL) 94265 [3081118] MEDICA CLAIMS [308111801] 149.4 percent of total billed charges 102.92 157.7 Technical (Hospital) Services Radex From Nose Rectum Foreign Body 1 View Chld PX-3207601000 CDM 76010 CPT 320 RC inpatient 166 166 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES HDHP [308136802] 131.44 percent of total billed charges 102.92 157.7 Technical (Hospital) Services Radex From Nose Rectum Foreign Body 1 View Chld PX-3207601000 CDM 76010 CPT 320 RC outpatient 166 166 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES EPO [308136803] 132.8 percent of total billed charges 102.92 157.7 Technical (Hospital) Services Radex From Nose Rectum Foreign Body 1 View Chld PX-3207601000 CDM 76010 CPT 320 RC outpatient 166 166 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES PPO [308136801] 132.8 percent of total billed charges 102.92 157.7 Technical (Hospital) Services Radex From Nose Rectum Foreign Body 1 View Chld PX-3207601000 CDM 76010 CPT 320 RC outpatient 166 166 BLUE CROSS BLUE SHIELD WELLMARK SB889 [3081026] BCBS WYOMING [308102603] 157.7 percent of total billed charges 102.92 157.7 Technical (Hospital) Services Radex From Nose Rectum Foreign Body 1 View Chld PX-3207601000 CDM 76010 CPT 320 RC outpatient 166 166 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES HDHP [308136802] 132.8 percent of total billed charges 102.92 157.7 Technical (Hospital) Services Radex From Nose Rectum Foreign Body 1 View Chld PX-3207601000 CDM 76010 CPT 320 RC outpatient 166 166 MULTIPLAN INC 34080 [3081285] MULTIPLAN INC [308128501] 157.7 percent of total billed charges 102.92 157.7 Technical (Hospital) Services Radex From Nose Rectum Foreign Body 1 View Chld PX-3207601000 CDM 76010 CPT 320 RC outpatient 166 166 HEALTHPARTNERS SX009 HEALTHPARTNERS 132.8 percent of total billed charges 102.92 157.7 Technical (Hospital) Services Radex From Nose Rectum Foreign Body 1 View Chld PX-3207601000 CDM 76010 CPT 320 RC outpatient 166 166 UNITED HEALTHCARE (COMMERCIAL) [3081199] UNITED HEALTHCARE 87726 [308119901] 102.92 percent of total billed charges 102.92 157.7 Technical (Hospital) Services Radex From Nose Rectum Foreign Body 1 View Chld PX-3207601000 CDM 76010 CPT 320 RC outpatient 166 166 MEDICA (COMMERCIAL) 94265 [3081118] MEDICA CLAIMS [308111801] 149.4 percent of total billed charges 102.92 157.7 Technical (Hospital) Services Radex From Nose Rectum Foreign Body 1 View Chld PX-3207601000 CDM 76010 CPT 320 RC outpatient 166 166 CIGNA 62308 [3081051] CIGNA 62308 [308105105] 132.8 percent of total billed charges 102.92 157.7 Technical (Hospital) Services Radex From Nose Rectum Foreign Body 1 View Chld PX-3207601000 CDM 76010 CPT 320 RC outpatient 166 166 CIGNA 62308 [3081051] CIGNA STATE OF WYOMING [308105107] 132.8 percent of total billed charges 102.92 157.7 Technical (Hospital) Services Cta Abdl Aorta&Bi Iliofem W/Contrast&Postp PX-3507563500 CDM 75635 CPT 350 RC inpatient 4339 4339 MULTIPLAN INC 34080 [3081285] MULTIPLAN INC [308128501] 4122.05 percent of total billed charges 2690.18 4122.05 Technical (Hospital) Services Cta Abdl Aorta&Bi Iliofem W/Contrast&Postp PX-3507563500 CDM 75635 CPT 350 RC inpatient 4339 4339 BLUE CROSS BLUE SHIELD WELLMARK SB889 [3081026] BCBS WYOMING [308102603] 4122.05 percent of total billed charges 2690.18 4122.05 Technical (Hospital) Services Cta Abdl Aorta&Bi Iliofem W/Contrast&Postp PX-3507563500 CDM 75635 CPT 350 RC inpatient 4339 4339 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES PPO [308136801] 3435.62 percent of total billed charges 2690.18 4122.05 Technical (Hospital) Services Cta Abdl Aorta&Bi Iliofem W/Contrast&Postp PX-3507563500 CDM 75635 CPT 350 RC inpatient 4339 4339 UNITED HEALTHCARE (COMMERCIAL) [3081199] UNITED HEALTHCARE 87726 [308119901] 2690.18 percent of total billed charges 2690.18 4122.05 Technical (Hospital) Services Cta Abdl Aorta&Bi Iliofem W/Contrast&Postp PX-3507563500 CDM 75635 CPT 350 RC inpatient 4339 4339 HEALTHPARTNERS SX009 HEALTHPARTNERS 3435.62 percent of total billed charges 2690.18 4122.05 Technical (Hospital) Services Cta Abdl Aorta&Bi Iliofem W/Contrast&Postp PX-3507563500 CDM 75635 CPT 350 RC inpatient 4339 4339 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES HDHP [308136802] 3435.62 percent of total billed charges 2690.18 4122.05 Technical (Hospital) Services Cta Abdl Aorta&Bi Iliofem W/Contrast&Postp PX-3507563500 CDM 75635 CPT 350 RC inpatient 4339 4339 MEDICA (COMMERCIAL) 94265 [3081118] MEDICA CLAIMS [308111801] 3905.1 percent of total billed charges 2690.18 4122.05 Technical (Hospital) Services Cta Abdl Aorta&Bi Iliofem W/Contrast&Postp PX-3507563500 CDM 75635 CPT 350 RC inpatient 4339 4339 CIGNA 62308 [3081051] CIGNA 62308 [308105105] 3435.62 percent of total billed charges 2690.18 4122.05 Technical (Hospital) Services Cta Abdl Aorta&Bi Iliofem W/Contrast&Postp PX-3507563500 CDM 75635 CPT 350 RC inpatient 4339 4339 CIGNA 62308 [3081051] CIGNA STATE OF WYOMING [308105107] 3435.62 percent of total billed charges 2690.18 4122.05 Technical (Hospital) Services Cta Abdl Aorta&Bi Iliofem W/Contrast&Postp PX-3507563500 CDM 75635 CPT 350 RC inpatient 4339 4339 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES EPO [308136803] 3435.62 percent of total billed charges 2690.18 4122.05 Technical (Hospital) Services Cta Abdl Aorta&Bi Iliofem W/Contrast&Postp PX-3507563500 CDM 75635 CPT 350 RC outpatient 4339 4339 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES HDHP [308136802] 3471.2 percent of total billed charges 2690.18 4122.05 Technical (Hospital) Services Cta Abdl Aorta&Bi Iliofem W/Contrast&Postp PX-3507563500 CDM 75635 CPT 350 RC outpatient 4339 4339 MULTIPLAN INC 34080 [3081285] MULTIPLAN INC [308128501] 4122.05 percent of total billed charges 2690.18 4122.05 Technical (Hospital) Services Cta Abdl Aorta&Bi Iliofem W/Contrast&Postp PX-3507563500 CDM 75635 CPT 350 RC outpatient 4339 4339 BLUE CROSS BLUE SHIELD WELLMARK SB889 [3081026] BCBS WYOMING [308102603] 4122.05 percent of total billed charges 2690.18 4122.05 Technical (Hospital) Services Cta Abdl Aorta&Bi Iliofem W/Contrast&Postp PX-3507563500 CDM 75635 CPT 350 RC outpatient 4339 4339 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES EPO [308136803] 3471.2 percent of total billed charges 2690.18 4122.05 Technical (Hospital) Services Cta Abdl Aorta&Bi Iliofem W/Contrast&Postp PX-3507563500 CDM 75635 CPT 350 RC outpatient 4339 4339 UNITED HEALTHCARE (COMMERCIAL) [3081199] UNITED HEALTHCARE 87726 [308119901] 2690.18 percent of total billed charges 2690.18 4122.05 Technical (Hospital) Services Cta Abdl Aorta&Bi Iliofem W/Contrast&Postp PX-3507563500 CDM 75635 CPT 350 RC outpatient 4339 4339 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES PPO [308136801] 3471.2 percent of total billed charges 2690.18 4122.05 Technical (Hospital) Services Cta Abdl Aorta&Bi Iliofem W/Contrast&Postp PX-3507563500 CDM 75635 CPT 350 RC outpatient 4339 4339 HEALTHPARTNERS SX009 HEALTHPARTNERS 3471.2 percent of total billed charges 2690.18 4122.05 Technical (Hospital) Services Cta Abdl Aorta&Bi Iliofem W/Contrast&Postp PX-3507563500 CDM 75635 CPT 350 RC outpatient 4339 4339 CIGNA 62308 [3081051] CIGNA 62308 [308105105] 3471.2 percent of total billed charges 2690.18 4122.05 Technical (Hospital) Services Cta Abdl Aorta&Bi Iliofem W/Contrast&Postp PX-3507563500 CDM 75635 CPT 350 RC outpatient 4339 4339 CIGNA 62308 [3081051] CIGNA STATE OF WYOMING [308105107] 3471.2 percent of total billed charges 2690.18 4122.05 Technical (Hospital) Services Cta Abdl Aorta&Bi Iliofem W/Contrast&Postp PX-3507563500 CDM 75635 CPT 350 RC outpatient 4339 4339 MEDICA (COMMERCIAL) 94265 [3081118] MEDICA CLAIMS [308111801] 3905.1 percent of total billed charges 2690.18 4122.05 Technical (Hospital) Services Urethrocystography Voiding Rs&I PX-3207445500 CDM 74455 CPT 320 RC outpatient 878 878 CIGNA 62308 [3081051] CIGNA 62308 [308105105] 702.4 percent of total billed charges 544.36 834.1 Technical (Hospital) Services Urethrocystography Voiding Rs&I PX-3207445500 CDM 74455 CPT 320 RC outpatient 878 878 CIGNA 62308 [3081051] CIGNA STATE OF WYOMING [308105107] 702.4 percent of total billed charges 544.36 834.1 Technical (Hospital) Services Urethrocystography Voiding Rs&I PX-3207445500 CDM 74455 CPT 320 RC outpatient 878 878 MEDICA (COMMERCIAL) 94265 [3081118] MEDICA CLAIMS [308111801] 790.2 percent of total billed charges 544.36 834.1 Technical (Hospital) Services Urethrocystography Voiding Rs&I PX-3207445500 CDM 74455 CPT 320 RC outpatient 878 878 HEALTHPARTNERS SX009 HEALTHPARTNERS 702.4 percent of total billed charges 544.36 834.1 Technical (Hospital) Services Urethrocystography Voiding Rs&I PX-3207445500 CDM 74455 CPT 320 RC outpatient 878 878 UNITED HEALTHCARE (COMMERCIAL) [3081199] UNITED HEALTHCARE 87726 [308119901] 544.36 percent of total billed charges 544.36 834.1 Technical (Hospital) Services Urethrocystography Voiding Rs&I PX-3207445500 CDM 74455 CPT 320 RC outpatient 878 878 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES PPO [308136801] 702.4 percent of total billed charges 544.36 834.1 Technical (Hospital) Services Urethrocystography Voiding Rs&I PX-3207445500 CDM 74455 CPT 320 RC outpatient 878 878 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES EPO [308136803] 702.4 percent of total billed charges 544.36 834.1 Technical (Hospital) Services Urethrocystography Voiding Rs&I PX-3207445500 CDM 74455 CPT 320 RC outpatient 878 878 BLUE CROSS BLUE SHIELD WELLMARK SB889 [3081026] BCBS WYOMING [308102603] 834.1 percent of total billed charges 544.36 834.1 Technical (Hospital) Services Urethrocystography Voiding Rs&I PX-3207445500 CDM 74455 CPT 320 RC outpatient 878 878 MULTIPLAN INC 34080 [3081285] MULTIPLAN INC [308128501] 834.1 percent of total billed charges 544.36 834.1 Technical (Hospital) Services Urethrocystography Voiding Rs&I PX-3207445500 CDM 74455 CPT 320 RC outpatient 878 878 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES HDHP [308136802] 702.4 percent of total billed charges 544.36 834.1 Technical (Hospital) Services Urethrocystography Voiding Rs&I PX-3207445500 CDM 74455 CPT 320 RC inpatient 878 878 HEALTHPARTNERS SX009 HEALTHPARTNERS 695.2 percent of total billed charges 544.36 834.1 Technical (Hospital) Services Urethrocystography Voiding Rs&I PX-3207445500 CDM 74455 CPT 320 RC inpatient 878 878 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES HDHP [308136802] 695.2 percent of total billed charges 544.36 834.1 Technical (Hospital) Services Urethrocystography Voiding Rs&I PX-3207445500 CDM 74455 CPT 320 RC inpatient 878 878 MEDICA (COMMERCIAL) 94265 [3081118] MEDICA CLAIMS [308111801] 790.2 percent of total billed charges 544.36 834.1 Technical (Hospital) Services Urethrocystography Voiding Rs&I PX-3207445500 CDM 74455 CPT 320 RC inpatient 878 878 MULTIPLAN INC 34080 [3081285] MULTIPLAN INC [308128501] 834.1 percent of total billed charges 544.36 834.1 Technical (Hospital) Services Urethrocystography Voiding Rs&I PX-3207445500 CDM 74455 CPT 320 RC inpatient 878 878 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES PPO [308136801] 695.2 percent of total billed charges 544.36 834.1 Technical (Hospital) Services Urethrocystography Voiding Rs&I PX-3207445500 CDM 74455 CPT 320 RC inpatient 878 878 BLUE CROSS BLUE SHIELD WELLMARK SB889 [3081026] BCBS WYOMING [308102603] 834.1 percent of total billed charges 544.36 834.1 Technical (Hospital) Services Urethrocystography Voiding Rs&I PX-3207445500 CDM 74455 CPT 320 RC inpatient 878 878 UNITED HEALTHCARE (COMMERCIAL) [3081199] UNITED HEALTHCARE 87726 [308119901] 544.36 percent of total billed charges 544.36 834.1 Technical (Hospital) Services Urethrocystography Voiding Rs&I PX-3207445500 CDM 74455 CPT 320 RC inpatient 878 878 CIGNA 62308 [3081051] CIGNA 62308 [308105105] 695.2 percent of total billed charges 544.36 834.1 Technical (Hospital) Services Urethrocystography Voiding Rs&I PX-3207445500 CDM 74455 CPT 320 RC inpatient 878 878 CIGNA 62308 [3081051] CIGNA STATE OF WYOMING [308105107] 695.2 percent of total billed charges 544.36 834.1 Technical (Hospital) Services Urethrocystography Voiding Rs&I PX-3207445500 CDM 74455 CPT 320 RC inpatient 878 878 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES EPO [308136803] 695.2 percent of total billed charges 544.36 834.1 Technical (Hospital) Services Urography IV W/WO Kub W/WO Tomography PX-3207440000 CDM 74400 CPT 320 RC inpatient 950 950 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES HDHP [308136802] 752.21 percent of total billed charges 589 902.5 Technical (Hospital) Services Urography IV W/WO Kub W/WO Tomography PX-3207440000 CDM 74400 CPT 320 RC inpatient 950 950 MEDICA (COMMERCIAL) 94265 [3081118] MEDICA CLAIMS [308111801] 855 percent of total billed charges 589 902.5 Technical (Hospital) Services Urography IV W/WO Kub W/WO Tomography PX-3207440000 CDM 74400 CPT 320 RC inpatient 950 950 HEALTHPARTNERS SX009 HEALTHPARTNERS 752.21 percent of total billed charges 589 902.5 Technical (Hospital) Services Urography IV W/WO Kub W/WO Tomography PX-3207440000 CDM 74400 CPT 320 RC inpatient 950 950 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES PPO [308136801] 752.21 percent of total billed charges 589 902.5 Technical (Hospital) Services Urography IV W/WO Kub W/WO Tomography PX-3207440000 CDM 74400 CPT 320 RC inpatient 950 950 BLUE CROSS BLUE SHIELD WELLMARK SB889 [3081026] BCBS WYOMING [308102603] 902.5 percent of total billed charges 589 902.5 Technical (Hospital) Services Urography IV W/WO Kub W/WO Tomography PX-3207440000 CDM 74400 CPT 320 RC inpatient 950 950 MULTIPLAN INC 34080 [3081285] MULTIPLAN INC [308128501] 902.5 percent of total billed charges 589 902.5 Technical (Hospital) Services Urography IV W/WO Kub W/WO Tomography PX-3207440000 CDM 74400 CPT 320 RC inpatient 950 950 UNITED HEALTHCARE (COMMERCIAL) [3081199] UNITED HEALTHCARE 87726 [308119901] 589 percent of total billed charges 589 902.5 Technical (Hospital) Services Urography IV W/WO Kub W/WO Tomography PX-3207440000 CDM 74400 CPT 320 RC inpatient 950 950 CIGNA 62308 [3081051] CIGNA STATE OF WYOMING [308105107] 752.21 percent of total billed charges 589 902.5 Technical (Hospital) Services Urography IV W/WO Kub W/WO Tomography PX-3207440000 CDM 74400 CPT 320 RC inpatient 950 950 CIGNA 62308 [3081051] CIGNA 62308 [308105105] 752.21 percent of total billed charges 589 902.5 Technical (Hospital) Services Urography IV W/WO Kub W/WO Tomography PX-3207440000 CDM 74400 CPT 320 RC inpatient 950 950 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES EPO [308136803] 752.21 percent of total billed charges 589 902.5 Technical (Hospital) Services Urography IV W/WO Kub W/WO Tomography PX-3207440000 CDM 74400 CPT 320 RC outpatient 950 950 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES HDHP [308136802] 760 percent of total billed charges 589 902.5 Technical (Hospital) Services Urography IV W/WO Kub W/WO Tomography PX-3207440000 CDM 74400 CPT 320 RC outpatient 950 950 MULTIPLAN INC 34080 [3081285] MULTIPLAN INC [308128501] 902.5 percent of total billed charges 589 902.5 Technical (Hospital) Services Urography IV W/WO Kub W/WO Tomography PX-3207440000 CDM 74400 CPT 320 RC outpatient 950 950 BLUE CROSS BLUE SHIELD WELLMARK SB889 [3081026] BCBS WYOMING [308102603] 902.5 percent of total billed charges 589 902.5 Technical (Hospital) Services Urography IV W/WO Kub W/WO Tomography PX-3207440000 CDM 74400 CPT 320 RC outpatient 950 950 UNITED HEALTHCARE (COMMERCIAL) [3081199] UNITED HEALTHCARE 87726 [308119901] 589 percent of total billed charges 589 902.5 Technical (Hospital) Services Urography IV W/WO Kub W/WO Tomography PX-3207440000 CDM 74400 CPT 320 RC outpatient 950 950 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES EPO [308136803] 760 percent of total billed charges 589 902.5 Technical (Hospital) Services Urography IV W/WO Kub W/WO Tomography PX-3207440000 CDM 74400 CPT 320 RC outpatient 950 950 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES PPO [308136801] 760 percent of total billed charges 589 902.5 Technical (Hospital) Services Urography IV W/WO Kub W/WO Tomography PX-3207440000 CDM 74400 CPT 320 RC outpatient 950 950 HEALTHPARTNERS SX009 HEALTHPARTNERS 760 percent of total billed charges 589 902.5 Technical (Hospital) Services Urography IV W/WO Kub W/WO Tomography PX-3207440000 CDM 74400 CPT 320 RC outpatient 950 950 CIGNA 62308 [3081051] CIGNA 62308 [308105105] 760 percent of total billed charges 589 902.5 Technical (Hospital) Services Urography IV W/WO Kub W/WO Tomography PX-3207440000 CDM 74400 CPT 320 RC outpatient 950 950 CIGNA 62308 [3081051] CIGNA STATE OF WYOMING [308105107] 760 percent of total billed charges 589 902.5 Technical (Hospital) Services Urography IV W/WO Kub W/WO Tomography PX-3207440000 CDM 74400 CPT 320 RC outpatient 950 950 MEDICA (COMMERCIAL) 94265 [3081118] MEDICA CLAIMS [308111801] 855 percent of total billed charges 589 902.5 Technical (Hospital) Services Cholangiography&/Pancreatography Ntraop Rs&I PX-3207430000 CDM 74300 CPT 320 RC outpatient 448 448 HEALTHPARTNERS SX009 HEALTHPARTNERS 358.4 percent of total billed charges 277.76 425.6 Technical (Hospital) Services Cholangiography&/Pancreatography Ntraop Rs&I PX-3207430000 CDM 74300 CPT 320 RC outpatient 448 448 BLUE CROSS BLUE SHIELD WELLMARK SB889 [3081026] BCBS WYOMING [308102603] 425.6 percent of total billed charges 277.76 425.6 Technical (Hospital) Services Cholangiography&/Pancreatography Ntraop Rs&I PX-3207430000 CDM 74300 CPT 320 RC outpatient 448 448 MULTIPLAN INC 34080 [3081285] MULTIPLAN INC [308128501] 425.6 percent of total billed charges 277.76 425.6 Technical (Hospital) Services Cholangiography&/Pancreatography Ntraop Rs&I PX-3207430000 CDM 74300 CPT 320 RC outpatient 448 448 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES HDHP [308136802] 358.4 percent of total billed charges 277.76 425.6 Technical (Hospital) Services Cholangiography&/Pancreatography Ntraop Rs&I PX-3207430000 CDM 74300 CPT 320 RC outpatient 448 448 UNITED HEALTHCARE (COMMERCIAL) [3081199] UNITED HEALTHCARE 87726 [308119901] 277.76 percent of total billed charges 277.76 425.6 Technical (Hospital) Services Cholangiography&/Pancreatography Ntraop Rs&I PX-3207430000 CDM 74300 CPT 320 RC outpatient 448 448 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES EPO [308136803] 358.4 percent of total billed charges 277.76 425.6 Technical (Hospital) Services Cholangiography&/Pancreatography Ntraop Rs&I PX-3207430000 CDM 74300 CPT 320 RC outpatient 448 448 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES PPO [308136801] 358.4 percent of total billed charges 277.76 425.6 Technical (Hospital) Services Cholangiography&/Pancreatography Ntraop Rs&I PX-3207430000 CDM 74300 CPT 320 RC outpatient 448 448 CIGNA 62308 [3081051] CIGNA 62308 [308105105] 358.4 percent of total billed charges 277.76 425.6 Technical (Hospital) Services Cholangiography&/Pancreatography Ntraop Rs&I PX-3207430000 CDM 74300 CPT 320 RC outpatient 448 448 CIGNA 62308 [3081051] CIGNA STATE OF WYOMING [308105107] 358.4 percent of total billed charges 277.76 425.6 Technical (Hospital) Services Cholangiography&/Pancreatography Ntraop Rs&I PX-3207430000 CDM 74300 CPT 320 RC outpatient 448 448 MEDICA (COMMERCIAL) 94265 [3081118] MEDICA CLAIMS [308111801] 403.2 percent of total billed charges 277.76 425.6 Technical (Hospital) Services Cholangiography&/Pancreatography Ntraop Rs&I PX-3207430000 CDM 74300 CPT 320 RC inpatient 448 448 CIGNA 62308 [3081051] CIGNA 62308 [308105105] 354.73 percent of total billed charges 277.76 425.6 Technical (Hospital) Services Cholangiography&/Pancreatography Ntraop Rs&I PX-3207430000 CDM 74300 CPT 320 RC inpatient 448 448 CIGNA 62308 [3081051] CIGNA STATE OF WYOMING [308105107] 354.73 percent of total billed charges 277.76 425.6 Technical (Hospital) Services Cholangiography&/Pancreatography Ntraop Rs&I PX-3207430000 CDM 74300 CPT 320 RC inpatient 448 448 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES EPO [308136803] 354.73 percent of total billed charges 277.76 425.6 Technical (Hospital) Services Cholangiography&/Pancreatography Ntraop Rs&I PX-3207430000 CDM 74300 CPT 320 RC inpatient 448 448 MEDICA (COMMERCIAL) 94265 [3081118] MEDICA CLAIMS [308111801] 403.2 percent of total billed charges 277.76 425.6 Technical (Hospital) Services Cholangiography&/Pancreatography Ntraop Rs&I PX-3207430000 CDM 74300 CPT 320 RC inpatient 448 448 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES HDHP [308136802] 354.73 percent of total billed charges 277.76 425.6 Technical (Hospital) Services Cholangiography&/Pancreatography Ntraop Rs&I PX-3207430000 CDM 74300 CPT 320 RC inpatient 448 448 HEALTHPARTNERS SX009 HEALTHPARTNERS 354.73 percent of total billed charges 277.76 425.6 Technical (Hospital) Services Cholangiography&/Pancreatography Ntraop Rs&I PX-3207430000 CDM 74300 CPT 320 RC inpatient 448 448 MULTIPLAN INC 34080 [3081285] MULTIPLAN INC [308128501] 425.6 percent of total billed charges 277.76 425.6 Technical (Hospital) Services Cholangiography&/Pancreatography Ntraop Rs&I PX-3207430000 CDM 74300 CPT 320 RC inpatient 448 448 BLUE CROSS BLUE SHIELD WELLMARK SB889 [3081026] BCBS WYOMING [308102603] 425.6 percent of total billed charges 277.76 425.6 Technical (Hospital) Services Cholangiography&/Pancreatography Ntraop Rs&I PX-3207430000 CDM 74300 CPT 320 RC inpatient 448 448 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES PPO [308136801] 354.73 percent of total billed charges 277.76 425.6 Technical (Hospital) Services Cholangiography&/Pancreatography Ntraop Rs&I PX-3207430000 CDM 74300 CPT 320 RC inpatient 448 448 UNITED HEALTHCARE (COMMERCIAL) [3081199] UNITED HEALTHCARE 87726 [308119901] 277.76 percent of total billed charges 277.76 425.6 Technical (Hospital) Services Mra Abdomen W Contrast Material PX-6187418500 CDM 74185 CPT 618 RC inpatient 3799 3799 MULTIPLAN INC 34080 [3081285] MULTIPLAN INC [308128501] 3609.05 percent of total billed charges 2355.38 3609.05 Technical (Hospital) Services Mra Abdomen W Contrast Material PX-6187418500 CDM 74185 CPT 618 RC inpatient 3799 3799 BLUE CROSS BLUE SHIELD WELLMARK SB889 [3081026] BCBS WYOMING [308102603] 3609.05 percent of total billed charges 2355.38 3609.05 Technical (Hospital) Services Mra Abdomen W Contrast Material PX-6187418500 CDM 74185 CPT 618 RC inpatient 3799 3799 UNITED HEALTHCARE (COMMERCIAL) [3081199] UNITED HEALTHCARE 87726 [308119901] 2355.38 percent of total billed charges 2355.38 3609.05 Technical (Hospital) Services Mra Abdomen W Contrast Material PX-6187418500 CDM 74185 CPT 618 RC inpatient 3799 3799 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES PPO [308136801] 3008.05 percent of total billed charges 2355.38 3609.05 Technical (Hospital) Services Mra Abdomen W Contrast Material PX-6187418500 CDM 74185 CPT 618 RC inpatient 3799 3799 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES HDHP [308136802] 3008.05 percent of total billed charges 2355.38 3609.05 Technical (Hospital) Services Mra Abdomen W Contrast Material PX-6187418500 CDM 74185 CPT 618 RC inpatient 3799 3799 MEDICA (COMMERCIAL) 94265 [3081118] MEDICA CLAIMS [308111801] 3419.1 percent of total billed charges 2355.38 3609.05 Technical (Hospital) Services Mra Abdomen W Contrast Material PX-6187418500 CDM 74185 CPT 618 RC inpatient 3799 3799 HEALTHPARTNERS SX009 HEALTHPARTNERS 3008.05 percent of total billed charges 2355.38 3609.05 Technical (Hospital) Services Mra Abdomen W Contrast Material PX-6187418500 CDM 74185 CPT 618 RC inpatient 3799 3799 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES EPO [308136803] 3008.05 percent of total billed charges 2355.38 3609.05 Technical (Hospital) Services Mra Abdomen W Contrast Material PX-6187418500 CDM 74185 CPT 618 RC inpatient 3799 3799 CIGNA 62308 [3081051] CIGNA 62308 [308105105] 3008.05 percent of total billed charges 2355.38 3609.05 Technical (Hospital) Services Mra Abdomen W Contrast Material PX-6187418500 CDM 74185 CPT 618 RC inpatient 3799 3799 CIGNA 62308 [3081051] CIGNA STATE OF WYOMING [308105107] 3008.05 percent of total billed charges 2355.38 3609.05 Technical (Hospital) Services Mra Abdomen W Contrast Material PX-6187418500 CDM 74185 CPT 618 RC outpatient 3799 3799 MEDICA (COMMERCIAL) 94265 [3081118] MEDICA CLAIMS [308111801] 3419.1 percent of total billed charges 2355.38 3609.05 Technical (Hospital) Services Mra Abdomen W Contrast Material PX-6187418500 CDM 74185 CPT 618 RC outpatient 3799 3799 CIGNA 62308 [3081051] CIGNA 62308 [308105105] 3039.2 percent of total billed charges 2355.38 3609.05 Technical (Hospital) Services Mra Abdomen W Contrast Material PX-6187418500 CDM 74185 CPT 618 RC outpatient 3799 3799 CIGNA 62308 [3081051] CIGNA STATE OF WYOMING [308105107] 3039.2 percent of total billed charges 2355.38 3609.05 Technical (Hospital) Services Mra Abdomen W Contrast Material PX-6187418500 CDM 74185 CPT 618 RC outpatient 3799 3799 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES HDHP [308136802] 3039.2 percent of total billed charges 2355.38 3609.05 Technical (Hospital) Services Mra Abdomen W Contrast Material PX-6187418500 CDM 74185 CPT 618 RC outpatient 3799 3799 MULTIPLAN INC 34080 [3081285] MULTIPLAN INC [308128501] 3609.05 percent of total billed charges 2355.38 3609.05 Technical (Hospital) Services Mra Abdomen W Contrast Material PX-6187418500 CDM 74185 CPT 618 RC outpatient 3799 3799 BLUE CROSS BLUE SHIELD WELLMARK SB889 [3081026] BCBS WYOMING [308102603] 3609.05 percent of total billed charges 2355.38 3609.05 Technical (Hospital) Services Mra Abdomen W Contrast Material PX-6187418500 CDM 74185 CPT 618 RC outpatient 3799 3799 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES PPO [308136801] 3039.2 percent of total billed charges 2355.38 3609.05 Technical (Hospital) Services Mra Abdomen W Contrast Material PX-6187418500 CDM 74185 CPT 618 RC outpatient 3799 3799 UNITED HEALTHCARE (COMMERCIAL) [3081199] UNITED HEALTHCARE 87726 [308119901] 2355.38 percent of total billed charges 2355.38 3609.05 Technical (Hospital) Services Mra Abdomen W Contrast Material PX-6187418500 CDM 74185 CPT 618 RC outpatient 3799 3799 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES EPO [308136803] 3039.2 percent of total billed charges 2355.38 3609.05 Technical (Hospital) Services Mra Abdomen W Contrast Material PX-6187418500 CDM 74185 CPT 618 RC outpatient 3799 3799 HEALTHPARTNERS SX009 HEALTHPARTNERS 3039.2 percent of total billed charges 2355.38 3609.05 Technical (Hospital) Services MRI Abdomen W/O & W/Contrast Material PX-6107418300 CDM 74183 CPT 610 RC inpatient 4286 4286 CIGNA 62308 [3081051] CIGNA 62308 [308105105] 3393.65 percent of total billed charges 2657.32 4071.7 Technical (Hospital) Services MRI Abdomen W/O & W/Contrast Material PX-6107418300 CDM 74183 CPT 610 RC inpatient 4286 4286 CIGNA 62308 [3081051] CIGNA STATE OF WYOMING [308105107] 3393.65 percent of total billed charges 2657.32 4071.7 Technical (Hospital) Services MRI Abdomen W/O & W/Contrast Material PX-6107418300 CDM 74183 CPT 610 RC inpatient 4286 4286 UNITED HEALTHCARE (COMMERCIAL) [3081199] UNITED HEALTHCARE 87726 [308119901] 2657.32 percent of total billed charges 2657.32 4071.7 Technical (Hospital) Services MRI Abdomen W/O & W/Contrast Material PX-6107418300 CDM 74183 CPT 610 RC inpatient 4286 4286 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES PPO [308136801] 3393.65 percent of total billed charges 2657.32 4071.7 Technical (Hospital) Services MRI Abdomen W/O & W/Contrast Material PX-6107418300 CDM 74183 CPT 610 RC inpatient 4286 4286 BLUE CROSS BLUE SHIELD WELLMARK SB889 [3081026] BCBS WYOMING [308102603] 4071.7 percent of total billed charges 2657.32 4071.7 Technical (Hospital) Services MRI Abdomen W/O & W/Contrast Material PX-6107418300 CDM 74183 CPT 610 RC inpatient 4286 4286 MULTIPLAN INC 34080 [3081285] MULTIPLAN INC [308128501] 4071.7 percent of total billed charges 2657.32 4071.7 Technical (Hospital) Services MRI Abdomen W/O & W/Contrast Material PX-6107418300 CDM 74183 CPT 610 RC inpatient 4286 4286 MEDICA (COMMERCIAL) 94265 [3081118] MEDICA CLAIMS [308111801] 3857.4 percent of total billed charges 2657.32 4071.7 Technical (Hospital) Services MRI Abdomen W/O & W/Contrast Material PX-6107418300 CDM 74183 CPT 610 RC inpatient 4286 4286 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES HDHP [308136802] 3393.65 percent of total billed charges 2657.32 4071.7 Technical (Hospital) Services MRI Abdomen W/O & W/Contrast Material PX-6107418300 CDM 74183 CPT 610 RC inpatient 4286 4286 HEALTHPARTNERS SX009 HEALTHPARTNERS 3393.65 percent of total billed charges 2657.32 4071.7 Technical (Hospital) Services MRI Abdomen W/O & W/Contrast Material PX-6107418300 CDM 74183 CPT 610 RC inpatient 4286 4286 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES EPO [308136803] 3393.65 percent of total billed charges 2657.32 4071.7 Technical (Hospital) Services MRI Abdomen W/O & W/Contrast Material PX-6107418300 CDM 74183 CPT 610 RC outpatient 4286 4286 MEDICA (COMMERCIAL) 94265 [3081118] MEDICA CLAIMS [308111801] 3857.4 percent of total billed charges 2657.32 4071.7 Technical (Hospital) Services MRI Abdomen W/O & W/Contrast Material PX-6107418300 CDM 74183 CPT 610 RC outpatient 4286 4286 CIGNA 62308 [3081051] CIGNA 62308 [308105105] 3428.8 percent of total billed charges 2657.32 4071.7 Technical (Hospital) Services MRI Abdomen W/O & W/Contrast Material PX-6107418300 CDM 74183 CPT 610 RC outpatient 4286 4286 CIGNA 62308 [3081051] CIGNA STATE OF WYOMING [308105107] 3428.8 percent of total billed charges 2657.32 4071.7 Technical (Hospital) Services MRI Abdomen W/O & W/Contrast Material PX-6107418300 CDM 74183 CPT 610 RC outpatient 4286 4286 BLUE CROSS BLUE SHIELD WELLMARK SB889 [3081026] BCBS WYOMING [308102603] 4071.7 percent of total billed charges 2657.32 4071.7 Technical (Hospital) Services MRI Abdomen W/O & W/Contrast Material PX-6107418300 CDM 74183 CPT 610 RC outpatient 4286 4286 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES HDHP [308136802] 3428.8 percent of total billed charges 2657.32 4071.7 Technical (Hospital) Services MRI Abdomen W/O & W/Contrast Material PX-6107418300 CDM 74183 CPT 610 RC outpatient 4286 4286 MULTIPLAN INC 34080 [3081285] MULTIPLAN INC [308128501] 4071.7 percent of total billed charges 2657.32 4071.7 Technical (Hospital) Services MRI Abdomen W/O & W/Contrast Material PX-6107418300 CDM 74183 CPT 610 RC outpatient 4286 4286 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES PPO [308136801] 3428.8 percent of total billed charges 2657.32 4071.7 Technical (Hospital) Services MRI Abdomen W/O & W/Contrast Material PX-6107418300 CDM 74183 CPT 610 RC outpatient 4286 4286 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES EPO [308136803] 3428.8 percent of total billed charges 2657.32 4071.7 Technical (Hospital) Services MRI Abdomen W/O & W/Contrast Material PX-6107418300 CDM 74183 CPT 610 RC outpatient 4286 4286 UNITED HEALTHCARE (COMMERCIAL) [3081199] UNITED HEALTHCARE 87726 [308119901] 2657.32 percent of total billed charges 2657.32 4071.7 Technical (Hospital) Services MRI Abdomen W/O & W/Contrast Material PX-6107418300 CDM 74183 CPT 610 RC outpatient 4286 4286 HEALTHPARTNERS SX009 HEALTHPARTNERS 3428.8 percent of total billed charges 2657.32 4071.7 Technical (Hospital) Services MRI Abdomen W/Contrast Material PX-6107418200 CDM 74182 CPT 610 RC inpatient 3275 3275 CIGNA 62308 [3081051] CIGNA 62308 [308105105] 2593.15 percent of total billed charges 2030.5 3111.25 Technical (Hospital) Services MRI Abdomen W/Contrast Material PX-6107418200 CDM 74182 CPT 610 RC inpatient 3275 3275 CIGNA 62308 [3081051] CIGNA STATE OF WYOMING [308105107] 2593.15 percent of total billed charges 2030.5 3111.25 Technical (Hospital) Services MRI Abdomen W/Contrast Material PX-6107418200 CDM 74182 CPT 610 RC inpatient 3275 3275 MULTIPLAN INC 34080 [3081285] MULTIPLAN INC [308128501] 3111.25 percent of total billed charges 2030.5 3111.25 Technical (Hospital) Services MRI Abdomen W/Contrast Material PX-6107418200 CDM 74182 CPT 610 RC inpatient 3275 3275 BLUE CROSS BLUE SHIELD WELLMARK SB889 [3081026] BCBS WYOMING [308102603] 3111.25 percent of total billed charges 2030.5 3111.25 Technical (Hospital) Services MRI Abdomen W/Contrast Material PX-6107418200 CDM 74182 CPT 610 RC inpatient 3275 3275 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES PPO [308136801] 2593.15 percent of total billed charges 2030.5 3111.25 Technical (Hospital) Services MRI Abdomen W/Contrast Material PX-6107418200 CDM 74182 CPT 610 RC inpatient 3275 3275 UNITED HEALTHCARE (COMMERCIAL) [3081199] UNITED HEALTHCARE 87726 [308119901] 2030.5 percent of total billed charges 2030.5 3111.25 Technical (Hospital) Services MRI Abdomen W/Contrast Material PX-6107418200 CDM 74182 CPT 610 RC inpatient 3275 3275 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES EPO [308136803] 2593.15 percent of total billed charges 2030.5 3111.25 Technical (Hospital) Services MRI Abdomen W/Contrast Material PX-6107418200 CDM 74182 CPT 610 RC inpatient 3275 3275 HEALTHPARTNERS SX009 HEALTHPARTNERS 2593.15 percent of total billed charges 2030.5 3111.25 Technical (Hospital) Services MRI Abdomen W/Contrast Material PX-6107418200 CDM 74182 CPT 610 RC inpatient 3275 3275 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES HDHP [308136802] 2593.15 percent of total billed charges 2030.5 3111.25 Technical (Hospital) Services MRI Abdomen W/Contrast Material PX-6107418200 CDM 74182 CPT 610 RC inpatient 3275 3275 MEDICA (COMMERCIAL) 94265 [3081118] MEDICA CLAIMS [308111801] 2947.5 percent of total billed charges 2030.5 3111.25 Technical (Hospital) Services MRI Abdomen W/Contrast Material PX-6107418200 CDM 74182 CPT 610 RC outpatient 3275 3275 UNITED HEALTHCARE (COMMERCIAL) [3081199] UNITED HEALTHCARE 87726 [308119901] 2030.5 percent of total billed charges 2030.5 3111.25 Technical (Hospital) Services MRI Abdomen W/Contrast Material PX-6107418200 CDM 74182 CPT 610 RC outpatient 3275 3275 HEALTHPARTNERS SX009 HEALTHPARTNERS 2620 percent of total billed charges 2030.5 3111.25 Technical (Hospital) Services MRI Abdomen W/Contrast Material PX-6107418200 CDM 74182 CPT 610 RC outpatient 3275 3275 MULTIPLAN INC 34080 [3081285] MULTIPLAN INC [308128501] 3111.25 percent of total billed charges 2030.5 3111.25 Technical (Hospital) Services MRI Abdomen W/Contrast Material PX-6107418200 CDM 74182 CPT 610 RC outpatient 3275 3275 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES HDHP [308136802] 2620 percent of total billed charges 2030.5 3111.25 Technical (Hospital) Services MRI Abdomen W/Contrast Material PX-6107418200 CDM 74182 CPT 610 RC outpatient 3275 3275 BLUE CROSS BLUE SHIELD WELLMARK SB889 [3081026] BCBS WYOMING [308102603] 3111.25 percent of total billed charges 2030.5 3111.25 Technical (Hospital) Services MRI Abdomen W/Contrast Material PX-6107418200 CDM 74182 CPT 610 RC outpatient 3275 3275 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES PPO [308136801] 2620 percent of total billed charges 2030.5 3111.25 Technical (Hospital) Services MRI Abdomen W/Contrast Material PX-6107418200 CDM 74182 CPT 610 RC outpatient 3275 3275 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES EPO [308136803] 2620 percent of total billed charges 2030.5 3111.25 Technical (Hospital) Services MRI Abdomen W/Contrast Material PX-6107418200 CDM 74182 CPT 610 RC outpatient 3275 3275 CIGNA 62308 [3081051] CIGNA 62308 [308105105] 2620 percent of total billed charges 2030.5 3111.25 Technical (Hospital) Services MRI Abdomen W/Contrast Material PX-6107418200 CDM 74182 CPT 610 RC outpatient 3275 3275 CIGNA 62308 [3081051] CIGNA STATE OF WYOMING [308105107] 2620 percent of total billed charges 2030.5 3111.25 Technical (Hospital) Services MRI Abdomen W/Contrast Material PX-6107418200 CDM 74182 CPT 610 RC outpatient 3275 3275 MEDICA (COMMERCIAL) 94265 [3081118] MEDICA CLAIMS [308111801] 2947.5 percent of total billed charges 2030.5 3111.25 Technical (Hospital) Services MRI Abdomen W/O Contrast Material PX-6107418100 CDM 74181 CPT 610 RC outpatient 2620 2620 UNITED HEALTHCARE (COMMERCIAL) [3081199] UNITED HEALTHCARE 87726 [308119901] 1624.4 percent of total billed charges 1624.4 2489 Technical (Hospital) Services MRI Abdomen W/O Contrast Material PX-6107418100 CDM 74181 CPT 610 RC outpatient 2620 2620 HEALTHPARTNERS SX009 HEALTHPARTNERS 2096 percent of total billed charges 1624.4 2489 Technical (Hospital) Services MRI Abdomen W/O Contrast Material PX-6107418100 CDM 74181 CPT 610 RC outpatient 2620 2620 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES PPO [308136801] 2096 percent of total billed charges 1624.4 2489 Technical (Hospital) Services MRI Abdomen W/O Contrast Material PX-6107418100 CDM 74181 CPT 610 RC outpatient 2620 2620 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES EPO [308136803] 2096 percent of total billed charges 1624.4 2489 Technical (Hospital) Services MRI Abdomen W/O Contrast Material PX-6107418100 CDM 74181 CPT 610 RC outpatient 2620 2620 MULTIPLAN INC 34080 [3081285] MULTIPLAN INC [308128501] 2489 percent of total billed charges 1624.4 2489 Technical (Hospital) Services MRI Abdomen W/O Contrast Material PX-6107418100 CDM 74181 CPT 610 RC outpatient 2620 2620 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES HDHP [308136802] 2096 percent of total billed charges 1624.4 2489 Technical (Hospital) Services MRI Abdomen W/O Contrast Material PX-6107418100 CDM 74181 CPT 610 RC outpatient 2620 2620 BLUE CROSS BLUE SHIELD WELLMARK SB889 [3081026] BCBS WYOMING [308102603] 2489 percent of total billed charges 1624.4 2489 Technical (Hospital) Services MRI Abdomen W/O Contrast Material PX-6107418100 CDM 74181 CPT 610 RC outpatient 2620 2620 CIGNA 62308 [3081051] CIGNA 62308 [308105105] 2096 percent of total billed charges 1624.4 2489 Technical (Hospital) Services MRI Abdomen W/O Contrast Material PX-6107418100 CDM 74181 CPT 610 RC outpatient 2620 2620 CIGNA 62308 [3081051] CIGNA STATE OF WYOMING [308105107] 2096 percent of total billed charges 1624.4 2489 Technical (Hospital) Services MRI Abdomen W/O Contrast Material PX-6107418100 CDM 74181 CPT 610 RC outpatient 2620 2620 MEDICA (COMMERCIAL) 94265 [3081118] MEDICA CLAIMS [308111801] 2358 percent of total billed charges 1624.4 2489 Technical (Hospital) Services MRI Abdomen W/O Contrast Material PX-6107418100 CDM 74181 CPT 610 RC inpatient 2620 2620 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES EPO [308136803] 2074.52 percent of total billed charges 1624.4 2489 Technical (Hospital) Services MRI Abdomen W/O Contrast Material PX-6107418100 CDM 74181 CPT 610 RC inpatient 2620 2620 HEALTHPARTNERS SX009 HEALTHPARTNERS 2074.52 percent of total billed charges 1624.4 2489 Technical (Hospital) Services MRI Abdomen W/O Contrast Material PX-6107418100 CDM 74181 CPT 610 RC inpatient 2620 2620 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES HDHP [308136802] 2074.52 percent of total billed charges 1624.4 2489 Technical (Hospital) Services MRI Abdomen W/O Contrast Material PX-6107418100 CDM 74181 CPT 610 RC inpatient 2620 2620 MEDICA (COMMERCIAL) 94265 [3081118] MEDICA CLAIMS [308111801] 2358 percent of total billed charges 1624.4 2489 Technical (Hospital) Services MRI Abdomen W/O Contrast Material PX-6107418100 CDM 74181 CPT 610 RC inpatient 2620 2620 MULTIPLAN INC 34080 [3081285] MULTIPLAN INC [308128501] 2489 percent of total billed charges 1624.4 2489 Technical (Hospital) Services MRI Abdomen W/O Contrast Material PX-6107418100 CDM 74181 CPT 610 RC inpatient 2620 2620 BLUE CROSS BLUE SHIELD WELLMARK SB889 [3081026] BCBS WYOMING [308102603] 2489 percent of total billed charges 1624.4 2489 Technical (Hospital) Services MRI Abdomen W/O Contrast Material PX-6107418100 CDM 74181 CPT 610 RC inpatient 2620 2620 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES PPO [308136801] 2074.52 percent of total billed charges 1624.4 2489 Technical (Hospital) Services MRI Abdomen W/O Contrast Material PX-6107418100 CDM 74181 CPT 610 RC inpatient 2620 2620 UNITED HEALTHCARE (COMMERCIAL) [3081199] UNITED HEALTHCARE 87726 [308119901] 1624.4 percent of total billed charges 1624.4 2489 Technical (Hospital) Services MRI Abdomen W/O Contrast Material PX-6107418100 CDM 74181 CPT 610 RC inpatient 2620 2620 CIGNA 62308 [3081051] CIGNA 62308 [308105105] 2074.52 percent of total billed charges 1624.4 2489 Technical (Hospital) Services MRI Abdomen W/O Contrast Material PX-6107418100 CDM 74181 CPT 610 RC inpatient 2620 2620 CIGNA 62308 [3081051] CIGNA STATE OF WYOMING [308105107] 2074.52 percent of total billed charges 1624.4 2489 Technical (Hospital) Services CT Abdomen & Pelvis W/O Contrst Followed by W Contrst 1/> Body Re PX-3527417800 CDM 74178 CPT 352 RC inpatient 5001 5001 CIGNA 62308 [3081051] CIGNA 62308 [308105105] 3959.79 percent of total billed charges 3100.62 4750.95 Technical (Hospital) Services CT Abdomen & Pelvis W/O Contrst Followed by W Contrst 1/> Body Re PX-3527417800 CDM 74178 CPT 352 RC inpatient 5001 5001 CIGNA 62308 [3081051] CIGNA STATE OF WYOMING [308105107] 3959.79 percent of total billed charges 3100.62 4750.95 Technical (Hospital) Services CT Abdomen & Pelvis W/O Contrst Followed by W Contrst 1/> Body Re PX-3527417800 CDM 74178 CPT 352 RC inpatient 5001 5001 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES EPO [308136803] 3959.79 percent of total billed charges 3100.62 4750.95 Technical (Hospital) Services CT Abdomen & Pelvis W/O Contrst Followed by W Contrst 1/> Body Re PX-3527417800 CDM 74178 CPT 352 RC inpatient 5001 5001 HEALTHPARTNERS SX009 HEALTHPARTNERS 3959.79 percent of total billed charges 3100.62 4750.95 Technical (Hospital) Services CT Abdomen & Pelvis W/O Contrst Followed by W Contrst 1/> Body Re PX-3527417800 CDM 74178 CPT 352 RC inpatient 5001 5001 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES HDHP [308136802] 3959.79 percent of total billed charges 3100.62 4750.95 Technical (Hospital) Services CT Abdomen & Pelvis W/O Contrst Followed by W Contrst 1/> Body Re PX-3527417800 CDM 74178 CPT 352 RC inpatient 5001 5001 MEDICA (COMMERCIAL) 94265 [3081118] MEDICA CLAIMS [308111801] 4500.9 percent of total billed charges 3100.62 4750.95 Technical (Hospital) Services CT Abdomen & Pelvis W/O Contrst Followed by W Contrst 1/> Body Re PX-3527417800 CDM 74178 CPT 352 RC inpatient 5001 5001 MULTIPLAN INC 34080 [3081285] MULTIPLAN INC [308128501] 4750.95 percent of total billed charges 3100.62 4750.95 Technical (Hospital) Services CT Abdomen & Pelvis W/O Contrst Followed by W Contrst 1/> Body Re PX-3527417800 CDM 74178 CPT 352 RC inpatient 5001 5001 BLUE CROSS BLUE SHIELD WELLMARK SB889 [3081026] BCBS WYOMING [308102603] 4750.95 percent of total billed charges 3100.62 4750.95 Technical (Hospital) Services CT Abdomen & Pelvis W/O Contrst Followed by W Contrst 1/> Body Re PX-3527417800 CDM 74178 CPT 352 RC inpatient 5001 5001 UNITED HEALTHCARE (COMMERCIAL) [3081199] UNITED HEALTHCARE 87726 [308119901] 3100.62 percent of total billed charges 3100.62 4750.95 Technical (Hospital) Services CT Abdomen & Pelvis W/O Contrst Followed by W Contrst 1/> Body Re PX-3527417800 CDM 74178 CPT 352 RC inpatient 5001 5001 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES PPO [308136801] 3959.79 percent of total billed charges 3100.62 4750.95 Technical (Hospital) Services CT Abdomen & Pelvis W/O Contrst Followed by W Contrst 1/> Body Re PX-3527417800 CDM 74178 CPT 352 RC outpatient 5001 5001 UNITED HEALTHCARE (COMMERCIAL) [3081199] UNITED HEALTHCARE 87726 [308119901] 3100.62 percent of total billed charges 3100.62 4750.95 Technical (Hospital) Services CT Abdomen & Pelvis W/O Contrst Followed by W Contrst 1/> Body Re PX-3527417800 CDM 74178 CPT 352 RC outpatient 5001 5001 HEALTHPARTNERS SX009 HEALTHPARTNERS 4000.8 percent of total billed charges 3100.62 4750.95 Technical (Hospital) Services CT Abdomen & Pelvis W/O Contrst Followed by W Contrst 1/> Body Re PX-3527417800 CDM 74178 CPT 352 RC outpatient 5001 5001 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES HDHP [308136802] 4000.8 percent of total billed charges 3100.62 4750.95 Technical (Hospital) Services CT Abdomen & Pelvis W/O Contrst Followed by W Contrst 1/> Body Re PX-3527417800 CDM 74178 CPT 352 RC outpatient 5001 5001 MULTIPLAN INC 34080 [3081285] MULTIPLAN INC [308128501] 4750.95 percent of total billed charges 3100.62 4750.95 Technical (Hospital) Services CT Abdomen & Pelvis W/O Contrst Followed by W Contrst 1/> Body Re PX-3527417800 CDM 74178 CPT 352 RC outpatient 5001 5001 BLUE CROSS BLUE SHIELD WELLMARK SB889 [3081026] BCBS WYOMING [308102603] 4750.95 percent of total billed charges 3100.62 4750.95 Technical (Hospital) Services CT Abdomen & Pelvis W/O Contrst Followed by W Contrst 1/> Body Re PX-3527417800 CDM 74178 CPT 352 RC outpatient 5001 5001 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES PPO [308136801] 4000.8 percent of total billed charges 3100.62 4750.95 Technical (Hospital) Services CT Abdomen & Pelvis W/O Contrst Followed by W Contrst 1/> Body Re PX-3527417800 CDM 74178 CPT 352 RC outpatient 5001 5001 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES EPO [308136803] 4000.8 percent of total billed charges 3100.62 4750.95 Technical (Hospital) Services CT Abdomen & Pelvis W/O Contrst Followed by W Contrst 1/> Body Re PX-3527417800 CDM 74178 CPT 352 RC outpatient 5001 5001 MEDICA (COMMERCIAL) 94265 [3081118] MEDICA CLAIMS [308111801] 4500.9 percent of total billed charges 3100.62 4750.95 Technical (Hospital) Services CT Abdomen & Pelvis W/O Contrst Followed by W Contrst 1/> Body Re PX-3527417800 CDM 74178 CPT 352 RC outpatient 5001 5001 CIGNA 62308 [3081051] CIGNA 62308 [308105105] 4000.8 percent of total billed charges 3100.62 4750.95 Technical (Hospital) Services CT Abdomen & Pelvis W/O Contrst Followed by W Contrst 1/> Body Re PX-3527417800 CDM 74178 CPT 352 RC outpatient 5001 5001 CIGNA 62308 [3081051] CIGNA STATE OF WYOMING [308105107] 4000.8 percent of total billed charges 3100.62 4750.95 Technical (Hospital) Services CT Abdomen & Pelvis W/Contrast Material PX-3527417700 CDM 74177 CPT 352 RC inpatient 4716 4716 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES EPO [308136803] 3734.13 percent of total billed charges 2923.92 4480.2 Technical (Hospital) Services CT Abdomen & Pelvis W/Contrast Material PX-3527417700 CDM 74177 CPT 352 RC inpatient 4716 4716 CIGNA 62308 [3081051] CIGNA 62308 [308105105] 3734.13 percent of total billed charges 2923.92 4480.2 Technical (Hospital) Services CT Abdomen & Pelvis W/Contrast Material PX-3527417700 CDM 74177 CPT 352 RC inpatient 4716 4716 CIGNA 62308 [3081051] CIGNA STATE OF WYOMING [308105107] 3734.13 percent of total billed charges 2923.92 4480.2 Technical (Hospital) Services CT Abdomen & Pelvis W/Contrast Material PX-3527417700 CDM 74177 CPT 352 RC inpatient 4716 4716 HEALTHPARTNERS SX009 HEALTHPARTNERS 3734.13 percent of total billed charges 2923.92 4480.2 Technical (Hospital) Services CT Abdomen & Pelvis W/Contrast Material PX-3527417700 CDM 74177 CPT 352 RC inpatient 4716 4716 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES HDHP [308136802] 3734.13 percent of total billed charges 2923.92 4480.2 Technical (Hospital) Services CT Abdomen & Pelvis W/Contrast Material PX-3527417700 CDM 74177 CPT 352 RC inpatient 4716 4716 MEDICA (COMMERCIAL) 94265 [3081118] MEDICA CLAIMS [308111801] 4244.4 percent of total billed charges 2923.92 4480.2 Technical (Hospital) Services CT Abdomen & Pelvis W/Contrast Material PX-3527417700 CDM 74177 CPT 352 RC inpatient 4716 4716 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES PPO [308136801] 3734.13 percent of total billed charges 2923.92 4480.2 Technical (Hospital) Services CT Abdomen & Pelvis W/Contrast Material PX-3527417700 CDM 74177 CPT 352 RC inpatient 4716 4716 UNITED HEALTHCARE (COMMERCIAL) [3081199] UNITED HEALTHCARE 87726 [308119901] 2923.92 percent of total billed charges 2923.92 4480.2 Technical (Hospital) Services CT Abdomen & Pelvis W/Contrast Material PX-3527417700 CDM 74177 CPT 352 RC inpatient 4716 4716 MULTIPLAN INC 34080 [3081285] MULTIPLAN INC [308128501] 4480.2 percent of total billed charges 2923.92 4480.2 Technical (Hospital) Services CT Abdomen & Pelvis W/Contrast Material PX-3527417700 CDM 74177 CPT 352 RC inpatient 4716 4716 BLUE CROSS BLUE SHIELD WELLMARK SB889 [3081026] BCBS WYOMING [308102603] 4480.2 percent of total billed charges 2923.92 4480.2 Technical (Hospital) Services CT Abdomen & Pelvis W/Contrast Material PX-3527417700 CDM 74177 CPT 352 RC outpatient 4716 4716 CIGNA 62308 [3081051] CIGNA 62308 [308105105] 3772.8 percent of total billed charges 2923.92 4480.2 Technical (Hospital) Services CT Abdomen & Pelvis W/Contrast Material PX-3527417700 CDM 74177 CPT 352 RC outpatient 4716 4716 CIGNA 62308 [3081051] CIGNA STATE OF WYOMING [308105107] 3772.8 percent of total billed charges 2923.92 4480.2 Technical (Hospital) Services CT Abdomen & Pelvis W/Contrast Material PX-3527417700 CDM 74177 CPT 352 RC outpatient 4716 4716 MEDICA (COMMERCIAL) 94265 [3081118] MEDICA CLAIMS [308111801] 4244.4 percent of total billed charges 2923.92 4480.2 Technical (Hospital) Services CT Abdomen & Pelvis W/Contrast Material PX-3527417700 CDM 74177 CPT 352 RC outpatient 4716 4716 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES EPO [308136803] 3772.8 percent of total billed charges 2923.92 4480.2 Technical (Hospital) Services CT Abdomen & Pelvis W/Contrast Material PX-3527417700 CDM 74177 CPT 352 RC outpatient 4716 4716 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES PPO [308136801] 3772.8 percent of total billed charges 2923.92 4480.2 Technical (Hospital) Services CT Abdomen & Pelvis W/Contrast Material PX-3527417700 CDM 74177 CPT 352 RC outpatient 4716 4716 BLUE CROSS BLUE SHIELD WELLMARK SB889 [3081026] BCBS WYOMING [308102603] 4480.2 percent of total billed charges 2923.92 4480.2 Technical (Hospital) Services CT Abdomen & Pelvis W/Contrast Material PX-3527417700 CDM 74177 CPT 352 RC outpatient 4716 4716 MULTIPLAN INC 34080 [3081285] MULTIPLAN INC [308128501] 4480.2 percent of total billed charges 2923.92 4480.2 Technical (Hospital) Services CT Abdomen & Pelvis W/Contrast Material PX-3527417700 CDM 74177 CPT 352 RC outpatient 4716 4716 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES HDHP [308136802] 3772.8 percent of total billed charges 2923.92 4480.2 Technical (Hospital) Services CT Abdomen & Pelvis W/Contrast Material PX-3527417700 CDM 74177 CPT 352 RC outpatient 4716 4716 HEALTHPARTNERS SX009 HEALTHPARTNERS 3772.8 percent of total billed charges 2923.92 4480.2 Technical (Hospital) Services CT Abdomen & Pelvis W/Contrast Material PX-3527417700 CDM 74177 CPT 352 RC outpatient 4716 4716 UNITED HEALTHCARE (COMMERCIAL) [3081199] UNITED HEALTHCARE 87726 [308119901] 2923.92 percent of total billed charges 2923.92 4480.2 Technical (Hospital) Services CT Abdomen & Pelvis W/O Contrast Material PX-3527417600 CDM 74176 CPT 352 RC outpatient 3453 3453 HEALTHPARTNERS SX009 HEALTHPARTNERS 2762.4 percent of total billed charges 2140.86 3280.35 Technical (Hospital) Services CT Abdomen & Pelvis W/O Contrast Material PX-3527417600 CDM 74176 CPT 352 RC outpatient 3453 3453 UNITED HEALTHCARE (COMMERCIAL) [3081199] UNITED HEALTHCARE 87726 [308119901] 2140.86 percent of total billed charges 2140.86 3280.35 Technical (Hospital) Services CT Abdomen & Pelvis W/O Contrast Material PX-3527417600 CDM 74176 CPT 352 RC outpatient 3453 3453 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES EPO [308136803] 2762.4 percent of total billed charges 2140.86 3280.35 Technical (Hospital) Services CT Abdomen & Pelvis W/O Contrast Material PX-3527417600 CDM 74176 CPT 352 RC outpatient 3453 3453 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES PPO [308136801] 2762.4 percent of total billed charges 2140.86 3280.35 Technical (Hospital) Services CT Abdomen & Pelvis W/O Contrast Material PX-3527417600 CDM 74176 CPT 352 RC outpatient 3453 3453 BLUE CROSS BLUE SHIELD WELLMARK SB889 [3081026] BCBS WYOMING [308102603] 3280.35 percent of total billed charges 2140.86 3280.35 Technical (Hospital) Services CT Abdomen & Pelvis W/O Contrast Material PX-3527417600 CDM 74176 CPT 352 RC outpatient 3453 3453 MULTIPLAN INC 34080 [3081285] MULTIPLAN INC [308128501] 3280.35 percent of total billed charges 2140.86 3280.35 Technical (Hospital) Services CT Abdomen & Pelvis W/O Contrast Material PX-3527417600 CDM 74176 CPT 352 RC outpatient 3453 3453 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES HDHP [308136802] 2762.4 percent of total billed charges 2140.86 3280.35 Technical (Hospital) Services CT Abdomen & Pelvis W/O Contrast Material PX-3527417600 CDM 74176 CPT 352 RC outpatient 3453 3453 CIGNA 62308 [3081051] CIGNA 62308 [308105105] 2762.4 percent of total billed charges 2140.86 3280.35 Technical (Hospital) Services CT Abdomen & Pelvis W/O Contrast Material PX-3527417600 CDM 74176 CPT 352 RC outpatient 3453 3453 CIGNA 62308 [3081051] CIGNA STATE OF WYOMING [308105107] 2762.4 percent of total billed charges 2140.86 3280.35 Technical (Hospital) Services CT Abdomen & Pelvis W/O Contrast Material PX-3527417600 CDM 74176 CPT 352 RC outpatient 3453 3453 MEDICA (COMMERCIAL) 94265 [3081118] MEDICA CLAIMS [308111801] 3107.7 percent of total billed charges 2140.86 3280.35 Technical (Hospital) Services CT Abdomen & Pelvis W/O Contrast Material PX-3527417600 CDM 74176 CPT 352 RC inpatient 3453 3453 CIGNA 62308 [3081051] CIGNA 62308 [308105105] 2734.09 percent of total billed charges 2140.86 3280.35 Technical (Hospital) Services CT Abdomen & Pelvis W/O Contrast Material PX-3527417600 CDM 74176 CPT 352 RC inpatient 3453 3453 CIGNA 62308 [3081051] CIGNA STATE OF WYOMING [308105107] 2734.09 percent of total billed charges 2140.86 3280.35 Technical (Hospital) Services CT Abdomen & Pelvis W/O Contrast Material PX-3527417600 CDM 74176 CPT 352 RC inpatient 3453 3453 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES EPO [308136803] 2734.09 percent of total billed charges 2140.86 3280.35 Technical (Hospital) Services CT Abdomen & Pelvis W/O Contrast Material PX-3527417600 CDM 74176 CPT 352 RC inpatient 3453 3453 UNITED HEALTHCARE (COMMERCIAL) [3081199] UNITED HEALTHCARE 87726 [308119901] 2140.86 percent of total billed charges 2140.86 3280.35 Technical (Hospital) Services CT Abdomen & Pelvis W/O Contrast Material PX-3527417600 CDM 74176 CPT 352 RC inpatient 3453 3453 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES PPO [308136801] 2734.09 percent of total billed charges 2140.86 3280.35 Technical (Hospital) Services CT Abdomen & Pelvis W/O Contrast Material PX-3527417600 CDM 74176 CPT 352 RC inpatient 3453 3453 MULTIPLAN INC 34080 [3081285] MULTIPLAN INC [308128501] 3280.35 percent of total billed charges 2140.86 3280.35 Technical (Hospital) Services CT Abdomen & Pelvis W/O Contrast Material PX-3527417600 CDM 74176 CPT 352 RC inpatient 3453 3453 BLUE CROSS BLUE SHIELD WELLMARK SB889 [3081026] BCBS WYOMING [308102603] 3280.35 percent of total billed charges 2140.86 3280.35 Technical (Hospital) Services CT Abdomen & Pelvis W/O Contrast Material PX-3527417600 CDM 74176 CPT 352 RC inpatient 3453 3453 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES HDHP [308136802] 2734.09 percent of total billed charges 2140.86 3280.35 Technical (Hospital) Services CT Abdomen & Pelvis W/O Contrast Material PX-3527417600 CDM 74176 CPT 352 RC inpatient 3453 3453 MEDICA (COMMERCIAL) 94265 [3081118] MEDICA CLAIMS [308111801] 3107.7 percent of total billed charges 2140.86 3280.35 Technical (Hospital) Services CT Abdomen & Pelvis W/O Contrast Material PX-3527417600 CDM 74176 CPT 352 RC inpatient 3453 3453 HEALTHPARTNERS SX009 HEALTHPARTNERS 2734.09 percent of total billed charges 2140.86 3280.35 Technical (Hospital) Services CT Angiography Abdomen W/Contrast/Noncontrast PX-3527417500 CDM 74175 CPT 352 RC inpatient 2816 2816 UNITED HEALTHCARE (COMMERCIAL) [3081199] UNITED HEALTHCARE 87726 [308119901] 1745.92 percent of total billed charges 1745.92 2675.2 Technical (Hospital) Services CT Angiography Abdomen W/Contrast/Noncontrast PX-3527417500 CDM 74175 CPT 352 RC inpatient 2816 2816 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES PPO [308136801] 2229.71 percent of total billed charges 1745.92 2675.2 Technical (Hospital) Services CT Angiography Abdomen W/Contrast/Noncontrast PX-3527417500 CDM 74175 CPT 352 RC inpatient 2816 2816 MULTIPLAN INC 34080 [3081285] MULTIPLAN INC [308128501] 2675.2 percent of total billed charges 1745.92 2675.2 Technical (Hospital) Services CT Angiography Abdomen W/Contrast/Noncontrast PX-3527417500 CDM 74175 CPT 352 RC inpatient 2816 2816 BLUE CROSS BLUE SHIELD WELLMARK SB889 [3081026] BCBS WYOMING [308102603] 2675.2 percent of total billed charges 1745.92 2675.2 Technical (Hospital) Services CT Angiography Abdomen W/Contrast/Noncontrast PX-3527417500 CDM 74175 CPT 352 RC inpatient 2816 2816 MEDICA (COMMERCIAL) 94265 [3081118] MEDICA CLAIMS [308111801] 2534.4 percent of total billed charges 1745.92 2675.2 Technical (Hospital) Services CT Angiography Abdomen W/Contrast/Noncontrast PX-3527417500 CDM 74175 CPT 352 RC inpatient 2816 2816 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES HDHP [308136802] 2229.71 percent of total billed charges 1745.92 2675.2 Technical (Hospital) Services CT Angiography Abdomen W/Contrast/Noncontrast PX-3527417500 CDM 74175 CPT 352 RC inpatient 2816 2816 HEALTHPARTNERS SX009 HEALTHPARTNERS 2229.71 percent of total billed charges 1745.92 2675.2 Technical (Hospital) Services CT Angiography Abdomen W/Contrast/Noncontrast PX-3527417500 CDM 74175 CPT 352 RC inpatient 2816 2816 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES EPO [308136803] 2229.71 percent of total billed charges 1745.92 2675.2 Technical (Hospital) Services CT Angiography Abdomen W/Contrast/Noncontrast PX-3527417500 CDM 74175 CPT 352 RC inpatient 2816 2816 CIGNA 62308 [3081051] CIGNA 62308 [308105105] 2229.71 percent of total billed charges 1745.92 2675.2 Technical (Hospital) Services CT Angiography Abdomen W/Contrast/Noncontrast PX-3527417500 CDM 74175 CPT 352 RC inpatient 2816 2816 CIGNA 62308 [3081051] CIGNA STATE OF WYOMING [308105107] 2229.71 percent of total billed charges 1745.92 2675.2 Technical (Hospital) Services CT Angiography Abdomen W/Contrast/Noncontrast PX-3527417500 CDM 74175 CPT 352 RC outpatient 2816 2816 BLUE CROSS BLUE SHIELD WELLMARK SB889 [3081026] BCBS WYOMING [308102603] 2675.2 percent of total billed charges 1745.92 2675.2 Technical (Hospital) Services CT Angiography Abdomen W/Contrast/Noncontrast PX-3527417500 CDM 74175 CPT 352 RC outpatient 2816 2816 MULTIPLAN INC 34080 [3081285] MULTIPLAN INC [308128501] 2675.2 percent of total billed charges 1745.92 2675.2 Technical (Hospital) Services CT Angiography Abdomen W/Contrast/Noncontrast PX-3527417500 CDM 74175 CPT 352 RC outpatient 2816 2816 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES HDHP [308136802] 2252.8 percent of total billed charges 1745.92 2675.2 Technical (Hospital) Services CT Angiography Abdomen W/Contrast/Noncontrast PX-3527417500 CDM 74175 CPT 352 RC outpatient 2816 2816 UNITED HEALTHCARE (COMMERCIAL) [3081199] UNITED HEALTHCARE 87726 [308119901] 1745.92 percent of total billed charges 1745.92 2675.2 Technical (Hospital) Services CT Angiography Abdomen W/Contrast/Noncontrast PX-3527417500 CDM 74175 CPT 352 RC outpatient 2816 2816 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES PPO [308136801] 2252.8 percent of total billed charges 1745.92 2675.2 Technical (Hospital) Services CT Angiography Abdomen W/Contrast/Noncontrast PX-3527417500 CDM 74175 CPT 352 RC outpatient 2816 2816 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES EPO [308136803] 2252.8 percent of total billed charges 1745.92 2675.2 Technical (Hospital) Services CT Angiography Abdomen W/Contrast/Noncontrast PX-3527417500 CDM 74175 CPT 352 RC outpatient 2816 2816 HEALTHPARTNERS SX009 HEALTHPARTNERS 2252.8 percent of total billed charges 1745.92 2675.2 Technical (Hospital) Services CT Angiography Abdomen W/Contrast/Noncontrast PX-3527417500 CDM 74175 CPT 352 RC outpatient 2816 2816 CIGNA 62308 [3081051] CIGNA 62308 [308105105] 2252.8 percent of total billed charges 1745.92 2675.2 Technical (Hospital) Services CT Angiography Abdomen W/Contrast/Noncontrast PX-3527417500 CDM 74175 CPT 352 RC outpatient 2816 2816 CIGNA 62308 [3081051] CIGNA STATE OF WYOMING [308105107] 2252.8 percent of total billed charges 1745.92 2675.2 Technical (Hospital) Services CT Angiography Abdomen W/Contrast/Noncontrast PX-3527417500 CDM 74175 CPT 352 RC outpatient 2816 2816 MEDICA (COMMERCIAL) 94265 [3081118] MEDICA CLAIMS [308111801] 2534.4 percent of total billed charges 1745.92 2675.2 Technical (Hospital) Services CT Angio Abd&Plvis Cntrst Mtrl W/WO Cntrst Img PX-3527417400 CDM 74174 CPT 352 RC outpatient 4519 4519 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES PPO [308136801] 3615.2 percent of total billed charges 2801.78 4293.05 Technical (Hospital) Services CT Angio Abd&Plvis Cntrst Mtrl W/WO Cntrst Img PX-3527417400 CDM 74174 CPT 352 RC outpatient 4519 4519 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES EPO [308136803] 3615.2 percent of total billed charges 2801.78 4293.05 Technical (Hospital) Services CT Angio Abd&Plvis Cntrst Mtrl W/WO Cntrst Img PX-3527417400 CDM 74174 CPT 352 RC outpatient 4519 4519 UNITED HEALTHCARE (COMMERCIAL) [3081199] UNITED HEALTHCARE 87726 [308119901] 2801.78 percent of total billed charges 2801.78 4293.05 Technical (Hospital) Services CT Angio Abd&Plvis Cntrst Mtrl W/WO Cntrst Img PX-3527417400 CDM 74174 CPT 352 RC outpatient 4519 4519 BLUE CROSS BLUE SHIELD WELLMARK SB889 [3081026] BCBS WYOMING [308102603] 4293.05 percent of total billed charges 2801.78 4293.05 Technical (Hospital) Services CT Angio Abd&Plvis Cntrst Mtrl W/WO Cntrst Img PX-3527417400 CDM 74174 CPT 352 RC outpatient 4519 4519 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES HDHP [308136802] 3615.2 percent of total billed charges 2801.78 4293.05 Technical (Hospital) Services CT Angio Abd&Plvis Cntrst Mtrl W/WO Cntrst Img PX-3527417400 CDM 74174 CPT 352 RC outpatient 4519 4519 MULTIPLAN INC 34080 [3081285] MULTIPLAN INC [308128501] 4293.05 percent of total billed charges 2801.78 4293.05 Technical (Hospital) Services CT Angio Abd&Plvis Cntrst Mtrl W/WO Cntrst Img PX-3527417400 CDM 74174 CPT 352 RC outpatient 4519 4519 HEALTHPARTNERS SX009 HEALTHPARTNERS 3615.2 percent of total billed charges 2801.78 4293.05 Technical (Hospital) Services CT Angio Abd&Plvis Cntrst Mtrl W/WO Cntrst Img PX-3527417400 CDM 74174 CPT 352 RC outpatient 4519 4519 MEDICA (COMMERCIAL) 94265 [3081118] MEDICA CLAIMS [308111801] 4067.1 percent of total billed charges 2801.78 4293.05 Technical (Hospital) Services CT Angio Abd&Plvis Cntrst Mtrl W/WO Cntrst Img PX-3527417400 CDM 74174 CPT 352 RC outpatient 4519 4519 CIGNA 62308 [3081051] CIGNA 62308 [308105105] 3615.2 percent of total billed charges 2801.78 4293.05 Technical (Hospital) Services CT Angio Abd&Plvis Cntrst Mtrl W/WO Cntrst Img PX-3527417400 CDM 74174 CPT 352 RC outpatient 4519 4519 CIGNA 62308 [3081051] CIGNA STATE OF WYOMING [308105107] 3615.2 percent of total billed charges 2801.78 4293.05 Technical (Hospital) Services CT Angio Abd&Plvis Cntrst Mtrl W/WO Cntrst Img PX-3527417400 CDM 74174 CPT 352 RC inpatient 4519 4519 CIGNA 62308 [3081051] CIGNA 62308 [308105105] 3578.14 percent of total billed charges 2801.78 4293.05 Technical (Hospital) Services CT Angio Abd&Plvis Cntrst Mtrl W/WO Cntrst Img PX-3527417400 CDM 74174 CPT 352 RC inpatient 4519 4519 CIGNA 62308 [3081051] CIGNA STATE OF WYOMING [308105107] 3578.14 percent of total billed charges 2801.78 4293.05 Technical (Hospital) Services CT Angio Abd&Plvis Cntrst Mtrl W/WO Cntrst Img PX-3527417400 CDM 74174 CPT 352 RC inpatient 4519 4519 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES EPO [308136803] 3578.14 percent of total billed charges 2801.78 4293.05 Technical (Hospital) Services CT Angio Abd&Plvis Cntrst Mtrl W/WO Cntrst Img PX-3527417400 CDM 74174 CPT 352 RC inpatient 4519 4519 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES PPO [308136801] 3578.14 percent of total billed charges 2801.78 4293.05 Technical (Hospital) Services CT Angio Abd&Plvis Cntrst Mtrl W/WO Cntrst Img PX-3527417400 CDM 74174 CPT 352 RC inpatient 4519 4519 UNITED HEALTHCARE (COMMERCIAL) [3081199] UNITED HEALTHCARE 87726 [308119901] 2801.78 percent of total billed charges 2801.78 4293.05 Technical (Hospital) Services CT Angio Abd&Plvis Cntrst Mtrl W/WO Cntrst Img PX-3527417400 CDM 74174 CPT 352 RC inpatient 4519 4519 BLUE CROSS BLUE SHIELD WELLMARK SB889 [3081026] BCBS WYOMING [308102603] 4293.05 percent of total billed charges 2801.78 4293.05 Technical (Hospital) Services CT Angio Abd&Plvis Cntrst Mtrl W/WO Cntrst Img PX-3527417400 CDM 74174 CPT 352 RC inpatient 4519 4519 MULTIPLAN INC 34080 [3081285] MULTIPLAN INC [308128501] 4293.05 percent of total billed charges 2801.78 4293.05 Technical (Hospital) Services CT Angio Abd&Plvis Cntrst Mtrl W/WO Cntrst Img PX-3527417400 CDM 74174 CPT 352 RC inpatient 4519 4519 HEALTHPARTNERS SX009 HEALTHPARTNERS 3578.14 percent of total billed charges 2801.78 4293.05 Technical (Hospital) Services CT Angio Abd&Plvis Cntrst Mtrl W/WO Cntrst Img PX-3527417400 CDM 74174 CPT 352 RC inpatient 4519 4519 MEDICA (COMMERCIAL) 94265 [3081118] MEDICA CLAIMS [308111801] 4067.1 percent of total billed charges 2801.78 4293.05 Technical (Hospital) Services CT Angio Abd&Plvis Cntrst Mtrl W/WO Cntrst Img PX-3527417400 CDM 74174 CPT 352 RC inpatient 4519 4519 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES HDHP [308136802] 3578.14 percent of total billed charges 2801.78 4293.05 Technical (Hospital) Services CT Abdomen W/O & W/Contrast Material PX-3527417000 CDM 74170 CPT 352 RC inpatient 2620 2620 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES PPO [308136801] 2074.52 percent of total billed charges 1624.4 2489 Technical (Hospital) Services CT Abdomen W/O & W/Contrast Material PX-3527417000 CDM 74170 CPT 352 RC inpatient 2620 2620 UNITED HEALTHCARE (COMMERCIAL) [3081199] UNITED HEALTHCARE 87726 [308119901] 1624.4 percent of total billed charges 1624.4 2489 Technical (Hospital) Services CT Abdomen W/O & W/Contrast Material PX-3527417000 CDM 74170 CPT 352 RC inpatient 2620 2620 MULTIPLAN INC 34080 [3081285] MULTIPLAN INC [308128501] 2489 percent of total billed charges 1624.4 2489 Technical (Hospital) Services CT Abdomen W/O & W/Contrast Material PX-3527417000 CDM 74170 CPT 352 RC inpatient 2620 2620 BLUE CROSS BLUE SHIELD WELLMARK SB889 [3081026] BCBS WYOMING [308102603] 2489 percent of total billed charges 1624.4 2489 Technical (Hospital) Services CT Abdomen W/O & W/Contrast Material PX-3527417000 CDM 74170 CPT 352 RC inpatient 2620 2620 MEDICA (COMMERCIAL) 94265 [3081118] MEDICA CLAIMS [308111801] 2358 percent of total billed charges 1624.4 2489 Technical (Hospital) Services CT Abdomen W/O & W/Contrast Material PX-3527417000 CDM 74170 CPT 352 RC inpatient 2620 2620 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES HDHP [308136802] 2074.52 percent of total billed charges 1624.4 2489 Technical (Hospital) Services CT Abdomen W/O & W/Contrast Material PX-3527417000 CDM 74170 CPT 352 RC inpatient 2620 2620 HEALTHPARTNERS SX009 HEALTHPARTNERS 2074.52 percent of total billed charges 1624.4 2489 Technical (Hospital) Services CT Abdomen W/O & W/Contrast Material PX-3527417000 CDM 74170 CPT 352 RC inpatient 2620 2620 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES EPO [308136803] 2074.52 percent of total billed charges 1624.4 2489 Technical (Hospital) Services CT Abdomen W/O & W/Contrast Material PX-3527417000 CDM 74170 CPT 352 RC inpatient 2620 2620 CIGNA 62308 [3081051] CIGNA 62308 [308105105] 2074.52 percent of total billed charges 1624.4 2489 Technical (Hospital) Services CT Abdomen W/O & W/Contrast Material PX-3527417000 CDM 74170 CPT 352 RC inpatient 2620 2620 CIGNA 62308 [3081051] CIGNA STATE OF WYOMING [308105107] 2074.52 percent of total billed charges 1624.4 2489 Technical (Hospital) Services CT Abdomen W/O & W/Contrast Material PX-3527417000 CDM 74170 CPT 352 RC outpatient 2620 2620 CIGNA 62308 [3081051] CIGNA 62308 [308105105] 2096 percent of total billed charges 1624.4 2489 Technical (Hospital) Services CT Abdomen W/O & W/Contrast Material PX-3527417000 CDM 74170 CPT 352 RC outpatient 2620 2620 CIGNA 62308 [3081051] CIGNA STATE OF WYOMING [308105107] 2096 percent of total billed charges 1624.4 2489 Technical (Hospital) Services CT Abdomen W/O & W/Contrast Material PX-3527417000 CDM 74170 CPT 352 RC outpatient 2620 2620 MEDICA (COMMERCIAL) 94265 [3081118] MEDICA CLAIMS [308111801] 2358 percent of total billed charges 1624.4 2489 Technical (Hospital) Services CT Abdomen W/O & W/Contrast Material PX-3527417000 CDM 74170 CPT 352 RC outpatient 2620 2620 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES EPO [308136803] 2096 percent of total billed charges 1624.4 2489 Technical (Hospital) Services CT Abdomen W/O & W/Contrast Material PX-3527417000 CDM 74170 CPT 352 RC outpatient 2620 2620 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES PPO [308136801] 2096 percent of total billed charges 1624.4 2489 Technical (Hospital) Services CT Abdomen W/O & W/Contrast Material PX-3527417000 CDM 74170 CPT 352 RC outpatient 2620 2620 BLUE CROSS BLUE SHIELD WELLMARK SB889 [3081026] BCBS WYOMING [308102603] 2489 percent of total billed charges 1624.4 2489 Technical (Hospital) Services CT Abdomen W/O & W/Contrast Material PX-3527417000 CDM 74170 CPT 352 RC outpatient 2620 2620 MULTIPLAN INC 34080 [3081285] MULTIPLAN INC [308128501] 2489 percent of total billed charges 1624.4 2489 Technical (Hospital) Services CT Abdomen W/O & W/Contrast Material PX-3527417000 CDM 74170 CPT 352 RC outpatient 2620 2620 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES HDHP [308136802] 2096 percent of total billed charges 1624.4 2489 Technical (Hospital) Services CT Abdomen W/O & W/Contrast Material PX-3527417000 CDM 74170 CPT 352 RC outpatient 2620 2620 HEALTHPARTNERS SX009 HEALTHPARTNERS 2096 percent of total billed charges 1624.4 2489 Technical (Hospital) Services CT Abdomen W/O & W/Contrast Material PX-3527417000 CDM 74170 CPT 352 RC outpatient 2620 2620 UNITED HEALTHCARE (COMMERCIAL) [3081199] UNITED HEALTHCARE 87726 [308119901] 1624.4 percent of total billed charges 1624.4 2489 Technical (Hospital) Services CT Abdomen W/Contrast Material PX-3527416000 CDM 74160 CPT 352 RC inpatient 2680 2680 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES HDHP [308136802] 2122.02 percent of total billed charges 1661.6 2546 Technical (Hospital) Services CT Abdomen W/Contrast Material PX-3527416000 CDM 74160 CPT 352 RC inpatient 2680 2680 MEDICA (COMMERCIAL) 94265 [3081118] MEDICA CLAIMS [308111801] 2412 percent of total billed charges 1661.6 2546 Technical (Hospital) Services CT Abdomen W/Contrast Material PX-3527416000 CDM 74160 CPT 352 RC inpatient 2680 2680 HEALTHPARTNERS SX009 HEALTHPARTNERS 2122.02 percent of total billed charges 1661.6 2546 Technical (Hospital) Services CT Abdomen W/Contrast Material PX-3527416000 CDM 74160 CPT 352 RC inpatient 2680 2680 MULTIPLAN INC 34080 [3081285] MULTIPLAN INC [308128501] 2546 percent of total billed charges 1661.6 2546 Technical (Hospital) Services CT Abdomen W/Contrast Material PX-3527416000 CDM 74160 CPT 352 RC inpatient 2680 2680 BLUE CROSS BLUE SHIELD WELLMARK SB889 [3081026] BCBS WYOMING [308102603] 2546 percent of total billed charges 1661.6 2546 Technical (Hospital) Services CT Abdomen W/Contrast Material PX-3527416000 CDM 74160 CPT 352 RC inpatient 2680 2680 UNITED HEALTHCARE (COMMERCIAL) [3081199] UNITED HEALTHCARE 87726 [308119901] 1661.6 percent of total billed charges 1661.6 2546 Technical (Hospital) Services CT Abdomen W/Contrast Material PX-3527416000 CDM 74160 CPT 352 RC inpatient 2680 2680 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES PPO [308136801] 2122.02 percent of total billed charges 1661.6 2546 Technical (Hospital) Services CT Abdomen W/Contrast Material PX-3527416000 CDM 74160 CPT 352 RC inpatient 2680 2680 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES EPO [308136803] 2122.02 percent of total billed charges 1661.6 2546 Technical (Hospital) Services CT Abdomen W/Contrast Material PX-3527416000 CDM 74160 CPT 352 RC inpatient 2680 2680 CIGNA 62308 [3081051] CIGNA STATE OF WYOMING [308105107] 2122.02 percent of total billed charges 1661.6 2546 Technical (Hospital) Services CT Abdomen W/Contrast Material PX-3527416000 CDM 74160 CPT 352 RC inpatient 2680 2680 CIGNA 62308 [3081051] CIGNA 62308 [308105105] 2122.02 percent of total billed charges 1661.6 2546 Technical (Hospital) Services CT Abdomen W/Contrast Material PX-3527416000 CDM 74160 CPT 352 RC outpatient 2680 2680 HEALTHPARTNERS SX009 HEALTHPARTNERS 2144 percent of total billed charges 1661.6 2546 Technical (Hospital) Services CT Abdomen W/Contrast Material PX-3527416000 CDM 74160 CPT 352 RC outpatient 2680 2680 UNITED HEALTHCARE (COMMERCIAL) [3081199] UNITED HEALTHCARE 87726 [308119901] 1661.6 percent of total billed charges 1661.6 2546 Technical (Hospital) Services CT Abdomen W/Contrast Material PX-3527416000 CDM 74160 CPT 352 RC outpatient 2680 2680 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES PPO [308136801] 2144 percent of total billed charges 1661.6 2546 Technical (Hospital) Services CT Abdomen W/Contrast Material PX-3527416000 CDM 74160 CPT 352 RC outpatient 2680 2680 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES EPO [308136803] 2144 percent of total billed charges 1661.6 2546 Technical (Hospital) Services CT Abdomen W/Contrast Material PX-3527416000 CDM 74160 CPT 352 RC outpatient 2680 2680 BLUE CROSS BLUE SHIELD WELLMARK SB889 [3081026] BCBS WYOMING [308102603] 2546 percent of total billed charges 1661.6 2546 Technical (Hospital) Services CT Abdomen W/Contrast Material PX-3527416000 CDM 74160 CPT 352 RC outpatient 2680 2680 MULTIPLAN INC 34080 [3081285] MULTIPLAN INC [308128501] 2546 percent of total billed charges 1661.6 2546 Technical (Hospital) Services CT Abdomen W/Contrast Material PX-3527416000 CDM 74160 CPT 352 RC outpatient 2680 2680 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES HDHP [308136802] 2144 percent of total billed charges 1661.6 2546 Technical (Hospital) Services CT Abdomen W/Contrast Material PX-3527416000 CDM 74160 CPT 352 RC outpatient 2680 2680 MEDICA (COMMERCIAL) 94265 [3081118] MEDICA CLAIMS [308111801] 2412 percent of total billed charges 1661.6 2546 Technical (Hospital) Services CT Abdomen W/Contrast Material PX-3527416000 CDM 74160 CPT 352 RC outpatient 2680 2680 CIGNA 62308 [3081051] CIGNA 62308 [308105105] 2144 percent of total billed charges 1661.6 2546 Technical (Hospital) Services CT Abdomen W/Contrast Material PX-3527416000 CDM 74160 CPT 352 RC outpatient 2680 2680 CIGNA 62308 [3081051] CIGNA STATE OF WYOMING [308105107] 2144 percent of total billed charges 1661.6 2546 Technical (Hospital) Services CT Abdomen W/O Contrast Material PX-3527415000 CDM 74150 CPT 352 RC outpatient 1638 1638 HEALTHPARTNERS SX009 HEALTHPARTNERS 1310.4 percent of total billed charges 1015.56 1556.1 Technical (Hospital) Services CT Abdomen W/O Contrast Material PX-3527415000 CDM 74150 CPT 352 RC outpatient 1638 1638 MULTIPLAN INC 34080 [3081285] MULTIPLAN INC [308128501] 1556.1 percent of total billed charges 1015.56 1556.1 Technical (Hospital) Services CT Abdomen W/O Contrast Material PX-3527415000 CDM 74150 CPT 352 RC outpatient 1638 1638 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES HDHP [308136802] 1310.4 percent of total billed charges 1015.56 1556.1 Technical (Hospital) Services CT Abdomen W/O Contrast Material PX-3527415000 CDM 74150 CPT 352 RC outpatient 1638 1638 BLUE CROSS BLUE SHIELD WELLMARK SB889 [3081026] BCBS WYOMING [308102603] 1556.1 percent of total billed charges 1015.56 1556.1 Technical (Hospital) Services CT Abdomen W/O Contrast Material PX-3527415000 CDM 74150 CPT 352 RC outpatient 1638 1638 UNITED HEALTHCARE (COMMERCIAL) [3081199] UNITED HEALTHCARE 87726 [308119901] 1015.56 percent of total billed charges 1015.56 1556.1 Technical (Hospital) Services CT Abdomen W/O Contrast Material PX-3527415000 CDM 74150 CPT 352 RC outpatient 1638 1638 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES PPO [308136801] 1310.4 percent of total billed charges 1015.56 1556.1 Technical (Hospital) Services CT Abdomen W/O Contrast Material PX-3527415000 CDM 74150 CPT 352 RC outpatient 1638 1638 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES EPO [308136803] 1310.4 percent of total billed charges 1015.56 1556.1 Technical (Hospital) Services CT Abdomen W/O Contrast Material PX-3527415000 CDM 74150 CPT 352 RC outpatient 1638 1638 MEDICA (COMMERCIAL) 94265 [3081118] MEDICA CLAIMS [308111801] 1474.2 percent of total billed charges 1015.56 1556.1 Technical (Hospital) Services CT Abdomen W/O Contrast Material PX-3527415000 CDM 74150 CPT 352 RC outpatient 1638 1638 CIGNA 62308 [3081051] CIGNA 62308 [308105105] 1310.4 percent of total billed charges 1015.56 1556.1 Technical (Hospital) Services CT Abdomen W/O Contrast Material PX-3527415000 CDM 74150 CPT 352 RC outpatient 1638 1638 CIGNA 62308 [3081051] CIGNA STATE OF WYOMING [308105107] 1310.4 percent of total billed charges 1015.56 1556.1 Technical (Hospital) Services CT Abdomen W/O Contrast Material PX-3527415000 CDM 74150 CPT 352 RC inpatient 1638 1638 CIGNA 62308 [3081051] CIGNA 62308 [308105105] 1296.97 percent of total billed charges 1015.56 1556.1 Technical (Hospital) Services CT Abdomen W/O Contrast Material PX-3527415000 CDM 74150 CPT 352 RC inpatient 1638 1638 CIGNA 62308 [3081051] CIGNA STATE OF WYOMING [308105107] 1296.97 percent of total billed charges 1015.56 1556.1 Technical (Hospital) Services CT Abdomen W/O Contrast Material PX-3527415000 CDM 74150 CPT 352 RC inpatient 1638 1638 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES EPO [308136803] 1296.97 percent of total billed charges 1015.56 1556.1 Technical (Hospital) Services CT Abdomen W/O Contrast Material PX-3527415000 CDM 74150 CPT 352 RC inpatient 1638 1638 HEALTHPARTNERS SX009 HEALTHPARTNERS 1296.97 percent of total billed charges 1015.56 1556.1 Technical (Hospital) Services CT Abdomen W/O Contrast Material PX-3527415000 CDM 74150 CPT 352 RC inpatient 1638 1638 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES HDHP [308136802] 1296.97 percent of total billed charges 1015.56 1556.1 Technical (Hospital) Services CT Abdomen W/O Contrast Material PX-3527415000 CDM 74150 CPT 352 RC inpatient 1638 1638 MEDICA (COMMERCIAL) 94265 [3081118] MEDICA CLAIMS [308111801] 1474.2 percent of total billed charges 1015.56 1556.1 Technical (Hospital) Services CT Abdomen W/O Contrast Material PX-3527415000 CDM 74150 CPT 352 RC inpatient 1638 1638 BLUE CROSS BLUE SHIELD WELLMARK SB889 [3081026] BCBS WYOMING [308102603] 1556.1 percent of total billed charges 1015.56 1556.1 Technical (Hospital) Services CT Abdomen W/O Contrast Material PX-3527415000 CDM 74150 CPT 352 RC inpatient 1638 1638 MULTIPLAN INC 34080 [3081285] MULTIPLAN INC [308128501] 1556.1 percent of total billed charges 1015.56 1556.1 Technical (Hospital) Services CT Abdomen W/O Contrast Material PX-3527415000 CDM 74150 CPT 352 RC inpatient 1638 1638 UNITED HEALTHCARE (COMMERCIAL) [3081199] UNITED HEALTHCARE 87726 [308119901] 1015.56 percent of total billed charges 1015.56 1556.1 Technical (Hospital) Services CT Abdomen W/O Contrast Material PX-3527415000 CDM 74150 CPT 352 RC inpatient 1638 1638 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES PPO [308136801] 1296.97 percent of total billed charges 1015.56 1556.1 Technical (Hospital) Services Radex Abd Compl Aqt Abd W/S/E/D Views 1 View Ch PX-3207402200 CDM 74022 CPT 320 RC inpatient 653 653 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES HDHP [308136802] 517.05 percent of total billed charges 404.86 620.35 Technical (Hospital) Services Radex Abd Compl Aqt Abd W/S/E/D Views 1 View Ch PX-3207402200 CDM 74022 CPT 320 RC inpatient 653 653 MEDICA (COMMERCIAL) 94265 [3081118] MEDICA CLAIMS [308111801] 587.7 percent of total billed charges 404.86 620.35 Technical (Hospital) Services Radex Abd Compl Aqt Abd W/S/E/D Views 1 View Ch PX-3207402200 CDM 74022 CPT 320 RC inpatient 653 653 HEALTHPARTNERS SX009 HEALTHPARTNERS 517.05 percent of total billed charges 404.86 620.35 Technical (Hospital) Services Radex Abd Compl Aqt Abd W/S/E/D Views 1 View Ch PX-3207402200 CDM 74022 CPT 320 RC inpatient 653 653 BLUE CROSS BLUE SHIELD WELLMARK SB889 [3081026] BCBS WYOMING [308102603] 620.35 percent of total billed charges 404.86 620.35 Technical (Hospital) Services Radex Abd Compl Aqt Abd W/S/E/D Views 1 View Ch PX-3207402200 CDM 74022 CPT 320 RC inpatient 653 653 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES PPO [308136801] 517.05 percent of total billed charges 404.86 620.35 Technical (Hospital) Services Radex Abd Compl Aqt Abd W/S/E/D Views 1 View Ch PX-3207402200 CDM 74022 CPT 320 RC inpatient 653 653 MULTIPLAN INC 34080 [3081285] MULTIPLAN INC [308128501] 620.35 percent of total billed charges 404.86 620.35 Technical (Hospital) Services Radex Abd Compl Aqt Abd W/S/E/D Views 1 View Ch PX-3207402200 CDM 74022 CPT 320 RC inpatient 653 653 UNITED HEALTHCARE (COMMERCIAL) [3081199] UNITED HEALTHCARE 87726 [308119901] 404.86 percent of total billed charges 404.86 620.35 Technical (Hospital) Services Radex Abd Compl Aqt Abd W/S/E/D Views 1 View Ch PX-3207402200 CDM 74022 CPT 320 RC inpatient 653 653 CIGNA 62308 [3081051] CIGNA 62308 [308105105] 517.05 percent of total billed charges 404.86 620.35 Technical (Hospital) Services Radex Abd Compl Aqt Abd W/S/E/D Views 1 View Ch PX-3207402200 CDM 74022 CPT 320 RC inpatient 653 653 CIGNA 62308 [3081051] CIGNA STATE OF WYOMING [308105107] 517.05 percent of total billed charges 404.86 620.35 Technical (Hospital) Services Radex Abd Compl Aqt Abd W/S/E/D Views 1 View Ch PX-3207402200 CDM 74022 CPT 320 RC inpatient 653 653 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES EPO [308136803] 517.05 percent of total billed charges 404.86 620.35 Technical (Hospital) Services Radex Abd Compl Aqt Abd W/S/E/D Views 1 View Ch PX-3207402200 CDM 74022 CPT 320 RC outpatient 653 653 CIGNA 62308 [3081051] CIGNA 62308 [308105105] 522.4 percent of total billed charges 404.86 620.35 Technical (Hospital) Services Radex Abd Compl Aqt Abd W/S/E/D Views 1 View Ch PX-3207402200 CDM 74022 CPT 320 RC outpatient 653 653 CIGNA 62308 [3081051] CIGNA STATE OF WYOMING [308105107] 522.4 percent of total billed charges 404.86 620.35 Technical (Hospital) Services Radex Abd Compl Aqt Abd W/S/E/D Views 1 View Ch PX-3207402200 CDM 74022 CPT 320 RC outpatient 653 653 MEDICA (COMMERCIAL) 94265 [3081118] MEDICA CLAIMS [308111801] 587.7 percent of total billed charges 404.86 620.35 Technical (Hospital) Services Radex Abd Compl Aqt Abd W/S/E/D Views 1 View Ch PX-3207402200 CDM 74022 CPT 320 RC outpatient 653 653 HEALTHPARTNERS SX009 HEALTHPARTNERS 522.4 percent of total billed charges 404.86 620.35 Technical (Hospital) Services Radex Abd Compl Aqt Abd W/S/E/D Views 1 View Ch PX-3207402200 CDM 74022 CPT 320 RC outpatient 653 653 BLUE CROSS BLUE SHIELD WELLMARK SB889 [3081026] BCBS WYOMING [308102603] 620.35 percent of total billed charges 404.86 620.35 Technical (Hospital) Services Radex Abd Compl Aqt Abd W/S/E/D Views 1 View Ch PX-3207402200 CDM 74022 CPT 320 RC outpatient 653 653 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES HDHP [308136802] 522.4 percent of total billed charges 404.86 620.35 Technical (Hospital) Services Radex Abd Compl Aqt Abd W/S/E/D Views 1 View Ch PX-3207402200 CDM 74022 CPT 320 RC outpatient 653 653 MULTIPLAN INC 34080 [3081285] MULTIPLAN INC [308128501] 620.35 percent of total billed charges 404.86 620.35 Technical (Hospital) Services Radex Abd Compl Aqt Abd W/S/E/D Views 1 View Ch PX-3207402200 CDM 74022 CPT 320 RC outpatient 653 653 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES PPO [308136801] 522.4 percent of total billed charges 404.86 620.35 Technical (Hospital) Services Radex Abd Compl Aqt Abd W/S/E/D Views 1 View Ch PX-3207402200 CDM 74022 CPT 320 RC outpatient 653 653 UNITED HEALTHCARE (COMMERCIAL) [3081199] UNITED HEALTHCARE 87726 [308119901] 404.86 percent of total billed charges 404.86 620.35 Technical (Hospital) Services Radex Abd Compl Aqt Abd W/S/E/D Views 1 View Ch PX-3207402200 CDM 74022 CPT 320 RC outpatient 653 653 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES EPO [308136803] 522.4 percent of total billed charges 404.86 620.35 Technical (Hospital) Services Radiologic Exam Abdomen 2 Views PX-3207401900 CDM 74019 CPT 320 RC inpatient 519 519 CIGNA 62308 [3081051] CIGNA 62308 [308105105] 410.94 percent of total billed charges 321.78 493.05 Technical (Hospital) Services Radiologic Exam Abdomen 2 Views PX-3207401900 CDM 74019 CPT 320 RC inpatient 519 519 CIGNA 62308 [3081051] CIGNA STATE OF WYOMING [308105107] 410.94 percent of total billed charges 321.78 493.05 Technical (Hospital) Services Radiologic Exam Abdomen 2 Views PX-3207401900 CDM 74019 CPT 320 RC inpatient 519 519 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES EPO [308136803] 410.94 percent of total billed charges 321.78 493.05 Technical (Hospital) Services Radiologic Exam Abdomen 2 Views PX-3207401900 CDM 74019 CPT 320 RC inpatient 519 519 MULTIPLAN INC 34080 [3081285] MULTIPLAN INC [308128501] 493.05 percent of total billed charges 321.78 493.05 Technical (Hospital) Services Radiologic Exam Abdomen 2 Views PX-3207401900 CDM 74019 CPT 320 RC inpatient 519 519 BLUE CROSS BLUE SHIELD WELLMARK SB889 [3081026] BCBS WYOMING [308102603] 493.05 percent of total billed charges 321.78 493.05 Technical (Hospital) Services Radiologic Exam Abdomen 2 Views PX-3207401900 CDM 74019 CPT 320 RC inpatient 519 519 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES PPO [308136801] 410.94 percent of total billed charges 321.78 493.05 Technical (Hospital) Services Radiologic Exam Abdomen 2 Views PX-3207401900 CDM 74019 CPT 320 RC inpatient 519 519 UNITED HEALTHCARE (COMMERCIAL) [3081199] UNITED HEALTHCARE 87726 [308119901] 321.78 percent of total billed charges 321.78 493.05 Technical (Hospital) Services Radiologic Exam Abdomen 2 Views PX-3207401900 CDM 74019 CPT 320 RC inpatient 519 519 HEALTHPARTNERS SX009 HEALTHPARTNERS 410.94 percent of total billed charges 321.78 493.05 Technical (Hospital) Services Radiologic Exam Abdomen 2 Views PX-3207401900 CDM 74019 CPT 320 RC inpatient 519 519 MEDICA (COMMERCIAL) 94265 [3081118] MEDICA CLAIMS [308111801] 467.1 percent of total billed charges 321.78 493.05 Technical (Hospital) Services Radiologic Exam Abdomen 2 Views PX-3207401900 CDM 74019 CPT 320 RC inpatient 519 519 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES HDHP [308136802] 410.94 percent of total billed charges 321.78 493.05 Technical (Hospital) Services Radiologic Exam Abdomen 2 Views PX-3207401900 CDM 74019 CPT 320 RC outpatient 519 519 CIGNA 62308 [3081051] CIGNA 62308 [308105105] 415.2 percent of total billed charges 321.78 493.05 Technical (Hospital) Services Radiologic Exam Abdomen 2 Views PX-3207401900 CDM 74019 CPT 320 RC outpatient 519 519 CIGNA 62308 [3081051] CIGNA STATE OF WYOMING [308105107] 415.2 percent of total billed charges 321.78 493.05 Technical (Hospital) Services Radiologic Exam Abdomen 2 Views PX-3207401900 CDM 74019 CPT 320 RC outpatient 519 519 HEALTHPARTNERS SX009 HEALTHPARTNERS 415.2 percent of total billed charges 321.78 493.05 Technical (Hospital) Services Radiologic Exam Abdomen 2 Views PX-3207401900 CDM 74019 CPT 320 RC outpatient 519 519 MEDICA (COMMERCIAL) 94265 [3081118] MEDICA CLAIMS [308111801] 467.1 percent of total billed charges 321.78 493.05 Technical (Hospital) Services Radiologic Exam Abdomen 2 Views PX-3207401900 CDM 74019 CPT 320 RC outpatient 519 519 BLUE CROSS BLUE SHIELD WELLMARK SB889 [3081026] BCBS WYOMING [308102603] 493.05 percent of total billed charges 321.78 493.05 Technical (Hospital) Services Radiologic Exam Abdomen 2 Views PX-3207401900 CDM 74019 CPT 320 RC outpatient 519 519 MULTIPLAN INC 34080 [3081285] MULTIPLAN INC [308128501] 493.05 percent of total billed charges 321.78 493.05 Technical (Hospital) Services Radiologic Exam Abdomen 2 Views PX-3207401900 CDM 74019 CPT 320 RC outpatient 519 519 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES HDHP [308136802] 415.2 percent of total billed charges 321.78 493.05 Technical (Hospital) Services Radiologic Exam Abdomen 2 Views PX-3207401900 CDM 74019 CPT 320 RC outpatient 519 519 UNITED HEALTHCARE (COMMERCIAL) [3081199] UNITED HEALTHCARE 87726 [308119901] 321.78 percent of total billed charges 321.78 493.05 Technical (Hospital) Services Radiologic Exam Abdomen 2 Views PX-3207401900 CDM 74019 CPT 320 RC outpatient 519 519 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES EPO [308136803] 415.2 percent of total billed charges 321.78 493.05 Technical (Hospital) Services Radiologic Exam Abdomen 2 Views PX-3207401900 CDM 74019 CPT 320 RC outpatient 519 519 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES PPO [308136801] 415.2 percent of total billed charges 321.78 493.05 Technical (Hospital) Services Radiologic Exam Abdomen 1 View PX-3207401800 CDM 74018 CPT 320 RC outpatient 352 352 CIGNA 62308 [3081051] CIGNA 62308 [308105105] 281.6 percent of total billed charges 218.24 334.4 Technical (Hospital) Services Radiologic Exam Abdomen 1 View PX-3207401800 CDM 74018 CPT 320 RC outpatient 352 352 CIGNA 62308 [3081051] CIGNA STATE OF WYOMING [308105107] 281.6 percent of total billed charges 218.24 334.4 Technical (Hospital) Services Radiologic Exam Abdomen 1 View PX-3207401800 CDM 74018 CPT 320 RC outpatient 352 352 BLUE CROSS BLUE SHIELD WELLMARK SB889 [3081026] BCBS WYOMING [308102603] 334.4 percent of total billed charges 218.24 334.4 Technical (Hospital) Services Radiologic Exam Abdomen 1 View PX-3207401800 CDM 74018 CPT 320 RC outpatient 352 352 MULTIPLAN INC 34080 [3081285] MULTIPLAN INC [308128501] 334.4 percent of total billed charges 218.24 334.4 Technical (Hospital) Services Radiologic Exam Abdomen 1 View PX-3207401800 CDM 74018 CPT 320 RC outpatient 352 352 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES HDHP [308136802] 281.6 percent of total billed charges 218.24 334.4 Technical (Hospital) Services Radiologic Exam Abdomen 1 View PX-3207401800 CDM 74018 CPT 320 RC outpatient 352 352 UNITED HEALTHCARE (COMMERCIAL) [3081199] UNITED HEALTHCARE 87726 [308119901] 218.24 percent of total billed charges 218.24 334.4 Technical (Hospital) Services Radiologic Exam Abdomen 1 View PX-3207401800 CDM 74018 CPT 320 RC outpatient 352 352 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES PPO [308136801] 281.6 percent of total billed charges 218.24 334.4 Technical (Hospital) Services Radiologic Exam Abdomen 1 View PX-3207401800 CDM 74018 CPT 320 RC outpatient 352 352 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES EPO [308136803] 281.6 percent of total billed charges 218.24 334.4 Technical (Hospital) Services Radiologic Exam Abdomen 1 View PX-3207401800 CDM 74018 CPT 320 RC outpatient 352 352 MEDICA (COMMERCIAL) 94265 [3081118] MEDICA CLAIMS [308111801] 316.8 percent of total billed charges 218.24 334.4 Technical (Hospital) Services Radiologic Exam Abdomen 1 View PX-3207401800 CDM 74018 CPT 320 RC outpatient 352 352 HEALTHPARTNERS SX009 HEALTHPARTNERS 281.6 percent of total billed charges 218.24 334.4 Technical (Hospital) Services Radiologic Exam Abdomen 1 View PX-3207401800 CDM 74018 CPT 320 RC inpatient 352 352 HEALTHPARTNERS SX009 HEALTHPARTNERS 278.71 percent of total billed charges 218.24 334.4 Technical (Hospital) Services Radiologic Exam Abdomen 1 View PX-3207401800 CDM 74018 CPT 320 RC inpatient 352 352 MEDICA (COMMERCIAL) 94265 [3081118] MEDICA CLAIMS [308111801] 316.8 percent of total billed charges 218.24 334.4 Technical (Hospital) Services Radiologic Exam Abdomen 1 View PX-3207401800 CDM 74018 CPT 320 RC inpatient 352 352 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES HDHP [308136802] 278.71 percent of total billed charges 218.24 334.4 Technical (Hospital) Services Radiologic Exam Abdomen 1 View PX-3207401800 CDM 74018 CPT 320 RC inpatient 352 352 MULTIPLAN INC 34080 [3081285] MULTIPLAN INC [308128501] 334.4 percent of total billed charges 218.24 334.4 Technical (Hospital) Services Radiologic Exam Abdomen 1 View PX-3207401800 CDM 74018 CPT 320 RC inpatient 352 352 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES PPO [308136801] 278.71 percent of total billed charges 218.24 334.4 Technical (Hospital) Services Radiologic Exam Abdomen 1 View PX-3207401800 CDM 74018 CPT 320 RC inpatient 352 352 BLUE CROSS BLUE SHIELD WELLMARK SB889 [3081026] BCBS WYOMING [308102603] 334.4 percent of total billed charges 218.24 334.4 Technical (Hospital) Services Radiologic Exam Abdomen 1 View PX-3207401800 CDM 74018 CPT 320 RC inpatient 352 352 UNITED HEALTHCARE (COMMERCIAL) [3081199] UNITED HEALTHCARE 87726 [308119901] 218.24 percent of total billed charges 218.24 334.4 Technical (Hospital) Services Radiologic Exam Abdomen 1 View PX-3207401800 CDM 74018 CPT 320 RC inpatient 352 352 CIGNA 62308 [3081051] CIGNA 62308 [308105105] 278.71 percent of total billed charges 218.24 334.4 Technical (Hospital) Services Radiologic Exam Abdomen 1 View PX-3207401800 CDM 74018 CPT 320 RC inpatient 352 352 CIGNA 62308 [3081051] CIGNA STATE OF WYOMING [308105107] 278.71 percent of total billed charges 218.24 334.4 Technical (Hospital) Services Radiologic Exam Abdomen 1 View PX-3207401800 CDM 74018 CPT 320 RC inpatient 352 352 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES EPO [308136803] 278.71 percent of total billed charges 218.24 334.4 Technical (Hospital) Services Mra Lower Extremity W/WO Contrast Material PX-6167372500 CDM 73725 CPT 616 RC inpatient 3144 3144 CIGNA 62308 [3081051] CIGNA 62308 [308105105] 2489.42 percent of total billed charges 1949.28 2986.8 Technical (Hospital) Services Mra Lower Extremity W/WO Contrast Material PX-6167372500 CDM 73725 CPT 616 RC inpatient 3144 3144 CIGNA 62308 [3081051] CIGNA STATE OF WYOMING [308105107] 2489.42 percent of total billed charges 1949.28 2986.8 Technical (Hospital) Services Mra Lower Extremity W/WO Contrast Material PX-6167372500 CDM 73725 CPT 616 RC inpatient 3144 3144 MEDICA (COMMERCIAL) 94265 [3081118] MEDICA CLAIMS [308111801] 2829.6 percent of total billed charges 1949.28 2986.8 Technical (Hospital) Services Mra Lower Extremity W/WO Contrast Material PX-6167372500 CDM 73725 CPT 616 RC inpatient 3144 3144 HEALTHPARTNERS SX009 HEALTHPARTNERS 2489.42 percent of total billed charges 1949.28 2986.8 Technical (Hospital) Services Mra Lower Extremity W/WO Contrast Material PX-6167372500 CDM 73725 CPT 616 RC inpatient 3144 3144 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES EPO [308136803] 2489.42 percent of total billed charges 1949.28 2986.8 Technical (Hospital) Services Mra Lower Extremity W/WO Contrast Material PX-6167372500 CDM 73725 CPT 616 RC inpatient 3144 3144 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES HDHP [308136802] 2489.42 percent of total billed charges 1949.28 2986.8 Technical (Hospital) Services Mra Lower Extremity W/WO Contrast Material PX-6167372500 CDM 73725 CPT 616 RC inpatient 3144 3144 BLUE CROSS BLUE SHIELD WELLMARK SB889 [3081026] BCBS WYOMING [308102603] 2986.8 percent of total billed charges 1949.28 2986.8 Technical (Hospital) Services Mra Lower Extremity W/WO Contrast Material PX-6167372500 CDM 73725 CPT 616 RC inpatient 3144 3144 MULTIPLAN INC 34080 [3081285] MULTIPLAN INC [308128501] 2986.8 percent of total billed charges 1949.28 2986.8 Technical (Hospital) Services Mra Lower Extremity W/WO Contrast Material PX-6167372500 CDM 73725 CPT 616 RC inpatient 3144 3144 UNITED HEALTHCARE (COMMERCIAL) [3081199] UNITED HEALTHCARE 87726 [308119901] 1949.28 percent of total billed charges 1949.28 2986.8 Technical (Hospital) Services Mra Lower Extremity W/WO Contrast Material PX-6167372500 CDM 73725 CPT 616 RC inpatient 3144 3144 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES PPO [308136801] 2489.42 percent of total billed charges 1949.28 2986.8 Technical (Hospital) Services Mra Lower Extremity W/WO Contrast Material PX-6167372500 CDM 73725 CPT 616 RC outpatient 3144 3144 HEALTHPARTNERS SX009 HEALTHPARTNERS 2515.2 percent of total billed charges 1949.28 2986.8 Technical (Hospital) Services Mra Lower Extremity W/WO Contrast Material PX-6167372500 CDM 73725 CPT 616 RC outpatient 3144 3144 UNITED HEALTHCARE (COMMERCIAL) [3081199] UNITED HEALTHCARE 87726 [308119901] 1949.28 percent of total billed charges 1949.28 2986.8 Technical (Hospital) Services Mra Lower Extremity W/WO Contrast Material PX-6167372500 CDM 73725 CPT 616 RC outpatient 3144 3144 BLUE CROSS BLUE SHIELD WELLMARK SB889 [3081026] BCBS WYOMING [308102603] 2986.8 percent of total billed charges 1949.28 2986.8 Technical (Hospital) Services Mra Lower Extremity W/WO Contrast Material PX-6167372500 CDM 73725 CPT 616 RC outpatient 3144 3144 MULTIPLAN INC 34080 [3081285] MULTIPLAN INC [308128501] 2986.8 percent of total billed charges 1949.28 2986.8 Technical (Hospital) Services Mra Lower Extremity W/WO Contrast Material PX-6167372500 CDM 73725 CPT 616 RC outpatient 3144 3144 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES HDHP [308136802] 2515.2 percent of total billed charges 1949.28 2986.8 Technical (Hospital) Services Mra Lower Extremity W/WO Contrast Material PX-6167372500 CDM 73725 CPT 616 RC outpatient 3144 3144 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES EPO [308136803] 2515.2 percent of total billed charges 1949.28 2986.8 Technical (Hospital) Services Mra Lower Extremity W/WO Contrast Material PX-6167372500 CDM 73725 CPT 616 RC outpatient 3144 3144 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES PPO [308136801] 2515.2 percent of total billed charges 1949.28 2986.8 Technical (Hospital) Services Mra Lower Extremity W/WO Contrast Material PX-6167372500 CDM 73725 CPT 616 RC outpatient 3144 3144 MEDICA (COMMERCIAL) 94265 [3081118] MEDICA CLAIMS [308111801] 2829.6 percent of total billed charges 1949.28 2986.8 Technical (Hospital) Services Mra Lower Extremity W/WO Contrast Material PX-6167372500 CDM 73725 CPT 616 RC outpatient 3144 3144 CIGNA 62308 [3081051] CIGNA 62308 [308105105] 2515.2 percent of total billed charges 1949.28 2986.8 Technical (Hospital) Services Mra Lower Extremity W/WO Contrast Material PX-6167372500 CDM 73725 CPT 616 RC outpatient 3144 3144 CIGNA 62308 [3081051] CIGNA STATE OF WYOMING [308105107] 2515.2 percent of total billed charges 1949.28 2986.8 Technical (Hospital) Services MRI Any Jt Lower Extrem W/O & W/Contrast Matrl PX-6107372300 CDM 73723 CPT 610 RC inpatient 3929 3929 MEDICA (COMMERCIAL) 94265 [3081118] MEDICA CLAIMS [308111801] 3536.1 percent of total billed charges 2435.98 3732.55 Technical (Hospital) Services MRI Any Jt Lower Extrem W/O & W/Contrast Matrl PX-6107372300 CDM 73723 CPT 610 RC inpatient 3929 3929 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES HDHP [308136802] 3110.98 percent of total billed charges 2435.98 3732.55 Technical (Hospital) Services MRI Any Jt Lower Extrem W/O & W/Contrast Matrl PX-6107372300 CDM 73723 CPT 610 RC inpatient 3929 3929 HEALTHPARTNERS SX009 HEALTHPARTNERS 3110.98 percent of total billed charges 2435.98 3732.55 Technical (Hospital) Services MRI Any Jt Lower Extrem W/O & W/Contrast Matrl PX-6107372300 CDM 73723 CPT 610 RC inpatient 3929 3929 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES EPO [308136803] 3110.98 percent of total billed charges 2435.98 3732.55 Technical (Hospital) Services MRI Any Jt Lower Extrem W/O & W/Contrast Matrl PX-6107372300 CDM 73723 CPT 610 RC inpatient 3929 3929 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES PPO [308136801] 3110.98 percent of total billed charges 2435.98 3732.55 Technical (Hospital) Services MRI Any Jt Lower Extrem W/O & W/Contrast Matrl PX-6107372300 CDM 73723 CPT 610 RC inpatient 3929 3929 UNITED HEALTHCARE (COMMERCIAL) [3081199] UNITED HEALTHCARE 87726 [308119901] 2435.98 percent of total billed charges 2435.98 3732.55 Technical (Hospital) Services MRI Any Jt Lower Extrem W/O & W/Contrast Matrl PX-6107372300 CDM 73723 CPT 610 RC inpatient 3929 3929 BLUE CROSS BLUE SHIELD WELLMARK SB889 [3081026] BCBS WYOMING [308102603] 3732.55 percent of total billed charges 2435.98 3732.55 Technical (Hospital) Services MRI Any Jt Lower Extrem W/O & W/Contrast Matrl PX-6107372300 CDM 73723 CPT 610 RC inpatient 3929 3929 MULTIPLAN INC 34080 [3081285] MULTIPLAN INC [308128501] 3732.55 percent of total billed charges 2435.98 3732.55 Technical (Hospital) Services MRI Any Jt Lower Extrem W/O & W/Contrast Matrl PX-6107372300 CDM 73723 CPT 610 RC inpatient 3929 3929 CIGNA 62308 [3081051] CIGNA 62308 [308105105] 3110.98 percent of total billed charges 2435.98 3732.55 Technical (Hospital) Services MRI Any Jt Lower Extrem W/O & W/Contrast Matrl PX-6107372300 CDM 73723 CPT 610 RC inpatient 3929 3929 CIGNA 62308 [3081051] CIGNA STATE OF WYOMING [308105107] 3110.98 percent of total billed charges 2435.98 3732.55 Technical (Hospital) Services MRI Any Jt Lower Extrem W/O & W/Contrast Matrl PX-6107372300 CDM 73723 CPT 610 RC outpatient 3929 3929 MEDICA (COMMERCIAL) 94265 [3081118] MEDICA CLAIMS [308111801] 3536.1 percent of total billed charges 2435.98 3732.55 Technical (Hospital) Services MRI Any Jt Lower Extrem W/O & W/Contrast Matrl PX-6107372300 CDM 73723 CPT 610 RC outpatient 3929 3929 CIGNA 62308 [3081051] CIGNA 62308 [308105105] 3143.2 percent of total billed charges 2435.98 3732.55 Technical (Hospital) Services MRI Any Jt Lower Extrem W/O & W/Contrast Matrl PX-6107372300 CDM 73723 CPT 610 RC outpatient 3929 3929 CIGNA 62308 [3081051] CIGNA STATE OF WYOMING [308105107] 3143.2 percent of total billed charges 2435.98 3732.55 Technical (Hospital) Services MRI Any Jt Lower Extrem W/O & W/Contrast Matrl PX-6107372300 CDM 73723 CPT 610 RC outpatient 3929 3929 UNITED HEALTHCARE (COMMERCIAL) [3081199] UNITED HEALTHCARE 87726 [308119901] 2435.98 percent of total billed charges 2435.98 3732.55 Technical (Hospital) Services MRI Any Jt Lower Extrem W/O & W/Contrast Matrl PX-6107372300 CDM 73723 CPT 610 RC outpatient 3929 3929 HEALTHPARTNERS SX009 HEALTHPARTNERS 3143.2 percent of total billed charges 2435.98 3732.55 Technical (Hospital) Services MRI Any Jt Lower Extrem W/O & W/Contrast Matrl PX-6107372300 CDM 73723 CPT 610 RC outpatient 3929 3929 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES EPO [308136803] 3143.2 percent of total billed charges 2435.98 3732.55 Technical (Hospital) Services MRI Any Jt Lower Extrem W/O & W/Contrast Matrl PX-6107372300 CDM 73723 CPT 610 RC outpatient 3929 3929 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES PPO [308136801] 3143.2 percent of total billed charges 2435.98 3732.55 Technical (Hospital) Services MRI Any Jt Lower Extrem W/O & W/Contrast Matrl PX-6107372300 CDM 73723 CPT 610 RC outpatient 3929 3929 BLUE CROSS BLUE SHIELD WELLMARK SB889 [3081026] BCBS WYOMING [308102603] 3732.55 percent of total billed charges 2435.98 3732.55 Technical (Hospital) Services MRI Any Jt Lower Extrem W/O & W/Contrast Matrl PX-6107372300 CDM 73723 CPT 610 RC outpatient 3929 3929 MULTIPLAN INC 34080 [3081285] MULTIPLAN INC [308128501] 3732.55 percent of total billed charges 2435.98 3732.55 Technical (Hospital) Services MRI Any Jt Lower Extrem W/O & W/Contrast Matrl PX-6107372300 CDM 73723 CPT 610 RC outpatient 3929 3929 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES HDHP [308136802] 3143.2 percent of total billed charges 2435.98 3732.55 Technical (Hospital) Services MRI Any Jt Lower Extrem W/O Contrast Matrl PX-6107372100 CDM 73721 CPT 610 RC outpatient 2620 2620 MEDICA (COMMERCIAL) 94265 [3081118] MEDICA CLAIMS [308111801] 2358 percent of total billed charges 1624.4 2489 Technical (Hospital) Services MRI Any Jt Lower Extrem W/O Contrast Matrl PX-6107372100 CDM 73721 CPT 610 RC outpatient 2620 2620 CIGNA 62308 [3081051] CIGNA 62308 [308105105] 2096 percent of total billed charges 1624.4 2489 Technical (Hospital) Services MRI Any Jt Lower Extrem W/O Contrast Matrl PX-6107372100 CDM 73721 CPT 610 RC outpatient 2620 2620 CIGNA 62308 [3081051] CIGNA STATE OF WYOMING [308105107] 2096 percent of total billed charges 1624.4 2489 Technical (Hospital) Services MRI Any Jt Lower Extrem W/O Contrast Matrl PX-6107372100 CDM 73721 CPT 610 RC outpatient 2620 2620 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES EPO [308136803] 2096 percent of total billed charges 1624.4 2489 Technical (Hospital) Services MRI Any Jt Lower Extrem W/O Contrast Matrl PX-6107372100 CDM 73721 CPT 610 RC outpatient 2620 2620 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES PPO [308136801] 2096 percent of total billed charges 1624.4 2489 Technical (Hospital) Services MRI Any Jt Lower Extrem W/O Contrast Matrl PX-6107372100 CDM 73721 CPT 610 RC outpatient 2620 2620 BLUE CROSS BLUE SHIELD WELLMARK SB889 [3081026] BCBS WYOMING [308102603] 2489 percent of total billed charges 1624.4 2489 Technical (Hospital) Services MRI Any Jt Lower Extrem W/O Contrast Matrl PX-6107372100 CDM 73721 CPT 610 RC outpatient 2620 2620 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES HDHP [308136802] 2096 percent of total billed charges 1624.4 2489 Technical (Hospital) Services MRI Any Jt Lower Extrem W/O Contrast Matrl PX-6107372100 CDM 73721 CPT 610 RC outpatient 2620 2620 MULTIPLAN INC 34080 [3081285] MULTIPLAN INC [308128501] 2489 percent of total billed charges 1624.4 2489 Technical (Hospital) Services MRI Any Jt Lower Extrem W/O Contrast Matrl PX-6107372100 CDM 73721 CPT 610 RC outpatient 2620 2620 HEALTHPARTNERS SX009 HEALTHPARTNERS 2096 percent of total billed charges 1624.4 2489 Technical (Hospital) Services MRI Any Jt Lower Extrem W/O Contrast Matrl PX-6107372100 CDM 73721 CPT 610 RC outpatient 2620 2620 UNITED HEALTHCARE (COMMERCIAL) [3081199] UNITED HEALTHCARE 87726 [308119901] 1624.4 percent of total billed charges 1624.4 2489 Technical (Hospital) Services MRI Any Jt Lower Extrem W/O Contrast Matrl PX-6107372100 CDM 73721 CPT 610 RC inpatient 2620 2620 CIGNA 62308 [3081051] CIGNA 62308 [308105105] 2074.52 percent of total billed charges 1624.4 2489 Technical (Hospital) Services MRI Any Jt Lower Extrem W/O Contrast Matrl PX-6107372100 CDM 73721 CPT 610 RC inpatient 2620 2620 CIGNA 62308 [3081051] CIGNA STATE OF WYOMING [308105107] 2074.52 percent of total billed charges 1624.4 2489 Technical (Hospital) Services MRI Any Jt Lower Extrem W/O Contrast Matrl PX-6107372100 CDM 73721 CPT 610 RC inpatient 2620 2620 HEALTHPARTNERS SX009 HEALTHPARTNERS 2074.52 percent of total billed charges 1624.4 2489 Technical (Hospital) Services MRI Any Jt Lower Extrem W/O Contrast Matrl PX-6107372100 CDM 73721 CPT 610 RC inpatient 2620 2620 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES EPO [308136803] 2074.52 percent of total billed charges 1624.4 2489 Technical (Hospital) Services MRI Any Jt Lower Extrem W/O Contrast Matrl PX-6107372100 CDM 73721 CPT 610 RC inpatient 2620 2620 MEDICA (COMMERCIAL) 94265 [3081118] MEDICA CLAIMS [308111801] 2358 percent of total billed charges 1624.4 2489 Technical (Hospital) Services MRI Any Jt Lower Extrem W/O Contrast Matrl PX-6107372100 CDM 73721 CPT 610 RC inpatient 2620 2620 UNITED HEALTHCARE (COMMERCIAL) [3081199] UNITED HEALTHCARE 87726 [308119901] 1624.4 percent of total billed charges 1624.4 2489 Technical (Hospital) Services MRI Any Jt Lower Extrem W/O Contrast Matrl PX-6107372100 CDM 73721 CPT 610 RC inpatient 2620 2620 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES PPO [308136801] 2074.52 percent of total billed charges 1624.4 2489 Technical (Hospital) Services MRI Any Jt Lower Extrem W/O Contrast Matrl PX-6107372100 CDM 73721 CPT 610 RC inpatient 2620 2620 BLUE CROSS BLUE SHIELD WELLMARK SB889 [3081026] BCBS WYOMING [308102603] 2489 percent of total billed charges 1624.4 2489 Technical (Hospital) Services MRI Any Jt Lower Extrem W/O Contrast Matrl PX-6107372100 CDM 73721 CPT 610 RC inpatient 2620 2620 MULTIPLAN INC 34080 [3081285] MULTIPLAN INC [308128501] 2489 percent of total billed charges 1624.4 2489 Technical (Hospital) Services MRI Any Jt Lower Extrem W/O Contrast Matrl PX-6107372100 CDM 73721 CPT 610 RC inpatient 2620 2620 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES HDHP [308136802] 2074.52 percent of total billed charges 1624.4 2489 Technical (Hospital) Services MRI Lower Extrem Oth/Thn Jt W/O & W/Contr Matr PX-6107372000 CDM 73720 CPT 610 RC outpatient 4125 4125 CIGNA 62308 [3081051] CIGNA 62308 [308105105] 3300 percent of total billed charges 2557.5 3918.75 Technical (Hospital) Services MRI Lower Extrem Oth/Thn Jt W/O & W/Contr Matr PX-6107372000 CDM 73720 CPT 610 RC outpatient 4125 4125 CIGNA 62308 [3081051] CIGNA STATE OF WYOMING [308105107] 3300 percent of total billed charges 2557.5 3918.75 Technical (Hospital) Services MRI Lower Extrem Oth/Thn Jt W/O & W/Contr Matr PX-6107372000 CDM 73720 CPT 610 RC outpatient 4125 4125 HEALTHPARTNERS SX009 HEALTHPARTNERS 3300 percent of total billed charges 2557.5 3918.75 Technical (Hospital) Services MRI Lower Extrem Oth/Thn Jt W/O & W/Contr Matr PX-6107372000 CDM 73720 CPT 610 RC outpatient 4125 4125 MEDICA (COMMERCIAL) 94265 [3081118] MEDICA CLAIMS [308111801] 3712.5 percent of total billed charges 2557.5 3918.75 Technical (Hospital) Services MRI Lower Extrem Oth/Thn Jt W/O & W/Contr Matr PX-6107372000 CDM 73720 CPT 610 RC outpatient 4125 4125 BLUE CROSS BLUE SHIELD WELLMARK SB889 [3081026] BCBS WYOMING [308102603] 3918.75 percent of total billed charges 2557.5 3918.75 Technical (Hospital) Services MRI Lower Extrem Oth/Thn Jt W/O & W/Contr Matr PX-6107372000 CDM 73720 CPT 610 RC outpatient 4125 4125 MULTIPLAN INC 34080 [3081285] MULTIPLAN INC [308128501] 3918.75 percent of total billed charges 2557.5 3918.75 Technical (Hospital) Services MRI Lower Extrem Oth/Thn Jt W/O & W/Contr Matr PX-6107372000 CDM 73720 CPT 610 RC outpatient 4125 4125 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES HDHP [308136802] 3300 percent of total billed charges 2557.5 3918.75 Technical (Hospital) Services MRI Lower Extrem Oth/Thn Jt W/O & W/Contr Matr PX-6107372000 CDM 73720 CPT 610 RC outpatient 4125 4125 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES EPO [308136803] 3300 percent of total billed charges 2557.5 3918.75 Technical (Hospital) Services MRI Lower Extrem Oth/Thn Jt W/O & W/Contr Matr PX-6107372000 CDM 73720 CPT 610 RC outpatient 4125 4125 UNITED HEALTHCARE (COMMERCIAL) [3081199] UNITED HEALTHCARE 87726 [308119901] 2557.5 percent of total billed charges 2557.5 3918.75 Technical (Hospital) Services MRI Lower Extrem Oth/Thn Jt W/O & W/Contr Matr PX-6107372000 CDM 73720 CPT 610 RC outpatient 4125 4125 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES PPO [308136801] 3300 percent of total billed charges 2557.5 3918.75 Technical (Hospital) Services MRI Lower Extrem Oth/Thn Jt W/O & W/Contr Matr PX-6107372000 CDM 73720 CPT 610 RC inpatient 4125 4125 MULTIPLAN INC 34080 [3081285] MULTIPLAN INC [308128501] 3918.75 percent of total billed charges 2557.5 3918.75 Technical (Hospital) Services MRI Lower Extrem Oth/Thn Jt W/O & W/Contr Matr PX-6107372000 CDM 73720 CPT 610 RC inpatient 4125 4125 BLUE CROSS BLUE SHIELD WELLMARK SB889 [3081026] BCBS WYOMING [308102603] 3918.75 percent of total billed charges 2557.5 3918.75 Technical (Hospital) Services MRI Lower Extrem Oth/Thn Jt W/O & W/Contr Matr PX-6107372000 CDM 73720 CPT 610 RC inpatient 4125 4125 UNITED HEALTHCARE (COMMERCIAL) [3081199] UNITED HEALTHCARE 87726 [308119901] 2557.5 percent of total billed charges 2557.5 3918.75 Technical (Hospital) Services MRI Lower Extrem Oth/Thn Jt W/O & W/Contr Matr PX-6107372000 CDM 73720 CPT 610 RC inpatient 4125 4125 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES PPO [308136801] 3266.18 percent of total billed charges 2557.5 3918.75 Technical (Hospital) Services MRI Lower Extrem Oth/Thn Jt W/O & W/Contr Matr PX-6107372000 CDM 73720 CPT 610 RC inpatient 4125 4125 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES HDHP [308136802] 3266.18 percent of total billed charges 2557.5 3918.75 Technical (Hospital) Services MRI Lower Extrem Oth/Thn Jt W/O & W/Contr Matr PX-6107372000 CDM 73720 CPT 610 RC inpatient 4125 4125 MEDICA (COMMERCIAL) 94265 [3081118] MEDICA CLAIMS [308111801] 3712.5 percent of total billed charges 2557.5 3918.75 Technical (Hospital) Services MRI Lower Extrem Oth/Thn Jt W/O & W/Contr Matr PX-6107372000 CDM 73720 CPT 610 RC inpatient 4125 4125 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES EPO [308136803] 3266.18 percent of total billed charges 2557.5 3918.75 Technical (Hospital) Services MRI Lower Extrem Oth/Thn Jt W/O & W/Contr Matr PX-6107372000 CDM 73720 CPT 610 RC inpatient 4125 4125 HEALTHPARTNERS SX009 HEALTHPARTNERS 3266.18 percent of total billed charges 2557.5 3918.75 Technical (Hospital) Services MRI Lower Extrem Oth/Thn Jt W/O & W/Contr Matr PX-6107372000 CDM 73720 CPT 610 RC inpatient 4125 4125 CIGNA 62308 [3081051] CIGNA 62308 [308105105] 3266.18 percent of total billed charges 2557.5 3918.75 Technical (Hospital) Services MRI Lower Extrem Oth/Thn Jt W/O & W/Contr Matr PX-6107372000 CDM 73720 CPT 610 RC inpatient 4125 4125 CIGNA 62308 [3081051] CIGNA STATE OF WYOMING [308105107] 3266.18 percent of total billed charges 2557.5 3918.75 Technical (Hospital) Services MRI Lower Extrem Oth/Thn Jt W/O Contr Matrl PX-6107371800 CDM 73718 CPT 610 RC inpatient 2685 2685 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES HDHP [308136802] 2125.98 percent of total billed charges 1664.7 2550.75 Technical (Hospital) Services MRI Lower Extrem Oth/Thn Jt W/O Contr Matrl PX-6107371800 CDM 73718 CPT 610 RC inpatient 2685 2685 MEDICA (COMMERCIAL) 94265 [3081118] MEDICA CLAIMS [308111801] 2416.5 percent of total billed charges 1664.7 2550.75 Technical (Hospital) Services MRI Lower Extrem Oth/Thn Jt W/O Contr Matrl PX-6107371800 CDM 73718 CPT 610 RC inpatient 2685 2685 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES EPO [308136803] 2125.98 percent of total billed charges 1664.7 2550.75 Technical (Hospital) Services MRI Lower Extrem Oth/Thn Jt W/O Contr Matrl PX-6107371800 CDM 73718 CPT 610 RC inpatient 2685 2685 HEALTHPARTNERS SX009 HEALTHPARTNERS 2125.98 percent of total billed charges 1664.7 2550.75 Technical (Hospital) Services MRI Lower Extrem Oth/Thn Jt W/O Contr Matrl PX-6107371800 CDM 73718 CPT 610 RC inpatient 2685 2685 UNITED HEALTHCARE (COMMERCIAL) [3081199] UNITED HEALTHCARE 87726 [308119901] 1664.7 percent of total billed charges 1664.7 2550.75 Technical (Hospital) Services MRI Lower Extrem Oth/Thn Jt W/O Contr Matrl PX-6107371800 CDM 73718 CPT 610 RC inpatient 2685 2685 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES PPO [308136801] 2125.98 percent of total billed charges 1664.7 2550.75 Technical (Hospital) Services MRI Lower Extrem Oth/Thn Jt W/O Contr Matrl PX-6107371800 CDM 73718 CPT 610 RC inpatient 2685 2685 MULTIPLAN INC 34080 [3081285] MULTIPLAN INC [308128501] 2550.75 percent of total billed charges 1664.7 2550.75 Technical (Hospital) Services MRI Lower Extrem Oth/Thn Jt W/O Contr Matrl PX-6107371800 CDM 73718 CPT 610 RC inpatient 2685 2685 BLUE CROSS BLUE SHIELD WELLMARK SB889 [3081026] BCBS WYOMING [308102603] 2550.75 percent of total billed charges 1664.7 2550.75 Technical (Hospital) Services MRI Lower Extrem Oth/Thn Jt W/O Contr Matrl PX-6107371800 CDM 73718 CPT 610 RC inpatient 2685 2685 CIGNA 62308 [3081051] CIGNA 62308 [308105105] 2125.98 percent of total billed charges 1664.7 2550.75 Technical (Hospital) Services MRI Lower Extrem Oth/Thn Jt W/O Contr Matrl PX-6107371800 CDM 73718 CPT 610 RC inpatient 2685 2685 CIGNA 62308 [3081051] CIGNA STATE OF WYOMING [308105107] 2125.98 percent of total billed charges 1664.7 2550.75 Technical (Hospital) Services MRI Lower Extrem Oth/Thn Jt W/O Contr Matrl PX-6107371800 CDM 73718 CPT 610 RC outpatient 2685 2685 UNITED HEALTHCARE (COMMERCIAL) [3081199] UNITED HEALTHCARE 87726 [308119901] 1664.7 percent of total billed charges 1664.7 2550.75 Technical (Hospital) Services MRI Lower Extrem Oth/Thn Jt W/O Contr Matrl PX-6107371800 CDM 73718 CPT 610 RC outpatient 2685 2685 HEALTHPARTNERS SX009 HEALTHPARTNERS 2148 percent of total billed charges 1664.7 2550.75 Technical (Hospital) Services MRI Lower Extrem Oth/Thn Jt W/O Contr Matrl PX-6107371800 CDM 73718 CPT 610 RC outpatient 2685 2685 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES EPO [308136803] 2148 percent of total billed charges 1664.7 2550.75 Technical (Hospital) Services MRI Lower Extrem Oth/Thn Jt W/O Contr Matrl PX-6107371800 CDM 73718 CPT 610 RC outpatient 2685 2685 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES PPO [308136801] 2148 percent of total billed charges 1664.7 2550.75 Technical (Hospital) Services MRI Lower Extrem Oth/Thn Jt W/O Contr Matrl PX-6107371800 CDM 73718 CPT 610 RC outpatient 2685 2685 BLUE CROSS BLUE SHIELD WELLMARK SB889 [3081026] BCBS WYOMING [308102603] 2550.75 percent of total billed charges 1664.7 2550.75 Technical (Hospital) Services MRI Lower Extrem Oth/Thn Jt W/O Contr Matrl PX-6107371800 CDM 73718 CPT 610 RC outpatient 2685 2685 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES HDHP [308136802] 2148 percent of total billed charges 1664.7 2550.75 Technical (Hospital) Services MRI Lower Extrem Oth/Thn Jt W/O Contr Matrl PX-6107371800 CDM 73718 CPT 610 RC outpatient 2685 2685 MULTIPLAN INC 34080 [3081285] MULTIPLAN INC [308128501] 2550.75 percent of total billed charges 1664.7 2550.75 Technical (Hospital) Services MRI Lower Extrem Oth/Thn Jt W/O Contr Matrl PX-6107371800 CDM 73718 CPT 610 RC outpatient 2685 2685 MEDICA (COMMERCIAL) 94265 [3081118] MEDICA CLAIMS [308111801] 2416.5 percent of total billed charges 1664.7 2550.75 Technical (Hospital) Services MRI Lower Extrem Oth/Thn Jt W/O Contr Matrl PX-6107371800 CDM 73718 CPT 610 RC outpatient 2685 2685 CIGNA 62308 [3081051] CIGNA 62308 [308105105] 2148 percent of total billed charges 1664.7 2550.75 Technical (Hospital) Services MRI Lower Extrem Oth/Thn Jt W/O Contr Matrl PX-6107371800 CDM 73718 CPT 610 RC outpatient 2685 2685 CIGNA 62308 [3081051] CIGNA STATE OF WYOMING [308105107] 2148 percent of total billed charges 1664.7 2550.75 Technical (Hospital) Services CT Angiography Lower Extremity PX-3527370600 CDM 73706 CPT 352 RC inpatient 2816 2816 UNITED HEALTHCARE (COMMERCIAL) [3081199] UNITED HEALTHCARE 87726 [308119901] 1745.92 percent of total billed charges 1745.92 2675.2 Technical (Hospital) Services CT Angiography Lower Extremity PX-3527370600 CDM 73706 CPT 352 RC inpatient 2816 2816 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES PPO [308136801] 2229.71 percent of total billed charges 1745.92 2675.2 Technical (Hospital) Services CT Angiography Lower Extremity PX-3527370600 CDM 73706 CPT 352 RC inpatient 2816 2816 BLUE CROSS BLUE SHIELD WELLMARK SB889 [3081026] BCBS WYOMING [308102603] 2675.2 percent of total billed charges 1745.92 2675.2 Technical (Hospital) Services CT Angiography Lower Extremity PX-3527370600 CDM 73706 CPT 352 RC inpatient 2816 2816 MULTIPLAN INC 34080 [3081285] MULTIPLAN INC [308128501] 2675.2 percent of total billed charges 1745.92 2675.2 Technical (Hospital) Services CT Angiography Lower Extremity PX-3527370600 CDM 73706 CPT 352 RC inpatient 2816 2816 HEALTHPARTNERS SX009 HEALTHPARTNERS 2229.71 percent of total billed charges 1745.92 2675.2 Technical (Hospital) Services CT Angiography Lower Extremity PX-3527370600 CDM 73706 CPT 352 RC inpatient 2816 2816 MEDICA (COMMERCIAL) 94265 [3081118] MEDICA CLAIMS [308111801] 2534.4 percent of total billed charges 1745.92 2675.2 Technical (Hospital) Services CT Angiography Lower Extremity PX-3527370600 CDM 73706 CPT 352 RC inpatient 2816 2816 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES HDHP [308136802] 2229.71 percent of total billed charges 1745.92 2675.2 Technical (Hospital) Services CT Angiography Lower Extremity PX-3527370600 CDM 73706 CPT 352 RC inpatient 2816 2816 CIGNA 62308 [3081051] CIGNA STATE OF WYOMING [308105107] 2229.71 percent of total billed charges 1745.92 2675.2 Technical (Hospital) Services CT Angiography Lower Extremity PX-3527370600 CDM 73706 CPT 352 RC inpatient 2816 2816 CIGNA 62308 [3081051] CIGNA 62308 [308105105] 2229.71 percent of total billed charges 1745.92 2675.2 Technical (Hospital) Services CT Angiography Lower Extremity PX-3527370600 CDM 73706 CPT 352 RC inpatient 2816 2816 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES EPO [308136803] 2229.71 percent of total billed charges 1745.92 2675.2 Technical (Hospital) Services CT Angiography Lower Extremity PX-3527370600 CDM 73706 CPT 352 RC outpatient 2816 2816 CIGNA 62308 [3081051] CIGNA 62308 [308105105] 2252.8 percent of total billed charges 1745.92 2675.2 Technical (Hospital) Services CT Angiography Lower Extremity PX-3527370600 CDM 73706 CPT 352 RC outpatient 2816 2816 CIGNA 62308 [3081051] CIGNA STATE OF WYOMING [308105107] 2252.8 percent of total billed charges 1745.92 2675.2 Technical (Hospital) Services CT Angiography Lower Extremity PX-3527370600 CDM 73706 CPT 352 RC outpatient 2816 2816 MEDICA (COMMERCIAL) 94265 [3081118] MEDICA CLAIMS [308111801] 2534.4 percent of total billed charges 1745.92 2675.2 Technical (Hospital) Services CT Angiography Lower Extremity PX-3527370600 CDM 73706 CPT 352 RC outpatient 2816 2816 HEALTHPARTNERS SX009 HEALTHPARTNERS 2252.8 percent of total billed charges 1745.92 2675.2 Technical (Hospital) Services CT Angiography Lower Extremity PX-3527370600 CDM 73706 CPT 352 RC outpatient 2816 2816 UNITED HEALTHCARE (COMMERCIAL) [3081199] UNITED HEALTHCARE 87726 [308119901] 1745.92 percent of total billed charges 1745.92 2675.2 Technical (Hospital) Services CT Angiography Lower Extremity PX-3527370600 CDM 73706 CPT 352 RC outpatient 2816 2816 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES PPO [308136801] 2252.8 percent of total billed charges 1745.92 2675.2 Technical (Hospital) Services CT Angiography Lower Extremity PX-3527370600 CDM 73706 CPT 352 RC outpatient 2816 2816 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES EPO [308136803] 2252.8 percent of total billed charges 1745.92 2675.2 Technical (Hospital) Services CT Angiography Lower Extremity PX-3527370600 CDM 73706 CPT 352 RC outpatient 2816 2816 BLUE CROSS BLUE SHIELD WELLMARK SB889 [3081026] BCBS WYOMING [308102603] 2675.2 percent of total billed charges 1745.92 2675.2 Technical (Hospital) Services CT Angiography Lower Extremity PX-3527370600 CDM 73706 CPT 352 RC outpatient 2816 2816 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES HDHP [308136802] 2252.8 percent of total billed charges 1745.92 2675.2 Technical (Hospital) Services CT Angiography Lower Extremity PX-3527370600 CDM 73706 CPT 352 RC outpatient 2816 2816 MULTIPLAN INC 34080 [3081285] MULTIPLAN INC [308128501] 2675.2 percent of total billed charges 1745.92 2675.2 Technical (Hospital) Services CT Lower Extremity W/Contrast Material PX-3527370100 CDM 73701 CPT 352 RC outpatient 2292 2292 HEALTHPARTNERS SX009 HEALTHPARTNERS 1833.6 percent of total billed charges 1421.04 2177.4 Technical (Hospital) Services CT Lower Extremity W/Contrast Material PX-3527370100 CDM 73701 CPT 352 RC outpatient 2292 2292 UNITED HEALTHCARE (COMMERCIAL) [3081199] UNITED HEALTHCARE 87726 [308119901] 1421.04 percent of total billed charges 1421.04 2177.4 Technical (Hospital) Services CT Lower Extremity W/Contrast Material PX-3527370100 CDM 73701 CPT 352 RC outpatient 2292 2292 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES EPO [308136803] 1833.6 percent of total billed charges 1421.04 2177.4 Technical (Hospital) Services CT Lower Extremity W/Contrast Material PX-3527370100 CDM 73701 CPT 352 RC outpatient 2292 2292 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES PPO [308136801] 1833.6 percent of total billed charges 1421.04 2177.4 Technical (Hospital) Services CT Lower Extremity W/Contrast Material PX-3527370100 CDM 73701 CPT 352 RC outpatient 2292 2292 BLUE CROSS BLUE SHIELD WELLMARK SB889 [3081026] BCBS WYOMING [308102603] 2177.4 percent of total billed charges 1421.04 2177.4 Technical (Hospital) Services CT Lower Extremity W/Contrast Material PX-3527370100 CDM 73701 CPT 352 RC outpatient 2292 2292 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES HDHP [308136802] 1833.6 percent of total billed charges 1421.04 2177.4 Technical (Hospital) Services CT Lower Extremity W/Contrast Material PX-3527370100 CDM 73701 CPT 352 RC outpatient 2292 2292 MULTIPLAN INC 34080 [3081285] MULTIPLAN INC [308128501] 2177.4 percent of total billed charges 1421.04 2177.4 Technical (Hospital) Services CT Lower Extremity W/Contrast Material PX-3527370100 CDM 73701 CPT 352 RC outpatient 2292 2292 MEDICA (COMMERCIAL) 94265 [3081118] MEDICA CLAIMS [308111801] 2062.8 percent of total billed charges 1421.04 2177.4 Technical (Hospital) Services CT Lower Extremity W/Contrast Material PX-3527370100 CDM 73701 CPT 352 RC outpatient 2292 2292 CIGNA 62308 [3081051] CIGNA 62308 [308105105] 1833.6 percent of total billed charges 1421.04 2177.4 Technical (Hospital) Services CT Lower Extremity W/Contrast Material PX-3527370100 CDM 73701 CPT 352 RC outpatient 2292 2292 CIGNA 62308 [3081051] CIGNA STATE OF WYOMING [308105107] 1833.6 percent of total billed charges 1421.04 2177.4 Technical (Hospital) Services CT Lower Extremity W/Contrast Material PX-3527370100 CDM 73701 CPT 352 RC inpatient 2292 2292 UNITED HEALTHCARE (COMMERCIAL) [3081199] UNITED HEALTHCARE 87726 [308119901] 1421.04 percent of total billed charges 1421.04 2177.4 Technical (Hospital) Services CT Lower Extremity W/Contrast Material PX-3527370100 CDM 73701 CPT 352 RC inpatient 2292 2292 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES PPO [308136801] 1814.81 percent of total billed charges 1421.04 2177.4 Technical (Hospital) Services CT Lower Extremity W/Contrast Material PX-3527370100 CDM 73701 CPT 352 RC inpatient 2292 2292 BLUE CROSS BLUE SHIELD WELLMARK SB889 [3081026] BCBS WYOMING [308102603] 2177.4 percent of total billed charges 1421.04 2177.4 Technical (Hospital) Services CT Lower Extremity W/Contrast Material PX-3527370100 CDM 73701 CPT 352 RC inpatient 2292 2292 MULTIPLAN INC 34080 [3081285] MULTIPLAN INC [308128501] 2177.4 percent of total billed charges 1421.04 2177.4 Technical (Hospital) Services CT Lower Extremity W/Contrast Material PX-3527370100 CDM 73701 CPT 352 RC inpatient 2292 2292 MEDICA (COMMERCIAL) 94265 [3081118] MEDICA CLAIMS [308111801] 2062.8 percent of total billed charges 1421.04 2177.4 Technical (Hospital) Services CT Lower Extremity W/Contrast Material PX-3527370100 CDM 73701 CPT 352 RC inpatient 2292 2292 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES HDHP [308136802] 1814.81 percent of total billed charges 1421.04 2177.4 Technical (Hospital) Services CT Lower Extremity W/Contrast Material PX-3527370100 CDM 73701 CPT 352 RC inpatient 2292 2292 HEALTHPARTNERS SX009 HEALTHPARTNERS 1814.81 percent of total billed charges 1421.04 2177.4 Technical (Hospital) Services CT Lower Extremity W/Contrast Material PX-3527370100 CDM 73701 CPT 352 RC inpatient 2292 2292 CIGNA 62308 [3081051] CIGNA 62308 [308105105] 1814.81 percent of total billed charges 1421.04 2177.4 Technical (Hospital) Services CT Lower Extremity W/Contrast Material PX-3527370100 CDM 73701 CPT 352 RC inpatient 2292 2292 CIGNA 62308 [3081051] CIGNA STATE OF WYOMING [308105107] 1814.81 percent of total billed charges 1421.04 2177.4 Technical (Hospital) Services CT Lower Extremity W/Contrast Material PX-3527370100 CDM 73701 CPT 352 RC inpatient 2292 2292 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES EPO [308136803] 1814.81 percent of total billed charges 1421.04 2177.4 Technical (Hospital) Services CT Lower Extremity W/O Contrast Material PX-3527370000 CDM 73700 CPT 352 RC outpatient 1638 1638 CIGNA 62308 [3081051] CIGNA 62308 [308105105] 1310.4 percent of total billed charges 1015.56 1556.1 Technical (Hospital) Services CT Lower Extremity W/O Contrast Material PX-3527370000 CDM 73700 CPT 352 RC outpatient 1638 1638 CIGNA 62308 [3081051] CIGNA STATE OF WYOMING [308105107] 1310.4 percent of total billed charges 1015.56 1556.1 Technical (Hospital) Services CT Lower Extremity W/O Contrast Material PX-3527370000 CDM 73700 CPT 352 RC outpatient 1638 1638 MEDICA (COMMERCIAL) 94265 [3081118] MEDICA CLAIMS [308111801] 1474.2 percent of total billed charges 1015.56 1556.1 Technical (Hospital) Services CT Lower Extremity W/O Contrast Material PX-3527370000 CDM 73700 CPT 352 RC outpatient 1638 1638 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES EPO [308136803] 1310.4 percent of total billed charges 1015.56 1556.1 Technical (Hospital) Services CT Lower Extremity W/O Contrast Material PX-3527370000 CDM 73700 CPT 352 RC outpatient 1638 1638 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES PPO [308136801] 1310.4 percent of total billed charges 1015.56 1556.1 Technical (Hospital) Services CT Lower Extremity W/O Contrast Material PX-3527370000 CDM 73700 CPT 352 RC outpatient 1638 1638 UNITED HEALTHCARE (COMMERCIAL) [3081199] UNITED HEALTHCARE 87726 [308119901] 1015.56 percent of total billed charges 1015.56 1556.1 Technical (Hospital) Services CT Lower Extremity W/O Contrast Material PX-3527370000 CDM 73700 CPT 352 RC outpatient 1638 1638 MULTIPLAN INC 34080 [3081285] MULTIPLAN INC [308128501] 1556.1 percent of total billed charges 1015.56 1556.1 Technical (Hospital) Services CT Lower Extremity W/O Contrast Material PX-3527370000 CDM 73700 CPT 352 RC outpatient 1638 1638 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES HDHP [308136802] 1310.4 percent of total billed charges 1015.56 1556.1 Technical (Hospital) Services CT Lower Extremity W/O Contrast Material PX-3527370000 CDM 73700 CPT 352 RC outpatient 1638 1638 BLUE CROSS BLUE SHIELD WELLMARK SB889 [3081026] BCBS WYOMING [308102603] 1556.1 percent of total billed charges 1015.56 1556.1 Technical (Hospital) Services CT Lower Extremity W/O Contrast Material PX-3527370000 CDM 73700 CPT 352 RC outpatient 1638 1638 HEALTHPARTNERS SX009 HEALTHPARTNERS 1310.4 percent of total billed charges 1015.56 1556.1 Technical (Hospital) Services CT Lower Extremity W/O Contrast Material PX-3527370000 CDM 73700 CPT 352 RC inpatient 1638 1638 CIGNA 62308 [3081051] CIGNA 62308 [308105105] 1296.97 percent of total billed charges 1015.56 1556.1 Technical (Hospital) Services CT Lower Extremity W/O Contrast Material PX-3527370000 CDM 73700 CPT 352 RC inpatient 1638 1638 CIGNA 62308 [3081051] CIGNA STATE OF WYOMING [308105107] 1296.97 percent of total billed charges 1015.56 1556.1 Technical (Hospital) Services CT Lower Extremity W/O Contrast Material PX-3527370000 CDM 73700 CPT 352 RC inpatient 1638 1638 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES EPO [308136803] 1296.97 percent of total billed charges 1015.56 1556.1 Technical (Hospital) Services CT Lower Extremity W/O Contrast Material PX-3527370000 CDM 73700 CPT 352 RC inpatient 1638 1638 MULTIPLAN INC 34080 [3081285] MULTIPLAN INC [308128501] 1556.1 percent of total billed charges 1015.56 1556.1 Technical (Hospital) Services CT Lower Extremity W/O Contrast Material PX-3527370000 CDM 73700 CPT 352 RC inpatient 1638 1638 BLUE CROSS BLUE SHIELD WELLMARK SB889 [3081026] BCBS WYOMING [308102603] 1556.1 percent of total billed charges 1015.56 1556.1 Technical (Hospital) Services CT Lower Extremity W/O Contrast Material PX-3527370000 CDM 73700 CPT 352 RC inpatient 1638 1638 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES PPO [308136801] 1296.97 percent of total billed charges 1015.56 1556.1 Technical (Hospital) Services CT Lower Extremity W/O Contrast Material PX-3527370000 CDM 73700 CPT 352 RC inpatient 1638 1638 UNITED HEALTHCARE (COMMERCIAL) [3081199] UNITED HEALTHCARE 87726 [308119901] 1015.56 percent of total billed charges 1015.56 1556.1 Technical (Hospital) Services CT Lower Extremity W/O Contrast Material PX-3527370000 CDM 73700 CPT 352 RC inpatient 1638 1638 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES HDHP [308136802] 1296.97 percent of total billed charges 1015.56 1556.1 Technical (Hospital) Services CT Lower Extremity W/O Contrast Material PX-3527370000 CDM 73700 CPT 352 RC inpatient 1638 1638 MEDICA (COMMERCIAL) 94265 [3081118] MEDICA CLAIMS [308111801] 1474.2 percent of total billed charges 1015.56 1556.1 Technical (Hospital) Services CT Lower Extremity W/O Contrast Material PX-3527370000 CDM 73700 CPT 352 RC inpatient 1638 1638 HEALTHPARTNERS SX009 HEALTHPARTNERS 1296.97 percent of total billed charges 1015.56 1556.1 Technical (Hospital) Services Radex Toe Minimum 2 Views PX-3207366000 CDM 73660 CPT 320 RC outpatient 158 158 CIGNA 62308 [3081051] CIGNA 62308 [308105105] 126.4 percent of total billed charges 97.96 150.1 Technical (Hospital) Services Radex Toe Minimum 2 Views PX-3207366000 CDM 73660 CPT 320 RC outpatient 158 158 CIGNA 62308 [3081051] CIGNA STATE OF WYOMING [308105107] 126.4 percent of total billed charges 97.96 150.1 Technical (Hospital) Services Radex Toe Minimum 2 Views PX-3207366000 CDM 73660 CPT 320 RC outpatient 158 158 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES HDHP [308136802] 126.4 percent of total billed charges 97.96 150.1 Technical (Hospital) Services Radex Toe Minimum 2 Views PX-3207366000 CDM 73660 CPT 320 RC outpatient 158 158 MULTIPLAN INC 34080 [3081285] MULTIPLAN INC [308128501] 150.1 percent of total billed charges 97.96 150.1 Technical (Hospital) Services Radex Toe Minimum 2 Views PX-3207366000 CDM 73660 CPT 320 RC outpatient 158 158 BLUE CROSS BLUE SHIELD WELLMARK SB889 [3081026] BCBS WYOMING [308102603] 150.1 percent of total billed charges 97.96 150.1 Technical (Hospital) Services Radex Toe Minimum 2 Views PX-3207366000 CDM 73660 CPT 320 RC outpatient 158 158 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES EPO [308136803] 126.4 percent of total billed charges 97.96 150.1 Technical (Hospital) Services Radex Toe Minimum 2 Views PX-3207366000 CDM 73660 CPT 320 RC outpatient 158 158 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES PPO [308136801] 126.4 percent of total billed charges 97.96 150.1 Technical (Hospital) Services Radex Toe Minimum 2 Views PX-3207366000 CDM 73660 CPT 320 RC outpatient 158 158 UNITED HEALTHCARE (COMMERCIAL) [3081199] UNITED HEALTHCARE 87726 [308119901] 97.96 percent of total billed charges 97.96 150.1 Technical (Hospital) Services Radex Toe Minimum 2 Views PX-3207366000 CDM 73660 CPT 320 RC outpatient 158 158 MEDICA (COMMERCIAL) 94265 [3081118] MEDICA CLAIMS [308111801] 142.2 percent of total billed charges 97.96 150.1 Technical (Hospital) Services Radex Toe Minimum 2 Views PX-3207366000 CDM 73660 CPT 320 RC outpatient 158 158 HEALTHPARTNERS SX009 HEALTHPARTNERS 126.4 percent of total billed charges 97.96 150.1 Technical (Hospital) Services Radex Toe Minimum 2 Views PX-3207366000 CDM 73660 CPT 320 RC inpatient 158 158 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES EPO [308136803] 125.1 percent of total billed charges 97.96 150.1 Technical (Hospital) Services Radex Toe Minimum 2 Views PX-3207366000 CDM 73660 CPT 320 RC inpatient 158 158 CIGNA 62308 [3081051] CIGNA 62308 [308105105] 125.1 percent of total billed charges 97.96 150.1 Technical (Hospital) Services Radex Toe Minimum 2 Views PX-3207366000 CDM 73660 CPT 320 RC inpatient 158 158 CIGNA 62308 [3081051] CIGNA STATE OF WYOMING [308105107] 125.1 percent of total billed charges 97.96 150.1 Technical (Hospital) Services Radex Toe Minimum 2 Views PX-3207366000 CDM 73660 CPT 320 RC inpatient 158 158 HEALTHPARTNERS SX009 HEALTHPARTNERS 125.1 percent of total billed charges 97.96 150.1 Technical (Hospital) Services Radex Toe Minimum 2 Views PX-3207366000 CDM 73660 CPT 320 RC inpatient 158 158 MEDICA (COMMERCIAL) 94265 [3081118] MEDICA CLAIMS [308111801] 142.2 percent of total billed charges 97.96 150.1 Technical (Hospital) Services Radex Toe Minimum 2 Views PX-3207366000 CDM 73660 CPT 320 RC inpatient 158 158 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES HDHP [308136802] 125.1 percent of total billed charges 97.96 150.1 Technical (Hospital) Services Radex Toe Minimum 2 Views PX-3207366000 CDM 73660 CPT 320 RC inpatient 158 158 MULTIPLAN INC 34080 [3081285] MULTIPLAN INC [308128501] 150.1 percent of total billed charges 97.96 150.1 Technical (Hospital) Services Radex Toe Minimum 2 Views PX-3207366000 CDM 73660 CPT 320 RC inpatient 158 158 BLUE CROSS BLUE SHIELD WELLMARK SB889 [3081026] BCBS WYOMING [308102603] 150.1 percent of total billed charges 97.96 150.1 Technical (Hospital) Services Radex Toe Minimum 2 Views PX-3207366000 CDM 73660 CPT 320 RC inpatient 158 158 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES PPO [308136801] 125.1 percent of total billed charges 97.96 150.1 Technical (Hospital) Services Radex Toe Minimum 2 Views PX-3207366000 CDM 73660 CPT 320 RC inpatient 158 158 UNITED HEALTHCARE (COMMERCIAL) [3081199] UNITED HEALTHCARE 87726 [308119901] 97.96 percent of total billed charges 97.96 150.1 Technical (Hospital) Services Radex Calcaneus Minimum 2 Views PX-3207365000 CDM 73650 CPT 320 RC outpatient 167 167 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES EPO [308136803] 133.6 percent of total billed charges 103.54 158.65 Technical (Hospital) Services Radex Calcaneus Minimum 2 Views PX-3207365000 CDM 73650 CPT 320 RC outpatient 167 167 UNITED HEALTHCARE (COMMERCIAL) [3081199] UNITED HEALTHCARE 87726 [308119901] 103.54 percent of total billed charges 103.54 158.65 Technical (Hospital) Services Radex Calcaneus Minimum 2 Views PX-3207365000 CDM 73650 CPT 320 RC outpatient 167 167 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES PPO [308136801] 133.6 percent of total billed charges 103.54 158.65 Technical (Hospital) Services Radex Calcaneus Minimum 2 Views PX-3207365000 CDM 73650 CPT 320 RC outpatient 167 167 MULTIPLAN INC 34080 [3081285] MULTIPLAN INC [308128501] 158.65 percent of total billed charges 103.54 158.65 Technical (Hospital) Services Radex Calcaneus Minimum 2 Views PX-3207365000 CDM 73650 CPT 320 RC outpatient 167 167 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES HDHP [308136802] 133.6 percent of total billed charges 103.54 158.65 Technical (Hospital) Services Radex Calcaneus Minimum 2 Views PX-3207365000 CDM 73650 CPT 320 RC outpatient 167 167 BLUE CROSS BLUE SHIELD WELLMARK SB889 [3081026] BCBS WYOMING [308102603] 158.65 percent of total billed charges 103.54 158.65 Technical (Hospital) Services Radex Calcaneus Minimum 2 Views PX-3207365000 CDM 73650 CPT 320 RC outpatient 167 167 HEALTHPARTNERS SX009 HEALTHPARTNERS 133.6 percent of total billed charges 103.54 158.65 Technical (Hospital) Services Radex Calcaneus Minimum 2 Views PX-3207365000 CDM 73650 CPT 320 RC outpatient 167 167 MEDICA (COMMERCIAL) 94265 [3081118] MEDICA CLAIMS [308111801] 150.3 percent of total billed charges 103.54 158.65 Technical (Hospital) Services Radex Calcaneus Minimum 2 Views PX-3207365000 CDM 73650 CPT 320 RC outpatient 167 167 CIGNA 62308 [3081051] CIGNA 62308 [308105105] 133.6 percent of total billed charges 103.54 158.65 Technical (Hospital) Services Radex Calcaneus Minimum 2 Views PX-3207365000 CDM 73650 CPT 320 RC outpatient 167 167 CIGNA 62308 [3081051] CIGNA STATE OF WYOMING [308105107] 133.6 percent of total billed charges 103.54 158.65 Technical (Hospital) Services Radex Calcaneus Minimum 2 Views PX-3207365000 CDM 73650 CPT 320 RC inpatient 167 167 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES EPO [308136803] 132.23 percent of total billed charges 103.54 158.65 Technical (Hospital) Services Radex Calcaneus Minimum 2 Views PX-3207365000 CDM 73650 CPT 320 RC inpatient 167 167 CIGNA 62308 [3081051] CIGNA 62308 [308105105] 132.23 percent of total billed charges 103.54 158.65 Technical (Hospital) Services Radex Calcaneus Minimum 2 Views PX-3207365000 CDM 73650 CPT 320 RC inpatient 167 167 CIGNA 62308 [3081051] CIGNA STATE OF WYOMING [308105107] 132.23 percent of total billed charges 103.54 158.65 Technical (Hospital) Services Radex Calcaneus Minimum 2 Views PX-3207365000 CDM 73650 CPT 320 RC inpatient 167 167 HEALTHPARTNERS SX009 HEALTHPARTNERS 132.23 percent of total billed charges 103.54 158.65 Technical (Hospital) Services Radex Calcaneus Minimum 2 Views PX-3207365000 CDM 73650 CPT 320 RC inpatient 167 167 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES HDHP [308136802] 132.23 percent of total billed charges 103.54 158.65 Technical (Hospital) Services Radex Calcaneus Minimum 2 Views PX-3207365000 CDM 73650 CPT 320 RC inpatient 167 167 MEDICA (COMMERCIAL) 94265 [3081118] MEDICA CLAIMS [308111801] 150.3 percent of total billed charges 103.54 158.65 Technical (Hospital) Services Radex Calcaneus Minimum 2 Views PX-3207365000 CDM 73650 CPT 320 RC inpatient 167 167 MULTIPLAN INC 34080 [3081285] MULTIPLAN INC [308128501] 158.65 percent of total billed charges 103.54 158.65 Technical (Hospital) Services Radex Calcaneus Minimum 2 Views PX-3207365000 CDM 73650 CPT 320 RC inpatient 167 167 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES PPO [308136801] 132.23 percent of total billed charges 103.54 158.65 Technical (Hospital) Services Radex Calcaneus Minimum 2 Views PX-3207365000 CDM 73650 CPT 320 RC inpatient 167 167 BLUE CROSS BLUE SHIELD WELLMARK SB889 [3081026] BCBS WYOMING [308102603] 158.65 percent of total billed charges 103.54 158.65 Technical (Hospital) Services Radex Calcaneus Minimum 2 Views PX-3207365000 CDM 73650 CPT 320 RC inpatient 167 167 UNITED HEALTHCARE (COMMERCIAL) [3081199] UNITED HEALTHCARE 87726 [308119901] 103.54 percent of total billed charges 103.54 158.65 Technical (Hospital) Services Radex Foot Complete Minimum 3 Views PX-3207363000 CDM 73630 CPT 320 RC inpatient 435 435 HEALTHPARTNERS SX009 HEALTHPARTNERS 344.43 percent of total billed charges 269.7 413.25 Technical (Hospital) Services Radex Foot Complete Minimum 3 Views PX-3207363000 CDM 73630 CPT 320 RC inpatient 435 435 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES HDHP [308136802] 344.43 percent of total billed charges 269.7 413.25 Technical (Hospital) Services Radex Foot Complete Minimum 3 Views PX-3207363000 CDM 73630 CPT 320 RC inpatient 435 435 MEDICA (COMMERCIAL) 94265 [3081118] MEDICA CLAIMS [308111801] 391.5 percent of total billed charges 269.7 413.25 Technical (Hospital) Services Radex Foot Complete Minimum 3 Views PX-3207363000 CDM 73630 CPT 320 RC inpatient 435 435 BLUE CROSS BLUE SHIELD WELLMARK SB889 [3081026] BCBS WYOMING [308102603] 413.25 percent of total billed charges 269.7 413.25 Technical (Hospital) Services Radex Foot Complete Minimum 3 Views PX-3207363000 CDM 73630 CPT 320 RC inpatient 435 435 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES PPO [308136801] 344.43 percent of total billed charges 269.7 413.25 Technical (Hospital) Services Radex Foot Complete Minimum 3 Views PX-3207363000 CDM 73630 CPT 320 RC inpatient 435 435 MULTIPLAN INC 34080 [3081285] MULTIPLAN INC [308128501] 413.25 percent of total billed charges 269.7 413.25 Technical (Hospital) Services Radex Foot Complete Minimum 3 Views PX-3207363000 CDM 73630 CPT 320 RC inpatient 435 435 UNITED HEALTHCARE (COMMERCIAL) [3081199] UNITED HEALTHCARE 87726 [308119901] 269.7 percent of total billed charges 269.7 413.25 Technical (Hospital) Services Radex Foot Complete Minimum 3 Views PX-3207363000 CDM 73630 CPT 320 RC inpatient 435 435 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES EPO [308136803] 344.43 percent of total billed charges 269.7 413.25 Technical (Hospital) Services Radex Foot Complete Minimum 3 Views PX-3207363000 CDM 73630 CPT 320 RC inpatient 435 435 CIGNA 62308 [3081051] CIGNA 62308 [308105105] 344.43 percent of total billed charges 269.7 413.25 Technical (Hospital) Services Radex Foot Complete Minimum 3 Views PX-3207363000 CDM 73630 CPT 320 RC inpatient 435 435 CIGNA 62308 [3081051] CIGNA STATE OF WYOMING [308105107] 344.43 percent of total billed charges 269.7 413.25 Technical (Hospital) Services Radex Foot Complete Minimum 3 Views PX-3207363000 CDM 73630 CPT 320 RC outpatient 435 435 UNITED HEALTHCARE (COMMERCIAL) [3081199] UNITED HEALTHCARE 87726 [308119901] 269.7 percent of total billed charges 269.7 413.25 Technical (Hospital) Services Radex Foot Complete Minimum 3 Views PX-3207363000 CDM 73630 CPT 320 RC outpatient 435 435 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES EPO [308136803] 348 percent of total billed charges 269.7 413.25 Technical (Hospital) Services Radex Foot Complete Minimum 3 Views PX-3207363000 CDM 73630 CPT 320 RC outpatient 435 435 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES PPO [308136801] 348 percent of total billed charges 269.7 413.25 Technical (Hospital) Services Radex Foot Complete Minimum 3 Views PX-3207363000 CDM 73630 CPT 320 RC outpatient 435 435 BLUE CROSS BLUE SHIELD WELLMARK SB889 [3081026] BCBS WYOMING [308102603] 413.25 percent of total billed charges 269.7 413.25 Technical (Hospital) Services Radex Foot Complete Minimum 3 Views PX-3207363000 CDM 73630 CPT 320 RC outpatient 435 435 MULTIPLAN INC 34080 [3081285] MULTIPLAN INC [308128501] 413.25 percent of total billed charges 269.7 413.25 Technical (Hospital) Services Radex Foot Complete Minimum 3 Views PX-3207363000 CDM 73630 CPT 320 RC outpatient 435 435 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES HDHP [308136802] 348 percent of total billed charges 269.7 413.25 Technical (Hospital) Services Radex Foot Complete Minimum 3 Views PX-3207363000 CDM 73630 CPT 320 RC outpatient 435 435 MEDICA (COMMERCIAL) 94265 [3081118] MEDICA CLAIMS [308111801] 391.5 percent of total billed charges 269.7 413.25 Technical (Hospital) Services Radex Foot Complete Minimum 3 Views PX-3207363000 CDM 73630 CPT 320 RC outpatient 435 435 HEALTHPARTNERS SX009 HEALTHPARTNERS 348 percent of total billed charges 269.7 413.25 Technical (Hospital) Services Radex Foot Complete Minimum 3 Views PX-3207363000 CDM 73630 CPT 320 RC outpatient 435 435 CIGNA 62308 [3081051] CIGNA 62308 [308105105] 348 percent of total billed charges 269.7 413.25 Technical (Hospital) Services Radex Foot Complete Minimum 3 Views PX-3207363000 CDM 73630 CPT 320 RC outpatient 435 435 CIGNA 62308 [3081051] CIGNA STATE OF WYOMING [308105107] 348 percent of total billed charges 269.7 413.25 Technical (Hospital) Services Radiologic Examination Foot 2 Views PX-3207362000 CDM 73620 CPT 320 RC outpatient 182 182 UNITED HEALTHCARE (COMMERCIAL) [3081199] UNITED HEALTHCARE 87726 [308119901] 112.84 percent of total billed charges 112.84 172.9 Technical (Hospital) Services Radiologic Examination Foot 2 Views PX-3207362000 CDM 73620 CPT 320 RC outpatient 182 182 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES EPO [308136803] 145.6 percent of total billed charges 112.84 172.9 Technical (Hospital) Services Radiologic Examination Foot 2 Views PX-3207362000 CDM 73620 CPT 320 RC outpatient 182 182 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES PPO [308136801] 145.6 percent of total billed charges 112.84 172.9 Technical (Hospital) Services Radiologic Examination Foot 2 Views PX-3207362000 CDM 73620 CPT 320 RC outpatient 182 182 BLUE CROSS BLUE SHIELD WELLMARK SB889 [3081026] BCBS WYOMING [308102603] 172.9 percent of total billed charges 112.84 172.9 Technical (Hospital) Services Radiologic Examination Foot 2 Views PX-3207362000 CDM 73620 CPT 320 RC outpatient 182 182 MULTIPLAN INC 34080 [3081285] MULTIPLAN INC [308128501] 172.9 percent of total billed charges 112.84 172.9 Technical (Hospital) Services Radiologic Examination Foot 2 Views PX-3207362000 CDM 73620 CPT 320 RC outpatient 182 182 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES HDHP [308136802] 145.6 percent of total billed charges 112.84 172.9 Technical (Hospital) Services Radiologic Examination Foot 2 Views PX-3207362000 CDM 73620 CPT 320 RC outpatient 182 182 HEALTHPARTNERS SX009 HEALTHPARTNERS 145.6 percent of total billed charges 112.84 172.9 Technical (Hospital) Services Radiologic Examination Foot 2 Views PX-3207362000 CDM 73620 CPT 320 RC outpatient 182 182 CIGNA 62308 [3081051] CIGNA 62308 [308105105] 145.6 percent of total billed charges 112.84 172.9 Technical (Hospital) Services Radiologic Examination Foot 2 Views PX-3207362000 CDM 73620 CPT 320 RC outpatient 182 182 CIGNA 62308 [3081051] CIGNA STATE OF WYOMING [308105107] 145.6 percent of total billed charges 112.84 172.9 Technical (Hospital) Services Radiologic Examination Foot 2 Views PX-3207362000 CDM 73620 CPT 320 RC outpatient 182 182 MEDICA (COMMERCIAL) 94265 [3081118] MEDICA CLAIMS [308111801] 163.8 percent of total billed charges 112.84 172.9 Technical (Hospital) Services Radiologic Examination Foot 2 Views PX-3207362000 CDM 73620 CPT 320 RC inpatient 182 182 CIGNA 62308 [3081051] CIGNA 62308 [308105105] 144.11 percent of total billed charges 112.84 172.9 Technical (Hospital) Services Radiologic Examination Foot 2 Views PX-3207362000 CDM 73620 CPT 320 RC inpatient 182 182 CIGNA 62308 [3081051] CIGNA STATE OF WYOMING [308105107] 144.11 percent of total billed charges 112.84 172.9 Technical (Hospital) Services Radiologic Examination Foot 2 Views PX-3207362000 CDM 73620 CPT 320 RC inpatient 182 182 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES EPO [308136803] 144.11 percent of total billed charges 112.84 172.9 Technical (Hospital) Services Radiologic Examination Foot 2 Views PX-3207362000 CDM 73620 CPT 320 RC inpatient 182 182 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES PPO [308136801] 144.11 percent of total billed charges 112.84 172.9 Technical (Hospital) Services Radiologic Examination Foot 2 Views PX-3207362000 CDM 73620 CPT 320 RC inpatient 182 182 BLUE CROSS BLUE SHIELD WELLMARK SB889 [3081026] BCBS WYOMING [308102603] 172.9 percent of total billed charges 112.84 172.9 Technical (Hospital) Services Radiologic Examination Foot 2 Views PX-3207362000 CDM 73620 CPT 320 RC inpatient 182 182 MULTIPLAN INC 34080 [3081285] MULTIPLAN INC [308128501] 172.9 percent of total billed charges 112.84 172.9 Technical (Hospital) Services Radiologic Examination Foot 2 Views PX-3207362000 CDM 73620 CPT 320 RC inpatient 182 182 UNITED HEALTHCARE (COMMERCIAL) [3081199] UNITED HEALTHCARE 87726 [308119901] 112.84 percent of total billed charges 112.84 172.9 Technical (Hospital) Services Radiologic Examination Foot 2 Views PX-3207362000 CDM 73620 CPT 320 RC inpatient 182 182 HEALTHPARTNERS SX009 HEALTHPARTNERS 144.11 percent of total billed charges 112.84 172.9 Technical (Hospital) Services Radiologic Examination Foot 2 Views PX-3207362000 CDM 73620 CPT 320 RC inpatient 182 182 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES HDHP [308136802] 144.11 percent of total billed charges 112.84 172.9 Technical (Hospital) Services Radiologic Examination Foot 2 Views PX-3207362000 CDM 73620 CPT 320 RC inpatient 182 182 MEDICA (COMMERCIAL) 94265 [3081118] MEDICA CLAIMS [308111801] 163.8 percent of total billed charges 112.84 172.9 Technical (Hospital) Services Radex Ankle Complete Minimum 3 Views PX-3207361000 CDM 73610 CPT 320 RC outpatient 406 406 HEALTHPARTNERS SX009 HEALTHPARTNERS 324.8 percent of total billed charges 251.72 385.7 Technical (Hospital) Services Radex Ankle Complete Minimum 3 Views PX-3207361000 CDM 73610 CPT 320 RC outpatient 406 406 MEDICA (COMMERCIAL) 94265 [3081118] MEDICA CLAIMS [308111801] 365.4 percent of total billed charges 251.72 385.7 Technical (Hospital) Services Radex Ankle Complete Minimum 3 Views PX-3207361000 CDM 73610 CPT 320 RC outpatient 406 406 UNITED HEALTHCARE (COMMERCIAL) [3081199] UNITED HEALTHCARE 87726 [308119901] 251.72 percent of total billed charges 251.72 385.7 Technical (Hospital) Services Radex Ankle Complete Minimum 3 Views PX-3207361000 CDM 73610 CPT 320 RC outpatient 406 406 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES EPO [308136803] 324.8 percent of total billed charges 251.72 385.7 Technical (Hospital) Services Radex Ankle Complete Minimum 3 Views PX-3207361000 CDM 73610 CPT 320 RC outpatient 406 406 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES PPO [308136801] 324.8 percent of total billed charges 251.72 385.7 Technical (Hospital) Services Radex Ankle Complete Minimum 3 Views PX-3207361000 CDM 73610 CPT 320 RC outpatient 406 406 BLUE CROSS BLUE SHIELD WELLMARK SB889 [3081026] BCBS WYOMING [308102603] 385.7 percent of total billed charges 251.72 385.7 Technical (Hospital) Services Radex Ankle Complete Minimum 3 Views PX-3207361000 CDM 73610 CPT 320 RC outpatient 406 406 MULTIPLAN INC 34080 [3081285] MULTIPLAN INC [308128501] 385.7 percent of total billed charges 251.72 385.7 Technical (Hospital) Services Radex Ankle Complete Minimum 3 Views PX-3207361000 CDM 73610 CPT 320 RC outpatient 406 406 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES HDHP [308136802] 324.8 percent of total billed charges 251.72 385.7 Technical (Hospital) Services Radex Ankle Complete Minimum 3 Views PX-3207361000 CDM 73610 CPT 320 RC outpatient 406 406 CIGNA 62308 [3081051] CIGNA 62308 [308105105] 324.8 percent of total billed charges 251.72 385.7 Technical (Hospital) Services Radex Ankle Complete Minimum 3 Views PX-3207361000 CDM 73610 CPT 320 RC outpatient 406 406 CIGNA 62308 [3081051] CIGNA STATE OF WYOMING [308105107] 324.8 percent of total billed charges 251.72 385.7 Technical (Hospital) Services Radex Ankle Complete Minimum 3 Views PX-3207361000 CDM 73610 CPT 320 RC inpatient 406 406 UNITED HEALTHCARE (COMMERCIAL) [3081199] UNITED HEALTHCARE 87726 [308119901] 251.72 percent of total billed charges 251.72 385.7 Technical (Hospital) Services Radex Ankle Complete Minimum 3 Views PX-3207361000 CDM 73610 CPT 320 RC inpatient 406 406 BLUE CROSS BLUE SHIELD WELLMARK SB889 [3081026] BCBS WYOMING [308102603] 385.7 percent of total billed charges 251.72 385.7 Technical (Hospital) Services Radex Ankle Complete Minimum 3 Views PX-3207361000 CDM 73610 CPT 320 RC inpatient 406 406 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES PPO [308136801] 321.47 percent of total billed charges 251.72 385.7 Technical (Hospital) Services Radex Ankle Complete Minimum 3 Views PX-3207361000 CDM 73610 CPT 320 RC inpatient 406 406 MULTIPLAN INC 34080 [3081285] MULTIPLAN INC [308128501] 385.7 percent of total billed charges 251.72 385.7 Technical (Hospital) Services Radex Ankle Complete Minimum 3 Views PX-3207361000 CDM 73610 CPT 320 RC inpatient 406 406 MEDICA (COMMERCIAL) 94265 [3081118] MEDICA CLAIMS [308111801] 365.4 percent of total billed charges 251.72 385.7 Technical (Hospital) Services Radex Ankle Complete Minimum 3 Views PX-3207361000 CDM 73610 CPT 320 RC inpatient 406 406 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES HDHP [308136802] 321.47 percent of total billed charges 251.72 385.7 Technical (Hospital) Services Radex Ankle Complete Minimum 3 Views PX-3207361000 CDM 73610 CPT 320 RC inpatient 406 406 HEALTHPARTNERS SX009 HEALTHPARTNERS 321.47 percent of total billed charges 251.72 385.7 Technical (Hospital) Services Radex Ankle Complete Minimum 3 Views PX-3207361000 CDM 73610 CPT 320 RC inpatient 406 406 CIGNA 62308 [3081051] CIGNA 62308 [308105105] 321.47 percent of total billed charges 251.72 385.7 Technical (Hospital) Services Radex Ankle Complete Minimum 3 Views PX-3207361000 CDM 73610 CPT 320 RC inpatient 406 406 CIGNA 62308 [3081051] CIGNA STATE OF WYOMING [308105107] 321.47 percent of total billed charges 251.72 385.7 Technical (Hospital) Services Radex Ankle Complete Minimum 3 Views PX-3207361000 CDM 73610 CPT 320 RC inpatient 406 406 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES EPO [308136803] 321.47 percent of total billed charges 251.72 385.7 Technical (Hospital) Services Radiologic Examination Ankle 2 Views PX-3207360000 CDM 73600 CPT 320 RC outpatient 173 173 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES EPO [308136803] 138.4 percent of total billed charges 107.26 164.35 Technical (Hospital) Services Radiologic Examination Ankle 2 Views PX-3207360000 CDM 73600 CPT 320 RC outpatient 173 173 UNITED HEALTHCARE (COMMERCIAL) [3081199] UNITED HEALTHCARE 87726 [308119901] 107.26 percent of total billed charges 107.26 164.35 Technical (Hospital) Services Radiologic Examination Ankle 2 Views PX-3207360000 CDM 73600 CPT 320 RC outpatient 173 173 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES PPO [308136801] 138.4 percent of total billed charges 107.26 164.35 Technical (Hospital) Services Radiologic Examination Ankle 2 Views PX-3207360000 CDM 73600 CPT 320 RC outpatient 173 173 BLUE CROSS BLUE SHIELD WELLMARK SB889 [3081026] BCBS WYOMING [308102603] 164.35 percent of total billed charges 107.26 164.35 Technical (Hospital) Services Radiologic Examination Ankle 2 Views PX-3207360000 CDM 73600 CPT 320 RC outpatient 173 173 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES HDHP [308136802] 138.4 percent of total billed charges 107.26 164.35 Technical (Hospital) Services Radiologic Examination Ankle 2 Views PX-3207360000 CDM 73600 CPT 320 RC outpatient 173 173 MULTIPLAN INC 34080 [3081285] MULTIPLAN INC [308128501] 164.35 percent of total billed charges 107.26 164.35 Technical (Hospital) Services Radiologic Examination Ankle 2 Views PX-3207360000 CDM 73600 CPT 320 RC outpatient 173 173 HEALTHPARTNERS SX009 HEALTHPARTNERS 138.4 percent of total billed charges 107.26 164.35 Technical (Hospital) Services Radiologic Examination Ankle 2 Views PX-3207360000 CDM 73600 CPT 320 RC outpatient 173 173 MEDICA (COMMERCIAL) 94265 [3081118] MEDICA CLAIMS [308111801] 155.7 percent of total billed charges 107.26 164.35 Technical (Hospital) Services Radiologic Examination Ankle 2 Views PX-3207360000 CDM 73600 CPT 320 RC outpatient 173 173 CIGNA 62308 [3081051] CIGNA 62308 [308105105] 138.4 percent of total billed charges 107.26 164.35 Technical (Hospital) Services Radiologic Examination Ankle 2 Views PX-3207360000 CDM 73600 CPT 320 RC outpatient 173 173 CIGNA 62308 [3081051] CIGNA STATE OF WYOMING [308105107] 138.4 percent of total billed charges 107.26 164.35 Technical (Hospital) Services Radiologic Examination Ankle 2 Views PX-3207360000 CDM 73600 CPT 320 RC inpatient 173 173 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES EPO [308136803] 136.98 percent of total billed charges 107.26 164.35 Technical (Hospital) Services Radiologic Examination Ankle 2 Views PX-3207360000 CDM 73600 CPT 320 RC inpatient 173 173 CIGNA 62308 [3081051] CIGNA 62308 [308105105] 136.98 percent of total billed charges 107.26 164.35 Technical (Hospital) Services Radiologic Examination Ankle 2 Views PX-3207360000 CDM 73600 CPT 320 RC inpatient 173 173 CIGNA 62308 [3081051] CIGNA STATE OF WYOMING [308105107] 136.98 percent of total billed charges 107.26 164.35 Technical (Hospital) Services Radiologic Examination Ankle 2 Views PX-3207360000 CDM 73600 CPT 320 RC inpatient 173 173 HEALTHPARTNERS SX009 HEALTHPARTNERS 136.98 percent of total billed charges 107.26 164.35 Technical (Hospital) Services Radiologic Examination Ankle 2 Views PX-3207360000 CDM 73600 CPT 320 RC inpatient 173 173 MEDICA (COMMERCIAL) 94265 [3081118] MEDICA CLAIMS [308111801] 155.7 percent of total billed charges 107.26 164.35 Technical (Hospital) Services Radiologic Examination Ankle 2 Views PX-3207360000 CDM 73600 CPT 320 RC inpatient 173 173 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES HDHP [308136802] 136.98 percent of total billed charges 107.26 164.35 Technical (Hospital) Services Radiologic Examination Ankle 2 Views PX-3207360000 CDM 73600 CPT 320 RC inpatient 173 173 MULTIPLAN INC 34080 [3081285] MULTIPLAN INC [308128501] 164.35 percent of total billed charges 107.26 164.35 Technical (Hospital) Services Radiologic Examination Ankle 2 Views PX-3207360000 CDM 73600 CPT 320 RC inpatient 173 173 BLUE CROSS BLUE SHIELD WELLMARK SB889 [3081026] BCBS WYOMING [308102603] 164.35 percent of total billed charges 107.26 164.35 Technical (Hospital) Services Radiologic Examination Ankle 2 Views PX-3207360000 CDM 73600 CPT 320 RC inpatient 173 173 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES PPO [308136801] 136.98 percent of total billed charges 107.26 164.35 Technical (Hospital) Services Radiologic Examination Ankle 2 Views PX-3207360000 CDM 73600 CPT 320 RC inpatient 173 173 UNITED HEALTHCARE (COMMERCIAL) [3081199] UNITED HEALTHCARE 87726 [308119901] 107.26 percent of total billed charges 107.26 164.35 Technical (Hospital) Services Radex Lower Extremity Infant Minimum 2 Views PX-3207359200 CDM 73592 CPT 320 RC inpatient 193 193 CIGNA 62308 [3081051] CIGNA 62308 [308105105] 152.82 percent of total billed charges 119.66 183.35 Technical (Hospital) Services Radex Lower Extremity Infant Minimum 2 Views PX-3207359200 CDM 73592 CPT 320 RC inpatient 193 193 CIGNA 62308 [3081051] CIGNA STATE OF WYOMING [308105107] 152.82 percent of total billed charges 119.66 183.35 Technical (Hospital) Services Radex Lower Extremity Infant Minimum 2 Views PX-3207359200 CDM 73592 CPT 320 RC inpatient 193 193 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES EPO [308136803] 152.82 percent of total billed charges 119.66 183.35 Technical (Hospital) Services Radex Lower Extremity Infant Minimum 2 Views PX-3207359200 CDM 73592 CPT 320 RC inpatient 193 193 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES PPO [308136801] 152.82 percent of total billed charges 119.66 183.35 Technical (Hospital) Services Radex Lower Extremity Infant Minimum 2 Views PX-3207359200 CDM 73592 CPT 320 RC inpatient 193 193 BLUE CROSS BLUE SHIELD WELLMARK SB889 [3081026] BCBS WYOMING [308102603] 183.35 percent of total billed charges 119.66 183.35 Technical (Hospital) Services Radex Lower Extremity Infant Minimum 2 Views PX-3207359200 CDM 73592 CPT 320 RC inpatient 193 193 MULTIPLAN INC 34080 [3081285] MULTIPLAN INC [308128501] 183.35 percent of total billed charges 119.66 183.35 Technical (Hospital) Services Radex Lower Extremity Infant Minimum 2 Views PX-3207359200 CDM 73592 CPT 320 RC inpatient 193 193 UNITED HEALTHCARE (COMMERCIAL) [3081199] UNITED HEALTHCARE 87726 [308119901] 119.66 percent of total billed charges 119.66 183.35 Technical (Hospital) Services Radex Lower Extremity Infant Minimum 2 Views PX-3207359200 CDM 73592 CPT 320 RC inpatient 193 193 HEALTHPARTNERS SX009 HEALTHPARTNERS 152.82 percent of total billed charges 119.66 183.35 Technical (Hospital) Services Radex Lower Extremity Infant Minimum 2 Views PX-3207359200 CDM 73592 CPT 320 RC inpatient 193 193 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES HDHP [308136802] 152.82 percent of total billed charges 119.66 183.35 Technical (Hospital) Services Radex Lower Extremity Infant Minimum 2 Views PX-3207359200 CDM 73592 CPT 320 RC inpatient 193 193 MEDICA (COMMERCIAL) 94265 [3081118] MEDICA CLAIMS [308111801] 173.7 percent of total billed charges 119.66 183.35 Technical (Hospital) Services Radex Lower Extremity Infant Minimum 2 Views PX-3207359200 CDM 73592 CPT 320 RC outpatient 193 193 HEALTHPARTNERS SX009 HEALTHPARTNERS 154.4 percent of total billed charges 119.66 183.35 Technical (Hospital) Services Radex Lower Extremity Infant Minimum 2 Views PX-3207359200 CDM 73592 CPT 320 RC outpatient 193 193 UNITED HEALTHCARE (COMMERCIAL) [3081199] UNITED HEALTHCARE 87726 [308119901] 119.66 percent of total billed charges 119.66 183.35 Technical (Hospital) Services Radex Lower Extremity Infant Minimum 2 Views PX-3207359200 CDM 73592 CPT 320 RC outpatient 193 193 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES EPO [308136803] 154.4 percent of total billed charges 119.66 183.35 Technical (Hospital) Services Radex Lower Extremity Infant Minimum 2 Views PX-3207359200 CDM 73592 CPT 320 RC outpatient 193 193 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES PPO [308136801] 154.4 percent of total billed charges 119.66 183.35 Technical (Hospital) Services Radex Lower Extremity Infant Minimum 2 Views PX-3207359200 CDM 73592 CPT 320 RC outpatient 193 193 BLUE CROSS BLUE SHIELD WELLMARK SB889 [3081026] BCBS WYOMING [308102603] 183.35 percent of total billed charges 119.66 183.35 Technical (Hospital) Services Radex Lower Extremity Infant Minimum 2 Views PX-3207359200 CDM 73592 CPT 320 RC outpatient 193 193 MULTIPLAN INC 34080 [3081285] MULTIPLAN INC [308128501] 183.35 percent of total billed charges 119.66 183.35 Technical (Hospital) Services Radex Lower Extremity Infant Minimum 2 Views PX-3207359200 CDM 73592 CPT 320 RC outpatient 193 193 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES HDHP [308136802] 154.4 percent of total billed charges 119.66 183.35 Technical (Hospital) Services Radex Lower Extremity Infant Minimum 2 Views PX-3207359200 CDM 73592 CPT 320 RC outpatient 193 193 MEDICA (COMMERCIAL) 94265 [3081118] MEDICA CLAIMS [308111801] 173.7 percent of total billed charges 119.66 183.35 Technical (Hospital) Services Radex Lower Extremity Infant Minimum 2 Views PX-3207359200 CDM 73592 CPT 320 RC outpatient 193 193 CIGNA 62308 [3081051] CIGNA 62308 [308105105] 154.4 percent of total billed charges 119.66 183.35 Technical (Hospital) Services Radex Lower Extremity Infant Minimum 2 Views PX-3207359200 CDM 73592 CPT 320 RC outpatient 193 193 CIGNA 62308 [3081051] CIGNA STATE OF WYOMING [308105107] 154.4 percent of total billed charges 119.66 183.35 Technical (Hospital) Services Radiologic Examination Tibia & Fibula 2 Views PX-3207359000 CDM 73590 CPT 320 RC outpatient 384 384 MEDICA (COMMERCIAL) 94265 [3081118] MEDICA CLAIMS [308111801] 345.6 percent of total billed charges 238.08 364.8 Technical (Hospital) Services Radiologic Examination Tibia & Fibula 2 Views PX-3207359000 CDM 73590 CPT 320 RC outpatient 384 384 CIGNA 62308 [3081051] CIGNA 62308 [308105105] 307.2 percent of total billed charges 238.08 364.8 Technical (Hospital) Services Radiologic Examination Tibia & Fibula 2 Views PX-3207359000 CDM 73590 CPT 320 RC outpatient 384 384 CIGNA 62308 [3081051] CIGNA STATE OF WYOMING [308105107] 307.2 percent of total billed charges 238.08 364.8 Technical (Hospital) Services Radiologic Examination Tibia & Fibula 2 Views PX-3207359000 CDM 73590 CPT 320 RC outpatient 384 384 UNITED HEALTHCARE (COMMERCIAL) [3081199] UNITED HEALTHCARE 87726 [308119901] 238.08 percent of total billed charges 238.08 364.8 Technical (Hospital) Services Radiologic Examination Tibia & Fibula 2 Views PX-3207359000 CDM 73590 CPT 320 RC outpatient 384 384 HEALTHPARTNERS SX009 HEALTHPARTNERS 307.2 percent of total billed charges 238.08 364.8 Technical (Hospital) Services Radiologic Examination Tibia & Fibula 2 Views PX-3207359000 CDM 73590 CPT 320 RC outpatient 384 384 BLUE CROSS BLUE SHIELD WELLMARK SB889 [3081026] BCBS WYOMING [308102603] 364.8 percent of total billed charges 238.08 364.8 Technical (Hospital) Services Radiologic Examination Tibia & Fibula 2 Views PX-3207359000 CDM 73590 CPT 320 RC outpatient 384 384 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES HDHP [308136802] 307.2 percent of total billed charges 238.08 364.8 Technical (Hospital) Services Radiologic Examination Tibia & Fibula 2 Views PX-3207359000 CDM 73590 CPT 320 RC outpatient 384 384 MULTIPLAN INC 34080 [3081285] MULTIPLAN INC [308128501] 364.8 percent of total billed charges 238.08 364.8 Technical (Hospital) Services Radiologic Examination Tibia & Fibula 2 Views PX-3207359000 CDM 73590 CPT 320 RC outpatient 384 384 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES EPO [308136803] 307.2 percent of total billed charges 238.08 364.8 Technical (Hospital) Services Radiologic Examination Tibia & Fibula 2 Views PX-3207359000 CDM 73590 CPT 320 RC outpatient 384 384 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES PPO [308136801] 307.2 percent of total billed charges 238.08 364.8 Technical (Hospital) Services Radiologic Examination Tibia & Fibula 2 Views PX-3207359000 CDM 73590 CPT 320 RC inpatient 384 384 MULTIPLAN INC 34080 [3081285] MULTIPLAN INC [308128501] 364.8 percent of total billed charges 238.08 364.8 Technical (Hospital) Services Radiologic Examination Tibia & Fibula 2 Views PX-3207359000 CDM 73590 CPT 320 RC inpatient 384 384 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES PPO [308136801] 304.05 percent of total billed charges 238.08 364.8 Technical (Hospital) Services Radiologic Examination Tibia & Fibula 2 Views PX-3207359000 CDM 73590 CPT 320 RC inpatient 384 384 BLUE CROSS BLUE SHIELD WELLMARK SB889 [3081026] BCBS WYOMING [308102603] 364.8 percent of total billed charges 238.08 364.8 Technical (Hospital) Services Radiologic Examination Tibia & Fibula 2 Views PX-3207359000 CDM 73590 CPT 320 RC inpatient 384 384 UNITED HEALTHCARE (COMMERCIAL) [3081199] UNITED HEALTHCARE 87726 [308119901] 238.08 percent of total billed charges 238.08 364.8 Technical (Hospital) Services Radiologic Examination Tibia & Fibula 2 Views PX-3207359000 CDM 73590 CPT 320 RC inpatient 384 384 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES HDHP [308136802] 304.05 percent of total billed charges 238.08 364.8 Technical (Hospital) Services Radiologic Examination Tibia & Fibula 2 Views PX-3207359000 CDM 73590 CPT 320 RC inpatient 384 384 MEDICA (COMMERCIAL) 94265 [3081118] MEDICA CLAIMS [308111801] 345.6 percent of total billed charges 238.08 364.8 Technical (Hospital) Services Radiologic Examination Tibia & Fibula 2 Views PX-3207359000 CDM 73590 CPT 320 RC inpatient 384 384 HEALTHPARTNERS SX009 HEALTHPARTNERS 304.05 percent of total billed charges 238.08 364.8 Technical (Hospital) Services Radiologic Examination Tibia & Fibula 2 Views PX-3207359000 CDM 73590 CPT 320 RC inpatient 384 384 CIGNA 62308 [3081051] CIGNA 62308 [308105105] 304.05 percent of total billed charges 238.08 364.8 Technical (Hospital) Services Radiologic Examination Tibia & Fibula 2 Views PX-3207359000 CDM 73590 CPT 320 RC inpatient 384 384 CIGNA 62308 [3081051] CIGNA STATE OF WYOMING [308105107] 304.05 percent of total billed charges 238.08 364.8 Technical (Hospital) Services Radiologic Examination Tibia & Fibula 2 Views PX-3207359000 CDM 73590 CPT 320 RC inpatient 384 384 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES EPO [308136803] 304.05 percent of total billed charges 238.08 364.8 Technical (Hospital) Services Radiologic Exam Both Knees Standing Anteropost PX-3207356500 CDM 73565 CPT 320 RC inpatient 278 278 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES EPO [308136803] 220.12 percent of total billed charges 172.36 264.1 Technical (Hospital) Services Radiologic Exam Both Knees Standing Anteropost PX-3207356500 CDM 73565 CPT 320 RC inpatient 278 278 CIGNA 62308 [3081051] CIGNA 62308 [308105105] 220.12 percent of total billed charges 172.36 264.1 Technical (Hospital) Services Radiologic Exam Both Knees Standing Anteropost PX-3207356500 CDM 73565 CPT 320 RC inpatient 278 278 CIGNA 62308 [3081051] CIGNA STATE OF WYOMING [308105107] 220.12 percent of total billed charges 172.36 264.1 Technical (Hospital) Services Radiologic Exam Both Knees Standing Anteropost PX-3207356500 CDM 73565 CPT 320 RC inpatient 278 278 UNITED HEALTHCARE (COMMERCIAL) [3081199] UNITED HEALTHCARE 87726 [308119901] 172.36 percent of total billed charges 172.36 264.1 Technical (Hospital) Services Radiologic Exam Both Knees Standing Anteropost PX-3207356500 CDM 73565 CPT 320 RC inpatient 278 278 BLUE CROSS BLUE SHIELD WELLMARK SB889 [3081026] BCBS WYOMING [308102603] 264.1 percent of total billed charges 172.36 264.1 Technical (Hospital) Services Radiologic Exam Both Knees Standing Anteropost PX-3207356500 CDM 73565 CPT 320 RC inpatient 278 278 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES PPO [308136801] 220.12 percent of total billed charges 172.36 264.1 Technical (Hospital) Services Radiologic Exam Both Knees Standing Anteropost PX-3207356500 CDM 73565 CPT 320 RC inpatient 278 278 MULTIPLAN INC 34080 [3081285] MULTIPLAN INC [308128501] 264.1 percent of total billed charges 172.36 264.1 Technical (Hospital) Services Radiologic Exam Both Knees Standing Anteropost PX-3207356500 CDM 73565 CPT 320 RC inpatient 278 278 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES HDHP [308136802] 220.12 percent of total billed charges 172.36 264.1 Technical (Hospital) Services Radiologic Exam Both Knees Standing Anteropost PX-3207356500 CDM 73565 CPT 320 RC inpatient 278 278 MEDICA (COMMERCIAL) 94265 [3081118] MEDICA CLAIMS [308111801] 250.2 percent of total billed charges 172.36 264.1 Technical (Hospital) Services Radiologic Exam Both Knees Standing Anteropost PX-3207356500 CDM 73565 CPT 320 RC inpatient 278 278 HEALTHPARTNERS SX009 HEALTHPARTNERS 220.12 percent of total billed charges 172.36 264.1 Technical (Hospital) Services Radiologic Exam Both Knees Standing Anteropost PX-3207356500 CDM 73565 CPT 320 RC outpatient 278 278 MEDICA (COMMERCIAL) 94265 [3081118] MEDICA CLAIMS [308111801] 250.2 percent of total billed charges 172.36 264.1 Technical (Hospital) Services Radiologic Exam Both Knees Standing Anteropost PX-3207356500 CDM 73565 CPT 320 RC outpatient 278 278 CIGNA 62308 [3081051] CIGNA 62308 [308105105] 222.4 percent of total billed charges 172.36 264.1 Technical (Hospital) Services Radiologic Exam Both Knees Standing Anteropost PX-3207356500 CDM 73565 CPT 320 RC outpatient 278 278 CIGNA 62308 [3081051] CIGNA STATE OF WYOMING [308105107] 222.4 percent of total billed charges 172.36 264.1 Technical (Hospital) Services Radiologic Exam Both Knees Standing Anteropost PX-3207356500 CDM 73565 CPT 320 RC outpatient 278 278 BLUE CROSS BLUE SHIELD WELLMARK SB889 [3081026] BCBS WYOMING [308102603] 264.1 percent of total billed charges 172.36 264.1 Technical (Hospital) Services Radiologic Exam Both Knees Standing Anteropost PX-3207356500 CDM 73565 CPT 320 RC outpatient 278 278 MULTIPLAN INC 34080 [3081285] MULTIPLAN INC [308128501] 264.1 percent of total billed charges 172.36 264.1 Technical (Hospital) Services Radiologic Exam Both Knees Standing Anteropost PX-3207356500 CDM 73565 CPT 320 RC outpatient 278 278 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES HDHP [308136802] 222.4 percent of total billed charges 172.36 264.1 Technical (Hospital) Services Radiologic Exam Both Knees Standing Anteropost PX-3207356500 CDM 73565 CPT 320 RC outpatient 278 278 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES PPO [308136801] 222.4 percent of total billed charges 172.36 264.1 Technical (Hospital) Services Radiologic Exam Both Knees Standing Anteropost PX-3207356500 CDM 73565 CPT 320 RC outpatient 278 278 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES EPO [308136803] 222.4 percent of total billed charges 172.36 264.1 Technical (Hospital) Services Radiologic Exam Both Knees Standing Anteropost PX-3207356500 CDM 73565 CPT 320 RC outpatient 278 278 HEALTHPARTNERS SX009 HEALTHPARTNERS 222.4 percent of total billed charges 172.36 264.1 Technical (Hospital) Services Radiologic Exam Both Knees Standing Anteropost PX-3207356500 CDM 73565 CPT 320 RC outpatient 278 278 UNITED HEALTHCARE (COMMERCIAL) [3081199] UNITED HEALTHCARE 87726 [308119901] 172.36 percent of total billed charges 172.36 264.1 Technical (Hospital) Services Radiologic Exam Knee Complete 4/More Views PX-3207356400 CDM 73564 CPT 320 RC outpatient 417 417 MEDICA (COMMERCIAL) 94265 [3081118] MEDICA CLAIMS [308111801] 375.3 percent of total billed charges 258.54 396.15 Technical (Hospital) Services Radiologic Exam Knee Complete 4/More Views PX-3207356400 CDM 73564 CPT 320 RC outpatient 417 417 CIGNA 62308 [3081051] CIGNA 62308 [308105105] 333.6 percent of total billed charges 258.54 396.15 Technical (Hospital) Services Radiologic Exam Knee Complete 4/More Views PX-3207356400 CDM 73564 CPT 320 RC outpatient 417 417 CIGNA 62308 [3081051] CIGNA STATE OF WYOMING [308105107] 333.6 percent of total billed charges 258.54 396.15 Technical (Hospital) Services Radiologic Exam Knee Complete 4/More Views PX-3207356400 CDM 73564 CPT 320 RC outpatient 417 417 BLUE CROSS BLUE SHIELD WELLMARK SB889 [3081026] BCBS WYOMING [308102603] 396.15 percent of total billed charges 258.54 396.15 Technical (Hospital) Services Radiologic Exam Knee Complete 4/More Views PX-3207356400 CDM 73564 CPT 320 RC outpatient 417 417 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES HDHP [308136802] 333.6 percent of total billed charges 258.54 396.15 Technical (Hospital) Services Radiologic Exam Knee Complete 4/More Views PX-3207356400 CDM 73564 CPT 320 RC outpatient 417 417 MULTIPLAN INC 34080 [3081285] MULTIPLAN INC [308128501] 396.15 percent of total billed charges 258.54 396.15 Technical (Hospital) Services Radiologic Exam Knee Complete 4/More Views PX-3207356400 CDM 73564 CPT 320 RC outpatient 417 417 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES EPO [308136803] 333.6 percent of total billed charges 258.54 396.15 Technical (Hospital) Services Radiologic Exam Knee Complete 4/More Views PX-3207356400 CDM 73564 CPT 320 RC outpatient 417 417 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES PPO [308136801] 333.6 percent of total billed charges 258.54 396.15 Technical (Hospital) Services Radiologic Exam Knee Complete 4/More Views PX-3207356400 CDM 73564 CPT 320 RC outpatient 417 417 HEALTHPARTNERS SX009 HEALTHPARTNERS 333.6 percent of total billed charges 258.54 396.15 Technical (Hospital) Services Radiologic Exam Knee Complete 4/More Views PX-3207356400 CDM 73564 CPT 320 RC outpatient 417 417 UNITED HEALTHCARE (COMMERCIAL) [3081199] UNITED HEALTHCARE 87726 [308119901] 258.54 percent of total billed charges 258.54 396.15 Technical (Hospital) Services Radiologic Exam Knee Complete 4/More Views PX-3207356400 CDM 73564 CPT 320 RC inpatient 417 417 CIGNA 62308 [3081051] CIGNA 62308 [308105105] 330.18 percent of total billed charges 258.54 396.15 Technical (Hospital) Services Radiologic Exam Knee Complete 4/More Views PX-3207356400 CDM 73564 CPT 320 RC inpatient 417 417 CIGNA 62308 [3081051] CIGNA STATE OF WYOMING [308105107] 330.18 percent of total billed charges 258.54 396.15 Technical (Hospital) Services Radiologic Exam Knee Complete 4/More Views PX-3207356400 CDM 73564 CPT 320 RC inpatient 417 417 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES EPO [308136803] 330.18 percent of total billed charges 258.54 396.15 Technical (Hospital) Services Radiologic Exam Knee Complete 4/More Views PX-3207356400 CDM 73564 CPT 320 RC inpatient 417 417 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES PPO [308136801] 330.18 percent of total billed charges 258.54 396.15 Technical (Hospital) Services Radiologic Exam Knee Complete 4/More Views PX-3207356400 CDM 73564 CPT 320 RC inpatient 417 417 BLUE CROSS BLUE SHIELD WELLMARK SB889 [3081026] BCBS WYOMING [308102603] 396.15 percent of total billed charges 258.54 396.15 Technical (Hospital) Services Radiologic Exam Knee Complete 4/More Views PX-3207356400 CDM 73564 CPT 320 RC inpatient 417 417 MULTIPLAN INC 34080 [3081285] MULTIPLAN INC [308128501] 396.15 percent of total billed charges 258.54 396.15 Technical (Hospital) Services Radiologic Exam Knee Complete 4/More Views PX-3207356400 CDM 73564 CPT 320 RC inpatient 417 417 UNITED HEALTHCARE (COMMERCIAL) [3081199] UNITED HEALTHCARE 87726 [308119901] 258.54 percent of total billed charges 258.54 396.15 Technical (Hospital) Services Radiologic Exam Knee Complete 4/More Views PX-3207356400 CDM 73564 CPT 320 RC inpatient 417 417 HEALTHPARTNERS SX009 HEALTHPARTNERS 330.18 percent of total billed charges 258.54 396.15 Technical (Hospital) Services Radiologic Exam Knee Complete 4/More Views PX-3207356400 CDM 73564 CPT 320 RC inpatient 417 417 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES HDHP [308136802] 330.18 percent of total billed charges 258.54 396.15 Technical (Hospital) Services Radiologic Exam Knee Complete 4/More Views PX-3207356400 CDM 73564 CPT 320 RC inpatient 417 417 MEDICA (COMMERCIAL) 94265 [3081118] MEDICA CLAIMS [308111801] 375.3 percent of total billed charges 258.54 396.15 Technical (Hospital) Services Radiologic Examination Knee 3 Views PX-3207356200 CDM 73562 CPT 320 RC outpatient 357 357 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES PPO [308136801] 285.6 percent of total billed charges 221.34 339.15 Technical (Hospital) Services Radiologic Examination Knee 3 Views PX-3207356200 CDM 73562 CPT 320 RC outpatient 357 357 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES EPO [308136803] 285.6 percent of total billed charges 221.34 339.15 Technical (Hospital) Services Radiologic Examination Knee 3 Views PX-3207356200 CDM 73562 CPT 320 RC outpatient 357 357 MULTIPLAN INC 34080 [3081285] MULTIPLAN INC [308128501] 339.15 percent of total billed charges 221.34 339.15 Technical (Hospital) Services Radiologic Examination Knee 3 Views PX-3207356200 CDM 73562 CPT 320 RC outpatient 357 357 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES HDHP [308136802] 285.6 percent of total billed charges 221.34 339.15 Technical (Hospital) Services Radiologic Examination Knee 3 Views PX-3207356200 CDM 73562 CPT 320 RC outpatient 357 357 BLUE CROSS BLUE SHIELD WELLMARK SB889 [3081026] BCBS WYOMING [308102603] 339.15 percent of total billed charges 221.34 339.15 Technical (Hospital) Services Radiologic Examination Knee 3 Views PX-3207356200 CDM 73562 CPT 320 RC outpatient 357 357 HEALTHPARTNERS SX009 HEALTHPARTNERS 285.6 percent of total billed charges 221.34 339.15 Technical (Hospital) Services Radiologic Examination Knee 3 Views PX-3207356200 CDM 73562 CPT 320 RC outpatient 357 357 UNITED HEALTHCARE (COMMERCIAL) [3081199] UNITED HEALTHCARE 87726 [308119901] 221.34 percent of total billed charges 221.34 339.15 Technical (Hospital) Services Radiologic Examination Knee 3 Views PX-3207356200 CDM 73562 CPT 320 RC outpatient 357 357 CIGNA 62308 [3081051] CIGNA 62308 [308105105] 285.6 percent of total billed charges 221.34 339.15 Technical (Hospital) Services Radiologic Examination Knee 3 Views PX-3207356200 CDM 73562 CPT 320 RC outpatient 357 357 CIGNA 62308 [3081051] CIGNA STATE OF WYOMING [308105107] 285.6 percent of total billed charges 221.34 339.15 Technical (Hospital) Services Radiologic Examination Knee 3 Views PX-3207356200 CDM 73562 CPT 320 RC outpatient 357 357 MEDICA (COMMERCIAL) 94265 [3081118] MEDICA CLAIMS [308111801] 321.3 percent of total billed charges 221.34 339.15 Technical (Hospital) Services Radiologic Examination Knee 3 Views PX-3207356200 CDM 73562 CPT 320 RC inpatient 357 357 UNITED HEALTHCARE (COMMERCIAL) [3081199] UNITED HEALTHCARE 87726 [308119901] 221.34 percent of total billed charges 221.34 339.15 Technical (Hospital) Services Radiologic Examination Knee 3 Views PX-3207356200 CDM 73562 CPT 320 RC inpatient 357 357 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES PPO [308136801] 282.67 percent of total billed charges 221.34 339.15 Technical (Hospital) Services Radiologic Examination Knee 3 Views PX-3207356200 CDM 73562 CPT 320 RC inpatient 357 357 BLUE CROSS BLUE SHIELD WELLMARK SB889 [3081026] BCBS WYOMING [308102603] 339.15 percent of total billed charges 221.34 339.15 Technical (Hospital) Services Radiologic Examination Knee 3 Views PX-3207356200 CDM 73562 CPT 320 RC inpatient 357 357 MULTIPLAN INC 34080 [3081285] MULTIPLAN INC [308128501] 339.15 percent of total billed charges 221.34 339.15 Technical (Hospital) Services Radiologic Examination Knee 3 Views PX-3207356200 CDM 73562 CPT 320 RC inpatient 357 357 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES HDHP [308136802] 282.67 percent of total billed charges 221.34 339.15 Technical (Hospital) Services Radiologic Examination Knee 3 Views PX-3207356200 CDM 73562 CPT 320 RC inpatient 357 357 MEDICA (COMMERCIAL) 94265 [3081118] MEDICA CLAIMS [308111801] 321.3 percent of total billed charges 221.34 339.15 Technical (Hospital) Services Radiologic Examination Knee 3 Views PX-3207356200 CDM 73562 CPT 320 RC inpatient 357 357 HEALTHPARTNERS SX009 HEALTHPARTNERS 282.67 percent of total billed charges 221.34 339.15 Technical (Hospital) Services Radiologic Examination Knee 3 Views PX-3207356200 CDM 73562 CPT 320 RC inpatient 357 357 CIGNA 62308 [3081051] CIGNA 62308 [308105105] 282.67 percent of total billed charges 221.34 339.15 Technical (Hospital) Services Radiologic Examination Knee 3 Views PX-3207356200 CDM 73562 CPT 320 RC inpatient 357 357 CIGNA 62308 [3081051] CIGNA STATE OF WYOMING [308105107] 282.67 percent of total billed charges 221.34 339.15 Technical (Hospital) Services Radiologic Examination Knee 3 Views PX-3207356200 CDM 73562 CPT 320 RC inpatient 357 357 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES EPO [308136803] 282.67 percent of total billed charges 221.34 339.15 Technical (Hospital) Services Radiologic Examination Knee 1/2 Views PX-3207356000 CDM 73560 CPT 320 RC outpatient 298 298 MEDICA (COMMERCIAL) 94265 [3081118] MEDICA CLAIMS [308111801] 268.2 percent of total billed charges 184.76 283.1 Technical (Hospital) Services Radiologic Examination Knee 1/2 Views PX-3207356000 CDM 73560 CPT 320 RC outpatient 298 298 CIGNA 62308 [3081051] CIGNA 62308 [308105105] 238.4 percent of total billed charges 184.76 283.1 Technical (Hospital) Services Radiologic Examination Knee 1/2 Views PX-3207356000 CDM 73560 CPT 320 RC outpatient 298 298 CIGNA 62308 [3081051] CIGNA STATE OF WYOMING [308105107] 238.4 percent of total billed charges 184.76 283.1 Technical (Hospital) Services Radiologic Examination Knee 1/2 Views PX-3207356000 CDM 73560 CPT 320 RC outpatient 298 298 UNITED HEALTHCARE (COMMERCIAL) [3081199] UNITED HEALTHCARE 87726 [308119901] 184.76 percent of total billed charges 184.76 283.1 Technical (Hospital) Services Radiologic Examination Knee 1/2 Views PX-3207356000 CDM 73560 CPT 320 RC outpatient 298 298 HEALTHPARTNERS SX009 HEALTHPARTNERS 238.4 percent of total billed charges 184.76 283.1 Technical (Hospital) Services Radiologic Examination Knee 1/2 Views PX-3207356000 CDM 73560 CPT 320 RC outpatient 298 298 BLUE CROSS BLUE SHIELD WELLMARK SB889 [3081026] BCBS WYOMING [308102603] 283.1 percent of total billed charges 184.76 283.1 Technical (Hospital) Services Radiologic Examination Knee 1/2 Views PX-3207356000 CDM 73560 CPT 320 RC outpatient 298 298 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES HDHP [308136802] 238.4 percent of total billed charges 184.76 283.1 Technical (Hospital) Services Radiologic Examination Knee 1/2 Views PX-3207356000 CDM 73560 CPT 320 RC outpatient 298 298 MULTIPLAN INC 34080 [3081285] MULTIPLAN INC [308128501] 283.1 percent of total billed charges 184.76 283.1 Technical (Hospital) Services Radiologic Examination Knee 1/2 Views PX-3207356000 CDM 73560 CPT 320 RC outpatient 298 298 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES EPO [308136803] 238.4 percent of total billed charges 184.76 283.1 Technical (Hospital) Services Radiologic Examination Knee 1/2 Views PX-3207356000 CDM 73560 CPT 320 RC outpatient 298 298 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES PPO [308136801] 238.4 percent of total billed charges 184.76 283.1 Technical (Hospital) Services Radiologic Examination Knee 1/2 Views PX-3207356000 CDM 73560 CPT 320 RC inpatient 298 298 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES HDHP [308136802] 235.96 percent of total billed charges 184.76 283.1 Technical (Hospital) Services Radiologic Examination Knee 1/2 Views PX-3207356000 CDM 73560 CPT 320 RC inpatient 298 298 MEDICA (COMMERCIAL) 94265 [3081118] MEDICA CLAIMS [308111801] 268.2 percent of total billed charges 184.76 283.1 Technical (Hospital) Services Radiologic Examination Knee 1/2 Views PX-3207356000 CDM 73560 CPT 320 RC inpatient 298 298 HEALTHPARTNERS SX009 HEALTHPARTNERS 235.96 percent of total billed charges 184.76 283.1 Technical (Hospital) Services Radiologic Examination Knee 1/2 Views PX-3207356000 CDM 73560 CPT 320 RC inpatient 298 298 MULTIPLAN INC 34080 [3081285] MULTIPLAN INC [308128501] 283.1 percent of total billed charges 184.76 283.1 Technical (Hospital) Services Radiologic Examination Knee 1/2 Views PX-3207356000 CDM 73560 CPT 320 RC inpatient 298 298 BLUE CROSS BLUE SHIELD WELLMARK SB889 [3081026] BCBS WYOMING [308102603] 283.1 percent of total billed charges 184.76 283.1 Technical (Hospital) Services Radiologic Examination Knee 1/2 Views PX-3207356000 CDM 73560 CPT 320 RC inpatient 298 298 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES PPO [308136801] 235.96 percent of total billed charges 184.76 283.1 Technical (Hospital) Services Radiologic Examination Knee 1/2 Views PX-3207356000 CDM 73560 CPT 320 RC inpatient 298 298 UNITED HEALTHCARE (COMMERCIAL) [3081199] UNITED HEALTHCARE 87726 [308119901] 184.76 percent of total billed charges 184.76 283.1 Technical (Hospital) Services Radiologic Examination Knee 1/2 Views PX-3207356000 CDM 73560 CPT 320 RC inpatient 298 298 CIGNA 62308 [3081051] CIGNA 62308 [308105105] 235.96 percent of total billed charges 184.76 283.1 Technical (Hospital) Services Radiologic Examination Knee 1/2 Views PX-3207356000 CDM 73560 CPT 320 RC inpatient 298 298 CIGNA 62308 [3081051] CIGNA STATE OF WYOMING [308105107] 235.96 percent of total billed charges 184.76 283.1 Technical (Hospital) Services Radiologic Examination Knee 1/2 Views PX-3207356000 CDM 73560 CPT 320 RC inpatient 298 298 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES EPO [308136803] 235.96 percent of total billed charges 184.76 283.1 Technical (Hospital) Services Radiologic Examination Femur Minimum 2 Views PX-3207355200 CDM 73552 CPT 320 RC inpatient 238 238 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES HDHP [308136802] 188.45 percent of total billed charges 147.56 226.1 Technical (Hospital) Services Radiologic Examination Femur Minimum 2 Views PX-3207355200 CDM 73552 CPT 320 RC inpatient 238 238 MEDICA (COMMERCIAL) 94265 [3081118] MEDICA CLAIMS [308111801] 214.2 percent of total billed charges 147.56 226.1 Technical (Hospital) Services Radiologic Examination Femur Minimum 2 Views PX-3207355200 CDM 73552 CPT 320 RC inpatient 238 238 HEALTHPARTNERS SX009 HEALTHPARTNERS 188.45 percent of total billed charges 147.56 226.1 Technical (Hospital) Services Radiologic Examination Femur Minimum 2 Views PX-3207355200 CDM 73552 CPT 320 RC inpatient 238 238 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES PPO [308136801] 188.45 percent of total billed charges 147.56 226.1 Technical (Hospital) Services Radiologic Examination Femur Minimum 2 Views PX-3207355200 CDM 73552 CPT 320 RC inpatient 238 238 MULTIPLAN INC 34080 [3081285] MULTIPLAN INC [308128501] 226.1 percent of total billed charges 147.56 226.1 Technical (Hospital) Services Radiologic Examination Femur Minimum 2 Views PX-3207355200 CDM 73552 CPT 320 RC inpatient 238 238 BLUE CROSS BLUE SHIELD WELLMARK SB889 [3081026] BCBS WYOMING [308102603] 226.1 percent of total billed charges 147.56 226.1 Technical (Hospital) Services Radiologic Examination Femur Minimum 2 Views PX-3207355200 CDM 73552 CPT 320 RC inpatient 238 238 UNITED HEALTHCARE (COMMERCIAL) [3081199] UNITED HEALTHCARE 87726 [308119901] 147.56 percent of total billed charges 147.56 226.1 Technical (Hospital) Services Radiologic Examination Femur Minimum 2 Views PX-3207355200 CDM 73552 CPT 320 RC inpatient 238 238 CIGNA 62308 [3081051] CIGNA 62308 [308105105] 188.45 percent of total billed charges 147.56 226.1 Technical (Hospital) Services Radiologic Examination Femur Minimum 2 Views PX-3207355200 CDM 73552 CPT 320 RC inpatient 238 238 CIGNA 62308 [3081051] CIGNA STATE OF WYOMING [308105107] 188.45 percent of total billed charges 147.56 226.1 Technical (Hospital) Services Radiologic Examination Femur Minimum 2 Views PX-3207355200 CDM 73552 CPT 320 RC inpatient 238 238 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES EPO [308136803] 188.45 percent of total billed charges 147.56 226.1 Technical (Hospital) Services Radiologic Examination Femur Minimum 2 Views PX-3207355200 CDM 73552 CPT 320 RC outpatient 238 238 UNITED HEALTHCARE (COMMERCIAL) [3081199] UNITED HEALTHCARE 87726 [308119901] 147.56 percent of total billed charges 147.56 226.1 Technical (Hospital) Services Radiologic Examination Femur Minimum 2 Views PX-3207355200 CDM 73552 CPT 320 RC outpatient 238 238 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES EPO [308136803] 190.4 percent of total billed charges 147.56 226.1 Technical (Hospital) Services Radiologic Examination Femur Minimum 2 Views PX-3207355200 CDM 73552 CPT 320 RC outpatient 238 238 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES PPO [308136801] 190.4 percent of total billed charges 147.56 226.1 Technical (Hospital) Services Radiologic Examination Femur Minimum 2 Views PX-3207355200 CDM 73552 CPT 320 RC outpatient 238 238 MULTIPLAN INC 34080 [3081285] MULTIPLAN INC [308128501] 226.1 percent of total billed charges 147.56 226.1 Technical (Hospital) Services Radiologic Examination Femur Minimum 2 Views PX-3207355200 CDM 73552 CPT 320 RC outpatient 238 238 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES HDHP [308136802] 190.4 percent of total billed charges 147.56 226.1 Technical (Hospital) Services Radiologic Examination Femur Minimum 2 Views PX-3207355200 CDM 73552 CPT 320 RC outpatient 238 238 BLUE CROSS BLUE SHIELD WELLMARK SB889 [3081026] BCBS WYOMING [308102603] 226.1 percent of total billed charges 147.56 226.1 Technical (Hospital) Services Radiologic Examination Femur Minimum 2 Views PX-3207355200 CDM 73552 CPT 320 RC outpatient 238 238 MEDICA (COMMERCIAL) 94265 [3081118] MEDICA CLAIMS [308111801] 214.2 percent of total billed charges 147.56 226.1 Technical (Hospital) Services Radiologic Examination Femur Minimum 2 Views PX-3207355200 CDM 73552 CPT 320 RC outpatient 238 238 HEALTHPARTNERS SX009 HEALTHPARTNERS 190.4 percent of total billed charges 147.56 226.1 Technical (Hospital) Services Radiologic Examination Femur Minimum 2 Views PX-3207355200 CDM 73552 CPT 320 RC outpatient 238 238 CIGNA 62308 [3081051] CIGNA 62308 [308105105] 190.4 percent of total billed charges 147.56 226.1 Technical (Hospital) Services Radiologic Examination Femur Minimum 2 Views PX-3207355200 CDM 73552 CPT 320 RC outpatient 238 238 CIGNA 62308 [3081051] CIGNA STATE OF WYOMING [308105107] 190.4 percent of total billed charges 147.56 226.1 Technical (Hospital) Services Radiologic Examination Femur 1 View PX-3207355100 CDM 73551 CPT 320 RC inpatient 203 203 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES EPO [308136803] 160.74 percent of total billed charges 125.86 192.85 Technical (Hospital) Services Radiologic Examination Femur 1 View PX-3207355100 CDM 73551 CPT 320 RC inpatient 203 203 CIGNA 62308 [3081051] CIGNA 62308 [308105105] 160.74 percent of total billed charges 125.86 192.85 Technical (Hospital) Services Radiologic Examination Femur 1 View PX-3207355100 CDM 73551 CPT 320 RC inpatient 203 203 CIGNA 62308 [3081051] CIGNA STATE OF WYOMING [308105107] 160.74 percent of total billed charges 125.86 192.85 Technical (Hospital) Services Radiologic Examination Femur 1 View PX-3207355100 CDM 73551 CPT 320 RC inpatient 203 203 UNITED HEALTHCARE (COMMERCIAL) [3081199] UNITED HEALTHCARE 87726 [308119901] 125.86 percent of total billed charges 125.86 192.85 Technical (Hospital) Services Radiologic Examination Femur 1 View PX-3207355100 CDM 73551 CPT 320 RC inpatient 203 203 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES PPO [308136801] 160.74 percent of total billed charges 125.86 192.85 Technical (Hospital) Services Radiologic Examination Femur 1 View PX-3207355100 CDM 73551 CPT 320 RC inpatient 203 203 BLUE CROSS BLUE SHIELD WELLMARK SB889 [3081026] BCBS WYOMING [308102603] 192.85 percent of total billed charges 125.86 192.85 Technical (Hospital) Services Radiologic Examination Femur 1 View PX-3207355100 CDM 73551 CPT 320 RC inpatient 203 203 MULTIPLAN INC 34080 [3081285] MULTIPLAN INC [308128501] 192.85 percent of total billed charges 125.86 192.85 Technical (Hospital) Services Radiologic Examination Femur 1 View PX-3207355100 CDM 73551 CPT 320 RC inpatient 203 203 HEALTHPARTNERS SX009 HEALTHPARTNERS 160.74 percent of total billed charges 125.86 192.85 Technical (Hospital) Services Radiologic Examination Femur 1 View PX-3207355100 CDM 73551 CPT 320 RC inpatient 203 203 MEDICA (COMMERCIAL) 94265 [3081118] MEDICA CLAIMS [308111801] 182.7 percent of total billed charges 125.86 192.85 Technical (Hospital) Services Radiologic Examination Femur 1 View PX-3207355100 CDM 73551 CPT 320 RC inpatient 203 203 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES HDHP [308136802] 160.74 percent of total billed charges 125.86 192.85 Technical (Hospital) Services Radiologic Examination Femur 1 View PX-3207355100 CDM 73551 CPT 320 RC outpatient 203 203 CIGNA 62308 [3081051] CIGNA 62308 [308105105] 162.4 percent of total billed charges 125.86 192.85 Technical (Hospital) Services Radiologic Examination Femur 1 View PX-3207355100 CDM 73551 CPT 320 RC outpatient 203 203 CIGNA 62308 [3081051] CIGNA STATE OF WYOMING [308105107] 162.4 percent of total billed charges 125.86 192.85 Technical (Hospital) Services Radiologic Examination Femur 1 View PX-3207355100 CDM 73551 CPT 320 RC outpatient 203 203 MEDICA (COMMERCIAL) 94265 [3081118] MEDICA CLAIMS [308111801] 182.7 percent of total billed charges 125.86 192.85 Technical (Hospital) Services Radiologic Examination Femur 1 View PX-3207355100 CDM 73551 CPT 320 RC outpatient 203 203 HEALTHPARTNERS SX009 HEALTHPARTNERS 162.4 percent of total billed charges 125.86 192.85 Technical (Hospital) Services Radiologic Examination Femur 1 View PX-3207355100 CDM 73551 CPT 320 RC outpatient 203 203 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES PPO [308136801] 162.4 percent of total billed charges 125.86 192.85 Technical (Hospital) Services Radiologic Examination Femur 1 View PX-3207355100 CDM 73551 CPT 320 RC outpatient 203 203 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES EPO [308136803] 162.4 percent of total billed charges 125.86 192.85 Technical (Hospital) Services Radiologic Examination Femur 1 View PX-3207355100 CDM 73551 CPT 320 RC outpatient 203 203 UNITED HEALTHCARE (COMMERCIAL) [3081199] UNITED HEALTHCARE 87726 [308119901] 125.86 percent of total billed charges 125.86 192.85 Technical (Hospital) Services Radiologic Examination Femur 1 View PX-3207355100 CDM 73551 CPT 320 RC outpatient 203 203 MULTIPLAN INC 34080 [3081285] MULTIPLAN INC [308128501] 192.85 percent of total billed charges 125.86 192.85 Technical (Hospital) Services Radiologic Examination Femur 1 View PX-3207355100 CDM 73551 CPT 320 RC outpatient 203 203 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES HDHP [308136802] 162.4 percent of total billed charges 125.86 192.85 Technical (Hospital) Services Radiologic Examination Femur 1 View PX-3207355100 CDM 73551 CPT 320 RC outpatient 203 203 BLUE CROSS BLUE SHIELD WELLMARK SB889 [3081026] BCBS WYOMING [308102603] 192.85 percent of total billed charges 125.86 192.85 Technical (Hospital) Services Radex Hips Bilateral With Pelvis 3-4 Views PX-3207352200 CDM 73522 CPT 320 RC outpatient 295 295 HEALTHPARTNERS SX009 HEALTHPARTNERS 236 percent of total billed charges 182.9 280.25 Technical (Hospital) Services Radex Hips Bilateral With Pelvis 3-4 Views PX-3207352200 CDM 73522 CPT 320 RC outpatient 295 295 UNITED HEALTHCARE (COMMERCIAL) [3081199] UNITED HEALTHCARE 87726 [308119901] 182.9 percent of total billed charges 182.9 280.25 Technical (Hospital) Services Radex Hips Bilateral With Pelvis 3-4 Views PX-3207352200 CDM 73522 CPT 320 RC outpatient 295 295 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES PPO [308136801] 236 percent of total billed charges 182.9 280.25 Technical (Hospital) Services Radex Hips Bilateral With Pelvis 3-4 Views PX-3207352200 CDM 73522 CPT 320 RC outpatient 295 295 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES EPO [308136803] 236 percent of total billed charges 182.9 280.25 Technical (Hospital) Services Radex Hips Bilateral With Pelvis 3-4 Views PX-3207352200 CDM 73522 CPT 320 RC outpatient 295 295 MULTIPLAN INC 34080 [3081285] MULTIPLAN INC [308128501] 280.25 percent of total billed charges 182.9 280.25 Technical (Hospital) Services Radex Hips Bilateral With Pelvis 3-4 Views PX-3207352200 CDM 73522 CPT 320 RC outpatient 295 295 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES HDHP [308136802] 236 percent of total billed charges 182.9 280.25 Technical (Hospital) Services Radex Hips Bilateral With Pelvis 3-4 Views PX-3207352200 CDM 73522 CPT 320 RC outpatient 295 295 BLUE CROSS BLUE SHIELD WELLMARK SB889 [3081026] BCBS WYOMING [308102603] 280.25 percent of total billed charges 182.9 280.25 Technical (Hospital) Services Radex Hips Bilateral With Pelvis 3-4 Views PX-3207352200 CDM 73522 CPT 320 RC outpatient 295 295 CIGNA 62308 [3081051] CIGNA 62308 [308105105] 236 percent of total billed charges 182.9 280.25 Technical (Hospital) Services Radex Hips Bilateral With Pelvis 3-4 Views PX-3207352200 CDM 73522 CPT 320 RC outpatient 295 295 CIGNA 62308 [3081051] CIGNA STATE OF WYOMING [308105107] 236 percent of total billed charges 182.9 280.25 Technical (Hospital) Services Radex Hips Bilateral With Pelvis 3-4 Views PX-3207352200 CDM 73522 CPT 320 RC outpatient 295 295 MEDICA (COMMERCIAL) 94265 [3081118] MEDICA CLAIMS [308111801] 265.5 percent of total billed charges 182.9 280.25 Technical (Hospital) Services Radex Hips Bilateral With Pelvis 3-4 Views PX-3207352200 CDM 73522 CPT 320 RC inpatient 295 295 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES EPO [308136803] 233.58 percent of total billed charges 182.9 280.25 Technical (Hospital) Services Radex Hips Bilateral With Pelvis 3-4 Views PX-3207352200 CDM 73522 CPT 320 RC inpatient 295 295 CIGNA 62308 [3081051] CIGNA 62308 [308105105] 233.58 percent of total billed charges 182.9 280.25 Technical (Hospital) Services Radex Hips Bilateral With Pelvis 3-4 Views PX-3207352200 CDM 73522 CPT 320 RC inpatient 295 295 CIGNA 62308 [3081051] CIGNA STATE OF WYOMING [308105107] 233.58 percent of total billed charges 182.9 280.25 Technical (Hospital) Services Radex Hips Bilateral With Pelvis 3-4 Views PX-3207352200 CDM 73522 CPT 320 RC inpatient 295 295 HEALTHPARTNERS SX009 HEALTHPARTNERS 233.58 percent of total billed charges 182.9 280.25 Technical (Hospital) Services Radex Hips Bilateral With Pelvis 3-4 Views PX-3207352200 CDM 73522 CPT 320 RC inpatient 295 295 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES HDHP [308136802] 233.58 percent of total billed charges 182.9 280.25 Technical (Hospital) Services Radex Hips Bilateral With Pelvis 3-4 Views PX-3207352200 CDM 73522 CPT 320 RC inpatient 295 295 MEDICA (COMMERCIAL) 94265 [3081118] MEDICA CLAIMS [308111801] 265.5 percent of total billed charges 182.9 280.25 Technical (Hospital) Services Radex Hips Bilateral With Pelvis 3-4 Views PX-3207352200 CDM 73522 CPT 320 RC inpatient 295 295 MULTIPLAN INC 34080 [3081285] MULTIPLAN INC [308128501] 280.25 percent of total billed charges 182.9 280.25 Technical (Hospital) Services Radex Hips Bilateral With Pelvis 3-4 Views PX-3207352200 CDM 73522 CPT 320 RC inpatient 295 295 BLUE CROSS BLUE SHIELD WELLMARK SB889 [3081026] BCBS WYOMING [308102603] 280.25 percent of total billed charges 182.9 280.25 Technical (Hospital) Services Radex Hips Bilateral With Pelvis 3-4 Views PX-3207352200 CDM 73522 CPT 320 RC inpatient 295 295 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES PPO [308136801] 233.58 percent of total billed charges 182.9 280.25 Technical (Hospital) Services Radex Hips Bilateral With Pelvis 3-4 Views PX-3207352200 CDM 73522 CPT 320 RC inpatient 295 295 UNITED HEALTHCARE (COMMERCIAL) [3081199] UNITED HEALTHCARE 87726 [308119901] 182.9 percent of total billed charges 182.9 280.25 Technical (Hospital) Services Radex Hips Bilateral With Pelvis 2 Views PX-3207352100 CDM 73521 CPT 320 RC outpatient 251 251 HEALTHPARTNERS SX009 HEALTHPARTNERS 200.8 percent of total billed charges 155.62 238.45 Technical (Hospital) Services Radex Hips Bilateral With Pelvis 2 Views PX-3207352100 CDM 73521 CPT 320 RC outpatient 251 251 MEDICA (COMMERCIAL) 94265 [3081118] MEDICA CLAIMS [308111801] 225.9 percent of total billed charges 155.62 238.45 Technical (Hospital) Services Radex Hips Bilateral With Pelvis 2 Views PX-3207352100 CDM 73521 CPT 320 RC outpatient 251 251 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES EPO [308136803] 200.8 percent of total billed charges 155.62 238.45 Technical (Hospital) Services Radex Hips Bilateral With Pelvis 2 Views PX-3207352100 CDM 73521 CPT 320 RC outpatient 251 251 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES PPO [308136801] 200.8 percent of total billed charges 155.62 238.45 Technical (Hospital) Services Radex Hips Bilateral With Pelvis 2 Views PX-3207352100 CDM 73521 CPT 320 RC outpatient 251 251 UNITED HEALTHCARE (COMMERCIAL) [3081199] UNITED HEALTHCARE 87726 [308119901] 155.62 percent of total billed charges 155.62 238.45 Technical (Hospital) Services Radex Hips Bilateral With Pelvis 2 Views PX-3207352100 CDM 73521 CPT 320 RC outpatient 251 251 BLUE CROSS BLUE SHIELD WELLMARK SB889 [3081026] BCBS WYOMING [308102603] 238.45 percent of total billed charges 155.62 238.45 Technical (Hospital) Services Radex Hips Bilateral With Pelvis 2 Views PX-3207352100 CDM 73521 CPT 320 RC outpatient 251 251 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES HDHP [308136802] 200.8 percent of total billed charges 155.62 238.45 Technical (Hospital) Services Radex Hips Bilateral With Pelvis 2 Views PX-3207352100 CDM 73521 CPT 320 RC outpatient 251 251 MULTIPLAN INC 34080 [3081285] MULTIPLAN INC [308128501] 238.45 percent of total billed charges 155.62 238.45 Technical (Hospital) Services Radex Hips Bilateral With Pelvis 2 Views PX-3207352100 CDM 73521 CPT 320 RC outpatient 251 251 CIGNA 62308 [3081051] CIGNA 62308 [308105105] 200.8 percent of total billed charges 155.62 238.45 Technical (Hospital) Services Radex Hips Bilateral With Pelvis 2 Views PX-3207352100 CDM 73521 CPT 320 RC outpatient 251 251 CIGNA 62308 [3081051] CIGNA STATE OF WYOMING [308105107] 200.8 percent of total billed charges 155.62 238.45 Technical (Hospital) Services Radex Hips Bilateral With Pelvis 2 Views PX-3207352100 CDM 73521 CPT 320 RC inpatient 251 251 MEDICA (COMMERCIAL) 94265 [3081118] MEDICA CLAIMS [308111801] 225.9 percent of total billed charges 155.62 238.45 Technical (Hospital) Services Radex Hips Bilateral With Pelvis 2 Views PX-3207352100 CDM 73521 CPT 320 RC inpatient 251 251 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES HDHP [308136802] 198.74 percent of total billed charges 155.62 238.45 Technical (Hospital) Services Radex Hips Bilateral With Pelvis 2 Views PX-3207352100 CDM 73521 CPT 320 RC inpatient 251 251 HEALTHPARTNERS SX009 HEALTHPARTNERS 198.74 percent of total billed charges 155.62 238.45 Technical (Hospital) Services Radex Hips Bilateral With Pelvis 2 Views PX-3207352100 CDM 73521 CPT 320 RC inpatient 251 251 UNITED HEALTHCARE (COMMERCIAL) [3081199] UNITED HEALTHCARE 87726 [308119901] 155.62 percent of total billed charges 155.62 238.45 Technical (Hospital) Services Radex Hips Bilateral With Pelvis 2 Views PX-3207352100 CDM 73521 CPT 320 RC inpatient 251 251 MULTIPLAN INC 34080 [3081285] MULTIPLAN INC [308128501] 238.45 percent of total billed charges 155.62 238.45 Technical (Hospital) Services Radex Hips Bilateral With Pelvis 2 Views PX-3207352100 CDM 73521 CPT 320 RC inpatient 251 251 BLUE CROSS BLUE SHIELD WELLMARK SB889 [3081026] BCBS WYOMING [308102603] 238.45 percent of total billed charges 155.62 238.45 Technical (Hospital) Services Radex Hips Bilateral With Pelvis 2 Views PX-3207352100 CDM 73521 CPT 320 RC inpatient 251 251 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES PPO [308136801] 198.74 percent of total billed charges 155.62 238.45 Technical (Hospital) Services Radex Hips Bilateral With Pelvis 2 Views PX-3207352100 CDM 73521 CPT 320 RC inpatient 251 251 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES EPO [308136803] 198.74 percent of total billed charges 155.62 238.45 Technical (Hospital) Services Radex Hips Bilateral With Pelvis 2 Views PX-3207352100 CDM 73521 CPT 320 RC inpatient 251 251 CIGNA 62308 [3081051] CIGNA 62308 [308105105] 198.74 percent of total billed charges 155.62 238.45 Technical (Hospital) Services Radex Hips Bilateral With Pelvis 2 Views PX-3207352100 CDM 73521 CPT 320 RC inpatient 251 251 CIGNA 62308 [3081051] CIGNA STATE OF WYOMING [308105107] 198.74 percent of total billed charges 155.62 238.45 Technical (Hospital) Services Radex Hip Unilateral With Pelvis 2-3 Views PX-3207350200 CDM 73502 CPT 320 RC inpatient 251 251 MEDICA (COMMERCIAL) 94265 [3081118] MEDICA CLAIMS [308111801] 225.9 percent of total billed charges 155.62 238.45 Technical (Hospital) Services Radex Hip Unilateral With Pelvis 2-3 Views PX-3207350200 CDM 73502 CPT 320 RC inpatient 251 251 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES HDHP [308136802] 198.74 percent of total billed charges 155.62 238.45 Technical (Hospital) Services Radex Hip Unilateral With Pelvis 2-3 Views PX-3207350200 CDM 73502 CPT 320 RC inpatient 251 251 HEALTHPARTNERS SX009 HEALTHPARTNERS 198.74 percent of total billed charges 155.62 238.45 Technical (Hospital) Services Radex Hip Unilateral With Pelvis 2-3 Views PX-3207350200 CDM 73502 CPT 320 RC inpatient 251 251 UNITED HEALTHCARE (COMMERCIAL) [3081199] UNITED HEALTHCARE 87726 [308119901] 155.62 percent of total billed charges 155.62 238.45 Technical (Hospital) Services Radex Hip Unilateral With Pelvis 2-3 Views PX-3207350200 CDM 73502 CPT 320 RC inpatient 251 251 MULTIPLAN INC 34080 [3081285] MULTIPLAN INC [308128501] 238.45 percent of total billed charges 155.62 238.45 Technical (Hospital) Services Radex Hip Unilateral With Pelvis 2-3 Views PX-3207350200 CDM 73502 CPT 320 RC inpatient 251 251 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES PPO [308136801] 198.74 percent of total billed charges 155.62 238.45 Technical (Hospital) Services Radex Hip Unilateral With Pelvis 2-3 Views PX-3207350200 CDM 73502 CPT 320 RC inpatient 251 251 BLUE CROSS BLUE SHIELD WELLMARK SB889 [3081026] BCBS WYOMING [308102603] 238.45 percent of total billed charges 155.62 238.45 Technical (Hospital) Services Radex Hip Unilateral With Pelvis 2-3 Views PX-3207350200 CDM 73502 CPT 320 RC inpatient 251 251 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES EPO [308136803] 198.74 percent of total billed charges 155.62 238.45 Technical (Hospital) Services Radex Hip Unilateral With Pelvis 2-3 Views PX-3207350200 CDM 73502 CPT 320 RC inpatient 251 251 CIGNA 62308 [3081051] CIGNA 62308 [308105105] 198.74 percent of total billed charges 155.62 238.45 Technical (Hospital) Services Radex Hip Unilateral With Pelvis 2-3 Views PX-3207350200 CDM 73502 CPT 320 RC inpatient 251 251 CIGNA 62308 [3081051] CIGNA STATE OF WYOMING [308105107] 198.74 percent of total billed charges 155.62 238.45 Technical (Hospital) Services Radex Hip Unilateral With Pelvis 2-3 Views PX-3207350200 CDM 73502 CPT 320 RC outpatient 251 251 BLUE CROSS BLUE SHIELD WELLMARK SB889 [3081026] BCBS WYOMING [308102603] 238.45 percent of total billed charges 155.62 238.45 Technical (Hospital) Services Radex Hip Unilateral With Pelvis 2-3 Views PX-3207350200 CDM 73502 CPT 320 RC outpatient 251 251 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES HDHP [308136802] 200.8 percent of total billed charges 155.62 238.45 Technical (Hospital) Services Radex Hip Unilateral With Pelvis 2-3 Views PX-3207350200 CDM 73502 CPT 320 RC outpatient 251 251 MULTIPLAN INC 34080 [3081285] MULTIPLAN INC [308128501] 238.45 percent of total billed charges 155.62 238.45 Technical (Hospital) Services Radex Hip Unilateral With Pelvis 2-3 Views PX-3207350200 CDM 73502 CPT 320 RC outpatient 251 251 UNITED HEALTHCARE (COMMERCIAL) [3081199] UNITED HEALTHCARE 87726 [308119901] 155.62 percent of total billed charges 155.62 238.45 Technical (Hospital) Services Radex Hip Unilateral With Pelvis 2-3 Views PX-3207350200 CDM 73502 CPT 320 RC outpatient 251 251 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES EPO [308136803] 200.8 percent of total billed charges 155.62 238.45 Technical (Hospital) Services Radex Hip Unilateral With Pelvis 2-3 Views PX-3207350200 CDM 73502 CPT 320 RC outpatient 251 251 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES PPO [308136801] 200.8 percent of total billed charges 155.62 238.45 Technical (Hospital) Services Radex Hip Unilateral With Pelvis 2-3 Views PX-3207350200 CDM 73502 CPT 320 RC outpatient 251 251 HEALTHPARTNERS SX009 HEALTHPARTNERS 200.8 percent of total billed charges 155.62 238.45 Technical (Hospital) Services Radex Hip Unilateral With Pelvis 2-3 Views PX-3207350200 CDM 73502 CPT 320 RC outpatient 251 251 CIGNA 62308 [3081051] CIGNA 62308 [308105105] 200.8 percent of total billed charges 155.62 238.45 Technical (Hospital) Services Radex Hip Unilateral With Pelvis 2-3 Views PX-3207350200 CDM 73502 CPT 320 RC outpatient 251 251 CIGNA 62308 [3081051] CIGNA STATE OF WYOMING [308105107] 200.8 percent of total billed charges 155.62 238.45 Technical (Hospital) Services Radex Hip Unilateral With Pelvis 2-3 Views PX-3207350200 CDM 73502 CPT 320 RC outpatient 251 251 MEDICA (COMMERCIAL) 94265 [3081118] MEDICA CLAIMS [308111801] 225.9 percent of total billed charges 155.62 238.45 Technical (Hospital) Services "Radiologic Exam, Hip W Pelvis When Performed, Unilateral, 1 View" PX-3207350100 CDM 73501 CPT 320 RC inpatient 183 183 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES EPO [308136803] 144.9 percent of total billed charges 113.46 173.85 Technical (Hospital) Services "Radiologic Exam, Hip W Pelvis When Performed, Unilateral, 1 View" PX-3207350100 CDM 73501 CPT 320 RC inpatient 183 183 CIGNA 62308 [3081051] CIGNA 62308 [308105105] 144.9 percent of total billed charges 113.46 173.85 Technical (Hospital) Services "Radiologic Exam, Hip W Pelvis When Performed, Unilateral, 1 View" PX-3207350100 CDM 73501 CPT 320 RC inpatient 183 183 CIGNA 62308 [3081051] CIGNA STATE OF WYOMING [308105107] 144.9 percent of total billed charges 113.46 173.85 Technical (Hospital) Services "Radiologic Exam, Hip W Pelvis When Performed, Unilateral, 1 View" PX-3207350100 CDM 73501 CPT 320 RC inpatient 183 183 UNITED HEALTHCARE (COMMERCIAL) [3081199] UNITED HEALTHCARE 87726 [308119901] 113.46 percent of total billed charges 113.46 173.85 Technical (Hospital) Services "Radiologic Exam, Hip W Pelvis When Performed, Unilateral, 1 View" PX-3207350100 CDM 73501 CPT 320 RC inpatient 183 183 BLUE CROSS BLUE SHIELD WELLMARK SB889 [3081026] BCBS WYOMING [308102603] 173.85 percent of total billed charges 113.46 173.85 Technical (Hospital) Services "Radiologic Exam, Hip W Pelvis When Performed, Unilateral, 1 View" PX-3207350100 CDM 73501 CPT 320 RC inpatient 183 183 MULTIPLAN INC 34080 [3081285] MULTIPLAN INC [308128501] 173.85 percent of total billed charges 113.46 173.85 Technical (Hospital) Services "Radiologic Exam, Hip W Pelvis When Performed, Unilateral, 1 View" PX-3207350100 CDM 73501 CPT 320 RC inpatient 183 183 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES PPO [308136801] 144.9 percent of total billed charges 113.46 173.85 Technical (Hospital) Services "Radiologic Exam, Hip W Pelvis When Performed, Unilateral, 1 View" PX-3207350100 CDM 73501 CPT 320 RC inpatient 183 183 HEALTHPARTNERS SX009 HEALTHPARTNERS 144.9 percent of total billed charges 113.46 173.85 Technical (Hospital) Services "Radiologic Exam, Hip W Pelvis When Performed, Unilateral, 1 View" PX-3207350100 CDM 73501 CPT 320 RC inpatient 183 183 MEDICA (COMMERCIAL) 94265 [3081118] MEDICA CLAIMS [308111801] 164.7 percent of total billed charges 113.46 173.85 Technical (Hospital) Services "Radiologic Exam, Hip W Pelvis When Performed, Unilateral, 1 View" PX-3207350100 CDM 73501 CPT 320 RC inpatient 183 183 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES HDHP [308136802] 144.9 percent of total billed charges 113.46 173.85 Technical (Hospital) Services "Radiologic Exam, Hip W Pelvis When Performed, Unilateral, 1 View" PX-3207350100 CDM 73501 CPT 320 RC outpatient 183 183 MEDICA (COMMERCIAL) 94265 [3081118] MEDICA CLAIMS [308111801] 164.7 percent of total billed charges 113.46 173.85 Technical (Hospital) Services "Radiologic Exam, Hip W Pelvis When Performed, Unilateral, 1 View" PX-3207350100 CDM 73501 CPT 320 RC outpatient 183 183 CIGNA 62308 [3081051] CIGNA 62308 [308105105] 146.4 percent of total billed charges 113.46 173.85 Technical (Hospital) Services "Radiologic Exam, Hip W Pelvis When Performed, Unilateral, 1 View" PX-3207350100 CDM 73501 CPT 320 RC outpatient 183 183 CIGNA 62308 [3081051] CIGNA STATE OF WYOMING [308105107] 146.4 percent of total billed charges 113.46 173.85 Technical (Hospital) Services "Radiologic Exam, Hip W Pelvis When Performed, Unilateral, 1 View" PX-3207350100 CDM 73501 CPT 320 RC outpatient 183 183 HEALTHPARTNERS SX009 HEALTHPARTNERS 146.4 percent of total billed charges 113.46 173.85 Technical (Hospital) Services "Radiologic Exam, Hip W Pelvis When Performed, Unilateral, 1 View" PX-3207350100 CDM 73501 CPT 320 RC outpatient 183 183 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES HDHP [308136802] 146.4 percent of total billed charges 113.46 173.85 Technical (Hospital) Services "Radiologic Exam, Hip W Pelvis When Performed, Unilateral, 1 View" PX-3207350100 CDM 73501 CPT 320 RC outpatient 183 183 MULTIPLAN INC 34080 [3081285] MULTIPLAN INC [308128501] 173.85 percent of total billed charges 113.46 173.85 Technical (Hospital) Services "Radiologic Exam, Hip W Pelvis When Performed, Unilateral, 1 View" PX-3207350100 CDM 73501 CPT 320 RC outpatient 183 183 BLUE CROSS BLUE SHIELD WELLMARK SB889 [3081026] BCBS WYOMING [308102603] 173.85 percent of total billed charges 113.46 173.85 Technical (Hospital) Services "Radiologic Exam, Hip W Pelvis When Performed, Unilateral, 1 View" PX-3207350100 CDM 73501 CPT 320 RC outpatient 183 183 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES PPO [308136801] 146.4 percent of total billed charges 113.46 173.85 Technical (Hospital) Services "Radiologic Exam, Hip W Pelvis When Performed, Unilateral, 1 View" PX-3207350100 CDM 73501 CPT 320 RC outpatient 183 183 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES EPO [308136803] 146.4 percent of total billed charges 113.46 173.85 Technical (Hospital) Services "Radiologic Exam, Hip W Pelvis When Performed, Unilateral, 1 View" PX-3207350100 CDM 73501 CPT 320 RC outpatient 183 183 UNITED HEALTHCARE (COMMERCIAL) [3081199] UNITED HEALTHCARE 87726 [308119901] 113.46 percent of total billed charges 113.46 173.85 Technical (Hospital) Services MRI Any Jt Upper Extremity W/O Contrast Matrl PX-6107322100 CDM 73221 CPT 610 RC inpatient 2620 2620 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES EPO [308136803] 2074.52 percent of total billed charges 1624.4 2489 Technical (Hospital) Services MRI Any Jt Upper Extremity W/O Contrast Matrl PX-6107322100 CDM 73221 CPT 610 RC inpatient 2620 2620 HEALTHPARTNERS SX009 HEALTHPARTNERS 2074.52 percent of total billed charges 1624.4 2489 Technical (Hospital) Services MRI Any Jt Upper Extremity W/O Contrast Matrl PX-6107322100 CDM 73221 CPT 610 RC inpatient 2620 2620 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES HDHP [308136802] 2074.52 percent of total billed charges 1624.4 2489 Technical (Hospital) Services MRI Any Jt Upper Extremity W/O Contrast Matrl PX-6107322100 CDM 73221 CPT 610 RC inpatient 2620 2620 MEDICA (COMMERCIAL) 94265 [3081118] MEDICA CLAIMS [308111801] 2358 percent of total billed charges 1624.4 2489 Technical (Hospital) Services MRI Any Jt Upper Extremity W/O Contrast Matrl PX-6107322100 CDM 73221 CPT 610 RC inpatient 2620 2620 MULTIPLAN INC 34080 [3081285] MULTIPLAN INC [308128501] 2489 percent of total billed charges 1624.4 2489 Technical (Hospital) Services MRI Any Jt Upper Extremity W/O Contrast Matrl PX-6107322100 CDM 73221 CPT 610 RC inpatient 2620 2620 BLUE CROSS BLUE SHIELD WELLMARK SB889 [3081026] BCBS WYOMING [308102603] 2489 percent of total billed charges 1624.4 2489 Technical (Hospital) Services MRI Any Jt Upper Extremity W/O Contrast Matrl PX-6107322100 CDM 73221 CPT 610 RC inpatient 2620 2620 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES PPO [308136801] 2074.52 percent of total billed charges 1624.4 2489 Technical (Hospital) Services MRI Any Jt Upper Extremity W/O Contrast Matrl PX-6107322100 CDM 73221 CPT 610 RC inpatient 2620 2620 UNITED HEALTHCARE (COMMERCIAL) [3081199] UNITED HEALTHCARE 87726 [308119901] 1624.4 percent of total billed charges 1624.4 2489 Technical (Hospital) Services MRI Any Jt Upper Extremity W/O Contrast Matrl PX-6107322100 CDM 73221 CPT 610 RC inpatient 2620 2620 CIGNA 62308 [3081051] CIGNA 62308 [308105105] 2074.52 percent of total billed charges 1624.4 2489 Technical (Hospital) Services MRI Any Jt Upper Extremity W/O Contrast Matrl PX-6107322100 CDM 73221 CPT 610 RC inpatient 2620 2620 CIGNA 62308 [3081051] CIGNA STATE OF WYOMING [308105107] 2074.52 percent of total billed charges 1624.4 2489 Technical (Hospital) Services MRI Any Jt Upper Extremity W/O Contrast Matrl PX-6107322100 CDM 73221 CPT 610 RC outpatient 2620 2620 HEALTHPARTNERS SX009 HEALTHPARTNERS 2096 percent of total billed charges 1624.4 2489 Technical (Hospital) Services MRI Any Jt Upper Extremity W/O Contrast Matrl PX-6107322100 CDM 73221 CPT 610 RC outpatient 2620 2620 UNITED HEALTHCARE (COMMERCIAL) [3081199] UNITED HEALTHCARE 87726 [308119901] 1624.4 percent of total billed charges 1624.4 2489 Technical (Hospital) Services MRI Any Jt Upper Extremity W/O Contrast Matrl PX-6107322100 CDM 73221 CPT 610 RC outpatient 2620 2620 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES EPO [308136803] 2096 percent of total billed charges 1624.4 2489 Technical (Hospital) Services MRI Any Jt Upper Extremity W/O Contrast Matrl PX-6107322100 CDM 73221 CPT 610 RC outpatient 2620 2620 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES PPO [308136801] 2096 percent of total billed charges 1624.4 2489 Technical (Hospital) Services MRI Any Jt Upper Extremity W/O Contrast Matrl PX-6107322100 CDM 73221 CPT 610 RC outpatient 2620 2620 MULTIPLAN INC 34080 [3081285] MULTIPLAN INC [308128501] 2489 percent of total billed charges 1624.4 2489 Technical (Hospital) Services MRI Any Jt Upper Extremity W/O Contrast Matrl PX-6107322100 CDM 73221 CPT 610 RC outpatient 2620 2620 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES HDHP [308136802] 2096 percent of total billed charges 1624.4 2489 Technical (Hospital) Services MRI Any Jt Upper Extremity W/O Contrast Matrl PX-6107322100 CDM 73221 CPT 610 RC outpatient 2620 2620 BLUE CROSS BLUE SHIELD WELLMARK SB889 [3081026] BCBS WYOMING [308102603] 2489 percent of total billed charges 1624.4 2489 Technical (Hospital) Services MRI Any Jt Upper Extremity W/O Contrast Matrl PX-6107322100 CDM 73221 CPT 610 RC outpatient 2620 2620 CIGNA 62308 [3081051] CIGNA 62308 [308105105] 2096 percent of total billed charges 1624.4 2489 Technical (Hospital) Services MRI Any Jt Upper Extremity W/O Contrast Matrl PX-6107322100 CDM 73221 CPT 610 RC outpatient 2620 2620 CIGNA 62308 [3081051] CIGNA STATE OF WYOMING [308105107] 2096 percent of total billed charges 1624.4 2489 Technical (Hospital) Services MRI Any Jt Upper Extremity W/O Contrast Matrl PX-6107322100 CDM 73221 CPT 610 RC outpatient 2620 2620 MEDICA (COMMERCIAL) 94265 [3081118] MEDICA CLAIMS [308111801] 2358 percent of total billed charges 1624.4 2489 Technical (Hospital) Services MRI Upper Extrem Other Than Jt W/O & W/Contras PX-6107322000 CDM 73220 CPT 610 RC inpatient 4125 4125 HEALTHPARTNERS SX009 HEALTHPARTNERS 3266.18 percent of total billed charges 2557.5 3918.75 Technical (Hospital) Services MRI Upper Extrem Other Than Jt W/O & W/Contras PX-6107322000 CDM 73220 CPT 610 RC inpatient 4125 4125 MEDICA (COMMERCIAL) 94265 [3081118] MEDICA CLAIMS [308111801] 3712.5 percent of total billed charges 2557.5 3918.75 Technical (Hospital) Services MRI Upper Extrem Other Than Jt W/O & W/Contras PX-6107322000 CDM 73220 CPT 610 RC inpatient 4125 4125 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES HDHP [308136802] 3266.18 percent of total billed charges 2557.5 3918.75 Technical (Hospital) Services MRI Upper Extrem Other Than Jt W/O & W/Contras PX-6107322000 CDM 73220 CPT 610 RC inpatient 4125 4125 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES PPO [308136801] 3266.18 percent of total billed charges 2557.5 3918.75 Technical (Hospital) Services MRI Upper Extrem Other Than Jt W/O & W/Contras PX-6107322000 CDM 73220 CPT 610 RC inpatient 4125 4125 UNITED HEALTHCARE (COMMERCIAL) [3081199] UNITED HEALTHCARE 87726 [308119901] 2557.5 percent of total billed charges 2557.5 3918.75 Technical (Hospital) Services MRI Upper Extrem Other Than Jt W/O & W/Contras PX-6107322000 CDM 73220 CPT 610 RC inpatient 4125 4125 MULTIPLAN INC 34080 [3081285] MULTIPLAN INC [308128501] 3918.75 percent of total billed charges 2557.5 3918.75 Technical (Hospital) Services MRI Upper Extrem Other Than Jt W/O & W/Contras PX-6107322000 CDM 73220 CPT 610 RC inpatient 4125 4125 BLUE CROSS BLUE SHIELD WELLMARK SB889 [3081026] BCBS WYOMING [308102603] 3918.75 percent of total billed charges 2557.5 3918.75 Technical (Hospital) Services MRI Upper Extrem Other Than Jt W/O & W/Contras PX-6107322000 CDM 73220 CPT 610 RC inpatient 4125 4125 CIGNA 62308 [3081051] CIGNA 62308 [308105105] 3266.18 percent of total billed charges 2557.5 3918.75 Technical (Hospital) Services MRI Upper Extrem Other Than Jt W/O & W/Contras PX-6107322000 CDM 73220 CPT 610 RC inpatient 4125 4125 CIGNA 62308 [3081051] CIGNA STATE OF WYOMING [308105107] 3266.18 percent of total billed charges 2557.5 3918.75 Technical (Hospital) Services MRI Upper Extrem Other Than Jt W/O & W/Contras PX-6107322000 CDM 73220 CPT 610 RC inpatient 4125 4125 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES EPO [308136803] 3266.18 percent of total billed charges 2557.5 3918.75 Technical (Hospital) Services MRI Upper Extrem Other Than Jt W/O & W/Contras PX-6107322000 CDM 73220 CPT 610 RC outpatient 4125 4125 UNITED HEALTHCARE (COMMERCIAL) [3081199] UNITED HEALTHCARE 87726 [308119901] 2557.5 percent of total billed charges 2557.5 3918.75 Technical (Hospital) Services MRI Upper Extrem Other Than Jt W/O & W/Contras PX-6107322000 CDM 73220 CPT 610 RC outpatient 4125 4125 HEALTHPARTNERS SX009 HEALTHPARTNERS 3300 percent of total billed charges 2557.5 3918.75 Technical (Hospital) Services MRI Upper Extrem Other Than Jt W/O & W/Contras PX-6107322000 CDM 73220 CPT 610 RC outpatient 4125 4125 MULTIPLAN INC 34080 [3081285] MULTIPLAN INC [308128501] 3918.75 percent of total billed charges 2557.5 3918.75 Technical (Hospital) Services MRI Upper Extrem Other Than Jt W/O & W/Contras PX-6107322000 CDM 73220 CPT 610 RC outpatient 4125 4125 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES HDHP [308136802] 3300 percent of total billed charges 2557.5 3918.75 Technical (Hospital) Services MRI Upper Extrem Other Than Jt W/O & W/Contras PX-6107322000 CDM 73220 CPT 610 RC outpatient 4125 4125 BLUE CROSS BLUE SHIELD WELLMARK SB889 [3081026] BCBS WYOMING [308102603] 3918.75 percent of total billed charges 2557.5 3918.75 Technical (Hospital) Services MRI Upper Extrem Other Than Jt W/O & W/Contras PX-6107322000 CDM 73220 CPT 610 RC outpatient 4125 4125 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES PPO [308136801] 3300 percent of total billed charges 2557.5 3918.75 Technical (Hospital) Services MRI Upper Extrem Other Than Jt W/O & W/Contras PX-6107322000 CDM 73220 CPT 610 RC outpatient 4125 4125 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES EPO [308136803] 3300 percent of total billed charges 2557.5 3918.75 Technical (Hospital) Services MRI Upper Extrem Other Than Jt W/O & W/Contras PX-6107322000 CDM 73220 CPT 610 RC outpatient 4125 4125 CIGNA 62308 [3081051] CIGNA 62308 [308105105] 3300 percent of total billed charges 2557.5 3918.75 Technical (Hospital) Services MRI Upper Extrem Other Than Jt W/O & W/Contras PX-6107322000 CDM 73220 CPT 610 RC outpatient 4125 4125 CIGNA 62308 [3081051] CIGNA STATE OF WYOMING [308105107] 3300 percent of total billed charges 2557.5 3918.75 Technical (Hospital) Services MRI Upper Extrem Other Than Jt W/O & W/Contras PX-6107322000 CDM 73220 CPT 610 RC outpatient 4125 4125 MEDICA (COMMERCIAL) 94265 [3081118] MEDICA CLAIMS [308111801] 3712.5 percent of total billed charges 2557.5 3918.75 Technical (Hospital) Services CT Angiography Upper Extremity PX-3527320600 CDM 73206 CPT 352 RC outpatient 2620 2620 HEALTHPARTNERS SX009 HEALTHPARTNERS 2096 percent of total billed charges 1624.4 2489 Technical (Hospital) Services CT Angiography Upper Extremity PX-3527320600 CDM 73206 CPT 352 RC outpatient 2620 2620 UNITED HEALTHCARE (COMMERCIAL) [3081199] UNITED HEALTHCARE 87726 [308119901] 1624.4 percent of total billed charges 1624.4 2489 Technical (Hospital) Services CT Angiography Upper Extremity PX-3527320600 CDM 73206 CPT 352 RC outpatient 2620 2620 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES EPO [308136803] 2096 percent of total billed charges 1624.4 2489 Technical (Hospital) Services CT Angiography Upper Extremity PX-3527320600 CDM 73206 CPT 352 RC outpatient 2620 2620 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES PPO [308136801] 2096 percent of total billed charges 1624.4 2489 Technical (Hospital) Services CT Angiography Upper Extremity PX-3527320600 CDM 73206 CPT 352 RC outpatient 2620 2620 BLUE CROSS BLUE SHIELD WELLMARK SB889 [3081026] BCBS WYOMING [308102603] 2489 percent of total billed charges 1624.4 2489 Technical (Hospital) Services CT Angiography Upper Extremity PX-3527320600 CDM 73206 CPT 352 RC outpatient 2620 2620 MULTIPLAN INC 34080 [3081285] MULTIPLAN INC [308128501] 2489 percent of total billed charges 1624.4 2489 Technical (Hospital) Services CT Angiography Upper Extremity PX-3527320600 CDM 73206 CPT 352 RC outpatient 2620 2620 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES HDHP [308136802] 2096 percent of total billed charges 1624.4 2489 Technical (Hospital) Services CT Angiography Upper Extremity PX-3527320600 CDM 73206 CPT 352 RC outpatient 2620 2620 MEDICA (COMMERCIAL) 94265 [3081118] MEDICA CLAIMS [308111801] 2358 percent of total billed charges 1624.4 2489 Technical (Hospital) Services CT Angiography Upper Extremity PX-3527320600 CDM 73206 CPT 352 RC outpatient 2620 2620 CIGNA 62308 [3081051] CIGNA 62308 [308105105] 2096 percent of total billed charges 1624.4 2489 Technical (Hospital) Services CT Angiography Upper Extremity PX-3527320600 CDM 73206 CPT 352 RC outpatient 2620 2620 CIGNA 62308 [3081051] CIGNA STATE OF WYOMING [308105107] 2096 percent of total billed charges 1624.4 2489 Technical (Hospital) Services CT Angiography Upper Extremity PX-3527320600 CDM 73206 CPT 352 RC inpatient 2620 2620 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES EPO [308136803] 2074.52 percent of total billed charges 1624.4 2489 Technical (Hospital) Services CT Angiography Upper Extremity PX-3527320600 CDM 73206 CPT 352 RC inpatient 2620 2620 CIGNA 62308 [3081051] CIGNA 62308 [308105105] 2074.52 percent of total billed charges 1624.4 2489 Technical (Hospital) Services CT Angiography Upper Extremity PX-3527320600 CDM 73206 CPT 352 RC inpatient 2620 2620 CIGNA 62308 [3081051] CIGNA STATE OF WYOMING [308105107] 2074.52 percent of total billed charges 1624.4 2489 Technical (Hospital) Services CT Angiography Upper Extremity PX-3527320600 CDM 73206 CPT 352 RC inpatient 2620 2620 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES HDHP [308136802] 2074.52 percent of total billed charges 1624.4 2489 Technical (Hospital) Services CT Angiography Upper Extremity PX-3527320600 CDM 73206 CPT 352 RC inpatient 2620 2620 MEDICA (COMMERCIAL) 94265 [3081118] MEDICA CLAIMS [308111801] 2358 percent of total billed charges 1624.4 2489 Technical (Hospital) Services CT Angiography Upper Extremity PX-3527320600 CDM 73206 CPT 352 RC inpatient 2620 2620 HEALTHPARTNERS SX009 HEALTHPARTNERS 2074.52 percent of total billed charges 1624.4 2489 Technical (Hospital) Services CT Angiography Upper Extremity PX-3527320600 CDM 73206 CPT 352 RC inpatient 2620 2620 MULTIPLAN INC 34080 [3081285] MULTIPLAN INC [308128501] 2489 percent of total billed charges 1624.4 2489 Technical (Hospital) Services CT Angiography Upper Extremity PX-3527320600 CDM 73206 CPT 352 RC inpatient 2620 2620 BLUE CROSS BLUE SHIELD WELLMARK SB889 [3081026] BCBS WYOMING [308102603] 2489 percent of total billed charges 1624.4 2489 Technical (Hospital) Services CT Angiography Upper Extremity PX-3527320600 CDM 73206 CPT 352 RC inpatient 2620 2620 UNITED HEALTHCARE (COMMERCIAL) [3081199] UNITED HEALTHCARE 87726 [308119901] 1624.4 percent of total billed charges 1624.4 2489 Technical (Hospital) Services CT Angiography Upper Extremity PX-3527320600 CDM 73206 CPT 352 RC inpatient 2620 2620 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES PPO [308136801] 2074.52 percent of total billed charges 1624.4 2489 Technical (Hospital) Services CT Upper Extremity W/Contrast Material PX-3527320100 CDM 73201 CPT 352 RC outpatient 2292 2292 CIGNA 62308 [3081051] CIGNA 62308 [308105105] 1833.6 percent of total billed charges 1421.04 2177.4 Technical (Hospital) Services CT Upper Extremity W/Contrast Material PX-3527320100 CDM 73201 CPT 352 RC outpatient 2292 2292 CIGNA 62308 [3081051] CIGNA STATE OF WYOMING [308105107] 1833.6 percent of total billed charges 1421.04 2177.4 Technical (Hospital) Services CT Upper Extremity W/Contrast Material PX-3527320100 CDM 73201 CPT 352 RC outpatient 2292 2292 MEDICA (COMMERCIAL) 94265 [3081118] MEDICA CLAIMS [308111801] 2062.8 percent of total billed charges 1421.04 2177.4 Technical (Hospital) Services CT Upper Extremity W/Contrast Material PX-3527320100 CDM 73201 CPT 352 RC outpatient 2292 2292 HEALTHPARTNERS SX009 HEALTHPARTNERS 1833.6 percent of total billed charges 1421.04 2177.4 Technical (Hospital) Services CT Upper Extremity W/Contrast Material PX-3527320100 CDM 73201 CPT 352 RC outpatient 2292 2292 UNITED HEALTHCARE (COMMERCIAL) [3081199] UNITED HEALTHCARE 87726 [308119901] 1421.04 percent of total billed charges 1421.04 2177.4 Technical (Hospital) Services CT Upper Extremity W/Contrast Material PX-3527320100 CDM 73201 CPT 352 RC outpatient 2292 2292 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES PPO [308136801] 1833.6 percent of total billed charges 1421.04 2177.4 Technical (Hospital) Services CT Upper Extremity W/Contrast Material PX-3527320100 CDM 73201 CPT 352 RC outpatient 2292 2292 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES EPO [308136803] 1833.6 percent of total billed charges 1421.04 2177.4 Technical (Hospital) Services CT Upper Extremity W/Contrast Material PX-3527320100 CDM 73201 CPT 352 RC outpatient 2292 2292 BLUE CROSS BLUE SHIELD WELLMARK SB889 [3081026] BCBS WYOMING [308102603] 2177.4 percent of total billed charges 1421.04 2177.4 Technical (Hospital) Services CT Upper Extremity W/Contrast Material PX-3527320100 CDM 73201 CPT 352 RC outpatient 2292 2292 MULTIPLAN INC 34080 [3081285] MULTIPLAN INC [308128501] 2177.4 percent of total billed charges 1421.04 2177.4 Technical (Hospital) Services CT Upper Extremity W/Contrast Material PX-3527320100 CDM 73201 CPT 352 RC outpatient 2292 2292 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES HDHP [308136802] 1833.6 percent of total billed charges 1421.04 2177.4 Technical (Hospital) Services CT Upper Extremity W/Contrast Material PX-3527320100 CDM 73201 CPT 352 RC inpatient 2292 2292 MULTIPLAN INC 34080 [3081285] MULTIPLAN INC [308128501] 2177.4 percent of total billed charges 1421.04 2177.4 Technical (Hospital) Services CT Upper Extremity W/Contrast Material PX-3527320100 CDM 73201 CPT 352 RC inpatient 2292 2292 BLUE CROSS BLUE SHIELD WELLMARK SB889 [3081026] BCBS WYOMING [308102603] 2177.4 percent of total billed charges 1421.04 2177.4 Technical (Hospital) Services CT Upper Extremity W/Contrast Material PX-3527320100 CDM 73201 CPT 352 RC inpatient 2292 2292 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES PPO [308136801] 1814.81 percent of total billed charges 1421.04 2177.4 Technical (Hospital) Services CT Upper Extremity W/Contrast Material PX-3527320100 CDM 73201 CPT 352 RC inpatient 2292 2292 UNITED HEALTHCARE (COMMERCIAL) [3081199] UNITED HEALTHCARE 87726 [308119901] 1421.04 percent of total billed charges 1421.04 2177.4 Technical (Hospital) Services CT Upper Extremity W/Contrast Material PX-3527320100 CDM 73201 CPT 352 RC inpatient 2292 2292 HEALTHPARTNERS SX009 HEALTHPARTNERS 1814.81 percent of total billed charges 1421.04 2177.4 Technical (Hospital) Services CT Upper Extremity W/Contrast Material PX-3527320100 CDM 73201 CPT 352 RC inpatient 2292 2292 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES HDHP [308136802] 1814.81 percent of total billed charges 1421.04 2177.4 Technical (Hospital) Services CT Upper Extremity W/Contrast Material PX-3527320100 CDM 73201 CPT 352 RC inpatient 2292 2292 MEDICA (COMMERCIAL) 94265 [3081118] MEDICA CLAIMS [308111801] 2062.8 percent of total billed charges 1421.04 2177.4 Technical (Hospital) Services CT Upper Extremity W/Contrast Material PX-3527320100 CDM 73201 CPT 352 RC inpatient 2292 2292 CIGNA 62308 [3081051] CIGNA 62308 [308105105] 1814.81 percent of total billed charges 1421.04 2177.4 Technical (Hospital) Services CT Upper Extremity W/Contrast Material PX-3527320100 CDM 73201 CPT 352 RC inpatient 2292 2292 CIGNA 62308 [3081051] CIGNA STATE OF WYOMING [308105107] 1814.81 percent of total billed charges 1421.04 2177.4 Technical (Hospital) Services CT Upper Extremity W/Contrast Material PX-3527320100 CDM 73201 CPT 352 RC inpatient 2292 2292 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES EPO [308136803] 1814.81 percent of total billed charges 1421.04 2177.4 Technical (Hospital) Services CT Upper Extremity W/O Contrast Material PX-3527320000 CDM 73200 CPT 352 RC outpatient 1638 1638 CIGNA 62308 [3081051] CIGNA 62308 [308105105] 1310.4 percent of total billed charges 1015.56 1556.1 Technical (Hospital) Services CT Upper Extremity W/O Contrast Material PX-3527320000 CDM 73200 CPT 352 RC outpatient 1638 1638 CIGNA 62308 [3081051] CIGNA STATE OF WYOMING [308105107] 1310.4 percent of total billed charges 1015.56 1556.1 Technical (Hospital) Services CT Upper Extremity W/O Contrast Material PX-3527320000 CDM 73200 CPT 352 RC outpatient 1638 1638 MEDICA (COMMERCIAL) 94265 [3081118] MEDICA CLAIMS [308111801] 1474.2 percent of total billed charges 1015.56 1556.1 Technical (Hospital) Services CT Upper Extremity W/O Contrast Material PX-3527320000 CDM 73200 CPT 352 RC outpatient 1638 1638 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES EPO [308136803] 1310.4 percent of total billed charges 1015.56 1556.1 Technical (Hospital) Services CT Upper Extremity W/O Contrast Material PX-3527320000 CDM 73200 CPT 352 RC outpatient 1638 1638 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES PPO [308136801] 1310.4 percent of total billed charges 1015.56 1556.1 Technical (Hospital) Services CT Upper Extremity W/O Contrast Material PX-3527320000 CDM 73200 CPT 352 RC outpatient 1638 1638 UNITED HEALTHCARE (COMMERCIAL) [3081199] UNITED HEALTHCARE 87726 [308119901] 1015.56 percent of total billed charges 1015.56 1556.1 Technical (Hospital) Services CT Upper Extremity W/O Contrast Material PX-3527320000 CDM 73200 CPT 352 RC outpatient 1638 1638 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES HDHP [308136802] 1310.4 percent of total billed charges 1015.56 1556.1 Technical (Hospital) Services CT Upper Extremity W/O Contrast Material PX-3527320000 CDM 73200 CPT 352 RC outpatient 1638 1638 MULTIPLAN INC 34080 [3081285] MULTIPLAN INC [308128501] 1556.1 percent of total billed charges 1015.56 1556.1 Technical (Hospital) Services CT Upper Extremity W/O Contrast Material PX-3527320000 CDM 73200 CPT 352 RC outpatient 1638 1638 BLUE CROSS BLUE SHIELD WELLMARK SB889 [3081026] BCBS WYOMING [308102603] 1556.1 percent of total billed charges 1015.56 1556.1 Technical (Hospital) Services CT Upper Extremity W/O Contrast Material PX-3527320000 CDM 73200 CPT 352 RC outpatient 1638 1638 HEALTHPARTNERS SX009 HEALTHPARTNERS 1310.4 percent of total billed charges 1015.56 1556.1 Technical (Hospital) Services CT Upper Extremity W/O Contrast Material PX-3527320000 CDM 73200 CPT 352 RC inpatient 1638 1638 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES EPO [308136803] 1296.97 percent of total billed charges 1015.56 1556.1 Technical (Hospital) Services CT Upper Extremity W/O Contrast Material PX-3527320000 CDM 73200 CPT 352 RC inpatient 1638 1638 CIGNA 62308 [3081051] CIGNA 62308 [308105105] 1296.97 percent of total billed charges 1015.56 1556.1 Technical (Hospital) Services CT Upper Extremity W/O Contrast Material PX-3527320000 CDM 73200 CPT 352 RC inpatient 1638 1638 CIGNA 62308 [3081051] CIGNA STATE OF WYOMING [308105107] 1296.97 percent of total billed charges 1015.56 1556.1 Technical (Hospital) Services CT Upper Extremity W/O Contrast Material PX-3527320000 CDM 73200 CPT 352 RC inpatient 1638 1638 HEALTHPARTNERS SX009 HEALTHPARTNERS 1296.97 percent of total billed charges 1015.56 1556.1 Technical (Hospital) Services CT Upper Extremity W/O Contrast Material PX-3527320000 CDM 73200 CPT 352 RC inpatient 1638 1638 MEDICA (COMMERCIAL) 94265 [3081118] MEDICA CLAIMS [308111801] 1474.2 percent of total billed charges 1015.56 1556.1 Technical (Hospital) Services CT Upper Extremity W/O Contrast Material PX-3527320000 CDM 73200 CPT 352 RC inpatient 1638 1638 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES HDHP [308136802] 1296.97 percent of total billed charges 1015.56 1556.1 Technical (Hospital) Services CT Upper Extremity W/O Contrast Material PX-3527320000 CDM 73200 CPT 352 RC inpatient 1638 1638 UNITED HEALTHCARE (COMMERCIAL) [3081199] UNITED HEALTHCARE 87726 [308119901] 1015.56 percent of total billed charges 1015.56 1556.1 Technical (Hospital) Services CT Upper Extremity W/O Contrast Material PX-3527320000 CDM 73200 CPT 352 RC inpatient 1638 1638 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES PPO [308136801] 1296.97 percent of total billed charges 1015.56 1556.1 Technical (Hospital) Services CT Upper Extremity W/O Contrast Material PX-3527320000 CDM 73200 CPT 352 RC inpatient 1638 1638 BLUE CROSS BLUE SHIELD WELLMARK SB889 [3081026] BCBS WYOMING [308102603] 1556.1 percent of total billed charges 1015.56 1556.1 Technical (Hospital) Services CT Upper Extremity W/O Contrast Material PX-3527320000 CDM 73200 CPT 352 RC inpatient 1638 1638 MULTIPLAN INC 34080 [3081285] MULTIPLAN INC [308128501] 1556.1 percent of total billed charges 1015.56 1556.1 Technical (Hospital) Services Radex Fingr Minimum 2 Views PX-3207314000 CDM 73140 CPT 320 RC inpatient 147 147 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES EPO [308136803] 116.39 percent of total billed charges 91.14 139.65 Technical (Hospital) Services Radex Fingr Minimum 2 Views PX-3207314000 CDM 73140 CPT 320 RC inpatient 147 147 CIGNA 62308 [3081051] CIGNA 62308 [308105105] 116.39 percent of total billed charges 91.14 139.65 Technical (Hospital) Services Radex Fingr Minimum 2 Views PX-3207314000 CDM 73140 CPT 320 RC inpatient 147 147 CIGNA 62308 [3081051] CIGNA STATE OF WYOMING [308105107] 116.39 percent of total billed charges 91.14 139.65 Technical (Hospital) Services Radex Fingr Minimum 2 Views PX-3207314000 CDM 73140 CPT 320 RC inpatient 147 147 MULTIPLAN INC 34080 [3081285] MULTIPLAN INC [308128501] 139.65 percent of total billed charges 91.14 139.65 Technical (Hospital) Services Radex Fingr Minimum 2 Views PX-3207314000 CDM 73140 CPT 320 RC inpatient 147 147 BLUE CROSS BLUE SHIELD WELLMARK SB889 [3081026] BCBS WYOMING [308102603] 139.65 percent of total billed charges 91.14 139.65 Technical (Hospital) Services Radex Fingr Minimum 2 Views PX-3207314000 CDM 73140 CPT 320 RC inpatient 147 147 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES PPO [308136801] 116.39 percent of total billed charges 91.14 139.65 Technical (Hospital) Services Radex Fingr Minimum 2 Views PX-3207314000 CDM 73140 CPT 320 RC inpatient 147 147 UNITED HEALTHCARE (COMMERCIAL) [3081199] UNITED HEALTHCARE 87726 [308119901] 91.14 percent of total billed charges 91.14 139.65 Technical (Hospital) Services Radex Fingr Minimum 2 Views PX-3207314000 CDM 73140 CPT 320 RC inpatient 147 147 HEALTHPARTNERS SX009 HEALTHPARTNERS 116.39 percent of total billed charges 91.14 139.65 Technical (Hospital) Services Radex Fingr Minimum 2 Views PX-3207314000 CDM 73140 CPT 320 RC inpatient 147 147 MEDICA (COMMERCIAL) 94265 [3081118] MEDICA CLAIMS [308111801] 132.3 percent of total billed charges 91.14 139.65 Technical (Hospital) Services Radex Fingr Minimum 2 Views PX-3207314000 CDM 73140 CPT 320 RC inpatient 147 147 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES HDHP [308136802] 116.39 percent of total billed charges 91.14 139.65 Technical (Hospital) Services Radex Fingr Minimum 2 Views PX-3207314000 CDM 73140 CPT 320 RC outpatient 147 147 HEALTHPARTNERS SX009 HEALTHPARTNERS 117.6 percent of total billed charges 91.14 139.65 Technical (Hospital) Services Radex Fingr Minimum 2 Views PX-3207314000 CDM 73140 CPT 320 RC outpatient 147 147 UNITED HEALTHCARE (COMMERCIAL) [3081199] UNITED HEALTHCARE 87726 [308119901] 91.14 percent of total billed charges 91.14 139.65 Technical (Hospital) Services Radex Fingr Minimum 2 Views PX-3207314000 CDM 73140 CPT 320 RC outpatient 147 147 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES EPO [308136803] 117.6 percent of total billed charges 91.14 139.65 Technical (Hospital) Services Radex Fingr Minimum 2 Views PX-3207314000 CDM 73140 CPT 320 RC outpatient 147 147 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES PPO [308136801] 117.6 percent of total billed charges 91.14 139.65 Technical (Hospital) Services Radex Fingr Minimum 2 Views PX-3207314000 CDM 73140 CPT 320 RC outpatient 147 147 BLUE CROSS BLUE SHIELD WELLMARK SB889 [3081026] BCBS WYOMING [308102603] 139.65 percent of total billed charges 91.14 139.65 Technical (Hospital) Services Radex Fingr Minimum 2 Views PX-3207314000 CDM 73140 CPT 320 RC outpatient 147 147 MULTIPLAN INC 34080 [3081285] MULTIPLAN INC [308128501] 139.65 percent of total billed charges 91.14 139.65 Technical (Hospital) Services Radex Fingr Minimum 2 Views PX-3207314000 CDM 73140 CPT 320 RC outpatient 147 147 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES HDHP [308136802] 117.6 percent of total billed charges 91.14 139.65 Technical (Hospital) Services Radex Fingr Minimum 2 Views PX-3207314000 CDM 73140 CPT 320 RC outpatient 147 147 MEDICA (COMMERCIAL) 94265 [3081118] MEDICA CLAIMS [308111801] 132.3 percent of total billed charges 91.14 139.65 Technical (Hospital) Services Radex Fingr Minimum 2 Views PX-3207314000 CDM 73140 CPT 320 RC outpatient 147 147 CIGNA 62308 [3081051] CIGNA 62308 [308105105] 117.6 percent of total billed charges 91.14 139.65 Technical (Hospital) Services Radex Fingr Minimum 2 Views PX-3207314000 CDM 73140 CPT 320 RC outpatient 147 147 CIGNA 62308 [3081051] CIGNA STATE OF WYOMING [308105107] 117.6 percent of total billed charges 91.14 139.65 Technical (Hospital) Services Radex Hand Minimum 3 Views PX-3207313000 CDM 73130 CPT 320 RC inpatient 198 198 CIGNA 62308 [3081051] CIGNA 62308 [308105105] 156.78 percent of total billed charges 122.76 188.1 Technical (Hospital) Services Radex Hand Minimum 3 Views PX-3207313000 CDM 73130 CPT 320 RC inpatient 198 198 CIGNA 62308 [3081051] CIGNA STATE OF WYOMING [308105107] 156.78 percent of total billed charges 122.76 188.1 Technical (Hospital) Services Radex Hand Minimum 3 Views PX-3207313000 CDM 73130 CPT 320 RC inpatient 198 198 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES EPO [308136803] 156.78 percent of total billed charges 122.76 188.1 Technical (Hospital) Services Radex Hand Minimum 3 Views PX-3207313000 CDM 73130 CPT 320 RC inpatient 198 198 BLUE CROSS BLUE SHIELD WELLMARK SB889 [3081026] BCBS WYOMING [308102603] 188.1 percent of total billed charges 122.76 188.1 Technical (Hospital) Services Radex Hand Minimum 3 Views PX-3207313000 CDM 73130 CPT 320 RC inpatient 198 198 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES PPO [308136801] 156.78 percent of total billed charges 122.76 188.1 Technical (Hospital) Services Radex Hand Minimum 3 Views PX-3207313000 CDM 73130 CPT 320 RC inpatient 198 198 MULTIPLAN INC 34080 [3081285] MULTIPLAN INC [308128501] 188.1 percent of total billed charges 122.76 188.1 Technical (Hospital) Services Radex Hand Minimum 3 Views PX-3207313000 CDM 73130 CPT 320 RC inpatient 198 198 UNITED HEALTHCARE (COMMERCIAL) [3081199] UNITED HEALTHCARE 87726 [308119901] 122.76 percent of total billed charges 122.76 188.1 Technical (Hospital) Services Radex Hand Minimum 3 Views PX-3207313000 CDM 73130 CPT 320 RC inpatient 198 198 HEALTHPARTNERS SX009 HEALTHPARTNERS 156.78 percent of total billed charges 122.76 188.1 Technical (Hospital) Services Radex Hand Minimum 3 Views PX-3207313000 CDM 73130 CPT 320 RC inpatient 198 198 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES HDHP [308136802] 156.78 percent of total billed charges 122.76 188.1 Technical (Hospital) Services Radex Hand Minimum 3 Views PX-3207313000 CDM 73130 CPT 320 RC inpatient 198 198 MEDICA (COMMERCIAL) 94265 [3081118] MEDICA CLAIMS [308111801] 178.2 percent of total billed charges 122.76 188.1 Technical (Hospital) Services Radex Hand Minimum 3 Views PX-3207313000 CDM 73130 CPT 320 RC outpatient 198 198 CIGNA 62308 [3081051] CIGNA 62308 [308105105] 158.4 percent of total billed charges 122.76 188.1 Technical (Hospital) Services Radex Hand Minimum 3 Views PX-3207313000 CDM 73130 CPT 320 RC outpatient 198 198 CIGNA 62308 [3081051] CIGNA STATE OF WYOMING [308105107] 158.4 percent of total billed charges 122.76 188.1 Technical (Hospital) Services Radex Hand Minimum 3 Views PX-3207313000 CDM 73130 CPT 320 RC outpatient 198 198 MEDICA (COMMERCIAL) 94265 [3081118] MEDICA CLAIMS [308111801] 178.2 percent of total billed charges 122.76 188.1 Technical (Hospital) Services Radex Hand Minimum 3 Views PX-3207313000 CDM 73130 CPT 320 RC outpatient 198 198 HEALTHPARTNERS SX009 HEALTHPARTNERS 158.4 percent of total billed charges 122.76 188.1 Technical (Hospital) Services Radex Hand Minimum 3 Views PX-3207313000 CDM 73130 CPT 320 RC outpatient 198 198 BLUE CROSS BLUE SHIELD WELLMARK SB889 [3081026] BCBS WYOMING [308102603] 188.1 percent of total billed charges 122.76 188.1 Technical (Hospital) Services Radex Hand Minimum 3 Views PX-3207313000 CDM 73130 CPT 320 RC outpatient 198 198 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES HDHP [308136802] 158.4 percent of total billed charges 122.76 188.1 Technical (Hospital) Services Radex Hand Minimum 3 Views PX-3207313000 CDM 73130 CPT 320 RC outpatient 198 198 MULTIPLAN INC 34080 [3081285] MULTIPLAN INC [308128501] 188.1 percent of total billed charges 122.76 188.1 Technical (Hospital) Services Radex Hand Minimum 3 Views PX-3207313000 CDM 73130 CPT 320 RC outpatient 198 198 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES PPO [308136801] 158.4 percent of total billed charges 122.76 188.1 Technical (Hospital) Services Radex Hand Minimum 3 Views PX-3207313000 CDM 73130 CPT 320 RC outpatient 198 198 UNITED HEALTHCARE (COMMERCIAL) [3081199] UNITED HEALTHCARE 87726 [308119901] 122.76 percent of total billed charges 122.76 188.1 Technical (Hospital) Services Radex Hand Minimum 3 Views PX-3207313000 CDM 73130 CPT 320 RC outpatient 198 198 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES EPO [308136803] 158.4 percent of total billed charges 122.76 188.1 Technical (Hospital) Services Radex Hand 2 Views PX-3207312000 CDM 73120 CPT 320 RC outpatient 172 172 MEDICA (COMMERCIAL) 94265 [3081118] MEDICA CLAIMS [308111801] 154.8 percent of total billed charges 106.64 163.4 Technical (Hospital) Services Radex Hand 2 Views PX-3207312000 CDM 73120 CPT 320 RC outpatient 172 172 CIGNA 62308 [3081051] CIGNA 62308 [308105105] 137.6 percent of total billed charges 106.64 163.4 Technical (Hospital) Services Radex Hand 2 Views PX-3207312000 CDM 73120 CPT 320 RC outpatient 172 172 CIGNA 62308 [3081051] CIGNA STATE OF WYOMING [308105107] 137.6 percent of total billed charges 106.64 163.4 Technical (Hospital) Services Radex Hand 2 Views PX-3207312000 CDM 73120 CPT 320 RC outpatient 172 172 BLUE CROSS BLUE SHIELD WELLMARK SB889 [3081026] BCBS WYOMING [308102603] 163.4 percent of total billed charges 106.64 163.4 Technical (Hospital) Services Radex Hand 2 Views PX-3207312000 CDM 73120 CPT 320 RC outpatient 172 172 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES HDHP [308136802] 137.6 percent of total billed charges 106.64 163.4 Technical (Hospital) Services Radex Hand 2 Views PX-3207312000 CDM 73120 CPT 320 RC outpatient 172 172 MULTIPLAN INC 34080 [3081285] MULTIPLAN INC [308128501] 163.4 percent of total billed charges 106.64 163.4 Technical (Hospital) Services Radex Hand 2 Views PX-3207312000 CDM 73120 CPT 320 RC outpatient 172 172 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES EPO [308136803] 137.6 percent of total billed charges 106.64 163.4 Technical (Hospital) Services Radex Hand 2 Views PX-3207312000 CDM 73120 CPT 320 RC outpatient 172 172 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES PPO [308136801] 137.6 percent of total billed charges 106.64 163.4 Technical (Hospital) Services Radex Hand 2 Views PX-3207312000 CDM 73120 CPT 320 RC outpatient 172 172 UNITED HEALTHCARE (COMMERCIAL) [3081199] UNITED HEALTHCARE 87726 [308119901] 106.64 percent of total billed charges 106.64 163.4 Technical (Hospital) Services Radex Hand 2 Views PX-3207312000 CDM 73120 CPT 320 RC outpatient 172 172 HEALTHPARTNERS SX009 HEALTHPARTNERS 137.6 percent of total billed charges 106.64 163.4 Technical (Hospital) Services Radex Hand 2 Views PX-3207312000 CDM 73120 CPT 320 RC inpatient 172 172 CIGNA 62308 [3081051] CIGNA 62308 [308105105] 136.19 percent of total billed charges 106.64 163.4 Technical (Hospital) Services Radex Hand 2 Views PX-3207312000 CDM 73120 CPT 320 RC inpatient 172 172 CIGNA 62308 [3081051] CIGNA STATE OF WYOMING [308105107] 136.19 percent of total billed charges 106.64 163.4 Technical (Hospital) Services Radex Hand 2 Views PX-3207312000 CDM 73120 CPT 320 RC inpatient 172 172 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES EPO [308136803] 136.19 percent of total billed charges 106.64 163.4 Technical (Hospital) Services Radex Hand 2 Views PX-3207312000 CDM 73120 CPT 320 RC inpatient 172 172 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES PPO [308136801] 136.19 percent of total billed charges 106.64 163.4 Technical (Hospital) Services Radex Hand 2 Views PX-3207312000 CDM 73120 CPT 320 RC inpatient 172 172 BLUE CROSS BLUE SHIELD WELLMARK SB889 [3081026] BCBS WYOMING [308102603] 163.4 percent of total billed charges 106.64 163.4 Technical (Hospital) Services Radex Hand 2 Views PX-3207312000 CDM 73120 CPT 320 RC inpatient 172 172 MULTIPLAN INC 34080 [3081285] MULTIPLAN INC [308128501] 163.4 percent of total billed charges 106.64 163.4 Technical (Hospital) Services Radex Hand 2 Views PX-3207312000 CDM 73120 CPT 320 RC inpatient 172 172 UNITED HEALTHCARE (COMMERCIAL) [3081199] UNITED HEALTHCARE 87726 [308119901] 106.64 percent of total billed charges 106.64 163.4 Technical (Hospital) Services Radex Hand 2 Views PX-3207312000 CDM 73120 CPT 320 RC inpatient 172 172 HEALTHPARTNERS SX009 HEALTHPARTNERS 136.19 percent of total billed charges 106.64 163.4 Technical (Hospital) Services Radex Hand 2 Views PX-3207312000 CDM 73120 CPT 320 RC inpatient 172 172 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES HDHP [308136802] 136.19 percent of total billed charges 106.64 163.4 Technical (Hospital) Services Radex Hand 2 Views PX-3207312000 CDM 73120 CPT 320 RC inpatient 172 172 MEDICA (COMMERCIAL) 94265 [3081118] MEDICA CLAIMS [308111801] 154.8 percent of total billed charges 106.64 163.4 Technical (Hospital) Services Radex Wrist Complete Minimum 3 Views PX-3207311000 CDM 73110 CPT 320 RC outpatient 419 419 MEDICA (COMMERCIAL) 94265 [3081118] MEDICA CLAIMS [308111801] 377.1 percent of total billed charges 259.78 398.05 Technical (Hospital) Services Radex Wrist Complete Minimum 3 Views PX-3207311000 CDM 73110 CPT 320 RC outpatient 419 419 CIGNA 62308 [3081051] CIGNA 62308 [308105105] 335.2 percent of total billed charges 259.78 398.05 Technical (Hospital) Services Radex Wrist Complete Minimum 3 Views PX-3207311000 CDM 73110 CPT 320 RC outpatient 419 419 CIGNA 62308 [3081051] CIGNA STATE OF WYOMING [308105107] 335.2 percent of total billed charges 259.78 398.05 Technical (Hospital) Services Radex Wrist Complete Minimum 3 Views PX-3207311000 CDM 73110 CPT 320 RC outpatient 419 419 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES HDHP [308136802] 335.2 percent of total billed charges 259.78 398.05 Technical (Hospital) Services Radex Wrist Complete Minimum 3 Views PX-3207311000 CDM 73110 CPT 320 RC outpatient 419 419 MULTIPLAN INC 34080 [3081285] MULTIPLAN INC [308128501] 398.05 percent of total billed charges 259.78 398.05 Technical (Hospital) Services Radex Wrist Complete Minimum 3 Views PX-3207311000 CDM 73110 CPT 320 RC outpatient 419 419 BLUE CROSS BLUE SHIELD WELLMARK SB889 [3081026] BCBS WYOMING [308102603] 398.05 percent of total billed charges 259.78 398.05 Technical (Hospital) Services Radex Wrist Complete Minimum 3 Views PX-3207311000 CDM 73110 CPT 320 RC outpatient 419 419 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES EPO [308136803] 335.2 percent of total billed charges 259.78 398.05 Technical (Hospital) Services Radex Wrist Complete Minimum 3 Views PX-3207311000 CDM 73110 CPT 320 RC outpatient 419 419 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES PPO [308136801] 335.2 percent of total billed charges 259.78 398.05 Technical (Hospital) Services Radex Wrist Complete Minimum 3 Views PX-3207311000 CDM 73110 CPT 320 RC outpatient 419 419 HEALTHPARTNERS SX009 HEALTHPARTNERS 335.2 percent of total billed charges 259.78 398.05 Technical (Hospital) Services Radex Wrist Complete Minimum 3 Views PX-3207311000 CDM 73110 CPT 320 RC outpatient 419 419 UNITED HEALTHCARE (COMMERCIAL) [3081199] UNITED HEALTHCARE 87726 [308119901] 259.78 percent of total billed charges 259.78 398.05 Technical (Hospital) Services Radex Wrist Complete Minimum 3 Views PX-3207311000 CDM 73110 CPT 320 RC inpatient 419 419 UNITED HEALTHCARE (COMMERCIAL) [3081199] UNITED HEALTHCARE 87726 [308119901] 259.78 percent of total billed charges 259.78 398.05 Technical (Hospital) Services Radex Wrist Complete Minimum 3 Views PX-3207311000 CDM 73110 CPT 320 RC inpatient 419 419 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES PPO [308136801] 331.76 percent of total billed charges 259.78 398.05 Technical (Hospital) Services Radex Wrist Complete Minimum 3 Views PX-3207311000 CDM 73110 CPT 320 RC inpatient 419 419 BLUE CROSS BLUE SHIELD WELLMARK SB889 [3081026] BCBS WYOMING [308102603] 398.05 percent of total billed charges 259.78 398.05 Technical (Hospital) Services Radex Wrist Complete Minimum 3 Views PX-3207311000 CDM 73110 CPT 320 RC inpatient 419 419 MULTIPLAN INC 34080 [3081285] MULTIPLAN INC [308128501] 398.05 percent of total billed charges 259.78 398.05 Technical (Hospital) Services Radex Wrist Complete Minimum 3 Views PX-3207311000 CDM 73110 CPT 320 RC inpatient 419 419 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES HDHP [308136802] 331.76 percent of total billed charges 259.78 398.05 Technical (Hospital) Services Radex Wrist Complete Minimum 3 Views PX-3207311000 CDM 73110 CPT 320 RC inpatient 419 419 MEDICA (COMMERCIAL) 94265 [3081118] MEDICA CLAIMS [308111801] 377.1 percent of total billed charges 259.78 398.05 Technical (Hospital) Services Radex Wrist Complete Minimum 3 Views PX-3207311000 CDM 73110 CPT 320 RC inpatient 419 419 HEALTHPARTNERS SX009 HEALTHPARTNERS 331.76 percent of total billed charges 259.78 398.05 Technical (Hospital) Services Radex Wrist Complete Minimum 3 Views PX-3207311000 CDM 73110 CPT 320 RC inpatient 419 419 CIGNA 62308 [3081051] CIGNA 62308 [308105105] 331.76 percent of total billed charges 259.78 398.05 Technical (Hospital) Services Radex Wrist Complete Minimum 3 Views PX-3207311000 CDM 73110 CPT 320 RC inpatient 419 419 CIGNA 62308 [3081051] CIGNA STATE OF WYOMING [308105107] 331.76 percent of total billed charges 259.78 398.05 Technical (Hospital) Services Radex Wrist Complete Minimum 3 Views PX-3207311000 CDM 73110 CPT 320 RC inpatient 419 419 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES EPO [308136803] 331.76 percent of total billed charges 259.78 398.05 Technical (Hospital) Services Radex Wrist 2 Views PX-3207310000 CDM 73100 CPT 320 RC outpatient 284 284 MEDICA (COMMERCIAL) 94265 [3081118] MEDICA CLAIMS [308111801] 255.6 percent of total billed charges 176.08 269.8 Technical (Hospital) Services Radex Wrist 2 Views PX-3207310000 CDM 73100 CPT 320 RC outpatient 284 284 CIGNA 62308 [3081051] CIGNA 62308 [308105105] 227.2 percent of total billed charges 176.08 269.8 Technical (Hospital) Services Radex Wrist 2 Views PX-3207310000 CDM 73100 CPT 320 RC outpatient 284 284 CIGNA 62308 [3081051] CIGNA STATE OF WYOMING [308105107] 227.2 percent of total billed charges 176.08 269.8 Technical (Hospital) Services Radex Wrist 2 Views PX-3207310000 CDM 73100 CPT 320 RC outpatient 284 284 UNITED HEALTHCARE (COMMERCIAL) [3081199] UNITED HEALTHCARE 87726 [308119901] 176.08 percent of total billed charges 176.08 269.8 Technical (Hospital) Services Radex Wrist 2 Views PX-3207310000 CDM 73100 CPT 320 RC outpatient 284 284 HEALTHPARTNERS SX009 HEALTHPARTNERS 227.2 percent of total billed charges 176.08 269.8 Technical (Hospital) Services Radex Wrist 2 Views PX-3207310000 CDM 73100 CPT 320 RC outpatient 284 284 BLUE CROSS BLUE SHIELD WELLMARK SB889 [3081026] BCBS WYOMING [308102603] 269.8 percent of total billed charges 176.08 269.8 Technical (Hospital) Services Radex Wrist 2 Views PX-3207310000 CDM 73100 CPT 320 RC outpatient 284 284 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES HDHP [308136802] 227.2 percent of total billed charges 176.08 269.8 Technical (Hospital) Services Radex Wrist 2 Views PX-3207310000 CDM 73100 CPT 320 RC outpatient 284 284 MULTIPLAN INC 34080 [3081285] MULTIPLAN INC [308128501] 269.8 percent of total billed charges 176.08 269.8 Technical (Hospital) Services Radex Wrist 2 Views PX-3207310000 CDM 73100 CPT 320 RC outpatient 284 284 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES EPO [308136803] 227.2 percent of total billed charges 176.08 269.8 Technical (Hospital) Services Radex Wrist 2 Views PX-3207310000 CDM 73100 CPT 320 RC outpatient 284 284 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES PPO [308136801] 227.2 percent of total billed charges 176.08 269.8 Technical (Hospital) Services Radex Wrist 2 Views PX-3207310000 CDM 73100 CPT 320 RC inpatient 284 284 MULTIPLAN INC 34080 [3081285] MULTIPLAN INC [308128501] 269.8 percent of total billed charges 176.08 269.8 Technical (Hospital) Services Radex Wrist 2 Views PX-3207310000 CDM 73100 CPT 320 RC inpatient 284 284 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES PPO [308136801] 224.87 percent of total billed charges 176.08 269.8 Technical (Hospital) Services Radex Wrist 2 Views PX-3207310000 CDM 73100 CPT 320 RC inpatient 284 284 BLUE CROSS BLUE SHIELD WELLMARK SB889 [3081026] BCBS WYOMING [308102603] 269.8 percent of total billed charges 176.08 269.8 Technical (Hospital) Services Radex Wrist 2 Views PX-3207310000 CDM 73100 CPT 320 RC inpatient 284 284 UNITED HEALTHCARE (COMMERCIAL) [3081199] UNITED HEALTHCARE 87726 [308119901] 176.08 percent of total billed charges 176.08 269.8 Technical (Hospital) Services Radex Wrist 2 Views PX-3207310000 CDM 73100 CPT 320 RC inpatient 284 284 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES HDHP [308136802] 224.87 percent of total billed charges 176.08 269.8 Technical (Hospital) Services Radex Wrist 2 Views PX-3207310000 CDM 73100 CPT 320 RC inpatient 284 284 MEDICA (COMMERCIAL) 94265 [3081118] MEDICA CLAIMS [308111801] 255.6 percent of total billed charges 176.08 269.8 Technical (Hospital) Services Radex Wrist 2 Views PX-3207310000 CDM 73100 CPT 320 RC inpatient 284 284 HEALTHPARTNERS SX009 HEALTHPARTNERS 224.87 percent of total billed charges 176.08 269.8 Technical (Hospital) Services Radex Wrist 2 Views PX-3207310000 CDM 73100 CPT 320 RC inpatient 284 284 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES EPO [308136803] 224.87 percent of total billed charges 176.08 269.8 Technical (Hospital) Services Radex Wrist 2 Views PX-3207310000 CDM 73100 CPT 320 RC inpatient 284 284 CIGNA 62308 [3081051] CIGNA 62308 [308105105] 224.87 percent of total billed charges 176.08 269.8 Technical (Hospital) Services Radex Wrist 2 Views PX-3207310000 CDM 73100 CPT 320 RC inpatient 284 284 CIGNA 62308 [3081051] CIGNA STATE OF WYOMING [308105107] 224.87 percent of total billed charges 176.08 269.8 Technical (Hospital) Services Radex Upper Extremity Infant Minimum 2 Views PX-3207309200 CDM 73092 CPT 320 RC outpatient 182 182 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES EPO [308136803] 145.6 percent of total billed charges 112.84 172.9 Technical (Hospital) Services Radex Upper Extremity Infant Minimum 2 Views PX-3207309200 CDM 73092 CPT 320 RC outpatient 182 182 UNITED HEALTHCARE (COMMERCIAL) [3081199] UNITED HEALTHCARE 87726 [308119901] 112.84 percent of total billed charges 112.84 172.9 Technical (Hospital) Services Radex Upper Extremity Infant Minimum 2 Views PX-3207309200 CDM 73092 CPT 320 RC outpatient 182 182 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES PPO [308136801] 145.6 percent of total billed charges 112.84 172.9 Technical (Hospital) Services Radex Upper Extremity Infant Minimum 2 Views PX-3207309200 CDM 73092 CPT 320 RC outpatient 182 182 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES HDHP [308136802] 145.6 percent of total billed charges 112.84 172.9 Technical (Hospital) Services Radex Upper Extremity Infant Minimum 2 Views PX-3207309200 CDM 73092 CPT 320 RC outpatient 182 182 MULTIPLAN INC 34080 [3081285] MULTIPLAN INC [308128501] 172.9 percent of total billed charges 112.84 172.9 Technical (Hospital) Services Radex Upper Extremity Infant Minimum 2 Views PX-3207309200 CDM 73092 CPT 320 RC outpatient 182 182 BLUE CROSS BLUE SHIELD WELLMARK SB889 [3081026] BCBS WYOMING [308102603] 172.9 percent of total billed charges 112.84 172.9 Technical (Hospital) Services Radex Upper Extremity Infant Minimum 2 Views PX-3207309200 CDM 73092 CPT 320 RC outpatient 182 182 HEALTHPARTNERS SX009 HEALTHPARTNERS 145.6 percent of total billed charges 112.84 172.9 Technical (Hospital) Services Radex Upper Extremity Infant Minimum 2 Views PX-3207309200 CDM 73092 CPT 320 RC outpatient 182 182 MEDICA (COMMERCIAL) 94265 [3081118] MEDICA CLAIMS [308111801] 163.8 percent of total billed charges 112.84 172.9 Technical (Hospital) Services Radex Upper Extremity Infant Minimum 2 Views PX-3207309200 CDM 73092 CPT 320 RC outpatient 182 182 CIGNA 62308 [3081051] CIGNA 62308 [308105105] 145.6 percent of total billed charges 112.84 172.9 Technical (Hospital) Services Radex Upper Extremity Infant Minimum 2 Views PX-3207309200 CDM 73092 CPT 320 RC outpatient 182 182 CIGNA 62308 [3081051] CIGNA STATE OF WYOMING [308105107] 145.6 percent of total billed charges 112.84 172.9 Technical (Hospital) Services Radex Upper Extremity Infant Minimum 2 Views PX-3207309200 CDM 73092 CPT 320 RC inpatient 182 182 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES HDHP [308136802] 144.11 percent of total billed charges 112.84 172.9 Technical (Hospital) Services Radex Upper Extremity Infant Minimum 2 Views PX-3207309200 CDM 73092 CPT 320 RC inpatient 182 182 MEDICA (COMMERCIAL) 94265 [3081118] MEDICA CLAIMS [308111801] 163.8 percent of total billed charges 112.84 172.9 Technical (Hospital) Services Radex Upper Extremity Infant Minimum 2 Views PX-3207309200 CDM 73092 CPT 320 RC inpatient 182 182 HEALTHPARTNERS SX009 HEALTHPARTNERS 144.11 percent of total billed charges 112.84 172.9 Technical (Hospital) Services Radex Upper Extremity Infant Minimum 2 Views PX-3207309200 CDM 73092 CPT 320 RC inpatient 182 182 UNITED HEALTHCARE (COMMERCIAL) [3081199] UNITED HEALTHCARE 87726 [308119901] 112.84 percent of total billed charges 112.84 172.9 Technical (Hospital) Services Radex Upper Extremity Infant Minimum 2 Views PX-3207309200 CDM 73092 CPT 320 RC inpatient 182 182 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES PPO [308136801] 144.11 percent of total billed charges 112.84 172.9 Technical (Hospital) Services Radex Upper Extremity Infant Minimum 2 Views PX-3207309200 CDM 73092 CPT 320 RC inpatient 182 182 BLUE CROSS BLUE SHIELD WELLMARK SB889 [3081026] BCBS WYOMING [308102603] 172.9 percent of total billed charges 112.84 172.9 Technical (Hospital) Services Radex Upper Extremity Infant Minimum 2 Views PX-3207309200 CDM 73092 CPT 320 RC inpatient 182 182 MULTIPLAN INC 34080 [3081285] MULTIPLAN INC [308128501] 172.9 percent of total billed charges 112.84 172.9 Technical (Hospital) Services Radex Upper Extremity Infant Minimum 2 Views PX-3207309200 CDM 73092 CPT 320 RC inpatient 182 182 CIGNA 62308 [3081051] CIGNA 62308 [308105105] 144.11 percent of total billed charges 112.84 172.9 Technical (Hospital) Services Radex Upper Extremity Infant Minimum 2 Views PX-3207309200 CDM 73092 CPT 320 RC inpatient 182 182 CIGNA 62308 [3081051] CIGNA STATE OF WYOMING [308105107] 144.11 percent of total billed charges 112.84 172.9 Technical (Hospital) Services Radex Upper Extremity Infant Minimum 2 Views PX-3207309200 CDM 73092 CPT 320 RC inpatient 182 182 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES EPO [308136803] 144.11 percent of total billed charges 112.84 172.9 Technical (Hospital) Services Radex Forearm 2 Views PX-3207309000 CDM 73090 CPT 320 RC inpatient 188 188 CIGNA 62308 [3081051] CIGNA 62308 [308105105] 148.86 percent of total billed charges 116.56 178.6 Technical (Hospital) Services Radex Forearm 2 Views PX-3207309000 CDM 73090 CPT 320 RC inpatient 188 188 CIGNA 62308 [3081051] CIGNA STATE OF WYOMING [308105107] 148.86 percent of total billed charges 116.56 178.6 Technical (Hospital) Services Radex Forearm 2 Views PX-3207309000 CDM 73090 CPT 320 RC inpatient 188 188 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES EPO [308136803] 148.86 percent of total billed charges 116.56 178.6 Technical (Hospital) Services Radex Forearm 2 Views PX-3207309000 CDM 73090 CPT 320 RC inpatient 188 188 UNITED HEALTHCARE (COMMERCIAL) [3081199] UNITED HEALTHCARE 87726 [308119901] 116.56 percent of total billed charges 116.56 178.6 Technical (Hospital) Services Radex Forearm 2 Views PX-3207309000 CDM 73090 CPT 320 RC inpatient 188 188 MULTIPLAN INC 34080 [3081285] MULTIPLAN INC [308128501] 178.6 percent of total billed charges 116.56 178.6 Technical (Hospital) Services Radex Forearm 2 Views PX-3207309000 CDM 73090 CPT 320 RC inpatient 188 188 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES PPO [308136801] 148.86 percent of total billed charges 116.56 178.6 Technical (Hospital) Services Radex Forearm 2 Views PX-3207309000 CDM 73090 CPT 320 RC inpatient 188 188 BLUE CROSS BLUE SHIELD WELLMARK SB889 [3081026] BCBS WYOMING [308102603] 178.6 percent of total billed charges 116.56 178.6 Technical (Hospital) Services Radex Forearm 2 Views PX-3207309000 CDM 73090 CPT 320 RC inpatient 188 188 MEDICA (COMMERCIAL) 94265 [3081118] MEDICA CLAIMS [308111801] 169.2 percent of total billed charges 116.56 178.6 Technical (Hospital) Services Radex Forearm 2 Views PX-3207309000 CDM 73090 CPT 320 RC inpatient 188 188 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES HDHP [308136802] 148.86 percent of total billed charges 116.56 178.6 Technical (Hospital) Services Radex Forearm 2 Views PX-3207309000 CDM 73090 CPT 320 RC inpatient 188 188 HEALTHPARTNERS SX009 HEALTHPARTNERS 148.86 percent of total billed charges 116.56 178.6 Technical (Hospital) Services Radex Forearm 2 Views PX-3207309000 CDM 73090 CPT 320 RC outpatient 188 188 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES EPO [308136803] 150.4 percent of total billed charges 116.56 178.6 Technical (Hospital) Services Radex Forearm 2 Views PX-3207309000 CDM 73090 CPT 320 RC outpatient 188 188 UNITED HEALTHCARE (COMMERCIAL) [3081199] UNITED HEALTHCARE 87726 [308119901] 116.56 percent of total billed charges 116.56 178.6 Technical (Hospital) Services Radex Forearm 2 Views PX-3207309000 CDM 73090 CPT 320 RC outpatient 188 188 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES PPO [308136801] 150.4 percent of total billed charges 116.56 178.6 Technical (Hospital) Services Radex Forearm 2 Views PX-3207309000 CDM 73090 CPT 320 RC outpatient 188 188 MULTIPLAN INC 34080 [3081285] MULTIPLAN INC [308128501] 178.6 percent of total billed charges 116.56 178.6 Technical (Hospital) Services Radex Forearm 2 Views PX-3207309000 CDM 73090 CPT 320 RC outpatient 188 188 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES HDHP [308136802] 150.4 percent of total billed charges 116.56 178.6 Technical (Hospital) Services Radex Forearm 2 Views PX-3207309000 CDM 73090 CPT 320 RC outpatient 188 188 BLUE CROSS BLUE SHIELD WELLMARK SB889 [3081026] BCBS WYOMING [308102603] 178.6 percent of total billed charges 116.56 178.6 Technical (Hospital) Services Radex Forearm 2 Views PX-3207309000 CDM 73090 CPT 320 RC outpatient 188 188 HEALTHPARTNERS SX009 HEALTHPARTNERS 150.4 percent of total billed charges 116.56 178.6 Technical (Hospital) Services Radex Forearm 2 Views PX-3207309000 CDM 73090 CPT 320 RC outpatient 188 188 MEDICA (COMMERCIAL) 94265 [3081118] MEDICA CLAIMS [308111801] 169.2 percent of total billed charges 116.56 178.6 Technical (Hospital) Services Radex Forearm 2 Views PX-3207309000 CDM 73090 CPT 320 RC outpatient 188 188 CIGNA 62308 [3081051] CIGNA 62308 [308105105] 150.4 percent of total billed charges 116.56 178.6 Technical (Hospital) Services Radex Forearm 2 Views PX-3207309000 CDM 73090 CPT 320 RC outpatient 188 188 CIGNA 62308 [3081051] CIGNA STATE OF WYOMING [308105107] 150.4 percent of total billed charges 116.56 178.6 Technical (Hospital) Services Radex Elbow Complete Minimum 3 Views PX-3207308000 CDM 73080 CPT 320 RC inpatient 213 213 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES HDHP [308136802] 168.65 percent of total billed charges 132.06 202.35 Technical (Hospital) Services Radex Elbow Complete Minimum 3 Views PX-3207308000 CDM 73080 CPT 320 RC inpatient 213 213 MEDICA (COMMERCIAL) 94265 [3081118] MEDICA CLAIMS [308111801] 191.7 percent of total billed charges 132.06 202.35 Technical (Hospital) Services Radex Elbow Complete Minimum 3 Views PX-3207308000 CDM 73080 CPT 320 RC inpatient 213 213 HEALTHPARTNERS SX009 HEALTHPARTNERS 168.65 percent of total billed charges 132.06 202.35 Technical (Hospital) Services Radex Elbow Complete Minimum 3 Views PX-3207308000 CDM 73080 CPT 320 RC inpatient 213 213 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES PPO [308136801] 168.65 percent of total billed charges 132.06 202.35 Technical (Hospital) Services Radex Elbow Complete Minimum 3 Views PX-3207308000 CDM 73080 CPT 320 RC inpatient 213 213 MULTIPLAN INC 34080 [3081285] MULTIPLAN INC [308128501] 202.35 percent of total billed charges 132.06 202.35 Technical (Hospital) Services Radex Elbow Complete Minimum 3 Views PX-3207308000 CDM 73080 CPT 320 RC inpatient 213 213 BLUE CROSS BLUE SHIELD WELLMARK SB889 [3081026] BCBS WYOMING [308102603] 202.35 percent of total billed charges 132.06 202.35 Technical (Hospital) Services Radex Elbow Complete Minimum 3 Views PX-3207308000 CDM 73080 CPT 320 RC inpatient 213 213 UNITED HEALTHCARE (COMMERCIAL) [3081199] UNITED HEALTHCARE 87726 [308119901] 132.06 percent of total billed charges 132.06 202.35 Technical (Hospital) Services Radex Elbow Complete Minimum 3 Views PX-3207308000 CDM 73080 CPT 320 RC inpatient 213 213 CIGNA 62308 [3081051] CIGNA 62308 [308105105] 168.65 percent of total billed charges 132.06 202.35 Technical (Hospital) Services Radex Elbow Complete Minimum 3 Views PX-3207308000 CDM 73080 CPT 320 RC inpatient 213 213 CIGNA 62308 [3081051] CIGNA STATE OF WYOMING [308105107] 168.65 percent of total billed charges 132.06 202.35 Technical (Hospital) Services Radex Elbow Complete Minimum 3 Views PX-3207308000 CDM 73080 CPT 320 RC inpatient 213 213 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES EPO [308136803] 168.65 percent of total billed charges 132.06 202.35 Technical (Hospital) Services Radex Elbow Complete Minimum 3 Views PX-3207308000 CDM 73080 CPT 320 RC outpatient 213 213 HEALTHPARTNERS SX009 HEALTHPARTNERS 170.4 percent of total billed charges 132.06 202.35 Technical (Hospital) Services Radex Elbow Complete Minimum 3 Views PX-3207308000 CDM 73080 CPT 320 RC outpatient 213 213 UNITED HEALTHCARE (COMMERCIAL) [3081199] UNITED HEALTHCARE 87726 [308119901] 132.06 percent of total billed charges 132.06 202.35 Technical (Hospital) Services Radex Elbow Complete Minimum 3 Views PX-3207308000 CDM 73080 CPT 320 RC outpatient 213 213 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES EPO [308136803] 170.4 percent of total billed charges 132.06 202.35 Technical (Hospital) Services Radex Elbow Complete Minimum 3 Views PX-3207308000 CDM 73080 CPT 320 RC outpatient 213 213 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES PPO [308136801] 170.4 percent of total billed charges 132.06 202.35 Technical (Hospital) Services Radex Elbow Complete Minimum 3 Views PX-3207308000 CDM 73080 CPT 320 RC outpatient 213 213 BLUE CROSS BLUE SHIELD WELLMARK SB889 [3081026] BCBS WYOMING [308102603] 202.35 percent of total billed charges 132.06 202.35 Technical (Hospital) Services Radex Elbow Complete Minimum 3 Views PX-3207308000 CDM 73080 CPT 320 RC outpatient 213 213 MULTIPLAN INC 34080 [3081285] MULTIPLAN INC [308128501] 202.35 percent of total billed charges 132.06 202.35 Technical (Hospital) Services Radex Elbow Complete Minimum 3 Views PX-3207308000 CDM 73080 CPT 320 RC outpatient 213 213 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES HDHP [308136802] 170.4 percent of total billed charges 132.06 202.35 Technical (Hospital) Services Radex Elbow Complete Minimum 3 Views PX-3207308000 CDM 73080 CPT 320 RC outpatient 213 213 CIGNA 62308 [3081051] CIGNA 62308 [308105105] 170.4 percent of total billed charges 132.06 202.35 Technical (Hospital) Services Radex Elbow Complete Minimum 3 Views PX-3207308000 CDM 73080 CPT 320 RC outpatient 213 213 CIGNA 62308 [3081051] CIGNA STATE OF WYOMING [308105107] 170.4 percent of total billed charges 132.06 202.35 Technical (Hospital) Services Radex Elbow Complete Minimum 3 Views PX-3207308000 CDM 73080 CPT 320 RC outpatient 213 213 MEDICA (COMMERCIAL) 94265 [3081118] MEDICA CLAIMS [308111801] 191.7 percent of total billed charges 132.06 202.35 Technical (Hospital) Services Radex Elbow 2 Views PX-3207307000 CDM 73070 CPT 320 RC outpatient 185 185 CIGNA 62308 [3081051] CIGNA 62308 [308105105] 148 percent of total billed charges 114.7 175.75 Technical (Hospital) Services Radex Elbow 2 Views PX-3207307000 CDM 73070 CPT 320 RC outpatient 185 185 CIGNA 62308 [3081051] CIGNA STATE OF WYOMING [308105107] 148 percent of total billed charges 114.7 175.75 Technical (Hospital) Services Radex Elbow 2 Views PX-3207307000 CDM 73070 CPT 320 RC outpatient 185 185 MEDICA (COMMERCIAL) 94265 [3081118] MEDICA CLAIMS [308111801] 166.5 percent of total billed charges 114.7 175.75 Technical (Hospital) Services Radex Elbow 2 Views PX-3207307000 CDM 73070 CPT 320 RC outpatient 185 185 UNITED HEALTHCARE (COMMERCIAL) [3081199] UNITED HEALTHCARE 87726 [308119901] 114.7 percent of total billed charges 114.7 175.75 Technical (Hospital) Services Radex Elbow 2 Views PX-3207307000 CDM 73070 CPT 320 RC outpatient 185 185 HEALTHPARTNERS SX009 HEALTHPARTNERS 148 percent of total billed charges 114.7 175.75 Technical (Hospital) Services Radex Elbow 2 Views PX-3207307000 CDM 73070 CPT 320 RC outpatient 185 185 BLUE CROSS BLUE SHIELD WELLMARK SB889 [3081026] BCBS WYOMING [308102603] 175.75 percent of total billed charges 114.7 175.75 Technical (Hospital) Services Radex Elbow 2 Views PX-3207307000 CDM 73070 CPT 320 RC outpatient 185 185 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES HDHP [308136802] 148 percent of total billed charges 114.7 175.75 Technical (Hospital) Services Radex Elbow 2 Views PX-3207307000 CDM 73070 CPT 320 RC outpatient 185 185 MULTIPLAN INC 34080 [3081285] MULTIPLAN INC [308128501] 175.75 percent of total billed charges 114.7 175.75 Technical (Hospital) Services Radex Elbow 2 Views PX-3207307000 CDM 73070 CPT 320 RC outpatient 185 185 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES EPO [308136803] 148 percent of total billed charges 114.7 175.75 Technical (Hospital) Services Radex Elbow 2 Views PX-3207307000 CDM 73070 CPT 320 RC outpatient 185 185 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES PPO [308136801] 148 percent of total billed charges 114.7 175.75 Technical (Hospital) Services Radex Elbow 2 Views PX-3207307000 CDM 73070 CPT 320 RC inpatient 185 185 MEDICA (COMMERCIAL) 94265 [3081118] MEDICA CLAIMS [308111801] 166.5 percent of total billed charges 114.7 175.75 Technical (Hospital) Services Radex Elbow 2 Views PX-3207307000 CDM 73070 CPT 320 RC inpatient 185 185 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES HDHP [308136802] 146.48 percent of total billed charges 114.7 175.75 Technical (Hospital) Services Radex Elbow 2 Views PX-3207307000 CDM 73070 CPT 320 RC inpatient 185 185 HEALTHPARTNERS SX009 HEALTHPARTNERS 146.48 percent of total billed charges 114.7 175.75 Technical (Hospital) Services Radex Elbow 2 Views PX-3207307000 CDM 73070 CPT 320 RC inpatient 185 185 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES PPO [308136801] 146.48 percent of total billed charges 114.7 175.75 Technical (Hospital) Services Radex Elbow 2 Views PX-3207307000 CDM 73070 CPT 320 RC inpatient 185 185 BLUE CROSS BLUE SHIELD WELLMARK SB889 [3081026] BCBS WYOMING [308102603] 175.75 percent of total billed charges 114.7 175.75 Technical (Hospital) Services Radex Elbow 2 Views PX-3207307000 CDM 73070 CPT 320 RC inpatient 185 185 MULTIPLAN INC 34080 [3081285] MULTIPLAN INC [308128501] 175.75 percent of total billed charges 114.7 175.75 Technical (Hospital) Services Radex Elbow 2 Views PX-3207307000 CDM 73070 CPT 320 RC inpatient 185 185 UNITED HEALTHCARE (COMMERCIAL) [3081199] UNITED HEALTHCARE 87726 [308119901] 114.7 percent of total billed charges 114.7 175.75 Technical (Hospital) Services Radex Elbow 2 Views PX-3207307000 CDM 73070 CPT 320 RC inpatient 185 185 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES EPO [308136803] 146.48 percent of total billed charges 114.7 175.75 Technical (Hospital) Services Radex Elbow 2 Views PX-3207307000 CDM 73070 CPT 320 RC inpatient 185 185 CIGNA 62308 [3081051] CIGNA 62308 [308105105] 146.48 percent of total billed charges 114.7 175.75 Technical (Hospital) Services Radex Elbow 2 Views PX-3207307000 CDM 73070 CPT 320 RC inpatient 185 185 CIGNA 62308 [3081051] CIGNA STATE OF WYOMING [308105107] 146.48 percent of total billed charges 114.7 175.75 Technical (Hospital) Services Radex Humerus Minimum 2 Views PX-3207306000 CDM 73060 CPT 320 RC outpatient 221 221 MEDICA (COMMERCIAL) 94265 [3081118] MEDICA CLAIMS [308111801] 198.9 percent of total billed charges 137.02 209.95 Technical (Hospital) Services Radex Humerus Minimum 2 Views PX-3207306000 CDM 73060 CPT 320 RC outpatient 221 221 CIGNA 62308 [3081051] CIGNA 62308 [308105105] 176.8 percent of total billed charges 137.02 209.95 Technical (Hospital) Services Radex Humerus Minimum 2 Views PX-3207306000 CDM 73060 CPT 320 RC outpatient 221 221 CIGNA 62308 [3081051] CIGNA STATE OF WYOMING [308105107] 176.8 percent of total billed charges 137.02 209.95 Technical (Hospital) Services Radex Humerus Minimum 2 Views PX-3207306000 CDM 73060 CPT 320 RC outpatient 221 221 HEALTHPARTNERS SX009 HEALTHPARTNERS 176.8 percent of total billed charges 137.02 209.95 Technical (Hospital) Services Radex Humerus Minimum 2 Views PX-3207306000 CDM 73060 CPT 320 RC outpatient 221 221 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES PPO [308136801] 176.8 percent of total billed charges 137.02 209.95 Technical (Hospital) Services Radex Humerus Minimum 2 Views PX-3207306000 CDM 73060 CPT 320 RC outpatient 221 221 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES EPO [308136803] 176.8 percent of total billed charges 137.02 209.95 Technical (Hospital) Services Radex Humerus Minimum 2 Views PX-3207306000 CDM 73060 CPT 320 RC outpatient 221 221 UNITED HEALTHCARE (COMMERCIAL) [3081199] UNITED HEALTHCARE 87726 [308119901] 137.02 percent of total billed charges 137.02 209.95 Technical (Hospital) Services Radex Humerus Minimum 2 Views PX-3207306000 CDM 73060 CPT 320 RC outpatient 221 221 MULTIPLAN INC 34080 [3081285] MULTIPLAN INC [308128501] 209.95 percent of total billed charges 137.02 209.95 Technical (Hospital) Services Radex Humerus Minimum 2 Views PX-3207306000 CDM 73060 CPT 320 RC outpatient 221 221 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES HDHP [308136802] 176.8 percent of total billed charges 137.02 209.95 Technical (Hospital) Services Radex Humerus Minimum 2 Views PX-3207306000 CDM 73060 CPT 320 RC outpatient 221 221 BLUE CROSS BLUE SHIELD WELLMARK SB889 [3081026] BCBS WYOMING [308102603] 209.95 percent of total billed charges 137.02 209.95 Technical (Hospital) Services Radex Humerus Minimum 2 Views PX-3207306000 CDM 73060 CPT 320 RC inpatient 221 221 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES HDHP [308136802] 174.99 percent of total billed charges 137.02 209.95 Technical (Hospital) Services Radex Humerus Minimum 2 Views PX-3207306000 CDM 73060 CPT 320 RC inpatient 221 221 MEDICA (COMMERCIAL) 94265 [3081118] MEDICA CLAIMS [308111801] 198.9 percent of total billed charges 137.02 209.95 Technical (Hospital) Services Radex Humerus Minimum 2 Views PX-3207306000 CDM 73060 CPT 320 RC inpatient 221 221 HEALTHPARTNERS SX009 HEALTHPARTNERS 174.99 percent of total billed charges 137.02 209.95 Technical (Hospital) Services Radex Humerus Minimum 2 Views PX-3207306000 CDM 73060 CPT 320 RC inpatient 221 221 MULTIPLAN INC 34080 [3081285] MULTIPLAN INC [308128501] 209.95 percent of total billed charges 137.02 209.95 Technical (Hospital) Services Radex Humerus Minimum 2 Views PX-3207306000 CDM 73060 CPT 320 RC inpatient 221 221 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES PPO [308136801] 174.99 percent of total billed charges 137.02 209.95 Technical (Hospital) Services Radex Humerus Minimum 2 Views PX-3207306000 CDM 73060 CPT 320 RC inpatient 221 221 BLUE CROSS BLUE SHIELD WELLMARK SB889 [3081026] BCBS WYOMING [308102603] 209.95 percent of total billed charges 137.02 209.95 Technical (Hospital) Services Radex Humerus Minimum 2 Views PX-3207306000 CDM 73060 CPT 320 RC inpatient 221 221 UNITED HEALTHCARE (COMMERCIAL) [3081199] UNITED HEALTHCARE 87726 [308119901] 137.02 percent of total billed charges 137.02 209.95 Technical (Hospital) Services Radex Humerus Minimum 2 Views PX-3207306000 CDM 73060 CPT 320 RC inpatient 221 221 CIGNA 62308 [3081051] CIGNA 62308 [308105105] 174.99 percent of total billed charges 137.02 209.95 Technical (Hospital) Services Radex Humerus Minimum 2 Views PX-3207306000 CDM 73060 CPT 320 RC inpatient 221 221 CIGNA 62308 [3081051] CIGNA STATE OF WYOMING [308105107] 174.99 percent of total billed charges 137.02 209.95 Technical (Hospital) Services Radex Humerus Minimum 2 Views PX-3207306000 CDM 73060 CPT 320 RC inpatient 221 221 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES EPO [308136803] 174.99 percent of total billed charges 137.02 209.95 Technical (Hospital) Services Radex a-C Joints Bi W/WO Weighted Distrcj PX-3207305000 CDM 73050 CPT 320 RC outpatient 249 249 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES PPO [308136801] 199.2 percent of total billed charges 154.38 236.55 Technical (Hospital) Services Radex a-C Joints Bi W/WO Weighted Distrcj PX-3207305000 CDM 73050 CPT 320 RC outpatient 249 249 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES EPO [308136803] 199.2 percent of total billed charges 154.38 236.55 Technical (Hospital) Services Radex a-C Joints Bi W/WO Weighted Distrcj PX-3207305000 CDM 73050 CPT 320 RC outpatient 249 249 MULTIPLAN INC 34080 [3081285] MULTIPLAN INC [308128501] 236.55 percent of total billed charges 154.38 236.55 Technical (Hospital) Services Radex a-C Joints Bi W/WO Weighted Distrcj PX-3207305000 CDM 73050 CPT 320 RC outpatient 249 249 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES HDHP [308136802] 199.2 percent of total billed charges 154.38 236.55 Technical (Hospital) Services Radex a-C Joints Bi W/WO Weighted Distrcj PX-3207305000 CDM 73050 CPT 320 RC outpatient 249 249 BLUE CROSS BLUE SHIELD WELLMARK SB889 [3081026] BCBS WYOMING [308102603] 236.55 percent of total billed charges 154.38 236.55 Technical (Hospital) Services Radex a-C Joints Bi W/WO Weighted Distrcj PX-3207305000 CDM 73050 CPT 320 RC outpatient 249 249 HEALTHPARTNERS SX009 HEALTHPARTNERS 199.2 percent of total billed charges 154.38 236.55 Technical (Hospital) Services Radex a-C Joints Bi W/WO Weighted Distrcj PX-3207305000 CDM 73050 CPT 320 RC outpatient 249 249 UNITED HEALTHCARE (COMMERCIAL) [3081199] UNITED HEALTHCARE 87726 [308119901] 154.38 percent of total billed charges 154.38 236.55 Technical (Hospital) Services Radex a-C Joints Bi W/WO Weighted Distrcj PX-3207305000 CDM 73050 CPT 320 RC outpatient 249 249 MEDICA (COMMERCIAL) 94265 [3081118] MEDICA CLAIMS [308111801] 224.1 percent of total billed charges 154.38 236.55 Technical (Hospital) Services Radex a-C Joints Bi W/WO Weighted Distrcj PX-3207305000 CDM 73050 CPT 320 RC outpatient 249 249 CIGNA 62308 [3081051] CIGNA 62308 [308105105] 199.2 percent of total billed charges 154.38 236.55 Technical (Hospital) Services Radex a-C Joints Bi W/WO Weighted Distrcj PX-3207305000 CDM 73050 CPT 320 RC outpatient 249 249 CIGNA 62308 [3081051] CIGNA STATE OF WYOMING [308105107] 199.2 percent of total billed charges 154.38 236.55 Technical (Hospital) Services Radex a-C Joints Bi W/WO Weighted Distrcj PX-3207305000 CDM 73050 CPT 320 RC inpatient 249 249 CIGNA 62308 [3081051] CIGNA 62308 [308105105] 197.16 percent of total billed charges 154.38 236.55 Technical (Hospital) Services Radex a-C Joints Bi W/WO Weighted Distrcj PX-3207305000 CDM 73050 CPT 320 RC inpatient 249 249 CIGNA 62308 [3081051] CIGNA STATE OF WYOMING [308105107] 197.16 percent of total billed charges 154.38 236.55 Technical (Hospital) Services Radex a-C Joints Bi W/WO Weighted Distrcj PX-3207305000 CDM 73050 CPT 320 RC inpatient 249 249 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES EPO [308136803] 197.16 percent of total billed charges 154.38 236.55 Technical (Hospital) Services Radex a-C Joints Bi W/WO Weighted Distrcj PX-3207305000 CDM 73050 CPT 320 RC inpatient 249 249 HEALTHPARTNERS SX009 HEALTHPARTNERS 197.16 percent of total billed charges 154.38 236.55 Technical (Hospital) Services Radex a-C Joints Bi W/WO Weighted Distrcj PX-3207305000 CDM 73050 CPT 320 RC inpatient 249 249 MEDICA (COMMERCIAL) 94265 [3081118] MEDICA CLAIMS [308111801] 224.1 percent of total billed charges 154.38 236.55 Technical (Hospital) Services Radex a-C Joints Bi W/WO Weighted Distrcj PX-3207305000 CDM 73050 CPT 320 RC inpatient 249 249 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES HDHP [308136802] 197.16 percent of total billed charges 154.38 236.55 Technical (Hospital) Services Radex a-C Joints Bi W/WO Weighted Distrcj PX-3207305000 CDM 73050 CPT 320 RC inpatient 249 249 UNITED HEALTHCARE (COMMERCIAL) [3081199] UNITED HEALTHCARE 87726 [308119901] 154.38 percent of total billed charges 154.38 236.55 Technical (Hospital) Services Radex a-C Joints Bi W/WO Weighted Distrcj PX-3207305000 CDM 73050 CPT 320 RC inpatient 249 249 BLUE CROSS BLUE SHIELD WELLMARK SB889 [3081026] BCBS WYOMING [308102603] 236.55 percent of total billed charges 154.38 236.55 Technical (Hospital) Services Radex a-C Joints Bi W/WO Weighted Distrcj PX-3207305000 CDM 73050 CPT 320 RC inpatient 249 249 MULTIPLAN INC 34080 [3081285] MULTIPLAN INC [308128501] 236.55 percent of total billed charges 154.38 236.55 Technical (Hospital) Services Radex a-C Joints Bi W/WO Weighted Distrcj PX-3207305000 CDM 73050 CPT 320 RC inpatient 249 249 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES PPO [308136801] 197.16 percent of total billed charges 154.38 236.55 Technical (Hospital) Services Radex Shoulder Complete Minimum 2 Views PX-3207303000 CDM 73030 CPT 320 RC outpatient 468 468 HEALTHPARTNERS SX009 HEALTHPARTNERS 374.4 percent of total billed charges 290.16 444.6 Technical (Hospital) Services Radex Shoulder Complete Minimum 2 Views PX-3207303000 CDM 73030 CPT 320 RC outpatient 468 468 UNITED HEALTHCARE (COMMERCIAL) [3081199] UNITED HEALTHCARE 87726 [308119901] 290.16 percent of total billed charges 290.16 444.6 Technical (Hospital) Services Radex Shoulder Complete Minimum 2 Views PX-3207303000 CDM 73030 CPT 320 RC outpatient 468 468 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES PPO [308136801] 374.4 percent of total billed charges 290.16 444.6 Technical (Hospital) Services Radex Shoulder Complete Minimum 2 Views PX-3207303000 CDM 73030 CPT 320 RC outpatient 468 468 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES EPO [308136803] 374.4 percent of total billed charges 290.16 444.6 Technical (Hospital) Services Radex Shoulder Complete Minimum 2 Views PX-3207303000 CDM 73030 CPT 320 RC outpatient 468 468 MULTIPLAN INC 34080 [3081285] MULTIPLAN INC [308128501] 444.6 percent of total billed charges 290.16 444.6 Technical (Hospital) Services Radex Shoulder Complete Minimum 2 Views PX-3207303000 CDM 73030 CPT 320 RC outpatient 468 468 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES HDHP [308136802] 374.4 percent of total billed charges 290.16 444.6 Technical (Hospital) Services Radex Shoulder Complete Minimum 2 Views PX-3207303000 CDM 73030 CPT 320 RC outpatient 468 468 BLUE CROSS BLUE SHIELD WELLMARK SB889 [3081026] BCBS WYOMING [308102603] 444.6 percent of total billed charges 290.16 444.6 Technical (Hospital) Services Radex Shoulder Complete Minimum 2 Views PX-3207303000 CDM 73030 CPT 320 RC outpatient 468 468 CIGNA 62308 [3081051] CIGNA 62308 [308105105] 374.4 percent of total billed charges 290.16 444.6 Technical (Hospital) Services Radex Shoulder Complete Minimum 2 Views PX-3207303000 CDM 73030 CPT 320 RC outpatient 468 468 CIGNA 62308 [3081051] CIGNA STATE OF WYOMING [308105107] 374.4 percent of total billed charges 290.16 444.6 Technical (Hospital) Services Radex Shoulder Complete Minimum 2 Views PX-3207303000 CDM 73030 CPT 320 RC outpatient 468 468 MEDICA (COMMERCIAL) 94265 [3081118] MEDICA CLAIMS [308111801] 421.2 percent of total billed charges 290.16 444.6 Technical (Hospital) Services Radex Shoulder Complete Minimum 2 Views PX-3207303000 CDM 73030 CPT 320 RC inpatient 468 468 MEDICA (COMMERCIAL) 94265 [3081118] MEDICA CLAIMS [308111801] 421.2 percent of total billed charges 290.16 444.6 Technical (Hospital) Services Radex Shoulder Complete Minimum 2 Views PX-3207303000 CDM 73030 CPT 320 RC inpatient 468 468 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES HDHP [308136802] 370.56 percent of total billed charges 290.16 444.6 Technical (Hospital) Services Radex Shoulder Complete Minimum 2 Views PX-3207303000 CDM 73030 CPT 320 RC inpatient 468 468 HEALTHPARTNERS SX009 HEALTHPARTNERS 370.56 percent of total billed charges 290.16 444.6 Technical (Hospital) Services Radex Shoulder Complete Minimum 2 Views PX-3207303000 CDM 73030 CPT 320 RC inpatient 468 468 UNITED HEALTHCARE (COMMERCIAL) [3081199] UNITED HEALTHCARE 87726 [308119901] 290.16 percent of total billed charges 290.16 444.6 Technical (Hospital) Services Radex Shoulder Complete Minimum 2 Views PX-3207303000 CDM 73030 CPT 320 RC inpatient 468 468 BLUE CROSS BLUE SHIELD WELLMARK SB889 [3081026] BCBS WYOMING [308102603] 444.6 percent of total billed charges 290.16 444.6 Technical (Hospital) Services Radex Shoulder Complete Minimum 2 Views PX-3207303000 CDM 73030 CPT 320 RC inpatient 468 468 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES PPO [308136801] 370.56 percent of total billed charges 290.16 444.6 Technical (Hospital) Services Radex Shoulder Complete Minimum 2 Views PX-3207303000 CDM 73030 CPT 320 RC inpatient 468 468 MULTIPLAN INC 34080 [3081285] MULTIPLAN INC [308128501] 444.6 percent of total billed charges 290.16 444.6 Technical (Hospital) Services Radex Shoulder Complete Minimum 2 Views PX-3207303000 CDM 73030 CPT 320 RC inpatient 468 468 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES EPO [308136803] 370.56 percent of total billed charges 290.16 444.6 Technical (Hospital) Services Radex Shoulder Complete Minimum 2 Views PX-3207303000 CDM 73030 CPT 320 RC inpatient 468 468 CIGNA 62308 [3081051] CIGNA 62308 [308105105] 370.56 percent of total billed charges 290.16 444.6 Technical (Hospital) Services Radex Shoulder Complete Minimum 2 Views PX-3207303000 CDM 73030 CPT 320 RC inpatient 468 468 CIGNA 62308 [3081051] CIGNA STATE OF WYOMING [308105107] 370.56 percent of total billed charges 290.16 444.6 Technical (Hospital) Services Radex Shoulder 1 View PX-3207302000 CDM 73020 CPT 320 RC outpatient 186 186 HEALTHPARTNERS SX009 HEALTHPARTNERS 148.8 percent of total billed charges 115.32 176.7 Technical (Hospital) Services Radex Shoulder 1 View PX-3207302000 CDM 73020 CPT 320 RC outpatient 186 186 MEDICA (COMMERCIAL) 94265 [3081118] MEDICA CLAIMS [308111801] 167.4 percent of total billed charges 115.32 176.7 Technical (Hospital) Services Radex Shoulder 1 View PX-3207302000 CDM 73020 CPT 320 RC outpatient 186 186 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES PPO [308136801] 148.8 percent of total billed charges 115.32 176.7 Technical (Hospital) Services Radex Shoulder 1 View PX-3207302000 CDM 73020 CPT 320 RC outpatient 186 186 UNITED HEALTHCARE (COMMERCIAL) [3081199] UNITED HEALTHCARE 87726 [308119901] 115.32 percent of total billed charges 115.32 176.7 Technical (Hospital) Services Radex Shoulder 1 View PX-3207302000 CDM 73020 CPT 320 RC outpatient 186 186 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES EPO [308136803] 148.8 percent of total billed charges 115.32 176.7 Technical (Hospital) Services Radex Shoulder 1 View PX-3207302000 CDM 73020 CPT 320 RC outpatient 186 186 BLUE CROSS BLUE SHIELD WELLMARK SB889 [3081026] BCBS WYOMING [308102603] 176.7 percent of total billed charges 115.32 176.7 Technical (Hospital) Services Radex Shoulder 1 View PX-3207302000 CDM 73020 CPT 320 RC outpatient 186 186 MULTIPLAN INC 34080 [3081285] MULTIPLAN INC [308128501] 176.7 percent of total billed charges 115.32 176.7 Technical (Hospital) Services Radex Shoulder 1 View PX-3207302000 CDM 73020 CPT 320 RC outpatient 186 186 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES HDHP [308136802] 148.8 percent of total billed charges 115.32 176.7 Technical (Hospital) Services Radex Shoulder 1 View PX-3207302000 CDM 73020 CPT 320 RC outpatient 186 186 CIGNA 62308 [3081051] CIGNA 62308 [308105105] 148.8 percent of total billed charges 115.32 176.7 Technical (Hospital) Services Radex Shoulder 1 View PX-3207302000 CDM 73020 CPT 320 RC outpatient 186 186 CIGNA 62308 [3081051] CIGNA STATE OF WYOMING [308105107] 148.8 percent of total billed charges 115.32 176.7 Technical (Hospital) Services Radex Shoulder 1 View PX-3207302000 CDM 73020 CPT 320 RC inpatient 186 186 CIGNA 62308 [3081051] CIGNA 62308 [308105105] 147.27 percent of total billed charges 115.32 176.7 Technical (Hospital) Services Radex Shoulder 1 View PX-3207302000 CDM 73020 CPT 320 RC inpatient 186 186 CIGNA 62308 [3081051] CIGNA STATE OF WYOMING [308105107] 147.27 percent of total billed charges 115.32 176.7 Technical (Hospital) Services Radex Shoulder 1 View PX-3207302000 CDM 73020 CPT 320 RC inpatient 186 186 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES EPO [308136803] 147.27 percent of total billed charges 115.32 176.7 Technical (Hospital) Services Radex Shoulder 1 View PX-3207302000 CDM 73020 CPT 320 RC inpatient 186 186 MULTIPLAN INC 34080 [3081285] MULTIPLAN INC [308128501] 176.7 percent of total billed charges 115.32 176.7 Technical (Hospital) Services Radex Shoulder 1 View PX-3207302000 CDM 73020 CPT 320 RC inpatient 186 186 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES PPO [308136801] 147.27 percent of total billed charges 115.32 176.7 Technical (Hospital) Services Radex Shoulder 1 View PX-3207302000 CDM 73020 CPT 320 RC inpatient 186 186 BLUE CROSS BLUE SHIELD WELLMARK SB889 [3081026] BCBS WYOMING [308102603] 176.7 percent of total billed charges 115.32 176.7 Technical (Hospital) Services Radex Shoulder 1 View PX-3207302000 CDM 73020 CPT 320 RC inpatient 186 186 UNITED HEALTHCARE (COMMERCIAL) [3081199] UNITED HEALTHCARE 87726 [308119901] 115.32 percent of total billed charges 115.32 176.7 Technical (Hospital) Services Radex Shoulder 1 View PX-3207302000 CDM 73020 CPT 320 RC inpatient 186 186 HEALTHPARTNERS SX009 HEALTHPARTNERS 147.27 percent of total billed charges 115.32 176.7 Technical (Hospital) Services Radex Shoulder 1 View PX-3207302000 CDM 73020 CPT 320 RC inpatient 186 186 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES HDHP [308136802] 147.27 percent of total billed charges 115.32 176.7 Technical (Hospital) Services Radex Shoulder 1 View PX-3207302000 CDM 73020 CPT 320 RC inpatient 186 186 MEDICA (COMMERCIAL) 94265 [3081118] MEDICA CLAIMS [308111801] 167.4 percent of total billed charges 115.32 176.7 Technical (Hospital) Services Radex Scapula Complete PX-3207301000 CDM 73010 CPT 320 RC inpatient 480 480 CIGNA 62308 [3081051] CIGNA 62308 [308105105] 380.06 percent of total billed charges 297.6 456 Technical (Hospital) Services Radex Scapula Complete PX-3207301000 CDM 73010 CPT 320 RC inpatient 480 480 CIGNA 62308 [3081051] CIGNA STATE OF WYOMING [308105107] 380.06 percent of total billed charges 297.6 456 Technical (Hospital) Services Radex Scapula Complete PX-3207301000 CDM 73010 CPT 320 RC inpatient 480 480 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES EPO [308136803] 380.06 percent of total billed charges 297.6 456 Technical (Hospital) Services Radex Scapula Complete PX-3207301000 CDM 73010 CPT 320 RC inpatient 480 480 BLUE CROSS BLUE SHIELD WELLMARK SB889 [3081026] BCBS WYOMING [308102603] 456 percent of total billed charges 297.6 456 Technical (Hospital) Services Radex Scapula Complete PX-3207301000 CDM 73010 CPT 320 RC inpatient 480 480 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES PPO [308136801] 380.06 percent of total billed charges 297.6 456 Technical (Hospital) Services Radex Scapula Complete PX-3207301000 CDM 73010 CPT 320 RC inpatient 480 480 MULTIPLAN INC 34080 [3081285] MULTIPLAN INC [308128501] 456 percent of total billed charges 297.6 456 Technical (Hospital) Services Radex Scapula Complete PX-3207301000 CDM 73010 CPT 320 RC inpatient 480 480 UNITED HEALTHCARE (COMMERCIAL) [3081199] UNITED HEALTHCARE 87726 [308119901] 297.6 percent of total billed charges 297.6 456 Technical (Hospital) Services Radex Scapula Complete PX-3207301000 CDM 73010 CPT 320 RC inpatient 480 480 HEALTHPARTNERS SX009 HEALTHPARTNERS 380.06 percent of total billed charges 297.6 456 Technical (Hospital) Services Radex Scapula Complete PX-3207301000 CDM 73010 CPT 320 RC inpatient 480 480 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES HDHP [308136802] 380.06 percent of total billed charges 297.6 456 Technical (Hospital) Services Radex Scapula Complete PX-3207301000 CDM 73010 CPT 320 RC inpatient 480 480 MEDICA (COMMERCIAL) 94265 [3081118] MEDICA CLAIMS [308111801] 432 percent of total billed charges 297.6 456 Technical (Hospital) Services Radex Scapula Complete PX-3207301000 CDM 73010 CPT 320 RC outpatient 480 480 MEDICA (COMMERCIAL) 94265 [3081118] MEDICA CLAIMS [308111801] 432 percent of total billed charges 297.6 456 Technical (Hospital) Services Radex Scapula Complete PX-3207301000 CDM 73010 CPT 320 RC outpatient 480 480 CIGNA 62308 [3081051] CIGNA 62308 [308105105] 384 percent of total billed charges 297.6 456 Technical (Hospital) Services Radex Scapula Complete PX-3207301000 CDM 73010 CPT 320 RC outpatient 480 480 CIGNA 62308 [3081051] CIGNA STATE OF WYOMING [308105107] 384 percent of total billed charges 297.6 456 Technical (Hospital) Services Radex Scapula Complete PX-3207301000 CDM 73010 CPT 320 RC outpatient 480 480 BLUE CROSS BLUE SHIELD WELLMARK SB889 [3081026] BCBS WYOMING [308102603] 456 percent of total billed charges 297.6 456 Technical (Hospital) Services Radex Scapula Complete PX-3207301000 CDM 73010 CPT 320 RC outpatient 480 480 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES HDHP [308136802] 384 percent of total billed charges 297.6 456 Technical (Hospital) Services Radex Scapula Complete PX-3207301000 CDM 73010 CPT 320 RC outpatient 480 480 MULTIPLAN INC 34080 [3081285] MULTIPLAN INC [308128501] 456 percent of total billed charges 297.6 456 Technical (Hospital) Services Radex Scapula Complete PX-3207301000 CDM 73010 CPT 320 RC outpatient 480 480 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES EPO [308136803] 384 percent of total billed charges 297.6 456 Technical (Hospital) Services Radex Scapula Complete PX-3207301000 CDM 73010 CPT 320 RC outpatient 480 480 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES PPO [308136801] 384 percent of total billed charges 297.6 456 Technical (Hospital) Services Radex Scapula Complete PX-3207301000 CDM 73010 CPT 320 RC outpatient 480 480 UNITED HEALTHCARE (COMMERCIAL) [3081199] UNITED HEALTHCARE 87726 [308119901] 297.6 percent of total billed charges 297.6 456 Technical (Hospital) Services Radex Scapula Complete PX-3207301000 CDM 73010 CPT 320 RC outpatient 480 480 HEALTHPARTNERS SX009 HEALTHPARTNERS 384 percent of total billed charges 297.6 456 Technical (Hospital) Services Radex Clavicle Complete PX-3207300000 CDM 73000 CPT 320 RC inpatient 362 362 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES EPO [308136803] 286.63 percent of total billed charges 224.44 343.9 Technical (Hospital) Services Radex Clavicle Complete PX-3207300000 CDM 73000 CPT 320 RC inpatient 362 362 CIGNA 62308 [3081051] CIGNA 62308 [308105105] 286.63 percent of total billed charges 224.44 343.9 Technical (Hospital) Services Radex Clavicle Complete PX-3207300000 CDM 73000 CPT 320 RC inpatient 362 362 CIGNA 62308 [3081051] CIGNA STATE OF WYOMING [308105107] 286.63 percent of total billed charges 224.44 343.9 Technical (Hospital) Services Radex Clavicle Complete PX-3207300000 CDM 73000 CPT 320 RC inpatient 362 362 HEALTHPARTNERS SX009 HEALTHPARTNERS 286.63 percent of total billed charges 224.44 343.9 Technical (Hospital) Services Radex Clavicle Complete PX-3207300000 CDM 73000 CPT 320 RC inpatient 362 362 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES HDHP [308136802] 286.63 percent of total billed charges 224.44 343.9 Technical (Hospital) Services Radex Clavicle Complete PX-3207300000 CDM 73000 CPT 320 RC inpatient 362 362 MEDICA (COMMERCIAL) 94265 [3081118] MEDICA CLAIMS [308111801] 325.8 percent of total billed charges 224.44 343.9 Technical (Hospital) Services Radex Clavicle Complete PX-3207300000 CDM 73000 CPT 320 RC inpatient 362 362 UNITED HEALTHCARE (COMMERCIAL) [3081199] UNITED HEALTHCARE 87726 [308119901] 224.44 percent of total billed charges 224.44 343.9 Technical (Hospital) Services Radex Clavicle Complete PX-3207300000 CDM 73000 CPT 320 RC inpatient 362 362 MULTIPLAN INC 34080 [3081285] MULTIPLAN INC [308128501] 343.9 percent of total billed charges 224.44 343.9 Technical (Hospital) Services Radex Clavicle Complete PX-3207300000 CDM 73000 CPT 320 RC inpatient 362 362 BLUE CROSS BLUE SHIELD WELLMARK SB889 [3081026] BCBS WYOMING [308102603] 343.9 percent of total billed charges 224.44 343.9 Technical (Hospital) Services Radex Clavicle Complete PX-3207300000 CDM 73000 CPT 320 RC inpatient 362 362 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES PPO [308136801] 286.63 percent of total billed charges 224.44 343.9 Technical (Hospital) Services Radex Clavicle Complete PX-3207300000 CDM 73000 CPT 320 RC outpatient 362 362 CIGNA 62308 [3081051] CIGNA 62308 [308105105] 289.6 percent of total billed charges 224.44 343.9 Technical (Hospital) Services Radex Clavicle Complete PX-3207300000 CDM 73000 CPT 320 RC outpatient 362 362 CIGNA 62308 [3081051] CIGNA STATE OF WYOMING [308105107] 289.6 percent of total billed charges 224.44 343.9 Technical (Hospital) Services Radex Clavicle Complete PX-3207300000 CDM 73000 CPT 320 RC outpatient 362 362 MEDICA (COMMERCIAL) 94265 [3081118] MEDICA CLAIMS [308111801] 325.8 percent of total billed charges 224.44 343.9 Technical (Hospital) Services Radex Clavicle Complete PX-3207300000 CDM 73000 CPT 320 RC outpatient 362 362 HEALTHPARTNERS SX009 HEALTHPARTNERS 289.6 percent of total billed charges 224.44 343.9 Technical (Hospital) Services Radex Clavicle Complete PX-3207300000 CDM 73000 CPT 320 RC outpatient 362 362 BLUE CROSS BLUE SHIELD WELLMARK SB889 [3081026] BCBS WYOMING [308102603] 343.9 percent of total billed charges 224.44 343.9 Technical (Hospital) Services Radex Clavicle Complete PX-3207300000 CDM 73000 CPT 320 RC outpatient 362 362 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES HDHP [308136802] 289.6 percent of total billed charges 224.44 343.9 Technical (Hospital) Services Radex Clavicle Complete PX-3207300000 CDM 73000 CPT 320 RC outpatient 362 362 MULTIPLAN INC 34080 [3081285] MULTIPLAN INC [308128501] 343.9 percent of total billed charges 224.44 343.9 Technical (Hospital) Services Radex Clavicle Complete PX-3207300000 CDM 73000 CPT 320 RC outpatient 362 362 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES PPO [308136801] 289.6 percent of total billed charges 224.44 343.9 Technical (Hospital) Services Radex Clavicle Complete PX-3207300000 CDM 73000 CPT 320 RC outpatient 362 362 UNITED HEALTHCARE (COMMERCIAL) [3081199] UNITED HEALTHCARE 87726 [308119901] 224.44 percent of total billed charges 224.44 343.9 Technical (Hospital) Services Radex Clavicle Complete PX-3207300000 CDM 73000 CPT 320 RC outpatient 362 362 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES EPO [308136803] 289.6 percent of total billed charges 224.44 343.9 Technical (Hospital) Services Radex Sacrum & Coccyx Minimum 2 Views PX-3207222000 CDM 72220 CPT 320 RC inpatient 256 256 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES EPO [308136803] 202.7 percent of total billed charges 158.72 243.2 Technical (Hospital) Services Radex Sacrum & Coccyx Minimum 2 Views PX-3207222000 CDM 72220 CPT 320 RC inpatient 256 256 CIGNA 62308 [3081051] CIGNA 62308 [308105105] 202.7 percent of total billed charges 158.72 243.2 Technical (Hospital) Services Radex Sacrum & Coccyx Minimum 2 Views PX-3207222000 CDM 72220 CPT 320 RC inpatient 256 256 CIGNA 62308 [3081051] CIGNA STATE OF WYOMING [308105107] 202.7 percent of total billed charges 158.72 243.2 Technical (Hospital) Services Radex Sacrum & Coccyx Minimum 2 Views PX-3207222000 CDM 72220 CPT 320 RC inpatient 256 256 HEALTHPARTNERS SX009 HEALTHPARTNERS 202.7 percent of total billed charges 158.72 243.2 Technical (Hospital) Services Radex Sacrum & Coccyx Minimum 2 Views PX-3207222000 CDM 72220 CPT 320 RC inpatient 256 256 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES HDHP [308136802] 202.7 percent of total billed charges 158.72 243.2 Technical (Hospital) Services Radex Sacrum & Coccyx Minimum 2 Views PX-3207222000 CDM 72220 CPT 320 RC inpatient 256 256 MEDICA (COMMERCIAL) 94265 [3081118] MEDICA CLAIMS [308111801] 230.4 percent of total billed charges 158.72 243.2 Technical (Hospital) Services Radex Sacrum & Coccyx Minimum 2 Views PX-3207222000 CDM 72220 CPT 320 RC inpatient 256 256 UNITED HEALTHCARE (COMMERCIAL) [3081199] UNITED HEALTHCARE 87726 [308119901] 158.72 percent of total billed charges 158.72 243.2 Technical (Hospital) Services Radex Sacrum & Coccyx Minimum 2 Views PX-3207222000 CDM 72220 CPT 320 RC inpatient 256 256 MULTIPLAN INC 34080 [3081285] MULTIPLAN INC [308128501] 243.2 percent of total billed charges 158.72 243.2 Technical (Hospital) Services Radex Sacrum & Coccyx Minimum 2 Views PX-3207222000 CDM 72220 CPT 320 RC inpatient 256 256 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES PPO [308136801] 202.7 percent of total billed charges 158.72 243.2 Technical (Hospital) Services Radex Sacrum & Coccyx Minimum 2 Views PX-3207222000 CDM 72220 CPT 320 RC inpatient 256 256 BLUE CROSS BLUE SHIELD WELLMARK SB889 [3081026] BCBS WYOMING [308102603] 243.2 percent of total billed charges 158.72 243.2 Technical (Hospital) Services Radex Sacrum & Coccyx Minimum 2 Views PX-3207222000 CDM 72220 CPT 320 RC outpatient 256 256 HEALTHPARTNERS SX009 HEALTHPARTNERS 204.8 percent of total billed charges 158.72 243.2 Technical (Hospital) Services Radex Sacrum & Coccyx Minimum 2 Views PX-3207222000 CDM 72220 CPT 320 RC outpatient 256 256 UNITED HEALTHCARE (COMMERCIAL) [3081199] UNITED HEALTHCARE 87726 [308119901] 158.72 percent of total billed charges 158.72 243.2 Technical (Hospital) Services Radex Sacrum & Coccyx Minimum 2 Views PX-3207222000 CDM 72220 CPT 320 RC outpatient 256 256 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES PPO [308136801] 204.8 percent of total billed charges 158.72 243.2 Technical (Hospital) Services Radex Sacrum & Coccyx Minimum 2 Views PX-3207222000 CDM 72220 CPT 320 RC outpatient 256 256 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES EPO [308136803] 204.8 percent of total billed charges 158.72 243.2 Technical (Hospital) Services Radex Sacrum & Coccyx Minimum 2 Views PX-3207222000 CDM 72220 CPT 320 RC outpatient 256 256 BLUE CROSS BLUE SHIELD WELLMARK SB889 [3081026] BCBS WYOMING [308102603] 243.2 percent of total billed charges 158.72 243.2 Technical (Hospital) Services Radex Sacrum & Coccyx Minimum 2 Views PX-3207222000 CDM 72220 CPT 320 RC outpatient 256 256 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES HDHP [308136802] 204.8 percent of total billed charges 158.72 243.2 Technical (Hospital) Services Radex Sacrum & Coccyx Minimum 2 Views PX-3207222000 CDM 72220 CPT 320 RC outpatient 256 256 MULTIPLAN INC 34080 [3081285] MULTIPLAN INC [308128501] 243.2 percent of total billed charges 158.72 243.2 Technical (Hospital) Services Radex Sacrum & Coccyx Minimum 2 Views PX-3207222000 CDM 72220 CPT 320 RC outpatient 256 256 MEDICA (COMMERCIAL) 94265 [3081118] MEDICA CLAIMS [308111801] 230.4 percent of total billed charges 158.72 243.2 Technical (Hospital) Services Radex Sacrum & Coccyx Minimum 2 Views PX-3207222000 CDM 72220 CPT 320 RC outpatient 256 256 CIGNA 62308 [3081051] CIGNA 62308 [308105105] 204.8 percent of total billed charges 158.72 243.2 Technical (Hospital) Services Radex Sacrum & Coccyx Minimum 2 Views PX-3207222000 CDM 72220 CPT 320 RC outpatient 256 256 CIGNA 62308 [3081051] CIGNA STATE OF WYOMING [308105107] 204.8 percent of total billed charges 158.72 243.2 Technical (Hospital) Services Radiologic Exam Sacroiliac Joints 3/More Views PX-3207220200 CDM 72202 CPT 320 RC inpatient 298 298 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES HDHP [308136802] 235.96 percent of total billed charges 184.76 283.1 Technical (Hospital) Services Radiologic Exam Sacroiliac Joints 3/More Views PX-3207220200 CDM 72202 CPT 320 RC inpatient 298 298 MEDICA (COMMERCIAL) 94265 [3081118] MEDICA CLAIMS [308111801] 268.2 percent of total billed charges 184.76 283.1 Technical (Hospital) Services Radiologic Exam Sacroiliac Joints 3/More Views PX-3207220200 CDM 72202 CPT 320 RC inpatient 298 298 HEALTHPARTNERS SX009 HEALTHPARTNERS 235.96 percent of total billed charges 184.76 283.1 Technical (Hospital) Services Radiologic Exam Sacroiliac Joints 3/More Views PX-3207220200 CDM 72202 CPT 320 RC inpatient 298 298 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES PPO [308136801] 235.96 percent of total billed charges 184.76 283.1 Technical (Hospital) Services Radiologic Exam Sacroiliac Joints 3/More Views PX-3207220200 CDM 72202 CPT 320 RC inpatient 298 298 MULTIPLAN INC 34080 [3081285] MULTIPLAN INC [308128501] 283.1 percent of total billed charges 184.76 283.1 Technical (Hospital) Services Radiologic Exam Sacroiliac Joints 3/More Views PX-3207220200 CDM 72202 CPT 320 RC inpatient 298 298 BLUE CROSS BLUE SHIELD WELLMARK SB889 [3081026] BCBS WYOMING [308102603] 283.1 percent of total billed charges 184.76 283.1 Technical (Hospital) Services Radiologic Exam Sacroiliac Joints 3/More Views PX-3207220200 CDM 72202 CPT 320 RC inpatient 298 298 UNITED HEALTHCARE (COMMERCIAL) [3081199] UNITED HEALTHCARE 87726 [308119901] 184.76 percent of total billed charges 184.76 283.1 Technical (Hospital) Services Radiologic Exam Sacroiliac Joints 3/More Views PX-3207220200 CDM 72202 CPT 320 RC inpatient 298 298 CIGNA 62308 [3081051] CIGNA 62308 [308105105] 235.96 percent of total billed charges 184.76 283.1 Technical (Hospital) Services Radiologic Exam Sacroiliac Joints 3/More Views PX-3207220200 CDM 72202 CPT 320 RC inpatient 298 298 CIGNA 62308 [3081051] CIGNA STATE OF WYOMING [308105107] 235.96 percent of total billed charges 184.76 283.1 Technical (Hospital) Services Radiologic Exam Sacroiliac Joints 3/More Views PX-3207220200 CDM 72202 CPT 320 RC inpatient 298 298 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES EPO [308136803] 235.96 percent of total billed charges 184.76 283.1 Technical (Hospital) Services Radiologic Exam Sacroiliac Joints 3/More Views PX-3207220200 CDM 72202 CPT 320 RC outpatient 298 298 UNITED HEALTHCARE (COMMERCIAL) [3081199] UNITED HEALTHCARE 87726 [308119901] 184.76 percent of total billed charges 184.76 283.1 Technical (Hospital) Services Radiologic Exam Sacroiliac Joints 3/More Views PX-3207220200 CDM 72202 CPT 320 RC outpatient 298 298 HEALTHPARTNERS SX009 HEALTHPARTNERS 238.4 percent of total billed charges 184.76 283.1 Technical (Hospital) Services Radiologic Exam Sacroiliac Joints 3/More Views PX-3207220200 CDM 72202 CPT 320 RC outpatient 298 298 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES PPO [308136801] 238.4 percent of total billed charges 184.76 283.1 Technical (Hospital) Services Radiologic Exam Sacroiliac Joints 3/More Views PX-3207220200 CDM 72202 CPT 320 RC outpatient 298 298 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES EPO [308136803] 238.4 percent of total billed charges 184.76 283.1 Technical (Hospital) Services Radiologic Exam Sacroiliac Joints 3/More Views PX-3207220200 CDM 72202 CPT 320 RC outpatient 298 298 MULTIPLAN INC 34080 [3081285] MULTIPLAN INC [308128501] 283.1 percent of total billed charges 184.76 283.1 Technical (Hospital) Services Radiologic Exam Sacroiliac Joints 3/More Views PX-3207220200 CDM 72202 CPT 320 RC outpatient 298 298 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES HDHP [308136802] 238.4 percent of total billed charges 184.76 283.1 Technical (Hospital) Services Radiologic Exam Sacroiliac Joints 3/More Views PX-3207220200 CDM 72202 CPT 320 RC outpatient 298 298 BLUE CROSS BLUE SHIELD WELLMARK SB889 [3081026] BCBS WYOMING [308102603] 283.1 percent of total billed charges 184.76 283.1 Technical (Hospital) Services Radiologic Exam Sacroiliac Joints 3/More Views PX-3207220200 CDM 72202 CPT 320 RC outpatient 298 298 CIGNA 62308 [3081051] CIGNA 62308 [308105105] 238.4 percent of total billed charges 184.76 283.1 Technical (Hospital) Services Radiologic Exam Sacroiliac Joints 3/More Views PX-3207220200 CDM 72202 CPT 320 RC outpatient 298 298 CIGNA 62308 [3081051] CIGNA STATE OF WYOMING [308105107] 238.4 percent of total billed charges 184.76 283.1 Technical (Hospital) Services Radiologic Exam Sacroiliac Joints 3/More Views PX-3207220200 CDM 72202 CPT 320 RC outpatient 298 298 MEDICA (COMMERCIAL) 94265 [3081118] MEDICA CLAIMS [308111801] 268.2 percent of total billed charges 184.76 283.1 Technical (Hospital) Services Radiologic Examination Sacroiliac Jnts <3 Views PX-3207220000 CDM 72200 CPT 320 RC outpatient 161 161 HEALTHPARTNERS SX009 HEALTHPARTNERS 128.8 percent of total billed charges 99.82 152.95 Technical (Hospital) Services Radiologic Examination Sacroiliac Jnts <3 Views PX-3207220000 CDM 72200 CPT 320 RC outpatient 161 161 MEDICA (COMMERCIAL) 94265 [3081118] MEDICA CLAIMS [308111801] 144.9 percent of total billed charges 99.82 152.95 Technical (Hospital) Services Radiologic Examination Sacroiliac Jnts <3 Views PX-3207220000 CDM 72200 CPT 320 RC outpatient 161 161 UNITED HEALTHCARE (COMMERCIAL) [3081199] UNITED HEALTHCARE 87726 [308119901] 99.82 percent of total billed charges 99.82 152.95 Technical (Hospital) Services Radiologic Examination Sacroiliac Jnts <3 Views PX-3207220000 CDM 72200 CPT 320 RC outpatient 161 161 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES EPO [308136803] 128.8 percent of total billed charges 99.82 152.95 Technical (Hospital) Services Radiologic Examination Sacroiliac Jnts <3 Views PX-3207220000 CDM 72200 CPT 320 RC outpatient 161 161 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES PPO [308136801] 128.8 percent of total billed charges 99.82 152.95 Technical (Hospital) Services Radiologic Examination Sacroiliac Jnts <3 Views PX-3207220000 CDM 72200 CPT 320 RC outpatient 161 161 BLUE CROSS BLUE SHIELD WELLMARK SB889 [3081026] BCBS WYOMING [308102603] 152.95 percent of total billed charges 99.82 152.95 Technical (Hospital) Services Radiologic Examination Sacroiliac Jnts <3 Views PX-3207220000 CDM 72200 CPT 320 RC outpatient 161 161 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES HDHP [308136802] 128.8 percent of total billed charges 99.82 152.95 Technical (Hospital) Services Radiologic Examination Sacroiliac Jnts <3 Views PX-3207220000 CDM 72200 CPT 320 RC outpatient 161 161 MULTIPLAN INC 34080 [3081285] MULTIPLAN INC [308128501] 152.95 percent of total billed charges 99.82 152.95 Technical (Hospital) Services Radiologic Examination Sacroiliac Jnts <3 Views PX-3207220000 CDM 72200 CPT 320 RC outpatient 161 161 CIGNA 62308 [3081051] CIGNA 62308 [308105105] 128.8 percent of total billed charges 99.82 152.95 Technical (Hospital) Services Radiologic Examination Sacroiliac Jnts <3 Views PX-3207220000 CDM 72200 CPT 320 RC outpatient 161 161 CIGNA 62308 [3081051] CIGNA STATE OF WYOMING [308105107] 128.8 percent of total billed charges 99.82 152.95 Technical (Hospital) Services Radiologic Examination Sacroiliac Jnts <3 Views PX-3207220000 CDM 72200 CPT 320 RC inpatient 161 161 MEDICA (COMMERCIAL) 94265 [3081118] MEDICA CLAIMS [308111801] 144.9 percent of total billed charges 99.82 152.95 Technical (Hospital) Services Radiologic Examination Sacroiliac Jnts <3 Views PX-3207220000 CDM 72200 CPT 320 RC inpatient 161 161 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES HDHP [308136802] 127.48 percent of total billed charges 99.82 152.95 Technical (Hospital) Services Radiologic Examination Sacroiliac Jnts <3 Views PX-3207220000 CDM 72200 CPT 320 RC inpatient 161 161 HEALTHPARTNERS SX009 HEALTHPARTNERS 127.48 percent of total billed charges 99.82 152.95 Technical (Hospital) Services Radiologic Examination Sacroiliac Jnts <3 Views PX-3207220000 CDM 72200 CPT 320 RC inpatient 161 161 MULTIPLAN INC 34080 [3081285] MULTIPLAN INC [308128501] 152.95 percent of total billed charges 99.82 152.95 Technical (Hospital) Services Radiologic Examination Sacroiliac Jnts <3 Views PX-3207220000 CDM 72200 CPT 320 RC inpatient 161 161 BLUE CROSS BLUE SHIELD WELLMARK SB889 [3081026] BCBS WYOMING [308102603] 152.95 percent of total billed charges 99.82 152.95 Technical (Hospital) Services Radiologic Examination Sacroiliac Jnts <3 Views PX-3207220000 CDM 72200 CPT 320 RC inpatient 161 161 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES PPO [308136801] 127.48 percent of total billed charges 99.82 152.95 Technical (Hospital) Services Radiologic Examination Sacroiliac Jnts <3 Views PX-3207220000 CDM 72200 CPT 320 RC inpatient 161 161 UNITED HEALTHCARE (COMMERCIAL) [3081199] UNITED HEALTHCARE 87726 [308119901] 99.82 percent of total billed charges 99.82 152.95 Technical (Hospital) Services Radiologic Examination Sacroiliac Jnts <3 Views PX-3207220000 CDM 72200 CPT 320 RC inpatient 161 161 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES EPO [308136803] 127.48 percent of total billed charges 99.82 152.95 Technical (Hospital) Services Radiologic Examination Sacroiliac Jnts <3 Views PX-3207220000 CDM 72200 CPT 320 RC inpatient 161 161 CIGNA 62308 [3081051] CIGNA 62308 [308105105] 127.48 percent of total billed charges 99.82 152.95 Technical (Hospital) Services Radiologic Examination Sacroiliac Jnts <3 Views PX-3207220000 CDM 72200 CPT 320 RC inpatient 161 161 CIGNA 62308 [3081051] CIGNA STATE OF WYOMING [308105107] 127.48 percent of total billed charges 99.82 152.95 Technical (Hospital) Services Mra Pelvis W/ Contrast Material PX-6187219800 CDM 72198 CPT 618 RC outpatient 3799 3799 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES EPO [308136803] 3039.2 percent of total billed charges 2355.38 3609.05 Technical (Hospital) Services Mra Pelvis W/ Contrast Material PX-6187219800 CDM 72198 CPT 618 RC outpatient 3799 3799 UNITED HEALTHCARE (COMMERCIAL) [3081199] UNITED HEALTHCARE 87726 [308119901] 2355.38 percent of total billed charges 2355.38 3609.05 Technical (Hospital) Services Mra Pelvis W/ Contrast Material PX-6187219800 CDM 72198 CPT 618 RC outpatient 3799 3799 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES PPO [308136801] 3039.2 percent of total billed charges 2355.38 3609.05 Technical (Hospital) Services Mra Pelvis W/ Contrast Material PX-6187219800 CDM 72198 CPT 618 RC outpatient 3799 3799 BLUE CROSS BLUE SHIELD WELLMARK SB889 [3081026] BCBS WYOMING [308102603] 3609.05 percent of total billed charges 2355.38 3609.05 Technical (Hospital) Services Mra Pelvis W/ Contrast Material PX-6187219800 CDM 72198 CPT 618 RC outpatient 3799 3799 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES HDHP [308136802] 3039.2 percent of total billed charges 2355.38 3609.05 Technical (Hospital) Services Mra Pelvis W/ Contrast Material PX-6187219800 CDM 72198 CPT 618 RC outpatient 3799 3799 MULTIPLAN INC 34080 [3081285] MULTIPLAN INC [308128501] 3609.05 percent of total billed charges 2355.38 3609.05 Technical (Hospital) Services Mra Pelvis W/ Contrast Material PX-6187219800 CDM 72198 CPT 618 RC outpatient 3799 3799 HEALTHPARTNERS SX009 HEALTHPARTNERS 3039.2 percent of total billed charges 2355.38 3609.05 Technical (Hospital) Services Mra Pelvis W/ Contrast Material PX-6187219800 CDM 72198 CPT 618 RC outpatient 3799 3799 MEDICA (COMMERCIAL) 94265 [3081118] MEDICA CLAIMS [308111801] 3419.1 percent of total billed charges 2355.38 3609.05 Technical (Hospital) Services Mra Pelvis W/ Contrast Material PX-6187219800 CDM 72198 CPT 618 RC outpatient 3799 3799 CIGNA 62308 [3081051] CIGNA 62308 [308105105] 3039.2 percent of total billed charges 2355.38 3609.05 Technical (Hospital) Services Mra Pelvis W/ Contrast Material PX-6187219800 CDM 72198 CPT 618 RC outpatient 3799 3799 CIGNA 62308 [3081051] CIGNA STATE OF WYOMING [308105107] 3039.2 percent of total billed charges 2355.38 3609.05 Technical (Hospital) Services Mra Pelvis W/ Contrast Material PX-6187219800 CDM 72198 CPT 618 RC inpatient 3799 3799 UNITED HEALTHCARE (COMMERCIAL) [3081199] UNITED HEALTHCARE 87726 [308119901] 2355.38 percent of total billed charges 2355.38 3609.05 Technical (Hospital) Services Mra Pelvis W/ Contrast Material PX-6187219800 CDM 72198 CPT 618 RC inpatient 3799 3799 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES PPO [308136801] 3008.05 percent of total billed charges 2355.38 3609.05 Technical (Hospital) Services Mra Pelvis W/ Contrast Material PX-6187219800 CDM 72198 CPT 618 RC inpatient 3799 3799 BLUE CROSS BLUE SHIELD WELLMARK SB889 [3081026] BCBS WYOMING [308102603] 3609.05 percent of total billed charges 2355.38 3609.05 Technical (Hospital) Services Mra Pelvis W/ Contrast Material PX-6187219800 CDM 72198 CPT 618 RC inpatient 3799 3799 MULTIPLAN INC 34080 [3081285] MULTIPLAN INC [308128501] 3609.05 percent of total billed charges 2355.38 3609.05 Technical (Hospital) Services Mra Pelvis W/ Contrast Material PX-6187219800 CDM 72198 CPT 618 RC inpatient 3799 3799 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES HDHP [308136802] 3008.05 percent of total billed charges 2355.38 3609.05 Technical (Hospital) Services Mra Pelvis W/ Contrast Material PX-6187219800 CDM 72198 CPT 618 RC inpatient 3799 3799 MEDICA (COMMERCIAL) 94265 [3081118] MEDICA CLAIMS [308111801] 3419.1 percent of total billed charges 2355.38 3609.05 Technical (Hospital) Services Mra Pelvis W/ Contrast Material PX-6187219800 CDM 72198 CPT 618 RC inpatient 3799 3799 HEALTHPARTNERS SX009 HEALTHPARTNERS 3008.05 percent of total billed charges 2355.38 3609.05 Technical (Hospital) Services Mra Pelvis W/ Contrast Material PX-6187219800 CDM 72198 CPT 618 RC inpatient 3799 3799 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES EPO [308136803] 3008.05 percent of total billed charges 2355.38 3609.05 Technical (Hospital) Services Mra Pelvis W/ Contrast Material PX-6187219800 CDM 72198 CPT 618 RC inpatient 3799 3799 CIGNA 62308 [3081051] CIGNA 62308 [308105105] 3008.05 percent of total billed charges 2355.38 3609.05 Technical (Hospital) Services Mra Pelvis W/ Contrast Material PX-6187219800 CDM 72198 CPT 618 RC inpatient 3799 3799 CIGNA 62308 [3081051] CIGNA STATE OF WYOMING [308105107] 3008.05 percent of total billed charges 2355.38 3609.05 Technical (Hospital) Services MRI Pelvis W/O & W/Contrast Material PX-6147219700 CDM 72197 CPT 614 RC outpatient 4192 4192 MEDICA (COMMERCIAL) 94265 [3081118] MEDICA CLAIMS [308111801] 3772.8 percent of total billed charges 2599.04 3982.4 Technical (Hospital) Services MRI Pelvis W/O & W/Contrast Material PX-6147219700 CDM 72197 CPT 614 RC outpatient 4192 4192 CIGNA 62308 [3081051] CIGNA 62308 [308105105] 3353.6 percent of total billed charges 2599.04 3982.4 Technical (Hospital) Services MRI Pelvis W/O & W/Contrast Material PX-6147219700 CDM 72197 CPT 614 RC outpatient 4192 4192 CIGNA 62308 [3081051] CIGNA STATE OF WYOMING [308105107] 3353.6 percent of total billed charges 2599.04 3982.4 Technical (Hospital) Services MRI Pelvis W/O & W/Contrast Material PX-6147219700 CDM 72197 CPT 614 RC outpatient 4192 4192 BLUE CROSS BLUE SHIELD WELLMARK SB889 [3081026] BCBS WYOMING [308102603] 3982.4 percent of total billed charges 2599.04 3982.4 Technical (Hospital) Services MRI Pelvis W/O & W/Contrast Material PX-6147219700 CDM 72197 CPT 614 RC outpatient 4192 4192 MULTIPLAN INC 34080 [3081285] MULTIPLAN INC [308128501] 3982.4 percent of total billed charges 2599.04 3982.4 Technical (Hospital) Services MRI Pelvis W/O & W/Contrast Material PX-6147219700 CDM 72197 CPT 614 RC outpatient 4192 4192 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES HDHP [308136802] 3353.6 percent of total billed charges 2599.04 3982.4 Technical (Hospital) Services MRI Pelvis W/O & W/Contrast Material PX-6147219700 CDM 72197 CPT 614 RC outpatient 4192 4192 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES EPO [308136803] 3353.6 percent of total billed charges 2599.04 3982.4 Technical (Hospital) Services MRI Pelvis W/O & W/Contrast Material PX-6147219700 CDM 72197 CPT 614 RC outpatient 4192 4192 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES PPO [308136801] 3353.6 percent of total billed charges 2599.04 3982.4 Technical (Hospital) Services MRI Pelvis W/O & W/Contrast Material PX-6147219700 CDM 72197 CPT 614 RC outpatient 4192 4192 UNITED HEALTHCARE (COMMERCIAL) [3081199] UNITED HEALTHCARE 87726 [308119901] 2599.04 percent of total billed charges 2599.04 3982.4 Technical (Hospital) Services MRI Pelvis W/O & W/Contrast Material PX-6147219700 CDM 72197 CPT 614 RC outpatient 4192 4192 HEALTHPARTNERS SX009 HEALTHPARTNERS 3353.6 percent of total billed charges 2599.04 3982.4 Technical (Hospital) Services MRI Pelvis W/O & W/Contrast Material PX-6147219700 CDM 72197 CPT 614 RC inpatient 4192 4192 HEALTHPARTNERS SX009 HEALTHPARTNERS 3319.23 percent of total billed charges 2599.04 3982.4 Technical (Hospital) Services MRI Pelvis W/O & W/Contrast Material PX-6147219700 CDM 72197 CPT 614 RC inpatient 4192 4192 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES EPO [308136803] 3319.23 percent of total billed charges 2599.04 3982.4 Technical (Hospital) Services MRI Pelvis W/O & W/Contrast Material PX-6147219700 CDM 72197 CPT 614 RC inpatient 4192 4192 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES HDHP [308136802] 3319.23 percent of total billed charges 2599.04 3982.4 Technical (Hospital) Services MRI Pelvis W/O & W/Contrast Material PX-6147219700 CDM 72197 CPT 614 RC inpatient 4192 4192 MEDICA (COMMERCIAL) 94265 [3081118] MEDICA CLAIMS [308111801] 3772.8 percent of total billed charges 2599.04 3982.4 Technical (Hospital) Services MRI Pelvis W/O & W/Contrast Material PX-6147219700 CDM 72197 CPT 614 RC inpatient 4192 4192 MULTIPLAN INC 34080 [3081285] MULTIPLAN INC [308128501] 3982.4 percent of total billed charges 2599.04 3982.4 Technical (Hospital) Services MRI Pelvis W/O & W/Contrast Material PX-6147219700 CDM 72197 CPT 614 RC inpatient 4192 4192 BLUE CROSS BLUE SHIELD WELLMARK SB889 [3081026] BCBS WYOMING [308102603] 3982.4 percent of total billed charges 2599.04 3982.4 Technical (Hospital) Services MRI Pelvis W/O & W/Contrast Material PX-6147219700 CDM 72197 CPT 614 RC inpatient 4192 4192 UNITED HEALTHCARE (COMMERCIAL) [3081199] UNITED HEALTHCARE 87726 [308119901] 2599.04 percent of total billed charges 2599.04 3982.4 Technical (Hospital) Services MRI Pelvis W/O & W/Contrast Material PX-6147219700 CDM 72197 CPT 614 RC inpatient 4192 4192 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES PPO [308136801] 3319.23 percent of total billed charges 2599.04 3982.4 Technical (Hospital) Services MRI Pelvis W/O & W/Contrast Material PX-6147219700 CDM 72197 CPT 614 RC inpatient 4192 4192 CIGNA 62308 [3081051] CIGNA 62308 [308105105] 3319.23 percent of total billed charges 2599.04 3982.4 Technical (Hospital) Services MRI Pelvis W/O & W/Contrast Material PX-6147219700 CDM 72197 CPT 614 RC inpatient 4192 4192 CIGNA 62308 [3081051] CIGNA STATE OF WYOMING [308105107] 3319.23 percent of total billed charges 2599.04 3982.4 Technical (Hospital) Services MRI Pelvis W/Contrast Material PX-6147219600 CDM 72196 CPT 614 RC outpatient 3275 3275 CIGNA 62308 [3081051] CIGNA 62308 [308105105] 2620 percent of total billed charges 2030.5 3111.25 Technical (Hospital) Services MRI Pelvis W/Contrast Material PX-6147219600 CDM 72196 CPT 614 RC outpatient 3275 3275 CIGNA 62308 [3081051] CIGNA STATE OF WYOMING [308105107] 2620 percent of total billed charges 2030.5 3111.25 Technical (Hospital) Services MRI Pelvis W/Contrast Material PX-6147219600 CDM 72196 CPT 614 RC outpatient 3275 3275 MEDICA (COMMERCIAL) 94265 [3081118] MEDICA CLAIMS [308111801] 2947.5 percent of total billed charges 2030.5 3111.25 Technical (Hospital) Services MRI Pelvis W/Contrast Material PX-6147219600 CDM 72196 CPT 614 RC outpatient 3275 3275 BLUE CROSS BLUE SHIELD WELLMARK SB889 [3081026] BCBS WYOMING [308102603] 3111.25 percent of total billed charges 2030.5 3111.25 Technical (Hospital) Services MRI Pelvis W/Contrast Material PX-6147219600 CDM 72196 CPT 614 RC outpatient 3275 3275 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES HDHP [308136802] 2620 percent of total billed charges 2030.5 3111.25 Technical (Hospital) Services MRI Pelvis W/Contrast Material PX-6147219600 CDM 72196 CPT 614 RC outpatient 3275 3275 MULTIPLAN INC 34080 [3081285] MULTIPLAN INC [308128501] 3111.25 percent of total billed charges 2030.5 3111.25 Technical (Hospital) Services MRI Pelvis W/Contrast Material PX-6147219600 CDM 72196 CPT 614 RC outpatient 3275 3275 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES EPO [308136803] 2620 percent of total billed charges 2030.5 3111.25 Technical (Hospital) Services MRI Pelvis W/Contrast Material PX-6147219600 CDM 72196 CPT 614 RC outpatient 3275 3275 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES PPO [308136801] 2620 percent of total billed charges 2030.5 3111.25 Technical (Hospital) Services MRI Pelvis W/Contrast Material PX-6147219600 CDM 72196 CPT 614 RC outpatient 3275 3275 HEALTHPARTNERS SX009 HEALTHPARTNERS 2620 percent of total billed charges 2030.5 3111.25 Technical (Hospital) Services MRI Pelvis W/Contrast Material PX-6147219600 CDM 72196 CPT 614 RC outpatient 3275 3275 UNITED HEALTHCARE (COMMERCIAL) [3081199] UNITED HEALTHCARE 87726 [308119901] 2030.5 percent of total billed charges 2030.5 3111.25 Technical (Hospital) Services MRI Pelvis W/Contrast Material PX-6147219600 CDM 72196 CPT 614 RC inpatient 3275 3275 MULTIPLAN INC 34080 [3081285] MULTIPLAN INC [308128501] 3111.25 percent of total billed charges 2030.5 3111.25 Technical (Hospital) Services MRI Pelvis W/Contrast Material PX-6147219600 CDM 72196 CPT 614 RC inpatient 3275 3275 BLUE CROSS BLUE SHIELD WELLMARK SB889 [3081026] BCBS WYOMING [308102603] 3111.25 percent of total billed charges 2030.5 3111.25 Technical (Hospital) Services MRI Pelvis W/Contrast Material PX-6147219600 CDM 72196 CPT 614 RC inpatient 3275 3275 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES HDHP [308136802] 2593.15 percent of total billed charges 2030.5 3111.25 Technical (Hospital) Services MRI Pelvis W/Contrast Material PX-6147219600 CDM 72196 CPT 614 RC inpatient 3275 3275 UNITED HEALTHCARE (COMMERCIAL) [3081199] UNITED HEALTHCARE 87726 [308119901] 2030.5 percent of total billed charges 2030.5 3111.25 Technical (Hospital) Services MRI Pelvis W/Contrast Material PX-6147219600 CDM 72196 CPT 614 RC inpatient 3275 3275 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES PPO [308136801] 2593.15 percent of total billed charges 2030.5 3111.25 Technical (Hospital) Services MRI Pelvis W/Contrast Material PX-6147219600 CDM 72196 CPT 614 RC inpatient 3275 3275 MEDICA (COMMERCIAL) 94265 [3081118] MEDICA CLAIMS [308111801] 2947.5 percent of total billed charges 2030.5 3111.25 Technical (Hospital) Services MRI Pelvis W/Contrast Material PX-6147219600 CDM 72196 CPT 614 RC inpatient 3275 3275 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES EPO [308136803] 2593.15 percent of total billed charges 2030.5 3111.25 Technical (Hospital) Services MRI Pelvis W/Contrast Material PX-6147219600 CDM 72196 CPT 614 RC inpatient 3275 3275 HEALTHPARTNERS SX009 HEALTHPARTNERS 2593.15 percent of total billed charges 2030.5 3111.25 Technical (Hospital) Services MRI Pelvis W/Contrast Material PX-6147219600 CDM 72196 CPT 614 RC inpatient 3275 3275 CIGNA 62308 [3081051] CIGNA 62308 [308105105] 2593.15 percent of total billed charges 2030.5 3111.25 Technical (Hospital) Services MRI Pelvis W/Contrast Material PX-6147219600 CDM 72196 CPT 614 RC inpatient 3275 3275 CIGNA 62308 [3081051] CIGNA STATE OF WYOMING [308105107] 2593.15 percent of total billed charges 2030.5 3111.25 Technical (Hospital) Services MRI Pelvis W/O Contrast Material PX-6147219500 CDM 72195 CPT 614 RC inpatient 2751 2751 CIGNA 62308 [3081051] CIGNA 62308 [308105105] 2178.24 percent of total billed charges 1705.62 2613.45 Technical (Hospital) Services MRI Pelvis W/O Contrast Material PX-6147219500 CDM 72195 CPT 614 RC inpatient 2751 2751 CIGNA 62308 [3081051] CIGNA STATE OF WYOMING [308105107] 2178.24 percent of total billed charges 1705.62 2613.45 Technical (Hospital) Services MRI Pelvis W/O Contrast Material PX-6147219500 CDM 72195 CPT 614 RC inpatient 2751 2751 MEDICA (COMMERCIAL) 94265 [3081118] MEDICA CLAIMS [308111801] 2475.9 percent of total billed charges 1705.62 2613.45 Technical (Hospital) Services MRI Pelvis W/O Contrast Material PX-6147219500 CDM 72195 CPT 614 RC inpatient 2751 2751 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES EPO [308136803] 2178.24 percent of total billed charges 1705.62 2613.45 Technical (Hospital) Services MRI Pelvis W/O Contrast Material PX-6147219500 CDM 72195 CPT 614 RC inpatient 2751 2751 HEALTHPARTNERS SX009 HEALTHPARTNERS 2178.24 percent of total billed charges 1705.62 2613.45 Technical (Hospital) Services MRI Pelvis W/O Contrast Material PX-6147219500 CDM 72195 CPT 614 RC inpatient 2751 2751 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES HDHP [308136802] 2178.24 percent of total billed charges 1705.62 2613.45 Technical (Hospital) Services MRI Pelvis W/O Contrast Material PX-6147219500 CDM 72195 CPT 614 RC inpatient 2751 2751 BLUE CROSS BLUE SHIELD WELLMARK SB889 [3081026] BCBS WYOMING [308102603] 2613.45 percent of total billed charges 1705.62 2613.45 Technical (Hospital) Services MRI Pelvis W/O Contrast Material PX-6147219500 CDM 72195 CPT 614 RC inpatient 2751 2751 MULTIPLAN INC 34080 [3081285] MULTIPLAN INC [308128501] 2613.45 percent of total billed charges 1705.62 2613.45 Technical (Hospital) Services MRI Pelvis W/O Contrast Material PX-6147219500 CDM 72195 CPT 614 RC inpatient 2751 2751 UNITED HEALTHCARE (COMMERCIAL) [3081199] UNITED HEALTHCARE 87726 [308119901] 1705.62 percent of total billed charges 1705.62 2613.45 Technical (Hospital) Services MRI Pelvis W/O Contrast Material PX-6147219500 CDM 72195 CPT 614 RC inpatient 2751 2751 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES PPO [308136801] 2178.24 percent of total billed charges 1705.62 2613.45 Technical (Hospital) Services MRI Pelvis W/O Contrast Material PX-6147219500 CDM 72195 CPT 614 RC outpatient 2751 2751 MEDICA (COMMERCIAL) 94265 [3081118] MEDICA CLAIMS [308111801] 2475.9 percent of total billed charges 1705.62 2613.45 Technical (Hospital) Services MRI Pelvis W/O Contrast Material PX-6147219500 CDM 72195 CPT 614 RC outpatient 2751 2751 CIGNA 62308 [3081051] CIGNA 62308 [308105105] 2200.8 percent of total billed charges 1705.62 2613.45 Technical (Hospital) Services MRI Pelvis W/O Contrast Material PX-6147219500 CDM 72195 CPT 614 RC outpatient 2751 2751 CIGNA 62308 [3081051] CIGNA STATE OF WYOMING [308105107] 2200.8 percent of total billed charges 1705.62 2613.45 Technical (Hospital) Services MRI Pelvis W/O Contrast Material PX-6147219500 CDM 72195 CPT 614 RC outpatient 2751 2751 UNITED HEALTHCARE (COMMERCIAL) [3081199] UNITED HEALTHCARE 87726 [308119901] 1705.62 percent of total billed charges 1705.62 2613.45 Technical (Hospital) Services MRI Pelvis W/O Contrast Material PX-6147219500 CDM 72195 CPT 614 RC outpatient 2751 2751 HEALTHPARTNERS SX009 HEALTHPARTNERS 2200.8 percent of total billed charges 1705.62 2613.45 Technical (Hospital) Services MRI Pelvis W/O Contrast Material PX-6147219500 CDM 72195 CPT 614 RC outpatient 2751 2751 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES PPO [308136801] 2200.8 percent of total billed charges 1705.62 2613.45 Technical (Hospital) Services MRI Pelvis W/O Contrast Material PX-6147219500 CDM 72195 CPT 614 RC outpatient 2751 2751 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES EPO [308136803] 2200.8 percent of total billed charges 1705.62 2613.45 Technical (Hospital) Services MRI Pelvis W/O Contrast Material PX-6147219500 CDM 72195 CPT 614 RC outpatient 2751 2751 BLUE CROSS BLUE SHIELD WELLMARK SB889 [3081026] BCBS WYOMING [308102603] 2613.45 percent of total billed charges 1705.62 2613.45 Technical (Hospital) Services MRI Pelvis W/O Contrast Material PX-6147219500 CDM 72195 CPT 614 RC outpatient 2751 2751 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES HDHP [308136802] 2200.8 percent of total billed charges 1705.62 2613.45 Technical (Hospital) Services MRI Pelvis W/O Contrast Material PX-6147219500 CDM 72195 CPT 614 RC outpatient 2751 2751 MULTIPLAN INC 34080 [3081285] MULTIPLAN INC [308128501] 2613.45 percent of total billed charges 1705.62 2613.45 Technical (Hospital) Services CT Pelvis W/O & W/Contrast Material PX-3527219400 CDM 72194 CPT 352 RC outpatient 2620 2620 CIGNA 62308 [3081051] CIGNA 62308 [308105105] 2096 percent of total billed charges 1624.4 2489 Technical (Hospital) Services CT Pelvis W/O & W/Contrast Material PX-3527219400 CDM 72194 CPT 352 RC outpatient 2620 2620 CIGNA 62308 [3081051] CIGNA STATE OF WYOMING [308105107] 2096 percent of total billed charges 1624.4 2489 Technical (Hospital) Services CT Pelvis W/O & W/Contrast Material PX-3527219400 CDM 72194 CPT 352 RC outpatient 2620 2620 MEDICA (COMMERCIAL) 94265 [3081118] MEDICA CLAIMS [308111801] 2358 percent of total billed charges 1624.4 2489 Technical (Hospital) Services CT Pelvis W/O & W/Contrast Material PX-3527219400 CDM 72194 CPT 352 RC outpatient 2620 2620 HEALTHPARTNERS SX009 HEALTHPARTNERS 2096 percent of total billed charges 1624.4 2489 Technical (Hospital) Services CT Pelvis W/O & W/Contrast Material PX-3527219400 CDM 72194 CPT 352 RC outpatient 2620 2620 UNITED HEALTHCARE (COMMERCIAL) [3081199] UNITED HEALTHCARE 87726 [308119901] 1624.4 percent of total billed charges 1624.4 2489 Technical (Hospital) Services CT Pelvis W/O & W/Contrast Material PX-3527219400 CDM 72194 CPT 352 RC outpatient 2620 2620 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES PPO [308136801] 2096 percent of total billed charges 1624.4 2489 Technical (Hospital) Services CT Pelvis W/O & W/Contrast Material PX-3527219400 CDM 72194 CPT 352 RC outpatient 2620 2620 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES EPO [308136803] 2096 percent of total billed charges 1624.4 2489 Technical (Hospital) Services CT Pelvis W/O & W/Contrast Material PX-3527219400 CDM 72194 CPT 352 RC outpatient 2620 2620 BLUE CROSS BLUE SHIELD WELLMARK SB889 [3081026] BCBS WYOMING [308102603] 2489 percent of total billed charges 1624.4 2489 Technical (Hospital) Services CT Pelvis W/O & W/Contrast Material PX-3527219400 CDM 72194 CPT 352 RC outpatient 2620 2620 MULTIPLAN INC 34080 [3081285] MULTIPLAN INC [308128501] 2489 percent of total billed charges 1624.4 2489 Technical (Hospital) Services CT Pelvis W/O & W/Contrast Material PX-3527219400 CDM 72194 CPT 352 RC outpatient 2620 2620 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES HDHP [308136802] 2096 percent of total billed charges 1624.4 2489 Technical (Hospital) Services CT Pelvis W/O & W/Contrast Material PX-3527219400 CDM 72194 CPT 352 RC inpatient 2620 2620 MULTIPLAN INC 34080 [3081285] MULTIPLAN INC [308128501] 2489 percent of total billed charges 1624.4 2489 Technical (Hospital) Services CT Pelvis W/O & W/Contrast Material PX-3527219400 CDM 72194 CPT 352 RC inpatient 2620 2620 BLUE CROSS BLUE SHIELD WELLMARK SB889 [3081026] BCBS WYOMING [308102603] 2489 percent of total billed charges 1624.4 2489 Technical (Hospital) Services CT Pelvis W/O & W/Contrast Material PX-3527219400 CDM 72194 CPT 352 RC inpatient 2620 2620 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES PPO [308136801] 2074.52 percent of total billed charges 1624.4 2489 Technical (Hospital) Services CT Pelvis W/O & W/Contrast Material PX-3527219400 CDM 72194 CPT 352 RC inpatient 2620 2620 UNITED HEALTHCARE (COMMERCIAL) [3081199] UNITED HEALTHCARE 87726 [308119901] 1624.4 percent of total billed charges 1624.4 2489 Technical (Hospital) Services CT Pelvis W/O & W/Contrast Material PX-3527219400 CDM 72194 CPT 352 RC inpatient 2620 2620 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES HDHP [308136802] 2074.52 percent of total billed charges 1624.4 2489 Technical (Hospital) Services CT Pelvis W/O & W/Contrast Material PX-3527219400 CDM 72194 CPT 352 RC inpatient 2620 2620 MEDICA (COMMERCIAL) 94265 [3081118] MEDICA CLAIMS [308111801] 2358 percent of total billed charges 1624.4 2489 Technical (Hospital) Services CT Pelvis W/O & W/Contrast Material PX-3527219400 CDM 72194 CPT 352 RC inpatient 2620 2620 HEALTHPARTNERS SX009 HEALTHPARTNERS 2074.52 percent of total billed charges 1624.4 2489 Technical (Hospital) Services CT Pelvis W/O & W/Contrast Material PX-3527219400 CDM 72194 CPT 352 RC inpatient 2620 2620 CIGNA 62308 [3081051] CIGNA 62308 [308105105] 2074.52 percent of total billed charges 1624.4 2489 Technical (Hospital) Services CT Pelvis W/O & W/Contrast Material PX-3527219400 CDM 72194 CPT 352 RC inpatient 2620 2620 CIGNA 62308 [3081051] CIGNA STATE OF WYOMING [308105107] 2074.52 percent of total billed charges 1624.4 2489 Technical (Hospital) Services CT Pelvis W/O & W/Contrast Material PX-3527219400 CDM 72194 CPT 352 RC inpatient 2620 2620 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES EPO [308136803] 2074.52 percent of total billed charges 1624.4 2489 Technical (Hospital) Services CT Pelvis W/Contrast Material PX-3527219300 CDM 72193 CPT 352 RC outpatient 2292 2292 CIGNA 62308 [3081051] CIGNA 62308 [308105105] 1833.6 percent of total billed charges 1421.04 2177.4 Technical (Hospital) Services CT Pelvis W/Contrast Material PX-3527219300 CDM 72193 CPT 352 RC outpatient 2292 2292 CIGNA 62308 [3081051] CIGNA STATE OF WYOMING [308105107] 1833.6 percent of total billed charges 1421.04 2177.4 Technical (Hospital) Services CT Pelvis W/Contrast Material PX-3527219300 CDM 72193 CPT 352 RC outpatient 2292 2292 MEDICA (COMMERCIAL) 94265 [3081118] MEDICA CLAIMS [308111801] 2062.8 percent of total billed charges 1421.04 2177.4 Technical (Hospital) Services CT Pelvis W/Contrast Material PX-3527219300 CDM 72193 CPT 352 RC outpatient 2292 2292 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES EPO [308136803] 1833.6 percent of total billed charges 1421.04 2177.4 Technical (Hospital) Services CT Pelvis W/Contrast Material PX-3527219300 CDM 72193 CPT 352 RC outpatient 2292 2292 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES PPO [308136801] 1833.6 percent of total billed charges 1421.04 2177.4 Technical (Hospital) Services CT Pelvis W/Contrast Material PX-3527219300 CDM 72193 CPT 352 RC outpatient 2292 2292 UNITED HEALTHCARE (COMMERCIAL) [3081199] UNITED HEALTHCARE 87726 [308119901] 1421.04 percent of total billed charges 1421.04 2177.4 Technical (Hospital) Services CT Pelvis W/Contrast Material PX-3527219300 CDM 72193 CPT 352 RC outpatient 2292 2292 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES HDHP [308136802] 1833.6 percent of total billed charges 1421.04 2177.4 Technical (Hospital) Services CT Pelvis W/Contrast Material PX-3527219300 CDM 72193 CPT 352 RC outpatient 2292 2292 MULTIPLAN INC 34080 [3081285] MULTIPLAN INC [308128501] 2177.4 percent of total billed charges 1421.04 2177.4 Technical (Hospital) Services CT Pelvis W/Contrast Material PX-3527219300 CDM 72193 CPT 352 RC outpatient 2292 2292 BLUE CROSS BLUE SHIELD WELLMARK SB889 [3081026] BCBS WYOMING [308102603] 2177.4 percent of total billed charges 1421.04 2177.4 Technical (Hospital) Services CT Pelvis W/Contrast Material PX-3527219300 CDM 72193 CPT 352 RC outpatient 2292 2292 HEALTHPARTNERS SX009 HEALTHPARTNERS 1833.6 percent of total billed charges 1421.04 2177.4 Technical (Hospital) Services CT Pelvis W/Contrast Material PX-3527219300 CDM 72193 CPT 352 RC inpatient 2292 2292 HEALTHPARTNERS SX009 HEALTHPARTNERS 1814.81 percent of total billed charges 1421.04 2177.4 Technical (Hospital) Services CT Pelvis W/Contrast Material PX-3527219300 CDM 72193 CPT 352 RC inpatient 2292 2292 MEDICA (COMMERCIAL) 94265 [3081118] MEDICA CLAIMS [308111801] 2062.8 percent of total billed charges 1421.04 2177.4 Technical (Hospital) Services CT Pelvis W/Contrast Material PX-3527219300 CDM 72193 CPT 352 RC inpatient 2292 2292 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES HDHP [308136802] 1814.81 percent of total billed charges 1421.04 2177.4 Technical (Hospital) Services CT Pelvis W/Contrast Material PX-3527219300 CDM 72193 CPT 352 RC inpatient 2292 2292 MULTIPLAN INC 34080 [3081285] MULTIPLAN INC [308128501] 2177.4 percent of total billed charges 1421.04 2177.4 Technical (Hospital) Services CT Pelvis W/Contrast Material PX-3527219300 CDM 72193 CPT 352 RC inpatient 2292 2292 BLUE CROSS BLUE SHIELD WELLMARK SB889 [3081026] BCBS WYOMING [308102603] 2177.4 percent of total billed charges 1421.04 2177.4 Technical (Hospital) Services CT Pelvis W/Contrast Material PX-3527219300 CDM 72193 CPT 352 RC inpatient 2292 2292 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES PPO [308136801] 1814.81 percent of total billed charges 1421.04 2177.4 Technical (Hospital) Services CT Pelvis W/Contrast Material PX-3527219300 CDM 72193 CPT 352 RC inpatient 2292 2292 UNITED HEALTHCARE (COMMERCIAL) [3081199] UNITED HEALTHCARE 87726 [308119901] 1421.04 percent of total billed charges 1421.04 2177.4 Technical (Hospital) Services CT Pelvis W/Contrast Material PX-3527219300 CDM 72193 CPT 352 RC inpatient 2292 2292 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES EPO [308136803] 1814.81 percent of total billed charges 1421.04 2177.4 Technical (Hospital) Services CT Pelvis W/Contrast Material PX-3527219300 CDM 72193 CPT 352 RC inpatient 2292 2292 CIGNA 62308 [3081051] CIGNA 62308 [308105105] 1814.81 percent of total billed charges 1421.04 2177.4 Technical (Hospital) Services CT Pelvis W/Contrast Material PX-3527219300 CDM 72193 CPT 352 RC inpatient 2292 2292 CIGNA 62308 [3081051] CIGNA STATE OF WYOMING [308105107] 1814.81 percent of total billed charges 1421.04 2177.4 Technical (Hospital) Services CT Pelvis W/O Contrast Material PX-3527219200 CDM 72192 CPT 352 RC outpatient 1786 1786 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES EPO [308136803] 1428.8 percent of total billed charges 1107.32 1696.7 Technical (Hospital) Services CT Pelvis W/O Contrast Material PX-3527219200 CDM 72192 CPT 352 RC outpatient 1786 1786 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES PPO [308136801] 1428.8 percent of total billed charges 1107.32 1696.7 Technical (Hospital) Services CT Pelvis W/O Contrast Material PX-3527219200 CDM 72192 CPT 352 RC outpatient 1786 1786 UNITED HEALTHCARE (COMMERCIAL) [3081199] UNITED HEALTHCARE 87726 [308119901] 1107.32 percent of total billed charges 1107.32 1696.7 Technical (Hospital) Services CT Pelvis W/O Contrast Material PX-3527219200 CDM 72192 CPT 352 RC outpatient 1786 1786 BLUE CROSS BLUE SHIELD WELLMARK SB889 [3081026] BCBS WYOMING [308102603] 1696.7 percent of total billed charges 1107.32 1696.7 Technical (Hospital) Services CT Pelvis W/O Contrast Material PX-3527219200 CDM 72192 CPT 352 RC outpatient 1786 1786 MULTIPLAN INC 34080 [3081285] MULTIPLAN INC [308128501] 1696.7 percent of total billed charges 1107.32 1696.7 Technical (Hospital) Services CT Pelvis W/O Contrast Material PX-3527219200 CDM 72192 CPT 352 RC outpatient 1786 1786 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES HDHP [308136802] 1428.8 percent of total billed charges 1107.32 1696.7 Technical (Hospital) Services CT Pelvis W/O Contrast Material PX-3527219200 CDM 72192 CPT 352 RC outpatient 1786 1786 HEALTHPARTNERS SX009 HEALTHPARTNERS 1428.8 percent of total billed charges 1107.32 1696.7 Technical (Hospital) Services CT Pelvis W/O Contrast Material PX-3527219200 CDM 72192 CPT 352 RC outpatient 1786 1786 MEDICA (COMMERCIAL) 94265 [3081118] MEDICA CLAIMS [308111801] 1607.4 percent of total billed charges 1107.32 1696.7 Technical (Hospital) Services CT Pelvis W/O Contrast Material PX-3527219200 CDM 72192 CPT 352 RC outpatient 1786 1786 CIGNA 62308 [3081051] CIGNA 62308 [308105105] 1428.8 percent of total billed charges 1107.32 1696.7 Technical (Hospital) Services CT Pelvis W/O Contrast Material PX-3527219200 CDM 72192 CPT 352 RC outpatient 1786 1786 CIGNA 62308 [3081051] CIGNA STATE OF WYOMING [308105107] 1428.8 percent of total billed charges 1107.32 1696.7 Technical (Hospital) Services CT Pelvis W/O Contrast Material PX-3527219200 CDM 72192 CPT 352 RC inpatient 1786 1786 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES EPO [308136803] 1414.15 percent of total billed charges 1107.32 1696.7 Technical (Hospital) Services CT Pelvis W/O Contrast Material PX-3527219200 CDM 72192 CPT 352 RC inpatient 1786 1786 CIGNA 62308 [3081051] CIGNA 62308 [308105105] 1414.15 percent of total billed charges 1107.32 1696.7 Technical (Hospital) Services CT Pelvis W/O Contrast Material PX-3527219200 CDM 72192 CPT 352 RC inpatient 1786 1786 CIGNA 62308 [3081051] CIGNA STATE OF WYOMING [308105107] 1414.15 percent of total billed charges 1107.32 1696.7 Technical (Hospital) Services CT Pelvis W/O Contrast Material PX-3527219200 CDM 72192 CPT 352 RC inpatient 1786 1786 HEALTHPARTNERS SX009 HEALTHPARTNERS 1414.15 percent of total billed charges 1107.32 1696.7 Technical (Hospital) Services CT Pelvis W/O Contrast Material PX-3527219200 CDM 72192 CPT 352 RC inpatient 1786 1786 MEDICA (COMMERCIAL) 94265 [3081118] MEDICA CLAIMS [308111801] 1607.4 percent of total billed charges 1107.32 1696.7 Technical (Hospital) Services CT Pelvis W/O Contrast Material PX-3527219200 CDM 72192 CPT 352 RC inpatient 1786 1786 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES HDHP [308136802] 1414.15 percent of total billed charges 1107.32 1696.7 Technical (Hospital) Services CT Pelvis W/O Contrast Material PX-3527219200 CDM 72192 CPT 352 RC inpatient 1786 1786 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES PPO [308136801] 1414.15 percent of total billed charges 1107.32 1696.7 Technical (Hospital) Services CT Pelvis W/O Contrast Material PX-3527219200 CDM 72192 CPT 352 RC inpatient 1786 1786 UNITED HEALTHCARE (COMMERCIAL) [3081199] UNITED HEALTHCARE 87726 [308119901] 1107.32 percent of total billed charges 1107.32 1696.7 Technical (Hospital) Services CT Pelvis W/O Contrast Material PX-3527219200 CDM 72192 CPT 352 RC inpatient 1786 1786 BLUE CROSS BLUE SHIELD WELLMARK SB889 [3081026] BCBS WYOMING [308102603] 1696.7 percent of total billed charges 1107.32 1696.7 Technical (Hospital) Services CT Pelvis W/O Contrast Material PX-3527219200 CDM 72192 CPT 352 RC inpatient 1786 1786 MULTIPLAN INC 34080 [3081285] MULTIPLAN INC [308128501] 1696.7 percent of total billed charges 1107.32 1696.7 Technical (Hospital) Services CT Angiography Pelvis W/Contrast/Noncontrast PX-3527219100 CDM 72191 CPT 352 RC inpatient 2816 2816 UNITED HEALTHCARE (COMMERCIAL) [3081199] UNITED HEALTHCARE 87726 [308119901] 1745.92 percent of total billed charges 1745.92 2675.2 Technical (Hospital) Services CT Angiography Pelvis W/Contrast/Noncontrast PX-3527219100 CDM 72191 CPT 352 RC inpatient 2816 2816 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES PPO [308136801] 2229.71 percent of total billed charges 1745.92 2675.2 Technical (Hospital) Services CT Angiography Pelvis W/Contrast/Noncontrast PX-3527219100 CDM 72191 CPT 352 RC inpatient 2816 2816 BLUE CROSS BLUE SHIELD WELLMARK SB889 [3081026] BCBS WYOMING [308102603] 2675.2 percent of total billed charges 1745.92 2675.2 Technical (Hospital) Services CT Angiography Pelvis W/Contrast/Noncontrast PX-3527219100 CDM 72191 CPT 352 RC inpatient 2816 2816 MULTIPLAN INC 34080 [3081285] MULTIPLAN INC [308128501] 2675.2 percent of total billed charges 1745.92 2675.2 Technical (Hospital) Services CT Angiography Pelvis W/Contrast/Noncontrast PX-3527219100 CDM 72191 CPT 352 RC inpatient 2816 2816 HEALTHPARTNERS SX009 HEALTHPARTNERS 2229.71 percent of total billed charges 1745.92 2675.2 Technical (Hospital) Services CT Angiography Pelvis W/Contrast/Noncontrast PX-3527219100 CDM 72191 CPT 352 RC inpatient 2816 2816 MEDICA (COMMERCIAL) 94265 [3081118] MEDICA CLAIMS [308111801] 2534.4 percent of total billed charges 1745.92 2675.2 Technical (Hospital) Services CT Angiography Pelvis W/Contrast/Noncontrast PX-3527219100 CDM 72191 CPT 352 RC inpatient 2816 2816 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES HDHP [308136802] 2229.71 percent of total billed charges 1745.92 2675.2 Technical (Hospital) Services CT Angiography Pelvis W/Contrast/Noncontrast PX-3527219100 CDM 72191 CPT 352 RC inpatient 2816 2816 CIGNA 62308 [3081051] CIGNA 62308 [308105105] 2229.71 percent of total billed charges 1745.92 2675.2 Technical (Hospital) Services CT Angiography Pelvis W/Contrast/Noncontrast PX-3527219100 CDM 72191 CPT 352 RC inpatient 2816 2816 CIGNA 62308 [3081051] CIGNA STATE OF WYOMING [308105107] 2229.71 percent of total billed charges 1745.92 2675.2 Technical (Hospital) Services CT Angiography Pelvis W/Contrast/Noncontrast PX-3527219100 CDM 72191 CPT 352 RC inpatient 2816 2816 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES EPO [308136803] 2229.71 percent of total billed charges 1745.92 2675.2 Technical (Hospital) Services CT Angiography Pelvis W/Contrast/Noncontrast PX-3527219100 CDM 72191 CPT 352 RC outpatient 2816 2816 MEDICA (COMMERCIAL) 94265 [3081118] MEDICA CLAIMS [308111801] 2534.4 percent of total billed charges 1745.92 2675.2 Technical (Hospital) Services CT Angiography Pelvis W/Contrast/Noncontrast PX-3527219100 CDM 72191 CPT 352 RC outpatient 2816 2816 CIGNA 62308 [3081051] CIGNA 62308 [308105105] 2252.8 percent of total billed charges 1745.92 2675.2 Technical (Hospital) Services CT Angiography Pelvis W/Contrast/Noncontrast PX-3527219100 CDM 72191 CPT 352 RC outpatient 2816 2816 CIGNA 62308 [3081051] CIGNA STATE OF WYOMING [308105107] 2252.8 percent of total billed charges 1745.92 2675.2 Technical (Hospital) Services CT Angiography Pelvis W/Contrast/Noncontrast PX-3527219100 CDM 72191 CPT 352 RC outpatient 2816 2816 BLUE CROSS BLUE SHIELD WELLMARK SB889 [3081026] BCBS WYOMING [308102603] 2675.2 percent of total billed charges 1745.92 2675.2 Technical (Hospital) Services CT Angiography Pelvis W/Contrast/Noncontrast PX-3527219100 CDM 72191 CPT 352 RC outpatient 2816 2816 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES HDHP [308136802] 2252.8 percent of total billed charges 1745.92 2675.2 Technical (Hospital) Services CT Angiography Pelvis W/Contrast/Noncontrast PX-3527219100 CDM 72191 CPT 352 RC outpatient 2816 2816 MULTIPLAN INC 34080 [3081285] MULTIPLAN INC [308128501] 2675.2 percent of total billed charges 1745.92 2675.2 Technical (Hospital) Services CT Angiography Pelvis W/Contrast/Noncontrast PX-3527219100 CDM 72191 CPT 352 RC outpatient 2816 2816 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES EPO [308136803] 2252.8 percent of total billed charges 1745.92 2675.2 Technical (Hospital) Services CT Angiography Pelvis W/Contrast/Noncontrast PX-3527219100 CDM 72191 CPT 352 RC outpatient 2816 2816 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES PPO [308136801] 2252.8 percent of total billed charges 1745.92 2675.2 Technical (Hospital) Services CT Angiography Pelvis W/Contrast/Noncontrast PX-3527219100 CDM 72191 CPT 352 RC outpatient 2816 2816 UNITED HEALTHCARE (COMMERCIAL) [3081199] UNITED HEALTHCARE 87726 [308119901] 1745.92 percent of total billed charges 1745.92 2675.2 Technical (Hospital) Services CT Angiography Pelvis W/Contrast/Noncontrast PX-3527219100 CDM 72191 CPT 352 RC outpatient 2816 2816 HEALTHPARTNERS SX009 HEALTHPARTNERS 2252.8 percent of total billed charges 1745.92 2675.2 Technical (Hospital) Services Radiologic Exam Pelvis Compl Minimum 3 Views PX-3207219000 CDM 72190 CPT 320 RC outpatient 301 301 UNITED HEALTHCARE (COMMERCIAL) [3081199] UNITED HEALTHCARE 87726 [308119901] 186.62 percent of total billed charges 186.62 285.95 Technical (Hospital) Services Radiologic Exam Pelvis Compl Minimum 3 Views PX-3207219000 CDM 72190 CPT 320 RC outpatient 301 301 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES EPO [308136803] 240.8 percent of total billed charges 186.62 285.95 Technical (Hospital) Services Radiologic Exam Pelvis Compl Minimum 3 Views PX-3207219000 CDM 72190 CPT 320 RC outpatient 301 301 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES PPO [308136801] 240.8 percent of total billed charges 186.62 285.95 Technical (Hospital) Services Radiologic Exam Pelvis Compl Minimum 3 Views PX-3207219000 CDM 72190 CPT 320 RC outpatient 301 301 BLUE CROSS BLUE SHIELD WELLMARK SB889 [3081026] BCBS WYOMING [308102603] 285.95 percent of total billed charges 186.62 285.95 Technical (Hospital) Services Radiologic Exam Pelvis Compl Minimum 3 Views PX-3207219000 CDM 72190 CPT 320 RC outpatient 301 301 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES HDHP [308136802] 240.8 percent of total billed charges 186.62 285.95 Technical (Hospital) Services Radiologic Exam Pelvis Compl Minimum 3 Views PX-3207219000 CDM 72190 CPT 320 RC outpatient 301 301 MULTIPLAN INC 34080 [3081285] MULTIPLAN INC [308128501] 285.95 percent of total billed charges 186.62 285.95 Technical (Hospital) Services Radiologic Exam Pelvis Compl Minimum 3 Views PX-3207219000 CDM 72190 CPT 320 RC outpatient 301 301 HEALTHPARTNERS SX009 HEALTHPARTNERS 240.8 percent of total billed charges 186.62 285.95 Technical (Hospital) Services Radiologic Exam Pelvis Compl Minimum 3 Views PX-3207219000 CDM 72190 CPT 320 RC outpatient 301 301 CIGNA 62308 [3081051] CIGNA 62308 [308105105] 240.8 percent of total billed charges 186.62 285.95 Technical (Hospital) Services Radiologic Exam Pelvis Compl Minimum 3 Views PX-3207219000 CDM 72190 CPT 320 RC outpatient 301 301 CIGNA 62308 [3081051] CIGNA STATE OF WYOMING [308105107] 240.8 percent of total billed charges 186.62 285.95 Technical (Hospital) Services Radiologic Exam Pelvis Compl Minimum 3 Views PX-3207219000 CDM 72190 CPT 320 RC outpatient 301 301 MEDICA (COMMERCIAL) 94265 [3081118] MEDICA CLAIMS [308111801] 270.9 percent of total billed charges 186.62 285.95 Technical (Hospital) Services Radiologic Exam Pelvis Compl Minimum 3 Views PX-3207219000 CDM 72190 CPT 320 RC inpatient 301 301 MEDICA (COMMERCIAL) 94265 [3081118] MEDICA CLAIMS [308111801] 270.9 percent of total billed charges 186.62 285.95 Technical (Hospital) Services Radiologic Exam Pelvis Compl Minimum 3 Views PX-3207219000 CDM 72190 CPT 320 RC inpatient 301 301 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES HDHP [308136802] 238.33 percent of total billed charges 186.62 285.95 Technical (Hospital) Services Radiologic Exam Pelvis Compl Minimum 3 Views PX-3207219000 CDM 72190 CPT 320 RC inpatient 301 301 HEALTHPARTNERS SX009 HEALTHPARTNERS 238.33 percent of total billed charges 186.62 285.95 Technical (Hospital) Services Radiologic Exam Pelvis Compl Minimum 3 Views PX-3207219000 CDM 72190 CPT 320 RC inpatient 301 301 UNITED HEALTHCARE (COMMERCIAL) [3081199] UNITED HEALTHCARE 87726 [308119901] 186.62 percent of total billed charges 186.62 285.95 Technical (Hospital) Services Radiologic Exam Pelvis Compl Minimum 3 Views PX-3207219000 CDM 72190 CPT 320 RC inpatient 301 301 MULTIPLAN INC 34080 [3081285] MULTIPLAN INC [308128501] 285.95 percent of total billed charges 186.62 285.95 Technical (Hospital) Services Radiologic Exam Pelvis Compl Minimum 3 Views PX-3207219000 CDM 72190 CPT 320 RC inpatient 301 301 BLUE CROSS BLUE SHIELD WELLMARK SB889 [3081026] BCBS WYOMING [308102603] 285.95 percent of total billed charges 186.62 285.95 Technical (Hospital) Services Radiologic Exam Pelvis Compl Minimum 3 Views PX-3207219000 CDM 72190 CPT 320 RC inpatient 301 301 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES PPO [308136801] 238.33 percent of total billed charges 186.62 285.95 Technical (Hospital) Services Radiologic Exam Pelvis Compl Minimum 3 Views PX-3207219000 CDM 72190 CPT 320 RC inpatient 301 301 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES EPO [308136803] 238.33 percent of total billed charges 186.62 285.95 Technical (Hospital) Services Radiologic Exam Pelvis Compl Minimum 3 Views PX-3207219000 CDM 72190 CPT 320 RC inpatient 301 301 CIGNA 62308 [3081051] CIGNA 62308 [308105105] 238.33 percent of total billed charges 186.62 285.95 Technical (Hospital) Services Radiologic Exam Pelvis Compl Minimum 3 Views PX-3207219000 CDM 72190 CPT 320 RC inpatient 301 301 CIGNA 62308 [3081051] CIGNA STATE OF WYOMING [308105107] 238.33 percent of total billed charges 186.62 285.95 Technical (Hospital) Services Radiologic Examination Pelvis 1/2 Views PX-3207217000 CDM 72170 CPT 320 RC inpatient 366 366 UNITED HEALTHCARE (COMMERCIAL) [3081199] UNITED HEALTHCARE 87726 [308119901] 226.92 percent of total billed charges 226.92 347.7 Technical (Hospital) Services Radiologic Examination Pelvis 1/2 Views PX-3207217000 CDM 72170 CPT 320 RC inpatient 366 366 BLUE CROSS BLUE SHIELD WELLMARK SB889 [3081026] BCBS WYOMING [308102603] 347.7 percent of total billed charges 226.92 347.7 Technical (Hospital) Services Radiologic Examination Pelvis 1/2 Views PX-3207217000 CDM 72170 CPT 320 RC inpatient 366 366 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES PPO [308136801] 289.8 percent of total billed charges 226.92 347.7 Technical (Hospital) Services Radiologic Examination Pelvis 1/2 Views PX-3207217000 CDM 72170 CPT 320 RC inpatient 366 366 MULTIPLAN INC 34080 [3081285] MULTIPLAN INC [308128501] 347.7 percent of total billed charges 226.92 347.7 Technical (Hospital) Services Radiologic Examination Pelvis 1/2 Views PX-3207217000 CDM 72170 CPT 320 RC inpatient 366 366 MEDICA (COMMERCIAL) 94265 [3081118] MEDICA CLAIMS [308111801] 329.4 percent of total billed charges 226.92 347.7 Technical (Hospital) Services Radiologic Examination Pelvis 1/2 Views PX-3207217000 CDM 72170 CPT 320 RC inpatient 366 366 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES HDHP [308136802] 289.8 percent of total billed charges 226.92 347.7 Technical (Hospital) Services Radiologic Examination Pelvis 1/2 Views PX-3207217000 CDM 72170 CPT 320 RC inpatient 366 366 HEALTHPARTNERS SX009 HEALTHPARTNERS 289.8 percent of total billed charges 226.92 347.7 Technical (Hospital) Services Radiologic Examination Pelvis 1/2 Views PX-3207217000 CDM 72170 CPT 320 RC inpatient 366 366 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES EPO [308136803] 289.8 percent of total billed charges 226.92 347.7 Technical (Hospital) Services Radiologic Examination Pelvis 1/2 Views PX-3207217000 CDM 72170 CPT 320 RC inpatient 366 366 CIGNA 62308 [3081051] CIGNA STATE OF WYOMING [308105107] 289.8 percent of total billed charges 226.92 347.7 Technical (Hospital) Services Radiologic Examination Pelvis 1/2 Views PX-3207217000 CDM 72170 CPT 320 RC inpatient 366 366 CIGNA 62308 [3081051] CIGNA 62308 [308105105] 289.8 percent of total billed charges 226.92 347.7 Technical (Hospital) Services Radiologic Examination Pelvis 1/2 Views PX-3207217000 CDM 72170 CPT 320 RC outpatient 366 366 CIGNA 62308 [3081051] CIGNA 62308 [308105105] 292.8 percent of total billed charges 226.92 347.7 Technical (Hospital) Services Radiologic Examination Pelvis 1/2 Views PX-3207217000 CDM 72170 CPT 320 RC outpatient 366 366 CIGNA 62308 [3081051] CIGNA STATE OF WYOMING [308105107] 292.8 percent of total billed charges 226.92 347.7 Technical (Hospital) Services Radiologic Examination Pelvis 1/2 Views PX-3207217000 CDM 72170 CPT 320 RC outpatient 366 366 MEDICA (COMMERCIAL) 94265 [3081118] MEDICA CLAIMS [308111801] 329.4 percent of total billed charges 226.92 347.7 Technical (Hospital) Services Radiologic Examination Pelvis 1/2 Views PX-3207217000 CDM 72170 CPT 320 RC outpatient 366 366 MULTIPLAN INC 34080 [3081285] MULTIPLAN INC [308128501] 347.7 percent of total billed charges 226.92 347.7 Technical (Hospital) Services Radiologic Examination Pelvis 1/2 Views PX-3207217000 CDM 72170 CPT 320 RC outpatient 366 366 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES HDHP [308136802] 292.8 percent of total billed charges 226.92 347.7 Technical (Hospital) Services Radiologic Examination Pelvis 1/2 Views PX-3207217000 CDM 72170 CPT 320 RC outpatient 366 366 BLUE CROSS BLUE SHIELD WELLMARK SB889 [3081026] BCBS WYOMING [308102603] 347.7 percent of total billed charges 226.92 347.7 Technical (Hospital) Services Radiologic Examination Pelvis 1/2 Views PX-3207217000 CDM 72170 CPT 320 RC outpatient 366 366 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES PPO [308136801] 292.8 percent of total billed charges 226.92 347.7 Technical (Hospital) Services Radiologic Examination Pelvis 1/2 Views PX-3207217000 CDM 72170 CPT 320 RC outpatient 366 366 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES EPO [308136803] 292.8 percent of total billed charges 226.92 347.7 Technical (Hospital) Services Radiologic Examination Pelvis 1/2 Views PX-3207217000 CDM 72170 CPT 320 RC outpatient 366 366 UNITED HEALTHCARE (COMMERCIAL) [3081199] UNITED HEALTHCARE 87726 [308119901] 226.92 percent of total billed charges 226.92 347.7 Technical (Hospital) Services Radiologic Examination Pelvis 1/2 Views PX-3207217000 CDM 72170 CPT 320 RC outpatient 366 366 HEALTHPARTNERS SX009 HEALTHPARTNERS 292.8 percent of total billed charges 226.92 347.7 Technical (Hospital) Services MRI Spinal Canal Lumbar W/O & W/Contr Matrl PX-6127215800 CDM 72158 CPT 612 RC inpatient 4167 4167 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES HDHP [308136802] 3299.43 percent of total billed charges 2583.54 3958.65 Technical (Hospital) Services MRI Spinal Canal Lumbar W/O & W/Contr Matrl PX-6127215800 CDM 72158 CPT 612 RC inpatient 4167 4167 MEDICA (COMMERCIAL) 94265 [3081118] MEDICA CLAIMS [308111801] 3750.3 percent of total billed charges 2583.54 3958.65 Technical (Hospital) Services MRI Spinal Canal Lumbar W/O & W/Contr Matrl PX-6127215800 CDM 72158 CPT 612 RC inpatient 4167 4167 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES EPO [308136803] 3299.43 percent of total billed charges 2583.54 3958.65 Technical (Hospital) Services MRI Spinal Canal Lumbar W/O & W/Contr Matrl PX-6127215800 CDM 72158 CPT 612 RC inpatient 4167 4167 HEALTHPARTNERS SX009 HEALTHPARTNERS 3299.43 percent of total billed charges 2583.54 3958.65 Technical (Hospital) Services MRI Spinal Canal Lumbar W/O & W/Contr Matrl PX-6127215800 CDM 72158 CPT 612 RC inpatient 4167 4167 UNITED HEALTHCARE (COMMERCIAL) [3081199] UNITED HEALTHCARE 87726 [308119901] 2583.54 percent of total billed charges 2583.54 3958.65 Technical (Hospital) Services MRI Spinal Canal Lumbar W/O & W/Contr Matrl PX-6127215800 CDM 72158 CPT 612 RC inpatient 4167 4167 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES PPO [308136801] 3299.43 percent of total billed charges 2583.54 3958.65 Technical (Hospital) Services MRI Spinal Canal Lumbar W/O & W/Contr Matrl PX-6127215800 CDM 72158 CPT 612 RC inpatient 4167 4167 MULTIPLAN INC 34080 [3081285] MULTIPLAN INC [308128501] 3958.65 percent of total billed charges 2583.54 3958.65 Technical (Hospital) Services MRI Spinal Canal Lumbar W/O & W/Contr Matrl PX-6127215800 CDM 72158 CPT 612 RC inpatient 4167 4167 BLUE CROSS BLUE SHIELD WELLMARK SB889 [3081026] BCBS WYOMING [308102603] 3958.65 percent of total billed charges 2583.54 3958.65 Technical (Hospital) Services MRI Spinal Canal Lumbar W/O & W/Contr Matrl PX-6127215800 CDM 72158 CPT 612 RC inpatient 4167 4167 CIGNA 62308 [3081051] CIGNA 62308 [308105105] 3299.43 percent of total billed charges 2583.54 3958.65 Technical (Hospital) Services MRI Spinal Canal Lumbar W/O & W/Contr Matrl PX-6127215800 CDM 72158 CPT 612 RC inpatient 4167 4167 CIGNA 62308 [3081051] CIGNA STATE OF WYOMING [308105107] 3299.43 percent of total billed charges 2583.54 3958.65 Technical (Hospital) Services MRI Spinal Canal Lumbar W/O & W/Contr Matrl PX-6127215800 CDM 72158 CPT 612 RC outpatient 4167 4167 HEALTHPARTNERS SX009 HEALTHPARTNERS 3333.6 percent of total billed charges 2583.54 3958.65 Technical (Hospital) Services MRI Spinal Canal Lumbar W/O & W/Contr Matrl PX-6127215800 CDM 72158 CPT 612 RC outpatient 4167 4167 UNITED HEALTHCARE (COMMERCIAL) [3081199] UNITED HEALTHCARE 87726 [308119901] 2583.54 percent of total billed charges 2583.54 3958.65 Technical (Hospital) Services MRI Spinal Canal Lumbar W/O & W/Contr Matrl PX-6127215800 CDM 72158 CPT 612 RC outpatient 4167 4167 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES EPO [308136803] 3333.6 percent of total billed charges 2583.54 3958.65 Technical (Hospital) Services MRI Spinal Canal Lumbar W/O & W/Contr Matrl PX-6127215800 CDM 72158 CPT 612 RC outpatient 4167 4167 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES PPO [308136801] 3333.6 percent of total billed charges 2583.54 3958.65 Technical (Hospital) Services MRI Spinal Canal Lumbar W/O & W/Contr Matrl PX-6127215800 CDM 72158 CPT 612 RC outpatient 4167 4167 BLUE CROSS BLUE SHIELD WELLMARK SB889 [3081026] BCBS WYOMING [308102603] 3958.65 percent of total billed charges 2583.54 3958.65 Technical (Hospital) Services MRI Spinal Canal Lumbar W/O & W/Contr Matrl PX-6127215800 CDM 72158 CPT 612 RC outpatient 4167 4167 MULTIPLAN INC 34080 [3081285] MULTIPLAN INC [308128501] 3958.65 percent of total billed charges 2583.54 3958.65 Technical (Hospital) Services MRI Spinal Canal Lumbar W/O & W/Contr Matrl PX-6127215800 CDM 72158 CPT 612 RC outpatient 4167 4167 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES HDHP [308136802] 3333.6 percent of total billed charges 2583.54 3958.65 Technical (Hospital) Services MRI Spinal Canal Lumbar W/O & W/Contr Matrl PX-6127215800 CDM 72158 CPT 612 RC outpatient 4167 4167 MEDICA (COMMERCIAL) 94265 [3081118] MEDICA CLAIMS [308111801] 3750.3 percent of total billed charges 2583.54 3958.65 Technical (Hospital) Services MRI Spinal Canal Lumbar W/O & W/Contr Matrl PX-6127215800 CDM 72158 CPT 612 RC outpatient 4167 4167 CIGNA 62308 [3081051] CIGNA 62308 [308105105] 3333.6 percent of total billed charges 2583.54 3958.65 Technical (Hospital) Services MRI Spinal Canal Lumbar W/O & W/Contr Matrl PX-6127215800 CDM 72158 CPT 612 RC outpatient 4167 4167 CIGNA 62308 [3081051] CIGNA STATE OF WYOMING [308105107] 3333.6 percent of total billed charges 2583.54 3958.65 Technical (Hospital) Services MRI Spinal Canal Thoracic W/O & W/Contr Matrl PX-6127215700 CDM 72157 CPT 612 RC outpatient 4049 4049 UNITED HEALTHCARE (COMMERCIAL) [3081199] UNITED HEALTHCARE 87726 [308119901] 2510.38 percent of total billed charges 2510.38 3846.55 Technical (Hospital) Services MRI Spinal Canal Thoracic W/O & W/Contr Matrl PX-6127215700 CDM 72157 CPT 612 RC outpatient 4049 4049 HEALTHPARTNERS SX009 HEALTHPARTNERS 3239.2 percent of total billed charges 2510.38 3846.55 Technical (Hospital) Services MRI Spinal Canal Thoracic W/O & W/Contr Matrl PX-6127215700 CDM 72157 CPT 612 RC outpatient 4049 4049 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES EPO [308136803] 3239.2 percent of total billed charges 2510.38 3846.55 Technical (Hospital) Services MRI Spinal Canal Thoracic W/O & W/Contr Matrl PX-6127215700 CDM 72157 CPT 612 RC outpatient 4049 4049 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES PPO [308136801] 3239.2 percent of total billed charges 2510.38 3846.55 Technical (Hospital) Services MRI Spinal Canal Thoracic W/O & W/Contr Matrl PX-6127215700 CDM 72157 CPT 612 RC outpatient 4049 4049 BLUE CROSS BLUE SHIELD WELLMARK SB889 [3081026] BCBS WYOMING [308102603] 3846.55 percent of total billed charges 2510.38 3846.55 Technical (Hospital) Services MRI Spinal Canal Thoracic W/O & W/Contr Matrl PX-6127215700 CDM 72157 CPT 612 RC outpatient 4049 4049 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES HDHP [308136802] 3239.2 percent of total billed charges 2510.38 3846.55 Technical (Hospital) Services MRI Spinal Canal Thoracic W/O & W/Contr Matrl PX-6127215700 CDM 72157 CPT 612 RC outpatient 4049 4049 MULTIPLAN INC 34080 [3081285] MULTIPLAN INC [308128501] 3846.55 percent of total billed charges 2510.38 3846.55 Technical (Hospital) Services MRI Spinal Canal Thoracic W/O & W/Contr Matrl PX-6127215700 CDM 72157 CPT 612 RC outpatient 4049 4049 MEDICA (COMMERCIAL) 94265 [3081118] MEDICA CLAIMS [308111801] 3644.1 percent of total billed charges 2510.38 3846.55 Technical (Hospital) Services MRI Spinal Canal Thoracic W/O & W/Contr Matrl PX-6127215700 CDM 72157 CPT 612 RC outpatient 4049 4049 CIGNA 62308 [3081051] CIGNA 62308 [308105105] 3239.2 percent of total billed charges 2510.38 3846.55 Technical (Hospital) Services MRI Spinal Canal Thoracic W/O & W/Contr Matrl PX-6127215700 CDM 72157 CPT 612 RC outpatient 4049 4049 CIGNA 62308 [3081051] CIGNA STATE OF WYOMING [308105107] 3239.2 percent of total billed charges 2510.38 3846.55 Technical (Hospital) Services MRI Spinal Canal Thoracic W/O & W/Contr Matrl PX-6127215700 CDM 72157 CPT 612 RC inpatient 4049 4049 CIGNA 62308 [3081051] CIGNA STATE OF WYOMING [308105107] 3206 percent of total billed charges 2510.38 3846.55 Technical (Hospital) Services MRI Spinal Canal Thoracic W/O & W/Contr Matrl PX-6127215700 CDM 72157 CPT 612 RC inpatient 4049 4049 CIGNA 62308 [3081051] CIGNA 62308 [308105105] 3206 percent of total billed charges 2510.38 3846.55 Technical (Hospital) Services MRI Spinal Canal Thoracic W/O & W/Contr Matrl PX-6127215700 CDM 72157 CPT 612 RC inpatient 4049 4049 BLUE CROSS BLUE SHIELD WELLMARK SB889 [3081026] BCBS WYOMING [308102603] 3846.55 percent of total billed charges 2510.38 3846.55 Technical (Hospital) Services MRI Spinal Canal Thoracic W/O & W/Contr Matrl PX-6127215700 CDM 72157 CPT 612 RC inpatient 4049 4049 MULTIPLAN INC 34080 [3081285] MULTIPLAN INC [308128501] 3846.55 percent of total billed charges 2510.38 3846.55 Technical (Hospital) Services MRI Spinal Canal Thoracic W/O & W/Contr Matrl PX-6127215700 CDM 72157 CPT 612 RC inpatient 4049 4049 UNITED HEALTHCARE (COMMERCIAL) [3081199] UNITED HEALTHCARE 87726 [308119901] 2510.38 percent of total billed charges 2510.38 3846.55 Technical (Hospital) Services MRI Spinal Canal Thoracic W/O & W/Contr Matrl PX-6127215700 CDM 72157 CPT 612 RC inpatient 4049 4049 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES PPO [308136801] 3206 percent of total billed charges 2510.38 3846.55 Technical (Hospital) Services MRI Spinal Canal Thoracic W/O & W/Contr Matrl PX-6127215700 CDM 72157 CPT 612 RC inpatient 4049 4049 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES HDHP [308136802] 3206 percent of total billed charges 2510.38 3846.55 Technical (Hospital) Services MRI Spinal Canal Thoracic W/O & W/Contr Matrl PX-6127215700 CDM 72157 CPT 612 RC inpatient 4049 4049 MEDICA (COMMERCIAL) 94265 [3081118] MEDICA CLAIMS [308111801] 3644.1 percent of total billed charges 2510.38 3846.55 Technical (Hospital) Services MRI Spinal Canal Thoracic W/O & W/Contr Matrl PX-6127215700 CDM 72157 CPT 612 RC inpatient 4049 4049 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES EPO [308136803] 3206 percent of total billed charges 2510.38 3846.55 Technical (Hospital) Services MRI Spinal Canal Thoracic W/O & W/Contr Matrl PX-6127215700 CDM 72157 CPT 612 RC inpatient 4049 4049 HEALTHPARTNERS SX009 HEALTHPARTNERS 3206 percent of total billed charges 2510.38 3846.55 Technical (Hospital) Services MRI Spinal Canal Cervical W/O & W/Contr Matrl PX-6127215600 CDM 72156 CPT 612 RC inpatient 3929 3929 CIGNA 62308 [3081051] CIGNA 62308 [308105105] 3110.98 percent of total billed charges 2435.98 3732.55 Technical (Hospital) Services MRI Spinal Canal Cervical W/O & W/Contr Matrl PX-6127215600 CDM 72156 CPT 612 RC inpatient 3929 3929 CIGNA 62308 [3081051] CIGNA STATE OF WYOMING [308105107] 3110.98 percent of total billed charges 2435.98 3732.55 Technical (Hospital) Services MRI Spinal Canal Cervical W/O & W/Contr Matrl PX-6127215600 CDM 72156 CPT 612 RC inpatient 3929 3929 BLUE CROSS BLUE SHIELD WELLMARK SB889 [3081026] BCBS WYOMING [308102603] 3732.55 percent of total billed charges 2435.98 3732.55 Technical (Hospital) Services MRI Spinal Canal Cervical W/O & W/Contr Matrl PX-6127215600 CDM 72156 CPT 612 RC inpatient 3929 3929 MULTIPLAN INC 34080 [3081285] MULTIPLAN INC [308128501] 3732.55 percent of total billed charges 2435.98 3732.55 Technical (Hospital) Services MRI Spinal Canal Cervical W/O & W/Contr Matrl PX-6127215600 CDM 72156 CPT 612 RC inpatient 3929 3929 UNITED HEALTHCARE (COMMERCIAL) [3081199] UNITED HEALTHCARE 87726 [308119901] 2435.98 percent of total billed charges 2435.98 3732.55 Technical (Hospital) Services MRI Spinal Canal Cervical W/O & W/Contr Matrl PX-6127215600 CDM 72156 CPT 612 RC inpatient 3929 3929 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES PPO [308136801] 3110.98 percent of total billed charges 2435.98 3732.55 Technical (Hospital) Services MRI Spinal Canal Cervical W/O & W/Contr Matrl PX-6127215600 CDM 72156 CPT 612 RC inpatient 3929 3929 HEALTHPARTNERS SX009 HEALTHPARTNERS 3110.98 percent of total billed charges 2435.98 3732.55 Technical (Hospital) Services MRI Spinal Canal Cervical W/O & W/Contr Matrl PX-6127215600 CDM 72156 CPT 612 RC inpatient 3929 3929 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES EPO [308136803] 3110.98 percent of total billed charges 2435.98 3732.55 Technical (Hospital) Services MRI Spinal Canal Cervical W/O & W/Contr Matrl PX-6127215600 CDM 72156 CPT 612 RC inpatient 3929 3929 MEDICA (COMMERCIAL) 94265 [3081118] MEDICA CLAIMS [308111801] 3536.1 percent of total billed charges 2435.98 3732.55 Technical (Hospital) Services MRI Spinal Canal Cervical W/O & W/Contr Matrl PX-6127215600 CDM 72156 CPT 612 RC inpatient 3929 3929 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES HDHP [308136802] 3110.98 percent of total billed charges 2435.98 3732.55 Technical (Hospital) Services MRI Spinal Canal Cervical W/O & W/Contr Matrl PX-6127215600 CDM 72156 CPT 612 RC outpatient 3929 3929 HEALTHPARTNERS SX009 HEALTHPARTNERS 3143.2 percent of total billed charges 2435.98 3732.55 Technical (Hospital) Services MRI Spinal Canal Cervical W/O & W/Contr Matrl PX-6127215600 CDM 72156 CPT 612 RC outpatient 3929 3929 UNITED HEALTHCARE (COMMERCIAL) [3081199] UNITED HEALTHCARE 87726 [308119901] 2435.98 percent of total billed charges 2435.98 3732.55 Technical (Hospital) Services MRI Spinal Canal Cervical W/O & W/Contr Matrl PX-6127215600 CDM 72156 CPT 612 RC outpatient 3929 3929 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES EPO [308136803] 3143.2 percent of total billed charges 2435.98 3732.55 Technical (Hospital) Services MRI Spinal Canal Cervical W/O & W/Contr Matrl PX-6127215600 CDM 72156 CPT 612 RC outpatient 3929 3929 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES PPO [308136801] 3143.2 percent of total billed charges 2435.98 3732.55 Technical (Hospital) Services MRI Spinal Canal Cervical W/O & W/Contr Matrl PX-6127215600 CDM 72156 CPT 612 RC outpatient 3929 3929 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES HDHP [308136802] 3143.2 percent of total billed charges 2435.98 3732.55 Technical (Hospital) Services MRI Spinal Canal Cervical W/O & W/Contr Matrl PX-6127215600 CDM 72156 CPT 612 RC outpatient 3929 3929 MULTIPLAN INC 34080 [3081285] MULTIPLAN INC [308128501] 3732.55 percent of total billed charges 2435.98 3732.55 Technical (Hospital) Services MRI Spinal Canal Cervical W/O & W/Contr Matrl PX-6127215600 CDM 72156 CPT 612 RC outpatient 3929 3929 BLUE CROSS BLUE SHIELD WELLMARK SB889 [3081026] BCBS WYOMING [308102603] 3732.55 percent of total billed charges 2435.98 3732.55 Technical (Hospital) Services MRI Spinal Canal Cervical W/O & W/Contr Matrl PX-6127215600 CDM 72156 CPT 612 RC outpatient 3929 3929 CIGNA 62308 [3081051] CIGNA STATE OF WYOMING [308105107] 3143.2 percent of total billed charges 2435.98 3732.55 Technical (Hospital) Services MRI Spinal Canal Cervical W/O & W/Contr Matrl PX-6127215600 CDM 72156 CPT 612 RC outpatient 3929 3929 CIGNA 62308 [3081051] CIGNA 62308 [308105105] 3143.2 percent of total billed charges 2435.98 3732.55 Technical (Hospital) Services MRI Spinal Canal Cervical W/O & W/Contr Matrl PX-6127215600 CDM 72156 CPT 612 RC outpatient 3929 3929 MEDICA (COMMERCIAL) 94265 [3081118] MEDICA CLAIMS [308111801] 3536.1 percent of total billed charges 2435.98 3732.55 Technical (Hospital) Services MRI Spinal Canal Lumbar W/Contrast Material PX-6127214900 CDM 72149 CPT 612 RC inpatient 3014 3014 BLUE CROSS BLUE SHIELD WELLMARK SB889 [3081026] BCBS WYOMING [308102603] 2863.3 percent of total billed charges 1868.68 2863.3 Technical (Hospital) Services MRI Spinal Canal Lumbar W/Contrast Material PX-6127214900 CDM 72149 CPT 612 RC inpatient 3014 3014 MULTIPLAN INC 34080 [3081285] MULTIPLAN INC [308128501] 2863.3 percent of total billed charges 1868.68 2863.3 Technical (Hospital) Services MRI Spinal Canal Lumbar W/Contrast Material PX-6127214900 CDM 72149 CPT 612 RC inpatient 3014 3014 UNITED HEALTHCARE (COMMERCIAL) [3081199] UNITED HEALTHCARE 87726 [308119901] 1868.68 percent of total billed charges 1868.68 2863.3 Technical (Hospital) Services MRI Spinal Canal Lumbar W/Contrast Material PX-6127214900 CDM 72149 CPT 612 RC inpatient 3014 3014 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES PPO [308136801] 2386.49 percent of total billed charges 1868.68 2863.3 Technical (Hospital) Services MRI Spinal Canal Lumbar W/Contrast Material PX-6127214900 CDM 72149 CPT 612 RC inpatient 3014 3014 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES HDHP [308136802] 2386.49 percent of total billed charges 1868.68 2863.3 Technical (Hospital) Services MRI Spinal Canal Lumbar W/Contrast Material PX-6127214900 CDM 72149 CPT 612 RC inpatient 3014 3014 MEDICA (COMMERCIAL) 94265 [3081118] MEDICA CLAIMS [308111801] 2712.6 percent of total billed charges 1868.68 2863.3 Technical (Hospital) Services MRI Spinal Canal Lumbar W/Contrast Material PX-6127214900 CDM 72149 CPT 612 RC inpatient 3014 3014 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES EPO [308136803] 2386.49 percent of total billed charges 1868.68 2863.3 Technical (Hospital) Services MRI Spinal Canal Lumbar W/Contrast Material PX-6127214900 CDM 72149 CPT 612 RC inpatient 3014 3014 HEALTHPARTNERS SX009 HEALTHPARTNERS 2386.49 percent of total billed charges 1868.68 2863.3 Technical (Hospital) Services MRI Spinal Canal Lumbar W/Contrast Material PX-6127214900 CDM 72149 CPT 612 RC inpatient 3014 3014 CIGNA 62308 [3081051] CIGNA 62308 [308105105] 2386.49 percent of total billed charges 1868.68 2863.3 Technical (Hospital) Services MRI Spinal Canal Lumbar W/Contrast Material PX-6127214900 CDM 72149 CPT 612 RC inpatient 3014 3014 CIGNA 62308 [3081051] CIGNA STATE OF WYOMING [308105107] 2386.49 percent of total billed charges 1868.68 2863.3 Technical (Hospital) Services MRI Spinal Canal Lumbar W/Contrast Material PX-6127214900 CDM 72149 CPT 612 RC outpatient 3014 3014 MULTIPLAN INC 34080 [3081285] MULTIPLAN INC [308128501] 2863.3 percent of total billed charges 1868.68 2863.3 Technical (Hospital) Services MRI Spinal Canal Lumbar W/Contrast Material PX-6127214900 CDM 72149 CPT 612 RC outpatient 3014 3014 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES HDHP [308136802] 2411.2 percent of total billed charges 1868.68 2863.3 Technical (Hospital) Services MRI Spinal Canal Lumbar W/Contrast Material PX-6127214900 CDM 72149 CPT 612 RC outpatient 3014 3014 BLUE CROSS BLUE SHIELD WELLMARK SB889 [3081026] BCBS WYOMING [308102603] 2863.3 percent of total billed charges 1868.68 2863.3 Technical (Hospital) Services MRI Spinal Canal Lumbar W/Contrast Material PX-6127214900 CDM 72149 CPT 612 RC outpatient 3014 3014 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES EPO [308136803] 2411.2 percent of total billed charges 1868.68 2863.3 Technical (Hospital) Services MRI Spinal Canal Lumbar W/Contrast Material PX-6127214900 CDM 72149 CPT 612 RC outpatient 3014 3014 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES PPO [308136801] 2411.2 percent of total billed charges 1868.68 2863.3 Technical (Hospital) Services MRI Spinal Canal Lumbar W/Contrast Material PX-6127214900 CDM 72149 CPT 612 RC outpatient 3014 3014 HEALTHPARTNERS SX009 HEALTHPARTNERS 2411.2 percent of total billed charges 1868.68 2863.3 Technical (Hospital) Services MRI Spinal Canal Lumbar W/Contrast Material PX-6127214900 CDM 72149 CPT 612 RC outpatient 3014 3014 UNITED HEALTHCARE (COMMERCIAL) [3081199] UNITED HEALTHCARE 87726 [308119901] 1868.68 percent of total billed charges 1868.68 2863.3 Technical (Hospital) Services MRI Spinal Canal Lumbar W/Contrast Material PX-6127214900 CDM 72149 CPT 612 RC outpatient 3014 3014 CIGNA 62308 [3081051] CIGNA STATE OF WYOMING [308105107] 2411.2 percent of total billed charges 1868.68 2863.3 Technical (Hospital) Services MRI Spinal Canal Lumbar W/Contrast Material PX-6127214900 CDM 72149 CPT 612 RC outpatient 3014 3014 CIGNA 62308 [3081051] CIGNA 62308 [308105105] 2411.2 percent of total billed charges 1868.68 2863.3 Technical (Hospital) Services MRI Spinal Canal Lumbar W/Contrast Material PX-6127214900 CDM 72149 CPT 612 RC outpatient 3014 3014 MEDICA (COMMERCIAL) 94265 [3081118] MEDICA CLAIMS [308111801] 2712.6 percent of total billed charges 1868.68 2863.3 Technical (Hospital) Services MRI Spinal Canal Lumbar W/O Contrast Material PX-6127214800 CDM 72148 CPT 612 RC inpatient 2858 2858 CIGNA 62308 [3081051] CIGNA 62308 [308105105] 2262.96 percent of total billed charges 1771.96 2715.1 Technical (Hospital) Services MRI Spinal Canal Lumbar W/O Contrast Material PX-6127214800 CDM 72148 CPT 612 RC inpatient 2858 2858 CIGNA 62308 [3081051] CIGNA STATE OF WYOMING [308105107] 2262.96 percent of total billed charges 1771.96 2715.1 Technical (Hospital) Services MRI Spinal Canal Lumbar W/O Contrast Material PX-6127214800 CDM 72148 CPT 612 RC inpatient 2858 2858 HEALTHPARTNERS SX009 HEALTHPARTNERS 2262.96 percent of total billed charges 1771.96 2715.1 Technical (Hospital) Services MRI Spinal Canal Lumbar W/O Contrast Material PX-6127214800 CDM 72148 CPT 612 RC inpatient 2858 2858 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES EPO [308136803] 2262.96 percent of total billed charges 1771.96 2715.1 Technical (Hospital) Services MRI Spinal Canal Lumbar W/O Contrast Material PX-6127214800 CDM 72148 CPT 612 RC inpatient 2858 2858 MEDICA (COMMERCIAL) 94265 [3081118] MEDICA CLAIMS [308111801] 2572.2 percent of total billed charges 1771.96 2715.1 Technical (Hospital) Services MRI Spinal Canal Lumbar W/O Contrast Material PX-6127214800 CDM 72148 CPT 612 RC inpatient 2858 2858 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES HDHP [308136802] 2262.96 percent of total billed charges 1771.96 2715.1 Technical (Hospital) Services MRI Spinal Canal Lumbar W/O Contrast Material PX-6127214800 CDM 72148 CPT 612 RC inpatient 2858 2858 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES PPO [308136801] 2262.96 percent of total billed charges 1771.96 2715.1 Technical (Hospital) Services MRI Spinal Canal Lumbar W/O Contrast Material PX-6127214800 CDM 72148 CPT 612 RC inpatient 2858 2858 UNITED HEALTHCARE (COMMERCIAL) [3081199] UNITED HEALTHCARE 87726 [308119901] 1771.96 percent of total billed charges 1771.96 2715.1 Technical (Hospital) Services MRI Spinal Canal Lumbar W/O Contrast Material PX-6127214800 CDM 72148 CPT 612 RC inpatient 2858 2858 MULTIPLAN INC 34080 [3081285] MULTIPLAN INC [308128501] 2715.1 percent of total billed charges 1771.96 2715.1 Technical (Hospital) Services MRI Spinal Canal Lumbar W/O Contrast Material PX-6127214800 CDM 72148 CPT 612 RC inpatient 2858 2858 BLUE CROSS BLUE SHIELD WELLMARK SB889 [3081026] BCBS WYOMING [308102603] 2715.1 percent of total billed charges 1771.96 2715.1 Technical (Hospital) Services MRI Spinal Canal Lumbar W/O Contrast Material PX-6127214800 CDM 72148 CPT 612 RC outpatient 2858 2858 CIGNA 62308 [3081051] CIGNA 62308 [308105105] 2286.4 percent of total billed charges 1771.96 2715.1 Technical (Hospital) Services MRI Spinal Canal Lumbar W/O Contrast Material PX-6127214800 CDM 72148 CPT 612 RC outpatient 2858 2858 CIGNA 62308 [3081051] CIGNA STATE OF WYOMING [308105107] 2286.4 percent of total billed charges 1771.96 2715.1 Technical (Hospital) Services MRI Spinal Canal Lumbar W/O Contrast Material PX-6127214800 CDM 72148 CPT 612 RC outpatient 2858 2858 MEDICA (COMMERCIAL) 94265 [3081118] MEDICA CLAIMS [308111801] 2572.2 percent of total billed charges 1771.96 2715.1 Technical (Hospital) Services MRI Spinal Canal Lumbar W/O Contrast Material PX-6127214800 CDM 72148 CPT 612 RC outpatient 2858 2858 BLUE CROSS BLUE SHIELD WELLMARK SB889 [3081026] BCBS WYOMING [308102603] 2715.1 percent of total billed charges 1771.96 2715.1 Technical (Hospital) Services MRI Spinal Canal Lumbar W/O Contrast Material PX-6127214800 CDM 72148 CPT 612 RC outpatient 2858 2858 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES HDHP [308136802] 2286.4 percent of total billed charges 1771.96 2715.1 Technical (Hospital) Services MRI Spinal Canal Lumbar W/O Contrast Material PX-6127214800 CDM 72148 CPT 612 RC outpatient 2858 2858 MULTIPLAN INC 34080 [3081285] MULTIPLAN INC [308128501] 2715.1 percent of total billed charges 1771.96 2715.1 Technical (Hospital) Services MRI Spinal Canal Lumbar W/O Contrast Material PX-6127214800 CDM 72148 CPT 612 RC outpatient 2858 2858 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES EPO [308136803] 2286.4 percent of total billed charges 1771.96 2715.1 Technical (Hospital) Services MRI Spinal Canal Lumbar W/O Contrast Material PX-6127214800 CDM 72148 CPT 612 RC outpatient 2858 2858 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES PPO [308136801] 2286.4 percent of total billed charges 1771.96 2715.1 Technical (Hospital) Services MRI Spinal Canal Lumbar W/O Contrast Material PX-6127214800 CDM 72148 CPT 612 RC outpatient 2858 2858 HEALTHPARTNERS SX009 HEALTHPARTNERS 2286.4 percent of total billed charges 1771.96 2715.1 Technical (Hospital) Services MRI Spinal Canal Lumbar W/O Contrast Material PX-6127214800 CDM 72148 CPT 612 RC outpatient 2858 2858 UNITED HEALTHCARE (COMMERCIAL) [3081199] UNITED HEALTHCARE 87726 [308119901] 1771.96 percent of total billed charges 1771.96 2715.1 Technical (Hospital) Services MRI Spinal Canal Thoracic W/Contrast Matrl PX-6127214700 CDM 72147 CPT 612 RC inpatient 3275 3275 CIGNA 62308 [3081051] CIGNA 62308 [308105105] 2593.15 percent of total billed charges 2030.5 3111.25 Technical (Hospital) Services MRI Spinal Canal Thoracic W/Contrast Matrl PX-6127214700 CDM 72147 CPT 612 RC inpatient 3275 3275 CIGNA 62308 [3081051] CIGNA STATE OF WYOMING [308105107] 2593.15 percent of total billed charges 2030.5 3111.25 Technical (Hospital) Services MRI Spinal Canal Thoracic W/Contrast Matrl PX-6127214700 CDM 72147 CPT 612 RC inpatient 3275 3275 MEDICA (COMMERCIAL) 94265 [3081118] MEDICA CLAIMS [308111801] 2947.5 percent of total billed charges 2030.5 3111.25 Technical (Hospital) Services MRI Spinal Canal Thoracic W/Contrast Matrl PX-6127214700 CDM 72147 CPT 612 RC inpatient 3275 3275 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES EPO [308136803] 2593.15 percent of total billed charges 2030.5 3111.25 Technical (Hospital) Services MRI Spinal Canal Thoracic W/Contrast Matrl PX-6127214700 CDM 72147 CPT 612 RC inpatient 3275 3275 HEALTHPARTNERS SX009 HEALTHPARTNERS 2593.15 percent of total billed charges 2030.5 3111.25 Technical (Hospital) Services MRI Spinal Canal Thoracic W/Contrast Matrl PX-6127214700 CDM 72147 CPT 612 RC inpatient 3275 3275 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES HDHP [308136802] 2593.15 percent of total billed charges 2030.5 3111.25 Technical (Hospital) Services MRI Spinal Canal Thoracic W/Contrast Matrl PX-6127214700 CDM 72147 CPT 612 RC inpatient 3275 3275 BLUE CROSS BLUE SHIELD WELLMARK SB889 [3081026] BCBS WYOMING [308102603] 3111.25 percent of total billed charges 2030.5 3111.25 Technical (Hospital) Services MRI Spinal Canal Thoracic W/Contrast Matrl PX-6127214700 CDM 72147 CPT 612 RC inpatient 3275 3275 MULTIPLAN INC 34080 [3081285] MULTIPLAN INC [308128501] 3111.25 percent of total billed charges 2030.5 3111.25 Technical (Hospital) Services MRI Spinal Canal Thoracic W/Contrast Matrl PX-6127214700 CDM 72147 CPT 612 RC inpatient 3275 3275 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES PPO [308136801] 2593.15 percent of total billed charges 2030.5 3111.25 Technical (Hospital) Services MRI Spinal Canal Thoracic W/Contrast Matrl PX-6127214700 CDM 72147 CPT 612 RC inpatient 3275 3275 UNITED HEALTHCARE (COMMERCIAL) [3081199] UNITED HEALTHCARE 87726 [308119901] 2030.5 percent of total billed charges 2030.5 3111.25 Technical (Hospital) Services MRI Spinal Canal Thoracic W/Contrast Matrl PX-6127214700 CDM 72147 CPT 612 RC outpatient 3275 3275 UNITED HEALTHCARE (COMMERCIAL) [3081199] UNITED HEALTHCARE 87726 [308119901] 2030.5 percent of total billed charges 2030.5 3111.25 Technical (Hospital) Services MRI Spinal Canal Thoracic W/Contrast Matrl PX-6127214700 CDM 72147 CPT 612 RC outpatient 3275 3275 HEALTHPARTNERS SX009 HEALTHPARTNERS 2620 percent of total billed charges 2030.5 3111.25 Technical (Hospital) Services MRI Spinal Canal Thoracic W/Contrast Matrl PX-6127214700 CDM 72147 CPT 612 RC outpatient 3275 3275 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES PPO [308136801] 2620 percent of total billed charges 2030.5 3111.25 Technical (Hospital) Services MRI Spinal Canal Thoracic W/Contrast Matrl PX-6127214700 CDM 72147 CPT 612 RC outpatient 3275 3275 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES EPO [308136803] 2620 percent of total billed charges 2030.5 3111.25 Technical (Hospital) Services MRI Spinal Canal Thoracic W/Contrast Matrl PX-6127214700 CDM 72147 CPT 612 RC outpatient 3275 3275 MULTIPLAN INC 34080 [3081285] MULTIPLAN INC [308128501] 3111.25 percent of total billed charges 2030.5 3111.25 Technical (Hospital) Services MRI Spinal Canal Thoracic W/Contrast Matrl PX-6127214700 CDM 72147 CPT 612 RC outpatient 3275 3275 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES HDHP [308136802] 2620 percent of total billed charges 2030.5 3111.25 Technical (Hospital) Services MRI Spinal Canal Thoracic W/Contrast Matrl PX-6127214700 CDM 72147 CPT 612 RC outpatient 3275 3275 BLUE CROSS BLUE SHIELD WELLMARK SB889 [3081026] BCBS WYOMING [308102603] 3111.25 percent of total billed charges 2030.5 3111.25 Technical (Hospital) Services MRI Spinal Canal Thoracic W/Contrast Matrl PX-6127214700 CDM 72147 CPT 612 RC outpatient 3275 3275 MEDICA (COMMERCIAL) 94265 [3081118] MEDICA CLAIMS [308111801] 2947.5 percent of total billed charges 2030.5 3111.25 Technical (Hospital) Services MRI Spinal Canal Thoracic W/Contrast Matrl PX-6127214700 CDM 72147 CPT 612 RC outpatient 3275 3275 CIGNA 62308 [3081051] CIGNA 62308 [308105105] 2620 percent of total billed charges 2030.5 3111.25 Technical (Hospital) Services MRI Spinal Canal Thoracic W/Contrast Matrl PX-6127214700 CDM 72147 CPT 612 RC outpatient 3275 3275 CIGNA 62308 [3081051] CIGNA STATE OF WYOMING [308105107] 2620 percent of total billed charges 2030.5 3111.25 Technical (Hospital) Services MRI Spinal Canal Thoracic W/O Contrast Matrl PX-6127214600 CDM 72146 CPT 612 RC outpatient 2620 2620 CIGNA 62308 [3081051] CIGNA 62308 [308105105] 2096 percent of total billed charges 1624.4 2489 Technical (Hospital) Services MRI Spinal Canal Thoracic W/O Contrast Matrl PX-6127214600 CDM 72146 CPT 612 RC outpatient 2620 2620 CIGNA 62308 [3081051] CIGNA STATE OF WYOMING [308105107] 2096 percent of total billed charges 1624.4 2489 Technical (Hospital) Services MRI Spinal Canal Thoracic W/O Contrast Matrl PX-6127214600 CDM 72146 CPT 612 RC outpatient 2620 2620 HEALTHPARTNERS SX009 HEALTHPARTNERS 2096 percent of total billed charges 1624.4 2489 Technical (Hospital) Services MRI Spinal Canal Thoracic W/O Contrast Matrl PX-6127214600 CDM 72146 CPT 612 RC outpatient 2620 2620 MEDICA (COMMERCIAL) 94265 [3081118] MEDICA CLAIMS [308111801] 2358 percent of total billed charges 1624.4 2489 Technical (Hospital) Services MRI Spinal Canal Thoracic W/O Contrast Matrl PX-6127214600 CDM 72146 CPT 612 RC outpatient 2620 2620 BLUE CROSS BLUE SHIELD WELLMARK SB889 [3081026] BCBS WYOMING [308102603] 2489 percent of total billed charges 1624.4 2489 Technical (Hospital) Services MRI Spinal Canal Thoracic W/O Contrast Matrl PX-6127214600 CDM 72146 CPT 612 RC outpatient 2620 2620 MULTIPLAN INC 34080 [3081285] MULTIPLAN INC [308128501] 2489 percent of total billed charges 1624.4 2489 Technical (Hospital) Services MRI Spinal Canal Thoracic W/O Contrast Matrl PX-6127214600 CDM 72146 CPT 612 RC outpatient 2620 2620 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES HDHP [308136802] 2096 percent of total billed charges 1624.4 2489 Technical (Hospital) Services MRI Spinal Canal Thoracic W/O Contrast Matrl PX-6127214600 CDM 72146 CPT 612 RC outpatient 2620 2620 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES EPO [308136803] 2096 percent of total billed charges 1624.4 2489 Technical (Hospital) Services MRI Spinal Canal Thoracic W/O Contrast Matrl PX-6127214600 CDM 72146 CPT 612 RC outpatient 2620 2620 UNITED HEALTHCARE (COMMERCIAL) [3081199] UNITED HEALTHCARE 87726 [308119901] 1624.4 percent of total billed charges 1624.4 2489 Technical (Hospital) Services MRI Spinal Canal Thoracic W/O Contrast Matrl PX-6127214600 CDM 72146 CPT 612 RC outpatient 2620 2620 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES PPO [308136801] 2096 percent of total billed charges 1624.4 2489 Technical (Hospital) Services MRI Spinal Canal Thoracic W/O Contrast Matrl PX-6127214600 CDM 72146 CPT 612 RC inpatient 2620 2620 UNITED HEALTHCARE (COMMERCIAL) [3081199] UNITED HEALTHCARE 87726 [308119901] 1624.4 percent of total billed charges 1624.4 2489 Technical (Hospital) Services MRI Spinal Canal Thoracic W/O Contrast Matrl PX-6127214600 CDM 72146 CPT 612 RC inpatient 2620 2620 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES PPO [308136801] 2074.52 percent of total billed charges 1624.4 2489 Technical (Hospital) Services MRI Spinal Canal Thoracic W/O Contrast Matrl PX-6127214600 CDM 72146 CPT 612 RC inpatient 2620 2620 MULTIPLAN INC 34080 [3081285] MULTIPLAN INC [308128501] 2489 percent of total billed charges 1624.4 2489 Technical (Hospital) Services MRI Spinal Canal Thoracic W/O Contrast Matrl PX-6127214600 CDM 72146 CPT 612 RC inpatient 2620 2620 BLUE CROSS BLUE SHIELD WELLMARK SB889 [3081026] BCBS WYOMING [308102603] 2489 percent of total billed charges 1624.4 2489 Technical (Hospital) Services MRI Spinal Canal Thoracic W/O Contrast Matrl PX-6127214600 CDM 72146 CPT 612 RC inpatient 2620 2620 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES HDHP [308136802] 2074.52 percent of total billed charges 1624.4 2489 Technical (Hospital) Services MRI Spinal Canal Thoracic W/O Contrast Matrl PX-6127214600 CDM 72146 CPT 612 RC inpatient 2620 2620 HEALTHPARTNERS SX009 HEALTHPARTNERS 2074.52 percent of total billed charges 1624.4 2489 Technical (Hospital) Services MRI Spinal Canal Thoracic W/O Contrast Matrl PX-6127214600 CDM 72146 CPT 612 RC inpatient 2620 2620 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES EPO [308136803] 2074.52 percent of total billed charges 1624.4 2489 Technical (Hospital) Services MRI Spinal Canal Thoracic W/O Contrast Matrl PX-6127214600 CDM 72146 CPT 612 RC inpatient 2620 2620 MEDICA (COMMERCIAL) 94265 [3081118] MEDICA CLAIMS [308111801] 2358 percent of total billed charges 1624.4 2489 Technical (Hospital) Services MRI Spinal Canal Thoracic W/O Contrast Matrl PX-6127214600 CDM 72146 CPT 612 RC inpatient 2620 2620 CIGNA 62308 [3081051] CIGNA 62308 [308105105] 2074.52 percent of total billed charges 1624.4 2489 Technical (Hospital) Services MRI Spinal Canal Thoracic W/O Contrast Matrl PX-6127214600 CDM 72146 CPT 612 RC inpatient 2620 2620 CIGNA 62308 [3081051] CIGNA STATE OF WYOMING [308105107] 2074.52 percent of total billed charges 1624.4 2489 Technical (Hospital) Services MRI Spinal Canal Cervical W/Contrast Matrl PX-6127214200 CDM 72142 CPT 612 RC inpatient 3275 3275 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES HDHP [308136802] 2593.15 percent of total billed charges 2030.5 3111.25 Technical (Hospital) Services MRI Spinal Canal Cervical W/Contrast Matrl PX-6127214200 CDM 72142 CPT 612 RC inpatient 3275 3275 MEDICA (COMMERCIAL) 94265 [3081118] MEDICA CLAIMS [308111801] 2947.5 percent of total billed charges 2030.5 3111.25 Technical (Hospital) Services MRI Spinal Canal Cervical W/Contrast Matrl PX-6127214200 CDM 72142 CPT 612 RC inpatient 3275 3275 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES EPO [308136803] 2593.15 percent of total billed charges 2030.5 3111.25 Technical (Hospital) Services MRI Spinal Canal Cervical W/Contrast Matrl PX-6127214200 CDM 72142 CPT 612 RC inpatient 3275 3275 HEALTHPARTNERS SX009 HEALTHPARTNERS 2593.15 percent of total billed charges 2030.5 3111.25 Technical (Hospital) Services MRI Spinal Canal Cervical W/Contrast Matrl PX-6127214200 CDM 72142 CPT 612 RC inpatient 3275 3275 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES PPO [308136801] 2593.15 percent of total billed charges 2030.5 3111.25 Technical (Hospital) Services MRI Spinal Canal Cervical W/Contrast Matrl PX-6127214200 CDM 72142 CPT 612 RC inpatient 3275 3275 UNITED HEALTHCARE (COMMERCIAL) [3081199] UNITED HEALTHCARE 87726 [308119901] 2030.5 percent of total billed charges 2030.5 3111.25 Technical (Hospital) Services MRI Spinal Canal Cervical W/Contrast Matrl PX-6127214200 CDM 72142 CPT 612 RC inpatient 3275 3275 MULTIPLAN INC 34080 [3081285] MULTIPLAN INC [308128501] 3111.25 percent of total billed charges 2030.5 3111.25 Technical (Hospital) Services MRI Spinal Canal Cervical W/Contrast Matrl PX-6127214200 CDM 72142 CPT 612 RC inpatient 3275 3275 BLUE CROSS BLUE SHIELD WELLMARK SB889 [3081026] BCBS WYOMING [308102603] 3111.25 percent of total billed charges 2030.5 3111.25 Technical (Hospital) Services MRI Spinal Canal Cervical W/Contrast Matrl PX-6127214200 CDM 72142 CPT 612 RC inpatient 3275 3275 CIGNA 62308 [3081051] CIGNA 62308 [308105105] 2593.15 percent of total billed charges 2030.5 3111.25 Technical (Hospital) Services MRI Spinal Canal Cervical W/Contrast Matrl PX-6127214200 CDM 72142 CPT 612 RC inpatient 3275 3275 CIGNA 62308 [3081051] CIGNA STATE OF WYOMING [308105107] 2593.15 percent of total billed charges 2030.5 3111.25 Technical (Hospital) Services MRI Spinal Canal Cervical W/Contrast Matrl PX-6127214200 CDM 72142 CPT 612 RC outpatient 3275 3275 HEALTHPARTNERS SX009 HEALTHPARTNERS 2620 percent of total billed charges 2030.5 3111.25 Technical (Hospital) Services MRI Spinal Canal Cervical W/Contrast Matrl PX-6127214200 CDM 72142 CPT 612 RC outpatient 3275 3275 UNITED HEALTHCARE (COMMERCIAL) [3081199] UNITED HEALTHCARE 87726 [308119901] 2030.5 percent of total billed charges 2030.5 3111.25 Technical (Hospital) Services MRI Spinal Canal Cervical W/Contrast Matrl PX-6127214200 CDM 72142 CPT 612 RC outpatient 3275 3275 BLUE CROSS BLUE SHIELD WELLMARK SB889 [3081026] BCBS WYOMING [308102603] 3111.25 percent of total billed charges 2030.5 3111.25 Technical (Hospital) Services MRI Spinal Canal Cervical W/Contrast Matrl PX-6127214200 CDM 72142 CPT 612 RC outpatient 3275 3275 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES HDHP [308136802] 2620 percent of total billed charges 2030.5 3111.25 Technical (Hospital) Services MRI Spinal Canal Cervical W/Contrast Matrl PX-6127214200 CDM 72142 CPT 612 RC outpatient 3275 3275 MULTIPLAN INC 34080 [3081285] MULTIPLAN INC [308128501] 3111.25 percent of total billed charges 2030.5 3111.25 Technical (Hospital) Services MRI Spinal Canal Cervical W/Contrast Matrl PX-6127214200 CDM 72142 CPT 612 RC outpatient 3275 3275 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES EPO [308136803] 2620 percent of total billed charges 2030.5 3111.25 Technical (Hospital) Services MRI Spinal Canal Cervical W/Contrast Matrl PX-6127214200 CDM 72142 CPT 612 RC outpatient 3275 3275 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES PPO [308136801] 2620 percent of total billed charges 2030.5 3111.25 Technical (Hospital) Services MRI Spinal Canal Cervical W/Contrast Matrl PX-6127214200 CDM 72142 CPT 612 RC outpatient 3275 3275 MEDICA (COMMERCIAL) 94265 [3081118] MEDICA CLAIMS [308111801] 2947.5 percent of total billed charges 2030.5 3111.25 Technical (Hospital) Services MRI Spinal Canal Cervical W/Contrast Matrl PX-6127214200 CDM 72142 CPT 612 RC outpatient 3275 3275 CIGNA 62308 [3081051] CIGNA 62308 [308105105] 2620 percent of total billed charges 2030.5 3111.25 Technical (Hospital) Services MRI Spinal Canal Cervical W/Contrast Matrl PX-6127214200 CDM 72142 CPT 612 RC outpatient 3275 3275 CIGNA 62308 [3081051] CIGNA STATE OF WYOMING [308105107] 2620 percent of total billed charges 2030.5 3111.25 Technical (Hospital) Services MRI Spinal Canal Cervical W/O Contrast Matrl PX-6127214100 CDM 72141 CPT 612 RC inpatient 2858 2858 CIGNA 62308 [3081051] CIGNA 62308 [308105105] 2262.96 percent of total billed charges 1771.96 2715.1 Technical (Hospital) Services MRI Spinal Canal Cervical W/O Contrast Matrl PX-6127214100 CDM 72141 CPT 612 RC inpatient 2858 2858 CIGNA 62308 [3081051] CIGNA STATE OF WYOMING [308105107] 2262.96 percent of total billed charges 1771.96 2715.1 Technical (Hospital) Services MRI Spinal Canal Cervical W/O Contrast Matrl PX-6127214100 CDM 72141 CPT 612 RC inpatient 2858 2858 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES EPO [308136803] 2262.96 percent of total billed charges 1771.96 2715.1 Technical (Hospital) Services MRI Spinal Canal Cervical W/O Contrast Matrl PX-6127214100 CDM 72141 CPT 612 RC inpatient 2858 2858 HEALTHPARTNERS SX009 HEALTHPARTNERS 2262.96 percent of total billed charges 1771.96 2715.1 Technical (Hospital) Services MRI Spinal Canal Cervical W/O Contrast Matrl PX-6127214100 CDM 72141 CPT 612 RC inpatient 2858 2858 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES HDHP [308136802] 2262.96 percent of total billed charges 1771.96 2715.1 Technical (Hospital) Services MRI Spinal Canal Cervical W/O Contrast Matrl PX-6127214100 CDM 72141 CPT 612 RC inpatient 2858 2858 MEDICA (COMMERCIAL) 94265 [3081118] MEDICA CLAIMS [308111801] 2572.2 percent of total billed charges 1771.96 2715.1 Technical (Hospital) Services MRI Spinal Canal Cervical W/O Contrast Matrl PX-6127214100 CDM 72141 CPT 612 RC inpatient 2858 2858 BLUE CROSS BLUE SHIELD WELLMARK SB889 [3081026] BCBS WYOMING [308102603] 2715.1 percent of total billed charges 1771.96 2715.1 Technical (Hospital) Services MRI Spinal Canal Cervical W/O Contrast Matrl PX-6127214100 CDM 72141 CPT 612 RC inpatient 2858 2858 MULTIPLAN INC 34080 [3081285] MULTIPLAN INC [308128501] 2715.1 percent of total billed charges 1771.96 2715.1 Technical (Hospital) Services MRI Spinal Canal Cervical W/O Contrast Matrl PX-6127214100 CDM 72141 CPT 612 RC inpatient 2858 2858 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES PPO [308136801] 2262.96 percent of total billed charges 1771.96 2715.1 Technical (Hospital) Services MRI Spinal Canal Cervical W/O Contrast Matrl PX-6127214100 CDM 72141 CPT 612 RC inpatient 2858 2858 UNITED HEALTHCARE (COMMERCIAL) [3081199] UNITED HEALTHCARE 87726 [308119901] 1771.96 percent of total billed charges 1771.96 2715.1 Technical (Hospital) Services MRI Spinal Canal Cervical W/O Contrast Matrl PX-6127214100 CDM 72141 CPT 612 RC outpatient 2858 2858 UNITED HEALTHCARE (COMMERCIAL) [3081199] UNITED HEALTHCARE 87726 [308119901] 1771.96 percent of total billed charges 1771.96 2715.1 Technical (Hospital) Services MRI Spinal Canal Cervical W/O Contrast Matrl PX-6127214100 CDM 72141 CPT 612 RC outpatient 2858 2858 HEALTHPARTNERS SX009 HEALTHPARTNERS 2286.4 percent of total billed charges 1771.96 2715.1 Technical (Hospital) Services MRI Spinal Canal Cervical W/O Contrast Matrl PX-6127214100 CDM 72141 CPT 612 RC outpatient 2858 2858 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES PPO [308136801] 2286.4 percent of total billed charges 1771.96 2715.1 Technical (Hospital) Services MRI Spinal Canal Cervical W/O Contrast Matrl PX-6127214100 CDM 72141 CPT 612 RC outpatient 2858 2858 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES EPO [308136803] 2286.4 percent of total billed charges 1771.96 2715.1 Technical (Hospital) Services MRI Spinal Canal Cervical W/O Contrast Matrl PX-6127214100 CDM 72141 CPT 612 RC outpatient 2858 2858 MULTIPLAN INC 34080 [3081285] MULTIPLAN INC [308128501] 2715.1 percent of total billed charges 1771.96 2715.1 Technical (Hospital) Services MRI Spinal Canal Cervical W/O Contrast Matrl PX-6127214100 CDM 72141 CPT 612 RC outpatient 2858 2858 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES HDHP [308136802] 2286.4 percent of total billed charges 1771.96 2715.1 Technical (Hospital) Services MRI Spinal Canal Cervical W/O Contrast Matrl PX-6127214100 CDM 72141 CPT 612 RC outpatient 2858 2858 BLUE CROSS BLUE SHIELD WELLMARK SB889 [3081026] BCBS WYOMING [308102603] 2715.1 percent of total billed charges 1771.96 2715.1 Technical (Hospital) Services MRI Spinal Canal Cervical W/O Contrast Matrl PX-6127214100 CDM 72141 CPT 612 RC outpatient 2858 2858 MEDICA (COMMERCIAL) 94265 [3081118] MEDICA CLAIMS [308111801] 2572.2 percent of total billed charges 1771.96 2715.1 Technical (Hospital) Services MRI Spinal Canal Cervical W/O Contrast Matrl PX-6127214100 CDM 72141 CPT 612 RC outpatient 2858 2858 CIGNA 62308 [3081051] CIGNA 62308 [308105105] 2286.4 percent of total billed charges 1771.96 2715.1 Technical (Hospital) Services MRI Spinal Canal Cervical W/O Contrast Matrl PX-6127214100 CDM 72141 CPT 612 RC outpatient 2858 2858 CIGNA 62308 [3081051] CIGNA STATE OF WYOMING [308105107] 2286.4 percent of total billed charges 1771.96 2715.1 Technical (Hospital) Services CT Lumbar Spine W/Contrast Material PX-3527213200 CDM 72132 CPT 352 RC outpatient 2084 2084 CIGNA 62308 [3081051] CIGNA 62308 [308105105] 1667.2 percent of total billed charges 1292.08 1979.8 Technical (Hospital) Services CT Lumbar Spine W/Contrast Material PX-3527213200 CDM 72132 CPT 352 RC outpatient 2084 2084 CIGNA 62308 [3081051] CIGNA STATE OF WYOMING [308105107] 1667.2 percent of total billed charges 1292.08 1979.8 Technical (Hospital) Services CT Lumbar Spine W/Contrast Material PX-3527213200 CDM 72132 CPT 352 RC outpatient 2084 2084 MEDICA (COMMERCIAL) 94265 [3081118] MEDICA CLAIMS [308111801] 1875.6 percent of total billed charges 1292.08 1979.8 Technical (Hospital) Services CT Lumbar Spine W/Contrast Material PX-3527213200 CDM 72132 CPT 352 RC outpatient 2084 2084 MULTIPLAN INC 34080 [3081285] MULTIPLAN INC [308128501] 1979.8 percent of total billed charges 1292.08 1979.8 Technical (Hospital) Services CT Lumbar Spine W/Contrast Material PX-3527213200 CDM 72132 CPT 352 RC outpatient 2084 2084 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES HDHP [308136802] 1667.2 percent of total billed charges 1292.08 1979.8 Technical (Hospital) Services CT Lumbar Spine W/Contrast Material PX-3527213200 CDM 72132 CPT 352 RC outpatient 2084 2084 BLUE CROSS BLUE SHIELD WELLMARK SB889 [3081026] BCBS WYOMING [308102603] 1979.8 percent of total billed charges 1292.08 1979.8 Technical (Hospital) Services CT Lumbar Spine W/Contrast Material PX-3527213200 CDM 72132 CPT 352 RC outpatient 2084 2084 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES PPO [308136801] 1667.2 percent of total billed charges 1292.08 1979.8 Technical (Hospital) Services CT Lumbar Spine W/Contrast Material PX-3527213200 CDM 72132 CPT 352 RC outpatient 2084 2084 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES EPO [308136803] 1667.2 percent of total billed charges 1292.08 1979.8 Technical (Hospital) Services CT Lumbar Spine W/Contrast Material PX-3527213200 CDM 72132 CPT 352 RC outpatient 2084 2084 UNITED HEALTHCARE (COMMERCIAL) [3081199] UNITED HEALTHCARE 87726 [308119901] 1292.08 percent of total billed charges 1292.08 1979.8 Technical (Hospital) Services CT Lumbar Spine W/Contrast Material PX-3527213200 CDM 72132 CPT 352 RC outpatient 2084 2084 HEALTHPARTNERS SX009 HEALTHPARTNERS 1667.2 percent of total billed charges 1292.08 1979.8 Technical (Hospital) Services CT Lumbar Spine W/Contrast Material PX-3527213200 CDM 72132 CPT 352 RC inpatient 2084 2084 CIGNA 62308 [3081051] CIGNA 62308 [308105105] 1650.11 percent of total billed charges 1292.08 1979.8 Technical (Hospital) Services CT Lumbar Spine W/Contrast Material PX-3527213200 CDM 72132 CPT 352 RC inpatient 2084 2084 CIGNA 62308 [3081051] CIGNA STATE OF WYOMING [308105107] 1650.11 percent of total billed charges 1292.08 1979.8 Technical (Hospital) Services CT Lumbar Spine W/Contrast Material PX-3527213200 CDM 72132 CPT 352 RC inpatient 2084 2084 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES EPO [308136803] 1650.11 percent of total billed charges 1292.08 1979.8 Technical (Hospital) Services CT Lumbar Spine W/Contrast Material PX-3527213200 CDM 72132 CPT 352 RC inpatient 2084 2084 UNITED HEALTHCARE (COMMERCIAL) [3081199] UNITED HEALTHCARE 87726 [308119901] 1292.08 percent of total billed charges 1292.08 1979.8 Technical (Hospital) Services CT Lumbar Spine W/Contrast Material PX-3527213200 CDM 72132 CPT 352 RC inpatient 2084 2084 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES PPO [308136801] 1650.11 percent of total billed charges 1292.08 1979.8 Technical (Hospital) Services CT Lumbar Spine W/Contrast Material PX-3527213200 CDM 72132 CPT 352 RC inpatient 2084 2084 BLUE CROSS BLUE SHIELD WELLMARK SB889 [3081026] BCBS WYOMING [308102603] 1979.8 percent of total billed charges 1292.08 1979.8 Technical (Hospital) Services CT Lumbar Spine W/Contrast Material PX-3527213200 CDM 72132 CPT 352 RC inpatient 2084 2084 MULTIPLAN INC 34080 [3081285] MULTIPLAN INC [308128501] 1979.8 percent of total billed charges 1292.08 1979.8 Technical (Hospital) Services CT Lumbar Spine W/Contrast Material PX-3527213200 CDM 72132 CPT 352 RC inpatient 2084 2084 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES HDHP [308136802] 1650.11 percent of total billed charges 1292.08 1979.8 Technical (Hospital) Services CT Lumbar Spine W/Contrast Material PX-3527213200 CDM 72132 CPT 352 RC inpatient 2084 2084 MEDICA (COMMERCIAL) 94265 [3081118] MEDICA CLAIMS [308111801] 1875.6 percent of total billed charges 1292.08 1979.8 Technical (Hospital) Services CT Lumbar Spine W/Contrast Material PX-3527213200 CDM 72132 CPT 352 RC inpatient 2084 2084 HEALTHPARTNERS SX009 HEALTHPARTNERS 1650.11 percent of total billed charges 1292.08 1979.8 Technical (Hospital) Services CT Lumbar Spine W/O Contrast Material PX-3527213100 CDM 72131 CPT 352 RC inpatient 1786 1786 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES EPO [308136803] 1414.15 percent of total billed charges 1107.32 1696.7 Technical (Hospital) Services CT Lumbar Spine W/O Contrast Material PX-3527213100 CDM 72131 CPT 352 RC inpatient 1786 1786 CIGNA 62308 [3081051] CIGNA 62308 [308105105] 1414.15 percent of total billed charges 1107.32 1696.7 Technical (Hospital) Services CT Lumbar Spine W/O Contrast Material PX-3527213100 CDM 72131 CPT 352 RC inpatient 1786 1786 CIGNA 62308 [3081051] CIGNA STATE OF WYOMING [308105107] 1414.15 percent of total billed charges 1107.32 1696.7 Technical (Hospital) Services CT Lumbar Spine W/O Contrast Material PX-3527213100 CDM 72131 CPT 352 RC inpatient 1786 1786 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES PPO [308136801] 1414.15 percent of total billed charges 1107.32 1696.7 Technical (Hospital) Services CT Lumbar Spine W/O Contrast Material PX-3527213100 CDM 72131 CPT 352 RC inpatient 1786 1786 UNITED HEALTHCARE (COMMERCIAL) [3081199] UNITED HEALTHCARE 87726 [308119901] 1107.32 percent of total billed charges 1107.32 1696.7 Technical (Hospital) Services CT Lumbar Spine W/O Contrast Material PX-3527213100 CDM 72131 CPT 352 RC inpatient 1786 1786 MULTIPLAN INC 34080 [3081285] MULTIPLAN INC [308128501] 1696.7 percent of total billed charges 1107.32 1696.7 Technical (Hospital) Services CT Lumbar Spine W/O Contrast Material PX-3527213100 CDM 72131 CPT 352 RC inpatient 1786 1786 BLUE CROSS BLUE SHIELD WELLMARK SB889 [3081026] BCBS WYOMING [308102603] 1696.7 percent of total billed charges 1107.32 1696.7 Technical (Hospital) Services CT Lumbar Spine W/O Contrast Material PX-3527213100 CDM 72131 CPT 352 RC inpatient 1786 1786 HEALTHPARTNERS SX009 HEALTHPARTNERS 1414.15 percent of total billed charges 1107.32 1696.7 Technical (Hospital) Services CT Lumbar Spine W/O Contrast Material PX-3527213100 CDM 72131 CPT 352 RC inpatient 1786 1786 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES HDHP [308136802] 1414.15 percent of total billed charges 1107.32 1696.7 Technical (Hospital) Services CT Lumbar Spine W/O Contrast Material PX-3527213100 CDM 72131 CPT 352 RC inpatient 1786 1786 MEDICA (COMMERCIAL) 94265 [3081118] MEDICA CLAIMS [308111801] 1607.4 percent of total billed charges 1107.32 1696.7 Technical (Hospital) Services CT Lumbar Spine W/O Contrast Material PX-3527213100 CDM 72131 CPT 352 RC outpatient 1786 1786 BLUE CROSS BLUE SHIELD WELLMARK SB889 [3081026] BCBS WYOMING [308102603] 1696.7 percent of total billed charges 1107.32 1696.7 Technical (Hospital) Services CT Lumbar Spine W/O Contrast Material PX-3527213100 CDM 72131 CPT 352 RC outpatient 1786 1786 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES HDHP [308136802] 1428.8 percent of total billed charges 1107.32 1696.7 Technical (Hospital) Services CT Lumbar Spine W/O Contrast Material PX-3527213100 CDM 72131 CPT 352 RC outpatient 1786 1786 MULTIPLAN INC 34080 [3081285] MULTIPLAN INC [308128501] 1696.7 percent of total billed charges 1107.32 1696.7 Technical (Hospital) Services CT Lumbar Spine W/O Contrast Material PX-3527213100 CDM 72131 CPT 352 RC outpatient 1786 1786 UNITED HEALTHCARE (COMMERCIAL) [3081199] UNITED HEALTHCARE 87726 [308119901] 1107.32 percent of total billed charges 1107.32 1696.7 Technical (Hospital) Services CT Lumbar Spine W/O Contrast Material PX-3527213100 CDM 72131 CPT 352 RC outpatient 1786 1786 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES EPO [308136803] 1428.8 percent of total billed charges 1107.32 1696.7 Technical (Hospital) Services CT Lumbar Spine W/O Contrast Material PX-3527213100 CDM 72131 CPT 352 RC outpatient 1786 1786 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES PPO [308136801] 1428.8 percent of total billed charges 1107.32 1696.7 Technical (Hospital) Services CT Lumbar Spine W/O Contrast Material PX-3527213100 CDM 72131 CPT 352 RC outpatient 1786 1786 HEALTHPARTNERS SX009 HEALTHPARTNERS 1428.8 percent of total billed charges 1107.32 1696.7 Technical (Hospital) Services CT Lumbar Spine W/O Contrast Material PX-3527213100 CDM 72131 CPT 352 RC outpatient 1786 1786 CIGNA 62308 [3081051] CIGNA 62308 [308105105] 1428.8 percent of total billed charges 1107.32 1696.7 Technical (Hospital) Services CT Lumbar Spine W/O Contrast Material PX-3527213100 CDM 72131 CPT 352 RC outpatient 1786 1786 CIGNA 62308 [3081051] CIGNA STATE OF WYOMING [308105107] 1428.8 percent of total billed charges 1107.32 1696.7 Technical (Hospital) Services CT Lumbar Spine W/O Contrast Material PX-3527213100 CDM 72131 CPT 352 RC outpatient 1786 1786 MEDICA (COMMERCIAL) 94265 [3081118] MEDICA CLAIMS [308111801] 1607.4 percent of total billed charges 1107.32 1696.7 Technical (Hospital) Services CT Thoracic Spine W/Contrast Material PX-3527212900 CDM 72129 CPT 352 RC inpatient 166 166 HEALTHPARTNERS SX009 HEALTHPARTNERS 131.44 percent of total billed charges 102.92 157.7 Technical (Hospital) Services CT Thoracic Spine W/Contrast Material PX-3527212900 CDM 72129 CPT 352 RC inpatient 166 166 MEDICA (COMMERCIAL) 94265 [3081118] MEDICA CLAIMS [308111801] 149.4 percent of total billed charges 102.92 157.7 Technical (Hospital) Services CT Thoracic Spine W/Contrast Material PX-3527212900 CDM 72129 CPT 352 RC inpatient 166 166 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES HDHP [308136802] 131.44 percent of total billed charges 102.92 157.7 Technical (Hospital) Services CT Thoracic Spine W/Contrast Material PX-3527212900 CDM 72129 CPT 352 RC inpatient 166 166 UNITED HEALTHCARE (COMMERCIAL) [3081199] UNITED HEALTHCARE 87726 [308119901] 102.92 percent of total billed charges 102.92 157.7 Technical (Hospital) Services CT Thoracic Spine W/Contrast Material PX-3527212900 CDM 72129 CPT 352 RC inpatient 166 166 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES PPO [308136801] 131.44 percent of total billed charges 102.92 157.7 Technical (Hospital) Services CT Thoracic Spine W/Contrast Material PX-3527212900 CDM 72129 CPT 352 RC inpatient 166 166 BLUE CROSS BLUE SHIELD WELLMARK SB889 [3081026] BCBS WYOMING [308102603] 157.7 percent of total billed charges 102.92 157.7 Technical (Hospital) Services CT Thoracic Spine W/Contrast Material PX-3527212900 CDM 72129 CPT 352 RC inpatient 166 166 MULTIPLAN INC 34080 [3081285] MULTIPLAN INC [308128501] 157.7 percent of total billed charges 102.92 157.7 Technical (Hospital) Services CT Thoracic Spine W/Contrast Material PX-3527212900 CDM 72129 CPT 352 RC inpatient 166 166 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES EPO [308136803] 131.44 percent of total billed charges 102.92 157.7 Technical (Hospital) Services CT Thoracic Spine W/Contrast Material PX-3527212900 CDM 72129 CPT 352 RC inpatient 166 166 CIGNA 62308 [3081051] CIGNA 62308 [308105105] 131.44 percent of total billed charges 102.92 157.7 Technical (Hospital) Services CT Thoracic Spine W/Contrast Material PX-3527212900 CDM 72129 CPT 352 RC inpatient 166 166 CIGNA 62308 [3081051] CIGNA STATE OF WYOMING [308105107] 131.44 percent of total billed charges 102.92 157.7 Technical (Hospital) Services CT Thoracic Spine W/Contrast Material PX-3527212900 CDM 72129 CPT 352 RC outpatient 166 166 CIGNA 62308 [3081051] CIGNA 62308 [308105105] 132.8 percent of total billed charges 102.92 157.7 Technical (Hospital) Services CT Thoracic Spine W/Contrast Material PX-3527212900 CDM 72129 CPT 352 RC outpatient 166 166 CIGNA 62308 [3081051] CIGNA STATE OF WYOMING [308105107] 132.8 percent of total billed charges 102.92 157.7 Technical (Hospital) Services CT Thoracic Spine W/Contrast Material PX-3527212900 CDM 72129 CPT 352 RC outpatient 166 166 MEDICA (COMMERCIAL) 94265 [3081118] MEDICA CLAIMS [308111801] 149.4 percent of total billed charges 102.92 157.7 Technical (Hospital) Services CT Thoracic Spine W/Contrast Material PX-3527212900 CDM 72129 CPT 352 RC outpatient 166 166 BLUE CROSS BLUE SHIELD WELLMARK SB889 [3081026] BCBS WYOMING [308102603] 157.7 percent of total billed charges 102.92 157.7 Technical (Hospital) Services CT Thoracic Spine W/Contrast Material PX-3527212900 CDM 72129 CPT 352 RC outpatient 166 166 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES HDHP [308136802] 132.8 percent of total billed charges 102.92 157.7 Technical (Hospital) Services CT Thoracic Spine W/Contrast Material PX-3527212900 CDM 72129 CPT 352 RC outpatient 166 166 MULTIPLAN INC 34080 [3081285] MULTIPLAN INC [308128501] 157.7 percent of total billed charges 102.92 157.7 Technical (Hospital) Services CT Thoracic Spine W/Contrast Material PX-3527212900 CDM 72129 CPT 352 RC outpatient 166 166 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES EPO [308136803] 132.8 percent of total billed charges 102.92 157.7 Technical (Hospital) Services CT Thoracic Spine W/Contrast Material PX-3527212900 CDM 72129 CPT 352 RC outpatient 166 166 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES PPO [308136801] 132.8 percent of total billed charges 102.92 157.7 Technical (Hospital) Services CT Thoracic Spine W/Contrast Material PX-3527212900 CDM 72129 CPT 352 RC outpatient 166 166 HEALTHPARTNERS SX009 HEALTHPARTNERS 132.8 percent of total billed charges 102.92 157.7 Technical (Hospital) Services CT Thoracic Spine W/Contrast Material PX-3527212900 CDM 72129 CPT 352 RC outpatient 166 166 UNITED HEALTHCARE (COMMERCIAL) [3081199] UNITED HEALTHCARE 87726 [308119901] 102.92 percent of total billed charges 102.92 157.7 Technical (Hospital) Services CT Thoracic Spine W/O Contrast Material PX-3527212800 CDM 72128 CPT 352 RC outpatient 1786 1786 MEDICA (COMMERCIAL) 94265 [3081118] MEDICA CLAIMS [308111801] 1607.4 percent of total billed charges 1107.32 1696.7 Technical (Hospital) Services CT Thoracic Spine W/O Contrast Material PX-3527212800 CDM 72128 CPT 352 RC outpatient 1786 1786 CIGNA 62308 [3081051] CIGNA 62308 [308105105] 1428.8 percent of total billed charges 1107.32 1696.7 Technical (Hospital) Services CT Thoracic Spine W/O Contrast Material PX-3527212800 CDM 72128 CPT 352 RC outpatient 1786 1786 CIGNA 62308 [3081051] CIGNA STATE OF WYOMING [308105107] 1428.8 percent of total billed charges 1107.32 1696.7 Technical (Hospital) Services CT Thoracic Spine W/O Contrast Material PX-3527212800 CDM 72128 CPT 352 RC outpatient 1786 1786 HEALTHPARTNERS SX009 HEALTHPARTNERS 1428.8 percent of total billed charges 1107.32 1696.7 Technical (Hospital) Services CT Thoracic Spine W/O Contrast Material PX-3527212800 CDM 72128 CPT 352 RC outpatient 1786 1786 UNITED HEALTHCARE (COMMERCIAL) [3081199] UNITED HEALTHCARE 87726 [308119901] 1107.32 percent of total billed charges 1107.32 1696.7 Technical (Hospital) Services CT Thoracic Spine W/O Contrast Material PX-3527212800 CDM 72128 CPT 352 RC outpatient 1786 1786 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES PPO [308136801] 1428.8 percent of total billed charges 1107.32 1696.7 Technical (Hospital) Services CT Thoracic Spine W/O Contrast Material PX-3527212800 CDM 72128 CPT 352 RC outpatient 1786 1786 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES EPO [308136803] 1428.8 percent of total billed charges 1107.32 1696.7 Technical (Hospital) Services CT Thoracic Spine W/O Contrast Material PX-3527212800 CDM 72128 CPT 352 RC outpatient 1786 1786 BLUE CROSS BLUE SHIELD WELLMARK SB889 [3081026] BCBS WYOMING [308102603] 1696.7 percent of total billed charges 1107.32 1696.7 Technical (Hospital) Services CT Thoracic Spine W/O Contrast Material PX-3527212800 CDM 72128 CPT 352 RC outpatient 1786 1786 MULTIPLAN INC 34080 [3081285] MULTIPLAN INC [308128501] 1696.7 percent of total billed charges 1107.32 1696.7 Technical (Hospital) Services CT Thoracic Spine W/O Contrast Material PX-3527212800 CDM 72128 CPT 352 RC outpatient 1786 1786 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES HDHP [308136802] 1428.8 percent of total billed charges 1107.32 1696.7 Technical (Hospital) Services CT Thoracic Spine W/O Contrast Material PX-3527212800 CDM 72128 CPT 352 RC inpatient 1786 1786 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES EPO [308136803] 1414.15 percent of total billed charges 1107.32 1696.7 Technical (Hospital) Services CT Thoracic Spine W/O Contrast Material PX-3527212800 CDM 72128 CPT 352 RC inpatient 1786 1786 CIGNA 62308 [3081051] CIGNA 62308 [308105105] 1414.15 percent of total billed charges 1107.32 1696.7 Technical (Hospital) Services CT Thoracic Spine W/O Contrast Material PX-3527212800 CDM 72128 CPT 352 RC inpatient 1786 1786 CIGNA 62308 [3081051] CIGNA STATE OF WYOMING [308105107] 1414.15 percent of total billed charges 1107.32 1696.7 Technical (Hospital) Services CT Thoracic Spine W/O Contrast Material PX-3527212800 CDM 72128 CPT 352 RC inpatient 1786 1786 MEDICA (COMMERCIAL) 94265 [3081118] MEDICA CLAIMS [308111801] 1607.4 percent of total billed charges 1107.32 1696.7 Technical (Hospital) Services CT Thoracic Spine W/O Contrast Material PX-3527212800 CDM 72128 CPT 352 RC inpatient 1786 1786 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES HDHP [308136802] 1414.15 percent of total billed charges 1107.32 1696.7 Technical (Hospital) Services CT Thoracic Spine W/O Contrast Material PX-3527212800 CDM 72128 CPT 352 RC inpatient 1786 1786 HEALTHPARTNERS SX009 HEALTHPARTNERS 1414.15 percent of total billed charges 1107.32 1696.7 Technical (Hospital) Services CT Thoracic Spine W/O Contrast Material PX-3527212800 CDM 72128 CPT 352 RC inpatient 1786 1786 UNITED HEALTHCARE (COMMERCIAL) [3081199] UNITED HEALTHCARE 87726 [308119901] 1107.32 percent of total billed charges 1107.32 1696.7 Technical (Hospital) Services CT Thoracic Spine W/O Contrast Material PX-3527212800 CDM 72128 CPT 352 RC inpatient 1786 1786 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES PPO [308136801] 1414.15 percent of total billed charges 1107.32 1696.7 Technical (Hospital) Services CT Thoracic Spine W/O Contrast Material PX-3527212800 CDM 72128 CPT 352 RC inpatient 1786 1786 BLUE CROSS BLUE SHIELD WELLMARK SB889 [3081026] BCBS WYOMING [308102603] 1696.7 percent of total billed charges 1107.32 1696.7 Technical (Hospital) Services CT Thoracic Spine W/O Contrast Material PX-3527212800 CDM 72128 CPT 352 RC inpatient 1786 1786 MULTIPLAN INC 34080 [3081285] MULTIPLAN INC [308128501] 1696.7 percent of total billed charges 1107.32 1696.7 Technical (Hospital) Services CT Cervical Spine W/O &W/Contrast Material PX-3527212700 CDM 72127 CPT 352 RC inpatient 2490 2490 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES EPO [308136803] 1971.58 percent of total billed charges 1543.8 2365.5 Technical (Hospital) Services CT Cervical Spine W/O &W/Contrast Material PX-3527212700 CDM 72127 CPT 352 RC inpatient 2490 2490 CIGNA 62308 [3081051] CIGNA 62308 [308105105] 1971.58 percent of total billed charges 1543.8 2365.5 Technical (Hospital) Services CT Cervical Spine W/O &W/Contrast Material PX-3527212700 CDM 72127 CPT 352 RC inpatient 2490 2490 CIGNA 62308 [3081051] CIGNA STATE OF WYOMING [308105107] 1971.58 percent of total billed charges 1543.8 2365.5 Technical (Hospital) Services CT Cervical Spine W/O &W/Contrast Material PX-3527212700 CDM 72127 CPT 352 RC inpatient 2490 2490 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES HDHP [308136802] 1971.58 percent of total billed charges 1543.8 2365.5 Technical (Hospital) Services CT Cervical Spine W/O &W/Contrast Material PX-3527212700 CDM 72127 CPT 352 RC inpatient 2490 2490 MEDICA (COMMERCIAL) 94265 [3081118] MEDICA CLAIMS [308111801] 2241 percent of total billed charges 1543.8 2365.5 Technical (Hospital) Services CT Cervical Spine W/O &W/Contrast Material PX-3527212700 CDM 72127 CPT 352 RC inpatient 2490 2490 HEALTHPARTNERS SX009 HEALTHPARTNERS 1971.58 percent of total billed charges 1543.8 2365.5 Technical (Hospital) Services CT Cervical Spine W/O &W/Contrast Material PX-3527212700 CDM 72127 CPT 352 RC inpatient 2490 2490 MULTIPLAN INC 34080 [3081285] MULTIPLAN INC [308128501] 2365.5 percent of total billed charges 1543.8 2365.5 Technical (Hospital) Services CT Cervical Spine W/O &W/Contrast Material PX-3527212700 CDM 72127 CPT 352 RC inpatient 2490 2490 BLUE CROSS BLUE SHIELD WELLMARK SB889 [3081026] BCBS WYOMING [308102603] 2365.5 percent of total billed charges 1543.8 2365.5 Technical (Hospital) Services CT Cervical Spine W/O &W/Contrast Material PX-3527212700 CDM 72127 CPT 352 RC inpatient 2490 2490 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES PPO [308136801] 1971.58 percent of total billed charges 1543.8 2365.5 Technical (Hospital) Services CT Cervical Spine W/O &W/Contrast Material PX-3527212700 CDM 72127 CPT 352 RC inpatient 2490 2490 UNITED HEALTHCARE (COMMERCIAL) [3081199] UNITED HEALTHCARE 87726 [308119901] 1543.8 percent of total billed charges 1543.8 2365.5 Technical (Hospital) Services CT Cervical Spine W/O &W/Contrast Material PX-3527212700 CDM 72127 CPT 352 RC outpatient 2490 2490 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES PPO [308136801] 1992 percent of total billed charges 1543.8 2365.5 Technical (Hospital) Services CT Cervical Spine W/O &W/Contrast Material PX-3527212700 CDM 72127 CPT 352 RC outpatient 2490 2490 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES EPO [308136803] 1992 percent of total billed charges 1543.8 2365.5 Technical (Hospital) Services CT Cervical Spine W/O &W/Contrast Material PX-3527212700 CDM 72127 CPT 352 RC outpatient 2490 2490 UNITED HEALTHCARE (COMMERCIAL) [3081199] UNITED HEALTHCARE 87726 [308119901] 1543.8 percent of total billed charges 1543.8 2365.5 Technical (Hospital) Services CT Cervical Spine W/O &W/Contrast Material PX-3527212700 CDM 72127 CPT 352 RC outpatient 2490 2490 BLUE CROSS BLUE SHIELD WELLMARK SB889 [3081026] BCBS WYOMING [308102603] 2365.5 percent of total billed charges 1543.8 2365.5 Technical (Hospital) Services CT Cervical Spine W/O &W/Contrast Material PX-3527212700 CDM 72127 CPT 352 RC outpatient 2490 2490 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES HDHP [308136802] 1992 percent of total billed charges 1543.8 2365.5 Technical (Hospital) Services CT Cervical Spine W/O &W/Contrast Material PX-3527212700 CDM 72127 CPT 352 RC outpatient 2490 2490 MULTIPLAN INC 34080 [3081285] MULTIPLAN INC [308128501] 2365.5 percent of total billed charges 1543.8 2365.5 Technical (Hospital) Services CT Cervical Spine W/O &W/Contrast Material PX-3527212700 CDM 72127 CPT 352 RC outpatient 2490 2490 HEALTHPARTNERS SX009 HEALTHPARTNERS 1992 percent of total billed charges 1543.8 2365.5 Technical (Hospital) Services CT Cervical Spine W/O &W/Contrast Material PX-3527212700 CDM 72127 CPT 352 RC outpatient 2490 2490 MEDICA (COMMERCIAL) 94265 [3081118] MEDICA CLAIMS [308111801] 2241 percent of total billed charges 1543.8 2365.5 Technical (Hospital) Services CT Cervical Spine W/O &W/Contrast Material PX-3527212700 CDM 72127 CPT 352 RC outpatient 2490 2490 CIGNA 62308 [3081051] CIGNA 62308 [308105105] 1992 percent of total billed charges 1543.8 2365.5 Technical (Hospital) Services CT Cervical Spine W/O &W/Contrast Material PX-3527212700 CDM 72127 CPT 352 RC outpatient 2490 2490 CIGNA 62308 [3081051] CIGNA STATE OF WYOMING [308105107] 1992 percent of total billed charges 1543.8 2365.5 Technical (Hospital) Services CT Cervical Spine W/Contrast Material PX-3527212600 CDM 72126 CPT 352 RC inpatient 2381 2381 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES HDHP [308136802] 1885.28 percent of total billed charges 1476.22 2261.95 Technical (Hospital) Services CT Cervical Spine W/Contrast Material PX-3527212600 CDM 72126 CPT 352 RC inpatient 2381 2381 MEDICA (COMMERCIAL) 94265 [3081118] MEDICA CLAIMS [308111801] 2142.9 percent of total billed charges 1476.22 2261.95 Technical (Hospital) Services CT Cervical Spine W/Contrast Material PX-3527212600 CDM 72126 CPT 352 RC inpatient 2381 2381 HEALTHPARTNERS SX009 HEALTHPARTNERS 1885.28 percent of total billed charges 1476.22 2261.95 Technical (Hospital) Services CT Cervical Spine W/Contrast Material PX-3527212600 CDM 72126 CPT 352 RC inpatient 2381 2381 MULTIPLAN INC 34080 [3081285] MULTIPLAN INC [308128501] 2261.95 percent of total billed charges 1476.22 2261.95 Technical (Hospital) Services CT Cervical Spine W/Contrast Material PX-3527212600 CDM 72126 CPT 352 RC inpatient 2381 2381 BLUE CROSS BLUE SHIELD WELLMARK SB889 [3081026] BCBS WYOMING [308102603] 2261.95 percent of total billed charges 1476.22 2261.95 Technical (Hospital) Services CT Cervical Spine W/Contrast Material PX-3527212600 CDM 72126 CPT 352 RC inpatient 2381 2381 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES PPO [308136801] 1885.28 percent of total billed charges 1476.22 2261.95 Technical (Hospital) Services CT Cervical Spine W/Contrast Material PX-3527212600 CDM 72126 CPT 352 RC inpatient 2381 2381 UNITED HEALTHCARE (COMMERCIAL) [3081199] UNITED HEALTHCARE 87726 [308119901] 1476.22 percent of total billed charges 1476.22 2261.95 Technical (Hospital) Services CT Cervical Spine W/Contrast Material PX-3527212600 CDM 72126 CPT 352 RC inpatient 2381 2381 CIGNA 62308 [3081051] CIGNA 62308 [308105105] 1885.28 percent of total billed charges 1476.22 2261.95 Technical (Hospital) Services CT Cervical Spine W/Contrast Material PX-3527212600 CDM 72126 CPT 352 RC inpatient 2381 2381 CIGNA 62308 [3081051] CIGNA STATE OF WYOMING [308105107] 1885.28 percent of total billed charges 1476.22 2261.95 Technical (Hospital) Services CT Cervical Spine W/Contrast Material PX-3527212600 CDM 72126 CPT 352 RC inpatient 2381 2381 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES EPO [308136803] 1885.28 percent of total billed charges 1476.22 2261.95 Technical (Hospital) Services CT Cervical Spine W/Contrast Material PX-3527212600 CDM 72126 CPT 352 RC outpatient 2381 2381 HEALTHPARTNERS SX009 HEALTHPARTNERS 1904.8 percent of total billed charges 1476.22 2261.95 Technical (Hospital) Services CT Cervical Spine W/Contrast Material PX-3527212600 CDM 72126 CPT 352 RC outpatient 2381 2381 UNITED HEALTHCARE (COMMERCIAL) [3081199] UNITED HEALTHCARE 87726 [308119901] 1476.22 percent of total billed charges 1476.22 2261.95 Technical (Hospital) Services CT Cervical Spine W/Contrast Material PX-3527212600 CDM 72126 CPT 352 RC outpatient 2381 2381 BLUE CROSS BLUE SHIELD WELLMARK SB889 [3081026] BCBS WYOMING [308102603] 2261.95 percent of total billed charges 1476.22 2261.95 Technical (Hospital) Services CT Cervical Spine W/Contrast Material PX-3527212600 CDM 72126 CPT 352 RC outpatient 2381 2381 MULTIPLAN INC 34080 [3081285] MULTIPLAN INC [308128501] 2261.95 percent of total billed charges 1476.22 2261.95 Technical (Hospital) Services CT Cervical Spine W/Contrast Material PX-3527212600 CDM 72126 CPT 352 RC outpatient 2381 2381 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES HDHP [308136802] 1904.8 percent of total billed charges 1476.22 2261.95 Technical (Hospital) Services CT Cervical Spine W/Contrast Material PX-3527212600 CDM 72126 CPT 352 RC outpatient 2381 2381 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES EPO [308136803] 1904.8 percent of total billed charges 1476.22 2261.95 Technical (Hospital) Services CT Cervical Spine W/Contrast Material PX-3527212600 CDM 72126 CPT 352 RC outpatient 2381 2381 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES PPO [308136801] 1904.8 percent of total billed charges 1476.22 2261.95 Technical (Hospital) Services CT Cervical Spine W/Contrast Material PX-3527212600 CDM 72126 CPT 352 RC outpatient 2381 2381 MEDICA (COMMERCIAL) 94265 [3081118] MEDICA CLAIMS [308111801] 2142.9 percent of total billed charges 1476.22 2261.95 Technical (Hospital) Services CT Cervical Spine W/Contrast Material PX-3527212600 CDM 72126 CPT 352 RC outpatient 2381 2381 CIGNA 62308 [3081051] CIGNA 62308 [308105105] 1904.8 percent of total billed charges 1476.22 2261.95 Technical (Hospital) Services CT Cervical Spine W/Contrast Material PX-3527212600 CDM 72126 CPT 352 RC outpatient 2381 2381 CIGNA 62308 [3081051] CIGNA STATE OF WYOMING [308105107] 1904.8 percent of total billed charges 1476.22 2261.95 Technical (Hospital) Services CT Cervical Spine W/O Contrast Material PX-3527212500 CDM 72125 CPT 352 RC outpatient 1905 1905 HEALTHPARTNERS SX009 HEALTHPARTNERS 1524 percent of total billed charges 1181.1 1809.75 Technical (Hospital) Services CT Cervical Spine W/O Contrast Material PX-3527212500 CDM 72125 CPT 352 RC outpatient 1905 1905 UNITED HEALTHCARE (COMMERCIAL) [3081199] UNITED HEALTHCARE 87726 [308119901] 1181.1 percent of total billed charges 1181.1 1809.75 Technical (Hospital) Services CT Cervical Spine W/O Contrast Material PX-3527212500 CDM 72125 CPT 352 RC outpatient 1905 1905 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES PPO [308136801] 1524 percent of total billed charges 1181.1 1809.75 Technical (Hospital) Services CT Cervical Spine W/O Contrast Material PX-3527212500 CDM 72125 CPT 352 RC outpatient 1905 1905 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES EPO [308136803] 1524 percent of total billed charges 1181.1 1809.75 Technical (Hospital) Services CT Cervical Spine W/O Contrast Material PX-3527212500 CDM 72125 CPT 352 RC outpatient 1905 1905 MULTIPLAN INC 34080 [3081285] MULTIPLAN INC [308128501] 1809.75 percent of total billed charges 1181.1 1809.75 Technical (Hospital) Services CT Cervical Spine W/O Contrast Material PX-3527212500 CDM 72125 CPT 352 RC outpatient 1905 1905 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES HDHP [308136802] 1524 percent of total billed charges 1181.1 1809.75 Technical (Hospital) Services CT Cervical Spine W/O Contrast Material PX-3527212500 CDM 72125 CPT 352 RC outpatient 1905 1905 BLUE CROSS BLUE SHIELD WELLMARK SB889 [3081026] BCBS WYOMING [308102603] 1809.75 percent of total billed charges 1181.1 1809.75 Technical (Hospital) Services CT Cervical Spine W/O Contrast Material PX-3527212500 CDM 72125 CPT 352 RC outpatient 1905 1905 CIGNA 62308 [3081051] CIGNA 62308 [308105105] 1524 percent of total billed charges 1181.1 1809.75 Technical (Hospital) Services CT Cervical Spine W/O Contrast Material PX-3527212500 CDM 72125 CPT 352 RC outpatient 1905 1905 CIGNA 62308 [3081051] CIGNA STATE OF WYOMING [308105107] 1524 percent of total billed charges 1181.1 1809.75 Technical (Hospital) Services CT Cervical Spine W/O Contrast Material PX-3527212500 CDM 72125 CPT 352 RC outpatient 1905 1905 MEDICA (COMMERCIAL) 94265 [3081118] MEDICA CLAIMS [308111801] 1714.5 percent of total billed charges 1181.1 1809.75 Technical (Hospital) Services CT Cervical Spine W/O Contrast Material PX-3527212500 CDM 72125 CPT 352 RC inpatient 1905 1905 CIGNA 62308 [3081051] CIGNA 62308 [308105105] 1508.38 percent of total billed charges 1181.1 1809.75 Technical (Hospital) Services CT Cervical Spine W/O Contrast Material PX-3527212500 CDM 72125 CPT 352 RC inpatient 1905 1905 CIGNA 62308 [3081051] CIGNA STATE OF WYOMING [308105107] 1508.38 percent of total billed charges 1181.1 1809.75 Technical (Hospital) Services CT Cervical Spine W/O Contrast Material PX-3527212500 CDM 72125 CPT 352 RC inpatient 1905 1905 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES EPO [308136803] 1508.38 percent of total billed charges 1181.1 1809.75 Technical (Hospital) Services CT Cervical Spine W/O Contrast Material PX-3527212500 CDM 72125 CPT 352 RC inpatient 1905 1905 UNITED HEALTHCARE (COMMERCIAL) [3081199] UNITED HEALTHCARE 87726 [308119901] 1181.1 percent of total billed charges 1181.1 1809.75 Technical (Hospital) Services CT Cervical Spine W/O Contrast Material PX-3527212500 CDM 72125 CPT 352 RC inpatient 1905 1905 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES PPO [308136801] 1508.38 percent of total billed charges 1181.1 1809.75 Technical (Hospital) Services CT Cervical Spine W/O Contrast Material PX-3527212500 CDM 72125 CPT 352 RC inpatient 1905 1905 BLUE CROSS BLUE SHIELD WELLMARK SB889 [3081026] BCBS WYOMING [308102603] 1809.75 percent of total billed charges 1181.1 1809.75 Technical (Hospital) Services CT Cervical Spine W/O Contrast Material PX-3527212500 CDM 72125 CPT 352 RC inpatient 1905 1905 MULTIPLAN INC 34080 [3081285] MULTIPLAN INC [308128501] 1809.75 percent of total billed charges 1181.1 1809.75 Technical (Hospital) Services CT Cervical Spine W/O Contrast Material PX-3527212500 CDM 72125 CPT 352 RC inpatient 1905 1905 HEALTHPARTNERS SX009 HEALTHPARTNERS 1508.38 percent of total billed charges 1181.1 1809.75 Technical (Hospital) Services CT Cervical Spine W/O Contrast Material PX-3527212500 CDM 72125 CPT 352 RC inpatient 1905 1905 MEDICA (COMMERCIAL) 94265 [3081118] MEDICA CLAIMS [308111801] 1714.5 percent of total billed charges 1181.1 1809.75 Technical (Hospital) Services CT Cervical Spine W/O Contrast Material PX-3527212500 CDM 72125 CPT 352 RC inpatient 1905 1905 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES HDHP [308136802] 1508.38 percent of total billed charges 1181.1 1809.75 Technical (Hospital) Services Radex Spine Lumbosacral Only Bending 2/3 Views PX-3207212000 CDM 72120 CPT 320 RC outpatient 310 310 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES EPO [308136803] 248 percent of total billed charges 192.2 294.5 Technical (Hospital) Services Radex Spine Lumbosacral Only Bending 2/3 Views PX-3207212000 CDM 72120 CPT 320 RC outpatient 310 310 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES PPO [308136801] 248 percent of total billed charges 192.2 294.5 Technical (Hospital) Services Radex Spine Lumbosacral Only Bending 2/3 Views PX-3207212000 CDM 72120 CPT 320 RC outpatient 310 310 BLUE CROSS BLUE SHIELD WELLMARK SB889 [3081026] BCBS WYOMING [308102603] 294.5 percent of total billed charges 192.2 294.5 Technical (Hospital) Services Radex Spine Lumbosacral Only Bending 2/3 Views PX-3207212000 CDM 72120 CPT 320 RC outpatient 310 310 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES HDHP [308136802] 248 percent of total billed charges 192.2 294.5 Technical (Hospital) Services Radex Spine Lumbosacral Only Bending 2/3 Views PX-3207212000 CDM 72120 CPT 320 RC outpatient 310 310 MULTIPLAN INC 34080 [3081285] MULTIPLAN INC [308128501] 294.5 percent of total billed charges 192.2 294.5 Technical (Hospital) Services Radex Spine Lumbosacral Only Bending 2/3 Views PX-3207212000 CDM 72120 CPT 320 RC outpatient 310 310 HEALTHPARTNERS SX009 HEALTHPARTNERS 248 percent of total billed charges 192.2 294.5 Technical (Hospital) Services Radex Spine Lumbosacral Only Bending 2/3 Views PX-3207212000 CDM 72120 CPT 320 RC outpatient 310 310 UNITED HEALTHCARE (COMMERCIAL) [3081199] UNITED HEALTHCARE 87726 [308119901] 192.2 percent of total billed charges 192.2 294.5 Technical (Hospital) Services Radex Spine Lumbosacral Only Bending 2/3 Views PX-3207212000 CDM 72120 CPT 320 RC outpatient 310 310 MEDICA (COMMERCIAL) 94265 [3081118] MEDICA CLAIMS [308111801] 279 percent of total billed charges 192.2 294.5 Technical (Hospital) Services Radex Spine Lumbosacral Only Bending 2/3 Views PX-3207212000 CDM 72120 CPT 320 RC outpatient 310 310 CIGNA 62308 [3081051] CIGNA 62308 [308105105] 248 percent of total billed charges 192.2 294.5 Technical (Hospital) Services Radex Spine Lumbosacral Only Bending 2/3 Views PX-3207212000 CDM 72120 CPT 320 RC outpatient 310 310 CIGNA 62308 [3081051] CIGNA STATE OF WYOMING [308105107] 248 percent of total billed charges 192.2 294.5 Technical (Hospital) Services Radex Spine Lumbosacral Only Bending 2/3 Views PX-3207212000 CDM 72120 CPT 320 RC inpatient 310 310 CIGNA 62308 [3081051] CIGNA 62308 [308105105] 245.46 percent of total billed charges 192.2 294.5 Technical (Hospital) Services Radex Spine Lumbosacral Only Bending 2/3 Views PX-3207212000 CDM 72120 CPT 320 RC inpatient 310 310 CIGNA 62308 [3081051] CIGNA STATE OF WYOMING [308105107] 245.46 percent of total billed charges 192.2 294.5 Technical (Hospital) Services Radex Spine Lumbosacral Only Bending 2/3 Views PX-3207212000 CDM 72120 CPT 320 RC inpatient 310 310 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES EPO [308136803] 245.46 percent of total billed charges 192.2 294.5 Technical (Hospital) Services Radex Spine Lumbosacral Only Bending 2/3 Views PX-3207212000 CDM 72120 CPT 320 RC inpatient 310 310 UNITED HEALTHCARE (COMMERCIAL) [3081199] UNITED HEALTHCARE 87726 [308119901] 192.2 percent of total billed charges 192.2 294.5 Technical (Hospital) Services Radex Spine Lumbosacral Only Bending 2/3 Views PX-3207212000 CDM 72120 CPT 320 RC inpatient 310 310 MULTIPLAN INC 34080 [3081285] MULTIPLAN INC [308128501] 294.5 percent of total billed charges 192.2 294.5 Technical (Hospital) Services Radex Spine Lumbosacral Only Bending 2/3 Views PX-3207212000 CDM 72120 CPT 320 RC inpatient 310 310 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES PPO [308136801] 245.46 percent of total billed charges 192.2 294.5 Technical (Hospital) Services Radex Spine Lumbosacral Only Bending 2/3 Views PX-3207212000 CDM 72120 CPT 320 RC inpatient 310 310 BLUE CROSS BLUE SHIELD WELLMARK SB889 [3081026] BCBS WYOMING [308102603] 294.5 percent of total billed charges 192.2 294.5 Technical (Hospital) Services Radex Spine Lumbosacral Only Bending 2/3 Views PX-3207212000 CDM 72120 CPT 320 RC inpatient 310 310 HEALTHPARTNERS SX009 HEALTHPARTNERS 245.46 percent of total billed charges 192.2 294.5 Technical (Hospital) Services Radex Spine Lumbosacral Only Bending 2/3 Views PX-3207212000 CDM 72120 CPT 320 RC inpatient 310 310 MEDICA (COMMERCIAL) 94265 [3081118] MEDICA CLAIMS [308111801] 279 percent of total billed charges 192.2 294.5 Technical (Hospital) Services Radex Spine Lumbosacral Only Bending 2/3 Views PX-3207212000 CDM 72120 CPT 320 RC inpatient 310 310 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES HDHP [308136802] 245.46 percent of total billed charges 192.2 294.5 Technical (Hospital) Services Radex Spine Lumbscrl Compl W/Bending Views Min 6 PX-3207211400 CDM 72114 CPT 320 RC inpatient 422 422 CIGNA 62308 [3081051] CIGNA 62308 [308105105] 334.14 percent of total billed charges 261.64 400.9 Technical (Hospital) Services Radex Spine Lumbscrl Compl W/Bending Views Min 6 PX-3207211400 CDM 72114 CPT 320 RC inpatient 422 422 CIGNA 62308 [3081051] CIGNA STATE OF WYOMING [308105107] 334.14 percent of total billed charges 261.64 400.9 Technical (Hospital) Services Radex Spine Lumbscrl Compl W/Bending Views Min 6 PX-3207211400 CDM 72114 CPT 320 RC inpatient 422 422 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES EPO [308136803] 334.14 percent of total billed charges 261.64 400.9 Technical (Hospital) Services Radex Spine Lumbscrl Compl W/Bending Views Min 6 PX-3207211400 CDM 72114 CPT 320 RC inpatient 422 422 MULTIPLAN INC 34080 [3081285] MULTIPLAN INC [308128501] 400.9 percent of total billed charges 261.64 400.9 Technical (Hospital) Services Radex Spine Lumbscrl Compl W/Bending Views Min 6 PX-3207211400 CDM 72114 CPT 320 RC inpatient 422 422 BLUE CROSS BLUE SHIELD WELLMARK SB889 [3081026] BCBS WYOMING [308102603] 400.9 percent of total billed charges 261.64 400.9 Technical (Hospital) Services Radex Spine Lumbscrl Compl W/Bending Views Min 6 PX-3207211400 CDM 72114 CPT 320 RC inpatient 422 422 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES PPO [308136801] 334.14 percent of total billed charges 261.64 400.9 Technical (Hospital) Services Radex Spine Lumbscrl Compl W/Bending Views Min 6 PX-3207211400 CDM 72114 CPT 320 RC inpatient 422 422 UNITED HEALTHCARE (COMMERCIAL) [3081199] UNITED HEALTHCARE 87726 [308119901] 261.64 percent of total billed charges 261.64 400.9 Technical (Hospital) Services Radex Spine Lumbscrl Compl W/Bending Views Min 6 PX-3207211400 CDM 72114 CPT 320 RC inpatient 422 422 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES HDHP [308136802] 334.14 percent of total billed charges 261.64 400.9 Technical (Hospital) Services Radex Spine Lumbscrl Compl W/Bending Views Min 6 PX-3207211400 CDM 72114 CPT 320 RC inpatient 422 422 MEDICA (COMMERCIAL) 94265 [3081118] MEDICA CLAIMS [308111801] 379.8 percent of total billed charges 261.64 400.9 Technical (Hospital) Services Radex Spine Lumbscrl Compl W/Bending Views Min 6 PX-3207211400 CDM 72114 CPT 320 RC inpatient 422 422 HEALTHPARTNERS SX009 HEALTHPARTNERS 334.14 percent of total billed charges 261.64 400.9 Technical (Hospital) Services Radex Spine Lumbscrl Compl W/Bending Views Min 6 PX-3207211400 CDM 72114 CPT 320 RC outpatient 422 422 HEALTHPARTNERS SX009 HEALTHPARTNERS 337.6 percent of total billed charges 261.64 400.9 Technical (Hospital) Services Radex Spine Lumbscrl Compl W/Bending Views Min 6 PX-3207211400 CDM 72114 CPT 320 RC outpatient 422 422 UNITED HEALTHCARE (COMMERCIAL) [3081199] UNITED HEALTHCARE 87726 [308119901] 261.64 percent of total billed charges 261.64 400.9 Technical (Hospital) Services Radex Spine Lumbscrl Compl W/Bending Views Min 6 PX-3207211400 CDM 72114 CPT 320 RC outpatient 422 422 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES EPO [308136803] 337.6 percent of total billed charges 261.64 400.9 Technical (Hospital) Services Radex Spine Lumbscrl Compl W/Bending Views Min 6 PX-3207211400 CDM 72114 CPT 320 RC outpatient 422 422 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES PPO [308136801] 337.6 percent of total billed charges 261.64 400.9 Technical (Hospital) Services Radex Spine Lumbscrl Compl W/Bending Views Min 6 PX-3207211400 CDM 72114 CPT 320 RC outpatient 422 422 BLUE CROSS BLUE SHIELD WELLMARK SB889 [3081026] BCBS WYOMING [308102603] 400.9 percent of total billed charges 261.64 400.9 Technical (Hospital) Services Radex Spine Lumbscrl Compl W/Bending Views Min 6 PX-3207211400 CDM 72114 CPT 320 RC outpatient 422 422 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES HDHP [308136802] 337.6 percent of total billed charges 261.64 400.9 Technical (Hospital) Services Radex Spine Lumbscrl Compl W/Bending Views Min 6 PX-3207211400 CDM 72114 CPT 320 RC outpatient 422 422 MULTIPLAN INC 34080 [3081285] MULTIPLAN INC [308128501] 400.9 percent of total billed charges 261.64 400.9 Technical (Hospital) Services Radex Spine Lumbscrl Compl W/Bending Views Min 6 PX-3207211400 CDM 72114 CPT 320 RC outpatient 422 422 MEDICA (COMMERCIAL) 94265 [3081118] MEDICA CLAIMS [308111801] 379.8 percent of total billed charges 261.64 400.9 Technical (Hospital) Services Radex Spine Lumbscrl Compl W/Bending Views Min 6 PX-3207211400 CDM 72114 CPT 320 RC outpatient 422 422 CIGNA 62308 [3081051] CIGNA 62308 [308105105] 337.6 percent of total billed charges 261.64 400.9 Technical (Hospital) Services Radex Spine Lumbscrl Compl W/Bending Views Min 6 PX-3207211400 CDM 72114 CPT 320 RC outpatient 422 422 CIGNA 62308 [3081051] CIGNA STATE OF WYOMING [308105107] 337.6 percent of total billed charges 261.64 400.9 Technical (Hospital) Services Radex Spine Lumbosacral Minimum 4 Views PX-3207211000 CDM 72110 CPT 320 RC outpatient 617 617 BLUE CROSS BLUE SHIELD WELLMARK SB889 [3081026] BCBS WYOMING [308102603] 586.15 percent of total billed charges 382.54 586.15 Technical (Hospital) Services Radex Spine Lumbosacral Minimum 4 Views PX-3207211000 CDM 72110 CPT 320 RC outpatient 617 617 MULTIPLAN INC 34080 [3081285] MULTIPLAN INC [308128501] 586.15 percent of total billed charges 382.54 586.15 Technical (Hospital) Services Radex Spine Lumbosacral Minimum 4 Views PX-3207211000 CDM 72110 CPT 320 RC outpatient 617 617 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES HDHP [308136802] 493.6 percent of total billed charges 382.54 586.15 Technical (Hospital) Services Radex Spine Lumbosacral Minimum 4 Views PX-3207211000 CDM 72110 CPT 320 RC outpatient 617 617 UNITED HEALTHCARE (COMMERCIAL) [3081199] UNITED HEALTHCARE 87726 [308119901] 382.54 percent of total billed charges 382.54 586.15 Technical (Hospital) Services Radex Spine Lumbosacral Minimum 4 Views PX-3207211000 CDM 72110 CPT 320 RC outpatient 617 617 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES PPO [308136801] 493.6 percent of total billed charges 382.54 586.15 Technical (Hospital) Services Radex Spine Lumbosacral Minimum 4 Views PX-3207211000 CDM 72110 CPT 320 RC outpatient 617 617 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES EPO [308136803] 493.6 percent of total billed charges 382.54 586.15 Technical (Hospital) Services Radex Spine Lumbosacral Minimum 4 Views PX-3207211000 CDM 72110 CPT 320 RC outpatient 617 617 HEALTHPARTNERS SX009 HEALTHPARTNERS 493.6 percent of total billed charges 382.54 586.15 Technical (Hospital) Services Radex Spine Lumbosacral Minimum 4 Views PX-3207211000 CDM 72110 CPT 320 RC outpatient 617 617 CIGNA 62308 [3081051] CIGNA 62308 [308105105] 493.6 percent of total billed charges 382.54 586.15 Technical (Hospital) Services Radex Spine Lumbosacral Minimum 4 Views PX-3207211000 CDM 72110 CPT 320 RC outpatient 617 617 CIGNA 62308 [3081051] CIGNA STATE OF WYOMING [308105107] 493.6 percent of total billed charges 382.54 586.15 Technical (Hospital) Services Radex Spine Lumbosacral Minimum 4 Views PX-3207211000 CDM 72110 CPT 320 RC outpatient 617 617 MEDICA (COMMERCIAL) 94265 [3081118] MEDICA CLAIMS [308111801] 555.3 percent of total billed charges 382.54 586.15 Technical (Hospital) Services Radex Spine Lumbosacral Minimum 4 Views PX-3207211000 CDM 72110 CPT 320 RC inpatient 617 617 CIGNA 62308 [3081051] CIGNA 62308 [308105105] 488.54 percent of total billed charges 382.54 586.15 Technical (Hospital) Services Radex Spine Lumbosacral Minimum 4 Views PX-3207211000 CDM 72110 CPT 320 RC inpatient 617 617 CIGNA 62308 [3081051] CIGNA STATE OF WYOMING [308105107] 488.54 percent of total billed charges 382.54 586.15 Technical (Hospital) Services Radex Spine Lumbosacral Minimum 4 Views PX-3207211000 CDM 72110 CPT 320 RC inpatient 617 617 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES EPO [308136803] 488.54 percent of total billed charges 382.54 586.15 Technical (Hospital) Services Radex Spine Lumbosacral Minimum 4 Views PX-3207211000 CDM 72110 CPT 320 RC inpatient 617 617 MULTIPLAN INC 34080 [3081285] MULTIPLAN INC [308128501] 586.15 percent of total billed charges 382.54 586.15 Technical (Hospital) Services Radex Spine Lumbosacral Minimum 4 Views PX-3207211000 CDM 72110 CPT 320 RC inpatient 617 617 BLUE CROSS BLUE SHIELD WELLMARK SB889 [3081026] BCBS WYOMING [308102603] 586.15 percent of total billed charges 382.54 586.15 Technical (Hospital) Services Radex Spine Lumbosacral Minimum 4 Views PX-3207211000 CDM 72110 CPT 320 RC inpatient 617 617 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES PPO [308136801] 488.54 percent of total billed charges 382.54 586.15 Technical (Hospital) Services Radex Spine Lumbosacral Minimum 4 Views PX-3207211000 CDM 72110 CPT 320 RC inpatient 617 617 UNITED HEALTHCARE (COMMERCIAL) [3081199] UNITED HEALTHCARE 87726 [308119901] 382.54 percent of total billed charges 382.54 586.15 Technical (Hospital) Services Radex Spine Lumbosacral Minimum 4 Views PX-3207211000 CDM 72110 CPT 320 RC inpatient 617 617 HEALTHPARTNERS SX009 HEALTHPARTNERS 488.54 percent of total billed charges 382.54 586.15 Technical (Hospital) Services Radex Spine Lumbosacral Minimum 4 Views PX-3207211000 CDM 72110 CPT 320 RC inpatient 617 617 MEDICA (COMMERCIAL) 94265 [3081118] MEDICA CLAIMS [308111801] 555.3 percent of total billed charges 382.54 586.15 Technical (Hospital) Services Radex Spine Lumbosacral Minimum 4 Views PX-3207211000 CDM 72110 CPT 320 RC inpatient 617 617 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES HDHP [308136802] 488.54 percent of total billed charges 382.54 586.15 Technical (Hospital) Services Radex Spine Lumbosacral 2/3 Views PX-3207210000 CDM 72100 CPT 320 RC inpatient 567 567 CIGNA 62308 [3081051] CIGNA 62308 [308105105] 448.95 percent of total billed charges 351.54 538.65 Technical (Hospital) Services Radex Spine Lumbosacral 2/3 Views PX-3207210000 CDM 72100 CPT 320 RC inpatient 567 567 CIGNA 62308 [3081051] CIGNA STATE OF WYOMING [308105107] 448.95 percent of total billed charges 351.54 538.65 Technical (Hospital) Services Radex Spine Lumbosacral 2/3 Views PX-3207210000 CDM 72100 CPT 320 RC inpatient 567 567 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES EPO [308136803] 448.95 percent of total billed charges 351.54 538.65 Technical (Hospital) Services Radex Spine Lumbosacral 2/3 Views PX-3207210000 CDM 72100 CPT 320 RC inpatient 567 567 UNITED HEALTHCARE (COMMERCIAL) [3081199] UNITED HEALTHCARE 87726 [308119901] 351.54 percent of total billed charges 351.54 538.65 Technical (Hospital) Services Radex Spine Lumbosacral 2/3 Views PX-3207210000 CDM 72100 CPT 320 RC inpatient 567 567 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES PPO [308136801] 448.95 percent of total billed charges 351.54 538.65 Technical (Hospital) Services Radex Spine Lumbosacral 2/3 Views PX-3207210000 CDM 72100 CPT 320 RC inpatient 567 567 BLUE CROSS BLUE SHIELD WELLMARK SB889 [3081026] BCBS WYOMING [308102603] 538.65 percent of total billed charges 351.54 538.65 Technical (Hospital) Services Radex Spine Lumbosacral 2/3 Views PX-3207210000 CDM 72100 CPT 320 RC inpatient 567 567 MULTIPLAN INC 34080 [3081285] MULTIPLAN INC [308128501] 538.65 percent of total billed charges 351.54 538.65 Technical (Hospital) Services Radex Spine Lumbosacral 2/3 Views PX-3207210000 CDM 72100 CPT 320 RC inpatient 567 567 MEDICA (COMMERCIAL) 94265 [3081118] MEDICA CLAIMS [308111801] 510.3 percent of total billed charges 351.54 538.65 Technical (Hospital) Services Radex Spine Lumbosacral 2/3 Views PX-3207210000 CDM 72100 CPT 320 RC inpatient 567 567 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES HDHP [308136802] 448.95 percent of total billed charges 351.54 538.65 Technical (Hospital) Services Radex Spine Lumbosacral 2/3 Views PX-3207210000 CDM 72100 CPT 320 RC inpatient 567 567 HEALTHPARTNERS SX009 HEALTHPARTNERS 448.95 percent of total billed charges 351.54 538.65 Technical (Hospital) Services Radex Spine Lumbosacral 2/3 Views PX-3207210000 CDM 72100 CPT 320 RC outpatient 567 567 CIGNA 62308 [3081051] CIGNA 62308 [308105105] 453.6 percent of total billed charges 351.54 538.65 Technical (Hospital) Services Radex Spine Lumbosacral 2/3 Views PX-3207210000 CDM 72100 CPT 320 RC outpatient 567 567 CIGNA 62308 [3081051] CIGNA STATE OF WYOMING [308105107] 453.6 percent of total billed charges 351.54 538.65 Technical (Hospital) Services Radex Spine Lumbosacral 2/3 Views PX-3207210000 CDM 72100 CPT 320 RC outpatient 567 567 MEDICA (COMMERCIAL) 94265 [3081118] MEDICA CLAIMS [308111801] 510.3 percent of total billed charges 351.54 538.65 Technical (Hospital) Services Radex Spine Lumbosacral 2/3 Views PX-3207210000 CDM 72100 CPT 320 RC outpatient 567 567 MULTIPLAN INC 34080 [3081285] MULTIPLAN INC [308128501] 538.65 percent of total billed charges 351.54 538.65 Technical (Hospital) Services Radex Spine Lumbosacral 2/3 Views PX-3207210000 CDM 72100 CPT 320 RC outpatient 567 567 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES HDHP [308136802] 453.6 percent of total billed charges 351.54 538.65 Technical (Hospital) Services Radex Spine Lumbosacral 2/3 Views PX-3207210000 CDM 72100 CPT 320 RC outpatient 567 567 BLUE CROSS BLUE SHIELD WELLMARK SB889 [3081026] BCBS WYOMING [308102603] 538.65 percent of total billed charges 351.54 538.65 Technical (Hospital) Services Radex Spine Lumbosacral 2/3 Views PX-3207210000 CDM 72100 CPT 320 RC outpatient 567 567 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES EPO [308136803] 453.6 percent of total billed charges 351.54 538.65 Technical (Hospital) Services Radex Spine Lumbosacral 2/3 Views PX-3207210000 CDM 72100 CPT 320 RC outpatient 567 567 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES PPO [308136801] 453.6 percent of total billed charges 351.54 538.65 Technical (Hospital) Services Radex Spine Lumbosacral 2/3 Views PX-3207210000 CDM 72100 CPT 320 RC outpatient 567 567 UNITED HEALTHCARE (COMMERCIAL) [3081199] UNITED HEALTHCARE 87726 [308119901] 351.54 percent of total billed charges 351.54 538.65 Technical (Hospital) Services Radex Spine Lumbosacral 2/3 Views PX-3207210000 CDM 72100 CPT 320 RC outpatient 567 567 HEALTHPARTNERS SX009 HEALTHPARTNERS 453.6 percent of total billed charges 351.54 538.65 Technical (Hospital) Services Radex Entir Thrc Lmbr Crv Sac Spi W/Skull 2/3 Vw PX-3207208200 CDM 72082 CPT 320 RC outpatient 450 450 MEDICA (COMMERCIAL) 94265 [3081118] MEDICA CLAIMS [308111801] 405 percent of total billed charges 279 427.5 Technical (Hospital) Services Radex Entir Thrc Lmbr Crv Sac Spi W/Skull 2/3 Vw PX-3207208200 CDM 72082 CPT 320 RC outpatient 450 450 CIGNA 62308 [3081051] CIGNA 62308 [308105105] 360 percent of total billed charges 279 427.5 Technical (Hospital) Services Radex Entir Thrc Lmbr Crv Sac Spi W/Skull 2/3 Vw PX-3207208200 CDM 72082 CPT 320 RC outpatient 450 450 CIGNA 62308 [3081051] CIGNA STATE OF WYOMING [308105107] 360 percent of total billed charges 279 427.5 Technical (Hospital) Services Radex Entir Thrc Lmbr Crv Sac Spi W/Skull 2/3 Vw PX-3207208200 CDM 72082 CPT 320 RC outpatient 450 450 MULTIPLAN INC 34080 [3081285] MULTIPLAN INC [308128501] 427.5 percent of total billed charges 279 427.5 Technical (Hospital) Services Radex Entir Thrc Lmbr Crv Sac Spi W/Skull 2/3 Vw PX-3207208200 CDM 72082 CPT 320 RC outpatient 450 450 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES HDHP [308136802] 360 percent of total billed charges 279 427.5 Technical (Hospital) Services Radex Entir Thrc Lmbr Crv Sac Spi W/Skull 2/3 Vw PX-3207208200 CDM 72082 CPT 320 RC outpatient 450 450 BLUE CROSS BLUE SHIELD WELLMARK SB889 [3081026] BCBS WYOMING [308102603] 427.5 percent of total billed charges 279 427.5 Technical (Hospital) Services Radex Entir Thrc Lmbr Crv Sac Spi W/Skull 2/3 Vw PX-3207208200 CDM 72082 CPT 320 RC outpatient 450 450 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES PPO [308136801] 360 percent of total billed charges 279 427.5 Technical (Hospital) Services Radex Entir Thrc Lmbr Crv Sac Spi W/Skull 2/3 Vw PX-3207208200 CDM 72082 CPT 320 RC outpatient 450 450 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES EPO [308136803] 360 percent of total billed charges 279 427.5 Technical (Hospital) Services Radex Entir Thrc Lmbr Crv Sac Spi W/Skull 2/3 Vw PX-3207208200 CDM 72082 CPT 320 RC outpatient 450 450 UNITED HEALTHCARE (COMMERCIAL) [3081199] UNITED HEALTHCARE 87726 [308119901] 279 percent of total billed charges 279 427.5 Technical (Hospital) Services Radex Entir Thrc Lmbr Crv Sac Spi W/Skull 2/3 Vw PX-3207208200 CDM 72082 CPT 320 RC outpatient 450 450 HEALTHPARTNERS SX009 HEALTHPARTNERS 360 percent of total billed charges 279 427.5 Technical (Hospital) Services Radex Entir Thrc Lmbr Crv Sac Spi W/Skull 2/3 Vw PX-3207208200 CDM 72082 CPT 320 RC inpatient 450 450 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES HDHP [308136802] 356.31 percent of total billed charges 279 427.5 Technical (Hospital) Services Radex Entir Thrc Lmbr Crv Sac Spi W/Skull 2/3 Vw PX-3207208200 CDM 72082 CPT 320 RC inpatient 450 450 MEDICA (COMMERCIAL) 94265 [3081118] MEDICA CLAIMS [308111801] 405 percent of total billed charges 279 427.5 Technical (Hospital) Services Radex Entir Thrc Lmbr Crv Sac Spi W/Skull 2/3 Vw PX-3207208200 CDM 72082 CPT 320 RC inpatient 450 450 HEALTHPARTNERS SX009 HEALTHPARTNERS 356.31 percent of total billed charges 279 427.5 Technical (Hospital) Services Radex Entir Thrc Lmbr Crv Sac Spi W/Skull 2/3 Vw PX-3207208200 CDM 72082 CPT 320 RC inpatient 450 450 UNITED HEALTHCARE (COMMERCIAL) [3081199] UNITED HEALTHCARE 87726 [308119901] 279 percent of total billed charges 279 427.5 Technical (Hospital) Services Radex Entir Thrc Lmbr Crv Sac Spi W/Skull 2/3 Vw PX-3207208200 CDM 72082 CPT 320 RC inpatient 450 450 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES PPO [308136801] 356.31 percent of total billed charges 279 427.5 Technical (Hospital) Services Radex Entir Thrc Lmbr Crv Sac Spi W/Skull 2/3 Vw PX-3207208200 CDM 72082 CPT 320 RC inpatient 450 450 BLUE CROSS BLUE SHIELD WELLMARK SB889 [3081026] BCBS WYOMING [308102603] 427.5 percent of total billed charges 279 427.5 Technical (Hospital) Services Radex Entir Thrc Lmbr Crv Sac Spi W/Skull 2/3 Vw PX-3207208200 CDM 72082 CPT 320 RC inpatient 450 450 MULTIPLAN INC 34080 [3081285] MULTIPLAN INC [308128501] 427.5 percent of total billed charges 279 427.5 Technical (Hospital) Services Radex Entir Thrc Lmbr Crv Sac Spi W/Skull 2/3 Vw PX-3207208200 CDM 72082 CPT 320 RC inpatient 450 450 CIGNA 62308 [3081051] CIGNA 62308 [308105105] 356.31 percent of total billed charges 279 427.5 Technical (Hospital) Services Radex Entir Thrc Lmbr Crv Sac Spi W/Skull 2/3 Vw PX-3207208200 CDM 72082 CPT 320 RC inpatient 450 450 CIGNA 62308 [3081051] CIGNA STATE OF WYOMING [308105107] 356.31 percent of total billed charges 279 427.5 Technical (Hospital) Services Radex Entir Thrc Lmbr Crv Sac Spi W/Skull 2/3 Vw PX-3207208200 CDM 72082 CPT 320 RC inpatient 450 450 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES EPO [308136803] 356.31 percent of total billed charges 279 427.5 Technical (Hospital) Services Radex Entir Thrc Lmbr Crv Sac Spi W/Skull 1 Vw PX-3207208100 CDM 72081 CPT 320 RC outpatient 282 282 HEALTHPARTNERS SX009 HEALTHPARTNERS 225.6 percent of total billed charges 174.84 267.9 Technical (Hospital) Services Radex Entir Thrc Lmbr Crv Sac Spi W/Skull 1 Vw PX-3207208100 CDM 72081 CPT 320 RC outpatient 282 282 MEDICA (COMMERCIAL) 94265 [3081118] MEDICA CLAIMS [308111801] 253.8 percent of total billed charges 174.84 267.9 Technical (Hospital) Services Radex Entir Thrc Lmbr Crv Sac Spi W/Skull 1 Vw PX-3207208100 CDM 72081 CPT 320 RC outpatient 282 282 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES PPO [308136801] 225.6 percent of total billed charges 174.84 267.9 Technical (Hospital) Services Radex Entir Thrc Lmbr Crv Sac Spi W/Skull 1 Vw PX-3207208100 CDM 72081 CPT 320 RC outpatient 282 282 UNITED HEALTHCARE (COMMERCIAL) [3081199] UNITED HEALTHCARE 87726 [308119901] 174.84 percent of total billed charges 174.84 267.9 Technical (Hospital) Services Radex Entir Thrc Lmbr Crv Sac Spi W/Skull 1 Vw PX-3207208100 CDM 72081 CPT 320 RC outpatient 282 282 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES EPO [308136803] 225.6 percent of total billed charges 174.84 267.9 Technical (Hospital) Services Radex Entir Thrc Lmbr Crv Sac Spi W/Skull 1 Vw PX-3207208100 CDM 72081 CPT 320 RC outpatient 282 282 BLUE CROSS BLUE SHIELD WELLMARK SB889 [3081026] BCBS WYOMING [308102603] 267.9 percent of total billed charges 174.84 267.9 Technical (Hospital) Services Radex Entir Thrc Lmbr Crv Sac Spi W/Skull 1 Vw PX-3207208100 CDM 72081 CPT 320 RC outpatient 282 282 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES HDHP [308136802] 225.6 percent of total billed charges 174.84 267.9 Technical (Hospital) Services Radex Entir Thrc Lmbr Crv Sac Spi W/Skull 1 Vw PX-3207208100 CDM 72081 CPT 320 RC outpatient 282 282 MULTIPLAN INC 34080 [3081285] MULTIPLAN INC [308128501] 267.9 percent of total billed charges 174.84 267.9 Technical (Hospital) Services Radex Entir Thrc Lmbr Crv Sac Spi W/Skull 1 Vw PX-3207208100 CDM 72081 CPT 320 RC outpatient 282 282 CIGNA 62308 [3081051] CIGNA 62308 [308105105] 225.6 percent of total billed charges 174.84 267.9 Technical (Hospital) Services Radex Entir Thrc Lmbr Crv Sac Spi W/Skull 1 Vw PX-3207208100 CDM 72081 CPT 320 RC outpatient 282 282 CIGNA 62308 [3081051] CIGNA STATE OF WYOMING [308105107] 225.6 percent of total billed charges 174.84 267.9 Technical (Hospital) Services Radex Entir Thrc Lmbr Crv Sac Spi W/Skull 1 Vw PX-3207208100 CDM 72081 CPT 320 RC inpatient 282 282 CIGNA 62308 [3081051] CIGNA 62308 [308105105] 223.29 percent of total billed charges 174.84 267.9 Technical (Hospital) Services Radex Entir Thrc Lmbr Crv Sac Spi W/Skull 1 Vw PX-3207208100 CDM 72081 CPT 320 RC inpatient 282 282 CIGNA 62308 [3081051] CIGNA STATE OF WYOMING [308105107] 223.29 percent of total billed charges 174.84 267.9 Technical (Hospital) Services Radex Entir Thrc Lmbr Crv Sac Spi W/Skull 1 Vw PX-3207208100 CDM 72081 CPT 320 RC inpatient 282 282 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES EPO [308136803] 223.29 percent of total billed charges 174.84 267.9 Technical (Hospital) Services Radex Entir Thrc Lmbr Crv Sac Spi W/Skull 1 Vw PX-3207208100 CDM 72081 CPT 320 RC inpatient 282 282 UNITED HEALTHCARE (COMMERCIAL) [3081199] UNITED HEALTHCARE 87726 [308119901] 174.84 percent of total billed charges 174.84 267.9 Technical (Hospital) Services Radex Entir Thrc Lmbr Crv Sac Spi W/Skull 1 Vw PX-3207208100 CDM 72081 CPT 320 RC inpatient 282 282 MULTIPLAN INC 34080 [3081285] MULTIPLAN INC [308128501] 267.9 percent of total billed charges 174.84 267.9 Technical (Hospital) Services Radex Entir Thrc Lmbr Crv Sac Spi W/Skull 1 Vw PX-3207208100 CDM 72081 CPT 320 RC inpatient 282 282 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES PPO [308136801] 223.29 percent of total billed charges 174.84 267.9 Technical (Hospital) Services Radex Entir Thrc Lmbr Crv Sac Spi W/Skull 1 Vw PX-3207208100 CDM 72081 CPT 320 RC inpatient 282 282 BLUE CROSS BLUE SHIELD WELLMARK SB889 [3081026] BCBS WYOMING [308102603] 267.9 percent of total billed charges 174.84 267.9 Technical (Hospital) Services Radex Entir Thrc Lmbr Crv Sac Spi W/Skull 1 Vw PX-3207208100 CDM 72081 CPT 320 RC inpatient 282 282 MEDICA (COMMERCIAL) 94265 [3081118] MEDICA CLAIMS [308111801] 253.8 percent of total billed charges 174.84 267.9 Technical (Hospital) Services Radex Entir Thrc Lmbr Crv Sac Spi W/Skull 1 Vw PX-3207208100 CDM 72081 CPT 320 RC inpatient 282 282 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES HDHP [308136802] 223.29 percent of total billed charges 174.84 267.9 Technical (Hospital) Services Radex Entir Thrc Lmbr Crv Sac Spi W/Skull 1 Vw PX-3207208100 CDM 72081 CPT 320 RC inpatient 282 282 HEALTHPARTNERS SX009 HEALTHPARTNERS 223.29 percent of total billed charges 174.84 267.9 Technical (Hospital) Services Radex Spine Thoracolumbar Junction Min 2 Views PX-3207208000 CDM 72080 CPT 320 RC outpatient 253 253 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES EPO [308136803] 202.4 percent of total billed charges 156.86 240.35 Technical (Hospital) Services Radex Spine Thoracolumbar Junction Min 2 Views PX-3207208000 CDM 72080 CPT 320 RC outpatient 253 253 UNITED HEALTHCARE (COMMERCIAL) [3081199] UNITED HEALTHCARE 87726 [308119901] 156.86 percent of total billed charges 156.86 240.35 Technical (Hospital) Services Radex Spine Thoracolumbar Junction Min 2 Views PX-3207208000 CDM 72080 CPT 320 RC outpatient 253 253 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES PPO [308136801] 202.4 percent of total billed charges 156.86 240.35 Technical (Hospital) Services Radex Spine Thoracolumbar Junction Min 2 Views PX-3207208000 CDM 72080 CPT 320 RC outpatient 253 253 BLUE CROSS BLUE SHIELD WELLMARK SB889 [3081026] BCBS WYOMING [308102603] 240.35 percent of total billed charges 156.86 240.35 Technical (Hospital) Services Radex Spine Thoracolumbar Junction Min 2 Views PX-3207208000 CDM 72080 CPT 320 RC outpatient 253 253 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES HDHP [308136802] 202.4 percent of total billed charges 156.86 240.35 Technical (Hospital) Services Radex Spine Thoracolumbar Junction Min 2 Views PX-3207208000 CDM 72080 CPT 320 RC outpatient 253 253 MULTIPLAN INC 34080 [3081285] MULTIPLAN INC [308128501] 240.35 percent of total billed charges 156.86 240.35 Technical (Hospital) Services Radex Spine Thoracolumbar Junction Min 2 Views PX-3207208000 CDM 72080 CPT 320 RC outpatient 253 253 HEALTHPARTNERS SX009 HEALTHPARTNERS 202.4 percent of total billed charges 156.86 240.35 Technical (Hospital) Services Radex Spine Thoracolumbar Junction Min 2 Views PX-3207208000 CDM 72080 CPT 320 RC outpatient 253 253 MEDICA (COMMERCIAL) 94265 [3081118] MEDICA CLAIMS [308111801] 227.7 percent of total billed charges 156.86 240.35 Technical (Hospital) Services Radex Spine Thoracolumbar Junction Min 2 Views PX-3207208000 CDM 72080 CPT 320 RC outpatient 253 253 CIGNA 62308 [3081051] CIGNA 62308 [308105105] 202.4 percent of total billed charges 156.86 240.35 Technical (Hospital) Services Radex Spine Thoracolumbar Junction Min 2 Views PX-3207208000 CDM 72080 CPT 320 RC outpatient 253 253 CIGNA 62308 [3081051] CIGNA STATE OF WYOMING [308105107] 202.4 percent of total billed charges 156.86 240.35 Technical (Hospital) Services Radex Spine Thoracolumbar Junction Min 2 Views PX-3207208000 CDM 72080 CPT 320 RC inpatient 253 253 MULTIPLAN INC 34080 [3081285] MULTIPLAN INC [308128501] 240.35 percent of total billed charges 156.86 240.35 Technical (Hospital) Services Radex Spine Thoracolumbar Junction Min 2 Views PX-3207208000 CDM 72080 CPT 320 RC inpatient 253 253 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES PPO [308136801] 200.33 percent of total billed charges 156.86 240.35 Technical (Hospital) Services Radex Spine Thoracolumbar Junction Min 2 Views PX-3207208000 CDM 72080 CPT 320 RC inpatient 253 253 BLUE CROSS BLUE SHIELD WELLMARK SB889 [3081026] BCBS WYOMING [308102603] 240.35 percent of total billed charges 156.86 240.35 Technical (Hospital) Services Radex Spine Thoracolumbar Junction Min 2 Views PX-3207208000 CDM 72080 CPT 320 RC inpatient 253 253 UNITED HEALTHCARE (COMMERCIAL) [3081199] UNITED HEALTHCARE 87726 [308119901] 156.86 percent of total billed charges 156.86 240.35 Technical (Hospital) Services Radex Spine Thoracolumbar Junction Min 2 Views PX-3207208000 CDM 72080 CPT 320 RC inpatient 253 253 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES HDHP [308136802] 200.33 percent of total billed charges 156.86 240.35 Technical (Hospital) Services Radex Spine Thoracolumbar Junction Min 2 Views PX-3207208000 CDM 72080 CPT 320 RC inpatient 253 253 MEDICA (COMMERCIAL) 94265 [3081118] MEDICA CLAIMS [308111801] 227.7 percent of total billed charges 156.86 240.35 Technical (Hospital) Services Radex Spine Thoracolumbar Junction Min 2 Views PX-3207208000 CDM 72080 CPT 320 RC inpatient 253 253 HEALTHPARTNERS SX009 HEALTHPARTNERS 200.33 percent of total billed charges 156.86 240.35 Technical (Hospital) Services Radex Spine Thoracolumbar Junction Min 2 Views PX-3207208000 CDM 72080 CPT 320 RC inpatient 253 253 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES EPO [308136803] 200.33 percent of total billed charges 156.86 240.35 Technical (Hospital) Services Radex Spine Thoracolumbar Junction Min 2 Views PX-3207208000 CDM 72080 CPT 320 RC inpatient 253 253 CIGNA 62308 [3081051] CIGNA 62308 [308105105] 200.33 percent of total billed charges 156.86 240.35 Technical (Hospital) Services Radex Spine Thoracolumbar Junction Min 2 Views PX-3207208000 CDM 72080 CPT 320 RC inpatient 253 253 CIGNA 62308 [3081051] CIGNA STATE OF WYOMING [308105107] 200.33 percent of total billed charges 156.86 240.35 Technical (Hospital) Services Radex Spine Thoracic 3 Views PX-3207207200 CDM 72072 CPT 320 RC outpatient 553 553 CIGNA 62308 [3081051] CIGNA 62308 [308105105] 442.4 percent of total billed charges 342.86 525.35 Technical (Hospital) Services Radex Spine Thoracic 3 Views PX-3207207200 CDM 72072 CPT 320 RC outpatient 553 553 CIGNA 62308 [3081051] CIGNA STATE OF WYOMING [308105107] 442.4 percent of total billed charges 342.86 525.35 Technical (Hospital) Services Radex Spine Thoracic 3 Views PX-3207207200 CDM 72072 CPT 320 RC outpatient 553 553 MEDICA (COMMERCIAL) 94265 [3081118] MEDICA CLAIMS [308111801] 497.7 percent of total billed charges 342.86 525.35 Technical (Hospital) Services Radex Spine Thoracic 3 Views PX-3207207200 CDM 72072 CPT 320 RC outpatient 553 553 HEALTHPARTNERS SX009 HEALTHPARTNERS 442.4 percent of total billed charges 342.86 525.35 Technical (Hospital) Services Radex Spine Thoracic 3 Views PX-3207207200 CDM 72072 CPT 320 RC outpatient 553 553 BLUE CROSS BLUE SHIELD WELLMARK SB889 [3081026] BCBS WYOMING [308102603] 525.35 percent of total billed charges 342.86 525.35 Technical (Hospital) Services Radex Spine Thoracic 3 Views PX-3207207200 CDM 72072 CPT 320 RC outpatient 553 553 MULTIPLAN INC 34080 [3081285] MULTIPLAN INC [308128501] 525.35 percent of total billed charges 342.86 525.35 Technical (Hospital) Services Radex Spine Thoracic 3 Views PX-3207207200 CDM 72072 CPT 320 RC outpatient 553 553 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES HDHP [308136802] 442.4 percent of total billed charges 342.86 525.35 Technical (Hospital) Services Radex Spine Thoracic 3 Views PX-3207207200 CDM 72072 CPT 320 RC outpatient 553 553 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES PPO [308136801] 442.4 percent of total billed charges 342.86 525.35 Technical (Hospital) Services Radex Spine Thoracic 3 Views PX-3207207200 CDM 72072 CPT 320 RC outpatient 553 553 UNITED HEALTHCARE (COMMERCIAL) [3081199] UNITED HEALTHCARE 87726 [308119901] 342.86 percent of total billed charges 342.86 525.35 Technical (Hospital) Services Radex Spine Thoracic 3 Views PX-3207207200 CDM 72072 CPT 320 RC outpatient 553 553 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES EPO [308136803] 442.4 percent of total billed charges 342.86 525.35 Technical (Hospital) Services Radex Spine Thoracic 3 Views PX-3207207200 CDM 72072 CPT 320 RC inpatient 553 553 UNITED HEALTHCARE (COMMERCIAL) [3081199] UNITED HEALTHCARE 87726 [308119901] 342.86 percent of total billed charges 342.86 525.35 Technical (Hospital) Services Radex Spine Thoracic 3 Views PX-3207207200 CDM 72072 CPT 320 RC inpatient 553 553 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES PPO [308136801] 437.87 percent of total billed charges 342.86 525.35 Technical (Hospital) Services Radex Spine Thoracic 3 Views PX-3207207200 CDM 72072 CPT 320 RC inpatient 553 553 BLUE CROSS BLUE SHIELD WELLMARK SB889 [3081026] BCBS WYOMING [308102603] 525.35 percent of total billed charges 342.86 525.35 Technical (Hospital) Services Radex Spine Thoracic 3 Views PX-3207207200 CDM 72072 CPT 320 RC inpatient 553 553 MULTIPLAN INC 34080 [3081285] MULTIPLAN INC [308128501] 525.35 percent of total billed charges 342.86 525.35 Technical (Hospital) Services Radex Spine Thoracic 3 Views PX-3207207200 CDM 72072 CPT 320 RC inpatient 553 553 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES HDHP [308136802] 437.87 percent of total billed charges 342.86 525.35 Technical (Hospital) Services Radex Spine Thoracic 3 Views PX-3207207200 CDM 72072 CPT 320 RC inpatient 553 553 MEDICA (COMMERCIAL) 94265 [3081118] MEDICA CLAIMS [308111801] 497.7 percent of total billed charges 342.86 525.35 Technical (Hospital) Services Radex Spine Thoracic 3 Views PX-3207207200 CDM 72072 CPT 320 RC inpatient 553 553 HEALTHPARTNERS SX009 HEALTHPARTNERS 437.87 percent of total billed charges 342.86 525.35 Technical (Hospital) Services Radex Spine Thoracic 3 Views PX-3207207200 CDM 72072 CPT 320 RC inpatient 553 553 CIGNA 62308 [3081051] CIGNA 62308 [308105105] 437.87 percent of total billed charges 342.86 525.35 Technical (Hospital) Services Radex Spine Thoracic 3 Views PX-3207207200 CDM 72072 CPT 320 RC inpatient 553 553 CIGNA 62308 [3081051] CIGNA STATE OF WYOMING [308105107] 437.87 percent of total billed charges 342.86 525.35 Technical (Hospital) Services Radex Spine Thoracic 3 Views PX-3207207200 CDM 72072 CPT 320 RC inpatient 553 553 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES EPO [308136803] 437.87 percent of total billed charges 342.86 525.35 Technical (Hospital) Services Radex Spine Thoracic 2 Views PX-3207207000 CDM 72070 CPT 320 RC outpatient 455 455 CIGNA 62308 [3081051] CIGNA 62308 [308105105] 364 percent of total billed charges 282.1 432.25 Technical (Hospital) Services Radex Spine Thoracic 2 Views PX-3207207000 CDM 72070 CPT 320 RC outpatient 455 455 CIGNA 62308 [3081051] CIGNA STATE OF WYOMING [308105107] 364 percent of total billed charges 282.1 432.25 Technical (Hospital) Services Radex Spine Thoracic 2 Views PX-3207207000 CDM 72070 CPT 320 RC outpatient 455 455 MEDICA (COMMERCIAL) 94265 [3081118] MEDICA CLAIMS [308111801] 409.5 percent of total billed charges 282.1 432.25 Technical (Hospital) Services Radex Spine Thoracic 2 Views PX-3207207000 CDM 72070 CPT 320 RC outpatient 455 455 UNITED HEALTHCARE (COMMERCIAL) [3081199] UNITED HEALTHCARE 87726 [308119901] 282.1 percent of total billed charges 282.1 432.25 Technical (Hospital) Services Radex Spine Thoracic 2 Views PX-3207207000 CDM 72070 CPT 320 RC outpatient 455 455 HEALTHPARTNERS SX009 HEALTHPARTNERS 364 percent of total billed charges 282.1 432.25 Technical (Hospital) Services Radex Spine Thoracic 2 Views PX-3207207000 CDM 72070 CPT 320 RC outpatient 455 455 MULTIPLAN INC 34080 [3081285] MULTIPLAN INC [308128501] 432.25 percent of total billed charges 282.1 432.25 Technical (Hospital) Services Radex Spine Thoracic 2 Views PX-3207207000 CDM 72070 CPT 320 RC outpatient 455 455 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES HDHP [308136802] 364 percent of total billed charges 282.1 432.25 Technical (Hospital) Services Radex Spine Thoracic 2 Views PX-3207207000 CDM 72070 CPT 320 RC outpatient 455 455 BLUE CROSS BLUE SHIELD WELLMARK SB889 [3081026] BCBS WYOMING [308102603] 432.25 percent of total billed charges 282.1 432.25 Technical (Hospital) Services Radex Spine Thoracic 2 Views PX-3207207000 CDM 72070 CPT 320 RC outpatient 455 455 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES PPO [308136801] 364 percent of total billed charges 282.1 432.25 Technical (Hospital) Services Radex Spine Thoracic 2 Views PX-3207207000 CDM 72070 CPT 320 RC outpatient 455 455 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES EPO [308136803] 364 percent of total billed charges 282.1 432.25 Technical (Hospital) Services Radex Spine Thoracic 2 Views PX-3207207000 CDM 72070 CPT 320 RC inpatient 455 455 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES EPO [308136803] 360.27 percent of total billed charges 282.1 432.25 Technical (Hospital) Services Radex Spine Thoracic 2 Views PX-3207207000 CDM 72070 CPT 320 RC inpatient 455 455 CIGNA 62308 [3081051] CIGNA 62308 [308105105] 360.27 percent of total billed charges 282.1 432.25 Technical (Hospital) Services Radex Spine Thoracic 2 Views PX-3207207000 CDM 72070 CPT 320 RC inpatient 455 455 CIGNA 62308 [3081051] CIGNA STATE OF WYOMING [308105107] 360.27 percent of total billed charges 282.1 432.25 Technical (Hospital) Services Radex Spine Thoracic 2 Views PX-3207207000 CDM 72070 CPT 320 RC inpatient 455 455 HEALTHPARTNERS SX009 HEALTHPARTNERS 360.27 percent of total billed charges 282.1 432.25 Technical (Hospital) Services Radex Spine Thoracic 2 Views PX-3207207000 CDM 72070 CPT 320 RC inpatient 455 455 MEDICA (COMMERCIAL) 94265 [3081118] MEDICA CLAIMS [308111801] 409.5 percent of total billed charges 282.1 432.25 Technical (Hospital) Services Radex Spine Thoracic 2 Views PX-3207207000 CDM 72070 CPT 320 RC inpatient 455 455 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES HDHP [308136802] 360.27 percent of total billed charges 282.1 432.25 Technical (Hospital) Services Radex Spine Thoracic 2 Views PX-3207207000 CDM 72070 CPT 320 RC inpatient 455 455 BLUE CROSS BLUE SHIELD WELLMARK SB889 [3081026] BCBS WYOMING [308102603] 432.25 percent of total billed charges 282.1 432.25 Technical (Hospital) Services Radex Spine Thoracic 2 Views PX-3207207000 CDM 72070 CPT 320 RC inpatient 455 455 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES PPO [308136801] 360.27 percent of total billed charges 282.1 432.25 Technical (Hospital) Services Radex Spine Thoracic 2 Views PX-3207207000 CDM 72070 CPT 320 RC inpatient 455 455 MULTIPLAN INC 34080 [3081285] MULTIPLAN INC [308128501] 432.25 percent of total billed charges 282.1 432.25 Technical (Hospital) Services Radex Spine Thoracic 2 Views PX-3207207000 CDM 72070 CPT 320 RC inpatient 455 455 UNITED HEALTHCARE (COMMERCIAL) [3081199] UNITED HEALTHCARE 87726 [308119901] 282.1 percent of total billed charges 282.1 432.25 Technical (Hospital) Services Radex Spine Cervical 6 or More Views PX-3207205200 CDM 72052 CPT 320 RC inpatient 860 860 HEALTHPARTNERS SX009 HEALTHPARTNERS 680.95 percent of total billed charges 533.2 817 Technical (Hospital) Services Radex Spine Cervical 6 or More Views PX-3207205200 CDM 72052 CPT 320 RC inpatient 860 860 MEDICA (COMMERCIAL) 94265 [3081118] MEDICA CLAIMS [308111801] 774 percent of total billed charges 533.2 817 Technical (Hospital) Services Radex Spine Cervical 6 or More Views PX-3207205200 CDM 72052 CPT 320 RC inpatient 860 860 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES HDHP [308136802] 680.95 percent of total billed charges 533.2 817 Technical (Hospital) Services Radex Spine Cervical 6 or More Views PX-3207205200 CDM 72052 CPT 320 RC inpatient 860 860 MULTIPLAN INC 34080 [3081285] MULTIPLAN INC [308128501] 817 percent of total billed charges 533.2 817 Technical (Hospital) Services Radex Spine Cervical 6 or More Views PX-3207205200 CDM 72052 CPT 320 RC inpatient 860 860 BLUE CROSS BLUE SHIELD WELLMARK SB889 [3081026] BCBS WYOMING [308102603] 817 percent of total billed charges 533.2 817 Technical (Hospital) Services Radex Spine Cervical 6 or More Views PX-3207205200 CDM 72052 CPT 320 RC inpatient 860 860 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES PPO [308136801] 680.95 percent of total billed charges 533.2 817 Technical (Hospital) Services Radex Spine Cervical 6 or More Views PX-3207205200 CDM 72052 CPT 320 RC inpatient 860 860 UNITED HEALTHCARE (COMMERCIAL) [3081199] UNITED HEALTHCARE 87726 [308119901] 533.2 percent of total billed charges 533.2 817 Technical (Hospital) Services Radex Spine Cervical 6 or More Views PX-3207205200 CDM 72052 CPT 320 RC inpatient 860 860 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES EPO [308136803] 680.95 percent of total billed charges 533.2 817 Technical (Hospital) Services Radex Spine Cervical 6 or More Views PX-3207205200 CDM 72052 CPT 320 RC inpatient 860 860 CIGNA 62308 [3081051] CIGNA 62308 [308105105] 680.95 percent of total billed charges 533.2 817 Technical (Hospital) Services Radex Spine Cervical 6 or More Views PX-3207205200 CDM 72052 CPT 320 RC inpatient 860 860 CIGNA 62308 [3081051] CIGNA STATE OF WYOMING [308105107] 680.95 percent of total billed charges 533.2 817 Technical (Hospital) Services Radex Spine Cervical 6 or More Views PX-3207205200 CDM 72052 CPT 320 RC outpatient 860 860 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES EPO [308136803] 688 percent of total billed charges 533.2 817 Technical (Hospital) Services Radex Spine Cervical 6 or More Views PX-3207205200 CDM 72052 CPT 320 RC outpatient 860 860 UNITED HEALTHCARE (COMMERCIAL) [3081199] UNITED HEALTHCARE 87726 [308119901] 533.2 percent of total billed charges 533.2 817 Technical (Hospital) Services Radex Spine Cervical 6 or More Views PX-3207205200 CDM 72052 CPT 320 RC outpatient 860 860 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES PPO [308136801] 688 percent of total billed charges 533.2 817 Technical (Hospital) Services Radex Spine Cervical 6 or More Views PX-3207205200 CDM 72052 CPT 320 RC outpatient 860 860 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES HDHP [308136802] 688 percent of total billed charges 533.2 817 Technical (Hospital) Services Radex Spine Cervical 6 or More Views PX-3207205200 CDM 72052 CPT 320 RC outpatient 860 860 MULTIPLAN INC 34080 [3081285] MULTIPLAN INC [308128501] 817 percent of total billed charges 533.2 817 Technical (Hospital) Services Radex Spine Cervical 6 or More Views PX-3207205200 CDM 72052 CPT 320 RC outpatient 860 860 BLUE CROSS BLUE SHIELD WELLMARK SB889 [3081026] BCBS WYOMING [308102603] 817 percent of total billed charges 533.2 817 Technical (Hospital) Services Radex Spine Cervical 6 or More Views PX-3207205200 CDM 72052 CPT 320 RC outpatient 860 860 HEALTHPARTNERS SX009 HEALTHPARTNERS 688 percent of total billed charges 533.2 817 Technical (Hospital) Services Radex Spine Cervical 6 or More Views PX-3207205200 CDM 72052 CPT 320 RC outpatient 860 860 MEDICA (COMMERCIAL) 94265 [3081118] MEDICA CLAIMS [308111801] 774 percent of total billed charges 533.2 817 Technical (Hospital) Services Radex Spine Cervical 6 or More Views PX-3207205200 CDM 72052 CPT 320 RC outpatient 860 860 CIGNA 62308 [3081051] CIGNA 62308 [308105105] 688 percent of total billed charges 533.2 817 Technical (Hospital) Services Radex Spine Cervical 6 or More Views PX-3207205200 CDM 72052 CPT 320 RC outpatient 860 860 CIGNA 62308 [3081051] CIGNA STATE OF WYOMING [308105107] 688 percent of total billed charges 533.2 817 Technical (Hospital) Services Radex Spine Cervical 4 or 5 Views PX-3207205000 CDM 72050 CPT 320 RC inpatient 614 614 MEDICA (COMMERCIAL) 94265 [3081118] MEDICA CLAIMS [308111801] 552.6 percent of total billed charges 380.68 583.3 Technical (Hospital) Services Radex Spine Cervical 4 or 5 Views PX-3207205000 CDM 72050 CPT 320 RC inpatient 614 614 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES HDHP [308136802] 486.17 percent of total billed charges 380.68 583.3 Technical (Hospital) Services Radex Spine Cervical 4 or 5 Views PX-3207205000 CDM 72050 CPT 320 RC inpatient 614 614 HEALTHPARTNERS SX009 HEALTHPARTNERS 486.17 percent of total billed charges 380.68 583.3 Technical (Hospital) Services Radex Spine Cervical 4 or 5 Views PX-3207205000 CDM 72050 CPT 320 RC inpatient 614 614 BLUE CROSS BLUE SHIELD WELLMARK SB889 [3081026] BCBS WYOMING [308102603] 583.3 percent of total billed charges 380.68 583.3 Technical (Hospital) Services Radex Spine Cervical 4 or 5 Views PX-3207205000 CDM 72050 CPT 320 RC inpatient 614 614 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES PPO [308136801] 486.17 percent of total billed charges 380.68 583.3 Technical (Hospital) Services Radex Spine Cervical 4 or 5 Views PX-3207205000 CDM 72050 CPT 320 RC inpatient 614 614 MULTIPLAN INC 34080 [3081285] MULTIPLAN INC [308128501] 583.3 percent of total billed charges 380.68 583.3 Technical (Hospital) Services Radex Spine Cervical 4 or 5 Views PX-3207205000 CDM 72050 CPT 320 RC inpatient 614 614 UNITED HEALTHCARE (COMMERCIAL) [3081199] UNITED HEALTHCARE 87726 [308119901] 380.68 percent of total billed charges 380.68 583.3 Technical (Hospital) Services Radex Spine Cervical 4 or 5 Views PX-3207205000 CDM 72050 CPT 320 RC inpatient 614 614 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES EPO [308136803] 486.17 percent of total billed charges 380.68 583.3 Technical (Hospital) Services Radex Spine Cervical 4 or 5 Views PX-3207205000 CDM 72050 CPT 320 RC inpatient 614 614 CIGNA 62308 [3081051] CIGNA 62308 [308105105] 486.17 percent of total billed charges 380.68 583.3 Technical (Hospital) Services Radex Spine Cervical 4 or 5 Views PX-3207205000 CDM 72050 CPT 320 RC inpatient 614 614 CIGNA 62308 [3081051] CIGNA STATE OF WYOMING [308105107] 486.17 percent of total billed charges 380.68 583.3 Technical (Hospital) Services Radex Spine Cervical 4 or 5 Views PX-3207205000 CDM 72050 CPT 320 RC outpatient 614 614 MEDICA (COMMERCIAL) 94265 [3081118] MEDICA CLAIMS [308111801] 552.6 percent of total billed charges 380.68 583.3 Technical (Hospital) Services Radex Spine Cervical 4 or 5 Views PX-3207205000 CDM 72050 CPT 320 RC outpatient 614 614 CIGNA 62308 [3081051] CIGNA 62308 [308105105] 491.2 percent of total billed charges 380.68 583.3 Technical (Hospital) Services Radex Spine Cervical 4 or 5 Views PX-3207205000 CDM 72050 CPT 320 RC outpatient 614 614 CIGNA 62308 [3081051] CIGNA STATE OF WYOMING [308105107] 491.2 percent of total billed charges 380.68 583.3 Technical (Hospital) Services Radex Spine Cervical 4 or 5 Views PX-3207205000 CDM 72050 CPT 320 RC outpatient 614 614 HEALTHPARTNERS SX009 HEALTHPARTNERS 491.2 percent of total billed charges 380.68 583.3 Technical (Hospital) Services Radex Spine Cervical 4 or 5 Views PX-3207205000 CDM 72050 CPT 320 RC outpatient 614 614 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES EPO [308136803] 491.2 percent of total billed charges 380.68 583.3 Technical (Hospital) Services Radex Spine Cervical 4 or 5 Views PX-3207205000 CDM 72050 CPT 320 RC outpatient 614 614 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES PPO [308136801] 491.2 percent of total billed charges 380.68 583.3 Technical (Hospital) Services Radex Spine Cervical 4 or 5 Views PX-3207205000 CDM 72050 CPT 320 RC outpatient 614 614 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES HDHP [308136802] 491.2 percent of total billed charges 380.68 583.3 Technical (Hospital) Services Radex Spine Cervical 4 or 5 Views PX-3207205000 CDM 72050 CPT 320 RC outpatient 614 614 MULTIPLAN INC 34080 [3081285] MULTIPLAN INC [308128501] 583.3 percent of total billed charges 380.68 583.3 Technical (Hospital) Services Radex Spine Cervical 4 or 5 Views PX-3207205000 CDM 72050 CPT 320 RC outpatient 614 614 UNITED HEALTHCARE (COMMERCIAL) [3081199] UNITED HEALTHCARE 87726 [308119901] 380.68 percent of total billed charges 380.68 583.3 Technical (Hospital) Services Radex Spine Cervical 4 or 5 Views PX-3207205000 CDM 72050 CPT 320 RC outpatient 614 614 BLUE CROSS BLUE SHIELD WELLMARK SB889 [3081026] BCBS WYOMING [308102603] 583.3 percent of total billed charges 380.68 583.3 Technical (Hospital) Services Radex Spine Cervical 2 or 3 Views PX-3207204000 CDM 72040 CPT 320 RC outpatient 434 434 HEALTHPARTNERS SX009 HEALTHPARTNERS 347.2 percent of total billed charges 269.08 412.3 Technical (Hospital) Services Radex Spine Cervical 2 or 3 Views PX-3207204000 CDM 72040 CPT 320 RC outpatient 434 434 MEDICA (COMMERCIAL) 94265 [3081118] MEDICA CLAIMS [308111801] 390.6 percent of total billed charges 269.08 412.3 Technical (Hospital) Services Radex Spine Cervical 2 or 3 Views PX-3207204000 CDM 72040 CPT 320 RC outpatient 434 434 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES PPO [308136801] 347.2 percent of total billed charges 269.08 412.3 Technical (Hospital) Services Radex Spine Cervical 2 or 3 Views PX-3207204000 CDM 72040 CPT 320 RC outpatient 434 434 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES EPO [308136803] 347.2 percent of total billed charges 269.08 412.3 Technical (Hospital) Services Radex Spine Cervical 2 or 3 Views PX-3207204000 CDM 72040 CPT 320 RC outpatient 434 434 BLUE CROSS BLUE SHIELD WELLMARK SB889 [3081026] BCBS WYOMING [308102603] 412.3 percent of total billed charges 269.08 412.3 Technical (Hospital) Services Radex Spine Cervical 2 or 3 Views PX-3207204000 CDM 72040 CPT 320 RC outpatient 434 434 UNITED HEALTHCARE (COMMERCIAL) [3081199] UNITED HEALTHCARE 87726 [308119901] 269.08 percent of total billed charges 269.08 412.3 Technical (Hospital) Services Radex Spine Cervical 2 or 3 Views PX-3207204000 CDM 72040 CPT 320 RC outpatient 434 434 MULTIPLAN INC 34080 [3081285] MULTIPLAN INC [308128501] 412.3 percent of total billed charges 269.08 412.3 Technical (Hospital) Services Radex Spine Cervical 2 or 3 Views PX-3207204000 CDM 72040 CPT 320 RC outpatient 434 434 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES HDHP [308136802] 347.2 percent of total billed charges 269.08 412.3 Technical (Hospital) Services Radex Spine Cervical 2 or 3 Views PX-3207204000 CDM 72040 CPT 320 RC outpatient 434 434 CIGNA 62308 [3081051] CIGNA 62308 [308105105] 347.2 percent of total billed charges 269.08 412.3 Technical (Hospital) Services Radex Spine Cervical 2 or 3 Views PX-3207204000 CDM 72040 CPT 320 RC outpatient 434 434 CIGNA 62308 [3081051] CIGNA STATE OF WYOMING [308105107] 347.2 percent of total billed charges 269.08 412.3 Technical (Hospital) Services Radex Spine Cervical 2 or 3 Views PX-3207204000 CDM 72040 CPT 320 RC inpatient 434 434 MEDICA (COMMERCIAL) 94265 [3081118] MEDICA CLAIMS [308111801] 390.6 percent of total billed charges 269.08 412.3 Technical (Hospital) Services Radex Spine Cervical 2 or 3 Views PX-3207204000 CDM 72040 CPT 320 RC inpatient 434 434 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES HDHP [308136802] 343.64 percent of total billed charges 269.08 412.3 Technical (Hospital) Services Radex Spine Cervical 2 or 3 Views PX-3207204000 CDM 72040 CPT 320 RC inpatient 434 434 HEALTHPARTNERS SX009 HEALTHPARTNERS 343.64 percent of total billed charges 269.08 412.3 Technical (Hospital) Services Radex Spine Cervical 2 or 3 Views PX-3207204000 CDM 72040 CPT 320 RC inpatient 434 434 UNITED HEALTHCARE (COMMERCIAL) [3081199] UNITED HEALTHCARE 87726 [308119901] 269.08 percent of total billed charges 269.08 412.3 Technical (Hospital) Services Radex Spine Cervical 2 or 3 Views PX-3207204000 CDM 72040 CPT 320 RC inpatient 434 434 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES PPO [308136801] 343.64 percent of total billed charges 269.08 412.3 Technical (Hospital) Services Radex Spine Cervical 2 or 3 Views PX-3207204000 CDM 72040 CPT 320 RC inpatient 434 434 BLUE CROSS BLUE SHIELD WELLMARK SB889 [3081026] BCBS WYOMING [308102603] 412.3 percent of total billed charges 269.08 412.3 Technical (Hospital) Services Radex Spine Cervical 2 or 3 Views PX-3207204000 CDM 72040 CPT 320 RC inpatient 434 434 MULTIPLAN INC 34080 [3081285] MULTIPLAN INC [308128501] 412.3 percent of total billed charges 269.08 412.3 Technical (Hospital) Services Radex Spine Cervical 2 or 3 Views PX-3207204000 CDM 72040 CPT 320 RC inpatient 434 434 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES EPO [308136803] 343.64 percent of total billed charges 269.08 412.3 Technical (Hospital) Services Radex Spine Cervical 2 or 3 Views PX-3207204000 CDM 72040 CPT 320 RC inpatient 434 434 CIGNA 62308 [3081051] CIGNA 62308 [308105105] 343.64 percent of total billed charges 269.08 412.3 Technical (Hospital) Services Radex Spine Cervical 2 or 3 Views PX-3207204000 CDM 72040 CPT 320 RC inpatient 434 434 CIGNA 62308 [3081051] CIGNA STATE OF WYOMING [308105107] 343.64 percent of total billed charges 269.08 412.3 Technical (Hospital) Services Radex Spine 1 View Specify Level PX-3207202000 CDM 72020 CPT 320 RC outpatient 166 166 MEDICA (COMMERCIAL) 94265 [3081118] MEDICA CLAIMS [308111801] 149.4 percent of total billed charges 102.92 157.7 Technical (Hospital) Services Radex Spine 1 View Specify Level PX-3207202000 CDM 72020 CPT 320 RC outpatient 166 166 CIGNA 62308 [3081051] CIGNA 62308 [308105105] 132.8 percent of total billed charges 102.92 157.7 Technical (Hospital) Services Radex Spine 1 View Specify Level PX-3207202000 CDM 72020 CPT 320 RC outpatient 166 166 CIGNA 62308 [3081051] CIGNA STATE OF WYOMING [308105107] 132.8 percent of total billed charges 102.92 157.7 Technical (Hospital) Services Radex Spine 1 View Specify Level PX-3207202000 CDM 72020 CPT 320 RC outpatient 166 166 BLUE CROSS BLUE SHIELD WELLMARK SB889 [3081026] BCBS WYOMING [308102603] 157.7 percent of total billed charges 102.92 157.7 Technical (Hospital) Services Radex Spine 1 View Specify Level PX-3207202000 CDM 72020 CPT 320 RC outpatient 166 166 UNITED HEALTHCARE (COMMERCIAL) [3081199] UNITED HEALTHCARE 87726 [308119901] 102.92 percent of total billed charges 102.92 157.7 Technical (Hospital) Services Radex Spine 1 View Specify Level PX-3207202000 CDM 72020 CPT 320 RC outpatient 166 166 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES HDHP [308136802] 132.8 percent of total billed charges 102.92 157.7 Technical (Hospital) Services Radex Spine 1 View Specify Level PX-3207202000 CDM 72020 CPT 320 RC outpatient 166 166 MULTIPLAN INC 34080 [3081285] MULTIPLAN INC [308128501] 157.7 percent of total billed charges 102.92 157.7 Technical (Hospital) Services Radex Spine 1 View Specify Level PX-3207202000 CDM 72020 CPT 320 RC outpatient 166 166 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES EPO [308136803] 132.8 percent of total billed charges 102.92 157.7 Technical (Hospital) Services Radex Spine 1 View Specify Level PX-3207202000 CDM 72020 CPT 320 RC outpatient 166 166 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES PPO [308136801] 132.8 percent of total billed charges 102.92 157.7 Technical (Hospital) Services Radex Spine 1 View Specify Level PX-3207202000 CDM 72020 CPT 320 RC outpatient 166 166 HEALTHPARTNERS SX009 HEALTHPARTNERS 132.8 percent of total billed charges 102.92 157.7 Technical (Hospital) Services Radex Spine 1 View Specify Level PX-3207202000 CDM 72020 CPT 320 RC inpatient 166 166 CIGNA 62308 [3081051] CIGNA 62308 [308105105] 131.44 percent of total billed charges 102.92 157.7 Technical (Hospital) Services Radex Spine 1 View Specify Level PX-3207202000 CDM 72020 CPT 320 RC inpatient 166 166 CIGNA 62308 [3081051] CIGNA STATE OF WYOMING [308105107] 131.44 percent of total billed charges 102.92 157.7 Technical (Hospital) Services Radex Spine 1 View Specify Level PX-3207202000 CDM 72020 CPT 320 RC inpatient 166 166 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES EPO [308136803] 131.44 percent of total billed charges 102.92 157.7 Technical (Hospital) Services Radex Spine 1 View Specify Level PX-3207202000 CDM 72020 CPT 320 RC inpatient 166 166 MULTIPLAN INC 34080 [3081285] MULTIPLAN INC [308128501] 157.7 percent of total billed charges 102.92 157.7 Technical (Hospital) Services Radex Spine 1 View Specify Level PX-3207202000 CDM 72020 CPT 320 RC inpatient 166 166 BLUE CROSS BLUE SHIELD WELLMARK SB889 [3081026] BCBS WYOMING [308102603] 157.7 percent of total billed charges 102.92 157.7 Technical (Hospital) Services Radex Spine 1 View Specify Level PX-3207202000 CDM 72020 CPT 320 RC inpatient 166 166 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES PPO [308136801] 131.44 percent of total billed charges 102.92 157.7 Technical (Hospital) Services Radex Spine 1 View Specify Level PX-3207202000 CDM 72020 CPT 320 RC inpatient 166 166 UNITED HEALTHCARE (COMMERCIAL) [3081199] UNITED HEALTHCARE 87726 [308119901] 102.92 percent of total billed charges 102.92 157.7 Technical (Hospital) Services Radex Spine 1 View Specify Level PX-3207202000 CDM 72020 CPT 320 RC inpatient 166 166 HEALTHPARTNERS SX009 HEALTHPARTNERS 131.44 percent of total billed charges 102.92 157.7 Technical (Hospital) Services Radex Spine 1 View Specify Level PX-3207202000 CDM 72020 CPT 320 RC inpatient 166 166 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES HDHP [308136802] 131.44 percent of total billed charges 102.92 157.7 Technical (Hospital) Services Radex Spine 1 View Specify Level PX-3207202000 CDM 72020 CPT 320 RC inpatient 166 166 MEDICA (COMMERCIAL) 94265 [3081118] MEDICA CLAIMS [308111801] 149.4 percent of total billed charges 102.92 157.7 Technical (Hospital) Services Mra Chest W/ Contrast Material PX-6187155500 CDM 71555 CPT 618 RC outpatient 3929 3929 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES EPO [308136803] 3143.2 percent of total billed charges 2435.98 3732.55 Technical (Hospital) Services Mra Chest W/ Contrast Material PX-6187155500 CDM 71555 CPT 618 RC outpatient 3929 3929 UNITED HEALTHCARE (COMMERCIAL) [3081199] UNITED HEALTHCARE 87726 [308119901] 2435.98 percent of total billed charges 2435.98 3732.55 Technical (Hospital) Services Mra Chest W/ Contrast Material PX-6187155500 CDM 71555 CPT 618 RC outpatient 3929 3929 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES PPO [308136801] 3143.2 percent of total billed charges 2435.98 3732.55 Technical (Hospital) Services Mra Chest W/ Contrast Material PX-6187155500 CDM 71555 CPT 618 RC outpatient 3929 3929 BLUE CROSS BLUE SHIELD WELLMARK SB889 [3081026] BCBS WYOMING [308102603] 3732.55 percent of total billed charges 2435.98 3732.55 Technical (Hospital) Services Mra Chest W/ Contrast Material PX-6187155500 CDM 71555 CPT 618 RC outpatient 3929 3929 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES HDHP [308136802] 3143.2 percent of total billed charges 2435.98 3732.55 Technical (Hospital) Services Mra Chest W/ Contrast Material PX-6187155500 CDM 71555 CPT 618 RC outpatient 3929 3929 MULTIPLAN INC 34080 [3081285] MULTIPLAN INC [308128501] 3732.55 percent of total billed charges 2435.98 3732.55 Technical (Hospital) Services Mra Chest W/ Contrast Material PX-6187155500 CDM 71555 CPT 618 RC outpatient 3929 3929 HEALTHPARTNERS SX009 HEALTHPARTNERS 3143.2 percent of total billed charges 2435.98 3732.55 Technical (Hospital) Services Mra Chest W/ Contrast Material PX-6187155500 CDM 71555 CPT 618 RC outpatient 3929 3929 MEDICA (COMMERCIAL) 94265 [3081118] MEDICA CLAIMS [308111801] 3536.1 percent of total billed charges 2435.98 3732.55 Technical (Hospital) Services Mra Chest W/ Contrast Material PX-6187155500 CDM 71555 CPT 618 RC outpatient 3929 3929 CIGNA 62308 [3081051] CIGNA 62308 [308105105] 3143.2 percent of total billed charges 2435.98 3732.55 Technical (Hospital) Services Mra Chest W/ Contrast Material PX-6187155500 CDM 71555 CPT 618 RC outpatient 3929 3929 CIGNA 62308 [3081051] CIGNA STATE OF WYOMING [308105107] 3143.2 percent of total billed charges 2435.98 3732.55 Technical (Hospital) Services Mra Chest W/ Contrast Material PX-6187155500 CDM 71555 CPT 618 RC inpatient 3929 3929 HEALTHPARTNERS SX009 HEALTHPARTNERS 3110.98 percent of total billed charges 2435.98 3732.55 Technical (Hospital) Services Mra Chest W/ Contrast Material PX-6187155500 CDM 71555 CPT 618 RC inpatient 3929 3929 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES EPO [308136803] 3110.98 percent of total billed charges 2435.98 3732.55 Technical (Hospital) Services Mra Chest W/ Contrast Material PX-6187155500 CDM 71555 CPT 618 RC inpatient 3929 3929 MEDICA (COMMERCIAL) 94265 [3081118] MEDICA CLAIMS [308111801] 3536.1 percent of total billed charges 2435.98 3732.55 Technical (Hospital) Services Mra Chest W/ Contrast Material PX-6187155500 CDM 71555 CPT 618 RC inpatient 3929 3929 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES HDHP [308136802] 3110.98 percent of total billed charges 2435.98 3732.55 Technical (Hospital) Services Mra Chest W/ Contrast Material PX-6187155500 CDM 71555 CPT 618 RC inpatient 3929 3929 MULTIPLAN INC 34080 [3081285] MULTIPLAN INC [308128501] 3732.55 percent of total billed charges 2435.98 3732.55 Technical (Hospital) Services Mra Chest W/ Contrast Material PX-6187155500 CDM 71555 CPT 618 RC inpatient 3929 3929 BLUE CROSS BLUE SHIELD WELLMARK SB889 [3081026] BCBS WYOMING [308102603] 3732.55 percent of total billed charges 2435.98 3732.55 Technical (Hospital) Services Mra Chest W/ Contrast Material PX-6187155500 CDM 71555 CPT 618 RC inpatient 3929 3929 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES PPO [308136801] 3110.98 percent of total billed charges 2435.98 3732.55 Technical (Hospital) Services Mra Chest W/ Contrast Material PX-6187155500 CDM 71555 CPT 618 RC inpatient 3929 3929 UNITED HEALTHCARE (COMMERCIAL) [3081199] UNITED HEALTHCARE 87726 [308119901] 2435.98 percent of total billed charges 2435.98 3732.55 Technical (Hospital) Services Mra Chest W/ Contrast Material PX-6187155500 CDM 71555 CPT 618 RC inpatient 3929 3929 CIGNA 62308 [3081051] CIGNA 62308 [308105105] 3110.98 percent of total billed charges 2435.98 3732.55 Technical (Hospital) Services Mra Chest W/ Contrast Material PX-6187155500 CDM 71555 CPT 618 RC inpatient 3929 3929 CIGNA 62308 [3081051] CIGNA STATE OF WYOMING [308105107] 3110.98 percent of total billed charges 2435.98 3732.55 Technical (Hospital) Services MRI Chest W/O & W/Contrast Material PX-6107155200 CDM 71552 CPT 610 RC outpatient 4584 4584 CIGNA 62308 [3081051] CIGNA 62308 [308105105] 3667.2 percent of total billed charges 2842.08 4354.8 Technical (Hospital) Services MRI Chest W/O & W/Contrast Material PX-6107155200 CDM 71552 CPT 610 RC outpatient 4584 4584 CIGNA 62308 [3081051] CIGNA STATE OF WYOMING [308105107] 3667.2 percent of total billed charges 2842.08 4354.8 Technical (Hospital) Services MRI Chest W/O & W/Contrast Material PX-6107155200 CDM 71552 CPT 610 RC outpatient 4584 4584 MEDICA (COMMERCIAL) 94265 [3081118] MEDICA CLAIMS [308111801] 4125.6 percent of total billed charges 2842.08 4354.8 Technical (Hospital) Services MRI Chest W/O & W/Contrast Material PX-6107155200 CDM 71552 CPT 610 RC outpatient 4584 4584 MULTIPLAN INC 34080 [3081285] MULTIPLAN INC [308128501] 4354.8 percent of total billed charges 2842.08 4354.8 Technical (Hospital) Services MRI Chest W/O & W/Contrast Material PX-6107155200 CDM 71552 CPT 610 RC outpatient 4584 4584 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES HDHP [308136802] 3667.2 percent of total billed charges 2842.08 4354.8 Technical (Hospital) Services MRI Chest W/O & W/Contrast Material PX-6107155200 CDM 71552 CPT 610 RC outpatient 4584 4584 BLUE CROSS BLUE SHIELD WELLMARK SB889 [3081026] BCBS WYOMING [308102603] 4354.8 percent of total billed charges 2842.08 4354.8 Technical (Hospital) Services MRI Chest W/O & W/Contrast Material PX-6107155200 CDM 71552 CPT 610 RC outpatient 4584 4584 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES PPO [308136801] 3667.2 percent of total billed charges 2842.08 4354.8 Technical (Hospital) Services MRI Chest W/O & W/Contrast Material PX-6107155200 CDM 71552 CPT 610 RC outpatient 4584 4584 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES EPO [308136803] 3667.2 percent of total billed charges 2842.08 4354.8 Technical (Hospital) Services MRI Chest W/O & W/Contrast Material PX-6107155200 CDM 71552 CPT 610 RC outpatient 4584 4584 HEALTHPARTNERS SX009 HEALTHPARTNERS 3667.2 percent of total billed charges 2842.08 4354.8 Technical (Hospital) Services MRI Chest W/O & W/Contrast Material PX-6107155200 CDM 71552 CPT 610 RC outpatient 4584 4584 UNITED HEALTHCARE (COMMERCIAL) [3081199] UNITED HEALTHCARE 87726 [308119901] 2842.08 percent of total billed charges 2842.08 4354.8 Technical (Hospital) Services MRI Chest W/O & W/Contrast Material PX-6107155200 CDM 71552 CPT 610 RC inpatient 4584 4584 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES HDHP [308136802] 3629.61 percent of total billed charges 2842.08 4354.8 Technical (Hospital) Services MRI Chest W/O & W/Contrast Material PX-6107155200 CDM 71552 CPT 610 RC inpatient 4584 4584 MULTIPLAN INC 34080 [3081285] MULTIPLAN INC [308128501] 4354.8 percent of total billed charges 2842.08 4354.8 Technical (Hospital) Services MRI Chest W/O & W/Contrast Material PX-6107155200 CDM 71552 CPT 610 RC inpatient 4584 4584 BLUE CROSS BLUE SHIELD WELLMARK SB889 [3081026] BCBS WYOMING [308102603] 4354.8 percent of total billed charges 2842.08 4354.8 Technical (Hospital) Services MRI Chest W/O & W/Contrast Material PX-6107155200 CDM 71552 CPT 610 RC inpatient 4584 4584 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES PPO [308136801] 3629.61 percent of total billed charges 2842.08 4354.8 Technical (Hospital) Services MRI Chest W/O & W/Contrast Material PX-6107155200 CDM 71552 CPT 610 RC inpatient 4584 4584 UNITED HEALTHCARE (COMMERCIAL) [3081199] UNITED HEALTHCARE 87726 [308119901] 2842.08 percent of total billed charges 2842.08 4354.8 Technical (Hospital) Services MRI Chest W/O & W/Contrast Material PX-6107155200 CDM 71552 CPT 610 RC inpatient 4584 4584 MEDICA (COMMERCIAL) 94265 [3081118] MEDICA CLAIMS [308111801] 4125.6 percent of total billed charges 2842.08 4354.8 Technical (Hospital) Services MRI Chest W/O & W/Contrast Material PX-6107155200 CDM 71552 CPT 610 RC inpatient 4584 4584 HEALTHPARTNERS SX009 HEALTHPARTNERS 3629.61 percent of total billed charges 2842.08 4354.8 Technical (Hospital) Services MRI Chest W/O & W/Contrast Material PX-6107155200 CDM 71552 CPT 610 RC inpatient 4584 4584 CIGNA 62308 [3081051] CIGNA STATE OF WYOMING [308105107] 3629.61 percent of total billed charges 2842.08 4354.8 Technical (Hospital) Services MRI Chest W/O & W/Contrast Material PX-6107155200 CDM 71552 CPT 610 RC inpatient 4584 4584 CIGNA 62308 [3081051] CIGNA 62308 [308105105] 3629.61 percent of total billed charges 2842.08 4354.8 Technical (Hospital) Services MRI Chest W/O & W/Contrast Material PX-6107155200 CDM 71552 CPT 610 RC inpatient 4584 4584 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES EPO [308136803] 3629.61 percent of total billed charges 2842.08 4354.8 Technical (Hospital) Services MRI Chest W/O Contrast Material PX-6107155000 CDM 71550 CPT 610 RC inpatient 3000 3000 CIGNA 62308 [3081051] CIGNA 62308 [308105105] 2375.4 percent of total billed charges 1860 2850 Technical (Hospital) Services MRI Chest W/O Contrast Material PX-6107155000 CDM 71550 CPT 610 RC inpatient 3000 3000 CIGNA 62308 [3081051] CIGNA STATE OF WYOMING [308105107] 2375.4 percent of total billed charges 1860 2850 Technical (Hospital) Services MRI Chest W/O Contrast Material PX-6107155000 CDM 71550 CPT 610 RC inpatient 3000 3000 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES EPO [308136803] 2375.4 percent of total billed charges 1860 2850 Technical (Hospital) Services MRI Chest W/O Contrast Material PX-6107155000 CDM 71550 CPT 610 RC inpatient 3000 3000 UNITED HEALTHCARE (COMMERCIAL) [3081199] UNITED HEALTHCARE 87726 [308119901] 1860 percent of total billed charges 1860 2850 Technical (Hospital) Services MRI Chest W/O Contrast Material PX-6107155000 CDM 71550 CPT 610 RC inpatient 3000 3000 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES PPO [308136801] 2375.4 percent of total billed charges 1860 2850 Technical (Hospital) Services MRI Chest W/O Contrast Material PX-6107155000 CDM 71550 CPT 610 RC inpatient 3000 3000 BLUE CROSS BLUE SHIELD WELLMARK SB889 [3081026] BCBS WYOMING [308102603] 2850 percent of total billed charges 1860 2850 Technical (Hospital) Services MRI Chest W/O Contrast Material PX-6107155000 CDM 71550 CPT 610 RC inpatient 3000 3000 MULTIPLAN INC 34080 [3081285] MULTIPLAN INC [308128501] 2850 percent of total billed charges 1860 2850 Technical (Hospital) Services MRI Chest W/O Contrast Material PX-6107155000 CDM 71550 CPT 610 RC inpatient 3000 3000 MEDICA (COMMERCIAL) 94265 [3081118] MEDICA CLAIMS [308111801] 2700 percent of total billed charges 1860 2850 Technical (Hospital) Services MRI Chest W/O Contrast Material PX-6107155000 CDM 71550 CPT 610 RC inpatient 3000 3000 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES HDHP [308136802] 2375.4 percent of total billed charges 1860 2850 Technical (Hospital) Services MRI Chest W/O Contrast Material PX-6107155000 CDM 71550 CPT 610 RC inpatient 3000 3000 HEALTHPARTNERS SX009 HEALTHPARTNERS 2375.4 percent of total billed charges 1860 2850 Technical (Hospital) Services MRI Chest W/O Contrast Material PX-6107155000 CDM 71550 CPT 610 RC outpatient 3000 3000 MEDICA (COMMERCIAL) 94265 [3081118] MEDICA CLAIMS [308111801] 2700 percent of total billed charges 1860 2850 Technical (Hospital) Services MRI Chest W/O Contrast Material PX-6107155000 CDM 71550 CPT 610 RC outpatient 3000 3000 CIGNA 62308 [3081051] CIGNA 62308 [308105105] 2400 percent of total billed charges 1860 2850 Technical (Hospital) Services MRI Chest W/O Contrast Material PX-6107155000 CDM 71550 CPT 610 RC outpatient 3000 3000 CIGNA 62308 [3081051] CIGNA STATE OF WYOMING [308105107] 2400 percent of total billed charges 1860 2850 Technical (Hospital) Services MRI Chest W/O Contrast Material PX-6107155000 CDM 71550 CPT 610 RC outpatient 3000 3000 BLUE CROSS BLUE SHIELD WELLMARK SB889 [3081026] BCBS WYOMING [308102603] 2850 percent of total billed charges 1860 2850 Technical (Hospital) Services MRI Chest W/O Contrast Material PX-6107155000 CDM 71550 CPT 610 RC outpatient 3000 3000 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES HDHP [308136802] 2400 percent of total billed charges 1860 2850 Technical (Hospital) Services MRI Chest W/O Contrast Material PX-6107155000 CDM 71550 CPT 610 RC outpatient 3000 3000 MULTIPLAN INC 34080 [3081285] MULTIPLAN INC [308128501] 2850 percent of total billed charges 1860 2850 Technical (Hospital) Services MRI Chest W/O Contrast Material PX-6107155000 CDM 71550 CPT 610 RC outpatient 3000 3000 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES PPO [308136801] 2400 percent of total billed charges 1860 2850 Technical (Hospital) Services MRI Chest W/O Contrast Material PX-6107155000 CDM 71550 CPT 610 RC outpatient 3000 3000 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES EPO [308136803] 2400 percent of total billed charges 1860 2850 Technical (Hospital) Services MRI Chest W/O Contrast Material PX-6107155000 CDM 71550 CPT 610 RC outpatient 3000 3000 UNITED HEALTHCARE (COMMERCIAL) [3081199] UNITED HEALTHCARE 87726 [308119901] 1860 percent of total billed charges 1860 2850 Technical (Hospital) Services MRI Chest W/O Contrast Material PX-6107155000 CDM 71550 CPT 610 RC outpatient 3000 3000 HEALTHPARTNERS SX009 HEALTHPARTNERS 2400 percent of total billed charges 1860 2850 Technical (Hospital) Services CT Angiography Chest W/Contrast/Noncontrast PX-3527127500 CDM 71275 CPT 352 RC inpatient 2816 2816 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES EPO [308136803] 2229.71 percent of total billed charges 1745.92 2675.2 Technical (Hospital) Services CT Angiography Chest W/Contrast/Noncontrast PX-3527127500 CDM 71275 CPT 352 RC inpatient 2816 2816 CIGNA 62308 [3081051] CIGNA 62308 [308105105] 2229.71 percent of total billed charges 1745.92 2675.2 Technical (Hospital) Services CT Angiography Chest W/Contrast/Noncontrast PX-3527127500 CDM 71275 CPT 352 RC inpatient 2816 2816 CIGNA 62308 [3081051] CIGNA STATE OF WYOMING [308105107] 2229.71 percent of total billed charges 1745.92 2675.2 Technical (Hospital) Services CT Angiography Chest W/Contrast/Noncontrast PX-3527127500 CDM 71275 CPT 352 RC inpatient 2816 2816 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES HDHP [308136802] 2229.71 percent of total billed charges 1745.92 2675.2 Technical (Hospital) Services CT Angiography Chest W/Contrast/Noncontrast PX-3527127500 CDM 71275 CPT 352 RC inpatient 2816 2816 MEDICA (COMMERCIAL) 94265 [3081118] MEDICA CLAIMS [308111801] 2534.4 percent of total billed charges 1745.92 2675.2 Technical (Hospital) Services CT Angiography Chest W/Contrast/Noncontrast PX-3527127500 CDM 71275 CPT 352 RC inpatient 2816 2816 HEALTHPARTNERS SX009 HEALTHPARTNERS 2229.71 percent of total billed charges 1745.92 2675.2 Technical (Hospital) Services CT Angiography Chest W/Contrast/Noncontrast PX-3527127500 CDM 71275 CPT 352 RC inpatient 2816 2816 MULTIPLAN INC 34080 [3081285] MULTIPLAN INC [308128501] 2675.2 percent of total billed charges 1745.92 2675.2 Technical (Hospital) Services CT Angiography Chest W/Contrast/Noncontrast PX-3527127500 CDM 71275 CPT 352 RC inpatient 2816 2816 BLUE CROSS BLUE SHIELD WELLMARK SB889 [3081026] BCBS WYOMING [308102603] 2675.2 percent of total billed charges 1745.92 2675.2 Technical (Hospital) Services CT Angiography Chest W/Contrast/Noncontrast PX-3527127500 CDM 71275 CPT 352 RC inpatient 2816 2816 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES PPO [308136801] 2229.71 percent of total billed charges 1745.92 2675.2 Technical (Hospital) Services CT Angiography Chest W/Contrast/Noncontrast PX-3527127500 CDM 71275 CPT 352 RC inpatient 2816 2816 UNITED HEALTHCARE (COMMERCIAL) [3081199] UNITED HEALTHCARE 87726 [308119901] 1745.92 percent of total billed charges 1745.92 2675.2 Technical (Hospital) Services CT Angiography Chest W/Contrast/Noncontrast PX-3527127500 CDM 71275 CPT 352 RC outpatient 2816 2816 CIGNA 62308 [3081051] CIGNA 62308 [308105105] 2252.8 percent of total billed charges 1745.92 2675.2 Technical (Hospital) Services CT Angiography Chest W/Contrast/Noncontrast PX-3527127500 CDM 71275 CPT 352 RC outpatient 2816 2816 CIGNA 62308 [3081051] CIGNA STATE OF WYOMING [308105107] 2252.8 percent of total billed charges 1745.92 2675.2 Technical (Hospital) Services CT Angiography Chest W/Contrast/Noncontrast PX-3527127500 CDM 71275 CPT 352 RC outpatient 2816 2816 MEDICA (COMMERCIAL) 94265 [3081118] MEDICA CLAIMS [308111801] 2534.4 percent of total billed charges 1745.92 2675.2 Technical (Hospital) Services CT Angiography Chest W/Contrast/Noncontrast PX-3527127500 CDM 71275 CPT 352 RC outpatient 2816 2816 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES HDHP [308136802] 2252.8 percent of total billed charges 1745.92 2675.2 Technical (Hospital) Services CT Angiography Chest W/Contrast/Noncontrast PX-3527127500 CDM 71275 CPT 352 RC outpatient 2816 2816 MULTIPLAN INC 34080 [3081285] MULTIPLAN INC [308128501] 2675.2 percent of total billed charges 1745.92 2675.2 Technical (Hospital) Services CT Angiography Chest W/Contrast/Noncontrast PX-3527127500 CDM 71275 CPT 352 RC outpatient 2816 2816 BLUE CROSS BLUE SHIELD WELLMARK SB889 [3081026] BCBS WYOMING [308102603] 2675.2 percent of total billed charges 1745.92 2675.2 Technical (Hospital) Services CT Angiography Chest W/Contrast/Noncontrast PX-3527127500 CDM 71275 CPT 352 RC outpatient 2816 2816 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES EPO [308136803] 2252.8 percent of total billed charges 1745.92 2675.2 Technical (Hospital) Services CT Angiography Chest W/Contrast/Noncontrast PX-3527127500 CDM 71275 CPT 352 RC outpatient 2816 2816 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES PPO [308136801] 2252.8 percent of total billed charges 1745.92 2675.2 Technical (Hospital) Services CT Angiography Chest W/Contrast/Noncontrast PX-3527127500 CDM 71275 CPT 352 RC outpatient 2816 2816 UNITED HEALTHCARE (COMMERCIAL) [3081199] UNITED HEALTHCARE 87726 [308119901] 1745.92 percent of total billed charges 1745.92 2675.2 Technical (Hospital) Services CT Angiography Chest W/Contrast/Noncontrast PX-3527127500 CDM 71275 CPT 352 RC outpatient 2816 2816 HEALTHPARTNERS SX009 HEALTHPARTNERS 2252.8 percent of total billed charges 1745.92 2675.2 Technical (Hospital) Services Computed Tomography Thorax Lw Dose Lng Ca Scr C- PX-3527127100 CDM 71271 CPT 352 RC outpatient 389 389 CIGNA 62308 [3081051] CIGNA 62308 [308105105] 311.2 percent of total billed charges 241.18 369.55 Technical (Hospital) Services Computed Tomography Thorax Lw Dose Lng Ca Scr C- PX-3527127100 CDM 71271 CPT 352 RC outpatient 389 389 CIGNA 62308 [3081051] CIGNA STATE OF WYOMING [308105107] 311.2 percent of total billed charges 241.18 369.55 Technical (Hospital) Services Computed Tomography Thorax Lw Dose Lng Ca Scr C- PX-3527127100 CDM 71271 CPT 352 RC outpatient 389 389 BLUE CROSS BLUE SHIELD WELLMARK SB889 [3081026] BCBS WYOMING [308102603] 369.55 percent of total billed charges 241.18 369.55 Technical (Hospital) Services Computed Tomography Thorax Lw Dose Lng Ca Scr C- PX-3527127100 CDM 71271 CPT 352 RC outpatient 389 389 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES HDHP [308136802] 311.2 percent of total billed charges 241.18 369.55 Technical (Hospital) Services Computed Tomography Thorax Lw Dose Lng Ca Scr C- PX-3527127100 CDM 71271 CPT 352 RC outpatient 389 389 MULTIPLAN INC 34080 [3081285] MULTIPLAN INC [308128501] 369.55 percent of total billed charges 241.18 369.55 Technical (Hospital) Services Computed Tomography Thorax Lw Dose Lng Ca Scr C- PX-3527127100 CDM 71271 CPT 352 RC outpatient 389 389 UNITED HEALTHCARE (COMMERCIAL) [3081199] UNITED HEALTHCARE 87726 [308119901] 241.18 percent of total billed charges 241.18 369.55 Technical (Hospital) Services Computed Tomography Thorax Lw Dose Lng Ca Scr C- PX-3527127100 CDM 71271 CPT 352 RC outpatient 389 389 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES PPO [308136801] 311.2 percent of total billed charges 241.18 369.55 Technical (Hospital) Services Computed Tomography Thorax Lw Dose Lng Ca Scr C- PX-3527127100 CDM 71271 CPT 352 RC outpatient 389 389 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES EPO [308136803] 311.2 percent of total billed charges 241.18 369.55 Technical (Hospital) Services Computed Tomography Thorax Lw Dose Lng Ca Scr C- PX-3527127100 CDM 71271 CPT 352 RC outpatient 389 389 MEDICA (COMMERCIAL) 94265 [3081118] MEDICA CLAIMS [308111801] 350.1 percent of total billed charges 241.18 369.55 Technical (Hospital) Services Computed Tomography Thorax Lw Dose Lng Ca Scr C- PX-3527127100 CDM 71271 CPT 352 RC outpatient 389 389 HEALTHPARTNERS SX009 HEALTHPARTNERS 311.2 percent of total billed charges 241.18 369.55 Technical (Hospital) Services Computed Tomography Thorax Lw Dose Lng Ca Scr C- PX-3527127100 CDM 71271 CPT 352 RC inpatient 389 389 HEALTHPARTNERS SX009 HEALTHPARTNERS 308.01 percent of total billed charges 241.18 369.55 Technical (Hospital) Services Computed Tomography Thorax Lw Dose Lng Ca Scr C- PX-3527127100 CDM 71271 CPT 352 RC inpatient 389 389 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES HDHP [308136802] 308.01 percent of total billed charges 241.18 369.55 Technical (Hospital) Services Computed Tomography Thorax Lw Dose Lng Ca Scr C- PX-3527127100 CDM 71271 CPT 352 RC inpatient 389 389 MEDICA (COMMERCIAL) 94265 [3081118] MEDICA CLAIMS [308111801] 350.1 percent of total billed charges 241.18 369.55 Technical (Hospital) Services Computed Tomography Thorax Lw Dose Lng Ca Scr C- PX-3527127100 CDM 71271 CPT 352 RC inpatient 389 389 MULTIPLAN INC 34080 [3081285] MULTIPLAN INC [308128501] 369.55 percent of total billed charges 241.18 369.55 Technical (Hospital) Services Computed Tomography Thorax Lw Dose Lng Ca Scr C- PX-3527127100 CDM 71271 CPT 352 RC inpatient 389 389 UNITED HEALTHCARE (COMMERCIAL) [3081199] UNITED HEALTHCARE 87726 [308119901] 241.18 percent of total billed charges 241.18 369.55 Technical (Hospital) Services Computed Tomography Thorax Lw Dose Lng Ca Scr C- PX-3527127100 CDM 71271 CPT 352 RC inpatient 389 389 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES PPO [308136801] 308.01 percent of total billed charges 241.18 369.55 Technical (Hospital) Services Computed Tomography Thorax Lw Dose Lng Ca Scr C- PX-3527127100 CDM 71271 CPT 352 RC inpatient 389 389 BLUE CROSS BLUE SHIELD WELLMARK SB889 [3081026] BCBS WYOMING [308102603] 369.55 percent of total billed charges 241.18 369.55 Technical (Hospital) Services Computed Tomography Thorax Lw Dose Lng Ca Scr C- PX-3527127100 CDM 71271 CPT 352 RC inpatient 389 389 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES EPO [308136803] 308.01 percent of total billed charges 241.18 369.55 Technical (Hospital) Services Computed Tomography Thorax Lw Dose Lng Ca Scr C- PX-3527127100 CDM 71271 CPT 352 RC inpatient 389 389 CIGNA 62308 [3081051] CIGNA 62308 [308105105] 308.01 percent of total billed charges 241.18 369.55 Technical (Hospital) Services Computed Tomography Thorax Lw Dose Lng Ca Scr C- PX-3527127100 CDM 71271 CPT 352 RC inpatient 389 389 CIGNA 62308 [3081051] CIGNA STATE OF WYOMING [308105107] 308.01 percent of total billed charges 241.18 369.55 Technical (Hospital) Services Diagnostic Computed Tomography Thorax C-/C+ PX-3527127000 CDM 71270 CPT 352 RC outpatient 2620 2620 BLUE CROSS BLUE SHIELD WELLMARK SB889 [3081026] BCBS WYOMING [308102603] 2489 percent of total billed charges 1624.4 2489 Technical (Hospital) Services Diagnostic Computed Tomography Thorax C-/C+ PX-3527127000 CDM 71270 CPT 352 RC outpatient 2620 2620 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES HDHP [308136802] 2096 percent of total billed charges 1624.4 2489 Technical (Hospital) Services Diagnostic Computed Tomography Thorax C-/C+ PX-3527127000 CDM 71270 CPT 352 RC outpatient 2620 2620 MULTIPLAN INC 34080 [3081285] MULTIPLAN INC [308128501] 2489 percent of total billed charges 1624.4 2489 Technical (Hospital) Services Diagnostic Computed Tomography Thorax C-/C+ PX-3527127000 CDM 71270 CPT 352 RC outpatient 2620 2620 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES PPO [308136801] 2096 percent of total billed charges 1624.4 2489 Technical (Hospital) Services Diagnostic Computed Tomography Thorax C-/C+ PX-3527127000 CDM 71270 CPT 352 RC outpatient 2620 2620 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES EPO [308136803] 2096 percent of total billed charges 1624.4 2489 Technical (Hospital) Services Diagnostic Computed Tomography Thorax C-/C+ PX-3527127000 CDM 71270 CPT 352 RC outpatient 2620 2620 HEALTHPARTNERS SX009 HEALTHPARTNERS 2096 percent of total billed charges 1624.4 2489 Technical (Hospital) Services Diagnostic Computed Tomography Thorax C-/C+ PX-3527127000 CDM 71270 CPT 352 RC outpatient 2620 2620 UNITED HEALTHCARE (COMMERCIAL) [3081199] UNITED HEALTHCARE 87726 [308119901] 1624.4 percent of total billed charges 1624.4 2489 Technical (Hospital) Services Diagnostic Computed Tomography Thorax C-/C+ PX-3527127000 CDM 71270 CPT 352 RC outpatient 2620 2620 CIGNA 62308 [3081051] CIGNA 62308 [308105105] 2096 percent of total billed charges 1624.4 2489 Technical (Hospital) Services Diagnostic Computed Tomography Thorax C-/C+ PX-3527127000 CDM 71270 CPT 352 RC outpatient 2620 2620 CIGNA 62308 [3081051] CIGNA STATE OF WYOMING [308105107] 2096 percent of total billed charges 1624.4 2489 Technical (Hospital) Services Diagnostic Computed Tomography Thorax C-/C+ PX-3527127000 CDM 71270 CPT 352 RC outpatient 2620 2620 MEDICA (COMMERCIAL) 94265 [3081118] MEDICA CLAIMS [308111801] 2358 percent of total billed charges 1624.4 2489 Technical (Hospital) Services Diagnostic Computed Tomography Thorax C-/C+ PX-3527127000 CDM 71270 CPT 352 RC inpatient 2620 2620 CIGNA 62308 [3081051] CIGNA 62308 [308105105] 2074.52 percent of total billed charges 1624.4 2489 Technical (Hospital) Services Diagnostic Computed Tomography Thorax C-/C+ PX-3527127000 CDM 71270 CPT 352 RC inpatient 2620 2620 CIGNA 62308 [3081051] CIGNA STATE OF WYOMING [308105107] 2074.52 percent of total billed charges 1624.4 2489 Technical (Hospital) Services Diagnostic Computed Tomography Thorax C-/C+ PX-3527127000 CDM 71270 CPT 352 RC inpatient 2620 2620 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES EPO [308136803] 2074.52 percent of total billed charges 1624.4 2489 Technical (Hospital) Services Diagnostic Computed Tomography Thorax C-/C+ PX-3527127000 CDM 71270 CPT 352 RC inpatient 2620 2620 HEALTHPARTNERS SX009 HEALTHPARTNERS 2074.52 percent of total billed charges 1624.4 2489 Technical (Hospital) Services Diagnostic Computed Tomography Thorax C-/C+ PX-3527127000 CDM 71270 CPT 352 RC inpatient 2620 2620 MEDICA (COMMERCIAL) 94265 [3081118] MEDICA CLAIMS [308111801] 2358 percent of total billed charges 1624.4 2489 Technical (Hospital) Services Diagnostic Computed Tomography Thorax C-/C+ PX-3527127000 CDM 71270 CPT 352 RC inpatient 2620 2620 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES HDHP [308136802] 2074.52 percent of total billed charges 1624.4 2489 Technical (Hospital) Services Diagnostic Computed Tomography Thorax C-/C+ PX-3527127000 CDM 71270 CPT 352 RC inpatient 2620 2620 UNITED HEALTHCARE (COMMERCIAL) [3081199] UNITED HEALTHCARE 87726 [308119901] 1624.4 percent of total billed charges 1624.4 2489 Technical (Hospital) Services Diagnostic Computed Tomography Thorax C-/C+ PX-3527127000 CDM 71270 CPT 352 RC inpatient 2620 2620 BLUE CROSS BLUE SHIELD WELLMARK SB889 [3081026] BCBS WYOMING [308102603] 2489 percent of total billed charges 1624.4 2489 Technical (Hospital) Services Diagnostic Computed Tomography Thorax C-/C+ PX-3527127000 CDM 71270 CPT 352 RC inpatient 2620 2620 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES PPO [308136801] 2074.52 percent of total billed charges 1624.4 2489 Technical (Hospital) Services Diagnostic Computed Tomography Thorax C-/C+ PX-3527127000 CDM 71270 CPT 352 RC inpatient 2620 2620 MULTIPLAN INC 34080 [3081285] MULTIPLAN INC [308128501] 2489 percent of total billed charges 1624.4 2489 Technical (Hospital) Services Diagnostic Computed Tomography Thorax W/Contrast PX-3527126000 CDM 71260 CPT 352 RC outpatient 2680 2680 HEALTHPARTNERS SX009 HEALTHPARTNERS 2144 percent of total billed charges 1661.6 2546 Technical (Hospital) Services Diagnostic Computed Tomography Thorax W/Contrast PX-3527126000 CDM 71260 CPT 352 RC outpatient 2680 2680 UNITED HEALTHCARE (COMMERCIAL) [3081199] UNITED HEALTHCARE 87726 [308119901] 1661.6 percent of total billed charges 1661.6 2546 Technical (Hospital) Services Diagnostic Computed Tomography Thorax W/Contrast PX-3527126000 CDM 71260 CPT 352 RC outpatient 2680 2680 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES EPO [308136803] 2144 percent of total billed charges 1661.6 2546 Technical (Hospital) Services Diagnostic Computed Tomography Thorax W/Contrast PX-3527126000 CDM 71260 CPT 352 RC outpatient 2680 2680 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES PPO [308136801] 2144 percent of total billed charges 1661.6 2546 Technical (Hospital) Services Diagnostic Computed Tomography Thorax W/Contrast PX-3527126000 CDM 71260 CPT 352 RC outpatient 2680 2680 BLUE CROSS BLUE SHIELD WELLMARK SB889 [3081026] BCBS WYOMING [308102603] 2546 percent of total billed charges 1661.6 2546 Technical (Hospital) Services Diagnostic Computed Tomography Thorax W/Contrast PX-3527126000 CDM 71260 CPT 352 RC outpatient 2680 2680 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES HDHP [308136802] 2144 percent of total billed charges 1661.6 2546 Technical (Hospital) Services Diagnostic Computed Tomography Thorax W/Contrast PX-3527126000 CDM 71260 CPT 352 RC outpatient 2680 2680 MULTIPLAN INC 34080 [3081285] MULTIPLAN INC [308128501] 2546 percent of total billed charges 1661.6 2546 Technical (Hospital) Services Diagnostic Computed Tomography Thorax W/Contrast PX-3527126000 CDM 71260 CPT 352 RC outpatient 2680 2680 CIGNA 62308 [3081051] CIGNA 62308 [308105105] 2144 percent of total billed charges 1661.6 2546 Technical (Hospital) Services Diagnostic Computed Tomography Thorax W/Contrast PX-3527126000 CDM 71260 CPT 352 RC outpatient 2680 2680 CIGNA 62308 [3081051] CIGNA STATE OF WYOMING [308105107] 2144 percent of total billed charges 1661.6 2546 Technical (Hospital) Services Diagnostic Computed Tomography Thorax W/Contrast PX-3527126000 CDM 71260 CPT 352 RC outpatient 2680 2680 MEDICA (COMMERCIAL) 94265 [3081118] MEDICA CLAIMS [308111801] 2412 percent of total billed charges 1661.6 2546 Technical (Hospital) Services Diagnostic Computed Tomography Thorax W/Contrast PX-3527126000 CDM 71260 CPT 352 RC inpatient 2680 2680 CIGNA 62308 [3081051] CIGNA 62308 [308105105] 2122.02 percent of total billed charges 1661.6 2546 Technical (Hospital) Services Diagnostic Computed Tomography Thorax W/Contrast PX-3527126000 CDM 71260 CPT 352 RC inpatient 2680 2680 CIGNA 62308 [3081051] CIGNA STATE OF WYOMING [308105107] 2122.02 percent of total billed charges 1661.6 2546 Technical (Hospital) Services Diagnostic Computed Tomography Thorax W/Contrast PX-3527126000 CDM 71260 CPT 352 RC inpatient 2680 2680 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES EPO [308136803] 2122.02 percent of total billed charges 1661.6 2546 Technical (Hospital) Services Diagnostic Computed Tomography Thorax W/Contrast PX-3527126000 CDM 71260 CPT 352 RC inpatient 2680 2680 BLUE CROSS BLUE SHIELD WELLMARK SB889 [3081026] BCBS WYOMING [308102603] 2546 percent of total billed charges 1661.6 2546 Technical (Hospital) Services Diagnostic Computed Tomography Thorax W/Contrast PX-3527126000 CDM 71260 CPT 352 RC inpatient 2680 2680 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES PPO [308136801] 2122.02 percent of total billed charges 1661.6 2546 Technical (Hospital) Services Diagnostic Computed Tomography Thorax W/Contrast PX-3527126000 CDM 71260 CPT 352 RC inpatient 2680 2680 MULTIPLAN INC 34080 [3081285] MULTIPLAN INC [308128501] 2546 percent of total billed charges 1661.6 2546 Technical (Hospital) Services Diagnostic Computed Tomography Thorax W/Contrast PX-3527126000 CDM 71260 CPT 352 RC inpatient 2680 2680 UNITED HEALTHCARE (COMMERCIAL) [3081199] UNITED HEALTHCARE 87726 [308119901] 1661.6 percent of total billed charges 1661.6 2546 Technical (Hospital) Services Diagnostic Computed Tomography Thorax W/Contrast PX-3527126000 CDM 71260 CPT 352 RC inpatient 2680 2680 MEDICA (COMMERCIAL) 94265 [3081118] MEDICA CLAIMS [308111801] 2412 percent of total billed charges 1661.6 2546 Technical (Hospital) Services Diagnostic Computed Tomography Thorax W/Contrast PX-3527126000 CDM 71260 CPT 352 RC inpatient 2680 2680 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES HDHP [308136802] 2122.02 percent of total billed charges 1661.6 2546 Technical (Hospital) Services Diagnostic Computed Tomography Thorax W/Contrast PX-3527126000 CDM 71260 CPT 352 RC inpatient 2680 2680 HEALTHPARTNERS SX009 HEALTHPARTNERS 2122.02 percent of total billed charges 1661.6 2546 Technical (Hospital) Services Diagnostic Computed Tomography Thorax W/O Cntrst PX-3527125000 CDM 71250 CPT 352 RC outpatient 1786 1786 CIGNA 62308 [3081051] CIGNA 62308 [308105105] 1428.8 percent of total billed charges 1107.32 1696.7 Technical (Hospital) Services Diagnostic Computed Tomography Thorax W/O Cntrst PX-3527125000 CDM 71250 CPT 352 RC outpatient 1786 1786 CIGNA 62308 [3081051] CIGNA STATE OF WYOMING [308105107] 1428.8 percent of total billed charges 1107.32 1696.7 Technical (Hospital) Services Diagnostic Computed Tomography Thorax W/O Cntrst PX-3527125000 CDM 71250 CPT 352 RC outpatient 1786 1786 MEDICA (COMMERCIAL) 94265 [3081118] MEDICA CLAIMS [308111801] 1607.4 percent of total billed charges 1107.32 1696.7 Technical (Hospital) Services Diagnostic Computed Tomography Thorax W/O Cntrst PX-3527125000 CDM 71250 CPT 352 RC outpatient 1786 1786 HEALTHPARTNERS SX009 HEALTHPARTNERS 1428.8 percent of total billed charges 1107.32 1696.7 Technical (Hospital) Services Diagnostic Computed Tomography Thorax W/O Cntrst PX-3527125000 CDM 71250 CPT 352 RC outpatient 1786 1786 UNITED HEALTHCARE (COMMERCIAL) [3081199] UNITED HEALTHCARE 87726 [308119901] 1107.32 percent of total billed charges 1107.32 1696.7 Technical (Hospital) Services Diagnostic Computed Tomography Thorax W/O Cntrst PX-3527125000 CDM 71250 CPT 352 RC outpatient 1786 1786 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES EPO [308136803] 1428.8 percent of total billed charges 1107.32 1696.7 Technical (Hospital) Services Diagnostic Computed Tomography Thorax W/O Cntrst PX-3527125000 CDM 71250 CPT 352 RC outpatient 1786 1786 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES PPO [308136801] 1428.8 percent of total billed charges 1107.32 1696.7 Technical (Hospital) Services Diagnostic Computed Tomography Thorax W/O Cntrst PX-3527125000 CDM 71250 CPT 352 RC outpatient 1786 1786 BLUE CROSS BLUE SHIELD WELLMARK SB889 [3081026] BCBS WYOMING [308102603] 1696.7 percent of total billed charges 1107.32 1696.7 Technical (Hospital) Services Diagnostic Computed Tomography Thorax W/O Cntrst PX-3527125000 CDM 71250 CPT 352 RC outpatient 1786 1786 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES HDHP [308136802] 1428.8 percent of total billed charges 1107.32 1696.7 Technical (Hospital) Services Diagnostic Computed Tomography Thorax W/O Cntrst PX-3527125000 CDM 71250 CPT 352 RC outpatient 1786 1786 MULTIPLAN INC 34080 [3081285] MULTIPLAN INC [308128501] 1696.7 percent of total billed charges 1107.32 1696.7 Technical (Hospital) Services Diagnostic Computed Tomography Thorax W/O Cntrst PX-3527125000 CDM 71250 CPT 352 RC inpatient 1786 1786 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES PPO [308136801] 1414.15 percent of total billed charges 1107.32 1696.7 Technical (Hospital) Services Diagnostic Computed Tomography Thorax W/O Cntrst PX-3527125000 CDM 71250 CPT 352 RC inpatient 1786 1786 BLUE CROSS BLUE SHIELD WELLMARK SB889 [3081026] BCBS WYOMING [308102603] 1696.7 percent of total billed charges 1107.32 1696.7 Technical (Hospital) Services Diagnostic Computed Tomography Thorax W/O Cntrst PX-3527125000 CDM 71250 CPT 352 RC inpatient 1786 1786 MULTIPLAN INC 34080 [3081285] MULTIPLAN INC [308128501] 1696.7 percent of total billed charges 1107.32 1696.7 Technical (Hospital) Services Diagnostic Computed Tomography Thorax W/O Cntrst PX-3527125000 CDM 71250 CPT 352 RC inpatient 1786 1786 UNITED HEALTHCARE (COMMERCIAL) [3081199] UNITED HEALTHCARE 87726 [308119901] 1107.32 percent of total billed charges 1107.32 1696.7 Technical (Hospital) Services Diagnostic Computed Tomography Thorax W/O Cntrst PX-3527125000 CDM 71250 CPT 352 RC inpatient 1786 1786 HEALTHPARTNERS SX009 HEALTHPARTNERS 1414.15 percent of total billed charges 1107.32 1696.7 Technical (Hospital) Services Diagnostic Computed Tomography Thorax W/O Cntrst PX-3527125000 CDM 71250 CPT 352 RC inpatient 1786 1786 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES HDHP [308136802] 1414.15 percent of total billed charges 1107.32 1696.7 Technical (Hospital) Services Diagnostic Computed Tomography Thorax W/O Cntrst PX-3527125000 CDM 71250 CPT 352 RC inpatient 1786 1786 MEDICA (COMMERCIAL) 94265 [3081118] MEDICA CLAIMS [308111801] 1607.4 percent of total billed charges 1107.32 1696.7 Technical (Hospital) Services Diagnostic Computed Tomography Thorax W/O Cntrst PX-3527125000 CDM 71250 CPT 352 RC inpatient 1786 1786 CIGNA 62308 [3081051] CIGNA 62308 [308105105] 1414.15 percent of total billed charges 1107.32 1696.7 Technical (Hospital) Services Diagnostic Computed Tomography Thorax W/O Cntrst PX-3527125000 CDM 71250 CPT 352 RC inpatient 1786 1786 CIGNA 62308 [3081051] CIGNA STATE OF WYOMING [308105107] 1414.15 percent of total billed charges 1107.32 1696.7 Technical (Hospital) Services Diagnostic Computed Tomography Thorax W/O Cntrst PX-3527125000 CDM 71250 CPT 352 RC inpatient 1786 1786 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES EPO [308136803] 1414.15 percent of total billed charges 1107.32 1696.7 Technical (Hospital) Services Radex Sternoclavicular Jt/Jts Minimum 3 Views PX-3207113000 CDM 71130 CPT 320 RC inpatient 270 270 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES EPO [308136803] 213.79 percent of total billed charges 167.4 256.5 Technical (Hospital) Services Radex Sternoclavicular Jt/Jts Minimum 3 Views PX-3207113000 CDM 71130 CPT 320 RC inpatient 270 270 CIGNA 62308 [3081051] CIGNA 62308 [308105105] 213.79 percent of total billed charges 167.4 256.5 Technical (Hospital) Services Radex Sternoclavicular Jt/Jts Minimum 3 Views PX-3207113000 CDM 71130 CPT 320 RC inpatient 270 270 CIGNA 62308 [3081051] CIGNA STATE OF WYOMING [308105107] 213.79 percent of total billed charges 167.4 256.5 Technical (Hospital) Services Radex Sternoclavicular Jt/Jts Minimum 3 Views PX-3207113000 CDM 71130 CPT 320 RC inpatient 270 270 UNITED HEALTHCARE (COMMERCIAL) [3081199] UNITED HEALTHCARE 87726 [308119901] 167.4 percent of total billed charges 167.4 256.5 Technical (Hospital) Services Radex Sternoclavicular Jt/Jts Minimum 3 Views PX-3207113000 CDM 71130 CPT 320 RC inpatient 270 270 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES PPO [308136801] 213.79 percent of total billed charges 167.4 256.5 Technical (Hospital) Services Radex Sternoclavicular Jt/Jts Minimum 3 Views PX-3207113000 CDM 71130 CPT 320 RC inpatient 270 270 BLUE CROSS BLUE SHIELD WELLMARK SB889 [3081026] BCBS WYOMING [308102603] 256.5 percent of total billed charges 167.4 256.5 Technical (Hospital) Services Radex Sternoclavicular Jt/Jts Minimum 3 Views PX-3207113000 CDM 71130 CPT 320 RC inpatient 270 270 MULTIPLAN INC 34080 [3081285] MULTIPLAN INC [308128501] 256.5 percent of total billed charges 167.4 256.5 Technical (Hospital) Services Radex Sternoclavicular Jt/Jts Minimum 3 Views PX-3207113000 CDM 71130 CPT 320 RC inpatient 270 270 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES HDHP [308136802] 213.79 percent of total billed charges 167.4 256.5 Technical (Hospital) Services Radex Sternoclavicular Jt/Jts Minimum 3 Views PX-3207113000 CDM 71130 CPT 320 RC inpatient 270 270 HEALTHPARTNERS SX009 HEALTHPARTNERS 213.79 percent of total billed charges 167.4 256.5 Technical (Hospital) Services Radex Sternoclavicular Jt/Jts Minimum 3 Views PX-3207113000 CDM 71130 CPT 320 RC inpatient 270 270 MEDICA (COMMERCIAL) 94265 [3081118] MEDICA CLAIMS [308111801] 243 percent of total billed charges 167.4 256.5 Technical (Hospital) Services Radex Sternoclavicular Jt/Jts Minimum 3 Views PX-3207113000 CDM 71130 CPT 320 RC outpatient 270 270 BLUE CROSS BLUE SHIELD WELLMARK SB889 [3081026] BCBS WYOMING [308102603] 256.5 percent of total billed charges 167.4 256.5 Technical (Hospital) Services Radex Sternoclavicular Jt/Jts Minimum 3 Views PX-3207113000 CDM 71130 CPT 320 RC outpatient 270 270 UNITED HEALTHCARE (COMMERCIAL) [3081199] UNITED HEALTHCARE 87726 [308119901] 167.4 percent of total billed charges 167.4 256.5 Technical (Hospital) Services Radex Sternoclavicular Jt/Jts Minimum 3 Views PX-3207113000 CDM 71130 CPT 320 RC outpatient 270 270 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES HDHP [308136802] 216 percent of total billed charges 167.4 256.5 Technical (Hospital) Services Radex Sternoclavicular Jt/Jts Minimum 3 Views PX-3207113000 CDM 71130 CPT 320 RC outpatient 270 270 MULTIPLAN INC 34080 [3081285] MULTIPLAN INC [308128501] 256.5 percent of total billed charges 167.4 256.5 Technical (Hospital) Services Radex Sternoclavicular Jt/Jts Minimum 3 Views PX-3207113000 CDM 71130 CPT 320 RC outpatient 270 270 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES EPO [308136803] 216 percent of total billed charges 167.4 256.5 Technical (Hospital) Services Radex Sternoclavicular Jt/Jts Minimum 3 Views PX-3207113000 CDM 71130 CPT 320 RC outpatient 270 270 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES PPO [308136801] 216 percent of total billed charges 167.4 256.5 Technical (Hospital) Services Radex Sternoclavicular Jt/Jts Minimum 3 Views PX-3207113000 CDM 71130 CPT 320 RC outpatient 270 270 HEALTHPARTNERS SX009 HEALTHPARTNERS 216 percent of total billed charges 167.4 256.5 Technical (Hospital) Services Radex Sternoclavicular Jt/Jts Minimum 3 Views PX-3207113000 CDM 71130 CPT 320 RC outpatient 270 270 CIGNA 62308 [3081051] CIGNA 62308 [308105105] 216 percent of total billed charges 167.4 256.5 Technical (Hospital) Services Radex Sternoclavicular Jt/Jts Minimum 3 Views PX-3207113000 CDM 71130 CPT 320 RC outpatient 270 270 CIGNA 62308 [3081051] CIGNA STATE OF WYOMING [308105107] 216 percent of total billed charges 167.4 256.5 Technical (Hospital) Services Radex Sternoclavicular Jt/Jts Minimum 3 Views PX-3207113000 CDM 71130 CPT 320 RC outpatient 270 270 MEDICA (COMMERCIAL) 94265 [3081118] MEDICA CLAIMS [308111801] 243 percent of total billed charges 167.4 256.5 Technical (Hospital) Services Radex Sternum Minimum 2 Views PX-3207112000 CDM 71120 CPT 320 RC inpatient 244 244 CIGNA 62308 [3081051] CIGNA 62308 [308105105] 193.2 percent of total billed charges 151.28 231.8 Technical (Hospital) Services Radex Sternum Minimum 2 Views PX-3207112000 CDM 71120 CPT 320 RC inpatient 244 244 CIGNA 62308 [3081051] CIGNA STATE OF WYOMING [308105107] 193.2 percent of total billed charges 151.28 231.8 Technical (Hospital) Services Radex Sternum Minimum 2 Views PX-3207112000 CDM 71120 CPT 320 RC inpatient 244 244 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES EPO [308136803] 193.2 percent of total billed charges 151.28 231.8 Technical (Hospital) Services Radex Sternum Minimum 2 Views PX-3207112000 CDM 71120 CPT 320 RC inpatient 244 244 HEALTHPARTNERS SX009 HEALTHPARTNERS 193.2 percent of total billed charges 151.28 231.8 Technical (Hospital) Services Radex Sternum Minimum 2 Views PX-3207112000 CDM 71120 CPT 320 RC inpatient 244 244 MEDICA (COMMERCIAL) 94265 [3081118] MEDICA CLAIMS [308111801] 219.6 percent of total billed charges 151.28 231.8 Technical (Hospital) Services Radex Sternum Minimum 2 Views PX-3207112000 CDM 71120 CPT 320 RC inpatient 244 244 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES HDHP [308136802] 193.2 percent of total billed charges 151.28 231.8 Technical (Hospital) Services Radex Sternum Minimum 2 Views PX-3207112000 CDM 71120 CPT 320 RC inpatient 244 244 UNITED HEALTHCARE (COMMERCIAL) [3081199] UNITED HEALTHCARE 87726 [308119901] 151.28 percent of total billed charges 151.28 231.8 Technical (Hospital) Services Radex Sternum Minimum 2 Views PX-3207112000 CDM 71120 CPT 320 RC inpatient 244 244 BLUE CROSS BLUE SHIELD WELLMARK SB889 [3081026] BCBS WYOMING [308102603] 231.8 percent of total billed charges 151.28 231.8 Technical (Hospital) Services Radex Sternum Minimum 2 Views PX-3207112000 CDM 71120 CPT 320 RC inpatient 244 244 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES PPO [308136801] 193.2 percent of total billed charges 151.28 231.8 Technical (Hospital) Services Radex Sternum Minimum 2 Views PX-3207112000 CDM 71120 CPT 320 RC inpatient 244 244 MULTIPLAN INC 34080 [3081285] MULTIPLAN INC [308128501] 231.8 percent of total billed charges 151.28 231.8 Technical (Hospital) Services Radex Sternum Minimum 2 Views PX-3207112000 CDM 71120 CPT 320 RC outpatient 244 244 HEALTHPARTNERS SX009 HEALTHPARTNERS 195.2 percent of total billed charges 151.28 231.8 Technical (Hospital) Services Radex Sternum Minimum 2 Views PX-3207112000 CDM 71120 CPT 320 RC outpatient 244 244 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES PPO [308136801] 195.2 percent of total billed charges 151.28 231.8 Technical (Hospital) Services Radex Sternum Minimum 2 Views PX-3207112000 CDM 71120 CPT 320 RC outpatient 244 244 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES EPO [308136803] 195.2 percent of total billed charges 151.28 231.8 Technical (Hospital) Services Radex Sternum Minimum 2 Views PX-3207112000 CDM 71120 CPT 320 RC outpatient 244 244 BLUE CROSS BLUE SHIELD WELLMARK SB889 [3081026] BCBS WYOMING [308102603] 231.8 percent of total billed charges 151.28 231.8 Technical (Hospital) Services Radex Sternum Minimum 2 Views PX-3207112000 CDM 71120 CPT 320 RC outpatient 244 244 UNITED HEALTHCARE (COMMERCIAL) [3081199] UNITED HEALTHCARE 87726 [308119901] 151.28 percent of total billed charges 151.28 231.8 Technical (Hospital) Services Radex Sternum Minimum 2 Views PX-3207112000 CDM 71120 CPT 320 RC outpatient 244 244 MULTIPLAN INC 34080 [3081285] MULTIPLAN INC [308128501] 231.8 percent of total billed charges 151.28 231.8 Technical (Hospital) Services Radex Sternum Minimum 2 Views PX-3207112000 CDM 71120 CPT 320 RC outpatient 244 244 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES HDHP [308136802] 195.2 percent of total billed charges 151.28 231.8 Technical (Hospital) Services Radex Sternum Minimum 2 Views PX-3207112000 CDM 71120 CPT 320 RC outpatient 244 244 CIGNA 62308 [3081051] CIGNA 62308 [308105105] 195.2 percent of total billed charges 151.28 231.8 Technical (Hospital) Services Radex Sternum Minimum 2 Views PX-3207112000 CDM 71120 CPT 320 RC outpatient 244 244 CIGNA 62308 [3081051] CIGNA STATE OF WYOMING [308105107] 195.2 percent of total billed charges 151.28 231.8 Technical (Hospital) Services Radex Sternum Minimum 2 Views PX-3207112000 CDM 71120 CPT 320 RC outpatient 244 244 MEDICA (COMMERCIAL) 94265 [3081118] MEDICA CLAIMS [308111801] 219.6 percent of total billed charges 151.28 231.8 Technical (Hospital) Services Radex Ribs Bi W/Posteroant Ch Minimum 4 Views PX-3207111100 CDM 71111 CPT 320 RC outpatient 356 356 MEDICA (COMMERCIAL) 94265 [3081118] MEDICA CLAIMS [308111801] 320.4 percent of total billed charges 220.72 338.2 Technical (Hospital) Services Radex Ribs Bi W/Posteroant Ch Minimum 4 Views PX-3207111100 CDM 71111 CPT 320 RC outpatient 356 356 CIGNA 62308 [3081051] CIGNA 62308 [308105105] 284.8 percent of total billed charges 220.72 338.2 Technical (Hospital) Services Radex Ribs Bi W/Posteroant Ch Minimum 4 Views PX-3207111100 CDM 71111 CPT 320 RC outpatient 356 356 CIGNA 62308 [3081051] CIGNA STATE OF WYOMING [308105107] 284.8 percent of total billed charges 220.72 338.2 Technical (Hospital) Services Radex Ribs Bi W/Posteroant Ch Minimum 4 Views PX-3207111100 CDM 71111 CPT 320 RC outpatient 356 356 HEALTHPARTNERS SX009 HEALTHPARTNERS 284.8 percent of total billed charges 220.72 338.2 Technical (Hospital) Services Radex Ribs Bi W/Posteroant Ch Minimum 4 Views PX-3207111100 CDM 71111 CPT 320 RC outpatient 356 356 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES EPO [308136803] 284.8 percent of total billed charges 220.72 338.2 Technical (Hospital) Services Radex Ribs Bi W/Posteroant Ch Minimum 4 Views PX-3207111100 CDM 71111 CPT 320 RC outpatient 356 356 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES PPO [308136801] 284.8 percent of total billed charges 220.72 338.2 Technical (Hospital) Services Radex Ribs Bi W/Posteroant Ch Minimum 4 Views PX-3207111100 CDM 71111 CPT 320 RC outpatient 356 356 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES HDHP [308136802] 284.8 percent of total billed charges 220.72 338.2 Technical (Hospital) Services Radex Ribs Bi W/Posteroant Ch Minimum 4 Views PX-3207111100 CDM 71111 CPT 320 RC outpatient 356 356 MULTIPLAN INC 34080 [3081285] MULTIPLAN INC [308128501] 338.2 percent of total billed charges 220.72 338.2 Technical (Hospital) Services Radex Ribs Bi W/Posteroant Ch Minimum 4 Views PX-3207111100 CDM 71111 CPT 320 RC outpatient 356 356 UNITED HEALTHCARE (COMMERCIAL) [3081199] UNITED HEALTHCARE 87726 [308119901] 220.72 percent of total billed charges 220.72 338.2 Technical (Hospital) Services Radex Ribs Bi W/Posteroant Ch Minimum 4 Views PX-3207111100 CDM 71111 CPT 320 RC outpatient 356 356 BLUE CROSS BLUE SHIELD WELLMARK SB889 [3081026] BCBS WYOMING [308102603] 338.2 percent of total billed charges 220.72 338.2 Technical (Hospital) Services Radex Ribs Bi W/Posteroant Ch Minimum 4 Views PX-3207111100 CDM 71111 CPT 320 RC inpatient 356 356 MULTIPLAN INC 34080 [3081285] MULTIPLAN INC [308128501] 338.2 percent of total billed charges 220.72 338.2 Technical (Hospital) Services Radex Ribs Bi W/Posteroant Ch Minimum 4 Views PX-3207111100 CDM 71111 CPT 320 RC inpatient 356 356 UNITED HEALTHCARE (COMMERCIAL) [3081199] UNITED HEALTHCARE 87726 [308119901] 220.72 percent of total billed charges 220.72 338.2 Technical (Hospital) Services Radex Ribs Bi W/Posteroant Ch Minimum 4 Views PX-3207111100 CDM 71111 CPT 320 RC inpatient 356 356 BLUE CROSS BLUE SHIELD WELLMARK SB889 [3081026] BCBS WYOMING [308102603] 338.2 percent of total billed charges 220.72 338.2 Technical (Hospital) Services Radex Ribs Bi W/Posteroant Ch Minimum 4 Views PX-3207111100 CDM 71111 CPT 320 RC inpatient 356 356 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES PPO [308136801] 281.88 percent of total billed charges 220.72 338.2 Technical (Hospital) Services Radex Ribs Bi W/Posteroant Ch Minimum 4 Views PX-3207111100 CDM 71111 CPT 320 RC inpatient 356 356 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES HDHP [308136802] 281.88 percent of total billed charges 220.72 338.2 Technical (Hospital) Services Radex Ribs Bi W/Posteroant Ch Minimum 4 Views PX-3207111100 CDM 71111 CPT 320 RC inpatient 356 356 MEDICA (COMMERCIAL) 94265 [3081118] MEDICA CLAIMS [308111801] 320.4 percent of total billed charges 220.72 338.2 Technical (Hospital) Services Radex Ribs Bi W/Posteroant Ch Minimum 4 Views PX-3207111100 CDM 71111 CPT 320 RC inpatient 356 356 HEALTHPARTNERS SX009 HEALTHPARTNERS 281.88 percent of total billed charges 220.72 338.2 Technical (Hospital) Services Radex Ribs Bi W/Posteroant Ch Minimum 4 Views PX-3207111100 CDM 71111 CPT 320 RC inpatient 356 356 CIGNA 62308 [3081051] CIGNA 62308 [308105105] 281.88 percent of total billed charges 220.72 338.2 Technical (Hospital) Services Radex Ribs Bi W/Posteroant Ch Minimum 4 Views PX-3207111100 CDM 71111 CPT 320 RC inpatient 356 356 CIGNA 62308 [3081051] CIGNA STATE OF WYOMING [308105107] 281.88 percent of total billed charges 220.72 338.2 Technical (Hospital) Services Radex Ribs Bi W/Posteroant Ch Minimum 4 Views PX-3207111100 CDM 71111 CPT 320 RC inpatient 356 356 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES EPO [308136803] 281.88 percent of total billed charges 220.72 338.2 Technical (Hospital) Services Radex Ribs Bilateral 3 Views PX-3207111000 CDM 71110 CPT 320 RC outpatient 311 311 HEALTHPARTNERS SX009 HEALTHPARTNERS 248.8 percent of total billed charges 192.82 295.45 Technical (Hospital) Services Radex Ribs Bilateral 3 Views PX-3207111000 CDM 71110 CPT 320 RC outpatient 311 311 MEDICA (COMMERCIAL) 94265 [3081118] MEDICA CLAIMS [308111801] 279.9 percent of total billed charges 192.82 295.45 Technical (Hospital) Services Radex Ribs Bilateral 3 Views PX-3207111000 CDM 71110 CPT 320 RC outpatient 311 311 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES PPO [308136801] 248.8 percent of total billed charges 192.82 295.45 Technical (Hospital) Services Radex Ribs Bilateral 3 Views PX-3207111000 CDM 71110 CPT 320 RC outpatient 311 311 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES EPO [308136803] 248.8 percent of total billed charges 192.82 295.45 Technical (Hospital) Services Radex Ribs Bilateral 3 Views PX-3207111000 CDM 71110 CPT 320 RC outpatient 311 311 UNITED HEALTHCARE (COMMERCIAL) [3081199] UNITED HEALTHCARE 87726 [308119901] 192.82 percent of total billed charges 192.82 295.45 Technical (Hospital) Services Radex Ribs Bilateral 3 Views PX-3207111000 CDM 71110 CPT 320 RC outpatient 311 311 BLUE CROSS BLUE SHIELD WELLMARK SB889 [3081026] BCBS WYOMING [308102603] 295.45 percent of total billed charges 192.82 295.45 Technical (Hospital) Services Radex Ribs Bilateral 3 Views PX-3207111000 CDM 71110 CPT 320 RC outpatient 311 311 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES HDHP [308136802] 248.8 percent of total billed charges 192.82 295.45 Technical (Hospital) Services Radex Ribs Bilateral 3 Views PX-3207111000 CDM 71110 CPT 320 RC outpatient 311 311 MULTIPLAN INC 34080 [3081285] MULTIPLAN INC [308128501] 295.45 percent of total billed charges 192.82 295.45 Technical (Hospital) Services Radex Ribs Bilateral 3 Views PX-3207111000 CDM 71110 CPT 320 RC outpatient 311 311 CIGNA 62308 [3081051] CIGNA 62308 [308105105] 248.8 percent of total billed charges 192.82 295.45 Technical (Hospital) Services Radex Ribs Bilateral 3 Views PX-3207111000 CDM 71110 CPT 320 RC outpatient 311 311 CIGNA 62308 [3081051] CIGNA STATE OF WYOMING [308105107] 248.8 percent of total billed charges 192.82 295.45 Technical (Hospital) Services Radex Ribs Bilateral 3 Views PX-3207111000 CDM 71110 CPT 320 RC inpatient 311 311 CIGNA 62308 [3081051] CIGNA 62308 [308105105] 246.25 percent of total billed charges 192.82 295.45 Technical (Hospital) Services Radex Ribs Bilateral 3 Views PX-3207111000 CDM 71110 CPT 320 RC inpatient 311 311 CIGNA 62308 [3081051] CIGNA STATE OF WYOMING [308105107] 246.25 percent of total billed charges 192.82 295.45 Technical (Hospital) Services Radex Ribs Bilateral 3 Views PX-3207111000 CDM 71110 CPT 320 RC inpatient 311 311 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES EPO [308136803] 246.25 percent of total billed charges 192.82 295.45 Technical (Hospital) Services Radex Ribs Bilateral 3 Views PX-3207111000 CDM 71110 CPT 320 RC inpatient 311 311 HEALTHPARTNERS SX009 HEALTHPARTNERS 246.25 percent of total billed charges 192.82 295.45 Technical (Hospital) Services Radex Ribs Bilateral 3 Views PX-3207111000 CDM 71110 CPT 320 RC inpatient 311 311 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES HDHP [308136802] 246.25 percent of total billed charges 192.82 295.45 Technical (Hospital) Services Radex Ribs Bilateral 3 Views PX-3207111000 CDM 71110 CPT 320 RC inpatient 311 311 MEDICA (COMMERCIAL) 94265 [3081118] MEDICA CLAIMS [308111801] 279.9 percent of total billed charges 192.82 295.45 Technical (Hospital) Services Radex Ribs Bilateral 3 Views PX-3207111000 CDM 71110 CPT 320 RC inpatient 311 311 BLUE CROSS BLUE SHIELD WELLMARK SB889 [3081026] BCBS WYOMING [308102603] 295.45 percent of total billed charges 192.82 295.45 Technical (Hospital) Services Radex Ribs Bilateral 3 Views PX-3207111000 CDM 71110 CPT 320 RC inpatient 311 311 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES PPO [308136801] 246.25 percent of total billed charges 192.82 295.45 Technical (Hospital) Services Radex Ribs Bilateral 3 Views PX-3207111000 CDM 71110 CPT 320 RC inpatient 311 311 MULTIPLAN INC 34080 [3081285] MULTIPLAN INC [308128501] 295.45 percent of total billed charges 192.82 295.45 Technical (Hospital) Services Radex Ribs Bilateral 3 Views PX-3207111000 CDM 71110 CPT 320 RC inpatient 311 311 UNITED HEALTHCARE (COMMERCIAL) [3081199] UNITED HEALTHCARE 87726 [308119901] 192.82 percent of total billed charges 192.82 295.45 Technical (Hospital) Services Radex Ribs Uni W/Posteroant Ch Minimum 3 Views PX-3207110100 CDM 71101 CPT 320 RC inpatient 494 494 UNITED HEALTHCARE (COMMERCIAL) [3081199] UNITED HEALTHCARE 87726 [308119901] 306.28 percent of total billed charges 306.28 469.3 Technical (Hospital) Services Radex Ribs Uni W/Posteroant Ch Minimum 3 Views PX-3207110100 CDM 71101 CPT 320 RC inpatient 494 494 MULTIPLAN INC 34080 [3081285] MULTIPLAN INC [308128501] 469.3 percent of total billed charges 306.28 469.3 Technical (Hospital) Services Radex Ribs Uni W/Posteroant Ch Minimum 3 Views PX-3207110100 CDM 71101 CPT 320 RC inpatient 494 494 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES PPO [308136801] 391.15 percent of total billed charges 306.28 469.3 Technical (Hospital) Services Radex Ribs Uni W/Posteroant Ch Minimum 3 Views PX-3207110100 CDM 71101 CPT 320 RC inpatient 494 494 BLUE CROSS BLUE SHIELD WELLMARK SB889 [3081026] BCBS WYOMING [308102603] 469.3 percent of total billed charges 306.28 469.3 Technical (Hospital) Services Radex Ribs Uni W/Posteroant Ch Minimum 3 Views PX-3207110100 CDM 71101 CPT 320 RC inpatient 494 494 MEDICA (COMMERCIAL) 94265 [3081118] MEDICA CLAIMS [308111801] 444.6 percent of total billed charges 306.28 469.3 Technical (Hospital) Services Radex Ribs Uni W/Posteroant Ch Minimum 3 Views PX-3207110100 CDM 71101 CPT 320 RC inpatient 494 494 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES HDHP [308136802] 391.15 percent of total billed charges 306.28 469.3 Technical (Hospital) Services Radex Ribs Uni W/Posteroant Ch Minimum 3 Views PX-3207110100 CDM 71101 CPT 320 RC inpatient 494 494 HEALTHPARTNERS SX009 HEALTHPARTNERS 391.15 percent of total billed charges 306.28 469.3 Technical (Hospital) Services Radex Ribs Uni W/Posteroant Ch Minimum 3 Views PX-3207110100 CDM 71101 CPT 320 RC inpatient 494 494 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES EPO [308136803] 391.15 percent of total billed charges 306.28 469.3 Technical (Hospital) Services Radex Ribs Uni W/Posteroant Ch Minimum 3 Views PX-3207110100 CDM 71101 CPT 320 RC inpatient 494 494 CIGNA 62308 [3081051] CIGNA 62308 [308105105] 391.15 percent of total billed charges 306.28 469.3 Technical (Hospital) Services Radex Ribs Uni W/Posteroant Ch Minimum 3 Views PX-3207110100 CDM 71101 CPT 320 RC inpatient 494 494 CIGNA 62308 [3081051] CIGNA STATE OF WYOMING [308105107] 391.15 percent of total billed charges 306.28 469.3 Technical (Hospital) Services Radex Ribs Uni W/Posteroant Ch Minimum 3 Views PX-3207110100 CDM 71101 CPT 320 RC outpatient 494 494 CIGNA 62308 [3081051] CIGNA 62308 [308105105] 395.2 percent of total billed charges 306.28 469.3 Technical (Hospital) Services Radex Ribs Uni W/Posteroant Ch Minimum 3 Views PX-3207110100 CDM 71101 CPT 320 RC outpatient 494 494 CIGNA 62308 [3081051] CIGNA STATE OF WYOMING [308105107] 395.2 percent of total billed charges 306.28 469.3 Technical (Hospital) Services Radex Ribs Uni W/Posteroant Ch Minimum 3 Views PX-3207110100 CDM 71101 CPT 320 RC outpatient 494 494 HEALTHPARTNERS SX009 HEALTHPARTNERS 395.2 percent of total billed charges 306.28 469.3 Technical (Hospital) Services Radex Ribs Uni W/Posteroant Ch Minimum 3 Views PX-3207110100 CDM 71101 CPT 320 RC outpatient 494 494 MEDICA (COMMERCIAL) 94265 [3081118] MEDICA CLAIMS [308111801] 444.6 percent of total billed charges 306.28 469.3 Technical (Hospital) Services Radex Ribs Uni W/Posteroant Ch Minimum 3 Views PX-3207110100 CDM 71101 CPT 320 RC outpatient 494 494 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES HDHP [308136802] 395.2 percent of total billed charges 306.28 469.3 Technical (Hospital) Services Radex Ribs Uni W/Posteroant Ch Minimum 3 Views PX-3207110100 CDM 71101 CPT 320 RC outpatient 494 494 MULTIPLAN INC 34080 [3081285] MULTIPLAN INC [308128501] 469.3 percent of total billed charges 306.28 469.3 Technical (Hospital) Services Radex Ribs Uni W/Posteroant Ch Minimum 3 Views PX-3207110100 CDM 71101 CPT 320 RC outpatient 494 494 UNITED HEALTHCARE (COMMERCIAL) [3081199] UNITED HEALTHCARE 87726 [308119901] 306.28 percent of total billed charges 306.28 469.3 Technical (Hospital) Services Radex Ribs Uni W/Posteroant Ch Minimum 3 Views PX-3207110100 CDM 71101 CPT 320 RC outpatient 494 494 BLUE CROSS BLUE SHIELD WELLMARK SB889 [3081026] BCBS WYOMING [308102603] 469.3 percent of total billed charges 306.28 469.3 Technical (Hospital) Services Radex Ribs Uni W/Posteroant Ch Minimum 3 Views PX-3207110100 CDM 71101 CPT 320 RC outpatient 494 494 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES EPO [308136803] 395.2 percent of total billed charges 306.28 469.3 Technical (Hospital) Services Radex Ribs Uni W/Posteroant Ch Minimum 3 Views PX-3207110100 CDM 71101 CPT 320 RC outpatient 494 494 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES PPO [308136801] 395.2 percent of total billed charges 306.28 469.3 Technical (Hospital) Services Radex Ribs Unilateral 2 Views PX-3207110000 CDM 71100 CPT 320 RC outpatient 237 237 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES PPO [308136801] 189.6 percent of total billed charges 146.94 225.15 Technical (Hospital) Services Radex Ribs Unilateral 2 Views PX-3207110000 CDM 71100 CPT 320 RC outpatient 237 237 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES EPO [308136803] 189.6 percent of total billed charges 146.94 225.15 Technical (Hospital) Services Radex Ribs Unilateral 2 Views PX-3207110000 CDM 71100 CPT 320 RC outpatient 237 237 BLUE CROSS BLUE SHIELD WELLMARK SB889 [3081026] BCBS WYOMING [308102603] 225.15 percent of total billed charges 146.94 225.15 Technical (Hospital) Services Radex Ribs Unilateral 2 Views PX-3207110000 CDM 71100 CPT 320 RC outpatient 237 237 UNITED HEALTHCARE (COMMERCIAL) [3081199] UNITED HEALTHCARE 87726 [308119901] 146.94 percent of total billed charges 146.94 225.15 Technical (Hospital) Services Radex Ribs Unilateral 2 Views PX-3207110000 CDM 71100 CPT 320 RC outpatient 237 237 MULTIPLAN INC 34080 [3081285] MULTIPLAN INC [308128501] 225.15 percent of total billed charges 146.94 225.15 Technical (Hospital) Services Radex Ribs Unilateral 2 Views PX-3207110000 CDM 71100 CPT 320 RC outpatient 237 237 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES HDHP [308136802] 189.6 percent of total billed charges 146.94 225.15 Technical (Hospital) Services Radex Ribs Unilateral 2 Views PX-3207110000 CDM 71100 CPT 320 RC outpatient 237 237 MEDICA (COMMERCIAL) 94265 [3081118] MEDICA CLAIMS [308111801] 213.3 percent of total billed charges 146.94 225.15 Technical (Hospital) Services Radex Ribs Unilateral 2 Views PX-3207110000 CDM 71100 CPT 320 RC outpatient 237 237 HEALTHPARTNERS SX009 HEALTHPARTNERS 189.6 percent of total billed charges 146.94 225.15 Technical (Hospital) Services Radex Ribs Unilateral 2 Views PX-3207110000 CDM 71100 CPT 320 RC outpatient 237 237 CIGNA 62308 [3081051] CIGNA 62308 [308105105] 189.6 percent of total billed charges 146.94 225.15 Technical (Hospital) Services Radex Ribs Unilateral 2 Views PX-3207110000 CDM 71100 CPT 320 RC outpatient 237 237 CIGNA 62308 [3081051] CIGNA STATE OF WYOMING [308105107] 189.6 percent of total billed charges 146.94 225.15 Technical (Hospital) Services Radex Ribs Unilateral 2 Views PX-3207110000 CDM 71100 CPT 320 RC inpatient 237 237 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES EPO [308136803] 187.66 percent of total billed charges 146.94 225.15 Technical (Hospital) Services Radex Ribs Unilateral 2 Views PX-3207110000 CDM 71100 CPT 320 RC inpatient 237 237 CIGNA 62308 [3081051] CIGNA 62308 [308105105] 187.66 percent of total billed charges 146.94 225.15 Technical (Hospital) Services Radex Ribs Unilateral 2 Views PX-3207110000 CDM 71100 CPT 320 RC inpatient 237 237 CIGNA 62308 [3081051] CIGNA STATE OF WYOMING [308105107] 187.66 percent of total billed charges 146.94 225.15 Technical (Hospital) Services Radex Ribs Unilateral 2 Views PX-3207110000 CDM 71100 CPT 320 RC inpatient 237 237 HEALTHPARTNERS SX009 HEALTHPARTNERS 187.66 percent of total billed charges 146.94 225.15 Technical (Hospital) Services Radex Ribs Unilateral 2 Views PX-3207110000 CDM 71100 CPT 320 RC inpatient 237 237 MEDICA (COMMERCIAL) 94265 [3081118] MEDICA CLAIMS [308111801] 213.3 percent of total billed charges 146.94 225.15 Technical (Hospital) Services Radex Ribs Unilateral 2 Views PX-3207110000 CDM 71100 CPT 320 RC inpatient 237 237 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES HDHP [308136802] 187.66 percent of total billed charges 146.94 225.15 Technical (Hospital) Services Radex Ribs Unilateral 2 Views PX-3207110000 CDM 71100 CPT 320 RC inpatient 237 237 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES PPO [308136801] 187.66 percent of total billed charges 146.94 225.15 Technical (Hospital) Services Radex Ribs Unilateral 2 Views PX-3207110000 CDM 71100 CPT 320 RC inpatient 237 237 BLUE CROSS BLUE SHIELD WELLMARK SB889 [3081026] BCBS WYOMING [308102603] 225.15 percent of total billed charges 146.94 225.15 Technical (Hospital) Services Radex Ribs Unilateral 2 Views PX-3207110000 CDM 71100 CPT 320 RC inpatient 237 237 UNITED HEALTHCARE (COMMERCIAL) [3081199] UNITED HEALTHCARE 87726 [308119901] 146.94 percent of total billed charges 146.94 225.15 Technical (Hospital) Services Radex Ribs Unilateral 2 Views PX-3207110000 CDM 71100 CPT 320 RC inpatient 237 237 MULTIPLAN INC 34080 [3081285] MULTIPLAN INC [308128501] 225.15 percent of total billed charges 146.94 225.15 Technical (Hospital) Services Radiologic Exam Chest 3 Views PX-3247104700 CDM 71047 CPT 324 RC inpatient 293 293 CIGNA 62308 [3081051] CIGNA 62308 [308105105] 232 percent of total billed charges 181.66 278.35 Technical (Hospital) Services Radiologic Exam Chest 3 Views PX-3247104700 CDM 71047 CPT 324 RC inpatient 293 293 CIGNA 62308 [3081051] CIGNA STATE OF WYOMING [308105107] 232 percent of total billed charges 181.66 278.35 Technical (Hospital) Services Radiologic Exam Chest 3 Views PX-3247104700 CDM 71047 CPT 324 RC inpatient 293 293 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES EPO [308136803] 232 percent of total billed charges 181.66 278.35 Technical (Hospital) Services Radiologic Exam Chest 3 Views PX-3247104700 CDM 71047 CPT 324 RC inpatient 293 293 HEALTHPARTNERS SX009 HEALTHPARTNERS 232 percent of total billed charges 181.66 278.35 Technical (Hospital) Services Radiologic Exam Chest 3 Views PX-3247104700 CDM 71047 CPT 324 RC inpatient 293 293 MEDICA (COMMERCIAL) 94265 [3081118] MEDICA CLAIMS [308111801] 263.7 percent of total billed charges 181.66 278.35 Technical (Hospital) Services Radiologic Exam Chest 3 Views PX-3247104700 CDM 71047 CPT 324 RC inpatient 293 293 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES HDHP [308136802] 232 percent of total billed charges 181.66 278.35 Technical (Hospital) Services Radiologic Exam Chest 3 Views PX-3247104700 CDM 71047 CPT 324 RC inpatient 293 293 UNITED HEALTHCARE (COMMERCIAL) [3081199] UNITED HEALTHCARE 87726 [308119901] 181.66 percent of total billed charges 181.66 278.35 Technical (Hospital) Services Radiologic Exam Chest 3 Views PX-3247104700 CDM 71047 CPT 324 RC inpatient 293 293 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES PPO [308136801] 232 percent of total billed charges 181.66 278.35 Technical (Hospital) Services Radiologic Exam Chest 3 Views PX-3247104700 CDM 71047 CPT 324 RC inpatient 293 293 BLUE CROSS BLUE SHIELD WELLMARK SB889 [3081026] BCBS WYOMING [308102603] 278.35 percent of total billed charges 181.66 278.35 Technical (Hospital) Services Radiologic Exam Chest 3 Views PX-3247104700 CDM 71047 CPT 324 RC inpatient 293 293 MULTIPLAN INC 34080 [3081285] MULTIPLAN INC [308128501] 278.35 percent of total billed charges 181.66 278.35 Technical (Hospital) Services Radiologic Exam Chest 3 Views PX-3247104700 CDM 71047 CPT 324 RC outpatient 293 293 HEALTHPARTNERS SX009 HEALTHPARTNERS 234.4 percent of total billed charges 181.66 278.35 Technical (Hospital) Services Radiologic Exam Chest 3 Views PX-3247104700 CDM 71047 CPT 324 RC outpatient 293 293 MEDICA (COMMERCIAL) 94265 [3081118] MEDICA CLAIMS [308111801] 263.7 percent of total billed charges 181.66 278.35 Technical (Hospital) Services Radiologic Exam Chest 3 Views PX-3247104700 CDM 71047 CPT 324 RC outpatient 293 293 UNITED HEALTHCARE (COMMERCIAL) [3081199] UNITED HEALTHCARE 87726 [308119901] 181.66 percent of total billed charges 181.66 278.35 Technical (Hospital) Services Radiologic Exam Chest 3 Views PX-3247104700 CDM 71047 CPT 324 RC outpatient 293 293 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES EPO [308136803] 234.4 percent of total billed charges 181.66 278.35 Technical (Hospital) Services Radiologic Exam Chest 3 Views PX-3247104700 CDM 71047 CPT 324 RC outpatient 293 293 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES PPO [308136801] 234.4 percent of total billed charges 181.66 278.35 Technical (Hospital) Services Radiologic Exam Chest 3 Views PX-3247104700 CDM 71047 CPT 324 RC outpatient 293 293 BLUE CROSS BLUE SHIELD WELLMARK SB889 [3081026] BCBS WYOMING [308102603] 278.35 percent of total billed charges 181.66 278.35 Technical (Hospital) Services Radiologic Exam Chest 3 Views PX-3247104700 CDM 71047 CPT 324 RC outpatient 293 293 MULTIPLAN INC 34080 [3081285] MULTIPLAN INC [308128501] 278.35 percent of total billed charges 181.66 278.35 Technical (Hospital) Services Radiologic Exam Chest 3 Views PX-3247104700 CDM 71047 CPT 324 RC outpatient 293 293 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES HDHP [308136802] 234.4 percent of total billed charges 181.66 278.35 Technical (Hospital) Services Radiologic Exam Chest 3 Views PX-3247104700 CDM 71047 CPT 324 RC outpatient 293 293 CIGNA 62308 [3081051] CIGNA 62308 [308105105] 234.4 percent of total billed charges 181.66 278.35 Technical (Hospital) Services Radiologic Exam Chest 3 Views PX-3247104700 CDM 71047 CPT 324 RC outpatient 293 293 CIGNA 62308 [3081051] CIGNA STATE OF WYOMING [308105107] 234.4 percent of total billed charges 181.66 278.35 Technical (Hospital) Services Radiologic Exam Chest 2 Views PX-3247104600 CDM 71046 CPT 324 RC inpatient 420 420 MULTIPLAN INC 34080 [3081285] MULTIPLAN INC [308128501] 399 percent of total billed charges 260.4 399 Technical (Hospital) Services Radiologic Exam Chest 2 Views PX-3247104600 CDM 71046 CPT 324 RC inpatient 420 420 BLUE CROSS BLUE SHIELD WELLMARK SB889 [3081026] BCBS WYOMING [308102603] 399 percent of total billed charges 260.4 399 Technical (Hospital) Services Radiologic Exam Chest 2 Views PX-3247104600 CDM 71046 CPT 324 RC inpatient 420 420 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES PPO [308136801] 332.56 percent of total billed charges 260.4 399 Technical (Hospital) Services Radiologic Exam Chest 2 Views PX-3247104600 CDM 71046 CPT 324 RC inpatient 420 420 UNITED HEALTHCARE (COMMERCIAL) [3081199] UNITED HEALTHCARE 87726 [308119901] 260.4 percent of total billed charges 260.4 399 Technical (Hospital) Services Radiologic Exam Chest 2 Views PX-3247104600 CDM 71046 CPT 324 RC inpatient 420 420 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES HDHP [308136802] 332.56 percent of total billed charges 260.4 399 Technical (Hospital) Services Radiologic Exam Chest 2 Views PX-3247104600 CDM 71046 CPT 324 RC inpatient 420 420 MEDICA (COMMERCIAL) 94265 [3081118] MEDICA CLAIMS [308111801] 378 percent of total billed charges 260.4 399 Technical (Hospital) Services Radiologic Exam Chest 2 Views PX-3247104600 CDM 71046 CPT 324 RC inpatient 420 420 HEALTHPARTNERS SX009 HEALTHPARTNERS 332.56 percent of total billed charges 260.4 399 Technical (Hospital) Services Radiologic Exam Chest 2 Views PX-3247104600 CDM 71046 CPT 324 RC inpatient 420 420 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES EPO [308136803] 332.56 percent of total billed charges 260.4 399 Technical (Hospital) Services Radiologic Exam Chest 2 Views PX-3247104600 CDM 71046 CPT 324 RC inpatient 420 420 CIGNA 62308 [3081051] CIGNA 62308 [308105105] 332.56 percent of total billed charges 260.4 399 Technical (Hospital) Services Radiologic Exam Chest 2 Views PX-3247104600 CDM 71046 CPT 324 RC inpatient 420 420 CIGNA 62308 [3081051] CIGNA STATE OF WYOMING [308105107] 332.56 percent of total billed charges 260.4 399 Technical (Hospital) Services Radiologic Exam Chest 2 Views PX-3247104600 CDM 71046 CPT 324 RC outpatient 420 420 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES PPO [308136801] 336 percent of total billed charges 260.4 399 Technical (Hospital) Services Radiologic Exam Chest 2 Views PX-3247104600 CDM 71046 CPT 324 RC outpatient 420 420 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES EPO [308136803] 336 percent of total billed charges 260.4 399 Technical (Hospital) Services Radiologic Exam Chest 2 Views PX-3247104600 CDM 71046 CPT 324 RC outpatient 420 420 UNITED HEALTHCARE (COMMERCIAL) [3081199] UNITED HEALTHCARE 87726 [308119901] 260.4 percent of total billed charges 260.4 399 Technical (Hospital) Services Radiologic Exam Chest 2 Views PX-3247104600 CDM 71046 CPT 324 RC outpatient 420 420 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES HDHP [308136802] 336 percent of total billed charges 260.4 399 Technical (Hospital) Services Radiologic Exam Chest 2 Views PX-3247104600 CDM 71046 CPT 324 RC outpatient 420 420 MULTIPLAN INC 34080 [3081285] MULTIPLAN INC [308128501] 399 percent of total billed charges 260.4 399 Technical (Hospital) Services Radiologic Exam Chest 2 Views PX-3247104600 CDM 71046 CPT 324 RC outpatient 420 420 BLUE CROSS BLUE SHIELD WELLMARK SB889 [3081026] BCBS WYOMING [308102603] 399 percent of total billed charges 260.4 399 Technical (Hospital) Services Radiologic Exam Chest 2 Views PX-3247104600 CDM 71046 CPT 324 RC outpatient 420 420 MEDICA (COMMERCIAL) 94265 [3081118] MEDICA CLAIMS [308111801] 378 percent of total billed charges 260.4 399 Technical (Hospital) Services Radiologic Exam Chest 2 Views PX-3247104600 CDM 71046 CPT 324 RC outpatient 420 420 HEALTHPARTNERS SX009 HEALTHPARTNERS 336 percent of total billed charges 260.4 399 Technical (Hospital) Services Radiologic Exam Chest 2 Views PX-3247104600 CDM 71046 CPT 324 RC outpatient 420 420 CIGNA 62308 [3081051] CIGNA 62308 [308105105] 336 percent of total billed charges 260.4 399 Technical (Hospital) Services Radiologic Exam Chest 2 Views PX-3247104600 CDM 71046 CPT 324 RC outpatient 420 420 CIGNA 62308 [3081051] CIGNA STATE OF WYOMING [308105107] 336 percent of total billed charges 260.4 399 Technical (Hospital) Services Radiologic Exam Chest Single View PX-3247104500 CDM 71045 CPT 324 RC outpatient 327 327 CIGNA 62308 [3081051] CIGNA 62308 [308105105] 261.6 percent of total billed charges 202.74 310.65 Technical (Hospital) Services Radiologic Exam Chest Single View PX-3247104500 CDM 71045 CPT 324 RC outpatient 327 327 CIGNA 62308 [3081051] CIGNA STATE OF WYOMING [308105107] 261.6 percent of total billed charges 202.74 310.65 Technical (Hospital) Services Radiologic Exam Chest Single View PX-3247104500 CDM 71045 CPT 324 RC outpatient 327 327 MEDICA (COMMERCIAL) 94265 [3081118] MEDICA CLAIMS [308111801] 294.3 percent of total billed charges 202.74 310.65 Technical (Hospital) Services Radiologic Exam Chest Single View PX-3247104500 CDM 71045 CPT 324 RC outpatient 327 327 HEALTHPARTNERS SX009 HEALTHPARTNERS 261.6 percent of total billed charges 202.74 310.65 Technical (Hospital) Services Radiologic Exam Chest Single View PX-3247104500 CDM 71045 CPT 324 RC outpatient 327 327 MULTIPLAN INC 34080 [3081285] MULTIPLAN INC [308128501] 310.65 percent of total billed charges 202.74 310.65 Technical (Hospital) Services Radiologic Exam Chest Single View PX-3247104500 CDM 71045 CPT 324 RC outpatient 327 327 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES HDHP [308136802] 261.6 percent of total billed charges 202.74 310.65 Technical (Hospital) Services Radiologic Exam Chest Single View PX-3247104500 CDM 71045 CPT 324 RC outpatient 327 327 BLUE CROSS BLUE SHIELD WELLMARK SB889 [3081026] BCBS WYOMING [308102603] 310.65 percent of total billed charges 202.74 310.65 Technical (Hospital) Services Radiologic Exam Chest Single View PX-3247104500 CDM 71045 CPT 324 RC outpatient 327 327 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES PPO [308136801] 261.6 percent of total billed charges 202.74 310.65 Technical (Hospital) Services Radiologic Exam Chest Single View PX-3247104500 CDM 71045 CPT 324 RC outpatient 327 327 UNITED HEALTHCARE (COMMERCIAL) [3081199] UNITED HEALTHCARE 87726 [308119901] 202.74 percent of total billed charges 202.74 310.65 Technical (Hospital) Services Radiologic Exam Chest Single View PX-3247104500 CDM 71045 CPT 324 RC outpatient 327 327 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES EPO [308136803] 261.6 percent of total billed charges 202.74 310.65 Technical (Hospital) Services Radiologic Exam Chest Single View PX-3247104500 CDM 71045 CPT 324 RC inpatient 327 327 BLUE CROSS BLUE SHIELD WELLMARK SB889 [3081026] BCBS WYOMING [308102603] 310.65 percent of total billed charges 202.74 310.65 Technical (Hospital) Services Radiologic Exam Chest Single View PX-3247104500 CDM 71045 CPT 324 RC inpatient 327 327 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES PPO [308136801] 258.92 percent of total billed charges 202.74 310.65 Technical (Hospital) Services Radiologic Exam Chest Single View PX-3247104500 CDM 71045 CPT 324 RC inpatient 327 327 MULTIPLAN INC 34080 [3081285] MULTIPLAN INC [308128501] 310.65 percent of total billed charges 202.74 310.65 Technical (Hospital) Services Radiologic Exam Chest Single View PX-3247104500 CDM 71045 CPT 324 RC inpatient 327 327 UNITED HEALTHCARE (COMMERCIAL) [3081199] UNITED HEALTHCARE 87726 [308119901] 202.74 percent of total billed charges 202.74 310.65 Technical (Hospital) Services Radiologic Exam Chest Single View PX-3247104500 CDM 71045 CPT 324 RC inpatient 327 327 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES HDHP [308136802] 258.92 percent of total billed charges 202.74 310.65 Technical (Hospital) Services Radiologic Exam Chest Single View PX-3247104500 CDM 71045 CPT 324 RC inpatient 327 327 MEDICA (COMMERCIAL) 94265 [3081118] MEDICA CLAIMS [308111801] 294.3 percent of total billed charges 202.74 310.65 Technical (Hospital) Services Radiologic Exam Chest Single View PX-3247104500 CDM 71045 CPT 324 RC inpatient 327 327 HEALTHPARTNERS SX009 HEALTHPARTNERS 258.92 percent of total billed charges 202.74 310.65 Technical (Hospital) Services Radiologic Exam Chest Single View PX-3247104500 CDM 71045 CPT 324 RC inpatient 327 327 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES EPO [308136803] 258.92 percent of total billed charges 202.74 310.65 Technical (Hospital) Services Radiologic Exam Chest Single View PX-3247104500 CDM 71045 CPT 324 RC inpatient 327 327 CIGNA 62308 [3081051] CIGNA 62308 [308105105] 258.92 percent of total billed charges 202.74 310.65 Technical (Hospital) Services Radiologic Exam Chest Single View PX-3247104500 CDM 71045 CPT 324 RC inpatient 327 327 CIGNA 62308 [3081051] CIGNA STATE OF WYOMING [308105107] 258.92 percent of total billed charges 202.74 310.65 Technical (Hospital) Services MRI Brain Brain Stem W/O W/Contrast Material PX-6117055300 CDM 70553 CPT 611 RC outpatient 3929 3929 UNITED HEALTHCARE (COMMERCIAL) [3081199] UNITED HEALTHCARE 87726 [308119901] 2435.98 percent of total billed charges 2435.98 3732.55 Technical (Hospital) Services MRI Brain Brain Stem W/O W/Contrast Material PX-6117055300 CDM 70553 CPT 611 RC outpatient 3929 3929 HEALTHPARTNERS SX009 HEALTHPARTNERS 3143.2 percent of total billed charges 2435.98 3732.55 Technical (Hospital) Services MRI Brain Brain Stem W/O W/Contrast Material PX-6117055300 CDM 70553 CPT 611 RC outpatient 3929 3929 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES EPO [308136803] 3143.2 percent of total billed charges 2435.98 3732.55 Technical (Hospital) Services MRI Brain Brain Stem W/O W/Contrast Material PX-6117055300 CDM 70553 CPT 611 RC outpatient 3929 3929 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES PPO [308136801] 3143.2 percent of total billed charges 2435.98 3732.55 Technical (Hospital) Services MRI Brain Brain Stem W/O W/Contrast Material PX-6117055300 CDM 70553 CPT 611 RC outpatient 3929 3929 BLUE CROSS BLUE SHIELD WELLMARK SB889 [3081026] BCBS WYOMING [308102603] 3732.55 percent of total billed charges 2435.98 3732.55 Technical (Hospital) Services MRI Brain Brain Stem W/O W/Contrast Material PX-6117055300 CDM 70553 CPT 611 RC outpatient 3929 3929 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES HDHP [308136802] 3143.2 percent of total billed charges 2435.98 3732.55 Technical (Hospital) Services MRI Brain Brain Stem W/O W/Contrast Material PX-6117055300 CDM 70553 CPT 611 RC outpatient 3929 3929 MULTIPLAN INC 34080 [3081285] MULTIPLAN INC [308128501] 3732.55 percent of total billed charges 2435.98 3732.55 Technical (Hospital) Services MRI Brain Brain Stem W/O W/Contrast Material PX-6117055300 CDM 70553 CPT 611 RC outpatient 3929 3929 MEDICA (COMMERCIAL) 94265 [3081118] MEDICA CLAIMS [308111801] 3536.1 percent of total billed charges 2435.98 3732.55 Technical (Hospital) Services MRI Brain Brain Stem W/O W/Contrast Material PX-6117055300 CDM 70553 CPT 611 RC outpatient 3929 3929 CIGNA 62308 [3081051] CIGNA 62308 [308105105] 3143.2 percent of total billed charges 2435.98 3732.55 Technical (Hospital) Services MRI Brain Brain Stem W/O W/Contrast Material PX-6117055300 CDM 70553 CPT 611 RC outpatient 3929 3929 CIGNA 62308 [3081051] CIGNA STATE OF WYOMING [308105107] 3143.2 percent of total billed charges 2435.98 3732.55 Technical (Hospital) Services MRI Brain Brain Stem W/O W/Contrast Material PX-6117055300 CDM 70553 CPT 611 RC inpatient 3929 3929 CIGNA 62308 [3081051] CIGNA 62308 [308105105] 3110.98 percent of total billed charges 2435.98 3732.55 Technical (Hospital) Services MRI Brain Brain Stem W/O W/Contrast Material PX-6117055300 CDM 70553 CPT 611 RC inpatient 3929 3929 CIGNA 62308 [3081051] CIGNA STATE OF WYOMING [308105107] 3110.98 percent of total billed charges 2435.98 3732.55 Technical (Hospital) Services MRI Brain Brain Stem W/O W/Contrast Material PX-6117055300 CDM 70553 CPT 611 RC inpatient 3929 3929 HEALTHPARTNERS SX009 HEALTHPARTNERS 3110.98 percent of total billed charges 2435.98 3732.55 Technical (Hospital) Services MRI Brain Brain Stem W/O W/Contrast Material PX-6117055300 CDM 70553 CPT 611 RC inpatient 3929 3929 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES EPO [308136803] 3110.98 percent of total billed charges 2435.98 3732.55 Technical (Hospital) Services MRI Brain Brain Stem W/O W/Contrast Material PX-6117055300 CDM 70553 CPT 611 RC inpatient 3929 3929 MEDICA (COMMERCIAL) 94265 [3081118] MEDICA CLAIMS [308111801] 3536.1 percent of total billed charges 2435.98 3732.55 Technical (Hospital) Services MRI Brain Brain Stem W/O W/Contrast Material PX-6117055300 CDM 70553 CPT 611 RC inpatient 3929 3929 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES HDHP [308136802] 3110.98 percent of total billed charges 2435.98 3732.55 Technical (Hospital) Services MRI Brain Brain Stem W/O W/Contrast Material PX-6117055300 CDM 70553 CPT 611 RC inpatient 3929 3929 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES PPO [308136801] 3110.98 percent of total billed charges 2435.98 3732.55 Technical (Hospital) Services MRI Brain Brain Stem W/O W/Contrast Material PX-6117055300 CDM 70553 CPT 611 RC inpatient 3929 3929 UNITED HEALTHCARE (COMMERCIAL) [3081199] UNITED HEALTHCARE 87726 [308119901] 2435.98 percent of total billed charges 2435.98 3732.55 Technical (Hospital) Services MRI Brain Brain Stem W/O W/Contrast Material PX-6117055300 CDM 70553 CPT 611 RC inpatient 3929 3929 BLUE CROSS BLUE SHIELD WELLMARK SB889 [3081026] BCBS WYOMING [308102603] 3732.55 percent of total billed charges 2435.98 3732.55 Technical (Hospital) Services MRI Brain Brain Stem W/O W/Contrast Material PX-6117055300 CDM 70553 CPT 611 RC inpatient 3929 3929 MULTIPLAN INC 34080 [3081285] MULTIPLAN INC [308128501] 3732.55 percent of total billed charges 2435.98 3732.55 Technical (Hospital) Services MRI Brain Brain Stem W/Contrast Material PX-6117055200 CDM 70552 CPT 611 RC outpatient 2751 2751 CIGNA 62308 [3081051] CIGNA STATE OF WYOMING [308105107] 2200.8 percent of total billed charges 1705.62 2613.45 Technical (Hospital) Services MRI Brain Brain Stem W/Contrast Material PX-6117055200 CDM 70552 CPT 611 RC outpatient 2751 2751 MEDICA (COMMERCIAL) 94265 [3081118] MEDICA CLAIMS [308111801] 2475.9 percent of total billed charges 1705.62 2613.45 Technical (Hospital) Services MRI Brain Brain Stem W/Contrast Material PX-6117055200 CDM 70552 CPT 611 RC outpatient 2751 2751 CIGNA 62308 [3081051] CIGNA 62308 [308105105] 2200.8 percent of total billed charges 1705.62 2613.45 Technical (Hospital) Services MRI Brain Brain Stem W/Contrast Material PX-6117055200 CDM 70552 CPT 611 RC outpatient 2751 2751 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES PPO [308136801] 2200.8 percent of total billed charges 1705.62 2613.45 Technical (Hospital) Services MRI Brain Brain Stem W/Contrast Material PX-6117055200 CDM 70552 CPT 611 RC outpatient 2751 2751 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES EPO [308136803] 2200.8 percent of total billed charges 1705.62 2613.45 Technical (Hospital) Services MRI Brain Brain Stem W/Contrast Material PX-6117055200 CDM 70552 CPT 611 RC outpatient 2751 2751 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES HDHP [308136802] 2200.8 percent of total billed charges 1705.62 2613.45 Technical (Hospital) Services MRI Brain Brain Stem W/Contrast Material PX-6117055200 CDM 70552 CPT 611 RC outpatient 2751 2751 MULTIPLAN INC 34080 [3081285] MULTIPLAN INC [308128501] 2613.45 percent of total billed charges 1705.62 2613.45 Technical (Hospital) Services MRI Brain Brain Stem W/Contrast Material PX-6117055200 CDM 70552 CPT 611 RC outpatient 2751 2751 BLUE CROSS BLUE SHIELD WELLMARK SB889 [3081026] BCBS WYOMING [308102603] 2613.45 percent of total billed charges 1705.62 2613.45 Technical (Hospital) Services MRI Brain Brain Stem W/Contrast Material PX-6117055200 CDM 70552 CPT 611 RC outpatient 2751 2751 UNITED HEALTHCARE (COMMERCIAL) [3081199] UNITED HEALTHCARE 87726 [308119901] 1705.62 percent of total billed charges 1705.62 2613.45 Technical (Hospital) Services MRI Brain Brain Stem W/Contrast Material PX-6117055200 CDM 70552 CPT 611 RC outpatient 2751 2751 HEALTHPARTNERS SX009 HEALTHPARTNERS 2200.8 percent of total billed charges 1705.62 2613.45 Technical (Hospital) Services MRI Brain Brain Stem W/Contrast Material PX-6117055200 CDM 70552 CPT 611 RC inpatient 2751 2751 MULTIPLAN INC 34080 [3081285] MULTIPLAN INC [308128501] 2613.45 percent of total billed charges 1705.62 2613.45 Technical (Hospital) Services MRI Brain Brain Stem W/Contrast Material PX-6117055200 CDM 70552 CPT 611 RC inpatient 2751 2751 BLUE CROSS BLUE SHIELD WELLMARK SB889 [3081026] BCBS WYOMING [308102603] 2613.45 percent of total billed charges 1705.62 2613.45 Technical (Hospital) Services MRI Brain Brain Stem W/Contrast Material PX-6117055200 CDM 70552 CPT 611 RC inpatient 2751 2751 UNITED HEALTHCARE (COMMERCIAL) [3081199] UNITED HEALTHCARE 87726 [308119901] 1705.62 percent of total billed charges 1705.62 2613.45 Technical (Hospital) Services MRI Brain Brain Stem W/Contrast Material PX-6117055200 CDM 70552 CPT 611 RC inpatient 2751 2751 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES PPO [308136801] 2178.24 percent of total billed charges 1705.62 2613.45 Technical (Hospital) Services MRI Brain Brain Stem W/Contrast Material PX-6117055200 CDM 70552 CPT 611 RC inpatient 2751 2751 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES HDHP [308136802] 2178.24 percent of total billed charges 1705.62 2613.45 Technical (Hospital) Services MRI Brain Brain Stem W/Contrast Material PX-6117055200 CDM 70552 CPT 611 RC inpatient 2751 2751 MEDICA (COMMERCIAL) 94265 [3081118] MEDICA CLAIMS [308111801] 2475.9 percent of total billed charges 1705.62 2613.45 Technical (Hospital) Services MRI Brain Brain Stem W/Contrast Material PX-6117055200 CDM 70552 CPT 611 RC inpatient 2751 2751 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES EPO [308136803] 2178.24 percent of total billed charges 1705.62 2613.45 Technical (Hospital) Services MRI Brain Brain Stem W/Contrast Material PX-6117055200 CDM 70552 CPT 611 RC inpatient 2751 2751 HEALTHPARTNERS SX009 HEALTHPARTNERS 2178.24 percent of total billed charges 1705.62 2613.45 Technical (Hospital) Services MRI Brain Brain Stem W/Contrast Material PX-6117055200 CDM 70552 CPT 611 RC inpatient 2751 2751 CIGNA 62308 [3081051] CIGNA 62308 [308105105] 2178.24 percent of total billed charges 1705.62 2613.45 Technical (Hospital) Services MRI Brain Brain Stem W/Contrast Material PX-6117055200 CDM 70552 CPT 611 RC inpatient 2751 2751 CIGNA 62308 [3081051] CIGNA STATE OF WYOMING [308105107] 2178.24 percent of total billed charges 1705.62 2613.45 Technical (Hospital) Services MRI Brain Brain Stem W/O Contrast Material PX-6117055100 CDM 70551 CPT 611 RC outpatient 2858 2858 HEALTHPARTNERS SX009 HEALTHPARTNERS 2286.4 percent of total billed charges 1771.96 2715.1 Technical (Hospital) Services MRI Brain Brain Stem W/O Contrast Material PX-6117055100 CDM 70551 CPT 611 RC outpatient 2858 2858 UNITED HEALTHCARE (COMMERCIAL) [3081199] UNITED HEALTHCARE 87726 [308119901] 1771.96 percent of total billed charges 1771.96 2715.1 Technical (Hospital) Services MRI Brain Brain Stem W/O Contrast Material PX-6117055100 CDM 70551 CPT 611 RC outpatient 2858 2858 BLUE CROSS BLUE SHIELD WELLMARK SB889 [3081026] BCBS WYOMING [308102603] 2715.1 percent of total billed charges 1771.96 2715.1 Technical (Hospital) Services MRI Brain Brain Stem W/O Contrast Material PX-6117055100 CDM 70551 CPT 611 RC outpatient 2858 2858 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES HDHP [308136802] 2286.4 percent of total billed charges 1771.96 2715.1 Technical (Hospital) Services MRI Brain Brain Stem W/O Contrast Material PX-6117055100 CDM 70551 CPT 611 RC outpatient 2858 2858 MULTIPLAN INC 34080 [3081285] MULTIPLAN INC [308128501] 2715.1 percent of total billed charges 1771.96 2715.1 Technical (Hospital) Services MRI Brain Brain Stem W/O Contrast Material PX-6117055100 CDM 70551 CPT 611 RC outpatient 2858 2858 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES EPO [308136803] 2286.4 percent of total billed charges 1771.96 2715.1 Technical (Hospital) Services MRI Brain Brain Stem W/O Contrast Material PX-6117055100 CDM 70551 CPT 611 RC outpatient 2858 2858 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES PPO [308136801] 2286.4 percent of total billed charges 1771.96 2715.1 Technical (Hospital) Services MRI Brain Brain Stem W/O Contrast Material PX-6117055100 CDM 70551 CPT 611 RC outpatient 2858 2858 CIGNA 62308 [3081051] CIGNA 62308 [308105105] 2286.4 percent of total billed charges 1771.96 2715.1 Technical (Hospital) Services MRI Brain Brain Stem W/O Contrast Material PX-6117055100 CDM 70551 CPT 611 RC outpatient 2858 2858 CIGNA 62308 [3081051] CIGNA STATE OF WYOMING [308105107] 2286.4 percent of total billed charges 1771.96 2715.1 Technical (Hospital) Services MRI Brain Brain Stem W/O Contrast Material PX-6117055100 CDM 70551 CPT 611 RC outpatient 2858 2858 MEDICA (COMMERCIAL) 94265 [3081118] MEDICA CLAIMS [308111801] 2572.2 percent of total billed charges 1771.96 2715.1 Technical (Hospital) Services MRI Brain Brain Stem W/O Contrast Material PX-6117055100 CDM 70551 CPT 611 RC inpatient 2858 2858 CIGNA 62308 [3081051] CIGNA 62308 [308105105] 2262.96 percent of total billed charges 1771.96 2715.1 Technical (Hospital) Services MRI Brain Brain Stem W/O Contrast Material PX-6117055100 CDM 70551 CPT 611 RC inpatient 2858 2858 CIGNA 62308 [3081051] CIGNA STATE OF WYOMING [308105107] 2262.96 percent of total billed charges 1771.96 2715.1 Technical (Hospital) Services MRI Brain Brain Stem W/O Contrast Material PX-6117055100 CDM 70551 CPT 611 RC inpatient 2858 2858 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES EPO [308136803] 2262.96 percent of total billed charges 1771.96 2715.1 Technical (Hospital) Services MRI Brain Brain Stem W/O Contrast Material PX-6117055100 CDM 70551 CPT 611 RC inpatient 2858 2858 HEALTHPARTNERS SX009 HEALTHPARTNERS 2262.96 percent of total billed charges 1771.96 2715.1 Technical (Hospital) Services MRI Brain Brain Stem W/O Contrast Material PX-6117055100 CDM 70551 CPT 611 RC inpatient 2858 2858 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES HDHP [308136802] 2262.96 percent of total billed charges 1771.96 2715.1 Technical (Hospital) Services MRI Brain Brain Stem W/O Contrast Material PX-6117055100 CDM 70551 CPT 611 RC inpatient 2858 2858 MEDICA (COMMERCIAL) 94265 [3081118] MEDICA CLAIMS [308111801] 2572.2 percent of total billed charges 1771.96 2715.1 Technical (Hospital) Services MRI Brain Brain Stem W/O Contrast Material PX-6117055100 CDM 70551 CPT 611 RC inpatient 2858 2858 MULTIPLAN INC 34080 [3081285] MULTIPLAN INC [308128501] 2715.1 percent of total billed charges 1771.96 2715.1 Technical (Hospital) Services MRI Brain Brain Stem W/O Contrast Material PX-6117055100 CDM 70551 CPT 611 RC inpatient 2858 2858 BLUE CROSS BLUE SHIELD WELLMARK SB889 [3081026] BCBS WYOMING [308102603] 2715.1 percent of total billed charges 1771.96 2715.1 Technical (Hospital) Services MRI Brain Brain Stem W/O Contrast Material PX-6117055100 CDM 70551 CPT 611 RC inpatient 2858 2858 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES PPO [308136801] 2262.96 percent of total billed charges 1771.96 2715.1 Technical (Hospital) Services MRI Brain Brain Stem W/O Contrast Material PX-6117055100 CDM 70551 CPT 611 RC inpatient 2858 2858 UNITED HEALTHCARE (COMMERCIAL) [3081199] UNITED HEALTHCARE 87726 [308119901] 1771.96 percent of total billed charges 1771.96 2715.1 Technical (Hospital) Services Mra Neck W/O &W/Contrast Material PX-6157054900 CDM 70549 CPT 615 RC outpatient 4323 4323 MEDICA (COMMERCIAL) 94265 [3081118] MEDICA CLAIMS [308111801] 3890.7 percent of total billed charges 2680.26 4106.85 Technical (Hospital) Services Mra Neck W/O &W/Contrast Material PX-6157054900 CDM 70549 CPT 615 RC outpatient 4323 4323 CIGNA 62308 [3081051] CIGNA 62308 [308105105] 3458.4 percent of total billed charges 2680.26 4106.85 Technical (Hospital) Services Mra Neck W/O &W/Contrast Material PX-6157054900 CDM 70549 CPT 615 RC outpatient 4323 4323 CIGNA 62308 [3081051] CIGNA STATE OF WYOMING [308105107] 3458.4 percent of total billed charges 2680.26 4106.85 Technical (Hospital) Services Mra Neck W/O &W/Contrast Material PX-6157054900 CDM 70549 CPT 615 RC outpatient 4323 4323 BLUE CROSS BLUE SHIELD WELLMARK SB889 [3081026] BCBS WYOMING [308102603] 4106.85 percent of total billed charges 2680.26 4106.85 Technical (Hospital) Services Mra Neck W/O &W/Contrast Material PX-6157054900 CDM 70549 CPT 615 RC outpatient 4323 4323 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES HDHP [308136802] 3458.4 percent of total billed charges 2680.26 4106.85 Technical (Hospital) Services Mra Neck W/O &W/Contrast Material PX-6157054900 CDM 70549 CPT 615 RC outpatient 4323 4323 MULTIPLAN INC 34080 [3081285] MULTIPLAN INC [308128501] 4106.85 percent of total billed charges 2680.26 4106.85 Technical (Hospital) Services Mra Neck W/O &W/Contrast Material PX-6157054900 CDM 70549 CPT 615 RC outpatient 4323 4323 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES EPO [308136803] 3458.4 percent of total billed charges 2680.26 4106.85 Technical (Hospital) Services Mra Neck W/O &W/Contrast Material PX-6157054900 CDM 70549 CPT 615 RC outpatient 4323 4323 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES PPO [308136801] 3458.4 percent of total billed charges 2680.26 4106.85 Technical (Hospital) Services Mra Neck W/O &W/Contrast Material PX-6157054900 CDM 70549 CPT 615 RC outpatient 4323 4323 UNITED HEALTHCARE (COMMERCIAL) [3081199] UNITED HEALTHCARE 87726 [308119901] 2680.26 percent of total billed charges 2680.26 4106.85 Technical (Hospital) Services Mra Neck W/O &W/Contrast Material PX-6157054900 CDM 70549 CPT 615 RC outpatient 4323 4323 HEALTHPARTNERS SX009 HEALTHPARTNERS 3458.4 percent of total billed charges 2680.26 4106.85 Technical (Hospital) Services Mra Neck W/O &W/Contrast Material PX-6157054900 CDM 70549 CPT 615 RC inpatient 4323 4323 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES EPO [308136803] 3422.95 percent of total billed charges 2680.26 4106.85 Technical (Hospital) Services Mra Neck W/O &W/Contrast Material PX-6157054900 CDM 70549 CPT 615 RC inpatient 4323 4323 HEALTHPARTNERS SX009 HEALTHPARTNERS 3422.95 percent of total billed charges 2680.26 4106.85 Technical (Hospital) Services Mra Neck W/O &W/Contrast Material PX-6157054900 CDM 70549 CPT 615 RC inpatient 4323 4323 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES HDHP [308136802] 3422.95 percent of total billed charges 2680.26 4106.85 Technical (Hospital) Services Mra Neck W/O &W/Contrast Material PX-6157054900 CDM 70549 CPT 615 RC inpatient 4323 4323 MEDICA (COMMERCIAL) 94265 [3081118] MEDICA CLAIMS [308111801] 3890.7 percent of total billed charges 2680.26 4106.85 Technical (Hospital) Services Mra Neck W/O &W/Contrast Material PX-6157054900 CDM 70549 CPT 615 RC inpatient 4323 4323 MULTIPLAN INC 34080 [3081285] MULTIPLAN INC [308128501] 4106.85 percent of total billed charges 2680.26 4106.85 Technical (Hospital) Services Mra Neck W/O &W/Contrast Material PX-6157054900 CDM 70549 CPT 615 RC inpatient 4323 4323 BLUE CROSS BLUE SHIELD WELLMARK SB889 [3081026] BCBS WYOMING [308102603] 4106.85 percent of total billed charges 2680.26 4106.85 Technical (Hospital) Services Mra Neck W/O &W/Contrast Material PX-6157054900 CDM 70549 CPT 615 RC inpatient 4323 4323 UNITED HEALTHCARE (COMMERCIAL) [3081199] UNITED HEALTHCARE 87726 [308119901] 2680.26 percent of total billed charges 2680.26 4106.85 Technical (Hospital) Services Mra Neck W/O &W/Contrast Material PX-6157054900 CDM 70549 CPT 615 RC inpatient 4323 4323 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES PPO [308136801] 3422.95 percent of total billed charges 2680.26 4106.85 Technical (Hospital) Services Mra Neck W/O &W/Contrast Material PX-6157054900 CDM 70549 CPT 615 RC inpatient 4323 4323 CIGNA 62308 [3081051] CIGNA 62308 [308105105] 3422.95 percent of total billed charges 2680.26 4106.85 Technical (Hospital) Services Mra Neck W/O &W/Contrast Material PX-6157054900 CDM 70549 CPT 615 RC inpatient 4323 4323 CIGNA 62308 [3081051] CIGNA STATE OF WYOMING [308105107] 3422.95 percent of total billed charges 2680.26 4106.85 Technical (Hospital) Services Mra Neck W/Contrast Material PX-6157054800 CDM 70548 CPT 615 RC inpatient 3014 3014 BLUE CROSS BLUE SHIELD WELLMARK SB889 [3081026] BCBS WYOMING [308102603] 2863.3 percent of total billed charges 1868.68 2863.3 Technical (Hospital) Services Mra Neck W/Contrast Material PX-6157054800 CDM 70548 CPT 615 RC inpatient 3014 3014 MULTIPLAN INC 34080 [3081285] MULTIPLAN INC [308128501] 2863.3 percent of total billed charges 1868.68 2863.3 Technical (Hospital) Services Mra Neck W/Contrast Material PX-6157054800 CDM 70548 CPT 615 RC inpatient 3014 3014 UNITED HEALTHCARE (COMMERCIAL) [3081199] UNITED HEALTHCARE 87726 [308119901] 1868.68 percent of total billed charges 1868.68 2863.3 Technical (Hospital) Services Mra Neck W/Contrast Material PX-6157054800 CDM 70548 CPT 615 RC inpatient 3014 3014 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES PPO [308136801] 2386.49 percent of total billed charges 1868.68 2863.3 Technical (Hospital) Services Mra Neck W/Contrast Material PX-6157054800 CDM 70548 CPT 615 RC inpatient 3014 3014 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES EPO [308136803] 2386.49 percent of total billed charges 1868.68 2863.3 Technical (Hospital) Services Mra Neck W/Contrast Material PX-6157054800 CDM 70548 CPT 615 RC inpatient 3014 3014 HEALTHPARTNERS SX009 HEALTHPARTNERS 2386.49 percent of total billed charges 1868.68 2863.3 Technical (Hospital) Services Mra Neck W/Contrast Material PX-6157054800 CDM 70548 CPT 615 RC inpatient 3014 3014 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES HDHP [308136802] 2386.49 percent of total billed charges 1868.68 2863.3 Technical (Hospital) Services Mra Neck W/Contrast Material PX-6157054800 CDM 70548 CPT 615 RC inpatient 3014 3014 MEDICA (COMMERCIAL) 94265 [3081118] MEDICA CLAIMS [308111801] 2712.6 percent of total billed charges 1868.68 2863.3 Technical (Hospital) Services Mra Neck W/Contrast Material PX-6157054800 CDM 70548 CPT 615 RC inpatient 3014 3014 CIGNA 62308 [3081051] CIGNA 62308 [308105105] 2386.49 percent of total billed charges 1868.68 2863.3 Technical (Hospital) Services Mra Neck W/Contrast Material PX-6157054800 CDM 70548 CPT 615 RC inpatient 3014 3014 CIGNA 62308 [3081051] CIGNA STATE OF WYOMING [308105107] 2386.49 percent of total billed charges 1868.68 2863.3 Technical (Hospital) Services Mra Neck W/Contrast Material PX-6157054800 CDM 70548 CPT 615 RC outpatient 3014 3014 MEDICA (COMMERCIAL) 94265 [3081118] MEDICA CLAIMS [308111801] 2712.6 percent of total billed charges 1868.68 2863.3 Technical (Hospital) Services Mra Neck W/Contrast Material PX-6157054800 CDM 70548 CPT 615 RC outpatient 3014 3014 CIGNA 62308 [3081051] CIGNA 62308 [308105105] 2411.2 percent of total billed charges 1868.68 2863.3 Technical (Hospital) Services Mra Neck W/Contrast Material PX-6157054800 CDM 70548 CPT 615 RC outpatient 3014 3014 CIGNA 62308 [3081051] CIGNA STATE OF WYOMING [308105107] 2411.2 percent of total billed charges 1868.68 2863.3 Technical (Hospital) Services Mra Neck W/Contrast Material PX-6157054800 CDM 70548 CPT 615 RC outpatient 3014 3014 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES EPO [308136803] 2411.2 percent of total billed charges 1868.68 2863.3 Technical (Hospital) Services Mra Neck W/Contrast Material PX-6157054800 CDM 70548 CPT 615 RC outpatient 3014 3014 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES PPO [308136801] 2411.2 percent of total billed charges 1868.68 2863.3 Technical (Hospital) Services Mra Neck W/Contrast Material PX-6157054800 CDM 70548 CPT 615 RC outpatient 3014 3014 BLUE CROSS BLUE SHIELD WELLMARK SB889 [3081026] BCBS WYOMING [308102603] 2863.3 percent of total billed charges 1868.68 2863.3 Technical (Hospital) Services Mra Neck W/Contrast Material PX-6157054800 CDM 70548 CPT 615 RC outpatient 3014 3014 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES HDHP [308136802] 2411.2 percent of total billed charges 1868.68 2863.3 Technical (Hospital) Services Mra Neck W/Contrast Material PX-6157054800 CDM 70548 CPT 615 RC outpatient 3014 3014 MULTIPLAN INC 34080 [3081285] MULTIPLAN INC [308128501] 2863.3 percent of total billed charges 1868.68 2863.3 Technical (Hospital) Services Mra Neck W/Contrast Material PX-6157054800 CDM 70548 CPT 615 RC outpatient 3014 3014 HEALTHPARTNERS SX009 HEALTHPARTNERS 2411.2 percent of total billed charges 1868.68 2863.3 Technical (Hospital) Services Mra Neck W/Contrast Material PX-6157054800 CDM 70548 CPT 615 RC outpatient 3014 3014 UNITED HEALTHCARE (COMMERCIAL) [3081199] UNITED HEALTHCARE 87726 [308119901] 1868.68 percent of total billed charges 1868.68 2863.3 Technical (Hospital) Services Mra Neck W/O Contrst Material PX-6157054700 CDM 70547 CPT 615 RC inpatient 3014 3014 BLUE CROSS BLUE SHIELD WELLMARK SB889 [3081026] BCBS WYOMING [308102603] 2863.3 percent of total billed charges 1868.68 2863.3 Technical (Hospital) Services Mra Neck W/O Contrst Material PX-6157054700 CDM 70547 CPT 615 RC inpatient 3014 3014 MULTIPLAN INC 34080 [3081285] MULTIPLAN INC [308128501] 2863.3 percent of total billed charges 1868.68 2863.3 Technical (Hospital) Services Mra Neck W/O Contrst Material PX-6157054700 CDM 70547 CPT 615 RC inpatient 3014 3014 UNITED HEALTHCARE (COMMERCIAL) [3081199] UNITED HEALTHCARE 87726 [308119901] 1868.68 percent of total billed charges 1868.68 2863.3 Technical (Hospital) Services Mra Neck W/O Contrst Material PX-6157054700 CDM 70547 CPT 615 RC inpatient 3014 3014 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES PPO [308136801] 2386.49 percent of total billed charges 1868.68 2863.3 Technical (Hospital) Services Mra Neck W/O Contrst Material PX-6157054700 CDM 70547 CPT 615 RC inpatient 3014 3014 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES HDHP [308136802] 2386.49 percent of total billed charges 1868.68 2863.3 Technical (Hospital) Services Mra Neck W/O Contrst Material PX-6157054700 CDM 70547 CPT 615 RC inpatient 3014 3014 MEDICA (COMMERCIAL) 94265 [3081118] MEDICA CLAIMS [308111801] 2712.6 percent of total billed charges 1868.68 2863.3 Technical (Hospital) Services Mra Neck W/O Contrst Material PX-6157054700 CDM 70547 CPT 615 RC inpatient 3014 3014 HEALTHPARTNERS SX009 HEALTHPARTNERS 2386.49 percent of total billed charges 1868.68 2863.3 Technical (Hospital) Services Mra Neck W/O Contrst Material PX-6157054700 CDM 70547 CPT 615 RC inpatient 3014 3014 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES EPO [308136803] 2386.49 percent of total billed charges 1868.68 2863.3 Technical (Hospital) Services Mra Neck W/O Contrst Material PX-6157054700 CDM 70547 CPT 615 RC inpatient 3014 3014 CIGNA 62308 [3081051] CIGNA 62308 [308105105] 2386.49 percent of total billed charges 1868.68 2863.3 Technical (Hospital) Services Mra Neck W/O Contrst Material PX-6157054700 CDM 70547 CPT 615 RC inpatient 3014 3014 CIGNA 62308 [3081051] CIGNA STATE OF WYOMING [308105107] 2386.49 percent of total billed charges 1868.68 2863.3 Technical (Hospital) Services Mra Neck W/O Contrst Material PX-6157054700 CDM 70547 CPT 615 RC outpatient 3014 3014 MEDICA (COMMERCIAL) 94265 [3081118] MEDICA CLAIMS [308111801] 2712.6 percent of total billed charges 1868.68 2863.3 Technical (Hospital) Services Mra Neck W/O Contrst Material PX-6157054700 CDM 70547 CPT 615 RC outpatient 3014 3014 CIGNA 62308 [3081051] CIGNA STATE OF WYOMING [308105107] 2411.2 percent of total billed charges 1868.68 2863.3 Technical (Hospital) Services Mra Neck W/O Contrst Material PX-6157054700 CDM 70547 CPT 615 RC outpatient 3014 3014 CIGNA 62308 [3081051] CIGNA 62308 [308105105] 2411.2 percent of total billed charges 1868.68 2863.3 Technical (Hospital) Services Mra Neck W/O Contrst Material PX-6157054700 CDM 70547 CPT 615 RC outpatient 3014 3014 BLUE CROSS BLUE SHIELD WELLMARK SB889 [3081026] BCBS WYOMING [308102603] 2863.3 percent of total billed charges 1868.68 2863.3 Technical (Hospital) Services Mra Neck W/O Contrst Material PX-6157054700 CDM 70547 CPT 615 RC outpatient 3014 3014 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES HDHP [308136802] 2411.2 percent of total billed charges 1868.68 2863.3 Technical (Hospital) Services Mra Neck W/O Contrst Material PX-6157054700 CDM 70547 CPT 615 RC outpatient 3014 3014 MULTIPLAN INC 34080 [3081285] MULTIPLAN INC [308128501] 2863.3 percent of total billed charges 1868.68 2863.3 Technical (Hospital) Services Mra Neck W/O Contrst Material PX-6157054700 CDM 70547 CPT 615 RC outpatient 3014 3014 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES EPO [308136803] 2411.2 percent of total billed charges 1868.68 2863.3 Technical (Hospital) Services Mra Neck W/O Contrst Material PX-6157054700 CDM 70547 CPT 615 RC outpatient 3014 3014 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES PPO [308136801] 2411.2 percent of total billed charges 1868.68 2863.3 Technical (Hospital) Services Mra Neck W/O Contrst Material PX-6157054700 CDM 70547 CPT 615 RC outpatient 3014 3014 HEALTHPARTNERS SX009 HEALTHPARTNERS 2411.2 percent of total billed charges 1868.68 2863.3 Technical (Hospital) Services Mra Neck W/O Contrst Material PX-6157054700 CDM 70547 CPT 615 RC outpatient 3014 3014 UNITED HEALTHCARE (COMMERCIAL) [3081199] UNITED HEALTHCARE 87726 [308119901] 1868.68 percent of total billed charges 1868.68 2863.3 Technical (Hospital) Services Mra Head W/O & W/Contrast Material PX-6157054600 CDM 70546 CPT 615 RC outpatient 4323 4323 CIGNA 62308 [3081051] CIGNA 62308 [308105105] 3458.4 percent of total billed charges 2680.26 4106.85 Technical (Hospital) Services Mra Head W/O & W/Contrast Material PX-6157054600 CDM 70546 CPT 615 RC outpatient 4323 4323 CIGNA 62308 [3081051] CIGNA STATE OF WYOMING [308105107] 3458.4 percent of total billed charges 2680.26 4106.85 Technical (Hospital) Services Mra Head W/O & W/Contrast Material PX-6157054600 CDM 70546 CPT 615 RC outpatient 4323 4323 MEDICA (COMMERCIAL) 94265 [3081118] MEDICA CLAIMS [308111801] 3890.7 percent of total billed charges 2680.26 4106.85 Technical (Hospital) Services Mra Head W/O & W/Contrast Material PX-6157054600 CDM 70546 CPT 615 RC outpatient 4323 4323 HEALTHPARTNERS SX009 HEALTHPARTNERS 3458.4 percent of total billed charges 2680.26 4106.85 Technical (Hospital) Services Mra Head W/O & W/Contrast Material PX-6157054600 CDM 70546 CPT 615 RC outpatient 4323 4323 MULTIPLAN INC 34080 [3081285] MULTIPLAN INC [308128501] 4106.85 percent of total billed charges 2680.26 4106.85 Technical (Hospital) Services Mra Head W/O & W/Contrast Material PX-6157054600 CDM 70546 CPT 615 RC outpatient 4323 4323 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES HDHP [308136802] 3458.4 percent of total billed charges 2680.26 4106.85 Technical (Hospital) Services Mra Head W/O & W/Contrast Material PX-6157054600 CDM 70546 CPT 615 RC outpatient 4323 4323 BLUE CROSS BLUE SHIELD WELLMARK SB889 [3081026] BCBS WYOMING [308102603] 4106.85 percent of total billed charges 2680.26 4106.85 Technical (Hospital) Services Mra Head W/O & W/Contrast Material PX-6157054600 CDM 70546 CPT 615 RC outpatient 4323 4323 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES PPO [308136801] 3458.4 percent of total billed charges 2680.26 4106.85 Technical (Hospital) Services Mra Head W/O & W/Contrast Material PX-6157054600 CDM 70546 CPT 615 RC outpatient 4323 4323 UNITED HEALTHCARE (COMMERCIAL) [3081199] UNITED HEALTHCARE 87726 [308119901] 2680.26 percent of total billed charges 2680.26 4106.85 Technical (Hospital) Services Mra Head W/O & W/Contrast Material PX-6157054600 CDM 70546 CPT 615 RC outpatient 4323 4323 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES EPO [308136803] 3458.4 percent of total billed charges 2680.26 4106.85 Technical (Hospital) Services Mra Head W/O & W/Contrast Material PX-6157054600 CDM 70546 CPT 615 RC inpatient 4323 4323 CIGNA 62308 [3081051] CIGNA STATE OF WYOMING [308105107] 3422.95 percent of total billed charges 2680.26 4106.85 Technical (Hospital) Services Mra Head W/O & W/Contrast Material PX-6157054600 CDM 70546 CPT 615 RC inpatient 4323 4323 CIGNA 62308 [3081051] CIGNA 62308 [308105105] 3422.95 percent of total billed charges 2680.26 4106.85 Technical (Hospital) Services Mra Head W/O & W/Contrast Material PX-6157054600 CDM 70546 CPT 615 RC inpatient 4323 4323 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES EPO [308136803] 3422.95 percent of total billed charges 2680.26 4106.85 Technical (Hospital) Services Mra Head W/O & W/Contrast Material PX-6157054600 CDM 70546 CPT 615 RC inpatient 4323 4323 HEALTHPARTNERS SX009 HEALTHPARTNERS 3422.95 percent of total billed charges 2680.26 4106.85 Technical (Hospital) Services Mra Head W/O & W/Contrast Material PX-6157054600 CDM 70546 CPT 615 RC inpatient 4323 4323 MEDICA (COMMERCIAL) 94265 [3081118] MEDICA CLAIMS [308111801] 3890.7 percent of total billed charges 2680.26 4106.85 Technical (Hospital) Services Mra Head W/O & W/Contrast Material PX-6157054600 CDM 70546 CPT 615 RC inpatient 4323 4323 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES HDHP [308136802] 3422.95 percent of total billed charges 2680.26 4106.85 Technical (Hospital) Services Mra Head W/O & W/Contrast Material PX-6157054600 CDM 70546 CPT 615 RC inpatient 4323 4323 BLUE CROSS BLUE SHIELD WELLMARK SB889 [3081026] BCBS WYOMING [308102603] 4106.85 percent of total billed charges 2680.26 4106.85 Technical (Hospital) Services Mra Head W/O & W/Contrast Material PX-6157054600 CDM 70546 CPT 615 RC inpatient 4323 4323 MULTIPLAN INC 34080 [3081285] MULTIPLAN INC [308128501] 4106.85 percent of total billed charges 2680.26 4106.85 Technical (Hospital) Services Mra Head W/O & W/Contrast Material PX-6157054600 CDM 70546 CPT 615 RC inpatient 4323 4323 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES PPO [308136801] 3422.95 percent of total billed charges 2680.26 4106.85 Technical (Hospital) Services Mra Head W/O & W/Contrast Material PX-6157054600 CDM 70546 CPT 615 RC inpatient 4323 4323 UNITED HEALTHCARE (COMMERCIAL) [3081199] UNITED HEALTHCARE 87726 [308119901] 2680.26 percent of total billed charges 2680.26 4106.85 Technical (Hospital) Services Mra Head W/Contrast Material PX-6157054500 CDM 70545 CPT 615 RC inpatient 4323 4323 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES HDHP [308136802] 3422.95 percent of total billed charges 2680.26 4106.85 Technical (Hospital) Services Mra Head W/Contrast Material PX-6157054500 CDM 70545 CPT 615 RC inpatient 4323 4323 MULTIPLAN INC 34080 [3081285] MULTIPLAN INC [308128501] 4106.85 percent of total billed charges 2680.26 4106.85 Technical (Hospital) Services Mra Head W/Contrast Material PX-6157054500 CDM 70545 CPT 615 RC inpatient 4323 4323 BLUE CROSS BLUE SHIELD WELLMARK SB889 [3081026] BCBS WYOMING [308102603] 4106.85 percent of total billed charges 2680.26 4106.85 Technical (Hospital) Services Mra Head W/Contrast Material PX-6157054500 CDM 70545 CPT 615 RC inpatient 4323 4323 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES PPO [308136801] 3422.95 percent of total billed charges 2680.26 4106.85 Technical (Hospital) Services Mra Head W/Contrast Material PX-6157054500 CDM 70545 CPT 615 RC inpatient 4323 4323 UNITED HEALTHCARE (COMMERCIAL) [3081199] UNITED HEALTHCARE 87726 [308119901] 2680.26 percent of total billed charges 2680.26 4106.85 Technical (Hospital) Services Mra Head W/Contrast Material PX-6157054500 CDM 70545 CPT 615 RC inpatient 4323 4323 MEDICA (COMMERCIAL) 94265 [3081118] MEDICA CLAIMS [308111801] 3890.7 percent of total billed charges 2680.26 4106.85 Technical (Hospital) Services Mra Head W/Contrast Material PX-6157054500 CDM 70545 CPT 615 RC inpatient 4323 4323 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES EPO [308136803] 3422.95 percent of total billed charges 2680.26 4106.85 Technical (Hospital) Services Mra Head W/Contrast Material PX-6157054500 CDM 70545 CPT 615 RC inpatient 4323 4323 HEALTHPARTNERS SX009 HEALTHPARTNERS 3422.95 percent of total billed charges 2680.26 4106.85 Technical (Hospital) Services Mra Head W/Contrast Material PX-6157054500 CDM 70545 CPT 615 RC inpatient 4323 4323 CIGNA 62308 [3081051] CIGNA 62308 [308105105] 3422.95 percent of total billed charges 2680.26 4106.85 Technical (Hospital) Services Mra Head W/Contrast Material PX-6157054500 CDM 70545 CPT 615 RC inpatient 4323 4323 CIGNA 62308 [3081051] CIGNA STATE OF WYOMING [308105107] 3422.95 percent of total billed charges 2680.26 4106.85 Technical (Hospital) Services Mra Head W/Contrast Material PX-6157054500 CDM 70545 CPT 615 RC outpatient 4323 4323 HEALTHPARTNERS SX009 HEALTHPARTNERS 3458.4 percent of total billed charges 2680.26 4106.85 Technical (Hospital) Services Mra Head W/Contrast Material PX-6157054500 CDM 70545 CPT 615 RC outpatient 4323 4323 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES EPO [308136803] 3458.4 percent of total billed charges 2680.26 4106.85 Technical (Hospital) Services Mra Head W/Contrast Material PX-6157054500 CDM 70545 CPT 615 RC outpatient 4323 4323 UNITED HEALTHCARE (COMMERCIAL) [3081199] UNITED HEALTHCARE 87726 [308119901] 2680.26 percent of total billed charges 2680.26 4106.85 Technical (Hospital) Services Mra Head W/Contrast Material PX-6157054500 CDM 70545 CPT 615 RC outpatient 4323 4323 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES PPO [308136801] 3458.4 percent of total billed charges 2680.26 4106.85 Technical (Hospital) Services Mra Head W/Contrast Material PX-6157054500 CDM 70545 CPT 615 RC outpatient 4323 4323 BLUE CROSS BLUE SHIELD WELLMARK SB889 [3081026] BCBS WYOMING [308102603] 4106.85 percent of total billed charges 2680.26 4106.85 Technical (Hospital) Services Mra Head W/Contrast Material PX-6157054500 CDM 70545 CPT 615 RC outpatient 4323 4323 MULTIPLAN INC 34080 [3081285] MULTIPLAN INC [308128501] 4106.85 percent of total billed charges 2680.26 4106.85 Technical (Hospital) Services Mra Head W/Contrast Material PX-6157054500 CDM 70545 CPT 615 RC outpatient 4323 4323 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES HDHP [308136802] 3458.4 percent of total billed charges 2680.26 4106.85 Technical (Hospital) Services Mra Head W/Contrast Material PX-6157054500 CDM 70545 CPT 615 RC outpatient 4323 4323 CIGNA 62308 [3081051] CIGNA 62308 [308105105] 3458.4 percent of total billed charges 2680.26 4106.85 Technical (Hospital) Services Mra Head W/Contrast Material PX-6157054500 CDM 70545 CPT 615 RC outpatient 4323 4323 CIGNA 62308 [3081051] CIGNA STATE OF WYOMING [308105107] 3458.4 percent of total billed charges 2680.26 4106.85 Technical (Hospital) Services Mra Head W/Contrast Material PX-6157054500 CDM 70545 CPT 615 RC outpatient 4323 4323 MEDICA (COMMERCIAL) 94265 [3081118] MEDICA CLAIMS [308111801] 3890.7 percent of total billed charges 2680.26 4106.85 Technical (Hospital) Services Mra Head W/O Contrst Material PX-6157054400 CDM 70544 CPT 615 RC inpatient 3014 3014 CIGNA 62308 [3081051] CIGNA 62308 [308105105] 2386.49 percent of total billed charges 1868.68 2863.3 Technical (Hospital) Services Mra Head W/O Contrst Material PX-6157054400 CDM 70544 CPT 615 RC inpatient 3014 3014 CIGNA 62308 [3081051] CIGNA STATE OF WYOMING [308105107] 2386.49 percent of total billed charges 1868.68 2863.3 Technical (Hospital) Services Mra Head W/O Contrst Material PX-6157054400 CDM 70544 CPT 615 RC inpatient 3014 3014 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES EPO [308136803] 2386.49 percent of total billed charges 1868.68 2863.3 Technical (Hospital) Services Mra Head W/O Contrst Material PX-6157054400 CDM 70544 CPT 615 RC inpatient 3014 3014 HEALTHPARTNERS SX009 HEALTHPARTNERS 2386.49 percent of total billed charges 1868.68 2863.3 Technical (Hospital) Services Mra Head W/O Contrst Material PX-6157054400 CDM 70544 CPT 615 RC inpatient 3014 3014 MEDICA (COMMERCIAL) 94265 [3081118] MEDICA CLAIMS [308111801] 2712.6 percent of total billed charges 1868.68 2863.3 Technical (Hospital) Services Mra Head W/O Contrst Material PX-6157054400 CDM 70544 CPT 615 RC inpatient 3014 3014 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES HDHP [308136802] 2386.49 percent of total billed charges 1868.68 2863.3 Technical (Hospital) Services Mra Head W/O Contrst Material PX-6157054400 CDM 70544 CPT 615 RC inpatient 3014 3014 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES PPO [308136801] 2386.49 percent of total billed charges 1868.68 2863.3 Technical (Hospital) Services Mra Head W/O Contrst Material PX-6157054400 CDM 70544 CPT 615 RC inpatient 3014 3014 UNITED HEALTHCARE (COMMERCIAL) [3081199] UNITED HEALTHCARE 87726 [308119901] 1868.68 percent of total billed charges 1868.68 2863.3 Technical (Hospital) Services Mra Head W/O Contrst Material PX-6157054400 CDM 70544 CPT 615 RC inpatient 3014 3014 MULTIPLAN INC 34080 [3081285] MULTIPLAN INC [308128501] 2863.3 percent of total billed charges 1868.68 2863.3 Technical (Hospital) Services Mra Head W/O Contrst Material PX-6157054400 CDM 70544 CPT 615 RC inpatient 3014 3014 BLUE CROSS BLUE SHIELD WELLMARK SB889 [3081026] BCBS WYOMING [308102603] 2863.3 percent of total billed charges 1868.68 2863.3 Technical (Hospital) Services Mra Head W/O Contrst Material PX-6157054400 CDM 70544 CPT 615 RC outpatient 3014 3014 MEDICA (COMMERCIAL) 94265 [3081118] MEDICA CLAIMS [308111801] 2712.6 percent of total billed charges 1868.68 2863.3 Technical (Hospital) Services Mra Head W/O Contrst Material PX-6157054400 CDM 70544 CPT 615 RC outpatient 3014 3014 CIGNA 62308 [3081051] CIGNA 62308 [308105105] 2411.2 percent of total billed charges 1868.68 2863.3 Technical (Hospital) Services Mra Head W/O Contrst Material PX-6157054400 CDM 70544 CPT 615 RC outpatient 3014 3014 CIGNA 62308 [3081051] CIGNA STATE OF WYOMING [308105107] 2411.2 percent of total billed charges 1868.68 2863.3 Technical (Hospital) Services Mra Head W/O Contrst Material PX-6157054400 CDM 70544 CPT 615 RC outpatient 3014 3014 UNITED HEALTHCARE (COMMERCIAL) [3081199] UNITED HEALTHCARE 87726 [308119901] 1868.68 percent of total billed charges 1868.68 2863.3 Technical (Hospital) Services Mra Head W/O Contrst Material PX-6157054400 CDM 70544 CPT 615 RC outpatient 3014 3014 HEALTHPARTNERS SX009 HEALTHPARTNERS 2411.2 percent of total billed charges 1868.68 2863.3 Technical (Hospital) Services Mra Head W/O Contrst Material PX-6157054400 CDM 70544 CPT 615 RC outpatient 3014 3014 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES PPO [308136801] 2411.2 percent of total billed charges 1868.68 2863.3 Technical (Hospital) Services Mra Head W/O Contrst Material PX-6157054400 CDM 70544 CPT 615 RC outpatient 3014 3014 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES EPO [308136803] 2411.2 percent of total billed charges 1868.68 2863.3 Technical (Hospital) Services Mra Head W/O Contrst Material PX-6157054400 CDM 70544 CPT 615 RC outpatient 3014 3014 BLUE CROSS BLUE SHIELD WELLMARK SB889 [3081026] BCBS WYOMING [308102603] 2863.3 percent of total billed charges 1868.68 2863.3 Technical (Hospital) Services Mra Head W/O Contrst Material PX-6157054400 CDM 70544 CPT 615 RC outpatient 3014 3014 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES HDHP [308136802] 2411.2 percent of total billed charges 1868.68 2863.3 Technical (Hospital) Services Mra Head W/O Contrst Material PX-6157054400 CDM 70544 CPT 615 RC outpatient 3014 3014 MULTIPLAN INC 34080 [3081285] MULTIPLAN INC [308128501] 2863.3 percent of total billed charges 1868.68 2863.3 Technical (Hospital) Services MRI Orbit Face & Neck W/O & W/Contrast Matrl PX-6117054300 CDM 70543 CPT 611 RC inpatient 4060 4060 CIGNA 62308 [3081051] CIGNA 62308 [308105105] 3214.71 percent of total billed charges 2517.2 3857 Technical (Hospital) Services MRI Orbit Face & Neck W/O & W/Contrast Matrl PX-6117054300 CDM 70543 CPT 611 RC inpatient 4060 4060 CIGNA 62308 [3081051] CIGNA STATE OF WYOMING [308105107] 3214.71 percent of total billed charges 2517.2 3857 Technical (Hospital) Services MRI Orbit Face & Neck W/O & W/Contrast Matrl PX-6117054300 CDM 70543 CPT 611 RC inpatient 4060 4060 BLUE CROSS BLUE SHIELD WELLMARK SB889 [3081026] BCBS WYOMING [308102603] 3857 percent of total billed charges 2517.2 3857 Technical (Hospital) Services MRI Orbit Face & Neck W/O & W/Contrast Matrl PX-6117054300 CDM 70543 CPT 611 RC inpatient 4060 4060 MULTIPLAN INC 34080 [3081285] MULTIPLAN INC [308128501] 3857 percent of total billed charges 2517.2 3857 Technical (Hospital) Services MRI Orbit Face & Neck W/O & W/Contrast Matrl PX-6117054300 CDM 70543 CPT 611 RC inpatient 4060 4060 UNITED HEALTHCARE (COMMERCIAL) [3081199] UNITED HEALTHCARE 87726 [308119901] 2517.2 percent of total billed charges 2517.2 3857 Technical (Hospital) Services MRI Orbit Face & Neck W/O & W/Contrast Matrl PX-6117054300 CDM 70543 CPT 611 RC inpatient 4060 4060 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES PPO [308136801] 3214.71 percent of total billed charges 2517.2 3857 Technical (Hospital) Services MRI Orbit Face & Neck W/O & W/Contrast Matrl PX-6117054300 CDM 70543 CPT 611 RC inpatient 4060 4060 HEALTHPARTNERS SX009 HEALTHPARTNERS 3214.71 percent of total billed charges 2517.2 3857 Technical (Hospital) Services MRI Orbit Face & Neck W/O & W/Contrast Matrl PX-6117054300 CDM 70543 CPT 611 RC inpatient 4060 4060 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES EPO [308136803] 3214.71 percent of total billed charges 2517.2 3857 Technical (Hospital) Services MRI Orbit Face & Neck W/O & W/Contrast Matrl PX-6117054300 CDM 70543 CPT 611 RC inpatient 4060 4060 MEDICA (COMMERCIAL) 94265 [3081118] MEDICA CLAIMS [308111801] 3654 percent of total billed charges 2517.2 3857 Technical (Hospital) Services MRI Orbit Face & Neck W/O & W/Contrast Matrl PX-6117054300 CDM 70543 CPT 611 RC inpatient 4060 4060 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES HDHP [308136802] 3214.71 percent of total billed charges 2517.2 3857 Technical (Hospital) Services MRI Orbit Face & Neck W/O & W/Contrast Matrl PX-6117054300 CDM 70543 CPT 611 RC outpatient 4060 4060 CIGNA 62308 [3081051] CIGNA 62308 [308105105] 3248 percent of total billed charges 2517.2 3857 Technical (Hospital) Services MRI Orbit Face & Neck W/O & W/Contrast Matrl PX-6117054300 CDM 70543 CPT 611 RC outpatient 4060 4060 CIGNA 62308 [3081051] CIGNA STATE OF WYOMING [308105107] 3248 percent of total billed charges 2517.2 3857 Technical (Hospital) Services MRI Orbit Face & Neck W/O & W/Contrast Matrl PX-6117054300 CDM 70543 CPT 611 RC outpatient 4060 4060 MEDICA (COMMERCIAL) 94265 [3081118] MEDICA CLAIMS [308111801] 3654 percent of total billed charges 2517.2 3857 Technical (Hospital) Services MRI Orbit Face & Neck W/O & W/Contrast Matrl PX-6117054300 CDM 70543 CPT 611 RC outpatient 4060 4060 MULTIPLAN INC 34080 [3081285] MULTIPLAN INC [308128501] 3857 percent of total billed charges 2517.2 3857 Technical (Hospital) Services MRI Orbit Face & Neck W/O & W/Contrast Matrl PX-6117054300 CDM 70543 CPT 611 RC outpatient 4060 4060 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES HDHP [308136802] 3248 percent of total billed charges 2517.2 3857 Technical (Hospital) Services MRI Orbit Face & Neck W/O & W/Contrast Matrl PX-6117054300 CDM 70543 CPT 611 RC outpatient 4060 4060 BLUE CROSS BLUE SHIELD WELLMARK SB889 [3081026] BCBS WYOMING [308102603] 3857 percent of total billed charges 2517.2 3857 Technical (Hospital) Services MRI Orbit Face & Neck W/O & W/Contrast Matrl PX-6117054300 CDM 70543 CPT 611 RC outpatient 4060 4060 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES PPO [308136801] 3248 percent of total billed charges 2517.2 3857 Technical (Hospital) Services MRI Orbit Face & Neck W/O & W/Contrast Matrl PX-6117054300 CDM 70543 CPT 611 RC outpatient 4060 4060 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES EPO [308136803] 3248 percent of total billed charges 2517.2 3857 Technical (Hospital) Services MRI Orbit Face & Neck W/O & W/Contrast Matrl PX-6117054300 CDM 70543 CPT 611 RC outpatient 4060 4060 HEALTHPARTNERS SX009 HEALTHPARTNERS 3248 percent of total billed charges 2517.2 3857 Technical (Hospital) Services MRI Orbit Face & Neck W/O & W/Contrast Matrl PX-6117054300 CDM 70543 CPT 611 RC outpatient 4060 4060 UNITED HEALTHCARE (COMMERCIAL) [3081199] UNITED HEALTHCARE 87726 [308119901] 2517.2 percent of total billed charges 2517.2 3857 Technical (Hospital) Services MRI Orbit Face &/Neck W/O Contrast PX-6117054000 CDM 70540 CPT 611 RC inpatient 2751 2751 CIGNA 62308 [3081051] CIGNA 62308 [308105105] 2178.24 percent of total billed charges 1705.62 2613.45 Technical (Hospital) Services MRI Orbit Face &/Neck W/O Contrast PX-6117054000 CDM 70540 CPT 611 RC inpatient 2751 2751 CIGNA 62308 [3081051] CIGNA STATE OF WYOMING [308105107] 2178.24 percent of total billed charges 1705.62 2613.45 Technical (Hospital) Services MRI Orbit Face &/Neck W/O Contrast PX-6117054000 CDM 70540 CPT 611 RC inpatient 2751 2751 MEDICA (COMMERCIAL) 94265 [3081118] MEDICA CLAIMS [308111801] 2475.9 percent of total billed charges 1705.62 2613.45 Technical (Hospital) Services MRI Orbit Face &/Neck W/O Contrast PX-6117054000 CDM 70540 CPT 611 RC inpatient 2751 2751 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES EPO [308136803] 2178.24 percent of total billed charges 1705.62 2613.45 Technical (Hospital) Services MRI Orbit Face &/Neck W/O Contrast PX-6117054000 CDM 70540 CPT 611 RC inpatient 2751 2751 HEALTHPARTNERS SX009 HEALTHPARTNERS 2178.24 percent of total billed charges 1705.62 2613.45 Technical (Hospital) Services MRI Orbit Face &/Neck W/O Contrast PX-6117054000 CDM 70540 CPT 611 RC inpatient 2751 2751 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES HDHP [308136802] 2178.24 percent of total billed charges 1705.62 2613.45 Technical (Hospital) Services MRI Orbit Face &/Neck W/O Contrast PX-6117054000 CDM 70540 CPT 611 RC inpatient 2751 2751 BLUE CROSS BLUE SHIELD WELLMARK SB889 [3081026] BCBS WYOMING [308102603] 2613.45 percent of total billed charges 1705.62 2613.45 Technical (Hospital) Services MRI Orbit Face &/Neck W/O Contrast PX-6117054000 CDM 70540 CPT 611 RC inpatient 2751 2751 MULTIPLAN INC 34080 [3081285] MULTIPLAN INC [308128501] 2613.45 percent of total billed charges 1705.62 2613.45 Technical (Hospital) Services MRI Orbit Face &/Neck W/O Contrast PX-6117054000 CDM 70540 CPT 611 RC inpatient 2751 2751 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES PPO [308136801] 2178.24 percent of total billed charges 1705.62 2613.45 Technical (Hospital) Services MRI Orbit Face &/Neck W/O Contrast PX-6117054000 CDM 70540 CPT 611 RC inpatient 2751 2751 UNITED HEALTHCARE (COMMERCIAL) [3081199] UNITED HEALTHCARE 87726 [308119901] 1705.62 percent of total billed charges 1705.62 2613.45 Technical (Hospital) Services MRI Orbit Face &/Neck W/O Contrast PX-6117054000 CDM 70540 CPT 611 RC outpatient 2751 2751 HEALTHPARTNERS SX009 HEALTHPARTNERS 2200.8 percent of total billed charges 1705.62 2613.45 Technical (Hospital) Services MRI Orbit Face &/Neck W/O Contrast PX-6117054000 CDM 70540 CPT 611 RC outpatient 2751 2751 UNITED HEALTHCARE (COMMERCIAL) [3081199] UNITED HEALTHCARE 87726 [308119901] 1705.62 percent of total billed charges 1705.62 2613.45 Technical (Hospital) Services MRI Orbit Face &/Neck W/O Contrast PX-6117054000 CDM 70540 CPT 611 RC outpatient 2751 2751 BLUE CROSS BLUE SHIELD WELLMARK SB889 [3081026] BCBS WYOMING [308102603] 2613.45 percent of total billed charges 1705.62 2613.45 Technical (Hospital) Services MRI Orbit Face &/Neck W/O Contrast PX-6117054000 CDM 70540 CPT 611 RC outpatient 2751 2751 MULTIPLAN INC 34080 [3081285] MULTIPLAN INC [308128501] 2613.45 percent of total billed charges 1705.62 2613.45 Technical (Hospital) Services MRI Orbit Face &/Neck W/O Contrast PX-6117054000 CDM 70540 CPT 611 RC outpatient 2751 2751 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES HDHP [308136802] 2200.8 percent of total billed charges 1705.62 2613.45 Technical (Hospital) Services MRI Orbit Face &/Neck W/O Contrast PX-6117054000 CDM 70540 CPT 611 RC outpatient 2751 2751 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES EPO [308136803] 2200.8 percent of total billed charges 1705.62 2613.45 Technical (Hospital) Services MRI Orbit Face &/Neck W/O Contrast PX-6117054000 CDM 70540 CPT 611 RC outpatient 2751 2751 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES PPO [308136801] 2200.8 percent of total billed charges 1705.62 2613.45 Technical (Hospital) Services MRI Orbit Face &/Neck W/O Contrast PX-6117054000 CDM 70540 CPT 611 RC outpatient 2751 2751 CIGNA 62308 [3081051] CIGNA 62308 [308105105] 2200.8 percent of total billed charges 1705.62 2613.45 Technical (Hospital) Services MRI Orbit Face &/Neck W/O Contrast PX-6117054000 CDM 70540 CPT 611 RC outpatient 2751 2751 CIGNA 62308 [3081051] CIGNA STATE OF WYOMING [308105107] 2200.8 percent of total billed charges 1705.62 2613.45 Technical (Hospital) Services MRI Orbit Face &/Neck W/O Contrast PX-6117054000 CDM 70540 CPT 611 RC outpatient 2751 2751 MEDICA (COMMERCIAL) 94265 [3081118] MEDICA CLAIMS [308111801] 2475.9 percent of total billed charges 1705.62 2613.45 Technical (Hospital) Services CT Angiography Neck W/Contrast/Noncontrast PX-3517049800 CDM 70498 CPT 351 RC inpatient 3078 3078 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES EPO [308136803] 2437.16 percent of total billed charges 1908.36 2924.1 Technical (Hospital) Services CT Angiography Neck W/Contrast/Noncontrast PX-3517049800 CDM 70498 CPT 351 RC inpatient 3078 3078 CIGNA 62308 [3081051] CIGNA 62308 [308105105] 2437.16 percent of total billed charges 1908.36 2924.1 Technical (Hospital) Services CT Angiography Neck W/Contrast/Noncontrast PX-3517049800 CDM 70498 CPT 351 RC inpatient 3078 3078 CIGNA 62308 [3081051] CIGNA STATE OF WYOMING [308105107] 2437.16 percent of total billed charges 1908.36 2924.1 Technical (Hospital) Services CT Angiography Neck W/Contrast/Noncontrast PX-3517049800 CDM 70498 CPT 351 RC inpatient 3078 3078 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES HDHP [308136802] 2437.16 percent of total billed charges 1908.36 2924.1 Technical (Hospital) Services CT Angiography Neck W/Contrast/Noncontrast PX-3517049800 CDM 70498 CPT 351 RC inpatient 3078 3078 MEDICA (COMMERCIAL) 94265 [3081118] MEDICA CLAIMS [308111801] 2770.2 percent of total billed charges 1908.36 2924.1 Technical (Hospital) Services CT Angiography Neck W/Contrast/Noncontrast PX-3517049800 CDM 70498 CPT 351 RC inpatient 3078 3078 HEALTHPARTNERS SX009 HEALTHPARTNERS 2437.16 percent of total billed charges 1908.36 2924.1 Technical (Hospital) Services CT Angiography Neck W/Contrast/Noncontrast PX-3517049800 CDM 70498 CPT 351 RC inpatient 3078 3078 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES PPO [308136801] 2437.16 percent of total billed charges 1908.36 2924.1 Technical (Hospital) Services CT Angiography Neck W/Contrast/Noncontrast PX-3517049800 CDM 70498 CPT 351 RC inpatient 3078 3078 MULTIPLAN INC 34080 [3081285] MULTIPLAN INC [308128501] 2924.1 percent of total billed charges 1908.36 2924.1 Technical (Hospital) Services CT Angiography Neck W/Contrast/Noncontrast PX-3517049800 CDM 70498 CPT 351 RC inpatient 3078 3078 BLUE CROSS BLUE SHIELD WELLMARK SB889 [3081026] BCBS WYOMING [308102603] 2924.1 percent of total billed charges 1908.36 2924.1 Technical (Hospital) Services CT Angiography Neck W/Contrast/Noncontrast PX-3517049800 CDM 70498 CPT 351 RC inpatient 3078 3078 UNITED HEALTHCARE (COMMERCIAL) [3081199] UNITED HEALTHCARE 87726 [308119901] 1908.36 percent of total billed charges 1908.36 2924.1 Technical (Hospital) Services CT Angiography Neck W/Contrast/Noncontrast PX-3517049800 CDM 70498 CPT 351 RC outpatient 3078 3078 CIGNA 62308 [3081051] CIGNA 62308 [308105105] 2462.4 percent of total billed charges 1908.36 2924.1 Technical (Hospital) Services CT Angiography Neck W/Contrast/Noncontrast PX-3517049800 CDM 70498 CPT 351 RC outpatient 3078 3078 CIGNA 62308 [3081051] CIGNA STATE OF WYOMING [308105107] 2462.4 percent of total billed charges 1908.36 2924.1 Technical (Hospital) Services CT Angiography Neck W/Contrast/Noncontrast PX-3517049800 CDM 70498 CPT 351 RC outpatient 3078 3078 MEDICA (COMMERCIAL) 94265 [3081118] MEDICA CLAIMS [308111801] 2770.2 percent of total billed charges 1908.36 2924.1 Technical (Hospital) Services CT Angiography Neck W/Contrast/Noncontrast PX-3517049800 CDM 70498 CPT 351 RC outpatient 3078 3078 HEALTHPARTNERS SX009 HEALTHPARTNERS 2462.4 percent of total billed charges 1908.36 2924.1 Technical (Hospital) Services CT Angiography Neck W/Contrast/Noncontrast PX-3517049800 CDM 70498 CPT 351 RC outpatient 3078 3078 MULTIPLAN INC 34080 [3081285] MULTIPLAN INC [308128501] 2924.1 percent of total billed charges 1908.36 2924.1 Technical (Hospital) Services CT Angiography Neck W/Contrast/Noncontrast PX-3517049800 CDM 70498 CPT 351 RC outpatient 3078 3078 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES HDHP [308136802] 2462.4 percent of total billed charges 1908.36 2924.1 Technical (Hospital) Services CT Angiography Neck W/Contrast/Noncontrast PX-3517049800 CDM 70498 CPT 351 RC outpatient 3078 3078 BLUE CROSS BLUE SHIELD WELLMARK SB889 [3081026] BCBS WYOMING [308102603] 2924.1 percent of total billed charges 1908.36 2924.1 Technical (Hospital) Services CT Angiography Neck W/Contrast/Noncontrast PX-3517049800 CDM 70498 CPT 351 RC outpatient 3078 3078 UNITED HEALTHCARE (COMMERCIAL) [3081199] UNITED HEALTHCARE 87726 [308119901] 1908.36 percent of total billed charges 1908.36 2924.1 Technical (Hospital) Services CT Angiography Neck W/Contrast/Noncontrast PX-3517049800 CDM 70498 CPT 351 RC outpatient 3078 3078 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES EPO [308136803] 2462.4 percent of total billed charges 1908.36 2924.1 Technical (Hospital) Services CT Angiography Neck W/Contrast/Noncontrast PX-3517049800 CDM 70498 CPT 351 RC outpatient 3078 3078 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES PPO [308136801] 2462.4 percent of total billed charges 1908.36 2924.1 Technical (Hospital) Services CT Angiography Head W/Contrast/Noncontrast PX-3517049600 CDM 70496 CPT 351 RC inpatient 3078 3078 HEALTHPARTNERS SX009 HEALTHPARTNERS 2437.16 percent of total billed charges 1908.36 2924.1 Technical (Hospital) Services CT Angiography Head W/Contrast/Noncontrast PX-3517049600 CDM 70496 CPT 351 RC inpatient 3078 3078 MEDICA (COMMERCIAL) 94265 [3081118] MEDICA CLAIMS [308111801] 2770.2 percent of total billed charges 1908.36 2924.1 Technical (Hospital) Services CT Angiography Head W/Contrast/Noncontrast PX-3517049600 CDM 70496 CPT 351 RC inpatient 3078 3078 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES HDHP [308136802] 2437.16 percent of total billed charges 1908.36 2924.1 Technical (Hospital) Services CT Angiography Head W/Contrast/Noncontrast PX-3517049600 CDM 70496 CPT 351 RC inpatient 3078 3078 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES PPO [308136801] 2437.16 percent of total billed charges 1908.36 2924.1 Technical (Hospital) Services CT Angiography Head W/Contrast/Noncontrast PX-3517049600 CDM 70496 CPT 351 RC inpatient 3078 3078 BLUE CROSS BLUE SHIELD WELLMARK SB889 [3081026] BCBS WYOMING [308102603] 2924.1 percent of total billed charges 1908.36 2924.1 Technical (Hospital) Services CT Angiography Head W/Contrast/Noncontrast PX-3517049600 CDM 70496 CPT 351 RC inpatient 3078 3078 MULTIPLAN INC 34080 [3081285] MULTIPLAN INC [308128501] 2924.1 percent of total billed charges 1908.36 2924.1 Technical (Hospital) Services CT Angiography Head W/Contrast/Noncontrast PX-3517049600 CDM 70496 CPT 351 RC inpatient 3078 3078 UNITED HEALTHCARE (COMMERCIAL) [3081199] UNITED HEALTHCARE 87726 [308119901] 1908.36 percent of total billed charges 1908.36 2924.1 Technical (Hospital) Services CT Angiography Head W/Contrast/Noncontrast PX-3517049600 CDM 70496 CPT 351 RC inpatient 3078 3078 CIGNA 62308 [3081051] CIGNA 62308 [308105105] 2437.16 percent of total billed charges 1908.36 2924.1 Technical (Hospital) Services CT Angiography Head W/Contrast/Noncontrast PX-3517049600 CDM 70496 CPT 351 RC inpatient 3078 3078 CIGNA 62308 [3081051] CIGNA STATE OF WYOMING [308105107] 2437.16 percent of total billed charges 1908.36 2924.1 Technical (Hospital) Services CT Angiography Head W/Contrast/Noncontrast PX-3517049600 CDM 70496 CPT 351 RC inpatient 3078 3078 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES EPO [308136803] 2437.16 percent of total billed charges 1908.36 2924.1 Technical (Hospital) Services CT Angiography Head W/Contrast/Noncontrast PX-3517049600 CDM 70496 CPT 351 RC outpatient 3078 3078 UNITED HEALTHCARE (COMMERCIAL) [3081199] UNITED HEALTHCARE 87726 [308119901] 1908.36 percent of total billed charges 1908.36 2924.1 Technical (Hospital) Services CT Angiography Head W/Contrast/Noncontrast PX-3517049600 CDM 70496 CPT 351 RC outpatient 3078 3078 HEALTHPARTNERS SX009 HEALTHPARTNERS 2462.4 percent of total billed charges 1908.36 2924.1 Technical (Hospital) Services CT Angiography Head W/Contrast/Noncontrast PX-3517049600 CDM 70496 CPT 351 RC outpatient 3078 3078 MULTIPLAN INC 34080 [3081285] MULTIPLAN INC [308128501] 2924.1 percent of total billed charges 1908.36 2924.1 Technical (Hospital) Services CT Angiography Head W/Contrast/Noncontrast PX-3517049600 CDM 70496 CPT 351 RC outpatient 3078 3078 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES HDHP [308136802] 2462.4 percent of total billed charges 1908.36 2924.1 Technical (Hospital) Services CT Angiography Head W/Contrast/Noncontrast PX-3517049600 CDM 70496 CPT 351 RC outpatient 3078 3078 BLUE CROSS BLUE SHIELD WELLMARK SB889 [3081026] BCBS WYOMING [308102603] 2924.1 percent of total billed charges 1908.36 2924.1 Technical (Hospital) Services CT Angiography Head W/Contrast/Noncontrast PX-3517049600 CDM 70496 CPT 351 RC outpatient 3078 3078 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES PPO [308136801] 2462.4 percent of total billed charges 1908.36 2924.1 Technical (Hospital) Services CT Angiography Head W/Contrast/Noncontrast PX-3517049600 CDM 70496 CPT 351 RC outpatient 3078 3078 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES EPO [308136803] 2462.4 percent of total billed charges 1908.36 2924.1 Technical (Hospital) Services CT Angiography Head W/Contrast/Noncontrast PX-3517049600 CDM 70496 CPT 351 RC outpatient 3078 3078 MEDICA (COMMERCIAL) 94265 [3081118] MEDICA CLAIMS [308111801] 2770.2 percent of total billed charges 1908.36 2924.1 Technical (Hospital) Services CT Angiography Head W/Contrast/Noncontrast PX-3517049600 CDM 70496 CPT 351 RC outpatient 3078 3078 CIGNA 62308 [3081051] CIGNA 62308 [308105105] 2462.4 percent of total billed charges 1908.36 2924.1 Technical (Hospital) Services CT Angiography Head W/Contrast/Noncontrast PX-3517049600 CDM 70496 CPT 351 RC outpatient 3078 3078 CIGNA 62308 [3081051] CIGNA STATE OF WYOMING [308105107] 2462.4 percent of total billed charges 1908.36 2924.1 Technical (Hospital) Services CT Soft Tissue Neck W/O & W/Contrast Material PX-3517049200 CDM 70492 CPT 351 RC outpatient 2620 2620 CIGNA 62308 [3081051] CIGNA 62308 [308105105] 2096 percent of total billed charges 1624.4 2489 Technical (Hospital) Services CT Soft Tissue Neck W/O & W/Contrast Material PX-3517049200 CDM 70492 CPT 351 RC outpatient 2620 2620 CIGNA 62308 [3081051] CIGNA STATE OF WYOMING [308105107] 2096 percent of total billed charges 1624.4 2489 Technical (Hospital) Services CT Soft Tissue Neck W/O & W/Contrast Material PX-3517049200 CDM 70492 CPT 351 RC outpatient 2620 2620 MEDICA (COMMERCIAL) 94265 [3081118] MEDICA CLAIMS [308111801] 2358 percent of total billed charges 1624.4 2489 Technical (Hospital) Services CT Soft Tissue Neck W/O & W/Contrast Material PX-3517049200 CDM 70492 CPT 351 RC outpatient 2620 2620 HEALTHPARTNERS SX009 HEALTHPARTNERS 2096 percent of total billed charges 1624.4 2489 Technical (Hospital) Services CT Soft Tissue Neck W/O & W/Contrast Material PX-3517049200 CDM 70492 CPT 351 RC outpatient 2620 2620 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES HDHP [308136802] 2096 percent of total billed charges 1624.4 2489 Technical (Hospital) Services CT Soft Tissue Neck W/O & W/Contrast Material PX-3517049200 CDM 70492 CPT 351 RC outpatient 2620 2620 MULTIPLAN INC 34080 [3081285] MULTIPLAN INC [308128501] 2489 percent of total billed charges 1624.4 2489 Technical (Hospital) Services CT Soft Tissue Neck W/O & W/Contrast Material PX-3517049200 CDM 70492 CPT 351 RC outpatient 2620 2620 BLUE CROSS BLUE SHIELD WELLMARK SB889 [3081026] BCBS WYOMING [308102603] 2489 percent of total billed charges 1624.4 2489 Technical (Hospital) Services CT Soft Tissue Neck W/O & W/Contrast Material PX-3517049200 CDM 70492 CPT 351 RC outpatient 2620 2620 UNITED HEALTHCARE (COMMERCIAL) [3081199] UNITED HEALTHCARE 87726 [308119901] 1624.4 percent of total billed charges 1624.4 2489 Technical (Hospital) Services CT Soft Tissue Neck W/O & W/Contrast Material PX-3517049200 CDM 70492 CPT 351 RC outpatient 2620 2620 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES PPO [308136801] 2096 percent of total billed charges 1624.4 2489 Technical (Hospital) Services CT Soft Tissue Neck W/O & W/Contrast Material PX-3517049200 CDM 70492 CPT 351 RC outpatient 2620 2620 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES EPO [308136803] 2096 percent of total billed charges 1624.4 2489 Technical (Hospital) Services CT Soft Tissue Neck W/O & W/Contrast Material PX-3517049200 CDM 70492 CPT 351 RC inpatient 2620 2620 BLUE CROSS BLUE SHIELD WELLMARK SB889 [3081026] BCBS WYOMING [308102603] 2489 percent of total billed charges 1624.4 2489 Technical (Hospital) Services CT Soft Tissue Neck W/O & W/Contrast Material PX-3517049200 CDM 70492 CPT 351 RC inpatient 2620 2620 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES PPO [308136801] 2074.52 percent of total billed charges 1624.4 2489 Technical (Hospital) Services CT Soft Tissue Neck W/O & W/Contrast Material PX-3517049200 CDM 70492 CPT 351 RC inpatient 2620 2620 MULTIPLAN INC 34080 [3081285] MULTIPLAN INC [308128501] 2489 percent of total billed charges 1624.4 2489 Technical (Hospital) Services CT Soft Tissue Neck W/O & W/Contrast Material PX-3517049200 CDM 70492 CPT 351 RC inpatient 2620 2620 UNITED HEALTHCARE (COMMERCIAL) [3081199] UNITED HEALTHCARE 87726 [308119901] 1624.4 percent of total billed charges 1624.4 2489 Technical (Hospital) Services CT Soft Tissue Neck W/O & W/Contrast Material PX-3517049200 CDM 70492 CPT 351 RC inpatient 2620 2620 HEALTHPARTNERS SX009 HEALTHPARTNERS 2074.52 percent of total billed charges 1624.4 2489 Technical (Hospital) Services CT Soft Tissue Neck W/O & W/Contrast Material PX-3517049200 CDM 70492 CPT 351 RC inpatient 2620 2620 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES HDHP [308136802] 2074.52 percent of total billed charges 1624.4 2489 Technical (Hospital) Services CT Soft Tissue Neck W/O & W/Contrast Material PX-3517049200 CDM 70492 CPT 351 RC inpatient 2620 2620 MEDICA (COMMERCIAL) 94265 [3081118] MEDICA CLAIMS [308111801] 2358 percent of total billed charges 1624.4 2489 Technical (Hospital) Services CT Soft Tissue Neck W/O & W/Contrast Material PX-3517049200 CDM 70492 CPT 351 RC inpatient 2620 2620 CIGNA 62308 [3081051] CIGNA 62308 [308105105] 2074.52 percent of total billed charges 1624.4 2489 Technical (Hospital) Services CT Soft Tissue Neck W/O & W/Contrast Material PX-3517049200 CDM 70492 CPT 351 RC inpatient 2620 2620 CIGNA 62308 [3081051] CIGNA STATE OF WYOMING [308105107] 2074.52 percent of total billed charges 1624.4 2489 Technical (Hospital) Services CT Soft Tissue Neck W/O & W/Contrast Material PX-3517049200 CDM 70492 CPT 351 RC inpatient 2620 2620 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES EPO [308136803] 2074.52 percent of total billed charges 1624.4 2489 Technical (Hospital) Services CT Soft Tissue Neck W/Contrast Material PX-3517049100 CDM 70491 CPT 351 RC outpatient 2292 2292 HEALTHPARTNERS SX009 HEALTHPARTNERS 1833.6 percent of total billed charges 1421.04 2177.4 Technical (Hospital) Services CT Soft Tissue Neck W/Contrast Material PX-3517049100 CDM 70491 CPT 351 RC outpatient 2292 2292 BLUE CROSS BLUE SHIELD WELLMARK SB889 [3081026] BCBS WYOMING [308102603] 2177.4 percent of total billed charges 1421.04 2177.4 Technical (Hospital) Services CT Soft Tissue Neck W/Contrast Material PX-3517049100 CDM 70491 CPT 351 RC outpatient 2292 2292 MULTIPLAN INC 34080 [3081285] MULTIPLAN INC [308128501] 2177.4 percent of total billed charges 1421.04 2177.4 Technical (Hospital) Services CT Soft Tissue Neck W/Contrast Material PX-3517049100 CDM 70491 CPT 351 RC outpatient 2292 2292 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES HDHP [308136802] 1833.6 percent of total billed charges 1421.04 2177.4 Technical (Hospital) Services CT Soft Tissue Neck W/Contrast Material PX-3517049100 CDM 70491 CPT 351 RC outpatient 2292 2292 UNITED HEALTHCARE (COMMERCIAL) [3081199] UNITED HEALTHCARE 87726 [308119901] 1421.04 percent of total billed charges 1421.04 2177.4 Technical (Hospital) Services CT Soft Tissue Neck W/Contrast Material PX-3517049100 CDM 70491 CPT 351 RC outpatient 2292 2292 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES PPO [308136801] 1833.6 percent of total billed charges 1421.04 2177.4 Technical (Hospital) Services CT Soft Tissue Neck W/Contrast Material PX-3517049100 CDM 70491 CPT 351 RC outpatient 2292 2292 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES EPO [308136803] 1833.6 percent of total billed charges 1421.04 2177.4 Technical (Hospital) Services CT Soft Tissue Neck W/Contrast Material PX-3517049100 CDM 70491 CPT 351 RC outpatient 2292 2292 MEDICA (COMMERCIAL) 94265 [3081118] MEDICA CLAIMS [308111801] 2062.8 percent of total billed charges 1421.04 2177.4 Technical (Hospital) Services CT Soft Tissue Neck W/Contrast Material PX-3517049100 CDM 70491 CPT 351 RC outpatient 2292 2292 CIGNA 62308 [3081051] CIGNA 62308 [308105105] 1833.6 percent of total billed charges 1421.04 2177.4 Technical (Hospital) Services CT Soft Tissue Neck W/Contrast Material PX-3517049100 CDM 70491 CPT 351 RC outpatient 2292 2292 CIGNA 62308 [3081051] CIGNA STATE OF WYOMING [308105107] 1833.6 percent of total billed charges 1421.04 2177.4 Technical (Hospital) Services CT Soft Tissue Neck W/Contrast Material PX-3517049100 CDM 70491 CPT 351 RC inpatient 2292 2292 CIGNA 62308 [3081051] CIGNA 62308 [308105105] 1814.81 percent of total billed charges 1421.04 2177.4 Technical (Hospital) Services CT Soft Tissue Neck W/Contrast Material PX-3517049100 CDM 70491 CPT 351 RC inpatient 2292 2292 CIGNA 62308 [3081051] CIGNA STATE OF WYOMING [308105107] 1814.81 percent of total billed charges 1421.04 2177.4 Technical (Hospital) Services CT Soft Tissue Neck W/Contrast Material PX-3517049100 CDM 70491 CPT 351 RC inpatient 2292 2292 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES EPO [308136803] 1814.81 percent of total billed charges 1421.04 2177.4 Technical (Hospital) Services CT Soft Tissue Neck W/Contrast Material PX-3517049100 CDM 70491 CPT 351 RC inpatient 2292 2292 MULTIPLAN INC 34080 [3081285] MULTIPLAN INC [308128501] 2177.4 percent of total billed charges 1421.04 2177.4 Technical (Hospital) Services CT Soft Tissue Neck W/Contrast Material PX-3517049100 CDM 70491 CPT 351 RC inpatient 2292 2292 BLUE CROSS BLUE SHIELD WELLMARK SB889 [3081026] BCBS WYOMING [308102603] 2177.4 percent of total billed charges 1421.04 2177.4 Technical (Hospital) Services CT Soft Tissue Neck W/Contrast Material PX-3517049100 CDM 70491 CPT 351 RC inpatient 2292 2292 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES PPO [308136801] 1814.81 percent of total billed charges 1421.04 2177.4 Technical (Hospital) Services CT Soft Tissue Neck W/Contrast Material PX-3517049100 CDM 70491 CPT 351 RC inpatient 2292 2292 UNITED HEALTHCARE (COMMERCIAL) [3081199] UNITED HEALTHCARE 87726 [308119901] 1421.04 percent of total billed charges 1421.04 2177.4 Technical (Hospital) Services CT Soft Tissue Neck W/Contrast Material PX-3517049100 CDM 70491 CPT 351 RC inpatient 2292 2292 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES HDHP [308136802] 1814.81 percent of total billed charges 1421.04 2177.4 Technical (Hospital) Services CT Soft Tissue Neck W/Contrast Material PX-3517049100 CDM 70491 CPT 351 RC inpatient 2292 2292 MEDICA (COMMERCIAL) 94265 [3081118] MEDICA CLAIMS [308111801] 2062.8 percent of total billed charges 1421.04 2177.4 Technical (Hospital) Services CT Soft Tissue Neck W/Contrast Material PX-3517049100 CDM 70491 CPT 351 RC inpatient 2292 2292 HEALTHPARTNERS SX009 HEALTHPARTNERS 1814.81 percent of total billed charges 1421.04 2177.4 Technical (Hospital) Services CT Soft Tissue Neck W/O Contrast Material PX-3517049000 CDM 70490 CPT 351 RC outpatient 1638 1638 MULTIPLAN INC 34080 [3081285] MULTIPLAN INC [308128501] 1556.1 percent of total billed charges 1015.56 1556.1 Technical (Hospital) Services CT Soft Tissue Neck W/O Contrast Material PX-3517049000 CDM 70490 CPT 351 RC outpatient 1638 1638 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES HDHP [308136802] 1310.4 percent of total billed charges 1015.56 1556.1 Technical (Hospital) Services CT Soft Tissue Neck W/O Contrast Material PX-3517049000 CDM 70490 CPT 351 RC outpatient 1638 1638 BLUE CROSS BLUE SHIELD WELLMARK SB889 [3081026] BCBS WYOMING [308102603] 1556.1 percent of total billed charges 1015.56 1556.1 Technical (Hospital) Services CT Soft Tissue Neck W/O Contrast Material PX-3517049000 CDM 70490 CPT 351 RC outpatient 1638 1638 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES EPO [308136803] 1310.4 percent of total billed charges 1015.56 1556.1 Technical (Hospital) Services CT Soft Tissue Neck W/O Contrast Material PX-3517049000 CDM 70490 CPT 351 RC outpatient 1638 1638 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES PPO [308136801] 1310.4 percent of total billed charges 1015.56 1556.1 Technical (Hospital) Services CT Soft Tissue Neck W/O Contrast Material PX-3517049000 CDM 70490 CPT 351 RC outpatient 1638 1638 UNITED HEALTHCARE (COMMERCIAL) [3081199] UNITED HEALTHCARE 87726 [308119901] 1015.56 percent of total billed charges 1015.56 1556.1 Technical (Hospital) Services CT Soft Tissue Neck W/O Contrast Material PX-3517049000 CDM 70490 CPT 351 RC outpatient 1638 1638 HEALTHPARTNERS SX009 HEALTHPARTNERS 1310.4 percent of total billed charges 1015.56 1556.1 Technical (Hospital) Services CT Soft Tissue Neck W/O Contrast Material PX-3517049000 CDM 70490 CPT 351 RC outpatient 1638 1638 MEDICA (COMMERCIAL) 94265 [3081118] MEDICA CLAIMS [308111801] 1474.2 percent of total billed charges 1015.56 1556.1 Technical (Hospital) Services CT Soft Tissue Neck W/O Contrast Material PX-3517049000 CDM 70490 CPT 351 RC outpatient 1638 1638 CIGNA 62308 [3081051] CIGNA 62308 [308105105] 1310.4 percent of total billed charges 1015.56 1556.1 Technical (Hospital) Services CT Soft Tissue Neck W/O Contrast Material PX-3517049000 CDM 70490 CPT 351 RC outpatient 1638 1638 CIGNA 62308 [3081051] CIGNA STATE OF WYOMING [308105107] 1310.4 percent of total billed charges 1015.56 1556.1 Technical (Hospital) Services CT Soft Tissue Neck W/O Contrast Material PX-3517049000 CDM 70490 CPT 351 RC inpatient 1638 1638 BLUE CROSS BLUE SHIELD WELLMARK SB889 [3081026] BCBS WYOMING [308102603] 1556.1 percent of total billed charges 1015.56 1556.1 Technical (Hospital) Services CT Soft Tissue Neck W/O Contrast Material PX-3517049000 CDM 70490 CPT 351 RC inpatient 1638 1638 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES PPO [308136801] 1296.97 percent of total billed charges 1015.56 1556.1 Technical (Hospital) Services CT Soft Tissue Neck W/O Contrast Material PX-3517049000 CDM 70490 CPT 351 RC inpatient 1638 1638 UNITED HEALTHCARE (COMMERCIAL) [3081199] UNITED HEALTHCARE 87726 [308119901] 1015.56 percent of total billed charges 1015.56 1556.1 Technical (Hospital) Services CT Soft Tissue Neck W/O Contrast Material PX-3517049000 CDM 70490 CPT 351 RC inpatient 1638 1638 MULTIPLAN INC 34080 [3081285] MULTIPLAN INC [308128501] 1556.1 percent of total billed charges 1015.56 1556.1 Technical (Hospital) Services CT Soft Tissue Neck W/O Contrast Material PX-3517049000 CDM 70490 CPT 351 RC inpatient 1638 1638 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES HDHP [308136802] 1296.97 percent of total billed charges 1015.56 1556.1 Technical (Hospital) Services CT Soft Tissue Neck W/O Contrast Material PX-3517049000 CDM 70490 CPT 351 RC inpatient 1638 1638 MEDICA (COMMERCIAL) 94265 [3081118] MEDICA CLAIMS [308111801] 1474.2 percent of total billed charges 1015.56 1556.1 Technical (Hospital) Services CT Soft Tissue Neck W/O Contrast Material PX-3517049000 CDM 70490 CPT 351 RC inpatient 1638 1638 HEALTHPARTNERS SX009 HEALTHPARTNERS 1296.97 percent of total billed charges 1015.56 1556.1 Technical (Hospital) Services CT Soft Tissue Neck W/O Contrast Material PX-3517049000 CDM 70490 CPT 351 RC inpatient 1638 1638 CIGNA 62308 [3081051] CIGNA 62308 [308105105] 1296.97 percent of total billed charges 1015.56 1556.1 Technical (Hospital) Services CT Soft Tissue Neck W/O Contrast Material PX-3517049000 CDM 70490 CPT 351 RC inpatient 1638 1638 CIGNA 62308 [3081051] CIGNA STATE OF WYOMING [308105107] 1296.97 percent of total billed charges 1015.56 1556.1 Technical (Hospital) Services CT Soft Tissue Neck W/O Contrast Material PX-3517049000 CDM 70490 CPT 351 RC inpatient 1638 1638 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES EPO [308136803] 1296.97 percent of total billed charges 1015.56 1556.1 Technical (Hospital) Services CT Maxillofacial W/O & W/Contrast Material PX-3517048800 CDM 70488 CPT 351 RC outpatient 2620 2620 UNITED HEALTHCARE (COMMERCIAL) [3081199] UNITED HEALTHCARE 87726 [308119901] 1624.4 percent of total billed charges 1624.4 2489 Technical (Hospital) Services CT Maxillofacial W/O & W/Contrast Material PX-3517048800 CDM 70488 CPT 351 RC outpatient 2620 2620 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES PPO [308136801] 2096 percent of total billed charges 1624.4 2489 Technical (Hospital) Services CT Maxillofacial W/O & W/Contrast Material PX-3517048800 CDM 70488 CPT 351 RC outpatient 2620 2620 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES EPO [308136803] 2096 percent of total billed charges 1624.4 2489 Technical (Hospital) Services CT Maxillofacial W/O & W/Contrast Material PX-3517048800 CDM 70488 CPT 351 RC outpatient 2620 2620 BLUE CROSS BLUE SHIELD WELLMARK SB889 [3081026] BCBS WYOMING [308102603] 2489 percent of total billed charges 1624.4 2489 Technical (Hospital) Services CT Maxillofacial W/O & W/Contrast Material PX-3517048800 CDM 70488 CPT 351 RC outpatient 2620 2620 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES HDHP [308136802] 2096 percent of total billed charges 1624.4 2489 Technical (Hospital) Services CT Maxillofacial W/O & W/Contrast Material PX-3517048800 CDM 70488 CPT 351 RC outpatient 2620 2620 MULTIPLAN INC 34080 [3081285] MULTIPLAN INC [308128501] 2489 percent of total billed charges 1624.4 2489 Technical (Hospital) Services CT Maxillofacial W/O & W/Contrast Material PX-3517048800 CDM 70488 CPT 351 RC outpatient 2620 2620 HEALTHPARTNERS SX009 HEALTHPARTNERS 2096 percent of total billed charges 1624.4 2489 Technical (Hospital) Services CT Maxillofacial W/O & W/Contrast Material PX-3517048800 CDM 70488 CPT 351 RC outpatient 2620 2620 MEDICA (COMMERCIAL) 94265 [3081118] MEDICA CLAIMS [308111801] 2358 percent of total billed charges 1624.4 2489 Technical (Hospital) Services CT Maxillofacial W/O & W/Contrast Material PX-3517048800 CDM 70488 CPT 351 RC outpatient 2620 2620 CIGNA 62308 [3081051] CIGNA 62308 [308105105] 2096 percent of total billed charges 1624.4 2489 Technical (Hospital) Services CT Maxillofacial W/O & W/Contrast Material PX-3517048800 CDM 70488 CPT 351 RC outpatient 2620 2620 CIGNA 62308 [3081051] CIGNA STATE OF WYOMING [308105107] 2096 percent of total billed charges 1624.4 2489 Technical (Hospital) Services CT Maxillofacial W/O & W/Contrast Material PX-3517048800 CDM 70488 CPT 351 RC inpatient 2620 2620 HEALTHPARTNERS SX009 HEALTHPARTNERS 2074.52 percent of total billed charges 1624.4 2489 Technical (Hospital) Services CT Maxillofacial W/O & W/Contrast Material PX-3517048800 CDM 70488 CPT 351 RC inpatient 2620 2620 MEDICA (COMMERCIAL) 94265 [3081118] MEDICA CLAIMS [308111801] 2358 percent of total billed charges 1624.4 2489 Technical (Hospital) Services CT Maxillofacial W/O & W/Contrast Material PX-3517048800 CDM 70488 CPT 351 RC inpatient 2620 2620 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES HDHP [308136802] 2074.52 percent of total billed charges 1624.4 2489 Technical (Hospital) Services CT Maxillofacial W/O & W/Contrast Material PX-3517048800 CDM 70488 CPT 351 RC inpatient 2620 2620 UNITED HEALTHCARE (COMMERCIAL) [3081199] UNITED HEALTHCARE 87726 [308119901] 1624.4 percent of total billed charges 1624.4 2489 Technical (Hospital) Services CT Maxillofacial W/O & W/Contrast Material PX-3517048800 CDM 70488 CPT 351 RC inpatient 2620 2620 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES PPO [308136801] 2074.52 percent of total billed charges 1624.4 2489 Technical (Hospital) Services CT Maxillofacial W/O & W/Contrast Material PX-3517048800 CDM 70488 CPT 351 RC inpatient 2620 2620 BLUE CROSS BLUE SHIELD WELLMARK SB889 [3081026] BCBS WYOMING [308102603] 2489 percent of total billed charges 1624.4 2489 Technical (Hospital) Services CT Maxillofacial W/O & W/Contrast Material PX-3517048800 CDM 70488 CPT 351 RC inpatient 2620 2620 MULTIPLAN INC 34080 [3081285] MULTIPLAN INC [308128501] 2489 percent of total billed charges 1624.4 2489 Technical (Hospital) Services CT Maxillofacial W/O & W/Contrast Material PX-3517048800 CDM 70488 CPT 351 RC inpatient 2620 2620 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES EPO [308136803] 2074.52 percent of total billed charges 1624.4 2489 Technical (Hospital) Services CT Maxillofacial W/O & W/Contrast Material PX-3517048800 CDM 70488 CPT 351 RC inpatient 2620 2620 CIGNA 62308 [3081051] CIGNA 62308 [308105105] 2074.52 percent of total billed charges 1624.4 2489 Technical (Hospital) Services CT Maxillofacial W/O & W/Contrast Material PX-3517048800 CDM 70488 CPT 351 RC inpatient 2620 2620 CIGNA 62308 [3081051] CIGNA STATE OF WYOMING [308105107] 2074.52 percent of total billed charges 1624.4 2489 Technical (Hospital) Services CT Maxillofacial W/Contrast Material PX-3517048700 CDM 70487 CPT 351 RC inpatient 2292 2292 CIGNA 62308 [3081051] CIGNA 62308 [308105105] 1814.81 percent of total billed charges 1421.04 2177.4 Technical (Hospital) Services CT Maxillofacial W/Contrast Material PX-3517048700 CDM 70487 CPT 351 RC inpatient 2292 2292 CIGNA 62308 [3081051] CIGNA STATE OF WYOMING [308105107] 1814.81 percent of total billed charges 1421.04 2177.4 Technical (Hospital) Services CT Maxillofacial W/Contrast Material PX-3517048700 CDM 70487 CPT 351 RC inpatient 2292 2292 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES EPO [308136803] 1814.81 percent of total billed charges 1421.04 2177.4 Technical (Hospital) Services CT Maxillofacial W/Contrast Material PX-3517048700 CDM 70487 CPT 351 RC inpatient 2292 2292 MULTIPLAN INC 34080 [3081285] MULTIPLAN INC [308128501] 2177.4 percent of total billed charges 1421.04 2177.4 Technical (Hospital) Services CT Maxillofacial W/Contrast Material PX-3517048700 CDM 70487 CPT 351 RC inpatient 2292 2292 BLUE CROSS BLUE SHIELD WELLMARK SB889 [3081026] BCBS WYOMING [308102603] 2177.4 percent of total billed charges 1421.04 2177.4 Technical (Hospital) Services CT Maxillofacial W/Contrast Material PX-3517048700 CDM 70487 CPT 351 RC inpatient 2292 2292 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES PPO [308136801] 1814.81 percent of total billed charges 1421.04 2177.4 Technical (Hospital) Services CT Maxillofacial W/Contrast Material PX-3517048700 CDM 70487 CPT 351 RC inpatient 2292 2292 UNITED HEALTHCARE (COMMERCIAL) [3081199] UNITED HEALTHCARE 87726 [308119901] 1421.04 percent of total billed charges 1421.04 2177.4 Technical (Hospital) Services CT Maxillofacial W/Contrast Material PX-3517048700 CDM 70487 CPT 351 RC inpatient 2292 2292 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES HDHP [308136802] 1814.81 percent of total billed charges 1421.04 2177.4 Technical (Hospital) Services CT Maxillofacial W/Contrast Material PX-3517048700 CDM 70487 CPT 351 RC inpatient 2292 2292 MEDICA (COMMERCIAL) 94265 [3081118] MEDICA CLAIMS [308111801] 2062.8 percent of total billed charges 1421.04 2177.4 Technical (Hospital) Services CT Maxillofacial W/Contrast Material PX-3517048700 CDM 70487 CPT 351 RC inpatient 2292 2292 HEALTHPARTNERS SX009 HEALTHPARTNERS 1814.81 percent of total billed charges 1421.04 2177.4 Technical (Hospital) Services CT Maxillofacial W/Contrast Material PX-3517048700 CDM 70487 CPT 351 RC outpatient 2292 2292 CIGNA 62308 [3081051] CIGNA 62308 [308105105] 1833.6 percent of total billed charges 1421.04 2177.4 Technical (Hospital) Services CT Maxillofacial W/Contrast Material PX-3517048700 CDM 70487 CPT 351 RC outpatient 2292 2292 CIGNA 62308 [3081051] CIGNA STATE OF WYOMING [308105107] 1833.6 percent of total billed charges 1421.04 2177.4 Technical (Hospital) Services CT Maxillofacial W/Contrast Material PX-3517048700 CDM 70487 CPT 351 RC outpatient 2292 2292 MEDICA (COMMERCIAL) 94265 [3081118] MEDICA CLAIMS [308111801] 2062.8 percent of total billed charges 1421.04 2177.4 Technical (Hospital) Services CT Maxillofacial W/Contrast Material PX-3517048700 CDM 70487 CPT 351 RC outpatient 2292 2292 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES PPO [308136801] 1833.6 percent of total billed charges 1421.04 2177.4 Technical (Hospital) Services CT Maxillofacial W/Contrast Material PX-3517048700 CDM 70487 CPT 351 RC outpatient 2292 2292 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES EPO [308136803] 1833.6 percent of total billed charges 1421.04 2177.4 Technical (Hospital) Services CT Maxillofacial W/Contrast Material PX-3517048700 CDM 70487 CPT 351 RC outpatient 2292 2292 MULTIPLAN INC 34080 [3081285] MULTIPLAN INC [308128501] 2177.4 percent of total billed charges 1421.04 2177.4 Technical (Hospital) Services CT Maxillofacial W/Contrast Material PX-3517048700 CDM 70487 CPT 351 RC outpatient 2292 2292 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES HDHP [308136802] 1833.6 percent of total billed charges 1421.04 2177.4 Technical (Hospital) Services CT Maxillofacial W/Contrast Material PX-3517048700 CDM 70487 CPT 351 RC outpatient 2292 2292 BLUE CROSS BLUE SHIELD WELLMARK SB889 [3081026] BCBS WYOMING [308102603] 2177.4 percent of total billed charges 1421.04 2177.4 Technical (Hospital) Services CT Maxillofacial W/Contrast Material PX-3517048700 CDM 70487 CPT 351 RC outpatient 2292 2292 UNITED HEALTHCARE (COMMERCIAL) [3081199] UNITED HEALTHCARE 87726 [308119901] 1421.04 percent of total billed charges 1421.04 2177.4 Technical (Hospital) Services CT Maxillofacial W/Contrast Material PX-3517048700 CDM 70487 CPT 351 RC outpatient 2292 2292 HEALTHPARTNERS SX009 HEALTHPARTNERS 1833.6 percent of total billed charges 1421.04 2177.4 Technical (Hospital) Services CT Maxillofacial W/O Contrast Material PX-3517048600 CDM 70486 CPT 351 RC inpatient 1638 1638 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES EPO [308136803] 1296.97 percent of total billed charges 1015.56 1556.1 Technical (Hospital) Services CT Maxillofacial W/O Contrast Material PX-3517048600 CDM 70486 CPT 351 RC inpatient 1638 1638 CIGNA 62308 [3081051] CIGNA 62308 [308105105] 1296.97 percent of total billed charges 1015.56 1556.1 Technical (Hospital) Services CT Maxillofacial W/O Contrast Material PX-3517048600 CDM 70486 CPT 351 RC inpatient 1638 1638 CIGNA 62308 [3081051] CIGNA STATE OF WYOMING [308105107] 1296.97 percent of total billed charges 1015.56 1556.1 Technical (Hospital) Services CT Maxillofacial W/O Contrast Material PX-3517048600 CDM 70486 CPT 351 RC inpatient 1638 1638 HEALTHPARTNERS SX009 HEALTHPARTNERS 1296.97 percent of total billed charges 1015.56 1556.1 Technical (Hospital) Services CT Maxillofacial W/O Contrast Material PX-3517048600 CDM 70486 CPT 351 RC inpatient 1638 1638 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES HDHP [308136802] 1296.97 percent of total billed charges 1015.56 1556.1 Technical (Hospital) Services CT Maxillofacial W/O Contrast Material PX-3517048600 CDM 70486 CPT 351 RC inpatient 1638 1638 MEDICA (COMMERCIAL) 94265 [3081118] MEDICA CLAIMS [308111801] 1474.2 percent of total billed charges 1015.56 1556.1 Technical (Hospital) Services CT Maxillofacial W/O Contrast Material PX-3517048600 CDM 70486 CPT 351 RC inpatient 1638 1638 BLUE CROSS BLUE SHIELD WELLMARK SB889 [3081026] BCBS WYOMING [308102603] 1556.1 percent of total billed charges 1015.56 1556.1 Technical (Hospital) Services CT Maxillofacial W/O Contrast Material PX-3517048600 CDM 70486 CPT 351 RC inpatient 1638 1638 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES PPO [308136801] 1296.97 percent of total billed charges 1015.56 1556.1 Technical (Hospital) Services CT Maxillofacial W/O Contrast Material PX-3517048600 CDM 70486 CPT 351 RC inpatient 1638 1638 UNITED HEALTHCARE (COMMERCIAL) [3081199] UNITED HEALTHCARE 87726 [308119901] 1015.56 percent of total billed charges 1015.56 1556.1 Technical (Hospital) Services CT Maxillofacial W/O Contrast Material PX-3517048600 CDM 70486 CPT 351 RC inpatient 1638 1638 MULTIPLAN INC 34080 [3081285] MULTIPLAN INC [308128501] 1556.1 percent of total billed charges 1015.56 1556.1 Technical (Hospital) Services CT Maxillofacial W/O Contrast Material PX-3517048600 CDM 70486 CPT 351 RC outpatient 1638 1638 HEALTHPARTNERS SX009 HEALTHPARTNERS 1310.4 percent of total billed charges 1015.56 1556.1 Technical (Hospital) Services CT Maxillofacial W/O Contrast Material PX-3517048600 CDM 70486 CPT 351 RC outpatient 1638 1638 UNITED HEALTHCARE (COMMERCIAL) [3081199] UNITED HEALTHCARE 87726 [308119901] 1015.56 percent of total billed charges 1015.56 1556.1 Technical (Hospital) Services CT Maxillofacial W/O Contrast Material PX-3517048600 CDM 70486 CPT 351 RC outpatient 1638 1638 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES EPO [308136803] 1310.4 percent of total billed charges 1015.56 1556.1 Technical (Hospital) Services CT Maxillofacial W/O Contrast Material PX-3517048600 CDM 70486 CPT 351 RC outpatient 1638 1638 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES PPO [308136801] 1310.4 percent of total billed charges 1015.56 1556.1 Technical (Hospital) Services CT Maxillofacial W/O Contrast Material PX-3517048600 CDM 70486 CPT 351 RC outpatient 1638 1638 BLUE CROSS BLUE SHIELD WELLMARK SB889 [3081026] BCBS WYOMING [308102603] 1556.1 percent of total billed charges 1015.56 1556.1 Technical (Hospital) Services CT Maxillofacial W/O Contrast Material PX-3517048600 CDM 70486 CPT 351 RC outpatient 1638 1638 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES HDHP [308136802] 1310.4 percent of total billed charges 1015.56 1556.1 Technical (Hospital) Services CT Maxillofacial W/O Contrast Material PX-3517048600 CDM 70486 CPT 351 RC outpatient 1638 1638 MULTIPLAN INC 34080 [3081285] MULTIPLAN INC [308128501] 1556.1 percent of total billed charges 1015.56 1556.1 Technical (Hospital) Services CT Maxillofacial W/O Contrast Material PX-3517048600 CDM 70486 CPT 351 RC outpatient 1638 1638 MEDICA (COMMERCIAL) 94265 [3081118] MEDICA CLAIMS [308111801] 1474.2 percent of total billed charges 1015.56 1556.1 Technical (Hospital) Services CT Maxillofacial W/O Contrast Material PX-3517048600 CDM 70486 CPT 351 RC outpatient 1638 1638 CIGNA 62308 [3081051] CIGNA 62308 [308105105] 1310.4 percent of total billed charges 1015.56 1556.1 Technical (Hospital) Services CT Maxillofacial W/O Contrast Material PX-3517048600 CDM 70486 CPT 351 RC outpatient 1638 1638 CIGNA 62308 [3081051] CIGNA STATE OF WYOMING [308105107] 1310.4 percent of total billed charges 1015.56 1556.1 Technical (Hospital) Services CT Orbit Sella/Post Fossa/Ear W/O & W/Contr Matr PX-3517048200 CDM 70482 CPT 351 RC inpatient 2292 2292 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES EPO [308136803] 1814.81 percent of total billed charges 1421.04 2177.4 Technical (Hospital) Services CT Orbit Sella/Post Fossa/Ear W/O & W/Contr Matr PX-3517048200 CDM 70482 CPT 351 RC inpatient 2292 2292 CIGNA 62308 [3081051] CIGNA 62308 [308105105] 1814.81 percent of total billed charges 1421.04 2177.4 Technical (Hospital) Services CT Orbit Sella/Post Fossa/Ear W/O & W/Contr Matr PX-3517048200 CDM 70482 CPT 351 RC inpatient 2292 2292 CIGNA 62308 [3081051] CIGNA STATE OF WYOMING [308105107] 1814.81 percent of total billed charges 1421.04 2177.4 Technical (Hospital) Services CT Orbit Sella/Post Fossa/Ear W/O & W/Contr Matr PX-3517048200 CDM 70482 CPT 351 RC inpatient 2292 2292 UNITED HEALTHCARE (COMMERCIAL) [3081199] UNITED HEALTHCARE 87726 [308119901] 1421.04 percent of total billed charges 1421.04 2177.4 Technical (Hospital) Services CT Orbit Sella/Post Fossa/Ear W/O & W/Contr Matr PX-3517048200 CDM 70482 CPT 351 RC inpatient 2292 2292 MULTIPLAN INC 34080 [3081285] MULTIPLAN INC [308128501] 2177.4 percent of total billed charges 1421.04 2177.4 Technical (Hospital) Services CT Orbit Sella/Post Fossa/Ear W/O & W/Contr Matr PX-3517048200 CDM 70482 CPT 351 RC inpatient 2292 2292 BLUE CROSS BLUE SHIELD WELLMARK SB889 [3081026] BCBS WYOMING [308102603] 2177.4 percent of total billed charges 1421.04 2177.4 Technical (Hospital) Services CT Orbit Sella/Post Fossa/Ear W/O & W/Contr Matr PX-3517048200 CDM 70482 CPT 351 RC inpatient 2292 2292 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES PPO [308136801] 1814.81 percent of total billed charges 1421.04 2177.4 Technical (Hospital) Services CT Orbit Sella/Post Fossa/Ear W/O & W/Contr Matr PX-3517048200 CDM 70482 CPT 351 RC inpatient 2292 2292 HEALTHPARTNERS SX009 HEALTHPARTNERS 1814.81 percent of total billed charges 1421.04 2177.4 Technical (Hospital) Services CT Orbit Sella/Post Fossa/Ear W/O & W/Contr Matr PX-3517048200 CDM 70482 CPT 351 RC inpatient 2292 2292 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES HDHP [308136802] 1814.81 percent of total billed charges 1421.04 2177.4 Technical (Hospital) Services CT Orbit Sella/Post Fossa/Ear W/O & W/Contr Matr PX-3517048200 CDM 70482 CPT 351 RC inpatient 2292 2292 MEDICA (COMMERCIAL) 94265 [3081118] MEDICA CLAIMS [308111801] 2062.8 percent of total billed charges 1421.04 2177.4 Technical (Hospital) Services CT Orbit Sella/Post Fossa/Ear W/O & W/Contr Matr PX-3517048200 CDM 70482 CPT 351 RC outpatient 2292 2292 CIGNA 62308 [3081051] CIGNA 62308 [308105105] 1833.6 percent of total billed charges 1421.04 2177.4 Technical (Hospital) Services CT Orbit Sella/Post Fossa/Ear W/O & W/Contr Matr PX-3517048200 CDM 70482 CPT 351 RC outpatient 2292 2292 CIGNA 62308 [3081051] CIGNA STATE OF WYOMING [308105107] 1833.6 percent of total billed charges 1421.04 2177.4 Technical (Hospital) Services CT Orbit Sella/Post Fossa/Ear W/O & W/Contr Matr PX-3517048200 CDM 70482 CPT 351 RC outpatient 2292 2292 MEDICA (COMMERCIAL) 94265 [3081118] MEDICA CLAIMS [308111801] 2062.8 percent of total billed charges 1421.04 2177.4 Technical (Hospital) Services CT Orbit Sella/Post Fossa/Ear W/O & W/Contr Matr PX-3517048200 CDM 70482 CPT 351 RC outpatient 2292 2292 MULTIPLAN INC 34080 [3081285] MULTIPLAN INC [308128501] 2177.4 percent of total billed charges 1421.04 2177.4 Technical (Hospital) Services CT Orbit Sella/Post Fossa/Ear W/O & W/Contr Matr PX-3517048200 CDM 70482 CPT 351 RC outpatient 2292 2292 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES HDHP [308136802] 1833.6 percent of total billed charges 1421.04 2177.4 Technical (Hospital) Services CT Orbit Sella/Post Fossa/Ear W/O & W/Contr Matr PX-3517048200 CDM 70482 CPT 351 RC outpatient 2292 2292 BLUE CROSS BLUE SHIELD WELLMARK SB889 [3081026] BCBS WYOMING [308102603] 2177.4 percent of total billed charges 1421.04 2177.4 Technical (Hospital) Services CT Orbit Sella/Post Fossa/Ear W/O & W/Contr Matr PX-3517048200 CDM 70482 CPT 351 RC outpatient 2292 2292 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES PPO [308136801] 1833.6 percent of total billed charges 1421.04 2177.4 Technical (Hospital) Services CT Orbit Sella/Post Fossa/Ear W/O & W/Contr Matr PX-3517048200 CDM 70482 CPT 351 RC outpatient 2292 2292 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES EPO [308136803] 1833.6 percent of total billed charges 1421.04 2177.4 Technical (Hospital) Services CT Orbit Sella/Post Fossa/Ear W/O & W/Contr Matr PX-3517048200 CDM 70482 CPT 351 RC outpatient 2292 2292 UNITED HEALTHCARE (COMMERCIAL) [3081199] UNITED HEALTHCARE 87726 [308119901] 1421.04 percent of total billed charges 1421.04 2177.4 Technical (Hospital) Services CT Orbit Sella/Post Fossa/Ear W/O & W/Contr Matr PX-3517048200 CDM 70482 CPT 351 RC outpatient 2292 2292 HEALTHPARTNERS SX009 HEALTHPARTNERS 1833.6 percent of total billed charges 1421.04 2177.4 Technical (Hospital) Services CT Orbit Sella/Post Fossa/Ear W/Contrast Matrl PX-3517048100 CDM 70481 CPT 351 RC inpatient 2292 2292 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES EPO [308136803] 1814.81 percent of total billed charges 1421.04 2177.4 Technical (Hospital) Services CT Orbit Sella/Post Fossa/Ear W/Contrast Matrl PX-3517048100 CDM 70481 CPT 351 RC inpatient 2292 2292 CIGNA 62308 [3081051] CIGNA 62308 [308105105] 1814.81 percent of total billed charges 1421.04 2177.4 Technical (Hospital) Services CT Orbit Sella/Post Fossa/Ear W/Contrast Matrl PX-3517048100 CDM 70481 CPT 351 RC inpatient 2292 2292 CIGNA 62308 [3081051] CIGNA STATE OF WYOMING [308105107] 1814.81 percent of total billed charges 1421.04 2177.4 Technical (Hospital) Services CT Orbit Sella/Post Fossa/Ear W/Contrast Matrl PX-3517048100 CDM 70481 CPT 351 RC inpatient 2292 2292 UNITED HEALTHCARE (COMMERCIAL) [3081199] UNITED HEALTHCARE 87726 [308119901] 1421.04 percent of total billed charges 1421.04 2177.4 Technical (Hospital) Services CT Orbit Sella/Post Fossa/Ear W/Contrast Matrl PX-3517048100 CDM 70481 CPT 351 RC inpatient 2292 2292 MULTIPLAN INC 34080 [3081285] MULTIPLAN INC [308128501] 2177.4 percent of total billed charges 1421.04 2177.4 Technical (Hospital) Services CT Orbit Sella/Post Fossa/Ear W/Contrast Matrl PX-3517048100 CDM 70481 CPT 351 RC inpatient 2292 2292 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES PPO [308136801] 1814.81 percent of total billed charges 1421.04 2177.4 Technical (Hospital) Services CT Orbit Sella/Post Fossa/Ear W/Contrast Matrl PX-3517048100 CDM 70481 CPT 351 RC inpatient 2292 2292 BLUE CROSS BLUE SHIELD WELLMARK SB889 [3081026] BCBS WYOMING [308102603] 2177.4 percent of total billed charges 1421.04 2177.4 Technical (Hospital) Services CT Orbit Sella/Post Fossa/Ear W/Contrast Matrl PX-3517048100 CDM 70481 CPT 351 RC inpatient 2292 2292 HEALTHPARTNERS SX009 HEALTHPARTNERS 1814.81 percent of total billed charges 1421.04 2177.4 Technical (Hospital) Services CT Orbit Sella/Post Fossa/Ear W/Contrast Matrl PX-3517048100 CDM 70481 CPT 351 RC inpatient 2292 2292 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES HDHP [308136802] 1814.81 percent of total billed charges 1421.04 2177.4 Technical (Hospital) Services CT Orbit Sella/Post Fossa/Ear W/Contrast Matrl PX-3517048100 CDM 70481 CPT 351 RC inpatient 2292 2292 MEDICA (COMMERCIAL) 94265 [3081118] MEDICA CLAIMS [308111801] 2062.8 percent of total billed charges 1421.04 2177.4 Technical (Hospital) Services CT Orbit Sella/Post Fossa/Ear W/Contrast Matrl PX-3517048100 CDM 70481 CPT 351 RC outpatient 2292 2292 UNITED HEALTHCARE (COMMERCIAL) [3081199] UNITED HEALTHCARE 87726 [308119901] 1421.04 percent of total billed charges 1421.04 2177.4 Technical (Hospital) Services CT Orbit Sella/Post Fossa/Ear W/Contrast Matrl PX-3517048100 CDM 70481 CPT 351 RC outpatient 2292 2292 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES EPO [308136803] 1833.6 percent of total billed charges 1421.04 2177.4 Technical (Hospital) Services CT Orbit Sella/Post Fossa/Ear W/Contrast Matrl PX-3517048100 CDM 70481 CPT 351 RC outpatient 2292 2292 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES PPO [308136801] 1833.6 percent of total billed charges 1421.04 2177.4 Technical (Hospital) Services CT Orbit Sella/Post Fossa/Ear W/Contrast Matrl PX-3517048100 CDM 70481 CPT 351 RC outpatient 2292 2292 BLUE CROSS BLUE SHIELD WELLMARK SB889 [3081026] BCBS WYOMING [308102603] 2177.4 percent of total billed charges 1421.04 2177.4 Technical (Hospital) Services CT Orbit Sella/Post Fossa/Ear W/Contrast Matrl PX-3517048100 CDM 70481 CPT 351 RC outpatient 2292 2292 MULTIPLAN INC 34080 [3081285] MULTIPLAN INC [308128501] 2177.4 percent of total billed charges 1421.04 2177.4 Technical (Hospital) Services CT Orbit Sella/Post Fossa/Ear W/Contrast Matrl PX-3517048100 CDM 70481 CPT 351 RC outpatient 2292 2292 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES HDHP [308136802] 1833.6 percent of total billed charges 1421.04 2177.4 Technical (Hospital) Services CT Orbit Sella/Post Fossa/Ear W/Contrast Matrl PX-3517048100 CDM 70481 CPT 351 RC outpatient 2292 2292 HEALTHPARTNERS SX009 HEALTHPARTNERS 1833.6 percent of total billed charges 1421.04 2177.4 Technical (Hospital) Services CT Orbit Sella/Post Fossa/Ear W/Contrast Matrl PX-3517048100 CDM 70481 CPT 351 RC outpatient 2292 2292 MEDICA (COMMERCIAL) 94265 [3081118] MEDICA CLAIMS [308111801] 2062.8 percent of total billed charges 1421.04 2177.4 Technical (Hospital) Services CT Orbit Sella/Post Fossa/Ear W/Contrast Matrl PX-3517048100 CDM 70481 CPT 351 RC outpatient 2292 2292 CIGNA 62308 [3081051] CIGNA 62308 [308105105] 1833.6 percent of total billed charges 1421.04 2177.4 Technical (Hospital) Services CT Orbit Sella/Post Fossa/Ear W/Contrast Matrl PX-3517048100 CDM 70481 CPT 351 RC outpatient 2292 2292 CIGNA 62308 [3081051] CIGNA STATE OF WYOMING [308105107] 1833.6 percent of total billed charges 1421.04 2177.4 Technical (Hospital) Services CT Orbit Sella/Post Fossa/Ear W/O Contrast Matrl PX-3517048000 CDM 70480 CPT 351 RC outpatient 1638 1638 HEALTHPARTNERS SX009 HEALTHPARTNERS 1310.4 percent of total billed charges 1015.56 1556.1 Technical (Hospital) Services CT Orbit Sella/Post Fossa/Ear W/O Contrast Matrl PX-3517048000 CDM 70480 CPT 351 RC outpatient 1638 1638 BLUE CROSS BLUE SHIELD WELLMARK SB889 [3081026] BCBS WYOMING [308102603] 1556.1 percent of total billed charges 1015.56 1556.1 Technical (Hospital) Services CT Orbit Sella/Post Fossa/Ear W/O Contrast Matrl PX-3517048000 CDM 70480 CPT 351 RC outpatient 1638 1638 MULTIPLAN INC 34080 [3081285] MULTIPLAN INC [308128501] 1556.1 percent of total billed charges 1015.56 1556.1 Technical (Hospital) Services CT Orbit Sella/Post Fossa/Ear W/O Contrast Matrl PX-3517048000 CDM 70480 CPT 351 RC outpatient 1638 1638 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES HDHP [308136802] 1310.4 percent of total billed charges 1015.56 1556.1 Technical (Hospital) Services CT Orbit Sella/Post Fossa/Ear W/O Contrast Matrl PX-3517048000 CDM 70480 CPT 351 RC outpatient 1638 1638 UNITED HEALTHCARE (COMMERCIAL) [3081199] UNITED HEALTHCARE 87726 [308119901] 1015.56 percent of total billed charges 1015.56 1556.1 Technical (Hospital) Services CT Orbit Sella/Post Fossa/Ear W/O Contrast Matrl PX-3517048000 CDM 70480 CPT 351 RC outpatient 1638 1638 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES PPO [308136801] 1310.4 percent of total billed charges 1015.56 1556.1 Technical (Hospital) Services CT Orbit Sella/Post Fossa/Ear W/O Contrast Matrl PX-3517048000 CDM 70480 CPT 351 RC outpatient 1638 1638 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES EPO [308136803] 1310.4 percent of total billed charges 1015.56 1556.1 Technical (Hospital) Services CT Orbit Sella/Post Fossa/Ear W/O Contrast Matrl PX-3517048000 CDM 70480 CPT 351 RC outpatient 1638 1638 MEDICA (COMMERCIAL) 94265 [3081118] MEDICA CLAIMS [308111801] 1474.2 percent of total billed charges 1015.56 1556.1 Technical (Hospital) Services CT Orbit Sella/Post Fossa/Ear W/O Contrast Matrl PX-3517048000 CDM 70480 CPT 351 RC outpatient 1638 1638 CIGNA 62308 [3081051] CIGNA 62308 [308105105] 1310.4 percent of total billed charges 1015.56 1556.1 Technical (Hospital) Services CT Orbit Sella/Post Fossa/Ear W/O Contrast Matrl PX-3517048000 CDM 70480 CPT 351 RC outpatient 1638 1638 CIGNA 62308 [3081051] CIGNA STATE OF WYOMING [308105107] 1310.4 percent of total billed charges 1015.56 1556.1 Technical (Hospital) Services CT Orbit Sella/Post Fossa/Ear W/O Contrast Matrl PX-3517048000 CDM 70480 CPT 351 RC inpatient 1638 1638 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES PPO [308136801] 1296.97 percent of total billed charges 1015.56 1556.1 Technical (Hospital) Services CT Orbit Sella/Post Fossa/Ear W/O Contrast Matrl PX-3517048000 CDM 70480 CPT 351 RC inpatient 1638 1638 MULTIPLAN INC 34080 [3081285] MULTIPLAN INC [308128501] 1556.1 percent of total billed charges 1015.56 1556.1 Technical (Hospital) Services CT Orbit Sella/Post Fossa/Ear W/O Contrast Matrl PX-3517048000 CDM 70480 CPT 351 RC inpatient 1638 1638 BLUE CROSS BLUE SHIELD WELLMARK SB889 [3081026] BCBS WYOMING [308102603] 1556.1 percent of total billed charges 1015.56 1556.1 Technical (Hospital) Services CT Orbit Sella/Post Fossa/Ear W/O Contrast Matrl PX-3517048000 CDM 70480 CPT 351 RC inpatient 1638 1638 UNITED HEALTHCARE (COMMERCIAL) [3081199] UNITED HEALTHCARE 87726 [308119901] 1015.56 percent of total billed charges 1015.56 1556.1 Technical (Hospital) Services CT Orbit Sella/Post Fossa/Ear W/O Contrast Matrl PX-3517048000 CDM 70480 CPT 351 RC inpatient 1638 1638 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES HDHP [308136802] 1296.97 percent of total billed charges 1015.56 1556.1 Technical (Hospital) Services CT Orbit Sella/Post Fossa/Ear W/O Contrast Matrl PX-3517048000 CDM 70480 CPT 351 RC inpatient 1638 1638 MEDICA (COMMERCIAL) 94265 [3081118] MEDICA CLAIMS [308111801] 1474.2 percent of total billed charges 1015.56 1556.1 Technical (Hospital) Services CT Orbit Sella/Post Fossa/Ear W/O Contrast Matrl PX-3517048000 CDM 70480 CPT 351 RC inpatient 1638 1638 HEALTHPARTNERS SX009 HEALTHPARTNERS 1296.97 percent of total billed charges 1015.56 1556.1 Technical (Hospital) Services CT Orbit Sella/Post Fossa/Ear W/O Contrast Matrl PX-3517048000 CDM 70480 CPT 351 RC inpatient 1638 1638 CIGNA 62308 [3081051] CIGNA 62308 [308105105] 1296.97 percent of total billed charges 1015.56 1556.1 Technical (Hospital) Services CT Orbit Sella/Post Fossa/Ear W/O Contrast Matrl PX-3517048000 CDM 70480 CPT 351 RC inpatient 1638 1638 CIGNA 62308 [3081051] CIGNA STATE OF WYOMING [308105107] 1296.97 percent of total billed charges 1015.56 1556.1 Technical (Hospital) Services CT Orbit Sella/Post Fossa/Ear W/O Contrast Matrl PX-3517048000 CDM 70480 CPT 351 RC inpatient 1638 1638 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES EPO [308136803] 1296.97 percent of total billed charges 1015.56 1556.1 Technical (Hospital) Services CT Head/Brain W/O & W/Contrast Material PX-3517047000 CDM 70470 CPT 351 RC inpatient 2620 2620 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES EPO [308136803] 2074.52 percent of total billed charges 1624.4 2489 Technical (Hospital) Services CT Head/Brain W/O & W/Contrast Material PX-3517047000 CDM 70470 CPT 351 RC inpatient 2620 2620 CIGNA 62308 [3081051] CIGNA 62308 [308105105] 2074.52 percent of total billed charges 1624.4 2489 Technical (Hospital) Services CT Head/Brain W/O & W/Contrast Material PX-3517047000 CDM 70470 CPT 351 RC inpatient 2620 2620 CIGNA 62308 [3081051] CIGNA STATE OF WYOMING [308105107] 2074.52 percent of total billed charges 1624.4 2489 Technical (Hospital) Services CT Head/Brain W/O & W/Contrast Material PX-3517047000 CDM 70470 CPT 351 RC inpatient 2620 2620 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES HDHP [308136802] 2074.52 percent of total billed charges 1624.4 2489 Technical (Hospital) Services CT Head/Brain W/O & W/Contrast Material PX-3517047000 CDM 70470 CPT 351 RC inpatient 2620 2620 MEDICA (COMMERCIAL) 94265 [3081118] MEDICA CLAIMS [308111801] 2358 percent of total billed charges 1624.4 2489 Technical (Hospital) Services CT Head/Brain W/O & W/Contrast Material PX-3517047000 CDM 70470 CPT 351 RC inpatient 2620 2620 HEALTHPARTNERS SX009 HEALTHPARTNERS 2074.52 percent of total billed charges 1624.4 2489 Technical (Hospital) Services CT Head/Brain W/O & W/Contrast Material PX-3517047000 CDM 70470 CPT 351 RC inpatient 2620 2620 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES PPO [308136801] 2074.52 percent of total billed charges 1624.4 2489 Technical (Hospital) Services CT Head/Brain W/O & W/Contrast Material PX-3517047000 CDM 70470 CPT 351 RC inpatient 2620 2620 MULTIPLAN INC 34080 [3081285] MULTIPLAN INC [308128501] 2489 percent of total billed charges 1624.4 2489 Technical (Hospital) Services CT Head/Brain W/O & W/Contrast Material PX-3517047000 CDM 70470 CPT 351 RC inpatient 2620 2620 BLUE CROSS BLUE SHIELD WELLMARK SB889 [3081026] BCBS WYOMING [308102603] 2489 percent of total billed charges 1624.4 2489 Technical (Hospital) Services CT Head/Brain W/O & W/Contrast Material PX-3517047000 CDM 70470 CPT 351 RC inpatient 2620 2620 UNITED HEALTHCARE (COMMERCIAL) [3081199] UNITED HEALTHCARE 87726 [308119901] 1624.4 percent of total billed charges 1624.4 2489 Technical (Hospital) Services CT Head/Brain W/O & W/Contrast Material PX-3517047000 CDM 70470 CPT 351 RC outpatient 2620 2620 HEALTHPARTNERS SX009 HEALTHPARTNERS 2096 percent of total billed charges 1624.4 2489 Technical (Hospital) Services CT Head/Brain W/O & W/Contrast Material PX-3517047000 CDM 70470 CPT 351 RC outpatient 2620 2620 BLUE CROSS BLUE SHIELD WELLMARK SB889 [3081026] BCBS WYOMING [308102603] 2489 percent of total billed charges 1624.4 2489 Technical (Hospital) Services CT Head/Brain W/O & W/Contrast Material PX-3517047000 CDM 70470 CPT 351 RC outpatient 2620 2620 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES HDHP [308136802] 2096 percent of total billed charges 1624.4 2489 Technical (Hospital) Services CT Head/Brain W/O & W/Contrast Material PX-3517047000 CDM 70470 CPT 351 RC outpatient 2620 2620 MULTIPLAN INC 34080 [3081285] MULTIPLAN INC [308128501] 2489 percent of total billed charges 1624.4 2489 Technical (Hospital) Services CT Head/Brain W/O & W/Contrast Material PX-3517047000 CDM 70470 CPT 351 RC outpatient 2620 2620 UNITED HEALTHCARE (COMMERCIAL) [3081199] UNITED HEALTHCARE 87726 [308119901] 1624.4 percent of total billed charges 1624.4 2489 Technical (Hospital) Services CT Head/Brain W/O & W/Contrast Material PX-3517047000 CDM 70470 CPT 351 RC outpatient 2620 2620 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES PPO [308136801] 2096 percent of total billed charges 1624.4 2489 Technical (Hospital) Services CT Head/Brain W/O & W/Contrast Material PX-3517047000 CDM 70470 CPT 351 RC outpatient 2620 2620 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES EPO [308136803] 2096 percent of total billed charges 1624.4 2489 Technical (Hospital) Services CT Head/Brain W/O & W/Contrast Material PX-3517047000 CDM 70470 CPT 351 RC outpatient 2620 2620 MEDICA (COMMERCIAL) 94265 [3081118] MEDICA CLAIMS [308111801] 2358 percent of total billed charges 1624.4 2489 Technical (Hospital) Services CT Head/Brain W/O & W/Contrast Material PX-3517047000 CDM 70470 CPT 351 RC outpatient 2620 2620 CIGNA 62308 [3081051] CIGNA 62308 [308105105] 2096 percent of total billed charges 1624.4 2489 Technical (Hospital) Services CT Head/Brain W/O & W/Contrast Material PX-3517047000 CDM 70470 CPT 351 RC outpatient 2620 2620 CIGNA 62308 [3081051] CIGNA STATE OF WYOMING [308105107] 2096 percent of total billed charges 1624.4 2489 Technical (Hospital) Services CT Head/Brain W/Contrast Material PX-3517046000 CDM 70460 CPT 351 RC outpatient 2292 2292 HEALTHPARTNERS SX009 HEALTHPARTNERS 1833.6 percent of total billed charges 1421.04 2177.4 Technical (Hospital) Services CT Head/Brain W/Contrast Material PX-3517046000 CDM 70460 CPT 351 RC outpatient 2292 2292 BLUE CROSS BLUE SHIELD WELLMARK SB889 [3081026] BCBS WYOMING [308102603] 2177.4 percent of total billed charges 1421.04 2177.4 Technical (Hospital) Services CT Head/Brain W/Contrast Material PX-3517046000 CDM 70460 CPT 351 RC outpatient 2292 2292 MULTIPLAN INC 34080 [3081285] MULTIPLAN INC [308128501] 2177.4 percent of total billed charges 1421.04 2177.4 Technical (Hospital) Services CT Head/Brain W/Contrast Material PX-3517046000 CDM 70460 CPT 351 RC outpatient 2292 2292 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES HDHP [308136802] 1833.6 percent of total billed charges 1421.04 2177.4 Technical (Hospital) Services CT Head/Brain W/Contrast Material PX-3517046000 CDM 70460 CPT 351 RC outpatient 2292 2292 UNITED HEALTHCARE (COMMERCIAL) [3081199] UNITED HEALTHCARE 87726 [308119901] 1421.04 percent of total billed charges 1421.04 2177.4 Technical (Hospital) Services CT Head/Brain W/Contrast Material PX-3517046000 CDM 70460 CPT 351 RC outpatient 2292 2292 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES EPO [308136803] 1833.6 percent of total billed charges 1421.04 2177.4 Technical (Hospital) Services CT Head/Brain W/Contrast Material PX-3517046000 CDM 70460 CPT 351 RC outpatient 2292 2292 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES PPO [308136801] 1833.6 percent of total billed charges 1421.04 2177.4 Technical (Hospital) Services CT Head/Brain W/Contrast Material PX-3517046000 CDM 70460 CPT 351 RC outpatient 2292 2292 MEDICA (COMMERCIAL) 94265 [3081118] MEDICA CLAIMS [308111801] 2062.8 percent of total billed charges 1421.04 2177.4 Technical (Hospital) Services CT Head/Brain W/Contrast Material PX-3517046000 CDM 70460 CPT 351 RC outpatient 2292 2292 CIGNA 62308 [3081051] CIGNA 62308 [308105105] 1833.6 percent of total billed charges 1421.04 2177.4 Technical (Hospital) Services CT Head/Brain W/Contrast Material PX-3517046000 CDM 70460 CPT 351 RC outpatient 2292 2292 CIGNA 62308 [3081051] CIGNA STATE OF WYOMING [308105107] 1833.6 percent of total billed charges 1421.04 2177.4 Technical (Hospital) Services CT Head/Brain W/Contrast Material PX-3517046000 CDM 70460 CPT 351 RC inpatient 2292 2292 CIGNA 62308 [3081051] CIGNA 62308 [308105105] 1814.81 percent of total billed charges 1421.04 2177.4 Technical (Hospital) Services CT Head/Brain W/Contrast Material PX-3517046000 CDM 70460 CPT 351 RC inpatient 2292 2292 CIGNA 62308 [3081051] CIGNA STATE OF WYOMING [308105107] 1814.81 percent of total billed charges 1421.04 2177.4 Technical (Hospital) Services CT Head/Brain W/Contrast Material PX-3517046000 CDM 70460 CPT 351 RC inpatient 2292 2292 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES EPO [308136803] 1814.81 percent of total billed charges 1421.04 2177.4 Technical (Hospital) Services CT Head/Brain W/Contrast Material PX-3517046000 CDM 70460 CPT 351 RC inpatient 2292 2292 HEALTHPARTNERS SX009 HEALTHPARTNERS 1814.81 percent of total billed charges 1421.04 2177.4 Technical (Hospital) Services CT Head/Brain W/Contrast Material PX-3517046000 CDM 70460 CPT 351 RC inpatient 2292 2292 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES HDHP [308136802] 1814.81 percent of total billed charges 1421.04 2177.4 Technical (Hospital) Services CT Head/Brain W/Contrast Material PX-3517046000 CDM 70460 CPT 351 RC inpatient 2292 2292 MEDICA (COMMERCIAL) 94265 [3081118] MEDICA CLAIMS [308111801] 2062.8 percent of total billed charges 1421.04 2177.4 Technical (Hospital) Services CT Head/Brain W/Contrast Material PX-3517046000 CDM 70460 CPT 351 RC inpatient 2292 2292 BLUE CROSS BLUE SHIELD WELLMARK SB889 [3081026] BCBS WYOMING [308102603] 2177.4 percent of total billed charges 1421.04 2177.4 Technical (Hospital) Services CT Head/Brain W/Contrast Material PX-3517046000 CDM 70460 CPT 351 RC inpatient 2292 2292 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES PPO [308136801] 1814.81 percent of total billed charges 1421.04 2177.4 Technical (Hospital) Services CT Head/Brain W/Contrast Material PX-3517046000 CDM 70460 CPT 351 RC inpatient 2292 2292 MULTIPLAN INC 34080 [3081285] MULTIPLAN INC [308128501] 2177.4 percent of total billed charges 1421.04 2177.4 Technical (Hospital) Services CT Head/Brain W/Contrast Material PX-3517046000 CDM 70460 CPT 351 RC inpatient 2292 2292 UNITED HEALTHCARE (COMMERCIAL) [3081199] UNITED HEALTHCARE 87726 [308119901] 1421.04 percent of total billed charges 1421.04 2177.4 Technical (Hospital) Services CT Head/Brain W/O Contrast Material PX-3517045000 CDM 70450 CPT 351 RC outpatient 1905 1905 MULTIPLAN INC 34080 [3081285] MULTIPLAN INC [308128501] 1809.75 percent of total billed charges 1181.1 1809.75 Technical (Hospital) Services CT Head/Brain W/O Contrast Material PX-3517045000 CDM 70450 CPT 351 RC outpatient 1905 1905 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES HDHP [308136802] 1524 percent of total billed charges 1181.1 1809.75 Technical (Hospital) Services CT Head/Brain W/O Contrast Material PX-3517045000 CDM 70450 CPT 351 RC outpatient 1905 1905 BLUE CROSS BLUE SHIELD WELLMARK SB889 [3081026] BCBS WYOMING [308102603] 1809.75 percent of total billed charges 1181.1 1809.75 Technical (Hospital) Services CT Head/Brain W/O Contrast Material PX-3517045000 CDM 70450 CPT 351 RC outpatient 1905 1905 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES EPO [308136803] 1524 percent of total billed charges 1181.1 1809.75 Technical (Hospital) Services CT Head/Brain W/O Contrast Material PX-3517045000 CDM 70450 CPT 351 RC outpatient 1905 1905 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES PPO [308136801] 1524 percent of total billed charges 1181.1 1809.75 Technical (Hospital) Services CT Head/Brain W/O Contrast Material PX-3517045000 CDM 70450 CPT 351 RC outpatient 1905 1905 UNITED HEALTHCARE (COMMERCIAL) [3081199] UNITED HEALTHCARE 87726 [308119901] 1181.1 percent of total billed charges 1181.1 1809.75 Technical (Hospital) Services CT Head/Brain W/O Contrast Material PX-3517045000 CDM 70450 CPT 351 RC outpatient 1905 1905 HEALTHPARTNERS SX009 HEALTHPARTNERS 1524 percent of total billed charges 1181.1 1809.75 Technical (Hospital) Services CT Head/Brain W/O Contrast Material PX-3517045000 CDM 70450 CPT 351 RC outpatient 1905 1905 MEDICA (COMMERCIAL) 94265 [3081118] MEDICA CLAIMS [308111801] 1714.5 percent of total billed charges 1181.1 1809.75 Technical (Hospital) Services CT Head/Brain W/O Contrast Material PX-3517045000 CDM 70450 CPT 351 RC outpatient 1905 1905 CIGNA 62308 [3081051] CIGNA 62308 [308105105] 1524 percent of total billed charges 1181.1 1809.75 Technical (Hospital) Services CT Head/Brain W/O Contrast Material PX-3517045000 CDM 70450 CPT 351 RC outpatient 1905 1905 CIGNA 62308 [3081051] CIGNA STATE OF WYOMING [308105107] 1524 percent of total billed charges 1181.1 1809.75 Technical (Hospital) Services CT Head/Brain W/O Contrast Material PX-3517045000 CDM 70450 CPT 351 RC inpatient 1905 1905 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES EPO [308136803] 1508.38 percent of total billed charges 1181.1 1809.75 Technical (Hospital) Services CT Head/Brain W/O Contrast Material PX-3517045000 CDM 70450 CPT 351 RC inpatient 1905 1905 CIGNA 62308 [3081051] CIGNA 62308 [308105105] 1508.38 percent of total billed charges 1181.1 1809.75 Technical (Hospital) Services CT Head/Brain W/O Contrast Material PX-3517045000 CDM 70450 CPT 351 RC inpatient 1905 1905 CIGNA 62308 [3081051] CIGNA STATE OF WYOMING [308105107] 1508.38 percent of total billed charges 1181.1 1809.75 Technical (Hospital) Services CT Head/Brain W/O Contrast Material PX-3517045000 CDM 70450 CPT 351 RC inpatient 1905 1905 HEALTHPARTNERS SX009 HEALTHPARTNERS 1508.38 percent of total billed charges 1181.1 1809.75 Technical (Hospital) Services CT Head/Brain W/O Contrast Material PX-3517045000 CDM 70450 CPT 351 RC inpatient 1905 1905 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES HDHP [308136802] 1508.38 percent of total billed charges 1181.1 1809.75 Technical (Hospital) Services CT Head/Brain W/O Contrast Material PX-3517045000 CDM 70450 CPT 351 RC inpatient 1905 1905 MEDICA (COMMERCIAL) 94265 [3081118] MEDICA CLAIMS [308111801] 1714.5 percent of total billed charges 1181.1 1809.75 Technical (Hospital) Services CT Head/Brain W/O Contrast Material PX-3517045000 CDM 70450 CPT 351 RC inpatient 1905 1905 BLUE CROSS BLUE SHIELD WELLMARK SB889 [3081026] BCBS WYOMING [308102603] 1809.75 percent of total billed charges 1181.1 1809.75 Technical (Hospital) Services CT Head/Brain W/O Contrast Material PX-3517045000 CDM 70450 CPT 351 RC inpatient 1905 1905 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES PPO [308136801] 1508.38 percent of total billed charges 1181.1 1809.75 Technical (Hospital) Services CT Head/Brain W/O Contrast Material PX-3517045000 CDM 70450 CPT 351 RC inpatient 1905 1905 UNITED HEALTHCARE (COMMERCIAL) [3081199] UNITED HEALTHCARE 87726 [308119901] 1181.1 percent of total billed charges 1181.1 1809.75 Technical (Hospital) Services CT Head/Brain W/O Contrast Material PX-3517045000 CDM 70450 CPT 351 RC inpatient 1905 1905 MULTIPLAN INC 34080 [3081285] MULTIPLAN INC [308128501] 1809.75 percent of total billed charges 1181.1 1809.75 Technical (Hospital) Services Radiologic Examination Neck Soft Tissue PX-3207036000 CDM 70360 CPT 320 RC outpatient 197 197 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES PPO [308136801] 157.6 percent of total billed charges 122.14 187.15 Technical (Hospital) Services Radiologic Examination Neck Soft Tissue PX-3207036000 CDM 70360 CPT 320 RC outpatient 197 197 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES EPO [308136803] 157.6 percent of total billed charges 122.14 187.15 Technical (Hospital) Services Radiologic Examination Neck Soft Tissue PX-3207036000 CDM 70360 CPT 320 RC outpatient 197 197 BLUE CROSS BLUE SHIELD WELLMARK SB889 [3081026] BCBS WYOMING [308102603] 187.15 percent of total billed charges 122.14 187.15 Technical (Hospital) Services Radiologic Examination Neck Soft Tissue PX-3207036000 CDM 70360 CPT 320 RC outpatient 197 197 UNITED HEALTHCARE (COMMERCIAL) [3081199] UNITED HEALTHCARE 87726 [308119901] 122.14 percent of total billed charges 122.14 187.15 Technical (Hospital) Services Radiologic Examination Neck Soft Tissue PX-3207036000 CDM 70360 CPT 320 RC outpatient 197 197 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES HDHP [308136802] 157.6 percent of total billed charges 122.14 187.15 Technical (Hospital) Services Radiologic Examination Neck Soft Tissue PX-3207036000 CDM 70360 CPT 320 RC outpatient 197 197 MULTIPLAN INC 34080 [3081285] MULTIPLAN INC [308128501] 187.15 percent of total billed charges 122.14 187.15 Technical (Hospital) Services Radiologic Examination Neck Soft Tissue PX-3207036000 CDM 70360 CPT 320 RC outpatient 197 197 HEALTHPARTNERS SX009 HEALTHPARTNERS 157.6 percent of total billed charges 122.14 187.15 Technical (Hospital) Services Radiologic Examination Neck Soft Tissue PX-3207036000 CDM 70360 CPT 320 RC outpatient 197 197 CIGNA 62308 [3081051] CIGNA 62308 [308105105] 157.6 percent of total billed charges 122.14 187.15 Technical (Hospital) Services Radiologic Examination Neck Soft Tissue PX-3207036000 CDM 70360 CPT 320 RC outpatient 197 197 CIGNA 62308 [3081051] CIGNA STATE OF WYOMING [308105107] 157.6 percent of total billed charges 122.14 187.15 Technical (Hospital) Services Radiologic Examination Neck Soft Tissue PX-3207036000 CDM 70360 CPT 320 RC outpatient 197 197 MEDICA (COMMERCIAL) 94265 [3081118] MEDICA CLAIMS [308111801] 177.3 percent of total billed charges 122.14 187.15 Technical (Hospital) Services Radiologic Examination Neck Soft Tissue PX-3207036000 CDM 70360 CPT 320 RC inpatient 197 197 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES EPO [308136803] 155.98 percent of total billed charges 122.14 187.15 Technical (Hospital) Services Radiologic Examination Neck Soft Tissue PX-3207036000 CDM 70360 CPT 320 RC inpatient 197 197 CIGNA 62308 [3081051] CIGNA 62308 [308105105] 155.98 percent of total billed charges 122.14 187.15 Technical (Hospital) Services Radiologic Examination Neck Soft Tissue PX-3207036000 CDM 70360 CPT 320 RC inpatient 197 197 CIGNA 62308 [3081051] CIGNA STATE OF WYOMING [308105107] 155.98 percent of total billed charges 122.14 187.15 Technical (Hospital) Services Radiologic Examination Neck Soft Tissue PX-3207036000 CDM 70360 CPT 320 RC inpatient 197 197 HEALTHPARTNERS SX009 HEALTHPARTNERS 155.98 percent of total billed charges 122.14 187.15 Technical (Hospital) Services Radiologic Examination Neck Soft Tissue PX-3207036000 CDM 70360 CPT 320 RC inpatient 197 197 MEDICA (COMMERCIAL) 94265 [3081118] MEDICA CLAIMS [308111801] 177.3 percent of total billed charges 122.14 187.15 Technical (Hospital) Services Radiologic Examination Neck Soft Tissue PX-3207036000 CDM 70360 CPT 320 RC inpatient 197 197 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES HDHP [308136802] 155.98 percent of total billed charges 122.14 187.15 Technical (Hospital) Services Radiologic Examination Neck Soft Tissue PX-3207036000 CDM 70360 CPT 320 RC inpatient 197 197 BLUE CROSS BLUE SHIELD WELLMARK SB889 [3081026] BCBS WYOMING [308102603] 187.15 percent of total billed charges 122.14 187.15 Technical (Hospital) Services Radiologic Examination Neck Soft Tissue PX-3207036000 CDM 70360 CPT 320 RC inpatient 197 197 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES PPO [308136801] 155.98 percent of total billed charges 122.14 187.15 Technical (Hospital) Services Radiologic Examination Neck Soft Tissue PX-3207036000 CDM 70360 CPT 320 RC inpatient 197 197 UNITED HEALTHCARE (COMMERCIAL) [3081199] UNITED HEALTHCARE 87726 [308119901] 122.14 percent of total billed charges 122.14 187.15 Technical (Hospital) Services Radiologic Examination Neck Soft Tissue PX-3207036000 CDM 70360 CPT 320 RC inpatient 197 197 MULTIPLAN INC 34080 [3081285] MULTIPLAN INC [308128501] 187.15 percent of total billed charges 122.14 187.15 Technical (Hospital) Services Radex Temporomandble Jt Opn & Clsd Mouth Bilat PX-3207033000 CDM 70330 CPT 320 RC inpatient 356 356 MEDICA (COMMERCIAL) 94265 [3081118] MEDICA CLAIMS [308111801] 320.4 percent of total billed charges 220.72 338.2 Technical (Hospital) Services Radex Temporomandble Jt Opn & Clsd Mouth Bilat PX-3207033000 CDM 70330 CPT 320 RC inpatient 356 356 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES HDHP [308136802] 281.88 percent of total billed charges 220.72 338.2 Technical (Hospital) Services Radex Temporomandble Jt Opn & Clsd Mouth Bilat PX-3207033000 CDM 70330 CPT 320 RC inpatient 356 356 HEALTHPARTNERS SX009 HEALTHPARTNERS 281.88 percent of total billed charges 220.72 338.2 Technical (Hospital) Services Radex Temporomandble Jt Opn & Clsd Mouth Bilat PX-3207033000 CDM 70330 CPT 320 RC inpatient 356 356 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES PPO [308136801] 281.88 percent of total billed charges 220.72 338.2 Technical (Hospital) Services Radex Temporomandble Jt Opn & Clsd Mouth Bilat PX-3207033000 CDM 70330 CPT 320 RC inpatient 356 356 MULTIPLAN INC 34080 [3081285] MULTIPLAN INC [308128501] 338.2 percent of total billed charges 220.72 338.2 Technical (Hospital) Services Radex Temporomandble Jt Opn & Clsd Mouth Bilat PX-3207033000 CDM 70330 CPT 320 RC inpatient 356 356 BLUE CROSS BLUE SHIELD WELLMARK SB889 [3081026] BCBS WYOMING [308102603] 338.2 percent of total billed charges 220.72 338.2 Technical (Hospital) Services Radex Temporomandble Jt Opn & Clsd Mouth Bilat PX-3207033000 CDM 70330 CPT 320 RC inpatient 356 356 UNITED HEALTHCARE (COMMERCIAL) [3081199] UNITED HEALTHCARE 87726 [308119901] 220.72 percent of total billed charges 220.72 338.2 Technical (Hospital) Services Radex Temporomandble Jt Opn & Clsd Mouth Bilat PX-3207033000 CDM 70330 CPT 320 RC inpatient 356 356 CIGNA 62308 [3081051] CIGNA 62308 [308105105] 281.88 percent of total billed charges 220.72 338.2 Technical (Hospital) Services Radex Temporomandble Jt Opn & Clsd Mouth Bilat PX-3207033000 CDM 70330 CPT 320 RC inpatient 356 356 CIGNA 62308 [3081051] CIGNA STATE OF WYOMING [308105107] 281.88 percent of total billed charges 220.72 338.2 Technical (Hospital) Services Radex Temporomandble Jt Opn & Clsd Mouth Bilat PX-3207033000 CDM 70330 CPT 320 RC inpatient 356 356 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES EPO [308136803] 281.88 percent of total billed charges 220.72 338.2 Technical (Hospital) Services Radex Temporomandble Jt Opn & Clsd Mouth Bilat PX-3207033000 CDM 70330 CPT 320 RC outpatient 356 356 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES EPO [308136803] 284.8 percent of total billed charges 220.72 338.2 Technical (Hospital) Services Radex Temporomandble Jt Opn & Clsd Mouth Bilat PX-3207033000 CDM 70330 CPT 320 RC outpatient 356 356 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES PPO [308136801] 284.8 percent of total billed charges 220.72 338.2 Technical (Hospital) Services Radex Temporomandble Jt Opn & Clsd Mouth Bilat PX-3207033000 CDM 70330 CPT 320 RC outpatient 356 356 BLUE CROSS BLUE SHIELD WELLMARK SB889 [3081026] BCBS WYOMING [308102603] 338.2 percent of total billed charges 220.72 338.2 Technical (Hospital) Services Radex Temporomandble Jt Opn & Clsd Mouth Bilat PX-3207033000 CDM 70330 CPT 320 RC outpatient 356 356 UNITED HEALTHCARE (COMMERCIAL) [3081199] UNITED HEALTHCARE 87726 [308119901] 220.72 percent of total billed charges 220.72 338.2 Technical (Hospital) Services Radex Temporomandble Jt Opn & Clsd Mouth Bilat PX-3207033000 CDM 70330 CPT 320 RC outpatient 356 356 MULTIPLAN INC 34080 [3081285] MULTIPLAN INC [308128501] 338.2 percent of total billed charges 220.72 338.2 Technical (Hospital) Services Radex Temporomandble Jt Opn & Clsd Mouth Bilat PX-3207033000 CDM 70330 CPT 320 RC outpatient 356 356 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES HDHP [308136802] 284.8 percent of total billed charges 220.72 338.2 Technical (Hospital) Services Radex Temporomandble Jt Opn & Clsd Mouth Bilat PX-3207033000 CDM 70330 CPT 320 RC outpatient 356 356 MEDICA (COMMERCIAL) 94265 [3081118] MEDICA CLAIMS [308111801] 320.4 percent of total billed charges 220.72 338.2 Technical (Hospital) Services Radex Temporomandble Jt Opn & Clsd Mouth Bilat PX-3207033000 CDM 70330 CPT 320 RC outpatient 356 356 HEALTHPARTNERS SX009 HEALTHPARTNERS 284.8 percent of total billed charges 220.72 338.2 Technical (Hospital) Services Radex Temporomandble Jt Opn & Clsd Mouth Bilat PX-3207033000 CDM 70330 CPT 320 RC outpatient 356 356 CIGNA 62308 [3081051] CIGNA 62308 [308105105] 284.8 percent of total billed charges 220.72 338.2 Technical (Hospital) Services Radex Temporomandble Jt Opn & Clsd Mouth Bilat PX-3207033000 CDM 70330 CPT 320 RC outpatient 356 356 CIGNA 62308 [3081051] CIGNA STATE OF WYOMING [308105107] 284.8 percent of total billed charges 220.72 338.2 Technical (Hospital) Services Radex Temporomandble Jt Opn & Clsd Mouth Unilat PX-3207032800 CDM 70328 CPT 320 RC inpatient 247 247 MEDICA (COMMERCIAL) 94265 [3081118] MEDICA CLAIMS [308111801] 222.3 percent of total billed charges 153.14 234.65 Technical (Hospital) Services Radex Temporomandble Jt Opn & Clsd Mouth Unilat PX-3207032800 CDM 70328 CPT 320 RC inpatient 247 247 HEALTHPARTNERS SX009 HEALTHPARTNERS 195.57 percent of total billed charges 153.14 234.65 Technical (Hospital) Services Radex Temporomandble Jt Opn & Clsd Mouth Unilat PX-3207032800 CDM 70328 CPT 320 RC inpatient 247 247 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES HDHP [308136802] 195.57 percent of total billed charges 153.14 234.65 Technical (Hospital) Services Radex Temporomandble Jt Opn & Clsd Mouth Unilat PX-3207032800 CDM 70328 CPT 320 RC inpatient 247 247 MULTIPLAN INC 34080 [3081285] MULTIPLAN INC [308128501] 234.65 percent of total billed charges 153.14 234.65 Technical (Hospital) Services Radex Temporomandble Jt Opn & Clsd Mouth Unilat PX-3207032800 CDM 70328 CPT 320 RC inpatient 247 247 BLUE CROSS BLUE SHIELD WELLMARK SB889 [3081026] BCBS WYOMING [308102603] 234.65 percent of total billed charges 153.14 234.65 Technical (Hospital) Services Radex Temporomandble Jt Opn & Clsd Mouth Unilat PX-3207032800 CDM 70328 CPT 320 RC inpatient 247 247 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES PPO [308136801] 195.57 percent of total billed charges 153.14 234.65 Technical (Hospital) Services Radex Temporomandble Jt Opn & Clsd Mouth Unilat PX-3207032800 CDM 70328 CPT 320 RC inpatient 247 247 UNITED HEALTHCARE (COMMERCIAL) [3081199] UNITED HEALTHCARE 87726 [308119901] 153.14 percent of total billed charges 153.14 234.65 Technical (Hospital) Services Radex Temporomandble Jt Opn & Clsd Mouth Unilat PX-3207032800 CDM 70328 CPT 320 RC inpatient 247 247 CIGNA 62308 [3081051] CIGNA 62308 [308105105] 195.57 percent of total billed charges 153.14 234.65 Technical (Hospital) Services Radex Temporomandble Jt Opn & Clsd Mouth Unilat PX-3207032800 CDM 70328 CPT 320 RC inpatient 247 247 CIGNA 62308 [3081051] CIGNA STATE OF WYOMING [308105107] 195.57 percent of total billed charges 153.14 234.65 Technical (Hospital) Services Radex Temporomandble Jt Opn & Clsd Mouth Unilat PX-3207032800 CDM 70328 CPT 320 RC inpatient 247 247 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES EPO [308136803] 195.57 percent of total billed charges 153.14 234.65 Technical (Hospital) Services Radex Temporomandble Jt Opn & Clsd Mouth Unilat PX-3207032800 CDM 70328 CPT 320 RC outpatient 247 247 CIGNA 62308 [3081051] CIGNA 62308 [308105105] 197.6 percent of total billed charges 153.14 234.65 Technical (Hospital) Services Radex Temporomandble Jt Opn & Clsd Mouth Unilat PX-3207032800 CDM 70328 CPT 320 RC outpatient 247 247 CIGNA 62308 [3081051] CIGNA STATE OF WYOMING [308105107] 197.6 percent of total billed charges 153.14 234.65 Technical (Hospital) Services Radex Temporomandble Jt Opn & Clsd Mouth Unilat PX-3207032800 CDM 70328 CPT 320 RC outpatient 247 247 HEALTHPARTNERS SX009 HEALTHPARTNERS 197.6 percent of total billed charges 153.14 234.65 Technical (Hospital) Services Radex Temporomandble Jt Opn & Clsd Mouth Unilat PX-3207032800 CDM 70328 CPT 320 RC outpatient 247 247 MEDICA (COMMERCIAL) 94265 [3081118] MEDICA CLAIMS [308111801] 222.3 percent of total billed charges 153.14 234.65 Technical (Hospital) Services Radex Temporomandble Jt Opn & Clsd Mouth Unilat PX-3207032800 CDM 70328 CPT 320 RC outpatient 247 247 MULTIPLAN INC 34080 [3081285] MULTIPLAN INC [308128501] 234.65 percent of total billed charges 153.14 234.65 Technical (Hospital) Services Radex Temporomandble Jt Opn & Clsd Mouth Unilat PX-3207032800 CDM 70328 CPT 320 RC outpatient 247 247 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES HDHP [308136802] 197.6 percent of total billed charges 153.14 234.65 Technical (Hospital) Services Radex Temporomandble Jt Opn & Clsd Mouth Unilat PX-3207032800 CDM 70328 CPT 320 RC outpatient 247 247 UNITED HEALTHCARE (COMMERCIAL) [3081199] UNITED HEALTHCARE 87726 [308119901] 153.14 percent of total billed charges 153.14 234.65 Technical (Hospital) Services Radex Temporomandble Jt Opn & Clsd Mouth Unilat PX-3207032800 CDM 70328 CPT 320 RC outpatient 247 247 BLUE CROSS BLUE SHIELD WELLMARK SB889 [3081026] BCBS WYOMING [308102603] 234.65 percent of total billed charges 153.14 234.65 Technical (Hospital) Services Radex Temporomandble Jt Opn & Clsd Mouth Unilat PX-3207032800 CDM 70328 CPT 320 RC outpatient 247 247 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES PPO [308136801] 197.6 percent of total billed charges 153.14 234.65 Technical (Hospital) Services Radex Temporomandble Jt Opn & Clsd Mouth Unilat PX-3207032800 CDM 70328 CPT 320 RC outpatient 247 247 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES EPO [308136803] 197.6 percent of total billed charges 153.14 234.65 Technical (Hospital) Services Radiologic Exam Skull Complete Minimum 4 Views PX-3207026000 CDM 70260 CPT 320 RC outpatient 338 338 BLUE CROSS BLUE SHIELD WELLMARK SB889 [3081026] BCBS WYOMING [308102603] 321.1 percent of total billed charges 209.56 321.1 Technical (Hospital) Services Radiologic Exam Skull Complete Minimum 4 Views PX-3207026000 CDM 70260 CPT 320 RC outpatient 338 338 UNITED HEALTHCARE (COMMERCIAL) [3081199] UNITED HEALTHCARE 87726 [308119901] 209.56 percent of total billed charges 209.56 321.1 Technical (Hospital) Services Radiologic Exam Skull Complete Minimum 4 Views PX-3207026000 CDM 70260 CPT 320 RC outpatient 338 338 MULTIPLAN INC 34080 [3081285] MULTIPLAN INC [308128501] 321.1 percent of total billed charges 209.56 321.1 Technical (Hospital) Services Radiologic Exam Skull Complete Minimum 4 Views PX-3207026000 CDM 70260 CPT 320 RC outpatient 338 338 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES HDHP [308136802] 270.4 percent of total billed charges 209.56 321.1 Technical (Hospital) Services Radiologic Exam Skull Complete Minimum 4 Views PX-3207026000 CDM 70260 CPT 320 RC outpatient 338 338 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES EPO [308136803] 270.4 percent of total billed charges 209.56 321.1 Technical (Hospital) Services Radiologic Exam Skull Complete Minimum 4 Views PX-3207026000 CDM 70260 CPT 320 RC outpatient 338 338 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES PPO [308136801] 270.4 percent of total billed charges 209.56 321.1 Technical (Hospital) Services Radiologic Exam Skull Complete Minimum 4 Views PX-3207026000 CDM 70260 CPT 320 RC outpatient 338 338 HEALTHPARTNERS SX009 HEALTHPARTNERS 270.4 percent of total billed charges 209.56 321.1 Technical (Hospital) Services Radiologic Exam Skull Complete Minimum 4 Views PX-3207026000 CDM 70260 CPT 320 RC outpatient 338 338 MEDICA (COMMERCIAL) 94265 [3081118] MEDICA CLAIMS [308111801] 304.2 percent of total billed charges 209.56 321.1 Technical (Hospital) Services Radiologic Exam Skull Complete Minimum 4 Views PX-3207026000 CDM 70260 CPT 320 RC outpatient 338 338 CIGNA 62308 [3081051] CIGNA 62308 [308105105] 270.4 percent of total billed charges 209.56 321.1 Technical (Hospital) Services Radiologic Exam Skull Complete Minimum 4 Views PX-3207026000 CDM 70260 CPT 320 RC outpatient 338 338 CIGNA 62308 [3081051] CIGNA STATE OF WYOMING [308105107] 270.4 percent of total billed charges 209.56 321.1 Technical (Hospital) Services Radiologic Exam Skull Complete Minimum 4 Views PX-3207026000 CDM 70260 CPT 320 RC inpatient 338 338 CIGNA 62308 [3081051] CIGNA 62308 [308105105] 267.63 percent of total billed charges 209.56 321.1 Technical (Hospital) Services Radiologic Exam Skull Complete Minimum 4 Views PX-3207026000 CDM 70260 CPT 320 RC inpatient 338 338 CIGNA 62308 [3081051] CIGNA STATE OF WYOMING [308105107] 267.63 percent of total billed charges 209.56 321.1 Technical (Hospital) Services Radiologic Exam Skull Complete Minimum 4 Views PX-3207026000 CDM 70260 CPT 320 RC inpatient 338 338 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES EPO [308136803] 267.63 percent of total billed charges 209.56 321.1 Technical (Hospital) Services Radiologic Exam Skull Complete Minimum 4 Views PX-3207026000 CDM 70260 CPT 320 RC inpatient 338 338 BLUE CROSS BLUE SHIELD WELLMARK SB889 [3081026] BCBS WYOMING [308102603] 321.1 percent of total billed charges 209.56 321.1 Technical (Hospital) Services Radiologic Exam Skull Complete Minimum 4 Views PX-3207026000 CDM 70260 CPT 320 RC inpatient 338 338 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES PPO [308136801] 267.63 percent of total billed charges 209.56 321.1 Technical (Hospital) Services Radiologic Exam Skull Complete Minimum 4 Views PX-3207026000 CDM 70260 CPT 320 RC inpatient 338 338 MULTIPLAN INC 34080 [3081285] MULTIPLAN INC [308128501] 321.1 percent of total billed charges 209.56 321.1 Technical (Hospital) Services Radiologic Exam Skull Complete Minimum 4 Views PX-3207026000 CDM 70260 CPT 320 RC inpatient 338 338 UNITED HEALTHCARE (COMMERCIAL) [3081199] UNITED HEALTHCARE 87726 [308119901] 209.56 percent of total billed charges 209.56 321.1 Technical (Hospital) Services Radiologic Exam Skull Complete Minimum 4 Views PX-3207026000 CDM 70260 CPT 320 RC inpatient 338 338 HEALTHPARTNERS SX009 HEALTHPARTNERS 267.63 percent of total billed charges 209.56 321.1 Technical (Hospital) Services Radiologic Exam Skull Complete Minimum 4 Views PX-3207026000 CDM 70260 CPT 320 RC inpatient 338 338 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES HDHP [308136802] 267.63 percent of total billed charges 209.56 321.1 Technical (Hospital) Services Radiologic Exam Skull Complete Minimum 4 Views PX-3207026000 CDM 70260 CPT 320 RC inpatient 338 338 MEDICA (COMMERCIAL) 94265 [3081118] MEDICA CLAIMS [308111801] 304.2 percent of total billed charges 209.56 321.1 Technical (Hospital) Services Radiologic Examination Skull <4 Views PX-3207025000 CDM 70250 CPT 320 RC outpatient 238 238 CIGNA 62308 [3081051] CIGNA 62308 [308105105] 190.4 percent of total billed charges 147.56 226.1 Technical (Hospital) Services Radiologic Examination Skull <4 Views PX-3207025000 CDM 70250 CPT 320 RC outpatient 238 238 CIGNA 62308 [3081051] CIGNA STATE OF WYOMING [308105107] 190.4 percent of total billed charges 147.56 226.1 Technical (Hospital) Services Radiologic Examination Skull <4 Views PX-3207025000 CDM 70250 CPT 320 RC outpatient 238 238 MULTIPLAN INC 34080 [3081285] MULTIPLAN INC [308128501] 226.1 percent of total billed charges 147.56 226.1 Technical (Hospital) Services Radiologic Examination Skull <4 Views PX-3207025000 CDM 70250 CPT 320 RC outpatient 238 238 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES HDHP [308136802] 190.4 percent of total billed charges 147.56 226.1 Technical (Hospital) Services Radiologic Examination Skull <4 Views PX-3207025000 CDM 70250 CPT 320 RC outpatient 238 238 BLUE CROSS BLUE SHIELD WELLMARK SB889 [3081026] BCBS WYOMING [308102603] 226.1 percent of total billed charges 147.56 226.1 Technical (Hospital) Services Radiologic Examination Skull <4 Views PX-3207025000 CDM 70250 CPT 320 RC outpatient 238 238 UNITED HEALTHCARE (COMMERCIAL) [3081199] UNITED HEALTHCARE 87726 [308119901] 147.56 percent of total billed charges 147.56 226.1 Technical (Hospital) Services Radiologic Examination Skull <4 Views PX-3207025000 CDM 70250 CPT 320 RC outpatient 238 238 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES PPO [308136801] 190.4 percent of total billed charges 147.56 226.1 Technical (Hospital) Services Radiologic Examination Skull <4 Views PX-3207025000 CDM 70250 CPT 320 RC outpatient 238 238 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES EPO [308136803] 190.4 percent of total billed charges 147.56 226.1 Technical (Hospital) Services Radiologic Examination Skull <4 Views PX-3207025000 CDM 70250 CPT 320 RC outpatient 238 238 MEDICA (COMMERCIAL) 94265 [3081118] MEDICA CLAIMS [308111801] 214.2 percent of total billed charges 147.56 226.1 Technical (Hospital) Services Radiologic Examination Skull <4 Views PX-3207025000 CDM 70250 CPT 320 RC outpatient 238 238 HEALTHPARTNERS SX009 HEALTHPARTNERS 190.4 percent of total billed charges 147.56 226.1 Technical (Hospital) Services Radiologic Examination Skull <4 Views PX-3207025000 CDM 70250 CPT 320 RC inpatient 238 238 HEALTHPARTNERS SX009 HEALTHPARTNERS 188.45 percent of total billed charges 147.56 226.1 Technical (Hospital) Services Radiologic Examination Skull <4 Views PX-3207025000 CDM 70250 CPT 320 RC inpatient 238 238 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES HDHP [308136802] 188.45 percent of total billed charges 147.56 226.1 Technical (Hospital) Services Radiologic Examination Skull <4 Views PX-3207025000 CDM 70250 CPT 320 RC inpatient 238 238 MEDICA (COMMERCIAL) 94265 [3081118] MEDICA CLAIMS [308111801] 214.2 percent of total billed charges 147.56 226.1 Technical (Hospital) Services Radiologic Examination Skull <4 Views PX-3207025000 CDM 70250 CPT 320 RC inpatient 238 238 MULTIPLAN INC 34080 [3081285] MULTIPLAN INC [308128501] 226.1 percent of total billed charges 147.56 226.1 Technical (Hospital) Services Radiologic Examination Skull <4 Views PX-3207025000 CDM 70250 CPT 320 RC inpatient 238 238 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES PPO [308136801] 188.45 percent of total billed charges 147.56 226.1 Technical (Hospital) Services Radiologic Examination Skull <4 Views PX-3207025000 CDM 70250 CPT 320 RC inpatient 238 238 BLUE CROSS BLUE SHIELD WELLMARK SB889 [3081026] BCBS WYOMING [308102603] 226.1 percent of total billed charges 147.56 226.1 Technical (Hospital) Services Radiologic Examination Skull <4 Views PX-3207025000 CDM 70250 CPT 320 RC inpatient 238 238 UNITED HEALTHCARE (COMMERCIAL) [3081199] UNITED HEALTHCARE 87726 [308119901] 147.56 percent of total billed charges 147.56 226.1 Technical (Hospital) Services Radiologic Examination Skull <4 Views PX-3207025000 CDM 70250 CPT 320 RC inpatient 238 238 CIGNA 62308 [3081051] CIGNA 62308 [308105105] 188.45 percent of total billed charges 147.56 226.1 Technical (Hospital) Services Radiologic Examination Skull <4 Views PX-3207025000 CDM 70250 CPT 320 RC inpatient 238 238 CIGNA 62308 [3081051] CIGNA STATE OF WYOMING [308105107] 188.45 percent of total billed charges 147.56 226.1 Technical (Hospital) Services Radiologic Examination Skull <4 Views PX-3207025000 CDM 70250 CPT 320 RC inpatient 238 238 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES EPO [308136803] 188.45 percent of total billed charges 147.56 226.1 Technical (Hospital) Services Radiologic Examination Sella Turcica PX-3207024000 CDM 70240 CPT 320 RC inpatient 170 170 CIGNA 62308 [3081051] CIGNA 62308 [308105105] 134.61 percent of total billed charges 105.4 161.5 Technical (Hospital) Services Radiologic Examination Sella Turcica PX-3207024000 CDM 70240 CPT 320 RC inpatient 170 170 CIGNA 62308 [3081051] CIGNA STATE OF WYOMING [308105107] 134.61 percent of total billed charges 105.4 161.5 Technical (Hospital) Services Radiologic Examination Sella Turcica PX-3207024000 CDM 70240 CPT 320 RC inpatient 170 170 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES EPO [308136803] 134.61 percent of total billed charges 105.4 161.5 Technical (Hospital) Services Radiologic Examination Sella Turcica PX-3207024000 CDM 70240 CPT 320 RC inpatient 170 170 UNITED HEALTHCARE (COMMERCIAL) [3081199] UNITED HEALTHCARE 87726 [308119901] 105.4 percent of total billed charges 105.4 161.5 Technical (Hospital) Services Radiologic Examination Sella Turcica PX-3207024000 CDM 70240 CPT 320 RC inpatient 170 170 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES PPO [308136801] 134.61 percent of total billed charges 105.4 161.5 Technical (Hospital) Services Radiologic Examination Sella Turcica PX-3207024000 CDM 70240 CPT 320 RC inpatient 170 170 BLUE CROSS BLUE SHIELD WELLMARK SB889 [3081026] BCBS WYOMING [308102603] 161.5 percent of total billed charges 105.4 161.5 Technical (Hospital) Services Radiologic Examination Sella Turcica PX-3207024000 CDM 70240 CPT 320 RC inpatient 170 170 MULTIPLAN INC 34080 [3081285] MULTIPLAN INC [308128501] 161.5 percent of total billed charges 105.4 161.5 Technical (Hospital) Services Radiologic Examination Sella Turcica PX-3207024000 CDM 70240 CPT 320 RC inpatient 170 170 HEALTHPARTNERS SX009 HEALTHPARTNERS 134.61 percent of total billed charges 105.4 161.5 Technical (Hospital) Services Radiologic Examination Sella Turcica PX-3207024000 CDM 70240 CPT 320 RC inpatient 170 170 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES HDHP [308136802] 134.61 percent of total billed charges 105.4 161.5 Technical (Hospital) Services Radiologic Examination Sella Turcica PX-3207024000 CDM 70240 CPT 320 RC inpatient 170 170 MEDICA (COMMERCIAL) 94265 [3081118] MEDICA CLAIMS [308111801] 153 percent of total billed charges 105.4 161.5 Technical (Hospital) Services Radiologic Examination Sella Turcica PX-3207024000 CDM 70240 CPT 320 RC outpatient 170 170 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES PPO [308136801] 136 percent of total billed charges 105.4 161.5 Technical (Hospital) Services Radiologic Examination Sella Turcica PX-3207024000 CDM 70240 CPT 320 RC outpatient 170 170 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES EPO [308136803] 136 percent of total billed charges 105.4 161.5 Technical (Hospital) Services Radiologic Examination Sella Turcica PX-3207024000 CDM 70240 CPT 320 RC outpatient 170 170 MULTIPLAN INC 34080 [3081285] MULTIPLAN INC [308128501] 161.5 percent of total billed charges 105.4 161.5 Technical (Hospital) Services Radiologic Examination Sella Turcica PX-3207024000 CDM 70240 CPT 320 RC outpatient 170 170 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES HDHP [308136802] 136 percent of total billed charges 105.4 161.5 Technical (Hospital) Services Radiologic Examination Sella Turcica PX-3207024000 CDM 70240 CPT 320 RC outpatient 170 170 BLUE CROSS BLUE SHIELD WELLMARK SB889 [3081026] BCBS WYOMING [308102603] 161.5 percent of total billed charges 105.4 161.5 Technical (Hospital) Services Radiologic Examination Sella Turcica PX-3207024000 CDM 70240 CPT 320 RC outpatient 170 170 UNITED HEALTHCARE (COMMERCIAL) [3081199] UNITED HEALTHCARE 87726 [308119901] 105.4 percent of total billed charges 105.4 161.5 Technical (Hospital) Services Radiologic Examination Sella Turcica PX-3207024000 CDM 70240 CPT 320 RC outpatient 170 170 HEALTHPARTNERS SX009 HEALTHPARTNERS 136 percent of total billed charges 105.4 161.5 Technical (Hospital) Services Radiologic Examination Sella Turcica PX-3207024000 CDM 70240 CPT 320 RC outpatient 170 170 CIGNA 62308 [3081051] CIGNA 62308 [308105105] 136 percent of total billed charges 105.4 161.5 Technical (Hospital) Services Radiologic Examination Sella Turcica PX-3207024000 CDM 70240 CPT 320 RC outpatient 170 170 CIGNA 62308 [3081051] CIGNA STATE OF WYOMING [308105107] 136 percent of total billed charges 105.4 161.5 Technical (Hospital) Services Radiologic Examination Sella Turcica PX-3207024000 CDM 70240 CPT 320 RC outpatient 170 170 MEDICA (COMMERCIAL) 94265 [3081118] MEDICA CLAIMS [308111801] 153 percent of total billed charges 105.4 161.5 Technical (Hospital) Services Radex Sinuses Paranasal Compl Minimum 3 Views PX-3207022000 CDM 70220 CPT 320 RC inpatient 338 338 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES EPO [308136803] 267.63 percent of total billed charges 209.56 321.1 Technical (Hospital) Services Radex Sinuses Paranasal Compl Minimum 3 Views PX-3207022000 CDM 70220 CPT 320 RC inpatient 338 338 CIGNA 62308 [3081051] CIGNA 62308 [308105105] 267.63 percent of total billed charges 209.56 321.1 Technical (Hospital) Services Radex Sinuses Paranasal Compl Minimum 3 Views PX-3207022000 CDM 70220 CPT 320 RC inpatient 338 338 CIGNA 62308 [3081051] CIGNA STATE OF WYOMING [308105107] 267.63 percent of total billed charges 209.56 321.1 Technical (Hospital) Services Radex Sinuses Paranasal Compl Minimum 3 Views PX-3207022000 CDM 70220 CPT 320 RC inpatient 338 338 HEALTHPARTNERS SX009 HEALTHPARTNERS 267.63 percent of total billed charges 209.56 321.1 Technical (Hospital) Services Radex Sinuses Paranasal Compl Minimum 3 Views PX-3207022000 CDM 70220 CPT 320 RC inpatient 338 338 MEDICA (COMMERCIAL) 94265 [3081118] MEDICA CLAIMS [308111801] 304.2 percent of total billed charges 209.56 321.1 Technical (Hospital) Services Radex Sinuses Paranasal Compl Minimum 3 Views PX-3207022000 CDM 70220 CPT 320 RC inpatient 338 338 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES HDHP [308136802] 267.63 percent of total billed charges 209.56 321.1 Technical (Hospital) Services Radex Sinuses Paranasal Compl Minimum 3 Views PX-3207022000 CDM 70220 CPT 320 RC inpatient 338 338 UNITED HEALTHCARE (COMMERCIAL) [3081199] UNITED HEALTHCARE 87726 [308119901] 209.56 percent of total billed charges 209.56 321.1 Technical (Hospital) Services Radex Sinuses Paranasal Compl Minimum 3 Views PX-3207022000 CDM 70220 CPT 320 RC inpatient 338 338 MULTIPLAN INC 34080 [3081285] MULTIPLAN INC [308128501] 321.1 percent of total billed charges 209.56 321.1 Technical (Hospital) Services Radex Sinuses Paranasal Compl Minimum 3 Views PX-3207022000 CDM 70220 CPT 320 RC inpatient 338 338 BLUE CROSS BLUE SHIELD WELLMARK SB889 [3081026] BCBS WYOMING [308102603] 321.1 percent of total billed charges 209.56 321.1 Technical (Hospital) Services Radex Sinuses Paranasal Compl Minimum 3 Views PX-3207022000 CDM 70220 CPT 320 RC inpatient 338 338 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES PPO [308136801] 267.63 percent of total billed charges 209.56 321.1 Technical (Hospital) Services Radex Sinuses Paranasal Compl Minimum 3 Views PX-3207022000 CDM 70220 CPT 320 RC outpatient 338 338 CIGNA 62308 [3081051] CIGNA 62308 [308105105] 270.4 percent of total billed charges 209.56 321.1 Technical (Hospital) Services Radex Sinuses Paranasal Compl Minimum 3 Views PX-3207022000 CDM 70220 CPT 320 RC outpatient 338 338 CIGNA 62308 [3081051] CIGNA STATE OF WYOMING [308105107] 270.4 percent of total billed charges 209.56 321.1 Technical (Hospital) Services Radex Sinuses Paranasal Compl Minimum 3 Views PX-3207022000 CDM 70220 CPT 320 RC outpatient 338 338 MEDICA (COMMERCIAL) 94265 [3081118] MEDICA CLAIMS [308111801] 304.2 percent of total billed charges 209.56 321.1 Technical (Hospital) Services Radex Sinuses Paranasal Compl Minimum 3 Views PX-3207022000 CDM 70220 CPT 320 RC outpatient 338 338 HEALTHPARTNERS SX009 HEALTHPARTNERS 270.4 percent of total billed charges 209.56 321.1 Technical (Hospital) Services Radex Sinuses Paranasal Compl Minimum 3 Views PX-3207022000 CDM 70220 CPT 320 RC outpatient 338 338 BLUE CROSS BLUE SHIELD WELLMARK SB889 [3081026] BCBS WYOMING [308102603] 321.1 percent of total billed charges 209.56 321.1 Technical (Hospital) Services Radex Sinuses Paranasal Compl Minimum 3 Views PX-3207022000 CDM 70220 CPT 320 RC outpatient 338 338 UNITED HEALTHCARE (COMMERCIAL) [3081199] UNITED HEALTHCARE 87726 [308119901] 209.56 percent of total billed charges 209.56 321.1 Technical (Hospital) Services Radex Sinuses Paranasal Compl Minimum 3 Views PX-3207022000 CDM 70220 CPT 320 RC outpatient 338 338 MULTIPLAN INC 34080 [3081285] MULTIPLAN INC [308128501] 321.1 percent of total billed charges 209.56 321.1 Technical (Hospital) Services Radex Sinuses Paranasal Compl Minimum 3 Views PX-3207022000 CDM 70220 CPT 320 RC outpatient 338 338 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES HDHP [308136802] 270.4 percent of total billed charges 209.56 321.1 Technical (Hospital) Services Radex Sinuses Paranasal Compl Minimum 3 Views PX-3207022000 CDM 70220 CPT 320 RC outpatient 338 338 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES PPO [308136801] 270.4 percent of total billed charges 209.56 321.1 Technical (Hospital) Services Radex Sinuses Paranasal Compl Minimum 3 Views PX-3207022000 CDM 70220 CPT 320 RC outpatient 338 338 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES EPO [308136803] 270.4 percent of total billed charges 209.56 321.1 Technical (Hospital) Services Radex Sinuses Paranasal <3 Views PX-3207021000 CDM 70210 CPT 320 RC inpatient 197 197 CIGNA 62308 [3081051] CIGNA 62308 [308105105] 155.98 percent of total billed charges 122.14 187.15 Technical (Hospital) Services Radex Sinuses Paranasal <3 Views PX-3207021000 CDM 70210 CPT 320 RC inpatient 197 197 CIGNA 62308 [3081051] CIGNA STATE OF WYOMING [308105107] 155.98 percent of total billed charges 122.14 187.15 Technical (Hospital) Services Radex Sinuses Paranasal <3 Views PX-3207021000 CDM 70210 CPT 320 RC inpatient 197 197 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES EPO [308136803] 155.98 percent of total billed charges 122.14 187.15 Technical (Hospital) Services Radex Sinuses Paranasal <3 Views PX-3207021000 CDM 70210 CPT 320 RC inpatient 197 197 UNITED HEALTHCARE (COMMERCIAL) [3081199] UNITED HEALTHCARE 87726 [308119901] 122.14 percent of total billed charges 122.14 187.15 Technical (Hospital) Services Radex Sinuses Paranasal <3 Views PX-3207021000 CDM 70210 CPT 320 RC inpatient 197 197 MULTIPLAN INC 34080 [3081285] MULTIPLAN INC [308128501] 187.15 percent of total billed charges 122.14 187.15 Technical (Hospital) Services Radex Sinuses Paranasal <3 Views PX-3207021000 CDM 70210 CPT 320 RC inpatient 197 197 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES PPO [308136801] 155.98 percent of total billed charges 122.14 187.15 Technical (Hospital) Services Radex Sinuses Paranasal <3 Views PX-3207021000 CDM 70210 CPT 320 RC inpatient 197 197 BLUE CROSS BLUE SHIELD WELLMARK SB889 [3081026] BCBS WYOMING [308102603] 187.15 percent of total billed charges 122.14 187.15 Technical (Hospital) Services Radex Sinuses Paranasal <3 Views PX-3207021000 CDM 70210 CPT 320 RC inpatient 197 197 HEALTHPARTNERS SX009 HEALTHPARTNERS 155.98 percent of total billed charges 122.14 187.15 Technical (Hospital) Services Radex Sinuses Paranasal <3 Views PX-3207021000 CDM 70210 CPT 320 RC inpatient 197 197 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES HDHP [308136802] 155.98 percent of total billed charges 122.14 187.15 Technical (Hospital) Services Radex Sinuses Paranasal <3 Views PX-3207021000 CDM 70210 CPT 320 RC inpatient 197 197 MEDICA (COMMERCIAL) 94265 [3081118] MEDICA CLAIMS [308111801] 177.3 percent of total billed charges 122.14 187.15 Technical (Hospital) Services Radex Sinuses Paranasal <3 Views PX-3207021000 CDM 70210 CPT 320 RC outpatient 197 197 BLUE CROSS BLUE SHIELD WELLMARK SB889 [3081026] BCBS WYOMING [308102603] 187.15 percent of total billed charges 122.14 187.15 Technical (Hospital) Services Radex Sinuses Paranasal <3 Views PX-3207021000 CDM 70210 CPT 320 RC outpatient 197 197 UNITED HEALTHCARE (COMMERCIAL) [3081199] UNITED HEALTHCARE 87726 [308119901] 122.14 percent of total billed charges 122.14 187.15 Technical (Hospital) Services Radex Sinuses Paranasal <3 Views PX-3207021000 CDM 70210 CPT 320 RC outpatient 197 197 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES HDHP [308136802] 157.6 percent of total billed charges 122.14 187.15 Technical (Hospital) Services Radex Sinuses Paranasal <3 Views PX-3207021000 CDM 70210 CPT 320 RC outpatient 197 197 MULTIPLAN INC 34080 [3081285] MULTIPLAN INC [308128501] 187.15 percent of total billed charges 122.14 187.15 Technical (Hospital) Services Radex Sinuses Paranasal <3 Views PX-3207021000 CDM 70210 CPT 320 RC outpatient 197 197 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES EPO [308136803] 157.6 percent of total billed charges 122.14 187.15 Technical (Hospital) Services Radex Sinuses Paranasal <3 Views PX-3207021000 CDM 70210 CPT 320 RC outpatient 197 197 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES PPO [308136801] 157.6 percent of total billed charges 122.14 187.15 Technical (Hospital) Services Radex Sinuses Paranasal <3 Views PX-3207021000 CDM 70210 CPT 320 RC outpatient 197 197 HEALTHPARTNERS SX009 HEALTHPARTNERS 157.6 percent of total billed charges 122.14 187.15 Technical (Hospital) Services Radex Sinuses Paranasal <3 Views PX-3207021000 CDM 70210 CPT 320 RC outpatient 197 197 CIGNA 62308 [3081051] CIGNA 62308 [308105105] 157.6 percent of total billed charges 122.14 187.15 Technical (Hospital) Services Radex Sinuses Paranasal <3 Views PX-3207021000 CDM 70210 CPT 320 RC outpatient 197 197 CIGNA 62308 [3081051] CIGNA STATE OF WYOMING [308105107] 157.6 percent of total billed charges 122.14 187.15 Technical (Hospital) Services Radex Sinuses Paranasal <3 Views PX-3207021000 CDM 70210 CPT 320 RC outpatient 197 197 MEDICA (COMMERCIAL) 94265 [3081118] MEDICA CLAIMS [308111801] 177.3 percent of total billed charges 122.14 187.15 Technical (Hospital) Services Radex Orbits Complete Minimum 4 Views PX-3207020000 CDM 70200 CPT 320 RC inpatient 270 270 CIGNA 62308 [3081051] CIGNA 62308 [308105105] 213.79 percent of total billed charges 167.4 256.5 Technical (Hospital) Services Radex Orbits Complete Minimum 4 Views PX-3207020000 CDM 70200 CPT 320 RC inpatient 270 270 CIGNA 62308 [3081051] CIGNA STATE OF WYOMING [308105107] 213.79 percent of total billed charges 167.4 256.5 Technical (Hospital) Services Radex Orbits Complete Minimum 4 Views PX-3207020000 CDM 70200 CPT 320 RC inpatient 270 270 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES EPO [308136803] 213.79 percent of total billed charges 167.4 256.5 Technical (Hospital) Services Radex Orbits Complete Minimum 4 Views PX-3207020000 CDM 70200 CPT 320 RC inpatient 270 270 BLUE CROSS BLUE SHIELD WELLMARK SB889 [3081026] BCBS WYOMING [308102603] 256.5 percent of total billed charges 167.4 256.5 Technical (Hospital) Services Radex Orbits Complete Minimum 4 Views PX-3207020000 CDM 70200 CPT 320 RC inpatient 270 270 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES PPO [308136801] 213.79 percent of total billed charges 167.4 256.5 Technical (Hospital) Services Radex Orbits Complete Minimum 4 Views PX-3207020000 CDM 70200 CPT 320 RC inpatient 270 270 MULTIPLAN INC 34080 [3081285] MULTIPLAN INC [308128501] 256.5 percent of total billed charges 167.4 256.5 Technical (Hospital) Services Radex Orbits Complete Minimum 4 Views PX-3207020000 CDM 70200 CPT 320 RC inpatient 270 270 UNITED HEALTHCARE (COMMERCIAL) [3081199] UNITED HEALTHCARE 87726 [308119901] 167.4 percent of total billed charges 167.4 256.5 Technical (Hospital) Services Radex Orbits Complete Minimum 4 Views PX-3207020000 CDM 70200 CPT 320 RC inpatient 270 270 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES HDHP [308136802] 213.79 percent of total billed charges 167.4 256.5 Technical (Hospital) Services Radex Orbits Complete Minimum 4 Views PX-3207020000 CDM 70200 CPT 320 RC inpatient 270 270 HEALTHPARTNERS SX009 HEALTHPARTNERS 213.79 percent of total billed charges 167.4 256.5 Technical (Hospital) Services Radex Orbits Complete Minimum 4 Views PX-3207020000 CDM 70200 CPT 320 RC inpatient 270 270 MEDICA (COMMERCIAL) 94265 [3081118] MEDICA CLAIMS [308111801] 243 percent of total billed charges 167.4 256.5 Technical (Hospital) Services Radex Orbits Complete Minimum 4 Views PX-3207020000 CDM 70200 CPT 320 RC outpatient 270 270 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES PPO [308136801] 216 percent of total billed charges 167.4 256.5 Technical (Hospital) Services Radex Orbits Complete Minimum 4 Views PX-3207020000 CDM 70200 CPT 320 RC outpatient 270 270 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES EPO [308136803] 216 percent of total billed charges 167.4 256.5 Technical (Hospital) Services Radex Orbits Complete Minimum 4 Views PX-3207020000 CDM 70200 CPT 320 RC outpatient 270 270 BLUE CROSS BLUE SHIELD WELLMARK SB889 [3081026] BCBS WYOMING [308102603] 256.5 percent of total billed charges 167.4 256.5 Technical (Hospital) Services Radex Orbits Complete Minimum 4 Views PX-3207020000 CDM 70200 CPT 320 RC outpatient 270 270 UNITED HEALTHCARE (COMMERCIAL) [3081199] UNITED HEALTHCARE 87726 [308119901] 167.4 percent of total billed charges 167.4 256.5 Technical (Hospital) Services Radex Orbits Complete Minimum 4 Views PX-3207020000 CDM 70200 CPT 320 RC outpatient 270 270 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES HDHP [308136802] 216 percent of total billed charges 167.4 256.5 Technical (Hospital) Services Radex Orbits Complete Minimum 4 Views PX-3207020000 CDM 70200 CPT 320 RC outpatient 270 270 MULTIPLAN INC 34080 [3081285] MULTIPLAN INC [308128501] 256.5 percent of total billed charges 167.4 256.5 Technical (Hospital) Services Radex Orbits Complete Minimum 4 Views PX-3207020000 CDM 70200 CPT 320 RC outpatient 270 270 MEDICA (COMMERCIAL) 94265 [3081118] MEDICA CLAIMS [308111801] 243 percent of total billed charges 167.4 256.5 Technical (Hospital) Services Radex Orbits Complete Minimum 4 Views PX-3207020000 CDM 70200 CPT 320 RC outpatient 270 270 HEALTHPARTNERS SX009 HEALTHPARTNERS 216 percent of total billed charges 167.4 256.5 Technical (Hospital) Services Radex Orbits Complete Minimum 4 Views PX-3207020000 CDM 70200 CPT 320 RC outpatient 270 270 CIGNA 62308 [3081051] CIGNA 62308 [308105105] 216 percent of total billed charges 167.4 256.5 Technical (Hospital) Services Radex Orbits Complete Minimum 4 Views PX-3207020000 CDM 70200 CPT 320 RC outpatient 270 270 CIGNA 62308 [3081051] CIGNA STATE OF WYOMING [308105107] 216 percent of total billed charges 167.4 256.5 Technical (Hospital) Services Radex Optic Foramina PX-3207019000 CDM 70190 CPT 320 RC outpatient 167 167 CIGNA 62308 [3081051] CIGNA 62308 [308105105] 133.6 percent of total billed charges 103.54 158.65 Technical (Hospital) Services Radex Optic Foramina PX-3207019000 CDM 70190 CPT 320 RC outpatient 167 167 CIGNA 62308 [3081051] CIGNA STATE OF WYOMING [308105107] 133.6 percent of total billed charges 103.54 158.65 Technical (Hospital) Services Radex Optic Foramina PX-3207019000 CDM 70190 CPT 320 RC outpatient 167 167 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES HDHP [308136802] 133.6 percent of total billed charges 103.54 158.65 Technical (Hospital) Services Radex Optic Foramina PX-3207019000 CDM 70190 CPT 320 RC outpatient 167 167 MULTIPLAN INC 34080 [3081285] MULTIPLAN INC [308128501] 158.65 percent of total billed charges 103.54 158.65 Technical (Hospital) Services Radex Optic Foramina PX-3207019000 CDM 70190 CPT 320 RC outpatient 167 167 BLUE CROSS BLUE SHIELD WELLMARK SB889 [3081026] BCBS WYOMING [308102603] 158.65 percent of total billed charges 103.54 158.65 Technical (Hospital) Services Radex Optic Foramina PX-3207019000 CDM 70190 CPT 320 RC outpatient 167 167 UNITED HEALTHCARE (COMMERCIAL) [3081199] UNITED HEALTHCARE 87726 [308119901] 103.54 percent of total billed charges 103.54 158.65 Technical (Hospital) Services Radex Optic Foramina PX-3207019000 CDM 70190 CPT 320 RC outpatient 167 167 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES EPO [308136803] 133.6 percent of total billed charges 103.54 158.65 Technical (Hospital) Services Radex Optic Foramina PX-3207019000 CDM 70190 CPT 320 RC outpatient 167 167 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES PPO [308136801] 133.6 percent of total billed charges 103.54 158.65 Technical (Hospital) Services Radex Optic Foramina PX-3207019000 CDM 70190 CPT 320 RC outpatient 167 167 MEDICA (COMMERCIAL) 94265 [3081118] MEDICA CLAIMS [308111801] 150.3 percent of total billed charges 103.54 158.65 Technical (Hospital) Services Radex Optic Foramina PX-3207019000 CDM 70190 CPT 320 RC outpatient 167 167 HEALTHPARTNERS SX009 HEALTHPARTNERS 133.6 percent of total billed charges 103.54 158.65 Technical (Hospital) Services Radex Optic Foramina PX-3207019000 CDM 70190 CPT 320 RC inpatient 167 167 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES EPO [308136803] 132.23 percent of total billed charges 103.54 158.65 Technical (Hospital) Services Radex Optic Foramina PX-3207019000 CDM 70190 CPT 320 RC inpatient 167 167 CIGNA 62308 [3081051] CIGNA 62308 [308105105] 132.23 percent of total billed charges 103.54 158.65 Technical (Hospital) Services Radex Optic Foramina PX-3207019000 CDM 70190 CPT 320 RC inpatient 167 167 CIGNA 62308 [3081051] CIGNA STATE OF WYOMING [308105107] 132.23 percent of total billed charges 103.54 158.65 Technical (Hospital) Services Radex Optic Foramina PX-3207019000 CDM 70190 CPT 320 RC inpatient 167 167 HEALTHPARTNERS SX009 HEALTHPARTNERS 132.23 percent of total billed charges 103.54 158.65 Technical (Hospital) Services Radex Optic Foramina PX-3207019000 CDM 70190 CPT 320 RC inpatient 167 167 MEDICA (COMMERCIAL) 94265 [3081118] MEDICA CLAIMS [308111801] 150.3 percent of total billed charges 103.54 158.65 Technical (Hospital) Services Radex Optic Foramina PX-3207019000 CDM 70190 CPT 320 RC inpatient 167 167 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES HDHP [308136802] 132.23 percent of total billed charges 103.54 158.65 Technical (Hospital) Services Radex Optic Foramina PX-3207019000 CDM 70190 CPT 320 RC inpatient 167 167 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES PPO [308136801] 132.23 percent of total billed charges 103.54 158.65 Technical (Hospital) Services Radex Optic Foramina PX-3207019000 CDM 70190 CPT 320 RC inpatient 167 167 BLUE CROSS BLUE SHIELD WELLMARK SB889 [3081026] BCBS WYOMING [308102603] 158.65 percent of total billed charges 103.54 158.65 Technical (Hospital) Services Radex Optic Foramina PX-3207019000 CDM 70190 CPT 320 RC inpatient 167 167 UNITED HEALTHCARE (COMMERCIAL) [3081199] UNITED HEALTHCARE 87726 [308119901] 103.54 percent of total billed charges 103.54 158.65 Technical (Hospital) Services Radex Optic Foramina PX-3207019000 CDM 70190 CPT 320 RC inpatient 167 167 MULTIPLAN INC 34080 [3081285] MULTIPLAN INC [308128501] 158.65 percent of total billed charges 103.54 158.65 Technical (Hospital) Services Radex Nasal Bones Complete Minimum 3 Views PX-3207016000 CDM 70160 CPT 320 RC outpatient 174 174 BLUE CROSS BLUE SHIELD WELLMARK SB889 [3081026] BCBS WYOMING [308102603] 165.3 percent of total billed charges 107.88 165.3 Technical (Hospital) Services Radex Nasal Bones Complete Minimum 3 Views PX-3207016000 CDM 70160 CPT 320 RC outpatient 174 174 UNITED HEALTHCARE (COMMERCIAL) [3081199] UNITED HEALTHCARE 87726 [308119901] 107.88 percent of total billed charges 107.88 165.3 Technical (Hospital) Services Radex Nasal Bones Complete Minimum 3 Views PX-3207016000 CDM 70160 CPT 320 RC outpatient 174 174 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES HDHP [308136802] 139.2 percent of total billed charges 107.88 165.3 Technical (Hospital) Services Radex Nasal Bones Complete Minimum 3 Views PX-3207016000 CDM 70160 CPT 320 RC outpatient 174 174 MULTIPLAN INC 34080 [3081285] MULTIPLAN INC [308128501] 165.3 percent of total billed charges 107.88 165.3 Technical (Hospital) Services Radex Nasal Bones Complete Minimum 3 Views PX-3207016000 CDM 70160 CPT 320 RC outpatient 174 174 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES EPO [308136803] 139.2 percent of total billed charges 107.88 165.3 Technical (Hospital) Services Radex Nasal Bones Complete Minimum 3 Views PX-3207016000 CDM 70160 CPT 320 RC outpatient 174 174 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES PPO [308136801] 139.2 percent of total billed charges 107.88 165.3 Technical (Hospital) Services Radex Nasal Bones Complete Minimum 3 Views PX-3207016000 CDM 70160 CPT 320 RC outpatient 174 174 HEALTHPARTNERS SX009 HEALTHPARTNERS 139.2 percent of total billed charges 107.88 165.3 Technical (Hospital) Services Radex Nasal Bones Complete Minimum 3 Views PX-3207016000 CDM 70160 CPT 320 RC outpatient 174 174 MEDICA (COMMERCIAL) 94265 [3081118] MEDICA CLAIMS [308111801] 156.6 percent of total billed charges 107.88 165.3 Technical (Hospital) Services Radex Nasal Bones Complete Minimum 3 Views PX-3207016000 CDM 70160 CPT 320 RC outpatient 174 174 CIGNA 62308 [3081051] CIGNA 62308 [308105105] 139.2 percent of total billed charges 107.88 165.3 Technical (Hospital) Services Radex Nasal Bones Complete Minimum 3 Views PX-3207016000 CDM 70160 CPT 320 RC outpatient 174 174 CIGNA 62308 [3081051] CIGNA STATE OF WYOMING [308105107] 139.2 percent of total billed charges 107.88 165.3 Technical (Hospital) Services Radex Nasal Bones Complete Minimum 3 Views PX-3207016000 CDM 70160 CPT 320 RC inpatient 174 174 UNITED HEALTHCARE (COMMERCIAL) [3081199] UNITED HEALTHCARE 87726 [308119901] 107.88 percent of total billed charges 107.88 165.3 Technical (Hospital) Services Radex Nasal Bones Complete Minimum 3 Views PX-3207016000 CDM 70160 CPT 320 RC inpatient 174 174 MULTIPLAN INC 34080 [3081285] MULTIPLAN INC [308128501] 165.3 percent of total billed charges 107.88 165.3 Technical (Hospital) Services Radex Nasal Bones Complete Minimum 3 Views PX-3207016000 CDM 70160 CPT 320 RC inpatient 174 174 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES PPO [308136801] 137.77 percent of total billed charges 107.88 165.3 Technical (Hospital) Services Radex Nasal Bones Complete Minimum 3 Views PX-3207016000 CDM 70160 CPT 320 RC inpatient 174 174 BLUE CROSS BLUE SHIELD WELLMARK SB889 [3081026] BCBS WYOMING [308102603] 165.3 percent of total billed charges 107.88 165.3 Technical (Hospital) Services Radex Nasal Bones Complete Minimum 3 Views PX-3207016000 CDM 70160 CPT 320 RC inpatient 174 174 MEDICA (COMMERCIAL) 94265 [3081118] MEDICA CLAIMS [308111801] 156.6 percent of total billed charges 107.88 165.3 Technical (Hospital) Services Radex Nasal Bones Complete Minimum 3 Views PX-3207016000 CDM 70160 CPT 320 RC inpatient 174 174 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES HDHP [308136802] 137.77 percent of total billed charges 107.88 165.3 Technical (Hospital) Services Radex Nasal Bones Complete Minimum 3 Views PX-3207016000 CDM 70160 CPT 320 RC inpatient 174 174 HEALTHPARTNERS SX009 HEALTHPARTNERS 137.77 percent of total billed charges 107.88 165.3 Technical (Hospital) Services Radex Nasal Bones Complete Minimum 3 Views PX-3207016000 CDM 70160 CPT 320 RC inpatient 174 174 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES EPO [308136803] 137.77 percent of total billed charges 107.88 165.3 Technical (Hospital) Services Radex Nasal Bones Complete Minimum 3 Views PX-3207016000 CDM 70160 CPT 320 RC inpatient 174 174 CIGNA 62308 [3081051] CIGNA 62308 [308105105] 137.77 percent of total billed charges 107.88 165.3 Technical (Hospital) Services Radex Nasal Bones Complete Minimum 3 Views PX-3207016000 CDM 70160 CPT 320 RC inpatient 174 174 CIGNA 62308 [3081051] CIGNA STATE OF WYOMING [308105107] 137.77 percent of total billed charges 107.88 165.3 Technical (Hospital) Services Radex Facial Bones Complete Minimum 3 Views PX-3207015000 CDM 70150 CPT 320 RC inpatient 542 542 MEDICA (COMMERCIAL) 94265 [3081118] MEDICA CLAIMS [308111801] 487.8 percent of total billed charges 336.04 514.9 Technical (Hospital) Services Radex Facial Bones Complete Minimum 3 Views PX-3207015000 CDM 70150 CPT 320 RC inpatient 542 542 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES HDHP [308136802] 429.16 percent of total billed charges 336.04 514.9 Technical (Hospital) Services Radex Facial Bones Complete Minimum 3 Views PX-3207015000 CDM 70150 CPT 320 RC inpatient 542 542 HEALTHPARTNERS SX009 HEALTHPARTNERS 429.16 percent of total billed charges 336.04 514.9 Technical (Hospital) Services Radex Facial Bones Complete Minimum 3 Views PX-3207015000 CDM 70150 CPT 320 RC inpatient 542 542 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES PPO [308136801] 429.16 percent of total billed charges 336.04 514.9 Technical (Hospital) Services Radex Facial Bones Complete Minimum 3 Views PX-3207015000 CDM 70150 CPT 320 RC inpatient 542 542 MULTIPLAN INC 34080 [3081285] MULTIPLAN INC [308128501] 514.9 percent of total billed charges 336.04 514.9 Technical (Hospital) Services Radex Facial Bones Complete Minimum 3 Views PX-3207015000 CDM 70150 CPT 320 RC inpatient 542 542 BLUE CROSS BLUE SHIELD WELLMARK SB889 [3081026] BCBS WYOMING [308102603] 514.9 percent of total billed charges 336.04 514.9 Technical (Hospital) Services Radex Facial Bones Complete Minimum 3 Views PX-3207015000 CDM 70150 CPT 320 RC inpatient 542 542 UNITED HEALTHCARE (COMMERCIAL) [3081199] UNITED HEALTHCARE 87726 [308119901] 336.04 percent of total billed charges 336.04 514.9 Technical (Hospital) Services Radex Facial Bones Complete Minimum 3 Views PX-3207015000 CDM 70150 CPT 320 RC inpatient 542 542 CIGNA 62308 [3081051] CIGNA 62308 [308105105] 429.16 percent of total billed charges 336.04 514.9 Technical (Hospital) Services Radex Facial Bones Complete Minimum 3 Views PX-3207015000 CDM 70150 CPT 320 RC inpatient 542 542 CIGNA 62308 [3081051] CIGNA STATE OF WYOMING [308105107] 429.16 percent of total billed charges 336.04 514.9 Technical (Hospital) Services Radex Facial Bones Complete Minimum 3 Views PX-3207015000 CDM 70150 CPT 320 RC inpatient 542 542 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES EPO [308136803] 429.16 percent of total billed charges 336.04 514.9 Technical (Hospital) Services Radex Facial Bones Complete Minimum 3 Views PX-3207015000 CDM 70150 CPT 320 RC outpatient 542 542 CIGNA 62308 [3081051] CIGNA 62308 [308105105] 433.6 percent of total billed charges 336.04 514.9 Technical (Hospital) Services Radex Facial Bones Complete Minimum 3 Views PX-3207015000 CDM 70150 CPT 320 RC outpatient 542 542 CIGNA 62308 [3081051] CIGNA STATE OF WYOMING [308105107] 433.6 percent of total billed charges 336.04 514.9 Technical (Hospital) Services Radex Facial Bones Complete Minimum 3 Views PX-3207015000 CDM 70150 CPT 320 RC outpatient 542 542 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES HDHP [308136802] 433.6 percent of total billed charges 336.04 514.9 Technical (Hospital) Services Radex Facial Bones Complete Minimum 3 Views PX-3207015000 CDM 70150 CPT 320 RC outpatient 542 542 MULTIPLAN INC 34080 [3081285] MULTIPLAN INC [308128501] 514.9 percent of total billed charges 336.04 514.9 Technical (Hospital) Services Radex Facial Bones Complete Minimum 3 Views PX-3207015000 CDM 70150 CPT 320 RC outpatient 542 542 BLUE CROSS BLUE SHIELD WELLMARK SB889 [3081026] BCBS WYOMING [308102603] 514.9 percent of total billed charges 336.04 514.9 Technical (Hospital) Services Radex Facial Bones Complete Minimum 3 Views PX-3207015000 CDM 70150 CPT 320 RC outpatient 542 542 UNITED HEALTHCARE (COMMERCIAL) [3081199] UNITED HEALTHCARE 87726 [308119901] 336.04 percent of total billed charges 336.04 514.9 Technical (Hospital) Services Radex Facial Bones Complete Minimum 3 Views PX-3207015000 CDM 70150 CPT 320 RC outpatient 542 542 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES EPO [308136803] 433.6 percent of total billed charges 336.04 514.9 Technical (Hospital) Services Radex Facial Bones Complete Minimum 3 Views PX-3207015000 CDM 70150 CPT 320 RC outpatient 542 542 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES PPO [308136801] 433.6 percent of total billed charges 336.04 514.9 Technical (Hospital) Services Radex Facial Bones Complete Minimum 3 Views PX-3207015000 CDM 70150 CPT 320 RC outpatient 542 542 MEDICA (COMMERCIAL) 94265 [3081118] MEDICA CLAIMS [308111801] 487.8 percent of total billed charges 336.04 514.9 Technical (Hospital) Services Radex Facial Bones Complete Minimum 3 Views PX-3207015000 CDM 70150 CPT 320 RC outpatient 542 542 HEALTHPARTNERS SX009 HEALTHPARTNERS 433.6 percent of total billed charges 336.04 514.9 Technical (Hospital) Services Radex Facial Bones < 3 Views PX-3207014000 CDM 70140 CPT 320 RC outpatient 238 238 MEDICA (COMMERCIAL) 94265 [3081118] MEDICA CLAIMS [308111801] 214.2 percent of total billed charges 147.56 226.1 Technical (Hospital) Services Radex Facial Bones < 3 Views PX-3207014000 CDM 70140 CPT 320 RC outpatient 238 238 CIGNA 62308 [3081051] CIGNA 62308 [308105105] 190.4 percent of total billed charges 147.56 226.1 Technical (Hospital) Services Radex Facial Bones < 3 Views PX-3207014000 CDM 70140 CPT 320 RC outpatient 238 238 CIGNA 62308 [3081051] CIGNA STATE OF WYOMING [308105107] 190.4 percent of total billed charges 147.56 226.1 Technical (Hospital) Services Radex Facial Bones < 3 Views PX-3207014000 CDM 70140 CPT 320 RC outpatient 238 238 HEALTHPARTNERS SX009 HEALTHPARTNERS 190.4 percent of total billed charges 147.56 226.1 Technical (Hospital) Services Radex Facial Bones < 3 Views PX-3207014000 CDM 70140 CPT 320 RC outpatient 238 238 BLUE CROSS BLUE SHIELD WELLMARK SB889 [3081026] BCBS WYOMING [308102603] 226.1 percent of total billed charges 147.56 226.1 Technical (Hospital) Services Radex Facial Bones < 3 Views PX-3207014000 CDM 70140 CPT 320 RC outpatient 238 238 UNITED HEALTHCARE (COMMERCIAL) [3081199] UNITED HEALTHCARE 87726 [308119901] 147.56 percent of total billed charges 147.56 226.1 Technical (Hospital) Services Radex Facial Bones < 3 Views PX-3207014000 CDM 70140 CPT 320 RC outpatient 238 238 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES HDHP [308136802] 190.4 percent of total billed charges 147.56 226.1 Technical (Hospital) Services Radex Facial Bones < 3 Views PX-3207014000 CDM 70140 CPT 320 RC outpatient 238 238 MULTIPLAN INC 34080 [3081285] MULTIPLAN INC [308128501] 226.1 percent of total billed charges 147.56 226.1 Technical (Hospital) Services Radex Facial Bones < 3 Views PX-3207014000 CDM 70140 CPT 320 RC outpatient 238 238 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES EPO [308136803] 190.4 percent of total billed charges 147.56 226.1 Technical (Hospital) Services Radex Facial Bones < 3 Views PX-3207014000 CDM 70140 CPT 320 RC outpatient 238 238 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES PPO [308136801] 190.4 percent of total billed charges 147.56 226.1 Technical (Hospital) Services Radex Facial Bones < 3 Views PX-3207014000 CDM 70140 CPT 320 RC inpatient 238 238 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES PPO [308136801] 188.45 percent of total billed charges 147.56 226.1 Technical (Hospital) Services Radex Facial Bones < 3 Views PX-3207014000 CDM 70140 CPT 320 RC inpatient 238 238 MULTIPLAN INC 34080 [3081285] MULTIPLAN INC [308128501] 226.1 percent of total billed charges 147.56 226.1 Technical (Hospital) Services Radex Facial Bones < 3 Views PX-3207014000 CDM 70140 CPT 320 RC inpatient 238 238 BLUE CROSS BLUE SHIELD WELLMARK SB889 [3081026] BCBS WYOMING [308102603] 226.1 percent of total billed charges 147.56 226.1 Technical (Hospital) Services Radex Facial Bones < 3 Views PX-3207014000 CDM 70140 CPT 320 RC inpatient 238 238 UNITED HEALTHCARE (COMMERCIAL) [3081199] UNITED HEALTHCARE 87726 [308119901] 147.56 percent of total billed charges 147.56 226.1 Technical (Hospital) Services Radex Facial Bones < 3 Views PX-3207014000 CDM 70140 CPT 320 RC inpatient 238 238 MEDICA (COMMERCIAL) 94265 [3081118] MEDICA CLAIMS [308111801] 214.2 percent of total billed charges 147.56 226.1 Technical (Hospital) Services Radex Facial Bones < 3 Views PX-3207014000 CDM 70140 CPT 320 RC inpatient 238 238 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES HDHP [308136802] 188.45 percent of total billed charges 147.56 226.1 Technical (Hospital) Services Radex Facial Bones < 3 Views PX-3207014000 CDM 70140 CPT 320 RC inpatient 238 238 HEALTHPARTNERS SX009 HEALTHPARTNERS 188.45 percent of total billed charges 147.56 226.1 Technical (Hospital) Services Radex Facial Bones < 3 Views PX-3207014000 CDM 70140 CPT 320 RC inpatient 238 238 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES EPO [308136803] 188.45 percent of total billed charges 147.56 226.1 Technical (Hospital) Services Radex Facial Bones < 3 Views PX-3207014000 CDM 70140 CPT 320 RC inpatient 238 238 CIGNA 62308 [3081051] CIGNA 62308 [308105105] 188.45 percent of total billed charges 147.56 226.1 Technical (Hospital) Services Radex Facial Bones < 3 Views PX-3207014000 CDM 70140 CPT 320 RC inpatient 238 238 CIGNA 62308 [3081051] CIGNA STATE OF WYOMING [308105107] 188.45 percent of total billed charges 147.56 226.1 Technical (Hospital) Services Radex Mastoids Compl Minimum 3 Views PR Side PX-3207013000 CDM 70130 CPT 320 RC inpatient 326 326 CIGNA 62308 [3081051] CIGNA 62308 [308105105] 258.13 percent of total billed charges 202.12 309.7 Technical (Hospital) Services Radex Mastoids Compl Minimum 3 Views PR Side PX-3207013000 CDM 70130 CPT 320 RC inpatient 326 326 CIGNA 62308 [3081051] CIGNA STATE OF WYOMING [308105107] 258.13 percent of total billed charges 202.12 309.7 Technical (Hospital) Services Radex Mastoids Compl Minimum 3 Views PR Side PX-3207013000 CDM 70130 CPT 320 RC inpatient 326 326 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES EPO [308136803] 258.13 percent of total billed charges 202.12 309.7 Technical (Hospital) Services Radex Mastoids Compl Minimum 3 Views PR Side PX-3207013000 CDM 70130 CPT 320 RC inpatient 326 326 HEALTHPARTNERS SX009 HEALTHPARTNERS 258.13 percent of total billed charges 202.12 309.7 Technical (Hospital) Services Radex Mastoids Compl Minimum 3 Views PR Side PX-3207013000 CDM 70130 CPT 320 RC inpatient 326 326 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES HDHP [308136802] 258.13 percent of total billed charges 202.12 309.7 Technical (Hospital) Services Radex Mastoids Compl Minimum 3 Views PR Side PX-3207013000 CDM 70130 CPT 320 RC inpatient 326 326 MEDICA (COMMERCIAL) 94265 [3081118] MEDICA CLAIMS [308111801] 293.4 percent of total billed charges 202.12 309.7 Technical (Hospital) Services Radex Mastoids Compl Minimum 3 Views PR Side PX-3207013000 CDM 70130 CPT 320 RC inpatient 326 326 BLUE CROSS BLUE SHIELD WELLMARK SB889 [3081026] BCBS WYOMING [308102603] 309.7 percent of total billed charges 202.12 309.7 Technical (Hospital) Services Radex Mastoids Compl Minimum 3 Views PR Side PX-3207013000 CDM 70130 CPT 320 RC inpatient 326 326 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES PPO [308136801] 258.13 percent of total billed charges 202.12 309.7 Technical (Hospital) Services Radex Mastoids Compl Minimum 3 Views PR Side PX-3207013000 CDM 70130 CPT 320 RC inpatient 326 326 MULTIPLAN INC 34080 [3081285] MULTIPLAN INC [308128501] 309.7 percent of total billed charges 202.12 309.7 Technical (Hospital) Services Radex Mastoids Compl Minimum 3 Views PR Side PX-3207013000 CDM 70130 CPT 320 RC inpatient 326 326 UNITED HEALTHCARE (COMMERCIAL) [3081199] UNITED HEALTHCARE 87726 [308119901] 202.12 percent of total billed charges 202.12 309.7 Technical (Hospital) Services Radex Mastoids Compl Minimum 3 Views PR Side PX-3207013000 CDM 70130 CPT 320 RC outpatient 326 326 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES PPO [308136801] 260.8 percent of total billed charges 202.12 309.7 Technical (Hospital) Services Radex Mastoids Compl Minimum 3 Views PR Side PX-3207013000 CDM 70130 CPT 320 RC outpatient 326 326 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES EPO [308136803] 260.8 percent of total billed charges 202.12 309.7 Technical (Hospital) Services Radex Mastoids Compl Minimum 3 Views PR Side PX-3207013000 CDM 70130 CPT 320 RC outpatient 326 326 BLUE CROSS BLUE SHIELD WELLMARK SB889 [3081026] BCBS WYOMING [308102603] 309.7 percent of total billed charges 202.12 309.7 Technical (Hospital) Services Radex Mastoids Compl Minimum 3 Views PR Side PX-3207013000 CDM 70130 CPT 320 RC outpatient 326 326 UNITED HEALTHCARE (COMMERCIAL) [3081199] UNITED HEALTHCARE 87726 [308119901] 202.12 percent of total billed charges 202.12 309.7 Technical (Hospital) Services Radex Mastoids Compl Minimum 3 Views PR Side PX-3207013000 CDM 70130 CPT 320 RC outpatient 326 326 MULTIPLAN INC 34080 [3081285] MULTIPLAN INC [308128501] 309.7 percent of total billed charges 202.12 309.7 Technical (Hospital) Services Radex Mastoids Compl Minimum 3 Views PR Side PX-3207013000 CDM 70130 CPT 320 RC outpatient 326 326 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES HDHP [308136802] 260.8 percent of total billed charges 202.12 309.7 Technical (Hospital) Services Radex Mastoids Compl Minimum 3 Views PR Side PX-3207013000 CDM 70130 CPT 320 RC outpatient 326 326 MEDICA (COMMERCIAL) 94265 [3081118] MEDICA CLAIMS [308111801] 293.4 percent of total billed charges 202.12 309.7 Technical (Hospital) Services Radex Mastoids Compl Minimum 3 Views PR Side PX-3207013000 CDM 70130 CPT 320 RC outpatient 326 326 HEALTHPARTNERS SX009 HEALTHPARTNERS 260.8 percent of total billed charges 202.12 309.7 Technical (Hospital) Services Radex Mastoids Compl Minimum 3 Views PR Side PX-3207013000 CDM 70130 CPT 320 RC outpatient 326 326 CIGNA 62308 [3081051] CIGNA 62308 [308105105] 260.8 percent of total billed charges 202.12 309.7 Technical (Hospital) Services Radex Mastoids Compl Minimum 3 Views PR Side PX-3207013000 CDM 70130 CPT 320 RC outpatient 326 326 CIGNA 62308 [3081051] CIGNA STATE OF WYOMING [308105107] 260.8 percent of total billed charges 202.12 309.7 Technical (Hospital) Services Radiolog Exam Mandible Compl Minimum 4 Views PX-3207011000 CDM 70110 CPT 320 RC outpatient 502 502 MEDICA (COMMERCIAL) 94265 [3081118] MEDICA CLAIMS [308111801] 451.8 percent of total billed charges 311.24 476.9 Technical (Hospital) Services Radiolog Exam Mandible Compl Minimum 4 Views PX-3207011000 CDM 70110 CPT 320 RC outpatient 502 502 CIGNA 62308 [3081051] CIGNA 62308 [308105105] 401.6 percent of total billed charges 311.24 476.9 Technical (Hospital) Services Radiolog Exam Mandible Compl Minimum 4 Views PX-3207011000 CDM 70110 CPT 320 RC outpatient 502 502 CIGNA 62308 [3081051] CIGNA STATE OF WYOMING [308105107] 401.6 percent of total billed charges 311.24 476.9 Technical (Hospital) Services Radiolog Exam Mandible Compl Minimum 4 Views PX-3207011000 CDM 70110 CPT 320 RC outpatient 502 502 HEALTHPARTNERS SX009 HEALTHPARTNERS 401.6 percent of total billed charges 311.24 476.9 Technical (Hospital) Services Radiolog Exam Mandible Compl Minimum 4 Views PX-3207011000 CDM 70110 CPT 320 RC outpatient 502 502 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES EPO [308136803] 401.6 percent of total billed charges 311.24 476.9 Technical (Hospital) Services Radiolog Exam Mandible Compl Minimum 4 Views PX-3207011000 CDM 70110 CPT 320 RC outpatient 502 502 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES PPO [308136801] 401.6 percent of total billed charges 311.24 476.9 Technical (Hospital) Services Radiolog Exam Mandible Compl Minimum 4 Views PX-3207011000 CDM 70110 CPT 320 RC outpatient 502 502 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES HDHP [308136802] 401.6 percent of total billed charges 311.24 476.9 Technical (Hospital) Services Radiolog Exam Mandible Compl Minimum 4 Views PX-3207011000 CDM 70110 CPT 320 RC outpatient 502 502 MULTIPLAN INC 34080 [3081285] MULTIPLAN INC [308128501] 476.9 percent of total billed charges 311.24 476.9 Technical (Hospital) Services Radiolog Exam Mandible Compl Minimum 4 Views PX-3207011000 CDM 70110 CPT 320 RC outpatient 502 502 UNITED HEALTHCARE (COMMERCIAL) [3081199] UNITED HEALTHCARE 87726 [308119901] 311.24 percent of total billed charges 311.24 476.9 Technical (Hospital) Services Radiolog Exam Mandible Compl Minimum 4 Views PX-3207011000 CDM 70110 CPT 320 RC outpatient 502 502 BLUE CROSS BLUE SHIELD WELLMARK SB889 [3081026] BCBS WYOMING [308102603] 476.9 percent of total billed charges 311.24 476.9 Technical (Hospital) Services Radiolog Exam Mandible Compl Minimum 4 Views PX-3207011000 CDM 70110 CPT 320 RC inpatient 502 502 BLUE CROSS BLUE SHIELD WELLMARK SB889 [3081026] BCBS WYOMING [308102603] 476.9 percent of total billed charges 311.24 476.9 Technical (Hospital) Services Radiolog Exam Mandible Compl Minimum 4 Views PX-3207011000 CDM 70110 CPT 320 RC inpatient 502 502 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES PPO [308136801] 397.48 percent of total billed charges 311.24 476.9 Technical (Hospital) Services Radiolog Exam Mandible Compl Minimum 4 Views PX-3207011000 CDM 70110 CPT 320 RC inpatient 502 502 MULTIPLAN INC 34080 [3081285] MULTIPLAN INC [308128501] 476.9 percent of total billed charges 311.24 476.9 Technical (Hospital) Services Radiolog Exam Mandible Compl Minimum 4 Views PX-3207011000 CDM 70110 CPT 320 RC inpatient 502 502 UNITED HEALTHCARE (COMMERCIAL) [3081199] UNITED HEALTHCARE 87726 [308119901] 311.24 percent of total billed charges 311.24 476.9 Technical (Hospital) Services Radiolog Exam Mandible Compl Minimum 4 Views PX-3207011000 CDM 70110 CPT 320 RC inpatient 502 502 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES HDHP [308136802] 397.48 percent of total billed charges 311.24 476.9 Technical (Hospital) Services Radiolog Exam Mandible Compl Minimum 4 Views PX-3207011000 CDM 70110 CPT 320 RC inpatient 502 502 MEDICA (COMMERCIAL) 94265 [3081118] MEDICA CLAIMS [308111801] 451.8 percent of total billed charges 311.24 476.9 Technical (Hospital) Services Radiolog Exam Mandible Compl Minimum 4 Views PX-3207011000 CDM 70110 CPT 320 RC inpatient 502 502 HEALTHPARTNERS SX009 HEALTHPARTNERS 397.48 percent of total billed charges 311.24 476.9 Technical (Hospital) Services Radiolog Exam Mandible Compl Minimum 4 Views PX-3207011000 CDM 70110 CPT 320 RC inpatient 502 502 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES EPO [308136803] 397.48 percent of total billed charges 311.24 476.9 Technical (Hospital) Services Radiolog Exam Mandible Compl Minimum 4 Views PX-3207011000 CDM 70110 CPT 320 RC inpatient 502 502 CIGNA 62308 [3081051] CIGNA 62308 [308105105] 397.48 percent of total billed charges 311.24 476.9 Technical (Hospital) Services Radiolog Exam Mandible Compl Minimum 4 Views PX-3207011000 CDM 70110 CPT 320 RC inpatient 502 502 CIGNA 62308 [3081051] CIGNA STATE OF WYOMING [308105107] 397.48 percent of total billed charges 311.24 476.9 Technical (Hospital) Services Radiologic Examination Mandiple Prtl <4 Views PX-3207010000 CDM 70100 CPT 320 RC outpatient 181 181 CIGNA 62308 [3081051] CIGNA 62308 [308105105] 144.8 percent of total billed charges 112.22 171.95 Technical (Hospital) Services Radiologic Examination Mandiple Prtl <4 Views PX-3207010000 CDM 70100 CPT 320 RC outpatient 181 181 CIGNA 62308 [3081051] CIGNA STATE OF WYOMING [308105107] 144.8 percent of total billed charges 112.22 171.95 Technical (Hospital) Services Radiologic Examination Mandiple Prtl <4 Views PX-3207010000 CDM 70100 CPT 320 RC outpatient 181 181 MEDICA (COMMERCIAL) 94265 [3081118] MEDICA CLAIMS [308111801] 162.9 percent of total billed charges 112.22 171.95 Technical (Hospital) Services Radiologic Examination Mandiple Prtl <4 Views PX-3207010000 CDM 70100 CPT 320 RC outpatient 181 181 HEALTHPARTNERS SX009 HEALTHPARTNERS 144.8 percent of total billed charges 112.22 171.95 Technical (Hospital) Services Radiologic Examination Mandiple Prtl <4 Views PX-3207010000 CDM 70100 CPT 320 RC outpatient 181 181 UNITED HEALTHCARE (COMMERCIAL) [3081199] UNITED HEALTHCARE 87726 [308119901] 112.22 percent of total billed charges 112.22 171.95 Technical (Hospital) Services Radiologic Examination Mandiple Prtl <4 Views PX-3207010000 CDM 70100 CPT 320 RC outpatient 181 181 BLUE CROSS BLUE SHIELD WELLMARK SB889 [3081026] BCBS WYOMING [308102603] 171.95 percent of total billed charges 112.22 171.95 Technical (Hospital) Services Radiologic Examination Mandiple Prtl <4 Views PX-3207010000 CDM 70100 CPT 320 RC outpatient 181 181 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES HDHP [308136802] 144.8 percent of total billed charges 112.22 171.95 Technical (Hospital) Services Radiologic Examination Mandiple Prtl <4 Views PX-3207010000 CDM 70100 CPT 320 RC outpatient 181 181 MULTIPLAN INC 34080 [3081285] MULTIPLAN INC [308128501] 171.95 percent of total billed charges 112.22 171.95 Technical (Hospital) Services Radiologic Examination Mandiple Prtl <4 Views PX-3207010000 CDM 70100 CPT 320 RC outpatient 181 181 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES PPO [308136801] 144.8 percent of total billed charges 112.22 171.95 Technical (Hospital) Services Radiologic Examination Mandiple Prtl <4 Views PX-3207010000 CDM 70100 CPT 320 RC outpatient 181 181 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES EPO [308136803] 144.8 percent of total billed charges 112.22 171.95 Technical (Hospital) Services Radiologic Examination Mandiple Prtl <4 Views PX-3207010000 CDM 70100 CPT 320 RC inpatient 181 181 CIGNA 62308 [3081051] CIGNA 62308 [308105105] 143.32 percent of total billed charges 112.22 171.95 Technical (Hospital) Services Radiologic Examination Mandiple Prtl <4 Views PX-3207010000 CDM 70100 CPT 320 RC inpatient 181 181 CIGNA 62308 [3081051] CIGNA STATE OF WYOMING [308105107] 143.32 percent of total billed charges 112.22 171.95 Technical (Hospital) Services Radiologic Examination Mandiple Prtl <4 Views PX-3207010000 CDM 70100 CPT 320 RC inpatient 181 181 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES EPO [308136803] 143.32 percent of total billed charges 112.22 171.95 Technical (Hospital) Services Radiologic Examination Mandiple Prtl <4 Views PX-3207010000 CDM 70100 CPT 320 RC inpatient 181 181 MULTIPLAN INC 34080 [3081285] MULTIPLAN INC [308128501] 171.95 percent of total billed charges 112.22 171.95 Technical (Hospital) Services Radiologic Examination Mandiple Prtl <4 Views PX-3207010000 CDM 70100 CPT 320 RC inpatient 181 181 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES PPO [308136801] 143.32 percent of total billed charges 112.22 171.95 Technical (Hospital) Services Radiologic Examination Mandiple Prtl <4 Views PX-3207010000 CDM 70100 CPT 320 RC inpatient 181 181 BLUE CROSS BLUE SHIELD WELLMARK SB889 [3081026] BCBS WYOMING [308102603] 171.95 percent of total billed charges 112.22 171.95 Technical (Hospital) Services Radiologic Examination Mandiple Prtl <4 Views PX-3207010000 CDM 70100 CPT 320 RC inpatient 181 181 UNITED HEALTHCARE (COMMERCIAL) [3081199] UNITED HEALTHCARE 87726 [308119901] 112.22 percent of total billed charges 112.22 171.95 Technical (Hospital) Services Radiologic Examination Mandiple Prtl <4 Views PX-3207010000 CDM 70100 CPT 320 RC inpatient 181 181 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES HDHP [308136802] 143.32 percent of total billed charges 112.22 171.95 Technical (Hospital) Services Radiologic Examination Mandiple Prtl <4 Views PX-3207010000 CDM 70100 CPT 320 RC inpatient 181 181 HEALTHPARTNERS SX009 HEALTHPARTNERS 143.32 percent of total billed charges 112.22 171.95 Technical (Hospital) Services Radiologic Examination Mandiple Prtl <4 Views PX-3207010000 CDM 70100 CPT 320 RC inpatient 181 181 MEDICA (COMMERCIAL) 94265 [3081118] MEDICA CLAIMS [308111801] 162.9 percent of total billed charges 112.22 171.95 Technical (Hospital) Services Removal Impacted Cerumen Instrumentation Unilat PX-69210 CDM 69210 CPT inpatient 218 218 CIGNA 62308 [3081051] CIGNA 62308 [308105105] 174.4 percent of total billed charges 135.16 207.1 Professional (doctor) services Removal Impacted Cerumen Instrumentation Unilat PX-69210 CDM 69210 CPT inpatient 218 218 CIGNA 62308 [3081051] CIGNA STATE OF WYOMING [308105107] 174.4 percent of total billed charges 135.16 207.1 Professional (doctor) services Removal Impacted Cerumen Instrumentation Unilat PX-69210 CDM 69210 CPT outpatient 218 218 CIGNA 62308 [3081051] CIGNA 62308 [308105105] 174.4 percent of total billed charges 135.16 207.1 Professional (doctor) services Removal Impacted Cerumen Instrumentation Unilat PX-69210 CDM 69210 CPT outpatient 218 218 CIGNA 62308 [3081051] CIGNA STATE OF WYOMING [308105107] 174.4 percent of total billed charges 135.16 207.1 Professional (doctor) services Removal Impacted Cerumen Instrumentation Unilat PX-69210 CDM 69210 CPT inpatient 218 218 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES EPO [308136803] 174.4 percent of total billed charges 135.16 207.1 Professional (doctor) services Removal Impacted Cerumen Instrumentation Unilat PX-69210 CDM 69210 CPT inpatient 218 218 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES HDHP [308136802] 174.4 percent of total billed charges 135.16 207.1 Professional (doctor) services Removal Impacted Cerumen Instrumentation Unilat PX-69210 CDM 69210 CPT inpatient 218 218 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES PPO [308136801] 174.4 percent of total billed charges 135.16 207.1 Professional (doctor) services Removal Impacted Cerumen Instrumentation Unilat PX-69210 CDM 69210 CPT outpatient 218 218 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES EPO [308136803] 174.4 percent of total billed charges 135.16 207.1 Professional (doctor) services Removal Impacted Cerumen Instrumentation Unilat PX-69210 CDM 69210 CPT outpatient 218 218 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES HDHP [308136802] 174.4 percent of total billed charges 135.16 207.1 Professional (doctor) services Removal Impacted Cerumen Instrumentation Unilat PX-69210 CDM 69210 CPT outpatient 218 218 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES PPO [308136801] 174.4 percent of total billed charges 135.16 207.1 Professional (doctor) services Removal Impacted Cerumen Instrumentation Unilat PX-69210 CDM 69210 CPT inpatient 218 218 HEALTHPARTNERS SX009 HEALTHPARTNERS 174.4 percent of total billed charges 135.16 207.1 Professional (doctor) services Removal Impacted Cerumen Instrumentation Unilat PX-69210 CDM 69210 CPT outpatient 218 218 HEALTHPARTNERS SX009 HEALTHPARTNERS 174.4 percent of total billed charges 135.16 207.1 Professional (doctor) services Removal Impacted Cerumen Instrumentation Unilat PX-69210 CDM 69210 CPT inpatient 218 218 MEDICA (COMMERCIAL) 94265 [3081118] MEDICA CLAIMS [308111801] 196.2 percent of total billed charges 135.16 207.1 Professional (doctor) services Removal Impacted Cerumen Instrumentation Unilat PX-69210 CDM 69210 CPT outpatient 218 218 MEDICA (COMMERCIAL) 94265 [3081118] MEDICA CLAIMS [308111801] 196.2 percent of total billed charges 135.16 207.1 Professional (doctor) services Removal Impacted Cerumen Instrumentation Unilat PX-69210 CDM 69210 CPT inpatient 218 218 MULTIPLAN INC 34080 [3081285] MULTIPLAN INC [308128501] 207.1 percent of total billed charges 135.16 207.1 Professional (doctor) services Removal Impacted Cerumen Instrumentation Unilat PX-69210 CDM 69210 CPT outpatient 218 218 MULTIPLAN INC 34080 [3081285] MULTIPLAN INC [308128501] 207.1 percent of total billed charges 135.16 207.1 Professional (doctor) services Removal Impacted Cerumen Instrumentation Unilat PX-69210 CDM 69210 CPT inpatient 218 218 UNITED HEALTHCARE (COMMERCIAL) [3081199] UNITED HEALTHCARE 87726 [308119901] 135.16 percent of total billed charges 135.16 207.1 Professional (doctor) services Removal Impacted Cerumen Instrumentation Unilat PX-69210 CDM 69210 CPT outpatient 218 218 UNITED HEALTHCARE (COMMERCIAL) [3081199] UNITED HEALTHCARE 87726 [308119901] 135.16 percent of total billed charges 135.16 207.1 Professional (doctor) services Rmvl FB Xtrnl Auditory Canal W/O Anes PX-3606920000 CDM 69200 CPT 360 RC outpatient 550 550 MEDICA (COMMERCIAL) 94265 [3081118] MEDICA CLAIMS [308111801] 495 percent of total billed charges 341 522.5 Technical (Hospital) Services Rmvl FB Xtrnl Auditory Canal W/O Anes PX-3606920000 CDM 69200 CPT 360 RC outpatient 550 550 CIGNA 62308 [3081051] CIGNA 62308 [308105105] 440 percent of total billed charges 341 522.5 Technical (Hospital) Services Rmvl FB Xtrnl Auditory Canal W/O Anes PX-3606920000 CDM 69200 CPT 360 RC outpatient 550 550 CIGNA 62308 [3081051] CIGNA STATE OF WYOMING [308105107] 440 percent of total billed charges 341 522.5 Technical (Hospital) Services Rmvl FB Xtrnl Auditory Canal W/O Anes PX-3606920000 CDM 69200 CPT 360 RC outpatient 550 550 HEALTHPARTNERS SX009 HEALTHPARTNERS 440 percent of total billed charges 341 522.5 Technical (Hospital) Services Rmvl FB Xtrnl Auditory Canal W/O Anes PX-3606920000 CDM 69200 CPT 360 RC outpatient 550 550 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES EPO [308136803] 440 percent of total billed charges 341 522.5 Technical (Hospital) Services Rmvl FB Xtrnl Auditory Canal W/O Anes PX-3606920000 CDM 69200 CPT 360 RC outpatient 550 550 UNITED HEALTHCARE (COMMERCIAL) [3081199] UNITED HEALTHCARE 87726 [308119901] 341 percent of total billed charges 341 522.5 Technical (Hospital) Services Rmvl FB Xtrnl Auditory Canal W/O Anes PX-3606920000 CDM 69200 CPT 360 RC outpatient 550 550 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES PPO [308136801] 440 percent of total billed charges 341 522.5 Technical (Hospital) Services Rmvl FB Xtrnl Auditory Canal W/O Anes PX-3606920000 CDM 69200 CPT 360 RC outpatient 550 550 BLUE CROSS BLUE SHIELD WELLMARK SB889 [3081026] BCBS WYOMING [308102603] 522.5 percent of total billed charges 341 522.5 Technical (Hospital) Services Rmvl FB Xtrnl Auditory Canal W/O Anes PX-3606920000 CDM 69200 CPT 360 RC outpatient 550 550 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES HDHP [308136802] 440 percent of total billed charges 341 522.5 Technical (Hospital) Services Rmvl FB Xtrnl Auditory Canal W/O Anes PX-3606920000 CDM 69200 CPT 360 RC outpatient 550 550 MULTIPLAN INC 34080 [3081285] MULTIPLAN INC [308128501] 522.5 percent of total billed charges 341 522.5 Technical (Hospital) Services Rmvl FB Xtrnl Auditory Canal W/O Anes PX-3606920000 CDM 69200 CPT 360 RC inpatient 550 550 CIGNA 62308 [3081051] CIGNA 62308 [308105105] 435.49 percent of total billed charges 341 522.5 Technical (Hospital) Services Rmvl FB Xtrnl Auditory Canal W/O Anes PX-3606920000 CDM 69200 CPT 360 RC inpatient 550 550 CIGNA 62308 [3081051] CIGNA STATE OF WYOMING [308105107] 435.49 percent of total billed charges 341 522.5 Technical (Hospital) Services Rmvl FB Xtrnl Auditory Canal W/O Anes PX-3606920000 CDM 69200 CPT 360 RC inpatient 550 550 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES EPO [308136803] 435.49 percent of total billed charges 341 522.5 Technical (Hospital) Services Rmvl FB Xtrnl Auditory Canal W/O Anes PX-3606920000 CDM 69200 CPT 360 RC inpatient 550 550 HEALTHPARTNERS SX009 HEALTHPARTNERS 435.49 percent of total billed charges 341 522.5 Technical (Hospital) Services Rmvl FB Xtrnl Auditory Canal W/O Anes PX-3606920000 CDM 69200 CPT 360 RC inpatient 550 550 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES HDHP [308136802] 435.49 percent of total billed charges 341 522.5 Technical (Hospital) Services Rmvl FB Xtrnl Auditory Canal W/O Anes PX-3606920000 CDM 69200 CPT 360 RC inpatient 550 550 MEDICA (COMMERCIAL) 94265 [3081118] MEDICA CLAIMS [308111801] 495 percent of total billed charges 341 522.5 Technical (Hospital) Services Rmvl FB Xtrnl Auditory Canal W/O Anes PX-3606920000 CDM 69200 CPT 360 RC inpatient 550 550 UNITED HEALTHCARE (COMMERCIAL) [3081199] UNITED HEALTHCARE 87726 [308119901] 341 percent of total billed charges 341 522.5 Technical (Hospital) Services Rmvl FB Xtrnl Auditory Canal W/O Anes PX-3606920000 CDM 69200 CPT 360 RC inpatient 550 550 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES PPO [308136801] 435.49 percent of total billed charges 341 522.5 Technical (Hospital) Services Rmvl FB Xtrnl Auditory Canal W/O Anes PX-3606920000 CDM 69200 CPT 360 RC inpatient 550 550 BLUE CROSS BLUE SHIELD WELLMARK SB889 [3081026] BCBS WYOMING [308102603] 522.5 percent of total billed charges 341 522.5 Technical (Hospital) Services Rmvl FB Xtrnl Auditory Canal W/O Anes PX-3606920000 CDM 69200 CPT 360 RC inpatient 550 550 MULTIPLAN INC 34080 [3081285] MULTIPLAN INC [308128501] 522.5 percent of total billed charges 341 522.5 Technical (Hospital) Services Remv Ext Canal Foreign Body PX-69200 CDM 69200 CPT inpatient 550 550 CIGNA 62308 [3081051] CIGNA 62308 [308105105] 440 percent of total billed charges 341 522.5 Professional (doctor) services Remv Ext Canal Foreign Body PX-69200 CDM 69200 CPT inpatient 550 550 CIGNA 62308 [3081051] CIGNA STATE OF WYOMING [308105107] 440 percent of total billed charges 341 522.5 Professional (doctor) services Remv Ext Canal Foreign Body PX-69200 CDM 69200 CPT outpatient 550 550 CIGNA 62308 [3081051] CIGNA 62308 [308105105] 440 percent of total billed charges 341 522.5 Professional (doctor) services Remv Ext Canal Foreign Body PX-69200 CDM 69200 CPT outpatient 550 550 CIGNA 62308 [3081051] CIGNA STATE OF WYOMING [308105107] 440 percent of total billed charges 341 522.5 Professional (doctor) services Remv Ext Canal Foreign Body PX-69200 CDM 69200 CPT inpatient 550 550 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES EPO [308136803] 440 percent of total billed charges 341 522.5 Professional (doctor) services Remv Ext Canal Foreign Body PX-69200 CDM 69200 CPT inpatient 550 550 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES HDHP [308136802] 440 percent of total billed charges 341 522.5 Professional (doctor) services Remv Ext Canal Foreign Body PX-69200 CDM 69200 CPT inpatient 550 550 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES PPO [308136801] 440 percent of total billed charges 341 522.5 Professional (doctor) services Remv Ext Canal Foreign Body PX-69200 CDM 69200 CPT outpatient 550 550 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES EPO [308136803] 440 percent of total billed charges 341 522.5 Professional (doctor) services Remv Ext Canal Foreign Body PX-69200 CDM 69200 CPT outpatient 550 550 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES HDHP [308136802] 440 percent of total billed charges 341 522.5 Professional (doctor) services Remv Ext Canal Foreign Body PX-69200 CDM 69200 CPT outpatient 550 550 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES PPO [308136801] 440 percent of total billed charges 341 522.5 Professional (doctor) services Remv Ext Canal Foreign Body PX-69200 CDM 69200 CPT inpatient 550 550 HEALTHPARTNERS SX009 HEALTHPARTNERS 440 percent of total billed charges 341 522.5 Professional (doctor) services Remv Ext Canal Foreign Body PX-69200 CDM 69200 CPT outpatient 550 550 HEALTHPARTNERS SX009 HEALTHPARTNERS 440 percent of total billed charges 341 522.5 Professional (doctor) services Remv Ext Canal Foreign Body PX-69200 CDM 69200 CPT inpatient 550 550 MEDICA (COMMERCIAL) 94265 [3081118] MEDICA CLAIMS [308111801] 495 percent of total billed charges 341 522.5 Professional (doctor) services Remv Ext Canal Foreign Body PX-69200 CDM 69200 CPT outpatient 550 550 MEDICA (COMMERCIAL) 94265 [3081118] MEDICA CLAIMS [308111801] 495 percent of total billed charges 341 522.5 Professional (doctor) services Remv Ext Canal Foreign Body PX-69200 CDM 69200 CPT inpatient 550 550 MULTIPLAN INC 34080 [3081285] MULTIPLAN INC [308128501] 522.5 percent of total billed charges 341 522.5 Professional (doctor) services Remv Ext Canal Foreign Body PX-69200 CDM 69200 CPT outpatient 550 550 MULTIPLAN INC 34080 [3081285] MULTIPLAN INC [308128501] 522.5 percent of total billed charges 341 522.5 Professional (doctor) services Remv Ext Canal Foreign Body PX-69200 CDM 69200 CPT inpatient 550 550 UNITED HEALTHCARE (COMMERCIAL) [3081199] UNITED HEALTHCARE 87726 [308119901] 341 percent of total billed charges 341 522.5 Professional (doctor) services Remv Ext Canal Foreign Body PX-69200 CDM 69200 CPT outpatient 550 550 UNITED HEALTHCARE (COMMERCIAL) [3081199] UNITED HEALTHCARE 87726 [308119901] 341 percent of total billed charges 341 522.5 Professional (doctor) services Rmvl FB Xtrnl Eye Corneal W/O Slit Lamp PX-3606522000 CDM 65220 CPT 360 RC inpatient 428 428 HEALTHPARTNERS SX009 HEALTHPARTNERS 338.89 percent of total billed charges 265.36 406.6 Technical (Hospital) Services Rmvl FB Xtrnl Eye Corneal W/O Slit Lamp PX-3606522000 CDM 65220 CPT 360 RC inpatient 428 428 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES HDHP [308136802] 338.89 percent of total billed charges 265.36 406.6 Technical (Hospital) Services Rmvl FB Xtrnl Eye Corneal W/O Slit Lamp PX-3606522000 CDM 65220 CPT 360 RC inpatient 428 428 MEDICA (COMMERCIAL) 94265 [3081118] MEDICA CLAIMS [308111801] 385.2 percent of total billed charges 265.36 406.6 Technical (Hospital) Services Rmvl FB Xtrnl Eye Corneal W/O Slit Lamp PX-3606522000 CDM 65220 CPT 360 RC inpatient 428 428 MULTIPLAN INC 34080 [3081285] MULTIPLAN INC [308128501] 406.6 percent of total billed charges 265.36 406.6 Technical (Hospital) Services Rmvl FB Xtrnl Eye Corneal W/O Slit Lamp PX-3606522000 CDM 65220 CPT 360 RC inpatient 428 428 BLUE CROSS BLUE SHIELD WELLMARK SB889 [3081026] BCBS WYOMING [308102603] 406.6 percent of total billed charges 265.36 406.6 Technical (Hospital) Services Rmvl FB Xtrnl Eye Corneal W/O Slit Lamp PX-3606522000 CDM 65220 CPT 360 RC inpatient 428 428 UNITED HEALTHCARE (COMMERCIAL) [3081199] UNITED HEALTHCARE 87726 [308119901] 265.36 percent of total billed charges 265.36 406.6 Technical (Hospital) Services Rmvl FB Xtrnl Eye Corneal W/O Slit Lamp PX-3606522000 CDM 65220 CPT 360 RC inpatient 428 428 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES PPO [308136801] 338.89 percent of total billed charges 265.36 406.6 Technical (Hospital) Services Rmvl FB Xtrnl Eye Corneal W/O Slit Lamp PX-3606522000 CDM 65220 CPT 360 RC inpatient 428 428 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES EPO [308136803] 338.89 percent of total billed charges 265.36 406.6 Technical (Hospital) Services Rmvl FB Xtrnl Eye Corneal W/O Slit Lamp PX-3606522000 CDM 65220 CPT 360 RC inpatient 428 428 CIGNA 62308 [3081051] CIGNA 62308 [308105105] 338.89 percent of total billed charges 265.36 406.6 Technical (Hospital) Services Rmvl FB Xtrnl Eye Corneal W/O Slit Lamp PX-3606522000 CDM 65220 CPT 360 RC inpatient 428 428 CIGNA 62308 [3081051] CIGNA STATE OF WYOMING [308105107] 338.89 percent of total billed charges 265.36 406.6 Technical (Hospital) Services Rmvl FB Xtrnl Eye Corneal W/O Slit Lamp PX-3606522000 CDM 65220 CPT 360 RC outpatient 428 428 HEALTHPARTNERS SX009 HEALTHPARTNERS 342.4 percent of total billed charges 265.36 406.6 Technical (Hospital) Services Rmvl FB Xtrnl Eye Corneal W/O Slit Lamp PX-3606522000 CDM 65220 CPT 360 RC outpatient 428 428 MEDICA (COMMERCIAL) 94265 [3081118] MEDICA CLAIMS [308111801] 385.2 percent of total billed charges 265.36 406.6 Technical (Hospital) Services Rmvl FB Xtrnl Eye Corneal W/O Slit Lamp PX-3606522000 CDM 65220 CPT 360 RC outpatient 428 428 UNITED HEALTHCARE (COMMERCIAL) [3081199] UNITED HEALTHCARE 87726 [308119901] 265.36 percent of total billed charges 265.36 406.6 Technical (Hospital) Services Rmvl FB Xtrnl Eye Corneal W/O Slit Lamp PX-3606522000 CDM 65220 CPT 360 RC outpatient 428 428 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES PPO [308136801] 342.4 percent of total billed charges 265.36 406.6 Technical (Hospital) Services Rmvl FB Xtrnl Eye Corneal W/O Slit Lamp PX-3606522000 CDM 65220 CPT 360 RC outpatient 428 428 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES EPO [308136803] 342.4 percent of total billed charges 265.36 406.6 Technical (Hospital) Services Rmvl FB Xtrnl Eye Corneal W/O Slit Lamp PX-3606522000 CDM 65220 CPT 360 RC outpatient 428 428 BLUE CROSS BLUE SHIELD WELLMARK SB889 [3081026] BCBS WYOMING [308102603] 406.6 percent of total billed charges 265.36 406.6 Technical (Hospital) Services Rmvl FB Xtrnl Eye Corneal W/O Slit Lamp PX-3606522000 CDM 65220 CPT 360 RC outpatient 428 428 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES HDHP [308136802] 342.4 percent of total billed charges 265.36 406.6 Technical (Hospital) Services Rmvl FB Xtrnl Eye Corneal W/O Slit Lamp PX-3606522000 CDM 65220 CPT 360 RC outpatient 428 428 MULTIPLAN INC 34080 [3081285] MULTIPLAN INC [308128501] 406.6 percent of total billed charges 265.36 406.6 Technical (Hospital) Services Rmvl FB Xtrnl Eye Corneal W/O Slit Lamp PX-3606522000 CDM 65220 CPT 360 RC outpatient 428 428 CIGNA 62308 [3081051] CIGNA 62308 [308105105] 342.4 percent of total billed charges 265.36 406.6 Technical (Hospital) Services Rmvl FB Xtrnl Eye Corneal W/O Slit Lamp PX-3606522000 CDM 65220 CPT 360 RC outpatient 428 428 CIGNA 62308 [3081051] CIGNA STATE OF WYOMING [308105107] 342.4 percent of total billed charges 265.36 406.6 Technical (Hospital) Services "Remv F.B.,Eye,Cornea,No Slit" PX-65220 CDM 65220 CPT inpatient 434 434 CIGNA 62308 [3081051] CIGNA 62308 [308105105] 347.2 percent of total billed charges 269.08 412.3 Professional (doctor) services "Remv F.B.,Eye,Cornea,No Slit" PX-65220 CDM 65220 CPT inpatient 434 434 CIGNA 62308 [3081051] CIGNA STATE OF WYOMING [308105107] 347.2 percent of total billed charges 269.08 412.3 Professional (doctor) services "Remv F.B.,Eye,Cornea,No Slit" PX-65220 CDM 65220 CPT outpatient 434 434 CIGNA 62308 [3081051] CIGNA 62308 [308105105] 347.2 percent of total billed charges 269.08 412.3 Professional (doctor) services "Remv F.B.,Eye,Cornea,No Slit" PX-65220 CDM 65220 CPT outpatient 434 434 CIGNA 62308 [3081051] CIGNA STATE OF WYOMING [308105107] 347.2 percent of total billed charges 269.08 412.3 Professional (doctor) services "Remv F.B.,Eye,Cornea,No Slit" PX-65220 CDM 65220 CPT inpatient 434 434 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES EPO [308136803] 347.2 percent of total billed charges 269.08 412.3 Professional (doctor) services "Remv F.B.,Eye,Cornea,No Slit" PX-65220 CDM 65220 CPT inpatient 434 434 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES HDHP [308136802] 347.2 percent of total billed charges 269.08 412.3 Professional (doctor) services "Remv F.B.,Eye,Cornea,No Slit" PX-65220 CDM 65220 CPT inpatient 434 434 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES PPO [308136801] 347.2 percent of total billed charges 269.08 412.3 Professional (doctor) services "Remv F.B.,Eye,Cornea,No Slit" PX-65220 CDM 65220 CPT outpatient 434 434 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES EPO [308136803] 347.2 percent of total billed charges 269.08 412.3 Professional (doctor) services "Remv F.B.,Eye,Cornea,No Slit" PX-65220 CDM 65220 CPT outpatient 434 434 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES HDHP [308136802] 347.2 percent of total billed charges 269.08 412.3 Professional (doctor) services "Remv F.B.,Eye,Cornea,No Slit" PX-65220 CDM 65220 CPT outpatient 434 434 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES PPO [308136801] 347.2 percent of total billed charges 269.08 412.3 Professional (doctor) services "Remv F.B.,Eye,Cornea,No Slit" PX-65220 CDM 65220 CPT inpatient 434 434 HEALTHPARTNERS SX009 HEALTHPARTNERS 347.2 percent of total billed charges 269.08 412.3 Professional (doctor) services "Remv F.B.,Eye,Cornea,No Slit" PX-65220 CDM 65220 CPT outpatient 434 434 HEALTHPARTNERS SX009 HEALTHPARTNERS 347.2 percent of total billed charges 269.08 412.3 Professional (doctor) services "Remv F.B.,Eye,Cornea,No Slit" PX-65220 CDM 65220 CPT inpatient 434 434 MEDICA (COMMERCIAL) 94265 [3081118] MEDICA CLAIMS [308111801] 390.6 percent of total billed charges 269.08 412.3 Professional (doctor) services "Remv F.B.,Eye,Cornea,No Slit" PX-65220 CDM 65220 CPT outpatient 434 434 MEDICA (COMMERCIAL) 94265 [3081118] MEDICA CLAIMS [308111801] 390.6 percent of total billed charges 269.08 412.3 Professional (doctor) services "Remv F.B.,Eye,Cornea,No Slit" PX-65220 CDM 65220 CPT inpatient 434 434 MULTIPLAN INC 34080 [3081285] MULTIPLAN INC [308128501] 412.3 percent of total billed charges 269.08 412.3 Professional (doctor) services "Remv F.B.,Eye,Cornea,No Slit" PX-65220 CDM 65220 CPT outpatient 434 434 MULTIPLAN INC 34080 [3081285] MULTIPLAN INC [308128501] 412.3 percent of total billed charges 269.08 412.3 Professional (doctor) services "Remv F.B.,Eye,Cornea,No Slit" PX-65220 CDM 65220 CPT inpatient 434 434 UNITED HEALTHCARE (COMMERCIAL) [3081199] UNITED HEALTHCARE 87726 [308119901] 269.08 percent of total billed charges 269.08 412.3 Professional (doctor) services "Remv F.B.,Eye,Cornea,No Slit" PX-65220 CDM 65220 CPT outpatient 434 434 UNITED HEALTHCARE (COMMERCIAL) [3081199] UNITED HEALTHCARE 87726 [308119901] 269.08 percent of total billed charges 269.08 412.3 Professional (doctor) services Removal FB Eye Conjunctival Superficial PX-3606520500 CDM 65205 CPT 360 RC inpatient 255 255 BLUE CROSS BLUE SHIELD WELLMARK SB889 [3081026] BCBS WYOMING [308102603] 242.25 percent of total billed charges 158.1 242.25 Technical (Hospital) Services Removal FB Eye Conjunctival Superficial PX-3606520500 CDM 65205 CPT 360 RC inpatient 255 255 MULTIPLAN INC 34080 [3081285] MULTIPLAN INC [308128501] 242.25 percent of total billed charges 158.1 242.25 Technical (Hospital) Services Removal FB Eye Conjunctival Superficial PX-3606520500 CDM 65205 CPT 360 RC inpatient 255 255 UNITED HEALTHCARE (COMMERCIAL) [3081199] UNITED HEALTHCARE 87726 [308119901] 158.1 percent of total billed charges 158.1 242.25 Technical (Hospital) Services Removal FB Eye Conjunctival Superficial PX-3606520500 CDM 65205 CPT 360 RC inpatient 255 255 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES PPO [308136801] 201.91 percent of total billed charges 158.1 242.25 Technical (Hospital) Services Removal FB Eye Conjunctival Superficial PX-3606520500 CDM 65205 CPT 360 RC inpatient 255 255 HEALTHPARTNERS SX009 HEALTHPARTNERS 201.91 percent of total billed charges 158.1 242.25 Technical (Hospital) Services Removal FB Eye Conjunctival Superficial PX-3606520500 CDM 65205 CPT 360 RC inpatient 255 255 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES HDHP [308136802] 201.91 percent of total billed charges 158.1 242.25 Technical (Hospital) Services Removal FB Eye Conjunctival Superficial PX-3606520500 CDM 65205 CPT 360 RC inpatient 255 255 MEDICA (COMMERCIAL) 94265 [3081118] MEDICA CLAIMS [308111801] 229.5 percent of total billed charges 158.1 242.25 Technical (Hospital) Services Removal FB Eye Conjunctival Superficial PX-3606520500 CDM 65205 CPT 360 RC inpatient 255 255 CIGNA 62308 [3081051] CIGNA 62308 [308105105] 201.91 percent of total billed charges 158.1 242.25 Technical (Hospital) Services Removal FB Eye Conjunctival Superficial PX-3606520500 CDM 65205 CPT 360 RC inpatient 255 255 CIGNA 62308 [3081051] CIGNA STATE OF WYOMING [308105107] 201.91 percent of total billed charges 158.1 242.25 Technical (Hospital) Services Removal FB Eye Conjunctival Superficial PX-3606520500 CDM 65205 CPT 360 RC inpatient 255 255 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES EPO [308136803] 201.91 percent of total billed charges 158.1 242.25 Technical (Hospital) Services Removal FB Eye Conjunctival Superficial PX-3606520500 CDM 65205 CPT 360 RC outpatient 255 255 CIGNA 62308 [3081051] CIGNA 62308 [308105105] 204 percent of total billed charges 158.1 242.25 Technical (Hospital) Services Removal FB Eye Conjunctival Superficial PX-3606520500 CDM 65205 CPT 360 RC outpatient 255 255 CIGNA 62308 [3081051] CIGNA STATE OF WYOMING [308105107] 204 percent of total billed charges 158.1 242.25 Technical (Hospital) Services Removal FB Eye Conjunctival Superficial PX-3606520500 CDM 65205 CPT 360 RC outpatient 255 255 MEDICA (COMMERCIAL) 94265 [3081118] MEDICA CLAIMS [308111801] 229.5 percent of total billed charges 158.1 242.25 Technical (Hospital) Services Removal FB Eye Conjunctival Superficial PX-3606520500 CDM 65205 CPT 360 RC outpatient 255 255 UNITED HEALTHCARE (COMMERCIAL) [3081199] UNITED HEALTHCARE 87726 [308119901] 158.1 percent of total billed charges 158.1 242.25 Technical (Hospital) Services Removal FB Eye Conjunctival Superficial PX-3606520500 CDM 65205 CPT 360 RC outpatient 255 255 HEALTHPARTNERS SX009 HEALTHPARTNERS 204 percent of total billed charges 158.1 242.25 Technical (Hospital) Services Removal FB Eye Conjunctival Superficial PX-3606520500 CDM 65205 CPT 360 RC outpatient 255 255 BLUE CROSS BLUE SHIELD WELLMARK SB889 [3081026] BCBS WYOMING [308102603] 242.25 percent of total billed charges 158.1 242.25 Technical (Hospital) Services Removal FB Eye Conjunctival Superficial PX-3606520500 CDM 65205 CPT 360 RC outpatient 255 255 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES HDHP [308136802] 204 percent of total billed charges 158.1 242.25 Technical (Hospital) Services Removal FB Eye Conjunctival Superficial PX-3606520500 CDM 65205 CPT 360 RC outpatient 255 255 MULTIPLAN INC 34080 [3081285] MULTIPLAN INC [308128501] 242.25 percent of total billed charges 158.1 242.25 Technical (Hospital) Services Removal FB Eye Conjunctival Superficial PX-3606520500 CDM 65205 CPT 360 RC outpatient 255 255 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES EPO [308136803] 204 percent of total billed charges 158.1 242.25 Technical (Hospital) Services Removal FB Eye Conjunctival Superficial PX-3606520500 CDM 65205 CPT 360 RC outpatient 255 255 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES PPO [308136801] 204 percent of total billed charges 158.1 242.25 Technical (Hospital) Services "Inject Nerv Blck,Sphenopalat Gangln" PX-64505 CDM 64505 CPT inpatient 1401 1401 CIGNA 62308 [3081051] CIGNA 62308 [308105105] 1120.8 percent of total billed charges 868.62 1330.95 Professional (doctor) services "Inject Nerv Blck,Sphenopalat Gangln" PX-64505 CDM 64505 CPT inpatient 1401 1401 CIGNA 62308 [3081051] CIGNA STATE OF WYOMING [308105107] 1120.8 percent of total billed charges 868.62 1330.95 Professional (doctor) services "Inject Nerv Blck,Sphenopalat Gangln" PX-64505 CDM 64505 CPT outpatient 1401 1401 CIGNA 62308 [3081051] CIGNA 62308 [308105105] 1120.8 percent of total billed charges 868.62 1330.95 Professional (doctor) services "Inject Nerv Blck,Sphenopalat Gangln" PX-64505 CDM 64505 CPT outpatient 1401 1401 CIGNA 62308 [3081051] CIGNA STATE OF WYOMING [308105107] 1120.8 percent of total billed charges 868.62 1330.95 Professional (doctor) services "Inject Nerv Blck,Sphenopalat Gangln" PX-64505 CDM 64505 CPT inpatient 1401 1401 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES EPO [308136803] 1120.8 percent of total billed charges 868.62 1330.95 Professional (doctor) services "Inject Nerv Blck,Sphenopalat Gangln" PX-64505 CDM 64505 CPT inpatient 1401 1401 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES HDHP [308136802] 1120.8 percent of total billed charges 868.62 1330.95 Professional (doctor) services "Inject Nerv Blck,Sphenopalat Gangln" PX-64505 CDM 64505 CPT inpatient 1401 1401 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES PPO [308136801] 1120.8 percent of total billed charges 868.62 1330.95 Professional (doctor) services "Inject Nerv Blck,Sphenopalat Gangln" PX-64505 CDM 64505 CPT outpatient 1401 1401 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES EPO [308136803] 1120.8 percent of total billed charges 868.62 1330.95 Professional (doctor) services "Inject Nerv Blck,Sphenopalat Gangln" PX-64505 CDM 64505 CPT outpatient 1401 1401 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES HDHP [308136802] 1120.8 percent of total billed charges 868.62 1330.95 Professional (doctor) services "Inject Nerv Blck,Sphenopalat Gangln" PX-64505 CDM 64505 CPT outpatient 1401 1401 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES PPO [308136801] 1120.8 percent of total billed charges 868.62 1330.95 Professional (doctor) services "Inject Nerv Blck,Sphenopalat Gangln" PX-64505 CDM 64505 CPT inpatient 1401 1401 HEALTHPARTNERS SX009 HEALTHPARTNERS 1120.8 percent of total billed charges 868.62 1330.95 Professional (doctor) services "Inject Nerv Blck,Sphenopalat Gangln" PX-64505 CDM 64505 CPT outpatient 1401 1401 HEALTHPARTNERS SX009 HEALTHPARTNERS 1120.8 percent of total billed charges 868.62 1330.95 Professional (doctor) services "Inject Nerv Blck,Sphenopalat Gangln" PX-64505 CDM 64505 CPT inpatient 1401 1401 MEDICA (COMMERCIAL) 94265 [3081118] MEDICA CLAIMS [308111801] 1260.9 percent of total billed charges 868.62 1330.95 Professional (doctor) services "Inject Nerv Blck,Sphenopalat Gangln" PX-64505 CDM 64505 CPT outpatient 1401 1401 MEDICA (COMMERCIAL) 94265 [3081118] MEDICA CLAIMS [308111801] 1260.9 percent of total billed charges 868.62 1330.95 Professional (doctor) services "Inject Nerv Blck,Sphenopalat Gangln" PX-64505 CDM 64505 CPT inpatient 1401 1401 MULTIPLAN INC 34080 [3081285] MULTIPLAN INC [308128501] 1330.95 percent of total billed charges 868.62 1330.95 Professional (doctor) services "Inject Nerv Blck,Sphenopalat Gangln" PX-64505 CDM 64505 CPT outpatient 1401 1401 MULTIPLAN INC 34080 [3081285] MULTIPLAN INC [308128501] 1330.95 percent of total billed charges 868.62 1330.95 Professional (doctor) services "Inject Nerv Blck,Sphenopalat Gangln" PX-64505 CDM 64505 CPT inpatient 1401 1401 UNITED HEALTHCARE (COMMERCIAL) [3081199] UNITED HEALTHCARE 87726 [308119901] 868.62 percent of total billed charges 868.62 1330.95 Professional (doctor) services "Inject Nerv Blck,Sphenopalat Gangln" PX-64505 CDM 64505 CPT outpatient 1401 1401 UNITED HEALTHCARE (COMMERCIAL) [3081199] UNITED HEALTHCARE 87726 [308119901] 868.62 percent of total billed charges 868.62 1330.95 Professional (doctor) services Injection Anes Other Peripheral Nerve/Branch PX-3606445000 CDM 64450 CPT 360 RC inpatient 548 548 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES PPO [308136801] 433.91 percent of total billed charges 339.76 520.6 Technical (Hospital) Services Injection Anes Other Peripheral Nerve/Branch PX-3606445000 CDM 64450 CPT 360 RC inpatient 548 548 UNITED HEALTHCARE (COMMERCIAL) [3081199] UNITED HEALTHCARE 87726 [308119901] 339.76 percent of total billed charges 339.76 520.6 Technical (Hospital) Services Injection Anes Other Peripheral Nerve/Branch PX-3606445000 CDM 64450 CPT 360 RC inpatient 548 548 MULTIPLAN INC 34080 [3081285] MULTIPLAN INC [308128501] 520.6 percent of total billed charges 339.76 520.6 Technical (Hospital) Services Injection Anes Other Peripheral Nerve/Branch PX-3606445000 CDM 64450 CPT 360 RC inpatient 548 548 BLUE CROSS BLUE SHIELD WELLMARK SB889 [3081026] BCBS WYOMING [308102603] 520.6 percent of total billed charges 339.76 520.6 Technical (Hospital) Services Injection Anes Other Peripheral Nerve/Branch PX-3606445000 CDM 64450 CPT 360 RC inpatient 548 548 HEALTHPARTNERS SX009 HEALTHPARTNERS 433.91 percent of total billed charges 339.76 520.6 Technical (Hospital) Services Injection Anes Other Peripheral Nerve/Branch PX-3606445000 CDM 64450 CPT 360 RC inpatient 548 548 MEDICA (COMMERCIAL) 94265 [3081118] MEDICA CLAIMS [308111801] 493.2 percent of total billed charges 339.76 520.6 Technical (Hospital) Services Injection Anes Other Peripheral Nerve/Branch PX-3606445000 CDM 64450 CPT 360 RC inpatient 548 548 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES HDHP [308136802] 433.91 percent of total billed charges 339.76 520.6 Technical (Hospital) Services Injection Anes Other Peripheral Nerve/Branch PX-3606445000 CDM 64450 CPT 360 RC inpatient 548 548 CIGNA 62308 [3081051] CIGNA 62308 [308105105] 433.91 percent of total billed charges 339.76 520.6 Technical (Hospital) Services Injection Anes Other Peripheral Nerve/Branch PX-3606445000 CDM 64450 CPT 360 RC inpatient 548 548 CIGNA 62308 [3081051] CIGNA STATE OF WYOMING [308105107] 433.91 percent of total billed charges 339.76 520.6 Technical (Hospital) Services Injection Anes Other Peripheral Nerve/Branch PX-3606445000 CDM 64450 CPT 360 RC inpatient 548 548 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES EPO [308136803] 433.91 percent of total billed charges 339.76 520.6 Technical (Hospital) Services Injection Anes Other Peripheral Nerve/Branch PX-3606445000 CDM 64450 CPT 360 RC outpatient 548 548 MULTIPLAN INC 34080 [3081285] MULTIPLAN INC [308128501] 520.6 percent of total billed charges 339.76 520.6 Technical (Hospital) Services Injection Anes Other Peripheral Nerve/Branch PX-3606445000 CDM 64450 CPT 360 RC outpatient 548 548 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES HDHP [308136802] 438.4 percent of total billed charges 339.76 520.6 Technical (Hospital) Services Injection Anes Other Peripheral Nerve/Branch PX-3606445000 CDM 64450 CPT 360 RC outpatient 548 548 BLUE CROSS BLUE SHIELD WELLMARK SB889 [3081026] BCBS WYOMING [308102603] 520.6 percent of total billed charges 339.76 520.6 Technical (Hospital) Services Injection Anes Other Peripheral Nerve/Branch PX-3606445000 CDM 64450 CPT 360 RC outpatient 548 548 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES EPO [308136803] 438.4 percent of total billed charges 339.76 520.6 Technical (Hospital) Services Injection Anes Other Peripheral Nerve/Branch PX-3606445000 CDM 64450 CPT 360 RC outpatient 548 548 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES PPO [308136801] 438.4 percent of total billed charges 339.76 520.6 Technical (Hospital) Services Injection Anes Other Peripheral Nerve/Branch PX-3606445000 CDM 64450 CPT 360 RC outpatient 548 548 UNITED HEALTHCARE (COMMERCIAL) [3081199] UNITED HEALTHCARE 87726 [308119901] 339.76 percent of total billed charges 339.76 520.6 Technical (Hospital) Services Injection Anes Other Peripheral Nerve/Branch PX-3606445000 CDM 64450 CPT 360 RC outpatient 548 548 HEALTHPARTNERS SX009 HEALTHPARTNERS 438.4 percent of total billed charges 339.76 520.6 Technical (Hospital) Services Injection Anes Other Peripheral Nerve/Branch PX-3606445000 CDM 64450 CPT 360 RC outpatient 548 548 CIGNA 62308 [3081051] CIGNA 62308 [308105105] 438.4 percent of total billed charges 339.76 520.6 Technical (Hospital) Services Injection Anes Other Peripheral Nerve/Branch PX-3606445000 CDM 64450 CPT 360 RC outpatient 548 548 CIGNA 62308 [3081051] CIGNA STATE OF WYOMING [308105107] 438.4 percent of total billed charges 339.76 520.6 Technical (Hospital) Services Injection Anes Other Peripheral Nerve/Branch PX-3606445000 CDM 64450 CPT 360 RC outpatient 548 548 MEDICA (COMMERCIAL) 94265 [3081118] MEDICA CLAIMS [308111801] 493.2 percent of total billed charges 339.76 520.6 Technical (Hospital) Services "Inject Nerv Blck,Othr Periph Nerv" PX-64450 CDM 64450 CPT inpatient 802 802 CIGNA 62308 [3081051] CIGNA 62308 [308105105] 641.6 percent of total billed charges 497.24 761.9 Professional (doctor) services "Inject Nerv Blck,Othr Periph Nerv" PX-64450 CDM 64450 CPT inpatient 802 802 CIGNA 62308 [3081051] CIGNA STATE OF WYOMING [308105107] 641.6 percent of total billed charges 497.24 761.9 Professional (doctor) services "Inject Nerv Blck,Othr Periph Nerv" PX-64450 CDM 64450 CPT outpatient 802 802 CIGNA 62308 [3081051] CIGNA 62308 [308105105] 641.6 percent of total billed charges 497.24 761.9 Professional (doctor) services "Inject Nerv Blck,Othr Periph Nerv" PX-64450 CDM 64450 CPT outpatient 802 802 CIGNA 62308 [3081051] CIGNA STATE OF WYOMING [308105107] 641.6 percent of total billed charges 497.24 761.9 Professional (doctor) services "Inject Nerv Blck,Othr Periph Nerv" PX-64450 CDM 64450 CPT inpatient 802 802 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES EPO [308136803] 641.6 percent of total billed charges 497.24 761.9 Professional (doctor) services "Inject Nerv Blck,Othr Periph Nerv" PX-64450 CDM 64450 CPT inpatient 802 802 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES HDHP [308136802] 641.6 percent of total billed charges 497.24 761.9 Professional (doctor) services "Inject Nerv Blck,Othr Periph Nerv" PX-64450 CDM 64450 CPT inpatient 802 802 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES PPO [308136801] 641.6 percent of total billed charges 497.24 761.9 Professional (doctor) services "Inject Nerv Blck,Othr Periph Nerv" PX-64450 CDM 64450 CPT outpatient 802 802 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES EPO [308136803] 641.6 percent of total billed charges 497.24 761.9 Professional (doctor) services "Inject Nerv Blck,Othr Periph Nerv" PX-64450 CDM 64450 CPT outpatient 802 802 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES HDHP [308136802] 641.6 percent of total billed charges 497.24 761.9 Professional (doctor) services "Inject Nerv Blck,Othr Periph Nerv" PX-64450 CDM 64450 CPT outpatient 802 802 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES PPO [308136801] 641.6 percent of total billed charges 497.24 761.9 Professional (doctor) services "Inject Nerv Blck,Othr Periph Nerv" PX-64450 CDM 64450 CPT inpatient 802 802 HEALTHPARTNERS SX009 HEALTHPARTNERS 641.6 percent of total billed charges 497.24 761.9 Professional (doctor) services "Inject Nerv Blck,Othr Periph Nerv" PX-64450 CDM 64450 CPT outpatient 802 802 HEALTHPARTNERS SX009 HEALTHPARTNERS 641.6 percent of total billed charges 497.24 761.9 Professional (doctor) services "Inject Nerv Blck,Othr Periph Nerv" PX-64450 CDM 64450 CPT inpatient 802 802 MEDICA (COMMERCIAL) 94265 [3081118] MEDICA CLAIMS [308111801] 721.8 percent of total billed charges 497.24 761.9 Professional (doctor) services "Inject Nerv Blck,Othr Periph Nerv" PX-64450 CDM 64450 CPT outpatient 802 802 MEDICA (COMMERCIAL) 94265 [3081118] MEDICA CLAIMS [308111801] 721.8 percent of total billed charges 497.24 761.9 Professional (doctor) services "Inject Nerv Blck,Othr Periph Nerv" PX-64450 CDM 64450 CPT inpatient 802 802 MULTIPLAN INC 34080 [3081285] MULTIPLAN INC [308128501] 761.9 percent of total billed charges 497.24 761.9 Professional (doctor) services "Inject Nerv Blck,Othr Periph Nerv" PX-64450 CDM 64450 CPT outpatient 802 802 MULTIPLAN INC 34080 [3081285] MULTIPLAN INC [308128501] 761.9 percent of total billed charges 497.24 761.9 Professional (doctor) services "Inject Nerv Blck,Othr Periph Nerv" PX-64450 CDM 64450 CPT inpatient 802 802 UNITED HEALTHCARE (COMMERCIAL) [3081199] UNITED HEALTHCARE 87726 [308119901] 497.24 percent of total billed charges 497.24 761.9 Professional (doctor) services "Inject Nerv Blck,Othr Periph Nerv" PX-64450 CDM 64450 CPT outpatient 802 802 UNITED HEALTHCARE (COMMERCIAL) [3081199] UNITED HEALTHCARE 87726 [308119901] 497.24 percent of total billed charges 497.24 761.9 Professional (doctor) services Njx Anes Trigeminal Nrv Each Branch PX-3606440000 CDM 64400 CPT 360 RC outpatient 655 655 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES PPO [308136801] 524 percent of total billed charges 406.1 622.25 Technical (Hospital) Services Njx Anes Trigeminal Nrv Each Branch PX-3606440000 CDM 64400 CPT 360 RC outpatient 655 655 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES EPO [308136803] 524 percent of total billed charges 406.1 622.25 Technical (Hospital) Services Njx Anes Trigeminal Nrv Each Branch PX-3606440000 CDM 64400 CPT 360 RC outpatient 655 655 UNITED HEALTHCARE (COMMERCIAL) [3081199] UNITED HEALTHCARE 87726 [308119901] 406.1 percent of total billed charges 406.1 622.25 Technical (Hospital) Services Njx Anes Trigeminal Nrv Each Branch PX-3606440000 CDM 64400 CPT 360 RC outpatient 655 655 MULTIPLAN INC 34080 [3081285] MULTIPLAN INC [308128501] 622.25 percent of total billed charges 406.1 622.25 Technical (Hospital) Services Njx Anes Trigeminal Nrv Each Branch PX-3606440000 CDM 64400 CPT 360 RC outpatient 655 655 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES HDHP [308136802] 524 percent of total billed charges 406.1 622.25 Technical (Hospital) Services Njx Anes Trigeminal Nrv Each Branch PX-3606440000 CDM 64400 CPT 360 RC outpatient 655 655 BLUE CROSS BLUE SHIELD WELLMARK SB889 [3081026] BCBS WYOMING [308102603] 622.25 percent of total billed charges 406.1 622.25 Technical (Hospital) Services Njx Anes Trigeminal Nrv Each Branch PX-3606440000 CDM 64400 CPT 360 RC outpatient 655 655 MEDICA (COMMERCIAL) 94265 [3081118] MEDICA CLAIMS [308111801] 589.5 percent of total billed charges 406.1 622.25 Technical (Hospital) Services Njx Anes Trigeminal Nrv Each Branch PX-3606440000 CDM 64400 CPT 360 RC outpatient 655 655 HEALTHPARTNERS SX009 HEALTHPARTNERS 524 percent of total billed charges 406.1 622.25 Technical (Hospital) Services Njx Anes Trigeminal Nrv Each Branch PX-3606440000 CDM 64400 CPT 360 RC outpatient 655 655 CIGNA 62308 [3081051] CIGNA 62308 [308105105] 524 percent of total billed charges 406.1 622.25 Technical (Hospital) Services Njx Anes Trigeminal Nrv Each Branch PX-3606440000 CDM 64400 CPT 360 RC outpatient 655 655 CIGNA 62308 [3081051] CIGNA STATE OF WYOMING [308105107] 524 percent of total billed charges 406.1 622.25 Technical (Hospital) Services Njx Anes Trigeminal Nrv Each Branch PX-3606440000 CDM 64400 CPT 360 RC inpatient 655 655 MULTIPLAN INC 34080 [3081285] MULTIPLAN INC [308128501] 622.25 percent of total billed charges 406.1 622.25 Technical (Hospital) Services Njx Anes Trigeminal Nrv Each Branch PX-3606440000 CDM 64400 CPT 360 RC inpatient 655 655 BLUE CROSS BLUE SHIELD WELLMARK SB889 [3081026] BCBS WYOMING [308102603] 622.25 percent of total billed charges 406.1 622.25 Technical (Hospital) Services Njx Anes Trigeminal Nrv Each Branch PX-3606440000 CDM 64400 CPT 360 RC inpatient 655 655 UNITED HEALTHCARE (COMMERCIAL) [3081199] UNITED HEALTHCARE 87726 [308119901] 406.1 percent of total billed charges 406.1 622.25 Technical (Hospital) Services Njx Anes Trigeminal Nrv Each Branch PX-3606440000 CDM 64400 CPT 360 RC inpatient 655 655 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES PPO [308136801] 518.63 percent of total billed charges 406.1 622.25 Technical (Hospital) Services Njx Anes Trigeminal Nrv Each Branch PX-3606440000 CDM 64400 CPT 360 RC inpatient 655 655 HEALTHPARTNERS SX009 HEALTHPARTNERS 518.63 percent of total billed charges 406.1 622.25 Technical (Hospital) Services Njx Anes Trigeminal Nrv Each Branch PX-3606440000 CDM 64400 CPT 360 RC inpatient 655 655 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES HDHP [308136802] 518.63 percent of total billed charges 406.1 622.25 Technical (Hospital) Services Njx Anes Trigeminal Nrv Each Branch PX-3606440000 CDM 64400 CPT 360 RC inpatient 655 655 MEDICA (COMMERCIAL) 94265 [3081118] MEDICA CLAIMS [308111801] 589.5 percent of total billed charges 406.1 622.25 Technical (Hospital) Services Njx Anes Trigeminal Nrv Each Branch PX-3606440000 CDM 64400 CPT 360 RC inpatient 655 655 CIGNA 62308 [3081051] CIGNA 62308 [308105105] 518.63 percent of total billed charges 406.1 622.25 Technical (Hospital) Services Njx Anes Trigeminal Nrv Each Branch PX-3606440000 CDM 64400 CPT 360 RC inpatient 655 655 CIGNA 62308 [3081051] CIGNA STATE OF WYOMING [308105107] 518.63 percent of total billed charges 406.1 622.25 Technical (Hospital) Services Njx Anes Trigeminal Nrv Each Branch PX-3606440000 CDM 64400 CPT 360 RC inpatient 655 655 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES EPO [308136803] 518.63 percent of total billed charges 406.1 622.25 Technical (Hospital) Services "Inject Nerv Blck,Trigeminal" PX-64400 CDM 64400 CPT inpatient 639 639 CIGNA 62308 [3081051] CIGNA 62308 [308105105] 511.2 percent of total billed charges 396.18 607.05 Professional (doctor) services "Inject Nerv Blck,Trigeminal" PX-64400 CDM 64400 CPT inpatient 639 639 CIGNA 62308 [3081051] CIGNA STATE OF WYOMING [308105107] 511.2 percent of total billed charges 396.18 607.05 Professional (doctor) services "Inject Nerv Blck,Trigeminal" PX-64400 CDM 64400 CPT outpatient 639 639 CIGNA 62308 [3081051] CIGNA 62308 [308105105] 511.2 percent of total billed charges 396.18 607.05 Professional (doctor) services "Inject Nerv Blck,Trigeminal" PX-64400 CDM 64400 CPT outpatient 639 639 CIGNA 62308 [3081051] CIGNA STATE OF WYOMING [308105107] 511.2 percent of total billed charges 396.18 607.05 Professional (doctor) services "Inject Nerv Blck,Trigeminal" PX-64400 CDM 64400 CPT inpatient 639 639 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES EPO [308136803] 511.2 percent of total billed charges 396.18 607.05 Professional (doctor) services "Inject Nerv Blck,Trigeminal" PX-64400 CDM 64400 CPT inpatient 639 639 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES HDHP [308136802] 511.2 percent of total billed charges 396.18 607.05 Professional (doctor) services "Inject Nerv Blck,Trigeminal" PX-64400 CDM 64400 CPT inpatient 639 639 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES PPO [308136801] 511.2 percent of total billed charges 396.18 607.05 Professional (doctor) services "Inject Nerv Blck,Trigeminal" PX-64400 CDM 64400 CPT outpatient 639 639 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES EPO [308136803] 511.2 percent of total billed charges 396.18 607.05 Professional (doctor) services "Inject Nerv Blck,Trigeminal" PX-64400 CDM 64400 CPT outpatient 639 639 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES HDHP [308136802] 511.2 percent of total billed charges 396.18 607.05 Professional (doctor) services "Inject Nerv Blck,Trigeminal" PX-64400 CDM 64400 CPT outpatient 639 639 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES PPO [308136801] 511.2 percent of total billed charges 396.18 607.05 Professional (doctor) services "Inject Nerv Blck,Trigeminal" PX-64400 CDM 64400 CPT inpatient 639 639 HEALTHPARTNERS SX009 HEALTHPARTNERS 511.2 percent of total billed charges 396.18 607.05 Professional (doctor) services "Inject Nerv Blck,Trigeminal" PX-64400 CDM 64400 CPT outpatient 639 639 HEALTHPARTNERS SX009 HEALTHPARTNERS 511.2 percent of total billed charges 396.18 607.05 Professional (doctor) services "Inject Nerv Blck,Trigeminal" PX-64400 CDM 64400 CPT inpatient 639 639 MEDICA (COMMERCIAL) 94265 [3081118] MEDICA CLAIMS [308111801] 575.1 percent of total billed charges 396.18 607.05 Professional (doctor) services "Inject Nerv Blck,Trigeminal" PX-64400 CDM 64400 CPT outpatient 639 639 MEDICA (COMMERCIAL) 94265 [3081118] MEDICA CLAIMS [308111801] 575.1 percent of total billed charges 396.18 607.05 Professional (doctor) services "Inject Nerv Blck,Trigeminal" PX-64400 CDM 64400 CPT inpatient 639 639 MULTIPLAN INC 34080 [3081285] MULTIPLAN INC [308128501] 607.05 percent of total billed charges 396.18 607.05 Professional (doctor) services "Inject Nerv Blck,Trigeminal" PX-64400 CDM 64400 CPT outpatient 639 639 MULTIPLAN INC 34080 [3081285] MULTIPLAN INC [308128501] 607.05 percent of total billed charges 396.18 607.05 Professional (doctor) services "Inject Nerv Blck,Trigeminal" PX-64400 CDM 64400 CPT inpatient 639 639 UNITED HEALTHCARE (COMMERCIAL) [3081199] UNITED HEALTHCARE 87726 [308119901] 396.18 percent of total billed charges 396.18 607.05 Professional (doctor) services "Inject Nerv Blck,Trigeminal" PX-64400 CDM 64400 CPT outpatient 639 639 UNITED HEALTHCARE (COMMERCIAL) [3081199] UNITED HEALTHCARE 87726 [308119901] 396.18 percent of total billed charges 396.18 607.05 Professional (doctor) services Fetal Nonstress Test PX-7205902500 CDM 59025 CPT 720 RC inpatient 352 352 CIGNA 62308 [3081051] CIGNA 62308 [308105105] 278.71 percent of total billed charges 218.24 334.4 Technical (Hospital) Services Fetal Nonstress Test PX-7205902500 CDM 59025 CPT 720 RC inpatient 352 352 CIGNA 62308 [3081051] CIGNA STATE OF WYOMING [308105107] 278.71 percent of total billed charges 218.24 334.4 Technical (Hospital) Services Fetal Nonstress Test PX-7205902500 CDM 59025 CPT 720 RC inpatient 352 352 UNITED HEALTHCARE (COMMERCIAL) [3081199] UNITED HEALTHCARE 87726 [308119901] 218.24 percent of total billed charges 218.24 334.4 Technical (Hospital) Services Fetal Nonstress Test PX-7205902500 CDM 59025 CPT 720 RC inpatient 352 352 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES PPO [308136801] 278.71 percent of total billed charges 218.24 334.4 Technical (Hospital) Services Fetal Nonstress Test PX-7205902500 CDM 59025 CPT 720 RC inpatient 352 352 MULTIPLAN INC 34080 [3081285] MULTIPLAN INC [308128501] 334.4 percent of total billed charges 218.24 334.4 Technical (Hospital) Services Fetal Nonstress Test PX-7205902500 CDM 59025 CPT 720 RC inpatient 352 352 BLUE CROSS BLUE SHIELD WELLMARK SB889 [3081026] BCBS WYOMING [308102603] 334.4 percent of total billed charges 218.24 334.4 Technical (Hospital) Services Fetal Nonstress Test PX-7205902500 CDM 59025 CPT 720 RC inpatient 352 352 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES HDHP [308136802] 278.71 percent of total billed charges 218.24 334.4 Technical (Hospital) Services Fetal Nonstress Test PX-7205902500 CDM 59025 CPT 720 RC inpatient 352 352 MEDICA (COMMERCIAL) 94265 [3081118] MEDICA CLAIMS [308111801] 316.8 percent of total billed charges 218.24 334.4 Technical (Hospital) Services Fetal Nonstress Test PX-7205902500 CDM 59025 CPT 720 RC inpatient 352 352 HEALTHPARTNERS SX009 HEALTHPARTNERS 278.71 percent of total billed charges 218.24 334.4 Technical (Hospital) Services Fetal Nonstress Test PX-7205902500 CDM 59025 CPT 720 RC inpatient 352 352 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES EPO [308136803] 278.71 percent of total billed charges 218.24 334.4 Technical (Hospital) Services Fetal Nonstress Test PX-7205902500 CDM 59025 CPT 720 RC outpatient 352 352 UNITED HEALTHCARE (COMMERCIAL) [3081199] UNITED HEALTHCARE 87726 [308119901] 218.24 percent of total billed charges 218.24 334.4 Technical (Hospital) Services Fetal Nonstress Test PX-7205902500 CDM 59025 CPT 720 RC outpatient 352 352 HEALTHPARTNERS SX009 HEALTHPARTNERS 281.6 percent of total billed charges 218.24 334.4 Technical (Hospital) Services Fetal Nonstress Test PX-7205902500 CDM 59025 CPT 720 RC outpatient 352 352 BLUE CROSS BLUE SHIELD WELLMARK SB889 [3081026] BCBS WYOMING [308102603] 334.4 percent of total billed charges 218.24 334.4 Technical (Hospital) Services Fetal Nonstress Test PX-7205902500 CDM 59025 CPT 720 RC outpatient 352 352 MULTIPLAN INC 34080 [3081285] MULTIPLAN INC [308128501] 334.4 percent of total billed charges 218.24 334.4 Technical (Hospital) Services Fetal Nonstress Test PX-7205902500 CDM 59025 CPT 720 RC outpatient 352 352 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES HDHP [308136802] 281.6 percent of total billed charges 218.24 334.4 Technical (Hospital) Services Fetal Nonstress Test PX-7205902500 CDM 59025 CPT 720 RC outpatient 352 352 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES PPO [308136801] 281.6 percent of total billed charges 218.24 334.4 Technical (Hospital) Services Fetal Nonstress Test PX-7205902500 CDM 59025 CPT 720 RC outpatient 352 352 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES EPO [308136803] 281.6 percent of total billed charges 218.24 334.4 Technical (Hospital) Services Fetal Nonstress Test PX-7205902500 CDM 59025 CPT 720 RC outpatient 352 352 CIGNA 62308 [3081051] CIGNA 62308 [308105105] 281.6 percent of total billed charges 218.24 334.4 Technical (Hospital) Services Fetal Nonstress Test PX-7205902500 CDM 59025 CPT 720 RC outpatient 352 352 CIGNA 62308 [3081051] CIGNA STATE OF WYOMING [308105107] 281.6 percent of total billed charges 218.24 334.4 Technical (Hospital) Services Fetal Nonstress Test PX-7205902500 CDM 59025 CPT 720 RC outpatient 352 352 MEDICA (COMMERCIAL) 94265 [3081118] MEDICA CLAIMS [308111801] 316.8 percent of total billed charges 218.24 334.4 Technical (Hospital) Services I&D Bartholin's Gland Abscess PX-3605642000 CDM 56420 CPT 360 RC inpatient 652 652 BLUE CROSS BLUE SHIELD WELLMARK SB889 [3081026] BCBS WYOMING [308102603] 619.4 percent of total billed charges 404.24 619.4 Technical (Hospital) Services I&D Bartholin's Gland Abscess PX-3605642000 CDM 56420 CPT 360 RC inpatient 652 652 MULTIPLAN INC 34080 [3081285] MULTIPLAN INC [308128501] 619.4 percent of total billed charges 404.24 619.4 Technical (Hospital) Services I&D Bartholin's Gland Abscess PX-3605642000 CDM 56420 CPT 360 RC inpatient 652 652 UNITED HEALTHCARE (COMMERCIAL) [3081199] UNITED HEALTHCARE 87726 [308119901] 404.24 percent of total billed charges 404.24 619.4 Technical (Hospital) Services I&D Bartholin's Gland Abscess PX-3605642000 CDM 56420 CPT 360 RC inpatient 652 652 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES PPO [308136801] 516.25 percent of total billed charges 404.24 619.4 Technical (Hospital) Services I&D Bartholin's Gland Abscess PX-3605642000 CDM 56420 CPT 360 RC inpatient 652 652 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES HDHP [308136802] 516.25 percent of total billed charges 404.24 619.4 Technical (Hospital) Services I&D Bartholin's Gland Abscess PX-3605642000 CDM 56420 CPT 360 RC inpatient 652 652 MEDICA (COMMERCIAL) 94265 [3081118] MEDICA CLAIMS [308111801] 586.8 percent of total billed charges 404.24 619.4 Technical (Hospital) Services I&D Bartholin's Gland Abscess PX-3605642000 CDM 56420 CPT 360 RC inpatient 652 652 HEALTHPARTNERS SX009 HEALTHPARTNERS 516.25 percent of total billed charges 404.24 619.4 Technical (Hospital) Services I&D Bartholin's Gland Abscess PX-3605642000 CDM 56420 CPT 360 RC inpatient 652 652 CIGNA 62308 [3081051] CIGNA 62308 [308105105] 516.25 percent of total billed charges 404.24 619.4 Technical (Hospital) Services I&D Bartholin's Gland Abscess PX-3605642000 CDM 56420 CPT 360 RC inpatient 652 652 CIGNA 62308 [3081051] CIGNA STATE OF WYOMING [308105107] 516.25 percent of total billed charges 404.24 619.4 Technical (Hospital) Services I&D Bartholin's Gland Abscess PX-3605642000 CDM 56420 CPT 360 RC inpatient 652 652 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES EPO [308136803] 516.25 percent of total billed charges 404.24 619.4 Technical (Hospital) Services I&D Bartholin's Gland Abscess PX-3605642000 CDM 56420 CPT 360 RC outpatient 652 652 MEDICA (COMMERCIAL) 94265 [3081118] MEDICA CLAIMS [308111801] 586.8 percent of total billed charges 404.24 619.4 Technical (Hospital) Services I&D Bartholin's Gland Abscess PX-3605642000 CDM 56420 CPT 360 RC outpatient 652 652 CIGNA 62308 [3081051] CIGNA 62308 [308105105] 521.6 percent of total billed charges 404.24 619.4 Technical (Hospital) Services I&D Bartholin's Gland Abscess PX-3605642000 CDM 56420 CPT 360 RC outpatient 652 652 CIGNA 62308 [3081051] CIGNA STATE OF WYOMING [308105107] 521.6 percent of total billed charges 404.24 619.4 Technical (Hospital) Services I&D Bartholin's Gland Abscess PX-3605642000 CDM 56420 CPT 360 RC outpatient 652 652 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES HDHP [308136802] 521.6 percent of total billed charges 404.24 619.4 Technical (Hospital) Services I&D Bartholin's Gland Abscess PX-3605642000 CDM 56420 CPT 360 RC outpatient 652 652 MULTIPLAN INC 34080 [3081285] MULTIPLAN INC [308128501] 619.4 percent of total billed charges 404.24 619.4 Technical (Hospital) Services I&D Bartholin's Gland Abscess PX-3605642000 CDM 56420 CPT 360 RC outpatient 652 652 BLUE CROSS BLUE SHIELD WELLMARK SB889 [3081026] BCBS WYOMING [308102603] 619.4 percent of total billed charges 404.24 619.4 Technical (Hospital) Services I&D Bartholin's Gland Abscess PX-3605642000 CDM 56420 CPT 360 RC outpatient 652 652 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES PPO [308136801] 521.6 percent of total billed charges 404.24 619.4 Technical (Hospital) Services I&D Bartholin's Gland Abscess PX-3605642000 CDM 56420 CPT 360 RC outpatient 652 652 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES EPO [308136803] 521.6 percent of total billed charges 404.24 619.4 Technical (Hospital) Services I&D Bartholin's Gland Abscess PX-3605642000 CDM 56420 CPT 360 RC outpatient 652 652 UNITED HEALTHCARE (COMMERCIAL) [3081199] UNITED HEALTHCARE 87726 [308119901] 404.24 percent of total billed charges 404.24 619.4 Technical (Hospital) Services I&D Bartholin's Gland Abscess PX-3605642000 CDM 56420 CPT 360 RC outpatient 652 652 HEALTHPARTNERS SX009 HEALTHPARTNERS 521.6 percent of total billed charges 404.24 619.4 Technical (Hospital) Services Change Cystostomy Tube Simple PX-3605170500 CDM 51705 CPT 360 RC outpatient 760 760 MEDICA (COMMERCIAL) 94265 [3081118] MEDICA CLAIMS [308111801] 684 percent of total billed charges 471.2 722 Technical (Hospital) Services Change Cystostomy Tube Simple PX-3605170500 CDM 51705 CPT 360 RC outpatient 760 760 CIGNA 62308 [3081051] CIGNA 62308 [308105105] 608 percent of total billed charges 471.2 722 Technical (Hospital) Services Change Cystostomy Tube Simple PX-3605170500 CDM 51705 CPT 360 RC outpatient 760 760 CIGNA 62308 [3081051] CIGNA STATE OF WYOMING [308105107] 608 percent of total billed charges 471.2 722 Technical (Hospital) Services Change Cystostomy Tube Simple PX-3605170500 CDM 51705 CPT 360 RC outpatient 760 760 UNITED HEALTHCARE (COMMERCIAL) [3081199] UNITED HEALTHCARE 87726 [308119901] 471.2 percent of total billed charges 471.2 722 Technical (Hospital) Services Change Cystostomy Tube Simple PX-3605170500 CDM 51705 CPT 360 RC outpatient 760 760 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES EPO [308136803] 608 percent of total billed charges 471.2 722 Technical (Hospital) Services Change Cystostomy Tube Simple PX-3605170500 CDM 51705 CPT 360 RC outpatient 760 760 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES PPO [308136801] 608 percent of total billed charges 471.2 722 Technical (Hospital) Services Change Cystostomy Tube Simple PX-3605170500 CDM 51705 CPT 360 RC outpatient 760 760 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES HDHP [308136802] 608 percent of total billed charges 471.2 722 Technical (Hospital) Services Change Cystostomy Tube Simple PX-3605170500 CDM 51705 CPT 360 RC outpatient 760 760 MULTIPLAN INC 34080 [3081285] MULTIPLAN INC [308128501] 722 percent of total billed charges 471.2 722 Technical (Hospital) Services Change Cystostomy Tube Simple PX-3605170500 CDM 51705 CPT 360 RC outpatient 760 760 BLUE CROSS BLUE SHIELD WELLMARK SB889 [3081026] BCBS WYOMING [308102603] 722 percent of total billed charges 471.2 722 Technical (Hospital) Services Change Cystostomy Tube Simple PX-3605170500 CDM 51705 CPT 360 RC outpatient 760 760 HEALTHPARTNERS SX009 HEALTHPARTNERS 608 percent of total billed charges 471.2 722 Technical (Hospital) Services Change Cystostomy Tube Simple PX-3605170500 CDM 51705 CPT 360 RC inpatient 760 760 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES EPO [308136803] 601.77 percent of total billed charges 471.2 722 Technical (Hospital) Services Change Cystostomy Tube Simple PX-3605170500 CDM 51705 CPT 360 RC inpatient 760 760 CIGNA 62308 [3081051] CIGNA 62308 [308105105] 601.77 percent of total billed charges 471.2 722 Technical (Hospital) Services Change Cystostomy Tube Simple PX-3605170500 CDM 51705 CPT 360 RC inpatient 760 760 CIGNA 62308 [3081051] CIGNA STATE OF WYOMING [308105107] 601.77 percent of total billed charges 471.2 722 Technical (Hospital) Services Change Cystostomy Tube Simple PX-3605170500 CDM 51705 CPT 360 RC inpatient 760 760 UNITED HEALTHCARE (COMMERCIAL) [3081199] UNITED HEALTHCARE 87726 [308119901] 471.2 percent of total billed charges 471.2 722 Technical (Hospital) Services Change Cystostomy Tube Simple PX-3605170500 CDM 51705 CPT 360 RC inpatient 760 760 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES PPO [308136801] 601.77 percent of total billed charges 471.2 722 Technical (Hospital) Services Change Cystostomy Tube Simple PX-3605170500 CDM 51705 CPT 360 RC inpatient 760 760 MULTIPLAN INC 34080 [3081285] MULTIPLAN INC [308128501] 722 percent of total billed charges 471.2 722 Technical (Hospital) Services Change Cystostomy Tube Simple PX-3605170500 CDM 51705 CPT 360 RC inpatient 760 760 BLUE CROSS BLUE SHIELD WELLMARK SB889 [3081026] BCBS WYOMING [308102603] 722 percent of total billed charges 471.2 722 Technical (Hospital) Services Change Cystostomy Tube Simple PX-3605170500 CDM 51705 CPT 360 RC inpatient 760 760 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES HDHP [308136802] 601.77 percent of total billed charges 471.2 722 Technical (Hospital) Services Change Cystostomy Tube Simple PX-3605170500 CDM 51705 CPT 360 RC inpatient 760 760 MEDICA (COMMERCIAL) 94265 [3081118] MEDICA CLAIMS [308111801] 684 percent of total billed charges 471.2 722 Technical (Hospital) Services Change Cystostomy Tube Simple PX-3605170500 CDM 51705 CPT 360 RC inpatient 760 760 HEALTHPARTNERS SX009 HEALTHPARTNERS 601.77 percent of total billed charges 471.2 722 Technical (Hospital) Services Insj Temp Ndwellg Bladder Catheter Simple PX-3605170200 CDM 51702 CPT 360 RC inpatient 298 298 CIGNA 62308 [3081051] CIGNA 62308 [308105105] 235.96 percent of total billed charges 184.76 283.1 Technical (Hospital) Services Insj Temp Ndwellg Bladder Catheter Simple PX-3605170200 CDM 51702 CPT 360 RC inpatient 298 298 CIGNA 62308 [3081051] CIGNA STATE OF WYOMING [308105107] 235.96 percent of total billed charges 184.76 283.1 Technical (Hospital) Services Insj Temp Ndwellg Bladder Catheter Simple PX-3605170200 CDM 51702 CPT 360 RC inpatient 298 298 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES EPO [308136803] 235.96 percent of total billed charges 184.76 283.1 Technical (Hospital) Services Insj Temp Ndwellg Bladder Catheter Simple PX-3605170200 CDM 51702 CPT 360 RC inpatient 298 298 MEDICA (COMMERCIAL) 94265 [3081118] MEDICA CLAIMS [308111801] 268.2 percent of total billed charges 184.76 283.1 Technical (Hospital) Services Insj Temp Ndwellg Bladder Catheter Simple PX-3605170200 CDM 51702 CPT 360 RC inpatient 298 298 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES HDHP [308136802] 235.96 percent of total billed charges 184.76 283.1 Technical (Hospital) Services Insj Temp Ndwellg Bladder Catheter Simple PX-3605170200 CDM 51702 CPT 360 RC inpatient 298 298 HEALTHPARTNERS SX009 HEALTHPARTNERS 235.96 percent of total billed charges 184.76 283.1 Technical (Hospital) Services Insj Temp Ndwellg Bladder Catheter Simple PX-3605170200 CDM 51702 CPT 360 RC inpatient 298 298 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES PPO [308136801] 235.96 percent of total billed charges 184.76 283.1 Technical (Hospital) Services Insj Temp Ndwellg Bladder Catheter Simple PX-3605170200 CDM 51702 CPT 360 RC inpatient 298 298 UNITED HEALTHCARE (COMMERCIAL) [3081199] UNITED HEALTHCARE 87726 [308119901] 184.76 percent of total billed charges 184.76 283.1 Technical (Hospital) Services Insj Temp Ndwellg Bladder Catheter Simple PX-3605170200 CDM 51702 CPT 360 RC inpatient 298 298 MULTIPLAN INC 34080 [3081285] MULTIPLAN INC [308128501] 283.1 percent of total billed charges 184.76 283.1 Technical (Hospital) Services Insj Temp Ndwellg Bladder Catheter Simple PX-3605170200 CDM 51702 CPT 360 RC inpatient 298 298 BLUE CROSS BLUE SHIELD WELLMARK SB889 [3081026] BCBS WYOMING [308102603] 283.1 percent of total billed charges 184.76 283.1 Technical (Hospital) Services Insj Temp Ndwellg Bladder Catheter Simple PX-3605170200 CDM 51702 CPT 360 RC outpatient 298 298 MEDICA (COMMERCIAL) 94265 [3081118] MEDICA CLAIMS [308111801] 268.2 percent of total billed charges 184.76 283.1 Technical (Hospital) Services Insj Temp Ndwellg Bladder Catheter Simple PX-3605170200 CDM 51702 CPT 360 RC outpatient 298 298 CIGNA 62308 [3081051] CIGNA 62308 [308105105] 238.4 percent of total billed charges 184.76 283.1 Technical (Hospital) Services Insj Temp Ndwellg Bladder Catheter Simple PX-3605170200 CDM 51702 CPT 360 RC outpatient 298 298 CIGNA 62308 [3081051] CIGNA STATE OF WYOMING [308105107] 238.4 percent of total billed charges 184.76 283.1 Technical (Hospital) Services Insj Temp Ndwellg Bladder Catheter Simple PX-3605170200 CDM 51702 CPT 360 RC outpatient 298 298 HEALTHPARTNERS SX009 HEALTHPARTNERS 238.4 percent of total billed charges 184.76 283.1 Technical (Hospital) Services Insj Temp Ndwellg Bladder Catheter Simple PX-3605170200 CDM 51702 CPT 360 RC outpatient 298 298 UNITED HEALTHCARE (COMMERCIAL) [3081199] UNITED HEALTHCARE 87726 [308119901] 184.76 percent of total billed charges 184.76 283.1 Technical (Hospital) Services Insj Temp Ndwellg Bladder Catheter Simple PX-3605170200 CDM 51702 CPT 360 RC outpatient 298 298 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES PPO [308136801] 238.4 percent of total billed charges 184.76 283.1 Technical (Hospital) Services Insj Temp Ndwellg Bladder Catheter Simple PX-3605170200 CDM 51702 CPT 360 RC outpatient 298 298 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES EPO [308136803] 238.4 percent of total billed charges 184.76 283.1 Technical (Hospital) Services Insj Temp Ndwellg Bladder Catheter Simple PX-3605170200 CDM 51702 CPT 360 RC outpatient 298 298 BLUE CROSS BLUE SHIELD WELLMARK SB889 [3081026] BCBS WYOMING [308102603] 283.1 percent of total billed charges 184.76 283.1 Technical (Hospital) Services Insj Temp Ndwellg Bladder Catheter Simple PX-3605170200 CDM 51702 CPT 360 RC outpatient 298 298 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES HDHP [308136802] 238.4 percent of total billed charges 184.76 283.1 Technical (Hospital) Services Insj Temp Ndwellg Bladder Catheter Simple PX-3605170200 CDM 51702 CPT 360 RC outpatient 298 298 MULTIPLAN INC 34080 [3081285] MULTIPLAN INC [308128501] 283.1 percent of total billed charges 184.76 283.1 Technical (Hospital) Services Insj Non-Ndwellg Bladder Catheter PX-3605170100 CDM 51701 CPT 360 RC outpatient 238 238 MEDICA (COMMERCIAL) 94265 [3081118] MEDICA CLAIMS [308111801] 214.2 percent of total billed charges 147.56 226.1 Technical (Hospital) Services Insj Non-Ndwellg Bladder Catheter PX-3605170100 CDM 51701 CPT 360 RC outpatient 238 238 CIGNA 62308 [3081051] CIGNA 62308 [308105105] 190.4 percent of total billed charges 147.56 226.1 Technical (Hospital) Services Insj Non-Ndwellg Bladder Catheter PX-3605170100 CDM 51701 CPT 360 RC outpatient 238 238 CIGNA 62308 [3081051] CIGNA STATE OF WYOMING [308105107] 190.4 percent of total billed charges 147.56 226.1 Technical (Hospital) Services Insj Non-Ndwellg Bladder Catheter PX-3605170100 CDM 51701 CPT 360 RC outpatient 238 238 MULTIPLAN INC 34080 [3081285] MULTIPLAN INC [308128501] 226.1 percent of total billed charges 147.56 226.1 Technical (Hospital) Services Insj Non-Ndwellg Bladder Catheter PX-3605170100 CDM 51701 CPT 360 RC outpatient 238 238 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES HDHP [308136802] 190.4 percent of total billed charges 147.56 226.1 Technical (Hospital) Services Insj Non-Ndwellg Bladder Catheter PX-3605170100 CDM 51701 CPT 360 RC outpatient 238 238 BLUE CROSS BLUE SHIELD WELLMARK SB889 [3081026] BCBS WYOMING [308102603] 226.1 percent of total billed charges 147.56 226.1 Technical (Hospital) Services Insj Non-Ndwellg Bladder Catheter PX-3605170100 CDM 51701 CPT 360 RC outpatient 238 238 UNITED HEALTHCARE (COMMERCIAL) [3081199] UNITED HEALTHCARE 87726 [308119901] 147.56 percent of total billed charges 147.56 226.1 Technical (Hospital) Services Insj Non-Ndwellg Bladder Catheter PX-3605170100 CDM 51701 CPT 360 RC outpatient 238 238 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES PPO [308136801] 190.4 percent of total billed charges 147.56 226.1 Technical (Hospital) Services Insj Non-Ndwellg Bladder Catheter PX-3605170100 CDM 51701 CPT 360 RC outpatient 238 238 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES EPO [308136803] 190.4 percent of total billed charges 147.56 226.1 Technical (Hospital) Services Insj Non-Ndwellg Bladder Catheter PX-3605170100 CDM 51701 CPT 360 RC outpatient 238 238 HEALTHPARTNERS SX009 HEALTHPARTNERS 190.4 percent of total billed charges 147.56 226.1 Technical (Hospital) Services Insj Non-Ndwellg Bladder Catheter PX-3605170100 CDM 51701 CPT 360 RC inpatient 238 238 HEALTHPARTNERS SX009 HEALTHPARTNERS 188.45 percent of total billed charges 147.56 226.1 Technical (Hospital) Services Insj Non-Ndwellg Bladder Catheter PX-3605170100 CDM 51701 CPT 360 RC inpatient 238 238 MEDICA (COMMERCIAL) 94265 [3081118] MEDICA CLAIMS [308111801] 214.2 percent of total billed charges 147.56 226.1 Technical (Hospital) Services Insj Non-Ndwellg Bladder Catheter PX-3605170100 CDM 51701 CPT 360 RC inpatient 238 238 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES HDHP [308136802] 188.45 percent of total billed charges 147.56 226.1 Technical (Hospital) Services Insj Non-Ndwellg Bladder Catheter PX-3605170100 CDM 51701 CPT 360 RC inpatient 238 238 UNITED HEALTHCARE (COMMERCIAL) [3081199] UNITED HEALTHCARE 87726 [308119901] 147.56 percent of total billed charges 147.56 226.1 Technical (Hospital) Services Insj Non-Ndwellg Bladder Catheter PX-3605170100 CDM 51701 CPT 360 RC inpatient 238 238 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES PPO [308136801] 188.45 percent of total billed charges 147.56 226.1 Technical (Hospital) Services Insj Non-Ndwellg Bladder Catheter PX-3605170100 CDM 51701 CPT 360 RC inpatient 238 238 BLUE CROSS BLUE SHIELD WELLMARK SB889 [3081026] BCBS WYOMING [308102603] 226.1 percent of total billed charges 147.56 226.1 Technical (Hospital) Services Insj Non-Ndwellg Bladder Catheter PX-3605170100 CDM 51701 CPT 360 RC inpatient 238 238 MULTIPLAN INC 34080 [3081285] MULTIPLAN INC [308128501] 226.1 percent of total billed charges 147.56 226.1 Technical (Hospital) Services Insj Non-Ndwellg Bladder Catheter PX-3605170100 CDM 51701 CPT 360 RC inpatient 238 238 CIGNA 62308 [3081051] CIGNA 62308 [308105105] 188.45 percent of total billed charges 147.56 226.1 Technical (Hospital) Services Insj Non-Ndwellg Bladder Catheter PX-3605170100 CDM 51701 CPT 360 RC inpatient 238 238 CIGNA 62308 [3081051] CIGNA STATE OF WYOMING [308105107] 188.45 percent of total billed charges 147.56 226.1 Technical (Hospital) Services Insj Non-Ndwellg Bladder Catheter PX-3605170100 CDM 51701 CPT 360 RC inpatient 238 238 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES EPO [308136803] 188.45 percent of total billed charges 147.56 226.1 Technical (Hospital) Services Bldr Irrigation Smpl Lavage &/Instlj PX-3605170000 CDM 51700 CPT 360 RC outpatient 295 295 CIGNA 62308 [3081051] CIGNA 62308 [308105105] 236 percent of total billed charges 182.9 280.25 Technical (Hospital) Services Bldr Irrigation Smpl Lavage &/Instlj PX-3605170000 CDM 51700 CPT 360 RC outpatient 295 295 CIGNA 62308 [3081051] CIGNA STATE OF WYOMING [308105107] 236 percent of total billed charges 182.9 280.25 Technical (Hospital) Services Bldr Irrigation Smpl Lavage &/Instlj PX-3605170000 CDM 51700 CPT 360 RC outpatient 295 295 MEDICA (COMMERCIAL) 94265 [3081118] MEDICA CLAIMS [308111801] 265.5 percent of total billed charges 182.9 280.25 Technical (Hospital) Services Bldr Irrigation Smpl Lavage &/Instlj PX-3605170000 CDM 51700 CPT 360 RC outpatient 295 295 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES HDHP [308136802] 236 percent of total billed charges 182.9 280.25 Technical (Hospital) Services Bldr Irrigation Smpl Lavage &/Instlj PX-3605170000 CDM 51700 CPT 360 RC outpatient 295 295 MULTIPLAN INC 34080 [3081285] MULTIPLAN INC [308128501] 280.25 percent of total billed charges 182.9 280.25 Technical (Hospital) Services Bldr Irrigation Smpl Lavage &/Instlj PX-3605170000 CDM 51700 CPT 360 RC outpatient 295 295 BLUE CROSS BLUE SHIELD WELLMARK SB889 [3081026] BCBS WYOMING [308102603] 280.25 percent of total billed charges 182.9 280.25 Technical (Hospital) Services Bldr Irrigation Smpl Lavage &/Instlj PX-3605170000 CDM 51700 CPT 360 RC outpatient 295 295 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES EPO [308136803] 236 percent of total billed charges 182.9 280.25 Technical (Hospital) Services Bldr Irrigation Smpl Lavage &/Instlj PX-3605170000 CDM 51700 CPT 360 RC outpatient 295 295 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES PPO [308136801] 236 percent of total billed charges 182.9 280.25 Technical (Hospital) Services Bldr Irrigation Smpl Lavage &/Instlj PX-3605170000 CDM 51700 CPT 360 RC outpatient 295 295 UNITED HEALTHCARE (COMMERCIAL) [3081199] UNITED HEALTHCARE 87726 [308119901] 182.9 percent of total billed charges 182.9 280.25 Technical (Hospital) Services Bldr Irrigation Smpl Lavage &/Instlj PX-3605170000 CDM 51700 CPT 360 RC outpatient 295 295 HEALTHPARTNERS SX009 HEALTHPARTNERS 236 percent of total billed charges 182.9 280.25 Technical (Hospital) Services Bldr Irrigation Smpl Lavage &/Instlj PX-3605170000 CDM 51700 CPT 360 RC inpatient 295 295 CIGNA 62308 [3081051] CIGNA 62308 [308105105] 233.58 percent of total billed charges 182.9 280.25 Technical (Hospital) Services Bldr Irrigation Smpl Lavage &/Instlj PX-3605170000 CDM 51700 CPT 360 RC inpatient 295 295 CIGNA 62308 [3081051] CIGNA STATE OF WYOMING [308105107] 233.58 percent of total billed charges 182.9 280.25 Technical (Hospital) Services Bldr Irrigation Smpl Lavage &/Instlj PX-3605170000 CDM 51700 CPT 360 RC inpatient 295 295 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES EPO [308136803] 233.58 percent of total billed charges 182.9 280.25 Technical (Hospital) Services Bldr Irrigation Smpl Lavage &/Instlj PX-3605170000 CDM 51700 CPT 360 RC inpatient 295 295 MULTIPLAN INC 34080 [3081285] MULTIPLAN INC [308128501] 280.25 percent of total billed charges 182.9 280.25 Technical (Hospital) Services Bldr Irrigation Smpl Lavage &/Instlj PX-3605170000 CDM 51700 CPT 360 RC inpatient 295 295 BLUE CROSS BLUE SHIELD WELLMARK SB889 [3081026] BCBS WYOMING [308102603] 280.25 percent of total billed charges 182.9 280.25 Technical (Hospital) Services Bldr Irrigation Smpl Lavage &/Instlj PX-3605170000 CDM 51700 CPT 360 RC inpatient 295 295 UNITED HEALTHCARE (COMMERCIAL) [3081199] UNITED HEALTHCARE 87726 [308119901] 182.9 percent of total billed charges 182.9 280.25 Technical (Hospital) Services Bldr Irrigation Smpl Lavage &/Instlj PX-3605170000 CDM 51700 CPT 360 RC inpatient 295 295 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES PPO [308136801] 233.58 percent of total billed charges 182.9 280.25 Technical (Hospital) Services Bldr Irrigation Smpl Lavage &/Instlj PX-3605170000 CDM 51700 CPT 360 RC inpatient 295 295 HEALTHPARTNERS SX009 HEALTHPARTNERS 233.58 percent of total billed charges 182.9 280.25 Technical (Hospital) Services Bldr Irrigation Smpl Lavage &/Instlj PX-3605170000 CDM 51700 CPT 360 RC inpatient 295 295 MEDICA (COMMERCIAL) 94265 [3081118] MEDICA CLAIMS [308111801] 265.5 percent of total billed charges 182.9 280.25 Technical (Hospital) Services Bldr Irrigation Smpl Lavage &/Instlj PX-3605170000 CDM 51700 CPT 360 RC inpatient 295 295 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES HDHP [308136802] 233.58 percent of total billed charges 182.9 280.25 Technical (Hospital) Services Aspiration Bladder Insert Suprapubic Catheter PX-51102 CDM 51102 CPT inpatient 1781 1781 CIGNA 62308 [3081051] CIGNA 62308 [308105105] 1424.8 percent of total billed charges 1104.22 1691.95 Professional (doctor) services Aspiration Bladder Insert Suprapubic Catheter PX-51102 CDM 51102 CPT inpatient 1781 1781 CIGNA 62308 [3081051] CIGNA STATE OF WYOMING [308105107] 1424.8 percent of total billed charges 1104.22 1691.95 Professional (doctor) services Aspiration Bladder Insert Suprapubic Catheter PX-51102 CDM 51102 CPT outpatient 1781 1781 CIGNA 62308 [3081051] CIGNA 62308 [308105105] 1424.8 percent of total billed charges 1104.22 1691.95 Professional (doctor) services Aspiration Bladder Insert Suprapubic Catheter PX-51102 CDM 51102 CPT outpatient 1781 1781 CIGNA 62308 [3081051] CIGNA STATE OF WYOMING [308105107] 1424.8 percent of total billed charges 1104.22 1691.95 Professional (doctor) services Aspiration Bladder Insert Suprapubic Catheter PX-51102 CDM 51102 CPT inpatient 1781 1781 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES EPO [308136803] 1424.8 percent of total billed charges 1104.22 1691.95 Professional (doctor) services Aspiration Bladder Insert Suprapubic Catheter PX-51102 CDM 51102 CPT inpatient 1781 1781 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES HDHP [308136802] 1424.8 percent of total billed charges 1104.22 1691.95 Professional (doctor) services Aspiration Bladder Insert Suprapubic Catheter PX-51102 CDM 51102 CPT inpatient 1781 1781 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES PPO [308136801] 1424.8 percent of total billed charges 1104.22 1691.95 Professional (doctor) services Aspiration Bladder Insert Suprapubic Catheter PX-51102 CDM 51102 CPT outpatient 1781 1781 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES EPO [308136803] 1424.8 percent of total billed charges 1104.22 1691.95 Professional (doctor) services Aspiration Bladder Insert Suprapubic Catheter PX-51102 CDM 51102 CPT outpatient 1781 1781 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES HDHP [308136802] 1424.8 percent of total billed charges 1104.22 1691.95 Professional (doctor) services Aspiration Bladder Insert Suprapubic Catheter PX-51102 CDM 51102 CPT outpatient 1781 1781 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES PPO [308136801] 1424.8 percent of total billed charges 1104.22 1691.95 Professional (doctor) services Aspiration Bladder Insert Suprapubic Catheter PX-51102 CDM 51102 CPT inpatient 1781 1781 HEALTHPARTNERS SX009 HEALTHPARTNERS 1424.8 percent of total billed charges 1104.22 1691.95 Professional (doctor) services Aspiration Bladder Insert Suprapubic Catheter PX-51102 CDM 51102 CPT outpatient 1781 1781 HEALTHPARTNERS SX009 HEALTHPARTNERS 1424.8 percent of total billed charges 1104.22 1691.95 Professional (doctor) services Aspiration Bladder Insert Suprapubic Catheter PX-51102 CDM 51102 CPT inpatient 1781 1781 MEDICA (COMMERCIAL) 94265 [3081118] MEDICA CLAIMS [308111801] 1602.9 percent of total billed charges 1104.22 1691.95 Professional (doctor) services Aspiration Bladder Insert Suprapubic Catheter PX-51102 CDM 51102 CPT outpatient 1781 1781 MEDICA (COMMERCIAL) 94265 [3081118] MEDICA CLAIMS [308111801] 1602.9 percent of total billed charges 1104.22 1691.95 Professional (doctor) services Aspiration Bladder Insert Suprapubic Catheter PX-51102 CDM 51102 CPT inpatient 1781 1781 MULTIPLAN INC 34080 [3081285] MULTIPLAN INC [308128501] 1691.95 percent of total billed charges 1104.22 1691.95 Professional (doctor) services Aspiration Bladder Insert Suprapubic Catheter PX-51102 CDM 51102 CPT outpatient 1781 1781 MULTIPLAN INC 34080 [3081285] MULTIPLAN INC [308128501] 1691.95 percent of total billed charges 1104.22 1691.95 Professional (doctor) services Aspiration Bladder Insert Suprapubic Catheter PX-51102 CDM 51102 CPT inpatient 1781 1781 UNITED HEALTHCARE (COMMERCIAL) [3081199] UNITED HEALTHCARE 87726 [308119901] 1104.22 percent of total billed charges 1104.22 1691.95 Professional (doctor) services Aspiration Bladder Insert Suprapubic Catheter PX-51102 CDM 51102 CPT outpatient 1781 1781 UNITED HEALTHCARE (COMMERCIAL) [3081199] UNITED HEALTHCARE 87726 [308119901] 1104.22 percent of total billed charges 1104.22 1691.95 Professional (doctor) services Abdom Paracentesis Dx/Ther W/Imaging Guidance PX-3604908300 CDM 49083 CPT 360 RC inpatient 834 834 HEALTHPARTNERS SX009 HEALTHPARTNERS 660.36 percent of total billed charges 517.08 792.3 Technical (Hospital) Services Abdom Paracentesis Dx/Ther W/Imaging Guidance PX-3604908300 CDM 49083 CPT 360 RC inpatient 834 834 MEDICA (COMMERCIAL) 94265 [3081118] MEDICA CLAIMS [308111801] 750.6 percent of total billed charges 517.08 792.3 Technical (Hospital) Services Abdom Paracentesis Dx/Ther W/Imaging Guidance PX-3604908300 CDM 49083 CPT 360 RC inpatient 834 834 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES HDHP [308136802] 660.36 percent of total billed charges 517.08 792.3 Technical (Hospital) Services Abdom Paracentesis Dx/Ther W/Imaging Guidance PX-3604908300 CDM 49083 CPT 360 RC inpatient 834 834 BLUE CROSS BLUE SHIELD WELLMARK SB889 [3081026] BCBS WYOMING [308102603] 792.3 percent of total billed charges 517.08 792.3 Technical (Hospital) Services Abdom Paracentesis Dx/Ther W/Imaging Guidance PX-3604908300 CDM 49083 CPT 360 RC inpatient 834 834 MULTIPLAN INC 34080 [3081285] MULTIPLAN INC [308128501] 792.3 percent of total billed charges 517.08 792.3 Technical (Hospital) Services Abdom Paracentesis Dx/Ther W/Imaging Guidance PX-3604908300 CDM 49083 CPT 360 RC inpatient 834 834 UNITED HEALTHCARE (COMMERCIAL) [3081199] UNITED HEALTHCARE 87726 [308119901] 517.08 percent of total billed charges 517.08 792.3 Technical (Hospital) Services Abdom Paracentesis Dx/Ther W/Imaging Guidance PX-3604908300 CDM 49083 CPT 360 RC inpatient 834 834 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES PPO [308136801] 660.36 percent of total billed charges 517.08 792.3 Technical (Hospital) Services Abdom Paracentesis Dx/Ther W/Imaging Guidance PX-3604908300 CDM 49083 CPT 360 RC inpatient 834 834 CIGNA 62308 [3081051] CIGNA 62308 [308105105] 660.36 percent of total billed charges 517.08 792.3 Technical (Hospital) Services Abdom Paracentesis Dx/Ther W/Imaging Guidance PX-3604908300 CDM 49083 CPT 360 RC inpatient 834 834 CIGNA 62308 [3081051] CIGNA STATE OF WYOMING [308105107] 660.36 percent of total billed charges 517.08 792.3 Technical (Hospital) Services Abdom Paracentesis Dx/Ther W/Imaging Guidance PX-3604908300 CDM 49083 CPT 360 RC inpatient 834 834 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES EPO [308136803] 660.36 percent of total billed charges 517.08 792.3 Technical (Hospital) Services Abdom Paracentesis Dx/Ther W/Imaging Guidance PX-3604908300 CDM 49083 CPT 360 RC outpatient 834 834 CIGNA 62308 [3081051] CIGNA 62308 [308105105] 667.2 percent of total billed charges 517.08 792.3 Technical (Hospital) Services Abdom Paracentesis Dx/Ther W/Imaging Guidance PX-3604908300 CDM 49083 CPT 360 RC outpatient 834 834 CIGNA 62308 [3081051] CIGNA STATE OF WYOMING [308105107] 667.2 percent of total billed charges 517.08 792.3 Technical (Hospital) Services Abdom Paracentesis Dx/Ther W/Imaging Guidance PX-3604908300 CDM 49083 CPT 360 RC outpatient 834 834 MEDICA (COMMERCIAL) 94265 [3081118] MEDICA CLAIMS [308111801] 750.6 percent of total billed charges 517.08 792.3 Technical (Hospital) Services Abdom Paracentesis Dx/Ther W/Imaging Guidance PX-3604908300 CDM 49083 CPT 360 RC outpatient 834 834 HEALTHPARTNERS SX009 HEALTHPARTNERS 667.2 percent of total billed charges 517.08 792.3 Technical (Hospital) Services Abdom Paracentesis Dx/Ther W/Imaging Guidance PX-3604908300 CDM 49083 CPT 360 RC outpatient 834 834 UNITED HEALTHCARE (COMMERCIAL) [3081199] UNITED HEALTHCARE 87726 [308119901] 517.08 percent of total billed charges 517.08 792.3 Technical (Hospital) Services Abdom Paracentesis Dx/Ther W/Imaging Guidance PX-3604908300 CDM 49083 CPT 360 RC outpatient 834 834 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES PPO [308136801] 667.2 percent of total billed charges 517.08 792.3 Technical (Hospital) Services Abdom Paracentesis Dx/Ther W/Imaging Guidance PX-3604908300 CDM 49083 CPT 360 RC outpatient 834 834 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES EPO [308136803] 667.2 percent of total billed charges 517.08 792.3 Technical (Hospital) Services Abdom Paracentesis Dx/Ther W/Imaging Guidance PX-3604908300 CDM 49083 CPT 360 RC outpatient 834 834 BLUE CROSS BLUE SHIELD WELLMARK SB889 [3081026] BCBS WYOMING [308102603] 792.3 percent of total billed charges 517.08 792.3 Technical (Hospital) Services Abdom Paracentesis Dx/Ther W/Imaging Guidance PX-3604908300 CDM 49083 CPT 360 RC outpatient 834 834 MULTIPLAN INC 34080 [3081285] MULTIPLAN INC [308128501] 792.3 percent of total billed charges 517.08 792.3 Technical (Hospital) Services Abdom Paracentesis Dx/Ther W/Imaging Guidance PX-3604908300 CDM 49083 CPT 360 RC outpatient 834 834 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES HDHP [308136802] 667.2 percent of total billed charges 517.08 792.3 Technical (Hospital) Services Abdom Paracentesis Dx/Ther W/O Imaging Guidance PX-3604908200 CDM 49082 CPT 360 RC outpatient 916 916 BLUE CROSS BLUE SHIELD WELLMARK SB889 [3081026] BCBS WYOMING [308102603] 870.2 percent of total billed charges 567.92 870.2 Technical (Hospital) Services Abdom Paracentesis Dx/Ther W/O Imaging Guidance PX-3604908200 CDM 49082 CPT 360 RC outpatient 916 916 MULTIPLAN INC 34080 [3081285] MULTIPLAN INC [308128501] 870.2 percent of total billed charges 567.92 870.2 Technical (Hospital) Services Abdom Paracentesis Dx/Ther W/O Imaging Guidance PX-3604908200 CDM 49082 CPT 360 RC outpatient 916 916 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES HDHP [308136802] 732.8 percent of total billed charges 567.92 870.2 Technical (Hospital) Services Abdom Paracentesis Dx/Ther W/O Imaging Guidance PX-3604908200 CDM 49082 CPT 360 RC outpatient 916 916 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES PPO [308136801] 732.8 percent of total billed charges 567.92 870.2 Technical (Hospital) Services Abdom Paracentesis Dx/Ther W/O Imaging Guidance PX-3604908200 CDM 49082 CPT 360 RC outpatient 916 916 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES EPO [308136803] 732.8 percent of total billed charges 567.92 870.2 Technical (Hospital) Services Abdom Paracentesis Dx/Ther W/O Imaging Guidance PX-3604908200 CDM 49082 CPT 360 RC outpatient 916 916 UNITED HEALTHCARE (COMMERCIAL) [3081199] UNITED HEALTHCARE 87726 [308119901] 567.92 percent of total billed charges 567.92 870.2 Technical (Hospital) Services Abdom Paracentesis Dx/Ther W/O Imaging Guidance PX-3604908200 CDM 49082 CPT 360 RC outpatient 916 916 HEALTHPARTNERS SX009 HEALTHPARTNERS 732.8 percent of total billed charges 567.92 870.2 Technical (Hospital) Services Abdom Paracentesis Dx/Ther W/O Imaging Guidance PX-3604908200 CDM 49082 CPT 360 RC outpatient 916 916 MEDICA (COMMERCIAL) 94265 [3081118] MEDICA CLAIMS [308111801] 824.4 percent of total billed charges 567.92 870.2 Technical (Hospital) Services Abdom Paracentesis Dx/Ther W/O Imaging Guidance PX-3604908200 CDM 49082 CPT 360 RC outpatient 916 916 CIGNA 62308 [3081051] CIGNA 62308 [308105105] 732.8 percent of total billed charges 567.92 870.2 Technical (Hospital) Services Abdom Paracentesis Dx/Ther W/O Imaging Guidance PX-3604908200 CDM 49082 CPT 360 RC inpatient 916 916 HEALTHPARTNERS SX009 HEALTHPARTNERS 725.29 percent of total billed charges 567.92 870.2 Technical (Hospital) Services Abdom Paracentesis Dx/Ther W/O Imaging Guidance PX-3604908200 CDM 49082 CPT 360 RC inpatient 916 916 MEDICA (COMMERCIAL) 94265 [3081118] MEDICA CLAIMS [308111801] 824.4 percent of total billed charges 567.92 870.2 Technical (Hospital) Services Abdom Paracentesis Dx/Ther W/O Imaging Guidance PX-3604908200 CDM 49082 CPT 360 RC inpatient 916 916 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES HDHP [308136802] 725.29 percent of total billed charges 567.92 870.2 Technical (Hospital) Services Abdom Paracentesis Dx/Ther W/O Imaging Guidance PX-3604908200 CDM 49082 CPT 360 RC inpatient 916 916 BLUE CROSS BLUE SHIELD WELLMARK SB889 [3081026] BCBS WYOMING [308102603] 870.2 percent of total billed charges 567.92 870.2 Technical (Hospital) Services Abdom Paracentesis Dx/Ther W/O Imaging Guidance PX-3604908200 CDM 49082 CPT 360 RC inpatient 916 916 MULTIPLAN INC 34080 [3081285] MULTIPLAN INC [308128501] 870.2 percent of total billed charges 567.92 870.2 Technical (Hospital) Services Abdom Paracentesis Dx/Ther W/O Imaging Guidance PX-3604908200 CDM 49082 CPT 360 RC inpatient 916 916 UNITED HEALTHCARE (COMMERCIAL) [3081199] UNITED HEALTHCARE 87726 [308119901] 567.92 percent of total billed charges 567.92 870.2 Technical (Hospital) Services Abdom Paracentesis Dx/Ther W/O Imaging Guidance PX-3604908200 CDM 49082 CPT 360 RC inpatient 916 916 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES PPO [308136801] 725.29 percent of total billed charges 567.92 870.2 Technical (Hospital) Services Abdom Paracentesis Dx/Ther W/O Imaging Guidance PX-3604908200 CDM 49082 CPT 360 RC inpatient 916 916 CIGNA 62308 [3081051] CIGNA 62308 [308105105] 725.29 percent of total billed charges 567.92 870.2 Technical (Hospital) Services Abdom Paracentesis Dx/Ther W/O Imaging Guidance PX-3604908200 CDM 49082 CPT 360 RC inpatient 916 916 CIGNA 62308 [3081051] CIGNA STATE OF WYOMING [308105107] 725.29 percent of total billed charges 567.92 870.2 Technical (Hospital) Services Abdom Paracentesis Dx/Ther W/O Imaging Guidance PX-3604908200 CDM 49082 CPT 360 RC outpatient 916 916 CIGNA 62308 [3081051] CIGNA STATE OF WYOMING [308105107] 732.8 percent of total billed charges 567.92 870.2 Technical (Hospital) Services Abdom Paracentesis Dx/Ther W/O Imaging Guidance PX-3604908200 CDM 49082 CPT 360 RC inpatient 916 916 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES EPO [308136803] 725.29 percent of total billed charges 567.92 870.2 Technical (Hospital) Services Introduction of Long Gastrointestinal Tube PX-7504450000 CDM 44500 CPT 750 RC inpatient 282 282 MEDICA (COMMERCIAL) 94265 [3081118] MEDICA CLAIMS [308111801] 253.8 percent of total billed charges 174.84 267.9 Technical (Hospital) Services Introduction of Long Gastrointestinal Tube PX-7504450000 CDM 44500 CPT 750 RC inpatient 282 282 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES HDHP [308136802] 223.29 percent of total billed charges 174.84 267.9 Technical (Hospital) Services Introduction of Long Gastrointestinal Tube PX-7504450000 CDM 44500 CPT 750 RC inpatient 282 282 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES EPO [308136803] 223.29 percent of total billed charges 174.84 267.9 Technical (Hospital) Services Introduction of Long Gastrointestinal Tube PX-7504450000 CDM 44500 CPT 750 RC inpatient 282 282 HEALTHPARTNERS SX009 HEALTHPARTNERS 223.29 percent of total billed charges 174.84 267.9 Technical (Hospital) Services Introduction of Long Gastrointestinal Tube PX-7504450000 CDM 44500 CPT 750 RC inpatient 282 282 UNITED HEALTHCARE (COMMERCIAL) [3081199] UNITED HEALTHCARE 87726 [308119901] 174.84 percent of total billed charges 174.84 267.9 Technical (Hospital) Services Introduction of Long Gastrointestinal Tube PX-7504450000 CDM 44500 CPT 750 RC inpatient 282 282 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES PPO [308136801] 223.29 percent of total billed charges 174.84 267.9 Technical (Hospital) Services Introduction of Long Gastrointestinal Tube PX-7504450000 CDM 44500 CPT 750 RC inpatient 282 282 BLUE CROSS BLUE SHIELD WELLMARK SB889 [3081026] BCBS WYOMING [308102603] 267.9 percent of total billed charges 174.84 267.9 Technical (Hospital) Services Introduction of Long Gastrointestinal Tube PX-7504450000 CDM 44500 CPT 750 RC inpatient 282 282 MULTIPLAN INC 34080 [3081285] MULTIPLAN INC [308128501] 267.9 percent of total billed charges 174.84 267.9 Technical (Hospital) Services Introduction of Long Gastrointestinal Tube PX-7504450000 CDM 44500 CPT 750 RC inpatient 282 282 CIGNA 62308 [3081051] CIGNA 62308 [308105105] 223.29 percent of total billed charges 174.84 267.9 Technical (Hospital) Services Introduction of Long Gastrointestinal Tube PX-7504450000 CDM 44500 CPT 750 RC inpatient 282 282 CIGNA 62308 [3081051] CIGNA STATE OF WYOMING [308105107] 223.29 percent of total billed charges 174.84 267.9 Technical (Hospital) Services Introduction of Long Gastrointestinal Tube PX-7504450000 CDM 44500 CPT 750 RC outpatient 282 282 MEDICA (COMMERCIAL) 94265 [3081118] MEDICA CLAIMS [308111801] 253.8 percent of total billed charges 174.84 267.9 Technical (Hospital) Services Introduction of Long Gastrointestinal Tube PX-7504450000 CDM 44500 CPT 750 RC outpatient 282 282 CIGNA 62308 [3081051] CIGNA 62308 [308105105] 225.6 percent of total billed charges 174.84 267.9 Technical (Hospital) Services Introduction of Long Gastrointestinal Tube PX-7504450000 CDM 44500 CPT 750 RC outpatient 282 282 CIGNA 62308 [3081051] CIGNA STATE OF WYOMING [308105107] 225.6 percent of total billed charges 174.84 267.9 Technical (Hospital) Services Introduction of Long Gastrointestinal Tube PX-7504450000 CDM 44500 CPT 750 RC outpatient 282 282 HEALTHPARTNERS SX009 HEALTHPARTNERS 225.6 percent of total billed charges 174.84 267.9 Technical (Hospital) Services Introduction of Long Gastrointestinal Tube PX-7504450000 CDM 44500 CPT 750 RC outpatient 282 282 UNITED HEALTHCARE (COMMERCIAL) [3081199] UNITED HEALTHCARE 87726 [308119901] 174.84 percent of total billed charges 174.84 267.9 Technical (Hospital) Services Introduction of Long Gastrointestinal Tube PX-7504450000 CDM 44500 CPT 750 RC outpatient 282 282 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES EPO [308136803] 225.6 percent of total billed charges 174.84 267.9 Technical (Hospital) Services Introduction of Long Gastrointestinal Tube PX-7504450000 CDM 44500 CPT 750 RC outpatient 282 282 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES PPO [308136801] 225.6 percent of total billed charges 174.84 267.9 Technical (Hospital) Services Introduction of Long Gastrointestinal Tube PX-7504450000 CDM 44500 CPT 750 RC outpatient 282 282 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES HDHP [308136802] 225.6 percent of total billed charges 174.84 267.9 Technical (Hospital) Services Introduction of Long Gastrointestinal Tube PX-7504450000 CDM 44500 CPT 750 RC outpatient 282 282 MULTIPLAN INC 34080 [3081285] MULTIPLAN INC [308128501] 267.9 percent of total billed charges 174.84 267.9 Technical (Hospital) Services Introduction of Long Gastrointestinal Tube PX-7504450000 CDM 44500 CPT 750 RC outpatient 282 282 BLUE CROSS BLUE SHIELD WELLMARK SB889 [3081026] BCBS WYOMING [308102603] 267.9 percent of total billed charges 174.84 267.9 Technical (Hospital) Services Drainage of Gum Lesion PX-41800 CDM 41800 CPT inpatient 836 836 CIGNA 62308 [3081051] CIGNA 62308 [308105105] 668.8 percent of total billed charges 518.32 794.2 Professional (doctor) services Drainage of Gum Lesion PX-41800 CDM 41800 CPT inpatient 836 836 CIGNA 62308 [3081051] CIGNA STATE OF WYOMING [308105107] 668.8 percent of total billed charges 518.32 794.2 Professional (doctor) services Drainage of Gum Lesion PX-41800 CDM 41800 CPT outpatient 836 836 CIGNA 62308 [3081051] CIGNA 62308 [308105105] 668.8 percent of total billed charges 518.32 794.2 Professional (doctor) services Drainage of Gum Lesion PX-41800 CDM 41800 CPT outpatient 836 836 CIGNA 62308 [3081051] CIGNA STATE OF WYOMING [308105107] 668.8 percent of total billed charges 518.32 794.2 Professional (doctor) services Drainage of Gum Lesion PX-41800 CDM 41800 CPT inpatient 836 836 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES EPO [308136803] 668.8 percent of total billed charges 518.32 794.2 Professional (doctor) services Drainage of Gum Lesion PX-41800 CDM 41800 CPT inpatient 836 836 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES HDHP [308136802] 668.8 percent of total billed charges 518.32 794.2 Professional (doctor) services Drainage of Gum Lesion PX-41800 CDM 41800 CPT inpatient 836 836 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES PPO [308136801] 668.8 percent of total billed charges 518.32 794.2 Professional (doctor) services Drainage of Gum Lesion PX-41800 CDM 41800 CPT outpatient 836 836 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES EPO [308136803] 668.8 percent of total billed charges 518.32 794.2 Professional (doctor) services Drainage of Gum Lesion PX-41800 CDM 41800 CPT outpatient 836 836 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES HDHP [308136802] 668.8 percent of total billed charges 518.32 794.2 Professional (doctor) services Drainage of Gum Lesion PX-41800 CDM 41800 CPT outpatient 836 836 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES PPO [308136801] 668.8 percent of total billed charges 518.32 794.2 Professional (doctor) services Drainage of Gum Lesion PX-41800 CDM 41800 CPT inpatient 836 836 HEALTHPARTNERS SX009 HEALTHPARTNERS 668.8 percent of total billed charges 518.32 794.2 Professional (doctor) services Drainage of Gum Lesion PX-41800 CDM 41800 CPT outpatient 836 836 HEALTHPARTNERS SX009 HEALTHPARTNERS 668.8 percent of total billed charges 518.32 794.2 Professional (doctor) services Drainage of Gum Lesion PX-41800 CDM 41800 CPT inpatient 836 836 MEDICA (COMMERCIAL) 94265 [3081118] MEDICA CLAIMS [308111801] 752.4 percent of total billed charges 518.32 794.2 Professional (doctor) services Drainage of Gum Lesion PX-41800 CDM 41800 CPT outpatient 836 836 MEDICA (COMMERCIAL) 94265 [3081118] MEDICA CLAIMS [308111801] 752.4 percent of total billed charges 518.32 794.2 Professional (doctor) services Drainage of Gum Lesion PX-41800 CDM 41800 CPT inpatient 836 836 MULTIPLAN INC 34080 [3081285] MULTIPLAN INC [308128501] 794.2 percent of total billed charges 518.32 794.2 Professional (doctor) services Drainage of Gum Lesion PX-41800 CDM 41800 CPT outpatient 836 836 MULTIPLAN INC 34080 [3081285] MULTIPLAN INC [308128501] 794.2 percent of total billed charges 518.32 794.2 Professional (doctor) services Drainage of Gum Lesion PX-41800 CDM 41800 CPT inpatient 836 836 UNITED HEALTHCARE (COMMERCIAL) [3081199] UNITED HEALTHCARE 87726 [308119901] 518.32 percent of total billed charges 518.32 794.2 Professional (doctor) services Drainage of Gum Lesion PX-41800 CDM 41800 CPT outpatient 836 836 UNITED HEALTHCARE (COMMERCIAL) [3081199] UNITED HEALTHCARE 87726 [308119901] 518.32 percent of total billed charges 518.32 794.2 Professional (doctor) services "Drain Mouth Absc/Cyst/Hematoma,Simpl" PX-40800 CDM 40800 CPT inpatient 543 543 CIGNA 62308 [3081051] CIGNA 62308 [308105105] 434.4 percent of total billed charges 336.66 515.85 Professional (doctor) services "Drain Mouth Absc/Cyst/Hematoma,Simpl" PX-40800 CDM 40800 CPT inpatient 543 543 CIGNA 62308 [3081051] CIGNA STATE OF WYOMING [308105107] 434.4 percent of total billed charges 336.66 515.85 Professional (doctor) services "Drain Mouth Absc/Cyst/Hematoma,Simpl" PX-40800 CDM 40800 CPT outpatient 543 543 CIGNA 62308 [3081051] CIGNA 62308 [308105105] 434.4 percent of total billed charges 336.66 515.85 Professional (doctor) services "Drain Mouth Absc/Cyst/Hematoma,Simpl" PX-40800 CDM 40800 CPT outpatient 543 543 CIGNA 62308 [3081051] CIGNA STATE OF WYOMING [308105107] 434.4 percent of total billed charges 336.66 515.85 Professional (doctor) services "Drain Mouth Absc/Cyst/Hematoma,Simpl" PX-40800 CDM 40800 CPT inpatient 543 543 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES EPO [308136803] 434.4 percent of total billed charges 336.66 515.85 Professional (doctor) services "Drain Mouth Absc/Cyst/Hematoma,Simpl" PX-40800 CDM 40800 CPT inpatient 543 543 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES HDHP [308136802] 434.4 percent of total billed charges 336.66 515.85 Professional (doctor) services "Drain Mouth Absc/Cyst/Hematoma,Simpl" PX-40800 CDM 40800 CPT inpatient 543 543 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES PPO [308136801] 434.4 percent of total billed charges 336.66 515.85 Professional (doctor) services "Drain Mouth Absc/Cyst/Hematoma,Simpl" PX-40800 CDM 40800 CPT outpatient 543 543 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES EPO [308136803] 434.4 percent of total billed charges 336.66 515.85 Professional (doctor) services "Drain Mouth Absc/Cyst/Hematoma,Simpl" PX-40800 CDM 40800 CPT outpatient 543 543 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES HDHP [308136802] 434.4 percent of total billed charges 336.66 515.85 Professional (doctor) services "Drain Mouth Absc/Cyst/Hematoma,Simpl" PX-40800 CDM 40800 CPT outpatient 543 543 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES PPO [308136801] 434.4 percent of total billed charges 336.66 515.85 Professional (doctor) services "Drain Mouth Absc/Cyst/Hematoma,Simpl" PX-40800 CDM 40800 CPT inpatient 543 543 HEALTHPARTNERS SX009 HEALTHPARTNERS 434.4 percent of total billed charges 336.66 515.85 Professional (doctor) services "Drain Mouth Absc/Cyst/Hematoma,Simpl" PX-40800 CDM 40800 CPT outpatient 543 543 HEALTHPARTNERS SX009 HEALTHPARTNERS 434.4 percent of total billed charges 336.66 515.85 Professional (doctor) services "Drain Mouth Absc/Cyst/Hematoma,Simpl" PX-40800 CDM 40800 CPT inpatient 543 543 MEDICA (COMMERCIAL) 94265 [3081118] MEDICA CLAIMS [308111801] 488.7 percent of total billed charges 336.66 515.85 Professional (doctor) services "Drain Mouth Absc/Cyst/Hematoma,Simpl" PX-40800 CDM 40800 CPT outpatient 543 543 MEDICA (COMMERCIAL) 94265 [3081118] MEDICA CLAIMS [308111801] 488.7 percent of total billed charges 336.66 515.85 Professional (doctor) services "Drain Mouth Absc/Cyst/Hematoma,Simpl" PX-40800 CDM 40800 CPT inpatient 543 543 MULTIPLAN INC 34080 [3081285] MULTIPLAN INC [308128501] 515.85 percent of total billed charges 336.66 515.85 Professional (doctor) services "Drain Mouth Absc/Cyst/Hematoma,Simpl" PX-40800 CDM 40800 CPT outpatient 543 543 MULTIPLAN INC 34080 [3081285] MULTIPLAN INC [308128501] 515.85 percent of total billed charges 336.66 515.85 Professional (doctor) services "Drain Mouth Absc/Cyst/Hematoma,Simpl" PX-40800 CDM 40800 CPT inpatient 543 543 UNITED HEALTHCARE (COMMERCIAL) [3081199] UNITED HEALTHCARE 87726 [308119901] 336.66 percent of total billed charges 336.66 515.85 Professional (doctor) services "Drain Mouth Absc/Cyst/Hematoma,Simpl" PX-40800 CDM 40800 CPT outpatient 543 543 UNITED HEALTHCARE (COMMERCIAL) [3081199] UNITED HEALTHCARE 87726 [308119901] 336.66 percent of total billed charges 336.66 515.85 Professional (doctor) services Placement Needle Intraosseous Infusion PX-3603668000 CDM 36680 CPT 360 RC outpatient 888 888 HEALTHPARTNERS SX009 HEALTHPARTNERS 710.4 percent of total billed charges 550.56 843.6 Technical (Hospital) Services Placement Needle Intraosseous Infusion PX-3603668000 CDM 36680 CPT 360 RC outpatient 888 888 UNITED HEALTHCARE (COMMERCIAL) [3081199] UNITED HEALTHCARE 87726 [308119901] 550.56 percent of total billed charges 550.56 843.6 Technical (Hospital) Services Placement Needle Intraosseous Infusion PX-3603668000 CDM 36680 CPT 360 RC outpatient 888 888 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES EPO [308136803] 710.4 percent of total billed charges 550.56 843.6 Technical (Hospital) Services Placement Needle Intraosseous Infusion PX-3603668000 CDM 36680 CPT 360 RC outpatient 888 888 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES PPO [308136801] 710.4 percent of total billed charges 550.56 843.6 Technical (Hospital) Services Placement Needle Intraosseous Infusion PX-3603668000 CDM 36680 CPT 360 RC outpatient 888 888 BLUE CROSS BLUE SHIELD WELLMARK SB889 [3081026] BCBS WYOMING [308102603] 843.6 percent of total billed charges 550.56 843.6 Technical (Hospital) Services Placement Needle Intraosseous Infusion PX-3603668000 CDM 36680 CPT 360 RC outpatient 888 888 MULTIPLAN INC 34080 [3081285] MULTIPLAN INC [308128501] 843.6 percent of total billed charges 550.56 843.6 Technical (Hospital) Services Placement Needle Intraosseous Infusion PX-3603668000 CDM 36680 CPT 360 RC outpatient 888 888 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES HDHP [308136802] 710.4 percent of total billed charges 550.56 843.6 Technical (Hospital) Services Placement Needle Intraosseous Infusion PX-3603668000 CDM 36680 CPT 360 RC outpatient 888 888 MEDICA (COMMERCIAL) 94265 [3081118] MEDICA CLAIMS [308111801] 799.2 percent of total billed charges 550.56 843.6 Technical (Hospital) Services Placement Needle Intraosseous Infusion PX-3603668000 CDM 36680 CPT 360 RC outpatient 888 888 CIGNA 62308 [3081051] CIGNA 62308 [308105105] 710.4 percent of total billed charges 550.56 843.6 Technical (Hospital) Services Placement Needle Intraosseous Infusion PX-3603668000 CDM 36680 CPT 360 RC outpatient 888 888 CIGNA 62308 [3081051] CIGNA STATE OF WYOMING [308105107] 710.4 percent of total billed charges 550.56 843.6 Technical (Hospital) Services Placement Needle Intraosseous Infusion PX-3603668000 CDM 36680 CPT 360 RC inpatient 888 888 HEALTHPARTNERS SX009 HEALTHPARTNERS 703.12 percent of total billed charges 550.56 843.6 Technical (Hospital) Services Placement Needle Intraosseous Infusion PX-3603668000 CDM 36680 CPT 360 RC inpatient 888 888 MEDICA (COMMERCIAL) 94265 [3081118] MEDICA CLAIMS [308111801] 799.2 percent of total billed charges 550.56 843.6 Technical (Hospital) Services Placement Needle Intraosseous Infusion PX-3603668000 CDM 36680 CPT 360 RC inpatient 888 888 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES HDHP [308136802] 703.12 percent of total billed charges 550.56 843.6 Technical (Hospital) Services Placement Needle Intraosseous Infusion PX-3603668000 CDM 36680 CPT 360 RC inpatient 888 888 BLUE CROSS BLUE SHIELD WELLMARK SB889 [3081026] BCBS WYOMING [308102603] 843.6 percent of total billed charges 550.56 843.6 Technical (Hospital) Services Placement Needle Intraosseous Infusion PX-3603668000 CDM 36680 CPT 360 RC inpatient 888 888 MULTIPLAN INC 34080 [3081285] MULTIPLAN INC [308128501] 843.6 percent of total billed charges 550.56 843.6 Technical (Hospital) Services Placement Needle Intraosseous Infusion PX-3603668000 CDM 36680 CPT 360 RC inpatient 888 888 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES PPO [308136801] 703.12 percent of total billed charges 550.56 843.6 Technical (Hospital) Services Placement Needle Intraosseous Infusion PX-3603668000 CDM 36680 CPT 360 RC inpatient 888 888 UNITED HEALTHCARE (COMMERCIAL) [3081199] UNITED HEALTHCARE 87726 [308119901] 550.56 percent of total billed charges 550.56 843.6 Technical (Hospital) Services Placement Needle Intraosseous Infusion PX-3603668000 CDM 36680 CPT 360 RC inpatient 888 888 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES EPO [308136803] 703.12 percent of total billed charges 550.56 843.6 Technical (Hospital) Services Placement Needle Intraosseous Infusion PX-3603668000 CDM 36680 CPT 360 RC inpatient 888 888 CIGNA 62308 [3081051] CIGNA 62308 [308105105] 703.12 percent of total billed charges 550.56 843.6 Technical (Hospital) Services Placement Needle Intraosseous Infusion PX-3603668000 CDM 36680 CPT 360 RC inpatient 888 888 CIGNA 62308 [3081051] CIGNA STATE OF WYOMING [308105107] 703.12 percent of total billed charges 550.56 843.6 Technical (Hospital) Services Arterial Puncture Withdrawal Blood Dx PX-3603660000 CDM 36600 CPT 360 RC outpatient 477 477 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES PPO [308136801] 381.6 percent of total billed charges 295.74 453.15 Technical (Hospital) Services Arterial Puncture Withdrawal Blood Dx PX-3603660000 CDM 36600 CPT 360 RC outpatient 477 477 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES EPO [308136803] 381.6 percent of total billed charges 295.74 453.15 Technical (Hospital) Services Arterial Puncture Withdrawal Blood Dx PX-3603660000 CDM 36600 CPT 360 RC outpatient 477 477 BLUE CROSS BLUE SHIELD WELLMARK SB889 [3081026] BCBS WYOMING [308102603] 453.15 percent of total billed charges 295.74 453.15 Technical (Hospital) Services Arterial Puncture Withdrawal Blood Dx PX-3603660000 CDM 36600 CPT 360 RC outpatient 477 477 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES HDHP [308136802] 381.6 percent of total billed charges 295.74 453.15 Technical (Hospital) Services Arterial Puncture Withdrawal Blood Dx PX-3603660000 CDM 36600 CPT 360 RC outpatient 477 477 MULTIPLAN INC 34080 [3081285] MULTIPLAN INC [308128501] 453.15 percent of total billed charges 295.74 453.15 Technical (Hospital) Services Arterial Puncture Withdrawal Blood Dx PX-3603660000 CDM 36600 CPT 360 RC outpatient 477 477 UNITED HEALTHCARE (COMMERCIAL) [3081199] UNITED HEALTHCARE 87726 [308119901] 295.74 percent of total billed charges 295.74 453.15 Technical (Hospital) Services Arterial Puncture Withdrawal Blood Dx PX-3603660000 CDM 36600 CPT 360 RC outpatient 477 477 HEALTHPARTNERS SX009 HEALTHPARTNERS 381.6 percent of total billed charges 295.74 453.15 Technical (Hospital) Services Arterial Puncture Withdrawal Blood Dx PX-3603660000 CDM 36600 CPT 360 RC outpatient 477 477 MEDICA (COMMERCIAL) 94265 [3081118] MEDICA CLAIMS [308111801] 429.3 percent of total billed charges 295.74 453.15 Technical (Hospital) Services Arterial Puncture Withdrawal Blood Dx PX-3603660000 CDM 36600 CPT 360 RC outpatient 477 477 CIGNA 62308 [3081051] CIGNA 62308 [308105105] 381.6 percent of total billed charges 295.74 453.15 Technical (Hospital) Services Arterial Puncture Withdrawal Blood Dx PX-3603660000 CDM 36600 CPT 360 RC outpatient 477 477 CIGNA 62308 [3081051] CIGNA STATE OF WYOMING [308105107] 381.6 percent of total billed charges 295.74 453.15 Technical (Hospital) Services Arterial Puncture Withdrawal Blood Dx PX-3603660000 CDM 36600 CPT 360 RC inpatient 477 477 CIGNA 62308 [3081051] CIGNA 62308 [308105105] 377.69 percent of total billed charges 295.74 453.15 Technical (Hospital) Services Arterial Puncture Withdrawal Blood Dx PX-3603660000 CDM 36600 CPT 360 RC inpatient 477 477 CIGNA 62308 [3081051] CIGNA STATE OF WYOMING [308105107] 377.69 percent of total billed charges 295.74 453.15 Technical (Hospital) Services Arterial Puncture Withdrawal Blood Dx PX-3603660000 CDM 36600 CPT 360 RC inpatient 477 477 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES EPO [308136803] 377.69 percent of total billed charges 295.74 453.15 Technical (Hospital) Services Arterial Puncture Withdrawal Blood Dx PX-3603660000 CDM 36600 CPT 360 RC inpatient 477 477 BLUE CROSS BLUE SHIELD WELLMARK SB889 [3081026] BCBS WYOMING [308102603] 453.15 percent of total billed charges 295.74 453.15 Technical (Hospital) Services Arterial Puncture Withdrawal Blood Dx PX-3603660000 CDM 36600 CPT 360 RC inpatient 477 477 UNITED HEALTHCARE (COMMERCIAL) [3081199] UNITED HEALTHCARE 87726 [308119901] 295.74 percent of total billed charges 295.74 453.15 Technical (Hospital) Services Arterial Puncture Withdrawal Blood Dx PX-3603660000 CDM 36600 CPT 360 RC inpatient 477 477 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES PPO [308136801] 377.69 percent of total billed charges 295.74 453.15 Technical (Hospital) Services Arterial Puncture Withdrawal Blood Dx PX-3603660000 CDM 36600 CPT 360 RC inpatient 477 477 MULTIPLAN INC 34080 [3081285] MULTIPLAN INC [308128501] 453.15 percent of total billed charges 295.74 453.15 Technical (Hospital) Services Arterial Puncture Withdrawal Blood Dx PX-3603660000 CDM 36600 CPT 360 RC inpatient 477 477 MEDICA (COMMERCIAL) 94265 [3081118] MEDICA CLAIMS [308111801] 429.3 percent of total billed charges 295.74 453.15 Technical (Hospital) Services Arterial Puncture Withdrawal Blood Dx PX-3603660000 CDM 36600 CPT 360 RC inpatient 477 477 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES HDHP [308136802] 377.69 percent of total billed charges 295.74 453.15 Technical (Hospital) Services Arterial Puncture Withdrawal Blood Dx PX-3603660000 CDM 36600 CPT 360 RC inpatient 477 477 HEALTHPARTNERS SX009 HEALTHPARTNERS 377.69 percent of total billed charges 295.74 453.15 Technical (Hospital) Services Collect Blood From Catheter Venous Nos PX-3603659200 CDM 36592 CPT 360 RC inpatient 286 286 HEALTHPARTNERS SX009 HEALTHPARTNERS 226.45 percent of total billed charges 177.32 271.7 Technical (Hospital) Services Collect Blood From Catheter Venous Nos PX-3603659200 CDM 36592 CPT 360 RC inpatient 286 286 MEDICA (COMMERCIAL) 94265 [3081118] MEDICA CLAIMS [308111801] 257.4 percent of total billed charges 177.32 271.7 Technical (Hospital) Services Collect Blood From Catheter Venous Nos PX-3603659200 CDM 36592 CPT 360 RC inpatient 286 286 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES HDHP [308136802] 226.45 percent of total billed charges 177.32 271.7 Technical (Hospital) Services Collect Blood From Catheter Venous Nos PX-3603659200 CDM 36592 CPT 360 RC inpatient 286 286 MULTIPLAN INC 34080 [3081285] MULTIPLAN INC [308128501] 271.7 percent of total billed charges 177.32 271.7 Technical (Hospital) Services Collect Blood From Catheter Venous Nos PX-3603659200 CDM 36592 CPT 360 RC inpatient 286 286 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES PPO [308136801] 226.45 percent of total billed charges 177.32 271.7 Technical (Hospital) Services Collect Blood From Catheter Venous Nos PX-3603659200 CDM 36592 CPT 360 RC inpatient 286 286 UNITED HEALTHCARE (COMMERCIAL) [3081199] UNITED HEALTHCARE 87726 [308119901] 177.32 percent of total billed charges 177.32 271.7 Technical (Hospital) Services Collect Blood From Catheter Venous Nos PX-3603659200 CDM 36592 CPT 360 RC inpatient 286 286 BLUE CROSS BLUE SHIELD WELLMARK SB889 [3081026] BCBS WYOMING [308102603] 271.7 percent of total billed charges 177.32 271.7 Technical (Hospital) Services Collect Blood From Catheter Venous Nos PX-3603659200 CDM 36592 CPT 360 RC inpatient 286 286 CIGNA 62308 [3081051] CIGNA 62308 [308105105] 226.45 percent of total billed charges 177.32 271.7 Technical (Hospital) Services Collect Blood From Catheter Venous Nos PX-3603659200 CDM 36592 CPT 360 RC inpatient 286 286 CIGNA 62308 [3081051] CIGNA STATE OF WYOMING [308105107] 226.45 percent of total billed charges 177.32 271.7 Technical (Hospital) Services Collect Blood From Catheter Venous Nos PX-3603659200 CDM 36592 CPT 360 RC inpatient 286 286 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES EPO [308136803] 226.45 percent of total billed charges 177.32 271.7 Technical (Hospital) Services Collect Blood From Catheter Venous Nos PX-3603659200 CDM 36592 CPT 360 RC outpatient 286 286 MEDICA (COMMERCIAL) 94265 [3081118] MEDICA CLAIMS [308111801] 257.4 percent of total billed charges 177.32 271.7 Technical (Hospital) Services Collect Blood From Catheter Venous Nos PX-3603659200 CDM 36592 CPT 360 RC outpatient 286 286 CIGNA 62308 [3081051] CIGNA 62308 [308105105] 228.8 percent of total billed charges 177.32 271.7 Technical (Hospital) Services Collect Blood From Catheter Venous Nos PX-3603659200 CDM 36592 CPT 360 RC outpatient 286 286 CIGNA 62308 [3081051] CIGNA STATE OF WYOMING [308105107] 228.8 percent of total billed charges 177.32 271.7 Technical (Hospital) Services Collect Blood From Catheter Venous Nos PX-3603659200 CDM 36592 CPT 360 RC outpatient 286 286 HEALTHPARTNERS SX009 HEALTHPARTNERS 228.8 percent of total billed charges 177.32 271.7 Technical (Hospital) Services Collect Blood From Catheter Venous Nos PX-3603659200 CDM 36592 CPT 360 RC outpatient 286 286 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES EPO [308136803] 228.8 percent of total billed charges 177.32 271.7 Technical (Hospital) Services Collect Blood From Catheter Venous Nos PX-3603659200 CDM 36592 CPT 360 RC outpatient 286 286 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES PPO [308136801] 228.8 percent of total billed charges 177.32 271.7 Technical (Hospital) Services Collect Blood From Catheter Venous Nos PX-3603659200 CDM 36592 CPT 360 RC outpatient 286 286 UNITED HEALTHCARE (COMMERCIAL) [3081199] UNITED HEALTHCARE 87726 [308119901] 177.32 percent of total billed charges 177.32 271.7 Technical (Hospital) Services Collect Blood From Catheter Venous Nos PX-3603659200 CDM 36592 CPT 360 RC outpatient 286 286 BLUE CROSS BLUE SHIELD WELLMARK SB889 [3081026] BCBS WYOMING [308102603] 271.7 percent of total billed charges 177.32 271.7 Technical (Hospital) Services Collect Blood From Catheter Venous Nos PX-3603659200 CDM 36592 CPT 360 RC outpatient 286 286 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES HDHP [308136802] 228.8 percent of total billed charges 177.32 271.7 Technical (Hospital) Services Collect Blood From Catheter Venous Nos PX-3603659200 CDM 36592 CPT 360 RC outpatient 286 286 MULTIPLAN INC 34080 [3081285] MULTIPLAN INC [308128501] 271.7 percent of total billed charges 177.32 271.7 Technical (Hospital) Services Collect Blood From Implant Venous Access Device PX-3603659100 CDM 36591 CPT 360 RC inpatient 110 110 CIGNA 62308 [3081051] CIGNA 62308 [308105105] 87.1 percent of total billed charges 68.2 104.5 Technical (Hospital) Services Collect Blood From Implant Venous Access Device PX-3603659100 CDM 36591 CPT 360 RC inpatient 110 110 CIGNA 62308 [3081051] CIGNA STATE OF WYOMING [308105107] 87.1 percent of total billed charges 68.2 104.5 Technical (Hospital) Services Collect Blood From Implant Venous Access Device PX-3603659100 CDM 36591 CPT 360 RC inpatient 110 110 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES EPO [308136803] 87.1 percent of total billed charges 68.2 104.5 Technical (Hospital) Services Collect Blood From Implant Venous Access Device PX-3603659100 CDM 36591 CPT 360 RC inpatient 110 110 MEDICA (COMMERCIAL) 94265 [3081118] MEDICA CLAIMS [308111801] 99 percent of total billed charges 68.2 104.5 Technical (Hospital) Services Collect Blood From Implant Venous Access Device PX-3603659100 CDM 36591 CPT 360 RC inpatient 110 110 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES HDHP [308136802] 87.1 percent of total billed charges 68.2 104.5 Technical (Hospital) Services Collect Blood From Implant Venous Access Device PX-3603659100 CDM 36591 CPT 360 RC inpatient 110 110 HEALTHPARTNERS SX009 HEALTHPARTNERS 87.1 percent of total billed charges 68.2 104.5 Technical (Hospital) Services Collect Blood From Implant Venous Access Device PX-3603659100 CDM 36591 CPT 360 RC inpatient 110 110 UNITED HEALTHCARE (COMMERCIAL) [3081199] UNITED HEALTHCARE 87726 [308119901] 68.2 percent of total billed charges 68.2 104.5 Technical (Hospital) Services Collect Blood From Implant Venous Access Device PX-3603659100 CDM 36591 CPT 360 RC inpatient 110 110 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES PPO [308136801] 87.1 percent of total billed charges 68.2 104.5 Technical (Hospital) Services Collect Blood From Implant Venous Access Device PX-3603659100 CDM 36591 CPT 360 RC inpatient 110 110 MULTIPLAN INC 34080 [3081285] MULTIPLAN INC [308128501] 104.5 percent of total billed charges 68.2 104.5 Technical (Hospital) Services Collect Blood From Implant Venous Access Device PX-3603659100 CDM 36591 CPT 360 RC inpatient 110 110 BLUE CROSS BLUE SHIELD WELLMARK SB889 [3081026] BCBS WYOMING [308102603] 104.5 percent of total billed charges 68.2 104.5 Technical (Hospital) Services Collect Blood From Implant Venous Access Device PX-3603659100 CDM 36591 CPT 360 RC outpatient 110 110 CIGNA 62308 [3081051] CIGNA 62308 [308105105] 88 percent of total billed charges 68.2 104.5 Technical (Hospital) Services Collect Blood From Implant Venous Access Device PX-3603659100 CDM 36591 CPT 360 RC outpatient 110 110 CIGNA 62308 [3081051] CIGNA STATE OF WYOMING [308105107] 88 percent of total billed charges 68.2 104.5 Technical (Hospital) Services Collect Blood From Implant Venous Access Device PX-3603659100 CDM 36591 CPT 360 RC outpatient 110 110 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES EPO [308136803] 88 percent of total billed charges 68.2 104.5 Technical (Hospital) Services Collect Blood From Implant Venous Access Device PX-3603659100 CDM 36591 CPT 360 RC outpatient 110 110 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES PPO [308136801] 88 percent of total billed charges 68.2 104.5 Technical (Hospital) Services Collect Blood From Implant Venous Access Device PX-3603659100 CDM 36591 CPT 360 RC outpatient 110 110 UNITED HEALTHCARE (COMMERCIAL) [3081199] UNITED HEALTHCARE 87726 [308119901] 68.2 percent of total billed charges 68.2 104.5 Technical (Hospital) Services Collect Blood From Implant Venous Access Device PX-3603659100 CDM 36591 CPT 360 RC outpatient 110 110 BLUE CROSS BLUE SHIELD WELLMARK SB889 [3081026] BCBS WYOMING [308102603] 104.5 percent of total billed charges 68.2 104.5 Technical (Hospital) Services Collect Blood From Implant Venous Access Device PX-3603659100 CDM 36591 CPT 360 RC outpatient 110 110 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES HDHP [308136802] 88 percent of total billed charges 68.2 104.5 Technical (Hospital) Services Collect Blood From Implant Venous Access Device PX-3603659100 CDM 36591 CPT 360 RC outpatient 110 110 MULTIPLAN INC 34080 [3081285] MULTIPLAN INC [308128501] 104.5 percent of total billed charges 68.2 104.5 Technical (Hospital) Services Collect Blood From Implant Venous Access Device PX-3603659100 CDM 36591 CPT 360 RC outpatient 110 110 MEDICA (COMMERCIAL) 94265 [3081118] MEDICA CLAIMS [308111801] 99 percent of total billed charges 68.2 104.5 Technical (Hospital) Services Collect Blood From Implant Venous Access Device PX-3603659100 CDM 36591 CPT 360 RC outpatient 110 110 HEALTHPARTNERS SX009 HEALTHPARTNERS 88 percent of total billed charges 68.2 104.5 Technical (Hospital) Services "Transfusion, Blood or Blood Components" PX-3913643000 CDM 36430 CPT 391 RC inpatient 595 595 MULTIPLAN INC 34080 [3081285] MULTIPLAN INC [308128501] 565.25 percent of total billed charges 368.9 565.25 Technical (Hospital) Services "Transfusion, Blood or Blood Components" PX-3913643000 CDM 36430 CPT 391 RC inpatient 595 595 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES PPO [308136801] 471.12 percent of total billed charges 368.9 565.25 Technical (Hospital) Services "Transfusion, Blood or Blood Components" PX-3913643000 CDM 36430 CPT 391 RC inpatient 595 595 UNITED HEALTHCARE (COMMERCIAL) [3081199] UNITED HEALTHCARE 87726 [308119901] 368.9 percent of total billed charges 368.9 565.25 Technical (Hospital) Services "Transfusion, Blood or Blood Components" PX-3913643000 CDM 36430 CPT 391 RC inpatient 595 595 BLUE CROSS BLUE SHIELD WELLMARK SB889 [3081026] BCBS WYOMING [308102603] 565.25 percent of total billed charges 368.9 565.25 Technical (Hospital) Services "Transfusion, Blood or Blood Components" PX-3913643000 CDM 36430 CPT 391 RC inpatient 595 595 MEDICA (COMMERCIAL) 94265 [3081118] MEDICA CLAIMS [308111801] 535.5 percent of total billed charges 368.9 565.25 Technical (Hospital) Services "Transfusion, Blood or Blood Components" PX-3913643000 CDM 36430 CPT 391 RC inpatient 595 595 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES HDHP [308136802] 471.12 percent of total billed charges 368.9 565.25 Technical (Hospital) Services "Transfusion, Blood or Blood Components" PX-3913643000 CDM 36430 CPT 391 RC inpatient 595 595 HEALTHPARTNERS SX009 HEALTHPARTNERS 471.12 percent of total billed charges 368.9 565.25 Technical (Hospital) Services "Transfusion, Blood or Blood Components" PX-3913643000 CDM 36430 CPT 391 RC inpatient 595 595 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES EPO [308136803] 471.12 percent of total billed charges 368.9 565.25 Technical (Hospital) Services "Transfusion, Blood or Blood Components" PX-3913643000 CDM 36430 CPT 391 RC inpatient 595 595 CIGNA 62308 [3081051] CIGNA 62308 [308105105] 471.12 percent of total billed charges 368.9 565.25 Technical (Hospital) Services "Transfusion, Blood or Blood Components" PX-3913643000 CDM 36430 CPT 391 RC inpatient 595 595 CIGNA 62308 [3081051] CIGNA STATE OF WYOMING [308105107] 471.12 percent of total billed charges 368.9 565.25 Technical (Hospital) Services "Transfusion, Blood or Blood Components" PX-3913643000 CDM 36430 CPT 391 RC outpatient 595 595 UNITED HEALTHCARE (COMMERCIAL) [3081199] UNITED HEALTHCARE 87726 [308119901] 368.9 percent of total billed charges 368.9 565.25 Technical (Hospital) Services "Transfusion, Blood or Blood Components" PX-3913643000 CDM 36430 CPT 391 RC outpatient 595 595 HEALTHPARTNERS SX009 HEALTHPARTNERS 476 percent of total billed charges 368.9 565.25 Technical (Hospital) Services "Transfusion, Blood or Blood Components" PX-3913643000 CDM 36430 CPT 391 RC outpatient 595 595 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES PPO [308136801] 476 percent of total billed charges 368.9 565.25 Technical (Hospital) Services "Transfusion, Blood or Blood Components" PX-3913643000 CDM 36430 CPT 391 RC outpatient 595 595 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES EPO [308136803] 476 percent of total billed charges 368.9 565.25 Technical (Hospital) Services "Transfusion, Blood or Blood Components" PX-3913643000 CDM 36430 CPT 391 RC outpatient 595 595 MULTIPLAN INC 34080 [3081285] MULTIPLAN INC [308128501] 565.25 percent of total billed charges 368.9 565.25 Technical (Hospital) Services "Transfusion, Blood or Blood Components" PX-3913643000 CDM 36430 CPT 391 RC outpatient 595 595 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES HDHP [308136802] 476 percent of total billed charges 368.9 565.25 Technical (Hospital) Services "Transfusion, Blood or Blood Components" PX-3913643000 CDM 36430 CPT 391 RC outpatient 595 595 BLUE CROSS BLUE SHIELD WELLMARK SB889 [3081026] BCBS WYOMING [308102603] 565.25 percent of total billed charges 368.9 565.25 Technical (Hospital) Services "Transfusion, Blood or Blood Components" PX-3913643000 CDM 36430 CPT 391 RC outpatient 595 595 MEDICA (COMMERCIAL) 94265 [3081118] MEDICA CLAIMS [308111801] 535.5 percent of total billed charges 368.9 565.25 Technical (Hospital) Services "Transfusion, Blood or Blood Components" PX-3913643000 CDM 36430 CPT 391 RC outpatient 595 595 CIGNA 62308 [3081051] CIGNA 62308 [308105105] 476 percent of total billed charges 368.9 565.25 Technical (Hospital) Services "Transfusion, Blood or Blood Components" PX-3913643000 CDM 36430 CPT 391 RC outpatient 595 595 CIGNA 62308 [3081051] CIGNA STATE OF WYOMING [308105107] 476 percent of total billed charges 368.9 565.25 Technical (Hospital) Services "Transfusion, Blood or Blood Components" PX-3913643001 CDM 36430 CPT 391 RC inpatient 595 595 CIGNA 62308 [3081051] CIGNA 62308 [308105105] 471.12 percent of total billed charges 368.9 565.25 Technical (Hospital) Services "Transfusion, Blood or Blood Components" PX-3913643001 CDM 36430 CPT 391 RC inpatient 595 595 CIGNA 62308 [3081051] CIGNA STATE OF WYOMING [308105107] 471.12 percent of total billed charges 368.9 565.25 Technical (Hospital) Services "Transfusion, Blood or Blood Components" PX-3913643001 CDM 36430 CPT 391 RC inpatient 595 595 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES EPO [308136803] 471.12 percent of total billed charges 368.9 565.25 Technical (Hospital) Services "Transfusion, Blood or Blood Components" PX-3913643001 CDM 36430 CPT 391 RC inpatient 595 595 UNITED HEALTHCARE (COMMERCIAL) [3081199] UNITED HEALTHCARE 87726 [308119901] 368.9 percent of total billed charges 368.9 565.25 Technical (Hospital) Services "Transfusion, Blood or Blood Components" PX-3913643001 CDM 36430 CPT 391 RC inpatient 595 595 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES PPO [308136801] 471.12 percent of total billed charges 368.9 565.25 Technical (Hospital) Services "Transfusion, Blood or Blood Components" PX-3913643001 CDM 36430 CPT 391 RC inpatient 595 595 MULTIPLAN INC 34080 [3081285] MULTIPLAN INC [308128501] 565.25 percent of total billed charges 368.9 565.25 Technical (Hospital) Services "Transfusion, Blood or Blood Components" PX-3913643001 CDM 36430 CPT 391 RC inpatient 595 595 BLUE CROSS BLUE SHIELD WELLMARK SB889 [3081026] BCBS WYOMING [308102603] 565.25 percent of total billed charges 368.9 565.25 Technical (Hospital) Services "Transfusion, Blood or Blood Components" PX-3913643001 CDM 36430 CPT 391 RC inpatient 595 595 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES HDHP [308136802] 471.12 percent of total billed charges 368.9 565.25 Technical (Hospital) Services "Transfusion, Blood or Blood Components" PX-3913643001 CDM 36430 CPT 391 RC inpatient 595 595 MEDICA (COMMERCIAL) 94265 [3081118] MEDICA CLAIMS [308111801] 535.5 percent of total billed charges 368.9 565.25 Technical (Hospital) Services "Transfusion, Blood or Blood Components" PX-3913643001 CDM 36430 CPT 391 RC inpatient 595 595 HEALTHPARTNERS SX009 HEALTHPARTNERS 471.12 percent of total billed charges 368.9 565.25 Technical (Hospital) Services "Transfusion, Blood or Blood Components" PX-3913643001 CDM 36430 CPT 391 RC outpatient 595 595 CIGNA 62308 [3081051] CIGNA 62308 [308105105] 476 percent of total billed charges 368.9 565.25 Technical (Hospital) Services "Transfusion, Blood or Blood Components" PX-3913643001 CDM 36430 CPT 391 RC outpatient 595 595 CIGNA 62308 [3081051] CIGNA STATE OF WYOMING [308105107] 476 percent of total billed charges 368.9 565.25 Technical (Hospital) Services "Transfusion, Blood or Blood Components" PX-3913643001 CDM 36430 CPT 391 RC outpatient 595 595 MEDICA (COMMERCIAL) 94265 [3081118] MEDICA CLAIMS [308111801] 535.5 percent of total billed charges 368.9 565.25 Technical (Hospital) Services "Transfusion, Blood or Blood Components" PX-3913643001 CDM 36430 CPT 391 RC outpatient 595 595 HEALTHPARTNERS SX009 HEALTHPARTNERS 476 percent of total billed charges 368.9 565.25 Technical (Hospital) Services "Transfusion, Blood or Blood Components" PX-3913643001 CDM 36430 CPT 391 RC outpatient 595 595 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES EPO [308136803] 476 percent of total billed charges 368.9 565.25 Technical (Hospital) Services "Transfusion, Blood or Blood Components" PX-3913643001 CDM 36430 CPT 391 RC outpatient 595 595 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES PPO [308136801] 476 percent of total billed charges 368.9 565.25 Technical (Hospital) Services "Transfusion, Blood or Blood Components" PX-3913643001 CDM 36430 CPT 391 RC outpatient 595 595 UNITED HEALTHCARE (COMMERCIAL) [3081199] UNITED HEALTHCARE 87726 [308119901] 368.9 percent of total billed charges 368.9 565.25 Technical (Hospital) Services "Transfusion, Blood or Blood Components" PX-3913643001 CDM 36430 CPT 391 RC outpatient 595 595 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES HDHP [308136802] 476 percent of total billed charges 368.9 565.25 Technical (Hospital) Services "Transfusion, Blood or Blood Components" PX-3913643001 CDM 36430 CPT 391 RC outpatient 595 595 MULTIPLAN INC 34080 [3081285] MULTIPLAN INC [308128501] 565.25 percent of total billed charges 368.9 565.25 Technical (Hospital) Services "Transfusion, Blood or Blood Components" PX-3913643001 CDM 36430 CPT 391 RC outpatient 595 595 BLUE CROSS BLUE SHIELD WELLMARK SB889 [3081026] BCBS WYOMING [308102603] 565.25 percent of total billed charges 368.9 565.25 Technical (Hospital) Services "Transfusion, Blood or Blood Components" PX-3913643002 CDM 36430 CPT 391 RC outpatient 595 595 UNITED HEALTHCARE (COMMERCIAL) [3081199] UNITED HEALTHCARE 87726 [308119901] 368.9 percent of total billed charges 368.9 565.25 Technical (Hospital) Services "Transfusion, Blood or Blood Components" PX-3913643002 CDM 36430 CPT 391 RC outpatient 595 595 HEALTHPARTNERS SX009 HEALTHPARTNERS 476 percent of total billed charges 368.9 565.25 Technical (Hospital) Services "Transfusion, Blood or Blood Components" PX-3913643002 CDM 36430 CPT 391 RC outpatient 595 595 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES PPO [308136801] 476 percent of total billed charges 368.9 565.25 Technical (Hospital) Services "Transfusion, Blood or Blood Components" PX-3913643002 CDM 36430 CPT 391 RC outpatient 595 595 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES EPO [308136803] 476 percent of total billed charges 368.9 565.25 Technical (Hospital) Services "Transfusion, Blood or Blood Components" PX-3913643002 CDM 36430 CPT 391 RC outpatient 595 595 BLUE CROSS BLUE SHIELD WELLMARK SB889 [3081026] BCBS WYOMING [308102603] 565.25 percent of total billed charges 368.9 565.25 Technical (Hospital) Services "Transfusion, Blood or Blood Components" PX-3913643002 CDM 36430 CPT 391 RC outpatient 595 595 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES HDHP [308136802] 476 percent of total billed charges 368.9 565.25 Technical (Hospital) Services "Transfusion, Blood or Blood Components" PX-3913643002 CDM 36430 CPT 391 RC outpatient 595 595 MULTIPLAN INC 34080 [3081285] MULTIPLAN INC [308128501] 565.25 percent of total billed charges 368.9 565.25 Technical (Hospital) Services "Transfusion, Blood or Blood Components" PX-3913643002 CDM 36430 CPT 391 RC outpatient 595 595 CIGNA 62308 [3081051] CIGNA 62308 [308105105] 476 percent of total billed charges 368.9 565.25 Technical (Hospital) Services "Transfusion, Blood or Blood Components" PX-3913643002 CDM 36430 CPT 391 RC outpatient 595 595 CIGNA 62308 [3081051] CIGNA STATE OF WYOMING [308105107] 476 percent of total billed charges 368.9 565.25 Technical (Hospital) Services "Transfusion, Blood or Blood Components" PX-3913643002 CDM 36430 CPT 391 RC outpatient 595 595 MEDICA (COMMERCIAL) 94265 [3081118] MEDICA CLAIMS [308111801] 535.5 percent of total billed charges 368.9 565.25 Technical (Hospital) Services "Transfusion, Blood or Blood Components" PX-3913643002 CDM 36430 CPT 391 RC inpatient 595 595 CIGNA 62308 [3081051] CIGNA 62308 [308105105] 471.12 percent of total billed charges 368.9 565.25 Technical (Hospital) Services "Transfusion, Blood or Blood Components" PX-3913643002 CDM 36430 CPT 391 RC inpatient 595 595 CIGNA 62308 [3081051] CIGNA STATE OF WYOMING [308105107] 471.12 percent of total billed charges 368.9 565.25 Technical (Hospital) Services "Transfusion, Blood or Blood Components" PX-3913643002 CDM 36430 CPT 391 RC inpatient 595 595 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES EPO [308136803] 471.12 percent of total billed charges 368.9 565.25 Technical (Hospital) Services "Transfusion, Blood or Blood Components" PX-3913643002 CDM 36430 CPT 391 RC inpatient 595 595 HEALTHPARTNERS SX009 HEALTHPARTNERS 471.12 percent of total billed charges 368.9 565.25 Technical (Hospital) Services "Transfusion, Blood or Blood Components" PX-3913643002 CDM 36430 CPT 391 RC inpatient 595 595 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES HDHP [308136802] 471.12 percent of total billed charges 368.9 565.25 Technical (Hospital) Services "Transfusion, Blood or Blood Components" PX-3913643002 CDM 36430 CPT 391 RC inpatient 595 595 MEDICA (COMMERCIAL) 94265 [3081118] MEDICA CLAIMS [308111801] 535.5 percent of total billed charges 368.9 565.25 Technical (Hospital) Services "Transfusion, Blood or Blood Components" PX-3913643002 CDM 36430 CPT 391 RC inpatient 595 595 BLUE CROSS BLUE SHIELD WELLMARK SB889 [3081026] BCBS WYOMING [308102603] 565.25 percent of total billed charges 368.9 565.25 Technical (Hospital) Services "Transfusion, Blood or Blood Components" PX-3913643002 CDM 36430 CPT 391 RC inpatient 595 595 UNITED HEALTHCARE (COMMERCIAL) [3081199] UNITED HEALTHCARE 87726 [308119901] 368.9 percent of total billed charges 368.9 565.25 Technical (Hospital) Services "Transfusion, Blood or Blood Components" PX-3913643002 CDM 36430 CPT 391 RC inpatient 595 595 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES PPO [308136801] 471.12 percent of total billed charges 368.9 565.25 Technical (Hospital) Services "Transfusion, Blood or Blood Components" PX-3913643002 CDM 36430 CPT 391 RC inpatient 595 595 MULTIPLAN INC 34080 [3081285] MULTIPLAN INC [308128501] 565.25 percent of total billed charges 368.9 565.25 Technical (Hospital) Services Collection Capillary Blood Specimen PX-3003641600 CDM 36416 CPT 300 RC outpatient 30 30 HEALTHPARTNERS SX009 HEALTHPARTNERS 24 percent of total billed charges 18.6 28.5 Technical (Hospital) Services Collection Capillary Blood Specimen PX-3003641600 CDM 36416 CPT 300 RC outpatient 30 30 UNITED HEALTHCARE (COMMERCIAL) [3081199] UNITED HEALTHCARE 87726 [308119901] 18.6 percent of total billed charges 18.6 28.5 Technical (Hospital) Services Collection Capillary Blood Specimen PX-3003641600 CDM 36416 CPT 300 RC outpatient 30 30 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES EPO [308136803] 24 percent of total billed charges 18.6 28.5 Technical (Hospital) Services Collection Capillary Blood Specimen PX-3003641600 CDM 36416 CPT 300 RC outpatient 30 30 BLUE CROSS BLUE SHIELD WELLMARK SB889 [3081026] BCBS WYOMING [308102603] 28.5 percent of total billed charges 18.6 28.5 Technical (Hospital) Services Collection Capillary Blood Specimen PX-3003641600 CDM 36416 CPT 300 RC outpatient 30 30 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES HDHP [308136802] 24 percent of total billed charges 18.6 28.5 Technical (Hospital) Services Collection Capillary Blood Specimen PX-3003641600 CDM 36416 CPT 300 RC outpatient 30 30 MULTIPLAN INC 34080 [3081285] MULTIPLAN INC [308128501] 28.5 percent of total billed charges 18.6 28.5 Technical (Hospital) Services Collection Capillary Blood Specimen PX-3003641600 CDM 36416 CPT 300 RC outpatient 30 30 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES PPO [308136801] 24 percent of total billed charges 18.6 28.5 Technical (Hospital) Services Collection Capillary Blood Specimen PX-3003641600 CDM 36416 CPT 300 RC outpatient 30 30 CIGNA 62308 [3081051] CIGNA 62308 [308105105] 24 percent of total billed charges 18.6 28.5 Technical (Hospital) Services Collection Capillary Blood Specimen PX-3003641600 CDM 36416 CPT 300 RC outpatient 30 30 CIGNA 62308 [3081051] CIGNA STATE OF WYOMING [308105107] 24 percent of total billed charges 18.6 28.5 Technical (Hospital) Services Collection Capillary Blood Specimen PX-3003641600 CDM 36416 CPT 300 RC outpatient 30 30 MEDICA (COMMERCIAL) 94265 [3081118] MEDICA CLAIMS [308111801] 27 percent of total billed charges 18.6 28.5 Technical (Hospital) Services Collection Capillary Blood Specimen PX-3003641600 CDM 36416 CPT 300 RC inpatient 30 30 CIGNA 62308 [3081051] CIGNA 62308 [308105105] 23.75 percent of total billed charges 18.6 28.5 Technical (Hospital) Services Collection Capillary Blood Specimen PX-3003641600 CDM 36416 CPT 300 RC inpatient 30 30 CIGNA 62308 [3081051] CIGNA STATE OF WYOMING [308105107] 23.75 percent of total billed charges 18.6 28.5 Technical (Hospital) Services Collection Capillary Blood Specimen PX-3003641600 CDM 36416 CPT 300 RC inpatient 30 30 BLUE CROSS BLUE SHIELD WELLMARK SB889 [3081026] BCBS WYOMING [308102603] 28.5 percent of total billed charges 18.6 28.5 Technical (Hospital) Services Collection Capillary Blood Specimen PX-3003641600 CDM 36416 CPT 300 RC inpatient 30 30 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES HDHP [308136802] 23.75 percent of total billed charges 18.6 28.5 Technical (Hospital) Services Collection Capillary Blood Specimen PX-3003641600 CDM 36416 CPT 300 RC inpatient 30 30 UNITED HEALTHCARE (COMMERCIAL) [3081199] UNITED HEALTHCARE 87726 [308119901] 18.6 percent of total billed charges 18.6 28.5 Technical (Hospital) Services Collection Capillary Blood Specimen PX-3003641600 CDM 36416 CPT 300 RC inpatient 30 30 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES PPO [308136801] 23.75 percent of total billed charges 18.6 28.5 Technical (Hospital) Services Collection Capillary Blood Specimen PX-3003641600 CDM 36416 CPT 300 RC inpatient 30 30 MULTIPLAN INC 34080 [3081285] MULTIPLAN INC [308128501] 28.5 percent of total billed charges 18.6 28.5 Technical (Hospital) Services Collection Capillary Blood Specimen PX-3003641600 CDM 36416 CPT 300 RC inpatient 30 30 MEDICA (COMMERCIAL) 94265 [3081118] MEDICA CLAIMS [308111801] 27 percent of total billed charges 18.6 28.5 Technical (Hospital) Services Collection Capillary Blood Specimen PX-3003641600 CDM 36416 CPT 300 RC inpatient 30 30 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES EPO [308136803] 23.75 percent of total billed charges 18.6 28.5 Technical (Hospital) Services Collection Capillary Blood Specimen PX-3003641600 CDM 36416 CPT 300 RC inpatient 30 30 HEALTHPARTNERS SX009 HEALTHPARTNERS 23.75 percent of total billed charges 18.6 28.5 Technical (Hospital) Services Collection Venous Blood Venipuncture PX-3003641500 CDM 36415 CPT 300 RC inpatient 40 40 CIGNA 62308 [3081051] CIGNA 62308 [308105105] 31.67 percent of total billed charges 24.8 38 Technical (Hospital) Services Collection Venous Blood Venipuncture PX-3003641500 CDM 36415 CPT 300 RC inpatient 40 40 CIGNA 62308 [3081051] CIGNA STATE OF WYOMING [308105107] 31.67 percent of total billed charges 24.8 38 Technical (Hospital) Services Collection Venous Blood Venipuncture PX-3003641500 CDM 36415 CPT 300 RC inpatient 40 40 UNITED HEALTHCARE (COMMERCIAL) [3081199] UNITED HEALTHCARE 87726 [308119901] 24.8 percent of total billed charges 24.8 38 Technical (Hospital) Services Collection Venous Blood Venipuncture PX-3003641500 CDM 36415 CPT 300 RC inpatient 40 40 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES PPO [308136801] 31.67 percent of total billed charges 24.8 38 Technical (Hospital) Services Collection Venous Blood Venipuncture PX-3003641500 CDM 36415 CPT 300 RC inpatient 40 40 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES HDHP [308136802] 31.67 percent of total billed charges 24.8 38 Technical (Hospital) Services Collection Venous Blood Venipuncture PX-3003641500 CDM 36415 CPT 300 RC inpatient 40 40 BLUE CROSS BLUE SHIELD WELLMARK SB889 [3081026] BCBS WYOMING [308102603] 38 percent of total billed charges 24.8 38 Technical (Hospital) Services Collection Venous Blood Venipuncture PX-3003641500 CDM 36415 CPT 300 RC inpatient 40 40 MULTIPLAN INC 34080 [3081285] MULTIPLAN INC [308128501] 38 percent of total billed charges 24.8 38 Technical (Hospital) Services Collection Venous Blood Venipuncture PX-3003641500 CDM 36415 CPT 300 RC inpatient 40 40 HEALTHPARTNERS SX009 HEALTHPARTNERS 31.67 percent of total billed charges 24.8 38 Technical (Hospital) Services Collection Venous Blood Venipuncture PX-3003641500 CDM 36415 CPT 300 RC inpatient 40 40 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES EPO [308136803] 31.67 percent of total billed charges 24.8 38 Technical (Hospital) Services Collection Venous Blood Venipuncture PX-3003641500 CDM 36415 CPT 300 RC inpatient 40 40 MEDICA (COMMERCIAL) 94265 [3081118] MEDICA CLAIMS [308111801] 36 percent of total billed charges 24.8 38 Technical (Hospital) Services Collection Venous Blood Venipuncture PX-3003641500 CDM 36415 CPT 300 RC outpatient 40 40 MEDICA (COMMERCIAL) 94265 [3081118] MEDICA CLAIMS [308111801] 36 percent of total billed charges 24.8 38 Technical (Hospital) Services Collection Venous Blood Venipuncture PX-3003641500 CDM 36415 CPT 300 RC outpatient 40 40 CIGNA 62308 [3081051] CIGNA 62308 [308105105] 32 percent of total billed charges 24.8 38 Technical (Hospital) Services Collection Venous Blood Venipuncture PX-3003641500 CDM 36415 CPT 300 RC outpatient 40 40 CIGNA 62308 [3081051] CIGNA STATE OF WYOMING [308105107] 32 percent of total billed charges 24.8 38 Technical (Hospital) Services Collection Venous Blood Venipuncture PX-3003641500 CDM 36415 CPT 300 RC outpatient 40 40 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES PPO [308136801] 32 percent of total billed charges 24.8 38 Technical (Hospital) Services Collection Venous Blood Venipuncture PX-3003641500 CDM 36415 CPT 300 RC outpatient 40 40 MULTIPLAN INC 34080 [3081285] MULTIPLAN INC [308128501] 38 percent of total billed charges 24.8 38 Technical (Hospital) Services Collection Venous Blood Venipuncture PX-3003641500 CDM 36415 CPT 300 RC outpatient 40 40 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES HDHP [308136802] 32 percent of total billed charges 24.8 38 Technical (Hospital) Services Collection Venous Blood Venipuncture PX-3003641500 CDM 36415 CPT 300 RC outpatient 40 40 BLUE CROSS BLUE SHIELD WELLMARK SB889 [3081026] BCBS WYOMING [308102603] 38 percent of total billed charges 24.8 38 Technical (Hospital) Services Collection Venous Blood Venipuncture PX-3003641500 CDM 36415 CPT 300 RC outpatient 40 40 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES EPO [308136803] 32 percent of total billed charges 24.8 38 Technical (Hospital) Services Collection Venous Blood Venipuncture PX-3003641500 CDM 36415 CPT 300 RC outpatient 40 40 UNITED HEALTHCARE (COMMERCIAL) [3081199] UNITED HEALTHCARE 87726 [308119901] 24.8 percent of total billed charges 24.8 38 Technical (Hospital) Services Collection Venous Blood Venipuncture PX-3003641500 CDM 36415 CPT 300 RC outpatient 40 40 HEALTHPARTNERS SX009 HEALTHPARTNERS 32 percent of total billed charges 24.8 38 Technical (Hospital) Services PR Collection Venous Blood Venipuncture PX-3641500 CDM 36415 CPT 300 RC outpatient 40 40 CIGNA 62308 [3081051] CIGNA 62308 [308105105] 32 percent of total billed charges 24.8 38 Technical (Hospital) Services PR Collection Venous Blood Venipuncture PX-3641500 CDM 36415 CPT 300 RC outpatient 40 40 CIGNA 62308 [3081051] CIGNA STATE OF WYOMING [308105107] 32 percent of total billed charges 24.8 38 Technical (Hospital) Services PR Collection Venous Blood Venipuncture PX-3641500 CDM 36415 CPT 300 RC outpatient 40 40 MEDICA (COMMERCIAL) 94265 [3081118] MEDICA CLAIMS [308111801] 36 percent of total billed charges 24.8 38 Technical (Hospital) Services PR Collection Venous Blood Venipuncture PX-3641500 CDM 36415 CPT 300 RC outpatient 40 40 HEALTHPARTNERS SX009 HEALTHPARTNERS 32 percent of total billed charges 24.8 38 Technical (Hospital) Services PR Collection Venous Blood Venipuncture PX-3641500 CDM 36415 CPT 300 RC outpatient 40 40 BLUE CROSS BLUE SHIELD WELLMARK SB889 [3081026] BCBS WYOMING [308102603] 38 percent of total billed charges 24.8 38 Technical (Hospital) Services PR Collection Venous Blood Venipuncture PX-3641500 CDM 36415 CPT 300 RC outpatient 40 40 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES HDHP [308136802] 32 percent of total billed charges 24.8 38 Technical (Hospital) Services PR Collection Venous Blood Venipuncture PX-3641500 CDM 36415 CPT 300 RC outpatient 40 40 MULTIPLAN INC 34080 [3081285] MULTIPLAN INC [308128501] 38 percent of total billed charges 24.8 38 Technical (Hospital) Services PR Collection Venous Blood Venipuncture PX-3641500 CDM 36415 CPT 300 RC outpatient 40 40 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES EPO [308136803] 32 percent of total billed charges 24.8 38 Technical (Hospital) Services PR Collection Venous Blood Venipuncture PX-3641500 CDM 36415 CPT 300 RC outpatient 40 40 UNITED HEALTHCARE (COMMERCIAL) [3081199] UNITED HEALTHCARE 87726 [308119901] 24.8 percent of total billed charges 24.8 38 Technical (Hospital) Services PR Collection Venous Blood Venipuncture PX-3641500 CDM 36415 CPT 300 RC outpatient 40 40 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES PPO [308136801] 32 percent of total billed charges 24.8 38 Technical (Hospital) Services PR Collection Venous Blood Venipuncture PX-3641500 CDM 36415 CPT 300 RC inpatient 40 40 CIGNA 62308 [3081051] CIGNA 62308 [308105105] 31.67 percent of total billed charges 24.8 38 Technical (Hospital) Services PR Collection Venous Blood Venipuncture PX-3641500 CDM 36415 CPT 300 RC inpatient 40 40 CIGNA 62308 [3081051] CIGNA STATE OF WYOMING [308105107] 31.67 percent of total billed charges 24.8 38 Technical (Hospital) Services PR Collection Venous Blood Venipuncture PX-3641500 CDM 36415 CPT 300 RC inpatient 40 40 UNITED HEALTHCARE (COMMERCIAL) [3081199] UNITED HEALTHCARE 87726 [308119901] 24.8 percent of total billed charges 24.8 38 Technical (Hospital) Services PR Collection Venous Blood Venipuncture PX-3641500 CDM 36415 CPT 300 RC inpatient 40 40 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES PPO [308136801] 31.67 percent of total billed charges 24.8 38 Technical (Hospital) Services PR Collection Venous Blood Venipuncture PX-3641500 CDM 36415 CPT 300 RC inpatient 40 40 MULTIPLAN INC 34080 [3081285] MULTIPLAN INC [308128501] 38 percent of total billed charges 24.8 38 Technical (Hospital) Services PR Collection Venous Blood Venipuncture PX-3641500 CDM 36415 CPT 300 RC inpatient 40 40 BLUE CROSS BLUE SHIELD WELLMARK SB889 [3081026] BCBS WYOMING [308102603] 38 percent of total billed charges 24.8 38 Technical (Hospital) Services PR Collection Venous Blood Venipuncture PX-3641500 CDM 36415 CPT 300 RC inpatient 40 40 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES HDHP [308136802] 31.67 percent of total billed charges 24.8 38 Technical (Hospital) Services PR Collection Venous Blood Venipuncture PX-3641500 CDM 36415 CPT 300 RC inpatient 40 40 MEDICA (COMMERCIAL) 94265 [3081118] MEDICA CLAIMS [308111801] 36 percent of total billed charges 24.8 38 Technical (Hospital) Services PR Collection Venous Blood Venipuncture PX-3641500 CDM 36415 CPT 300 RC inpatient 40 40 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES EPO [308136803] 31.67 percent of total billed charges 24.8 38 Technical (Hospital) Services PR Collection Venous Blood Venipuncture PX-3641500 CDM 36415 CPT 300 RC inpatient 40 40 HEALTHPARTNERS SX009 HEALTHPARTNERS 31.67 percent of total billed charges 24.8 38 Technical (Hospital) Services Tube Thoracostomy Includes Water Seal PX-3603255100 CDM 32551 CPT 360 RC outpatient 1280 1280 BLUE CROSS BLUE SHIELD WELLMARK SB889 [3081026] BCBS WYOMING [308102603] 1216 percent of total billed charges 793.6 1216 Technical (Hospital) Services Tube Thoracostomy Includes Water Seal PX-3603255100 CDM 32551 CPT 360 RC outpatient 1280 1280 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES HDHP [308136802] 1024 percent of total billed charges 793.6 1216 Technical (Hospital) Services Tube Thoracostomy Includes Water Seal PX-3603255100 CDM 32551 CPT 360 RC outpatient 1280 1280 MULTIPLAN INC 34080 [3081285] MULTIPLAN INC [308128501] 1216 percent of total billed charges 793.6 1216 Technical (Hospital) Services Tube Thoracostomy Includes Water Seal PX-3603255100 CDM 32551 CPT 360 RC outpatient 1280 1280 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES PPO [308136801] 1024 percent of total billed charges 793.6 1216 Technical (Hospital) Services Tube Thoracostomy Includes Water Seal PX-3603255100 CDM 32551 CPT 360 RC outpatient 1280 1280 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES EPO [308136803] 1024 percent of total billed charges 793.6 1216 Technical (Hospital) Services Tube Thoracostomy Includes Water Seal PX-3603255100 CDM 32551 CPT 360 RC outpatient 1280 1280 UNITED HEALTHCARE (COMMERCIAL) [3081199] UNITED HEALTHCARE 87726 [308119901] 793.6 percent of total billed charges 793.6 1216 Technical (Hospital) Services Tube Thoracostomy Includes Water Seal PX-3603255100 CDM 32551 CPT 360 RC outpatient 1280 1280 HEALTHPARTNERS SX009 HEALTHPARTNERS 1024 percent of total billed charges 793.6 1216 Technical (Hospital) Services Tube Thoracostomy Includes Water Seal PX-3603255100 CDM 32551 CPT 360 RC outpatient 1280 1280 MEDICA (COMMERCIAL) 94265 [3081118] MEDICA CLAIMS [308111801] 1152 percent of total billed charges 793.6 1216 Technical (Hospital) Services Tube Thoracostomy Includes Water Seal PX-3603255100 CDM 32551 CPT 360 RC outpatient 1280 1280 CIGNA 62308 [3081051] CIGNA 62308 [308105105] 1024 percent of total billed charges 793.6 1216 Technical (Hospital) Services Tube Thoracostomy Includes Water Seal PX-3603255100 CDM 32551 CPT 360 RC outpatient 1280 1280 CIGNA 62308 [3081051] CIGNA STATE OF WYOMING [308105107] 1024 percent of total billed charges 793.6 1216 Technical (Hospital) Services Tube Thoracostomy Includes Water Seal PX-3603255100 CDM 32551 CPT 360 RC inpatient 1280 1280 CIGNA 62308 [3081051] CIGNA 62308 [308105105] 1013.5 percent of total billed charges 793.6 1216 Technical (Hospital) Services Tube Thoracostomy Includes Water Seal PX-3603255100 CDM 32551 CPT 360 RC inpatient 1280 1280 CIGNA 62308 [3081051] CIGNA STATE OF WYOMING [308105107] 1013.5 percent of total billed charges 793.6 1216 Technical (Hospital) Services Tube Thoracostomy Includes Water Seal PX-3603255100 CDM 32551 CPT 360 RC inpatient 1280 1280 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES EPO [308136803] 1013.5 percent of total billed charges 793.6 1216 Technical (Hospital) Services Tube Thoracostomy Includes Water Seal PX-3603255100 CDM 32551 CPT 360 RC inpatient 1280 1280 HEALTHPARTNERS SX009 HEALTHPARTNERS 1013.5 percent of total billed charges 793.6 1216 Technical (Hospital) Services Tube Thoracostomy Includes Water Seal PX-3603255100 CDM 32551 CPT 360 RC inpatient 1280 1280 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES HDHP [308136802] 1013.5 percent of total billed charges 793.6 1216 Technical (Hospital) Services Tube Thoracostomy Includes Water Seal PX-3603255100 CDM 32551 CPT 360 RC inpatient 1280 1280 MEDICA (COMMERCIAL) 94265 [3081118] MEDICA CLAIMS [308111801] 1152 percent of total billed charges 793.6 1216 Technical (Hospital) Services Tube Thoracostomy Includes Water Seal PX-3603255100 CDM 32551 CPT 360 RC inpatient 1280 1280 MULTIPLAN INC 34080 [3081285] MULTIPLAN INC [308128501] 1216 percent of total billed charges 793.6 1216 Technical (Hospital) Services Tube Thoracostomy Includes Water Seal PX-3603255100 CDM 32551 CPT 360 RC inpatient 1280 1280 BLUE CROSS BLUE SHIELD WELLMARK SB889 [3081026] BCBS WYOMING [308102603] 1216 percent of total billed charges 793.6 1216 Technical (Hospital) Services Tube Thoracostomy Includes Water Seal PX-3603255100 CDM 32551 CPT 360 RC inpatient 1280 1280 UNITED HEALTHCARE (COMMERCIAL) [3081199] UNITED HEALTHCARE 87726 [308119901] 793.6 percent of total billed charges 793.6 1216 Technical (Hospital) Services Tube Thoracostomy Includes Water Seal PX-3603255100 CDM 32551 CPT 360 RC inpatient 1280 1280 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES PPO [308136801] 1013.5 percent of total billed charges 793.6 1216 Technical (Hospital) Services Tube Thoracostomy Includes Water Seal PX-32551 CDM 32551 CPT inpatient 1280 1280 CIGNA 62308 [3081051] CIGNA 62308 [308105105] 1024 percent of total billed charges 793.6 1216 Professional (doctor) services Tube Thoracostomy Includes Water Seal PX-32551 CDM 32551 CPT inpatient 1280 1280 CIGNA 62308 [3081051] CIGNA STATE OF WYOMING [308105107] 1024 percent of total billed charges 793.6 1216 Professional (doctor) services Tube Thoracostomy Includes Water Seal PX-32551 CDM 32551 CPT outpatient 1280 1280 CIGNA 62308 [3081051] CIGNA 62308 [308105105] 1024 percent of total billed charges 793.6 1216 Professional (doctor) services Tube Thoracostomy Includes Water Seal PX-32551 CDM 32551 CPT outpatient 1280 1280 CIGNA 62308 [3081051] CIGNA STATE OF WYOMING [308105107] 1024 percent of total billed charges 793.6 1216 Professional (doctor) services Tube Thoracostomy Includes Water Seal PX-32551 CDM 32551 CPT inpatient 1280 1280 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES EPO [308136803] 1024 percent of total billed charges 793.6 1216 Professional (doctor) services Tube Thoracostomy Includes Water Seal PX-32551 CDM 32551 CPT inpatient 1280 1280 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES HDHP [308136802] 1024 percent of total billed charges 793.6 1216 Professional (doctor) services Tube Thoracostomy Includes Water Seal PX-32551 CDM 32551 CPT inpatient 1280 1280 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES PPO [308136801] 1024 percent of total billed charges 793.6 1216 Professional (doctor) services Tube Thoracostomy Includes Water Seal PX-32551 CDM 32551 CPT outpatient 1280 1280 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES EPO [308136803] 1024 percent of total billed charges 793.6 1216 Professional (doctor) services Tube Thoracostomy Includes Water Seal PX-32551 CDM 32551 CPT outpatient 1280 1280 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES HDHP [308136802] 1024 percent of total billed charges 793.6 1216 Professional (doctor) services Tube Thoracostomy Includes Water Seal PX-32551 CDM 32551 CPT outpatient 1280 1280 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES PPO [308136801] 1024 percent of total billed charges 793.6 1216 Professional (doctor) services Tube Thoracostomy Includes Water Seal PX-32551 CDM 32551 CPT inpatient 1280 1280 HEALTHPARTNERS SX009 HEALTHPARTNERS 1024 percent of total billed charges 793.6 1216 Professional (doctor) services Tube Thoracostomy Includes Water Seal PX-32551 CDM 32551 CPT outpatient 1280 1280 HEALTHPARTNERS SX009 HEALTHPARTNERS 1024 percent of total billed charges 793.6 1216 Professional (doctor) services Tube Thoracostomy Includes Water Seal PX-32551 CDM 32551 CPT inpatient 1280 1280 MEDICA (COMMERCIAL) 94265 [3081118] MEDICA CLAIMS [308111801] 1152 percent of total billed charges 793.6 1216 Professional (doctor) services Tube Thoracostomy Includes Water Seal PX-32551 CDM 32551 CPT outpatient 1280 1280 MEDICA (COMMERCIAL) 94265 [3081118] MEDICA CLAIMS [308111801] 1152 percent of total billed charges 793.6 1216 Professional (doctor) services Tube Thoracostomy Includes Water Seal PX-32551 CDM 32551 CPT inpatient 1280 1280 MULTIPLAN INC 34080 [3081285] MULTIPLAN INC [308128501] 1216 percent of total billed charges 793.6 1216 Professional (doctor) services Tube Thoracostomy Includes Water Seal PX-32551 CDM 32551 CPT outpatient 1280 1280 MULTIPLAN INC 34080 [3081285] MULTIPLAN INC [308128501] 1216 percent of total billed charges 793.6 1216 Professional (doctor) services Tube Thoracostomy Includes Water Seal PX-32551 CDM 32551 CPT inpatient 1280 1280 UNITED HEALTHCARE (COMMERCIAL) [3081199] UNITED HEALTHCARE 87726 [308119901] 793.6 percent of total billed charges 793.6 1216 Professional (doctor) services Tube Thoracostomy Includes Water Seal PX-32551 CDM 32551 CPT outpatient 1280 1280 UNITED HEALTHCARE (COMMERCIAL) [3081199] UNITED HEALTHCARE 87726 [308119901] 793.6 percent of total billed charges 793.6 1216 Professional (doctor) services Intubation Endotracheal Emergency Procedure PX-4103150000 CDM 31500 CPT 410 RC inpatient 1091 1091 MEDICA (COMMERCIAL) 94265 [3081118] MEDICA CLAIMS [308111801] 981.9 percent of total billed charges 676.42 1036.45 Technical (Hospital) Services Intubation Endotracheal Emergency Procedure PX-4103150000 CDM 31500 CPT 410 RC inpatient 1091 1091 HEALTHPARTNERS SX009 HEALTHPARTNERS 863.85 percent of total billed charges 676.42 1036.45 Technical (Hospital) Services Intubation Endotracheal Emergency Procedure PX-4103150000 CDM 31500 CPT 410 RC inpatient 1091 1091 BLUE CROSS BLUE SHIELD WELLMARK SB889 [3081026] BCBS WYOMING [308102603] 1036.45 percent of total billed charges 676.42 1036.45 Technical (Hospital) Services Intubation Endotracheal Emergency Procedure PX-4103150000 CDM 31500 CPT 410 RC inpatient 1091 1091 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES HDHP [308136802] 863.85 percent of total billed charges 676.42 1036.45 Technical (Hospital) Services Intubation Endotracheal Emergency Procedure PX-4103150000 CDM 31500 CPT 410 RC inpatient 1091 1091 MULTIPLAN INC 34080 [3081285] MULTIPLAN INC [308128501] 1036.45 percent of total billed charges 676.42 1036.45 Technical (Hospital) Services Intubation Endotracheal Emergency Procedure PX-4103150000 CDM 31500 CPT 410 RC inpatient 1091 1091 UNITED HEALTHCARE (COMMERCIAL) [3081199] UNITED HEALTHCARE 87726 [308119901] 676.42 percent of total billed charges 676.42 1036.45 Technical (Hospital) Services Intubation Endotracheal Emergency Procedure PX-4103150000 CDM 31500 CPT 410 RC inpatient 1091 1091 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES PPO [308136801] 863.85 percent of total billed charges 676.42 1036.45 Technical (Hospital) Services Intubation Endotracheal Emergency Procedure PX-4103150000 CDM 31500 CPT 410 RC inpatient 1091 1091 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES EPO [308136803] 863.85 percent of total billed charges 676.42 1036.45 Technical (Hospital) Services Intubation Endotracheal Emergency Procedure PX-4103150000 CDM 31500 CPT 410 RC inpatient 1091 1091 CIGNA 62308 [3081051] CIGNA 62308 [308105105] 863.85 percent of total billed charges 676.42 1036.45 Technical (Hospital) Services Intubation Endotracheal Emergency Procedure PX-4103150000 CDM 31500 CPT 410 RC inpatient 1091 1091 CIGNA 62308 [3081051] CIGNA STATE OF WYOMING [308105107] 863.85 percent of total billed charges 676.42 1036.45 Technical (Hospital) Services Intubation Endotracheal Emergency Procedure PX-4103150000 CDM 31500 CPT 410 RC outpatient 1091 1091 MEDICA (COMMERCIAL) 94265 [3081118] MEDICA CLAIMS [308111801] 981.9 percent of total billed charges 676.42 1036.45 Technical (Hospital) Services Intubation Endotracheal Emergency Procedure PX-4103150000 CDM 31500 CPT 410 RC outpatient 1091 1091 CIGNA 62308 [3081051] CIGNA 62308 [308105105] 872.8 percent of total billed charges 676.42 1036.45 Technical (Hospital) Services Intubation Endotracheal Emergency Procedure PX-4103150000 CDM 31500 CPT 410 RC outpatient 1091 1091 CIGNA 62308 [3081051] CIGNA STATE OF WYOMING [308105107] 872.8 percent of total billed charges 676.42 1036.45 Technical (Hospital) Services Intubation Endotracheal Emergency Procedure PX-4103150000 CDM 31500 CPT 410 RC outpatient 1091 1091 UNITED HEALTHCARE (COMMERCIAL) [3081199] UNITED HEALTHCARE 87726 [308119901] 676.42 percent of total billed charges 676.42 1036.45 Technical (Hospital) Services Intubation Endotracheal Emergency Procedure PX-4103150000 CDM 31500 CPT 410 RC outpatient 1091 1091 HEALTHPARTNERS SX009 HEALTHPARTNERS 872.8 percent of total billed charges 676.42 1036.45 Technical (Hospital) Services Intubation Endotracheal Emergency Procedure PX-4103150000 CDM 31500 CPT 410 RC outpatient 1091 1091 BLUE CROSS BLUE SHIELD WELLMARK SB889 [3081026] BCBS WYOMING [308102603] 1036.45 percent of total billed charges 676.42 1036.45 Technical (Hospital) Services Intubation Endotracheal Emergency Procedure PX-4103150000 CDM 31500 CPT 410 RC outpatient 1091 1091 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES HDHP [308136802] 872.8 percent of total billed charges 676.42 1036.45 Technical (Hospital) Services Intubation Endotracheal Emergency Procedure PX-4103150000 CDM 31500 CPT 410 RC outpatient 1091 1091 MULTIPLAN INC 34080 [3081285] MULTIPLAN INC [308128501] 1036.45 percent of total billed charges 676.42 1036.45 Technical (Hospital) Services Intubation Endotracheal Emergency Procedure PX-4103150000 CDM 31500 CPT 410 RC outpatient 1091 1091 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES EPO [308136803] 872.8 percent of total billed charges 676.42 1036.45 Technical (Hospital) Services Intubation Endotracheal Emergency Procedure PX-4103150000 CDM 31500 CPT 410 RC outpatient 1091 1091 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES PPO [308136801] 872.8 percent of total billed charges 676.42 1036.45 Technical (Hospital) Services Insert Emergency Endotrach Airway PX-31500 CDM 31500 CPT inpatient 1091 1091 CIGNA 62308 [3081051] CIGNA 62308 [308105105] 872.8 percent of total billed charges 676.42 1036.45 Professional (doctor) services Insert Emergency Endotrach Airway PX-31500 CDM 31500 CPT inpatient 1091 1091 CIGNA 62308 [3081051] CIGNA STATE OF WYOMING [308105107] 872.8 percent of total billed charges 676.42 1036.45 Professional (doctor) services Insert Emergency Endotrach Airway PX-31500 CDM 31500 CPT outpatient 1091 1091 CIGNA 62308 [3081051] CIGNA 62308 [308105105] 872.8 percent of total billed charges 676.42 1036.45 Professional (doctor) services Insert Emergency Endotrach Airway PX-31500 CDM 31500 CPT outpatient 1091 1091 CIGNA 62308 [3081051] CIGNA STATE OF WYOMING [308105107] 872.8 percent of total billed charges 676.42 1036.45 Professional (doctor) services Insert Emergency Endotrach Airway PX-31500 CDM 31500 CPT inpatient 1091 1091 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES EPO [308136803] 872.8 percent of total billed charges 676.42 1036.45 Professional (doctor) services Insert Emergency Endotrach Airway PX-31500 CDM 31500 CPT inpatient 1091 1091 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES HDHP [308136802] 872.8 percent of total billed charges 676.42 1036.45 Professional (doctor) services Insert Emergency Endotrach Airway PX-31500 CDM 31500 CPT inpatient 1091 1091 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES PPO [308136801] 872.8 percent of total billed charges 676.42 1036.45 Professional (doctor) services Insert Emergency Endotrach Airway PX-31500 CDM 31500 CPT outpatient 1091 1091 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES EPO [308136803] 872.8 percent of total billed charges 676.42 1036.45 Professional (doctor) services Insert Emergency Endotrach Airway PX-31500 CDM 31500 CPT outpatient 1091 1091 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES HDHP [308136802] 872.8 percent of total billed charges 676.42 1036.45 Professional (doctor) services Insert Emergency Endotrach Airway PX-31500 CDM 31500 CPT outpatient 1091 1091 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES PPO [308136801] 872.8 percent of total billed charges 676.42 1036.45 Professional (doctor) services Insert Emergency Endotrach Airway PX-31500 CDM 31500 CPT inpatient 1091 1091 HEALTHPARTNERS SX009 HEALTHPARTNERS 872.8 percent of total billed charges 676.42 1036.45 Professional (doctor) services Insert Emergency Endotrach Airway PX-31500 CDM 31500 CPT outpatient 1091 1091 HEALTHPARTNERS SX009 HEALTHPARTNERS 872.8 percent of total billed charges 676.42 1036.45 Professional (doctor) services Insert Emergency Endotrach Airway PX-31500 CDM 31500 CPT inpatient 1091 1091 MEDICA (COMMERCIAL) 94265 [3081118] MEDICA CLAIMS [308111801] 981.9 percent of total billed charges 676.42 1036.45 Professional (doctor) services Insert Emergency Endotrach Airway PX-31500 CDM 31500 CPT outpatient 1091 1091 MEDICA (COMMERCIAL) 94265 [3081118] MEDICA CLAIMS [308111801] 981.9 percent of total billed charges 676.42 1036.45 Professional (doctor) services Insert Emergency Endotrach Airway PX-31500 CDM 31500 CPT inpatient 1091 1091 MULTIPLAN INC 34080 [3081285] MULTIPLAN INC [308128501] 1036.45 percent of total billed charges 676.42 1036.45 Professional (doctor) services Insert Emergency Endotrach Airway PX-31500 CDM 31500 CPT outpatient 1091 1091 MULTIPLAN INC 34080 [3081285] MULTIPLAN INC [308128501] 1036.45 percent of total billed charges 676.42 1036.45 Professional (doctor) services Insert Emergency Endotrach Airway PX-31500 CDM 31500 CPT inpatient 1091 1091 UNITED HEALTHCARE (COMMERCIAL) [3081199] UNITED HEALTHCARE 87726 [308119901] 676.42 percent of total billed charges 676.42 1036.45 Professional (doctor) services Insert Emergency Endotrach Airway PX-31500 CDM 31500 CPT outpatient 1091 1091 UNITED HEALTHCARE (COMMERCIAL) [3081199] UNITED HEALTHCARE 87726 [308119901] 676.42 percent of total billed charges 676.42 1036.45 Professional (doctor) services Control Nasal Hemorrhage Anterior Simple PX-3603090100 CDM 30901 CPT 360 RC outpatient 485 485 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES PPO [308136801] 388 percent of total billed charges 300.7 460.75 Technical (Hospital) Services Control Nasal Hemorrhage Anterior Simple PX-3603090100 CDM 30901 CPT 360 RC outpatient 485 485 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES EPO [308136803] 388 percent of total billed charges 300.7 460.75 Technical (Hospital) Services Control Nasal Hemorrhage Anterior Simple PX-3603090100 CDM 30901 CPT 360 RC outpatient 485 485 MULTIPLAN INC 34080 [3081285] MULTIPLAN INC [308128501] 460.75 percent of total billed charges 300.7 460.75 Technical (Hospital) Services Control Nasal Hemorrhage Anterior Simple PX-3603090100 CDM 30901 CPT 360 RC outpatient 485 485 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES HDHP [308136802] 388 percent of total billed charges 300.7 460.75 Technical (Hospital) Services Control Nasal Hemorrhage Anterior Simple PX-3603090100 CDM 30901 CPT 360 RC outpatient 485 485 BLUE CROSS BLUE SHIELD WELLMARK SB889 [3081026] BCBS WYOMING [308102603] 460.75 percent of total billed charges 300.7 460.75 Technical (Hospital) Services Control Nasal Hemorrhage Anterior Simple PX-3603090100 CDM 30901 CPT 360 RC outpatient 485 485 UNITED HEALTHCARE (COMMERCIAL) [3081199] UNITED HEALTHCARE 87726 [308119901] 300.7 percent of total billed charges 300.7 460.75 Technical (Hospital) Services Control Nasal Hemorrhage Anterior Simple PX-3603090100 CDM 30901 CPT 360 RC outpatient 485 485 HEALTHPARTNERS SX009 HEALTHPARTNERS 388 percent of total billed charges 300.7 460.75 Technical (Hospital) Services Control Nasal Hemorrhage Anterior Simple PX-3603090100 CDM 30901 CPT 360 RC outpatient 485 485 CIGNA 62308 [3081051] CIGNA 62308 [308105105] 388 percent of total billed charges 300.7 460.75 Technical (Hospital) Services Control Nasal Hemorrhage Anterior Simple PX-3603090100 CDM 30901 CPT 360 RC outpatient 485 485 CIGNA 62308 [3081051] CIGNA STATE OF WYOMING [308105107] 388 percent of total billed charges 300.7 460.75 Technical (Hospital) Services Control Nasal Hemorrhage Anterior Simple PX-3603090100 CDM 30901 CPT 360 RC outpatient 485 485 MEDICA (COMMERCIAL) 94265 [3081118] MEDICA CLAIMS [308111801] 436.5 percent of total billed charges 300.7 460.75 Technical (Hospital) Services Control Nasal Hemorrhage Anterior Simple PX-3603090100 CDM 30901 CPT 360 RC inpatient 485 485 MEDICA (COMMERCIAL) 94265 [3081118] MEDICA CLAIMS [308111801] 436.5 percent of total billed charges 300.7 460.75 Technical (Hospital) Services Control Nasal Hemorrhage Anterior Simple PX-3603090100 CDM 30901 CPT 360 RC inpatient 485 485 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES HDHP [308136802] 384.02 percent of total billed charges 300.7 460.75 Technical (Hospital) Services Control Nasal Hemorrhage Anterior Simple PX-3603090100 CDM 30901 CPT 360 RC inpatient 485 485 HEALTHPARTNERS SX009 HEALTHPARTNERS 384.02 percent of total billed charges 300.7 460.75 Technical (Hospital) Services Control Nasal Hemorrhage Anterior Simple PX-3603090100 CDM 30901 CPT 360 RC inpatient 485 485 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES PPO [308136801] 384.02 percent of total billed charges 300.7 460.75 Technical (Hospital) Services Control Nasal Hemorrhage Anterior Simple PX-3603090100 CDM 30901 CPT 360 RC inpatient 485 485 UNITED HEALTHCARE (COMMERCIAL) [3081199] UNITED HEALTHCARE 87726 [308119901] 300.7 percent of total billed charges 300.7 460.75 Technical (Hospital) Services Control Nasal Hemorrhage Anterior Simple PX-3603090100 CDM 30901 CPT 360 RC inpatient 485 485 BLUE CROSS BLUE SHIELD WELLMARK SB889 [3081026] BCBS WYOMING [308102603] 460.75 percent of total billed charges 300.7 460.75 Technical (Hospital) Services Control Nasal Hemorrhage Anterior Simple PX-3603090100 CDM 30901 CPT 360 RC inpatient 485 485 MULTIPLAN INC 34080 [3081285] MULTIPLAN INC [308128501] 460.75 percent of total billed charges 300.7 460.75 Technical (Hospital) Services Control Nasal Hemorrhage Anterior Simple PX-3603090100 CDM 30901 CPT 360 RC inpatient 485 485 CIGNA 62308 [3081051] CIGNA 62308 [308105105] 384.02 percent of total billed charges 300.7 460.75 Technical (Hospital) Services Control Nasal Hemorrhage Anterior Simple PX-3603090100 CDM 30901 CPT 360 RC inpatient 485 485 CIGNA 62308 [3081051] CIGNA STATE OF WYOMING [308105107] 384.02 percent of total billed charges 300.7 460.75 Technical (Hospital) Services Control Nasal Hemorrhage Anterior Simple PX-3603090100 CDM 30901 CPT 360 RC inpatient 485 485 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES EPO [308136803] 384.02 percent of total billed charges 300.7 460.75 Technical (Hospital) Services "Ctrl Nosebleed,Anter,Simple" PX-30901 CDM 30901 CPT inpatient 485 485 CIGNA 62308 [3081051] CIGNA 62308 [308105105] 388 percent of total billed charges 300.7 460.75 Professional (doctor) services "Ctrl Nosebleed,Anter,Simple" PX-30901 CDM 30901 CPT inpatient 485 485 CIGNA 62308 [3081051] CIGNA STATE OF WYOMING [308105107] 388 percent of total billed charges 300.7 460.75 Professional (doctor) services "Ctrl Nosebleed,Anter,Simple" PX-30901 CDM 30901 CPT outpatient 485 485 CIGNA 62308 [3081051] CIGNA 62308 [308105105] 388 percent of total billed charges 300.7 460.75 Professional (doctor) services "Ctrl Nosebleed,Anter,Simple" PX-30901 CDM 30901 CPT outpatient 485 485 CIGNA 62308 [3081051] CIGNA STATE OF WYOMING [308105107] 388 percent of total billed charges 300.7 460.75 Professional (doctor) services "Ctrl Nosebleed,Anter,Simple" PX-30901 CDM 30901 CPT inpatient 485 485 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES EPO [308136803] 388 percent of total billed charges 300.7 460.75 Professional (doctor) services "Ctrl Nosebleed,Anter,Simple" PX-30901 CDM 30901 CPT inpatient 485 485 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES HDHP [308136802] 388 percent of total billed charges 300.7 460.75 Professional (doctor) services "Ctrl Nosebleed,Anter,Simple" PX-30901 CDM 30901 CPT inpatient 485 485 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES PPO [308136801] 388 percent of total billed charges 300.7 460.75 Professional (doctor) services "Ctrl Nosebleed,Anter,Simple" PX-30901 CDM 30901 CPT outpatient 485 485 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES EPO [308136803] 388 percent of total billed charges 300.7 460.75 Professional (doctor) services "Ctrl Nosebleed,Anter,Simple" PX-30901 CDM 30901 CPT outpatient 485 485 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES HDHP [308136802] 388 percent of total billed charges 300.7 460.75 Professional (doctor) services "Ctrl Nosebleed,Anter,Simple" PX-30901 CDM 30901 CPT outpatient 485 485 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES PPO [308136801] 388 percent of total billed charges 300.7 460.75 Professional (doctor) services "Ctrl Nosebleed,Anter,Simple" PX-30901 CDM 30901 CPT inpatient 485 485 HEALTHPARTNERS SX009 HEALTHPARTNERS 388 percent of total billed charges 300.7 460.75 Professional (doctor) services "Ctrl Nosebleed,Anter,Simple" PX-30901 CDM 30901 CPT outpatient 485 485 HEALTHPARTNERS SX009 HEALTHPARTNERS 388 percent of total billed charges 300.7 460.75 Professional (doctor) services "Ctrl Nosebleed,Anter,Simple" PX-30901 CDM 30901 CPT inpatient 485 485 MEDICA (COMMERCIAL) 94265 [3081118] MEDICA CLAIMS [308111801] 436.5 percent of total billed charges 300.7 460.75 Professional (doctor) services "Ctrl Nosebleed,Anter,Simple" PX-30901 CDM 30901 CPT outpatient 485 485 MEDICA (COMMERCIAL) 94265 [3081118] MEDICA CLAIMS [308111801] 436.5 percent of total billed charges 300.7 460.75 Professional (doctor) services "Ctrl Nosebleed,Anter,Simple" PX-30901 CDM 30901 CPT inpatient 485 485 MULTIPLAN INC 34080 [3081285] MULTIPLAN INC [308128501] 460.75 percent of total billed charges 300.7 460.75 Professional (doctor) services "Ctrl Nosebleed,Anter,Simple" PX-30901 CDM 30901 CPT outpatient 485 485 MULTIPLAN INC 34080 [3081285] MULTIPLAN INC [308128501] 460.75 percent of total billed charges 300.7 460.75 Professional (doctor) services "Ctrl Nosebleed,Anter,Simple" PX-30901 CDM 30901 CPT inpatient 485 485 UNITED HEALTHCARE (COMMERCIAL) [3081199] UNITED HEALTHCARE 87726 [308119901] 300.7 percent of total billed charges 300.7 460.75 Professional (doctor) services "Ctrl Nosebleed,Anter,Simple" PX-30901 CDM 30901 CPT outpatient 485 485 UNITED HEALTHCARE (COMMERCIAL) [3081199] UNITED HEALTHCARE 87726 [308119901] 300.7 percent of total billed charges 300.7 460.75 Professional (doctor) services Remove Nasal Foreign Body PX-30300 CDM 30300 CPT inpatient 483 483 CIGNA 62308 [3081051] CIGNA 62308 [308105105] 386.4 percent of total billed charges 299.46 458.85 Professional (doctor) services Remove Nasal Foreign Body PX-30300 CDM 30300 CPT inpatient 483 483 CIGNA 62308 [3081051] CIGNA STATE OF WYOMING [308105107] 386.4 percent of total billed charges 299.46 458.85 Professional (doctor) services Remove Nasal Foreign Body PX-30300 CDM 30300 CPT outpatient 483 483 CIGNA 62308 [3081051] CIGNA 62308 [308105105] 386.4 percent of total billed charges 299.46 458.85 Professional (doctor) services Remove Nasal Foreign Body PX-30300 CDM 30300 CPT outpatient 483 483 CIGNA 62308 [3081051] CIGNA STATE OF WYOMING [308105107] 386.4 percent of total billed charges 299.46 458.85 Professional (doctor) services Remove Nasal Foreign Body PX-30300 CDM 30300 CPT inpatient 483 483 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES EPO [308136803] 386.4 percent of total billed charges 299.46 458.85 Professional (doctor) services Remove Nasal Foreign Body PX-30300 CDM 30300 CPT inpatient 483 483 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES HDHP [308136802] 386.4 percent of total billed charges 299.46 458.85 Professional (doctor) services Remove Nasal Foreign Body PX-30300 CDM 30300 CPT inpatient 483 483 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES PPO [308136801] 386.4 percent of total billed charges 299.46 458.85 Professional (doctor) services Remove Nasal Foreign Body PX-30300 CDM 30300 CPT outpatient 483 483 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES EPO [308136803] 386.4 percent of total billed charges 299.46 458.85 Professional (doctor) services Remove Nasal Foreign Body PX-30300 CDM 30300 CPT outpatient 483 483 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES HDHP [308136802] 386.4 percent of total billed charges 299.46 458.85 Professional (doctor) services Remove Nasal Foreign Body PX-30300 CDM 30300 CPT outpatient 483 483 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES PPO [308136801] 386.4 percent of total billed charges 299.46 458.85 Professional (doctor) services Remove Nasal Foreign Body PX-30300 CDM 30300 CPT inpatient 483 483 HEALTHPARTNERS SX009 HEALTHPARTNERS 386.4 percent of total billed charges 299.46 458.85 Professional (doctor) services Remove Nasal Foreign Body PX-30300 CDM 30300 CPT outpatient 483 483 HEALTHPARTNERS SX009 HEALTHPARTNERS 386.4 percent of total billed charges 299.46 458.85 Professional (doctor) services Remove Nasal Foreign Body PX-30300 CDM 30300 CPT inpatient 483 483 MEDICA (COMMERCIAL) 94265 [3081118] MEDICA CLAIMS [308111801] 434.7 percent of total billed charges 299.46 458.85 Professional (doctor) services Remove Nasal Foreign Body PX-30300 CDM 30300 CPT outpatient 483 483 MEDICA (COMMERCIAL) 94265 [3081118] MEDICA CLAIMS [308111801] 434.7 percent of total billed charges 299.46 458.85 Professional (doctor) services Remove Nasal Foreign Body PX-30300 CDM 30300 CPT inpatient 483 483 MULTIPLAN INC 34080 [3081285] MULTIPLAN INC [308128501] 458.85 percent of total billed charges 299.46 458.85 Professional (doctor) services Remove Nasal Foreign Body PX-30300 CDM 30300 CPT outpatient 483 483 MULTIPLAN INC 34080 [3081285] MULTIPLAN INC [308128501] 458.85 percent of total billed charges 299.46 458.85 Professional (doctor) services Remove Nasal Foreign Body PX-30300 CDM 30300 CPT inpatient 483 483 UNITED HEALTHCARE (COMMERCIAL) [3081199] UNITED HEALTHCARE 87726 [308119901] 299.46 percent of total billed charges 299.46 458.85 Professional (doctor) services Remove Nasal Foreign Body PX-30300 CDM 30300 CPT outpatient 483 483 UNITED HEALTHCARE (COMMERCIAL) [3081199] UNITED HEALTHCARE 87726 [308119901] 299.46 percent of total billed charges 299.46 458.85 Professional (doctor) services Appl Mltlayr Compres Leg Below Knee W/Ankle Foot PX-3602958100 CDM 29581 CPT 360 RC outpatient 380 380 MEDICA (COMMERCIAL) 94265 [3081118] MEDICA CLAIMS [308111801] 342 percent of total billed charges 235.6 361 Technical (Hospital) Services Appl Mltlayr Compres Leg Below Knee W/Ankle Foot PX-3602958100 CDM 29581 CPT 360 RC outpatient 380 380 CIGNA 62308 [3081051] CIGNA 62308 [308105105] 304 percent of total billed charges 235.6 361 Technical (Hospital) Services Appl Mltlayr Compres Leg Below Knee W/Ankle Foot PX-3602958100 CDM 29581 CPT 360 RC outpatient 380 380 CIGNA 62308 [3081051] CIGNA STATE OF WYOMING [308105107] 304 percent of total billed charges 235.6 361 Technical (Hospital) Services Appl Mltlayr Compres Leg Below Knee W/Ankle Foot PX-3602958100 CDM 29581 CPT 360 RC outpatient 380 380 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES PPO [308136801] 304 percent of total billed charges 235.6 361 Technical (Hospital) Services Appl Mltlayr Compres Leg Below Knee W/Ankle Foot PX-3602958100 CDM 29581 CPT 360 RC outpatient 380 380 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES EPO [308136803] 304 percent of total billed charges 235.6 361 Technical (Hospital) Services Appl Mltlayr Compres Leg Below Knee W/Ankle Foot PX-3602958100 CDM 29581 CPT 360 RC outpatient 380 380 UNITED HEALTHCARE (COMMERCIAL) [3081199] UNITED HEALTHCARE 87726 [308119901] 235.6 percent of total billed charges 235.6 361 Technical (Hospital) Services Appl Mltlayr Compres Leg Below Knee W/Ankle Foot PX-3602958100 CDM 29581 CPT 360 RC outpatient 380 380 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES HDHP [308136802] 304 percent of total billed charges 235.6 361 Technical (Hospital) Services Appl Mltlayr Compres Leg Below Knee W/Ankle Foot PX-3602958100 CDM 29581 CPT 360 RC outpatient 380 380 MULTIPLAN INC 34080 [3081285] MULTIPLAN INC [308128501] 361 percent of total billed charges 235.6 361 Technical (Hospital) Services Appl Mltlayr Compres Leg Below Knee W/Ankle Foot PX-3602958100 CDM 29581 CPT 360 RC outpatient 380 380 BLUE CROSS BLUE SHIELD WELLMARK SB889 [3081026] BCBS WYOMING [308102603] 361 percent of total billed charges 235.6 361 Technical (Hospital) Services Appl Mltlayr Compres Leg Below Knee W/Ankle Foot PX-3602958100 CDM 29581 CPT 360 RC outpatient 380 380 HEALTHPARTNERS SX009 HEALTHPARTNERS 304 percent of total billed charges 235.6 361 Technical (Hospital) Services Appl Mltlayr Compres Leg Below Knee W/Ankle Foot PX-3602958100 CDM 29581 CPT 360 RC inpatient 380 380 MULTIPLAN INC 34080 [3081285] MULTIPLAN INC [308128501] 361 percent of total billed charges 235.6 361 Technical (Hospital) Services Appl Mltlayr Compres Leg Below Knee W/Ankle Foot PX-3602958100 CDM 29581 CPT 360 RC inpatient 380 380 BLUE CROSS BLUE SHIELD WELLMARK SB889 [3081026] BCBS WYOMING [308102603] 361 percent of total billed charges 235.6 361 Technical (Hospital) Services Appl Mltlayr Compres Leg Below Knee W/Ankle Foot PX-3602958100 CDM 29581 CPT 360 RC inpatient 380 380 UNITED HEALTHCARE (COMMERCIAL) [3081199] UNITED HEALTHCARE 87726 [308119901] 235.6 percent of total billed charges 235.6 361 Technical (Hospital) Services Appl Mltlayr Compres Leg Below Knee W/Ankle Foot PX-3602958100 CDM 29581 CPT 360 RC inpatient 380 380 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES PPO [308136801] 300.88 percent of total billed charges 235.6 361 Technical (Hospital) Services Appl Mltlayr Compres Leg Below Knee W/Ankle Foot PX-3602958100 CDM 29581 CPT 360 RC inpatient 380 380 MEDICA (COMMERCIAL) 94265 [3081118] MEDICA CLAIMS [308111801] 342 percent of total billed charges 235.6 361 Technical (Hospital) Services Appl Mltlayr Compres Leg Below Knee W/Ankle Foot PX-3602958100 CDM 29581 CPT 360 RC inpatient 380 380 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES HDHP [308136802] 300.88 percent of total billed charges 235.6 361 Technical (Hospital) Services Appl Mltlayr Compres Leg Below Knee W/Ankle Foot PX-3602958100 CDM 29581 CPT 360 RC inpatient 380 380 HEALTHPARTNERS SX009 HEALTHPARTNERS 300.88 percent of total billed charges 235.6 361 Technical (Hospital) Services Appl Mltlayr Compres Leg Below Knee W/Ankle Foot PX-3602958100 CDM 29581 CPT 360 RC inpatient 380 380 CIGNA 62308 [3081051] CIGNA 62308 [308105105] 300.88 percent of total billed charges 235.6 361 Technical (Hospital) Services Appl Mltlayr Compres Leg Below Knee W/Ankle Foot PX-3602958100 CDM 29581 CPT 360 RC inpatient 380 380 CIGNA 62308 [3081051] CIGNA STATE OF WYOMING [308105107] 300.88 percent of total billed charges 235.6 361 Technical (Hospital) Services Appl Mltlayr Compres Leg Below Knee W/Ankle Foot PX-3602958100 CDM 29581 CPT 360 RC inpatient 380 380 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES EPO [308136803] 300.88 percent of total billed charges 235.6 361 Technical (Hospital) Services Strapping Unna Boot PX-3602958000 CDM 29580 CPT 360 RC inpatient 227 227 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES EPO [308136803] 179.74 percent of total billed charges 140.74 215.65 Technical (Hospital) Services Strapping Unna Boot PX-3602958000 CDM 29580 CPT 360 RC inpatient 227 227 CIGNA 62308 [3081051] CIGNA 62308 [308105105] 179.74 percent of total billed charges 140.74 215.65 Technical (Hospital) Services Strapping Unna Boot PX-3602958000 CDM 29580 CPT 360 RC inpatient 227 227 CIGNA 62308 [3081051] CIGNA STATE OF WYOMING [308105107] 179.74 percent of total billed charges 140.74 215.65 Technical (Hospital) Services Strapping Unna Boot PX-3602958000 CDM 29580 CPT 360 RC inpatient 227 227 UNITED HEALTHCARE (COMMERCIAL) [3081199] UNITED HEALTHCARE 87726 [308119901] 140.74 percent of total billed charges 140.74 215.65 Technical (Hospital) Services Strapping Unna Boot PX-3602958000 CDM 29580 CPT 360 RC inpatient 227 227 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES PPO [308136801] 179.74 percent of total billed charges 140.74 215.65 Technical (Hospital) Services Strapping Unna Boot PX-3602958000 CDM 29580 CPT 360 RC inpatient 227 227 BLUE CROSS BLUE SHIELD WELLMARK SB889 [3081026] BCBS WYOMING [308102603] 215.65 percent of total billed charges 140.74 215.65 Technical (Hospital) Services Strapping Unna Boot PX-3602958000 CDM 29580 CPT 360 RC inpatient 227 227 MULTIPLAN INC 34080 [3081285] MULTIPLAN INC [308128501] 215.65 percent of total billed charges 140.74 215.65 Technical (Hospital) Services Strapping Unna Boot PX-3602958000 CDM 29580 CPT 360 RC inpatient 227 227 HEALTHPARTNERS SX009 HEALTHPARTNERS 179.74 percent of total billed charges 140.74 215.65 Technical (Hospital) Services Strapping Unna Boot PX-3602958000 CDM 29580 CPT 360 RC inpatient 227 227 MEDICA (COMMERCIAL) 94265 [3081118] MEDICA CLAIMS [308111801] 204.3 percent of total billed charges 140.74 215.65 Technical (Hospital) Services Strapping Unna Boot PX-3602958000 CDM 29580 CPT 360 RC inpatient 227 227 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES HDHP [308136802] 179.74 percent of total billed charges 140.74 215.65 Technical (Hospital) Services Strapping Unna Boot PX-3602958000 CDM 29580 CPT 360 RC outpatient 227 227 UNITED HEALTHCARE (COMMERCIAL) [3081199] UNITED HEALTHCARE 87726 [308119901] 140.74 percent of total billed charges 140.74 215.65 Technical (Hospital) Services Strapping Unna Boot PX-3602958000 CDM 29580 CPT 360 RC outpatient 227 227 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES EPO [308136803] 181.6 percent of total billed charges 140.74 215.65 Technical (Hospital) Services Strapping Unna Boot PX-3602958000 CDM 29580 CPT 360 RC outpatient 227 227 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES PPO [308136801] 181.6 percent of total billed charges 140.74 215.65 Technical (Hospital) Services Strapping Unna Boot PX-3602958000 CDM 29580 CPT 360 RC outpatient 227 227 BLUE CROSS BLUE SHIELD WELLMARK SB889 [3081026] BCBS WYOMING [308102603] 215.65 percent of total billed charges 140.74 215.65 Technical (Hospital) Services Strapping Unna Boot PX-3602958000 CDM 29580 CPT 360 RC outpatient 227 227 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES HDHP [308136802] 181.6 percent of total billed charges 140.74 215.65 Technical (Hospital) Services Strapping Unna Boot PX-3602958000 CDM 29580 CPT 360 RC outpatient 227 227 MULTIPLAN INC 34080 [3081285] MULTIPLAN INC [308128501] 215.65 percent of total billed charges 140.74 215.65 Technical (Hospital) Services Strapping Unna Boot PX-3602958000 CDM 29580 CPT 360 RC outpatient 227 227 HEALTHPARTNERS SX009 HEALTHPARTNERS 181.6 percent of total billed charges 140.74 215.65 Technical (Hospital) Services Strapping Unna Boot PX-3602958000 CDM 29580 CPT 360 RC outpatient 227 227 MEDICA (COMMERCIAL) 94265 [3081118] MEDICA CLAIMS [308111801] 204.3 percent of total billed charges 140.74 215.65 Technical (Hospital) Services Strapping Unna Boot PX-3602958000 CDM 29580 CPT 360 RC outpatient 227 227 CIGNA 62308 [3081051] CIGNA 62308 [308105105] 181.6 percent of total billed charges 140.74 215.65 Technical (Hospital) Services Strapping Unna Boot PX-3602958000 CDM 29580 CPT 360 RC outpatient 227 227 CIGNA 62308 [3081051] CIGNA STATE OF WYOMING [308105107] 181.6 percent of total billed charges 140.74 215.65 Technical (Hospital) Services Application Short Leg Splint Calf Foot PX-3602951500 CDM 29515 CPT 360 RC inpatient 284 284 BLUE CROSS BLUE SHIELD WELLMARK SB889 [3081026] BCBS WYOMING [308102603] 269.8 percent of total billed charges 176.08 269.8 Technical (Hospital) Services Application Short Leg Splint Calf Foot PX-3602951500 CDM 29515 CPT 360 RC inpatient 284 284 MULTIPLAN INC 34080 [3081285] MULTIPLAN INC [308128501] 269.8 percent of total billed charges 176.08 269.8 Technical (Hospital) Services Application Short Leg Splint Calf Foot PX-3602951500 CDM 29515 CPT 360 RC inpatient 284 284 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES PPO [308136801] 224.87 percent of total billed charges 176.08 269.8 Technical (Hospital) Services Application Short Leg Splint Calf Foot PX-3602951500 CDM 29515 CPT 360 RC inpatient 284 284 UNITED HEALTHCARE (COMMERCIAL) [3081199] UNITED HEALTHCARE 87726 [308119901] 176.08 percent of total billed charges 176.08 269.8 Technical (Hospital) Services Application Short Leg Splint Calf Foot PX-3602951500 CDM 29515 CPT 360 RC inpatient 284 284 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES HDHP [308136802] 224.87 percent of total billed charges 176.08 269.8 Technical (Hospital) Services Application Short Leg Splint Calf Foot PX-3602951500 CDM 29515 CPT 360 RC inpatient 284 284 MEDICA (COMMERCIAL) 94265 [3081118] MEDICA CLAIMS [308111801] 255.6 percent of total billed charges 176.08 269.8 Technical (Hospital) Services Application Short Leg Splint Calf Foot PX-3602951500 CDM 29515 CPT 360 RC inpatient 284 284 HEALTHPARTNERS SX009 HEALTHPARTNERS 224.87 percent of total billed charges 176.08 269.8 Technical (Hospital) Services Application Short Leg Splint Calf Foot PX-3602951500 CDM 29515 CPT 360 RC inpatient 284 284 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES EPO [308136803] 224.87 percent of total billed charges 176.08 269.8 Technical (Hospital) Services Application Short Leg Splint Calf Foot PX-3602951500 CDM 29515 CPT 360 RC inpatient 284 284 CIGNA 62308 [3081051] CIGNA 62308 [308105105] 224.87 percent of total billed charges 176.08 269.8 Technical (Hospital) Services Application Short Leg Splint Calf Foot PX-3602951500 CDM 29515 CPT 360 RC inpatient 284 284 CIGNA 62308 [3081051] CIGNA STATE OF WYOMING [308105107] 224.87 percent of total billed charges 176.08 269.8 Technical (Hospital) Services Application Short Leg Splint Calf Foot PX-3602951500 CDM 29515 CPT 360 RC outpatient 284 284 CIGNA 62308 [3081051] CIGNA 62308 [308105105] 227.2 percent of total billed charges 176.08 269.8 Technical (Hospital) Services Application Short Leg Splint Calf Foot PX-3602951500 CDM 29515 CPT 360 RC outpatient 284 284 CIGNA 62308 [3081051] CIGNA STATE OF WYOMING [308105107] 227.2 percent of total billed charges 176.08 269.8 Technical (Hospital) Services Application Short Leg Splint Calf Foot PX-3602951500 CDM 29515 CPT 360 RC outpatient 284 284 BLUE CROSS BLUE SHIELD WELLMARK SB889 [3081026] BCBS WYOMING [308102603] 269.8 percent of total billed charges 176.08 269.8 Technical (Hospital) Services Application Short Leg Splint Calf Foot PX-3602951500 CDM 29515 CPT 360 RC outpatient 284 284 MULTIPLAN INC 34080 [3081285] MULTIPLAN INC [308128501] 269.8 percent of total billed charges 176.08 269.8 Technical (Hospital) Services Application Short Leg Splint Calf Foot PX-3602951500 CDM 29515 CPT 360 RC outpatient 284 284 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES HDHP [308136802] 227.2 percent of total billed charges 176.08 269.8 Technical (Hospital) Services Application Short Leg Splint Calf Foot PX-3602951500 CDM 29515 CPT 360 RC outpatient 284 284 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES EPO [308136803] 227.2 percent of total billed charges 176.08 269.8 Technical (Hospital) Services Application Short Leg Splint Calf Foot PX-3602951500 CDM 29515 CPT 360 RC outpatient 284 284 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES PPO [308136801] 227.2 percent of total billed charges 176.08 269.8 Technical (Hospital) Services Application Short Leg Splint Calf Foot PX-3602951500 CDM 29515 CPT 360 RC outpatient 284 284 UNITED HEALTHCARE (COMMERCIAL) [3081199] UNITED HEALTHCARE 87726 [308119901] 176.08 percent of total billed charges 176.08 269.8 Technical (Hospital) Services Application Short Leg Splint Calf Foot PX-3602951500 CDM 29515 CPT 360 RC outpatient 284 284 MEDICA (COMMERCIAL) 94265 [3081118] MEDICA CLAIMS [308111801] 255.6 percent of total billed charges 176.08 269.8 Technical (Hospital) Services Application Short Leg Splint Calf Foot PX-3602951500 CDM 29515 CPT 360 RC outpatient 284 284 HEALTHPARTNERS SX009 HEALTHPARTNERS 227.2 percent of total billed charges 176.08 269.8 Technical (Hospital) Services Apply Lower Leg Splint PX-29515 CDM 29515 CPT inpatient 281 281 CIGNA 62308 [3081051] CIGNA 62308 [308105105] 224.8 percent of total billed charges 174.22 266.95 Professional (doctor) services Apply Lower Leg Splint PX-29515 CDM 29515 CPT inpatient 281 281 CIGNA 62308 [3081051] CIGNA STATE OF WYOMING [308105107] 224.8 percent of total billed charges 174.22 266.95 Professional (doctor) services Apply Lower Leg Splint PX-29515 CDM 29515 CPT outpatient 281 281 CIGNA 62308 [3081051] CIGNA 62308 [308105105] 224.8 percent of total billed charges 174.22 266.95 Professional (doctor) services Apply Lower Leg Splint PX-29515 CDM 29515 CPT outpatient 281 281 CIGNA 62308 [3081051] CIGNA STATE OF WYOMING [308105107] 224.8 percent of total billed charges 174.22 266.95 Professional (doctor) services Apply Lower Leg Splint PX-29515 CDM 29515 CPT inpatient 281 281 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES EPO [308136803] 224.8 percent of total billed charges 174.22 266.95 Professional (doctor) services Apply Lower Leg Splint PX-29515 CDM 29515 CPT inpatient 281 281 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES HDHP [308136802] 224.8 percent of total billed charges 174.22 266.95 Professional (doctor) services Apply Lower Leg Splint PX-29515 CDM 29515 CPT inpatient 281 281 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES PPO [308136801] 224.8 percent of total billed charges 174.22 266.95 Professional (doctor) services Apply Lower Leg Splint PX-29515 CDM 29515 CPT outpatient 281 281 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES EPO [308136803] 224.8 percent of total billed charges 174.22 266.95 Professional (doctor) services Apply Lower Leg Splint PX-29515 CDM 29515 CPT outpatient 281 281 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES HDHP [308136802] 224.8 percent of total billed charges 174.22 266.95 Professional (doctor) services Apply Lower Leg Splint PX-29515 CDM 29515 CPT outpatient 281 281 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES PPO [308136801] 224.8 percent of total billed charges 174.22 266.95 Professional (doctor) services Apply Lower Leg Splint PX-29515 CDM 29515 CPT inpatient 281 281 HEALTHPARTNERS SX009 HEALTHPARTNERS 224.8 percent of total billed charges 174.22 266.95 Professional (doctor) services Apply Lower Leg Splint PX-29515 CDM 29515 CPT outpatient 281 281 HEALTHPARTNERS SX009 HEALTHPARTNERS 224.8 percent of total billed charges 174.22 266.95 Professional (doctor) services Apply Lower Leg Splint PX-29515 CDM 29515 CPT inpatient 281 281 MEDICA (COMMERCIAL) 94265 [3081118] MEDICA CLAIMS [308111801] 252.9 percent of total billed charges 174.22 266.95 Professional (doctor) services Apply Lower Leg Splint PX-29515 CDM 29515 CPT outpatient 281 281 MEDICA (COMMERCIAL) 94265 [3081118] MEDICA CLAIMS [308111801] 252.9 percent of total billed charges 174.22 266.95 Professional (doctor) services Apply Lower Leg Splint PX-29515 CDM 29515 CPT inpatient 281 281 MULTIPLAN INC 34080 [3081285] MULTIPLAN INC [308128501] 266.95 percent of total billed charges 174.22 266.95 Professional (doctor) services Apply Lower Leg Splint PX-29515 CDM 29515 CPT outpatient 281 281 MULTIPLAN INC 34080 [3081285] MULTIPLAN INC [308128501] 266.95 percent of total billed charges 174.22 266.95 Professional (doctor) services Apply Lower Leg Splint PX-29515 CDM 29515 CPT inpatient 281 281 UNITED HEALTHCARE (COMMERCIAL) [3081199] UNITED HEALTHCARE 87726 [308119901] 174.22 percent of total billed charges 174.22 266.95 Professional (doctor) services Apply Lower Leg Splint PX-29515 CDM 29515 CPT outpatient 281 281 UNITED HEALTHCARE (COMMERCIAL) [3081199] UNITED HEALTHCARE 87726 [308119901] 174.22 percent of total billed charges 174.22 266.95 Professional (doctor) services Application Long Leg Splint Thigh Ankle/Toes PX-3602950500 CDM 29505 CPT 360 RC outpatient 483 483 CIGNA 62308 [3081051] CIGNA 62308 [308105105] 386.4 percent of total billed charges 299.46 458.85 Technical (Hospital) Services Application Long Leg Splint Thigh Ankle/Toes PX-3602950500 CDM 29505 CPT 360 RC outpatient 483 483 CIGNA 62308 [3081051] CIGNA STATE OF WYOMING [308105107] 386.4 percent of total billed charges 299.46 458.85 Technical (Hospital) Services Application Long Leg Splint Thigh Ankle/Toes PX-3602950500 CDM 29505 CPT 360 RC outpatient 483 483 BLUE CROSS BLUE SHIELD WELLMARK SB889 [3081026] BCBS WYOMING [308102603] 458.85 percent of total billed charges 299.46 458.85 Technical (Hospital) Services Application Long Leg Splint Thigh Ankle/Toes PX-3602950500 CDM 29505 CPT 360 RC outpatient 483 483 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES HDHP [308136802] 386.4 percent of total billed charges 299.46 458.85 Technical (Hospital) Services Application Long Leg Splint Thigh Ankle/Toes PX-3602950500 CDM 29505 CPT 360 RC outpatient 483 483 MULTIPLAN INC 34080 [3081285] MULTIPLAN INC [308128501] 458.85 percent of total billed charges 299.46 458.85 Technical (Hospital) Services Application Long Leg Splint Thigh Ankle/Toes PX-3602950500 CDM 29505 CPT 360 RC outpatient 483 483 UNITED HEALTHCARE (COMMERCIAL) [3081199] UNITED HEALTHCARE 87726 [308119901] 299.46 percent of total billed charges 299.46 458.85 Technical (Hospital) Services Application Long Leg Splint Thigh Ankle/Toes PX-3602950500 CDM 29505 CPT 360 RC outpatient 483 483 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES PPO [308136801] 386.4 percent of total billed charges 299.46 458.85 Technical (Hospital) Services Application Long Leg Splint Thigh Ankle/Toes PX-3602950500 CDM 29505 CPT 360 RC outpatient 483 483 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES EPO [308136803] 386.4 percent of total billed charges 299.46 458.85 Technical (Hospital) Services Application Long Leg Splint Thigh Ankle/Toes PX-3602950500 CDM 29505 CPT 360 RC outpatient 483 483 MEDICA (COMMERCIAL) 94265 [3081118] MEDICA CLAIMS [308111801] 434.7 percent of total billed charges 299.46 458.85 Technical (Hospital) Services Application Long Leg Splint Thigh Ankle/Toes PX-3602950500 CDM 29505 CPT 360 RC outpatient 483 483 HEALTHPARTNERS SX009 HEALTHPARTNERS 386.4 percent of total billed charges 299.46 458.85 Technical (Hospital) Services Application Long Leg Splint Thigh Ankle/Toes PX-3602950500 CDM 29505 CPT 360 RC inpatient 483 483 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES EPO [308136803] 382.44 percent of total billed charges 299.46 458.85 Technical (Hospital) Services Application Long Leg Splint Thigh Ankle/Toes PX-3602950500 CDM 29505 CPT 360 RC inpatient 483 483 CIGNA 62308 [3081051] CIGNA 62308 [308105105] 382.44 percent of total billed charges 299.46 458.85 Technical (Hospital) Services Application Long Leg Splint Thigh Ankle/Toes PX-3602950500 CDM 29505 CPT 360 RC inpatient 483 483 CIGNA 62308 [3081051] CIGNA STATE OF WYOMING [308105107] 382.44 percent of total billed charges 299.46 458.85 Technical (Hospital) Services Application Long Leg Splint Thigh Ankle/Toes PX-3602950500 CDM 29505 CPT 360 RC inpatient 483 483 BLUE CROSS BLUE SHIELD WELLMARK SB889 [3081026] BCBS WYOMING [308102603] 458.85 percent of total billed charges 299.46 458.85 Technical (Hospital) Services Application Long Leg Splint Thigh Ankle/Toes PX-3602950500 CDM 29505 CPT 360 RC inpatient 483 483 UNITED HEALTHCARE (COMMERCIAL) [3081199] UNITED HEALTHCARE 87726 [308119901] 299.46 percent of total billed charges 299.46 458.85 Technical (Hospital) Services Application Long Leg Splint Thigh Ankle/Toes PX-3602950500 CDM 29505 CPT 360 RC inpatient 483 483 MULTIPLAN INC 34080 [3081285] MULTIPLAN INC [308128501] 458.85 percent of total billed charges 299.46 458.85 Technical (Hospital) Services Application Long Leg Splint Thigh Ankle/Toes PX-3602950500 CDM 29505 CPT 360 RC inpatient 483 483 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES PPO [308136801] 382.44 percent of total billed charges 299.46 458.85 Technical (Hospital) Services Application Long Leg Splint Thigh Ankle/Toes PX-3602950500 CDM 29505 CPT 360 RC inpatient 483 483 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES HDHP [308136802] 382.44 percent of total billed charges 299.46 458.85 Technical (Hospital) Services Application Long Leg Splint Thigh Ankle/Toes PX-3602950500 CDM 29505 CPT 360 RC inpatient 483 483 MEDICA (COMMERCIAL) 94265 [3081118] MEDICA CLAIMS [308111801] 434.7 percent of total billed charges 299.46 458.85 Technical (Hospital) Services Application Long Leg Splint Thigh Ankle/Toes PX-3602950500 CDM 29505 CPT 360 RC inpatient 483 483 HEALTHPARTNERS SX009 HEALTHPARTNERS 382.44 percent of total billed charges 299.46 458.85 Technical (Hospital) Services Apply Long Leg Splint PX-29505 CDM 29505 CPT inpatient 437 437 CIGNA 62308 [3081051] CIGNA 62308 [308105105] 349.6 percent of total billed charges 270.94 415.15 Professional (doctor) services Apply Long Leg Splint PX-29505 CDM 29505 CPT inpatient 437 437 CIGNA 62308 [3081051] CIGNA STATE OF WYOMING [308105107] 349.6 percent of total billed charges 270.94 415.15 Professional (doctor) services Apply Long Leg Splint PX-29505 CDM 29505 CPT outpatient 437 437 CIGNA 62308 [3081051] CIGNA 62308 [308105105] 349.6 percent of total billed charges 270.94 415.15 Professional (doctor) services Apply Long Leg Splint PX-29505 CDM 29505 CPT outpatient 437 437 CIGNA 62308 [3081051] CIGNA STATE OF WYOMING [308105107] 349.6 percent of total billed charges 270.94 415.15 Professional (doctor) services Apply Long Leg Splint PX-29505 CDM 29505 CPT inpatient 437 437 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES EPO [308136803] 349.6 percent of total billed charges 270.94 415.15 Professional (doctor) services Apply Long Leg Splint PX-29505 CDM 29505 CPT inpatient 437 437 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES HDHP [308136802] 349.6 percent of total billed charges 270.94 415.15 Professional (doctor) services Apply Long Leg Splint PX-29505 CDM 29505 CPT inpatient 437 437 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES PPO [308136801] 349.6 percent of total billed charges 270.94 415.15 Professional (doctor) services Apply Long Leg Splint PX-29505 CDM 29505 CPT outpatient 437 437 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES EPO [308136803] 349.6 percent of total billed charges 270.94 415.15 Professional (doctor) services Apply Long Leg Splint PX-29505 CDM 29505 CPT outpatient 437 437 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES HDHP [308136802] 349.6 percent of total billed charges 270.94 415.15 Professional (doctor) services Apply Long Leg Splint PX-29505 CDM 29505 CPT outpatient 437 437 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES PPO [308136801] 349.6 percent of total billed charges 270.94 415.15 Professional (doctor) services Apply Long Leg Splint PX-29505 CDM 29505 CPT inpatient 437 437 HEALTHPARTNERS SX009 HEALTHPARTNERS 349.6 percent of total billed charges 270.94 415.15 Professional (doctor) services Apply Long Leg Splint PX-29505 CDM 29505 CPT outpatient 437 437 HEALTHPARTNERS SX009 HEALTHPARTNERS 349.6 percent of total billed charges 270.94 415.15 Professional (doctor) services Apply Long Leg Splint PX-29505 CDM 29505 CPT inpatient 437 437 MEDICA (COMMERCIAL) 94265 [3081118] MEDICA CLAIMS [308111801] 393.3 percent of total billed charges 270.94 415.15 Professional (doctor) services Apply Long Leg Splint PX-29505 CDM 29505 CPT outpatient 437 437 MEDICA (COMMERCIAL) 94265 [3081118] MEDICA CLAIMS [308111801] 393.3 percent of total billed charges 270.94 415.15 Professional (doctor) services Apply Long Leg Splint PX-29505 CDM 29505 CPT inpatient 437 437 MULTIPLAN INC 34080 [3081285] MULTIPLAN INC [308128501] 415.15 percent of total billed charges 270.94 415.15 Professional (doctor) services Apply Long Leg Splint PX-29505 CDM 29505 CPT outpatient 437 437 MULTIPLAN INC 34080 [3081285] MULTIPLAN INC [308128501] 415.15 percent of total billed charges 270.94 415.15 Professional (doctor) services Apply Long Leg Splint PX-29505 CDM 29505 CPT inpatient 437 437 UNITED HEALTHCARE (COMMERCIAL) [3081199] UNITED HEALTHCARE 87726 [308119901] 270.94 percent of total billed charges 270.94 415.15 Professional (doctor) services Apply Long Leg Splint PX-29505 CDM 29505 CPT outpatient 437 437 UNITED HEALTHCARE (COMMERCIAL) [3081199] UNITED HEALTHCARE 87726 [308119901] 270.94 percent of total billed charges 270.94 415.15 Professional (doctor) services Application Short Leg Cast Below Knee-Toe PX-3602940500 CDM 29405 CPT 360 RC inpatient 539 539 UNITED HEALTHCARE (COMMERCIAL) [3081199] UNITED HEALTHCARE 87726 [308119901] 334.18 percent of total billed charges 334.18 512.05 Technical (Hospital) Services Application Short Leg Cast Below Knee-Toe PX-3602940500 CDM 29405 CPT 360 RC inpatient 539 539 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES PPO [308136801] 426.78 percent of total billed charges 334.18 512.05 Technical (Hospital) Services Application Short Leg Cast Below Knee-Toe PX-3602940500 CDM 29405 CPT 360 RC inpatient 539 539 MULTIPLAN INC 34080 [3081285] MULTIPLAN INC [308128501] 512.05 percent of total billed charges 334.18 512.05 Technical (Hospital) Services Application Short Leg Cast Below Knee-Toe PX-3602940500 CDM 29405 CPT 360 RC inpatient 539 539 BLUE CROSS BLUE SHIELD WELLMARK SB889 [3081026] BCBS WYOMING [308102603] 512.05 percent of total billed charges 334.18 512.05 Technical (Hospital) Services Application Short Leg Cast Below Knee-Toe PX-3602940500 CDM 29405 CPT 360 RC inpatient 539 539 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES HDHP [308136802] 426.78 percent of total billed charges 334.18 512.05 Technical (Hospital) Services Application Short Leg Cast Below Knee-Toe PX-3602940500 CDM 29405 CPT 360 RC inpatient 539 539 MEDICA (COMMERCIAL) 94265 [3081118] MEDICA CLAIMS [308111801] 485.1 percent of total billed charges 334.18 512.05 Technical (Hospital) Services Application Short Leg Cast Below Knee-Toe PX-3602940500 CDM 29405 CPT 360 RC inpatient 539 539 HEALTHPARTNERS SX009 HEALTHPARTNERS 426.78 percent of total billed charges 334.18 512.05 Technical (Hospital) Services Application Short Leg Cast Below Knee-Toe PX-3602940500 CDM 29405 CPT 360 RC inpatient 539 539 CIGNA 62308 [3081051] CIGNA 62308 [308105105] 426.78 percent of total billed charges 334.18 512.05 Technical (Hospital) Services Application Short Leg Cast Below Knee-Toe PX-3602940500 CDM 29405 CPT 360 RC inpatient 539 539 CIGNA 62308 [3081051] CIGNA STATE OF WYOMING [308105107] 426.78 percent of total billed charges 334.18 512.05 Technical (Hospital) Services Application Short Leg Cast Below Knee-Toe PX-3602940500 CDM 29405 CPT 360 RC inpatient 539 539 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES EPO [308136803] 426.78 percent of total billed charges 334.18 512.05 Technical (Hospital) Services Application Short Leg Cast Below Knee-Toe PX-3602940500 CDM 29405 CPT 360 RC outpatient 539 539 HEALTHPARTNERS SX009 HEALTHPARTNERS 431.2 percent of total billed charges 334.18 512.05 Technical (Hospital) Services Application Short Leg Cast Below Knee-Toe PX-3602940500 CDM 29405 CPT 360 RC outpatient 539 539 BLUE CROSS BLUE SHIELD WELLMARK SB889 [3081026] BCBS WYOMING [308102603] 512.05 percent of total billed charges 334.18 512.05 Technical (Hospital) Services Application Short Leg Cast Below Knee-Toe PX-3602940500 CDM 29405 CPT 360 RC outpatient 539 539 MULTIPLAN INC 34080 [3081285] MULTIPLAN INC [308128501] 512.05 percent of total billed charges 334.18 512.05 Technical (Hospital) Services Application Short Leg Cast Below Knee-Toe PX-3602940500 CDM 29405 CPT 360 RC outpatient 539 539 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES HDHP [308136802] 431.2 percent of total billed charges 334.18 512.05 Technical (Hospital) Services Application Short Leg Cast Below Knee-Toe PX-3602940500 CDM 29405 CPT 360 RC outpatient 539 539 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES EPO [308136803] 431.2 percent of total billed charges 334.18 512.05 Technical (Hospital) Services Application Short Leg Cast Below Knee-Toe PX-3602940500 CDM 29405 CPT 360 RC outpatient 539 539 UNITED HEALTHCARE (COMMERCIAL) [3081199] UNITED HEALTHCARE 87726 [308119901] 334.18 percent of total billed charges 334.18 512.05 Technical (Hospital) Services Application Short Leg Cast Below Knee-Toe PX-3602940500 CDM 29405 CPT 360 RC outpatient 539 539 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES PPO [308136801] 431.2 percent of total billed charges 334.18 512.05 Technical (Hospital) Services Application Short Leg Cast Below Knee-Toe PX-3602940500 CDM 29405 CPT 360 RC outpatient 539 539 CIGNA 62308 [3081051] CIGNA 62308 [308105105] 431.2 percent of total billed charges 334.18 512.05 Technical (Hospital) Services Application Short Leg Cast Below Knee-Toe PX-3602940500 CDM 29405 CPT 360 RC outpatient 539 539 CIGNA 62308 [3081051] CIGNA STATE OF WYOMING [308105107] 431.2 percent of total billed charges 334.18 512.05 Technical (Hospital) Services Application Short Leg Cast Below Knee-Toe PX-3602940500 CDM 29405 CPT 360 RC outpatient 539 539 MEDICA (COMMERCIAL) 94265 [3081118] MEDICA CLAIMS [308111801] 485.1 percent of total billed charges 334.18 512.05 Technical (Hospital) Services Application Short Arm Splint Forearm-Hand Static PX-3602912500 CDM 29125 CPT 360 RC inpatient 350 350 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES EPO [308136803] 277.13 percent of total billed charges 217 332.5 Technical (Hospital) Services Application Short Arm Splint Forearm-Hand Static PX-3602912500 CDM 29125 CPT 360 RC inpatient 350 350 CIGNA 62308 [3081051] CIGNA 62308 [308105105] 277.13 percent of total billed charges 217 332.5 Technical (Hospital) Services Application Short Arm Splint Forearm-Hand Static PX-3602912500 CDM 29125 CPT 360 RC inpatient 350 350 CIGNA 62308 [3081051] CIGNA STATE OF WYOMING [308105107] 277.13 percent of total billed charges 217 332.5 Technical (Hospital) Services Application Short Arm Splint Forearm-Hand Static PX-3602912500 CDM 29125 CPT 360 RC inpatient 350 350 HEALTHPARTNERS SX009 HEALTHPARTNERS 277.13 percent of total billed charges 217 332.5 Technical (Hospital) Services Application Short Arm Splint Forearm-Hand Static PX-3602912500 CDM 29125 CPT 360 RC inpatient 350 350 MEDICA (COMMERCIAL) 94265 [3081118] MEDICA CLAIMS [308111801] 315 percent of total billed charges 217 332.5 Technical (Hospital) Services Application Short Arm Splint Forearm-Hand Static PX-3602912500 CDM 29125 CPT 360 RC inpatient 350 350 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES HDHP [308136802] 277.13 percent of total billed charges 217 332.5 Technical (Hospital) Services Application Short Arm Splint Forearm-Hand Static PX-3602912500 CDM 29125 CPT 360 RC inpatient 350 350 BLUE CROSS BLUE SHIELD WELLMARK SB889 [3081026] BCBS WYOMING [308102603] 332.5 percent of total billed charges 217 332.5 Technical (Hospital) Services Application Short Arm Splint Forearm-Hand Static PX-3602912500 CDM 29125 CPT 360 RC inpatient 350 350 MULTIPLAN INC 34080 [3081285] MULTIPLAN INC [308128501] 332.5 percent of total billed charges 217 332.5 Technical (Hospital) Services Application Short Arm Splint Forearm-Hand Static PX-3602912500 CDM 29125 CPT 360 RC inpatient 350 350 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES PPO [308136801] 277.13 percent of total billed charges 217 332.5 Technical (Hospital) Services Application Short Arm Splint Forearm-Hand Static PX-3602912500 CDM 29125 CPT 360 RC inpatient 350 350 UNITED HEALTHCARE (COMMERCIAL) [3081199] UNITED HEALTHCARE 87726 [308119901] 217 percent of total billed charges 217 332.5 Technical (Hospital) Services Application Short Arm Splint Forearm-Hand Static PX-3602912500 CDM 29125 CPT 360 RC outpatient 350 350 HEALTHPARTNERS SX009 HEALTHPARTNERS 280 percent of total billed charges 217 332.5 Technical (Hospital) Services Application Short Arm Splint Forearm-Hand Static PX-3602912500 CDM 29125 CPT 360 RC outpatient 350 350 UNITED HEALTHCARE (COMMERCIAL) [3081199] UNITED HEALTHCARE 87726 [308119901] 217 percent of total billed charges 217 332.5 Technical (Hospital) Services Application Short Arm Splint Forearm-Hand Static PX-3602912500 CDM 29125 CPT 360 RC outpatient 350 350 MEDICA (COMMERCIAL) 94265 [3081118] MEDICA CLAIMS [308111801] 315 percent of total billed charges 217 332.5 Technical (Hospital) Services Application Short Arm Splint Forearm-Hand Static PX-3602912500 CDM 29125 CPT 360 RC outpatient 350 350 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES PPO [308136801] 280 percent of total billed charges 217 332.5 Technical (Hospital) Services Application Short Arm Splint Forearm-Hand Static PX-3602912500 CDM 29125 CPT 360 RC outpatient 350 350 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES EPO [308136803] 280 percent of total billed charges 217 332.5 Technical (Hospital) Services Application Short Arm Splint Forearm-Hand Static PX-3602912500 CDM 29125 CPT 360 RC outpatient 350 350 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES HDHP [308136802] 280 percent of total billed charges 217 332.5 Technical (Hospital) Services Application Short Arm Splint Forearm-Hand Static PX-3602912500 CDM 29125 CPT 360 RC outpatient 350 350 MULTIPLAN INC 34080 [3081285] MULTIPLAN INC [308128501] 332.5 percent of total billed charges 217 332.5 Technical (Hospital) Services Application Short Arm Splint Forearm-Hand Static PX-3602912500 CDM 29125 CPT 360 RC outpatient 350 350 BLUE CROSS BLUE SHIELD WELLMARK SB889 [3081026] BCBS WYOMING [308102603] 332.5 percent of total billed charges 217 332.5 Technical (Hospital) Services Application Short Arm Splint Forearm-Hand Static PX-3602912500 CDM 29125 CPT 360 RC outpatient 350 350 CIGNA 62308 [3081051] CIGNA 62308 [308105105] 280 percent of total billed charges 217 332.5 Technical (Hospital) Services Application Short Arm Splint Forearm-Hand Static PX-3602912500 CDM 29125 CPT 360 RC outpatient 350 350 CIGNA 62308 [3081051] CIGNA STATE OF WYOMING [308105107] 280 percent of total billed charges 217 332.5 Technical (Hospital) Services "Apply Forearm Splint,Static" PX-29125 CDM 29125 CPT inpatient 350 350 CIGNA 62308 [3081051] CIGNA 62308 [308105105] 280 percent of total billed charges 217 332.5 Professional (doctor) services "Apply Forearm Splint,Static" PX-29125 CDM 29125 CPT inpatient 350 350 CIGNA 62308 [3081051] CIGNA STATE OF WYOMING [308105107] 280 percent of total billed charges 217 332.5 Professional (doctor) services "Apply Forearm Splint,Static" PX-29125 CDM 29125 CPT outpatient 350 350 CIGNA 62308 [3081051] CIGNA 62308 [308105105] 280 percent of total billed charges 217 332.5 Professional (doctor) services "Apply Forearm Splint,Static" PX-29125 CDM 29125 CPT outpatient 350 350 CIGNA 62308 [3081051] CIGNA STATE OF WYOMING [308105107] 280 percent of total billed charges 217 332.5 Professional (doctor) services "Apply Forearm Splint,Static" PX-29125 CDM 29125 CPT inpatient 350 350 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES EPO [308136803] 280 percent of total billed charges 217 332.5 Professional (doctor) services "Apply Forearm Splint,Static" PX-29125 CDM 29125 CPT inpatient 350 350 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES HDHP [308136802] 280 percent of total billed charges 217 332.5 Professional (doctor) services "Apply Forearm Splint,Static" PX-29125 CDM 29125 CPT inpatient 350 350 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES PPO [308136801] 280 percent of total billed charges 217 332.5 Professional (doctor) services "Apply Forearm Splint,Static" PX-29125 CDM 29125 CPT outpatient 350 350 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES EPO [308136803] 280 percent of total billed charges 217 332.5 Professional (doctor) services "Apply Forearm Splint,Static" PX-29125 CDM 29125 CPT outpatient 350 350 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES HDHP [308136802] 280 percent of total billed charges 217 332.5 Professional (doctor) services "Apply Forearm Splint,Static" PX-29125 CDM 29125 CPT outpatient 350 350 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES PPO [308136801] 280 percent of total billed charges 217 332.5 Professional (doctor) services "Apply Forearm Splint,Static" PX-29125 CDM 29125 CPT inpatient 350 350 HEALTHPARTNERS SX009 HEALTHPARTNERS 280 percent of total billed charges 217 332.5 Professional (doctor) services "Apply Forearm Splint,Static" PX-29125 CDM 29125 CPT outpatient 350 350 HEALTHPARTNERS SX009 HEALTHPARTNERS 280 percent of total billed charges 217 332.5 Professional (doctor) services "Apply Forearm Splint,Static" PX-29125 CDM 29125 CPT inpatient 350 350 MEDICA (COMMERCIAL) 94265 [3081118] MEDICA CLAIMS [308111801] 315 percent of total billed charges 217 332.5 Professional (doctor) services "Apply Forearm Splint,Static" PX-29125 CDM 29125 CPT outpatient 350 350 MEDICA (COMMERCIAL) 94265 [3081118] MEDICA CLAIMS [308111801] 315 percent of total billed charges 217 332.5 Professional (doctor) services "Apply Forearm Splint,Static" PX-29125 CDM 29125 CPT inpatient 350 350 MULTIPLAN INC 34080 [3081285] MULTIPLAN INC [308128501] 332.5 percent of total billed charges 217 332.5 Professional (doctor) services "Apply Forearm Splint,Static" PX-29125 CDM 29125 CPT outpatient 350 350 MULTIPLAN INC 34080 [3081285] MULTIPLAN INC [308128501] 332.5 percent of total billed charges 217 332.5 Professional (doctor) services "Apply Forearm Splint,Static" PX-29125 CDM 29125 CPT inpatient 350 350 UNITED HEALTHCARE (COMMERCIAL) [3081199] UNITED HEALTHCARE 87726 [308119901] 217 percent of total billed charges 217 332.5 Professional (doctor) services "Apply Forearm Splint,Static" PX-29125 CDM 29125 CPT outpatient 350 350 UNITED HEALTHCARE (COMMERCIAL) [3081199] UNITED HEALTHCARE 87726 [308119901] 217 percent of total billed charges 217 332.5 Professional (doctor) services Application Long Arm Splint Shoulder Hand PX-3602910500 CDM 29105 CPT 360 RC inpatient 498 498 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES EPO [308136803] 394.32 percent of total billed charges 308.76 473.1 Technical (Hospital) Services Application Long Arm Splint Shoulder Hand PX-3602910500 CDM 29105 CPT 360 RC inpatient 498 498 CIGNA 62308 [3081051] CIGNA 62308 [308105105] 394.32 percent of total billed charges 308.76 473.1 Technical (Hospital) Services Application Long Arm Splint Shoulder Hand PX-3602910500 CDM 29105 CPT 360 RC inpatient 498 498 CIGNA 62308 [3081051] CIGNA STATE OF WYOMING [308105107] 394.32 percent of total billed charges 308.76 473.1 Technical (Hospital) Services Application Long Arm Splint Shoulder Hand PX-3602910500 CDM 29105 CPT 360 RC inpatient 498 498 HEALTHPARTNERS SX009 HEALTHPARTNERS 394.32 percent of total billed charges 308.76 473.1 Technical (Hospital) Services Application Long Arm Splint Shoulder Hand PX-3602910500 CDM 29105 CPT 360 RC inpatient 498 498 MEDICA (COMMERCIAL) 94265 [3081118] MEDICA CLAIMS [308111801] 448.2 percent of total billed charges 308.76 473.1 Technical (Hospital) Services Application Long Arm Splint Shoulder Hand PX-3602910500 CDM 29105 CPT 360 RC inpatient 498 498 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES HDHP [308136802] 394.32 percent of total billed charges 308.76 473.1 Technical (Hospital) Services Application Long Arm Splint Shoulder Hand PX-3602910500 CDM 29105 CPT 360 RC inpatient 498 498 BLUE CROSS BLUE SHIELD WELLMARK SB889 [3081026] BCBS WYOMING [308102603] 473.1 percent of total billed charges 308.76 473.1 Technical (Hospital) Services Application Long Arm Splint Shoulder Hand PX-3602910500 CDM 29105 CPT 360 RC inpatient 498 498 MULTIPLAN INC 34080 [3081285] MULTIPLAN INC [308128501] 473.1 percent of total billed charges 308.76 473.1 Technical (Hospital) Services Application Long Arm Splint Shoulder Hand PX-3602910500 CDM 29105 CPT 360 RC inpatient 498 498 UNITED HEALTHCARE (COMMERCIAL) [3081199] UNITED HEALTHCARE 87726 [308119901] 308.76 percent of total billed charges 308.76 473.1 Technical (Hospital) Services Application Long Arm Splint Shoulder Hand PX-3602910500 CDM 29105 CPT 360 RC inpatient 498 498 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES PPO [308136801] 394.32 percent of total billed charges 308.76 473.1 Technical (Hospital) Services Application Long Arm Splint Shoulder Hand PX-3602910500 CDM 29105 CPT 360 RC outpatient 498 498 HEALTHPARTNERS SX009 HEALTHPARTNERS 398.4 percent of total billed charges 308.76 473.1 Technical (Hospital) Services Application Long Arm Splint Shoulder Hand PX-3602910500 CDM 29105 CPT 360 RC outpatient 498 498 UNITED HEALTHCARE (COMMERCIAL) [3081199] UNITED HEALTHCARE 87726 [308119901] 308.76 percent of total billed charges 308.76 473.1 Technical (Hospital) Services Application Long Arm Splint Shoulder Hand PX-3602910500 CDM 29105 CPT 360 RC outpatient 498 498 MEDICA (COMMERCIAL) 94265 [3081118] MEDICA CLAIMS [308111801] 448.2 percent of total billed charges 308.76 473.1 Technical (Hospital) Services Application Long Arm Splint Shoulder Hand PX-3602910500 CDM 29105 CPT 360 RC outpatient 498 498 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES PPO [308136801] 398.4 percent of total billed charges 308.76 473.1 Technical (Hospital) Services Application Long Arm Splint Shoulder Hand PX-3602910500 CDM 29105 CPT 360 RC outpatient 498 498 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES EPO [308136803] 398.4 percent of total billed charges 308.76 473.1 Technical (Hospital) Services Application Long Arm Splint Shoulder Hand PX-3602910500 CDM 29105 CPT 360 RC outpatient 498 498 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES HDHP [308136802] 398.4 percent of total billed charges 308.76 473.1 Technical (Hospital) Services Application Long Arm Splint Shoulder Hand PX-3602910500 CDM 29105 CPT 360 RC outpatient 498 498 MULTIPLAN INC 34080 [3081285] MULTIPLAN INC [308128501] 473.1 percent of total billed charges 308.76 473.1 Technical (Hospital) Services Application Long Arm Splint Shoulder Hand PX-3602910500 CDM 29105 CPT 360 RC outpatient 498 498 BLUE CROSS BLUE SHIELD WELLMARK SB889 [3081026] BCBS WYOMING [308102603] 473.1 percent of total billed charges 308.76 473.1 Technical (Hospital) Services Application Long Arm Splint Shoulder Hand PX-3602910500 CDM 29105 CPT 360 RC outpatient 498 498 CIGNA 62308 [3081051] CIGNA 62308 [308105105] 398.4 percent of total billed charges 308.76 473.1 Technical (Hospital) Services Application Long Arm Splint Shoulder Hand PX-3602910500 CDM 29105 CPT 360 RC outpatient 498 498 CIGNA 62308 [3081051] CIGNA STATE OF WYOMING [308105107] 398.4 percent of total billed charges 308.76 473.1 Technical (Hospital) Services Apply Long Arm Splint PX-29105 CDM 29105 CPT inpatient 406 406 CIGNA 62308 [3081051] CIGNA 62308 [308105105] 324.8 percent of total billed charges 251.72 385.7 Professional (doctor) services Apply Long Arm Splint PX-29105 CDM 29105 CPT inpatient 406 406 CIGNA 62308 [3081051] CIGNA STATE OF WYOMING [308105107] 324.8 percent of total billed charges 251.72 385.7 Professional (doctor) services Apply Long Arm Splint PX-29105 CDM 29105 CPT outpatient 406 406 CIGNA 62308 [3081051] CIGNA 62308 [308105105] 324.8 percent of total billed charges 251.72 385.7 Professional (doctor) services Apply Long Arm Splint PX-29105 CDM 29105 CPT outpatient 406 406 CIGNA 62308 [3081051] CIGNA STATE OF WYOMING [308105107] 324.8 percent of total billed charges 251.72 385.7 Professional (doctor) services Apply Long Arm Splint PX-29105 CDM 29105 CPT inpatient 406 406 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES EPO [308136803] 324.8 percent of total billed charges 251.72 385.7 Professional (doctor) services Apply Long Arm Splint PX-29105 CDM 29105 CPT inpatient 406 406 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES HDHP [308136802] 324.8 percent of total billed charges 251.72 385.7 Professional (doctor) services Apply Long Arm Splint PX-29105 CDM 29105 CPT inpatient 406 406 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES PPO [308136801] 324.8 percent of total billed charges 251.72 385.7 Professional (doctor) services Apply Long Arm Splint PX-29105 CDM 29105 CPT outpatient 406 406 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES EPO [308136803] 324.8 percent of total billed charges 251.72 385.7 Professional (doctor) services Apply Long Arm Splint PX-29105 CDM 29105 CPT outpatient 406 406 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES HDHP [308136802] 324.8 percent of total billed charges 251.72 385.7 Professional (doctor) services Apply Long Arm Splint PX-29105 CDM 29105 CPT outpatient 406 406 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES PPO [308136801] 324.8 percent of total billed charges 251.72 385.7 Professional (doctor) services Apply Long Arm Splint PX-29105 CDM 29105 CPT inpatient 406 406 HEALTHPARTNERS SX009 HEALTHPARTNERS 324.8 percent of total billed charges 251.72 385.7 Professional (doctor) services Apply Long Arm Splint PX-29105 CDM 29105 CPT outpatient 406 406 HEALTHPARTNERS SX009 HEALTHPARTNERS 324.8 percent of total billed charges 251.72 385.7 Professional (doctor) services Apply Long Arm Splint PX-29105 CDM 29105 CPT inpatient 406 406 MEDICA (COMMERCIAL) 94265 [3081118] MEDICA CLAIMS [308111801] 365.4 percent of total billed charges 251.72 385.7 Professional (doctor) services Apply Long Arm Splint PX-29105 CDM 29105 CPT outpatient 406 406 MEDICA (COMMERCIAL) 94265 [3081118] MEDICA CLAIMS [308111801] 365.4 percent of total billed charges 251.72 385.7 Professional (doctor) services Apply Long Arm Splint PX-29105 CDM 29105 CPT inpatient 406 406 MULTIPLAN INC 34080 [3081285] MULTIPLAN INC [308128501] 385.7 percent of total billed charges 251.72 385.7 Professional (doctor) services Apply Long Arm Splint PX-29105 CDM 29105 CPT outpatient 406 406 MULTIPLAN INC 34080 [3081285] MULTIPLAN INC [308128501] 385.7 percent of total billed charges 251.72 385.7 Professional (doctor) services Apply Long Arm Splint PX-29105 CDM 29105 CPT inpatient 406 406 UNITED HEALTHCARE (COMMERCIAL) [3081199] UNITED HEALTHCARE 87726 [308119901] 251.72 percent of total billed charges 251.72 385.7 Professional (doctor) services Apply Long Arm Splint PX-29105 CDM 29105 CPT outpatient 406 406 UNITED HEALTHCARE (COMMERCIAL) [3081199] UNITED HEALTHCARE 87726 [308119901] 251.72 percent of total billed charges 251.72 385.7 Professional (doctor) services "Closed Rx I-P Jt,Toe Dislocation" PX-28660 CDM 28660 CPT inpatient 494 494 CIGNA 62308 [3081051] CIGNA 62308 [308105105] 395.2 percent of total billed charges 306.28 469.3 Professional (doctor) services "Closed Rx I-P Jt,Toe Dislocation" PX-28660 CDM 28660 CPT inpatient 494 494 CIGNA 62308 [3081051] CIGNA STATE OF WYOMING [308105107] 395.2 percent of total billed charges 306.28 469.3 Professional (doctor) services "Closed Rx I-P Jt,Toe Dislocation" PX-28660 CDM 28660 CPT outpatient 494 494 CIGNA 62308 [3081051] CIGNA 62308 [308105105] 395.2 percent of total billed charges 306.28 469.3 Professional (doctor) services "Closed Rx I-P Jt,Toe Dislocation" PX-28660 CDM 28660 CPT outpatient 494 494 CIGNA 62308 [3081051] CIGNA STATE OF WYOMING [308105107] 395.2 percent of total billed charges 306.28 469.3 Professional (doctor) services "Closed Rx I-P Jt,Toe Dislocation" PX-28660 CDM 28660 CPT inpatient 494 494 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES EPO [308136803] 395.2 percent of total billed charges 306.28 469.3 Professional (doctor) services "Closed Rx I-P Jt,Toe Dislocation" PX-28660 CDM 28660 CPT inpatient 494 494 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES HDHP [308136802] 395.2 percent of total billed charges 306.28 469.3 Professional (doctor) services "Closed Rx I-P Jt,Toe Dislocation" PX-28660 CDM 28660 CPT inpatient 494 494 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES PPO [308136801] 395.2 percent of total billed charges 306.28 469.3 Professional (doctor) services "Closed Rx I-P Jt,Toe Dislocation" PX-28660 CDM 28660 CPT outpatient 494 494 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES EPO [308136803] 395.2 percent of total billed charges 306.28 469.3 Professional (doctor) services "Closed Rx I-P Jt,Toe Dislocation" PX-28660 CDM 28660 CPT outpatient 494 494 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES HDHP [308136802] 395.2 percent of total billed charges 306.28 469.3 Professional (doctor) services "Closed Rx I-P Jt,Toe Dislocation" PX-28660 CDM 28660 CPT outpatient 494 494 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES PPO [308136801] 395.2 percent of total billed charges 306.28 469.3 Professional (doctor) services "Closed Rx I-P Jt,Toe Dislocation" PX-28660 CDM 28660 CPT inpatient 494 494 HEALTHPARTNERS SX009 HEALTHPARTNERS 395.2 percent of total billed charges 306.28 469.3 Professional (doctor) services "Closed Rx I-P Jt,Toe Dislocation" PX-28660 CDM 28660 CPT outpatient 494 494 HEALTHPARTNERS SX009 HEALTHPARTNERS 395.2 percent of total billed charges 306.28 469.3 Professional (doctor) services "Closed Rx I-P Jt,Toe Dislocation" PX-28660 CDM 28660 CPT inpatient 494 494 MEDICA (COMMERCIAL) 94265 [3081118] MEDICA CLAIMS [308111801] 444.6 percent of total billed charges 306.28 469.3 Professional (doctor) services "Closed Rx I-P Jt,Toe Dislocation" PX-28660 CDM 28660 CPT outpatient 494 494 MEDICA (COMMERCIAL) 94265 [3081118] MEDICA CLAIMS [308111801] 444.6 percent of total billed charges 306.28 469.3 Professional (doctor) services "Closed Rx I-P Jt,Toe Dislocation" PX-28660 CDM 28660 CPT inpatient 494 494 MULTIPLAN INC 34080 [3081285] MULTIPLAN INC [308128501] 469.3 percent of total billed charges 306.28 469.3 Professional (doctor) services "Closed Rx I-P Jt,Toe Dislocation" PX-28660 CDM 28660 CPT outpatient 494 494 MULTIPLAN INC 34080 [3081285] MULTIPLAN INC [308128501] 469.3 percent of total billed charges 306.28 469.3 Professional (doctor) services "Closed Rx I-P Jt,Toe Dislocation" PX-28660 CDM 28660 CPT inpatient 494 494 UNITED HEALTHCARE (COMMERCIAL) [3081199] UNITED HEALTHCARE 87726 [308119901] 306.28 percent of total billed charges 306.28 469.3 Professional (doctor) services "Closed Rx I-P Jt,Toe Dislocation" PX-28660 CDM 28660 CPT outpatient 494 494 UNITED HEALTHCARE (COMMERCIAL) [3081199] UNITED HEALTHCARE 87726 [308119901] 306.28 percent of total billed charges 306.28 469.3 Professional (doctor) services Closed Tx Ankle Dislocation W/O Anesthesia PX-3602784000 CDM 27840 CPT 360 RC outpatient 2004 2004 UNITED HEALTHCARE (COMMERCIAL) [3081199] UNITED HEALTHCARE 87726 [308119901] 1242.48 percent of total billed charges 1242.48 1903.8 Technical (Hospital) Services Closed Tx Ankle Dislocation W/O Anesthesia PX-3602784000 CDM 27840 CPT 360 RC outpatient 2004 2004 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES EPO [308136803] 1603.2 percent of total billed charges 1242.48 1903.8 Technical (Hospital) Services Closed Tx Ankle Dislocation W/O Anesthesia PX-3602784000 CDM 27840 CPT 360 RC outpatient 2004 2004 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES PPO [308136801] 1603.2 percent of total billed charges 1242.48 1903.8 Technical (Hospital) Services Closed Tx Ankle Dislocation W/O Anesthesia PX-3602784000 CDM 27840 CPT 360 RC outpatient 2004 2004 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES HDHP [308136802] 1603.2 percent of total billed charges 1242.48 1903.8 Technical (Hospital) Services Closed Tx Ankle Dislocation W/O Anesthesia PX-3602784000 CDM 27840 CPT 360 RC outpatient 2004 2004 MULTIPLAN INC 34080 [3081285] MULTIPLAN INC [308128501] 1903.8 percent of total billed charges 1242.48 1903.8 Technical (Hospital) Services Closed Tx Ankle Dislocation W/O Anesthesia PX-3602784000 CDM 27840 CPT 360 RC outpatient 2004 2004 BLUE CROSS BLUE SHIELD WELLMARK SB889 [3081026] BCBS WYOMING [308102603] 1903.8 percent of total billed charges 1242.48 1903.8 Technical (Hospital) Services Closed Tx Ankle Dislocation W/O Anesthesia PX-3602784000 CDM 27840 CPT 360 RC outpatient 2004 2004 HEALTHPARTNERS SX009 HEALTHPARTNERS 1603.2 percent of total billed charges 1242.48 1903.8 Technical (Hospital) Services Closed Tx Ankle Dislocation W/O Anesthesia PX-3602784000 CDM 27840 CPT 360 RC outpatient 2004 2004 CIGNA 62308 [3081051] CIGNA 62308 [308105105] 1603.2 percent of total billed charges 1242.48 1903.8 Technical (Hospital) Services Closed Tx Ankle Dislocation W/O Anesthesia PX-3602784000 CDM 27840 CPT 360 RC outpatient 2004 2004 CIGNA 62308 [3081051] CIGNA STATE OF WYOMING [308105107] 1603.2 percent of total billed charges 1242.48 1903.8 Technical (Hospital) Services Closed Tx Ankle Dislocation W/O Anesthesia PX-3602784000 CDM 27840 CPT 360 RC outpatient 2004 2004 MEDICA (COMMERCIAL) 94265 [3081118] MEDICA CLAIMS [308111801] 1803.6 percent of total billed charges 1242.48 1903.8 Technical (Hospital) Services Closed Tx Ankle Dislocation W/O Anesthesia PX-3602784000 CDM 27840 CPT 360 RC inpatient 2004 2004 CIGNA 62308 [3081051] CIGNA 62308 [308105105] 1586.77 percent of total billed charges 1242.48 1903.8 Technical (Hospital) Services Closed Tx Ankle Dislocation W/O Anesthesia PX-3602784000 CDM 27840 CPT 360 RC inpatient 2004 2004 CIGNA 62308 [3081051] CIGNA STATE OF WYOMING [308105107] 1586.77 percent of total billed charges 1242.48 1903.8 Technical (Hospital) Services Closed Tx Ankle Dislocation W/O Anesthesia PX-3602784000 CDM 27840 CPT 360 RC inpatient 2004 2004 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES EPO [308136803] 1586.77 percent of total billed charges 1242.48 1903.8 Technical (Hospital) Services Closed Tx Ankle Dislocation W/O Anesthesia PX-3602784000 CDM 27840 CPT 360 RC inpatient 2004 2004 MULTIPLAN INC 34080 [3081285] MULTIPLAN INC [308128501] 1903.8 percent of total billed charges 1242.48 1903.8 Technical (Hospital) Services Closed Tx Ankle Dislocation W/O Anesthesia PX-3602784000 CDM 27840 CPT 360 RC inpatient 2004 2004 BLUE CROSS BLUE SHIELD WELLMARK SB889 [3081026] BCBS WYOMING [308102603] 1903.8 percent of total billed charges 1242.48 1903.8 Technical (Hospital) Services Closed Tx Ankle Dislocation W/O Anesthesia PX-3602784000 CDM 27840 CPT 360 RC inpatient 2004 2004 UNITED HEALTHCARE (COMMERCIAL) [3081199] UNITED HEALTHCARE 87726 [308119901] 1242.48 percent of total billed charges 1242.48 1903.8 Technical (Hospital) Services Closed Tx Ankle Dislocation W/O Anesthesia PX-3602784000 CDM 27840 CPT 360 RC inpatient 2004 2004 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES PPO [308136801] 1586.77 percent of total billed charges 1242.48 1903.8 Technical (Hospital) Services Closed Tx Ankle Dislocation W/O Anesthesia PX-3602784000 CDM 27840 CPT 360 RC inpatient 2004 2004 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES HDHP [308136802] 1586.77 percent of total billed charges 1242.48 1903.8 Technical (Hospital) Services Closed Tx Ankle Dislocation W/O Anesthesia PX-3602784000 CDM 27840 CPT 360 RC inpatient 2004 2004 MEDICA (COMMERCIAL) 94265 [3081118] MEDICA CLAIMS [308111801] 1803.6 percent of total billed charges 1242.48 1903.8 Technical (Hospital) Services Closed Tx Ankle Dislocation W/O Anesthesia PX-3602784000 CDM 27840 CPT 360 RC inpatient 2004 2004 HEALTHPARTNERS SX009 HEALTHPARTNERS 1586.77 percent of total billed charges 1242.48 1903.8 Technical (Hospital) Services Closed Tx Bimalleolar Ankle Fracture W/Manj PX-3602781000 CDM 27810 CPT 360 RC inpatient 2079 2079 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES HDHP [308136802] 1646.15 percent of total billed charges 1288.98 1975.05 Technical (Hospital) Services Closed Tx Bimalleolar Ankle Fracture W/Manj PX-3602781000 CDM 27810 CPT 360 RC inpatient 2079 2079 MEDICA (COMMERCIAL) 94265 [3081118] MEDICA CLAIMS [308111801] 1871.1 percent of total billed charges 1288.98 1975.05 Technical (Hospital) Services Closed Tx Bimalleolar Ankle Fracture W/Manj PX-3602781000 CDM 27810 CPT 360 RC inpatient 2079 2079 HEALTHPARTNERS SX009 HEALTHPARTNERS 1646.15 percent of total billed charges 1288.98 1975.05 Technical (Hospital) Services Closed Tx Bimalleolar Ankle Fracture W/Manj PX-3602781000 CDM 27810 CPT 360 RC inpatient 2079 2079 UNITED HEALTHCARE (COMMERCIAL) [3081199] UNITED HEALTHCARE 87726 [308119901] 1288.98 percent of total billed charges 1288.98 1975.05 Technical (Hospital) Services Closed Tx Bimalleolar Ankle Fracture W/Manj PX-3602781000 CDM 27810 CPT 360 RC inpatient 2079 2079 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES PPO [308136801] 1646.15 percent of total billed charges 1288.98 1975.05 Technical (Hospital) Services Closed Tx Bimalleolar Ankle Fracture W/Manj PX-3602781000 CDM 27810 CPT 360 RC inpatient 2079 2079 MULTIPLAN INC 34080 [3081285] MULTIPLAN INC [308128501] 1975.05 percent of total billed charges 1288.98 1975.05 Technical (Hospital) Services Closed Tx Bimalleolar Ankle Fracture W/Manj PX-3602781000 CDM 27810 CPT 360 RC inpatient 2079 2079 BLUE CROSS BLUE SHIELD WELLMARK SB889 [3081026] BCBS WYOMING [308102603] 1975.05 percent of total billed charges 1288.98 1975.05 Technical (Hospital) Services Closed Tx Bimalleolar Ankle Fracture W/Manj PX-3602781000 CDM 27810 CPT 360 RC inpatient 2079 2079 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES EPO [308136803] 1646.15 percent of total billed charges 1288.98 1975.05 Technical (Hospital) Services Closed Tx Bimalleolar Ankle Fracture W/Manj PX-3602781000 CDM 27810 CPT 360 RC outpatient 2079 2079 BLUE CROSS BLUE SHIELD WELLMARK SB889 [3081026] BCBS WYOMING [308102603] 1975.05 percent of total billed charges 1288.98 1975.05 Technical (Hospital) Services Closed Tx Bimalleolar Ankle Fracture W/Manj PX-3602781000 CDM 27810 CPT 360 RC outpatient 2079 2079 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES HDHP [308136802] 1663.2 percent of total billed charges 1288.98 1975.05 Technical (Hospital) Services Closed Tx Bimalleolar Ankle Fracture W/Manj PX-3602781000 CDM 27810 CPT 360 RC outpatient 2079 2079 MULTIPLAN INC 34080 [3081285] MULTIPLAN INC [308128501] 1975.05 percent of total billed charges 1288.98 1975.05 Technical (Hospital) Services Closed Tx Bimalleolar Ankle Fracture W/Manj PX-3602781000 CDM 27810 CPT 360 RC outpatient 2079 2079 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES PPO [308136801] 1663.2 percent of total billed charges 1288.98 1975.05 Technical (Hospital) Services Closed Tx Bimalleolar Ankle Fracture W/Manj PX-3602781000 CDM 27810 CPT 360 RC outpatient 2079 2079 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES EPO [308136803] 1663.2 percent of total billed charges 1288.98 1975.05 Technical (Hospital) Services Closed Tx Bimalleolar Ankle Fracture W/Manj PX-3602781000 CDM 27810 CPT 360 RC outpatient 2079 2079 MEDICA (COMMERCIAL) 94265 [3081118] MEDICA CLAIMS [308111801] 1871.1 percent of total billed charges 1288.98 1975.05 Technical (Hospital) Services Closed Tx Bimalleolar Ankle Fracture W/Manj PX-3602781000 CDM 27810 CPT 360 RC outpatient 2079 2079 UNITED HEALTHCARE (COMMERCIAL) [3081199] UNITED HEALTHCARE 87726 [308119901] 1288.98 percent of total billed charges 1288.98 1975.05 Technical (Hospital) Services Closed Tx Bimalleolar Ankle Fracture W/Manj PX-3602781000 CDM 27810 CPT 360 RC outpatient 2079 2079 HEALTHPARTNERS SX009 HEALTHPARTNERS 1663.2 percent of total billed charges 1288.98 1975.05 Technical (Hospital) Services Closed Tx Bimalleolar Ankle Fracture W/Manj PX-3602781000 CDM 27810 CPT 360 RC outpatient 2079 2079 CIGNA 62308 [3081051] CIGNA 62308 [308105105] 1663.2 percent of total billed charges 1288.98 1975.05 Technical (Hospital) Services Closed Tx Bimalleolar Ankle Fracture W/Manj PX-3602781000 CDM 27810 CPT 360 RC inpatient 2079 2079 CIGNA 62308 [3081051] CIGNA 62308 [308105105] 1646.15 percent of total billed charges 1288.98 1975.05 Technical (Hospital) Services Closed Tx Bimalleolar Ankle Fracture W/Manj PX-3602781000 CDM 27810 CPT 360 RC inpatient 2079 2079 CIGNA 62308 [3081051] CIGNA STATE OF WYOMING [308105107] 1646.15 percent of total billed charges 1288.98 1975.05 Technical (Hospital) Services Closed Tx Bimalleolar Ankle Fracture W/Manj PX-3602781000 CDM 27810 CPT 360 RC outpatient 2079 2079 CIGNA 62308 [3081051] CIGNA STATE OF WYOMING [308105107] 1663.2 percent of total billed charges 1288.98 1975.05 Technical (Hospital) Services Closed Tx Bimalleolar Ankle Fracture W Manip PX-27810 CDM 27810 CPT inpatient 2563 2563 CIGNA 62308 [3081051] CIGNA 62308 [308105105] 2050.4 percent of total billed charges 1589.06 2434.85 Professional (doctor) services Closed Tx Bimalleolar Ankle Fracture W Manip PX-27810 CDM 27810 CPT inpatient 2563 2563 CIGNA 62308 [3081051] CIGNA STATE OF WYOMING [308105107] 2050.4 percent of total billed charges 1589.06 2434.85 Professional (doctor) services Closed Tx Bimalleolar Ankle Fracture W Manip PX-27810 CDM 27810 CPT outpatient 2563 2563 CIGNA 62308 [3081051] CIGNA 62308 [308105105] 2050.4 percent of total billed charges 1589.06 2434.85 Professional (doctor) services Closed Tx Bimalleolar Ankle Fracture W Manip PX-27810 CDM 27810 CPT outpatient 2563 2563 CIGNA 62308 [3081051] CIGNA STATE OF WYOMING [308105107] 2050.4 percent of total billed charges 1589.06 2434.85 Professional (doctor) services Closed Tx Bimalleolar Ankle Fracture W Manip PX-27810 CDM 27810 CPT inpatient 2563 2563 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES EPO [308136803] 2050.4 percent of total billed charges 1589.06 2434.85 Professional (doctor) services Closed Tx Bimalleolar Ankle Fracture W Manip PX-27810 CDM 27810 CPT inpatient 2563 2563 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES HDHP [308136802] 2050.4 percent of total billed charges 1589.06 2434.85 Professional (doctor) services Closed Tx Bimalleolar Ankle Fracture W Manip PX-27810 CDM 27810 CPT inpatient 2563 2563 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES PPO [308136801] 2050.4 percent of total billed charges 1589.06 2434.85 Professional (doctor) services Closed Tx Bimalleolar Ankle Fracture W Manip PX-27810 CDM 27810 CPT outpatient 2563 2563 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES EPO [308136803] 2050.4 percent of total billed charges 1589.06 2434.85 Professional (doctor) services Closed Tx Bimalleolar Ankle Fracture W Manip PX-27810 CDM 27810 CPT outpatient 2563 2563 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES HDHP [308136802] 2050.4 percent of total billed charges 1589.06 2434.85 Professional (doctor) services Closed Tx Bimalleolar Ankle Fracture W Manip PX-27810 CDM 27810 CPT outpatient 2563 2563 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES PPO [308136801] 2050.4 percent of total billed charges 1589.06 2434.85 Professional (doctor) services Closed Tx Bimalleolar Ankle Fracture W Manip PX-27810 CDM 27810 CPT inpatient 2563 2563 HEALTHPARTNERS SX009 HEALTHPARTNERS 2050.4 percent of total billed charges 1589.06 2434.85 Professional (doctor) services Closed Tx Bimalleolar Ankle Fracture W Manip PX-27810 CDM 27810 CPT outpatient 2563 2563 HEALTHPARTNERS SX009 HEALTHPARTNERS 2050.4 percent of total billed charges 1589.06 2434.85 Professional (doctor) services Closed Tx Bimalleolar Ankle Fracture W Manip PX-27810 CDM 27810 CPT inpatient 2563 2563 MEDICA (COMMERCIAL) 94265 [3081118] MEDICA CLAIMS [308111801] 2306.7 percent of total billed charges 1589.06 2434.85 Professional (doctor) services Closed Tx Bimalleolar Ankle Fracture W Manip PX-27810 CDM 27810 CPT outpatient 2563 2563 MEDICA (COMMERCIAL) 94265 [3081118] MEDICA CLAIMS [308111801] 2306.7 percent of total billed charges 1589.06 2434.85 Professional (doctor) services Closed Tx Bimalleolar Ankle Fracture W Manip PX-27810 CDM 27810 CPT inpatient 2563 2563 MULTIPLAN INC 34080 [3081285] MULTIPLAN INC [308128501] 2434.85 percent of total billed charges 1589.06 2434.85 Professional (doctor) services Closed Tx Bimalleolar Ankle Fracture W Manip PX-27810 CDM 27810 CPT outpatient 2563 2563 MULTIPLAN INC 34080 [3081285] MULTIPLAN INC [308128501] 2434.85 percent of total billed charges 1589.06 2434.85 Professional (doctor) services Closed Tx Bimalleolar Ankle Fracture W Manip PX-27810 CDM 27810 CPT inpatient 2563 2563 UNITED HEALTHCARE (COMMERCIAL) [3081199] UNITED HEALTHCARE 87726 [308119901] 1589.06 percent of total billed charges 1589.06 2434.85 Professional (doctor) services Closed Tx Bimalleolar Ankle Fracture W Manip PX-27810 CDM 27810 CPT outpatient 2563 2563 UNITED HEALTHCARE (COMMERCIAL) [3081199] UNITED HEALTHCARE 87726 [308119901] 1589.06 percent of total billed charges 1589.06 2434.85 Professional (doctor) services Closed Rx Kneecap Dislocatn PX-27560 CDM 27560 CPT inpatient 1148 1148 CIGNA 62308 [3081051] CIGNA 62308 [308105105] 918.4 percent of total billed charges 711.76 1090.6 Professional (doctor) services Closed Rx Kneecap Dislocatn PX-27560 CDM 27560 CPT inpatient 1148 1148 CIGNA 62308 [3081051] CIGNA STATE OF WYOMING [308105107] 918.4 percent of total billed charges 711.76 1090.6 Professional (doctor) services Closed Rx Kneecap Dislocatn PX-27560 CDM 27560 CPT outpatient 1148 1148 CIGNA 62308 [3081051] CIGNA 62308 [308105105] 918.4 percent of total billed charges 711.76 1090.6 Professional (doctor) services Closed Rx Kneecap Dislocatn PX-27560 CDM 27560 CPT outpatient 1148 1148 CIGNA 62308 [3081051] CIGNA STATE OF WYOMING [308105107] 918.4 percent of total billed charges 711.76 1090.6 Professional (doctor) services Closed Rx Kneecap Dislocatn PX-27560 CDM 27560 CPT inpatient 1148 1148 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES EPO [308136803] 918.4 percent of total billed charges 711.76 1090.6 Professional (doctor) services Closed Rx Kneecap Dislocatn PX-27560 CDM 27560 CPT inpatient 1148 1148 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES HDHP [308136802] 918.4 percent of total billed charges 711.76 1090.6 Professional (doctor) services Closed Rx Kneecap Dislocatn PX-27560 CDM 27560 CPT inpatient 1148 1148 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES PPO [308136801] 918.4 percent of total billed charges 711.76 1090.6 Professional (doctor) services Closed Rx Kneecap Dislocatn PX-27560 CDM 27560 CPT outpatient 1148 1148 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES EPO [308136803] 918.4 percent of total billed charges 711.76 1090.6 Professional (doctor) services Closed Rx Kneecap Dislocatn PX-27560 CDM 27560 CPT outpatient 1148 1148 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES HDHP [308136802] 918.4 percent of total billed charges 711.76 1090.6 Professional (doctor) services Closed Rx Kneecap Dislocatn PX-27560 CDM 27560 CPT outpatient 1148 1148 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES PPO [308136801] 918.4 percent of total billed charges 711.76 1090.6 Professional (doctor) services Closed Rx Kneecap Dislocatn PX-27560 CDM 27560 CPT inpatient 1148 1148 HEALTHPARTNERS SX009 HEALTHPARTNERS 918.4 percent of total billed charges 711.76 1090.6 Professional (doctor) services Closed Rx Kneecap Dislocatn PX-27560 CDM 27560 CPT outpatient 1148 1148 HEALTHPARTNERS SX009 HEALTHPARTNERS 918.4 percent of total billed charges 711.76 1090.6 Professional (doctor) services Closed Rx Kneecap Dislocatn PX-27560 CDM 27560 CPT inpatient 1148 1148 MEDICA (COMMERCIAL) 94265 [3081118] MEDICA CLAIMS [308111801] 1033.2 percent of total billed charges 711.76 1090.6 Professional (doctor) services Closed Rx Kneecap Dislocatn PX-27560 CDM 27560 CPT outpatient 1148 1148 MEDICA (COMMERCIAL) 94265 [3081118] MEDICA CLAIMS [308111801] 1033.2 percent of total billed charges 711.76 1090.6 Professional (doctor) services Closed Rx Kneecap Dislocatn PX-27560 CDM 27560 CPT inpatient 1148 1148 MULTIPLAN INC 34080 [3081285] MULTIPLAN INC [308128501] 1090.6 percent of total billed charges 711.76 1090.6 Professional (doctor) services Closed Rx Kneecap Dislocatn PX-27560 CDM 27560 CPT outpatient 1148 1148 MULTIPLAN INC 34080 [3081285] MULTIPLAN INC [308128501] 1090.6 percent of total billed charges 711.76 1090.6 Professional (doctor) services Closed Rx Kneecap Dislocatn PX-27560 CDM 27560 CPT inpatient 1148 1148 UNITED HEALTHCARE (COMMERCIAL) [3081199] UNITED HEALTHCARE 87726 [308119901] 711.76 percent of total billed charges 711.76 1090.6 Professional (doctor) services Closed Rx Kneecap Dislocatn PX-27560 CDM 27560 CPT outpatient 1148 1148 UNITED HEALTHCARE (COMMERCIAL) [3081199] UNITED HEALTHCARE 87726 [308119901] 711.76 percent of total billed charges 711.76 1090.6 Professional (doctor) services Closed Tx Knee Dislocation W/O Anesthesia PX-3602755000 CDM 27550 CPT 360 RC outpatient 2620 2620 CIGNA 62308 [3081051] CIGNA 62308 [308105105] 2096 percent of total billed charges 1624.4 2489 Technical (Hospital) Services Closed Tx Knee Dislocation W/O Anesthesia PX-3602755000 CDM 27550 CPT 360 RC outpatient 2620 2620 CIGNA 62308 [3081051] CIGNA STATE OF WYOMING [308105107] 2096 percent of total billed charges 1624.4 2489 Technical (Hospital) Services Closed Tx Knee Dislocation W/O Anesthesia PX-3602755000 CDM 27550 CPT 360 RC outpatient 2620 2620 HEALTHPARTNERS SX009 HEALTHPARTNERS 2096 percent of total billed charges 1624.4 2489 Technical (Hospital) Services Closed Tx Knee Dislocation W/O Anesthesia PX-3602755000 CDM 27550 CPT 360 RC outpatient 2620 2620 MEDICA (COMMERCIAL) 94265 [3081118] MEDICA CLAIMS [308111801] 2358 percent of total billed charges 1624.4 2489 Technical (Hospital) Services Closed Tx Knee Dislocation W/O Anesthesia PX-3602755000 CDM 27550 CPT 360 RC outpatient 2620 2620 BLUE CROSS BLUE SHIELD WELLMARK SB889 [3081026] BCBS WYOMING [308102603] 2489 percent of total billed charges 1624.4 2489 Technical (Hospital) Services Closed Tx Knee Dislocation W/O Anesthesia PX-3602755000 CDM 27550 CPT 360 RC outpatient 2620 2620 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES HDHP [308136802] 2096 percent of total billed charges 1624.4 2489 Technical (Hospital) Services Closed Tx Knee Dislocation W/O Anesthesia PX-3602755000 CDM 27550 CPT 360 RC outpatient 2620 2620 MULTIPLAN INC 34080 [3081285] MULTIPLAN INC [308128501] 2489 percent of total billed charges 1624.4 2489 Technical (Hospital) Services Closed Tx Knee Dislocation W/O Anesthesia PX-3602755000 CDM 27550 CPT 360 RC outpatient 2620 2620 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES EPO [308136803] 2096 percent of total billed charges 1624.4 2489 Technical (Hospital) Services Closed Tx Knee Dislocation W/O Anesthesia PX-3602755000 CDM 27550 CPT 360 RC outpatient 2620 2620 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES PPO [308136801] 2096 percent of total billed charges 1624.4 2489 Technical (Hospital) Services Closed Tx Knee Dislocation W/O Anesthesia PX-3602755000 CDM 27550 CPT 360 RC outpatient 2620 2620 UNITED HEALTHCARE (COMMERCIAL) [3081199] UNITED HEALTHCARE 87726 [308119901] 1624.4 percent of total billed charges 1624.4 2489 Technical (Hospital) Services Closed Tx Knee Dislocation W/O Anesthesia PX-3602755000 CDM 27550 CPT 360 RC inpatient 2620 2620 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES EPO [308136803] 2074.52 percent of total billed charges 1624.4 2489 Technical (Hospital) Services Closed Tx Knee Dislocation W/O Anesthesia PX-3602755000 CDM 27550 CPT 360 RC inpatient 2620 2620 CIGNA 62308 [3081051] CIGNA 62308 [308105105] 2074.52 percent of total billed charges 1624.4 2489 Technical (Hospital) Services Closed Tx Knee Dislocation W/O Anesthesia PX-3602755000 CDM 27550 CPT 360 RC inpatient 2620 2620 CIGNA 62308 [3081051] CIGNA STATE OF WYOMING [308105107] 2074.52 percent of total billed charges 1624.4 2489 Technical (Hospital) Services Closed Tx Knee Dislocation W/O Anesthesia PX-3602755000 CDM 27550 CPT 360 RC inpatient 2620 2620 BLUE CROSS BLUE SHIELD WELLMARK SB889 [3081026] BCBS WYOMING [308102603] 2489 percent of total billed charges 1624.4 2489 Technical (Hospital) Services Closed Tx Knee Dislocation W/O Anesthesia PX-3602755000 CDM 27550 CPT 360 RC inpatient 2620 2620 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES HDHP [308136802] 2074.52 percent of total billed charges 1624.4 2489 Technical (Hospital) Services Closed Tx Knee Dislocation W/O Anesthesia PX-3602755000 CDM 27550 CPT 360 RC inpatient 2620 2620 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES PPO [308136801] 2074.52 percent of total billed charges 1624.4 2489 Technical (Hospital) Services Closed Tx Knee Dislocation W/O Anesthesia PX-3602755000 CDM 27550 CPT 360 RC inpatient 2620 2620 UNITED HEALTHCARE (COMMERCIAL) [3081199] UNITED HEALTHCARE 87726 [308119901] 1624.4 percent of total billed charges 1624.4 2489 Technical (Hospital) Services Closed Tx Knee Dislocation W/O Anesthesia PX-3602755000 CDM 27550 CPT 360 RC inpatient 2620 2620 MULTIPLAN INC 34080 [3081285] MULTIPLAN INC [308128501] 2489 percent of total billed charges 1624.4 2489 Technical (Hospital) Services Closed Tx Knee Dislocation W/O Anesthesia PX-3602755000 CDM 27550 CPT 360 RC inpatient 2620 2620 MEDICA (COMMERCIAL) 94265 [3081118] MEDICA CLAIMS [308111801] 2358 percent of total billed charges 1624.4 2489 Technical (Hospital) Services Closed Tx Knee Dislocation W/O Anesthesia PX-3602755000 CDM 27550 CPT 360 RC inpatient 2620 2620 HEALTHPARTNERS SX009 HEALTHPARTNERS 2074.52 percent of total billed charges 1624.4 2489 Technical (Hospital) Services Closed Rx Knee Dislocatn PX-27550 CDM 27550 CPT inpatient 2620 2620 CIGNA 62308 [3081051] CIGNA 62308 [308105105] 2096 percent of total billed charges 1624.4 2489 Professional (doctor) services Closed Rx Knee Dislocatn PX-27550 CDM 27550 CPT inpatient 2620 2620 CIGNA 62308 [3081051] CIGNA STATE OF WYOMING [308105107] 2096 percent of total billed charges 1624.4 2489 Professional (doctor) services Closed Rx Knee Dislocatn PX-27550 CDM 27550 CPT outpatient 2620 2620 CIGNA 62308 [3081051] CIGNA 62308 [308105105] 2096 percent of total billed charges 1624.4 2489 Professional (doctor) services Closed Rx Knee Dislocatn PX-27550 CDM 27550 CPT outpatient 2620 2620 CIGNA 62308 [3081051] CIGNA STATE OF WYOMING [308105107] 2096 percent of total billed charges 1624.4 2489 Professional (doctor) services Closed Rx Knee Dislocatn PX-27550 CDM 27550 CPT inpatient 2620 2620 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES EPO [308136803] 2096 percent of total billed charges 1624.4 2489 Professional (doctor) services Closed Rx Knee Dislocatn PX-27550 CDM 27550 CPT inpatient 2620 2620 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES HDHP [308136802] 2096 percent of total billed charges 1624.4 2489 Professional (doctor) services Closed Rx Knee Dislocatn PX-27550 CDM 27550 CPT inpatient 2620 2620 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES PPO [308136801] 2096 percent of total billed charges 1624.4 2489 Professional (doctor) services Closed Rx Knee Dislocatn PX-27550 CDM 27550 CPT outpatient 2620 2620 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES EPO [308136803] 2096 percent of total billed charges 1624.4 2489 Professional (doctor) services Closed Rx Knee Dislocatn PX-27550 CDM 27550 CPT outpatient 2620 2620 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES HDHP [308136802] 2096 percent of total billed charges 1624.4 2489 Professional (doctor) services Closed Rx Knee Dislocatn PX-27550 CDM 27550 CPT outpatient 2620 2620 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES PPO [308136801] 2096 percent of total billed charges 1624.4 2489 Professional (doctor) services Closed Rx Knee Dislocatn PX-27550 CDM 27550 CPT inpatient 2620 2620 HEALTHPARTNERS SX009 HEALTHPARTNERS 2096 percent of total billed charges 1624.4 2489 Professional (doctor) services Closed Rx Knee Dislocatn PX-27550 CDM 27550 CPT outpatient 2620 2620 HEALTHPARTNERS SX009 HEALTHPARTNERS 2096 percent of total billed charges 1624.4 2489 Professional (doctor) services Closed Rx Knee Dislocatn PX-27550 CDM 27550 CPT inpatient 2620 2620 MEDICA (COMMERCIAL) 94265 [3081118] MEDICA CLAIMS [308111801] 2358 percent of total billed charges 1624.4 2489 Professional (doctor) services Closed Rx Knee Dislocatn PX-27550 CDM 27550 CPT outpatient 2620 2620 MEDICA (COMMERCIAL) 94265 [3081118] MEDICA CLAIMS [308111801] 2358 percent of total billed charges 1624.4 2489 Professional (doctor) services Closed Rx Knee Dislocatn PX-27550 CDM 27550 CPT inpatient 2620 2620 MULTIPLAN INC 34080 [3081285] MULTIPLAN INC [308128501] 2489 percent of total billed charges 1624.4 2489 Professional (doctor) services Closed Rx Knee Dislocatn PX-27550 CDM 27550 CPT outpatient 2620 2620 MULTIPLAN INC 34080 [3081285] MULTIPLAN INC [308128501] 2489 percent of total billed charges 1624.4 2489 Professional (doctor) services Closed Rx Knee Dislocatn PX-27550 CDM 27550 CPT inpatient 2620 2620 UNITED HEALTHCARE (COMMERCIAL) [3081199] UNITED HEALTHCARE 87726 [308119901] 1624.4 percent of total billed charges 1624.4 2489 Professional (doctor) services Closed Rx Knee Dislocatn PX-27550 CDM 27550 CPT outpatient 2620 2620 UNITED HEALTHCARE (COMMERCIAL) [3081199] UNITED HEALTHCARE 87726 [308119901] 1624.4 percent of total billed charges 1624.4 2489 Professional (doctor) services Cltx Iphal Jt Dislc W/Manj W/O Anes PX-3602677000 CDM 26770 CPT 360 RC inpatient 1403 1403 MULTIPLAN INC 34080 [3081285] MULTIPLAN INC [308128501] 1332.85 percent of total billed charges 869.86 1332.85 Technical (Hospital) Services Cltx Iphal Jt Dislc W/Manj W/O Anes PX-3602677000 CDM 26770 CPT 360 RC inpatient 1403 1403 BLUE CROSS BLUE SHIELD WELLMARK SB889 [3081026] BCBS WYOMING [308102603] 1332.85 percent of total billed charges 869.86 1332.85 Technical (Hospital) Services Cltx Iphal Jt Dislc W/Manj W/O Anes PX-3602677000 CDM 26770 CPT 360 RC inpatient 1403 1403 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES PPO [308136801] 1110.9 percent of total billed charges 869.86 1332.85 Technical (Hospital) Services Cltx Iphal Jt Dislc W/Manj W/O Anes PX-3602677000 CDM 26770 CPT 360 RC inpatient 1403 1403 UNITED HEALTHCARE (COMMERCIAL) [3081199] UNITED HEALTHCARE 87726 [308119901] 869.86 percent of total billed charges 869.86 1332.85 Technical (Hospital) Services Cltx Iphal Jt Dislc W/Manj W/O Anes PX-3602677000 CDM 26770 CPT 360 RC inpatient 1403 1403 HEALTHPARTNERS SX009 HEALTHPARTNERS 1110.9 percent of total billed charges 869.86 1332.85 Technical (Hospital) Services Cltx Iphal Jt Dislc W/Manj W/O Anes PX-3602677000 CDM 26770 CPT 360 RC inpatient 1403 1403 MEDICA (COMMERCIAL) 94265 [3081118] MEDICA CLAIMS [308111801] 1262.7 percent of total billed charges 869.86 1332.85 Technical (Hospital) Services Cltx Iphal Jt Dislc W/Manj W/O Anes PX-3602677000 CDM 26770 CPT 360 RC inpatient 1403 1403 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES HDHP [308136802] 1110.9 percent of total billed charges 869.86 1332.85 Technical (Hospital) Services Cltx Iphal Jt Dislc W/Manj W/O Anes PX-3602677000 CDM 26770 CPT 360 RC inpatient 1403 1403 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES EPO [308136803] 1110.9 percent of total billed charges 869.86 1332.85 Technical (Hospital) Services Cltx Iphal Jt Dislc W/Manj W/O Anes PX-3602677000 CDM 26770 CPT 360 RC inpatient 1403 1403 CIGNA 62308 [3081051] CIGNA 62308 [308105105] 1110.9 percent of total billed charges 869.86 1332.85 Technical (Hospital) Services Cltx Iphal Jt Dislc W/Manj W/O Anes PX-3602677000 CDM 26770 CPT 360 RC inpatient 1403 1403 CIGNA 62308 [3081051] CIGNA STATE OF WYOMING [308105107] 1110.9 percent of total billed charges 869.86 1332.85 Technical (Hospital) Services Cltx Iphal Jt Dislc W/Manj W/O Anes PX-3602677000 CDM 26770 CPT 360 RC outpatient 1403 1403 CIGNA 62308 [3081051] CIGNA 62308 [308105105] 1122.4 percent of total billed charges 869.86 1332.85 Technical (Hospital) Services Cltx Iphal Jt Dislc W/Manj W/O Anes PX-3602677000 CDM 26770 CPT 360 RC outpatient 1403 1403 CIGNA 62308 [3081051] CIGNA STATE OF WYOMING [308105107] 1122.4 percent of total billed charges 869.86 1332.85 Technical (Hospital) Services Cltx Iphal Jt Dislc W/Manj W/O Anes PX-3602677000 CDM 26770 CPT 360 RC outpatient 1403 1403 HEALTHPARTNERS SX009 HEALTHPARTNERS 1122.4 percent of total billed charges 869.86 1332.85 Technical (Hospital) Services Cltx Iphal Jt Dislc W/Manj W/O Anes PX-3602677000 CDM 26770 CPT 360 RC outpatient 1403 1403 MEDICA (COMMERCIAL) 94265 [3081118] MEDICA CLAIMS [308111801] 1262.7 percent of total billed charges 869.86 1332.85 Technical (Hospital) Services Cltx Iphal Jt Dislc W/Manj W/O Anes PX-3602677000 CDM 26770 CPT 360 RC outpatient 1403 1403 UNITED HEALTHCARE (COMMERCIAL) [3081199] UNITED HEALTHCARE 87726 [308119901] 869.86 percent of total billed charges 869.86 1332.85 Technical (Hospital) Services Cltx Iphal Jt Dislc W/Manj W/O Anes PX-3602677000 CDM 26770 CPT 360 RC outpatient 1403 1403 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES PPO [308136801] 1122.4 percent of total billed charges 869.86 1332.85 Technical (Hospital) Services Cltx Iphal Jt Dislc W/Manj W/O Anes PX-3602677000 CDM 26770 CPT 360 RC outpatient 1403 1403 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES EPO [308136803] 1122.4 percent of total billed charges 869.86 1332.85 Technical (Hospital) Services Cltx Iphal Jt Dislc W/Manj W/O Anes PX-3602677000 CDM 26770 CPT 360 RC outpatient 1403 1403 BLUE CROSS BLUE SHIELD WELLMARK SB889 [3081026] BCBS WYOMING [308102603] 1332.85 percent of total billed charges 869.86 1332.85 Technical (Hospital) Services Cltx Iphal Jt Dislc W/Manj W/O Anes PX-3602677000 CDM 26770 CPT 360 RC outpatient 1403 1403 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES HDHP [308136802] 1122.4 percent of total billed charges 869.86 1332.85 Technical (Hospital) Services Cltx Iphal Jt Dislc W/Manj W/O Anes PX-3602677000 CDM 26770 CPT 360 RC outpatient 1403 1403 MULTIPLAN INC 34080 [3081285] MULTIPLAN INC [308128501] 1332.85 percent of total billed charges 869.86 1332.85 Technical (Hospital) Services Closed Rx IP Jt Dislocation PX-26770 CDM 26770 CPT inpatient 1403 1403 CIGNA 62308 [3081051] CIGNA 62308 [308105105] 1122.4 percent of total billed charges 869.86 1332.85 Professional (doctor) services Closed Rx IP Jt Dislocation PX-26770 CDM 26770 CPT inpatient 1403 1403 CIGNA 62308 [3081051] CIGNA STATE OF WYOMING [308105107] 1122.4 percent of total billed charges 869.86 1332.85 Professional (doctor) services Closed Rx IP Jt Dislocation PX-26770 CDM 26770 CPT outpatient 1403 1403 CIGNA 62308 [3081051] CIGNA 62308 [308105105] 1122.4 percent of total billed charges 869.86 1332.85 Professional (doctor) services Closed Rx IP Jt Dislocation PX-26770 CDM 26770 CPT outpatient 1403 1403 CIGNA 62308 [3081051] CIGNA STATE OF WYOMING [308105107] 1122.4 percent of total billed charges 869.86 1332.85 Professional (doctor) services Closed Rx IP Jt Dislocation PX-26770 CDM 26770 CPT inpatient 1403 1403 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES EPO [308136803] 1122.4 percent of total billed charges 869.86 1332.85 Professional (doctor) services Closed Rx IP Jt Dislocation PX-26770 CDM 26770 CPT inpatient 1403 1403 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES HDHP [308136802] 1122.4 percent of total billed charges 869.86 1332.85 Professional (doctor) services Closed Rx IP Jt Dislocation PX-26770 CDM 26770 CPT inpatient 1403 1403 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES PPO [308136801] 1122.4 percent of total billed charges 869.86 1332.85 Professional (doctor) services Closed Rx IP Jt Dislocation PX-26770 CDM 26770 CPT outpatient 1403 1403 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES EPO [308136803] 1122.4 percent of total billed charges 869.86 1332.85 Professional (doctor) services Closed Rx IP Jt Dislocation PX-26770 CDM 26770 CPT outpatient 1403 1403 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES HDHP [308136802] 1122.4 percent of total billed charges 869.86 1332.85 Professional (doctor) services Closed Rx IP Jt Dislocation PX-26770 CDM 26770 CPT outpatient 1403 1403 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES PPO [308136801] 1122.4 percent of total billed charges 869.86 1332.85 Professional (doctor) services Closed Rx IP Jt Dislocation PX-26770 CDM 26770 CPT inpatient 1403 1403 HEALTHPARTNERS SX009 HEALTHPARTNERS 1122.4 percent of total billed charges 869.86 1332.85 Professional (doctor) services Closed Rx IP Jt Dislocation PX-26770 CDM 26770 CPT outpatient 1403 1403 HEALTHPARTNERS SX009 HEALTHPARTNERS 1122.4 percent of total billed charges 869.86 1332.85 Professional (doctor) services Closed Rx IP Jt Dislocation PX-26770 CDM 26770 CPT inpatient 1403 1403 MEDICA (COMMERCIAL) 94265 [3081118] MEDICA CLAIMS [308111801] 1262.7 percent of total billed charges 869.86 1332.85 Professional (doctor) services Closed Rx IP Jt Dislocation PX-26770 CDM 26770 CPT outpatient 1403 1403 MEDICA (COMMERCIAL) 94265 [3081118] MEDICA CLAIMS [308111801] 1262.7 percent of total billed charges 869.86 1332.85 Professional (doctor) services Closed Rx IP Jt Dislocation PX-26770 CDM 26770 CPT inpatient 1403 1403 MULTIPLAN INC 34080 [3081285] MULTIPLAN INC [308128501] 1332.85 percent of total billed charges 869.86 1332.85 Professional (doctor) services Closed Rx IP Jt Dislocation PX-26770 CDM 26770 CPT outpatient 1403 1403 MULTIPLAN INC 34080 [3081285] MULTIPLAN INC [308128501] 1332.85 percent of total billed charges 869.86 1332.85 Professional (doctor) services Closed Rx IP Jt Dislocation PX-26770 CDM 26770 CPT inpatient 1403 1403 UNITED HEALTHCARE (COMMERCIAL) [3081199] UNITED HEALTHCARE 87726 [308119901] 869.86 percent of total billed charges 869.86 1332.85 Professional (doctor) services Closed Rx IP Jt Dislocation PX-26770 CDM 26770 CPT outpatient 1403 1403 UNITED HEALTHCARE (COMMERCIAL) [3081199] UNITED HEALTHCARE 87726 [308119901] 869.86 percent of total billed charges 869.86 1332.85 Professional (doctor) services Cltx Artclr Fx Invg Mtcarphlngl/Iphal Jt W/Manj PX-3602674200 CDM 26742 CPT 360 RC inpatient 2139 2139 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES EPO [308136803] 1693.66 percent of total billed charges 1326.18 2032.05 Technical (Hospital) Services Cltx Artclr Fx Invg Mtcarphlngl/Iphal Jt W/Manj PX-3602674200 CDM 26742 CPT 360 RC inpatient 2139 2139 CIGNA 62308 [3081051] CIGNA 62308 [308105105] 1693.66 percent of total billed charges 1326.18 2032.05 Technical (Hospital) Services Cltx Artclr Fx Invg Mtcarphlngl/Iphal Jt W/Manj PX-3602674200 CDM 26742 CPT 360 RC inpatient 2139 2139 CIGNA 62308 [3081051] CIGNA STATE OF WYOMING [308105107] 1693.66 percent of total billed charges 1326.18 2032.05 Technical (Hospital) Services Cltx Artclr Fx Invg Mtcarphlngl/Iphal Jt W/Manj PX-3602674200 CDM 26742 CPT 360 RC inpatient 2139 2139 BLUE CROSS BLUE SHIELD WELLMARK SB889 [3081026] BCBS WYOMING [308102603] 2032.05 percent of total billed charges 1326.18 2032.05 Technical (Hospital) Services Cltx Artclr Fx Invg Mtcarphlngl/Iphal Jt W/Manj PX-3602674200 CDM 26742 CPT 360 RC inpatient 2139 2139 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES PPO [308136801] 1693.66 percent of total billed charges 1326.18 2032.05 Technical (Hospital) Services Cltx Artclr Fx Invg Mtcarphlngl/Iphal Jt W/Manj PX-3602674200 CDM 26742 CPT 360 RC inpatient 2139 2139 UNITED HEALTHCARE (COMMERCIAL) [3081199] UNITED HEALTHCARE 87726 [308119901] 1326.18 percent of total billed charges 1326.18 2032.05 Technical (Hospital) Services Cltx Artclr Fx Invg Mtcarphlngl/Iphal Jt W/Manj PX-3602674200 CDM 26742 CPT 360 RC inpatient 2139 2139 MULTIPLAN INC 34080 [3081285] MULTIPLAN INC [308128501] 2032.05 percent of total billed charges 1326.18 2032.05 Technical (Hospital) Services Cltx Artclr Fx Invg Mtcarphlngl/Iphal Jt W/Manj PX-3602674200 CDM 26742 CPT 360 RC inpatient 2139 2139 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES HDHP [308136802] 1693.66 percent of total billed charges 1326.18 2032.05 Technical (Hospital) Services Cltx Artclr Fx Invg Mtcarphlngl/Iphal Jt W/Manj PX-3602674200 CDM 26742 CPT 360 RC inpatient 2139 2139 MEDICA (COMMERCIAL) 94265 [3081118] MEDICA CLAIMS [308111801] 1925.1 percent of total billed charges 1326.18 2032.05 Technical (Hospital) Services Cltx Artclr Fx Invg Mtcarphlngl/Iphal Jt W/Manj PX-3602674200 CDM 26742 CPT 360 RC inpatient 2139 2139 HEALTHPARTNERS SX009 HEALTHPARTNERS 1693.66 percent of total billed charges 1326.18 2032.05 Technical (Hospital) Services Cltx Artclr Fx Invg Mtcarphlngl/Iphal Jt W/Manj PX-3602674200 CDM 26742 CPT 360 RC outpatient 2139 2139 HEALTHPARTNERS SX009 HEALTHPARTNERS 1711.2 percent of total billed charges 1326.18 2032.05 Technical (Hospital) Services Cltx Artclr Fx Invg Mtcarphlngl/Iphal Jt W/Manj PX-3602674200 CDM 26742 CPT 360 RC outpatient 2139 2139 UNITED HEALTHCARE (COMMERCIAL) [3081199] UNITED HEALTHCARE 87726 [308119901] 1326.18 percent of total billed charges 1326.18 2032.05 Technical (Hospital) Services Cltx Artclr Fx Invg Mtcarphlngl/Iphal Jt W/Manj PX-3602674200 CDM 26742 CPT 360 RC outpatient 2139 2139 BLUE CROSS BLUE SHIELD WELLMARK SB889 [3081026] BCBS WYOMING [308102603] 2032.05 percent of total billed charges 1326.18 2032.05 Technical (Hospital) Services Cltx Artclr Fx Invg Mtcarphlngl/Iphal Jt W/Manj PX-3602674200 CDM 26742 CPT 360 RC outpatient 2139 2139 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES HDHP [308136802] 1711.2 percent of total billed charges 1326.18 2032.05 Technical (Hospital) Services Cltx Artclr Fx Invg Mtcarphlngl/Iphal Jt W/Manj PX-3602674200 CDM 26742 CPT 360 RC outpatient 2139 2139 MULTIPLAN INC 34080 [3081285] MULTIPLAN INC [308128501] 2032.05 percent of total billed charges 1326.18 2032.05 Technical (Hospital) Services Cltx Artclr Fx Invg Mtcarphlngl/Iphal Jt W/Manj PX-3602674200 CDM 26742 CPT 360 RC outpatient 2139 2139 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES EPO [308136803] 1711.2 percent of total billed charges 1326.18 2032.05 Technical (Hospital) Services Cltx Artclr Fx Invg Mtcarphlngl/Iphal Jt W/Manj PX-3602674200 CDM 26742 CPT 360 RC outpatient 2139 2139 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES PPO [308136801] 1711.2 percent of total billed charges 1326.18 2032.05 Technical (Hospital) Services Cltx Artclr Fx Invg Mtcarphlngl/Iphal Jt W/Manj PX-3602674200 CDM 26742 CPT 360 RC outpatient 2139 2139 CIGNA 62308 [3081051] CIGNA 62308 [308105105] 1711.2 percent of total billed charges 1326.18 2032.05 Technical (Hospital) Services Cltx Artclr Fx Invg Mtcarphlngl/Iphal Jt W/Manj PX-3602674200 CDM 26742 CPT 360 RC outpatient 2139 2139 CIGNA 62308 [3081051] CIGNA STATE OF WYOMING [308105107] 1711.2 percent of total billed charges 1326.18 2032.05 Technical (Hospital) Services Cltx Artclr Fx Invg Mtcarphlngl/Iphal Jt W/Manj PX-3602674200 CDM 26742 CPT 360 RC outpatient 2139 2139 MEDICA (COMMERCIAL) 94265 [3081118] MEDICA CLAIMS [308111801] 1925.1 percent of total billed charges 1326.18 2032.05 Technical (Hospital) Services "Close Rx Fingr Articular Fx,Manip" PX-26742 CDM 26742 CPT inpatient 2139 2139 CIGNA 62308 [3081051] CIGNA 62308 [308105105] 1711.2 percent of total billed charges 1326.18 2032.05 Professional (doctor) services "Close Rx Fingr Articular Fx,Manip" PX-26742 CDM 26742 CPT inpatient 2139 2139 CIGNA 62308 [3081051] CIGNA STATE OF WYOMING [308105107] 1711.2 percent of total billed charges 1326.18 2032.05 Professional (doctor) services "Close Rx Fingr Articular Fx,Manip" PX-26742 CDM 26742 CPT outpatient 2139 2139 CIGNA 62308 [3081051] CIGNA 62308 [308105105] 1711.2 percent of total billed charges 1326.18 2032.05 Professional (doctor) services "Close Rx Fingr Articular Fx,Manip" PX-26742 CDM 26742 CPT outpatient 2139 2139 CIGNA 62308 [3081051] CIGNA STATE OF WYOMING [308105107] 1711.2 percent of total billed charges 1326.18 2032.05 Professional (doctor) services "Close Rx Fingr Articular Fx,Manip" PX-26742 CDM 26742 CPT inpatient 2139 2139 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES EPO [308136803] 1711.2 percent of total billed charges 1326.18 2032.05 Professional (doctor) services "Close Rx Fingr Articular Fx,Manip" PX-26742 CDM 26742 CPT inpatient 2139 2139 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES HDHP [308136802] 1711.2 percent of total billed charges 1326.18 2032.05 Professional (doctor) services "Close Rx Fingr Articular Fx,Manip" PX-26742 CDM 26742 CPT inpatient 2139 2139 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES PPO [308136801] 1711.2 percent of total billed charges 1326.18 2032.05 Professional (doctor) services "Close Rx Fingr Articular Fx,Manip" PX-26742 CDM 26742 CPT outpatient 2139 2139 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES EPO [308136803] 1711.2 percent of total billed charges 1326.18 2032.05 Professional (doctor) services "Close Rx Fingr Articular Fx,Manip" PX-26742 CDM 26742 CPT outpatient 2139 2139 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES HDHP [308136802] 1711.2 percent of total billed charges 1326.18 2032.05 Professional (doctor) services "Close Rx Fingr Articular Fx,Manip" PX-26742 CDM 26742 CPT outpatient 2139 2139 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES PPO [308136801] 1711.2 percent of total billed charges 1326.18 2032.05 Professional (doctor) services "Close Rx Fingr Articular Fx,Manip" PX-26742 CDM 26742 CPT inpatient 2139 2139 HEALTHPARTNERS SX009 HEALTHPARTNERS 1711.2 percent of total billed charges 1326.18 2032.05 Professional (doctor) services "Close Rx Fingr Articular Fx,Manip" PX-26742 CDM 26742 CPT outpatient 2139 2139 HEALTHPARTNERS SX009 HEALTHPARTNERS 1711.2 percent of total billed charges 1326.18 2032.05 Professional (doctor) services "Close Rx Fingr Articular Fx,Manip" PX-26742 CDM 26742 CPT inpatient 2139 2139 MEDICA (COMMERCIAL) 94265 [3081118] MEDICA CLAIMS [308111801] 1925.1 percent of total billed charges 1326.18 2032.05 Professional (doctor) services "Close Rx Fingr Articular Fx,Manip" PX-26742 CDM 26742 CPT outpatient 2139 2139 MEDICA (COMMERCIAL) 94265 [3081118] MEDICA CLAIMS [308111801] 1925.1 percent of total billed charges 1326.18 2032.05 Professional (doctor) services "Close Rx Fingr Articular Fx,Manip" PX-26742 CDM 26742 CPT inpatient 2139 2139 MULTIPLAN INC 34080 [3081285] MULTIPLAN INC [308128501] 2032.05 percent of total billed charges 1326.18 2032.05 Professional (doctor) services "Close Rx Fingr Articular Fx,Manip" PX-26742 CDM 26742 CPT outpatient 2139 2139 MULTIPLAN INC 34080 [3081285] MULTIPLAN INC [308128501] 2032.05 percent of total billed charges 1326.18 2032.05 Professional (doctor) services "Close Rx Fingr Articular Fx,Manip" PX-26742 CDM 26742 CPT inpatient 2139 2139 UNITED HEALTHCARE (COMMERCIAL) [3081199] UNITED HEALTHCARE 87726 [308119901] 1326.18 percent of total billed charges 1326.18 2032.05 Professional (doctor) services "Close Rx Fingr Articular Fx,Manip" PX-26742 CDM 26742 CPT outpatient 2139 2139 UNITED HEALTHCARE (COMMERCIAL) [3081199] UNITED HEALTHCARE 87726 [308119901] 1326.18 percent of total billed charges 1326.18 2032.05 Professional (doctor) services Cltx Metacarpal Fx W/O Manipulation Each Bone PX-3602660000 CDM 26600 CPT 360 RC outpatient 1334 1334 MEDICA (COMMERCIAL) 94265 [3081118] MEDICA CLAIMS [308111801] 1200.6 percent of total billed charges 827.08 1267.3 Technical (Hospital) Services Cltx Metacarpal Fx W/O Manipulation Each Bone PX-3602660000 CDM 26600 CPT 360 RC outpatient 1334 1334 CIGNA 62308 [3081051] CIGNA 62308 [308105105] 1067.2 percent of total billed charges 827.08 1267.3 Technical (Hospital) Services Cltx Metacarpal Fx W/O Manipulation Each Bone PX-3602660000 CDM 26600 CPT 360 RC outpatient 1334 1334 CIGNA 62308 [3081051] CIGNA STATE OF WYOMING [308105107] 1067.2 percent of total billed charges 827.08 1267.3 Technical (Hospital) Services Cltx Metacarpal Fx W/O Manipulation Each Bone PX-3602660000 CDM 26600 CPT 360 RC outpatient 1334 1334 HEALTHPARTNERS SX009 HEALTHPARTNERS 1067.2 percent of total billed charges 827.08 1267.3 Technical (Hospital) Services Cltx Metacarpal Fx W/O Manipulation Each Bone PX-3602660000 CDM 26600 CPT 360 RC outpatient 1334 1334 BLUE CROSS BLUE SHIELD WELLMARK SB889 [3081026] BCBS WYOMING [308102603] 1267.3 percent of total billed charges 827.08 1267.3 Technical (Hospital) Services Cltx Metacarpal Fx W/O Manipulation Each Bone PX-3602660000 CDM 26600 CPT 360 RC outpatient 1334 1334 MULTIPLAN INC 34080 [3081285] MULTIPLAN INC [308128501] 1267.3 percent of total billed charges 827.08 1267.3 Technical (Hospital) Services Cltx Metacarpal Fx W/O Manipulation Each Bone PX-3602660000 CDM 26600 CPT 360 RC outpatient 1334 1334 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES HDHP [308136802] 1067.2 percent of total billed charges 827.08 1267.3 Technical (Hospital) Services Cltx Metacarpal Fx W/O Manipulation Each Bone PX-3602660000 CDM 26600 CPT 360 RC outpatient 1334 1334 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES PPO [308136801] 1067.2 percent of total billed charges 827.08 1267.3 Technical (Hospital) Services Cltx Metacarpal Fx W/O Manipulation Each Bone PX-3602660000 CDM 26600 CPT 360 RC outpatient 1334 1334 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES EPO [308136803] 1067.2 percent of total billed charges 827.08 1267.3 Technical (Hospital) Services Cltx Metacarpal Fx W/O Manipulation Each Bone PX-3602660000 CDM 26600 CPT 360 RC outpatient 1334 1334 UNITED HEALTHCARE (COMMERCIAL) [3081199] UNITED HEALTHCARE 87726 [308119901] 827.08 percent of total billed charges 827.08 1267.3 Technical (Hospital) Services Cltx Metacarpal Fx W/O Manipulation Each Bone PX-3602660000 CDM 26600 CPT 360 RC inpatient 1334 1334 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES HDHP [308136802] 1056.26 percent of total billed charges 827.08 1267.3 Technical (Hospital) Services Cltx Metacarpal Fx W/O Manipulation Each Bone PX-3602660000 CDM 26600 CPT 360 RC inpatient 1334 1334 MEDICA (COMMERCIAL) 94265 [3081118] MEDICA CLAIMS [308111801] 1200.6 percent of total billed charges 827.08 1267.3 Technical (Hospital) Services Cltx Metacarpal Fx W/O Manipulation Each Bone PX-3602660000 CDM 26600 CPT 360 RC inpatient 1334 1334 HEALTHPARTNERS SX009 HEALTHPARTNERS 1056.26 percent of total billed charges 827.08 1267.3 Technical (Hospital) Services Cltx Metacarpal Fx W/O Manipulation Each Bone PX-3602660000 CDM 26600 CPT 360 RC inpatient 1334 1334 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES PPO [308136801] 1056.26 percent of total billed charges 827.08 1267.3 Technical (Hospital) Services Cltx Metacarpal Fx W/O Manipulation Each Bone PX-3602660000 CDM 26600 CPT 360 RC inpatient 1334 1334 UNITED HEALTHCARE (COMMERCIAL) [3081199] UNITED HEALTHCARE 87726 [308119901] 827.08 percent of total billed charges 827.08 1267.3 Technical (Hospital) Services Cltx Metacarpal Fx W/O Manipulation Each Bone PX-3602660000 CDM 26600 CPT 360 RC inpatient 1334 1334 BLUE CROSS BLUE SHIELD WELLMARK SB889 [3081026] BCBS WYOMING [308102603] 1267.3 percent of total billed charges 827.08 1267.3 Technical (Hospital) Services Cltx Metacarpal Fx W/O Manipulation Each Bone PX-3602660000 CDM 26600 CPT 360 RC inpatient 1334 1334 MULTIPLAN INC 34080 [3081285] MULTIPLAN INC [308128501] 1267.3 percent of total billed charges 827.08 1267.3 Technical (Hospital) Services Cltx Metacarpal Fx W/O Manipulation Each Bone PX-3602660000 CDM 26600 CPT 360 RC inpatient 1334 1334 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES EPO [308136803] 1056.26 percent of total billed charges 827.08 1267.3 Technical (Hospital) Services Cltx Metacarpal Fx W/O Manipulation Each Bone PX-3602660000 CDM 26600 CPT 360 RC inpatient 1334 1334 CIGNA 62308 [3081051] CIGNA 62308 [308105105] 1056.26 percent of total billed charges 827.08 1267.3 Technical (Hospital) Services Cltx Metacarpal Fx W/O Manipulation Each Bone PX-3602660000 CDM 26600 CPT 360 RC inpatient 1334 1334 CIGNA 62308 [3081051] CIGNA STATE OF WYOMING [308105107] 1056.26 percent of total billed charges 827.08 1267.3 Technical (Hospital) Services Cltx Dstl Rdl Fx/Epiphysl Sep W/Manj When Perf PX-3602560500 CDM 25605 CPT 360 RC inpatient 3267 3267 HEALTHPARTNERS SX009 HEALTHPARTNERS 2586.81 percent of total billed charges 2025.54 3103.65 Technical (Hospital) Services Cltx Dstl Rdl Fx/Epiphysl Sep W/Manj When Perf PX-3602560500 CDM 25605 CPT 360 RC inpatient 3267 3267 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES HDHP [308136802] 2586.81 percent of total billed charges 2025.54 3103.65 Technical (Hospital) Services Cltx Dstl Rdl Fx/Epiphysl Sep W/Manj When Perf PX-3602560500 CDM 25605 CPT 360 RC inpatient 3267 3267 MEDICA (COMMERCIAL) 94265 [3081118] MEDICA CLAIMS [308111801] 2940.3 percent of total billed charges 2025.54 3103.65 Technical (Hospital) Services Cltx Dstl Rdl Fx/Epiphysl Sep W/Manj When Perf PX-3602560500 CDM 25605 CPT 360 RC inpatient 3267 3267 UNITED HEALTHCARE (COMMERCIAL) [3081199] UNITED HEALTHCARE 87726 [308119901] 2025.54 percent of total billed charges 2025.54 3103.65 Technical (Hospital) Services Cltx Dstl Rdl Fx/Epiphysl Sep W/Manj When Perf PX-3602560500 CDM 25605 CPT 360 RC inpatient 3267 3267 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES PPO [308136801] 2586.81 percent of total billed charges 2025.54 3103.65 Technical (Hospital) Services Cltx Dstl Rdl Fx/Epiphysl Sep W/Manj When Perf PX-3602560500 CDM 25605 CPT 360 RC inpatient 3267 3267 MULTIPLAN INC 34080 [3081285] MULTIPLAN INC [308128501] 3103.65 percent of total billed charges 2025.54 3103.65 Technical (Hospital) Services Cltx Dstl Rdl Fx/Epiphysl Sep W/Manj When Perf PX-3602560500 CDM 25605 CPT 360 RC inpatient 3267 3267 BLUE CROSS BLUE SHIELD WELLMARK SB889 [3081026] BCBS WYOMING [308102603] 3103.65 percent of total billed charges 2025.54 3103.65 Technical (Hospital) Services Cltx Dstl Rdl Fx/Epiphysl Sep W/Manj When Perf PX-3602560500 CDM 25605 CPT 360 RC inpatient 3267 3267 CIGNA 62308 [3081051] CIGNA 62308 [308105105] 2586.81 percent of total billed charges 2025.54 3103.65 Technical (Hospital) Services Cltx Dstl Rdl Fx/Epiphysl Sep W/Manj When Perf PX-3602560500 CDM 25605 CPT 360 RC inpatient 3267 3267 CIGNA 62308 [3081051] CIGNA STATE OF WYOMING [308105107] 2586.81 percent of total billed charges 2025.54 3103.65 Technical (Hospital) Services Cltx Dstl Rdl Fx/Epiphysl Sep W/Manj When Perf PX-3602560500 CDM 25605 CPT 360 RC inpatient 3267 3267 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES EPO [308136803] 2586.81 percent of total billed charges 2025.54 3103.65 Technical (Hospital) Services Cltx Dstl Rdl Fx/Epiphysl Sep W/Manj When Perf PX-3602560500 CDM 25605 CPT 360 RC outpatient 3267 3267 HEALTHPARTNERS SX009 HEALTHPARTNERS 2613.6 percent of total billed charges 2025.54 3103.65 Technical (Hospital) Services Cltx Dstl Rdl Fx/Epiphysl Sep W/Manj When Perf PX-3602560500 CDM 25605 CPT 360 RC outpatient 3267 3267 MEDICA (COMMERCIAL) 94265 [3081118] MEDICA CLAIMS [308111801] 2940.3 percent of total billed charges 2025.54 3103.65 Technical (Hospital) Services Cltx Dstl Rdl Fx/Epiphysl Sep W/Manj When Perf PX-3602560500 CDM 25605 CPT 360 RC outpatient 3267 3267 MULTIPLAN INC 34080 [3081285] MULTIPLAN INC [308128501] 3103.65 percent of total billed charges 2025.54 3103.65 Technical (Hospital) Services Cltx Dstl Rdl Fx/Epiphysl Sep W/Manj When Perf PX-3602560500 CDM 25605 CPT 360 RC outpatient 3267 3267 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES HDHP [308136802] 2613.6 percent of total billed charges 2025.54 3103.65 Technical (Hospital) Services Cltx Dstl Rdl Fx/Epiphysl Sep W/Manj When Perf PX-3602560500 CDM 25605 CPT 360 RC outpatient 3267 3267 BLUE CROSS BLUE SHIELD WELLMARK SB889 [3081026] BCBS WYOMING [308102603] 3103.65 percent of total billed charges 2025.54 3103.65 Technical (Hospital) Services Cltx Dstl Rdl Fx/Epiphysl Sep W/Manj When Perf PX-3602560500 CDM 25605 CPT 360 RC outpatient 3267 3267 UNITED HEALTHCARE (COMMERCIAL) [3081199] UNITED HEALTHCARE 87726 [308119901] 2025.54 percent of total billed charges 2025.54 3103.65 Technical (Hospital) Services Cltx Dstl Rdl Fx/Epiphysl Sep W/Manj When Perf PX-3602560500 CDM 25605 CPT 360 RC outpatient 3267 3267 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES PPO [308136801] 2613.6 percent of total billed charges 2025.54 3103.65 Technical (Hospital) Services Cltx Dstl Rdl Fx/Epiphysl Sep W/Manj When Perf PX-3602560500 CDM 25605 CPT 360 RC outpatient 3267 3267 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES EPO [308136803] 2613.6 percent of total billed charges 2025.54 3103.65 Technical (Hospital) Services Cltx Dstl Rdl Fx/Epiphysl Sep W/Manj When Perf PX-3602560500 CDM 25605 CPT 360 RC outpatient 3267 3267 CIGNA 62308 [3081051] CIGNA 62308 [308105105] 2613.6 percent of total billed charges 2025.54 3103.65 Technical (Hospital) Services Cltx Dstl Rdl Fx/Epiphysl Sep W/Manj When Perf PX-3602560500 CDM 25605 CPT 360 RC outpatient 3267 3267 CIGNA 62308 [3081051] CIGNA STATE OF WYOMING [308105107] 2613.6 percent of total billed charges 2025.54 3103.65 Technical (Hospital) Services "Closed Rx Dist Rad/Ulna Fx,Manipul" PX-25605 CDM 25605 CPT inpatient 3267 3267 CIGNA 62308 [3081051] CIGNA 62308 [308105105] 2613.6 percent of total billed charges 2025.54 3103.65 Professional (doctor) services "Closed Rx Dist Rad/Ulna Fx,Manipul" PX-25605 CDM 25605 CPT inpatient 3267 3267 CIGNA 62308 [3081051] CIGNA STATE OF WYOMING [308105107] 2613.6 percent of total billed charges 2025.54 3103.65 Professional (doctor) services "Closed Rx Dist Rad/Ulna Fx,Manipul" PX-25605 CDM 25605 CPT outpatient 3267 3267 CIGNA 62308 [3081051] CIGNA 62308 [308105105] 2613.6 percent of total billed charges 2025.54 3103.65 Professional (doctor) services "Closed Rx Dist Rad/Ulna Fx,Manipul" PX-25605 CDM 25605 CPT outpatient 3267 3267 CIGNA 62308 [3081051] CIGNA STATE OF WYOMING [308105107] 2613.6 percent of total billed charges 2025.54 3103.65 Professional (doctor) services "Closed Rx Dist Rad/Ulna Fx,Manipul" PX-25605 CDM 25605 CPT inpatient 3267 3267 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES EPO [308136803] 2613.6 percent of total billed charges 2025.54 3103.65 Professional (doctor) services "Closed Rx Dist Rad/Ulna Fx,Manipul" PX-25605 CDM 25605 CPT inpatient 3267 3267 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES HDHP [308136802] 2613.6 percent of total billed charges 2025.54 3103.65 Professional (doctor) services "Closed Rx Dist Rad/Ulna Fx,Manipul" PX-25605 CDM 25605 CPT inpatient 3267 3267 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES PPO [308136801] 2613.6 percent of total billed charges 2025.54 3103.65 Professional (doctor) services "Closed Rx Dist Rad/Ulna Fx,Manipul" PX-25605 CDM 25605 CPT outpatient 3267 3267 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES EPO [308136803] 2613.6 percent of total billed charges 2025.54 3103.65 Professional (doctor) services "Closed Rx Dist Rad/Ulna Fx,Manipul" PX-25605 CDM 25605 CPT outpatient 3267 3267 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES HDHP [308136802] 2613.6 percent of total billed charges 2025.54 3103.65 Professional (doctor) services "Closed Rx Dist Rad/Ulna Fx,Manipul" PX-25605 CDM 25605 CPT outpatient 3267 3267 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES PPO [308136801] 2613.6 percent of total billed charges 2025.54 3103.65 Professional (doctor) services "Closed Rx Dist Rad/Ulna Fx,Manipul" PX-25605 CDM 25605 CPT inpatient 3267 3267 HEALTHPARTNERS SX009 HEALTHPARTNERS 2613.6 percent of total billed charges 2025.54 3103.65 Professional (doctor) services "Closed Rx Dist Rad/Ulna Fx,Manipul" PX-25605 CDM 25605 CPT outpatient 3267 3267 HEALTHPARTNERS SX009 HEALTHPARTNERS 2613.6 percent of total billed charges 2025.54 3103.65 Professional (doctor) services "Closed Rx Dist Rad/Ulna Fx,Manipul" PX-25605 CDM 25605 CPT inpatient 3267 3267 MEDICA (COMMERCIAL) 94265 [3081118] MEDICA CLAIMS [308111801] 2940.3 percent of total billed charges 2025.54 3103.65 Professional (doctor) services "Closed Rx Dist Rad/Ulna Fx,Manipul" PX-25605 CDM 25605 CPT outpatient 3267 3267 MEDICA (COMMERCIAL) 94265 [3081118] MEDICA CLAIMS [308111801] 2940.3 percent of total billed charges 2025.54 3103.65 Professional (doctor) services "Closed Rx Dist Rad/Ulna Fx,Manipul" PX-25605 CDM 25605 CPT inpatient 3267 3267 MULTIPLAN INC 34080 [3081285] MULTIPLAN INC [308128501] 3103.65 percent of total billed charges 2025.54 3103.65 Professional (doctor) services "Closed Rx Dist Rad/Ulna Fx,Manipul" PX-25605 CDM 25605 CPT outpatient 3267 3267 MULTIPLAN INC 34080 [3081285] MULTIPLAN INC [308128501] 3103.65 percent of total billed charges 2025.54 3103.65 Professional (doctor) services "Closed Rx Dist Rad/Ulna Fx,Manipul" PX-25605 CDM 25605 CPT inpatient 3267 3267 UNITED HEALTHCARE (COMMERCIAL) [3081199] UNITED HEALTHCARE 87726 [308119901] 2025.54 percent of total billed charges 2025.54 3103.65 Professional (doctor) services "Closed Rx Dist Rad/Ulna Fx,Manipul" PX-25605 CDM 25605 CPT outpatient 3267 3267 UNITED HEALTHCARE (COMMERCIAL) [3081199] UNITED HEALTHCARE 87726 [308119901] 2025.54 percent of total billed charges 2025.54 3103.65 Professional (doctor) services Closed Tx Radial&Ulnar Shaft Fractures W/Manj PX-3602556500 CDM 25565 CPT 360 RC inpatient 3100 3100 CIGNA 62308 [3081051] CIGNA 62308 [308105105] 2454.58 percent of total billed charges 1922 2945 Technical (Hospital) Services Closed Tx Radial&Ulnar Shaft Fractures W/Manj PX-3602556500 CDM 25565 CPT 360 RC inpatient 3100 3100 CIGNA 62308 [3081051] CIGNA STATE OF WYOMING [308105107] 2454.58 percent of total billed charges 1922 2945 Technical (Hospital) Services Closed Tx Radial&Ulnar Shaft Fractures W/Manj PX-3602556500 CDM 25565 CPT 360 RC inpatient 3100 3100 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES EPO [308136803] 2454.58 percent of total billed charges 1922 2945 Technical (Hospital) Services Closed Tx Radial&Ulnar Shaft Fractures W/Manj PX-3602556500 CDM 25565 CPT 360 RC inpatient 3100 3100 MULTIPLAN INC 34080 [3081285] MULTIPLAN INC [308128501] 2945 percent of total billed charges 1922 2945 Technical (Hospital) Services Closed Tx Radial&Ulnar Shaft Fractures W/Manj PX-3602556500 CDM 25565 CPT 360 RC inpatient 3100 3100 BLUE CROSS BLUE SHIELD WELLMARK SB889 [3081026] BCBS WYOMING [308102603] 2945 percent of total billed charges 1922 2945 Technical (Hospital) Services Closed Tx Radial&Ulnar Shaft Fractures W/Manj PX-3602556500 CDM 25565 CPT 360 RC inpatient 3100 3100 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES PPO [308136801] 2454.58 percent of total billed charges 1922 2945 Technical (Hospital) Services Closed Tx Radial&Ulnar Shaft Fractures W/Manj PX-3602556500 CDM 25565 CPT 360 RC inpatient 3100 3100 UNITED HEALTHCARE (COMMERCIAL) [3081199] UNITED HEALTHCARE 87726 [308119901] 1922 percent of total billed charges 1922 2945 Technical (Hospital) Services Closed Tx Radial&Ulnar Shaft Fractures W/Manj PX-3602556500 CDM 25565 CPT 360 RC inpatient 3100 3100 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES HDHP [308136802] 2454.58 percent of total billed charges 1922 2945 Technical (Hospital) Services Closed Tx Radial&Ulnar Shaft Fractures W/Manj PX-3602556500 CDM 25565 CPT 360 RC inpatient 3100 3100 MEDICA (COMMERCIAL) 94265 [3081118] MEDICA CLAIMS [308111801] 2790 percent of total billed charges 1922 2945 Technical (Hospital) Services Closed Tx Radial&Ulnar Shaft Fractures W/Manj PX-3602556500 CDM 25565 CPT 360 RC inpatient 3100 3100 HEALTHPARTNERS SX009 HEALTHPARTNERS 2454.58 percent of total billed charges 1922 2945 Technical (Hospital) Services Closed Tx Radial&Ulnar Shaft Fractures W/Manj PX-3602556500 CDM 25565 CPT 360 RC outpatient 3100 3100 HEALTHPARTNERS SX009 HEALTHPARTNERS 2480 percent of total billed charges 1922 2945 Technical (Hospital) Services Closed Tx Radial&Ulnar Shaft Fractures W/Manj PX-3602556500 CDM 25565 CPT 360 RC outpatient 3100 3100 MEDICA (COMMERCIAL) 94265 [3081118] MEDICA CLAIMS [308111801] 2790 percent of total billed charges 1922 2945 Technical (Hospital) Services Closed Tx Radial&Ulnar Shaft Fractures W/Manj PX-3602556500 CDM 25565 CPT 360 RC outpatient 3100 3100 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES HDHP [308136802] 2480 percent of total billed charges 1922 2945 Technical (Hospital) Services Closed Tx Radial&Ulnar Shaft Fractures W/Manj PX-3602556500 CDM 25565 CPT 360 RC outpatient 3100 3100 MULTIPLAN INC 34080 [3081285] MULTIPLAN INC [308128501] 2945 percent of total billed charges 1922 2945 Technical (Hospital) Services Closed Tx Radial&Ulnar Shaft Fractures W/Manj PX-3602556500 CDM 25565 CPT 360 RC outpatient 3100 3100 BLUE CROSS BLUE SHIELD WELLMARK SB889 [3081026] BCBS WYOMING [308102603] 2945 percent of total billed charges 1922 2945 Technical (Hospital) Services Closed Tx Radial&Ulnar Shaft Fractures W/Manj PX-3602556500 CDM 25565 CPT 360 RC outpatient 3100 3100 UNITED HEALTHCARE (COMMERCIAL) [3081199] UNITED HEALTHCARE 87726 [308119901] 1922 percent of total billed charges 1922 2945 Technical (Hospital) Services Closed Tx Radial&Ulnar Shaft Fractures W/Manj PX-3602556500 CDM 25565 CPT 360 RC outpatient 3100 3100 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES EPO [308136803] 2480 percent of total billed charges 1922 2945 Technical (Hospital) Services Closed Tx Radial&Ulnar Shaft Fractures W/Manj PX-3602556500 CDM 25565 CPT 360 RC outpatient 3100 3100 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES PPO [308136801] 2480 percent of total billed charges 1922 2945 Technical (Hospital) Services Closed Tx Radial&Ulnar Shaft Fractures W/Manj PX-3602556500 CDM 25565 CPT 360 RC outpatient 3100 3100 CIGNA 62308 [3081051] CIGNA 62308 [308105105] 2480 percent of total billed charges 1922 2945 Technical (Hospital) Services Closed Tx Radial&Ulnar Shaft Fractures W/Manj PX-3602556500 CDM 25565 CPT 360 RC outpatient 3100 3100 CIGNA 62308 [3081051] CIGNA STATE OF WYOMING [308105107] 2480 percent of total billed charges 1922 2945 Technical (Hospital) Services "Closed Rx Radial Head Disloc,Child" PX-24640 CDM 24640 CPT inpatient 720 720 CIGNA 62308 [3081051] CIGNA 62308 [308105105] 576 percent of total billed charges 446.4 684 Professional (doctor) services "Closed Rx Radial Head Disloc,Child" PX-24640 CDM 24640 CPT inpatient 720 720 CIGNA 62308 [3081051] CIGNA STATE OF WYOMING [308105107] 576 percent of total billed charges 446.4 684 Professional (doctor) services "Closed Rx Radial Head Disloc,Child" PX-24640 CDM 24640 CPT outpatient 720 720 CIGNA 62308 [3081051] CIGNA 62308 [308105105] 576 percent of total billed charges 446.4 684 Professional (doctor) services "Closed Rx Radial Head Disloc,Child" PX-24640 CDM 24640 CPT outpatient 720 720 CIGNA 62308 [3081051] CIGNA STATE OF WYOMING [308105107] 576 percent of total billed charges 446.4 684 Professional (doctor) services "Closed Rx Radial Head Disloc,Child" PX-24640 CDM 24640 CPT inpatient 720 720 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES EPO [308136803] 576 percent of total billed charges 446.4 684 Professional (doctor) services "Closed Rx Radial Head Disloc,Child" PX-24640 CDM 24640 CPT inpatient 720 720 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES HDHP [308136802] 576 percent of total billed charges 446.4 684 Professional (doctor) services "Closed Rx Radial Head Disloc,Child" PX-24640 CDM 24640 CPT inpatient 720 720 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES PPO [308136801] 576 percent of total billed charges 446.4 684 Professional (doctor) services "Closed Rx Radial Head Disloc,Child" PX-24640 CDM 24640 CPT outpatient 720 720 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES EPO [308136803] 576 percent of total billed charges 446.4 684 Professional (doctor) services "Closed Rx Radial Head Disloc,Child" PX-24640 CDM 24640 CPT outpatient 720 720 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES HDHP [308136802] 576 percent of total billed charges 446.4 684 Professional (doctor) services "Closed Rx Radial Head Disloc,Child" PX-24640 CDM 24640 CPT outpatient 720 720 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES PPO [308136801] 576 percent of total billed charges 446.4 684 Professional (doctor) services "Closed Rx Radial Head Disloc,Child" PX-24640 CDM 24640 CPT inpatient 720 720 HEALTHPARTNERS SX009 HEALTHPARTNERS 576 percent of total billed charges 446.4 684 Professional (doctor) services "Closed Rx Radial Head Disloc,Child" PX-24640 CDM 24640 CPT outpatient 720 720 HEALTHPARTNERS SX009 HEALTHPARTNERS 576 percent of total billed charges 446.4 684 Professional (doctor) services "Closed Rx Radial Head Disloc,Child" PX-24640 CDM 24640 CPT inpatient 720 720 MEDICA (COMMERCIAL) 94265 [3081118] MEDICA CLAIMS [308111801] 648 percent of total billed charges 446.4 684 Professional (doctor) services "Closed Rx Radial Head Disloc,Child" PX-24640 CDM 24640 CPT outpatient 720 720 MEDICA (COMMERCIAL) 94265 [3081118] MEDICA CLAIMS [308111801] 648 percent of total billed charges 446.4 684 Professional (doctor) services "Closed Rx Radial Head Disloc,Child" PX-24640 CDM 24640 CPT inpatient 720 720 MULTIPLAN INC 34080 [3081285] MULTIPLAN INC [308128501] 684 percent of total billed charges 446.4 684 Professional (doctor) services "Closed Rx Radial Head Disloc,Child" PX-24640 CDM 24640 CPT outpatient 720 720 MULTIPLAN INC 34080 [3081285] MULTIPLAN INC [308128501] 684 percent of total billed charges 446.4 684 Professional (doctor) services "Closed Rx Radial Head Disloc,Child" PX-24640 CDM 24640 CPT inpatient 720 720 UNITED HEALTHCARE (COMMERCIAL) [3081199] UNITED HEALTHCARE 87726 [308119901] 446.4 percent of total billed charges 446.4 684 Professional (doctor) services "Closed Rx Radial Head Disloc,Child" PX-24640 CDM 24640 CPT outpatient 720 720 UNITED HEALTHCARE (COMMERCIAL) [3081199] UNITED HEALTHCARE 87726 [308119901] 446.4 percent of total billed charges 446.4 684 Professional (doctor) services Treatment Closed Elbow Dislocation W/O Anes PX-3602460000 CDM 24600 CPT 360 RC outpatient 1617 1617 CIGNA 62308 [3081051] CIGNA 62308 [308105105] 1293.6 percent of total billed charges 1002.54 1536.15 Technical (Hospital) Services Treatment Closed Elbow Dislocation W/O Anes PX-3602460000 CDM 24600 CPT 360 RC outpatient 1617 1617 CIGNA 62308 [3081051] CIGNA STATE OF WYOMING [308105107] 1293.6 percent of total billed charges 1002.54 1536.15 Technical (Hospital) Services Treatment Closed Elbow Dislocation W/O Anes PX-3602460000 CDM 24600 CPT 360 RC outpatient 1617 1617 MEDICA (COMMERCIAL) 94265 [3081118] MEDICA CLAIMS [308111801] 1455.3 percent of total billed charges 1002.54 1536.15 Technical (Hospital) Services Treatment Closed Elbow Dislocation W/O Anes PX-3602460000 CDM 24600 CPT 360 RC outpatient 1617 1617 HEALTHPARTNERS SX009 HEALTHPARTNERS 1293.6 percent of total billed charges 1002.54 1536.15 Technical (Hospital) Services Treatment Closed Elbow Dislocation W/O Anes PX-3602460000 CDM 24600 CPT 360 RC outpatient 1617 1617 UNITED HEALTHCARE (COMMERCIAL) [3081199] UNITED HEALTHCARE 87726 [308119901] 1002.54 percent of total billed charges 1002.54 1536.15 Technical (Hospital) Services Treatment Closed Elbow Dislocation W/O Anes PX-3602460000 CDM 24600 CPT 360 RC outpatient 1617 1617 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES EPO [308136803] 1293.6 percent of total billed charges 1002.54 1536.15 Technical (Hospital) Services Treatment Closed Elbow Dislocation W/O Anes PX-3602460000 CDM 24600 CPT 360 RC outpatient 1617 1617 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES PPO [308136801] 1293.6 percent of total billed charges 1002.54 1536.15 Technical (Hospital) Services Treatment Closed Elbow Dislocation W/O Anes PX-3602460000 CDM 24600 CPT 360 RC outpatient 1617 1617 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES HDHP [308136802] 1293.6 percent of total billed charges 1002.54 1536.15 Technical (Hospital) Services Treatment Closed Elbow Dislocation W/O Anes PX-3602460000 CDM 24600 CPT 360 RC outpatient 1617 1617 MULTIPLAN INC 34080 [3081285] MULTIPLAN INC [308128501] 1536.15 percent of total billed charges 1002.54 1536.15 Technical (Hospital) Services Treatment Closed Elbow Dislocation W/O Anes PX-3602460000 CDM 24600 CPT 360 RC outpatient 1617 1617 BLUE CROSS BLUE SHIELD WELLMARK SB889 [3081026] BCBS WYOMING [308102603] 1536.15 percent of total billed charges 1002.54 1536.15 Technical (Hospital) Services Treatment Closed Elbow Dislocation W/O Anes PX-3602460000 CDM 24600 CPT 360 RC inpatient 1617 1617 BLUE CROSS BLUE SHIELD WELLMARK SB889 [3081026] BCBS WYOMING [308102603] 1536.15 percent of total billed charges 1002.54 1536.15 Technical (Hospital) Services Treatment Closed Elbow Dislocation W/O Anes PX-3602460000 CDM 24600 CPT 360 RC inpatient 1617 1617 MULTIPLAN INC 34080 [3081285] MULTIPLAN INC [308128501] 1536.15 percent of total billed charges 1002.54 1536.15 Technical (Hospital) Services Treatment Closed Elbow Dislocation W/O Anes PX-3602460000 CDM 24600 CPT 360 RC inpatient 1617 1617 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES PPO [308136801] 1280.34 percent of total billed charges 1002.54 1536.15 Technical (Hospital) Services Treatment Closed Elbow Dislocation W/O Anes PX-3602460000 CDM 24600 CPT 360 RC inpatient 1617 1617 UNITED HEALTHCARE (COMMERCIAL) [3081199] UNITED HEALTHCARE 87726 [308119901] 1002.54 percent of total billed charges 1002.54 1536.15 Technical (Hospital) Services Treatment Closed Elbow Dislocation W/O Anes PX-3602460000 CDM 24600 CPT 360 RC inpatient 1617 1617 HEALTHPARTNERS SX009 HEALTHPARTNERS 1280.34 percent of total billed charges 1002.54 1536.15 Technical (Hospital) Services Treatment Closed Elbow Dislocation W/O Anes PX-3602460000 CDM 24600 CPT 360 RC inpatient 1617 1617 MEDICA (COMMERCIAL) 94265 [3081118] MEDICA CLAIMS [308111801] 1455.3 percent of total billed charges 1002.54 1536.15 Technical (Hospital) Services Treatment Closed Elbow Dislocation W/O Anes PX-3602460000 CDM 24600 CPT 360 RC inpatient 1617 1617 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES HDHP [308136802] 1280.34 percent of total billed charges 1002.54 1536.15 Technical (Hospital) Services Treatment Closed Elbow Dislocation W/O Anes PX-3602460000 CDM 24600 CPT 360 RC inpatient 1617 1617 CIGNA 62308 [3081051] CIGNA 62308 [308105105] 1280.34 percent of total billed charges 1002.54 1536.15 Technical (Hospital) Services Treatment Closed Elbow Dislocation W/O Anes PX-3602460000 CDM 24600 CPT 360 RC inpatient 1617 1617 CIGNA 62308 [3081051] CIGNA STATE OF WYOMING [308105107] 1280.34 percent of total billed charges 1002.54 1536.15 Technical (Hospital) Services Treatment Closed Elbow Dislocation W/O Anes PX-3602460000 CDM 24600 CPT 360 RC inpatient 1617 1617 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES EPO [308136803] 1280.34 percent of total billed charges 1002.54 1536.15 Technical (Hospital) Services Clsd Tx Shoulder Dislc W/Manipulation W/O Anes PX-3602365000 CDM 23650 CPT 360 RC inpatient 1596 1596 CIGNA 62308 [3081051] CIGNA 62308 [308105105] 1263.71 percent of total billed charges 989.52 1516.2 Technical (Hospital) Services Clsd Tx Shoulder Dislc W/Manipulation W/O Anes PX-3602365000 CDM 23650 CPT 360 RC inpatient 1596 1596 CIGNA 62308 [3081051] CIGNA STATE OF WYOMING [308105107] 1263.71 percent of total billed charges 989.52 1516.2 Technical (Hospital) Services Clsd Tx Shoulder Dislc W/Manipulation W/O Anes PX-3602365000 CDM 23650 CPT 360 RC inpatient 1596 1596 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES EPO [308136803] 1263.71 percent of total billed charges 989.52 1516.2 Technical (Hospital) Services Clsd Tx Shoulder Dislc W/Manipulation W/O Anes PX-3602365000 CDM 23650 CPT 360 RC inpatient 1596 1596 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES HDHP [308136802] 1263.71 percent of total billed charges 989.52 1516.2 Technical (Hospital) Services Clsd Tx Shoulder Dislc W/Manipulation W/O Anes PX-3602365000 CDM 23650 CPT 360 RC inpatient 1596 1596 MEDICA (COMMERCIAL) 94265 [3081118] MEDICA CLAIMS [308111801] 1436.4 percent of total billed charges 989.52 1516.2 Technical (Hospital) Services Clsd Tx Shoulder Dislc W/Manipulation W/O Anes PX-3602365000 CDM 23650 CPT 360 RC inpatient 1596 1596 HEALTHPARTNERS SX009 HEALTHPARTNERS 1263.71 percent of total billed charges 989.52 1516.2 Technical (Hospital) Services Clsd Tx Shoulder Dislc W/Manipulation W/O Anes PX-3602365000 CDM 23650 CPT 360 RC inpatient 1596 1596 UNITED HEALTHCARE (COMMERCIAL) [3081199] UNITED HEALTHCARE 87726 [308119901] 989.52 percent of total billed charges 989.52 1516.2 Technical (Hospital) Services Clsd Tx Shoulder Dislc W/Manipulation W/O Anes PX-3602365000 CDM 23650 CPT 360 RC inpatient 1596 1596 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES PPO [308136801] 1263.71 percent of total billed charges 989.52 1516.2 Technical (Hospital) Services Clsd Tx Shoulder Dislc W/Manipulation W/O Anes PX-3602365000 CDM 23650 CPT 360 RC inpatient 1596 1596 BLUE CROSS BLUE SHIELD WELLMARK SB889 [3081026] BCBS WYOMING [308102603] 1516.2 percent of total billed charges 989.52 1516.2 Technical (Hospital) Services Clsd Tx Shoulder Dislc W/Manipulation W/O Anes PX-3602365000 CDM 23650 CPT 360 RC inpatient 1596 1596 MULTIPLAN INC 34080 [3081285] MULTIPLAN INC [308128501] 1516.2 percent of total billed charges 989.52 1516.2 Technical (Hospital) Services Clsd Tx Shoulder Dislc W/Manipulation W/O Anes PX-3602365000 CDM 23650 CPT 360 RC outpatient 1596 1596 CIGNA 62308 [3081051] CIGNA 62308 [308105105] 1276.8 percent of total billed charges 989.52 1516.2 Technical (Hospital) Services Clsd Tx Shoulder Dislc W/Manipulation W/O Anes PX-3602365000 CDM 23650 CPT 360 RC outpatient 1596 1596 CIGNA 62308 [3081051] CIGNA STATE OF WYOMING [308105107] 1276.8 percent of total billed charges 989.52 1516.2 Technical (Hospital) Services Clsd Tx Shoulder Dislc W/Manipulation W/O Anes PX-3602365000 CDM 23650 CPT 360 RC outpatient 1596 1596 HEALTHPARTNERS SX009 HEALTHPARTNERS 1276.8 percent of total billed charges 989.52 1516.2 Technical (Hospital) Services Clsd Tx Shoulder Dislc W/Manipulation W/O Anes PX-3602365000 CDM 23650 CPT 360 RC outpatient 1596 1596 MEDICA (COMMERCIAL) 94265 [3081118] MEDICA CLAIMS [308111801] 1436.4 percent of total billed charges 989.52 1516.2 Technical (Hospital) Services Clsd Tx Shoulder Dislc W/Manipulation W/O Anes PX-3602365000 CDM 23650 CPT 360 RC outpatient 1596 1596 UNITED HEALTHCARE (COMMERCIAL) [3081199] UNITED HEALTHCARE 87726 [308119901] 989.52 percent of total billed charges 989.52 1516.2 Technical (Hospital) Services Clsd Tx Shoulder Dislc W/Manipulation W/O Anes PX-3602365000 CDM 23650 CPT 360 RC outpatient 1596 1596 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES EPO [308136803] 1276.8 percent of total billed charges 989.52 1516.2 Technical (Hospital) Services Clsd Tx Shoulder Dislc W/Manipulation W/O Anes PX-3602365000 CDM 23650 CPT 360 RC outpatient 1596 1596 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES PPO [308136801] 1276.8 percent of total billed charges 989.52 1516.2 Technical (Hospital) Services Clsd Tx Shoulder Dislc W/Manipulation W/O Anes PX-3602365000 CDM 23650 CPT 360 RC outpatient 1596 1596 BLUE CROSS BLUE SHIELD WELLMARK SB889 [3081026] BCBS WYOMING [308102603] 1516.2 percent of total billed charges 989.52 1516.2 Technical (Hospital) Services Clsd Tx Shoulder Dislc W/Manipulation W/O Anes PX-3602365000 CDM 23650 CPT 360 RC outpatient 1596 1596 MULTIPLAN INC 34080 [3081285] MULTIPLAN INC [308128501] 1516.2 percent of total billed charges 989.52 1516.2 Technical (Hospital) Services Clsd Tx Shoulder Dislc W/Manipulation W/O Anes PX-3602365000 CDM 23650 CPT 360 RC outpatient 1596 1596 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES HDHP [308136802] 1276.8 percent of total billed charges 989.52 1516.2 Technical (Hospital) Services Closed Rx Shldr Dislocation PX-23650 CDM 23650 CPT inpatient 1596 1596 CIGNA 62308 [3081051] CIGNA 62308 [308105105] 1276.8 percent of total billed charges 989.52 1516.2 Professional (doctor) services Closed Rx Shldr Dislocation PX-23650 CDM 23650 CPT inpatient 1596 1596 CIGNA 62308 [3081051] CIGNA STATE OF WYOMING [308105107] 1276.8 percent of total billed charges 989.52 1516.2 Professional (doctor) services Closed Rx Shldr Dislocation PX-23650 CDM 23650 CPT outpatient 1596 1596 CIGNA 62308 [3081051] CIGNA 62308 [308105105] 1276.8 percent of total billed charges 989.52 1516.2 Professional (doctor) services Closed Rx Shldr Dislocation PX-23650 CDM 23650 CPT outpatient 1596 1596 CIGNA 62308 [3081051] CIGNA STATE OF WYOMING [308105107] 1276.8 percent of total billed charges 989.52 1516.2 Professional (doctor) services Closed Rx Shldr Dislocation PX-23650 CDM 23650 CPT inpatient 1596 1596 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES EPO [308136803] 1276.8 percent of total billed charges 989.52 1516.2 Professional (doctor) services Closed Rx Shldr Dislocation PX-23650 CDM 23650 CPT inpatient 1596 1596 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES HDHP [308136802] 1276.8 percent of total billed charges 989.52 1516.2 Professional (doctor) services Closed Rx Shldr Dislocation PX-23650 CDM 23650 CPT inpatient 1596 1596 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES PPO [308136801] 1276.8 percent of total billed charges 989.52 1516.2 Professional (doctor) services Closed Rx Shldr Dislocation PX-23650 CDM 23650 CPT outpatient 1596 1596 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES EPO [308136803] 1276.8 percent of total billed charges 989.52 1516.2 Professional (doctor) services Closed Rx Shldr Dislocation PX-23650 CDM 23650 CPT outpatient 1596 1596 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES HDHP [308136802] 1276.8 percent of total billed charges 989.52 1516.2 Professional (doctor) services Closed Rx Shldr Dislocation PX-23650 CDM 23650 CPT outpatient 1596 1596 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES PPO [308136801] 1276.8 percent of total billed charges 989.52 1516.2 Professional (doctor) services Closed Rx Shldr Dislocation PX-23650 CDM 23650 CPT inpatient 1596 1596 HEALTHPARTNERS SX009 HEALTHPARTNERS 1276.8 percent of total billed charges 989.52 1516.2 Professional (doctor) services Closed Rx Shldr Dislocation PX-23650 CDM 23650 CPT outpatient 1596 1596 HEALTHPARTNERS SX009 HEALTHPARTNERS 1276.8 percent of total billed charges 989.52 1516.2 Professional (doctor) services Closed Rx Shldr Dislocation PX-23650 CDM 23650 CPT inpatient 1596 1596 MEDICA (COMMERCIAL) 94265 [3081118] MEDICA CLAIMS [308111801] 1436.4 percent of total billed charges 989.52 1516.2 Professional (doctor) services Closed Rx Shldr Dislocation PX-23650 CDM 23650 CPT outpatient 1596 1596 MEDICA (COMMERCIAL) 94265 [3081118] MEDICA CLAIMS [308111801] 1436.4 percent of total billed charges 989.52 1516.2 Professional (doctor) services Closed Rx Shldr Dislocation PX-23650 CDM 23650 CPT inpatient 1596 1596 MULTIPLAN INC 34080 [3081285] MULTIPLAN INC [308128501] 1516.2 percent of total billed charges 989.52 1516.2 Professional (doctor) services Closed Rx Shldr Dislocation PX-23650 CDM 23650 CPT outpatient 1596 1596 MULTIPLAN INC 34080 [3081285] MULTIPLAN INC [308128501] 1516.2 percent of total billed charges 989.52 1516.2 Professional (doctor) services Closed Rx Shldr Dislocation PX-23650 CDM 23650 CPT inpatient 1596 1596 UNITED HEALTHCARE (COMMERCIAL) [3081199] UNITED HEALTHCARE 87726 [308119901] 989.52 percent of total billed charges 989.52 1516.2 Professional (doctor) services Closed Rx Shldr Dislocation PX-23650 CDM 23650 CPT outpatient 1596 1596 UNITED HEALTHCARE (COMMERCIAL) [3081199] UNITED HEALTHCARE 87726 [308119901] 989.52 percent of total billed charges 989.52 1516.2 Professional (doctor) services Closed Tx Temporomandibular Dislocation 1st/Sbsq PX-3602148000 CDM 21480 CPT 360 RC outpatient 637 637 CIGNA 62308 [3081051] CIGNA 62308 [308105105] 509.6 percent of total billed charges 394.94 605.15 Technical (Hospital) Services Closed Tx Temporomandibular Dislocation 1st/Sbsq PX-3602148000 CDM 21480 CPT 360 RC outpatient 637 637 CIGNA 62308 [3081051] CIGNA STATE OF WYOMING [308105107] 509.6 percent of total billed charges 394.94 605.15 Technical (Hospital) Services Closed Tx Temporomandibular Dislocation 1st/Sbsq PX-3602148000 CDM 21480 CPT 360 RC outpatient 637 637 MEDICA (COMMERCIAL) 94265 [3081118] MEDICA CLAIMS [308111801] 573.3 percent of total billed charges 394.94 605.15 Technical (Hospital) Services Closed Tx Temporomandibular Dislocation 1st/Sbsq PX-3602148000 CDM 21480 CPT 360 RC outpatient 637 637 MULTIPLAN INC 34080 [3081285] MULTIPLAN INC [308128501] 605.15 percent of total billed charges 394.94 605.15 Technical (Hospital) Services Closed Tx Temporomandibular Dislocation 1st/Sbsq PX-3602148000 CDM 21480 CPT 360 RC outpatient 637 637 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES HDHP [308136802] 509.6 percent of total billed charges 394.94 605.15 Technical (Hospital) Services Closed Tx Temporomandibular Dislocation 1st/Sbsq PX-3602148000 CDM 21480 CPT 360 RC outpatient 637 637 BLUE CROSS BLUE SHIELD WELLMARK SB889 [3081026] BCBS WYOMING [308102603] 605.15 percent of total billed charges 394.94 605.15 Technical (Hospital) Services Closed Tx Temporomandibular Dislocation 1st/Sbsq PX-3602148000 CDM 21480 CPT 360 RC outpatient 637 637 UNITED HEALTHCARE (COMMERCIAL) [3081199] UNITED HEALTHCARE 87726 [308119901] 394.94 percent of total billed charges 394.94 605.15 Technical (Hospital) Services Closed Tx Temporomandibular Dislocation 1st/Sbsq PX-3602148000 CDM 21480 CPT 360 RC outpatient 637 637 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES PPO [308136801] 509.6 percent of total billed charges 394.94 605.15 Technical (Hospital) Services Closed Tx Temporomandibular Dislocation 1st/Sbsq PX-3602148000 CDM 21480 CPT 360 RC outpatient 637 637 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES EPO [308136803] 509.6 percent of total billed charges 394.94 605.15 Technical (Hospital) Services Closed Tx Temporomandibular Dislocation 1st/Sbsq PX-3602148000 CDM 21480 CPT 360 RC outpatient 637 637 HEALTHPARTNERS SX009 HEALTHPARTNERS 509.6 percent of total billed charges 394.94 605.15 Technical (Hospital) Services Closed Tx Temporomandibular Dislocation 1st/Sbsq PX-3602148000 CDM 21480 CPT 360 RC inpatient 637 637 CIGNA 62308 [3081051] CIGNA 62308 [308105105] 504.38 percent of total billed charges 394.94 605.15 Technical (Hospital) Services Closed Tx Temporomandibular Dislocation 1st/Sbsq PX-3602148000 CDM 21480 CPT 360 RC inpatient 637 637 CIGNA 62308 [3081051] CIGNA STATE OF WYOMING [308105107] 504.38 percent of total billed charges 394.94 605.15 Technical (Hospital) Services Closed Tx Temporomandibular Dislocation 1st/Sbsq PX-3602148000 CDM 21480 CPT 360 RC inpatient 637 637 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES EPO [308136803] 504.38 percent of total billed charges 394.94 605.15 Technical (Hospital) Services Closed Tx Temporomandibular Dislocation 1st/Sbsq PX-3602148000 CDM 21480 CPT 360 RC inpatient 637 637 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES HDHP [308136802] 504.38 percent of total billed charges 394.94 605.15 Technical (Hospital) Services Closed Tx Temporomandibular Dislocation 1st/Sbsq PX-3602148000 CDM 21480 CPT 360 RC inpatient 637 637 MEDICA (COMMERCIAL) 94265 [3081118] MEDICA CLAIMS [308111801] 573.3 percent of total billed charges 394.94 605.15 Technical (Hospital) Services Closed Tx Temporomandibular Dislocation 1st/Sbsq PX-3602148000 CDM 21480 CPT 360 RC inpatient 637 637 HEALTHPARTNERS SX009 HEALTHPARTNERS 504.38 percent of total billed charges 394.94 605.15 Technical (Hospital) Services Closed Tx Temporomandibular Dislocation 1st/Sbsq PX-3602148000 CDM 21480 CPT 360 RC inpatient 637 637 MULTIPLAN INC 34080 [3081285] MULTIPLAN INC [308128501] 605.15 percent of total billed charges 394.94 605.15 Technical (Hospital) Services Closed Tx Temporomandibular Dislocation 1st/Sbsq PX-3602148000 CDM 21480 CPT 360 RC inpatient 637 637 BLUE CROSS BLUE SHIELD WELLMARK SB889 [3081026] BCBS WYOMING [308102603] 605.15 percent of total billed charges 394.94 605.15 Technical (Hospital) Services Closed Tx Temporomandibular Dislocation 1st/Sbsq PX-3602148000 CDM 21480 CPT 360 RC inpatient 637 637 UNITED HEALTHCARE (COMMERCIAL) [3081199] UNITED HEALTHCARE 87726 [308119901] 394.94 percent of total billed charges 394.94 605.15 Technical (Hospital) Services Closed Tx Temporomandibular Dislocation 1st/Sbsq PX-3602148000 CDM 21480 CPT 360 RC inpatient 637 637 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES PPO [308136801] 504.38 percent of total billed charges 394.94 605.15 Technical (Hospital) Services Arthrocentesis Aspir&/Inj Major Jt/Bursa W/O US PX-3602061000 CDM 20610 CPT 360 RC outpatient 408 408 HEALTHPARTNERS SX009 HEALTHPARTNERS 326.4 percent of total billed charges 252.96 387.6 Technical (Hospital) Services Arthrocentesis Aspir&/Inj Major Jt/Bursa W/O US PX-3602061000 CDM 20610 CPT 360 RC outpatient 408 408 UNITED HEALTHCARE (COMMERCIAL) [3081199] UNITED HEALTHCARE 87726 [308119901] 252.96 percent of total billed charges 252.96 387.6 Technical (Hospital) Services Arthrocentesis Aspir&/Inj Major Jt/Bursa W/O US PX-3602061000 CDM 20610 CPT 360 RC outpatient 408 408 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES EPO [308136803] 326.4 percent of total billed charges 252.96 387.6 Technical (Hospital) Services Arthrocentesis Aspir&/Inj Major Jt/Bursa W/O US PX-3602061000 CDM 20610 CPT 360 RC outpatient 408 408 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES PPO [308136801] 326.4 percent of total billed charges 252.96 387.6 Technical (Hospital) Services Arthrocentesis Aspir&/Inj Major Jt/Bursa W/O US PX-3602061000 CDM 20610 CPT 360 RC outpatient 408 408 BLUE CROSS BLUE SHIELD WELLMARK SB889 [3081026] BCBS WYOMING [308102603] 387.6 percent of total billed charges 252.96 387.6 Technical (Hospital) Services Arthrocentesis Aspir&/Inj Major Jt/Bursa W/O US PX-3602061000 CDM 20610 CPT 360 RC outpatient 408 408 MULTIPLAN INC 34080 [3081285] MULTIPLAN INC [308128501] 387.6 percent of total billed charges 252.96 387.6 Technical (Hospital) Services Arthrocentesis Aspir&/Inj Major Jt/Bursa W/O US PX-3602061000 CDM 20610 CPT 360 RC outpatient 408 408 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES HDHP [308136802] 326.4 percent of total billed charges 252.96 387.6 Technical (Hospital) Services Arthrocentesis Aspir&/Inj Major Jt/Bursa W/O US PX-3602061000 CDM 20610 CPT 360 RC outpatient 408 408 CIGNA 62308 [3081051] CIGNA 62308 [308105105] 326.4 percent of total billed charges 252.96 387.6 Technical (Hospital) Services Arthrocentesis Aspir&/Inj Major Jt/Bursa W/O US PX-3602061000 CDM 20610 CPT 360 RC outpatient 408 408 CIGNA 62308 [3081051] CIGNA STATE OF WYOMING [308105107] 326.4 percent of total billed charges 252.96 387.6 Technical (Hospital) Services Arthrocentesis Aspir&/Inj Major Jt/Bursa W/O US PX-3602061000 CDM 20610 CPT 360 RC outpatient 408 408 MEDICA (COMMERCIAL) 94265 [3081118] MEDICA CLAIMS [308111801] 367.2 percent of total billed charges 252.96 387.6 Technical (Hospital) Services Arthrocentesis Aspir&/Inj Major Jt/Bursa W/O US PX-3602061000 CDM 20610 CPT 360 RC inpatient 408 408 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES PPO [308136801] 323.05 percent of total billed charges 252.96 387.6 Technical (Hospital) Services Arthrocentesis Aspir&/Inj Major Jt/Bursa W/O US PX-3602061000 CDM 20610 CPT 360 RC inpatient 408 408 UNITED HEALTHCARE (COMMERCIAL) [3081199] UNITED HEALTHCARE 87726 [308119901] 252.96 percent of total billed charges 252.96 387.6 Technical (Hospital) Services Arthrocentesis Aspir&/Inj Major Jt/Bursa W/O US PX-3602061000 CDM 20610 CPT 360 RC inpatient 408 408 BLUE CROSS BLUE SHIELD WELLMARK SB889 [3081026] BCBS WYOMING [308102603] 387.6 percent of total billed charges 252.96 387.6 Technical (Hospital) Services Arthrocentesis Aspir&/Inj Major Jt/Bursa W/O US PX-3602061000 CDM 20610 CPT 360 RC inpatient 408 408 MULTIPLAN INC 34080 [3081285] MULTIPLAN INC [308128501] 387.6 percent of total billed charges 252.96 387.6 Technical (Hospital) Services Arthrocentesis Aspir&/Inj Major Jt/Bursa W/O US PX-3602061000 CDM 20610 CPT 360 RC inpatient 408 408 HEALTHPARTNERS SX009 HEALTHPARTNERS 323.05 percent of total billed charges 252.96 387.6 Technical (Hospital) Services Arthrocentesis Aspir&/Inj Major Jt/Bursa W/O US PX-3602061000 CDM 20610 CPT 360 RC inpatient 408 408 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES HDHP [308136802] 323.05 percent of total billed charges 252.96 387.6 Technical (Hospital) Services Arthrocentesis Aspir&/Inj Major Jt/Bursa W/O US PX-3602061000 CDM 20610 CPT 360 RC inpatient 408 408 MEDICA (COMMERCIAL) 94265 [3081118] MEDICA CLAIMS [308111801] 367.2 percent of total billed charges 252.96 387.6 Technical (Hospital) Services Arthrocentesis Aspir&/Inj Major Jt/Bursa W/O US PX-3602061000 CDM 20610 CPT 360 RC inpatient 408 408 CIGNA 62308 [3081051] CIGNA 62308 [308105105] 323.05 percent of total billed charges 252.96 387.6 Technical (Hospital) Services Arthrocentesis Aspir&/Inj Major Jt/Bursa W/O US PX-3602061000 CDM 20610 CPT 360 RC inpatient 408 408 CIGNA 62308 [3081051] CIGNA STATE OF WYOMING [308105107] 323.05 percent of total billed charges 252.96 387.6 Technical (Hospital) Services Arthrocentesis Aspir&/Inj Major Jt/Bursa W/O US PX-3602061000 CDM 20610 CPT 360 RC inpatient 408 408 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES EPO [308136803] 323.05 percent of total billed charges 252.96 387.6 Technical (Hospital) Services Arthrocentesis Aspir&/Inj Major Jt/Bursa W/O US PX-20610 CDM 20610 CPT inpatient 408 408 CIGNA 62308 [3081051] CIGNA 62308 [308105105] 326.4 percent of total billed charges 252.96 387.6 Professional (doctor) services Arthrocentesis Aspir&/Inj Major Jt/Bursa W/O US PX-20610 CDM 20610 CPT inpatient 408 408 CIGNA 62308 [3081051] CIGNA STATE OF WYOMING [308105107] 326.4 percent of total billed charges 252.96 387.6 Professional (doctor) services Arthrocentesis Aspir&/Inj Major Jt/Bursa W/O US PX-20610 CDM 20610 CPT outpatient 408 408 CIGNA 62308 [3081051] CIGNA 62308 [308105105] 326.4 percent of total billed charges 252.96 387.6 Professional (doctor) services Arthrocentesis Aspir&/Inj Major Jt/Bursa W/O US PX-20610 CDM 20610 CPT outpatient 408 408 CIGNA 62308 [3081051] CIGNA STATE OF WYOMING [308105107] 326.4 percent of total billed charges 252.96 387.6 Professional (doctor) services Arthrocentesis Aspir&/Inj Major Jt/Bursa W/O US PX-20610 CDM 20610 CPT inpatient 408 408 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES EPO [308136803] 326.4 percent of total billed charges 252.96 387.6 Professional (doctor) services Arthrocentesis Aspir&/Inj Major Jt/Bursa W/O US PX-20610 CDM 20610 CPT inpatient 408 408 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES HDHP [308136802] 326.4 percent of total billed charges 252.96 387.6 Professional (doctor) services Arthrocentesis Aspir&/Inj Major Jt/Bursa W/O US PX-20610 CDM 20610 CPT inpatient 408 408 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES PPO [308136801] 326.4 percent of total billed charges 252.96 387.6 Professional (doctor) services Arthrocentesis Aspir&/Inj Major Jt/Bursa W/O US PX-20610 CDM 20610 CPT outpatient 408 408 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES EPO [308136803] 326.4 percent of total billed charges 252.96 387.6 Professional (doctor) services Arthrocentesis Aspir&/Inj Major Jt/Bursa W/O US PX-20610 CDM 20610 CPT outpatient 408 408 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES HDHP [308136802] 326.4 percent of total billed charges 252.96 387.6 Professional (doctor) services Arthrocentesis Aspir&/Inj Major Jt/Bursa W/O US PX-20610 CDM 20610 CPT outpatient 408 408 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES PPO [308136801] 326.4 percent of total billed charges 252.96 387.6 Professional (doctor) services Arthrocentesis Aspir&/Inj Major Jt/Bursa W/O US PX-20610 CDM 20610 CPT inpatient 408 408 HEALTHPARTNERS SX009 HEALTHPARTNERS 326.4 percent of total billed charges 252.96 387.6 Professional (doctor) services Arthrocentesis Aspir&/Inj Major Jt/Bursa W/O US PX-20610 CDM 20610 CPT outpatient 408 408 HEALTHPARTNERS SX009 HEALTHPARTNERS 326.4 percent of total billed charges 252.96 387.6 Professional (doctor) services Arthrocentesis Aspir&/Inj Major Jt/Bursa W/O US PX-20610 CDM 20610 CPT inpatient 408 408 MEDICA (COMMERCIAL) 94265 [3081118] MEDICA CLAIMS [308111801] 367.2 percent of total billed charges 252.96 387.6 Professional (doctor) services Arthrocentesis Aspir&/Inj Major Jt/Bursa W/O US PX-20610 CDM 20610 CPT outpatient 408 408 MEDICA (COMMERCIAL) 94265 [3081118] MEDICA CLAIMS [308111801] 367.2 percent of total billed charges 252.96 387.6 Professional (doctor) services Arthrocentesis Aspir&/Inj Major Jt/Bursa W/O US PX-20610 CDM 20610 CPT inpatient 408 408 MULTIPLAN INC 34080 [3081285] MULTIPLAN INC [308128501] 387.6 percent of total billed charges 252.96 387.6 Professional (doctor) services Arthrocentesis Aspir&/Inj Major Jt/Bursa W/O US PX-20610 CDM 20610 CPT outpatient 408 408 MULTIPLAN INC 34080 [3081285] MULTIPLAN INC [308128501] 387.6 percent of total billed charges 252.96 387.6 Professional (doctor) services Arthrocentesis Aspir&/Inj Major Jt/Bursa W/O US PX-20610 CDM 20610 CPT inpatient 408 408 UNITED HEALTHCARE (COMMERCIAL) [3081199] UNITED HEALTHCARE 87726 [308119901] 252.96 percent of total billed charges 252.96 387.6 Professional (doctor) services Arthrocentesis Aspir&/Inj Major Jt/Bursa W/O US PX-20610 CDM 20610 CPT outpatient 408 408 UNITED HEALTHCARE (COMMERCIAL) [3081199] UNITED HEALTHCARE 87726 [308119901] 252.96 percent of total billed charges 252.96 387.6 Professional (doctor) services Arthrocentesis Aspir&/Inj Interm Jt/Burs W/O US PX-3602060500 CDM 20605 CPT 360 RC inpatient 342 342 CIGNA 62308 [3081051] CIGNA 62308 [308105105] 270.8 percent of total billed charges 212.04 324.9 Technical (Hospital) Services Arthrocentesis Aspir&/Inj Interm Jt/Burs W/O US PX-3602060500 CDM 20605 CPT 360 RC inpatient 342 342 CIGNA 62308 [3081051] CIGNA STATE OF WYOMING [308105107] 270.8 percent of total billed charges 212.04 324.9 Technical (Hospital) Services Arthrocentesis Aspir&/Inj Interm Jt/Burs W/O US PX-3602060500 CDM 20605 CPT 360 RC inpatient 342 342 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES EPO [308136803] 270.8 percent of total billed charges 212.04 324.9 Technical (Hospital) Services Arthrocentesis Aspir&/Inj Interm Jt/Burs W/O US PX-3602060500 CDM 20605 CPT 360 RC inpatient 342 342 HEALTHPARTNERS SX009 HEALTHPARTNERS 270.8 percent of total billed charges 212.04 324.9 Technical (Hospital) Services Arthrocentesis Aspir&/Inj Interm Jt/Burs W/O US PX-3602060500 CDM 20605 CPT 360 RC inpatient 342 342 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES HDHP [308136802] 270.8 percent of total billed charges 212.04 324.9 Technical (Hospital) Services Arthrocentesis Aspir&/Inj Interm Jt/Burs W/O US PX-3602060500 CDM 20605 CPT 360 RC inpatient 342 342 MEDICA (COMMERCIAL) 94265 [3081118] MEDICA CLAIMS [308111801] 307.8 percent of total billed charges 212.04 324.9 Technical (Hospital) Services Arthrocentesis Aspir&/Inj Interm Jt/Burs W/O US PX-3602060500 CDM 20605 CPT 360 RC inpatient 342 342 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES PPO [308136801] 270.8 percent of total billed charges 212.04 324.9 Technical (Hospital) Services Arthrocentesis Aspir&/Inj Interm Jt/Burs W/O US PX-3602060500 CDM 20605 CPT 360 RC inpatient 342 342 UNITED HEALTHCARE (COMMERCIAL) [3081199] UNITED HEALTHCARE 87726 [308119901] 212.04 percent of total billed charges 212.04 324.9 Technical (Hospital) Services Arthrocentesis Aspir&/Inj Interm Jt/Burs W/O US PX-3602060500 CDM 20605 CPT 360 RC inpatient 342 342 BLUE CROSS BLUE SHIELD WELLMARK SB889 [3081026] BCBS WYOMING [308102603] 324.9 percent of total billed charges 212.04 324.9 Technical (Hospital) Services Arthrocentesis Aspir&/Inj Interm Jt/Burs W/O US PX-3602060500 CDM 20605 CPT 360 RC inpatient 342 342 MULTIPLAN INC 34080 [3081285] MULTIPLAN INC [308128501] 324.9 percent of total billed charges 212.04 324.9 Technical (Hospital) Services Arthrocentesis Aspir&/Inj Interm Jt/Burs W/O US PX-3602060500 CDM 20605 CPT 360 RC outpatient 342 342 HEALTHPARTNERS SX009 HEALTHPARTNERS 273.6 percent of total billed charges 212.04 324.9 Technical (Hospital) Services Arthrocentesis Aspir&/Inj Interm Jt/Burs W/O US PX-3602060500 CDM 20605 CPT 360 RC outpatient 342 342 MEDICA (COMMERCIAL) 94265 [3081118] MEDICA CLAIMS [308111801] 307.8 percent of total billed charges 212.04 324.9 Technical (Hospital) Services Arthrocentesis Aspir&/Inj Interm Jt/Burs W/O US PX-3602060500 CDM 20605 CPT 360 RC outpatient 342 342 UNITED HEALTHCARE (COMMERCIAL) [3081199] UNITED HEALTHCARE 87726 [308119901] 212.04 percent of total billed charges 212.04 324.9 Technical (Hospital) Services Arthrocentesis Aspir&/Inj Interm Jt/Burs W/O US PX-3602060500 CDM 20605 CPT 360 RC outpatient 342 342 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES EPO [308136803] 273.6 percent of total billed charges 212.04 324.9 Technical (Hospital) Services Arthrocentesis Aspir&/Inj Interm Jt/Burs W/O US PX-3602060500 CDM 20605 CPT 360 RC outpatient 342 342 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES PPO [308136801] 273.6 percent of total billed charges 212.04 324.9 Technical (Hospital) Services Arthrocentesis Aspir&/Inj Interm Jt/Burs W/O US PX-3602060500 CDM 20605 CPT 360 RC outpatient 342 342 BLUE CROSS BLUE SHIELD WELLMARK SB889 [3081026] BCBS WYOMING [308102603] 324.9 percent of total billed charges 212.04 324.9 Technical (Hospital) Services Arthrocentesis Aspir&/Inj Interm Jt/Burs W/O US PX-3602060500 CDM 20605 CPT 360 RC outpatient 342 342 MULTIPLAN INC 34080 [3081285] MULTIPLAN INC [308128501] 324.9 percent of total billed charges 212.04 324.9 Technical (Hospital) Services Arthrocentesis Aspir&/Inj Interm Jt/Burs W/O US PX-3602060500 CDM 20605 CPT 360 RC outpatient 342 342 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES HDHP [308136802] 273.6 percent of total billed charges 212.04 324.9 Technical (Hospital) Services Arthrocentesis Aspir&/Inj Interm Jt/Burs W/O US PX-3602060500 CDM 20605 CPT 360 RC outpatient 342 342 CIGNA 62308 [3081051] CIGNA 62308 [308105105] 273.6 percent of total billed charges 212.04 324.9 Technical (Hospital) Services Arthrocentesis Aspir&/Inj Interm Jt/Burs W/O US PX-3602060500 CDM 20605 CPT 360 RC outpatient 342 342 CIGNA 62308 [3081051] CIGNA STATE OF WYOMING [308105107] 273.6 percent of total billed charges 212.04 324.9 Technical (Hospital) Services Arthrocentesis Aspir&/Inj Interm Jt/Burs W/O US PX-20605 CDM 20605 CPT inpatient 342 342 CIGNA 62308 [3081051] CIGNA 62308 [308105105] 273.6 percent of total billed charges 212.04 324.9 Professional (doctor) services Arthrocentesis Aspir&/Inj Interm Jt/Burs W/O US PX-20605 CDM 20605 CPT inpatient 342 342 CIGNA 62308 [3081051] CIGNA STATE OF WYOMING [308105107] 273.6 percent of total billed charges 212.04 324.9 Professional (doctor) services Arthrocentesis Aspir&/Inj Interm Jt/Burs W/O US PX-20605 CDM 20605 CPT outpatient 342 342 CIGNA 62308 [3081051] CIGNA 62308 [308105105] 273.6 percent of total billed charges 212.04 324.9 Professional (doctor) services Arthrocentesis Aspir&/Inj Interm Jt/Burs W/O US PX-20605 CDM 20605 CPT outpatient 342 342 CIGNA 62308 [3081051] CIGNA STATE OF WYOMING [308105107] 273.6 percent of total billed charges 212.04 324.9 Professional (doctor) services Arthrocentesis Aspir&/Inj Interm Jt/Burs W/O US PX-20605 CDM 20605 CPT inpatient 342 342 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES EPO [308136803] 273.6 percent of total billed charges 212.04 324.9 Professional (doctor) services Arthrocentesis Aspir&/Inj Interm Jt/Burs W/O US PX-20605 CDM 20605 CPT inpatient 342 342 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES HDHP [308136802] 273.6 percent of total billed charges 212.04 324.9 Professional (doctor) services Arthrocentesis Aspir&/Inj Interm Jt/Burs W/O US PX-20605 CDM 20605 CPT inpatient 342 342 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES PPO [308136801] 273.6 percent of total billed charges 212.04 324.9 Professional (doctor) services Arthrocentesis Aspir&/Inj Interm Jt/Burs W/O US PX-20605 CDM 20605 CPT outpatient 342 342 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES EPO [308136803] 273.6 percent of total billed charges 212.04 324.9 Professional (doctor) services Arthrocentesis Aspir&/Inj Interm Jt/Burs W/O US PX-20605 CDM 20605 CPT outpatient 342 342 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES HDHP [308136802] 273.6 percent of total billed charges 212.04 324.9 Professional (doctor) services Arthrocentesis Aspir&/Inj Interm Jt/Burs W/O US PX-20605 CDM 20605 CPT outpatient 342 342 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES PPO [308136801] 273.6 percent of total billed charges 212.04 324.9 Professional (doctor) services Arthrocentesis Aspir&/Inj Interm Jt/Burs W/O US PX-20605 CDM 20605 CPT inpatient 342 342 HEALTHPARTNERS SX009 HEALTHPARTNERS 273.6 percent of total billed charges 212.04 324.9 Professional (doctor) services Arthrocentesis Aspir&/Inj Interm Jt/Burs W/O US PX-20605 CDM 20605 CPT outpatient 342 342 HEALTHPARTNERS SX009 HEALTHPARTNERS 273.6 percent of total billed charges 212.04 324.9 Professional (doctor) services Arthrocentesis Aspir&/Inj Interm Jt/Burs W/O US PX-20605 CDM 20605 CPT inpatient 342 342 MEDICA (COMMERCIAL) 94265 [3081118] MEDICA CLAIMS [308111801] 307.8 percent of total billed charges 212.04 324.9 Professional (doctor) services Arthrocentesis Aspir&/Inj Interm Jt/Burs W/O US PX-20605 CDM 20605 CPT outpatient 342 342 MEDICA (COMMERCIAL) 94265 [3081118] MEDICA CLAIMS [308111801] 307.8 percent of total billed charges 212.04 324.9 Professional (doctor) services Arthrocentesis Aspir&/Inj Interm Jt/Burs W/O US PX-20605 CDM 20605 CPT inpatient 342 342 MULTIPLAN INC 34080 [3081285] MULTIPLAN INC [308128501] 324.9 percent of total billed charges 212.04 324.9 Professional (doctor) services Arthrocentesis Aspir&/Inj Interm Jt/Burs W/O US PX-20605 CDM 20605 CPT outpatient 342 342 MULTIPLAN INC 34080 [3081285] MULTIPLAN INC [308128501] 324.9 percent of total billed charges 212.04 324.9 Professional (doctor) services Arthrocentesis Aspir&/Inj Interm Jt/Burs W/O US PX-20605 CDM 20605 CPT inpatient 342 342 UNITED HEALTHCARE (COMMERCIAL) [3081199] UNITED HEALTHCARE 87726 [308119901] 212.04 percent of total billed charges 212.04 324.9 Professional (doctor) services Arthrocentesis Aspir&/Inj Interm Jt/Burs W/O US PX-20605 CDM 20605 CPT outpatient 342 342 UNITED HEALTHCARE (COMMERCIAL) [3081199] UNITED HEALTHCARE 87726 [308119901] 212.04 percent of total billed charges 212.04 324.9 Professional (doctor) services Needle Insertion W/O Injection 3 or More Muscles PX-3602056100 CDM 20561 CPT 360 RC inpatient 67 67 CIGNA 62308 [3081051] CIGNA 62308 [308105105] 53.05 percent of total billed charges 41.54 63.65 Technical (Hospital) Services Needle Insertion W/O Injection 3 or More Muscles PX-3602056100 CDM 20561 CPT 360 RC inpatient 67 67 CIGNA 62308 [3081051] CIGNA STATE OF WYOMING [308105107] 53.05 percent of total billed charges 41.54 63.65 Technical (Hospital) Services Needle Insertion W/O Injection 3 or More Muscles PX-3602056100 CDM 20561 CPT 360 RC inpatient 67 67 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES EPO [308136803] 53.05 percent of total billed charges 41.54 63.65 Technical (Hospital) Services Needle Insertion W/O Injection 3 or More Muscles PX-3602056100 CDM 20561 CPT 360 RC inpatient 67 67 UNITED HEALTHCARE (COMMERCIAL) [3081199] UNITED HEALTHCARE 87726 [308119901] 41.54 percent of total billed charges 41.54 63.65 Technical (Hospital) Services Needle Insertion W/O Injection 3 or More Muscles PX-3602056100 CDM 20561 CPT 360 RC inpatient 67 67 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES PPO [308136801] 53.05 percent of total billed charges 41.54 63.65 Technical (Hospital) Services Needle Insertion W/O Injection 3 or More Muscles PX-3602056100 CDM 20561 CPT 360 RC inpatient 67 67 MULTIPLAN INC 34080 [3081285] MULTIPLAN INC [308128501] 63.65 percent of total billed charges 41.54 63.65 Technical (Hospital) Services Needle Insertion W/O Injection 3 or More Muscles PX-3602056100 CDM 20561 CPT 360 RC inpatient 67 67 BLUE CROSS BLUE SHIELD WELLMARK SB889 [3081026] BCBS WYOMING [308102603] 63.65 percent of total billed charges 41.54 63.65 Technical (Hospital) Services Needle Insertion W/O Injection 3 or More Muscles PX-3602056100 CDM 20561 CPT 360 RC inpatient 67 67 MEDICA (COMMERCIAL) 94265 [3081118] MEDICA CLAIMS [308111801] 60.3 percent of total billed charges 41.54 63.65 Technical (Hospital) Services Needle Insertion W/O Injection 3 or More Muscles PX-3602056100 CDM 20561 CPT 360 RC inpatient 67 67 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES HDHP [308136802] 53.05 percent of total billed charges 41.54 63.65 Technical (Hospital) Services Needle Insertion W/O Injection 3 or More Muscles PX-3602056100 CDM 20561 CPT 360 RC inpatient 67 67 HEALTHPARTNERS SX009 HEALTHPARTNERS 53.05 percent of total billed charges 41.54 63.65 Technical (Hospital) Services Needle Insertion W/O Injection 3 or More Muscles PX-3602056100 CDM 20561 CPT 360 RC outpatient 67 67 BLUE CROSS BLUE SHIELD WELLMARK SB889 [3081026] BCBS WYOMING [308102603] 63.65 percent of total billed charges 41.54 63.65 Technical (Hospital) Services Needle Insertion W/O Injection 3 or More Muscles PX-3602056100 CDM 20561 CPT 360 RC outpatient 67 67 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES HDHP [308136802] 53.6 percent of total billed charges 41.54 63.65 Technical (Hospital) Services Needle Insertion W/O Injection 3 or More Muscles PX-3602056100 CDM 20561 CPT 360 RC outpatient 67 67 MULTIPLAN INC 34080 [3081285] MULTIPLAN INC [308128501] 63.65 percent of total billed charges 41.54 63.65 Technical (Hospital) Services Needle Insertion W/O Injection 3 or More Muscles PX-3602056100 CDM 20561 CPT 360 RC outpatient 67 67 UNITED HEALTHCARE (COMMERCIAL) [3081199] UNITED HEALTHCARE 87726 [308119901] 41.54 percent of total billed charges 41.54 63.65 Technical (Hospital) Services Needle Insertion W/O Injection 3 or More Muscles PX-3602056100 CDM 20561 CPT 360 RC outpatient 67 67 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES PPO [308136801] 53.6 percent of total billed charges 41.54 63.65 Technical (Hospital) Services Needle Insertion W/O Injection 3 or More Muscles PX-3602056100 CDM 20561 CPT 360 RC outpatient 67 67 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES EPO [308136803] 53.6 percent of total billed charges 41.54 63.65 Technical (Hospital) Services Needle Insertion W/O Injection 3 or More Muscles PX-3602056100 CDM 20561 CPT 360 RC outpatient 67 67 HEALTHPARTNERS SX009 HEALTHPARTNERS 53.6 percent of total billed charges 41.54 63.65 Technical (Hospital) Services Needle Insertion W/O Injection 3 or More Muscles PX-3602056100 CDM 20561 CPT 360 RC outpatient 67 67 MEDICA (COMMERCIAL) 94265 [3081118] MEDICA CLAIMS [308111801] 60.3 percent of total billed charges 41.54 63.65 Technical (Hospital) Services Needle Insertion W/O Injection 3 or More Muscles PX-3602056100 CDM 20561 CPT 360 RC outpatient 67 67 CIGNA 62308 [3081051] CIGNA 62308 [308105105] 53.6 percent of total billed charges 41.54 63.65 Technical (Hospital) Services Needle Insertion W/O Injection 3 or More Muscles PX-3602056100 CDM 20561 CPT 360 RC outpatient 67 67 CIGNA 62308 [3081051] CIGNA STATE OF WYOMING [308105107] 53.6 percent of total billed charges 41.54 63.65 Technical (Hospital) Services Needle Insertion W/O Injection 1 or 2 Muscles PX-3602056000 CDM 20560 CPT 360 RC inpatient 55 55 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES HDHP [308136802] 43.55 percent of total billed charges 34.1 52.25 Technical (Hospital) Services Needle Insertion W/O Injection 1 or 2 Muscles PX-3602056000 CDM 20560 CPT 360 RC inpatient 55 55 MEDICA (COMMERCIAL) 94265 [3081118] MEDICA CLAIMS [308111801] 49.5 percent of total billed charges 34.1 52.25 Technical (Hospital) Services Needle Insertion W/O Injection 1 or 2 Muscles PX-3602056000 CDM 20560 CPT 360 RC inpatient 55 55 HEALTHPARTNERS SX009 HEALTHPARTNERS 43.55 percent of total billed charges 34.1 52.25 Technical (Hospital) Services Needle Insertion W/O Injection 1 or 2 Muscles PX-3602056000 CDM 20560 CPT 360 RC inpatient 55 55 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES PPO [308136801] 43.55 percent of total billed charges 34.1 52.25 Technical (Hospital) Services Needle Insertion W/O Injection 1 or 2 Muscles PX-3602056000 CDM 20560 CPT 360 RC inpatient 55 55 UNITED HEALTHCARE (COMMERCIAL) [3081199] UNITED HEALTHCARE 87726 [308119901] 34.1 percent of total billed charges 34.1 52.25 Technical (Hospital) Services Needle Insertion W/O Injection 1 or 2 Muscles PX-3602056000 CDM 20560 CPT 360 RC inpatient 55 55 MULTIPLAN INC 34080 [3081285] MULTIPLAN INC [308128501] 52.25 percent of total billed charges 34.1 52.25 Technical (Hospital) Services Needle Insertion W/O Injection 1 or 2 Muscles PX-3602056000 CDM 20560 CPT 360 RC inpatient 55 55 BLUE CROSS BLUE SHIELD WELLMARK SB889 [3081026] BCBS WYOMING [308102603] 52.25 percent of total billed charges 34.1 52.25 Technical (Hospital) Services Needle Insertion W/O Injection 1 or 2 Muscles PX-3602056000 CDM 20560 CPT 360 RC inpatient 55 55 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES EPO [308136803] 43.55 percent of total billed charges 34.1 52.25 Technical (Hospital) Services Needle Insertion W/O Injection 1 or 2 Muscles PX-3602056000 CDM 20560 CPT 360 RC inpatient 55 55 CIGNA 62308 [3081051] CIGNA 62308 [308105105] 43.55 percent of total billed charges 34.1 52.25 Technical (Hospital) Services Needle Insertion W/O Injection 1 or 2 Muscles PX-3602056000 CDM 20560 CPT 360 RC inpatient 55 55 CIGNA 62308 [3081051] CIGNA STATE OF WYOMING [308105107] 43.55 percent of total billed charges 34.1 52.25 Technical (Hospital) Services Needle Insertion W/O Injection 1 or 2 Muscles PX-3602056000 CDM 20560 CPT 360 RC outpatient 55 55 MEDICA (COMMERCIAL) 94265 [3081118] MEDICA CLAIMS [308111801] 49.5 percent of total billed charges 34.1 52.25 Technical (Hospital) Services Needle Insertion W/O Injection 1 or 2 Muscles PX-3602056000 CDM 20560 CPT 360 RC outpatient 55 55 CIGNA 62308 [3081051] CIGNA 62308 [308105105] 44 percent of total billed charges 34.1 52.25 Technical (Hospital) Services Needle Insertion W/O Injection 1 or 2 Muscles PX-3602056000 CDM 20560 CPT 360 RC outpatient 55 55 CIGNA 62308 [3081051] CIGNA STATE OF WYOMING [308105107] 44 percent of total billed charges 34.1 52.25 Technical (Hospital) Services Needle Insertion W/O Injection 1 or 2 Muscles PX-3602056000 CDM 20560 CPT 360 RC outpatient 55 55 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES EPO [308136803] 44 percent of total billed charges 34.1 52.25 Technical (Hospital) Services Needle Insertion W/O Injection 1 or 2 Muscles PX-3602056000 CDM 20560 CPT 360 RC outpatient 55 55 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES PPO [308136801] 44 percent of total billed charges 34.1 52.25 Technical (Hospital) Services Needle Insertion W/O Injection 1 or 2 Muscles PX-3602056000 CDM 20560 CPT 360 RC outpatient 55 55 BLUE CROSS BLUE SHIELD WELLMARK SB889 [3081026] BCBS WYOMING [308102603] 52.25 percent of total billed charges 34.1 52.25 Technical (Hospital) Services Needle Insertion W/O Injection 1 or 2 Muscles PX-3602056000 CDM 20560 CPT 360 RC outpatient 55 55 MULTIPLAN INC 34080 [3081285] MULTIPLAN INC [308128501] 52.25 percent of total billed charges 34.1 52.25 Technical (Hospital) Services Needle Insertion W/O Injection 1 or 2 Muscles PX-3602056000 CDM 20560 CPT 360 RC outpatient 55 55 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES HDHP [308136802] 44 percent of total billed charges 34.1 52.25 Technical (Hospital) Services Needle Insertion W/O Injection 1 or 2 Muscles PX-3602056000 CDM 20560 CPT 360 RC outpatient 55 55 UNITED HEALTHCARE (COMMERCIAL) [3081199] UNITED HEALTHCARE 87726 [308119901] 34.1 percent of total billed charges 34.1 52.25 Technical (Hospital) Services Needle Insertion W/O Injection 1 or 2 Muscles PX-3602056000 CDM 20560 CPT 360 RC outpatient 55 55 HEALTHPARTNERS SX009 HEALTHPARTNERS 44 percent of total billed charges 34.1 52.25 Technical (Hospital) Services "Inject Trigger Points, > 3" PX-20553 CDM 20553 CPT inpatient 161 161 CIGNA 62308 [3081051] CIGNA 62308 [308105105] 128.8 percent of total billed charges 99.82 152.95 Professional (doctor) services "Inject Trigger Points, > 3" PX-20553 CDM 20553 CPT inpatient 161 161 CIGNA 62308 [3081051] CIGNA STATE OF WYOMING [308105107] 128.8 percent of total billed charges 99.82 152.95 Professional (doctor) services "Inject Trigger Points, > 3" PX-20553 CDM 20553 CPT outpatient 161 161 CIGNA 62308 [3081051] CIGNA 62308 [308105105] 128.8 percent of total billed charges 99.82 152.95 Professional (doctor) services "Inject Trigger Points, > 3" PX-20553 CDM 20553 CPT outpatient 161 161 CIGNA 62308 [3081051] CIGNA STATE OF WYOMING [308105107] 128.8 percent of total billed charges 99.82 152.95 Professional (doctor) services "Inject Trigger Points, > 3" PX-20553 CDM 20553 CPT inpatient 161 161 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES EPO [308136803] 128.8 percent of total billed charges 99.82 152.95 Professional (doctor) services "Inject Trigger Points, > 3" PX-20553 CDM 20553 CPT inpatient 161 161 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES HDHP [308136802] 128.8 percent of total billed charges 99.82 152.95 Professional (doctor) services "Inject Trigger Points, > 3" PX-20553 CDM 20553 CPT inpatient 161 161 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES PPO [308136801] 128.8 percent of total billed charges 99.82 152.95 Professional (doctor) services "Inject Trigger Points, > 3" PX-20553 CDM 20553 CPT outpatient 161 161 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES EPO [308136803] 128.8 percent of total billed charges 99.82 152.95 Professional (doctor) services "Inject Trigger Points, > 3" PX-20553 CDM 20553 CPT outpatient 161 161 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES HDHP [308136802] 128.8 percent of total billed charges 99.82 152.95 Professional (doctor) services "Inject Trigger Points, > 3" PX-20553 CDM 20553 CPT outpatient 161 161 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES PPO [308136801] 128.8 percent of total billed charges 99.82 152.95 Professional (doctor) services "Inject Trigger Points, > 3" PX-20553 CDM 20553 CPT inpatient 161 161 HEALTHPARTNERS SX009 HEALTHPARTNERS 128.8 percent of total billed charges 99.82 152.95 Professional (doctor) services "Inject Trigger Points, > 3" PX-20553 CDM 20553 CPT outpatient 161 161 HEALTHPARTNERS SX009 HEALTHPARTNERS 128.8 percent of total billed charges 99.82 152.95 Professional (doctor) services "Inject Trigger Points, > 3" PX-20553 CDM 20553 CPT inpatient 161 161 MEDICA (COMMERCIAL) 94265 [3081118] MEDICA CLAIMS [308111801] 144.9 percent of total billed charges 99.82 152.95 Professional (doctor) services "Inject Trigger Points, > 3" PX-20553 CDM 20553 CPT outpatient 161 161 MEDICA (COMMERCIAL) 94265 [3081118] MEDICA CLAIMS [308111801] 144.9 percent of total billed charges 99.82 152.95 Professional (doctor) services "Inject Trigger Points, > 3" PX-20553 CDM 20553 CPT inpatient 161 161 MULTIPLAN INC 34080 [3081285] MULTIPLAN INC [308128501] 152.95 percent of total billed charges 99.82 152.95 Professional (doctor) services "Inject Trigger Points, > 3" PX-20553 CDM 20553 CPT outpatient 161 161 MULTIPLAN INC 34080 [3081285] MULTIPLAN INC [308128501] 152.95 percent of total billed charges 99.82 152.95 Professional (doctor) services "Inject Trigger Points, > 3" PX-20553 CDM 20553 CPT inpatient 161 161 UNITED HEALTHCARE (COMMERCIAL) [3081199] UNITED HEALTHCARE 87726 [308119901] 99.82 percent of total billed charges 99.82 152.95 Professional (doctor) services "Inject Trigger Points, > 3" PX-20553 CDM 20553 CPT outpatient 161 161 UNITED HEALTHCARE (COMMERCIAL) [3081199] UNITED HEALTHCARE 87726 [308119901] 99.82 percent of total billed charges 99.82 152.95 Professional (doctor) services "Inject Trigger Point, 1 or 2" PX-20552 CDM 20552 CPT inpatient 335 335 CIGNA 62308 [3081051] CIGNA 62308 [308105105] 268 percent of total billed charges 207.7 318.25 Professional (doctor) services "Inject Trigger Point, 1 or 2" PX-20552 CDM 20552 CPT inpatient 335 335 CIGNA 62308 [3081051] CIGNA STATE OF WYOMING [308105107] 268 percent of total billed charges 207.7 318.25 Professional (doctor) services "Inject Trigger Point, 1 or 2" PX-20552 CDM 20552 CPT outpatient 335 335 CIGNA 62308 [3081051] CIGNA 62308 [308105105] 268 percent of total billed charges 207.7 318.25 Professional (doctor) services "Inject Trigger Point, 1 or 2" PX-20552 CDM 20552 CPT outpatient 335 335 CIGNA 62308 [3081051] CIGNA STATE OF WYOMING [308105107] 268 percent of total billed charges 207.7 318.25 Professional (doctor) services "Inject Trigger Point, 1 or 2" PX-20552 CDM 20552 CPT inpatient 335 335 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES EPO [308136803] 268 percent of total billed charges 207.7 318.25 Professional (doctor) services "Inject Trigger Point, 1 or 2" PX-20552 CDM 20552 CPT inpatient 335 335 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES HDHP [308136802] 268 percent of total billed charges 207.7 318.25 Professional (doctor) services "Inject Trigger Point, 1 or 2" PX-20552 CDM 20552 CPT inpatient 335 335 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES PPO [308136801] 268 percent of total billed charges 207.7 318.25 Professional (doctor) services "Inject Trigger Point, 1 or 2" PX-20552 CDM 20552 CPT outpatient 335 335 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES EPO [308136803] 268 percent of total billed charges 207.7 318.25 Professional (doctor) services "Inject Trigger Point, 1 or 2" PX-20552 CDM 20552 CPT outpatient 335 335 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES HDHP [308136802] 268 percent of total billed charges 207.7 318.25 Professional (doctor) services "Inject Trigger Point, 1 or 2" PX-20552 CDM 20552 CPT outpatient 335 335 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES PPO [308136801] 268 percent of total billed charges 207.7 318.25 Professional (doctor) services "Inject Trigger Point, 1 or 2" PX-20552 CDM 20552 CPT inpatient 335 335 HEALTHPARTNERS SX009 HEALTHPARTNERS 268 percent of total billed charges 207.7 318.25 Professional (doctor) services "Inject Trigger Point, 1 or 2" PX-20552 CDM 20552 CPT outpatient 335 335 HEALTHPARTNERS SX009 HEALTHPARTNERS 268 percent of total billed charges 207.7 318.25 Professional (doctor) services "Inject Trigger Point, 1 or 2" PX-20552 CDM 20552 CPT inpatient 335 335 MEDICA (COMMERCIAL) 94265 [3081118] MEDICA CLAIMS [308111801] 301.5 percent of total billed charges 207.7 318.25 Professional (doctor) services "Inject Trigger Point, 1 or 2" PX-20552 CDM 20552 CPT outpatient 335 335 MEDICA (COMMERCIAL) 94265 [3081118] MEDICA CLAIMS [308111801] 301.5 percent of total billed charges 207.7 318.25 Professional (doctor) services "Inject Trigger Point, 1 or 2" PX-20552 CDM 20552 CPT inpatient 335 335 MULTIPLAN INC 34080 [3081285] MULTIPLAN INC [308128501] 318.25 percent of total billed charges 207.7 318.25 Professional (doctor) services "Inject Trigger Point, 1 or 2" PX-20552 CDM 20552 CPT outpatient 335 335 MULTIPLAN INC 34080 [3081285] MULTIPLAN INC [308128501] 318.25 percent of total billed charges 207.7 318.25 Professional (doctor) services "Inject Trigger Point, 1 or 2" PX-20552 CDM 20552 CPT inpatient 335 335 UNITED HEALTHCARE (COMMERCIAL) [3081199] UNITED HEALTHCARE 87726 [308119901] 207.7 percent of total billed charges 207.7 318.25 Professional (doctor) services "Inject Trigger Point, 1 or 2" PX-20552 CDM 20552 CPT outpatient 335 335 UNITED HEALTHCARE (COMMERCIAL) [3081199] UNITED HEALTHCARE 87726 [308119901] 207.7 percent of total billed charges 207.7 318.25 Professional (doctor) services "Recmpl Wnd Head,Fac,Hand 2.6-7.5 Cm" PX-13132 CDM 13132 CPT inpatient 2650 2650 CIGNA 62308 [3081051] CIGNA 62308 [308105105] 2120 percent of total billed charges 1643 2517.5 Professional (doctor) services "Recmpl Wnd Head,Fac,Hand 2.6-7.5 Cm" PX-13132 CDM 13132 CPT inpatient 2650 2650 CIGNA 62308 [3081051] CIGNA STATE OF WYOMING [308105107] 2120 percent of total billed charges 1643 2517.5 Professional (doctor) services "Recmpl Wnd Head,Fac,Hand 2.6-7.5 Cm" PX-13132 CDM 13132 CPT outpatient 2650 2650 CIGNA 62308 [3081051] CIGNA 62308 [308105105] 2120 percent of total billed charges 1643 2517.5 Professional (doctor) services "Recmpl Wnd Head,Fac,Hand 2.6-7.5 Cm" PX-13132 CDM 13132 CPT outpatient 2650 2650 CIGNA 62308 [3081051] CIGNA STATE OF WYOMING [308105107] 2120 percent of total billed charges 1643 2517.5 Professional (doctor) services "Recmpl Wnd Head,Fac,Hand 2.6-7.5 Cm" PX-13132 CDM 13132 CPT inpatient 2650 2650 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES EPO [308136803] 2120 percent of total billed charges 1643 2517.5 Professional (doctor) services "Recmpl Wnd Head,Fac,Hand 2.6-7.5 Cm" PX-13132 CDM 13132 CPT inpatient 2650 2650 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES HDHP [308136802] 2120 percent of total billed charges 1643 2517.5 Professional (doctor) services "Recmpl Wnd Head,Fac,Hand 2.6-7.5 Cm" PX-13132 CDM 13132 CPT inpatient 2650 2650 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES PPO [308136801] 2120 percent of total billed charges 1643 2517.5 Professional (doctor) services "Recmpl Wnd Head,Fac,Hand 2.6-7.5 Cm" PX-13132 CDM 13132 CPT outpatient 2650 2650 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES EPO [308136803] 2120 percent of total billed charges 1643 2517.5 Professional (doctor) services "Recmpl Wnd Head,Fac,Hand 2.6-7.5 Cm" PX-13132 CDM 13132 CPT outpatient 2650 2650 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES HDHP [308136802] 2120 percent of total billed charges 1643 2517.5 Professional (doctor) services "Recmpl Wnd Head,Fac,Hand 2.6-7.5 Cm" PX-13132 CDM 13132 CPT outpatient 2650 2650 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES PPO [308136801] 2120 percent of total billed charges 1643 2517.5 Professional (doctor) services "Recmpl Wnd Head,Fac,Hand 2.6-7.5 Cm" PX-13132 CDM 13132 CPT inpatient 2650 2650 HEALTHPARTNERS SX009 HEALTHPARTNERS 2120 percent of total billed charges 1643 2517.5 Professional (doctor) services "Recmpl Wnd Head,Fac,Hand 2.6-7.5 Cm" PX-13132 CDM 13132 CPT outpatient 2650 2650 HEALTHPARTNERS SX009 HEALTHPARTNERS 2120 percent of total billed charges 1643 2517.5 Professional (doctor) services "Recmpl Wnd Head,Fac,Hand 2.6-7.5 Cm" PX-13132 CDM 13132 CPT inpatient 2650 2650 MEDICA (COMMERCIAL) 94265 [3081118] MEDICA CLAIMS [308111801] 2385 percent of total billed charges 1643 2517.5 Professional (doctor) services "Recmpl Wnd Head,Fac,Hand 2.6-7.5 Cm" PX-13132 CDM 13132 CPT outpatient 2650 2650 MEDICA (COMMERCIAL) 94265 [3081118] MEDICA CLAIMS [308111801] 2385 percent of total billed charges 1643 2517.5 Professional (doctor) services "Recmpl Wnd Head,Fac,Hand 2.6-7.5 Cm" PX-13132 CDM 13132 CPT inpatient 2650 2650 MULTIPLAN INC 34080 [3081285] MULTIPLAN INC [308128501] 2517.5 percent of total billed charges 1643 2517.5 Professional (doctor) services "Recmpl Wnd Head,Fac,Hand 2.6-7.5 Cm" PX-13132 CDM 13132 CPT outpatient 2650 2650 MULTIPLAN INC 34080 [3081285] MULTIPLAN INC [308128501] 2517.5 percent of total billed charges 1643 2517.5 Professional (doctor) services "Recmpl Wnd Head,Fac,Hand 2.6-7.5 Cm" PX-13132 CDM 13132 CPT inpatient 2650 2650 UNITED HEALTHCARE (COMMERCIAL) [3081199] UNITED HEALTHCARE 87726 [308119901] 1643 percent of total billed charges 1643 2517.5 Professional (doctor) services "Recmpl Wnd Head,Fac,Hand 2.6-7.5 Cm" PX-13132 CDM 13132 CPT outpatient 2650 2650 UNITED HEALTHCARE (COMMERCIAL) [3081199] UNITED HEALTHCARE 87726 [308119901] 1643 percent of total billed charges 1643 2517.5 Professional (doctor) services "Recmpl Wnd Head,Fac,Hand 1.1-2.5 Cm" PX-13131 CDM 13131 CPT inpatient 1365 1365 CIGNA 62308 [3081051] CIGNA 62308 [308105105] 1092 percent of total billed charges 846.3 1296.75 Professional (doctor) services "Recmpl Wnd Head,Fac,Hand 1.1-2.5 Cm" PX-13131 CDM 13131 CPT inpatient 1365 1365 CIGNA 62308 [3081051] CIGNA STATE OF WYOMING [308105107] 1092 percent of total billed charges 846.3 1296.75 Professional (doctor) services "Recmpl Wnd Head,Fac,Hand 1.1-2.5 Cm" PX-13131 CDM 13131 CPT outpatient 1365 1365 CIGNA 62308 [3081051] CIGNA 62308 [308105105] 1092 percent of total billed charges 846.3 1296.75 Professional (doctor) services "Recmpl Wnd Head,Fac,Hand 1.1-2.5 Cm" PX-13131 CDM 13131 CPT outpatient 1365 1365 CIGNA 62308 [3081051] CIGNA STATE OF WYOMING [308105107] 1092 percent of total billed charges 846.3 1296.75 Professional (doctor) services "Recmpl Wnd Head,Fac,Hand 1.1-2.5 Cm" PX-13131 CDM 13131 CPT inpatient 1365 1365 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES EPO [308136803] 1092 percent of total billed charges 846.3 1296.75 Professional (doctor) services "Recmpl Wnd Head,Fac,Hand 1.1-2.5 Cm" PX-13131 CDM 13131 CPT inpatient 1365 1365 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES HDHP [308136802] 1092 percent of total billed charges 846.3 1296.75 Professional (doctor) services "Recmpl Wnd Head,Fac,Hand 1.1-2.5 Cm" PX-13131 CDM 13131 CPT inpatient 1365 1365 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES PPO [308136801] 1092 percent of total billed charges 846.3 1296.75 Professional (doctor) services "Recmpl Wnd Head,Fac,Hand 1.1-2.5 Cm" PX-13131 CDM 13131 CPT outpatient 1365 1365 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES EPO [308136803] 1092 percent of total billed charges 846.3 1296.75 Professional (doctor) services "Recmpl Wnd Head,Fac,Hand 1.1-2.5 Cm" PX-13131 CDM 13131 CPT outpatient 1365 1365 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES HDHP [308136802] 1092 percent of total billed charges 846.3 1296.75 Professional (doctor) services "Recmpl Wnd Head,Fac,Hand 1.1-2.5 Cm" PX-13131 CDM 13131 CPT outpatient 1365 1365 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES PPO [308136801] 1092 percent of total billed charges 846.3 1296.75 Professional (doctor) services "Recmpl Wnd Head,Fac,Hand 1.1-2.5 Cm" PX-13131 CDM 13131 CPT inpatient 1365 1365 HEALTHPARTNERS SX009 HEALTHPARTNERS 1092 percent of total billed charges 846.3 1296.75 Professional (doctor) services "Recmpl Wnd Head,Fac,Hand 1.1-2.5 Cm" PX-13131 CDM 13131 CPT outpatient 1365 1365 HEALTHPARTNERS SX009 HEALTHPARTNERS 1092 percent of total billed charges 846.3 1296.75 Professional (doctor) services "Recmpl Wnd Head,Fac,Hand 1.1-2.5 Cm" PX-13131 CDM 13131 CPT inpatient 1365 1365 MEDICA (COMMERCIAL) 94265 [3081118] MEDICA CLAIMS [308111801] 1228.5 percent of total billed charges 846.3 1296.75 Professional (doctor) services "Recmpl Wnd Head,Fac,Hand 1.1-2.5 Cm" PX-13131 CDM 13131 CPT outpatient 1365 1365 MEDICA (COMMERCIAL) 94265 [3081118] MEDICA CLAIMS [308111801] 1228.5 percent of total billed charges 846.3 1296.75 Professional (doctor) services "Recmpl Wnd Head,Fac,Hand 1.1-2.5 Cm" PX-13131 CDM 13131 CPT inpatient 1365 1365 MULTIPLAN INC 34080 [3081285] MULTIPLAN INC [308128501] 1296.75 percent of total billed charges 846.3 1296.75 Professional (doctor) services "Recmpl Wnd Head,Fac,Hand 1.1-2.5 Cm" PX-13131 CDM 13131 CPT outpatient 1365 1365 MULTIPLAN INC 34080 [3081285] MULTIPLAN INC [308128501] 1296.75 percent of total billed charges 846.3 1296.75 Professional (doctor) services "Recmpl Wnd Head,Fac,Hand 1.1-2.5 Cm" PX-13131 CDM 13131 CPT inpatient 1365 1365 UNITED HEALTHCARE (COMMERCIAL) [3081199] UNITED HEALTHCARE 87726 [308119901] 846.3 percent of total billed charges 846.3 1296.75 Professional (doctor) services "Recmpl Wnd Head,Fac,Hand 1.1-2.5 Cm" PX-13131 CDM 13131 CPT outpatient 1365 1365 UNITED HEALTHCARE (COMMERCIAL) [3081199] UNITED HEALTHCARE 87726 [308119901] 846.3 percent of total billed charges 846.3 1296.75 Professional (doctor) services "Layr Clos Wnd Face,Facial 2.5-5 Cm" PX-12052 CDM 12052 CPT inpatient 1372 1372 CIGNA 62308 [3081051] CIGNA 62308 [308105105] 1097.6 percent of total billed charges 850.64 1303.4 Professional (doctor) services "Layr Clos Wnd Face,Facial 2.5-5 Cm" PX-12052 CDM 12052 CPT inpatient 1372 1372 CIGNA 62308 [3081051] CIGNA STATE OF WYOMING [308105107] 1097.6 percent of total billed charges 850.64 1303.4 Professional (doctor) services "Layr Clos Wnd Face,Facial 2.5-5 Cm" PX-12052 CDM 12052 CPT outpatient 1372 1372 CIGNA 62308 [3081051] CIGNA 62308 [308105105] 1097.6 percent of total billed charges 850.64 1303.4 Professional (doctor) services "Layr Clos Wnd Face,Facial 2.5-5 Cm" PX-12052 CDM 12052 CPT outpatient 1372 1372 CIGNA 62308 [3081051] CIGNA STATE OF WYOMING [308105107] 1097.6 percent of total billed charges 850.64 1303.4 Professional (doctor) services "Layr Clos Wnd Face,Facial 2.5-5 Cm" PX-12052 CDM 12052 CPT inpatient 1372 1372 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES EPO [308136803] 1097.6 percent of total billed charges 850.64 1303.4 Professional (doctor) services "Layr Clos Wnd Face,Facial 2.5-5 Cm" PX-12052 CDM 12052 CPT inpatient 1372 1372 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES HDHP [308136802] 1097.6 percent of total billed charges 850.64 1303.4 Professional (doctor) services "Layr Clos Wnd Face,Facial 2.5-5 Cm" PX-12052 CDM 12052 CPT inpatient 1372 1372 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES PPO [308136801] 1097.6 percent of total billed charges 850.64 1303.4 Professional (doctor) services "Layr Clos Wnd Face,Facial 2.5-5 Cm" PX-12052 CDM 12052 CPT outpatient 1372 1372 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES EPO [308136803] 1097.6 percent of total billed charges 850.64 1303.4 Professional (doctor) services "Layr Clos Wnd Face,Facial 2.5-5 Cm" PX-12052 CDM 12052 CPT outpatient 1372 1372 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES HDHP [308136802] 1097.6 percent of total billed charges 850.64 1303.4 Professional (doctor) services "Layr Clos Wnd Face,Facial 2.5-5 Cm" PX-12052 CDM 12052 CPT outpatient 1372 1372 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES PPO [308136801] 1097.6 percent of total billed charges 850.64 1303.4 Professional (doctor) services "Layr Clos Wnd Face,Facial 2.5-5 Cm" PX-12052 CDM 12052 CPT inpatient 1372 1372 HEALTHPARTNERS SX009 HEALTHPARTNERS 1097.6 percent of total billed charges 850.64 1303.4 Professional (doctor) services "Layr Clos Wnd Face,Facial 2.5-5 Cm" PX-12052 CDM 12052 CPT outpatient 1372 1372 HEALTHPARTNERS SX009 HEALTHPARTNERS 1097.6 percent of total billed charges 850.64 1303.4 Professional (doctor) services "Layr Clos Wnd Face,Facial 2.5-5 Cm" PX-12052 CDM 12052 CPT inpatient 1372 1372 MEDICA (COMMERCIAL) 94265 [3081118] MEDICA CLAIMS [308111801] 1234.8 percent of total billed charges 850.64 1303.4 Professional (doctor) services "Layr Clos Wnd Face,Facial 2.5-5 Cm" PX-12052 CDM 12052 CPT outpatient 1372 1372 MEDICA (COMMERCIAL) 94265 [3081118] MEDICA CLAIMS [308111801] 1234.8 percent of total billed charges 850.64 1303.4 Professional (doctor) services "Layr Clos Wnd Face,Facial 2.5-5 Cm" PX-12052 CDM 12052 CPT inpatient 1372 1372 MULTIPLAN INC 34080 [3081285] MULTIPLAN INC [308128501] 1303.4 percent of total billed charges 850.64 1303.4 Professional (doctor) services "Layr Clos Wnd Face,Facial 2.5-5 Cm" PX-12052 CDM 12052 CPT outpatient 1372 1372 MULTIPLAN INC 34080 [3081285] MULTIPLAN INC [308128501] 1303.4 percent of total billed charges 850.64 1303.4 Professional (doctor) services "Layr Clos Wnd Face,Facial 2.5-5 Cm" PX-12052 CDM 12052 CPT inpatient 1372 1372 UNITED HEALTHCARE (COMMERCIAL) [3081199] UNITED HEALTHCARE 87726 [308119901] 850.64 percent of total billed charges 850.64 1303.4 Professional (doctor) services "Layr Clos Wnd Face,Facial 2.5-5 Cm" PX-12052 CDM 12052 CPT outpatient 1372 1372 UNITED HEALTHCARE (COMMERCIAL) [3081199] UNITED HEALTHCARE 87726 [308119901] 850.64 percent of total billed charges 850.64 1303.4 Professional (doctor) services Repair Intermediate F/E/E/N/L&/Muc 2.5 Cm/< PX-3601205100 CDM 12051 CPT 360 RC inpatient 1206 1206 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES HDHP [308136802] 954.91 percent of total billed charges 747.72 1145.7 Technical (Hospital) Services Repair Intermediate F/E/E/N/L&/Muc 2.5 Cm/< PX-3601205100 CDM 12051 CPT 360 RC inpatient 1206 1206 MEDICA (COMMERCIAL) 94265 [3081118] MEDICA CLAIMS [308111801] 1085.4 percent of total billed charges 747.72 1145.7 Technical (Hospital) Services Repair Intermediate F/E/E/N/L&/Muc 2.5 Cm/< PX-3601205100 CDM 12051 CPT 360 RC inpatient 1206 1206 HEALTHPARTNERS SX009 HEALTHPARTNERS 954.91 percent of total billed charges 747.72 1145.7 Technical (Hospital) Services Repair Intermediate F/E/E/N/L&/Muc 2.5 Cm/< PX-3601205100 CDM 12051 CPT 360 RC inpatient 1206 1206 MULTIPLAN INC 34080 [3081285] MULTIPLAN INC [308128501] 1145.7 percent of total billed charges 747.72 1145.7 Technical (Hospital) Services Repair Intermediate F/E/E/N/L&/Muc 2.5 Cm/< PX-3601205100 CDM 12051 CPT 360 RC inpatient 1206 1206 BLUE CROSS BLUE SHIELD WELLMARK SB889 [3081026] BCBS WYOMING [308102603] 1145.7 percent of total billed charges 747.72 1145.7 Technical (Hospital) Services Repair Intermediate F/E/E/N/L&/Muc 2.5 Cm/< PX-3601205100 CDM 12051 CPT 360 RC inpatient 1206 1206 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES PPO [308136801] 954.91 percent of total billed charges 747.72 1145.7 Technical (Hospital) Services Repair Intermediate F/E/E/N/L&/Muc 2.5 Cm/< PX-3601205100 CDM 12051 CPT 360 RC inpatient 1206 1206 UNITED HEALTHCARE (COMMERCIAL) [3081199] UNITED HEALTHCARE 87726 [308119901] 747.72 percent of total billed charges 747.72 1145.7 Technical (Hospital) Services Repair Intermediate F/E/E/N/L&/Muc 2.5 Cm/< PX-3601205100 CDM 12051 CPT 360 RC inpatient 1206 1206 CIGNA 62308 [3081051] CIGNA 62308 [308105105] 954.91 percent of total billed charges 747.72 1145.7 Technical (Hospital) Services Repair Intermediate F/E/E/N/L&/Muc 2.5 Cm/< PX-3601205100 CDM 12051 CPT 360 RC inpatient 1206 1206 CIGNA 62308 [3081051] CIGNA STATE OF WYOMING [308105107] 954.91 percent of total billed charges 747.72 1145.7 Technical (Hospital) Services Repair Intermediate F/E/E/N/L&/Muc 2.5 Cm/< PX-3601205100 CDM 12051 CPT 360 RC inpatient 1206 1206 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES EPO [308136803] 954.91 percent of total billed charges 747.72 1145.7 Technical (Hospital) Services Repair Intermediate F/E/E/N/L&/Muc 2.5 Cm/< PX-3601205100 CDM 12051 CPT 360 RC outpatient 1206 1206 CIGNA 62308 [3081051] CIGNA 62308 [308105105] 964.8 percent of total billed charges 747.72 1145.7 Technical (Hospital) Services Repair Intermediate F/E/E/N/L&/Muc 2.5 Cm/< PX-3601205100 CDM 12051 CPT 360 RC outpatient 1206 1206 CIGNA 62308 [3081051] CIGNA STATE OF WYOMING [308105107] 964.8 percent of total billed charges 747.72 1145.7 Technical (Hospital) Services Repair Intermediate F/E/E/N/L&/Muc 2.5 Cm/< PX-3601205100 CDM 12051 CPT 360 RC outpatient 1206 1206 MEDICA (COMMERCIAL) 94265 [3081118] MEDICA CLAIMS [308111801] 1085.4 percent of total billed charges 747.72 1145.7 Technical (Hospital) Services Repair Intermediate F/E/E/N/L&/Muc 2.5 Cm/< PX-3601205100 CDM 12051 CPT 360 RC outpatient 1206 1206 HEALTHPARTNERS SX009 HEALTHPARTNERS 964.8 percent of total billed charges 747.72 1145.7 Technical (Hospital) Services Repair Intermediate F/E/E/N/L&/Muc 2.5 Cm/< PX-3601205100 CDM 12051 CPT 360 RC outpatient 1206 1206 BLUE CROSS BLUE SHIELD WELLMARK SB889 [3081026] BCBS WYOMING [308102603] 1145.7 percent of total billed charges 747.72 1145.7 Technical (Hospital) Services Repair Intermediate F/E/E/N/L&/Muc 2.5 Cm/< PX-3601205100 CDM 12051 CPT 360 RC outpatient 1206 1206 MULTIPLAN INC 34080 [3081285] MULTIPLAN INC [308128501] 1145.7 percent of total billed charges 747.72 1145.7 Technical (Hospital) Services Repair Intermediate F/E/E/N/L&/Muc 2.5 Cm/< PX-3601205100 CDM 12051 CPT 360 RC outpatient 1206 1206 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES HDHP [308136802] 964.8 percent of total billed charges 747.72 1145.7 Technical (Hospital) Services Repair Intermediate F/E/E/N/L&/Muc 2.5 Cm/< PX-3601205100 CDM 12051 CPT 360 RC outpatient 1206 1206 UNITED HEALTHCARE (COMMERCIAL) [3081199] UNITED HEALTHCARE 87726 [308119901] 747.72 percent of total billed charges 747.72 1145.7 Technical (Hospital) Services Repair Intermediate F/E/E/N/L&/Muc 2.5 Cm/< PX-3601205100 CDM 12051 CPT 360 RC outpatient 1206 1206 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES PPO [308136801] 964.8 percent of total billed charges 747.72 1145.7 Technical (Hospital) Services Repair Intermediate F/E/E/N/L&/Muc 2.5 Cm/< PX-3601205100 CDM 12051 CPT 360 RC outpatient 1206 1206 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES EPO [308136803] 964.8 percent of total billed charges 747.72 1145.7 Technical (Hospital) Services "Layr Clos Wnd Face,Facial <2.5 Cm" PX-12051 CDM 12051 CPT inpatient 1206 1206 CIGNA 62308 [3081051] CIGNA 62308 [308105105] 964.8 percent of total billed charges 747.72 1145.7 Professional (doctor) services "Layr Clos Wnd Face,Facial <2.5 Cm" PX-12051 CDM 12051 CPT inpatient 1206 1206 CIGNA 62308 [3081051] CIGNA STATE OF WYOMING [308105107] 964.8 percent of total billed charges 747.72 1145.7 Professional (doctor) services "Layr Clos Wnd Face,Facial <2.5 Cm" PX-12051 CDM 12051 CPT outpatient 1206 1206 CIGNA 62308 [3081051] CIGNA 62308 [308105105] 964.8 percent of total billed charges 747.72 1145.7 Professional (doctor) services "Layr Clos Wnd Face,Facial <2.5 Cm" PX-12051 CDM 12051 CPT outpatient 1206 1206 CIGNA 62308 [3081051] CIGNA STATE OF WYOMING [308105107] 964.8 percent of total billed charges 747.72 1145.7 Professional (doctor) services "Layr Clos Wnd Face,Facial <2.5 Cm" PX-12051 CDM 12051 CPT inpatient 1206 1206 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES EPO [308136803] 964.8 percent of total billed charges 747.72 1145.7 Professional (doctor) services "Layr Clos Wnd Face,Facial <2.5 Cm" PX-12051 CDM 12051 CPT inpatient 1206 1206 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES HDHP [308136802] 964.8 percent of total billed charges 747.72 1145.7 Professional (doctor) services "Layr Clos Wnd Face,Facial <2.5 Cm" PX-12051 CDM 12051 CPT inpatient 1206 1206 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES PPO [308136801] 964.8 percent of total billed charges 747.72 1145.7 Professional (doctor) services "Layr Clos Wnd Face,Facial <2.5 Cm" PX-12051 CDM 12051 CPT outpatient 1206 1206 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES EPO [308136803] 964.8 percent of total billed charges 747.72 1145.7 Professional (doctor) services "Layr Clos Wnd Face,Facial <2.5 Cm" PX-12051 CDM 12051 CPT outpatient 1206 1206 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES HDHP [308136802] 964.8 percent of total billed charges 747.72 1145.7 Professional (doctor) services "Layr Clos Wnd Face,Facial <2.5 Cm" PX-12051 CDM 12051 CPT outpatient 1206 1206 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES PPO [308136801] 964.8 percent of total billed charges 747.72 1145.7 Professional (doctor) services "Layr Clos Wnd Face,Facial <2.5 Cm" PX-12051 CDM 12051 CPT inpatient 1206 1206 HEALTHPARTNERS SX009 HEALTHPARTNERS 964.8 percent of total billed charges 747.72 1145.7 Professional (doctor) services "Layr Clos Wnd Face,Facial <2.5 Cm" PX-12051 CDM 12051 CPT outpatient 1206 1206 HEALTHPARTNERS SX009 HEALTHPARTNERS 964.8 percent of total billed charges 747.72 1145.7 Professional (doctor) services "Layr Clos Wnd Face,Facial <2.5 Cm" PX-12051 CDM 12051 CPT inpatient 1206 1206 MEDICA (COMMERCIAL) 94265 [3081118] MEDICA CLAIMS [308111801] 1085.4 percent of total billed charges 747.72 1145.7 Professional (doctor) services "Layr Clos Wnd Face,Facial <2.5 Cm" PX-12051 CDM 12051 CPT outpatient 1206 1206 MEDICA (COMMERCIAL) 94265 [3081118] MEDICA CLAIMS [308111801] 1085.4 percent of total billed charges 747.72 1145.7 Professional (doctor) services "Layr Clos Wnd Face,Facial <2.5 Cm" PX-12051 CDM 12051 CPT inpatient 1206 1206 MULTIPLAN INC 34080 [3081285] MULTIPLAN INC [308128501] 1145.7 percent of total billed charges 747.72 1145.7 Professional (doctor) services "Layr Clos Wnd Face,Facial <2.5 Cm" PX-12051 CDM 12051 CPT outpatient 1206 1206 MULTIPLAN INC 34080 [3081285] MULTIPLAN INC [308128501] 1145.7 percent of total billed charges 747.72 1145.7 Professional (doctor) services "Layr Clos Wnd Face,Facial <2.5 Cm" PX-12051 CDM 12051 CPT inpatient 1206 1206 UNITED HEALTHCARE (COMMERCIAL) [3081199] UNITED HEALTHCARE 87726 [308119901] 747.72 percent of total billed charges 747.72 1145.7 Professional (doctor) services "Layr Clos Wnd Face,Facial <2.5 Cm" PX-12051 CDM 12051 CPT outpatient 1206 1206 UNITED HEALTHCARE (COMMERCIAL) [3081199] UNITED HEALTHCARE 87726 [308119901] 747.72 percent of total billed charges 747.72 1145.7 Professional (doctor) services Repair Intermediate N/H/F/Xtrnl Gent 7.6-12.5cm PX-3601204400 CDM 12044 CPT 360 RC inpatient 1409 1409 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES EPO [308136803] 1115.65 percent of total billed charges 873.58 1338.55 Technical (Hospital) Services Repair Intermediate N/H/F/Xtrnl Gent 7.6-12.5cm PX-3601204400 CDM 12044 CPT 360 RC inpatient 1409 1409 CIGNA 62308 [3081051] CIGNA 62308 [308105105] 1115.65 percent of total billed charges 873.58 1338.55 Technical (Hospital) Services Repair Intermediate N/H/F/Xtrnl Gent 7.6-12.5cm PX-3601204400 CDM 12044 CPT 360 RC inpatient 1409 1409 CIGNA 62308 [3081051] CIGNA STATE OF WYOMING [308105107] 1115.65 percent of total billed charges 873.58 1338.55 Technical (Hospital) Services Repair Intermediate N/H/F/Xtrnl Gent 7.6-12.5cm PX-3601204400 CDM 12044 CPT 360 RC inpatient 1409 1409 HEALTHPARTNERS SX009 HEALTHPARTNERS 1115.65 percent of total billed charges 873.58 1338.55 Technical (Hospital) Services Repair Intermediate N/H/F/Xtrnl Gent 7.6-12.5cm PX-3601204400 CDM 12044 CPT 360 RC inpatient 1409 1409 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES HDHP [308136802] 1115.65 percent of total billed charges 873.58 1338.55 Technical (Hospital) Services Repair Intermediate N/H/F/Xtrnl Gent 7.6-12.5cm PX-3601204400 CDM 12044 CPT 360 RC inpatient 1409 1409 MEDICA (COMMERCIAL) 94265 [3081118] MEDICA CLAIMS [308111801] 1268.1 percent of total billed charges 873.58 1338.55 Technical (Hospital) Services Repair Intermediate N/H/F/Xtrnl Gent 7.6-12.5cm PX-3601204400 CDM 12044 CPT 360 RC inpatient 1409 1409 BLUE CROSS BLUE SHIELD WELLMARK SB889 [3081026] BCBS WYOMING [308102603] 1338.55 percent of total billed charges 873.58 1338.55 Technical (Hospital) Services Repair Intermediate N/H/F/Xtrnl Gent 7.6-12.5cm PX-3601204400 CDM 12044 CPT 360 RC inpatient 1409 1409 MULTIPLAN INC 34080 [3081285] MULTIPLAN INC [308128501] 1338.55 percent of total billed charges 873.58 1338.55 Technical (Hospital) Services Repair Intermediate N/H/F/Xtrnl Gent 7.6-12.5cm PX-3601204400 CDM 12044 CPT 360 RC inpatient 1409 1409 UNITED HEALTHCARE (COMMERCIAL) [3081199] UNITED HEALTHCARE 87726 [308119901] 873.58 percent of total billed charges 873.58 1338.55 Technical (Hospital) Services Repair Intermediate N/H/F/Xtrnl Gent 7.6-12.5cm PX-3601204400 CDM 12044 CPT 360 RC inpatient 1409 1409 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES PPO [308136801] 1115.65 percent of total billed charges 873.58 1338.55 Technical (Hospital) Services Repair Intermediate N/H/F/Xtrnl Gent 7.6-12.5cm PX-3601204400 CDM 12044 CPT 360 RC outpatient 1409 1409 CIGNA 62308 [3081051] CIGNA 62308 [308105105] 1127.2 percent of total billed charges 873.58 1338.55 Technical (Hospital) Services Repair Intermediate N/H/F/Xtrnl Gent 7.6-12.5cm PX-3601204400 CDM 12044 CPT 360 RC outpatient 1409 1409 CIGNA 62308 [3081051] CIGNA STATE OF WYOMING [308105107] 1127.2 percent of total billed charges 873.58 1338.55 Technical (Hospital) Services Repair Intermediate N/H/F/Xtrnl Gent 7.6-12.5cm PX-3601204400 CDM 12044 CPT 360 RC outpatient 1409 1409 MEDICA (COMMERCIAL) 94265 [3081118] MEDICA CLAIMS [308111801] 1268.1 percent of total billed charges 873.58 1338.55 Technical (Hospital) Services Repair Intermediate N/H/F/Xtrnl Gent 7.6-12.5cm PX-3601204400 CDM 12044 CPT 360 RC outpatient 1409 1409 BLUE CROSS BLUE SHIELD WELLMARK SB889 [3081026] BCBS WYOMING [308102603] 1338.55 percent of total billed charges 873.58 1338.55 Technical (Hospital) Services Repair Intermediate N/H/F/Xtrnl Gent 7.6-12.5cm PX-3601204400 CDM 12044 CPT 360 RC outpatient 1409 1409 MULTIPLAN INC 34080 [3081285] MULTIPLAN INC [308128501] 1338.55 percent of total billed charges 873.58 1338.55 Technical (Hospital) Services Repair Intermediate N/H/F/Xtrnl Gent 7.6-12.5cm PX-3601204400 CDM 12044 CPT 360 RC outpatient 1409 1409 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES HDHP [308136802] 1127.2 percent of total billed charges 873.58 1338.55 Technical (Hospital) Services Repair Intermediate N/H/F/Xtrnl Gent 7.6-12.5cm PX-3601204400 CDM 12044 CPT 360 RC outpatient 1409 1409 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES PPO [308136801] 1127.2 percent of total billed charges 873.58 1338.55 Technical (Hospital) Services Repair Intermediate N/H/F/Xtrnl Gent 7.6-12.5cm PX-3601204400 CDM 12044 CPT 360 RC outpatient 1409 1409 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES EPO [308136803] 1127.2 percent of total billed charges 873.58 1338.55 Technical (Hospital) Services Repair Intermediate N/H/F/Xtrnl Gent 7.6-12.5cm PX-3601204400 CDM 12044 CPT 360 RC outpatient 1409 1409 UNITED HEALTHCARE (COMMERCIAL) [3081199] UNITED HEALTHCARE 87726 [308119901] 873.58 percent of total billed charges 873.58 1338.55 Technical (Hospital) Services Repair Intermediate N/H/F/Xtrnl Gent 7.6-12.5cm PX-3601204400 CDM 12044 CPT 360 RC outpatient 1409 1409 HEALTHPARTNERS SX009 HEALTHPARTNERS 1127.2 percent of total billed charges 873.58 1338.55 Technical (Hospital) Services Repair Intermediate N/H/F/Xtrnl Gent 2.6-7.5 Cm PX-3601204200 CDM 12042 CPT 360 RC outpatient 1208 1208 CIGNA 62308 [3081051] CIGNA 62308 [308105105] 966.4 percent of total billed charges 748.96 1147.6 Technical (Hospital) Services Repair Intermediate N/H/F/Xtrnl Gent 2.6-7.5 Cm PX-3601204200 CDM 12042 CPT 360 RC outpatient 1208 1208 CIGNA 62308 [3081051] CIGNA STATE OF WYOMING [308105107] 966.4 percent of total billed charges 748.96 1147.6 Technical (Hospital) Services Repair Intermediate N/H/F/Xtrnl Gent 2.6-7.5 Cm PX-3601204200 CDM 12042 CPT 360 RC outpatient 1208 1208 MEDICA (COMMERCIAL) 94265 [3081118] MEDICA CLAIMS [308111801] 1087.2 percent of total billed charges 748.96 1147.6 Technical (Hospital) Services Repair Intermediate N/H/F/Xtrnl Gent 2.6-7.5 Cm PX-3601204200 CDM 12042 CPT 360 RC outpatient 1208 1208 HEALTHPARTNERS SX009 HEALTHPARTNERS 966.4 percent of total billed charges 748.96 1147.6 Technical (Hospital) Services Repair Intermediate N/H/F/Xtrnl Gent 2.6-7.5 Cm PX-3601204200 CDM 12042 CPT 360 RC outpatient 1208 1208 MULTIPLAN INC 34080 [3081285] MULTIPLAN INC [308128501] 1147.6 percent of total billed charges 748.96 1147.6 Technical (Hospital) Services Repair Intermediate N/H/F/Xtrnl Gent 2.6-7.5 Cm PX-3601204200 CDM 12042 CPT 360 RC outpatient 1208 1208 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES HDHP [308136802] 966.4 percent of total billed charges 748.96 1147.6 Technical (Hospital) Services Repair Intermediate N/H/F/Xtrnl Gent 2.6-7.5 Cm PX-3601204200 CDM 12042 CPT 360 RC outpatient 1208 1208 BLUE CROSS BLUE SHIELD WELLMARK SB889 [3081026] BCBS WYOMING [308102603] 1147.6 percent of total billed charges 748.96 1147.6 Technical (Hospital) Services Repair Intermediate N/H/F/Xtrnl Gent 2.6-7.5 Cm PX-3601204200 CDM 12042 CPT 360 RC outpatient 1208 1208 UNITED HEALTHCARE (COMMERCIAL) [3081199] UNITED HEALTHCARE 87726 [308119901] 748.96 percent of total billed charges 748.96 1147.6 Technical (Hospital) Services Repair Intermediate N/H/F/Xtrnl Gent 2.6-7.5 Cm PX-3601204200 CDM 12042 CPT 360 RC outpatient 1208 1208 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES PPO [308136801] 966.4 percent of total billed charges 748.96 1147.6 Technical (Hospital) Services Repair Intermediate N/H/F/Xtrnl Gent 2.6-7.5 Cm PX-3601204200 CDM 12042 CPT 360 RC outpatient 1208 1208 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES EPO [308136803] 966.4 percent of total billed charges 748.96 1147.6 Technical (Hospital) Services Repair Intermediate N/H/F/Xtrnl Gent 2.6-7.5 Cm PX-3601204200 CDM 12042 CPT 360 RC inpatient 1208 1208 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES HDHP [308136802] 956.49 percent of total billed charges 748.96 1147.6 Technical (Hospital) Services Repair Intermediate N/H/F/Xtrnl Gent 2.6-7.5 Cm PX-3601204200 CDM 12042 CPT 360 RC inpatient 1208 1208 MEDICA (COMMERCIAL) 94265 [3081118] MEDICA CLAIMS [308111801] 1087.2 percent of total billed charges 748.96 1147.6 Technical (Hospital) Services Repair Intermediate N/H/F/Xtrnl Gent 2.6-7.5 Cm PX-3601204200 CDM 12042 CPT 360 RC inpatient 1208 1208 HEALTHPARTNERS SX009 HEALTHPARTNERS 956.49 percent of total billed charges 748.96 1147.6 Technical (Hospital) Services Repair Intermediate N/H/F/Xtrnl Gent 2.6-7.5 Cm PX-3601204200 CDM 12042 CPT 360 RC inpatient 1208 1208 MULTIPLAN INC 34080 [3081285] MULTIPLAN INC [308128501] 1147.6 percent of total billed charges 748.96 1147.6 Technical (Hospital) Services Repair Intermediate N/H/F/Xtrnl Gent 2.6-7.5 Cm PX-3601204200 CDM 12042 CPT 360 RC inpatient 1208 1208 BLUE CROSS BLUE SHIELD WELLMARK SB889 [3081026] BCBS WYOMING [308102603] 1147.6 percent of total billed charges 748.96 1147.6 Technical (Hospital) Services Repair Intermediate N/H/F/Xtrnl Gent 2.6-7.5 Cm PX-3601204200 CDM 12042 CPT 360 RC inpatient 1208 1208 UNITED HEALTHCARE (COMMERCIAL) [3081199] UNITED HEALTHCARE 87726 [308119901] 748.96 percent of total billed charges 748.96 1147.6 Technical (Hospital) Services Repair Intermediate N/H/F/Xtrnl Gent 2.6-7.5 Cm PX-3601204200 CDM 12042 CPT 360 RC inpatient 1208 1208 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES PPO [308136801] 956.49 percent of total billed charges 748.96 1147.6 Technical (Hospital) Services Repair Intermediate N/H/F/Xtrnl Gent 2.6-7.5 Cm PX-3601204200 CDM 12042 CPT 360 RC inpatient 1208 1208 CIGNA 62308 [3081051] CIGNA 62308 [308105105] 956.49 percent of total billed charges 748.96 1147.6 Technical (Hospital) Services Repair Intermediate N/H/F/Xtrnl Gent 2.6-7.5 Cm PX-3601204200 CDM 12042 CPT 360 RC inpatient 1208 1208 CIGNA 62308 [3081051] CIGNA STATE OF WYOMING [308105107] 956.49 percent of total billed charges 748.96 1147.6 Technical (Hospital) Services Repair Intermediate N/H/F/Xtrnl Gent 2.6-7.5 Cm PX-3601204200 CDM 12042 CPT 360 RC inpatient 1208 1208 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES EPO [308136803] 956.49 percent of total billed charges 748.96 1147.6 Technical (Hospital) Services Layr Clos Wnd Rest Body 2.6-7.5 Cm PX-12042 CDM 12042 CPT inpatient 1206 1206 CIGNA 62308 [3081051] CIGNA 62308 [308105105] 964.8 percent of total billed charges 747.72 1145.7 Professional (doctor) services Layr Clos Wnd Rest Body 2.6-7.5 Cm PX-12042 CDM 12042 CPT inpatient 1206 1206 CIGNA 62308 [3081051] CIGNA STATE OF WYOMING [308105107] 964.8 percent of total billed charges 747.72 1145.7 Professional (doctor) services Layr Clos Wnd Rest Body 2.6-7.5 Cm PX-12042 CDM 12042 CPT outpatient 1206 1206 CIGNA 62308 [3081051] CIGNA 62308 [308105105] 964.8 percent of total billed charges 747.72 1145.7 Professional (doctor) services Layr Clos Wnd Rest Body 2.6-7.5 Cm PX-12042 CDM 12042 CPT outpatient 1206 1206 CIGNA 62308 [3081051] CIGNA STATE OF WYOMING [308105107] 964.8 percent of total billed charges 747.72 1145.7 Professional (doctor) services Layr Clos Wnd Rest Body 2.6-7.5 Cm PX-12042 CDM 12042 CPT inpatient 1206 1206 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES EPO [308136803] 964.8 percent of total billed charges 747.72 1145.7 Professional (doctor) services Layr Clos Wnd Rest Body 2.6-7.5 Cm PX-12042 CDM 12042 CPT inpatient 1206 1206 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES HDHP [308136802] 964.8 percent of total billed charges 747.72 1145.7 Professional (doctor) services Layr Clos Wnd Rest Body 2.6-7.5 Cm PX-12042 CDM 12042 CPT inpatient 1206 1206 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES PPO [308136801] 964.8 percent of total billed charges 747.72 1145.7 Professional (doctor) services Layr Clos Wnd Rest Body 2.6-7.5 Cm PX-12042 CDM 12042 CPT outpatient 1206 1206 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES EPO [308136803] 964.8 percent of total billed charges 747.72 1145.7 Professional (doctor) services Layr Clos Wnd Rest Body 2.6-7.5 Cm PX-12042 CDM 12042 CPT outpatient 1206 1206 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES HDHP [308136802] 964.8 percent of total billed charges 747.72 1145.7 Professional (doctor) services Layr Clos Wnd Rest Body 2.6-7.5 Cm PX-12042 CDM 12042 CPT outpatient 1206 1206 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES PPO [308136801] 964.8 percent of total billed charges 747.72 1145.7 Professional (doctor) services Layr Clos Wnd Rest Body 2.6-7.5 Cm PX-12042 CDM 12042 CPT inpatient 1206 1206 HEALTHPARTNERS SX009 HEALTHPARTNERS 964.8 percent of total billed charges 747.72 1145.7 Professional (doctor) services Layr Clos Wnd Rest Body 2.6-7.5 Cm PX-12042 CDM 12042 CPT outpatient 1206 1206 HEALTHPARTNERS SX009 HEALTHPARTNERS 964.8 percent of total billed charges 747.72 1145.7 Professional (doctor) services Layr Clos Wnd Rest Body 2.6-7.5 Cm PX-12042 CDM 12042 CPT inpatient 1206 1206 MEDICA (COMMERCIAL) 94265 [3081118] MEDICA CLAIMS [308111801] 1085.4 percent of total billed charges 747.72 1145.7 Professional (doctor) services Layr Clos Wnd Rest Body 2.6-7.5 Cm PX-12042 CDM 12042 CPT outpatient 1206 1206 MEDICA (COMMERCIAL) 94265 [3081118] MEDICA CLAIMS [308111801] 1085.4 percent of total billed charges 747.72 1145.7 Professional (doctor) services Layr Clos Wnd Rest Body 2.6-7.5 Cm PX-12042 CDM 12042 CPT inpatient 1206 1206 MULTIPLAN INC 34080 [3081285] MULTIPLAN INC [308128501] 1145.7 percent of total billed charges 747.72 1145.7 Professional (doctor) services Layr Clos Wnd Rest Body 2.6-7.5 Cm PX-12042 CDM 12042 CPT outpatient 1206 1206 MULTIPLAN INC 34080 [3081285] MULTIPLAN INC [308128501] 1145.7 percent of total billed charges 747.72 1145.7 Professional (doctor) services Layr Clos Wnd Rest Body 2.6-7.5 Cm PX-12042 CDM 12042 CPT inpatient 1206 1206 UNITED HEALTHCARE (COMMERCIAL) [3081199] UNITED HEALTHCARE 87726 [308119901] 747.72 percent of total billed charges 747.72 1145.7 Professional (doctor) services Layr Clos Wnd Rest Body 2.6-7.5 Cm PX-12042 CDM 12042 CPT outpatient 1206 1206 UNITED HEALTHCARE (COMMERCIAL) [3081199] UNITED HEALTHCARE 87726 [308119901] 747.72 percent of total billed charges 747.72 1145.7 Professional (doctor) services Layr Clos Wnd Rest Body <2.5 Cm PX-12041 CDM 12041 CPT inpatient 776 776 CIGNA 62308 [3081051] CIGNA 62308 [308105105] 620.8 percent of total billed charges 481.12 737.2 Professional (doctor) services Layr Clos Wnd Rest Body <2.5 Cm PX-12041 CDM 12041 CPT inpatient 776 776 CIGNA 62308 [3081051] CIGNA STATE OF WYOMING [308105107] 620.8 percent of total billed charges 481.12 737.2 Professional (doctor) services Layr Clos Wnd Rest Body <2.5 Cm PX-12041 CDM 12041 CPT outpatient 776 776 CIGNA 62308 [3081051] CIGNA 62308 [308105105] 620.8 percent of total billed charges 481.12 737.2 Professional (doctor) services Layr Clos Wnd Rest Body <2.5 Cm PX-12041 CDM 12041 CPT outpatient 776 776 CIGNA 62308 [3081051] CIGNA STATE OF WYOMING [308105107] 620.8 percent of total billed charges 481.12 737.2 Professional (doctor) services Layr Clos Wnd Rest Body <2.5 Cm PX-12041 CDM 12041 CPT inpatient 776 776 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES EPO [308136803] 620.8 percent of total billed charges 481.12 737.2 Professional (doctor) services Layr Clos Wnd Rest Body <2.5 Cm PX-12041 CDM 12041 CPT inpatient 776 776 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES HDHP [308136802] 620.8 percent of total billed charges 481.12 737.2 Professional (doctor) services Layr Clos Wnd Rest Body <2.5 Cm PX-12041 CDM 12041 CPT inpatient 776 776 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES PPO [308136801] 620.8 percent of total billed charges 481.12 737.2 Professional (doctor) services Layr Clos Wnd Rest Body <2.5 Cm PX-12041 CDM 12041 CPT outpatient 776 776 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES EPO [308136803] 620.8 percent of total billed charges 481.12 737.2 Professional (doctor) services Layr Clos Wnd Rest Body <2.5 Cm PX-12041 CDM 12041 CPT outpatient 776 776 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES HDHP [308136802] 620.8 percent of total billed charges 481.12 737.2 Professional (doctor) services Layr Clos Wnd Rest Body <2.5 Cm PX-12041 CDM 12041 CPT outpatient 776 776 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES PPO [308136801] 620.8 percent of total billed charges 481.12 737.2 Professional (doctor) services Layr Clos Wnd Rest Body <2.5 Cm PX-12041 CDM 12041 CPT inpatient 776 776 HEALTHPARTNERS SX009 HEALTHPARTNERS 620.8 percent of total billed charges 481.12 737.2 Professional (doctor) services Layr Clos Wnd Rest Body <2.5 Cm PX-12041 CDM 12041 CPT outpatient 776 776 HEALTHPARTNERS SX009 HEALTHPARTNERS 620.8 percent of total billed charges 481.12 737.2 Professional (doctor) services Layr Clos Wnd Rest Body <2.5 Cm PX-12041 CDM 12041 CPT inpatient 776 776 MEDICA (COMMERCIAL) 94265 [3081118] MEDICA CLAIMS [308111801] 698.4 percent of total billed charges 481.12 737.2 Professional (doctor) services Layr Clos Wnd Rest Body <2.5 Cm PX-12041 CDM 12041 CPT outpatient 776 776 MEDICA (COMMERCIAL) 94265 [3081118] MEDICA CLAIMS [308111801] 698.4 percent of total billed charges 481.12 737.2 Professional (doctor) services Layr Clos Wnd Rest Body <2.5 Cm PX-12041 CDM 12041 CPT inpatient 776 776 MULTIPLAN INC 34080 [3081285] MULTIPLAN INC [308128501] 737.2 percent of total billed charges 481.12 737.2 Professional (doctor) services Layr Clos Wnd Rest Body <2.5 Cm PX-12041 CDM 12041 CPT outpatient 776 776 MULTIPLAN INC 34080 [3081285] MULTIPLAN INC [308128501] 737.2 percent of total billed charges 481.12 737.2 Professional (doctor) services Layr Clos Wnd Rest Body <2.5 Cm PX-12041 CDM 12041 CPT inpatient 776 776 UNITED HEALTHCARE (COMMERCIAL) [3081199] UNITED HEALTHCARE 87726 [308119901] 481.12 percent of total billed charges 481.12 737.2 Professional (doctor) services Layr Clos Wnd Rest Body <2.5 Cm PX-12041 CDM 12041 CPT outpatient 776 776 UNITED HEALTHCARE (COMMERCIAL) [3081199] UNITED HEALTHCARE 87726 [308119901] 481.12 percent of total billed charges 481.12 737.2 Professional (doctor) services Repair Intermediate S/a/T/E 12.6-20.0cm PX-3601203500 CDM 12035 CPT 360 RC outpatient 1836 1836 MEDICA (COMMERCIAL) 94265 [3081118] MEDICA CLAIMS [308111801] 1652.4 percent of total billed charges 1138.32 1744.2 Technical (Hospital) Services Repair Intermediate S/a/T/E 12.6-20.0cm PX-3601203500 CDM 12035 CPT 360 RC outpatient 1836 1836 HEALTHPARTNERS SX009 HEALTHPARTNERS 1468.8 percent of total billed charges 1138.32 1744.2 Technical (Hospital) Services Repair Intermediate S/a/T/E 12.6-20.0cm PX-3601203500 CDM 12035 CPT 360 RC outpatient 1836 1836 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES EPO [308136803] 1468.8 percent of total billed charges 1138.32 1744.2 Technical (Hospital) Services Repair Intermediate S/a/T/E 12.6-20.0cm PX-3601203500 CDM 12035 CPT 360 RC outpatient 1836 1836 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES PPO [308136801] 1468.8 percent of total billed charges 1138.32 1744.2 Technical (Hospital) Services Repair Intermediate S/a/T/E 12.6-20.0cm PX-3601203500 CDM 12035 CPT 360 RC outpatient 1836 1836 UNITED HEALTHCARE (COMMERCIAL) [3081199] UNITED HEALTHCARE 87726 [308119901] 1138.32 percent of total billed charges 1138.32 1744.2 Technical (Hospital) Services Repair Intermediate S/a/T/E 12.6-20.0cm PX-3601203500 CDM 12035 CPT 360 RC outpatient 1836 1836 BLUE CROSS BLUE SHIELD WELLMARK SB889 [3081026] BCBS WYOMING [308102603] 1744.2 percent of total billed charges 1138.32 1744.2 Technical (Hospital) Services Repair Intermediate S/a/T/E 12.6-20.0cm PX-3601203500 CDM 12035 CPT 360 RC outpatient 1836 1836 MULTIPLAN INC 34080 [3081285] MULTIPLAN INC [308128501] 1744.2 percent of total billed charges 1138.32 1744.2 Technical (Hospital) Services Repair Intermediate S/a/T/E 12.6-20.0cm PX-3601203500 CDM 12035 CPT 360 RC outpatient 1836 1836 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES HDHP [308136802] 1468.8 percent of total billed charges 1138.32 1744.2 Technical (Hospital) Services Repair Intermediate S/a/T/E 12.6-20.0cm PX-3601203500 CDM 12035 CPT 360 RC outpatient 1836 1836 CIGNA 62308 [3081051] CIGNA 62308 [308105105] 1468.8 percent of total billed charges 1138.32 1744.2 Technical (Hospital) Services Repair Intermediate S/a/T/E 12.6-20.0cm PX-3601203500 CDM 12035 CPT 360 RC outpatient 1836 1836 CIGNA 62308 [3081051] CIGNA STATE OF WYOMING [308105107] 1468.8 percent of total billed charges 1138.32 1744.2 Technical (Hospital) Services Repair Intermediate S/a/T/E 12.6-20.0cm PX-3601203500 CDM 12035 CPT 360 RC inpatient 1836 1836 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES HDHP [308136802] 1453.74 percent of total billed charges 1138.32 1744.2 Technical (Hospital) Services Repair Intermediate S/a/T/E 12.6-20.0cm PX-3601203500 CDM 12035 CPT 360 RC inpatient 1836 1836 MEDICA (COMMERCIAL) 94265 [3081118] MEDICA CLAIMS [308111801] 1652.4 percent of total billed charges 1138.32 1744.2 Technical (Hospital) Services Repair Intermediate S/a/T/E 12.6-20.0cm PX-3601203500 CDM 12035 CPT 360 RC inpatient 1836 1836 HEALTHPARTNERS SX009 HEALTHPARTNERS 1453.74 percent of total billed charges 1138.32 1744.2 Technical (Hospital) Services Repair Intermediate S/a/T/E 12.6-20.0cm PX-3601203500 CDM 12035 CPT 360 RC inpatient 1836 1836 MULTIPLAN INC 34080 [3081285] MULTIPLAN INC [308128501] 1744.2 percent of total billed charges 1138.32 1744.2 Technical (Hospital) Services Repair Intermediate S/a/T/E 12.6-20.0cm PX-3601203500 CDM 12035 CPT 360 RC inpatient 1836 1836 BLUE CROSS BLUE SHIELD WELLMARK SB889 [3081026] BCBS WYOMING [308102603] 1744.2 percent of total billed charges 1138.32 1744.2 Technical (Hospital) Services Repair Intermediate S/a/T/E 12.6-20.0cm PX-3601203500 CDM 12035 CPT 360 RC inpatient 1836 1836 UNITED HEALTHCARE (COMMERCIAL) [3081199] UNITED HEALTHCARE 87726 [308119901] 1138.32 percent of total billed charges 1138.32 1744.2 Technical (Hospital) Services Repair Intermediate S/a/T/E 12.6-20.0cm PX-3601203500 CDM 12035 CPT 360 RC inpatient 1836 1836 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES PPO [308136801] 1453.74 percent of total billed charges 1138.32 1744.2 Technical (Hospital) Services Repair Intermediate S/a/T/E 12.6-20.0cm PX-3601203500 CDM 12035 CPT 360 RC inpatient 1836 1836 CIGNA 62308 [3081051] CIGNA 62308 [308105105] 1453.74 percent of total billed charges 1138.32 1744.2 Technical (Hospital) Services Repair Intermediate S/a/T/E 12.6-20.0cm PX-3601203500 CDM 12035 CPT 360 RC inpatient 1836 1836 CIGNA 62308 [3081051] CIGNA STATE OF WYOMING [308105107] 1453.74 percent of total billed charges 1138.32 1744.2 Technical (Hospital) Services Repair Intermediate S/a/T/E 12.6-20.0cm PX-3601203500 CDM 12035 CPT 360 RC inpatient 1836 1836 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES EPO [308136803] 1453.74 percent of total billed charges 1138.32 1744.2 Technical (Hospital) Services "Layr Clos Wnd Trunk,Arm,Leg 12.6-20 Cm" PX-12035 CDM 12035 CPT inpatient 1628 1628 CIGNA 62308 [3081051] CIGNA 62308 [308105105] 1302.4 percent of total billed charges 1009.36 1546.6 Professional (doctor) services "Layr Clos Wnd Trunk,Arm,Leg 12.6-20 Cm" PX-12035 CDM 12035 CPT inpatient 1628 1628 CIGNA 62308 [3081051] CIGNA STATE OF WYOMING [308105107] 1302.4 percent of total billed charges 1009.36 1546.6 Professional (doctor) services "Layr Clos Wnd Trunk,Arm,Leg 12.6-20 Cm" PX-12035 CDM 12035 CPT outpatient 1628 1628 CIGNA 62308 [3081051] CIGNA 62308 [308105105] 1302.4 percent of total billed charges 1009.36 1546.6 Professional (doctor) services "Layr Clos Wnd Trunk,Arm,Leg 12.6-20 Cm" PX-12035 CDM 12035 CPT outpatient 1628 1628 CIGNA 62308 [3081051] CIGNA STATE OF WYOMING [308105107] 1302.4 percent of total billed charges 1009.36 1546.6 Professional (doctor) services "Layr Clos Wnd Trunk,Arm,Leg 12.6-20 Cm" PX-12035 CDM 12035 CPT inpatient 1628 1628 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES EPO [308136803] 1302.4 percent of total billed charges 1009.36 1546.6 Professional (doctor) services "Layr Clos Wnd Trunk,Arm,Leg 12.6-20 Cm" PX-12035 CDM 12035 CPT inpatient 1628 1628 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES HDHP [308136802] 1302.4 percent of total billed charges 1009.36 1546.6 Professional (doctor) services "Layr Clos Wnd Trunk,Arm,Leg 12.6-20 Cm" PX-12035 CDM 12035 CPT inpatient 1628 1628 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES PPO [308136801] 1302.4 percent of total billed charges 1009.36 1546.6 Professional (doctor) services "Layr Clos Wnd Trunk,Arm,Leg 12.6-20 Cm" PX-12035 CDM 12035 CPT outpatient 1628 1628 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES EPO [308136803] 1302.4 percent of total billed charges 1009.36 1546.6 Professional (doctor) services "Layr Clos Wnd Trunk,Arm,Leg 12.6-20 Cm" PX-12035 CDM 12035 CPT outpatient 1628 1628 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES HDHP [308136802] 1302.4 percent of total billed charges 1009.36 1546.6 Professional (doctor) services "Layr Clos Wnd Trunk,Arm,Leg 12.6-20 Cm" PX-12035 CDM 12035 CPT outpatient 1628 1628 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES PPO [308136801] 1302.4 percent of total billed charges 1009.36 1546.6 Professional (doctor) services "Layr Clos Wnd Trunk,Arm,Leg 12.6-20 Cm" PX-12035 CDM 12035 CPT inpatient 1628 1628 HEALTHPARTNERS SX009 HEALTHPARTNERS 1302.4 percent of total billed charges 1009.36 1546.6 Professional (doctor) services "Layr Clos Wnd Trunk,Arm,Leg 12.6-20 Cm" PX-12035 CDM 12035 CPT outpatient 1628 1628 HEALTHPARTNERS SX009 HEALTHPARTNERS 1302.4 percent of total billed charges 1009.36 1546.6 Professional (doctor) services "Layr Clos Wnd Trunk,Arm,Leg 12.6-20 Cm" PX-12035 CDM 12035 CPT inpatient 1628 1628 MEDICA (COMMERCIAL) 94265 [3081118] MEDICA CLAIMS [308111801] 1465.2 percent of total billed charges 1009.36 1546.6 Professional (doctor) services "Layr Clos Wnd Trunk,Arm,Leg 12.6-20 Cm" PX-12035 CDM 12035 CPT outpatient 1628 1628 MEDICA (COMMERCIAL) 94265 [3081118] MEDICA CLAIMS [308111801] 1465.2 percent of total billed charges 1009.36 1546.6 Professional (doctor) services "Layr Clos Wnd Trunk,Arm,Leg 12.6-20 Cm" PX-12035 CDM 12035 CPT inpatient 1628 1628 MULTIPLAN INC 34080 [3081285] MULTIPLAN INC [308128501] 1546.6 percent of total billed charges 1009.36 1546.6 Professional (doctor) services "Layr Clos Wnd Trunk,Arm,Leg 12.6-20 Cm" PX-12035 CDM 12035 CPT outpatient 1628 1628 MULTIPLAN INC 34080 [3081285] MULTIPLAN INC [308128501] 1546.6 percent of total billed charges 1009.36 1546.6 Professional (doctor) services "Layr Clos Wnd Trunk,Arm,Leg 12.6-20 Cm" PX-12035 CDM 12035 CPT inpatient 1628 1628 UNITED HEALTHCARE (COMMERCIAL) [3081199] UNITED HEALTHCARE 87726 [308119901] 1009.36 percent of total billed charges 1009.36 1546.6 Professional (doctor) services "Layr Clos Wnd Trunk,Arm,Leg 12.6-20 Cm" PX-12035 CDM 12035 CPT outpatient 1628 1628 UNITED HEALTHCARE (COMMERCIAL) [3081199] UNITED HEALTHCARE 87726 [308119901] 1009.36 percent of total billed charges 1009.36 1546.6 Professional (doctor) services Repair Intermediate S/a/T/E 7.6-12.5 Cm PX-3601203400 CDM 12034 CPT 360 RC outpatient 1065 1065 CIGNA 62308 [3081051] CIGNA 62308 [308105105] 852 percent of total billed charges 660.3 1011.75 Technical (Hospital) Services Repair Intermediate S/a/T/E 7.6-12.5 Cm PX-3601203400 CDM 12034 CPT 360 RC outpatient 1065 1065 CIGNA 62308 [3081051] CIGNA STATE OF WYOMING [308105107] 852 percent of total billed charges 660.3 1011.75 Technical (Hospital) Services Repair Intermediate S/a/T/E 7.6-12.5 Cm PX-3601203400 CDM 12034 CPT 360 RC outpatient 1065 1065 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES HDHP [308136802] 852 percent of total billed charges 660.3 1011.75 Technical (Hospital) Services Repair Intermediate S/a/T/E 7.6-12.5 Cm PX-3601203400 CDM 12034 CPT 360 RC outpatient 1065 1065 MULTIPLAN INC 34080 [3081285] MULTIPLAN INC [308128501] 1011.75 percent of total billed charges 660.3 1011.75 Technical (Hospital) Services Repair Intermediate S/a/T/E 7.6-12.5 Cm PX-3601203400 CDM 12034 CPT 360 RC outpatient 1065 1065 BLUE CROSS BLUE SHIELD WELLMARK SB889 [3081026] BCBS WYOMING [308102603] 1011.75 percent of total billed charges 660.3 1011.75 Technical (Hospital) Services Repair Intermediate S/a/T/E 7.6-12.5 Cm PX-3601203400 CDM 12034 CPT 360 RC outpatient 1065 1065 UNITED HEALTHCARE (COMMERCIAL) [3081199] UNITED HEALTHCARE 87726 [308119901] 660.3 percent of total billed charges 660.3 1011.75 Technical (Hospital) Services Repair Intermediate S/a/T/E 7.6-12.5 Cm PX-3601203400 CDM 12034 CPT 360 RC outpatient 1065 1065 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES PPO [308136801] 852 percent of total billed charges 660.3 1011.75 Technical (Hospital) Services Repair Intermediate S/a/T/E 7.6-12.5 Cm PX-3601203400 CDM 12034 CPT 360 RC outpatient 1065 1065 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES EPO [308136803] 852 percent of total billed charges 660.3 1011.75 Technical (Hospital) Services Repair Intermediate S/a/T/E 7.6-12.5 Cm PX-3601203400 CDM 12034 CPT 360 RC outpatient 1065 1065 HEALTHPARTNERS SX009 HEALTHPARTNERS 852 percent of total billed charges 660.3 1011.75 Technical (Hospital) Services Repair Intermediate S/a/T/E 7.6-12.5 Cm PX-3601203400 CDM 12034 CPT 360 RC outpatient 1065 1065 MEDICA (COMMERCIAL) 94265 [3081118] MEDICA CLAIMS [308111801] 958.5 percent of total billed charges 660.3 1011.75 Technical (Hospital) Services Repair Intermediate S/a/T/E 7.6-12.5 Cm PX-3601203400 CDM 12034 CPT 360 RC inpatient 1065 1065 BLUE CROSS BLUE SHIELD WELLMARK SB889 [3081026] BCBS WYOMING [308102603] 1011.75 percent of total billed charges 660.3 1011.75 Technical (Hospital) Services Repair Intermediate S/a/T/E 7.6-12.5 Cm PX-3601203400 CDM 12034 CPT 360 RC inpatient 1065 1065 MULTIPLAN INC 34080 [3081285] MULTIPLAN INC [308128501] 1011.75 percent of total billed charges 660.3 1011.75 Technical (Hospital) Services Repair Intermediate S/a/T/E 7.6-12.5 Cm PX-3601203400 CDM 12034 CPT 360 RC inpatient 1065 1065 UNITED HEALTHCARE (COMMERCIAL) [3081199] UNITED HEALTHCARE 87726 [308119901] 660.3 percent of total billed charges 660.3 1011.75 Technical (Hospital) Services Repair Intermediate S/a/T/E 7.6-12.5 Cm PX-3601203400 CDM 12034 CPT 360 RC inpatient 1065 1065 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES PPO [308136801] 843.27 percent of total billed charges 660.3 1011.75 Technical (Hospital) Services Repair Intermediate S/a/T/E 7.6-12.5 Cm PX-3601203400 CDM 12034 CPT 360 RC inpatient 1065 1065 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES HDHP [308136802] 843.27 percent of total billed charges 660.3 1011.75 Technical (Hospital) Services Repair Intermediate S/a/T/E 7.6-12.5 Cm PX-3601203400 CDM 12034 CPT 360 RC inpatient 1065 1065 MEDICA (COMMERCIAL) 94265 [3081118] MEDICA CLAIMS [308111801] 958.5 percent of total billed charges 660.3 1011.75 Technical (Hospital) Services Repair Intermediate S/a/T/E 7.6-12.5 Cm PX-3601203400 CDM 12034 CPT 360 RC inpatient 1065 1065 HEALTHPARTNERS SX009 HEALTHPARTNERS 843.27 percent of total billed charges 660.3 1011.75 Technical (Hospital) Services Repair Intermediate S/a/T/E 7.6-12.5 Cm PX-3601203400 CDM 12034 CPT 360 RC inpatient 1065 1065 CIGNA 62308 [3081051] CIGNA 62308 [308105105] 843.27 percent of total billed charges 660.3 1011.75 Technical (Hospital) Services Repair Intermediate S/a/T/E 7.6-12.5 Cm PX-3601203400 CDM 12034 CPT 360 RC inpatient 1065 1065 CIGNA 62308 [3081051] CIGNA STATE OF WYOMING [308105107] 843.27 percent of total billed charges 660.3 1011.75 Technical (Hospital) Services Repair Intermediate S/a/T/E 7.6-12.5 Cm PX-3601203400 CDM 12034 CPT 360 RC inpatient 1065 1065 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES EPO [308136803] 843.27 percent of total billed charges 660.3 1011.75 Technical (Hospital) Services "Layr Clos Wnd Trunk,Arm,Leg 7.6-12.5 Cm" PX-12034 CDM 12034 CPT inpatient 1235 1235 CIGNA 62308 [3081051] CIGNA 62308 [308105105] 988 percent of total billed charges 765.7 1173.25 Professional (doctor) services "Layr Clos Wnd Trunk,Arm,Leg 7.6-12.5 Cm" PX-12034 CDM 12034 CPT inpatient 1235 1235 CIGNA 62308 [3081051] CIGNA STATE OF WYOMING [308105107] 988 percent of total billed charges 765.7 1173.25 Professional (doctor) services "Layr Clos Wnd Trunk,Arm,Leg 7.6-12.5 Cm" PX-12034 CDM 12034 CPT outpatient 1235 1235 CIGNA 62308 [3081051] CIGNA 62308 [308105105] 988 percent of total billed charges 765.7 1173.25 Professional (doctor) services "Layr Clos Wnd Trunk,Arm,Leg 7.6-12.5 Cm" PX-12034 CDM 12034 CPT outpatient 1235 1235 CIGNA 62308 [3081051] CIGNA STATE OF WYOMING [308105107] 988 percent of total billed charges 765.7 1173.25 Professional (doctor) services "Layr Clos Wnd Trunk,Arm,Leg 7.6-12.5 Cm" PX-12034 CDM 12034 CPT inpatient 1235 1235 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES EPO [308136803] 988 percent of total billed charges 765.7 1173.25 Professional (doctor) services "Layr Clos Wnd Trunk,Arm,Leg 7.6-12.5 Cm" PX-12034 CDM 12034 CPT inpatient 1235 1235 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES HDHP [308136802] 988 percent of total billed charges 765.7 1173.25 Professional (doctor) services "Layr Clos Wnd Trunk,Arm,Leg 7.6-12.5 Cm" PX-12034 CDM 12034 CPT inpatient 1235 1235 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES PPO [308136801] 988 percent of total billed charges 765.7 1173.25 Professional (doctor) services "Layr Clos Wnd Trunk,Arm,Leg 7.6-12.5 Cm" PX-12034 CDM 12034 CPT outpatient 1235 1235 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES EPO [308136803] 988 percent of total billed charges 765.7 1173.25 Professional (doctor) services "Layr Clos Wnd Trunk,Arm,Leg 7.6-12.5 Cm" PX-12034 CDM 12034 CPT outpatient 1235 1235 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES HDHP [308136802] 988 percent of total billed charges 765.7 1173.25 Professional (doctor) services "Layr Clos Wnd Trunk,Arm,Leg 7.6-12.5 Cm" PX-12034 CDM 12034 CPT outpatient 1235 1235 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES PPO [308136801] 988 percent of total billed charges 765.7 1173.25 Professional (doctor) services "Layr Clos Wnd Trunk,Arm,Leg 7.6-12.5 Cm" PX-12034 CDM 12034 CPT inpatient 1235 1235 HEALTHPARTNERS SX009 HEALTHPARTNERS 988 percent of total billed charges 765.7 1173.25 Professional (doctor) services "Layr Clos Wnd Trunk,Arm,Leg 7.6-12.5 Cm" PX-12034 CDM 12034 CPT outpatient 1235 1235 HEALTHPARTNERS SX009 HEALTHPARTNERS 988 percent of total billed charges 765.7 1173.25 Professional (doctor) services "Layr Clos Wnd Trunk,Arm,Leg 7.6-12.5 Cm" PX-12034 CDM 12034 CPT inpatient 1235 1235 MEDICA (COMMERCIAL) 94265 [3081118] MEDICA CLAIMS [308111801] 1111.5 percent of total billed charges 765.7 1173.25 Professional (doctor) services "Layr Clos Wnd Trunk,Arm,Leg 7.6-12.5 Cm" PX-12034 CDM 12034 CPT outpatient 1235 1235 MEDICA (COMMERCIAL) 94265 [3081118] MEDICA CLAIMS [308111801] 1111.5 percent of total billed charges 765.7 1173.25 Professional (doctor) services "Layr Clos Wnd Trunk,Arm,Leg 7.6-12.5 Cm" PX-12034 CDM 12034 CPT inpatient 1235 1235 MULTIPLAN INC 34080 [3081285] MULTIPLAN INC [308128501] 1173.25 percent of total billed charges 765.7 1173.25 Professional (doctor) services "Layr Clos Wnd Trunk,Arm,Leg 7.6-12.5 Cm" PX-12034 CDM 12034 CPT outpatient 1235 1235 MULTIPLAN INC 34080 [3081285] MULTIPLAN INC [308128501] 1173.25 percent of total billed charges 765.7 1173.25 Professional (doctor) services "Layr Clos Wnd Trunk,Arm,Leg 7.6-12.5 Cm" PX-12034 CDM 12034 CPT inpatient 1235 1235 UNITED HEALTHCARE (COMMERCIAL) [3081199] UNITED HEALTHCARE 87726 [308119901] 765.7 percent of total billed charges 765.7 1173.25 Professional (doctor) services "Layr Clos Wnd Trunk,Arm,Leg 7.6-12.5 Cm" PX-12034 CDM 12034 CPT outpatient 1235 1235 UNITED HEALTHCARE (COMMERCIAL) [3081199] UNITED HEALTHCARE 87726 [308119901] 765.7 percent of total billed charges 765.7 1173.25 Professional (doctor) services Repair Intermediate S/a/T/E 2.6-7.5 Cm PX-3601203200 CDM 12032 CPT 360 RC outpatient 834 834 MEDICA (COMMERCIAL) 94265 [3081118] MEDICA CLAIMS [308111801] 750.6 percent of total billed charges 517.08 792.3 Technical (Hospital) Services Repair Intermediate S/a/T/E 2.6-7.5 Cm PX-3601203200 CDM 12032 CPT 360 RC outpatient 834 834 CIGNA 62308 [3081051] CIGNA 62308 [308105105] 667.2 percent of total billed charges 517.08 792.3 Technical (Hospital) Services Repair Intermediate S/a/T/E 2.6-7.5 Cm PX-3601203200 CDM 12032 CPT 360 RC outpatient 834 834 CIGNA 62308 [3081051] CIGNA STATE OF WYOMING [308105107] 667.2 percent of total billed charges 517.08 792.3 Technical (Hospital) Services Repair Intermediate S/a/T/E 2.6-7.5 Cm PX-3601203200 CDM 12032 CPT 360 RC outpatient 834 834 BLUE CROSS BLUE SHIELD WELLMARK SB889 [3081026] BCBS WYOMING [308102603] 792.3 percent of total billed charges 517.08 792.3 Technical (Hospital) Services Repair Intermediate S/a/T/E 2.6-7.5 Cm PX-3601203200 CDM 12032 CPT 360 RC outpatient 834 834 MULTIPLAN INC 34080 [3081285] MULTIPLAN INC [308128501] 792.3 percent of total billed charges 517.08 792.3 Technical (Hospital) Services Repair Intermediate S/a/T/E 2.6-7.5 Cm PX-3601203200 CDM 12032 CPT 360 RC outpatient 834 834 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES HDHP [308136802] 667.2 percent of total billed charges 517.08 792.3 Technical (Hospital) Services Repair Intermediate S/a/T/E 2.6-7.5 Cm PX-3601203200 CDM 12032 CPT 360 RC outpatient 834 834 UNITED HEALTHCARE (COMMERCIAL) [3081199] UNITED HEALTHCARE 87726 [308119901] 517.08 percent of total billed charges 517.08 792.3 Technical (Hospital) Services Repair Intermediate S/a/T/E 2.6-7.5 Cm PX-3601203200 CDM 12032 CPT 360 RC outpatient 834 834 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES PPO [308136801] 667.2 percent of total billed charges 517.08 792.3 Technical (Hospital) Services Repair Intermediate S/a/T/E 2.6-7.5 Cm PX-3601203200 CDM 12032 CPT 360 RC outpatient 834 834 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES EPO [308136803] 667.2 percent of total billed charges 517.08 792.3 Technical (Hospital) Services Repair Intermediate S/a/T/E 2.6-7.5 Cm PX-3601203200 CDM 12032 CPT 360 RC outpatient 834 834 HEALTHPARTNERS SX009 HEALTHPARTNERS 667.2 percent of total billed charges 517.08 792.3 Technical (Hospital) Services Repair Intermediate S/a/T/E 2.6-7.5 Cm PX-3601203200 CDM 12032 CPT 360 RC inpatient 834 834 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES EPO [308136803] 660.36 percent of total billed charges 517.08 792.3 Technical (Hospital) Services Repair Intermediate S/a/T/E 2.6-7.5 Cm PX-3601203200 CDM 12032 CPT 360 RC inpatient 834 834 CIGNA 62308 [3081051] CIGNA 62308 [308105105] 660.36 percent of total billed charges 517.08 792.3 Technical (Hospital) Services Repair Intermediate S/a/T/E 2.6-7.5 Cm PX-3601203200 CDM 12032 CPT 360 RC inpatient 834 834 CIGNA 62308 [3081051] CIGNA STATE OF WYOMING [308105107] 660.36 percent of total billed charges 517.08 792.3 Technical (Hospital) Services Repair Intermediate S/a/T/E 2.6-7.5 Cm PX-3601203200 CDM 12032 CPT 360 RC inpatient 834 834 HEALTHPARTNERS SX009 HEALTHPARTNERS 660.36 percent of total billed charges 517.08 792.3 Technical (Hospital) Services Repair Intermediate S/a/T/E 2.6-7.5 Cm PX-3601203200 CDM 12032 CPT 360 RC inpatient 834 834 MEDICA (COMMERCIAL) 94265 [3081118] MEDICA CLAIMS [308111801] 750.6 percent of total billed charges 517.08 792.3 Technical (Hospital) Services Repair Intermediate S/a/T/E 2.6-7.5 Cm PX-3601203200 CDM 12032 CPT 360 RC inpatient 834 834 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES HDHP [308136802] 660.36 percent of total billed charges 517.08 792.3 Technical (Hospital) Services Repair Intermediate S/a/T/E 2.6-7.5 Cm PX-3601203200 CDM 12032 CPT 360 RC inpatient 834 834 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES PPO [308136801] 660.36 percent of total billed charges 517.08 792.3 Technical (Hospital) Services Repair Intermediate S/a/T/E 2.6-7.5 Cm PX-3601203200 CDM 12032 CPT 360 RC inpatient 834 834 UNITED HEALTHCARE (COMMERCIAL) [3081199] UNITED HEALTHCARE 87726 [308119901] 517.08 percent of total billed charges 517.08 792.3 Technical (Hospital) Services Repair Intermediate S/a/T/E 2.6-7.5 Cm PX-3601203200 CDM 12032 CPT 360 RC inpatient 834 834 MULTIPLAN INC 34080 [3081285] MULTIPLAN INC [308128501] 792.3 percent of total billed charges 517.08 792.3 Technical (Hospital) Services Repair Intermediate S/a/T/E 2.6-7.5 Cm PX-3601203200 CDM 12032 CPT 360 RC inpatient 834 834 BLUE CROSS BLUE SHIELD WELLMARK SB889 [3081026] BCBS WYOMING [308102603] 792.3 percent of total billed charges 517.08 792.3 Technical (Hospital) Services "Layr Clos Wnd Trunk,Arm,Leg 2.6-7.5 Cm" PX-12032 CDM 12032 CPT inpatient 1099 1099 CIGNA 62308 [3081051] CIGNA 62308 [308105105] 879.2 percent of total billed charges 681.38 1044.05 Professional (doctor) services "Layr Clos Wnd Trunk,Arm,Leg 2.6-7.5 Cm" PX-12032 CDM 12032 CPT inpatient 1099 1099 CIGNA 62308 [3081051] CIGNA STATE OF WYOMING [308105107] 879.2 percent of total billed charges 681.38 1044.05 Professional (doctor) services "Layr Clos Wnd Trunk,Arm,Leg 2.6-7.5 Cm" PX-12032 CDM 12032 CPT outpatient 1099 1099 CIGNA 62308 [3081051] CIGNA 62308 [308105105] 879.2 percent of total billed charges 681.38 1044.05 Professional (doctor) services "Layr Clos Wnd Trunk,Arm,Leg 2.6-7.5 Cm" PX-12032 CDM 12032 CPT outpatient 1099 1099 CIGNA 62308 [3081051] CIGNA STATE OF WYOMING [308105107] 879.2 percent of total billed charges 681.38 1044.05 Professional (doctor) services "Layr Clos Wnd Trunk,Arm,Leg 2.6-7.5 Cm" PX-12032 CDM 12032 CPT inpatient 1099 1099 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES EPO [308136803] 879.2 percent of total billed charges 681.38 1044.05 Professional (doctor) services "Layr Clos Wnd Trunk,Arm,Leg 2.6-7.5 Cm" PX-12032 CDM 12032 CPT inpatient 1099 1099 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES HDHP [308136802] 879.2 percent of total billed charges 681.38 1044.05 Professional (doctor) services "Layr Clos Wnd Trunk,Arm,Leg 2.6-7.5 Cm" PX-12032 CDM 12032 CPT inpatient 1099 1099 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES PPO [308136801] 879.2 percent of total billed charges 681.38 1044.05 Professional (doctor) services "Layr Clos Wnd Trunk,Arm,Leg 2.6-7.5 Cm" PX-12032 CDM 12032 CPT outpatient 1099 1099 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES EPO [308136803] 879.2 percent of total billed charges 681.38 1044.05 Professional (doctor) services "Layr Clos Wnd Trunk,Arm,Leg 2.6-7.5 Cm" PX-12032 CDM 12032 CPT outpatient 1099 1099 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES HDHP [308136802] 879.2 percent of total billed charges 681.38 1044.05 Professional (doctor) services "Layr Clos Wnd Trunk,Arm,Leg 2.6-7.5 Cm" PX-12032 CDM 12032 CPT outpatient 1099 1099 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES PPO [308136801] 879.2 percent of total billed charges 681.38 1044.05 Professional (doctor) services "Layr Clos Wnd Trunk,Arm,Leg 2.6-7.5 Cm" PX-12032 CDM 12032 CPT inpatient 1099 1099 HEALTHPARTNERS SX009 HEALTHPARTNERS 879.2 percent of total billed charges 681.38 1044.05 Professional (doctor) services "Layr Clos Wnd Trunk,Arm,Leg 2.6-7.5 Cm" PX-12032 CDM 12032 CPT outpatient 1099 1099 HEALTHPARTNERS SX009 HEALTHPARTNERS 879.2 percent of total billed charges 681.38 1044.05 Professional (doctor) services "Layr Clos Wnd Trunk,Arm,Leg 2.6-7.5 Cm" PX-12032 CDM 12032 CPT inpatient 1099 1099 MEDICA (COMMERCIAL) 94265 [3081118] MEDICA CLAIMS [308111801] 989.1 percent of total billed charges 681.38 1044.05 Professional (doctor) services "Layr Clos Wnd Trunk,Arm,Leg 2.6-7.5 Cm" PX-12032 CDM 12032 CPT outpatient 1099 1099 MEDICA (COMMERCIAL) 94265 [3081118] MEDICA CLAIMS [308111801] 989.1 percent of total billed charges 681.38 1044.05 Professional (doctor) services "Layr Clos Wnd Trunk,Arm,Leg 2.6-7.5 Cm" PX-12032 CDM 12032 CPT inpatient 1099 1099 MULTIPLAN INC 34080 [3081285] MULTIPLAN INC [308128501] 1044.05 percent of total billed charges 681.38 1044.05 Professional (doctor) services "Layr Clos Wnd Trunk,Arm,Leg 2.6-7.5 Cm" PX-12032 CDM 12032 CPT outpatient 1099 1099 MULTIPLAN INC 34080 [3081285] MULTIPLAN INC [308128501] 1044.05 percent of total billed charges 681.38 1044.05 Professional (doctor) services "Layr Clos Wnd Trunk,Arm,Leg 2.6-7.5 Cm" PX-12032 CDM 12032 CPT inpatient 1099 1099 UNITED HEALTHCARE (COMMERCIAL) [3081199] UNITED HEALTHCARE 87726 [308119901] 681.38 percent of total billed charges 681.38 1044.05 Professional (doctor) services "Layr Clos Wnd Trunk,Arm,Leg 2.6-7.5 Cm" PX-12032 CDM 12032 CPT outpatient 1099 1099 UNITED HEALTHCARE (COMMERCIAL) [3081199] UNITED HEALTHCARE 87726 [308119901] 681.38 percent of total billed charges 681.38 1044.05 Professional (doctor) services Repair Intermediate S/a/T/E 2.5 Cm/< PX-3601203100 CDM 12031 CPT 360 RC outpatient 669 669 CIGNA 62308 [3081051] CIGNA 62308 [308105105] 535.2 percent of total billed charges 414.78 635.55 Technical (Hospital) Services Repair Intermediate S/a/T/E 2.5 Cm/< PX-3601203100 CDM 12031 CPT 360 RC outpatient 669 669 CIGNA 62308 [3081051] CIGNA STATE OF WYOMING [308105107] 535.2 percent of total billed charges 414.78 635.55 Technical (Hospital) Services Repair Intermediate S/a/T/E 2.5 Cm/< PX-3601203100 CDM 12031 CPT 360 RC outpatient 669 669 MEDICA (COMMERCIAL) 94265 [3081118] MEDICA CLAIMS [308111801] 602.1 percent of total billed charges 414.78 635.55 Technical (Hospital) Services Repair Intermediate S/a/T/E 2.5 Cm/< PX-3601203100 CDM 12031 CPT 360 RC outpatient 669 669 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES EPO [308136803] 535.2 percent of total billed charges 414.78 635.55 Technical (Hospital) Services Repair Intermediate S/a/T/E 2.5 Cm/< PX-3601203100 CDM 12031 CPT 360 RC outpatient 669 669 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES PPO [308136801] 535.2 percent of total billed charges 414.78 635.55 Technical (Hospital) Services Repair Intermediate S/a/T/E 2.5 Cm/< PX-3601203100 CDM 12031 CPT 360 RC outpatient 669 669 BLUE CROSS BLUE SHIELD WELLMARK SB889 [3081026] BCBS WYOMING [308102603] 635.55 percent of total billed charges 414.78 635.55 Technical (Hospital) Services Repair Intermediate S/a/T/E 2.5 Cm/< PX-3601203100 CDM 12031 CPT 360 RC outpatient 669 669 MULTIPLAN INC 34080 [3081285] MULTIPLAN INC [308128501] 635.55 percent of total billed charges 414.78 635.55 Technical (Hospital) Services Repair Intermediate S/a/T/E 2.5 Cm/< PX-3601203100 CDM 12031 CPT 360 RC outpatient 669 669 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES HDHP [308136802] 535.2 percent of total billed charges 414.78 635.55 Technical (Hospital) Services Repair Intermediate S/a/T/E 2.5 Cm/< PX-3601203100 CDM 12031 CPT 360 RC outpatient 669 669 HEALTHPARTNERS SX009 HEALTHPARTNERS 535.2 percent of total billed charges 414.78 635.55 Technical (Hospital) Services Repair Intermediate S/a/T/E 2.5 Cm/< PX-3601203100 CDM 12031 CPT 360 RC outpatient 669 669 UNITED HEALTHCARE (COMMERCIAL) [3081199] UNITED HEALTHCARE 87726 [308119901] 414.78 percent of total billed charges 414.78 635.55 Technical (Hospital) Services Repair Intermediate S/a/T/E 2.5 Cm/< PX-3601203100 CDM 12031 CPT 360 RC inpatient 669 669 BLUE CROSS BLUE SHIELD WELLMARK SB889 [3081026] BCBS WYOMING [308102603] 635.55 percent of total billed charges 414.78 635.55 Technical (Hospital) Services Repair Intermediate S/a/T/E 2.5 Cm/< PX-3601203100 CDM 12031 CPT 360 RC inpatient 669 669 MULTIPLAN INC 34080 [3081285] MULTIPLAN INC [308128501] 635.55 percent of total billed charges 414.78 635.55 Technical (Hospital) Services Repair Intermediate S/a/T/E 2.5 Cm/< PX-3601203100 CDM 12031 CPT 360 RC inpatient 669 669 UNITED HEALTHCARE (COMMERCIAL) [3081199] UNITED HEALTHCARE 87726 [308119901] 414.78 percent of total billed charges 414.78 635.55 Technical (Hospital) Services Repair Intermediate S/a/T/E 2.5 Cm/< PX-3601203100 CDM 12031 CPT 360 RC inpatient 669 669 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES PPO [308136801] 529.71 percent of total billed charges 414.78 635.55 Technical (Hospital) Services Repair Intermediate S/a/T/E 2.5 Cm/< PX-3601203100 CDM 12031 CPT 360 RC inpatient 669 669 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES HDHP [308136802] 529.71 percent of total billed charges 414.78 635.55 Technical (Hospital) Services Repair Intermediate S/a/T/E 2.5 Cm/< PX-3601203100 CDM 12031 CPT 360 RC inpatient 669 669 MEDICA (COMMERCIAL) 94265 [3081118] MEDICA CLAIMS [308111801] 602.1 percent of total billed charges 414.78 635.55 Technical (Hospital) Services Repair Intermediate S/a/T/E 2.5 Cm/< PX-3601203100 CDM 12031 CPT 360 RC inpatient 669 669 HEALTHPARTNERS SX009 HEALTHPARTNERS 529.71 percent of total billed charges 414.78 635.55 Technical (Hospital) Services Repair Intermediate S/a/T/E 2.5 Cm/< PX-3601203100 CDM 12031 CPT 360 RC inpatient 669 669 CIGNA 62308 [3081051] CIGNA STATE OF WYOMING [308105107] 529.71 percent of total billed charges 414.78 635.55 Technical (Hospital) Services Repair Intermediate S/a/T/E 2.5 Cm/< PX-3601203100 CDM 12031 CPT 360 RC inpatient 669 669 CIGNA 62308 [3081051] CIGNA 62308 [308105105] 529.71 percent of total billed charges 414.78 635.55 Technical (Hospital) Services Repair Intermediate S/a/T/E 2.5 Cm/< PX-3601203100 CDM 12031 CPT 360 RC inpatient 669 669 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES EPO [308136803] 529.71 percent of total billed charges 414.78 635.55 Technical (Hospital) Services Resuperf Wnd Face 7.6-12.5 Cm PX-12015 CDM 12015 CPT inpatient 1373 1373 CIGNA 62308 [3081051] CIGNA 62308 [308105105] 1098.4 percent of total billed charges 851.26 1304.35 Professional (doctor) services Resuperf Wnd Face 7.6-12.5 Cm PX-12015 CDM 12015 CPT inpatient 1373 1373 CIGNA 62308 [3081051] CIGNA STATE OF WYOMING [308105107] 1098.4 percent of total billed charges 851.26 1304.35 Professional (doctor) services Resuperf Wnd Face 7.6-12.5 Cm PX-12015 CDM 12015 CPT outpatient 1373 1373 CIGNA 62308 [3081051] CIGNA 62308 [308105105] 1098.4 percent of total billed charges 851.26 1304.35 Professional (doctor) services Resuperf Wnd Face 7.6-12.5 Cm PX-12015 CDM 12015 CPT outpatient 1373 1373 CIGNA 62308 [3081051] CIGNA STATE OF WYOMING [308105107] 1098.4 percent of total billed charges 851.26 1304.35 Professional (doctor) services Resuperf Wnd Face 7.6-12.5 Cm PX-12015 CDM 12015 CPT inpatient 1373 1373 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES EPO [308136803] 1098.4 percent of total billed charges 851.26 1304.35 Professional (doctor) services Resuperf Wnd Face 7.6-12.5 Cm PX-12015 CDM 12015 CPT inpatient 1373 1373 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES HDHP [308136802] 1098.4 percent of total billed charges 851.26 1304.35 Professional (doctor) services Resuperf Wnd Face 7.6-12.5 Cm PX-12015 CDM 12015 CPT inpatient 1373 1373 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES PPO [308136801] 1098.4 percent of total billed charges 851.26 1304.35 Professional (doctor) services Resuperf Wnd Face 7.6-12.5 Cm PX-12015 CDM 12015 CPT outpatient 1373 1373 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES EPO [308136803] 1098.4 percent of total billed charges 851.26 1304.35 Professional (doctor) services Resuperf Wnd Face 7.6-12.5 Cm PX-12015 CDM 12015 CPT outpatient 1373 1373 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES HDHP [308136802] 1098.4 percent of total billed charges 851.26 1304.35 Professional (doctor) services Resuperf Wnd Face 7.6-12.5 Cm PX-12015 CDM 12015 CPT outpatient 1373 1373 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES PPO [308136801] 1098.4 percent of total billed charges 851.26 1304.35 Professional (doctor) services Resuperf Wnd Face 7.6-12.5 Cm PX-12015 CDM 12015 CPT inpatient 1373 1373 HEALTHPARTNERS SX009 HEALTHPARTNERS 1098.4 percent of total billed charges 851.26 1304.35 Professional (doctor) services Resuperf Wnd Face 7.6-12.5 Cm PX-12015 CDM 12015 CPT outpatient 1373 1373 HEALTHPARTNERS SX009 HEALTHPARTNERS 1098.4 percent of total billed charges 851.26 1304.35 Professional (doctor) services Resuperf Wnd Face 7.6-12.5 Cm PX-12015 CDM 12015 CPT inpatient 1373 1373 MEDICA (COMMERCIAL) 94265 [3081118] MEDICA CLAIMS [308111801] 1235.7 percent of total billed charges 851.26 1304.35 Professional (doctor) services Resuperf Wnd Face 7.6-12.5 Cm PX-12015 CDM 12015 CPT outpatient 1373 1373 MEDICA (COMMERCIAL) 94265 [3081118] MEDICA CLAIMS [308111801] 1235.7 percent of total billed charges 851.26 1304.35 Professional (doctor) services Resuperf Wnd Face 7.6-12.5 Cm PX-12015 CDM 12015 CPT inpatient 1373 1373 MULTIPLAN INC 34080 [3081285] MULTIPLAN INC [308128501] 1304.35 percent of total billed charges 851.26 1304.35 Professional (doctor) services Resuperf Wnd Face 7.6-12.5 Cm PX-12015 CDM 12015 CPT outpatient 1373 1373 MULTIPLAN INC 34080 [3081285] MULTIPLAN INC [308128501] 1304.35 percent of total billed charges 851.26 1304.35 Professional (doctor) services Resuperf Wnd Face 7.6-12.5 Cm PX-12015 CDM 12015 CPT inpatient 1373 1373 UNITED HEALTHCARE (COMMERCIAL) [3081199] UNITED HEALTHCARE 87726 [308119901] 851.26 percent of total billed charges 851.26 1304.35 Professional (doctor) services Resuperf Wnd Face 7.6-12.5 Cm PX-12015 CDM 12015 CPT outpatient 1373 1373 UNITED HEALTHCARE (COMMERCIAL) [3081199] UNITED HEALTHCARE 87726 [308119901] 851.26 percent of total billed charges 851.26 1304.35 Professional (doctor) services Resuperf Wnd Face 5.1-7.5 Cm PX-12014 CDM 12014 CPT inpatient 1122 1122 CIGNA 62308 [3081051] CIGNA 62308 [308105105] 897.6 percent of total billed charges 695.64 1065.9 Professional (doctor) services Resuperf Wnd Face 5.1-7.5 Cm PX-12014 CDM 12014 CPT inpatient 1122 1122 CIGNA 62308 [3081051] CIGNA STATE OF WYOMING [308105107] 897.6 percent of total billed charges 695.64 1065.9 Professional (doctor) services Resuperf Wnd Face 5.1-7.5 Cm PX-12014 CDM 12014 CPT outpatient 1122 1122 CIGNA 62308 [3081051] CIGNA 62308 [308105105] 897.6 percent of total billed charges 695.64 1065.9 Professional (doctor) services Resuperf Wnd Face 5.1-7.5 Cm PX-12014 CDM 12014 CPT outpatient 1122 1122 CIGNA 62308 [3081051] CIGNA STATE OF WYOMING [308105107] 897.6 percent of total billed charges 695.64 1065.9 Professional (doctor) services Resuperf Wnd Face 5.1-7.5 Cm PX-12014 CDM 12014 CPT inpatient 1122 1122 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES EPO [308136803] 897.6 percent of total billed charges 695.64 1065.9 Professional (doctor) services Resuperf Wnd Face 5.1-7.5 Cm PX-12014 CDM 12014 CPT inpatient 1122 1122 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES HDHP [308136802] 897.6 percent of total billed charges 695.64 1065.9 Professional (doctor) services Resuperf Wnd Face 5.1-7.5 Cm PX-12014 CDM 12014 CPT inpatient 1122 1122 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES PPO [308136801] 897.6 percent of total billed charges 695.64 1065.9 Professional (doctor) services Resuperf Wnd Face 5.1-7.5 Cm PX-12014 CDM 12014 CPT outpatient 1122 1122 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES EPO [308136803] 897.6 percent of total billed charges 695.64 1065.9 Professional (doctor) services Resuperf Wnd Face 5.1-7.5 Cm PX-12014 CDM 12014 CPT outpatient 1122 1122 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES HDHP [308136802] 897.6 percent of total billed charges 695.64 1065.9 Professional (doctor) services Resuperf Wnd Face 5.1-7.5 Cm PX-12014 CDM 12014 CPT outpatient 1122 1122 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES PPO [308136801] 897.6 percent of total billed charges 695.64 1065.9 Professional (doctor) services Resuperf Wnd Face 5.1-7.5 Cm PX-12014 CDM 12014 CPT inpatient 1122 1122 HEALTHPARTNERS SX009 HEALTHPARTNERS 897.6 percent of total billed charges 695.64 1065.9 Professional (doctor) services Resuperf Wnd Face 5.1-7.5 Cm PX-12014 CDM 12014 CPT outpatient 1122 1122 HEALTHPARTNERS SX009 HEALTHPARTNERS 897.6 percent of total billed charges 695.64 1065.9 Professional (doctor) services Resuperf Wnd Face 5.1-7.5 Cm PX-12014 CDM 12014 CPT inpatient 1122 1122 MEDICA (COMMERCIAL) 94265 [3081118] MEDICA CLAIMS [308111801] 1009.8 percent of total billed charges 695.64 1065.9 Professional (doctor) services Resuperf Wnd Face 5.1-7.5 Cm PX-12014 CDM 12014 CPT outpatient 1122 1122 MEDICA (COMMERCIAL) 94265 [3081118] MEDICA CLAIMS [308111801] 1009.8 percent of total billed charges 695.64 1065.9 Professional (doctor) services Resuperf Wnd Face 5.1-7.5 Cm PX-12014 CDM 12014 CPT inpatient 1122 1122 MULTIPLAN INC 34080 [3081285] MULTIPLAN INC [308128501] 1065.9 percent of total billed charges 695.64 1065.9 Professional (doctor) services Resuperf Wnd Face 5.1-7.5 Cm PX-12014 CDM 12014 CPT outpatient 1122 1122 MULTIPLAN INC 34080 [3081285] MULTIPLAN INC [308128501] 1065.9 percent of total billed charges 695.64 1065.9 Professional (doctor) services Resuperf Wnd Face 5.1-7.5 Cm PX-12014 CDM 12014 CPT inpatient 1122 1122 UNITED HEALTHCARE (COMMERCIAL) [3081199] UNITED HEALTHCARE 87726 [308119901] 695.64 percent of total billed charges 695.64 1065.9 Professional (doctor) services Resuperf Wnd Face 5.1-7.5 Cm PX-12014 CDM 12014 CPT outpatient 1122 1122 UNITED HEALTHCARE (COMMERCIAL) [3081199] UNITED HEALTHCARE 87726 [308119901] 695.64 percent of total billed charges 695.64 1065.9 Professional (doctor) services Simple Repair F/E/E/N/L/M 2.6cm-5.0 Cm PX-3601201300 CDM 12013 CPT 360 RC inpatient 775 775 HEALTHPARTNERS SX009 HEALTHPARTNERS 613.65 percent of total billed charges 480.5 736.25 Technical (Hospital) Services Simple Repair F/E/E/N/L/M 2.6cm-5.0 Cm PX-3601201300 CDM 12013 CPT 360 RC inpatient 775 775 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES HDHP [308136802] 613.65 percent of total billed charges 480.5 736.25 Technical (Hospital) Services Simple Repair F/E/E/N/L/M 2.6cm-5.0 Cm PX-3601201300 CDM 12013 CPT 360 RC inpatient 775 775 MEDICA (COMMERCIAL) 94265 [3081118] MEDICA CLAIMS [308111801] 697.5 percent of total billed charges 480.5 736.25 Technical (Hospital) Services Simple Repair F/E/E/N/L/M 2.6cm-5.0 Cm PX-3601201300 CDM 12013 CPT 360 RC inpatient 775 775 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES PPO [308136801] 613.65 percent of total billed charges 480.5 736.25 Technical (Hospital) Services Simple Repair F/E/E/N/L/M 2.6cm-5.0 Cm PX-3601201300 CDM 12013 CPT 360 RC inpatient 775 775 UNITED HEALTHCARE (COMMERCIAL) [3081199] UNITED HEALTHCARE 87726 [308119901] 480.5 percent of total billed charges 480.5 736.25 Technical (Hospital) Services Simple Repair F/E/E/N/L/M 2.6cm-5.0 Cm PX-3601201300 CDM 12013 CPT 360 RC inpatient 775 775 MULTIPLAN INC 34080 [3081285] MULTIPLAN INC [308128501] 736.25 percent of total billed charges 480.5 736.25 Technical (Hospital) Services Simple Repair F/E/E/N/L/M 2.6cm-5.0 Cm PX-3601201300 CDM 12013 CPT 360 RC inpatient 775 775 BLUE CROSS BLUE SHIELD WELLMARK SB889 [3081026] BCBS WYOMING [308102603] 736.25 percent of total billed charges 480.5 736.25 Technical (Hospital) Services Simple Repair F/E/E/N/L/M 2.6cm-5.0 Cm PX-3601201300 CDM 12013 CPT 360 RC inpatient 775 775 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES EPO [308136803] 613.65 percent of total billed charges 480.5 736.25 Technical (Hospital) Services Simple Repair F/E/E/N/L/M 2.6cm-5.0 Cm PX-3601201300 CDM 12013 CPT 360 RC inpatient 775 775 CIGNA 62308 [3081051] CIGNA 62308 [308105105] 613.65 percent of total billed charges 480.5 736.25 Technical (Hospital) Services Simple Repair F/E/E/N/L/M 2.6cm-5.0 Cm PX-3601201300 CDM 12013 CPT 360 RC inpatient 775 775 CIGNA 62308 [3081051] CIGNA STATE OF WYOMING [308105107] 613.65 percent of total billed charges 480.5 736.25 Technical (Hospital) Services Simple Repair F/E/E/N/L/M 2.6cm-5.0 Cm PX-3601201300 CDM 12013 CPT 360 RC outpatient 775 775 CIGNA 62308 [3081051] CIGNA 62308 [308105105] 620 percent of total billed charges 480.5 736.25 Technical (Hospital) Services Simple Repair F/E/E/N/L/M 2.6cm-5.0 Cm PX-3601201300 CDM 12013 CPT 360 RC outpatient 775 775 CIGNA 62308 [3081051] CIGNA STATE OF WYOMING [308105107] 620 percent of total billed charges 480.5 736.25 Technical (Hospital) Services Simple Repair F/E/E/N/L/M 2.6cm-5.0 Cm PX-3601201300 CDM 12013 CPT 360 RC outpatient 775 775 HEALTHPARTNERS SX009 HEALTHPARTNERS 620 percent of total billed charges 480.5 736.25 Technical (Hospital) Services Simple Repair F/E/E/N/L/M 2.6cm-5.0 Cm PX-3601201300 CDM 12013 CPT 360 RC outpatient 775 775 MEDICA (COMMERCIAL) 94265 [3081118] MEDICA CLAIMS [308111801] 697.5 percent of total billed charges 480.5 736.25 Technical (Hospital) Services Simple Repair F/E/E/N/L/M 2.6cm-5.0 Cm PX-3601201300 CDM 12013 CPT 360 RC outpatient 775 775 MULTIPLAN INC 34080 [3081285] MULTIPLAN INC [308128501] 736.25 percent of total billed charges 480.5 736.25 Technical (Hospital) Services Simple Repair F/E/E/N/L/M 2.6cm-5.0 Cm PX-3601201300 CDM 12013 CPT 360 RC outpatient 775 775 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES HDHP [308136802] 620 percent of total billed charges 480.5 736.25 Technical (Hospital) Services Simple Repair F/E/E/N/L/M 2.6cm-5.0 Cm PX-3601201300 CDM 12013 CPT 360 RC outpatient 775 775 BLUE CROSS BLUE SHIELD WELLMARK SB889 [3081026] BCBS WYOMING [308102603] 736.25 percent of total billed charges 480.5 736.25 Technical (Hospital) Services Simple Repair F/E/E/N/L/M 2.6cm-5.0 Cm PX-3601201300 CDM 12013 CPT 360 RC outpatient 775 775 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES EPO [308136803] 620 percent of total billed charges 480.5 736.25 Technical (Hospital) Services Simple Repair F/E/E/N/L/M 2.6cm-5.0 Cm PX-3601201300 CDM 12013 CPT 360 RC outpatient 775 775 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES PPO [308136801] 620 percent of total billed charges 480.5 736.25 Technical (Hospital) Services Simple Repair F/E/E/N/L/M 2.6cm-5.0 Cm PX-3601201300 CDM 12013 CPT 360 RC outpatient 775 775 UNITED HEALTHCARE (COMMERCIAL) [3081199] UNITED HEALTHCARE 87726 [308119901] 480.5 percent of total billed charges 480.5 736.25 Technical (Hospital) Services Resuperf Wnd Face 2.6-5 Cm PX-12013 CDM 12013 CPT inpatient 1063 1063 CIGNA 62308 [3081051] CIGNA 62308 [308105105] 850.4 percent of total billed charges 659.06 1009.85 Professional (doctor) services Resuperf Wnd Face 2.6-5 Cm PX-12013 CDM 12013 CPT inpatient 1063 1063 CIGNA 62308 [3081051] CIGNA STATE OF WYOMING [308105107] 850.4 percent of total billed charges 659.06 1009.85 Professional (doctor) services Resuperf Wnd Face 2.6-5 Cm PX-12013 CDM 12013 CPT outpatient 1063 1063 CIGNA 62308 [3081051] CIGNA 62308 [308105105] 850.4 percent of total billed charges 659.06 1009.85 Professional (doctor) services Resuperf Wnd Face 2.6-5 Cm PX-12013 CDM 12013 CPT outpatient 1063 1063 CIGNA 62308 [3081051] CIGNA STATE OF WYOMING [308105107] 850.4 percent of total billed charges 659.06 1009.85 Professional (doctor) services Resuperf Wnd Face 2.6-5 Cm PX-12013 CDM 12013 CPT inpatient 1063 1063 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES EPO [308136803] 850.4 percent of total billed charges 659.06 1009.85 Professional (doctor) services Resuperf Wnd Face 2.6-5 Cm PX-12013 CDM 12013 CPT inpatient 1063 1063 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES HDHP [308136802] 850.4 percent of total billed charges 659.06 1009.85 Professional (doctor) services Resuperf Wnd Face 2.6-5 Cm PX-12013 CDM 12013 CPT inpatient 1063 1063 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES PPO [308136801] 850.4 percent of total billed charges 659.06 1009.85 Professional (doctor) services Resuperf Wnd Face 2.6-5 Cm PX-12013 CDM 12013 CPT outpatient 1063 1063 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES EPO [308136803] 850.4 percent of total billed charges 659.06 1009.85 Professional (doctor) services Resuperf Wnd Face 2.6-5 Cm PX-12013 CDM 12013 CPT outpatient 1063 1063 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES HDHP [308136802] 850.4 percent of total billed charges 659.06 1009.85 Professional (doctor) services Resuperf Wnd Face 2.6-5 Cm PX-12013 CDM 12013 CPT outpatient 1063 1063 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES PPO [308136801] 850.4 percent of total billed charges 659.06 1009.85 Professional (doctor) services Resuperf Wnd Face 2.6-5 Cm PX-12013 CDM 12013 CPT inpatient 1063 1063 HEALTHPARTNERS SX009 HEALTHPARTNERS 850.4 percent of total billed charges 659.06 1009.85 Professional (doctor) services Resuperf Wnd Face 2.6-5 Cm PX-12013 CDM 12013 CPT outpatient 1063 1063 HEALTHPARTNERS SX009 HEALTHPARTNERS 850.4 percent of total billed charges 659.06 1009.85 Professional (doctor) services Resuperf Wnd Face 2.6-5 Cm PX-12013 CDM 12013 CPT inpatient 1063 1063 MEDICA (COMMERCIAL) 94265 [3081118] MEDICA CLAIMS [308111801] 956.7 percent of total billed charges 659.06 1009.85 Professional (doctor) services Resuperf Wnd Face 2.6-5 Cm PX-12013 CDM 12013 CPT outpatient 1063 1063 MEDICA (COMMERCIAL) 94265 [3081118] MEDICA CLAIMS [308111801] 956.7 percent of total billed charges 659.06 1009.85 Professional (doctor) services Resuperf Wnd Face 2.6-5 Cm PX-12013 CDM 12013 CPT inpatient 1063 1063 MULTIPLAN INC 34080 [3081285] MULTIPLAN INC [308128501] 1009.85 percent of total billed charges 659.06 1009.85 Professional (doctor) services Resuperf Wnd Face 2.6-5 Cm PX-12013 CDM 12013 CPT outpatient 1063 1063 MULTIPLAN INC 34080 [3081285] MULTIPLAN INC [308128501] 1009.85 percent of total billed charges 659.06 1009.85 Professional (doctor) services Resuperf Wnd Face 2.6-5 Cm PX-12013 CDM 12013 CPT inpatient 1063 1063 UNITED HEALTHCARE (COMMERCIAL) [3081199] UNITED HEALTHCARE 87726 [308119901] 659.06 percent of total billed charges 659.06 1009.85 Professional (doctor) services Resuperf Wnd Face 2.6-5 Cm PX-12013 CDM 12013 CPT outpatient 1063 1063 UNITED HEALTHCARE (COMMERCIAL) [3081199] UNITED HEALTHCARE 87726 [308119901] 659.06 percent of total billed charges 659.06 1009.85 Professional (doctor) services Simple Repair F/E/E/N/L/M 2.5cm/< PX-3601201100 CDM 12011 CPT 360 RC inpatient 714 714 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES HDHP [308136802] 565.35 percent of total billed charges 442.68 678.3 Technical (Hospital) Services Simple Repair F/E/E/N/L/M 2.5cm/< PX-3601201100 CDM 12011 CPT 360 RC inpatient 714 714 MEDICA (COMMERCIAL) 94265 [3081118] MEDICA CLAIMS [308111801] 642.6 percent of total billed charges 442.68 678.3 Technical (Hospital) Services Simple Repair F/E/E/N/L/M 2.5cm/< PX-3601201100 CDM 12011 CPT 360 RC inpatient 714 714 HEALTHPARTNERS SX009 HEALTHPARTNERS 565.35 percent of total billed charges 442.68 678.3 Technical (Hospital) Services Simple Repair F/E/E/N/L/M 2.5cm/< PX-3601201100 CDM 12011 CPT 360 RC inpatient 714 714 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES PPO [308136801] 565.35 percent of total billed charges 442.68 678.3 Technical (Hospital) Services Simple Repair F/E/E/N/L/M 2.5cm/< PX-3601201100 CDM 12011 CPT 360 RC inpatient 714 714 UNITED HEALTHCARE (COMMERCIAL) [3081199] UNITED HEALTHCARE 87726 [308119901] 442.68 percent of total billed charges 442.68 678.3 Technical (Hospital) Services Simple Repair F/E/E/N/L/M 2.5cm/< PX-3601201100 CDM 12011 CPT 360 RC inpatient 714 714 MULTIPLAN INC 34080 [3081285] MULTIPLAN INC [308128501] 678.3 percent of total billed charges 442.68 678.3 Technical (Hospital) Services Simple Repair F/E/E/N/L/M 2.5cm/< PX-3601201100 CDM 12011 CPT 360 RC inpatient 714 714 BLUE CROSS BLUE SHIELD WELLMARK SB889 [3081026] BCBS WYOMING [308102603] 678.3 percent of total billed charges 442.68 678.3 Technical (Hospital) Services Simple Repair F/E/E/N/L/M 2.5cm/< PX-3601201100 CDM 12011 CPT 360 RC inpatient 714 714 CIGNA 62308 [3081051] CIGNA 62308 [308105105] 565.35 percent of total billed charges 442.68 678.3 Technical (Hospital) Services Simple Repair F/E/E/N/L/M 2.5cm/< PX-3601201100 CDM 12011 CPT 360 RC inpatient 714 714 CIGNA 62308 [3081051] CIGNA STATE OF WYOMING [308105107] 565.35 percent of total billed charges 442.68 678.3 Technical (Hospital) Services Simple Repair F/E/E/N/L/M 2.5cm/< PX-3601201100 CDM 12011 CPT 360 RC inpatient 714 714 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES EPO [308136803] 565.35 percent of total billed charges 442.68 678.3 Technical (Hospital) Services Simple Repair F/E/E/N/L/M 2.5cm/< PX-3601201100 CDM 12011 CPT 360 RC outpatient 714 714 CIGNA 62308 [3081051] CIGNA 62308 [308105105] 571.2 percent of total billed charges 442.68 678.3 Technical (Hospital) Services Simple Repair F/E/E/N/L/M 2.5cm/< PX-3601201100 CDM 12011 CPT 360 RC outpatient 714 714 CIGNA 62308 [3081051] CIGNA STATE OF WYOMING [308105107] 571.2 percent of total billed charges 442.68 678.3 Technical (Hospital) Services Simple Repair F/E/E/N/L/M 2.5cm/< PX-3601201100 CDM 12011 CPT 360 RC outpatient 714 714 MEDICA (COMMERCIAL) 94265 [3081118] MEDICA CLAIMS [308111801] 642.6 percent of total billed charges 442.68 678.3 Technical (Hospital) Services Simple Repair F/E/E/N/L/M 2.5cm/< PX-3601201100 CDM 12011 CPT 360 RC outpatient 714 714 HEALTHPARTNERS SX009 HEALTHPARTNERS 571.2 percent of total billed charges 442.68 678.3 Technical (Hospital) Services Simple Repair F/E/E/N/L/M 2.5cm/< PX-3601201100 CDM 12011 CPT 360 RC outpatient 714 714 UNITED HEALTHCARE (COMMERCIAL) [3081199] UNITED HEALTHCARE 87726 [308119901] 442.68 percent of total billed charges 442.68 678.3 Technical (Hospital) Services Simple Repair F/E/E/N/L/M 2.5cm/< PX-3601201100 CDM 12011 CPT 360 RC outpatient 714 714 BLUE CROSS BLUE SHIELD WELLMARK SB889 [3081026] BCBS WYOMING [308102603] 678.3 percent of total billed charges 442.68 678.3 Technical (Hospital) Services Simple Repair F/E/E/N/L/M 2.5cm/< PX-3601201100 CDM 12011 CPT 360 RC outpatient 714 714 MULTIPLAN INC 34080 [3081285] MULTIPLAN INC [308128501] 678.3 percent of total billed charges 442.68 678.3 Technical (Hospital) Services Simple Repair F/E/E/N/L/M 2.5cm/< PX-3601201100 CDM 12011 CPT 360 RC outpatient 714 714 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES HDHP [308136802] 571.2 percent of total billed charges 442.68 678.3 Technical (Hospital) Services Simple Repair F/E/E/N/L/M 2.5cm/< PX-3601201100 CDM 12011 CPT 360 RC outpatient 714 714 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES EPO [308136803] 571.2 percent of total billed charges 442.68 678.3 Technical (Hospital) Services Simple Repair F/E/E/N/L/M 2.5cm/< PX-3601201100 CDM 12011 CPT 360 RC outpatient 714 714 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES PPO [308136801] 571.2 percent of total billed charges 442.68 678.3 Technical (Hospital) Services Resuperf Wnd Face <2.5 Cm PX-12011 CDM 12011 CPT inpatient 906 906 CIGNA 62308 [3081051] CIGNA 62308 [308105105] 724.8 percent of total billed charges 561.72 860.7 Professional (doctor) services Resuperf Wnd Face <2.5 Cm PX-12011 CDM 12011 CPT inpatient 906 906 CIGNA 62308 [3081051] CIGNA STATE OF WYOMING [308105107] 724.8 percent of total billed charges 561.72 860.7 Professional (doctor) services Resuperf Wnd Face <2.5 Cm PX-12011 CDM 12011 CPT outpatient 906 906 CIGNA 62308 [3081051] CIGNA 62308 [308105105] 724.8 percent of total billed charges 561.72 860.7 Professional (doctor) services Resuperf Wnd Face <2.5 Cm PX-12011 CDM 12011 CPT outpatient 906 906 CIGNA 62308 [3081051] CIGNA STATE OF WYOMING [308105107] 724.8 percent of total billed charges 561.72 860.7 Professional (doctor) services Resuperf Wnd Face <2.5 Cm PX-12011 CDM 12011 CPT inpatient 906 906 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES EPO [308136803] 724.8 percent of total billed charges 561.72 860.7 Professional (doctor) services Resuperf Wnd Face <2.5 Cm PX-12011 CDM 12011 CPT inpatient 906 906 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES HDHP [308136802] 724.8 percent of total billed charges 561.72 860.7 Professional (doctor) services Resuperf Wnd Face <2.5 Cm PX-12011 CDM 12011 CPT inpatient 906 906 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES PPO [308136801] 724.8 percent of total billed charges 561.72 860.7 Professional (doctor) services Resuperf Wnd Face <2.5 Cm PX-12011 CDM 12011 CPT outpatient 906 906 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES EPO [308136803] 724.8 percent of total billed charges 561.72 860.7 Professional (doctor) services Resuperf Wnd Face <2.5 Cm PX-12011 CDM 12011 CPT outpatient 906 906 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES HDHP [308136802] 724.8 percent of total billed charges 561.72 860.7 Professional (doctor) services Resuperf Wnd Face <2.5 Cm PX-12011 CDM 12011 CPT outpatient 906 906 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES PPO [308136801] 724.8 percent of total billed charges 561.72 860.7 Professional (doctor) services Resuperf Wnd Face <2.5 Cm PX-12011 CDM 12011 CPT inpatient 906 906 HEALTHPARTNERS SX009 HEALTHPARTNERS 724.8 percent of total billed charges 561.72 860.7 Professional (doctor) services Resuperf Wnd Face <2.5 Cm PX-12011 CDM 12011 CPT outpatient 906 906 HEALTHPARTNERS SX009 HEALTHPARTNERS 724.8 percent of total billed charges 561.72 860.7 Professional (doctor) services Resuperf Wnd Face <2.5 Cm PX-12011 CDM 12011 CPT inpatient 906 906 MEDICA (COMMERCIAL) 94265 [3081118] MEDICA CLAIMS [308111801] 815.4 percent of total billed charges 561.72 860.7 Professional (doctor) services Resuperf Wnd Face <2.5 Cm PX-12011 CDM 12011 CPT outpatient 906 906 MEDICA (COMMERCIAL) 94265 [3081118] MEDICA CLAIMS [308111801] 815.4 percent of total billed charges 561.72 860.7 Professional (doctor) services Resuperf Wnd Face <2.5 Cm PX-12011 CDM 12011 CPT inpatient 906 906 MULTIPLAN INC 34080 [3081285] MULTIPLAN INC [308128501] 860.7 percent of total billed charges 561.72 860.7 Professional (doctor) services Resuperf Wnd Face <2.5 Cm PX-12011 CDM 12011 CPT outpatient 906 906 MULTIPLAN INC 34080 [3081285] MULTIPLAN INC [308128501] 860.7 percent of total billed charges 561.72 860.7 Professional (doctor) services Resuperf Wnd Face <2.5 Cm PX-12011 CDM 12011 CPT inpatient 906 906 UNITED HEALTHCARE (COMMERCIAL) [3081199] UNITED HEALTHCARE 87726 [308119901] 561.72 percent of total billed charges 561.72 860.7 Professional (doctor) services Resuperf Wnd Face <2.5 Cm PX-12011 CDM 12011 CPT outpatient 906 906 UNITED HEALTHCARE (COMMERCIAL) [3081199] UNITED HEALTHCARE 87726 [308119901] 561.72 percent of total billed charges 561.72 860.7 Professional (doctor) services Simple Repair Scalp/Neck/Ax/Genit/Trunk >30.0cm PX-3601200700 CDM 12007 CPT 360 RC inpatient 1424 1424 MEDICA (COMMERCIAL) 94265 [3081118] MEDICA CLAIMS [308111801] 1281.6 percent of total billed charges 882.88 1352.8 Technical (Hospital) Services Simple Repair Scalp/Neck/Ax/Genit/Trunk >30.0cm PX-3601200700 CDM 12007 CPT 360 RC inpatient 1424 1424 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES HDHP [308136802] 1127.52 percent of total billed charges 882.88 1352.8 Technical (Hospital) Services Simple Repair Scalp/Neck/Ax/Genit/Trunk >30.0cm PX-3601200700 CDM 12007 CPT 360 RC inpatient 1424 1424 HEALTHPARTNERS SX009 HEALTHPARTNERS 1127.52 percent of total billed charges 882.88 1352.8 Technical (Hospital) Services Simple Repair Scalp/Neck/Ax/Genit/Trunk >30.0cm PX-3601200700 CDM 12007 CPT 360 RC inpatient 1424 1424 UNITED HEALTHCARE (COMMERCIAL) [3081199] UNITED HEALTHCARE 87726 [308119901] 882.88 percent of total billed charges 882.88 1352.8 Technical (Hospital) Services Simple Repair Scalp/Neck/Ax/Genit/Trunk >30.0cm PX-3601200700 CDM 12007 CPT 360 RC inpatient 1424 1424 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES PPO [308136801] 1127.52 percent of total billed charges 882.88 1352.8 Technical (Hospital) Services Simple Repair Scalp/Neck/Ax/Genit/Trunk >30.0cm PX-3601200700 CDM 12007 CPT 360 RC inpatient 1424 1424 MULTIPLAN INC 34080 [3081285] MULTIPLAN INC [308128501] 1352.8 percent of total billed charges 882.88 1352.8 Technical (Hospital) Services Simple Repair Scalp/Neck/Ax/Genit/Trunk >30.0cm PX-3601200700 CDM 12007 CPT 360 RC inpatient 1424 1424 BLUE CROSS BLUE SHIELD WELLMARK SB889 [3081026] BCBS WYOMING [308102603] 1352.8 percent of total billed charges 882.88 1352.8 Technical (Hospital) Services Simple Repair Scalp/Neck/Ax/Genit/Trunk >30.0cm PX-3601200700 CDM 12007 CPT 360 RC inpatient 1424 1424 CIGNA 62308 [3081051] CIGNA 62308 [308105105] 1127.52 percent of total billed charges 882.88 1352.8 Technical (Hospital) Services Simple Repair Scalp/Neck/Ax/Genit/Trunk >30.0cm PX-3601200700 CDM 12007 CPT 360 RC inpatient 1424 1424 CIGNA 62308 [3081051] CIGNA STATE OF WYOMING [308105107] 1127.52 percent of total billed charges 882.88 1352.8 Technical (Hospital) Services Simple Repair Scalp/Neck/Ax/Genit/Trunk >30.0cm PX-3601200700 CDM 12007 CPT 360 RC inpatient 1424 1424 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES EPO [308136803] 1127.52 percent of total billed charges 882.88 1352.8 Technical (Hospital) Services Simple Repair Scalp/Neck/Ax/Genit/Trunk >30.0cm PX-3601200700 CDM 12007 CPT 360 RC outpatient 1424 1424 CIGNA 62308 [3081051] CIGNA 62308 [308105105] 1139.2 percent of total billed charges 882.88 1352.8 Technical (Hospital) Services Simple Repair Scalp/Neck/Ax/Genit/Trunk >30.0cm PX-3601200700 CDM 12007 CPT 360 RC outpatient 1424 1424 CIGNA 62308 [3081051] CIGNA STATE OF WYOMING [308105107] 1139.2 percent of total billed charges 882.88 1352.8 Technical (Hospital) Services Simple Repair Scalp/Neck/Ax/Genit/Trunk >30.0cm PX-3601200700 CDM 12007 CPT 360 RC outpatient 1424 1424 MEDICA (COMMERCIAL) 94265 [3081118] MEDICA CLAIMS [308111801] 1281.6 percent of total billed charges 882.88 1352.8 Technical (Hospital) Services Simple Repair Scalp/Neck/Ax/Genit/Trunk >30.0cm PX-3601200700 CDM 12007 CPT 360 RC outpatient 1424 1424 HEALTHPARTNERS SX009 HEALTHPARTNERS 1139.2 percent of total billed charges 882.88 1352.8 Technical (Hospital) Services Simple Repair Scalp/Neck/Ax/Genit/Trunk >30.0cm PX-3601200700 CDM 12007 CPT 360 RC outpatient 1424 1424 UNITED HEALTHCARE (COMMERCIAL) [3081199] UNITED HEALTHCARE 87726 [308119901] 882.88 percent of total billed charges 882.88 1352.8 Technical (Hospital) Services Simple Repair Scalp/Neck/Ax/Genit/Trunk >30.0cm PX-3601200700 CDM 12007 CPT 360 RC outpatient 1424 1424 BLUE CROSS BLUE SHIELD WELLMARK SB889 [3081026] BCBS WYOMING [308102603] 1352.8 percent of total billed charges 882.88 1352.8 Technical (Hospital) Services Simple Repair Scalp/Neck/Ax/Genit/Trunk >30.0cm PX-3601200700 CDM 12007 CPT 360 RC outpatient 1424 1424 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES HDHP [308136802] 1139.2 percent of total billed charges 882.88 1352.8 Technical (Hospital) Services Simple Repair Scalp/Neck/Ax/Genit/Trunk >30.0cm PX-3601200700 CDM 12007 CPT 360 RC outpatient 1424 1424 MULTIPLAN INC 34080 [3081285] MULTIPLAN INC [308128501] 1352.8 percent of total billed charges 882.88 1352.8 Technical (Hospital) Services Simple Repair Scalp/Neck/Ax/Genit/Trunk >30.0cm PX-3601200700 CDM 12007 CPT 360 RC outpatient 1424 1424 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES EPO [308136803] 1139.2 percent of total billed charges 882.88 1352.8 Technical (Hospital) Services Simple Repair Scalp/Neck/Ax/Genit/Trunk >30.0cm PX-3601200700 CDM 12007 CPT 360 RC outpatient 1424 1424 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES PPO [308136801] 1139.2 percent of total billed charges 882.88 1352.8 Technical (Hospital) Services Simple Rpr Scalp/Neck/Ax/Genit/Trunk 7.6-12.5cm PX-3601200400 CDM 12004 CPT 360 RC inpatient 834 834 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES EPO [308136803] 660.36 percent of total billed charges 517.08 792.3 Technical (Hospital) Services Simple Rpr Scalp/Neck/Ax/Genit/Trunk 7.6-12.5cm PX-3601200400 CDM 12004 CPT 360 RC inpatient 834 834 CIGNA 62308 [3081051] CIGNA 62308 [308105105] 660.36 percent of total billed charges 517.08 792.3 Technical (Hospital) Services Simple Rpr Scalp/Neck/Ax/Genit/Trunk 7.6-12.5cm PX-3601200400 CDM 12004 CPT 360 RC inpatient 834 834 CIGNA 62308 [3081051] CIGNA STATE OF WYOMING [308105107] 660.36 percent of total billed charges 517.08 792.3 Technical (Hospital) Services Simple Rpr Scalp/Neck/Ax/Genit/Trunk 7.6-12.5cm PX-3601200400 CDM 12004 CPT 360 RC inpatient 834 834 UNITED HEALTHCARE (COMMERCIAL) [3081199] UNITED HEALTHCARE 87726 [308119901] 517.08 percent of total billed charges 517.08 792.3 Technical (Hospital) Services Simple Rpr Scalp/Neck/Ax/Genit/Trunk 7.6-12.5cm PX-3601200400 CDM 12004 CPT 360 RC inpatient 834 834 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES PPO [308136801] 660.36 percent of total billed charges 517.08 792.3 Technical (Hospital) Services Simple Rpr Scalp/Neck/Ax/Genit/Trunk 7.6-12.5cm PX-3601200400 CDM 12004 CPT 360 RC inpatient 834 834 MULTIPLAN INC 34080 [3081285] MULTIPLAN INC [308128501] 792.3 percent of total billed charges 517.08 792.3 Technical (Hospital) Services Simple Rpr Scalp/Neck/Ax/Genit/Trunk 7.6-12.5cm PX-3601200400 CDM 12004 CPT 360 RC inpatient 834 834 BLUE CROSS BLUE SHIELD WELLMARK SB889 [3081026] BCBS WYOMING [308102603] 792.3 percent of total billed charges 517.08 792.3 Technical (Hospital) Services Simple Rpr Scalp/Neck/Ax/Genit/Trunk 7.6-12.5cm PX-3601200400 CDM 12004 CPT 360 RC inpatient 834 834 HEALTHPARTNERS SX009 HEALTHPARTNERS 660.36 percent of total billed charges 517.08 792.3 Technical (Hospital) Services Simple Rpr Scalp/Neck/Ax/Genit/Trunk 7.6-12.5cm PX-3601200400 CDM 12004 CPT 360 RC inpatient 834 834 MEDICA (COMMERCIAL) 94265 [3081118] MEDICA CLAIMS [308111801] 750.6 percent of total billed charges 517.08 792.3 Technical (Hospital) Services Simple Rpr Scalp/Neck/Ax/Genit/Trunk 7.6-12.5cm PX-3601200400 CDM 12004 CPT 360 RC inpatient 834 834 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES HDHP [308136802] 660.36 percent of total billed charges 517.08 792.3 Technical (Hospital) Services Simple Rpr Scalp/Neck/Ax/Genit/Trunk 7.6-12.5cm PX-3601200400 CDM 12004 CPT 360 RC outpatient 834 834 MEDICA (COMMERCIAL) 94265 [3081118] MEDICA CLAIMS [308111801] 750.6 percent of total billed charges 517.08 792.3 Technical (Hospital) Services Simple Rpr Scalp/Neck/Ax/Genit/Trunk 7.6-12.5cm PX-3601200400 CDM 12004 CPT 360 RC outpatient 834 834 CIGNA 62308 [3081051] CIGNA 62308 [308105105] 667.2 percent of total billed charges 517.08 792.3 Technical (Hospital) Services Simple Rpr Scalp/Neck/Ax/Genit/Trunk 7.6-12.5cm PX-3601200400 CDM 12004 CPT 360 RC outpatient 834 834 CIGNA 62308 [3081051] CIGNA STATE OF WYOMING [308105107] 667.2 percent of total billed charges 517.08 792.3 Technical (Hospital) Services Simple Rpr Scalp/Neck/Ax/Genit/Trunk 7.6-12.5cm PX-3601200400 CDM 12004 CPT 360 RC outpatient 834 834 HEALTHPARTNERS SX009 HEALTHPARTNERS 667.2 percent of total billed charges 517.08 792.3 Technical (Hospital) Services Simple Rpr Scalp/Neck/Ax/Genit/Trunk 7.6-12.5cm PX-3601200400 CDM 12004 CPT 360 RC outpatient 834 834 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES EPO [308136803] 667.2 percent of total billed charges 517.08 792.3 Technical (Hospital) Services Simple Rpr Scalp/Neck/Ax/Genit/Trunk 7.6-12.5cm PX-3601200400 CDM 12004 CPT 360 RC outpatient 834 834 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES PPO [308136801] 667.2 percent of total billed charges 517.08 792.3 Technical (Hospital) Services Simple Rpr Scalp/Neck/Ax/Genit/Trunk 7.6-12.5cm PX-3601200400 CDM 12004 CPT 360 RC outpatient 834 834 UNITED HEALTHCARE (COMMERCIAL) [3081199] UNITED HEALTHCARE 87726 [308119901] 517.08 percent of total billed charges 517.08 792.3 Technical (Hospital) Services Simple Rpr Scalp/Neck/Ax/Genit/Trunk 7.6-12.5cm PX-3601200400 CDM 12004 CPT 360 RC outpatient 834 834 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES HDHP [308136802] 667.2 percent of total billed charges 517.08 792.3 Technical (Hospital) Services Simple Rpr Scalp/Neck/Ax/Genit/Trunk 7.6-12.5cm PX-3601200400 CDM 12004 CPT 360 RC outpatient 834 834 MULTIPLAN INC 34080 [3081285] MULTIPLAN INC [308128501] 792.3 percent of total billed charges 517.08 792.3 Technical (Hospital) Services Simple Rpr Scalp/Neck/Ax/Genit/Trunk 7.6-12.5cm PX-3601200400 CDM 12004 CPT 360 RC outpatient 834 834 BLUE CROSS BLUE SHIELD WELLMARK SB889 [3081026] BCBS WYOMING [308102603] 792.3 percent of total billed charges 517.08 792.3 Technical (Hospital) Services Resuperf Wnd Body 7.6-12.5 Cm PX-12004 CDM 12004 CPT inpatient 1122 1122 CIGNA 62308 [3081051] CIGNA 62308 [308105105] 897.6 percent of total billed charges 695.64 1065.9 Professional (doctor) services Resuperf Wnd Body 7.6-12.5 Cm PX-12004 CDM 12004 CPT inpatient 1122 1122 CIGNA 62308 [3081051] CIGNA STATE OF WYOMING [308105107] 897.6 percent of total billed charges 695.64 1065.9 Professional (doctor) services Resuperf Wnd Body 7.6-12.5 Cm PX-12004 CDM 12004 CPT outpatient 1122 1122 CIGNA 62308 [3081051] CIGNA 62308 [308105105] 897.6 percent of total billed charges 695.64 1065.9 Professional (doctor) services Resuperf Wnd Body 7.6-12.5 Cm PX-12004 CDM 12004 CPT outpatient 1122 1122 CIGNA 62308 [3081051] CIGNA STATE OF WYOMING [308105107] 897.6 percent of total billed charges 695.64 1065.9 Professional (doctor) services Resuperf Wnd Body 7.6-12.5 Cm PX-12004 CDM 12004 CPT inpatient 1122 1122 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES EPO [308136803] 897.6 percent of total billed charges 695.64 1065.9 Professional (doctor) services Resuperf Wnd Body 7.6-12.5 Cm PX-12004 CDM 12004 CPT inpatient 1122 1122 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES HDHP [308136802] 897.6 percent of total billed charges 695.64 1065.9 Professional (doctor) services Resuperf Wnd Body 7.6-12.5 Cm PX-12004 CDM 12004 CPT inpatient 1122 1122 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES PPO [308136801] 897.6 percent of total billed charges 695.64 1065.9 Professional (doctor) services Resuperf Wnd Body 7.6-12.5 Cm PX-12004 CDM 12004 CPT outpatient 1122 1122 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES EPO [308136803] 897.6 percent of total billed charges 695.64 1065.9 Professional (doctor) services Resuperf Wnd Body 7.6-12.5 Cm PX-12004 CDM 12004 CPT outpatient 1122 1122 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES HDHP [308136802] 897.6 percent of total billed charges 695.64 1065.9 Professional (doctor) services Resuperf Wnd Body 7.6-12.5 Cm PX-12004 CDM 12004 CPT outpatient 1122 1122 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES PPO [308136801] 897.6 percent of total billed charges 695.64 1065.9 Professional (doctor) services Resuperf Wnd Body 7.6-12.5 Cm PX-12004 CDM 12004 CPT inpatient 1122 1122 HEALTHPARTNERS SX009 HEALTHPARTNERS 897.6 percent of total billed charges 695.64 1065.9 Professional (doctor) services Resuperf Wnd Body 7.6-12.5 Cm PX-12004 CDM 12004 CPT outpatient 1122 1122 HEALTHPARTNERS SX009 HEALTHPARTNERS 897.6 percent of total billed charges 695.64 1065.9 Professional (doctor) services Resuperf Wnd Body 7.6-12.5 Cm PX-12004 CDM 12004 CPT inpatient 1122 1122 MEDICA (COMMERCIAL) 94265 [3081118] MEDICA CLAIMS [308111801] 1009.8 percent of total billed charges 695.64 1065.9 Professional (doctor) services Resuperf Wnd Body 7.6-12.5 Cm PX-12004 CDM 12004 CPT outpatient 1122 1122 MEDICA (COMMERCIAL) 94265 [3081118] MEDICA CLAIMS [308111801] 1009.8 percent of total billed charges 695.64 1065.9 Professional (doctor) services Resuperf Wnd Body 7.6-12.5 Cm PX-12004 CDM 12004 CPT inpatient 1122 1122 MULTIPLAN INC 34080 [3081285] MULTIPLAN INC [308128501] 1065.9 percent of total billed charges 695.64 1065.9 Professional (doctor) services Resuperf Wnd Body 7.6-12.5 Cm PX-12004 CDM 12004 CPT outpatient 1122 1122 MULTIPLAN INC 34080 [3081285] MULTIPLAN INC [308128501] 1065.9 percent of total billed charges 695.64 1065.9 Professional (doctor) services Resuperf Wnd Body 7.6-12.5 Cm PX-12004 CDM 12004 CPT inpatient 1122 1122 UNITED HEALTHCARE (COMMERCIAL) [3081199] UNITED HEALTHCARE 87726 [308119901] 695.64 percent of total billed charges 695.64 1065.9 Professional (doctor) services Resuperf Wnd Body 7.6-12.5 Cm PX-12004 CDM 12004 CPT outpatient 1122 1122 UNITED HEALTHCARE (COMMERCIAL) [3081199] UNITED HEALTHCARE 87726 [308119901] 695.64 percent of total billed charges 695.64 1065.9 Professional (doctor) services Smpl Repair Scalp/Neck/Ax/Genit/Trunk 2.6-7.5cm PX-3601200200 CDM 12002 CPT 360 RC outpatient 775 775 HEALTHPARTNERS SX009 HEALTHPARTNERS 620 percent of total billed charges 480.5 736.25 Technical (Hospital) Services Smpl Repair Scalp/Neck/Ax/Genit/Trunk 2.6-7.5cm PX-3601200200 CDM 12002 CPT 360 RC outpatient 775 775 MEDICA (COMMERCIAL) 94265 [3081118] MEDICA CLAIMS [308111801] 697.5 percent of total billed charges 480.5 736.25 Technical (Hospital) Services Smpl Repair Scalp/Neck/Ax/Genit/Trunk 2.6-7.5cm PX-3601200200 CDM 12002 CPT 360 RC outpatient 775 775 UNITED HEALTHCARE (COMMERCIAL) [3081199] UNITED HEALTHCARE 87726 [308119901] 480.5 percent of total billed charges 480.5 736.25 Technical (Hospital) Services Smpl Repair Scalp/Neck/Ax/Genit/Trunk 2.6-7.5cm PX-3601200200 CDM 12002 CPT 360 RC outpatient 775 775 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES PPO [308136801] 620 percent of total billed charges 480.5 736.25 Technical (Hospital) Services Smpl Repair Scalp/Neck/Ax/Genit/Trunk 2.6-7.5cm PX-3601200200 CDM 12002 CPT 360 RC outpatient 775 775 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES EPO [308136803] 620 percent of total billed charges 480.5 736.25 Technical (Hospital) Services Smpl Repair Scalp/Neck/Ax/Genit/Trunk 2.6-7.5cm PX-3601200200 CDM 12002 CPT 360 RC outpatient 775 775 MULTIPLAN INC 34080 [3081285] MULTIPLAN INC [308128501] 736.25 percent of total billed charges 480.5 736.25 Technical (Hospital) Services Smpl Repair Scalp/Neck/Ax/Genit/Trunk 2.6-7.5cm PX-3601200200 CDM 12002 CPT 360 RC outpatient 775 775 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES HDHP [308136802] 620 percent of total billed charges 480.5 736.25 Technical (Hospital) Services Smpl Repair Scalp/Neck/Ax/Genit/Trunk 2.6-7.5cm PX-3601200200 CDM 12002 CPT 360 RC outpatient 775 775 BLUE CROSS BLUE SHIELD WELLMARK SB889 [3081026] BCBS WYOMING [308102603] 736.25 percent of total billed charges 480.5 736.25 Technical (Hospital) Services Smpl Repair Scalp/Neck/Ax/Genit/Trunk 2.6-7.5cm PX-3601200200 CDM 12002 CPT 360 RC outpatient 775 775 CIGNA 62308 [3081051] CIGNA 62308 [308105105] 620 percent of total billed charges 480.5 736.25 Technical (Hospital) Services Smpl Repair Scalp/Neck/Ax/Genit/Trunk 2.6-7.5cm PX-3601200200 CDM 12002 CPT 360 RC outpatient 775 775 CIGNA 62308 [3081051] CIGNA STATE OF WYOMING [308105107] 620 percent of total billed charges 480.5 736.25 Technical (Hospital) Services Smpl Repair Scalp/Neck/Ax/Genit/Trunk 2.6-7.5cm PX-3601200200 CDM 12002 CPT 360 RC inpatient 775 775 CIGNA 62308 [3081051] CIGNA 62308 [308105105] 613.65 percent of total billed charges 480.5 736.25 Technical (Hospital) Services Smpl Repair Scalp/Neck/Ax/Genit/Trunk 2.6-7.5cm PX-3601200200 CDM 12002 CPT 360 RC inpatient 775 775 CIGNA 62308 [3081051] CIGNA STATE OF WYOMING [308105107] 613.65 percent of total billed charges 480.5 736.25 Technical (Hospital) Services Smpl Repair Scalp/Neck/Ax/Genit/Trunk 2.6-7.5cm PX-3601200200 CDM 12002 CPT 360 RC inpatient 775 775 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES EPO [308136803] 613.65 percent of total billed charges 480.5 736.25 Technical (Hospital) Services Smpl Repair Scalp/Neck/Ax/Genit/Trunk 2.6-7.5cm PX-3601200200 CDM 12002 CPT 360 RC inpatient 775 775 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES PPO [308136801] 613.65 percent of total billed charges 480.5 736.25 Technical (Hospital) Services Smpl Repair Scalp/Neck/Ax/Genit/Trunk 2.6-7.5cm PX-3601200200 CDM 12002 CPT 360 RC inpatient 775 775 UNITED HEALTHCARE (COMMERCIAL) [3081199] UNITED HEALTHCARE 87726 [308119901] 480.5 percent of total billed charges 480.5 736.25 Technical (Hospital) Services Smpl Repair Scalp/Neck/Ax/Genit/Trunk 2.6-7.5cm PX-3601200200 CDM 12002 CPT 360 RC inpatient 775 775 MULTIPLAN INC 34080 [3081285] MULTIPLAN INC [308128501] 736.25 percent of total billed charges 480.5 736.25 Technical (Hospital) Services Smpl Repair Scalp/Neck/Ax/Genit/Trunk 2.6-7.5cm PX-3601200200 CDM 12002 CPT 360 RC inpatient 775 775 BLUE CROSS BLUE SHIELD WELLMARK SB889 [3081026] BCBS WYOMING [308102603] 736.25 percent of total billed charges 480.5 736.25 Technical (Hospital) Services Smpl Repair Scalp/Neck/Ax/Genit/Trunk 2.6-7.5cm PX-3601200200 CDM 12002 CPT 360 RC inpatient 775 775 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES HDHP [308136802] 613.65 percent of total billed charges 480.5 736.25 Technical (Hospital) Services Smpl Repair Scalp/Neck/Ax/Genit/Trunk 2.6-7.5cm PX-3601200200 CDM 12002 CPT 360 RC inpatient 775 775 MEDICA (COMMERCIAL) 94265 [3081118] MEDICA CLAIMS [308111801] 697.5 percent of total billed charges 480.5 736.25 Technical (Hospital) Services Smpl Repair Scalp/Neck/Ax/Genit/Trunk 2.6-7.5cm PX-3601200200 CDM 12002 CPT 360 RC inpatient 775 775 HEALTHPARTNERS SX009 HEALTHPARTNERS 613.65 percent of total billed charges 480.5 736.25 Technical (Hospital) Services Resup Npterf Wnd Body 2.6-7.5 Cm PX-12002 CDM 12002 CPT inpatient 906 906 CIGNA 62308 [3081051] CIGNA 62308 [308105105] 724.8 percent of total billed charges 561.72 860.7 Professional (doctor) services Resup Npterf Wnd Body 2.6-7.5 Cm PX-12002 CDM 12002 CPT inpatient 906 906 CIGNA 62308 [3081051] CIGNA STATE OF WYOMING [308105107] 724.8 percent of total billed charges 561.72 860.7 Professional (doctor) services Resup Npterf Wnd Body 2.6-7.5 Cm PX-12002 CDM 12002 CPT outpatient 906 906 CIGNA 62308 [3081051] CIGNA 62308 [308105105] 724.8 percent of total billed charges 561.72 860.7 Professional (doctor) services Resup Npterf Wnd Body 2.6-7.5 Cm PX-12002 CDM 12002 CPT outpatient 906 906 CIGNA 62308 [3081051] CIGNA STATE OF WYOMING [308105107] 724.8 percent of total billed charges 561.72 860.7 Professional (doctor) services Resup Npterf Wnd Body 2.6-7.5 Cm PX-12002 CDM 12002 CPT inpatient 906 906 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES EPO [308136803] 724.8 percent of total billed charges 561.72 860.7 Professional (doctor) services Resup Npterf Wnd Body 2.6-7.5 Cm PX-12002 CDM 12002 CPT inpatient 906 906 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES HDHP [308136802] 724.8 percent of total billed charges 561.72 860.7 Professional (doctor) services Resup Npterf Wnd Body 2.6-7.5 Cm PX-12002 CDM 12002 CPT inpatient 906 906 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES PPO [308136801] 724.8 percent of total billed charges 561.72 860.7 Professional (doctor) services Resup Npterf Wnd Body 2.6-7.5 Cm PX-12002 CDM 12002 CPT outpatient 906 906 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES EPO [308136803] 724.8 percent of total billed charges 561.72 860.7 Professional (doctor) services Resup Npterf Wnd Body 2.6-7.5 Cm PX-12002 CDM 12002 CPT outpatient 906 906 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES HDHP [308136802] 724.8 percent of total billed charges 561.72 860.7 Professional (doctor) services Resup Npterf Wnd Body 2.6-7.5 Cm PX-12002 CDM 12002 CPT outpatient 906 906 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES PPO [308136801] 724.8 percent of total billed charges 561.72 860.7 Professional (doctor) services Resup Npterf Wnd Body 2.6-7.5 Cm PX-12002 CDM 12002 CPT inpatient 906 906 HEALTHPARTNERS SX009 HEALTHPARTNERS 724.8 percent of total billed charges 561.72 860.7 Professional (doctor) services Resup Npterf Wnd Body 2.6-7.5 Cm PX-12002 CDM 12002 CPT outpatient 906 906 HEALTHPARTNERS SX009 HEALTHPARTNERS 724.8 percent of total billed charges 561.72 860.7 Professional (doctor) services Resup Npterf Wnd Body 2.6-7.5 Cm PX-12002 CDM 12002 CPT inpatient 906 906 MEDICA (COMMERCIAL) 94265 [3081118] MEDICA CLAIMS [308111801] 815.4 percent of total billed charges 561.72 860.7 Professional (doctor) services Resup Npterf Wnd Body 2.6-7.5 Cm PX-12002 CDM 12002 CPT outpatient 906 906 MEDICA (COMMERCIAL) 94265 [3081118] MEDICA CLAIMS [308111801] 815.4 percent of total billed charges 561.72 860.7 Professional (doctor) services Resup Npterf Wnd Body 2.6-7.5 Cm PX-12002 CDM 12002 CPT inpatient 906 906 MULTIPLAN INC 34080 [3081285] MULTIPLAN INC [308128501] 860.7 percent of total billed charges 561.72 860.7 Professional (doctor) services Resup Npterf Wnd Body 2.6-7.5 Cm PX-12002 CDM 12002 CPT outpatient 906 906 MULTIPLAN INC 34080 [3081285] MULTIPLAN INC [308128501] 860.7 percent of total billed charges 561.72 860.7 Professional (doctor) services Resup Npterf Wnd Body 2.6-7.5 Cm PX-12002 CDM 12002 CPT inpatient 906 906 UNITED HEALTHCARE (COMMERCIAL) [3081199] UNITED HEALTHCARE 87726 [308119901] 561.72 percent of total billed charges 561.72 860.7 Professional (doctor) services Resup Npterf Wnd Body 2.6-7.5 Cm PX-12002 CDM 12002 CPT outpatient 906 906 UNITED HEALTHCARE (COMMERCIAL) [3081199] UNITED HEALTHCARE 87726 [308119901] 561.72 percent of total billed charges 561.72 860.7 Professional (doctor) services Simple Repair Scalp/Neck/Ax/Genit/Trunk 2.5cm/< PX-3601200100 CDM 12001 CPT 360 RC inpatient 714 714 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES HDHP [308136802] 565.35 percent of total billed charges 442.68 678.3 Technical (Hospital) Services Simple Repair Scalp/Neck/Ax/Genit/Trunk 2.5cm/< PX-3601200100 CDM 12001 CPT 360 RC inpatient 714 714 MEDICA (COMMERCIAL) 94265 [3081118] MEDICA CLAIMS [308111801] 642.6 percent of total billed charges 442.68 678.3 Technical (Hospital) Services Simple Repair Scalp/Neck/Ax/Genit/Trunk 2.5cm/< PX-3601200100 CDM 12001 CPT 360 RC inpatient 714 714 HEALTHPARTNERS SX009 HEALTHPARTNERS 565.35 percent of total billed charges 442.68 678.3 Technical (Hospital) Services Simple Repair Scalp/Neck/Ax/Genit/Trunk 2.5cm/< PX-3601200100 CDM 12001 CPT 360 RC inpatient 714 714 BLUE CROSS BLUE SHIELD WELLMARK SB889 [3081026] BCBS WYOMING [308102603] 678.3 percent of total billed charges 442.68 678.3 Technical (Hospital) Services Simple Repair Scalp/Neck/Ax/Genit/Trunk 2.5cm/< PX-3601200100 CDM 12001 CPT 360 RC inpatient 714 714 MULTIPLAN INC 34080 [3081285] MULTIPLAN INC [308128501] 678.3 percent of total billed charges 442.68 678.3 Technical (Hospital) Services Simple Repair Scalp/Neck/Ax/Genit/Trunk 2.5cm/< PX-3601200100 CDM 12001 CPT 360 RC inpatient 714 714 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES PPO [308136801] 565.35 percent of total billed charges 442.68 678.3 Technical (Hospital) Services Simple Repair Scalp/Neck/Ax/Genit/Trunk 2.5cm/< PX-3601200100 CDM 12001 CPT 360 RC inpatient 714 714 UNITED HEALTHCARE (COMMERCIAL) [3081199] UNITED HEALTHCARE 87726 [308119901] 442.68 percent of total billed charges 442.68 678.3 Technical (Hospital) Services Simple Repair Scalp/Neck/Ax/Genit/Trunk 2.5cm/< PX-3601200100 CDM 12001 CPT 360 RC inpatient 714 714 CIGNA 62308 [3081051] CIGNA 62308 [308105105] 565.35 percent of total billed charges 442.68 678.3 Technical (Hospital) Services Simple Repair Scalp/Neck/Ax/Genit/Trunk 2.5cm/< PX-3601200100 CDM 12001 CPT 360 RC inpatient 714 714 CIGNA 62308 [3081051] CIGNA STATE OF WYOMING [308105107] 565.35 percent of total billed charges 442.68 678.3 Technical (Hospital) Services Simple Repair Scalp/Neck/Ax/Genit/Trunk 2.5cm/< PX-3601200100 CDM 12001 CPT 360 RC inpatient 714 714 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES EPO [308136803] 565.35 percent of total billed charges 442.68 678.3 Technical (Hospital) Services Simple Repair Scalp/Neck/Ax/Genit/Trunk 2.5cm/< PX-3601200100 CDM 12001 CPT 360 RC outpatient 714 714 MEDICA (COMMERCIAL) 94265 [3081118] MEDICA CLAIMS [308111801] 642.6 percent of total billed charges 442.68 678.3 Technical (Hospital) Services Simple Repair Scalp/Neck/Ax/Genit/Trunk 2.5cm/< PX-3601200100 CDM 12001 CPT 360 RC outpatient 714 714 CIGNA 62308 [3081051] CIGNA 62308 [308105105] 571.2 percent of total billed charges 442.68 678.3 Technical (Hospital) Services Simple Repair Scalp/Neck/Ax/Genit/Trunk 2.5cm/< PX-3601200100 CDM 12001 CPT 360 RC outpatient 714 714 CIGNA 62308 [3081051] CIGNA STATE OF WYOMING [308105107] 571.2 percent of total billed charges 442.68 678.3 Technical (Hospital) Services Simple Repair Scalp/Neck/Ax/Genit/Trunk 2.5cm/< PX-3601200100 CDM 12001 CPT 360 RC outpatient 714 714 HEALTHPARTNERS SX009 HEALTHPARTNERS 571.2 percent of total billed charges 442.68 678.3 Technical (Hospital) Services Simple Repair Scalp/Neck/Ax/Genit/Trunk 2.5cm/< PX-3601200100 CDM 12001 CPT 360 RC outpatient 714 714 UNITED HEALTHCARE (COMMERCIAL) [3081199] UNITED HEALTHCARE 87726 [308119901] 442.68 percent of total billed charges 442.68 678.3 Technical (Hospital) Services Simple Repair Scalp/Neck/Ax/Genit/Trunk 2.5cm/< PX-3601200100 CDM 12001 CPT 360 RC outpatient 714 714 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES EPO [308136803] 571.2 percent of total billed charges 442.68 678.3 Technical (Hospital) Services Simple Repair Scalp/Neck/Ax/Genit/Trunk 2.5cm/< PX-3601200100 CDM 12001 CPT 360 RC outpatient 714 714 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES PPO [308136801] 571.2 percent of total billed charges 442.68 678.3 Technical (Hospital) Services Simple Repair Scalp/Neck/Ax/Genit/Trunk 2.5cm/< PX-3601200100 CDM 12001 CPT 360 RC outpatient 714 714 BLUE CROSS BLUE SHIELD WELLMARK SB889 [3081026] BCBS WYOMING [308102603] 678.3 percent of total billed charges 442.68 678.3 Technical (Hospital) Services Simple Repair Scalp/Neck/Ax/Genit/Trunk 2.5cm/< PX-3601200100 CDM 12001 CPT 360 RC outpatient 714 714 MULTIPLAN INC 34080 [3081285] MULTIPLAN INC [308128501] 678.3 percent of total billed charges 442.68 678.3 Technical (Hospital) Services Simple Repair Scalp/Neck/Ax/Genit/Trunk 2.5cm/< PX-3601200100 CDM 12001 CPT 360 RC outpatient 714 714 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES HDHP [308136802] 571.2 percent of total billed charges 442.68 678.3 Technical (Hospital) Services Resuperf Wnd Body <2.5cm PX-12001 CDM 12001 CPT inpatient 749 749 CIGNA 62308 [3081051] CIGNA 62308 [308105105] 599.2 percent of total billed charges 464.38 711.55 Professional (doctor) services Resuperf Wnd Body <2.5cm PX-12001 CDM 12001 CPT inpatient 749 749 CIGNA 62308 [3081051] CIGNA STATE OF WYOMING [308105107] 599.2 percent of total billed charges 464.38 711.55 Professional (doctor) services Resuperf Wnd Body <2.5cm PX-12001 CDM 12001 CPT outpatient 749 749 CIGNA 62308 [3081051] CIGNA 62308 [308105105] 599.2 percent of total billed charges 464.38 711.55 Professional (doctor) services Resuperf Wnd Body <2.5cm PX-12001 CDM 12001 CPT outpatient 749 749 CIGNA 62308 [3081051] CIGNA STATE OF WYOMING [308105107] 599.2 percent of total billed charges 464.38 711.55 Professional (doctor) services Resuperf Wnd Body <2.5cm PX-12001 CDM 12001 CPT inpatient 749 749 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES EPO [308136803] 599.2 percent of total billed charges 464.38 711.55 Professional (doctor) services Resuperf Wnd Body <2.5cm PX-12001 CDM 12001 CPT inpatient 749 749 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES HDHP [308136802] 599.2 percent of total billed charges 464.38 711.55 Professional (doctor) services Resuperf Wnd Body <2.5cm PX-12001 CDM 12001 CPT inpatient 749 749 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES PPO [308136801] 599.2 percent of total billed charges 464.38 711.55 Professional (doctor) services Resuperf Wnd Body <2.5cm PX-12001 CDM 12001 CPT outpatient 749 749 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES EPO [308136803] 599.2 percent of total billed charges 464.38 711.55 Professional (doctor) services Resuperf Wnd Body <2.5cm PX-12001 CDM 12001 CPT outpatient 749 749 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES HDHP [308136802] 599.2 percent of total billed charges 464.38 711.55 Professional (doctor) services Resuperf Wnd Body <2.5cm PX-12001 CDM 12001 CPT outpatient 749 749 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES PPO [308136801] 599.2 percent of total billed charges 464.38 711.55 Professional (doctor) services Resuperf Wnd Body <2.5cm PX-12001 CDM 12001 CPT inpatient 749 749 HEALTHPARTNERS SX009 HEALTHPARTNERS 599.2 percent of total billed charges 464.38 711.55 Professional (doctor) services Resuperf Wnd Body <2.5cm PX-12001 CDM 12001 CPT outpatient 749 749 HEALTHPARTNERS SX009 HEALTHPARTNERS 599.2 percent of total billed charges 464.38 711.55 Professional (doctor) services Resuperf Wnd Body <2.5cm PX-12001 CDM 12001 CPT inpatient 749 749 MEDICA (COMMERCIAL) 94265 [3081118] MEDICA CLAIMS [308111801] 674.1 percent of total billed charges 464.38 711.55 Professional (doctor) services Resuperf Wnd Body <2.5cm PX-12001 CDM 12001 CPT outpatient 749 749 MEDICA (COMMERCIAL) 94265 [3081118] MEDICA CLAIMS [308111801] 674.1 percent of total billed charges 464.38 711.55 Professional (doctor) services Resuperf Wnd Body <2.5cm PX-12001 CDM 12001 CPT inpatient 749 749 MULTIPLAN INC 34080 [3081285] MULTIPLAN INC [308128501] 711.55 percent of total billed charges 464.38 711.55 Professional (doctor) services Resuperf Wnd Body <2.5cm PX-12001 CDM 12001 CPT outpatient 749 749 MULTIPLAN INC 34080 [3081285] MULTIPLAN INC [308128501] 711.55 percent of total billed charges 464.38 711.55 Professional (doctor) services Resuperf Wnd Body <2.5cm PX-12001 CDM 12001 CPT inpatient 749 749 UNITED HEALTHCARE (COMMERCIAL) [3081199] UNITED HEALTHCARE 87726 [308119901] 464.38 percent of total billed charges 464.38 711.55 Professional (doctor) services Resuperf Wnd Body <2.5cm PX-12001 CDM 12001 CPT outpatient 749 749 UNITED HEALTHCARE (COMMERCIAL) [3081199] UNITED HEALTHCARE 87726 [308119901] 464.38 percent of total billed charges 464.38 711.55 Professional (doctor) services Removal of Nail Bed PX-11750 CDM 11750 CPT inpatient 542 542 CIGNA 62308 [3081051] CIGNA 62308 [308105105] 433.6 percent of total billed charges 336.04 514.9 Professional (doctor) services Removal of Nail Bed PX-11750 CDM 11750 CPT inpatient 542 542 CIGNA 62308 [3081051] CIGNA STATE OF WYOMING [308105107] 433.6 percent of total billed charges 336.04 514.9 Professional (doctor) services Removal of Nail Bed PX-11750 CDM 11750 CPT outpatient 542 542 CIGNA 62308 [3081051] CIGNA 62308 [308105105] 433.6 percent of total billed charges 336.04 514.9 Professional (doctor) services Removal of Nail Bed PX-11750 CDM 11750 CPT outpatient 542 542 CIGNA 62308 [3081051] CIGNA STATE OF WYOMING [308105107] 433.6 percent of total billed charges 336.04 514.9 Professional (doctor) services Removal of Nail Bed PX-11750 CDM 11750 CPT inpatient 542 542 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES EPO [308136803] 433.6 percent of total billed charges 336.04 514.9 Professional (doctor) services Removal of Nail Bed PX-11750 CDM 11750 CPT inpatient 542 542 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES HDHP [308136802] 433.6 percent of total billed charges 336.04 514.9 Professional (doctor) services Removal of Nail Bed PX-11750 CDM 11750 CPT inpatient 542 542 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES PPO [308136801] 433.6 percent of total billed charges 336.04 514.9 Professional (doctor) services Removal of Nail Bed PX-11750 CDM 11750 CPT outpatient 542 542 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES EPO [308136803] 433.6 percent of total billed charges 336.04 514.9 Professional (doctor) services Removal of Nail Bed PX-11750 CDM 11750 CPT outpatient 542 542 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES HDHP [308136802] 433.6 percent of total billed charges 336.04 514.9 Professional (doctor) services Removal of Nail Bed PX-11750 CDM 11750 CPT outpatient 542 542 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES PPO [308136801] 433.6 percent of total billed charges 336.04 514.9 Professional (doctor) services Removal of Nail Bed PX-11750 CDM 11750 CPT inpatient 542 542 HEALTHPARTNERS SX009 HEALTHPARTNERS 433.6 percent of total billed charges 336.04 514.9 Professional (doctor) services Removal of Nail Bed PX-11750 CDM 11750 CPT outpatient 542 542 HEALTHPARTNERS SX009 HEALTHPARTNERS 433.6 percent of total billed charges 336.04 514.9 Professional (doctor) services Removal of Nail Bed PX-11750 CDM 11750 CPT inpatient 542 542 MEDICA (COMMERCIAL) 94265 [3081118] MEDICA CLAIMS [308111801] 487.8 percent of total billed charges 336.04 514.9 Professional (doctor) services Removal of Nail Bed PX-11750 CDM 11750 CPT outpatient 542 542 MEDICA (COMMERCIAL) 94265 [3081118] MEDICA CLAIMS [308111801] 487.8 percent of total billed charges 336.04 514.9 Professional (doctor) services Removal of Nail Bed PX-11750 CDM 11750 CPT inpatient 542 542 MULTIPLAN INC 34080 [3081285] MULTIPLAN INC [308128501] 514.9 percent of total billed charges 336.04 514.9 Professional (doctor) services Removal of Nail Bed PX-11750 CDM 11750 CPT outpatient 542 542 MULTIPLAN INC 34080 [3081285] MULTIPLAN INC [308128501] 514.9 percent of total billed charges 336.04 514.9 Professional (doctor) services Removal of Nail Bed PX-11750 CDM 11750 CPT inpatient 542 542 UNITED HEALTHCARE (COMMERCIAL) [3081199] UNITED HEALTHCARE 87726 [308119901] 336.04 percent of total billed charges 336.04 514.9 Professional (doctor) services Removal of Nail Bed PX-11750 CDM 11750 CPT outpatient 542 542 UNITED HEALTHCARE (COMMERCIAL) [3081199] UNITED HEALTHCARE 87726 [308119901] 336.04 percent of total billed charges 336.04 514.9 Professional (doctor) services Evacuation Subungual Hematoma PX-3601174000 CDM 11740 CPT 360 RC inpatient 214 214 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES HDHP [308136802] 169.45 percent of total billed charges 132.68 203.3 Technical (Hospital) Services Evacuation Subungual Hematoma PX-3601174000 CDM 11740 CPT 360 RC inpatient 214 214 MEDICA (COMMERCIAL) 94265 [3081118] MEDICA CLAIMS [308111801] 192.6 percent of total billed charges 132.68 203.3 Technical (Hospital) Services Evacuation Subungual Hematoma PX-3601174000 CDM 11740 CPT 360 RC inpatient 214 214 HEALTHPARTNERS SX009 HEALTHPARTNERS 169.45 percent of total billed charges 132.68 203.3 Technical (Hospital) Services Evacuation Subungual Hematoma PX-3601174000 CDM 11740 CPT 360 RC inpatient 214 214 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES PPO [308136801] 169.45 percent of total billed charges 132.68 203.3 Technical (Hospital) Services Evacuation Subungual Hematoma PX-3601174000 CDM 11740 CPT 360 RC inpatient 214 214 UNITED HEALTHCARE (COMMERCIAL) [3081199] UNITED HEALTHCARE 87726 [308119901] 132.68 percent of total billed charges 132.68 203.3 Technical (Hospital) Services Evacuation Subungual Hematoma PX-3601174000 CDM 11740 CPT 360 RC inpatient 214 214 BLUE CROSS BLUE SHIELD WELLMARK SB889 [3081026] BCBS WYOMING [308102603] 203.3 percent of total billed charges 132.68 203.3 Technical (Hospital) Services Evacuation Subungual Hematoma PX-3601174000 CDM 11740 CPT 360 RC inpatient 214 214 MULTIPLAN INC 34080 [3081285] MULTIPLAN INC [308128501] 203.3 percent of total billed charges 132.68 203.3 Technical (Hospital) Services Evacuation Subungual Hematoma PX-3601174000 CDM 11740 CPT 360 RC inpatient 214 214 CIGNA 62308 [3081051] CIGNA 62308 [308105105] 169.45 percent of total billed charges 132.68 203.3 Technical (Hospital) Services Evacuation Subungual Hematoma PX-3601174000 CDM 11740 CPT 360 RC inpatient 214 214 CIGNA 62308 [3081051] CIGNA STATE OF WYOMING [308105107] 169.45 percent of total billed charges 132.68 203.3 Technical (Hospital) Services Evacuation Subungual Hematoma PX-3601174000 CDM 11740 CPT 360 RC inpatient 214 214 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES EPO [308136803] 169.45 percent of total billed charges 132.68 203.3 Technical (Hospital) Services Evacuation Subungual Hematoma PX-3601174000 CDM 11740 CPT 360 RC outpatient 214 214 MEDICA (COMMERCIAL) 94265 [3081118] MEDICA CLAIMS [308111801] 192.6 percent of total billed charges 132.68 203.3 Technical (Hospital) Services Evacuation Subungual Hematoma PX-3601174000 CDM 11740 CPT 360 RC outpatient 214 214 CIGNA 62308 [3081051] CIGNA 62308 [308105105] 171.2 percent of total billed charges 132.68 203.3 Technical (Hospital) Services Evacuation Subungual Hematoma PX-3601174000 CDM 11740 CPT 360 RC outpatient 214 214 CIGNA 62308 [3081051] CIGNA STATE OF WYOMING [308105107] 171.2 percent of total billed charges 132.68 203.3 Technical (Hospital) Services Evacuation Subungual Hematoma PX-3601174000 CDM 11740 CPT 360 RC outpatient 214 214 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES EPO [308136803] 171.2 percent of total billed charges 132.68 203.3 Technical (Hospital) Services Evacuation Subungual Hematoma PX-3601174000 CDM 11740 CPT 360 RC outpatient 214 214 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES PPO [308136801] 171.2 percent of total billed charges 132.68 203.3 Technical (Hospital) Services Evacuation Subungual Hematoma PX-3601174000 CDM 11740 CPT 360 RC outpatient 214 214 UNITED HEALTHCARE (COMMERCIAL) [3081199] UNITED HEALTHCARE 87726 [308119901] 132.68 percent of total billed charges 132.68 203.3 Technical (Hospital) Services Evacuation Subungual Hematoma PX-3601174000 CDM 11740 CPT 360 RC outpatient 214 214 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES HDHP [308136802] 171.2 percent of total billed charges 132.68 203.3 Technical (Hospital) Services Evacuation Subungual Hematoma PX-3601174000 CDM 11740 CPT 360 RC outpatient 214 214 MULTIPLAN INC 34080 [3081285] MULTIPLAN INC [308128501] 203.3 percent of total billed charges 132.68 203.3 Technical (Hospital) Services Evacuation Subungual Hematoma PX-3601174000 CDM 11740 CPT 360 RC outpatient 214 214 BLUE CROSS BLUE SHIELD WELLMARK SB889 [3081026] BCBS WYOMING [308102603] 203.3 percent of total billed charges 132.68 203.3 Technical (Hospital) Services Evacuation Subungual Hematoma PX-3601174000 CDM 11740 CPT 360 RC outpatient 214 214 HEALTHPARTNERS SX009 HEALTHPARTNERS 171.2 percent of total billed charges 132.68 203.3 Technical (Hospital) Services Drain Blood From Under Nail PX-11740 CDM 11740 CPT inpatient 155 155 CIGNA 62308 [3081051] CIGNA 62308 [308105105] 124 percent of total billed charges 96.1 147.25 Professional (doctor) services Drain Blood From Under Nail PX-11740 CDM 11740 CPT inpatient 155 155 CIGNA 62308 [3081051] CIGNA STATE OF WYOMING [308105107] 124 percent of total billed charges 96.1 147.25 Professional (doctor) services Drain Blood From Under Nail PX-11740 CDM 11740 CPT outpatient 155 155 CIGNA 62308 [3081051] CIGNA 62308 [308105105] 124 percent of total billed charges 96.1 147.25 Professional (doctor) services Drain Blood From Under Nail PX-11740 CDM 11740 CPT outpatient 155 155 CIGNA 62308 [3081051] CIGNA STATE OF WYOMING [308105107] 124 percent of total billed charges 96.1 147.25 Professional (doctor) services Drain Blood From Under Nail PX-11740 CDM 11740 CPT inpatient 155 155 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES EPO [308136803] 124 percent of total billed charges 96.1 147.25 Professional (doctor) services Drain Blood From Under Nail PX-11740 CDM 11740 CPT inpatient 155 155 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES HDHP [308136802] 124 percent of total billed charges 96.1 147.25 Professional (doctor) services Drain Blood From Under Nail PX-11740 CDM 11740 CPT inpatient 155 155 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES PPO [308136801] 124 percent of total billed charges 96.1 147.25 Professional (doctor) services Drain Blood From Under Nail PX-11740 CDM 11740 CPT outpatient 155 155 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES EPO [308136803] 124 percent of total billed charges 96.1 147.25 Professional (doctor) services Drain Blood From Under Nail PX-11740 CDM 11740 CPT outpatient 155 155 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES HDHP [308136802] 124 percent of total billed charges 96.1 147.25 Professional (doctor) services Drain Blood From Under Nail PX-11740 CDM 11740 CPT outpatient 155 155 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES PPO [308136801] 124 percent of total billed charges 96.1 147.25 Professional (doctor) services Drain Blood From Under Nail PX-11740 CDM 11740 CPT inpatient 155 155 HEALTHPARTNERS SX009 HEALTHPARTNERS 124 percent of total billed charges 96.1 147.25 Professional (doctor) services Drain Blood From Under Nail PX-11740 CDM 11740 CPT outpatient 155 155 HEALTHPARTNERS SX009 HEALTHPARTNERS 124 percent of total billed charges 96.1 147.25 Professional (doctor) services Drain Blood From Under Nail PX-11740 CDM 11740 CPT inpatient 155 155 MEDICA (COMMERCIAL) 94265 [3081118] MEDICA CLAIMS [308111801] 139.5 percent of total billed charges 96.1 147.25 Professional (doctor) services Drain Blood From Under Nail PX-11740 CDM 11740 CPT outpatient 155 155 MEDICA (COMMERCIAL) 94265 [3081118] MEDICA CLAIMS [308111801] 139.5 percent of total billed charges 96.1 147.25 Professional (doctor) services Drain Blood From Under Nail PX-11740 CDM 11740 CPT inpatient 155 155 MULTIPLAN INC 34080 [3081285] MULTIPLAN INC [308128501] 147.25 percent of total billed charges 96.1 147.25 Professional (doctor) services Drain Blood From Under Nail PX-11740 CDM 11740 CPT outpatient 155 155 MULTIPLAN INC 34080 [3081285] MULTIPLAN INC [308128501] 147.25 percent of total billed charges 96.1 147.25 Professional (doctor) services Drain Blood From Under Nail PX-11740 CDM 11740 CPT inpatient 155 155 UNITED HEALTHCARE (COMMERCIAL) [3081199] UNITED HEALTHCARE 87726 [308119901] 96.1 percent of total billed charges 96.1 147.25 Professional (doctor) services Drain Blood From Under Nail PX-11740 CDM 11740 CPT outpatient 155 155 UNITED HEALTHCARE (COMMERCIAL) [3081199] UNITED HEALTHCARE 87726 [308119901] 96.1 percent of total billed charges 96.1 147.25 Professional (doctor) services Incision & Removal Foreign Body Subq Tiss Simple PX-3601012000 CDM 10120 CPT 360 RC inpatient 600 600 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES EPO [308136803] 475.08 percent of total billed charges 372 570 Technical (Hospital) Services Incision & Removal Foreign Body Subq Tiss Simple PX-3601012000 CDM 10120 CPT 360 RC inpatient 600 600 CIGNA 62308 [3081051] CIGNA 62308 [308105105] 475.08 percent of total billed charges 372 570 Technical (Hospital) Services Incision & Removal Foreign Body Subq Tiss Simple PX-3601012000 CDM 10120 CPT 360 RC inpatient 600 600 CIGNA 62308 [3081051] CIGNA STATE OF WYOMING [308105107] 475.08 percent of total billed charges 372 570 Technical (Hospital) Services Incision & Removal Foreign Body Subq Tiss Simple PX-3601012000 CDM 10120 CPT 360 RC inpatient 600 600 HEALTHPARTNERS SX009 HEALTHPARTNERS 475.08 percent of total billed charges 372 570 Technical (Hospital) Services Incision & Removal Foreign Body Subq Tiss Simple PX-3601012000 CDM 10120 CPT 360 RC inpatient 600 600 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES HDHP [308136802] 475.08 percent of total billed charges 372 570 Technical (Hospital) Services Incision & Removal Foreign Body Subq Tiss Simple PX-3601012000 CDM 10120 CPT 360 RC inpatient 600 600 MEDICA (COMMERCIAL) 94265 [3081118] MEDICA CLAIMS [308111801] 540 percent of total billed charges 372 570 Technical (Hospital) Services Incision & Removal Foreign Body Subq Tiss Simple PX-3601012000 CDM 10120 CPT 360 RC inpatient 600 600 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES PPO [308136801] 475.08 percent of total billed charges 372 570 Technical (Hospital) Services Incision & Removal Foreign Body Subq Tiss Simple PX-3601012000 CDM 10120 CPT 360 RC inpatient 600 600 UNITED HEALTHCARE (COMMERCIAL) [3081199] UNITED HEALTHCARE 87726 [308119901] 372 percent of total billed charges 372 570 Technical (Hospital) Services Incision & Removal Foreign Body Subq Tiss Simple PX-3601012000 CDM 10120 CPT 360 RC inpatient 600 600 BLUE CROSS BLUE SHIELD WELLMARK SB889 [3081026] BCBS WYOMING [308102603] 570 percent of total billed charges 372 570 Technical (Hospital) Services Incision & Removal Foreign Body Subq Tiss Simple PX-3601012000 CDM 10120 CPT 360 RC inpatient 600 600 MULTIPLAN INC 34080 [3081285] MULTIPLAN INC [308128501] 570 percent of total billed charges 372 570 Technical (Hospital) Services Incision & Removal Foreign Body Subq Tiss Simple PX-3601012000 CDM 10120 CPT 360 RC outpatient 600 600 HEALTHPARTNERS SX009 HEALTHPARTNERS 480 percent of total billed charges 372 570 Technical (Hospital) Services Incision & Removal Foreign Body Subq Tiss Simple PX-3601012000 CDM 10120 CPT 360 RC outpatient 600 600 MEDICA (COMMERCIAL) 94265 [3081118] MEDICA CLAIMS [308111801] 540 percent of total billed charges 372 570 Technical (Hospital) Services Incision & Removal Foreign Body Subq Tiss Simple PX-3601012000 CDM 10120 CPT 360 RC outpatient 600 600 UNITED HEALTHCARE (COMMERCIAL) [3081199] UNITED HEALTHCARE 87726 [308119901] 372 percent of total billed charges 372 570 Technical (Hospital) Services Incision & Removal Foreign Body Subq Tiss Simple PX-3601012000 CDM 10120 CPT 360 RC outpatient 600 600 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES EPO [308136803] 480 percent of total billed charges 372 570 Technical (Hospital) Services Incision & Removal Foreign Body Subq Tiss Simple PX-3601012000 CDM 10120 CPT 360 RC outpatient 600 600 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES PPO [308136801] 480 percent of total billed charges 372 570 Technical (Hospital) Services Incision & Removal Foreign Body Subq Tiss Simple PX-3601012000 CDM 10120 CPT 360 RC outpatient 600 600 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES HDHP [308136802] 480 percent of total billed charges 372 570 Technical (Hospital) Services Incision & Removal Foreign Body Subq Tiss Simple PX-3601012000 CDM 10120 CPT 360 RC outpatient 600 600 MULTIPLAN INC 34080 [3081285] MULTIPLAN INC [308128501] 570 percent of total billed charges 372 570 Technical (Hospital) Services Incision & Removal Foreign Body Subq Tiss Simple PX-3601012000 CDM 10120 CPT 360 RC outpatient 600 600 BLUE CROSS BLUE SHIELD WELLMARK SB889 [3081026] BCBS WYOMING [308102603] 570 percent of total billed charges 372 570 Technical (Hospital) Services Incision & Removal Foreign Body Subq Tiss Simple PX-3601012000 CDM 10120 CPT 360 RC outpatient 600 600 CIGNA 62308 [3081051] CIGNA 62308 [308105105] 480 percent of total billed charges 372 570 Technical (Hospital) Services Incision & Removal Foreign Body Subq Tiss Simple PX-3601012000 CDM 10120 CPT 360 RC outpatient 600 600 CIGNA 62308 [3081051] CIGNA STATE OF WYOMING [308105107] 480 percent of total billed charges 372 570 Technical (Hospital) Services Remove Foreign Body Simple PX-10120 CDM 10120 CPT inpatient 627 627 CIGNA 62308 [3081051] CIGNA 62308 [308105105] 501.6 percent of total billed charges 388.74 595.65 Professional (doctor) services Remove Foreign Body Simple PX-10120 CDM 10120 CPT inpatient 627 627 CIGNA 62308 [3081051] CIGNA STATE OF WYOMING [308105107] 501.6 percent of total billed charges 388.74 595.65 Professional (doctor) services Remove Foreign Body Simple PX-10120 CDM 10120 CPT outpatient 627 627 CIGNA 62308 [3081051] CIGNA 62308 [308105105] 501.6 percent of total billed charges 388.74 595.65 Professional (doctor) services Remove Foreign Body Simple PX-10120 CDM 10120 CPT outpatient 627 627 CIGNA 62308 [3081051] CIGNA STATE OF WYOMING [308105107] 501.6 percent of total billed charges 388.74 595.65 Professional (doctor) services Remove Foreign Body Simple PX-10120 CDM 10120 CPT inpatient 627 627 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES EPO [308136803] 501.6 percent of total billed charges 388.74 595.65 Professional (doctor) services Remove Foreign Body Simple PX-10120 CDM 10120 CPT inpatient 627 627 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES HDHP [308136802] 501.6 percent of total billed charges 388.74 595.65 Professional (doctor) services Remove Foreign Body Simple PX-10120 CDM 10120 CPT inpatient 627 627 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES PPO [308136801] 501.6 percent of total billed charges 388.74 595.65 Professional (doctor) services Remove Foreign Body Simple PX-10120 CDM 10120 CPT outpatient 627 627 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES EPO [308136803] 501.6 percent of total billed charges 388.74 595.65 Professional (doctor) services Remove Foreign Body Simple PX-10120 CDM 10120 CPT outpatient 627 627 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES HDHP [308136802] 501.6 percent of total billed charges 388.74 595.65 Professional (doctor) services Remove Foreign Body Simple PX-10120 CDM 10120 CPT outpatient 627 627 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES PPO [308136801] 501.6 percent of total billed charges 388.74 595.65 Professional (doctor) services Remove Foreign Body Simple PX-10120 CDM 10120 CPT inpatient 627 627 HEALTHPARTNERS SX009 HEALTHPARTNERS 501.6 percent of total billed charges 388.74 595.65 Professional (doctor) services Remove Foreign Body Simple PX-10120 CDM 10120 CPT outpatient 627 627 HEALTHPARTNERS SX009 HEALTHPARTNERS 501.6 percent of total billed charges 388.74 595.65 Professional (doctor) services Remove Foreign Body Simple PX-10120 CDM 10120 CPT inpatient 627 627 MEDICA (COMMERCIAL) 94265 [3081118] MEDICA CLAIMS [308111801] 564.3 percent of total billed charges 388.74 595.65 Professional (doctor) services Remove Foreign Body Simple PX-10120 CDM 10120 CPT outpatient 627 627 MEDICA (COMMERCIAL) 94265 [3081118] MEDICA CLAIMS [308111801] 564.3 percent of total billed charges 388.74 595.65 Professional (doctor) services Remove Foreign Body Simple PX-10120 CDM 10120 CPT inpatient 627 627 MULTIPLAN INC 34080 [3081285] MULTIPLAN INC [308128501] 595.65 percent of total billed charges 388.74 595.65 Professional (doctor) services Remove Foreign Body Simple PX-10120 CDM 10120 CPT outpatient 627 627 MULTIPLAN INC 34080 [3081285] MULTIPLAN INC [308128501] 595.65 percent of total billed charges 388.74 595.65 Professional (doctor) services Remove Foreign Body Simple PX-10120 CDM 10120 CPT inpatient 627 627 UNITED HEALTHCARE (COMMERCIAL) [3081199] UNITED HEALTHCARE 87726 [308119901] 388.74 percent of total billed charges 388.74 595.65 Professional (doctor) services Remove Foreign Body Simple PX-10120 CDM 10120 CPT outpatient 627 627 UNITED HEALTHCARE (COMMERCIAL) [3081199] UNITED HEALTHCARE 87726 [308119901] 388.74 percent of total billed charges 388.74 595.65 Professional (doctor) services Incision & Drainage Pilonidal Cyst Simple PX-3601008000 CDM 10080 CPT 360 RC inpatient 817 817 CIGNA 62308 [3081051] CIGNA 62308 [308105105] 646.9 percent of total billed charges 506.54 776.15 Technical (Hospital) Services Incision & Drainage Pilonidal Cyst Simple PX-3601008000 CDM 10080 CPT 360 RC inpatient 817 817 CIGNA 62308 [3081051] CIGNA STATE OF WYOMING [308105107] 646.9 percent of total billed charges 506.54 776.15 Technical (Hospital) Services Incision & Drainage Pilonidal Cyst Simple PX-3601008000 CDM 10080 CPT 360 RC inpatient 817 817 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES EPO [308136803] 646.9 percent of total billed charges 506.54 776.15 Technical (Hospital) Services Incision & Drainage Pilonidal Cyst Simple PX-3601008000 CDM 10080 CPT 360 RC inpatient 817 817 HEALTHPARTNERS SX009 HEALTHPARTNERS 646.9 percent of total billed charges 506.54 776.15 Technical (Hospital) Services Incision & Drainage Pilonidal Cyst Simple PX-3601008000 CDM 10080 CPT 360 RC inpatient 817 817 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES HDHP [308136802] 646.9 percent of total billed charges 506.54 776.15 Technical (Hospital) Services Incision & Drainage Pilonidal Cyst Simple PX-3601008000 CDM 10080 CPT 360 RC inpatient 817 817 MEDICA (COMMERCIAL) 94265 [3081118] MEDICA CLAIMS [308111801] 735.3 percent of total billed charges 506.54 776.15 Technical (Hospital) Services Incision & Drainage Pilonidal Cyst Simple PX-3601008000 CDM 10080 CPT 360 RC inpatient 817 817 UNITED HEALTHCARE (COMMERCIAL) [3081199] UNITED HEALTHCARE 87726 [308119901] 506.54 percent of total billed charges 506.54 776.15 Technical (Hospital) Services Incision & Drainage Pilonidal Cyst Simple PX-3601008000 CDM 10080 CPT 360 RC inpatient 817 817 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES PPO [308136801] 646.9 percent of total billed charges 506.54 776.15 Technical (Hospital) Services Incision & Drainage Pilonidal Cyst Simple PX-3601008000 CDM 10080 CPT 360 RC inpatient 817 817 BLUE CROSS BLUE SHIELD WELLMARK SB889 [3081026] BCBS WYOMING [308102603] 776.15 percent of total billed charges 506.54 776.15 Technical (Hospital) Services Incision & Drainage Pilonidal Cyst Simple PX-3601008000 CDM 10080 CPT 360 RC inpatient 817 817 MULTIPLAN INC 34080 [3081285] MULTIPLAN INC [308128501] 776.15 percent of total billed charges 506.54 776.15 Technical (Hospital) Services Incision & Drainage Pilonidal Cyst Simple PX-3601008000 CDM 10080 CPT 360 RC outpatient 817 817 CIGNA 62308 [3081051] CIGNA 62308 [308105105] 653.6 percent of total billed charges 506.54 776.15 Technical (Hospital) Services Incision & Drainage Pilonidal Cyst Simple PX-3601008000 CDM 10080 CPT 360 RC outpatient 817 817 CIGNA 62308 [3081051] CIGNA STATE OF WYOMING [308105107] 653.6 percent of total billed charges 506.54 776.15 Technical (Hospital) Services Incision & Drainage Pilonidal Cyst Simple PX-3601008000 CDM 10080 CPT 360 RC outpatient 817 817 BLUE CROSS BLUE SHIELD WELLMARK SB889 [3081026] BCBS WYOMING [308102603] 776.15 percent of total billed charges 506.54 776.15 Technical (Hospital) Services Incision & Drainage Pilonidal Cyst Simple PX-3601008000 CDM 10080 CPT 360 RC outpatient 817 817 MULTIPLAN INC 34080 [3081285] MULTIPLAN INC [308128501] 776.15 percent of total billed charges 506.54 776.15 Technical (Hospital) Services Incision & Drainage Pilonidal Cyst Simple PX-3601008000 CDM 10080 CPT 360 RC outpatient 817 817 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES HDHP [308136802] 653.6 percent of total billed charges 506.54 776.15 Technical (Hospital) Services Incision & Drainage Pilonidal Cyst Simple PX-3601008000 CDM 10080 CPT 360 RC outpatient 817 817 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES PPO [308136801] 653.6 percent of total billed charges 506.54 776.15 Technical (Hospital) Services Incision & Drainage Pilonidal Cyst Simple PX-3601008000 CDM 10080 CPT 360 RC outpatient 817 817 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES EPO [308136803] 653.6 percent of total billed charges 506.54 776.15 Technical (Hospital) Services Incision & Drainage Pilonidal Cyst Simple PX-3601008000 CDM 10080 CPT 360 RC outpatient 817 817 UNITED HEALTHCARE (COMMERCIAL) [3081199] UNITED HEALTHCARE 87726 [308119901] 506.54 percent of total billed charges 506.54 776.15 Technical (Hospital) Services Incision & Drainage Pilonidal Cyst Simple PX-3601008000 CDM 10080 CPT 360 RC outpatient 817 817 MEDICA (COMMERCIAL) 94265 [3081118] MEDICA CLAIMS [308111801] 735.3 percent of total billed charges 506.54 776.15 Technical (Hospital) Services Incision & Drainage Pilonidal Cyst Simple PX-3601008000 CDM 10080 CPT 360 RC outpatient 817 817 HEALTHPARTNERS SX009 HEALTHPARTNERS 653.6 percent of total billed charges 506.54 776.15 Technical (Hospital) Services Drain Skin Abscess Complic PX-10061 CDM 10061 CPT inpatient 927 927 CIGNA 62308 [3081051] CIGNA 62308 [308105105] 741.6 percent of total billed charges 574.74 880.65 Professional (doctor) services Drain Skin Abscess Complic PX-10061 CDM 10061 CPT inpatient 927 927 CIGNA 62308 [3081051] CIGNA STATE OF WYOMING [308105107] 741.6 percent of total billed charges 574.74 880.65 Professional (doctor) services Drain Skin Abscess Complic PX-10061 CDM 10061 CPT outpatient 927 927 CIGNA 62308 [3081051] CIGNA 62308 [308105105] 741.6 percent of total billed charges 574.74 880.65 Professional (doctor) services Drain Skin Abscess Complic PX-10061 CDM 10061 CPT outpatient 927 927 CIGNA 62308 [3081051] CIGNA STATE OF WYOMING [308105107] 741.6 percent of total billed charges 574.74 880.65 Professional (doctor) services Drain Skin Abscess Complic PX-10061 CDM 10061 CPT inpatient 927 927 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES EPO [308136803] 741.6 percent of total billed charges 574.74 880.65 Professional (doctor) services Drain Skin Abscess Complic PX-10061 CDM 10061 CPT inpatient 927 927 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES HDHP [308136802] 741.6 percent of total billed charges 574.74 880.65 Professional (doctor) services Drain Skin Abscess Complic PX-10061 CDM 10061 CPT inpatient 927 927 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES PPO [308136801] 741.6 percent of total billed charges 574.74 880.65 Professional (doctor) services Drain Skin Abscess Complic PX-10061 CDM 10061 CPT outpatient 927 927 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES EPO [308136803] 741.6 percent of total billed charges 574.74 880.65 Professional (doctor) services Drain Skin Abscess Complic PX-10061 CDM 10061 CPT outpatient 927 927 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES HDHP [308136802] 741.6 percent of total billed charges 574.74 880.65 Professional (doctor) services Drain Skin Abscess Complic PX-10061 CDM 10061 CPT outpatient 927 927 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES PPO [308136801] 741.6 percent of total billed charges 574.74 880.65 Professional (doctor) services Drain Skin Abscess Complic PX-10061 CDM 10061 CPT inpatient 927 927 HEALTHPARTNERS SX009 HEALTHPARTNERS 741.6 percent of total billed charges 574.74 880.65 Professional (doctor) services Drain Skin Abscess Complic PX-10061 CDM 10061 CPT outpatient 927 927 HEALTHPARTNERS SX009 HEALTHPARTNERS 741.6 percent of total billed charges 574.74 880.65 Professional (doctor) services Drain Skin Abscess Complic PX-10061 CDM 10061 CPT inpatient 927 927 MEDICA (COMMERCIAL) 94265 [3081118] MEDICA CLAIMS [308111801] 834.3 percent of total billed charges 574.74 880.65 Professional (doctor) services Drain Skin Abscess Complic PX-10061 CDM 10061 CPT outpatient 927 927 MEDICA (COMMERCIAL) 94265 [3081118] MEDICA CLAIMS [308111801] 834.3 percent of total billed charges 574.74 880.65 Professional (doctor) services Drain Skin Abscess Complic PX-10061 CDM 10061 CPT inpatient 927 927 MULTIPLAN INC 34080 [3081285] MULTIPLAN INC [308128501] 880.65 percent of total billed charges 574.74 880.65 Professional (doctor) services Drain Skin Abscess Complic PX-10061 CDM 10061 CPT outpatient 927 927 MULTIPLAN INC 34080 [3081285] MULTIPLAN INC [308128501] 880.65 percent of total billed charges 574.74 880.65 Professional (doctor) services Drain Skin Abscess Complic PX-10061 CDM 10061 CPT inpatient 927 927 UNITED HEALTHCARE (COMMERCIAL) [3081199] UNITED HEALTHCARE 87726 [308119901] 574.74 percent of total billed charges 574.74 880.65 Professional (doctor) services Drain Skin Abscess Complic PX-10061 CDM 10061 CPT outpatient 927 927 UNITED HEALTHCARE (COMMERCIAL) [3081199] UNITED HEALTHCARE 87726 [308119901] 574.74 percent of total billed charges 574.74 880.65 Professional (doctor) services Incision & Drainage Abscess Simple/Single PX-3601006000 CDM 10060 CPT 360 RC inpatient 477 477 MULTIPLAN INC 34080 [3081285] MULTIPLAN INC [308128501] 453.15 percent of total billed charges 295.74 453.15 Technical (Hospital) Services Incision & Drainage Abscess Simple/Single PX-3601006000 CDM 10060 CPT 360 RC inpatient 477 477 BLUE CROSS BLUE SHIELD WELLMARK SB889 [3081026] BCBS WYOMING [308102603] 453.15 percent of total billed charges 295.74 453.15 Technical (Hospital) Services Incision & Drainage Abscess Simple/Single PX-3601006000 CDM 10060 CPT 360 RC inpatient 477 477 UNITED HEALTHCARE (COMMERCIAL) [3081199] UNITED HEALTHCARE 87726 [308119901] 295.74 percent of total billed charges 295.74 453.15 Technical (Hospital) Services Incision & Drainage Abscess Simple/Single PX-3601006000 CDM 10060 CPT 360 RC inpatient 477 477 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES PPO [308136801] 377.69 percent of total billed charges 295.74 453.15 Technical (Hospital) Services Incision & Drainage Abscess Simple/Single PX-3601006000 CDM 10060 CPT 360 RC inpatient 477 477 MEDICA (COMMERCIAL) 94265 [3081118] MEDICA CLAIMS [308111801] 429.3 percent of total billed charges 295.74 453.15 Technical (Hospital) Services Incision & Drainage Abscess Simple/Single PX-3601006000 CDM 10060 CPT 360 RC inpatient 477 477 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES HDHP [308136802] 377.69 percent of total billed charges 295.74 453.15 Technical (Hospital) Services Incision & Drainage Abscess Simple/Single PX-3601006000 CDM 10060 CPT 360 RC inpatient 477 477 HEALTHPARTNERS SX009 HEALTHPARTNERS 377.69 percent of total billed charges 295.74 453.15 Technical (Hospital) Services Incision & Drainage Abscess Simple/Single PX-3601006000 CDM 10060 CPT 360 RC inpatient 477 477 CIGNA 62308 [3081051] CIGNA 62308 [308105105] 377.69 percent of total billed charges 295.74 453.15 Technical (Hospital) Services Incision & Drainage Abscess Simple/Single PX-3601006000 CDM 10060 CPT 360 RC inpatient 477 477 CIGNA 62308 [3081051] CIGNA STATE OF WYOMING [308105107] 377.69 percent of total billed charges 295.74 453.15 Technical (Hospital) Services Incision & Drainage Abscess Simple/Single PX-3601006000 CDM 10060 CPT 360 RC inpatient 477 477 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES EPO [308136803] 377.69 percent of total billed charges 295.74 453.15 Technical (Hospital) Services Incision & Drainage Abscess Simple/Single PX-3601006000 CDM 10060 CPT 360 RC outpatient 477 477 CIGNA 62308 [3081051] CIGNA 62308 [308105105] 381.6 percent of total billed charges 295.74 453.15 Technical (Hospital) Services Incision & Drainage Abscess Simple/Single PX-3601006000 CDM 10060 CPT 360 RC outpatient 477 477 CIGNA 62308 [3081051] CIGNA STATE OF WYOMING [308105107] 381.6 percent of total billed charges 295.74 453.15 Technical (Hospital) Services Incision & Drainage Abscess Simple/Single PX-3601006000 CDM 10060 CPT 360 RC outpatient 477 477 MEDICA (COMMERCIAL) 94265 [3081118] MEDICA CLAIMS [308111801] 429.3 percent of total billed charges 295.74 453.15 Technical (Hospital) Services Incision & Drainage Abscess Simple/Single PX-3601006000 CDM 10060 CPT 360 RC outpatient 477 477 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES HDHP [308136802] 381.6 percent of total billed charges 295.74 453.15 Technical (Hospital) Services Incision & Drainage Abscess Simple/Single PX-3601006000 CDM 10060 CPT 360 RC outpatient 477 477 MULTIPLAN INC 34080 [3081285] MULTIPLAN INC [308128501] 453.15 percent of total billed charges 295.74 453.15 Technical (Hospital) Services Incision & Drainage Abscess Simple/Single PX-3601006000 CDM 10060 CPT 360 RC outpatient 477 477 BLUE CROSS BLUE SHIELD WELLMARK SB889 [3081026] BCBS WYOMING [308102603] 453.15 percent of total billed charges 295.74 453.15 Technical (Hospital) Services Incision & Drainage Abscess Simple/Single PX-3601006000 CDM 10060 CPT 360 RC outpatient 477 477 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES EPO [308136803] 381.6 percent of total billed charges 295.74 453.15 Technical (Hospital) Services Incision & Drainage Abscess Simple/Single PX-3601006000 CDM 10060 CPT 360 RC outpatient 477 477 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES PPO [308136801] 381.6 percent of total billed charges 295.74 453.15 Technical (Hospital) Services Incision & Drainage Abscess Simple/Single PX-3601006000 CDM 10060 CPT 360 RC outpatient 477 477 HEALTHPARTNERS SX009 HEALTHPARTNERS 381.6 percent of total billed charges 295.74 453.15 Technical (Hospital) Services Incision & Drainage Abscess Simple/Single PX-3601006000 CDM 10060 CPT 360 RC outpatient 477 477 UNITED HEALTHCARE (COMMERCIAL) [3081199] UNITED HEALTHCARE 87726 [308119901] 295.74 percent of total billed charges 295.74 453.15 Technical (Hospital) Services Drain Skin Abscess Simple PX-10060 CDM 10060 CPT inpatient 463 463 CIGNA 62308 [3081051] CIGNA 62308 [308105105] 370.4 percent of total billed charges 287.06 439.85 Professional (doctor) services Drain Skin Abscess Simple PX-10060 CDM 10060 CPT inpatient 463 463 CIGNA 62308 [3081051] CIGNA STATE OF WYOMING [308105107] 370.4 percent of total billed charges 287.06 439.85 Professional (doctor) services Drain Skin Abscess Simple PX-10060 CDM 10060 CPT outpatient 463 463 CIGNA 62308 [3081051] CIGNA 62308 [308105105] 370.4 percent of total billed charges 287.06 439.85 Professional (doctor) services Drain Skin Abscess Simple PX-10060 CDM 10060 CPT outpatient 463 463 CIGNA 62308 [3081051] CIGNA STATE OF WYOMING [308105107] 370.4 percent of total billed charges 287.06 439.85 Professional (doctor) services Drain Skin Abscess Simple PX-10060 CDM 10060 CPT inpatient 463 463 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES EPO [308136803] 370.4 percent of total billed charges 287.06 439.85 Professional (doctor) services Drain Skin Abscess Simple PX-10060 CDM 10060 CPT inpatient 463 463 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES HDHP [308136802] 370.4 percent of total billed charges 287.06 439.85 Professional (doctor) services Drain Skin Abscess Simple PX-10060 CDM 10060 CPT inpatient 463 463 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES PPO [308136801] 370.4 percent of total billed charges 287.06 439.85 Professional (doctor) services Drain Skin Abscess Simple PX-10060 CDM 10060 CPT outpatient 463 463 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES EPO [308136803] 370.4 percent of total billed charges 287.06 439.85 Professional (doctor) services Drain Skin Abscess Simple PX-10060 CDM 10060 CPT outpatient 463 463 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES HDHP [308136802] 370.4 percent of total billed charges 287.06 439.85 Professional (doctor) services Drain Skin Abscess Simple PX-10060 CDM 10060 CPT outpatient 463 463 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES PPO [308136801] 370.4 percent of total billed charges 287.06 439.85 Professional (doctor) services Drain Skin Abscess Simple PX-10060 CDM 10060 CPT inpatient 463 463 HEALTHPARTNERS SX009 HEALTHPARTNERS 370.4 percent of total billed charges 287.06 439.85 Professional (doctor) services Drain Skin Abscess Simple PX-10060 CDM 10060 CPT outpatient 463 463 HEALTHPARTNERS SX009 HEALTHPARTNERS 370.4 percent of total billed charges 287.06 439.85 Professional (doctor) services Drain Skin Abscess Simple PX-10060 CDM 10060 CPT inpatient 463 463 MEDICA (COMMERCIAL) 94265 [3081118] MEDICA CLAIMS [308111801] 416.7 percent of total billed charges 287.06 439.85 Professional (doctor) services Drain Skin Abscess Simple PX-10060 CDM 10060 CPT outpatient 463 463 MEDICA (COMMERCIAL) 94265 [3081118] MEDICA CLAIMS [308111801] 416.7 percent of total billed charges 287.06 439.85 Professional (doctor) services Drain Skin Abscess Simple PX-10060 CDM 10060 CPT inpatient 463 463 MULTIPLAN INC 34080 [3081285] MULTIPLAN INC [308128501] 439.85 percent of total billed charges 287.06 439.85 Professional (doctor) services Drain Skin Abscess Simple PX-10060 CDM 10060 CPT outpatient 463 463 MULTIPLAN INC 34080 [3081285] MULTIPLAN INC [308128501] 439.85 percent of total billed charges 287.06 439.85 Professional (doctor) services Drain Skin Abscess Simple PX-10060 CDM 10060 CPT inpatient 463 463 UNITED HEALTHCARE (COMMERCIAL) [3081199] UNITED HEALTHCARE 87726 [308119901] 287.06 percent of total billed charges 287.06 439.85 Professional (doctor) services Drain Skin Abscess Simple PX-10060 CDM 10060 CPT outpatient 463 463 UNITED HEALTHCARE (COMMERCIAL) [3081199] UNITED HEALTHCARE 87726 [308119901] 287.06 percent of total billed charges 287.06 439.85 Professional (doctor) services Room Private Swingbed Intermediate PX-1100000300 CDM 110 RC outpatient 328 328 HEALTHPARTNERS SX009 HEALTHPARTNERS 262.4 percent of total billed charges 203.36 311.6 Technical (Hospital) Services Room Private Swingbed Intermediate PX-1100000300 CDM 110 RC outpatient 328 328 MEDICA (COMMERCIAL) 94265 [3081118] MEDICA CLAIMS [308111801] 295.2 percent of total billed charges 203.36 311.6 Technical (Hospital) Services Room Private Swingbed Intermediate PX-1100000300 CDM 110 RC outpatient 328 328 MULTIPLAN INC 34080 [3081285] MULTIPLAN INC [308128501] 311.6 percent of total billed charges 203.36 311.6 Technical (Hospital) Services Room Private Swingbed Intermediate PX-1100000300 CDM 110 RC outpatient 328 328 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES HDHP [308136802] 262.4 percent of total billed charges 203.36 311.6 Technical (Hospital) Services Room Private Swingbed Intermediate PX-1100000300 CDM 110 RC outpatient 328 328 UNITED HEALTHCARE (COMMERCIAL) [3081199] UNITED HEALTHCARE 87726 [308119901] 203.36 percent of total billed charges 203.36 311.6 Technical (Hospital) Services Room Private Swingbed Intermediate PX-1100000300 CDM 110 RC outpatient 328 328 BLUE CROSS BLUE SHIELD WELLMARK SB889 [3081026] BCBS WYOMING [308102603] 311.6 percent of total billed charges 203.36 311.6 Technical (Hospital) Services Room Private Swingbed Intermediate PX-1100000300 CDM 110 RC outpatient 328 328 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES EPO [308136803] 262.4 percent of total billed charges 203.36 311.6 Technical (Hospital) Services Room Private Swingbed Intermediate PX-1100000300 CDM 110 RC outpatient 328 328 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES PPO [308136801] 262.4 percent of total billed charges 203.36 311.6 Technical (Hospital) Services Room Private Swingbed Intermediate PX-1100000300 CDM 110 RC outpatient 328 328 CIGNA 62308 [3081051] CIGNA 62308 [308105105] 262.4 percent of total billed charges 203.36 311.6 Technical (Hospital) Services Room Private Swingbed Intermediate PX-1100000300 CDM 110 RC outpatient 328 328 CIGNA 62308 [3081051] CIGNA STATE OF WYOMING [308105107] 262.4 percent of total billed charges 203.36 311.6 Technical (Hospital) Services Room Private Swingbed Intermediate PX-1100000300 CDM 110 RC inpatient 328 328 HEALTHPARTNERS SX009 HEALTHPARTNERS 259.71 percent of total billed charges 203.36 311.6 Technical (Hospital) Services Room Private Swingbed Intermediate PX-1100000300 CDM 110 RC inpatient 328 328 MEDICA (COMMERCIAL) 94265 [3081118] MEDICA CLAIMS [308111801] 295.2 percent of total billed charges 203.36 311.6 Technical (Hospital) Services Room Private Swingbed Intermediate PX-1100000300 CDM 110 RC inpatient 328 328 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES HDHP [308136802] 259.71 percent of total billed charges 203.36 311.6 Technical (Hospital) Services Room Private Swingbed Intermediate PX-1100000300 CDM 110 RC inpatient 328 328 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES PPO [308136801] 259.71 percent of total billed charges 203.36 311.6 Technical (Hospital) Services Room Private Swingbed Intermediate PX-1100000300 CDM 110 RC inpatient 328 328 MULTIPLAN INC 34080 [3081285] MULTIPLAN INC [308128501] 311.6 percent of total billed charges 203.36 311.6 Technical (Hospital) Services Room Private Swingbed Intermediate PX-1100000300 CDM 110 RC inpatient 328 328 BLUE CROSS BLUE SHIELD WELLMARK SB889 [3081026] BCBS WYOMING [308102603] 311.6 percent of total billed charges 203.36 311.6 Technical (Hospital) Services Room Private Swingbed Intermediate PX-1100000300 CDM 110 RC inpatient 328 328 UNITED HEALTHCARE (COMMERCIAL) [3081199] UNITED HEALTHCARE 87726 [308119901] 203.36 percent of total billed charges 203.36 311.6 Technical (Hospital) Services Room Private Swingbed Intermediate PX-1100000300 CDM 110 RC inpatient 328 328 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES EPO [308136803] 259.71 percent of total billed charges 203.36 311.6 Technical (Hospital) Services Room Private Swingbed Intermediate PX-1100000300 CDM 110 RC inpatient 328 328 CIGNA 62308 [3081051] CIGNA 62308 [308105105] 259.71 percent of total billed charges 203.36 311.6 Technical (Hospital) Services Room Private Swingbed Intermediate PX-1100000300 CDM 110 RC inpatient 328 328 CIGNA 62308 [3081051] CIGNA STATE OF WYOMING [308105107] 259.71 percent of total billed charges 203.36 311.6 Technical (Hospital) Services Room Semi Private Swingbed Skilled PX-1200000200 CDM 120 RC inpatient 1985 1985 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES EPO [308136803] 1571.72 percent of total billed charges 1230.7 1885.75 Technical (Hospital) Services Room Semi Private Swingbed Skilled PX-1200000200 CDM 120 RC inpatient 1985 1985 CIGNA 62308 [3081051] CIGNA 62308 [308105105] 1571.72 percent of total billed charges 1230.7 1885.75 Technical (Hospital) Services Room Semi Private Swingbed Skilled PX-1200000200 CDM 120 RC inpatient 1985 1985 CIGNA 62308 [3081051] CIGNA STATE OF WYOMING [308105107] 1571.72 percent of total billed charges 1230.7 1885.75 Technical (Hospital) Services Room Semi Private Swingbed Skilled PX-1200000200 CDM 120 RC inpatient 1985 1985 MULTIPLAN INC 34080 [3081285] MULTIPLAN INC [308128501] 1885.75 percent of total billed charges 1230.7 1885.75 Technical (Hospital) Services Room Semi Private Swingbed Skilled PX-1200000200 CDM 120 RC inpatient 1985 1985 MEDICA (COMMERCIAL) 94265 [3081118] MEDICA CLAIMS [308111801] 1786.5 percent of total billed charges 1230.7 1885.75 Technical (Hospital) Services Room Semi Private Swingbed Skilled PX-1200000200 CDM 120 RC inpatient 1985 1985 HEALTHPARTNERS SX009 HEALTHPARTNERS 1571.72 percent of total billed charges 1230.7 1885.75 Technical (Hospital) Services Room Semi Private Swingbed Skilled PX-1200000200 CDM 120 RC inpatient 1985 1985 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES HDHP [308136802] 1571.72 percent of total billed charges 1230.7 1885.75 Technical (Hospital) Services Room Semi Private Swingbed Skilled PX-1200000200 CDM 120 RC inpatient 1985 1985 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES PPO [308136801] 1571.72 percent of total billed charges 1230.7 1885.75 Technical (Hospital) Services Room Semi Private Swingbed Skilled PX-1200000200 CDM 120 RC inpatient 1985 1985 BLUE CROSS BLUE SHIELD WELLMARK SB889 [3081026] BCBS WYOMING [308102603] 1885.75 percent of total billed charges 1230.7 1885.75 Technical (Hospital) Services Room Semi Private Swingbed Skilled PX-1200000200 CDM 120 RC inpatient 1985 1985 UNITED HEALTHCARE (COMMERCIAL) [3081199] UNITED HEALTHCARE 87726 [308119901] 1230.7 percent of total billed charges 1230.7 1885.75 Technical (Hospital) Services Room Semi Private Swingbed Skilled PX-1200000200 CDM 120 RC outpatient 1985 1985 MULTIPLAN INC 34080 [3081285] MULTIPLAN INC [308128501] 1885.75 percent of total billed charges 1230.7 1885.75 Technical (Hospital) Services Room Semi Private Swingbed Skilled PX-1200000200 CDM 120 RC outpatient 1985 1985 CIGNA 62308 [3081051] CIGNA 62308 [308105105] 1588 percent of total billed charges 1230.7 1885.75 Technical (Hospital) Services Room Semi Private Swingbed Skilled PX-1200000200 CDM 120 RC outpatient 1985 1985 CIGNA 62308 [3081051] CIGNA STATE OF WYOMING [308105107] 1588 percent of total billed charges 1230.7 1885.75 Technical (Hospital) Services Room Semi Private Swingbed Skilled PX-1200000200 CDM 120 RC outpatient 1985 1985 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES EPO [308136803] 1588 percent of total billed charges 1230.7 1885.75 Technical (Hospital) Services Room Semi Private Swingbed Skilled PX-1200000200 CDM 120 RC outpatient 1985 1985 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES PPO [308136801] 1588 percent of total billed charges 1230.7 1885.75 Technical (Hospital) Services Room Semi Private Swingbed Skilled PX-1200000200 CDM 120 RC outpatient 1985 1985 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES HDHP [308136802] 1588 percent of total billed charges 1230.7 1885.75 Technical (Hospital) Services Room Semi Private Swingbed Skilled PX-1200000200 CDM 120 RC outpatient 1985 1985 BLUE CROSS BLUE SHIELD WELLMARK SB889 [3081026] BCBS WYOMING [308102603] 1885.75 percent of total billed charges 1230.7 1885.75 Technical (Hospital) Services Room Semi Private Swingbed Skilled PX-1200000200 CDM 120 RC outpatient 1985 1985 UNITED HEALTHCARE (COMMERCIAL) [3081199] UNITED HEALTHCARE 87726 [308119901] 1230.7 percent of total billed charges 1230.7 1885.75 Technical (Hospital) Services Room Semi Private Swingbed Skilled PX-1200000200 CDM 120 RC outpatient 1985 1985 MEDICA (COMMERCIAL) 94265 [3081118] MEDICA CLAIMS [308111801] 1786.5 percent of total billed charges 1230.7 1885.75 Technical (Hospital) Services Room Semi Private Swingbed Skilled PX-1200000200 CDM 120 RC outpatient 1985 1985 HEALTHPARTNERS SX009 HEALTHPARTNERS 1588 percent of total billed charges 1230.7 1885.75 Technical (Hospital) Services Room Semi Private W Tele PX-1210000100 CDM 121 RC inpatient 3827 3827 HEALTHPARTNERS SX009 HEALTHPARTNERS 3030.22 percent of total billed charges 2372.74 3635.65 Technical (Hospital) Services Room Semi Private W Tele PX-1210000100 CDM 121 RC inpatient 3827 3827 MULTIPLAN INC 34080 [3081285] MULTIPLAN INC [308128501] 3635.65 percent of total billed charges 2372.74 3635.65 Technical (Hospital) Services Room Semi Private W Tele PX-1210000100 CDM 121 RC inpatient 3827 3827 MEDICA (COMMERCIAL) 94265 [3081118] MEDICA CLAIMS [308111801] 3444.3 percent of total billed charges 2372.74 3635.65 Technical (Hospital) Services Room Semi Private W Tele PX-1210000100 CDM 121 RC inpatient 3827 3827 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES HDHP [308136802] 3030.22 percent of total billed charges 2372.74 3635.65 Technical (Hospital) Services Room Semi Private W Tele PX-1210000100 CDM 121 RC inpatient 3827 3827 UNITED HEALTHCARE (COMMERCIAL) [3081199] UNITED HEALTHCARE 87726 [308119901] 2372.74 percent of total billed charges 2372.74 3635.65 Technical (Hospital) Services Room Semi Private W Tele PX-1210000100 CDM 121 RC inpatient 3827 3827 BLUE CROSS BLUE SHIELD WELLMARK SB889 [3081026] BCBS WYOMING [308102603] 3635.65 percent of total billed charges 2372.74 3635.65 Technical (Hospital) Services Room Semi Private W Tele PX-1210000100 CDM 121 RC inpatient 3827 3827 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES PPO [308136801] 3030.22 percent of total billed charges 2372.74 3635.65 Technical (Hospital) Services Room Semi Private W Tele PX-1210000100 CDM 121 RC inpatient 3827 3827 CIGNA 62308 [3081051] CIGNA 62308 [308105105] 3030.22 percent of total billed charges 2372.74 3635.65 Technical (Hospital) Services Room Semi Private W Tele PX-1210000100 CDM 121 RC inpatient 3827 3827 CIGNA 62308 [3081051] CIGNA STATE OF WYOMING [308105107] 3030.22 percent of total billed charges 2372.74 3635.65 Technical (Hospital) Services Room Semi Private W Tele PX-1210000100 CDM 121 RC inpatient 3827 3827 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES EPO [308136803] 3030.22 percent of total billed charges 2372.74 3635.65 Technical (Hospital) Services Room Semi Private W Tele PX-1210000100 CDM 121 RC outpatient 3827 3827 CIGNA 62308 [3081051] CIGNA 62308 [308105105] 3061.6 percent of total billed charges 2372.74 3635.65 Technical (Hospital) Services Room Semi Private W Tele PX-1210000100 CDM 121 RC outpatient 3827 3827 CIGNA 62308 [3081051] CIGNA STATE OF WYOMING [308105107] 3061.6 percent of total billed charges 2372.74 3635.65 Technical (Hospital) Services Room Semi Private W Tele PX-1210000100 CDM 121 RC outpatient 3827 3827 MULTIPLAN INC 34080 [3081285] MULTIPLAN INC [308128501] 3635.65 percent of total billed charges 2372.74 3635.65 Technical (Hospital) Services Room Semi Private W Tele PX-1210000100 CDM 121 RC outpatient 3827 3827 MEDICA (COMMERCIAL) 94265 [3081118] MEDICA CLAIMS [308111801] 3444.3 percent of total billed charges 2372.74 3635.65 Technical (Hospital) Services Room Semi Private W Tele PX-1210000100 CDM 121 RC outpatient 3827 3827 HEALTHPARTNERS SX009 HEALTHPARTNERS 3061.6 percent of total billed charges 2372.74 3635.65 Technical (Hospital) Services Room Semi Private W Tele PX-1210000100 CDM 121 RC outpatient 3827 3827 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES EPO [308136803] 3061.6 percent of total billed charges 2372.74 3635.65 Technical (Hospital) Services Room Semi Private W Tele PX-1210000100 CDM 121 RC outpatient 3827 3827 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES PPO [308136801] 3061.6 percent of total billed charges 2372.74 3635.65 Technical (Hospital) Services Room Semi Private W Tele PX-1210000100 CDM 121 RC outpatient 3827 3827 UNITED HEALTHCARE (COMMERCIAL) [3081199] UNITED HEALTHCARE 87726 [308119901] 2372.74 percent of total billed charges 2372.74 3635.65 Technical (Hospital) Services Room Semi Private W Tele PX-1210000100 CDM 121 RC outpatient 3827 3827 BLUE CROSS BLUE SHIELD WELLMARK SB889 [3081026] BCBS WYOMING [308102603] 3635.65 percent of total billed charges 2372.74 3635.65 Technical (Hospital) Services Room Semi Private W Tele PX-1210000100 CDM 121 RC outpatient 3827 3827 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES HDHP [308136802] 3061.6 percent of total billed charges 2372.74 3635.65 Technical (Hospital) Services Room Semi Private PX-1210000200 CDM 121 RC outpatient 3232 3232 MEDICA (COMMERCIAL) 94265 [3081118] MEDICA CLAIMS [308111801] 2908.8 percent of total billed charges 2003.84 3070.4 Technical (Hospital) Services Room Semi Private PX-1210000200 CDM 121 RC outpatient 3232 3232 MULTIPLAN INC 34080 [3081285] MULTIPLAN INC [308128501] 3070.4 percent of total billed charges 2003.84 3070.4 Technical (Hospital) Services Room Semi Private PX-1210000200 CDM 121 RC outpatient 3232 3232 CIGNA 62308 [3081051] CIGNA 62308 [308105105] 2585.6 percent of total billed charges 2003.84 3070.4 Technical (Hospital) Services Room Semi Private PX-1210000200 CDM 121 RC outpatient 3232 3232 CIGNA 62308 [3081051] CIGNA STATE OF WYOMING [308105107] 2585.6 percent of total billed charges 2003.84 3070.4 Technical (Hospital) Services Room Semi Private PX-1210000200 CDM 121 RC outpatient 3232 3232 HEALTHPARTNERS SX009 HEALTHPARTNERS 2585.6 percent of total billed charges 2003.84 3070.4 Technical (Hospital) Services Room Semi Private PX-1210000200 CDM 121 RC outpatient 3232 3232 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES PPO [308136801] 2585.6 percent of total billed charges 2003.84 3070.4 Technical (Hospital) Services Room Semi Private PX-1210000200 CDM 121 RC outpatient 3232 3232 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES EPO [308136803] 2585.6 percent of total billed charges 2003.84 3070.4 Technical (Hospital) Services Room Semi Private PX-1210000200 CDM 121 RC outpatient 3232 3232 BLUE CROSS BLUE SHIELD WELLMARK SB889 [3081026] BCBS WYOMING [308102603] 3070.4 percent of total billed charges 2003.84 3070.4 Technical (Hospital) Services Room Semi Private PX-1210000200 CDM 121 RC outpatient 3232 3232 UNITED HEALTHCARE (COMMERCIAL) [3081199] UNITED HEALTHCARE 87726 [308119901] 2003.84 percent of total billed charges 2003.84 3070.4 Technical (Hospital) Services Room Semi Private PX-1210000200 CDM 121 RC outpatient 3232 3232 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES HDHP [308136802] 2585.6 percent of total billed charges 2003.84 3070.4 Technical (Hospital) Services Room Semi Private PX-1210000200 CDM 121 RC inpatient 3232 3232 CIGNA 62308 [3081051] CIGNA 62308 [308105105] 2559.1 percent of total billed charges 2003.84 3070.4 Technical (Hospital) Services Room Semi Private PX-1210000200 CDM 121 RC inpatient 3232 3232 CIGNA 62308 [3081051] CIGNA STATE OF WYOMING [308105107] 2559.1 percent of total billed charges 2003.84 3070.4 Technical (Hospital) Services Room Semi Private PX-1210000200 CDM 121 RC inpatient 3232 3232 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES EPO [308136803] 2559.1 percent of total billed charges 2003.84 3070.4 Technical (Hospital) Services Room Semi Private PX-1210000200 CDM 121 RC inpatient 3232 3232 UNITED HEALTHCARE (COMMERCIAL) [3081199] UNITED HEALTHCARE 87726 [308119901] 2003.84 percent of total billed charges 2003.84 3070.4 Technical (Hospital) Services Room Semi Private PX-1210000200 CDM 121 RC inpatient 3232 3232 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES PPO [308136801] 2559.1 percent of total billed charges 2003.84 3070.4 Technical (Hospital) Services Room Semi Private PX-1210000200 CDM 121 RC inpatient 3232 3232 BLUE CROSS BLUE SHIELD WELLMARK SB889 [3081026] BCBS WYOMING [308102603] 3070.4 percent of total billed charges 2003.84 3070.4 Technical (Hospital) Services Room Semi Private PX-1210000200 CDM 121 RC inpatient 3232 3232 MEDICA (COMMERCIAL) 94265 [3081118] MEDICA CLAIMS [308111801] 2908.8 percent of total billed charges 2003.84 3070.4 Technical (Hospital) Services Room Semi Private PX-1210000200 CDM 121 RC inpatient 3232 3232 MULTIPLAN INC 34080 [3081285] MULTIPLAN INC [308128501] 3070.4 percent of total billed charges 2003.84 3070.4 Technical (Hospital) Services Room Semi Private PX-1210000200 CDM 121 RC inpatient 3232 3232 HEALTHPARTNERS SX009 HEALTHPARTNERS 2559.1 percent of total billed charges 2003.84 3070.4 Technical (Hospital) Services Room Semi Private PX-1210000200 CDM 121 RC inpatient 3232 3232 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES HDHP [308136802] 2559.1 percent of total billed charges 2003.84 3070.4 Technical (Hospital) Services Room Ward 5 or More per Room PX-1500000100 CDM 150 RC inpatient 1191 1191 HEALTHPARTNERS SX009 HEALTHPARTNERS 943.03 percent of total billed charges 738.42 1131.45 Technical (Hospital) Services Room Ward 5 or More per Room PX-1500000100 CDM 150 RC inpatient 1191 1191 MEDICA (COMMERCIAL) 94265 [3081118] MEDICA CLAIMS [308111801] 1071.9 percent of total billed charges 738.42 1131.45 Technical (Hospital) Services Room Ward 5 or More per Room PX-1500000100 CDM 150 RC inpatient 1191 1191 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES HDHP [308136802] 943.03 percent of total billed charges 738.42 1131.45 Technical (Hospital) Services Room Ward 5 or More per Room PX-1500000100 CDM 150 RC inpatient 1191 1191 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES PPO [308136801] 943.03 percent of total billed charges 738.42 1131.45 Technical (Hospital) Services Room Ward 5 or More per Room PX-1500000100 CDM 150 RC inpatient 1191 1191 BLUE CROSS BLUE SHIELD WELLMARK SB889 [3081026] BCBS WYOMING [308102603] 1131.45 percent of total billed charges 738.42 1131.45 Technical (Hospital) Services Room Ward 5 or More per Room PX-1500000100 CDM 150 RC inpatient 1191 1191 MULTIPLAN INC 34080 [3081285] MULTIPLAN INC [308128501] 1131.45 percent of total billed charges 738.42 1131.45 Technical (Hospital) Services Room Ward 5 or More per Room PX-1500000100 CDM 150 RC inpatient 1191 1191 UNITED HEALTHCARE (COMMERCIAL) [3081199] UNITED HEALTHCARE 87726 [308119901] 738.42 percent of total billed charges 738.42 1131.45 Technical (Hospital) Services Room Ward 5 or More per Room PX-1500000100 CDM 150 RC inpatient 1191 1191 CIGNA 62308 [3081051] CIGNA 62308 [308105105] 943.03 percent of total billed charges 738.42 1131.45 Technical (Hospital) Services Room Ward 5 or More per Room PX-1500000100 CDM 150 RC inpatient 1191 1191 CIGNA 62308 [3081051] CIGNA STATE OF WYOMING [308105107] 943.03 percent of total billed charges 738.42 1131.45 Technical (Hospital) Services Room Ward 5 or More per Room PX-1500000100 CDM 150 RC inpatient 1191 1191 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES EPO [308136803] 943.03 percent of total billed charges 738.42 1131.45 Technical (Hospital) Services Room Ward 5 or More per Room PX-1500000100 CDM 150 RC outpatient 1191 1191 HEALTHPARTNERS SX009 HEALTHPARTNERS 952.8 percent of total billed charges 738.42 1131.45 Technical (Hospital) Services Room Ward 5 or More per Room PX-1500000100 CDM 150 RC outpatient 1191 1191 MEDICA (COMMERCIAL) 94265 [3081118] MEDICA CLAIMS [308111801] 1071.9 percent of total billed charges 738.42 1131.45 Technical (Hospital) Services Room Ward 5 or More per Room PX-1500000100 CDM 150 RC outpatient 1191 1191 UNITED HEALTHCARE (COMMERCIAL) [3081199] UNITED HEALTHCARE 87726 [308119901] 738.42 percent of total billed charges 738.42 1131.45 Technical (Hospital) Services Room Ward 5 or More per Room PX-1500000100 CDM 150 RC outpatient 1191 1191 BLUE CROSS BLUE SHIELD WELLMARK SB889 [3081026] BCBS WYOMING [308102603] 1131.45 percent of total billed charges 738.42 1131.45 Technical (Hospital) Services Room Ward 5 or More per Room PX-1500000100 CDM 150 RC outpatient 1191 1191 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES HDHP [308136802] 952.8 percent of total billed charges 738.42 1131.45 Technical (Hospital) Services Room Ward 5 or More per Room PX-1500000100 CDM 150 RC outpatient 1191 1191 MULTIPLAN INC 34080 [3081285] MULTIPLAN INC [308128501] 1131.45 percent of total billed charges 738.42 1131.45 Technical (Hospital) Services Room Ward 5 or More per Room PX-1500000100 CDM 150 RC outpatient 1191 1191 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES PPO [308136801] 952.8 percent of total billed charges 738.42 1131.45 Technical (Hospital) Services Room Ward 5 or More per Room PX-1500000100 CDM 150 RC outpatient 1191 1191 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES EPO [308136803] 952.8 percent of total billed charges 738.42 1131.45 Technical (Hospital) Services Room Ward 5 or More per Room PX-1500000100 CDM 150 RC outpatient 1191 1191 CIGNA 62308 [3081051] CIGNA 62308 [308105105] 952.8 percent of total billed charges 738.42 1131.45 Technical (Hospital) Services Room Ward 5 or More per Room PX-1500000100 CDM 150 RC outpatient 1191 1191 CIGNA 62308 [3081051] CIGNA STATE OF WYOMING [308105107] 952.8 percent of total billed charges 738.42 1131.45 Technical (Hospital) Services Room Icu Medical PX-2020000100 CDM 202 RC inpatient 4495 4495 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES EPO [308136803] 3559.14 percent of total billed charges 2786.9 4270.25 Technical (Hospital) Services Room Icu Medical PX-2020000100 CDM 202 RC inpatient 4495 4495 CIGNA 62308 [3081051] CIGNA 62308 [308105105] 3559.14 percent of total billed charges 2786.9 4270.25 Technical (Hospital) Services Room Icu Medical PX-2020000100 CDM 202 RC inpatient 4495 4495 CIGNA 62308 [3081051] CIGNA STATE OF WYOMING [308105107] 3559.14 percent of total billed charges 2786.9 4270.25 Technical (Hospital) Services Room Icu Medical PX-2020000100 CDM 202 RC inpatient 4495 4495 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES PPO [308136801] 3559.14 percent of total billed charges 2786.9 4270.25 Technical (Hospital) Services Room Icu Medical PX-2020000100 CDM 202 RC inpatient 4495 4495 BLUE CROSS BLUE SHIELD WELLMARK SB889 [3081026] BCBS WYOMING [308102603] 4270.25 percent of total billed charges 2786.9 4270.25 Technical (Hospital) Services Room Icu Medical PX-2020000100 CDM 202 RC inpatient 4495 4495 UNITED HEALTHCARE (COMMERCIAL) [3081199] UNITED HEALTHCARE 87726 [308119901] 2786.9 percent of total billed charges 2786.9 4270.25 Technical (Hospital) Services Room Icu Medical PX-2020000100 CDM 202 RC inpatient 4495 4495 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES HDHP [308136802] 3559.14 percent of total billed charges 2786.9 4270.25 Technical (Hospital) Services Room Icu Medical PX-2020000100 CDM 202 RC inpatient 4495 4495 MEDICA (COMMERCIAL) 94265 [3081118] MEDICA CLAIMS [308111801] 4045.5 percent of total billed charges 2786.9 4270.25 Technical (Hospital) Services Room Icu Medical PX-2020000100 CDM 202 RC inpatient 4495 4495 MULTIPLAN INC 34080 [3081285] MULTIPLAN INC [308128501] 4270.25 percent of total billed charges 2786.9 4270.25 Technical (Hospital) Services Room Icu Medical PX-2020000100 CDM 202 RC inpatient 4495 4495 HEALTHPARTNERS SX009 HEALTHPARTNERS 3559.14 percent of total billed charges 2786.9 4270.25 Technical (Hospital) Services Room Icu Medical PX-2020000100 CDM 202 RC outpatient 4495 4495 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES HDHP [308136802] 3596 percent of total billed charges 2786.9 4270.25 Technical (Hospital) Services Room Icu Medical PX-2020000100 CDM 202 RC outpatient 4495 4495 BLUE CROSS BLUE SHIELD WELLMARK SB889 [3081026] BCBS WYOMING [308102603] 4270.25 percent of total billed charges 2786.9 4270.25 Technical (Hospital) Services Room Icu Medical PX-2020000100 CDM 202 RC outpatient 4495 4495 UNITED HEALTHCARE (COMMERCIAL) [3081199] UNITED HEALTHCARE 87726 [308119901] 2786.9 percent of total billed charges 2786.9 4270.25 Technical (Hospital) Services Room Icu Medical PX-2020000100 CDM 202 RC outpatient 4495 4495 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES EPO [308136803] 3596 percent of total billed charges 2786.9 4270.25 Technical (Hospital) Services Room Icu Medical PX-2020000100 CDM 202 RC outpatient 4495 4495 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES PPO [308136801] 3596 percent of total billed charges 2786.9 4270.25 Technical (Hospital) Services Room Icu Medical PX-2020000100 CDM 202 RC outpatient 4495 4495 HEALTHPARTNERS SX009 HEALTHPARTNERS 3596 percent of total billed charges 2786.9 4270.25 Technical (Hospital) Services Room Icu Medical PX-2020000100 CDM 202 RC outpatient 4495 4495 MEDICA (COMMERCIAL) 94265 [3081118] MEDICA CLAIMS [308111801] 4045.5 percent of total billed charges 2786.9 4270.25 Technical (Hospital) Services Room Icu Medical PX-2020000100 CDM 202 RC outpatient 4495 4495 MULTIPLAN INC 34080 [3081285] MULTIPLAN INC [308128501] 4270.25 percent of total billed charges 2786.9 4270.25 Technical (Hospital) Services Room Icu Medical PX-2020000100 CDM 202 RC outpatient 4495 4495 CIGNA 62308 [3081051] CIGNA 62308 [308105105] 3596 percent of total billed charges 2786.9 4270.25 Technical (Hospital) Services Room Icu Medical PX-2020000100 CDM 202 RC outpatient 4495 4495 CIGNA 62308 [3081051] CIGNA STATE OF WYOMING [308105107] 3596 percent of total billed charges 2786.9 4270.25 Technical (Hospital) Services HC Wch Pt Maintenance PX-4200000300 CDM 420 RC inpatient 10 10 HEALTHPARTNERS SX009 HEALTHPARTNERS 7.92 percent of total billed charges 6.2 9.5 Technical (Hospital) Services HC Wch Pt Maintenance PX-4200000300 CDM 420 RC inpatient 10 10 MULTIPLAN INC 34080 [3081285] MULTIPLAN INC [308128501] 9.5 percent of total billed charges 6.2 9.5 Technical (Hospital) Services HC Wch Pt Maintenance PX-4200000300 CDM 420 RC inpatient 10 10 MEDICA (COMMERCIAL) 94265 [3081118] MEDICA CLAIMS [308111801] 9 percent of total billed charges 6.2 9.5 Technical (Hospital) Services HC Wch Pt Maintenance PX-4200000300 CDM 420 RC inpatient 10 10 UNITED HEALTHCARE (COMMERCIAL) [3081199] UNITED HEALTHCARE 87726 [308119901] 6.2 percent of total billed charges 6.2 9.5 Technical (Hospital) Services HC Wch Pt Maintenance PX-4200000300 CDM 420 RC inpatient 10 10 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES PPO [308136801] 7.92 percent of total billed charges 6.2 9.5 Technical (Hospital) Services HC Wch Pt Maintenance PX-4200000300 CDM 420 RC inpatient 10 10 BLUE CROSS BLUE SHIELD WELLMARK SB889 [3081026] BCBS WYOMING [308102603] 9.5 percent of total billed charges 6.2 9.5 Technical (Hospital) Services HC Wch Pt Maintenance PX-4200000300 CDM 420 RC inpatient 10 10 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES HDHP [308136802] 7.92 percent of total billed charges 6.2 9.5 Technical (Hospital) Services HC Wch Pt Maintenance PX-4200000300 CDM 420 RC inpatient 10 10 CIGNA 62308 [3081051] CIGNA 62308 [308105105] 7.92 percent of total billed charges 6.2 9.5 Technical (Hospital) Services HC Wch Pt Maintenance PX-4200000300 CDM 420 RC inpatient 10 10 CIGNA 62308 [3081051] CIGNA STATE OF WYOMING [308105107] 7.92 percent of total billed charges 6.2 9.5 Technical (Hospital) Services HC Wch Pt Maintenance PX-4200000300 CDM 420 RC inpatient 10 10 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES EPO [308136803] 7.92 percent of total billed charges 6.2 9.5 Technical (Hospital) Services HC Wch Pt Maintenance PX-4200000300 CDM 420 RC outpatient 10 10 MEDICA (COMMERCIAL) 94265 [3081118] MEDICA CLAIMS [308111801] 9 percent of total billed charges 6.2 9.5 Technical (Hospital) Services HC Wch Pt Maintenance PX-4200000300 CDM 420 RC outpatient 10 10 MULTIPLAN INC 34080 [3081285] MULTIPLAN INC [308128501] 9.5 percent of total billed charges 6.2 9.5 Technical (Hospital) Services HC Wch Pt Maintenance PX-4200000300 CDM 420 RC outpatient 10 10 CIGNA 62308 [3081051] CIGNA 62308 [308105105] 8 percent of total billed charges 6.2 9.5 Technical (Hospital) Services HC Wch Pt Maintenance PX-4200000300 CDM 420 RC outpatient 10 10 CIGNA 62308 [3081051] CIGNA STATE OF WYOMING [308105107] 8 percent of total billed charges 6.2 9.5 Technical (Hospital) Services HC Wch Pt Maintenance PX-4200000300 CDM 420 RC outpatient 10 10 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES PPO [308136801] 8 percent of total billed charges 6.2 9.5 Technical (Hospital) Services HC Wch Pt Maintenance PX-4200000300 CDM 420 RC outpatient 10 10 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES EPO [308136803] 8 percent of total billed charges 6.2 9.5 Technical (Hospital) Services HC Wch Pt Maintenance PX-4200000300 CDM 420 RC outpatient 10 10 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES HDHP [308136802] 8 percent of total billed charges 6.2 9.5 Technical (Hospital) Services HC Wch Pt Maintenance PX-4200000300 CDM 420 RC outpatient 10 10 BLUE CROSS BLUE SHIELD WELLMARK SB889 [3081026] BCBS WYOMING [308102603] 9.5 percent of total billed charges 6.2 9.5 Technical (Hospital) Services HC Wch Pt Maintenance PX-4200000300 CDM 420 RC outpatient 10 10 UNITED HEALTHCARE (COMMERCIAL) [3081199] UNITED HEALTHCARE 87726 [308119901] 6.2 percent of total billed charges 6.2 9.5 Technical (Hospital) Services HC Wch Pt Maintenance PX-4200000300 CDM 420 RC outpatient 10 10 HEALTHPARTNERS SX009 HEALTHPARTNERS 8 percent of total billed charges 6.2 9.5 Technical (Hospital) Services Bhss per 15 Min PX-4200000200 CDM 420 RC outpatient 542 542 HEALTHPARTNERS SX009 HEALTHPARTNERS 433.6 percent of total billed charges 336.04 514.9 Technical (Hospital) Services Bhss per 15 Min PX-4200000200 CDM 420 RC outpatient 542 542 UNITED HEALTHCARE (COMMERCIAL) [3081199] UNITED HEALTHCARE 87726 [308119901] 336.04 percent of total billed charges 336.04 514.9 Technical (Hospital) Services Bhss per 15 Min PX-4200000200 CDM 420 RC outpatient 542 542 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES HDHP [308136802] 433.6 percent of total billed charges 336.04 514.9 Technical (Hospital) Services Bhss per 15 Min PX-4200000200 CDM 420 RC outpatient 542 542 MULTIPLAN INC 34080 [3081285] MULTIPLAN INC [308128501] 514.9 percent of total billed charges 336.04 514.9 Technical (Hospital) Services Bhss per 15 Min PX-4200000200 CDM 420 RC outpatient 542 542 BLUE CROSS BLUE SHIELD WELLMARK SB889 [3081026] BCBS WYOMING [308102603] 514.9 percent of total billed charges 336.04 514.9 Technical (Hospital) Services Bhss per 15 Min PX-4200000200 CDM 420 RC outpatient 542 542 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES EPO [308136803] 433.6 percent of total billed charges 336.04 514.9 Technical (Hospital) Services Bhss per 15 Min PX-4200000200 CDM 420 RC outpatient 542 542 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES PPO [308136801] 433.6 percent of total billed charges 336.04 514.9 Technical (Hospital) Services Bhss per 15 Min PX-4200000200 CDM 420 RC outpatient 542 542 CIGNA 62308 [3081051] CIGNA 62308 [308105105] 433.6 percent of total billed charges 336.04 514.9 Technical (Hospital) Services Bhss per 15 Min PX-4200000200 CDM 420 RC outpatient 542 542 CIGNA 62308 [3081051] CIGNA STATE OF WYOMING [308105107] 433.6 percent of total billed charges 336.04 514.9 Technical (Hospital) Services Bhss per 15 Min PX-4200000200 CDM 420 RC outpatient 542 542 MEDICA (COMMERCIAL) 94265 [3081118] MEDICA CLAIMS [308111801] 487.8 percent of total billed charges 336.04 514.9 Technical (Hospital) Services Bhss per 15 Min PX-4200000200 CDM 420 RC inpatient 542 542 MULTIPLAN INC 34080 [3081285] MULTIPLAN INC [308128501] 514.9 percent of total billed charges 336.04 514.9 Technical (Hospital) Services Bhss per 15 Min PX-4200000200 CDM 420 RC inpatient 542 542 BLUE CROSS BLUE SHIELD WELLMARK SB889 [3081026] BCBS WYOMING [308102603] 514.9 percent of total billed charges 336.04 514.9 Technical (Hospital) Services Bhss per 15 Min PX-4200000200 CDM 420 RC inpatient 542 542 UNITED HEALTHCARE (COMMERCIAL) [3081199] UNITED HEALTHCARE 87726 [308119901] 336.04 percent of total billed charges 336.04 514.9 Technical (Hospital) Services Bhss per 15 Min PX-4200000200 CDM 420 RC inpatient 542 542 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES PPO [308136801] 429.16 percent of total billed charges 336.04 514.9 Technical (Hospital) Services Bhss per 15 Min PX-4200000200 CDM 420 RC inpatient 542 542 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES HDHP [308136802] 429.16 percent of total billed charges 336.04 514.9 Technical (Hospital) Services Bhss per 15 Min PX-4200000200 CDM 420 RC inpatient 542 542 MEDICA (COMMERCIAL) 94265 [3081118] MEDICA CLAIMS [308111801] 487.8 percent of total billed charges 336.04 514.9 Technical (Hospital) Services Bhss per 15 Min PX-4200000200 CDM 420 RC inpatient 542 542 HEALTHPARTNERS SX009 HEALTHPARTNERS 429.16 percent of total billed charges 336.04 514.9 Technical (Hospital) Services Bhss per 15 Min PX-4200000200 CDM 420 RC inpatient 542 542 CIGNA 62308 [3081051] CIGNA STATE OF WYOMING [308105107] 429.16 percent of total billed charges 336.04 514.9 Technical (Hospital) Services Bhss per 15 Min PX-4200000200 CDM 420 RC inpatient 542 542 CIGNA 62308 [3081051] CIGNA 62308 [308105105] 429.16 percent of total billed charges 336.04 514.9 Technical (Hospital) Services Bhss per 15 Min PX-4200000200 CDM 420 RC inpatient 542 542 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES EPO [308136803] 429.16 percent of total billed charges 336.04 514.9 Technical (Hospital) Services HC Wch Cardiac Wellness Maintenance PX-9430000100 CDM 943 RC inpatient 10 10 CIGNA 62308 [3081051] CIGNA 62308 [308105105] 7.92 percent of total billed charges 6.2 9.5 Technical (Hospital) Services HC Wch Cardiac Wellness Maintenance PX-9430000100 CDM 943 RC inpatient 10 10 CIGNA 62308 [3081051] CIGNA STATE OF WYOMING [308105107] 7.92 percent of total billed charges 6.2 9.5 Technical (Hospital) Services HC Wch Cardiac Wellness Maintenance PX-9430000100 CDM 943 RC inpatient 10 10 BLUE CROSS BLUE SHIELD WELLMARK SB889 [3081026] BCBS WYOMING [308102603] 9.5 percent of total billed charges 6.2 9.5 Technical (Hospital) Services HC Wch Cardiac Wellness Maintenance PX-9430000100 CDM 943 RC inpatient 10 10 UNITED HEALTHCARE (COMMERCIAL) [3081199] UNITED HEALTHCARE 87726 [308119901] 6.2 percent of total billed charges 6.2 9.5 Technical (Hospital) Services HC Wch Cardiac Wellness Maintenance PX-9430000100 CDM 943 RC inpatient 10 10 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES PPO [308136801] 7.92 percent of total billed charges 6.2 9.5 Technical (Hospital) Services HC Wch Cardiac Wellness Maintenance PX-9430000100 CDM 943 RC inpatient 10 10 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES HDHP [308136802] 7.92 percent of total billed charges 6.2 9.5 Technical (Hospital) Services HC Wch Cardiac Wellness Maintenance PX-9430000100 CDM 943 RC inpatient 10 10 MEDICA (COMMERCIAL) 94265 [3081118] MEDICA CLAIMS [308111801] 9 percent of total billed charges 6.2 9.5 Technical (Hospital) Services HC Wch Cardiac Wellness Maintenance PX-9430000100 CDM 943 RC inpatient 10 10 MULTIPLAN INC 34080 [3081285] MULTIPLAN INC [308128501] 9.5 percent of total billed charges 6.2 9.5 Technical (Hospital) Services HC Wch Cardiac Wellness Maintenance PX-9430000100 CDM 943 RC inpatient 10 10 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES EPO [308136803] 7.92 percent of total billed charges 6.2 9.5 Technical (Hospital) Services HC Wch Cardiac Wellness Maintenance PX-9430000100 CDM 943 RC inpatient 10 10 HEALTHPARTNERS SX009 HEALTHPARTNERS 7.92 percent of total billed charges 6.2 9.5 Technical (Hospital) Services HC Wch Cardiac Wellness Maintenance PX-9430000100 CDM 943 RC outpatient 10 10 CIGNA 62308 [3081051] CIGNA 62308 [308105105] 8 percent of total billed charges 6.2 9.5 Technical (Hospital) Services HC Wch Cardiac Wellness Maintenance PX-9430000100 CDM 943 RC outpatient 10 10 CIGNA 62308 [3081051] CIGNA STATE OF WYOMING [308105107] 8 percent of total billed charges 6.2 9.5 Technical (Hospital) Services HC Wch Cardiac Wellness Maintenance PX-9430000100 CDM 943 RC outpatient 10 10 MULTIPLAN INC 34080 [3081285] MULTIPLAN INC [308128501] 9.5 percent of total billed charges 6.2 9.5 Technical (Hospital) Services HC Wch Cardiac Wellness Maintenance PX-9430000100 CDM 943 RC outpatient 10 10 MEDICA (COMMERCIAL) 94265 [3081118] MEDICA CLAIMS [308111801] 9 percent of total billed charges 6.2 9.5 Technical (Hospital) Services HC Wch Cardiac Wellness Maintenance PX-9430000100 CDM 943 RC outpatient 10 10 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES HDHP [308136802] 8 percent of total billed charges 6.2 9.5 Technical (Hospital) Services HC Wch Cardiac Wellness Maintenance PX-9430000100 CDM 943 RC outpatient 10 10 BLUE CROSS BLUE SHIELD WELLMARK SB889 [3081026] BCBS WYOMING [308102603] 9.5 percent of total billed charges 6.2 9.5 Technical (Hospital) Services HC Wch Cardiac Wellness Maintenance PX-9430000100 CDM 943 RC outpatient 10 10 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES EPO [308136803] 8 percent of total billed charges 6.2 9.5 Technical (Hospital) Services HC Wch Cardiac Wellness Maintenance PX-9430000100 CDM 943 RC outpatient 10 10 HEALTHPARTNERS [3081368] HEALTHPARTNERS MH EMPLOYEES PPO [308136801] 8 percent of total billed charges 6.2 9.5 Technical (Hospital) Services HC Wch Cardiac Wellness Maintenance PX-9430000100 CDM 943 RC outpatient 10 10 HEALTHPARTNERS SX009 HEALTHPARTNERS 8 percent of total billed charges 6.2 9.5 Technical (Hospital) Services HC Wch Cardiac Wellness Maintenance PX-9430000100 CDM 943 RC outpatient 10 10 UNITED HEALTHCARE (COMMERCIAL) [3081199] UNITED HEALTHCARE 87726 [308119901] 6.2 percent of total billed charges 6.2 9.5 Technical (Hospital) Services